2017
FORMULARY (LIST OF COVERED DRUGS)
Superior HealthPlan STAR+PLUS (MMP)
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.
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN.
00017412, Version 10
Updated 06/01/2017. For more recent information or other
questions, please contact Superior HealthPlan Member
Services at 1-866-896-1844, TTY: 711. Member Service hours
are from 8 a.m. to 8 p.m., Monday through Friday.
After hours, on weekends and on holidays, you may be asked
to leave a message. Your call will be returned within the next
business day.
Or visit http://mmp.superiorhealthplan.com
H6870 LOD17 Approved 09082016
H6870_LOD17_Approved_09082016
Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) | 2017
List of Covered Drugs (Formulary)
This is a list of drugs that members can get in Superior STAR+PLUS MMP.
� Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) is a health plan that contracts with both
Medicare and Texas Medicaid to provide benefits of both programs to enrollees.
� The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will
send you a notice before we make a change that affects you.
� Benefits may change on January 1 of each year.
� You can always check Superior STAR+PLUS MMP’s up-to-date List of Covered Drugs online at
http://mmp.SuperiorHealthPlan.com.
� Limitations and restrictions may apply. For more information, call Superior STAR+PLUS MMP Member
Services or read the Superior STAR+PLUS MMP Member Handbook.
� You can get this information for free in other languages. Call Member Services at 1-866-896-1844. Hours are
from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked
to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is
free.
� Puede obtener esta información en otros idiomas gratis. Llame al 1-866-896-1844. El horario de atención es
de 8 a. m. a 8 p. m., de lunes a viernes. Luego del horario de atención, los fines de semana y los días
feriado, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. La
llamada es gratuita.
� You can get this information for free in other formats, such as large print, braille, or audio. Call
Member Services at 1-866-896-1844 from 8 a.m. to 8 p.m. CST, Monday through Friday. After hours,
on weekends and on holidays, you may be asked to leave a message. Your call will be returned
within the next business day. TTY users call 711. The call is free.
� If you would like this information in a format other than English or in an alternate format, please call 1­
866-896-1844 (TTY: 711), 8 a.m. to 8 p.m. CST, Monday through Friday. After hours, on weekends
and on holidays, you may be asked to leave a message. Your call will be returned the next business
day. The call is free. You can also email [email protected].
?
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
8 p.m. CST, Monday through Friday. After hours, on weekends and on holidays, you may be asked to
leave a message. Your call will be returned the next business day. The call is free. For more information,
visit http://mmp.SuperiorHealthPlan.com.
1
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn
more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 11 are the drugs covered by Superior STAR+PLUS
MMP. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an
agreement with them to work with us and provide you services. We refer to these pharmacies as “network
pharmacies.”
- Superior STAR+PLUS MMP will cover all medically necessary drugs on the Drug List if:
• your doctor or other prescriber says you need them to get better or stay healthy, and
• you fill the prescription at a Superior STAR+PLUS MMP network pharmacy.
- Superior STAR+PLUS MMP may have additional steps to access certain drugs (see question #5 below).
• You can also see an up-to-date list of drugs that we cover on our website at
http://mmp.SuperiorHealthPlan.com or call Member Services at 1-866-896-1844 (TTY: 711).
2.
Does the Drug List ever change?
Yes. Superior STAR+PLUS MMP may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
• a cheaper drug comes along that works as well as a drug on the Drug List now, or
• we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
• Decide to require or not require prior approval for a drug. (Prior approval is permission from Superior
STAR+PLUS MMP before you can get a drug.)
• Add or change the amount of a drug you can get (called “quantity limits”).
• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we
will cover another drug.)
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
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(For more information on these drug rules, see page 4.)
We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
- You can always check Superior STAR+PLUS MMP’s up to date Drug List online at
http://mmp.SuperiorHealthPlan.com.
- You can also call Member Services to check the current Drug List at 1-866-896-1844 (TTY: 711).
3.
What happens when a cheaper drug comes along that works as well as a drug
on the Drug List now?
If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask
for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made.
We will mail you a notice if we change our coverage rules for a drug you are taking. You will receive the notice
by mail at least 60 days before we change the drug rules or remove the drug from our List of Covered Drugs. For
example, if you are taking a drug, and we add prior authorization (approval) and/or quantity limits, the notice you
receive will explain the new rules. We must tell you of this change at least 60 days before it becomes effective.
Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will
receive a 60-day supply of the drug. For more information on these drug rules, see page 4. If you have questions
about the notice you receive from Superior STAR+PLUS MMP, call Member Services at 1-866-896-1844 (TTY:
711) from 8 a.m. to 8 p.m. CST, Monday through Friday. After hours, on weekends and on holidays, you may be
asked to leave a message. Your call will be returned within the next business day. The call is free.
4.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List
right away. We will also send you a letter telling you that. If you have any questions after being notified of the
change, you should contact the doctor who prescribed the drug for you.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
3
5.
Are there any restrictions or limits on drug coverage? Or are there any
required actions to take in order to get certain drugs?
• Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must
do something before you can get the drug. For example:
• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get
approval from Superior STAR+PLUS MMP before you fill your prescription. If you don’t get approval,
Superior STAR+PLUS MMP may not cover the drug.
• Quantity limits: Sometimes Superior STAR+PLUS MMP limits the amount of a drug you can get.
• Step therapy: Sometimes Superior STAR+PLUS MMP requires you to do step therapy. This means you
will have to try drugs in a certain order for your medical condition. You might have to try one drug before
we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the
second.
You can find out if your drug has any additional requirements or limits by looking in the tables on page 9. You
can also get more information by visiting our web site at http://mmp.SuperiorHealthPlan.com. We have posted
online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send
you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
- If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if
you cannot easily get the drug you need, we can help. We will cover a 31day emergency supply of the drug
you need (unless you have a prescription for fewer days), whether or not you are a new Superior
STAR+PLUS MMP member. This will give you time to talk to your doctor or other prescriber. He or she can
help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an
exception. Please see question 11 for more information about exceptions.
6.
How will you know if the drug you want has limitations or if there are required
actions to take to get the drug?
The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions, or limits on use.”
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
4
7.
What happens if we change our rules on how we cover some drugs? For
example, if we add prior authorization (approval), quantity limits, and/or step
therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you
at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day
supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other
prescriber about what to do next.
8.
How can you find a drug on the Drug List?
There are two ways to find a drug:
� You can search alphabetically (if you know how to spell the drug), or
� You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs
beginning on page7.
To search by medical condition, find the section labeled “List of drugs by medical condition” on page 11. The
drugs in this section are grouped into categories depending on the type of medical conditions they are used to
treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is
where you will find drugs that treat heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-866-896-1844 (TTY: 711) and ask about
it. If you learn that Superior STAR+PLUS MMP will not cover the drug, you can do one of these things:
� Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or
other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
� You can ask the health plan to make an exception to cover your drug. Please see question 11 for more
information about exceptions.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
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10.
What if you are a new Superior STAR+PLUS MMP member and can’t find your
drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member
of Superior STAR+PLUS MMP. This will give you time to talk to your doctor or other prescriber. He or she can
help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an
exception.
We will cover a 30-day supply of your drug if:
• you are taking a drug that is not on our Drug List, or
• health plan rules do not let you get the amount ordered by your prescriber, or
• the drug requires prior approval by Superior STAR+PLUS MMP, or
• you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This
gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
Throughout the plan year, you may have a change in your treatment setting (the place where you get and take
your medicine) because of the level of care you require. Such transitions may include, but are not limited to:
•
Members who are discharged from a hospital or skilled-nursing facility to a home setting
•
Members who are admitted to a hospital or skilled-nursing facility from a home setting
•
Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy
•
Members who end their skilled-nursing facility Medicare Part A stay (where payments include all
pharmacy charges) and who now need to use their Part D plan benefit
•
Members who give up Hospice Status and go back to standard Medicare Part A and B coverage
•
Members discharged from chronic psychiatric hospitals with highly individualized drug regimes
For these changes in treatment settings, Superior STAR+PLUS MMP will cover as much as a 31-day temporary
supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment
settings multiple times within the same month, you may have to request an exception or prior authorization and
get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a
case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask
for a temporary supply of a drug, call Member Services.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
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11.
Can you ask for an exception to cover your drug?
Yes. You can ask Superior STAR+PLUS MMP to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
� For example, Superior STAR+PLUS MMP may limit the amount of a drug we will cover. If your drug has a
limit, you can ask us to change the limit and cover more.
� Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
12.
How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an
exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can
ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give
you a decision within 24 hours of getting your prescriber’s supporting statement.
13.
How can you ask for an exception?
To ask for an exception, call Member Services. A representative will work with you and your provider to help you
ask for an exception.
14.
What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the
brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug
Administration (FDA).
Superior STAR+PLUS MMP covers both brand name drugs and generic drugs.
15.
What are OTC drugs?
OTC stands for “over-the-counter.” Superior STAR+PLUS MMP covers some OTC drugs when they are written
as prescriptions by your provider.
You can read the Superior STAR+PLUS MMP Drug List to see what OTC drugs are covered.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
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16.
What is your copay?
As a Superior STAR+PLUS MMP member, you have no copays for prescription and OTC drugs as long as you
follow Superior STAR+PLUS MMP’s rules.
Copays are listed by tiers. Tiers are groups of drugs with the same copay.
•
Tier 1 drugs are generic drugs. The co-pay is $0.
•
Tier 2 drugs are brand name drugs. The co-pay is $0.
•
Tier 3 drugs are Non-Medicare Rx/OTC Drugs. The co-pay is $0.
17. What
are drug tiers?
Tiers are groups of drugs on our Drug List.
•
Tier 1 drugs are generic drugs.
•
Tier 2 drugs are brand name drugs
•
Tier 3 drugs are Non-Medicare Rx/OTC brand name and generic drugs.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
8
List of Covered Drugs
The list of covered drugs that begins on page 11 gives you information about the drugs covered by Superior
STAR+PLUS MMP. If you have trouble finding your drug in the list, turn to the Index that begins on page107.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., JANUVIA) and
generic drugs are listed in lower-case italics (e.g., metformin).
The information in the necessary actions, restrictions, or limits on use column tells you if Superior STAR+PLUS
MMP has any rules for covering your drug.
Abbreviations Descriptions
B/D
This prescription drug has a Part B versus Part D administrative prior authorization
requirement. This drug may be covered under Medicare Part B or Part D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the
drug to make the determination.
DP
Drug is not a Part D drug. This item is covered under your Medicaid benefits. These drugs
also have different rules for appeals.
LA
Limited Access. This prescription may be available only at certain pharmacies. For more
information call Member Services at 1-866-896-1844. TTY users should call 711.
PA
Prior Authorization (or prior approval). Superior STAR+PLUS MMP requires your doctor or
you to get prior approval for certain drugs. This means that you will need to get approval from
Superior STAR+PLUS MMP before you fill your prescriptions. If you don’t get approval,
Superior STAR+PLUS MMP may not cover the drug.
QL
Quantity Limit. For certain drugs, Superior STAR+PLUS MMP limits the amount of the drug
that will be covered. For example, only 30 tablets of JANUVIA per 30 days. This may be in
addition to a standard one-month or three-month supply.
MO
Maintenance Drug. This prescription drug is eligible for a 90-day supply through our mail
order service as well as through certain retail network pharmacies. Consider using mail order
for your long-term (maintenance) medications (such as high blood pressure medications).
Retail network pharmacies may be more appropriate for short- term prescriptions (such as
antibiotics).
NDS
Non-Extended Day Supply. This prescription drug is not available for an extended days'
supply.
ST
Step Therapy. Sometimes Superior STAR+PLUS MMP requires you to do step therapy. This
means you might have to try one drug before we will cover another drug.
Note: The DP next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a
prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help
you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
9
will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is
a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For
example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas
Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to
appeal, call Member Services at 1-866-896-1844 (TTY: 711). You can also read the Member Handbook to learn
how to appeal a decision.
If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to
? 8 p.m. CST, Monday through Friday. On weekends, and on holidays, you may be asked to leave a
message. Your call will be returned the next business day. The call is free. For more information, visit
http://mmp.SuperiorHealthPlan.com.
10
Name of drug
Analgesics
Analgesics
acephen
acetaminophen tablet 325mg
alagesic lq
allzital
butalbital/acetaminophen
butalbital/acetaminophen/caffeine/codeine capsule 325mg;
50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine capsule 325mg; 50mg;
40mg
butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg
butalbital/acetaminophen/caffeine tablet 500mg; 50mg; 40mg
butalbital/aspirin/caffeine capsule
childrens mapap rapid tabs
ed-apap
gnp arthritis pain relief
GRALISE
GRALISE STARTER
junior mapap
mapap acetaminophen extrastrength
mapap arthritis pain
mapap childrens
mapap capsule, tablet chewable, liquid, tablet
pain & fever
pain & fever childrens
pain & fever extra strength
q-pap
q-pap childrens
q-pap extra strength
q-pap infants
qc arthritis pain relief
tencon tablet 325mg; 50mg
Nonsteroidal Anti-inflammatory Drugs
all day pain relief
all day relief
aspir-low
aspirin adult low strength tablet chewable
aspirin ec low dose
aspirin ec tablet delayed release 325mg
aspirin low dose tablet chewable
aspirin tablet chewable
aspirin tablet delayed release 325mg, 81mg
aspirin tablet 325mg
childrens aspirin
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
11
Name of drug
childrens ibuprofen suspension 100mg/5ml
childs ibuprofen
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal tablet 500mg
effervescent pain relief
enteric coated aspirin
etodolac er
etodolac capsule, tablet
fenoprofen calcium capsule 400mg
fenoprofen calcium tablet
flurbiprofen tablet
gnp ibuprofen junior strength
gnp ibuprofen tablet
goodsense ibuprofen
goodsense ibuprofen childrens
goodsense ibuprofen infants
goodsense ibuprofen junior strength
ibu-200
ibu-drops
ibu-drops infants
ibuprofen childrens
ibuprofen capsule
ibuprofen suspension 100mg/5ml
ibuprofen suspension 100mg/5ml
ibuprofen tablet 400mg, 600mg, 800mg
ibuprofen tablet 200mg
indomethacin er
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
indomethacin capsule
$0(Tier 1)
infants ibuprofen
ketoprofen er capsule extended release 24 hour 200mg
$0(Tier 3)
$0(Tier 1)
ketoprofen capsule 50mg, 75mg
ketorolac tromethamine injection 15mg/ml, 30mg/ml
meclofenamate sodium capsule
meloxicam suspension
meloxicam tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
migraine formula
nabumetone
naproxen dr
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
MO
MO
MO
MO
DP
DP
MO
MO
MO
MO
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
MO
DP
PA (High Risk
Medication-Anti
inflammatory Agents) MO
PA (High Risk
Medication-Anti
inflammatory Agents) MO
DP
QL (30 EA per 30 days)
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
DP
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
12
Name of drug
naproxen sodium tablet 275mg, 550mg
naproxen suspension, tablet
oxaprozin
piroxicam capsule
qc ibuprofen capsule
qc naproxen sodium
sm ibuprofen tablet
sulindac tablet
tolmetin sodium capsule
tolmetin sodium tablet 600mg
Opioid Analgesics, Long-acting
fentanyl
levorphanol tartrate tablet
METHADONE HCL INJECTION
methadone hcl oral solution 5mg/5ml
methadone hcl oral solution 10mg/5ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
morphine sulfate er tablet extended release 60mg
morphine sulfate er tablet extended release 15mg, 30mg
morphine sulfate er tablet extended release 200mg
morphine sulfate er tablet extended release 100mg
Opioid Analgesics, Short-acting
acetaminophen/codeine tablet 300mg; 60mg
acetaminophen/codeine tablet 300mg; 15mg, 300mg; 30mg
ascomp/codeine
butorphanol tartrate nasal solution
butorphanol tartrate injection 2mg/ml
butorphanol tartrate injection 1mg/ml
duramorph injection 1mg/ml
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
DP
DP
DP
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
QL (10 EA per 30 days)
QL (120 EA per 30 days)
QL (160 ML per 30 days)
QL (1200 ML per 30
days)
QL (600 ML per 30 days)
QL (120 EA per 30 days)
QL (240 EA per 30 days)
QL (100 EA per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (5 ML per 28 days)
QL (360 ML per 30 days)
QL (720 ML per 30 days)
QL (2000 ML per 30
days)
QL (4000 ML per 30
days)
QL (360 EA per 30 days)
QL (120 EA per 30 days)
PA (Fentanyl Citrate Oral
Transmucosal) NDS
QL (5550 ML per 30
days)
QL (360 EA per 30 days)
$0(Tier 1)
QL (360 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
duramorph injection 0.5mg/ml
$0(Tier 1)
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
fentanyl citrate oral transmucosal
$0(Tier 1)
$0(Tier 1)
hydrocodone bitartrate/acetaminophen solution 325mg/15ml;
7.5mg/15ml
hydrocodone bitartrate/acetaminophen tablet 300mg; 7.5mg,
325mg; 2.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tablet 10mg; 200mg, 5mg; 200mg
hydromorphone hcl tablet
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
13
Name of drug
hydromorphone hcl injection 10mg/ml, 50mg/5ml
hydromorphone hcl injection 2mg/ml
LAZANDA SOLUTION 300MCG/ACT
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
LAZANDA SOLUTION 100MCG/ACT, 400MCG/ACT
$0(Tier 2)
morphine sulfate tablet
morphine sulfate solution 100mg/5ml
morphine sulfate solution 10mg/5ml, 20mg/5ml
nalbuphine hcl injection 20mg/ml
nalbuphine hcl injection 10mg/ml
oxycodone hcl tablet 30mg
oxycodone hcl tablet 10mg, 15mg, 20mg
oxycodone hcl tablet 5mg
oxycodone/acetaminophen solution
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, $0(Tier 1)
325mg; 7.5mg
TALWIN
$0(Tier 2)
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
Anesthetics
Local Anesthetics
lidocaine hcl jelly
lidocaine hcl external solution
lidocaine hcl injection 0.5%, 2%
lidocaine viscous
lidocaine/prilocaine cream
lidocaine ointment
lidocaine patch
$0(Tier 1)
$0(Tier 1)
sore throat & cough lozenges
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram tablet
Opioid Dependence Treatments
buprenorphine hcl injection
buprenorphine hcl tablet sublingual 2mg
$0(Tier 3)
$0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (150 ML per 30 days)
QL (750 ML per 30 days)
QL (150 EA per 30 days)
PA (Lazanda)
QL (30 EA per 30 days)
PA (Lazanda)
QL (180 EA per 30 days)
QL (300 ML per 30 days)
QL (900 ML per 30 days)
QL (100 ML per 30 days)
QL (200 ML per 30 days)
QL (134 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (1800 ML per 30
days)
QL (360 EA per 30 days)
PA (High Risk
Medications)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (90 EA per 30 days) PA (Anesthetics)
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
buprenorphine hcl tablet sublingual 8mg
$0(Tier 1)
naltrexone hcl tablet
SUBOXONE FILM 12MG; 3MG
$0(Tier 1)
$0(Tier 2)
QL (267 ML per 30 days)
QL (300 EA per 30 days)
PA (Suboxone)
QL (75 EA per 30 days)
PA (Suboxone)
QL (60 EA per 30 days)
PA (Suboxone)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
14
What the drug
will cost you
Name of drug
(tier level)
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG $0(Tier 2)
ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG,
11.4MG; 2.9MG, 2.9MG; 0.71MG
ZUBSOLV TABLET SUBLINGUAL 8.6MG; 2.1MG
$0(Tier 2)
ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG
$0(Tier 2)
Opioid Reversal Agents
naloxone hcl injection 0.4mg/ml, 2mg/2ml
Smoking Cessation Agents
buproban
bupropion hcl sr tablet extended release 12 hour 150mg
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
NICODERM CQ
nicorelief gum
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine polacrilex gum, lozenge
nicotine transdermal system step 1
NICOTINE TRANSDERMAL SYSTEM KIT
nicotine transdermal system patch 24 hour 14mg/24hr,
21mg/24hr, 7mg/24hr
NICOTROL NS
Antibacterials
Aminoglycosides
amikacin sulfate injection 500mg/2ml
gentak ointment
gentamicin sulfate/0.9% sodium chloride injection 1.2mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%
gentamicin sulfate cream, external ointment, ophthalmic
ointment, ophthalmic solution
gentamicin sulfate injection 10mg/ml, 40mg/ml
isotonic gentamicin
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
streptomycin sulfate injection 1gm
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
Antibacterials, Other
alcohol prep pads
baciim
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
PA (Suboxone)
QL (30 EA per 30 days)
PA (Zubsolv)
QL (60 EA per 30 days)
PA (Zubsolv)
QL (90 EA per 30 days)
PA (Zubsolv)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
