Mercy Care Advantage (HMO SNP)
2017 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00017473, Version 6
This formulary was updated on 12/28/2016. For more recent information or other questions, please contact
Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or 1‑800‑624‑3879 or, for TTY users,
711, 8:00 a.m. - 8:00 p.m., 7 days a week, or visit www.MercyCareAdvantage.com.
Mercy Care Advantage (HMO SNP)
Formulario de 2017 (Lista de medicamentos cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE
CUBRIMOS EN ESTE PLAN
Identificación del Formulario 00017473, Versión 6
Este formulario fue actualizado en 12/28/2016. Para la información más reciente o para otras preguntas,
por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑263‑3000 ó al
1‑800‑624‑3879, ó para los usuarios de TTY, al 711, 8:00 a.m. a 8:00 p.m., 7 días de la semana, ó visite
www.MercyCareAdvantage.com.
AZ-17-01-01
Mercy Care Advantage (HMO SNP)
2017 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
DRUGS WE COVER IN THIS PLAN
Formulary ID 00017473, Version 6
This formulary was updated on 12/28/2016. For more recent information or other questions, please contact
Mercy Care Advantage (HMO SNP) Member Services, at 602-263-3000 or 1-800-624-3879 or, for TTY users,
711, 8:00 a.m. - 8:00 p.m., 7 days a week, or visit www.MercyCareAdvantage.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Southwest Catholic Health Network.
When it refers to “plan” or “our plan,” it means Mercy Care Advantage (HMO SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of 12/28/2016. For
an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to
time during the year. This information is not a complete description of benefits. Contact the plan for more
information. Limitations, copayments, and restrictions may apply.
Mercy Care Advantage (HMO SNP) is a Coordinated Care Plan with a Medicare contract and a contract with
the Arizona Medicaid Program. Enrollment in Mercy Care Advantage depends on contract renewal.
This information is available for free in other languages. Please contact our Member Services number
at 602-263-3000 or 1-800-624-3879 (TTY 711) for additional information. Hours of operation:
8:00 a.m. - 8:00 p.m., 7 days a week. Esta información está disponible gratis en otros idiomas. Por favor
comuníquese a nuestro número de Servicios al Miembro al 602-263-3000 o 1-800-624-3879 (TTY 711)
para información adicional. Horario de operación: 8:00 a.m. a 8:00 p.m., 7 días a la semana.
The formulary, pharmacy network and/or provider network may change at any time. You will receive notice
when necessary.
H5580_17_007 CMS Accepted
I
II
What is the Mercy Care Advantage
(HMO SNP) Formulary?
A formulary is a list of covered drugs selected by
Mercy Care Advantage (HMO SNP) in consultation
with a team of health care providers, which
represents the prescription therapies believed
to be a necessary part of a quality treatment
program. Mercy Care Advantage (HMO SNP) will
generally cover the drugs listed in our formulary
as long as the drug is medically necessary, the
prescription is filled at a Mercy Care Advantage
(HMO SNP) network pharmacy, and other plan rules
are followed. For more information on how to fill
your prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list)
change?
Generally, if you are taking a drug on our 2017
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2017 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information about
the safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not affect
members who are currently taking the drug. It
will remain available at the same cost-sharing for
those members taking it for the remainder of the
coverage year. We feel it is important that you have
continued access for the remainder of the coverage
year to the formulary drugs that were available
when you chose our plan, except for cases in which
you can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step therapy
restrictions on a drug, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who take
the drug. The enclosed formulary is current as of
12/28/2016. To get updated information about the
drugs covered by Mercy Care Advantage
(HMO SNP), please contact us. Our contact
information appears on the front and back cover
pages. If we update the formulary during 2017,
a notice will be posted on our website at
www.MercyCareAdvantage.com and impacted
members will be notified by mail.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
“Cardiovascular Agents”. If you know what your
drug is used for, look for the category name in the
list that begins on page 1. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you
should look for your drug in the Index that begins
on page 84. The Index provides an alphabetical list
of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in
the Index. Look in the Index and find your drug.
Next to your drug, you will see the page number
where you can find coverage information. Turn to
the page listed in the Index and find the name of
your drug in the first column of the list.
What are generic drugs?
Mercy Care Advantage (HMO SNP) covers both
brand name drugs and generic drugs. A generic
drug is approved by the FDA as having the same
active ingredient as the brand name drug.
Generally, generic drugs cost less than brand name
drugs.
III
Are there any restrictions on my
coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
• Prior Authorization: Mercy Care Advantage
(HMO SNP) requires you or your physician to get
prior authorization for certain drugs. This means
that you will need to get approval from Mercy
Care Advantage (HMO SNP) before you fill your
prescriptions. If you don’t get approval, Mercy
Care Advantage (HMO SNP) may not cover
the drug.
• Quantity Limits: For certain drugs, Mercy Care
Advantage (HMO SNP) limits the amount of the
drug that Mercy Care Advantage (HMO SNP) will
cover. For example, Mercy Care Advantage (HMO
SNP) provides 30 EA per 30 days per prescription
for simvastatin. This may be in addition to a
standard one-month or three-month supply.
• Step Therapy: In some cases, Mercy Care
Advantage (HMO SNP) requires you to first try
certain drugs to treat your medical condition
before we will cover another drug for that
condition. For example, if Drug A and Drug B
both treat your medical condition, Mercy Care
Advantage (HMO SNP) may not cover Drug B
unless you try Drug A first. If Drug A does not
work for you, Mercy Care Advantage (HMO SNP)
will then cover Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 1. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted online documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our contact
information, along with the date we last updated
the formulary, appears on the front and back cover
pages.
You can ask Mercy Care Advantage (HMO SNP)
to make an exception to these restrictions or
limits or for a list of other, similar drugs that may
treat your health condition. See the section,
IV
“How do I request an exception to the Mercy Care
Advantage (HMO SNP)’s formulary?” on page IV for
information about how to request an exception.
What if my drug is not on the
Formulary?
If your drug is not included in this formulary (list of
covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that Mercy Care Advantage (HMO SNP)
does not cover your drug, you have two options:
• You can ask Member Services for a list of similar
drugs that are covered by Mercy Care Advantage
(HMO SNP). When you receive the list, show it
to your doctor and ask him or her to prescribe
a similar drug that is covered by Mercy Care
Advantage (HMO SNP).
• You can ask Mercy Care Advantage (HMO SNP)
to make an exception and cover your drug. See
below for information about how to request an
exception.
How do I request an exception to
the Mercy Care Advantage (HMO
SNP) Formulary?
You can ask Mercy Care Advantage (HMO SNP) to
make an exception to our coverage rules. There are
several types of exceptions that you can ask us to
make.
• You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level,
and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, Mercy Care Advantage (HMO SNP) limits
the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive
the limit and cover a greater amount.
Generally, Mercy Care Advantage (HMO SNP) will
only approve your request for an exception if the
alternative drugs included on the plan’s formulary,
or additional utilization restrictions would not be
as effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, or utilization
restriction exception. When you request a
formulary or utilization restriction exception
you should submit a statement from your
prescriber or physician supporting your request.
Generally, we must make our decision within 72
hours of getting your prescriber’s supporting
statement. You can request an expedited (fast)
exception if you or your doctor believe that your
health could be seriously harmed by waiting up to
72 hours for a decision. If your request to expedite
is granted, we must give you a decision no later
than 24 hours after we get a supporting statement
from your doctor or other prescriber.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan
you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on
our formulary but your ability to get it is limited.
For example, you may need a prior authorization
from us before you can fill your prescription. You
should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or
request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to
determine the right course of action for you, we
may cover your drug in certain cases during the first
90 days you are a member of our plan.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a
prescription written for fewer days) when you go to
a network pharmacy. After your first 30‑day supply,
we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility,
we will allow you to refill your prescription until we
have provided you with a 98-day transition supply,
consistent with dispensing increment, (unless you
have a prescription written for fewer days). We will
cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you
need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past
the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug
(unless you have a prescription for fewer days) while
you pursue a formulary exception.
If you are admitted to or discharged from a
long‑term care facility, you will be allowed to refill a
prescription upon admission or discharge.
For more information
For more detailed information about your Mercy
Care Advantage (HMO SNP) prescription drug
coverage, please review your Evidence of Coverage
and other plan materials.
If you have questions about Mercy Care Advantage
(HMO SNP), please contact us. Our contact
information, along with the date we last updated
the formulary, appears on the front and back cover
pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227)
24 hours a day/7 days a week. TTY users should
call 1-877-486-2048. Or, visit
http://www.medicare.gov.
V
Mercy Care Advantage (HMO SNP)’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by Mercy Care
Advantage (HMO SNP). If you have trouble finding your drug in the list, turn to the Index that begins on
page 84.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and
generic drugs are listed in lower-case italics (e.g., levothyroxine).
The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend
on which category the drug is in:
Category
Generic drugs
(including brand drugs treated as generic)
Cost-sharing amount
All other drugs
$0/$3.70/$8.25 copay
$0/$1.20/$3.30 copay
Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will pay
for your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phone
numbers for Member Services are on the front and back cover pages.
The information in the Requirements/Limits column tells you if Mercy Care Advantage (HMO SNP) has
any special requirements for coverage of your drug.
Abbreviation
B/D
EA
LA
MO
PA
QL
ST
VI
Requirements/Limits
Covered under Medicare Part B or Part D. Most drugs are covered under Part D, but
there are some drugs that can be covered under both Part B or Part D depending on
what the drug is used for and how it is administered.
Each. Medications listed with EA indicates number of pills dispensed.
Limited Access. This prescription may be available only at certain pharmacies. For more
information consult the Pharmacy Directory.
Available through Mail Order.
Prior Authorization. You or your provider need to get approval from our plan before we
will agree to cover the drug.
Quantity Limits. The amount per fill or refill is shown.
Step Therapy. This prescription drug requires that you've tried another drug first, which
did not work for you.
Southwest Catholic Health Network d/b/a Mercy Care Advantage (HMO SNP) complies with applicable
Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or
sex. Mercy Care Advantage does not exclude people or treat them differently because of race, color, national
origin, age, disability, or sex.
Mercy Care Advantage:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other
formats)
• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact Civil Rights Coordinator (CRC): Matthew A. Evans, Director of Operations
Integrity Group.
If you believe that Mercy Care Advantage has failed to provide these services or discriminated in another way
on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Civil Rights Coordinator (CRC): Matthew A. Evans, Director-Operations Integrity Group
4500 E. Cotton Center Blvd, Phoenix, AZ 85040
Phone Number- 1-888-234-7358 (TTY: 711)
Fax Number- 1-860-900-7667
[email protected]
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Matthew A.
Evans, Director-Operations Integrity Group is available to help you. You can also file a civil rights complaint
with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or
phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
VII
Multi-language Interpreter Services
SPANISH:
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame
al 1-800-624-3879 (TTY: 711).
NAVAJO:
CHINESE:
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-624-3879（TTY：
711）。
VIETNAMESE:
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800624-3879 (TTY: 711).
ARABIC:
1-800-624-3879 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.)711 :‫(رقم هاتف الصم والبكم‬
TAGALOG:
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-800-624-3879 (TTY: 711).
KOREAN:
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800624-3879 (TTY: 711)번으로 전화해 주십시오.
FRENCH:
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-800-624-3879 (ATS : 711).
GERMAN:
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-800-624-3879 (TTY: 711).
RUSSIAN:
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-800-624-3879 (телетайп: 711).
H5580_17_014 CMS Accepted
VIII
JAPANESE:
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
1-800-624-3879（TTY: 711）まで、お電話にてご連絡ください。
PERSIAN:
‫ تسهیالت زبانی بصورت رایگان برای شما فراهم می‬،‫ اگر به زبان فارسی گفتگو می کنید‬:‫توجه‬
.‫ تماس بگیرید‬1-800-624-3879 (TTY: 711)
‫ با‬.‫باشد‬
SYRIAC:
ܵ ܵ
ܵ ܲ ‫ܩܒܠܝܬܘܢ ܚܠ ܲܡܬܐ ܕ ܲܗ‬
ܲ ‫ܐ‬
ܲ
ܲ
ܲ ‫ܚܬܘܢ ܟܐ ܲܗܡܙܡ‬
ܲ ‫ܐ‬
ܵ ܵ ‫ܝܪܬܐ ܒ‬
ܵ ܵ ‫ܝܬܘܢ‬
ܲ ‫ ܐܢ‬:
‫ܘܗܪܐ‬
ܵ ‫ܠܫܢܐ‬
ܵ ܵ ‫ܬܘ‬
‫ܠܫܢܐ‬
ܼ ܼ
ܼ ܼܲ ‫ ܵܡܨ ܼܝܬܘܢ ܕ‬،‫ܪܝܐ‬
ܼ
ܼ ܸ ܼ ܹ
ܼ‫ܙ‬
ܸ
ܹ ܼ ܸ
ܸ
ܸ
ܲ
ܵ
ܵ
ܵ
ܵ ܸ ‫ ܩܪܘܢ ܼܲܥܠ‬.‫ܬ‬
‫ܲ ܼܡܓܢܐ ܼܝ‬
1-800-624-3879 (TTY: 711)
‫ܡܢܝܢܐ‬
SERBO-CROATIAN:
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 1-800-624-3879 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).
THAI:
เรยน:
ี
ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร
้ ุ ู
ุ
้ ิ ่
ื
้ ี โทร 1-800-624-3879 (TTY: 711).
H5580_17_014 CMS Accepted
IX
Mercy Care Advantage (HMO SNP)
Formulario 2017
(Lista de Medicamentos Cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS CUBIERTOS POR ESTE PLAN
ID del Formulario 00017473, Versión 6
Este formulario se actualizó el 28 de diciembre 2016. Para obtener información más reciente o si tiene otras
preguntas, comuníquese con el Departamento de Servicios para miembros de Mercy Care Advantage (HMO
SNP) al 602-263-3000 o al 1-800-624-3879, los usuarios de TTY deben llamar al 711, de 8:00 a.m. a
8:00 p.m., los 7 días de la semana, o ingrese a www.MercyCareAdvantage.com.
Nota para los miembros existentes: el formulario ha cambiado desde el año pasado. Revise este
documento para asegurarse de que aún contiene los medicamentos que toma.
Cuando esta lista de medicamentos (formulario) dice “nosotros” o “nuestro”, hace referencia a Southwest
Catholic Health Network. Cuando dice “plan” o a “nuestro plan”, hace referencia a Mercy Care Advantage
(HMO SNP).
Este documento incluye la lista de medicamentos (formulario) de nuestro plan que está vigente desde el 28
de diciembre 2016. Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra información
de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de portada y
la portada posterior.
En general, debe utilizar farmacias de la red para aprovechar su beneficio de medicamentos con receta.
Los beneficios, el formulario, la red de farmacias o los copagos/coseguros pueden cambiar el 1 de enero de
2018 y ocasionalmente durante el año. Esta información no es una descripción completa de los beneficios.
Comuníquese con el plan para obtener más información. Pueden aplicarse ciertas limitaciones, copagos y
restricciones.
Mercy Care Advantage (HMO SNP) es un plan de atención coordinada con un contrato con Medicare y el
programa Medicaid de Arizona. La inscripción en Mercy Care Advantage depende de la renovación del
contrato.
H5580_17_018 Aceptado por CMS
X
Esta información está disponible sin cargo en otros idiomas. Para obtener información adicional,
comuníquese con el Departamento de Servicios para miembros al 602-263-3000 o al 1-800-624-3879
(TTY 711). Horario de atención: de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. This information is
available for free in other languages. Please contact our Member Services number at 602-263-3000 or
1-800-624-3879 (TTY 711) for additional information. Hours of operation: 8:00 a.m. - 8:00 p.m.,
7 days a week.
El formulario, la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Usted
recibirá un aviso cuando sea necesario.
XI
¿Qué es el Formulario de Mercy
Care Advantage (HMO SNP)?
Un formulario es una lista de medicamentos
cubiertos seleccionados por Mercy Care Advantage
(HMO SNP) con el asesoramiento de un equipo de
proveedores de atención médica, que representa
los tratamientos con receta que se consideran
necesarios como parte de un programa de
tratamiento de calidad. Por lo general, Mercy Care
Advantage (HMO SNP) cubrirá los medicamentos
que aparecen en nuestro formulario siempre que
el medicamento sea médicamente necesario,
el medicamento con receta se obtenga en una
farmacia de la red de Mercy Care Advantage
(HMO SNP), y se sigan otras normas del plan. Para
obtener más información sobre cómo obtener sus
medicamentos con receta, consulte su Evidencia de
cobertura.
¿Puede cambiar el Formulario (la
lista de medicamentos)?
Por lo general, si toma un medicamento que
se encuentra en nuestro Formulario 2017 y
que estaba cubierto al comienzo del año, no
discontinuaremos ni reduciremos la cobertura
del medicamento durante el año de cobertura
2017, excepto si aparece un nuevo medicamento
genérico menos costoso o si se publica información
adversa nueva sobre la seguridad o efectividad
de un medicamento. Otros tipos de cambios
en el formulario, como la eliminación de un
medicamento de nuestro formulario, no afectarán
a los miembros que actualmente toman ese
medicamento. Continuará estando disponible al
mismo costo compartido para aquellos miembros
que lo tomen por el resto del año de cobertura.
Consideramos que es importante que tenga acceso
continuo durante el resto del año de cobertura
a los medicamentos del formulario que estaban
disponibles cuando eligió nuestro plan, excepto en
los casos en los que pueda ahorrar algo de dinero o
si podemos garantizar su seguridad.
Si eliminamos medicamentos de nuestro
formulario, o agregamos la necesidad de una
autorización previa, límites de cantidad o
restricciones de tratamiento escalonado para un
medicamento, debemos notificar a los miembros
XII
afectados del cambio al menos 60 días antes
de que el cambio entre en vigencia, o cuando el
miembro resurta el medicamento, momento en el
cual el miembro recibirá un suministro para 60 días
del medicamento. Si la Administración de Drogas
y Alimentos considera que un medicamento
de nuestro formulario no es seguro o si el
fabricante del medicamento lo retira del mercado,
inmediatamente eliminaremos el medicamento
de nuestro formulario y proporcionaremos un
aviso a los miembros que toman el medicamento.
El formulario adjunto está vigente desde el 28
de diciembre 2016. Para obtener información
actualizada sobre los medicamentos cubiertos por
Mercy Care Advantage (HMO SNP), comuníquese
con nosotros. Nuestra información de contacto
aparece en las páginas de la portada y la portada
posterior. Si actualizamos el formulario durante el
2017, se publicará un aviso en nuestro sitio web,
www.MercyCareAdvantage.com, y los miembros
afectados recibirán una notificación por correo.
¿Cómo utilizo el Formulario?
Hay dos formas para encontrar un medicamento
dentro del formulario:
Afección médica
El formulario comienza en la página 1. Los
medicamentos en este formulario están
agrupados en categorías dependiendo del tipo de
afecciones médicas que traten. Por ejemplo, los
medicamentos utilizados para tratar una afección
cardíaca están incluidos en la categoría “Agentes
cardiovasculares”. Si usted sabe para qué se utiliza
el medicamento, busque el nombre de la categoría
en la lista que comienza en la página 1. Luego,
busque su medicamento debajo del nombre de esa
categoría.
Listado alfabético
Si no está seguro de en qué categoría debe buscar,
busque su medicamento en el Índice que comienza
en la página 84. El Índice proporciona un listado
alfabético de todos los medicamentos incluidos
en este documento. Tanto los medicamentos
de marca como los genéricos se encuentran
en el Índice. Consulte el Índice y busque su
medicamento. Junto al medicamento, verá el
número de página en el que puede encontrar la
información de cobertura. Vaya a la página que
aparece en el Índice y busque el nombre de su
medicamento en la primera columna de la lista.
¿Qué son los medicamentos
genéricos?
Mercy Care Advantage (HMO SNP) cubre tanto
los medicamentos de marca como los genéricos.
Un medicamento genérico está aprobado por
la Administración de Drogas y Alimentos (Food
and Drug Administration, FDA) dado que se
considera que tiene el mismo ingrediente activo
que el medicamento de marca. En general, los
medicamentos genéricos cuestan menos que los
de marca.
¿Hay alguna restricción en mi
cobertura?
Algunos medicamentos cubiertos pueden tener
requisitos adicionales o límites en la cobertura.
Estos requisitos y límites pueden incluir:
• Autorización previa: Mercy Care Advantage
(HMO SNP) exige que usted o su médico
obtengan autorización previa para ciertos
medicamentos. Esto significa que necesitará
obtener una aprobación de Mercy Care
Advantage (HMO SNP) antes de que obtenga
sus medicamentos con receta. Si no obtiene
la aprobación, es posible que Mercy Care
Advantage (HMO SNP) no cubra el medicamento.
• Límites de cantidad: para ciertos
medicamentos, Mercy Care Advantage (HMO
SNP) limita la cantidad de medicamento que
Mercy Care Advantage (HMO SNP) cubrirá. Por
ejemplo, Mercy Care Advantage (HMO SNP)
ofrece simvastatina a 30 por receta cada 30 días.
Esto puede ser además de un suministro estándar
para un mes o tres meses.
• Tratamiento escalonado: en algunos casos,
Mercy Care Advantage (HMO SNP) le exige que
primero pruebe ciertos medicamentos para tratar
su afección médica antes de que cubramos otro
medicamento para su afección. Por ejemplo, si
tanto el medicamento A como el medicamento
B tratan su afección médica, es posible que
Mercy Care Advantage (HMO SNP) no cubra el
medicamento B a menos que usted pruebe el
medicamento A primero. Si el medicamento A no
funciona para su afección, entonces Mercy Care
Advantage (HMO SNP) cubrirá el medicamento B.
Puede averiguar si su medicamento tiene
requisitos adicionales o límites consultando el
formulario que comienza en la página 1. También
puede obtener más información sobre las
restricciones aplicadas a medicamentos cubiertos
específicos visitando nuestro sitio web. Hemos
publicado documentos en Internet que explican
nuestra autorización previa y las restricciones
en tratamientos escalonados. También puede
pedirnos que le enviemos una copia. Nuestra
información de contacto, junto con la fecha de la
última actualización del formulario, aparece en las
páginas de portada y la portada posterior.
También puede solicitar a Mercy Care Advantage
(HMO SNP) que haga una excepción a estas
restricciones o límites, o pedir una lista de otros
medicamentos similares que traten su afección
de salud. Consulte la sección “¿Cómo solicito una
excepción al Formulario Mercy Care Advantage
(HMO SNP)?” que se encuentra en la página XIV
para obtener información sobre cómo solicitar una
excepción.
¿Qué sucede si mi medicamento no
está incluido en el Formulario?
Si su medicamento no está incluido en este
formulario (lista de medicamentos cubiertos),
primero debe comunicarse con el Departamento
de Servicios para miembros y consultar si su
medicamento está cubierto.
Si se le informa que Mercy Care Advantage
(HMO SNP) no cubre su medicamento, tiene dos
opciones:
• Puede solicitar al Departamento de Servicios para
miembros una lista de medicamentos similares
que estén cubiertos por Mercy Care Advantage
(HMO SNP). Una vez que reciba la lista, debe
mostrársela a su médico y pedirle que le recete
un medicamento similar que esté cubierto por
Mercy Care Advantage (HMO SNP).
XIII
• Puede solicitar a Mercy Care Advantage (HMO
SNP) que haga una excepción y cubra su
medicamento. Consulte la información sobre
cómo solicitar una excepción a continuación.
¿Cómo solicito una excepción
al Formulario de Mercy Care
Advantage (HMO SNP)?
Puede solicitar a Mercy Care Advantage (HMO SNP)
que haga una excepción a nuestras normas de
cobertura. Existen varios tipos de excepciones que
puede solicitarnos.
• Puede solicitarnos que cubramos un
medicamento incluso si este no se encuentra
en nuestro formulario. Si se aprueba, el
medicamento estará cubierto a un nivel de
costo compartido determinado previamente,
y no podrá solicitar que el medicamento se
proporcione a un costo compartido menor.
• Puede solicitar que no se apliquen restricciones
o límites de cobertura a su medicamento. Por
ejemplo, para ciertos medicamentos, Mercy
Care Advantage (HMO SNP) limita la cantidad de
medicamento que cubrirá. Si su medicamento
tiene un límite en la cantidad, puede solicitarnos
que no apliquemos el límite y que cubramos una
cantidad mayor.
Por lo general, Mercy Care Advantage (HMO SNP)
solo aprobará su solicitud de una excepción si
los medicamentos alternativos incluidos en el
formulario del plan, o si las restricciones adicionales
de utilización, no son tan efectivos para su afección
o pudieran ocasionar efectos médicos adversos.
Debe comunicarse con nosotros para solicitar una
decisión de cobertura inicial para una excepción
al formulario o a una restricción de utilización.
Cuando solicite una excepción al formulario o a
las restricciones de utilización, debe presentar
una declaración de la persona autorizada a
dar recetas o de su médico que respalde su
solicitud. Por lo general, debemos tomar una
decisión en un plazo de 72 horas después de
obtener la declaración de respaldo de la persona
autorizada a dar recetas. Puede solicitar una
excepción acelerada (rápida) si usted o su médico
XIV
cree que esperar hasta 72 horas para obtener una
decisión podría dañar gravemente su salud. Si se le
concede la solicitud acelerada, debemos tomar una
decisión antes de las 24 horas después de obtener
una declaración de respaldo de su médico o de otra
persona autorizada a dar recetas.
¿Qué debo hacer antes de poder
hablar con mi médico sobre
cambiar mis medicamentos o
solicitar una excepción?
Como un miembro nuevo o continuo de nuestro
plan, es posible que tome medicamentos que no
se encuentren en nuestro formulario. También
puede suceder que el medicamento se encuentre
en nuestro formulario, pero su capacidad de
obtenerlo sea limitada. Por ejemplo, es posible
que necesite nuestra autorización previa antes
de poder obtener su medicamento con receta.
Debe consultar con su médico para decidir si debe
comenzar a tomar un medicamento apropiado
que cubramos, o si debe solicitar una excepción
al formulario para que cubramos el medicamento
que toma. Mientras usted consulta con su médico
para determinar la acción más apropiada, podemos
cubrir su medicamento en ciertos casos durante los
primeros 90 días como miembro de nuestro plan.
Para cada uno de sus medicamentos que no se
encuentre en nuestro formulario, o si su capacidad
de obtener sus medicamentos es limitada,
cubriremos un suministro temporal para 30 días
(a menos que tenga una receta para menos días)
si va a una farmacia de la red. Luego del primer
suministro para 30 días, no pagaremos esos
medicamentos, incluso si hace menos de 90 días
que es miembro del plan.
Si reside en un centro de atención a largo plazo,
le permitimos obtener un resurtido de sus
medicamentos con receta hasta que le hayamos
proporcionado un suministro de transición para 98
días, según el incremento de provisión (a menos
que tenga una receta para menos días). Cubriremos
más de un resurtido de estos medicamentos
durante los primeros 90 días como miembro
de nuestro plan. Si necesita un medicamento
que no se encuentra en nuestro formulario o
si su capacidad de obtener el medicamento es
limitada, pero ya pasaron los primeros 90 días
como miembro de nuestro plan, cubriremos un
suministro de emergencia para 31 días de ese
medicamento (a menos que tenga una receta para
menos días) mientras usted intenta conseguir una
excepción al formulario.
Si usted es ingresado en un centro de atención
a largo plazo o si recibe el alta de este centro,
le permitiremos obtener un resurtido del
medicamento con receta en el momento del
ingreso o el alta.
Si tiene preguntas sobre Mercy Care Advantage
(HMO SNP), comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha de la
última actualización del formulario, aparece en las
páginas de portada y la portada posterior.
Si tiene alguna pregunta general sobre la
cobertura para medicamentos con receta de
Medicare, llame al Medicare al 1-800-MEDICARE
(1-800-633-4227), durante las 24 horas, los 7 días
de la semana. Los usuarios de TTY deben llamar
al 1-877-486-2048. O bien, visite http://www.
medicare.gov.
Para obtener más información
Para obtener información más detallada sobre su
cobertura para medicamentos con receta de Mercy
Care Advantage (HMO SNP), consulte su Evidencia
de cobertura y los otros materiales del plan.
XV
Formulario de Mercy Care Advantage (HMO SNP)
El formulario que comienza en la página 1 proporciona información sobre los medicamentos cubiertos por
Mercy Care Advantage (HMO SNP). Si tiene alguna dificultad para encontrar en la lista el medicamento que
toma, consulte el Índice que comienza en la página 84.
En la primera columna de esta tabla, se indica el nombre del medicamento. Los medicamentos de marca
están escritos en letra mayúscula (por ej., SYNTHROID) y los medicamentos genéricos están escritos en letra
minúscula y cursiva (p. ej., levotiroxina).
La columna “Nivel del medicamento” de la tabla, indica la categoría de cada medicamento. Sus montos
de costos compartidos dependen de la categoría en la que se encuentre el medicamento:
Categoría
Medicamentos genéricos (incluye medicamentos
de marca considerados genéricos)
Monto de costo compartido
Todos los otros medicamentos
Copago de $0/$3.70/$8.25
Copago de $0/$1.20/$3.30
Sus copagos pueden ser menores, esto depende del nivel de “Ayuda adicional” que reciba. El inserto Evidence
of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (Cláusula adicional a la
Evidencia de cobertura para las personas que reciben ayuda adicional para pagar los medicamentos con
receta) (Cláusula adicional LIS) indica el monto que debe pagar por sus medicamentos con receta. También
puede llamar al Departamento de Servicios para miembros para conocer su monto de costo compartido.
En las páginas de portada y la portada posterior, encontrará los números de teléfono del Departamento de
Servicios para miembros.
La información en la columna Requisitos/límites le informa si Mercy Care Advantage (HMO SNP)
establece requisitos especiales de cobertura para su medicamento.
Abreviatura
B/D
EA
LA
MO
PA
QL
ST
XVI
Requisitos/límites
Cubiertos por la Parte B o la Parte D de Medicare. La mayoría de los medicamentos
están cubiertos por la Parte D, pero hay algunos medicamentos que pueden estar
cubiertos tanto por la Parte B como por la Parte D según para qué se utiliza el
medicamento y cómo se administra.
Cada uno. Los medicamentos que tienen EA indican el número de píldoras provistas.
Acceso limitado. Este medicamento con receta puede estar disponible solo en ciertas
farmacias. Para obtener más información, consulte el Directorio de farmacias.
Disponible para pedido por correo.
Autorización previa. Usted o su proveedor deben obtener la autorización de nuestro
plan antes de que aceptemos cubrir el medicamento.
Límites de cantidad. Se muestra la cantidad por surtido o resurtido.
Tratamiento escalonado. Este medicamento con receta requiere que usted haya
probado otro medicamento antes, y que no haya funcionado.
Southwest Catholic Health Network d/b/a Mercy Care Advantage (HMO SNP) cumple con las leyes federales
de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o
sexo. Mercy Care Advantage no excluye a las personas ni las trata de forma diferente debido a su origen étnico,
color, nacionalidad, edad, discapacidad o sexo.
Mercy Care Advantage:
• Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen
de manera eficaz con nosotros, como los siguientes:
○ Intérpretes de lenguaje de señas capacitados.
○ Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,
otros formatos).
• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los
siguientes:
○ Intérpretes capacitados.
○ Información escrita en otros idiomas.
Si necesita recibir estos servicios, comuníquese con Coordinador de Derechos Civiles (CRC): Matthew A.
Evans, Director de Operaciones de Grupo de Integridad.
Si considera que Mercy Care Advantage no le proporcionó estos servicios o lo discriminó de otra manera por
motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la
siguiente personaestá a su disposición para brindársela:
Coordinador de Derechos Civiles (CRC): Matthew A. Evans, Director de Operaciones de Grupo de Integridad
4500 E. Cotton Center Blvd, Phoenix, AZ 85040
Phone Number- 1-888-234-7358 (TTY: 711)
Fax Number- 1-860-900-7667
[email protected]
También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos
Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE.
UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a
los números que figuran a continuación:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html
XVII
Multi-language Interpreter Services
SPANISH:
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame
al 1-800-624-3879 (TTY: 711).
NAVAJO:
CHINESE:
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-624-3879（TTY：
711）。
VIETNAMESE:
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800624-3879 (TTY: 711).
ARABIC:
1-800-624-3879 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.)711 :‫(رقم هاتف الصم والبكم‬
TAGALOG:
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-800-624-3879 (TTY: 711).
KOREAN:
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800624-3879 (TTY: 711)번으로 전화해 주십시오.
FRENCH:
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-800-624-3879 (ATS : 711).
GERMAN:
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-800-624-3879 (TTY: 711).
RUSSIAN:
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-800-624-3879 (телетайп: 711).
H5580_17_014 CMS Accepted
XVIII
JAPANESE:
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
1-800-624-3879（TTY: 711）まで、お電話にてご連絡ください。
PERSIAN:
‫ تسهیالت زبانی بصورت رایگان برای شما فراهم می‬،‫ اگر به زبان فارسی گفتگو می کنید‬:‫توجه‬
.‫ تماس بگیرید‬1-800-624-3879 (TTY: 711)
‫ با‬.‫باشد‬
SYRIAC:
ܵ ܵ
ܵ ܲ ‫ܝܬܘܢ ܚܠ ܲܡܬܐ ܕ ܲܗ‬
ܲ ‫ܐ‬
ܲ ‫ܝܬܘܢ ܕ ܲܩܒܠ‬
ܲ ‫ ܵܡܨ‬،‫ܪܝܐ‬
ܲ ‫ܚܬܘܢ ܟܐ ܲܗܡܙܡ‬
ܲ ‫ܐ‬
ܵ ܵ ‫ܝܪܬܐ ܒ‬
ܵ ܵ ‫ܝܬܘܢ‬
ܲ ‫ ܐܢ‬:
‫ܘܗܪܐ‬
ܵ ‫ܠܫܢܐ‬
ܵ ܵ ‫ܬܘ‬
‫ܠܫܢܐ‬
ܼ ܼ
ܼ ܼ
ܼ
ܼ
ܼ ܸ ܼ ܹ
ܼ‫ܙ‬
ܸ
ܹ ܼ ܸ
ܸ
ܸ
ܲ
ܵ
ܵ
ܵ
ܲ
ܵ
‫ܐܝ‬
1-800-624-3879 (TTY: 711)
‫ ܩܪܘܢ ܼܥܠ ܸܡܢܝܢܐ‬.‫ܬ‬
ܼ ‫ܲ ܼܡܓܢ‬
SERBO-CROATIAN:
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 1-800-624-3879 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).
THAI:
เรยน:
ี
ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร
้ ุ ู
ุ
้ ิ ่
ื
้ ี โทร 1-800-624-3879 (TTY: 711).
