Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
Lista de Medicamentos
Cubiertos de 2016 (Formulario)
Esta lista de medicamentos fue actualizada el 12/1/2016.
Si tiene preguntas, llame a
Health Net Cal MediConnect al 1-855-464-3571 para el condado de Los Angeles o al
1-855-464-3572 para el condado de San Diego, TTY: 711. Una persona está aquí, en vivo, para
hablar con usted de lunes a viernes, de 8:00 a. m. a 8:00 p. m. Puede dejar un mensaje de voz
los sábados, domingos y días feriados federales, de 8:00 a. m. a 8:00 p. m. Le devolveremos la
llamada el siguiente día hábil. La llamada es gratuita.
Para obtener más información, visite www.healthnet.com/calmediconnect.
HPMS Approved Formulary File Submission ID: 16213 Version Number: 23
H3237_2016_0006_ SPN CMS Approved 07102015
Esta es una lista de medicamentos que los afiliados pueden obtener en
Health Net Cal MediConnect.
• Health Net Cal MediConnect Plan
(Medicare-Medicaid Plan) es un plan de
salud que tiene contrato con Medicare y
Medi-Cal para brindar los beneficios de
ambos programas a las personas inscritas.
• Es posible que se modifique la Lista de
Medicamentos Cubiertos y/o las redes de
farmacias y de proveedores durante el año.
Le enviaremos un aviso antes de realizar un
cambio que le afecte.
• Los beneficios y/o copagos pueden cambiar
el 1.º de enero de cada año.
• Puede consultar la Lista de Medicamentos
Cubiertos actualizada de Health Net
Cal MediConnect en línea en
www.healthnet.com/calmediconnect o
llamando al 1-855-464-3571 para el condado
de Los Angeles o al 1-855-464-3572 para el
condado de San Diego, TTY: 711.
• Los copagos para medicamentos que requieren
receta médica pueden variar según el nivel de
Ayuda Adicional que reciba. Comuníquese con
el plan para obtener más detalles.
• You can get this information for free in
other languages. Call 1-855-464-3571 for Los
Angeles County or 1-855-464-3572 for San
Diego County, TTY: 711. The call is free.
Usted puede obtener esta información de
forma gratuita en otros idiomas. Llame al
1-855-464-3571 para el condado de Los Ángeles
o 1-855-464-3572 para el condado de San
Diego, TTY: 711. La llamada es gratuita.
• Puede obtener esta información de forma
gratuita en otros formatos, como en
letras grandes, braille o audio. Llame al
1-855-464-3571 para el condado de Los
Angeles o al 1-855-464-3572 para el condado
de San Diego, TTY: 711. La llamada es
gratuita.
• Pueden aplicarse limitaciones, copagos y
restricciones. Para obtener más información,
llame al Departamento de Servicios al
Afiliado de Health Net Cal MediConnect o
consulte el Manual del Afiliado de Health Net
Cal MediConnect.
?
Si tiene preguntas, llame a Health Net Cal MediConnect al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego, TTY: 711.
Una persona está aquí, en vivo, para hablar con usted de lunes a viernes, de 8:00 a. m. a
8:00 p. m. Puede dejar un mensaje de voz los sábados, domingos y días feriados federales,
de 8:00 a. m. a 8:00 p. m. Le devolveremos la llamada el siguiente día hábil. La llamada es
gratuita. Para obtener más información, visite www.healthnet.com/calmediconnect.
i
Preguntas frecuentes
(FAQ, por
sus siglas en inglés)
Encuentre respuestas a las preguntas que tenga
sobre esta Lista de Medicamentos Cubiertos.
Puede leer todas las FAQ para averiguar más o
buscar una pregunta y respuesta.
1. ¿Qué medicamentos que requieren receta
médica están en la Lista de Medicamentos
Cubiertos?
(Llamamos a la Lista de Medicamentos
Cubiertos la “Lista de Medicamentos” para
abreviar).
Los medicamentos que figuran en la Lista
de Medicamentos son los medicamentos
cubiertos por Health Net Cal MediConnect.
Los medicamentos están disponibles en las
farmacias de nuestra red. Una farmacia está en
nuestra red si tenemos un acuerdo para que
ellos trabajen con nosotros y le presten servicios
a usted. Nos referimos a estas farmacias como
“farmacias de la red”.
Health Net Cal MediConnect cubrirá todos los
medicamentos médicamente necesarios de la
Lista de Medicamentos si:
• su médico u otra persona que receta dice que
usted los necesita para mejorar o mantenerse
saludable, y
• usted surte la receta en una farmacia de la red
de Health Net Cal MediConnect.
En algunos casos, usted tiene que hacer algo
antes de obtener un medicamento (vea la
pregunta n.° 5 más abajo).
También puede ver una lista actualizada de los
medicamentos que cubrimos en nuestro sitio
web en www.healthnet.com/calmediconnect o
llame al Departamento de Servicios al Afiliado
al 1-855-464-3571 para el condado de Los
Angeles o al 1-855-464-3572 para el condado de
San Diego, TTY: 711.
ii
2. ¿Alguna vez cambia la Lista de
Medicamentos?
Sí. Health Net Cal MediConnect puede agregar
o eliminar medicamentos de la Lista de
Medicamentos durante el año. En general, la
Lista de Medicamentos solo cambiará si:
• surge un medicamento más barato que
funciona igual de bien que un medicamento
que ya figura en la Lista de Medicamentos, o
• nos enteramos de que el medicamento no es
seguro.
También podemos cambiar nuestras reglas sobre
los medicamentos. Por ejemplo, podríamos:
• Decidir requerir o no requerir aprobación
previa para un medicamento. (Aprobación
previa es un permiso que otorga Health Net
Cal MediConnect antes de que usted pueda
obtener un medicamento).
• Agregar o cambiar la cantidad que usted
puede obtener de un medicamento (lo que se
denomina “límites de cantidad”).
• Agregar o cambiar las restricciones de terapia
escalonada de un medicamento. (Terapia
escalonada significa que usted debe probar
un medicamento antes de que cubramos otro
medicamento).
(Para obtener más información acerca de estas
reglas sobre medicamentos, consulte la página iv).
Le informaremos cuando un medicamento que
usted está tomando sea eliminado de la Lista
de Medicamentos. También le informaremos
cuando cambiemos nuestras reglas para cubrir
un medicamento. Las siguientes preguntas
3, 4 y 7 tienen más información acerca de
lo que sucede cuando cambia la Lista de
Medicamentos.
• Puede consultar siempre la Lista de
Medicamentos actualizada de Health Net
Cal MediConnect en línea en
www.healthnet.com/calmediconnect.
También puede llamar al Departamento de
Servicios al Afiliado para consultar la Lista de
Medicamentos actual al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572
para el condado de San Diego, TTY: 711.
3. ¿Qué ocurre cuando surge un
medicamento más barato que funciona
igual de bien que un medicamento que ya
figura en la Lista de Medicamentos?
Si usted está tomando un medicamento que
es eliminado porque surge un medicamento
más barato que funciona igual de bien, le
informaremos. Le informaremos al menos
60 días antes de eliminarlo de la Lista de
Medicamentos o cuando usted solicite una
repetición de la receta. Entonces, usted
puede obtener un suministro de 60 días del
medicamento antes de que el medicamento
sea eliminado de la lista de medicamentos. Si
hacemos algún otro cambio negativo a la Lista de
Medicamentos, le enviaremos una carta en la que
se le informará acerca de estos cambios. También
publicaremos los cambios en nuestro sitio web en
www.healthnet.com/calmediconnect.
4. ¿Qué ocurre cuando averiguamos que un
medicamento no es seguro?
Si la Administración de Alimentos y
Medicamentos de los Estados Unidos (FDA, por
sus siglas en inglés) estipula que un medicamento
que usted está tomando no es seguro, lo
eliminaremos de la Lista de Medicamentos
inmediatamente. También le enviaremos una
carta para informarle eso. Si usted recibe una de
estas cartas, comuníquese con su médico para
hablar sobre otras opciones de medicamentos.
?
Si tiene preguntas, llame a Health Net Cal MediConnect al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego, TTY: 711.
Una persona está aquí, en vivo, para hablar con usted de lunes a viernes, de 8:00 a. m. a
8:00 p. m. Puede dejar un mensaje de voz los sábados, domingos y días feriados federales,
de 8:00 a. m. a 8:00 p. m. Le devolveremos la llamada el siguiente día hábil. La llamada es
gratuita. Para obtener más información, visite www.healthnet.com/calmediconnect.
iii
5. ¿Existe alguna restricción o límite en la
cobertura de los medicamentos? ¿O debe
tomarse alguna medida para obtener
ciertos medicamentos?
Sí, algunos medicamentos tienen reglas de
cobertura o tienen límites en la cantidad
que usted puede obtener. En algunos casos,
su médico u otra persona que receta deben
hacer algo antes de que usted pueda obtener el
medicamento. Por ejemplo:
• Aprobación previa (o autorización previa):
Para algunos medicamentos, usted o su
médico u otra persona que receta deben
obtener aprobación de Health Net
Cal MediConnect antes de surtir su receta.
Si no obtiene aprobación, es posible que
Health Net Cal MediConnect no cubra el
medicamento.
• Límites de cantidad: En algunos casos,
Health Net Cal MediConnect limita la
cantidad que usted puede obtener de un
medicamento.
• Terapia escalonada: En algunos casos,
Health Net Cal MediConnect requiere
que usted realice una terapia escalonada.
Esto significa que usted tendrá que probar
los medicamentos en un cierto orden por
su afección médica. Usted podría tener
que probar un medicamento antes de que
cubramos otro. Si su médico opina que el
primer medicamento no funciona para usted,
entonces cubriremos el segundo.
Puede averiguar si su medicamento tiene
restricciones o limitaciones adicionales
consultando las tablas de la página 1 – Índice 1.
También puede obtener más información
visitando nuestro sitio web en
www.healthnet.com/calmediconnect.
Publicamos documentos en línea que explican
nuestras restricciones de autorización previa y
terapia escalonada. También puede solicitarnos
una copia.
También puede solicitar una “excepción” de
estos límites. Consulte la Pregunta 11 para
obtener más información sobre las excepciones.
iv
• Si usted está en una casa de reposo u otro
centro de cuidados a largo plazo y necesita
un medicamento que no está en la Lista de
Medicamentos, o si usted no puede obtener
fácilmente el medicamento que necesita,
podemos ayudar. Cubriremos un suministro
de emergencia de 31 días del medicamento
que necesita (a menos que usted tenga una
receta por menos días), sea usted un afiliado
nuevo de Health Net Cal MediConnect o no.
Esto le dará tiempo para hablar con su médico
u otra persona que receta. Ellos podrán
ayudarle a decidir si hay un medicamento
similar en la Lista de Medicamentos que usted
pueda tomar o si debe solicitar una excepción.
Consulte la Pregunta 11 para obtener más
información sobre las excepciones.
6. ¿Cómo saber si el medicamento que desea
tiene limitaciones o si deben tomarse
medidas para obtener el medicamento?
La Lista de Medicamentos Cubiertos que figura
en la página 1 tiene una columna denominada
“Medidas necesarias, restricciones o límites
de uso”.
7. ¿Qué ocurre si cambiamos nuestras reglas
sobre la manera en que cubrimos algunos
de los medicamentos? Por ejemplo,
si añadimos una autorización previa
(aprobación), límites de cantidad y/o
restricciones de terapia escalonada sobre
un medicamento.
Le informaremos si añadimos una aprobación
previa, límites de cantidad y/o restricciones
de terapia escalonada a un medicamento. Le
informaremos al menos 60 días antes de que
se agregue la restricción o la siguiente vez que
usted solicita una repetición de la receta en su
farmacia. Entonces, usted puede obtener un
suministro de 60 días del medicamento antes
de que se efectivice el cambio de las reglas de
cobertura. Esto le dará tiempo para hablar con
su médico u otra persona que receta sobre lo
que debe hacer después.
8. ¿Cómo puede encontrar un medicamento
en la Lista de Medicamentos?
Existen dos maneras de encontrar un
medicamento:
• puede buscar alfabéticamente (si usted sabe
cómo se escribe el nombre del medicamento), o
• puede buscar por afección médica.
Para buscar alfabéticamente, visite la
sección Listado por Orden Alfabético. Puede
encontrarlo en el Índice que comienza en la
página 1 del Índice.
Para buscar por afección médica, busque la
sección denominada “Lista de Medicamentos
por Afección Médica” de la página 1. Los
medicamentos en esta sección se agrupan en
categorías según el tipo de afección médica
que traten. Por ejemplo, si usted tiene una
enfermedad cardíaca, debería buscar en la
categoría: AGENTES CARDIOVASCULARES
(VARIOS): Medicamentos para tratar las
afecciones cardíacas y de la circulación. Allí es
donde encontrará los medicamentos que tratan
afecciones cardíacas.
9. ¿Qué pasa si el medicamento que usted
quiere tomar no está en la Lista de
Medicamentos?
Si usted no ve su medicamento en la Lista de
Medicamentos, llame al Departamento de
Servicios al Afiliado al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572
para el condado de San Diego, TTY: 711 y
pregunte por él. Si le informan que Health Net
Cal MediConnect no cubrirá el medicamento,
usted puede hacer una de estas cosas:
• Solicite al Departamento de Servicios al
Afiliado una lista de medicamentos como el
que usted desea tomar. Luego, muéstrele esa
lista a su médico o a otra persona que recete.
Ellos pueden recetar un medicamento que esté
en la Lista de Medicamentos y que sea como el
que usted quiere tomar. O bien
• Puede solicitar al plan de salud que haga una
excepción y cubra su medicamento. Consulte
la Pregunta 11 para obtener más información
sobre las excepciones.
10.¿Qué pasa si usted es un afiliado nuevo
de Health Net Cal MediConnect y no
puede encontrar su medicamento en la
Lista de Medicamentos o tiene problemas
para obtenerlo?
Le podemos ayudar. Podemos cubrir un
suministro temporario de 30 días de su
medicamento durante los primeros 90 días
que usted es afiliado de Health Net
Cal MediConnect. Esto le dará tiempo para
hablar con su médico u otra persona que
receta. Ellos podrán ayudarle a decidir si
hay un medicamento similar en la Lista de
Medicamentos que usted pueda tomar o si debe
solicitar una excepción.
Cubriremos un suministro de 30 días de su
medicamento si:
• usted está tomando un medicamento que no
está en nuestra Lista de Medicamentos, o
• las reglas del plan de salud no le permiten
obtener la cantidad pedida por la persona que
lo recetó, o
• el medicamento requiere aprobación previa de
Health Net Cal MediConnect, o
• usted está tomando un medicamento que es
parte de una restricción de terapia escalonada.
Si usted está en una casa de reposo u otro
centro de cuidados a largo plazo, usted puede
obtener una repetición de la receta por un
?
Si tiene preguntas, llame a Health Net Cal MediConnect al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego, TTY: 711.
Una persona está aquí, en vivo, para hablar con usted de lunes a viernes, de 8:00 a. m. a
8:00 p. m. Puede dejar un mensaje de voz los sábados, domingos y días feriados federales,
de 8:00 a. m. a 8:00 p. m. Le devolveremos la llamada el siguiente día hábil. La llamada es
gratuita. Para obtener más información, visite www.healthnet.com/calmediconnect.
v
máximo de 98 días. Usted puede obtener una
repetición de la receta varias veces durante los
primeros 90 días en el plan. Esto le otorga a la
persona que le receta tiempo de reemplazar sus
medicamentos por aquellos que están en la Lista
de Medicamentos o de pedir una excepción.
Cambios en el Nivel de Atención
Si su nivel de atención cambia, cubriremos un
suministro de transición de sus medicamentos.
Un cambio en el nivel de atención tiene lugar
cuando usted recibe el alta del hospital. También
ocurre cuando se traslada a un centro de
atención a largo plazo o cuando se va de este.
• Si usted se traslada de un centro de atención
a largo plazo o un hospital y necesita un
suministro de transición, cubriremos un
suministro de 30 días. Si en su receta se
establecen menos días, permitiremos las
repeticiones de recetas hasta alcanzar el total
de un suministro para un período de 30 días.
• Si se traslada de su hogar o de un hospital a
un centro de atención a largo plazo y necesita
un suministro de transición, cubriremos
un suministro de 31 días. Si en su receta se
establecen menos días, permitiremos las
repeticiones de recetas hasta alcanzar el total
de un suministro para un período de 31 días.
11. ¿Puede pedir una excepción para que se le
brinde cobertura para su medicamento?
Sí. Usted puede solicitar a Health Net
Cal MediConnect que haga una excepción para
cubrir un medicamento que no está en la Lista
de Medicamentos.
También puede solicitarnos que cambiemos las
reglas que afectan a su medicamento.
• Por ejemplo, Health Net Cal MediConnect
puede limitar la cantidad de un medicamento
que cubriremos. Si su medicamento tiene
un límite, puede pedirnos que cambiemos el
límite y cubramos más.
vi
• Otros ejemplos: Puede solicitarnos
que anulemos las restricciones de
terapia escalonada o los requisitos de
aprobación previa.
12. ¿Cuánto puede demorar obtener una
excepción?
Primero, debemos recibir una declaración de
la persona que receta en la que se respalde su
solicitud de una excepción. Luego de recibir la
declaración, le otorgaremos nuestra decisión
dentro de las 72 horas.
Si usted o la persona que le receta creen que su
salud puede verse perjudicada si usted tiene que
esperar 72 horas por una decisión, usted puede
solicitar una excepción acelerada. Esta es una
decisión más rápida. Si la persona que le receta
respalda su solicitud, le daremos una decisión
dentro de las 24 horas posteriores a recibir la
declaración de respaldo de esta persona.
13. ¿Cómo puede solicitar una excepción?
Para solicitar una excepción, llame al
Departamento de Servicios al Afiliado.
El Departamento de Servicios al Afiliado
trabajará con usted y su proveedor para ayudarle
a solicitar una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos tienen los mismos
ingredientes que los medicamentos de
marca. Normalmente cuestan menos que los
medicamentos de marca y sus nombres son
menos conocidos. Los medicamentos genéricos
están aprobados por la Administración de
Alimentos y Medicamentos (FDA).
Health Net Cal MediConnect cubre los
medicamentos de marca y los genéricos.
15. ¿Qué son los medicamentos OTC?
OTC son las siglas de “over-the-counter”:
de venta libre. Health Net Cal MediConnect
cubre algunos medicamentos OTC cuando
son recetados por su proveedor.
Puede consultar la Lista de Medicamentos
de Health Net Cal MediConnect para ver
qué medicamentos OTC están cubiertos.
16. ¿Health Net Cal MediConnect
cubre los productos OTC no
medicamentosos?
Health Net Cal MediConnect
cubre algunos productos OTC no
medicamentosos cuando son recetados
por su proveedor.
Puede consultar la Lista de Medicamentos
de Health Net Cal MediConnect para ver
qué productos OTC no medicamentosos
están cubiertos.
17. ¿Qué es su copago?
Puede consultar la Lista de Medicamentos
de Health Net Cal MediConnect para
averiguar el copago de cada medicamento.
Los afiliados de Health Net
Cal MediConnect que viven en casas de
reposo o en otros centros de atención
a largo plazo no tendrán copagos.
Algunos afiliados que reciben atención
a largo plazo en la comunidad tampoco
tendrán copagos.
Los copagos se describen por niveles. Los
niveles son grupos de medicamentos con
el mismo copago.
• Los medicamentos del nivel 1 tienen
un copago bajo. Son medicamentos
genéricos. El copago será de $0.00
a $2.95. Esto depende de su nivel de
cobertura de Medi-Cal.
• Los medicamentos del nivel 2 tienen un
copago más alto. Son medicamentos de
marca. El copago será de $0.00 a $7.40.
Esto depende de su nivel de cobertura de
Medi-Cal.
• Los medicamentos del nivel 3 tienen un
copago de $0.00. Son medicamentos
que requieren receta médica y OTC que
están cubiertos por Medi-Cal.
?
Si tiene preguntas, llame a Health Net Cal MediConnect al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego, TTY: 711.
Una persona está aquí, en vivo, para hablar con usted de lunes a viernes, de 8:00 a. m. a
8:00 p. m. Puede dejar un mensaje de voz los sábados, domingos y días feriados federales,
de 8:00 a. m. a 8:00 p. m. Le devolveremos la llamada el siguiente día hábil. La llamada es
gratuita. Para obtener más información, visite www.healthnet.com/calmediconnect.
vii
Lista de Medicamentos Cubiertos
La Lista de Medicamentos Cubiertos que
comienza en la página 1 le brinda información
sobre los medicamentos cubiertos por
Health Net Cal MediConnect. Si tiene
problemas para ubicar su medicamento en
la lista, consulte el Índice que comienza en la
página 1.
La primera columna del cuadro menciona el
nombre del medicamento. Los medicamentos
de marca están escritos en letra mayúscula
(por ejemplo, LIPITOR) y los medicamentos
genéricos, en letra minúscula y cursiva (por
ejemplo, atorvastatina cálcica).
La información mencionada en la columna
“Medidas necesarias, restricciones o límites de
uso” le indica si Health Net Cal MediConnect
tiene alguna regla para cubrir su medicamento.
Abreviatura
¿Qué significa esto? ¿Cómo funciona?
AL
Límite de Edad
B/D
Medicare Parte B
frente a Medicare
Parte D
GL
Límite de Género
LA
Acceso Limitado
Algunos medicamentos pueden necesitar
autorización previa si su edad no cumple
con las pautas clínicas, del fabricante de
medicamentos o de la FDA.
Algunos medicamentos pueden necesitar
autorización previa para decidir si el
medicamento debe ser cubierto de acuerdo
con Medicare Parte B o Parte D. Esto es una
regla de Medicare. Su médico u otra persona
que receta quizá deba ofrecer más datos para
ayudar a tomar esta decisión.
Algunos medicamentos pueden ser seguros
solo para los varones o las mujeres.
Algunos medicamentos quizá se encuentren
en una o en pocas farmacias porque:
• la FDA limita el medicamento a ciertos
centros, farmacias o personas que recetan, o
• ciertos medicamentos necesitan una
atención especial o una capacitación del
paciente que no puede ofrecerse en una
farmacia de venta minorista.
Puede hablar con su médico, otra persona
que receta o el farmacéutico acerca de los
detalles sobre conseguir medicamentos de
acceso limitado.
viii
Abreviatura
¿Qué significa esto? ¿Cómo funciona?
MO
Compra por Correo
NF
Sin Cobertura
NT
No Parte D
PA
Autorización Previa
QL
Límite de Cantidad
RX/OTC
SL
Medicamentos que
Requieren Receta
Médica y de Venta
Libre (OTC)
Límite de seguridad
ST
Terapia Escalonada
Puede obtener este medicamento en una
farmacia de compra por correo de Health Net
Cal MediConnect.
Este medicamento no está cubierto en la
Lista de Medicamentos. Puede solicitar una
excepción para que se cubra el medicamento.
Este medicamento no es un “medicamento
de la Parte D”. No se requerirá que usted
pague un copago por estos medicamentos.
Este medicamento requiere autorización
previa. Esto significa que usted o su médico
deben obtener aprobación de Health Net
Cal MediConnect antes de surtir su receta.
Si no obtiene aprobación, es posible que no
cubramos el medicamento.
Este medicamento tiene un límite en la
cantidad que Health Net Cal MediConnect
cubrirá.
Este medicamento tiene una presentación que
requiere receta médica y otra que es OTC.
Este medicamento tiene un límite de dosis
diaria máxima por motivos de seguridad
respaldado por la Administración de
Alimentos y Medicamentos (FDA, por sus
siglas en inglés). Esto significa que Health Net
no cubrirá más que la dosis diaria máxima.
Por ejemplo, la dosis diaria máxima de la FDA
para simvastatin es de 80 mg. Por lo tanto,
solo cubriremos dos tabletas por día para
simvastatin 40 mg.
Este medicamento requiere una terapia
escalonada. Esto significa que usted tendrá
que probar los medicamentos en un cierto
orden por su afección médica. Usted podría
tener que probar un medicamento antes de
que cubramos otro. Si su médico opina que el
primer medicamento no funciona para usted,
entonces cubriremos el segundo.
?
Si tiene preguntas, llame a Health Net Cal MediConnect al 1-855-464-3571 para el
condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego, TTY: 711.
Una persona está aquí, en vivo, para hablar con usted de lunes a viernes, de 8:00 a. m. a
8:00 p. m. Puede dejar un mensaje de voz los sábados, domingos y días feriados federales,
de 8:00 a. m. a 8:00 p. m. Le devolveremos la llamada el siguiente día hábil. La llamada es
gratuita. Para obtener más información, visite www.healthnet.com/calmediconnect.
ix
Nota: NT al lado de un medicamento
significa que el medicamento no es un
“medicamento de la Parte D”. No se
requerirá que usted pague un copago por
estos medicamentos. Estos medicamentos
también tienen reglas diferentes para
apelaciones. Una apelación es una
manera formal de solicitarnos que
revisemos una decisión que tomamos
acerca de su cobertura y solicitarnos que
la cambiemos, si cree que fue un error.
Por ejemplo, podemos decidir que un
medicamento que desea no está cubierto
o que ya no está cubierto por Medicare
o Medi-Cal. Si usted o su médico no
están de acuerdo con nuestra decisión,
usted puede apelar. Si alguna vez tiene
una pregunta, llame al Departamento de
Servicios al Afiliado al 1-855-464-3571
para el condado de Los Angeles o al
1-855-464-3572 para el condado de San
Diego, TTY: 711. También puede leer el
Manual del Afiliado para averiguar cómo
apelar una decisión.
x
Lista de Medicamentos por
Afección Médica
Los medicamentos en esta sección se
agrupan en categorías según el tipo de
afección médica que traten. Por ejemplo,
si usted tiene una enfermedad cardíaca,
debería buscar en la categoría: AGENTES
CARDIOVASCULARES (VARIOS):
Medicamentos para tratar las afecciones
cardíacas y de la circulación. Allí es donde
encontrará los medicamentos que tratan
enfermedades cardíacas.
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders
Amphetamines
ADDERALL XR CP24
(AmphetamineDextroamphetamine)
amphetaminedextroamphetamine cp24
amphetaminedextroamphetamine tabs
DESOXYN TABS
(Methamphetamine HCl)
DEXEDRINE CP24
(Dextroamphetamine
Sulfate)
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
Name of drug
diethylpropion hcl tabs 25
mg
DIETHYLPROPION HCL
TABS 25 MG
(Diethylpropion HCl)
diethylpropion hcl tb24 75
mg
phentermine hcl caps
phentermine hcl tabs
QSYMIA CP24
MO
NF
$0dextroamphetamine sulfate $2.95
(Tier
cp24 10 mg, 15 mg, 5 mg
1)
$0dextroamphetamine sulfate $2.95
(Tier
tabs 10 mg, 5 mg
1)
$0methamphetamine hcl tabs $2.95
(Tier
1)
Anorexiants Non-Amphetamine
ADIPEX-P CAPS
NF
(Phentermine HCl)
ADIPEX-P TABS
NF
(Phentermine HCl)
$0
benzphetamine hcl tabs 25 (Tier
mg
3)
REGIMEX TABS
MO
SUPRENZA TBDP 15 MG,
30 MG
MO
MO
BELVIQ TABS
BELVIQ XR TB24
PA; MO; NT
PA; MO; NT
Necessary
actions,
restrictions, or
limits on use
PA; MO; NT
PA; MO; NT
NF
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
PA; MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
PA; NT
PA; MO; NT
PA; MO; NT
PA; NT
PA; MO; NT
PA; MO; NT
Anti-Obesity Agents
ALLI CAPS
PA; MO; NT
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
CONTRAVE TB12
SAXENDA SOPN
PA; MO; NT
PA; MO; NT
PA; MO; NT
PA; MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
1
Name of drug
XENICAL CAPS
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
PA; MO; NT
Attention-Deficit/Hyperactivity Disorder (ADHD)
$0- MO
$2.95
clonidine hcl (adhd) tb12
(Tier
1)
$0- AL; MO
$2.95
guanfacine hcl (adhd) tb24 (Tier
1)
INTUNIV TB24
NF AL; MO
(Guanfacine HCl (ADHD))
KAPVAY TB12 (Clonidine
NF MO
HCl (ADHD))
$0- SL(10 ea daily);
$7.40 MO
STRATTERA CAPS 10 MG (Tier
2)
$0- SL(1 ea daily);
$7.40 MO
STRATTERA CAPS 100
(Tier
MG
2)
$0- SL(5.55 ea
$7.40 daily); MO
STRATTERA CAPS 18 MG (Tier
2)
$0- SL(4 ea daily);
$7.40 MO
STRATTERA CAPS 25 MG (Tier
2)
$0- SL(2.5 ea
$7.40
STRATTERA CAPS 40 MG (Tier daily); MO
2)
$0- SL(1.66 ea
$7.40 daily); MO
STRATTERA CAPS 60 MG (Tier
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
STRATTERA CAPS 80 MG (Tier
2)
Stimulants - Misc.
