LEGEND
TIER
1
DESCRIPTION
Formulary
TYPE
Generic or Brand - No Copayment for a 30 Days Supply at
Participating Retail Pharmacy
DESCRIPTION
Quantity Limit
For certain drugs, AlohaCare QUEST Integration limits the amount of
drug that AlohaCare QUEST Integration will cover.
PA
Prior Authorization
AlohaCare QUEST Integration requires you or your physician to get
prior authorization for certain drugs. This means that you will need
to get approval from AlohaCare QUEST Integration before you fill
your prescriptions. If you do not get approval, AlohaCare QUEST
Integration may not cover the drug.
ST
Step Therapy
In some cases, AlohaCare QUEST Integration requires you to first try
certain drug(s) to treat your medical condition before we will cover
another drug for that condition.
GL
Gender Limit
This prescription drug may only be covered for a single gender.
AL
Age Limit
This prescription drug may only be covered if you meet the minimum
or maximum age limit.
QL
PAGE 1
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ivermectin 3 mg tablet
1
ANTIBACTERIALS
amoxicillin 125 mg tab chew
1
amoxicillin 125 mg/5ml susp recon
1
amoxicillin 200 mg/5ml susp recon
1
amoxicillin 250 mg capsule
1
amoxicillin 250 mg tab chew
1
amoxicillin 250 mg/5ml susp recon
1
amoxicillin 400 mg/5ml susp recon
1
amoxicillin 500 mg capsule
1
amoxicillin 500 mg tablet
1
amoxicillin 875 mg tablet
1
amoxicillin/potassium clav 1000-62.5 tab er 12h
1
amoxicillin/potassium clav 200-28.5/5 susp recon
1
amoxicillin/potassium clav 200-28.5mg tab chew
1
amoxicillin/potassium clav 250-125 mg tablet
1
amoxicillin/potassium clav 250-62.5/5 susp recon
1
amoxicillin/potassium clav 400-57mg tab chew
1
amoxicillin/potassium clav 400-57mg/5 susp recon
1
amoxicillin/potassium clav 500-125 mg tablet
1
amoxicillin/potassium clav 600-42.9/5 susp recon
1
amoxicillin/potassium clav 875-125 mg tablet
1
ampicillin trihydrate 125 mg/5ml susp recon
1
ampicillin trihydrate 250 mg capsule
1
ampicillin trihydrate 250 mg/5ml susp recon
1
ampicillin trihydrate 500 mg capsule
1
AUGMENTIN 125-31.25 MG/5 ML
amoxicillin/potassium clavulanate
1
PAGE 2
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
AVELOX ABC PACK 400 MG TAB
moxifloxacin hcl
1
AVIDOXY 100 MG TABLET
doxycycline monohydrate
1
azithromycin 1 g packet
1
azithromycin 100 mg/5ml susp recon
1
azithromycin 200 mg/5ml susp recon
1
azithromycin 250 mg tablet
1
azithromycin 500 mg tablet
1
azithromycin 600 mg tablet
1
bacitracin 5mm unit powder(ea)
1
BICILLIN L-A 1,200,000 UNITS
penicillin g benzathine
1
BICILLIN L-A 2,400,000 UNITS
penicillin g benzathine
1
BICILLIN L-A 600,000 UNIT/ML
penicillin g benzathine
1
cefaclor 125 mg/5ml susp recon
1
cefaclor 250 mg capsule
1
cefaclor 250 mg/5ml susp recon
1
cefaclor 375 mg/5ml susp recon
1
cefaclor 500 mg capsule
1
cefaclor 500 mg tab er 12h
1
cefadroxil 1 g tablet
1
cefadroxil 250 mg/5ml susp recon
1
cefadroxil 500 mg capsule
1
cefadroxil 500 mg/5ml susp recon
1
cefdinir 125 mg/5ml susp recon
1
cefdinir 250 mg/5ml susp recon
1
cefdinir 300 mg capsule
1
cefixime 100 mg/5ml susp recon
1
cefixime 200 mg/5ml susp recon
1
cefpodoxime proxetil 100 mg tablet
1
PAGE 3
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
cefpodoxime proxetil 100 mg/5ml susp recon
1
cefpodoxime proxetil 200 mg tablet
1
cefpodoxime proxetil 50 mg/5 ml susp recon
1
cefprozil 125 mg/5ml susp recon
1
cefprozil 250 mg tablet
1
cefprozil 250 mg/5ml susp recon
1
cefprozil 500 mg tablet
1
ceftibuten 180 mg/5ml susp recon
1
ceftibuten 400 mg capsule
1
CEFTIN 125 MG/5 ML ORAL SUSP
cefuroxime axetil
1
CEFTIN 250 MG/5 ML ORAL SUSP
cefuroxime axetil
1
ceftriaxone sodium 1 g pggybk btl
1
ceftriaxone sodium 1 g vial
1
ceftriaxone sodium 1 g vial port
1
ceftriaxone sodium 10 g vial
1
ceftriaxone sodium 2 g pggybk btl
1
ceftriaxone sodium 2 g vial
1
ceftriaxone sodium 2 g vial port
1
ceftriaxone sodium 250 mg vial
1
ceftriaxone sodium 500 mg vial
1
cefuroxime axetil 250 mg tablet
1
cefuroxime axetil 500 mg tablet
1
cephalexin 125 mg/5ml susp recon
1
cephalexin 250 mg capsule
1
cephalexin 250 mg tablet
1
cephalexin 250 mg/5ml susp recon
1
cephalexin 500 mg capsule
1
cephalexin 500 mg tablet
1
cephalexin 750 mg capsule
1
ciprofloxacin 250 mg/5ml sus mc rec
1
PAGE 4
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ciprofloxacin 500 mg/5ml sus mc rec
1
ciprofloxacin hcl 100 % crystals
1
ciprofloxacin hcl 100 mg tablet
1
ciprofloxacin hcl 250 mg tablet
1
ciprofloxacin hcl 500 mg tablet
1
ciprofloxacin hcl 750 mg tablet
1
ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr
1
ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr
1
clarithromycin 125 mg/5ml susp recon
1
clarithromycin 250 mg tablet
1
clarithromycin 250 mg/5ml susp recon
1
clarithromycin 500 mg tab er 24h
1
clarithromycin 500 mg tablet
1
clindamycin hcl 150 mg capsule
1
clindamycin hcl 300 mg capsule
1
clindamycin hcl 75 mg capsule
1
clindamycin palmitate hcl 75 mg/5 ml soln recon
1
demeclocycline hcl 150 mg tablet
1
demeclocycline hcl 300 mg tablet
1
dicloxacillin sodium 250 mg capsule
1
dicloxacillin sodium 500 mg capsule
1
doxycycline hyclate 100 mg capsule
1
doxycycline hyclate 100 mg tablet
1
doxycycline hyclate 100 mg tablet dr
1
doxycycline hyclate 150 mg tablet dr
1
doxycycline hyclate 20 mg tablet
1
doxycycline hyclate 50 mg capsule
1
doxycycline hyclate 75 mg tablet dr
1
doxycycline monohydrate 100 mg capsule
1
doxycycline monohydrate 100 mg tablet
1
doxycycline monohydrate 150 mg tablet
1
PAGE 5
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
doxycycline monohydrate 25 mg/5 ml susp recon
1
doxycycline monohydrate 50 mg capsule
1
doxycycline monohydrate 50 mg tablet
1
doxycycline monohydrate 75 mg capsule
1
doxycycline monohydrate 75 mg tablet
1
E.E.S. 200 MG/5 ML GRANULES
erythromycin ethylsuccinate
1
E.E.S. 400 FILMTAB
erythromycin ethylsuccinate
1
ery e-succ/sulfisoxazole 200-600/5 susp recon
1
ERY-TAB EC 250 MG TABLET
erythromycin base
1
ERY-TAB EC 333 MG TABLET
erythromycin base
1
ERYPED 200 MG/5 ML SUSPENSION
erythromycin ethylsuccinate
1
ERYTHROCIN 250 MG FILMTAB
erythromycin stearate
1
erythromycin base 250 mg capsule dr
1
erythromycin base 250 mg tablet
1
erythromycin base 500 mg tablet
1
erythromycin ethylsuccinate 400 mg tablet
1
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg
1
levofloxacin 250 mg tablet
1
levofloxacin 250mg/10ml solution
1
levofloxacin 500 mg tablet
1
levofloxacin 750 mg tablet
1
minocycline hcl 100 mg capsule
1
minocycline hcl 100 mg tablet
1
minocycline hcl 135 mg tab er 24h
1
minocycline hcl 45 mg tab er 24h
1
minocycline hcl 50 mg capsule
1
minocycline hcl 50 mg tablet
1
PAGE 6
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
minocycline hcl 75 mg capsule
1
minocycline hcl 75 mg tablet
1
minocycline hcl 90 mg tab er 24h
1
MORGIDOX 100 MG CAPSULE
doxycycline hyclate
1
moxifloxacin hcl 400 mg tablet
1
neomycin sulfate 500 mg tablet
1
ofloxacin 200 mg tablet
1
ofloxacin 300 mg tablet
1
ofloxacin 400 mg tablet
1
paromomycin sulfate 250 mg capsule
1
penicillin v potassium 125 mg/5ml soln recon
1
penicillin v potassium 250 mg tablet
1
penicillin v potassium 250 mg/5ml soln recon
1
penicillin v potassium 500 mg tablet
1
polymyxin b sulfate,micronized 100mm unit powder(ea)
1
rifabutin 150 mg capsule
1
PA
rifampin 150 mg capsule
1
PA
rifampin 300 mg capsule
1
PA
sulfadiazine 500 mg tablet
1
sulfamethoxazole/trimethoprim 200-40mg/5 oral susp
1
sulfamethoxazole/trimethoprim 400mg-80mg tablet
1
sulfamethoxazole/trimethoprim 800-160 mg tablet
1
sulfamethoxazole/trimethoprim 800-160/20 oral susp
1
sulfasalazine 500 mg tablet
1
sulfasalazine 500 mg tablet dr
1
SULFATRIM PEDIATRIC SUSPENSION
sulfamethoxazole/trimethoprim
1
SULFAZINE 500 MG TABLET
sulfasalazine
1
SULFAZINE EC 500 MG TAB
sulfasalazine
1
PAGE 7
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
tetracycline hcl 250 mg capsule
1
tetracycline hcl 500 mg capsule
1
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb
1
LIMITS & RESTRICTIONS
ANTIFUNGAL (SYSTEMIC)
fluconazole 10 mg/ml susp recon
1
fluconazole 100 mg tablet
1
QL
30 / 30 days
fluconazole 150 mg tablet
1
QL
2 / 30 days
fluconazole 200 mg tablet
1
QL
60 / 30 days
fluconazole 40 mg/ml susp recon
1
fluconazole 50 mg tablet
1
QL
30 / 30 days
flucytosine 250 mg capsule
1
flucytosine 500 mg capsule
1
griseofulvin ultramicrosize 125 mg tablet
1
griseofulvin ultramicrosize 250 mg tablet
1
griseofulvin, microsize 125 mg/5ml oral susp
1
griseofulvin, microsize 500 mg tablet
1
itraconazole 100 mg capsule
1
QL
120 / 30 days
ketoconazole 200 mg tablet
1
LAMISIL 125 MG GRANULES PACKET
terbinafine hcl
1
LAMISIL 187.5 MG GRANULES PACK
terbinafine hcl
1
LUGOL'S SOLUTION
potassium iodide/iodine
1
NOXAFIL 40 MG/ML SUSPENSION
posaconazole
1
NOXAFIL DR 100 MG TABLET
posaconazole
1
nystatin 100000/ml oral susp
1
nystatin 150mm unit powder(ea)
1
nystatin 500k unit tablet
1
nystatin 500mm unit powder(ea)
1
PAGE 8
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nystatin 50mm unit powder(ea)
1
potassium iodide granules
1
potassium iodide 100 % crystals
1
potassium iodide/iodine 5 % solution
1
terbinafine hcl 250 mg tablet
1
LIMITS & RESTRICTIONS
QL
30 / 30 days
Antifungals
fluconazole 10 mg/ml susp recon
1
fluconazole 100 mg tablet
1
QL
30 / 30 days
fluconazole 150 mg tablet
1
QL
2 / 30 days
fluconazole 200 mg tablet
1
QL
60 / 30 days
fluconazole 40 mg/ml susp recon
1
fluconazole 50 mg tablet
1
QL
30 / 30 days
flucytosine 250 mg capsule
1
flucytosine 500 mg capsule
1
griseofulvin ultramicrosize 125 mg tablet
1
griseofulvin ultramicrosize 250 mg tablet
1
griseofulvin, microsize 125 mg/5ml oral susp
1
griseofulvin, microsize 500 mg tablet
1
itraconazole 100 mg capsule
1
QL
120 / 30 days
ketoconazole 200 mg tablet
1
LAMISIL 125 MG GRANULES PACKET
terbinafine hcl
1
LAMISIL 187.5 MG GRANULES PACK
terbinafine hcl
1
LUGOL'S SOLUTION
potassium iodide/iodine
1
NOXAFIL 40 MG/ML SUSPENSION
posaconazole
1
NOXAFIL DR 100 MG TABLET
posaconazole
1
nystatin 100000/ml oral susp
1
nystatin 150mm unit powder(ea)
1
PAGE 9
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nystatin 500k unit tablet
1
nystatin 500mm unit powder(ea)
1
nystatin 50mm unit powder(ea)
1
potassium iodide granules
1
potassium iodide 100 % crystals
1
potassium iodide/iodine 5 % solution
1
terbinafine hcl 250 mg tablet
1
LIMITS & RESTRICTIONS
QL
30 / 30 days
ANTIMYCOBACTERIALS
AVELOX ABC PACK 400 MG TAB
moxifloxacin hcl
1
ciprofloxacin 250 mg/5ml sus mc rec
1
ciprofloxacin 500 mg/5ml sus mc rec
1
ciprofloxacin hcl 100 % crystals
1
ciprofloxacin hcl 100 mg tablet
1
ciprofloxacin hcl 250 mg tablet
1
ciprofloxacin hcl 500 mg tablet
1
ciprofloxacin hcl 750 mg tablet
1
ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr
1
ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr
1
clarithromycin 125 mg/5ml susp recon
1
clarithromycin 250 mg tablet
1
clarithromycin 250 mg/5ml susp recon
1
clarithromycin 500 mg tab er 24h
1
clarithromycin 500 mg tablet
1
dapsone 100 mg tablet
1
dapsone 25 mg tablet
1
ethambutol hcl 100 mg tablet
1
PA
ethambutol hcl 400 mg tablet
1
PA
isoniazid 100 mg tablet
1
PA
isoniazid 300 mg tablet
1
PA
PAGE 10
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
isoniazid 50 mg/5 ml solution
1
levofloxacin 250 mg tablet
1
levofloxacin 250mg/10ml solution
1
levofloxacin 500 mg tablet
1
levofloxacin 750 mg tablet
1
moxifloxacin hcl 400 mg tablet
1
pyrazinamide 500 mg tablet
1
PA
rifabutin 150 mg capsule
1
PA
rifampin 150 mg capsule
1
PA
rifampin 300 mg capsule
1
PA
PA
ANTIPROTOZOALS
atovaquone 750 mg/5ml oral susp
1
atovaquone/proguanil hcl 250-100 mg tablet
1
PA
atovaquone/proguanil hcl 62.5-25 mg tablet
1
PA
AVIDOXY 100 MG TABLET
doxycycline monohydrate
1
chloroquine phosphate 250 mg tablet
1
chloroquine phosphate 500 mg tablet
1
dapsone 100 mg tablet
1
dapsone 25 mg tablet
1
doxycycline hyclate 100 mg capsule
1
doxycycline hyclate 100 mg tablet
1
doxycycline hyclate 100 mg tablet dr
1
doxycycline hyclate 150 mg tablet dr
1
doxycycline hyclate 50 mg capsule
1
doxycycline hyclate 75 mg tablet dr
1
doxycycline monohydrate 100 mg capsule
1
doxycycline monohydrate 100 mg tablet
1
doxycycline monohydrate 150 mg tablet
1
doxycycline monohydrate 25 mg/5 ml susp recon
1
PAGE 11
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
doxycycline monohydrate 50 mg capsule
1
doxycycline monohydrate 50 mg tablet
1
doxycycline monohydrate 75 mg capsule
1
doxycycline monohydrate 75 mg tablet
1
hydroxychloroquine sulfate 200 mg tablet
1
mefloquine hcl 250 mg tablet
1
metronidazole 0.75 % gel w/appl
1
metronidazole 250 mg tablet
1
metronidazole 375 mg capsule
1
metronidazole 500 mg tablet
1
minocycline hcl 100 mg capsule
1
minocycline hcl 100 mg tablet
1
minocycline hcl 50 mg capsule
1
minocycline hcl 50 mg tablet
1
minocycline hcl 75 mg capsule
1
minocycline hcl 75 mg tablet
1
MORGIDOX 100 MG CAPSULE
doxycycline hyclate
1
NEBUPENT 300 MG INHAL POWDER
pentamidine isethionate
1
paromomycin sulfate 250 mg capsule
1
quinidine gluconate 324 mg tablet er
1
quinidine sulfate 200 mg tablet
1
quinidine sulfate 300 mg tablet
1
quinidine sulfate 300 mg tablet er
1
quinine sulfate 324 mg capsule
1
sulfamethoxazole/trimethoprim 200-40mg/5 oral susp
1
sulfamethoxazole/trimethoprim 400mg-80mg tablet
1
sulfamethoxazole/trimethoprim 800-160 mg tablet
1
sulfamethoxazole/trimethoprim 800-160/20 oral susp
1
SULFATRIM PEDIATRIC SUSPENSION
sulfamethoxazole/trimethoprim
1
PAGE 12
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
tetracycline hcl 250 mg capsule
1
tetracycline hcl 500 mg capsule
1
VANDAZOLE VAGINAL 0.75% GEL
metronidazole
1
YODOXIN 210 MG TABLET
iodoquinol
1
YODOXIN 650 MG TABLET
iodoquinol
1
LIMITS & RESTRICTIONS
Antivirals
abacavir sulfate 300 mg tablet
1
abacavir/lamivudine/zidovudine 150-300mg tablet
1
acyclovir 200 mg capsule
1
acyclovir 200 mg/5ml oral susp
1
acyclovir 400 mg tablet
1
acyclovir 800 mg tablet
1
adefovir dipivoxil 10 mg tablet
1
ALFERON N 5 MILLION UNITS VIAL
interferon alfa-n3
1
amantadine hcl 100 mg capsule
1
amantadine hcl 100 mg tablet
1
amantadine hcl 50 mg/5 ml solution
1
APTIVUS 100 MG/ML SOLUTION
tipranavir/vitamin e tpgs
1
APTIVUS 250 MG CAPSULE
tipranavir
1
ATRIPLA TABLET
efavirenz/emtricitabine/tenofovir disoproxil fumarate
1
BARACLUDE 0.05 MG/ML SOLUTION
entecavir
QL
60 / 30 days
QL
60 / 30 days
QL
30 / 30 days
1
QL
630 / 30 days
BARACLUDE 0.5 MG TABLET
entecavir
1
QL
30 / 30 days
BARACLUDE 1 MG TABLET
entecavir
1
QL
30 / 30 days
COMBIVIR TABLET
lamivudine/zidovudine
1
PAGE 13
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
COMPLERA TABLET
emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
1
COPEGUS 200 MG TABLET
ribavirin
1
CRIXIVAN 200 MG CAPSULE
indinavir sulfate
1
CRIXIVAN 400 MG CAPSULE
indinavir sulfate
1
didanosine 125 mg capsule dr
1
didanosine 200 mg capsule dr
1
didanosine 250 mg capsule dr
1
didanosine 400 mg capsule dr
1
EDURANT 25 MG TABLET
rilpivirine hcl
1
EMTRIVA 10 MG/ML SOLUTION
emtricitabine
1
EMTRIVA 200 MG CAPSULE
emtricitabine
1
entecavir 0.5 mg tablet
LIMITS & RESTRICTIONS
QL
180 / 30 days
1
QL
30 / 30 days
entecavir 1 mg tablet
1
QL
30 / 30 days
EPIVIR 10 MG/ML ORAL SOLN
lamivudine
1
EPIVIR 150 MG TABLET
lamivudine
1
EPIVIR 300 MG TABLET
lamivudine
1
EPIVIR HBV 25 MG/5 ML SOLN
lamivudine
1
EPZICOM TABLET
abacavir sulfate/lamivudine
1
EVOTAZ 300 MG-150 MG TABLET
atazanavir sulfate/cobicistat
1
famciclovir 125 mg tablet
1
QL
60 / 30 days
famciclovir 250 mg tablet
1
QL
60 / 30 days
famciclovir 500 mg tablet
1
QL
10 / 30 days
PAGE 14
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
foscarnet sodium 24 mg/ml infus. btl
1
FOSCAVIR 6,000 MG/250 ML BTTL
foscarnet sodium
1
FUZEON 90 MG VIAL
enfuvirtide
1
FUZEON CONVENIENCE KIT
enfuvirtide
1
ganciclovir sodium 500 mg vial
1
HARVONI 90-400 MG TABLET
ledipasvir/sofosbuvir
1
PA
HEPSERA 10 MG TABLET
adefovir dipivoxil
1
QL
INCIVEK 375 MG TABLET
telaprevir
1
INFERGEN 15 MCG/0.5 ML VIAL
interferon alfacon-1
1
INFERGEN 9 MCG/0.3 ML VIAL
interferon alfacon-1
1
INTELENCE 100 MG TABLET
etravirine
1
INTELENCE 200 MG TABLET
etravirine
1
INTELENCE 25 MG TABLET
etravirine
1
INTRON A 10 MILLION UNIT/ML
interferon alfa-2b,recomb.
1
INTRON A 10 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 18 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 50 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 6 MILLION UNIT/ML VL
interferon alfa-2b,recomb.
1
INVIRASE 200 MG CAPSULE
saquinavir mesylate
1
INVIRASE 500 MG TABLET
saquinavir mesylate
1
PAGE 15
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ISENTRESS 100 MG POWDER PACKET
raltegravir potassium
1
ISENTRESS 100 MG TABLET CHEW
raltegravir potassium
1
ISENTRESS 25 MG TABLET CHEW
raltegravir potassium
1
ISENTRESS 400 MG TABLET
raltegravir potassium
1
KALETRA 100-25 MG TABLET
lopinavir/ritonavir
1
KALETRA 200-50 MG TABLET
lopinavir/ritonavir
1
KALETRA 400-100/5 ML ORAL SOLU
lopinavir/ritonavir
1
lamivudine 10 mg/ml solution
1
lamivudine 100 mg tablet
1
lamivudine 150 mg tablet
1
lamivudine 300 mg tablet
1
lamivudine/zidovudine 150-300mg tablet
1
LEXIVA 50 MG/ML SUSPENSION
fosamprenavir calcium
1
LEXIVA 700 MG TABLET
fosamprenavir calcium
1
MODERIBA 200 MG TABLET
ribavirin
1
MODERIBA 200-400 MG DOSEPACK
ribavirin
1
MODERIBA 400-400 MG DOSEPACK
ribavirin
1
MODERIBA 600-400 MG DOSEPACK
ribavirin
1
MODERIBA 600-600 MG DOSEPACK
ribavirin
1
nevirapine 200 mg tablet
1
nevirapine 400 mg tab er 24h
1
nevirapine 50 mg/5 ml oral susp
1
NORVIR 100 MG SOFTGEL CAP
ritonavir
1
PAGE 16
LIMITS & RESTRICTIONS
QL
180 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NORVIR 100 MG TABLET
ritonavir
1
NORVIR 80 MG/ML SOLUTION
ritonavir
1
OLYSIO 150 MG CAPSULE
simeprevir sodium
1
PEGASYS 180 MCG/0.5 ML SYRINGE
peginterferon alfa-2a
1
PEGASYS 180 MCG/ML VIAL
peginterferon alfa-2a
1
PEGASYS PROCLICK 135 MCG/0.5
peginterferon alfa-2a
1
PEGASYS PROCLICK 180 MCG/0.5
peginterferon alfa-2a
1
PEGINTRON 120 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 150 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 50 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 80 MCG KIT
peginterferon alfa-2b
1
PEGINTRON REDIPEN 120 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 120 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 150 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 150 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 50 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 50 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 80 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 80 MCG 4PK
peginterferon alfa-2b
1
PREZCOBIX 800 MG-150 MG TABLET
darunavir ethanolate/cobicistat
1
PAGE 17
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PREZISTA 100 MG/ML SUSPENSION
darunavir ethanolate
1
PREZISTA 150 MG TABLET
darunavir ethanolate
1
PREZISTA 400 MG TABLET
darunavir ethanolate
1
PREZISTA 600 MG TABLET
darunavir ethanolate
1
PREZISTA 75 MG TABLET
darunavir ethanolate
1
PREZISTA 800 MG TABLET
darunavir ethanolate
1
REBETOL 200 MG CAPSULE
ribavirin
1
QL
180 / 30 days
REBETOL 40 MG/ML SOLUTION
ribavirin
1
QL
300 / 30 days
RELENZA 5 MG DISKHALER
zanamivir
1
QL
20 / 30 days
RESCRIPTOR 100 MG TABLET
delavirdine mesylate
1
RESCRIPTOR 200 MG TABLET
delavirdine mesylate
1
RETROVIR 10 MG/ML SYRUP
zidovudine
1
RETROVIR 10 MG/ML VIAL
zidovudine
1
RETROVIR 100 MG CAPSULE
zidovudine
1
RETROVIR 300 MG TABLET
zidovudine
1
REYATAZ 100 MG CAPSULE
atazanavir sulfate
1
REYATAZ 150 MG CAPSULE
atazanavir sulfate
1
REYATAZ 200 MG CAPSULE
atazanavir sulfate
1
REYATAZ 300 MG CAPSULE
atazanavir sulfate
1
REYATAZ 50 MG POWDER PACKET
atazanavir sulfate
1
PAGE 18
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
RIBASPHERE 200 MG CAPSULE
ribavirin
1
QL
180 / 30 days
RIBASPHERE 200 MG TABLET
ribavirin
1
QL
180 / 30 days
RIBASPHERE 400 MG TABLET
ribavirin
1
RIBASPHERE 600 MG TABLET
ribavirin
1
RIBASPHERE RIBAPAK 200-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 400-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 600-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 600-600 MG
ribavirin
1
RIBATAB 400-400 MG DOSEPACK
ribavirin
1
RIBATAB 400-600 MG DOSEPACK
ribavirin
1
RIBATAB 600-600 MG DOSEPACK
ribavirin
1
ribavirin 200 mg capsule
1
QL
180 / 30 days
ribavirin 200 mg tablet
1
QL
180 / 30 days
rimantadine hcl 100 mg tablet
1
SELZENTRY 150 MG TABLET
maraviroc
1
SELZENTRY 300 MG TABLET
maraviroc
1
SOVALDI 400 MG TABLET
sofosbuvir
1
stavudine 1 mg/ml soln recon
1
stavudine 15 mg capsule
1
stavudine 20 mg capsule
1
stavudine 30 mg capsule
1
stavudine 40 mg capsule
1
PAGE 19
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
STRIBILD TABLET
elvitegravir/cobicistat/emtricitabine/tenofovir
1
SUSTIVA 200 MG CAPSULE
efavirenz
1
SUSTIVA 50 MG CAPSULE
efavirenz
1
SUSTIVA 600 MG TABLET
efavirenz
1
SYNAGIS 100 MG/1 ML VIAL
palivizumab
1
SYNAGIS 50 MG/0.5 ML VIAL
palivizumab
1
TAMIFLU 12 MG/ML SUSPENSION
oseltamivir phosphate
1
TAMIFLU 30 MG CAPSULE
oseltamivir phosphate
1
QL
20 / 30 days
TAMIFLU 45 MG CAPSULE
oseltamivir phosphate
1
QL
10 / 30 days
TAMIFLU 6 MG/ML SUSPENSION
oseltamivir phosphate
1
QL
180 / 30 days
TAMIFLU 75 MG CAPSULE
oseltamivir phosphate
1
QL
10 / 30 days
TIVICAY 50 MG TABLET
dolutegravir sodium
1
TRIUMEQ TABLET
abacavir sulfate/dolutegravir sodium/lamivudine
1
TRIZIVIR TABLET
abacavir sulfate/lamivudine/zidovudine
1
TRUVADA 200 MG-300 MG TABLET
emtricitabine/tenofovir disoproxil fumarate
1
TYZEKA 600 MG TABLET
telbivudine
1
QL
30 / 30 days
valacyclovir hcl 1000 mg tablet
1
valacyclovir hcl 500 mg tablet
1
QL
30 / 30 days
VALCYTE 50 MG/ML SOLUTION
valganciclovir hcl
1
valganciclovir hcl 450 mg tablet
1
PAGE 20
QL
1 / 30 days
PA
QL
1 / 30 days
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VICTRELIS 200 MG CAPSULE
boceprevir
1
VIDEX 2 GM PEDIATRIC SOLN
didanosine
1
VIDEX 4 GM PEDIATRIC SOLN
didanosine
1
VIDEX EC 125 MG CAPSULE
didanosine
1
VIDEX EC 200 MG CAPSULE
didanosine
1
VIDEX EC 250 MG CAPSULE
didanosine
1
VIDEX EC 400 MG CAPSULE
didanosine
1
VIRACEPT 250 MG TABLET
nelfinavir mesylate
1
VIRACEPT 625 MG TABLET
nelfinavir mesylate
1
VIRAMUNE 200 MG TABLET
nevirapine
1
VIRAMUNE 50 MG/5 ML SUSP
nevirapine
1
VIRAMUNE XR 100 MG TABLET
nevirapine
1
VIRAMUNE XR 400 MG TABLET
nevirapine
1
VIRAZOLE 6 GM VIAL
ribavirin
1
VIREAD 150 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 200 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 250 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 300 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD POWDER
tenofovir disoproxil fumarate
1
VITEKTA 150 MG TABLET
elvitegravir
1
PAGE 21
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VITEKTA 85 MG TABLET
elvitegravir
1
ZERIT 1 MG/ML SOLUTION
stavudine
1
ZERIT 15 MG CAPSULE
stavudine
1
ZERIT 20 MG CAPSULE
stavudine
1
ZERIT 30 MG CAPSULE
stavudine
1
ZERIT 40 MG CAPSULE
stavudine
1
ZIAGEN 20 MG/ML SOLUTION
abacavir sulfate
1
ZIAGEN 300 MG TABLET
abacavir sulfate
1
zidovudine 10 mg/ml syrup
1
zidovudine 100 mg capsule
1
zidovudine 300 mg tablet
1
LIMITS & RESTRICTIONS
ANTIVIRALS (SYSTEMIC)
abacavir sulfate 300 mg tablet
1
abacavir/lamivudine/zidovudine 150-300mg tablet
1
acyclovir 200 mg capsule
1
acyclovir 200 mg/5ml oral susp
1
acyclovir 400 mg tablet
1
acyclovir 800 mg tablet
1
adefovir dipivoxil 10 mg tablet
1
ALFERON N 5 MILLION UNITS VIAL
interferon alfa-n3
1
amantadine hcl 100 mg capsule
1
amantadine hcl 100 mg tablet
1
amantadine hcl 50 mg/5 ml solution
1
APTIVUS 100 MG/ML SOLUTION
tipranavir/vitamin e tpgs
1
PAGE 22
QL
60 / 30 days
QL
60 / 30 days
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
APTIVUS 250 MG CAPSULE
tipranavir
1
ATRIPLA TABLET
efavirenz/emtricitabine/tenofovir disoproxil fumarate
1
BARACLUDE 0.05 MG/ML SOLUTION
entecavir
1
QL
630 / 30 days
BARACLUDE 0.5 MG TABLET
entecavir
1
QL
30 / 30 days
BARACLUDE 1 MG TABLET
entecavir
1
QL
30 / 30 days
COMBIVIR TABLET
lamivudine/zidovudine
1
COMPLERA TABLET
emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
1
COPEGUS 200 MG TABLET
ribavirin
1
QL
180 / 30 days
CRIXIVAN 200 MG CAPSULE
indinavir sulfate
1
CRIXIVAN 400 MG CAPSULE
indinavir sulfate
1
didanosine 125 mg capsule dr
1
didanosine 200 mg capsule dr
1
didanosine 250 mg capsule dr
1
didanosine 400 mg capsule dr
1
EDURANT 25 MG TABLET
rilpivirine hcl
1
EMTRIVA 10 MG/ML SOLUTION
emtricitabine
1
EMTRIVA 200 MG CAPSULE
emtricitabine
1
entecavir 0.5 mg tablet
1
QL
30 / 30 days
entecavir 1 mg tablet
1
QL
30 / 30 days
EPIVIR 10 MG/ML ORAL SOLN
lamivudine
1
EPIVIR 150 MG TABLET
lamivudine
1
EPIVIR 300 MG TABLET
lamivudine
1
PAGE 23
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
EPIVIR HBV 25 MG/5 ML SOLN
lamivudine
1
EPZICOM TABLET
abacavir sulfate/lamivudine
1
EVOTAZ 300 MG-150 MG TABLET
atazanavir sulfate/cobicistat
1
famciclovir 125 mg tablet
1
QL
60 / 30 days
famciclovir 250 mg tablet
1
QL
60 / 30 days
famciclovir 500 mg tablet
1
QL
10 / 30 days
foscarnet sodium 24 mg/ml infus. btl
1
FOSCAVIR 6,000 MG/250 ML BTTL
foscarnet sodium
1
FUZEON 90 MG VIAL
enfuvirtide
1
FUZEON CONVENIENCE KIT
enfuvirtide
1
ganciclovir sodium 500 mg vial
1
HARVONI 90-400 MG TABLET
ledipasvir/sofosbuvir
1
PA
HEPSERA 10 MG TABLET
adefovir dipivoxil
1
QL
INCIVEK 375 MG TABLET
telaprevir
1
INFERGEN 15 MCG/0.5 ML VIAL
interferon alfacon-1
1
INFERGEN 9 MCG/0.3 ML VIAL
interferon alfacon-1
1
INTELENCE 100 MG TABLET
etravirine
1
INTELENCE 200 MG TABLET
etravirine
1
INTELENCE 25 MG TABLET
etravirine
1
INTRON A 10 MILLION UNIT/ML
interferon alfa-2b,recomb.
1
INTRON A 10 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
PAGE 24
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
INTRON A 18 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 50 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 6 MILLION UNIT/ML VL
interferon alfa-2b,recomb.
1
INVIRASE 200 MG CAPSULE
saquinavir mesylate
1
INVIRASE 500 MG TABLET
saquinavir mesylate
1
ISENTRESS 100 MG POWDER PACKET
raltegravir potassium
1
ISENTRESS 100 MG TABLET CHEW
raltegravir potassium
1
ISENTRESS 25 MG TABLET CHEW
raltegravir potassium
1
ISENTRESS 400 MG TABLET
raltegravir potassium
1
KALETRA 100-25 MG TABLET
lopinavir/ritonavir
1
KALETRA 200-50 MG TABLET
lopinavir/ritonavir
1
KALETRA 400-100/5 ML ORAL SOLU
lopinavir/ritonavir
1
lamivudine 10 mg/ml solution
1
lamivudine 100 mg tablet
1
lamivudine 150 mg tablet
1
lamivudine 300 mg tablet
1
lamivudine/zidovudine 150-300mg tablet
1
LEXIVA 50 MG/ML SUSPENSION
fosamprenavir calcium
1
LEXIVA 700 MG TABLET
fosamprenavir calcium
1
MODERIBA 200 MG TABLET
ribavirin
1
MODERIBA 200-400 MG DOSEPACK
ribavirin
1
PAGE 25
LIMITS & RESTRICTIONS
QL
180 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
MODERIBA 400-400 MG DOSEPACK
ribavirin
1
MODERIBA 600-400 MG DOSEPACK
ribavirin
1
MODERIBA 600-600 MG DOSEPACK
ribavirin
1
nevirapine 200 mg tablet
1
nevirapine 400 mg tab er 24h
1
nevirapine 50 mg/5 ml oral susp
1
NORVIR 100 MG SOFTGEL CAP
ritonavir
1
NORVIR 100 MG TABLET
ritonavir
1
NORVIR 80 MG/ML SOLUTION
ritonavir
1
OLYSIO 150 MG CAPSULE
simeprevir sodium
1
PEGASYS 180 MCG/0.5 ML SYRINGE
peginterferon alfa-2a
1
PEGASYS 180 MCG/ML VIAL
peginterferon alfa-2a
1
PEGASYS PROCLICK 135 MCG/0.5
peginterferon alfa-2a
1
PEGASYS PROCLICK 180 MCG/0.5
peginterferon alfa-2a
1
PEGINTRON 120 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 150 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 50 MCG KIT
peginterferon alfa-2b
1
PEGINTRON 80 MCG KIT
peginterferon alfa-2b
1
PEGINTRON REDIPEN 120 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 120 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 150 MCG
peginterferon alfa-2b
1
PAGE 26
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PEGINTRON REDIPEN 150 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 50 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 50 MCG 4PK
peginterferon alfa-2b
1
PEGINTRON REDIPEN 80 MCG
peginterferon alfa-2b
1
PEGINTRON REDIPEN 80 MCG 4PK
peginterferon alfa-2b
1
PREZCOBIX 800 MG-150 MG TABLET
darunavir ethanolate/cobicistat
1
PREZISTA 100 MG/ML SUSPENSION
darunavir ethanolate
1
PREZISTA 150 MG TABLET
darunavir ethanolate
1
PREZISTA 400 MG TABLET
darunavir ethanolate
1
PREZISTA 600 MG TABLET
darunavir ethanolate
1
PREZISTA 75 MG TABLET
darunavir ethanolate
1
PREZISTA 800 MG TABLET
darunavir ethanolate
1
REBETOL 200 MG CAPSULE
ribavirin
1
QL
180 / 30 days
REBETOL 40 MG/ML SOLUTION
ribavirin
1
QL
300 / 30 days
RELENZA 5 MG DISKHALER
zanamivir
1
QL
20 / 30 days
RESCRIPTOR 100 MG TABLET
delavirdine mesylate
1
RESCRIPTOR 200 MG TABLET
delavirdine mesylate
1
RETROVIR 10 MG/ML SYRUP
zidovudine
1
RETROVIR 10 MG/ML VIAL
zidovudine
1
RETROVIR 100 MG CAPSULE
zidovudine
1
PAGE 27
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
RETROVIR 300 MG TABLET
zidovudine
1
REYATAZ 100 MG CAPSULE
atazanavir sulfate
1
REYATAZ 150 MG CAPSULE
atazanavir sulfate
1
REYATAZ 200 MG CAPSULE
atazanavir sulfate
1
REYATAZ 300 MG CAPSULE
atazanavir sulfate
1
REYATAZ 50 MG POWDER PACKET
atazanavir sulfate
1
RIBASPHERE 200 MG CAPSULE
ribavirin
1
QL
180 / 30 days
RIBASPHERE 200 MG TABLET
ribavirin
1
QL
180 / 30 days
RIBASPHERE 400 MG TABLET
ribavirin
1
RIBASPHERE 600 MG TABLET
ribavirin
1
RIBASPHERE RIBAPAK 200-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 400-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 600-400 MG
ribavirin
1
RIBASPHERE RIBAPAK 600-600 MG
ribavirin
1
RIBATAB 400-400 MG DOSEPACK
ribavirin
1
RIBATAB 400-600 MG DOSEPACK
ribavirin
1
RIBATAB 600-600 MG DOSEPACK
ribavirin
1
ribavirin 200 mg capsule
1
QL
180 / 30 days
ribavirin 200 mg tablet
1
QL
180 / 30 days
rimantadine hcl 100 mg tablet
1
PAGE 28
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SELZENTRY 150 MG TABLET
maraviroc
1
SELZENTRY 300 MG TABLET
maraviroc
1
SOVALDI 400 MG TABLET
sofosbuvir
1
stavudine 1 mg/ml soln recon
1
stavudine 15 mg capsule
1
stavudine 20 mg capsule
1
stavudine 30 mg capsule
1
stavudine 40 mg capsule
1
STRIBILD TABLET
elvitegravir/cobicistat/emtricitabine/tenofovir
1
SUSTIVA 200 MG CAPSULE
efavirenz
1
SUSTIVA 50 MG CAPSULE
efavirenz
1
SUSTIVA 600 MG TABLET
efavirenz
1
SYNAGIS 100 MG/1 ML VIAL
palivizumab
1
SYNAGIS 50 MG/0.5 ML VIAL
palivizumab
1
TAMIFLU 12 MG/ML SUSPENSION
oseltamivir phosphate
1
TAMIFLU 30 MG CAPSULE
oseltamivir phosphate
1
QL
20 / 30 days
TAMIFLU 45 MG CAPSULE
oseltamivir phosphate
1
QL
10 / 30 days
TAMIFLU 6 MG/ML SUSPENSION
oseltamivir phosphate
1
QL
180 / 30 days
TAMIFLU 75 MG CAPSULE
oseltamivir phosphate
1
QL
10 / 30 days
TIVICAY 50 MG TABLET
dolutegravir sodium
1
TRIUMEQ TABLET
abacavir sulfate/dolutegravir sodium/lamivudine
1
PAGE 29
PA
QL
1 / 30 days
PA
QL
1 / 30 days
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRIZIVIR TABLET
abacavir sulfate/lamivudine/zidovudine
1
TRUVADA 200 MG-300 MG TABLET
emtricitabine/tenofovir disoproxil fumarate
1
TYZEKA 600 MG TABLET
telbivudine
1
valacyclovir hcl 1000 mg tablet
1
valacyclovir hcl 500 mg tablet
1
VALCYTE 50 MG/ML SOLUTION
valganciclovir hcl
1
valganciclovir hcl 450 mg tablet
1
VICTRELIS 200 MG CAPSULE
boceprevir
1
VIDEX 2 GM PEDIATRIC SOLN
didanosine
1
VIDEX 4 GM PEDIATRIC SOLN
didanosine
1
VIDEX EC 125 MG CAPSULE
didanosine
1
VIDEX EC 200 MG CAPSULE
didanosine
1
VIDEX EC 250 MG CAPSULE
didanosine
1
VIDEX EC 400 MG CAPSULE
didanosine
1
VIRACEPT 250 MG TABLET
nelfinavir mesylate
1
VIRACEPT 625 MG TABLET
nelfinavir mesylate
1
VIRAMUNE 200 MG TABLET
nevirapine
1
VIRAMUNE 50 MG/5 ML SUSP
nevirapine
1
VIRAMUNE XR 100 MG TABLET
nevirapine
1
VIRAMUNE XR 400 MG TABLET
nevirapine
1
VIRAZOLE 6 GM VIAL
ribavirin
1
PAGE 30
LIMITS & RESTRICTIONS
QL
30 / 30 days
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VIREAD 150 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 200 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 250 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD 300 MG TABLET
tenofovir disoproxil fumarate
1
VIREAD POWDER
tenofovir disoproxil fumarate
1
VITEKTA 150 MG TABLET
elvitegravir
1
VITEKTA 85 MG TABLET
elvitegravir
1
ZERIT 1 MG/ML SOLUTION
stavudine
1
ZERIT 15 MG CAPSULE
stavudine
1
ZERIT 20 MG CAPSULE
stavudine
1
ZERIT 30 MG CAPSULE
stavudine
1
ZERIT 40 MG CAPSULE
stavudine
1
ZIAGEN 20 MG/ML SOLUTION
abacavir sulfate
1
ZIAGEN 300 MG TABLET
abacavir sulfate
1
zidovudine 10 mg/ml syrup
1
zidovudine 100 mg capsule
1
zidovudine 300 mg tablet
1
LIMITS & RESTRICTIONS
URINARY ANTI-INFECTIVES
HYOPHEN TABLET
methenamine/methylene blue/benzoic acid/salicylate/hyoscy
1
methenamine hippurate 1 g tablet
1
methenamine mandelate 1 g tablet
1
methenamine mandelate 500 mg tablet
1
PAGE 31
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nitrofurantoin 25 mg/5 ml oral susp
1
nitrofurantoin macrocrystal 100 mg capsule
1
nitrofurantoin macrocrystal 50 mg capsule
1
nitrofurantoin monohyd/m-cryst 100 mg capsule
1
PHOSPHASAL TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
sulfamethoxazole/trimethoprim 200-40mg/5 oral susp
1
sulfamethoxazole/trimethoprim 400mg-80mg tablet
1
sulfamethoxazole/trimethoprim 800-160 mg tablet
1
sulfamethoxazole/trimethoprim 800-160/20 oral susp
1
SULFATRIM PEDIATRIC SUSPENSION
sulfamethoxazole/trimethoprim
1
trimethoprim 100 mg tablet
1
UR N-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URETRON D-S TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URETRON D-S TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URIMAR-T TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URIN D.S. TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-L TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-MP CAPSULE
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
USTELL CAPSULE
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
UTIRA-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
LIMITS & RESTRICTIONS
ANTIHISTAMINE DRUGS
promethazine hcl 25 mg tablet
1
FIRST GENERATION ANTIHISTAMINES
ANABAR CAPLET
salicylamide/acetaminophen/phenyltoloxamine
PAGE 32
1
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ARBINOXA 4 MG TABLET
carbinoxamine maleate
1
ARBINOXA 4 MG/5 ML LIQUID
carbinoxamine maleate
1
CAFGESIC FORTE TABLET
magnesium
salicylate/acetaminophen/phenyltoloxamine/caffeine
1
carbinoxamine maleate 4 mg tablet
1
carbinoxamine maleate 4 mg/5 ml liquid
1
CENTERGY DM PEDIATRIC DROPS
dextromethorphan hbr/phenylephrine hcl/chlorpheniramine
1
CENTERGY PEDIATRIC DROPS
phenylephrine hcl/chlorpheniramine maleate
1
clemastine fumarate 0.67mg/5ml syrup
1
clemastine fumarate 2.68 mg tablet
1
cyproheptadine hcl 2 mg/5 ml syrup
1
cyproheptadine hcl 4 mg tablet
1
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
1
d-methorphan hb/prometh hcl 15-6.25/5 syrup
1
dexchlorpheniramine maleate 2 mg/5 ml syrup
1
diphenhydramine hcl 12.5mg/5ml elixir
1
diphenhydramine hcl 50 mg capsule
1
DOXYTEX 2.5 MG/2.5 ML LIQUID
doxylamine succinate
1
DURAXIN CAPSULE
salicylamide/acetaminophen/phenyltoloxamine
1
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
ENDACOF-C LIQUID
chlorpheniramine maleate/codeine phosphate
1
hydroxyzine hcl 10 mg tablet
1
hydroxyzine hcl 10 mg/5 ml solution
1
hydroxyzine hcl 25 mg tablet
1
hydroxyzine hcl 50 mg tablet
1
hydroxyzine pamoate 100 mg capsule
1
PAGE 33
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
hydroxyzine pamoate 25 mg capsule
1
hydroxyzine pamoate 50 mg capsule
1
INDAMIX DM SUSPENSION
dextromethorphan tannate/p-epd tan/dexchlorpheniramine
1
meclizine hcl 12.5 mg tablet
1
meclizine hcl 25 mg tablet
1
NOVAGESIC CAPLET
acetaminophen/phenyltoloxamine cit
1
PALGIC 4 MG TABLET
carbinoxamine maleate
1
PALGIC 4 MG/5 ML LIQUID
carbinoxamine maleate
1
PHENADOZ 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENADOZ 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 50 MG SUPPOSITORY
promethazine hcl
1
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup
1
promethazine hcl 12.5 mg supp.rect
1
promethazine hcl 12.5 mg tablet
1
promethazine hcl 25 mg supp.rect
1
promethazine hcl 25 mg tablet
1
promethazine hcl 50 mg supp.rect
1
promethazine hcl 50 mg tablet
1
promethazine hcl 6.25mg/5ml syrup
1
promethazine hcl/codeine 6.25-10/5 syrup
1
promethazine/dextromethorphan 6.25-15/5 syrup
1
promethazine/phenyleph/codeine 6.25-5-10 syrup
1
PROMETHEGAN 12.5 MG SUPPOS
promethazine hcl
1
PAGE 34
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PROMETHEGAN 25 MG SUPP
promethazine hcl
1
PROMETHEGAN 50 MG SUPPOSITORY
promethazine hcl
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
R-TANNA TABLET
phenylephrine tannate/chlorpheniramine tannate
1
RHINOFLEX 500 MG-50 MG TABLET
acetaminophen/phenyltoloxamine citrate
1
RHINOFLEX-650 TABLET
acetaminophen/phenyltoloxamine citrate
1
RU-HIST FORTE TABLET SA
phenylephrine hcl/pyrilamine maleate/chlorpheniramine
1
ZFLEX TABLET
acetaminophen/phenyltoloxamine citrate
1
ZGESIC TABLET
acetaminophen/phenyltoloxamine citrate
1
LIMITS & RESTRICTIONS
OTHER ANTIHISTAMINES
cimetidine 200 mg tablet
1
cimetidine 300 mg tablet
1
cimetidine 400 mg tablet
1
cimetidine 800 mg tablet
1
cimetidine hcl 300 mg/5ml solution
1
famotidine 20 mg tablet
1
famotidine 40 mg tablet
1
hydroxyzine hcl 10 mg tablet
1
hydroxyzine hcl 10 mg/5 ml solution
1
hydroxyzine hcl 25 mg tablet
1
hydroxyzine hcl 50 mg tablet
1
hydroxyzine pamoate 100 mg capsule
1
hydroxyzine pamoate 25 mg capsule
1
hydroxyzine pamoate 50 mg capsule
1
nizatidine 150 mg capsule
1
nizatidine 150mg/10ml solution
1
PAGE 35
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nizatidine 300 mg capsule
1
olopatadine hcl 0.6 % spray/pump
1
ranitidine hcl 15 mg/ml syrup
1
ranitidine hcl 150 mg capsule
1
ranitidine hcl 150 mg tablet
1
ranitidine hcl 300 mg capsule
1
ranitidine hcl 300 mg tablet
1
LIMITS & RESTRICTIONS
SECOND GENERATION ANTIHISTAMINES
cetirizine hcl 1 mg/ml solution
1
desloratadine 2.5 mg tab rapdis
1
desloratadine 5 mg tab rapdis
1
desloratadine 5 mg tablet
1
fexofenadine hcl 180 mg tablet
1
fexofenadine hcl 60 mg tablet
1
loratadine 100 % powder
1
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANASPAZ 0.125 MG TABLET ODT
hyoscyamine sulfate
1
ATROVENT HFA INHALER
ipratropium bromide
1
benztropine mesylate 0.5 mg tablet
1
benztropine mesylate 1 mg tablet
1
benztropine mesylate 2 mg tablet
1
COMBIVENT INHALER
ipratropium bromide/albuterol sulfate
1
COMBIVENT RESPIMAT INHAL SPRAY
ipratropium bromide/albuterol sulfate
1
dicyclomine hcl 10 mg capsule
1
dicyclomine hcl 10 mg/5 ml solution
1
dicyclomine hcl 20 mg tablet
1
diphenhydramine hcl 12.5mg/5ml elixir
1
PAGE 36
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
diphenhydramine hcl 50 mg capsule
1
diphenoxylate hcl/atropine 2.5-.025/5 liquid
1
diphenoxylate hcl/atropine 2.5-.025mg tablet
1
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
ED-SPAZ 0.125 MG ODT
hyoscyamine sulfate
1
glycopyrrolate 1 mg tablet
1
glycopyrrolate 2 mg tablet
1
hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet
1
hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup
1
HYDROMET SYRUP
hydrocodone bitartrate/homatropine methylbromide
1
HYOMAX-SL 0.125 MG TABLET SL
hyoscyamine sulfate
1
HYOPHEN TABLET
methenamine/methylene blue/benzoic acid/salicylate/hyoscy
1
hyoscyamine sulfate 0.125 mg tab rapdis
1
hyoscyamine sulfate 0.125 mg tab subl
1
hyoscyamine sulfate 0.125 mg tablet
1
hyoscyamine sulfate 0.125mg/ml drops
1
hyoscyamine sulfate 0.375 mg tab er 12h
1
hyoscyamine sulfate 125mcg/5ml elixir
1
HYOSYNE 0.125 MG/ML DROP
hyoscyamine sulfate
1
HYOSYNE 125 MCG/5 ML ELIXIR
hyoscyamine sulfate
1
ipratropium bromide 0.2 mg/ml solution
1
ipratropium bromide 21 mcg spray
1
ipratropium bromide 42mcg spray
1
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
1
ME-PB-HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
ME-PB-HYOS TABLET
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
PAGE 37
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
methscopolamine bromide 2.5 mg tablet
1
methscopolamine bromide 5 mg tablet
1
opium/belladonna alkaloids 30-16.2mg supp.rect
1
opium/belladonna alkaloids 60-16.2mg supp.rect
1
OSCIMIN 0.125 MG ODT
hyoscyamine sulfate
1
OSCIMIN 0.125 MG TABLET
hyoscyamine sulfate
1
OSCIMIN SL 0.125 MG TABLET
hyoscyamine sulfate
1
OSCIMIN SR 0.375 MG TABLET
hyoscyamine sulfate
1
PHOSPHASAL TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
propantheline bromide 15 mg tablet
1
QUADRAPAX ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
SE-DONNA PB HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
SPIRIVA 18 MCG CP-HANDIHALER
tiotropium bromide
1
SYMAX FASTABS 0.125 MG TABLET
hyoscyamine sulfate
1
SYMAX-SL 0.125 MG TABLET SL
hyoscyamine sulfate
1
SYMAX-SR 0.375 MG TABLET
hyoscyamine sulfate
1
trihexyphenidyl hcl 2 mg tablet
1
trihexyphenidyl hcl 2 mg/5 ml elixir
1
trihexyphenidyl hcl 5 mg tablet
1
TUSSIGON 5-1.5 MG TABLET
hydrocodone bitartrate/homatropine methylbromide
1
UR N-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URETRON D-S TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URETRON D-S TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
PAGE 38
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
URIMAR-T TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URIN D.S. TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-L TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-MP CAPSULE
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
USTELL CAPSULE
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
UTIRA-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
bethanechol chloride 10 mg tablet
1
bethanechol chloride 25 mg tablet
1
bethanechol chloride 5 mg tablet
1
bethanechol chloride 50 mg tablet
1
cevimeline hcl 30 mg capsule
1
galantamine hbr 12 mg tablet
1
galantamine hbr 16 mg cap24h pel
1
QL
30 / 30 days
galantamine hbr 24 mg cap24h pel
1
QL
30 / 30 days
galantamine hbr 4 mg tablet
1
galantamine hbr 4 mg/ml solution
1
galantamine hbr 8 mg cap24h pel
1
QL
30 / 30 days
galantamine hbr 8 mg tablet
1
guanidine hcl 125 mg tablet
1
pilocarpine hcl 5 mg tablet
1
pilocarpine hcl 7.5 mg tablet
1
pyridostigmine bromide 60 mg tablet
1
SKELETAL MUSCLE RELAXANTS
baclofen 10 mg tablet
1
baclofen 20 mg tablet
1
chlorzoxazone 500 mg tablet
1
cyclobenzaprine hcl 10 mg tablet
1
PAGE 39
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
cyclobenzaprine hcl 5 mg tablet
1
cyclobenzaprine hcl 7.5 mg tablet
1
dantrolene sodium 100 mg capsule
1
dantrolene sodium 25 mg capsule
1
dantrolene sodium 50 mg capsule
1
metaxalone 400 mg tablet
1
metaxalone 800 mg tablet
1
methocarbamol 500 mg tablet
1
methocarbamol 750 mg tablet
1
orphenadrine citrate 100 mg tablet er
1
orphenadrine/aspirin/caffeine 25-385-30 tablet
1
orphenadrine/aspirin/caffeine 50-770-60 tablet
1
tizanidine hcl 2 mg capsule
1
tizanidine hcl 2 mg tablet
1
tizanidine hcl 4 mg capsule
1
tizanidine hcl 4 mg tablet
1
tizanidine hcl 6 mg capsule
1
LIMITS & RESTRICTIONS
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
acebutolol hcl 200 mg capsule
1
acebutolol hcl 400 mg capsule
1
alfuzosin hcl 10 mg tab er 24h
1
atenolol 100 mg tablet
1
atenolol 25 mg tablet
1
atenolol 50 mg tablet
1
atenolol/chlorthalidone 100mg-25mg tablet
1
atenolol/chlorthalidone 50 mg-25mg tablet
1
betaxolol hcl 10 mg tablet
1
betaxolol hcl 20 mg tablet
1
bisoprolol fumarate 10 mg tablet
1
bisoprolol fumarate 5 mg tablet
1
bisoprolol fumarate/hctz 10-6.25mg tablet
1
PAGE 40
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
bisoprolol fumarate/hctz 2.5-6.25mg tablet
1
bisoprolol fumarate/hctz 5-6.25mg tablet
1
carvedilol 12.5 mg tablet
1
carvedilol 25 mg tablet
1
carvedilol 3.125 mg tablet
1
carvedilol 6.25 mg tablet
1
dihydroergotamine mesylate 0.5mg/spry spray/pump
1
doxazosin mesylate 1 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 2 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 4 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 8 mg tablet
1
QL
60 / 30 days
ergoloid mesylates 1 mg tablet
1
ERGOMAR 2 MG TABLET SL
ergotamine tartrate
1
ergotamine tartrate/caffeine 1 mg-100mg tablet
1
labetalol hcl 100 mg tablet
1
labetalol hcl 200 mg tablet
1
labetalol hcl 300 mg tablet
1
metoprolol succinate 100 mg tab er 24h
1
metoprolol succinate 200 mg tab er 24h
1
metoprolol succinate 25 mg tab er 24h
1
metoprolol succinate 50 mg tab er 24h
1
metoprolol tartrate 100 mg tablet
1
metoprolol tartrate 25 mg tablet
1
metoprolol tartrate 50 mg tablet
1
metoprolol/hydrochlorothiazide 100mg-25mg tablet
1
metoprolol/hydrochlorothiazide 100mg-50mg tablet
1
metoprolol/hydrochlorothiazide 50 mg-25mg tablet
1
MIGERGOT SUPPOSITORY
ergotamine tartrate/caffeine
1
nadolol 20 mg tablet
1
PAGE 41
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
nadolol 40 mg tablet
1
nadolol 80 mg tablet
1
nadolol/bendroflumethiazide 40 mg-5 mg tablet
1
nadolol/bendroflumethiazide 80 mg-5 mg tablet
1
pindolol 10 mg tablet
1
pindolol 5 mg tablet
1
prazosin hcl 1 mg capsule
1
QL
90 / 30 days
prazosin hcl 2 mg capsule
1
QL
120 / 30 days
prazosin hcl 5 mg capsule
1
QL
120 / 30 days
propranolol hcl 10 mg tablet
1
propranolol hcl 120 mg cap sa 24h
1
propranolol hcl 160 mg cap sa 24h
1
propranolol hcl 20 mg tablet
1
propranolol hcl 20 mg/5 ml solution
1
propranolol hcl 40 mg tablet
1
propranolol hcl 40mg/5ml solution
1
propranolol hcl 60 mg cap sa 24h
1
propranolol hcl 60 mg tablet
1
propranolol hcl 80 mg cap sa 24h
1
propranolol hcl 80 mg tablet
1
propranolol/hydrochlorothiazid 40 mg-25mg tablet
1
propranolol/hydrochlorothiazid 80 mg-25mg tablet
1
SORINE 120 MG TABLET
sotalol hcl
1
SORINE 160 MG TABLET
sotalol hcl
1
SORINE 240 MG TABLET
sotalol hcl
1
SORINE 80 MG TABLET
sotalol hcl
1
sotalol hcl 120 mg tablet
1
sotalol hcl 160 mg tablet
1
PAGE 42
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
sotalol hcl 240 mg tablet
1
sotalol hcl 80 mg tablet
1
tamsulosin hcl 0.4 mg cap er 24h
1
QL
60 / 30 days
terazosin hcl 1 mg capsule
1
QL
60 / 30 days
terazosin hcl 10 mg capsule
1
QL
60 / 30 days
terazosin hcl 2 mg capsule
1
QL
60 / 30 days
terazosin hcl 5 mg capsule
1
QL
60 / 30 days
timolol maleate 10 mg tablet
1
timolol maleate 20 mg tablet
1
timolol maleate 5 mg tablet
1
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR 100-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 250-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 500-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 115-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 230-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 45-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
albuterol sulfate 0.63mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 1.25mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 2 mg tablet
1
albuterol sulfate 2 mg/5 ml syrup
1
albuterol sulfate 2.5 mg/0.5 vial-neb
1
albuterol sulfate 2.5 mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 4 mg tab er 12h
1
albuterol sulfate 4 mg tablet
1
albuterol sulfate 5 mg/ml solution
1
PAGE 43
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
albuterol sulfate 8 mg tab er 12h
1
AMBI 10PEH-400GFN-20DM TABLET
guaifenesin/dextromethorphan hbr/phenylephrine
1
CENTERGY DM PEDIATRIC DROPS
dextromethorphan hbr/phenylephrine hcl/chlorpheniramine
1
CENTERGY PEDIATRIC DROPS
phenylephrine hcl/chlorpheniramine maleate
1
clonidine 0.1mg/24hr patch tdwk
1
clonidine 0.2mg/24hr patch tdwk
1
clonidine 0.3mg/24hr patch tdwk
1
clonidine hcl 0.1 mg tab er 12h
1
clonidine hcl 0.1 mg tablet
1
clonidine hcl 0.2 mg tablet
1
clonidine hcl 0.3 mg tablet
1
COMBIVENT INHALER
ipratropium bromide/albuterol sulfate
1
COMBIVENT RESPIMAT INHAL SPRAY
ipratropium bromide/albuterol sulfate
1
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
1
DESPEC-EXP SYRUP
guaifenesin/pseudoephedrine hcl/dihydrocodeine
1
epinephrine 0.15/0.15 auto injct
1
epinephrine 0.3mg/0.3 auto injct
1
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
epinephrine
1
EPIPEN JR 2-PAK 0.15 MG INJCTR
epinephrine
1
guaifenesin/phenylephrine hcl 20-1.5/ml drops
1
INDAMIX DM SUSPENSION
dextromethorphan tannate/p-epd tan/dexchlorpheniramine
1
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
1
KAPVAY 0.1-0.2 MG DOSEPACK
clonidine hcl
1
levalbuterol hcl 0.31mg/3ml vial-neb
1
ST
levalbuterol hcl 0.63mg/3ml vial-neb
1
ST
PAGE 44
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
levalbuterol hcl 1.25mg/0.5 vial-neb
1
ST
levalbuterol hcl 1.25mg/3ml vial-neb
1
ST
metaproterenol sulfate 10 mg tablet
1
metaproterenol sulfate 10 mg/5 ml syrup
1
metaproterenol sulfate 20 mg tablet
1
methyldopa 250 mg tablet
1
methyldopa 500 mg tablet
1
methyldopa/hydrochlorothiazide 250mg-15mg tablet
1
methyldopa/hydrochlorothiazide 250mg-25mg tablet
1
midodrine hcl 10 mg tablet
1
midodrine hcl 2.5 mg tablet
1
midodrine hcl 5 mg tablet
1
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup
1
promethazine/phenyleph/codeine 6.25-5-10 syrup
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
R-TANNA TABLET
phenylephrine tannate/chlorpheniramine tannate
1
RU-HIST FORTE TABLET SA
phenylephrine hcl/pyrilamine maleate/chlorpheniramine
1
SEREVENT DISKUS 50 MCG
salmeterol xinafoate
1
SYMBICORT 160-4.5 MCG INHALER
budesonide/formoterol fumarate
1
SYMBICORT 80-4.5 MCG INHALER
budesonide/formoterol fumarate
1
terbutaline sulfate 2.5 mg tablet
1
terbutaline sulfate 5 mg tablet
1
VENTOLIN HFA 90 MCG INHALER
albuterol sulfate
1
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIANEMIA DRUGS
BAL-CARE DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
PAGE 45
1
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BP MULTINATAL PLUS CHEW TABLET
prenatal vitamin w-o vit a/ferrous fumarate/folic acid
1
C-NATE DHA SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
CALCIUM-PNV 28-1-250 MG SFTGL
prenatal vits with calcium #70/ferrous fumarate/fa/dha
1
CAVAN-ALPHA KIT COMBO PACK
prenatal vitamin no.67/sodium feredetate-iron poly/fa/omega3
1
CAVAN-EC SOD DHA VITAMINS
prenatal vitamins comb no.48/iron na feredetate/fa/omega-3
1
CENTRATEX CAPSULE
ferrous fumarate/folic acid/multivitamins with min no. 15
1
CHOICE-OB + DHA COMBO PACK
prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha
1
COMPLETE NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
COMPLETENATE TABLET CHEW
prenatal vitamins combo no.14/ferrous fumarate/folic acid
1
ELITE OB DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
ELITE-OB 400 CAPSULE
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
ELITE-OB CAPLET
iron,carbonyl/folic acid/multivitamin w-minerals
1
FE 90 PLUS TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
FE C PLUS TABLET
iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
1
FEROCON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
FEROTRIN CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
FERRAPLUS 90 TABLET
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
1
FERREX 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
FERREX 150 FORTE PLUS CAPSULE
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
FERREX 28 TABLET
iron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
1
PAGE 46
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FERROCITE PLUS TABLET
iron/folic acid/vitamin b comp w-c/minerals
1
FERROGELS FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
fluoride/iron/vit a,c&d 0.25 mg/ml drops
1
FOCALGIN 90 DHA COMBO PACK
prenatal vitamins no.72/iron carbonyl & gluconate/fa/dss/dha
1
FOCALGIN CA COMBO PACK
prenatal vitamins no.73/iron carbonyl & gluconate/fa/dss/dha
1
FOCALGIN DSS TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
FOLIVANE-F CAPSULE
iron fumarate & polysac comp/folic acid/vitamin c/niacin
1
FOLIVANE-OB CAPSULE
prenatal vitamins no.15/iron fumarate & polysac comp/fa
1
FOLIVANE-PLUS CAPSULE
iron fumarate & polysac comp/folic acid/vit b comp & c no.9
1
FOLIVANE-PRX DHA NF CAPSULE
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
HEMATINIC-FOLIC ACID TABLET
ferrous fumarate/folic acid
1
HEMATINIC-VITAMIN-MINERAL TAB
iron/folic acid/vitamin b comp w-c/minerals
1
HEMATOGEN FA SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
HEMATOGEN FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
HEMATOGEN SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/stomach conc
1
HEMENATAL OB + DHA COMBO PACK
prenatal vitamin combo no.22/iron/folic acid/omega-3/dha
1
HEMENATAL OB TABLET
prenatal vitamin no.21/iron polysaccharid & heme polypep/fa
1
HEMETAB IRON SUPPLEMENT TABLET
iron polysacchar complx/iron heme polypeptide/folic acid/b12
1
IFEREX 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
INATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
PAGE 47
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
INATAL GT TABLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
INATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
INFANATE PLUS SOFTGEL
prenatal vitamins no.59/iron carbonyl & fumarate/fa/dss/dha
1
iron ag/c/b12/ca/suc.acid/stom 70-150-10 tablet
1
iron aspgly&ps/c/b12/fa/ca/suc 150-25-1 capsule
1
iron fum & ag/c/b12/fa/ca/succ 151-60-1mg tablet
1
L-METHYLFOLATE PNV DHA SOFTGEL
prenatal vit with calcium no42/iron fum/fa/l-mefolate ca/dha
1
LACTOCAL-F TABLET
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MACNATAL CN DHA SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
MULTIGEN CAPLET
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach
1
MULTIGEN FOLIC CAPLET
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
1
MULTIGEN PLUS CAPLET
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
multivits with iron & fluoride 0.25 mg/ml drops
1
multivits with iron & fluoride 0.5 mg/ml drops
1
MYFERON-150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
MYNATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
MYNATAL CAPSULE
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL PLUS CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL ULTRACAPLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
MYNATAL-Z CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATE 90 PLUS CAPLET SA
prenatal vitamins with calcium/ferrous fumarate/docusate/fa
1
PAGE 48
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NATALVIRT 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
NATALVIRT CA COMBO PACK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
NATALVIRT FLT TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
NEWGEN TABLET
prenatal vitamin no.86/iron bis-glycinate/folic acid
1
pedi mv #45/fluoride/iron 0.25-10/ml drops
1
pedi mv #75/fluoride/iron 0.25-10/ml drops
1
pnv #19/iron ps&heme/folic/dha 22-6-1-200 capsule
1
PNV OB+DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
pnv w-o ca no5/fe fumarate/fa 106.5-1mg capsule
1