QL (56 EA per 28 days)
QL (56 EA per 28 days)
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
15
Name of drug
bacitracin zinc ointment
bacitracin/neomycin/polymyxin ointment
BACITRACIN INJECTION
bacitracin ophthalmic ointment
bacitracin external ointment
CHLORAMPHENICOL SODIUM SUCCINATE
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
clindamax gel
clindamycin hcl capsule
clindamycin palmitate hcl
clindamycin phosphate in d5w
clindamycin phosphate cream, gel, lotion, external solution,
swab
clindamycin phosphate injection 300mg/2ml, 600mg/4ml,
900mg/6ml
colistimethate sodium
CUBICIN
daptomycin
LINCOCIN INJECTION
lincomycin hcl injection
linezolid tablet
linezolid suspension reconstituted
linezolid injection 600mg/300ml
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole gel 0.75%
metronidazole cream, lotion, tablet
mupirocin ointment
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/hydrocortisone ophthalmic suspension
1%; 3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
B/D
NDS
NDS
$0(Tier 1)
PA (High Risk Medication
- Nitrofurantoin)
PA (High Risk Medication
- Nitrofurantoin)
nitrofurantoin monohydrate/macrocrystals
$0(Tier 1)
polymyxin b sulfate injection
povidone-iodine ointment, solution
silver sulfadiazine cream
ssd
SYNERCID INJECTION 350MG; 150MG
trimethoprim tablet
triple antibiotic plus ointment 500unit/gm; 5mg/gm;
10000unit/gm; 10mg/gm
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
QL (20 EA per 10 days)
QL (600 ML per 10 days)
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
16
Name of drug
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm, 400unit/gm; 5mg/gm; 5000unit/gm
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm, 500mg
vandazole
XIFAXAN TABLET 200MG
XIFAXAN TABLET 550MG
Beta-lactam, Cephalosporins
cefaclor er tablet extended release 12 hour 500mg
cefaclor capsule
cefadroxil
cefazolin sodium injection 10gm, 1gm, 500mg
cefdinir
cefepime injection 1gm, 2gm
cefotaxime sodium injection 1gm, 2gm, 500mg
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil tablet
cefprozil
ceftazidime injection 1gm, 2gm, 6gm
ceftriaxone sodium injection 10gm, 1gm, 250mg, 2gm, 500mg
cefuroxime axetil tablet
cefuroxime sodium injection 1.5gm, 7.5gm, 750mg
cephalexin capsule 250mg, 500mg
cephalexin suspension reconstituted, tablet
CLAFORAN INJECTION 10GM, 500MG
FORTAZ INJECTION 1GM, 2GM
SUPRAX CAPSULE, TABLET CHEWABLE,
SUSPENSION RECONSTITUTED
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE
aztreonam injection 1gm
imipenem/cilastatin
INVANZ
meropenem injection 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin capsule, suspension reconstituted, tablet
amoxicillin tablet chewable 125mg, 250mg
ampicillin
ampicillin sodium injection 10gm, 125mg, 1gm
ampicillin-sulbactam
BACTOCILL IN DEXTROSE
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
NDS
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
17
Name of drug
BICILLIN C-R INJECTION 300000UNIT/ML;
300000UNIT/ML, 900000UNIT/2ML; 300000UNIT/2ML
BICILLIN L-A INJECTION 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML
dicloxacillin sodium
nafcillin sodium injection 10gm, 1gm
oxacillin sodium injection 10gm, 2gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 40000UNIT/ML, 0;
60000UNIT/ML
penicillin g potassium injection 5000000unit
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
piperacillin/tazobactam injection 4gm; 0.5gm
ZOSYN INJECTION 36GM; 4.5GM, 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML
Macrolides
AZASITE
azithromycin injection 500mg
azithromycin suspension reconstituted 100mg/5ml
azithromycin suspension reconstituted 200mg/5ml
azithromycin tablet 500mg
azithromycin tablet 250mg
azithromycin tablet 600mg
clarithromycin er
clarithromycin suspension reconstituted
clarithromycin tablet 250mg
clarithromycin tablet 500mg
e.e.s. 400 tablet
e.e.s. granules
ERY-TAB
ERYPED 400
ERYTHROCIN LACTOBIONATE INJECTION 500MG
erythrocin stearate tablet 250mg
erythromycin base
erythromycin ethylsuccinate suspension reconstituted
erythromycin capsule delayed release particles, ointment
erythromycin solution 2%
KETEK
ZMAX
Quinolones
AVELOX INJECTION
ciprofloxacin hcl solution, tablet
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin injection 400mg/40ml
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QL (15 ML per 5 days)
QL (22.5 ML per 5 days)
QL (3 EA per 3 days)
QL (6 EA per 5 days)
QL (8 EA per 28 days)
QL (28 EA per 14 days)
QL (42 EA per 21 days)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
18
Name of drug
levofloxacin in d5w injection 5%; 500mg/100ml, 5%;
750mg/150ml
levofloxacin injection, oral solution
levofloxacin tablet 250mg
levofloxacin tablet 500mg, 750mg
moxifloxacin hcl injection
ofloxacin ophthalmic solution, otic solution
ofloxacin tablet 300mg, 400mg
Sulfonamides
sodium sulfacetamide solution
sulfacetamide sodium suspension
sulfadiazine tablet
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
Tetracyclines
demeclocycline hcl tablet
doxy 100
doxycycline hyclate capsule, injection, tablet
doxycycline monohydrate capsule 100mg, 50mg
minocycline hcl capsule
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG, 400MG, 800MG
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (10 EA per 10 days)
QL (14 EA per 14 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
APTIOM TABLET 600MG
$0(Tier 2)
BRIVIACT INJECTION
BRIVIACT TABLET
$0(Tier 2)
$0(Tier 2)
BRIVIACT ORAL SOLUTION
$0(Tier 2)
FYCOMPA TABLET
$0(Tier 2)
FYCOMPA SUSPENSION
$0(Tier 2)
levetiracetam injection
levetiracetam oral solution, tablet
POTIGA TABLET 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
POTIGA TABLET 200MG, 300MG, 400MG
$0(Tier 2)
SPRITAM
Calcium Channel Modifying Agents
CELONTIN CAPSULE 300MG
ethosuximide
LYRICA SOLUTION
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (600 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (720 ML per 30 days)
MO
$0(Tier 2)
MO
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
19
Name of drug
LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG
LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
zonisamide
$0(Tier 1)
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tablet disintegrating 0.125mg, 0.25mg, 0.5mg, $0(Tier 1)
1mg
clonazepam odt tablet disintegrating 2mg
$0(Tier 1)
clonazepam tablet 0.5mg, 1mg
$0(Tier 1)
clonazepam tablet 2mg
$0(Tier 1)
diazepam gel 20mg
$0(Tier 1)
diazepam gel 2.5mg
$0(Tier 1)
diazepam gel 10mg
$0(Tier 1)
divalproex sodium dr
$0(Tier 1)
divalproex sodium er
$0(Tier 1)
divalproex sodium capsule delayed release sprinkle
$0(Tier 1)
gabapentin capsule, solution
$0(Tier 1)
gabapentin tablet 600mg, 800mg
$0(Tier 1)
GABITRIL TABLET 12MG, 16MG
$0(Tier 2)
ONFI SUSPENSION
ONFI TABLET 10MG, 20MG
phenobarbital elixir
phenobarbital tablet 100mg, 15mg, 16.2mg, 30mg, 32.4mg,
60mg, 64.8mg, 97.2mg
primidone tablet
SABRIL
tiagabine hydrochloride
valproate sodium injection
valproic acid capsule, solution
Glutamate Reducing Agents
felbamate
lamotrigine odt
lamotrigine tablet chewable, tablet
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG $0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG, $0(Tier 2)
200MG
topiramate er capsule er 24 hour sprinkle 100mg, 25mg, 50mg$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (100 EA per 30 days)
QL (24.9 EA per 30 days)
QL (50 EA per 30 days)
MO
MO
MO
MO
MO
QL (90 EA per 30 days) MO
MO
MO
MO
QL (360 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
20
Name of drug
topiramate er capsule er 24 hour sprinkle 150mg, 200mg
topiramate capsule sprinkle, tablet
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 25MG, 50MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 100MG
Sodium Channel Agents
BANZEL SUSPENSION
BANZEL TABLET 200MG
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
BANZEL TABLET 400MG
$0(Tier 2)
carbamazepine er
carbamazepine tablet chewable, suspension, tablet
CARBATROL
CEREBYX INJECTION 500MG PE/10ML
DILANTIN INFATABS
DILANTIN-125
DILANTIN CAPSULE
epitol
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 600MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
PEGANONE TABLET 250MG
PHENYTEK
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
TEGRETOL-XR
TEGRETOL SUSPENSION, TABLET
VIMPAT INJECTION
VIMPAT ORAL SOLUTION
VIMPAT TABLET 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
VIMPAT TABLET 100MG, 150MG, 200MG
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
NDS
QL (240 EA per 30 days)
MO
QL (240 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
Antidementia Agents
Antidementia Agents, Other
You can find information on what the symbols and abbreviations in this table mean by going to page 9
21
Name of drug
ergoloid mesylates tablet
Cholinesterase Inhibitors
donepezil hcl tablet disintegrating
What the drug
will cost you
(tier level)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
PA (High Risk
Medications) MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
donepezil hcl tablet 10mg, 5mg
$0(Tier 1)
galantamine hydrobromide er
$0(Tier 1)
galantamine hydrobromide solution
galantamine hydrobromide tablet 4mg
$0(Tier 1)
$0(Tier 1)
galantamine hydrobromide tablet 12mg
$0(Tier 1)
galantamine hydrobromide tablet 8mg
$0(Tier 1)
rivastigmine tartrate
$0(Tier 1)
rivastigmine transdermal system
$0(Tier 1)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl
memantine hcl titration pak
memantine hydrochloride solution
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Antidepressants
Antidepressants, Other
bupropion hcl sr tablet extended release 12 hour 100mg,
150mg, 200mg
bupropion hcl xl
$0(Tier 1)
$0(Tier 1)
bupropion hcl tablet 75mg
bupropion hcl tablet 100mg
$0(Tier 1)
$0(Tier 1)
maprotiline hcl
mirtazapine odt
$0(Tier 1)
$0(Tier 1)
mirtazapine tablet
nefazodone hcl
trazodone hcl tablet
TRINTELLIX
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
QL (60 EA per 30 days)
MO
MO
QL (360 ML per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
Monoamine Oxidase Inhibitors
You can find information on what the symbols and abbreviations in this table mean by going to page 9
22
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
EMSAM
MARPLAN
$0(Tier 2)
phenelzine sulfate
$0(Tier 1)
tranylcypromine sulfate
$0(Tier 1)
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide solution
$0(Tier 1)
citalopram hydrobromide tablet 10mg
$0(Tier 1)
citalopram hydrobromide tablet 40mg
$0(Tier 1)
citalopram hydrobromide tablet 20mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 100mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 25mg, 50mg$0(Tier 1)
duloxetine hcl capsule delayed release particles
$0(Tier 1)
escitalopram oxalate solution
escitalopram oxalate tablet
$0(Tier 1)
$0(Tier 1)
FETZIMA
$0(Tier 2)
FETZIMA TITRATION PACK
$0(Tier 2)
fluoxetine hcl capsule, solution
fluoxetine hcl tablet 10mg
fluvoxamine maleate
paroxetine hcl
paroxetine hcl er tablet extended release 24 hour 37.5mg
PAXIL SUSPENSION
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
25MG, 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
100MG
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) NDS
MO
MO
MO
QL (600 ML per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
23
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
Name of drug
sertraline hcl concentrate, tablet
venlafaxine hcl
venlafaxine hcl er
$0(Tier 1)
VIIBRYD STARTER PACK
$0(Tier 2)
VIIBRYD TABLET
$0(Tier 2)
Tricyclics
amitriptyline hcl tablet
amoxapine
chlordiazepoxide/amitriptyline
clomipramine hcl capsule
desipramine hcl tablet
doxepin hcl capsule, concentrate
imipramine hcl tablet
imipramine pamoate
nortriptyline hcl capsule, solution
perphenazine/amitriptyline
protriptyline hcl
trimipramine maleate capsule
Antiemetics
Antiemetics, Other
anti-nausea
dimenhydrinate tablet
formula em
meclizine hcl tablet 12.5mg, 25mg
meclizine hcl tablet 12.5mg
phenadoz suppository 12.5mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
DP
DP
DP
promethazine hcl injection, suppository, syrup, tablet
$0(Tier 1)
promethegan suppository 25mg, 50mg
$0(Tier 1)
TRANSDERM-SCOP
travel sickness
trimethobenzamide hcl capsule 300mg
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
Emetogenic Therapy Adjuncts
aprepitant capsule 40mg
Necessary actions,
restrictions, or limits on
use
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 180 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
DP
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
QL (10 EA per 30 days)
DP
PA (High Risk
Medications)
QL (1 EA per 14 days)
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9
24
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
aprepitant capsule 0
aprepitant capsule 125mg
$0(Tier 1)
aprepitant capsule 80mg
$0(Tier 1)
dronabinol
$0(Tier 1)
EMEND CAPSULE 40MG
$0(Tier 2)
EMEND CAPSULE 0
$0(Tier 2)
EMEND CAPSULE 125MG
$0(Tier 2)
EMEND CAPSULE 80MG
$0(Tier 2)
granisetron hcl injection 0.1mg/ml, 1mg/ml
ondansetron hcl oral solution
ondansetron hcl injection 4mg/2ml
ondansetron hcl tablet 24mg
ondansetron hcl tablet 4mg, 8mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
ondansetron odt
$0(Tier 1)
Antifungals
Antifungals
ABELCET
AMBISOME
amphotericin b
anti-fungal powder
antifungal aerosol, cream
CANCIDAS
ciclopirox olamine cream
ciclopirox suspension
clotrimazole anti-fungal
clotrimazole external cream 1%
clotrimazole external cream 1%
clotrimazole vaginal cream 1%
clotrimazole troche
clotrimazole solution 1%
clotrimazole solution 1%
econazole nitrate cream
fluconazole in nacl injection 200mg/100ml; 0.9%,
400mg/200ml; 0.9%
fluconazole suspension reconstituted, tablet
flucytosine
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
QL (60 EA per 30 days)
B/D
QL (1 EA per 14 days)
B/D
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
B/D
B/D
QL (90 EA per 30 days)
B/D
QL (90 EA per 30 days)
B/D
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
25
What the drug
will cost you
Name of drug
(tier level)
FUNGOID TINCTURE SOLUTION
$0(Tier 3)
griseofulvin microsize tablet
$0(Tier 1)
griseofulvin ultramicrosize tablet 125mg, 250mg
$0(Tier 1)
itraconazole capsule
$0(Tier 1)
ketoconazole cream, shampoo, tablet
$0(Tier 1)
miconazole 3 suppository
$0(Tier 1)
miconazole 7 suppository
$0(Tier 3)
miconazole nitrate external cream, vaginal cream, suppository$0(Tier 3)
miconazole cream
$0(Tier 3)
MYCAMINE
$0(Tier 2)
naftifine hcl
$0(Tier 1)
naftifine hydrochloride
$0(Tier 1)
NAFTIN GEL 1%
$0(Tier 2)
NATACYN
$0(Tier 2)
NOXAFIL SUSPENSION, TABLET DELAYED RELEASE $0(Tier 2)
nyamyc
$0(Tier 1)
nystatin/triamcinolone
$0(Tier 1)
nystatin cream, ointment, powder, suspension, tablet
$0(Tier 1)
nystop
$0(Tier 1)
qc tolnaftate
$0(Tier 3)
sm miconazole 7 cream
$0(Tier 3)
SPORANOX SOLUTION
$0(Tier 2)
terbinafine hcl tablet
$0(Tier 1)
terbinafine hcl cream
$0(Tier 3)
terconazole cream
$0(Tier 1)
terconazole suppository
$0(Tier 1)
tioconazole-1
$0(Tier 3)
tolnaftate cream, powder
$0(Tier 3)
voriconazole injection
$0(Tier 1)
voriconazole suspension reconstituted, tablet
$0(Tier 1)
zeasorb-af powder
$0(Tier 3)
Antigout Agents
Antigout Agents
allopurinol sodium
$0(Tier 1)
allopurinol tablet
$0(Tier 1)
ALOPRIM
$0(Tier 2)
colchicine capsule
$0(Tier 1)
colchicine tablet 0.6mg
$0(Tier 1)
COLCRYS
$0(Tier 2)
probenecid/colchicine
$0(Tier 1)
probenecid tablet
$0(Tier 1)
Antimigraine Agents
Antimigraine Agents
BOTOX INJECTION 100UNIT
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
QL (12 EA per 30 days)
DP
DP
DP
NDS
DP
DP
DP
QL (3 EA per 30 days)
DP
DP
NDS
DP
MO
MO
MO
MO
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
26
Name of drug
Ergot Alkaloids
dihydroergotamine mesylate injection
dihydroergotamine mesylate nasal solution
ERGOMAR
migergot
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML
IMITREX SOLUTION
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan succinate refill
sumatriptan succinate injection
sumatriptan succinate tablet
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON SYRUP
pyridostigmine bromide er
pyridostigmine bromide tablet
Antimycobacterials
Antimycobacterials, Other
DAPSONE TABLET
MYCOBUTIN
rifabutin
Antituberculars
CAPASTAT SULFATE
ethambutol hcl tablet
isoniazid injection
isoniazid syrup, tablet
PASER
PRIFTIN
pyrazinamide tablet
rifampin capsule, injection
RIFATER
SIRTURO
TRECATOR
Antineoplastics
Alkylating Agents
ALKERAN INJECTION
BICNU
BUSULFEX
cyclophosphamide capsule
dacarbazine injection 200mg
GLEOSTINE
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (8 ML per 28 days)
QL (4 ML per 30 days)
QL (9 EA per 30 days)
QL (12 EA per 30 days)
QL (12 EA per 30 days)
QL (4 ML per 30 days)
QL (4 ML per 30 days)
QL (9 EA per 30 days)
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
QL (120 EA per 30 days)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
B/D
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9
27
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Name of drug
HEXALEN
IFEX INJECTION 1GM
ifosfamide injection 1gm
LEUKERAN
MATULANE
melphalan hydrochloride
MUSTARGEN
THIOTEPA INJECTION 15MG
TREANDA INJECTION 100MG
VALCHLOR
YONDELIS
ZANOSAR
Antiandrogens
bicalutamide
Necessary actions,
restrictions, or limits on
use
NDS
NDS
PA (Valchlor, new starts
only)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
flutamide
NILANDRON TABLET 150MG
$0(Tier 1)
$0(Tier 2)
nilutamide
XTANDI
$0(Tier 1)
$0(Tier 2)
ZYTIGA
$0(Tier 2)
Antiangiogenic Agents
POMALYST
REVLIMID CAPSULE 2.5MG, 20MG
$0(Tier 2)
$0(Tier 2)
REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJECTION 250MG/5ML
SOLTAMOX
tamoxifen citrate tablet
Antimetabolites
adrucil injection 500mg/10ml
ALIMTA INJECTION 500MG
ARRANON
cladribine
CLOLAR
cytarabine aqueous
DROXIA
ELITEK
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QL (30 EA per 30 days)
MO
MO
QL (60 EA per 30 days)
NDS
QL (60 EA per 30 days)
QL (120 EA per 30 days)
NDS
PA (zytiga, new starts
only) NDS
NDS
PA (revlimid, new starts
only)
PA (revlimid, new starts
only) LA
NDS
MO
MO
MO
B/D
NDS
B/D
B/D
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
28
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Name of drug
fluorouracil injection 2.5gm/50ml
FOLOTYN INJECTION 40MG/2ML
gemcitabine hcl injection 1gm
hydroxyurea capsule
LONSURF
mercaptopurine tablet
PURIXAN
TABLOID
Antineoplastics, Other
ABRAXANE
adriamycin injection 2mg/ml
amifostine
azacitidine
BELEODAQ
Necessary actions,
restrictions, or limits on
use
B/D
PA (LONSURF, new
starts only) NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
bleomycin sulfate injection 30unit
CAMPTOSAR INJECTION 100MG/5ML
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COSMEGEN
COTELLIC
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
DACOGEN
daunorubicin hcl injection 5mg/ml
decitabine
dexrazoxane injection 250mg
DOCEFREZ INJECTION 20MG
DOCETAXEL INJECTION 80MG/8ML
docetaxel injection 80mg/4ml
doxorubicin hcl liposome
doxorubicin hcl injection 2mg/ml
ELLENCE INJECTION 200MG/100ML
epirubicin hcl injection 200mg/100ml
ERWINAZE
fludarabine phosphate injection 50mg
FUSILEV
GILOTRIF
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
HALAVEN
IBRANCE
$0(Tier 2)
$0(Tier 2)
IDAMYCIN PFS INJECTION 20MG/20ML
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
PA (beleodaq, new starts
only)
B/D
NDS
QL (63 EA per 21 days)
PA (Cotellic, new starts
only) NDS
NDS
PA (gilotrif, new starts
only) NDS
QL (30 EA per 30 days)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
29
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Name of drug
ISTODAX
ISTODAX (OVERFILL)
JEVTANA
KISQALI
LARTRUVO INJECTION 500MG/50ML
$0(Tier 2)
leucovorin calcium tablet
leucovorin calcium injection 100mg, 350mg
levoleucovorin calcium
LYNPARZA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
mesna
MESNEX
mitomycin injection
mitoxantrone hcl injection 2mg/ml
NINLARO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ODOMZO
$0(Tier 2)
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PROLEUKIN
RUBRACA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
SYLATRON
SYNRIBO
TAGRISSO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TRISENOX
VELCADE
VENCLEXTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
VENCLEXTA STARTING PACK
$0(Tier 2)
VINBLASTINE SULFATE INJECTION 1MG/ML
vincristine sulfate
vinorelbine tartrate injection 50mg/5ml
ZINECARD INJECTION 250MG
ZOLINZA
Antineoplastics
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Kisqali, new starts
only) NDS
PA (Lartruvo, new starts
only) NDS
QL (480 EA per 30 days)
NDS
QL (4 EA per 28 days) PA
(Ninlaro, new starts only)
NDS
QL (30 EA per 30 days)
PA (Odomzo, new starts
only) NDS
QL (120 EA per 30 days)
PA (Rubraca, new starts
only) NDS
NDS
QL (30 EA per 30 days)
PA (Tagrisso, new starts
only)
NDS
PA (Venclexta, new starts
only)
PA (Venclexta, new starts
only)
B/D
B/D
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
30
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
FARYDAK
ZALTRAP INJECTION 100MG/4ML
$0(Tier 2)
ZYKADIA
$0(Tier 2)
Aromatase Inhibitors, 3rd Generation
anastrozole tablet
$0(Tier 1)
exemestane
letrozole
Enzyme Inhibitors
ETOPOPHOS
etoposide injection 500mg/25ml
KYPROLIS
$0(Tier 1)
$0(Tier 1)
toposar injection 1gm/50ml
topotecan hcl injection 4mg
ZYDELIG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
Molecular Target Inhibitors
AFINITOR
$0(Tier 2)
AFINITOR DISPERZ
$0(Tier 2)
ALECENSA
$0(Tier 2)
BOSULIF
$0(Tier 2)
CABOMETYX TABLET 20MG, 60MG
$0(Tier 2)
CABOMETYX TABLET 40MG
$0(Tier 2)
CAPRELSA
$0(Tier 2)
COMETRIQ
$0(Tier 2)
ERIVEDGE
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (6 EA per 21 days) PA
(Farydak, new starts only)
PA (zaltrap, new starts
only)
QL (150 EA per 30 days)
PA (zykadia, new starts
only) NDS
QL (30 EA per 30 days)
MO
MO
MO
PA (Kyprolis, new starts
only) NDS
QL (60 EA per 30 days)
PA (zydelig, new starts
only) NDS
QL (30 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (60 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (240 EA per 30 days)
PA (Alecensa, new starts
only)
PA (bosulif, new starts
only) NDS
QL (30 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
QL (60 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
PA (caprelsa, new starts
only) NDS
PA (cometriq, new starts
only) NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
31
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
ICLUSIG TABLET 45MG
ICLUSIG TABLET 15MG
$0(Tier 2)
imatinib mesylate tablet 400mg
$0(Tier 1)
imatinib mesylate tablet 100mg
$0(Tier 1)
IMBRUVICA
$0(Tier 2)
INLYTA
$0(Tier 2)
IRESSA
JAKAFI
$0(Tier 2)
$0(Tier 2)
LENVIMA 10 MG DAILY DOSE
$0(Tier 2)
LENVIMA 14 MG DAILY DOSE
$0(Tier 2)
LENVIMA 18 MG DAILY DOSE
$0(Tier 2)
LENVIMA 20 MG DAILY DOSE
$0(Tier 2)
LENVIMA 24 MG DAILY DOSE
$0(Tier 2)
LENVIMA 8 MG DAILY DOSE
$0(Tier 2)
MEKINIST
$0(Tier 2)
NEXAVAR
$0(Tier 2)
SPRYCEL
$0(Tier 2)
STIVARGA
$0(Tier 2)
SUTENT
$0(Tier 2)
TAFINLAR
TARCEVA
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
PA (iclusig, new starts
only) NDS
QL (90 EA per 30 days)
PA (iclusig, new starts
only) NDS
QL (60 EA per 30 days)
PA (Imatinib, new starts
only)
QL (90 EA per 30 days)
PA (Imatinib, new starts
only)
QL (120 EA per 30 days)
PA (imbruvica, new starts
only) NDS
PA (inlyta, new starts
only) NDS
QL (60 EA per 30 days)
PA (jakafi, new starts
only) NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
PA (mekinist, new starts
only) NDS
PA (nexavar, new starts
only) NDS
PA (sprycel, new starts
only) NDS
PA (stivarga, new starts
only) NDS
PA (sutent, new starts
only) NDS
NDS
PA (tarceva, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
32
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
TASIGNA
TYKERB
VOTRIENT
$0(Tier 2)
$0(Tier 2)
XALKORI
$0(Tier 2)
ZELBORAF
$0(Tier 2)
Monoclonal Antibodies
AVASTIN
$0(Tier 2)
CYRAMZA
DARZALEX INJECTION 100MG/5ML
EMPLICITI
ERBITUX INJECTION 100MG/50ML
HERCEPTIN
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
KADCYLA INJECTION 100MG
$0(Tier 2)
KEYTRUDA INJECTION 50MG
$0(Tier 2)
KEYTRUDA INJECTION 100MG/4ML
$0(Tier 2)
OPDIVO INJECTION 40MG/4ML
PERJETA
RITUXAN INJECTION 500MG/50ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
SYLVANT INJECTION 100MG
TECENTRIQ
$0(Tier 2)
$0(Tier 2)
VECTIBIX INJECTION 100MG/5ML
YERVOY INJECTION 50MG/10ML
$0(Tier 2)
$0(Tier 2)
Retinoids
bexarotene
PANRETIN
TARGRETIN GEL
tretinoin capsule 10mg
Antiparasitics
Anthelmintics
ALBENZA
ivermectin tablet
Antiprotozoals
ALINIA
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
PA (tarceva, new starts
only) NDS
NDS
QL (120 EA per 30 days)
PA (votrient, new starts
only) NDS
PA (xalkori, new starts
only) NDS
PA (zelboraf, new starts
only) NDS
PA (avastin, new starts
only) NDS
NDS
NDS
NDS
PA (herceptin, new starts
only) NDS
PA (kadcyla, new starts
only) NDS
PA (keytruda, new starts
only)
PA (keytruda, new starts
only) NDS
PA (rituxan, new starts
only) NDS
PA (Tecentriq, new starts
only) NDS
PA (yervoy, new starts
only)
NDS
NDS
NDS
NDS
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
33
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Name of drug
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
MEPRON SUSPENSION
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE TABLET
quinine sulfate capsule 324mg
tinidazole tablet
Pediculicides/Scabicides
malathion
permethrin cream
permethrin lotion