CONCERTA TBCR 27 MG,
36 MG (Methylphenidate
HCl)
dexmethylphenidate hcl
cp24 15 mg
dexmethylphenidate hcl
tabs 10 mg, 2.5 mg, 5 mg
FOCALIN TABS
(Dexmethylphenidate HCl)
FOCALIN XR CP24 15 MG
(Dexmethylphenidate HCl)
METADATE CD CPCR
(Methylphenidate HCl)
methylphenidate hcl cp24
or 20 mg, 30 mg, 40 mg
methylphenidate hcl cpcr or
10 mg, 20 mg, 30 mg, 40
mg, 50 mg, 60 mg
methylphenidate hcl tabs or
10 mg, 20 mg, 5 mg
methylphenidate hcl tb24 or
27 mg, 36 mg
methylphenidate hcl tbcr or
20 mg, 27 mg, 36 mg
Necessary
actions,
restrictions, or
limits on use
SL(1.25 ea
daily); MO
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
NF MO
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
2
Name of drug
modafinil tabs
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
PROVIGIL TABS
(Modafinil)
RITALIN LA CP24 20 MG,
30 MG, 40 MG
(Methylphenidate HCl)
RITALIN LA CP24 60 MG
RITALIN TABS
(Methylphenidate HCl)
Necessary
actions,
restrictions, or
limits on use
PA; MO
NF PA; MO
MO
NF
$0- MO
$7.40
(Tier
2)
NF MO
ALTERNATIVE MEDICINES
Alternative Medicine - A's
ALPHA LIPOIC ACID
CAPS OR 50 MG
alpha-lipoic acid (thioctic
acid) caps 100 mg
ALPHA-LIPOIC ACID
CAPS
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
Alternative Medicine - C's
CHEW Q CHEW 100 MG
coenzyme q10
(ubidecarenone) caps 10
mg, 150 mg, 60 mg
coenzyme q10
(ubidecarenone) caps 30
mg
COENZYME Q10 CHEW
OR 60 MG
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
Name of drug
COENZYME Q10 TABS
OR 25 MG
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
Alternative Medicine - G's
$0 MO; NT
(Tier
3)
$0 NT
glucosamine sulfate tabs or (Tier
500 mg
3)
glucosamine sulfate caps
or 500 mg
Alternative Medicine - L's
lutein caps or 6 mg
$0 NT
(Tier
3)
Alternative Medicine Combinations
$0 NT
glucosamine-chondroitin
(Tier
caps 200mg-250mg
3)
$0 NT
glucosamine-chondroitin
(Tier
tabs 200mg-250mg
3)
LIQ-10 SYRP 50MG/5ML15UNIT/5ML
VITALINE
COQ10/VITAMIN E WAFR
100MG-300UNIT
$0 NT
(Tier
3)
$0 NT
(Tier
3)
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections
Aminoglycosides
NT
amikacin sulfate soln ij 1
gm/4ml, 500 mg/2ml
MO; NT
NT
BETHKIS NEBU
$0- MO
$2.95
(Tier
1)
$0- B/D
$7.40
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
3
Name of drug
gentamicin in saline soln
0.9%-1mg/ml
gentamicin sulfate soln ij
40 mg/ml
KITABIS PAK NEBU
neomycin sulfate tabs or
paromomycin sulfate caps
TOBI NEBU (Tobramycin)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
B/D
MO
MO
NF B/D
$0$7.40
TOBI PODHALER CAPS
(Tier
2)
$0- B/D
$2.95
tobramycin nebu in
(Tier
1)
$0- MO
tobramycin sulfate soln ij
1.2 gm/30ml, 40 mg/ml, 80 $2.95
(Tier
mg/2ml
1)
$0$2.95
tobramycin sulfate solr ij
(Tier
1.2 gm
1)
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint
Conditions
Anti-TNF-alpha - Monoclonal Antibodies
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0HUMIRA PEDIATRIC
$7.40
CROHNS DISEASE
(Tier
STARTER PACK PSKT
2)
$0$7.40
HUMIRA PEN PNKT
(Tier
2)
$0$7.40
HUMIRA PEN-CROHNS
DISEASESTARTER PNKT (Tier
2)
$0HUMIRA PEN-PSORIASIS $7.40
(Tier
STARTER PNKT
2)
$0$7.40
HUMIRA PSKT
(Tier
2)
$0$7.40
SIMPONI ARIA SOLN
(Tier
2)
$0$7.40
SIMPONI SOAJ
(Tier
2)
$0$7.40
SIMPONI SOSY
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
PA
PA
PA
PA
Antirheumatic - Enzyme Inhibitors
$0- PA
$7.40
XELJANZ TABS
(Tier
2)
Antirheumatic Antimetabolites
$0- PA
$7.40
OTREXUP SOAJ
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
4
Name of drug
RASUVO SOAJ
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
Gold Compounds
RIDAURA CAPS
$0- MO
$7.40
(Tier
2)
Interleukin-1 Blockers
ARCALYST SOLR
$0- LA
$7.40
(Tier
2)
Interleukin-1 Receptor Antagonist (IL-1Ra)
$0- PA
$7.40
KINERET SOSY
(Tier
2)
Interleukin-1beta Blockers
ILARIS SOLR
$0- LA
$7.40
(Tier
2)
Interleukin-6 Receptor Inhibitors
$0- PA
$7.40
ACTEMRA SOLN
(Tier
2)
$0- PA
$7.40
ACTEMRA SOSY
(Tier
2)
Name of drug
ALEVE CAPS (Naproxen
Sodium)
ANAPROX DS TABS
(Naproxen Sodium)
ARTHROTEC 50 TBEC
(Diclofenac w/ Misoprostol)
ARTHROTEC 75 TBEC
(Diclofenac w/ Misoprostol)
CATAFLAM TABS
(Diclofenac Potassium)
CELEBREX CAPS
(Celecoxib)
celecoxib caps
CHILDRENS MOTRIN
JUNIOR STRENGTH
CHEW (Ibuprofen)
DAYPRO TABS
(Oxaprozin)
diclofenac potassium tabs
diclofenac sodium tb24 or
100 mg
diclofenac sodium tbec or
25 mg, 50 mg, 75 mg
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
NF MO; NT
ADVIL CAPS (Ibuprofen)
diclofenac w/ misoprostol
tbec
ADVIL MIGRAINE CAPS
(Ibuprofen)
NF MO; NT
EC-NAPROSYN TBEC
(Naproxen)
ADVIL TABS (Ibuprofen)
NF MO; NT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF NT
NF MO
NF MO
NF MO
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
MO; NT
NF
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
5
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0etodolac caps 200 mg, 300 $2.95
(Tier
mg
1)
$0etodolac tabs 400 mg, 500 $2.95
(Tier
mg
1)
$0etodolac tb24 400 mg, 500 $2.95
(Tier
mg, 600 mg
1)
FELDENE CAPS
NF
(Piroxicam)
$0flurbiprofen tabs or 100 mg, $2.95
(Tier
50 mg
1)
$0
(Tier
ibuprofen caps or 200 mg
3)
$0
ibuprofen chew or 100 mg (Tier
3)
$0$2.95
ibuprofen susp or 100
(Tier
mg/5ml
1)
$0
ibuprofen susp or 40
(Tier
mg/ml, 50 mg/1.25ml
3)
$0
(Tier
ibuprofen tabs or 100 mg
3)
$0
(Tier
ibuprofen tabs or 200 mg
3)
$0$2.95
ibuprofen tabs or 400 mg
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
ibuprofen tabs or 600 mg
MO
ibuprofen tabs or 800 mg
MO
indomethacin caps or 25
mg, 50 mg
MO
MO
indomethacin cpcr or 75
mg
INFANTS ADVIL SUSP
(Ibuprofen)
MO; NT
ketoprofen caps or 50 mg,
75 mg
MO; NT
RX/OTC; MO
ketorolac tromethamine
soln ij 15 mg/ml, 30 mg/ml
NT
ketorolac tromethamine
soln im 30 mg/ml, 60
mg/2ml
NT
MO; NT
SL(8 ea daily);
MO
mefenamic acid caps or
meloxicam tabs or 15 mg,
7.5 mg
MOBIC TABS 15 MG, 7.5
MG (Meloxicam)
MOTRIN INFANTS
DROPS SUSP (Ibuprofen)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(5.33 ea
daily); MO
SL(4 ea daily);
MO
AL; MO
AL; MO
NF NT
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
AL; MO
AL; MO
MO
MO
NF MO
NF NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
6
Name of drug
MOTRIN INFANTS SUSP
(Ibuprofen)
MOTRIN JUNIOR
STRENGTH TABS
(Ibuprofen)
nabumetone tabs
NAPROSYN TABS 250
MG, 375 MG, 500 MG
(Naproxen)
naproxen sodium caps or
220 mg
naproxen sodium tabs or
275 mg, 550 mg
naproxen tabs or 250 mg,
375 mg, 500 mg
naproxen tbec or 375 mg,
500 mg
oxaprozin tabs
piroxicam caps or 10 mg,
20 mg
PONSTEL CAPS
(Mefenamic Acid)
sulindac tabs or 150 mg,
200 mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF NT
NT
Name of drug
tolmetin sodium caps 400
mg
NF
$0- MO
$2.95
(Tier
1)
MO
NF
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
NT
MO
MO
MO
MO
MO
NF MO
$0- MO
$2.95
(Tier
1)
tolmetin sodium tabs 200
mg
VOLTAREN-XR TB24
(Diclofenac Sodium)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
Phosphodiesterase 4 (PDE4) Inhibitors
$0- PA
$7.40
OTEZLA TABS
(Tier
2)
$0- PA
$7.40
OTEZLA TBPK
(Tier
2)
Pyrimidine Synthesis Inhibitors
ARAVA TABS
NF MO
(Leflunomide)
$0- MO
leflunomide tabs or 10 mg, $2.95
(Tier
20 mg
1)
Selective Costimulation Modulators
$0- PA
$7.40
ORENCIA CLICKJECT
(Tier
SOAJ
2)
$0- PA
$7.40
ORENCIA SOLR
(Tier
2)
$0- PA
$7.40
ORENCIA SOSY
(Tier
2)
Soluble Tumor Necrosis Factor Receptor Agents
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
7
Name of drug
ENBREL SOLR
ENBREL SOSY
ENBREL SURECLICK
SOAJ
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
ANALGESICS - NonNarcotic - Drugs to Treat
Pain, Muscle and Joint Conditions
Analgesic Combinations
acetaminophen-caffeinepyrilamine tabs
BIPHENOX TABS
MIDOL COMPLETE TABS
500MG-15MG-60MG
(Acetaminophen-CaffeinePyrilamine)
MIDOL MAXIMUM
STRENGTH MENSTRUAL
FORMULA TABS
(Acetaminophen-CaffeinePyrilamine)
MIDOL MAXIMUM
STRENGTH MENSTRUAL
TABS (AcetaminophenCaffeine-Pyrilamine)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NT
NF
NT
NF
NT
NF
Analgesics Other
$0 NT
(Tier
3)
$0 MO; NT
acetaminophen chew or 80 (Tier
mg
3)
acetaminophen chew or
160 mg
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
acetaminophen elix or 160 (Tier
mg/5ml, 80 mg/2.5ml
3)
$0
acetaminophen liqd or 160 (Tier
mg/5ml
3)
$0
acetaminophen soln or 160 (Tier
mg/5ml, 80 mg/0.8ml
3)
$0
acetaminophen supp re
(Tier
120 mg
3)
$0
acetaminophen susp or
(Tier
160 mg/5ml, 80 mg/2.5ml
3)
$0
acetaminophen susp or 80 (Tier
mg/0.8ml
3)
$0
acetaminophen tbdp or 160 (Tier
mg
3)
$0
acetaminophen tbdp or 80 (Tier
mg
3)
$0
ELIXSURE FEVER/PAIN
(Tier
GEL
3)
$0
FEVERALL INFANTS
(Tier
SUPP
3)
$0
INFANTS SILAPAP SOLN (Tier
3)
TYLENOL CHILDRENS
NF
SUSP (Acetaminophen)
TYLENOL INFANTS
NF
PAIN+FEVER SUSP
(Acetaminophen)
TYLENOL INFANTS SUSP NF
(Acetaminophen)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
Salicylates
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
8
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
ASCRIPTIN TABS
3)
$0
aspirin buffered (cal carbmag carb-mag oxide) tabs (Tier
3)
$0
ASPIRIN LOW DOSE
(Tier
TABS
3)
$0
ASPIRIN SUPP RE 120
(Tier
MG, 200 MG
3)
$0
aspirin supp re 300 mg,
(Tier
600 mg
3)
$0
(Tier
aspirin tabs or 325 mg
3)
$0
aspirin tbec or 324 mg, 325 (Tier
mg, 500 mg, 81 mg
3)
BUFFERIN TABS (Aspirin
NF
Buffered (Cal Carb-Mag
Carb-Mag Oxide))
$0$2.95
diflunisal tabs
(Tier
1)
ECOTRIN MAXIMUM
NF
STRENGTH TBEC
(Aspirin)
ECOTRIN REGULAR
NF
STRENGTH TBEC
(Aspirin)
$0
ST JOSEPH ADULT
(Tier
ANALGESICLOW DOSE
3)
BITE SIZE CHEW
$0
ST JOSEPH ADULT
(Tier
CHEW
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
NT
NT
NT
MO; NT
MO; NT
Name of drug
Opioid Agonists
ACTIQ LPOP 1200 MCG,
1600 MCG, 400 MCG, 600
MCG, 800 MCG (Fentanyl
Citrate)
ACTIQ LPOP 200 MCG
(Fentanyl Citrate)
DEMEROL SOLN IJ 100
MG/ML, 50 MG/ML
(Meperidine HCl)
DEMEROL SOLN IJ 25
MG/ML (Meperidine HCl)
DILAUDID LIQD OR 1
MG/ML (Hydromorphone
HCl)
DILAUDID SOLN IJ 2
MG/ML
NT
DILAUDID TABS OR 2 MG
(Hydromorphone HCl)
DILAUDID TABS OR 4 MG
(Hydromorphone HCl)
DILAUDID TABS OR 8 MG
(Hydromorphone HCl)
DILAUDID-HP SOLN 10
MG/ML (Hydromorphone
HCl)
DOLOPHINE TABS 10 MG
(Methadone HCl)
DOLOPHINE TABS 5 MG
(Methadone HCl)
DURAGESIC PT72 100
MCG/HR (Fentanyl)
NT
DURAGESIC PT72 12
MCG/HR (Fentanyl)
MO; NT
MO
MO; NT
MO; NT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
PA; QL(4 ea
NF daily); MO
NF PA; QL(6 ea
daily); MO
AL; MO
NF
NF AL
QL(32 ml
NF daily); MO
$0$7.40
(Tier
2)
NF QL(29 ea
daily); MO
NF QL(14 ea
daily); MO
NF QL(7 ea daily);
MO
NF
NF QL(19 ea
daily); MO
NF QL(38 ea
daily); MO
NF QL(1 ea daily);
MO
Limit 43
NF patches per
month;QL(1.44
ea daily); MO
ANALGESICS - OPIOID - Drugs to Treat Pain,
Muscle and Joint Conditions
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
9
Name of drug
What
the
drug
will
cost
you
(tier
level)
DURAGESIC PT72 25
MCG/HR (Fentanyl)
NF
DURAGESIC PT72 50
MCG/HR (Fentanyl)
NF
DURAGESIC PT72 75
MCG/HR (Fentanyl)
NF
$0$2.95
(Tier
1)
$0fentanyl citrate lpop bu 200 $2.95
(Tier
mcg
1)
$0$2.95
fentanyl pt72 100 mcg/hr
(Tier
1)
$0$2.95
fentanyl pt72 12 mcg/hr
(Tier
1)
$0$2.95
fentanyl pt72 25 mcg/hr
(Tier
1)
$0$2.95
fentanyl pt72 50 mcg/hr
(Tier
1)
$0$2.95
fentanyl pt72 75 mcg/hr
(Tier
1)
fentanyl citrate lpop bu
1200 mcg, 1600 mcg, 400
mcg, 600 mcg, 800 mcg
Necessary
actions,
restrictions, or
limits on use
Limit 21
patches per
month;QL(0.7
ea daily); MO
Limit 22
patches per
month;QL(0.74
ea daily); MO
Limit 18
patches per
month;QL(0.61
ea daily); MO
PA; QL(4 ea
daily); MO
PA; QL(6 ea
daily); MO
QL(1 ea daily);
MO
Limit 43
patches per
month;QL(1.44
ea daily); MO
Limit 21
patches per
month;QL(0.7
ea daily); MO
Limit 22
patches per
month;QL(0.74
ea daily); MO
Limit 18
patches per
month;QL(0.61
ea daily); MO
Name of drug
hydromorphone hcl liqd or
1 mg/ml
hydromorphone hcl soln ij
10 mg/ml, 50 mg/5ml, 500
mg/50ml
hydromorphone hcl soln ij 2
mg/ml
hydromorphone hcl tabs or
2 mg
hydromorphone hcl tabs or
4 mg
hydromorphone hcl tabs or
8 mg
KADIAN CP24 10 MG
(Morphine Sulfate)
KADIAN CP24 100 MG
(Morphine Sulfate)
KADIAN CP24 20 MG, 30
MG, 50 MG, 60 MG, 80 MG
(Morphine Sulfate)
LAZANDA SOLN 100
MCG/ACT
LAZANDA SOLN 300
MCG/ACT
LAZANDA SOLN 400
MCG/ACT
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(32 ml
daily); MO
MO
QL(29 ea
daily); MO
QL(14 ea
daily); MO
QL(7 ea daily);
MO
NF QL(20 ea
daily); MO
NF QL(6 ea daily);
MO
QL(5 ea daily);
NF MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
PA; QL(6 ea
daily); MO
PA; QL(5 ea
daily)
PA; QL(4 ea
daily)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
10
Name of drug
meperidine hcl soln ij 100
mg/ml, 50 mg/ml
meperidine hcl soln ij 25
mg/ml
methadone hcl conc or 10
mg/ml
methadone hcl soln or 10
mg/5ml
methadone hcl soln or 5
mg/5ml
methadone hcl tabs or 10
mg
methadone hcl tabs or 5
mg
METHADOSE CONC
(Methadone HCl)
METHADOSE SUGARFREE CONC (Methadone
HCl)
morphine sulfate cp24 or
10 mg
morphine sulfate cp24 or
100 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
morphine sulfate cp24 or
20 mg, 30 mg, 50 mg, 60
mg, 80 mg
AL
morphine sulfate soln ij 0.5
mg/ml
QL(4 ml daily);
MO
QL(20 ml
daily); MO
QL(40 ml
daily); MO
QL(19 ea
daily); MO
QL(38 ea
daily); MO
NF QL(4 ml daily);
MO
QL(4 ml daily);
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Name of drug
morphine sulfate soln ij 1
mg/ml
morphine sulfate soln or 10
mg/5ml
morphine sulfate soln or
100 mg/5ml, 20 mg/ml
morphine sulfate soln or 20
mg/5ml
MORPHINE SULFATE
TABS OR 15 MG
MORPHINE SULFATE
TABS OR 30 MG
QL(20 ea
daily); MO
morphine sulfate tbcr or
100 mg
QL(6 ea daily);
MO
morphine sulfate tbcr or 15
mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(5 ea daily);
MO
MO
QL(60 ml
daily); MO
QL(6 ml daily);
MO
QL(30 ml
daily); MO
QL(8 ea daily);
MO
QL(14 ea
daily); MO
QL(6 ea daily);
MO
QL(8 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
11
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
morphine sulfate tbcr or
(Tier
200 mg
1)
$0morphine sulfate tbcr or 30 $2.95
(Tier
mg, 60 mg
1)
MS CONTIN TBCR 100
NF
MG (Morphine Sulfate)
MS CONTIN TBCR 15 MG NF
(Morphine Sulfate)
MS CONTIN TBCR 200
NF
MG (Morphine Sulfate)
MS CONTIN TBCR 30 MG, NF
60 MG (Morphine Sulfate)
OPANA TABS OR 10 MG
NF
(Oxymorphone HCl)
OPANA TABS OR 5 MG
NF
(Oxymorphone HCl)
$0$2.95
oxycodone hcl caps or 5
(Tier
mg
1)
$0oxycodone hcl conc or 100 $2.95
(Tier
mg/5ml
1)
$0$2.95
oxycodone hcl tabs or 15
(Tier
mg
1)
$0$2.95
oxycodone hcl tabs or 30
(Tier
mg
1)
$0$2.95
oxycodone hcl tabs or 5 mg (Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(3 ea daily);
MO
QL(5 ea daily);
MO
QL(6 ea daily);
MO
QL(8 ea daily);
MO
QL(3 ea daily);
MO
QL(5 ea daily);
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(17 ea
daily); MO
QL(4 ml daily);
MO
QL(11 ea
daily); MO
QL(15 ea
daily); MO
QL(17 ea
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
oxymorphone hcl tabs 10
(Tier
mg
1)
$0oxymorphone hcl tabs 5 mg $2.95
(Tier
1)
$0oxymorphone hcl tb12 15 $2.95
(Tier
mg
1)
$0oxymorphone hcl tb12 7.5 $2.95
(Tier
mg
1)
ROXICODONE TABS 15
NF
MG (Oxycodone HCl)
ROXICODONE TABS 30
NF
MG (Oxycodone HCl)
ROXICODONE TABS 5
NF
MG (Oxycodone HCl)
$0SUBSYS LIQD 100 MCG, $7.40
(Tier
200 MCG
2)
$0$7.40
SUBSYS LIQD 1200 MCG (Tier
2)
$0SUBSYS LIQD 1600 MCG, $7.40
400 MCG, 600 MCG, 800
(Tier
MCG
2)
$0$2.95
tramadol hcl tabs or 50 mg (Tier
1)
$0$2.95
tramadol hcl tb24 or 100
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(2.67 ea
daily); MO
QL(5 ea daily);
MO
QL(11 ea
daily); MO
QL(15 ea
daily); MO
QL(17 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily)
PA; QL(4 ea
daily); MO
SL(8 ea daily);
MO
SL(3 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
12
Name of drug
tramadol hcl tb24 or 200
mg
tramadol hcl tb24 or 300
mg
ULTRAM ER TB24 100
MG (Tramadol HCl)
ULTRAM ER TB24 200
MG (Tramadol HCl)
ULTRAM ER TB24 300
MG (Tramadol HCl)
ULTRAM TABS (Tramadol
HCl)
ZOHYDRO ER C12A 10
MG, 15 MG, 20 MG, 30
MG, 40 MG, 50 MG
ZOHYDRO ER CP12 10
MG, 15 MG, 20 MG, 30
MG, 40 MG, 50 MG
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(1.5 ea
daily); MO
SL(1 ea daily);
MO
NF SL(3 ea daily);
MO
NF SL(1.5 ea
daily); MO
NF SL(1 ea daily);
MO
NF SL(8 ea daily);
MO
$0- PA; QL(2 ea
$7.40 daily); MO
(Tier
2)
$0- PA; QL(2 ea
$7.40 daily)
(Tier
2)
Opioid Combinations
$0acetaminophen w/ codeine $2.95
soln 120mg/5ml-12mg/5ml (Tier
1)
$0acetaminophen w/ codeine $2.95
(Tier
tabs 300mg-15mg
1)
$0acetaminophen w/ codeine $2.95
tabs 300mg-30mg, 300mg- (Tier
60mg
1)
$0$2.95
butalbital-aspirin-caffeine
(Tier
w/cod caps
1)
SL(166 ml
daily); MO
SL(13.3 ea
daily); MO
SL(13 ea daily);
MO
AL; MO
Name of drug
FIORINAL/CODEINE #3
CAPS (Butalbital-AspirinCaffeine w/Cod)
hydrocodoneacetaminophen soln
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
hydrocodoneacetaminophen tabs 10mg300mg, 5mg-300mg,
7.5mg-300mg
hydrocodoneacetaminophen tabs 10mg325mg, 5mg-325mg,
7.5mg-325mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
AL; MO
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
hydrocodone-ibuprofen
(Tier
tabs
1)
$0oxycodone w/
$2.95
acetaminophen soln
(Tier
5mg/5ml-325mg/5ml
1)
$0oxycodone w/
acetaminophen tabs 10mg- $2.95
(Tier
325mg, 2.5mg-325mg,
5mg-325mg, 7.5mg-325mg 1)
$0$2.95
oxycodone-aspirin tabs
(Tier
1)
PERCODAN TABS
NF
(Oxycodone-Aspirin)
$0$2.95
tramadol-acetaminophen
(Tier
tabs
1)
ULTRACET TABS
NF
(Tramadol-Acetaminophen)
VICOPROFEN TABS
NF
(Hydrocodone-Ibuprofen)
Limit 5535mls
per
month;SL(184.
5 ml daily); MO
SL(13.3 ea
daily); MO
SL(12.3 ea
daily); MO
MO
Limit 1845mls
per
month;SL(61.5
ml daily)
SL(12.3 ea
daily); MO
MO
MO
SL(8 ea daily);
MO
SL(8 ea daily);
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
13
Name of drug
Opioid Partial Agonists
BUPRENEX SOLN
(Buprenorphine HCl)
buprenorphine hcl soln ij
0.3 mg/ml
buprenorphine hcl subl sl 2
mg
buprenorphine hcl subl sl 8
mg
buprenorphine hclnaloxone hcl dihydrate subl
2mg-0.5mg
buprenorphine hclnaloxone hcl dihydrate subl
8mg-2mg
butorphanol tartrate soln ij
2 mg/ml
butorphanol tartrate soln na
10 mg/ml
nalbuphine hcl soln ij 10
mg/ml, 20 mg/ml
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
PA; QL(16 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(16 ea
daily); MO
PA; QL(4 ea
daily); MO
MO
Limit 126mls
per
month;QL(4.2
ml daily); MO
MO
ANDROGENS-ANABOLIC - Drugs to Regulate
Hormones
Anabolic Steroids
ANADROL-50 TABS
$0- MO
$7.40
(Tier
2)
Name of drug
OXANDRIN TABS
(Oxandrolone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0oxandrolone tabs or 10 mg, $2.95
(Tier
2.5 mg
1)
Androgens
$0$7.40
ANDRODERM PT24
(Tier
2)
$0ANDROGEL GEL 20.25
$7.40
MG/1.25GM, 40.5
(Tier
MG/2.5GM
2)
$0ANDROGEL GEL 25
$7.40
MG/2.5GM, 50 MG/5GM
(Tier
(Testosterone)
2)
$0$7.40
ANDROGEL PUMP GEL
(Tier
1.62 %
2)
$0$7.40
AVEED SOLN
(Tier
2)
$0$2.95
danazol caps or 100 mg,
(Tier
200 mg, 50 mg
1)
$0$2.95
fluoxymesterone tabs or
(Tier
1)
$0$2.95
testosterone cypionate soln (Tier
1)
$0$2.95
testosterone enanthate
(Tier
soln im
1)
MO
GL; MO
GL; MO
GL; MO
GL; MO
LA
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
14
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0testosterone gel td 1 %, 25 $2.95
(Tier
mg/2.5gm, 50 mg/5gm
1)
$0TESTOSTERONE GEL TD $7.40
1 %, 25 MG/2.5GM, 50
(Tier
MG/5GM
2)
$0TESTOSTERONE PUMP $7.40
(Tier
GEL
2)
$0$7.40
VOGELXO GEL
(Tier
2)
$0$7.40
VOGELXO PUMP GEL
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
GL; MO
starch (topical) supp
GL; MO
GL; MO
NT
Rectal Steroids
$0- MO
$2.95
hydrocortisone (rectal) crea (Tier
1)
PROCTOCORT CREA 1 % NF MO
(Hydrocortisone (Rectal))
GL; MO
RECTIV OINT
GL; MO
MO
NF
$0- MO
hydrocortisone (intrarectal) $2.95
(Tier
enem
1)
$0- MO
$7.40
UCERIS FOAM RE 2
(Tier
MG/ACT
2)
Rectal Combinations
$0 NT
phenylephrine-shark liver
(Tier
oil-glycerin-petrolatum crea 3)
Rectal Products - Misc.