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
1
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
1
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
1
PNV-DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
PNV-FIRST SOFTGEL
prenatal vitamins no.26/iron polysaccharides/fa/dha
1
PNV-OB WITH DHA COMBO PACK
prenatal vitamins comb 10/ferrous fumarate/folic acid/dha
1
PNV-OMEGA SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
PNV-SELECT TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
PNV-TOTAL SOFTGEL
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
PNV-VP-U CAPSULE
prenatal vits without calc no5/ferrous fumarate/folic acid
1
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
1
POLY-IRON 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
PR NATAL 400 COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 400 EC COMBO PACK
prenatal vitamins comb no.19/iron bg hcl&suc-prot/fa/omega-3
1
PAGE 49
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PR NATAL 430 COMBO PACK
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 430 EC COMBO PACK
prenatal vitamins comb no.55/iron bg hcl&suc-prot/fa/omega-3
1
PRENA1 PEARL SOFTGEL
prenatal vit no.71/iron fum-sodium feredetate/folic acid/dha
1
PRENAFIRST TABLET
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
PRENAISSANCE 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PRENAISSANCE CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
PRENAISSANCE DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
PRENAISSANCE PLUS SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
PRENAISSANCE PROMISE COMBO PCK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
PRENAPLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
1
PRENATE PLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
PREPLUS CA-FE 27 MG-FA 1 MG TB
prenatal vits with calcium #72/ferrous fumarate/folic acid
1
PUREVIT DUALFE PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
RELNATE DHA PRENATAL SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
SE-CARE CHEWABLE TABLET
prenatal vitamin w-o vit a/ferrous fumarate/folic acid
1
SE-NATAL 19 CHEWABLE TABLET
prenatal vits with calcium#118/ferrous fumarate/folic acid
1
SE-NATAL 19 TABLET
prenatal vitamins comb no.119/iron fumarate/folic acid/dss
1
SE-NATAL ONE TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
SE-PLETE DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
PAGE 50
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
SE-TAN DHA CAPSULE
prenatal vit w/o calc no.10/iron fum&polysac comp/fa/omega-3
1
SE-TAN PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
SETONET PRENATAL VITAMIN
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
SETONET-EC PRENATAL VITAMINS
prenatal vitamins comb no.55/iron bg hcl&succ-p2/fa/omega-3
1
STROVITE PLUS CAPLET
multivits, iron, minerals combo no #6, folic acid
1
TARON FORTE CAPSULE
iron bisgly & ps cmplx/ascorbate ca/b12/folic acid/ca-threo
1
TARON-BC TABLET
prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6
1
TARON-C DHA CAPSULE
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
TARON-DUO EC COMB PACK
prenatal vitamins comb no.19/iron bg hcl&succ-p2/fa/omega-3
1
TARON-PREX PRENATAL DHA CAP
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
THERAPEUTIC HEMATINIC TAB
multivits,therap w-fe,hematin
1
TL ICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
TL-CARE DHA SOFTGEL
pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa
1
TL-FLUORIVITE CHEWABLE TABLET
pediatric multivitamin no.47 with iron & sodium fluoride
1
TL-FOL 500 CAPLET
ferrous sulfate/ascorbic acid/folic acid
1
TL-HEM 150 CAPLET
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
1
TL-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
TRI RX TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
TRI-TABS DHA COMBO PACK
prenatal vitamins comb no.87/iron bisgly/folic acid/dha
1
TRIADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
PAGE 51
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
TRIGELS-F FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
TRINATAL GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
TRINATAL RX 1 TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
TRINATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
TRIVEEN-DUO DHA COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
TRIVEEN-TEN TABLETS
prenatal vitamins no.18/iron,carbonyl/fa/ubidecarenone/dha
1
TRIVEEN-U CAPSULE
prenatal vits without calc no5/ferrous fumarate/folic acid
1
TRUST NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
ULTIMATE OB DHA COMBO PACK
prenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
1
VENA-BAL DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
VENATAL COMPLETE DHA COMBO
prenatal vitamin no.77/sodium feredetate-iron poly/fa/omega3
1
VINACAL PRENATAL TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
VINATE AZ TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
VINATE CALCIUM PRENATAL TABLET
prenatal vit comb no.4/iron carbonyl-iron gluconate/fa/doss
1
VINATE CARE CHEWABLE TABLET
prenatal vits with calcium#109/ferrous fumarate/folic acid
1
VINATE DHA GELCAP
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha
1
VINATE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VINATE IC CAPSULE
prenatal vits cmb w-o ca no.2
1
VINATE II TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
PAGE 52
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VINATE ONE TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
VINATE PN CARE TABLET
prenatal vits with calcium #7/fe asp gly/docusate/folic acid
1
VINATE ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
VINATE-M TABLET
prenatal vitamins with calcium/ferrous fumarate/fa/selenium
1
VIRT-ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
VIRT-C DHA SOFTGEL
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
VIRT-PN DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
VIRT-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
VIRT-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
VIRT-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
VIRT-VITE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VITAFOL-OB CAPLET
prenatal vitamins comb 10/ferrous fumarate/folic acid
1
VITAFOL-PN CAPLET
prenatal vit with calcium cmb 11/ferrous fumarate/folic acid
1
VITASPIRE TABLET
prenatal vits with calcium #44/iron,carbonyl/folic acid
1
VOL-PLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
VOL-PLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
1
VP-CH PLUS SOFTGEL
prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha
1
VP-ERA OB PLUS TABLET
prenatal vitamin no.8/iron polysacchar & heme polypeptide/fa
1
VP-HEME OB + DHA COMBO PACK
prenatal vitamin combo no.22/iron/folic acid/omega-3/dha
1
VP-HEME OB TABLET
prenatal vitamin no.21/iron polysaccharid & heme polypep/fa
1
PAGE 53
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VP-HEME ONE SOFTGEL
prenatal vitamin no.19/iron polysacc & iron hem/folic ac/dha
1
ZATEAN-CH CAPSULE
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
ZATEAN-PN DHA CAPSULE
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
ZATEAN-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
ZATEAN-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
LIMITS & RESTRICTIONS
ANTIHEMORRHAGIC AGENTS
aminocaproic acid 250 mg/ml solution
1
aminocaproic acid 500 mg tablet
1
desmopressin (nonrefrigerated) 10/spray spray/pump
1
desmopressin acetate 0.1 mg tablet
1
desmopressin acetate 0.1 mg/ml solution
1
desmopressin acetate 0.2 mg tablet
1
desmopressin acetate 10/spray spray/pump
1
tranexamic acid 1000 mg/10 ampul
1
tranexamic acid 1000 mg/10 vial
1
tranexamic acid 650 mg tablet
1
ANTITHROMBOTIC AGENTS
anagrelide hcl 0.5 mg capsule
1
anagrelide hcl 1 mg capsule
1
aspirin 975 mg tablet dr
1
butalbital/aspirin/caffeine 50-325-40 capsule
1
butalbital/aspirin/caffeine 50-325-40 tablet
1
cilostazol 100 mg tablet
1
QL
60 / 30 days
cilostazol 50 mg tablet
1
QL
60 / 30 days
clopidogrel bisulfate 300 mg tablet
1
clopidogrel bisulfate 75 mg tablet
1
QL
30 / 30 days
dipyridamole 25 mg tablet
1
PAGE 54
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
dipyridamole 50 mg tablet
1
dipyridamole 75 mg tablet
1
EFFIENT 10 MG TABLET
prasugrel hcl
1
EFFIENT 5 MG TABLET
prasugrel hcl
1
enoxaparin sodium 100 mg/ml syringe
1
QL
28 / 30 days
enoxaparin sodium 120mg/.8ml syringe
1
QL
34 / 30 days
enoxaparin sodium 150 mg/ml syringe
1
QL
42 / 30 days
enoxaparin sodium 300mg/3ml vial
1
enoxaparin sodium 30mg/0.3ml syringe
1
QL
9 / 30 days
enoxaparin sodium 40mg/0.4ml syringe
1
QL
12 / 30 days
enoxaparin sodium 60mg/0.6ml syringe
1
QL
17 / 30 days
enoxaparin sodium 80mg/0.8ml syringe
1
QL
23 / 30 days
heparin sod,porcine-0.9 % nacl 10 unit/ml kit
1
heparin sod,porcine-0.9 % nacl 100/ml kit
1
heparin sodium,porcine 10 unit/ml syringe
1
heparin sodium,porcine 10 unit/ml vial
1
heparin sodium,porcine 100/ml (1) syringe
1
heparin sodium,porcine 100/ml vial
1
heparin sodium,porcine 200/2 ml syringe
1
heparin sodium,porcine 300/3 ml syringe
1
heparin sodium,porcine 500/5 ml syringe
1
heparin sodium,porcine/pf 1 unit/ml syringe
1
heparin sodium,porcine/pf 10 unit/ml syringe
1
heparin sodium,porcine/pf 10 unit/ml vial
1
heparin sodium,porcine/pf 100/ml (1) syringe
1
heparin sodium,porcine/pf 100/ml (1) vial
1
heparin sodium,porcine/pf 1000/10 ml syringe
1
heparin sodium,porcine/pf 200/2 ml syringe
1
PAGE 55
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
heparin sodium,porcine/pf 300/3 ml syringe
1
heparin sodium,porcine/pf 500/5 ml syringe
1
JANTOVEN 1 MG TABLET
warfarin sodium
1
JANTOVEN 10 MG TABLET
warfarin sodium
1
JANTOVEN 2 MG TABLET
warfarin sodium
1
JANTOVEN 2.5 MG TABLET
warfarin sodium
1
JANTOVEN 3 MG TABLET
warfarin sodium
1
JANTOVEN 4 MG TABLET
warfarin sodium
1
JANTOVEN 5 MG TABLET
warfarin sodium
1
JANTOVEN 6 MG TABLET
warfarin sodium
1
JANTOVEN 7.5 MG TABLET
warfarin sodium
1
LEVACET CAPLET
aspirin/salicylamide/acetaminophen/caffeine
1
warfarin sodium 1 mg tablet
1
warfarin sodium 10 mg tablet
1
warfarin sodium 2 mg tablet
1
warfarin sodium 2.5 mg tablet
1
warfarin sodium 3 mg tablet
1
warfarin sodium 4 mg tablet
1
warfarin sodium 5 mg tablet
1
warfarin sodium 6 mg tablet
1
warfarin sodium 7.5 mg tablet
1
pentoxifylline 400 mg tablet er
1
PAGE 56
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
ADVANCED AM/PM COMBO PACK
omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13
1
amlodipine/atorvastatin 10 mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-80mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-10 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-20 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-40 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-80 mg tablet
1
QL
30 / 30 days
atorvastatin calcium 10 mg tablet
1
QL
30 / 30 days
atorvastatin calcium 20 mg tablet
1
QL
30 / 30 days
atorvastatin calcium 40 mg tablet
1
QL
30 / 30 days
atorvastatin calcium 80 mg tablet
1
QL
30 / 30 days
BP VIT 3 CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
cholestyramine (with sugar) 4 g powd pack
1
cholestyramine (with sugar) 4 g powder
1
cholestyramine/aspartame 4 g powd pack
1
cholestyramine/aspartame 4 g powder
1
colestipol hcl 1 g tablet
1
colestipol hcl 5 g granules
1
colestipol hcl 5 g packet
1
fenofibrate 160 mg tablet
1
PAGE 57
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
fenofibrate 54 mg tablet
1
fenofibrate nanocrystallized 145mg tablet
1
fenofibrate nanocrystallized 48 mg tablet
1
fenofibrate,micronized 130 mg capsule
1
fenofibrate,micronized 134mg capsule
1
fenofibrate,micronized 200 mg capsule
1
fenofibrate,micronized 43 mg capsule
1
fenofibrate,micronized 67 mg capsule
1
fenofibric acid (choline) 135 mg capsule dr
1
QL
30 / 30 days
fenofibric acid (choline) 45 mg capsule dr
1
QL
60 / 30 days
fenofibric acid 105 mg tablet
1
fenofibric acid 35 mg tablet
1
gemfibrozil 600 mg tablet
1
lovastatin 10 mg tablet
1
QL
30 / 30 days
lovastatin 20 mg tablet
1
QL
60 / 30 days
lovastatin 40 mg tablet
1
QL
60 / 30 days
MI-OMEGA NF CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
niacin 1000 mg tab er 24h
1
niacin 500 mg tab er 24h
1
niacin 750 mg tab er 24h
1
omega-3 acid ethyl esters 1 g capsule
1
QL
120 / 30 days
pravastatin sodium 10 mg tablet
1
QL
30 / 30 days
pravastatin sodium 20 mg tablet
1
QL
30 / 30 days
pravastatin sodium 40 mg tablet
1
QL
30 / 30 days
pravastatin sodium 80 mg tablet
1
QL
30 / 30 days
PREVALITE PACKET
cholestyramine/aspartame
1
PREVALITE POWDER
cholestyramine/aspartame
1
PAGE 58
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
simvastatin 10 mg tablet
1
QL
30 / 30 days
simvastatin 20 mg tablet
1
QL
30 / 30 days
simvastatin 40 mg tablet
1
QL
30 / 30 days
simvastatin 5 mg tablet
1
QL
30 / 30 days
simvastatin 80 mg tablet
1
QL
30 / 30 days
VASCAZEN CAPSULE
omega-3 fatty acids/dha/epa/other omega-3s/fish oil
1
VAYAROL CAPSULES
phytosterol/omega-3 fatty acids/dha/epa/fish oil
1
QL
30 / 30 days
CALCIUM-CHANNEL BLOCKING AGENTS
ADALAT CC 30 MG TABLET
nifedipine
1
ADALAT CC 60 MG TABLET
nifedipine
1
ADALAT CC 90 MG TABLET
nifedipine
1
AFEDITAB CR 30 MG TABLET
nifedipine
1
AFEDITAB CR 60 MG TABLET
nifedipine
1
amlodipine besylate 10 mg tablet
1
amlodipine besylate 2.5 mg tablet
1
amlodipine besylate 5 mg tablet
1
amlodipine besylate/benazepril 10 mg-20mg capsule
1
amlodipine besylate/benazepril 10 mg-40mg capsule
1
amlodipine besylate/benazepril 2.5mg-10mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-10 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-20 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-40 mg capsule
1
amlodipine/atorvastatin 10 mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-40mg tablet
1
QL
30 / 30 days
PAGE 59
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
amlodipine/atorvastatin 10 mg-80mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-10 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-20 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-40 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-80 mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-160-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-320-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-12.5 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-25mg tablet
1
QL
30 / 30 days
CARTIA XT 120 MG CAPSULE
diltiazem hcl
1
CARTIA XT 180 MG CAPSULE
diltiazem hcl
1
CARTIA XT 240 MG CAPSULE
diltiazem hcl
1
CARTIA XT 300 MG CAPSULE
diltiazem hcl
1
DILT XR 120 MG CAPSULE
diltiazem hcl
1
DILT XR 180 MG CAPSULE
diltiazem hcl
1
DILT XR 240 MG CAPSULE
diltiazem hcl
1
PAGE 60
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DILT-CD 120 MG CAPSULE
diltiazem hcl
1
DILT-CD 180 MG CAPSULE
diltiazem hcl
1
DILT-CD 240 MG CAPSULE
diltiazem hcl
1
DILT-CD ER 300 MG CAPSULE
diltiazem hcl
1
DILTIA XT 120 MG CAPSULE
diltiazem hcl
1
DILTIA XT 180 MG CAPSULE
diltiazem hcl
1
DILTIA XT 240 MG CAPSULE
diltiazem hcl
1
diltiazem hcl 120 mg cap er 12h
1
diltiazem hcl 120 mg cap er 24h
1
diltiazem hcl 120 mg cap er deg
1
diltiazem hcl 120 mg capsule er
1
diltiazem hcl 120 mg tablet
1
diltiazem hcl 180 mg cap er 24h
1
diltiazem hcl 180 mg cap er deg
1
diltiazem hcl 180 mg capsule er
1
diltiazem hcl 240 mg cap er 24h
1
diltiazem hcl 240 mg cap er deg
1
diltiazem hcl 240 mg capsule er
1
diltiazem hcl 30 mg tablet
1
diltiazem hcl 300 mg cap er 24h
1
diltiazem hcl 300 mg capsule er
1
diltiazem hcl 360 mg cap er 24h
1
diltiazem hcl 360 mg capsule er
1
diltiazem hcl 420mg capsule er
1
diltiazem hcl 60 mg cap er 12h
1
diltiazem hcl 60 mg tablet
1
diltiazem hcl 90 mg cap er 12h
1
PAGE 61
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
diltiazem hcl 90 mg tablet
1
DILTZAC ER 120 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 180 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 240 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 300 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 360 MG CAPSULE
diltiazem hcl
1
felodipine 10 mg tab er 24h
1
felodipine 2.5 mg tab er 24h
1
felodipine 5 mg tab er 24h
1
isradipine 2.5 mg capsule
1
isradipine 5 mg capsule
1
MATZIM LA 180 MG TABLET
diltiazem hcl
1
MATZIM LA 240 MG TABLET
diltiazem hcl
1
MATZIM LA 300 MG TABLET
diltiazem hcl
1
MATZIM LA 360 MG TABLET
diltiazem hcl
1
MATZIM LA 420 MG TABLET
diltiazem hcl
1
nicardipine hcl 20 mg capsule
1
nicardipine hcl 30 mg capsule
1
NIFEDIAC CC 30 MG TABLET
nifedipine
1
NIFEDIAC CC 60 MG TABLET
nifedipine
1
NIFEDIAC CC 90 MG TABLET
nifedipine
1
NIFEDICAL XL 30 MG TABLET
nifedipine
1
NIFEDICAL XL 60 MG TABLET
nifedipine
1
PAGE 62
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
nifedipine 10 mg capsule
1
nifedipine 20 mg capsule
1
nifedipine 30 mg tab er 24
1
nifedipine 30 mg tablet er
1
nifedipine 60 mg tab er 24
1
nifedipine 60 mg tablet er
1
nifedipine 90 mg tab er 24
1
nifedipine 90 mg tablet er
1
nimodipine 30 mg capsule
1
nisoldipine 17 mg tab er 24h
1
nisoldipine 20 mg tab er 24h
1
nisoldipine 25.5 mg tab er 24h
1
nisoldipine 30 mg tab er 24h
1
nisoldipine 34 mg tab er 24h
1
nisoldipine 40 mg tab er 24h
1
nisoldipine 8.5mg tab er 24h
1
TAZTIA XT 120 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 180 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 240 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 300 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 360 MG CAPSULE
diltiazem hcl
1
telmisartan/amlodipine 40 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-5 mg tablet
1
QL
30 / 30 days
verapamil hcl 100 mg cap24h pct
1
verapamil hcl 120 mg cap24h pel
1
PAGE 63
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
verapamil hcl 120 mg tablet
1
verapamil hcl 120 mg tablet er
1
verapamil hcl 180 mg cap24h pel
1
verapamil hcl 180 mg tablet er
1
verapamil hcl 200 mg cap24h pct
1
verapamil hcl 240 mg cap24h pel
1
verapamil hcl 240 mg tablet er
1
verapamil hcl 300 mg cap24h pct
1
verapamil hcl 360 mg cap24h pel
1
verapamil hcl 40 mg tablet
1
verapamil hcl 80 mg tablet
1
LIMITS & RESTRICTIONS
CARDIAC DRUGS
acebutolol hcl 200 mg capsule
1
acebutolol hcl 400 mg capsule
1
amiodarone hcl 100 mg tablet
1
amiodarone hcl 200 mg tablet
1
amiodarone hcl 400 mg tablet
1
atenolol 100 mg tablet
1
atenolol 25 mg tablet
1
atenolol 50 mg tablet
1
atenolol/chlorthalidone 100mg-25mg tablet
1
atenolol/chlorthalidone 50 mg-25mg tablet
1
betaxolol hcl 10 mg tablet
1
betaxolol hcl 20 mg tablet
1
bisoprolol fumarate 10 mg tablet
1
bisoprolol fumarate 5 mg tablet
1
bisoprolol fumarate/hctz 10-6.25mg tablet
1
bisoprolol fumarate/hctz 2.5-6.25mg tablet
1
bisoprolol fumarate/hctz 5-6.25mg tablet
1
CARTIA XT 120 MG CAPSULE
diltiazem hcl
1
PAGE 64
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CARTIA XT 180 MG CAPSULE
diltiazem hcl
1
CARTIA XT 240 MG CAPSULE
diltiazem hcl
1
CARTIA XT 300 MG CAPSULE
diltiazem hcl
1
carvedilol 12.5 mg tablet
1
carvedilol 25 mg tablet
1
carvedilol 3.125 mg tablet
1
carvedilol 6.25 mg tablet
1
DIGITEK 125 MCG TABLET
digoxin
1
DIGITEK 250 MCG TABLET
digoxin
1
DIGOX 125 MCG TABLET
digoxin
1
DIGOX 250 MCG TABLET
digoxin
1
digoxin 125 mcg tablet
1
digoxin 250 mcg tablet
1
digoxin 50 mcg/ml solution
1
DILANTIN 100 MG CAPSULE
phenytoin sodium extended
1
DILANTIN 125 MG/5 ML SUSP
phenytoin
1
DILANTIN 30 MG CAPSULE
phenytoin sodium extended
1
DILANTIN 50 MG INFATAB
phenytoin
1
DILT XR 120 MG CAPSULE
diltiazem hcl
1
DILT XR 180 MG CAPSULE
diltiazem hcl
1
DILT XR 240 MG CAPSULE
diltiazem hcl
1
DILT-CD 120 MG CAPSULE
diltiazem hcl
1
PAGE 65
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DILT-CD 180 MG CAPSULE
diltiazem hcl
1
DILT-CD 240 MG CAPSULE
diltiazem hcl
1
DILT-CD ER 300 MG CAPSULE
diltiazem hcl
1
DILTIA XT 120 MG CAPSULE
diltiazem hcl
1
DILTIA XT 180 MG CAPSULE
diltiazem hcl
1
DILTIA XT 240 MG CAPSULE
diltiazem hcl
1
diltiazem hcl 120 mg cap er 12h
1
diltiazem hcl 120 mg cap er 24h
1
diltiazem hcl 120 mg cap er deg
1
diltiazem hcl 120 mg capsule er
1
diltiazem hcl 120 mg tablet
1
diltiazem hcl 180 mg cap er 24h
1
diltiazem hcl 180 mg cap er deg
1
diltiazem hcl 180 mg capsule er
1
diltiazem hcl 240 mg cap er 24h
1
diltiazem hcl 240 mg cap er deg
1
diltiazem hcl 240 mg capsule er
1
diltiazem hcl 30 mg tablet
1
diltiazem hcl 300 mg cap er 24h
1
diltiazem hcl 300 mg capsule er
1
diltiazem hcl 360 mg cap er 24h
1
diltiazem hcl 360 mg capsule er
1
diltiazem hcl 420mg capsule er
1
diltiazem hcl 60 mg cap er 12h
1
diltiazem hcl 60 mg tablet
1
diltiazem hcl 90 mg cap er 12h
1
diltiazem hcl 90 mg tablet
1
PAGE 66
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DILTZAC ER 120 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 180 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 240 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 300 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 360 MG CAPSULE
diltiazem hcl
1
disopyramide phosphate 100 mg capsule
1
disopyramide phosphate 150 mg capsule
1
flecainide acetate 100 mg tablet
1
flecainide acetate 150 mg tablet
1
flecainide acetate 50 mg tablet
1
labetalol hcl 100 mg tablet
1
labetalol hcl 200 mg tablet
1
labetalol hcl 300 mg tablet
1
LANOXIN 187.5 MCG TABLET
digoxin
1
LANOXIN 62.5 MCG TABLET
digoxin
1
MATZIM LA 180 MG TABLET
diltiazem hcl
1
MATZIM LA 240 MG TABLET
diltiazem hcl
1
MATZIM LA 300 MG TABLET
diltiazem hcl
1
MATZIM LA 360 MG TABLET
diltiazem hcl
1
MATZIM LA 420 MG TABLET
diltiazem hcl
1
metoprolol succinate 100 mg tab er 24h
1
metoprolol succinate 200 mg tab er 24h
1
metoprolol succinate 25 mg tab er 24h
1
metoprolol succinate 50 mg tab er 24h
1
PAGE 67
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
metoprolol tartrate 100 mg tablet
1
metoprolol tartrate 25 mg tablet
1
metoprolol tartrate 50 mg tablet
1
metoprolol/hydrochlorothiazide 100mg-25mg tablet
1
metoprolol/hydrochlorothiazide 100mg-50mg tablet
1
metoprolol/hydrochlorothiazide 50 mg-25mg tablet
1
mexiletine hcl 150 mg capsule
1
mexiletine hcl 200 mg capsule
1
mexiletine hcl 250 mg capsule
1
nadolol 20 mg tablet
1
nadolol 40 mg tablet
1
nadolol 80 mg tablet
1
nadolol/bendroflumethiazide 40 mg-5 mg tablet
1
nadolol/bendroflumethiazide 80 mg-5 mg tablet
1
NORPACE CR 100 MG CAPSULE
disopyramide phosphate
1
NORPACE CR 150 MG CAPSULE
disopyramide phosphate
1
PACERONE 100 MG TABLET
amiodarone hcl
1
PACERONE 200 MG TABLET
amiodarone hcl
1
PHENYTEK 200 MG CAPSULE
phenytoin sodium extended
1
PHENYTEK 300 MG CAPSULE
phenytoin sodium extended
1
phenytoin 100 mg/4ml oral susp
1
phenytoin 125 mg/5ml oral susp
1
phenytoin 50 mg tab chew
1
phenytoin sodium extended 100 mg capsule
1
phenytoin sodium extended 200 mg capsule
1
phenytoin sodium extended 300 mg capsule
1
pindolol 10 mg tablet
1
PAGE 68
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
pindolol 5 mg tablet
1
propafenone hcl 150 mg tablet
1
propafenone hcl 225 mg cap er 12h
1
propafenone hcl 225 mg tablet
1
propafenone hcl 300 mg tablet
1
propafenone hcl 325 mg cap er 12h
1
propafenone hcl 425 mg cap er 12h
1
propranolol hcl 10 mg tablet
1
propranolol hcl 120 mg cap sa 24h
1
propranolol hcl 160 mg cap sa 24h
1
propranolol hcl 20 mg tablet
1
propranolol hcl 20 mg/5 ml solution
1
propranolol hcl 40 mg tablet
1
propranolol hcl 40mg/5ml solution
1
propranolol hcl 60 mg cap sa 24h
1
propranolol hcl 60 mg tablet
1
propranolol hcl 80 mg cap sa 24h
1
propranolol hcl 80 mg tablet
1
propranolol/hydrochlorothiazid 40 mg-25mg tablet
1
propranolol/hydrochlorothiazid 80 mg-25mg tablet
1
quinidine gluconate 324 mg tablet er
1
quinidine sulfate 200 mg tablet
1
quinidine sulfate 300 mg tablet
1
quinidine sulfate 300 mg tablet er
1
SORINE 120 MG TABLET
sotalol hcl
1
SORINE 160 MG TABLET
sotalol hcl
1
SORINE 240 MG TABLET
sotalol hcl
1
SORINE 80 MG TABLET
sotalol hcl
1
sotalol hcl 120 mg tablet
1
PAGE 69
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sotalol hcl 160 mg tablet
1
sotalol hcl 240 mg tablet
1
sotalol hcl 80 mg tablet
1
TAZTIA XT 120 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 180 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 240 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 300 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 360 MG CAPSULE
diltiazem hcl
1
timolol maleate 10 mg tablet
1
timolol maleate 20 mg tablet
1
timolol maleate 5 mg tablet
1
verapamil hcl 100 mg cap24h pct
1
verapamil hcl 120 mg cap24h pel
1
verapamil hcl 120 mg tablet
1
verapamil hcl 120 mg tablet er
1
verapamil hcl 180 mg cap24h pel
1
verapamil hcl 180 mg tablet er
1
verapamil hcl 200 mg cap24h pct
1
verapamil hcl 240 mg cap24h pel
1
verapamil hcl 240 mg tablet er
1
verapamil hcl 300 mg cap24h pct
1
verapamil hcl 360 mg cap24h pel
1
verapamil hcl 40 mg tablet
1
verapamil hcl 80 mg tablet
1
acebutolol hcl 200 mg capsule
1
acebutolol hcl 400 mg capsule
1
atenolol 100 mg tablet
1
atenolol 25 mg tablet
1
PAGE 70
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
atenolol 50 mg tablet
1
atenolol/chlorthalidone 100mg-25mg tablet
1
atenolol/chlorthalidone 50 mg-25mg tablet
1
betaxolol hcl 10 mg tablet
1
betaxolol hcl 20 mg tablet
1
bisoprolol fumarate 10 mg tablet
1
bisoprolol fumarate 5 mg tablet
1
bisoprolol fumarate/hctz 10-6.25mg tablet
1
bisoprolol fumarate/hctz 2.5-6.25mg tablet
1
bisoprolol fumarate/hctz 5-6.25mg tablet
1
carvedilol 12.5 mg tablet
1
carvedilol 25 mg tablet
1
carvedilol 3.125 mg tablet
1
carvedilol 6.25 mg tablet
1
doxazosin mesylate 1 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 2 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 4 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 8 mg tablet
1
QL
60 / 30 days
labetalol hcl 100 mg tablet
1
labetalol hcl 200 mg tablet
1
labetalol hcl 300 mg tablet
1
metoprolol succinate 100 mg tab er 24h
1
metoprolol succinate 200 mg tab er 24h
1
metoprolol succinate 25 mg tab er 24h
1
metoprolol succinate 50 mg tab er 24h
1
metoprolol tartrate 100 mg tablet
1
metoprolol tartrate 25 mg tablet
1
metoprolol tartrate 50 mg tablet
1
metoprolol/hydrochlorothiazide 100mg-25mg tablet
1
metoprolol/hydrochlorothiazide 100mg-50mg tablet
1
PAGE 71
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
metoprolol/hydrochlorothiazide 50 mg-25mg tablet
1
nadolol 20 mg tablet
1
nadolol 40 mg tablet
1
nadolol 80 mg tablet
1
nadolol/bendroflumethiazide 40 mg-5 mg tablet
1
nadolol/bendroflumethiazide 80 mg-5 mg tablet
1
pindolol 10 mg tablet
1
pindolol 5 mg tablet
1
prazosin hcl 1 mg capsule
1
QL
90 / 30 days
prazosin hcl 2 mg capsule
1
QL
120 / 30 days
prazosin hcl 5 mg capsule
1
QL
120 / 30 days
propranolol hcl 10 mg tablet
1
propranolol hcl 120 mg cap sa 24h
1
propranolol hcl 160 mg cap sa 24h
1
propranolol hcl 20 mg tablet
1
propranolol hcl 20 mg/5 ml solution
1
propranolol hcl 40 mg tablet
1
propranolol hcl 40mg/5ml solution
1
propranolol hcl 60 mg cap sa 24h
1
propranolol hcl 60 mg tablet
1
propranolol hcl 80 mg cap sa 24h
1
propranolol hcl 80 mg tablet
1
propranolol/hydrochlorothiazid 40 mg-25mg tablet
1
propranolol/hydrochlorothiazid 80 mg-25mg tablet
1
SORINE 120 MG TABLET
sotalol hcl
1
SORINE 160 MG TABLET
sotalol hcl
1
SORINE 240 MG TABLET
sotalol hcl
1
SORINE 80 MG TABLET
sotalol hcl
1
PAGE 72
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
sotalol hcl 120 mg tablet
1
sotalol hcl 160 mg tablet
1
sotalol hcl 240 mg tablet
1
sotalol hcl 80 mg tablet
1
terazosin hcl 1 mg capsule
1
QL
60 / 30 days
terazosin hcl 10 mg capsule
1
QL
60 / 30 days
terazosin hcl 2 mg capsule
1
QL
60 / 30 days
terazosin hcl 5 mg capsule
1
QL
60 / 30 days
timolol maleate 10 mg tablet
1
timolol maleate 20 mg tablet
1
timolol maleate 5 mg tablet
1
HYPOTENSIVE AGENTS
acebutolol hcl 200 mg capsule
1
acebutolol hcl 400 mg capsule
1
acetazolamide 125 mg tablet
1
acetazolamide 250 mg tablet
1
acetazolamide 500 mg capsule er
1
ADALAT CC 30 MG TABLET
nifedipine
1
ADALAT CC 60 MG TABLET
nifedipine
1
ADALAT CC 90 MG TABLET
nifedipine
1
AFEDITAB CR 30 MG TABLET
nifedipine
1
AFEDITAB CR 60 MG TABLET
nifedipine
1
amiloride hcl 5 mg tablet
1
amiloride/hydrochlorothiazide 5 mg-50 mg tablet
1
amlodipine besylate 10 mg tablet
1
amlodipine besylate 2.5 mg tablet
1
amlodipine besylate 5 mg tablet
1
PAGE 73
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
amlodipine besylate/benazepril 10 mg-20mg capsule
1
amlodipine besylate/benazepril 10 mg-40mg capsule
1
amlodipine besylate/benazepril 2.5mg-10mg capsule
LIMITS & RESTRICTIONS
QL
30 / 30 days
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-10 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-20 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-40 mg capsule
1
amlodipine/atorvastatin 10 mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-80mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-10 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-20 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-40 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-80 mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-160-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-320-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-12.5 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-25mg tablet
1
QL
30 / 30 days
PAGE 74
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
atenolol 100 mg tablet
1
atenolol 25 mg tablet
1
atenolol 50 mg tablet
1
atenolol/chlorthalidone 100mg-25mg tablet
1
atenolol/chlorthalidone 50 mg-25mg tablet
1
benazepril hcl 10 mg tablet
1
QL
60 / 30 days
benazepril hcl 20 mg tablet
1
QL
60 / 30 days
benazepril hcl 40 mg tablet
1
QL
60 / 30 days
benazepril hcl 5 mg tablet
1
QL
60 / 30 days
benazepril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 5-6.25mg tablet
1
QL
30 / 30 days
betaxolol hcl 10 mg tablet
1
betaxolol hcl 20 mg tablet
1
bisoprolol fumarate 10 mg tablet
1
bisoprolol fumarate 5 mg tablet
1
bisoprolol fumarate/hctz 10-6.25mg tablet
1
bisoprolol fumarate/hctz 2.5-6.25mg tablet
1
bisoprolol fumarate/hctz 5-6.25mg tablet
1
bumetanide 0.5 mg tablet
1
bumetanide 1 mg tablet
1
bumetanide 2 mg tablet
1
candesartan cilexetil 16 mg tablet
1
QL
60 / 30 days
candesartan cilexetil 32 mg tablet
1
QL
30 / 30 days
candesartan cilexetil 4 mg tablet
1
QL
60 / 30 days
candesartan cilexetil 8 mg tablet
1
QL
60 / 30 days
candesartan/hydrochlorothiazid 16-12.5mg tablet
1
QL
30 / 30 days
PAGE 75
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
candesartan/hydrochlorothiazid 32-12.5mg tablet
1
QL
30 / 30 days
candesartan/hydrochlorothiazid 32mg-25mg tablet
1
QL
30 / 30 days
captopril 100 mg tablet
1
QL
120 / 30 days
captopril 12.5 mg tablet
1
QL
90 / 30 days
captopril 25 mg tablet
1
QL
90 / 30 days
captopril 50 mg tablet
1
QL
90 / 30 days
captopril/hydrochlorothiazide 25 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 25 mg-25mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-25mg tablet
1
QL
30 / 30 days
CARTIA XT 120 MG CAPSULE
diltiazem hcl
1
CARTIA XT 180 MG CAPSULE
diltiazem hcl
1
CARTIA XT 240 MG CAPSULE
diltiazem hcl
1
CARTIA XT 300 MG CAPSULE
diltiazem hcl
1
carvedilol 12.5 mg tablet
1
carvedilol 25 mg tablet
1
carvedilol 3.125 mg tablet
1
carvedilol 6.25 mg tablet
1
chlorothiazide 250 mg tablet
1
chlorothiazide 500 mg tablet
1
chlorthalidone 25 mg tablet
1
chlorthalidone 50 mg tablet
1
clonidine 0.1mg/24hr patch tdwk
1
clonidine 0.2mg/24hr patch tdwk
1
clonidine 0.3mg/24hr patch tdwk
1
clonidine hcl 0.1 mg tab er 12h
1
clonidine hcl 0.1 mg tablet
1
PAGE 76
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
clonidine hcl 0.2 mg tablet
1
clonidine hcl 0.3 mg tablet
1
CLORPRES 0.1-15 TABLET
clonidine hcl/chlorthalidone
1
CLORPRES 0.2-15 TABLET
clonidine hcl/chlorthalidone
1
DILT XR 120 MG CAPSULE
diltiazem hcl
1
DILT XR 180 MG CAPSULE
diltiazem hcl
1
DILT XR 240 MG CAPSULE
diltiazem hcl
1
DILT-CD 120 MG CAPSULE
diltiazem hcl
1
DILT-CD 180 MG CAPSULE
diltiazem hcl
1
DILT-CD 240 MG CAPSULE
diltiazem hcl
1
DILT-CD ER 300 MG CAPSULE
diltiazem hcl
1
DILTIA XT 120 MG CAPSULE
diltiazem hcl
1
DILTIA XT 180 MG CAPSULE
diltiazem hcl
1
DILTIA XT 240 MG CAPSULE
diltiazem hcl
1
diltiazem hcl 120 mg cap er 12h
1
diltiazem hcl 120 mg cap er 24h
1
diltiazem hcl 120 mg cap er deg
1
diltiazem hcl 120 mg capsule er
1
diltiazem hcl 120 mg tablet
1
diltiazem hcl 180 mg cap er 24h
1
diltiazem hcl 180 mg cap er deg
1
diltiazem hcl 180 mg capsule er
1
diltiazem hcl 240 mg cap er 24h
1
diltiazem hcl 240 mg cap er deg
1
PAGE 77
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
diltiazem hcl 240 mg capsule er
1
diltiazem hcl 30 mg tablet
1
diltiazem hcl 300 mg cap er 24h
1
diltiazem hcl 300 mg capsule er
1
diltiazem hcl 360 mg cap er 24h
1
diltiazem hcl 360 mg capsule er
1
diltiazem hcl 420mg capsule er
1
diltiazem hcl 60 mg cap er 12h
1
diltiazem hcl 60 mg tablet
1
diltiazem hcl 90 mg cap er 12h
1
diltiazem hcl 90 mg tablet
1
DILTZAC ER 120 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 180 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 240 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 300 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 360 MG CAPSULE
diltiazem hcl
1
doxazosin mesylate 1 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 2 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 4 mg tablet
1
QL
60 / 30 days
doxazosin mesylate 8 mg tablet
1
QL
60 / 30 days
DYRENIUM 100 MG CAPSULE
triamterene
1
DYRENIUM 50 MG CAPSULE
triamterene
1
enalapril maleate 10 mg tablet
1
QL
60 / 30 days
enalapril maleate 2.5 mg tablet
1
QL
60 / 30 days
enalapril maleate 20 mg tablet
1
QL
60 / 30 days
PAGE 78
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
enalapril maleate 5 mg tablet
1
QL
60 / 30 days
enalapril/hydrochlorothiazide 10 mg-25mg tablet
1
QL
60 / 30 days
enalapril/hydrochlorothiazide 5mg-12.5mg tablet
1
QL
60 / 30 days
eplerenone 25 mg tablet
1
QL
30 / 30 days
eplerenone 50 mg tablet
1
QL
60 / 30 days
felodipine 10 mg tab er 24h
1
felodipine 2.5 mg tab er 24h
1
felodipine 5 mg tab er 24h
1
fosinopril sodium 10 mg tablet
1
QL
60 / 30 days
fosinopril sodium 20 mg tablet
1
QL
60 / 30 days
fosinopril sodium 40 mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
furosemide 10 mg/ml solution
1
furosemide 20 mg tablet
1
furosemide 40 mg tablet
1
furosemide 40mg/5ml solution
1
furosemide 80 mg tablet
1
guanfacine hcl 1 mg tab er 24h
1
guanfacine hcl 1 mg tablet
1
guanfacine hcl 2 mg tab er 24h
1
guanfacine hcl 2 mg tablet
1
guanfacine hcl 3 mg tab er 24h
1
guanfacine hcl 4 mg tab er 24h
1
hydralazine hcl 10 mg tablet
1
hydralazine hcl 100 mg tablet
1
hydralazine hcl 25 mg tablet
1
hydralazine hcl 50 mg tablet
1
hydrochlorothiazide 12.5 mg capsule
1
PAGE 79
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
hydrochlorothiazide 12.5 mg tablet
1
hydrochlorothiazide 25 mg tablet
1
hydrochlorothiazide 50 mg tablet
1
indapamide 1.25 mg tablet
1
indapamide 2.5 mg tablet
1
irbesartan 150 mg tablet
1
QL
30 / 30 days
irbesartan 300 mg tablet
1
QL
30 / 30 days
irbesartan 75 mg tablet
1
QL
30 / 30 days
irbesartan/hydrochlorothiazide 150-12.5mg tablet
1
QL
60 / 30 days
irbesartan/hydrochlorothiazide 300-12.5mg tablet
1
QL
30 / 30 days
isradipine 2.5 mg capsule
1
isradipine 5 mg capsule
1
KAPVAY 0.1-0.2 MG DOSEPACK
clonidine hcl
1
labetalol hcl 100 mg tablet
1
labetalol hcl 200 mg tablet
1
labetalol hcl 300 mg tablet
1
lisinopril 10 mg tablet
1
QL
60 / 30 days
lisinopril 2.5 mg tablet
1
QL
60 / 30 days
lisinopril 20 mg tablet
1
QL
60 / 30 days
lisinopril 30 mg tablet
1
QL
60 / 30 days
lisinopril 40 mg tablet
1
QL
60 / 30 days
lisinopril 5 mg tablet
1
QL
60 / 30 days
lisinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
lisinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
lisinopril/hydrochlorothiazide 20-25mg tablet
1
QL
60 / 30 days
losartan potassium 100 mg tablet
1
QL
30 / 30 days
losartan potassium 25 mg tablet
1
QL
60 / 30 days
PAGE 80
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
losartan potassium 50 mg tablet
1
QL
60 / 30 days
losartan/hydrochlorothiazide 100-12.5mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 100mg-25mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 50-12.5 mg tablet
1
QL
30 / 30 days
MATZIM LA 180 MG TABLET
diltiazem hcl
1
MATZIM LA 240 MG TABLET
diltiazem hcl
1
MATZIM LA 300 MG TABLET
diltiazem hcl
1
MATZIM LA 360 MG TABLET
diltiazem hcl
1
MATZIM LA 420 MG TABLET
diltiazem hcl
1
methazolamide 25 mg tablet
1
methazolamide 50 mg tablet
1
methyclothiazide 5 mg tablet
1
methyldopa 250 mg tablet
1
methyldopa 500 mg tablet
1
methyldopa/hydrochlorothiazide 250mg-15mg tablet
1
methyldopa/hydrochlorothiazide 250mg-25mg tablet
1
metolazone 10 mg tablet
1
metolazone 2.5 mg tablet
1
metolazone 5 mg tablet
1
metoprolol succinate 100 mg tab er 24h
1
metoprolol succinate 200 mg tab er 24h
1
metoprolol succinate 25 mg tab er 24h
1
metoprolol succinate 50 mg tab er 24h
1
metoprolol tartrate 100 mg tablet
1
metoprolol tartrate 25 mg tablet
1
metoprolol tartrate 50 mg tablet
1
metoprolol/hydrochlorothiazide 100mg-25mg tablet
1
PAGE 81
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
metoprolol/hydrochlorothiazide 100mg-50mg tablet
1
metoprolol/hydrochlorothiazide 50 mg-25mg tablet
1
minoxidil 10 mg tablet
1
minoxidil 2.5 mg tablet
1
moexipril hcl 15 mg tablet
1
QL
60 / 30 days
moexipril hcl 7.5 mg tablet
1
QL
60 / 30 days
moexipril/hydrochlorothiazide 15-12.5mg tablet
1
QL
30 / 30 days
moexipril/hydrochlorothiazide 15-25mg tablet
1
QL
60 / 30 days
moexipril/hydrochlorothiazide 7.5-12.5mg tablet
1
QL
30 / 30 days
nadolol 20 mg tablet
1
nadolol 40 mg tablet
1
nadolol 80 mg tablet
1
nadolol/bendroflumethiazide 40 mg-5 mg tablet
1
nadolol/bendroflumethiazide 80 mg-5 mg tablet
1
nicardipine hcl 20 mg capsule
1
nicardipine hcl 30 mg capsule
1
NIFEDIAC CC 30 MG TABLET
nifedipine
1
NIFEDIAC CC 60 MG TABLET
nifedipine
1
NIFEDIAC CC 90 MG TABLET
nifedipine
1
NIFEDICAL XL 30 MG TABLET
nifedipine
1
NIFEDICAL XL 60 MG TABLET
nifedipine
1
nifedipine 10 mg capsule
1
nifedipine 20 mg capsule
1
nifedipine 30 mg tab er 24
1
nifedipine 30 mg tablet er
1
nifedipine 60 mg tab er 24
1
nifedipine 60 mg tablet er
1
PAGE 82
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
nifedipine 90 mg tab er 24
1
nifedipine 90 mg tablet er
1
nimodipine 30 mg capsule
1
nisoldipine 17 mg tab er 24h
1
nisoldipine 20 mg tab er 24h
1
nisoldipine 25.5 mg tab er 24h
1
nisoldipine 30 mg tab er 24h
1
nisoldipine 34 mg tab er 24h
1
nisoldipine 40 mg tab er 24h
1
nisoldipine 8.5mg tab er 24h
1
pindolol 10 mg tablet
1
pindolol 5 mg tablet
1
prazosin hcl 1 mg capsule
1
QL
90 / 30 days
prazosin hcl 2 mg capsule
1
QL
120 / 30 days
prazosin hcl 5 mg capsule
1
QL
120 / 30 days
propranolol hcl 10 mg tablet
1
propranolol hcl 120 mg cap sa 24h
1
propranolol hcl 160 mg cap sa 24h
1
propranolol hcl 20 mg tablet
1
propranolol hcl 20 mg/5 ml solution
1
propranolol hcl 40 mg tablet
1
propranolol hcl 40mg/5ml solution
1
propranolol hcl 60 mg cap sa 24h
1
propranolol hcl 60 mg tablet
1
propranolol hcl 80 mg cap sa 24h
1
propranolol hcl 80 mg tablet
1
propranolol/hydrochlorothiazid 40 mg-25mg tablet
1
propranolol/hydrochlorothiazid 80 mg-25mg tablet
1
quinapril hcl 10 mg tablet
1
QL
60 / 30 days
quinapril hcl 20 mg tablet
1
QL
60 / 30 days
PAGE 83
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
quinapril hcl 40 mg tablet
1
QL
60 / 30 days
quinapril hcl 5 mg tablet
1
QL
60 / 30 days
quinapril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
quinapril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
quinapril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
ramipril 1.25 mg capsule
1
QL
60 / 30 days
ramipril 10 mg capsule
1
QL
60 / 30 days
ramipril 2.5 mg capsule
1
QL
60 / 30 days
ramipril 5 mg capsule
1
QL
60 / 30 days
reserpine 0.1 mg tablet
1
reserpine 0.25 mg tablet
1
SORINE 120 MG TABLET
sotalol hcl
1
SORINE 160 MG TABLET
sotalol hcl
1
SORINE 240 MG TABLET
sotalol hcl
1
SORINE 80 MG TABLET
sotalol hcl
1
sotalol hcl 120 mg tablet
1
sotalol hcl 160 mg tablet
1
sotalol hcl 240 mg tablet
1
sotalol hcl 80 mg tablet
1
spironolact/hydrochlorothiazid 25 mg-25mg tablet
1
spironolactone 100 mg tablet
1
spironolactone 25 mg tablet
1
spironolactone 50 mg tablet
1
TAZTIA XT 120 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 180 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 240 MG CAPSULE
diltiazem hcl
1
PAGE 84
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
TAZTIA XT 300 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 360 MG CAPSULE
diltiazem hcl
1
telmisartan 20 mg tablet
1
QL
30 / 30 days
telmisartan 40 mg tablet
1
QL
30 / 30 days
telmisartan 80 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 40-12.5 mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80 mg-25mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80-12.5mg tablet
1
QL
30 / 30 days
terazosin hcl 1 mg capsule
1
QL
60 / 30 days
terazosin hcl 10 mg capsule
1
QL
60 / 30 days
terazosin hcl 2 mg capsule
1
QL
60 / 30 days
terazosin hcl 5 mg capsule
1
QL
60 / 30 days
THEO-24 ER 100 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 200 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 300 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 400 MG CAPSULE
theophylline anhydrous
1
THEOCHRON ER 100 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 200 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 300 MG TABLET
theophylline anhydrous
1
PAGE 85
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
theophylline anhydrous 100 mg tab er 12h
1
theophylline anhydrous 200 mg tab er 12h
1
theophylline anhydrous 300 mg tab er 12h
1
theophylline anhydrous 400 mg tablet er
1
theophylline anhydrous 450 mg tab er 12h
1
theophylline anhydrous 600 mg tablet er
1
theophylline anhydrous 80 mg/15ml elixir
1
theophylline anhydrous 80 mg/15ml solution
1
timolol maleate 10 mg tablet
1
timolol maleate 20 mg tablet
1
timolol maleate 5 mg tablet
1
torsemide 10 mg tablet
1
torsemide 100 mg tablet
1
torsemide 20 mg tablet
1
torsemide 5 mg tablet
1
trandolapril 1 mg tablet
1
QL
60 / 30 days
trandolapril 2 mg tablet
1
QL
60 / 30 days
trandolapril 4 mg tablet
1
QL
60 / 30 days
triamterene/hydrochlorothiazid 37.5-25 mg capsule
1
triamterene/hydrochlorothiazid 37.5-25 mg tablet
1
triamterene/hydrochlorothiazid 50 mg-25mg capsule
1
triamterene/hydrochlorothiazid 75 mg-50mg tablet
1
valsartan 160 mg tablet
1
QL
60 / 30 days
valsartan 320 mg tablet
1
QL
30 / 30 days
valsartan 40 mg tablet
1
QL
60 / 30 days
valsartan 80 mg tablet
1
QL
60 / 30 days
valsartan/hydrochlorothiazide 160-12.5mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 160-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 320-12.5mg tablet
1
QL
30 / 30 days
PAGE 86
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
valsartan/hydrochlorothiazide 320mg-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 80-12.5mg tablet
1
QL
30 / 30 days
verapamil hcl 100 mg cap24h pct
1
verapamil hcl 120 mg cap24h pel
1
verapamil hcl 120 mg tablet
1
verapamil hcl 120 mg tablet er
1
verapamil hcl 180 mg cap24h pel
1
verapamil hcl 180 mg tablet er
1
verapamil hcl 200 mg cap24h pct
1
verapamil hcl 240 mg cap24h pel
1
verapamil hcl 240 mg tablet er
1
verapamil hcl 300 mg cap24h pct
1
verapamil hcl 360 mg cap24h pel
1
verapamil hcl 40 mg tablet
1
verapamil hcl 80 mg tablet
1
QL
30 / 30 days
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
amlodipine besylate/benazepril 10 mg-20mg capsule
1
amlodipine besylate/benazepril 10 mg-40mg capsule
1
amlodipine besylate/benazepril 2.5mg-10mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-10 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-20 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-40 mg capsule
1
amlodipine/valsartan 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-160-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-320-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10mg-160mg tablet
1
QL
30 / 30 days
PAGE 87
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
amlodipine/valsartan/hcthiazid 5-160-12.5 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-25mg tablet
1
QL
30 / 30 days
benazepril hcl 10 mg tablet
1
QL
60 / 30 days
benazepril hcl 20 mg tablet
1
QL
60 / 30 days
benazepril hcl 40 mg tablet
1
QL
60 / 30 days
benazepril hcl 5 mg tablet
1
QL
60 / 30 days
benazepril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 5-6.25mg tablet
1
QL
30 / 30 days
candesartan cilexetil 16 mg tablet
1
QL
60 / 30 days
candesartan cilexetil 32 mg tablet
1
QL
30 / 30 days
candesartan cilexetil 4 mg tablet
1
QL
60 / 30 days
candesartan cilexetil 8 mg tablet
1
QL
60 / 30 days
candesartan/hydrochlorothiazid 16-12.5mg tablet
1
QL
30 / 30 days
candesartan/hydrochlorothiazid 32-12.5mg tablet
1
QL
30 / 30 days
candesartan/hydrochlorothiazid 32mg-25mg tablet
1
QL
30 / 30 days
captopril 100 mg tablet
1
QL
120 / 30 days
captopril 12.5 mg tablet
1
QL
90 / 30 days
captopril 25 mg tablet
1
QL
90 / 30 days
captopril 50 mg tablet
1
QL
90 / 30 days
captopril/hydrochlorothiazide 25 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 25 mg-25mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-25mg tablet
1
QL
30 / 30 days
enalapril maleate 10 mg tablet
1
QL
60 / 30 days
PAGE 88
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
enalapril maleate 2.5 mg tablet
1
QL
60 / 30 days
enalapril maleate 20 mg tablet
1
QL
60 / 30 days
enalapril maleate 5 mg tablet
1
QL
60 / 30 days
enalapril/hydrochlorothiazide 10 mg-25mg tablet
1
QL
60 / 30 days
enalapril/hydrochlorothiazide 5mg-12.5mg tablet
1
QL
60 / 30 days
eplerenone 25 mg tablet
1
QL
30 / 30 days
eplerenone 50 mg tablet
1
QL
60 / 30 days
fosinopril sodium 10 mg tablet
1
QL
60 / 30 days
fosinopril sodium 20 mg tablet
1
QL
60 / 30 days
fosinopril sodium 40 mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
irbesartan 150 mg tablet
1
QL
30 / 30 days
irbesartan 300 mg tablet
1
QL
30 / 30 days
irbesartan 75 mg tablet
1
QL
30 / 30 days
irbesartan/hydrochlorothiazide 150-12.5mg tablet
1
QL
60 / 30 days
irbesartan/hydrochlorothiazide 300-12.5mg tablet
1
QL
30 / 30 days
lisinopril 10 mg tablet
1
QL
60 / 30 days
lisinopril 2.5 mg tablet
1
QL
60 / 30 days
lisinopril 20 mg tablet
1
QL
60 / 30 days
lisinopril 30 mg tablet
1
QL
60 / 30 days
lisinopril 40 mg tablet
1
QL
60 / 30 days
lisinopril 5 mg tablet
1
QL
60 / 30 days
lisinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
lisinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
lisinopril/hydrochlorothiazide 20-25mg tablet
1
QL
60 / 30 days
PAGE 89
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
losartan potassium 100 mg tablet
1
QL
30 / 30 days
losartan potassium 25 mg tablet
1
QL
60 / 30 days
losartan potassium 50 mg tablet
1
QL
60 / 30 days
losartan/hydrochlorothiazide 100-12.5mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 100mg-25mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 50-12.5 mg tablet
1
QL
30 / 30 days
moexipril hcl 15 mg tablet
1
QL
60 / 30 days
moexipril hcl 7.5 mg tablet
1
QL
60 / 30 days
moexipril/hydrochlorothiazide 15-12.5mg tablet
1
QL
30 / 30 days
moexipril/hydrochlorothiazide 15-25mg tablet
1
QL
60 / 30 days
moexipril/hydrochlorothiazide 7.5-12.5mg tablet
1
QL
30 / 30 days
quinapril hcl 10 mg tablet
1
QL
60 / 30 days
quinapril hcl 20 mg tablet
1
QL
60 / 30 days
quinapril hcl 40 mg tablet
1
QL
60 / 30 days
quinapril hcl 5 mg tablet
1
QL
60 / 30 days
quinapril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
quinapril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
quinapril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
ramipril 1.25 mg capsule
1
QL
60 / 30 days
ramipril 10 mg capsule
1
QL
60 / 30 days
ramipril 2.5 mg capsule
1
QL
60 / 30 days
ramipril 5 mg capsule
1
QL
60 / 30 days
spironolact/hydrochlorothiazid 25 mg-25mg tablet
1
spironolactone 100 mg tablet
1
spironolactone 25 mg tablet
1
spironolactone 50 mg tablet
1
telmisartan 20 mg tablet
1
QL
30 / 30 days
PAGE 90
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
telmisartan 40 mg tablet
1
QL
30 / 30 days
telmisartan 80 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 40-12.5 mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80 mg-25mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80-12.5mg tablet
1
QL
30 / 30 days
trandolapril 1 mg tablet
1
QL
60 / 30 days
trandolapril 2 mg tablet
1
QL
60 / 30 days
trandolapril 4 mg tablet
1
QL
60 / 30 days
valsartan 160 mg tablet
1
QL
60 / 30 days
valsartan 320 mg tablet
1
QL
30 / 30 days
valsartan 40 mg tablet
1
QL
60 / 30 days
valsartan 80 mg tablet
1
QL
60 / 30 days
valsartan/hydrochlorothiazide 160-12.5mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 160-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 320-12.5mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 320mg-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 80-12.5mg tablet
1
QL
30 / 30 days
VASODILATING AGENTS
ADALAT CC 30 MG TABLET
nifedipine
1
ADALAT CC 60 MG TABLET
nifedipine
1
ADALAT CC 90 MG TABLET
nifedipine
1
PAGE 91
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
AFEDITAB CR 30 MG TABLET
nifedipine
1
AFEDITAB CR 60 MG TABLET
nifedipine
1
amlodipine besylate 10 mg tablet
1
amlodipine besylate 2.5 mg tablet
1
amlodipine besylate 5 mg tablet
1
amlodipine besylate/benazepril 10 mg-20mg capsule
1
amlodipine besylate/benazepril 10 mg-40mg capsule
1
amlodipine besylate/benazepril 2.5mg-10mg capsule
LIMITS & RESTRICTIONS
QL
30 / 30 days
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-10 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-20 mg capsule
1
QL
30 / 30 days
amlodipine besylate/benazepril 5 mg-40 mg capsule
1
amlodipine/atorvastatin 10 mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 10 mg-80mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-10mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-20mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 2.5mg-40mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-10 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-20 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-40 mg tablet
1
QL
30 / 30 days
amlodipine/atorvastatin 5 mg-80 mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 10mg-320mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan 5mg-320mg tablet
1
QL
30 / 30 days
PAGE 92
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
CARTIA XT 120 MG CAPSULE
diltiazem hcl
1
CARTIA XT 180 MG CAPSULE
diltiazem hcl
1
CARTIA XT 240 MG CAPSULE
diltiazem hcl
1
CARTIA XT 300 MG CAPSULE
diltiazem hcl
1
cilostazol 100 mg tablet
1
QL
60 / 30 days
cilostazol 50 mg tablet
1
QL
60 / 30 days
DILT XR 120 MG CAPSULE
diltiazem hcl
1
DILT XR 180 MG CAPSULE
diltiazem hcl
1
DILT XR 240 MG CAPSULE
diltiazem hcl
1
DILT-CD 120 MG CAPSULE
diltiazem hcl
1
DILT-CD 180 MG CAPSULE
diltiazem hcl
1
DILT-CD 240 MG CAPSULE
diltiazem hcl
1
DILT-CD ER 300 MG CAPSULE
diltiazem hcl
1
DILTIA XT 120 MG CAPSULE
diltiazem hcl
1
DILTIA XT 180 MG CAPSULE
diltiazem hcl
1
DILTIA XT 240 MG CAPSULE
diltiazem hcl
1
diltiazem hcl 120 mg cap er 12h
1
diltiazem hcl 120 mg cap er 24h
1
diltiazem hcl 120 mg cap er deg
1
diltiazem hcl 120 mg capsule er
1
diltiazem hcl 120 mg tablet
1
diltiazem hcl 180 mg cap er 24h
1
PAGE 93
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
diltiazem hcl 180 mg cap er deg
1
diltiazem hcl 180 mg capsule er
1
diltiazem hcl 240 mg cap er 24h
1
diltiazem hcl 240 mg cap er deg
1
diltiazem hcl 240 mg capsule er
1
diltiazem hcl 30 mg tablet
1
diltiazem hcl 300 mg cap er 24h
1
diltiazem hcl 300 mg capsule er
1
diltiazem hcl 360 mg cap er 24h
1
diltiazem hcl 360 mg capsule er
1
diltiazem hcl 420mg capsule er
1
diltiazem hcl 60 mg cap er 12h
1
diltiazem hcl 60 mg tablet
1
diltiazem hcl 90 mg cap er 12h
1
diltiazem hcl 90 mg tablet
1
DILTZAC ER 120 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 180 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 240 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 300 MG CAPSULE
diltiazem hcl
1
DILTZAC ER 360 MG CAPSULE
diltiazem hcl
1
dipyridamole 25 mg tablet
1
dipyridamole 50 mg tablet
1
dipyridamole 75 mg tablet
1
IMDUR ER 120 MG TABLET
isosorbide mononitrate
1
IMDUR ER 30 MG TABLET
isosorbide mononitrate
1
IMDUR ER 60 MG TABLET
isosorbide mononitrate
1
PAGE 94
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
isosorbide dinitrate 10 mg tablet
1
isosorbide dinitrate 2.5 mg tab subl
1
isosorbide dinitrate 20 mg tablet
1
isosorbide dinitrate 30 mg tablet
1
isosorbide dinitrate 40 mg tablet er
1
isosorbide dinitrate 5 mg tab subl
1
isosorbide dinitrate 5 mg tablet
1
isosorbide mononitrate 10 mg tablet
1
isosorbide mononitrate 120 mg tab er 24h
1
isosorbide mononitrate 20 mg tablet
1
isosorbide mononitrate 30 mg tab er 24h
1
isosorbide mononitrate 60 mg tab er 24h
1
MATZIM LA 180 MG TABLET
diltiazem hcl
1
MATZIM LA 240 MG TABLET
diltiazem hcl
1
MATZIM LA 300 MG TABLET
diltiazem hcl
1
MATZIM LA 360 MG TABLET
diltiazem hcl
1
MATZIM LA 420 MG TABLET
diltiazem hcl
1
nicardipine hcl 20 mg capsule
1
nicardipine hcl 30 mg capsule
1
NIFEDIAC CC 30 MG TABLET
nifedipine
1
NIFEDIAC CC 60 MG TABLET
nifedipine
1
NIFEDIAC CC 90 MG TABLET
nifedipine
1
NIFEDICAL XL 30 MG TABLET
nifedipine
1
NIFEDICAL XL 60 MG TABLET
nifedipine
1
nifedipine 10 mg capsule
1
PAGE 95
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nifedipine 20 mg capsule
1
nifedipine 30 mg tab er 24
1
nifedipine 30 mg tablet er
1
nifedipine 60 mg tab er 24
1
nifedipine 60 mg tablet er
1
nifedipine 90 mg tab er 24
1
nifedipine 90 mg tablet er
1
nimodipine 30 mg capsule
1
NITRO-BID 2% OINTMENT
nitroglycerin
1
nitroglycerin 0.1mg/hr patch td24
1
nitroglycerin 0.2mg/hr patch td24
1
nitroglycerin 0.4mg/hr patch td24
1
nitroglycerin 0.6mg/hr patch td24
1
nitroglycerin 400mcg/spr spray
1
NITROSTAT 0.3 MG TABLET SL
nitroglycerin
1
NITROSTAT 0.4 MG TABLET SL
nitroglycerin
1
NITROSTAT 0.6 MG TABLET SL
nitroglycerin
1
papaverine hcl 150 mg capsule er
1
sildenafil citrate 10 mg/12.5 vial
1
sildenafil citrate 20 mg tablet
1
TAZTIA XT 120 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 180 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 240 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 300 MG CAPSULE
diltiazem hcl
1
TAZTIA XT 360 MG CAPSULE
diltiazem hcl
1
PAGE 96
LIMITS & RESTRICTIONS
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
telmisartan/amlodipine 40 mg-5 mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 40mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-10mg tablet
1
QL
30 / 30 days
telmisartan/amlodipine 80 mg-5 mg tablet
1
QL
30 / 30 days
verapamil hcl 100 mg cap24h pct
1
verapamil hcl 120 mg cap24h pel