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection
benztropine mesylate tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
trihexyphenidyl hcl
$0(Tier 1)
Antiparkinson Agents, Other
entacapone
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
B/D
PA (Quinine)
DP
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
QL (240 EA per 30 days)
MO
MO
tolcapone
Dopamine Agonists
APOKYN INJECTION 30MG/3ML
bromocriptine mesylate capsule, tablet
NEUPRO
$0(Tier 1)
pramipexole dihydrochloride
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
Monoamine Oxidase B (MAO-B) Inhibitors
$0(Tier 1)
$0(Tier 1)
NDS
MO
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
34
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
AZILECT
ELDEPRYL CAPSULE
rasagiline mesylate tablet
$0(Tier 2)
$0(Tier 1)
selegiline hcl capsule, tablet
ZELAPAR
Antipsychotics
1st Generation/Typical
chlorpromazine hcl tablet
CHLORPROMAZINE HCL INJECTION 50MG/2ML
compro
fluphenazine decanoate injection
FLUPHENAZINE HCL INJECTION
fluphenazine hcl concentrate, elixir
fluphenazine hcl tablet
haloperidol decanoate
haloperidol lactate
haloperidol concentrate
haloperidol tablet
loxapine succinate capsule
perphenazine tablet
pimozide
prochlorperazine edisylate injection
prochlorperazine maleate tablet
prochlorperazine suppository 25mg
thioridazine hcl tablet 100mg, 10mg, 25mg, 50mg
thiothixene capsule 10mg, 1mg, 2mg, 5mg
trifluoperazine hcl tablet
2nd Generation/Atypical
ABILIFY MAINTENA
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
$0(Tier 2)
QL (1 EA per 30 days)
NDS
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (1.6 ML per 30 days)
NDS
QL (2.4 ML per 30 days)
NDS
QL (3.2 ML per 30 days)
NDS
QL (60 EA per 30 days)
MO
aripiprazole odt
$0(Tier 1)
aripiprazole tablet
$0(Tier 1)
ARISTADA INJECTION 441MG/1.6ML
$0(Tier 2)
ARISTADA INJECTION 662MG/2.4ML
$0(Tier 2)
ARISTADA INJECTION 882MG/3.2ML
$0(Tier 2)
FANAPT
$0(Tier 2)
FANAPT TITRATION PACK
GEODON INJECTION
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
35
Name of drug
INVEGA SUSTENNA INJECTION 39MG/0.25ML
INVEGA SUSTENNA INJECTION 78MG/0.5ML
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
INVEGA SUSTENNA INJECTION 117MG/0.75ML
$0(Tier 2)
INVEGA SUSTENNA INJECTION 156MG/ML
$0(Tier 2)
INVEGA SUSTENNA INJECTION 234MG/1.5ML
$0(Tier 2)
INVEGA TRINZA INJECTION 273MG/0.875ML
$0(Tier 2)
INVEGA TRINZA INJECTION 410MG/1.315ML
$0(Tier 2)
INVEGA TRINZA INJECTION 546MG/1.75ML
$0(Tier 2)
INVEGA TRINZA INJECTION 819MG/2.625ML
$0(Tier 2)
LATUDA
$0(Tier 2)
NUPLAZID
$0(Tier 2)
olanzapine odt
olanzapine injection
olanzapine tablet
paliperidone er tablet extended release 24 hour 1.5mg, 3mg,
9mg
paliperidone er tablet extended release 24 hour 6mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
quetiapine fumarate
REXULTI
$0(Tier 1)
$0(Tier 2)
RISPERDAL CONSTA
risperidone odt
risperidone solution
risperidone tablet
SAPHRIS
VRAYLAR CAPSULE THERAPY PACK
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
VRAYLAR CAPSULE 1.5MG
$0(Tier 2)
VRAYLAR CAPSULE 4.5MG, 6MG
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (0.25 ML per 28 days)
QL (0.5 ML per 28 days)
NDS
QL (0.75 ML per 28 days)
NDS
QL (1 ML per 28 days)
NDS
QL (1.5 ML per 28 days)
NDS
QL (0.88 ML per 90 days)
NDS
QL (1.32 ML per 90 days)
NDS
QL (1.75 ML per 90 days)
NDS
QL (2.63 ML per 90 days)
NDS
QL (30 EA per 30 days)
PA (Latuda, new starts
only) MO
QL (60 EA per 30 days)
NDS
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
PA (Rexulti, new starts
only) MO
MO
MO
QL (60 EA per 30 days)
PA (Vraylar, new starts
only)
QL (120 EA per 30 days)
PA (Vraylar, new starts
only) NDS
QL (30 EA per 30 days)
PA (Vraylar, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
36
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
VRAYLAR CAPSULE 3MG
ziprasidone hcl
ZYPREXA RELPREVV INJECTION 210MG
Antipsychotics
molindone hydrochloride
Treatment-Resistant
clozapine odt tablet disintegrating 12.5mg, 25mg
clozapine odt tablet disintegrating 200mg
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
PA (Vraylar, new starts
only) NDS
MO
$0(Tier 1)
MO
$0(Tier 1)
$0(Tier 1)
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (270 EA per 30 days)
MO
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days) MO
clozapine odt tablet disintegrating 150mg
$0(Tier 1)
clozapine odt tablet disintegrating 100mg
$0(Tier 1)
clozapine tablet 100mg, 200mg, 25mg, 50mg
FAZACLO TABLET DISINTEGRATING 200MG
$0(Tier 1)
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 150MG
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 100MG, 12.5MG,
25MG
VERSACLOZ
Antispasticity Agents
Antispasticity Agents
baclofen tablet
dantrolene sodium capsule
tizanidine hcl tablet
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir
ganciclovir injection
VALCYTE
valganciclovir
valganciclovir hydrochlorde
ZIRGAN
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE SOLUTION
entecavir
EPIVIR HBV SOLUTION
INTRON A W/DILUENT INJECTION 10MU
INTRON A INJECTION 10MU, 18MU, 50MU,
6000000UNIT/ML
lamivudine tablet 100mg
TYZEKA
$0(Tier 2)
$0(Tier 2) $0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
B/D
NDS
MO
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
NDS
MO
MO
MO
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
37
Name of drug
Anti-hepatitis C (HCV) Agents
HARVONI
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
QL (30 EA per 30 days)
PA (harvoni) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PEG-INTRON REDIPEN
$0(Tier 2)
PEGASYS
$0(Tier 2)
PEGASYS PROCLICK
$0(Tier 2)
PEGINTRON
$0(Tier 2)
REBETOL SOLUTION
ribasphere ribapak
ribasphere tablet
ribavirin capsule
ribavirin tablet 200mg
SOVALDI
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
VIRAZOLE
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
$0(Tier 2)
$0(Tier 2)
ISENTRESS TABLET CHEWABLE, PACKET
ISENTRESS TABLET
TIVICAY TABLET 10MG
TIVICAY TABLET 25MG, 50MG
VITEKTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABLET 25MG
INTELENCE TABLET 100MG, 200MG
nevirapine
nevirapine er
ODEFSEY
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
RESCRIPTOR
STRIBILD
SUSTIVA TABLET
QL (28 EA per 28 days)
PA (Immunological
Agents - Sovaldi) NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
MO
MO
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
38
Name of drug
SUSTIVA CAPSULE 50MG
SUSTIVA CAPSULE 200MG
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
DESCOVY
didanosine
EMTRIVA
EPZICOM
lamivudine/zidovudine
lamivudine solution 10mg/ml
lamivudine tablet 150mg, 300mg
RETROVIR IV INFUSION
stavudine
TRIUMEQ
TRUVADA TABLET 200MG; 300MG
TRUVADA TABLET 100MG; 150MG, 133MG; 200MG,
167MG; 250MG
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM
VIREAD
ZERIT SOLUTION RECONSTITUTED
ZIAGEN SOLUTION
zidovudine
Anti-HIV Agents, Other
FUZEON
SELZENTRY TABLET 25MG, 75MG
SELZENTRY TABLET 150MG, 300MG
TYBOST
Anti-HIV Agents, Protease Inhibitors
APTIVUS
CRIXIVAN CAPSULE 200MG, 400MG
EVOTAZ
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
QL (30 EA per 30 days)
NDS
MO
MO
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
MO
MO
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
MO
NDS
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
MO
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
INVIRASE
KALETRA SOLUTION
KALETRA TABLET 100MG; 25MG
KALETRA TABLET 200MG; 50MG
LEXIVA
lopinavir/ritonavir
NORVIR
PREZCOBIX
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
PREZISTA SUSPENSION
$0(Tier 2)
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
39
Name of drug
PREZISTA TABLET 150MG, 600MG, 75MG, 800MG
REYATAZ
VIRACEPT
Anti-influenza Agents
amantadine hcl capsule, syrup, tablet
oseltamivir phosphate capsule 75mg
oseltamivir phosphate capsule 45mg
oseltamivir phosphate capsule 30mg
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPSULE 75MG
TAMIFLU CAPSULE 45MG
TAMIFLU CAPSULE 30MG
TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule, suspension, tablet
acyclovir ointment
DENAVIR
famciclovir tablet
trifluridine solution
valacyclovir hcl
ZOVIRAX CREAM, OINTMENT
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
buspirone hcl tablet
meprobamate
Benzodiazepines
alprazolam intensol
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg, 1mg, 2mg
clorazepate dipotassium tablet 15mg
clorazepate dipotassium tablet 3.75mg, 7.5mg
diazepam intensol
diazepam solution 1mg/ml
diazepam tablet 10mg, 2mg, 5mg
LORAZEPAM INTENSOL
lorazepam tablet 0.5mg
lorazepam tablet 1mg, 2mg
triazolam
Bipolar Agents
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
NDS
NDS
NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
B/D
MO
QL (30 GM per 30 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (56 EA per 180 days)
QL (28 EA per 180 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (540 ML per 180
days)
QL (60 EA per 30 days)
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 GM per 30 days)
$0(Tier 2)
NDS
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
40
Name of drug
Mood Stabilizers
lithium
lithium carbonate er
lithium carbonate capsule, tablet
LITHOBID
Blood Glucose Regulators
Antidiabetic Agents
acarbose
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
MO
$0(Tier 1)
QL (90 EA per 30 days)
MO
QL (2.4 ML per 30 days)
ST (INCRETIN
MIMETICS #2) MO
ST (INCRETIN
MIMETICS #2) MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (60 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (120 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
PA (High Risk Medication
- Glyburide) MO
BYETTA INJECTION 10MCG/0.04ML
$0(Tier 2)
BYETTA INJECTION 5MCG/0.02ML
$0(Tier 2)
CYCLOSET
FARXIGA
$0(Tier 2)
$0(Tier 2)
glimepiride tablet 1mg, 2mg
$0(Tier 1)
glimepiride tablet 4mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 2.5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 10mg
$0(Tier 1)
glipizide/metformin hcl
$0(Tier 1)
glipizide tablet 10mg
$0(Tier 1)
glipizide tablet 5mg
$0(Tier 1)
glyburide micronized tablet 1.5mg, 3mg
$0(Tier 1)
glyburide micronized tablet 6mg
$0(Tier 1)
glyburide/metformin hcl
$0(Tier 1)
glyburide tablet 5mg
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
41
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
glyburide tablet 1.25mg, 2.5mg
JANUVIA
$0(Tier 2)
JENTADUETO
$0(Tier 2)
JENTADUETO XR
$0(Tier 2)
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG, 500MG; 5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
metformin hcl er tablet extended release 24 hour 500mg
$0(Tier 2)
metformin hcl er tablet extended release 24 hour 750mg
$0(Tier 1)
metformin hcl tablet 500mg
$0(Tier 1)
metformin hcl tablet 1000mg
$0(Tier 1)
metformin hcl tablet 850mg
$0(Tier 1)
miglitol
$0(Tier 1)
nateglinide
$0(Tier 1)
ONGLYZA
$0(Tier 2)
pioglitazone hcl
$0(Tier 1)
pioglitazone hcl-glimepiride
$0(Tier 1)
pioglitazone hcl/metformin hcl
$0(Tier 1)
repaglinide
SYMLINPEN 120
$0(Tier 1)
$0(Tier 2)
SYMLINPEN 60
$0(Tier 2)
tolbutamide
TRADJENTA
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
PA (Blood Glucose
Regulators Amylinomimetics) MO
PA (Blood Glucose
Regulators Amylinomimetics) MO
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
42
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
VICTOZA
Glycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insulins
APIDRA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
APIDRA SOLOSTAR
$0(Tier 2)
HUMALOG KWIKPEN
$0(Tier 2)
HUMALOG MIX 50/50
$0(Tier 2)
HUMALOG MIX 50/50 KWIKPEN
$0(Tier 2)
HUMALOG MIX 75/25
$0(Tier 2)
HUMALOG MIX 75/25 KWIKPEN
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMULIN 70/30
$0(Tier 2)
HUMULIN 70/30 KWIKPEN
$0(Tier 2)
HUMULIN N
$0(Tier 2)
HUMULIN N KWIKPEN
$0(Tier 2)
HUMULIN R
$0(Tier 2)
HUMULIN R U-500 (CONCENTRATED)
$0(Tier 2)
HUMULIN R U-500 KWIKPEN
$0(Tier 2)
LANTUS
$0(Tier 2)
LANTUS SOLOSTAR
$0(Tier 2)
LEVEMIR
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
ST (INCRETIN
MIMETICS #2) MO
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
43
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
$0(Tier 2)
NOVOLIN N
$0(Tier 2)
NOVOLIN R
$0(Tier 2)
NOVOLOG
$0(Tier 2)
NOVOLOG FLEXPEN
$0(Tier 2)
NOVOLOG MIX 70/30
$0(Tier 2)
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
$0(Tier 2)
NOVOLOG PENFILL
$0(Tier 2)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN TABLET
$0(Tier 2)
enoxaparin sodium
$0(Tier 1)
FONDAPARINUX SODIUM INJECTION 10MG/0.8ML,
$0(Tier 1)
5MG/0.4ML, 7.5MG/0.6ML
fondaparinux sodium injection 2.5mg/0.5ml
$0(Tier 1)
FRAGMIN INJECTION 10000UNIT/ML, 2500UNIT/0.2ML, $0(Tier 2) 5000UNIT/0.2ML
heparin sodium/d5w
$0(Tier 1) heparin sodium injection 10000unit/ml, 1000unit/ml,
$0(Tier 1) 20000unit/ml, 5000unit/ml
jantoven
$0(Tier 1)
PRADAXA CAPSULE 150MG, 75MG
$0(Tier 2)
PRADAXA CAPSULE 110MG
$0(Tier 2)
warfarin sodium tablet
$0(Tier 1)
XARELTO STARTER PACK
$0(Tier 2) XARELTO TABLET 10MG
$0(Tier 2) XARELTO TABLET 15MG, 20MG
$0(Tier 2)
Blood Formation Modifiers
anagrelide hydrochloride
$0(Tier 1)
ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML, $0(Tier 2)
25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML, $0(Tier 2)
100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML
Necessary actions,
restrictions, or limits on
use
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
MO
NDS
MO
MO
QL (60 EA per 30 days)
MO
MO
MO
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Blood
Products/Modifiers/
Volume Expanders) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
44
Name of drug
EPOGEN INJECTION 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
What the drug
will cost you
(tier level)
$0(Tier 2)
GRANIX
LEUKINE INJECTION 250MCG
NEUPOGEN
PROCRIT
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
PROMACTA TABLET 50MG
$0(Tier 2)
PROMACTA TABLET 25MG
$0(Tier 2)
Coagulants
IXINITY INJECTION 1000UNIT, 1500UNIT
tranexamic acid injection
tranexamic acid tablet
Platelet Modifying Agents
aspirin/dipyridamole
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
DP
$0(Tier 1)
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
BRILINTA
$0(Tier 2)
cilostazol
clopidogrel tablet 300mg
clopidogrel tablet 75mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dipyridamole tablet
$0(Tier 1)
EFFIENT
$0(Tier 2)
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er
clonidine hcl tablet
clonidine hcl patch weekly
Necessary actions,
restrictions, or limits on
use
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Granix)
NDS
PA (Neupogen) NDS
PA (Blood
Products/Modifiers/
Volume Expanders)
QL (30 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
QL (90 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
guanfacine hcl
$0(Tier 1)
methyldopa/hydrochlorothiazide
$0(Tier 1)
MO
QL (30 EA per 30 days)
MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
MO
MO
MO
QL (4 EA per 28 days)
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
45
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
methyldopa tablet 250mg, 500mg
methyldopate hcl
midodrine hcl
Alpha-adrenergic Blocking Agents
prazosin hcl capsule
reserpine tablet 0.25mg
Necessary actions,
restrictions, or limits on
use
PA (High Risk
Medications) MO
$0(Tier 1)
$0(Tier 1)
Angiotensin II Receptor Antagonists
BENICAR
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications) MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
BENICAR HCT
$0(Tier 2)
candesartan cilexetil
$0(Tier 1)
candesartan cilexetil/hydrochlorothiazide
$0(Tier 1)
eprosartan mesylate
$0(Tier 1)
ezetimibe
$0(Tier 1)
irbesartan
$0(Tier 1)
irbesartan/hydrochlorothiazide
$0(Tier 1)
losartan potassium
$0(Tier 1)
losartan potassium/hydrochlorothiazide
$0(Tier 1)
olmesartan medoxomil
$0(Tier 1)
olmesartan medoxomil/hydrochlorothiazide
$0(Tier 1)
telmisartan
$0(Tier 1)
telmisartan/amlodipine
$0(Tier 1)
telmisartan/hydrochlorothiazide
$0(Tier 1)
valsartan
$0(Tier 1)
valsartan/hydrochlorothiazide
$0(Tier 1)
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
$0(Tier 1)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
46
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
benazepril hcl tablet 10mg, 20mg, 5mg
benazepril hcl tablet 40mg
$0(Tier 1)
captopril/hydrochlorothiazide
captopril tablet
enalapril maleate/hydrochlorothiazide
enalapril maleate tablet
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
quinapril hcl
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
quinapril/hydrochlorothiazide
$0(Tier 1)
ramipril
$0(Tier 1)
trandolapril tablet 1mg, 2mg
$0(Tier 1)
trandolapril tablet 4mg
$0(Tier 1)
Antiarrhythmics
amiodarone hcl tablet
amiodarone hcl injection 50mg/ml
disopyramide phosphate capsule
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dofetilide
$0(Tier 1)
flecainide acetate
mexiletine hcl
MULTAQ
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
pacerone tablet 100mg, 200mg, 400mg
PROCAINAMIDE HCL INJECTION
propafenone hcl
quinidine gluconate cr
QUINIDINE GLUCONATE INJECTION
quinidine sulfate tablet
sorine
sotalol hcl (af) tablet 120mg
sotalol hcl tablet 160mg, 240mg, 80mg
Beta-adrenergic Blocking Agents
acebutolol hcl capsule
atenolol/chlorthalidone
atenolol tablet
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
PA (High Risk
Medications) MO
QL (60 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
47
Name of drug
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
carvedilol
labetalol hcl injection
labetalol hcl tablet
metoprolol succinate er
metoprolol tartrate injection
metoprolol tartrate tablet 100mg, 25mg, 50mg
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol tablet 20mg, 40mg, 80mg
pindolol tablet
propranolol hcl er
propranolol hcl injection
propranolol hcl oral solution, tablet
propranolol/hydrochlorothiazide
timolol maleate tablet 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
afeditab cr
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
amlodipine besylate/benazepril hydrochloride
$0(Tier 1)
amlodipine besylate/valsartan
$0(Tier 1)
amlodipine besylate tablet
$0(Tier 1)
amlodipine/valsartan/hctz
$0(Tier 1)
cartia xt
$0(Tier 1)
dilt-xr capsule extended release 24 hour 120mg, 240mg
$0(Tier 1)
dilt-xr capsule extended release 24 hour 180mg
$0(Tier 1)
diltiazem cd capsule extended release 24 hour 240mg
$0(Tier 1)
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 120mg,
300mg, 360mg, 420mg
diltiazem hcl er capsule extended release 12 hour
diltiazem hcl tablet
DILTIAZEM HCL INJECTION 100MG
diltiazem hcl injection 50mg/10ml
felodipine er
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
48
Name of drug
matzim la tablet extended release 24 hour 180mg, 240mg,
300mg
matzim la tablet extended release 24 hour 360mg, 420mg
What the drug
will cost you
(tier level)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
nicardipine hcl capsule
nifedical xl
$0(Tier 1)
$0(Tier 1)
nifedipine er
$0(Tier 1)
taztia xt
$0(Tier 1)
verapamil hcl er tablet extended release
verapamil hcl er capsule extended release 24 hour
$0(Tier 1)
$0(Tier 1)
verapamil hcl sr capsule extended release 24 hour 360mg
verapamil hcl injection
verapamil hcl tablet
Cardiovascular Agents, Other
DEMSER
digitek tablet 0.125mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
digitek tablet 0.25mg
$0(Tier 1)
digoxin oral solution
$0(Tier 1)
digoxin injection 0.25mg/ml
$0(Tier 1)
digoxin tablet 125mcg
$0(Tier 1)
digoxin tablet 250mcg
$0(Tier 1)
LANOXIN INJECTION
$0(Tier 2)
LANOXIN TABLET 125MCG
$0(Tier 2)
LANOXIN TABLET 250MCG
$0(Tier 2)
NORTHERA CAPSULE 200MG, 300MG
$0(Tier 2)
NORTHERA CAPSULE 100MG
$0(Tier 2)
pentoxifylline er
$0(Tier 1)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
QL (180 EA per 30 days)
PA (Northera)
QL (90 EA per 30 days)
PA (Northera)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
49
Name of drug
RANEXA TABLET EXTENDED RELEASE 12 HOUR
1000MG
What the drug
will cost you
(tier level)
$0(Tier 2)
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
$0(Tier 2)
REPATHA
$0(Tier 2)
REPATHA PUSHTRONEX SYSTEM
$0(Tier 2)
REPATHA SURECLICK
$0(Tier 2)
TEKTURNA
$0(Tier 2)
TEKTURNA HCT
$0(Tier 2)
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium
acetazolamide tablet
Diuretics, Loop
bumetanide injection
bumetanide tablet
furosemide injection
furosemide oral solution, tablet
torsemide tablet
Diuretics, Potassium-sparing
amiloride hcl tablet
amiloride/hydrochlorothiazide
DYRENIUM
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tablet
triamterene/hydrochlorothiazide
Diuretics, Thiazide
chlorothiazide
chlorothiazide sodium
chlorthalidone tablet 25mg, 50mg
hydrochlorothiazide capsule, tablet
indapamide tablet
methyclothiazide tablet
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
fenofibrate capsule 130mg, 43mg
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (90 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (3 ML per 30 days)
PA (Repatha)
QL (3.5 ML per 28 days)
PA (Repatha) NDS
QL (3 ML per 30 days)
PA (Repatha)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 1)
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
50
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
fenofibrate tablet
fenofibric acid tablet 105mg
$0(Tier 1)
fenofibric acid tablet 35mg
$0(Tier 1)
gemfibrozil tablet
$0(Tier 1)
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
$0(Tier 1)
fluvastatin sodium er
$0(Tier 1)
fluvastatin capsule 40mg
$0(Tier 1)
fluvastatin capsule 20mg
$0(Tier 1)
lovastatin tablet 10mg, 20mg
$0(Tier 1)
lovastatin tablet 40mg
$0(Tier 1)
pravastatin sodium
$0(Tier 1)
rosuvastatin calcium
$0(Tier 1)
simvastatin tablet
$0(Tier 1)
Dyslipidemics, Other
cholestyramine light
colestipol hcl granules, tablet
JUXTAPID CAPSULE 10MG, 40MG, 5MG, 60MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
JUXTAPID CAPSULE 30MG
$0(Tier 2)
JUXTAPID CAPSULE 20MG
$0(Tier 2)
KYNAMRO
$0(Tier 2)
niacin er tablet extended release 500mg
$0(Tier 1)
niacin er tablet extended release 1000mg, 750mg
$0(Tier 1)
niacin tablet 100mg, 500mg, 50mg
niacor
omega-3-acid ethyl esters
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
PA (Juxtapid) MO
QL (60 EA per 30 days)
PA (Juxtapid) MO
QL (90 EA per 30 days)
PA (Juxtapid) MO
QL (4 ML per 28 days)
PA (Kynamro)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
DP
MO
QL (120 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
51
Name of drug
prevalite powder
ra niacin tablet 100mg
WELCHOL
ZETIA
Vasodilators, Direct-acting Arterial/Venous
BIDIL
isosorbide dinitrate er
isosorbide dinitrate tablet 10mg, 20mg, 30mg, 5mg
isosorbide mononitrate
isosorbide mononitrate er
NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR
nitroglycerin transdermal
nitroglycerin injection 5mg/ml
nitroglycerin tablet sublingual 0.3mg, 0.4mg, 0.6mg
NITROSTAT TABLET SUBLINGUAL
Vasodilators, Direct-acting Arterial
hydralazine hcl injection
hydralazine hcl tablet
minoxidil tablet
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg;
5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg
dextroamphetamine sulfate tablet
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
guanfacine er
INTUNIV
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
DP
MO
QL (30 EA per 30 days)
MO
$0(Tier 2)
QL (180 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (60 EA per 30 days)
$0(Tier 1)
QL (90 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 30MG $0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 20MG $0(Tier 2)
methylphenidate hcl cd capsule extended release 30mg
$0(Tier 1)
methylphenidate hcl cd capsule extended release 10mg, 50mg, $0(Tier 1)
60mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
40mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
20mg
methylphenidate hcl er tablet extended release 20mg
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
52
Name of drug
methylphenidate hcl tablet
STRATTERA
Central Nervous System, Other
HETLIOZ
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
QL (60 EA per 30 days)
$0(Tier 2)
QL (30 EA per 30 days)
PA (Hetlioz) NDS
QL (60 EA per 30 days)
NUEDEXTA
riluzole
tetrabenazine tablet 25mg
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
tetrabenazine tablet 12.5mg
$0(Tier 1)
Fibromyalgia Agents
SAVELLA
$0(Tier 2)
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AMPYRA
QL (120 EA per 30 days)
PA (Tetrabenazine)
QL (180 EA per 30 days)
PA (Tetrabenazine)
QL (60 EA per 30 days)
MO
$0(Tier 2)
$0(Tier 2)
AUBAGIO
$0(Tier 2)
AVONEX
AVONEX PEN
BETASERON
GILENYA
glatopa
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
TECFIDERA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TECFIDERA STARTER PACK
TYSABRI
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse
chlorhexidine gluconate solution
KEPIVANCE
periogard
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride
triamcinolone in orabase
Dermatological Agents
Dermatological Agents
ACNE MEDICATION 10 LOTION
acne medication 10 gel
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
QL (60 EA per 30 days)
PA (Ampyra) NDS
QL (30 EA per 30 days)
PA (Aubagio) NDS
PA (Avonex) NDS
PA (Avonex) NDS
PA (Betaseron) NDS
PA (Gilenya) NDS
PA (Copaxone) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
QL (60 EA per 30 days)
PA (Tecfidera)
PA (Tecfidera)
PA (Tysabri) NDS
MO
MO
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
53
Name of drug
acne medication 5 gel
adapalene gel 0.1%
adapalene cream
ammonium lactate cream, lotion
anu-med