Necessary
actions,
restrictions, or
limits on use
Vasodilating Agents
ANORECTAL AGENTS - Rectal Drugs to Treat
Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA ENEM
(Hydrocortisone
(Intrarectal))
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0- MO
$7.40
(Tier
2)
ANTACIDS - Ulcer and Stomach Acid Drugs
Antacid Combinations
alum & mag hydroxsimethicone chew 200mg25mg-200mg
alum & mag hydroxsimethicone liqd
200mg/5ml-20mg/5ml200mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
alum & mag hydroxsimethicone susp
200mg/5ml-200mg/5ml20mg/5ml-20mg/5ml200mg/5ml-200mg/5ml,
200mg/5ml-20mg/5ml200mg/5ml, 400mg/5ml400mg/5ml-40mg/5ml40mg/5ml-400mg/5ml400mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
aluminum hydroxide-mag
trisil chew
$0 NT
(Tier
3)
MO; NT
$0
(Tier
3)
MO; NT
$0
(Tier
3)
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
15
Name of drug
GELUSIL CHEW 200MG25MG-200MG (Alum &
Mag Hydrox-Simethicone)
HYVEE ADVANCED
ANTACID MAXIMUM
STRENGTH SUSP (Alum
& Mag HydroxSimethicone)
MYLANTA DOUBLESTRENGTH SUSP (Alum
& Mag HydroxSimethicone)
MYLANTA SUSP
200MG/5ML-20MG/5ML200MG/5ML (Alum & Mag
Hydrox-Simethicone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NT
NF
MO; NT
NF
MO; NT
NF
MO; NT
Name of drug
TUMS LASTING EFFECTS
CHEW (Calcium Carbonate
(Antacid))
TUMS SMOOTHIES
CHEW (Calcium Carbonate
(Antacid))
Antacids - Calcium Salts
calcium carbonate
(antacid) chew 500 mg,
750 mg
ALBENZA TABS
ivermectin tabs or
calcium carbonate
(antacid) chew 600 mg
calcium carbonate
(antacid) tabs 648 mg
MAALOX CHEW
TUMS CHEW (Calcium
Carbonate (Antacid))
TUMS E-X 750 CHEW
(Calcium Carbonate
(Antacid))
TUMS KIDS CHEW
(Calcium Carbonate
(Antacid))
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
NT
MO; NT
NT
NF MO; NT
MO; NT
NF
MO; NT
NF
MO; NT
NF
MO; NT
NF
Anthelmintics
NF
$0 NT
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
ANTHELMINTICS - Drugs to Treat Worm
Infections
Antacids - Aluminum Salts
ALUMINUM HYDROXIDE
SUSP OR
What
the
drug
will
cost
you
(tier
level)
STROMECTOL TABS
(Ivermectin)
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
Anti-infective Agents - Misc.
AZACTAM SOLR
NF
(Aztreonam)
$0$2.95
aztreonam solr
(Tier
1)
$0$7.40
CAYSTON SOLR
(Tier
2)
$0$2.95
colistimethate sodium solr ij (Tier
1)
COLY-MYCIN M SOLR
NF
(Colistimethate Sodium)
MO
MO
LA
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
16
Name of drug
FLAGYL CAPS 375 MG
(Metronidazole)
FLAGYL TABS 250 MG
(Metronidazole)
FLAGYL TABS 500 MG
(Metronidazole)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF SL(10.6 ea
daily); MO
NF SL(16 ea daily);
MO
NF SL(8 ea daily);
MO
$0- SL(10.6 ea
metronidazole caps or 375 $2.95 daily); MO
(Tier
mg
1)
$0$2.95
metronidazole in nacl soln (Tier
1)
$0- SL(16 ea daily);
metronidazole tabs or 250 $2.95 MO
(Tier
mg
1)
$0- SL(8 ea daily);
metronidazole tabs or 500 $2.95 MO
(Tier
mg
1)
$0- MO; B/D
$7.40
NEBUPENT SOLR
(Tier
2)
$0$7.40
ORBACTIV SOLR
(Tier
2)
$0- MO
$7.40
PENTAM 300 SOLR
(Tier
2)
TINDAMAX TABS
NF MO
(Tinidazole)
$0- MO
tinidazole tabs or 250 mg, $2.95
(Tier
500 mg
1)
Name of drug
trimethoprim tabs or
VANCOCIN HCL CAPS
(Vancomycin HCl)
vancomycin hcl caps or
125 mg, 250 mg
VANCOMYCIN HCL IN
DEXTROSE SOLN
vancomycin hcl solr iv 10
gm, 1000 mg, 5000 mg
vancomycin hcl solr iv 500
mg
XIFAXAN TABS
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF PA; MO
$0- PA; MO
$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
Anti-infective Misc. - Combinations
BACTRIM DS TABS
MO
NF
(SulfamethoxazoleTrimethoprim)
BACTRIM TABS
MO
NF
(SulfamethoxazoleTrimethoprim)
$0- MO
$2.95
sulfamethoxazole(Tier
trimethoprim soln
1)
$0- MO
$2.95
sulfamethoxazole(Tier
trimethoprim susp
1)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
17
Name of drug
sulfamethoxazoletrimethoprim tabs
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Antiprotozoal Agents
ALINIA TABS 500 MG
atovaquone susp
MEPRON SUSP
(Atovaquone)
Name of drug
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
NF MO
CUBICIN RF SOLR
(Daptomycin)
CUBICIN SOLR
(Daptomycin)
daptomycin solr
imipenem-cilastatin solr
INVANZ SOLR IJ
meropenem solr
MERREM SOLR
(Meropenem)
PRIMAXIN IV SOLR
(Imipenem-Cilastatin)
TIGECYCLINE SOLR
NF MO
Chloramphenicols
chloramphenicol sodium
succinate solr
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Glycylcyclines
Carbapenems
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
NF MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
TYGACIL SOLR
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Leprostatics
dapsone tabs or 100 mg,
25 mg
Lincosamides
CLEOCIN CAPS OR 150
MG, 300 MG, 75 MG
(Clindamycin HCl)
CLEOCIN IN D5W SOLN
(Clindamycin Phosphate in
D5W)
CLEOCIN PHOSPHATE
SOLN IJ 600 MG/4ML, 900
MG/6ML (Clindamycin
Phosphate)
$0- MO
$2.95
(Tier
1)
MO
NF
NF
MO
NF
Cyclic Lipopeptides
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
18
Name of drug
CLEOCIN PHOSPHATE
SOLN IV 300MG/50ML5%, 600MG/50ML-5%,
900MG/50ML-5%
(Clindamycin Phosphate in
D5W)
clindamycin hcl caps or
150 mg, 300 mg, 75 mg
clindamycin palmitate
hydrochloride solr
clindamycin phosphate in
d5w soln
clindamycin phosphate
soln ij 150 mg/ml, 9000
mg/60ml
clindamycin phosphate
soln ij 600 mg/4ml, 900
mg/6ml
clindamycin phosphate
soln iv 150 mg/ml, 600
mg/4ml
LINCOCIN SOLN
(Lincomycin HCl)
lincomycin hcl soln ij
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Oxazolidinones
$0linezolid in sodium chloride $2.95
(Tier
soln
1)
MO
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
linezolid soln iv 600
(Tier
mg/300ml
1)
$0$2.95
linezolid susr or 100
(Tier
mg/5ml
1)
$0$2.95
linezolid tabs or 600 mg
(Tier
1)
$0$7.40
SIVEXTRO SOLR IV
(Tier
2)
$0$7.40
SIVEXTRO TABS OR
(Tier
2)
$0$7.40
ZYVOX SOLN IV 200
(Tier
MG/100ML
2)
$0$7.40
ZYVOX SOLN IV 600
(Tier
MG/300ML (Linezolid)
2)
$0$7.40
ZYVOX SUSR OR 100
(Tier
MG/5ML (Linezolid)
2)
$0ZYVOX TABS OR 600 MG $7.40
(Tier
(Linezolid)
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
Polymyxins
polymyxin b sulfate solr ij
$0$2.95
(Tier
1)
Streptogramins
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
19
Name of drug
SYNERCID SOLR
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
ANTIANGINAL AGENTS - Drugs to Treat Chest
Pain
Antianginals-Other
RANEXA TB12
Nitrates
ISORDIL TITRADOSE
TABS 5 MG (Isosorbide
Dinitrate)
$0- PA; MO
$7.40
(Tier
2)
MO
NF
$0$2.95
isosorbide dinitrate tabs
(Tier
1)
$0$2.95
isosorbide dinitrate tbcr
(Tier
1)
$0$2.95
isosorbide mononitrate
(Tier
tabs 10 mg, 20 mg
1)
$0$2.95
isosorbide mononitrate
tb24 120 mg, 30 mg, 60 mg (Tier
1)
NITRO-DUR PT24 0.1
MG/HR, 0.2 MG/HR, 0.4
NF
MG/HR, 0.6 MG/HR
(Nitroglycerin)
$0$7.40
NITROGLYCERIN
(Tier
LINGUAL AERS
2)
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0nitroglycerin pt24 td 0.1
$2.95
mg/hr, 0.2 mg/hr, 0.4
(Tier
mg/hr, 0.6 mg/hr
1)
$0$2.95
nitroglycerin soln tl 0.4
(Tier
mg/spray
1)
$0nitroglycerin subl sl 0.3 mg, $2.95
(Tier
0.4 mg, 0.6 mg
1)
NITROLINGUAL
NF
PUMPSPRAY SOLN
(Nitroglycerin)
$0$7.40
NITROMIST AERS
(Tier
2)
$0$7.40
NITROSTAT SUBL
(Tier
(Nitroglycerin)
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Antianxiety Agents - Misc.
MO
buspirone hcl tabs or 10
mg, 15 mg, 30 mg, 5 mg,
7.5 mg
MO
hydroxyzine hcl soln im 50
mg/ml
MO
hydroxyzine hcl soln or 10
mg/5ml
hydroxyzine hcl syrp or 10
mg/5ml
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
AL; MO
AL; MO
AL; MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
20
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0hydroxyzine hcl tabs or 10 $2.95
(Tier
mg, 25 mg, 50 mg
1)
$0hydroxyzine pamoate caps $2.95
(Tier
or 25 mg, 50 mg
1)
VISTARIL CAPS
NF
(Hydroxyzine Pamoate)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; MO
AL; MO
Benzodiazepines
$0- MO
$2.95
(Tier
1)
$0- MO
alprazolam tb24 or 0.5 mg, $2.95
(Tier
1 mg, 2 mg, 3 mg
1)
$0- MO
$2.95
alprazolam tbdp or 0.25
(Tier
mg, 0.5 mg, 1 mg, 2 mg
1)
ATIVAN SOLN IJ 2 MG/ML NF MO
(Lorazepam)
ATIVAN SOLN IJ 4 MG/ML NF
(Lorazepam)
ATIVAN TABS OR 0.5 MG, NF MO
1 MG, 2 MG (Lorazepam)
$0- MO
$2.95
clorazepate dipotassium
(Tier
tabs
1)
$0- MO
$2.95
diazepam conc or 5 mg/ml (Tier
1)
$0- MO
$2.95
diazepam soln or 1 mg/ml (Tier
1)
alprazolam tabs or 0.25
mg, 0.5 mg, 1 mg, 2 mg
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0diazepam tabs or 10 mg, 2 $2.95
(Tier
mg, 5 mg
1)
$0lorazepam conc or 2 mg/ml $2.95
(Tier
1)
$0lorazepam soln ij 2 mg/ml, $2.95
(Tier
20 mg/10ml
1)
$0$2.95
lorazepam soln ij 4 mg/ml
(Tier
1)
$0lorazepam tabs or 0.5 mg, $2.95
(Tier
1 mg, 2 mg
1)
$0$2.95
oxazepam caps
(Tier
1)
TRANXENE T TABS
NF
(Clorazepate Dipotassium)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
VALIUM TABS (Diazepam)
NF MO
XANAX TABS (Alprazolam)
NF MO
XANAX XR TB24
(Alprazolam)
NF MO
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms
Antiarrhythmics Type I-A
disopyramide phosphate
caps
NORPACE CAPS
(Disopyramide Phosphate)
$0- AL; MO
$2.95
(Tier
1)
NF AL; MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
21
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0quinidine gluconate tbcr or $2.95
(Tier
324 mg
1)
$0$2.95
quinidine sulfate tabs
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
Antiarrhythmics Type I-B
mexiletine hcl caps
$0- MO
$2.95
(Tier
1)
Antiarrhythmics Type I-C
$0flecainide acetate tabs 100 $2.95
(Tier
mg
1)
$0flecainide acetate tabs 150 $2.95
(Tier
mg
1)
$0flecainide acetate tabs 50 $2.95
(Tier
mg
1)
$0$2.95
propafenone hcl cp12
(Tier
1)
$0$2.95
propafenone hcl tabs
(Tier
1)
RYTHMOL SR CP12
NF
(Propafenone HCl)
RYTHMOL TABS
NF
(Propafenone HCl)
Antiarrhythmics Type III
SL(4 ea daily);
MO
SL(2.66 ea
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0amiodarone hcl tabs or 100 $2.95
(Tier
mg, 200 mg, 400 mg
1)
CORDARONE TABS
NF
(Amiodarone HCl)
$0$2.95
dofetilide caps
(Tier
1)
$0$7.40
MULTAQ TABS
(Tier
2)
$0$7.40
TIKOSYN CAPS
(Tier
(Dofetilide)
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
SL(8 ea daily);
MO
MO
MO
MO
MO
cromolyn sodium nebu in
$0- MO; B/D
$2.95
(Tier
1)
Antiasthmatic - Monoclonal Antibodies
$0- PA
$7.40
CINQAIR SOLN
(Tier
2)
$0- PA; LA
$7.40
NUCALA SOLR
(Tier
2)
$0- PA; LA
$7.40
XOLAIR SOLR
(Tier
2)
Asthma and Bronchodilator Agent Combinations
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
22
Name of drug
dyphylline-guaifenesin liqd
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Bronchodilators - Anticholinergics
$0$7.40
ATROVENT HFA AERS
(Tier
2)
$0$2.95
ipratropium bromide soln in (Tier
1)
$0$7.40
SPIRIVA HANDIHALER
(Tier
CAPS
2)
$0SPIRIVA RESPIMAT
$7.40
AERS 1.25 MCG/ACT, 2.5 (Tier
MCG/ACT
2)
SPIRIVA RESPIMAT
AERS 2.5 MCG/ACT
$0$7.40
(Tier
2)
TUDORZA PRESSAIR
AEPB
$0$7.40
(Tier
2)
Leukotriene Modulators
ACCOLATE TABS
(Zafirlukast)
montelukast sodium chew
4 mg, 5 mg
montelukast sodium tabs
10 mg
Necessary
actions,
restrictions, or
limits on use
NT
Limit 2 inhalers
per
month;QL(0.86
gm daily); MO
MO; B/D
QL(1 ea daily);
MO
Name of drug
SINGULAIR CHEW 4 MG,
5 MG (Montelukast
Sodium)
SINGULAIR TABS 10 MG
(Montelukast Sodium)
zafirlukast tabs
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
NF MO
$0- MO
$2.95
(Tier
1)
Selective Phosphodiesterase 4 (PDE4) Inhibitors
$0- QL(1 ea daily);
$7.40 MO
DALIRESP TABS
(Tier
2)
Steroid Inhalants
Limit 1 inhaler
per month (60
actuations);SL(
0.14 gm daily);
MO
Limit 2 inhalers
per month
(Institutional
Pack) ;SL(0.29
gm daily); MO
Limit 1 inhaler
per
month;QL(0.04
ea daily); MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
AEROSPAN AERS
$0$7.40
(Tier
2)
AEROSPAN AERS
$0$7.40
(Tier
2)
budesonide (inhalation)
susp 0.25 mg/2ml, 0.5
mg/2ml
FLOVENT DISKUS AEPB
100 MCG/BLIST
FLOVENT DISKUS AEPB
250 MCG/BLIST
FLOVENT DISKUS AEPB
50 MCG/BLIST
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Limit 2 inhalers
per month (120
actuations);SL(
0.6 gm daily);
MO
Limit 3 inhalers
per month
(Institutional
pack);SL(0.6
gm daily); MO
MO; B/D
SL(20 ea daily);
MO
SL(8 ea daily);
MO
SL(40 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
23
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0FLOVENT HFA AERO 110 $7.40
MCG/ACT, 220 MCG/ACT (Tier
2)
$0FLOVENT HFA AERO 44 $7.40
(Tier
MCG/ACT
2)
PULMICORT SUSP 0.25
NF
MG/2ML, 0.5 MG/2ML
(Budesonide (Inhalation))
$0$7.40
QVAR AERS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Limit 2 inhalers
per
month;QL(0.8
gm daily); MO
Limit 1 inhaler
per
month;QL(0.36
gm daily); MO
MO; B/D
Limit 3 inhalers
per
month;QL(0.87
gm daily); MO
Sympathomimetics
ADVAIR DISKUS AEPB
ADVAIR HFA AERO
albuterol sulfate nebu in
0.083 %, 0.5 %, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate syrp or 2
mg/5ml
albuterol sulfate tabs or 2
mg, 4 mg
albuterol sulfate tb12 or 4
mg, 8 mg
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
QL(4 gm daily);
MO
MO; B/D
MO
MO
MO
Name of drug
ANORO ELLIPTA AEPB
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(2 ea daily);
MO
$0- Limit 2 inhalers
BREO ELLIPTA AEPB
$7.40 per month
25MCG/INH-100MCG/INH, (Tier (Institutional
25MCG/INH-200MCG/INH
2) Pack);SL(2 ea
daily); MO
$0- Limit 1 inhaler
BREO ELLIPTA AEPB
$7.40
25MCG/INH-100MCG/INH, (Tier per month;SL(2
ea daily); MO
25MCG/INH-200MCG/INH
2)
$0- Limit 1 inhaler
COMBIVENT RESPIMAT $7.40 per
(Tier month;SL(0.2
AERS
2) gm daily); MO
$0- QL(4 gm daily);
$7.40 MO
DULERA AERO
(Tier
2)
$0 NT
EPHEDRINE HCL TABS
(Tier
OR
3)
$0$7.40
(Tier
2)
$0$2.95
ipratropium-albuterol soln
(Tier
1)
$0levalbuterol hcl nebu in
0.31 mg/3ml, 0.63 mg/3ml, $2.95
(Tier
1.25 mg/0.5ml, 1.25
1)
mg/3ml
$0$7.40
PROAIR HFA AERS
(Tier
2)
QL(2 ea daily)
FORADIL AEROLIZER
CAPS
MO; B/D
MO; B/D
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
24
Name of drug
PROAIR RESPICLICK
AEPB
PROVENTIL HFA AERS
SEREVENT DISKUS
AEPB
STIOLTO RESPIMAT
AERS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
STRIVERDI RESPIMAT
AERS
$0$7.40
(Tier
2)
terbutaline sulfate tabs or
2.5 mg, 5 mg
$0$2.95
(Tier
1)
XOPENEX
CONCENTRATE NEBU
(Levalbuterol HCl)
XOPENEX NEBU
(Levalbuterol HCl)
Necessary
actions,
restrictions, or
limits on use
MO
MO
Limit 1 inhaler
per
month;QL(0.14
gm daily); MO
Limit 1 inhaler
per month (60
actuations);SL(
0.14 gm daily);
MO
MO
MO; B/D
NF
NF MO; B/D
theophylline tb12 100 mg,
200 mg, 300 mg, 450 mg
theophylline tb24 400 mg,
600 mg
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants
COUMADIN TABS
(Warfarin Sodium)
warfarin sodium tabs
QL(2 ea daily);
MO
Xanthines
aminophylline soln
Name of drug
What
the
drug
will
cost
you
(tier
level)
NF MO
$0- MO
$2.95
(Tier
1)
Direct Factor Xa Inhibitors
ELIQUIS TABS
XARELTO STARTER
PACK TBPK
XARELTO TABS
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
Heparins And Heparinoid-Like Agents
ARIXTRA SOLN
NF MO
(Fondaparinux Sodium)
$0- MO
$2.95
enoxaparin sodium soln
(Tier
1)
$0- MO
$2.95
fondaparinux sodium soln
(Tier
1)
FRAGMIN SOLN 10000
MO
UNIT/ML, 12500
UNIT/0.5ML, 15000
$0UNIT/0.6ML, 18000
$7.40
UNT/0.72ML, 2500
(Tier
UNIT/0.2ML, 5000
2)
UNIT/0.2ML, 7500
UNIT/0.3ML, 95000
UNIT/3.8ML
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
25
Name of drug
FRAGMIN SOLN 25000
UNIT/ML
heparin sodium (porcine)
soln
LOVENOX SOLN
(Enoxaparin Sodium)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
Thrombin Inhibitors
argatroban soln 250
mg/2.5ml
IPRIVASK SOLR
PRADAXA CAPS
$0- MO
$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
ANTICONVULSANTS - Drugs to Treat Seizures
AMPA Glutamate Receptor Antagonists
$0$7.40
FYCOMPA SUSP 0.5
(Tier
MG/ML
2)
$0- MO
FYCOMPA TABS 10 MG, $7.40
12 MG, 2 MG, 4 MG, 6 MG, (Tier
8 MG
2)
Anticonvulsants - Benzodiazepines
$0- SL(40 ea daily);
$2.95 MO
clonazepam tabs or 0.5 mg (Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
clonazepam tabs or 1 mg
(Tier
1)
$0clonazepam tabs or 2 mg $2.95
(Tier
1)
$0clonazepam tbdp or 0.125 $2.95
mg, 0.25 mg, 0.5 mg, 1 mg, (Tier
2 mg
1)
$0$7.40
DIASTAT ACUDIAL GEL
(Tier
2)
$0$7.40
DIASTAT PEDIATRIC GEL (Tier
2)
$0$7.40
DIAZEPAM GEL RE 10
(Tier
MG, 2.5 MG, 20 MG
2)
KLONOPIN TABS 0.5 MG
NF
(Clonazepam)
KLONOPIN TABS 1 MG
NF
(Clonazepam)
KLONOPIN TABS 2 MG
NF
(Clonazepam)
$0$7.40
ONFI SUSP
(Tier
2)
$0$7.40
ONFI TABS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(20 ea daily);
MO
SL(10 ea daily);
MO
MO
MO
MO
MO
SL(40 ea daily);
MO
SL(20 ea daily);
MO
SL(10 ea daily);
MO
MO
MO
Anticonvulsants - Misc.