1
verapamil hcl 120 mg tablet
1
verapamil hcl 120 mg tablet er
1
verapamil hcl 180 mg cap24h pel
1
verapamil hcl 180 mg tablet er
1
verapamil hcl 200 mg cap24h pct
1
verapamil hcl 240 mg cap24h pel
1
verapamil hcl 240 mg tablet er
1
verapamil hcl 300 mg cap24h pct
1
verapamil hcl 360 mg cap24h pel
1
verapamil hcl 40 mg tablet
1
verapamil hcl 80 mg tablet
1
QL
450 / 30 days
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
acetaminophen with codeine 120-12mg/5 solution
1
acetaminophen with codeine 240-24/10 solution
1
acetaminophen with codeine 300mg-15mg tablet
1
acetaminophen with codeine 300mg-30mg tablet
1
acetaminophen with codeine 300mg-60mg tablet
1
acetaminophen with codeine 300mg/12.5 solution
1
acetaminophen with codeine 360-36/15 solution
1
ALAGESIC LQ ORAL SOLUTION
butalbital/acetaminophen/caffeine
1
ANABAR CAPLET
salicylamide/acetaminophen/phenyltoloxamine
1
ASCOMP WITH CODEINE CAPSULE
codeine phosphate/butalbital/aspirin/caffeine
1
PAGE 97
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
aspirin 975 mg tablet dr
1
BUPAP TABLET
butalbital/acetaminophen
1
buprenorphine hcl 2 mg tab subl
1
buprenorphine hcl 8 mg tab subl
1
buprenorphine hcl/naloxone hcl 2 mg-0.5mg tab subl
1
buprenorphine hcl/naloxone hcl 8 mg-2 mg tab subl
1
butalb/acetaminophen/caffeine 50-300-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 tablet
1
butalb/acetaminophen/caffeine 50-500-40 tablet
1
butalbit/acetamin/caff/codeine 50-300-30 capsule
1
butalbit/acetamin/caff/codeine 50-325-30 capsule
1
butalbital/acetaminophen 50mg-325mg tablet
1
butalbital/aspirin/caffeine 50-325-40 capsule
1
butalbital/aspirin/caffeine 50-325-40 tablet
1
butorphanol tartrate 10 mg/ml spray
1
CAFGESIC FORTE TABLET
magnesium
salicylate/acetaminophen/phenyltoloxamine/caffeine
1
CAPACET CAPSULE
butalbital/acetaminophen/caffeine
1
celecoxib 100 mg capsule
1
PA
celecoxib 200 mg capsule
1
PA
celecoxib 400 mg capsule
1
PA
celecoxib 50 mg capsule
1
PA
CEPHADYN TABLET
butalbital/acetaminophen
1
choline sal/mag salicylate 500 mg tablet
1
choline sal/mag salicylate 500 mg/5ml liquid
1
choline sal/mag salicylate 750 mg tablet
1
CO-GESIC 5-500 TABLET
hydrocodone bitartrate/acetaminophen
1
PAGE 98
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
COCET TABLET
acetaminophen with codeine phosphate
1
codeine sulfate 15 mg tablet
1
codeine sulfate 30 mg tablet
1
codeine sulfate 60 mg tablet
1
codeine/butalbital/asa/caffein 30-50-325 capsule
1
dhcodeine bt/acetaminophn/caff 32-713-60 tablet
1
diclofenac potassium 50 mg tablet
1
diclofenac sodium 1.5 % drops
1
diclofenac sodium 100 mg tab er 24h
1
diclofenac sodium 25 mg tablet dr
1
diclofenac sodium 50 mg tablet dr
1
diclofenac sodium 75 mg tablet dr
1
diflunisal 500 mg tablet
1
dihydrocodeine/aspirin/caffein 16-356-30 capsule
1
DISKETS 40 MG TABLET DISPR
methadone hcl
1
DURAXIN CAPSULE
salicylamide/acetaminophen/phenyltoloxamine
1
ENDACOF-C LIQUID
chlorpheniramine maleate/codeine phosphate
1
ENDOCET 10-325 MG TABLET
oxycodone hcl/acetaminophen
1
ENDOCET 10-650 MG TABLET
oxycodone hcl/acetaminophen
1
ENDOCET 2.5-325 MG TABLET
oxycodone hcl/acetaminophen
1
ENDOCET 5-325 TABLET
oxycodone hcl/acetaminophen
1
ENDOCET 7.5-325 MG TABLET
oxycodone hcl/acetaminophen
1
ENDOCET 7.5-500 MG TABLET
oxycodone hcl/acetaminophen
1
ENDODAN 4.8355-325 MG TABLET
oxycodone hcl/aspirin
1
PAGE 99
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
etodolac 200 mg capsule
1
etodolac 300 mg capsule
1
etodolac 400 mg tab er 24h
1
etodolac 400 mg tablet
1
etodolac 500 mg tab er 24h
1
etodolac 500 mg tablet
1
etodolac 600 mg tab er 24h
1
fenoprofen calcium 600 mg tablet
1
fentanyl 100 mcg/hr patch td72
1
fentanyl 12 mcg/hr patch td72
1
fentanyl 25mcg/hr patch td72
1
fentanyl 50mcg/hr patch td72
1
fentanyl 75mcg/hr patch td72
1
fentanyl citrate 1200 mcg lozenge hd
1
PA
fentanyl citrate 1600 mcg lozenge hd
1
PA
fentanyl citrate 200 mcg lozenge hd
1
PA
fentanyl citrate 400 mcg lozenge hd
1
PA
fentanyl citrate 600 mcg lozenge hd
1
PA
fentanyl citrate 800 mcg lozenge hd
1
PA
flurbiprofen 100 mg tablet
1
flurbiprofen 50 mg tablet
1
gabapentin 100 mg capsule
1
gabapentin 250 mg/5ml solution
1
gabapentin 300 mg capsule
1
gabapentin 300 mg/6ml solution
1
gabapentin 400 mg capsule
1
gabapentin 600 mg tablet
1
gabapentin 800 mg tablet
1
hydrocodone/acetaminophen 10-325/15 solution
1
hydrocodone/acetaminophen 10-660mg tablet
1
PAGE 100
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
hydrocodone/acetaminophen 10-750mg tablet
1
hydrocodone/acetaminophen 10mg-325mg tablet
1
hydrocodone/acetaminophen 10mg-500mg tablet
1
hydrocodone/acetaminophen 10mg-650mg tablet
1
hydrocodone/acetaminophen 2.5-167/5 solution
1
hydrocodone/acetaminophen 2.5-325mg tablet
1
hydrocodone/acetaminophen 2.5-500 mg tablet
1
hydrocodone/acetaminophen 5 mg-325mg tablet
1
hydrocodone/acetaminophen 5 mg-500mg capsule
1
hydrocodone/acetaminophen 5 mg-500mg tablet
1
hydrocodone/acetaminophen 5-163/7.5 solution
1
hydrocodone/acetaminophen 5-334mg/10 solution
1
hydrocodone/acetaminophen 5mg-300mg tablet
1
hydrocodone/acetaminophen 7.5-325/15 solution
1
hydrocodone/acetaminophen 7.5-325mg tablet
1
hydrocodone/acetaminophen 7.5-500/15 solution
1
hydrocodone/acetaminophen 7.5-500mg tablet
1
hydrocodone/acetaminophen 7.5-650 mg tablet
1
hydrocodone/acetaminophen 7.5-750mg tablet
1
hydrocodone/ibuprofen 10mg-200mg tablet
1
hydrocodone/ibuprofen 2.5-200mg tablet
1
hydrocodone/ibuprofen 5mg-200mg tablet
1
hydrocodone/ibuprofen 7.5-200 mg tablet
1
hydromorphone hcl 1 mg/ml liquid
1
hydromorphone hcl 12 mg tab er 24h
1
hydromorphone hcl 16 mg tab er 24h
1
hydromorphone hcl 2 mg tablet
1
hydromorphone hcl 3 mg supp.rect
1
hydromorphone hcl 32 mg tab er 24h
1
hydromorphone hcl 4 mg tablet
1
hydromorphone hcl 8 mg tab er 24h
1
PAGE 101
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
hydromorphone hcl 8 mg tablet
1
HYOPHEN TABLET
methenamine/methylene blue/benzoic acid/salicylate/hyoscy
1
ibuprofen 100 mg/5ml oral susp
1
ibuprofen 400 mg tablet
1
ibuprofen 600 mg tablet
1
ibuprofen 800 mg tablet
1
ibuprofen/oxycodone hcl 400mg-5mg tablet
1
indomethacin 25 mg capsule
1
indomethacin 50 mg capsule
1
indomethacin 75 mg capsule er
1
isomethepten/caf/acetaminophen 130-20-500 tablet
1
isomethepten/caf/acetaminophen 65-20-325 tablet
1
ketoprofen 200 mg cap24h pel
1
ketoprofen 50 mg capsule
1
ketoprofen 75 mg capsule
1
ketorolac tromethamine 10 mg tablet
1
LEVACET CAPLET
aspirin/salicylamide/acetaminophen/caffeine
1
levorphanol tartrate 2 mg tablet
1
LORCET 5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
LORCET HD 10-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
LORCET PLUS 7.5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
LORTAB 10-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
LORTAB 5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
LORTAB 7.5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
MARGESIC CAPSULE
butalbital/acetaminophen/caffeine
1
PAGE 102
LIMITS & RESTRICTIONS
QL
20 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
MARTEN-TAB 325-50 TABLET
butalbital/acetaminophen
1
meclofenamate sodium 100 mg capsule
1
meclofenamate sodium 50 mg capsule
1
mefenamic acid 250 mg capsule
1
meloxicam 15 mg tablet
1
meloxicam 7.5 mg tablet
1
meloxicam 7.5 mg/5ml oral susp
1
meperidine hcl 100 mg tablet
1
meperidine hcl 50 mg tablet
1
meperidine hcl 50 mg/5 ml solution
1
MEPERITAB 100 MG TABLET
meperidine hcl
1
methadone hcl 10 mg tablet
1
methadone hcl 10 mg/5 ml solution
1
methadone hcl 10 mg/ml oral conc
1
methadone hcl 40 mg tablet sol
1
methadone hcl 5 mg tablet
1
methadone hcl 5 mg/5 ml solution
1
METHADONE INTENSOL 10 MG/ML
methadone hcl
1
METHADOSE 10 MG/ML ORAL CONC
methadone hcl
1
METHADOSE 40 MG TABLET DISPR
methadone hcl
1
methyl salicylate liquid
1
MIGRAGESIC IDA CAPSULE
isometheptene mucate/dichloralphenazone/acetaminophen
1
morphine sulfate 10 mg cap er pel
1
morphine sulfate 10 mg supp.rect
1
morphine sulfate 10 mg/5 ml solution
1
morphine sulfate 100 mg cap er pel
1
morphine sulfate 100 mg tablet er
1
PAGE 103
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
morphine sulfate 100 mg/5ml solution
1
morphine sulfate 120 mg cpmp 24hr
1
morphine sulfate 15 mg tablet
1
morphine sulfate 15 mg tablet er
1
morphine sulfate 20 mg cap er pel
1
morphine sulfate 20 mg supp.rect
1
morphine sulfate 20 mg/5 ml solution
1
morphine sulfate 200 mg tablet er
1
morphine sulfate 30 mg cap er pel
1
morphine sulfate 30 mg cpmp 24hr
1
morphine sulfate 30 mg supp.rect
1
morphine sulfate 30 mg tablet
1
morphine sulfate 30 mg tablet er
1
morphine sulfate 45 mg cpmp 24hr
1
morphine sulfate 5 mg supp.rect
1
morphine sulfate 50 mg cap er pel
1
morphine sulfate 60 mg cap er pel
1
morphine sulfate 60 mg cpmp 24hr
1
morphine sulfate 60 mg tablet er
1
morphine sulfate 75 mg cpmp 24hr
1
morphine sulfate 80 mg cap er pel
1
morphine sulfate 90 mg cpmp 24hr
1
MST 600 TABLET
magnesium salicylate
1
nabumetone 500 mg tablet
1
nabumetone 750 mg tablet
1
naproxen 125 mg/5ml oral susp
1
naproxen 250 mg tablet
1
naproxen 375 mg tablet
1
naproxen 375 mg tablet dr
1
naproxen 500 mg tablet
1
PAGE 104
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
naproxen 500 mg tablet dr
1
naproxen sodium 275 mg tablet
1
naproxen sodium 500 mg tbmp 24hr
1
naproxen sodium 550 mg tablet
1
NEURONTIN 100 MG CAPSULE
gabapentin
1
NEURONTIN 250 MG/5 ML SOLN
gabapentin
1
NEURONTIN 300 MG CAPSULE
gabapentin
1
NEURONTIN 400 MG CAPSULE
gabapentin
1
NEURONTIN 600 MG TABLET
gabapentin
1
NEURONTIN 800 MG TABLET
gabapentin
1
NOVAGESIC CAPLET
acetaminophen/phenyltoloxamine cit
1
opium/belladonna alkaloids 30-16.2mg supp.rect
1
opium/belladonna alkaloids 60-16.2mg supp.rect
1
orphenadrine/aspirin/caffeine 25-385-30 tablet
1
orphenadrine/aspirin/caffeine 50-770-60 tablet
1
oxaprozin 600 mg tablet
1
oxycodone hcl 10 mg tablet
1
oxycodone hcl 15 mg tablet
1
oxycodone hcl 20 mg tablet
1
oxycodone hcl 20 mg/ml oral conc
1
oxycodone hcl 30 mg tablet
1
oxycodone hcl 5 mg capsule
1
oxycodone hcl 5 mg tablet
1
oxycodone hcl 5 mg/5 ml solution
1
oxycodone hcl/acetaminophen 10mg-325mg tablet
1
oxycodone hcl/acetaminophen 10mg-650mg tablet
1
oxycodone hcl/acetaminophen 2.5-325mg tablet
1
PAGE 105
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
oxycodone hcl/acetaminophen 5 mg-325mg tablet
1
oxycodone hcl/acetaminophen 5 mg-500mg capsule
1
oxycodone hcl/acetaminophen 7.5-325mg tablet
1
oxycodone hcl/acetaminophen 7.5-500mg tablet
1
oxycodone hcl/aspirin 4.8355-325 tablet
1
oxymorphone hcl 10 mg tab er 12h
1
oxymorphone hcl 15 mg tab er 12h
1
oxymorphone hcl 20 mg tab er 12h
1
oxymorphone hcl 30 mg tab er 12h
1
oxymorphone hcl 40 mg tab er 12h
1
oxymorphone hcl 5 mg tab er 12h
1
oxymorphone hcl 7.5 mg tab er 12h
1
pentazocine hcl/acetaminophen 25-650mg tablet
1
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet
1
PHOSPHASAL TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
piroxicam 10 mg capsule
1
piroxicam 20 mg capsule
1
PROMACET 50-650 MG TABLET
butalbital/acetaminophen
1
promethazine/phenyleph/codeine 6.25-5-10 syrup
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
REPAN 50-325-40 MG TABLET
butalbital/acetaminophen/caffeine
1
REPREXAIN 10-200 MG TABLET
hydrocodone/ibuprofen
1
REPREXAIN 2.5-200 MG TABLET
hydrocodone/ibuprofen
1
REPREXAIN 5-200 MG TABLET
hydrocodone/ibuprofen
1
RHINOFLEX 500 MG-50 MG TABLET
acetaminophen/phenyltoloxamine citrate
1
RHINOFLEX-650 TABLET
acetaminophen/phenyltoloxamine citrate
1
PAGE 106
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ROXICET 5-325 TABLET
oxycodone hcl/acetaminophen
1
salsalate 500 mg tablet
1
salsalate 750 mg tablet
1
SEDAPAP TABLET
butalbital/acetaminophen
1
STAGESIC 5-500 CAPSULE
hydrocodone bitartrate/acetaminophen
1
sulindac 150 mg tablet
1
sulindac 200 mg tablet
1
TENCON 50-325 MG TABLET
butalbital/acetaminophen
1
TENCON TABLET
butalbital/acetaminophen
1
tolmetin sodium 200 mg tablet
1
tolmetin sodium 400 mg capsule
1
tolmetin sodium 600 mg tablet
1
tramadol hcl 100 mg tab er 24h
1
tramadol hcl 100 mg tbmp 24hr
1
tramadol hcl 200 mg tab er 24h
1
tramadol hcl 200 mg tbmp 24hr
1
tramadol hcl 300 mg tab er 24h
1
tramadol hcl 300 mg tbmp 24hr
1
tramadol hcl 50 mg tablet
1
tramadol hcl/acetaminophen 37.5-325mg tablet
1
TREZIX CAPSULE
dihydrocodeine bitartrate/acetaminophen/caffeine
1
UR N-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URETRON D-S TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URETRON D-S TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URIMAR-T TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
PAGE 107
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
URIN D.S. TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-L TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-MP CAPSULE
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
USTELL CAPSULE
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
UTIRA-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
VERDROCET 2.5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
1
VICODIN 5-300 MG TABLET
hydrocodone bitartrate/acetaminophen
1
VICODIN ES 7.5-300 MG TABLET
hydrocodone bitartrate/acetaminophen
1
VICODIN HP 10-300 MG TABLET
hydrocodone bitartrate/acetaminophen
1
XOLOX 10-500 MG TABLET
oxycodone hcl/acetaminophen
1
XYLON 10-200 MG TABLET
hydrocodone/ibuprofen
1
ZAMICET 10-325 MG/15 ML SOLN
hydrocodone bitartrate/acetaminophen
1
ZEBUTAL 50-325-40 MG CAPSULE
butalbital/acetaminophen/caffeine
1
ZEBUTAL CAPSULE
butalbital/acetaminophen/caffeine
1
ZFLEX TABLET
acetaminophen/phenyltoloxamine citrate
1
ZGESIC TABLET
acetaminophen/phenyltoloxamine citrate
1
LIMITS & RESTRICTIONS
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
ADDERALL 10 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL 12.5 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
PAGE 108
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ADDERALL 15 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL 20 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL 30 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL 5 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL 7.5 MG TABLET
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 10 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 15 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 20 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 25 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 30 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ADDERALL XR 5 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
1
ALAGESIC LQ ORAL SOLUTION
butalbital/acetaminophen/caffeine
1
APTENSIO XR 10 MG CAPSULE
methylphenidate hcl
1
APTENSIO XR 15 MG CAPSULE
methylphenidate hcl
1
APTENSIO XR 20 MG CAPSULE
methylphenidate hcl
1
PAGE 109
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
APTENSIO XR 30 MG CAPSULE
methylphenidate hcl
1
APTENSIO XR 40 MG CAPSULE
methylphenidate hcl
1
APTENSIO XR 50 MG CAPSULE
methylphenidate hcl
1
APTENSIO XR 60 MG CAPSULE
methylphenidate hcl
1
ASCOMP WITH CODEINE CAPSULE
codeine phosphate/butalbital/aspirin/caffeine
1
benzphetamine hcl 50 mg tablet
1
BONTRIL SR 105 MG CAPSULE
phendimetrazine tartrate
1
butalb/acetaminophen/caffeine 50-300-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 tablet
1
butalb/acetaminophen/caffeine 50-500-40 tablet
1
butalbit/acetamin/caff/codeine 50-300-30 capsule
1
butalbit/acetamin/caff/codeine 50-325-30 capsule
1
butalbital/aspirin/caffeine 50-325-40 capsule
1
butalbital/aspirin/caffeine 50-325-40 tablet
1
caffeine citrated 60 mg/3 ml solution
1
CAFGESIC FORTE TABLET
magnesium
salicylate/acetaminophen/phenyltoloxamine/caffeine
1
CAPACET CAPSULE
butalbital/acetaminophen/caffeine
1
codeine/butalbital/asa/caffein 30-50-325 capsule
1
CONCERTA ER 18 MG TABLET
methylphenidate hcl
1
CONCERTA ER 27 MG TABLET
methylphenidate hcl
1
CONCERTA ER 36 MG TABLET
methylphenidate hcl
1
CONCERTA ER 54 MG TABLET
methylphenidate hcl
1
PAGE 110
LIMITS & RESTRICTIONS
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DAYTRANA 10 MG/9 HR PATCH
methylphenidate
1
DAYTRANA 15 MG/9 HR PATCH
methylphenidate
1
DAYTRANA 20 MG/9 HOUR PATCH
methylphenidate
1
DAYTRANA 30 MG/9 HOUR PATCH
methylphenidate
1
DEXEDRINE 10 MG TABLET
dextroamphetamine sulfate
1
DEXEDRINE 5 MG TABLET
dextroamphetamine sulfate
1
DEXEDRINE SPANSULE 10 MG
dextroamphetamine sulfate
1
DEXEDRINE SPANSULE 15 MG
dextroamphetamine sulfate
1
DEXEDRINE SPANSULE 5 MG
dextroamphetamine sulfate
1
dexmethylphenidate hcl 10 mg cpbp 50-50
1
dexmethylphenidate hcl 10 mg tablet
1
dexmethylphenidate hcl 15 mg cpbp 50-50
1
dexmethylphenidate hcl 2.5 mg tablet
1
dexmethylphenidate hcl 30 mg cpbp 50-50
1
dexmethylphenidate hcl 40 mg cpbp 50-50
1
dexmethylphenidate hcl 5 mg cpbp 50-50
1
dexmethylphenidate hcl 5 mg tablet
1
dextroamphetamine sulfate 10 mg capsule er
1
dextroamphetamine sulfate 10 mg tablet
1
dextroamphetamine sulfate 15 mg capsule er
1
dextroamphetamine sulfate 5 mg capsule er
1
dextroamphetamine sulfate 5 mg tablet
1
dextroamphetamine sulfate 5 mg/5 ml solution
1
dextroamphetamine/amphetamine 10 mg cap er 24h
1
dextroamphetamine/amphetamine 10 mg tablet
1
dextroamphetamine/amphetamine 12.5 mg tablet
1
PAGE 111
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
dextroamphetamine/amphetamine 15 mg cap er 24h
1
dextroamphetamine/amphetamine 15 mg tablet
1
dextroamphetamine/amphetamine 20 mg cap er 24h
1
dextroamphetamine/amphetamine 20 mg tablet
1
dextroamphetamine/amphetamine 25 mg cap er 24h
1
dextroamphetamine/amphetamine 30 mg cap er 24h
1
dextroamphetamine/amphetamine 30 mg tablet
1
dextroamphetamine/amphetamine 5 mg cap er 24h
1
dextroamphetamine/amphetamine 5 mg tablet
1
dextroamphetamine/amphetamine 7.5 mg tablet
1
dhcodeine bt/acetaminophn/caff 32-713-60 tablet
1
diethylpropion hcl 25 mg tablet
1
PA
diethylpropion hcl 75 mg tablet er
1
PA
dihydrocodeine/aspirin/caffein 16-356-30 capsule
1
FOCALIN 10 MG TABLET
dexmethylphenidate hcl
1
FOCALIN 2.5 MG TABLET
dexmethylphenidate hcl
1
FOCALIN 5 MG TABLET
dexmethylphenidate hcl
1
FOCALIN XR 10 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 15 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 20 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 25 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 30 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 35 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 40 MG CAPSULE
dexmethylphenidate hcl
1
FOCALIN XR 5 MG CAPSULE
dexmethylphenidate hcl
1
PAGE 112
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
isomethepten/caf/acetaminophen 130-20-500 tablet
1
isomethepten/caf/acetaminophen 65-20-325 tablet
1
LEVACET CAPLET
aspirin/salicylamide/acetaminophen/caffeine
1
MARGESIC CAPSULE
butalbital/acetaminophen/caffeine
1
METADATE CD 10 MG CAPSULE
methylphenidate hcl
1
METADATE CD 20 MG CAPSULE
methylphenidate hcl
1
METADATE CD 30 MG CAPSULE
methylphenidate hcl
1
METADATE CD 40 MG CAPSULE
methylphenidate hcl
1
METADATE CD 50 MG CAPSULE
methylphenidate hcl
1
METADATE CD 60 MG CAPSULE
methylphenidate hcl
1
METADATE ER 20 MG TABLET
methylphenidate hcl
1
methamphetamine hcl 5 mg tablet
1
METHYLIN 10 MG CHEWABLE TABLET
methylphenidate hcl
1
METHYLIN 10 MG/5 ML SOLUTION
methylphenidate hcl
1
METHYLIN 2.5 MG CHEWABLE TAB
methylphenidate hcl
1
METHYLIN 5 MG CHEWABLE TABLET
methylphenidate hcl
1
METHYLIN 5 MG/5 ML SOLUTION
methylphenidate hcl
1
methylphenidate hcl 10 mg cpbp 30-70
1
methylphenidate hcl 10 mg tab chew
1
methylphenidate hcl 10 mg tablet
1
methylphenidate hcl 10 mg tablet er
1
methylphenidate hcl 10 mg/5 ml solution
1
methylphenidate hcl 18 mg tab er 24
1
PAGE 113
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
methylphenidate hcl 2.5 mg tab chew
1
methylphenidate hcl 20 mg cpbp 30-70
1
methylphenidate hcl 20 mg cpbp 50-50
1
methylphenidate hcl 20 mg tablet
1
methylphenidate hcl 20 mg tablet er
1
methylphenidate hcl 27 mg tab er 24
1
methylphenidate hcl 30 mg cpbp 30-70
1
methylphenidate hcl 30 mg cpbp 50-50
1
methylphenidate hcl 36 mg tab er 24
1
methylphenidate hcl 40 mg cpbp 30-70
1
methylphenidate hcl 40 mg cpbp 50-50
1
methylphenidate hcl 5 mg tab chew
1
methylphenidate hcl 5 mg tablet
1
methylphenidate hcl 5 mg/5 ml solution
1
methylphenidate hcl 50 mg cpbp 30-70
1
methylphenidate hcl 54 mg tab er 24
1
methylphenidate hcl 60 mg cpbp 30-70
1
MIGERGOT SUPPOSITORY
ergotamine tartrate/caffeine
1
orphenadrine/aspirin/caffeine 25-385-30 tablet
1
orphenadrine/aspirin/caffeine 50-770-60 tablet
1
phendimetrazine tartrate 105 mg capsule er
1
PA
phendimetrazine tartrate 35 mg tablet
1
PA
phentermine hcl 15 mg capsule
1
PA
phentermine hcl 30 mg capsule
1
PA
phentermine hcl 37.5 mg capsule
1
PA
phentermine hcl 37.5 mg tablet
1
PA
PROCENTRA 5 MG/5 ML SOLUTION
dextroamphetamine sulfate
1
QSYMIA 11.25 MG-69 MG CAPSULE
phentermine hcl/topiramate
1
PAGE 114
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
QSYMIA 15 MG-92 MG CAPSULE
phentermine hcl/topiramate
1
PA
QSYMIA 3.75 MG-23 MG CAPSULE
phentermine hcl/topiramate
1
PA
QSYMIA 7.5 MG-46 MG CAPSULE
phentermine hcl/topiramate
1
PA
QUILLIVANT XR 25 MG/5 ML SUSP
methylphenidate hcl
1
REPAN 50-325-40 MG TABLET
butalbital/acetaminophen/caffeine
1
RITALIN 10 MG TABLET
methylphenidate hcl
1
RITALIN 20 MG TABLET
methylphenidate hcl
1
RITALIN 5 MG TABLET
methylphenidate hcl
1
RITALIN LA 10 MG CAPSULE
methylphenidate hcl
1
RITALIN LA 20 MG CAPSULE
methylphenidate hcl
1
RITALIN LA 30 MG CAPSULE
methylphenidate hcl
1
RITALIN LA 40 MG CAPSULE
methylphenidate hcl
1
RITALIN SR 20 MG TABLET
methylphenidate hcl
1
THEO-24 ER 100 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 200 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 300 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 400 MG CAPSULE
theophylline anhydrous
1
THEOCHRON ER 100 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 200 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 300 MG TABLET
theophylline anhydrous
1
PAGE 115
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
theophylline anhydrous 100 mg tab er 12h
1
theophylline anhydrous 200 mg tab er 12h
1
theophylline anhydrous 300 mg tab er 12h
1
theophylline anhydrous 400 mg tablet er
1
theophylline anhydrous 450 mg tab er 12h
1
theophylline anhydrous 600 mg tablet er
1
theophylline anhydrous 80 mg/15ml elixir
1
theophylline anhydrous 80 mg/15ml solution
1
TREZIX CAPSULE
dihydrocodeine bitartrate/acetaminophen/caffeine
1
VYVANSE 10 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 20 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 30 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 40 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 50 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 60 MG CAPSULE
lisdexamfetamine dimesylate
1
VYVANSE 70 MG CAPSULE
lisdexamfetamine dimesylate
1
ZEBUTAL 50-325-40 MG CAPSULE
butalbital/acetaminophen/caffeine
1
ZEBUTAL CAPSULE
butalbital/acetaminophen/caffeine
1
ZENZEDI 10 MG TABLET
dextroamphetamine sulfate
1
ZENZEDI 15 MG TABLET
dextroamphetamine sulfate
1
ZENZEDI 2.5 MG TABLET
dextroamphetamine sulfate
1
ZENZEDI 20 MG TABLET
dextroamphetamine sulfate
1
ZENZEDI 30 MG TABLET
dextroamphetamine sulfate
1
PAGE 116
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ZENZEDI 5 MG TABLET
dextroamphetamine sulfate
1
ZENZEDI 7.5 MG TABLET
dextroamphetamine sulfate
1
LIMITS & RESTRICTIONS
ANTICONVULSANTS
acetazolamide 125 mg tablet
1
acetazolamide 250 mg tablet
1
acetazolamide 500 mg capsule er
1
APTIOM 200 MG TABLET
eslicarbazepine acetate
1
APTIOM 400 MG TABLET
eslicarbazepine acetate
1
APTIOM 600 MG TABLET
eslicarbazepine acetate
1
APTIOM 800 MG TABLET
eslicarbazepine acetate
1
ATIVAN 0.5 MG TABLET
lorazepam
1
ATIVAN 1 MG TABLET
lorazepam
1
ATIVAN 2 MG TABLET
lorazepam
1
ATIVAN 2 MG/ML VIAL
lorazepam
1
ATIVAN 20 MG/10 ML VIAL
lorazepam
1
ATIVAN 4 MG/ML VIAL
lorazepam
1
ATIVAN 40 MG/10 ML VIAL
lorazepam
1
BANZEL 200 MG TABLET
rufinamide
1
BANZEL 40 MG/ML SUSPENSION
rufinamide
1
BANZEL 400 MG TABLET
rufinamide
1
PAGE 117
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
carbamazepine 100 mg cpmp 12hr
1
carbamazepine 100 mg tab chew
1
carbamazepine 100 mg/5ml oral susp
1
carbamazepine 200 mg cpmp 12hr
1
carbamazepine 200 mg tab er 12h
1
carbamazepine 200 mg tablet
1
carbamazepine 300 mg cpmp 12hr
1
carbamazepine 400 mg tab er 12h
1
CELONTIN 300 MG KAPSEAL
methsuximide
1
clonazepam 0.125 mg tab rapdis
1
clonazepam 0.25 mg tab rapdis
1
clonazepam 0.5 mg tab rapdis
1
clonazepam 0.5 mg tablet
1
clonazepam 1 mg tab rapdis
1
clonazepam 1 mg tablet
1
clonazepam 2 mg tab rapdis
1
clonazepam 2 mg tablet
1
clorazepate dipotassium 15 mg tablet
1
LIMITS & RESTRICTIONS
PA
AL
At least 9 yrs old
PA
clorazepate dipotassium 3.75 mg tablet
1
AL
At least 9 yrs old
PA
clorazepate dipotassium 7.5 mg tablet
1
AL
DEPAKENE 250 MG CAPSULE
valproic acid
1
DEPAKENE 250 MG/5 ML SOLUTION
valproic acid (as sodium salt) (valproate sodium)
1
DEPAKOTE 125 MG SPRINKLE CAP
divalproex sodium
1
DEPAKOTE DR 125 MG TABLET
divalproex sodium
1
DEPAKOTE DR 250 MG TABLET
divalproex sodium
1
PAGE 118
At least 9 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DEPAKOTE DR 500 MG TABLET
divalproex sodium
1
DEPAKOTE ER 250 MG TABLET
divalproex sodium
1
DEPAKOTE ER 500 MG TABLET
divalproex sodium
1
DIASTAT 2.5 MG PEDI SYSTEM
diazepam
1
DIASTAT ACUDIAL 12.5-15-20 MG
diazepam
1
DIASTAT ACUDIAL 5-7.5-10 MG KT
diazepam
1
diazepam 10 mg tablet
1
LIMITS & RESTRICTIONS
PA
AL
diazepam 12.5-15-20 kit
1
diazepam 2 mg tablet
1
At least 1 yrs old
PA
AL
diazepam 2.5 mg kit
1
diazepam 5 mg tablet
1
At least 1 yrs old
PA
AL
At least 1 yrs old
PA
diazepam 5 mg/5 ml solution
1
AL
At least 1 yrs old
PA
diazepam 5 mg/ml oral conc
1
AL
diazepam 5 mg/ml syringe
1
diazepam 5 mg/ml vial
1
diazepam 5-7.5-10mg kit
1
DILANTIN 100 MG CAPSULE
phenytoin sodium extended
1
DILANTIN 125 MG/5 ML SUSP
phenytoin
1
DILANTIN 30 MG CAPSULE
phenytoin sodium extended
1
DILANTIN 50 MG INFATAB
phenytoin
1
PAGE 119
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
divalproex sodium 125 mg cap sprink
1
divalproex sodium 125 mg tablet dr
1
divalproex sodium 250 mg tab er 24h
1
divalproex sodium 250 mg tablet dr
1
divalproex sodium 500 mg tab er 24h
1
divalproex sodium 500 mg tablet dr
1
EPITOL 200 MG TABLET
carbamazepine
1
EQUETRO 100 MG CAPSULE
carbamazepine
1
EQUETRO 200 MG CAPSULE
carbamazepine
1
EQUETRO 300 MG CAPSULE
carbamazepine
1
ethosuximide 250 mg capsule
1
ethosuximide 250 mg/5ml solution
1
felbamate 400 mg tablet
1
felbamate 600 mg tablet
1
felbamate 600 mg/5ml oral susp
1
gabapentin 100 mg capsule
1
gabapentin 250 mg/5ml solution
1
gabapentin 300 mg capsule
1
gabapentin 300 mg/6ml solution
1
gabapentin 400 mg capsule
1
gabapentin 600 mg tablet
1
gabapentin 800 mg tablet
1
KEPPRA 1,000 MG TABLET
levetiracetam
1
KEPPRA 100 MG/ML ORAL SOLN
levetiracetam
1
KEPPRA 250 MG TABLET
levetiracetam
1
KEPPRA 500 MG TABLET
levetiracetam
1
PAGE 120
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
KEPPRA 750 MG TABLET
levetiracetam
1
KLONOPIN 0.5 MG TABLET
clonazepam
1
KLONOPIN 1 MG TABLET
clonazepam
1
KLONOPIN 2 MG TABLET
clonazepam
1
LAMICTAL 100 MG TABLET
lamotrigine
1
LAMICTAL 150 MG TABLET
lamotrigine
1
LAMICTAL 200 MG TABLET
lamotrigine
1
LAMICTAL 25 MG DISPER TABLET
lamotrigine
1
LAMICTAL 25 MG TABLET
lamotrigine
1
LAMICTAL 5 MG DISPER TABLET
lamotrigine
1
LAMICTAL ODT START KIT (BLUE)
lamotrigine
1
LAMICTAL ODT START KIT (GREEN)
lamotrigine
1
LAMICTAL ODT START KT (ORANGE)
lamotrigine
1
LAMICTAL TAB START KIT (BLUE)
lamotrigine
1
LAMICTAL TAB START KIT (GREEN)
lamotrigine
1
LAMICTAL TB START KIT (ORANGE)
lamotrigine
1
LAMICTAL XR 100 MG TABLET
lamotrigine
1
LAMICTAL XR 200 MG TABLET
lamotrigine
1
LAMICTAL XR 25 MG TABLET
lamotrigine
1
LAMICTAL XR 250 MG TABLET
lamotrigine
1
PAGE 121
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LAMICTAL XR 300 MG TABLET
lamotrigine
1
LAMICTAL XR 50 MG TABLET
lamotrigine
1
LAMICTAL XR START KIT (BLUE)
lamotrigine
1
LAMICTAL XR START KIT (GREEN)
lamotrigine
1
LAMICTAL XR START KIT (ORANGE)
lamotrigine
1
lamotrigine 100 mg tab er 24
1
lamotrigine 100 mg tab rapdis
1
lamotrigine 100 mg tablet
1
lamotrigine 150 mg tablet
1
lamotrigine 200 mg tab er 24
1
lamotrigine 200 mg tab rapdis
1
lamotrigine 200 mg tablet
1
lamotrigine 25 mg tab er 24
1
lamotrigine 25 mg tab rapdis
1
lamotrigine 25 mg tablet
1
lamotrigine 25 mg tb chw dsp
1
lamotrigine 250 mg tab er 24
1
lamotrigine 25mg (35) tab ds pk
1
lamotrigine 300 mg tab er 24
1
lamotrigine 5 mg tb chw dsp
1
lamotrigine 50 mg tab er 24
1
lamotrigine 50 mg tab rapdis
1
levetiracetam 100 mg/ml solution
1
levetiracetam 1000 mg tablet
1
levetiracetam 250 mg tablet
1
levetiracetam 500 mg tab er 24h
1
levetiracetam 500 mg tablet
1
levetiracetam 500 mg/5ml solution
1
PAGE 122
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
levetiracetam 500 mg/5ml vial
1
levetiracetam 750 mg tab er 24h
1
levetiracetam 750 mg tablet
1
lorazepam 0.5 mg tablet
1
LIMITS & RESTRICTIONS
PA
AL
At least 12 yrs old
PA
lorazepam 1 mg tablet
1
AL
At least 12 yrs old
PA
lorazepam 2 mg tablet
1
AL
At least 12 yrs old
PA
lorazepam 2 mg/ml oral conc
1
AL
lorazepam 2 mg/ml syringe
1
lorazepam 2 mg/ml vial
1
lorazepam 4 mg/ml syringe
1
lorazepam 4 mg/ml vial
1
ME-PB-HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
ME-PB-HYOS TABLET
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
MYSOLINE 250 MG TABLET
primidone
1
MYSOLINE 50 MG TABLET
primidone
1
NEURONTIN 100 MG CAPSULE
gabapentin
1
NEURONTIN 250 MG/5 ML SOLN
gabapentin
1
NEURONTIN 300 MG CAPSULE
gabapentin
1
NEURONTIN 400 MG CAPSULE
gabapentin
1
NEURONTIN 600 MG TABLET
gabapentin
1
NEURONTIN 800 MG TABLET
gabapentin
1
PAGE 123
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
oxcarbazepine 150 mg tablet
1
oxcarbazepine 300 mg tablet
1
oxcarbazepine 300 mg/5ml oral susp
1
oxcarbazepine 600 mg tablet
1
OXTELLAR XR 150 MG TABLET
oxcarbazepine
1
OXTELLAR XR 300 MG TABLET
oxcarbazepine
1
OXTELLAR XR 600 MG TABLET
oxcarbazepine
1
phenobarbital 100 mg tablet
1
phenobarbital 15 mg tablet
1
phenobarbital 16.2 mg tablet
1
phenobarbital 20 mg/5 ml elixir
1
phenobarbital 30 mg tablet
1
phenobarbital 32.4 mg tablet
1
phenobarbital 60 mg tablet
1
phenobarbital 64.8 mg tablet
1
phenobarbital 97.2mg tablet
1
PHENYTEK 200 MG CAPSULE
phenytoin sodium extended
1
PHENYTEK 300 MG CAPSULE
phenytoin sodium extended
1
phenytoin 100 mg/4ml oral susp
1
phenytoin 125 mg/5ml oral susp
1
phenytoin 50 mg tab chew
1
phenytoin sodium extended 100 mg capsule
1
phenytoin sodium extended 200 mg capsule
1
phenytoin sodium extended 300 mg capsule
1
POTIGA 200 MG TABLET
ezogabine
1
POTIGA 300 MG TABLET
ezogabine
1
POTIGA 400 MG TABLET
ezogabine
1
PAGE 124
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
POTIGA 50 MG TABLET
ezogabine
1
primidone 250 mg tablet
1
primidone 50 mg tablet
1
QSYMIA 11.25 MG-69 MG CAPSULE
phentermine hcl/topiramate
1
PA
QSYMIA 15 MG-92 MG CAPSULE
phentermine hcl/topiramate
1
PA
QSYMIA 3.75 MG-23 MG CAPSULE
phentermine hcl/topiramate
1
PA
QSYMIA 7.5 MG-46 MG CAPSULE
phentermine hcl/topiramate
1
PA
QUADRAPAX ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
SE-DONNA PB HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
STAVZOR DR 125 MG CAPSULE
valproic acid
1
STAVZOR DR 250 MG CAPSULE
valproic acid
1
STAVZOR DR 500 MG CAPSULE
valproic acid
1
TEGRETOL 100 MG TABLET CHEW
carbamazepine
1
TEGRETOL 100 MG/5 ML SUSP
carbamazepine
1
TEGRETOL 200 MG TABLET
carbamazepine
1
TEGRETOL XR 100 MG TABLET
carbamazepine
1
TEGRETOL XR 200 MG TABLET
carbamazepine
1
TEGRETOL XR 400 MG TABLET
carbamazepine
1
tiagabine hcl 2 mg tablet
1
tiagabine hcl 4 mg tablet
1
TOPAMAX 100 MG TABLET
topiramate
1
PAGE 125
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TOPAMAX 15 MG SPRINKLE CAP
topiramate
1
TOPAMAX 200 MG TABLET
topiramate
1
TOPAMAX 25 MG SPRINKLE CAP
topiramate
1
TOPAMAX 25 MG TABLET
topiramate
1
TOPAMAX 50 MG TABLET
topiramate
1
TOPIRAGEN 100 MG TABLET
topiramate
1
TOPIRAGEN 200 MG TABLET
topiramate
1
TOPIRAGEN 25 MG TABLET
topiramate
1
TOPIRAGEN 50 MG TABLET
topiramate
1
topiramate 100 mg tablet
1
topiramate 15 mg cap sprink
1
topiramate 200 mg tablet
1
topiramate 25 mg cap sprink
1
topiramate 25 mg tablet
1
topiramate 50 mg tablet
1
TRANXENE T-TAB 15 MG
clorazepate dipotassium
1
TRANXENE T-TAB 3.75 MG
clorazepate dipotassium
1
TRANXENE T-TAB 7.5 MG
clorazepate dipotassium
1
TRILEPTAL 150 MG TABLET
oxcarbazepine
1
TRILEPTAL 300 MG TABLET
oxcarbazepine
1
TRILEPTAL 300 MG/5 ML SUSP
oxcarbazepine
1
PAGE 126
LIMITS & RESTRICTIONS
PA
AL
At least 9 yrs old
PA
AL
At least 9 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRILEPTAL 600 MG TABLET
oxcarbazepine
1
TROKENDI XR 100 MG CAPSULE
topiramate
1
TROKENDI XR 200 MG CAPSULE
topiramate
1
TROKENDI XR 25 MG CAPSULE
topiramate
1
TROKENDI XR 50 MG CAPSULE
topiramate
1
VALIUM 10 MG TABLET
diazepam
1
VALIUM 2 MG TABLET
diazepam
1
VALIUM 5 MG TABLET
diazepam
1
valproic acid (as sodium salt) 250 mg/5ml solution
1
valproic acid (as sodium salt) 500mg/10ml solution
1
valproic acid 100 % liquid
1
valproic acid 250 mg capsule
1
VIMPAT 10 MG/ML SOLUTION
lacosamide
1
VIMPAT 100 MG TABLET
lacosamide
1
VIMPAT 150 MG TABLET
lacosamide
1
VIMPAT 200 MG TABLET
lacosamide
1
VIMPAT 50 MG TABLET
lacosamide
1
ZARONTIN 250 MG CAPSULE
ethosuximide
1
ZARONTIN 250 MG/5 ML SOLUTION
ethosuximide
1
ZONEGRAN 100 MG CAPSULE
zonisamide
1
PAGE 127
LIMITS & RESTRICTIONS
PA
AL
At least 1 yrs old
PA
AL
At least 1 yrs old
PA
AL
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ZONEGRAN 25 MG CAPSULE
zonisamide
1
zonisamide 100 mg capsule
1
zonisamide 25 mg capsule
1
zonisamide 50 mg capsule
1
LIMITS & RESTRICTIONS
ANTIMIGRAINE AGENTS
ALAGESIC LQ ORAL SOLUTION
butalbital/acetaminophen/caffeine
1
ASCOMP WITH CODEINE CAPSULE
codeine phosphate/butalbital/aspirin/caffeine
1
aspirin 975 mg tablet dr
1
AXERT 12.5 MG TABLET
almotriptan malate
1
QL
8 / 30 days
AXERT 6.25 MG TABLET
almotriptan malate
1
QL
8 / 30 days
butalb/acetaminophen/caffeine 50-300-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 tablet
1
butalb/acetaminophen/caffeine 50-500-40 tablet
1
butalbit/acetamin/caff/codeine 50-300-30 capsule
1
butalbit/acetamin/caff/codeine 50-325-30 capsule
1
butalbital/aspirin/caffeine 50-325-40 capsule
1
butalbital/aspirin/caffeine 50-325-40 tablet
1
butorphanol tartrate 10 mg/ml spray
1
caffeine citrated 60 mg/3 ml solution
1
CAPACET CAPSULE
butalbital/acetaminophen/caffeine
1
codeine/butalbital/asa/caffein 30-50-325 capsule
1
DEPAKENE 250 MG CAPSULE
valproic acid
1
DEPAKENE 250 MG/5 ML SOLUTION
valproic acid (as sodium salt) (valproate sodium)
1
DEPAKOTE 125 MG SPRINKLE CAP
divalproex sodium
1
DEPAKOTE DR 125 MG TABLET
divalproex sodium
1
PAGE 128
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DEPAKOTE DR 250 MG TABLET
divalproex sodium
1
DEPAKOTE DR 500 MG TABLET
divalproex sodium
1
DEPAKOTE ER 250 MG TABLET
divalproex sodium
1
DEPAKOTE ER 500 MG TABLET
divalproex sodium
1
dihydroergotamine mesylate 0.5mg/spry spray/pump
1
divalproex sodium 125 mg cap sprink
1
divalproex sodium 125 mg tablet dr
1
divalproex sodium 250 mg tab er 24h
1
divalproex sodium 250 mg tablet dr
1
divalproex sodium 500 mg tab er 24h
1
divalproex sodium 500 mg tablet dr
1
ERGOMAR 2 MG TABLET SL
ergotamine tartrate
1
ergotamine tartrate/caffeine 1 mg-100mg tablet
1
ibuprofen 100 mg/5ml oral susp
1
ibuprofen 400 mg tablet
1
ibuprofen 600 mg tablet
1
ibuprofen 800 mg tablet
1
isomethepten/caf/acetaminophen 130-20-500 tablet
1
isomethepten/caf/acetaminophen 65-20-325 tablet
1
ketoprofen 200 mg cap24h pel
1
ketoprofen 50 mg capsule
1
ketoprofen 75 mg capsule
1
LEVACET CAPLET
aspirin/salicylamide/acetaminophen/caffeine
1
MARGESIC CAPSULE
butalbital/acetaminophen/caffeine
1
MIGERGOT SUPPOSITORY
ergotamine tartrate/caffeine
1
MIGRAGESIC IDA CAPSULE
isometheptene mucate/dichloralphenazone/acetaminophen
1
PAGE 129
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
naproxen 125 mg/5ml oral susp
1
naproxen 250 mg tablet
1
naproxen 375 mg tablet
1
naproxen 375 mg tablet dr
1
naproxen 500 mg tablet
1
naproxen 500 mg tablet dr
1
naproxen sodium 275 mg tablet
1
naproxen sodium 500 mg tbmp 24hr
1
naproxen sodium 550 mg tablet
1
propranolol hcl 10 mg tablet
1
propranolol hcl 120 mg cap sa 24h
1
propranolol hcl 160 mg cap sa 24h
1
propranolol hcl 20 mg tablet
1
propranolol hcl 20 mg/5 ml solution
1
propranolol hcl 40 mg tablet
1
propranolol hcl 40mg/5ml solution
1
propranolol hcl 60 mg cap sa 24h
1
propranolol hcl 60 mg tablet
1
propranolol hcl 80 mg cap sa 24h
1
propranolol hcl 80 mg tablet
1
REPAN 50-325-40 MG TABLET
butalbital/acetaminophen/caffeine
1
rizatriptan benzoate 10 mg tab rapdis
1
QL
12 / 30 days
rizatriptan benzoate 10 mg tablet
1
QL
12 / 30 days
rizatriptan benzoate 5 mg tab rapdis
1
QL
12 / 30 days
rizatriptan benzoate 5 mg tablet
1
QL
12 / 30 days
STAVZOR DR 125 MG CAPSULE
valproic acid
1
STAVZOR DR 250 MG CAPSULE
valproic acid
1
STAVZOR DR 500 MG CAPSULE
valproic acid
1
PAGE 130
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sumatriptan 20 mg spray
1
sumatriptan 5 mg spray
1
sumatriptan succinate 100 mg tablet
1
sumatriptan succinate 25 mg tablet
1
sumatriptan succinate 4 mg/0.5ml cartridge
1
sumatriptan succinate 4 mg/0.5ml pen injctr
1
sumatriptan succinate 50 mg tablet
1
sumatriptan succinate 6 mg/0.5ml cartridge
1
sumatriptan succinate 6 mg/0.5ml pen injctr
1
sumatriptan succinate 6 mg/0.5ml syringe
1
sumatriptan succinate 6 mg/0.5ml vial
1
timolol maleate 10 mg tablet
1
timolol maleate 20 mg tablet
1
timolol maleate 5 mg tablet
1
TOPAMAX 100 MG TABLET
topiramate
1
TOPAMAX 15 MG SPRINKLE CAP
topiramate
1
TOPAMAX 200 MG TABLET
topiramate
1
TOPAMAX 25 MG SPRINKLE CAP
topiramate
1
TOPAMAX 25 MG TABLET
topiramate
1
TOPAMAX 50 MG TABLET
topiramate
1
TOPIRAGEN 100 MG TABLET
topiramate
1
TOPIRAGEN 200 MG TABLET
topiramate
1
TOPIRAGEN 25 MG TABLET
topiramate
1
TOPIRAGEN 50 MG TABLET
topiramate
1
topiramate 100 mg tablet
1
PAGE 131
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
topiramate 15 mg cap sprink
1
topiramate 200 mg tablet
1
topiramate 25 mg cap sprink
1
topiramate 25 mg tablet
1
topiramate 50 mg tablet
1
tramadol hcl/acetaminophen 37.5-325mg tablet
1
TROKENDI XR 100 MG CAPSULE
topiramate
1
TROKENDI XR 200 MG CAPSULE
topiramate
1
TROKENDI XR 25 MG CAPSULE
topiramate
1
TROKENDI XR 50 MG CAPSULE
topiramate
1
valproic acid (as sodium salt) 250 mg/5ml solution
1
valproic acid (as sodium salt) 500mg/10ml solution
1
valproic acid 100 % liquid
1
valproic acid 250 mg capsule
1
ZEBUTAL 50-325-40 MG CAPSULE
butalbital/acetaminophen/caffeine
1
ZEBUTAL CAPSULE
butalbital/acetaminophen/caffeine
1
zolmitriptan 2.5 mg tab rapdis
1
zolmitriptan 2.5 mg tablet
1
zolmitriptan 5 mg tab rapdis
1
zolmitriptan 5 mg tablet
1
LIMITS & RESTRICTIONS
ANTIPARKINSONIAN AGENTS (CNS)
amantadine hcl 100 mg capsule
1
amantadine hcl 100 mg tablet
1
amantadine hcl 50 mg/5 ml solution
1
benztropine mesylate 0.5 mg tablet
1
benztropine mesylate 1 mg tablet
1
benztropine mesylate 2 mg tablet
1
PAGE 132
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
bromocriptine mesylate 2.5 mg tablet
1
bromocriptine mesylate 5 mg capsule
1
cabergoline 0.5 mg tablet
1
carbidopa 25 mg tablet
1
carbidopa/levodopa 10mg-100mg tab rapdis
1
carbidopa/levodopa 10mg-100mg tablet
1
carbidopa/levodopa 25mg-100mg tab rapdis
1
carbidopa/levodopa 25mg-100mg tablet
1
carbidopa/levodopa 25mg-100mg tablet er
1
carbidopa/levodopa 25mg-250mg tab rapdis
1
carbidopa/levodopa 25mg-250mg tablet
1
carbidopa/levodopa 50mg-200mg tablet er
1
diphenhydramine hcl 12.5mg/5ml elixir
1
diphenhydramine hcl 50 mg capsule
1
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
EMSAM 12 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
EMSAM 6 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
EMSAM 9 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
entacapone 200 mg tablet
1
orphenadrine citrate 100 mg tablet er
1
pramipexole di-hcl 0.125 mg tablet
1
pramipexole di-hcl 0.25 mg tablet
1
pramipexole di-hcl 0.375 mg tab er 24h
1
pramipexole di-hcl 0.5 mg tablet
1
pramipexole di-hcl 0.75 mg tab er 24h
1
pramipexole di-hcl 0.75 mg tablet
1
pramipexole di-hcl 1 mg tablet
1
pramipexole di-hcl 1.5 mg tab er 24h
1
pramipexole di-hcl 1.5 mg tablet
1
PAGE 133
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ropinirole hcl 0.25 mg tablet
1
ropinirole hcl 0.5 mg tablet
1
ropinirole hcl 1 mg tablet
1
ropinirole hcl 12 mg tab er 24h
1
ropinirole hcl 2 mg tab er 24h
1
ropinirole hcl 2 mg tablet
1
ropinirole hcl 3 mg tablet
1
ropinirole hcl 4 mg tab er 24h
1
ropinirole hcl 4 mg tablet
1
ropinirole hcl 5 mg tablet
1
ropinirole hcl 6 mg tab er 24h
1
ropinirole hcl 8 mg tab er 24h
1
selegiline hcl 5 mg capsule
1
selegiline hcl 5 mg tablet
1
tolcapone 100 mg tablet
1
trihexyphenidyl hcl 2 mg tablet
1
trihexyphenidyl hcl 2 mg/5 ml elixir
1
trihexyphenidyl hcl 5 mg tablet
1
LIMITS & RESTRICTIONS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ALAGESIC LQ ORAL SOLUTION
butalbital/acetaminophen/caffeine
1
alprazolam 0.25 mg tab rapdis
1
PA
AL
At least 18 yrs old
PA
alprazolam 0.25 mg tablet
1
AL
At least 18 yrs old
PA
alprazolam 0.5 mg tab er 24h
1
AL
At least 18 yrs old
PA
alprazolam 0.5 mg tab rapdis
1
AL
At least 18 yrs old
PA
alprazolam 0.5 mg tablet
1
AL
PAGE 134
At least 18 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
alprazolam 1 mg tab er 24h
1
AL
At least 18 yrs old
PA
alprazolam 1 mg tab rapdis
1
AL
At least 18 yrs old
PA
alprazolam 1 mg tablet
1
AL
At least 18 yrs old
PA
ALPRAZOLAM 1 MG/ML ORAL CONC
alprazolam
1
alprazolam 2 mg tab er 24h
1
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
alprazolam 2 mg tab rapdis
1
AL
At least 18 yrs old
PA
alprazolam 2 mg tablet
1
AL
At least 18 yrs old
PA
alprazolam 3 mg tab er 24h
1
AL
At least 18 yrs old
PA
amitrip hcl/chlordiazepoxide 12.5mg-5mg tablet
1
AL
At least 18 yrs old
PA
amitrip hcl/chlordiazepoxide 25 mg-10mg tablet
1
AL
ASCOMP WITH CODEINE CAPSULE
codeine phosphate/butalbital/aspirin/caffeine
1
ATIVAN 0.5 MG TABLET
lorazepam
1
ATIVAN 1 MG TABLET
lorazepam
1
ATIVAN 2 MG TABLET
lorazepam
1
ATIVAN 2 MG/ML VIAL
lorazepam
1
ATIVAN 20 MG/10 ML VIAL
lorazepam
1
PAGE 135
At least 18 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ATIVAN 4 MG/ML VIAL
lorazepam
1
ATIVAN 40 MG/10 ML VIAL
lorazepam
1
BUPAP TABLET
butalbital/acetaminophen
1
buspirone hcl 10 mg tablet
1
LIMITS & RESTRICTIONS
PA
AL
At least 18 yrs old
PA
buspirone hcl 15 mg tablet
1
AL
At least 18 yrs old
PA
buspirone hcl 30 mg tablet
1
AL
At least 18 yrs old
PA
buspirone hcl 5 mg tablet
1
AL
At least 18 yrs old
PA
buspirone hcl 7.5 mg tablet
1
AL
butalb/acetaminophen/caffeine 50-300-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 capsule
1
butalb/acetaminophen/caffeine 50-325-40 tablet
1
butalb/acetaminophen/caffeine 50-500-40 tablet
1
butalbit/acetamin/caff/codeine 50-300-30 capsule
1
butalbit/acetamin/caff/codeine 50-325-30 capsule
1
butalbital/acetaminophen 50mg-325mg tablet
1
butalbital/aspirin/caffeine 50-325-40 capsule
1
butalbital/aspirin/caffeine 50-325-40 tablet
1
CAPACET CAPSULE
butalbital/acetaminophen/caffeine
1
CEPHADYN TABLET
butalbital/acetaminophen
1
chloral hydrate 500 mg/5ml syrup
1
chlordiazepoxide hcl 10 mg capsule
1
At least 18 yrs old
PA
AL
PAGE 136
At least 6 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
chlordiazepoxide hcl 25 mg capsule
1
AL
At least 6 yrs old
PA
chlordiazepoxide hcl 5 mg capsule
1
AL
clonazepam 0.125 mg tab rapdis
1
clonazepam 0.25 mg tab rapdis
1
clonazepam 0.5 mg tab rapdis
1
clonazepam 0.5 mg tablet
1
clonazepam 1 mg tab rapdis
1
clonazepam 1 mg tablet
1
clonazepam 2 mg tab rapdis
1
clonazepam 2 mg tablet
1
clorazepate dipotassium 15 mg tablet
1
At least 6 yrs old
PA
AL
At least 9 yrs old
PA
clorazepate dipotassium 3.75 mg tablet
1
AL
At least 9 yrs old
PA
clorazepate dipotassium 7.5 mg tablet
1
AL
codeine/butalbital/asa/caffein 30-50-325 capsule
1
DIASTAT 2.5 MG PEDI SYSTEM
diazepam
1
DIASTAT ACUDIAL 12.5-15-20 MG
diazepam
1
DIASTAT ACUDIAL 5-7.5-10 MG KT
diazepam
1
diazepam 10 mg tablet
1
At least 9 yrs old
PA
AL
diazepam 12.5-15-20 kit
1
diazepam 2 mg tablet
1
At least 1 yrs old
PA
AL
diazepam 2.5 mg kit
1
diazepam 5 mg tablet
1
At least 1 yrs old
PA
AL
PAGE 137
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
diazepam 5 mg/5 ml solution
1
AL
At least 1 yrs old
PA
diazepam 5 mg/ml oral conc
1
AL
diazepam 5 mg/ml syringe
1
diazepam 5 mg/ml vial
1
diazepam 5-7.5-10mg kit
1
diphenhydramine hcl 12.5mg/5ml elixir
1
diphenhydramine hcl 50 mg capsule
1
DOXYTEX 2.5 MG/2.5 ML LIQUID
doxylamine succinate
1
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
estazolam 1 mg tablet
1
estazolam 2 mg tablet
1
eszopiclone 1 mg tablet
1
eszopiclone 2 mg tablet
1
eszopiclone 3 mg tablet
1
flurazepam hcl 15 mg capsule
1
flurazepam hcl 30 mg capsule
1
hydroxyzine hcl 10 mg tablet
1
hydroxyzine hcl 10 mg/5 ml solution
1
hydroxyzine hcl 25 mg tablet
1
hydroxyzine hcl 50 mg tablet
1
hydroxyzine pamoate 100 mg capsule
1
hydroxyzine pamoate 25 mg capsule
1
hydroxyzine pamoate 50 mg capsule
1
KLONOPIN 0.5 MG TABLET
clonazepam
1
KLONOPIN 1 MG TABLET
clonazepam
1
KLONOPIN 2 MG TABLET
clonazepam
1
PAGE 138
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
lorazepam 0.5 mg tablet
1
AL
At least 12 yrs old
PA
lorazepam 1 mg tablet
1
AL
At least 12 yrs old
PA
lorazepam 2 mg tablet
1
AL
At least 12 yrs old
PA
lorazepam 2 mg/ml oral conc
1
AL
lorazepam 2 mg/ml syringe
1
lorazepam 2 mg/ml vial
1
lorazepam 4 mg/ml syringe
1
lorazepam 4 mg/ml vial
1
LORAZEPAM INTENSOL 2 MG/ML
lorazepam
1
MARGESIC CAPSULE
butalbital/acetaminophen/caffeine
1
MARTEN-TAB 325-50 TABLET
butalbital/acetaminophen
1
ME-PB-HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
ME-PB-HYOS TABLET
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
meprobamate 200 mg tablet
1
meprobamate 400 mg tablet
1
midazolam hcl 10 mg/10ml vial
1
midazolam hcl 10 mg/2 ml vial
1
midazolam hcl 2 mg/2 ml vial
1
midazolam hcl 2 mg/ml syrup
1
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
midazolam hcl 5 mg/5 ml vial
1
midazolam hcl 5 mg/ml vial
1
midazolam hcl 5 mg/ml(1) vial
1
PAGE 139
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
midazolam hcl/pf 2 mg/2 ml cartridge
1
midazolam hcl/pf 5 mg/ml cartridge
1
MIGRAGESIC IDA CAPSULE
isometheptene mucate/dichloralphenazone/acetaminophen
1
NIRAVAM 0.25 MG ODT
alprazolam
1
NIRAVAM 0.5 MG ODT
alprazolam
1
NIRAVAM 1 MG ODT
alprazolam
1
NIRAVAM 2 MG ODT
alprazolam
1
oxazepam 10 mg capsule
1
LIMITS & RESTRICTIONS
PA
AL
At least 12 yrs old
PA
oxazepam 15 mg capsule
1
AL
At least 12 yrs old
PA
oxazepam 30 mg capsule
1
AL
PHENADOZ 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENADOZ 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 50 MG SUPPOSITORY
promethazine hcl
1
phenobarbital 100 mg tablet
1
phenobarbital 15 mg tablet
1
phenobarbital 16.2 mg tablet
1
phenobarbital 20 mg/5 ml elixir
1
phenobarbital 30 mg tablet
1
phenobarbital 32.4 mg tablet
1
phenobarbital 60 mg tablet
1
PAGE 140
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
phenobarbital 64.8 mg tablet
1
phenobarbital 97.2mg tablet
1
PROMACET 50-650 MG TABLET
butalbital/acetaminophen
1
promethazine hcl 12.5 mg supp.rect
1
promethazine hcl 12.5 mg tablet
1
promethazine hcl 25 mg supp.rect
1
promethazine hcl 25 mg tablet
1
promethazine hcl 50 mg supp.rect
1
promethazine hcl 50 mg tablet
1
promethazine hcl 6.25mg/5ml syrup
1
PROMETHEGAN 12.5 MG SUPPOS
promethazine hcl
1
PROMETHEGAN 25 MG SUPP
promethazine hcl
1
PROMETHEGAN 50 MG SUPPOSITORY
promethazine hcl
1
QUADRAPAX ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
quazepam 15 mg tablet
1
REPAN 50-325-40 MG TABLET
butalbital/acetaminophen/caffeine
1
SE-DONNA PB HYOS ELIXIR
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb
1
SECONAL SODIUM 100 MG CAPSULE
secobarbital sodium
1
SEDAPAP TABLET
butalbital/acetaminophen
1
temazepam 15 mg capsule
1
temazepam 22.5 mg capsule
1
temazepam 30 mg capsule
1
temazepam 7.5 mg capsule
1
TENCON 50-325 MG TABLET
butalbital/acetaminophen
1
TENCON TABLET
butalbital/acetaminophen
1
PAGE 141
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRANXENE T-TAB 15 MG
clorazepate dipotassium
1
TRANXENE T-TAB 3.75 MG
clorazepate dipotassium
1
TRANXENE T-TAB 7.5 MG
clorazepate dipotassium
1
triazolam 0.125 mg tablet
1
triazolam 0.25 mg tablet
1
VALIUM 10 MG TABLET
diazepam
1
VALIUM 2 MG TABLET
diazepam
1
VALIUM 5 MG TABLET
diazepam
1
XANAX 0.25 MG TABLET
alprazolam
1
XANAX 0.5 MG TABLET
alprazolam
1
XANAX 1 MG TABLET
alprazolam
1
XANAX 2 MG TABLET
alprazolam
1
XANAX XR 0.5 MG TABLET
alprazolam
1
XANAX XR 1 MG TABLET
alprazolam
1
XANAX XR 2 MG TABLET
alprazolam
1
XANAX XR 3 MG TABLET
alprazolam
1
PAGE 142
LIMITS & RESTRICTIONS
PA
AL
At least 9 yrs old
PA
AL
At least 9 yrs old
PA
AL
At least 1 yrs old
PA
AL
At least 1 yrs old
PA
AL
At least 1 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
zaleplon 10 mg capsule
1
zaleplon 5 mg capsule
1
ZEBUTAL 50-325-40 MG CAPSULE
butalbital/acetaminophen/caffeine
1
ZEBUTAL CAPSULE
butalbital/acetaminophen/caffeine
1
zolpidem tartrate 10 mg tablet
1
zolpidem tartrate 12.5 mg tab mphase
1
zolpidem tartrate 5 mg tablet
1
zolpidem tartrate 6.25 mg tab mphase
1
ABILIFY 1 MG/ML SOLUTION
aripiprazole
1
ABILIFY 9.7 MG/1.3 ML VIAL
aripiprazole
1
ABILIFY DISCMELT 10 MG TABLET
aripiprazole
1
ABILIFY DISCMELT 15 MG TABLET
aripiprazole
1
ABILIFY MAINTENA ER 300 MG SYR
aripiprazole
1
ABILIFY MAINTENA ER 300 MG VL
aripiprazole
1
ABILIFY MAINTENA ER 400 MG SYR
aripiprazole
1
ABILIFY MAINTENA ER 400 MG VL
aripiprazole
1
acamprosate calcium 333 mg tablet dr
LIMITS & RESTRICTIONS
QL
60 / 30 days
1
QL
180 / 30 days
aripiprazole 10 mg tablet
1
QL
60 / 30 days
aripiprazole 15 mg tablet
1
QL
60 / 30 days
aripiprazole 2 mg tablet
1
QL
60 / 30 days
aripiprazole 20 mg tablet
1
QL
30 / 30 days
aripiprazole 30 mg tablet
1
QL
30 / 30 days
aripiprazole 5 mg tablet
1
QL
60 / 30 days
buprenorphine hcl/naloxone hcl 2 mg-0.5mg tab subl
1
PAGE 143
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
buprenorphine hcl/naloxone hcl 8 mg-2 mg tab subl
1
carbamazepine 100 mg cpmp 12hr
1
carbamazepine 100 mg tab chew
1
carbamazepine 100 mg/5ml oral susp
1
carbamazepine 200 mg cpmp 12hr
1
carbamazepine 200 mg tab er 12h
1
carbamazepine 200 mg tablet
1
carbamazepine 300 mg cpmp 12hr
1
carbamazepine 400 mg tab er 12h
1
carbidopa 25 mg tablet
1
DEPADE 50 MG TABLET
naltrexone hcl
1
DEPAKENE 250 MG CAPSULE
valproic acid
1
DEPAKENE 250 MG/5 ML SOLUTION
valproic acid (as sodium salt) (valproate sodium)
1
DEPAKOTE 125 MG SPRINKLE CAP
divalproex sodium
1
DEPAKOTE DR 125 MG TABLET
divalproex sodium
1
DEPAKOTE DR 250 MG TABLET
divalproex sodium
1
DEPAKOTE DR 500 MG TABLET
divalproex sodium
1
DEPAKOTE ER 250 MG TABLET
divalproex sodium
1
DEPAKOTE ER 500 MG TABLET
divalproex sodium
1
divalproex sodium 125 mg cap sprink
1
divalproex sodium 125 mg tablet dr
1
divalproex sodium 250 mg tab er 24h
1
divalproex sodium 250 mg tablet dr
1
divalproex sodium 500 mg tab er 24h
1
divalproex sodium 500 mg tablet dr
1
duloxetine hcl 100 % powder
1
PAGE 144
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
duloxetine hcl 20 mg capsule dr
1
QL
60 / 30 days
duloxetine hcl 30 mg capsule dr
1
QL
60 / 30 days
duloxetine hcl 40 mg capsule dr
1
duloxetine hcl 60 mg capsule dr
1
QL
30 / 30 days
EPITOL 200 MG TABLET
carbamazepine
1
EQUETRO 100 MG CAPSULE
carbamazepine
1
EQUETRO 200 MG CAPSULE
carbamazepine
1
EQUETRO 300 MG CAPSULE
carbamazepine
1
GEODON 20 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 20 MG/ML VIAL
ziprasidone mesylate
1
GEODON 40 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 60 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 80 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
guanfacine hcl 1 mg tab er 24h
1
guanfacine hcl 1 mg tablet
1
guanfacine hcl 2 mg tab er 24h
1
guanfacine hcl 2 mg tablet
1
guanfacine hcl 3 mg tab er 24h
1
guanfacine hcl 4 mg tab er 24h
1
IRENKA DR 40 MG CAPSULE
duloxetine hcl
1
LAMICTAL 100 MG TABLET
lamotrigine
1
LAMICTAL 150 MG TABLET
lamotrigine
1
LAMICTAL 200 MG TABLET
lamotrigine
1
PAGE 145
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LAMICTAL 25 MG DISPER TABLET
lamotrigine
1
LAMICTAL 25 MG TABLET
lamotrigine
1
LAMICTAL 5 MG DISPER TABLET
lamotrigine
1
LAMICTAL ODT START KIT (BLUE)
lamotrigine
1
LAMICTAL ODT START KIT (GREEN)
lamotrigine
1
LAMICTAL ODT START KT (ORANGE)
lamotrigine
1
LAMICTAL TAB START KIT (BLUE)
lamotrigine
1
LAMICTAL TAB START KIT (GREEN)
lamotrigine
1
LAMICTAL TB START KIT (ORANGE)
lamotrigine
1
LAMICTAL XR 100 MG TABLET
lamotrigine
1
LAMICTAL XR 200 MG TABLET
lamotrigine
1
LAMICTAL XR 25 MG TABLET
lamotrigine
1
LAMICTAL XR 250 MG TABLET
lamotrigine
1
LAMICTAL XR 300 MG TABLET
lamotrigine
1
LAMICTAL XR 50 MG TABLET
lamotrigine
1
LAMICTAL XR START KIT (BLUE)
lamotrigine
1
LAMICTAL XR START KIT (GREEN)
lamotrigine
1
LAMICTAL XR START KIT (ORANGE)
lamotrigine
1
lamotrigine 100 mg tab er 24
1
lamotrigine 100 mg tab rapdis
1
PAGE 146
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
lamotrigine 100 mg tablet
1
lamotrigine 150 mg tablet
1
lamotrigine 200 mg tab er 24
1
lamotrigine 200 mg tab rapdis
1
lamotrigine 200 mg tablet
1
lamotrigine 25 mg tab er 24
1
lamotrigine 25 mg tab rapdis
1
lamotrigine 25 mg tablet
1
lamotrigine 25 mg tb chw dsp
1
lamotrigine 250 mg tab er 24
1
lamotrigine 300 mg tab er 24
1
lamotrigine 5 mg tb chw dsp
1
lamotrigine 50 mg tab er 24
1
lamotrigine 50 mg tab rapdis
1
lithium carbonate 150 mg capsule
1
lithium carbonate 300 mg capsule
1
lithium carbonate 300 mg tablet
1
lithium carbonate 300 mg tablet er
1
lithium carbonate 450 mg tablet er
1
lithium carbonate 600 mg capsule
1
lithium citrate 8 meq/5 ml solution
1
LITHOBID ER 300 MG TABLET
lithium carbonate
1
naltrexone hcl 50 mg tablet
1
olanzapine 10 mg tab rapdis
1
QL
30 / 30 days
olanzapine 10 mg tablet
1
QL
30 / 30 days
olanzapine 10 mg vial
1
olanzapine 15 mg tab rapdis
1
QL
30 / 30 days
olanzapine 15 mg tablet
1
QL
30 / 30 days
olanzapine 2.5 mg tablet
1
QL
30 / 30 days
PAGE 147
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
olanzapine 20 mg tab rapdis
1
QL
30 / 30 days
olanzapine 20 mg tablet
1
QL
30 / 30 days
olanzapine 5 mg tab rapdis
1
QL
30 / 30 days
olanzapine 5 mg tablet
1
QL
30 / 30 days
olanzapine 7.5 mg tablet
1
QL
30 / 30 days
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet
1
quetiapine fumarate 100 mg tablet