H5580_17_014 CMS Accepted
XIX
XX
2017 Formulary (List of Covered Drugs)
Drug
Drug Name
Tier
ANALGESICS-DRUGS USED TO TREAT PAIN AND INFLAMMATION
Analgesics
Generic
ascomp/codeine
Generic
butalbital/acetaminophen/caffeine/codeine caps
325mg; 50mg; 40mg; 30mg
Generic
butalbital/acetaminophen/caffeine/codeine caps
300mg; 50mg; 40mg; 30mg
Generic
butalbital/acetaminophen/caffeine caps
Generic
butalbital/acetaminophen/caffeine tabs 325mg;
50mg; 40mg
Generic
butalbital/aspirin/caffeine/codeine
Generic
butalbital/aspirin/caffeine caps
Generic
capacet
Generic
esgic caps
Generic
margesic
Generic
zebutal caps 325mg; 50mg; 40mg
Nonsteroidal Anti-inflammatory Drugs
Generic
celecoxib caps 400mg
Generic
celecoxib caps 100mg, 200mg, 50mg
Generic
diclofenac potassium
Generic
diclofenac sodium dr
Generic
diclofenac sodium er
Generic
diflunisal tabs 500mg
Generic
etodolac er tb24 600mg
Generic
etodolac er tb24 400mg, 500mg
Generic
etodolac tabs
Generic
etodolac caps
Generic
flurbiprofen tabs 100mg
Generic
flurbiprofen tabs 50mg
Generic
ibuprofen susp
Generic
ibuprofen tabs 400mg, 600mg, 800mg
Generic
ketoprofen er cp24 200mg
Generic
ketoprofen caps 50mg, 75mg
Generic
meclofenamate sodium caps
Generic
meloxicam tabs
Generic
meloxicam susp
Requirements/Limits
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
1
Drug Name
nabumetone
naproxen dr tbec 375mg
naproxen dr tbec 500mg
naproxen sodium tabs 275mg, 550mg
naproxen tabs
naproxen susp
oxaprozin
piroxicam caps 20mg
piroxicam caps 10mg
sulindac tabs 150mg
sulindac tabs 200mg
tolmetin sodium caps
tolmetin sodium tabs 200mg
tolmetin sodium tabs 600mg
VOLTAREN GEL
Opioid Analgesics, Long-acting
fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr
fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/
hr, 62.5mcg/hr, 87.5mcg/hr
methadone hcl inj
methadone hcl tabs
methadone hcl oral soln
methadone hcl conc
methadone hcl tbso
methadose tbso
morphine sulfate er cp24 120mg, 45mg, 75mg,
90mg
morphine sulfate er cp24 100mg, 20mg, 30mg,
50mg, 60mg, 80mg
morphine sulfate er cp24 10mg, 30mg, 60mg
morphine sulfate er tbcr 100mg, 200mg, 30mg,
60mg
morphine sulfate er tbcr 15mg
Opioid Analgesics, Short-acting
acetaminophen/codeine tabs
acetaminophen/codeine soln
butalbital compound/codeine caps 325mg;
50mg; 40mg; 30mg
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
MO
QL (1020 GM per 30 days)
Generic
Generic
QL (15 EA per 30 days)
QL (15 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA
QL (180 EA per 30 days) PA
QL (3000 ML per 30 days) PA
QL (360 ML per 30 days) PA
QL (90 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (30 EA per 30 days) MO
Generic
QL (60 EA per 30 days)
Generic
Generic
QL (60 EA per 30 days) MO
QL (60 EA per 30 days)
Generic
QL (90 EA per 30 days)
Generic
Generic
Generic
QL (180 EA per 30 days)
QL (4500 ML per 30 days)
QL (180 EA per 30 days) PA
Requirements/Limits
MO
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
2
Drug Name
codeine sulfate tabs
duramorph
endocet tabs 325mg; 2.5mg, 325mg; 5mg
endocet tabs 325mg; 10mg, 325mg; 7.5mg
endodan tabs 325mg; 4.835mg
fentanyl citrate oral transmucosal
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml
hydrocodone bitartrate/acetaminophen tabs
325mg; 2.5mg
hydrocodone bitartrate/acetaminophen tabs
300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg
hydrocodone/acetaminophen tabs 325mg; 10mg
hydrocodone/acetaminophen tabs 325mg; 5mg,
325mg; 7.5mg
hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg;
200mg
hydrocodone/ibuprofen tabs 2.5mg; 200mg,
7.5mg; 200mg
hydromorphone hcl tabs
hydromorphone hcl liqd
hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/
ml, 50mg/5ml
hydromorphone hcl inj 4mg/ml
ibudone tabs 5mg; 200mg
lorcet
lorcet hd
lorcet plus tabs 325mg; 7.5mg
lortab tabs 325mg; 5mg
lortab tabs 325mg; 10mg, 325mg; 7.5mg
morphine sulfate inj 0.5mg/ml, 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml,
2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml
morphine sulfate inj 10mg/ml, 1mg/ml
morphine sulfate oral soln 20mg/5ml
morphine sulfate oral soln 100mg/5ml
morphine sulfate oral soln 10mg/5ml
morphine sulfate tabs 30mg
morphine sulfate tabs 15mg
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
QL (180 EA per 30 days) MO
B/D
QL (180 EA per 30 days)
QL (180 EA per 30 days) MO
QL (180 EA per 30 days)
QL (120 EA per 30 days) PA
QL (5550 ML per 30 days)
Generic
QL (180 EA per 30 days)
Generic
QL (180 EA per 30 days) MO
Generic
Generic
QL (180 EA per 30 days)
QL (180 EA per 30 days) MO
Generic
QL (150 EA per 30 days)
Generic
QL (150 EA per 30 days) MO
Generic
Generic
Generic
QL (180 EA per 30 days)
QL (2400 ML per 30 days) MO
B/D
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
B/D MO
QL (150 EA per 30 days) MO
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days) MO
B/D
Generic
Generic
Generic
Generic
Generic
Generic
B/D MO
QL (1020 ML per 30 days)
QL (180 ML per 30 days)
QL (1800 ML per 30 days)
QL (180 EA per 30 days) MO
QL (60 EA per 30 days) MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
3
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Drug Name
nalbuphine hcl inj 10mg/ml, 20mg/ml
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl soln
oxycodone hcl tabs 30mg
oxycodone hcl tabs 10mg, 15mg, 20mg
oxycodone hcl tabs 5mg
oxycodone/acetaminophen soln
oxycodone/acetaminophen tabs 325mg; 10mg,
325mg; 2.5mg, 325mg; 5mg
Generic
oxycodone/acetaminophen tabs 325mg; 7.5mg
Generic
oxycodone/aspirin tabs 325mg; 4.835mg
Generic
oxycodone/ibuprofen
Generic
reprexain tabs 10mg; 200mg
ROXICET SOLN
OTHER
Generic
roxicet tabs
Generic
tramadol hcl tabs
Generic
tramadol hydrochloride/acetaminophen
Generic
vicodin es tabs 300mg; 7.5mg
Generic
vicodin tabs 300mg; 5mg
Generic
xylon
Generic
zamicet
ANESTHETICS-DRUGS USED FOR NUMBING
Local Anesthetics
Generic
glydo
Generic
lidocaine hcl jelly gel 2%
Generic
lidocaine hcl gel 2%
Generic
lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%
Generic
lidocaine hcl external soln 4%
Generic
lidocaine hcl mouth/throat soln 4%
Generic
lidocaine viscous
Generic
lidocaine/prilocaine kit
Generic
lidocaine/prilocaine crea
Generic
lidocaine oint
Generic
lidocaine ptch
Generic
relador pak plus
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Alcohol Deterrents/Anti-craving
Requirements/Limits
MO
QL (180 EA per 30 days)
QL (180 ML per 30 days)
QL (5400 ML per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days) MO
QL (180 EA per 30 days)
QL (1800 ML per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days) MO
QL (180 EA per 30 days)
QL (120 EA per 30 days) MO
QL (150 EA per 30 days) MO
QL (1800 ML per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (150 EA per 30 days)
QL (5550 ML per 30 days) MO
MO
MO
MO
QL (90 EA per 30 days) PA
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
4
Drug Name
acamprosate calcium dr
disulfiram tabs
naltrexone hcl tabs
Opioid Dependence Treatments
buprenorphine hcl/naloxone hcl
buprenorphine hcl subl
SUBOXONE FILM 12MG; 3MG
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG,
8MG; 2MG
Opioid Reversal Agents
EVZIO
naloxone hcl inj 0.4mg/ml, 4mg/10ml
naloxone hcl inj 2mg/2ml
NARCAN LIQD
Smoking Cessation Agents
buproban
bupropion hcl sr tb12 150mg
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABS 0.5MG, 1MG
NICOTROL NS
ANTIBACTERIALS-DRUGS USED TO TREAT INFECTIONS
Aminoglycosides
amikacin sulfate inj 500mg/2ml
amikacin sulfate inj 1gm/4ml
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium chloride inj
0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml;
0.9%
gentamicin sulfate/0.9% sodium chloride inj
0.8mg/ml; 0.9%
gentamicin sulfate inj 10mg/ml
gentamicin sulfate inj 40mg/ml
isotonic gentamicin inj 0.8mg/ml; 0.9%
neomycin sulfate
paromomycin sulfate
streptomycin sulfate inj 1gm
Drug
Tier
Generic
Generic
Generic
Requirements/Limits
MO
Generic
Generic
OTHER
OTHER
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
OTHER
Generic
Generic
OTHER
MO
MO
MO
Generic
Generic
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (336 EA per 365 days)
QL (106 EA per 365 days) MO
QL (336 EA per 365 days) MO
QL (40 ML per 30 days) MO
Generic
Generic
Generic
Generic
MO
MO
Generic
MO
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
5
Drug Name
tobramycin sulfate inj 1.2gm/30ml, 1.2gm,
10mg/ml, 40mg/ml, 80mg/2ml
Antibacterials, Other
baciim
bacitracin inj 50000unit
chloramphenicol sodium succinate
clindamycin hcl caps 150mg, 300mg
clindamycin hcl caps 75mg
clindamycin palmitate hcl
clindamycin phosphate add-vantage inj
900mg/6ml
clindamycin phosphate in d5w
clindamycin phosphate crea 2%
clindamycin phosphate inj 150mg/ml,
300mg/2ml, 600mg/4ml, 9000mg/60ml,
900mg/6ml
colistimethate sodium
CUBICIN
CUBICIN RF
DALVANCE
linezolid inj
linezolid susr
linezolid tabs
methenamine hippurate
METRO IV
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole caps 375mg
metronidazole tabs 250mg, 500mg
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin monohydrate/macrocrystals
nitrofurantoin susp
SIVEXTRO INJ
SIVEXTRO TABS
SYNERCID INJ 350MG; 150MG
tinidazole
trimethoprim tabs
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
PA
PA
QL (1800 ML per 28 days) PA MO
QL (56 EA per 28 days) PA
MO
PA
PA
PA
PA
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
6
Drug Name
TYGACIL
vancomycin
vancomycin hcl in dextrose
vancomycin hcl inj
vancomycin hcl caps
vandazole
ZYVOX SUSR
ZYVOX TABS
ZYVOX INJ 600MG/300ML
Beta-lactam, Cephalosporins
cefaclor er tb12 500mg
cefaclor caps
cefaclor susr 250mg/5ml, 375mg/5ml
cefaclor susr 125mg/5ml
cefadroxil caps, tabs
cefadroxil susr 250mg/5ml
cefadroxil susr 500mg/5ml
cefazolin sodium/dextrose
cefazolin sodium inj 100gm, 10gm, 1gm, 1gm;
5%, 20gm, 300gm, 500mg
cefazolin inj 2gm/100ml; 4%
cefdinir
cefditoren pivoxil tabs 400mg
cefepime
cefepime/dextrose
cefixime
cefotaxime sodium inj 10gm, 2gm, 500mg
cefotaxime sodium inj 1gm
cefotetan
cefotetan/dextrose
cefoxitin sodium
cefpodoxime proxetil susr
cefpodoxime proxetil tabs 200mg
cefpodoxime proxetil tabs 100mg
cefprozil
ceftazidime/dextrose
ceftazidime inj 1gm, 2gm, 6gm
ceftriaxone in iso-osmotic dextrose
Drug
Tier
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
PA
MO
QL (1800 ML per 28 days) PA MO
QL (56 EA per 28 days) PA MO
PA
MO
MO
MO
MO
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
7
Drug Name
ceftriaxone sodium inj 100gm, 10gm, 1gm,
250mg, 2gm, 500mg
ceftriaxone sodium inj 2gm
ceftriaxone/dextrose
cefuroxime axetil tabs
cefuroxime sodium inj 1.5gm, 225gm, 7.5gm,
75gm
cefuroxime sodium inj 750mg
cephalexin caps 250mg, 500mg
cephalexin caps 750mg
cephalexin susr
cephalexin tabs
SUPRAX CAPS
SUPRAX CHEW 100MG
SUPRAX CHEW 200MG
SUPRAX SUSR 500MG/5ML
tazicef inj 1gm, 2gm, 6gm
TEFLARO
Beta-lactam, Other
aztreonam
imipenem/cilastatin
INVANZ INJ 1GM
meropenem
meropenem/sodium chloride
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er
amoxicillin/clavulanate potassium chew
amoxicillin/clavulanate potassium susr
200mg/5ml; 28.5mg/5ml, 400mg/5ml;
57mg/5ml, 600mg/5ml; 42.9mg/5ml
amoxicillin/clavulanate potassium susr
250mg/5ml; 62.5mg/5ml
amoxicillin/clavulanate potassium tabs 500mg;
125mg, 875mg; 125mg
amoxicillin/clavulanate potassium tabs 250mg;
125mg
amoxicillin chew 125mg, 250mg
amoxicillin caps, susr
Drug
Tier
Generic
Requirements/Limits
Generic
Generic
Generic
Generic
MO
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
MO
Generic
Generic
OTHER
Generic
Generic
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
MO
Generic
MO
Generic
Generic
MO
Generic
Generic
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
8
Drug Name
amoxicillin tabs 875mg
amoxicillin tabs 500mg
ampicillin sodium inj 10gm, 125mg, 1gm,
250mg, 2gm, 500mg
ampicillin sodium inj 1gm
ampicillin-sulbactam
ampicillin caps
ampicillin susr 125mg/5ml
ampicillin susr 250mg/5ml
BICILLIN L-A INJ 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML
dicloxacillin sodium
nafcillin
oxacillin sodium inj 10gm, 1gm
oxacillin sodium inj 2gm
penicillin g potassium inj 5000000unit
penicillin g potassium inj 20000000unit
penicillin g procaine
penicillin g sodium
penicillin v potassium tabs
penicillin v potassium solr 125mg/5ml
penicillin v potassium solr 250mg/5ml
piperacillin sodium/ tazobactam sodium
piperacillin sodium/tazobactam sodium
piperacillin/tazobactam inj 36gm; 4.5gm, 4gm;
0.5gm
Macrolides
azithromycin tabs
azithromycin pack, susr
azithromycin inj 500mg
clarithromycin tabs
clarithromycin susr
DIFICID
ERYTHROCIN LACTOBIONATE INJ 500MG
erythromycin base
erythromycin ethylsuccinate tabs
erythromycin stearate tabs 250mg
erythromycin cpep 250mg
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
9
Drug Name
Quinolones
ciprofloxacin er
ciprofloxacin hcl tabs 250mg, 500mg
ciprofloxacin hcl tabs 100mg, 750mg
ciprofloxacin i.v.-in d5w
ciprofloxacin inj, otic soln, susr
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25mg/ml
levofloxacin tabs 250mg, 500mg, 750mg
ofloxacin tabs 300mg, 400mg
Sulfonamides
sulfadiazine tabs
sulfamethoxazole/trimethoprim ds
sulfamethoxazole/trimethoprim inj, tabs
sulfamethoxazole/trimethoprim susp
sulfatrim pediatric
Tetracyclines
doxy 100
doxycycline hyclate dr
doxycycline hyclate caps 100mg
doxycycline hyclate caps 50mg
doxycycline hyclate inj
doxycycline hyclate tabs 100mg
doxycycline hyclate tabs 20mg
doxycycline monohydrate caps 100mg, 150mg
doxycycline monohydrate caps 50mg, 75mg
doxycycline monohydrate tabs 50mg, 75mg
doxycycline monohydrate tabs 100mg, 150mg
doxycycline susr
minocycline hcl caps
morgidox 1x100mg caps
morgidox 1x50mg
morgidox 2x100mg caps
tetracycline hcl caps 250mg, 500mg
ANTICONVULSANTS-DRUGS USED TO TREAT SEIZURES
Anticonvulsants, Other
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
10
Drug Name
APTIOM TABS 200MG, 400MG, 800MG
APTIOM TABS 600MG
BRIVIACT TABS
BRIVIACT INJ, ORAL SOLN
FYCOMPA SUSP
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG,
8MG
FYCOMPA TABS 2MG
levetiracetam inj, oral soln, tabs
POTIGA TABS 50MG
POTIGA TABS 200MG, 300MG, 400MG
roweepra
SPRITAM TB3D 250MG, 500MG, 750MG
SPRITAM TB3D 1000MG
Calcium Channel Modifying Agents
CELONTIN CAPS 300MG
ethosuximide
LYRICA SOLN
LYRICA CAPS 225MG, 300MG
LYRICA CAPS 100MG, 150MG, 200MG, 25MG,
50MG, 75MG
zonisamide
Gamma-aminobutyric Acid (GABA) Augmenting
Agents
clonazepam odt tbdp 1mg
clonazepam odt tbdp 2mg
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg
clonazepam tabs 1mg
clonazepam tabs 2mg
clonazepam tabs 0.5mg
diazepam gel 10mg, 2.5mg, 20mg
divalproex sodium dr
divalproex sodium er
divalproex sodium csdr
gabapentin caps, soln
gabapentin tabs 600mg, 800mg
GABITRIL TABS 12MG, 16MG
ONFI SUSP
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/Limits
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA
QL (600 ML per 30 days) PA
QL (1020 ML per 30 days) PA
QL (30 EA per 30 days) PA MO
OTHER
Generic
OTHER
OTHER
Generic
OTHER
OTHER
QL (60 EA per 30 days) PA MO
OTHER
Generic
OTHER
OTHER
OTHER
MO
QL (270 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (900 ML per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
QL (120 EA per 30 days)
QL (300 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (300 EA per 30 days)
QL (90 EA per 30 days)
MO
MO
MO
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
11
Drug
Tier
OTHER
Generic
Generic
Drug Name
Requirements/Limits
ONFI TABS 10MG, 20MG
MO
QL (1500 ML per 30 days) PA MO
phenobarbital elix
QL (120 EA per 30 days) PA
phenobarbital tabs 16.2mg, 32.4mg, 64.8mg,
97.2mg
Generic
QL (120 EA per 30 days) PA MO
phenobarbital tabs 100mg, 15mg, 30mg, 60mg
Generic
primidone tabs
SABRIL
OTHER
PA
Generic
tiagabine hydrochloride
Generic
valproate sodium inj
Generic
valproic acid caps
Generic
MO
valproic acid syrp
Glutamate Reducing Agents
Generic
felbamate
Generic
MO
lamotrigine titration
Generic
lamotrigine chew, tabs
Generic
topiramate cpsp 15mg
Generic
MO
topiramate cpsp 25mg
Generic
MO
topiramate tabs
Sodium Channel Agents
BANZEL
OTHER
PA MO
Generic
carbamazepine er cp12
Generic
MO
carbamazepine er tb12
Generic
carbamazepine chew, susp, tabs
DILANTIN CAPS 30MG
OTHER
MO
Generic
MO
epitol
Generic
fosphenytoin sodium
Generic
oxcarbazepine tabs
Generic
MO
oxcarbazepine susp
PEGANONE TABS 250MG
OTHER
MO
Generic
phenytoin sodium extended
Generic
phenytoin sodium inj
Generic
phenytoin susp
Generic
MO
phenytoin chew
VIMPAT INJ
OTHER
VIMPAT ORAL SOLN
OTHER
MO
VIMPAT TABS 50MG
OTHER
QL (180 EA per 30 days) MO
VIMPAT TABS 100MG, 150MG, 200MG
OTHER
QL (60 EA per 30 days) MO
ANTIDEMENTIA AGENTS-DRUGS USED TO TREAT DEMENTIA AND MEMORY LOSS
B/D - Covered Under Medicare B or D
LA - Limited Access
MO - Available at Mail Order
PA - Prior Authorization
QL - Quantity Limit
ST - Step Therapy
01/01/2017
Formulary ID 00017473 v6
12
Drug
Tier
Drug Name
Antidementia Agents, Other
Generic
ergoloid mesylates tabs
Cholinesterase Inhibitors
Generic
donepezil hcl tbdp
Generic
donepezil hcl tabs 23mg, 5mg
Generic
donepezil hcl tabs 10mg
Generic
galantamine hydrobromide soln
Generic
galantamine hydrobromide cp24
Generic
galantamine hydrobromide tabs
NAMZARIC C4PK
OTHER
NAMZARIC CP24 10MG; 21MG, 10MG; 7MG
OTHER
NAMZARIC CP24 10MG; 14MG, 10MG; 28MG
OTHER
Generic
rivastigmine tartrate
Generic
rivastigmine transdermal system
N-methyl-D-aspartate (NMDA) Receptor Antagonist
Generic
memantine hcl
Generic
memantine hcl titration pak
Generic
memantine hydrochloride soln
NAMENDA TITRATION PAK
OTHER
NAMENDA XR TITRATION PACK
OTHER
NAMENDA XR CP24 14MG
OTHER
NAMENDA XR CP24 21MG, 28MG, 7MG
OTHER
NAMENDA SOLN
OTHER
NAMENDA TABS
OTHER
ANTIDEPRESSANTS-DRUGS USED TO TREAT DEPRESSION
Antidepressants, Other
Generic
bupropion hcl sr tb12 100mg, 150mg, 200mg
Generic
bupropion hcl xl tb24 300mg
Generic
bupropion hcl xl tb24 150mg
Generic
bupropion hcl tabs
Generic
mirtazapine odt
Generic
mirtazapine tabs
TRINTELLIX
OTHER
Monoamine Oxidase Inhibitors
EMSAM
OTHER
MARPLAN
OTHER
Generic
phenelzine sulfate
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
PA MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (200 ML per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (56 EA per 365 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days)
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) PA
QL (98 EA per 365 days) PA MO
QL (360 ML per 30 days) PA
QL (98 EA per 365 days) PA MO
QL (56 EA per 365 days) PA MO
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (360 ML per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (180 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
13
Drug Name
tranylcypromine sulfate
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake
Inhibitor
BRINTELLIX TABS 20MG
BRINTELLIX TABS 10MG, 5MG
citalopram hydrobromide soln
citalopram hydrobromide tabs 10mg
citalopram hydrobromide tabs 40mg
citalopram hydrobromide tabs 20mg
desvenlafaxine er tb24 100mg, 50mg
desvenlafaxine er tb24 50mg
duloxetine hcl cpep 20mg, 60mg
duloxetine hcl cpep 40mg
duloxetine hcl cpep 30mg
escitalopram oxalate soln
escitalopram oxalate tabs 20mg
escitalopram oxalate tabs 10mg, 5mg
FETZIMA
FETZIMA TITRATION PACK
fluoxetine
fluoxetine dr
fluoxetine hcl caps, soln
fluoxetine hcl tabs 10mg, 20mg
fluoxetine hcl tabs 60mg
fluvoxamine maleate tabs 100mg, 50mg
fluvoxamine maleate tabs 25mg
maprotiline hcl
nefazodone hcl
olanzapine/fluoxetine caps 25mg; 12mg, 25mg;
6mg, 50mg; 12mg, 50mg; 6mg
olanzapine/fluoxetine caps 25mg; 3mg
paroxetine hcl
PAXIL SUSP
PRISTIQ TB24 25MG
sertraline hcl conc, tabs
trazodone hcl
venlafaxine hcl
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
14
Drug
Tier
Generic
Requirements/Limits
MO
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (600 ML per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (600 ML per 30 days)
QL (30 EA per 30 days)
QL (45 EA per 30 days)
QL (30 EA per 30 days) PA MO
QL (56 EA per 365 days) PA MO
MO
QL (4 EA per 28 days) MO
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
QL (30 EA per 30 days) MO
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (120 EA per 30 days) PA MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
venlafaxine hcl er cp24 37.5mg, 75mg
venlafaxine hcl er cp24 150mg
venlafaxine hcl er tb24 37.5mg, 75mg
venlafaxine hcl er tb24 225mg
venlafaxine hcl er tb24 150mg
VIIBRYD STARTER PACK
VIIBRYD TABS
VIIBRYD KIT
Tricyclics
amitriptyline hcl tabs 100mg, 25mg, 50mg,
75mg
amitriptyline hcl tabs 10mg, 150mg
amoxapine
clomipramine hcl caps
desipramine hcl tabs 100mg, 150mg, 25mg,
50mg
desipramine hcl tabs 10mg, 75mg
doxepin hcl caps 100mg, 10mg, 25mg, 50mg,
75mg
doxepin hcl caps 150mg
doxepin hcl conc
imipramine hcl tabs
nortriptyline hcl caps 10mg, 25mg, 75mg
nortriptyline hcl caps 50mg
nortriptyline hcl soln
perphenazine/amitriptyline tabs 25mg; 4mg
perphenazine/amitriptyline tabs 10mg; 2mg,
10mg; 4mg, 25mg; 2mg, 50mg; 4mg
protriptyline hcl
trimipramine maleate caps
ANTIEMETICS-DRUGS FOR NAUSEA AND VOMITING
Antiemetics, Other
meclizine hcl tabs
phenadoz supp 25mg
phenadoz supp 12.5mg
phenergan supp
promethazine hcl supp 12.5mg, 50mg
promethazine hcl supp 25mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Requirements/Limits
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (60 EA per 30 days)
QL (60 EA per 365 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 365 days)
Generic
PA
Generic
Generic
Generic
Generic
PA MO
MO
PA
Generic
Generic
MO
PA
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA MO
PA MO
PA
MO
MO
MO
Generic
Generic
PA
Generic
Generic
Generic
Generic
Generic
Generic
PA
PA MO
PA
PA
PA MO
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
15
Drug
Tier
Generic
Generic
OTHER
Drug Name
promethegan supp 12.5mg, 25mg
promethegan supp 50mg
TRANSDERM-SCOP
Emetogenic Therapy Adjuncts
Generic
dronabinol
EMEND SUSR
OTHER
EMEND CAPS 40MG
OTHER
EMEND CAPS 0, 125MG, 80MG
OTHER
Generic
granisetron hcl tabs
Generic
ondansetron hcl oral soln
Generic
ondansetron hcl inj 40mg/20ml, 4mg/2ml
Generic
ondansetron hcl inj 4mg/2ml
Generic
ondansetron hcl tabs 4mg, 8mg
Generic
ondansetron hcl tabs 24mg
Generic
ondansetron odt tbdp 8mg
Generic
ondansetron odt tbdp 4mg
ANTIFUNGALS-DRUGS USED TO TREAT FUNGAL INFECTIONS
Antifungals
ABELCET
OTHER
AMBISOME
OTHER
Generic
amphotericin b
CANCIDAS INJ 50MG
OTHER
CANCIDAS INJ 70MG
OTHER
Generic
ciclodan
Generic
ciclopirox nail lacquer
Generic
ciclopirox olamine crea
Generic
ciclopirox gel, susp
Generic
ciclopirox sham
Generic
clotrimazole/betamethasone dipropionate
Generic
clotrimazole soln
Generic
clotrimazole crea, troc
Generic
econazole nitrate crea
ERAXIS
OTHER
Generic
fluconazole in dextrose inj 56mg/ml;
200mg/100ml, 56mg/ml; 400mg/200ml
Generic
fluconazole in nacl
Generic
fluconazole susr, tabs
Generic
flucytosine
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
16
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
PA
PA MO
MO
QL (60 EA per 30 days) PA
QL (6 EA per 30 days) B/D
QL (1 EA per 30 days) B/D
QL (6 EA per 30 days) B/D MO
QL (60 EA per 30 days) B/D
QL (900 ML per 30 days) B/D MO
MO
B/D
B/D MO
B/D
B/D MO
B/D
B/D
B/D MO
MO
MO
MO
MO
PA
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Drug Name
Requirements/Limits
griseofulvin microsize susp
MO
griseofulvin microsize tabs
griseofulvin ultramicrosize tabs 125mg, 250mg
PA
itraconazole caps
ketoconazole tabs
MO
ketoconazole crea, sham
NOXAFIL INJ
PA
NOXAFIL SUSP, TBEC
PA MO
MO
nyamyc
nystatin crea, oint, powd, susp, tabs
MO
nystop
SPORANOX SOLN
PA MO
terbinafine hcl tabs
MO
terconazole
voriconazole inj, tabs
MO
voriconazole susr
zazole
ANTIGOUT AGENTS- DRUGS USED TO TREAT GOUT
Antigout Agents
Generic
allopurinol tabs 300mg
Generic
MO
allopurinol tabs 100mg
Generic
MO
colchicine caps
Generic
MO
colchicine tabs 0.6mg
Generic
probenecid/colchicine
Generic
MO
probenecid tabs
ULORIC
OTHER
ST MO
ANTIMIGRAINE AGENTS- DRUGS USED TO TREAT SEVERE HEADACHES
Ergot Alkaloids
Generic
MO
dihydroergotamine mesylate inj
MIGERGOT
OTHER
QL (20 EA per 28 days) MO
Serotonin (5-HT) 1b/1d Receptor Agonists
Generic
QL (9 EA per 30 days)
naratriptan hcl
Generic
QL (12 EA per 30 days)
rizatriptan benzoate odt
Generic
QL (12 EA per 30 days)
rizatriptan benzoate tabs 5mg
Generic
QL (12 EA per 30 days) MO
rizatriptan benzoate tabs 10mg
Generic
QL (4 ML per 30 days)
sumatriptan succinate refill inj 6mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate refill inj 4mg/0.5ml
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
17
Drug
Drug Name
Tier
Requirements/Limits
Generic
QL (4 ML per 30 days)
sumatriptan succinate inj 6mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate inj 4mg/0.5ml
Generic
QL (9 EA per 30 days)
sumatriptan succinate tabs 100mg, 50mg
Generic
QL (9 EA per 30 days) MO
sumatriptan succinate tabs 25mg
Generic
QL (12 EA per 30 days) MO
sumatriptan soln
Generic
QL (6 EA per 30 days)
zolmitriptan odt
Generic
QL (6 EA per 30 days)
zolmitriptan tabs
ANTIMYASTHENIC AGENTS- DRUGS USED TO TREAT MYASTHENIA GRAVIS
Parasympathomimetics
Generic
guanidine hcl
MESTINON TIMESPAN
OTHER
MO
MESTINON SYRP
OTHER
MO
Generic
pyridostigmine bromide er
Generic
pyridostigmine bromide tabs
ANTIMYCOBACTERIALS- DRUGS USED TO TREAT TUBERCULOSIS
Antimycobacterials, Other
Generic
MO
dapsone tabs
Generic
MO
rifabutin
Antituberculars
CAPASTAT SULFATE
OTHER
Generic
MO
cycloserine
Generic
MO
ethambutol hcl tabs
Generic
isoniazid inj
Generic
MO
isoniazid syrp
Generic
isoniazid tabs 300mg
Generic
MO
isoniazid tabs 100mg
PASER
OTHER
MO
PRIFTIN
OTHER
Generic
MO
pyrazinamide tabs
Generic
rifampin caps, inj
RIFATER
OTHER
MO
SIRTURO
OTHER
QL (188 EA per 365 days) PA
TRECATOR
OTHER
MO
ANTINEOPLASTICS- DRUGS USED TO TREAT CANCER
Alkylating Agents
ALKERAN TABS
OTHER
B/D MO
BENDEKA
OTHER
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
18
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
BUSULFEX
cyclophosphamide inj
cyclophosphamide caps
GLEOSTINE CAPS 5MG
HEXALEN
LEUKERAN
lomustine
MATULANE
melphalan hydrochloride
MUSTARGEN
TEMODAR INJ
thiotepa inj 15mg
TREANDA
VALCHLOR
YONDELIS
Antiandrogens
bicalutamide
flutamide
NILANDRON TABS 150MG
nilutamide
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID CAPS 100MG, 150MG, 50MG
THALOMID CAPS 200MG
Antiestrogens/Modifiers
EMCYT
FARESTON
SOLTAMOX
tamoxifen citrate tabs 20mg
tamoxifen citrate tabs 10mg
Antimetabolites
DEPOCYT
DROXIA
hydroxyurea caps
LONSURF TABS 6.14MG; 15MG
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Generic
Generic
OTHER
OTHER
OTHER
Generic
OTHER
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
Requirements/Limits
B/D MO
MO
MO
B/D
PA LA
PA
Generic
Generic
OTHER
Generic
OTHER
OTHER
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
OTHER
OTHER
OTHER
OTHER
QL (21 EA per 28 days) PA
QL (30 EA per 30 days) PA
QL (28 EA per 28 days) PA
QL (56 EA per 28 days) PA
OTHER
OTHER
OTHER
Generic
Generic
MO
MO
PA MO
OTHER
OTHER
Generic
OTHER
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
QL (100 EA per 28 days) PA
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
19
Drug Name
LONSURF TABS 8.19MG; 20MG
mercaptopurine tabs
PURIXAN
TABLOID
Antineoplastics, Other
ABRAXANE
adriamycin inj 2mg/ml
adrucil
ALIMTA
amifostine
ARRANON
AVASTIN
azacitidine
BELEODAQ
BICNU
BLEO 15K
bleomycin sulfate
carboplatin inj 150mg/15ml, 450mg/45ml,
50mg/5ml, 600mg/60ml
cisplatin inj 100mg/100ml, 200mg/200ml,
50mg/50ml
cladribine
CLOLAR
COSMEGEN
COTELLIC
cytarabine aqueous
dacarbazine
daunorubicin hcl inj 5mg/ml
decitabine
dexrazoxane
DOCEFREZ INJ 20MG
docetaxel inj 140mg/7ml, 160mg/16ml,
160mg/8ml, 200mg/20ml, 20mg/2ml, 20mg/
ml, 80mg/4ml, 80mg/8ml
doxorubicin hcl liposome
doxorubicin hcl inj 10mg, 2mg/ml, 50mg
ELITEK
epirubicin hcl inj 200mg/100ml, 50mg/25ml
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
20
Drug
Tier
OTHER
Generic
OTHER
OTHER
OTHER
Generic
Generic
OTHER
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
Generic
Generic
Requirements/Limits
QL (84 EA per 28 days) PA
PA
MO
B/D
B/D
PA
PA
PA
PA
B/D
B/D
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
OTHER
Generic
LA - Limited Access
QL - Quantity Limit
B/D
QL (63 EA per 28 days) PA
B/D
B/D
PA
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
ERBITUX
ERWINAZE
FARYDAK
FASLODEX
fludarabine phosphate
fluorouracil inj 1gm/20ml, 2.5gm/50ml
FOLOTYN
FUSILEV
gemcitabine
gemcitabine hcl
HALAVEN
HERCEPTIN
IBRANCE
idarubicin hcl
ifosfamide
INTRON A W/DILUENT
INTRON A INJ 10MU/ML, 18MU, 50MU,
6000000UNIT/ML
irinotecan
ISTODAX
IXEMPRA KIT
JEVTANA
KADCYLA
LARTRUVO
leucovorin calcium inj 100mg, 200mg, 350mg,
500mg, 50mg
leucovorin calcium tabs 5mg
leucovorin calcium tabs 10mg, 15mg, 25mg
levoleucovorin calcium
levoleucovorin inj 250mg/25ml, 50mg
LYNPARZA
MARQIBO
mesna
MESNEX TABS
mitomycin
mitoxantrone hcl inj 2mg/ml
NINLARO
NIPENT
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
OTHER
Generic
Generic
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
PA
PA
QL (6 EA per 21 days) PA
PA MO
B/D
PA
PA
QL (21 EA per 28 days) PA
PA
PA
PA
PA
PA
PA
PA
MO
QL (448 EA per 28 days) PA LA
PA LA
MO
QL (3 EA per 28 days) PA
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
21
Drug Name
ODOMZO
ONCASPAR
oxaliplatin
paclitaxel inj 100mg/16.7ml, 150mg/25ml,
300mg/50ml, 30mg/5ml
PERJETA
PORTRAZZA
PROLEUKIN
SYLATRON
SYNRIBO
TAGRISSO
THERACYS INJ 81MG/VIAL
TICE BCG
TRISENOX
UVADEX
VALSTAR
VECTIBIX
VELCADE
VENCLEXTA
VENCLEXTA STARTING PACK
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
YERVOY
ZALTRAP
ZANOSAR
ZOLINZA
Aromatase Inhibitors, 3rd Generation
anastrozole tabs
exemestane
letrozole
Enzyme Inhibitors
etoposide inj 100mg/5ml, 1gm/50ml,
500mg/25ml
toposar inj 100mg/5ml, 1gm/50ml,
500mg/25ml
topotecan hcl
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
22
Drug
Tier
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Requirements/Limits
QL (30 EA per 30 days) PA
PA
PA LA
PA
PA
QL (30 EA per 30 days) PA LA
PA
PA
PA
QL (120 EA per 30 days) PA LA
QL (84 EA per 365 days) PA LA
B/D
B/D
B/D
PA
PA
QL (120 EA per 30 days) PA
MO
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
ZYDELIG
Molecular Target Inhibitors
AFINITOR
AFINITOR DISPERZ
ALECENSA
BOSULIF
CABOMETYX
CAPRELSA TABS 300MG
CAPRELSA TABS 100MG
COMETRIQ
ERIVEDGE
GILOTRIF
GLEEVEC TABS 400MG
GLEEVEC TABS 100MG
ICLUSIG TABS 45MG
ICLUSIG TABS 15MG
imatinib mesylate tabs 400mg
imatinib mesylate tabs 100mg
IMBRUVICA
INLYTA TABS 5MG
INLYTA TABS 1MG
IRESSA
JAKAFI
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
MEKINIST TABS 0.5MG
MEKINIST TABS 2MG
NEXAVAR
SPRYCEL TABS 100MG, 140MG
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG
STIVARGA
SUTENT CAPS 25MG, 37.5MG, 50MG
SUTENT CAPS 12.5MG
TAFINLAR CAPS 75MG
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Requirements/Limits
QL (60 EA per 30 days) PA LA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (240 EA per 30 days) PA
PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
PA LA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA LA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (30 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
QL (120 EA per 30 days) PA
QL (240 EA per 30 days) PA
QL (30 EA per 30 days) PA LA
QL (60 EA per 30 days) PA
PA LA
PA LA
PA
PA LA
PA LA
PA
QL (120 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
23
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Drug Name
TAFINLAR CAPS 50MG
TARCEVA TABS 25MG
TARCEVA TABS 100MG, 150MG
TASIGNA
TORISEL
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Monoclonal Antibodies
ARZERRA
OTHER
BLINCYTO
OTHER
CYRAMZA
OTHER
DARZALEX
OTHER
EMPLICITI
OTHER
GAZYVA
OTHER
KEYTRUDA
OTHER
OPDIVO
OTHER
RITUXAN
OTHER
TECENTRIQ
OTHER
Retinoids
Generic
bexarotene
PANRETIN
OTHER
TARGRETIN
OTHER
Generic
tretinoin caps 10mg
ANTIPARASITICS-DRUGS USED TO TREAT MALARIA AND LICE
Anthelmintics
ALBENZA
OTHER
Generic
ivermectin tabs
Antiprotozoals
ALINIA SUSR
OTHER
ALINIA TABS
OTHER
Generic
atovaquone
Generic
atovaquone/proguanil hcl
Generic
chloroquine phosphate tabs
COARTEM
OTHER
DARAPRIM
OTHER
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
24
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
QL (180 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (180 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (240 EA per 30 days) PA
QL (150 EA per 30 days) PA
PA
PA
PA LA
PA
PA
PA
PA
PA
PA
PA
PA
MO
PA
MO
MO
MO
PA MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Tier
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Drug Name
Requirements/Limits
hydroxychloroquine sulfate tabs
MO
mefloquine hcl
MEPRON SUSP
PA MO
NEBUPENT
B/D MO
PENTAM 300
MO
MO
primaquine phosphate tabs
PA MO
quinine sulfate caps 324mg
Pediculicides/Scabicides
Generic
lindane sham
Generic
MO
lindane lotn
Generic
MO
malathion
Generic
MO
permethrin crea
ANTIPARKINSON AGENTS- DRUGS USED TO TREAT PARKINSONS DISEASE
Anticholinergics
Generic
PA MO
benztropine mesylate inj
Generic
PA
benztropine mesylate tabs 2mg
Generic
PA MO
benztropine mesylate tabs 0.5mg, 1mg
Generic
PA
trihexyphenidyl hcl
Antiparkinson Agents, Other
Generic
amantadine hcl caps, syrp
Generic
MO
amantadine hcl tabs
Generic
entacapone
Dopamine Agonists
APOKYN
OTHER
PA
Generic
bromocriptine mesylate caps, tabs
NEUPRO
OTHER
QL (30 EA per 30 days) MO
Generic
pramipexole dihydrochloride
Generic
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
Generic
carbidopa/levodopa
Generic
carbidopa/levodopa er
Generic
MO
carbidopa/levodopa odt
Generic
carbidopa/levodopa/entacapone tabs 18.75mg;
200mg; 75mg, 25mg; 200mg; 100mg,
31.25mg; 200mg; 125mg, 37.5mg; 200mg;
150mg, 50mg; 200mg; 200mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
25
Drug
Tier
Generic
Drug Name
Requirements/Limits
MO
carbidopa/levodopa/entacapone tabs 12.5mg;
200mg; 50mg
Generic
carbidopa tabs
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
OTHER
QL (30 EA per 30 days) MO
Generic
selegiline hcl tabs
Generic
MO
selegiline hcl caps
ANTIPSYCHOTICS- DRUGS USED TO TREAT PSYCHOSES AND SCHIZOPHRENIA
1st Generation/Typical
Generic
chlorpromazine hcl inj
Generic
chlorpromazine hcl tabs 100mg, 200mg, 25mg,
50mg
Generic
MO
chlorpromazine hcl tabs 10mg
Generic
MO
compro
Generic
MO
fluphenazine decanoate inj
Generic
fluphenazine hcl elix
Generic
MO
fluphenazine hcl conc, inj
Generic
fluphenazine hcl tabs 10mg, 1mg, 5mg
Generic
MO
fluphenazine hcl tabs 2.5mg
Generic
haloperidol decanoate
Generic
haloperidol lactate
Generic
MO
haloperidol conc
Generic
haloperidol tabs 0.5mg, 1mg, 20mg, 5mg
Generic
MO
haloperidol tabs 10mg, 2mg
Generic
loxapine succinate caps 10mg, 50mg, 5mg
Generic
MO
loxapine succinate caps 25mg
Generic
perphenazine tabs 4mg
Generic
MO
perphenazine tabs 16mg, 2mg, 8mg
Generic
MO
pimozide
Generic
MO
prochlorperazine edisylate inj
Generic
prochlorperazine maleate tabs
Generic
prochlorperazine supp 25mg
Generic
PA
thioridazine hcl tabs 10mg, 25mg, 50mg
Generic
PA MO
thioridazine hcl tabs 100mg
Generic
thiothixene caps 1mg
Generic
MO
thiothixene caps 10mg, 2mg, 5mg
Generic
trifluoperazine hcl tabs 1mg
Generic
MO
trifluoperazine hcl tabs 10mg, 2mg, 5mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
26
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
2nd Generation/Atypical
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY INJ
ABILIFY ORAL SOLN
aripiprazole odt tbdp 15mg
aripiprazole odt tbdp 10mg
aripiprazole tabs
aripiprazole soln
ARISTADA
FANAPT TITRATION PACK
FANAPT TABS 10MG
FANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG,
8MG
GEODON INJ
INVEGA SUSTENNA
INVEGA TRINZA
LATUDA TABS 40MG, 80MG
LATUDA TABS 120MG, 20MG, 60MG
NUPLAZID
olanzapine odt
olanzapine inj
olanzapine tabs 10mg, 15mg, 20mg, 5mg,
7.5mg
olanzapine tabs 2.5mg
paliperidone er tb24 1.5mg, 3mg, 9mg
paliperidone er tb24 6mg
quetiapine fumarate er tb24 50mg
quetiapine fumarate er tb24 150mg, 200mg