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
26
Name of drug
APTIOM TABS
BANZEL SUSP
BANZEL TABS
BRIVIACT SOLN IV 50
MG/5ML
BRIVIACT SOLN OR 10
MG/ML
BRIVIACT TABS OR 10
MG
BRIVIACT TABS OR 100
MG
BRIVIACT TABS OR 25
MG
BRIVIACT TABS OR 50
MG
BRIVIACT TABS OR 75
MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
SL(20 ml daily)
PA; SL(20 ml
daily)
PA; SL(20 ea
daily)
PA; SL(2 ea
daily); MO
PA; SL(8 ea
daily); MO
PA; SL(4 ea
daily); MO
PA; SL(2.67 ea
daily)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
carbamazepine chew or
(Tier
100 mg
1)
$0$2.95
carbamazepine cp12 or
(Tier
100 mg, 200 mg, 300 mg
1)
$0$2.95
carbamazepine susp or
(Tier
100 mg/5ml
1)
$0carbamazepine tabs or 200 $2.95
(Tier
mg
1)
$0carbamazepine tb12 or 100 $2.95
(Tier
mg, 200 mg, 400 mg
1)
CARBATROL CP12
NF
(Carbamazepine)
$0$2.95
gabapentin caps or 100
(Tier
mg, 300 mg, 400 mg
1)
$0$2.95
gabapentin soln or 250
(Tier
mg/5ml, 300 mg/6ml
1)
$0gabapentin tabs or 600 mg, $2.95
(Tier
800 mg
1)
KEPPRA SOLN
NF
(Levetiracetam)
KEPPRA TABS
NF
(Levetiracetam)
KEPPRA XR TB24
NF
(Levetiracetam)
LAMICTAL CHEWABLE
NF
DISPERSIBLE CHEW
(Lamotrigine)
Necessary
actions,
restrictions, or
limits on use
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 viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
27
Name of drug
LAMICTAL TABS
(Lamotrigine)
LAMICTAL XR KIT
LAMICTAL XR TB24 100
MG, 200 MG, 25 MG, 250
MG, 300 MG, 50 MG
(Lamotrigine)
lamotrigine chew 25 mg, 5
mg
lamotrigine tabs 100 mg,
150 mg, 200 mg, 25 mg
lamotrigine tb24 100 mg,
200 mg, 25 mg, 250 mg,
300 mg, 50 mg
LEVETIRACETAM SOLN
IV 1000MG/100ML750MG/100ML,
1500MG/100ML540MG/100ML,
500MG/100ML820MG/100ML
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$7.40
(Tier
2)
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0- MO
$2.95
levetiracetam soln iv 500
(Tier
mg/5ml
1)
$0- MO
levetiracetam soln or 100 $2.95
(Tier
mg/ml, 500 mg/5ml
1)
$0- MO
levetiracetam tabs or 1000 $2.95
mg, 250 mg, 500 mg, 750 (Tier
mg
1)
Name of drug
levetiracetam tb24 or 500
mg, 750 mg
LYRICA CAPS 100 MG
LYRICA CAPS 150 MG
LYRICA CAPS 200 MG
LYRICA CAPS 225 MG
LYRICA CAPS 25 MG
LYRICA CAPS 300 MG
LYRICA CAPS 50 MG
LYRICA CAPS 75 MG
LYRICA SOLN 20 MG/ML
MYSOLINE TABS
(Primidone)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
SL(6 ea daily);
MO
SL(4 ea daily);
MO
SL(3 ea daily);
MO
SL(2.66 ea
daily); MO
SL(24 ea daily);
MO
SL(2 ea daily);
MO
SL(12 ea daily);
MO
SL(8 ea daily);
MO
SL(30 ml daily);
MO
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
28
Name of drug
NEURONTIN CAPS
(Gabapentin)
NEURONTIN SOLN
(Gabapentin)
NEURONTIN TABS
(Gabapentin)
oxcarbazepine susp
oxcarbazepine tabs
POTIGA TABS 200 MG
POTIGA TABS 300 MG
POTIGA TABS 400 MG
POTIGA TABS 50 MG
primidone tabs or 250 mg,
50 mg
SPRITAM TB3D 1000 MG
SPRITAM TB3D 250 MG
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NF MO
NF MO
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
SPRITAM TB3D 500 MG
SPRITAM TB3D 750 MG
MO
MO
SL(6 ea daily);
MO
SL(4 ea daily);
MO
SL(3 ea daily);
MO
TEGRETOL SUSP
(Carbamazepine)
TEGRETOL TABS
(Carbamazepine)
TEGRETOL-XR TB12 100
MG (Carbamazepine)
TEGRETOL-XR TB12 200
MG, 400 MG
(Carbamazepine)
TOPAMAX SPRINKLE
CPSP (Topiramate)
TOPAMAX TABS
(Topiramate)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; SL(6 ea
daily); MO
PA; SL(4 ea
daily); MO
NF MO
NF MO
$0- MO
$7.40
(Tier
2)
MO
NF
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
topiramate tabs or 100 mg, $2.95
(Tier
200 mg, 25 mg, 50 mg
1)
TRILEPTAL SUSP
NF MO
(Oxcarbazepine)
TRILEPTAL TABS
NF MO
(Oxcarbazepine)
$0$7.40
VIMPAT SOLN IV 200
(Tier
MG/20ML
2)
topiramate cpsp or 15 mg,
25 mg
SL(24 ea daily);
MO
MO
PA; SL(3 ea
daily); MO
PA; SL(12 ea
daily)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
29
Name of drug
VIMPAT SOLN OR 10
MG/ML
VIMPAT TABS OR 100
MG, 150 MG, 200 MG, 50
MG
ZONEGRAN CAPS
(Zonisamide)
zonisamide caps
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
tiagabine hcl tabs
MO
NF MO
$0- MO
$2.95
(Tier
1)
Carbamates
felbamate susp
felbamate tabs
FELBATOL SUSP
(Felbamate)
FELBATOL TABS
(Felbamate)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
NF MO
GABA Modulators
GABITRIL TABS 12 MG,
16 MG
GABITRIL TABS 2 MG, 4
MG (Tiagabine HCl)
SABRIL PACK
SABRIL TABS
Name of drug
$0- MO
$7.40
(Tier
2)
NF MO
$0- LA
$7.40
(Tier
2)
$0- LA
$7.40
(Tier
2)
Hydantoins
CEREBYX SOLN 100 MG
PE/2ML (Fosphenytoin
Sodium)
CEREBYX SOLN 500 MG
PE/10ML (Fosphenytoin
Sodium)
DILANTIN-125 SUSP
(Phenytoin)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF
MO
NF
NF MO
$0$2.95
(Tier
1)
$0fosphenytoin sodium soln $2.95
(Tier
500 mg pe/10ml
1)
$0$7.40
PEGANONE TABS
(Tier
2)
$0$2.95
phenytoin chew or 50 mg
(Tier
1)
$0phenytoin sodium extended $2.95
(Tier
caps
1)
$0$2.95
phenytoin sodium soln ij
(Tier
1)
$0$2.95
phenytoin susp or 125
(Tier
mg/5ml
1)
fosphenytoin sodium soln
100 mg pe/2ml
MO
MO
MO
MO
MO
Succinimides
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
30
Name of drug
CELONTIN CAPS
ethosuximide caps or 250
mg
ethosuximide soln or 250
mg/5ml
ZARONTIN CAPS
(Ethosuximide)
Valproic Acid
DEPACON SOLN
(Valproate Sodium)
DEPAKENE CAPS
(Valproic Acid)
DEPAKENE SYRP
(Valproate Sodium)
DEPAKOTE ER TB24
(Divalproex Sodium)
DEPAKOTE SPRINKLES
CSDR (Divalproex Sodium)
DEPAKOTE TBEC
(Divalproex Sodium)
divalproex sodium csdr
divalproex sodium tb24
divalproex sodium tbec
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
valproate sodium soln iv
100 mg/ml, 500 mg/5ml
MO
valproate sodium soln or
250 mg/5ml
MO
valproate sodium syrp or
250 mg/5ml
NF MO
valproic acid caps or
NF
NF MO
NF MO
NF MO
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
ANTIDEPRESSANTS - Drugs to Treat Depression
Alpha-2 Receptor Antagonists (Tetracyclics)
$0- MO
$2.95
mirtazapine tabs
(Tier
1)
$0- MO
$2.95
mirtazapine tbdp
(Tier
1)
REMERON SOLTAB TBDP NF MO
(Mirtazapine)
REMERON TABS
NF MO
(Mirtazapine)
Antidepressants - Misc.
bupropion hcl tabs or 100
mg
bupropion hcl tabs or 75
mg
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
SL(4.5 ea
daily); MO
SL(6 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
31
Name of drug
bupropion hcl tb12 or 100
mg
bupropion hcl tb12 or 150
mg
bupropion hcl tb12 or 200
mg
bupropion hcl tb24 or 150
mg
bupropion hcl tb24 or 300
mg
FORFIVO XL TB24
maprotiline hcl tabs
WELLBUTRIN SR TB12
100 MG (Bupropion HCl)
WELLBUTRIN SR TB12
150 MG (Bupropion HCl)
WELLBUTRIN SR TB12
200 MG (Bupropion HCl)
WELLBUTRIN TABS 100
MG (Bupropion HCl)
WELLBUTRIN TABS 75
MG (Bupropion HCl)
WELLBUTRIN XL TB24
150 MG (Bupropion HCl)
WELLBUTRIN XL TB24
300 MG (Bupropion HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(4 ea daily);
MO
SL(2.66 ea
daily); MO
SL(2 ea daily);
MO
SL(3 ea daily);
MO
SL(1.5 ea
daily); MO
ST; MO
MO
NF SL(4 ea daily);
MO
NF SL(2.66 ea
daily); MO
NF SL(2 ea daily);
MO
NF SL(4.5 ea
daily); MO
NF SL(6 ea daily);
MO
NF SL(3 ea daily);
MO
NF SL(1.5 ea
daily); MO
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Monoamine Oxidase Inhibitors (MAOIs)
$0- MO
$7.40
EMSAM PT24
(Tier
2)
$0- MO
$7.40
MARPLAN TABS
(Tier
2)
NARDIL TABS (Phenelzine NF MO
Sulfate)
PARNATE TABS
NF MO
(Tranylcypromine Sulfate)
$0- MO
$2.95
phenelzine sulfate tabs or
(Tier
1)
$0- MO
$2.95
tranylcypromine sulfate
(Tier
tabs
1)
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA TABS 10 MG
NF SL(4 ea daily);
(Citalopram Hydrobromide)
MO
CELEXA TABS 20 MG
NF SL(2 ea daily);
(Citalopram Hydrobromide)
MO
CELEXA TABS 40 MG
NF SL(1 ea daily);
(Citalopram Hydrobromide)
MO
$0- SL(20 ml daily);
$2.95 MO
citalopram hydrobromide
(Tier
soln 10 mg/5ml
1)
$0- SL(4 ea daily);
$2.95 MO
citalopram hydrobromide
(Tier
tabs 10 mg
1)
$0- SL(2 ea daily);
$2.95 MO
citalopram hydrobromide
(Tier
tabs 20 mg
1)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
32
Name of drug
citalopram hydrobromide
tabs 40 mg
escitalopram oxalate soln
escitalopram oxalate tabs
fluoxetine hcl caps or 10
mg, 20 mg, 40 mg
fluoxetine hcl cpdr or 90
mg
fluoxetine hcl soln or 20
mg/5ml
fluoxetine hcl tabs or 10
mg, 20 mg
fluvoxamine maleate cp24
fluvoxamine maleate tabs
LEXAPRO SOLN
(Escitalopram Oxalate)
LEXAPRO TABS
(Escitalopram Oxalate)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(1 ea daily);
MO
Name of drug
paroxetine hcl tabs
MO
paroxetine hcl tb24
MO
MO
MO
MO
MO
MO
MO
NF MO
NF MO
PAXIL CR TB24
(Paroxetine HCl)
PAXIL SUSP 10 MG/5ML
PAXIL TABS 10 MG, 20
MG, 30 MG, 40 MG
(Paroxetine HCl)
PROZAC CAPS
(Fluoxetine HCl)
PROZAC WEEKLY CPDR
(Fluoxetine HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF MO
$0- MO
$7.40
(Tier
2)
MO
NF
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
sertraline hcl tabs or 100
(Tier
mg, 25 mg, 50 mg
1)
ZOLOFT CONC (Sertraline NF MO
HCl)
ZOLOFT TABS (Sertraline
NF MO
HCl)
sertraline hcl conc or 20
mg/ml
Serotonin Modulators
$0$7.40
BRINTELLIX TABS 10 MG (Tier
2)
$0$7.40
BRINTELLIX TABS 20 MG (Tier
2)
ST; QL(2 ea
daily); MO
ST; QL(1 ea
daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
33
Name of drug
BRINTELLIX TABS 5 MG
nefazodone hcl tabs
trazodone hcl tabs or 100
mg, 150 mg, 300 mg, 50
mg
TRINTELLIX TABS 10 MG
TRINTELLIX TABS 20 MG
TRINTELLIX TABS 5 MG
VIIBRYD KIT
VIIBRYD STARTER PACK
KIT
VIIBRYD TABS 10 MG, 20
MG, 40 MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
ST; QL(4 ea
daily); MO
MO
MO
ST; QL(2 ea
daily); MO
ST; QL(1 ea
daily); MO
ST; QL(4 ea
daily); MO
ST
ST; MO
ST; MO
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA CPEP
NF MO
(Duloxetine HCl)
$0- ST; MO
$7.40
DESVENLAFAXINE ER
(Tier
TB24 100 MG, 50 MG
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
DESVENLAFAXINE ER
(Tier
TB24 100 MG, 50 MG
2)
$0duloxetine hcl cpep 20 mg, $2.95
(Tier
30 mg, 60 mg
1)
EFFEXOR XR CP24 150
NF
MG (Venlafaxine HCl)
EFFEXOR XR CP24 37.5
NF
MG (Venlafaxine HCl)
EFFEXOR XR CP24 75
NF
MG (Venlafaxine HCl)
$0$7.40
FETZIMA CP24 120 MG,
(Tier
40 MG, 80 MG
2)
$0$7.40
FETZIMA CP24 20 MG
(Tier
2)
$0$7.40
FETZIMA TITRATION
(Tier
PACK C4PK
2)
$0$7.40
KHEDEZLA TB24
(Tier
2)
$0$7.40
PRISTIQ TB24
(Tier
2)
$0$2.95
venlafaxine hcl cp24 150
(Tier
mg
1)
$0venlafaxine hcl cp24 37.5 $2.95
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
ST; Fumarate
MO
SL(1.5 ea
daily); MO
SL(6 ea daily);
MO
SL(3 ea daily);
MO
ST; QL(1 ea
daily); MO
ST; QL(2 ea
daily); MO
ST; MO
ST; MO
ST; MO
SL(1.5 ea
daily); MO
SL(6 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
34
Name of drug
venlafaxine hcl cp24 75 mg
VENLAFAXINE HCL ER
TB24
venlafaxine hcl tabs 100
mg
venlafaxine hcl tabs 25 mg
venlafaxine hcl tabs 37.5
mg
venlafaxine hcl tabs 50 mg
venlafaxine hcl tabs 75 mg
venlafaxine hcl tb24 150
mg
venlafaxine hcl tb24 37.5
mg
venlafaxine hcl tb24 75 mg
Tricyclic Agents
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(3 ea daily);
MO
Name of drug
amitriptyline hcl tabs
ST; SL(1 ea
daily); MO
amoxapine tabs
SL(3.75 ea
daily); MO
ANAFRANIL CAPS
(Clomipramine HCl)
SL(15 ea daily);
MO
SL(10 ea daily);
MO
SL(7.5 ea
daily); MO
SL(5 ea daily);
MO
SL(1.5 ea
daily); MO
SL(6 ea daily);
MO
SL(3 ea daily);
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
MO
NF AL; MO
$0$2.95
(Tier
1)
$0desipramine hcl tabs or 10 $2.95
mg, 100 mg, 150 mg, 25
(Tier
mg, 50 mg, 75 mg
1)
$0doxepin hcl caps or 10 mg, $2.95
100 mg, 150 mg, 25 mg, 50 (Tier
mg, 75 mg
1)
$0$2.95
doxepin hcl conc or 10
(Tier
mg/ml
1)
ELAVIL TABS
NF
(Amitriptyline HCl)
$0$2.95
imipramine hcl tabs or 10
(Tier
mg, 25 mg, 50 mg
1)
$0$2.95
imipramine pamoate caps (Tier
1)
NORPRAMIN TABS
NF
(Desipramine HCl)
$0nortriptyline hcl caps or 10 $2.95
(Tier
mg, 25 mg, 50 mg, 75 mg
1)
AL; MO
clomipramine hcl caps or
25 mg, 50 mg, 75 mg
MO
AL; MO
AL; MO
AL; MO
AL; MO
AL; MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
35
Name of drug
nortriptyline hcl soln or 10
mg/5ml
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
PAMELOR CAPS
(Nortriptyline HCl)
protriptyline hcl tabs
SURMONTIL CAPS
TOFRANIL-PM CAPS
(Imipramine Pamoate)
Necessary
actions,
restrictions, or
limits on use
MO
SYMLINPEN 60 SOPN
NF MO
$0- MO
$2.95
(Tier
1)
$0- AL; MO
$7.40
(Tier
2)
NF AL; MO
$0- AL; MO
trimipramine maleate caps $2.95
(Tier
or 100 mg, 25 mg, 50 mg
1)
ANTIDIABETICS - Drugs to Regulate Blood Sugar
Alpha-Glucosidase Inhibitors
acarbose tabs
GLYSET TABS (Miglitol)
miglitol tabs
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
PRECOSE TABS
(Acarbose)
QL(3 ea daily);
MO
QL(3 ea daily);
MO
QL(3 ea daily);
MO
NF QL(3 ea daily);
MO
Antidiabetic - Amylin Analogs
SYMLINPEN 120 SOPN
Name of drug
$0- Limit 12mls per
$7.40 month;QL(0.4
(Tier ml daily); MO
2)
Antidiabetic Combinations
ACTOPLUS MET TABS
(Pioglitazone HClMetformin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Limit 12mls per
month;QL(0.4
ml daily); MO
SL(3 ea daily);
NF MO
$0ALOGLIPTIN/METFORMIN $7.40
(Tier
HCL TABS
2)
$0ALOGLIPTIN/PIOGLITAZO $7.40
(Tier
NE TABS 12.5MG-15MG
2)
$0ALOGLIPTIN/PIOGLITAZO $7.40
(Tier
NE TABS 12.5MG-30MG
2)
ALOGLIPTIN/PIOGLITAZO $0NE TABS 12.5MG-45MG, $7.40
(Tier
25MG-15MG, 25MG2)
30MG, 25MG-45MG
DUETACT TABS
NF
(Pioglitazone HClGlimepiride)
$0glipizide-metformin hcl tabs $2.95
(Tier
2.5mg-250mg
1)
$0glipizide-metformin hcl tabs $2.95
2.5mg-500mg, 5mg-500mg (Tier
1)
GLUCOVANCE TABS
NF
1.25MG-250MG
(Glyburide-Metformin)
GLUCOVANCE TABS
2.5MG-500MG, 5MGNF
500MG (GlyburideMetformin)
PA; SL(2 ea
daily); MO
PA; SL(2 ea
daily); MO
PA; SL(1.5 ea
daily); MO
PA; SL(1 ea
daily); MO
SL(1.5 ea
daily); MO
SL(8 ea daily);
MO
SL(4 ea daily);
MO
AL; SL(8 ea
daily); MO
AL; SL(4 ea
daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
36
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
glyburide-metformin tabs
(Tier
1.25mg-250mg
1)
$0$2.95
glyburide-metformin tabs
2.5mg-500mg, 5mg-500mg (Tier
1)
$0INVOKAMET TABS
$7.40
150MG-1000MG, 150MG- (Tier
500MG, 50MG-1000MG
2)
$0INVOKAMET TABS 50MG- $7.40
(Tier
500MG
2)
$0$7.40
JANUMET TABS
(Tier
2)
$0$7.40
JANUMET XR TB24
(Tier
100MG-1000MG
2)
$0JANUMET XR TB24
$7.40
50MG-1000MG, 50MG(Tier
500MG
2)
$0$7.40
JENTADUETO TABS
(Tier
2)
$0$7.40
JENTADUETO XR TB24
(Tier
2.5MG-1000MG
2)
$0$7.40
JENTADUETO XR TB24
(Tier
5MG-1000MG
2)
Necessary
actions,
restrictions, or
limits on use
AL; SL(8 ea
daily); MO
AL; SL(4 ea
daily); MO
SL(2 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
SL(1 ea daily);
MO
SL(2 ea daily);
MO
SL(2 ea daily);
MO
SL(2 ea daily);
MO
SL(1 ea daily);
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
KAZANO TABS
(Tier
2)
$0$7.40
KOMBIGLYZE XR TB24
(Tier
2.5MG-1000MG
2)
$0KOMBIGLYZE XR TB24
$7.40
5MG-1000MG, 5MG(Tier
500MG
2)
$0$7.40
OSENI TABS 12.5MG(Tier
15MG
2)
$0$7.40
OSENI TABS 12.5MG(Tier
30MG
2)
$0OSENI TABS 12.5MG$7.40
45MG, 25MG-15MG,
(Tier
25MG-30MG, 25MG-45MG 2)
$0pioglitazone hcl-glimepiride $2.95
(Tier
tabs
1)
$0pioglitazone hcl-metformin $2.95
(Tier
hcl tabs
1)
$0PRANDIMET TABS
$7.40
(Repaglinide-Metformin
(Tier
HCl)
2)
$0repaglinide-metformin hcl $2.95
(Tier
tabs
1)
Necessary
actions,
restrictions, or
limits on use
PA; SL(2 ea
daily); MO
PA; SL(2 ea
daily); MO
PA; SL(1 ea
daily); MO
PA; SL(2 ea
daily); MO
PA; SL(1.5 ea
daily); MO
PA; SL(1 ea
daily); MO
SL(1.5 ea
daily); MO
SL(3 ea daily);
MO
SL(5 ea daily);
MO
SL(5 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
37
Name of drug
SYNJARDY TABS
12.5MG-1000MG, 5MG1000MG
SYNJARDY TABS
12.5MG-500MG, 5MG500MG
Biguanides
FORTAMET TB24 1000
MG (Metformin HCl)
FORTAMET TB24 500 MG
(Metformin HCl)
GLUCOPHAGE TABS
1000 MG (Metformin HCl)
GLUCOPHAGE TABS 500
MG (Metformin HCl)
GLUCOPHAGE TABS 850
MG (Metformin HCl)
GLUCOPHAGE XR TB24
500 MG (Metformin HCl)
GLUCOPHAGE XR TB24
750 MG (Metformin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(2 ea daily);
MO
SL(4 ea daily);
MO
NF Osmotic;SL(2.5
ea daily); MO
NF Osmotic;SL(5
ea daily); MO
NF SL(2.55 ea
daily); MO
NF SL(5.1 ea
daily); MO
NF SL(3 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(2.66 ea
daily); MO
$0- SL(2.55 ea
metformin hcl tabs or 1000 $2.95 daily); MO
(Tier
mg
1)
$0- SL(5.1 ea
metformin hcl tabs or 500 $2.95 daily); MO
(Tier
mg
1)
$0- SL(3 ea daily);
metformin hcl tabs or 850 $2.95 MO
(Tier
mg
1)
$0- (GLUMETZA);
metformin hcl tb24 or 1000 $2.95 SL(2 ea daily);
(Tier MO
mg
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0metformin hcl tb24 or 1000 $2.95
(Tier
mg
1)
$0metformin hcl tb24 or 500 $2.95
(Tier
mg
1)
$0metformin hcl tb24 or 500 $2.95
(Tier
mg
1)
$0metformin hcl tb24 or 500 $2.95
(Tier
mg
1)
$0metformin hcl tb24 or 750 $2.95
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
Osmotic;SL(2.5
ea daily); MO
(GLUMETZA);
SL(4 ea daily);
MO
Osmotic;SL(5
ea daily); MO
SL(4 ea daily);
MO
SL(2.66 ea
daily); MO
Diabetic Other
BD GLUCOSE CHEW
CVS GLUCOSE CHEW 4
GM
DEX4 QUICK DISSOLVE
GLUCOSE CHEW
dextrose (diabetic use) gel
15 gm/38gm, 40 %
GLUCAGEN HYPOKIT
SOLR
glucagon (rdna) kit
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
NT
MO; NT
MO; NT
MO; NT
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
38
Name of drug
GLUCOSE CHEW 4 GM
GNP GLUCOSE CHEW 4
GM
GNP QUICK DISSOLVE
GLUCOSE CHEW
KORLYM TABS
LEADER QUICK
DISSOLVE GLUCOSE
CHEW
PROGLYCEM SUSP
SM GLUCOSE CHEW 4
GM
WALGREENS GLUCOSE
CHEW 4 GM
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0$7.40
(Tier
2)
$0
(Tier
3)
$0$7.40
(Tier
2)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
ONGLYZA TABS
MO; NT
MO; NT
SL(4 ea daily);
LA
MO; NT
MO
MO; NT
MO; NT
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
$0- PA; MO
$7.40
ALOGLIPTIN TABS
(Tier
2)
$0- MO
$7.40
JANUVIA TABS
(Tier
2)
$0- PA; MO
$7.40
NESINA TABS
(Tier
2)
TRADJENTA TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; MO
MO
Dopamine Receptor Agonists - Antidiabetic
$0- QL(6 ea daily);
$7.40 MO
CYCLOSET TABS
(Tier
2)
Incretin Mimetic Agents (GLP-1 Receptor
$0- ST; MO
$7.40
BYDUREON PEN PEN
(Tier
2)
$0- ST; MO
$7.40
BYDUREON SRER
(Tier
2)
$0- ST; MO
$7.40
BYETTA SOPN
(Tier
2)
$0- ST; Limit 9mls
$7.40 per
VICTOZA SOPN
(Tier month;QL(0.3
2) ml daily); MO
Insulin Sensitizing Agents
ACTOS TABS 15 MG
(Pioglitazone HCl)
ACTOS TABS 30 MG
(Pioglitazone HCl)
ACTOS TABS 45 MG
(Pioglitazone HCl)
AVANDIA TABS 2 MG
NF SL(3 ea daily);
MO
NF SL(1.5 ea
daily); MO
NF SL(1 ea daily);
MO
$0- SL(4 ea daily);
$7.40 MO
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
39
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
AVANDIA TABS 4 MG
(Tier
2)
$0pioglitazone hcl tabs 15 mg $2.95
(Tier
1)
$0$2.95
pioglitazone hcl tabs 30 mg (Tier
1)
$0$2.95
pioglitazone hcl tabs 45 mg (Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(2 ea daily);
MO
SL(3 ea daily);
MO
SL(1.5 ea
daily); MO
SL(1 ea daily);
MO
Insulin
HUMALOG KWIKPEN
SOPN
HUMALOG MIX 50/50
KWIKPEN SUPN
HUMALOG MIX 50/50
SUSP
HUMALOG MIX 75/25
KWIKPEN SUPN
HUMALOG MIX 75/25
SUSP
HUMALOG SOCT
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
HUMALOG SOLN
(Tier
2)
$0HUMULIN 70/30 KWIKPEN $7.40
(Tier
SUPN
2)
$0$7.40
HUMULIN 70/30 SUSP
(Tier
2)
$0$7.40
HUMULIN N KWIKPEN
(Tier
SUPN
2)
$0$7.40
HUMULIN N SUSP
(Tier
2)
$0$7.40
HUMULIN R SOLN
(Tier
2)
$0$7.40
HUMULIN R U-500
(CONCENTRATED) SOLN (Tier
2)
$0$7.40
HUMULIN R U-500
(Tier
KWIKPEN SOPN
2)
$0$7.40
LANTUS SOLN
(Tier
2)
$0$7.40
LANTUS SOLOSTAR
(Tier
SOPN
2)
Necessary
actions,
restrictions, or
limits on use
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
Limit 45mls per
month;QL(1.5
ml daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
40
Name of drug
LEVEMIR FLEXTOUCH
SOPN
LEVEMIR SOLN
TOUJEO SOLOSTAR
SOPN
TRESIBA FLEXTOUCH
SOPN 100 UNIT/ML
TRESIBA FLEXTOUCH
SOPN 200 UNIT/ML
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Limit 45mls per
month;QL(1.5
ml daily); MO
repaglinide tabs 2 mg
Limit 45mls per
month;QL(1.5
ml daily); MO
STARLIX TABS
(Nateglinide)
Limit 15mls per
month;QL(0.5
ml daily); MO
QL(1.5 ml
daily); MO
QL(0.9 ml
daily); MO
Meglitinide Analogues
nateglinide tabs
PRANDIN TABS 0.5 MG
(Repaglinide)
PRANDIN TABS 1 MG
(Repaglinide)
PRANDIN TABS 2 MG
(Repaglinide)
repaglinide tabs 0.5 mg
repaglinide tabs 1 mg
Name of drug
$0- QL(3 ea daily);
$2.95 MO
(Tier
1)
NF SL(32 ea daily);
MO
NF SL(16 ea daily);
MO
NF SL(8 ea daily);
MO
$0- SL(32 ea daily);
$2.95 MO
(Tier
1)
$0- SL(16 ea daily);
$2.95 MO
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(8 ea daily);
MO
NF QL(3 ea daily);
MO
Sodium-Glucose Co-Transporter 2 (SGLT2)
$0- MO
$7.40
INVOKANA TABS
(Tier
2)
$0- MO
$7.40
JARDIANCE TABS
(Tier
2)
Sulfonylureas
AMARYL TABS 1 MG
(Glimepiride)
AMARYL TABS 2 MG
(Glimepiride)
AMARYL TABS 4 MG
(Glimepiride)
DIABETA TABS 1.25 MG
(Glyburide)
DIABETA TABS 2.5 MG
(Glyburide)
DIABETA TABS 5 MG
(Glyburide)
glimepiride tabs 1 mg
glimepiride tabs 2 mg
NF SL(8 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(2 ea daily);
MO
$0- AL; SL(16 ea
$7.40 daily); MO
(Tier
2)
$0- AL; SL(8 ea
$7.40 daily); MO
(Tier
2)
$0- AL; SL(4 ea
$7.40 daily); MO
(Tier
2)
$0- SL(8 ea daily);
$2.95 MO
(Tier
1)
$0- SL(4 ea daily);
$2.95 MO
(Tier
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
41
Name of drug
glimepiride tabs 4 mg
glipizide tabs or 10 mg
glipizide tabs or 5 mg
glipizide tb24 or 10 mg
glipizide tb24 or 2.5 mg
glipizide tb24 or 5 mg
GLUCOTROL TABS 10
MG (Glipizide)
GLUCOTROL TABS 5 MG
(Glipizide)
GLUCOTROL XL TB24 10
MG (Glipizide)
GLUCOTROL XL TB24 2.5
MG (Glipizide)
GLUCOTROL XL TB24 5
MG (Glipizide)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(2 ea daily);
MO
SL(4 ea daily);
MO
SL(8 ea daily);
MO
SL(2 ea daily);
MO
SL(8 ea daily);
MO
SL(4 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(8 ea daily);
MO
NF SL(2 ea daily);
MO
NF SL(8 ea daily);
MO
NF SL(4 ea daily);
MO
$0- AL; SL(8 ea
glyburide micronized tabs $2.95 daily); MO
(Tier
1.5 mg
1)
$0- AL; SL(4 ea
glyburide micronized tabs 3 $2.95 daily); MO
(Tier
mg
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0glyburide micronized tabs 6 $2.95
(Tier
mg
1)
$0glyburide tabs or 1.25 mg $2.95
(Tier
1)
$0$2.95
glyburide tabs or 2.5 mg
(Tier
1)
$0$2.95
glyburide tabs or 5 mg
(Tier
1)
GLYNASE TABS 1.5 MG
NF
(Glyburide Micronized)
GLYNASE TABS 3 MG
NF
(Glyburide Micronized)
GLYNASE TABS 6 MG
NF
(Glyburide Micronized)
$0$2.95
tolazamide tabs 250 mg
(Tier
1)
$0$2.95
tolazamide tabs 500 mg
(Tier
1)
$0$2.95
tolbutamide tabs
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
AL; SL(2 ea
daily); MO
AL; SL(16 ea
daily); MO
AL; SL(8 ea
daily); MO
AL; SL(4 ea
daily); MO
AL; SL(8 ea
daily); MO
AL; SL(4 ea
daily); MO
AL; SL(2 ea
daily); MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
SL(6 ea daily);
MO
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal Agents - Misc.
