2017
FORMULARY (LIST OF COVERED DRUGS)
IlliniCare Health – MMAI (MMP)
Note to existing members:
This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN.
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IlliniCare Health – MMAI (Medicare-Medicaid Plan) | 2017 List of Covered
Drugs (Formulary)
This is a list of drugs that members can get in IlliniCare Health.
! IlliniCare Health – MMAI (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and
Illinois Medicaid to provide benefits of both programs to enrollees.
! The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We
will send you a notice before we make a change that affects you.
! Benefits may change on January 1 of each year. You can always check IlliniCare Health’s up-to-date List of
Covered Drugs online at http://mmp.illinicare.com.
! Limitations and restrictions may apply. For more information, call IlliniCare Heallth Member Services at 1877-941-0482 or ready the IlliniCare Health Member Handbook. Hours are from 8 a.m. to 8 p.m., Monday
through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call
will be returned within the next business day. TTY users call 711.
! Puede obtener este documento en espanol o consultar a alguien sobre cómo obtener esta información en
otros idiomas gratis. Llame al 1-877-941-0482. El horario de atención es de 8 a. m. a 8 p. m., de lunes a
viernes. Luego del horario de atención, los fines de semana y los días feriado, es posible que se le pida que
deje un mensaje. Le devolveremos la llamada el próximo día hábil. Los usuarios de TTY deben llamar al
711. La llamada es gratuita.
! You can get this information for free in Spanish or speak with someone about this information in other
languages for free. Call 1-877-941-0482. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After
hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned
within the next business day. TTY users call 711. The call is free.
! You can get this information for free in other formats, such as large print, braille, or audio. Call 1-877-9410482. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays,
you may be asked to leave a message. Your call will be returned within the next business day. TTY users
call 711. The call is free.
! If you would like this information in a format other than English or in an alternate format, please call 1-877941-0482. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on
holidays, you may be asked to leave a message. Your call will be returned within the next business day.
TTY users call 711. The call is free. You can also email
[email protected]
! In addition to asking for materials in other languages and formats, you can also ask that we send you future
materials in the same language or format. To get these materials, please call Member Services.
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If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
1
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn
more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 11 are the drugs covered by IlliniCare Health. These
drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement
with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
! IlliniCare Health will cover all medically necessary drugs on the Drug List if:
" your doctor or other prescriber says you need them to get better or stay healthy, and
" you fill the prescription at a IlliniCare Health network pharmacy.
! IlliniCare Health may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at http://mmp.illinicare.com or call
Member Services at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on
weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next
business day. TTY users call 711. The call is free.
2.
Does the Drug List ever change?
Yes. IlliniCare Health may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
" a cheaper drug comes along that works as well as a drug on the Drug List now, or
" we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
" Decide to require or not require prior approval for a drug. (Prior approval is permission from IlliniCare
Health before you can get a drug.)
" Add or change the amount of a drug you can get (called “quantity limits”).
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
2
"
Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before
we will cover another drug.)
(For more information on these drug rules, see Question 5 below.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change
our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the
Drug List changes.
! You can always check IlliniCare Health’s up to date Drug List online at http://mmp.illinicare.com. You can
also call Member Services to check the current Drug List at 1-877-941-0482. Hours are from 8 a.m. to 8
p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a
message. Your call will be returned within the next business day. TTY users call 711. The call is free.
3.
What happens when a cheaper drug comes along that works as well as a drug
on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell
you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then
you can get a 60-day supply of the drug before the change to the Drug List is made.
We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will receive the
notice by mail at least 60 days before we remove the drug from our List of Covered Drugs. Or, we have to tell
you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60-day
supply of the drug. For more information on these drug rules, see page 4. If you have questions about the
notice you receive from IlliniCare Health, call Member Services at the phone number listed at the bottom of this
page.
4.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List
right away. We will also send you a letter telling you that. If you have any questions after being notified of the
change, you should contact the doctor who prescribed the drug for you.
5.
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Are there any restrictions or limits on drug coverage? Or are there any
required actions to take in order to get certain drugs?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
3
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your
doctor or other prescriber must do something before you can get the drug. For example
" Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get
approval from IlliniCare Health before you fill your prescription. If you don’t get approval, IlliniCare Health
may not cover the drug.
" Quantity limits: Sometimes IlliniCare Health limits the amount of a drug you can get.
" Step therapy: Sometimes IlliniCare Health requires you to do step therapy. This means you will have to
try drugs in a certain order for your medical condition. You might have to try one drug before we will cover
another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 9. You
can also get more information by visiting our web site at http://mmp.illinicare.com. We have posted online
documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a
copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
! If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if
you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug
you need (unless you have a prescription for fewer days), whether or not you are a new IlliniCare Health
member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if
there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see
question 11 for more information about exceptions.
6.
How will you know if the drug you want has limitations or if there are
required actions to take to get the drug?
The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions, or limits on use.”
7.
What happens if we change our rules on how we cover some drugs? For
example, if we add prior authorization (approval), quantity limits, and/or step
therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell
you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
4
supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other
prescriber about what to do next.
How can you find a drug on the Drug List?
8.
There are two ways to find a drug:
" You can search alphabetically (if you know how to spell the drug), or
" You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs
that begins on page 103.
To search by medical condition, find the section labeled “List of drugs by medical condition” on page 11. The
drugs in this section are grouped into categories depending on the type of medical conditions they are used to
treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That
is where you will find drugs that treat heart conditions.
What if the drug you want to take is not on the Drug List?
9.
If you don’t see your drug on the Drug List, call Member Services at 1-877-941-0482. Hours are from 8 a.m. to 8
p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a
message. Your call will be returned within the next business day. TTY users call 711. The call is free. If you
learn that IlliniCare Health will not cover the drug, you can do one of these things:
" Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or
other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
" You can ask the health plan to make an exception to cover your drug. Please see question 11 for more
information about exceptions.
10.
What if you are a new IlliniCare Health member and can’t find your drug on
the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member
of IlliniCare Health. This will give you time to talk to your doctor or other prescriber. He or she can help you
decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
5
We will cover a 30-day supply of your drug if:
" you are taking a drug that is not on our Drug List, or
" health plan rules do not let you get the amount ordered by your prescriber, or
" the drug requires prior approval by IlliniCare Health, or
" you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This
gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
Throughout the plan year, you may have a change in your treatment setting (the place where you get and take
your medicine) because of the level of care you require. Such transitions may include, but are not limited to:
"
Members who are discharged from a hospital or skilled-nursing facility to a home setting
"
Members who are admitted to a hospital or skilled-nursing facility from a home setting
"
Members who transfer from one skilled-nursing facility to another and are served by a different
pharmacy
"
Members who end their skilled-nursing facility Medicare Part A stay (where payments include all
pharmacy charges) and who now need to use their Part D plan benefit
"
Members who give up Hospice Status and go back to standard Medicare Part A and B coverage
"
Members discharged from psychiatric hospitals with highly individualized drug regimens
For these changes in treatment settings, IlliniCare will cover as much as a 31-day temporary supply of a Part Dcovered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple
times within the same month, you may have to request an exception or prior authorization and get approval for
continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case
basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a
temporary supply of a drug, call Member Services.
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
6
11.
Can you ask for an exception to cover your drug?
Yes. You can ask IlliniCare Health to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
" For example, IlliniCare Health may limit the amount of a drug we will cover. If your drug has
a limit, you can ask us to change the limit and cover more.
" Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
12.
How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your ask for an
exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can
ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give
you a decision within 24 hours of getting your prescriber’s supporting statement.
13.
How can you ask for an exception?
To ask for an exception, call Member Services at 1-877-941-0482. TTY users call 711. A Member Services
representative will work with you and your provider to help you ask for an exception.
14.
What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than
the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and
Drug Administration (FDA).
IlliniCare Health covers both brand name drugs and generic drugs.
15.
What are OTC drugs?
OTC stands for “over-the-counter”. IlliniCare Health covers some OTC drugs when they are written as
prescriptions by your provider.
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
7
You can read the IlliniCare Health Drug List to see what OTC drugs are covered.
16.
What is your copay?
You can read the IlliniCare Health Drug List to learn about the copay for each drug.
IlliniCare Health members living in nursing homes or other long-term care facilities will have no copays. Some
members getting long-term care in the community will also have no copays.
As an IlliniCare Health member, you have no copays for prescription and OTC drugs as long as you follow
IlliniCare Health’s rules.
Copays are listed by tiers. Tiers are groups of drugs with the same copay.
"
Tier 1 drugs are generic drugs. The copay is $0.
"
Tier 2 drugs are brand name drugs. The copay is $0.
"
Tier 3 drugs are Non-Medicare Rx/OTC drugs. The copay is $0.
17.
What are drug tiers?
Tiers are groups of drugs on our Drug List.
"
Tier 1 drugs are generic drugs.
"
Tier 2 drugs are brand name drugs.
"
Tier 3 drugs are Non-Medicare Rx/OTC drugs.
There is no copay for all drug tiers.
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
8
List of Covered Drugs
The list of covered drugs that begins on page 11 gives you information about the drugs covered by IlliniCare
Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 103.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., JANUVIA) and
generic drugs are listed in lower-case italics (e.g., metformin).
The information in the necessary actions, restrictions, or limits on use column tells you if IlliniCare Health has
any rules for covering your drug.
Abbreviations Descriptions
B/D
This prescription drug has a Part B versus Part D administrative prior authorization
requirement. This drug may be covered under Medicare Part B or Part D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the
drug to make the determination.
DP
Drug is not a Part D drug. This item is covered under your Medicaid benefits. These drugs
also have different rules for appeals.
LA
Limited Access. This prescription may be available only at certain pharmacies. For more
information call Member Service at 1-866-549-8289. TTY users should call 711.
PA
Prior Authorization (or prior approval). IlliniCare Health requires your doctor or you to get prior
approval for certain drugs. This means that you will need to get approval from IlliniCare
Health before you fill your prescriptions. If you don’t get approval, IlliniCare Health may not
cover the drug.
QL
Quantity Limit. For certain drugs, IlliniCare Health limits the amount of the drug that will be
covered. For example, only 30 tablets of JANUVIA per 30 days. This may be in addition to a
standard one-month or three-month supply.
MO
Maintenance Drug. This prescription drug is eligible for a 90-day supply through our mail
order service as well as through certain retail network pharmacies. Consider using mail order
for your long-term (maintenance) medications (such as high blood pressure medications).
Retail network pharmacies may be more appropriate for short- term prescriptions (such as
antibiotics).
NDS
Non-Extended Day Supply. This prescription drug is not available for an extended days'
supply.
ST
Step Therapy. Sometimes IlliniCare Health requires you to do step therapy. This means you
might have to try one drug before we will cover another drug.
Note: The DP next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a
prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not
help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your
prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
9
appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we
made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered
by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for
instructions on how to appeal, call Member Services at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. You can also read
the Member Handbook to learn how to appeal a decision.
?
If you have questions, please call IlliniCare Health at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message.
Your call will be returned within the next business day. TTY users call 711. The call is free. The call is free.
For more information, visit http://mmp.illinicare.com.
10
Name of drug
Analgesics
Analgesics
acephen suppository 120mg, 325mg
acetaminophen extra strength tablet
acetaminophen liquid
acetaminophen suppository 120mg
acetaminophen tablet 325mg, 500mg
allzital
apap tablet 325mg
butalbital/acetaminophen
butalbital/acetaminophen/caffeine/codeine capsule 325mg;
50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine capsule 325mg; 50mg;
40mg
butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg
butalbital/aspirin/caffeine capsule
childrens acetaminophen suspension 160mg/5ml
childrens apap tablet chewable
childrens non-aspirin tablet chewable
childrens silapap
ed-apap
extra strength pain relief
fever reducer childrens
feverall childrens
FEVERALL INFANTS
feverall junior strength
gnp childrens pain relief
gnp infants pain relief suspension
gnp infants pain/fever
gnp pain & fever childrens
gnp pain relief
gnp pain relief extra strength tablet
gnp pain reliever extra strength
goodsense pain & fever childrens
GRALISE
GRALISE STARTER
hm pain & fever childrens
hm pain & fever infants
hm pain relief childrens
hm pain relief extra strength
hm pain reliever
infants pain relief suspension 80mg/0.8ml
INFANTS SILAPAP
mapap acetaminophen extrastrength
mapap childrens suspension
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
DP
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
11
Name of drug
mapap extra strength
mapap tablet chewable, liquid, tablet
non-aspirin extra strength tablet
pain & fever
pain & fever childrens
pain & fever extra strength
pain & fever infants
pain relief childrens suspension
pain relief extra strength tablet
pain relief tablet
pain reliever extra strength
pharbetol
pharbetol extra strength
q-pap
q-pap childrens
q-pap extra strength
q-pap infants
qc non-aspirin childrens suspension
qc non-aspirin extra strength
sb non-aspirin extra strength
sb non-aspirin tablet
sb pain reliever childrens
sm pain & fever childrens
sm pain & fever infants
sm pain reliever
sm pain reliever childrens
sm pain reliever extra strength
tactinal
tactinal extra strength
tencon tablet 325mg; 50mg
TYLENOL INFANTS PAIN+FEVER
Nonsteroidal Anti-inflammatory Drugs
ADVIL TABLET
all day pain relief
all day relief
aspir-81
aspir-low
aspirin adult low strength tablet chewable
aspirin childrens
aspirin ec low dose
aspirin ec tablet delayed release 325mg, 81mg
aspirin enteric coated adult low strength
aspirin low dose tablet chewable, tablet delayed release
aspirin tablet chewable
aspirin tablet delayed release 325mg, 81mg
aspirin tablet 325mg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
12
Name of drug
childrens aspirin
childrens aspirin low strength
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal tablet 500mg
ecpirin
enteric coated aspirin
eql all day relief
etodolac er
etodolac capsule, tablet
fenoprofen calcium capsule 400mg
fenoprofen calcium tablet
flurbiprofen tablet
gnp adult aspirin low strength tablet chewable
gnp all day pain relief
gnp aspirin low dose
gnp aspirin tablet delayed release 325mg
gnp aspirin tablet 325mg
gnp ibuprofen
goodsense aspirin
goodsense ibuprofen
hm aspirin
hm aspirin ec
hm aspirin ec low dose
hm ibuprofen ib
hm ibuprofen capsule, tablet
hm naproxen sodium tablet
ibu-200
ibuprofen suspension
ibuprofen capsule
ibuprofen tablet 400mg, 600mg, 800mg
ibuprofen tablet 200mg
indomethacin er
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
indomethacin capsule
$0(Tier 1)
ketoprofen er capsule extended release 24 hour 200mg
$0(Tier 1)
ketoprofen capsule 50mg, 75mg
ketorolac tromethamine injection 15mg/ml, 30mg/ml
kp aspirin
meclofenamate sodium capsule
meloxicam suspension
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
MO
MO
MO
MO
DP
DP
DP
MO
MO
MO
MO
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
MO
DP
PA (High Risk
Medication-Anti
inflammatory Agents) MO
PA (High Risk
Medication-Anti
inflammatory Agents) MO
QL (30 EA per 30 days)
MO
MO
DP
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
13
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
meloxicam tablet
miniprin low dose
motrin ib
nabumetone
naproxen dr
naproxen sodium tablet 275mg, 550mg
naproxen sodium tablet 220mg
naproxen suspension, tablet
oxaprozin
piroxicam capsule
provil
qc aspirin tablet
qc childrens aspirin
qc ibuprofen ib
qc naproxen sodium
ra ibuprofen tablet
ra naproxen sodium tablet
sb aspirin
sb childrens aspirin
sb ibuprofen
sb low dose asa ec
sb naproxen sodium
sm all day pain relief
sm aspirin
sm aspirin adult low strength tablet chewable 81mg
sm aspirin adult low strength tablet delayed release 81mg
sm aspirin enteric coated
sm childrens aspirin
sm ibuprofen ib tablet
sm ibuprofen tablet
sm naproxen sodium tablet
st joseph aspirin
sulindac tablet
tolmetin sodium capsule
tolmetin sodium tablet 600mg
wal-profen capsule
Opioid Analgesics, Long-acting
fentanyl
levorphanol tartrate tablet
METHADONE HCL INJECTION
methadone hcl oral solution 5mg/5ml
methadone hcl oral solution 10mg/5ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
DP
DP
MO
MO
MO
DP
MO
MO
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
MO
MO
DP
QL (10 EA per 30 days)
QL (120 EA per 30 days)
QL (160 ML per 30 days)
QL (1200 ML per 30
days)
QL (600 ML per 30 days)
QL (120 EA per 30 days)
QL (240 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
14
Name of drug
morphine sulfate er tablet extended release 60mg
morphine sulfate er tablet extended release 15mg, 30mg
morphine sulfate er tablet extended release 200mg
morphine sulfate er tablet extended release 100mg
Opioid Analgesics, Short-acting
acetaminophen/codeine tablet 300mg; 60mg
acetaminophen/codeine tablet 300mg; 15mg, 300mg; 30mg
ascomp/codeine
butorphanol tartrate nasal solution
butorphanol tartrate injection 2mg/ml
butorphanol tartrate injection 1mg/ml
duramorph injection 1mg/ml
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (100 EA per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (5 ML per 28 days)
QL (360 ML per 30 days)
QL (720 ML per 30 days)
QL (2000 ML per 30
days)
QL (4000 ML per 30
days)
QL (360 EA per 30 days)
QL (120 EA per 30 days)
PA (Fentanyl Citrate Oral
Transmucosal) NDS
QL (5550 ML per 30
days)
QL (360 EA per 30 days)
$0(Tier 1)
QL (360 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (150 ML per 30 days)
QL (750 ML per 30 days)
QL (150 EA per 30 days)
PA (Lazanda)
QL (30 EA per 30 days)
PA (Lazanda)
QL (180 EA per 30 days)
QL (300 ML per 30 days)
QL (900 ML per 30 days)
QL (100 ML per 30 days)
QL (200 ML per 30 days)
QL (134 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (1800 ML per 30
days)
QL (360 EA per 30 days)
duramorph injection 0.5mg/ml
$0(Tier 1)
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
fentanyl citrate oral transmucosal
$0(Tier 1)
$0(Tier 1)
hydrocodone bitartrate/acetaminophen solution 325mg/15ml;
7.5mg/15ml
hydrocodone bitartrate/acetaminophen tablet 300mg; 7.5mg,
325mg; 2.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tablet 10mg; 200mg, 5mg; 200mg
hydromorphone hcl tablet
hydromorphone hcl injection 10mg/ml, 50mg/5ml
hydromorphone hcl injection 2mg/ml
LAZANDA SOLUTION 300MCG/ACT
$0(Tier 1)
LAZANDA SOLUTION 100MCG/ACT, 400MCG/ACT
$0(Tier 2)
morphine sulfate tablet
morphine sulfate solution 100mg/5ml
morphine sulfate solution 10mg/5ml, 20mg/5ml
nalbuphine hcl injection 20mg/ml
nalbuphine hcl injection 10mg/ml
oxycodone hcl tablet 30mg
oxycodone hcl tablet 10mg, 15mg, 20mg
oxycodone hcl tablet 5mg
oxycodone/acetaminophen solution
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, $0(Tier 1)
325mg; 7.5mg
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
15
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
TALWIN
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
Anesthetics
Local Anesthetics
hm triple antibiotic plus maximum strength
lidocaine hcl jelly
lidocaine hcl external solution
lidocaine hcl injection 0.5%, 2%
lidocaine viscous
lidocaine/prilocaine cream
lidocaine cream 4%
lidocaine ointment 5%
lidocaine patch 5%
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram tablet
Opioid Dependence Treatments
buprenorphine hcl injection
buprenorphine hcl tablet sublingual 2mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
DP
DP
QL (90 EA per 30 days)
PA (Anesthetics)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
buprenorphine hcl tablet sublingual 8mg
$0(Tier 1)
naltrexone hcl tablet
SUBOXONE FILM 12MG; 3MG
$0(Tier 1)
$0(Tier 2)
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG $0(Tier 2)
ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG,
11.4MG; 2.9MG, 2.9MG; 0.71MG
ZUBSOLV TABLET SUBLINGUAL 8.6MG; 2.1MG
$0(Tier 2)
ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG
$0(Tier 2)
Opioid Reversal Agents
naloxone hcl injection 0.4mg/ml, 2mg/2ml
Smoking Cessation Agents
buproban
bupropion hcl sr tablet extended release 12 hour 150mg
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
gnp nicotine mini lozenge
Necessary actions,
restrictions, or limits on
use
PA (High Risk
Medications)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
$0(Tier 2)
QL (267 ML per 30 days)
QL (300 EA per 30 days)
PA (Suboxone)
QL (75 EA per 30 days)
PA (Suboxone)
QL (60 EA per 30 days)
PA (Suboxone)
QL (90 EA per 30 days)