1
QL
90 / 30 days
quetiapine fumarate 200 mg tablet
1
QL
90 / 30 days
quetiapine fumarate 25 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 300 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 400 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 50 mg tablet
1
QL
90 / 30 days
riluzole 50 mg tablet
1
RISPERDAL 0.25 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 0.5 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 1 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 2 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 3 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 4 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL CONSTA 12.5 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 25 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 37.5 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 50 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
PAGE 148
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
RISPERDAL M-TAB 0.5 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 1 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 2 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 3 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 4 MG ODT
risperidone
1
QL
60 / 30 days
risperidone 0.25 mg tab rapdis
1
QL
60 / 30 days
risperidone 0.25 mg tablet
1
QL
60 / 30 days
risperidone 0.5 mg tab rapdis
1
QL
60 / 30 days
risperidone 0.5 mg tablet
1
QL
60 / 30 days
risperidone 1 mg tab rapdis
1
QL
60 / 30 days
risperidone 1 mg tablet
1
QL
60 / 30 days
risperidone 1 mg/ml solution
1
QL
240 / 30 days
risperidone 2 mg tab rapdis
1
QL
60 / 30 days
risperidone 2 mg tablet
1
QL
60 / 30 days
risperidone 3 mg tab rapdis
1
QL
60 / 30 days
risperidone 3 mg tablet
1
QL
60 / 30 days
risperidone 4 mg tab rapdis
1
QL
60 / 30 days
risperidone 4 mg tablet
1
QL
60 / 30 days
SAPHRIS 10 MG TAB SL BLK CHERY
asenapine maleate
1
QL
60 / 30 days
SAPHRIS 10 MG TAB SUBLINGUAL
asenapine maleate
1
SAPHRIS 2.5 MG TAB SL BLK CHRY
asenapine maleate
1
SAPHRIS 5 MG TAB SL BLK CHERRY
asenapine maleate
1
QL
60 / 30 days
SAPHRIS 5 MG TABLET SUBLINGUAL
asenapine maleate
1
PAGE 149
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SAVELLA 100 MG TABLET
milnacipran hcl
1
PA
SAVELLA 12.5 MG TABLET
milnacipran hcl
1
PA
SAVELLA 25 MG TABLET
milnacipran hcl
1
PA
SAVELLA 50 MG TABLET
milnacipran hcl
1
PA
SAVELLA TITRATION PACK
milnacipran hcl
1
PA
SEROQUEL 100 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL 200 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL 25 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 300 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 400 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 50 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL XR 150 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 200 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL XR 300 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 400 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 50 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
STAVZOR DR 125 MG CAPSULE
valproic acid
1
STAVZOR DR 250 MG CAPSULE
valproic acid
1
STAVZOR DR 500 MG CAPSULE
valproic acid
1
STRATTERA 10 MG CAPSULE
atomoxetine hcl
1
PAGE 150
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
STRATTERA 100 MG CAPSULE
atomoxetine hcl
1
STRATTERA 18 MG CAPSULE
atomoxetine hcl
1
STRATTERA 25 MG CAPSULE
atomoxetine hcl
1
STRATTERA 40 MG CAPSULE
atomoxetine hcl
1
STRATTERA 60 MG CAPSULE
atomoxetine hcl
1
STRATTERA 80 MG CAPSULE
atomoxetine hcl
1
TEGRETOL 100 MG TABLET CHEW
carbamazepine
1
TEGRETOL 100 MG/5 ML SUSP
carbamazepine
1
TEGRETOL 200 MG TABLET
carbamazepine
1
TEGRETOL XR 100 MG TABLET
carbamazepine
1
TEGRETOL XR 200 MG TABLET
carbamazepine
1
TEGRETOL XR 400 MG TABLET
carbamazepine
1
valproic acid (as sodium salt) 250 mg/5ml solution
1
valproic acid (as sodium salt) 500mg/10ml solution
1
valproic acid 100 % liquid
1
valproic acid 250 mg capsule
1
ziprasidone hcl 20 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 40 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 60 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 80 mg capsule
1
QL
60 / 30 days
ZYPREXA 10 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 10 MG VIAL
olanzapine
1
PAGE 151
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ZYPREXA 15 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 2.5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 20 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 7.5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA RELPREVV 210 MG VIAL
olanzapine pamoate
1
ZYPREXA RELPREVV 210 MG VL KIT
olanzapine pamoate
1
ZYPREXA RELPREVV 300 MG VIAL
olanzapine pamoate
1
ZYPREXA RELPREVV 300 MG VL KIT
olanzapine pamoate
1
ZYPREXA RELPREVV 405 MG VIAL
olanzapine pamoate
1
ZYPREXA RELPREVV 405 MG VL KIT
olanzapine pamoate
1
ZYPREXA ZYDIS 10 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 15 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 20 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 5 MG TABLET
olanzapine
1
QL
30 / 30 days
GENERAL ANESTHETICS
COMPOUND 347 INHALATION
enflurane
1
ETHRANE INHALATION
enflurane
1
FORANE LIQUID
isoflurane
1
isoflurane 99.9 % liquid
1
PAGE 152
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sevoflurane liquid
1
SOJOURN INHALATION LIQUID
sevoflurane
1
TERRELL LIQUID
isoflurane
1
LIMITS & RESTRICTIONS
PSYCHOTHERAPEUTIC AGENTS
ABILIFY 1 MG/ML SOLUTION
aripiprazole
1
ABILIFY 9.7 MG/1.3 ML VIAL
aripiprazole
1
ABILIFY DISCMELT 10 MG TABLET
aripiprazole
1
ABILIFY DISCMELT 15 MG TABLET
aripiprazole
1
ABILIFY MAINTENA ER 300 MG SYR
aripiprazole
1
ABILIFY MAINTENA ER 300 MG VL
aripiprazole
1
ABILIFY MAINTENA ER 400 MG SYR
aripiprazole
1
ABILIFY MAINTENA ER 400 MG VL
aripiprazole
1
amitrip hcl/chlordiazepoxide 12.5mg-5mg tablet
1
QL
60 / 30 days
PA
AL
At least 18 yrs old
PA
amitrip hcl/chlordiazepoxide 25 mg-10mg tablet
1
AL
At least 18 yrs old
PA
amitriptyline hcl 10 mg tablet
1
AL
At least 12 yrs old
PA
amitriptyline hcl 100 mg tablet
1
AL
At least 12 yrs old
PA
amitriptyline hcl 150 mg tablet
1
AL
At least 12 yrs old
PA
amitriptyline hcl 25 mg tablet
1
AL
PAGE 153
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
amitriptyline hcl 50 mg tablet
1
AL
At least 12 yrs old
PA
amitriptyline hcl 75 mg tablet
1
AL
At least 12 yrs old
PA
amoxapine 100 mg tablet
1
AL
At least 18 yrs old
PA
amoxapine 150 mg tablet
1
AL
At least 18 yrs old
PA
amoxapine 25 mg tablet
1
AL
At least 18 yrs old
PA
amoxapine 50 mg tablet
1
AL
At least 18 yrs old
PA
ANAFRANIL 25 MG CAPSULE
clomipramine hcl
1
ANAFRANIL 50 MG CAPSULE
clomipramine hcl
1
ANAFRANIL 75 MG CAPSULE
clomipramine hcl
1
aripiprazole 10 mg tablet
AL
At least 10 yrs old
PA
AL
At least 10 yrs old
PA
AL
At least 10 yrs old
1
QL
60 / 30 days
aripiprazole 15 mg tablet
1
QL
60 / 30 days
aripiprazole 2 mg tablet
1
QL
60 / 30 days
aripiprazole 20 mg tablet
1
QL
30 / 30 days
aripiprazole 30 mg tablet
1
QL
30 / 30 days
aripiprazole 5 mg tablet
1
QL
60 / 30 days
BRINTELLIX 10 MG TABLET
vortioxetine hydrobromide
1
BRINTELLIX 20 MG TABLET
vortioxetine hydrobromide
1
BRINTELLIX 5 MG TABLET
vortioxetine hydrobromide
1
PAGE 154
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BRISDELLE 7.5 MG CAPSULE
paroxetine mesylate
1
BUDEPRION SR 100 MG TABLET
bupropion hcl
1
BUDEPRION SR 150 MG TABLET
bupropion hcl
1
BUDEPRION XL 150 MG TABLET
bupropion hcl
1
BUDEPRION XL 300 MG TABLET
bupropion hcl
1
BUPROBAN 150 MG TABLET
bupropion hcl
1
bupropion hcl 100 mg tablet
1
LIMITS & RESTRICTIONS
PA
AL
At least 18 yrs old
bupropion hcl 100 mg tablet er
1
QL
60 / 30 days
bupropion hcl 150 mg tab er 24h
1
QL
90 / 30 days
bupropion hcl 150 mg tablet er
1
QL
60 / 30 days
bupropion hcl 200 mg tablet er
1
QL
60 / 30 days
bupropion hcl 300 mg tab er 24h
1
QL
30 / 30 days
bupropion hcl 75 mg tablet
1
PA
AL
At least 18 yrs old
CELEXA 10 MG TABLET
citalopram hydrobromide
1
QL
60 / 30 days
CELEXA 20 MG TABLET
citalopram hydrobromide
1
QL
60 / 30 days
CELEXA 40 MG TABLET
citalopram hydrobromide
1
QL
30 / 30 days
chlorpromazine hcl 10 mg tablet
1
PA
AL
At least 1 yrs old
PA
chlorpromazine hcl 100 mg tablet
1
AL
At least 1 yrs old
PA
chlorpromazine hcl 200 mg tablet
1
AL
PAGE 155
At least 1 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
chlorpromazine hcl 25 mg tablet
1
AL
At least 1 yrs old
PA
chlorpromazine hcl 25 mg/ml ampul
1
AL
At least 1 yrs old
PA
chlorpromazine hcl 50 mg tablet
1
AL
At least 1 yrs old
QL
60 / 30 days
citalopram hydrobromide 10 mg tablet
1
citalopram hydrobromide 10 mg/5 ml solution
1
citalopram hydrobromide 20 mg tablet
1
QL
60 / 30 days
citalopram hydrobromide 40 mg tablet
1
QL
30 / 30 days
clomipramine hcl 25 mg capsule
1
PA
AL
At least 10 yrs old
PA
clomipramine hcl 50 mg capsule
1
AL
At least 10 yrs old
PA
clomipramine hcl 75 mg capsule
1
AL
clozapine 100 mg tab rapdis
1
clozapine 100 mg tablet
1
clozapine 12.5 mg tab rapdis
1
clozapine 150 mg tab rapdis
1
clozapine 200 mg tab rapdis
1
clozapine 200 mg tablet
1
clozapine 25 mg tab rapdis
1
clozapine 25 mg tablet
1
clozapine 50 mg tablet
1
CLOZARIL 100 MG TABLET
clozapine
1
CLOZARIL 25 MG TABLET
clozapine
1
COMPRO 25 MG SUPPOSITORY
prochlorperazine
1
PAGE 156
At least 10 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
desipramine hcl 10 mg tablet
1
AL
At least 18 yrs old
PA
desipramine hcl 100 mg tablet
1
AL
At least 18 yrs old
PA
desipramine hcl 150 mg tablet
1
AL
At least 18 yrs old
PA
desipramine hcl 25 mg tablet
1
AL
At least 18 yrs old
PA
desipramine hcl 50 mg tablet
1
AL
At least 18 yrs old
PA
desipramine hcl 75 mg tablet
1
AL
desvenlafaxine 100 mg tab er 24
1
desvenlafaxine 100 mg tab er 24h
1
desvenlafaxine 50 mg tab er 24
1
desvenlafaxine 50 mg tab er 24h
1
doxepin hcl 10 mg capsule
1
At least 18 yrs old
PA
AL
At least 12 yrs old
PA
doxepin hcl 10 mg/ml oral conc
1
AL
At least 12 yrs old
PA
doxepin hcl 100 mg capsule
1
AL
At least 12 yrs old
PA
doxepin hcl 150 mg capsule
1
AL
At least 12 yrs old
PA
doxepin hcl 25 mg capsule
1
AL
At least 12 yrs old
PA
doxepin hcl 50 mg capsule
1
AL
At least 12 yrs old
PA
doxepin hcl 75 mg capsule
1
AL
PAGE 157
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
duloxetine hcl 100 % powder
1
duloxetine hcl 20 mg capsule dr
1
QL
60 / 30 days
duloxetine hcl 30 mg capsule dr
1
QL
60 / 30 days
duloxetine hcl 40 mg capsule dr
1
duloxetine hcl 60 mg capsule dr
1
QL
30 / 30 days
EFFEXOR XR 150 MG CAPSULE
venlafaxine hcl
1
QL
30 / 30 days
EFFEXOR XR 37.5 MG CAPSULE
venlafaxine hcl
1
QL
30 / 30 days
EFFEXOR XR 75 MG CAPSULE
venlafaxine hcl
1
QL
90 / 30 days
EMSAM 12 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
EMSAM 6 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
EMSAM 9 MG/24 HOURS PATCH
selegiline
1
QL
30 / 30 days
escitalopram oxalate 10 mg tablet
1
QL
30 / 30 days
escitalopram oxalate 20 mg tablet
1
QL
30 / 30 days
escitalopram oxalate 5 mg tablet
1
QL
30 / 30 days
escitalopram oxalate 5 mg/5 ml solution
1
FANAPT 1 MG TABLET
iloperidone
1
QL
2 / 30 days
FANAPT 10 MG TABLET
iloperidone
1
QL
60 / 30 days
FANAPT 12 MG TABLET
iloperidone
1
QL
60 / 30 days
FANAPT 2 MG TABLET
iloperidone
1
QL
2 / 30 days
FANAPT 4 MG TABLET
iloperidone
1
QL
2 / 30 days
FANAPT 6 MG TABLET
iloperidone
1
QL
60 / 30 days
FANAPT 8 MG TABLET
iloperidone
1
QL
60 / 30 days
PAGE 158
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FANAPT TITRATION PACK
iloperidone
1
FAZACLO 100 MG ODT
clozapine
1
FAZACLO 12.5 MG ODT
clozapine
1
FAZACLO 150 MG ODT
clozapine
1
FAZACLO 200 MG ODT
clozapine
1
FAZACLO 25 MG ODT
clozapine
1
FETZIMA 20-40 MG TITRATION PAK
levomilnacipran hydrochloride
1
FETZIMA ER 120 MG CAPSULE
levomilnacipran hydrochloride
1
FETZIMA ER 20 MG CAPSULE
levomilnacipran hydrochloride
1
FETZIMA ER 40 MG CAPSULE
levomilnacipran hydrochloride
1
FETZIMA ER 80 MG CAPSULE
levomilnacipran hydrochloride
1
fluoxetine hcl 10 mg capsule
LIMITS & RESTRICTIONS
QL
8 / 30 days
1
QL
60 / 30 days
fluoxetine hcl 10 mg tablet
1
QL
60 / 30 days
fluoxetine hcl 20 mg capsule
1
QL
90 / 30 days
fluoxetine hcl 20 mg tablet
1
QL
90 / 30 days
fluoxetine hcl 20 mg/5 ml solution
1
fluoxetine hcl 40 mg capsule
1
QL
60 / 30 days
fluoxetine hcl 60 mg tablet
1
fluoxetine hcl 90 mg capsule dr
1
QL
4 / 30 days
fluphenazine decanoate 100 % liquid
1
fluphenazine decanoate 2.5 %(w/w) oil
1
fluphenazine decanoate 25 mg/ml vial
1
fluphenazine hcl 1 mg tablet
1
PAGE 159
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
fluphenazine hcl 10 mg tablet
1
fluphenazine hcl 2.5 mg tablet
1
fluphenazine hcl 2.5 mg/5ml elixir
1
fluphenazine hcl 2.5 mg/ml vial
1
fluphenazine hcl 5 mg tablet
1
fluphenazine hcl 5 mg/ml oral conc
1
fluvoxamine maleate 100 mg cap er 24h
1
QL
60 / 30 days
fluvoxamine maleate 100 mg tablet
1
QL
90 / 30 days
fluvoxamine maleate 150 mg cap er 24h
1
QL
60 / 30 days
fluvoxamine maleate 25 mg tablet
1
QL
90 / 30 days
fluvoxamine maleate 50 mg tablet
1
QL
90 / 30 days
FORFIVO XL 450 MG TABLET
bupropion hcl
1
GEODON 20 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 20 MG/ML VIAL
ziprasidone mesylate
1
GEODON 40 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 60 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
GEODON 80 MG CAPSULE
ziprasidone hcl
1
QL
60 / 30 days
HALDOL 5 MG/ML AMPUL
haloperidol lactate
1
HALDOL DECANOATE 100 AMPUL
haloperidol decanoate
1
HALDOL DECANOATE 50 AMPUL
haloperidol decanoate
1
haloperidol 0.5 mg tablet
1
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
haloperidol 1 mg tablet
1
AL
PAGE 160
At least 12 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
haloperidol 10 mg tablet
1
AL
At least 12 yrs old
PA
haloperidol 2 mg tablet
1
AL
At least 12 yrs old
PA
haloperidol 20 mg tablet
1
AL
At least 12 yrs old
PA
haloperidol 5 mg tablet
1
AL
haloperidol decanoate 100 % powder
1
haloperidol decanoate 100 mg/ml ampul
1
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
haloperidol decanoate 100 mg/ml vial
1
AL
At least 12 yrs old
PA
haloperidol decanoate 50 mg/ml ampul
1
AL
At least 12 yrs old
PA
haloperidol decanoate 50 mg/ml vial
1
AL
At least 12 yrs old
PA
haloperidol lactate 2 mg/ml oral conc
1
AL
haloperidol lactate 5 mg/ml ampul
1
haloperidol lactate 5 mg/ml vial
1
imipramine hcl 10 mg tablet
1
At least 12 yrs old
PA
AL
At least 6 yrs old
PA
imipramine hcl 25 mg tablet
1
AL
At least 6 yrs old
PA
imipramine hcl 50 mg tablet
1
AL
At least 6 yrs old
PA
imipramine pamoate 100 mg capsule
1
AL
At least 18 yrs old
PA
imipramine pamoate 125 mg capsule
1
AL
PAGE 161
At least 18 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
imipramine pamoate 150 mg capsule
1
AL
At least 18 yrs old
PA
imipramine pamoate 75 mg capsule
1
AL
At least 18 yrs old
INVEGA ER 1.5 MG TABLET
paliperidone
1
QL
60 / 30 days
INVEGA ER 3 MG TABLET
paliperidone
1
QL
30 / 30 days
INVEGA ER 6 MG TABLET
paliperidone
1
QL
60 / 30 days
INVEGA ER 9 MG TABLET
paliperidone
1
QL
30 / 30 days
INVEGA SUSTENNA 117 MG PREF SY
paliperidone palmitate
1
INVEGA SUSTENNA 156 MG PREF SY
paliperidone palmitate
1
INVEGA SUSTENNA 234 MG PREF SY
paliperidone palmitate
1
INVEGA SUSTENNA 39 MG PREF SYR
paliperidone palmitate
1
INVEGA SUSTENNA 78 MG PREF SYR
paliperidone palmitate
1
IRENKA DR 40 MG CAPSULE
duloxetine hcl
1
KHEDEZLA ER 100 MG TABLET
desvenlafaxine
1
KHEDEZLA ER 50 MG TABLET
desvenlafaxine
1
LATUDA 120 MG TABLET
lurasidone hcl
1
LATUDA 20 MG TABLET
lurasidone hcl
1
LATUDA 40 MG TABLET
lurasidone hcl
1
QL
30 / 30 days
LATUDA 60 MG TABLET
lurasidone hcl
1
LATUDA 80 MG TABLET
lurasidone hcl
1
QL
30 / 30 days
PAGE 162
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
LEXAPRO 10 MG TABLET
escitalopram oxalate
1
QL
30 / 30 days
LEXAPRO 20 MG TABLET
escitalopram oxalate
1
QL
30 / 30 days
LEXAPRO 5 MG TABLET
escitalopram oxalate
1
QL
30 / 30 days
LEXAPRO 5 MG/5 ML SOLUTION
escitalopram oxalate
1
loxapine succinate 10 mg capsule
1
loxapine succinate 100 % powder
1
loxapine succinate 25 mg capsule
1
loxapine succinate 5 mg capsule
1
loxapine succinate 50 mg capsule
1
LOXITANE 10 MG CAPSULE
loxapine succinate
1
LOXITANE 25 MG CAPSULE
loxapine succinate
1
LOXITANE 5 MG CAPSULE
loxapine succinate
1
LOXITANE 50 MG CAPSULE
loxapine succinate
1
LUVOX CR 100 MG CAPSULE
fluvoxamine maleate
1
LUVOX CR 150 MG CAPSULE
fluvoxamine maleate
1
maprotiline hcl 25 mg tablet
1
PA
AL
At least 18 yrs old
PA
maprotiline hcl 50 mg tablet
1
AL
At least 18 yrs old
PA
maprotiline hcl 75 mg tablet
1
AL
PA
MARPLAN 10 MG TABLET
isocarboxazid
1
mirtazapine 100 % powder
1
mirtazapine 15 mg tab rapdis
1
PAGE 163
At least 18 yrs old
AL
At least 16 yrs old
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
mirtazapine 15 mg tablet
1
QL
30 / 30 days
mirtazapine 30 mg tab rapdis
1
QL
30 / 30 days
mirtazapine 30 mg tablet
1
QL
30 / 30 days
mirtazapine 45 mg tab rapdis
1
QL
30 / 30 days
mirtazapine 45 mg tablet
1
QL
30 / 30 days
mirtazapine 7.5 mg tablet
1
MOBAN 10 MG TABLET
molindone hcl
1
MOBAN 50 MG TABLET
molindone hcl
1
NARDIL 15 MG TABLET
phenelzine sulfate
1
nefazodone hcl 100 mg tablet
PA
AL
At least 18 yrs old
1
QL
60 / 30 days
nefazodone hcl 150 mg tablet
1
QL
60 / 30 days
nefazodone hcl 200 mg tablet
1
QL
60 / 30 days
nefazodone hcl 250 mg tablet
1
QL
60 / 30 days
nefazodone hcl 50 mg tablet
1
QL
60 / 30 days
NORPRAMIN 10 MG TABLET
desipramine hcl
1
NORPRAMIN 100 MG TABLET
desipramine hcl
1
NORPRAMIN 150 MG TABLET
desipramine hcl
1
NORPRAMIN 25 MG TABLET
desipramine hcl
1
NORPRAMIN 50 MG TABLET
desipramine hcl
1
NORPRAMIN 75 MG TABLET
desipramine hcl
1
PAGE 164
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
nortriptyline hcl 10 mg capsule
1
AL
At least 12 yrs old
PA
nortriptyline hcl 10 mg/5 ml solution
1
AL
At least 12 yrs old
PA
nortriptyline hcl 25 mg capsule
1
AL
At least 12 yrs old
PA
nortriptyline hcl 50 mg capsule
1
AL
At least 12 yrs old
PA
nortriptyline hcl 75 mg capsule
1
AL
At least 12 yrs old
olanzapine 10 mg tab rapdis
1
QL
30 / 30 days
olanzapine 10 mg tablet
1
QL
30 / 30 days
olanzapine 10 mg vial
1
olanzapine 15 mg tab rapdis
1
QL
30 / 30 days
olanzapine 15 mg tablet
1
QL
30 / 30 days
olanzapine 2.5 mg tablet
1
QL
30 / 30 days
olanzapine 20 mg tab rapdis
1
QL
30 / 30 days
olanzapine 20 mg tablet
1
QL
30 / 30 days
olanzapine 5 mg tab rapdis
1
QL
30 / 30 days
olanzapine 5 mg tablet
1
QL
30 / 30 days
olanzapine 7.5 mg tablet
1
QL
30 / 30 days
olanzapine/fluoxetine hcl 12mg-25mg capsule
1
QL
30 / 30 days
olanzapine/fluoxetine hcl 12mg-50mg capsule
1
QL
30 / 30 days
olanzapine/fluoxetine hcl 3 mg-25 mg capsule
1
QL
30 / 30 days
olanzapine/fluoxetine hcl 6mg-25mg capsule
1
QL
30 / 30 days
olanzapine/fluoxetine hcl 6mg-50mg capsule
1
QL
30 / 30 days
OLEPTRO ER 150 MG TABLET
trazodone hcl
1
QL
75 / 30 days
PAGE 165
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
OLEPTRO ER 300 MG TABLET
trazodone hcl
1
ORAP 1 MG TABLET
pimozide
1
ORAP 2 MG TABLET
pimozide
1
PAMELOR 10 MG CAPSULE
nortriptyline hcl
1
PAMELOR 25 MG CAPSULE
nortriptyline hcl
1
PAMELOR 50 MG CAPSULE
nortriptyline hcl
1
PAMELOR 75 MG CAPSULE
nortriptyline hcl
1
PARNATE 10 MG TABLET
tranylcypromine sulfate
1
paroxetine hcl 10 mg tablet
LIMITS & RESTRICTIONS
QL
30 / 30 days
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 12 yrs old
PA
AL
At least 18 yrs old
1
QL
60 / 30 days
paroxetine hcl 12.5 mg tab er 24h
1
QL
60 / 30 days
paroxetine hcl 20 mg tablet
1
QL
30 / 30 days
paroxetine hcl 25 mg tab er 24h
1
QL
90 / 30 days
paroxetine hcl 30 mg tablet
1
QL
60 / 30 days
paroxetine hcl 37.5 mg tab er 24h
1
QL
60 / 30 days
paroxetine hcl 40 mg tablet
1
QL
30 / 30 days
PAXIL 10 MG TABLET
paroxetine hcl
1
QL
60 / 30 days
PAXIL 10 MG/5 ML SUSPENSION
paroxetine hcl
1
PAXIL 20 MG TABLET
paroxetine hcl
1
QL
30 / 30 days
PAXIL 30 MG TABLET
paroxetine hcl
1
QL
60 / 30 days
PAGE 166
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PAXIL 40 MG TABLET
paroxetine hcl
1
perphenazine 100 % powder
1
perphenazine 16 mg tablet
1
LIMITS & RESTRICTIONS
QL
30 / 30 days
PA
AL
At least 12 yrs old
PA
perphenazine 2 mg tablet
1
AL
At least 12 yrs old
PA
perphenazine 4 mg tablet
1
AL
At least 12 yrs old
PA
perphenazine 8 mg tablet
1
AL
At least 12 yrs old
PA
perphenazine/amitriptyline hcl 2 mg-10 mg tablet
1
AL
At least 18 yrs old
PA
perphenazine/amitriptyline hcl 2 mg-25 mg tablet
1
AL
At least 18 yrs old
PA
perphenazine/amitriptyline hcl 4 mg-25 mg tablet
1
AL
At least 18 yrs old
PA
perphenazine/amitriptyline hcl 4mg-10mg tablet
1
AL
At least 18 yrs old
PA
perphenazine/amitriptyline hcl 4mg-50mg tablet
1
AL
At least 18 yrs old
PEXEVA 10 MG TABLET
paroxetine mesylate
1
QL
60 / 30 days
PEXEVA 20 MG TABLET
paroxetine mesylate
1
QL
30 / 30 days
PEXEVA 30 MG TABLET
paroxetine mesylate
1
QL
60 / 30 days
PEXEVA 40 MG TABLET
paroxetine mesylate
1
QL
30 / 30 days
phenelzine sulfate 15 mg tablet
1
PA
PRISTIQ ER 100 MG TABLET
desvenlafaxine succinate
PAGE 167
1
AL
At least 18 yrs old
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PRISTIQ ER 25 MG TABLET
desvenlafaxine succinate
1
PRISTIQ ER 50 MG TABLET
desvenlafaxine succinate
1
prochlorperazine 25 mg supp.rect
1
prochlorperazine maleate 10 mg tablet
1
prochlorperazine maleate 5 mg tablet
1
protriptyline hcl 10 mg tablet
1
LIMITS & RESTRICTIONS
QL
30 / 30 days
PA
AL
At least 18 yrs old
PA
protriptyline hcl 5 mg tablet
1
AL
At least 18 yrs old
PROZAC 10 MG PULVULE
fluoxetine hcl
1
QL
60 / 30 days
PROZAC 20 MG PULVULE
fluoxetine hcl
1
QL
90 / 30 days
PROZAC 40 MG PULVULE
fluoxetine hcl
1
QL
60 / 30 days
PROZAC WEEKLY 90 MG CAPSULE
fluoxetine hcl
1
QL
4 / 30 days
quetiapine fumarate 100 mg tablet
1
QL
90 / 30 days
quetiapine fumarate 200 mg tablet
1
QL
90 / 30 days
quetiapine fumarate 25 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 300 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 400 mg tablet
1
QL
60 / 30 days
quetiapine fumarate 50 mg tablet
1
QL
90 / 30 days
REMERON 15 MG SOLTAB
mirtazapine
1
QL
30 / 30 days
REMERON 15 MG TABLET
mirtazapine
1
QL
30 / 30 days
REMERON 30 MG SOLTAB
mirtazapine
1
QL
30 / 30 days
REMERON 30 MG TABLET
mirtazapine
1
QL
30 / 30 days
REMERON 45 MG SOLTAB
mirtazapine
1
QL
30 / 30 days
PAGE 168
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
REMERON 45 MG TABLET
mirtazapine
1
QL
30 / 30 days
RISPERDAL 0.25 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 0.5 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 1 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 2 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 3 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL 4 MG TABLET
risperidone
1
QL
60 / 30 days
RISPERDAL CONSTA 12.5 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 25 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 37.5 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL CONSTA 50 MG SYR
risperidone microspheres
1
QL
2 / 30 Days
RISPERDAL M-TAB 0.5 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 1 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 2 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 3 MG ODT
risperidone
1
QL
60 / 30 days
RISPERDAL M-TAB 4 MG ODT
risperidone
1
QL
60 / 30 days
risperidone 0.25 mg tab rapdis
1
QL
60 / 30 days
risperidone 0.25 mg tablet
1
QL
60 / 30 days
risperidone 0.5 mg tab rapdis
1
QL
60 / 30 days
risperidone 0.5 mg tablet
1
QL
60 / 30 days
risperidone 1 mg tab rapdis
1
QL
60 / 30 days
PAGE 169
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
risperidone 1 mg tablet
1
QL
60 / 30 days
risperidone 1 mg/ml solution
1
QL
240 / 30 days
risperidone 2 mg tab rapdis
1
QL
60 / 30 days
risperidone 2 mg tablet
1
QL
60 / 30 days
risperidone 3 mg tab rapdis
1
QL
60 / 30 days
risperidone 3 mg tablet
1
QL
60 / 30 days
risperidone 4 mg tab rapdis
1
QL
60 / 30 days
risperidone 4 mg tablet
1
QL
60 / 30 days
SAPHRIS 10 MG TAB SL BLK CHERY
asenapine maleate
1
QL
60 / 30 days
SAPHRIS 10 MG TAB SUBLINGUAL
asenapine maleate
1
SAPHRIS 2.5 MG TAB SL BLK CHRY
asenapine maleate
1
SAPHRIS 5 MG TAB SL BLK CHERRY
asenapine maleate
1
QL
60 / 30 days
SAPHRIS 5 MG TABLET SUBLINGUAL
asenapine maleate
1
SARAFEM 10 MG TABLET
fluoxetine hcl
1
QL
60 / 30 days
SARAFEM 20 MG TABLET
fluoxetine hcl
1
QL
90 / 30 days
SAVELLA 100 MG TABLET
milnacipran hcl
1
PA
SAVELLA 12.5 MG TABLET
milnacipran hcl
1
PA
SAVELLA 25 MG TABLET
milnacipran hcl
1
PA
SAVELLA 50 MG TABLET
milnacipran hcl
1
PA
SAVELLA TITRATION PACK
milnacipran hcl
1
PA
selegiline hcl 5 mg capsule
1
selegiline hcl 5 mg tablet
1
PAGE 170
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SEROQUEL 100 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL 200 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL 25 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 300 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 400 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL 50 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL XR 150 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 200 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
SEROQUEL XR 300 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 400 MG TABLET
quetiapine fumarate
1
QL
60 / 30 days
SEROQUEL XR 50 MG TABLET
quetiapine fumarate
1
QL
90 / 30 days
sertraline hcl 100 mg tablet
1
QL
60 / 30 days
sertraline hcl 20 mg/ml oral conc
1
sertraline hcl 25 mg tablet
1
QL
60 / 30 days
sertraline hcl 50 mg tablet
1
QL
90 / 30 days
SURMONTIL 100 MG CAPSULE
trimipramine maleate
1
SURMONTIL 25 MG CAPSULE
trimipramine maleate
1
SURMONTIL 50 MG CAPSULE
trimipramine maleate
1
SYMBYAX 12-25 MG CAPSULE
olanzapine/fluoxetine hcl
SYMBYAX 12-50 MG CAPSULE
olanzapine/fluoxetine hcl
PAGE 171
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
1
QL
30 / 30 days
1
QL
30 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SYMBYAX 3-25 MG CAPSULE
olanzapine/fluoxetine hcl
1
QL
30 / 30 days
SYMBYAX 6-25 MG CAPSULE
olanzapine/fluoxetine hcl
1
QL
30 / 30 days
SYMBYAX 6-50 MG CAPSULE
olanzapine/fluoxetine hcl
1
QL
30 / 30 days
thioridazine hcl 10 mg tablet
1
PA
AL
At least 2 yrs old
PA
thioridazine hcl 100 mg tablet
1
AL
At least 2 yrs old
PA
thioridazine hcl 25 mg tablet
1
AL
At least 2 yrs old
PA
thioridazine hcl 50 mg tablet
1
AL
At least 2 yrs old
PA
thiothixene 1 mg capsule
1
AL
At least 12 yrs old
PA
thiothixene 10 mg capsule
1
AL
At least 12 yrs old
PA
thiothixene 2 mg capsule
1
AL
At least 12 yrs old
PA
thiothixene 5 mg capsule
1
AL
PA
TOFRANIL 10 MG TABLET
imipramine hcl
1
TOFRANIL 25 MG TABLET
imipramine hcl
1
TOFRANIL 50 MG TABLET
imipramine hcl
1
TOFRANIL-PM 100 MG CAPSULE
imipramine pamoate
1
TOFRANIL-PM 125 MG CAPSULE
imipramine pamoate
1
PAGE 172
At least 12 yrs old
AL
At least 6 yrs old
PA
AL
At least 6 yrs old
PA
AL
At least 6 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
TOFRANIL-PM 150 MG CAPSULE
imipramine pamoate
1
TOFRANIL-PM 75 MG CAPSULE
imipramine pamoate
1
tranylcypromine sulfate 10 mg tablet
1
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
PA
trazodone hcl 100 mg tablet
1
AL
At least 18 yrs old
PA
trazodone hcl 150 mg tablet
1
AL
At least 18 yrs old
PA
trazodone hcl 300 mg tablet
1
AL
At least 18 yrs old
PA
trazodone hcl 50 mg tablet
1
AL
At least 18 yrs old
PA
trifluoperazine hcl 1 mg tablet
1
AL
At least 6 yrs old
PA
trifluoperazine hcl 10 mg tablet
1
AL
At least 6 yrs old
PA
trifluoperazine hcl 2 mg tablet
1
AL
At least 6 yrs old
PA
trifluoperazine hcl 5 mg tablet
1
AL
At least 6 yrs old
trimipramine maleate 100 mg capsule
1
trimipramine maleate 25 mg capsule
1
trimipramine maleate 50 mg capsule
1
venlafaxine hcl 100 mg tablet
1
QL
90 / 30 days
venlafaxine hcl 150 mg cap er 24h
1
QL
30 / 30 days
venlafaxine hcl 150 mg tab er 24
1
QL
30 / 30 days
venlafaxine hcl 225 mg tab er 24
1
QL
30 / 30 days
PAGE 173
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
venlafaxine hcl 25 mg tablet
1
QL
90 / 30 days
venlafaxine hcl 37.5 mg cap er 24h
1
QL
30 / 30 days
venlafaxine hcl 37.5 mg tab er 24
1
QL
30 / 30 days
venlafaxine hcl 37.5 mg tablet
1
QL
90 / 30 days
venlafaxine hcl 50 mg tablet
1
QL
90 / 30 days
venlafaxine hcl 75 mg cap er 24h
1
QL
90 / 30 days
venlafaxine hcl 75 mg tab er 24
1
QL
90 / 30 days
venlafaxine hcl 75 mg tablet
1
QL
90 / 30 days
VERSACLOZ 50 MG/ML SUSPENSION
clozapine
1
VIIBRYD 10 MG TABLET
vilazodone hydrochloride
1
QL
30 / 30 days
VIIBRYD 10-20-40 MG STARTER PK
vilazodone hydrochloride
1
VIIBRYD 20 MG TABLET
vilazodone hydrochloride
1
QL
30 / 30 days
VIIBRYD 40 MG TABLET
vilazodone hydrochloride
1
QL
30 / 30 days
VIVACTIL 10 MG TABLET
protriptyline hcl
1
VIVACTIL 5 MG TABLET
protriptyline hcl
1
WELLBUTRIN 100 MG TABLET
bupropion hcl
1
WELLBUTRIN 75 MG TABLET
bupropion hcl
1
WELLBUTRIN SR 100 MG TABLET
bupropion hcl
PA
AL
At least 18 yrs old
PA
AL
At least 18 yrs old
1
QL
60 / 30 days
WELLBUTRIN SR 150 MG TABLET
bupropion hcl
1
QL
60 / 30 days
WELLBUTRIN SR 200 MG TABLET
bupropion hcl
1
QL
60 / 30 days
WELLBUTRIN XL 150 MG TABLET
bupropion hcl
1
QL
90 / 30 days
PAGE 174
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
WELLBUTRIN XL 300 MG TABLET
bupropion hcl
1
QL
30 / 30 days
ziprasidone hcl 20 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 40 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 60 mg capsule
1
QL
60 / 30 days
ziprasidone hcl 80 mg capsule
1
QL
60 / 30 days
ZOLOFT 100 MG TABLET
sertraline hcl
1
QL
60 / 30 days
ZOLOFT 20 MG/ML ORAL CONC
sertraline hcl
1
ZOLOFT 25 MG TABLET
sertraline hcl
1
QL
60 / 30 days
ZOLOFT 50 MG TABLET
sertraline hcl
1
QL
90 / 30 days
ZYPREXA 10 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 10 MG VIAL
olanzapine
1
ZYPREXA 15 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 2.5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 20 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA 7.5 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA RELPREVV 210 MG VIAL
olanzapine pamoate
1
ZYPREXA RELPREVV 210 MG VL KIT
olanzapine pamoate
1
ZYPREXA RELPREVV 300 MG VIAL
olanzapine pamoate
1
ZYPREXA RELPREVV 300 MG VL KIT
olanzapine pamoate
1
ZYPREXA RELPREVV 405 MG VIAL
olanzapine pamoate
1
PAGE 175
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ZYPREXA RELPREVV 405 MG VL KIT
olanzapine pamoate
1
ZYPREXA ZYDIS 10 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 15 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 20 MG TABLET
olanzapine
1
QL
30 / 30 days
ZYPREXA ZYDIS 5 MG TABLET
olanzapine
1
QL
30 / 30 days
ELECTROLYTIC, CALORIC, AND WATER BALANCE
DIURETICS
acetazolamide 125 mg tablet
1
acetazolamide 250 mg tablet
1
acetazolamide 500 mg capsule er
1
amiloride hcl 5 mg tablet
1
amiloride/hydrochlorothiazide 5 mg-50 mg tablet
1
amlodipine/valsartan/hcthiazid 10-160-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10-320-25 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 10mg-160mg tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-12.5 tablet
1
QL
30 / 30 days
amlodipine/valsartan/hcthiazid 5-160-25mg tablet
1
QL
30 / 30 days
atenolol/chlorthalidone 100mg-25mg tablet
1
atenolol/chlorthalidone 50 mg-25mg tablet
1
benazepril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
benazepril/hydrochlorothiazide 5-6.25mg tablet
1
QL
30 / 30 days
bisoprolol fumarate/hctz 10-6.25mg tablet
1
bisoprolol fumarate/hctz 2.5-6.25mg tablet
1
bisoprolol fumarate/hctz 5-6.25mg tablet
1
PAGE 176
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
bumetanide 0.5 mg tablet
1
bumetanide 1 mg tablet
1
bumetanide 2 mg tablet
1
candesartan/hydrochlorothiazid 16-12.5mg tablet
1
QL
30 / 30 days
candesartan/hydrochlorothiazid 32-12.5mg tablet
1
QL
30 / 30 days
candesartan/hydrochlorothiazid 32mg-25mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 25 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 25 mg-25mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-15mg tablet
1
QL
30 / 30 days
captopril/hydrochlorothiazide 50 mg-25mg tablet
1
QL
30 / 30 days
chlorothiazide 250 mg tablet
1
chlorothiazide 500 mg tablet
1
chlorthalidone 25 mg tablet
1
chlorthalidone 50 mg tablet
1
CLORPRES 0.1-15 TABLET
clonidine hcl/chlorthalidone
1
CLORPRES 0.2-15 TABLET
clonidine hcl/chlorthalidone
1
DYRENIUM 100 MG CAPSULE
triamterene
1
DYRENIUM 50 MG CAPSULE
triamterene
1
enalapril/hydrochlorothiazide 10 mg-25mg tablet
1
QL
60 / 30 days
enalapril/hydrochlorothiazide 5mg-12.5mg tablet
1
QL
60 / 30 days
eplerenone 25 mg tablet
1
QL
30 / 30 days
eplerenone 50 mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
60 / 30 days
fosinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
furosemide 10 mg/ml solution
1
furosemide 20 mg tablet
1
PAGE 177
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
furosemide 40 mg tablet
1
furosemide 40mg/5ml solution
1
furosemide 80 mg tablet
1
hydrochlorothiazide 12.5 mg capsule
1
hydrochlorothiazide 12.5 mg tablet
1
hydrochlorothiazide 25 mg tablet
1
hydrochlorothiazide 50 mg tablet
1
indapamide 1.25 mg tablet
1
indapamide 2.5 mg tablet
1
irbesartan/hydrochlorothiazide 150-12.5mg tablet
1
QL
60 / 30 days
irbesartan/hydrochlorothiazide 300-12.5mg tablet
1
QL
30 / 30 days
lisinopril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
lisinopril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
lisinopril/hydrochlorothiazide 20-25mg tablet
1
QL
60 / 30 days
losartan/hydrochlorothiazide 100-12.5mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 100mg-25mg tablet
1
QL
30 / 30 days
losartan/hydrochlorothiazide 50-12.5 mg tablet
1
QL
30 / 30 days
methyclothiazide 5 mg tablet
1
methyldopa/hydrochlorothiazide 250mg-15mg tablet
1
methyldopa/hydrochlorothiazide 250mg-25mg tablet
1
metolazone 10 mg tablet
1
metolazone 2.5 mg tablet
1
metolazone 5 mg tablet
1
metoprolol/hydrochlorothiazide 100mg-25mg tablet
1
metoprolol/hydrochlorothiazide 100mg-50mg tablet
1
metoprolol/hydrochlorothiazide 50 mg-25mg tablet
1
moexipril/hydrochlorothiazide 15-12.5mg tablet
1
QL
30 / 30 days
moexipril/hydrochlorothiazide 15-25mg tablet
1
QL
60 / 30 days
moexipril/hydrochlorothiazide 7.5-12.5mg tablet
1
QL
30 / 30 days
PAGE 178
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
nadolol/bendroflumethiazide 40 mg-5 mg tablet
1
nadolol/bendroflumethiazide 80 mg-5 mg tablet
1
propranolol/hydrochlorothiazid 40 mg-25mg tablet
1
propranolol/hydrochlorothiazid 80 mg-25mg tablet
1
quinapril/hydrochlorothiazide 10-12.5mg tablet
1
QL
30 / 30 days
quinapril/hydrochlorothiazide 20-12.5 mg tablet
1
QL
60 / 30 days
quinapril/hydrochlorothiazide 20-25mg tablet
1
QL
30 / 30 days
spironolact/hydrochlorothiazid 25 mg-25mg tablet
1
spironolactone 100 mg tablet
1
spironolactone 25 mg tablet
1
spironolactone 50 mg tablet
1
telmisartan/hydrochlorothiazid 40-12.5 mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80 mg-25mg tablet
1
QL
30 / 30 days
telmisartan/hydrochlorothiazid 80-12.5mg tablet
1
QL
30 / 30 days
THEO-24 ER 100 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 200 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 300 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 400 MG CAPSULE
theophylline anhydrous
1
THEOCHRON ER 100 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 200 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 300 MG TABLET
theophylline anhydrous
1
theophylline anhydrous 100 mg tab er 12h
1
theophylline anhydrous 200 mg tab er 12h
1
theophylline anhydrous 300 mg tab er 12h
1
theophylline anhydrous 400 mg tablet er
1
theophylline anhydrous 450 mg tab er 12h
1
PAGE 179
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
theophylline anhydrous 600 mg tablet er
1
theophylline anhydrous 80 mg/15ml elixir
1
theophylline anhydrous 80 mg/15ml solution
1
torsemide 10 mg tablet
1
torsemide 100 mg tablet
1
torsemide 20 mg tablet
1
torsemide 5 mg tablet
1
triamterene/hydrochlorothiazid 37.5-25 mg capsule
1
triamterene/hydrochlorothiazid 37.5-25 mg tablet
1
triamterene/hydrochlorothiazid 50 mg-25mg capsule
1
triamterene/hydrochlorothiazid 75 mg-50mg tablet
1
valsartan/hydrochlorothiazide 160-12.5mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 160-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 320-12.5mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 320mg-25mg tablet
1
QL
30 / 30 days
valsartan/hydrochlorothiazide 80-12.5mg tablet
1
QL
30 / 30 days
0.9 % sodium chloride 0.9 % syringe
1
ADVANCED AM/PM COMBO PACK
omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13
1
AP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
b3/azel/quer/tur/fa/b6/zn/copp 700 mg-500 tablet
1
BAL-CARE DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
BP FOLINATAL PLUS B TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
cal carb/mgox/d3/b12/fa/b6/bor 500-300-1 wafer
1
calcium acetate 667 mg capsule
1
calcium acetate 667 mg tablet
1
CALCIUM-PNV 28-1-250 MG SFTGL
prenatal vits with calcium #70/ferrous fumarate/fa/dha
1
CAVAN-ALPHA KIT COMBO PACK
prenatal vitamin no.67/sodium feredetate-iron poly/fa/omega3
1
PAGE 180
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CENTRATEX CAPSULE
ferrous fumarate/folic acid/multivitamins with min no. 15
1
CHOICE-OB + DHA COMBO PACK
prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha
1
CHOICE-TABS TABLET
multivit with min#10/folic acid//vit d3/a lipoic acid/lutein
1
citric acid/sodium citrate 334-500mg solution
1
colchicine/probenecid 0.5-500mg tablet
1
COMPLETE NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
CONSTULOSE 10 GM/15 ML SOLN
lactulose
1
CYTRA-2 ORAL SOLUTION
citric acid/sodium citrate
1
CYTRA-3 SYRUP
sodium/potassium/potassium citrate/sodium citrate/cit ac
1
CYTRA-K CRYSTALS PACKET
potassium citrate/citric acid
1
CYTRA-K ORAL SOLUTION
potassium citrate/citric acid
1
DIALYVITE WITH ZINC TABLET
vitamin b complex#11/folic acid/ascorbic acid/biotin/zn oxid
1
EFFER-K 25 MEQ TABLET EFF
potassium bicarbonate/citric acid
1
ELIPHOS 667 MG TABLET
calcium acetate
1
ENULOSE 10 GM/15 ML SOLUTION
lactulose
1
fa/niacinamide/cupric ox/zn ox 0.5-750 mg tab mphase
1
FERREX 150 FORTE PLUS CAPSULE
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
FERROCITE PLUS TABLET
iron/folic acid/vitamin b comp w-c/minerals
1
FOLBECAL TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
FOLBEE PLUS CZ TABLET
folic acid/vitamin b comp w-c/copper/zinc oxide
1
GENERLAC 10 GM/15 ML SOLUTION
lactulose
1
PAGE 181
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
HEMATINIC-VITAMIN-MINERAL TAB
iron/folic acid/vitamin b comp w-c/minerals
1
heparin sod,porcine-0.9 % nacl 10 unit/ml kit
1
heparin sod,porcine-0.9 % nacl 100/ml kit
1
INATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
INATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
iron ag/c/b12/ca/suc.acid/stom 70-150-10 tablet
1
iron aspgly&ps/c/b12/fa/ca/suc 150-25-1 capsule
1
iron fum & ag/c/b12/fa/ca/succ 151-60-1mg tablet
1
K EFFERVESCENT 25 MEQ TABLET
potassium bicarbonate/citric acid
1
K-PHOS NEUTRAL TABLET
phosphorus #1
1
K-SOL 10% (20 MEQ/15 ML) LIQ
potassium chloride
1
K-SOL 20% (40 MEQ/15 ML) LIQ
potassium chloride
1
K-TAB ER 8 MEQ TABLET
potassium chloride
1
KLOR-CON 10 MEQ TABLET
potassium chloride
1
KLOR-CON 20 MEQ PACKET
potassium chloride
1
KLOR-CON 8 MEQ TABLET
potassium chloride
1
KLOR-CON M10 TABLET
potassium chloride
1
KLOR-CON M15 TABLET
potassium chloride
1
KLOR-CON M20 TABLET
potassium chloride
1
KLOR-CON-EF 25 MEQ TAB EFF
potassium bicarbonate/citric acid
1
L-METHYLFOLATE PNV DHA SOFTGEL
prenatal vit with calcium no42/iron fum/fa/l-mefolate ca/dha
1
PAGE 182
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LACTOCAL-F TABLET
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
lactulose 10 g/15 ml solution
1
lactulose 20 g/30 ml solution
1
lmfol ca/acetyl/mb12/algal oil 6-600-2 mg tablet
1
MACNATAL CN DHA SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
METAFOLBIC PLUS RF CAPLET
levomefolate ca/acetylcysteine/mecobalamin/schiz. algal oil
1
MONOJECT PREFILL 0.9% FLUSH
0.9 % sodium chloride
1
MONOJECT PREFILL 0.9% NA SYR
0.9 % sodium chloride
1
MULTIGEN CAPLET
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach
1
MULTIGEN FOLIC CAPLET
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
1
MULTIGEN PLUS CAPLET
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
MULTIVITAMINS CHEWABLES TABLET
pediatric multivitamin no.22/cholecalciferol/phytonadione
1
MYNATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
MYNATAL CAPSULE
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL PLUS CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL-Z CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
NATALVIRT 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
NATALVIRT CA COMBO PACK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
NEPHPLEX RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin/znox
1
NEWGEN TABLET
prenatal vitamin no.86/iron bis-glycinate/folic acid
1
NICOTINAMIDE TABLET
folic acid/niacinamide/cupric oxide/zinc oxide
1
PAGE 183
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PHOSPHA 250 NEUTRAL TABLET
phosphorus #1
1
PNV OB+DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
1
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
1
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
1
PNV-DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
PNV-FIRST SOFTGEL
prenatal vitamins no.26/iron polysaccharides/fa/dha
1
PNV-OB WITH DHA COMBO PACK
prenatal vitamins comb 10/ferrous fumarate/folic acid/dha
1
PNV-OMEGA SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
PNV-SELECT TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
pot chloride/pot bicarb/cit ac 25 meq tablet eff
1
potassium bicarbonate/cit ac 25 meq tablet eff
1
potassium chloride 10 meq capsule er
1
potassium chloride 10 meq tab er prt
1
potassium chloride 10 meq tablet er
1
potassium chloride 20 meq packet
1
potassium chloride 20 meq tab er prt
1
potassium chloride 20 meq tablet er
1
potassium chloride 20meq/15ml liquid
1
potassium chloride 40meq/15ml liquid
1
potassium chloride 8 meq capsule er
1
potassium chloride 8 meq tablet er
1
potassium citrate 10 meq tablet er
1
potassium citrate 15 meq tablet er
1
potassium citrate 5 meq tablet er
1
potassium citrate/citric acid 1100-334/5 solution
1
potassium citrate/citric acid 3300-1002 packet
1
PAGE 184
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PR NATAL 400 COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 400 EC COMBO PACK
prenatal vitamins comb no.19/iron bg hcl&suc-prot/fa/omega-3
1
PR NATAL 430 COMBO PACK
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 430 EC COMBO PACK
prenatal vitamins comb no.55/iron bg hcl&suc-prot/fa/omega-3
1
PRENAISSANCE 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PRENAISSANCE CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
PRENAISSANCE DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
PRENAISSANCE PLUS SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
PRENAISSANCE PROMISE COMBO PCK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
PRENAPLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
1
PREPLUS CA-FE 27 MG-FA 1 MG TB
prenatal vits with calcium #72/ferrous fumarate/folic acid
1
probenecid 500 mg tablet
1
PULMOSAL 7% VIAL
sodium chloride for inhalation
1
PUREVIT DUALFE PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
SE-TAN PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
SETONET PRENATAL VITAMIN
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
SETONET-EC PRENATAL VITAMINS
prenatal vitamins comb no.55/iron bg hcl&succ-p2/fa/omega-3
1
sod/pot/k cit/sod cit/cit acid 500-550/5 solution
1
sodium chloride for inhalation 0.9 % vial-neb
1
sodium chloride for inhalation 10 % vial-neb
1
PAGE 185
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sodium chloride irrig solution 0.9 % irrig soln
1
sodium citrate dihydrate granules
1
sodium phenylbutyrate 0.94 g/g powder
1
STROVITE PLUS CAPLET
multivits, iron, minerals combo no #6, folic acid
1
SYREX SODIUM CHL 0.9% SYR
0.9 % sodium chloride
1
TARON-BC TABLET
prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6
1
TARON-CRYSTALS PACKET
potassium citrate/citric acid
1
TARON-DUO EC COMB PACK
prenatal vitamins comb no.19/iron bg hcl&succ-p2/fa/omega-3
1
THERAPEUTIC HEMATINIC TAB
multivits,therap w-fe,hematin
1
TL G-FOL OS TABLET
ca carbonate/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
1
TL-HEM 150 CAPLET
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
1
TL-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
TRI RX TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
TRI-TABS DHA COMBO PACK
prenatal vitamins comb no.87/iron bisgly/folic acid/dha
1
TRI-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
TRIADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
TRICITRATES ORAL SOLUTION
sodium/potassium/potassium citrate/sodium citrate/cit ac
1
TRIMESIS RX TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
TRINATAL RX 1 TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
TRINATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
TRIVEEN-DUO DHA COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
PAGE 186
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRIVEEN-TEN TABLETS
prenatal vitamins no.18/iron,carbonyl/fa/ubidecarenone/dha
1
TRUST NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
V-C FORTE CAPSULE
multivitamins with min no.7/folic acid
1
VENA-BAL DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
VENATAL COMPLETE DHA COMBO
prenatal vitamin no.77/sodium feredetate-iron poly/fa/omega3
1
VIC-FORTE CAPSULE
multivitamins with min no.7/folic acid
1
VINACAL PRENATAL TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
VINATE AZ TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
VINATE DHA GELCAP
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha
1
VINATE II TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
VINATE ONE TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
VINATE ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
VINATE-M TABLET
prenatal vitamins with calcium/ferrous fumarate/fa/selenium
1
VIRT-ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
VIRT-PHOS 250 NEUTRAL TABLET
phosphorus #1
1
VIRT-PN DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
VIRT-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
VIRT-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
VIRT-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
VIRTRATE-2 ORAL SOLUTION
citric acid/sodium citrate
1
PAGE 187
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VIRTRATE-3 SOLUTION
sodium/potassium/potassium citrate/sodium citrate/cit ac
1
VIRTRATE-K ORAL SOLUTION
potassium citrate/citric acid
1
VITAFOL-OB CAPLET
prenatal vitamins comb 10/ferrous fumarate/folic acid
1
VITAFOL-PN CAPLET
prenatal vit with calcium cmb 11/ferrous fumarate/folic acid
1
VOL-PLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
VOL-PLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
1
VP-GSTN CAPSULE
genistein/citrated zinc bisglycinate/vitamin d3
1
VP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
ZATEAN-CH CAPSULE
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
ZATEAN-PN DHA CAPSULE
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
ZATEAN-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
ZATEAN-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
zinc sulfate 220(50)mg capsule
1
ZINCATE 220 MG CAPSULE
zinc sulfate
1
ZINGIBER TABLET
prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger
1
LIMITS & RESTRICTIONS
ION-REMOVING AGENTS
calcium acetate 667 mg capsule
1
calcium acetate 667 mg tablet
1
ELIPHOS 667 MG TABLET
calcium acetate
1
KIONEX 15 GM/60 ML SUSPENSION
sodium polystyrene sulfonate
1
KIONEX POWDER
sodium polystyrene sulfonate
1
PAGE 188
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
MARLEXATE POWDER
sodium polystyrene sulfonate
1
sevelamer carbonate 800 mg tablet
1
sodium polystyrene sulfonate powder
1
sodium polystyrene sulfonate 15 g/60 ml oral susp
1
sodium polystyrene sulfonate 30g/120ml enema
1
SPS 15 GM/60 ML SUSPENSION
sodium polystyrene sulfonate
1
SPS 30 GM/120 ML ENEMA
sodium polystyrene sulfonate
1
LIMITS & RESTRICTIONS
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTI-INFECTIVES (EENT)
ACETASOL HC EAR DROPS
acetic acid/hydrocortisone
1
acetic acid 2 % solution
1
acetic acid/aluminum acetate 2 % drops
1
acetic acid/hydrocortisone 2 %-1 % drops
1
AK-POLY-BAC EYE OINTMENT
bacitracin/polymyxin b sulfate
1
bacitracin 500 unit/g oint. (g)
1
bacitracin/polymyxin b sulfate 500-10k/g oint. (g)
1
BLEPHAMIDE EYE DROPS
sulfacetamide sodium/prednisolone acetate
1
BLEPHAMIDE EYE OINTMENT
sulfacetamide sodium/prednisolone acetate
1
chlorhexidine gluconate 0.12 % mouthwash
1
ciprofloxacin hcl 0.3 % drops
1
doxycycline hyclate 20 mg tablet
1
erythromycin base 5 mg/g oint. (g)
1
GARAMYCIN 0.3% EYE DROPS
gentamicin sulfate
1
GARAMYCIN 3 MG/ML EYE DROPS
gentamicin sulfate
1
gatifloxacin 0.5 % drops
1
PAGE 189
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
GENTAK 0.3 % EYE OINTMENT
gentamicin sulfate
1
gentamicin sulfate 0.3 % drops
1
gentamicin sulfate 0.3 % oint. (g)
1
levofloxacin 0.5 % drops
1
MYOXIN OTIC SUSPENSION
chloroxylenol/benzocaine/hydrocortisone acetate
1
NEO-POLYCIN EYE OINTMENT
neomycin sulfate/bacitracin/polymyxin b
1
NEO-POLYCIN HC EYE OINTMENT
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone
1
neo/polymyx b sulf/dexameth 0.1 % drops susp
1
neo/polymyx b sulf/dexameth 3.5-10k-.1 oint. (g)
1
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g)
1
neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g)
1
neomycin/polymyxin b sulf/hc 3.5-10k-1 drops susp
1
neomycin/polymyxin b sulf/hc 3.5-10k-1 solution
1
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
1
neomycin/polymyxn b/gramicidin 1.75mg-10k drops
1
ofloxacin 0.3 % drops
1
OTICIN DROPS
chloroxylenol/pramoxine hcl
1
PAROEX 0.12% ORAL RINSE
chlorhexidine gluconate
1
PERIOGARD 0.12% ORAL RINSE
chlorhexidine gluconate
1
POLY-DEX EYE OINTMENT
neomycin/polymyxin b sulfate/dexamethasone
1
POLYCIN EYE OINTMENT
bacitracin/polymyxin b sulfate
1
polymyxin b sulf/trimethoprim 10000-1/ml drops
1
PRAMOXINE-HC OTIC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
1
ROMYCIN EYE OINTMENT
erythromycin base
1
PAGE 190
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
silver nitrate 0.5 % solution
1
silver nitrate 10 % oint. (g)
1
silver nitrate 10 % solution
1
silver nitrate 25 % solution
1
silver nitrate 50 % solution
1
silver nitrate applicator 75%-25% stick (ea)
1
sulfacetamide sodium 10 % drops
1
sulfacetamide sodium 10 % oint. (g)
1
sulfacetamide/prednisolone sp 10 %-0.23% drops
1
SULFAMIDE 10% EYE DROPS
sulfacetamide sodium
1
TOBRADEX EYE OINTMENT
tobramycin/dexamethasone
1
tobramycin 0.3 % drops
1
tobramycin/dexamethasone 0.3 %-0.1% drops susp
1
TOBREX 0.3% EYE OINTMENT
tobramycin
1
trifluridine 1 % drops
1
LIMITS & RESTRICTIONS
ANTI-INFLAMMATORY AGENTS (EENT)
ACETASOL HC EAR DROPS
acetic acid/hydrocortisone
1
acetic acid/hydrocortisone 2 %-1 % drops
1
antipyrine/benzocaine 5.4 %-1.4% drops
1
antipyrine/benzocaine 5.5 %-1.4% drops
1
AURODEX OTIC SOLUTION
antipyrine/benzocaine
1
AUROGUARD OTIC SOLUTION
antipyrine/benzocaine
1
BLEPHAMIDE EYE DROPS
sulfacetamide sodium/prednisolone acetate
1
BLEPHAMIDE EYE OINTMENT
sulfacetamide sodium/prednisolone acetate
1
bromfenac sodium 0.09% drops
1
budesonide 32mcg spray/pump
1
PAGE 191
ST
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
dexamethasone sod phosphate 0.1 % drops
1
DEXASOL 0.1% EYE DROPS
dexamethasone sod phosphate
1
diclofenac sodium 0.1 % drops
1
flunisolide 25 mcg spray
1
flunisolide 29mcg spray
1
fluocinolone acetonide oil 0.01 % drops
1
fluorometholone 0.1 % drops susp
1
flurbiprofen sodium 0.03 % drops
1
fluticasone propionate 50 mcg spray susp
1
FML FORTE 0.25% EYE DROPS
fluorometholone
1
FML S.O.P. 0.1% OINTMENT
fluorometholone
1
ketorolac tromethamine 0.4 % drops
1
ketorolac tromethamine 0.5 % drops
1
MAXIDEX 0.1% EYE DROPS
dexamethasone
1
MYOXIN OTIC SUSPENSION
chloroxylenol/benzocaine/hydrocortisone acetate
1
NEO-POLYCIN HC EYE OINTMENT
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone
1
neo/polymyx b sulf/dexameth 0.1 % drops susp
1
neo/polymyx b sulf/dexameth 3.5-10k-.1 oint. (g)
1
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g)
1
neomycin/polymyxin b sulf/hc 3.5-10k-1 drops susp
1
neomycin/polymyxin b sulf/hc 3.5-10k-1 solution
1
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
1
POLY-DEX EYE OINTMENT
neomycin/polymyxin b sulfate/dexamethasone
1
PRAMOXINE-HC OTIC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
1
prednisolone acetate 1 % drops susp
1
prednisolone sod phosphate 1 % drops
1
PAGE 192
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sulfacetamide/prednisolone sp 10 %-0.23% drops
1
TOBRADEX EYE OINTMENT
tobramycin/dexamethasone
1
tobramycin/dexamethasone 0.3 %-0.1% drops susp
1
TREAGAN OTIC DROPS
acetic acid/antipyrine/benzocaine/policosanol no.1/al acetat
1
triamcinolone acetonide 55 mcg spray
1
VERAMYST 27.5 MCG NASAL SPRAY
fluticasone furoate
1
LIMITS & RESTRICTIONS
AL
2 to 4 yrs old
ANTIGLAUCOMA AGENTS
acetazolamide 125 mg tablet
1
acetazolamide 250 mg tablet
1
acetazolamide 500 mg capsule er
1
BETAGAN 0.5% EYE DROPS
levobunolol hcl
1
betaxolol hcl 0.5 % drops
1
bimatoprost 0.03 % drops
1
brimonidine tartrate 0.15 % drops
1
brimonidine tartrate 0.2 % drops
1
carteolol hcl 1 % drops
1
dorzolamide hcl 2 % drops
1
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops
1
latanoprost 0.005 % drops
1
levobunolol hcl 0.25 % drops
1
levobunolol hcl 0.5 % drops
1
methazolamide 25 mg tablet
1
methazolamide 50 mg tablet
1
metipranolol 0.3 % drops
1
PHOSPHOLINE IODIDE 0.125%
echothiophate iodide
1
pilocarpine hcl 1 % drops
1
pilocarpine hcl 2 % drops
1
pilocarpine hcl 4 % drops
1
PAGE 193
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
pilocarpine nitrate crystals
1
timolol maleate 0.25 % drops
1
timolol maleate 0.25 % sol-gel
1
timolol maleate 0.5 % drops
1
timolol maleate 0.5 % sol-gel
1
travoprost (benzalkonium) 0.004 % drops
1
ACETASOL HC EAR DROPS
acetic acid/hydrocortisone
1
acetic acid 2 % solution
1
acetic acid/aluminum acetate 2 % drops
1
acetic acid/hydrocortisone 2 %-1 % drops
1
AK-PENTOLATE 1% EYE DROPS
cyclopentolate hcl
1
AKORN BALANCED SALT SOLN
balanced salt irrig soln no.2
1
ALTACAINE 0.5% EYE DROPS
tetracaine hcl
1
ALTAFLUOR EYE DROPS
benoxinate hcl/fluorescein sodium
1
ALTAFRIN 10% EYE DROPS
phenylephrine hcl
1
ALTAFRIN 2.5% EYE DROPS
phenylephrine hcl
1
antipyrine/benzocaine 5.4 %-1.4% drops
1
antipyrine/benzocaine 5.5 %-1.4% drops
1
apraclonidine hcl 0.5 % drops