$0 MO; NT
bismuth subsalicylate chew (Tier
or 262 mg
3)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
42
What
the
drug
will
Name of drug
cost
you
(tier
level)
bismuth subsalicylate susp $0
(Tier
or 262 mg/15ml, 525
3)
mg/30ml, 527 mg/30ml
$0
bismuth subsalicylate susp (Tier
or 525 mg/15ml
3)
$0
bismuth subsalicylate tabs (Tier
or 262 mg
3)
PEPTO BISMOL TABS
NF
(Bismuth Subsalicylate)
PEPTO-BISMOL CHEW
NF
262 MG (Bismuth
Subsalicylate)
PEPTO-BISMOL
NF
INSTACOOL CHEW
(Bismuth Subsalicylate)
PEPTO-BISMOL MAX
NF
STRENGTH SUSP
(Bismuth Subsalicylate)
PEPTO-BISMOL SUSP
NF
262 MG/15ML (Bismuth
Subsalicylate)
PEPTO-BISMOL TO-GO
NF
CHEW (Bismuth
Subsalicylate)
Necessary
actions,
restrictions, or
limits on use
MO; NT
EXJADE TBSO
NT
NT
FERRIPROX TABS 500
MG
NT
JADENU TABS
MO; NT
MO; NT
NT
MO; NT
MO; NT
Antiperistaltic Agents
diphenoxylate w/ atropine
tabs
LOMOTIL TABS
(Diphenoxylate w/
Atropine)
loperamide hcl caps or 2
mg
Name of drug
$0- MO
$2.95
(Tier
1)
MO
NF
$0- RX/OTC; MO
$2.95
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
PA; LA
Antidotes and Specific Antagonists
$0 NT
SM IPECAC SYRUP SYRP (Tier
3)
Opioid Antagonists
naloxone hcl sosy ij 2
mg/2ml
naltrexone hcl tabs or
REVIA TABS (Naltrexone
HCl)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
ANTIEMETICS - Drugs to Treat Nausea and
Vomiting
5-HT3 Receptor Antagonists
granisetron hcl tabs or 1
mg
ondansetron hcl soln ij 4
mg/2ml, 40 mg/20ml
$0- MO; B/D
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
ANTIDOTES AND SPECIFIC ANTAGONISTS
Antidotes - Chelating Agents
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
43
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0ondansetron hcl soln or 4 $2.95
(Tier
mg/5ml
1)
$0ondansetron hcl tabs or 24 $2.95
(Tier
mg, 4 mg, 8 mg
1)
$0$2.95
ondansetron tbdp
(Tier
1)
ZOFRAN ODT TBDP
NF
(Ondansetron)
ZOFRAN SOLN IJ 40
NF
MG/20ML (Ondansetron
HCl)
ZOFRAN SOLN OR 4
NF
MG/5ML (Ondansetron
HCl)
ZOFRAN TABS OR 4 MG, NF
8 MG (Ondansetron HCl)
Necessary
actions,
restrictions, or
limits on use
MO; B/D
CESAMET CAPS
MO; B/D
dronabinol caps
MO; B/D
MO; B/D
MO
MO; B/D
MO; B/D
Antiemetics - Anticholinergic
$0
(Tier
3)
$0meclizine hcl tabs 12.5 mg, $2.95
(Tier
25 mg
1)
$0$7.40
TIGAN SOLN IM 100
(Tier
MG/ML
2)
$0$7.40
TRANSDERM-SCOP PT72 (Tier
2)
MO; NT
meclizine hcl chew 25 mg
Antiemetics - Miscellaneous
Name of drug
RX/OTC; MO
AL; MO
MO
MARINOL CAPS
(Dronabinol)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO; B/D
MO; B/D
NF MO; B/D
Substance P/Neurokinin 1 (NK1) Receptor
$0- MO; B/D
$7.40
EMEND CAPS OR 125
(Tier
MG, 80 MG
2)
$0- PA; MO
$7.40
EMEND CAPS OR 40 MG (Tier
2)
$0- B/D
$7.40
VARUBI TABS
(Tier
2)
ANTIFUNGALS - Drugs to Treat Fungal Infections
Antifungal - Glucan Synthesis Inhibitors
$0$7.40
CANCIDAS SOLR 50 MG
(Tier
2)
$0- MO
$7.40
CANCIDAS SOLR 70 MG
(Tier
2)
$0$7.40
ERAXIS SOLR 100 MG
(Tier
2)
$0- MO
$7.40
MYCAMINE SOLR
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
44
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
Antifungals
$0$7.40
ABELCET SUSP
(Tier
2)
$0$7.40
AMBISOME SUSR
(Tier
2)
$0- MO
$2.95
amphotericin b solr ij 50 mg (Tier
1)
ANCOBON CAPS 500 MG NF MO
(Flucytosine)
$0- MO
$2.95
flucytosine caps 500 mg
(Tier
1)
GRIS-PEG TABS
MO
NF
(Griseofulvin
Ultramicrosize)
$0- MO
$2.95
griseofulvin microsize susp (Tier
1)
$0- MO
$2.95
griseofulvin microsize tabs (Tier
1)
$0- MO
griseofulvin ultramicrosize $2.95
(Tier
tabs
1)
LAMISIL TABS 250 MG
NF MO
(Terbinafine HCl)
$0- MO
$2.95
nystatin tabs or
(Tier
1)
terbinafine hcl tabs or
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Imidazole-Related Antifungals
$0$7.40
CRESEMBA CAPS OR
(Tier
186 MG
2)
$0CRESEMBA SOLR IV 372 $7.40
(Tier
MG
2)
DIFLUCAN SUSR
NF
(Fluconazole)
DIFLUCAN TABS
NF
(Fluconazole)
$0$2.95
fluconazole in dextrose
(Tier
soln
1)
$0fluconazole in nacl soln
$2.95
200mg/100ml-0.9%,
(Tier
400mg/200ml-0.9%
1)
$0$2.95
fluconazole susr or 10
(Tier
mg/ml, 40 mg/ml
1)
$0fluconazole tabs or 100 mg, $2.95
(Tier
150 mg, 200 mg, 50 mg
1)
$0$2.95
itraconazole caps or
(Tier
1)
$0$2.95
ketoconazole tabs or
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
45
Name of drug
NOXAFIL SOLN IV 300
MG/16.7ML
NOXAFIL SUSP OR 40
MG/ML
NOXAFIL TBEC OR 100
MG
SPORANOX CAPS 100
MG (Itraconazole)
SPORANOX PULSEPAK
CAPS (Itraconazole)
VFEND IV SOLR
(Voriconazole)
VFEND SUSR
(Voriconazole)
VFEND TABS
(Voriconazole)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
CHLOR-TRIMETON TABS
4 MG (Chlorpheniramine
Maleate)
MO
MO
NF MO
NF MO
NF
NF MO
NF MO
$0$2.95
voriconazole solr iv 200 mg (Tier
1)
$0- MO
$2.95
voriconazole susr or 40
(Tier
mg/ml
1)
$0- MO
$2.95
voriconazole tabs or 200
(Tier
mg, 50 mg
1)
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Alkylamines
CHLOR-TRIMETON SYRP
AL; NT
2 MG/5ML
NF
(Chlorpheniramine
Maleate)
chlorpheniramine maleate
syrp or 2 mg/5ml
chlorpheniramine maleate
tabs or 4 mg
ED CHLORPED LIQD
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
AL; MO; NT
NF
$0 AL; NT
(Tier
3)
$0 AL; MO; NT
(Tier
3)
$0 AL; NT
(Tier
3)
Antihistamines - Ethanolamines
$0
(Tier
ALER-DRYL TABS
3)
BENADRYL ALLERGY
NF
CAPS (Diphenhydramine
HCl)
BENADRYL ALLERGY
CHILDRENS CHEW 12.5
NF
MG (Diphenhydramine
HCl)
BENADRYL ALLERGY
CHILDRENS LIQD 12.5
NF
MG/5ML (Diphenhydramine
HCl)
BENADRYL ALLERGY
NF
TABS (Diphenhydramine
HCl)
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS
NF
CAPS (Diphenhydramine
HCl)
$0$2.95
carbinoxamine maleate
(Tier
soln
1)
$0$2.95
carbinoxamine maleate
(Tier
tabs
1)
AL; NT
AL; MO; NT
AL; NT
AL; MO; NT
AL; MO; NT
AL; MO; NT
AL; MO
AL; MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
46
Name of drug
clemastine fumarate tabs
or 2.68 mg
diphenhydramine hcl caps
or 25 mg
diphenhydramine hcl chew
or 12.5 mg
diphenhydramine hcl elix or
12.5 mg/5ml
diphenhydramine hcl liqd or
12.5 mg/5ml, 25 mg/10ml,
50 mg/20ml
diphenhydramine hcl soln ij
50 mg/ml
diphenhydramine hcl syrp
or 12.5 mg/5ml
diphenhydramine hcl tabs
or 25 mg
TRIAMINIC COUGH &
RUNNY NOSE STRP
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; MO; NT
AL; NT
Name of drug
CLARITIN TABS 10 MG
(Loratadine)
desloratadine tabs
desloratadine tbdp
AL; RX/OTC
levocetirizine
dihydrochloride soln
AL; MO; NT
levocetirizine
dihydrochloride tabs
AL; MO
loratadine tabs or 10 mg
AL; NT
AL; MO; NT
AL; NT
Antihistamines - Non-Sedating
$0- RX/OTC; MO
$2.95
cetirizine hcl soln 1 mg/ml (Tier
1)
$0- RX/OTC; MO
$2.95
cetirizine hcl syrp 1 mg/ml (Tier
1)
CLARINEX TABS 5 MG
NF MO
(Desloratadine)
XYZAL SOLN
(Levocetirizine
Dihydrochloride)
XYZAL TABS
(Levocetirizine
Dihydrochloride)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF QL(1 ea daily);
MO; NT
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0 QL(1 ea daily);
(Tier MO; NT
3)
MO
NF
MO
NF
Antihistamines - Phenothiazines
$0- AL; MO
promethazine hcl soln ij 25 $2.95
(Tier
mg/ml, 50 mg/ml
1)
$0- AL; MO
$2.95
promethazine hcl soln or
(Tier
6.25 mg/5ml
1)
$0- AL; MO
promethazine hcl supp re $2.95
(Tier
12.5 mg, 25 mg
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
47
Name of drug
promethazine hcl syrp or
6.25 mg/5ml
promethazine hcl tabs or
12.5 mg, 25 mg, 50 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
AL; MO
cholestyramine light pack
AL; MO
Antihistamines - Piperidines
$0- AL; MO
cyproheptadine hcl syrp or $2.95
(Tier
2 mg/5ml
1)
$0- AL; MO
cyproheptadine hcl tabs or $2.95
(Tier
4 mg
1)
ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
Antihyperlipidemics - Misc.
$0- PA; LA
$7.40
KYNAMRO SOSY
(Tier
2)
LOVAZA CAPS (Omega-3- NF MO
acid Ethyl Esters)
$0- MO
omega-3-acid ethyl esters $2.95
(Tier
caps
1)
$0- ST
$7.40
VASCEPA CAPS 0.5 GM
(Tier
2)
$0- ST; MO
$7.40
VASCEPA CAPS 1 GM
(Tier
2)
Bile Acid Sequestrants
cholestyramine light powd
cholestyramine pack or 4
gm
cholestyramine powd or 4
gm/dose
COLESTID FLAVORED
GRAN 5 GM (Colestipol
HCl)
COLESTID GRAN
(Colestipol HCl)
COLESTID PACK
(Colestipol HCl)
COLESTID TABS
(Colestipol HCl)
colestipol hcl gran
colestipol hcl pack
colestipol hcl tabs
WELCHOL PACK
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
NF
NF MO
NF MO
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
48
Name of drug
WELCHOL TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
TRIGLIDE TABS
Fibric Acid Derivatives
$0$7.40
ANTARA CAPS 30 MG
(Tier
2)
$0$7.40
ANTARA CAPS 90 MG
(Tier
2)
$0$2.95
choline fenofibrate cpdr
(Tier
1)
$0fenofibrate micronized caps $2.95
(Tier
130 mg
1)
$0fenofibrate micronized caps $2.95
(Tier
134 mg, 200 mg, 67 mg
1)
$0fenofibrate micronized caps $2.95
(Tier
43 mg
1)
$0$2.95
fenofibrate tabs 145 mg,
(Tier
160 mg, 48 mg, 54 mg
1)
$0$2.95
gemfibrozil tabs or
(Tier
1)
Name of drug
SL(4.33 ea
daily); MO
SL(1.44 ea
daily); MO
MO
SL(1 ea daily);
MO
MO
SL(3.02 ea
daily); MO
MO
MO
LOPID TABS (Gemfibrozil)
NF MO
TRICOR TABS
(Fenofibrate)
NF MO
TRILIPIX CPDR (Choline
Fenofibrate)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
HMG CoA Reductase Inhibitors
$0$2.95
atorvastatin calcium tabs
(Tier
1)
$0$7.40
CRESTOR TABS
(Tier
(Rosuvastatin Calcium)
2)
$0fluvastatin sodium caps 20 $2.95
(Tier
mg, 40 mg
1)
LESCOL CAPS
NF
(Fluvastatin Sodium)
LIPITOR TABS
NF
(Atorvastatin Calcium)
$0$2.95
lovastatin tabs
(Tier
1)
MEVACOR TABS
NF
(Lovastatin)
PRAVACHOL TABS
NF
(Pravastatin Sodium)
$0$2.95
pravastatin sodium tabs
(Tier
1)
$0$2.95
rosuvastatin calcium tabs
(Tier
1)
MO
ST; MO
MO
MO
MO
MO
MO
MO
MO
ST; MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
49
Name of drug
simvastatin tabs or 10 mg
simvastatin tabs or 20 mg
simvastatin tabs or 40 mg
simvastatin tabs or 5 mg
simvastatin tabs or 80 mg
ZOCOR TABS 10 MG
(Simvastatin)
ZOCOR TABS 20 MG
(Simvastatin)
ZOCOR TABS 40 MG
(Simvastatin)
ZOCOR TABS 5 MG
(Simvastatin)
ZOCOR TABS 80 MG
(Simvastatin)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(8 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
SL(16 ea daily);
MO
SL(1 ea daily);
MO
NF SL(8 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(2 ea daily);
MO
NF SL(16 ea daily);
MO
NF SL(1 ea daily);
MO
Intestinal Cholesterol Absorption Inhibitors
$0- MO
$7.40
ZETIA TABS
(Tier
2)
Microsomal Triglyceride Transfer Protein (MTP)
$0- PA; SL(6 ea
$7.40 daily); LA
JUXTAPID CAPS 10 MG
(Tier
2)
Name of drug
JUXTAPID CAPS 20 MG
JUXTAPID CAPS 30 MG
JUXTAPID CAPS 40 MG
JUXTAPID CAPS 5 MG
JUXTAPID CAPS 60 MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; SL(3 ea
daily); LA
PA; SL(2 ea
daily); LA
PA; SL(1.5 ea
daily); LA
PA; SL(12 ea
daily); LA
PA; SL(1 ea
daily); LA
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
tbcr
NIASPAN TBCR (Niacin
(Antihyperlipidemic))
$0- MO
$2.95
(Tier
1)
NF MO
Proprotein Convertase Subtilisin/Kexin Type 9
$0- PA; Limit 2mls
$7.40 per 28
PRALUENT SOPN 150
(Tier days;SL(0.08
MG/ML
2) ml daily)
$0- PA; Limit 4mls
$7.40 per 28
PRALUENT SOPN 75
(Tier days;SL(0.15
MG/ML
2) ml daily)
$0- PA; Limit 2mls
$7.40 per 28
PRALUENT SOSY 150
(Tier days;SL(0.08
MG/ML
2) ml daily)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
50
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
PRALUENT SOSY 75
(Tier
MG/ML
2)
$0REPATHA PUSHTRONEX $7.40
(Tier
SYSTEM SOCT
2)
$0$7.40
REPATHA SOSY
(Tier
2)
$0$7.40
REPATHA SURECLICK
(Tier
SOAJ
2)
Necessary
actions,
restrictions, or
limits on use
PA; Limit 4mls
per 28
days;SL(0.15
ml daily)
PA
PA
PA
ANTIHYPERTENSIVES - Drugs to Treat High
Blood Pressure
ACE Inhibitors
ACCUPRIL TABS
(Quinapril HCl)
ACEON TABS 4 MG
(Perindopril Erbumine)
ACEON TABS 8 MG
(Perindopril Erbumine)
ALTACE CAPS (Ramipril)
benazepril hcl tabs or 10
mg, 20 mg, 40 mg, 5 mg
captopril tabs or 100 mg,
12.5 mg, 25 mg, 50 mg
enalapril maleate tabs or
10 mg
NF MO
NF SL(4 ea daily);
MO
NF SL(2 ea daily);
MO
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
SL(4 ea daily);
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
enalapril maleate tabs or
(Tier
2.5 mg
1)
$0$2.95
enalapril maleate tabs or
(Tier
20 mg
1)
$0enalapril maleate tabs or 5 $2.95
(Tier
mg
1)
$0$2.95
fosinopril sodium tabs
(Tier
1)
$0lisinopril tabs or 10 mg, 2.5 $2.95
mg, 20 mg, 30 mg, 40 mg, (Tier
5 mg
1)
LOTENSIN TABS
NF
(Benazepril HCl)
MAVIK TABS (Trandolapril)
SL(16 ea daily);
MO
SL(2 ea daily);
MO
SL(8 ea daily);
MO
MO
MO
MO
NF MO
$0$2.95
moexipril hcl tabs
(Tier
1)
$0perindopril erbumine tabs 2 $2.95
(Tier
mg
1)
$0perindopril erbumine tabs 4 $2.95
(Tier
mg
1)
$0perindopril erbumine tabs 8 $2.95
(Tier
mg
1)
PRINIVIL TABS (Lisinopril)
Necessary
actions,
restrictions, or
limits on use
MO
SL(8 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
51
Name of drug
quinapril hcl tabs
ramipril caps
trandolapril tabs
VASOTEC TABS 10 MG
(Enalapril Maleate)
VASOTEC TABS 2.5 MG
(Enalapril Maleate)
VASOTEC TABS 20 MG
(Enalapril Maleate)
VASOTEC TABS 5 MG
(Enalapril Maleate)
ZESTRIL TABS (Lisinopril)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
candesartan cilexetil tabs
MO
Agents for Pheochromocytoma
$0- MO
$7.40
DEMSER CAPS
(Tier
2)
$0- MO
$7.40
DIBENZYLINE CAPS
(Tier
(Phenoxybenzamine HCl)
2)
$0- MO
$2.95
phenoxybenzamine hcl
(Tier
caps or
1)
Angiotensin II Receptor Antagonists
ATACAND TABS
NF MO
(Candesartan Cilexetil)
AVAPRO TABS
NF MO
(Irbesartan)
Necessary
actions,
restrictions, or
limits on use
MO
COZAAR TABS (Losartan
Potassium)
NF MO
DIOVAN TABS (Valsartan)
NF MO
MO
NF SL(4 ea daily);
MO
NF SL(16 ea daily);
MO
NF SL(2 ea daily);
MO
NF SL(8 ea daily);
MO
NF MO
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
eprosartan mesylate tabs
irbesartan tabs
losartan potassium tabs
valsartan tabs
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Antiadrenergic Antihypertensives
CARDURA TABS
NF
(Doxazosin Mesylate)
CATAPRES TABS
NF
(Clonidine HCl)
CATAPRES-TTS-1 PTWK
NF
(Clonidine HCl)
CATAPRES-TTS-2 PTWK
NF
(Clonidine HCl)
CATAPRES-TTS-3 PTWK
NF
(Clonidine HCl)
$0clonidine hcl ptwk td 0.1
$2.95
mg/24hr, 0.2 mg/24hr, 0.3 (Tier
mg/24hr
1)
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
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52
Name of drug
clonidine hcl tabs or 0.1
mg, 0.2 mg, 0.3 mg
doxazosin mesylate tabs
guanfacine hcl tabs
MINIPRESS CAPS
(Prazosin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
AL; MO
NF MO
$0- MO
$2.95
prazosin hcl caps
(Tier
1)
$0RESERPINE TABS OR 0.1 $7.40
(Tier
MG
2)
$0- AL
$7.40
RESERPINE TABS OR
(Tier
0.25 MG
2)
TENEX TABS (Guanfacine NF AL; MO
HCl)
$0- MO
$2.95
terazosin hcl caps
(Tier
1)
Antihypertensive Combinations
ACCURETIC TABS
MO
NF
(QuinaprilHydrochlorothiazide)
$0- MO
$2.95
amlodipine besylate(Tier
benazepril hcl caps
1)
Name of drug
ATACAND HCT TABS
(Candesartan CilexetilHydrochlorothiazide)
atenolol & chlorthalidone
tabs
AVALIDE TABS
(IrbesartanHydrochlorothiazide)
benazepril &
hydrochlorothiazide tabs
bisoprolol &
hydrochlorothiazide tabs
candesartan cilexetilhydrochlorothiazide tabs
captopril &
hydrochlorothiazide tabs
CORZIDE TABS (Nadolol
& Bendroflumethiazide)
DIOVAN HCT TABS
(ValsartanHydrochlorothiazide)
enalapril maleate &
hydrochlorothiazide tabs
fosinopril sodium &
hydrochlorothiazide tabs
HYZAAR TABS (Losartan
Potassium &
Hydrochlorothiazide)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0- MO
$2.95
(Tier
1)
MO
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
NF MO
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
MO
NF
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
53
Name of drug
irbesartanhydrochlorothiazide tabs
lisinopril &
hydrochlorothiazide tabs
LOPRESSOR HCT TABS
(Metoprolol &
Hydrochlorothiazide)
losartan potassium &
hydrochlorothiazide tabs
LOTENSIN HCT TABS
(Benazepril &
Hydrochlorothiazide)
LOTREL CAPS
(Amlodipine BesylateBenazepril HCl)
metoprolol &
hydrochlorothiazide tabs
moexiprilhydrochlorothiazide tabs
nadolol &
bendroflumethiazide tabs
quinaprilhydrochlorothiazide tabs
TEKTURNA HCT TABS
TENORETIC 100 TABS
(Atenolol & Chlorthalidone)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
NF
$0- MO
$2.95
(Tier
1)
MO
NF
Name of drug
TENORETIC 50 TABS
(Atenolol & Chlorthalidone)
valsartanhydrochlorothiazide tabs
VASERETIC TABS
(Enalapril Maleate &
Hydrochlorothiazide)
ZESTORETIC TABS
(Lisinopril &
Hydrochlorothiazide)
ZIAC TABS (Bisoprolol &
Hydrochlorothiazide)
TEKTURNA TABS
NF
MO
MO
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
MO
NF
MO
NF
NF MO
Direct Renin Inhibitors
MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0- MO
$7.40
(Tier
2)
Selective Aldosterone Receptor Antagonists
$0- MO
$2.95
eplerenone tabs
(Tier
1)
INSPRA TABS
NF MO
(Eplerenone)
Vasodilators
MO
MO
MO
$0- MO
hydralazine hcl tabs or 10 $2.95
mg, 100 mg, 25 mg, 50 mg (Tier
1)
$0- MO
minoxidil tabs or 10 mg, 2.5 $2.95
(Tier
mg
1)
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections)
Antimalarial Combinations
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
54
Name of drug
atovaquone-proguanil hcl
tabs 250mg-100mg
COARTEM TABS
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
QUALAQUIN CAPS
(Quinine Sulfate)
quinine sulfate caps or
Necessary
actions,
restrictions, or
limits on use
NF PA; MO
$0- PA; MO
$2.95
(Tier
1)
ANTIMYASTHENIC/CHOLINERGIC AGENTS
MALARONE TABS
250MG-100MG
(Atovaquone-Proguanil
HCl)
NF
Antimalarials
ARALEN TABS
(Chloroquine Phosphate)
NF MO
MO
$0- MO
$2.95
(Tier
1)
$0$7.40
DARAPRIM TABS
(Tier
2)
$0- MO
hydroxychloroquine sulfate $2.95
(Tier
tabs or
1)
$0- MO
$2.95
mefloquine hcl tabs
(Tier
1)
PLAQUENIL TABS
MO
NF
(Hydroxychloroquine
Sulfate)
$0- MO
$2.95
primaquine phosphate tabs (Tier
1)
$0- MO
$7.40
PRIMAQUINE
(Tier
PHOSPHATE TABS
2)
chloroquine phosphate
tabs or 250 mg, 500 mg
Name of drug
What
the
drug
will
cost
you
(tier
level)
Antimyasthenic/Cholinergic Agents
$0$2.95
guanidine hcl tabs
(Tier
1)
MESTINON TABS 60 MG
NF MO
(Pyridostigmine Bromide)
$0- MO
MESTINON TIMESPAN
$7.40
TBCR (Pyridostigmine
(Tier
Bromide)
2)
$0- MO
$2.95
pyridostigmine bromide
(Tier
tabs or 60 mg
1)
$0- MO
pyridostigmine bromide tbcr $2.95
(Tier
or 180 mg
1)
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections)
Anti TB Combinations
isoniazid & rifampin caps
RIFATER TABS
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
Antimycobacterial Agents
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
55
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
aminosalicylic acid pack or (Tier
1)
$0$7.40
CAPASTAT SULFATE
(Tier
SOLR
2)
$0ethambutol hcl tabs or 100 $2.95
(Tier
mg, 400 mg
1)
$0$2.95
isoniazid tabs or 100 mg,
(Tier
300 mg
1)
MYAMBUTOL TABS
NF
(Ethambutol HCl)
MYCOBUTIN CAPS
NF
(Rifabutin)
$0$7.40
PRIFTIN TABS
(Tier
2)
$0$2.95
pyrazinamide tabs or
(Tier
1)
$0$2.95
rifabutin caps
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
rifampin solr iv 600 mg
SIRTURO TABS
MO
TRECATOR TABS
MO
MO
MO
MO
MO
MO
RIFADIN CAPS (Rifampin)
NF MO
RIFADIN SOLR (Rifampin)
NF MO
rifampin caps or 150 mg,
300 mg
Name of drug
$0- MO
$2.95
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
Alkylating Agents
ALKERAN SOLR IV 50 MG
(Melphalan HCl)
NF
$0- MO; B/D
$7.40
ALKERAN TABS OR 2 MG (Tier
2)
$0$7.40
BENDEKA SOLN
(Tier
2)
$0$7.40
BICNU SOLR
(Tier
2)
$0$7.40
BUSULFEX SOLN
(Tier
2)
$0$2.95
carboplatin soln
(Tier
1)
$0cisplatin soln 100
$2.95
mg/100ml, 200 mg/200ml, (Tier
50 mg/50ml
1)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
56
Name of drug
CYCLOPHOSPHAMIDE
CAPS OR 25 MG, 50 MG
ELOXATIN SOLN
(Oxaliplatin)
EVOMELA SOLR
GLEOSTINE CAPS
HEXALEN CAPS
IFEX SOLR 1 GM
(Ifosfamide)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; B/D
melphalan hcl solr
NF
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
MUSTARGEN SOLR
oxaliplatin soln
oxaliplatin solr
TEMODAR SOLR
NF
$0$7.40
IFEX SOLR 3 GM
(Tier
2)
$0ifosfamide soln 1 gm/20ml, $2.95
(Tier
3 gm/60ml
1)
$0$2.95
ifosfamide solr 1 gm
(Tier
1)
$0$7.40
IFOSFAMIDE SOLR 3 GM (Tier
2)
$0- MO
$7.40
LEUKERAN TABS
(Tier
2)
THIOTEPA SOLR IJ
TREANDA SOLN
TREANDA SOLR
YONDELIS SOLR
ZANOSAR SOLR
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
MO
Antimetabolites
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