BENZOYL PEROXIDE GEL 2.5%
benzoyl peroxide gel 10%, 5%
benzoyl peroxide foam
blue gel gel 2%
calcipotriene cream, ointment
calcipotriene solution
claravis
clindamycin/benzoyl peroxide gel 5%; 1%
clotrimazole/betamethasone dipropionate
COATS ALOE CREME
COATS ALOE GELLY
COATS ALOE LINIMENT
COATS ALOE MOISTURIZING LOTION
curity gauze pads 2"x2"
cvs e oil oil 100unt/0.25ml
dibucaine
diclofenac sodium gel 1%
DR SMITHS DIAPER
DR SMITHS DIAPER RASH SPRAY
DR SMITHS RASH + SKIN AEROSOL
ELIDEL
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
erythromycin/benzoyl peroxide
fluorouracil cream 5%
fluorouracil cream 0.5%
fluorouracil external solution 2%, 5%
hemorrhoidal suppository 88.7%; 0.25%
imiquimod cream
major-prep hemorrhoidal ointment 14%; 74.9%; 0.25%
medicated body powder powder 0.15%
methoxsalen capsule
PICATO
podofilox solution
SANTYL
selenium sulfide lotion
SORIATANE CAPSULE 10MG, 17.5MG, 25MG
tacrolimus ointment 0.03%, 0.1%
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
TAZORAC
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
QL (240 GM per 30 days)
QL (60 ML per 30 days)
DP
DP
DP
DP
QL (204 EA per 30 days)
DP
DP
DP
DP
DP
QL (60 GM per 30 days)
PA (Dermatological
Agents)
NDS
DP
QL (24 EA per 30 days)
DP
DP
NDS
QL (60 GM per 30 days)
PA (Dermatological
Agents)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
54
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
Name of drug
thera-gesic cream 1%; 15%
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%, 0.05%
TRIXAICIN
trixaicin hp
UVADEX
VEREGEN
vitamin a & d ointment 15.5%; 53.4%
VOLTAREN
white petrolatum gel
zinc oxide ointment 20%
ZONALON
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CENTRUM PERFORMANCE
CEREZYME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME INJECTION 35MG
KUVAN
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
LUMIZYME
NAGLAZYME
PANCREAZE
RAVICTI
sodium phenylbutyrate powder
SUCRAID
VPRIV
ZAVESCA
ZENPEP
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE INJECTION 0.25MG/5ML
atropine sulfate injection 0.5mg/5ml
dicyclomine hcl
glycopyrrolate tablet
glycopyrrolate injection 4mg/20ml
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
QL (90 GM per 30 days)
DP
DP
QL (15 GM per 30 days)
DP
DP
DP
NDS
DP
PA (cerezyme) NDS
MO
NDS
PA (Enzyme
Replacements/ Modifiers Kuvan) NDS
NDS
MO
NDS
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
55
Name of drug
acid gone suspension
actidose/sorbitol liquid 50gm/240ml; 0
almacone double strength
almacone suspension
almacone tablet chewable 200mg; 200mg; 25mg
ALUMINUM HYDROXIDE
antacid calcium extra st rength
antacid calcium regular strength
antacid extra strength
antacid maximum strength
antacid plus anti-gas relief
anti-diarrheal tablet
bismatrol
bismatrol maximum strength
cal-gest antacid
calcium antacid
calcium antacid extra strength
calcium carbonate tablet chewable 500mg
CALCIUM CARBONATE TABLET 650MG
chewable antacid
cromolyn sodium concentrate 100mg/5ml
diocto syrup
diocto liquid 50mg/5ml
diphenoxylate/atropine tablet
docu
DOCUSOL KIDS
ENEMEEZ MINI
gas relief
gas relief extra strength capsule
gas relief maximum strength tablet chewable
GATTEX
gavilyte-h
gnp antacid anti-gas
gnp masanti maximum strength
gnp masanti regular strength
infants gas relief suspension 20mg/0.3ml
infants simethicone
kao-tin suspension 262mg/15ml
loperamide hcl capsule
loperamide hcl liquid, suspension
magnesium oxide tablet 241.3mg, 400mg, 420mg
magnesium tablet 500mg
metoclopramide hcl injection, oral solution, tablet
mi-acid gas relief
mi-acid maximum strength
mi-acid suspension
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (Gattex) NDS
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
56
Name of drug
MILK OF MAGNESIA CONCENTRATE
mintox maximum strength
mytab gas
mytab gas max str
peptic relief tablet chewable 262mg
pink bismuth tablet chewable 262mg
qc anti-diarrheal
ra magnesium
RELISTOR INJECTION
RELISTOR TABLET
rulox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
simethicone capsule 180mg
simethicone suspension
sm antacid anti-gas
sm antacid/antigas
sm anti-diarrheal tablet
sodium bicarbonate tablet
ursodiol capsule, tablet
Histamine2 (H2) Receptor Antagonists
acid reducer maximum strength tablet 20mg
cimetidine hcl solution
cimetidine tablet
FAMOTIDINE PREMIXED
famotidine injection 20mg/2ml
famotidine tablet 20mg, 40mg
famotidine tablet 10mg
ranitidine 150 maximum strength
ranitidine 75
ranitidine hcl capsule, syrup
ranitidine hcl injection 150mg/6ml, 50mg/2ml
ranitidine hcl tablet 150mg, 300mg
ranitidine maximum strength
ZANTAC INJECTION 25MG/ML
Irritable Bowel Syndrome Agents
alosetron hydrochloride
AMITIZA
Laxatives
bisacodyl ec
biscolax suppository
constulose
cvs laxative dietary supplement
doc-q-lax
docqlace
docusate sodium & senna stimulant laxative/stool softener
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
DP
MO
MO
$0(Tier 1)
$0(Tier 2)
QL (60 EA per 30 days)
PA (Irritable Bowel
Syndrome Agents) NDS
MO
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
MO
DP
DP
DP
DP
QL (90 EA per 30 days)
DP
DP
DP
DP
DP
DP
DP
MO
MO
DP
DP
DP
MO
MO
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
57
Name of drug
DOCUSOL PLUS MINI-ENEMA
dok
dok plus
enema ready-to-use enema 7gm/118ml; 19gm/118ml
ENEMEEZ PLUS
enulose
fiber laxative capsule
fiber tabs
fiber-lax
FLEET PEDIATRIC
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
gnp enema
kao-tin capsule 240mg
lactulose solution
laxative suppository
milk of magnesia suspension 400mg/5ml, 7.75%
natural fiber therapy powder 30.9%, 48.57%
NULYTELY/FLAVOR PACKS
peg 3350 packet
peg-3350/nacl/na bicarbonate/kcl
peg3350
polyethylene glycol 3350 powder
reguloid capsule
sani-supp adult
sani-supp pediatric
senexon
senna lax
senna plus
senna syrup, tablet
sennalax-s
stimulant laxative
stool softener extra strength
stool softener laxative dc
stool softener capsule
trilyte
Protectants
misoprostol
sucralfate tablet
Proton Pump Inhibitors
esomeprazole magnesium
esomeprazole sodium
GNP OMEPRAZOLE
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
DP
$0(Tier 1)
$0(Tier 3)
MO
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
58
Name of drug
heartburn treatment 24 hour
lansoprazole capsule delayed release 15mg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 1)
lansoprazole capsule delayed release 30mg
$0(Tier 1)
lansoprazole capsule delayed release 15mg
omeprazole magnesium
OMEPRAZOLE TABLET DELAYED RELEASE
omeprazole capsule delayed release 10mg
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
omeprazole capsule delayed release 20mg, 40mg
$0(Tier 1)
pantoprazole sodium injection
pantoprazole sodium tablet delayed release 20mg
$0(Tier 1)
$0(Tier 1)
pantoprazole sodium tablet delayed release 40mg
$0(Tier 1)
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide er
$0(Tier 1)
flavoxate hcl
MYRBETRIQ
$0(Tier 1)
$0(Tier 2)
oxybutynin chloride er
oxybutynin chloride tablet
tolterodine tartrate
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
tolterodine tartrate er
$0(Tier 1)
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
$0(Tier 1)
doxazosin
doxazosin mesylate tablet 1mg, 2mg, 8mg
dutasteride
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
finasteride tablet 5mg
$0(Tier 1)
tamsulosin hcl
$0(Tier 1)
terazosin hcl capsule
Genitourinary Agents, Other
bethanechol chloride
ELMIRON
Phosphate Binders
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
DP
DP
DP
QL (30 EA per 30 days)
MO
QL (90 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
QL (30 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
59
Name of drug
calcium acetate capsule
calcium acetate tablet 667mg
ELIPHOS
FOSRENOL TABLET CHEWABLE 1000MG, 500MG,
750MG
RENVELA TABLET
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
A-HYDROCORT INJECTION 100MG
alclometasone dipropionate cream, ointment
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate cream, lotion, ointment
betamethasone valerate cream, lotion, ointment
budesonide capsule delayed release particles 3mg
clobetasol propionate e
clobetasol propionate gel, ointment, shampoo, solution
clodan
cortisone acetate tablet 25mg
DEPO-MEDROL INJECTION 20MG/ML
desonide cream, lotion, ointment
desoximetasone cream, gel, ointment
dexamethasone sodium phosphate injection 120mg/30ml
dexamethasone elixir
dexamethasone tablet 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg,
6mg
fludrocortisone acetate tablet
fluocinolone acetonide cream, oil, ointment, solution
fluocinonide-e
fluocinonide gel, ointment, solution
fluticasone propionate cream 0.05%
fluticasone propionate ointment 0.005%
halobetasol propionate
hydro skin maximum strength
hydrocortisone butyrate ointment, solution
hydrocortisone valerate cream, ointment
hydrocortisone/aloe cream 0; 1%
hydrocortisone cream 1%, 2.5%
hydrocortisone cream 0.5%, 1%
hydrocortisone enema
hydrocortisone tablet
hydrocortisone lotion 2.5%
hydrocortisone ointment 1%, 2.5%
hydrocortisone ointment 0.5%, 1%
hydroskin
methylprednisolone acetate injection 40mg/ml, 80mg/ml
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
$0(Tier 2)
NDS
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
NDS
MO
DP
DP
DP
MO
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
60
Name of drug
methylprednisolone dose pack tablet therapy pack
methylprednisolone sodiumsuccinate injection 1000mg,
125mg, 40mg
methylprednisolone tablet
mometasone furoate cream 0.1%
mometasone furoate ointment 0.1%
prednicarbate cream
prednisolone sodium phosphate oral solution 10mg/5ml,
15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml
prednisone solution
prednisone tablet 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg
procto-med hc
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF INJECTION 100MG, 250MG
SOLU-MEDROL INJECTION 125MG, 2GM, 40MG,
500MG
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5%
triderm
UCERIS FOAM
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
desmopressin acetate injection
desmopressin acetate tablet
INCRELEX
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML,
30MG/3ML, 5MG/1.5ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
pregnyl w/diluent benzyl alcohol/nacl
$0(Tier 1)
SAIZEN
$0(Tier 2)
SAIZEN CLICK.EASY
$0(Tier 2)
PA (Chorionic
Gonadotropin)
MO
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Chorionic
Gonadotropin)
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
61
Name of drug
SEROSTIM INJECTION 4MG, 5MG, 6MG
STIMATE SOLUTION
ZORBTIVE
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
oxandrolone tablet
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR, 4MG/24HR
danazol capsule
METHITEST
testosterone cypionate injection
testosterone enanthate injection
Estrogens
ALORA
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Serostim) NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Zorbtive)
QL (120 EA per 30 days)
PA (Korlym)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
apri
aranelle
aubra
aviane
balziva
bekyree
blisovi fe 1.5/30
caziant
CLIMARA PRO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
cryselle-28
cyclafem 1/35
delyla
DEPO-ESTRADIOL INJECTION 5MG/ML
desogestrel/ethinyl estradiol tablet 0; 0
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
QL (8 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
62
Name of drug
drospirenone/ethinyl estradiol tablet 3mg; 0.02mg
enpresse-28
ESTRACE CREAM
estradiol valerate injection 20mg/ml, 40mg/ml
estradiol tablet
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
estradiol patch weekly
$0(Tier 1)
estropipate tablet
$0(Tier 1)
ethynodiol diacetate/ethinyl estradiol
falmina
gildess 1.5/30
introvale
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kariva
kelnor 1/35
kimidess
larin 1.5/30
leena
lessina
levonorgestrel/ethinyl estradiol tablet 0; 0
levora 0.15/30-28
low-ogestrel
lutera
marlissa
MENEST
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mononessa
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
PA (High Risk
Medications) MO
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
63
What the drug
will cost you
Name of drug
(tier level)
nortrel 1/35
$0(Tier 1)
nortrel 7/7/7
$0(Tier 1)
OGESTREL
$0(Tier 2)
portia-28
$0(Tier 1)
PREMARIN INJECTION
$0(Tier 2)
PREMARIN CREAM
$0(Tier 2)
PREMARIN TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, $0(Tier 2)
1.25MG
PREMPHASE
$0(Tier 2)
PREMPRO
$0(Tier 2)
previfem
quasense
$0(Tier 1)
$0(Tier 1)
sprintec 28
sronyx
tri-lo-estarylla
tri-lo-sprintec
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vienva
xulane
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zovia 1/35e
zovia 1/50e
Progestins
camila
deblitane
DEPO-SUBQ PROVERA 104
errin
hydroxyprogesterone caproate injection
jolivette
levonorgestrel tablet 1.5mg
lyza
medroxyprogesterone acetate injection, tablet
megestrol acetate tablet
megestrol acetate suspension 625mg/5ml
megestrol acetate suspension 40mg/ml
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
MO
QL (91 EA per 91 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (3 EA per 28 days)
MO
MO
MO
MO
MO
MO
MO
NDS
MO
DP
MO
MO
PA (High Risk
Medications)
PA (High Risk
Medications) MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
64
Name of drug
my way
nora-be
norethindrone acetate tablet
norethindrone tablet
norlyroc
progesterone capsule
PROMETRIUM
sharobel
Selective Estrogen Receptor Modifying Agents
EVISTA
raloxifene hydrochloride
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 1)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL
levothyroxine sodium tablet
levoxyl tablet 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg
liothyronine sodium injection
liothyronine sodium tablet
SYNTHROID TABLET
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
unithroid tablet 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 90MG
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
SENSIPAR TABLET 30MG
SENSIPAR TABLET 60MG
$0(Tier 2)
$0(Tier 2)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
ELIGARD
FIRMAGON
leuprolide acetate injection
LUPRON DEPOT (1-MONTH)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
QL (120 EA per 30 days)
NDS
QL (60 EA per 30 days)
QL (60 EA per 30 days)
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
65
What the drug
will cost you
Name of drug
(tier level)
LUPRON DEPOT (3-MONTH)
$0(Tier 2)
LUPRON DEPOT (4-MONTH)
$0(Tier 2)
LUPRON DEPOT-PED (1-MONTH) INJECTION 11.25MG, $0(Tier 2)
15MG
octreotide acetate
$0(Tier 1)
SIGNIFOR
$0(Tier 2)
SOMATULINE DEPOT INJECTION 120MG/0.5ML,
$0(Tier 2)
90MG/0.3ML
SOMAVERT
$0(Tier 2)
SYNAREL
TRELSTAR MIXJECT
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet 10mg, 5mg
propylthiouracil tablet
Immunological Agents
Angioedema (HAE) Agents
CINRYZE
$0(Tier 2)
$0(Tier 2)
FIRAZYR
Immune Suppressants
AZASAN
azathioprine tablet
BENLYSTA
CELLCEPT INTRAVENOUS
cyclosporine modified
cyclosporine capsule, injection
ENBREL
Necessary actions,
restrictions, or limits on
use
NDS
NDS
PA (Hormonal Agents,
Suppressant (Pituitary) Somavert) NDS
NDS
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 2) QL (100 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Cinryze) NDS
PA (FIRAZYR) NDS
$0(Tier 2) $0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ENBREL SURECLICK
$0(Tier 2)
ENVARSUS XR
gengraf
HUMIRA
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
HUMIRA PEN
$0(Tier 2)
HUMIRA PEN-CROHNS DISEASESTARTER
$0(Tier 2)
HUMIRA PEN-PSORIASIS STARTER
$0(Tier 2)
B/D
B/D MO
PA (Benlysta) NDS
B/D
B/D
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D MO
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9
66
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
KINERET
methotrexate sodium injection 1gm/40ml, 1gm, 50mg/2ml
methotrexate tablet
mycophenolate mofetil
mycophenolic acid dr
NULOJIX
ORENCIA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
ORENCIA CLICKJECT
$0(Tier 2)
PROGRAF INJECTION
RAPAMUNE SOLUTION
REMICADE
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
sirolimus tablet
tacrolimus capsule 0.5mg, 1mg, 5mg
TORISEL
ZORTRESS
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D
GAMMAGARD LIQUID INJECTION 2.5GM/25ML
GAMUNEX-C INJECTION 1GM/10ML
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS INJECTION 180MG
leflunomide
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
B/D
B/D MO
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D
B/D NDS
PA (Immunological
Agents) NDS
B/D
B/D
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
B/D
B/D NDS
B/D NDS
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 1)
SIMULECT INJECTION 20MG
SYNAGIS INJECTION 50MG/0.5ML
Vaccines
ACTHIB INJECTION 0
ADACEL
bcg vaccine
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
Necessary actions,
restrictions, or limits on
use
QL (28 ML per 28 days)
PA (Immunological
Agents) NDS
$0(Tier 2)
$0(Tier 2)
QL (2.4 EA per 28 days)
PA (Immunological
Agents - Ilaris)
QL (30 EA per 30 days)
MO
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
67
Name of drug
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX INJECTION 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 INJECTION 7.5MCG/0.5ML
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ SOLUTION
TENIVAC
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VARIZIG
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
DELZICOL
DIPENTUM
mesalamine dr
mesalamine kit
Sulfonamides
sulfasalazine tablet, tablet delayed release
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
B/D
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
QL (180 EA per 30 days)
MO
MO
$0(Tier 1)
MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9
68
Name of drug
alendronate sodium tablet 10mg, 40mg, 5mg
What the drug
will cost you
(tier level)
$0(Tier 1)
alendronate sodium tablet 70mg
$0(Tier 1)
alendronate sodium tablet 35mg
calcitonin-salmon solution
$0(Tier 1)
$0(Tier 1)
calcitriol capsule, oral solution
calcitriol injection 1mcg/ml
doxercalciferol capsule 0.5mcg, 1mcg
doxercalciferol capsule 2.5mcg
doxercalciferol injection
etidronate disodium
FORTEO INJECTION 600MCG/2.4ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
fortical
$0(Tier 1)
ibandronate sodium tablet
$0(Tier 1)
MIACALCIN INJECTION
PAMIDRONATE DISODIUM INJECTION 6MG/ML
pamidronate disodium injection 30mg/10ml, 90mg/10ml
PROLIA
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
risedronate sodium dr
$0(Tier 1)
risedronate sodium tablet 30mg, 5mg
$0(Tier 1)
risedronate sodium tablet 35mg
$0(Tier 1)
XGEVA
zoledronic acid injection 4mg/5ml, 5mg/100ml
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
$0(Tier 2)
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
$0(Tier 1)
$0(Tier 2)
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8"
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
QL (8 EA per 28 days)
QL (4 ML per 30 days)
MO
MO
MO
NDS
MO
PA (metabolic bone
disease agents - IV
osteoporosis)
QL (4 ML per 30 days)
MO
QL (1 EA per 30 days)
MO
QL (1 ML per 180 days)
PA (Metabolic Bone
Disease Agents - Prolia)
QL (4 EA per 28 days)
MO
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
NDS
MO
QL (200 EA per 30 days)
MO
QL (200 EA per 30 days)
MO
MO
QL (200 EA per 30 days)
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
69
Name of drug
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
bd pen needles short/ultrafine/31g x 5/16"
BOTOX INJECTION 200UNIT
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
CARNITOR INJECTION
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
exel comfort point insulin pen needles 31g x 8mm
FERRIPROX TABLET
insupen ultrafin 31gx8mm
INTRALIPID INJECTION 30GM/100ML
intralipid injection 20gm/100ml
IOSAT
lactated ringers irrigation
levocarnitine solution, tablet
lite touch pen needles/31g x 3/16"
methylergonovine maleate tablet
monoject insulin syringe/detach needle/1ml/25g x 5/8"
NATPARA
novofine 32gx6mm
nutrilipid
pantothenic acid
physiolyte
physiosol irrigation
PRO COMFORT LANCETS 31G
ringers irrigation
sterile water irrigation
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
SUSPENDOL-S
THYROSAFE
THYROSHIELD
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN
latanoprost
LUMIGAN
Ophthalmic Agents, Other
akwa tears
artificial tears ointment 15%; 83%
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
QL (200 EA per 30 days)
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
MO
MO
MO
MO
B/D
B/D
DP
MO
MO
MO
PA (Natpara) NDS
MO
B/D
DP
DP
MO
MO
DP
DP
DP
MO
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
$0(Tier 3)
$0(Tier 3)
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
70
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
Name of drug
artificial tears solution 1.4%
bacitracin/polymyxin b
CYSTARAN
eye drops solution 0.05%
FRESHKOTE
ISOPTO TEARS
liquitears
lubricating plus eye drops
lubrifresh p.m.
MURO 128 SOLUTION
naphazoline hcl
natural balance tears solution 0.4%
natures tears solution 0.4%
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
opti-clear
polymyxin b sulfate/trimethoprim sulfate
puralube ointment 15%; 85%
REFRESH CELLUVISC
refresh lacri-lube
REFRESH PLUS
RESTASIS
sodium chloride ointment 5%
sodium chloride ophthalmic solution 5%
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
olopatadine hcl ophthalmic solution 0.1%
PATANOL
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic solution 0.1%
diclofenac sodium solution 0.1%
DUREZOL
fluorometholone
flurbiprofen sodium
ketorolac tromethamine ophthalmic solution 0.4%, 0.5%
LOTEMAX SUSPENSION
neomycin/polymyxin/dexamethasone
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate ophthalmic solution 1%
sulfacetamide sodium/prednisolone sodium phosphate
TOBRADEX OINTMENT
tobramycin/dexamethasone
Ophthalmic Antiglaucoma Agents
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (60 EA per 30 days)
MO
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
71
What the drug
will cost you
Name of drug
(tier level)
acetazolamide er
$0(Tier 1)
ALPHAGAN P SOLUTION 0.1%
$0(Tier 2)
betaxolol hcl solution 0.5%
$0(Tier 1)
brimonidine tartrate
$0(Tier 1)
carteolol hcl
$0(Tier 1)
dorzolamide hcl
$0(Tier 1)
dorzolamide hcl/timolol maleate
$0(Tier 1)
levobunolol hcl solution 0.5%
$0(Tier 1)
methazolamide tablet
$0(Tier 1)
metipranolol
$0(Tier 1)
PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED $0(Tier 2)
0.125%
pilocarpine hcl solution 1%, 2%, 4%
$0(Tier 1)
timolol maleate ophthalmic gel forming
$0(Tier 1)
timolol maleate solution 0.25%, 0.5%
$0(Tier 1)
Otic Agents
Otic Agents
acetasol hc
$0(Tier 1)
acetic acid
$0(Tier 1)
CIPRODEX
$0(Tier 2)
ear drops earwax removal aid
$0(Tier 3)
earwax treatment drops
$0(Tier 3)
hydrocortisone/acetic acid
$0(Tier 1)
neomycin/polymyxin/hc
$0(Tier 1)
neomycin/polymyxin/hydrocortisone otic suspension 1%;
$0(Tier 1)
3.5mg/ml; 10000unit/ml
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
$0(Tier 2)
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT,
45MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT
$0(Tier 2)
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
budesonide inhalation suspension 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml
budesonide nasal suspension 32mcg/act
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
DULERA
FLOVENT DISKUS
FLOVENT HFA AEROSOL 44MCG/ACT
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DP
DP
QL (60 EA per 30 days)
MO
MO
QL (12 GM per 30 days)
MO
MO
MO
MO
MO
B/D MO
QL (17.2 GM per 30 days)
MO
MO
MO
QL (21.2 GM per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
72
What the drug
will cost you
Name of drug
(tier level)
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT $0(Tier 2)
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
$0(Tier 1)
$0(Tier 1)
fluticasone propionate suspension 50mcg/act
mometasone furoate suspension 50mcg/act
SYMBICORT
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
triamcinolone acetonide aerosol 55mcg/act
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
aceta-gesic tablet 325mg; 12.5mg
acetaminophen/diphenhydramine
ALA-HIST IR
ALA-HIST PE
all day allergy childrens tablet chewable 10mg
all day allergy-d
all day allergy tablet
aller-chlor
allergy relief child
allergy relief d-24
allergy relief tablet 10mg
allergy tablet disintegrating
allergy tablet 10mg, 4mg
azelastine hcl solution 0.15%
azelastine hcl solution 0.1%
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
banophen capsule 50mg
banophen liquid
brotapp
cetirizine hcl allergy childrens
cetirizine hcl childrens allergy syrup 1mg/ml
cetirizine hcl/pseudoephedrine hcl er
cetirizine hcl tablet chewable, tablet
childrens allergy
childrens loratadine
chlorpheniramine maleate tablet extended release
complete allergy medicine capsule
cyproheptadine hcl syrup, tablet
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
DALLERGY LIQUID 1MG/ML; 2.5MG/ML
DALLERGY TABLET 1MG; 5MG
dimaphen childrens
diphenhist capsule, liquid
diphenhydramine hcl capsule
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
QL (24 GM per 30 days)
MO
MO
QL (32 GM per 30 days)
MO
DP
QL (34 GM per 30 days)
QL (10.2 GM per 30 days)
MO
QL (33 GM per 30 days)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
QL (30 ML per 30 days)
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (High Risk
Medications) MO
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