quetiapine fumarate er tb24 300mg, 400mg
quetiapine fumarate tabs 200mg
quetiapine fumarate tabs 25mg
quetiapine fumarate tabs 300mg, 400mg
quetiapine fumarate tabs 100mg, 50mg
REXULTI
RISPERDAL CONSTA
risperidone odt tbdp 4mg
risperidone odt tbdp 1mg, 2mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Requirements/Limits
QL (60 EA per 30 days)
MO
MO
QL (900 ML per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (30 EA per 30 days)
QL (900 ML per 30 days)
QL (16 EA per 365 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (180 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (180 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days) PA MO
MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days)
LA - Limited Access
QL - Quantity Limit
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
27
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
Drug Name
Requirements/Limits
QL (90 EA per 30 days)
risperidone odt tbdp 0.5mg
QL (90 EA per 30 days) MO
risperidone odt tbdp 0.25mg, 3mg
risperidone soln
QL (120 EA per 30 days)
risperidone tabs 4mg
QL (60 EA per 30 days)
risperidone tabs 1mg, 2mg
QL (90 EA per 30 days)
risperidone tabs 0.25mg, 0.5mg, 3mg
SAPHRIS SUBL 10MG
QL (60 EA per 30 days) PA
SAPHRIS SUBL 2.5MG, 5MG
QL (60 EA per 30 days) PA MO
VRAYLAR CPPK
QL (14 EA per 365 days) PA MO
VRAYLAR CAPS
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days)
ziprasidone hcl caps 60mg, 80mg
QL (60 EA per 30 days) MO
ziprasidone hcl caps 20mg, 40mg
ZYPREXA RELPREVV INJ 405MG
QL (1 EA per 28 days)
ZYPREXA RELPREVV INJ 210MG, 300MG
QL (2 EA per 28 days)
Antipsychotics
Generic
QL (270 EA per 30 days) MO
molindone hydrochloride tabs 25mg
Generic
QL (60 EA per 30 days) MO
molindone hydrochloride tabs 10mg
Generic
QL (90 EA per 30 days) MO
molindone hydrochloride tabs 5mg
Treatment-Resistant
Generic
clozapine odt
Generic
clozapine tabs 100mg, 200mg, 25mg, 50mg
FAZACLO TBDP 12.5MG, 150MG, 200MG
OTHER
PA
VERSACLOZ
OTHER
PA
ANTISPASTICITY AGENTS - DRUGS USED TO TREAT MUSCLE SPASMS
Antispasticity Agents
Generic
baclofen tabs
Generic
MO
dantrolene sodium caps
Generic
tizanidine hcl tabs
ANTIVIRALS- DRUGS USED TO TREAT VIRAL INFECTIONS, HEPATITIS AND HIV/AIDS INFECTIONS
Anti-cytomegalovirus (CMV) Agents
Generic
B/D
ganciclovir inj
VALCYTE SOLR
OTHER
MO
Generic
valganciclovir
Anti-hepatitis B (HBV) Agents
Generic
QL (30 EA per 30 days) MO
adefovir dipivoxil
BARACLUDE SOLN
OTHER
QL (630 ML per 30 days) MO
Generic
QL (30 EA per 30 days)
entecavir
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
28
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
EPIVIR HBV SOLN
lamivudine tabs 100mg
TYZEKA
Anti-hepatitis C (HCV) Agents
EPCLUSA
HARVONI
moderiba tabs
PEG-INTRON REDIPEN
PEGINTRON
ribasphere caps
ribasphere tabs 200mg
ribavirin caps
ribavirin tabs 200mg
SOVALDI
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ATRIPLA
GENVOYA
ISENTRESS TABS
ISENTRESS CHEW
ISENTRESS PACK
TIVICAY TABS 10MG, 25MG
TIVICAY TABS 50MG
VITEKTA
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABS 25MG
INTELENCE TABS 100MG, 200MG
nevirapine er tb24 400mg
nevirapine er tb24 100mg
nevirapine tabs
nevirapine susp
ODEFSEY
RESCRIPTOR
STRIBILD
SUSTIVA TABS
SUSTIVA CAPS 200MG, 50MG
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Generic
OTHER
Requirements/Limits
MO
QL (30 EA per 30 days) MO
OTHER
OTHER
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
QL (28 EA per 28 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (300 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (30 EA per 30 days)
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (180 EA per 30 days)
QL (60 EA per 30 days) MO
LA - Limited Access
QL - Quantity Limit
QL (28 EA per 28 days) PA
QL (30 EA per 30 days) PA
PA
PA
MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
29
Drug Name
VIRAMUNE SUSP
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
DESCOVY
didanosine cpdr 200mg, 250mg, 400mg
didanosine cpdr 125mg
EMTRIVA
EPZICOM
lamivudine/zidovudine
lamivudine soln 10mg/ml
lamivudine tabs 150mg, 300mg
RETROVIR IV INFUSION
stavudine caps 15mg, 20mg
stavudine caps 30mg, 40mg
stavudine solr
TRIUMEQ
TRUVADA TABS 100MG; 150MG, 133MG;
200MG, 167MG; 250MG
TRUVADA TABS 200MG; 300MG
VIDEX PEDIATRIC SOLR 2GM
VIDEX PEDIATRIC SOLR 4GM
VIREAD
ZIAGEN SOLN
zidovudine
Anti-HIV Agents, Other
FUZEON
SELZENTRY TABS 300MG
SELZENTRY TABS 150MG
TYBOST
Anti-HIV Agents, Protease Inhibitors
APTIVUS SOLN
APTIVUS CAPS
CRIXIVAN CAPS 200MG, 400MG
EVOTAZ
INVIRASE
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
30
Drug
Tier
OTHER
Generic
Generic
Generic
OTHER
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
OTHER
OTHER
Requirements/Limits
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
QL (30 EA per 30 days) MO
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days)
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
OTHER
OTHER
OTHER
OTHER
OTHER
MO
MO
QL (30 EA per 30 days) MO
MO
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
KALETRA SOLN
KALETRA TABS 200MG; 50MG
KALETRA TABS 100MG; 25MG
LEXIVA
NORVIR
PREZCOBIX
PREZISTA SUSP
PREZISTA TABS 75MG
PREZISTA TABS 150MG, 600MG, 800MG
REYATAZ
VIRACEPT
Anti-influenza Agents
oseltamivir phosphate caps 30mg
oseltamivir phosphate caps 45mg, 75mg
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPS 30MG
TAMIFLU CAPS 45MG, 75MG
TAMIFLU SUSR 6MG/ML
Antiherpetic Agents
acyclovir sodium inj 50mg/ml
acyclovir caps, susp, tabs
acyclovir oint
DENAVIR
famciclovir tabs 125mg, 250mg
famciclovir tabs 500mg
valacyclovir hcl
Antivirals
VIRAZOLE
ZEPATIER
ANXIOLYTICS- DRUGS USED TO TREAT ANXIETY
Anxiolytics, Other
buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg
buspirone hcl tabs 30mg
Benzodiazepines
alprazolam tabs 0.25mg, 0.5mg
alprazolam tabs 1mg, 2mg
clorazepate dipotassium tabs 15mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/Limits
QL (390 ML per 30 days) MO
QL (120 EA per 30 days) MO
QL (240 EA per 30 days) MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
Generic
Generic
OTHER
Generic
OTHER
OTHER
OTHER
QL (168 EA per 365 days)
QL (84 EA per 365 days)
QL (120 EA per 365 days) MO
MO
QL (168 EA per 365 days) MO
QL (84 EA per 365 days) MO
QL (1080 ML per 365 days) MO
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
B/D
MO
MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
OTHER
OTHER
QL (30 EA per 30 days) PA
Generic
Generic
MO
Generic
Generic
Generic
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
31
Drug
Drug Name
Tier
Generic
clorazepate dipotassium tabs 3.75mg, 7.5mg
Generic
diazepam intensol
Generic
diazepam inj 5mg/ml
Generic
diazepam oral soln 1mg/ml
Generic
diazepam tabs 10mg, 2mg, 5mg
Generic
lorazepam intensol
Generic
lorazepam inj 2mg/ml, 4mg/ml
Generic
lorazepam tabs 0.5mg
Generic
lorazepam tabs 2mg
Generic
lorazepam tabs 1mg
BIPOLAR AGENTS- DRUGS USED TO TREAT BIPOLAR DISORDER
Mood Stabilizers
EQUETRO
OTHER
Generic
lithium
Generic
lithium carbonate er
Generic
lithium carbonate caps, tabs
BLOOD GLUCOSE REGULATORS- DRUGS USED TO TREAT DIABETES
Antidiabetic Agents
Generic
acarbose
Generic
alogliptin
Generic
alogliptin/metformin hcl
Generic
alogliptin/pioglitazone
Generic
glimepiride
Generic
glipizide er
Generic
glipizide xl tb24 10mg
Generic
glipizide xl tb24 2.5mg, 5mg
Generic
glipizide/metformin hcl tabs 2.5mg; 250mg
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; Generic
500mg
Generic
glipizide tabs
Generic
glyburide micronized tabs 3mg, 6mg
Generic
glyburide micronized tabs 1.5mg
Generic
glyburide/metformin hcl
Generic
glyburide tabs 2.5mg, 5mg
Generic
glyburide tabs 1.25mg
INVOKAMET
OTHER
INVOKAMET XR
OTHER
INVOKANA TABS 300MG
OTHER
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
32
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
QL (90 EA per 30 days) MO
MO
QL (240 ML per 30 days)
QL (1200 ML per 30 days) MO
QL (120 EA per 30 days)
QL (150 ML per 30 days)
QL (120 ML per 30 days)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
MO
MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
PA
PA MO
PA
PA
PA MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days)
QL (30 EA per 30 days)
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
INVOKANA TABS 100MG
JANUMET
JANUMET XR TB24 1000MG; 100MG, 500MG;
50MG
JANUMET XR TB24 1000MG; 50MG
JANUVIA TABS 100MG, 25MG
JANUVIA TABS 50MG
JENTADUETO
JENTADUETO XR
KORLYM
metformin hcl er (osmotic)
metformin hcl er tb24 500mg, 750mg
metformin hcl er tb24 1000mg
metformin hcl tabs
miglitol
nateglinide
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
repaglinide/metformin hydrochloride
repaglinide tabs 0.5mg, 1mg
repaglinide tabs 2mg
SYMLINPEN 120
SYMLINPEN 60
SYNJARDY TABS 12.5MG; 500MG, 5MG;
1000MG, 5MG; 500MG
SYNJARDY TABS 12.5MG; 1000MG
tolazamide tabs 250mg, 500mg
tolbutamide
TRADJENTA
TRULICITY
VICTOZA
Glycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insulins
HUMALOG
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Requirements/Limits
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (120 EA per 30 days) PA LA
MO
MO
QL (90 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (90 EA per 30 days)
QL (150 EA per 30 days) MO
QL (120 EA per 30 days)
QL (240 EA per 30 days)
QL (10.8 ML per 30 days) MO
QL (6 ML per 30 days) MO
QL (60 EA per 30 days)
OTHER
Generic
Generic
OTHER
OTHER
OTHER
QL (60 EA per 30 days) MO
MO
OTHER
OTHER
OTHER
QL (4 EA per 30 days) MO
QL (4 EA per 30 days) MO
MO
OTHER
MO
LA - Limited Access
QL - Quantity Limit
QL (2 ML per 28 days) MO
QL (9 ML per 30 days) MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
33
Drug
Drug Name
Tier
Requirements/Limits
HUMALOG KWIKPEN
OTHER
MO
HUMALOG MIX 50/50
OTHER
MO
HUMALOG MIX 50/50 KWIKPEN
OTHER
MO
HUMALOG MIX 75/25
OTHER
MO
HUMALOG MIX 75/25 KWIKPEN
OTHER
MO
HUMULIN 70/30
OTHER
MO
HUMULIN 70/30 KWIKPEN
OTHER
HUMULIN N
OTHER
MO
HUMULIN N KWIKPEN
OTHER
HUMULIN R
OTHER
MO
HUMULIN R U-500 (CONCENTRATED)
OTHER
MO
HUMULIN R U-500 KWIKPEN
OTHER
MO
LANTUS
OTHER
MO
LANTUS SOLOSTAR
OTHER
MO
LEVEMIR
OTHER
MO
LEVEMIR FLEXTOUCH
OTHER
MO
NOVOLIN 70/30
OTHER
MO
NOVOLIN 70/30 RELION
OTHER
NOVOLIN N
OTHER
MO
NOVOLIN N RELION
OTHER
NOVOLIN R
OTHER
MO
NOVOLIN R RELION
OTHER
NOVOLOG
OTHER
MO
NOVOLOG FLEXPEN
OTHER
MO
NOVOLOG MIX 70/30
OTHER
MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
OTHER
MO
NOVOLOG PENFILL
OTHER
MO
TRESIBA FLEXTOUCH
OTHER
MO
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS- DRUGS USED TO TREAT BLOOD DISORDERS;
ANTICOAGULANTS/BLOOD THINNERS
Anticoagulants
Generic
enoxaparin sodium
Generic
fondaparinux sodium
Generic
heparin sodium/d5w
Generic
heparin sodium/nacl 0.45%
Generic
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9%
Generic
heparin sodium/sodium chloride 0.9%
Generic
heparin sodium/sodium chloride 0.9% premix
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
34
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
heparin sodium inj 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/0.5ml, 5000unit/ml
jantoven tabs 10mg, 2.5mg, 5mg
jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg
PRADAXA
warfarin sodium tabs
XARELTO STARTER PACK
XARELTO TABS 10MG, 20MG
XARELTO TABS 15MG
Blood Formation Modifiers
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJ 500MCG/ML
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML,
60MCG/0.3ML
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML,
40MCG/0.4ML
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML
ARANESP ALBUMIN FREE INJ 150MC­
G/0.75ML
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML
ARANESP ALBUMIN FREE INJ 100MCG/ML,
200MCG/ML, 25MCG/ML, 300MCG/ML,
40MCG/ML, 60MCG/ML
LEUKINE INJ 250MCG
MOZOBIL
NEUMEGA
NEUPOGEN
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
PROCRIT INJ 40000UNIT/ML
PROMACTA
Coagulants
tranexamic acid inj
tranexamic acid tabs
Platelet Modifying Agents
aspirin/dipyridamole
BRILINTA
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Requirements/Limits
Generic
Generic
OTHER
Generic
OTHER
OTHER
OTHER
QL (102 EA per 365 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
Generic
OTHER
OTHER
MO
QL (1 ML per 21 days) PA
QL (1.2 ML per 28 days) PA
OTHER
QL (1.6 ML per 28 days) PA
OTHER
OTHER
OTHER
OTHER
QL (1.68 ML per 28 days) PA
QL (2 ML per 28 days) PA
QL (2.4 ML per 28 days) PA
QL (3 ML per 28 days) PA
OTHER
OTHER
QL (3.2 ML per 28 days) PA
QL (4 ML per 28 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
PA
PA
PA
PA
QL (12 ML per 28 days) PA
OTHER
OTHER
QL (8 ML per 28 days) PA
QL (30 EA per 30 days) PA
Generic
Generic
QL (30 EA per 5 days)
Generic
OTHER
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
LA - Limited Access
QL - Quantity Limit
MO
QL (60 EA per 30 days) MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
35
Drug
Drug Name
Tier
Requirements/Limits
Generic
cilostazol
Generic
QL (2 EA per 365 days)
clopidogrel tabs 300mg
Generic
QL (30 EA per 30 days)
clopidogrel tabs 75mg
EFFIENT
OTHER
QL (30 EA per 30 days)
CARDIOVASCULAR AGENTS - DRUGS USED TO TREAT HEART AND CIRCULATION CONDITIONS, HIGH
BLOOD PRESSURE, HEART RHYTHM, HIGH CHOLESTEROL
Alpha-adrenergic Agonists
Generic
clonidine hcl tabs
Generic
QL (8 EA per 28 days)
clonidine hcl ptwk
Generic
midodrine hcl
Alpha-adrenergic Blocking Agents
Generic
MO
doxazosin
Generic
doxazosin mesylate tabs 8mg
Generic
MO
doxazosin mesylate tabs 1mg, 2mg
Generic
prazosin hcl caps
Generic
terazosin hcl caps
Angiotensin II Receptor Antagonists
Generic
QL (30 EA per 30 days)
amlodipine/olmesartan medoxomil
Generic
QL (30 EA per 30 days)
candesartan cilexetil/hydrochlorothiazide tabs
32mg; 12.5mg, 32mg; 25mg
Generic
QL (60 EA per 30 days)
candesartan cilexetil/hydrochlorothiazide tabs
16mg; 12.5mg
Generic
QL (30 EA per 30 days)
candesartan cilexetil tabs 16mg, 32mg
Generic
QL (30 EA per 30 days) MO
candesartan cilexetil tabs 4mg, 8mg
EDARBI
OTHER
QL (30 EA per 30 days) MO
EDARBYCLOR
OTHER
QL (30 EA per 30 days) MO
ENTRESTO
OTHER
QL (60 EA per 30 days) PA MO
Generic
QL (30 EA per 30 days) MO
eprosartan mesylate
Generic
QL (30 EA per 30 days)
irbesartan
Generic
QL (30 EA per 30 days)
irbesartan/hydrochlorothiazide
Generic
QL (30 EA per 30 days)
losartan potassium/hydrochlorothiazide
Generic
QL (30 EA per 30 days)
losartan potassium tabs 100mg
Generic
QL (60 EA per 30 days)
losartan potassium tabs 25mg, 50mg
Generic
QL (30 EA per 30 days)
olmesartan medoxomil
Generic
QL (30 EA per 30 days)
olmesartan medoxomil/amlodipine/hydrochlorothiazide
Generic
QL (30 EA per 30 days)
olmesartan medoxomil/hydrochlorothiazide
Generic
QL (30 EA per 30 days)
telmisartan
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
36
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
benazepril hcl tabs
captopril/hydrochlorothiazide
captopril tabs 12.5mg, 25mg, 50mg
captopril tabs 100mg
enalapril maleate/hydrochlorothiazide
enalapril maleate tabs
fosinopril sodium/hydrochlorothiazide
fosinopril sodium tabs 20mg, 40mg
fosinopril sodium tabs 10mg
lisinopril
lisinopril/hydrochlorothiazide
moexipril hcl tabs 15mg
moexipril hcl tabs 7.5mg
moexipril/hydrochlorothiazide
perindopril erbumine
quinapril hcl tabs 10mg, 40mg
quinapril hcl tabs 20mg, 5mg
quinapril/hydrochlorothiazide
ramipril caps 10mg, 2.5mg, 5mg
ramipril caps 1.25mg
trandolapril
trandolapril/verapamil hcl
trandolapril/verapamil hcl er tbcr 1mg; 240mg,
2mg; 180mg, 2mg; 240mg, 4mg; 240mg
trandolapril/verapamil hcl er tbcr 4mg; 240mg
Antiarrhythmics
amiodarone hcl tabs 200mg
amiodarone hcl tabs 100mg, 400mg
disopyramide phosphate caps 150mg
disopyramide phosphate caps 100mg
dofetilide
flecainide acetate tabs 50mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
PA MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
37
Drug Name
flecainide acetate tabs 100mg, 150mg
lidocaine hcl inj 10mg/ml, 20mg/ml
mexiletine hcl
MULTAQ
pacerone tabs 100mg
pacerone tabs 200mg, 400mg
propafenone hcl
propafenone hcl er
quinidine gluconate cr
quinidine gluconate er
quinidine sulfate tabs 300mg
quinidine sulfate tabs 200mg
sorine
sotalol hcl (af) tabs 160mg, 80mg
sotalol hcl (af) tabs 120mg
sotalol hcl tabs 120mg, 160mg, 80mg
sotalol hcl tabs 240mg
TIKOSYN
Beta-adrenergic Blocking Agents
acebutolol hcl caps
atenolol/chlorthalidone tabs 50mg; 25mg
atenolol/chlorthalidone tabs 100mg; 25mg
atenolol tabs
betaxolol hcl tabs 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide tabs
2.5mg; 6.25mg, 5mg; 6.25mg
bisoprolol fumarate/hydrochlorothiazide tabs
10mg; 6.25mg
carvedilol
labetalol hcl inj, tabs
metoprolol succinate er tb24 100mg, 25mg,
50mg
metoprolol succinate er tb24 200mg
metoprolol tartrate inj
metoprolol tartrate tabs 100mg, 25mg, 50mg
metoprolol tartrate tabs 37.5mg, 75mg
metoprolol/hydrochlorothiazide
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
38
Drug
Tier
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
nadolol/bendroflumethiazide
nadolol tabs 40mg, 80mg
nadolol tabs 20mg
pindolol tabs
propranolol hcl er
propranolol hcl inj
propranolol hcl oral soln
propranolol hcl tabs 80mg
propranolol hcl tabs 10mg, 20mg, 40mg, 60mg
propranolol/hydrochlorothiazide
timolol maleate tabs 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
amlodipine besylate/atorvastatin calcium tabs
10mg; 20mg, 10mg; 40mg
amlodipine besylate/atorvastatin calcium tabs
10mg; 10mg, 10mg; 80mg, 2.5mg; 10mg,
2.5mg; 20mg, 2.5mg; 40mg, 5mg; 10mg, 5mg;
20mg, 5mg; 40mg, 5mg; 80mg
amlodipine besylate/benazepril hydrochloride
amlodipine besylate/valsartan
amlodipine besylate tabs
amlodipine/valsartan/hctz
cartia xt
dilt-xr
diltiazem cd
diltiazem hcl cd
diltiazem hcl er cp24 120mg, 180mg, 240mg,
300mg, 360mg, 420mg
diltiazem hcl er cp24 180mg, 360mg
diltiazem hcl er tb24
diltiazem hcl er cp12
diltiazem hcl inj 100mg, 125mg/25ml,
25mg/5ml, 50mg/10ml
diltiazem hcl tabs 30mg, 60mg
diltiazem hcl tabs 120mg, 90mg
felodipine er tb24 10mg
felodipine er tb24 2.5mg, 5mg
isradipine
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
Generic
Generic
Generic
Generic
MO
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
QL (30 EA per 30 days)
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
39
Drug Name
matzim la
nicardipine hcl caps 30mg
nicardipine hcl caps 20mg
nifedipine er tb24 30mg, 60mg, 90mg
nifedipine er tb24 90mg
nisoldipine
nisoldipine er
taztia xt
verapamil hcl er cp24 200mg
verapamil hcl er cp24 100mg, 120mg, 180mg,
240mg, 300mg
verapamil hcl er tbcr 120mg
verapamil hcl er tbcr 180mg, 240mg
verapamil hcl sr cp24 120mg, 180mg, 240mg
verapamil hcl sr cp24 360mg
verapamil hcl sr tbcr 240mg
verapamil hcl inj, tabs
Cardiovascular Agents, Other
CORLANOR
digitek
digoxin oral soln
digoxin inj 0.25mg/ml
digoxin tabs 125mcg
digoxin tabs 250mcg
digox tabs 125mcg
digox tabs 250mcg
NORTHERA
pentoxifylline cr
pentoxifylline er
PRALUENT
RANEXA
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide er
acetazolamide tabs 250mg
acetazolamide tabs 125mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
40
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
QL (2 ML per 28 days) PA
QL (60 EA per 30 days) MO
QL (3 ML per 28 days) PA
QL (3.5 ML per 28 days) PA
QL (3 ML per 28 days) PA
Generic
Generic
Generic
MO
LA - Limited Access
QL - Quantity Limit
PA MO
PA MO
PA MO
PA
PA
PA
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
methazolamide
Diuretics, Loop
bumetanide tabs
bumetanide inj
furosemide tabs
furosemide oral soln
furosemide inj 10mg/ml
torsemide tabs 10mg, 20mg, 5mg
torsemide tabs 100mg
Diuretics, Potassium-sparing
amiloride hcl tabs
amiloride/hydrochlorothiazide
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tabs
triamterene/hydrochlorothiazide caps 25mg;
37.5mg
triamterene/hydrochlorothiazide caps 25mg;
50mg
triamterene/hydrochlorothiazide tabs
Diuretics, Thiazide
chlorothiazide
chlorthalidone tabs 25mg
chlorthalidone tabs 50mg
hydrochlorothiazide caps
hydrochlorothiazide tabs 25mg, 50mg
hydrochlorothiazide tabs 12.5mg
indapamide tabs
methyclothiazide tabs
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized
fenofibrate caps 130mg, 43mg
fenofibrate caps 150mg, 50mg
fenofibrate tabs 145mg, 160mg, 48mg, 54mg
fenofibrate tabs 120mg, 40mg
fenofibric acid
fenofibric acid dr
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
41
Drug Name
gemfibrozil tabs
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
fluvastatin sodium er
fluvastatin caps 40mg
fluvastatin caps 20mg
lovastatin
pravastatin sodium tabs 10mg, 80mg
pravastatin sodium tabs 20mg, 40mg
rosuvastatin calcium tabs 10mg, 20mg, 5mg
rosuvastatin calcium tabs 40mg
simvastatin tabs 10mg, 20mg, 40mg, 5mg
simvastatin tabs 80mg
Dyslipidemics, Other
cholestyramine light
cholestyramine pack
cholestyramine powd
colestipol hcl tabs
colestipol hcl gran, pack
KYNAMRO
LOVAZA
niacin er
omega-3-acid ethyl esters
prevalite
VASCEPA CAPS 0.5GM
VASCEPA CAPS 1GM
ZETIA
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate er
isosorbide dinitrate tabs 10mg, 20mg, 30mg,
5mg
isosorbide mononitrate er
isosorbide mononitrate tabs 20mg
isosorbide mononitrate tabs 10mg
minitran
nitroglycerin lingual
nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/
hr, 0.6mg/hr
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
42
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
QL (30 EA per 30 days) MO
MO
MO
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
MO
MO
PA
QL (120 EA per 30 days) ST MO
QL (120 EA per 30 days)
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Tier
Generic
Generic
Generic
OTHER
Drug Name
Requirements/Limits
MO
nitroglycerin transdermal pt24 0.2mg/hr
nitroglycerin inj 5mg/ml
nitroglycerin subl 0.3mg, 0.4mg, 0.6mg
NITROSTAT SUBL
MO
Vasodilators, Direct-acting Arterial
Generic
hydralazine hcl inj, tabs
Generic
minoxidil tabs
CENTRAL NERVOUS SYSTEM AGENTS- DRUGS USED TO TREAT ADHD, MULTIPLE SCLEROSIS,
CHOREA ASSOCIATED WITH HUNTINGTON DISEASE
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
Generic
QL (60 EA per 30 days) PA
amphetamine/dextroamphetamine tabs 1.25mg;
1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg;
2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg;
3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
Generic
QL (60 EA per 30 days) PA MO
amphetamine/dextroamphetamine tabs
1.875mg; 1.875mg; 1.875mg; 1.875mg,
3.125mg; 3.125mg; 3.125mg; 3.125mg
Generic
QL (90 EA per 30 days) PA
amphetamine/dextroamphetamine tabs 5mg;
5mg; 5mg; 5mg
Generic
QL (180 EA per 30 days) PA MO
dextroamphetamine sulfate tabs
Generic
QL (1800 ML per 30 days) PA
dextroamphetamine sulfate soln
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
Generic
QL (60 EA per 30 days) PA MO
dexmethylphenidate hcl
Generic
QL (30 EA per 30 days)
guanfacine er
Generic
QL (90 EA per 30 days) PA
metadate er tbcr 20mg
Generic
QL (60 EA per 30 days) PA MO
methylphenidate hcl er cp24 30mg
Generic
QL (90 EA per 30 days) PA
methylphenidate hcl er tbcr 10mg, 20mg
Generic
QL (90 EA per 30 days) PA
methylphenidate hcl sr
Generic
PA
methylphenidate hcl tabs
STRATTERA CAPS 100MG, 80MG
OTHER
QL (30 EA per 30 days) PA MO
STRATTERA CAPS 10MG, 18MG, 25MG,
OTHER
QL (60 EA per 30 days) PA MO
40MG, 60MG
Central Nervous System, Other
NUEDEXTA
OTHER
QL (60 EA per 30 days) MO
Generic
riluzole
Generic
QL (120 EA per 30 days) PA
tetrabenazine tabs 25mg
Generic
QL (90 EA per 30 days) PA
tetrabenazine tabs 12.5mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
43
Drug
Tier
Drug Name
Requirements/Limits
Multiple Sclerosis Agents
AMPYRA
OTHER
QL (60 EA per 30 days) PA
COPAXONE INJ 40MG/ML
OTHER
QL (12 ML per 28 days) PA
COPAXONE INJ 20MG/ML
OTHER
QL (30 ML per 30 days) PA
GILENYA
OTHER
QL (30 EA per 30 days) PA
Generic
QL (30 ML per 30 days) PA
glatopa
REBIF
OTHER
QL (6 ML per 28 days) PA
REBIF REBIDOSE
OTHER
QL (6 ML per 28 days) PA
REBIF REBIDOSE TITRATION PACK
OTHER
QL (4.2 ML per 365 days) PA
REBIF TITRATION PACK
OTHER
QL (8.4 ML per 365 days) PA
TYSABRI
OTHER
QL (15 ML per 28 days) PA
DENTAL AND ORAL AGENTS
Dental and Oral Agents
Generic
chlorhexidine gluconate oral rinse
Generic
MO
clinpro 5000
Generic
MO
dentagel
Generic
fluoridex daily defense
Generic
oralone
Generic
paroex
Generic
MO
periogard
Generic
phos-flur
Generic
pilocarpine hcl tabs 7.5mg
Generic
pilocarpine hydrochloride
Generic
MO
sf
Generic
triamcinolone acetonide pste 0.1%
Generic
MO
triamcinolone in orabase
DERMATOLOGICAL AGENTS- ANTIPSORIATICS, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE,
ACNE, WOUND CARE AGENTS, ANTIBIOTICS
Dermatological Agents
8-MOP
OTHER
Generic
PA
acitretin caps 10mg, 25mg
Generic
PA MO
acitretin caps 17.5mg
ALTABAX
OTHER
Generic
ammonium lactate crea, lotn
Generic
amnesteem
Generic
PA MO
avita
Generic
calcipotriene
Generic
MO
calcitrene
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
44
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
claravis
clindacin etz pledgets
clindacin-p
clindamax gel
clindamycin phosphate/tretinoin
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotn 1%
clindamycin phosphate external soln 1%
clindamycin phosphate swab 1%
clindamycin/benzoyl peroxide gel 5%; 1.2%
clindamycin/benzoyl peroxide gel 5%; 1%
diclofenac sodium gel 1%
doxepin hydrochloride
ELIDEL
ery
erythromycin/benzoyl peroxide
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
fluocinolone acetonide body
fluocinolone acetonide scalp
fluorouracil crea 5%
fluorouracil crea 0.5%
fluorouracil external soln 2%, 5%
gentamicin sulfate crea 0.1%
gentamicin sulfate external oint 0.1%
imiquimod crea
methoxsalen caps
metronidazole crea 0.75%
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotn 0.75%
mupirocin calcium
mupirocin oint
mupirocin crea
myorisan
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
PA
MO
MO
MO
QL (1020 GM per 30 days) MO
MO
QL (60 GM per 30 days) ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
45
Drug
Drug Name
Tier
Requirements/Limits
Generic
MO
neuac
Generic
MO
podofilox soln
REGRANEX
OTHER
QL (15 GM per 30 days) PA MO
Generic
rosadan crea
Generic
MO
rosadan gel
SANTYL
OTHER
Generic
MO
selenium sulfide lotn
Generic
silver sulfadiazine
Generic
sodium sulfacetamide lotn 10%
Generic
ssd
Generic
sulfacetamide sodium susp 10%
SULFAMYLON
OTHER
MO
TAZORAC
OTHER
MO
Generic
PA MO
tretinoin crea 0.025%, 0.05%, 0.1%
Generic
PA
tretinoin gel 0.01%
Generic
PA MO
tretinoin gel 0.025%, 0.05%
Generic
zenatane
ZONALON
OTHER
MO
ENZYME REPLACEMENT/MODIFIERS- DRUGS USED TO TREAT ENZYME DEFICIENCIES, PANCREATIC
ENZYMES
Enzyme Replacement/Modifiers
ADAGEN
OTHER
PA LA
ALDURAZYME
OTHER
PA
BUPHENYL TABS
OTHER
PA
CARBAGLU
OTHER
LA
CEREZYME
OTHER
PA
OTHER
CREON CPEP 120000UNIT; 24000UNIT;
76000UNIT, 30000UNIT; 6000UNIT;
19000UNIT, 60000UNIT; 12000UNIT;
38000UNIT
OTHER
MO
CREON CPEP 15000UNIT; 3000UNIT;
9500UNIT, 180000UNIT; 36000UNIT;
114000UNIT
CYSTADANE
OTHER
LA
CYSTAGON
OTHER
PA
FABRAZYME
OTHER
PA
KUVAN
OTHER
PA
LUMIZYME
OTHER
NAGLAZYME
OTHER
PA
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
46
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Drug Name
Tier
Requirements/Limits
ORFADIN CAPS 20MG
OTHER
PA
ORFADIN CAPS 10MG, 2MG, 5MG
OTHER
PA LA
Generic
pancrelipase
RAVICTI
OTHER
PA
Generic
PA
sodium phenylbutyrate powd
VPRIV
OTHER
PA
ZAVESCA
OTHER
PA LA
ZENPEP
OTHER
MO
GASTROINTESTINAL- DRUGS USED TO TREAT STOMACH AND INTESTINAL DISORDERS, ANTI­
DIARRHEAL, LAXATIVES, ULCERS AND STOMACH ACID
Antispasmodics, Gastrointestinal
Generic
PA MO
dicyclomine hcl caps, soln, tabs
Generic
MO
glycopyrrolate tabs
Generic
glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml,
1mg/5ml
Generic
MO
glycopyrrolate inj 4mg/20ml
Generic
methscopolamine bromide
Gastrointestinal Agents, Other
Generic
cromolyn sodium conc 100mg/5ml
Generic
diphenatol
Generic
diphenoxylate/atropine tabs
Generic
MO
diphenoxylate/atropine liqd
GATTEX
OTHER
PA
Generic
MO
gavilyte-h
Generic
loperamide hcl caps
Generic
metoclopramide hcl oral soln, tabs
Generic
MO
metoclopramide hcl inj
MOVANTIK
OTHER
QL (30 EA per 30 days) PA MO
RELISTOR INJ
OTHER
PA MO
RELISTOR TABS
OTHER
QL (90 EA per 30 days) PA
Generic
MO
ursodiol caps, tabs
Histamine2 (H2) receptor Antagonists
Generic
MO
cimetidine hcl soln
Generic
cimetidine tabs 400mg
Generic
MO
cimetidine tabs 200mg, 300mg, 800mg
Generic
famotidine premixed
Generic
famotidine inj 200mg/20ml, 20mg/2ml,
40mg/4ml
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
47
Drug Name
famotidine susr 40mg/5ml
famotidine tabs 20mg, 40mg
ranitidine hcl caps 150mg, 300mg
ranitidine hcl inj 150mg/6ml
ranitidine hcl inj 50mg/2ml
ranitidine hcl syrp 15mg/ml
ranitidine hcl tabs 150mg, 300mg
Irritable Bowel Syndrome Agents
alosetron hydrochloride
AMITIZA
LINZESS
Laxatives
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
lactulose soln 10gm/15ml
MOVIPREP
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/kcl
polyethylene glycol 3350 pack, powd
PREPOPIK
SUPREP BOWEL PREP
trilyte
Protectants
CARAFATE SUSP
misoprostol
sucralfate susp, tabs
Proton Pump Inhibitors
esomeprazole magnesium
esomeprazole sodium
omeprazole cpdr 20mg
omeprazole cpdr 10mg
omeprazole cpdr 40mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
48
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Requirements/Limits
MO
MO
MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
OTHER
Generic
Generic
MO
Generic
Generic
Generic
Generic
Generic
QL (30 EA per 30 days)
LA - Limited Access
QL - Quantity Limit
QL (30 EA per 30 days)
QL (60 EA per 30 days)
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Tier
Generic
Generic
Generic
Drug Name
Requirements/Limits
pantoprazole sodium inj
QL (30 EA per 30 days)
pantoprazole sodium tbec 20mg
QL (60 EA per 30 days)
pantoprazole sodium tbec 40mg
GENITOURINARY- VAGINAL ANTI-INFECTIVES
Antispasmodics, Urinary
Generic
QL (30 EA per 30 days)
darifenacin hydrobromide er
MYRBETRIQ
OTHER
QL (30 EA per 30 days)
Generic
QL (30 EA per 30 days)
oxybutynin chloride er tb24 5mg
Generic
QL (60 EA per 30 days)
oxybutynin chloride er tb24 10mg
Generic
QL (60 EA per 30 days) MO
oxybutynin chloride er tb24 15mg
Generic
QL (120 EA per 30 days)
oxybutynin chloride tabs
Generic
QL (600 ML per 30 days)
oxybutynin chloride syrp
Generic
QL (60 EA per 30 days)
tolterodine tartrate
VESICARE
OTHER
QL (30 EA per 30 days) MO
Benign Prostatic Hypertrophy Agents
Generic
alfuzosin hcl er
Generic
QL (30 EA per 30 days)
dutasteride
Generic
QL (30 EA per 30 days) MO
dutasteride/tamsulosin hydrochloride
Generic
finasteride tabs 5mg
Generic
tamsulosin hcl
Genitourinary Agents, Other
Generic
bethanechol chloride
Generic
MO
methylergonovine maleate
RENACIDIN SOLN 6.602GM/100ML;
OTHER
MO
0.198GM/100ML; 3.177GM/100ML
Generic
sodium chloride 0.9%
THIOLA
OTHER
Phosphate Binders
Generic
calcium acetate caps
Generic
MO
calcium acetate tabs 667mg
FOSRENOL CHEW 1000MG, 500MG, 750MG
OTHER
ST MO
FOSRENOL PACK 750MG
OTHER
ST
FOSRENOL PACK 1000MG
OTHER
ST MO
RENVELA
OTHER
MO
VELPHORO
OTHER
MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)- CORTICOSTEROID
DRUGS THAT CAN BE USED FOR A VARIETY OF CONDITIONS SUCH AS INFLAMMATION
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
49
Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort inj 100mg
ala-cort crea 1%
alclometasone dipropionate crea, oint
amcinonide
augmented betamethasone dipropionate crea,
lotn
augmented betamethasone dipropionate gel, oint
baycadron
betamethasone dipropionate lotn
betamethasone dipropionate crea, oint
betamethasone valerate lotn
betamethasone valerate crea, foam, oint
budesonide cpep 3mg
clobetasol propionate e
clobetasol propionate emollient foam
clobetasol propionate foam 0.05%
clobetasol propionate crea, gel, lotn, oint, sham
clobetasol propionate liqd, soln
clodan
colocort
cormax scalp application
cortisone acetate tabs 25mg
deltasone tabs 20mg
desonide crea, lotn
desonide oint
desoximetasone crea 0.25%
desoximetasone crea 0.05%
desoximetasone oint
desoximetasone gel
DEXAMETHASONE INTENSOL
dexamethasone sodium phosphate inj
100mg/10ml, 10mg/ml, 20mg/5ml, 4mg/ml
dexamethasone sodium phosphate inj 10mg/ml,
120mg/30ml
dexamethasone elix
dexamethasone soln
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
50
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
MO
Generic
Generic
MO
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
dexamethasone tabs 0.5mg, 0.75mg, 1.5mg,
1mg, 2mg, 4mg, 6mg
diflorasone diacetate
fludrocortisone acetate tabs
fluocinolone acetonide crea 0.01%, 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide-e
fluocinonide crea 0.1%
fluocinonide crea 0.05%
fluocinonide oint, soln
fluocinonide gel
fluticasone propionate crea 0.05%
fluticasone propionate lotn 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate crea
halobetasol propionate oint
hydrocortisone butyrate (lipophilic)
hydrocortisone butyrate crea, oint, soln
hydrocortisone in absorbase
hydrocortisone valerate crea
hydrocortisone valerate oint
hydrocortisone crea 1%, 2.5%
hydrocortisone enem, tabs
hydrocortisone lotn 2.5%
hydrocortisone oint 2.5%
hydrocortisone oint 1%
lokara
methylprednisolone acetate inj 40mg/ml, 80mg/
ml
methylprednisolone dose pack tbpk
methylprednisolone sodiumsuccinate inj 1000mg,
125mg, 40mg
methylprednisolone tabs
MILLIPRED
MILLIPRED DP
mometasone furoate oint, soln
mometasone furoate crea
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
51
Drug
Tier
Generic
Generic
Generic
Drug Name
Requirements/Limits
prednicarbate crea
MO
prednicarbate oint
MO
prednisolone sodium phosphate oral soln
15mg/5ml, 25mg/5ml, 5mg/5ml
Generic
prednisolone soln
Generic
prednisolone syrp 15mg/5ml
PREDNISONE INTENSOL
OTHER
MO
Generic
MO
prednisone soln
Generic
prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg
Generic
MO
prednisone tabs 50mg
Generic
prednisone tbpk 10mg, 5mg
Generic
procto-med hc
Generic
MO
procto-pak
Generic
MO
proctosol hc
Generic
MO
proctozone-hc
Generic
MO
triamcinolone acetonide aers 0.147mg/gm
Generic
triamcinolone acetonide crea 0.1%
Generic
MO
triamcinolone acetonide crea 0.025%, 0.5%
Generic
MO
triamcinolone acetonide lotn 0.025%, 0.1%
Generic
triamcinolone acetonide oint 0.025%
Generic
MO
triamcinolone acetonide oint 0.1%, 0.5%
Generic
MO
triderm
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)- DRUGS USED TO
REGULATE PITUITARY HORMONES, GROWTH HORMONES
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Generic
desmopressin acetate inj, tabs
Generic
desmopressin acetate nasal soln 0.01%
EGRIFTA INJ 2MG
OTHER
QL (30 EA per 30 days) PA
EGRIFTA INJ 1MG
OTHER
QL (60 EA per 30 days) PA
H.P. ACTHAR
OTHER
PA
INCRELEX
OTHER
PA
NORDITROPIN FLEXPRO
OTHER
PA
OMNITROPE
OTHER
PA
VASOSTRICT
OTHER
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)BIRTH CONTROL, ENDOMETRIOSIS, ESTROGENS, MALE HORMONES
Anabolic Steroids
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
52
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
ANADROL-50
oxandrolone tabs 2.5mg
oxandrolone tabs 10mg
Androgens
ANDROGEL PUMP GEL 1.62%
ANDROGEL PUMP GEL 1%
ANDROGEL GEL 20.25MG/1.25GM,
40.5MG/2.5GM
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM
danazol caps
testosterone cypionate inj
testosterone enanthate inj
testosterone gel 1%, 25mg/2.5gm
Estrogens – Hormonal Replacement
ESTRACE CREA
estradiol ptwk
estradiol pttw
estradiol tabs 2mg
estradiol tabs 0.5mg, 1mg
MENEST
VAGIFEM TABS 10MCG
Estrogens – Birth Control
altavera
alyacen 1/35
alyacen 7/7/7 tabs
amethia
amethia lo
amethyst
apri
aranelle
ashlyna
aubra
aviane
azurette
balziva
bekyree
blisovi 24 fe
blisovi fe 1.5/30
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Generic
Generic
Requirements/Limits
MO
QL (120 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
OTHER
OTHER
OTHER
PA MO
QL (300 GM per 30 days) PA
PA MO
OTHER
Generic
Generic
Generic
Generic
QL (300 GM per 30 days) PA MO
MO
MO
QL (300 GM per 30 days) PA MO