57
Name of drug
ALIMTA SOLR 100 MG
ALIMTA SOLR 500 MG
ARRANON SOLN
azacitidine susr
cladribine soln
CLOLAR SOLN
cytarabine soln
DACOGEN SOLR
(Decitabine)
decitabine solr
FLUDARA SOLR
(Fludarabine Phosphate)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
NF
$0$2.95
(Tier
1)
NF
$0fludarabine phosphate solr $2.95
(Tier
50 mg
1)
Necessary
actions,
restrictions, or
limits on use
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0fluorouracil soln iv 1
$2.95
gm/20ml, 2.5 gm/50ml, 500 (Tier
mg/10ml
1)
$0$7.40
FOLOTYN SOLN
(Tier
2)
$0$2.95
gemcitabine hcl soln
(Tier
1)
$0$2.95
gemcitabine hcl solr
(Tier
1)
GEMZAR SOLR
NF
(Gemcitabine HCl)
$0$2.95
mercaptopurine tabs or
(Tier
1)
methotrexate sodium soln ij $0$2.95
1 gm/40ml, 100 mg/4ml,
200 mg/8ml, 250 mg/10ml, (Tier
1)
50 mg/2ml
$0methotrexate sodium solr ij $2.95
(Tier
1 gm
1)
$0methotrexate sodium tabs $2.95
or 10 mg, 15 mg, 2.5 mg, 5 (Tier
mg, 7.5 mg
1)
PURINETHOL TABS
NF
(Mercaptopurine)
$0$7.40
PURIXAN SUSP
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
PA
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
58
Name of drug
TABLOID TABS
VIDAZA SUSR
(Azacitidine)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
ERBITUX SOLN
NF
GAZYVA SOLN
Antineoplastic - Angiogenesis Inhibitors
$0$7.40
AVASTIN SOLN
(Tier
2)
$0- LA
$7.40
CYRAMZA SOLN
(Tier
2)
$0$7.40
ZALTRAP SOLN
(Tier
2)
HERCEPTIN SOLR
KADCYLA SOLR
KEYTRUDA SOLN
Antineoplastic - Antibodies
ARZERRA CONC
BLINCYTO SOLR
CAMPATH SOLN
DARZALEX SOLN
EMPLICITI SOLR
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0- LA
$7.40
(Tier
2)
$0$7.40
(Tier
2)
KEYTRUDA SOLR
LARTRUVO SOLN
OPDIVO SOLN
PERJETA SOLN
PORTRAZZA SOLN
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
You can find information on what the symbols and abbreviations in this table mean by going to
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59
Name of drug
RITUXAN SOLN
TECENTRIQ SOLN
VECTIBIX SOLN
YERVOY SOLN
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Antineoplastic - BCL-2 Inhibitors
$0- PA; LA
VENCLEXTA STARTING $7.40
(Tier
PACK TBPK
2)
$0- PA; LA
$7.40
VENCLEXTA TABS
(Tier
2)
Antineoplastic - Hedgehog Pathway Inhibitors
$0- LA
$7.40
ERIVEDGE CAPS
(Tier
2)
$0- LA
$7.40
ODOMZO CAPS
(Tier
2)
Antineoplastic - Hormonal and Related Agents
$0- MO
$2.95
anastrozole tabs or
(Tier
1)
ARIMIDEX TABS
NF MO
(Anastrozole)
Name of drug
AROMASIN TABS
(Exemestane)
bicalutamide tabs
CASODEX TABS
(Bicalutamide)
DEPO-PROVERA SUSP
ELIGARD KIT
EMCYT CAPS
exemestane tabs
FARESTON TABS
FASLODEX SOLN
FEMARA TABS (Letrozole)
FIRMAGON SOLR
flutamide caps
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
NF MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
MO
MO
MO
MO
NF MO
$0$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
60
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0HYDROXYPROGESTERO $7.40
NE CAPROATE SOLN IM (Tier
2)
$0$2.95
letrozole tabs
(Tier
1)
$0$2.95
leuprolide acetate kit ij
(Tier
1)
$0$7.40
LUPRON DEPOT KIT
(Tier
2)
$0$7.40
LYSODREN TABS
(Tier
2)
MEGACE ORAL SUSP
NF
(Megestrol Acetate)
$0megestrol acetate susp or $2.95
(Tier
40 mg/ml, 400 mg/10ml
1)
$0megestrol acetate tabs or $2.95
(Tier
20 mg, 40 mg
1)
$0$7.40
NILANDRON TABS
(Tier
(Nilutamide)
2)
$0$2.95
nilutamide tabs
(Tier
1)
$0$7.40
SOLTAMOX SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
AL; MO
AL; MO
AL; MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0tamoxifen citrate tabs or 10 $2.95
(Tier
mg, 20 mg
1)
$0$7.40
TRELSTAR MIXJECT
(Tier
SUSR
2)
$0$7.40
TRELSTAR SUSR
(Tier
2)
$0$7.40
VANTAS KIT
(Tier
2)
$0$7.40
XTANDI CAPS
(Tier
2)
$0$7.40
ZOLADEX IMPL
(Tier
2)
$0$7.40
ZYTIGA TABS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
PA; LA
Antineoplastic - Immunomodulators
$0- LA
$7.40
POMALYST CAPS
(Tier
2)
Antineoplastic Antibiotics
bleomycin sulfate solr
MO
COSMEGEN SOLR
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
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61
Name of drug
daunorubicin hcl inj
DOXIL INJ (Doxorubicin
HCl Liposomal)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
Necessary
actions,
restrictions, or
limits on use
Antineoplastic Combinations
LONSURF TABS
NF
$0doxorubicin hcl liposomal $2.95
(Tier
inj
1)
$0- MO
$2.95
doxorubicin hcl soln 2
(Tier
mg/ml
1)
$0doxorubicin hcl solr 10 mg, $2.95
(Tier
50 mg
1)
ELLENCE SOLN
NF
(Epirubicin HCl)
$0$2.95
epirubicin hcl soln
(Tier
1)
IDAMYCIN PFS SOLN
NF
(Idarubicin HCl)
$0$2.95
idarubicin hcl soln
(Tier
1)
$0- MO
mitomycin solr iv 20 mg, 40 $2.95
(Tier
mg, 5 mg
1)
$0$2.95
mitoxantrone hcl conc
(Tier
1)
$0$7.40
VALSTAR SOLN
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0- PA
$7.40
(Tier
2)
Antineoplastic Enzyme Inhibitors
$0$7.40
AFINITOR DISPERZ TBSO (Tier
2)
$0$7.40
AFINITOR TABS
(Tier
2)
$0$7.40
ALECENSA CAPS
(Tier
2)
$0$7.40
BELEODAQ SOLR
(Tier
2)
$0$7.40
BOSULIF TABS
(Tier
2)
$0$7.40
CABOMETYX TABS
(Tier
2)
$0$7.40
CAPRELSA TABS
(Tier
2)
$0$7.40
COMETRIQ KIT
(Tier
2)
$0$7.40
COTELLIC TABS
(Tier
2)
PA; LA
PA
PA
LA
LA
LA
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62
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
FARYDAK CAPS
(Tier
2)
$0$7.40
GILOTRIF TABS
(Tier
2)
$0GLEEVEC TABS 100 MG, $7.40
400 MG (Imatinib
(Tier
Mesylate)
2)
$0$7.40
GLEEVEC TABS 400 MG (Tier
2)
$0$7.40
IBRANCE CAPS
(Tier
2)
$0$7.40
ICLUSIG TABS
(Tier
2)
$0$2.95
imatinib mesylate tabs
(Tier
1)
$0$7.40
IMBRUVICA CAPS
(Tier
2)
$0$7.40
INLYTA TABS
(Tier
2)
$0$7.40
IRESSA TABS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
PA; LA
ISTODAX (OVERFILL)
SOLR
LA
ISTODAX SOLR
JAKAFI TABS
LENVIMA 10 MG DAILY
DOSE CPPK
LA
LENVIMA 14 MG DAILY
DOSE CPPK
LA
LENVIMA 18 MG DAILY
DOSE CPPK
LENVIMA 20 MG DAILY
DOSE CPPK
PA; LA
LENVIMA 24 MG DAILY
DOSE CPPK
PA; LA
LENVIMA 8 MG DAILY
DOSE CPPK
LA; MO
LYNPARZA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
PA
PA
PA
PA
PA
PA
PA; LA
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63
Name of drug
MEKINIST TABS
NEXAVAR TABS
NINLARO CAPS
SPRYCEL TABS
STIVARGA TABS
SUTENT CAPS
TAFINLAR CAPS
TAGRISSO TABS
TARCEVA TABS
TASIGNA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
TORISEL SOLN
LA
TYKERB TABS
PA
VELCADE SOLR
VOTRIENT TABS
PA; LA
XALKORI CAPS
ZELBORAF TABS
ZOLINZA CAPS
LA
ZYDELIG TABS
ZYKADIA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
PA; LA
PA; LA
Antineoplastic Enzymes
ERWINAZE SOLR
$0$7.40
(Tier
2)
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64
Name of drug
ONCASPAR SOLN
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Antineoplastics Misc.
ACTIMMUNE SOLN
bexarotene caps
dacarbazine solr
HYDREA CAPS
(Hydroxyurea)
hydroxyurea caps or
INTRON A SOLN
INTRON A SOLR
INTRON A W/DILUENT
SOLR
MATULANE CAPS
PROLEUKIN SOLR
$0- LA
$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
NF MO
$0- MO
$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0- LA
$7.40
(Tier
2)
$0$7.40
(Tier
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
SYLATRON KIT
(Tier
2)
$0$7.40
SYNRIBO SOLR
(Tier
2)
$0TARGRETIN CAPS OR 75 $7.40
(Tier
MG (Bexarotene)
2)
$0$7.40
THERACYS SUSR
(Tier
2)
$0$7.40
TICE BCG SUSR
(Tier
2)
$0$2.95
tretinoin (chemotherapy)
(Tier
caps
1)
$0$7.40
TRISENOX SOLN
(Tier
2)
$0$7.40
UVADEX SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Chemotherapy Adjuncts
ELITEK SOLR
KEPIVANCE SOLR
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Chemotherapy Rescue/Antidote Agents
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
65
Name of drug
amifostine crystalline solr
dexrazoxane solr 250 mg,
500 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
ETHYOL SOLR (Amifostine NF
Crystalline)
$0$7.40
FUSILEV SOLR
(Tier
(Levoleucovorin Calcium)
2)
$0$2.95
leucovorin calcium solr ij
(Tier
100 mg, 350 mg
1)
$0$2.95
leucovorin calcium solr ij
(Tier
200 mg, 50 mg, 500 mg
1)
$0leucovorin calcium tabs or $2.95
10 mg, 15 mg, 25 mg, 5 mg (Tier
1)
$0$2.95
levoleucovorin calcium soln (Tier
1)
$0$2.95
levoleucovorin calcium solr (Tier
1)
$0$7.40
LEVOLEUCOVORIN SOLN (Tier
2)
$0$2.95
mesna soln
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Name of drug
MO
MO
MO
Necessary
actions,
restrictions, or
limits on use
MESNEX SOLN IV 100
MG/ML (Mesna)
NF MO
MESNEX TABS OR 400
MG
$0- MO
$7.40
(Tier
2)
ZINECARD SOLR
(Dexrazoxane)
MO
What
the
drug
will
cost
you
(tier
level)
NF
Mitotic Inhibitors
$0- MO
$7.40
ABRAXANE SUSR
(Tier
2)
$0$7.40
DOCEFREZ SOLR
(Tier
2)
$0docetaxel conc 140
$2.95
mg/7ml, 20 mg/ml, 80
(Tier
mg/4ml
1)
$0$7.40
DOCETAXEL CONC 20
(Tier
MG/ML, 80 MG/4ML
2)
$0DOCETAXEL SOLN 160
$7.40
MG/16ML, 20 MG/2ML,
(Tier
200 MG/20ML, 80 MG/8ML 2)
$0$7.40
ETOPOPHOS SOLR
(Tier
2)
$0etoposide soln iv 1
gm/50ml, 100 mg/5ml, 500 $2.95
(Tier
mg/25ml
1)
$0$7.40
HALAVEN SOLN
(Tier
2)
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66
Name of drug
IXEMPRA KIT SOLR
JEVTANA SOLN
MARQIBO SUSP
NAVELBINE SOLN
(Vinorelbine Tartrate)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
$0$2.95
(Tier
1)
$0- MO
paclitaxel conc 30 mg/5ml, $2.95
(Tier
300 mg/50ml
1)
NF MO
TAXOL CONC (Paclitaxel)
vinblastine sulfate soln
vincristine sulfate soln
vinorelbine tartrate soln
Topoisomerase I Inhibitors
CAMPTOSAR SOLN 100
MG/5ML, 40 MG/2ML
(Irinotecan HCl)
NF
CAMPTOSAR SOLN 300
MG/15ML
$0$7.40
(Tier
2)
HYCAMTIN SOLR
(Topotecan HCl)
irinotecan hcl soln
NF MO
paclitaxel conc 100
mg/16.7ml, 150 mg/25ml
TAXOTERE CONC
(Docetaxel)
Name of drug
$0$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
TOPOTECAN HCL SOLN
4 MG/4ML
topotecan hcl solr 4 mg
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
ANTIPARKINSON AGENTS - Drugs to Treat
Parkinson's Disease
Antiparkinson Adjuvants
carbidopa tabs or
LODOSYN TABS
(Carbidopa)
$0- MO
$2.95
(Tier
1)
NF MO
Antiparkinson Anticholinergics
$0- MO
benztropine mesylate soln $2.95
(Tier
ij 1 mg/ml
1)
$0- AL; MO
benztropine mesylate tabs $2.95
(Tier
or 0.5 mg, 1 mg, 2 mg
1)
COGENTIN SOLN
NF MO
(Benztropine Mesylate)
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67
Name of drug
trihexyphenidyl hcl elix
trihexyphenidyl hcl tabs
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Antiparkinson COMT Inhibitors
COMTAN TABS
NF
(Entacapone)
$0$2.95
entacapone tabs
(Tier
1)
$0$7.40
TASMAR TABS
(Tier
(Tolcapone)
2)
$0$2.95
tolcapone tabs
(Tier
1)
Antiparkinson Dopaminergics
$0$2.95
amantadine hcl caps or
(Tier
100 mg
1)
$0amantadine hcl syrp or 50 $2.95
(Tier
mg/5ml
1)
$0amantadine hcl tabs or 100 $2.95
(Tier
mg
1)
$0$7.40
APOKYN SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
AL; MO
bromocriptine mesylate
caps or 5 mg
AL; MO
bromocriptine mesylate
tabs or 2.5 mg
SL(8 ea daily);
MO
SL(8 ea daily);
MO
carbidopa-levodopa tabs
carbidopa-levodopa tbcr
MO
carbidopa-levodopa tbdp
MO
DUOPA SUSP
MO
MO
MO
LA
MIRAPEX TABS
(Pramipexole
Dihydrochloride)
NEUPRO PT24
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
B/D
MO
NF
$0- MO
$7.40
(Tier
2)
NF MO
PARLODEL CAPS
(Bromocriptine Mesylate)
PARLODEL TABS
NF MO
(Bromocriptine Mesylate)
$0- MO
pramipexole
dihydrochloride tabs 0.125 $2.95
mg, 0.25 mg, 0.5 mg, 0.75 (Tier
1)
mg, 1 mg, 1.5 mg
REQUIP TABS (Ropinirole NF MO
Hydrochloride)
REQUIP XL TB24
NF MO
(Ropinirole Hydrochloride)
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68
Name of drug
ropinirole hydrochloride
tabs
ropinirole hydrochloride
tb24
RYTARY CPCR
SINEMET CR TBCR
(Carbidopa-Levodopa)
SINEMET TABS
(Carbidopa-Levodopa)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
lithium carbonate tabs or
300 mg
MO
lithium carbonate tbcr or
300 mg, 450 mg
MO
lithium soln
NF MO
LITHOBID TBCR (Lithium
Carbonate)
NF MO
Antipsychotics - Misc.
Antiparkinson Monoamine Oxidase Inhibitors
$0- MO
$7.40
AZILECT TABS
(Tier
2)
ELDEPRYL CAPS
NF MO
(Selegiline HCl)
$0- MO
$2.95
selegiline hcl caps or
(Tier
1)
$0- MO
$2.95
selegiline hcl tabs or
(Tier
1)
ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders
Antimanic Agents
$0- MO
$2.95
(Tier
1)
LITHIUM CARBONATE
MO
CAPS OR 600 MG (Lithium NF
Carbonate)
lithium carbonate caps or
150 mg, 300 mg, 600 mg
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
NF MO
$0- MO
$7.40
EQUETRO CP12
(Tier
2)
GEODON CAPS OR 20
MO
MG, 40 MG, 60 MG, 80 MG NF
(Ziprasidone HCl)
$0- MO
$7.40
GEODON SOLR IM 20 MG (Tier
2)
$0- SL(1.33 ea
$7.40 daily); MO
LATUDA TABS 120 MG
(Tier
2)
$0- SL(8 ea daily);
$7.40 MO
LATUDA TABS 20 MG
(Tier
2)
$0- SL(4 ea daily);
$7.40 MO
LATUDA TABS 40 MG
(Tier
2)
$0- SL(2.67 ea
$7.40 daily); MO
LATUDA TABS 60 MG
(Tier
2)
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69
Name of drug
LATUDA TABS 80 MG
NUPLAZID TABS
VRAYLAR CAPS 1.5 MG
VRAYLAR CAPS 3 MG
VRAYLAR CAPS 4.5 MG
VRAYLAR CAPS 6 MG
VRAYLAR CPPK
ziprasidone hcl caps
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(2 ea daily);
MO
Name of drug
INVEGA TB24 1.5 MG
(Paliperidone)
PA; LA
INVEGA TB24 3 MG
(Paliperidone)
PA; SL(4 ea
daily); MO
PA; SL(2 ea
daily); MO
PA; SL(1.4 ea
daily); MO
PA; SL(1 ea
daily); MO
INVEGA TB24 6 MG
(Paliperidone)
INVEGA TB24 9 MG
(Paliperidone)
INVEGA TRINZA SUSP
paliperidone tb24 1.5 mg
PA; MO
paliperidone tb24 3 mg
MO
paliperidone tb24 6 mg
Benzisoxazoles
FANAPT TABS
INVEGA SUSTENNA
SUSP
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
paliperidone tb24 9 mg
RISPERDAL CONSTA
SUSR 12.5 MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(8 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
SL(1.33 ea
daily); MO
SL(8 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
SL(1.33 ea
daily); MO
Limit 8 vials per
28
days;SL(0.29
ea daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to
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70
Name of drug
RISPERDAL CONSTA
SUSR 25 MG
RISPERDAL CONSTA
SUSR 37.5 MG
RISPERDAL CONSTA
SUSR 50 MG
RISPERDAL M-TAB TBDP
(Risperidone)
RISPERDAL SOLN
(Risperidone)
RISPERDAL TABS
(Risperidone)
risperidone soln
risperidone tabs
risperidone tbdp
Butyrophenones
HALDOL DECANOATE
100 SOLN (Haloperidol
Decanoate)
HALDOL DECANOATE 50
SOLN (Haloperidol
Decanoate)
HALDOL SOLN
(Haloperidol Lactate)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Limit 4 vials per
28
days;SL(0.15
ea daily); MO
Limit 4 vials per
42 days;SL(0.1
ea daily); MO
Limit 2 vials per
28
days;SL(0.08
ea daily); MO
NF MO
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
MO
NF
MO
NF
NF MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0haloperidol decanoate soln $2.95
(Tier
im 100 mg/ml, 50 mg/ml
1)
$0$2.95
haloperidol lactate conc
(Tier
1)
$0$2.95
haloperidol lactate soln
(Tier
1)
$0$2.95
haloperidol tabs
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
Dibenzapines
CLOZAPINE ODT TBDP
clozapine tabs
clozapine tbdp
CLOZARIL TABS
(Clozapine)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
NF
$0$7.40
(Tier
2)
$0FAZACLO TBDP 12.5 MG, $7.40
(Tier
150 MG, 200 MG
2)
$0- MO
$2.95
loxapine succinate caps
(Tier
1)
FAZACLO TBDP 100 MG,
25 MG (Clozapine)
You can find information on what the symbols and abbreviations in this table mean by going to
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71
Name of drug
olanzapine solr
olanzapine tabs
olanzapine tbdp
quetiapine fumarate tabs
100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg
SAPHRIS SUBL 10 MG
SAPHRIS SUBL 2.5 MG
SAPHRIS SUBL 5 MG
SEROQUEL TABS
(Quetiapine Fumarate)
VERSACLOZ SUSP
ZYPREXA RELPREVV
SUSR 210 MG
ZYPREXA SOLR
(Olanzapine)
ZYPREXA TABS
(Olanzapine)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Name of drug
ZYPREXA ZYDIS TBDP
(Olanzapine)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
Dihydroindolones
MO
molindone hcl tabs
MO
$0- MO
$2.95
(Tier
1)
Phenothiazines
$0$2.95
(Tier
1)
$0chlorpromazine hcl soln ij $2.95
(Tier
50 mg/2ml
1)
$0chlorpromazine hcl tabs or $2.95
10 mg, 100 mg, 200 mg, 25 (Tier
mg, 50 mg
1)
$0$2.95
fluphenazine decanoate
(Tier
soln ij
1)
$0fluphenazine hcl conc or 5 $2.95
(Tier
mg/ml
1)
$0fluphenazine hcl soln ij 2.5 $2.95
(Tier
mg/ml
1)
$0fluphenazine hcl tabs or 1 $2.95
(Tier
mg, 10 mg, 2.5 mg, 5 mg
1)
$0$2.95
perphenazine tabs or 16
(Tier
mg, 2 mg, 4 mg, 8 mg
1)
MO
chlorpromazine hcl soln ij
25 mg/ml
MO
SL(2 ea daily);
MO
SL(8 ea daily);
MO
SL(4 ea daily);
MO
NF MO
$0- PA; SL(18 ml
$7.40 daily)
(Tier
2)
$0$7.40
(Tier
2)
NF MO
NF MO
MO
MO
MO
MO
MO
MO
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72
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0prochlorperazine edisylate $2.95
(Tier
soln ij
1)
$0prochlorperazine maleate $2.95
(Tier
tabs or 10 mg, 5 mg
1)
$0$2.95
prochlorperazine supp
(Tier
1)
$0thioridazine hcl tabs or 10 $2.95
mg, 100 mg, 25 mg, 50 mg (Tier
1)
$0$2.95
trifluoperazine hcl tabs
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
ABILIFY TABS OR 10 MG
(Aripiprazole)
MO
ABILIFY TABS OR 15 MG
(Aripiprazole)
MO
ABILIFY TABS OR 2 MG
(Aripiprazole)
AL; MO
ABILIFY TABS OR 20 MG
(Aripiprazole)
MO
ABILIFY TABS OR 30 MG
(Aripiprazole)
Quinolinone Derivatives
$0ABILIFY DISCMELT TBDP $7.40
(Tier
10 MG
2)
$0ABILIFY DISCMELT TBDP $7.40
(Tier
15 MG
2)
$0$7.40
ABILIFY MAINTENA SUSR (Tier
2)
$0$7.40
ABILIFY SOLN IM 9.75
(Tier
MG/1.3ML
2)
$0$7.40
ABILIFY SOLN OR 1
(Tier
MG/ML
2)
Name of drug
SL(3 ea daily);
MO
SL(2 ea daily);
MO
MO
SL(4 ml daily);
MO
SL(30 ml daily);
MO
ABILIFY TABS OR 5 MG
(Aripiprazole)
aripiprazole soln 1 mg/ml
aripiprazole tabs 10 mg
aripiprazole tabs 15 mg
aripiprazole tabs 2 mg
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(3 ea daily);
MO
SL(2 ea daily);
MO
SL(15 ea daily);
MO
SL(1.5 ea
daily); MO
SL(1 ea daily);
MO
SL(6 ea daily);
MO
SL(30 ml daily);
MO
SL(3 ea daily);
MO
SL(2 ea daily);
MO
SL(15 ea daily);
MO
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Name of drug
aripiprazole tabs 20 mg
aripiprazole tabs 30 mg
aripiprazole tabs 5 mg
aripiprazole tbdp 10 mg
aripiprazole tbdp 15 mg
ARISTADA PRSY
REXULTI TABS 0.25 MG
REXULTI TABS 0.5 MG
REXULTI TABS 1 MG
REXULTI TABS 2 MG
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(1.5 ea
daily); MO
SL(1 ea daily);
MO
SL(6 ea daily);
MO
Name of drug
REXULTI TABS 3 MG
REXULTI TABS 4 MG
SL(2 ea daily);
MO
PA; SL(1.33 ea
daily); MO
PA; SL(1 ea
daily); MO
$0- MO
$2.95
(Tier
1)
ANTISEPTICS & DISINFECTANTS - Drugs to
Prevent Bacterial Skin Infections
Chlorine Antiseptics
BENZALKONIUM
CHLORIDE SOLN
dakin's solution soln 0.25
%, 0.5 %
PA; SL(16 ea
daily); MO
Necessary
actions,
restrictions, or
limits on use
Thioxanthenes
thiothixene caps
SL(3 ea daily);
MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
triclosan bar ex 0.3 %
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
ANTIVIRALS - Drugs to Treat Viral Infections
PA; SL(8 ea
daily); MO
PA; SL(4 ea
daily); MO
PA; SL(2 ea
daily); MO
Antiretrovirals
$0- MO
$2.95
abacavir sulfate tabs
(Tier
1)
$0- MO
abacavir sulfate-lamivudine $2.95
(Tier
tabs
1)
$0- MO
$2.95
abacavir sulfatelamivudine-zidovudine tabs (Tier
1)
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74
Name of drug
APTIVUS CAPS 250 MG
APTIVUS SOLN 100
MG/ML
ATRIPLA TABS
COMBIVIR TABS
(Lamivudine-Zidovudine)
COMPLERA TABS
CRIXIVAN CAPS
DESCOVY TABS
didanosine cpdr
EDURANT TABS
EMTRIVA CAPS
EMTRIVA SOLN
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
EPIVIR SOLN 10 MG/ML
(Lamivudine)
EPIVIR TABS 150 MG, 300
MG (Lamivudine)
MO
NF MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Name of drug
MO
MO
MO
MO
MO
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0EPZICOM TABS (Abacavir $7.40
(Tier
Sulfate-Lamivudine)
2)
$0$7.40
EVOTAZ TABS
(Tier
2)
$0$7.40
FUZEON SOLR
(Tier
2)
$0$7.40
GENVOYA TABS
(Tier
2)
$0$7.40
INTELENCE TABS 100
(Tier
MG, 200 MG
2)
$0$7.40
INTELENCE TABS 25 MG (Tier
2)
$0$7.40
INVIRASE CAPS
(Tier
2)
$0$7.40
INVIRASE TABS
(Tier
2)
$0$7.40
ISENTRESS CHEW 100
(Tier
MG
2)
MO
MO
MO
MO
MO
MO
SL(6 ea daily);
MO
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75
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
ISENTRESS CHEW 25 MG (Tier
2)
$0$7.40
ISENTRESS PACK 100
(Tier
MG
2)
$0$7.40
ISENTRESS TABS 400
(Tier
MG
2)
$0$7.40
KALETRA SOLN
(Tier
2)
$0$7.40