73
Name of drug
diphenhydramine hcl injection 50mg/ml
ED A-HIST LIQUID 4MG/5ML; 10MG/5ML
ED CHLORPED D
ed chlorped jr
ED CHLORPED LIQUID
ed-chlortan
fexofenadine hcl childrens allergy
fexofenadine hcl tablet 180mg, 60mg
gnp all day allergy
gnp allergy tablet 4mg
gnp dayhist allergy
gnp loratadine
gnp loratadine-d 24 hour
HISTEX PD LIQUID 0.938MG/ML
HISTEX SYRUP
hydroxyzine hcl injection, syrup, tablet
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
hydroxyzine pamoate capsule
$0(Tier 1)
J-TAN D PD
J-TAN PD
levocetirizine dihydrochloride solution
levocetirizine dihydrochloride tablet
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
LODRANE D
LOHIST-D
loratadine childrens
loratadine hives relief
loratadine-d 12hr
loratadine-d 24hr
loratadine tablet
mapap pm
NASOPEN PE
night time sleep aid
nohist-lq
olopatadine hcl nasal solution 0.6%
pain reliever pm extra strength
POLY-HIST PD
q-dryl
qc loratadine allergy relief
qc loratadine-d
quenalin
RESCON TABLET
restfully sleep
RU-HIST D
RYMED
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (High Risk
Medications)
PA (High Risk
Medications)
DP
DP
MO
QL (30 EA per 30 days)
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
74
Name of drug
rynex pe
rynex pse
siladryl allergy
silphen cough
sm allergy 4 hour
sm allergy relief liquid
sm allergy relief tablet 1.34mg
sm lorata-dine d
sm loratadine syrup
sm sleep aid
sudogest sinus & allergy
VANAHIST PD
virdec
Antileukotrienes
montelukast sodium
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
zafirlukast
$0(Tier 1)
ZYFLO CR
$0(Tier 2)
Bronchodilators, Anticholinergic
ATROVENT HFA
$0(Tier 2)
COMBIVENT RESPIMAT
$0(Tier 2)
ipratropium bromide/albuterol sulfate
$0(Tier 1)
ipratropium bromide inhalation solution
$0(Tier 1)
ipratropium bromide nasal solution 0.06%
$0(Tier 1)
ipratropium bromide nasal solution 0.03%
$0(Tier 1)
SPIRIVA HANDIHALER
$0(Tier 2)
SPIRIVA RESPIMAT
$0(Tier 2)
Bronchodilators, Sympathomimetic
ADRENACLICK
albuterol sulfate er
albuterol sulfate syrup, tablet
albuterol sulfate nebulization solution 0.083%
albuterol sulfate nebulization solution 0.63mg/3ml,
1.25mg/3ml
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (39 GM per 30 days)
MO
QL (8 GM per 30 days)
MO
QL (540 ML per 30 days)
B/D MO
QL (300 ML per 30 days)
B/D MO
QL (15 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (8 GM per 30 days)
MO
QL (4 EA per 30 days)
MO
MO
QL (1170 ML per 30
days) B/D MO
QL (1200 ML per 30
days) B/D MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9
75
EPINEPHRINE INJECTION 0.15MG/0.15ML,
0.3MG/0.3ML
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
levalbuterol hcl nebulization solution 0.31mg/3ml,
0.63mg/3ml
levalbuterol tartrate hfa
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (200 ML per 30 days)
B/D MO
QL (4 EA per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
QL (4 EA per 30 days)
QL (4 EA per 30 days)
B/D MO
$0(Tier 1)
levalbuterol nebulization solution
metaproterenol sulfate syrup, tablet
PROAIR HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
PROAIR RESPICLICK
$0(Tier 2)
SEREVENT DISKUS
$0(Tier 2)
QL (45 GM per 30 days)
MO
B/D MO
MO
QL (36 GM per 30 days)
MO
QL (2 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
terbutaline sulfate injection
terbutaline sulfate tablet
VENTOLIN HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
XOPENEX HFA
$0(Tier 2)
XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML
$0(Tier 2)
Name of drug
albuterol sulfate nebulization solution 0.5%
Cystic Fibrosis Agents
CAYSTON
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
KALYDECO PACKET
$0(Tier 2)
KALYDECO TABLET
$0(Tier 2)
ORKAMBI TABLET 125MG; 200MG
$0(Tier 2)
ORKAMBI TABLET 125MG; 100MG
$0(Tier 2)
PULMOZYME
TOBI PODHALER
tobramycin
Mast Cell Stabilizers
cromolyn sodium aerosol solution 5.2mg/act
cromolyn sodium nebulization solution 20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
MO
QL (36 GM per 30 days)
MO
QL (45 GM per 30 days)
MO
QL (450 ML per 30 days)
B/D MO
PA (Antibacterials - Beta
lactam, Other) NDS
QL (56 EA per 28 days)
PA (Kalydeco) NDS
QL (60 EA per 30 days)
PA (Kalydeco) NDS
QL (112 EA per 28 days)
PA (Orkambi)
QL (112 EA per 28 days)
PA (Orkambi) NDS
B/D
B/D
DP
QL (305 ML per 30 days)
B/D MO
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
76
What the drug
will cost you
Name of drug
(tier level)
DALIRESP
$0(Tier 2)
ELIXOPHYLLIN
$0(Tier 2)
THEO-24
$0(Tier 2)
theophylline cr tablet extended release 12 hour 100mg, 200mg$0(Tier 1)
theophylline er tablet extended release 24 hour
$0(Tier 1)
theophylline er tablet extended release 12 hour 300mg, 450mg$0(Tier 1)
theophylline solution
$0(Tier 1)
Pulmonary Antihypertensives
ADCIRCA
$0(Tier 2)
ADEMPAS
$0(Tier 2)
LETAIRIS
OPSUMIT
$0(Tier 2)
$0(Tier 2)
ORENITRAM
sildenafil injection
sildenafil tablet
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
TRACLEER
$0(Tier 2)
TYVASO
UPTRAVI TABLET THERAPY PACK
UPTRAVI TABLET
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Respiratory Tract Agents, Other
12 hour decongestant
acetylcysteine solution
ALAHIST DM LIQUID 4MG/5ML; 15MG/5ML;
7.5MG/5ML
all-nite multi-symptom cold/flu relief liquid 325mg/15ml;
15mg/15ml; 6.25mg/15ml
ap-hist dm
aprodine tablet
ARALAST NP INJECTION 500MG
benzonatate capsule 100mg, 200mg
bromfed dm
bromphen/pseudoephedrine hcl/dextromethorphan hbr
BROTAPP DM
cheratussin ac syrup
cheratussin dac
chest congestion relief
chest congestion relief pe
childrens silfedrine
CHLO TUSS EX
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
PA (Adcirca)
QL (90 EA per 30 days)
PA (Adempas) NDS
NDS
QL (30 EA per 30 days)
PA (Opsumit)
PA (Orenitram)
PA (Sildenafil - IV)
QL (90 EA per 30 days)
PA (Sildenafil - PAH)
QL (60 EA per 30 days)
LA NDS
B/D
PA (Uptravi)
QL (60 EA per 30 days)
PA (Uptravi)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
DP
B/D
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
77
Name of drug
CHLO TUSS LIQUID 12.5MG/5ML; 1MG/5ML;
30MG/5ML
codeine/guaifenesin solution
cold/cough dm childrens
cough dm
cough syrup syrup 100mg/5ml
DAY TIME MULTI-SYMPTOM COLD/FLU RELIEF
CAPSULE 325MG; 10MG; 5MG
DECONEX DMX TABLET 15MG; 380MG; 10MG
DECONEX IR TABLET 380MG; 10MG
deep sea nasal spray
delsym cough + chest congestion dm
delsym cough + chest congestion dm childrens
delsym cough + cold daytime
delsym cough + cold nighttime
delsym cough + cold nighttime childrens
DELSYM SUSPENSION EXTENDED RELEASE
dextromethorphan polistirex
dimaphen dm cold & cough
dimaphen dm cold/cough childrens
DURAFLU TABLET 500MG; 20MG; 200MG; 60MG
ED A-HIST DM TABLET
ed a-hist dm liquid
ed a-hist pse
ed a-hist tablet 4mg; 10mg
ED BRON GP
endacof-dm liquid
ESBRIET CAPSULE
extra action cough
FLOWTUSS
gnp tussin
gnp tussin dm
guaifenesin ac syrup
guaifenesin and pseudoephedrine hydrochloride
guaifenesin er
guaifenesin/codeine solution
HISTEX-DM
HISTEX-PE
HYCOFENIX
hydrocodone bitartrate/chlorpheniramine maleate/pse
hydrocodone bitartrate/homatropine methylbromide
hydrocodone polistirex/chlorpheniramine polistirex
hydrocodone/homatropine
hydromet
iophen c-nr
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (270 EA per 30 days)
PA (Esbriet) NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to page 9
78
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
iophen dm-nr
iophen-nr
J-MAX SYRUP
kidkare cough/cold
LOHIST-DM
M-END DMX
M-END MAX D
mapap cold formula multi-symptom
mapap sinus maximum strength congestion and pain
mucaphed
MUCINEX
mucinex chest congestion childrens
MUCINEX CHILDRENS COLD COUGH & SORE
THROAT
MUCINEX CHILDRENS MULTI-SYMPTOM COLD
$0(Tier 3)
MUCINEX CHILDRENS MULTI-SYMPTOM COLD &
$0(Tier 3)
FEVER
MUCINEX CONGESTION & COUGH CHILDRENS
$0(Tier 3)
mucinex cough childrens
$0(Tier 3)
MUCINEX COUGH FOR KIDS PACKET
$0(Tier 3)
MUCINEX D
$0(Tier 3)
MUCINEX D MAXIMUM STRENGTH
$0(Tier 3)
MUCINEX DM
$0(Tier 3)
MUCINEX DM MAXIMUM STRENGTH
$0(Tier 3)
mucinex fast-max cold & sinus tablet
$0(Tier 3)
MUCINEX FAST-MAX COLD FLU& SORE THROAT
$0(Tier 3)
LIQUID
mucinex fast-max cold flu& sore throat tablet
$0(Tier 3)
MUCINEX FAST-MAX DAY TIME/NIGHT TIME
$0(Tier 3)
MISCELLANEOUS 650MG/20ML; 20MG/20ML;
25MG/20ML; 400MG/20ML; 10MG/20ML
mucinex fast-max dm max
$0(Tier 3)
mucinex fast-max night time cold & flu liquid, tablet
$0(Tier 3)
MUCINEX FAST-MAX SEVERE COLD LIQUID
$0(Tier 3)
mucinex fast-max severe cold tablet
$0(Tier 3)
MUCINEX FAST-MAX SEVERE CONGESTION &
$0(Tier 3)
COUGH
MUCINEX FOR KIDS PACKET 100MG
$0(Tier 3)
MUCINEX MAXIMUM STRENGTH
$0(Tier 3)
MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK $0(Tier 3)
mucinex multi-symptom cold night time childrens
$0(Tier 3)
mucinex sinus-max day/night miscellaneous
$0(Tier 3)
mucinex sinus-max full force
$0(Tier 3)
mucinex sinus-max moisture smart
$0(Tier 3)
mucinex sinus-max pressure & pain tablet
$0(Tier 3)
mucinex sinus-max severe congestion relief tablet
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
79
Name of drug
MUCINEX STUFFY NOSE & COLD CHILDRENS
mucus relief
mucus-er
mucusrelief sinus
nasal decongestant pe
nasal decongestant spray
NASAL DECONGESTANT SYRUP
nasal decongestant solution
night time multi-symptom cold/flu relief
NINJACOF-XG
nohist-dm
nrs nasal relief
OFEV
organ-i nr
pain relief sinus pe daytime
pediatric cough/cold
phenylephrine hcl/pyrilamine maleate
PHENYLHISTINE DH
PROLASTIN-C
promethazine vc plain
promethazine vc/codeine
promethazine-dm
promethazine/codeine
promethazine/dextromethorphan
pseudoephedrine hcl tablet 30mg
q-tussin dm
q-tussin solution
qc cough/sore throat nighttime
RESCON DM
RESCON-GG
RESPAIRE-30
REZIRA
robafen
robafen cf cough & cold
robafen dm
robafen dm cough clear
rynex dm
siltussin dm das
siltussin sa
siltussin-dm
sm nasal decongestant maximum strength
sm nasal spray 12 hour
sm tussin dm
sm tussin dm cough/chest congestion
sudogest
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (60 EA per 30 days)
PA (Ofev) NDS
DP
DP
DP
DP
DP
NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
80
Name of drug
sudogest 12 hour
sudogest pe
tussin dm
tussin dm clear
TUSSIONEX PENNKINETIC EXTENDED RELEASE
SUSPENSION EXTENDED RELEASE
VANACOF
VANACOF DM
VANACOF-8
virdec dm
virtussin a/c
XOLAIR
ZEMAIRA
ZONATUSS
ZUTRIPRO
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet 500mg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
DP
DP
DP
DP
DP
PA (Respiratory Tract
Agents) NDS
NDS
DP
DP
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
cyclobenzaprine hcl tablet 10mg, 5mg
$0(Tier 1)
methocarbamol tablet
$0(Tier 1)
orphenadrine citrate er
$0(Tier 1)
orphenadrine citrate injection
Sleep Disorder Agents
GABA Receptor Modulators
flurazepam hcl
temazepam capsule 15mg, 30mg
zaleplon
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zolpidem tartrate er
$0(Tier 1)
zolpidem tartrate tablet
$0(Tier 1)
PA (High Risk
Medications)
QL (90 EA per 30 days)
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (30 EA per 30 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
Sleep Disorders, Other
You can find information on what the symbols and abbreviations in this table mean by going to page 9
81
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
modafinil tablet 200mg
ROZEREM
XYREM
$0(Tier 2)
$0(Tier 2)
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CARBAGLU
CHEMET
DEPEN TITRATABS
EXJADE
kionex powder
MYKIDZ IRON 10
SODIUM LACTATE INJECTION 5MEQ/ML
sodium polystyrene sulfonate suspension
sps
SYPRINE
Electrolyte/Mineral Replacement
ACTIVE FE
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
aminosyn ii 8.5%/electrolytes
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
PA (Central Nervous
System Agents) MO
QL (30 EA per 30 days)
QL (540 ML per 30 days)
LA NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
NDS
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
DP
B/D
B/D
B/D
MO
NDS
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
82
What the drug
will cost you
Name of drug
(tier level)
AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; $0(Tier 2)
1527MG/100ML; 1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML; 990MG/100ML;
1500MG/100ML; 1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML; 795MG/100ML;
50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML;
750MG/100ML, 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; 45.3MEQ/L;
400MG/100ML; 200MG/100ML; 270MG/100ML;
500MG/100ML
AMINOSYN-HBC
$0(Tier 2)
AMINOSYN-PF 7%
$0(Tier 2)
AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; $0(Tier 2)
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
$0(Tier 2)
AMMONIUM CHLORIDE
$0(Tier 2)
baby darlings pediatric electrolyte
$0(Tier 3)
CALCET CREAMY BITES
$0(Tier 3)
CALCET PETITES
$0(Tier 3)
CALCI-CHEW
$0(Tier 3)
calcitrate tablet 315mg; 250unit
$0(Tier 3)
calcium + d3
$0(Tier 3)
calcium 250+d
$0(Tier 3)
calcium 500/d tablet chewable
$0(Tier 3)
calcium 600 + d tablet 600mg; 400unit
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
B/D
B/D
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
83
What the drug
will cost you
Name of drug
(tier level)
calcium 600 with vitamin d tablet
$0(Tier 3)
calcium 600+d tablet 600mg; 800unit
$0(Tier 3)
calcium 600-d
$0(Tier 3)
calcium 600/vitamin d3
$0(Tier 3)
calcium 600 tablet 600mg
$0(Tier 3)
calcium carbonate/vitamin d
$0(Tier 3)
calcium carbonate suspension 1250mg/5ml
$0(Tier 3)
calcium carbonate tablet 1250mg, 600mg
$0(Tier 3)
CALCIUM CITRATE MALATE/VITAMIN D
$0(Tier 3)
CALCIUM CITRATE W/D
$0(Tier 3)
calcium citrate+d
$0(Tier 3)
calcium citrate/vitamin d tablet 315mg; 200unit
$0(Tier 3)
CALCIUM GLUCONATE TABLET 500MG
$0(Tier 3)
calcium high potency + vitamin d
$0(Tier 3)
calcium high potency tablet 600mg; 0
$0(Tier 3)
calcium oyster shell
$0(Tier 3)
calcium/magnesium/zinc tablet 333.333mg; 133.333mg; 5mg, $0(Tier 3)
333mg; 133mg; 5mg
calcium/vitamin d3 tablet 250mg; 125unit
$0(Tier 3)
calcium/vitamin d tablet 500mg; 200unit, 600mg; 125unit,
$0(Tier 3)
600mg; 200unit, 600mg; 400unit
calcium tablet 500mg, 600mg
$0(Tier 3)
CALTRATE 600+D PLUS MINERALS
$0(Tier 3)
CALTRATE 600+D3 SOFT CHEWS
$0(Tier 3)
CALTRATE 600+D TABLET 600MG; 800UNIT
$0(Tier 3)
calvite p&d
$0(Tier 3)
CENTRATEX
$0(Tier 3)
CHEWABLE CALCIUM TABLET CHEWABLE
$0(Tier 3)
citrus calcium +d
$0(Tier 3)
CLINIMIX 2.75%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX 4.25%/DEXTROSE 10%
$0(Tier 2)
CLINIMIX 4.25%/DEXTROSE 20%
$0(Tier 2)
CLINIMIX 4.25%/DEXTROSE 25%
$0(Tier 2)
CLINIMIX 4.25%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX 5%/DEXTROSE 15%
$0(Tier 2)
CLINIMIX 5%/DEXTROSE 20%
$0(Tier 2)
CLINIMIX 5%/DEXTROSE 25%
$0(Tier 2)
CLINIMIX E 2.75%/DEXTROSE 10%
$0(Tier 2)
CLINIMIX E 2.75%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 10%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 25%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 15%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 20%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 25%
$0(Tier 2)
CORAL CALCIUM CAPSULE 100UNIT; 185MG; 50MG $0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
84
What the drug
will cost you
Name of drug
(tier level)
cvs calcium 600 & vitamind3
$0(Tier 3)
cvs calcium 600+d tablet 600mg; 800unit
$0(Tier 3)
cvs calcium carbonate
$0(Tier 3)
cvs calcium citrate + d
$0(Tier 3)
cvs calcium citrate +d
$0(Tier 3)
cvs calcium citrate+d/magnesium
$0(Tier 3)
cvs calcium/magnesium/zinc
$0(Tier 3)
cvs calcium tablet
$0(Tier 3)
cvs electrolyte solution
$0(Tier 3)
cvs iron tablet 325mg
$0(Tier 3)
cvs magnesium tablet 250mg
$0(Tier 3)
cvs pediatric electrolyte
$0(Tier 3)
cvs pediatric electrolyte freezer pops
$0(Tier 3)
cvs selenium
$0(Tier 3)
cvs zinc
$0(Tier 3)
DEXTROSE 10%/NACL 0.45%
$0(Tier 2)
dextrose 10%
$0(Tier 1)
DEXTROSE 10%/NACL 0.2%
$0(Tier 2)
dextrose 2.5%/nacl 0.45%
$0(Tier 1)
dextrose 5%
$0(Tier 1)
dextrose 5%/lactated ringers
$0(Tier 1)
dextrose 5%/nacl 0.2%
$0(Tier 1)
DEXTROSE 5%/NACL 0.225%
$0(Tier 2)
dextrose 5%/nacl 0.33%
$0(Tier 1)
dextrose 5%/nacl 0.45%
$0(Tier 1)
dextrose 5%/nacl 0.9%
$0(Tier 1)
DIALYVITE 800/IRON
$0(Tier 3)
DUOFER
$0(Tier 3)
ENFAMIL ENFALYTE SOLUTION 45MEQ/L; 33MEQ/L; $0(Tier 3)
25MEQ/L; 50MEQ/L
ENLYTE
$0(Tier 3)
eql pediatric electrolyte
$0(Tier 3)
ezfe 200
$0(Tier 3)
FER-IN-SOL SOLUTION
$0(Tier 3)
fer-iron
$0(Tier 3)
ferate tablet 27mg
$0(Tier 3)
FERGON TABLET 240MG
$0(Tier 3)
FERIVAFA
$0(Tier 3)
ferosul
$0(Tier 3)
FERRALET 90
$0(Tier 3)
FERRAPLUS 90
$0(Tier 3)
FERRETTS
$0(Tier 3)
FERRETTS IPS
$0(Tier 3)
ferrex 150
$0(Tier 3)
FERREX 150 FORTE
$0(Tier 3)
ferric x-150
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
85
Name of drug
FERRIMIN 150
ferrocite
ferrous drops
ferrous fumarate 324
FERROUS GLUCONATE TABLET 324MG
ferrous gluconate tablet 240mg, 324mg
FERROUS SULFATE SYRUP, TABLET EXTENDED
RELEASE
ferrous sulfate elixir
FERROUS SULFATE LIQUID 220MG/5ML
ferrous sulfate solution 15mg/ml
FERROUS SULFATE TABLET DELAYED RELEASE
324MG
ferrous sulfate tablet delayed release 325mg
ferrous sulfate tablet 325mg
ferrousul
FOCALGIN DSS
FOLITAB 500
FREAMINE HBC 6.9%
gnp calcium 1200
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
gnp calcium 500/d
gnp calcium 600/d
gnp calcium citrate +d3
gnp calcium citrate+d maximum
gnp calcium/magnesium/zinc
gnp calcium tablet 600mg
gnp calcuim/vitamin d/minerals
gnp iron tablet 200mg
gnp magnesium tablet 250mg; 0; 0
gnp pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l
gnp zinc
HEMOCYTE
HEMOCYTE PLUS
hemocyte-f tablet
hepatamine
hm pediatric electrolyte
iferex 150
iferex 150 forte
INTEGRA F
INTEGRA PLUS
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iron supplement childrens
iron tablet 27mg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
B/D
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
86
Name of drug
IROSPAN 24/6
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
kp ferrous gluconate
kp ferrous sulfate
lactated ringers viaflex
liquid calcium/vitamin d
MAG-TAB SR
magnesium 27
MAGNESIUM ELEMENTAL
MAGNESIUM GLUCONATE TABLET 550MG
magnesium sulfate injection 50%
magnesium tablet 250mg
MOZOBIL
myferon 150
myferon 150 forte
NATALVIRT FLT
NEPHRAMINE
NEPHRON FA
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
NOVAFERRUM 125
NOVAFERRUM 50
NOVAFERRUM PEDIATRIC DROPS
nu-iron 150
NU-MAG
oralyte
oralyte freezer pops
ORAZINC TABLET
orazinc capsule 220mg
os-cal calcium + d3
os-cal extra d3
os-cal tablet chewable
OSTEO-PORETICAL
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
MO
MO
MO
MO
MO
DP
DP
DP
DP
DP
DP
DP
DP
PA (Mozobil)
DP
DP
DP
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
87
What the drug
will cost you
Name of drug
(tier level)
oysco 500
$0(Tier 3)
oysco 500+d tablet
$0(Tier 3)
oysco d
$0(Tier 3)
oyst-cal-d 500
$0(Tier 3)
oyster calcium
$0(Tier 3)
oyster shell calcium + d
$0(Tier 3)
oyster shell calcium + d3
$0(Tier 3)
oyster shell calcium + vitamin d
$0(Tier 3)
oyster shell calcium 500 + d
$0(Tier 3)
oyster shell calcium plusvitamin d
$0(Tier 3)
oyster shell calcium/d tablet 250mg; 125unit, 500mg; 200unit $0(Tier 3)
oyster shell calcium/vitamin d tablet 200unit; 500mg, 250mg; $0(Tier 3)
125unit; 0, 500mg; 200unit
oyster shell calcium tablet 500mg
$0(Tier 3)
pa oyster shell calcium
$0(Tier 3)
PEDIALYTE ADVANCED CARE
$0(Tier 3)
PEDIALYTE FREEZER POPS
$0(Tier 3)
PEDIALYTE SINGLES SOLUTION 7MEQ/200ML;
$0(Tier 3)
5.3GM/200ML; 4MEQ/200ML; 9MEQ/200ML; 1.6MG/200ML, 8.3MEQ/240ML; 7.1MEQ/240ML;
4.7GM/240ML; 1.2GM/240ML; 4.7MEQ/240ML; 10.6MEQ/240ML
PEDIALYTE SOLUTION 2.1MEQ/59ML; 1.5GM/59ML; $0(Tier 3)
1.2MEQ/59ML; 2.7MEQ/59ML; 0.5MG/59ML, 35MEQ/L; 20GM/L; 5GM/L; 20MEQ/L; 45MEQ/L, 35MEQ/L; 25GM/L; 20MEQ/L; 45MEQ/L; 7.8MG/L, 35MEQ/L; 30MEQ/L; 25GM/L; 20MEQ/L; 45MEQ/L, 4.2MEQ/118ML; 3.6MEQ/118ML; 3GM/118ML; 2.4MEQ/118ML;
5.3MEQ/118ML
pediatric electrolyte freeze pops
$0(Tier 3)
pediatric electrolyte freezer pops solution 35meq/1000ml;
$0(Tier 3)
25gm/1000ml; 20meq/1000ml; 45meq/1000ml
pediatric electrolyte/zinc
$0(Tier 3)
pediatric electrolyte solution 35meq/l; 20gm/l; 20meq/l;
$0(Tier 3)
45meq/l, 35meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm; 20meq/l; 45meq/l; 7.8mg/l, 35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 5gm/l; 20meq/l; 45meq/l
PLASMA-LYTE A
$0(Tier 2) PLASMA-LYTE-148
$0(Tier 2) PLASMA-LYTE-56/D5W
$0(Tier 2) PLENAMINE
$0(Tier 1)
poly-iron 150
$0(Tier 3)
poly-iron 150 forte
$0(Tier 3)
polysacc iron 150 complex
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
88
What the drug
will cost you
Name of drug
(tier level)
polysaccharide iron forte
$0(Tier 3)
potassium chloride 0.15% d5w/nacl 0.33%
$0(Tier 1)
potassium chloride 0.15% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride 0.22% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride er capsule extended release
$0(Tier 1)
potassium chloride er tablet extended release 10meq, 20meq, $0(Tier 1)
8meq
potassium chloride/dextrose
$0(Tier 1)
POTASSIUM CHLORIDE/DEXTROSE/LACTATED
$0(Tier 2)
RINGERS INJECTION 3MEQ/L; 149MEQ/L; 5%;
28MEQ/L; 24MEQ/L; 130MEQ/L
POTASSIUM CHLORIDE/SODIUM CHLORIDE
$0(Tier 1)
INJECTION 40MEQ/L; 0.9%
potassium chloride/sodium chloride injection 20meq/l; 0.45%, $0(Tier 1) 20meq/l; 0.9%
potassium chloride oral solution
$0(Tier 1) potassium chloride injection 10meq/100ml, 20meq/100ml,
$0(Tier 1) 2meq/ml, 40meq/100ml
potassium citrate er
$0(Tier 1)
PREMASOL INJECTION 52MEQ/L; 1760MG/100ML;
$0(Tier 2)
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 injection 56meq/l; 320mg/100ml; 730mg/100ml;
$0(Tier 1)
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
PROCALAMINE
$0(Tier 2)
PROFE
$0(Tier 3)
PROFERRIN-FORTE
$0(Tier 3)
PROSOL
$0(Tier 2)
qc calcium 600 +d3
$0(Tier 3)
qc calcium fast dissolution
$0(Tier 3)
qc calcium/minerals/vitamin d
$0(Tier 3)
qc ferrous sulfate
$0(Tier 3)
ra calcium 600
$0(Tier 3)
ra calcium 600 plus vitamin d-3
$0(Tier 3)
ra calcium 600/vit d/minerals
$0(Tier 3)
ra calcium citrate plus vitamin d-3
$0(Tier 3)
ra hi cal
$0(Tier 3)
ra hi-cal plus vitamin d
$0(Tier 3)
ra high potency iron
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
MO
MO
MO
B/D
B/D
B/D
DP
DP
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
89
Name of drug
ra iron tablet 325mg
RA OYSTER SHELL CALCIUM/VITAMIN D TABLET
200UNIT; 500MG
ra pediatric electrolyte freezer pops
ra pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l;
7.8mg/l, 35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l,
35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l
ra selenium tablet 50mcg
ra slow release iron tablet extended release 47.5mg
ra zinc tablet 50mg
ringers injection
sb pediatric electrolyte
se-tan plus
SELENIUM TABLET EXTENDED RELEASE
selenium tablet 100mcg, 200mcg, 50mcg
SLOW-MAG TABLET DELAYED RELEASE
sm calcium
sm calcium 500/vitamin d3
sm calcium 600
sm calcium 600/vitamin d
sm calcium citrate + d
sm calcium citrate w/vitamin d3
sm calcium plus/vitamin d/minerals
sm calcium/magnesium/zinc tablet 333mg; 133mg; 5mg
sm calcium/vitamin d tablet 600mg; 400unit
sm iron tablet 325mg
sm magnesium
sm oyster shell calcium/vitamin d3
sm oyster shell calcium/vitamin d tablet 500mg; 400unit
sm pediatric electrolyte
sm selenium
SM SLOW RELEASE IRON TABLET EXTENDED
RELEASE 143MG
sm zinc
sodium chloride 0.45% injection
sodium chloride 0.9% solution
sodium chloride injection 0.9%, 2.5meq/ml, 3%, 5%
sodium citrate/citric acid
sodium fluoride tablet 1mg
super calcium tablet 1500mg
TANDEM
TANDEM PLUS
TARON FORTE
tpn electrolytes
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
90
Name of drug
TRAVASOL INJECTION 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
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ZINC 15
zinc gluconate tablet 100mg, 50mg
zinc sulfate capsule
zinc sulfate tablet 220mg
zinc-220
zinc tablet 50mg
Therapeutic Nutrients/Minerals/Electrolytes
corvita
CORVITE
Vitamins
ABANEU-SL
ACEROLA C 500
actical
advanced stress formula/zinc
animal shapes + iron
animal shapes tablet chewable 60mg; 0; 4.5mcg; 400unit;
300mcg; 13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit
antioxidant formula capsule 250mg; 5000unit; 1mg; 1.5mg;
15mcg; 200unit; 7.5mg
APATATE FORTE
APETEX
APETIGEN
APETIGEN-PLUS
AQUADEKS CAPSULE, TABLET CHEWABLE
aquadeks liquid
AQUASOL E SOLUTION 15UNIT/0.3ML
aqueous vitamin d infants
aqueous vitamin e
ASCORBIC ACID POWDER
ascorbic acid tablet 250mg, 500mg
B COMPLEX/FOLIC ACID
b complex capsule 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;
3mg; 60mg
b-6 tablet 100mg
b-complex formula 1
b-complex natural
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
B/D
MO
MO
MO
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
91
What the drug
will cost you
Name of drug
(tier level)
b-complex plus vitamin c tablet 300mg; 150mg; 10mg; 50mg; $0(Tier 3)
5mg; 10.2mg; 15mg
b-complex w/c capsule 300mg; 50mg; 10mg; 5mg; 10mg;
$0(Tier 3)
15mg
b-complex with b-12
$0(Tier 3)
b-complex capsule 5mg; 1mcg; 400mcg; 60mg; 20mg; 0.5mg; $0(Tier 3)
3mg; 3mg; 60mg, 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;
3mg; 60mg
b-plex plus tablet 500mg; 0.15mg; 0.1mg; 3mg; 50mcg;
$0(Tier 3)
27mg; 0.8mg; 50mg; 5mg; 100mg; 25mg; 25mg; 20mg;
20mg; 30unit; 5000unit; 22.5mg
BACMIN TABLET 500MG; 150MCG; 25MG; 0.1MG;
$0(Tier 3)
3MG; 50MCG; 27MG; 1MG; 50MG; 50MG; 5MG; 100MG;
25MG; 20MG; 50MCG; 20MG; 30UNIT; 5000UNIT;
22.5MG
balance b-100
$0(Tier 3)
balance b-50 tablet 50mcg; 50mg; 50mcg; 400mcg; 50mg;