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
MO
QL (4 EA per 28 days) PA
QL (8 EA per 28 days) PA
PA
PA MO
PA MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
53
Drug Name
blisovi fe 1/20
briellyn
camrese
camrese lo
caziant
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
cyred
dasetta 1/35
dasetta 7/7/7
daysee
delyla
DEPO-ESTRADIOL INJ 5MG/ML
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol/levomefolate
calcium
drospirenone/ethinyl estradiol tabs 3mg; 0.02mg
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg
elinest
emoquette
enpresse-28
enskyce
estarylla
estradiol/norethindrone acetate
falmina
femynor
fyavolv
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess 24 fe
gildess fe 1.5/30
gildess fe 1/20
introvale
jinteli
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
54
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
MO
MO
MO
MO
PA
PA
PA MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
jolessa
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kaitlib fe
kariva
kelnor 1/35
kimidess
kurvelo
larin 1.5/30
larin 1/20
larin 24 fe
larin fe 1.5/30
larin fe 1/20
larissia
layolis fe
leena
lessina
levonest
levonorgestrel and ethinyl estradiol tabs 0; 0
levonorgestrel and ethinyl estradiol tabs 20mcg;
90mcg
levonorgestrel/ethinyl estradiol tabs 0.03mg;
0.15mg, 0; 0, 20mcg; 0.1mg
levonorgestrel/ethinyl estradiol tabs 0.03mg;
0.15mg
levora 0.15/30-28
lomedia 24 fe
lopreeza
loryna
low-ogestrel
lutera
marlissa
microgestin 1.5/30
microgestin 1/20
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
PA
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
55
Drug Name
microgestin 24 fe
microgestin fe
microgestin fe 1.5/30
mimvey
mimvey lo
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
NECON 1/50-28
NECON 10/11-28
necon 7/7/7
nikki
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol/ferrous
fumarate
norethindrone acetate/ethinyl estradiol tabs
2.5mcg; 0.5mg, 20mcg; 1mg
norethindrone acetate/ethinyl estradiol tabs
5mcg; 1mg
norgestimate/ethinyl estradiol
NORINYL 1+50
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
OGESTREL
orsythia
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
portia-28
previfem
quasense
rajani
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
56
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Requirements/Limits
PA
PA
MO
MO
MO
MO
Generic
Generic
PA
Generic
PA
Generic
OTHER
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
reclipsen
setlakin
sprintec 28
sronyx
syeda
tarina fe 1/20
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-sprintec
tri-previfem
tri-sprintec
trinessa
trinessa lo
trivora-28
velivet
vestura
vienva
viorele
vyfemla
wera
wymzya fe
yuvafem
zarah
zenchent
zenchent fe
zovia 1/35e
zovia 1/50e
Progesterone Agonists/Antagonists
ELLA
Progestins
camila
deblitane
DEPO-PROVERA INJ 400MG/ML
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
OTHER
Generic
Generic
OTHER
LA - Limited Access
QL - Quantity Limit
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
57
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Drug Name
Requirements/Limits
MO
errin
MO
heather
PA
hydroxyprogesterone caproate inj
jencycla
jolivette
levonorgestrel
lyza
medroxyprogesterone acetate inj
medroxyprogesterone acetate tabs 5mg
MO
medroxyprogesterone acetate tabs 10mg, 2.5mg
PA
megestrol acetate tabs
PA
megestrol acetate susp 40mg/ml
nora-be
norethindrone acetate tabs
norethindrone tabs
norlyroc
progesterone inj
MO
progesterone caps
sharobel
Selective Estrogen Receptor Modifying Agents
Generic
raloxifene hydrochloride
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) - DRUGS USED TO
REGULATE THYROID LEVELS
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Generic
MO
levothyroxine sodium inj
Generic
levothyroxine sodium tabs 100mcg, 112mcg,
125mcg, 150mcg, 25mcg, 50mcg, 75mcg,
88mcg
Generic
MO
levothyroxine sodium tabs 137mcg, 175mcg,
200mcg, 300mcg
Generic
levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg,
75mcg, 88mcg
Generic
MO
levoxyl tabs 125mcg, 137mcg, 175mcg,
200mcg, 25mcg
Generic
liothyronine sodium tabs
SYNTHROID TABS 112MCG
OTHER
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
58
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Tier
OTHER
Drug Name
Requirements/Limits
MO
SYNTHROID TABS 100MCG, 125MCG,
137MCG, 150MCG, 175MCG, 200MCG,
25MCG, 300MCG, 50MCG, 75MCG, 88MCG
THYROLAR-1
OTHER
MO
THYROLAR-1/2
OTHER
MO
THYROLAR-1/4
OTHER
MO
THYROLAR-2
OTHER
MO
THYROLAR-3
OTHER
Generic
unithroid tabs 200mcg
Generic
MO
unithroid tabs 100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg, 25mcg, 300mcg,
50mcg, 75mcg, 88mcg
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) - DRUG(S) USED TO TREAT ADRENAL CORTICAL
CANCER
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
OTHER
MO
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) - DRUGS USED TO TREAT HIGH CALCIUM
LEVELS IN PEOPLE WITH CHRONIC KIDNEY DISEASE
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 90MG
OTHER
QL (120 EA per 30 days)
SENSIPAR TABS 30MG, 60MG
OTHER
QL (60 EA per 30 days)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)- DRUGS USED TO TREAT PROSTATE CANCER AND
OTHER CONDITIONS ASSOCIATED WITH AN OVERACTIVE PITUITARY GLAND
Hormonal Agents, Suppressant (Pituitary)
Generic
cabergoline
FIRMAGON
OTHER
PA
Generic
PA
leuprolide acetate inj
LUPRON DEPOT
OTHER
PA
LUPRON DEPOT-PED
OTHER
PA
Generic
PA
octreotide acetate
SIGNIFOR
OTHER
QL (60 ML per 30 days) PA LA
SOMATULINE DEPOT INJ 60MG/0.2ML
OTHER
QL (0.2 ML per 28 days) PA
SOMATULINE DEPOT INJ 90MG/0.3ML
OTHER
QL (0.3 ML per 28 days) PA
SOMATULINE DEPOT INJ 120MG/0.5ML
OTHER
QL (0.5 ML per 28 days) PA
SOMAVERT
OTHER
PA
SYNAREL
OTHER
MO
TRELSTAR MIXJECT
OTHER
PA
VANTAS
OTHER
ZOLADEX
OTHER
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
59
Drug
Drug Name
Tier
Requirements/Limits
HORMONAL AGENTS, SUPPRESSANT (THYROID) - DRUGS USED TO LOWER THYROID LEVELS
Antithyroid Agents
Generic
methimazole tabs 10mg, 5mg
Generic
MO
propylthiouracil tabs
IMMUNOLOGICAL AGENTS- VACCINES, RHEUMATOID ARTHRITIS , IMMUNOGLOBULINS,
IMMUNOMODULATORS, IMMUNOSUPPRESSANTS
Angioedema (HAE) Agents
CINRYZE
OTHER
PA
FIRAZYR
OTHER
QL (270 ML per 30 days) PA
Immune Suppressants
Generic
B/D
azathioprine inj, tabs
CELLCEPT INTRAVENOUS
OTHER
B/D
Generic
PA
cyclosporine modified caps 100mg, 25mg
Generic
PA MO
cyclosporine modified caps 50mg
Generic
PA
cyclosporine modified soln
Generic
PA
cyclosporine inj
Generic
PA MO
cyclosporine caps
ENBREL SURECLICK
OTHER
QL (7.84 ML per 28 days) PA
ENBREL INJ 25MG/0.5ML
OTHER
QL (4.08 ML per 28 days) PA
ENBREL INJ 50MG/ML
OTHER
QL (7.84 ML per 28 days) PA
ENBREL INJ 25MG
OTHER
QL (8 EA per 28 days) PA
ENVARSUS XR
OTHER
B/D
Generic
PA
gengraf caps
Generic
PA MO
gengraf soln
Generic
B/D
hecoria
HUMIRA PEDIATRIC CROHNS DISEASE START­
OTHER
QL (6 EA per 28 days) PA
ER PACK
HUMIRA PEN
OTHER
QL (6 EA per 28 days) PA
HUMIRA PEN-CROHNS DISEASESTARTER
OTHER
QL (6 EA per 28 days) PA
HUMIRA PEN-PSORIASIS STARTER
OTHER
QL (6 EA per 28 days) PA
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML
OTHER
QL (2 EA per 28 days) PA
HUMIRA INJ 40MG/0.8ML
OTHER
QL (6 EA per 28 days) PA
Generic
methotrexate sodium inj 1gm/40ml, 1gm,
250mg/10ml, 50mg/2ml
Generic
methotrexate tabs
Generic
B/D
mycophenolate mofetil caps, inj, tabs
Generic
B/D MO
mycophenolate mofetil susr
NULOJIX
OTHER
PA
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
60
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
OTREXUP
PROGRAF INJ
RAPAMUNE SOLN
RASUVO
REMICADE
SANDIMMUNE SOLN
SIMULECT
sirolimus tabs 0.5mg, 2mg
sirolimus tabs 1mg
tacrolimus caps
XELJANZ
ZORTRESS
Immunizing Agents, Passive
ATGAM
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D IGA LESS THAN 1MCG/ML
GAMMAKED
GAMMAPLEX
GAMUNEX-C
OCTAGAM
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
BENLYSTA
ILARIS
leflunomide
OTEZLA TBPK
OTEZLA TABS
SYNAGIS INJ 100MG/ML, 50MG/0.5ML
XELJANZ XR
Vaccines
ACTHIB INJ 0
ADACEL
bcg vaccine
BEXSERO
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
Requirements/Limits
ST
B/D
B/D MO
ST
PA
PA MO
B/D
B/D
B/D MO
B/D
QL (60 EA per 30 days) PA
PA MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
B/D
PA
PA
PA
PA
PA
PA
PA
PA
B/D
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
PA
PA
PA
QL (2 EA per 28 days) PA
QL (110 EA per 365 days) PA
QL (60 EA per 30 days) PA
PA
QL (30 EA per 30 days) PA
OTHER
OTHER
Generic
OTHER
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
61
Drug Name
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
diphtheria/tetanus toxoids adsorbed pediatric
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB INJ 7.5MCG/0.5ML
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ SOLN
TENIVAC
tetanus/diphtheria toxoids-adsorbed
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
62
Drug
Tier
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
B/D
B/D
B/D
B/D
QL (1 EA per 365 days)
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Drug Name
Tier
Requirements/Limits
INFLAMMATORY BOWEL DISEASE AGENTS DRUGS USED TO MANAGE DISORDERS IN THE COLON
AND/OR INTESTINES
Aminosalicylates
APRISO
OTHER
MO
ASACOL HD
OTHER
ST MO
Generic
MO
balsalazide disodium
DELZICOL
OTHER
ST MO
LIALDA
OTHER
ST MO
Generic
mesalamine dr
Generic
mesalamine enem, kit
PENTASA
OTHER
ST MO
Sulfonamides
Generic
sulfasalazine tabs, tbec
METABOLIC BONE DISEASE AGENTS- DRUGS USED TO TREAT BONE LOSS
Metabolic Bone Disease Agents
Generic
MO
alendronate sodium soln
Generic
QL (30 EA per 30 days)
alendronate sodium tabs 10mg, 5mg
Generic
QL (30 EA per 30 days) MO
alendronate sodium tabs 40mg
Generic
QL (4 EA per 28 days)
alendronate sodium tabs 35mg, 70mg
Generic
MO
calcitonin-salmon soln
Generic
calcitriol caps
Generic
MO
calcitriol oral soln
Generic
calcitriol inj 1mcg/ml
Generic
doxercalciferol caps
Generic
MO
etidronate disodium
FORTEO INJ 600MCG/2.4ML
OTHER
QL (2.4 ML per 28 days) PA
MIACALCIN INJ
OTHER
MO
Generic
pamidronate disodium
Generic
paricalcitol
PROLIA
OTHER
QL (1 ML per 180 days)
Generic
QL (4 EA per 28 days) MO
risedronate sodium dr
Generic
QL (1 EA per 28 days)
risedronate sodium tabs 150mg
Generic
QL (12 EA per 84 days)
risedronate sodium tabs 35mg
Generic
QL (30 EA per 30 days) MO
risedronate sodium tabs 30mg, 5mg
XGEVA
OTHER
PA
Generic
zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
63
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
Drug Name
Requirements/Limits
ALCOHOL PREP PADS
EXONDYS 51
PA
FERRIPROX SOLN 100MG/ML
PA LA
GAUZE PADS 2”X2”
INSULIN SYRINGE SAFETYGLIDE/1ML/29G X
MO
1/2”
INSULIN SYRINGE ULTRAFINE/0.3ML/31G X
OTHER
5/16”
INSULIN SYRINGE ULTRAFINE/0.5ML/30G X
OTHER
MO
1/2”
INSULIN SYRINGE ULTRAFINE/1ML/31G X
OTHER
MO
5/16”
NATPARA
OTHER
QL (2 EA per 28 days) PA
ORFADIN SUSP 4MG/ML
OTHER
PA
PEN NEEDLE/ULTRAFINE/29G X 12.7MM
OTHER
SYLVANT
OTHER
PA
V-GO 20
OTHER
MO
V-GO 30
OTHER
MO
V-GO 40
OTHER
MO
OPHTHALMIC AGENTS- DRUGS USED TO TREAT EYE ALLERGIES, INFECTIONS, INFLAMMATION, AND
GLAUCOMA
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN
OTHER
MO
Generic
latanoprost
LUMIGAN
OTHER
MO
TRAVATAN Z
OTHER
ST MO
Generic
MO
travoprost
Ophthalmic Agents, Other
Generic
MO
ak-poly-bac
Generic
MO
atropine sulfate soln
AZASITE
OTHER
MO
Generic
bacitracin/neomycin/polymyxin
Generic
MO
bacitracin/polymyxin b
Generic
MO
bacitracin oint 500unit/gm
BESIVANCE
OTHER
MO
Generic
MO
ciprofloxacin hcl soln 0.3%
CYSTARAN
OTHER
QL (60 ML per 28 days) LA
Generic
erythromycin oint 5mg/gm
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
64
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
gatifloxacin
gentak oint
gentamicin sulfate ophthalmic oint 0.3%
gentamicin sulfate ophthalmic soln 0.3%
ilotycin
levofloxacin ophthalmic soln 0.5%
MOXEZA
naphazoline hcl
neo-polycin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone oint
neomycin/polymyxin/dexamethasone susp
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hydrocortisone ophthalmic
susp 1%; 3.5mg/ml; 10000unit/ml
ofloxacin ophthalmic soln 0.3%
polycin
polymyxin b sulfate/trimethoprim sulfate
proparacaine hcl
RESTASIS
sodium sulfacetamide soln 10%
sulfacetamide sodium/prednisolone sodium
phosphate
sulfacetamide sodium oint 10%
sulfacetamide sodium soln 10%
TOBRADEX
TOBRADEX ST
tobramycin sulfate ophthalmic soln 0.3%
tobramycin/dexamethasone
TOBREX
trifluridine
trimethoprim sulfate/polymyxin b sulfate
triple antibiotic oint 400unit/gm; 5mg/gm;
10000unit/gm
VIGAMOX
ZIRGAN
Ophthalmic Anti-allergy Agents
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
OTHER
Generic
Generic
Generic
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
65
Drug Name
azelastine hcl ophthalmic soln 0.05%
cromolyn sodium soln 4%
epinastine hcl
olopatadine hcl ophthalmic soln 0.1%
PATADAY
PAZEO
Ophthalmic Anti-inflammatories
ACUVAIL
bromfenac
dexamethasone sodium phosphate ophthalmic
soln 0.1%
DUREZOL
fluorometholone
flurbiprofen sodium
ILEVRO
ketorolac tromethamine
LOTEMAX
NEVANAC
prednisolone acetate
prednisolone sodium phosphate ophthalmic soln
1%
PROLENSA
Ophthalmic Antiglaucoma Agents
ALPHAGAN P SOLN 0.1%
apraclonidine
AZOPT
betaxolol hcl soln 0.5%
BETIMOL
BETOPTIC-S
brimonidine tartrate
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
levobunolol hcl soln 0.5%
metipranolol
PHOSPHOLINE IODIDE SOLR 0.125%
pilocarpine hcl soln 1%, 2%, 4%
SIMBRINZA
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
66
Drug
Tier
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
OTHER
Generic
Generic
OTHER
Generic
OTHER
OTHER
Generic
Generic
MO
OTHER
MO
OTHER
Generic
OTHER
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
OTHER
MO
MO
MO
MO
MO
MO
MO
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug
Drug Name
Tier
Requirements/Limits
Generic
MO
timolol maleate ophthalmic gel forming
Generic
timolol maleate soln 0.25%, 0.5%
OTIC AGENTS- DRUGS USED TO TREAT CONDITIONS OF THE EAR
Otic Agents
Generic
acetasol hc
Generic
acetic acid
Generic
MO
acetic acid/aluminum acetate soln 2%; 0
Generic
antibiotic ear soln 1%; 3.5mg/ml; 10000unit/ml
CIPRODEX
OTHER
MO
Generic
MO
fluocinolone acetonide oil 0.01%
Generic
hydrocortisone/acetic acid
Generic
MO
neomycin/polymyxin/hc
Generic
MO
neomycin/polymyxin/hydrocortisone otic susp
1%; 3.5mg/ml; 10000unit/ml
Generic
ofloxacin otic soln 0.3%
RESPIRATORY TRACT/PULMONARY AGENTS- DRUGS USED TO TREAT ALLERGIES, ASTHMA, COPD,
PULMONARY HYPERTENSION
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
OTHER
QL (60 EA per 30 days) MO
ADVAIR HFA
OTHER
QL (12 GM per 30 days) MO
ASMANEX HFA
OTHER
QL (13 GM per 30 days) MO
ASMANEX TWISTHALER 120 METERED DOSES OTHER
QL (1 EA per 30 days) MO
ASMANEX TWISTHALER 14 METERED DOSES
OTHER
QL (2 EA per 28 days)
ASMANEX TWISTHALER 30 METERED DOSES
OTHER
QL (1 EA per 30 days) MO
ASMANEX TWISTHALER 60 METERED DOSES
OTHER
QL (1 EA per 30 days) MO
ASMANEX TWISTHALER 7 METERED DOSES
OTHER
QL (4 EA per 28 days)
BREO ELLIPTA
OTHER
QL (60 EA per 30 days) MO
Generic
B/D MO
budesonide inhalation susp 0.25mg/2ml,
0.5mg/2ml, 1mg/2ml
Generic
QL (17.2 GM per 30 days)
budesonide nasal susp 32mcg/act
FLOVENT DISKUS AEPB 250MCG/BLIST
OTHER
QL (240 EA per 30 days) MO
FLOVENT DISKUS AEPB 100MCG/BLIST,
OTHER
QL (60 EA per 30 days) MO
50MCG/BLIST
FLOVENT HFA AERO 44MCG/ACT
OTHER
QL (21.2 GM per 30 days) MO
FLOVENT HFA AERO 110MCG/ACT, 220MCG/
OTHER
QL (24 GM per 30 days) MO
ACT
Generic
MO
flunisolide soln 0.025%
Generic
QL (16 GM per 30 days) MO
fluticasone propionate susp 50mcg/act
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
67
Drug Name
NASONEX
QVAR
triamcinolone acetonide aero 55mcg/act
Antihistamines
azelastine hcl nasal soln 0.15%
azelastine hcl nasal soln 0.1%
clemastine fumarate tabs 2.68mg
cyproheptadine hcl tabs
diphenhydramine hcl inj 50mg/ml
hydroxyzine hcl tabs
hydroxyzine hcl inj, syrp
hydroxyzine pamoate caps 25mg, 50mg
hydroxyzine pamoate caps 100mg
levocetirizine dihydrochloride tabs
levocetirizine dihydrochloride soln
olopatadine hcl nasal soln 0.6%
promethazine hcl tabs 25mg
promethazine hcl tabs 12.5mg, 50mg
Antileukotrienes
montelukast sodium
zafirlukast
Bronchodilators, Anticholinergic
ANORO ELLIPTA
COMBIVENT RESPIMAT
INCRUSE ELLIPTA
ipratropium bromide/albuterol sulfate
ipratropium bromide nasal soln
ipratropium bromide inhalation soln
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
Bronchodilators, Sympathomimetic
albuterol sulfate er
albuterol sulfate syrp
albuterol sulfate nebu 0.083%, 0.63mg/3ml,
1.25mg/3ml
albuterol sulfate nebu 0.5%
albuterol sulfate tabs 4mg
albuterol sulfate tabs 2mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
68
Drug
Tier
OTHER
OTHER
Generic
Requirements/Limits
QL (34 GM per 30 days) MO
QL (17.4 GM per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
QL (30 ML per 25 days)
PA
PA
PA
PA
PA MO
PA
PA MO
QL (30 EA per 30 days)
QL (300 ML per 30 days) MO
QL (30.5 GM per 30 days)
PA
PA MO
Generic
Generic
QL (30 EA per 30 days)
QL (60 EA per 30 days) MO
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
QL (60 EA per 30 days) MO
QL (8 GM per 30 days) MO
QL (30 EA per 30 days) MO
B/D
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
B/D
QL (30 EA per 30 days) MO
QL (4 GM per 30 days) MO
MO
B/D
B/D MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
ARCAPTA NEOHALER
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
FORADIL AEROLIZER
levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml
levalbuterol nebu
metaproterenol sulfate syrp, tabs
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
STRIVERDI RESPIMAT
terbutaline sulfate tabs
VENTOLIN HFA
Cystic Fibrosis Agents
CAYSTON
KALYDECO PACK
KALYDECO TABS
ORKAMBI
PULMOZYME
TOBI PODHALER
tobramycin
Mast Cell Stabilizers
cromolyn sodium nebu 20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
aminophylline inj
DALIRESP
theophylline
theophylline cr tb12 200mg
theophylline cr tb12 100mg
theophylline er tb24
theophylline er tb12 100mg, 200mg, 300mg
theophylline er tb12 450mg
Pulmonary Antihypertensives
ADEMPAS
epoprostenol sodium
LETAIRIS
OPSUMIT
REMODULIN
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
Requirements/Limits
QL (30 EA per 30 days) ST MO
QL (2 EA per 30 days) MO
QL (2 EA per 30 days) MO
QL (60 EA per 30 days) MO
B/D
B/D MO
MO
QL (17 GM per 30 days) MO
QL (2 EA per 30 days) MO
QL (60 EA per 30 days) ST MO
QL (4 GM per 30 days) MO
QL (36 GM per 30 days) MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
QL (84 ML per 56 days) LA
QL (56 EA per 28 days) PA
QL (60 EA per 30 days) PA
QL (112 EA per 28 days) PA
B/D
QL (224 EA per 56 days)
QL (280 ML per 56 days) B/D
Generic
B/D MO
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
OTHER
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
QL (30 EA per 30 days) MO
MO
MO
QL (90 EA per 30 days) PA
PA LA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
PA
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
69
Drug
Tier
Generic
OTHER
OTHER
Drug Name
Requirements/Limits
QL (90 EA per 30 days) PA
sildenafil tabs
TRACLEER
QL (60 EA per 30 days) PA
VENTAVIS
PA
Respiratory Tract Agents, Other
Generic
acetylcysteine inj
Generic
B/D
acetylcysteine inhalation soln 10%
Generic
B/D MO
acetylcysteine inhalation soln 20%
CETYLEV
OTHER
ESBRIET
OTHER
QL (270 EA per 30 days) PA
OFEV
OTHER
QL (60 EA per 30 days) PA
PROLASTIN-C
OTHER
PA LA
STIOLTO RESPIMAT
OTHER
QL (4 GM per 30 days) MO
TYZINE PEDIATRIC NASAL DROPS
OTHER
XOLAIR
OTHER
QL (6 EA per 28 days) PA
ZEMAIRA
OTHER
PA LA
SKELETAL MUSCLE RELAXANTS- DRUGS USED TO TREAT MUSCLE SPASMS
Skeletal Muscle Relaxants
Generic
QL (180 EA per 30 days) PA MO
chlorzoxazone tabs 500mg
Generic
QL (90 EA per 30 days) PA
cyclobenzaprine hcl tabs
SLEEP DISORDER AGENTS- DRUGS USED TO TREAT INSOMNIA OR SLEEP DISORDERS
GABA Receptor Modulators
Generic
QL (30 EA per 30 days) PA
zaleplon caps 5mg
Generic
QL (60 EA per 30 days) PA
zaleplon caps 10mg
Generic
QL (30 EA per 30 days) PA
zolpidem tartrate er
Generic
QL (30 EA per 30 days) PA
zolpidem tartrate tabs 10mg
Generic
QL (30 EA per 30 days) PA MO
zolpidem tartrate tabs 5mg
Sleep Disorders, Other
Generic
QL (30 EA per 30 days) PA
armodafinil
HETLIOZ
OTHER
QL (30 EA per 30 days) PA LA
Generic
QL (30 EA per 30 days) PA
modafinil tabs 100mg
Generic
QL (60 EA per 30 days) PA
modafinil tabs 200mg
ROZEREM
OTHER
QL (30 EA per 30 days)
XYREM
OTHER
QL (540 ML per 30 days) PA
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES, VITAMINS AND IV NUTRITION
Electrolyte/Mineral Modifiers
CUPRIMINE CAPS 250MG
OTHER
MO
DEPEN TITRATABS
OTHER
MO
EXJADE
OTHER
PA
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
70
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
FERRIPROX TABS 500MG
fomepizole
kionex
levocarnitine
SAMSCA TABS 15MG
SAMSCA TABS 30MG
sodium bicarbonate partial fill
sodium bicarbonate inj 8.4%
sodium polystyrene sulfonate
sps
SYPRINE
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
aminosyn ii 8.5%/electrolytes
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML;
517MG/100ML; 350MG/100ML;
210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML;
120MG/100ML; 209MG/100ML;
505MG/100ML; 371MG/100ML; 31.3MEQ/L;
280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML, 61.1MEQ/L;
844MG/100ML; 865MG/100ML;
595MG/100ML; 627MG/100ML;
425MG/100ML; 255MG/100ML;
561MG/100ML; 850MG/100ML;
893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML;
450MG/100ML; 33.3MEQ/L; 340MG/100ML;
170MG/100ML; 230MG/100ML;
425MG/100ML, 71.8MEQ/L; 993MG/100ML;
1018MG/100ML; 700MG/100ML;
738MG/100ML; 500MG/100ML;
300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML;
172MG/100ML; 298MG/100ML;
722MG/100ML; 530MG/100ML; 44.4MEQ/L;
400MG/100ML; 200MG/100ML;
270MG/100ML; 500MG/100ML
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
PA LA
MO
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
MO
MO
MO
B/D
B/D
B/D
B/D
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
71
Drug Name
AMINOSYN M INJ 65MEQ/L; 448MG/100ML;
343MG/100ML; 40MEQ/L; 448MG/100ML;
105MG/100ML; 252MG/100ML;
329MG/100ML; 252MG/100ML; 3MEQ/L;
140MG/100ML; 154MG/100ML;
3.5MMOLE/L; 13MEQ/L; 300MG/100ML;
147MG/100ML; 40MEQ/L; 182MG/100ML;
56MG/100ML; 31MG/100ML;
280MG/100ML
AMINOSYN-HBC
AMINOSYN-PF 7%
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;
1227MG/100ML; 527MG/100ML;
820MG/100ML; 385MG/100ML;
312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML;
180MG/100ML; 427MG/100ML;
812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML;
180MG/100ML; 44MG/100ML;
673MG/100ML
AMINOSYN-RF
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML;
300MG/100ML; 720MG/100ML;
940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML;
520MG/100ML; 160MG/100ML;
44MG/100ML; 800MG/100ML, 90MEQ/L;
1100MG/100ML; 850MG/100ML; 35MEQ/L;
1100MG/100ML; 260MG/100ML;
620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML;
380MG/100ML; 5.4MEQ/L; 750MG/100ML;
370MG/100ML; 460MG/100ML;
150MG/100ML; 44MG/100ML;
680MG/100ML
calcium chloride
calcium gluconate inj
citric acid/sodium citrate
clinisol sf 15%
dextrose 10%/nacl 0.45%
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
72
Drug
Tier
OTHER
Requirements/Limits
B/D
OTHER
OTHER
OTHER
B/D
B/D
B/D
OTHER
OTHER
B/D
B/D
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
B/D
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
dextrose 5% /electrolyte #48 viaflex
dextrose 10%
dextrose 10%/nacl 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 20%
dextrose 25% inj 250mg/ml
dextrose 30%
dextrose 40%
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.3%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
dextrose 50%
dextrose 70%
FLORIVA LIQD 0.25MG/ML; 400UNIT/ML
fluor-a-day soln
fluoride chew 1.1mg, 2.2mg
fluoride chew 0.25mg
fluoritab chew 0.5mg, 1mg
fluoritab soln 0.125mg/drop
FLURA-DROPS SOLN 0.25MG/DROP
FREAMINE III INJ 89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L; 24MG/100ML;
1400MG/100ML; 280MG/100ML;
690MG/100ML; 910MG/100ML;
730MG/100ML; 530MG/100ML;
560MG/100ML; 10MMOLE/L;
120MG/100ML; 1120MG/100ML;
590MG/100ML; 10MEQ/L; 400MG/100ML;
150MG/100ML; 660MG/100ML
hepatamine
INTRALIPID INJ 30GM/100ML
intralipid inj 20gm/100ml
k-sol soln
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
OTHER
Generic
Generic
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
MO
B/D
B/D
MO
MO
MO
B/D
B/D
B/D
B/D
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
73
Drug Name
KABIVEN
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.225%
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l;
0.45%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/lr iv lac ring
kcl 0.3%/d5w/nacl 0.45%
kcl 0.3%/d5w/nacl 0.9%
klor-con
klor-con 10
KLOR-CON 25
klor-con 8
klor-con m10
KLOR-CON M15
klor-con m20
klor-con sprinkle
klor-con/ef
lactated ringers viaflex
ludent
magnesium sulfate inj 20gm/500ml, 2gm/50ml,
40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%
NEPHRAMINE
nutrilipid
PERIKABIVEN
plenamine
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15% d5w/nacl 0.45% viaflex
potassium chloride 0.15% nacl 0.9%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.224%d5w/nacl 0.45%
viaflex
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
74
Drug
Tier
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
B/D
MO
MO
MO
B/D
B/D
B/D
B/D
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride cr tbcr 10meq, 20meq
potassium chloride er cpcr
potassium chloride er tbcr 10meq, 20meq, 8meq
potassium chloride er tbcr 20meq
potassium chloride sr tbcr 8meq
potassium chloride oral soln
potassium chloride inj 10meq/100ml,
10meq/50ml, 20meq/100ml, 2meq/ml,
40meq/100ml
potassium chloride inj 0.4meq/ml
potassium citrate er tbcr 15meq
potassium citrate er tbcr 1080mg, 540mg
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML
premasol inj 56meq/l; 320mg/100ml;
730mg/100ml; 190mg/100ml; 3meq/l;
20mg/100ml; 300mg/100ml; 220mg/100ml;
290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml;
410mg/100ml; 230mg/100ml; 5meq/l;
15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml
ringers injection
sodium chloride 0.45% inj
sodium chloride inj 0.9%, 5%
sodium chloride inj 2.5meq/ml, 3%
sodium fluoride chew 0.5mg, 1.1mg
sodium fluoride soln 0.5mg/ml
sodium phosphate
sterile water irrigation
tpn electrolytes
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/Limits
MO
Generic
Generic
Generic
OTHER
MO
B/D
Generic
B/D
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO
B/D
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
75
Drug Name
TRAVASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML
TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML;
1.2GM/100ML; 0.32GM/100ML; 0;
0; 0.5GM/100ML; 0.36GM/100ML;
0.48GM/100ML; 0.82GM/100ML;
1.4GM/100ML; 1.2GM/100ML;
0.34GM/100ML; 0.48GM/100ML;
0.68GM/100ML; 0.38GM/100ML; 5MEQ/L;
0.025GM/100ML; 0.42GM/100ML;
0.2GM/100ML; 0.24GM/100ML;
0.78GM/100ML
vitamins a/d/c/fluoride
Vitamins
ACTIVE OB
BAL-CARE DHA
CALCIUM PNV
CITRANATAL 90 DHA MISC 120MG; 159MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG;
0; 1MG; 90MG; 0; 20MG; 150MCG; 20MG;
3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL ASSURE MISC 120MG; 124MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG;
0; 1MG; 35MG; 0; 20MG; 150MCG; 25MG;
3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL B-CALM
CITRANATAL DHA MISC 625MG; 120MG;
0; 124MG; 400UNIT; 2MG; 250MG; 50MG;
0.625MG; 0; 1MG; 27MG; 0; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL RX TABS 120MG; 125MG;
400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG;
20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG
completenate
CONCEPT DHA
CONCEPT OB
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
76
Drug
Tier
OTHER
Requirements/Limits
B/D
OTHER
B/D
Generic
OTHER
OTHER
OTHER
OTHER
MO
OTHER
MO
OTHER
OTHER
MO
MO
OTHER
Generic
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
DUET DHA 400
DUET DHA BALANCED MISC 120MG;
2800UNIT; 215MG; 640UNIT; 55MG; 1.8MG;
12MCG; 0; 0; 0; 1MG; 25MG; 0; 25MG; 20MG;
267MG; 0; 210MCG; 50MG; 2MG; 0; 65MCG;
1.5MG; 15MG; 25MG
elite-ob
ENBRACE HR
ESCAVITE D
ESCAVITE LQ
EXTRA-VIRT PLUS DHA
floriva chew 75mg; 0; 40mcg; 600unit; 1mg;
6mcg; 262mcg; 0; 15mg; 1.8mg; 1.5mg;
0.25mg; 1.3mg; 20unit; 2000unit; 5mg
FOCALGIN 90 DHA
FOCALGIN CA
FOLCAL DHA CAPS 28MG; 160MG; 400UNIT;
300MG; 55MG; 27MG; 1.25MG; 25MG;
30UNIT
FOLCAPS OMEGA 3
FOLET ONE
FOLIVANE-OB
FOLIVANE-PRX DHA NF
HEMENATAL OB
HEMENATAL OB + DHA
inatal advance
inatal ultra
KOSHER PRENATAL PLUS IRON
MARNATAL-F CAPS
mult-vitamin/fluoride chew 60mg; 400unit;
4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg;
0; 1.05mg; 2500unit; 15unit
multi vitamin/fluoride chew 60mg; 400unit;
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg;
1.05mg; 15unit; 2500unit
multi-vit/fluoride soln 35mg/ml; 400unit/
ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
Generic
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
77
Drug Name
multi-vit/iron/fluoride soln 35mg/ml; 400unit/
ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
multi-vitamin/fluoride/iron soln 35mg/ml;
400unit/ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/
ml
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml;
2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/
ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml
multivitamin with fluoride chew 60mg; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg;
1.05mg; 2500unit; 400unit; 15unit, 60mg;
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg;
1.05mg; 2500unit; 400unit; 15unit
mvc-fluoride
NATACHEW CHEW 120MG; 2700UNIT;
400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG;
10MG; 3MG; 0; 2MG; 20UNIT
NATALVIRT 90 DHA
NATALVIRT CA
NATELLE ONE CAPS 30MG; 102MG; 250MG;
0.625MG; 28MG; 1MG; 25MG; 30UNIT
NESTABS ABC
NESTABS DHA
NESTABS TABS 65MG; 155MG; 450UNIT;
55MG; 10MCG; 32MG; 1000MCG; 100MCG;
50MG; 3MG; 120MG; 3MG; 30UNIT; 10MG
NEXA PLUS CAPS 28MG; 0; 250MCG; 660MG;
160MG; 0; 800UNIT; 350MG; 55MG; 29MG;
1.25MG; 25MG; 30UNIT
NIVA-PLUS
O-CAL PRENATAL
OB COMPLETE GOLD
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE/DHA
OB COMPLETE TABS
PAIRE OB
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
78
Drug
Tier
Generic
Requirements/Limits
Generic
Generic
Generic
Generic
OTHER
MO
OTHER
OTHER
OTHER
MO
OTHER
OTHER
OTHER
MO
MO
MO
OTHER
MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
MO
MO
MO
MO
MO
MO
MO
MO
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
PNV FERROUS FUMARATE/DOCUSATE/FOLIC
ACID
PNV FOLIC ACID + IRON MULTIVITAMIN
PNV OB+DHA
pnv prenatal plus multivitamin
pnv tabs 29-1
pnv-dha
pnv-select
PNV-VP-U
poly-vitamin/fluoride chew
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml;
2mcg/ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/
ml; 5unit/ml
pr natal 400
PREFERA OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG;
1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG;
10UNIT; 4.5MG
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 34MG; 0;
17MG; 0; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG, 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG;
28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG
PREFERAOB +DHA
PREFERAOB ONE
PRENAISSANCE
PRENAISSANCE PLUS
PRENATA
prenatabs fa
prenatal 19 chew 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 29mg; 1mg; 15mg;
20mg; 3mg; 3mg; 30unit; 20mg
prenatal 19 tabs 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 25mg; 29mg; 1mg;
15mg; 20mg; 3mg; 3mg; 30unit; 20mg
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Requirements/Limits
MO
MO
MO
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
MO
MO
MO
MO
MO
Generic
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
79
Drug Name
prenatal plus iron tabs 120mg; 0; 200mg;
400unit; 2mg; 12mcg; 1mg; 29mg; 20mg;
10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg
PRENATAL PLUS TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG;
10MG; 3MG; 1.84MG; 22MG; 4000UNIT;
25MG
PRENATE AM
PRENATE DHA CAPS 90MG; 145MG;
220UNIT; 13MCG; 300MG; 28MG; 400MCG;
600MCG; 50MG; 26MG; 10UNIT
PRENATE ELITE TABS 75MG; 2600UNIT;
330MCG; 100MG; 6MG; 450UNIT; 1.5MG;
13MCG; 26MG; 400MCG; 150MCG; 600MCG;
25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT;
15MG
PRENATE ELITE TABS 600MCG; 75MG;
2600UNIT; 330MCG; 155MG; 600UNIT;
1.5MG; 13MCG; 20MG; 400MCG; 25MG;
21MG; 150MCG; 21MG; 3.5MG; 3MG;
40UNIT; 15MG
PRENATE ENHANCE
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG;
29MG; 0; 400MCG; 600MCG; 50MG;
150MCG; 26MG; 10UNIT
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG; 300MG;
40MG; 18MG; 400MCG; 50MG; 150MCG;
26MG; 10UNIT
PRENATE MINI CAPS 60MG; 280MCG;
100MG; 220UNIT; 13MCG; 350MG; 400MCG;
29MG; 600MCG; 25MG; 150MCG; 26MG;
10UNIT; 25MG
PRENATE MINI CAPS 600MCG; 60MG;
280MCG; 80MG; 1000UNIT; 13MCG; 350MG;
0; 400MCG; 18MG; 0; 25MG; 150MCG;
26MG; 10UNIT; 25MG
PRENATE PIXIE
PRENATE RESTORE
PRENATE STAR
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
80
Drug
Tier
Generic
Requirements/Limits
OTHER
OTHER
OTHER
MO
OTHER
OTHER
MO
OTHER
OTHER
MO
OTHER
MO
OTHER
OTHER
MO
OTHER
OTHER
OTHER
MO
MO
MO
LA - Limited Access
QL - Quantity Limit
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
PREPLUS TABS 120MG; 0; 200MG; 400UNIT;
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG;
3MG; 1.84MG; 22MG; 4000UNIT; 25MG
PREQUE 10
PRETAB
PROVIDA DHA
PROVIDA OB
PUREFE OB PLUS
QUFLORA PEDIATRIC SOLN 45MG/ML;
400UNIT/ML; 1MG/ML; 3MCG/ML; 81MCG/
ML; 150MCG/ML; 12MG/ML; 2MG/ML;
1MG/ML; 1MG/ML; 0.5MG/ML; 1MG/ML;
1100UNIT/ML; 12UNIT/ML
QUFLORA PEDIATRIC SOLN 35MG/ML;
400UNIT/ML; 1MG/ML; 2MCG/ML; 35MCG/
ML; 65MCG/ML; 10MG/ML; 0.8MG/ML;
0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/
ML; 1000UNIT/ML; 5UNIT/ML
RELNATE DHA
se-natal 19
SELECT-OB+DHA
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG;
1.6MG; 30UNIT; 1700UNIT; 15MG
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG;
1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG
TARON-BC
TARON-PREX
thrivite rx
TL FOLATE
TL-CARE DHA
TL-SELECT
tri-vit/fluoride/iron
tri-vit/fluoride soln 35mg/ml; 400unit/ml;
0.25mg/ml; 1500unit/ml, 35mg/ml; 400unit/ml;
0.5mg/ml; 1500unit/ml
tri-vitamin/fluoride
triadvance
tricare
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
Requirements/Limits
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
MO
OTHER
MO
OTHER
Generic
OTHER
OTHER
MO
MO
MO
OTHER
MO
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
LA - Limited Access
QL - Quantity Limit
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
81
Drug Name
TRICARE PRENATAL 1
TRICARE PRENATAL COMPLEAT
TRICARE PRENATAL DHA ONE
TRINATAL GT
trinatal rx 1
triple-vitamin/fluoride
TRISTART DHA
TRIVEEN-DUO DHA
TRIVEEN-PRX RNF
ultimatecare one nf
VEMAVITE-PRX 2
VENA-BAL DHA
VIRT-ADVANCE
VIRT-C DHA
VIRT-CARE ONE
VIRT-PN
VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT;
12MCG; 300MG; 27MG; 400MCG; 600MCG;
45MG; 25MG; 10UNIT
VIRT-PN PLUS
VIRT-SELECT
VITAFOL FE+
VITAFOL GUMMIES
VITAFOL ULTRA
VITAFOL-NANO
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-ONE
VITAMEDMD ONE RX/QUATREFOLIC
VITAMEDMD PLUS RX/QUATRE FOLIC
vitamins a/c/d/fluoride
VOL-NATE
VOL-PLUS
VP CH ULTRA
VP-CH PLUS
VP-CH-PNV
VP-GGR-B6 PRENATAL
VP-HEME OB
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
82
Drug
Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
Drug Name
VP-HEME ONE
VP-PNV-DHA
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
B/D - Covered Under Medicare B or D
PA - Prior Authorization
01/01/2017
Drug
Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
LA - Limited Access
QL - Quantity Limit
Requirements/Limits
MO
MO
MO
MO
MO - Available at Mail Order
ST - Step Therapy
Formulary ID 00017473 v6
83
Drug Name
Page Number Drug Name
Page Number
Index of Drugs