PA (Suboxone)
QL (30 EA per 30 days)
PA (Zubsolv)
QL (60 EA per 30 days)
PA (Zubsolv)
QL (90 EA per 30 days)
PA (Zubsolv)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
QL (56 EA per 28 days)
QL (56 EA per 28 days)
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
16
Name of drug
gnp nicotine polacrilex
gnp nicotine polacrilex mini
NICODERM CQ
nicorelief gum
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine mini lozenge lozenge 4mg
nicotine polacrilex gum, lozenge
NICOTINE TRANSDERMAL SYSTEM KIT
nicotine transdermal system patch 24 hour 14mg/24hr,
21mg/24hr, 7mg/24hr
nicotine patch 24 hour 14mg/24hr, 21mg/24hr, 7mg/24hr
NICOTROL NS
sm nicotine patch 24 hour 14mg/24hr, 21mg/24hr
thrive gum 2mg
Antibacterials
Aminoglycosides
amikacin sulfate injection 500mg/2ml
gentak ointment
gentamicin sulfate/0.9% sodium chloride injection 1.2mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%
gentamicin sulfate cream, external ointment, ophthalmic
ointment, ophthalmic solution
gentamicin sulfate injection 10mg/ml, 40mg/ml
isotonic gentamicin
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
streptomycin sulfate injection 1gm
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
Antibacterials, Other
alcohol prep pads
baciim
bacitracin zinc ointment
bacitracin/neomycin/polymyxin ointment
BACITRACIN INJECTION
bacitracin ophthalmic ointment
bacitracin external ointment
BETADINE SKIN CLEANSER
BETADINE SURGICAL SCRUB
BETADINE SWAB AID
BETADINE SWABSTICKS
BETADINE SOLUTION 10%
CHLORAMPHENICOL SODIUM SUCCINATE
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
17
Name of drug
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
clindamax gel
clindamycin hcl capsule
clindamycin palmitate hcl
clindamycin phosphate in d5w
clindamycin phosphate cream, gel, lotion, external solution,
swab
clindamycin phosphate injection 300mg/2ml, 600mg/4ml,
900mg/6ml
colistimethate sodium
CUBICIN
daptomycin
double antibiotic
gnp bacitracin zinc
gnp triple antibiotic
hm bacitracin
hm double antibiotic
hm povidone-iodine
hm triple antibiotic
LINCOCIN INJECTION
lincomycin hcl injection
linezolid tablet
linezolid suspension reconstituted
linezolid injection 600mg/300ml
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole gel 0.75%
metronidazole cream, lotion, tablet
mupirocin ointment
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/hydrocortisone ophthalmic suspension
1%; 3.5mg/ml; 10000unit/ml
NEOSPORIN ORIGINAL
nitrofurantoin macrocrystals
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
B/D
NDS
NDS
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 1)
DP
PA (High Risk Medication
- Nitrofurantoin)
PA (High Risk Medication
- Nitrofurantoin)
nitrofurantoin monohydrate/macrocrystals
$0(Tier 1)
polymyxin b sulfate injection
povidone-iodine ointment, solution
qc povidone iodine
sb povidone-iodine
sb triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm
silver sulfadiazine cream
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
QL (20 EA per 10 days)
QL (600 ML per 10 days)
DP
DP
DP
DP
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
18
Name of drug
sm antibiotic
sm double antibiotic
sm triple antibiotic
ssd
SYNERCID INJECTION 350MG; 150MG
trimethoprim tablet
triple antibiotic plus ointment 500unit/gm; 3.5mg/gm;
10000unit/gm; 10mg/gm, 500unit/gm; 5mg/gm;
10000unit/gm; 10mg/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm, 400unit/gm; 5mg/gm; 5000unit/gm
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm, 500mg
vandazole
XIFAXAN TABLET 200MG
XIFAXAN TABLET 550MG
Beta-lactam, Cephalosporins
cefaclor er tablet extended release 12 hour 500mg
cefaclor capsule
cefadroxil
cefazolin sodium injection 10gm, 1gm, 500mg
cefdinir
cefepime injection 1gm, 2gm
cefotaxime sodium injection 1gm, 2gm, 500mg
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil tablet
cefprozil
ceftazidime injection 1gm, 2gm, 6gm
ceftriaxone sodium injection 10gm, 1gm, 250mg, 2gm, 500mg
cefuroxime axetil tablet
cefuroxime sodium injection 1.5gm, 7.5gm, 750mg
cephalexin capsule 250mg, 500mg
cephalexin suspension reconstituted, tablet
CLAFORAN INJECTION 10GM, 500MG
FORTAZ INJECTION 1GM, 2GM
SUPRAX CAPSULE, TABLET CHEWABLE,
SUSPENSION RECONSTITUTED
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE
aztreonam injection 1gm
imipenem/cilastatin
INVANZ
meropenem injection 500mg
Beta-lactam, Penicillins
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
NDS
DP
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
19
Name of drug
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin capsule, suspension reconstituted, tablet
amoxicillin tablet chewable 125mg, 250mg
ampicillin
ampicillin sodium injection 10gm, 125mg, 1gm
ampicillin-sulbactam
BACTOCILL IN DEXTROSE
BICILLIN C-R INJECTION 300000UNIT/ML;
300000UNIT/ML, 900000UNIT/2ML; 300000UNIT/2ML
BICILLIN L-A INJECTION 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML
dicloxacillin sodium
nafcillin sodium injection 10gm, 1gm
oxacillin sodium injection 10gm, 2gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 40000UNIT/ML, 0;
60000UNIT/ML
penicillin g potassium injection 5000000unit
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
piperacillin/tazobactam injection 4gm; 0.5gm
ZOSYN INJECTION 36GM; 4.5GM, 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML
Macrolides
AZASITE
azithromycin injection 500mg
azithromycin suspension reconstituted 100mg/5ml
azithromycin suspension reconstituted 200mg/5ml
azithromycin tablet 500mg
azithromycin tablet 250mg
azithromycin tablet 600mg
clarithromycin er
clarithromycin suspension reconstituted
clarithromycin tablet 250mg
clarithromycin tablet 500mg
e.e.s. 400 tablet
e.e.s. granules
ERY-TAB
ERYPED 400
ERYTHROCIN LACTOBIONATE INJECTION 500MG
erythrocin stearate tablet 250mg
erythromycin base
erythromycin ethylsuccinate suspension reconstituted
erythromycin capsule delayed release particles, ointment
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (15 ML per 5 days)
QL (22.5 ML per 5 days)
QL (3 EA per 3 days)
QL (6 EA per 5 days)
QL (8 EA per 28 days)
QL (28 EA per 14 days)
QL (42 EA per 21 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
20
Name of drug
erythromycin solution 2%
KETEK
ZMAX
Quinolones
AVELOX INJECTION
ciprofloxacin hcl solution, tablet
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin injection 400mg/40ml
levofloxacin in d5w injection 5%; 500mg/100ml, 5%;
750mg/150ml
levofloxacin injection, oral solution
levofloxacin tablet 250mg
levofloxacin tablet 500mg, 750mg
moxifloxacin hcl injection
ofloxacin ophthalmic solution, otic solution
ofloxacin tablet 300mg, 400mg
Sulfonamides
sodium sulfacetamide solution
sulfacetamide sodium suspension
sulfadiazine tablet
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
Tetracyclines
demeclocycline hcl tablet
doxy 100
doxycycline hyclate capsule, injection, tablet
doxycycline monohydrate capsule 100mg, 50mg
minocycline hcl capsule
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG, 400MG, 800MG
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (10 EA per 10 days)
QL (14 EA per 14 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
APTIOM TABLET 600MG
$0(Tier 2)
BRIVIACT INJECTION
BRIVIACT TABLET
$0(Tier 2)
$0(Tier 2)
BRIVIACT ORAL SOLUTION
$0(Tier 2)
FYCOMPA TABLET
$0(Tier 2)
FYCOMPA SUSPENSION
$0(Tier 2)
levetiracetam injection
levetiracetam oral solution, tablet
$0(Tier 1)
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (600 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (720 ML per 30 days)
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
21
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
POTIGA TABLET 50MG
POTIGA TABLET 200MG, 300MG, 400MG
$0(Tier 2)
SPRITAM
Calcium Channel Modifying Agents
CELONTIN CAPSULE 300MG
ethosuximide
LYRICA SOLUTION
LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG
$0(Tier 2)
LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
zonisamide
$0(Tier 1)
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tablet disintegrating 0.125mg, 0.25mg, 0.5mg, $0(Tier 1)
1mg
clonazepam odt tablet disintegrating 2mg
$0(Tier 1)
clonazepam tablet 0.5mg, 1mg
$0(Tier 1)
clonazepam tablet 2mg
$0(Tier 1)
diazepam gel 20mg
$0(Tier 1)
diazepam gel 2.5mg
$0(Tier 1)
diazepam gel 10mg
$0(Tier 1)
divalproex sodium dr
$0(Tier 1)
divalproex sodium er
$0(Tier 1)
divalproex sodium capsule delayed release sprinkle
$0(Tier 1)
gabapentin capsule, solution
$0(Tier 1)
gabapentin tablet 600mg, 800mg
$0(Tier 1)
GABITRIL TABLET 12MG, 16MG
$0(Tier 2)
ONFI SUSPENSION
ONFI TABLET 10MG, 20MG
phenobarbital elixir
phenobarbital tablet 100mg, 15mg, 16.2mg, 30mg, 32.4mg,
60mg, 64.8mg, 97.2mg
primidone tablet
SABRIL
tiagabine hydrochloride
valproate sodium injection
valproic acid capsule, solution
Glutamate Reducing Agents
felbamate
lamotrigine odt
lamotrigine tablet chewable, tablet
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (100 EA per 30 days)
QL (24.9 EA per 30 days)
QL (50 EA per 30 days)
MO
MO
MO
MO
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
QL (360 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
22
What the drug
will cost you
Name of drug
(tier level)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG $0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG $0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG, $0(Tier 2)
200MG
topiramate er capsule er 24 hour sprinkle 100mg, 25mg, 50mg $0(Tier 1)
topiramate er capsule er 24 hour sprinkle 150mg, 200mg
$0(Tier 1)
topiramate capsule sprinkle, tablet
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 25MG, 50MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 100MG
Sodium Channel Agents
BANZEL SUSPENSION
BANZEL TABLET 200MG
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
BANZEL TABLET 400MG
$0(Tier 2)
carbamazepine er
carbamazepine tablet chewable, suspension, tablet
CARBATROL
CEREBYX INJECTION 500MG PE/10ML
DILANTIN INFATABS
DILANTIN-125
DILANTIN CAPSULE
epitol
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 600MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
PEGANONE TABLET 250MG
PHENYTEK
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
TEGRETOL-XR
TEGRETOL SUSPENSION, TABLET
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
NDS
QL (240 EA per 30 days)
MO
QL (240 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
23
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Name of drug
VIMPAT INJECTION
VIMPAT ORAL SOLUTION
VIMPAT TABLET 50MG
VIMPAT TABLET 100MG, 150MG, 200MG
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates tablet
Cholinesterase Inhibitors
donepezil hcl tablet disintegrating
$0(Tier 2)
PA (High Risk
Medications) MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 1)
galantamine hydrobromide er
$0(Tier 1)
galantamine hydrobromide solution
galantamine hydrobromide tablet 4mg
$0(Tier 1)
$0(Tier 1)
galantamine hydrobromide tablet 12mg
$0(Tier 1)
galantamine hydrobromide tablet 8mg
$0(Tier 1)
rivastigmine tartrate
$0(Tier 1)
rivastigmine transdermal system
$0(Tier 1)
memantine hcl titration pak
memantine hydrochloride solution
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Antidepressants
Antidepressants, Other
bupropion hcl sr tablet extended release 12 hour 100mg,
150mg, 200mg
bupropion hcl xl
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
$0(Tier 1)
donepezil hcl tablet 10mg, 5mg
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
bupropion hcl tablet 75mg
bupropion hcl tablet 100mg
$0(Tier 1)
$0(Tier 1)
maprotiline hcl
mirtazapine odt
$0(Tier 1)
$0(Tier 1)
QL (60 EA per 30 days)
MO
MO
QL (360 ML per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
24
Name of drug
mirtazapine tablet
nefazodone hcl
trazodone hcl tablet
TRINTELLIX
Monoamine Oxidase Inhibitors
EMSAM
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
$0(Tier 2)
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) NDS
MO
MO
MO
MARPLAN
$0(Tier 2)
phenelzine sulfate
$0(Tier 1)
tranylcypromine sulfate
$0(Tier 1)
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide solution
$0(Tier 1)
citalopram hydrobromide tablet 10mg
$0(Tier 1)
citalopram hydrobromide tablet 40mg
$0(Tier 1)
citalopram hydrobromide tablet 20mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 100mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 25mg, 50mg $0(Tier 1)
duloxetine hcl capsule delayed release particles
$0(Tier 1)
escitalopram oxalate solution
escitalopram oxalate tablet
$0(Tier 1)
$0(Tier 1)
FETZIMA
$0(Tier 2)
FETZIMA TITRATION PACK
$0(Tier 2)
fluoxetine hcl capsule, solution
fluoxetine hcl tablet 10mg
fluvoxamine maleate
paroxetine hcl
paroxetine hcl er tablet extended release 24 hour 37.5mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (600 ML per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
25
Name of drug
PAXIL SUSPENSION
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
25MG, 50MG
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
100MG
$0(Tier 2)
sertraline hcl concentrate, tablet
venlafaxine hcl
$0(Tier 1)
$0(Tier 1)
venlafaxine hcl er
$0(Tier 1)
VIIBRYD STARTER PACK
$0(Tier 2)
VIIBRYD TABLET
$0(Tier 2)
Tricyclics
amitriptyline hcl tablet
amoxapine
chlordiazepoxide/amitriptyline
clomipramine hcl capsule
desipramine hcl tablet
doxepin hcl capsule, concentrate
imipramine hcl tablet
imipramine pamoate
nortriptyline hcl capsule, solution
perphenazine/amitriptyline
protriptyline hcl
trimipramine maleate capsule
Antiemetics
Antiemetics, Other
anti-nausea
dimenhydrinate tablet
dramamine less drowsy
DRAMAMINE TABLET
driminate
formula em
gnp anti-nausea
gnp motion sickness relief
hm motion relief
meclizine hcl tablet chewable
Necessary actions,
restrictions, or limits on
use
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 180 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
26
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
Name of drug
meclizine hcl tablet 12.5mg, 25mg
meclizine hcl tablet 12.5mg
motion sickness
motion-time
phenadoz suppository 12.5mg
promethazine hcl injection, suppository, syrup, tablet
$0(Tier 1)
promethegan suppository 25mg, 50mg
$0(Tier 1)
ra motion sickness relief tablet chewable
sb motion sickness
sm motion sickness relief
TRANSDERM-SCOP
travel sickness
trimethobenzamide hcl capsule 300mg
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
Emetogenic Therapy Adjuncts
aprepitant capsule 40mg
$0(Tier 1)
aprepitant capsule 0
$0(Tier 1)
aprepitant capsule 125mg
$0(Tier 1)
aprepitant capsule 80mg
$0(Tier 1)
dronabinol
$0(Tier 1)
EMEND CAPSULE 40MG
$0(Tier 2)
EMEND CAPSULE 0
$0(Tier 2)
EMEND CAPSULE 125MG
$0(Tier 2)
EMEND CAPSULE 80MG
$0(Tier 2)
granisetron hcl injection 0.1mg/ml, 1mg/ml
ondansetron hcl oral solution
ondansetron hcl injection 4mg/2ml
ondansetron hcl tablet 24mg
ondansetron hcl tablet 4mg, 8mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
ondansetron odt
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
DP
DP
DP
QL (10 EA per 30 days)
DP
PA (High Risk
Medications)
QL (1 EA per 14 days)
B/D
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
QL (60 EA per 30 days)
B/D
QL (1 EA per 14 days)
B/D
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
B/D
B/D
QL (90 EA per 30 days)
B/D
QL (90 EA per 30 days)
B/D
Antifungals
Antifungals
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
27
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Name of drug
3 day vaginal
ABELCET
AMBISOME
amphotericin b
antifungal cream 2%
baza antifungal
CANCIDAS
ciclopirox olamine cream
ciclopirox suspension
clotrimazole anti-fungal
clotrimazole external cream 1%
clotrimazole external cream 1%
clotrimazole vaginal cream 1%
clotrimazole troche
clotrimazole solution 1%
clotrimazole solution 1%
dermafungal
desenex shake powder
econazole nitrate cream
fluconazole in nacl injection 200mg/100ml; 0.9%,
400mg/200ml; 0.9%
fluconazole suspension reconstituted, tablet
$0(Tier 1)
flucytosine
$0(Tier 1)
FUNGOID TINCTURE SOLUTION
$0(Tier 3)
gnp athletes foot
$0(Tier 3)
gnp clotrimazole 3
$0(Tier 3)
gnp miconazole 3
$0(Tier 3)
gnp miconazole 7
$0(Tier 3)
gnp terbinafine hydrochloride
$0(Tier 3)
gnp tioconazole 1
$0(Tier 3)
griseofulvin microsize tablet
$0(Tier 1)
griseofulvin ultramicrosize tablet 125mg, 250mg
$0(Tier 1)
itraconazole capsule
$0(Tier 1)
ketoconazole cream, shampoo, tablet
$0(Tier 1)
LAMISIL AT CREAM
$0(Tier 3)
miconazole 3 combo pack
$0(Tier 3)
miconazole 3 suppository
$0(Tier 1)
miconazole 7
$0(Tier 3)
miconazole nitrate external cream, vaginal cream, suppository$0(Tier 3)
miconazole cream
$0(Tier 3)
micro guard powder
$0(Tier 3)
MYCAMINE
$0(Tier 2)
naftifine hcl
$0(Tier 1)
naftifine hydrochloride
$0(Tier 1)
NAFTIN GEL 1%
$0(Tier 2)
NATACYN
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (12 EA per 30 days)
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
28
What the drug
will cost you
Name of drug
(tier level)
NOXAFIL SUSPENSION, TABLET DELAYED RELEASE $0(Tier 2)
nyamyc
$0(Tier 1)
nystatin/triamcinolone
$0(Tier 1)
nystatin cream, ointment, powder, suspension, tablet
$0(Tier 1)
nystop
$0(Tier 1)
qc 3 day vaginal cream
$0(Tier 3)
qc clotrimazole
$0(Tier 3)
remedy antifungal cream
$0(Tier 3)
secura antifungal
$0(Tier 3)
sm antifungal clotrimazole cream
$0(Tier 3)
sm antifungal miconazole
$0(Tier 3)
sm miconazole 3
$0(Tier 3)
SPORANOX SOLUTION
$0(Tier 2)
terbinafine hcl tablet
$0(Tier 1)
terbinafine hcl cream
$0(Tier 3)
terconazole cream
$0(Tier 1)
terconazole suppository
$0(Tier 1)
vagistat-3
$0(Tier 3)
voriconazole injection
$0(Tier 1)
voriconazole suspension reconstituted, tablet
$0(Tier 1)
zeasorb-af powder
$0(Tier 3)
Antigout Agents
Antigout Agents
allopurinol sodium
$0(Tier 1)
allopurinol tablet
$0(Tier 1)
ALOPRIM
$0(Tier 2)
colchicine capsule
$0(Tier 1)
colchicine tablet 0.6mg
$0(Tier 1)
COLCRYS
$0(Tier 2)
probenecid/colchicine
$0(Tier 1)
probenecid tablet
$0(Tier 1)
Antimigraine Agents
Antimigraine Agents
BOTOX INJECTION 100UNIT
$0(Tier 2)
Ergot Alkaloids
dihydroergotamine mesylate injection
dihydroergotamine mesylate nasal solution
ERGOMAR
migergot
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML
IMITREX SOLUTION
naratriptan hcl
rizatriptan benzoate
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
NDS
DP
DP
DP
DP
DP
DP
DP
DP
QL (3 EA per 30 days)
DP
NDS
DP
MO
MO
MO
MO
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
QL (8 ML per 28 days)
QL (4 ML per 30 days)
QL (9 EA per 30 days)
QL (12 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
29
Name of drug
rizatriptan benzoate odt
sumatriptan succinate refill
sumatriptan succinate injection
sumatriptan succinate tablet
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON SYRUP
pyridostigmine bromide er
pyridostigmine bromide tablet
Antimycobacterials
Antimycobacterials, Other
DAPSONE TABLET
MYCOBUTIN
rifabutin
Antituberculars
CAPASTAT SULFATE
ethambutol hcl tablet
isoniazid injection
isoniazid syrup, tablet
PASER
PRIFTIN
pyrazinamide tablet
rifampin capsule, injection
RIFATER
SIRTURO
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (12 EA per 30 days)
QL (4 ML per 30 days)
QL (4 ML per 30 days)
QL (9 EA per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
TRECATOR
Antineoplastics
Alkylating Agents
ALKERAN INJECTION
BICNU
BUSULFEX
cyclophosphamide capsule
dacarbazine injection 200mg
GLEOSTINE
HEXALEN
IFEX INJECTION 1GM
ifosfamide injection 1gm
LEUKERAN
MATULANE
melphalan hydrochloride
MUSTARGEN
THIOTEPA INJECTION 15MG
TREANDA INJECTION 100MG
MO
MO
MO
MO
QL (120 EA per 30 days)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
B/D
NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
30
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
VALCHLOR
YONDELIS
ZANOSAR
Antiandrogens
bicalutamide
Necessary actions,
restrictions, or limits on
use
PA (Valchlor, new starts
only)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
flutamide
NILANDRON TABLET 150MG
$0(Tier 1)
$0(Tier 2)
nilutamide
XTANDI
$0(Tier 1)
$0(Tier 2)
ZYTIGA
$0(Tier 2)
Antiangiogenic Agents
POMALYST
REVLIMID CAPSULE 2.5MG, 20MG
$0(Tier 2)
$0(Tier 2)
REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJECTION 250MG/5ML
SOLTAMOX
tamoxifen citrate tablet
Antimetabolites
adrucil injection 500mg/10ml
ALIMTA INJECTION 500MG
ARRANON
cladribine
CLOLAR
cytarabine aqueous
DROXIA
ELITEK
fluorouracil injection 2.5gm/50ml
FOLOTYN INJECTION 40MG/2ML
gemcitabine hcl injection 1gm
hydroxyurea capsule
LONSURF
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
mercaptopurine tablet
PURIXAN
TABLOID
QL (30 EA per 30 days)
MO
MO
QL (60 EA per 30 days)
NDS
QL (60 EA per 30 days)
QL (120 EA per 30 days)
NDS
PA (zytiga, new starts
only) NDS
NDS
PA (revlimid, new starts
only)
PA (revlimid, new starts
only) LA
NDS
MO
MO
MO
B/D
NDS
B/D
B/D
MO
B/D
PA (LONSURF, new
starts only) NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
31
What the drug
will cost you
(tier level)
Name of drug
Antineoplastics, Other
ABRAXANE
adriamycin injection 2mg/ml
amifostine
azacitidine
BELEODAQ
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
bleomycin sulfate injection 30unit
CAMPTOSAR INJECTION 100MG/5ML
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COSMEGEN
COTELLIC
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
DACOGEN
daunorubicin hcl injection 5mg/ml
decitabine
dexrazoxane injection 250mg
DOCEFREZ INJECTION 20MG
DOCETAXEL INJECTION 80MG/8ML
docetaxel injection 80mg/4ml
doxorubicin hcl liposome
doxorubicin hcl injection 2mg/ml
ELLENCE INJECTION 200MG/100ML
epirubicin hcl injection 200mg/100ml
ERWINAZE
fludarabine phosphate injection 50mg
FUSILEV
GILOTRIF
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
HALAVEN
IBRANCE
$0(Tier 2)
$0(Tier 2)
IDAMYCIN PFS INJECTION 20MG/20ML
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
ISTODAX
ISTODAX (OVERFILL)
JEVTANA
KISQALI
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
LARTRUVO INJECTION 500MG/50ML
$0(Tier 2)
leucovorin calcium tablet
leucovorin calcium injection 100mg, 350mg
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
PA (beleodaq, new starts
only)
B/D
NDS
QL (63 EA per 21 days)
PA (Cotellic, new starts
only) NDS
NDS
PA (gilotrif, new starts
only) NDS
QL (30 EA per 30 days)
NDS
PA (Kisqali, new starts
only) NDS
PA (Lartruvo, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
32
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Name of drug
levoleucovorin calcium
LYNPARZA
mesna
MESNEX
mitomycin injection
mitoxantrone hcl injection 2mg/ml
NINLARO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ODOMZO
$0(Tier 2)
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PROLEUKIN
RUBRACA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
SYLATRON
SYNRIBO
TAGRISSO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TRISENOX
VELCADE
VENCLEXTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
VENCLEXTA STARTING PACK
$0(Tier 2)
VINBLASTINE SULFATE INJECTION 1MG/ML
vincristine sulfate
vinorelbine tartrate injection 50mg/5ml
ZINECARD INJECTION 250MG
ZOLINZA
Antineoplastics
FARYDAK
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
ZALTRAP INJECTION 100MG/4ML
$0(Tier 2)
ZYKADIA
$0(Tier 2)
Aromatase Inhibitors, 3rd Generation
anastrozole tablet
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (480 EA per 30 days)
NDS
QL (4 EA per 28 days) PA
(Ninlaro, new starts only)
NDS
QL (30 EA per 30 days)
PA (Odomzo, new starts
only) NDS
QL (120 EA per 30 days)
PA (Rubraca, new starts
only) NDS
NDS
QL (30 EA per 30 days)
PA (Tagrisso, new starts
only)
NDS
PA (Venclexta, new starts
only)
PA (Venclexta, new starts
only)
B/D
B/D
NDS
QL (6 EA per 21 days) PA
(Farydak, new starts only)
PA (zaltrap, new starts
only)
QL (150 EA per 30 days)
PA (zykadia, new starts
only) NDS
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
33
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
Name of drug
exemestane
letrozole
Enzyme Inhibitors
ETOPOPHOS
etoposide injection 500mg/25ml
KYPROLIS
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
toposar injection 1gm/50ml
topotecan hcl injection 4mg
ZYDELIG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Molecular Target Inhibitors
AFINITOR
$0(Tier 2)
AFINITOR DISPERZ
$0(Tier 2)
ALECENSA
$0(Tier 2)
BOSULIF
$0(Tier 2)
CABOMETYX TABLET 20MG, 60MG
$0(Tier 2)
CABOMETYX TABLET 40MG
$0(Tier 2)
CAPRELSA
$0(Tier 2)
COMETRIQ
$0(Tier 2)
ERIVEDGE
ICLUSIG TABLET 45MG
$0(Tier 2)
$0(Tier 2)
ICLUSIG TABLET 15MG
$0(Tier 2)
imatinib mesylate tablet 400mg
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
PA (KYPROLIS, new
starts only) NDS
QL (60 EA per 30 days)
PA (zydelig, new starts
only) NDS
QL (30 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (60 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (240 EA per 30 days)
PA (Alecensa, new starts
only)
PA (bosulif, new starts
only) NDS
QL (30 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
QL (60 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
PA (caprelsa, new starts
only) NDS
PA (cometriq, new starts
only) NDS
NDS
QL (30 EA per 30 days)
PA (iclusig, new starts
only) NDS
QL (90 EA per 30 days)
PA (iclusig, new starts
only) NDS
QL (60 EA per 30 days)
PA (Imatinib, new starts
only)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
34
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
imatinib mesylate tablet 100mg
IMBRUVICA
$0(Tier 2)
INLYTA
$0(Tier 2)
IRESSA
JAKAFI
$0(Tier 2)
$0(Tier 2)
LENVIMA 10 MG DAILY DOSE
$0(Tier 2)
LENVIMA 14 MG DAILY DOSE
$0(Tier 2)
LENVIMA 18 MG DAILY DOSE
$0(Tier 2)
LENVIMA 20 MG DAILY DOSE
$0(Tier 2)
LENVIMA 24 MG DAILY DOSE
$0(Tier 2)
LENVIMA 8 MG DAILY DOSE
$0(Tier 2)
MEKINIST
$0(Tier 2)
NEXAVAR
$0(Tier 2)
SPRYCEL
$0(Tier 2)
STIVARGA
$0(Tier 2)
SUTENT
$0(Tier 2)
TAFINLAR
TARCEVA
$0(Tier 2)
$0(Tier 2)
TASIGNA
$0(Tier 2)
TYKERB
VOTRIENT
$0(Tier 2)
$0(Tier 2)
XALKORI
$0(Tier 2)
ZELBORAF
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
PA (Imatinib, new starts
only)
QL (120 EA per 30 days)
PA (imbruvica, new starts
only) NDS
PA (inlyta, new starts
only) NDS
QL (60 EA per 30 days)
PA (jakafi, new starts
only) NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
PA (mekinist, new starts