KALETRA TABS
(Tier
2)
$0$2.95
lamivudine soln
(Tier
1)
$0$2.95
lamivudine tabs
(Tier
1)
$0$2.95
lamivudine-zidovudine tabs (Tier
1)
$0$7.40
LEXIVA SUSP
(Tier
2)
$0$7.40
LEXIVA TABS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(24 ea daily);
MO
Name of drug
NEVIRAPINE SUSP 50
MG/5ML
SL(2 ea daily)
nevirapine tabs 200 mg
MO
nevirapine tb24 100 mg,
400 mg
MO
NORVIR CAPS
MO
NORVIR SOLN
MO
NORVIR TABS
MO
ODEFSEY TABS
MO
PREZCOBIX TABS
MO
PREZISTA SUSP
MO
PREZISTA TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
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76
Name of drug
RESCRIPTOR TABS
RETROVIR CAPS
(Zidovudine)
RETROVIR IV INFUSION
SOLN
RETROVIR SYRP
(Zidovudine)
REYATAZ CAPS
REYATAZ PACK
SELZENTRY TABS
stavudine caps
stavudine solr
STRIBILD TABS
SUSTIVA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
SUSTIVA TABS
NF MO
TIVICAY TABS
$0$7.40
(Tier
2)
NF MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
MO
MO
TRIUMEQ TABS
TRIZIVIR TABS (Abacavir
Sulfate-LamivudineZidovudine)
TRUVADA TABS
MO
TYBOST TABS
MO
VIDEX EC CPDR
(Didanosine)
MO
VIDEXPEDIATRIC SOLR
MO
VIRACEPT TABS
MO
VIRAMUNE SUSP 50
MG/5ML
VIRAMUNE TABS 200 MG
(Nevirapine)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NF
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
MO
MO
MO
MO
MO
MO
NF MO
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77
Name of drug
VIRAMUNE XR TB24 100
MG (Nevirapine)
VIRAMUNE XR TB24 400
MG (Nevirapine)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
ZERIT CAPS (Stavudine)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
$0$7.40
(Tier
2)
NF MO
ZERIT SOLR (Stavudine)
NF MO
VIREAD POWD
VIREAD TABS
VITEKTA TABS
ZIAGEN SOLN 20 MG/ML
ZIAGEN TABS 300 MG
(Abacavir Sulfate)
zidovudine caps
zidovudine syrp
zidovudine tabs
CMV Agents
Name of drug
$0- MO
$7.40
(Tier
2)
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
cidofovir soln
CYTOVENE SOLR
(Ganciclovir Sodium)
ganciclovir sodium solr
VALCYTE TABS 450 MG
(Valganciclovir HCl)
valganciclovir hcl tabs 450
mg
VISTIDE SOLN (Cidofovir)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
NF
Hepatitis Agents
adefovir dipivoxil tabs
BARACLUDE SOLN 0.05
MG/ML
BARACLUDE TABS 0.5
MG, 1 MG (Entecavir)
COPEGUS TABS
(Ribavirin (Hepatitis C))
DAKLINZA TABS
entecavir tabs
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
NF
$0- PA
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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78
Name of drug
EPIVIR HBV SOLN 5
MG/ML
EPIVIR HBV TABS 100
MG (Lamivudine (HBV))
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NF MO
$0- PA
$7.40
HARVONI TABS
(Tier
2)
HEPSERA TABS (Adefovir NF MO
Dipivoxil)
$0- MO
$2.95
lamivudine (hbv) tabs
(Tier
1)
$0- PA
$7.40
OLYSIO CAPS
(Tier
2)
$0$7.40
PEG-INTRON KIT
(Tier
2)
$0$7.40
PEG-INTRON REDIPEN
(Tier
KIT
2)
$0$7.40
PEG-INTRON REDIPEN
(Tier
PAK 4 KIT
2)
$0$7.40
PEGASYS PROCLICK
(Tier
SOLN
2)
$0$7.40
PEGASYS SOLN
(Tier
2)
PEGINTRON KIT
REBETOL CAPS 200 MG
(Ribavirin (Hepatitis C))
ribavirin (hepatitis c) caps
ribavirin (hepatitis c) tabs
SOVALDI TABS
TECHNIVIE TABS
TYZEKA TABS
VICTRELIS CAPS
VIEKIRA PAK TBPK
ZEPATIER TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
PA
PA
MO
PA
PA
PA
Herpes Agents
acyclovir caps or 200 mg
$0- MO
$2.95
(Tier
1)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
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Name of drug
acyclovir sodium soln 50
mg/ml
acyclovir sodium solr 500
mg
acyclovir susp or 200
mg/5ml
acyclovir tabs or 400 mg,
800 mg
famciclovir tabs
FAMVIR TABS
(Famciclovir)
valacyclovir hcl tabs or 1
gm, 1000 mg, 500 mg
VALTREX TABS
(Valacyclovir HCl)
ZOVIRAX CAPS OR 200
MG (Acyclovir)
ZOVIRAX SUSP OR 200
MG/5ML (Acyclovir)
ZOVIRAX TABS OR 400
MG, 800 MG (Acyclovir)
Influenza Agents
FLUMADINE TABS
(Rimantadine
Hydrochloride)
RELENZA DISKHALER
AEPB
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
rimantadine hydrochloride
tabs
MO
TAMIFLU CAPS
MO
TAMIFLU SUSR
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
Respiratory Syncytial Virus (RSV) Agents
$0$7.40
VIRAZOLE SOLR
(Tier
2)
ASSORTED CLASSES - Miscellaneous Drugs
NF MO
$0- MO
$2.95
(Tier
1)
NF MO
NF MO
NF MO
NF MO
MO
NF
$0- MO
$7.40
(Tier
2)
Assorted Classes
gelatin caps or 650 mg
NULLO TABS
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Chelating Agents
$0- MO
$7.40
CUPRIMINE CAPS
(Tier
2)
$0- MO
$7.40
DEPEN TITRATABS TABS (Tier
2)
$0- MO
$7.40
SYPRINE CAPS
(Tier
2)
Enzymes
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Name of drug
papaya chew 5mg-5mg3mg-2mg-20mg
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
Name of drug
cyclosporine modified (for
microemulsion) caps 100
mg, 25 mg, 50 mg
Immunomodulators
REVLIMID CAPS
THALOMID CAPS
$0- LA
$7.40
(Tier
2)
$0$7.40
(Tier
2)
Immunosuppressive Agents
$0- MO; B/D
$7.40
ASTAGRAF XL CP24
(Tier
2)
$0- B/D
AZATHIOPRINE SOLR IJ $7.40
(Tier
100 MG
2)
$0- MO; B/D
$2.95
azathioprine tabs or 100
(Tier
mg, 50 mg, 75 mg
1)
CELLCEPT CAPS 250 MG NF MO; B/D
(Mycophenolate Mofetil)
$0- B/D
CELLCEPT
$7.40
INTRAVENOUS SOLR
(Tier
(Mycophenolate Mofetil
2)
HCl)
$0- MO; B/D
CELLCEPT SUSR 200
$7.40
MG/ML (Mycophenolate
(Tier
Mofetil)
2)
CELLCEPT TABS 500 MG NF MO; B/D
(Mycophenolate Mofetil)
$0- MO; B/D
$2.95
cyclosporine caps or 100
(Tier
mg, 25 mg
1)
cyclosporine soln iv 50
mg/ml
ENVARSUS XR TB24
IMURAN TABS
(Azathioprine)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO; B/D
B/D
MO; B/D
NF MO; B/D
$0$2.95
(Tier
1)
$0mycophenolate mofetil hcl $2.95
(Tier
solr
1)
$0mycophenolate mofetil susr $2.95
(Tier
1)
$0$2.95
mycophenolate mofetil tabs (Tier
1)
$0$2.95
mycophenolate sodium
(Tier
tbec
1)
MYFORTIC TBEC
NF
(Mycophenolate Sodium)
NEORAL CAPS 100 MG,
25 MG (Cyclosporine
NF
Modified (For
Microemulsion))
MO; B/D
mycophenolate mofetil
caps
B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
NULOJIX SOLR
PROGRAF CAPS OR 0.5
MG, 1 MG, 5 MG
(Tacrolimus)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
B/D
THYMOGLOBULIN SOLR
MO; B/D
NF
$0- B/D
$7.40
(Tier
2)
$0- MO; B/D
$7.40
RAPAMUNE SOLN 1
(Tier
MG/ML
2)
RAPAMUNE TABS 0.5 MG NF MO; B/D
(Sirolimus)
$0- MO; B/D
RAPAMUNE TABS 1 MG, $7.40
(Tier
2 MG (Sirolimus)
2)
SANDIMMUNE CAPS OR
MO; B/D
NF
100 MG, 25 MG
(Cyclosporine)
SANDIMMUNE SOLN IV
NF B/D
50 MG/ML (Cyclosporine)
$0- MO; B/D
SANDIMMUNE SOLN OR $7.40
(Tier
100 MG/ML
2)
$0- B/D
$7.40
SIMULECT SOLR
(Tier
2)
$0- MO; B/D
$2.95
sirolimus tabs
(Tier
1)
$0- MO; B/D
tacrolimus caps or 0.5 mg, $2.95
(Tier
1 mg, 5 mg
1)
PROGRAF SOLN IV 5
MG/ML
Name of drug
ZORTRESS TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
B/D
MO; B/D
Irrigation Solutions
irrigation solutions,
physiological soln
water for irrigation, sterile
soln
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Potassium Removing Agents
KAYEXALATE POWD
NF
(Sodium Polystyrene
Sulfonate)
$0$2.95
sodium polystyrene
(Tier
sulfonate powd or
1)
$0sodium polystyrene
$2.95
sulfonate susp or 15
(Tier
gm/60ml
1)
$0$7.40
VELTASSA PACK 16.8 GM (Tier
2)
$0$7.40
VELTASSA PACK 25.2 GM (Tier
2)
$0$7.40
VELTASSA PACK 8.4 GM (Tier
2)
MO
MO
MO
ST; SL(1.5 ea
daily); LA
ST; SL(1 ea
daily); LA
ST; SL(3 ea
daily); LA
Systemic Lupus Erythematosus Agents
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
BENLYSTA SOLR 120 MG (Tier
2)
Necessary
actions,
restrictions, or
limits on use
BETA BLOCKERS - Drugs to Treat High Blood
Pressure
Alpha-Beta Blockers
carvedilol tabs 12.5 mg
carvedilol tabs 25 mg
carvedilol tabs 3.125 mg
carvedilol tabs 6.25 mg
COREG CR CP24
COREG TABS 12.5 MG
(Carvedilol)
COREG TABS 25 MG
(Carvedilol)
COREG TABS 3.125 MG
(Carvedilol)
COREG TABS 6.25 MG
(Carvedilol)
labetalol hcl tabs or 100
mg, 200 mg, 300 mg
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
SL(8 ea daily);
MO
SL(4 ea daily);
MO
SL(32 ea daily);
MO
SL(16 ea daily);
MO
MO
NF SL(8 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(32 ea daily);
MO
NF SL(16 ea daily);
MO
$0- MO
$2.95
(Tier
1)
Beta Blockers Cardio-Selective
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0acebutolol hcl caps or 200 $2.95
(Tier
mg, 400 mg
1)
$0atenolol tabs or 100 mg, 25 $2.95
(Tier
mg, 50 mg
1)
$0$2.95
betaxolol hcl tabs
(Tier
1)
$0$2.95
bisoprolol fumarate tabs
(Tier
1)
KERLONE TABS
NF
(Betaxolol HCl)
LOPRESSOR TABS OR
NF
100 MG, 50 MG
(Metoprolol Tartrate)
$0$2.95
metoprolol succinate tb24
(Tier
1)
$0metoprolol tartrate tabs or $2.95
(Tier
100 mg, 25 mg, 50 mg
1)
$0METOPROLOL
$7.40
TARTRATE TABS OR 37.5 (Tier
MG, 75 MG
2)
SECTRAL CAPS
NF
(Acebutolol HCl)
TENORMIN TABS
NF
(Atenolol)
TOPROL XL TB24
NF
(Metoprolol Succinate)
ZEBETA TABS (Bisoprolol
NF
Fumarate)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Beta Blockers Non-Selective
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83
Name of drug
BETAPACE AF TABS
(Sotalol HCl (AFIB/AFL))
BETAPACE TABS (Sotalol
HCl)
CORGARD TABS
(Nadolol)
INDERAL LA CP24
(Propranolol HCl)
What
the
drug
will
cost
you
(tier
level)
sotalol hcl tabs
SOTYLIZE SOLN
NF tabs;MO
ADAGEN SOLN
Necessary
actions,
restrictions, or
limits on use
LA
NF MO
CALCIUM CHANNEL BLOCKERS - Drugs to
Treat High Blood Pressure
NF MO
Calcium Channel Blockers
ADALAT CC TB24
(Nifedipine)
MO
MO
MO
MO
MO
NF
$0- tabs;MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
BIOLOGICALS MISC - Drugs to Treat Low
Enzymes
Biologicals Misc
Name of drug
NF MO
$0nadolol tabs or 20 mg, 40 $2.95
(Tier
mg, 80 mg
1)
$0$2.95
pindolol tabs
(Tier
1)
$0propranolol hcl cp24 or 120 $2.95
mg, 160 mg, 60 mg, 80 mg (Tier
1)
$0propranolol hcl tabs or 10 $2.95
mg, 20 mg, 40 mg, 60 mg, (Tier
80 mg
1)
$0$2.95
sotalol hcl (afib/afl) tabs
(Tier
1)
Sotalol Hcl IV Soln
Necessary
actions,
restrictions, or
limits on use
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
NF MO
$0amlodipine besylate tabs or $2.95
(Tier
10 mg
1)
$0amlodipine besylate tabs or $2.95
(Tier
2.5 mg
1)
$0amlodipine besylate tabs or $2.95
(Tier
5 mg
1)
CALAN SR TBCR
NF
(Verapamil HCl)
CALAN TABS (Verapamil
NF
HCl)
CARDIZEM CD CP24
NF
(Diltiazem HCl Coated
Beads)
CARDIZEM LA TB24 180
MG, 240 MG, 300 MG, 360 NF
MG, 420 MG (Diltiazem
HCl Coated Beads)
CARDIZEM TABS
NF
(Diltiazem HCl)
$0diltiazem hcl coated beads $2.95
(Tier
cp24
1)
$0diltiazem hcl coated beads $2.95
(Tier
tb24
1)
SL(1 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
MO
MO
MO
MO
MO
MO
MO
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
diltiazem hcl cp12 or 120
(Tier
mg, 60 mg, 90 mg
1)
$0$2.95
diltiazem hcl cp24 or 120
(Tier
mg, 180 mg, 240 mg
1)
$0$2.95
diltiazem hcl extended
(Tier
release beads cp24
1)
$0$2.95
diltiazem hcl tabs or 120
mg, 30 mg, 60 mg, 90 mg (Tier
1)
$0$2.95
felodipine tb24
(Tier
1)
$0nicardipine hcl caps or 20 $2.95
(Tier
mg, 30 mg
1)
$0$2.95
nifedipine tb24 or 30 mg,
(Tier
60 mg, 90 mg
1)
$0nimodipine caps or 30 mg, $2.95
(Tier
30mg
1)
$0nisoldipine tb24 17 mg, 34 $2.95
(Tier
mg, 8.5 mg
1)
NORVASC TABS 10 MG
NF
(Amlodipine Besylate)
NORVASC TABS 2.5 MG
NF
(Amlodipine Besylate)
NORVASC TABS 5 MG
NF
(Amlodipine Besylate)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NYMALIZE SOLN
MO
MO
MO
NF MO
SULAR TB24 (Nisoldipine)
NF MO
TIAZAC CP24 (Diltiazem
HCl Extended Release
Beads)
verapamil hcl cp24 or 100
mg, 120 mg, 180 mg, 200
mg, 240 mg, 300 mg, 360
mg
verapamil hcl tabs or 120
mg, 40 mg, 80 mg
MO
verapamil hcl tbcr or 120
mg, 180 mg, 240 mg
MO
Necessary
actions,
restrictions, or
limits on use
PROCARDIA XL TB24
(Nifedipine)
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
VERELAN CP24
(Verapamil HCl)
VERELAN PM CP24
(Verapamil HCl)
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
NF MO
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
Cardiac Glycosides
MO
DIGOXIN SOLN OR 0.05
MG/ML
SL(1 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
digoxin tabs or 0.125 mg,
125 mcg
digoxin tabs or 0.25 mg,
250 mcg
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
$0- AL; MO
$2.95
(Tier
1)
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Name of drug
LANOXIN TABS OR 125
MCG (Digoxin)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NF MO
$0- AL; MO
LANOXIN TABS OR 187.5 $7.40
(Tier
MCG
2)
LANOXIN TABS OR 250
NF AL; MO
MCG (Digoxin)
$0- MO
LANOXIN TABS OR 62.5 $7.40
(Tier
MCG
2)
CARDIOVASCULAR AGENTS - MISC. - Drugs to
Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations
$0- PA; MO
$7.40
ENTRESTO TABS
(Tier
2)
Prostaglandin Vasodilators
$0$7.40
REMODULIN SOLN
(Tier
2)
$0$7.40
TYVASO REFILL SOLN
(Tier
2)
$0$7.40
TYVASO SOLN
(Tier
2)
$0$7.40
TYVASO STARTER SOLN (Tier
2)
$0$7.40
VENTAVIS SOLN
(Tier
2)
LA; B/D
LA; B/D
LA; B/D
LA; B/D
LA; B/D
Pulmonary Hypertension - Endothelin Receptor
LETAIRIS TABS
OPSUMIT TABS
TRACLEER TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
LA
Pulmonary Hypertension - Phosphodiesterase
$0- PA
$7.40
ADCIRCA TABS
(Tier
2)
$0- PA
REVATIO SOLN IV 10
$7.40
MG/12.5ML (Sildenafil
(Tier
Citrate (Pulmonary
2)
Hypertension))
REVATIO TABS OR 20
PA
NF
MG (Sildenafil Citrate
(Pulmonary Hypertension))
$0- PA
sildenafil citrate (pulmonary $2.95
(Tier
hypertension) soln
1)
$0- PA
sildenafil citrate (pulmonary $2.95
(Tier
hypertension) tabs
1)
Pulmonary Hypertension - Prostacyclin Receptor
$0- PA; LA
$7.40
UPTRAVI TABS
(Tier
2)
$0- PA; LA
$7.40
UPTRAVI TBPK
(Tier
2)
Pulmonary Hypertension - Sol Guanylate Cyclase
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Name of drug
ADEMPAS TABS 0.5 MG
ADEMPAS TABS 1 MG
ADEMPAS TABS 1.5 MG
ADEMPAS TABS 2 MG
ADEMPAS TABS 2.5 MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; SL(15 ea
daily)
PA; SL(7.5 ea
daily)
PA; SL(5 ea
daily)
PA; SL(3.75 ea
daily)
PA; SL(3 ea
daily)
Sinus Node Inhibitors
$0$7.40
CORLANOR TABS 5 MG
(Tier
2)
$0$7.40
CORLANOR TABS 7.5 MG (Tier
2)
SL(3 ea daily);
MO
SL(2 ea daily);
MO
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
Cephalosporins - 1st Generation
$0- MO
$2.95
cefadroxil caps 500 mg
(Tier
1)
$0- MO
cefadroxil susr 500 mg/5ml $2.95
(Tier
1)
Name of drug
cefadroxil tabs 1 gm
cefazolin sodium solr ij 1
gm, 10 gm, 500 mg
cephalexin caps 250 mg,
500 mg, 750 mg
cephalexin susr 125
mg/5ml, 250 mg/5ml
KEFLEX CAPS
(Cephalexin)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NF MO
Cephalosporins - 2nd Generation
$0cefaclor caps 250 mg, 500 $2.95
(Tier
mg
1)
$0$2.95
cefoxitin sodium solr ij 10
(Tier
gm
1)
$0$2.95
cefoxitin sodium solr iv 1
(Tier
gm
1)
$0$2.95
cefoxitin sodium solr iv 2
(Tier
gm
1)
$0$2.95
cefprozil susr 250 mg/5ml
(Tier
1)
$0cefprozil tabs 250 mg, 500 $2.95
(Tier
mg
1)
MO
MO
MO
MO
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Name of drug
CEFTIN TABS 250 MG,
500 MG (Cefuroxime
Axetil)
cefuroxime axetil tabs
cefuroxime sodium solr ij
1.5 gm
ZINACEF SOLR IJ 1.5 GM
(Cefuroxime Sodium)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0- MO
$2.95
(Tier
1)
$0$2.95
(Tier
1)
NF
Cephalosporins - 3rd Generation
$0$2.95
cefdinir caps
(Tier
1)
$0$2.95
cefdinir susr
(Tier
1)
$0$2.95
cefixime chew
(Tier
1)
$0$2.95
cefixime susr
(Tier
1)
$0cefpodoxime proxetil susr $2.95
(Tier
100 mg/5ml
1)
$0cefpodoxime proxetil tabs $2.95
(Tier
100 mg, 200 mg
1)
$0ceftazidime solr ij 1 gm, 2 $2.95
(Tier
gm
1)
MO
MO
MO
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
ceftazidime solr ij 6 gm
(Tier
1)
$0ceftriaxone sodium solr ij 1 $2.95
(Tier
gm
1)
$0ceftriaxone sodium solr ij 2 $2.95
(Tier
gm
1)
$0$2.95
ceftriaxone sodium solr ij
(Tier
250 mg
1)
$0$2.95
ceftriaxone sodium solr ij
(Tier
500 mg
1)
$0ceftriaxone sodium solr iv 1 $2.95
(Tier
gm
1)
$0ceftriaxone sodium solr iv $2.95
(Tier
10 gm
1)
FORTAZ SOLR IJ 1 GM, 2 NF
GM (Ceftazidime)
FORTAZ SOLR IJ 6 GM
NF
(Ceftazidime)
ROCEPHIN SOLR
NF
(Ceftriaxone Sodium)
$0$7.40
SUPRAX CAPS 400 MG
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
SL(4 ea daily)
SL(2 ea daily);
MO
SL(16 ea daily);
MO
SL(8 ea daily);
MO
SL(4 ea daily)
MO
MO
SL(4 ea daily)
MO
Cephalosporins - 4th Generation
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88
Name of drug
cefepime hcl solr
CEFEPIME SOLN 2
GM/100ML
MAXIPIME SOLR IJ 1 GM,
2 GM (Cefepime HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
COAL TAR SOLN XX
Solids
SODIUM
CHLORIDE/SODIUM
BICARBONATE POWD
NF MO
Cephalosporins - 5th Generation
$0$7.40
TEFLARO SOLR 600 MG (Tier
2)
Acids, Bases, & Buffers
LACTIC ACID SOLN
$0
(Tier
3)
$0
(Tier
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
Bulk Chemicals - S's
SODIUM CITRATE
DIHYDRATE GRAN
$0 NT
(Tier
3)
Liquids
GLYCERIN LIQD 99 %,
99.5 %
GLYCERINE LIQD
GLYCEROL FORMAL
LIQD
Semi-Solids
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
THYMOL CRYS
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
$0 NT
(Tier
3)
$0 RX/OTC; MO;
(Tier NT
3)
CONTRACEPTIVES - Drugs to Prevent
Pregnancy
CHEMICALS
LACTIC ACID RACEMIC
SOLN
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
Combination Contraceptives - Oral
BREVICON-28 TABS
MO
NF
(Norethindrone & Eth
Estradiol)
DESOGEN TABS
MO
NF
(Desogestrel & Ethinyl
Estradiol)
$0- MO
$2.95
desogestrel & ethinyl
(Tier
estradiol tabs
1)
$0- MO
$2.95
desogestrel-ethinyl
(Tier
estradiol (biphasic) tabs
1)
$0- MO
$2.95
drospirenone-ethinyl
(Tier
estradiol tabs
1)
$0- MO
$2.95
ethynodiol diacet & eth
(Tier
estrad tabs
1)
FEMCON FE CHEW
MO
NF
(Norethindrone & Ethinyl
Estradiol-Fe)
$0- MO
$2.95
levonorgestrel & eth
(Tier
estradiol tabs
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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89
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0levonorgestrel-eth estradiol $2.95
(Tier
(triphasic) tabs
1)
$0$2.95
levonorgestrel-ethinyl
(Tier
estradiol (91-day) tabs
1)
LOSEASONIQUE TABS
NF
(Levonorgestrel-Ethinyl
Estradiol (91-Day))
MODICON TABS
NF
(Norethindrone & Eth
Estradiol)
$0norethin acet & estrad-fe
$2.95
tabs 75mg-20mcg-1mg,
(Tier
75mg-30mcg-1.5mg
1)
$0$2.95
norethindrone & eth
(Tier
estradiol tabs
1)
$0norethindrone & ethinyl
$2.95
estradiol-fe chew 0.4mg(Tier
35mcg
1)
$0norethindrone acet & eth
$2.95
estra tabs 20mcg-1mg,
(Tier
30mcg-1.5mg
1)
$0norethindrone-eth estradiol $2.95
(Tier
(triphasic) tabs
1)
$0$2.95
norgestimate-ethinyl
(Tier
estradiol (triphasic) tabs
1)
$0$2.95
norgestimate-ethinyl
(Tier
estradiol tabs
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
norgestrel & ethinyl
estradiol tabs
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
NORINYL 1+35 TABS
(Norethindrone & Eth
Estradiol)
ORTHO TRI-CYCLEN
TABS (NorgestimateEthinyl Estradiol
(Triphasic))
ORTHO-CEPT TABS
(Desogestrel & Ethinyl
Estradiol)
ORTHO-CYCLEN TABS
(Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
TABS (Norethindrone & Eth
Estradiol)
ORTHO-NOVUM 7/7/7
TABS (Norethindrone-Eth
Estradiol (Triphasic))
SEASONIQUE TABS
(Levonorgestrel-Ethinyl
Estradiol (91-Day))
YASMIN 28 TABS
(Drospirenone-Ethinyl
Estradiol)
YAZ TABS (DrospirenoneEthinyl Estradiol)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
NF MO
Combination Contraceptives - Transdermal
$0- MO
$2.95
norelgestromin-ethinyl
(Tier
estradiol ptwk
1)
ORTHO EVRA PTWK
MO
NF
(Norelgestromin-Ethinyl
Estradiol)
Combination Contraceptives - Vaginal
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90
Name of drug
NUVARING RING
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
Emergency Contraceptives
$0$7.40
ELLA TABS
(Tier
2)
$0levonorgestrel (emergency $2.95
(Tier
oc) tabs 0.75 mg
1)
$0 RX/OTC; NT
levonorgestrel (emergency (Tier
oc) tabs 1.5 mg
3)
PLAN B ONE-STEP TABS
RX/OTC; NT
NF
(Levonorgestrel
(Emergency OC))
Progestin Contraceptives - Injectable
DEPO-PROVERA
MO
CONTRACEPTIVE SUSP
NF
(Medroxyprogesterone
Acetate (Contraceptive))
DEPO-PROVERA
MO
CONTRACEPTIVE SUSY
NF
(Medroxyprogesterone
Acetate (Contraceptive))
$0- MO
medroxyprogesterone
$2.95
acetate (contraceptive)
(Tier
susp
1)
$0- MO
medroxyprogesterone
$2.95
acetate (contraceptive)
(Tier
susy
1)
Progestin Contraceptives - Oral
NOR-QD TABS
MO
NF
(Norethindrone
(Contraceptive))
norethindrone
(contraceptive) tabs
ORTHO MICRONOR
TABS (Norethindrone
(Contraceptive))