8-MOP.............................................................................. 44
abacavir ....................................................................................30
abacavir/lamivudine ..............................................................30
abacavir sulfate/lamivudine/zidovudine ..........................30
ABELCET .......................................................................... 16
ABILIFY DISCMELT.......................................................... 27
ABILIFY INJ ....................................................................... 27
ABILIFY MAINTENA ....................................................... 27
ABILIFY ORAL SOLN ...................................................... 27
ABRAXANE ...................................................................... 20
acamprosate calcium dr ......................................................... 5
acarbose ...................................................................................32
acebutolol hcl caps.................................................................38
acetaminophen/codeine soln ................................................ 2
acetaminophen/codeine tabs ................................................ 2
acetasol hc ...............................................................................67
acetazolamide er ....................................................................40
acetazolamide tabs 125mg .................................................40
acetazolamide tabs 250mg .................................................40
acetic acid.................................................................................67
acetic acid/aluminum acetate soln 2%; 0 ........................67
acetylcysteine inhalation soln 10% ...................................70
acetylcysteine inhalation soln 20% ...................................70
acetylcysteine inj.....................................................................70
acitretin caps 10mg, 25mg .................................................44
acitretin caps 17.5mg ...........................................................44
ACTHIB INJ 0.................................................................... 61
ACTIMMUNE ................................................................... 61
ACTIVE OB ....................................................................... 76
ACUVAIL ........................................................................... 66
acyclovir caps, susp, tabs ......................................................31
acyclovir oint............................................................................31
acyclovir sodium inj 50mg/ml.............................................31
ADACEL ............................................................................ 61
ADAGEN ........................................................................... 46
adefovir dipivoxil .....................................................................28
ADEMPAS ......................................................................... 69
adriamycin inj 2mg/ml ..........................................................20
adrucil........................................................................................20
ADVAIR DISKUS............................................................... 67
ADVAIR HFA ..................................................................... 67
AFINITOR.......................................................................... 23
AFINITOR DISPERZ ......................................................... 23
a-hydrocort inj 100mg .........................................................50
ak-poly-bac .............................................................................64
ala-cort crea 1%.....................................................................50
84
ALBENZA ......................................................................... 24
albuterol sulfate er .................................................................68
albuterol sulfate nebu 0.5%.................................................68
albuterol sulfate nebu 0.083%, 0.63mg/3ml,
1.25mg/3ml ............................................................................68
albuterol sulfate syrp .............................................................68
albuterol sulfate tabs 2mg ...................................................68
albuterol sulfate tabs 4mg ...................................................68
alclometasone dipropionate crea, oint .............................50
ALCOHOL PREP PADS ................................................... 64
ALDURAZYME ................................................................. 46
ALECENSA ....................................................................... 23
alendronate sodium soln ......................................................63
alendronate sodium tabs 10mg, 5mg ..............................63
alendronate sodium tabs 35mg, 70mg ...........................63
alendronate sodium tabs 40mg .........................................63
alfuzosin hcl er ........................................................................49
ALIMTA ............................................................................. 20
ALINIA SUSR.................................................................... 24
ALINIA TABS .................................................................... 24
ALKERAN TABS ............................................................... 18
allopurinol tabs 100mg ........................................................17
allopurinol tabs 300mg ........................................................17
alogliptin ...................................................................................32
alogliptin/metformin hcl.......................................................32
alogliptin/pioglitazone ..........................................................32
alosetron hydrochloride .......................................................48
ALPHAGAN P SOLN 0.1% ............................................ 66
alprazolam tabs 0.25mg, 0.5mg .......................................31
alprazolam tabs 1mg, 2mg..................................................31
ALTABAX........................................................................... 44
altavera .....................................................................................53
alyacen 1/35 ...........................................................................53
alyacen 7/7/7 tabs.................................................................53
amantadine hcl caps, syrp....................................................25
amantadine hcl tabs ..............................................................25
AMBISOME ...................................................................... 16
amcinonide ..............................................................................50
amethia .....................................................................................53
amethia lo ................................................................................53
amethyst ...................................................................................53
amifostine ................................................................................20
amikacin sulfate inj 1gm/4ml ............................................... 5
amikacin sulfate inj 500mg/2ml.......................................... 5
amiloride hcl tabs ...................................................................41
amiloride/hydrochlorothiazide ...........................................41
Drug Name
Page Number
aminophylline inj ....................................................................69
AMINOSYN 7%/ELECTROLYTES ................................. 71
aminosyn 8.5%/electrolytes ................................................71
AMINOSYN-HBC ............................................................ 72
aminosyn ii 8.5%/electrolytes .............................................71
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML, 61.1MEQ/L;
844MG/100ML; 865MG/100ML; 595MG/100ML;
627MG/100ML; 425MG/100ML; 255MG/100ML;
561MG/100ML; 850MG/100ML; 893MG/100ML;
146MG/100ML; 253MG/100ML; 614MG/100ML;
450MG/100ML; 33.3MEQ/L; 340MG/100ML;
170MG/100ML; 230MG/100ML; 425MG/100ML,
71.8MEQ/L; 993MG/100ML; 1018MG/100ML;
700MG/100ML; 738MG/100ML; 500MG/100ML;
300MG/100ML; 660MG/100ML; 1000MG/100ML;
1050MG/100ML; 172MG/100ML; 298MG/100ML;
722MG/100ML; 530MG/100ML; 44.4MEQ/L;
400MG/100ML; 200MG/100ML; 270MG/100ML;
500MG/100ML .............................................................. 71
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML,
90MEQ/L; 1100MG/100ML; 850MG/100ML;
35MEQ/L; 1100MG/100ML; 260MG/100ML;
620MG/100ML; 810MG/100ML; 624MG/100ML;
340MG/100ML; 380MG/100ML; 5.4MEQ/L;
750MG/100ML; 370MG/100ML; 460MG/100ML;
150MG/100ML; 44MG/100ML; 680MG/100ML .. 72
AMINOSYN M INJ 65MEQ/L; 448MG/100ML;
343MG/100ML; 40MEQ/L; 448MG/100ML;
105MG/100ML; 252MG/100ML; 329MG/100ML;
252MG/100ML; 3MEQ/L; 140MG/100ML;
154MG/100ML; 3.5MMOLE/L; 13MEQ/L;
300MG/100ML; 147MG/100ML; 40MEQ/L;
182MG/100ML; 56MG/100ML; 31MG/100ML;
280MG/100ML .............................................................. 72
AMINOSYN-PF 7% ........................................................ 72
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;
1227MG/100ML; 527MG/100ML; 820MG/100ML;
385MG/100ML; 312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML; 180MG/100ML;
Drug Name
Page Number
427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML;
180MG/100ML; 44MG/100ML; 673MG/100ML .. 72
AMINOSYN-RF................................................................ 72
amiodarone hcl tabs 100mg, 400mg ..............................37
amiodarone hcl tabs 200mg...............................................37
AMITIZA ........................................................................... 48
amitriptyline hcl tabs 10mg, 150mg ................................15
amitriptyline hcl tabs 100mg, 25mg, 50mg, 75mg .....15
amlodipine besylate/atorvastatin calcium tabs 10mg;
10mg, 10mg; 80mg, 2.5mg; 10mg, 2.5mg; 20mg,
2.5mg; 40mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg,
5mg; 80mg ..............................................................................39
amlodipine besylate/atorvastatin calcium tabs 10mg;
20mg, 10mg; 40mg..............................................................39
amlodipine besylate/benazepril hydrochloride ..............39
amlodipine besylate tabs ......................................................39
amlodipine besylate/valsartan ............................................39
amlodipine/olmesartan medoxomil...................................36
amlodipine/valsartan/hctz...................................................39
ammonium lactate crea, lotn ..............................................44
amnesteem ..............................................................................44
amoxapine ................................................................................15
amoxicillin caps, susr ............................................................... 8
amoxicillin chew 125mg, 250mg ........................................ 8
amoxicillin/clavulanate potassium chew ............................ 8
amoxicillin/clavulanate potassium er .................................. 8
amoxicillin/clavulanate potassium susr 200mg/5ml;
28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml;
42.9mg/5ml .............................................................................. 8
amoxicillin/clavulanate potassium susr 250mg/5ml;
62.5mg/5ml .............................................................................. 8
amoxicillin/clavulanate potassium tabs 250mg; 125mg8
.
amoxicillin/clavulanate potassium tabs 500mg; 125mg,
875mg; 125mg ........................................................................ 8
amoxicillin tabs 500mg .......................................................... 9
amoxicillin tabs 875mg .......................................................... 9
amphetamine/dextroamphetamine tabs 1.25mg;
1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg; 2.5mg;
2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg;
7.5mg; 7.5mg; 7.5mg...........................................................43
amphetamine/dextroamphetamine tabs 1.875mg;
1.875mg; 1.875mg; 1.875mg, 3.125mg; 3.125mg;
3.125mg; 3.125mg ..............................................................43
amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg;
5mg............................................................................................43
amphotericin b ........................................................................16
ampicillin caps........................................................................... 9
85
Drug Name
Page Number
ampicillin sodium inj 1gm ...................................................... 9
ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm,
500mg ........................................................................................ 9
ampicillin-sulbactam .............................................................. 9
ampicillin susr 125mg/5ml ................................................... 9
ampicillin susr 250mg/5ml ................................................... 9
AMPYRA ........................................................................... 44
ANADROL-50 ................................................................. 53
anagrelide hydrochloride .....................................................35
anastrozole tabs......................................................................22
ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM
53
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM .......... 53
ANDROGEL PUMP GEL 1%.......................................... 53
ANDROGEL PUMP GEL 1.62%.................................... 53
ANORO ELLIPTA ............................................................. 68
antibiotic ear soln 1%; 3.5mg/ml; 10000unit/ml .........67
APOKYN ........................................................................... 25
apraclonidine...........................................................................66
apri .............................................................................................53
APRISO ............................................................................. 63
APTIOM TABS 200MG, 400MG, 800MG .................. 11
APTIOM TABS 600MG .................................................. 11
APTIVUS CAPS ................................................................ 30
APTIVUS SOLN ............................................................... 30
aranelle .....................................................................................53
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML ......... 35
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML ...... 35
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML ...... 35
ARANESP ALBUMIN FREE INJ 100MCG/ML,
200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/
ML, 60MCG/ML .............................................................. 35
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML,
60MCG/0.3ML................................................................ 35
ARANESP ALBUMIN FREE INJ 150MCG/0.75ML .... 35
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML,
40MCG/0.4ML................................................................ 35
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML ...... 35
ARANESP ALBUMIN FREE INJ 500MCG/ML ............ 35
ARCALYST ........................................................................ 61
ARCAPTA NEOHALER.................................................... 69
aripiprazole odt tbdp 10mg.................................................27
aripiprazole odt tbdp 15mg.................................................27
aripiprazole soln .....................................................................27
aripiprazole tabs .....................................................................27
ARISTADA......................................................................... 27
armodafinil...............................................................................70
ARRANON........................................................................ 20
ARZERRA .......................................................................... 24
86
Drug Name
Page Number
ASACOL HD ..................................................................... 63
ascomp/codeine........................................................................ 1
ashlyna ......................................................................................53
ASMANEX HFA ................................................................ 67
ASMANEX TWISTHALER 7 METERED DOSES .......... 67
ASMANEX TWISTHALER 14 METERED DOSES........ 67
ASMANEX TWISTHALER 30 METERED DOSES........ 67
ASMANEX TWISTHALER 60 METERED DOSES........ 67
ASMANEX TWISTHALER 120 METERED DOSES ..... 67
aspirin/dipyridamole .............................................................35
atenolol/chlorthalidone tabs 50mg; 25mg .....................38
atenolol/chlorthalidone tabs 100mg; 25mg ..................38
atenolol tabs ............................................................................38
ATGAM.............................................................................. 61
atorvastatin calcium ..............................................................42
atovaquone ..............................................................................24
atovaquone/proguanil hcl ....................................................24
ATRIPLA ............................................................................ 29
atropine sulfate soln ..............................................................64
aubra .........................................................................................53
augmented betamethasone dipropionate crea, lotn.....50
augmented betamethasone dipropionate gel, oint .......50
AVASTIN ........................................................................... 20
aviane ........................................................................................53
avita ...........................................................................................44
azacitidine ................................................................................20
AZASITE............................................................................ 64
azathioprine inj, tabs .............................................................60
azelastine hcl nasal soln 0.1% ............................................68
azelastine hcl nasal soln 0.15%..........................................68
azelastine hcl ophthalmic soln 0.05% ..............................66
AZILECT ............................................................................ 26
azithromycin inj 500mg ......................................................... 9
azithromycin pack, susr .......................................................... 9
azithromycin tabs ..................................................................... 9
AZOPT .............................................................................. 66
aztreonam .................................................................................. 8
azurette .....................................................................................53
baciim .......................................................................................... 6
bacitracin inj 50000unit ........................................................ 6
bacitracin/neomycin/polymyxin .........................................64
bacitracin oint 500unit/gm .................................................64
bacitracin/polymyxin b..........................................................64
baclofen tabs ...........................................................................28
BAL-CARE DHA .............................................................. 76
balsalazide disodium .............................................................63
balziva .......................................................................................53
BANZEL ............................................................................ 12
Drug Name
Page Number
BARACLUDE SOLN ........................................................ 28
baycadron ................................................................................50
bcg vaccine...............................................................................61
bekyree ......................................................................................53
BELEODAQ ...................................................................... 20
benazepril hcl/hydrochlorothiazide ...................................37
benazepril hcl tabs .................................................................37
BENDEKA ......................................................................... 18
BENLYSTA......................................................................... 61
benztropine mesylate inj.......................................................25
benztropine mesylate tabs 0.5mg, 1mg...........................25
benztropine mesylate tabs 2mg .........................................25
BESIVANCE ...................................................................... 64
betamethasone dipropionate crea, oint ...........................50
betamethasone dipropionate lotn .....................................50
betamethasone valerate crea, foam, oint ........................50
betamethasone valerate lotn ..............................................50
betaxolol hcl soln 0.5% .........................................................66
betaxolol hcl tabs 10mg, 20mg ..........................................38
bethanechol chloride.............................................................49
BETIMOL .......................................................................... 66
BETOPTIC-S .................................................................... 66
bexarotene................................................................................24
BEXSERO .......................................................................... 61
bicalutamide ............................................................................19
BICILLIN L-A INJ 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML ....................... 9
BICNU ............................................................................... 20
bisoprolol fumarate ...............................................................38
bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg;
6.25mg, 5mg; 6.25mg .........................................................38
bisoprolol fumarate/hydrochlorothiazide tabs 10mg;
6.25mg .....................................................................................38
BLEO 15K ......................................................................... 20
bleomycin sulfate....................................................................20
BLINCYTO ........................................................................ 24
blisovi 24 fe ..............................................................................53
blisovi fe 1.5/30......................................................................53
blisovi fe 1/20 .........................................................................54
BOOSTRIX ........................................................................ 62
BOSULIF ........................................................................... 23
BREO ELLIPTA ................................................................. 67
briellyn.......................................................................................54
BRILINTA .......................................................................... 35
brimonidine tartrate ..............................................................66
BRINTELLIX TABS 10MG, 5MG.................................... 14
BRINTELLIX TABS 20MG ............................................... 14
BRIVIACT INJ, ORAL SOLN ........................................... 11
BRIVIACT TABS ............................................................... 11
Drug Name
Page Number
bromfenac ................................................................................66
bromocriptine mesylate caps, tabs ....................................25
budesonide cpep 3mg...........................................................50
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml ..................................................................................67
budesonide nasal susp 32mcg/act ....................................67
bumetanide inj ........................................................................41
bumetanide tabs .....................................................................41
BUPHENYL TABS ............................................................ 46
buprenorphine hcl/naloxone hcl........................................... 5
buprenorphine hcl subl ........................................................... 5
buproban .................................................................................... 5
bupropion hcl sr tb12 100mg, 150mg, 200mg ...........13
bupropion hcl sr tb12 150mg .............................................. 5
bupropion hcl tabs .................................................................13
bupropion hcl xl tb24 150mg .............................................13
bupropion hcl xl tb24 300mg .............................................13
buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg ..............31
buspirone hcl tabs 30mg......................................................31
BUSULFEX........................................................................ 19
butalbital/acetaminophen/caffeine caps............................ 1
butalbital/acetaminophen/caffeine/codeine caps 300mg;
50mg; 40mg; 30mg................................................................ 1
butalbital/acetaminophen/caffeine/codeine caps 325mg;
50mg; 40mg; 30mg................................................................ 1
butalbital/acetaminophen/caffeine tabs 325mg; 50mg;
40mg ........................................................................................... 1
butalbital/aspirin/caffeine caps ............................................ 1
butalbital/aspirin/caffeine/codeine ...................................... 1
butalbital compound/codeine caps 325mg; 50mg;
40mg; 30mg ............................................................................. 2
cabergoline ..............................................................................59
CABOMETYX ................................................................... 23
calcipotriene ............................................................................44
calcitonin-salmon soln .........................................................63
calcitrene ..................................................................................44
calcitriol caps ...........................................................................63
calcitriol inj 1mcg/ml .............................................................63
calcitriol oral soln ...................................................................63
calcium acetate caps .............................................................49
calcium acetate tabs 667mg ...............................................49
calcium chloride......................................................................72
calcium gluconate inj.............................................................72
CALCIUM PNV................................................................. 76
camila ........................................................................................57
camrese.....................................................................................54
camrese lo ................................................................................54
CANCIDAS INJ 50MG..................................................... 16
87
Drug Name
Page Number
CANCIDAS INJ 70MG..................................................... 16
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg .....................................................................................36
candesartan cilexetil/hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg ..........................................................36
candesartan cilexetil tabs 4mg, 8mg.................................36
candesartan cilexetil tabs 16mg, 32mg ...........................36
capacet........................................................................................ 1
CAPASTAT SULFATE ....................................................... 18
CAPRELSA TABS 100MG .............................................. 23
CAPRELSA TABS 300MG .............................................. 23
captopril/hydrochlorothiazide ............................................37
captopril tabs 12.5mg, 25mg, 50mg ...............................37
captopril tabs 100mg ...........................................................37
CARAFATE SUSP ............................................................. 48
CARBAGLU ...................................................................... 46
carbamazepine chew, susp, tabs.........................................12
carbamazepine er cp12 ........................................................12
carbamazepine er tb12 ........................................................12
carbidopa/levodopa ..............................................................25
carbidopa/levodopa/entacapone tabs 12.5mg; 200mg;
50mg .........................................................................................26
carbidopa/levodopa/entacapone tabs 18.75mg; 200mg;
75mg, 25mg; 200mg; 100mg, 31.25mg; 200mg;
125mg, 37.5mg; 200mg; 150mg, 50mg; 200mg;
200mg ......................................................................................25
carbidopa/levodopa er..........................................................25
carbidopa/levodopa odt .......................................................25
carbidopa tabs ........................................................................26
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,
600mg/60ml ..........................................................................20
carteolol hcl..............................................................................66
cartia xt .....................................................................................39
carvedilol ..................................................................................38
CAYSTON ......................................................................... 69
caziant .......................................................................................54
cefaclor caps .............................................................................. 7
cefaclor er tb12 500mg ......................................................... 7
cefaclor susr 125mg/5ml ...................................................... 7
cefaclor susr 250mg/5ml, 375mg/5ml ............................ 7
cefadroxil caps, tabs ................................................................. 7
cefadroxil susr 250mg/5ml ................................................... 7
cefadroxil susr 500mg/5ml ................................................... 7
cefazolin inj 2gm/100ml; 4% ............................................... 7
cefazolin sodium/dextrose...................................................... 7
cefazolin sodium inj 100gm, 10gm, 1gm, 1gm; 5%,
20gm, 300gm, 500mg .......................................................... 7
cefdinir ........................................................................................ 7
88
Drug Name
Page Number
cefditoren pivoxil tabs 400mg .............................................. 7
cefepime ..................................................................................... 7
cefepime/dextrose .................................................................... 7
cefixime ....................................................................................... 7
cefotaxime sodium inj 1gm.................................................... 7
cefotaxime sodium inj 10gm, 2gm, 500mg...................... 7
cefotetan ..................................................................................... 7
cefotetan/dextrose ................................................................... 7
cefoxitin sodium ........................................................................ 7
cefpodoxime proxetil susr....................................................... 7
cefpodoxime proxetil tabs 100mg ....................................... 7
cefpodoxime proxetil tabs 200mg ....................................... 7
cefprozil ...................................................................................... 7
ceftazidime/dextrose ............................................................... 7
ceftazidime inj 1gm, 2gm, 6gm............................................ 7
ceftriaxone/dextrose ................................................................ 8
ceftriaxone in iso-osmotic dextrose..................................... 7
ceftriaxone sodium inj 2gm ................................................... 8
ceftriaxone sodium inj 100gm, 10gm, 1gm, 250mg,
2gm, 500mg ............................................................................. 8
cefuroxime axetil tabs .............................................................. 8
cefuroxime sodium inj 1.5gm, 225gm, 7.5gm, 75gm ... 8
cefuroxime sodium inj 750mg .............................................. 8
celecoxib caps 100mg, 200mg, 50mg .............................. 1
celecoxib caps 400mg ............................................................ 1
CELLCEPT INTRAVENOUS ............................................ 60
CELONTIN CAPS 300MG ............................................. 11
cephalexin caps 250mg, 500mg ......................................... 8
cephalexin caps 750mg.......................................................... 8
cephalexin susr .......................................................................... 8
cephalexin tabs.......................................................................... 8
CEREZYME ....................................................................... 46
CERVARIX ......................................................................... 62
CETYLEV ........................................................................... 70
CHANTIX CONTINUING MONTH PAK ......................... 5
CHANTIX STARTING MONTH PAK................................ 5
CHANTIX TABS 0.5MG, 1MG ......................................... 5
chateal.......................................................................................54
chloramphenicol sodium succinate ..................................... 6
chlorhexidine gluconate oral rinse .....................................44
chloroquine phosphate tabs ................................................24
chlorothiazide..........................................................................41
chlorpromazine hcl inj...........................................................26
chlorpromazine hcl tabs 10mg ..........................................26
chlorpromazine hcl tabs 100mg, 200mg, 25mg, 50mg .