only) NDS
PA (nexavar, new starts
only) NDS
PA (sprycel, new starts
only) NDS
PA (stivarga, new starts
only) NDS
PA (sutent, new starts
only) NDS
NDS
PA (tarceva, new starts
only) NDS
PA (tarceva, new starts
only) NDS
NDS
QL (120 EA per 30 days)
PA (votrient, new starts
only) NDS
PA (xalkori, new starts
only) NDS
PA (zelboraf, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
35
Name of drug
Monoclonal Antibodies
AVASTIN
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
PA (avastin, new starts
only) NDS
NDS
NDS
NDS
CYRAMZA
DARZALEX INJECTION 100MG/5ML
EMPLICITI
ERBITUX INJECTION 100MG/50ML
HERCEPTIN
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
KADCYLA INJECTION 100MG
$0(Tier 2)
KEYTRUDA INJECTION 50MG
$0(Tier 2)
KEYTRUDA INJECTION 100MG/4ML
$0(Tier 2)
OPDIVO INJECTION 40MG/4ML
PERJETA
RITUXAN INJECTION 500MG/50ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
SYLVANT INJECTION 100MG
TECENTRIQ
$0(Tier 2)
$0(Tier 2)
VECTIBIX INJECTION 100MG/5ML
YERVOY INJECTION 50MG/10ML
$0(Tier 2)
$0(Tier 2)
Retinoids
bexarotene
PANRETIN
TARGRETIN GEL
tretinoin capsule 10mg
Antiparasitics
Anthelmintics
ALBENZA
ivermectin tablet
pin-x suspension 50mg/ml
REESES PINWORM MEDICINE SUSPENSION
144MG/ML
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
PA (herceptin, new starts
only) NDS
PA (kadcyla, new starts
only) NDS
PA (keytruda, new starts
only)
PA (keytruda, new starts
only) NDS
PA (rituxan, new starts
only) NDS
PA (Tecentriq, new starts
only) NDS
PA (yervoy, new starts
only)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
NDS
NDS
NDS
NDS
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
36
Name of drug
MEPRON SUSPENSION
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE TABLET
quinine sulfate capsule 324mg
tinidazole tablet
Pediculicides/Scabicides
bedding spray lice treatment step 3
gnp lice solution kit
gnp lice treatment liquid
gnp lice treatment shampoo 4%; 0.33%
hm lice killing maximum strength
hm lice treatment lotion
lice killing maximum strength shampoo
malathion
permethrin lice treatment
permethrin cream
RID AEROSOL
sb lice killing maximum strength
sb lice killing shampoo maximum strength
sm lice treatment
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection
benztropine mesylate tablet
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
trihexyphenidyl hcl
$0(Tier 1)
Antiparkinson Agents, Other
entacapone
$0(Tier 1)
B/D
PA (Quinine)
DP
DP
DP
DP
DP
QL (240 EA per 30 days)
MO
MO
tolcapone
Dopamine Agonists
APOKYN INJECTION 30MG/3ML
bromocriptine mesylate capsule, tablet
NEUPRO
$0(Tier 1)
pramipexole dihydrochloride
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
STALEVO 100
STALEVO 125
STALEVO 150
$0(Tier 1)
$0(Tier 1)
NDS
MO
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
37
Name of drug
STALEVO 200
STALEVO 50
STALEVO 75
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
ELDEPRYL CAPSULE
rasagiline mesylate tablet
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 2)
$0(Tier 1)
selegiline hcl capsule, tablet
ZELAPAR
Antipsychotics
1st Generation/Typical
chlorpromazine hcl tablet
CHLORPROMAZINE HCL INJECTION 50MG/2ML
compro
fluphenazine decanoate injection
FLUPHENAZINE HCL INJECTION
fluphenazine hcl concentrate, elixir
fluphenazine hcl tablet
haloperidol decanoate
haloperidol lactate
haloperidol concentrate
haloperidol tablet
loxapine succinate capsule
perphenazine tablet
pimozide
prochlorperazine edisylate injection
prochlorperazine maleate tablet
prochlorperazine suppository 25mg
thioridazine hcl tablet 100mg, 10mg, 25mg, 50mg
thiothixene capsule 10mg, 1mg, 2mg, 5mg
trifluoperazine hcl tablet
2nd Generation/Atypical
ABILIFY MAINTENA
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
$0(Tier 2)
QL (1 EA per 30 days)
NDS
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (1.6 ML per 30 days)
NDS
QL (2.4 ML per 30 days)
NDS
QL (3.2 ML per 30 days)
NDS
aripiprazole odt
$0(Tier 1)
aripiprazole tablet
$0(Tier 1)
ARISTADA INJECTION 441MG/1.6ML
$0(Tier 2)
ARISTADA INJECTION 662MG/2.4ML
$0(Tier 2)
ARISTADA INJECTION 882MG/3.2ML
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
38
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
FANAPT
FANAPT TITRATION PACK
GEODON INJECTION
INVEGA SUSTENNA INJECTION 39MG/0.25ML
INVEGA SUSTENNA INJECTION 78MG/0.5ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
INVEGA SUSTENNA INJECTION 117MG/0.75ML
$0(Tier 2)
INVEGA SUSTENNA INJECTION 156MG/ML
$0(Tier 2)
INVEGA SUSTENNA INJECTION 234MG/1.5ML
$0(Tier 2)
INVEGA TRINZA INJECTION 273MG/0.875ML
$0(Tier 2)
INVEGA TRINZA INJECTION 410MG/1.315ML
$0(Tier 2)
INVEGA TRINZA INJECTION 546MG/1.75ML
$0(Tier 2)
INVEGA TRINZA INJECTION 819MG/2.625ML
$0(Tier 2)
LATUDA
$0(Tier 2)
NUPLAZID
$0(Tier 2)
olanzapine odt
olanzapine injection
olanzapine tablet
paliperidone er tablet extended release 24 hour 1.5mg, 3mg,
9mg
paliperidone er tablet extended release 24 hour 6mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
quetiapine fumarate
REXULTI
$0(Tier 1)
$0(Tier 2)
RISPERDAL CONSTA
risperidone odt
risperidone solution
risperidone tablet
SAPHRIS
VRAYLAR CAPSULE THERAPY PACK
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
MO
QL (0.25 ML per 28 days)
QL (0.5 ML per 28 days)
NDS
QL (0.75 ML per 28 days)
NDS
QL (1 ML per 28 days)
NDS
QL (1.5 ML per 28 days)
NDS
QL (0.88 ML per 90 days)
NDS
QL (1.32 ML per 90 days)
NDS
QL (1.75 ML per 90 days)
NDS
QL (2.63 ML per 90 days)
NDS
QL (30 EA per 30 days)
PA (Latuda, new starts
only) MO
QL (60 EA per 30 days)
NDS
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
PA (Rexulti, new starts
only) MO
MO
MO
QL (60 EA per 30 days)
PA (Vraylar, new starts
only)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
39
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
VRAYLAR CAPSULE 1.5MG
VRAYLAR CAPSULE 4.5MG, 6MG
$0(Tier 2)
VRAYLAR CAPSULE 3MG
$0(Tier 2)
ziprasidone hcl
ZYPREXA RELPREVV INJECTION 210MG
Antipsychotics
molindone hydrochloride
Treatment-Resistant
clozapine odt tablet disintegrating 12.5mg, 25mg
clozapine odt tablet disintegrating 200mg
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (120 EA per 30 days)
PA (Vraylar, new starts
only) NDS
QL (30 EA per 30 days)
PA (Vraylar, new starts
only) NDS
QL (60 EA per 30 days)
PA (Vraylar, new starts
only) NDS
MO
$0(Tier 1)
MO
$0(Tier 1)
$0(Tier 1)
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (270 EA per 30 days)
MO
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
clozapine odt tablet disintegrating 150mg
$0(Tier 1)
clozapine odt tablet disintegrating 100mg
$0(Tier 1)
clozapine tablet 100mg, 200mg, 25mg, 50mg
FAZACLO TABLET DISINTEGRATING 200MG
$0(Tier 1)
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 150MG
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 100MG, 12.5MG,
25MG
VERSACLOZ
Antispasticity Agents
Antispasticity Agents
baclofen tablet
dantrolene sodium capsule
tizanidine hcl tablet
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir
ganciclovir injection
VALCYTE
valganciclovir
valganciclovir hydrochlorde
ZIRGAN
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE SOLUTION
entecavir
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
B/D
NDS
MO
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
40
Name of drug
EPIVIR HBV SOLUTION
INTRON A W/DILUENT INJECTION 10MU
INTRON A INJECTION 10MU, 18MU, 50MU,
6000000UNIT/ML
lamivudine tablet 100mg
TYZEKA
Anti-hepatitis C (HCV) Agents
HARVONI
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 1)
$0(Tier 2)
MO
NDS
$0(Tier 2)
QL (30 EA per 30 days)
PA (harvoni) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PEG-INTRON REDIPEN
$0(Tier 2)
PEGASYS
$0(Tier 2)
PEGASYS PROCLICK
$0(Tier 2)
PEGINTRON
$0(Tier 2)
REBETOL SOLUTION
ribasphere ribapak
ribasphere tablet
ribavirin capsule
ribavirin tablet 200mg
SOVALDI
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
VIRAZOLE
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
QL (28 EA per 28 days)
PA (Immunological
Agents - Sovaldi) NDS
$0(Tier 2)
$0(Tier 2)
ISENTRESS TABLET CHEWABLE, PACKET
ISENTRESS TABLET
TIVICAY TABLET 10MG
TIVICAY TABLET 25MG, 50MG
VITEKTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABLET 25MG
INTELENCE TABLET 100MG, 200MG
nevirapine
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
41
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Name of drug
nevirapine er
ODEFSEY
RESCRIPTOR
STRIBILD
SUSTIVA TABLET
SUSTIVA CAPSULE 50MG
SUSTIVA CAPSULE 200MG
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
DESCOVY
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
didanosine
EMTRIVA
EPZICOM
lamivudine/zidovudine
lamivudine solution 10mg/ml
lamivudine tablet 150mg, 300mg
RETROVIR IV INFUSION
stavudine
TRIUMEQ
TRUVADA TABLET 200MG; 300MG
TRUVADA TABLET 100MG; 150MG, 133MG; 200MG,
167MG; 250MG
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM
VIREAD
ZERIT SOLUTION RECONSTITUTED
ZIAGEN SOLUTION
zidovudine
Anti-HIV Agents, Other
FUZEON
SELZENTRY TABLET 25MG, 75MG
SELZENTRY TABLET 150MG, 300MG
TYBOST
Anti-HIV Agents, Protease Inhibitors
APTIVUS
CRIXIVAN CAPSULE 200MG, 400MG
EVOTAZ
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
INVIRASE
KALETRA SOLUTION
KALETRA TABLET 100MG; 25MG
KALETRA TABLET 200MG; 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
MO
NDS
MO
MO
MO
QL (30 EA per 30 days)
NDS
MO
MO
NDS
MO
MO
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
MO
NDS
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
42
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Name of drug
LEXIVA
lopinavir/ritonavir
NORVIR
PREZCOBIX
PREZISTA SUSPENSION
PREZISTA TABLET 150MG, 600MG, 75MG, 800MG
REYATAZ
VIRACEPT
Anti-influenza Agents
amantadine hcl capsule, syrup, tablet
oseltamivir phosphate capsule 75mg
oseltamivir phosphate capsule 45mg
oseltamivir phosphate capsule 30mg
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPSULE 75MG
TAMIFLU CAPSULE 45MG
TAMIFLU CAPSULE 30MG
TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule, suspension, tablet
acyclovir ointment
DENAVIR
famciclovir tablet
trifluridine solution
valacyclovir hcl
ZOVIRAX CREAM, OINTMENT
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
buspirone hcl tablet
meprobamate
Benzodiazepines
alprazolam intensol
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg, 1mg, 2mg
clorazepate dipotassium tablet 15mg
clorazepate dipotassium tablet 3.75mg, 7.5mg
diazepam intensol
diazepam solution 1mg/ml
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
NDS
NDS
NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
B/D
MO
QL (30 GM per 30 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (56 EA per 180 days)
QL (28 EA per 180 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (540 ML per 180
days)
QL (60 EA per 30 days)
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 GM per 30 days)
$0(Tier 2)
NDS
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
43
Name of drug
diazepam tablet 10mg, 2mg, 5mg
LORAZEPAM INTENSOL
lorazepam tablet 0.5mg
lorazepam tablet 1mg, 2mg
triazolam
Bipolar Agents
Mood Stabilizers
lithium
lithium carbonate er
lithium carbonate capsule, tablet
LITHOBID
Blood Glucose Regulators
Antidiabetic Agents
acarbose
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (120 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
MO
$0(Tier 1)
QL (90 EA per 30 days)
MO
QL (2.4 ML per 30 days)
ST (INCRETIN
MIMETICS #2) MO
ST (INCRETIN
MIMETICS #2) MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (60 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
BYETTA INJECTION 10MCG/0.04ML
$0(Tier 2)
BYETTA INJECTION 5MCG/0.02ML
$0(Tier 2)
CYCLOSET
FARXIGA
$0(Tier 2)
$0(Tier 2)
glimepiride tablet 1mg, 2mg
$0(Tier 1)
glimepiride tablet 4mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 2.5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 10mg
$0(Tier 1)
glipizide/metformin hcl
$0(Tier 1)
glipizide tablet 10mg
$0(Tier 1)
glipizide tablet 5mg
$0(Tier 1)
glyburide micronized tablet 1.5mg, 3mg
$0(Tier 1)
glyburide micronized tablet 6mg
$0(Tier 1)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
44
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
glyburide/metformin hcl
glyburide tablet 5mg
$0(Tier 1)
glyburide tablet 1.25mg, 2.5mg
$0(Tier 1)
JANUVIA
$0(Tier 2)
JENTADUETO
$0(Tier 2)
JENTADUETO XR
$0(Tier 2)
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG, 500MG; 5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
metformin hcl er tablet extended release 24 hour 500mg
$0(Tier 2)
metformin hcl er tablet extended release 24 hour 750mg
$0(Tier 1)
metformin hcl tablet 500mg
$0(Tier 1)
metformin hcl tablet 1000mg
$0(Tier 1)
metformin hcl tablet 850mg
$0(Tier 1)
miglitol
$0(Tier 1)
nateglinide
$0(Tier 1)
ONGLYZA
$0(Tier 2)
pioglitazone hcl
$0(Tier 1)
pioglitazone hcl-glimepiride
$0(Tier 1)
pioglitazone hcl/metformin hcl
$0(Tier 1)
repaglinide
SYMLINPEN 120
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (120 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
PA (High Risk Medication
- Glyburide) MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
PA (Blood Glucose
Regulators Amylinomimetics) MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
45
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
SYMLINPEN 60
tolbutamide
TRADJENTA
$0(Tier 1)
$0(Tier 2)
VICTOZA
$0(Tier 2)
Glycemic Agents
DEX4 FAST ACTING GLUCOSE TABLET CHEWABLE
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLUCOSE TABLET CHEWABLE 4GM
glutose 15
HM GLUCOSE
INSTA-GLUCOSE
PROGLYCEM
ra glucose gel
Insulins
APIDRA
Necessary actions,
restrictions, or limits on
use
PA (Blood Glucose
Regulators Amylinomimetics) MO
MO
QL (30 EA per 30 days)
MO
ST (INCRETIN
MIMETICS #2) MO
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
DP
$0(Tier 2)
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
APIDRA SOLOSTAR
$0(Tier 2)
HUMALOG KWIKPEN
$0(Tier 2)
HUMALOG MIX 50/50
$0(Tier 2)
HUMALOG MIX 50/50 KWIKPEN
$0(Tier 2)
HUMALOG MIX 75/25
$0(Tier 2)
HUMALOG MIX 75/25 KWIKPEN
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMULIN 70/30
$0(Tier 2)
HUMULIN 70/30 KWIKPEN
$0(Tier 2)
HUMULIN N
$0(Tier 2)
HUMULIN N KWIKPEN
$0(Tier 2)
DP
DP
DP
DP
MO
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
46
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
$0(Tier 2)
HUMULIN R U-500 KWIKPEN
$0(Tier 2)
LANTUS
$0(Tier 2)
LANTUS SOLOSTAR
$0(Tier 2)
LEVEMIR
$0(Tier 2)
LEVEMIR FLEXTOUCH
$0(Tier 2)
NOVOLIN 70/30
$0(Tier 2)
NOVOLIN N
$0(Tier 2)
NOVOLIN R
$0(Tier 2)
NOVOLOG
$0(Tier 2)
NOVOLOG FLEXPEN
$0(Tier 2)
NOVOLOG MIX 70/30
$0(Tier 2)
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
$0(Tier 2)
NOVOLOG PENFILL
$0(Tier 2)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN TABLET
$0(Tier 2)
enoxaparin sodium
$0(Tier 1)
FONDAPARINUX SODIUM INJECTION 10MG/0.8ML,
$0(Tier 1)
5MG/0.4ML, 7.5MG/0.6ML
fondaparinux sodium injection 2.5mg/0.5ml
$0(Tier 1)
FRAGMIN INJECTION 10000UNIT/ML, 2500UNIT/0.2ML, $0(Tier 2)
5000UNIT/0.2ML
heparin sodium/d5w
$0(Tier 1)
heparin sodium injection 10000unit/ml, 1000unit/ml,
$0(Tier 1)
20000unit/ml, 5000unit/ml
jantoven
$0(Tier 1)
PRADAXA CAPSULE 150MG, 75MG
$0(Tier 2)
PRADAXA CAPSULE 110MG
$0(Tier 2)
warfarin sodium tablet
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (40 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
MO
NDS
MO
MO
QL (60 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
47
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Name of drug
XARELTO STARTER PACK
XARELTO TABLET 10MG
XARELTO TABLET 15MG, 20MG
Blood Formation Modifiers
anagrelide hydrochloride
$0(Tier 1)
ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML, $0(Tier 2)
25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML, $0(Tier 2)
100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML
EPOGEN INJECTION 10000UNIT/ML, 20000UNIT/ML,
$0(Tier 2)
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
GRANIX
LEUKINE INJECTION 250MCG
NEUPOGEN
PROCRIT
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
PROMACTA TABLET 50MG
$0(Tier 2)
PROMACTA TABLET 25MG
$0(Tier 2)
Coagulants
tranexamic acid injection
tranexamic acid tablet
Platelet Modifying Agents
aspirin/dipyridamole
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
BRILINTA
$0(Tier 2)
cilostazol
clopidogrel tablet 300mg
clopidogrel tablet 75mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dipyridamole tablet
$0(Tier 1)
EFFIENT
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Blood
Products/Modifiers/
Volume Expanders) NDS
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Granix)
NDS
PA (Neupogen) NDS
PA (Blood
Products/Modifiers/
Volume Expanders)
QL (30 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
QL (90 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
48
Name of drug
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er
clonidine hcl tablet
clonidine hcl patch weekly
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
QL (4 EA per 28 days)
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
guanfacine hcl
$0(Tier 1)
methyldopa/hydrochlorothiazide
$0(Tier 1)
methyldopa tablet 250mg, 500mg
$0(Tier 1)
methyldopate hcl
midodrine hcl
Alpha-adrenergic Blocking Agents
prazosin hcl capsule
reserpine tablet 0.25mg
$0(Tier 1)
$0(Tier 1)
Angiotensin II Receptor Antagonists
BENICAR
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications) MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
BENICAR HCT
$0(Tier 2)
candesartan cilexetil
$0(Tier 1)
candesartan cilexetil/hydrochlorothiazide
$0(Tier 1)
eprosartan mesylate
$0(Tier 1)
ezetimibe
$0(Tier 1)
irbesartan
$0(Tier 1)
irbesartan/hydrochlorothiazide
$0(Tier 1)
losartan potassium
$0(Tier 1)
losartan potassium/hydrochlorothiazide
$0(Tier 1)
olmesartan medoxomil
$0(Tier 1)
olmesartan medoxomil/hydrochlorothiazide
$0(Tier 1)
telmisartan
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
49
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
$0(Tier 1)
valsartan
$0(Tier 1)
valsartan/hydrochlorothiazide
$0(Tier 1)
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
benazepril hcl tablet 10mg, 20mg, 5mg
$0(Tier 1)
$0(Tier 1)
benazepril hcl tablet 40mg
$0(Tier 1)
captopril/hydrochlorothiazide
captopril tablet
enalapril maleate/hydrochlorothiazide
enalapril maleate tablet
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
quinapril hcl
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
quinapril/hydrochlorothiazide
$0(Tier 1)
ramipril
$0(Tier 1)
trandolapril tablet 1mg, 2mg
$0(Tier 1)
trandolapril tablet 4mg
$0(Tier 1)
Antiarrhythmics
amiodarone hcl tablet
amiodarone hcl injection 50mg/ml
disopyramide phosphate capsule
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dofetilide
$0(Tier 1)
flecainide acetate
mexiletine hcl
MULTAQ
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
pacerone tablet 100mg, 200mg, 400mg
PROCAINAMIDE HCL INJECTION
propafenone hcl
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
PA (High Risk
Medications) MO
QL (60 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
50
Name of drug
quinidine gluconate cr
QUINIDINE GLUCONATE INJECTION
quinidine sulfate tablet
sorine
sotalol hcl (af) tablet 120mg
sotalol hcl tablet 160mg, 240mg, 80mg
Beta-adrenergic Blocking Agents
acebutolol hcl capsule
atenolol/chlorthalidone
atenolol tablet
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
carvedilol
labetalol hcl injection
labetalol hcl tablet
metoprolol succinate er
metoprolol tartrate injection
metoprolol tartrate tablet 100mg, 25mg, 50mg
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol tablet 20mg, 40mg, 80mg
pindolol tablet
propranolol hcl er
propranolol hcl injection
propranolol hcl oral solution, tablet
propranolol/hydrochlorothiazide
timolol maleate tablet 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
afeditab cr
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
amlodipine besylate/benazepril hydrochloride
$0(Tier 1)
amlodipine besylate/valsartan
$0(Tier 1)
amlodipine besylate tablet
$0(Tier 1)
amlodipine/valsartan/hctz
$0(Tier 1)
cartia xt
$0(Tier 1)
dilt-xr capsule extended release 24 hour 120mg, 240mg
$0(Tier 1)
dilt-xr capsule extended release 24 hour 180mg
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
51
Name of drug
diltiazem cd capsule extended release 24 hour 240mg
What the drug
will cost you
(tier level)
$0(Tier 1)
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 120mg,
300mg, 360mg, 420mg
diltiazem hcl er capsule extended release 12 hour
diltiazem hcl tablet
DILTIAZEM HCL INJECTION 100MG
diltiazem hcl injection 50mg/10ml
felodipine er
$0(Tier 1)
$0(Tier 1)
matzim la tablet extended release 24 hour 180mg, 240mg,
300mg
matzim la tablet extended release 24 hour 360mg, 420mg
$0(Tier 1)
nicardipine hcl capsule
nifedical xl
$0(Tier 1)
$0(Tier 1)
nifedipine er
$0(Tier 1)
taztia xt
$0(Tier 1)
verapamil hcl er tablet extended release
verapamil hcl er capsule extended release 24 hour
$0(Tier 1)
$0(Tier 1)
verapamil hcl sr capsule extended release 24 hour 360mg
verapamil hcl injection
verapamil hcl tablet
Cardiovascular Agents, Other
DEMSER
digitek tablet 0.125mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
digitek tablet 0.25mg
$0(Tier 1)
digoxin oral solution
$0(Tier 1)
digoxin injection 0.25mg/ml
$0(Tier 1)
digoxin tablet 125mcg
$0(Tier 1)
digoxin tablet 250mcg
$0(Tier 1)
LANOXIN INJECTION
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
52
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
LANOXIN TABLET 125MCG
LANOXIN TABLET 250MCG
$0(Tier 2)
NORTHERA CAPSULE 200MG, 300MG
$0(Tier 2)
NORTHERA CAPSULE 100MG
$0(Tier 2)
pentoxifylline er
RANEXA TABLET EXTENDED RELEASE 12 HOUR
1000MG
$0(Tier 1)
$0(Tier 2)
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
$0(Tier 2)
REPATHA
$0(Tier 2)
REPATHA PUSHTRONEX SYSTEM
$0(Tier 2)
REPATHA SURECLICK
$0(Tier 2)
TEKTURNA
$0(Tier 2)
TEKTURNA HCT
$0(Tier 2)
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium
acetazolamide tablet
Diuretics, Loop
bumetanide injection
bumetanide tablet
furosemide injection
furosemide oral solution, tablet
torsemide tablet
Diuretics, Potassium-sparing
amiloride hcl tablet
amiloride/hydrochlorothiazide
DYRENIUM
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tablet
triamterene/hydrochlorothiazide
Diuretics, Thiazide
chlorothiazide
chlorothiazide sodium
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
QL (180 EA per 30 days)
PA (Northera)
QL (90 EA per 30 days)
PA (Northera)
MO
QL (60 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (90 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (3 ML per 30 days)
PA (Repatha)
QL (3.5 ML per 28 days)
PA (Repatha) NDS
QL (3 ML per 30 days)
PA (Repatha)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
53
Name of drug
chlorthalidone tablet 25mg, 50mg
hydrochlorothiazide capsule, tablet
indapamide tablet
methyclothiazide tablet
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
fenofibrate capsule 130mg, 43mg
$0(Tier 1)
fenofibrate tablet
$0(Tier 1)
fenofibric acid tablet 105mg
$0(Tier 1)
fenofibric acid tablet 35mg
$0(Tier 1)
gemfibrozil tablet
$0(Tier 1)
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
$0(Tier 1)
fluvastatin sodium er
$0(Tier 1)
fluvastatin capsule 40mg
$0(Tier 1)
fluvastatin capsule 20mg
$0(Tier 1)
lovastatin tablet 10mg, 20mg
$0(Tier 1)
lovastatin tablet 40mg
$0(Tier 1)
pravastatin sodium
$0(Tier 1)
rosuvastatin calcium
$0(Tier 1)
simvastatin tablet
$0(Tier 1)
Dyslipidemics, Other
cholestyramine light
colestipol hcl granules, tablet
JUXTAPID CAPSULE 10MG, 40MG, 5MG, 60MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
JUXTAPID CAPSULE 30MG
$0(Tier 2)
JUXTAPID CAPSULE 20MG
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
PA (Juxtapid) MO
QL (60 EA per 30 days)
PA (Juxtapid) MO
QL (90 EA per 30 days)
PA (Juxtapid) MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
54
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
KYNAMRO
niacin er tablet extended release 500mg
$0(Tier 1)
niacin er tablet extended release 1000mg, 750mg
$0(Tier 1)
niacor
omega-3-acid ethyl esters
$0(Tier 1)
$0(Tier 1)
prevalite powder
WELCHOL
ZETIA
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Vasodilators, Direct-acting Arterial/Venous
BIDIL
$0(Tier 2)
isosorbide dinitrate er
isosorbide dinitrate tablet 10mg, 20mg, 30mg, 5mg
isosorbide mononitrate
isosorbide mononitrate er
NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR
nitroglycerin transdermal
nitroglycerin injection 5mg/ml
nitroglycerin tablet sublingual 0.3mg, 0.4mg, 0.6mg
NITROSTAT TABLET SUBLINGUAL
Vasodilators, Direct-acting Arterial
hydralazine hcl injection
hydralazine hcl tablet
minoxidil tablet
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg;
5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg
dextroamphetamine sulfate tablet
Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines
guanfacine er
INTUNIV
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (4 ML per 28 days)
PA (Kynamro)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (120 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (60 EA per 30 days)
$0(Tier 1)
QL (90 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 30MG $0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 20MG $0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
55
What the drug
will cost you
Name of drug
(tier level)
methylphenidate hcl cd capsule extended release 30mg
$0(Tier 1)
methylphenidate hcl cd capsule extended release 10mg, 50mg, $0(Tier 1)
60mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
40mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
20mg
methylphenidate hcl er tablet extended release 20mg
$0(Tier 1)
methylphenidate hcl tablet
$0(Tier 1)
STRATTERA
$0(Tier 2)
Central Nervous System, Other
HETLIOZ
$0(Tier 2)
NUEDEXTA
riluzole
tetrabenazine tablet 25mg
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
tetrabenazine tablet 12.5mg
$0(Tier 1)
Fibromyalgia Agents
SAVELLA
$0(Tier 2)
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AMPYRA
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
PA (Hetlioz) NDS
QL (60 EA per 30 days)
QL (120 EA per 30 days)