1
ATROPINE CARE 1% EYE DROPS
atropine sulfate
1
atropine sulfate 1 % drops
1
atropine sulfate 1 % oint. (g)
1
atropine sulfate/pf 1 % drops
1
AURODEX OTIC SOLUTION
antipyrine/benzocaine
1
AUROGUARD OTIC SOLUTION
antipyrine/benzocaine
1
PAGE 194
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
azelastine hcl 137 mcg spray/pump
1
azelastine hcl 205.5mcg spray/pump
1
balanced salt irrig soln no.2 irrig soln
1
benoxinate hcl/fluorescein na 0.4%-0.25% drops
1
BSS EYE SOLUTION
balanced salt irrig soln no.2
1
cocaine hcl 10 % solution
1
cocaine hcl 4 % solution
1
cromolyn sodium 20 mg/2 ml ampul-neb
1
cromolyn sodium 4 % drops
1
cyclopentolate hcl 1 % drops
1
cyclopentolate hcl 2 % drops
1
DYNAMIC KIT
lidocaine hcl/glycerin
1
epinastine hcl 0.05 % drops
1
FLUCAINE EYE DROPS
proparacaine hcl/fluorescein sodium
1
FLUROX EYE DROPS
benoxinate hcl/fluorescein sodium
1
GLYDO 2% JELLY SYRINGE
lidocaine hcl
1
HOMATROPAIRE 5% EYE DROPS
homatropine hbr
1
homatropine hbr 5 % drops
1
ipratropium bromide 21 mcg spray
1
ipratropium bromide 42mcg spray
1
ISOPTO HOMATROPINE 2% DROPS
homatropine hbr
1
ISOPTO HYOSCINE 0.25% DROPS
scopolamine hydrobromide
1
lidocaine hcl 2 % jel (ml)
1
lidocaine hcl 2 % jel/pf app
1
lidocaine hcl 2 % solution
1
lidocaine hcl 4 % solution
1
PAGE 195
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
lidocaine hcl 40 mg/ml solution
1
MYDRAL 0.5% EYE DROPS
tropicamide
1
MYDRAL 1% EYE DROPS
tropicamide
1
MYOXIN OTIC SUSPENSION
chloroxylenol/benzocaine/hydrocortisone acetate
1
naphazoline hcl 0.1 % drops
1
NEOFRIN 10% EYE DROPS
phenylephrine hcl
1
NEOFRIN 2.5% EYE DROPS
phenylephrine hcl
1
NUMOISYN LOZENGE
sorbitol/saliva stimulant comb no. 1/malic acid/cal phos
1
olopatadine hcl 0.6 % spray/pump
1
OTICIN DROPS
chloroxylenol/pramoxine hcl
1
PARCAINE 0.5% EYE DROPS
proparacaine hcl
1
phenylephrine hcl 10 % drops
1
phenylephrine hcl 2.5 % drops
1
PRAMOXINE-HC OTIC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
1
PRE-ATTACHED LTA KIT
lidocaine hcl
1
PRO DNA COLLECTION KIT
lidocaine hcl/glycerin
1
proparacaine hcl 0.5 % drops
1
proparacaine/fluorescein sod 0.5%-0.25% drops
1
TETCAINE 0.5% EYE DROPS
tetracaine hcl
1
tetracaine hcl 0.5 % drops
1
tetracaine hcl/pf 0.5 % drops
1
TREAGAN OTIC DROPS
acetic acid/antipyrine/benzocaine/policosanol no.1/al acetat
1
tropicamide 0.5 % drops
1
PAGE 196
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
tropicamide 1 % drops
TIER
LIMITS & RESTRICTIONS
1
GASTROINTESTINAL DRUGS
ANTIEMETICS
COMPRO 25 MG SUPPOSITORY
prochlorperazine
1
granisetron hcl 1 mg tablet
1
GRANISOL 2 MG/10 ML SOLUTION
granisetron hcl
1
meclizine hcl 12.5 mg tablet
1
meclizine hcl 25 mg tablet
1
ondansetron 4 mg tab rapdis
1
ondansetron 8 mg tab rapdis
1
ondansetron hcl 24 mg tablet
1
ondansetron hcl 4 mg tablet
1
ondansetron hcl 4 mg/5 ml solution
1
ondansetron hcl 8 mg tablet
1
PHENADOZ 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENADOZ 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 50 MG SUPPOSITORY
promethazine hcl
1
prochlorperazine 25 mg supp.rect
1
prochlorperazine maleate 10 mg tablet
1
prochlorperazine maleate 5 mg tablet
1
promethazine hcl 12.5 mg supp.rect
1
promethazine hcl 12.5 mg tablet
1
promethazine hcl 25 mg supp.rect
1
promethazine hcl 25 mg tablet
1
promethazine hcl 50 mg supp.rect
1
PAGE 197
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
promethazine hcl 50 mg tablet
1
promethazine hcl 6.25mg/5ml syrup
1
PROMETHEGAN 12.5 MG SUPPOS
promethazine hcl
1
PROMETHEGAN 25 MG SUPP
promethazine hcl
1
PROMETHEGAN 50 MG SUPPOSITORY
promethazine hcl
1
trimethobenzamide hcl 300 mg capsule
1
LIMITS & RESTRICTIONS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
amoxicillin 125 mg tab chew
1
amoxicillin 125 mg/5ml susp recon
1
amoxicillin 200 mg/5ml susp recon
1
amoxicillin 250 mg capsule
1
amoxicillin 250 mg tab chew
1
amoxicillin 250 mg/5ml susp recon
1
amoxicillin 400 mg/5ml susp recon
1
amoxicillin 500 mg capsule
1
amoxicillin 500 mg tablet
1
amoxicillin 875 mg tablet
1
CARAFATE 1 GM/10 ML SUSP
sucralfate
1
cimetidine 200 mg tablet
1
cimetidine 300 mg tablet
1
cimetidine 400 mg tablet
1
cimetidine 800 mg tablet
1
cimetidine hcl 300 mg/5ml solution
1
clarithromycin 125 mg/5ml susp recon
1
clarithromycin 250 mg tablet
1
clarithromycin 250 mg/5ml susp recon
1
clarithromycin 500 mg tab er 24h
1
clarithromycin 500 mg tablet
1
famotidine 20 mg tablet
1
PAGE 198
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
famotidine 40 mg tablet
1
lansoprazole 15 mg capsule dr
1
lansoprazole 30 mg capsule dr
1
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg
1
metronidazole 250 mg tablet
1
metronidazole 375 mg capsule
1
metronidazole 500 mg tablet
1
misoprostol 100 mcg tablet
1
misoprostol 200 mcg tablet
1
nizatidine 150 mg capsule
1
nizatidine 150mg/10ml solution
1
nizatidine 300 mg capsule
1
rabeprazole sodium 20 mg tablet dr
1
ranitidine hcl 15 mg/ml syrup
1
ranitidine hcl 150 mg capsule
1
ranitidine hcl 150 mg tablet
1
ranitidine hcl 300 mg capsule
1
ranitidine hcl 300 mg tablet
1
sucralfate 1 g tablet
1
tetracycline hcl 250 mg capsule
1
tetracycline hcl 500 mg capsule
1
alosetron hcl 0.5 mg tablet
1
QL
60 / 30 days
alosetron hcl 1 mg tablet
1
QL
60 / 30 days
APRISO ER 0.375 GRAM CAPSULE
mesalamine
1
ASACOL EC 400 MG TABLET
mesalamine
1
ASACOL HD DR 800 MG TABLET
mesalamine
1
balsalazide disodium 750 mg capsule
1
CANASA 1,000 MG SUPPOSITORY
mesalamine
1
PAGE 199
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
CREON DR 12,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 24,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 3,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 36,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 6,000 UNITS CAPSULE
lipase/protease/amylase
1
DELZICOL DR 400 MG CAPSULE
mesalamine
1
diphenoxylate hcl/atropine 2.5-.025/5 liquid
1
diphenoxylate hcl/atropine 2.5-.025mg tablet
1
FE 90 PLUS TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
FERRAPLUS 90 TABLET
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
1
FOCALGIN 90 DHA COMBO PACK
prenatal vitamins no.72/iron carbonyl & gluconate/fa/dss/dha
1
FOCALGIN CA COMBO PACK
prenatal vitamins no.73/iron carbonyl & gluconate/fa/dss/dha
1
FOLIVANE-PRX DHA NF CAPSULE
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
GAVILYTE-C SOLUTION
peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl
1
GAVILYTE-G SOLUTION
peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl
1
GAVILYTE-H AND BISACODYL KIT
bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350
1
GAVILYTE-N SOLUTION
sodium chloride/sodium bicarbonate/potassium chloride/peg
1
HUMIRA 10 MG/0.2 ML SYRINGE
adalimumab
1
PA
HUMIRA 20 MG/0.4 ML SYRINGE
adalimumab
1
PA
HUMIRA 40 MG/0.8 ML PEN
adalimumab
1
PA
PAGE 200
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
HUMIRA 40 MG/0.8 ML SYRINGE
adalimumab
1
PA
HUMIRA CROHN'S STARTER PACK
adalimumab
1
PA
HUMIRA PSORIASIS STARTER PACK
adalimumab
1
PA
hydrochloric acid 37 % liquid
1
INATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
INATAL GT TABLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
INATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
INFANATE PLUS SOFTGEL
prenatal vitamins no.59/iron carbonyl & fumarate/fa/dss/dha
1
ipecac syrup
1
lactobacillus plantarum 10b unit/g granules
1
LIALDA DR 1.2 GM TABLET
mesalamine
1
loperamide hcl 2 mg capsule
1
MACNATAL CN DHA SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
mesalamine 4 g/60 ml enema
1
mesalamine w/cleansing wipes 4 g/60 ml enema kit
1
metoclopramide hcl 10 mg tablet
1
metoclopramide hcl 10 mg/10ml solution
1
metoclopramide hcl 5 mg tab rapdis
1
metoclopramide hcl 5 mg tablet
1
metoclopramide hcl 5 mg/5 ml solution
1
MYNATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
MYNATAL ULTRACAPLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
MYNATE 90 PLUS CAPLET SA
prenatal vitamins with calcium/ferrous fumarate/docusate/fa
1
NATALVIRT 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PAGE 201
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NATALVIRT CA COMBO PACK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
NATALVIRT FLT TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
octreotide acetate 100 mcg/ml ampul
1
octreotide acetate 100 mcg/ml syringe
1
octreotide acetate 100 mcg/ml vial
1
octreotide acetate 1000mcg/ml vial
1
octreotide acetate 200 mcg/ml vial
1
octreotide acetate 50 mcg/ml ampul
1
octreotide acetate 50 mcg/ml syringe
1
octreotide acetate 50 mcg/ml vial
1
octreotide acetate 500 mcg/ml ampul
1
octreotide acetate 500 mcg/ml syringe
1
octreotide acetate 500 mcg/ml vial
1
opium tincture 10 mg/ml tincture
1
PANCREAZE DR 10,500 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 16,800 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 21,000 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 4,200 UNIT CAP
lipase/protease/amylase
1
PANCRELIPASE DR 5,000 UNIT CAP
lipase/protease/amylase
1
paregoric 2 mg/5 ml liquid
1
peg 3350/na sulf,bicarb,cl/kcl 236-22.74g soln recon
1
peg 3350/na sulf,bicarb,cl/kcl 240-22.72g soln recon
1
PEG-PREP KIT
bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350
1
PENTASA 250 MG CAPSULE
mesalamine
1
PENTASA 500 MG CAPSULE
mesalamine
1
PAGE 202
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PNV OB+DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
1
polyethylene glycol 3350 17g powd pack
1
polyethylene glycol 3350 17g/dose powder
1
PRENAISSANCE 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PRENAISSANCE CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
PRENAISSANCE DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
PRENAISSANCE PLUS SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
PRENAISSANCE PROMISE COMBO PCK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
1
SE-NATAL 19 TABLET
prenatal vitamins comb no.119/iron fumarate/folic acid/dss
1
sodium chloride/nahco3/kcl/peg 420g soln recon
1
sorbitol solution 70 % solution
1
sulfasalazine 500 mg tablet
1
sulfasalazine 500 mg tablet dr
1
SULFAZINE 500 MG TABLET
sulfasalazine
1
SULFAZINE EC 500 MG TAB
sulfasalazine
1
TARON-PREX PRENATAL DHA CAP
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
TL-CARE DHA SOFTGEL
pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa
1
TL-HEM 150 CAPLET
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
1
TL-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
TRI RX TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
TRIADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
PAGE 203
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRILYTE WITH FLAVOR PACKETS
sodium chloride/sodium bicarbonate/potassium chloride/peg
1
TRINATAL GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
TRINATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
ursodiol 250 mg tablet
1
ursodiol 300 mg capsule
1
ursodiol 500 mg tablet
1
VINACAL PRENATAL TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
VINATE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VINATE PN CARE TABLET
prenatal vits with calcium #7/fe asp gly/docusate/folic acid
1
VINATE ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
VIOKASE 16 TABLET
lipase/protease/amylase
1
VIOKASE 8 TABLET
lipase/protease/amylase
1
VIRT-ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
VIRT-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
VIRT-VITE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VP-CH PLUS SOFTGEL
prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha
1
ZATEAN-CH CAPSULE
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
ZENPEP DR 10,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 15,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 20,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 25,000 UNITS CAPSULE
lipase/protease/amylase
1
PAGE 204
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ZENPEP DR 3,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 40,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 5,000 UNITS CAPSULE
lipase/protease/amylase
1
LIMITS & RESTRICTIONS
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
acarbose 100 mg tablet
1
acarbose 25 mg tablet
1
acarbose 50 mg tablet
1
APIDRA 100 UNITS/ML VIAL
insulin glulisine
1
APIDRA SOLOSTAR 100 UNITS/ML
insulin glulisine
1
chlorpropamide 100 mg tablet
1
chlorpropamide 250 mg tablet
1
glimepiride 1 mg tablet
1
glimepiride 2 mg tablet
1
glimepiride 4 mg tablet
1
glipizide 10 mg tab er 24
1
glipizide 10 mg tablet
1
glipizide 2.5 mg tab er 24
QL
60 / 30 days
1
QL
30 / 30 days
glipizide 5 mg tab er 24
1
QL
30 / 30 days
glipizide 5 mg tablet
1
glipizide/metformin hcl 2.5-250 mg tablet
1
glipizide/metformin hcl 2.5-500 mg tablet
1
glipizide/metformin hcl 5 mg-500mg tablet
1
glyburide 1.25 mg tablet
1
glyburide 2.5 mg tablet
1
glyburide 5 mg tablet
1
glyburide,micronized 1.5 mg tablet
1
QL
30 / 30 days
PAGE 205
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
glyburide,micronized 3 mg tablet
1
QL
30 / 30 days
glyburide,micronized 6 mg tablet
1
QL
60 / 30 days
glyburide/metformin hcl 1.25-250mg tablet
1
QL
60 / 30 days
glyburide/metformin hcl 2.5-500 mg tablet
1
QL
120 / 30 days
glyburide/metformin hcl 5 mg-500mg tablet
1
QL
120 / 30 days
HUMALOG 100 UNITS/ML CARTRIDGE
insulin lispro
1
HUMALOG 100 UNITS/ML KWIKPEN
insulin lispro
1
HUMALOG 100 UNITS/ML VIAL
insulin lispro
1
HUMALOG MIX 50-50 KWIKPEN
insulin lispro protamine & insulin lispro
1
HUMALOG MIX 50-50 VIAL
insulin lispro protamine & insulin lispro
1
HUMALOG MIX 75-25 KWIKPEN
insulin lispro protamine & insulin lispro
1
HUMALOG MIX 75-25 VIAL
insulin lispro protamine & insulin lispro
1
HUMULIN R 500 UNITS/ML VIAL
insulin regular, human
1
LANTUS 100 UNITS/ML VIAL
insulin glargine,human recombinant analog
1
LANTUS SOLOSTAR 100 UNITS/ML
insulin glargine,human recombinant analog
1
metformin hcl 1000 mg tab er 24
1
QL
60 / 30 days
metformin hcl 1000 mg tablet
1
metformin hcl 500 mg tab er 24
1
QL
150 / 30 days
metformin hcl 500 mg tab er 24h
1
QL
120 / 30 days
metformin hcl 500 mg tablet
1
metformin hcl 750 mg tab er 24h
1
QL
60 / 30 days
metformin hcl 850 mg tablet
1
nateglinide 120 mg tablet
1
PAGE 206
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
nateglinide 60 mg tablet
1
NOVOLOG 100 UNIT/ML CARTRIDGE
insulin aspart
1
NOVOLOG 100 UNIT/ML VIAL
insulin aspart
1
NOVOLOG 100 UNITS/ML FLEXPEN
insulin aspart
1
NOVOLOG MIX 70-30 FLEXPEN SYRN
insulin aspart protamine human/insulin aspart
1
NOVOLOG MIX 70-30 VIAL
insulin aspart protamine human/insulin aspart
1
pioglitazone hcl 15 mg tablet
1
LIMITS & RESTRICTIONS
QL
30 / 30 days
ST
QL
pioglitazone hcl 30 mg tablet
30 / 30 days
1
ST
QL
pioglitazone hcl 45 mg tablet
30 / 30 days
1
ST
QL
pioglitazone hcl/glimepiride 30 mg-2 mg tablet
30 / 30 days
1
ST
QL
pioglitazone hcl/glimepiride 30 mg-4 mg tablet
30 / 30 days
1
ST
pioglitazone hcl/metformin hcl 15mg-500mg tablet
1
ST
pioglitazone hcl/metformin hcl 15mg-850mg tablet
1
ST
repaglinide 0.5 mg tablet
1
QL
120 / 30 days
repaglinide 1 mg tablet
1
QL
120 / 30 days
repaglinide 2 mg tablet
1
QL
240 / 30 days
tolazamide 250 mg tablet
1
tolazamide 500 mg tablet
1
tolbutamide 500 mg tablet
1
TRADJENTA 5 MG TABLET
linagliptin
1
QL
30 / 30 days
VICTOZA 2-PAK 18 MG/3 ML PEN
liraglutide
1
PA
PAGE 207
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
VICTOZA 3-PAK 18 MG/3 ML PEN
liraglutide
TIER
1
LIMITS & RESTRICTIONS
PA
ANTIHYPOGLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKIT
glucagon,human recombinant
1
GLUCAGEN 1 MG HYPOKIT 2-PACK
glucagon,human recombinant
1
GLUCAGEN DIAGNOSTIC 1 MG VIAL
glucagon,human recombinant
1
GLUCAGON 1 MG EMERGENCY KIT
glucagon,human recombinant
1
ESTROGENS AND ANTIESTROGENS
ALTAVERA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ALYACEN 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ALYACEN 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
AMETHIA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
AMETHIA LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
AMETHYST 90-20 MCG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
APRI 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ARANELLE 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ASHLYNA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
AUBRA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
AVIANE-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
AZURETTE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
BALZIVA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PAGE 208
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
BRIELLYN TABLET
norethindrone-ethinyl estradiol
1
GL
Female
CAMRESE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
CAMRESE LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
CAZIANT 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
CHATEAL-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
CRYSELLE-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
CYCLAFEM 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
CYCLAFEM 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
DASETTA 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
DASETTA 7/7/7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
DAYSEE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
DELYLA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
desog-e.estradiol/e.estradiol 21-5 tablet
1
GL
Female
desogestrel-ethinyl estradiol 0.15-0.03 tablet
1
GL
Female
ELINEST-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
EMOQUETTE 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ENPRESSE-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ENSKYCE 28 TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ESTARYLLA 0.25-0.035 MG TABLET
norgestimate-ethinyl estradiol
1
GL
Female
ESTRACE 0.01% CREAM
estradiol
1
GL
Female
PAGE 209
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ESTRACE 0.5 MG TABLET
estradiol
1
GL
Female
ESTRACE 1 MG TABLET
estradiol
1
GL
Female
ESTRACE 2 MG TABLET
estradiol
1
GL
Female
estradiol .025mg/24h patch tdsw
1
GL
Female
estradiol .025mg/24h patch tdwk
1
GL
Female
estradiol .0375mg/24 patch tdsw
1
GL
Female
estradiol .0375mg/24 patch tdwk
1
GL
Female
estradiol .075mg/24h patch tdsw
1
GL
Female
estradiol .075mg/24h patch tdwk
1
GL
Female
estradiol 0.05mg/24h patch tdsw
1
GL
Female
estradiol 0.05mg/24h patch tdwk
1
GL
Female
estradiol 0.06mg/24h patch tdwk
1
GL
Female
estradiol 0.1mg/24hr patch tdsw
1
GL
Female
estradiol 0.1mg/24hr patch tdwk
1
GL
Female
estradiol 0.5 mg tablet
1
GL
Female
estradiol 1 mg tablet
1
GL
Female
estradiol 2 mg tablet
1
GL
Female
estradiol/norethindrone acet 0.5-0.1mg tablet
1
GL
Female
estradiol/norethindrone acet 1 mg-0.5mg tablet
1
GL
Female
estropipate 0.75 mg tablet
1
GL
Female
estropipate 1.5 mg tablet
1
GL
Female
estropipate 3 mg tablet
1
GL
Female
ethinyl estradiol/drospirenone 0.03mg-3mg tablet
1
GL
Female
FALMINA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
FEMHRT 0.5 MG-2.5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
PAGE 210
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
GIANVI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
GILDAGIA 0.4 MG-0.035 MG TAB
norethindrone-ethinyl estradiol
1
GL
Female
GILDESS 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
GILDESS 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
GILDESS 24 FE 1-0.02 MG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
GILDESS FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
GILDESS FE 1.5-30 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
INTROVALE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
JEVANTIQUE 1 MG-5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
JINTELI 1 MG-5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JOLESSA 0.15 MG-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
JUNEL 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JUNEL 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JUNEL FE 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
JUNEL FE 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
KARIVA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
KELNOR 1-35 28 TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
KURVELO TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
l-norgest/e.estradion-e.estrad 100-20(84) tbdspk 3mo
1
GL
Female
LARIN 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
PAGE 211
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
LARIN 21 1-20 TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
LARIN FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LARIN FE 1.5-30 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LAYOLIS FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
LEENA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
LESSINA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
LEVONEST-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
levonorgestrel-ethin estradiol 0.1-0.02 tablet
1
GL
Female
levonorgestrel-ethin estradiol 0.15-0.03 tablet
1
GL
Female
levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo
1
GL
Female
levonorgestrel-ethin estradiol 90-20mcg tablet
1
GL
Female
LEVORA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
LO-OVRAL-28 TABLET
norgestrel-ethinyl estradiol
1
LOMEDIA 24 FE 1 MG-20 MCG TAB
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LORYNA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
LOW-OGESTREL-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
LUTERA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
MARLISSA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
MICROGESTIN 21 1-20 TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
MICROGESTIN 21 1.5-30 TAB
norethindrone acetate-ethinyl estradiol
1
GL
Female
MICROGESTIN FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
PAGE 212
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
MICROGESTIN FE 1.5-30 TAB
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
MIMVEY 1-0.5 MG TABLET
estradiol/norethindrone acetate
1
GL
Female
MIMVEY LO 0.5-0.1 MG TABLET
estradiol/norethindrone acetate
1
GL
Female
MONO-LINYAH 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
MONONESSA 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
MYZILRA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
NECON 0.5-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 1-50-28 TABLET
norethindrone-mestranol
1
GL
Female
NECON 10-11-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NIKKI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
NORDETTE-28 TABLET
levonorgestrel-ethinyl estradiol
1
noreth-ethinyl estradiol/iron 0.4-35(21) tab chew
1
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew
1
GL
Female
norethindrone ac-eth estradiol 0.5mg-2.5 tablet
1
GL
Female
norethindrone ac-eth estradiol 1mg-20mcg tablet
1
GL
Female
norethindrone ac-eth estradiol 1mg-5mcg tablet
1
GL
Female
norethindrone-e.estradiol-iron 1mg-20(21) tablet
1
GL
Female
norethindrone-e.estradiol-iron 1mg-20(24) tablet
1
GL
Female
norgestimate-ethinyl estradiol 0.25-0.035 tablet
1
GL
Female
norgestimate-ethinyl estradiol 7daysx3 28 tablet
1
GL
Female
PAGE 213
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
norgestrel-ethinyl estradiol 0.3-0.03mg tablet
1
NORTREL 0.5-35 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NORTREL 1-35 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NORTREL 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NUVARING VAGINAL RING
etonogestrel/ethinyl estradiol
1
OCELLA 3 MG-0.03 MG TABLET
ethinyl estradiol/drospirenone
ST
GL
Female
1
GL
Female
OGESTREL TABLET
norgestrel-ethinyl estradiol
1
GL
Female
ORSYTHIA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ORTHO TRI-CYCLEN 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
ORTHO TRI-CYCLEN LO TABLET
norgestimate-ethinyl estradiol
1
GL
Female
PHILITH 0.4-0.035 MG TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PIMTREA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
PIRMELLA 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PIRMELLA 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PORTIA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
PREMARIN 0.3 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.45 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.625 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.9 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 1.25 MG TABLET
estrogens, conjugated
1
GL
Female
PAGE 214
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PREMARIN VAGINAL CREAM-APPL
estrogens, conjugated
1
GL
Female
PREMPHASE 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.3 MG-1.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.45-1.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.625-2.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREVIFEM TABLET
norgestimate-ethinyl estradiol
1
GL
Female
QUASENSE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
raloxifene hcl 60 mg tablet
1
QL
30 / 30 days
RECLIPSEN 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
SEASONIQUE 0.15-0.03-0.01 TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
SPRINTEC 28 DAY TABLET
norgestimate-ethinyl estradiol
1
GL
Female
SRONYX 0.10-0.02 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
SYEDA 28 TABLET
ethinyl estradiol/drospirenone
1
GL
Female
tamoxifen citrate 10 mg tablet
1
tamoxifen citrate 20 mg tablet
1
TARINA FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TILIA FE 28 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TRI-ESTARYLLA TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRI-LEGEST FE-28 DAY TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TRI-LINYAH TABLET
norgestimate-ethinyl estradiol
1
GL
Female
PAGE 215
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
TRI-PREVIFEM TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRI-SPRINTEC TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRINESSA TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRIVORA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
VELIVET 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
VESTURA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
VIORELE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
VYFEMLA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
WERA 0.5/0.035 MG 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
WYMZYA FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
XULANE PATCH
norelgestromin/ethinyl estradiol
1
ZARAH TABLET
ethinyl estradiol/drospirenone
ST
GL
Female
1
GL
Female
ZENCHENT 0.4 MG-35 MCG TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ZENCHENT FE TABLET CHEWABLE
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
ZEOSA CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
ZOVIA 1-35E TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
ZOVIA 1-50E TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
ADVAIR 100-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 250-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
PAGE 216
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ADVAIR 500-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 115-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 230-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 45-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ALTAVERA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ALYACEN 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ALYACEN 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
AMETHIA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
AMETHIA LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
AMETHYST 90-20 MCG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ANDROGEL 1% GEL PUMP
testosterone
1
PA
ANDROGEL 1%(2.5G) GEL PACKET
testosterone
1
PA
ANDROGEL 1%(5G) GEL PACKET
testosterone
1
PA
ANDROGEL 1.62% GEL PUMP
testosterone
1
PA
ANDROGEL 1.62%(1.25G) GEL PCKT
testosterone
1
PA
ANDROGEL 1.62%(2.5G) GEL PCKT
testosterone
1
PA
ANDROXY 10 MG TABLET
fluoxymesterone
1
APRI 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ARANELLE 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ASHLYNA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
PAGE 217
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
AUBRA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
AVIANE-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
AZURETTE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
BALZIVA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
BRIELLYN TABLET
norethindrone-ethinyl estradiol
1
GL
Female
budesonide 0.25mg/2ml ampul-neb
1
PA
AL
Up to 8 yrs old
PA
budesonide 0.5 mg/2ml ampul-neb
1
AL
Up to 8 yrs old
calcitonin,salmon,synthetic 200/spray spray/pump
1
QL
4 / 30 days
CAMILA TABLET
norethindrone
1
GL
Female
CAMRESE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
CAMRESE LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
CAZIANT 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
CHATEAL-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
cortisone acetate 25 mg tablet
1
CRYSELLE-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
CYCLAFEM 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
CYCLAFEM 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
danazol 100 mg capsule
1
danazol 200 mg capsule
1
danazol 50 mg capsule
1
DASETTA 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PAGE 218
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
DASETTA 7/7/7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
DAYSEE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
DEBLITANE 0.35 MG TABLET
norethindrone
1
GL
Female
DELYLA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
DEPO-PROVERA 400 MG/ML VIAL
medroxyprogesterone acetate
1
desmopressin (nonrefrigerated) 10/spray spray/pump
1
desmopressin acetate 0.1 mg tablet
1
desmopressin acetate 0.1 mg/ml solution
1
desmopressin acetate 0.2 mg tablet
1
desmopressin acetate 10/spray spray/pump
1
desog-e.estradiol/e.estradiol 21-5 tablet
1
GL
Female
desogestrel-ethinyl estradiol 0.15-0.03 tablet
1
GL
Female
dexamethasone 0.5 mg tablet
1
dexamethasone 0.5 mg/5ml elixir
1
dexamethasone 0.5 mg/5ml solution
1
dexamethasone 0.75 mg tablet
1
dexamethasone 1 mg tablet
1
dexamethasone 1.5 mg tablet
1
dexamethasone 2 mg tablet
1
dexamethasone 4 mg tablet
1
dexamethasone 6 mg tablet
1
DEXAMETHASONE INTENSOL 1MG/1ML
dexamethasone
1
ELINEST-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
EMOQUETTE 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ENPRESSE-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
PAGE 219
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ENSKYCE 28 TABLET
desogestrel-ethinyl estradiol
1
GL
Female
ERRIN 0.35 MG TABLET
norethindrone
1
GL
Female
ESTARYLLA 0.25-0.035 MG TABLET
norgestimate-ethinyl estradiol
1
GL
Female
estradiol/norethindrone acet 0.5-0.1mg tablet
1
GL
Female
estradiol/norethindrone acet 1 mg-0.5mg tablet
1
GL
Female
ethinyl estradiol/drospirenone 0.03mg-3mg tablet
1
GL
Female
FALMINA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
FEMHRT 0.5 MG-2.5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
FLOVENT HFA 110 MCG INHALER
fluticasone propionate
1
FLOVENT HFA 220 MCG INHALER
fluticasone propionate
1
FLOVENT HFA 44 MCG INHALER
fluticasone propionate
1
fludrocortisone acetate 0.1 mg tablet
1
flunisolide 25 mcg spray
1
flunisolide 29mcg spray
1
fluticasone propionate 50 mcg spray susp
1
FORTICAL 200 UNITS NASAL SPRAY
calcitonin,salmon,synthetic
1
QL
4 / 30 days
GIANVI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
GILDAGIA 0.4 MG-0.035 MG TAB
norethindrone-ethinyl estradiol
1
GL
Female
GILDESS 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
GILDESS 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
GILDESS 24 FE 1-0.02 MG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
GILDESS FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
PAGE 220
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
GILDESS FE 1.5-30 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
HEATHER TABLET
norethindrone
1
GL
Female
hydrocortisone 10 mg tablet
1
hydrocortisone 20 mg tablet
1
hydrocortisone 5 mg tablet
1
INTROVALE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
JENCYCLA 0.35 MG TABLET
norethindrone
1
GL
Female
JEVANTIQUE 1 MG-5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
JINTELI 1 MG-5 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JOLESSA 0.15 MG-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
JOLIVETTE TABLET
norethindrone
1
GL
Female
JUNEL 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JUNEL 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
JUNEL FE 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
JUNEL FE 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
JUNEL FE 24 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
KARIVA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
KELNOR 1-35 28 TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
KIMIDESS 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
KURVELO TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
l-norgest/e.estradion-e.estrad 100-20(84) tbdspk 3mo
1
GL
Female
PAGE 221
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
l-norgest/e.estradion-e.estrad 150-30(84) tbdspk 3mo
1
GL
Female
LARIN 1.5 MG-30 MCG TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
LARIN 21 1-20 TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
LARIN 24 FE 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LARIN FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LARIN FE 1.5-30 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LAYOLIS FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
LEENA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
LESSINA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
leuprolide acetate 1 mg/0.2ml kit
1
LEVONEST-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
QL
levonorgestrel 0.75 mg tablet
2 / 90 days
1
GL
Female
QL
1 / 90 days
GL
Female
levonorgestrel 1.5 mg tablet
1
levonorgestrel-ethin estradiol 0.1-0.02 tablet
1
GL
Female
levonorgestrel-ethin estradiol 0.15-0.03 tablet
1
GL
Female
levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo
1
GL
Female
levonorgestrel-ethin estradiol 90-20mcg tablet
1
GL
Female
LEVORA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
LO-OVRAL-28 TABLET
norgestrel-ethinyl estradiol
1
LOMEDIA 24 FE 1 MG-20 MCG TAB
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
LORYNA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
PAGE 222
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
LOW-OGESTREL-28 TABLET
norgestrel-ethinyl estradiol
1
GL
Female
LUTERA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
LYZA 0.35 MG TABLET
norethindrone
1
GL
Female
MARLISSA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
medroxyprogesterone acetate 10 mg tablet
1
medroxyprogesterone acetate 150 mg/ml syringe
1
GL
Female
medroxyprogesterone acetate 150 mg/ml vial
1
GL
Female
medroxyprogesterone acetate 2.5 mg tablet
1
medroxyprogesterone acetate 5 mg tablet
1
megestrol acetate 20 mg tablet
1
megestrol acetate 40 mg tablet
1
megestrol acetate 400mg/10ml oral susp
1
megestrol acetate 800mg/20ml oral susp
1
methylprednisolone 16 mg tablet
1
methylprednisolone 32 mg tablet
1
methylprednisolone 4 mg tab ds pk
1
methylprednisolone 4 mg tablet
1
methylprednisolone 8 mg tablet
1
MICROGESTIN 21 1-20 TABLET
norethindrone acetate-ethinyl estradiol
1
GL
Female
MICROGESTIN 21 1.5-30 TAB
norethindrone acetate-ethinyl estradiol
1
GL
Female
MICROGESTIN FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
MICROGESTIN FE 1.5-30 TAB
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
MILLIPRED 10 MG/5 ML SOLUTION
prednisolone sod phosphate
1
MILLIPRED 5 MG TABLET
prednisolone
1
MILLIPRED DP 5 MG 12-DAY PACK
prednisolone
1
PAGE 223
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
MILLIPRED DP 5 MG 6-DAY PACK
prednisolone
1
MIMVEY 1-0.5 MG TABLET
estradiol/norethindrone acetate
1
GL
Female
MIMVEY LO 0.5-0.1 MG TABLET
estradiol/norethindrone acetate
1
GL
Female
MONO-LINYAH 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
MONONESSA 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
MY WAY 1.5 MG TABLET
levonorgestrel
1
MYZILRA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
NECON 0.5-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 1-50-28 TABLET
norethindrone-mestranol
1
GL
Female
NECON 10-11-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NECON 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NEXT CHOICE 0.75 MG TABLET
levonorgestrel
1
NEXT CHOICE ONE DOSE 1.5 MG TB
levonorgestrel
1
NIKKI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
NORA-BE TABLET
norethindrone
1
GL
Female
NORDETTE-28 TABLET
levonorgestrel-ethinyl estradiol
1
noreth-ethinyl estradiol/iron 0.4-35(21) tab chew
1
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew
1
GL
Female
norethindrone 0.35 mg tablet
1
GL
Female
PAGE 224
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
norethindrone ac-eth estradiol 0.5mg-2.5 tablet
1
GL
Female
norethindrone ac-eth estradiol 1mg-20mcg tablet
1
GL
Female
norethindrone ac-eth estradiol 1mg-5mcg tablet
1
GL
Female
norethindrone acetate 5 mg tablet
1
norethindrone-e.estradiol-iron 1mg-20(21) tablet
1
GL
Female
norethindrone-e.estradiol-iron 1mg-20(24) tablet
1
GL
Female
norgestimate-ethinyl estradiol 0.25-0.035 tablet
1
GL
Female
norgestimate-ethinyl estradiol 7daysx3 28 tablet
1
GL
Female
norgestrel-ethinyl estradiol 0.3-0.03mg tablet
1
NORLYROC 0.35 MG TABLET
norethindrone
1
GL
Female
NORTREL 0.5-35 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NORTREL 1-35 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NORTREL 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
NUVARING VAGINAL RING
etonogestrel/ethinyl estradiol
1
OCELLA 3 MG-0.03 MG TABLET
ethinyl estradiol/drospirenone
ST
GL
Female
1
GL
Female
OGESTREL TABLET
norgestrel-ethinyl estradiol
1
GL
Female
ORSYTHIA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
ORTHO TRI-CYCLEN 28 TABLET
norgestimate-ethinyl estradiol
1
GL
Female
ORTHO TRI-CYCLEN LO TABLET
norgestimate-ethinyl estradiol
1
GL
Female
oxandrolone 10 mg tablet
1
oxandrolone 2.5 mg tablet
1
PHILITH 0.4-0.035 MG TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PIMTREA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
PAGE 225
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PIRMELLA 1-35-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PIRMELLA 7-7-7-28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
PORTIA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
prednisolone 15 mg/5 ml solution
1
prednisolone sod phosphate 10 mg tab rapdis
1
prednisolone sod phosphate 15 mg tab rapdis
1
prednisolone sod phosphate 15 mg/5 ml solution
1
prednisolone sod phosphate 25 mg/5 ml solution
1
prednisolone sod phosphate 30 mg tab rapdis
1
prednisolone sod phosphate 5 mg/5 ml solution
1
prednisone 1 mg tablet
1
prednisone 10 mg tab ds pk
1
prednisone 10 mg tablet
1
prednisone 2.5 mg tablet
1
prednisone 20 mg tablet
1
prednisone 5 mg tab ds pk
1
prednisone 5 mg tablet
1
prednisone 5 mg/5 ml solution
1
PREDNISONE 5 MG/ML SOLUTION
prednisone
1
prednisone 50 mg tablet
1
PREMPHASE 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.3 MG-1.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.45-1.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.625-2.5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
GL
Female
PREMPRO 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
1
PREVIFEM TABLET
norgestimate-ethinyl estradiol
1
GL
Female
PAGE 226
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
progesterone,micronized 100 mg capsule
1
progesterone,micronized 200 mg capsule
1
PROVERA 10 MG TABLET
medroxyprogesterone acetate
1
PROVERA 2.5 MG TABLET
medroxyprogesterone acetate
1
PROVERA 5 MG TABLET
medroxyprogesterone acetate
1
PULMICORT 1 MG/2 ML RESPULE
budesonide
1
PULMICORT 180 MCG FLEXHALER
budesonide
1
PULMICORT 90 MCG FLEXHALER
budesonide
1
QUASENSE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
1
QVAR 40 MCG ORAL INHALER
beclomethasone dipropionate
1
QVAR 80 MCG ORAL INHALER
beclomethasone dipropionate
1
RECLIPSEN 28 DAY TABLET
desogestrel-ethinyl estradiol
LIMITS & RESTRICTIONS
PA
AL
Up to 8 yrs old
GL
Female
1
GL
Female
SEASONIQUE 0.15-0.03-0.01 TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
1
GL
Female
SHAROBEL 0.35 MG TABLET
norethindrone
1
GL
Female
SPRINTEC 28 DAY TABLET
norgestimate-ethinyl estradiol
1
GL
Female
SRONYX 0.10-0.02 MG TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
SYEDA 28 TABLET
ethinyl estradiol/drospirenone
1
GL
Female
SYMBICORT 160-4.5 MCG INHALER
budesonide/formoterol fumarate
1
SYMBICORT 80-4.5 MCG INHALER
budesonide/formoterol fumarate
1
SYNAREL 2 MG/ML NASAL SPRAY
nafarelin acetate
1
PAGE 227
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
TARINA FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TILIA FE 28 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TRI-ESTARYLLA TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRI-LEGEST FE-28 DAY TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
1
GL
Female
TRI-LINYAH TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRI-PREVIFEM TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRI-SPRINTEC TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRINESSA TABLET
norgestimate-ethinyl estradiol
1
GL
Female
TRIVORA-28 TABLET
levonorgestrel-ethinyl estradiol
1
GL
Female
VELIVET 28 DAY TABLET
desogestrel-ethinyl estradiol
1
GL
Female
VERAMYST 27.5 MCG NASAL SPRAY
fluticasone furoate
1
AL
2 to 4 yrs old
VERIPRED 20 20 MG/5 ML SOLN
prednisolone sod phosphate
1
VESTURA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
1
GL
Female
VIORELE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
1
GL
Female
VYFEMLA 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
WERA 0.5/0.035 MG 28 TABLET
norethindrone-ethinyl estradiol
1
GL
Female
WYMZYA FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
XULANE PATCH
norelgestromin/ethinyl estradiol
1
ZARAH TABLET
ethinyl estradiol/drospirenone
1
PAGE 228
ST
GL
Female
GL
Female
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ZENCHENT 0.4 MG-35 MCG TABLET
norethindrone-ethinyl estradiol
1
GL
Female
ZENCHENT FE TABLET CHEWABLE
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
ZEOSA CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
1
GL
Female
ZOVIA 1-35E TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
ZOVIA 1-50E TABLET
ethynodiol diacetate-ethinyl estradiol
1
GL
Female
SOMATOSTATIN AGONISTS AND ANTAGONISTS
octreotide acetate 100 mcg/ml ampul
1
octreotide acetate 100 mcg/ml syringe
1
octreotide acetate 100 mcg/ml vial
1
octreotide acetate 1000mcg/ml vial
1
octreotide acetate 200 mcg/ml vial
1
octreotide acetate 50 mcg/ml ampul
1
octreotide acetate 50 mcg/ml syringe
1
octreotide acetate 50 mcg/ml vial
1
octreotide acetate 500 mcg/ml ampul
1
octreotide acetate 500 mcg/ml syringe
1
octreotide acetate 500 mcg/ml vial
1
THYROID AND ANTITHYROID AGENTS
ARMOUR THYROID 120 MG TABLET
thyroid,pork
1
ARMOUR THYROID 15 MG TABLET
thyroid,pork
1
ARMOUR THYROID 180 MG TABLET
thyroid,pork
1
ARMOUR THYROID 240 MG TABLET
thyroid,pork
1
ARMOUR THYROID 30 MG TABLET
thyroid,pork
1
ARMOUR THYROID 300 MG TABLET
thyroid,pork
1
PAGE 229
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ARMOUR THYROID 60 MG TABLET
thyroid,pork
1
ARMOUR THYROID 90 MG TABLET
thyroid,pork
1
LEVOTHROID 100 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 112 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 125 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 137 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 150 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 175 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 200 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 25 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 300 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 50 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 75 MCG TABLET
levothyroxine sodium
1
LEVOTHROID 88 MCG TABLET
levothyroxine sodium
1
levothyroxine sodium 100 mcg tablet
1
levothyroxine sodium 112 mcg tablet
1
levothyroxine sodium 125 mcg tablet
1
levothyroxine sodium 137 mcg tablet
1
levothyroxine sodium 150 mcg tablet
1
levothyroxine sodium 175mcg tablet
1
levothyroxine sodium 200 mcg tablet
1
levothyroxine sodium 25 mcg tablet
1
levothyroxine sodium 300 mcg tablet
1
PAGE 230
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
levothyroxine sodium 50 mcg tablet
1
levothyroxine sodium 75 mcg tablet
1
levothyroxine sodium 88 mcg tablet
1
LEVOXYL 100 MCG TABLET
levothyroxine sodium
1
LEVOXYL 112 MCG TABLET
levothyroxine sodium
1
LEVOXYL 125 MCG TABLET
levothyroxine sodium
1
LEVOXYL 137 MCG TABLET
levothyroxine sodium
1
LEVOXYL 150 MCG TABLET
levothyroxine sodium
1
LEVOXYL 175 MCG TABLET
levothyroxine sodium
1
LEVOXYL 200 MCG TABLET
levothyroxine sodium
1
LEVOXYL 25 MCG TABLET
levothyroxine sodium
1
LEVOXYL 50 MCG TABLET
levothyroxine sodium
1
LEVOXYL 75 MCG TABLET
levothyroxine sodium
1
LEVOXYL 88 MCG TABLET
levothyroxine sodium
1
liothyronine sodium 25 mcg tablet
1
liothyronine sodium 5 mcg tablet
1
liothyronine sodium 50 mcg tablet
1
LUGOL'S SOLUTION
potassium iodide/iodine
1
methimazole 10 mg tablet
1
methimazole 5 mg tablet
1
NATURE-THROID 113.75 MG TABLET
thyroid,pork
1
NATURE-THROID 130 MG TABLET
thyroid,pork
1
NATURE-THROID 146.25 MG TABLET
thyroid,pork
1
PAGE 231
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NATURE-THROID 16.25 MG TABLET
thyroid,pork
1
NATURE-THROID 162.5 MG TABLET
thyroid,pork
1
NATURE-THROID 195 MG TABLET
thyroid,pork
1
NATURE-THROID 260 MG TABLET
thyroid,pork
1
NATURE-THROID 32.5 MG TABLET
thyroid,pork
1
NATURE-THROID 325 MG TABLET
thyroid,pork
1
NATURE-THROID 48.75 MG TABLET
thyroid,pork
1
NATURE-THROID 65 MG TABLET
thyroid,pork
1
NATURE-THROID 81.25 MG TABLET
thyroid,pork
1
NATURE-THROID 97.5 MG TABLET
thyroid,pork
1
NP THYROID 30 MG TABLET
thyroid,pork
1
NP THYROID 60 MG TABLET
thyroid,pork
1
NP THYROID 90 MG TABLET
thyroid,pork
1
potassium iodide granules
1
potassium iodide 100 % crystals
1
potassium iodide/iodine 5 % solution
1
propylthiouracil 50 mg tablet
1
UNITHROID 100 MCG TABLET
levothyroxine sodium
1
UNITHROID 112 MCG TABLET
levothyroxine sodium
1
UNITHROID 125 MCG TABLET
levothyroxine sodium
1
UNITHROID 137 MCG TABLET
levothyroxine sodium
1
PAGE 232
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
UNITHROID 150 MCG TABLET
levothyroxine sodium
1
UNITHROID 175 MCG TABLET
levothyroxine sodium
1
UNITHROID 200 MCG TABLET
levothyroxine sodium
1
UNITHROID 25 MCG TABLET
levothyroxine sodium
1
UNITHROID 300 MCG TABLET
levothyroxine sodium
1
UNITHROID 50 MCG TABLET
levothyroxine sodium
1
UNITHROID 75 MCG TABLET
levothyroxine sodium
1
UNITHROID 88 MCG TABLET
levothyroxine sodium
1
WESTHROID 113.75 MG TABLET
thyroid,pork
1
WESTHROID 130 MG TABLET
thyroid,pork
1
WESTHROID 146.25 MG TABLET
thyroid,pork
1
WESTHROID 16.25 MG TABLET
thyroid,pork
1
WESTHROID 162.5 MG TABLET
thyroid,pork
1
WESTHROID 195 MG TABLET
thyroid,pork
1
WESTHROID 260 MG TABLET
thyroid,pork
1
WESTHROID 32.5 MG TABLET
thyroid,pork
1
WESTHROID 325 MG TABLET
thyroid,pork
1
WESTHROID 48.75 MG TABLET
thyroid,pork
1
WESTHROID 65 MG TABLET
thyroid,pork
1
WESTHROID 81.25 MG TABLET
thyroid,pork
1
PAGE 233
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
WESTHROID 97.5 MG TABLET
thyroid,pork
1
WESTHROID-P 130 MG TABLET
thyroid,pork
1
WESTHROID-P 32.5 MG TABLET
thyroid,pork
1
WESTHROID-P 65 MG TABLET
thyroid,pork
1
WP THYROID 130 MG TABLET
thyroid,pork
1
WP THYROID 32.5 MG TABLET
thyroid,pork
1
WP THYROID 65 MG TABLET
thyroid,pork
1
WP THYROID 81.25 MG TABLET
thyroid,pork
1
LIMITS & RESTRICTIONS
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine 100 mg/ml vial
1
acetylcysteine 200 mg/ml vial
1
ACTIMMUNE 100 MCG/0.5 ML VIAL
interferon gamma-1b,recomb.
1
alendronate sodium 10 mg tablet
1
alendronate sodium 35 mg tablet
1
alendronate sodium 40 mg tablet
1
alendronate sodium 5 mg tablet
1
alendronate sodium 70 mg tablet
1
alendronate sodium 70 mg/75ml solution
1
ALFERON N 5 MILLION UNITS VIAL
interferon alfa-n3
1
allopurinol 100 mg tablet
1
allopurinol 300 mg tablet
1
AP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
ASTAGRAF XL 0.5 MG CAPSULE
tacrolimus
1
ASTAGRAF XL 1 MG CAPSULE
tacrolimus
1
PAGE 234
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ASTAGRAF XL 5 MG CAPSULE
tacrolimus
1
AVONEX ADMIN PACK 30 MCG VL
interferon beta-1a/albumin human
1
QL
4 / 30 days
AVONEX PREFILLED SYR 30 MCG
interferon beta-1a
1
QL
4 / 30 days
AVONEX PREFILLED SYR 30 MCG KT
interferon beta-1a
1
QL
4 / 30 days
AZASAN 100 MG TABLET
azathioprine
1
AZASAN 75 MG TABLET
azathioprine
1
azathioprine 50 mg tablet
1
azathioprine sodium 100 mg vial
1
b3/azel/quer/tur/fa/b6/zn/copp 700 mg-500 tablet
1
BAL-CARE DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
BETASERON 0.3 MG KIT
interferon beta-1b
1
QL
15 / 30 days
BP VIT 3 CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
BP VIT 3 PLUS CAPSULE
omega-3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol
1
C-NATE DHA SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
calcitonin,salmon,synthetic 200/spray spray/pump
1
QL
4 / 30 days
CALCIUM-PNV 28-1-250 MG SFTGL
prenatal vits with calcium #70/ferrous fumarate/fa/dha
1
CAVAN-ALPHA KIT COMBO PACK
prenatal vitamin no.67/sodium feredetate-iron poly/fa/omega3
1
CAVAN-EC SOD DHA VITAMINS
prenatal vitamins comb no.48/iron na feredetate/fa/omega-3
1
CELLCEPT 200 MG/ML ORAL SUSP
mycophenolate mofetil
1
CELLCEPT 250 MG CAPSULE
mycophenolate mofetil
1
CELLCEPT 500 MG TABLET
mycophenolate mofetil
1
PAGE 235
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CELLCEPT 500 MG VIAL
mycophenolate mofetil hcl
1
CHOICE-OB + DHA COMBO PACK
prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha
1
colchicine 0.6 mg capsule
1
colchicine 0.6 mg tablet
1
colchicine/probenecid 0.5-500mg tablet
1
COMPLETE NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
CUPRIMINE 250 MG CAPSULE
penicillamine
1
cyclophosphamide 25 mg capsule
1
cyclophosphamide 25 mg tablet
1
cyclophosphamide 50 mg capsule
1
cyclophosphamide 50 mg tablet
1
cyclosporine 100 mg capsule
1
cyclosporine 25 mg capsule
1
cyclosporine 250 mg/5ml ampul
1
cyclosporine 250 mg/5ml vial
1
cyclosporine, modified 100 mg capsule
1
cyclosporine, modified 100 mg/ml solution
1
cyclosporine, modified 25 mg capsule
1
cyclosporine, modified 50 mg capsule
1
DENTA 5000 PLUS CREAM
sodium fluoride
1
DENTAGEL 1.1% GEL
sodium fluoride
1
DEPADE 50 MG TABLET
naltrexone hcl
1
dimethyl sulfoxide 99 % vial
1
disulfiram 250 mg tablet
1
disulfiram 500 mg tablet
1
ELITE OB DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
PAGE 236
LIMITS & RESTRICTIONS
QL
60 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ELITE-OB 400 CAPSULE
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
ESTRACE 0.01% CREAM
estradiol
1
GL
Female
ESTRACE 0.5 MG TABLET
estradiol
1
GL
Female
ESTRACE 1 MG TABLET
estradiol
1
GL
Female
ESTRACE 2 MG TABLET
estradiol
1
GL
Female
estradiol .025mg/24h patch tdsw
1
GL
Female
estradiol .025mg/24h patch tdwk
1
GL
Female
estradiol .0375mg/24 patch tdsw
1
GL
Female
estradiol .0375mg/24 patch tdwk
1
GL
Female
estradiol .075mg/24h patch tdsw
1
GL
Female
estradiol .075mg/24h patch tdwk
1
GL
Female
estradiol 0.05mg/24h patch tdsw
1
GL
Female
estradiol 0.05mg/24h patch tdwk
1
GL
Female
estradiol 0.06mg/24h patch tdwk
1
GL
Female
estradiol 0.1mg/24hr patch tdsw
1
GL
Female
estradiol 0.1mg/24hr patch tdwk
1
GL
Female
estradiol 0.5 mg tablet
1
GL
Female
estradiol 1 mg tablet
1
GL
Female
estradiol 2 mg tablet
1
GL
Female
estropipate 0.75 mg tablet
1
GL
Female
estropipate 1.5 mg tablet
1
GL
Female
estropipate 3 mg tablet
1
GL
Female
etidronate disodium 200 mg tablet
1
QL
75 / 30 days
etidronate disodium 400 mg tablet
1
QL
150 / 30 days
PAGE 237
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
EVOTAZ 300 MG-150 MG TABLET
atazanavir sulfate/cobicistat
1
FERREX 150 FORTE PLUS CAPSULE
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
FERREX 28 TABLET
iron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
1
finasteride 1 mg tablet
1
finasteride 5 mg tablet
1
FLUOR-A-DAY 0.25 MG TAB CHEW
sodium fluoride/xylitol
1
FLUOR-A-DAY 0.5 MG TAB CHEW
sodium fluoride/xylitol
1
FLUOR-A-DAY 1 MG TABLET CHEW
sodium fluoride/xylitol
1
FLUOR-A-DAY 2.5 MG/ML DROPS
sodium fluoride
1
FLUORABON 0.25 MG/0.6 ML DROPS
sodium fluoride
1
fluoride/iron/vit a,c&d 0.25 mg/ml drops
1
FLUORIDEX DEFENSE 1.1% GEL
sodium fluoride
1
FLUORITAB 0.125 MG/DRP DROPS
sodium fluoride
1
FLUORITAB 0.5 MG TABLET CHEW
sodium fluoride
1
FLUORITAB 1 MG TABLET CHEW
sodium fluoride
1
FLURA-DROPS 0.25 MG/DROP
sodium fluoride
1
FOLIVANE-PRX DHA NF CAPSULE
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
FORTICAL 200 UNITS NASAL SPRAY
calcitonin,salmon,synthetic
1
GENGRAF 100 MG CAPSULE
cyclosporine, modified
1
GENGRAF 100 MG/ML SOLUTION
cyclosporine, modified
1
GENGRAF 25 MG CAPSULE
cyclosporine, modified
1
PAGE 238
LIMITS & RESTRICTIONS
QL
30 / 30 days
QL
4 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
GLUCAGEN 1 MG HYPOKIT
glucagon,human recombinant
1
GLUCAGEN 1 MG HYPOKIT 2-PACK
glucagon,human recombinant
1
GLUCAGEN DIAGNOSTIC 1 MG VIAL
glucagon,human recombinant
1
GLUCAGON 1 MG EMERGENCY KIT
glucagon,human recombinant
1
HECORIA 0.5 MG CAPSULE
tacrolimus
1
HECORIA 1 MG CAPSULE
tacrolimus
1
HECORIA 5 MG CAPSULE
tacrolimus
1
HUMIRA 10 MG/0.2 ML SYRINGE
adalimumab
1
PA
HUMIRA 20 MG/0.4 ML SYRINGE
adalimumab
1
PA
HUMIRA 40 MG/0.8 ML PEN
adalimumab
1
PA
HUMIRA 40 MG/0.8 ML SYRINGE
adalimumab
1
PA
HUMIRA CROHN'S STARTER PACK
adalimumab
1
PA
HUMIRA PSORIASIS STARTER PACK
adalimumab
1
PA
hydroxychloroquine sulfate 200 mg tablet
1
ibandronate sodium 150 mg tablet
1
IMURAN 50 MG TABLET
azathioprine
1
indomethacin 25 mg capsule
1
indomethacin 50 mg capsule
1
indomethacin 75 mg capsule er
1
INFANATE PLUS SOFTGEL
prenatal vitamins no.59/iron carbonyl & fumarate/fa/dss/dha
1
INTRON A 10 MILLION UNIT/ML
interferon alfa-2b,recomb.
1
PAGE 239
QL
1 / 30 days
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
INTRON A 10 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 18 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 50 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 6 MILLION UNIT/ML VL
interferon alfa-2b,recomb.