26
chlorthalidone tabs 25mg ...................................................41
chlorthalidone tabs 50mg ...................................................41
Drug Name
Page Number
chlorzoxazone tabs 500mg .................................................70
cholestyramine light ..............................................................42
cholestyramine pack..............................................................42
cholestyramine powd ............................................................42
ciclodan.....................................................................................16
ciclopirox gel, susp..................................................................16
ciclopirox nail lacquer ............................................................16
ciclopirox olamine crea .........................................................16
ciclopirox sham .......................................................................16
cilostazol ...................................................................................36
cimetidine hcl soln..................................................................47
cimetidine tabs 200mg, 300mg, 800mg ........................47
cimetidine tabs 400mg ........................................................47
CINRYZE ........................................................................... 60
CIPRODEX ........................................................................ 67
ciprofloxacin er ........................................................................10
ciprofloxacin hcl soln 0.3% ..................................................64
ciprofloxacin hcl tabs 100mg, 750mg .............................10
ciprofloxacin hcl tabs 250mg, 500mg .............................10
ciprofloxacin inj, otic soln, susr............................................10
ciprofloxacin i.v-in
. d5w .........................................................10
cisplatin inj 100mg/100ml, 200mg/200ml,
50mg/50ml .............................................................................20
citalopram hydrobromide soln............................................14
citalopram hydrobromide tabs 10mg...............................14
citalopram hydrobromide tabs 20mg...............................14
citalopram hydrobromide tabs 40mg...............................14
CITRANATAL 90 DHA MISC 120MG; 159MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG;
90MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG;
30UNIT; 25MG ............................................................... 76
CITRANATAL ASSURE MISC 120MG; 124MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG;
35MG; 0; 20MG; 150MCG; 25MG; 3.4MG; 3MG;
30UNIT; 25MG ............................................................... 76
CITRANATAL B-CALM................................................... 76
CITRANATAL DHA MISC 625MG; 120MG; 0; 124MG;
400UNIT; 2MG; 250MG; 50MG; 0.625MG; 0; 1MG;
27MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG;
30UNIT; 25MG ............................................................... 76
CITRANATAL RX TABS 120MG; 125MG; 400UNIT;
2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 25MG ........................................ 76
citric acid/sodium citrate ......................................................72
cladribine ..................................................................................20
claravis ......................................................................................45
clarithromycin susr .................................................................. 9
clarithromycin tabs .................................................................. 9
Drug Name
Page Number
clemastine fumarate tabs 2.68mg ....................................68
clindacin etz pledgets ............................................................45
clindacin-p ...............................................................................45
clindamax gel...........................................................................45
clindamycin/benzoyl peroxide gel 5%; 1%.......................45
clindamycin/benzoyl peroxide gel 5%; 1.2% ...................45
clindamycin hcl caps 75mg ................................................... 6
clindamycin hcl caps 150mg, 300mg ................................ 6
clindamycin palmitate hcl ...................................................... 6
clindamycin phosphate add-vantage inj 900mg/6ml ... 6
clindamycin phosphate crea 2% .......................................... 6
clindamycin phosphate external soln 1%.........................45
clindamycin phosphate foam 1% ......................................45
clindamycin phosphate gel 1% ...........................................45
clindamycin phosphate in d5w ............................................. 6
clindamycin phosphate inj 150mg/ml, 300mg/2ml,
600mg/4ml, 9000mg/60ml, 900mg/6ml ...................... 6
clindamycin phosphate lotn 1% .........................................45
clindamycin phosphate swab 1%.......................................45
clindamycin phosphate/tretinoin .......................................45
clinisol sf 15% .........................................................................72
clinpro 5000............................................................................44
clobetasol propionate crea, gel, lotn, oint, sham............50
clobetasol propionate e ........................................................50
clobetasol propionate emollient foam ..............................50
clobetasol propionate foam 0.05% ...................................50
clobetasol propionate liqd, soln ..........................................50
clodan ........................................................................................50
CLOLAR ............................................................................ 20
clomipramine hcl caps ..........................................................15
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg .........11
clonazepam odt tbdp 1mg...................................................11
clonazepam odt tbdp 2mg...................................................11
clonazepam tabs 0.5mg .......................................................11
clonazepam tabs 1mg...........................................................11
clonazepam tabs 2mg...........................................................11
clonidine hcl ptwk...................................................................36
clonidine hcl tabs ....................................................................36
clopidogrel tabs 75mg ..........................................................36
clopidogrel tabs 300mg .......................................................36
clorazepate dipotassium tabs 3.75mg, 7.5mg...............32
clorazepate dipotassium tabs 15mg .................................31
clotrimazole/betamethasone dipropionate.....................16
clotrimazole crea, troc...........................................................16
clotrimazole soln ....................................................................16
clozapine odt ...........................................................................28
clozapine tabs 100mg, 200mg, 25mg, 50mg ...............28
COARTEM ........................................................................ 24
89
Drug Name
Page Number
codeine sulfate tabs ................................................................. 3
colchicine caps ........................................................................17
colchicine tabs 0.6mg ...........................................................17
colestipol hcl gran, pack .......................................................42
colestipol hcl tabs ...................................................................42
colistimethate sodium ............................................................. 6
colocort .....................................................................................50
COMBIGAN ..................................................................... 64
COMBIVENT RESPIMAT ................................................ 68
COMETRIQ....................................................................... 23
COMPLERA ...................................................................... 29
completenate...........................................................................76
compro ......................................................................................26
COMVAX........................................................................... 62
CONCEPT DHA ............................................................... 76
CONCEPT OB .................................................................. 76
constulose ................................................................................48
COPAXONE INJ 20MG/ML............................................ 44
COPAXONE INJ 40MG/ML............................................ 44
CORLANOR ..................................................................... 40
cormax scalp application ......................................................50
cortisone acetate tabs 25mg...............................................50
COSMEGEN ..................................................................... 20
COTELLIC ......................................................................... 20
CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT,
180000UNIT; 36000UNIT; 114000UNIT................. 46
CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT,
30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT;
12000UNIT; 38000UNIT.............................................. 46
CRIXIVAN CAPS 200MG, 400MG ............................... 30
cromolyn sodium conc 100mg/5ml .................................47
cromolyn sodium nebu 20mg/2ml ...................................69
cromolyn sodium soln 4%....................................................66
cryselle-28 ...............................................................................54
CUBICIN ............................................................................. 6
CUBICIN RF ........................................................................ 6
CUPRIMINE CAPS 250MG ........................................... 70
cyclafem 1/35 .........................................................................54
cyclafem 7/7/7 .......................................................................54
cyclobenzaprine hcl tabs ......................................................70
cyclophosphamide caps .......................................................19
cyclophosphamide inj ...........................................................19
cycloserine ...............................................................................18
cyclosporine caps ...................................................................60
cyclosporine inj .......................................................................60
cyclosporine modified caps 50mg .....................................60
cyclosporine modified caps 100mg, 25mg.....................60
cyclosporine modified soln ..................................................60
cyproheptadine hcl tabs .......................................................68
90
Drug Name
Page Number
CYRAMZA ........................................................................ 24
cyred ..........................................................................................54
CYSTADANE..................................................................... 46
CYSTAGON ...................................................................... 46
CYSTARAN ....................................................................... 64
cytarabine aqueous ...............................................................20
dacarbazine .............................................................................20
DALIRESP ......................................................................... 69
DALVANCE ......................................................................... 6
danazol caps ............................................................................53
dantrolene sodium caps .......................................................28
dapsone tabs ...........................................................................18
DAPTACEL ........................................................................ 62
DARAPRIM ....................................................................... 24
darifenacin hydrobromide er...............................................49
DARZALEX ....................................................................... 24
dasetta 1/35............................................................................54
dasetta 7/7/7 ..........................................................................54
daunorubicin hcl inj 5mg/ml ...............................................20
daysee .......................................................................................54
deblitane ...................................................................................57
decitabine .................................................................................20
deltasone tabs 20mg.............................................................50
delyla .........................................................................................54
DELZICOL ......................................................................... 63
DENAVIR........................................................................... 31
dentagel ....................................................................................44
DEPEN TITRATABS ......................................................... 70
DEPOCYT ......................................................................... 19
DEPO-ESTRADIOL INJ 5MG/ML ................................. 54
DEPO-PROVERA INJ 400MG/ML................................ 57
DESCOVY.......................................................................... 30
desipramine hcl tabs 10mg, 75mg ...................................15
desipramine hcl tabs 100mg, 150mg, 25mg, 50mg...15
desmopressin acetate inj, tabs ............................................52
desmopressin acetate nasal soln 0.01% ..........................52
desogestrel/ethinyl estradiol ...............................................54
desonide crea, lotn .................................................................50
desonide oint ...........................................................................50
desoximetasone crea 0.05% ...............................................50
desoximetasone crea 0.25% ...............................................50
desoximetasone gel................................................................50
desoximetasone oint ..............................................................50
desvenlafaxine er tb24 50mg .............................................14
desvenlafaxine er tb24 100mg, 50mg.............................14
dexamethasone elix................................................................50
DEXAMETHASONE INTENSOL.................................... 50
dexamethasone sodium phosphate inj 10mg/ml,
Drug Name
Page Number
120mg/30ml ..........................................................................50
dexamethasone sodium phosphate inj 100mg/10ml,
10mg/ml, 20mg/5ml, 4mg/ml ..........................................50
dexamethasone sodium phosphate ophthalmic soln
0.1% ..........................................................................................66
dexamethasone soln ..............................................................50
dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg,
4mg, 6mg .................................................................................51
dexmethylphenidate hcl........................................................43
dexrazoxane .............................................................................20
dextroamphetamine sulfate soln ........................................43
dextroamphetamine sulfate tabs........................................43
dextrose 2.5%/nacl 0.45% ..................................................73
dextrose 5% .............................................................................73
dextrose 5% /electrolyte #48 viaflex ................................73
dextrose 5%/lactated ringers ..............................................73
dextrose 5%/nacl 0.2% .........................................................73
dextrose 5%/nacl 0.3% .........................................................73
dextrose 5%/nacl 0.9% .........................................................73
dextrose 5%/nacl 0.33% ......................................................73
dextrose 5%/nacl 0.45% ......................................................73
dextrose 5%/nacl 0.225% ...................................................73
dextrose 5%/potassium chloride 0.15% ..........................73
dextrose 10% ..........................................................................73
dextrose 10%/nacl 0.2% ......................................................73
dextrose 10%/nacl 0.45% ..................................................72
dextrose 20% ..........................................................................73
dextrose 25% inj 250mg/ml ...............................................73
dextrose 30% ..........................................................................73
dextrose 40% ..........................................................................73
dextrose 50% ..........................................................................73
dextrose 70% ..........................................................................73
diazepam gel 10mg, 2.5mg, 20mg ...................................11
diazepam inj 5mg/ml ............................................................32
diazepam intensol ..................................................................32
diazepam oral soln 1mg/ml .................................................32
diazepam tabs 10mg, 2mg, 5mg .......................................32
diclofenac potassium .............................................................. 1
diclofenac sodium dr ............................................................... 1
diclofenac sodium er ............................................................... 1
diclofenac sodium gel 1% ....................................................45
dicloxacillin sodium .................................................................. 9
dicyclomine hcl caps, soln, tabs ..........................................47
didanosine cpdr 125mg .......................................................30
didanosine cpdr 200mg, 250mg, 400mg ......................30
DIFICID................................................................................ 9
diflorasone diacetate .............................................................51
Drug Name
Page Number
diflunisal tabs 500mg ............................................................. 1
digitek ........................................................................................40
digoxin inj 0.25mg/ml ...........................................................40
digoxin oral soln ......................................................................40
digoxin tabs 125mcg.............................................................40
digoxin tabs 250mcg.............................................................40
digox tabs 125mcg ................................................................40
digox tabs 250mcg ................................................................40
dihydroergotamine mesylate inj .........................................17
DILANTIN CAPS 30MG ................................................. 12
diltiazem cd ..............................................................................39
diltiazem hcl cd .......................................................................39
diltiazem hcl er cp12 .............................................................39
diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg,
360mg, 420mg ......................................................................39
diltiazem hcl er cp24 180mg, 360mg .............................39
diltiazem hcl er tb24 ..............................................................39
diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml,
50mg/10ml .............................................................................39
diltiazem hcl tabs 30mg, 60mg..........................................39
diltiazem hcl tabs 120mg, 90mg .......................................39
dilt-xr .........................................................................................39
diphenatol ................................................................................47
diphenhydramine hcl inj 50mg/ml ....................................68
diphenoxylate/atropine liqd .................................................47
diphenoxylate/atropine tabs ................................................47
diphtheria/tetanus toxoids adsorbed pediatric...............62
disopyramide phosphate caps 100mg .............................37
disopyramide phosphate caps 150mg .............................37
disulfiram tabs........................................................................... 5
divalproex sodium csdr..........................................................11
divalproex sodium dr .............................................................11
divalproex sodium er..............................................................11
DOCEFREZ INJ 20MG .................................................... 20
docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml,
200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml,
80mg/8ml................................................................................20
dofetilide ...................................................................................37
donepezil hcl tabs 10mg ......................................................13
donepezil hcl tabs 23mg, 5mg ...........................................13
donepezil hcl tbdp ..................................................................13
dorzolamide hcl ......................................................................66
dorzolamide hcl/timolol maleate .......................................66
doxazosin ..................................................................................36
doxazosin mesylate tabs 1mg, 2mg...................................36
doxazosin mesylate tabs 8mg .............................................36
doxepin hcl caps 100mg, 10mg, 25mg, 50mg, 75mg 15
doxepin hcl caps 150mg ......................................................15
91
Drug Name
Page Number
doxepin hcl conc .....................................................................15
doxepin hydrochloride...........................................................45
doxercalciferol caps................................................................63
doxorubicin hcl inj 10mg, 2mg/ml, 50mg .......................20
doxorubicin hcl liposome ......................................................20
doxy 100 ...................................................................................10
doxycycline hyclate caps 50mg ..........................................10
doxycycline hyclate caps 100mg........................................10
doxycycline hyclate dr............................................................10
doxycycline hyclate inj ...........................................................10
doxycycline hyclate tabs 20mg ...........................................10
doxycycline hyclate tabs 100mg ........................................10
doxycycline monohydrate caps 50mg, 75mg.................10
doxycycline monohydrate caps 100mg, 150mg ...........10
doxycycline monohydrate tabs 50mg, 75mg .................10
doxycycline monohydrate tabs 100mg, 150mg ............10
doxycycline susr ......................................................................10
dronabinol ................................................................................16
drospirenone/ethinyl estradiol/levomefolate calcium ..54
drospirenone/ethinyl estradiol tabs 3mg; 0.02mg ........54
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg ........54
DROXIA ............................................................................. 19
DUET DHA 400 ............................................................... 77
DUET DHA BALANCED MISC 120MG; 2800UNIT;
215MG; 640UNIT; 55MG; 1.8MG; 12MCG; 0; 0; 0;
1MG; 25MG; 0; 25MG; 20MG; 267MG; 0; 210MCG;
50MG; 2MG; 0; 65MCG; 1.5MG; 15MG; 25MG ...... 77
duloxetine hcl cpep 20mg, 60mg ......................................14
duloxetine hcl cpep 30mg ....................................................14
duloxetine hcl cpep 40mg ....................................................14
duramorph ................................................................................. 3
DUREZOL ......................................................................... 66
dutasteride ...............................................................................49
dutasteride/tamsulosin hydrochloride ..............................49
econazole nitrate crea ...........................................................16
EDARBI.............................................................................. 36
EDARBYCLOR .................................................................. 36
EDURANT......................................................................... 29
EFFIENT ............................................................................ 36
EGRIFTA INJ 1MG ............................................................ 52
EGRIFTA INJ 2MG ............................................................ 52
ELIDEL............................................................................... 45
elinest ........................................................................................54
ELITEK ............................................................................... 20
elite-ob ......................................................................................77
ELLA .................................................................................. 57
EMCYT .............................................................................. 19
EMEND CAPS 0, 125MG, 80MG ................................. 16
92
Drug Name
Page Number
EMEND CAPS 40MG...................................................... 16
EMEND SUSR................................................................... 16
emoquette ................................................................................54
EMPLICITI......................................................................... 24
EMSAM ............................................................................. 13
EMTRIVA........................................................................... 30
enalapril maleate/hydrochlorothiazide ............................37
enalapril maleate tabs ...........................................................37
ENBRACE HR ................................................................... 77
ENBREL INJ 25MG .......................................................... 60
ENBREL INJ 25MG/0.5ML ............................................ 60
ENBREL INJ 50MG/ML .................................................. 60
ENBREL SURECLICK....................................................... 60
endocet tabs 325mg; 2.5mg, 325mg; 5mg ..................... 3
endocet tabs 325mg; 10mg, 325mg; 7.5mg .................. 3
endodan tabs 325mg; 4.835mg ......................................... 3
ENGERIX-B ...................................................................... 62
enoxaparin sodium.................................................................34
enpresse-28 ............................................................................54
enskyce......................................................................................54
entacapone ..............................................................................25
entecavir ...................................................................................28
ENTRESTO ....................................................................... 36
enulose ......................................................................................48
ENVARSUS XR ................................................................. 60
EPCLUSA .......................................................................... 29
epinastine hcl ..........................................................................66
EPIPEN 2-PAK ................................................................. 69
EPIPEN-JR 2-PAK............................................................ 69
epirubicin hcl inj 200mg/100ml, 50mg/25ml ..............20
epitol ..........................................................................................12
EPIVIR HBV SOLN ........................................................... 29
eplerenone ...............................................................................41
epoprostenol sodium .............................................................69
eprosartan mesylate ..............................................................36
EPZICOM .......................................................................... 30
EQUETRO ......................................................................... 32
ERAXIS .............................................................................. 16
ERBITUX............................................................................ 21
ergoloid mesylates tabs ........................................................13
ERIVEDGE......................................................................... 23
errin............................................................................................58
ERWINAZE ....................................................................... 21
ery...............................................................................................45
ERYTHROCIN LACTOBIONATE INJ 500MG................. 9
erythromycin base ................................................................... 9
erythromycin/benzoyl peroxide ..........................................45
erythromycin cpep 250mg .................................................... 9
erythromycin ethylsuccinate tabs ........................................ 9
Drug Name
Page Number
erythromycin gel 2% .............................................................45
erythromycin oint 5mg/gm .................................................64
erythromycin pads 2% ..........................................................45
erythromycin soln 2% ...........................................................45
erythromycin stearate tabs 250mg..................................... 9
ESBRIET ............................................................................ 70
ESCAVITE D...................................................................... 77
ESCAVITE LQ ................................................................... 77
escitalopram oxalate soln .....................................................14
escitalopram oxalate tabs 10mg, 5mg .............................14
escitalopram oxalate tabs 20mg ........................................14
esgic caps ................................................................................... 1
esomeprazole magnesium ...................................................48
esomeprazole sodium ...........................................................48
estarylla.....................................................................................54
ESTRACE CREA ............................................................... 53
estradiol/norethindrone acetate ........................................54
estradiol pttw...........................................................................53
estradiol ptwk ..........................................................................53
estradiol tabs 0.5mg, 1mg...................................................53
estradiol tabs 2mg .................................................................53
ethambutol hcl tabs ...............................................................18
ethosuximide ...........................................................................11
etidronate disodium...............................................................63
etodolac caps............................................................................. 1
etodolac er tb24 400mg, 500mg ....................................... 1
etodolac er tb24 600mg ........................................................ 1
etodolac tabs ............................................................................. 1
etoposide inj 100mg/5ml, 1gm/50ml, 500mg/25ml .22
EVOTAZ............................................................................. 30
EVZIO .................................................................................. 5
exemestane ..............................................................................22
EXJADE.............................................................................. 70
EXONDYS 51 ................................................................... 64
EXTRA-VIRT PLUS DHA ................................................ 77
FABRAZYME..................................................................... 46
falmina ......................................................................................54
famciclovir tabs 125mg, 250mg .......................................31
famciclovir tabs 500mg .......................................................31
famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml .47
famotidine premixed..............................................................47
famotidine susr 40mg/5ml .................................................48
famotidine tabs 20mg, 40mg.............................................48
FANAPT TABS 10MG ..................................................... 27
FANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG, 8MG ...
27
FANAPT TITRATION PACK ............................................ 27
FARESTON........................................................................ 19
Drug Name
Page Number
FARYDAK .......................................................................... 21
FASLODEX ........................................................................ 21
FAZACLO TBDP 12.5MG, 150MG, 200MG .............. 28
felbamate .................................................................................12
felodipine er tb24 2.5mg, 5mg ..........................................39
felodipine er tb24 10mg ......................................................39
femynor.....................................................................................54
fenofibrate caps 130mg, 43mg .........................................41
fenofibrate caps 150mg, 50mg .........................................41
fenofibrate micronized ..........................................................41
fenofibrate tabs 120mg, 40mg ..........................................41
fenofibrate tabs 145mg, 160mg, 48mg, 54mg ............41
fenofibric acid..........................................................................41
fenofibric acid dr.....................................................................41
fentanyl citrate oral transmucosal ....................................... 3
fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr............... 2
fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/hr,
62.5mcg/hr, 87.5mcg/hr....................................................... 2
FERRIPROX SOLN 100MG/ML..................................... 64
FERRIPROX TABS 500MG ............................................. 71
FETZIMA ........................................................................... 14
FETZIMA TITRATION PACK........................................... 14
finasteride tabs 5mg ..............................................................49
FIRAZYR ............................................................................ 60
FIRMAGON ...................................................................... 59
FLEBOGAMMA DIF ........................................................ 61
flecainide acetate tabs 50mg ..............................................37
flecainide acetate tabs 100mg, 150mg ...........................38
floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg;
262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg;
20unit; 2000unit; 5mg ........................................................77
FLORIVA LIQD 0.25MG/ML; 400UNIT/ML ............... 73
FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/
BLIST ................................................................................. 67
FLOVENT DISKUS AEPB 250MCG/BLIST .................. 67
FLOVENT HFA AERO 44MCG/ACT ............................. 67
FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT67
fluconazole in dextrose inj 56mg/ml; 200mg/100ml,
56mg/ml; 400mg/200ml ...................................................16
fluconazole in nacl..................................................................16
fluconazole susr, tabs.............................................................16
flucytosine ................................................................................16
fludarabine phosphate ..........................................................21
fludrocortisone acetate tabs ................................................51
flunisolide soln 0.025% ........................................................67
fluocinolone acetonide body ...............................................45
fluocinolone acetonide crea 0.01%, 0.025% .................51
fluocinolone acetonide oil 0.01% ......................................67
93
Drug Name
Page Number
fluocinolone acetonide oint 0.025%.................................51
fluocinolone acetonide scalp ...............................................45
fluocinolone acetonide soln 0.01% ...................................51
fluocinonide crea 0.1% .........................................................51
fluocinonide crea 0.05% ......................................................51
fluocinonide-e .........................................................................51
fluocinonide gel.......................................................................51
fluocinonide oint, soln ...........................................................51
fluor-a-day soln ......................................................................73
fluoride chew 0.25mg ...........................................................73
fluoride chew 1.1mg, 2.2mg ...............................................73
fluoridex daily defense ...........................................................44
fluoritab chew 0.5mg, 1mg .................................................73
fluoritab soln 0.125mg/drop ..............................................73
fluorometholone.....................................................................66
fluorouracil crea 0.5%...........................................................45
fluorouracil crea 5% ..............................................................45
fluorouracil external soln 2%, 5% ......................................45
fluorouracil inj 1gm/20ml, 2.5gm/50ml .........................21
fluoxetine ..................................................................................14
fluoxetine dr .............................................................................14
fluoxetine hcl caps, soln ........................................................14
fluoxetine hcl tabs 10mg, 20mg.........................................14
fluoxetine hcl tabs 60mg ......................................................14
fluphenazine decanoate inj ..................................................26
fluphenazine hcl conc, inj .....................................................26
fluphenazine hcl elix...............................................................26
fluphenazine hcl tabs 2.5mg ...............................................26
fluphenazine hcl tabs 10mg, 1mg, 5mg ..........................26
FLURA-DROPS SOLN 0.25MG/DROP ....................... 73
flurbiprofen sodium ...............................................................66
flurbiprofen tabs 50mg........................................................... 1
flurbiprofen tabs 100mg ........................................................ 1
flutamide...................................................................................19
fluticasone propionate crea 0.05% ...................................51
fluticasone propionate lotn 0.05% ....................................51
fluticasone propionate oint 0.005% .................................51
fluticasone propionate susp 50mcg/act ...........................67
fluvastatin caps 20mg...........................................................42
fluvastatin caps 40mg...........................................................42
fluvastatin sodium er .............................................................42
fluvoxamine maleate tabs 25mg ........................................14
fluvoxamine maleate tabs 100mg, 50mg........................14
FOCALGIN 90 DHA ........................................................ 77
FOCALGIN CA ................................................................. 77
FOLCAL DHA CAPS 28MG; 160MG; 400UNIT; 300MG; 55MG; 27MG; 1.25MG; 25MG; 30UNIT ... 77
FOLCAPS OMEGA 3 ....................................................... 77
94
Drug Name
Page Number
FOLET ONE ...................................................................... 77
FOLIVANE-OB ................................................................. 77
FOLIVANE-PRX DHA NF................................................ 77
FOLOTYN.......................................................................... 21
fomepizole ................................................................................71
fondaparinux sodium ............................................................34
FORADIL AEROLIZER ..................................................... 69
FORTEO INJ 600MCG/2.4ML ....................................... 63
fosinopril sodium/hydrochlorothiazide ............................37
fosinopril sodium tabs 10mg ..............................................37
fosinopril sodium tabs 20mg, 40mg.................................37
fosphenytoin sodium .............................................................12
FOSRENOL CHEW 1000MG, 500MG, 750MG ........ 49
FOSRENOL PACK 750MG ............................................. 49
FOSRENOL PACK 1000MG........................................... 49
FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML 73
furosemide inj 10mg/ml .......................................................41
furosemide oral soln ..............................................................41
furosemide tabs ......................................................................41
FUSILEV ............................................................................ 21
FUZEON ............................................................................ 30
fyavolv .......................................................................................54
FYCOMPA SUSP .............................................................. 11
FYCOMPA TABS 2MG .................................................... 11
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG ... 11
gabapentin caps, soln............................................................11
gabapentin tabs 600mg, 800mg ......................................11
GABITRIL TABS 12MG, 16MG ..................................... 11
galantamine hydrobromide cp24 ......................................13
galantamine hydrobromide soln ........................................13
galantamine hydrobromide tabs ........................................13
GAMASTAN S/D ............................................................. 61
GAMMAGARD LIQUID .................................................. 61
GAMMAGARD S/D IGA LESS THAN 1MCG/ML ...... 61
GAMMAKED .................................................................... 61
GAMMAPLEX .................................................................. 61
GAMUNEX-C................................................................... 61
ganciclovir inj...........................................................................28
GARDASIL ........................................................................ 62
GARDASIL 9 ..................................................................... 62
gatifloxacin ...............................................................................65
GATTEX............................................................................. 47
GAUZE PADS 2”X2” ....................................................... 64
Drug Name
Page Number
gavilyte-c ..................................................................................48
gavilyte-g..................................................................................48
gavilyte-h..................................................................................47
gavilyte-n/flavor pack ...........................................................48
GAZYVA ............................................................................ 24
gemcitabine .............................................................................21
gemcitabine hcl.......................................................................21
gemfibrozil tabs.......................................................................42
generlac ....................................................................................48
gengraf caps ............................................................................60
gengraf soln .............................................................................60
gentak oint ...............................................................................65
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml;
0.9% ............................................................................................ 5
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/
ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml;
0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9% .................................. 5
gentamicin sulfate crea 0.1%..............................................45
gentamicin sulfate external oint 0.1% ..............................45
gentamicin sulfate inj 10mg/ml ........................................... 5
gentamicin sulfate inj 40mg/ml ........................................... 5
gentamicin sulfate ophthalmic oint 0.3%........................65
gentamicin sulfate ophthalmic soln 0.3% .......................65
gentamicin sulfate pediatric .................................................. 5
GENVOYA ......................................................................... 29
GEODON INJ .................................................................... 27
gianvi .........................................................................................54
gildagia......................................................................................54
gildess 1.5/30 .........................................................................54
gildess 1/20 .............................................................................54
gildess 24 fe .............................................................................54
gildess fe 1.5/30.....................................................................54
gildess fe 1/20 ........................................................................54
GILENYA ........................................................................... 44
GILOTRIF........................................................................... 23
glatopa ......................................................................................44
GLEEVEC TABS 100MG ................................................. 23
GLEEVEC TABS 400MG ................................................. 23
GLEOSTINE CAPS 5MG ................................................. 19
glimepiride ...............................................................................32
glipizide er ................................................................................32
glipizide/metformin hcl tabs 2.5mg; 250mg ..................32
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg;
500mg ......................................................................................32
glipizide tabs ............................................................................32
glipizide xl tb24 2.5mg, 5mg ..............................................32
glipizide xl tb24 10mg ..........................................................32
GLUCAGEN HYPOKIT .................................................... 33
Drug Name
Page Number
GLUCAGON EMERGENCY KIT ..................................... 33
glyburide/metformin hcl.......................................................32
glyburide micronized tabs 1.5mg.......................................32
glyburide micronized tabs 3mg, 6mg ...............................32
glyburide tabs 1.25mg..........................................................32
glyburide tabs 2.5mg, 5mg .................................................32
glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml ....47
glycopyrrolate inj 4mg/20ml ..............................................47
glycopyrrolate tabs.................................................................47
glydo ............................................................................................ 4
granisetron hcl tabs ...............................................................16
griseofulvin microsize susp ..................................................17
griseofulvin microsize tabs ...................................................17
griseofulvin ultramicrosize tabs 125mg, 250mg ..........17
guanfacine er...........................................................................43
guanidine hcl ...........................................................................18
HALAVEN ......................................................................... 21
halobetasol propionate crea ................................................51
halobetasol propionate oint ................................................51
haloperidol conc .....................................................................26
haloperidol decanoate ..........................................................26
haloperidol lactate .................................................................26
haloperidol tabs 0.5mg, 1mg, 20mg, 5mg .....................26
haloperidol tabs 10mg, 2mg...............................................26
HARVONI ......................................................................... 29
HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML ............... 62
heather......................................................................................58
hecoria ......................................................................................60
HEMENATAL OB ............................................................. 77
HEMENATAL OB + DHA ................................................ 77
heparin sodium/d5w .............................................................34
heparin sodium inj 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/0.5ml, 5000unit/ml.............35
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9% ...............34
heparin sodium/nacl 0.45% ................................................34
heparin sodium/sodium chloride 0.9% ............................34
heparin sodium/sodium chloride 0.9% premix ..............34
hepatamine ..............................................................................73
HERCEPTIN ...................................................................... 21
HETLIOZ ........................................................................... 70
HEXALEN ......................................................................... 19
HIBERIX............................................................................. 62
H.P. ACTHAR.................................................................... 52
HUMALOG ....................................................................... 33
HUMALOG KWIKPEN .................................................... 34
HUMALOG MIX 50/50 .................................................. 34
HUMALOG MIX 50/50 KWIKPEN................................ 34
HUMALOG MIX 75/25 .................................................. 34
95
Drug Name
Page Number
HUMALOG MIX 75/25 KWIKPEN................................ 34
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML ................ 60
HUMIRA INJ 40MG/0.8ML ........................................... 60
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK.................................................................................. 60
HUMIRA PEN ................................................................... 60
HUMIRA PEN-CROHNS DISEASESTARTER............... 60
HUMIRA PEN-PSORIASIS STARTER ........................... 60
HUMULIN 70/30 ............................................................ 34
HUMULIN 70/30 KWIKPEN ......................................... 34
HUMULIN N ..................................................................... 34
HUMULIN N KWIKPEN .................................................. 34
HUMULIN R ..................................................................... 34
HUMULIN R U-500 (CONCENTRATED)..................... 34
HUMULIN R U-500 KWIKPEN ..................................... 34
hydralazine hcl inj, tabs .........................................................43
hydrochlorothiazide caps .....................................................41
hydrochlorothiazide tabs 12.5mg .....................................41
hydrochlorothiazide tabs 25mg, 50mg ...........................41
hydrocodone/acetaminophen tabs 325mg; 5mg,
325mg; 7.5mg ......................................................................... 3
hydrocodone/acetaminophen tabs 325mg; 10mg......... 3
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml ................................................. 3
hydrocodone bitartrate/acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg; 7.5mg................................. 3
hydrocodone bitartrate/acetaminophen tabs 325mg;
2.5mg .......................................................................................... 3
hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg;
200mg ........................................................................................ 3
hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg;
200mg ........................................................................................ 3
hydrocortisone/acetic acid ...................................................67
hydrocortisone butyrate crea, oint, soln ...........................51
hydrocortisone butyrate (lipophilic)...................................51
hydrocortisone crea 1%, 2.5% ...........................................51
hydrocortisone enem, tabs ..................................................51
hydrocortisone in absorbase ...............................................51
hydrocortisone lotn 2.5%.....................................................51
hydrocortisone oint 1% ........................................................51
hydrocortisone oint 2.5%.....................................................51
hydrocortisone valerate crea ...............................................51
hydrocortisone valerate oint................................................51
hydromorphone hcl inj 4mg/ml ........................................... 3
hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml,
50mg/5ml.................................................................................. 3
hydromorphone hcl liqd ......................................................... 3
hydromorphone hcl tabs ........................................................ 3
96
Drug Name
Page Number
hydroxychloroquine sulfate tabs.........................................25
hydroxyprogesterone caproate inj .....................................58
hydroxyurea caps....................................................................19
hydroxyzine hcl inj, syrp ........................................................68
hydroxyzine hcl tabs ...............................................................68
hydroxyzine pamoate caps 25mg, 50mg ........................68
hydroxyzine pamoate caps 100mg ...................................68
IBRANCE .......................................................................... 21
ibudone tabs 5mg; 200mg .................................................... 3
ibuprofen susp........................................................................... 1
ibuprofen tabs 400mg, 600mg, 800mg ........................... 1
ICLUSIG TABS 15MG ..................................................... 23
ICLUSIG TABS 45MG ..................................................... 23
idarubicin hcl ...........................................................................21
ifosfamide.................................................................................21
ILARIS................................................................................ 61
ILEVRO .............................................................................. 66
ilotycin .......................................................................................65
imatinib mesylate tabs 100mg ...........................................23
imatinib mesylate tabs 400mg ...........................................23
IMBRUVICA...................................................................... 23
imipenem/cilastatin ................................................................. 8
imipramine hcl tabs ...............................................................15
imiquimod crea .......................................................................45
IMOVAX RABIES (H.D.C.V.) ............................................ 62
inatal advance .........................................................................77
inatal ultra ................................................................................77
INCRELEX ......................................................................... 52