PA (Tetrabenazine)
QL (180 EA per 30 days)
PA (Tetrabenazine)
QL (60 EA per 30 days)
MO
$0(Tier 2)
$0(Tier 2)
AUBAGIO
$0(Tier 2)
AVONEX
AVONEX PEN
BETASERON
GILENYA
glatopa
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
TECFIDERA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TECFIDERA STARTER PACK
TYSABRI
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse
chlorhexidine gluconate solution
KEPIVANCE
$0(Tier 2)
$0(Tier 2)
QL (60 EA per 30 days)
PA (Ampyra) NDS
QL (30 EA per 30 days)
PA (Aubagio) NDS
PA (Avonex) NDS
PA (Avonex) NDS
PA (Betaseron) NDS
PA (Gilenya) NDS
PA (Copaxone) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
QL (60 EA per 30 days)
PA (Tecfidera)
PA (Tecfidera)
PA (Tysabri) NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
56
Name of drug
periogard
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride
triamcinolone in orabase
Dermatological Agents
Dermatological Agents
4-N-1
ACNE MEDICATION 10 LOTION
acne medication 10 gel
ACNE MEDICATION 5 LOTION
acne medication 5 gel
adapalene gel 0.1%
adapalene cream
aloe vesta skin conditioner
ammonium lactate cream, lotion
anu-med
baza protect
benzoyl peroxide gel 10%, 5%
betasept surgical scrub
calcipotriene cream, ointment
calcipotriene solution
capsaicin cream 0.025%
cerave baby
claravis
clindamycin/benzoyl peroxide gel 5%; 1%
clotrimazole/betamethasone dipropionate
COMPOUND W LIQUID
curity gauze pads 2"x2"
dibucaine
diclofenac sodium gel 1%
duofilm solution
ELIDEL
erythromycin/benzoyl peroxide
fluorouracil cream 5%
fluorouracil cream 0.5%
fluorouracil external solution 2%, 5%
gnp wart remover
gnp zinc oxide
hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
hemorrhoidal suppository 88.7%; 0.25%
imiquimod cream
kp benzoyl peroxide gel 5%
lidocaine cream 5%
methoxsalen capsule
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
MO
MO
DP
DP
DP
DP
DP
QL (240 GM per 30 days)
QL (60 ML per 30 days)
DP
DP
DP
QL (204 EA per 30 days)
DP
DP
QL (60 GM per 30 days)
PA (Dermatological
Agents)
NDS
DP
DP
DP
DP
QL (24 EA per 30 days)
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
57
Name of drug
pedi-boro soak paks
periguard
PICATO
podofilox solution
PROSHIELD PLUS SKIN PROTECTANT CREAM 1%
SANTYL
selenium sulfide lotion
SM CALAMINE
SORIATANE CAPSULE 10MG, 17.5MG, 25MG
SWEEN CREAM
tacrolimus ointment 0.03%, 0.1%
TAZORAC
tgt wart remover
THERASEAL HAND PROTECTION
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%, 0.05%
TRIXAICIN
trixaicin hp
UVADEX
VEREGEN
vitamin a & d ointment 0; 0, 15.5%; 53.4%, 93.5%; 0; 0
VOLTAREN
zinc oxide ointment 20%
ZONALON
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CEREZYME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME INJECTION 35MG
KUVAN
LUMIZYME
NAGLAZYME
PANCREAZE
RAVICTI
sodium phenylbutyrate powder
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
NDS
DP
QL (60 GM per 30 days)
PA (Dermatological
Agents)
DP
DP
QL (90 GM per 30 days)
DP
DP
QL (15 GM per 30 days)
DP
DP
NDS
PA (cerezyme) NDS
MO
NDS
PA (Enzyme
Replacements/ Modifiers Kuvan) NDS
NDS
MO
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
58
Name of drug
SUCRAID
VPRIV
ZAVESCA
ZENPEP
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE INJECTION 0.25MG/5ML
atropine sulfate injection 0.5mg/5ml
dicyclomine hcl
glycopyrrolate tablet
glycopyrrolate injection 4mg/20ml
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
acid gone suspension
almacone double strength
almacone suspension
almacone tablet chewable 200mg; 200mg; 25mg
ALUMINUM HYDROXIDE
antacid anti-gas maximum strength
antacid calcium extra st rength
antacid calcium regular strength
antacid extra strength
antacid maximum strength
antacid plus anti-gas relief
antacid plus anti-gas relief maximum strength
antacid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
antacid tablet chewable 500mg
anti-diarrheal tablet
bismatrol
bismatrol maximum strength
cal-gest antacid
calcium antacid
calcium antacid extra strength
calcium antacid ultra maximum strength
calcium antacid ultra strength
calcium carbonate original
calcium carbonate tablet chewable 500mg
calcium carbonate tablet 648mg
chewable antacid
cromolyn sodium concentrate 100mg/5ml
diocto syrup
diocto liquid 50mg/5ml
diphenoxylate/atropine tablet
docu
docusate sodium liquid 50mg/5ml
fast acting antacid plus anti-gas maximum strength
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
59
Name of drug
GATTEX
gavilyte-h
GAVISCON
GAVISCON EXTRA STRENGTH RELIEF FORMULA
GAVISCON EXTRA STRENGTH SUSPENSION
gnp antacid
gnp antacid anti-gas
gnp antacid extra strength
gnp antacid maximum strength
gnp antacid ultra strength
gnp anti-diarrheal tablet
gnp loperamide hcl
gnp masanti maximum strength
gnp masanti regular strength
gnp stomach relief maximum strength
hm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
hm anti-diarrheal
hm calcium antacid
hm calcium antacid extra strength
hm loperamide hcl suspension
hm stomach relief tablet chewable
hm stomach relief suspension 262mg/15ml
kao-tin suspension 262mg/15ml
loperamide hcl capsule
loperamide hcl liquid, suspension
maalox max suspension
mag-al plus
mag-al plus xs
magnesium oxide tablet 241.3mg, 400mg
magnesium tablet 500mg
metoclopramide hcl injection, oral solution, tablet
mi-acid maximum strength
MI-ACID TABLET CHEWABLE
mi-acid suspension
mintox
mintox maximum strength
mintox plus
peptic relief suspension
peptic relief tablet chewable 262mg
PEPTO-BISMOL MAX STRENGTH
PEPTO-BISMOL SUSPENSION 524MG/30ML
PHILLIPS TABLET
pink bismuth tablet chewable 262mg
px antacid maximum strength tablet chewable
px calcium antacid regular strength
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
PA (Gattex) NDS
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
60
Name of drug
qc anti-diarrheal
RELISTOR INJECTION
RELISTOR TABLET
rulox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
sb antacid anti-gas double strength
sb antacid extra strength
sb antacid tablet chewable 500mg
sb anti-diarrhea
sb bismuth maximum strength
sb bismuth suspension
SENNA SYRUP 176MG/5ML
senna tablet 8.6mg
silace
sm antacid advanced maxi mum strength
sm calcium antacid
sm stool softener capsule 100mg
sodium bicarbonate tablet
soothe tablet chewable
stomach relief maximum strength
stomach relief suspension 262mg/15ml
tgt antacid
th antacid ultra strength
TUMS E-X 750
tums freshers
TUMS KIDS
TUMS SMOOTHIES TABLET CHEWABLE 750MG
tums smoothies tablet chewable 750mg
TUMS ULTRA 1000
TUMS TABLET CHEWABLE 500MG
ursodiol capsule, tablet
Histamine2 (H2) Receptor Antagonists
acid reducer tablet 10mg, 75mg
cimetidine hcl solution
cimetidine tablet
FAMOTIDINE PREMIXED
famotidine injection 20mg/2ml
famotidine tablet 20mg, 40mg
famotidine tablet 10mg
gnp acid reducer
heartburn relief tablet 10mg
hm acid reducer tablet 75mg
qc acid controller
ranitidine 75
ranitidine hcl capsule, syrup
ranitidine hcl injection 150mg/6ml, 50mg/2ml
ranitidine hcl tablet 150mg, 300mg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
DP
MO
MO
QL (90 EA per 30 days)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
MO
DP
DP
DP
DP
DP
DP
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
61
Name of drug
sm acid reducer tablet 10mg, 75mg
ZANTAC INJECTION 25MG/ML
Irritable Bowel Syndrome Agents
alosetron hydrochloride
AMITIZA
Laxatives
alophen
bisac-evac suppository
bisacodyl
bisacodyl ec
biscolax suppository
calcium polycarbophil
CITRUCEL FIBER LAXATIVE
CITRUCEL TABLET
clearlax powder
COLACE CLEAR
COLACE CAPSULE 100MG
constulose
cvs stool softener capsule 50mg
doc-q-lax
docqlace
docusate calcium
docusate sodium & senna stimulant laxative/stool softener
docusate sodium/senna
docusate sodium capsule 100mg, 250mg
docusate sodium tablet 100mg
docusil
dok
dok plus
ducodyl
dulcolax stool softener
easy-lax plus
enema ready-to-use enema 7gm/118ml; 19gm/118ml
enulose
EX-LAX TABLET
fiber laxative tablet
fiber tabs
fiber-lax
FIBERCON
FLEET ENEMA
FLEET ENEMA SIX PACK
fleet laxative
gavilyte-c
gavilyte-g
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 1)
QL (60 EA per 30 days)
PA (Irritable Bowel
Syndrome Agents) NDS
MO
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
62
Name of drug
gavilyte-n/flavor pack
generlac
geri-mucil
GLYCERIN ADULT SUPPOSITORY 2GM
glycerin adult suppository 2.1gm
glycerin infants & children suppository 1gm
glycolax powder
gnp bisa-lax
gnp clearlax
gnp enema
gnp fiber therapy
gnp fiber-caps
gnp fiber tablet
gnp glycerin adult suppository 2.1gm
gnp glycerin infant
gnp laxative tablet delayed release
gnp milk of magnesia
gnp natural fiber capsule
gnp natural fiber powder 28%, 28.3%, 48.57%
gnp natural vegetable
gnp senna plus
gnp senna-lax
gnp stool softener
gnp stool softener extra strength
gnp stool softener/stimulant laxative
hm clearlax
hm enema
hm fiber capsule 0.52gm
hm fiber tablet
hm fiber powder 48.57%, 58.6%
hm laxative tablet delayed release
hm milk of magnesia
hm senna-s
hm stool softener maximum strength
hm stool softener capsule
kao-tin capsule 240mg
KAOPECTATE STOOL SOFTENER
kls fiber-tabs
kls natural psyllium fiber
konsyl fiber
KONSYL-D POWDER
konsyl capsule
KONSYL POWDER 100%, 60.3%, 71.67%
konsyl powder 28.3%, 30.9%
ks stool softener
lactulose solution
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
63
Name of drug
laxative suppository
metamucil smooth texture sugar free
metamucil smooth texture powder
metamucil powder 28.3%
milk of magnesia suspension 1200mg/15ml, 400mg/5ml,
7.75%
MIRALAX POWDER
natural fiber therapy powder 30.9%, 48.57%
natural fiber powder 58.6%
NULYTELY/FLAVOR PACKS
NUTRISOURCE FIBER POWDER
PEDIA-LAX
peg 3350 powder
peg-3350/nacl/na bicarbonate/kcl
peg3350
perdiem overnight relief
peri-colace
polyethylene glycol 3350 powder 0
polyethylene glycol 3350 powder 0
px fiber
qc milk of magnesia
qc natural vegetable
qc natural vegetable laxative
qc stool softener plus laxative
ra fiber laxative
ra fiber powder
reguloid capsule
reguloid powder 28.3%, 48.57%, 58.6%
sani-supp adult
sani-supp pediatric
sb bisacodyl laxative ec
sb docusate sodium
sb fiber laxative tablet
sb laxative
sb milk of magnesia
sb polyethylene glycol 3 350
sb senna-lax
senexon
senexon-s
senna lax
senna laxative
senna plus
senna s
senna-plus
senna-s
senna-tabs
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
64
Name of drug
senna-time
senna-time s
sennalax-s
senna syrup 8.8mg/5ml
senna tablet 8.6mg
senno
sennosides/docusate sodium
SENOKOT
SENOKOT S
sm docusate calcium
sm fiber powder 28.3%, 48.57%, 58.6%
sm gentle laxative
sm milk of magnesia suspension 1200mg/15ml
sm natural laxative plus stool softener
sm stool softener plus laxative
sm stool softener capsule 100mg, 240mg
sof-lax
soluble fiber
stimulant laxative
stool softener extra strength
stool softener capsule
th natural fiber
total fiber
trilyte
womans stool softener
Protectants
misoprostol
sucralfate tablet
Proton Pump Inhibitors
esomeprazole magnesium
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
esomeprazole sodium
lansoprazole capsule delayed release 15mg
$0(Tier 1)
$0(Tier 1)
lansoprazole capsule delayed release 30mg
$0(Tier 1)
omeprazole capsule delayed release 10mg
$0(Tier 1)
omeprazole capsule delayed release 20mg, 40mg
$0(Tier 1)
pantoprazole sodium injection
pantoprazole sodium tablet delayed release 20mg
$0(Tier 1)
$0(Tier 1)
pantoprazole sodium tablet delayed release 40mg
$0(Tier 1)
DP
Genitourinary Agents
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
65
Name of drug
Antispasmodics, Urinary
darifenacin hydrobromide er
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
flavoxate hcl
MYRBETRIQ
$0(Tier 1)
$0(Tier 2)
oxybutynin chloride er
oxybutynin chloride tablet
tolterodine tartrate
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
tolterodine tartrate er
$0(Tier 1)
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
$0(Tier 1)
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
DP
$0(Tier 3)
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
MO
MO
DP
MO
MO
$0(Tier 2)
NDS
doxazosin
doxazosin mesylate tablet 1mg, 2mg, 8mg
dutasteride
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
finasteride tablet 5mg
$0(Tier 1)
tamsulosin hcl
$0(Tier 1)
terazosin hcl capsule
Genitourinary Agents, Other
bethanechol chloride
ELMIRON
RENACIDIN SOLUTION 6.602GM/100ML;
0.198GM/100ML; 3.177GM/100ML
surgilube
Phosphate Binders
calcium acetate capsule
calcium acetate tablet 667mg
calphron
ELIPHOS
FOSRENOL TABLET CHEWABLE 1000MG, 500MG,
750MG
RENVELA TABLET
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
A-HYDROCORT INJECTION 100MG
alclometasone dipropionate cream, ointment
amcinonide
anti-itch maximum strength
aquanil hc
augmented betamethasone dipropionate
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
66
What the drug
will cost you
Name of drug
(tier level)
betamethasone dipropionate cream, lotion, ointment
$0(Tier 1)
betamethasone valerate cream, lotion, ointment
$0(Tier 1)
budesonide capsule delayed release particles 3mg
$0(Tier 1)
clobetasol propionate e
$0(Tier 1)
clobetasol propionate gel, ointment, shampoo, solution
$0(Tier 1)
clodan
$0(Tier 1)
cortisone acetate tablet 25mg
$0(Tier 1)
DEPO-MEDROL INJECTION 20MG/ML
$0(Tier 2)
desonide cream, lotion, ointment
$0(Tier 1)
desoximetasone cream, gel, ointment
$0(Tier 1)
dexamethasone sodium phosphate injection 120mg/30ml
$0(Tier 1)
dexamethasone elixir
$0(Tier 1)
dexamethasone tablet 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg, $0(Tier 1)
6mg
fludrocortisone acetate tablet
$0(Tier 1)
fluocinolone acetonide cream, oil, ointment, solution
$0(Tier 1)
fluocinonide-e
$0(Tier 1)
fluocinonide gel, ointment, solution
$0(Tier 1)
fluticasone propionate cream 0.05%
$0(Tier 1)
fluticasone propionate ointment 0.005%
$0(Tier 1)
gnp hydro-lotion
$0(Tier 3)
gnp hydrocortisone maximum strength
$0(Tier 3)
gnp hydrocortisone plus
$0(Tier 3)
gnp hydrocortisone/aloe
$0(Tier 3)
gnp hydrocortisone cream 0.5%
$0(Tier 3)
halobetasol propionate
$0(Tier 1)
hydrocortisone butyrate ointment, solution
$0(Tier 1)
hydrocortisone maximum strength plus 12 moisturizers
$0(Tier 3)
hydrocortisone maximum strength cream
$0(Tier 3)
hydrocortisone valerate cream, ointment
$0(Tier 1)
hydrocortisone/aloe cream
$0(Tier 3)
hydrocortisone cream 1%, 2.5%
$0(Tier 1)
hydrocortisone cream 0.5%, 1%
$0(Tier 3)
hydrocortisone enema
$0(Tier 1)
hydrocortisone tablet
$0(Tier 1)
hydrocortisone lotion 2.5%
$0(Tier 1)
hydrocortisone ointment 1%, 2.5%
$0(Tier 1)
hydrocortisone ointment 1%
$0(Tier 3)
hydroskin
$0(Tier 3)
methylprednisolone acetate injection 40mg/ml, 80mg/ml
$0(Tier 1)
methylprednisolone dose pack tablet therapy pack
$0(Tier 1)
methylprednisolone sodiumsuccinate injection 1000mg,
$0(Tier 1)
125mg, 40mg
methylprednisolone tablet
$0(Tier 1)
mometasone furoate cream 0.1%
$0(Tier 1)
mometasone furoate ointment 0.1%
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
NDS
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
67
Name of drug
prednicarbate cream
prednisolone sodium phosphate oral solution 10mg/5ml,
15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml
prednisone solution
prednisone tablet 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg
preparation h hydrocortisone
procto-med hc
procto-pak
proctosol hc
proctozone-hc
qc hydrocortisone
qc hydrocortisone maximumstrength
sb hydrocortisone
sb hydrocortisone maximum strength
SOLU-CORTEF INJECTION 100MG, 250MG
SOLU-MEDROL INJECTION 125MG, 2GM, 40MG,
500MG
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5%
triderm
UCERIS FOAM
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
desmopressin acetate injection
desmopressin acetate tablet
INCRELEX
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML,
30MG/3ML, 5MG/1.5ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
pregnyl w/diluent benzyl alcohol/nacl
$0(Tier 1)
SAIZEN
$0(Tier 2)
SAIZEN CLICK.EASY
$0(Tier 2)
PA (Chorionic
Gonadotropin)
MO
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Chorionic
Gonadotropin)
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
68
Name of drug
SEROSTIM INJECTION 4MG, 5MG, 6MG
STIMATE SOLUTION
ZORBTIVE
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
oxandrolone tablet
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR, 4MG/24HR
danazol capsule
METHITEST
testosterone cypionate injection
testosterone enanthate injection
Estrogens
ALORA
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Serostim) NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Zorbtive)
QL (120 EA per 30 days)
PA (Korlym)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
apri
aranelle
aubra
aviane
balziva
bekyree
blisovi fe 1.5/30
caziant
CLIMARA PRO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
cryselle-28
cyclafem 1/35
delyla
DEPO-ESTRADIOL INJECTION 5MG/ML
desogestrel/ethinyl estradiol tablet 0; 0
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
QL (8 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
69
Name of drug
drospirenone/ethinyl estradiol tablet 3mg; 0.02mg
enpresse-28
ESTRACE CREAM
estradiol valerate injection 20mg/ml, 40mg/ml
estradiol tablet
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
estradiol patch weekly
$0(Tier 1)
estropipate tablet
$0(Tier 1)
ethynodiol diacetate/ethinyl estradiol
falmina
gildess 1.5/30
introvale
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kariva
kelnor 1/35
kimidess
larin 1.5/30
leena
lessina
levonorgestrel/ethinyl estradiol tablet 0; 0
levora 0.15/30-28
low-ogestrel
lutera
marlissa
MENEST
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mononessa
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
PA (High Risk
Medications) MO
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
70
What the drug
will cost you
Name of drug
(tier level)
nortrel 1/35
$0(Tier 1)
nortrel 7/7/7
$0(Tier 1)
OGESTREL
$0(Tier 2)
portia-28
$0(Tier 1)
PREMARIN INJECTION
$0(Tier 2)
PREMARIN CREAM
$0(Tier 2)
PREMARIN TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, $0(Tier 2)
1.25MG
PREMPHASE
$0(Tier 2)
PREMPRO
$0(Tier 2)
previfem
quasense
$0(Tier 1)
$0(Tier 1)
sprintec 28
sronyx
tri-lo-estarylla
tri-lo-sprintec
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vienva
xulane
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zovia 1/35e
zovia 1/50e
Progestins
aftera
camila
deblitane
DEPO-SUBQ PROVERA 104
econtra ez
errin
fallback solo
hydroxyprogesterone caproate injection
jolivette
levonorgestrel tablet 1.5mg
lyza
medroxyprogesterone acetate injection, tablet
megestrol acetate tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
MO
QL (91 EA per 91 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (3 EA per 28 days)
MO
MO
MO
DP
MO
MO
MO
DP
MO
DP
NDS
MO
DP
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
71
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
megestrol acetate suspension 625mg/5ml
megestrol acetate suspension 40mg/ml
$0(Tier 1)
my way
next choice one dose
nora-be
norethindrone acetate tablet
norethindrone tablet
norlyroc
opcicon one-step
PLAN B ONE-STEP
progesterone capsule
PROMETRIUM
sharobel
take action
Selective Estrogen Receptor Modifying Agents
EVISTA
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
raloxifene hydrochloride
$0(Tier 1)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL
levothyroxine sodium tablet
levoxyl tablet 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg
liothyronine sodium injection
liothyronine sodium tablet
SYNTHROID TABLET
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
unithroid tablet 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 90MG
SENSIPAR TABLET 30MG
Necessary actions,
restrictions, or limits on
use
PA (High Risk
Medications)
PA (High Risk
Medications) MO
DP
DP
MO
MO
MO
MO
DP
DP
MO
MO
MO
DP
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (120 EA per 30 days)
NDS
QL (60 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
72
Name of drug
SENSIPAR TABLET 60MG
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
ELIGARD
FIRMAGON
leuprolide acetate injection
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT-PED (1-MONTH) INJECTION 11.25MG,
15MG
octreotide acetate
SIGNIFOR
SOMATULINE DEPOT INJECTION 120MG/0.5ML,
90MG/0.3ML
SOMAVERT
SYNAREL
TRELSTAR MIXJECT
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet 10mg, 5mg
propylthiouracil tablet
Immunological Agents
Angioedema (HAE) Agents
CINRYZE
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
FIRAZYR
Immune Suppressants
AZASAN
azathioprine tablet
BENLYSTA
CELLCEPT INTRAVENOUS
cyclosporine modified
cyclosporine capsule, injection
ENBREL
NDS
NDS
PA (Hormonal Agents,
Suppressant (Pituitary) Somavert) NDS
NDS
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 2)
QL (100 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Cinryze) NDS
PA (FIRAZYR) NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ENBREL SURECLICK
$0(Tier 2)
ENVARSUS XR
$0(Tier 2)
B/D
B/D MO
PA (Benlysta) NDS
B/D
B/D
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
73
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Name of drug
gengraf
HUMIRA
HUMIRA PEN
$0(Tier 2)
HUMIRA PEN-CROHNS DISEASESTARTER
$0(Tier 2)
HUMIRA PEN-PSORIASIS STARTER
$0(Tier 2)
KINERET
$0(Tier 2)
methotrexate sodium injection 1gm/40ml, 1gm, 50mg/2ml
methotrexate tablet
mycophenolate mofetil
mycophenolic acid dr
NULOJIX
ORENCIA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
ORENCIA CLICKJECT
$0(Tier 2)
PROGRAF INJECTION
RAPAMUNE SOLUTION
REMICADE
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
sirolimus tablet
tacrolimus capsule 0.5mg, 1mg, 5mg
TORISEL
ZORTRESS
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D
GAMMAGARD LIQUID INJECTION 2.5GM/25ML
GAMUNEX-C INJECTION 1GM/10ML
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS INJECTION 180MG
leflunomide
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
B/D
B/D MO
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D
B/D NDS
PA (Immunological
Agents) NDS
B/D
B/D
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
B/D
B/D NDS
B/D NDS
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 1)
SIMULECT INJECTION 20MG
SYNAGIS INJECTION 50MG/0.5ML
Vaccines
Necessary actions,
restrictions, or limits on
use
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
QL (28 ML per 28 days)
PA (Immunological
Agents) NDS
$0(Tier 2)
$0(Tier 2)
QL (2.4 EA per 28 days)
PA (Immunological
Agents - Ilaris)
QL (30 EA per 30 days)
MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
74
Name of drug
ACTHIB INJECTION 0
ADACEL
bcg vaccine
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX INJECTION 1440ELU/ML, 720ELU/0.5ML
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB INJECTION 7.5MCG/0.5ML
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ SOLUTION
TENIVAC
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VARIZIG
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
DELZICOL
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
$0(Tier 1)
$0(Tier 2)
MO
MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
75
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
Name of drug
DIPENTUM
mesalamine dr
mesalamine kit
Sulfonamides
sulfasalazine tablet, tablet delayed release
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tablet 10mg, 40mg, 5mg
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
QL (180 EA per 30 days)
MO
MO
$0(Tier 1)
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
QL (8 EA per 28 days)
QL (4 ML per 30 days)
MO
MO
alendronate sodium tablet 70mg
$0(Tier 1)
alendronate sodium tablet 35mg
calcitonin-salmon solution
$0(Tier 1)
$0(Tier 1)
calcitriol capsule, oral solution
calcitriol injection 1mcg/ml
doxercalciferol capsule 0.5mcg, 1mcg
doxercalciferol capsule 2.5mcg
doxercalciferol injection
etidronate disodium
FORTEO INJECTION 600MCG/2.4ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
fortical
$0(Tier 1)
ibandronate sodium tablet
$0(Tier 1)
MIACALCIN INJECTION
PAMIDRONATE DISODIUM INJECTION 6MG/ML
pamidronate disodium injection 30mg/10ml, 90mg/10ml
PROLIA
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
risedronate sodium dr
$0(Tier 1)
risedronate sodium tablet 30mg, 5mg
$0(Tier 1)
risedronate sodium tablet 35mg
$0(Tier 1)
XGEVA
zoledronic acid injection 4mg/5ml, 5mg/100ml
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
NDS
MO
PA (metabolic bone
disease agents - IV
osteoporosis)
QL (4 ML per 30 days)
MO
QL (1 EA per 30 days)
MO
QL (1 ML per 180 days)
PA (Metabolic Bone
Disease Agents - Prolia)
QL (4 EA per 28 days)
MO
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
76
What the drug
will cost you
Name of drug
(tier level)
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" $0(Tier 2)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
$0(Tier 2)
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
$0(Tier 1)
$0(Tier 2)
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
bd pen needles short/ultrafine/31g x 5/16"
BOTOX INJECTION 200UNIT
$0(Tier 1)
$0(Tier 2)
CARNITOR INJECTION
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
exel comfort point insulin pen needles 31g x 8mm
FERRIPROX TABLET
glycerin external liquid 0
gnp glycerin external liquid 99.5%
insupen ultrafin 31gx8mm
INTRALIPID INJECTION 30GM/100ML
intralipid injection 20gm/100ml
lactated ringers irrigation
levocarnitine solution, tablet
lite touch pen needles/31g x 3/16"
methylergonovine maleate tablet
monoject insulin syringe/detach needle/1ml/25g x 5/8"
NATPARA
novofine 32gx6mm
nutrilipid
physiolyte
physiosol irrigation
PREMIUM CONDOMS LUBRICATED
ringers irrigation
sterile water irrigation
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (200 EA per 30 days)
MO
QL (200 EA per 30 days)
MO
MO
QL (200 EA per 30 days)
MO
MO
MO
MO
QL (200 EA per 30 days)
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
MO
MO
MO
DP
DP
MO
B/D
B/D
MO
MO
MO
PA (Natpara) NDS
MO
B/D
DP
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
77
Name of drug
latanoprost
LUMIGAN
Ophthalmic Agents, Other
akwa tears
artificial tears ointment 15%; 83%
artificial tears solution 1.4%
bacitracin/polymyxin b
CYSTARAN
hm artificial tears
liquitears
lubrifresh p.m.