$0(Tier 3)
50mg; 50mg; 50mg
balanced b-100 tablet 100mcg; 100mg; 100mcg; 100mcg;
$0(Tier 3)
100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg
balanced b-50 tablet 50mcg; 50mg; 50mcg; 100mcg; 50mg; $0(Tier 3)
50mg; 50mg; 50mg; 50mg; 50mg; 50mg
bee zee
$0(Tier 3)
beta carotene capsule 25000unit
$0(Tier 3)
BIOCAL
$0(Tier 3)
BIOSUPP
$0(Tier 3)
biotin capsule 5000mcg
$0(Tier 3)
biotin tablet 1000mcg, 300mcg
$0(Tier 3)
BIOVOL
$0(Tier 3)
c 1000/bioflavonoids/rosehips
$0(Tier 3)
c 250 tablet
$0(Tier 3)
c 500/rose hips tablet 500mg; 37mg
$0(Tier 3)
c complex
$0(Tier 3)
c-500 tablet chewable
$0(Tier 3)
CALCIUM & MAGNESIUM
$0(Tier 3)
centamin
$0(Tier 3)
CENTRUM ADULTS
$0(Tier 3)
centrum kids complete
$0(Tier 3)
CENTRUM SILVER ADULT 50+
$0(Tier 3)
CENTRUM SILVER ULTRA WOMENS
$0(Tier 3)
CENTRUM SILVER TABLET 60MG; 0; 30MCG; 220MG; $0(Tier 3)
10MG; 72MG; 500UNIT; 45MCG; 0.5MG; 25MCG;
400MCG; 0; 0; 50MG; 2.3MG; 20MG; 5MCG; 20MG;
30MCG; 80MG; 150MCG; 3MG; 1.7MG; 2MG; 150MCG;
10MCG; 45MCG; 55MCG; 1.5MG; 50UNIT; 2500UNIT;
11MG
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
92
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
CENTRUM SPECIALIST HEART
CENTRUM ULTRA MENS
CENTRUM TABLET CHEWABLE
CENTRUM LIQUID 0; 60MG/15ML; 300MCG/15ML;
400UNIT/15ML; 25MCG/15ML; 6MCG/15ML; 0;
150MCG/15ML; 9MG/15ML; 2MG/15ML; 25MCG/15ML;
20MG/15ML; 10MG/15ML; 0; 2MG/15ML; 1.7MG/15ML;
0; 1.1MG/15ML; 1300UNIT/15ML; 30UNIT/15ML;
3MG/15ML
CEREFOLIN
$0(Tier 3)
CEROVITE ADVANCED FORMULA LIQUID
$0(Tier 3)
cerovite advanced formula tablet
$0(Tier 3)
cerovite jr
$0(Tier 3)
CERTAVITE SENIOR/ANTIOXIDANT NUTRIENTS
$0(Tier 3)
certavite/antioxidants
$0(Tier 3)
chewable vite childrens
$0(Tier 3)
chewable vite with iron/childrens
$0(Tier 3)
childrens chewable vitamin
$0(Tier 3)
childrens chewable vitamins/iron tablet chewable 400unit;
$0(Tier 3)
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
childrens chewable vitamins tablet chewable 400unit; 4.5mcg; $0(Tier 3)
0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit;
2500unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0;
2500unit; 400unit; 15unit
compete
$0(Tier 3)
complete
$0(Tier 3)
complex b-100 tablet extended release 100mcg; 100mg;
$0(Tier 3)
100mg; 100mcg; 200mcg; 100mg; 100mg; 100mg; 100mg;
100mg; 100mg
CORVITE 150
$0(Tier 3)
CORVITE FE TABLET 160MG; 5MG; 1000UNIT; 10MG; $0(Tier 3)
15MG; 1MG; 150MG; 10MG; 25MG
corvite free
$0(Tier 3)
cvs b complex plus c
$0(Tier 3)
cvs b-1
$0(Tier 3)
cvs b-12 tablet 500mcg
$0(Tier 3)
cvs balanced b-100 tablet 100mcg; 100mg; 100mcg; 400mcg; $0(Tier 3)
100mg; 100mg; 100mg; 100mg
cvs balanced b-50
$0(Tier 3)
cvs beta carotene
$0(Tier 3)
cvs biotin high potency
$0(Tier 3)
cvs biotin capsule 5000mcg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
93
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
cvs childrens chewable complete tablet chewable 60mg; 0;
40mcg; 100mg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 20mg;
20mg; 10mg; 100mg; 150mcg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit; 15mg
cvs childrens chewable multivitamin/iron
$0(Tier 3)
cvs daily energy
$0(Tier 3)
cvs daily multiple
$0(Tier 3)
cvs daily multiple for men
$0(Tier 3)
cvs daily multiple for men 50+
$0(Tier 3)
cvs daily multiple for women
$0(Tier 3)
cvs daily multiple for women 50+
$0(Tier 3)
cvs daily multiple plus iron/calcium/zinc
$0(Tier 3)
cvs e oil oil 100unt/0.25ml
$0(Tier 3)
cvs gummy dinos tablet chewable 30mg; 75mcg; 5mg;
$0(Tier 3)
200unit; 38mg; 5mcg; 200mcg; 20mcg; 40mcg; 1mg; 20unit;
2000unit; 2.5mg
cvs hair skin & nails/an tioxidants
$0(Tier 3)
CVS HAIR/SKIN/NAILS
$0(Tier 3)
CVS SPECTRAVITE ADULT 50+ TABLET
$0(Tier 3)
cvs spectravite advanced formula
$0(Tier 3)
cvs spectravite senior tablet 60mg; 0; 30mcg; 150mcg;
$0(Tier 3)
220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg;
400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg;
30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg;
55mcg; 1.5mg; 50unit; 2500unit; 11mg
cvs spectravite ultra health mens
$0(Tier 3)
CVS SPECTRAVITE ULTRA MENS HEALTH
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMEN
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMENS HEALTH
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMENS HEALTH
$0(Tier 3)
SENIOR TABLET 100MG; 0; 30MCG; 150MCG; 500MG;
5MG; 20MG; 72MG; 800UNIT; 50MCG; 0.5MG; 50MCG;
8MG; 400MCG; 300MCG; 50MG; 2.3MG; 14MG; 5MCG;
50MCG; 80MG; 150MCG; 5MG; 1.1MG; 2MG; 10MCG;
50MCG; 55MCG; 1.1MG; 35UNIT; 3500UNIT; 15MG
cvs spectravite ultra womens health senior tablet 100mg; 0; $0(Tier 3)
30mcg; 150mcg; 500mg; 5mg; 72mg; 800unit; 50mcg; 0.5mg;
50mcg; 8mg; 400mcg; 300mcg; 50mg; 2.3mg; 14mg; 5mcg;
20mg; 50mcg; 80mg; 150mcg; 5mg; 1.1mg; 2mg; 10mcg;
50mcg; 55mcg; 1.1mg; 35unit; 3500unit; 15mg
cvs stress formula/zinc
$0(Tier 3)
cvs super b complex/c tablet 150mg; 5mcg; 15mcg; 400mcg; $0(Tier 3)
25mg; 5.5mg; 2mg; 20mg; 150mg; 100mg
cvs vitamin a
$0(Tier 3)
cvs vitamin b-12 tr
$0(Tier 3)
cvs vitamin b-12 tablet 2000mcg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
94
What the drug
will cost you
Name of drug
(tier level)
cvs vitamin b-2
$0(Tier 3)
cvs vitamin b-6 tablet 100mg
$0(Tier 3)
cvs vitamin b12 tablet
$0(Tier 3)
cvs vitamin c/rose hips
$0(Tier 3)
CVS VITAMIN C TABLET CHEWABLE 1000MG
$0(Tier 3)
cvs vitamin c tablet 1000mg, 500mg, 500mg; 25mg; 14mg
$0(Tier 3)
cvs vitamin e capsule 1000unit, 400unit
$0(Tier 3)
cyanocobalamin injection 1000mcg/ml
$0(Tier 3)
daily multiple vitamin/iron tablet 3mcg; 250mg; 30mg; 2mg; $0(Tier 3)
0.5mg; 5mg; 75mg; 5mg
daily multiple vitamins/iron tablet 60mg; 6mcg; 400unit;
$0(Tier 3)
400mcg; 18mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 5000unit;
30unit
daily multiple vitamins/minerals tablet 60mg; 30mcg; 130mg; $0(Tier 3)
34mg; 10mcg; 2mg; 6mcg; 0.4mg; 150mcg; 18mg; 100mg;
2.5mg; 10mcg; 20mg; 10mg; 100mg; 37.5mg; 2mg; 1.7mg;
10mcg; 1.5mg; 5000unit; 400unit; 30unit; 15mg
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit;
$0(Tier 3)
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily multiple vitamin tablet 60mg; 0; 45mg; 10mg; 400unit; $0(Tier 3)
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
daily vitamins tablet 60mg; 400unit; 6mcg; 0.4mg; 20mg;
$0(Tier 3)
2mg; 1.7mg; 1.5mg; 5000unit
daily vite with iron
$0(Tier 3)
daily vite tablet 60mg; 10mg; 400unit; 6mcg; 20mg; 2mg;
$0(Tier 3)
1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 6mcg; 0.4mg; 20mg;
10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit
daily-vite/iron/beta-carotene
$0(Tier 3)
daily-vite tablet 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit
dialyvite 800 tablet
$0(Tier 3)
dino-life
$0(Tier 3)
dino-life w extra c
$0(Tier 3)
DINO-LIFE W/IRON & ZINC
$0(Tier 3)
DRISDOL CAPSULE
$0(Tier 3)
e 400 blended
$0(Tier 3)
e-400
$0(Tier 3)
ecee plus
$0(Tier 3)
eql one daily essential tablet 60mg; 0; 6mcg; 400mcg; 20mg; $0(Tier 3)
10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit
ergocalciferol solution
$0(Tier 3)
fe c tab
$0(Tier 3)
FOLBEE AR
$0(Tier 3)
FOLIC ACID INJECTION
$0(Tier 3)
folic acid tablet 1mg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
95
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
foltabs 800
FOLTANX
FORTAVIT CAPSULE
FOSFREE
fruity c
fruity chewables multivitamin
FULL SPECTRUM B/VITAMIN C
FUSION PLUS
gnp animal shapes plus extra c tablet chewable 0; 400unit;
4.5mcg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 250mg; 1.05mg;
15unit; 2500unit
gnp animal shapes plus iron tablet chewable 0; 400unit;
$0(Tier 3)
4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
gnp animal shapes tablet chewable 0; 400unit; 4.5mcg;
$0(Tier 3)
300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit;
2500unit
gnp b-50 balanced tablet 50mcg; 50mg; 50mcg; 400mcg;
$0(Tier 3)
50mg; 50mg; 50mg; 50mg
gnp century adults 50+ senior tablet 60mg; 0; 30mcg; 220mg; $0(Tier 3)
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
1.5mg; 50unit; 2500unit; 11mg
gnp century cardio healthformula tablet 90mg; 0; 30mcg;
$0(Tier 3)
40mg; 10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg;
400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg;
150mcg; 6mg; 3.4mg; 2mg; 150mcg; 10mcg; 75mcg; 70mcg;
10mcg; 3mg; 60unit; 5000unit; 15mg
gnp century ultimate mens complete
$0(Tier 3)
gnp century ultimate womens complete
$0(Tier 3)
gnp century ultimate womens senior formula
$0(Tier 3)
gnp century tablet 60mg; 0; 30mcg; 200mg; 10mg; 72mg;
$0(Tier 3)
400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
gnp hair/skin/nails tablet 60mg; 1250mcg; 0.5mg; 100mg;
$0(Tier 3)
100unit; 50mg; 30unit; 1mg; 100mcg; 50mg; 250mcg; 25mg;
50mg; 10mg; 50mg; 0.85mg; 0.75mg; 2500unit; 7.5mg
gnp mega multi for men
$0(Tier 3)
gnp mega multi for women
$0(Tier 3)
gnp niacin tr tablet extended release 250mg
$0(Tier 3)
gnp one daily maximum
$0(Tier 3)
gnp one daily mens health 50+
$0(Tier 3)
gnp one daily womens health 50+
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
96
What the drug
will cost you
Name of drug
(tier level)
gnp opti-vitamins tablet 200mg; 1000unit; 2mg; 2mg; 55mcg; $0(Tier 3)
60unit; 40mg
gnp therapeutic-m tablet 90mg; 0; 30mcg; 150mcg; 40mg;
$0(Tier 3)
10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg;
100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg;
6mg; 3.4mg; 2mg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg;
60unit; 5000unit; 15mg
gnp vitamin a capsule 8000unit
$0(Tier 3)
gnp vitamin b-12
$0(Tier 3)
gnp vitamin b-12 tr
$0(Tier 3)
gnp vitamin b-6 tablet 100mg
$0(Tier 3)
gnp vitamin c
$0(Tier 3)
gnp vitamin c tr
$0(Tier 3)
gnp vitamin c w/rose hips tr
$0(Tier 3)
gnp vitamin c w/rose hips tablet 500mg
$0(Tier 3)
gnp vitamin e
$0(Tier 3)
gnp zoochews gummies
$0(Tier 3)
hair vitamins tablet 200mcg; 200mg; 1000mg; 12mcg; 4mg; $0(Tier 3)
0.8mg; 250mg; 0.3mg; 10mg; 70mg; 60mg; 30mg
HARD NAILS
$0(Tier 3)
HONEY BEARS
$0(Tier 3)
HONEY BEARS W/IRON AND ZINC
$0(Tier 3)
ICAPS AREDS FORMULA
$0(Tier 3)
icaps mv
$0(Tier 3)
ICAPS PLUS
$0(Tier 3)
INTEGRA
$0(Tier 3)
iron 100/c
$0(Tier 3)
kp adults 50+ daily formula
$0(Tier 3)
kp adults daily formula
$0(Tier 3)
kp b complex/c
$0(Tier 3)
kp mens 50+ daily formula
$0(Tier 3)
kp vitamin e
$0(Tier 3)
kp womens daily formula
$0(Tier 3)
L-METHYL-B6-B12
$0(Tier 3)
L-METHYL-MC
$0(Tier 3)
LIFE PACK MENS
$0(Tier 3)
LIFE PACK WOMENS
$0(Tier 3)
little animals/iron
$0(Tier 3)
little animals tablet chewable 60mg; 4.5mcg; 0.3mg; 13.5mg; $0(Tier 3)
1.05mg; 1.2mg; 1.05mg; 2500unit; 400unit; 15unit
lysiplex plus liquid
$0(Tier 3)
medtycholl b complex
$0(Tier 3)
mega multiple w/chelated minerals
$0(Tier 3)
MEGA MULTIVITAMIN FOR MEN
$0(Tier 3)
MEGA MULTIVITAMIN FOR WOMEN
$0(Tier 3)
MEPHYTON
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
97
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
meribin
METAFOLBIC
multi-day vitamins
multi-delyn
MULTI-DELYN/IRON
multi-vitamin hp/minerals
multi-vitamin/minerals tablet 60mg; 160mg; 6mcg; 18mg;
0.4mg; 150mcg; 100mg; 20mg; 125mg; 2mg; 1.7mg; 1.2mg;
5000unit; 400unit; 15mg
multi-vitamins
$0(Tier 3)
multi-vitamin tablet 60mg; 0; 30mcg; 10mg; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
multilex
$0(Tier 3)
multilex-t&m tablet 150mg; 10mg; 400unit; 1mg; 7.5mcg;
$0(Tier 3)
15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg;
5.5unit; 10000unit; 1.5mg
multiple vitamins plain
$0(Tier 3)
multiple vitamins/iron tablet chewable 60mg; 4.5mcg;
$0(Tier 3)
400unit; 15mg; 0.3mg; 13.5mg; 1.04mg; 1.2mg; 1.05mg;
2500unit; 15unit
multiple vitamins tablet 60mg; 20mg; 8mcg; 1.7mg; 1.5mg; $0(Tier 3)
5000unit; 400unit; 30unit
my-vitalife
$0(Tier 3)
MYKIDZ IRON
$0(Tier 3)
natural mixed tocopherols
$0(Tier 3)
NEPHRO-VITE
$0(Tier 3)
NEPHRONEX LIQUID
$0(Tier 3)
niacin er capsule extended release 250mg
$0(Tier 3)
niacin er tablet extended release 500mg
$0(Tier 3)
niacin sr capsule extended release 250mg
$0(Tier 3)
niacin tr capsule extended release 250mg
$0(Tier 3)
niacin tr tablet extended release 250mg, 500mg
$0(Tier 3)
niacin capsule extended release 250mg
$0(Tier 3)
niacin tablet extended release 500mg
$0(Tier 3)
NO IRON MULTIPLE VITAMIN/MINERALS
$0(Tier 3)
NUTRICAP
$0(Tier 3)
NUTRIVIT
$0(Tier 3)
once daily/iron
$0(Tier 3)
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg; $0(Tier 3)
5000unit; 400unit
ONCOVITE
$0(Tier 3)
one daily mens tablet 90mg; 0; 30mcg; 210mg; 120mcg; 2mg; $0(Tier 3)
3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg;
1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit;
20mcg; 15mg
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
98
What the drug
will cost you
Name of drug
(tier level)
one daily plus iron tablet 60mg; 75mg; 10mg; 400unit; 6mcg; $0(Tier 3)
18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
one daily plus minerals tablet 50mg; 19mg; 400unit; 5mcg; $0(Tier 3)
1mcg; 150mcg; 4.5mg; 10mg; 1mg; 20mg; 1mg; 10mg; 1mg;
2.5mg; 5mcg; 2mg; 5000unit; 3.75mg
one daily tablet 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg; $0(Tier 3)
1.7mg; 1.5mg; 5000unit; 400unit; 30unit
one-daily multi vitamins
$0(Tier 3)
pa b-complex with b-12
$0(Tier 3)
pa biotin capsule
$0(Tier 3)
pa vitamin b-12 tr
$0(Tier 3)
pa vitamin e
$0(Tier 3)
PERIDIN-C
$0(Tier 3)
poly vitamin
$0(Tier 3)
poly-vita drops solution 35mg/ml; 400unit/ml; 2mcg/ml;
$0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
poly-vita/iron drops solution 35mg/ml; 400unit/ml; 10mg/ml; $0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
polyvitamin/iron tablet chewable
$0(Tier 3)
polyvitamin/iron solution 35mg/ml; 400unit/ml; 10mg/ml;
$0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
polyvitamin solution 35mg/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; $0(Tier 3)
0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml,
35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml
prevent
$0(Tier 3)
PROBARIMIN QT
$0(Tier 3)
PROTECTIRON
$0(Tier 3)
pyridoxine hcl tablet 100mg, 25mg, 50mg
$0(Tier 3)
qc childrens chewable vitamins/extra c
$0(Tier 3)
qc maximum daily multivitamin/multimineral
$0(Tier 3)
qc multi-vite
$0(Tier 3)
qc womens daily multivitamin
$0(Tier 3)
ra b-complex
$0(Tier 3)
ra b-complex with b-12
$0(Tier 3)
ra b-complex/vitamin c tr
$0(Tier 3)
ra balanced b-100
$0(Tier 3)
ra balanced b-50 tablet 50mcg; 50mg; 50mg; 50mcg;
$0(Tier 3)
400mcg; 50mcg; 50mg; 50mg; 50mg; 50mg; 50mg
ra beta carotene
$0(Tier 3)
ra biotin capsule
$0(Tier 3)
ra calcium soft chews
$0(Tier 3)
ra central-vite cardio
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
99
What the drug
will cost you
Name of drug
(tier level)
ra central-vite energy
$0(Tier 3)
ra central-vite performance tablet 120mg; 0; 40mcg; 60mcg; $0(Tier 3)
100mg; 10mg; 72mg; 400unit; 120mcg; 2mg; 18mcg; 18mg;
400mcg; 60mg; 50mg; 40mg; 4mg; 40mg; 5mcg; 48mg;
25mcg; 80mg; 150mcg; 6mg; 5.1mg; 4mg; 10mcg; 75mcg; 70mcg; 10mcg; 4.5mg; 60unit; 5000unit; 15mg
ra central-vite select mature
$0(Tier 3)
ra central-vite senior
$0(Tier 3)
RA CENTRAL-VITE UNDER 50 MENS
$0(Tier 3)
RA CENTRAL-VITE UNDER 50 WOMENS
$0(Tier 3)
ra central-vite womens mature
$0(Tier 3)
ra central-vite/antioxidants tablet 60mg; 0; 30mcg; 162mg; $0(Tier 3)
10mg; 72mg; 120mcg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg
ra central-vite tablet 60mg; 0; 30mcg; 200mg; 10mg; 20mg; $0(Tier 3)
72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;
2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
ra natural vitamin e
$0(Tier 3)
ra one daily energy formula
$0(Tier 3)
ra one daily essential
$0(Tier 3)
ra one daily maximum
$0(Tier 3)
ra one daily mens 50+ with vitamin d-3
$0(Tier 3)
ra one daily multi-vitamin plus iron tablet 60mg; 10mg;
$0(Tier 3)
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit
ra one daily multi-vitamin tablet 60mg; 0; 10mg; 400unit;
$0(Tier 3)
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
ra stress formula advanced
$0(Tier 3)
ra stress formula energy
$0(Tier 3)
ra therapeutic m plus beta carotene tablet 90mg; 0; 30mcg; $0(Tier 3)
40mg; 10mg; 31mg; 7.5mg; 400unit; 26mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 28mcg; 7.5mg;
150mcg; 3mg; 3.4mg; 32mcg; 21mcg; 3mg; 30unit; 5000unit; 15mg
ra vitamin a capsule 10000unit
$0(Tier 3)
ra vitamin b-1
$0(Tier 3)
ra vitamin b-12 tr tablet extended release 1000mcg
$0(Tier 3)
ra vitamin b-6 tablet 50mg
$0(Tier 3)
ra vitamin b12
$0(Tier 3)
ra vitamin c drops
$0(Tier 3)
ra vitamin c tr tablet extended release 1000mg; 25mg, 500mg $0(Tier 3)
ra vitamin c/acerola
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
100
What the drug
will cost you
Name of drug
(tier level)
ra vitamin c/rose hips
$0(Tier 3)
ra vitamin c/rose hips tr
$0(Tier 3)
ra vitamin c tablet chewable 500mg; 0
$0(Tier 3)
ra vitamin c tablet 250mg, 500mg
$0(Tier 3)
ra vitamin e capsule 1000unit, 200unit, 400unit
$0(Tier 3)
ra whole source complete formula for men
$0(Tier 3)
ra whole source dietary
$0(Tier 3)
ra whole source dietary for men
$0(Tier 3)
ra whole source dietary mature
$0(Tier 3)
rabano yodado
$0(Tier 3)
rena-vite
$0(Tier 3)
renal-vite
$0(Tier 3)
senior tabs
$0(Tier 3)
sentry senior tablet 60mg; 0; 30mcg; 150mcg; 220mg; 10mg; $0(Tier 3)
20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg;
50unit; 2500unit; 11mg
sentry tablet 90mg; 0; 30mcg; 150mcg; 200mg; 10mg;
$0(Tier 3)
109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg;
250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 25mcg;
80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
SIDEROL TABLET
$0(Tier 3)
SLO-NIACIN TABLET EXTENDED RELEASE 500MG
$0(Tier 3)
slo-niacin tablet extended release 250mg
$0(Tier 3)
sm balanced b-50
$0(Tier 3)
sm calcium soft chews tablet chewable 500mg; 200unit;
$0(Tier 3)
40mcg
sm chewable c
$0(Tier 3)
sm complete advanced formula
$0(Tier 3)
sm complete senior formula tablet 60mg; 0; 30mcg; 220mg; $0(Tier 3)
10mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg;
80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg;
55mcg; 1.5mg; 50unit; 2500unit; 11mg
sm complete tablet 120mg; 0; 40mcg; 100mg; 10mg; 72mg; $0(Tier 3)
120mcg; 2mg; 16mcg; 400unit; 18mg; 400mcg; 60mg; 40mg;
4mg; 40mg; 5mcg; 50mg; 48mg; 25mcg; 80mg; 150mcg;
6mg; 5.1mg; 4mg; 60mcg; 10mcg; 75mcg; 70mcg; 10mcg;
4.5mg; 60unit; 3500unit; 15mg
sm multiple vitamins essential
$0(Tier 3)
sm multiple vitamins/iron
$0(Tier 3)
sm super b complex-vitamin c
$0(Tier 3)
sm therapeutic-m
$0(Tier 3)
sm vit c/rose hips
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
101
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
sm vitamin b-1
sm vitamin b-12
sm vitamin b-6 tablet 100mg
sm vitamin c
sm vitamin c/rose hips
sm vitamin e
sm vitamin e blended
stress formula w/iron
stress formula/iron tablet 500mg; 45mcg; 12mcg; 27mg;
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit, 500mg;
45mcg; 12mcg; 400mcg; 27mg; 100mg; 20mg; 5mg; 10mg;
10mg; 30unit
stress formula/zinc tablet 500mg; 45mcg; 3mg; 12mcg;
$0(Tier 3)
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg,
600mg; 45mg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg;
10mg; 15mg; 30unit; 23.9mg
stress formula tablet 500mg; 45mcg; 12mcg; 400mcg; 100mg; $0(Tier 3)
20mg; 3mg; 10mg; 10mg; 30unit, 500mg; 45mcg; 12mcg;
400mcg; 100mg; 20mg; 5mg; 10mg; 10mg; 30unit, 500mg;
45mcg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg; 15mg;
30unit
STROVITE FORTE TABLET
$0(Tier 3)
STROVITE ONE
$0(Tier 3)
super b with c
$0(Tier 3)
super b-50 complex plus
$0(Tier 3)
super multiple tablet 150mg; 25mg; 25mg; 20mcg; 87mg;
$0(Tier 3)
26mg; 50mg; 150mg; 0.25mg; 100mcg; 50mg; 50mg;
100mcg; 25mg; 5mg; 250mcg; 10mg; 7.2mg; 6.1mg; 100mg;
25mg; 13.5mg; 0.13mg; 25mg; 25mg; 25mg; 25mg; 25unit;
10000unit; 400unit; 18mg
super thera vite m
$0(Tier 3)
superplex-t
$0(Tier 3)
SUPERVITE EC
$0(Tier 3)
SUPLEVIT
$0(Tier 3)
SUPPORT-500
$0(Tier 3)
SUPPORT LIQUID 10MCG/5ML; 0.8MG/5ML;
$0(Tier 3)
275MG/5ML; 0.5MG/5ML; 30MG/5ML; 2MG/5ML;
2MG/5ML; 8MG/5ML; 1500UNIT/5ML; 100UNIT/5ML;
7MG/5ML
tab-a-vite maximum
$0(Tier 3)
tab-a-vite w/beta carotene
$0(Tier 3)
TAB-A-VITE WOMENS
$0(Tier 3)
tab-a-vite/iron
$0(Tier 3)
tab-a-vite tablet 60mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; $0(Tier 3)
1.7mg; 0; 1.5mg; 5000unit
THERA M PLUS
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
102
What the drug
will cost you
Name of drug
(tier level)
THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG;
$0(Tier 3)
50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG; 100MG; 2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG; 150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG; 70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
thera-m tablet 90mg; 0; 30mcg; 150mcg; 40mg; 7.5mg;
$0(Tier 3)
26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg; 3.5mg;
32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg;
21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit; 30unit; 28mcg; 15mg
thera-tabs
$0(Tier 3)
THERA/BETA-CAROTENE
$0(Tier 3)
THERAPEUTIC LIQUID
$0(Tier 3)
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg; $0(Tier 3)
3.4mg; 3mg; 5000unit; 400unit; 30unit
theratrum complete tablet 60mg; 0; 30mcg; 150mcg; 162mg; $0(Tier 3)
10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;
150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg;
2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg;
30unit; 5000unit; 25mcg; 15mg
therems
$0(Tier 3)
THEREMS-H
$0(Tier 3)
THEREMS-M
$0(Tier 3)
thiamine hcl tablet 100mg
$0(Tier 3)
total b/c
$0(Tier 3)
totalday multiple
$0(Tier 3)
TRI-VI-SOL SOLUTION 35MG/ML; 400UNIT/ML;
$0(Tier 3)
750UNIT/ML
tri-vitamin solution 35mg/ml; 400unit/ml; 1500unit/ml
$0(Tier 3)
tri-vita solution 35mg/ml; 400unit/ml; 1500unit/ml
$0(Tier 3)
triphrocaps
$0(Tier 3)
ultra b-100 complex tablet 100mcg; 100mg; 100mcg;
$0(Tier 3)
100mcg; 400mcg; 100mcg; 100mg; 100mcg; 100mg; 100mg;
100mg
UNICOMPLEX-M TABLET 60MG; 60MG; 10MG;
$0(Tier 3)
400UNIT; 2MG; 6MCG; 18MG; 400MCG; 1MG; 20MG; 0;
45MG; 150MCG; 5MG; 2MG; 1.7MG; 0; 1.5MG; 30UNIT;
5000UNIT; 15MG
v-c forte
$0(Tier 3)
vic-forte
$0(Tier 3)
vita-bee/c tablet 300mg; 300mcg; 400mcg; 50mg; 10mg;
$0(Tier 3)
5mg; 10.2mg; 15mg
vitamin a palmitate water dispersible
$0(Tier 3)
vitamin a&d capsule 5000unit; 400unit
$0(Tier 3)
vitamin a capsule 10000unit, 8000unit
$0(Tier 3)
vitamin b complex-c
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
103
Name of drug
vitamin b complex tablet 10mg; 10mg; 0.2mg; 2mg; 1.5mg
vitamin b-12 tablet sublingual 2500mcg
vitamin b-12 tablet 1000mcg, 100mcg, 250mcg, 500mcg,
50mcg
vitamin b-1 tablet 100mg, 250mg, 50mg
vitamin b-2 tablet 100mg, 25mg
vitamin b-6 tablet 100mg, 25mg, 50mg
vitamin b12 tablet extended release 1000mcg
vitamin b12 tablet 500mcg
vitamin c sr capsule extended release
vitamin c tr capsule extended release
vitamin c tr tablet extended release 1500mg
vitamin c/rose hips tablet 1000mg, 500mg
VITAMIN C SYRUP 500MG/5ML
vitamin c syrup 500mg/5ml
VITAMIN C TABLET CHEWABLE 0; 500MG; 0; 0; 0; 0
vitamin c tablet chewable 250mg, 500mg
vitamin c tablet 1000mg, 250mg, 500mg
vitamin d capsule 50000unit
vitamin e water dispersible
vitamin e water soluble capsule 400unit
vitamin e/d-alpha capsule 400unit
vitamin e/dl-alpha capsule 1000unit, 400unit
vitamin e capsule
vitamin forte
VITAMIN K1 INJECTION 10MG/ML
vitamins & minerals
vitamins for hair tablet 400mcg; 100mg; 250mg; 2mg; 6mcg;
18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg
vol-care rx
VP-PNV-DHA
womens one daily
ZINC LOZENGE 100MG; 50MG; 500UNIT; 15MG
zoo friends
zoo friends plus iron
Unclassified
No Classification
ALBA-LYBE NR
balance b-50 tablet 50mcg; 50mg; 50mcg; 400mcg; 50mg;
50mg; 50mg; 50mg
calcitrate tablet 950mg
calcium carbonate/d3
CALCIUM/MAGNESIUM
calcium/vitamin d tablet 600mg; 400unit
calcium tablet 500mg
cvs b-12 liquid 1000mcg/15ml
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
104
Name of drug
cvs b-6
cvs calcium 600 + d/minerals
cvs calcium 600+d tablet 600mg; 800unit
CVS CALCIUM CHEWABLES 600PLUS
cvs iron tablet 27mg
cvs magnesium tablet 500mg
cvs slow release iron
cvs super b complex/c tablet 150mg; 5mcg; 100mg; 5.5mg;
15mcg; 400mcg; 25mg; 2mg; 20mg; 100mg
cvs vitamin b-12 tablet 1000mcg, 500mcg
cvs vitamin c tablet 500mg
ENFAMIL ENFALYTE SOLUTION 45MEQ/L; 33MEQ/L;
25MEQ/L; 50MEQ/L
fe c
FERIVA 21/7
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
gnp calcium tablet 600mg
gnp childrens chewables/extra c
gnp childrens chewables/iron
gnp essential one daily
gnp iron tablet extended release 45mg
gnp little ones childrens
gnp one daily plus iron
gnp vitamin c drops
hematron
HISTAFLEX
I.L.X. B-12
ICAR PEDIATRIC
ICAR-C
LORTUSS DM
LORTUSS EX
LORTUSS LQ
magnesium oxide tablet 420mg
MONOCAL
MUCINEX FAST-MAX DAY/NIGHT MAXIMUM
STRENGTH
NINJACOF
NINJACOF-A
ONE-WAY VALVED
EXPIRATORYMOUTHPIECE/DISPOSABLE
ONE-WAY VALVED INSPIRATORY
MOUTHPIECE/DISPOSABLE
OS-CAL ULTRA
oyst-cal
oyster shell
POLY-HIST DM
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
105
Name of drug
POLY-VENT DM
POLY-VENT IR
PROFERRIN ES
pyridoxine hcl tablet 25mg
RA CALCIUM/BORON
ra calcium/magnesium/zinc/copper
ra coral calcium
ra natural magnesium
ra niacin tablet 500mg
RA OYSTER SHELL CALCIUM/VITAMIN D TABLET
125UNIT; 250MG
ra pediatric electrolyte solution 35meq/l; 25gm/l; 20meq/l;
45meq/l; 7.8mg/l
ra selenium natural
ra slow release iron tablet extended release 45mg