1
iron ag/c/b12/ca/suc.acid/stom 70-150-10 tablet
1
iron aspgly&ps/c/b12/fa/ca/suc 150-25-1 capsule
1
iron fum & ag/c/b12/fa/ca/succ 151-60-1mg tablet
1
KIONEX 15 GM/60 ML SUSPENSION
sodium polystyrene sulfonate
1
KIONEX POWDER
sodium polystyrene sulfonate
1
L-METHYLFOLATE FORTE 15 MG CAP
levomefolate calcium/schizochytrium algal oil
1
L-METHYLFOLATE FORTE 7.5 MG CP
levomefolate calcium/schizochytrium algal oil
1
L-METHYLFOLATE PNV DHA SOFTGEL
prenatal vit with calcium no42/iron fum/fa/l-mefolate ca/dha
1
leflunomide 10 mg tablet
1
leflunomide 20 mg tablet
1
leucovorin calcium 10 mg tablet
1
leucovorin calcium 15 mg tablet
1
leucovorin calcium 25 mg tablet
1
leucovorin calcium 5 mg tablet
1
levocarnitine (with sugar) 100 mg/ml solution
1
levocarnitine 330 mg tablet
1
levomefolate/algal oil 15-90.314 capsule
1
levomefolate/algal oil 7.5-90.314 capsule
1
lmfol ca/acetyl/mb12/algal oil 6-600-2 mg tablet
1
LOZI-FLUR 1 MG LOZENGE
sodium fluoride
1
LUDENT FLUORIDE 0.25 MG TB CHW
sodium fluoride
1
PAGE 240
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LUDENT FLUORIDE 0.5 MG TB CHEW
sodium fluoride
1
LUDENT FLUORIDE 1 MG TAB CHEW
sodium fluoride
1
LUGOL'S SOLUTION
potassium iodide/iodine
1
MACNATAL CN DHA SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
MARLEXATE POWDER
sodium polystyrene sulfonate
1
MEPHYTON 5 MG TABLET
phytonadione
1
mercaptopurine 50 mg tablet
1
METAFOLBIC PLUS RF CAPLET
levomefolate ca/acetylcysteine/mecobalamin/schiz. algal oil
1
methotrexate sodium 2.5 mg tablet
1
methotrexate sodium 25 mg/ml vial
1
MI-OMEGA NF CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
MULTIGEN CAPLET
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach
1
MULTIGEN FOLIC CAPLET
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
1
MULTIGEN PLUS CAPLET
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
multivitamins with fluoride 0.25 mg/ml drops
1
multivitamins with fluoride 0.5 mg/ml drops
1
multivits with iron & fluoride 0.25 mg/ml drops
1
multivits with iron & fluoride 0.5 mg/ml drops
1
MVC-FLUORIDE 0.25 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
MVC-FLUORIDE 0.5 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
MVC-FLUORIDE 1 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
mycophenolate mofetil 200 mg/ml susp recon
1
mycophenolate mofetil 250 mg capsule
1
PAGE 241
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
mycophenolate mofetil 500 mg tablet
1
mycophenolate sodium 180 mg tablet dr
1
mycophenolate sodium 360 mg tablet dr
1
MYFORTIC 180 MG TABLET
mycophenolate sodium
1
MYFORTIC 360 MG TABLET
mycophenolate sodium
1
NAFRINSE DAILY-NEUTRAL RINSE
sodium fluoride
1
naltrexone hcl 50 mg tablet
1
naproxen 125 mg/5ml oral susp
1
naproxen 250 mg tablet
1
naproxen 375 mg tablet
1
naproxen 375 mg tablet dr
1
naproxen 500 mg tablet
1
naproxen 500 mg tablet dr
1
naproxen sodium 275 mg tablet
1
naproxen sodium 500 mg tbmp 24hr
1
naproxen sodium 550 mg tablet
1
NATALVIRT 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
NATALVIRT CA COMBO PACK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
NEORAL 100 MG GELATIN CAPSULE
cyclosporine, modified
1
NEORAL 100 MG/ML SOLUTION
cyclosporine, modified
1
NEORAL 25 MG GELATIN CAPSULE
cyclosporine, modified
1
ped mv a,c,d3 #21 w-fluoride 0.25 mg/ml drops
1
ped mv a,c,d3 #21 w-fluoride 0.5 mg/ml drops
1
pedi m.vit no.17 with fluoride 0.25 mg tab chew
1
pedi m.vit no.17 with fluoride 0.5 mg tab chew
1
pedi m.vit no.17 with fluoride 1 mg tab chew
1
PAGE 242
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
pedi multivit no.2 w-fluoride 0.25 mg/ml drops
1
pedi multivit no.2 w-fluoride 0.5 mg/ml drops
1
pedi mv #45/fluoride/iron 0.25-10/ml drops
1
pedi mv #75/fluoride/iron 0.25-10/ml drops
1
pedi mvi no.16 with fluoride 0.25 mg tab chew
1
pedi mvi no.16 with fluoride 0.5 mg tab chew
1
pedi mvi no.16 with fluoride 1 mg tab chew
1
pedi mvi no.82 with fluoride 0.25 mg/ml drops
1
pedi mvi no.82 with fluoride 0.5 mg/ml drops
1
PERIO MED DENTAL RINSE
stannous fluoride
1
PHOSPHASAL TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
phytonadione crystals
1
phytonadione 100 % liquid
1
pnv #19/iron ps&heme/folic/dha 22-6-1-200 capsule
1
PNV OB+DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
1
PNV-DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
PNV-FIRST SOFTGEL
prenatal vitamins no.26/iron polysaccharides/fa/dha
1
PNV-OB WITH DHA COMBO PACK
prenatal vitamins comb 10/ferrous fumarate/folic acid/dha
1
PNV-OMEGA SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
PNV-TOTAL SOFTGEL
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
potassium iodide granules
1
potassium iodide 100 % crystals
1
potassium iodide/iodine 5 % solution
1
PR NATAL 400 COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 400 EC COMBO PACK
prenatal vitamins comb no.19/iron bg hcl&suc-prot/fa/omega-3
1
PAGE 243
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PR NATAL 430 COMBO PACK
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 430 EC COMBO PACK
prenatal vitamins comb no.55/iron bg hcl&suc-prot/fa/omega-3
1
PREMARIN 0.3 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.45 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.625 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 0.9 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN 1.25 MG TABLET
estrogens, conjugated
1
GL
Female
PREMARIN VAGINAL CREAM-APPL
estrogens, conjugated
1
GL
Female
PRENA1 PEARL SOFTGEL
prenatal vit no.71/iron fum-sodium feredetate/folic acid/dha
1
PRENAISSANCE 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PRENAISSANCE CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
PRENAISSANCE DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
PRENAISSANCE PLUS SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
PRENAISSANCE PROMISE COMBO PCK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
PREZCOBIX 800 MG-150 MG TABLET
darunavir ethanolate/cobicistat
1
probenecid 500 mg tablet
1
PROGRAF 0.5 MG CAPSULE
tacrolimus
1
PROGRAF 1 MG CAPSULE
tacrolimus
1
PROGRAF 5 MG CAPSULE
tacrolimus
1
PROGRAF 5 MG/ML AMPULE
tacrolimus
1
PAGE 244
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PURIXAN 20 MG/ML ORAL SUSP
mercaptopurine
1
raloxifene hcl 60 mg tablet
1
REBIF 22 MCG/0.5 ML SYRINGE
interferon beta-1a/albumin human
1
REBIF 44 MCG/0.5 ML SYRINGE
interferon beta-1a/albumin human
1
REBIF TITRATION PACK
interferon beta-1a/albumin human
1
RELAMINE TABLET
glucosamine sulfate/chondroitin sulfate a/antioxid multvit#5
1
RELNATE DHA PRENATAL SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
REVLIMID 10 MG CAPSULE
lenalidomide
1
REVLIMID 15 MG CAPSULE
lenalidomide
1
REVLIMID 2.5 MG CAPSULE
lenalidomide
1
REVLIMID 20 MG CAPSULE
lenalidomide
1
REVLIMID 25 MG CAPSULE
lenalidomide
1
REVLIMID 5 MG CAPSULE
lenalidomide
1
RIDAURA 3 MG CAPSULE
auranofin
1
risedronate sodium 150 mg tablet
LIMITS & RESTRICTIONS
QL
30 / 30 days
QL
6 / 30 days
1
QL
1 / 30 days
risedronate sodium 30 mg tablet
1
QL
30 / 30 days
risedronate sodium 35 mg tablet
1
QL
4 / 30 days
risedronate sodium 35 mg tablet dr
1
risedronate sodium 5 mg tablet
1
QL
30 / 30 days
SANDIMMUNE 100 MG CAPSULE
cyclosporine
1
SANDIMMUNE 100 MG/ML SOLN
cyclosporine
1
PAGE 245
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
SANDIMMUNE 25 MG CAPSULE
cyclosporine
1
SANDIMMUNE 50 MG/ML AMPUL
cyclosporine
1
SE-PLETE DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
SE-TAN DHA CAPSULE
prenatal vit w/o calc no.10/iron fum&polysac comp/fa/omega-3
1
SETONET PRENATAL VITAMIN
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
SETONET-EC PRENATAL VITAMINS
prenatal vitamins comb no.55/iron bg hcl&succ-p2/fa/omega-3
1
sevelamer carbonate 800 mg tablet
1
SF 1.1% GEL
sodium fluoride
1
SF 5000 PLUS CREAM
sodium fluoride
1
SIMULECT 10 MG VIAL
basiliximab
1
SIMULECT 20 MG VIAL
basiliximab
1
sirolimus 0.5 mg tablet
1
sirolimus 1 mg tablet
1
sirolimus 100 % powder
1
sirolimus 2 mg tablet
1
sodium bisulfite granules
1
sodium fluoride 0.2 % solution
1
sodium fluoride 0.25(0.55) tab chew
1
sodium fluoride 0.5 mg/ml drops
1
sodium fluoride 0.5(1.1)mg tab chew
1
sodium fluoride 1mg(2.2mg) tab chew
1
sodium fluoride 1mg(2.2mg) tablet
1
sodium polystyrene sulfonate powder
1
sodium polystyrene sulfonate 15 g/60 ml oral susp
1
sodium polystyrene sulfonate 30g/120ml enema
1
PAGE 246
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
SPS 15 GM/60 ML SUSPENSION
sodium polystyrene sulfonate
1
SPS 30 GM/120 ML ENEMA
sodium polystyrene sulfonate
1
stannous fluoride 0.63% soln(gram)
1
STRIBILD TABLET
elvitegravir/cobicistat/emtricitabine/tenofovir
1
sulfacetamide sodium 10 % cleanser
1
sulfasalazine 500 mg tablet
1
sulfasalazine 500 mg tablet dr
1
SULFAZINE 500 MG TABLET
sulfasalazine
1
SULFAZINE EC 500 MG TAB
sulfasalazine
1
tacrolimus 0.03 % oint. (g)
1
tacrolimus 0.1 % oint. (g)
1
tacrolimus 0.5 mg capsule
1
tacrolimus 1 mg capsule
1
tacrolimus 5 mg capsule
1
TARON-C DHA CAPSULE
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
TARON-DUO EC COMB PACK
prenatal vitamins comb no.19/iron bg hcl&succ-p2/fa/omega-3
1
TARON-PREX PRENATAL DHA CAP
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
TL-CARE DHA SOFTGEL
pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa
1
TL-FLUORIVITE CHEWABLE TABLET
pediatric multivitamin no.47 with iron & sodium fluoride
1
TL-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
tolu balsam lump
1
TRI-CHLOR 80% SOLUTION
trichloroacetic acid
1
TRI-TABS DHA COMBO PACK
prenatal vitamins comb no.87/iron bisgly/folic acid/dha
1
PAGE 247
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
TRI-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
TRIVEEN-DUO DHA COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
TRIVEEN-TEN TABLETS
prenatal vitamins no.18/iron,carbonyl/fa/ubidecarenone/dha
1
TRUST NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
TYBOST 150 MG TABLET
cobicistat
1
ULORIC 40 MG TABLET
febuxostat
1
ST
ULORIC 80 MG TABLET
febuxostat
1
ST
ULTIMATE OB DHA COMBO PACK
prenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
1
UR N-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URETRON D-S TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URETRON D-S TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URIMAR-T TABLET
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
URIN D.S. TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-L TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
URO-MP CAPSULE
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
USTELL CAPSULE
methenamine/methylene blue/salicylate/sodium phos/hyoscy
1
UTIRA-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc sul
1
VAYAROL CAPSULES
phytosterol/omega-3 fatty acids/dha/epa/fish oil
1
VENA-BAL DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
VENATAL COMPLETE DHA COMBO
prenatal vitamin no.77/sodium feredetate-iron poly/fa/omega3
1
PAGE 248
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VINATE DHA GELCAP
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha
1
VIRT-C DHA SOFTGEL
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
VIRT-PN DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
VIRT-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
VIRT-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
VP-CH PLUS SOFTGEL
prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha
1
VP-GSTN CAPSULE
genistein/citrated zinc bisglycinate/vitamin d3
1
VP-HEME ONE SOFTGEL
prenatal vitamin no.19/iron polysacc & iron hem/folic ac/dha
1
VP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
ZATEAN-CH CAPSULE
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
ZATEAN-PN DHA CAPSULE
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
ZATEAN-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
ZINGIBER TABLET
prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger
1
LIMITS & RESTRICTIONS
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
ADVAIR 100-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 250-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 500-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 115-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 230-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
PAGE 249
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ADVAIR HFA 45-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
budesonide 0.25mg/2ml ampul-neb
1
LIMITS & RESTRICTIONS
PA
AL
Up to 8 yrs old
PA
budesonide 0.5 mg/2ml ampul-neb
1
AL
budesonide 32mcg spray/pump
1
cromolyn sodium 20 mg/2 ml ampul-neb
1
cromolyn sodium 4 % drops
1
FLOVENT HFA 110 MCG INHALER
fluticasone propionate
1
FLOVENT HFA 220 MCG INHALER
fluticasone propionate
1
FLOVENT HFA 44 MCG INHALER
fluticasone propionate
1
flunisolide 25 mcg spray
1
flunisolide 29mcg spray
1
fluticasone propionate 50 mcg spray susp
1
montelukast sodium 10 mg tablet
1
montelukast sodium 4 mg gran pack
1
montelukast sodium 4 mg tab chew
1
ST
montelukast sodium 5 mg tab chew
1
ST
PULMICORT 1 MG/2 ML RESPULE
budesonide
1
PULMICORT 180 MCG FLEXHALER
budesonide
1
PULMICORT 90 MCG FLEXHALER
budesonide
1
QVAR 40 MCG ORAL INHALER
beclomethasone dipropionate
1
QVAR 80 MCG ORAL INHALER
beclomethasone dipropionate
1
SYMBICORT 160-4.5 MCG INHALER
budesonide/formoterol fumarate
1
PAGE 250
Up to 8 yrs old
ST
ST
PA
AL
Up to 8 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SYMBICORT 80-4.5 MCG INHALER
budesonide/formoterol fumarate
1
triamcinolone acetonide 55 mcg spray
1
VERAMYST 27.5 MCG NASAL SPRAY
fluticasone furoate
1
AL
zafirlukast 10 mg tablet
1
ST
zafirlukast 20 mg tablet
1
ST
2 to 4 yrs old
ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)
ARBINOXA 4 MG TABLET
carbinoxamine maleate
1
ARBINOXA 4 MG/5 ML LIQUID
carbinoxamine maleate
1
azelastine hcl 137 mcg spray/pump
1
azelastine hcl 205.5mcg spray/pump
1
carbinoxamine maleate 4 mg tablet
1
carbinoxamine maleate 4 mg/5 ml liquid
1
CENTERGY DM PEDIATRIC DROPS
dextromethorphan hbr/phenylephrine hcl/chlorpheniramine
1
CENTERGY PEDIATRIC DROPS
phenylephrine hcl/chlorpheniramine maleate
1
cetirizine hcl 1 mg/ml solution
1
clemastine fumarate 0.67mg/5ml syrup
1
clemastine fumarate 2.68 mg tablet
1
cyproheptadine hcl 2 mg/5 ml syrup
1
cyproheptadine hcl 4 mg tablet
1
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
1
d-methorphan hb/prometh hcl 15-6.25/5 syrup
1
desloratadine 2.5 mg tab rapdis
1
desloratadine 5 mg tab rapdis
1
desloratadine 5 mg tablet
1
diphenhydramine hcl 12.5mg/5ml elixir
1
diphenhydramine hcl 50 mg capsule
1
DOXYTEX 2.5 MG/2.5 ML LIQUID
doxylamine succinate
1
PAGE 251
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
ENDACOF-C LIQUID
chlorpheniramine maleate/codeine phosphate
1
fexofenadine hcl 180 mg tablet
1
fexofenadine hcl 60 mg tablet
1
loratadine 100 % powder
1
PALGIC 4 MG TABLET
carbinoxamine maleate
1
PALGIC 4 MG/5 ML LIQUID
carbinoxamine maleate
1
PHENADOZ 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENADOZ 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 12.5 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 25 MG SUPPOSITORY
promethazine hcl
1
PHENERGAN 50 MG SUPPOSITORY
promethazine hcl
1
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup
1
promethazine hcl 12.5 mg supp.rect
1
promethazine hcl 12.5 mg tablet
1
promethazine hcl 25 mg supp.rect
1
promethazine hcl 25 mg tablet
1
promethazine hcl 50 mg supp.rect
1
promethazine hcl 50 mg tablet
1
promethazine hcl 6.25mg/5ml syrup
1
promethazine hcl/codeine 6.25-10/5 syrup
1
promethazine/dextromethorphan 6.25-15/5 syrup
1
promethazine/phenyleph/codeine 6.25-5-10 syrup
1
PROMETHEGAN 12.5 MG SUPPOS
promethazine hcl
1
PROMETHEGAN 25 MG SUPP
promethazine hcl
1
PAGE 252
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PROMETHEGAN 50 MG SUPPOSITORY
promethazine hcl
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
LIMITS & RESTRICTIONS
BRONCHODILATORS
ADVAIR 100-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 250-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR 500-50 DISKUS
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 115-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 230-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
ADVAIR HFA 45-21 MCG INHALER
fluticasone propionate/salmeterol xinafoate
1
albuterol sulfate 0.63mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 1.25mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 2 mg tablet
1
albuterol sulfate 2 mg/5 ml syrup
1
albuterol sulfate 2.5 mg/0.5 vial-neb
1
albuterol sulfate 2.5 mg/3ml vial-neb
1
QL
540 / 30 days
albuterol sulfate 4 mg tab er 12h
1
albuterol sulfate 4 mg tablet
1
albuterol sulfate 5 mg/ml solution
1
albuterol sulfate 8 mg tab er 12h
1
ATROVENT HFA INHALER
ipratropium bromide
1
COMBIVENT INHALER
ipratropium bromide/albuterol sulfate
1
COMBIVENT RESPIMAT INHAL SPRAY
ipratropium bromide/albuterol sulfate
1
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
1
DESPEC-EXP SYRUP
guaifenesin/pseudoephedrine hcl/dihydrocodeine
1
PAGE 253
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
DIFIL-G 400 TABLET
guaifenesin/dyphylline
1
diphenoxylate hcl/atropine 2.5-.025/5 liquid
1
diphenoxylate hcl/atropine 2.5-.025mg tablet
1
DYLIX 100 MG/15 ML ELIXIR
dyphylline
1
epinephrine 0.15/0.15 auto injct
1
epinephrine 0.3mg/0.3 auto injct
1
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
epinephrine
1
EPIPEN JR 2-PAK 0.15 MG INJCTR
epinephrine
1
ipratropium bromide 0.2 mg/ml solution
1
ipratropium bromide 21 mcg spray
1
ipratropium bromide 42mcg spray
1
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
1
levalbuterol hcl 0.31mg/3ml vial-neb
1
ST
levalbuterol hcl 0.63mg/3ml vial-neb
1
ST
levalbuterol hcl 1.25mg/0.5 vial-neb
1
ST
levalbuterol hcl 1.25mg/3ml vial-neb
1
ST
metaproterenol sulfate 10 mg tablet
1
metaproterenol sulfate 10 mg/5 ml syrup
1
metaproterenol sulfate 20 mg tablet
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
SEREVENT DISKUS 50 MCG
salmeterol xinafoate
1
SPIRIVA 18 MCG CP-HANDIHALER
tiotropium bromide
1
SYMBICORT 160-4.5 MCG INHALER
budesonide/formoterol fumarate
1
SYMBICORT 80-4.5 MCG INHALER
budesonide/formoterol fumarate
1
terbutaline sulfate 2.5 mg tablet
1
PAGE 254
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
terbutaline sulfate 5 mg tablet
1
THEO-24 ER 100 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 200 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 300 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 400 MG CAPSULE
theophylline anhydrous
1
THEOCHRON ER 100 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 200 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 300 MG TABLET
theophylline anhydrous
1
theophylline anhydrous 100 mg tab er 12h
1
theophylline anhydrous 200 mg tab er 12h
1
theophylline anhydrous 300 mg tab er 12h
1
theophylline anhydrous 400 mg tablet er
1
theophylline anhydrous 450 mg tab er 12h
1
theophylline anhydrous 600 mg tablet er
1
theophylline anhydrous 80 mg/15ml elixir
1
theophylline anhydrous 80 mg/15ml solution
1
VENTOLIN HFA 90 MCG INHALER
albuterol sulfate
1
acetylcysteine 100 mg/ml vial
1
acetylcysteine 200 mg/ml vial
1
AMBI 10PEH-400GFN-20DM TABLET
guaifenesin/dextromethorphan hbr/phenylephrine
1
benzonatate 100 mg capsule
1
benzonatate 150 mg capsule
1
benzonatate 200 mg capsule
1
CENTERGY DM PEDIATRIC DROPS
dextromethorphan hbr/phenylephrine hcl/chlorpheniramine
1
codeine sulfate 15 mg tablet
1
PAGE 255
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
codeine sulfate 30 mg tablet
1
codeine sulfate 60 mg tablet
1
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
1
d-methorphan hb/prometh hcl 15-6.25/5 syrup
1
DESPEC-EXP SYRUP
guaifenesin/pseudoephedrine hcl/dihydrocodeine
1
DIFIL-G 400 TABLET
guaifenesin/dyphylline
1
diphenhydramine hcl 12.5mg/5ml elixir
1
diphenhydramine hcl 50 mg capsule
1
DYTUSS COUGH SYRUP
diphenhydramine hcl
1
ENDACOF-C LIQUID
chlorpheniramine maleate/codeine phosphate
1
guaifenesin/phenylephrine hcl 20-1.5/ml drops
1
hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet
1
hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup
1
HYDROMET SYRUP
hydrocodone bitartrate/homatropine methylbromide
1
INDAMIX DM SUSPENSION
dextromethorphan tannate/p-epd tan/dexchlorpheniramine
1
ipecac syrup
1
LUGOL'S SOLUTION
potassium iodide/iodine
1
LUGOL'S STRONG IODINE SOLUTION
iodine/potassium iodide
1
M-CLEAR CAPSULE
guaifenesin/codeine phosphate
1
potassium iodide granules
1
potassium iodide 100 % crystals
1
potassium iodide/iodine 5 % solution
1
promethazine hcl/codeine 6.25-10/5 syrup
1
promethazine/dextromethorphan 6.25-15/5 syrup
1
promethazine/phenyleph/codeine 6.25-5-10 syrup
1
pseudoephed/hydrocodone/cpm 60-5-4mg/5 solution
1
PAGE 256
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PULMOSAL 7% VIAL
sodium chloride for inhalation
1
PULMOZYME 1 MG/ML AMPUL
dornase alfa
1
ROBAFEN AC SYRUP
guaifenesin/codeine phosphate
1
sildenafil citrate 10 mg/12.5 vial
1
sildenafil citrate 20 mg tablet
1
sodium chloride for inhalation 0.9 % vial-neb
1
sodium chloride for inhalation 10 % vial-neb
1
TUSSIGON 5-1.5 MG TABLET
hydrocodone bitartrate/homatropine methylbromide
1
LIMITS & RESTRICTIONS
PA
PA
SERUMS, TOXOIDS, AND VACCINES
ADACEL TDAP SYRINGE
diphtheria,pertussis(acell),tetanus vaccine/pf
1
ADACEL TDAP VIAL
diphtheria,pertussis(acell),tetanus vaccine/pf
1
AFLURIA 2013-2014 SYRINGE
influenza virus vaccine tv split 2013-2014 (5 yr & older)/pf
1
AFLURIA 2013-2014 VIAL
influenza virus vaccine tv split 2013-2014 (5 yr & older)
1
AFLURIA 2014-2015 SYRINGE
influenza virus vaccine trivalnt 2014-2015 (5 yr & older)/pf
1
AFLURIA 2014-2015 VIAL
influenza virus vaccine trivalent 2014-2015 (5 yr & older)
1
AFLURIA 2015-2016 SYRINGE
influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf
1
AFLURIA 2015-2016 VIAL
influenza virus vaccine trivalent 2015-2016 (5 yr & older)
1
BOOSTRIX TDAP VACCINE SYRINGE
diphtheria,pertussis(acellular),tetanus vaccine
1
BOOSTRIX TDAP VACCINE VIAL
diphtheria,pertussis(acellular),tetanus vaccine
1
DECAVAC VIAL
tetanus and diphtheria toxoids, adsorbed, adult/pf
1
ENGERIX-B 10 MCG/0.5 ML PED VL
hepatitis b virus vaccine recombinant/pf
1
PAGE 257
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
ENGERIX-B 20 MCG/ML SYRN
hepatitis b virus vaccine recombinant/pf
1
PA
ENGERIX-B 20 MCG/ML VIAL
hepatitis b virus vaccine recombinant/pf
1
PA
ENGERIX-B PEDI 10 MCG/0.5 SYRN
hepatitis b virus vaccine recombinant/pf
1
PA
FLUARIX 2013-2014 SYRINGE
influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf
1
FLUARIX 2014-2015 SYRINGE
influenza virus vaccine trival 2014-15 (36 mos and older)/pf
1
FLUARIX QUAD 2013-2014 SYRINGE
influenza virus vaccine quad vs 2013-2014(36 mos & older)/pf
1
FLUARIX QUAD 2014-2015 SYRINGE
influenza virus vaccine quadrival 2014-15(36 mos & older)/pf
1
FLUARIX QUAD 2015-2016 SYRINGE
influenza virus vaccine quadrival split 2015-16(36 mos+)/pf
1
FLUBLOK 2013-2014 VIAL
influenza virus vaccine tv 2013-2014 (18 to 49 yrs)recomb/pf
1
FLUBLOK 2014-2015 VIAL
influenza virus vaccine tv 2014-2015(18 yrs & older)rcmb/pf
1
FLUBLOK 2015-2016 VIAL
influenza virus vaccine tv 2015-2016(18 yrs & older)rcmb/pf
1
FLUCELVAX 2013-2014 SYRINGE
influenza vaccine tv split 2013-14 (18 yr+) cell derived/pf
1
FLUCELVAX 2014-2015 SYRINGE
influenza vaccine trival.split 2014-15 (18 yr+) cell der/pf
1
FLUCELVAX 2015-2016 SYRINGE
influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf
1
FLULAVAL 2013-2014 VIAL
influenza virus vaccine tvs 2013-2014 (36 mos and older)
1
FLULAVAL 2014-2015 VIAL
influenza virus vaccine trivalent 2014-15 (36 mos and older)
1
FLULAVAL QUAD 2013-2014 VIAL
influenza virus vaccine quad vs 2013-2014 (36 mos & older)
1
FLULAVAL QUAD 2014-2015 SYR
influenza virus vaccine quadrival 2014-15(36 mos & older)/pf
1
FLULAVAL QUAD 2014-2015 VIAL
influenza virus vaccine quad vs 2014-2015 (36 mos & older)
1
FLULAVAL QUAD 2015-2016 VIAL
influenza virus vaccine quadrival 2015-2016 (36 mos & older)
1
PAGE 258
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FLUMIST NASAL 2013-14 VACCINE
influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs)
1
FLUMIST QUAD NASAL 2014-15 VAC
influenza vaccine quadrivalent live 2014-2015 (2 yrs-49 yrs)
1
FLUVIRIN 2013-2014 SYRINGE
influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf
1
FLUVIRIN 2013-2014 VIAL
influenza virus vaccine tv split 2013-2014 (4 yr & older)
1
FLUVIRIN 2014-2015 SYRINGE
influenza virus vaccine trivalnt 2014-2015 (4 yr & older)/pf
1
FLUVIRIN 2014-2015 VIAL
influenza virus vaccine trivalent 2014-2015 (4 yr & older)
1
FLUVIRIN 2015-2016 SYRINGE
influenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf
1
FLUVIRIN 2015-2016 VIAL
influenza virus vaccine trivalent 2015-2016 (4 yr & older)
1
FLUZONE 2013-2014 SYRINGE
influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf
1
FLUZONE 2013-2014 VIAL
influenza virus vaccine tri-split 2013-14 (6 mos and older)
1
FLUZONE 2013-2014 VIAL (PF)
influenza virus vaccine tvs 2013-2014 (36 mos and older)/pf
1
FLUZONE 2014-2015 SYRINGE
influenza virus vaccine trival 2014-15 (36 mos and older)/pf
1
FLUZONE 2014-2015 VIAL
influenza virus vaccine trivalent 2014-15 (6 mos and older)
1
FLUZONE 2015-2016 VIAL
influenza virus vaccine trivalent 2015-16 (6 mos and older)
1
FLUZONE HIGH-DOSE 2013-14 SYR
influenza virus vaccine tvs 2013-2014 (65 yr+)/pf
1
FLUZONE HIGH-DOSE 2014-15 SYR
influenza virus vaccine trivalent 2014-2015 (65 yr+)/pf
1
FLUZONE HIGH-DOSE 2015-16 SYR
influenza virus vaccine trivalent split 2015-2016(65 yr+)/pf
1
FLUZONE INTRADER 2013-2014 SYR
influenza virus vaccine tvs 2013-2014 (18 yrs-64 yrs)/pf
1
FLUZONE INTRADERM 2014-15 SYR
influenza virus vaccine trivalent 2014-15 (18 yrs-64 yrs)/pf
1
FLUZONE INTRADERM QUAD 2015-16
influenza virus vaccine quadrivalent 2015-16(18yrs-64yrs)/pf
1
PAGE 259
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FLUZONE PEDI 2013-2014 SYRINGE
influenza virus vaccine tvs 2013-2014 (6 mos-35 mos)/pf
1
FLUZONE QUAD 2013-2014 SYRINGE
influenza virus vaccine quad vs 2013-2014(36 mos & older)/pf
1
FLUZONE QUAD 2013-2014 VIAL
influenza virus vaccine quad vs 2013-2014(36 mos & older)/pf
1
FLUZONE QUAD 2014-2015 SYRINGE
influenza virus vaccine quadrival 2014-15(36 mos & older)/pf
1
FLUZONE QUAD 2014-2015 VIAL
influenza virus vaccine quadrival 2014-15(36 mos & older)/pf
1
FLUZONE QUAD 2014-2015 VIAL
influenza virus vaccine quadrival 2014-2015 (6 mos & older)
1
FLUZONE QUAD 2015-2016 SYRINGE
influenza virus vaccine quadrival split 2015-16(36 mos+)/pf
1
FLUZONE QUAD 2015-2016 VIAL
influenza virus vaccine quadrival split 2015-16(36 mos+)/pf
1
FLUZONE QUAD 2015-2016 VIAL
influenza virus vaccine qvalsplit 2015-2016(6 mos and older)
1
FLUZONE QUAD PEDI 2013-14 SYR
influenza virus vaccine quad vs 2013-2014 (6 mos-35 mos)/pf
1
FLUZONE QUAD PEDI 2014-15 SYR
influenza virus vaccine quadrival 2014-15 (6 mos-35 mos)/pf
1
GARDASIL SYRINGE
human papillomavirus vaccine, quadrivalent/pf
1
GARDASIL VIAL
human papillomavirus vaccine, quadrivalent/pf
1
HYPERRHO S-D 1500 UNITS SYR
rho(d) immune globulin
1
HYPERRHO S-D 250 UNITS SYRINGE
rho(d) immune globulin
1
MICRHOGAM ULTRA-FILTD PLUS SYR
rho(d) immune globulin
1
PNEUMOVAX 23 SYRINGE
pneumococcal 23-valent polysaccharide vaccine
1
PNEUMOVAX 23 VIAL
pneumococcal 23-valent polysaccharide vaccine
1
PREVNAR 13 SYRINGE
pneumococcal 13-valent conjugate vaccine (diphtheria crm)/pf
1
PAGE 260
LIMITS & RESTRICTIONS
PA
AL
19 to 26 yrs old
PA
AL
19 to 26 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
QUADRACEL DTAP-IPV VIAL
diphtheria, pertussis(acell),tetanus,polio vaccine/pf
1
RECOMBIVAX HB 10 MCG/ML SYR
hepatitis b virus vaccine recombinant/pf
1
PA
RECOMBIVAX HB 10 MCG/ML VIAL
hepatitis b virus vaccine recombinant/pf
1
PA
RECOMBIVAX HB 40 MCG/ML VIAL
hepatitis b virus vaccine recombinant/pf
1
PA
RECOMBIVAX HB 5 MCG/0.5 ML SYR
hepatitis b virus vaccine recombinant/pf
1
PA
RECOMBIVAX HB 5 MCG/0.5 ML VL
hepatitis b virus vaccine recombinant/pf
1
PA
RHOGAM ULTRA-FILTERED PLUS SYR
rho(d) immune globulin
1
RHOPHYLAC 300 MCG/2 ML SYRINGE
rho(d) immune globulin
1
ROTATEQ VACCINE
rotavirus vaccine, live oral pentavalent
1
SINGLE USE EZ FLU 2013-2014 KT
influenza virus vaccine quad vs 2013-2014(36 mos & older)/pf
1
SINGLE USE EZ FLU 2013-2014 KT
influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf
1
SINGLE USE EZ FLU 2014-2015 KT
influenza vaccine trival.split 2014-15 (18 yr+) cell der/pf
1
TENIVAC SYRINGE
tetanus and diphtheria toxoids, adsorbed, adult/pf
1
TENIVAC VIAL
tetanus and diphtheria toxoids, adsorbed, adult/pf
1
tetanus & diphtheria tox,adult 2-2 lf/0.5 vial
1
tetanus toxoid, adsorbed/pf 5 lf/0.5ml vial
1
TETANUS-DIPHTERIA-DECAVAC
tetanus and diphtheria toxoids, adsorbed, adult/pf
1
VARIVAX VACCINE VIAL
varicella virus vaccine live/pf
1
VARIVAX VACCINE WITH DILUENT
varicella virus vaccine live/pf
1
ZOSTAVAX VIAL
zoster vaccine live/pf
1
PAGE 261
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
acyclovir 5 % oint. (g)
1
AVAR CLEANSER
sulfacetamide sodium/sulfur
1
AVC 15% CREAM
sulfanilamide
1
bacitracin 5mm unit powder(ea)
1
benzalkonium chloride 17 % solution
1
BENZEPRO 6% FOAMING CLOTHS
benzoyl peroxide
1
benzoyl peroxide 10 % gel (gram)
1
benzoyl peroxide 3 % cleanser
1
benzoyl peroxide 3 % med. pad
1
benzoyl peroxide 5 % gel (gram)
1
benzoyl peroxide 5.3% foam
1
benzoyl peroxide 6 % cleanser
1
benzoyl peroxide 6 % med. pad
1
benzoyl peroxide 7 % cleanser
1
benzoyl peroxide 9% cleanser
1
benzoyl peroxide 9% med. pad
1
benzoyl peroxide 9.8 % foam
1
BP 10-1 WASH
sulfacetamide sodium/sulfur
1
BP CLEANSING WASH
sulfacetamide sodium/sulfur/urea
1
BP-50% UREA EMULSION
urea/lactic acid/zinc undecylenate
1
BPO 3% FOAMING CLOTHS
benzoyl peroxide
1
BPO 4% GEL
benzoyl peroxide
1
BPO 6% FOAMING CLOTHS
benzoyl peroxide
1
PAGE 262
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BPO 8% GEL
benzoyl peroxide
1
BPO 9% FOAMING CLOTHS
benzoyl peroxide
1
CERISA WASH
sulfacetamide sodium/sulfur
1
chlorhexidine gluconate 0.12 % mouthwash
1
CICLODAN 0.77% CREAM
ciclopirox olamine
1
CICLODAN 8% SOLUTION
ciclopirox
1
ciclopirox 0.77 % gel (gram)
1
ciclopirox 1 % shampoo
1
ciclopirox 8 % solution
1
ciclopirox olamine 0.77 % cream (g)
1
ciclopirox olamine 0.77 % suspension
1
ciclopirox/vite/nail lacq remo 8%-5% kit
1
CLARIS CLARIFYING WASH
sulfacetamide sodium/sulfur/urea
1
CLENIA FOAMING WASH
sulfacetamide sodium/sulfur
1
CLINDA-DERM 1% SOLUTION
clindamycin phosphate
1
CLINDACIN ETZ 1% PLEDGET
clindamycin phosphate
1
CLINDACIN P 1% PLEDGETS
clindamycin phosphate
1
clindamycin phos/benzoyl perox 1 %-5 % gel (gram)
1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram)
1
clindamycin phosphate 1 % gel (gram)
1
clindamycin phosphate 1 % lotion
1
clindamycin phosphate 1 % med. swab
1
clindamycin phosphate 1 % solution
1
clindamycin phosphate 2 % cream/appl
1
clotrimazole 1 % cream (g)
1
PAGE 263
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
clotrimazole 1 % solution
1
clotrimazole 10 mg troche
1
clotrimazole/betamethasone dip 1 %-0.05 % cream (g)
1
clotrimazole/betamethasone dip 1 %-0.05 % lotion
1
DESQUAM-X 10% WASH
benzoyl peroxide
1
DESQUAM-X 5% WASH
benzoyl peroxide
1
econazole nitrate 1 % cream (g)
1
EMGEL 2% TOPICAL GEL
erythromycin base/ethyl alcohol
1
ERY 2% PADS
erythromycin base/ethyl alcohol
1
ERYGEL 2% GEL
erythromycin base/ethyl alcohol
1
erythromycin base/ethanol 2 % gel (gram)
1
erythromycin base/ethanol 2 % med. swab
1
erythromycin base/ethanol 2 % solution
1
erythromycin/benzoyl peroxide 3 %-5 % gel (gram)
1
EURAX 10% CREAM
crotamiton
1
EURAX 10% LOTION
crotamiton
1
FEM PH VAGINAL JELLY
acetic acid/oxyquinoline sulfate
1
gentamicin sulfate 0.1 % cream (g)
1
gentamicin sulfate 0.1 % oint. (g)
1
hydrocortisone/iodoquinol/aloe 1.9 %-1 % cream pack
1
ketoconazole 2 % cream (g)
1
ketoconazole 2 % shampoo
1
KETODAN 2% FOAM
ketoconazole
1
LATRIX XM 45% EMULSION
urea/lactic acid/zinc undecylenate
1
LAVOCLEN-4 CREAMY WASH
benzoyl peroxide
1
PAGE 264
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
lindane 1 % lotion
1
lindane 1 % shampoo
1
LUGOL'S STRONG IODINE SOLUTION
iodine/potassium iodide
1
mafenide acetate 50 g packet
1
malathion 0.5 % lotion
1
METROGEL 1% KIT
metronidazole/skin cleanser
1
metronidazole 0.75 % cream (g)
1
metronidazole 0.75 % gel (gram)
1
metronidazole 0.75 % gel w/appl
1
metronidazole 0.75 % lotion
1
metronidazole 1 % gel (gram)
1
metronidazole 1 % gel w/pump
1
miconazole nitrate 200 mg supp.vag
1
mupirocin 2 % oint. (g)
1
mupirocin calcium 2 % cream (g)
1
NEUAC GEL
clindamycin phosphate/benzoyl peroxide
1
NORITATE 1% CREAM
metronidazole
1
NYAMYC 100,000 UNITS/GM POWDER
nystatin
1
nystatin 100000/g cream (g)
1
nystatin 100000/g oint. (g)
1
nystatin 100000/g powder
1
nystatin 100k unit tablet
1
nystatin/triamcin 100000-0.1 cream (g)
1
nystatin/triamcin 100000-0.1 oint. (g)
1
NYSTOP 100,000 UNITS/GM POWDER
nystatin
1
PAROEX 0.12% ORAL RINSE
chlorhexidine gluconate
1
PEDI-DRI TOPICAL POWDER
nystatin
1
PAGE 265
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PERIOGARD 0.12% ORAL RINSE
chlorhexidine gluconate
1
permethrin 5 % cream (g)
1
permethrin 92 % liquid
1
permethrin 95 % liquid
1
polymyxin b sulfate,micronized 100mm unit powder(ea)
1
PRASCION CLEANSER
sulfacetamide sodium/sulfur
1
PRASCION FC CLEANSING CLOTHS
sulfacetamide sodium/sulfur
1
PRASCION RA CREAM
sulfacetamide sodium/avobenzone/sulfur
1
ROSADAN 0.75% CREAM
metronidazole
1
ROSADAN 0.75% GEL
metronidazole
1
ROSULA 10%-5% CLOTHS
sulfacetamide sodium/sulfur
1
SE 10-5 SS CREAM
sulfacetamide sodium/sulfur/witch hazel
1
SE BPO 3% FOAMING CLOTHS
benzoyl peroxide
1
SE BPO 6% FOAMING CLOTHS
benzoyl peroxide
1
SE BPO 7% WASH
benzoyl peroxide microspheres
1
SE BPO 7-5.5% WASH KIT
benzoyl peroxide microspheres
1
SE BPO 9% FOAMING CLOTHS
benzoyl peroxide
1
SEB-PREV 10% WASH
sulfacetamide sodium
1
selenium sulfide 2.25 % shampoo
1
selenium sulfide 2.5 % suspension
1
silver nitrate 0.5 % solution
1
silver nitrate 10 % oint. (g)
1
silver nitrate 25 % solution
1
PAGE 266
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
silver nitrate 50 % solution
1
silver sulfadiazine 1 % cream (g)
1
SKLICE 0.5% LOTION
ivermectin
1
SS 10-2 CLEANSER
sulfacetamide sodium/sulfur
1
SSD 1% CREAM
silver sulfadiazine
1
SSS 10-5 CREAM
sulfacetamide sodium/sulfur
1
SSS 10-5 FOAM
sulfacetamide sodium/sulfur
1
sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser
1
sulfacetamide sodium 10 % cleanser
1
sulfacetamide sodium 10 % clnsgel er
1
sulfacetamide sodium 10 % shampoo
1
sulfacetamide sodium 10 % suspension
1
sulfacetamide sodium/sulfur 10 %-2 % cleanser
1
sulfacetamide sodium/sulfur 10 %-2 % cream (g)
1
sulfacetamide sodium/sulfur 10 %-4 % med. pad
1
sulfacetamide sodium/sulfur 10 %-5 % foam
1
sulfacetamide sodium/sulfur 10 %-5 % med. pad
1
sulfacetamide sodium/sulfur 10-5%(w/v) lotion
1
sulfacetamide sodium/sulfur 10-5%(w/w) cleanser
1
sulfacetamide sodium/sulfur 10-5%(w/w) cream (g)
1
sulfacetamide sodium/sulfur 10-5%(w/w) lotion
1
sulfacetamide sodium/sulfur 10-5%(w/w) suspension
1
sulfacetamide sodium/sulfur 8 %-4 % suspension
1
sulfacetamide sodium/sulfur 9 %-4 % cleanser
1
sulfacetamide sodium/sulfur 9 %-4.5 % cleanser
1
sulfacetamide sodium/sulfur 9.8%-4.8% cleanser
1
sulfacetamide sodium/sulfur 9.8%-4.8% cream (g)
1
sulfacetamide sodium/sulfur 9.8%-4.8% lotion
1
PAGE 267
LIMITS & RESTRICTIONS
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sulfacetamide sodium/urea 10 %-10 % med. pad
1
sulfacetamide/sulfur/cleansr23 9 %-4.5 % kit
1
SULFACLEANSE 8-4 SUSPENSION
sulfacetamide sodium/sulfur
1
sulfact sod/sulur/avob/otn/oct 9 %-4.5 % cmb cln cr
1
terconazole 0.4 % cream/appl
1
terconazole 0.8 % cream/appl
1
terconazole 80 mg supp.vag
1
THERMAZENE 1% CREAM
silver sulfadiazine
1
TRIPLE DYE APPLICATORS
gentian violet/brilliant green/proflavine
1
TRIPLE DYE SWAB
gentian violet/brilliant green/proflavine
1
urea 50 % sol/pf app
1
urea/lactic ac/zn undecylenate 50 % emulsn(g)
1
VANDAZOLE VAGINAL 0.75% GEL
metronidazole
1
VIRTI-SULF EMOLLIENT CREAM
sulfacetamide sodium/sulfur
1
VITAZOL 0.75% CREAM
metronidazole
1
VUSION OINTMENT
miconazole nitrate/zinc oxide/petrolatum,white
1
ZENCIA WASH
sulfacetamide sodium/sulfur
1
ZOVIRAX 5% CREAM
acyclovir
1
LIMITS & RESTRICTIONS
DEPIGMENTING AND PIGMENTING AGENTS
ALPHAQUIN HP 4% CREAM
oxybenzone/octinoxate/hydroquinone
1
LUSTRA-AF 4% CREAM
vitamin e acetate/avobenzone/octinoxate/hydroquinone
1
LUSTRA-ULTRA 4% CREAM
vitamin a/vitamin e/avobenzone/octinoxate/hydroquinone
1
MELPAQUE HP 4% CREAM
hydroquinone/ferric oxide
1
PAGE 268
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
methoxsalen, rapid 10 mg capsule
1
acitretin 10 mg capsule
1
acitretin 17.5 mg capsule
1
acitretin 25 mg capsule
1
adapalene 0.1 % cream (g)
1
adapalene 0.1 % gel (gram)
1
adapalene 0.3 % gel (gram)
1
adapalene 0.3 % gel w/pump
1
ALA-CORT 1% CREAM
hydrocortisone
1
alclometasone dipropionate 0.05 % cream (g)
1
alclometasone dipropionate 0.05 % oint. (g)
1
ALICLEN 6% SHAMPOO
salicylic acid
1
almond oil oil
1
aluminum acetate solution
1
amcinonide 0.1 % cream (g)
1
amcinonide 0.1 % lotion
1
amcinonide 0.1 % oint. (g)
1
ammonium lactate 12 % cream (g)
1
ammonium lactate 12 % lotion
1
AMNESTEEM 10 MG CAPSULE
isotretinoin
1
AMNESTEEM 20 MG CAPSULE
isotretinoin
1
AMNESTEEM 40 MG CAPSULE
isotretinoin
1
APEXICON E 0.05% CREAM
diflorasone diacetate/emollient base
1
AVAR CLEANSER
sulfacetamide sodium/sulfur
1
AVITA 0.025% CREAM
tretinoin
1
AVO CREAM TOPICAL EMULSION
emollient combination no.10
1
PAGE 269
LIMITS & RESTRICTIONS
PA
AL
Up to 35 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BENZEPRO 6% FOAMING CLOTHS
benzoyl peroxide
1
benzoin tincture
1
benzoyl peroxide 3 % cleanser
1
benzoyl peroxide 3 % med. pad
1
benzoyl peroxide 5 % gel (gram)
1
benzoyl peroxide 5.3% foam
1
benzoyl peroxide 6 % cleanser
1
benzoyl peroxide 6 % med. pad
1
benzoyl peroxide 7 % cleanser
1
benzoyl peroxide 9% cleanser
1
benzoyl peroxide 9% med. pad
1
benzoyl peroxide 9.8 % foam
1
betamethasone dipropionate 0.05 % cream (g)
1
betamethasone dipropionate 0.05 % gel (gram)
1
betamethasone dipropionate 0.05 % lotion
1
betamethasone dipropionate 0.05 % oint. (g)
1
betamethasone valerate 0.1 % cream (g)
1
betamethasone valerate 0.1 % lotion
1
betamethasone valerate 0.1 % oint. (g)
1
betamethasone valerate 0.12 % foam
1
betamethasone/propylene glyc 0.05 % cream (g)
1
betamethasone/propylene glyc 0.05 % lotion
1
betamethasone/propylene glyc 0.05 % oint. (g)
1
bismuth tribromoph/petrolatum 1"x8" bandage
1
bismuth tribromoph/petrolatum 2" x 2" bandage
1
bismuth tribromoph/petrolatum 4" x 4" bandage
1
bismuth tribromoph/petrolatum 4"x108" bandage
1
bismuth tribromoph/petrolatum 5"x9" bandage
1
BP 10-1 WASH
sulfacetamide sodium/sulfur
1
BP CLEANSING WASH
sulfacetamide sodium/sulfur/urea
1
PAGE 270
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BP-50% UREA EMULSION
urea/lactic acid/zinc undecylenate
1
BPO 3% FOAMING CLOTHS
benzoyl peroxide
1
BPO 4% GEL
benzoyl peroxide
1
BPO 6% FOAMING CLOTHS
benzoyl peroxide
1
BPO 8% GEL
benzoyl peroxide
1
BPO 9% FOAMING CLOTHS
benzoyl peroxide
1
calcipotriene 0.005 % cream (g)
1
calcipotriene 0.005 % oint. (g)
1
calcipotriene 0.005 % solution
1
calcipotriene/betamethasone 0.005-.064 oint. (g)
1
CALCITRENE 0.005% OINTMENT
calcipotriene
1
calcitriol 3 mcg/g oint. (g)
1
CAPTRACIN 0.0375%-5% PATCH
capsaicin/menthol
1
CARB-O-PHILIC 40% CREAM
urea
1
CELACYN GEL
emollient combination no.60
1
CEM-UREA 45% PRE-FILLED APPL
urea
1
CERISA WASH
sulfacetamide sodium/sulfur
1
ciclopirox/vite/nail lacq remo 8%-5% kit
1
CLARAVIS 10 MG CAPSULE
isotretinoin
1
CLARAVIS 20 MG CAPSULE
isotretinoin
1
CLARAVIS 30 MG CAPSULE
isotretinoin
1
CLARAVIS 40 MG CAPSULE
isotretinoin
1
PAGE 271
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CLARIS CLARIFYING WASH
sulfacetamide sodium/sulfur/urea
1
CLENIA FOAMING WASH
sulfacetamide sodium/sulfur
1
clindamycin phos/benzoyl perox 1 %-5 % gel (gram)
1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram)
1
clobetasol propionate 0.05 % cream (g)
1
clobetasol propionate 0.05 % foam
1
clobetasol propionate 0.05 % gel (gram)
1
clobetasol propionate 0.05 % lotion
1
clobetasol propionate 0.05 % oint. (g)
1
clobetasol propionate 0.05 % shampoo
1
clobetasol propionate 0.05 % solution
1
clobetasol propionate 0.05 % spray
1
clobetasol propionate/emoll 0.05 % cream (g)
1
clobetasol propionate/emoll 0.05 % foam
1
CLODAN 0.05% SHAMPOO
clobetasol propionate
1
clotrimazole/betamethasone dip 1 %-0.05 % cream (g)
1
clotrimazole/betamethasone dip 1 %-0.05 % lotion
1
COLOCORT 100 MG ENEMA
hydrocortisone
1
CORMAX 0.05% OINTMENT
clobetasol propionate
1
CORMAX 0.05% SOLUTION
clobetasol propionate
1
CUTIVATE 0.05% LOTION
fluticasone propionate
1
desonide 0.05 % cream (g)
1
desonide 0.05 % lotion
1
desonide 0.05 % oint. (g)
1
desoximetasone 0.05 % cream (g)
1
desoximetasone 0.05 % gel (gram)
1
desoximetasone 0.05 % oint. (g)
1
PAGE 272
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
desoximetasone 0.25 % cream (g)
1
desoximetasone 0.25 % oint. (g)
1
DESQUAM-X 10% WASH
benzoyl peroxide
1
DESQUAM-X 5% WASH
benzoyl peroxide
1
diclofenac sodium 1.5 % drops
1
diclofenac sodium 3 % gel (gram)
1
diflorasone diacetate 0.05 % cream (g)
1
diflorasone diacetate 0.05 % oint. (g)
1
DRITHOCREME HP 1% CREAM
anthralin
1
ELETONE CREAM
emollient combination no. 25
1
ELETONE CREAM TWIN PACK
emollient combination no. 25
1
EMULSION SB TOPICAL EMULSION
emollient combination no.32
1
EMULSION SB TOPICAL TWIN PACK
emollient combination no.32
1
ethyl chloride 100 % spray
1
FEM PH VAGINAL JELLY
acetic acid/oxyquinoline sulfate
1
finasteride 1 mg tablet
1
fluocinolone acetonide 0.01 % cream (g)
1
fluocinolone acetonide 0.01 % oil
1
fluocinolone acetonide 0.01 % solution
1
fluocinolone acetonide 0.025 % cream (g)
1
fluocinolone acetonide 0.025 % oint. (g)
1
fluocinolone/shower cap 0.01 % oil
1
fluocinonide 0.05 % cream (g)
1
fluocinonide 0.05 % gel (gram)
1
fluocinonide 0.05 % oint. (g)
1
fluocinonide 0.05 % solution
1
PAGE 273
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
fluocinonide 0.1 % cream (g)
1
fluocinonide/emollient base 0.05 % cream (g)
1
fluorouracil 2 % solution
1
fluorouracil 5 % cream (g)
1
fluorouracil 5 % solution
1
fluticasone propionate 0.005 % oint. (g)
1
fluticasone propionate 0.05 % cream (g)
1
fluticasone propionate 0.05 % lotion
1
FORMADON 10% SOLUTION
formaldehyde
1
formaldehyde 10 % sol w/appl
1
gel dressing gel (gram)
1
GLYDO 2% JELLY SYRINGE
lidocaine hcl
1
halobetasol propionate 0.05 % cream (g)
1
halobetasol propionate 0.05 % oint. (g)
1
HALONATE COMBO PACK
halobetasol propionate/ammonium lactate
1
HALONATE PAC COMBO PACK
halobetasol propionate/ammonium lactate
1
hc/mineral oil/petrolat,wht 1 % oint. (g)
1
HPR EMOLLIENT FOAM
emollient combination no.44
1
HPR PLUS CREAM
emollient combination no.53
1
HPR PLUS EMOLLIENT FOAM
emollient combination no.53
1
hydrocolloid dressing 1.5"x2.5" bandage
1
hydrocolloid dressing 2"x2.75" bandage
1
hydrocolloid dressing 3.5"x5.5" bandage
1
hydrocolloid dressing 4" x 4" bandage
1
hydrocolloid dressing 6" x 8" bandage
1
hydrocolloid dressing 7"x8" bandage
1
hydrocortisone 1 % cream (g)
1
PAGE 274
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
hydrocortisone 1 % oint. (g)
1
hydrocortisone 100mg/60ml enema
1
hydrocortisone 2.5 % cream (g)
1
hydrocortisone 2.5 % lotion
1
hydrocortisone 2.5 % oint. (g)
1
hydrocortisone acetate/aloe v 2 % gel (gram)
1
hydrocortisone butyrate 0.1 % cream (g)
1
hydrocortisone butyrate 0.1 % oint. (g)
1
hydrocortisone butyrate 0.1 % solution
1
hydrocortisone butyrate/emoll 0.1 % cream (g)
1
hydrocortisone valerate 0.2 % cream (g)
1
hydrocortisone valerate 0.2 % oint. (g)
1
hydrocortisone/iodoquinol/aloe 1.9 %-1 % cream pack
1
hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl
1
hydrocortisone/lidocaine/aloe 2 %-2 % kit
1
hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit
1
HYPERCARE 20% SOLUTION
aluminum chloride
1
imiquimod 5 % cream pack
1
LACLOTION 12% LOTION
ammonium lactate
1
lactic acid 10 % cream (g)
1
lactic acid 10 % lotion
1
lactic acid 88% to 92% liquid
1
LATRIX 50% TOPICAL SUSPENSION
urea/lactic acid/salicylic acid
1
LATRIX XM 45% EMULSION
urea/lactic acid/zinc undecylenate
1
lidocaine 5 % oint. (g)
1
lidocaine 5%(700mg) adh. patch
1
lidocaine hcl 2 % jel (ml)
1
lidocaine hcl 2 % jel/pf app
1
lidocaine hcl 3 % cream (g)
1
PAGE 275
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
lidocaine hcl 3 % lotion
1
lidocaine hcl 4 % solution
1
lidocaine hcl 40 mg/ml solution
1
lidocaine/hydrocortisone ac 3 %-0.5 % cream (g)
1
lidocaine/hydrocortisone ac 3 %-0.5 % cream/appl
1
lidocaine/hydrocortisone ac 3 %-0.5 % kit
1
lidocaine/hydrocortisone ac 3%-1%(7 g) kit
1
lidocaine/prilocaine 2.5 %-2.5% cream (g)
1
lidocaine/prilocaine 2.5 %-2.5% kit
1
LIDOPIN 3% CREAM
lidocaine hcl
1
LORENZA 4%-1% PATCH
lidocaine/menthol
1
MAC 0.0375%-5% PATCH
capsaicin/menthol
1
MB HYDROGEL KIT
emol#53/na mg fluorosilicate/cyclometh/phosph ac/nahco3/nacl
1
MB HYDROGEL KIT
emol53/e.water/namgfs/naphos/nacl/hypochlorous
acid/nahypocl
1
methyl salicylate liquid
1
minocycline hcl 135 mg tab er 24h
1
minocycline hcl 45 mg tab er 24h
1
minocycline hcl 90 mg tab er 24h
1
mometasone furoate 0.1 % cream (g)
1
mometasone furoate 0.1 % oint. (g)
1
mometasone furoate 0.1 % solution
1
MYORISAN 10 MG CAPSULE
isotretinoin
1
MYORISAN 20 MG CAPSULE
isotretinoin
1
MYORISAN 40 MG CAPSULE
isotretinoin
1
NEUAC GEL
clindamycin phosphate/benzoyl peroxide
1
PAGE 276
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NIVATOPIC PLUS CREAM
emollient combination no.53
1
nystatin/triamcin 100000-0.1 cream (g)
1
nystatin/triamcin 100000-0.1 oint. (g)
1
ORALONE 0.1% PASTE
triamcinolone acetonide
1
PAIN RELIEF 0.0375%-5% PATCH
capsaicin/menthol
1
phenazopyridine hcl 100 mg tablet
1
phenazopyridine hcl 200 mg tablet
1
podofilox 0.5 % solution
1
PR CREAM KIT
protectives combination no.2/ceramides 1,3,6-11
1
PRAMCORT 1% CREAM
hydrocortisone acetate/pramoxine hcl
1
PRASCION CLEANSER
sulfacetamide sodium/sulfur
1
PRASCION FC CLEANSING CLOTHS
sulfacetamide sodium/sulfur
1
PRASCION RA CREAM
sulfacetamide sodium/avobenzone/sulfur
1
PRE-ATTACHED LTA KIT
lidocaine hcl
1
prednicarbate 0.1 % cream (g)
1
prednicarbate 0.1 % oint. (g)
1
PROCTO-PAK 1% CREAM
hydrocortisone
1
PROCTOSOL-HC 2.5% CREAM
hydrocortisone
1
PROCTOZONE-HC 2.5% CREAM
hydrocortisone
1
PROVENZA 4%-1% PATCH
lidocaine hcl/menthol
1
PRUCLAIR NONSTEROIDAL CREAM
vitamin e acet (dl,tocopheryl)/grape/hyaluronic acid
1
PRUDOXIN 5% CREAM
doxepin hcl
1
PAGE 277
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PRUTECT TOPICAL EMULSION
emollient combination no.10
1
REA LO 39 CREAM
urea
1
REA LO 40 CREAM
urea
1
REA LO 40 LOTION
urea
1
RECEDO TOPICAL GEL
polydimethylsiloxanes/silicon dioxide
1
RECTACORT-HC 25 MG SUPPOSITORY
hydrocortisone acetate
1
REFISSA 0.05% CREAM
tretinoin/emollient base
1
RELADOR PAK 2.5-2.5% CRM-DRESS
lidocaine/prilocaine
1
REMEVEN 50% CREAM
urea
1
ROSULA 10%-5% CLOTHS
sulfacetamide sodium/sulfur
1
SALACYN 6% CREAM
salicylic acid
1
SALACYN 6% LOTION
salicylic acid
1
salicylic acid 26 % liquid
1
salicylic acid 27.5 % liq-film
1
salicylic acid 28.5 % sol-filmer
1
salicylic acid 6 % cream (g)
1
salicylic acid 6 % foam
1
salicylic acid 6 % gel (gram)
1
salicylic acid 6 % lotion
1
salicylic acid 6 % lotion er
1
salicylic acid 6 % shampoo
1
salicylic acid/ceramide cmb #1 6 % combo. pkg
1
salicylic acid/ceramide cmb #1 6 % kit clcmer
1
SALVAX 6% FOAM
salicylic acid
1
PAGE 278
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
SCALACORT 2% LOTION
hydrocortisone
1
SE 10-5 SS CREAM
sulfacetamide sodium/sulfur/witch hazel
1
SE BPO 7% WASH
benzoyl peroxide microspheres
1
SE BPO 7-5.5% WASH KIT
benzoyl peroxide microspheres
1
selenium sulfide 2.25 % shampoo
1
silver nitrate 10 % solution
1
silver nitrate applicator 75%-25% stick (ea)
1
SINELEE 0.0375%-5% PATCH
capsaicin/menthol
1
sodium lauryl sulfate crystals
1
SS 10-2 CLEANSER
sulfacetamide sodium/sulfur
1
SSS 10-5 CREAM
sulfacetamide sodium/sulfur
1
SSS 10-5 FOAM
sulfacetamide sodium/sulfur
1
sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser
1
sulfacetamide sodium/sulfur 10 %-2 % cleanser
1
sulfacetamide sodium/sulfur 10 %-2 % cream (g)
1
sulfacetamide sodium/sulfur 10 %-4 % med. pad
1
sulfacetamide sodium/sulfur 10 %-5 % foam
1
sulfacetamide sodium/sulfur 10 %-5 % med. pad
1
sulfacetamide sodium/sulfur 10-5%(w/v) lotion
1
sulfacetamide sodium/sulfur 10-5%(w/w) cleanser
1
sulfacetamide sodium/sulfur 10-5%(w/w) cream (g)
1
sulfacetamide sodium/sulfur 10-5%(w/w) lotion
1
sulfacetamide sodium/sulfur 10-5%(w/w) suspension
1
sulfacetamide sodium/sulfur 8 %-4 % suspension
1
sulfacetamide sodium/sulfur 9 %-4 % cleanser
1
sulfacetamide sodium/sulfur 9 %-4.5 % cleanser
1
PAGE 279
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
sulfacetamide sodium/sulfur 9.8%-4.8% cleanser
1
sulfacetamide sodium/sulfur 9.8%-4.8% cream (g)
1
sulfacetamide sodium/sulfur 9.8%-4.8% lotion
1
sulfacetamide sodium/urea 10 %-10 % med. pad
1
sulfacetamide/sulfur/cleansr23 9 %-4.5 % kit
1
SULFACLEANSE 8-4 SUSPENSION
sulfacetamide sodium/sulfur
1
sulfact sod/sulur/avob/otn/oct 9 %-4.5 % cmb cln cr
1
SYNERA PATCH
lidocaine/tetracaine
1
SYNVEXIA 4%-1% PATCH
lidocaine hcl/menthol
1
tacrolimus 0.03 % oint. (g)
1
tacrolimus 0.1 % oint. (g)
1
TARGRETIN 1% GEL
bexarotene
1
TL 45% UREA LOTION
urea
1
TL-CERMIDE SKIN EMULSION
emollient combination no.32
1
TRETIN-X 0.025% CREAM COMB PCK
tretinoin/emollient combination no. 9/skin cln1
1
TRETIN-X 0.05% COMBO PACK
tretinoin/emollient combination no. 9/skin cln1
1
TRETIN-X 0.1% COMBO PACK
tretinoin/emollient combination no. 9/skin cln1
1
tretinoin 0.01 % gel (gram)
1
LIMITS & RESTRICTIONS
PA
AL
Up to 35 yrs old
PA
AL
Up to 35 yrs old
PA
AL
Up to 35 yrs old
PA
AL
Up to 35 yrs old
PA
tretinoin 0.025 % cream (g)
1
AL
Up to 35 yrs old
PA
tretinoin 0.025 % gel (gram)
1
AL
Up to 35 yrs old
PA
tretinoin 0.05 % cream (g)
1
AL
PAGE 280
Up to 35 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
PA
tretinoin 0.1 % cream (g)
1
AL
Up to 35 yrs old
PA
tretinoin microspheres 0.04 % gel (gram)
1
AL
Up to 35 yrs old
PA
tretinoin microspheres 0.04 % gel w/pump
1
AL
Up to 35 yrs old
PA
tretinoin microspheres 0.1 % gel (gram)
1
AL
Up to 35 yrs old
PA
tretinoin microspheres 0.1 % gel w/pump
1
AL
tretinoin/emollient base 0.05 % cream (g)
1
TRI-CHLOR 80% SOLUTION
trichloroacetic acid
1
triamcinolone acetonide 0.025 % cream (g)
1
triamcinolone acetonide 0.025 % lotion
1
triamcinolone acetonide 0.025 % oint. (g)
1
triamcinolone acetonide 0.1 % cream (g)
1
triamcinolone acetonide 0.1 % lotion
1
triamcinolone acetonide 0.1 % oint. (g)
1
triamcinolone acetonide 0.1 % paste (g)
1
triamcinolone acetonide 0.147mg/g aerosol
1
triamcinolone acetonide 0.5 % cream (g)
1
triamcinolone acetonide 0.5 % oint. (g)
1
TRIANEX 0.05% OINTMENT
triamcinolone acetonide
1
TRIDERM 0.1% CREAM
triamcinolone acetonide
1
UMECTA 40% MOUSSE
urea
1
urea 35 % foam
1
urea 39 % cream (g)
1
urea 40 % cream (g)
1
PAGE 281
Up to 35 yrs old
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
urea 40 % gel (ml)
1
urea 40 % lotion
1
urea 40 % nl fm susp
1
urea 45 % cream (g)
1
urea 45 % gel (ml)
1
urea 45 % lotion
1
urea 47 % cream (g)
1
urea 50 % cream (g)
1
urea 50 % sol/pf app
1
urea/hyaluronate sodium 40%-0.2% kit
1
urea/lactic ac/zn undecylenate 50 % emulsn(g)
1
urea/lactic acid/salicylic ac 50 % suspension
1
VALCHLOR 0.016% GEL
mechlorethamine hcl
1
VIRTI-SULF EMOLLIENT CREAM
sulfacetamide sodium/sulfur
1
VUSION OINTMENT
miconazole nitrate/zinc oxide/petrolatum,white
1
X-VIATE 40% CREAM
urea
1
X-VIATE 40% GEL
urea
1
X-VIATE 40% LOTION
urea
1
XCLAIR CREAM
hyaluronate sodium/vite ac/emol cmb12/allantoin/shea tree
1
Z-PRAM CREAM KIT
hydrocortisone acetate/pramoxine hcl/skin cleanser no.16
1
ZENATANE 10 MG CAPSULE
isotretinoin
1
ZENATANE 20 MG CAPSULE
isotretinoin
1
ZENATANE 30 MG CAPSULE
isotretinoin
1
ZENATANE 40 MG CAPSULE
isotretinoin
1
PAGE 282
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ZENCIA WASH
sulfacetamide sodium/sulfur
1
ZERUVIA 4%-1% PATCH
lidocaine hcl/menthol
1
LIMITS & RESTRICTIONS
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
flavoxate hcl 100 mg tablet
1
oxybutynin chloride 10 mg tab er 24
1
QL
60 / 30 days
oxybutynin chloride 15 mg tab er 24
1
QL
60 / 30 days
oxybutynin chloride 5 mg tab er 24
1
QL
30 / 30 days
oxybutynin chloride 5 mg tablet
1
oxybutynin chloride 5 mg/5 ml syrup
1
tolterodine tartrate 1 mg tablet
1
tolterodine tartrate 2 mg cap er 24h
1
tolterodine tartrate 2 mg tablet
1
tolterodine tartrate 4 mg cap er 24h
1
trospium chloride 60 mg cap er 24h
1
aminophylline 100 mg tablet
1
aminophylline 200 mg tablet
1
DIFIL-G 400 TABLET
guaifenesin/dyphylline
1
DYLIX 100 MG/15 ML ELIXIR
dyphylline
1
sildenafil citrate 20 mg tablet
1
THEO-24 ER 100 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 200 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 300 MG CAPSULE
theophylline anhydrous
1
THEO-24 ER 400 MG CAPSULE
theophylline anhydrous
1
THEOCHRON ER 100 MG TABLET
theophylline anhydrous
1
PAGE 283
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
THEOCHRON ER 200 MG TABLET
theophylline anhydrous
1
THEOCHRON ER 300 MG TABLET
theophylline anhydrous
1
theophylline anhydrous 100 mg tab er 12h
1
theophylline anhydrous 200 mg tab er 12h
1
theophylline anhydrous 300 mg tab er 12h
1
theophylline anhydrous 400 mg tablet er
1
theophylline anhydrous 450 mg tab er 12h
1
theophylline anhydrous 600 mg tablet er
1
theophylline anhydrous 80 mg/15ml elixir
1
theophylline anhydrous 80 mg/15ml solution
1
LIMITS & RESTRICTIONS
UNCATEGORIZED
AFINITOR 10 MG TABLET
everolimus
1
AFINITOR 2.5 MG TABLET
everolimus
1
AFINITOR 5 MG TABLET
everolimus
1
AFINITOR 7.5 MG TABLET
everolimus
1
ALFERON N 5 MILLION UNITS VIAL
interferon alfa-n3
1
ALKERAN 2 MG TABLET
melphalan
1
almond oil oil
1
ALTAFLUOR EYE DROPS
benoxinate hcl/fluorescein sodium
1
anastrozole 1 mg tablet
1
AVO CREAM TOPICAL EMULSION
emollient combination no.10
1
benoxinate hcl/fluorescein na 0.4%-0.25% drops
1
benzalkonium chloride 17 % solution
1
benzoin tincture
1
bicalutamide 50 mg tablet
1
PAGE 284
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
BIOGLO 1 MG OPHTHALMIC STRIPS
fluorescein sodium
1
bismuth tribromoph/petrolatum 1"x8" bandage
1
bismuth tribromoph/petrolatum 2" x 2" bandage
1
bismuth tribromoph/petrolatum 4" x 4" bandage
1
bismuth tribromoph/petrolatum 4"x108" bandage
1
bismuth tribromoph/petrolatum 5"x9" bandage
1
BOSULIF 100 MG TABLET
bosutinib
1
BOSULIF 500 MG TABLET
bosutinib
1
capecitabine 150 mg tablet
1
capecitabine 500 mg tablet
1
CEENU 10 MG CAPSULE
lomustine
1
CEENU 100 MG CAPSULE
lomustine
1
CEENU 40 MG CAPSULE
lomustine
1
CERVIDIL 10 MG VAGINAL INSRT
dinoprostone
1
citric acid 100 % granules
1
citric acid monohydrate 100 % granules
1
colostomy bag, non-sterile 470-10 1/4 each
1
COMETRIQ 100 MG DAILY-DOSE PK
cabozantinib s-malate
1
COMETRIQ 140 MG DAILY-DOSE PK
cabozantinib s-malate
1
COMETRIQ 60 MG DAILY-DOSE PACK
cabozantinib s-malate
1
compressor, for nebulizer each
1
CREON DR 12,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 24,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 3,000 UNITS CAPSULE
lipase/protease/amylase
1
PAGE 285
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CREON DR 36,000 UNITS CAPSULE
lipase/protease/amylase
1
CREON DR 6,000 UNITS CAPSULE
lipase/protease/amylase
1
CUPRIMINE 250 MG CAPSULE
penicillamine
1
cyclophosphamide 25 mg capsule
1
cyclophosphamide 25 mg tablet
1
cyclophosphamide 50 mg capsule
1
cyclophosphamide 50 mg tablet
1
diaphragms, arc-spring 65mm kit
1
diaphragms, arc-spring 70mm kit
1
diaphragms, arc-spring 75mm kit
1
diaphragms, arc-spring 80mm kit
1
diaphragms, wide seal 60mm diaphragm
1
diaphragms, wide seal 65mm diaphragm
1
diaphragms, wide seal 70mm diaphragm
1
diaphragms, wide seal 75mm diaphragm
1
diaphragms, wide seal 80mm diaphragm
1
diaphragms, wide seal 85mm diaphragm
1
diaphragms, wide seal 90mm diaphragm
1
diaphragms, wide seal 95mm diaphragm
1
drainage bag each
1
drainage bag 2000ml each
1
DYNAMIC KIT
lidocaine hcl/glycerin
1
ELETONE CREAM
emollient combination no. 25
1
ELETONE CREAM TWIN PACK
emollient combination no. 25
1
EMCYT 140 MG CAPSULE
estramustine phosphate sodium
1
EMULSION SB TOPICAL EMULSION
emollient combination no.32
1
PAGE 286
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
EMULSION SB TOPICAL TWIN PACK
emollient combination no.32
1
ERIVEDGE 150 MG CAPSULE
vismodegib
1
ethyl acetate liquid
1
ethyl vanillin flakes
1
etoposide 50 mg capsule
1
exemestane 25 mg tablet
1
FARYDAK 10 MG CAPSULE
panobinostat lactate
1
FARYDAK 15 MG CAPSULE
panobinostat lactate
1
FARYDAK 20 MG CAPSULE
panobinostat lactate
1
FLUCAINE EYE DROPS
proparacaine hcl/fluorescein sodium
1
FLUORETS 1 MG OPTH STRIPS
fluorescein sodium
1
FLUROX EYE DROPS
benoxinate hcl/fluorescein sodium
1
flutamide 125 mg capsule
1
FORMA-RAY 20% SOLUTION
formaldehyde
1
FORMADON 10% SOLUTION
formaldehyde
1
formaldehyde 10 % sol w/appl
1
FUL-GLO 1 MG OPTH STRIPS
fluorescein sodium
1
gauze bandage 0.25"x36" bandage
1
gauze bandage 1" x 5yard bandage
1
gel dressing gel (gram)
1
GILOTRIF 20 MG TABLET
afatinib dimaleate
1
GILOTRIF 30 MG TABLET
afatinib dimaleate
1
GILOTRIF 40 MG TABLET
afatinib dimaleate
1
PAGE 287
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
GLEEVEC 100 MG TABLET
imatinib mesylate
1
GLEEVEC 400 MG TABLET
imatinib mesylate
1
GLEOSTINE 10 MG CAPSULE
lomustine
1
GLEOSTINE 100 MG CAPSULE
lomustine
1
GLEOSTINE 40 MG CAPSULE
lomustine
1
GLUCAGEN DIAGNOSTIC 1 MG VIAL
glucagon,human recombinant
1
HEXALEN 50 MG CAPSULE
altretamine
1
HPR EMOLLIENT FOAM
emollient combination no.44
1
HPR PLUS CREAM
emollient combination no.53
1
HPR PLUS EMOLLIENT FOAM
emollient combination no.53
1
HYCAMTIN 0.25 MG CAPSULE
topotecan hcl
1
HYCAMTIN 1 MG CAPSULE
topotecan hcl
1
hydrocolloid dressing 1.5"x2.5" bandage
1
hydrocolloid dressing 2"x2.75" bandage
1
hydrocolloid dressing 3.5"x5.5" bandage
1
hydrocolloid dressing 4" x 4" bandage
1
hydrocolloid dressing 6" x 8" bandage
1
hydrocolloid dressing 7"x8" bandage
1
hydroxyurea 500 mg capsule
1
IBRANCE 100 MG CAPSULE
palbociclib
1
IBRANCE 125 MG CAPSULE
palbociclib
1
IBRANCE 75 MG CAPSULE
palbociclib
1
PAGE 288
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ICLUSIG 15 MG TABLET
ponatinib hcl
1
ICLUSIG 45 MG TABLET
ponatinib hcl
1
IMBRUVICA 140 MG CAPSULE
ibrutinib
1
inhaler, assist devices spacer
1
inhaler,assist device,accesory each
1
INLYTA 1 MG TABLET
axitinib
1
INLYTA 5 MG TABLET
axitinib
1
INTRON A 10 MILLION UNIT/ML
interferon alfa-2b,recomb.
1
INTRON A 10 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 18 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 50 MILLION UNITS VIAL
interferon alfa-2b,recomb.
1
INTRON A 6 MILLION UNIT/ML VL
interferon alfa-2b,recomb.