MURO 128
naphazoline hcl
natural balance tears
natures tears solution 0.1%; 0.3%, 0.4%
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
polymyxin b sulfate/trimethoprim sulfate
refresh lacri-lube
RESTASIS
sodium chloride opthalmicsolution
sodium chloride ointment 5%
sodium chloride ophthalmic solution 5%
systane contacts soothing drops
tears naturale ii
tears pure
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
olopatadine hcl ophthalmic solution 0.1%
PATANOL
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic solution 0.1%
diclofenac sodium solution 0.1%
DUREZOL
fluorometholone
flurbiprofen sodium
ketorolac tromethamine ophthalmic solution 0.4%, 0.5%
LOTEMAX SUSPENSION
neomycin/polymyxin/dexamethasone
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate ophthalmic solution 1%
sulfacetamide sodium/prednisolone sodium phosphate
TOBRADEX OINTMENT
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
QL (60 EA per 30 days)
MO
DP
DP
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
78
Name of drug
tobramycin/dexamethasone
Ophthalmic Antiglaucoma Agents
acetazolamide er
ALPHAGAN P SOLUTION 0.1%
betaxolol hcl solution 0.5%
brimonidine tartrate
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
levobunolol hcl solution 0.5%
methazolamide tablet
metipranolol
PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED
0.125%
pilocarpine hcl solution 1%, 2%, 4%
timolol maleate ophthalmic gel forming
timolol maleate solution 0.25%, 0.5%
Otic Agents
Otic Agents
acetasol hc
acetic acid
CIPRODEX
e-r-o ear drops
e-r-o ear wax removal system
ear wax removal drops
earwax treatment drops
gnp ear drops
gnp ear systems
hm earwax removal aid
hm earwax removal kit
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic suspension 1%;
3.5mg/ml; 10000unit/ml
sb ear wax remover
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
What the drug
will cost you
(tier level)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 2)
QL (60 EA per 30 days)
MO
MO
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT,
45MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT
$0(Tier 2)
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (12 GM per 30 days)
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
79
Name of drug
ASMANEX TWISTHALER 60 METERED DOSES
budesonide inhalation suspension 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml
budesonide nasal suspension 32mcg/act
DULERA
FLOVENT DISKUS
FLOVENT HFA AEROSOL 44MCG/ACT
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
B/D MO
$0(Tier 1)
QL (17.2 GM per 30 days)
MO
MO
MO
QL (21.2 GM per 30 days)
MO
QL (24 GM per 30 days)
MO
MO
QL (32 GM per 30 days)
MO
QL (34 GM per 30 days)
QL (10.2 GM per 30 days)
MO
QL (33 GM per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT $0(Tier 2)
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
$0(Tier 1)
$0(Tier 1)
mometasone furoate suspension 50mcg/act
SYMBICORT
$0(Tier 1)
$0(Tier 2)
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
all day allergy childrens solution
all day allergy tablet
allergy childrens liquid
allergy relief child
allergy relief childrens liquid, solution
allergy relief capsule
allergy relief tablet 10mg
allergy capsule
allergy tablet 10mg
azelastine hcl solution 0.15%
azelastine hcl solution 0.1%
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
banophen capsule, liquid
BENADRYL ALLERGY CHILDRENS LIQUID
cetirizine hcl allergy childrens
cetirizine hcl childrens allergy syrup 1mg/ml
cetirizine hcl hives relief childrens
cetirizine hcl tablet 10mg
childrens allergy
childrens loratadine
complete allergy medicine capsule
cyproheptadine hcl syrup, tablet
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
diphenhist capsule, liquid
diphenhydramine hcl capsule
diphenhydramine hcl injection 50mg/ml
gnp all day allergy
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
QL (30 ML per 30 days)
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (High Risk
Medications) MO
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
80
Name of drug
gnp all day allergy childrens solution 1mg/ml
gnp all day allergy childrens syrup 5mg/5ml
gnp allergy capsule
gnp childrens allergy
gnp loratadine
gnp loratadine childrens
gnp sleep aid
goodsense all day allergy
hm all day allergy
hm allergy childrens
hm allergy relief childrens
hm allergy relief tablet 10mg
hm allgery multi symptom
hm cetirizine hcl childrens solution 5mg/5ml
hm loratadine childrens
hydroxyzine hcl injection, syrup, tablet
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
hydroxyzine pamoate capsule
$0(Tier 1)
levocetirizine dihydrochloride solution
levocetirizine dihydrochloride tablet
$0(Tier 1)
$0(Tier 1)
loratadine childrens
loratadine hives relief
loratadine tablet
multi-symptom allergy
olopatadine hcl nasal solution 0.6%
pharbedryl
q-dryl
qc all day allergy
qc loratadine allergy relief
sb allergy
sb loratadine allergy relief
sb loratadine tablet
siladryl allergy
sleep aid tablet
sm all day allergy
sm allergy relief childrens
sm allergy relief loratadine
sm allergy relief capsule, liquid
sm childrens loratadine
sm loratadine syrup
wal-dryl allergy capsule
ZYRTEC ALLERGY TABLET
ZYRTEC CHILDRENS ALLERGY SYRUP 1MG/ML
Antileukotrienes
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (High Risk
Medications)
PA (High Risk
Medications)
MO
QL (30 EA per 30 days)
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
81
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
montelukast sodium
zafirlukast
$0(Tier 1)
ZYFLO CR
$0(Tier 2)
Bronchodilators, Anticholinergic
ATROVENT HFA
$0(Tier 2)
COMBIVENT RESPIMAT
$0(Tier 2)
ipratropium bromide/albuterol sulfate
$0(Tier 1)
ipratropium bromide inhalation solution
$0(Tier 1)
ipratropium bromide nasal solution 0.06%
$0(Tier 1)
ipratropium bromide nasal solution 0.03%
$0(Tier 1)
SPIRIVA HANDIHALER
$0(Tier 2)
SPIRIVA RESPIMAT
$0(Tier 2)
Bronchodilators, Sympathomimetic
ADRENACLICK
albuterol sulfate er
albuterol sulfate syrup, tablet
albuterol sulfate nebulization solution 0.083%
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (39 GM per 30 days)
MO
QL (8 GM per 30 days)
MO
QL (540 ML per 30 days)
B/D MO
QL (300 ML per 30 days)
B/D MO
QL (15 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (8 GM per 30 days)
MO
albuterol sulfate nebulization solution 0.63mg/3ml,
1.25mg/3ml
albuterol sulfate nebulization solution 0.5%
$0(Tier 1)
EPINEPHRINE INJECTION 0.15MG/0.15ML,
0.3MG/0.3ML
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
levalbuterol hcl nebulization solution 0.31mg/3ml,
0.63mg/3ml
levalbuterol tartrate hfa
$0(Tier 2)
QL (4 EA per 30 days)
MO
MO
QL (1170 ML per 30
days) B/D MO
QL (1200 ML per 30
days) B/D MO
QL (200 ML per 30 days)
B/D MO
QL (4 EA per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
QL (4 EA per 30 days)
QL (4 EA per 30 days)
B/D MO
$0(Tier 1)
levalbuterol nebulization solution
metaproterenol sulfate syrup, tablet
PROAIR HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
QL (45 GM per 30 days)
MO
B/D MO
MO
QL (36 GM per 30 days)
MO
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
82
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
PROAIR RESPICLICK
SEREVENT DISKUS
$0(Tier 2)
terbutaline sulfate injection
terbutaline sulfate tablet
VENTOLIN HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
XOPENEX HFA
$0(Tier 2)
XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML
$0(Tier 2)
Cystic Fibrosis Agents
CAYSTON
$0(Tier 2)
KALYDECO PACKET
$0(Tier 2)
KALYDECO TABLET
$0(Tier 2)
ORKAMBI TABLET 125MG; 200MG
$0(Tier 2)
ORKAMBI TABLET 125MG; 100MG
$0(Tier 2)
PULMOZYME
TOBI PODHALER
tobramycin
Mast Cell Stabilizers
cromolyn sodium aerosol solution 5.2mg/act
cromolyn sodium nebulization solution 20mg/2ml
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection
$0(Tier 1)
DALIRESP
$0(Tier 2)
ELIXOPHYLLIN
$0(Tier 2)
THEO-24
$0(Tier 2)
theophylline cr tablet extended release 12 hour 100mg, 200mg $0(Tier 1)
theophylline er tablet extended release 24 hour
$0(Tier 1)
theophylline er tablet extended release 12 hour 300mg, 450mg $0(Tier 1)
theophylline solution
$0(Tier 1)
Pulmonary Antihypertensives
ADCIRCA
$0(Tier 2)
ADEMPAS
$0(Tier 2)
LETAIRIS
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (2 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (36 GM per 30 days)
MO
QL (45 GM per 30 days)
MO
QL (450 ML per 30 days)
B/D MO
PA (Antibacterials - Beta
lactam, Other) NDS
QL (56 EA per 28 days)
PA (Kalydeco) NDS
QL (60 EA per 30 days)
PA (Kalydeco) NDS
QL (112 EA per 28 days)
PA (Orkambi)
QL (112 EA per 28 days)
PA (Orkambi) NDS
B/D
B/D
DP
QL (305 ML per 30 days)
B/D MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
PA (Adcirca)
QL (90 EA per 30 days)
PA (Adempas) NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
83
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
OPSUMIT
ORENITRAM
sildenafil injection
sildenafil tablet
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
TRACLEER
$0(Tier 2)
TYVASO
UPTRAVI TABLET THERAPY PACK
UPTRAVI TABLET
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Respiratory Tract Agents, Other
acetylcysteine solution
altamist
ARALAST NP INJECTION 500MG
ayr solution
childrens mucus relief expectorant
cough control dm
cough syrup syrup 100mg/5ml
deep sea nasal spray
dextromethorphan/guaifenesin solution
diabetic siltussin das-na
diabetic siltussin-dm
diabetic siltussin-dm maximum strength
ESBRIET CAPSULE
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
extra action cough
gnp nasal decongestant
gnp nasal moisturizing
gnp tussin
gnp tussin dm
gnp tussin dm cough
gnp tussin dm max
guaifenesin-dm
guaifenesin solution
hm nasal decongestant
hm saline nasal spray
hm tussin adult
iophen dm-nr
iophen-nr
little noses saline
mucinex chest congestion childrens
MUCINEX DM
mucus relief childrens
nasal decongestant tablet 30mg
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
PA (Opsumit)
PA (Orenitram)
PA (Sildenafil - IV)
QL (90 EA per 30 days)
PA (Sildenafil - PAH)
QL (60 EA per 30 days)
LA NDS
B/D
PA (Uptravi)
QL (60 EA per 30 days)
PA (Uptravi)
B/D
DP
NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (270 EA per 30 days)
PA (Esbriet) NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
84
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
Name of drug
nasal moisturizing spray
OCEAN NASAL SPRAY
OFEV
PROLASTIN-C
promethazine vc plain
pseudoephedrine hcl tablet 30mg
px saline nasal spray
q-tussin dm
q-tussin solution
qc suphedrine
robafen
robafen dm
robafen dm cough clear
robitussin peak cold cough+ chest congestion dm
ROBITUSSIN PEAK COLD DM
saline mist
saline nasal mist
saline nasal spray
sb cough control dm liquid 10mg/5ml; 100mg/5ml
sb cough control syrup
sb saline nose
sea soft nasal mist
siltussin dm das
siltussin sa
siltussin-dm
sm nasal decongestant maximum strength
sm tussin
sm tussin dm
sm tussin dm cough/chest congestion
sodium chloride nebulization solution 0.9%
sudogest tablet 30mg
tgt saline nasal spray
theraflu warming relief severe cold daytime
tusnel diabetic
tussin chest congestion
tussin dm
tussin dm max
XOLAIR
ZEMAIRA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet 500mg
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
DP
DP
QL (60 EA per 30 days)
PA (Ofev) NDS
NDS
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (Respiratory Tract
Agents) NDS
NDS
PA (High Risk
Medications)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
85
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
cyclobenzaprine hcl tablet 10mg, 5mg
methocarbamol tablet
$0(Tier 1)
orphenadrine citrate er
$0(Tier 1)
orphenadrine citrate injection
Sleep Disorder Agents
GABA Receptor Modulators
flurazepam hcl
temazepam capsule 15mg, 30mg
zaleplon
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zolpidem tartrate er
$0(Tier 1)
zolpidem tartrate tablet
$0(Tier 1)
Sleep Disorders, Other
modafinil tablet 200mg
$0(Tier 1)
ROZEREM
XYREM
$0(Tier 2)
$0(Tier 2)
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CARBAGLU
CHEMET
DEPEN TITRATABS
EXJADE
kionex powder
SODIUM LACTATE INJECTION 5MEQ/ML
sodium polystyrene sulfonate suspension
sps
SYPRINE
ZINC TRACE METAL
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (30 EA per 30 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (30 EA per 30 days)
PA (Central Nervous
System Agents) MO
QL (30 EA per 30 days)
QL (540 ML per 30 days)
LA NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
NDS
$0(Tier 2)
$0(Tier 1)
B/D
B/D
MO
NDS
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
86
What the drug
will cost you
Name of drug
(tier level)
aminosyn ii 8.5%/electrolytes
$0(Tier 1)
AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; $0(Tier 2)
1527MG/100ML; 1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML; 990MG/100ML;
1500MG/100ML; 1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML; 795MG/100ML;
50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML;
750MG/100ML, 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML, 61.1MEQ/L;
844MG/100ML; 865MG/100ML; 595MG/100ML;
627MG/100ML; 425MG/100ML; 255MG/100ML;
561MG/100ML; 850MG/100ML; 893MG/100ML;
146MG/100ML; 253MG/100ML; 614MG/100ML;
450MG/100ML; 33.3MEQ/L; 340MG/100ML;
170MG/100ML; 230MG/100ML; 425MG/100ML,
71.8MEQ/L; 993MG/100ML; 1018MG/100ML;
700MG/100ML; 738MG/100ML; 500MG/100ML;
300MG/100ML; 660MG/100ML; 1000MG/100ML;
1050MG/100ML; 172MG/100ML; 298MG/100ML;
722MG/100ML; 530MG/100ML; 45.3MEQ/L;
400MG/100ML; 200MG/100ML; 270MG/100ML;
500MG/100ML
AMINOSYN-HBC
$0(Tier 2)
AMINOSYN-PF 7%
$0(Tier 2)
AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; $0(Tier 2)
1227MG/100ML; 527MG/100ML; 820MG/100ML;
385MG/100ML; 312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML; 180MG/100ML;
427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;
44MG/100ML; 673MG/100ML
AMINOSYN-RF
$0(Tier 2)
AMMONIUM CHLORIDE
$0(Tier 2)
CAL-MAG-ZINC-D
$0(Tier 3)
CALCI-CHEW
$0(Tier 3)
CALCIONATE
$0(Tier 3)
calcitrate tablet 315mg; 250unit
$0(Tier 3)
calcium + d3
$0(Tier 3)
calcium 250+d
$0(Tier 3)
calcium 500 + d
$0(Tier 3)
calcium 500/d tablet 200unit; 500mg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
B/D
B/D
B/D
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
87
Name of drug
calcium 500/vitamin d
CALCIUM 500 TABLET 500MG; 200UNIT; 250MG
calcium 600
calcium 600 high potency
calcium 600+d
calcium 600+d3 tablet 600mg; 800unit
calcium 600-d
calcium 600/vitamin d
calcium 600/vitamin d3
calcium carbonate/vitamin d tablet 600mg; 400unit
calcium carbonate suspension 1250mg/5ml
calcium carbonate tablet 1250mg, 600mg
calcium citrate + d
calcium citrate + d3 maximum
calcium citrate + d3 tablet 250mg; 200unit
calcium citrate maximum/vitamin d
calcium citrate petite/vitamin d
calcium citrate/vitamin d3 tablet
calcium citrate/vitamin d tablet 315mg; 200unit, 315mg;
250unit
calcium high potency
calcium high potency + vitamin d
calcium oyster shell
calcium+d3
calcium/d tablet
calcium/vitamin d3 tablet 250mg; 125unit
calcium/vitamin d tablet 500mg; 200unit, 500mg; 400unit,
600mg; 400unit
calcium tablet chewable 500mg; 0; 100unit; 0, 500mg;
100unit
calcium tablet 1500mg, 600mg
caltrate 600
CALTRATE 600+D TABLET 600MG; 800UNIT
CHROMIUM CHLORIDE INJECTION 40MCG/10ML
CITRACAL + D3 MAXIMUM
CITRACAL MAXIMUM
CITRACAL/VITAMIN D
citrus calcium +d
citrus calcium/vitamin d
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
88
What the drug
will cost you
Name of drug
(tier level)
CLINIMIX 5%/DEXTROSE 25%
$0(Tier 2)
CLINIMIX E 2.75%/DEXTROSE 10%
$0(Tier 2)
CLINIMIX E 2.75%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 10%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 25%
$0(Tier 2)
CLINIMIX E 4.25%/DEXTROSE 5%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 15%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 20%
$0(Tier 2)
CLINIMIX E 5%/DEXTROSE 25%
$0(Tier 2)
cvs calcium carbonate
$0(Tier 3)
cvs calcium tablet
$0(Tier 3)
cvs iron
$0(Tier 3)
cvs oyster shell calcium w/ vit d
$0(Tier 3)
DEXTROSE 10%/NACL 0.45%
$0(Tier 2)
dextrose 10%
$0(Tier 1)
DEXTROSE 10%/NACL 0.2%
$0(Tier 2)
dextrose 2.5%/nacl 0.45%
$0(Tier 1)
dextrose 5%
$0(Tier 1)
dextrose 5%/lactated ringers
$0(Tier 1)
dextrose 5%/nacl 0.2%
$0(Tier 1)
DEXTROSE 5%/NACL 0.225%
$0(Tier 2)
dextrose 5%/nacl 0.33%
$0(Tier 1)
dextrose 5%/nacl 0.45%
$0(Tier 1)
dextrose 5%/nacl 0.9%
$0(Tier 1)
ENFAMIL ENFALYTE SOLUTION 45MEQ/L; 33MEQ/L; $0(Tier 3)
25MEQ/L; 50MEQ/L
eql calcium
$0(Tier 3)
EQL CALCIUM/VITAMIN D CAPSULE
$0(Tier 3)
eql iron supplement therapy
$0(Tier 3)
eql oyster shell calcium/vitamin d
$0(Tier 3)
FEOSOL TABLET 200MG
$0(Tier 3)
fer-iron
$0(Tier 3)
ferosul
$0(Tier 3)
ferrex 150
$0(Tier 3)
FERRLECIT
$0(Tier 3)
ferro-bob
$0(Tier 3)
ferrous sulfate elixir 220mg/5ml
$0(Tier 3)
FERROUS SULFATE LIQUID 220MG/5ML
$0(Tier 3)
ferrous sulfate solution 15mg/ml
$0(Tier 3)
FERROUS SULFATE TABLET DELAYED RELEASE
$0(Tier 3)
324MG
ferrous sulfate tablet delayed release 325mg
$0(Tier 3)
ferrous sulfate tablet 325mg
$0(Tier 3)
ferrousul
$0(Tier 3)
FREAMINE HBC 6.9%
$0(Tier 2)
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
89
Name of drug
gnp calcium 600 +d3
gnp calcium citrate +d3
gnp calcium citrate+d3 maximum
gnp calcium tablet 600mg
gnp iron tablet
gnp pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l
h-e-b oral electrolyte solution
hepatamine
high potency calcium
hm calcium/vitamin d
hm iron
hm pediatric electrolyte
INFED
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iron supplement
iron tablet 325mg
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
kp ferrous sulfate
lactated ringers viaflex
magnesium sulfate injection 50%
meijer ferrous sulfate
MOZOBIL
MULTI-MINERALS
multitrace-4 concentrate
NEPHRAMINE
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
oralyte
os-cal calcium + d3
oysco 500
oysco 500+d
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
B/D
DP
DP
DP
DP
DP
DP
DP
MO
MO
MO
MO
MO
DP
DP
PA (Mozobil)
DP
DP
B/D
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
90
What the drug
will cost you
Name of drug
(tier level)
oysco d
$0(Tier 3)
oyst-cal-d 500
$0(Tier 3)
oyster calcium
$0(Tier 3)
oyster shell calcium + vitamin d
$0(Tier 3)
oyster shell calcium 500
$0(Tier 3)
oyster shell calcium 500 + d tablet 200unit; 500mg
$0(Tier 3)
oyster shell calcium 500/d
$0(Tier 3)
oyster shell calcium plusvitamin d
$0(Tier 3)
oyster shell calcium+d
$0(Tier 3)
oyster shell calcium/d3
$0(Tier 3)
oyster shell calcium/d tablet 500mg; 200unit
$0(Tier 3)
oyster shell calcium/vitamin d tablet 200unit; 500mg, 250mg; $0(Tier 3)
125unit; 0, 500mg; 200unit
oyster shell calcium tablet 500mg
$0(Tier 3)
oystercal
$0(Tier 3)
PEDIALYTE ADVANCED CARE
$0(Tier 3)
PEDIALYTE FREEZER POPS
$0(Tier 3)
PEDIALYTE SINGLES SOLUTION 7MEQ/200ML;
$0(Tier 3)
5.3GM/200ML; 4MEQ/200ML; 9MEQ/200ML;
1.6MG/200ML, 7MEQ/200ML; 5.6GM/200ML;
4MEQ/200ML; 9MEQ/200ML; 1.6MG/200ML,
8.3MEQ/240ML; 7.1MEQ/240ML; 4.7GM/240ML;
1.2GM/240ML; 4.7MEQ/240ML; 10.6MEQ/240ML
PEDIALYTE SOLUTION 35MEQ/L; 20GM/L; 5GM/L;
$0(Tier 3)
20MEQ/L; 45MEQ/L, 35MEQ/L; 25GM/L; 20MEQ/L;
45MEQ/L; 7.8MG/L, 35MEQ/L; 30MEQ/L; 25GM/L;
20MEQ/L; 45MEQ/L
pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
$0(Tier 3)
20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 20meq/l;
45meq/l
PHOS-NAK POWDER CONCENTRATE
$0(Tier 3)
PLASMA-LYTE A
$0(Tier 2)
PLASMA-LYTE-148
$0(Tier 2)
PLASMA-LYTE-56/D5W
$0(Tier 2)
PLENAMINE
$0(Tier 1)
potassium chloride 0.15% d5w/nacl 0.33%
$0(Tier 1)
potassium chloride 0.15% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride 0.22% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride er capsule extended release
$0(Tier 1)
potassium chloride er tablet extended release 10meq, 20meq, $0(Tier 1)
8meq
potassium chloride/dextrose
$0(Tier 1)
POTASSIUM CHLORIDE/DEXTROSE/LACTATED
$0(Tier 2)
RINGERS INJECTION 3MEQ/L; 149MEQ/L; 5%;
28MEQ/L; 24MEQ/L; 130MEQ/L
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
91
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
POTASSIUM CHLORIDE/SODIUM CHLORIDE
INJECTION 40MEQ/L; 0.9%
potassium chloride/sodium chloride injection 20meq/l; 0.45%, $0(Tier 1)
20meq/l; 0.9%
potassium chloride oral solution
$0(Tier 1)
potassium chloride injection 10meq/100ml, 20meq/100ml,
$0(Tier 1)
2meq/ml, 40meq/100ml
potassium citrate er
$0(Tier 1)
PREMASOL INJECTION 52MEQ/L; 1760MG/100ML;
$0(Tier 2)
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
premasol injection 56meq/l; 320mg/100ml; 730mg/100ml;
$0(Tier 1)
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml; 470mg/100ml
PROCALAMINE
$0(Tier 2)
pronutrients calcium+d3
$0(Tier 3)
PROSOL
$0(Tier 2)
qc calcium fast dissolution
$0(Tier 3)
ra calcium 600
$0(Tier 3)
ra calcium citrate plus vitamin d
$0(Tier 3)
ra hi cal
$0(Tier 3)
ra hi-cal plus vitamin d
$0(Tier 3)
ra iron tablet 325mg
$0(Tier 3)
RA OYSTER SHELL CALCIUM/VITAMIN D TABLET
$0(Tier 3)
200UNIT; 500MG
ra pediatric electrolyte solution 35meq/l; 30meq/l; 20gm/l;
$0(Tier 3)
5gm/l; 20meq/l; 45meq/l
rehydralyte
$0(Tier 3)
ringers injection
$0(Tier 1)
sb oyster shell calcium
$0(Tier 3)
sb pediatric electrolyte
$0(Tier 3)
sm calcium/vitamin d tablet 200unit; 500mg
$0(Tier 3)
sm iron tablet 325mg
$0(Tier 3)
sm oyster shell calcium/vitamin d3
$0(Tier 3)
sodium chloride 0.45% injection
$0(Tier 1)
sodium chloride 0.9% solution
$0(Tier 1)
sodium chloride injection 0.9%, 2.5meq/ml, 3%, 5%
$0(Tier 1)
sodium citrate/citric acid
$0(Tier 3)
sodium ferric gluconate complex/sucrose
$0(Tier 3)
sodium fluoride tablet 1mg
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
B/D
B/D
B/D
DP
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
92
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
Name of drug
super calcium tablet 600mg
th calcium
th calcium 600/vitamin d
th calcium citrate/vitamin d
th iron
th oyster shell calcium/vitamin d
tpn electrolytes
TRAVASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
TROPHAMINE
$0(Tier 2)