ra vitamin b-12
ra vitamin b-6 tablet 100mg
RISACAL-D
STAHIST AD
super b complex/c
vitamin b12 tablet 100mcg, 500mcg
vitamin c syrup 500mg/5ml
wee care
Z-BUM
zinc chelated
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9
106
Index Drug Name
12 hour decongestant
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
ABANEU-SL
ABELCET
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acephen
ACEROLA C 500
aceta-gesic
acetaminophen
acetaminophen/codeine
acetaminophen/diphenhydramine
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
acid gone
acid reducer maximum strength
ACNE MEDICATION 10
acne medication 5
ACTHIB
actical
actidose/sorbitol
ACTIMMUNE
ACTIVE FE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
ADCIRCA
adefovir dipivoxil
ADEMPAS
ADRENACLICK
adriamycin
adrucil
ADVAIR DISKUS
ADVAIR HFA
advanced stress formula/zinc
afeditab cr
Page #
77
39
39
39
91
25
35
29
14
41
47
11
91
73
11
13
73
72
50
72
50
72
77
56
57
53
54
67
91
56
67
82
40
40
67
55
54
77
37
77
75
29
28
72
72
91
48
107
Drug Name
AFINITOR
AFINITOR DISPERZ
A-HYDROCORT
akwa tears
alagesic lq
ALAHIST DM
ALA-HIST IR
ALA-HIST PE
ALBA-LYBE NR
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
alcohol prep pads
ALDURAZYME
ALECENSA
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all day allergy
all day allergy childrens
all day allergy-d
all day pain relief
all day relief
aller-chlor
allergy
allergy relief
allergy relief child
allergy relief d-24
all-nite multi-symptom cold/flu relief
allopurinol
allopurinol sodium
allzital
almacone
almacone double strength
ALOPRIM
ALORA
alosetron hydrochloride
ALPHAGAN P
alprazolam
alprazolam intensol
ALUMINUM HYDROXIDE
amantadine hcl
AMBISOME
amcinonide
amifostine
amikacin sulfate
amiloride hcl
Page #
31
31
60
70
11
77
73
73
104
33
75
75
60
15
55
31
69
59
28
33
27
73
73
73
11
11
73
73
73
73
73
77
26
26
11
56
56
26
62
57
72
40
40
56
40
25
60
29
15
50
Drug Name
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
AMMONIUM CHLORIDE
ammonium lactate
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
amphotericin b
ampicillin
ampicillin sodium
ampicillin-sulbactam
AMPYRA
ANADROL-50
anagrelide hydrochloride
anastrozole
ANDRODERM
animal shapes
animal shapes + iron
antacid calcium extra st rength
antacid calcium regular strength
antacid extra strength
antacid maximum strength
antacid plus anti-gas relief
anti-diarrheal
antifungal
anti-fungal powder
anti-nausea
antioxidant formula
anu-med
APATATE FORTE
APETEX
APETIGEN
Page #
50
76
82
82
83
82
83
83
83
83
47
57
24
48
48
48
48
83
54
24
17
17
17
52
25
17
17
17
53
62
44
31
62
91
91
56
56
56
56
56
56
25
25
24
91
54
91
91
91
108
Drug Name
APETIGEN-PLUS
ap-hist dm
APIDRA
APIDRA SOLOSTAR
APOKYN
aprepitant
apri
aprodine
APTIOM
APTIVUS
AQUADEKS
AQUASOL E
aqueous vitamin d infants
aqueous vitamin e
ARALAST NP
aranelle
ARANESP ALBUMIN FREE
ARCALYST
aripiprazole
aripiprazole odt
ARISTADA
ARRANON
artificial tears
ascomp/codeine
ASCORBIC ACID
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspirin
aspirin adult low strength
aspirin ec
aspirin ec low dose
aspirin low dose
aspirin/dipyridamole
aspir-low
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone dipropionate
Page #
91
77
43
43
34
24
62
77
19
39
91
91
91
91
77
62
44
67
35
35
35
28
70
13
91
72
72
72
72
11
11
11
11
11
45
11
47
47
51
34
34
40
55
75
53
62
60
Drug Name
AVASTIN
AVELOX
aviane
AVONEX
AVONEX PEN
azacitidine
AZACTAM IN ISO-OSMOTIC
DEXTROSE
AZASAN
AZASITE
azathioprine
azelastine hcl
AZILECT
azithromycin
aztreonam
b complex
B COMPLEX/FOLIC ACID
b-6
baby darlings pediatric electrolyte
baciim
BACITRACIN
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BACMIN
BACTOCILL IN DEXTROSE
balance b-100
balance b-50
balance b-50
balanced b-100
balanced b-50
balsalazide disodium
balziva
banophen
BANZEL
BARACLUDE
bcg vaccine
b-complex
b-complex formula 1
b-complex natural
b-complex plus vitamin c
b-complex w/c
b-complex with b-12
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
Page #
33
18
62
53
53
29
17
66
18
66
73
35
18
17
91
91
91
83
15
16
16
16
71
37
92
17
92
104
92
92
92
68
62
73
21
37
67
92
91
91
92
92
92
69
69
69
109
Drug Name
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
bd insulin syringe/detachable
needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM
bd pen needles short/ultrafine/31g x 5/16"
bee zee
bekyree
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENICAR
BENICAR HCT
BENLYSTA
benzonatate
BENZOYL PEROXIDE
benztropine mesylate
beta carotene
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
betaxolol hcl
bethanechol chloride
bexarotene
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
BICNU
BIDIL
BIOCAL
BIOSUPP
biotin
BIOVOL
bisacodyl ec
biscolax
bismatrol
bismatrol maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
blisovi fe 1.5/30
blue gel
BOOSTRIX
BOSULIF
Page #
69
69
69
70
70
70
70
92
62
29
47
46
46
46
66
77
54
34
92
60
60
53
48
72
59
33
67
28
18
18
27
52
92
92
92
92
57
57
56
56
48
48
29
62
54
67
31
Drug Name
BOTOX
BOTOX
b-plex plus
BRILINTA
brimonidine tartrate
BRIVIACT
bromfed dm
bromocriptine mesylate
bromphen/pseudoephedrine
hcl/dextromethorphan hbr
brotapp
BROTAPP DM
budesonide
budesonide
bumetanide
BUPHENYL
buprenorphine hcl
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYETTA
c 1000/bioflavonoids/rosehips
c 250
c 500/rose hips
c complex
c-500
cabergoline
CABOMETYX
CALCET CREAMY BITES
CALCET PETITES
CALCI-CHEW
calcipotriene
calcitonin-salmon
calcitrate
calcitrate
calcitriol
calcium
calcium
CALCIUM & MAGNESIUM
calcium + d3
calcium 250+d
Page #
26
70
92
45
72
19
77
34
77
73
77
60
72
50
55
14
15
22
15
22
22
40
27
11
11
11
11
13
41
92
92
92
92
92
65
31
83
83
83
54
69
104
83
69
104
84
92
83
83
110
Drug Name
calcium 500/d
calcium 600
calcium 600 + d
calcium 600 with vitamin d
calcium 600/vitamin d3
calcium 600+d
calcium 600-d
calcium acetate
calcium antacid
calcium antacid extra strength
calcium carbonate
calcium carbonate
calcium carbonate/d3
calcium carbonate/vitamin d
CALCIUM CITRATE
MALATE/VITAMIN D
CALCIUM CITRATE W/D
calcium citrate/vitamin d
calcium citrate+d
CALCIUM GLUCONATE
calcium high potency
calcium high potency + vitamin d
calcium oyster shell
CALCIUM/MAGNESIUM
calcium/magnesium/zinc
calcium/vitamin d
calcium/vitamin d
calcium/vitamin d3
cal-gest antacid
CALTRATE 600+D
CALTRATE 600+D PLUS MINERALS
CALTRATE 600+D3 SOFT CHEWS
calvite p&d
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
CARBAGLU
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
Page #
83
84
83
84
84
84
84
60
56
56
56
84
104
84
84
84
84
84
84
84
84
84
104
84
104
84
84
56
84
84
84
84
64
29
25
46
46
27
31
47
47
82
21
21
21
34
34
34
29
Drug Name
CARIMUNE NANOFILTERED
CARNITOR
carteolol hcl
cartia xt
carvedilol
CAYSTON
caziant
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT INTRAVENOUS
CELONTIN
centamin
CENTRATEX
CENTRUM
CENTRUM ADULTS
centrum kids complete
CENTRUM PERFORMANCE
CENTRUM SILVER
CENTRUM SILVER ADULT 50+
CENTRUM SILVER ULTRA WOMENS
CENTRUM SPECIALIST HEART
CENTRUM ULTRA MENS
cephalexin
CEREBYX
CEREFOLIN
CEREZYME
CEROVITE ADVANCED FORMULA
cerovite jr
CERTAVITE SENIOR/ANTIOXIDANT
NUTRIENTS
certavite/antioxidants
CERVARIX
cetirizine hcl
cetirizine hcl allergy childrens
cetirizine hcl childrens allergy
cetirizine hcl/pseudoephedrine hcl er
CHANTIX
CHANTIX CONTINUING MONTH PAK
Page #
67
70
72
48
48
76
62
17
17
17
17
17
17
17
17
17
17
17
17
17
17
66
19
92
84
93
92
92
55
92
92
92
93
93
17
21
93
55
93
93
93
93
67
73
73
73
73
15
15
111
Drug Name
CHANTIX STARTING MONTH PAK
CHEMET
cheratussin ac
cheratussin dac
chest congestion relief
chest congestion relief pe
chewable antacid
CHEWABLE CALCIUM
chewable vite childrens
chewable vite with iron/childrens
childrens allergy
childrens aspirin
childrens chewable vitamin
childrens chewable vitamins
childrens chewable vitamins/iron
childrens ibuprofen
childrens loratadine
childrens mapap rapid tabs
childrens silfedrine
childs ibuprofen
CHLO TUSS
CHLO TUSS EX
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpheniramine maleate
chlorpromazine hcl
chlorthalidone
chlorzoxazone
cholestyramine light
chorionic gonadotropin
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
cimetidine
cimetidine hcl
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
citrus calcium +d
Page #
15
82
77
77
77
77
56
84
93
93
73
11
93
93
93
12
73
11
77
12
78
77
16
24
53
53
34
50
50
73
35
50
81
51
61
25
25
37
45
57
57
66
72
18
18
18
29
23
84
Drug Name
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
CLIMARA PRO
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clobetasol propionate
clobetasol propionate e
clodan
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole anti-fungal
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
COATS ALOE CREME
COATS ALOE GELLY
COATS ALOE LINIMENT
Page #
28
17
54
18
18
16
16
62
16
16
16
16
16
54
84
84
84
84
84
84
84
84
84
84
84
84
84
84
84
84
60
60
60
28
24
20
20
45
45
45
40
25
25
54
37
37
34
54
54
54
112
Drug Name
COATS ALOE MOISTURIZING LOTION
codeine/guaifenesin
colchicine
COLCRYS
cold/cough dm childrens
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
compete
COMPLERA
complete
complete allergy medicine
complex b-100
compro
constulose
CORAL CALCIUM
cortisone acetate
corvita
CORVITE
CORVITE 150
CORVITE FE
corvite free
COSMEGEN
COTELLIC
cough dm
cough syrup
COUMADIN
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cvs b complex plus c
cvs b-1
cvs b-12
cvs b-12
cvs b-6
cvs balanced b-100
cvs balanced b-50
cvs beta carotene
cvs biotin
cvs biotin high potency
cvs calcium
cvs calcium 600 & vitamind3
cvs calcium 600 + d/minerals
Page #
54
78
26
26
78
51
16
70
75
31
93
38
93
73
93
35
57
84
60
91
91
93
93
93
29
29
78
78
44
55
39
56
71
76
62
16
54
93
93
104
93
105
93
93
93
93
93
85
85
105
Drug Name
cvs calcium 600+d
cvs calcium 600+d
cvs calcium carbonate
CVS CALCIUM CHEWABLES 600PLUS
cvs calcium citrate + d
cvs calcium citrate +d
cvs calcium citrate+d/magnesium
cvs calcium/magnesium/zinc
cvs childrens chewable complete
cvs childrens chewable multivitamin/iron
cvs daily energy
cvs daily multiple
cvs daily multiple for men
cvs daily multiple for men 50+
cvs daily multiple for women
cvs daily multiple for women 50+
cvs daily multiple plus iron/calcium/zinc
cvs e oil
cvs e oil
cvs electrolyte solution
cvs gummy dinos
cvs hair skin & nails/an tioxidants
CVS HAIR/SKIN/NAILS
cvs iron
cvs iron
cvs laxative dietary supplement
cvs magnesium
cvs magnesium
cvs pediatric electrolyte
cvs pediatric electrolyte freezer pops
cvs selenium
cvs slow release iron
CVS SPECTRAVITE ADULT 50+
cvs spectravite advanced formula
cvs spectravite senior
cvs spectravite ultra health mens
CVS SPECTRAVITE ULTRA MENS
HEALTH
CVS SPECTRAVITE ULTRA WOMEN
CVS SPECTRAVITE ULTRA WOMENS
HEALTH
CVS SPECTRAVITE ULTRA WOMENS
HEALTH SENIOR
cvs stress formula/zinc
cvs super b complex/c
cvs super b complex/c
cvs vitamin a
cvs vitamin b12
cvs vitamin b-12
cvs vitamin b-12
Page #
105
85
85
105
85
85
85
85
94
94
94
94
94
94
94
94
94
54
94
85
94
94
94
105
85
57
105
85
85
85
85
105
94
94
94
94
94
94
94
94
94
105
94
94
95
105
94
113
Drug Name
cvs vitamin b-12 tr
cvs vitamin b-2
cvs vitamin b-6
cvs vitamin c
CVS VITAMIN C
cvs vitamin c/rose hips
cvs vitamin e
cvs zinc
cyanocobalamin
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYRAMZA
CYSTADANE
CYSTAGON
CYSTARAN
cytarabine aqueous
CYTOMEL
dacarbazine
DACOGEN
daily multiple vitamin
daily multiple vitamin/iron
daily multiple vitamins
daily multiple vitamins/iron
daily multiple vitamins/minerals
daily vitamins
daily vite
daily vite with iron
daily-vite
daily-vite/iron/beta-carotene
DALIRESP
DALLERGY
danazol
dantrolene sodium
DAPSONE
DAPTACEL
daptomycin
DARAPRIM
darifenacin hydrobromide er
DARZALEX
daunorubicin hcl
DAY TIME MULTI-SYMPTOM
COLD/FLU RELIEF
deblitane
decitabine
DECONEX DMX
Page #
94
95
95
105
95
95
95
85
95
62
81
27
41
66
66
73
33
55
55
71
28
65
27
29
95
95
95
95
95
95
95
95
95
95
77
73
62
37
27
67
16
34
59
33
29
78
64
29
78
Drug Name
DECONEX IR
deep sea nasal spray
DELSYM
delsym cough + chest congestion dm
delsym cough + chest congestion dm
childrens
delsym cough + cold daytime
delsym cough + cold nighttime
delsym cough + cold nighttime childrens
delyla
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
DESCOVY
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexrazoxane
dextroamphetamine sulfate
dextromethorphan polistirex
DEXTROSE 10%/NACL 0.45%
dextrose 10%
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dialyvite 800
DIALYVITE 800/IRON
diazepam
diazepam
diazepam intensol
dibucaine
diclofenac potassium
diclofenac sodium
Page #
78
78
78
78
78
78
78
78
62
68
19
49
40
82
62
60
64
39
24
61
62
60
60
23
60
60
71
29
52
78
85
85
85
85
85
85
85
85
85
85
85
95
85
20
40
40
54
12
54
114
Drug Name
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
diltiazem cd
diltiazem hcl
diltiazem hcl er
dilt-xr
dimaphen childrens
dimaphen dm cold & cough
dimaphen dm cold/cough childrens
dimenhydrinate
dino-life
dino-life w extra c
DINO-LIFE W/IRON & ZINC
diocto
DIPENTUM
diphenhist
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
DOCETAXEL
docqlace
doc-q-lax
docu
docusate sodium & senna stimulant
laxative/stool softener
DOCUSOL KIDS
DOCUSOL PLUS MINI-ENEMA
dofetilide
dok
dok plus
donepezil hcl
Page #
71
12
12
18
55
39
12
49
49
27
21
21
21
48
48
48
48
73
78
78
24
95
95
95
56
68
73
73
56
67
45
47
14
20
20
20
29
29
57
57
56
57
56
58
47
58
58
22
Drug Name
dorzolamide hcl
dorzolamide hcl/timolol maleate
doxazosin
doxazosin mesylate
doxepin hcl
doxercalciferol
doxorubicin hcl
doxorubicin hcl liposome
doxy 100
doxycycline hyclate
doxycycline monohydrate
DR SMITHS DIAPER
DR SMITHS DIAPER RASH SPRAY
DR SMITHS RASH + SKIN
DRISDOL
dronabinol
drospirenone/ethinyl estradiol
DROXIA
DULERA
duloxetine hcl
DUOFER
DURAFLU
duramorph
DUREZOL
dutasteride
DYRENIUM
e 400 blended
e.e.s. 400
e.e.s. granules
e-400
ear drops earwax removal aid
earwax treatment drops
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
ecee plus
econazole nitrate
ED A-HIST
ed a-hist
ED A-HIST DM
ed a-hist pse
ED BRON GP
ED CHLORPED
ED CHLORPED D
ed chlorped jr
ed-apap
ed-chlortan
EDURANT
effervescent pain relief
EFFIENT
ELAPRASE
Page #
72
72
59
59
24
69
29
29
19
19
19
54
54
54
95
25
63
28
72
23
85
78
13
71
59
50
95
18
18
95
72
72
70
70
95
25
74
78
78
78
78
74
74
74
11
74
38
12
45
55
115
Drug Name
ELDEPRYL
ELELYSO
ELIDEL
ELIGARD
ELIPHOS
ELITEK
ELIXOPHYLLIN
ELLENCE
ELMIRON
EMCYT
EMEND
EMPLICITI
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
ENBREL SURECLICK
endacof-dm
endocet
enema ready-to-use
ENEMEEZ MINI
ENEMEEZ PLUS
ENFAMIL ENFALYTE
ENFAMIL ENFALYTE
ENGERIX-B
ENLYTE
enoxaparin sodium
enpresse-28
entacapone
entecavir
enteric coated aspirin
enulose
ENVARSUS XR
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
eql one daily essential
eql pediatric electrolyte
ERBITUX
ergocalciferol
ergoloid mesylates
ERGOMAR
Page #
35
55
54
65
60
28
77
29
59
28
25
33
23
39
47
47
66
66
78
13
58
56
58
105
85
68
85
44
63
34
37
12
58
66
76
76
76
29
21
37
50
45
46
39
95
85
33
95
22
27
Drug Name
ERIVEDGE
errin
ERWINAZE
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
erythromycin/benzoyl peroxide
ESBRIET
escitalopram oxalate
esomeprazole magnesium
esomeprazole sodium
ESTRACE
estradiol
estradiol valerate
estropipate
ethambutol hcl
ethosuximide
ethynodiol diacetate/ethinyl estradiol
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
etoposide
EVISTA
EVOTAZ
exel comfort point insulin pen needles 31g x
8mm
exemestane
EXJADE
extra action cough
eye drops
ezetimibe
ezfe 200
FABRAZYME
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FARESTON
FARXIGA
FARYDAK
FASLODEX
FAZACLO
fe c
Page #
31
64
29
18
18
18
18
18
18
18
54
78
23
58
58
63
63
63
63
27
19
63
69
12
12
31
31
65
39
70
31
82
78
71
46
85
55
63
40
57
57
35
35
28
41
31
28
37
105
116
Drug Name
fe c tab
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenofibric acid
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
ferate
FERGON
FER-IN-SOL
fer-iron
FERIVA 21/7
FERIVAFA
ferosul
FERRALET 90
FERRAPLUS 90
FERRETTS
FERRETTS IPS
ferrex 150
FERREX 150 FORTE
ferric x-150
FERRIMIN 150
FERRIPROX
ferrocite
ferrous drops
ferrous fumarate 324
FERROUS GLUCONATE
FERROUS SULFATE
ferrousul
FETZIMA
FETZIMA TITRATION PACK
fexofenadine hcl
fexofenadine hcl childrens allergy
fiber laxative
fiber tabs
fiber-lax
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
FLEET PEDIATRIC
FLOVENT DISKUS
FLOVENT HFA
FLOWTUSS
fluconazole
fluconazole in nacl
flucytosine
Page #
95
20
48
50
50
51
12
13
13
85
85
85
85
105
85
85
85
85
85
85
85
85
85
86
70
86
86
86
86
86
86
23
23
74
74
58
58
58
59
66
65
59
47
58
72
72
78
25
25
25
Drug Name
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorometholone
fluorouracil
fluorouracil
fluoxetine hcl
fluphenazine decanoate
FLUPHENAZINE HCL
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvastatin
fluvastatin sodium er
fluvoxamine maleate
FOCALGIN DSS
FOLBEE AR
FOLIC ACID
FOLITAB 500
FOLOTYN
foltabs 800
FOLTANX
FONDAPARINUX SODIUM
formula em
FORTAVIT
FORTAZ
FORTEO
fortical
FOSFREE
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC 6.9%
FRESHKOTE
fruity c
fruity chewables multivitamin
FULL SPECTRUM B/VITAMIN C
FUNGOID TINCTURE
furosemide
FUSILEV
FUSION PLUS
FUZEON
Page #
29
60
73
60
60
60
71
29
54
23
35
35
81
12
71
28
60
73
51
51
23
86
95
95
86
29
96
96
44
24
96
17
69
69
96
47
47
21
60
44
86
71
96
96
96
26
50
29
96
39
117
Drug Name
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
galantamine hydrobromide er
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
gas relief
gas relief extra strength
gas relief maximum strength
GATTEX
gavilyte-c
gavilyte-g
gavilyte-h
gavilyte-n/flavor pack
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate/0.9% sodium chloride
GENVOYA
GEODON
gildess 1.5/30
GILENYA
GILOTRIF
glatopa
GLEOSTINE
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glyburide
glyburide micronized
glyburide/metformin hcl
glycopyrrolate
gnp all day allergy
gnp allergy
gnp animal shapes
gnp animal shapes plus extra c
gnp animal shapes plus iron
gnp antacid anti-gas
gnp arthritis pain relief
Page #
19
20
20
22
22
67
67
67
37
68
68
56
56
56
56
58
58
56
58
29
51
58
66
15
15
15
38
35
63
53
29
53
27
41
41
41
41
43
43
41
41
41
55
74
74
96
96
96
56
11
Drug Name
gnp b-50 balanced
gnp calcium
gnp calcium
gnp calcium 1200
gnp calcium 500 +d3
gnp calcium 500 +d3
gnp calcium 500/d
gnp calcium 600/d
gnp calcium citrate +d3
gnp calcium citrate+d maximum
gnp calcium/magnesium/zinc
gnp calcuim/vitamin d/minerals
gnp century
gnp century adults 50+ senior
gnp century cardio healthformula
gnp century ultimate mens complete
gnp century ultimate womens complete
gnp century ultimate womens senior formula
gnp childrens chewables/extra c
gnp childrens chewables/iron
gnp dayhist allergy
gnp enema
gnp essential one daily
gnp hair/skin/nails
gnp ibuprofen
gnp ibuprofen junior strength
gnp iron
gnp iron
gnp little ones childrens
gnp loratadine
gnp loratadine-d 24 hour
gnp magnesium
gnp masanti maximum strength
gnp masanti regular strength
gnp mega multi for men
gnp mega multi for women
gnp niacin tr
GNP OMEPRAZOLE
gnp one daily maximum
gnp one daily mens health 50+
gnp one daily plus iron
gnp one daily womens health 50+
gnp opti-vitamins
gnp pediatric electrolyte
gnp therapeutic-m
gnp tussin
gnp tussin dm
gnp vitamin a
gnp vitamin b-12
gnp vitamin b-12 tr
Page #
96
105
86
86
105
86
86
86
86
86
86
86
96
96
96
96
96
96
105
105
74
58
105
96
12
12
105
86
105
74
74
86
56
56
96
96
96
58
96
96
105
96
97
86
97
78
78
97
97
97
118
Drug Name
gnp vitamin b-6
gnp vitamin c
gnp vitamin c drops
gnp vitamin c tr
gnp vitamin c w/rose hips
gnp vitamin c w/rose hips tr
gnp vitamin e
gnp zinc
gnp zoochews gummies
goodsense ibuprofen
goodsense ibuprofen childrens
goodsense ibuprofen infants
goodsense ibuprofen junior strength
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guaifenesin ac
guaifenesin and pseudoephedrine
hydrochloride
guaifenesin er
guaifenesin/codeine
guanfacine er
guanfacine hcl
GUANIDINE HCL
hair vitamins
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HARD NAILS
HARVONI
HAVRIX
heartburn treatment 24 hour
hematron
HEMOCYTE
HEMOCYTE PLUS
hemocyte-f
hemorrhoidal
heparin sodium
heparin sodium/d5w
hepatamine
HERCEPTIN
HETLIOZ
HEXALEN
HIBERIX
HISTAFLEX
Page #
97
97
105
97
97
97
97
86
97
12
12
12
12
11
11
25
45
26
26
78
78
78
78
52
45
27
97
29
60
35
35
35
97
38
68
59
105
86
86
86
54
44
44
86
33
53
28
68
105
Drug Name
HISTEX
HISTEX PD
HISTEX-DM
HISTEX-PE
hm pediatric electrolyte
HONEY BEARS
HONEY BEARS W/IRON AND ZINC
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
HUMULIN R U-500 KWIKPEN
HYCOFENIX
hydralazine hcl
hydro skin maximum strength
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone bitartrate/chlorpheniramine
maleate/pse
hydrocodone bitartrate/homatropine
methylbromide
hydrocodone polistirex/chlorpheniramine
polistirex
hydrocodone/acetaminophen
hydrocodone/homatropine
hydrocodone/ibuprofen
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone/acetic acid
hydrocortisone/aloe
hydromet
hydromorphone hcl
hydroskin
hydroxychloroquine sulfate
hydroxyprogesterone caproate
hydroxyurea
Page #
74
74
78
78
86
97
97
43
43
43
43
43
43
66
66
66
66
43
43
43
43
43
43
43
78
52
60
50
13
78
78
78
13
78
13
60
60
60
72
60
78
13
60
34
64
29
119
Drug Name
hydroxyzine hcl
hydroxyzine pamoate
I.L.X. B-12
ibandronate sodium
IBRANCE
ibu-200
ibu-drops
ibu-drops infants
ibuprofen
ibuprofen childrens
ICAPS AREDS FORMULA
icaps mv
ICAPS PLUS
ICAR PEDIATRIC
ICAR-C
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
iferex 150
iferex 150 forte
IFEX
ifosfamide
ILARIS
imatinib mesylate
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMITREX STATDOSE REFILL
IMOVAX RABIES (H.D.C.V.)
INCRELEX
indapamide
indomethacin
indomethacin er
INFANRIX
infants gas relief
infants ibuprofen
infants simethicone
INLYTA
insupen ultrafin 31gx8mm
INTEGRA
INTEGRA F
INTEGRA PLUS
INTELENCE
INTRALIPID
INTRON A
INTRON A W/DILUENT
introvale
Page #
74
74
105
69
29
12
12
12
12
12
97
97
97
105
105
32
29
29
86
86
28
28
67
32
32
17
24
24
54
27
27
68
61
50
12
12
68
56
12
56
32
70
97
86
86
38
70
37
37
63
Drug Name
INTUNIV
INVANZ
INVEGA SUSTENNA
INVEGA TRINZA
INVIRASE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iophen c-nr
iophen dm-nr
iophen-nr
IOSAT
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
IRESSA
irinotecan
iron
iron 100/c
iron supplement childrens
IROSPAN 24/6
ISENTRESS
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
isoniazid
ISOPTO TEARS
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTODAX
ISTODAX (OVERFILL)
itraconazole
ivermectin
IXIARO
IXINITY
JAKAFI
jantoven
JANUVIA
JENTADUETO
JENTADUETO XR
JEVTANA
J-MAX
jolivette
J-TAN D PD
J-TAN PD
juleber
junel 1.5/30
Page #
52
17
36
36
39
86
86
78
79
79
70
68
75
75
46
46
32
29
86
97
86
87
38
87
87
27
71
52
52
52
52
15
30
30
26
33
68
45
32
44
42
42
42
30
79
64
74
74
63
63
120
Drug Name
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
junior mapap
JUXTAPID
KADCYLA
KALETRA
KALYDECO
kao-tin
kao-tin
kariva
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelnor 1/35
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
KEYTRUDA
kidkare cough/cold
kimidess
KINERET
KINRIX
kionex
KISQALI
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
KOMBIGLYZE XR
KORLYM
kp adults 50+ daily formula
kp adults daily formula
kp b complex/c
kp ferrous gluconate
kp ferrous sulfate
kp mens 50+ daily formula
kp vitamin e
kp womens daily formula
KUVAN
KYNAMRO
Page #
63
63
63
63
11
51
33
39
76
56
58
63
87
87
87
87
87
87
63
53
18
26
12
12
12
71
33
79
63
67
68
82
30
87
87
87
87
87
42
62
97
97
97
87
87
97
97
97
55
51
Drug Name
KYPROLIS
labetalol hcl
lactated ringers irrigation
lactated ringers viaflex
lactulose
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
lamotrigine odt
LANOXIN
lansoprazole
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
LARTRUVO
latanoprost
LATUDA
laxative
LAZANDA
leena
leflunomide
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
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol
levalbuterol hcl
levalbuterol tartrate hfa
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levoleucovorin calcium
levonorgestrel
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
Page #
31
48
70
87
58
37
39
39
20
20
49
59
43
43
63
30
70
36
58
14
63
67
32
32
32
32
32
32
63
77
31
30
28
45
65
76
76
76
43
44
19
72
70
74
19
19
30
64
63
63
121
Drug Name
levorphanol tartrate
levothyroxine sodium
levoxyl
LEXIVA
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
LIFE PACK MENS
LIFE PACK WOMENS
LINCOCIN
lincomycin hcl
linezolid
liothyronine sodium
liquid calcium/vitamin d
liquitears
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
lithium carbonate er
LITHOBID
little animals
little animals/iron
L-METHYL-B6-B12
L-METHYL-MC
LODRANE D
LOHIST-D
LOHIST-DM
LONSURF
loperamide hcl
lopinavir/ritonavir
loratadine
loratadine childrens
loratadine hives relief
loratadine-d 12hr
loratadine-d 24hr
lorazepam
LORAZEPAM INTENSOL
LORTUSS DM
LORTUSS EX
LORTUSS LQ
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
lovastatin
low-ogestrel
loxapine succinate
Page #
13
65
65
39
14
14
14
14
14
97
97
16
16
16
65
87
71
47
47
70
41
41
41
41
97
97
97
97
74
74
79
29
56
39
74
74
74
74
74
40
40
105
105
105
46
46
71
51
63
35
Drug Name
lubricating plus eye drops
lubrifresh p.m.