1
IRESSA 250 MG TABLET
gefitinib
1
JAKAFI 10 MG TABLET
ruxolitinib phosphate
1
JAKAFI 15 MG TABLET
ruxolitinib phosphate
1
JAKAFI 20 MG TABLET
ruxolitinib phosphate
1
JAKAFI 25 MG TABLET
ruxolitinib phosphate
1
JAKAFI 5 MG TABLET
ruxolitinib phosphate
1
lactic acid 88% to 92% liquid
1
LENVIMA 10 MG DAILY DOSE
lenvatinib mesylate
1
LENVIMA 14 MG DAILY DOSE
lenvatinib mesylate
1
PAGE 289
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
LENVIMA 20 MG DAILY DOSE
lenvatinib mesylate
1
LENVIMA 24 MG DAILY DOSE
lenvatinib mesylate
1
letrozole 2.5 mg tablet
1
LEUKERAN 2 MG TABLET
chlorambucil
1
leuprolide acetate 1 mg/0.2ml kit
1
LYNPARZA 50 MG CAPSULE
olaparib
1
MATULANE 50 MG CAPSULE
procarbazine hcl
1
MB HYDROGEL KIT
emol#53/na mg fluorosilicate/cyclometh/phosph ac/nahco3/nacl
1
MB HYDROGEL KIT
emol53/e.water/namgfs/naphos/nacl/hypochlorous
acid/nahypocl
1
megestrol acetate 20 mg tablet
1
megestrol acetate 40 mg tablet
1
megestrol acetate 400mg/10ml oral susp
1
megestrol acetate 800mg/20ml oral susp
1
mercaptopurine 50 mg tablet
1
methotrexate sodium 2.5 mg tablet
1
methotrexate sodium 25 mg/ml vial
1
methylergonovine maleate 0.2 mg tablet
1
MYLERAN 2 MG TABLET
busulfan
1
nebulizer each
1
nebulizer accessories each
1
nebulizer accessories kit
1
nebulizer/compressor each
1
needles, insulin disposable 30gx5/16" dis needle
1
QL
100 / 30 days
needles, insulin disposable 31 gx3/16" dis needle
1
QL
100 / 30 days
needles, insulin disposable 31 gx5/16" dis needle
1
QL
100 / 30 days
PAGE 290
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NEXAVAR 200 MG TABLET
sorafenib tosylate
1
NIVATOPIC PLUS CREAM
emollient combination no.53
1
NUMOISYN LOZENGE
sorbitol/saliva stimulant comb no. 1/malic acid/cal phos
1
ostomy kit kit
1
ostomy supply each
1
PANCREAZE DR 10,500 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 16,800 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 21,000 UNIT CAP
lipase/protease/amylase
1
PANCREAZE DR 4,200 UNIT CAP
lipase/protease/amylase
1
PANCRELIPASE DR 5,000 UNIT CAP
lipase/protease/amylase
1
peak flow meter each
1
polyhexam biguan/gauze bandage 0.2%-1/2x3 strip
1
PR CREAM KIT
protectives combination no.2/ceramides 1,3,6-11
1
PREPIDIL 0.5 MG/3 GM GEL
dinoprostone
1
proparacaine/fluorescein sod 0.5%-0.25% drops
1
PROSTIN E2 VAGINAL 20 MG SUP
dinoprostone
1
PRUCLAIR NONSTEROIDAL CREAM
vitamin e acet (dl,tocopheryl)/grape/hyaluronic acid
1
PRUTECT TOPICAL EMULSION
emollient combination no.10
1
PULMOSAL 7% VIAL
sodium chloride for inhalation
1
PULMOZYME 1 MG/ML AMPUL
dornase alfa
1
PURIXAN 20 MG/ML ORAL SUSP
mercaptopurine
1
PAGE 291
LIMITS & RESTRICTIONS
PA
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
RECEDO TOPICAL GEL
polydimethylsiloxanes/silicon dioxide
1
REVLIMID 10 MG CAPSULE
lenalidomide
1
REVLIMID 15 MG CAPSULE
lenalidomide
1
REVLIMID 2.5 MG CAPSULE
lenalidomide
1
REVLIMID 20 MG CAPSULE
lenalidomide
1
REVLIMID 25 MG CAPSULE
lenalidomide
1
REVLIMID 5 MG CAPSULE
lenalidomide
1
RIDAURA 3 MG CAPSULE
auranofin
1
sodium bisulfite granules
1
sodium chloride for inhalation 0.9 % vial-neb
1
sodium chloride for inhalation 10 % vial-neb
1
sodium lauryl sulfate crystals
1
SPRYCEL 100 MG TABLET
dasatinib
1
SPRYCEL 140 MG TABLET
dasatinib
1
SPRYCEL 20 MG TABLET
dasatinib
1
SPRYCEL 50 MG TABLET
dasatinib
1
SPRYCEL 70 MG TABLET
dasatinib
1
SPRYCEL 80 MG TABLET
dasatinib
1
STIVARGA 40 MG TABLET
regorafenib
1
SUTENT 12.5 MG CAPSULE
sunitinib malate
1
SUTENT 25 MG CAPSULE
sunitinib malate
1
PAGE 292
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
LIMITS & RESTRICTIONS
SUTENT 37.5 MG CAPSULE
sunitinib malate
1
SUTENT 50 MG CAPSULE
sunitinib malate
1
syring w-ndl,disp,insul,0.3 ml 30gx5/16" disp syrin
1
QL
100 / 30 days
syring w-ndl,disp,insul,0.5 ml 28 gauge disp syrin
1
QL
100 / 30 days
syring w-ndl,disp,insul,0.5 ml 29 g x1/2" disp syrin
1
QL
100 / 30 days
syring w-ndl,disp,insul,0.5 ml 30gx5/16" disp syrin
1
QL
100 / 30 days
syringe & needle,insulin,1 ml disp syrin
1
QL
100 / 30 days
syringe & needle,insulin,1 ml 28gx1/2" disp syrin
1
QL
100 / 30 days
syringe & needle,insulin,1 ml 29 g x1/2" disp syrin
1
QL
100 / 30 days
syringe & needle,insulin,1 ml 30gx5/16" disp syrin
1
QL
100 / 30 days
TABLOID 40 MG TABLET
thioguanine
1
tamoxifen citrate 10 mg tablet
1
tamoxifen citrate 20 mg tablet
1
TARCEVA 100 MG TABLET
erlotinib hcl
1
TARCEVA 150 MG TABLET
erlotinib hcl
1
TARCEVA 25 MG TABLET
erlotinib hcl
1
TARGRETIN 75 MG CAPSULE
bexarotene
1
TARGRETIN 75 MG SOFTGEL
bexarotene
1
TASIGNA 150 MG CAPSULE
nilotinib hcl
1
TASIGNA 200 MG CAPSULE
nilotinib hcl
1
temozolomide 100 mg capsule
1
temozolomide 140 mg capsule
1
temozolomide 180 mg capsule
1
PAGE 293
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
temozolomide 20 mg capsule
1
temozolomide 250 mg capsule
1
temozolomide 5 mg capsule
1
TL-CERMIDE SKIN EMULSION
emollient combination no.32
1
tolbutamide 500 mg tablet
1
tolu balsam lump
1
tretinoin 10 mg capsule
1
TYKERB 250 MG TABLET
lapatinib ditosylate
1
vanillin crystals
1
VOTRIENT 200 MG TABLET
pazopanib hcl
1
XCLAIR CREAM
hyaluronate sodium/vite ac/emol cmb12/allantoin/shea tree
1
XTANDI 40 MG CAPSULE
enzalutamide
1
ZELBORAF 240 MG TABLET
vemurafenib
1
ZENPEP DR 10,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 15,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 20,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 25,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 3,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 40,000 UNITS CAPSULE
lipase/protease/amylase
1
ZENPEP DR 5,000 UNITS CAPSULE
lipase/protease/amylase
1
ZOLINZA 100 MG CAPSULE
vorinostat
1
ZYDELIG 100 MG TABLET
idelalisib
1
PAGE 294
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
ZYDELIG 150 MG TABLET
idelalisib
1
ZYKADIA 150 MG CAPSULE
ceritinib
1
ZYTIGA 250 MG TABLET
abiraterone acetate
1
LIMITS & RESTRICTIONS
VITAMINS
ADVANCED AM/PM COMBO PACK
omega-3 fatty acids/ca carbonate/vitamin d3/fa/mv cmb 13
1
AP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
B-PLEX TABLET
folic acid/vitamin b comp w-c
1
b12/levomefolate calcium/b-6 2-1.13-25 tablet
1
b3/azel/quer/tur/fa/b6/zn/copp 700 mg-500 tablet
1
BAL-CARE DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
BP FOLINATAL PLUS B TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
BP MULTINATAL PLUS CHEW TABLET
prenatal vitamin w-o vit a/ferrous fumarate/folic acid
1
BP VIT 3 CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
BP VIT 3 PLUS CAPSULE
omega-3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol
1
C-NATE DHA SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
cal carb/mgox/d3/b12/fa/b6/bor 500-300-1 wafer
1
calcitriol 0.25 mcg capsule
1
calcitriol 0.5 mcg capsule
1
calcitriol 1 mcg/ml solution
1
CALCIUM-PNV 28-1-250 MG SFTGL
prenatal vits with calcium #70/ferrous fumarate/fa/dha
1
CAVAN-ALPHA KIT COMBO PACK
prenatal vitamin no.67/sodium feredetate-iron poly/fa/omega3
1
CAVAN-EC SOD DHA VITAMINS
prenatal vitamins comb no.48/iron na feredetate/fa/omega-3
1
PAGE 295
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
CENTRATEX CAPSULE
ferrous fumarate/folic acid/multivitamins with min no. 15
1
CHOICE-OB + DHA COMBO PACK
prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha
1
CHOICE-TABS TABLET
multivit with min#10/folic acid//vit d3/a lipoic acid/lutein
1
CIFEREX 3,775 UNIT-1 MG CAP
cholecalciferol (vit d3)/folic acid
1
COMPLETE NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
COMPLETENATE TABLET CHEW
prenatal vitamins combo no.14/ferrous fumarate/folic acid
1
cyanocobalamin/fa/pyridoxine 0.5-2.2-25 tablet
1
cyanocobalamin/fa/pyridoxine 2-2.5-25mg tablet
1
DIALYVITE TABLET
folic acid/vitamin b comp w-c
1
DIALYVITE WITH ZINC TABLET
vitamin b complex#11/folic acid/ascorbic acid/biotin/zn oxid
1
doxercalciferol 0.5 mcg capsule
1
doxercalciferol 1 mcg capsule
1
doxercalciferol 2.5 mcg capsule
1
ELITE OB DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
ELITE-OB 400 CAPSULE
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
ELITE-OB CAPLET
iron,carbonyl/folic acid/multivitamin w-minerals
1
ergocalciferol (vitamin d2) 50000 unit capsule
1
fa/niacinamide/cupric ox/zn ox 0.5-750 mg tab mphase
1
FABB TABLET
cyanocobalamin/folic acid/pyridoxine
1
FE 90 PLUS TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
FE C PLUS TABLET
iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
1
FEROCON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
PAGE 296
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FERRAPLUS 90 TABLET
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
1
FERREX 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
FERREX 150 FORTE PLUS CAPSULE
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
FERREX 28 TABLET
iron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
1
FERROCITE PLUS TABLET
iron/folic acid/vitamin b comp w-c/minerals
1
FERROGELS FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
fluoride/iron/vit a,c&d 0.25 mg/ml drops
1
FOCALGIN 90 DHA COMBO PACK
prenatal vitamins no.72/iron carbonyl & gluconate/fa/dss/dha
1
FOCALGIN CA COMBO PACK
prenatal vitamins no.73/iron carbonyl & gluconate/fa/dss/dha
1
FOCALGIN DSS TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
FOLASTIN TABLET
cyanocobalamin/folic acid/pyridoxine
1
FOLBECAL TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
FOLBEE PLUS CZ TABLET
folic acid/vitamin b comp w-c/copper/zinc oxide
1
FOLBEE PLUS TABLET
folic acid/vitamin b comp w-c
1
FOLBEE TABLET
cyanocobalamin/folic acid/pyridoxine
1
FOLBIC RF TABLET
cyanocobalamin/levomefolate calcium/pyridoxine hcl
1
FOLBIC TABLET
cyanocobalamin/folic acid/pyridoxine
1
FOLCAPS TABLET
cyanocobalamin/folic acid/pyridoxine
1
folic acid 1 mg tablet
1
FOLIVANE-F CAPSULE
iron fumarate & polysac comp/folic acid/vitamin c/niacin
1
PAGE 297
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
FOLIVANE-OB CAPSULE
prenatal vitamins no.15/iron fumarate & polysac comp/fa
1
FOLIVANE-PLUS CAPSULE
iron fumarate & polysac comp/folic acid/vit b comp & c no.9
1
FOLIVANE-PRX DHA NF CAPSULE
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
FOLPLEX 2.2 TABLET
cyanocobalamin/folic acid/pyridoxine
1
FOLTANX TABLET
mecobalamin/levomefolate calcium/pyridoxal phosphate
1
HEMATINIC-FOLIC ACID TABLET
ferrous fumarate/folic acid
1
HEMATINIC-VITAMIN-MINERAL TAB
iron/folic acid/vitamin b comp w-c/minerals
1
HEMATOGEN FA SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
HEMATOGEN FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
HEMENATAL OB + DHA COMBO PACK
prenatal vitamin combo no.22/iron/folic acid/omega-3/dha
1
HEMENATAL OB TABLET
prenatal vitamin no.21/iron polysaccharid & heme polypep/fa
1
HEMETAB IRON SUPPLEMENT TABLET
iron polysacchar complx/iron heme polypeptide/folic acid/b12
1
IFEREX 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
INATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
INATAL GT TABLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
INATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
INFANATE PLUS SOFTGEL
prenatal vitamins no.59/iron carbonyl & fumarate/fa/dss/dha
1
iron ag/c/b12/ca/suc.acid/stom 70-150-10 tablet
1
iron aspgly&ps/c/b12/fa/ca/suc 150-25-1 capsule
1
iron fum & ag/c/b12/fa/ca/succ 151-60-1mg tablet
1
L-METHYL-B6-B12 TABLET
mecobalamin/levomefolate calcium/pyridoxal phosphate
1
PAGE 298
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
L-METHYL-MC TABLET
cyanocobalamin/levomefolate calcium/pyridoxine/riboflavin
1
L-METHYLFOLATE FORTE 15 MG CAP
levomefolate calcium/schizochytrium algal oil
1
L-METHYLFOLATE FORTE 7.5 MG CP
levomefolate calcium/schizochytrium algal oil
1
L-METHYLFOLATE PNV DHA SOFTGEL
prenatal vit with calcium no42/iron fum/fa/l-mefolate ca/dha
1
LACTOCAL-F TABLET
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
leucovorin calcium 10 mg tablet
1
leucovorin calcium 15 mg tablet
1
leucovorin calcium 25 mg tablet
1
leucovorin calcium 5 mg tablet
1
levomefolate/algal oil 15-90.314 capsule
1
levomefolate/algal oil 7.5-90.314 capsule
1
lmfol ca/acetyl/mb12/algal oil 6-600-2 mg tablet
1
LMTHF-PYRIDOXINE-CYANOCOBA TB
cyanocobalamin/levomefolate calcium/pyridoxine hcl
1
MACNATAL CN DHA SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
MEPHYTON 5 MG TABLET
phytonadione
1
METAFOLBIC PLUS RF CAPLET
levomefolate ca/acetylcysteine/mecobalamin/schiz. algal oil
1
METAFOLBIC TABLET
cyanocobalamin/levomefolate calcium/pyridoxine/riboflavin
1
methyl-b12/l-mefolate/b6 phos 2-3-35 mg tablet
1
MI-OMEGA NF CAPSULE
omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols
1
MULTIGEN CAPLET
iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach
1
MULTIGEN FOLIC CAPLET
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
1
MULTIGEN PLUS CAPLET
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
1
MULTIVITAMINS CHEWABLES TABLET
pediatric multivitamin no.22/cholecalciferol/phytonadione
1
PAGE 299
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
multivitamins with fluoride 0.25 mg/ml drops
1
multivitamins with fluoride 0.5 mg/ml drops
1
multivits with iron & fluoride 0.25 mg/ml drops
1
multivits with iron & fluoride 0.5 mg/ml drops
1
MVC-FLUORIDE 0.25 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
MVC-FLUORIDE 0.5 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
MVC-FLUORIDE 1 MG TAB CHEW
pediatric multivitamins combination no.12/sodium fluoride
1
MYFERON-150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
MYNATAL ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
MYNATAL CAPSULE
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL PLUS CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATAL ULTRACAPLET
prenatal vitamins with calcium/iron,carbonyl/docusate/fa
1
MYNATAL-Z CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
MYNATE 90 PLUS CAPLET SA
prenatal vitamins with calcium/ferrous fumarate/docusate/fa
1
MYNEPHROCAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
1
NATALVIRT 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
NATALVIRT CA COMBO PACK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
NATALVIRT FLT TABLET
iron, carbonyl & gluconate/fa/vit b12/vit c/docusate sodium
1
NEPHPLEX RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin/znox
1
NEPHRO-VITE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
1
NEWGEN TABLET
prenatal vitamin no.86/iron bis-glycinate/folic acid
1
PAGE 300
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
NICOTINAMIDE TABLET
folic acid/niacinamide/cupric oxide/zinc oxide
1
paricalcitol 1 mcg capsule
1
paricalcitol 2 mcg capsule
1
paricalcitol 4mcg capsule
1
ped mv a,c,d3 #21 w-fluoride 0.25 mg/ml drops
1
ped mv a,c,d3 #21 w-fluoride 0.5 mg/ml drops
1
pedi m.vit no.17 with fluoride 0.25 mg tab chew
1
pedi m.vit no.17 with fluoride 0.5 mg tab chew
1
pedi m.vit no.17 with fluoride 1 mg tab chew
1
pedi multivit no.2 w-fluoride 0.25 mg/ml drops
1
pedi multivit no.2 w-fluoride 0.5 mg/ml drops
1
pedi mv #45/fluoride/iron 0.25-10/ml drops
1
pedi mv #75/fluoride/iron 0.25-10/ml drops
1
pedi mvi no.16 with fluoride 0.25 mg tab chew
1
pedi mvi no.16 with fluoride 0.5 mg tab chew
1
pedi mvi no.16 with fluoride 1 mg tab chew
1
pedi mvi no.82 with fluoride 0.25 mg/ml drops
1
pedi mvi no.82 with fluoride 0.5 mg/ml drops
1
phytonadione crystals
1
phytonadione 100 % liquid
1
pnv #19/iron ps&heme/folic/dha 22-6-1-200 capsule
1
PNV OB+DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
pnv w-o ca no5/fe fumarate/fa 106.5-1mg capsule
1
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
1
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
1
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
1
PNV-DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
PNV-FIRST SOFTGEL
prenatal vitamins no.26/iron polysaccharides/fa/dha
1
PNV-OB WITH DHA COMBO PACK
prenatal vitamins comb 10/ferrous fumarate/folic acid/dha
1
PAGE 301
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PNV-OMEGA SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
PNV-SELECT TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
PNV-TOTAL SOFTGEL
pnv no17/iron,carb/iron bisgly/fa/fish oil/dha/omega 3,6 #1
1
PNV-VP-U CAPSULE
prenatal vits without calc no5/ferrous fumarate/folic acid
1
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
1
POLY-IRON 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
1
PR NATAL 400 COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 400 EC COMBO PACK
prenatal vitamins comb no.19/iron bg hcl&suc-prot/fa/omega-3
1
PR NATAL 430 COMBO PACK
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
PR NATAL 430 EC COMBO PACK
prenatal vitamins comb no.55/iron bg hcl&suc-prot/fa/omega-3
1
PRENA1 CHEW TABLET
prenatal vitamins combination no.42/folic acid
1
PRENA1 PEARL SOFTGEL
prenatal vit no.71/iron fum-sodium feredetate/folic acid/dha
1
PRENAFIRST TABLET
prenatal vitamins with calcium/ferrous fumarate/folic acid
1
PRENAISSANCE 90 DHA COMBO PACK
prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha
1
PRENAISSANCE CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
PRENAISSANCE DHA COMBO PACK
prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha
1
PRENAISSANCE PLUS SOFTGEL
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
PRENAISSANCE PROMISE COMBO PCK
prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha
1
PRENAPLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
1
PAGE 302
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
PRENATE PLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
PREPLUS CA-FE 27 MG-FA 1 MG TB
prenatal vits with calcium #72/ferrous fumarate/folic acid
1
PUREVIT DUALFE PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
RELAMINE TABLET
glucosamine sulfate/chondroitin sulfate a/antioxid multvit#5
1
RELNATE DHA PRENATAL SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
1
RENA-VITE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
1
RENAL CAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
1
RENO CAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
1
SE-CARE CHEWABLE TABLET
prenatal vitamin w-o vit a/ferrous fumarate/folic acid
1
SE-NATAL 19 CHEWABLE TABLET
prenatal vits with calcium#118/ferrous fumarate/folic acid
1
SE-NATAL 19 TABLET
prenatal vitamins comb no.119/iron fumarate/folic acid/dss
1
SE-NATAL ONE TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
SE-PLETE DHA SOFTGEL
prenatal vits w-o ca comb. no. 7 w/ iron & folic acid & dha
1
SE-TAN DHA CAPSULE
prenatal vit w/o calc no.10/iron fum&polysac comp/fa/omega-3
1
SE-TAN PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
1
SETONET PRENATAL VITAMIN
prenatal vitamins comb no.54/iron b-g hcl suc-p/fa/omega-3
1
SETONET-EC PRENATAL VITAMINS
prenatal vitamins comb no.55/iron bg hcl&succ-p2/fa/omega-3
1
STROVITE PLUS CAPLET
multivits, iron, minerals combo no #6, folic acid
1
STROVITE TABLET
vitamin b comp and vit c no.6
1
TARON FORTE CAPSULE
iron bisgly & ps cmplx/ascorbate ca/b12/folic acid/ca-threo
1
PAGE 303
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TARON-BC TABLET
prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6
1
TARON-C DHA CAPSULE
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
TARON-DUO EC COMB PACK
prenatal vitamins comb no.19/iron bg hcl&succ-p2/fa/omega-3
1
TARON-PREX PRENATAL DHA CAP
prenatal vit with calcium no.39/iron fum/folic acid/dss/dha
1
THERAPEUTIC HEMATINIC TAB
multivits,therap w-fe,hematin
1
TL G-FOL OS TABLET
ca carbonate/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
1
TL GARD RX TABLET
cyanocobalamin/folic acid/pyridoxine
1
TL ICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
TL-CARE DHA SOFTGEL
pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa
1
TL-FLUORIVITE CHEWABLE TABLET
pediatric multivitamin no.47 with iron & sodium fluoride
1
TL-FOL 500 CAPLET
ferrous sulfate/ascorbic acid/folic acid
1
TL-HEM 150 CAPLET
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
1
TL-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
TRI RX TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
TRI-TABS DHA COMBO PACK
prenatal vitamins comb no.87/iron bisgly/folic acid/dha
1
TRI-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
TRIADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
TRICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
1
TRIGELS-F FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
1
TRIMESIS RX TABLET
prenatal without iron/folic acid/calcium carb/pyridoxine/b12
1
PAGE 304
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
TRINATAL GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
TRINATAL RX 1 TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
TRINATAL ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
TRIPHROCAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
1
TRIVEEN-DUO DHA COMBO PACK
prenatal vitamins comb no.53/iron b-g hcl suc-p/fa/omega-3
1
TRIVEEN-TEN TABLETS
prenatal vitamins no.18/iron,carbonyl/fa/ubidecarenone/dha
1
TRIVEEN-U CAPSULE
prenatal vits without calc no5/ferrous fumarate/folic acid
1
TRUST NATAL DHA
prenatal vits with calcium #2/iron b-g suc-p/fa/omega-3
1
ULTIMATE OB DHA COMBO PACK
prenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
1
V-C FORTE CAPSULE
multivitamins with min no.7/folic acid
1
VENA-BAL DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron poly/fa/omega3
1
VENATAL COMPLETE DHA COMBO
prenatal vitamin no.77/sodium feredetate-iron poly/fa/omega3
1
VIC-FORTE CAPSULE
multivitamins with min no.7/folic acid
1
VINACAL PRENATAL TABLET
prenatal vitamins no.22/iron cbn & gluc/folic acid/dss
1
VINATE AZ TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
VINATE CALCIUM PRENATAL TABLET
prenatal vit comb no.4/iron carbonyl-iron gluconate/fa/doss
1
VINATE CARE CHEWABLE TABLET
prenatal vits with calcium#109/ferrous fumarate/folic acid
1
VINATE DHA GELCAP
prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha
1
VINATE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VINATE IC CAPSULE
prenatal vits cmb w-o ca no.2
1
PAGE 305
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VINATE II TABLET
prenatal vitamins with calcium/fe bisgly/folic acid
1
VINATE ONE TABLET
prenatal vitamin 27 with calcium/ferrous fumarate/folic acid
1
VINATE PN CARE TABLET
prenatal vits with calcium #7/fe asp gly/docusate/folic acid
1
VINATE ULTRA TABLET
prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod
1
VINATE-M TABLET
prenatal vitamins with calcium/ferrous fumarate/fa/selenium
1
VIRT-ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
1
VIRT-C DHA SOFTGEL
prenatal vit #16/iron fum & ps complex/folic acid/omega-3
1
VIRT-PN DHA SOFTGEL
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
VIRT-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
VIRT-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
VIRT-SELECT CAPSULE
prenatal vit with calcium no.80/iron fum/folic acid/dss/dha
1
VIRT-VITE FORTE TABLET
cyanocobalamin/folic acid/pyridoxine
1
VIRT-VITE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
1
VIRT-VITE TABLET
cyanocobalamin/folic acid/pyridoxine
1
VITACIRC-B TABLET
mecobalamin/levomefolate calcium/pyridoxal phosphate
1
VITAFOL-OB CAPLET
prenatal vitamins comb 10/ferrous fumarate/folic acid
1
VITAFOL-PN CAPLET
prenatal vit with calcium cmb 11/ferrous fumarate/folic acid
1
VITASPIRE TABLET
prenatal vits with calcium #44/iron,carbonyl/folic acid
1
VOL-CARE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
1
VOL-PLUS TABLET
prenatal vits with calcium #71/ferrous fumarate/folic acid
1
PAGE 306
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
DRUG DESCRIPTION (RX)
TIER
VOL-PLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
1
VP-CH PLUS SOFTGEL
prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha
1
VP-ERA OB PLUS TABLET
prenatal vitamin no.8/iron polysacchar & heme polypeptide/fa
1
VP-GSTN CAPSULE
genistein/citrated zinc bisglycinate/vitamin d3
1
VP-HEME OB + DHA COMBO PACK
prenatal vitamin combo no.22/iron/folic acid/omega-3/dha
1
VP-HEME OB TABLET
prenatal vitamin no.21/iron polysaccharid & heme polypep/fa
1
VP-HEME ONE SOFTGEL
prenatal vitamin no.19/iron polysacc & iron hem/folic ac/dha
1
VP-ZEL TABLET
niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa
1
ZATEAN-CH CAPSULE
prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha
1
ZATEAN-PN DHA CAPSULE
prenatal vits with calcium #47/fe fumarate/fa cmb #1/dha
1
ZATEAN-PN PLUS SOFTGEL
prenatal vit with ca no.68/iron fumarate/folic acid #1/dha
1
ZATEAN-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
1
ZINGIBER TABLET
prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger
1
PAGE 307
LIMITS & RESTRICTIONS
LAST UPDATED 08/2015
Index of covered drugs
ADALAT CC
0
59,73,91
ADALIMUMAB
0.9 % SODIUM CHLORIDE
180,183,186
200,201,239
ADAPALENE
269
ADDERALL
1
108,109
ADDERALL XR
10PEH-400GFN-20DM
44,255
A
ABACAVIR SULFATE
13,22,31
ABACAVIR SULFATE/DOLUTEGRAVIR
109
ADEFOVIR DIPIVOXIL
13,15,22,24
ADVAIR DISKUS
43,216,217,249,253
ADVAIR HFA
43,217,249,250,253
ADVANCED AM/PM
57,180,295
AFATINIB DIMALEATE
287
SODIUM/LAMIVUDINE
20,29
AFEDITAB CR
ABACAVIR SULFATE/LAMIVUDINE
14,24
AFINITOR
284
AFLURIA 2013-2014
257
13,20,22,30
AFLURIA 2014-2015
257
ABILIFY
143,153
AFLURIA 2015-2016
257
ABILIFY DISCMELT
143,153
AK-PENTOLATE
194
ABILIFY MAINTENA
143,153
AK-POLY-BAC
189
ABACAVIR
SULFATE/LAMIVUDINE/ZIDOVUDINE
59,73,92
ABIRATERONE ACETATE
295
AKORN BALANCED SALT
194
ACAMPROSATE CALCIUM
143
ALA-CORT
269
ACARBOSE
205
ALAGESIC LQ
ACEBUTOLOL HCL
40,64,70,73
ACETAMINOPHEN WITH CODEINE
PHOSPHATE
97,99
ACETAMINOPHEN/PHENYLTOLOXAMINE
CIT
97,109,128,134
ALBUTEROL SULFATE
ALCLOMETASONE DIPROPIONATE
269
ALENDRONATE SODIUM
234
ALFERON N
34,105
43,44,45,253,255
13,22,234,284
ALFUZOSIN HCL
40
ACETAMINOPHEN/PHENYLTOLOXAMINE
ALICLEN
269
CITRATE
ALKERAN
284
ALLOPURINOL
234
ACETASOL HC
ACETAZOLAMIDE
35,106,108
189,191,194
73,117,176,193
ALMOND OIL
269,284
ACETIC ACID
189,194
ALMOTRIPTAN MALATE
128
ACETIC ACID/ALUMINUM ACETATE
189,194
ALOSETRON HCL
199
ACETIC
ALPHAQUIN HP
268
ACID/ANTIPYRINE/BENZOCAINE/POLICOSANOL
ALPRAZOLAM
NO.1/AL ACETAT
ALPRAZOLAM INTENSOL
135
ALTACAINE
194
ACETIC ACID/HYDROCORTISONE
193,196
189,191,194
ACETIC ACID/OXYQUINOLINE SULFATE
264,273
ALTAFLUOR
ACETYLCYSTEINE
234,255
ALTAFRIN
134,135,140,142
194,284
194
ACITRETIN
269
ALTAVERA
ACTIMMUNE
234
ALTRETAMINE
288
ACYCLOVIR
13,22,262,268
ALUMINUM ACETATE
269
ALUMINUM CHLORIDE
275
ADACEL TDAP
PAGE 308
257
208,217
LAST UPDATED 08/2015
ALYACEN
208,217
AMANTADINE HCL
13,22,132
AMCINONIDE
269
APRACLONIDINE HCL
194
APRI
208,217
APRISO
199
AMETHIA
208,217
APTENSIO XR
AMETHIA LO
208,217
APTIOM
AMETHYST
208,217
APTIVUS
13,22,23
73,176
ARANELLE
208,217
AMILORIDE HCL/HYDROCHLOROTHIAZIDE 73,176
ARBINOXA
33,251
AMINOCAPROIC ACID
ARIPIPRAZOLE
AMILORIDE HCL
54
AMINOPHYLLINE
283
AMIODARONE HCL
64,68
AMITRIPTYLINE HCL
153,154
109,110
117
143,153,154
ARMOUR THYROID
229,230
ASACOL
199
ASACOL HD
199
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 135,153
ASCOMP WITH CODEINE
AMLODIPINE BESYLATE
ASENAPINE MALEATE
149,170
AMLODIPINE BESYLATE/ATORVASTATIN
ASHLYNA
208,217
CALCIUM
ASPIRIN
59,73,92
57,59,60,74,92
AMLODIPINE BESYLATE/BENAZEPRIL
97,110,128,135
54,98,128
ASPIRIN/SALICYLAMIDE/ACETAMINOPHEN/CAFFEI
HCL
59,74,87,92
NE
AMLODIPINE BESYLATE/VALSARTAN
60,74,87,92
ASTAGRAF XL
56,102,113,129
234,235
AMLODIPINE
ATAZANAVIR SULFATE
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
ATAZANAVIR SULFATE/COBICISTAT
60,74,87,88,176
ATENOLOL
AMMONIUM LACTATE
269,275
269
ATIVAN
AMOXAPINE
154
ATOMOXETINE HCL
AMOXICILLIN
2,198
14,24,238
40,64,70,71,75
ATENOLOL/CHLORTHALIDONE
AMNESTEEM
18,28
40,64,71,75,176
117,135,136
150,151
ATORVASTATIN CALCIUM
57
AMOXICILLIN/POTASSIUM CLAVULANATE
2
ATOVAQUONE
11
AMPICILLIN TRIHYDRATE
2
ATOVAQUONE/PROGUANIL HCL
11
ANABAR
ANAFRANIL
32,97
154
ATRIPLA
13,23
ATROPINE CARE
194
ANAGRELIDE HCL
54
ATROPINE SULFATE
194
ANASPAZ
36
ATROPINE SULFATE/PF
194
ANASTROZOLE
284
ATROVENT HFA
ANDROGEL
217
AUBRA
ANDROXY
217
AUGMENTIN
2
ANTHRALIN
273
AURANOFIN
245,292
AURODEX
191,194
AUROGUARD
191,194
262,269
ANTIPYRINE/BENZOCAINE
AP-ZEL
191,194
180,234,295
36,253
208,218
APEXICON E
269
AVAR
APIDRA
205
AVC
262
APIDRA SOLOSTAR
205
AVELOX ABC PACK
3,10
PAGE 309
LAST UPDATED 08/2015
AVIANE
208,218
BETAGAN
193
270
AVIDOXY
3,11
BETAMETHASONE DIPROPIONATE
AVITA
269
BETAMETHASONE DIPROPIONATE/PROPYLENE
AVO CREAM
269,284
GLYCOL
270
AVONEX
235
BETAMETHASONE VALERATE
270
AVONEX ADMINISTRATION PACK
235
BETASERON
235
AXERT
128
BETAXOLOL HCL
AXITINIB
289
BETHANECHOL CHLORIDE
AZASAN
235
BEXAROTENE
AZATHIOPRINE
235,239
AZATHIOPRINE SODIUM
235
AZELASTINE HCL
195,251
AZITHROMYCIN
3
AZURETTE
208,218
40,64,71,75,193
280,293
BICALUTAMIDE
284
BICILLIN L-A
3
BIMATOPROST
193
BIOGLO
285
BISACODYL/SODIUM CHLOR/SODIUM
BICARB/POTASSIUM CHL/PEG 3350
B
39
200,202
BISMUTH
B-PLEX
295
BACITRACIN
3,189,262
BACITRACIN/POLYMYXIN B SULFATE
BACLOFEN
189,190
39
BAL-CARE DHA
45,180,235,295
BALANCED SALT IRRIG SOLN NO.2
194,195
BALSALAZIDE DISODIUM
199
BALZIVA
208,218
BANZEL
117
BARACLUDE
13,23
BASILIXIMAB
246
BECLOMETHASONE DIPROPIONATE
BENAZEPRIL HCL
227,250
75,88
BENAZEPRIL
HCL/HYDROCHLOROTHIAZIDE
75,88,176
BENOXINATE HCL/FLUORESCEIN
SODIUM
TRIBROMOPHENATE/PETROLATUM,WHITE 270,285
BISOPROLOL FUMARATE
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE 40,41,64,71,7
5,176
BLEPHAMIDE
189,191
BLEPHAMIDE S.O.P.
189,191
BOCEPREVIR
21,30
BONTRIL SLOW-RELEASE
110
BOOSTRIX TDAP
257
BOSULIF
285
BOSUTINIB
285
BP 10-1
262,270
BP VIT 3 PLUS
235,295
BP-50% UREA
262,271
BPO
194,195,284,287
40,64,71,75
262,263,271
BRIELLYN
209,218
BENZALKONIUM CHLORIDE
262,284
BRIMONIDINE TARTRATE
193
BENZEPRO
262,270
BRINTELLIX
154
BENZOIN
270,284
BRISDELLE
155
BROMFENAC SODIUM
191
BROMOCRIPTINE MESYLATE
133
BSS
195
110
BUDEPRION SR
155
36,132
BUDEPRION XL
155
BENZONATATE
BENZOYL PEROXIDE
255
262,263,264,266,270,271,273
BENZOYL PEROXIDE MICROSPHERES
BENZPHETAMINE HCL
BENZTROPINE MESYLATE
PAGE 310
266,279
LAST UPDATED 08/2015
BUDESONIDE
191,218,227,250
BUDESONIDE/FORMOTEROL
FUMARATE
CANDESARTAN CILEXETIL
75,88
CANDESARTAN
45,227,250,251,254
CILEXETIL/HYDROCHLOROTHIAZIDE 75,76,88,177
BUMETANIDE
75,177
CAPACET
BUPAP
98,136
CAPECITABINE
BUPRENORPHINE HCL
98
98,110,128,136
285
CAPSAICIN/MENTHOL
271,276,277,279
BUPRENORPHINE HCL/NALOXONE HCL 98,143,144
CAPTOPRIL
BUPROBAN
CAPTOPRIL/HYDROCHLOROTHIAZIDE
155
BUPROPION HCL
155,160,174,175
BUSPIRONE HCL
BUSULFAN
76,88
CAPTRACIN
271
136
CARAFATE
198
290
CARB-O-PHILIC
271
BUTALBITAL/ACETAMINOPHEN 98,103,106,107,136,
CARBAMAZEPINE
139,141
CARBIDOPA
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 97,98,10
CARBIDOPA/LEVODOPA
2,106,108,109,110,113,115,116,128,129,130,132,134,
CARBINOXAMINE MALEATE
136,139,141,143
CARTEOLOL HCL
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
CARTIA XT
E PHOSPHATE
CARVEDILOL
98,110,128,136
BUTALBITAL/ASPIRIN/CAFFEINE 54,98,110,128,136
CAVAN-ALPHA KIT
BUTORPHANOL TARTRATE
CAVAN-EC SOD DHA
98,128
118,120,125,144,145,151
133,144
C
33,34,251,252
60,64,65,76,93
41,65,71,76
46,180,235,295
46,235,295
209,218
CEENU
46,235,295
133
193
CAZIANT
C-NATE DHA
76,88,177
285
CEFACLOR
3
CA CARBONATE/MAG OXIDE/VITAMIN D3/VIT
CEFADROXIL
3
B12/FA/VIT B6/BORON
180,186,295,304
CEFDINIR
3
CABERGOLINE
133
CEFIXIME
3
CABOZANTINIB S-MALATE
285
CEFPODOXIME PROXETIL
CAFFEINE CITRATED
CAFGESIC FORTE
CALCIPOTRIENE
110,128
33,98,110
271
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE
271
CEFPROZIL
4
CEFTIBUTEN
4
CEFTIN
4
CEFTRIAXONE SODIUM
4
CEFUROXIME AXETIL
4
CALCITONIN,SALMON,SYNTHETIC 218,220,235,238
CELACYN
CALCITRENE
CELECOXIB
CALCITRIOL
CALCIUM ACETATE
271
271,295
3,4
CELEXA
271
98
155
180,181,188
CELLCEPT
235,236
46,180,235,295
CELONTIN
118
218
CEM-UREA
271
CAMRESE
209,218
CENTERGY
33,44,251
CAMRESE LO
209,218
CENTERGY DM
CALCIUM PNV
CAMILA
CANASA
PAGE 311
199
CENTRATEX
33,44,251,255
46,181,296
LAST UPDATED 08/2015
CEPHADYN
98,136
CEPHALEXIN
4
CERISA
263,271
CIPROFLOXACIN/CIPROFLOXACIN HCL
CITALOPRAM HYDROBROMIDE
285
285
295
CITRIC ACID MONOHYDRATE
CERVIDIL
285
CITRIC ACID/SODIUM CITRATE
36,251
CEVIMELINE HCL
39
155,156
CITRIC ACID
CERITINIB
CETIRIZINE HCL
5,10
181,187
CLARAVIS
271
CLARIS
263,272
209,218
CLARITHROMYCIN
5,10,198
CHLORAL HYDRATE
136
CLEANSING WASH
262,270
CHLORAMBUCIL
290
CLEMASTINE FUMARATE
CHATEAL
CHLORDIAZEPOXIDE HCL
136,137
33,251
CLENIA
263,272
CHLORHEXIDINE GLUCONATE 189,190,263,265,266
CLINDA-DERM
263
CHLOROQUINE PHOSPHATE
CLINDACIN ETZ
263
CLINDACIN P
263
11
CHLOROTHIAZIDE
76,177
CHLOROXYLENOL/BENZOCAINE/HYDROCORTISO
CLINDAMYCIN HCL
5
NE ACETATE
CLINDAMYCIN PALMITATE HCL
5
190,192,196
CHLOROXYLENOL/PRAMOXINE HCL
190,196
CLINDAMYCIN PHOSPHATE
263
CHLORPHENIRAMINE MALEATE/CODEINE
CLINDAMYCIN PHOSPHATE/BENZOYL
PHOSPHATE
PEROXIDE
33,99,252,256
CHLORPROMAZINE HCL
155,156
CHLORPROPAMIDE
205
CHLORTHALIDONE
76,177
CHLORZOXAZONE
39
CHOICE-OB + DHA
46,181,236,296
CHOICE-TABS
181,296
CHOLECALCIFEROL (VIT D3)/FOLIC ACID
296
CHOLESTYRAMINE (WITH SUGAR)
CHOLESTYRAMINE/ASPARTAME
57
57,58
CHOLINE SALICYLATE/MAGNESIUM
263,265,272,276
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE/EMOLLIENT BASE 272
CLODAN
272
CLOMIPRAMINE HCL
154,156
CLONAZEPAM
118,121,137,138
CLONIDINE
44,76
CLONIDINE HCL
44,76,77,80
CLONIDINE HCL/CHLORTHALIDONE
CLOPIDOGREL BISULFATE
CLORAZEPATE DIPOTASSIUM
SALICYLATE
98
272
77,177
54
118,126,137,142
CLORPRES
77,177
CICLODAN
263
CLOTRIMAZOLE
263,264
CICLOPIROX
263
CLOTRIMAZOLE/BETAMETHASONE
CICLOPIROX OLAMINE
263
DIPROPIONATE
264,272
CICLOPIROX/VITAMIN E MIXED/NAIL LACQUER
CLOZAPINE
REMOVER, NON-ACET
263,271
CLOZARIL
156
296
CO-GESIC
98
CIFEREX
CILOSTAZOL
54,93
CIMETIDINE
156,159,174
COBICISTAT
248
35,198
COCAINE HCL
195
CIMETIDINE HCL
35,198
COCET
CIPROFLOXACIN
4,5,10
CIPROFLOXACIN HCL
PAGE 312
99
5,10,189
LAST UPDATED 08/2015
CODEINE
CYCLOSPORINE
236,245,246
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE97,99
CYCLOSPORINE, MODIFIED
236,238,242
,110,128,135,137
CYPROHEPTADINE HCL
CODEINE SULFATE
COLCHICINE
COLCHICINE/PROBENECID
COLESTIPOL HCL
33,251
99,255,256
CYTRA-2
181
236
CYTRA-3
181
181,236
CYTRA-K
181
57
COLOCORT
272
D
COLOSTOMY BAG, NON-STERILE
285
DANAZOL
218
COMBIVENT
36,44,253
DANTROLENE SODIUM
COMBIVENT RESPIMAT
36,44,253
DAPSONE
10,11
DARUNAVIR ETHANOLATE
18,27
COMBIVIR
13,23
COMETRIQ
285
COMPLERA
14,23
COMPLETE NATAL DHA
46,181,236,296
40
DARUNAVIR ETHANOLATE/COBICISTAT 17,27,244
DASATINIB
292
DASETTA
209,218,219
COMPLETENATE
46,296
COMPOUND 347
152
DAYTRANA
111
COMPRESSOR, FOR NEBULIZER
285
DEBLITANE
219
DECAVAC
257
COMPRO
156,197
DAYSEE
209,219
CONCERTA
110
DELAVIRDINE MESYLATE
CONSTULOSE
181
DELYLA
COPEGUS
14,23
18,27
209,219
DELZICOL
200
CORMAX
272
DEMECLOCYCLINE HCL
CORTISONE ACETATE
218
DENTA 5000 PLUS
236
DENTAGEL
236
CREON
200,285,286
CRIXIVAN
14,23
CROMOLYN SODIUM
CROTAMITON
5
DEPADE
144,236
195,250
DEPAKENE
118,128,144
264
DEPAKOTE
118,119,128,129,144
CRYSELLE
209,218
DEPAKOTE ER
119,129,144
CUPRIMINE
236,286
DEPAKOTE SPRINKLE
118,128,144
CUTIVATE
272
CYANOCOBALAMIN/FOLIC
ACID/PYRIDOXINE
296,297,298,304,306
CALCIUM/PYRIDOXINE HCL
295,297,299
CYANOCOBALAMIN/LEVOMEFOLATE
CALCIUM/PYRIDOXINE/RIBOFLAVIN
CYCLOBENZAPRINE HCL
157,164
DESLORATADINE
36,251
DESMOPRESSIN ACETATE
54,219
DESMOPRESSIN ACETATE (NONREFRIGERATED)
299
209,218
39,40
CYCLOPENTOLATE HCL
194,195
CYCLOPHOSPHAMIDE
236,286
PAGE 313
219
DESIPRAMINE HCL
CYANOCOBALAMIN/LEVOMEFOLATE
CYCLAFEM
DEPO-PROVERA
54,219
DESOGESTREL-ETHINYL
ESTRADIOL 208,209,215,216,217,218,219,220,227,22
8
LAST UPDATED 08/2015
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
DIFIL-G 400
ESTRADIOL 208,209,211,214,216,218,219,221,225,22
DIFLORASONE DIACETATE
8
DIFLORASONE DIACETATE/EMOLLIENT BASE 269
DESONIDE
272
DESOXIMETASONE
272,273
DESPEC-EXP
44,253,256
254,256,283
273
DIFLUNISAL
99
DIGITEK
65
DIGOX
65
DESQUAM-X
264,273
DIGOXIN
65,67
DESVENLAFAXINE
157,162
DIHYDROCODEINE
DESVENLAFAXINE SUCCINATE
167,168
BITARTRATE/ACETAMINOPHEN/CAFFEINE 99,107,1
DEXAMETHASONE
192,219
12,116
DEXAMETHASONE INTENSOL
219
DIHYDROCODEINE
DEXAMETHASONE SOD PHOSPHATE
192
BITARTRATE/ASPIRIN/CAFFEINE
99,112
DEXASOL
192
DIHYDROERGOTAMINE MESYLATE
41,129
DILANTIN
65,119
DILANTIN-125
65,119
DEXCHLORPHENIRAMINE MALEATE
33
DEXEDRINE
111
DEXMETHYLPHENIDATE HCL
111,112
DILT-CD
61,65,66,77,93
DEXTROAMPHETAMINE SULF-
DILT-XR
60,65,77,93
SACCHARATE/AMPHETAMINE SULF-
DILTIA XT
61,66,77,93
ASPARTATE
DILTIAZEM
108,109,111,112
DEXTROAMPHETAMINE SULFATE 111,114,116,117
HCL 60,61,62,63,64,65,66,67,70,76,77,78,81,84,85,93,
DEXTROMETHORPHAN HBR/PHENYLEPHRINE
94,95,96
HCL/CHLORPHENIRAMINE
DILTZAC ER
33,44,251,255
62,67,78,94
DEXTROMETHORPHAN HBR/PROMETHAZINE
DIMETHYL SULFOXIDE
HCL
DINOPROSTONE
33,251,256
DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE
DIPHENHYDRAMINE
HCL/BROMPHENIRAMINE
HCL
33,44,251,253,256
DEXTROMETHORPHAN TANNATE/P-EPD
TAN/DEXCHLORPHENIRAMINE
DIALYVITE
DIALYVITE ZINC
236
285,291
33,36,37,133,138,251,252,256
DIPHENOXYLATE HCL/ATROPINE
34,44,256
296
181,296
SULFATE
37,200,254
DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO
VACCINE/PF
261
DIAPHRAGMS, ARC-SPRING
286
DIPHTHERIA,PERTUSSIS(ACELL),TETANUS
DIAPHRAGMS, WIDE SEAL
286
VACCINE/PF
257
DIASTAT
119,137
DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS
DIASTAT ACUDIAL
119,137
VACCINE
DIAZEPAM
DICLOFENAC POTASSIUM
DICLOFENAC SODIUM
DICLOXACILLIN SODIUM
DICYCLOMINE HCL
DIDANOSINE
DIETHYLPROPION HCL
PAGE 314
119,127,137,138,142
99
99,192,273
5
36
14,21,23,30
112
257
DIPYRIDAMOLE
54,55,94
DISKETS
99
DISOPYRAMIDE PHOSPHATE
DISULFIRAM
236
DIVALPROEX SODIUM
DOLUTEGRAVIR SODIUM
DORNASE ALFA
67,68
118,119,120,128,129,144
20,29
257,291
LAST UPDATED 08/2015
DORZOLAMIDE HCL
193
EMCYT
286
DORZOLAMIDE HCL/TIMOLOL MALEATE
193
EMGEL
264
DOXAZOSIN MESYLATE
41,71,78
EMOL#53/NA MG
DOXEPIN HCL
157,277
FLUOROSILICATE/CYCLOMETH/PHOSPH
DOXERCALCIFEROL
296
DOXYCYCLINE HYCLATE
5,7,11,12,189
AC/NAHCO3/NACL
276,290
EMOL53/E.WATER/NAMGFS/NAPHOS/NACL/HYPO
DOXYCYCLINE MONOHYDRATE
3,5,6,11,12
CHLOROUS ACID/NAHYPOCL
276,290
DOXYLAMINE SUCCINATE
33,138,251
EMOLLIENT COMBINATION NO. 25
273,286
DOXYTEX
33,138,251
EMOLLIENT COMBINATION NO.10 269,278,284,291
DRAINAGE BAG
286
EMOLLIENT COMBINATION
DRITHOCREME HP
273
NO.32
DULOXETINE HCL
144,145,158,162
DURAXIN
33,99
273,280,286,287,294
EMOLLIENT COMBINATION NO.44
274,288
EMOLLIENT COMBINATION NO.53 274,277,288,291
DYLIX
254,283
EMOLLIENT COMBINATION NO.60
DYNAMIC
195,286
EMOQUETTE
209,219
DYPHYLLINE
254,283
EMSAM
133,158
DYRENIUM
DYTUSS
78,177
33,37,133,138,252,256
271
EMTRICITABINE
14,23
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE
E
14,23
EMTRICITABINE/TENOFOVIR DISOPROXIL
E.E.S. 200
6
FUMARATE
20,30
E.E.S. 400
6
EMTRIVA
14,23
ECHOTHIOPHATE IODIDE
193
EMULSION SB
273,286,287
ECONAZOLE NITRATE
264
ENALAPRIL MALEATE
78,79,88,89
ED-SPAZ
37
ENALAPRIL
EDURANT
14,23
MALEATE/HYDROCHLOROTHIAZIDE
EFAVIRENZ
20,29
ENDACOF-C
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE
13,23
99
ENDODAN
99
181
ENFLURANE
EFFEXOR XR
158
ENFUVIRTIDE
55
33,99,252,256
ENDOCET
EFFER-K
EFFIENT
79,89,177
152
15,24
ENGERIX-B ADULT
258
ELETONE
273,286
ENGERIX-B PEDIATRIC-ADOLESCENT
ELINEST
209,219
ENOXAPARIN SODIUM
ELIPHOS
181,188
ENPRESSE
209,219
ENSKYCE
209,220
ELITE OB DHA
ELITE-OB
ELITE-OB 400
ELVITEGRAVIR
46,236,296
46,296
46,237,296
ENTECAVIR
55
133
13,14,23
ENULOSE
181
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
ENZALUTAMIDE
294
OFOVIR
EPINASTINE HCL
195
PAGE 315
21,22,31
ENTACAPONE
257,258
20,29,247
LAST UPDATED 08/2015
EPINEPHRINE
44,254
ESTROGENS,
EPIPEN 2-PAK
44,254
CONJUGATED/MEDROXYPROGESTERONE
EPIPEN JR 2-PAK
44,254
ACETATE
215,226
EPITOL
120,145
ESTROPIPATE
210,237
EPIVIR
14,23
ESZOPICLONE
138
EPIVIR HBV
14,24
ETHAMBUTOL HCL
EPLERENONE
79,89,177
EPZICOM
14,24
EQUETRO
120,145
ERGOCALCIFEROL (VITAMIN D2)
296
ERGOLOID MESYLATES
41
10
ETHINYL
ESTRADIOL/DROSPIRENONE 210,211,212,213,214,2
15,216,220,222,224,225,227,228
ETHOSUXIMIDE
120,127
ETHRANE
152
ERGOMAR
41,129
ETHYL ACETATE
287
ERGOTAMINE TARTRATE
41,129
ETHYL CHLORIDE
273
ETHYL VANILLIN
287
ERGOTAMINE TARTRATE/CAFFEINE
41,114,129
ERIVEDGE
287
ETHYNODIOL DIACETATE-ETHINYL
ERLOTINIB HCL
293
ESTRADIOL
ERRIN
220
ETIDRONATE DISODIUM
237
ERY
264
ETODOLAC
100
211,216,221,229
ERY-TAB
6
ERYGEL
264
ETOPOSIDE
287
ERYPED 200
6
ETRAVIRINE
15,24
ERYTHROCIN STEARATE
6
EURAX
264
EVEROLIMUS
284
ERYTHROMYCIN BASE
6,189,190
ETONOGESTREL/ETHINYL ESTRADIOL
ERYTHROMYCIN BASE/BENZOYL PEROXIDE
264
EVOTAZ
ERYTHROMYCIN BASE/ETHYL ALCOHOL
264
EXEMESTANE
ERYTHROMYCIN ETHYLSUCCINATE
6
EZOGABINE
ETHYLSUCCINATE/SULFISOXAZOLE ACETYL
6
F
ERYTHROMYCIN STEARATE
6
FABB
ERYTHROMYCIN
ESCITALOPRAM OXALATE
158,163
ESLICARBAZEPINE ACETATE
117
ESTARYLLA
209,220
ESTAZOLAM
138
FALMINA
FAMCICLOVIR
FAMOTIDINE
FANAPT
214,225
14,24,238
287
124,125
296
210,220
14,24
35,198,199
158,159
ESTRACE
209,210,237
FARYDAK
287
ESTRADIOL
209,210,237
FAZACLO
159
ESTRADIOL/NORETHINDRONE
ACETATE
FE 90 PLUS
210,213,220,224
ESTRAMUSTINE PHOSPHATE SODIUM
ESTROGENS, CONJUGATED
286
214,215,244
FE C PLUS
46,296
FEBUXOSTAT
248
FELBAMATE
120
FELODIPINE
62,79
FEM PH
PAGE 316
46,200,296
264,273
LAST UPDATED 08/2015
FEMHRT
210,220
FLUBLOK 2014-2015
258
57,58
FLUBLOK 2015-2016
258
FENOFIBRATE
FENOFIBRATE NANOCRYSTALLIZED
58
FLUCAINE
195,287
FENOFIBRATE,MICRONIZED
58
FLUCELVAX
258
FENOFIBRIC ACID
58
FLUCELVAX 2014-2015
258
FENOFIBRIC ACID (CHOLINE)
58
FLUCELVAX 2015-2016
258
FENOPROFEN CALCIUM
100
FLUCONAZOLE
8,9
FENTANYL
100
FLUCYTOSINE
8,9
FENTANYL CITRATE
100
FLUDROCORTISONE ACETATE
220
FEROCON
46,296
FLULAVAL 2013-2014
258
FEROTRIN
46
FLULAVAL 2014-2015
258
46,200,297
FLULAVAL QUAD 2013-2014
258
46,297
FLULAVAL QUAD 2014-2015
258
46,181,238,297
FLULAVAL QUAD 2015-2016
258
FERRAPLUS 90
FERREX 150 FORTE
FERREX 150 FORTE PLUS
FERREX 28
46,238,297
FLUMIST
259
FERROCITE PLUS
47,181,297
FLUMIST QUAD 2014-2015
259
FERROGELS FORTE
47,297
FLUNISOLIDE
192,220,250
FERROUS FUMARATE/ASCORBIC ACID/B12-
FLUOCINOLONE ACETONIDE
273
IF/FOLIC ACID
FLUOCINOLONE ACETONIDE OIL
192
FERROUS FUMARATE/ASCORBIC
FLUOCINOLONE ACETONIDE/SHOWER CAP
273
ACID/CYANOCOBALAMIN/FOLIC
FLUOCINONIDE
ACID
46,51,52,296,304
47,52,297,298,304
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/STOMACH CONC
47
FERROUS FUMARATE/FOLIC ACID
47,298
273,274
FLUOCINONIDE/EMOLLIENT BASE
274
FLUOR-A-DAY
238
FLUORABON
238
FLUORESCEIN SODIUM
285,287
FERROUS FUMARATE/FOLIC
FLUORETS
ACID/MULTIVITAMINS WITH MIN NO. 15 46,181,296
FLUORIDE/IRON/VITAMINS A,C,AND D
FERROUS SULFATE/ASCORBIC ACID/FOLIC
FLUORIDEX DAILY DEFENSE
238
FLUORITAB
238
FLUOROMETHOLONE
192
FLUOROURACIL
274
ACID
FETZIMA
FEXOFENADINE HCL
FINASTERIDE
FLAVOXATE HCL
FLECAINIDE ACETATE
FLOVENT HFA
51,304
159
36,252
238,273
283
67
220,250
287
FLUOXETINE HCL
47,238,297
159,168,170
FLUOXYMESTERONE
217
FLUPHENAZINE DECANOATE
159
FLUPHENAZINE HCL
159,160
FLUARIX 2013-2014
258
FLURA-DROPS
238
FLUARIX 2014-2015
258
FLURAZEPAM HCL
138
FLUARIX QUAD 2013-2014
258
FLURBIPROFEN
100
FLUARIX QUAD 2014-2015
258
FLURBIPROFEN SODIUM
192
FLUARIX QUAD 2015-2016
258
FLUROX
FLUBLOK 2013-2014
258
FLUTAMIDE
PAGE 317
195,287
287
LAST UPDATED 08/2015
FLUTICASONE FUROATE
193,228,251
FLUTICASONE PROPIONATE
192,220,250,272,274
FOLIC ACID/VITAMIN B COMP W-C
295,296,297
FOLIC ACID/VITAMIN B COMP W-C/COPPER/ZINC
FLUTICASONE PROPIONATE/SALMETEROL
OXIDE
181,297
XINAFOATE
FOLINATAL PLUS B
180,295
43,216,217,249,250,253
FLUVIRIN 2013-2014
259
FOLIVANE-F
47,297
FLUVIRIN 2014-2015
259
FOLIVANE-OB
47,298
FLUVIRIN 2015-2016
259
FOLIVANE-PLUS
47,298
FLUVOXAMINE MALEATE
160,163
FOLIVANE-PRX DHA NF
47,200,238,298
FLUZONE 2013-2014
259
FOLPLEX 2.2
298
FLUZONE 2014-2015
259
FOLTANX
298
FLUZONE 2015-2016
259
FORANE
152
FLUZONE HIGH-DOSE 2013-2014
259
FORFIVO XL
160
FLUZONE HIGH-DOSE 2014-2015
259
FORMA-RAY
287
FLUZONE HIGH-DOSE 2015-2016
259
FORMADON
274,287
FLUZONE INTRADERM QUAD 2015-16
259
FORMALDEHYDE
274,287
FLUZONE INTRADERMAL 2013-2014
259
FORTICAL
220,238
FLUZONE INTRADERMAL 2014-2015
259
FOSAMPRENAVIR CALCIUM
16,25
FLUZONE PEDI 2013-2014
260
FOSCARNET SODIUM
15,24
FLUZONE QUAD 2013-2014
260
FOSCAVIR
15,24
FLUZONE QUAD 2014-2015
260
FOSINOPRIL SODIUM
79,89
FLUZONE QUAD 2015-2016
260
FOSINOPRIL
FLUZONE QUAD PEDI 2013-2014
260
SODIUM/HYDROCHLOROTHIAZIDE
FLUZONE QUAD PEDI 2014-2015
260
FUL-GLO
FML FORTE
192
FUROSEMIDE
FML S.O.P.
192
FUZEON
FOCALGIN 90 DHA
47,200,297
FOCALGIN CA
47,200,297
FOCALGIN DSS
47,297
79,89,177
287
79,177,178
15,24
G
GABAPENTIN
100,105,120,123
FOCALIN
112
GALANTAMINE HBR
FOCALIN XR
112
GANCICLOVIR SODIUM
FOLASTIN
297
GARAMYCIN
189
GARDASIL
260
FOLBECAL
181,297
39
15,24
FOLBEE
297
GATIFLOXACIN
189
FOLBEE PLUS
297
GAUZE BANDAGE
287
181,297
GAVILYTE-C
200
FOLBIC
297
GAVILYTE-G
200
FOLBIC RF
297
GAVILYTE-H AND BISACODYL
200
FOLCAPS
297
GAVILYTE-N
200
FOLIC ACID
297
GEFITINIB
289
FOLBEE PLUS CZ
FOLIC ACID/NIACINAMIDE/CUPRIC OXIDE/ZINC
GEL DRESSING
OXIDE
GEMFIBROZIL
PAGE 318
181,183,296,301
274,287
58
LAST UPDATED 08/2015
GENERLAC
181
GUANFACINE HCL
GENGRAF
238
GUANIDINE HCL
GENISTEIN/CITRATED ZINC
BISGLYCINATE/VITAMIN D3
GENTAK
GENTAMICIN SULFATE
188,249,307
190
189,190,264
GENTIAN VIOLET/BRILLIANT
GREEN/PROFLAVINE
268
79,145
39
H
HALDOL
160
HALDOL DECANOATE 100
160
HALDOL DECANOATE 50
160
HALOBETASOL PROPIONATE
274
GEODON
145,160
HALOBETASOL PROPIONATE/AMMONIUM
GIANVI
211,220
LACTATE
274
GILDAGIA
211,220
HALONATE
274
GILDESS
211,220
HALONATE PAC
274
GILDESS 24 FE
211,220
HALOPERIDOL
160,161
HALOPERIDOL DECANOATE
160,161
160,161
GILDESS FE
211,220,221
GILOTRIF
287
HALOPERIDOL LACTATE
GLEEVEC
288
HARVONI
15,24
GLEOSTINE
288
HEATHER
221
GLIMEPIRIDE
205
HECORIA
239
GLIPIZIDE
205
HEMATINIC PLUS
GLIPIZIDE/METFORMIN HCL
205
HEMATINIC WITH FOLIC ACID
GLUCAGEN
GLUCAGON EMERGENCY KIT
208,239,288
47,298
HEMATOGEN
47
HEMATOGEN FA
47,298
HEMATOGEN FORTE
47,298
GLUCOSAMINE SULFATE/CHONDROITIN SULFATE
HEMENATAL OB
47,298
A/ANTIOXID MULTVIT#5
HEMENATAL OB + DHA
47,298
HEMETAB
47,298
GLUCAGON,HUMAN RECOMBINANT
GLYBURIDE
GLYBURIDE,MICRONIZED
GLYBURIDE/METFORMIN HCL
GLYCOPYRROLATE
GLYDO
208,239
47,182,298
208,239,288
245,303
205
205,206
206
37
195,274
HEPARIN SODIUM,PORCINE
55
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE
55,182
HEPARIN SODIUM,PORCINE/PF
55,56
GRANISETRON HCL
197
HEPATITIS B VIRUS VACCINE
GRANISOL
197
RECOMBINANT/PF
GRISEOFULVIN ULTRAMICROSIZE
8,9
HEPSERA
15,24
GRISEOFULVIN, MICROSIZE
8,9
HEXALEN
288
HOMATROPAIRE
195
HOMATROPINE HBR
195
GUAIFENESIN/CODEINE PHOSPHATE
256,257
GUAIFENESIN/DEXTROMETHORPHAN
HBR/PHENYLEPHRINE
GUAIFENESIN/DYPHYLLINE
GUAIFENESIN/PHENYLEPHRINE HCL
44,255
HPR
274,288
254,256,283
HPR PLUS
274,288
44,256
HUMALOG
206
HUMALOG KWIKPEN
206
HUMALOG MIX 50-50
206
GUAIFENESIN/PSEUDOEPHEDRINE
HCL/DIHYDROCODEINE
PAGE 319
257,258,261
44,253,256
LAST UPDATED 08/2015
HUMALOG MIX 50-50 KWIKPEN
206
HYDROMET
HUMALOG MIX 75-25
206
HYDROMORPHONE HCL
HUMALOG MIX 75-25 KWIKPEN
206
HYDROQUINONE/FERRIC OXIDE
HUMAN PAPILLOMAVIRUS VACCINE,
260
200,201,239
HYDROXYUREA
268
HYDROXYZINE HCL
33,35,138
201,239
HYDROXYZINE PAMOATE
HUMIRA PSORIASIS
201,239
HYOMAX-SL
HUMULIN R U-500
206
HYALURONATE SODIUM/VITE AC/EMOL
282,294
HYCAMTIN
288
HYDRALAZINE HCL
79
HYDROCHLORIC ACID
201
79,80,178
33,34,35,138
37
HYOPHEN
31,37,102
HYOSCYAMINE SULFATE
CMB12/ALLANTOIN/SHEA TREE
12,239
288
HUMIRA CROHN'S
HYDROCHLOROTHIAZIDE
101,102
HYDROXYCHLOROQUINE SULFATE
QUADRIVALENT/PF
HUMIRA
37,256
HYOSYNE
36,37,38
37
HYPERCARE
275
HYPERRHO S-D
260
I
HYDROCODONE
IBANDRONATE SODIUM
239
BITARTRATE/ACETAMINOPHEN 98,100,101,102,107,
IBRANCE
288
108
IBRUTINIB
289
HYDROCODONE BITARTRATE/HOMATROPINE
IBUPROFEN
METHYLBROMIDE
IBUPROFEN/OXYCODONE HCL
102
ICLUSIG
289
37,38,256,257
HYDROCODONE/IBUPROFEN
101,106,108
HYDROCOLLOID DRESSING
HYDROCORTISONE
274,288
221,269,272,274,275,277,279
102,129
IDELALISIB
294,295
IFEREX 150 FORTE
47,298
HYDROCORTISONE ACETATE
278
ILOPERIDONE
HYDROCORTISONE ACETATE/ALOE VERA
275
IMATINIB MESYLATE
288
HYDROCORTISONE ACETATE/IODOQUINOL/ALOE
IMBRUVICA
289
VERA
IMDUR
264,275
HYDROCORTISONE ACETATE/LIDOCAINE
HCL/ALOE VERA
94
IMIPRAMINE HCL
275
HYDROCORTISONE ACETATE/PRAMOXINE
HCL
158,159
277
HYDROCORTISONE ACETATE/PRAMOXINE
IMIPRAMINE PAMOATE
161,162,172,173
IMIQUIMOD
275
IMURAN
239
INATAL ADVANCE
HCL/SKIN CLEANSER NO.16
282
INATAL GT
HYDROCORTISONE BUTYRATE
275
INATAL ULTRA
HYDROCORTISONE BUTYRATE/EMOLLIENT
161,172
INCIVEK
47,182,201,298
48,201,298
48,182,201,298
15,24
BASE
275
INDAMIX DM
34,44,256
HYDROCORTISONE VALERATE
275
INDAPAMIDE
80,178
HYDROCORTISONE/MINERAL
OIL/PETROLATUM,WHITE
INDINAVIR SULFATE
274
HYDROCORTISONE/PRAMOXINE
HCL/CHLOROXYLENOL
PAGE 320
190,192,196
14,23
INDOMETHACIN
102,239
INFANATE PLUS
48,201,239,298
INFERGEN
15,24
LAST UPDATED 08/2015
INFLUENZA VACCINE QUADRIVALENT LIVE 2014-
INFLUENZA VIRUS VACCINE TRIVALENT 2014-15
2015 (2 YRS-49 YRS)
(6 MOS AND OLDER)
259
259
INFLUENZA VACCINE TRIVAL.SPLIT 2014-15 (18
INFLUENZA VIRUS VACCINE TRIVALENT 2014-2015
YR+) CELL DER/PF
(4 YR & OLDER)
258,261
INFLUENZA VACCINE TRIVALENT 2015-2016(18
YR+)CELL DERIVED/PF
259
INFLUENZA VIRUS VACCINE TRIVALENT 2014-2015
258
(5 YR & OLDER)
257
INFLUENZA VACCINE TV SPLIT 2013-14 (18 YR+)
INFLUENZA VIRUS VACCINE TRIVALENT 2014-2015
CELL DERIVED/PF
(65 YR+)/PF
258
259
INFLUENZA VIRUS VACCINE QUAD VS 2013-2014
INFLUENZA VIRUS VACCINE TRIVALENT 2015-16
(36 MOS & OLDER)
(6 MOS AND OLDER)
258
259
INFLUENZA VIRUS VACCINE QUAD VS 2013-2014
INFLUENZA VIRUS VACCINE TRIVALENT 2015-2016
(6 MOS-35 MOS)/PF
(4 YR & OLDER)
260
259
INFLUENZA VIRUS VACCINE QUAD VS 2013-
INFLUENZA VIRUS VACCINE TRIVALENT 2015-2016
2014(36 MOS & OLDER)/PF
(5 YR & OLDER)
258,260,261
257
INFLUENZA VIRUS VACCINE QUAD VS 2014-2015
INFLUENZA VIRUS VACCINE TRIVALENT SPLIT
(36 MOS & OLDER)
2015-2016(65 YR+)/PF
258
259
INFLUENZA VIRUS VACCINE QUADRIVAL 2014-15
INFLUENZA VIRUS VACCINE TRIVALNT 2014-2015
(6 MOS-35 MOS)/PF
(4 YR & OLDER)/PF
260
259
INFLUENZA VIRUS VACCINE QUADRIVAL 2014-
INFLUENZA VIRUS VACCINE TRIVALNT 2014-2015
15(36 MOS & OLDER)/PF
(5 YR & OLDER)/PF
258,260
INFLUENZA VIRUS VACCINE QUADRIVAL 20142015 (6 MOS & OLDER)
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
260
INFLUENZA VIRUS VACCINE QUADRIVAL 20152016 (36 MOS & OLDER)
257
(4 YR & OLDER)/PF
259
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
258
(5 YR & OLDER)/PF
257
INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT
INFLUENZA VIRUS VACCINE TV 2013-2014 (18 TO
2015-16(36 MOS+)/PF
49 YRS)RECOMB/PF
258,260
INFLUENZA VIRUS VACCINE QUADRIVALENT
2015-16(18YRS-64YRS)/PF
258
INFLUENZA VIRUS VACCINE TV 2014-2015(18 YRS
259
& OLDER)RCMB/PF
258
INFLUENZA VIRUS VACCINE QVAL LIVE 2013-2014
INFLUENZA VIRUS VACCINE TV 2015-2016(18 YRS
(2 YRS-49 YRS)
& OLDER)RCMB/PF
259
INFLUENZA VIRUS VACCINE QVALSPLIT 20152016(6 MOS AND OLDER)
258
INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (4
260
YR & OLDER)
259
INFLUENZA VIRUS VACCINE TRI-SPLIT 2013-14 (6
INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (4
MOS AND OLDER)
YR & OLDER)/PF
259
259,261
INFLUENZA VIRUS VACCINE TRIVAL 2014-15 (36
INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (5
MOS AND OLDER)/PF
YR & OLDER)
258,259
257
INFLUENZA VIRUS VACCINE TRIVALENT 2014-15
INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (5
(18 YRS-64 YRS)/PF
YR & OLDER)/PF
259
257
INFLUENZA VIRUS VACCINE TRIVALENT 2014-15
INFLUENZA VIRUS VACCINE TVS 2013-2014 (18
(36 MOS AND OLDER)
YRS-64 YRS)/PF
PAGE 321
258
259
LAST UPDATED 08/2015
INFLUENZA VIRUS VACCINE TVS 2013-2014 (36
MOS AND OLDER)
IRBESARTAN
258
80,89
IRBESARTAN/HYDROCHLOROTHIAZIDE 80,89,178
INFLUENZA VIRUS VACCINE TVS 2013-2014 (36
IRENKA
145,162
MOS AND OLDER)/PF
IRESSA
289
258,259
INFLUENZA VIRUS VACCINE TVS 2013-2014 (6
MOS-35 MOS)/PF
IRON ASP GLY&PS CMPLX/ASCORB.CAL/VIT
260
INFLUENZA VIRUS VACCINE TVS 2013-2014 (65
B12/FA/CATHR/SUCC.ACID
46,48,181,182,238,240,297,298
YR+)/PF
259
IRON ASP GLY/ASCORB.CAL/VIT B12/FA/CA-
INHALER, ASSIST DEVICES
289
THREONTE/SUCCINIC ACID
INHALER, ASSIST DEVICES, ACCESSORIES
289
IRON ASP.GLYCIN & FUMARATE /VIT C/FA/MV
INLYTA
289
COMB 11/CA-THREONATE
INSULIN ASPART
207
IRON ASPGLY/ASCORB.CAL/VIT B12/CALCIUM
INSULIN ASPART PROTAMINE HUMAN/INSULIN
ASPART
48,183,241,299
46,238,297
THR/SUCC.ACID/STOMACH 48,182,183,240,241,298,
207
INSULIN GLARGINE,HUMAN RECOMBINANT
299
IRON BISGLY & PS CMPLX/ASCORBATE
ANALOG
206
CA/B12/FOLIC ACID/CA-THREO
INSULIN GLULISINE
205
IRON FUMARATE & POLYSAC COMP/FOLIC
INSULIN LISPRO
206
ACID/VIT B COMP & C NO.9
INSULIN LISPRO PROTAMINE & INSULIN
51,303
47,298
IRON FUMARATE & POLYSAC COMP/FOLIC
LISPRO
206
ACID/VITAMIN C/NIACIN
INSULIN REGULAR, HUMAN
206
IRON FUMARATE-IRON POLYSACCHAR/FOLIC
INTELENCE
15,24
INTERFERON ALFA2B,RECOMB.