UROCIT-K 10
$0(Tier 2)
UROCIT-K 15
$0(Tier 2)
UROCIT-K 5
$0(Tier 2)
VENOFER
$0(Tier 3)
zinc sulfate injection 5mg/ml
$0(Tier 3)
Vitamins
a thru z select advanced tablet 60mg; 0; 30mcg; 220mg;
$0(Tier 3)
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
1.5mg; 50unit; 2500unit; 11mg
advanced stress formula/zinc
$0(Tier 3)
airborne tablet chewable 250mg; 0; 0; 0; 0; 0; 0; 10mg; 0; 0; $0(Tier 3)
0.75mg; 0; 3.75mcg; 7.5unit; 500unit; 0; 2mg; 0
animal chews
$0(Tier 3)
animal shapes + iron
$0(Tier 3)
animal shapes tablet chewable 60mg; 0; 4.5mcg; 400unit;
$0(Tier 3)
300mcg; 13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit
antioxidant vitamins tablet
$0(Tier 3)
AQUASOL A PARENTERAL
$0(Tier 3)
bee zee
$0(Tier 3)
bite-a-mins
$0(Tier 3)
centavite a-z complete multivitamin/minerals
$0(Tier 3)
CENTRUM ADULTS
$0(Tier 3)
CENTRUM SILVER ULTRA MENS
$0(Tier 3)
CENTRUM SILVER TABLET
$0(Tier 3)
CENTRUM ULTRA WOMENS
$0(Tier 3)
CENTRUM TABLET CHEWABLE, LIQUID
$0(Tier 3)
CEROVITE ADVANCED FORMULA LIQUID
$0(Tier 3)
cerovite advanced formula tablet
$0(Tier 3)
cerovite jr
$0(Tier 3)
certa plus
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
B/D
B/D
MO
MO
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
93
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
CERTAVITE SENIOR/ANTIOXIDANT NUTRIENTS
certavite/antioxidants
chewable vite childrens
chewable vite with iron/childrens
childrens chewable vitamin
childrens chewable vitamins/iron tablet chewable 400unit;
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit, 50mg; 4mcg; 300mcg; 15mg;
13.5mg; 1.05mg; 1.2mg; 1.05mg; 2500unit; 400unit; 15unit
childrens chewable vitamins tablet chewable 400unit; 4.5mcg; $0(Tier 3)
0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit;
2500unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0;
2500unit; 400unit; 15unit
compete
$0(Tier 3)
complete
$0(Tier 3)
cvs childrens chewable multivitamin/iron
$0(Tier 3)
cvs daily multiple
$0(Tier 3)
cvs daily multiple for men
$0(Tier 3)
cvs daily multiple for women tablet 60mg; 0; 450mg; 5mg;
$0(Tier 3)
400unit; 6mcg; 18mg; 400mcg; 50mg; 10mg; 2mg; 1.7mg;
1.5mg; 30unit; 2500unit; 15mg
cvs hair skin & nails/an tioxidants
$0(Tier 3)
cvs spectravite advanced formula
$0(Tier 3)
cvs stress formula/zinc
$0(Tier 3)
cyanocobalamin injection 1000mcg/ml
$0(Tier 3)
daily multi-vitamins + iron
$0(Tier 3)
daily multiple vitamin/iron
$0(Tier 3)
daily multiple vitamins w/iron tablet 60mcg; 6mcg; 4mg;
$0(Tier 3)
18mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit;
15unit
daily multiple vitamins/iron tablet 60mg; 0; 10mg; 6mcg;
$0(Tier 3)
400unit; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
daily multiple vitamins/minerals tablet 60mg; 0; 30mcg;
$0(Tier 3)
162mg; 10mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg;
400mcg; 100mg; 3.5mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 160mcg; 20mcg;
10mcg; 1.5mg; 30unit; 2500unit; 15mg
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit;
$0(Tier 3)
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily multiple vitamin tablet 60mg; 0; 10mg; 6mcg; 400unit; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg;
0; 45mg; 10mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg; 30unit; 3000unit
daily value multivitamin
$0(Tier 3)
daily vitamin formula
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
94
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
daily vitamin formula+ir on
daily vitamin formula+iron
daily vitamin formula+minerals
daily vitamins tablet 60mg; 400unit; 6mcg; 0.4mg; 20mg;
2mg; 1.7mg; 1.5mg; 5000unit
daily vitamin tablet 60mg; 0; 20mg; 400unit; 6mcg; 400mcg; $0(Tier 3)
20mg; 2mg; 1.7mg; 1.5mg; 15unit; 5000unit
daily vite tablet 60mg; 10mg; 400unit; 6mcg; 20mg; 2mg;
$0(Tier 3)
1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 6mcg; 0.4mg; 20mg;
10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit
daily-vite/iron/beta-carotene
$0(Tier 3)
daily-vite tablet 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit
DEKAS ESSENTIAL CAPSULE
$0(Tier 3)
dialyvite 800 tablet
$0(Tier 3)
dino-life
$0(Tier 3)
dino-life w extra c
$0(Tier 3)
DINO-LIFE W/IRON & ZINC
$0(Tier 3)
DRISDOL CAPSULE
$0(Tier 3)
eq complete chewable multivitamin childrens
$0(Tier 3)
eq multivitamin gummies childrens tablet chewable 15mg;
$0(Tier 3)
38mcg; 2.5mg; 200unit; 19mg; 1.5mcg; 100mcg; 15mcg;
0.5mg; 9unit; 1000unit; 1.3mg
eql childrens c
$0(Tier 3)
EQL CHILDRENS MULTIVITAMINS
$0(Tier 3)
eql childrens multivitamins/ron
$0(Tier 3)
eql folic acid
$0(Tier 3)
eql one daily essential
$0(Tier 3)
eql one daily mens health formula
$0(Tier 3)
eql one daily womens
$0(Tier 3)
flintstones complete tablet chewable 0; 40mcg; 10mg; 100mg; $0(Tier 3)
400unit; 38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg; 15mg;
100mg; 150mcg; 2mg; 1.7mg; 60mg; 1.5mg; 3000unit;
30unit; 12mg
flintstones gummies plus omega-3 dha
$0(Tier 3)
flintstones plus extra c
$0(Tier 3)
flintstones/my first
$0(Tier 3)
FOLIC ACID INJECTION
$0(Tier 3)
folic acid tablet 1mg, 400mcg, 800mcg
$0(Tier 3)
fruity chewables multivitamin
$0(Tier 3)
fruity chews
$0(Tier 3)
fruity chews/iron
$0(Tier 3)
gnp animal shapes plus iron tablet chewable 0; 400unit;
$0(Tier 3)
4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
95
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
gnp animal shapes tablet chewable 0; 400unit; 4.5mcg;
300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit;
2500unit
gnp century adults 50+ senior tablet 60mg; 0; 30mcg; 220mg; $0(Tier 3)
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
1.5mg; 50unit; 2500unit; 11mg
gnp century ultimate womens complete
$0(Tier 3)
gnp century tablet 60mg; 0; 30mcg; 200mg; 10mg; 72mg;
$0(Tier 3)
400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
gnp folic acid
$0(Tier 3)
gnp healthy eyes
$0(Tier 3)
gnp healthy eyes supervision
$0(Tier 3)
gnp one daily womens 50+ advanced
$0(Tier 3)
gnp therapeutic-m tablet 90mg; 0; 30mcg; 150mcg; 40mg;
$0(Tier 3)
10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg;
100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg;
6mg; 3.4mg; 2mg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg;
60unit; 5000unit; 15mg
gnp zoochews gummies
$0(Tier 3)
gummi bear multivitamin/mineral
$0(Tier 3)
hair/skin/nails tablet 25mg; 300mcg; 20mg; 170mg; 200mg; $0(Tier 3)
6mcg; 1.8mg; 400mcg; 25mg; 10mg; 16mg; 150mcg; 5unit
healthy eyes
$0(Tier 3)
hm antioxidant vitamins
$0(Tier 3)
HM COMPLETE
$0(Tier 3)
hm complete 50+
$0(Tier 3)
hm folic acid
$0(Tier 3)
HM HAIR/SKIN/NAILS
$0(Tier 3)
HM ONE DAILY WOMENS
$0(Tier 3)
HONEY BEARS
$0(Tier 3)
HYDROXOCOBALAMIN INJECTION
$0(Tier 3)
i-vite
$0(Tier 3)
ICAPS PLUS
$0(Tier 3)
INFUVITE
$0(Tier 3)
INFUVITE ADULT
$0(Tier 3)
INFUVITE PEDIATRIC
$0(Tier 3)
kids vitamins
$0(Tier 3)
kids vitamins plus extra c
$0(Tier 3)
kids vitamins plus iron
$0(Tier 3)
kp mens daily formula
$0(Tier 3)
little animals plus iron
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
96
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
M.V.I. ADULT
mega multiple w/chelated minerals
MEPHYTON
multi vitamin daily
multi vitamin mens
multi-day vitamins
multi-delyn
multi-vitamin daily
multi-vitamin/minerals tablet 60mg; 160mg; 6mcg; 18mg;
0.4mg; 150mcg; 100mg; 20mg; 125mg; 2mg; 1.7mg; 1.2mg;
5000unit; 400unit; 15mg
multi-vitamins
$0(Tier 3)
multi-vitamin tablet 60mg; 0; 30mcg; 10mg; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
multilex
$0(Tier 3)
multilex-t&m tablet 150mg; 10mg; 400unit; 1mg; 7.5mcg;
$0(Tier 3)
15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg;
5.5unit; 10000unit; 1.5mg
multiple vitamin/minerals/no iron
$0(Tier 3)
multiple vitamins essential
$0(Tier 3)
multiple vitamins plain
$0(Tier 3)
multiple vitamins/iron tablet 60mg; 0; 10mg; 400unit; 6mcg; $0(Tier 3)
18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit,
60mg; 400unit; 6mcg; 18mg; 400mcg; 20mg; 10mg; 2mg;
1.7mg; 1.5mg; 30unit; 5000unit
multiple vitamins tablet 50mg; 1mcg; 20mg; 1mg; 1mg;
$0(Tier 3)
2.5mg; 2mg; 5000unit; 400unit, 60mg; 0; 10mg; 400unit;
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg;
0; 400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit, 60mg; 0; 6mcg; 400mcg; 20mg; 10mg;
2mg; 1.7mg; 1.5mg; 30unit; 5000unit; 400unit, 60mg; 20mg;
8mcg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit
multiple vitamin tablet 60mg; 6mcg; 400unit; 0.4mg; 20mg; $0(Tier 3)
2mg; 1.7mg; 1.5mg; 5000unit; 15unit
multivital platinum tablet 60mg; 0; 30mcg; 200mg; 10mg;
$0(Tier 3)
72mg; 400unit; 150mcg; 2mg; 25mcg; 18mg; 400mcg;
250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 48mg; 10mcg;
80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg;
20mcg; 1.5mg; 45unit; 3500unit; 15mg
multivitamin gummies childrens tablet chewable 15mg;
$0(Tier 3)
38mcg; 2.5mg; 100unit; 19mg; 2.5mcg; 100mcg; 10mcg;
20mcg; 0.5mg; 10unit; 1000unit; 1.3mg
multivitamins capsule
$0(Tier 3)
NATRUL-MEGA-75
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
97
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
Name of drug
NEPHRO-VITE
nephrocaps capsule 100mg; 150mcg; 5mg; 6mcg; 1mg;
20mg; 10mg; 1.7mg; 1.5mg
NO IRON MULTIPLE VITAMIN/MINERALS
$0(Tier 3)
ocutabs
$0(Tier 3)
ocuvite/lutein
$0(Tier 3)
once daily/iron
$0(Tier 3)
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg; $0(Tier 3)
5000unit; 400unit
ONCOVITE
$0(Tier 3)
one daily complete
$0(Tier 3)
one daily mens tablet 90mg; 0; 30mcg; 210mg; 120mcg; 2mg; $0(Tier 3)
3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg;
1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit;
20mcg; 15mg
one daily multivitamin/iron
$0(Tier 3)
one daily plus minerals tablet 50mg; 19mg; 400unit; 5mcg; $0(Tier 3)
1mcg; 150mcg; 4.5mg; 10mg; 1mg; 20mg; 1mg; 10mg; 1mg;
2.5mg; 5mcg; 2mg; 5000unit; 3.75mg
one daily/minerals tablet 50mg; 125mg; 1mg; 3mcg; 100mcg; $0(Tier 3)
150mcg; 5mg; 20mg; 1mg; 1.7mg; 1.5mg; 10unit; 5000unit;
400unit
one daily tablet 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg; $0(Tier 3)
1.7mg; 1.5mg; 5000unit; 400unit; 30unit, 60mg; 400unit;
6mcg; 20mg; 2mg; 1.7mg; 0; 1.5mg; 5000unit
ONE-A-DAY ESSENTIAL
$0(Tier 3)
ONE-A-DAY MAXIMUM FORMULA
$0(Tier 3)
one-a-day teen advantage for her
$0(Tier 3)
ONE-A-DAY TEEN ADVANTAGE FOR HIM
$0(Tier 3)
ONE-A-DAY WOMENS FORMULA
$0(Tier 3)
one-daily multi vitamins
$0(Tier 3)
phytonadione injection 1mg/0.5ml
$0(Tier 3)
poly vitamin
$0(Tier 3)
polyvitamin/iron tablet chewable
$0(Tier 3)
prosight
$0(Tier 3)
pyridoxine hcl injection
$0(Tier 3)
qc daily multivitamins/iron
$0(Tier 3)
qc therin-m
$0(Tier 3)
RA CENTRAL-VITE UNDER 50 WOMENS
$0(Tier 3)
ra central-vite tablet 60mg; 0; 30mcg; 200mg; 10mg; 20mg; $0(Tier 3)
72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;
2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
ra folic acid tablet 400mcg
$0(Tier 3)
ra one daily energy formula
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
98
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
Name of drug
ra one daily essential
ra one daily multi-vitamin plus iron tablet 60mg; 10mg;
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit
ra one daily multi-vitamin tablet 60mg; 0; 10mg; 400unit;
$0(Tier 3)
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
renal vitamin
$0(Tier 3)
sm complete advanced formula
$0(Tier 3)
sm complete tablet 60mg; 0; 30mcg; 200mg; 10mg; 72mg;
$0(Tier 3)
400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
sm folic acid
$0(Tier 3)
sm hair/skin/nails
$0(Tier 3)
sm multiple vitamins essential
$0(Tier 3)
sm multiple vitamins/iron
$0(Tier 3)
SM ONE DAILY WOMENS
$0(Tier 3)
sm opti-vitamins
$0(Tier 3)
stress 500 b-complex/zinc
$0(Tier 3)
stress b-complex/vitamin c/zinc
$0(Tier 3)
stress b/zinc tablet 500mg; 45mcg; 70mg; 20mg; 3mg; 12mcg;$0(Tier 3)
400mcg; 100mg; 5mg; 10mg; 10mg; 30unit; 23.9mg
stress formula/zinc tablet 500mg; 45mcg; 20mg; 3mg; 12mcg; $0(Tier 3)
400mcg; 100mg; 5mg; 10mg; 10mg; 30unit; 23.9mg, 500mg;
45mcg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg;
15mg; 30unit; 23.9mg, 600mg; 45mg; 3mg; 12mcg; 400mcg;
100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg
stress formula tablet 500mg; 45mcg; 20mg; 12mcg; 400mcg; $0(Tier 3)
100mg; 5mg; 10mg; 10mg; 30unit
stress plus zinc
$0(Tier 3)
super dec b-100
$0(Tier 3)
tab-a-vite maximum
$0(Tier 3)
tab-a-vite w/beta carotene
$0(Tier 3)
tab-a-vite/iron
$0(Tier 3)
tab-a-vite tablet 60mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; $0(Tier 3)
1.7mg; 0; 1.5mg; 5000unit
th childrens chewable multi vitamins
$0(Tier 3)
th daily multiple vitamins
$0(Tier 3)
th premium daily multiple
$0(Tier 3)
th theradex-m
$0(Tier 3)
th vision vitamins/lutein
$0(Tier 3)
THERA M PLUS
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
99
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG;
50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG; 100MG;
2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG;
150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG;
70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
thera-m tablet 120mg; 15mcg; 40mg; 10mg; 7.5mg; 400unit; $0(Tier 3)
15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg;
31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg;
30unit; 5500unit; 15mg, 120mg; 15mcg; 44mg; 10mg; 7.5mg;
400unit; 15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg;
30mg; 31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg;
3mg; 30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg;
40mg; 7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg;
100mg; 3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg;
3mg; 3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit;
400unit; 30unit; 28mcg; 15mg
THERA/BETA-CAROTENE
$0(Tier 3)
therapeutic
$0(Tier 3)
therapeutic liquid
$0(Tier 3)
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg; $0(Tier 3)
3.4mg; 3mg; 5000unit; 400unit; 30unit
therems
$0(Tier 3)
THEREMS-M
$0(Tier 3)
thiamine hcl injection
$0(Tier 3)
totalday multiple
$0(Tier 3)
tri-vitamin solution 35mg/ml; 400unit/ml; 1500unit/ml
$0(Tier 3)
UNICOMPLEX-M TABLET 60MG; 60MG; 10MG;
$0(Tier 3)
400UNIT; 2MG; 6MCG; 18MG; 400MCG; 1MG; 20MG; 0;
45MG; 150MCG; 5MG; 2MG; 1.7MG; 0; 1.5MG; 30UNIT;
5000UNIT; 15MG
vita-bee/c tablet 300mg; 300mcg; 400mcg; 50mg; 10mg;
$0(Tier 3)
5mg; 10.2mg; 15mg
VITALETS CHILDRENS TABLET CHEWABLE 40MG; 0; $0(Tier 3)
150MCG; 80MG; 5MG; 3MCG; 200UNIT; 10MG; 200MCG;
20MG; 0.1MG; 10MG; 60MG; 1MG; 0.85MG; 0.75MG;
15UNIT; 2500UNIT; 0.8MG
VITALETS TABLET CHEWABLE 40MG; 0; 150MCG;
$0(Tier 3)
80MG; 3MCG; 200UNIT; 10MG; 200MCG; 20MG; 0.1MG;
10MG; 5MG; 60MG; 1MG; 0.85MG; 0.75MG; 2500UNIT;
15UNIT; 0.8MG
vitamin d capsule 50000unit
$0(Tier 3)
VITAMIN K1 INJECTION 10MG/ML
$0(Tier 3)
vitamin k1 injection 1mg/0.5ml
$0(Tier 3)
vitamins & minerals
$0(Tier 3)
vitamins for hair tablet 400mcg; 100mg; 250mg; 2mg; 6mcg; $0(Tier 3)
18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
100
Name of drug
VP-PNV-DHA
WOMENS MULTI VITAMIN & MINERAL FORMULA
womens one daily
Unclassified
No Classification
antacid fast relief
antacid plus anti-gas fast acting
antacid ultra strength
calcitrate tablet 950mg
calcium carbonate/d3
calcium/vitamin d/minerals
calcium/vitamin d tablet 500mg; 400unit, 600mg; 400unit
calcium tablet 500mg, 600mg
cvs calcium 600 + d/minerals
cvs calcium 600+d
essential one daily multivitamin
FANTASY LUBRICATED
FANTASY LUBRICATED/SPERMICIDE
ferrous sulfate tablet 325mg
GLYCERIN DOES NOT APPLY LIQUID 99.5%
gnp all day allergy childrens solution 5mg/5ml
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
gnp calcium 600 +d3/minerals
gnp calcium tablet 600mg
gnp essential one daily
GNP GLYCERIN DOES NOT APPLY LIQUID 0
gnp miconazole 3 combination pack
gnp tussin dm max cough & chest congestion
hm acid reducer tablet 75mg
hm allergy complete childrens
hm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
hm anti-nausea
hm cetirizine hcl childrens solution 5mg/5ml
hm famotidine
hm hydrocortisone plus
hm hydrocortisone/aloe maximum strength
hm motion sickness relief
hm nicotine transdermal system step 3
hm sleep aid
hm stomach relief maximumstrength
hm tussin adult cough & chest congestion dm
iron tablet 65mg
KIMONO LUBRICATED
KIMONO MICRO THIN
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
101
Name of drug
KIMONO MICRO THIN PLUS SPERMICIDE
LUBRICATED
KIMONO SENSATION LUBRICATED
KIMONO SENSATION PLUS SPERMICIDE
LUBRICATED
kp miconazole nitrate
MAXX LUBRICATED
oyster shell calcium tablet 500mg
qc antacid
qc antacid/anti-gas
qc athletes foot
ra oyster shell calcium
RISACAL-D
sb antacid anti-gas
sb antacid/antigas
sb antacid suspension 225mg/5ml; 200mg/5ml
sb cough control dm liquid 10mg/5ml; 100mg/5ml
sm all day allergy childrens
sm aspirin adult low strength tablet delayed release 81mg
sm calcium/vitamin d tablet 200unit; 500mg, 600mg; 800unit
TRUSTEX LUBRICATED
TRUSTEX LUBRICATED EXTRA LARGE
TRUSTEX LUBRICATED EXTRA STRENGTH
TRUSTEX LUBRICATED/RIBBED/STUDDED
TRUSTEX LUBRICATED/SPERMICIDE
TRUSTEX LUBRICATED/SPERMICIDE EXTRA LARGE
TRUSTEX LUBRICATED/SPERMICIDE EXTRA
STRENGTH
TRUSTEX NON-LUBRICATED
TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDED
TRUSTEX/RIA LUBRICATED
TRUSTEX/RIA LUBRICATED SPERMICIDE
TRUSTEX/RIA LUBRICATED/SPERMICIDE
TRUSTEX/RIA NON-LUBRICATED
TUMS SMOOTHIES TABLET CHEWABLE 750MG
TUMS TABLET CHEWABLE 500MG
tussin mucus + chest congestion
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
102
Index
Drug Name
3 day vaginal
4-N-1
a thru z select advanced
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
ABELCET
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acephen
acetaminophen
acetaminophen extra strength
acetaminophen/codeine
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
acid gone
acid reducer
ACNE MEDICATION 10
ACNE MEDICATION 5
ACTHIB
ACTIMMUNE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
ADCIRCA
adefovir dipivoxil
ADEMPAS
ADRENACLICK
adriamycin
adrucil
ADVAIR DISKUS
ADVAIR HFA
advanced stress formula/zinc
ADVIL
afeditab cr
AFINITOR
AFINITOR DISPERZ
aftera
Page #
28
57
93
42
42
42
28
38
32
16
44
51
11
11
11
15
79
53
79
53
79
84
59
61
57
57
75
74
43
43
75
58
57
83
40
83
82
32
31
79
79
93
12
51
34
34
71
103
Drug Name
A-HYDROCORT
airborne
akwa tears
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
alcohol prep pads
ALDURAZYME
ALECENSA
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all day allergy
all day allergy childrens
all day pain relief
all day relief
allergy
allergy childrens
allergy relief
allergy relief child
allergy relief childrens
allopurinol
allopurinol sodium
allzital
almacone
almacone double strength
aloe vesta skin conditioner
alophen
ALOPRIM
ALORA
alosetron hydrochloride
ALPHAGAN P
alprazolam
alprazolam intensol
altamist
ALUMINUM HYDROXIDE
amantadine hcl
AMBISOME
amcinonide
amifostine
amikacin sulfate
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
Page #
66
93
78
36
82
82
66
17
58
34
76
66
31
36
30
80
80
12
12
80
80
80
80
80
29
29
11
59
59
57
62
29
69
62
79
43
43
84
59
43
28
66
32
17
53
53
83
86
86
87
Drug Name
aminosyn ii 8.5%/electrolytes
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
AMMONIUM CHLORIDE
ammonium lactate
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
amphotericin b
ampicillin
ampicillin sodium
ampicillin-sulbactam
AMPYRA
ANADROL-50
anagrelide hydrochloride
anastrozole
ANDRODERM
animal chews
animal shapes
animal shapes + iron
antacid
antacid anti-gas maximum strength
antacid calcium extra st rength
antacid calcium regular strength
antacid extra strength
antacid fast relief
antacid maximum strength
antacid plus anti-gas fast acting
antacid plus anti-gas relief
antacid plus anti-gas relief maximum
strength
antacid ultra strength
anti-diarrheal
antifungal
anti-itch maximum strength
anti-nausea
antioxidant vitamins
anu-med
Page #
87
87
87
87
87
50
62
26
51
51
51
51
87
57
26
20
20
20
55
28
20
20
20
56
69
48
33
69
93
93
93
59
59
59
59
59
101
59
101
59
59
101
59
28
66
26
93
57
104
Drug Name
apap
APIDRA
APIDRA SOLOSTAR
APOKYN
aprepitant
apri
APTIOM
APTIVUS
aquanil hc
AQUASOL A PARENTERAL
ARALAST NP
aranelle
ARANESP ALBUMIN FREE
ARCALYST
aripiprazole
aripiprazole odt
ARISTADA
ARRANON
artificial tears
ascomp/codeine
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspir-81
aspirin
aspirin adult low strength
aspirin childrens
aspirin ec
aspirin ec low dose
aspirin enteric coated adult low strength
aspirin low dose
aspirin/dipyridamole
aspir-low
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone dipropionate
AVASTIN
AVELOX
Page #
11
46
46
37
27
69
21
42
66
93
84
69
48
74
38
38
38
31
78
15
79
79
79
80
12
12
12
12
12
12
12
12
48
12
51
51
54
36
36
43
59
82
56
69
66
36
21
Drug Name
aviane
AVONEX
AVONEX PEN
ayr
azacitidine
AZACTAM IN ISO-OSMOTIC
DEXTROSE
AZASAN
AZASITE
azathioprine
azelastine hcl
AZILECT
azithromycin
aztreonam
baciim
BACITRACIN
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BACTOCILL IN DEXTROSE
balsalazide disodium
balziva
banophen
BANZEL
BARACLUDE
baza antifungal
baza protect
bcg vaccine
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
bd insulin syringe/detachable needle/u100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM
bd pen needles short/ultrafine/31g x 5/16"
bedding spray lice treatment step 3
bee zee
bekyree
BELEODAQ
BENADRYL ALLERGY CHILDRENS
Page #
69
56
56
84
32
19
73
20
73
80
38
20
19
17
17
17
17
78
40
20
75
69
80
23
40
28
57
75
76
77
77
77
77
77
77
77
77
77
37
93
69
32
80
105
Drug Name
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENICAR
BENICAR HCT
BENLYSTA
benzoyl peroxide
benztropine mesylate
BETADINE
BETADINE SKIN CLEANSER
BETADINE SURGICAL SCRUB
BETADINE SWAB AID
BETADINE SWABSTICKS
betamethasone dipropionate
betamethasone valerate
betasept surgical scrub
BETASERON
betaxolol hcl
betaxolol hcl
bethanechol chloride
bexarotene
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
BICNU
BIDIL
bisac-evac
bisacodyl
bisacodyl ec
biscolax