INCRUSE ELLIPTA ........................................................... 68
indapamide tabs .....................................................................41
INFANRIX .......................................................................... 62
INLYTA TABS 1MG .......................................................... 23
INLYTA TABS 5MG .......................................................... 23
INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” 64
INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”64
INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” . 64
INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” .. 64
INTELENCE TABS 25MG ............................................... 29
INTELENCE TABS 100MG, 200MG ............................ 29
intralipid inj 20gm/100ml ...................................................73
INTRALIPID INJ 30GM/100ML .................................... 73
INTRON A INJ 10MU/ML, 18MU, 50MU,
6000000UNIT/ML ......................................................... 21
INTRON A W/DILUENT.................................................. 21
introvale ....................................................................................54
INVANZ INJ 1GM............................................................... 8
INVEGA SUSTENNA ....................................................... 27
INVEGA TRINZA .............................................................. 27
INVIRASE .......................................................................... 30
Drug Name
Page Number
INVOKAMET .................................................................... 32
INVOKAMET XR .............................................................. 32
INVOKANA TABS 100MG ............................................. 33
INVOKANA TABS 300MG ............................................. 32
IPOL INACTIVATED IPV ................................................. 62
ipratropium bromide/albuterol sulfate .............................68
ipratropium bromide inhalation soln ................................68
ipratropium bromide nasal soln .........................................68
irbesartan .................................................................................36
irbesartan/hydrochlorothiazide..........................................36
IRESSA .............................................................................. 23
irinotecan .................................................................................21
ISENTRESS CHEW .......................................................... 29
ISENTRESS PACK ............................................................ 29
ISENTRESS TABS............................................................. 29
isoniazid inj...............................................................................18
isoniazid syrp ...........................................................................18
isoniazid tabs 100mg............................................................18
isoniazid tabs 300mg............................................................18
isosorbide dinitrate er............................................................42
isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg.....42
isosorbide mononitrate er ....................................................42
isosorbide mononitrate tabs 10mg ...................................42
isosorbide mononitrate tabs 20mg ...................................42
isotonic gentamicin inj 0.8mg/ml; 0.9% ............................ 5
isradipine ..................................................................................39
ISTODAX ........................................................................... 21
itraconazole caps....................................................................17
ivermectin tabs........................................................................24
IXEMPRA KIT ................................................................... 21
IXIARO .............................................................................. 62
JAKAFI ............................................................................... 23
jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg .......35
jantoven tabs 10mg, 2.5mg, 5mg .....................................35
JANUMET ......................................................................... 33
JANUMET XR TB24 1000MG; 50MG ......................... 33
JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG
33
JANUVIA TABS 50MG .................................................... 33
JANUVIA TABS 100MG, 25MG .................................... 33
jencycla .....................................................................................58
JENTADUETO ................................................................... 33
JENTADUETO XR ............................................................. 33
JEVTANA ........................................................................... 21
jinteli ..........................................................................................54
jolessa ........................................................................................55
jolivette ......................................................................................58
juleber........................................................................................55
junel 1.5/30 .............................................................................55
Drug Name
Page Number
junel 1/20.................................................................................55
junel fe 1.5/30 ........................................................................55
junel fe 1/20 ............................................................................55
junel fe 24.................................................................................55
KABIVEN........................................................................... 74
KADCYLA ......................................................................... 21
kaitlib fe.....................................................................................55
KALETRA SOLN .............................................................. 31
KALETRA TABS 100MG; 25MG ................................... 31
KALETRA TABS 200MG; 50MG ................................... 31
KALYDECO PACK............................................................. 69
KALYDECO TABS ............................................................. 69
kariva .........................................................................................55
kcl 0.3%/d5w/lr iv lac ring ....................................................74
kcl 0.3%/d5w/nacl 0.9% ......................................................74
kcl 0.3%/d5w/nacl 0.45%....................................................74
kcl 0.15%/d5w/lr ....................................................................74
kcl 0.15%/d5w/nacl 0.2%....................................................74
kcl 0.15%/d5w/nacl 0.9%....................................................74
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% ...74
kcl 0.15%/d5w/nacl 0.225% ..............................................74
kcl 0.075%/d5w/nacl 0.45% ..............................................74
kelnor 1/35 ..............................................................................55
ketoconazole crea, sham ......................................................17
ketoconazole tabs ...................................................................17
ketoprofen caps 50mg, 75mg .............................................. 1
ketoprofen er cp24 200mg ................................................... 1
ketorolac tromethamine.......................................................66
KEYTRUDA ....................................................................... 24
kimidess ....................................................................................55
KINRIX ............................................................................... 62
kionex ........................................................................................71
klor-con ....................................................................................74
klor-con 8.................................................................................74
klor-con 10 ..............................................................................74
KLOR-CON 25................................................................. 74
klor-con/ef ...............................................................................74
klor-con m10 ..........................................................................74
KLOR-CON M15 ............................................................. 74
klor-con m20 ..........................................................................74
klor-con sprinkle.....................................................................74
KORLYM ............................................................................ 33
KOSHER PRENATAL PLUS IRON .................................. 77
k-sol soln...................................................................................73
kurvelo.......................................................................................55
KUVAN .............................................................................. 46
KYNAMRO........................................................................ 42
labetalol hcl inj, tabs ..............................................................38
97
Drug Name
Page Number
lactated ringers viaflex ..........................................................74
lactulose soln 10gm/15ml ..................................................48
lamivudine soln 10mg/ml ....................................................30
lamivudine tabs 100mg .......................................................29
lamivudine tabs 150mg, 300mg .......................................30
lamivudine/zidovudine ..........................................................30
lamotrigine chew, tabs ..........................................................12
lamotrigine titration ..............................................................12
LANTUS ............................................................................ 34
LANTUS SOLOSTAR ....................................................... 34
larin 1.5/30 .............................................................................55
larin 1/20 .................................................................................55
larin 24 fe .................................................................................55
larin fe 1.5/30 .........................................................................55
larin fe 1/20.............................................................................55
larissia .......................................................................................55
LARTRUVO....................................................................... 21
latanoprost...............................................................................64
LATUDA TABS 40MG, 80MG ....................................... 27
LATUDA TABS 120MG, 20MG, 60MG ....................... 27
layolis fe ....................................................................................55
leena ..........................................................................................55
leflunomide ..............................................................................61
LENVIMA 8 MG DAILY DOSE ........................................ 23
LENVIMA 10 MG DAILY DOSE ..................................... 23
LENVIMA 14 MG DAILY DOSE ..................................... 23
LENVIMA 18 MG DAILY DOSE ..................................... 23
LENVIMA 20 MG DAILY DOSE ..................................... 23
LENVIMA 24 MG DAILY DOSE ..................................... 23
lessina........................................................................................55
LETAIRIS ........................................................................... 69
letrozole ....................................................................................22
leucovorin calcium inj 100mg, 200mg, 350mg, 500mg,
50mg .........................................................................................21
leucovorin calcium tabs 5mg ..............................................21
leucovorin calcium tabs 10mg, 15mg, 25mg ................21
LEUKERAN ....................................................................... 19
LEUKINE INJ 250MCG.................................................... 35
leuprolide acetate inj..............................................................59
levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml .........69
levalbuterol nebu ....................................................................69
LEVEMIR ........................................................................... 34
LEVEMIR FLEXTOUCH ................................................... 34
levetiracetam inj, oral soln, tabs .........................................11
levobunolol hcl soln 0.5% ....................................................66
levocarnitine ............................................................................71
levocetirizine dihydrochloride soln ....................................68
levocetirizine dihydrochloride tabs ....................................68
98
Drug Name
Page Number
levofloxacin in d5w .................................................................10
levofloxacin inj 25mg/ml ......................................................10
levofloxacin ophthalmic soln 0.5% ....................................65
levofloxacin oral soln 25mg/ml ..........................................10
levofloxacin tabs 250mg, 500mg, 750mg .....................10
levoleucovorin calcium..........................................................21
levoleucovorin inj 250mg/25ml, 50mg ...........................21
levonest .....................................................................................55
levonorgestrel..........................................................................58
levonorgestrel and ethinyl estradiol tabs 0; 0 .................55
levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg
55
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg55
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0;
0, 20mcg; 0.1mg....................................................................55
levora 0.15/30-28 ................................................................55
levothyroxine sodium inj .......................................................58
levothyroxine sodium tabs 100mcg, 112mcg, 125mcg,
150mcg, 25mcg, 50mcg, 75mcg, 88mcg......................58
levothyroxine sodium tabs 137mcg, 175mcg, 200mcg,
300mcg ....................................................................................58
levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg, 75mcg,
88mcg .......................................................................................58
levoxyl tabs 125mcg, 137mcg, 175mcg, 200mcg,
25mcg .......................................................................................58
LEXIVA .............................................................................. 31
LIALDA .............................................................................. 63
lidocaine hcl external soln 4% ............................................... 4
lidocaine hcl gel 2% ................................................................. 4
lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% ......................... 4
lidocaine hcl inj 10mg/ml, 20mg/ml .................................38
lidocaine hcl jelly gel 2% ......................................................... 4
lidocaine hcl mouth/throat soln 4% .................................... 4
lidocaine oint ............................................................................. 4
lidocaine/prilocaine crea ........................................................ 4
lidocaine/prilocaine kit ............................................................ 4
lidocaine ptch ............................................................................ 4
lidocaine viscous ....................................................................... 4
lindane lotn ..............................................................................25
lindane sham ...........................................................................25
linezolid inj.................................................................................. 6
linezolid susr .............................................................................. 6
linezolid tabs .............................................................................. 6
LINZESS ............................................................................ 48
liothyronine sodium tabs ......................................................58
lisinopril ....................................................................................37
lisinopril/hydrochlorothiazide .............................................37
lithium .......................................................................................32
Drug Name
Page Number
lithium carbonate caps, tabs ...............................................32
lithium carbonate er ..............................................................32
lokara .........................................................................................51
lomedia 24 fe ..........................................................................55
lomustine ..................................................................................19
LONSURF TABS 6.14MG; 15MG ................................. 19
LONSURF TABS 8.19MG; 20MG ................................. 20
loperamide hcl caps ...............................................................47
lopreeza.....................................................................................55
lorazepam inj 2mg/ml, 4mg/ml..........................................32
lorazepam intensol .................................................................32
lorazepam tabs 0.5mg ..........................................................32
lorazepam tabs 1mg..............................................................32
lorazepam tabs 2mg..............................................................32
lorcet ............................................................................................ 3
lorcet hd ...................................................................................... 3
lorcet plus tabs 325mg; 7.5mg ............................................ 3
lortab tabs 325mg; 5mg ........................................................ 3
lortab tabs 325mg; 10mg, 325mg; 7.5mg ...................... 3
loryna ........................................................................................55
losartan potassium/hydrochlorothiazide .........................36
losartan potassium tabs 25mg, 50mg .............................36
losartan potassium tabs 100mg ........................................36
LOTEMAX ......................................................................... 66
lovastatin ..................................................................................42
LOVAZA ............................................................................ 42
low-ogestrel .............................................................................55
loxapine succinate caps 10mg, 50mg, 5mg ...................26
loxapine succinate caps 25mg ............................................26
ludent ........................................................................................74
LUMIGAN ......................................................................... 64
LUMIZYME ....................................................................... 46
LUPRON DEPOT ............................................................. 59
LUPRON DEPOT-PED .................................................... 59
lutera..........................................................................................55
LYNPARZA ........................................................................ 21
LYRICA CAPS 100MG, 150MG, 200MG, 25MG,
50MG, 75MG .................................................................. 11
LYRICA CAPS 225MG, 300MG .................................... 11
LYRICA SOLN ................................................................... 11
LYSODREN ....................................................................... 59
lyza .............................................................................................58
magnesium sulfate inj 20gm/500ml, 2gm/50ml,
40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%............74
malathion .................................................................................25
maprotiline hcl ........................................................................14
margesic ..................................................................................... 1
marlissa.....................................................................................55
Drug Name
Page Number
MARNATAL-F CAPS ....................................................... 77
MARPLAN ........................................................................ 13
MARQIBO......................................................................... 21
MATULANE ...................................................................... 19
matzim la ..................................................................................40
meclizine hcl tabs ...................................................................15
meclofenamate sodium caps ................................................ 1
medroxyprogesterone acetate inj .......................................58
medroxyprogesterone acetate tabs 5mg .........................58
medroxyprogesterone acetate tabs 10mg, 2.5mg ........58
mefloquine hcl.........................................................................25
megestrol acetate susp 40mg/ml ......................................58
megestrol acetate tabs ..........................................................58
MEKINIST TABS 0.5MG ................................................. 23
MEKINIST TABS 2MG..................................................... 23
meloxicam susp......................................................................... 1
meloxicam tabs ......................................................................... 1
melphalan hydrochloride .....................................................19
memantine hcl ........................................................................13
memantine hcl titration pak ................................................13
memantine hydrochloride soln ...........................................13
MENACTRA ..................................................................... 62
MENEST............................................................................ 53
MENHIBRIX ...................................................................... 62
MENOMUNE-A/C/Y/W-135 ....................................... 62
MENVEO........................................................................... 62
MEPRON SUSP................................................................ 25
mercaptopurine tabs .............................................................20
meropenem ............................................................................... 8
meropenem/sodium chloride................................................ 8
mesalamine dr ........................................................................63
mesalamine enem, kit ...........................................................63
mesna ........................................................................................21
MESNEX TABS ................................................................. 21
MESTINON SYRP ............................................................ 18
MESTINON TIMESPAN .................................................. 18
metadate er tbcr 20mg.........................................................43
metaproterenol sulfate syrp, tabs .......................................69
metformin hcl er (osmotic) ..................................................33
metformin hcl er tb24 500mg, 750mg ...........................33
metformin hcl er tb24 1000mg.........................................33
metformin hcl tabs .................................................................33
methadone hcl conc ................................................................ 2
methadone hcl inj..................................................................... 2
methadone hcl oral soln ......................................................... 2
methadone hcl tabs ................................................................. 2
methadone hcl tbso ................................................................. 2
methadose tbso ........................................................................ 2
99
Drug Name
Page Number
methazolamide .......................................................................41
methenamine hippurate ......................................................... 6
methimazole tabs 10mg, 5mg ...........................................60
methotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml,
50mg/2ml................................................................................60
methotrexate tabs ..................................................................60
methoxsalen caps ...................................................................45
methscopolamine bromide..................................................47
methyclothiazide tabs ...........................................................41
methylergonovine maleate ..................................................49
methylphenidate hcl er cp24 30mg ..................................43
methylphenidate hcl er tbcr 10mg, 20mg.......................43
methylphenidate hcl sr..........................................................43
methylphenidate hcl tabs .....................................................43
methylprednisolone acetate inj 40mg/ml, 80mg/ml ....51
methylprednisolone dose pack tbpk ..................................51
methylprednisolone sodiumsuccinate inj 1000mg,
125mg, 40mg ........................................................................51
methylprednisolone tabs ......................................................51
metipranolol ............................................................................66
metoclopramide hcl inj .........................................................47
metoclopramide hcl oral soln, tabs ....................................47
metolazone ..............................................................................41
metoprolol/hydrochlorothiazide ........................................38
metoprolol succinate er tb24 100mg, 25mg, 50mg ...38
metoprolol succinate er tb24 200mg...............................38
metoprolol tartrate inj ...........................................................38
metoprolol tartrate tabs 37.5mg, 75mg..........................38
metoprolol tartrate tabs 100mg, 25mg, 50mg .............38
METRO IV ........................................................................... 6
metronidazole caps 375mg .................................................. 6
metronidazole crea 0.75% ..................................................45
metronidazole gel 0.75% .....................................................45
metronidazole gel 1% ...........................................................45
metronidazole in nacl 0.79% ................................................ 6
metronidazole lotn 0.75% ...................................................45
metronidazole tabs 250mg, 500mg................................... 6
metronidazole vaginal............................................................. 6
mexiletine hcl ...........................................................................38
MIACALCIN INJ................................................................ 63
microgestin 1.5/30................................................................55
microgestin 1/20 ...................................................................55
microgestin 24 fe ...................................................................56
microgestin fe..........................................................................56
microgestin fe 1.5/30 ...........................................................56
midodrine hcl ..........................................................................36
MIGERGOT....................................................................... 17
miglitol ......................................................................................33
100
Drug Name
Page Number
MILLIPRED ....................................................................... 51
MILLIPRED DP ................................................................. 51
mimvey......................................................................................56
mimvey lo .................................................................................56
minitran ....................................................................................42
minocycline hcl caps..............................................................10
minoxidil tabs...........................................................................43
mirtazapine odt.......................................................................13
mirtazapine tabs .....................................................................13
misoprostol ..............................................................................48
mitomycin ................................................................................21
mitoxantrone hcl inj 2mg/ml ...............................................21
M-M-R II........................................................................... 62
modafinil tabs 100mg ..........................................................70
modafinil tabs 200mg ..........................................................70
moderiba tabs .........................................................................29
moexipril hcl tabs 7.5mg ......................................................37
moexipril hcl tabs 15mg .......................................................37
moexipril/hydrochlorothiazide............................................37
molindone hydrochloride tabs 5mg ..................................28
molindone hydrochloride tabs 10mg ...............................28
molindone hydrochloride tabs 25mg ...............................28
mometasone furoate crea....................................................51
mometasone furoate oint, soln...........................................51
mono-linyah ............................................................................56
mononessa...............................................................................56
montelukast sodium ..............................................................68
morgidox 1x50mg .................................................................10
morgidox 1x100mg caps .....................................................10
morgidox 2x100mg caps .....................................................10
morphine sulfate er cp24 10mg, 30mg, 60mg ............... 2
morphine sulfate er cp24 100mg, 20mg, 30mg, 50mg,
60mg, 80mg ............................................................................. 2
morphine sulfate er cp24 120mg, 45mg, 75mg, 90mg2
morphine sulfate er tbcr 15mg............................................. 2
morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg2
morphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/
ml, 5mg/ml, 8mg/ml ............................................................... 3
morphine sulfate inj 10mg/ml, 1mg/ml ............................. 3
morphine sulfate oral soln 10mg/5ml ............................... 3
morphine sulfate oral soln 20mg/5ml ............................... 3
morphine sulfate oral soln 100mg/5ml ............................. 3
morphine sulfate tabs 15mg ................................................. 3
morphine sulfate tabs 30mg ................................................. 3
MOVANTIK....................................................................... 47
MOVIPREP ....................................................................... 48
MOXEZA ........................................................................... 65
Drug Name
Page Number
MOZOBIL.......................................................................... 35
MULTAQ ........................................................................... 38
multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit;
2500unit ..................................................................................77
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/
ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 1500unit/ml ...............................78
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/
ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml .......................................................78
multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit........................................................................................78
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml .........................................................77
multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml ....................................78
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit ...................................................................77
mupirocin calcium..................................................................45
mupirocin crea ........................................................................45
mupirocin oint .........................................................................45
MUSTARGEN ................................................................... 19
mvc-fluoride ............................................................................78
mycophenolate mofetil caps, inj, tabs ...............................60
mycophenolate mofetil susr ................................................60
myorisan ...................................................................................45
MYRBETRIQ ..................................................................... 49
myzilra .......................................................................................56
nabumetone .............................................................................. 2
nadolol/bendroflumethiazide .............................................39
nadolol tabs 20mg .................................................................39
nadolol tabs 40mg, 80mg ...................................................39
nafcillin........................................................................................ 9
NAGLAZYME ................................................................... 46
nalbuphine hcl inj 10mg/ml, 20mg/ml .............................. 4
naloxone hcl inj 0.4mg/ml, 4mg/10ml............................... 5
naloxone hcl inj 2mg/2ml ...................................................... 5
naltrexone hcl tabs ................................................................... 5
NAMENDA SOLN ........................................................... 13
NAMENDA TABS............................................................. 13
NAMENDA TITRATION PAK.......................................... 13
Drug Name
Page Number
NAMENDA XR CP24 14MG.......................................... 13
NAMENDA XR CP24 21MG, 28MG, 7MG ................. 13
NAMENDA XR TITRATION PACK ................................. 13
NAMZARIC C4PK............................................................ 13
NAMZARIC CP24 10MG; 14MG, 10MG; 28MG ...... 13
NAMZARIC CP24 10MG; 21MG, 10MG; 7MG ........ 13
naphazoline hcl .......................................................................65
naproxen dr tbec 375mg........................................................ 2
naproxen dr tbec 500mg........................................................ 2
naproxen sodium tabs 275mg, 550mg ............................. 2
naproxen susp ........................................................................... 2
naproxen tabs ............................................................................ 2
naratriptan hcl ........................................................................17
NARCAN LIQD .................................................................. 5
NASONEX ........................................................................ 68
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT .................................................................. 78
NATALVIRT 90 DHA........................................................ 78
NATALVIRT CA ................................................................. 78
nateglinide................................................................................33
NATELLE ONE CAPS 30MG; 102MG; 250MG; 0.625MG; 28MG; 1MG; 25MG; 30UNIT ................... 78
NATPARA ......................................................................... 64
NEBUPENT ...................................................................... 25
necon 0.5/35-28 ...................................................................56
necon 1/35 ..............................................................................56
NECON 1/50-28 ............................................................ 56
necon 7/7/7 ............................................................................56
NECON 10/11-28 .......................................................... 56
nefazodone hcl ........................................................................14
neomycin/bacitracin/polymyxin .........................................65
neomycin/polymyxin/bacitracin/hydrocortisone ...........65
neomycin/polymyxin/dexamethasone oint ......................65
neomycin/polymyxin/dexamethasone susp.....................65
neomycin/polymyxin/gramicidin ........................................65
neomycin/polymyxin/hc .......................................................67
neomycin/polymyxin/hydrocortisone ophthalmic susp
1%; 3.5mg/ml; 10000unit/ml............................................65
neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml ....................................................67
neomycin sulfate....................................................................... 5
neo-polycin ..............................................................................65
NEPHRAMINE ................................................................. 74
NESTABS ABC ................................................................. 78
NESTABS DHA................................................................. 78
NESTABS TABS 65MG; 155MG; 450UNIT; 55MG; 10MCG; 32MG; 1000MCG; 100MCG; 50MG; 3MG;
120MG; 3MG; 30UNIT; 10MG .................................... 78
101
Drug Name
Page Number
neuac .........................................................................................46
NEUMEGA ........................................................................ 35
NEUPOGEN ..................................................................... 35
NEUPRO ........................................................................... 25
NEVANAC......................................................................... 66
nevirapine er tb24 100mg ..................................................29
nevirapine er tb24 400mg ..................................................29
nevirapine susp .......................................................................29
nevirapine tabs ........................................................................29
NEXA PLUS CAPS 28MG; 0; 250MCG; 660MG;
160MG; 0; 800UNIT; 350MG; 55MG; 29MG; 1.25MG; 25MG; 30UNIT .............................................. 78
NEXAVAR.......................................................................... 23
niacin er ....................................................................................42
nicardipine hcl caps 20mg ...................................................40
nicardipine hcl caps 30mg ...................................................40
NICOTROL NS ................................................................... 5
nifedipine er tb24 30mg, 60mg, 90mg ...........................40
nifedipine er tb24 90mg ......................................................40
nikki ............................................................................................56
NILANDRON TABS 150MG .......................................... 19
nilutamide ................................................................................19
NINLARO .......................................................................... 21
NIPENT ............................................................................. 21
nisoldipine ................................................................................40
nisoldipine er ...........................................................................40
nitrofurantoin macrocrystals ................................................ 6
nitrofurantoin monohydrate ................................................. 6
nitrofurantoin monohydrate/macrocrystals ..................... 6
nitrofurantoin susp .................................................................. 6
nitroglycerin inj 5mg/ml .......................................................43
nitroglycerin lingual ...............................................................42
nitroglycerin subl 0.3mg, 0.4mg, 0.6mg .........................43
nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/hr,
0.6mg/hr ..................................................................................42
nitroglycerin transdermal pt24 0.2mg/hr .......................43
NITROSTAT SUBL............................................................ 43
NIVA-PLUS....................................................................... 78
nora-be .....................................................................................58
NORDITROPIN FLEXPRO .............................................. 52
norethindrone acetate/ethinyl estradiol/ferrous fumarate
56
norethindrone acetate/ethinyl estradiol tabs 2.5mcg;
0.5mg, 20mcg; 1mg .............................................................56
norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg
56
norethindrone acetate tabs .................................................58
norethindrone & ethinyl estradiol ferrous fumarate .....56
102
Drug Name
Page Number
norethindrone tabs ................................................................58
norgestimate/ethinyl estradiol ............................................56
NORINYL 1+50 ............................................................... 56
norlyroc .....................................................................................58
NORTHERA ...................................................................... 40
nortrel 0.5/35 (28) ................................................................56
nortrel 1/35 .............................................................................56
nortrel 7/7/7 ...........................................................................56
nortriptyline hcl caps 10mg, 25mg, 75mg .....................15
nortriptyline hcl caps 50mg ................................................15
nortriptyline hcl soln ..............................................................15
NORVIR............................................................................. 31
NOVOLIN 70/30 ............................................................. 34
NOVOLIN 70/30 RELION ............................................. 34
NOVOLIN N ..................................................................... 34
NOVOLIN N RELION ...................................................... 34
NOVOLIN R ...................................................................... 34
NOVOLIN R RELION ....................................................... 34
NOVOLOG........................................................................ 34
NOVOLOG FLEXPEN...................................................... 34
NOVOLOG MIX 70/30 ................................................... 34
NOVOLOG MIX 70/30 PREFILLED FLEXPEN ............ 34
NOVOLOG PENFILL ....................................................... 34
NOXAFIL INJ ..................................................................... 17
NOXAFIL SUSP, TBEC..................................................... 17
NUEDEXTA ....................................................................... 43
NULOJIX ............................................................................ 60
NUPLAZID ........................................................................ 27
nutrilipid ...................................................................................74
nyamyc ......................................................................................17
nystatin crea, oint, powd, susp, tabs ..................................17
nystop ........................................................................................17
OB COMPLETE/DHA ..................................................... 78
OB COMPLETE GOLD ................................................... 78
OB COMPLETE ONE ...................................................... 78
OB COMPLETE PETITE .................................................. 78
OB COMPLETE PREMIER .............................................. 78
OB COMPLETE TABS ..................................................... 78
O-CAL PRENATAL .......................................................... 78
ocella .........................................................................................56
OCTAGAM ....................................................................... 61
octreotide acetate ..................................................................59
ODEFSEY .......................................................................... 29
ODOMZO ......................................................................... 22
OFEV ................................................................................. 70
ofloxacin ophthalmic soln 0.3% .........................................65
ofloxacin otic soln 0.3% ........................................................67
ofloxacin tabs 300mg, 400mg ...........................................10
OGESTREL ....................................................................... 56
Drug Name
Page Number
olanzapine/fluoxetine caps 25mg; 3mg ...........................14
olanzapine/fluoxetine caps 25mg; 12mg, 25mg; 6mg, 50mg; 12mg, 50mg; 6mg ...................................................14
olanzapine inj ..........................................................................27
olanzapine odt.........................................................................27
olanzapine tabs 2.5mg .........................................................27
olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg......27
olmesartan medoxomil .........................................................36
olmesartan medoxomil/amlodipine/hydrochlorothiazide
36
olmesartan medoxomil/hydrochlorothiazide..................36
olopatadine hcl nasal soln 0.6%.........................................68
olopatadine hcl ophthalmic soln 0.1% .............................66
omega-3-acid ethyl esters ..................................................42
omeprazole cpdr 10mg ........................................................48
omeprazole cpdr 20mg ........................................................48
omeprazole cpdr 40mg ........................................................48
OMNITROPE .................................................................... 52
ONCASPAR ...................................................................... 22
ondansetron hcl inj 4mg/2ml .............................................16
ondansetron hcl inj 40mg/20ml, 4mg/2ml....................16
ondansetron hcl oral soln .....................................................16
ondansetron hcl tabs 4mg, 8mg ........................................16
ondansetron hcl tabs 24mg ................................................16
ondansetron odt tbdp 4mg .................................................16
ondansetron odt tbdp 8mg .................................................16
ONFI SUSP ....................................................................... 11
ONFI TABS 10MG, 20MG ............................................. 12
OPDIVO ............................................................................ 24
OPSUMIT.......................................................................... 69
oralone ......................................................................................44
ORFADIN CAPS 10MG, 2MG, 5MG ............................ 47
ORFADIN CAPS 20MG .................................................. 47
ORFADIN SUSP 4MG/ML .............................................. 64
ORKAMBI ......................................................................... 69
orsythia .....................................................................................56
oseltamivir phosphate caps 30mg.....................................31
oseltamivir phosphate caps 45mg, 75mg .......................31
OTEZLA TABS .................................................................. 61
OTEZLA TBPK.................................................................. 61
OTREXUP.......................................................................... 61
oxacillin sodium inj 2gm ......................................................... 9
oxacillin sodium inj 10gm, 1gm............................................ 9
oxaliplatin .................................................................................22
oxandrolone tabs 2.5mg ......................................................53
oxandrolone tabs 10mg .......................................................53
oxaprozin .................................................................................... 2
oxcarbazepine susp ................................................................12
Drug Name
Page Number
oxcarbazepine tabs.................................................................12
oxybutynin chloride er tb24 5mg .......................................49
oxybutynin chloride er tb24 10mg ....................................49
oxybutynin chloride er tb24 15mg ....................................49
oxybutynin chloride syrp.......................................................49
oxybutynin chloride tabs.......................................................49
oxycodone/acetaminophen soln........................................... 4
oxycodone/acetaminophen tabs 325mg; 7.5mg ............ 4
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg;
2.5mg, 325mg; 5mg............................................................... 4
oxycodone/aspirin tabs 325mg; 4.835mg........................ 4
oxycodone hcl caps .................................................................. 4
oxycodone hcl conc .................................................................. 4
oxycodone hcl soln ................................................................... 4
oxycodone hcl tabs 5mg ......................................................... 4
oxycodone hcl tabs 10mg, 15mg, 20mg ........................... 4
oxycodone hcl tabs 30mg ...................................................... 4
oxycodone/ibuprofen .............................................................. 4
pacerone tabs 100mg...........................................................38
pacerone tabs 200mg, 400mg ..........................................38
paclitaxel inj 100mg/16.7ml, 150mg/25ml,
300mg/50ml, 30mg/5ml ...................................................22
PAIRE OB .......................................................................... 78
paliperidone er tb24 1.5mg, 3mg, 9mg ..........................27
paliperidone er tb24 6mg ....................................................27
pamidronate disodium..........................................................63
pancrelipase.............................................................................47
PANRETIN ........................................................................ 24
pantoprazole sodium inj .......................................................49
pantoprazole sodium tbec 20mg .......................................49
pantoprazole sodium tbec 40mg .......................................49
paricalcitol................................................................................63
paroex ........................................................................................44
paromomycin sulfate............................................................... 5
paroxetine hcl ..........................................................................14
PASER................................................................................18
PATADAY ........................................................................... 66
PAXIL SUSP ......................................................................14
PAZEO ...............................................................................66
PEDIARIX .......................................................................... 62
PEDVAX HIB INJ 7.5MCG/0.5ML .................................62
peg 3350/electrolytes ...........................................................48
peg-3350/electrolytes ..........................................................48
peg-3350/nacl/na bicarbonate/kcl ..................................48
PEGANONE TABS 250MG ............................................12
PEGINTRON .....................................................................29
PEG-INTRON REDIPEN .................................................29
penicillin g potassium inj 5000000unit ............................. 9
103
Drug Name
Page Number
penicillin g potassium inj 20000000unit .......................... 9
penicillin g procaine ................................................................. 9
penicillin g sodium ................................................................... 9
penicillin v potassium solr 125mg/5ml.............................. 9
penicillin v potassium solr 250mg/5ml.............................. 9
penicillin v potassium tabs ..................................................... 9
PEN NEEDLE/ULTRAFINE/29G X 12.7MM................ 64
PENTACEL ........................................................................ 62
PENTAM 300 ................................................................... 25
PENTASA .......................................................................... 63
pentoxifylline cr .......................................................................40
pentoxifylline er.......................................................................40
PERIKABIVEN .................................................................. 74
perindopril erbumine.............................................................37
periogard ..................................................................................44
PERJETA ............................................................................ 22
permethrin crea ......................................................................25
perphenazine/amitriptyline tabs 10mg; 2mg, 10mg;
4mg, 25mg; 2mg, 50mg; 4mg...........................................15
perphenazine/amitriptyline tabs 25mg; 4mg .................15
perphenazine tabs 4mg ........................................................26
perphenazine tabs 16mg, 2mg, 8mg ...............................26
phenadoz supp 12.5mg .......................................................15
phenadoz supp 25mg ...........................................................15
phenelzine sulfate...................................................................13
phenergan supp ......................................................................15
phenobarbital elix ...................................................................12
phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg .
12
phenobarbital tabs 100mg, 15mg, 30mg, 60mg.........12
phenytoin chew .......................................................................12
phenytoin sodium extended.................................................12
phenytoin sodium inj .............................................................12
phenytoin susp ........................................................................12
philith.........................................................................................56
phos-flur ...................................................................................44
PHOSPHOLINE IODIDE SOLR 0.125% ...................... 66
pilocarpine hcl soln 1%, 2%, 4% ........................................66
pilocarpine hcl tabs 7.5mg ..................................................44
pilocarpine hydrochloride ....................................................44
pimozide ...................................................................................26
pimtrea......................................................................................56
pindolol tabs ............................................................................39
pioglitazone hcl .......................................................................33
pioglitazone hcl-glimepiride................................................33
pioglitazone hcl/metformin hcl...........................................33
piperacillin sodium/ tazobactam sodium ........................... 9
piperacillin sodium/tazobactam sodium ............................ 9
104
Drug Name
Page Number
piperacillin/tazobactam inj 36gm; 4.5gm, 4gm; 0.5gm 9
pirmella 1/35 ..........................................................................56
pirmella 7/7/7 ........................................................................56
piroxicam caps 10mg .............................................................. 2
piroxicam caps 20mg .............................................................. 2
plenamine ................................................................................74
pnv-dha ....................................................................................79
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID..