47,297
ACID/MV COMB18
50,51,185,303
IRON FUMARTE &ASP GLY/ASCORB.CAL/VIT
15,24,25,239,240,289
INTERFERON ALFA-N3
13,22,234,284
INTERFERON ALFACON-1
15,24
INTERFERON BETA-1A
235
INTERFERON BETA-1A/ALBUMIN HUMAN
235,245
B12/FA/CATHR/SUCC.ACID
48,182,183,240,241,298,299
IRON POLYSACCHAR COMPLX/IRON HEME
POLYPEPTIDE/FOLIC ACID/B12
47,298
IRON POLYSACCHARIDE
INTERFERON BETA-1B
235
COMPLEX/CYANOCOBALAMIN/FOLIC
INTERFERON GAMMA-1B,RECOMB.
234
ACID
INTRON A
15,24,25,239,240,289
INTROVALE
211,221
46,47,48,49,297,298,300,302
IRON, CARBONYL & GLUCONATE/FA/VIT B12/VIT
C/DOCUSATE SODIUM46,47,49,200,202,296,297,300
INVEGA
162
IRON,CARBONYL/ASCORBIC
INVEGA SUSTENNA
162
ACID/CYANOCOBALAMIN/FOLIC ACID
INVIRASE
15,25
IODINE/POTASSIUM IODIDE
256,265
IODOQUINOL
13
IPECAC
IPRATROPIUM BROMIDE
201,256
36,37,195,253,254
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE
PAGE 322
46,296
IRON,CARBONYL/DOCUSATE SODIUM/B12IF/FOLIC ACID/MULTIVIT-MIN
51,186,203,304
IRON,CARBONYL/FOLIC ACID/MULTIVITAMIN WMINERALS
46,296
IRON,CARBONYL/FOLIC ACID/VITAMIN
B12/VITAMIN C/DOCUSATE NA
46,200,297
36,37,44,253,254
LAST UPDATED 08/2015
IRON/FOLIC ACID/VITAMIN B COMP W-
KEPPRA
120,121
C/MINERALS
KETOCONAZOLE
8,9,264
ISENTRESS
ISOCARBOXAZID
ISOFLURANE
47,181,182,297,298
16,25
163
152,153
KETODAN
264
KETOPROFEN
102,129
KETOROLAC TROMETHAMINE
102,192
ISOMETHEPTENE
KHEDEZLA
162
MUCATE/CAFFEINE/ACETAMINOPHEN 102,113,129
KIMIDESS
221
ISOMETHEPTENE
KIONEX
188,240
MUCATE/DICHLORALPHENAZONE/ACETAMINOPH
KLONOPIN
121,138
EN
KLOR-CON
182
KLOR-CON 10
182
ISONIAZID
103,129,140
10,11
ISOPTO HOMATROPINE
195
KLOR-CON 8
182
ISOPTO HYOSCINE
195
KLOR-CON M10
182
95
KLOR-CON M15
182
94,95
KLOR-CON M20
182
KLOR-CON-EF
182
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
ISOTRETINOIN
ISRADIPINE
ITRACONAZOLE
IVERMECTIN
269,271,276,282
62,80
8,9
2,267
J
JAKAFI
289
JANTOVEN
56
JENCYCLA
221
KURVELO
211,221
L
L-METHYL-B6-B12
298
L-METHYL-MC
299
L-METHYLFOLATE FORTE
L-METHYLFOLATE PNV DHA
LABETALOL HCL
240,299
48,182,240,299
41,67,71,80
JEVANTIQUE
211,221
LACLOTION
275
JINTELI
211,221
LACOSAMIDE
127
JOLESSA
211,221
LACTIC ACID
JOLIVETTE
221
275,289
LACTOBACILLUS PLANTARUM
201
JUNEL
211,221
LACTOCAL-F
48,183,299
JUNEL FE
211,221
LACTULOSE
181,183
JUNEL FE 24
221
K
LAMICTAL
121,145,146
LAMICTAL (BLUE)
121,146
LAMICTAL (GREEN)
121,146
K EFFERVESCENT
182
LAMICTAL (ORANGE)
121,146
K-PHOS NEUTRAL
182
LAMICTAL ODT (BLUE)
121,146
K-SOL
182
LAMICTAL ODT (GREEN)
121,146
K-TAB ER
182
LAMICTAL ODT (ORANGE)
121,146
KALETRA
16,25
LAMICTAL XR
KAPVAY
44,80
LAMICTAL XR (BLUE)
122,146
121,122,146
KARIVA
211,221
LAMICTAL XR (GREEN)
122,146
KELNOR 1-35
211,221
LAMICTAL XR (ORANGE)
122,146
PAGE 323
LAST UPDATED 08/2015
LAMISIL
8,9
LAMIVUDINE
14,16,23,24,25
LAMIVUDINE/ZIDOVUDINE
LAMOTRIGINE
13,16,23,25
121,122,145,146,147
LANOXIN
67
LANSOPRAZOLE
199
LANSOPRAZOLE/AMOXICILLIN
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM
ALGAL OIL
240,299
LEVOMILNACIPRAN HYDROCHLORIDE
159
LEVONEST
212,222
LEVONORGESTREL
222,224
LEVONORGESTREL-ETHINYL
ESTRADIOL 208,209,210,211,212,213,214,215,216,21
TRIHYDRATE/CLARITHROMYCIN
6,199
7,218,219,220,221,222,223,224,225,226,227,228
LANTUS
206
LEVONORGESTREL/ETHINYL ESTRADIOL AND
LANTUS SOLOSTAR
206
ETHINYL
LAPATINIB DITOSYLATE
294
ESTRADIOL 208,209,211,215,217,218,219,221,222,22
LARIN
211,212,222
LARIN 24 FE
LARIN FE
222
212,222
7
LEVORA-28
212,222
LEVORPHANOL TARTRATE
102
230
LATANOPROST
193
LEVOTHROID
LATRIX
275
LEVOTHYROXINE SODIUM
LATRIX XM
230,231,232,233
264,275
LEVOXYL
231
LATUDA
162
LEXAPRO
163
LAVOCLEN-4
264
LEXIVA
16,25
212,222
LIALDA
201
LIDOCAINE
275
LAYOLIS FE
LEDIPASVIR/SOFOSBUVIR
LEENA
15,24
212,222
LEFLUNOMIDE
240
LIDOCAINE HCL
195,196,274,275,276,277
LIDOCAINE HCL/GLYCERIN
195,196,286
LENALIDOMIDE
245,292
LIDOCAINE HCL/HYDROCORTISONE ACETATE 276
LENVATINIB MESYLATE
289,290
LIDOCAINE HCL/MENTHOL
LENVIMA
289,290
LIDOCAINE/MENTHOL
LESSINA
212,222
LIDOCAINE/PRILOCAINE
276,278
290
LIDOCAINE/TETRACAINE
280
LIDOPIN
276
LINAGLIPTIN
207
LINDANE
265
LIOTHYRONINE SODIUM
231
LETROZOLE
LEUCOVORIN CALCIUM
240,299
LEUKERAN
LEUPROLIDE ACETATE
LEVACET
LEVALBUTEROL HCL
LEVETIRACETAM
290
222,290
56,102,113,129
44,45,254
120,121,122,123
276
LIPASE/PROTEASE/AMYLASE 200,202,204,205,285,
286,291,294
LEVOBUNOLOL HCL
193
LIRAGLUTIDE
LEVOCARNITINE
240
LISDEXAMFETAMINE DIMESYLATE
LEVOCARNITINE (WITH SUGAR)
240
LISINOPRIL
LEVOFLOXACIN
6,11,190
277,280,283
207,208
116
80,89
LISINOPRIL/HYDROCHLOROTHIAZIDE
80,89,178
LEVOMEFOLATE
LITHIUM CARBONATE
147
CA/ACETYLCYSTEINE/MECOBALAMIN/SCHIZ.
LITHIUM CITRATE
147
ALGAL OIL
LITHOBID
147
PAGE 324
183,240,241,299
LAST UPDATED 08/2015
LMTHF-PYRIDOXINE-CYANOCOBAL
299
MAGNESIUM
LO-OVRAL-28
212,222
SALICYLATE/ACETAMINOPHEN/PHENYLTOLOXAM
LOMEDIA 24 FE
212,222
INE/CAFFEINE
LOMUSTINE
285,288
MALATHION
265
MAPROTILINE HCL
163
LOPERAMIDE HCL
201
LOPINAVIR/RITONAVIR
16,25
LORATADINE
36,252
LORAZEPAM
117,123,135,136,139
33,98,110
MARAVIROC
19,29
MARGESIC
102,113,129,139
MARLEXATE
189,241
LORAZEPAM INTENSOL
139
MARLISSA
212,223
LORCET
102
MARPLAN
163
LORCET HD
102
MARTEN-TAB
LORCET PLUS
102
MATULANE
290
LORENZA
276
MATZIM LA
62,67,81,95
LORTAB
102
MAXIDEX
LORYNA
212,222
MB HYDROGEL
LOSARTAN POTASSIUM
80,81,90
ME-PB-HYOS
LOSARTAN
LOW-OGESTREL
192
276,290
37,123,139
MECHLORETHAMINE HCL
POTASSIUM/HYDROCHLOROTHIAZIDE
LOVASTATIN
103,139
81,90,178
58
212,223
282
MECLIZINE HCL
34,197
MECLOFENAMATE SODIUM
103
MECOBALAMIN/LEVOMEFOLATE
LOXAPINE SUCCINATE
163
CALCIUM/PYRIDOXAL PHOSPHATE
LOXITANE
163
MEDROXYPROGESTERONE ACETATE 219,223,227
LOZI-FLUR
240
MEFENAMIC ACID
103
240,241
MEFLOQUINE HCL
12
LUDENT FLUORIDE
LUGOL'S
8,9,231,241,256,265
298,299,306
MEGESTROL ACETATE
223,290
LURASIDONE HCL
162
MELOXICAM
103
LUSTRA-AF
268
MELPAQUE HP
268
LUSTRA-ULTRA
268
MELPHALAN
284
MEPERIDINE HCL
103
LUTERA
212,223
LUVOX CR
163
MEPERITAB
103
LYNPARZA
290
MEPHYTON
241,299
LYZA
223
MEPROBAMATE
M
139
MERCAPTOPURINE
241,245,290,291
MESALAMINE
199,200,201,202
M-CLEAR
256
MESALAMINE WITH CLEANSING WIPES
201
MAC
276
METADATE CD
113
48,183,201,241,299
METADATE ER
113
299
MACNATAL CN DHA
MAFENIDE ACETATE
265
METAFOLBIC
MAGNESIUM SALICYLATE
104
METAFOLBIC PLUS RF
METAPROTERENOL SULFATE
METAXALONE
PAGE 325
183,241,299
45,254
40
LAST UPDATED 08/2015
METFORMIN HCL
206
METHADONE HCL
99,103
METRONIDAZOLE/SKIN CLEANSER
MEXILETINE HCL
68
METHADONE INTENSOL
103
MI-OMEGA NF
METHADOSE
103
MICONAZOLE NITRATE
METHAMPHETAMINE HCL
113
MICONAZOLE NITRATE/ZINC
81,193
OXIDE/PETROLATUM,WHITE
METHAZOLAMIDE
265
58,241,299
265
268,282
METHENAMINE HIPPURATE
31
MICRHOGAM ULTRA-FILTERED PLUS
METHENAMINE MANDELATE
31
MICROGESTIN
260
212,223
METHENAMINE/METHYLENE BLUE/BENZOIC
MICROGESTIN FE
ACID/SALICYLATE/HYOSCY
MIDAZOLAM HCL
139
METHENAMINE/METHYLENE
MIDAZOLAM HCL/PF
140
BLUE/SALICYLATE/SODIUM
MIDODRINE HCL
PHOS/HYOSCY
31,37,102
32,38,39,107,108,248
212,213,223
45
MIGERGOT
41,114,129
METHENAMINE/METHYLENE BLUE/SODIUM
MIGRAGESIC IDA
PHOS/PNYL SAL/HYOSC
MILLIPRED
SUL
MILLIPRED DP
223,224
MILNACIPRAN HCL
150,170
MIMVEY
213,224
MIMVEY LO
213,224
32,38,39,106,107,108,243,248
METHIMAZOLE
231
METHOCARBAMOL
40
METHOTREXATE SODIUM
241,290
METHOXSALEN, RAPID
269
METHSCOPOLAMINE BROMIDE
METHSUXIMIDE
38
118
METHYCLOTHIAZIDE
81,178
METHYL SALICYLATE
103,276
METHYLDOPA
45,81
103,129,140
223
MINOCYCLINE HCL
6,7,12,276
MINOXIDIL
82
MIRTAZAPINE
163,164,168,169
MISOPROSTOL
199
MOBAN
164
MODERIBA
16,25,26
METHYLDOPA/HYDROCHLOROTHIAZIDE 45,81,178
MOEXIPRIL HCL
82,90
METHYLERGONOVINE MALEATE
290
MOEXIPRIL
METHYLIN
113
HCL/HYDROCHLOROTHIAZIDE
METHYLPHENIDATE
111
MOLINDONE HCL
164
MOMETASONE FUROATE
276
82,90,178
METHYLPHENIDATE HCL
109,110,113,114,115
METHYLPREDNISOLONE
223
MONO-LINYAH
METIPRANOLOL
193
MONOJECT PREFILL
183
METOCLOPRAMIDE HCL
201
MONOJECT PREFILL ADVANCED
183
METOLAZONE
81,178
213,224
MONONESSA
213,224
METOPROLOL SUCCINATE
41,67,71,81
MONTELUKAST SODIUM
250
METOPROLOL TARTRATE
41,68,71,81
MORGIDOX
7,12
METOPROLOL
MORPHINE SULFATE
103,104
TARTRATE/HYDROCHLOROTHIAZIDE 41,68,71,72,8
MOXIFLOXACIN HCL
3,7,10,11
1,82,178
MST 600
METROGEL
METRONIDAZOLE
PAGE 326
265
12,13,199,265,266,268
104
MULTIGEN
48,183,241,299
MULTIGEN FOLIC
48,183,241,299
LAST UPDATED 08/2015
MULTIGEN PLUS
48,183,241,299
MULTINATAL PLUS
46,295
NAFRINSE DAILY-NEUTRAL
242
NALTREXONE HCL
144,147,236,242
MULTIVIT WITH MIN#10/FOLIC ACID//VIT D3/A
NAPHAZOLINE HCL
196
LIPOIC ACID/LUTEIN
181,296
NAPROXEN
MULTIVITAMINS WITH FLUORIDE
241,300
NAPROXEN SODIUM
MULTIVITAMINS WITH IRON &
104,105,130,242
105,130,242
NARDIL
FLUORIDE
48,241,300
MULTIVITAMINS WITH MIN NO.7/FOLIC
164
NATALVIRT 90 DHA
49,183,201,242,300
NATALVIRT CA
49,183,202,242,300
ACID
187,305
NATALVIRT FLT
49,202,300
MULTIVITAMINS-A,B,D,E,K,ZN
183,299
NATEGLINIDE
206,207
MULTIVITS, IRON, MINERALS COMBO NO #6,
NATURE-THROID
231,232
FOLIC ACID
51,186,303
NEBULIZER
290
MULTIVITS,THERAP W-FE,HEMATIN
51,186,304
NEBULIZER ACCESSORIES
290
290
MUPIROCIN
265
NEBULIZER/COMPRESSOR, FOR NEBULIZER
MUPIROCIN CALCIUM
265
NEBUPENT
MVC-FLUORIDE
MY WAY
MYCOPHENOLATE MOFETIL
241,300
224
235,241,242
12
NECON
213,224
NEEDLES, INSULIN DISPOSABLE
290
NEFAZODONE HCL
164
MYCOPHENOLATE MOFETIL HCL
236
NELFINAVIR MESYLATE
MYCOPHENOLATE SODIUM
242
NEO-POLYCIN
MYDRAL
196
NEO-POLYCIN HC
MYFERON-150 FORTE
48,300
21,30
190
190,192
NEOFRIN
196
MYFORTIC
242
NEOMYCIN SULFATE
7
MYLERAN
290
NEOMYCIN SULFATE/BACITRACIN
MYNATAL
48,183,201,300
ZINC/POLYMYXIN B/HYDROCORTISONE
MYNATAL ADVANCE
48,183,201,300
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
MYNATAL PLUS
48,183,300
B
MYNATAL-Z
48,183,300
NEOMYCIN SULFATE/POLYMYXIN B
MYNATE 90 PLUS
48,201,300
SULFATE/GRAMICIDIN D
MYNEPHROCAPS
300
NEOMYCIN SULFATE/POLYMYXIN B
MYORISAN
276
SULFATE/HYDROCORTISONE
MYOXIN
MYSOLINE
MYZILRA
190,192,196
123
213,224
NABUMETONE
SULFATE/DEXAMETHASONE
NEORAL
NEPHRO-VITE RX
190
190,192
190,192
242
183,300
300
NEUAC
265,276
41,42,68,72,82
NEURONTIN
105,123
NADOLOL/BENDROFLUMETHIAZIDE 42,68,72,82,17
NEVIRAPINE
16,21,26,30
9
NEWGEN
49,183,300
NEXAVAR
291
NADOLOL
NAFARELIN ACETATE
PAGE 327
104
190
NEOMYCIN/POLYMYXIN B
NEPHPLEX RX
N
190,192
227
LAST UPDATED 08/2015
NEXT CHOICE
224
NORETHINDRONE-ETHINYL
NEXT CHOICE ONE DOSE
224
ESTRADIOL 208,209,211,212,213,214,216,217,218,21
NIACIN
58
9,220,222,224,225,226,228,229
NIACINAMIDE/AZELAIC
NORETHINDRONE-ETHINYL
AC/QUERCET/TURMER/FA/B6/ZINC
ESTRADIOL/FERROUS
OX/COPPER
180,235,295
FUMARATE
212,213,216,222,224,228,229
NIACINAMIDE/AZELAIC ACID/ZINC OXIDE/VIT
NORETHINDRONE-MESTRANOL
213,224
B6/COPPER/FA 180,186,188,234,248,249,295,304,30
NORGESTIMATE-ETHINYL
7
ESTRADIOL 209,213,214,215,216,220,224,225,226,22
NICARDIPINE HCL
62,82,95
7,228
NICOTINAMIDE
183,301
NORGESTREL-ETHINYL
NIFEDIAC CC
62,82,95
ESTRADIOL
NIFEDICAL XL
62,82,95
NORITATE
265
NORLYROC
225
NIFEDIPINE
59,62,63,73,82,83,91,92,95,96
NIKKI
213,224
NILOTINIB HCL
293
NIMODIPINE
63,83,96
NIRAVAM
140
NISOLDIPINE
63,83
209,212,214,218,219,222,223,225
NORPACE CR
68
NORPRAMIN
164
NORTREL
214,225
NORTRIPTYLINE HCL
165,166
NORVIR
16,17,26
NITRO-BID
96
NOVAGESIC
NITROFURANTOIN
32
NOVOLOG
207
NITROFURANTOIN MACROCRYSTAL
32
NOVOLOG FLEXPEN
207
NOVOLOG MIX 70-30
207
NITROFURANTOIN
34,105
MONOHYDRATE/MACROCRYSTALS
32
NOVOLOG MIX 70-30 FLEXPEN
207
NITROGLYCERIN
96
NOXAFIL
8,9
NITROSTAT
96
NP THYROID
232
NIVATOPIC PLUS
NIZATIDINE
NORA-BE
277,291
NUMOISYN
196,291
35,36,199
NUVARING
214,225
224
NORDETTE-28
213,224
NYAMYC
265
NYSTATIN
8,9,10,265
NORELGESTROMIN/ETHINYL ESTRADIOL 216,228
NYSTATIN/TRIAMCINOLONE ACETONIDE
NORETHINDRONE 218,219,220,221,223,224,225,227
NYSTOP
NORETHINDRONE ACETATE
225
265,277
265
NORETHINDRONE ACETATE-ETHINYL
O
ESTRADIOL
OCELLA
214,225
NORETHINDRONE ACETATE-ETHINYL
OCTREOTIDE ACETATE
202,229
ESTRADIOL/FERROUS
OFLOXACIN
FUMARATE 211,212,213,215,220,221,222,223,225,22
OGESTREL
8
OLANZAPINE
PAGE 328
210,211,212,213,220,221,222,223,225
7,190
214,225
147,148,151,152,165,175,176
OLANZAPINE PAMOATE
152,175,176
OLANZAPINE/FLUOXETINE HCL
165,171,172
LAST UPDATED 08/2015
OLAPARIB
290
OLEPTRO ER
165,166
OLOPATADINE HCL
36,196
OLYSIO
17,26
OMEGA-3 ACID ETHYL ESTERS
58
OXYCODONE
HCL/ACETAMINOPHEN
99,105,106,107,108
OXYCODONE HCL/ASPIRIN
99,106
OXYMORPHONE HCL
106
OMEGA-3 FATTY ACIDS/CA CARBONATE/VITAMIN
P
D3/FA/MV CMB 13
PACERONE
68
OMEGA-3 FATTY ACIDS/DHA/EPA/OTHER OMEGA-
PAIN RELIEF
277
3S/FISH OIL
PALBOCICLIB
288
57,180,295
59
OMEGA-3/DHA/EPA/B12/FOLIC ACID/PYRIDOXINE
PALGIC
HCL/PHYTOSTEROLS
PALIPERIDONE
162
OMEGA-3/DHA/EPA/D3/B12/FOLIC ACID/PYRIDOX
PALIPERIDONE PALMITATE
162
HCL/PHYTOSTEROL
PALIVIZUMAB
57,58,235,241,295,299
235,295
34,252
20,29
ONDANSETRON
197
PAMELOR
ONDANSETRON HCL
197
PANCREAZE
202,291
OPIUM TINCTURE
202
PANCRELIPASE 5,000
202,291
OPIUM/BELLADONNA ALKALOIDS
38,105
166
PANOBINOSTAT LACTATE
287
ORALONE
277
PAPAVERINE HCL
ORAP
166
PARCAINE
196
PAREGORIC
202
PARICALCITOL
301
PARNATE
166
ORPHENADRINE CITRATE
40,133
ORPHENADRINE
CITRATE/ASPIRIN/CAFFEINE
40,105,114
96
ORSYTHIA
214,225
PAROEX
190,265
ORTHO TRI-CYCLEN
214,225
PAROMOMYCIN SULFATE
ORTHO TRI-CYCLEN LO
214,225
PAROXETINE HCL
166,167
7,12
OSCIMIN
38
PAROXETINE MESYLATE
155,167
OSCIMIN SL
38
PAXIL
166,167
OSCIMIN SR
38
PAZOPANIB HCL
294
PEAK FLOW METER
291
265
OSELTAMIVIR PHOSPHATE
20,29
OSTOMY KIT
291
PEDI-DRI
OSTOMY SUPPLY
291
PEDIATRIC MULTIVITAMIN COMBINATION
OTICIN
190,196
NO.2/SODIUM FLUORIDE
OXANDROLONE
225
PEDIATRIC MULTIVITAMIN COMBO
OXAPROZIN
105
NO.45/FLUORIDE/FERROUS SULFATE
OXAZEPAM
140
PEDIATRIC MULTIVITAMIN COMBO
OXCARBAZEPINE
OXTELLAR XR
124,126,127
124
NO.75/FLUORIDE/FERROUS SULFATE
243,301
49,243,301
49,243,301
PEDIATRIC MULTIVITAMIN
OXYBENZONE/OCTINOXATE/HYDROQUINONE 268
NO.22/CHOLECALCIFEROL/PHYTONADIONE 183,29
OXYBUTYNIN CHLORIDE
283
9
OXYCODONE HCL
105
PEDIATRIC MULTIVITAMIN NO.47 WITH IRON &
SODIUM FLUORIDE
PAGE 329
51,247,304
LAST UPDATED 08/2015
PEDIATRIC MULTIVITAMINS A,C,& D3 NO.21 WITH
PHENTERMINE HCL
SODIUM FLUORIDE
PHENTERMINE HCL/TOPIRAMATE
242,301
PEDIATRIC MULTIVITAMINS COMBINATION
NO.12/SODIUM FLUORIDE
114
114,115,125
PHENYLEPHRINE HCL
241,300
194,196
PHENYLEPHRINE HCL/CHLORPHENIRAMINE
PEDIATRIC MULTIVITAMINS NO.16 WITH SODIUM
MALEATE
FLUORIDE
PHENYLEPHRINE HCL/PROMETHAZINE
243,301
33,44,251
PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM
HCL
FLUORIDE
PHENYLEPHRINE HCL/PYRILAMINE
242,301
34,45,252
PEDIATRIC MULTIVITAMINS NO.82 WITH SODIUM
MALEATE/CHLORPHENIRAMINE
FLUORIDE
PHENYLEPHRINE TANNATE/CHLORPHENIRAMINE
243,301
PEG 3350/SOD SULF/SOD BICARBONATE/SOD
TANNATE
CHLORIDE/POTASSIUM CHL
PHENYTEK
200,202
PEG-PREP
202
35,45
68,124
PHENYTOIN
65,68,119,124
65,68,119,124
PEGASYS
17,26
PHENYTOIN SODIUM EXTENDED
PEGASYS PROCLICK
17,26
PHILITH
PEGINTERFERON ALFA-2A
17,26
PHOSPHA 250 NEUTRAL
PEGINTERFERON ALFA-2B
17,26,27
PEGINTRON
17,26
35,45
214,225
184
PHOSPHASAL
32,38,106,243
PHOSPHOLINE IODIDE
PEGINTRON REDIPEN
17,26,27
PHOSPHORUS #1
PENICILLAMINE
236,286
PHYTONADIONE
193
182,184,187
241,243,299,301
PENICILLIN G BENZATHINE
3
PHYTOSTEROL/OMEGA-3 FATTY
PENICILLIN V POTASSIUM
7
ACIDS/DHA/EPA/FISH OIL
59,248
PILOCARPINE HCL
39,193
PENTAMIDINE ISETHIONATE
12
PENTASA
202
PILOCARPINE NITRATE
194
PENTAZOCINE HCL/ACETAMINOPHEN
106
PIMOZIDE
166
PENTAZOCINE HCL/NALOXONE HCL
106,148
PENTOXIFYLLINE
56
PERIO MED
243
PERIOGARD
190,266
PIMTREA
214,225
PINDOLOL
42,68,69,72,83
PIOGLITAZONE HCL
207
PIOGLITAZONE HCL/GLIMEPIRIDE
207
207
PERMETHRIN
266
PIOGLITAZONE HCL/METFORMIN HCL
PERPHENAZINE
167
PIRMELLA
PERPHENAZINE/AMITRIPTYLINE HCL
167
PIROXICAM
PEXEVA
167
PNEUMOCOCCAL 13-VALENT CONJUGATE
PHENADOZ
34,140,197,252
PHENAZOPYRIDINE HCL
277
214,226
106
VACCINE (DIPHTHERIA CRM)/PF
260
PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE
PHENDIMETRAZINE TARTRATE
110,114
VACCINE
260
PHENELZINE SULFATE
164,167
PNEUMOVAX 23
260
PHENERGAN
PHENOBARBITAL
34,140,197,252
124,140,141
PNV NO.20/IRON FUMARATE/FA/DOCUSATE
NA/FISH OIL CONC/DHA/EPA
51,203,247,304
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE
PNV NO17/IRON,CARB/IRON BISGLY/FA/FISH
SULF/SCOPOLAMINE HB
OIL/DHA/OMEGA 3,6 #1
PAGE 330
37,38,123,125,139,141
46,49,237,243,296,302
LAST UPDATED 08/2015
PNV OB+DHA
49,184,203,243,301
PRASCION
266,277
PNV-DHA
49,184,243,301
PRASCION FC
266,277
PNV-FIRST
49,184,243,301
PRASCION RA
266,277
PNV-OB WITH DHA
49,184,243,301
PRASUGREL HCL
55
PNV-OMEGA
49,184,243,302
PRAVASTATIN SODIUM
58
PNV-SELECT
49,184,302
PRAZOSIN HCL
42,72,83
PNV-TOTAL
49,243,302
PRE-ATTACHED LTA KIT
196,277
PNV-VP-U
49,302
PODOFILOX
277
POLY-DEX
190,192
POLY-IRON 150 FORTE
49,302
POLYCIN
190
POLYDIMETHYLSILOXANES/SILICON
DIOXIDE
278,292
POLYETHYLENE GLYCOL 3350
203
POLYHEXAMETHYLENE BIGUANIDE/GAUZE
BANDAGE
POLYMYXIN B SULFATE, MICRONIZED
PREDNICARBATE
277
PREDNISOLONE
223,224,226
PREDNISOLONE ACETATE
192
PREDNISOLONE SOD PHOSPHATE 192,223,226,228
PREDNISONE
226
PREDNISONE INTENSOL
226
PREMARIN
214,215,244
PREMPHASE
215,226
PREMPRO
215,226
291
PRENA1 CHEW
302
7,266
PRENA1 PEARL
50,244,302
POLYMYXIN B SULFATE/TRIMETHOPRIM
190
PRENAFIRST
PONATINIB HCL
289
PRENAISSANCE
50,185,203,244,302
PRENAISSANCE 90 DHA
50,185,203,244,302
PRENAISSANCE DHA
50,185,203,244,302
PRENAISSANCE PLUS
50,185,203,244,302
PRENAISSANCE PROMISE
50,185,203,244,302
PORTIA
214,226
POSACONAZOLE
8,9
POTASSIUM BICARBONATE/CITRIC
ACID
181,182,184
POTASSIUM CHLORIDE
182,184
POTASSIUM CHLORIDE/POTASSIUM
50,302
PRENAPLUS
50,185,302
PRENATAL VIT #16/IRON FUM & PS
BICARBONATE/CITRIC ACID
184
COMPLEX/FOLIC ACID/OMEGA-
POTASSIUM CITRATE
184
3
51,53,247,249,304,306
POTASSIUM CITRATE/CITRIC ACID 181,184,186,188
PRENATAL VIT COMB NO.4/IRON CARBONYL-IRON
POTASSIUM IODIDE
GLUCONATE/FA/DOSS
9,10,232,243,256
POTASSIUM
IODIDE/IODINE
52,305
PRENATAL VIT NO.71/IRON FUM-SODIUM
8,9,10,231,232,241,243,256
FEREDETATE/FOLIC ACID/DHA
50,244,302
POTIGA
124,125
PRENATAL VIT W/O CALC NO.10/IRON
PR CREAM
277,291
FUM&POLYSAC COMP/FA/OMEGA-3
PR NATAL 400
49,185,243,302
PRENATAL VIT WITH CA NO.64/IRON
PR NATAL 400 EC
49,185,243,302
CARB&GLUC/FOLIC
PR NATAL 430
50,185,244,302
ACID/DSS/DHA 49,50,183,185,201,203,242,244,300,3
PR NATAL 430 EC
50,185,244,302
02
PRAMCORT
277
PRENATAL VIT WITH CA NO.68/IRON
PRAMIPEXOLE DI-HCL
133
FUMARATE/FOLIC ACID
PRAMOXINE-HC
PAGE 331
190,192,196
#1/DHA
51,246,303
49,53,54,184,187,188,243,249,302,306,307
LAST UPDATED 08/2015
PRENATAL VIT WITH CALCIUM
PRENATAL VITAMIN
#69/IRON,CARBON/FOLIC
NO.18/IRON,CARBONYL/FOLIC ACID/DOCUSATE
ACID/DSS/DHA 48,50,54,183,185,188,201,203,204,24
SOD
1,244,249,299,302,307
PRENATAL VITAMIN NO.19/IRON POLYSACC &
PRENATAL VIT WITH CALCIUM CMB 11/FERROUS
IRON HEM/FOLIC AC/DHA
FUMARATE/FOLIC ACID
PRENATAL VITAMIN NO.21/IRON POLYSACCHARID
53,188,306
PRENATAL VIT WITH CALCIUM COMB
48,52,53,182,186,187,201,204,298,305,306
49,54,243,249,301,307
& HEME POLYPEP/FA
NO.63/IRON,CARBONYL/FA/B6
51,186,304
47,53,298,307
PRENATAL VITAMIN NO.67/SODIUM FEREDETATE-
PRENATAL VIT WITH CALCIUM NO. 40/IRON
IRON POLY/FA/OMEGA3
FUMARATE/FA CMB
PRENATAL VITAMIN NO.77/SODIUM FEREDETATE-
NO.1
IRON POLY/FA/OMEGA3
49,53,54,184,187,188,302,306,307
46,180,235,295
52,187,248,305
PRENATAL VIT WITH CALCIUM NO.39/IRON
PRENATAL VITAMIN NO.8/IRON POLYSACCHAR &
FUM/FOLIC
HEME POLYPEPTIDE/FA
ACID/DSS/DHA
47,51,200,203,238,247,298,304
53,307
PRENATAL VITAMIN NO.81/SODIUM FEREDETATE-
PRENATAL VIT WITH CALCIUM NO.80/IRON
IRON
FUM/FOLIC
POLY/FA/OMEGA3
ACID/DSS/DHA 50,51,53,185,186,187,203,204,244,24
PRENATAL VITAMIN NO.86/IRON BIS-
7,249,302,304,306
GLYCINATE/FOLIC ACID
PRENATAL VIT WITH CALCIUM NO42/IRON
PRENATAL VITAMIN W-O VIT A/FERROUS
FUM/FA/L-MEFOLATE CA/DHA
FUMARATE/FOLIC ACID
48,182,240,299
45,52,180,187,235,248,295,305
49,183,300
46,50,295,303
PRENATAL VIT/FOLIC ACID/B6/CALCIUM PHOS DI
PRENATAL VITAMINS COMB 10/FERROUS
& TRIBASIC/GINGER
FUMARATE/FOLIC ACID
188,249,307
53,188,306
PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS
PRENATAL VITAMINS COMB 10/FERROUS
FUMARATE/FOLIC
FUMARATE/FOLIC ACID/DHA
ACID
50,52,53,186,187,303,305,306
49,184,243,301
PRENATAL VITAMINS COMB NO.115/IRON
PRENATAL VITAMIN COMB NO.79/IRON
FUMARATE/FOLIC ACID/DSS
FUMARAT/FA/LMEFOLATE
PRENATAL VITAMINS COMB NO.119/IRON
CA/DHA
FUMARATE/FOLIC ACID/DSS
49,52,184,187,243,249,301,305
49,203,302
50,203,303
PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC
PRENATAL VITAMINS COMB NO.19/IRON BG
ACID/OMEGA-3/DHA
HCL&SUC-PROT/FA/OMEGA-3
47,53,298,307
49,185,243,302
PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX
PRENATAL VITAMINS COMB NO.19/IRON BG
& ASPGL/FA/DHA
HCL&SUCC-P2/FA/OMEGA-3
52,248,305
51,186,247,304
PRENATAL VITAMIN
PRENATAL VITAMINS COMB NO.48/IRON NA
NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE
FEREDETATE/FA/OMEGA-3
SOD47,48,50,51,53,182,183,185,186,187,201,203,204
PRENATAL VITAMINS COMB NO.53/IRON B-G HCL
,298,300,302,304,306
SUC-P/FA/OMEGA-3 49,52,185,186,243,248,302,305
PRENATAL VITAMIN
PRENATAL VITAMINS COMB NO.54/IRON B-G HCL
NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE
SUC-P/FA/OMEGA-3
SOD
PRENATAL VITAMINS COMB NO.55/IRON BG
52,53,204,305,306
50,51,185,244,246,302,303
HCL&SUC-PROT/FA/OMEGA-3
PAGE 332
46,235,295
50,185,244,302
LAST UPDATED 08/2015
PRENATAL VITAMINS COMB NO.55/IRON BG
PRENATAL VITAMINS WITH CALCIUM/FERROUS
HCL&SUCC-P2/FA/OMEGA-3
FUMARATE/DOCUSATE/FA
51,185,246,303
48,201,300
PRENATAL VITAMINS COMB NO.87/IRON
PRENATAL VITAMINS WITH CALCIUM/FERROUS
BISGLY/FOLIC ACID/DHA
FUMARATE/FA/SELENIUM
51,186,247,304
53,187,306
PRENATAL VITAMINS COMBINATION NO.42/FOLIC
PRENATAL VITAMINS WITH CALCIUM/FERROUS
ACID
FUMARATE/FOLIC ACID
302
48,50,183,299,300,302
PRENATAL VITAMINS COMBO NO.14/FERROUS
PRENATAL VITAMINS WITH
FUMARATE/FOLIC ACID
CALCIUM/IRON,CARBONYL/DOCUSATE/FA 48,201,2
46,296
PRENATAL VITAMINS COMBO NO.33/IRON PS
98,300
CMPLX/FOLIC ACID/DHA
PRENATAL VITS CMB W-O CA NO.2
46,181,236,296
52,305
PRENATAL VITAMINS COMBO
PRENATAL VITS W-O CA COMB. NO. 7 W/ IRON &
NO.59/IRON,CARB/FOLIC
FOLIC ACID & DHA
ACID/DSS/DHA
53,204,249,307
46,50,236,246,296,303
PRENATAL VITS WITH CALCIUM #2/IRON B-G SUC-
PRENATAL VITAMINS NO.11/FERROUS
P/FA/OMEGA-3
FUMARATE/FOLIC ACID/OMEGA-
PRENATAL VITS WITH CALCIUM
3
#44/IRON,CARBONYL/FOLIC ACID
46,50,235,245,295,303
46,52,181,187,236,248,296,305
53,306
PRENATAL VITAMINS NO.15/IRON FUMARATE &
PRENATAL VITS WITH CALCIUM #47/FE
POLYSAC COMP/FA
FUMARATE/FA CMB
47,298
PRENATAL VITAMINS
#1/DHA
NO.18/IRON,CARBONYL/FA/UBIDECARENONE/DHA
PRENATAL VITS WITH CALCIUM #7/FE ASP
52,187,248,305
GLY/DOCUSATE/FOLIC ACID
PRENATAL VITAMINS NO.22/IRON CBN &
PRENATAL VITS WITH CALCIUM #70/FERROUS
GLUC/FOLIC
FUMARATE/FA/DHA
ACID/DSS
51,52,186,187,203,204,304,305
49,53,54,184,187,188,243,249,301,306,307
53,204,306
46,180,235,295
PRENATAL VITS WITH CALCIUM #71/FERROUS
PRENATAL VITAMINS NO.22/IRON
FUMARATE/FOLIC ACID 50,53,185,188,302,303,306
CBN&GLUCON/FOLIC
PRENATAL VITS WITH CALCIUM #72/FERROUS
ACID/DSS/DHA
FUMARATE/FOLIC ACID
49,50,184,185,203,243,244,301,302
PRENATAL VITAMINS NO.26/IRON
POLYSACCHARIDES/FA/DHA
49,50,184,185,301,303
PRENATAL VITS WITH CALCIUM
49,184,243,301
#72/IRON,CARBONYL/FOLIC ACID
49,184,301
PRENATAL VITAMINS NO.38/IRON
PRENATAL VITS WITH CALCIUM #74/FERROUS
CBN&GLUCON/FOLIC
FUMARATE/FOLIC ACID
ACID/DSS/DHA 49,50,183,185,202,203,242,244,300,3
PRENATAL VITS WITH CALCIUM#109/FERROUS
02
FUMARATE/FOLIC ACID
PRENATAL VITAMINS NO.59/IRON CARBONYL &
PRENATAL VITS WITH CALCIUM#118/FERROUS
FUMARATE/FA/DSS/DHA
FUMARATE/FOLIC ACID
48,201,239,298
53,188,307
52,305
50,303
PRENATAL VITAMINS NO.72/IRON CARBONYL &
PRENATAL VITS WITHOUT CALC NO5/FERROUS
GLUCONATE/FA/DSS/DHA
FUMARATE/FOLIC ACID
47,200,297
49,52,301,302,305
PRENATAL VITAMINS NO.73/IRON CARBONYL &
PRENATAL WITHOUT IRON/FOLIC ACID/CALCIUM
GLUCONATE/FA/DSS/DHA
CARB/PYRIDOXINE/B12
47,200,297
PRENATAL VITAMINS WITH CALCIUM/FE
PRENATE PLUS
BISGLY/FOLIC ACID
PREPIDIL
PAGE 333
52,187,305,306
180,181,186,295,297,304
50,303
291
LAST UPDATED 08/2015
PREPLUS
50,185,303
PREVALITE
58
PREVIFEM
215,226
PREVNAR 13
260
PREZCOBIX
PROVENZA
277
PROVERA
227
PROZAC
168
PROZAC WEEKLY
168
17,27,244
PRUCLAIR
277,291
18,27
PRUDOXIN
277
PREZISTA
PRIMIDONE
123,125
PRUTECT
PRISTIQ ER
167,168
PSEUDOEPHEDRINE HCL/HYDROCODONE
PRO DNA COLLECTION
196
PROBENECID
185,244
278,291
BITARTRATE/CHLORPHENIRAMINE 35,45,106,253,2
54,256
PROCARBAZINE HCL
290
PULMICORT
227,250
PROCENTRA
114
PULMICORT FLEXHALER
227,250
PROCHLORPERAZINE
156,168,197
PROCHLORPERAZINE MALEATE
168,197
PULMOSAL
185,257,291
PULMOZYME
257,291
PROCTO-PAK
277
PUREVIT DUALFE PLUS
PROCTOSOL-HC
277
PURIXAN
PROCTOZONE-HC
277
PYRAZINAMIDE
11
PROGESTERONE,MICRONIZED
227
PYRIDOSTIGMINE BROMIDE
39
PROGRAF
244
PROMACET
106,141
PROMETHAZINE
HCL
245,291
Q
QSYMIA
32,34,35,140,141,197,198,252,253
PROMETHAZINE HCL/CODEINE
34,252,256
50,185,303
114,115,125
QUADRACEL DTAP-IPV
QUADRAPAX
261
38,125,141
PROMETHAZINE HCL/DEXTROMETHORPHAN
QUASENSE
215,227
HBR
QUAZEPAM
141
34,252,256
PROMETHAZINE/PHENYLEPHRINE
QUETIAPINE FUMARATE
HCL/CODEINE
34,45,106,252,256
QUILLIVANT XR
115
34,35,141,198,252,253
QUINAPRIL HCL
83,84,90
PROMETHEGAN
PROPAFENONE HCL
69
QUINAPRIL
PROPANTHELINE BROMIDE
38
HCL/HYDROCHLOROTHIAZIDE
PROPARACAINE HCL
196
148,150,168,171
84,90,179
QUINIDINE GLUCONATE
12,69
PROPARACAINE HCL/FLUORESCEIN
QUINIDINE SULFATE
12,69
SODIUM
195,196,287,291
QUININE SULFATE
PROPRANOLOL HCL
42,69,72,83,130
QVAR
42,69,72,83,179
R
PROPRANOLOL
HCL/HYDROCHLOROTHIAZIDE
12
227,250
PROPYLTHIOURACIL
232
R-TANNA
35,45
PROSTIN E2 VAGINAL SUPPOSITORY
291
RABEPRAZOLE SODIUM
199
PROTECTIVES COMBINATION NO.2/CERAMIDES
RALOXIFENE HCL
1,3,6-11
277,291
RALTEGRAVIR POTASSIUM
16,25
PROTRIPTYLINE HCL
168,174
RAMIPRIL
84,90
PAGE 334
215,245
LAST UPDATED 08/2015
RANITIDINE HCL
36,199
RILUZOLE
148
REA LO 39
278
RIMANTADINE HCL
REA LO 40
278
RISEDRONATE SODIUM
REBETOL
18,27
REBIF
245
19,28
245
RISPERDAL
148,169
RISPERDAL CONSTA
148,169
149,169
RECEDO
278,292
RISPERDAL M-TAB
RECLIPSEN
215,227
RISPERIDONE
148,149,169,170
RECOMBIVAX HB
261
RISPERIDONE MICROSPHERES
RECTACORT-HC
278
RITALIN
115
REFISSA
278
RITALIN LA
115
REGORAFENIB
292
RITALIN-SR
115
RELADOR PAK
278
RITONAVIR
16,17,26
RELAMINE
245,303
RELENZA
18,27
RELNATE DHA
50,245,303
148,169
RIZATRIPTAN BENZOATE
130
ROBAFEN AC
257
ROMYCIN
190
ROPINIROLE HCL
134
266
REMERON
168,169
REMEVEN
278
ROSADAN
RENA-VITE RX
303
ROSULA
RENAL CAPS
303
ROTATEQ
RENO CAPS
303
ROTAVIRUS VACCINE, LIVE ORAL
REPAGLINIDE
207
PENTAVALENT
261
ROXICET
107
REPAN
106,115,130,141
REPREXAIN
106
RESCRIPTOR
18,27
RESERPINE
84
RETROVIR
18,27,28
REVLIMID
245,292
REYATAZ
18,28
266,278
261
RU-HIST FORTE
35,45
RUFINAMIDE
117
RUXOLITINIB PHOSPHATE
289
S
SALACYN
278
RHINOFLEX
35,106
SALICYLAMIDE/ACETAMINOPHEN/PHENYLTOLOX
RHINOFLEX-650
35,106
AMINE
RHO(D) IMMUNE GLOBULIN
260,261
32,33,97,99
SALICYLIC ACID
269,278
RHOGAM ULTRA-FILTERED PLUS
261
SALICYLIC ACID/CERAMIDES 1,3,6-11
RHOPHYLAC
261
SALMETEROL XINAFOATE
RIBASPHERE
19,28
SALSALATE
107
RIBASPHERE RIBAPAK
19,28
SALVAX
278
RIBATAB
19,28
SANDIMMUNE
245,246
SAPHRIS
149,170
RIBAVIRIN
RIDAURA
14,16,18,19,21,23,25,26,27,28,30
245,292
SAQUINAVIR MESYLATE
RIFABUTIN
7,11
SARAFEM
RIFAMPIN
7,11
SAVELLA
RILPIVIRINE HCL
PAGE 335
14,23
SCALACORT
278
45,254
15,25
170
150,170
279
LAST UPDATED 08/2015
SCOPOLAMINE HYDROBROMIDE
195
SKLICE
267
SE 10-5 SS
266,279
SODIUM BISULFITE
SE BPO
266,279
SODIUM CHLORIDE FOR
SE-CARE
50,303
246,292
INHALATION
185,257,291,292
SE-DONNA PB HYOS
38,125,141
SODIUM CHLORIDE IRRIGATING SOLUTION
SE-NATAL 19
50,203,303
SODIUM CHLORIDE/SODIUM
SE-NATAL ONE
50,303
SE-PLETE DHA
50,246,303
CHLORIDE/PEG
SE-TAN DHA
51,246,303
SODIUM CITRATE DIHYDRATE
SE-TAN PLUS
51,185,303
SODIUM FLUORIDE
SEASONIQUE
215,227
186
BICARBONATE/POTASSIUM
200,203,204
186
236,238,240,241,242,246
SODIUM FLUORIDE/XYLITOL
SEB-PREV
266
SODIUM LAURYL SULFATE
SECOBARBITAL SODIUM
141
SODIUM PHENYLBUTYRATE
SECONAL SODIUM
141
SODIUM POLYSTYRENE
238
279,292
186
SEDAPAP
107,141
SULFONATE
SELEGILINE
133,158
SODIUM/POTASSIUM/POTASSIUM
SELEGILINE HCL
134,170
CITRATE/SODIUM CITRATE/CIT AC 181,185,186,188
SELENIUM SULFIDE
266,279
SOFOSBUVIR
SELZENTRY
19,29
SEREVENT DISKUS
45,254
188,189,240,241,246,247
19,29
SOJOURN
153
SORAFENIB TOSYLATE
291
203
SEROQUEL
150,171
SORBITOL SOLUTION
SEROQUEL XR
150,171
SORBITOL/SALIVA STIMULANT COMB NO. 1/MALIC
SERTRALINE HCL
171,175
ACID/CAL PHOS
SETONET
51,185,246,303
SORINE
SETONET-EC
51,185,246,303
SOTALOL HCL
SEVELAMER CARBONATE
189,246
196,291
42,69,72,84
42,43,69,70,72,73,84
SOVALDI
19,29
38,254
SEVOFLURANE
153
SPIRIVA
SF
246
SPIRONOLACTONE
SF 5000 PLUS
246
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 84,9
SHAROBEL
227
0,179
SILDENAFIL CITRATE
SILVER NITRATE
96,257,283
191,266,267,279
84,90,179
SPRINTEC
215,227
SPRYCEL
292
SILVER NITRATE/POTASSIUM NITRATE
191,279
SPS
189,247
SILVER SULFADIAZINE
267,268
SRONYX
215,227
SS 10-2
267,279
SIMEPREVIR SODIUM
SIMULECT
SIMVASTATIN
17,26
246
59
SSD
267
SSS 10-5
267,279
SINELEE
279
STAGESIC
SINGLE USE EZ FLU 2013-2014
261
STANNOUS FLUORIDE
SINGLE USE EZ FLU 2014-2015
261
STAVUDINE
19,22,29,31
SIROLIMUS
246
STAVZOR
125,130,150
PAGE 336
107
243,247
LAST UPDATED 08/2015
STIVARGA
292
SUTENT
292,293
150,151
SYEDA
215,227
20,29,247
SYMAX
38
303
SYMAX-SL
38
51,186,303
SYMAX-SR
38
STRATTERA
STRIBILD
STROVITE
STROVITE PLUS
SUCRALFATE
198,199
SULFACETAMIDE SODIUM
191,247,266,267
SULFACETAMIDE
SYMBICORT
45,227,250,251,254
SYMBYAX
171,172
SYNAGIS
20,29
SYNAREL
227
SULFACETAMIDE SODIUM/PREDNISOLONE
SYNERA
280
ACETATE
SYNVEXIA
280
SULFACETAMIDE SODIUM/PREDNISOLONE
SYREX
186
SODIUM PHOSPHATE
SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1
SODIUM/AVOBENZONE/SULFUR
266,277
189,191
191,193
SULFACETAMIDE
ML
SODIUM/SULFUR262,263,266,267,268,269,270,271,2
SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.3
72,277,278,279,280,282,283
ML
SULFACETAMIDE
SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.5
SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OC
ML
TYL SAL
268,280
SULFACETAMIDE SODIUM/SULFUR/SKIN
CLEANSER COMB NO.23
268,280
SULFACETAMIDE
SODIUM/SULFUR/UREA
293
293
293
T
TABLOID
293
TACROLIMUS
262,263,267,270,272,279
SULFACETAMIDE SODIUM/SULFUR/WITCH
234,235,239,244,247,280
TAMIFLU
20,29
TAMOXIFEN CITRATE
215,293
HAZEL
266,279
TAMSULOSIN HCL
SULFACETAMIDE SODIUM/UREA
268,280
TARCEVA
SULFACLEANSE 8-4
268,280
TARGRETIN
280,293
TARINA FE
215,228
SULFADIAZINE
SULFAMETHOXAZOLE/TRIMETHOPRIM
7
7,12,32
43
293
TARON FORTE
51,303
SULFAMIDE
191
TARON-BC
51,186,304
SULFANILAMIDE
262
TARON-C DHA
51,247,304
SULFASALAZINE
7,203,247
SULFATRIM
7,12,32
SULFAZINE
SULFAZINE EC
TARON-CRYSTALS
186
TARON-DUO EC
51,186,247,304
7,203,247
TARON-PREX PRENATAL
51,203,247,304
7,203,247
TASIGNA
293
SULINDAC
107
TAZTIA XT
SUMATRIPTAN
131
TEGRETOL
125,151
SUMATRIPTAN SUCCINATE
131
TEGRETOL XR
125,151
SUNITINIB MALATE
SURMONTIL
SUSTIVA
PAGE 337
292,293
171
20,29
63,70,84,85,96
TELAPREVIR
15,24
TELBIVUDINE
20,30
TELMISARTAN
85,90,91
LAST UPDATED 08/2015
TELMISARTAN/AMLODIPINE BESYLATE 63,85,91,97
TL G-FOL OS
186,304
TELMISARTAN/HYDROCHLOROTHIAZIDE 85,91,179
TL GARD RX
304
TEMAZEPAM
TL ICON
141
TEMOZOLOMIDE
293,294
TL-CARE DHA
TENCON
107,141
TL-CERMIDE
TENIVAC
261
TENOFOVIR DISOPROXIL FUMARATE
TERAZOSIN HCL
TERBINAFINE HCL
TERBUTALINE SULFATE
51,304
51,203,247,304
280,294
TL-FLUORIVITE
51,247,304
21,31
TL-FOL 500
51,304
43,73,85
TL-HEM 150
51,186,203,304
8,9,10
TL-SELECT
51,186,203,247,304
45,254,255
TOBRADEX
191,193
TERCONAZOLE
268
TOBRAMYCIN
TERRELL
153
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE
TESTOSTERONE
217
TOBRAMYCIN/DEXAMETHASONE
TETANUS AND DIPHTHERIA TOXOIDS,
ADSORBED, ADULT/PF
257,261
191
8
191,193
TOBREX
191
TOFRANIL
172
TETANUS AND DIPHTHERIA TOXOIDS, ADULT 261
TOFRANIL-PM
TETANUS TOXOID, ADSORBED/PF
261
TOLAZAMIDE
TETANUS-DIPHTERIA-DECAVAC
261
TOLBUTAMIDE
TETCAINE
196
TOLCAPONE
134
TOLMETIN SODIUM
107
TOLTERODINE TARTRATE
283
TETRACAINE HCL
194,196
TETRACAINE HCL/PF
196
TETRACYCLINE HCL
8,13,199
THEO-24
85,115,179,255,283
THEOCHRON
85,115,179,255,283,284
THEOPHYLLINE
ANHYDROUS
172,173
207
207,294
TOLU BALSAM
247,294
TOPAMAX
125,126,131
TOPIRAGEN
126,131
TOPIRAMATE
85,86,115,116,179,180,255,283,284
THERAPEUTIC HEMATINIC
125,126,127,131,132
TOPOTECAN HCL
288
51,186,304
TORSEMIDE
86,180
THERMAZENE
268
TRADJENTA
207
THIOGUANINE
293
TRAMADOL HCL
107
THIORIDAZINE HCL
172
TRAMADOL HCL/ACETAMINOPHEN
THIOTHIXENE
172
TRANDOLAPRIL
THYROID,PORK
229,230,231,232,233,234
TIAGABINE HCL
125
TILIA FE
TIMOLOL MALEATE
TIOTROPIUM BROMIDE
215,228
43,70,73,86,131,194
38,254
126,142
TRANYLCYPROMINE SULFATE
166,173
TRAVOPROST (BENZALKONIUM)
TRAZODONE HCL
TREAGAN OTIC
TIPRANAVIR/VITAMIN E TPGS
13,22
TRETIN-X
TIVICAY
20,29
TRETINOIN
PAGE 338
54
TRANXENE T-TAB
13,23
TL 45% UREA
86,91
TRANEXAMIC ACID
TIPRANAVIR
TIZANIDINE HCL
107,132
194
165,166,173
193,196
280
269,280,281,294
40
TRETINOIN MICROSPHERES
280
TRETINOIN/EMOLLIENT BASE
281
278,281
LAST UPDATED 08/2015
TRETINOIN/EMOLLIENT COMBINATION NO. 9/SKIN
TRIVEEN-U
52,305
CLN1
TRIVORA-28
216,228
280
TREZIX
107,116
TRI RX
51,186,203,304
TROKENDI XR
127,132
TRI-CHLOR
247,281
TROPICAMIDE
196,197
TRI-ESTARYLLA
215,228
TROSPIUM CHLORIDE
TRI-LEGEST FE
215,228
TRUST NATAL DHA
TRI-LINYAH
215,228
TRUVADA
20,30
TRI-PREVIFEM
216,228
TUSSIGON
38,257
TRI-SPRINTEC
216,228
TYBOST
248
TRI-TABS DHA
51,186,247,304
TYKERB
294
186,248,304
TYZEKA
20,30
TRI-ZEL
TRIADVANCE
TRIAMCINOLONE ACETONIDE
51,186,203,304
193,251,277,281
TRIZIVIR
78,177
ULORIC
TRIAMTERENE/HYDROCHLOROTHIAZIDE
86,180
ULTIMATE OB DHA
TRIANEX
281
UMECTA
TRIAZOLAM
142
UNITHROID
TRICITRATES
TRICON
247,281
186
52,304
283
52,187,248,305
U
TRIAMTERENE
TRICHLOROACETIC ACID
20,30
248
52,248,305
281
232,233
UR N-C
32,38,107,248
UREA
268,271,278,280,281,282
UREA/HYALURONATE SODIUM
TRIDERM
281
UREA/LACTIC ACID/SALICYLIC ACID
TRIFLUOPERAZINE HCL
173
UREA/LACTIC ACID/ZINC
TRIFLURIDINE
191
UNDECYLENATE
282
275,282
262,264,268,271,275,282
TRIGELS-F FORTE
52,304
URETRON D-S
32,38,107,248
TRIHEXYPHENIDYL HCL
38,134
URIMAR-T
32,39,107,248
126,127
URIN D.S.
32,39,108,248
URO-L
32,39,108,248
URO-MP
32,39,108,248
TRILEPTAL
TRILYTE WITH FLAVOR PACKETS
TRIMESIS RX
TRIMETHOBENZAMIDE HCL
TRIMETHOPRIM
TRIMIPRAMINE MALEATE
204
186,304
198
USTELL
32,39,108,248
171,173
UTIRA-C
32,39,108,248
52,204,305
TRINATAL RX 1
52,186,305
TRINESSA
204
32
TRINATAL GT
TRINATAL ULTRA
URSODIOL
52,186,204,305
216,228
V
V-C FORTE
187,305
VALACYCLOVIR HCL
20,30
TRIPHROCAPS
305
VALCHLOR
TRIPLE DYE
268
VALCYTE
20,30
VALGANCICLOVIR HCL
20,30
TRIUMEQ
20,29
TRIVEEN-DUO DHA
52,186,248,305
TRIVEEN-TEN
52,187,248,305
PAGE 339
VALIUM
282
127,142
LAST UPDATED 08/2015
VALPROIC
ACID
VINATE DHA
118,125,127,128,130,132,144,150,151
52,187,249,305
VINATE GT
52,204,305
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
VINATE IC
SODIUM)
VINATE II
52,187,306
VINATE ONE
53,187,306
VALSARTAN/HYDROCHLOROTHIAZIDE 86,87,91,18
VINATE PN CARE
53,204,306
0
VINATE ULTRA
118,127,128,132,144,151
VALSARTAN
86,91
VANDAZOLE
13,268
52,305
53,187,204,306
VINATE-M
53,187,306
VANILLIN
294
VIOKASE
204
VARICELLA VIRUS VACCINE LIVE/PF
261
VIORELE
216,228
VARIVAX VACCINE
261
VIRACEPT
21,30
59
VIRAMUNE
21,30
VIRAMUNE XR
21,30
VIRAZOLE
21,30
VIREAD
21,31
VASCAZEN
VAYAROL
VELIVET
59,248
216,228
VEMURAFENIB
294
VENA-BAL DHA
52,187,248,305
VIRT-ADVANCE
VENATAL COMPLETE DHA
52,187,248,305
VIRT-C DHA
VENLAFAXINE HCL
VENTOLIN HFA
VERAMYST
VERAPAMIL HCL
158,173,174
45,255
193,228,251
63,64,70,87,97
53,187,204,306
53,249,306
VIRT-PHOS 250 NEUTRAL
187
VIRT-PN
53,187,306
VIRT-PN DHA
53,187,249,306
VIRT-PN PLUS
53,187,249,306
VERDROCET
108
VIRT-SELECT
VERIPRED 20
228
VIRT-VITE
306
VERSACLOZ
174
VIRT-VITE FORTE
306
VESTURA
216,228
VIRT-VITE GT
VIC-FORTE
187,305
VIRTI-SULF
53,187,204,249,306
53,204,306
268,282
VICODIN
108
VIRTRATE-2
187
VICODIN ES
108
VIRTRATE-3
188
VICODIN HP
108
VIRTRATE-K
188
VICTOZA 2-PAK
207
VISMODEGIB
287
VICTOZA 3-PAK
208
VIT 3
57,235,295
VICTRELIS
21,30
VITACIRC-B
306
VIDEX
21,30
VITAFOL-OB
53,188,306
VIDEX EC
21,30
VITAFOL-PN
53,188,306
VIIBRYD
174
VITAMIN A/VITAMIN
VILAZODONE HYDROCHLORIDE
174
E/AVOBENZONE/OCTINOXATE/HYDROQUINONE 26
VIMPAT
127
8
VINACAL
VINATE AZ
52,187,204,305
52,187,305
VINATE CALCIUM
52,305
VINATE CARE
52,305
PAGE 340
VITAMIN B COMP AND VIT C NO.6
303
VITAMIN B COMPLEX & VITAMIN C NO.20/FOLIC
ACID
300,303,305
LAST UPDATED 08/2015
VITAMIN B COMPLEX#11/FOLIC ACID/ASCORBIC
ACID/BIOTIN/ZN OXID
WYMZYA FE
181,296
216,228
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
X
ACID/BIOTIN
X-VIATE
282
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
XANAX
142
ACID/BIOTIN/ZNOX
XANAX XR
142
300,303,306
183,300
VITAMIN E ACET
XCLAIR
282,294
(DL,TOCOPHERYL)/GRAPE/HYALURONIC
XOLOX
108
XTANDI
294
ACID
277,291
VITAMIN E
XULANE
ACETATE/AVOBENZONE/OCTINOXATE/HYDROQUI
XYLON 10
NONE
VITASPIRE
268
53,306
216,228
108
Y
VITAZOL
268
VITEKTA
21,22,31
VIVACTIL
174
Z
VOL-CARE RX
306
Z-PRAM
282
ZAFIRLUKAST
251
VOL-PLUS
53,188,306,307
YODOXIN
13
VORINOSTAT
294
ZALEPLON
143
VORTIOXETINE HYDROBROMIDE
154
ZAMICET
108
VOTRIENT
294
ZANAMIVIR
VP-CH PLUS
VP-ERA OB PLUS
VP-GSTN
53,204,249,307
53,307
ZARAH
ZARONTIN
18,27
216,228
127
188,249,307
ZATEAN-CH
54,188,204,249,307
VP-HEME OB
53,307
ZATEAN-PN
54,188,307
VP-HEME OB + DHA
53,307
ZATEAN-PN DHA
54,188,249,307
ZATEAN-PN PLUS
54,188,249,307
VP-HEME ONE
VP-ZEL
54,249,307
188,249,307
ZEBUTAL
108,116,132,143
VUSION
268,282
ZELBORAF
294
VYFEMLA
216,228
ZENATANE
282
VYVANSE
116
ZENCHENT
216,229
ZENCHENT FE
216,229
ZENCIA
268,283
W
WARFARIN SODIUM
56
ZENPEP
204,205,294
WELLBUTRIN
174
ZENZEDI
116,117
WELLBUTRIN SR
174
ZEOSA
216,229
WELLBUTRIN XL
174,175
ZERIT
WERA
216,228
ZERUVIA
WESTHROID
233,234
ZFLEX
35,108
22,31
283
WESTHROID-P
234
ZGESIC
35,108
WP THYROID
234
ZIAGEN
22,31
PAGE 341
LAST UPDATED 08/2015
ZIDOVUDINE
18,22,27,28,31
ZINC SULFATE
188
ZINCATE
188
ZINGIBER
ZIPRASIDONE HCL
ZIPRASIDONE MESYLATE
188,249,307
145,151,160,175
145,160
ZOLINZA
294
ZOLMITRIPTAN
132
ZOLOFT
175
ZOLPIDEM TARTRATE
143
ZONEGRAN
127,128
ZONISAMIDE
127,128
ZOSTAVAX
261
ZOSTER VACCINE LIVE/PF
261
ZOVIA 1-35E
216,229
ZOVIA 1-50E
216,229
ZOVIRAX
268
ZYDELIG
294,295
ZYKADIA
295
ZYPREXA
151,152,175
ZYPREXA RELPREVV
152,175,176
ZYPREXA ZYDIS
ZYTIGA
PAGE 342
152,176
295
LAST UPDATED 08/2015