bismatrol
bismatrol maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bite-a-mins
bleomycin sulfate
blisovi fe 1.5/30
BOOSTRIX
BOSULIF
BOTOX
BOTOX
BRILINTA
brimonidine tartrate
BRIVIACT
bromocriptine mesylate
budesonide
budesonide
bumetanide
BUPHENYL
buprenorphine hcl
Page #
50
50
49
49
73
57
37
17
17
17
17
17
67
67
57
56
51
79
66
36
75
31
20
20
30
55
62
62
62
62
59
59
51
51
93
32
69
75
34
29
77
48
79
21
37
67
80
53
58
16
Drug Name
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYETTA
cabergoline
CABOMETYX
CALCI-CHEW
CALCIONATE
calcipotriene
calcitonin-salmon
calcitrate
calcitrate
calcitriol
calcium
calcium
calcium + d3
calcium 250+d
CALCIUM 500
calcium 500 + d
calcium 500/d
calcium 500/vitamin d
calcium 600
calcium 600 high potency
calcium 600/vitamin d
calcium 600/vitamin d3
calcium 600+d
calcium 600+d3
calcium 600-d
calcium acetate
calcium antacid
calcium antacid extra strength
calcium antacid ultra maximum strength
calcium antacid ultra strength
calcium carbonate
calcium carbonate
calcium carbonate original
calcium carbonate/d3
calcium carbonate/vitamin d
calcium citrate + d
calcium citrate + d3
calcium citrate + d3 maximum
Page #
16
24
16
24
24
43
30
11
11
11
11
15
44
73
34
87
87
57
76
101
87
76
101
88
87
87
88
87
87
88
88
88
88
88
88
88
88
66
59
59
59
59
59
88
59
101
88
88
88
88
106
Drug Name
calcium citrate maximum/vitamin d
calcium citrate petite/vitamin d
calcium citrate/vitamin d
calcium citrate/vitamin d3
calcium high potency
calcium high potency + vitamin d
calcium oyster shell
calcium polycarbophil
calcium/d
calcium/vitamin d
calcium/vitamin d
calcium/vitamin d/minerals
calcium/vitamin d3
calcium+d3
cal-gest antacid
CAL-MAG-ZINC-D
calphron
caltrate 600
CALTRATE 600+D
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
capsaicin
captopril
captopril/hydrochlorothiazide
CARBAGLU
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
CARIMUNE NANOFILTERED
CARNITOR
carteolol hcl
cartia xt
carvedilol
CAYSTON
caziant
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefdinir
cefepime
Page #
88
88
88
88
88
88
88
62
88
101
88
101
88
88
59
87
66
88
88
71
32
28
49
49
30
34
57
50
50
86
23
23
23
37
37
37
32
74
77
79
51
51
83
69
19
19
19
19
19
19
Drug Name
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT INTRAVENOUS
CELONTIN
centavite a-z complete
multivitamin/minerals
CENTRUM
CENTRUM ADULTS
CENTRUM SILVER
CENTRUM SILVER ULTRA MENS
CENTRUM ULTRA WOMENS
cephalexin
cerave baby
CEREBYX
CEREZYME
CEROVITE ADVANCED FORMULA
cerovite jr
certa plus
CERTAVITE SENIOR/ANTIOXIDANT
NUTRIENTS
certavite/antioxidants
CERVARIX
cetirizine hcl
cetirizine hcl allergy childrens
cetirizine hcl childrens allergy
cetirizine hcl hives relief childrens
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHEMET
chewable antacid
chewable vite childrens
chewable vite with iron/childrens
childrens acetaminophen
childrens allergy
childrens apap
childrens aspirin
childrens aspirin low strength
childrens chewable vitamin
childrens chewable vitamins
childrens chewable vitamins/iron
childrens loratadine
childrens mucus relief expectorant
childrens non-aspirin
Page #
19
19
19
19
19
19
19
19
73
22
93
93
93
93
93
93
19
57
23
58
93
93
93
94
94
75
80
80
80
80
16
16
16
86
59
94
94
11
80
11
13
13
94
94
94
80
84
11
107
Drug Name
childrens silapap
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpromazine hcl
chlorthalidone
chlorzoxazone
cholestyramine light
chorionic gonadotropin
CHROMIUM CHLORIDE
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
cimetidine
cimetidine hcl
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
CITRACAL + D3 MAXIMUM
CITRACAL MAXIMUM
CITRACAL/VITAMIN D
CITRUCEL
CITRUCEL FIBER LAXATIVE
citrus calcium +d
citrus calcium/vitamin d
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
clearlax
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
CLIMARA PRO
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
Page #
11
17
26
56
56
36
53
53
38
54
85
54
68
88
28
28
40
48
61
61
73
79
21
21
21
32
25
88
88
88
62
62
88
88
31
19
57
20
20
62
18
18
69
18
18
18
18
18
57
Drug Name
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clobetasol propionate
clobetasol propionate e
clodan
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole anti-fungal
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
COLACE
COLACE CLEAR
colchicine
COLCRYS
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
compete
COMPLERA
complete
complete allergy medicine
COMPOUND W
compro
constulose
cortisone acetate
Page #
88
88
88
88
88
88
88
89
89
89
89
89
89
89
89
89
67
67
67
31
26
22
22
49
49
48
43
28
28
57
40
40
36
62
62
29
29
54
18
77
82
34
94
41
94
80
57
38
62
67
108
Drug Name
COSMEGEN
COTELLIC
cough control dm
cough syrup
COUMADIN
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cvs calcium
cvs calcium 600 + d/minerals
cvs calcium 600+d
cvs calcium carbonate
cvs childrens chewable multivitamin/iron
cvs daily multiple
cvs daily multiple for men
cvs daily multiple for women
cvs hair skin & nails/an tioxidants
cvs iron
cvs oyster shell calcium w/ vit d
cvs spectravite advanced formula
cvs stool softener
cvs stress formula/zinc
cyanocobalamin
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYRAMZA
CYSTADANE
CYSTAGON
CYSTARAN
cytarabine aqueous
CYTOMEL
dacarbazine
DACOGEN
daily multiple vitamin
daily multiple vitamin/iron
daily multiple vitamins
daily multiple vitamins w/iron
daily multiple vitamins/iron
daily multiple vitamins/minerals
daily multi-vitamins + iron
Page #
32
32
84
84
47
58
42
59
78
83
69
18
57
89
101
101
89
94
94
94
94
94
89
89
94
62
94
94
69
86
30
44
73
73
80
36
58
58
78
31
72
30
32
94
94
94
94
94
94
94
Drug Name
daily value multivitamin
daily vitamin
daily vitamin formula
daily vitamin formula+ir on
daily vitamin formula+iron
daily vitamin formula+minerals
daily vitamins
daily vite
daily-vite
daily-vite/iron/beta-carotene
DALIRESP
danazol
dantrolene sodium
DAPSONE
DAPTACEL
daptomycin
DARAPRIM
darifenacin hydrobromide er
DARZALEX
daunorubicin hcl
deblitane
decitabine
deep sea nasal spray
DEKAS ESSENTIAL
delyla
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
dermafungal
DESCOVY
desenex shake powder
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
DEX4 FAST ACTING GLUCOSE
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexrazoxane
dextroamphetamine sulfate
dextromethorphan/guaifenesin
DEXTROSE 10%/NACL 0.45%
Page #
94
95
94
95
95
95
95
95
95
95
83
69
40
30
75
18
36
66
36
32
71
32
84
95
69
75
21
52
43
86
69
67
71
28
42
28
26
68
69
67
67
25
46
67
67
78
32
55
84
89
109
Drug Name
dextrose 10%
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
diabetic siltussin das-na
diabetic siltussin-dm
diabetic siltussin-dm maximum strength
dialyvite 800
diazepam
diazepam
diazepam intensol
dibucaine
diclofenac potassium
diclofenac sodium
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
diltiazem cd
diltiazem hcl
diltiazem hcl er
dilt-xr
dimenhydrinate
dino-life
dino-life w extra c
DINO-LIFE W/IRON & ZINC
diocto
DIPENTUM
diphenhist
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disopyramide phosphate
Page #
89
89
89
89
89
89
89
89
89
89
84
84
84
95
22
43
43
57
13
57
78
13
13
20
59
42
13
52
52
29
23
23
23
52
52
52
51
26
95
95
95
59
76
80
80
59
75
48
50
Drug Name
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
DOCETAXEL
docqlace
doc-q-lax
docu
docusate calcium
docusate sodium
docusate sodium
docusate sodium & senna stimulant
laxative/stool softener
docusate sodium/senna
docusil
dofetilide
dok
dok plus
donepezil hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
double antibiotic
doxazosin
doxazosin mesylate
doxepin hcl
doxercalciferol
doxorubicin hcl
doxorubicin hcl liposome
doxy 100
doxycycline hyclate
doxycycline monohydrate
DRAMAMINE
dramamine less drowsy
driminate
DRISDOL
dronabinol
drospirenone/ethinyl estradiol
DROXIA
ducodyl
dulcolax stool softener
DULERA
duloxetine hcl
duofilm
duramorph
DUREZOL
dutasteride
DYRENIUM
e.e.s. 400
e.e.s. granules
Page #
16
22
22
22
32
32
62
62
59
62
59
62
62
62
62
50
62
62
24
79
79
18
66
66
26
76
32
32
21
21
21
26
26
26
95
27
70
31
62
62
80
25
57
15
78
66
53
20
20
110
Drug Name
ear wax removal drops
earwax treatment drops
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
easy-lax plus
econazole nitrate
econtra ez
ecpirin
ed-apap
EDURANT
EFFIENT
ELAPRASE
ELDEPRYL
ELELYSO
ELIDEL
ELIGARD
ELIPHOS
ELITEK
ELIXOPHYLLIN
ELLENCE
ELMIRON
EMCYT
EMEND
EMPLICITI
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
ENBREL SURECLICK
endocet
enema ready-to-use
ENFAMIL ENFALYTE
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
enteric coated aspirin
enulose
ENVARSUS XR
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
Page #
79
79
77
77
62
28
71
13
11
41
48
58
38
58
57
73
66
31
83
32
66
31
27
36
25
42
50
50
73
73
15
62
89
75
47
70
37
40
13
62
73
82
82
82
32
23
41
53
48
49
Drug Name
EPZICOM
eq complete chewable multivitamin
childrens
eq multivitamin gummies childrens
eql all day relief
eql calcium
EQL CALCIUM/VITAMIN D
eql childrens c
EQL CHILDRENS MULTIVITAMINS
eql childrens multivitamins/ron
eql folic acid
eql iron supplement therapy
eql one daily essential
eql one daily mens health formula
eql one daily womens
eql oyster shell calcium/vitamin d
ERBITUX
ergoloid mesylates
ERGOMAR
ERIVEDGE
e-r-o ear drops
e-r-o ear wax removal system
errin
ERWINAZE
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
erythromycin/benzoyl peroxide
ESBRIET
escitalopram oxalate
esomeprazole magnesium
esomeprazole sodium
essential one daily multivitamin
ESTRACE
estradiol
estradiol valerate
estropipate
ethambutol hcl
ethosuximide
ethynodiol diacetate/ethinyl estradiol
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
etoposide
EVISTA
Page #
42
95
95
13
89
89
95
95
95
95
89
95
95
95
89
36
24
29
34
79
79
71
32
20
20
20
20
20
20
20
57
84
25
65
65
101
70
70
70
70
30
22
70
76
13
13
34
34
72
111
Drug Name
EVOTAZ
exel comfort point insulin pen needles 31g x
8mm
exemestane
EXJADE
EX-LAX
extra action cough
extra strength pain relief
ezetimibe
FABRAZYME
fallback solo
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FANTASY LUBRICATED
FANTASY LUBRICATED/SPERMICIDE
FARESTON
FARXIGA
FARYDAK
FASLODEX
fast acting antacid plus anti-gas maximum
strength
FAZACLO
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenofibric acid
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
FEOSOL
fer-iron
ferosul
ferrex 150
FERRIPROX
FERRLECIT
ferro-bob
ferrous sulfate
ferrous sulfate
ferrousul
FETZIMA
FETZIMA TITRATION PACK
fever reducer childrens
feverall childrens
FEVERALL INFANTS
feverall junior strength
Page #
42
77
34
86
62
84
11
49
58
71
70
43
61
61
39
39
101
101
31
44
33
31
59
40
22
52
54
54
54
13
14
15
89
89
89
89
77
89
89
101
89
89
25
25
11
11
11
11
Drug Name
fiber laxative
fiber tabs
FIBERCON
fiber-lax
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
FLEET ENEMA
FLEET ENEMA SIX PACK
fleet laxative
flintstones complete
flintstones gummies plus omega-3 dha
flintstones plus extra c
flintstones/my first
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in nacl
flucytosine
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorometholone
fluorouracil
fluorouracil
fluoxetine hcl
fluphenazine decanoate
FLUPHENAZINE HCL
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvastatin
fluvastatin sodium er
fluvoxamine maleate
FOLIC ACID
FOLOTYN
FONDAPARINUX SODIUM
formula em
FORTAZ
FORTEO
fortical
fosinopril sodium
Page #
62
62
62
62
66
73
73
66
50
62
62
62
95
95
95
95
80
80
28
28
28
32
67
80
67
67
67
78
31
57
25
38
38
86
13
78
31
67
80
54
54
25
95
31
47
26
19
76
76
50
112
Drug Name
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC 6.9%
fruity chewables multivitamin
fruity chews
fruity chews/iron
FUNGOID TINCTURE
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
galantamine hydrobromide er
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
GATTEX
gavilyte-c
gavilyte-g
gavilyte-h
gavilyte-n/flavor pack
GAVISCON
GAVISCON EXTRA STRENGTH
GAVISCON EXTRA STRENGTH RELIEF
FORMULA
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate/0.9% sodium chloride
GENVOYA
GEODON
geri-mucil
gildess 1.5/30
GILENYA
GILOTRIF
glatopa
GLEOSTINE
glimepiride
glipizide
glipizide er
Page #
50
23
66
47
89
95
95
95
28
53
32
42
21
22
22
24
24
74
74
74
40
75
75
60
62
62
60
63
60
60
60
31
54
63
74
17
17
17
41
39
63
70
56
32
56
30
44
44
44
Drug Name
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLUCOSE
glutose 15
glyburide
glyburide micronized
glyburide/metformin hcl
GLYCERIN
glycerin
GLYCERIN ADULT
glycerin infants & children
glycolax
glycopyrrolate
gnp acid reducer
gnp adult aspirin low strength
gnp all day allergy
gnp all day allergy childrens
gnp all day allergy childrens
gnp all day pain relief
gnp allergy
gnp animal shapes
gnp animal shapes plus iron
gnp antacid
gnp antacid anti-gas
gnp antacid extra strength
gnp antacid maximum strength
gnp antacid ultra strength
gnp anti-diarrheal
gnp anti-nausea
gnp aspirin
gnp aspirin low dose
gnp athletes foot
gnp bacitracin zinc
gnp bisa-lax
gnp calcium
gnp calcium
gnp calcium 500 +d3
gnp calcium 500 +d3
gnp calcium 600 +d3
gnp calcium 600 +d3/minerals
gnp calcium citrate +d3
gnp calcium citrate+d3 maximum
gnp century
gnp century adults 50+ senior
gnp century ultimate womens complete
gnp childrens allergy
gnp childrens pain relief
gnp clearlax
gnp clotrimazole 3
Page #
44
46
46
46
46
45
44
45
101
77
63
63
63
59
61
13
80
101
81
13
81
96
95
60
60
60
60
60
60
26
13
13
28
18
63
101
90
101
89
90
101
90
90
96
96
96
81
11
63
28
113
Drug Name
gnp ear drops
gnp ear systems
gnp enema
gnp essential one daily
gnp fiber
gnp fiber therapy
gnp fiber-caps
gnp folic acid
GNP GLYCERIN
gnp glycerin
gnp glycerin adult
gnp glycerin infant
gnp healthy eyes
gnp healthy eyes supervision
gnp hydrocortisone
gnp hydrocortisone maximum strength
gnp hydrocortisone plus
gnp hydrocortisone/aloe
gnp hydro-lotion
gnp ibuprofen
gnp infants pain relief
gnp infants pain/fever
gnp iron
gnp laxative
gnp lice solution kit
gnp lice treatment
gnp loperamide hcl
gnp loratadine
gnp loratadine childrens
gnp masanti maximum strength
gnp masanti regular strength
gnp miconazole 3
gnp miconazole 3 combination pack
gnp miconazole 7
gnp milk of magnesia
gnp motion sickness relief
gnp nasal decongestant
gnp nasal moisturizing
gnp natural fiber
gnp natural vegetable
gnp nicotine mini lozenge
gnp nicotine polacrilex
gnp nicotine polacrilex mini
gnp one daily womens 50+ advanced
gnp pain & fever childrens
gnp pain relief
gnp pain relief extra strength
gnp pain reliever extra strength
gnp pediatric electrolyte
gnp senna plus
Page #
79
79
63
101
63
63
63
96
101
77
63
63
96
96
67
67
67
67
67
13
11
11
90
63
37
37
60
81
81
60
60
28
101
28
63
26
84
84
63
63
16
17
17
96
11
11
11
11
90
63
Drug Name
gnp senna-lax
gnp sleep aid
gnp stomach relief maximum strength
gnp stool softener
gnp stool softener extra strength
gnp stool softener/stimulant laxative
gnp terbinafine hydrochloride
gnp therapeutic-m
gnp tioconazole 1
gnp triple antibiotic
gnp tussin
gnp tussin dm
gnp tussin dm cough
gnp tussin dm max
gnp tussin dm max cough & chest
congestion
gnp wart remover
gnp zinc oxide
gnp zoochews gummies
goodsense all day allergy
goodsense aspirin
goodsense ibuprofen
goodsense pain & fever childrens
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guaifenesin
guaifenesin-dm
guanfacine er
guanfacine hcl
GUANIDINE HCL
gummi bear multivitamin/mineral
hair/skin/nails
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HARVONI
HAVRIX
healthy eyes
heartburn relief
h-e-b oral electrolyte solution
hemorrhoidal
heparin sodium
heparin sodium/d5w
hepatamine
Page #
63
81
60
63
63
63
28
96
28
18
84
84
84
84
101
57
57
96
81
13
13
11
11
11
27
48
28
28
84
84
55
49
30
96
96
32
67
38
38
38
41
75
96
61
90
57
47
47
90
114
Drug Name
HERCEPTIN
HETLIOZ
HEXALEN
HIBERIX
high potency calcium
hm acid reducer
hm acid reducer
hm all day allergy
hm allergy childrens
hm allergy complete childrens
hm allergy relief
hm allergy relief childrens
hm allgery multi symptom
hm antacid/antigas
hm antacid/antigas
hm anti-diarrheal
hm anti-nausea
hm antioxidant vitamins
hm artificial tears
hm aspirin
hm aspirin ec
hm aspirin ec low dose
hm bacitracin
hm calcium antacid
hm calcium antacid extra strength
hm calcium/vitamin d
hm cetirizine hcl childrens
hm cetirizine hcl childrens
hm clearlax
HM COMPLETE
hm complete 50+
hm double antibiotic
hm earwax removal aid
hm earwax removal kit
hm enema
hm famotidine
hm fiber
hm folic acid
HM GLUCOSE
HM HAIR/SKIN/NAILS
hm hydrocortisone plus
hm hydrocortisone/aloe maximum strength
hm ibuprofen
hm ibuprofen ib
hm iron
hm laxative
hm lice killing maximum strength
hm lice treatment
hm loperamide hcl
hm loratadine childrens
Page #
36
56
30
75
90
101
61
81
81
101
81
81
81
101
60
60
101
96
78
13
13
13
18
60
60
90
101
81
63
96
96
18
79
79
63
101
63
96
46
96
101
101
13
13
90
63
37
37
60
81
Drug Name
hm milk of magnesia
hm motion relief
hm motion sickness relief
hm naproxen sodium
hm nasal decongestant
hm nicotine transdermal system step 3
HM ONE DAILY WOMENS
hm pain & fever childrens
hm pain & fever infants
hm pain relief childrens
hm pain relief extra strength
hm pain reliever
hm pediatric electrolyte
hm povidone-iodine
hm saline nasal spray
hm senna-s
hm sleep aid
hm stomach relief
hm stomach relief maximumstrength
hm stool softener
hm stool softener maximum strength
hm triple antibiotic
hm triple antibiotic plus maximum strength
hm tussin adult
hm tussin adult cough & chest congestion
dm
HONEY BEARS
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
HUMULIN R U-500 KWIKPEN
hydralazine hcl
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
Page #
63
26
101
13
84
101
96
11
11
11
11
11
90
18
84
63
101
60
101
63
63
18
16
84
101
96
46
46
46
46
46
46
74
74
74
74
46
46
46
46
47
47
47
55
54
15
15
15
115
Drug Name
hydrocortisone
hydrocortisone butyrate
hydrocortisone maximum strength
hydrocortisone maximum strength plus 12
moisturizers
hydrocortisone valerate
hydrocortisone/acetic acid
hydrocortisone/aloe
hydromorphone hcl
hydroskin
HYDROXOCOBALAMIN
hydroxychloroquine sulfate
hydroxyprogesterone caproate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
ibandronate sodium
IBRANCE
ibu-200
ibuprofen
ICAPS PLUS
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide
ILARIS
imatinib mesylate
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMITREX STATDOSE REFILL
IMOVAX RABIES (H.D.C.V.)
INCRELEX
indapamide
indomethacin
indomethacin er
INFANRIX
infants pain relief
INFANTS SILAPAP
INFED
INFUVITE
INFUVITE ADULT
INFUVITE PEDIATRIC
INLYTA
INSTA-GLUCOSE
insupen ultrafin 31gx8mm
Page #
67
67
67
67
67
79
67
15
67
96
36
71
31
81
81
76
32
13
13
96
34
32
32
30
30
74
34
35
19
26
26
57
29
29
75
68
54
13
13
75
11
11
90
96
96
96
35
46
77
Drug Name
INTELENCE
INTRALIPID
INTRON A
INTRON A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA SUSTENNA
INVEGA TRINZA
INVIRASE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iophen dm-nr
iophen-nr
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
IRESSA
irinotecan
iron
iron
iron supplement
ISENTRESS
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
isoniazid
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTODAX
ISTODAX (OVERFILL)
itraconazole
ivermectin
i-vite
IXIARO
JAKAFI
jantoven
JANUVIA
JENTADUETO
JENTADUETO XR
JEVTANA
jolivette
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
Page #
41
77
41
41
70
55
19
39
39
42
90
90
84
84
75
82
82
49
49
35
32
101
90
90
41
90
90
30
55
55
55
55
17
32
32
28
36
96
75
35
47
45
45
45
32
71
70
70
70
70
116
Drug Name
junel fe 1/20
junel fe 24
JUXTAPID
KADCYLA
KALETRA
KALYDECO
KAOPECTATE STOOL SOFTENER
kao-tin
kao-tin
kariva
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelnor 1/35
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
KEYTRUDA
kids vitamins
kids vitamins plus extra c
kids vitamins plus iron
kimidess
KIMONO LUBRICATED
KIMONO MICRO THIN
KIMONO MICRO THIN PLUS
SPERMICIDE LUBRICATED
KIMONO SENSATION LUBRICATED
KIMONO SENSATION PLUS
SPERMICIDE LUBRICATED
KINERET
KINRIX
kionex
KISQALI
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
kls fiber-tabs
kls natural psyllium fiber
KOMBIGLYZE XR
konsyl
konsyl fiber
Page #
70
70
54
36
42
83
63
60
63
70
90
90
90
90
90
90
70
56
21
28
13
13
13
78
36
96
96
96
70
101
101
102
102
102
74
75
86
32
90
90
90
90
90
63
63
45
63
63
Drug Name
KONSYL-D
KORLYM
kp aspirin
kp benzoyl peroxide
kp ferrous sulfate
kp mens daily formula
kp miconazole nitrate
ks stool softener
KUVAN
KYNAMRO
KYPROLIS
labetalol hcl
lactated ringers irrigation
lactated ringers viaflex
lactulose
LAMISIL AT
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
lamotrigine odt
LANOXIN
lansoprazole
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
LARTRUVO
latanoprost
LATUDA
laxative
LAZANDA
leena
leflunomide
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol
levalbuterol hcl
levalbuterol tartrate hfa
LEVEMIR
Page #
63
69
13
57
90
96
102
63
58
55
34
51
77
90
63
28
41
42
42
22
22
52
65
47
47
70
32
78
39
64
15
70
74
35
35
35
35
35
35
70
83
34
32
30
48
73
82
82
82
47
117
Drug Name
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levoleucovorin calcium
levonorgestrel
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium
levoxyl
LEXIVA
lice killing maximum strength
lidocaine
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
LINCOCIN
lincomycin hcl
linezolid
liothyronine sodium
liquitears
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
lithium carbonate er
LITHOBID
little animals plus iron
little noses saline
LONSURF
loperamide hcl
lopinavir/ritonavir
loratadine
loratadine childrens
loratadine hives relief
lorazepam
LORAZEPAM INTENSOL
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
lovastatin
low-ogestrel
loxapine succinate
Page #
47
21
79
77
81
21
21
33
71
70
70
14
72
72
43
37
16
57
16
16
16
16
18
18
18
72
78
50
50
77
44
44
44
44
96
84
31
60
43
81
81
81
44
44
49
49
78
54
70
38
Drug Name
lubrifresh p.m.