LUMIGAN
LUMIZYME
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT-PED (1-MONTH)
lutera
LYNPARZA
LYRICA
lysiplex plus
LYSODREN
lyza
magnesium
magnesium
magnesium 27
MAGNESIUM ELEMENTAL
MAGNESIUM GLUCONATE
magnesium oxide
magnesium oxide
magnesium sulfate
MAG-TAB SR
major-prep hemorrhoidal
malathion
mapap
mapap acetaminophen extrastrength
mapap arthritis pain
mapap childrens
mapap cold formula multi-symptom
mapap pm
mapap sinus maximum strength congestion
and pain
maprotiline hcl
marlissa
MARPLAN
MATULANE
matzim la
meclizine hcl
meclofenamate sodium
medicated body powder
medroxyprogesterone acetate
medtycholl b complex
mefloquine hcl
mega multiple w/chelated minerals
MEGA MULTIVITAMIN FOR MEN
MEGA MULTIVITAMIN FOR WOMEN
megestrol acetate
MEKINIST
meloxicam
Page #
71
71
70
55
65
66
66
66
63
30
19
97
65
64
56
87
87
87
87
105
56
87
87
54
34
11
11
11
11
79
74
79
22
63
23
28
49
24
12
54
64
97
34
97
97
97
64
32
12
122
Drug Name
melphalan hydrochloride
memantine hcl
memantine hcl titration pak
memantine hydrochloride
MENACTRA
M-END DMX
M-END MAX D
MENEST
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
MEPHYTON
meprobamate
MEPRON
mercaptopurine
meribin
meropenem
mesalamine
mesalamine dr
mesna
MESNEX
MESTINON
METADATE CD
METAFOLBIC
metaproterenol sulfate
metformin hcl
metformin hcl er
METHADONE HCL
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
methyldopate hcl
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
Page #
28
22
22
22
68
79
79
63
68
68
68
97
40
34
29
98
17
68
68
30
30
27
52
98
76
42
42
13
72
16
66
62
81
67
67
54
55
50
46
45
46
70
53
52
52
61
60
61
61
72
Drug Name
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
mi-acid
mi-acid gas relief
mi-acid maximum strength
miconazole
miconazole 3
miconazole 7
miconazole nitrate
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
miglitol
migraine formula
milk of magnesia
MILK OF MAGNESIA CONCENTRATE
minocycline hcl
minoxidil
mintox maximum strength
mirtazapine
mirtazapine odt
misoprostol
mitomycin
mitoxantrone hcl
M-M-R II
modafinil
molindone hydrochloride
mometasone furoate
mometasone furoate
MONOCAL
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
moxifloxacin hcl
MOZOBIL
mucaphed
Page #
56
50
48
48
48
16
16
16
47
69
56
56
56
26
26
26
26
63
63
63
63
46
27
42
12
58
57
19
52
57
22
22
58
30
30
68
82
37
61
73
105
70
63
75
14
13
19
87
79
123
Drug Name
MUCINEX
mucinex chest congestion childrens
MUCINEX CHILDRENS COLD COUGH
& SORE THROAT
MUCINEX CHILDRENS
MULTI-SYMPTOM COLD
MUCINEX CHILDRENS
MULTI-SYMPTOM COLD & FEVER
MUCINEX CONGESTION & COUGH
CHILDRENS
mucinex cough childrens
MUCINEX COUGH FOR KIDS
MUCINEX D
MUCINEX D MAXIMUM STRENGTH
MUCINEX DM
MUCINEX DM MAXIMUM STRENGTH
mucinex fast-max cold & sinus
MUCINEX FAST-MAX COLD FLU&
SORE THROAT
MUCINEX FAST-MAX DAY
TIME/NIGHT TIME
MUCINEX FAST-MAX DAY/NIGHT
MAXIMUM STRENGTH
mucinex fast-max dm max
mucinex fast-max night time cold & flu
MUCINEX FAST-MAX SEVERE COLD
MUCINEX FAST-MAX SEVERE
CONGESTION & COUGH
MUCINEX FOR KIDS
MUCINEX MAXIMUM STRENGTH
MUCINEX MULTI-SYMPTOM COLD
DAY/NIGHT PACK
mucinex multi-symptom cold night time
childrens
mucinex sinus-max day/night
mucinex sinus-max full force
mucinex sinus-max moisture smart
mucinex sinus-max pressure & pain
mucinex sinus-max severe congestion relief
MUCINEX STUFFY NOSE & COLD
CHILDRENS
mucus relief
mucus-er
mucusrelief sinus
MULTAQ
multi-day vitamins
multi-delyn
MULTI-DELYN/IRON
multilex
multilex-t&m
Page #
79
79
79
79
79
79
79
79
79
79
79
79
79
79
79
105
79
79
79
79
79
79
79
79
79
79
79
79
79
80
80
80
80
47
98
98
98
98
98
Drug Name
multiple vitamins
multiple vitamins plain
multiple vitamins/iron
multi-vitamin
multi-vitamin hp/minerals
multi-vitamin/minerals
multi-vitamins
mupirocin
MURO 128
MUSTARGEN
my way
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
mycophenolic acid dr
myferon 150
myferon 150 forte
MYKIDZ IRON
MYKIDZ IRON 10
MYRBETRIQ
mytab gas
mytab gas max str
my-vitalife
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
naftifine hcl
naftifine hydrochloride
NAFTIN
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
NASAL DECONGESTANT
nasal decongestant pe
nasal decongestant spray
NASOPEN PE
NATACYN
NATALVIRT FLT
nateglinide
NATPARA
natural balance tears
natural fiber therapy
natural mixed tocopherols
Page #
98
98
98
98
98
98
98
16
71
28
65
26
27
67
67
87
87
98
82
59
57
57
98
12
48
48
18
26
26
26
55
14
15
14
71
13
12
13
27
80
80
80
74
26
87
42
70
71
58
98
124
Drug Name
natures tears
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
one
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
NEPHRAMINE
NEPHRON FA
NEPHRONEX
NEPHRO-VITE
NEUPOGEN
NEUPRO
nevirapine
nevirapine er
NEXAVAR
niacin
niacin
niacin er
niacin er
niacin sr
niacin tr
niacor
nicardipine hcl
NICODERM CQ
nicorelief
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine polacrilex
NICOTINE TRANSDERMAL SYSTEM
nicotine transdermal system step 1
NICOTROL NS
nifedical xl
nifedipine er
night time multi-symptom cold/flu relief
night time sleep aid
NILANDRON
nilutamide
NINJACOF
Page #
71
34
63
63
63
63
22
15
71
15
16
71
71
72
16
72
87
87
98
98
45
34
38
38
32
51
98
51
98
98
98
51
49
15
15
15
15
15
15
15
15
15
49
49
80
74
28
28
105
Drug Name
NINJACOF-A
NINJACOF-XG
NINLARO
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate/macrocrystals
nitroglycerin
nitroglycerin transdermal
NITROSTAT
NO IRON MULTIPLE
VITAMIN/MINERALS
nohist-dm
nohist-lq
nora-be
NORDITROPIN FLEXPRO
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
NORTHERA
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
NOVAFERRUM 125
NOVAFERRUM 50
NOVAFERRUM PEDIATRIC DROPS
novofine 32gx6mm
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
NOXAFIL
nrs nasal relief
NUEDEXTA
nu-iron 150
NULOJIX
NULYTELY/FLAVOR PACKS
NU-MAG
NUPLAZID
Page #
105
80
30
52
16
16
52
52
52
98
80
74
65
61
65
65
63
63
65
87
87
87
49
63
64
64
24
39
87
87
87
70
44
44
44
44
44
44
44
44
26
80
53
87
67
58
87
36
125
Drug Name
NUTRICAP
nutrilipid
NUTRIVIT
nyamyc
nystatin
nystatin/triamcinolone
nystop
octreotide acetate
ODEFSEY
ODOMZO
OFEV
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olmesartan medoxomil
olmesartan medoxomil/hydrochlorothiazide
olopatadine hcl
olopatadine hcl
omega-3-acid ethyl esters
OMEPRAZOLE
omeprazole magnesium
once daily
once daily/iron
ONCOVITE
ondansetron hcl
ondansetron odt
one daily
one daily mens
one daily plus iron
one daily plus minerals
one-daily multi vitamins
ONE-WAY VALVED
EXPIRATORYMOUTHPIECE/DISPOSAB
LE
ONE-WAY VALVED INSPIRATORY
MOUTHPIECE/DISPOSABLE
ONFI
ONGLYZA
OPDIVO
OPSUMIT
opti-clear
oralyte
oralyte freezer pops
ORAZINC
ORENCIA
ORENCIA CLICKJECT
ORENITRAM
organ-i nr
ORKAMBI
Page #
98
70
98
26
26
26
26
66
38
30
80
19
64
36
36
46
46
71
74
51
59
59
98
98
98
25
25
99
98
99
99
99
105
105
20
42
33
77
71
87
87
87
67
67
77
80
76
Drug Name
orphenadrine citrate
orphenadrine citrate er
os-cal
os-cal calcium + d3
os-cal extra d3
OS-CAL ULTRA
oseltamivir phosphate
OSTEO-PORETICAL
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
oysco 500
oysco 500+d
oysco d
oyst-cal
oyst-cal-d 500
oyster calcium
oyster shell
oyster shell calcium
oyster shell calcium + d
oyster shell calcium + d3
oyster shell calcium + vitamin d
oyster shell calcium 500 + d
oyster shell calcium plusvitamin d
oyster shell calcium/d
oyster shell calcium/vitamin d
pa b-complex with b-12
pa biotin
pa oyster shell calcium
pa vitamin b-12 tr
pa vitamin e
pacerone
paclitaxel
pain & fever
pain & fever childrens
pain & fever extra strength
pain relief sinus pe daytime
pain reliever pm extra strength
paliperidone er
PAMIDRONATE DISODIUM
PANCREAZE
PANRETIN
pantoprazole sodium
Page #
81
81
87
87
87
105
40
87
18
30
62
13
21
21
59
59
14
14
88
88
88
105
88
88
105
88
88
88
88
88
88
88
88
99
99
88
99
99
47
30
11
11
11
80
74
36
69
55
33
59
126
Drug Name
pantothenic acid
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PASER
PATANOL
PAXIL
PEDIALYTE
PEDIALYTE ADVANCED CARE
PEDIALYTE FREEZER POPS
PEDIALYTE SINGLES
PEDIARIX
pediatric cough/cold
pediatric electrolyte
pediatric electrolyte freeze pops
pediatric electrolyte freezer pops
pediatric electrolyte/zinc
PEDVAX HIB
peg 3350
peg3350
peg-3350/nacl/na bicarbonate/kcl
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEG-INTRON REDIPEN
penicillin g potassium
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
PENTAM 300
pentoxifylline er
peptic relief
PERIDIN-C
periogard
PERJETA
permethrin
perphenazine
perphenazine/amitriptyline
phenadoz
phenelzine sulfate
phenobarbital
phenylephrine hcl/pyrilamine maleate
PHENYLHISTINE DH
PHENYTEK
phenytoin
phenytoin sodium
phenytoin sodium extended
Page #
70
15
23
23
27
71
23
88
88
88
88
68
80
88
88
88
88
68
58
58
58
21
38
38
38
38
18
18
18
18
18
34
49
57
99
53
33
34
35
24
24
23
20
80
80
21
21
21
21
Drug Name
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
PICATO
pilocarpine hcl
pilocarpine hcl
pilocarpine hydrochloride
pimozide
pindolol
pink bismuth
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin/tazobactam
piroxicam
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
PLENAMINE
podofilox
poly vitamin
polyethylene glycol 3350
POLY-HIST DM
POLY-HIST PD
poly-iron 150
poly-iron 150 forte
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
polysacc iron 150 complex
polysaccharide iron forte
POLY-VENT DM
POLY-VENT IR
poly-vita drops
poly-vita/iron drops
polyvitamin
polyvitamin/iron
POMALYST
portia-28
potassium chloride
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride er
potassium chloride/dextrose
POTASSIUM
CHLORIDE/DEXTROSE/LACTATED
RINGERS
POTASSIUM CHLORIDE/SODIUM
CHLORIDE
potassium citrate er
Page #
72
70
70
54
53
72
53
35
48
57
42
42
42
18
13
88
88
88
88
54
99
58
105
74
88
88
16
71
88
89
106
106
99
99
99
99
28
64
89
89
89
89
89
89
89
89
89
127
Drug Name
POTIGA
povidone-iodine
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
prevalite
prevent
previfem
PREZCOBIX
PREZISTA
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRISTIQ
PRO COMFORT LANCETS 31G
PROAIR HFA
PROAIR RESPICLICK
PROBARIMIN QT
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
procto-med hc
procto-pak
proctosol hc
proctozone-hc
PROFE
PROFERRIN ES
PROFERRIN-FORTE
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
Page #
19
16
44
34
51
46
71
71
61
71
61
71
61
61
64
89
64
64
52
99
64
39
39
27
34
20
23
70
76
76
99
26
26
47
89
35
35
35
45
61
61
61
61
89
106
89
65
43
67
80
Drug Name
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
promethazine vc/codeine
promethazine/codeine
promethazine/dextromethorphan
promethazine-dm
promethegan
PROMETRIUM
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSOL
PROTECTIRON
protriptyline hcl
pseudoephedrine hcl
PULMOZYME
puralube
PURIXAN
pyrazinamide
pyridostigmine bromide
pyridostigmine bromide er
pyridoxine hcl
pyridoxine hcl
qc anti-diarrheal
qc arthritis pain relief
qc calcium 600 +d3
qc calcium fast dissolution
qc calcium/minerals/vitamin d
qc childrens chewable vitamins/extra c
qc cough/sore throat nighttime
qc ferrous sulfate
qc ibuprofen
qc loratadine allergy relief
qc loratadine-d
qc maximum daily
multivitamin/multimineral
qc multi-vite
qc naproxen sodium
qc tolnaftate
qc womens daily multivitamin
q-dryl
q-pap
q-pap childrens
q-pap extra strength
Page #
30
69
45
24
80
80
80
80
80
24
65
47
48
48
48
66
68
89
99
24
80
76
71
29
27
27
27
106
99
57
11
89
89
89
99
80
89
13
74
74
99
99
13
26
99
74
11
11
11
128
Drug Name
q-pap infants
q-tussin
q-tussin dm
QUADRACEL
quasense
QUDEXY XR
quenalin
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinine sulfate
ra balanced b-100
ra balanced b-50
ra b-complex
ra b-complex with b-12
ra b-complex/vitamin c tr
ra beta carotene
ra biotin
ra calcium 600
ra calcium 600 plus vitamin d-3
ra calcium 600/vit d/minerals
ra calcium citrate plus vitamin d-3
ra calcium soft chews
RA CALCIUM/BORON
ra calcium/magnesium/zinc/copper
ra central-vite
ra central-vite cardio
ra central-vite energy
ra central-vite performance
ra central-vite select mature
ra central-vite senior
RA CENTRAL-VITE UNDER 50 MENS
RA CENTRAL-VITE UNDER 50
WOMENS
ra central-vite womens mature
ra central-vite/antioxidants
ra coral calcium
ra hi cal
ra hi-cal plus vitamin d
ra high potency iron
ra iron
ra magnesium
ra natural magnesium
ra natural vitamin e
ra niacin
ra niacin
ra one daily energy formula
Page #
11
80
80
68
64
20
74
36
47
47
47
47
47
34
99
99
99
99
99
99
99
89
89
89
89
99
106
106
100
99
100
100
100
100
100
100
100
100
106
89
89
89
90
57
106
100
106
52
100
Drug Name
ra one daily essential
ra one daily maximum
ra one daily mens 50+ with vitamin d-3
ra one daily multi-vitamin
ra one daily multi-vitamin plus iron
RA OYSTER SHELL
CALCIUM/VITAMIN D
RA OYSTER SHELL
CALCIUM/VITAMIN D
ra pediatric electrolyte
ra pediatric electrolyte
ra pediatric electrolyte freezer pops
ra selenium
ra selenium natural
ra slow release iron
ra slow release iron
ra stress formula advanced
ra stress formula energy
ra therapeutic m plus beta carotene
ra vitamin a
ra vitamin b-1
ra vitamin b12
ra vitamin b-12
ra vitamin b-12 tr
ra vitamin b-6
ra vitamin b-6
ra vitamin c
ra vitamin c drops
ra vitamin c tr
ra vitamin c/acerola
ra vitamin c/rose hips
ra vitamin c/rose hips tr
ra vitamin e
ra whole source complete formula for men
ra whole source dietary
ra whole source dietary for men
ra whole source dietary mature
ra zinc
rabano yodado
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine 150 maximum strength
ranitidine 75
ranitidine hcl
ranitidine maximum strength
RAPAMUNE
rasagiline mesylate
RAVICTI
Page #
100
100
100
100
100
106
90
106
90
90
90
106
106
90
100
100
100
100
100
100
106
100
106
100
101
100
100
100
101
101
101
101
101
101
101
90
101
68
65
47
50
57
57
57
57
67
35
55
129
Drug Name
REBETOL
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB
REFRESH CELLUVISC
refresh lacri-lube
REFRESH PLUS
reguloid
RELENZA DISKHALER
RELISTOR
REMICADE
renal-vite
rena-vite
RENVELA
repaglinide
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
RESCON
RESCON DM
RESCON-GG
RESCRIPTOR
reserpine
RESPAIRE-30
RESTASIS
restfully sleep
RETROVIR IV INFUSION
REVLIMID
REXULTI
REYATAZ
REZIRA
ribasphere
ribasphere ribapak
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
RISACAL-D
risedronate sodium
risedronate sodium dr
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
Page #
38
53
53
53
53
68
71
71
71
58
40
57
67
101
101
60
42
50
50
50
74
80
80
38
46
80
71
74
39
28
36
40
80
38
38
38
27
27
27
53
40
90
70
106
69
69
36
36
36
33
Drug Name
rivastigmine tartrate
rivastigmine transdermal system
rizatriptan benzoate
rizatriptan benzoate odt
robafen
robafen cf cough & cold
robafen dm
robafen dm cough clear
ropinirole hcl
rosuvastatin calcium
ROTARIX
ROTATEQ
ROZEREM
RUBRACA
RU-HIST D
rulox
RYMED
rynex dm
rynex pe
rynex pse
SABRIL
SAIZEN
SAIZEN CLICK.EASY
sani-supp adult
sani-supp pediatric
SANTYL
SAPHRIS
SAVELLA
SAVELLA TITRATION PACK
sb pediatric electrolyte
selegiline hcl
SELENIUM
selenium sulfide
SELZENTRY
senexon
senior tabs
senna
senna lax
senna plus
sennalax-s
SENSIPAR
sentry
sentry senior
SEREVENT DISKUS
SEROSTIM
sertraline hcl
se-tan plus
sharobel
SIDEROL
SIGNIFOR
Page #
22
22
27
27
80
80
80
80
34
51
68
68
82
30
74
57
74
80
75
75
20
61
61
58
58
54
36
53
53
90
35
90
54
39
58
101
58
58
58
58
65
101
101
76
62
24
90
65
101
66
130
Drug Name
siladryl allergy
sildenafil
silphen cough
siltussin dm das
siltussin sa
siltussin-dm
silver sulfadiazine
simethicone
SIMULECT
simvastatin
sirolimus
SIRTURO
SLO-NIACIN
SLOW-MAG
sm allergy 4 hour
sm allergy relief
sm antacid anti-gas
sm antacid/antigas
sm anti-diarrheal
sm balanced b-50
sm calcium
sm calcium 500/vitamin d3
sm calcium 600
sm calcium 600/vitamin d
sm calcium citrate + d
sm calcium citrate w/vitamin d3
sm calcium plus/vitamin d/minerals
sm calcium soft chews
sm calcium/magnesium/zinc
sm calcium/vitamin d
sm chewable c
sm complete
sm complete advanced formula
sm complete senior formula
sm ibuprofen
sm iron
sm loratadine
sm lorata-dine d
sm magnesium
sm miconazole 7
sm multiple vitamins essential
sm multiple vitamins/iron
sm nasal decongestant maximum strength
sm nasal spray 12 hour
sm oyster shell calcium/vitamin d
sm oyster shell calcium/vitamin d3
sm pediatric electrolyte
sm selenium
sm sleep aid
SM SLOW RELEASE IRON
Page #
75
77
75
80
80
80
16
57
67
51
67
27
101
90
75
75
57
57
57
101
90
90
90
90
90
90
90
101
90
90
101
101
101
101
13
90
75
75
90
26
101
101
80
80
90
90
90
90
75
90
Drug Name
sm super b complex-vitamin c
sm therapeutic-m
sm tussin dm
sm tussin dm cough/chest congestion
sm vit c/rose hips
sm vitamin b-1
sm vitamin b-12
sm vitamin b-6
sm vitamin c
sm vitamin c/rose hips
sm vitamin e
sm vitamin e blended
sm zinc
sodium bicarbonate
sodium chloride
sodium chloride
sodium chloride 0.45%
sodium chloride 0.9%
sodium citrate/citric acid
sodium fluoride
SODIUM LACTATE
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
sore throat & cough lozenges
SORIATANE
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28
SPRITAM
SPRYCEL
sps
sronyx
ssd
STAHIST AD
STALEVO 100
STALEVO 125
STALEVO 150
Page #
101
101
80
80
101
102
102
102
102
102
102
102
90
57
71
90
90
90
90
90
82
55
82
19
28
61
61
66
66
14
54
47
47
47
38
75
75
50
50
26
64
19
32
82
64
16
106
34
34
34
131
Drug Name
STALEVO 200
STALEVO 50
STALEVO 75
stavudine
sterile water irrigation
STIMATE
stimulant laxative
STIVARGA
stool softener
stool softener extra strength
stool softener laxative dc
STRATTERA
streptomycin sulfate
stress formula
stress formula w/iron
stress formula/iron
stress formula/zinc
STRIBILD
STROVITE FORTE
STROVITE ONE
SUBOXONE
SUCRAID
sucralfate
sudogest
sudogest 12 hour
sudogest pe
sudogest sinus & allergy
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulindac
sumatriptan succinate
sumatriptan succinate refill
super b complex/c
super b with c
super b-50 complex plus
super calcium
super multiple
super thera vite m
superplex-t
SUPERVITE EC
SUPLEVIT
SUPPORT
SUPPORT-500
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
Page #
34
34
34
39
70
62
58
32
58
58
58
53
15
102
102
102
102
38
102
102
14
55
58
80
81
81
75
19
71
19
19
19
68
13
27
27
106
102
102
90
102
102
102
102
102
102
102
17
70
Drug Name
sure-fine pen needles 31gx5/16" 8mm
SUSPENDOL-S
SUSTIVA
SUTENT
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
tab-a-vite
tab-a-vite maximum
tab-a-vite w/beta carotene
TAB-A-VITE WOMENS
tab-a-vite/iron
TABLOID
tacrolimus
tacrolimus
TAFINLAR
TAGRISSO
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM
TANDEM PLUS
TARCEVA
TARGRETIN
TARON FORTE
TASIGNA
TAZORAC
taztia xt
TECENTRIQ
TECFIDERA
TECFIDERA STARTER PACK
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
temazepam
tencon
Page #
70
70
38
32
30
33
73
42
42
67
66
16
30
65
82
102
102
102
102
102
29
54
67
32
30
14
40
28
59
90
90
32
33
90
33
54
49
33
53
53
17
21
21
50
50
46
46
46
81
11
132
Drug Name
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
testosterone cypionate
testosterone enanthate
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
tetrabenazine
THALOMID
THEO-24
theophylline
theophylline cr
theophylline er
thera
THERA M PLUS
THERA/BETA-CAROTENE
thera-gesic
THERA-M
THERAPEUTIC LIQUID
thera-tabs
theratrum complete
therems
THEREMS-H
THEREMS-M
thiamine hcl
thioridazine hcl
THIOTEPA
thiothixene
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
THYROSAFE
THYROSHIELD
tiagabine hydrochloride
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
tioconazole-1
TIVICAY
tizanidine hcl
TOBI PODHALER
TOBRADEX
tobramycin
tobramycin sulfate
Page #
68
59
26
76
26
62
62
68
53
28
77
77
77
77
103
102
103
55
103
103
103
103
103
103
103
103
35
28
35
67
65
65
65
65
65
70
70
20
48
72
72
34
26
38
37
76
71
76
15
Drug Name
tobramycin/dexamethasone
tolbutamide
tolcapone
tolmetin sodium
tolnaftate
tolterodine tartrate
tolterodine tartrate er
topiramate
topiramate er
toposar
topotecan hcl
TORISEL
torsemide
total b/c
totalday multiple
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
travel sickness
trazodone hcl
TREANDA
TRECATOR
TRELSTAR MIXJECT
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
triazolam
triderm
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-lo-estarylla
tri-lo-sprintec
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
TRINTELLIX
triphrocaps
Page #
71
42
34
13
26
59
59
21
20
31
31
67
50
103
103
90
77
42
14
14
47
45
24
23
91
24
22
28
27
66
33
55
61
73
53
50
40
61
35
40
34
64
64
58
24
16
24
64
22
103
133
Drug Name
triple antibiotic
triple antibiotic plus
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
TRI-VI-SOL
tri-vita
tri-vitamin
trivora-28
TRIXAICIN
trixaicin hp
TROKENDI XR
TROPHAMINE
TRUMENBA
TRUVADA
tussin dm
tussin dm clear
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
TWINRIX
TYBOST
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYVASO
TYZEKA
UCERIS
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
ultra b-100 complex
UNICOMPLEX-M
unithroid
UPTRAVI
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir
valganciclovir hydrochlorde
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
VANACOF
Page #
17
16
64
30
64
39
103
103
103
64
55
55
21
91
68
39
81
81
81
68
39
17
33
68
53
77
37
61
70
70
103
103
65
77
91
91
91
57
55
40
28
37
37
37
20
20
46
46
81
Drug Name
VANACOF DM
VANACOF-8
VANAHIST PD
vancomycin hcl
vandazole
VAQTA
VARIVAX
VARIZIG
v-c forte
VECTIBIX
VELCADE
velivet
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
venlafaxine hcl er
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
vic-forte
VICTOZA
VIDEX PEDIATRIC
vienva
VIIBRYD
VIIBRYD STARTER PACK
VIMPAT
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAZOLE
virdec
virdec dm
VIREAD
virtussin a/c
vita-bee/c
vitamin a
vitamin a & d
vitamin a palmitate water dispersible
vitamin a&d
vitamin b complex
vitamin b complex-c
vitamin b-1
vitamin b12
vitamin b12
vitamin b-12
vitamin b-2
Page #
81
81
75
17
17
68
68
68
103
33
30
64
30
30
24
24
76
49
49
49
55
37
103
43
39
64
24
24
21
30
30
30
40
38
75
81
39
81
103
103
55
103
103
104
103
104
106
104
104
104
134
Drug Name
vitamin b-6
vitamin c
VITAMIN C
vitamin c sr
vitamin c tr
vitamin c/rose hips
vitamin d
vitamin e
vitamin e water dispersible
vitamin e water soluble
vitamin e/d-alpha
vitamin e/dl-alpha
vitamin forte
VITAMIN K1
vitamins & minerals
vitamins for hair
VITEKTA
vol-care rx
VOLTAREN
voriconazole
VOTRIENT
VP-PNV-DHA
VPRIV
VRAYLAR
warfarin sodium
wee care
WELCHOL
white petrolatum
womens one daily
XALKORI
XARELTO
XARELTO STARTER PACK
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX HFA
XTANDI
xulane
XYREM
YERVOY
YF-VAX
YONDELIS
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZANTAC
ZAVESCA
Z-BUM
Page #
104
106
104
104
104
104
104
104
104
104
104
104
104
104
104
104
38
104
55
26
33
104
55
36
44
106
52
55
104
33
44
44
69
17
81
76
76
28
64
82
33
68
28
75
81
31
28
57
55
106
Drug Name
zeasorb-af
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
ZERIT
ZETIA
ZIAGEN
zidovudine
zinc
ZINC
ZINC 15
zinc chelated
zinc gluconate
zinc oxide
zinc sulfate
zinc-220
ZINECARD
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
ZONATUSS
zonisamide
zoo friends
zoo friends plus iron
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
ZUBSOLV
ZUTRIPRO
ZYDELIG
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
Page #
26
35
33
81
55
39
52
39
39
91
104
91
106
91
55
91
91
30
37
37
18
69
30
81
81
69
55
81
20
104
104
62
67
68
18
64
64
40
15
81
31
75
31
37
28
135
Multi-Language Insert
Multi-language Interpreter Services
English:
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call
1-866-896-1844 (TTY: 711).
Spanish:
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-866-896-1844 (TTY: 711).
Chinese Mandarin:
5�::*f{f�Jt)'fOP%J�i§��.��0§��1-866-896-1844 (TTY: 711)0
Chinese Cantonese:
f�:P*1��J,1P�1�Js�itM��o��(1-866-896-1844(Im�H:711)o
Tagalog:
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-866-896-1844 (TTY: 711).
French:
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-866-896-1844 (ATS : 711).
Vietnamese:
CHÚ Ý: N6u bin nói Ti6ng Vi�t, có các dich v\ h6 trq ngôn ngf mi6n phí dành cho bin. G9i s6
1-866-896-1844 (TTY: 711).
German:
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-866-896-1844 (TTY: 711).
Korean:
�0: 2�0� NgoA� �S, 20 /@ AHA� �h� 0go� * V�LD.
1-866-896-1844 (TTY: 711) �0� �.o ��A2.
Russian:
BHIMAHIE: EcmH Bh noBopHTe Ha pyccKoM �3hKe, To BaM )ocTymHh 6ecmmaTHhe ycmynH mepeBo)a.
3BoHHTe 1-866-896-1844 (TemeTalm: 711).
Arabic:
�
\ LiLA � .) 1-866-896-1844 � Y. J i\ .0L�. L. - Y \j:i : j.. \ :. L.. \ wL..b 0� ,:.. \ YSj\ <..:i wiS \jj ::.j...
.(711 :� \_
H6870_MLI17R_Accepted_08302016
Hindi:
��
:f �
3q �
�
(TTY: 711) q
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3q �
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if � � fQ �
f� \q o� Q11-866-896-1844
f1
Italian:
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica
gratuiti. Chiamare il numero 1-866-896-1844 (TTY: 711).
Portugués:
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para
1-866-896-1844 (TTY: 711).
French Creole:
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele
1-866-896-1844 (TTY: 711).
Polish:
UWAGA: Jezeli mówisz po polsku, mozesz skorzysta6 z bezplatnej pomocy jyzykowej. Zadzwon pod numer
1-866-896-1844 (TTY: 711).
Japanese:
;�-r:a*����n��.,�*0���t�.�mlftr*901-866-896-1844 (TTY:
711)*-,i��r-.5�<t�l0
Superior HealthPlan (Superior) STAR+PLUS Medicare-Medicaid Plan (MMP) complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Superior
STAR+PLUS MMP does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
Superior STAR+PLUS MMP:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified
sign language interpreters and written information in other formats (large print, accessible electronic formats, other
formats).
• Provides free language services to people whose primary language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact Superior STAR+PLUS MMP's Member Services at 1-866-896-1844 (TTY: 711).
If you believe that Superior STAR+PLUS MMP 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 by calling the number
above and telling them you need help filing a grievance; Superior STAR+PLUS MMP's Member Services 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, DC 20201, 1-800–368–1019,
(TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Superior STAR+PLUS MMP cumple con las leyes federales de derechos civiles aplicables y no discrimina por
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Si necesita estos servicios, póngase en contacto con Servicios para afiliados de Superior STAR+PLUS MMP al 1­
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Si usted considera que Superior STAR+PLUS MMP no le ha brindado estos servicios o lo ha discriminado de
alguna otra manera debido a su raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo
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También puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles del Departamento de
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Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800-537-7697).
Los formularios de quejas se encuentran disponibles en http://www.hhs.gov/ocr/office/file/index.html.
2100 South IH-35
Suite 200
Austin, TX 78704
1-866-896-1844
TTY: 711
http://mmp.superiorhealthplan.com
FOR MORE INFORMATION,
contact Member Services at
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Monday through Friday. TTY users call 711.
After hours, on weekends and on holidays,
you may be asked to leave a message.
Your call will be returned within the next
business day.
http://mmp.superiorhealthplan.com
00017412, Version 10
Updated 06/01/2017
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