79
PNV FOLIC ACID + IRON MULTIVITAMIN .................. 79
PNV OB+DHA.................................................................. 79
pnv prenatal plus multivitamin ...........................................79
pnv-select .................................................................................79
pnv tabs 29-1 .........................................................................79
PNV-VP-U........................................................................ 79
podofilox soln ..........................................................................46
polycin .......................................................................................65
polyethylene glycol 3350 pack, powd ..............................48
polymyxin b sulfate/trimethoprim sulfate ........................65
poly-vitamin/fluoride chew..................................................79
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/
ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml ............79
POMALYST ....................................................................... 19
portia-28..................................................................................56
PORTRAZZA .................................................................... 22
potassium chloride 0.3%/d5w ............................................75
potassium chloride 0.3%/ nacl 0.9% ................................75
potassium chloride 0.15% d5w/nacl 0.33% ..................74
potassium chloride 0.15% d5w/nacl 0.45% ..................74
potassium chloride 0.15% d5w/nacl 0.45% viaflex .....74
potassium chloride 0.15% nacl 0.9% ...............................74
potassium chloride 0.15%/nacl 0.9% ..............................74
potassium chloride 0.15% /nacl 0.45% viaflex ..............74
potassium chloride 0.22% d5w/nacl 0.45% ..................74
potassium chloride 0.224%d5w/nacl 0.45% viaflex ...74
potassium chloride cr tbcr 10meq, 20meq .....................75
potassium chloride er cpcr ...................................................75
potassium chloride er tbcr 10meq, 20meq, 8meq........75
potassium chloride er tbcr 20meq.....................................75
potassium chloride inj 0.4meq/ml .....................................75
potassium chloride inj 10meq/100ml, 10meq/50ml,
20meq/100ml, 2meq/ml, 40meq/100ml ......................75
potassium chloride oral soln................................................75
potassium chloride sr tbcr 8meq........................................75
potassium citrate er tbcr 15meq ........................................75
potassium citrate er tbcr 1080mg, 540mg ....................75
POTIGA TABS 50MG...................................................... 11
Drug Name
Page Number
POTIGA TABS 200MG, 300MG, 400MG ................... 11
PRADAXA ......................................................................... 35
PRALUENT ....................................................................... 40
pramipexole dihydrochloride...............................................25
pravastatin sodium tabs 10mg, 80mg .............................42
pravastatin sodium tabs 20mg, 40mg .............................42
prazosin hcl caps ....................................................................36
prednicarbate crea .................................................................52
prednicarbate oint..................................................................52
prednisolone acetate .............................................................66
prednisolone sodium phosphate ophthalmic soln 1% .66
prednisolone sodium phosphate oral soln 15mg/5ml,
25mg/5ml, 5mg/5ml ...........................................................52
prednisolone soln ...................................................................52
prednisolone syrp 15mg/5ml .............................................52
PREDNISONE INTENSOL .............................................. 52
prednisone soln .......................................................................52
prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg ........52
prednisone tabs 50mg ..........................................................52
prednisone tbpk 10mg, 5mg...............................................52
PREFERAOB +DHA......................................................... 79
PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG;
17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG;
65MCG; 1.5MG; 10UNIT; 4.5MG ............................... 79
PREFERAOB ONE ........................................................... 79
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 34MG; 0; 17MG; 0;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG,
30MCG; 10MG; 400UNIT; 0.8MG; 12MCG; 10UNIT;
1MG; 6MG; 17MG; 28MG; 250MCG; 50MG; 1.6MG;
65MCG; 1.5MG; 4.5MG ................................................ 79
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML.................................. 75
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml;
840mg/100ml; 490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml; 230mg/100ml;
5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml ........................................75
PRENAISSANCE .............................................................. 79
PRENAISSANCE PLUS ................................................... 79
PRENATA .......................................................................... 79
prenatabs fa .............................................................................79
Drug Name
Page Number
prenatal 19 chew 100mg; 1000unit; 200mg; 7mg;
400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg;
30unit; 20mg ..........................................................................79
prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg;
400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg;
3mg; 3mg; 30unit; 20mg ....................................................79
prenatal plus iron tabs 120mg; 0; 200mg; 400unit;
2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg;
22unit; 4000unit; 25mg......................................................80
PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT;
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG;
1.84MG; 22MG; 4000UNIT; 25MG............................ 80
PRENATE AM ................................................................... 80
PRENATE DHA CAPS 90MG; 145MG; 220UNIT;
13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG;
26MG; 10UNIT ............................................................... 80
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG;
100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG;
400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG;
3.5MG; 3MG; 10UNIT; 15MG...................................... 80
PRENATE ELITE TABS 600MCG; 75MG; 2600UNIT;
330MCG; 155MG; 600UNIT; 1.5MG; 13MCG; 20MG;
400MCG; 25MG; 21MG; 150MCG; 21MG; 3.5MG;
3MG; 40UNIT; 15MG .................................................... 80
PRENATE ENHANCE ...................................................... 80
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0;
400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT
80
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG; 300MG;
40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG;
10UNIT ............................................................................. 80
PRENATE MINI CAPS 60MG; 280MCG; 100MG;
220UNIT; 13MCG; 350MG; 400MCG; 29MG;
600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG80
PRENATE MINI CAPS 600MCG; 60MG; 280MCG;
80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG;
18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG80
PRENATE PIXIE ................................................................ 80
PRENATE RESTORE ........................................................ 80
PRENATE STAR ................................................................ 80
PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG;
12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG ............................................. 81
PREPOPIK......................................................................... 48
PREQUE 10 ...................................................................... 81
PRETAB ............................................................................. 81
prevalite ....................................................................................42
previfem ....................................................................................56
105
Drug Name
Page Number Drug Name
PREZCOBIX ...................................................................... 31
PREZISTA SUSP ............................................................... 31
PREZISTA TABS 75MG ................................................... 31
PREZISTA TABS 150MG, 600MG, 800MG ................ 31
PRIFTIN ............................................................................. 18
primaquine phosphate tabs.................................................25
primidone tabs ........................................................................12
PRISTIQ TB24 25MG ..................................................... 14
pr natal 400 .............................................................................79
PROAIR HFA ..................................................................... 69
PROAIR RESPICLICK....................................................... 69
probenecid/colchicine ...........................................................17
probenecid tabs ......................................................................17
prochlorperazine edisylate inj .............................................26
prochlorperazine maleate tabs ...........................................26
prochlorperazine supp 25mg .............................................26
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML ........ 35
PROCRIT INJ 40000UNIT/ML....................................... 35
procto-med hc ........................................................................52
procto-pak ...............................................................................52
proctosol hc .............................................................................52
proctozone-hc .........................................................................52
progesterone caps ..................................................................58
progesterone inj ......................................................................58
PROGLYCEM .................................................................... 33
PROGRAF INJ ................................................................... 61
PROLASTIN-C ................................................................. 70
PROLENSA ....................................................................... 66
PROLEUKIN...................................................................... 22
PROLIA ............................................................................. 63
PROMACTA...................................................................... 35
promethazine hcl supp 12.5mg, 50mg............................15
promethazine hcl supp 25mg .............................................15
promethazine hcl tabs 12.5mg, 50mg.............................68
promethazine hcl tabs 25mg ..............................................68
promethegan supp 12.5mg, 25mg...................................16
promethegan supp 50mg ....................................................16
propafenone hcl......................................................................38
propafenone hcl er .................................................................38
proparacaine hcl .....................................................................65
propranolol hcl er ...................................................................39
propranolol hcl inj ..................................................................39
propranolol hcl oral soln.......................................................39
propranolol hcl tabs 10mg, 20mg, 40mg, 60mg .........39
propranolol hcl tabs 80mg ..................................................39
propranolol/hydrochlorothiazide.......................................39
propylthiouracil tabs..............................................................60
106
Page Number
PROQUAD........................................................................ 62
protriptyline hcl.......................................................................15
PROVIDA DHA................................................................. 81
PROVIDA OB.................................................................... 81
PULMOZYME................................................................... 69
PUREFE OB PLUS............................................................ 81
PURIXAN .......................................................................... 20
pyrazinamide tabs ..................................................................18
pyridostigmine bromide er...................................................18
pyridostigmine bromide tabs ..............................................18
QUADRACEL ................................................................... 62
quasense ...................................................................................56
quetiapine fumarate er tb24 50mg ..................................27
quetiapine fumarate er tb24 150mg, 200mg ...............27
quetiapine fumarate er tb24 300mg, 400mg ...............27
quetiapine fumarate tabs 25mg ........................................27
quetiapine fumarate tabs 100mg, 50mg ........................27
quetiapine fumarate tabs 200mg......................................27
quetiapine fumarate tabs 300mg, 400mg .....................27
QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/
ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/
ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML;
0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML ..
81
QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/
ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ML;
12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/
ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML ............... 81
quinapril hcl tabs 10mg, 40mg ..........................................37
quinapril hcl tabs 20mg, 5mg.............................................37
quinapril/hydrochlorothiazide ............................................37
quinidine gluconate cr...........................................................38
quinidine gluconate er...........................................................38
quinidine sulfate tabs 200mg .............................................38
quinidine sulfate tabs 300mg .............................................38
quinine sulfate caps 324mg ................................................25
QVAR ................................................................................. 68
RABAVERT ....................................................................... 62
rajani ..........................................................................................56
raloxifene hydrochloride .......................................................58
ramipril caps 1.25mg............................................................37
ramipril caps 10mg, 2.5mg, 5mg ......................................37
RANEXA............................................................................ 40
ranitidine hcl caps 150mg, 300mg...................................48
ranitidine hcl inj 50mg/2ml.................................................48
ranitidine hcl inj 150mg/6ml ..............................................48
ranitidine hcl syrp 15mg/ml ................................................48
ranitidine hcl tabs 150mg, 300mg ...................................48
Drug Name
Page Number Drug Name
RAPAMUNE SOLN .......................................................... 61
RASUVO ........................................................................... 61
RAVICTI............................................................................. 47
REBIF ................................................................................. 44
REBIF REBIDOSE ............................................................. 44
REBIF REBIDOSE TITRATION PACK ............................. 44
REBIF TITRATION PACK ................................................. 44
reclipsen ....................................................................................57
RECOMBIVAX HB ............................................................ 62
REGRANEX ....................................................................... 46
relador pak plus ........................................................................ 4
RELENZA DISKHALER.................................................... 31
RELISTOR INJ ................................................................... 47
RELISTOR TABS ............................................................... 47
RELNATE DHA ................................................................. 81
REMICADE ....................................................................... 61
REMODULIN .................................................................... 69
RENACIDIN SOLN 6.602GM/100ML;
0.198GM/100ML; 3.177GM/100ML ........................ 49
RENVELA .......................................................................... 49
repaglinide/metformin hydrochloride ..............................33
repaglinide tabs 0.5mg, 1mg ..............................................33
repaglinide tabs 2mg.............................................................33
REPATHA .......................................................................... 40
REPATHA PUSHTRONEX SYSTEM ............................... 40
REPATHA SURECLICK .................................................... 40
reprexain tabs 10mg; 200mg ............................................... 4
RESCRIPTOR .................................................................... 29
RESTASIS .......................................................................... 65
RETROVIR IV INFUSION................................................. 30
REVLIMID ......................................................................... 19
REXULTI ............................................................................ 27
REYATAZ ........................................................................... 31
ribasphere caps.......................................................................29
ribasphere tabs 200mg ........................................................29
ribavirin caps ...........................................................................29
ribavirin tabs 200mg ............................................................29
rifabutin ....................................................................................18
rifampin caps, inj ....................................................................18
RIFATER ............................................................................. 18
riluzole .......................................................................................43
rimantadine hcl .......................................................................31
ringers injection ......................................................................75
risedronate sodium dr ...........................................................63
risedronate sodium tabs 30mg, 5mg................................63
risedronate sodium tabs 35mg ..........................................63
risedronate sodium tabs 150mg ........................................63
RISPERDAL CONSTA ...................................................... 27
risperidone odt tbdp 0.5mg ................................................28
Page Number
risperidone odt tbdp 0.25mg, 3mg ...................................28
risperidone odt tbdp 1mg, 2mg .........................................27
risperidone odt tbdp 4mg ....................................................27
risperidone soln ......................................................................28
risperidone tabs 0.25mg, 0.5mg, 3mg ............................28
risperidone tabs 1mg, 2mg .................................................28
risperidone tabs 4mg ............................................................28
RITUXAN .......................................................................... 24
rivastigmine tartrate ..............................................................13
rivastigmine transdermal system .......................................13
rizatriptan benzoate odt .......................................................17
rizatriptan benzoate tabs 5mg ............................................17
rizatriptan benzoate tabs 10mg .........................................17
ropinirole hcl ............................................................................25
rosadan crea ............................................................................46
rosadan gel...............................................................................46
rosuvastatin calcium tabs 10mg, 20mg, 5mg................42
rosuvastatin calcium tabs 40mg ........................................42
ROTARIX ........................................................................... 62
ROTATEQ SOLN .............................................................. 62
roweepra ...................................................................................11
ROXICET SOLN.................................................................. 4
roxicet tabs ................................................................................. 4
ROZEREM ......................................................................... 70
SABRIL .............................................................................. 12
SAMSCA TABS 15MG .................................................... 71
SAMSCA TABS 30MG .................................................... 71
SANDIMMUNE SOLN .................................................... 61
SANTYL............................................................................. 46
SAPHRIS SUBL 2.5MG, 5MG........................................ 28
SAPHRIS SUBL 10MG.................................................... 28
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG;
1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG ........ 81
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 1.6MG;
30UNIT; 1700UNIT; 15MG .......................................... 81
SELECT-OB+DHA ........................................................... 81
selegiline hcl caps ...................................................................26
selegiline hcl tabs....................................................................26
selenium sulfide lotn ..............................................................46
SELZENTRY TABS 150MG............................................. 30
SELZENTRY TABS 300MG............................................. 30
se-natal 19 ..............................................................................81
SENSIPAR TABS 30MG, 60MG..................................... 59
SENSIPAR TABS 90MG .................................................. 59
SEREVENT DISKUS ......................................................... 69
sertraline hcl conc, tabs ........................................................14
setlakin ......................................................................................57
107
Page Number
Page Number Drug Name
sf .................................................................................................44 sps ..............................................................................................71
sharobel ....................................................................................58 sronyx ........................................................................................57
SIGNIFOR.......................................................................... 59 ssd ..............................................................................................46
sildenafil tabs ...........................................................................70 stavudine caps 15mg, 20mg ..............................................30
silver sulfadiazine ...................................................................46 stavudine caps 30mg, 40mg ..............................................30
SIMBRINZA ...................................................................... 66 stavudine solr...........................................................................30
SIMULECT ........................................................................ 61 sterile water irrigation ...........................................................75
simvastatin tabs 10mg, 20mg, 40mg, 5mg ...................42 STIOLTO RESPIMAT ........................................................ 70
simvastatin tabs 80mg .........................................................42 STIVARGA ........................................................................ 23
sirolimus tabs 0.5mg, 2mg ..................................................61 STRATTERA CAPS 10MG, 18MG, 25MG, 40MG,
sirolimus tabs 1mg.................................................................61 60MG ................................................................................ 43
SIRTURO ........................................................................... 18 STRATTERA CAPS 100MG, 80MG .............................. 43
SIVEXTRO INJ ..................................................................... 6 streptomycin sulfate inj 1gm ................................................. 5
SIVEXTRO TABS ................................................................ 6 STRIBILD........................................................................... 29
sodium bicarbonate inj 8.4% ..............................................71 STRIVERDI RESPIMAT .................................................... 69
sodium bicarbonate partial fill ............................................71 SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG;
sodium chloride 0.9% ...........................................................49 2MG .................................................................................... 5
sodium chloride 0.45% inj ...................................................75 SUBOXONE FILM 12MG; 3MG ...................................... 5
sodium chloride inj 0.9%, 5% .............................................75 sucralfate susp, tabs...............................................................48
sodium chloride inj 2.5meq/ml, 3% ..................................75 sulfacetamide sodium oint 10%.........................................65
sodium fluoride chew 0.5mg, 1.1mg ................................75 sulfacetamide sodium/prednisolone sodium phosphate ..
sodium fluoride soln 0.5mg/ml ..........................................75 65
sodium phenylbutyrate powd ..............................................47 sulfacetamide sodium soln 10% ........................................65
sodium phosphate..................................................................75 sulfacetamide sodium susp 10% .......................................46
sodium polystyrene sulfonate .............................................71 sulfadiazine tabs .....................................................................10
sodium sulfacetamide lotn 10%.........................................46 sulfamethoxazole/trimethoprim ds ...................................10
sodium sulfacetamide soln 10% ........................................65 sulfamethoxazole/trimethoprim inj, tabs .........................10
SOLTAMOX....................................................................... 19 sulfamethoxazole/trimethoprim susp ...............................10
SOMATULINE DEPOT INJ 60MG/0.2ML .................... 59 SULFAMYLON.................................................................. 46
SOMATULINE DEPOT INJ 90MG/0.3ML .................... 59 sulfasalazine tabs, tbec .........................................................63
SOMATULINE DEPOT INJ 120MG/0.5ML ................. 59 sulfatrim pediatric ..................................................................10
SOMAVERT ...................................................................... 59 sulindac tabs 150mg............................................................... 2
sorine .........................................................................................38 sulindac tabs 200mg............................................................... 2
sotalol hcl (af) tabs 120mg..................................................38 sumatriptan soln ....................................................................18
sotalol hcl (af) tabs 160mg, 80mg ....................................38 sumatriptan succinate inj 4mg/0.5ml ..............................18
sotalol hcl tabs 120mg, 160mg, 80mg ...........................38 sumatriptan succinate inj 6mg/0.5ml ..............................18
sotalol hcl tabs 240mg .........................................................38 sumatriptan succinate refill inj 4mg/0.5ml .....................17
SOVALDI ........................................................................... 29 sumatriptan succinate refill inj 6mg/0.5ml .....................17
SPIRIVA HANDIHALER................................................... 68 sumatriptan succinate tabs 25mg .....................................18
SPIRIVA RESPIMAT ......................................................... 68 sumatriptan succinate tabs 100mg, 50mg.....................18
spironolactone/hydrochlorothiazide .................................41 SUPRAX CAPS ................................................................... 8
spironolactone tabs ...............................................................41 SUPRAX CHEW 100MG .................................................. 8
SPORANOX SOLN .......................................................... 17 SUPRAX CHEW 200MG .................................................. 8
sprintec 28 ...............................................................................57 SUPRAX SUSR 500MG/5ML .......................................... 8
SPRITAM TB3D 250MG, 500MG, 750MG ................ 11 SUPREP BOWEL PREP ................................................... 48
SPRITAM TB3D 1000MG .............................................. 11 SUSTIVA CAPS 200MG, 50MG.................................... 29
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG ........... 23 SUSTIVA TABS ................................................................. 29
SPRYCEL TABS 100MG, 140MG ................................. 23 SUTENT CAPS 12.5MG ................................................. 23
SUTENT CAPS 25MG, 37.5MG, 50MG ...................... 23
Drug Name
108
Drug Name
Page Number Drug Name
syeda ..........................................................................................57
SYLATRON ....................................................................... 22
SYLVANT ........................................................................... 64
SYMLINPEN 60 ............................................................... 33
SYMLINPEN 120 ............................................................. 33
SYNAGIS INJ 100MG/ML, 50MG/0.5ML ................... 61
SYNAREL .......................................................................... 59
SYNERCID INJ 350MG; 150MG ..................................... 6
SYNJARDY TABS 12.5MG; 500MG, 5MG; 1000MG,
5MG; 500MG .................................................................. 33
SYNJARDY TABS 12.5MG; 1000MG ........................... 33
SYNRIBO........................................................................... 22
SYNTHROID TABS 100MCG, 125MCG, 137MCG,
150MCG, 175MCG, 200MCG, 25MCG, 300MCG,
50MCG, 75MCG, 88MCG ............................................. 59
SYNTHROID TABS 112MCG......................................... 58
SYPRINE............................................................................ 71
TABLOID ........................................................................... 20
tacrolimus caps .......................................................................61
TAFINLAR CAPS 50MG ................................................. 24
TAFINLAR CAPS 75MG ................................................. 23
TAGRISSO......................................................................... 22
TAMIFLU CAPS 30MG ................................................... 31
TAMIFLU CAPS 45MG, 75MG...................................... 31
TAMIFLU SUSR 6MG/ML............................................... 31
tamoxifen citrate tabs 10mg ...............................................19
tamoxifen citrate tabs 20mg ...............................................19
tamsulosin hcl .........................................................................49
TARCEVA TABS 25MG ................................................... 24
TARCEVA TABS 100MG, 150MG ................................ 24
TARGRETIN ...................................................................... 24
tarina fe 1/20 ..........................................................................57
TARON-BC ....................................................................... 81
TARON-PREX .................................................................. 81
TASIGNA........................................................................... 24
tazicef inj 1gm, 2gm, 6gm ..................................................... 8
TAZORAC ......................................................................... 46
taztia xt ......................................................................................40
TECENTRIQ ...................................................................... 24
TEFLARO ............................................................................ 8
telmisartan ...............................................................................36
telmisartan/amlodipine ........................................................37
telmisartan/hydrochlorothiazide........................................37
TEMODAR INJ .................................................................. 19
TENIVAC ........................................................................... 62
terazosin hcl caps ...................................................................36
terbinafine hcl tabs ................................................................17
terbutaline sulfate tabs..........................................................69
terconazole...............................................................................17
Page Number
testosterone cypionate inj ....................................................53
testosterone enanthate inj ...................................................53
testosterone gel 1%, 25mg/2.5gm ...................................53
tetanus/diphtheria toxoids-adsorbed................................62
tetrabenazine tabs 12.5mg .................................................43
tetrabenazine tabs 25mg .....................................................43
tetracycline hcl caps 250mg, 500mg ...............................10
THALOMID CAPS 100MG, 150MG, 50MG............... 19
THALOMID CAPS 200MG ............................................ 19
theophylline .............................................................................69
theophylline cr tb12 100mg ...............................................69
theophylline cr tb12 200mg ...............................................69
theophylline er tb12 100mg, 200mg, 300mg ..............69
theophylline er tb12 450mg ...............................................69
theophylline er tb24 ..............................................................69
THERACYS INJ 81MG/VIAL .......................................... 22
THIOLA ............................................................................. 49
thioridazine hcl tabs 10mg, 25mg, 50mg.......................26
thioridazine hcl tabs 100mg ...............................................26
thiotepa inj 15mg...................................................................19
thiothixene caps 1mg ............................................................26
thiothixene caps 10mg, 2mg, 5mg ...................................26
thrivite rx ...................................................................................81
THYMOGLOBULIN ......................................................... 61
THYROLAR-1 .................................................................. 59
THYROLAR-1/2 .............................................................. 59
THYROLAR-1/4 .............................................................. 59
THYROLAR-2 .................................................................. 59
THYROLAR-3 .................................................................. 59
tiagabine hydrochloride........................................................12
TICE BCG .......................................................................... 22
TIKOSYN ........................................................................... 38
tilia fe .........................................................................................57
timolol maleate ophthalmic gel forming ..........................67
timolol maleate soln 0.25%, 0.5% ....................................67
timolol maleate tabs 10mg, 20mg, 5mg .........................39
tinidazole .................................................................................... 6
TIVICAY TABS 10MG, 25MG ........................................ 29
TIVICAY TABS 50MG ...................................................... 29
tizanidine hcl tabs ...................................................................28
TL-CARE DHA ................................................................. 81
TL FOLATE........................................................................ 81
TL-SELECT ....................................................................... 81
TOBI PODHALER ............................................................ 69
TOBRADEX....................................................................... 65
TOBRADEX ST ................................................................. 65
tobramycin ...............................................................................69
tobramycin/dexamethasone................................................65
tobramycin sulfate inj 1.2gm/30ml, 1.2gm, 10mg/ml,
109
Drug Name
Page Number Drug Name
Page Number
40mg/ml, 80mg/2ml.............................................................. 6 triadvance.................................................................................81
tobramycin sulfate ophthalmic soln 0.3% .......................65 triamcinolone acetonide aero 55mcg/act .......................68
TOBREX ............................................................................ 65 triamcinolone acetonide aers 0.147mg/gm ...................52
tolazamide tabs 250mg, 500mg .......................................33 triamcinolone acetonide crea 0.1% ..................................52
tolbutamide..............................................................................33 triamcinolone acetonide crea 0.025%, 0.5% .................52
tolmetin sodium caps .............................................................. 2 triamcinolone acetonide lotn 0.025%, 0.1% .................52
tolmetin sodium tabs 200mg ............................................... 2 triamcinolone acetonide oint 0.1%, 0.5% .......................52
tolmetin sodium tabs 600mg ............................................... 2 triamcinolone acetonide oint 0.025%..............................52
tolterodine tartrate.................................................................49 triamcinolone acetonide pste 0.1%...................................44
topiramate cpsp 15mg .........................................................12 triamcinolone in orabase .....................................................44
topiramate cpsp 25mg .........................................................12 triamterene/hydrochlorothiazide caps 25mg; 37.5mg41
topiramate tabs.......................................................................12 triamterene/hydrochlorothiazide caps 25mg; 50mg ...41
toposar inj 100mg/5ml, 1gm/50ml, 500mg/25ml.....22 triamterene/hydrochlorothiazide tabs ..............................41
topotecan hcl ...........................................................................22 tricare ........................................................................................81
TORISEL ............................................................................ 24 TRICARE PRENATAL 1 ................................................... 82
torsemide tabs 10mg, 20mg, 5mg ...................................41 TRICARE PRENATAL COMPLEAT................................. 82
torsemide tabs 100mg .........................................................41 TRICARE PRENATAL DHA ONE ................................... 82
tpn electrolytes........................................................................75 triderm ......................................................................................52
TRACLEER ........................................................................ 70 tri-estarylla ..............................................................................57
TRADJENTA ...................................................................... 33 trifluoperazine hcl tabs 1mg................................................26
tramadol hcl tabs...................................................................... 4 trifluoperazine hcl tabs 10mg, 2mg, 5mg .......................26
tramadol hydrochloride/acetaminophen ........................... 4 trifluridine .................................................................................65
trandolapril ..............................................................................37 trihexyphenidyl hcl .................................................................25
trandolapril/verapamil hcl ...................................................37 tri-legest fe ...............................................................................57
trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg;
tri-linyah ...................................................................................57
180mg, 2mg; 240mg, 4mg; 240mg................................37 tri-lo-estarylla .........................................................................57
trandolapril/verapamil hcl er tbcr 4mg; 240mg ............37 tri-lo-marzia............................................................................57
tranexamic acid inj .................................................................35 tri-lo-sprintec ..........................................................................57
tranexamic acid tabs..............................................................35 trilyte..........................................................................................48
TRANSDERM-SCOP....................................................... 16 trimethoprim sulfate/polymyxin b sulfate ........................65
tranylcypromine sulfate ........................................................14 trimethoprim tabs .................................................................... 6
TRAVASOL INJ 52MEQ/L; 1760MG/100ML;
trimipramine maleate caps ..................................................15
880MG/100ML; 34MEQ/L; 1760MG/100ML;
TRINATAL GT ................................................................... 82
372MG/100ML; 406MG/100ML; 526MG/100ML;
trinatal rx 1...............................................................................82
492MG/100ML; 492MG/100ML; 526MG/100ML;
trinessa......................................................................................57
356MG/100ML; 356MG/100ML; 390MG/100ML;
trinessa lo .................................................................................57
34MG/100ML; 152MG/100ML.................................. 76 TRINTELLIX ...................................................................... 13
TRAVATAN Z .................................................................... 64 triple antibiotic oint 400unit/gm; 5mg/gm; 10000unit/
travoprost .................................................................................64 gm ..............................................................................................65
trazodone hcl ...........................................................................14 triple-vitamin/fluoride...........................................................82
TREANDA ......................................................................... 19
tri-previfem..............................................................................57
TRECATOR........................................................................ 18
TRISENOX......................................................................... 22
TRELSTAR MIXJECT ........................................................ 59
tri-sprintec ...............................................................................57
TRESIBA FLEXTOUCH ................................................... 34
TRISTART DHA ................................................................ 82
tretinoin caps 10mg ..............................................................24
TRIUMEQ.......................................................................... 30
tretinoin crea 0.025%, 0.05%, 0.1%................................46 TRIVEEN-DUO DHA....................................................... 82
tretinoin gel 0.01% ................................................................46 TRIVEEN-PRX RNF.......................................................... 82
tretinoin gel 0.025%, 0.05% ..............................................46 tri-vitamin/fluoride ................................................................81
110
Drug Name
Page Number Drug Name
tri-vit/fluoride/iron.................................................................81
tri-vit/fluoride soln 35mg/ml; 400unit/ml; 0.25mg/
ml; 1500unit/ml, 35mg/ml; 400unit/ml; 0.5mg/ml;
1500unit/ml............................................................................81
trivora-28 ................................................................................57
TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML;
1.2GM/100ML; 0.32GM/100ML; 0; 0;
0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML;
0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML;
0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML;
0.38GM/100ML; 5MEQ/L; 0.025GM/100ML;
0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML;
0.78GM/100ML ............................................................. 76
TRULICITY ........................................................................ 33
TRUMENBA ..................................................................... 62
TRUVADA TABS 100MG; 150MG, 133MG; 200MG,
167MG; 250MG ............................................................. 30
TRUVADA TABS 200MG; 300MG ............................... 30
TWINRIX ........................................................................... 62
TYBOST ............................................................................ 30
TYGACIL ............................................................................. 7
TYKERB ............................................................................. 24
TYPHIM VI ........................................................................ 62
TYSABRI............................................................................ 44
TYZEKA ............................................................................. 29
TYZINE PEDIATRIC NASAL DROPS ............................. 70
ULORIC ............................................................................. 17
ultimatecare one nf................................................................82
unithroid tabs 100mcg, 112mcg, 125mcg, 137mcg,
150mcg, 175mcg, 25mcg, 300mcg, 50mcg, 75mcg,
88mcg .......................................................................................59
unithroid tabs 200mcg .........................................................59
ursodiol caps, tabs ..................................................................47
UVADEX ............................................................................ 22
VAGIFEM TABS 10MCG................................................. 53
valacyclovir hcl ........................................................................31
VALCHLOR ....................................................................... 19
VALCYTE SOLR................................................................ 28
valganciclovir...........................................................................28
valproate sodium inj ..............................................................12
valproic acid caps ...................................................................12
valproic acid syrp ....................................................................12
valsartan ...................................................................................37
valsartan/hydrochlorothiazide............................................37
VALSTAR ........................................................................... 22
vancomycin ................................................................................ 7
vancomycin hcl caps ................................................................ 7
vancomycin hcl in dextrose .................................................... 7
vancomycin hcl inj .................................................................... 7
Page Number
vandazole ................................................................................... 7
VANTAS ............................................................................ 59
VAQTA ............................................................................... 62
VARIVAX ........................................................................... 62
VASCEPA CAPS 0.5GM ................................................. 42
VASCEPA CAPS 1GM ..................................................... 42
VASOSTRICT.................................................................... 52
VECTIBIX........................................................................... 22
VELCADE .......................................................................... 22
velivet.........................................................................................57
VELPHORO ...................................................................... 49
VEMAVITE-PRX 2 ........................................................... 82
VENA-BAL DHA ............................................................. 82
VENCLEXTA ..................................................................... 22
VENCLEXTA STARTING PACK ...................................... 22
venlafaxine hcl.........................................................................14
venlafaxine hcl er cp24 37.5mg, 75mg ...........................15
venlafaxine hcl er cp24 150mg..........................................15
venlafaxine hcl er tb24 37.5mg, 75mg............................15
venlafaxine hcl er tb24 150mg ..........................................15
venlafaxine hcl er tb24 225mg ..........................................15
VENTAVIS ......................................................................... 70
VENTOLIN HFA ............................................................... 69
verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg,
300mg ......................................................................................40
verapamil hcl er cp24 200mg ............................................40
verapamil hcl er tbcr 120mg...............................................40
verapamil hcl er tbcr 180mg, 240mg ..............................40
verapamil hcl inj, tabs ............................................................40
verapamil hcl sr cp24 120mg, 180mg, 240mg ............40
verapamil hcl sr cp24 360mg.............................................40
verapamil hcl sr tbcr 240mg ...............................................40
VERSACLOZ ..................................................................... 28
VESICARE ......................................................................... 49
vestura.......................................................................................57
V-GO 20 ........................................................................... 64
V-GO 30 ........................................................................... 64
V-GO 40 ........................................................................... 64
vicodin es tabs 300mg; 7.5mg ............................................. 4
vicodin tabs 300mg; 5mg ...................................................... 4
VICTOZA ........................................................................... 33
VIDEX PEDIATRIC SOLR 2GM ...................................... 30
VIDEX PEDIATRIC SOLR 4GM ...................................... 30
vienva ........................................................................................57
VIGAMOX ......................................................................... 65
VIIBRYD KIT ...................................................................... 15
VIIBRYD STARTER PACK ................................................ 15
VIIBRYD TABS .................................................................. 15
VIMPAT INJ ....................................................................... 12
111
Drug Name
Page Number Drug Name
VIMPAT ORAL SOLN ...................................................... 12
VIMPAT TABS 50MG ...................................................... 12
VIMPAT TABS 100MG, 150MG, 200MG.................... 12
vinblastine sulfate inj 1mg/ml .............................................22
vincasar pfs ..............................................................................22
vincristine sulfate....................................................................22
vinorelbine tartrate ................................................................22
viorele ........................................................................................57
VIRACEPT ......................................................................... 31
VIRAMUNE SUSP ............................................................ 30
VIRAZOLE......................................................................... 31
VIREAD ............................................................................. 30
VIRT-ADVANCE............................................................... 82
VIRT-CARE ONE.............................................................. 82
VIRT-C DHA ..................................................................... 82
VIRT-PN ............................................................................ 82
VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT;
12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG;
25MG; 10UNIT ............................................................... 82
VIRT-PN PLUS ................................................................. 82
VIRT-SELECT ................................................................... 82
VITAFOL FE+ .................................................................... 82
VITAFOL GUMMIES ........................................................ 82
VITAFOL-NANO .............................................................. 82
VITAFOL-OB .................................................................... 82
VITAFOL-OB+DHA ......................................................... 82
VITAFOL-ONE ................................................................. 82
VITAFOL ULTRA .............................................................. 82
VITAMEDMD ONE RX/QUATREFOLIC ........................ 82
VITAMEDMD PLUS RX/QUATRE FOLIC ...................... 82
vitamins a/c/d/fluoride ..........................................................82
vitamins a/d/c/fluoride ..........................................................76
VITEKTA ............................................................................ 29
VOL-NATE ........................................................................ 82
VOL-PLUS ........................................................................ 82
VOLTAREN GEL ................................................................. 2
voriconazole inj, tabs .............................................................17
voriconazole susr ....................................................................17
VOTRIENT ........................................................................ 24
VP-CH PLUS .................................................................... 82
VP-CH-PNV..................................................................... 82
VP CH ULTRA................................................................... 82
VP-GGR-B6 PRENATAL ................................................ 82
VP-HEME OB .................................................................. 82
VP-HEME ONE ................................................................ 83
VP-PNV-DHA .................................................................. 83
VPRIV ................................................................................ 47
VRAYLAR CAPS ............................................................... 28
VRAYLAR CPPK ............................................................... 28
vyfemla......................................................................................57
112
Page Number
warfarin sodium tabs.............................................................35
wera ...........................................................................................57
wymzya fe .................................................................................57
XALKORI ........................................................................... 24
XARELTO STARTER PACK .............................................. 35
XARELTO TABS 10MG, 20MG ...................................... 35
XARELTO TABS 15MG ................................................... 35
XELJANZ ........................................................................... 61
XELJANZ XR...................................................................... 61
XGEVA ............................................................................... 63
XOLAIR.............................................................................. 70
XTANDI ............................................................................. 19
xylon............................................................................................. 4
XYREM .............................................................................. 70
YERVOY............................................................................. 22
YF-VAX.............................................................................. 62
YONDELIS ........................................................................ 19
yuvafem ....................................................................................57
zafirlukast .................................................................................68
zaleplon caps 5mg .................................................................70
zaleplon caps 10mg...............................................................70
ZALTRAP........................................................................... 22
zamicet ........................................................................................ 4
ZANOSAR......................................................................... 22
zarah ..........................................................................................57
ZATEAN-CH .................................................................... 83
ZATEAN-PN ..................................................................... 83
ZATEAN-PN DHA ........................................................... 83
ZATEAN-PN PLUS .......................................................... 83
ZAVESCA .......................................................................... 47
zazole .........................................................................................17
zebutal caps 325mg; 50mg; 40mg ..................................... 1
ZELBORAF........................................................................ 24
ZEMAIRA .......................................................................... 70
zenatane ...................................................................................46
zenchent ...................................................................................57
zenchent fe ...............................................................................57
ZENPEP............................................................................. 47
ZEPATIER .......................................................................... 31
ZETIA................................................................................. 42
ZIAGEN SOLN ................................................................. 30
zidovudine ................................................................................30
ziprasidone hcl caps 20mg, 40mg ....................................28
ziprasidone hcl caps 60mg, 80mg ....................................28
ZIRGAN ............................................................................. 65
ZOLADEX.......................................................................... 59
zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml ...........63
ZOLINZA........................................................................... 22
zolmitriptan odt ......................................................................18
Drug Name
Page Number Drug Name
Page Number
zolmitriptan tabs.....................................................................18
zolpidem tartrate er ...............................................................70
zolpidem tartrate tabs 5mg .................................................70
zolpidem tartrate tabs 10mg ..............................................70
ZONALON ........................................................................ 46
zonisamide ...............................................................................11
ZORTRESS ........................................................................ 61
ZOSTAVAX ........................................................................ 62
zovia 1/35e ..............................................................................57
zovia 1/50e ..............................................................................57
ZYDELIG ........................................................................... 23
ZYKADIA ........................................................................... 24
ZYPREXA RELPREVV INJ 210MG, 300MG ................. 28
ZYPREXA RELPREVV INJ 405MG ................................. 28
ZYTIGA.............................................................................. 19
ZYVOX INJ 600MG/300ML ............................................. 7
ZYVOX SUSR ...................................................................... 7
ZYVOX TABS....................................................................... 7
113
Notes/Notas:
114
Notes/Notas:
115
Notes/Notas:
116
Mercy Care Advantage (HMO SNP) Member Services
Call
602‑263‑3000 or 1‑800‑624‑3879
Calls to these numbers are free. 8:00 a.m. - 8:00 p.m., 7 days a week.
Member Services also has free language interpreter services available for
non-English speakers.
TTY
711
Calls to this number are free. 8:00 a.m. - 8:00 p.m., 7 days a week.
Write
Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Website www.MercyCareAdvantage.com
This formulary was updated on 12/28/2016. For more recent information or other questions,
please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or
1‑800‑624‑3879 or, for TTY users, 711, 8:00 a.m. - 8:00 p.m., 7 days a week, or visit
www.MercyCareAdvantage.com.
Servicios al Miembro de Mercy Care Advantage (HMO SNP)
Llame
602‑263‑3000 ó 1‑800‑624‑3879
Las llamadas a estos números son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.
Servicios al Miembro también tiene servicios gratuitos de interpretación de
idiomas disponibles para personas que no hablan inglés.
TTY
711
Las llamadas a este número son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.
Escriba Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Sitio Web
www.MercyCareAdvantage.com
Este formulario fue actualizado en 12/28/2016. Para la información más reciente o para otras
preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al
602‑263‑3000 ó al 1‑800‑624‑3879, ó para los usuarios de TTY, al 711, 8:00 a.m. a 8:00 p.m.,
7 días de la semana, ó visite www.MercyCare Advantage.com.