LUMIGAN
LUMIZYME
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT-PED (1-MONTH)
lutera
LYNPARZA
LYRICA
LYSODREN
lyza
M.V.I. ADULT
maalox max
mag-al plus
mag-al plus xs
magnesium
magnesium oxide
magnesium sulfate
malathion
mapap
mapap acetaminophen extrastrength
mapap childrens
mapap extra strength
maprotiline hcl
marlissa
MARPLAN
MATULANE
matzim la
MAXX LUBRICATED
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefloquine hcl
mega multiple w/chelated minerals
megestrol acetate
meijer ferrous sulfate
MEKINIST
meloxicam
melphalan hydrochloride
memantine hcl
memantine hcl titration pak
memantine hydrochloride
MENACTRA
MENEST
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
MEPHYTON
meprobamate
Page #
78
78
58
73
73
73
73
70
33
22
72
71
97
60
60
60
60
60
90
37
12
11
11
12
24
70
25
30
52
102
26
13
71
36
97
71
90
35
13
30
24
24
24
75
70
75
75
75
97
43
118
Drug Name
MEPRON
mercaptopurine
meropenem
mesalamine
mesalamine dr
mesna
MESNEX
MESTINON
METADATE CD
metamucil
metamucil smooth texture
metamucil smooth texture sugar free
metaproterenol sulfate
metformin hcl
metformin hcl er
METHADONE HCL
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
methyldopate hcl
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
MI-ACID
mi-acid maximum strength
Page #
37
31
19
76
76
33
33
30
55
64
64
64
82
45
45
14
79
18
73
69
86
74
74
57
59
54
49
49
49
77
56
56
56
67
67
67
67
79
60
54
51
51
51
18
18
18
50
76
60
60
Drug Name
miconazole
miconazole 3
miconazole 3 combo pack
miconazole 7
miconazole nitrate
micro guard
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
miglitol
milk of magnesia
miniprin low dose
minocycline hcl
minoxidil
mintox
mintox maximum strength
mintox plus
MIRALAX
mirtazapine
mirtazapine odt
misoprostol
mitomycin
mitoxantrone hcl
M-M-R II
modafinil
molindone hydrochloride
mometasone furoate
mometasone furoate
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
motion sickness
motion-time
motrin ib
moxifloxacin hcl
MOZOBIL
mucinex chest congestion childrens
MUCINEX DM
mucus relief childrens
MULTAQ
multi vitamin daily
multi vitamin mens
multi-day vitamins
multi-delyn
Page #
28
28
28
28
28
28
70
70
70
70
49
29
45
64
14
21
55
60
60
60
64
25
24
65
33
33
75
86
40
67
80
77
70
82
15
15
27
27
14
21
90
84
84
84
50
97
97
97
97
119
Drug Name
multilex
multilex-t&m
MULTI-MINERALS
multiple vitamin
multiple vitamin/minerals/no iron
multiple vitamins
multiple vitamins essential
multiple vitamins plain
multiple vitamins/iron
multi-symptom allergy
multitrace-4 concentrate
multivital platinum
multi-vitamin
multi-vitamin daily
multivitamin gummies childrens
multi-vitamin/minerals
multivitamins
multi-vitamins
mupirocin
MURO 128
MUSTARGEN
my way
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
mycophenolic acid dr
MYRBETRIQ
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
naftifine hcl
naftifine hydrochloride
NAFTIN
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
nasal decongestant
nasal moisturizing spray
NATACYN
nateglinide
NATPARA
NATRUL-MEGA-75
natural balance tears
Page #
97
97
90
97
97
97
97
97
97
81
90
97
97
97
97
97
97
97
18
78
30
72
28
30
74
74
66
14
51
51
20
28
28
28
58
15
16
16
78
14
14
14
29
84
85
28
45
77
97
78
Drug Name
natural fiber
natural fiber therapy
natures tears
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
one
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
NEOSPORIN ORIGINAL
NEPHRAMINE
nephrocaps
NEPHRO-VITE
NEUPOGEN
NEUPRO
nevirapine
nevirapine er
NEXAVAR
next choice one dose
niacin er
niacor
nicardipine hcl
NICODERM CQ
nicorelief
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine
nicotine mini lozenge
nicotine polacrilex
NICOTINE TRANSDERMAL SYSTEM
NICOTROL NS
nifedical xl
nifedipine er
NILANDRON
nilutamide
NINLARO
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate/macrocrystals
Page #
64
64
78
37
70
70
70
70
25
17
78
17
18
78
78
79
18
79
18
90
98
98
48
37
41
42
35
72
55
55
52
17
17
17
17
17
17
17
17
17
17
52
52
31
31
33
55
18
18
120
Drug Name
nitroglycerin
nitroglycerin transdermal
NITROSTAT
NO IRON MULTIPLE
VITAMIN/MINERALS
non-aspirin extra strength
nora-be
NORDITROPIN FLEXPRO
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
NORTHERA
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
novofine 32gx6mm
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
NOXAFIL
NUEDEXTA
NULOJIX
NULYTELY/FLAVOR PACKS
NUPLAZID
nutrilipid
NUTRISOURCE FIBER
nyamyc
nystatin
nystatin/triamcinolone
nystop
OCEAN NASAL SPRAY
octreotide acetate
ocutabs
ocuvite/lutein
ODEFSEY
ODOMZO
OFEV
Page #
55
55
55
98
12
72
68
72
72
70
70
72
90
90
90
53
70
71
71
26
43
77
47
47
47
47
47
47
47
47
29
56
74
64
39
77
64
29
29
29
29
85
73
98
98
42
33
85
Drug Name
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olmesartan medoxomil
olmesartan medoxomil/hydrochlorothiazide
olopatadine hcl
olopatadine hcl
omega-3-acid ethyl esters
omeprazole
once daily
once daily/iron
ONCOVITE
ondansetron hcl
ondansetron odt
one daily
one daily complete
one daily mens
one daily multivitamin/iron
one daily plus minerals
one daily/minerals
ONE-A-DAY ESSENTIAL
ONE-A-DAY MAXIMUM FORMULA
one-a-day teen advantage for her
ONE-A-DAY TEEN ADVANTAGE FOR
HIM
ONE-A-DAY WOMENS FORMULA
one-daily multi vitamins
ONFI
ONGLYZA
opcicon one-step
OPDIVO
OPSUMIT
oralyte
ORENCIA
ORENCIA CLICKJECT
ORENITRAM
ORKAMBI
orphenadrine citrate
orphenadrine citrate er
os-cal calcium + d3
oseltamivir phosphate
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
Page #
21
71
39
39
49
49
78
81
55
65
98
98
98
27
27
98
98
98
98
98
98
98
98
98
98
98
98
22
45
72
36
84
90
74
74
84
83
86
86
90
43
20
33
69
14
23
23
66
66
121
Drug Name
oxycodone hcl
oxycodone/acetaminophen
oysco 500
oysco 500+d
oysco d
oyst-cal-d 500
oyster calcium
oyster shell calcium
oyster shell calcium
oyster shell calcium + vitamin d
oyster shell calcium 500
oyster shell calcium 500 + d
oyster shell calcium 500/d
oyster shell calcium plusvitamin d
oyster shell calcium/d
oyster shell calcium/d3
oyster shell calcium/vitamin d
oyster shell calcium+d
oystercal
pacerone
paclitaxel
pain & fever
pain & fever childrens
pain & fever extra strength
pain & fever infants
pain relief
pain relief childrens
pain relief extra strength
pain reliever extra strength
paliperidone er
PAMIDRONATE DISODIUM
PANCREAZE
PANRETIN
pantoprazole sodium
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PASER
PATANOL
PAXIL
PEDIA-LAX
PEDIALYTE
PEDIALYTE ADVANCED CARE
PEDIALYTE FREEZER POPS
PEDIALYTE SINGLES
PEDIARIX
pediatric electrolyte
pedi-boro soak paks
PEDVAX HIB
peg 3350
Page #
15
15
90
90
91
91
91
102
91
91
91
91
91
91
91
91
91
91
91
50
33
12
12
12
12
12
12
12
12
39
76
58
36
65
17
25
25
30
78
26
64
91
91
91
91
75
91
58
75
64
Drug Name
peg3350
peg-3350/nacl/na bicarbonate/kcl
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEG-INTRON REDIPEN
penicillin g potassium
PENICILLIN G POTASSIUM IN ISOOSMOTIC DEXTROSE
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
PENTAM 300
pentoxifylline er
peptic relief
PEPTO-BISMOL
PEPTO-BISMOL MAX STRENGTH
perdiem overnight relief
peri-colace
periguard
periogard
PERJETA
permethrin
permethrin lice treatment
perphenazine
perphenazine/amitriptyline
pharbedryl
pharbetol
pharbetol extra strength
phenadoz
phenelzine sulfate
phenobarbital
PHENYTEK
phenytoin
phenytoin sodium
phenytoin sodium extended
PHILLIPS
PHOS-NAK POWDER CONCENTRATE
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
phytonadione
PICATO
pilocarpine hcl
pilocarpine hcl
pilocarpine hydrochloride
pimozide
pindolol
pink bismuth
Page #
64
64
23
41
41
41
41
20
20
20
20
20
37
53
60
60
60
64
64
58
57
36
37
37
38
26
81
12
12
27
25
22
23
23
23
23
60
91
79
77
77
98
58
57
79
57
38
51
60
122
Drug Name
pin-x
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin/tazobactam
piroxicam
PLAN B ONE-STEP
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
PLENAMINE
podofilox
poly vitamin
polyethylene glycol 3350
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
polyvitamin/iron
POMALYST
portia-28
potassium chloride
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride er
potassium chloride/dextrose
POTASSIUM
CHLORIDE/DEXTROSE/LACTATED
RINGERS
POTASSIUM CHLORIDE/SODIUM
CHLORIDE
potassium citrate er
POTIGA
povidone-iodine
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMIUM CONDOMS LUBRICATED
PREMPHASE
PREMPRO
Page #
36
45
45
45
20
14
72
91
91
91
91
58
98
64
18
78
98
31
71
92
91
91
91
91
91
91
92
92
22
18
47
37
54
49
78
78
68
78
68
78
68
68
71
92
77
71
71
Drug Name
preparation h hydrocortisone
prevalite
previfem
PREZCOBIX
PREZISTA
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRISTIQ
PROAIR HFA
PROAIR RESPICLICK
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
procto-med hc
procto-pak
proctosol hc
proctozone-hc
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
promethegan
PROMETRIUM
pronutrients calcium+d3
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSHIELD PLUS SKIN PROTECTANT
prosight
PROSOL
protriptyline hcl
provil
pseudoephedrine hcl
PULMOZYME
PURIXAN
px antacid maximum strength
Page #
68
55
71
43
43
30
37
22
26
82
83
29
29
50
92
38
38
38
48
68
68
68
68
72
46
74
85
33
76
48
27
85
27
72
92
50
51
51
51
73
75
58
98
92
26
14
85
83
31
60
123
Drug Name
px calcium antacid regular strength
px fiber
px saline nasal spray
pyrazinamide
pyridostigmine bromide
pyridostigmine bromide er
pyridoxine hcl
qc 3 day vaginal cream
qc acid controller
qc all day allergy
qc antacid
qc antacid/anti-gas
qc anti-diarrheal
qc aspirin
qc athletes foot
qc calcium fast dissolution
qc childrens aspirin
qc clotrimazole
qc daily multivitamins/iron
qc hydrocortisone
qc hydrocortisone maximumstrength
qc ibuprofen ib
qc loratadine allergy relief
qc milk of magnesia
qc naproxen sodium
qc natural vegetable
qc natural vegetable laxative
qc non-aspirin childrens
qc non-aspirin extra strength
qc povidone iodine
qc stool softener plus laxative
qc suphedrine
qc therin-m
q-dryl
q-pap
q-pap childrens
q-pap extra strength
q-pap infants
q-tussin
q-tussin dm
QUADRACEL
quasense
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinine sulfate
Page #
60
64
85
30
30
30
98
29
61
81
102
102
61
14
102
92
14
29
98
68
68
14
81
64
14
64
64
12
12
18
64
85
98
81
12
12
12
12
85
85
75
71
22
39
50
50
51
51
51
37
Drug Name
ra calcium 600
ra calcium citrate plus vitamin d
ra central-vite
RA CENTRAL-VITE UNDER 50
WOMENS
ra fiber
ra fiber laxative
ra folic acid
ra glucose
ra hi cal
ra hi-cal plus vitamin d
ra ibuprofen
ra iron
ra motion sickness relief
ra naproxen sodium
ra one daily energy formula
ra one daily essential
ra one daily multi-vitamin
ra one daily multi-vitamin plus iron
ra oyster shell calcium
RA OYSTER SHELL
CALCIUM/VITAMIN D
ra pediatric electrolyte
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine 75
ranitidine hcl
RAPAMUNE
rasagiline mesylate
RAVICTI
REBETOL
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB
REESES PINWORM MEDICINE
refresh lacri-lube
reguloid
rehydralyte
RELENZA DISKHALER
RELISTOR
remedy antifungal
REMICADE
RENACIDIN
renal vitamin
RENVELA
repaglinide
Page #
92
92
98
98
64
64
98
46
92
92
14
92
27
14
98
99
99
99
102
92
92
75
72
50
53
61
61
74
38
58
41
56
56
56
56
75
36
78
64
92
43
61
29
74
66
99
66
45
124
Drug Name
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
RESCRIPTOR
reserpine
RESTASIS
RETROVIR IV INFUSION
REVLIMID
REXULTI
REYATAZ
ribasphere
ribasphere ribapak
ribavirin
RID
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
RISACAL-D
risedronate sodium
risedronate sodium dr
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rivastigmine transdermal system
rizatriptan benzoate
rizatriptan benzoate odt
robafen
robafen dm
robafen dm cough clear
robitussin peak cold cough+ chest
congestion dm
ROBITUSSIN PEAK COLD DM
ropinirole hcl
rosuvastatin calcium
ROTARIX
ROTATEQ
ROZEREM
RUBRACA
rulox
SABRIL
SAIZEN
SAIZEN CLICK.EASY
saline mist
saline nasal mist
Page #
53
53
53
42
49
78
42
31
39
43
41
41
41
37
30
30
30
56
43
92
77
102
76
76
39
39
39
36
24
24
29
30
85
85
85
85
85
37
54
75
75
86
33
61
22
68
68
85
85
Drug Name
saline nasal spray
sani-supp adult
sani-supp pediatric
SANTYL
SAPHRIS
SAVELLA
SAVELLA TITRATION PACK
sb allergy
sb antacid
sb antacid
sb antacid anti-gas
sb antacid anti-gas double strength
sb antacid extra strength
sb antacid/antigas
sb anti-diarrhea
sb aspirin
sb bisacodyl laxative ec
sb bismuth
sb bismuth maximum strength
sb childrens aspirin
sb cough control
sb cough control dm
sb cough control dm
sb docusate sodium
sb ear wax remover
sb fiber laxative
sb hydrocortisone
sb hydrocortisone maximum strength
sb ibuprofen
sb laxative
sb lice killing maximum strength
sb lice killing shampoo maximum strength
sb loratadine
sb loratadine allergy relief
sb low dose asa ec
sb milk of magnesia
sb motion sickness
sb naproxen sodium
sb non-aspirin
sb non-aspirin extra strength
sb oyster shell calcium
sb pain reliever childrens
sb pediatric electrolyte
sb polyethylene glycol 3 350
sb povidone-iodine
sb saline nose
sb senna-lax
sb triple antibiotic
sea soft nasal mist
secura antifungal
Page #
85
64
64
58
39
56
56
81
102
61
102
61
61
102
61
14
64
61
61
14
85
102
85
64
79
64
68
68
14
64
37
37
81
81
14
64
27
14
12
12
92
12
92
64
18
85
64
18
85
29
125
Drug Name
selegiline hcl
selenium sulfide
SELZENTRY
senexon
senexon-s
SENNA
senna
senna lax
senna laxative
senna plus
senna s
sennalax-s
senna-plus
senna-s
senna-tabs
senna-time
senna-time s
senno
sennosides/docusate sodium
SENOKOT
SENOKOT S
SENSIPAR
SEREVENT DISKUS
SEROSTIM
sertraline hcl
sharobel
SIGNIFOR
silace
siladryl allergy
sildenafil
siltussin dm das
siltussin sa
siltussin-dm
silver sulfadiazine
SIMULECT
simvastatin
sirolimus
SIRTURO
sleep aid
sm acid reducer
sm all day allergy
sm all day allergy childrens
sm all day pain relief
sm allergy relief
sm allergy relief childrens
sm allergy relief loratadine
sm antacid advanced maxi mum strength
sm antibiotic
sm antifungal clotrimazole
sm antifungal miconazole
Page #
38
58
42
64
64
61
65
64
64
64
64
65
64
64
64
65
65
65
65
65
65
72
83
69
26
72
73
61
81
84
85
85
85
18
74
54
74
30
81
62
81
102
14
81
81
81
61
19
29
29
Drug Name
sm aspirin
sm aspirin adult low strength
sm aspirin adult low strength
sm aspirin enteric coated
SM CALAMINE
sm calcium antacid
sm calcium/vitamin d
sm calcium/vitamin d
sm childrens aspirin
sm childrens loratadine
sm complete
sm complete advanced formula
sm docusate calcium
sm double antibiotic
sm fiber
sm folic acid
sm gentle laxative
sm hair/skin/nails
sm ibuprofen
sm ibuprofen ib
sm iron
sm lice treatment
sm loratadine
sm miconazole 3
sm milk of magnesia
sm motion sickness relief
sm multiple vitamins essential
sm multiple vitamins/iron
sm naproxen sodium
sm nasal decongestant maximum strength
sm natural laxative plus stool softener
sm nicotine
SM ONE DAILY WOMENS
sm opti-vitamins
sm oyster shell calcium/vitamin d3
sm pain & fever childrens
sm pain & fever infants
sm pain reliever
sm pain reliever childrens
sm pain reliever extra strength
sm stool softener
sm stool softener
sm stool softener plus laxative
sm triple antibiotic
sm tussin
sm tussin dm
sm tussin dm cough/chest congestion
sodium bicarbonate
sodium chloride
sodium chloride
Page #
14
102
14
14
58
61
102
92
14
81
99
99
65
19
65
99
65
99
14
14
92
37
81
29
65
27
99
99
14
85
65
17
99
99
92
12
12
12
12
12
61
65
65
19
85
85
85
61
78
85
126
Drug Name
sodium chloride
sodium chloride 0.45%
sodium chloride 0.9%
sodium chloride opthalmicsolution
sodium citrate/citric acid
sodium ferric gluconate complex/sucrose
sodium fluoride
SODIUM LACTATE
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
sof-lax
SOLTAMOX
soluble fiber
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
soothe
SORIATANE
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28
SPRITAM
SPRYCEL
sps
sronyx
ssd
st joseph aspirin
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
stavudine
sterile water irrigation
STIMATE
stimulant laxative
STIVARGA
stomach relief
stomach relief maximum strength
stool softener
Page #
92
92
92
78
92
92
92
86
58
86
21
65
31
65
68
68
73
73
61
58
51
51
51
41
82
82
53
53
29
71
22
35
86
71
19
14
37
37
37
38
38
38
42
77
69
65
35
61
61
65
Drug Name
stool softener extra strength
STRATTERA
streptomycin sulfate
stress 500 b-complex/zinc
stress b/zinc
stress b-complex/vitamin c/zinc
stress formula
stress formula/zinc
stress plus zinc
STRIBILD
SUBOXONE
SUCRAID
sucralfate
sudogest
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulindac
sumatriptan succinate
sumatriptan succinate refill
super calcium
super dec b-100
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
surgilube
SUSTIVA
SUTENT
SWEEN CREAM
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
systane contacts soothing drops
tab-a-vite
tab-a-vite maximum
tab-a-vite w/beta carotene
tab-a-vite/iron
TABLOID
Page #
65
56
17
99
99
99
99
99
99
42
16
59
65
85
21
78
21
21
21
76
14
30
30
93
99
19
77
77
66
42
35
58
33
36
80
45
46
74
73
19
33
72
86
78
99
99
99
99
31
127
Drug Name
tacrolimus
tacrolimus
tactinal
tactinal extra strength
TAFINLAR
TAGRISSO
take action
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TASIGNA
TAZORAC
taztia xt
tears naturale ii
tears pure
TECENTRIQ
TECFIDERA
TECFIDERA STARTER PACK
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
temazepam
tencon
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
testosterone cypionate
testosterone enanthate
TETANUS/DIPHTHERIA TOXOIDSADSORBED
tetrabenazine
tgt antacid
tgt saline nasal spray
tgt wart remover
th antacid ultra strength
th calcium
th calcium 600/vitamin d
th calcium citrate/vitamin d
th childrens chewable multi vitamins
th daily multiple vitamins
Page #
58
74
12
12
35
33
72
16
43
31
66
35
36
35
58
52
78
78
36
56
56
19
23
23
53
53
49
50
50
86
12
75
66
29
83
29
69
69
75
56
61
85
58
61
93
93
93
99
99
Drug Name
th iron
th natural fiber
th oyster shell calcium/vitamin d
th premium daily multiple
th theradex-m
th vision vitamins/lutein
THALOMID
THEO-24
theophylline
theophylline cr
theophylline er
thera
THERA M PLUS
THERA/BETA-CAROTENE
theraflu warming relief severe cold daytime
THERA-M
therapeutic
therapeutic liquid
THERASEAL HAND PROTECTION
therems
THEREMS-M
thiamine hcl
thioridazine hcl
THIOTEPA
thiothixene
thrive
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
tiagabine hydrochloride
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
TIVICAY
tizanidine hcl
TOBI PODHALER
TOBRADEX
tobramycin
tobramycin sulfate
tobramycin/dexamethasone
tolbutamide
tolcapone
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
topiramate
Page #
93
65
93
99
99
99
31
83
83
83
83
100
99
100
85
100
100
100
58
100
100
100
38
30
38
17
74
72
72
72
72
72
22
51
79
79
37
41
40
83
78
83
17
79
46
37
14
66
66
23
128
Drug Name
topiramate er
toposar
topotecan hcl
TORISEL
torsemide
total fiber
totalday multiple
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
travel sickness
trazodone hcl
TREANDA
TRECATOR
TRELSTAR MIXJECT
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
triazolam
triderm
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-lo-estarylla
tri-lo-sprintec
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
TRINTELLIX
triple antibiotic
triple antibiotic plus
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
tri-vitamin
trivora-28
TRIXAICIN
Page #
23
34
34
74
53
65
100
93
84
46
16
16
50
48
27
25
93
27
25
30
30
73
36
58
68
80
57
53
44
68
38
43
37
71
71
65
27
19
26
71
25
19
19
71
33
71
42
100
71
58
Drug Name
trixaicin hp
TROKENDI XR
TROPHAMINE
TRUMENBA
TRUSTEX LUBRICATED
TRUSTEX LUBRICATED EXTRA
LARGE
TRUSTEX LUBRICATED EXTRA
STRENGTH
TRUSTEX
LUBRICATED/RIBBED/STUDDED
TRUSTEX LUBRICATED/SPERMICIDE
TRUSTEX LUBRICATED/SPERMICIDE
EXTRA LARGE
TRUSTEX LUBRICATED/SPERMICIDE
EXTRA STRENGTH
TRUSTEX NON-LUBRICATED
TRUSTEX WITH NONOXYNOL9/RIBBED/STUDDED
TRUSTEX/RIA LUBRICATED
TRUSTEX/RIA LUBRICATED
SPERMICIDE
TRUSTEX/RIA
LUBRICATED/SPERMICIDE
TRUSTEX/RIA NON-LUBRICATED
TRUVADA
TUMS
TUMS
TUMS E-X 750
tums freshers
TUMS KIDS
TUMS SMOOTHIES
TUMS SMOOTHIES
TUMS ULTRA 1000
tusnel diabetic
tussin chest congestion
tussin dm
tussin dm max
tussin mucus + chest congestion
TWINRIX
TYBOST
TYGACIL
TYKERB
TYLENOL INFANTS PAIN+FEVER
TYPHIM VI
TYSABRI
TYVASO
TYZEKA
UCERIS
ulticare short pen needles 31gx8mm
Page #
58
23
93
75
102
102
102
102
102
102
102
102
102
102
102
102
102
42
102
61
61
61
61
102
61
61
85
85
85
85
102
75
42
19
35
12
75
56
84
41
68
77
129
Drug Name
ulticare short pen needles ulti-fine iv
UNICOMPLEX-M
unithroid
UPTRAVI
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
vagistat-3
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir
valganciclovir hydrochlorde
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
vandazole
VAQTA
VARIVAX
VARIZIG
VECTIBIX
VELCADE
velivet
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
venlafaxine hcl er
VENOFER
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
VICTOZA
VIDEX PEDIATRIC
vienva
VIIBRYD
VIIBRYD STARTER PACK
VIMPAT
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAZOLE
VIREAD
Page #
77
100
72
84
93
93
93
61
58
29
43
31
40
40
40
22
22
50
50
19
19
75
75
75
36
33
71
33
33
26
26
93
83
52
52
52
58
40
46
42
71
26
26
24
33
33
33
43
41
42
Drug Name
vita-bee/c
VITALETS
VITALETS CHILDRENS
vitamin a & d
vitamin d
VITAMIN K1
vitamins & minerals
vitamins for hair
VITEKTA
VOLTAREN
voriconazole
VOTRIENT
VP-PNV-DHA
VPRIV
VRAYLAR
wal-dryl allergy
wal-profen
warfarin sodium
WELCHOL
womans stool softener
WOMENS MULTI VITAMIN &
MINERAL FORMULA
womens one daily
XALKORI
XARELTO
XARELTO STARTER PACK
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX HFA
XTANDI
xulane
XYREM
YERVOY
YF-VAX
YONDELIS
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZANTAC
ZAVESCA
zeasorb-af
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
ZERIT
ZETIA
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Drug Name
ZIAGEN
zidovudine
zinc oxide
zinc sulfate
ZINC TRACE METAL
ZINECARD
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
ZUBSOLV
ZYDELIG
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYRTEC ALLERGY
ZYRTEC CHILDRENS ALLERGY
ZYTIGA
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Multi-language Interpreter Services
English: ATTENTION: If you speak English, language assistance services, free of
charge, are available to you. Call 1-877-941-0482 (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de
asistencia lingüística. Llame al 1-877-941-0482 (TTY: 711).
Polish: UWAGA: JeSeli mówisz po polsku, moSesz skorzysta1 z bezp;atnej pomocy
jezykowej. ZadzwoG pod numer 1-877-941-0482 (TTY: 711).
Chinese: -+6,;(3:#)5!/(81%94=&'.$7<0* "1-877-94104822TTY6711)!
Korean: 2@D *B(" C:,0+ %4! 1( =F &<G" '7; /:,5 A 3?>#E
1-877-941-0482 (TTY: 711) -8; .9) 260$E
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-941-0482 (TTY:
711).
Arabic:
IG<1 L7#! .D5(EK51 CK <:!"9# )2"@JK! ,.H53EK! &5F.4 D*: A)@JK! <B+! 6.89# %0B !+- :)="8JF
.(711 :I?/K!$ I7K! ;#5' IG>) 1-877-941-0482
Russian: `CWEbCW\: \T]a &< %X&XUaF" Z) UDTT^X[ €ˆ<^", FX &)[ #XTFDVZ<
'"TV])FZ<" DT]D%a V"U"&X#). Y&XZaF" 1-877-941-0482 (TTY: 711).
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B $'"# +)!"' -), ") %<::1B 4 *';' /-'& /.@'7 "('$' ('60
Gujarati: ,A
29!5> ?. . 8)< 4$) 1-877-941-0482 (TTY: 711).
Urdu:
B†z5 A!5 { B†L ‰!†|q4 B†‡ }I‡ }!‡48 u5 44‡ u5 ƒ!„w @5 J6 @| ?B†L |$@„ @4z> J6 z/> :z>4z„8
1-877-941-0482 (TTY: 711).
Vietnamese: CHÚ Ý: NKu b(n nói TiKng Vi*t, có các dkch v‚ hH tr… ngôn ngR mi+n
phí dành cho b(n. Gfi s_ 1-877-941-0482 (TTY: 711).
Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di
assistenza linguistica gratuiti. Chiamare il numero 1-877-941-0482 (TTY: 711).
H0281_MLI17R_Accepted_09022016
Hindi: ?3<, /( : 3"/ #* "7!/; 6>01: 7% 1> #*$: 90' 4)
@ 1 4( 5<+< 87<31< 8:.<'! B*0&- 7%=
1-877-941-0482 (TTY: 711) *2 $A0 $2( =
French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous
sont proposés gratuitement. Appelez le 1-877-941-0482 (ATS: 711).
Greek: xvyQyP: =r s-tOch htt0r-,O, dc0 j-O.hd: dml 3n7d,orcm- i90nhd7hl
2tMdd-,:l i9odc:n-p0l, o- o9o7hl 9mnNgorcm- jMnhOr. ~mtNdch 1-877-941-0482 (TTY:
711).
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos
sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-941-0482 (TTY:
711).
IlliniCare Health complies with applicable federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. IlliniCare Health does not exclude people or treat them
differently because of race, color, national origin, age, disability, or sex.
IlliniCare Health:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as
qualified sign language interpreters and written information in other formats (large print, accessible electronic
formats, other formats).
• Provides free language services to people whose primary language is not English, such as qualified
interpreters and information written in other languages.
If you need these services, contact IlliniCare Health's Member Services at 1-877-941-0482/TTY: 711.
If you believe that IlliniCare Health has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above
and telling them you need help filing a grievance; IlliniCare Health's Member Services is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–
1019, (TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
999 Oakmont Plaza Drive
Suite 400
Westmont, IL 60559
1-877-941-0482
TTY: 711
"++';2277'9JLLQ5Q@/!:9(F7
FOR MORE INFORMATION,
contact Member Services at
1-877-941-0482 from 8 a.m. to 8 p.m.,
Monday through Friday. TTY users call 711.
After hours, on weekends and on holidays,
you may be asked to leave a message.
Your call will be returned within the next
business day.
"++';2277'9JLLQ5Q@/!:9(F7
66664G046= <:!HQF5 11
&'>/+:> 6620122017
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