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
CORTICOSTEROIDS - Steroid Hormone Drugs to
Treat Systemic Swelling Conditions
Glucocorticosteroids
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
betamethasone sod
phosphate & acetate susp (Tier
1)
$0- MO
$2.95
budesonide cpep or
(Tier
1)
CELESTONE-SOLUSPAN
MO
NF
SUSP (Betamethasone
Sod Phosphate & Acetate)
CORTEF TABS
NF MO
(Hydrocortisone)
$0- MO
$2.95
cortisone acetate tabs or
(Tier
1)
$0- MO
DEPO-MEDROL SUSP 20 $7.40
(Tier
MG/ML
2)
DEPO-MEDROL SUSP 40
MO
MG/ML, 80 MG/ML
NF
(Methylprednisolone
Acetate)
ARISTOSPAN INTRAARTICULAR SUSP
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91
Name of drug
dexamethasone elix or 0.5
mg/5ml
dexamethasone sodium
phosphate soln ij 10 mg/ml
dexamethasone sodium
phosphate soln ij 10 mg/ml
dexamethasone sodium
phosphate soln ij 100
mg/10ml, 120 mg/30ml, 20
mg/5ml, 4 mg/ml
dexamethasone soln or 0.5
mg/5ml
dexamethasone tabs or 0.5
mg, 0.75 mg, 1 mg, 1.5 mg,
2 mg, 4 mg, 6 mg
dexamethasone tbpk or 1.5
mg
ENTOCORT EC CPEP
(Budesonide)
hydrocortisone tabs or 10
mg, 20 mg, 5 mg
KENALOG-10 SUSP
KENALOG-40 SUSP
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Name of drug
MEDROL DOSEPAK TBPK
(Methylprednisolone)
MEDROL TABS 16 MG, 32
MG, 4 MG, 8 MG
(Methylprednisolone)
MEDROL TABS 2 MG
Preservative
Free;MO
methylprednisolone acetate
susp ij 40 mg/ml, 80 mg/ml
MO
methylprednisolone sod
succ solr
MO
methylprednisolone tabs or
16 mg, 32 mg, 4 mg, 8 mg
MO
methylprednisolone tbpk or
4 mg
MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
ORAPRED ODT TBDP
(Prednisolone Sodium
Phosphate)
prednisolone sodium
phosphate soln or 15
mg/5ml, 5 mg/5ml, 6.7
mg/5ml
prednisolone sodium
phosphate tbdp or 10 mg,
15 mg, 30 mg
prednisolone soln or 15
mg/5ml
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
MO
NF
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
MO
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
prednisolone syrp or 15
(Tier
mg/5ml
1)
$0prednisolone tabs or 5 mg $2.95
(Tier
1)
$0$2.95
prednisone conc or 5
(Tier
mg/ml
1)
$0$2.95
prednisone soln or 5
(Tier
mg/5ml
1)
$0prednisone tabs or 1 mg,
$2.95
10 mg, 2.5 mg, 20 mg, 5
(Tier
mg, 50 mg
1)
$0prednisone tbpk or 10 mg, $2.95
(Tier
5 mg
1)
$0SOLU-CORTEF SOLR 100 $7.40
(Tier
MG, 250 MG, 500 MG
2)
$0$7.40
SOLU-CORTEF SOLR
(Tier
1000 MG
2)
SOLU-MEDROL SOLR
1000 MG, 125 MG, 40 MG NF
(Methylprednisolone Sod
Succ)
$0$7.40
SOLU-MEDROL SOLR
(Tier
500 MG
2)
Mineralocorticoids
Necessary
actions,
restrictions, or
limits on use
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0fludrocortisone acetate tabs $2.95
(Tier
or
1)
Necessary
actions,
restrictions, or
limits on use
MO
COUGH/COLD/ALLERGY - Drugs to Treat
Cough, Cold and Allergy Symptoms
Antitussives
MO
MO
MO
benzonatate caps 100 mg,
200 mg
hydrocodone w/
homatropine syrp
hydrocodone w/
homatropine tabs
TESSALON PERLES
CAPS (Benzonatate)
MO
MO
MO
MO
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
NF MO; NT
Cough/Cold/Allergy Combinations
$0
(Tier
ACTIDOM DMX LIQD
3)
$0
ADVIL ALLERGY &
(Tier
CONGESTION TABS
3)
brompheniramine &
$0
phenyleph elix 1mg/5ml(Tier
1mg/5ml-2.5mg/5ml3)
2.5mg/5ml, 1mg/5ml2.5mg/5ml
$0
brompheniramine &
(Tier
pseudoeph elix
3)
$0
brompheniramine &
(Tier
pseudoeph liqd
3)
$0
cetirizine-pseudoephedrine (Tier
tb12
3)
NT
AL; NT
AL; NT
AL; NT
AL; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
CHILDRENS PLUS COLD (Tier
SUSP
3)
$0
chlorpheniramine &
(Tier
phenylephrine tabs 4mg3)
10mg
$0
chlorpheniramine &
pseudoeph syrp 15mg/5ml- (Tier
3)
1mg/5ml
$0
chlorpheniramine w/
(Tier
codeine liqd
3)
$0
(Tier
CODITUSSIN AC LIQD
3)
$0
DECON-A ELIX 2MG/5ML- (Tier
5MG/5ML
3)
$0
dexbrompheniramine &
(Tier
pseudoephedrine tb12
3)
DIMETAPP COLD &
ALLERGY ELIX 1MG/5MLNF
2.5MG/5ML
(Brompheniramine &
Phenyleph)
$0
diphenhydramine(Tier
phenylephrine liqd
3)
12.5mg/5ml-5mg/5ml
$0
diphenhydramine(Tier
phenylephrine soln
3)
12.5mg/5ml-5mg/5ml
$0
diphenhydraminephenylephrine tabs 25mg- (Tier
3)
10mg
diphenhydramine$0
phenylephrine(Tier
acetaminophen susp
3)
12.5mg/5ml-160mg/5ml2.5mg/5ml
Necessary
actions,
restrictions, or
limits on use
AL; NT
AL; NT
AL; NT
AL; RX/OTC;
NT
NT
AL; NT
AL; MO; NT
AL; NT
AL; NT
AL; NT
AL; NT
AL; NT
Name of drug
diphenhydraminephenylephrineacetaminophen tabs
12.5mg-12.5mg-325mg325mg-5mg-5mg, 12.5mg325mg-5mg
diphenhydraminepseudoephedrineacetaminophen tabs
DOMETUSS-DMX LIQD
DRIXORAL
COLD/ALLERGY TB12
ED CHLORPED D LIQD
ENTRE-HIST PSE LIQD
EQ TRIACTING
COLD/ALLERGY SYRP
guaifenesin-codeine liqd
100mg/5ml-10mg/5ml
guaifenesin-codeine soln
100mg/5ml-10mg/5ml
guaifenesin-codeine syrp
100mg/5ml-10mg/5ml
hydrocodone polistirexchlorpheniramine polistirex
suer
LEXUSS 210 LIQD
NEXAFED SINUS
PRESSURE +PAIN TABS
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
AL; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
AL; NT
NT
AL; MO; NT
AL; NT
AL; NT
AL; NT
MO; NT
MO; NT
MO; NT
AL; MO; NT
AL; RX/OTC;
NT
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
phenyleph-promethazine
(Tier
w/ cod syrp
3)
$0
phenylephrine w/ dm-gg
liqd 30mg/5ml-200mg/5ml- (Tier
3)
10mg/5ml
phenylephrinechlorpheniramine-dm w/
apap susp 5mg/5ml$0
1mg/5ml-160mg/5ml(Tier
2.5mg/5ml, 5mg/5ml3)
5mg/5ml-1mg/5ml1mg/5ml-160mg/5ml160mg/5ml-2.5mg/5ml2.5mg/5ml
$0
promethazine w/codeine
(Tier
syrp
3)
$0
(Tier
promethazine-dm syrp
3)
$0
pseudoephedrine(Tier
acetaminophen tabs
3)
$0
pseudoephedrine-ibuprofen (Tier
susp 100mg/5ml-15mg/5ml 3)
$0
(Tier
RYMED TABS
3)
SUDAFED PE SEVERE
COLD MULTI-SYMPTOM
NF
TABS (DiphenhydraminePhenylephrineAcetaminophen)
$0
triprolidine &
(Tier
pseudoephedrine liqd
3)
0.938mg/ml-10mg/ml
triprolidine &
$0
pseudoephedrine tabs
(Tier
2.5mg-2.5mg-60mg-60mg,
3)
2.5mg-60mg
Necessary
actions,
restrictions, or
limits on use
AL; MO; NT
NT
NT
AL; MO; NT
AL; MO; NT
Name of drug
TUSSIONEX
PENNKINETIC
EXTENDED RELEASE
SUER (Hydrocodone
Polistirex-Chlorpheniramine
Polistirex)
TYLENOL CHILDRENS
PLUS FLU SUSP
(PhenylephrineChlorpheniramine-DM w/
APAP)
TYLENOL CHILDRENS
PLUS MULTI-SYMPTOM
COLD SUSP
(PhenylephrineChlorpheniramine-DM w/
APAP)
ZYRTEC-D
ALLERGY/CONGESTION
TB12 (CetirizinePseudoephedrine)
NT
Misc. Respiratory Inhalants
NT
sodium chloride (inhalant)
aers
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
AL; MO; NT
NF
NT
NF
NT
NF
MO; NT
NF
$0 NT
(Tier
3)
Mucolytics
AL; NT
AL; NT
AL; NT
AL; MO; NT
$0- MO; B/D
acetylcysteine soln in 10 %, $2.95
(Tier
20 %
1)
DERMATOLOGICALS - Drugs to Treat Skin
Conditions
Acne Products
$0ABSORICA CAPS 10 MG, $7.40
20 MG, 25 MG, 35 MG, 40 (Tier
MG
2)
$0ABSORICA CAPS 30 MG $7.40
(Tier
(Isotretinoin)
2)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
ACNE MEDICATION 10
(Tier
LOTN
3)
$0
ACNE MEDICATION LOTN (Tier
3)
$0$2.95
adapalene crea 0.1 %
(Tier
1)
$0$2.95
adapalene gel 0.1 %
(Tier
1)
$0
ADULT ACNOMEL CREA (Tier
3)
$0
(Tier
BENSULFOID CREA
3)
BENZACLIN GEL
NF
(Clindamycin PhosphateBenzoyl Peroxide)
BENZACLIN WITH PUMP
GEL (Clindamycin
NF
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN GEL
NF
(Benzoyl PeroxideErythromycin)
$0
benzoyl peroxide gel ex 5
(Tier
%
3)
$0$2.95
benzoyl peroxide(Tier
erythromycin gel
1)
$0
CLEARASIL DAILY CLEAR (Tier
CREA
3)
CLEOCIN-T GEL
NF
(Clindamycin Phosphate
(Topical))
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO
MO
NT
Name of drug
CLEOCIN-T LOTN
(Clindamycin Phosphate
(Topical))
CLEOCIN-T SOLN
(Clindamycin Phosphate
(Topical))
CLEOCIN-T SWAB
(Clindamycin Phosphate
(Topical))
CLINDAGEL GEL
clindamycin phosphate
(topical) foam
NT
clindamycin phosphate
(topical) gel
MO
MO
clindamycin phosphate
(topical) lotn
MO
clindamycin phosphate
(topical) soln
MO; NT
clindamycin phosphate
(topical) swab
MO
clindamycin phosphatebenzoyl peroxide
(refrigerate) gel
NT
MO
clindamycin phosphatebenzoyl peroxide gel
DIFFERIN CREA 0.1 %
(Adapalene)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
MO
NF
MO
NF
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
MO
MO
MO
MO
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
DIFFERIN GEL 0.1 %
(Adapalene)
DUAC GEL (Clindamycin
Phosphate-Benzoyl
Peroxide (Refrigerate))
erythromycin (acne aid)
soln
EVOCLIN FOAM
(Clindamycin Phosphate
(Topical))
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
MO
$0- MO
$2.95
(Tier
1)
MO
NF
RETIN-A GEL (Tretinoin)
NF MO
RETIN-A MICRO GEL
(Tretinoin Microsphere)
RETIN-A MICRO PUMP
GEL 0.04 %, 0.1 %
(Tretinoin Microsphere)
NF MO
sulfacetamide sodium
(acne) lotn
sulfacetamide sodium
(acne) susp
tretinoin crea ex 0.025 %,
0.05 %, 0.1 %
tretinoin gel ex 0.01 %,
0.025 %
NF
$0isotretinoin caps or 10 mg, $2.95
(Tier
20 mg, 30 mg, 40 mg
1)
KLARON LOTN
MO
NF
(Sulfacetamide Sodium
(Acne))
RETIN-A CREA (Tretinoin) NF MO
REZAMID LOTN
Name of drug
MO
NF
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO; NT
tretinoin microsphere gel
Necessary
actions,
restrictions, or
limits on use
MO
MO
Analgesics - Topical
menthol (topical analgesic)
pads 5 %
$0 MO; NT
(Tier
3)
Anti-inflammatory Agents - Topical
$0- MO
diclofenac sodium (topical) $2.95
(Tier
gel 1 %
1)
$0- PA; MO
$7.40
FLECTOR PTCH
(Tier
2)
$0- MO
VOLTAREN GEL
$7.40
(Diclofenac Sodium
(Tier
(Topical))
2)
Antibiotics - Topical
BACIGUENT OINT
(Bacitracin (Topical))
bacitracin (topical) oint
MO
bacitracin zinc oint ex
MO
bacitracin-polymyxin b oint
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
BACTROBAN CREA
(Mupirocin Calcium
(Topical))
NF MO; NT
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
MO
NF
You can find information on what the symbols and abbreviations in this table mean by going to
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97
Name of drug
BACTROBAN OINT
(Mupirocin)
CENTANY OINT
gentamicin sulfate (topical)
crea
gentamicin sulfate (topical)
oint
mupirocin calcium (topical)
crea
mupirocin oint ex
neomycin-bacitracinpolymyxin w/ lidocaine oint
POLYSPORIN OINT
(Bacitracin-Polymyxin B)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
MO
MO
MO
MO
MO
NT
NF MO; NT
Antifungals - Topical
ALEVAZOL OINT
ciclopirox gel 0.77 %
ciclopirox olamine crea ex
$0 NT
(Tier
3)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
ciclopirox olamine susp ex (Tier
1)
$0$2.95
ciclopirox sham 1 %
(Tier
1)
$0$2.95
ciclopirox soln 8 %
(Tier
1)
$0$2.95
clotrimazole (topical) crea
(Tier
1)
$0$2.95
clotrimazole (topical) soln
(Tier
1)
$0$2.95
clotrimazole w/
(Tier
betamethasone crea
1)
$0$2.95
clotrimazole w/
(Tier
betamethasone lotn
1)
$0
CLOVERINE SALVE OINT (Tier
3)
$0$2.95
econazole nitrate crea
(Tier
1)
EXTINA FOAM
NF
(Ketoconazole (Topical))
$0$2.95
ketoconazole (topical) crea (Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
MO
MO
NT
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
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98
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
ketoconazole (topical) foam (Tier
1)
$0$2.95
ketoconazole (topical)
(Tier
sham
1)
LAMISIL AT CREA
NF
(Terbinafine HCl (Topical))
LAMISIL AT JOCK ITCH
NF
CREA (Terbinafine HCl
(Topical))
LOPROX CREA 0.77 %
NF
(Ciclopirox Olamine)
LOPROX SHAMPOO
NF
SHAM (Ciclopirox)
LOTRISONE CREA
NF
(Clotrimazole w/
Betamethasone)
MICATIN CREA
NF
(Miconazole Nitrate
(Topical))
$0
miconazole nitrate (topical) (Tier
crea
3)
$0$2.95
naftifine hcl crea 2 %
(Tier
1)
$0$7.40
NAFTIN CREA 2 %
(Tier
(Naftifine HCl)
2)
$0$7.40
NAFTIN GEL 2 %
(Tier
2)
$0
(Tier
NIZORAL A-D SHAM
3)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO; NT
MO; NT
MO
MO
MO
MO; NT
MO; NT
MO
MO
MO
MO; NT
Name of drug
NIZORAL SHAM
(Ketoconazole (Topical))
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$2.95
nystatin (topical) crea
(Tier
1)
$0$2.95
nystatin (topical) oint
(Tier
1)
$0$2.95
nystatin (topical) powd
(Tier
1)
$0$2.95
nystatin-triamcinolone crea (Tier
1)
$0$2.95
nystatin-triamcinolone oint (Tier
1)
PENLAC NAIL LACQUER
NF
SOLN (Ciclopirox)
$0
terbinafine hcl (topical) crea (Tier
3)
TINACTIN CREA
NF
(Tolnaftate)
TINACTIN JOCK ITCH
NF
CREA (Tolnaftate)
$0
(Tier
tolnaftate crea ex
3)
$0
(Tier
tolnaftate liqd ex
3)
$0
(Tier
tolnaftate soln ex
3)
MO
MO
MO
MO
MO
MO
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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99
Name of drug
UNDELENIC TINCTURE
TINC
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NT
TARGRETIN GEL EX 1 %
Antihistamines-Topical
diphenhydramine hcl
(topical) crea
$0 NT
(Tier
3)
Antineoplastic or Premalignant Lesion Agents $0- MO
$7.40
CARAC CREA
(Tier
2)
$0- MO
diclofenac sodium (actinic $2.95
(Tier
keratoses) gel
1)
EFUDEX CREA
NF MO
(Fluorouracil (Topical))
$0- MO
$2.95
fluorouracil (topical) crea
(Tier
1)
$0- MO
$2.95
fluorouracil (topical) soln
(Tier
1)
$0- MO
$7.40
FLUOROURACIL CREA
(Tier
EX 0.5 %
2)
$0- MO
$7.40
PANRETIN GEL
(Tier
2)
$0- MO
$7.40
PICATO GEL
(Tier
2)
SOLARAZE GEL
MO
(Diclofenac Sodium (Actinic NF
Keratoses))
VALCHLOR GEL
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
Antipsoriatics
$0$2.95
acitretin caps
(Tier
1)
$0$2.95
calcipotriene crea
(Tier
1)
$0$2.95
calcipotriene oint
(Tier
1)
$0$2.95
calcipotriene soln
(Tier
1)
$0$7.40
COSENTYX
SENSOREADY PEN SOAJ (Tier
2)
$0$7.40
COSENTYX SOSY
(Tier
2)
DOVONEX CREA
NF
(Calcipotriene)
$0$2.95
methoxsalen rapid caps
(Tier
1)
$0$7.40
OXSORALEN ULTRA
CAPS (Methoxsalen Rapid) (Tier
2)
MO
MO
MO
MO
PA; LA
PA; LA
MO
MO
MO
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100
Name of drug
SORIATANE CAPS
(Acitretin)
STELARA SOSY SC 45
MG/0.5ML, 90 MG/ML
TALTZ SOAJ
TALTZ SOSY
TAZORAC CREA
TAZORAC GEL
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
PA
PA
PA
acyclovir topical oint
MO
DENAVIR CREA
MO
ZOVIRAX CREA EX 5 %
$0 MO; NT
DERMAZINC BABY LIQD (Tier
3)
$0 MO; NT
DERMAZINC SCALP LIQD (Tier
3)
DERMAZINC SPRAY LIQD NF MO; NT
(Pyrithione Zinc)
DHS ZINC SHAM
NF MO; NT
(Pyrithione Zinc)
$0
NOBLE FORMULA BAR 2 (Tier NT
%
3)
pyrithione zinc liqd 0.25 %
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO
Antivirals - Topical
Antiseborrheic Products
P & S LIQD
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
pyrithione zinc sham 2 %
3)
$0selenium sulfide lotn ex 2.5 $2.95
(Tier
%
1)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
ZOVIRAX OINT EX 5 %
(Acyclovir Topical)
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
NF MO
Bath Products
$0
(Tier
3)
$0
bath products oil 40%-40%- (Tier
40%-40%, 5%-5%-5%
3)
$0
(Tier
BODI WHIRL OIL OIL
3)
$0
(Tier
GERISILK BATH OIL OIL
3)
$0
ULTRA DERM BATH OIL
(Tier
OIL
3)
AVEENO SKIN RELIEF
SHOWER& BATH OIL
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
Burn Products
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101
Name of drug
mafenide acetate pack ex
SILVADENE CREA (Silver
Sulfadiazine)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
betamethasone
dipropionate augmented
crea
NF MO
betamethasone
dipropionate augmented
gel
$0- MO
$2.95
silver sulfadiazine crea ex (Tier
1)
$0- MO
SULFAMYLON CREA 85 $7.40
(Tier
MG/GM
2)
SULFAMYLON PACK 5 % NF MO
(Mafenide Acetate)
Corticosteroids - Topical
$0alclometasone dipropionate $2.95
(Tier
crea
1)
$0alclometasone dipropionate $2.95
(Tier
oint
1)
$0$2.95
amcinonide crea
(Tier
1)
$0$2.95
betamethasone
dipropionate (topical) crea (Tier
1)
$0$2.95
betamethasone
(Tier
dipropionate (topical) lotn
1)
$0$2.95
betamethasone
(Tier
dipropionate (topical) oint
1)
betamethasone
dipropionate augmented
lotn
betamethasone
dipropionate augmented
oint
MO
betamethasone valerate
crea ex 0.1 %
MO
betamethasone valerate
foam ex 0.12 %
MO
betamethasone valerate
lotn ex 0.1 %
MO
betamethasone valerate
oint ex 0.1 %
MO
clobetasol propionate crea
ex
MO
clobetasol propionate
emollient base crea
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
clobetasol propionate
(Tier
emulsion foam
1)
$0clobetasol propionate foam $2.95
(Tier
ex
1)
$0$2.95
clobetasol propionate gel
(Tier
ex
1)
$0clobetasol propionate lotn $2.95
(Tier
ex
1)
$0clobetasol propionate oint $2.95
(Tier
ex
1)
$0clobetasol propionate sham $2.95
(Tier
ex
1)
$0clobetasol propionate soln $2.95
(Tier
ex
1)
CLOBEX LOTN
NF
(Clobetasol Propionate)
CLOBEX SHAM
NF
(Clobetasol Propionate)
CUTIVATE CREA
NF
(Fluticasone Propionate)
CUTIVATE LOTN
NF
(Fluticasone Propionate)
$0
CVS HDYROCORTISONE (Tier
ACETATE CREA
3)
DERMA-SMOOTHE/FS
NF
BODY OIL (Fluocinolone
Acetonide)
Necessary
actions,
restrictions, or
limits on use
MO
MO
Name of drug
DERMA-SMOOTHE/FS
SCALP OIL (Fluocinolone
Acetonide)
DERMATOP CREA
(Prednicarbate)
desonide crea ex
MO
desonide lotn ex
MO
desonide oint ex
MO
DESOWEN CREA
(Desonide)
MO
desoximetasone crea ex
0.25 %
MO
desoximetasone gel ex
0.05 %
MO
desoximetasone oint ex
0.25 %
MO
MO
diflorasone diacetate oint
MO
NT
MO
DIPROLENE AF CREA
(Betamethasone
Dipropionate Augmented)
DIPROLENE LOTN
(Betamethasone
Dipropionate Augmented)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
MO
NF
MO
NF
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103
Name of drug
DIPROLENE OINT
(Betamethasone
Dipropionate Augmented)
ELOCON CREA
(Mometasone Furoate)
ELOCON OINT
(Mometasone Furoate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
fluticasone propionate crea
ex 0.05 %
NF
NF MO
NF MO
$0fluocinolone acetonide crea $2.95
(Tier
ex 0.01 %, 0.025 %
1)
$0fluocinolone acetonide oil $2.95
(Tier
ex 0.01 %
1)
$0fluocinolone acetonide oint $2.95
(Tier
ex 0.025 %
1)
$0fluocinolone acetonide soln $2.95
(Tier
ex 0.01 %
1)
$0$2.95
fluocinonide crea ex 0.05
(Tier
%
1)
$0$2.95
fluocinonide emulsified
(Tier
base crea
1)
$0$2.95
fluocinonide gel ex 0.05 % (Tier
1)
$0$2.95
fluocinonide oint ex 0.05 % (Tier
1)
$0fluocinonide soln ex 0.05 % $2.95
(Tier
1)
fluticasone propionate lotn
ex 0.05 %
MO
fluticasone propionate oint
ex 0.005 %
MO
halobetasol propionate
crea
MO
halobetasol propionate oint
MO
hydrocortisone (topical)
crea 0.5 %
MO
MO
hydrocortisone (topical)
crea 1 %
hydrocortisone (topical)
crea 2.5 %
MO
hydrocortisone (topical) lotn
1%
MO
hydrocortisone (topical) lotn
2.5 %
MO
hydrocortisone (topical) oint
0.5 %
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO; NT
RX/OTC; MO
MO
MO; NT
MO
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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104
Name of drug
hydrocortisone (topical)
oint 1 %
hydrocortisone (topical)
oint 2.5 %
hydrocortisone (topical)
soln 1 %
hydrocortisone acetate
(topical) crea
hydrocortisone butyrate
crea
hydrocortisone butyrate
hydrophilic lipo base crea
hydrocortisone butyrate
oint
hydrocortisone butyrate
soln
hydrocortisone valerate
crea
hydrocortisone valerate
oint
hydrocortisone-aloe vera
crea
LOCOID CREA
(Hydrocortisone Butyrate)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO
MO
Name of drug
LOCOID LIPOCREAM
CREA (Hydrocortisone
Butyrate Hydrophilic Lipo
Base)
LOCOID OINT
(Hydrocortisone Butyrate)
LOCOID SOLN
(Hydrocortisone Butyrate)
NT
LUXIQ FOAM
(Betamethasone Valerate)
NT
MO
mometasone furoate crea
ex
MO
mometasone furoate oint
ex
MO
mometasone furoate soln
ex
MO
OLUX FOAM (Clobetasol
Propionate)
OLUX-E FOAM (Clobetasol
Propionate Emulsion)
MO
MO
NT
prednicarbate crea
SYNALAR CREA
(Fluocinolone Acetonide)
SYNALAR OINT
(Fluocinolone Acetonide)
SYNALAR SOLN
(Fluocinolone Acetonide)
TEMOVATE CREA
(Clobetasol Propionate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
NF MO
NF MO
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
NF MO
NF MO
NF MO
NF MO
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
TEMOVATE E CREA
(Clobetasol Propionate
Emollient Base)
TEMOVATE GEL
(Clobetasol Propionate)
TEMOVATE OINT
(Clobetasol Propionate)
TEMOVATE SOLN
(Clobetasol Propionate)
What
the
drug
will
cost
you
(tier
level)
CARMOL SHAM
ULTRA MIDE 25 LOTN
(Urea)
urea crea ex 20 %
Name of drug
MO
NF
urea lotn ex 25 %
NF MO
Emollients
LAC-HYDRIN CREA
(Lactic Acid (Ammonium
Lactate))
LAC-HYDRIN LOTN (Lactic
Acid (Ammonium Lactate))
NF MO
NF MO
$0triamcinolone acetonide
$2.95
(topical) crea 0.025 %, 0.1 (Tier
%, 0.5 %
1)
$0triamcinolone acetonide
$2.95
(topical) lotn 0.025 %, 0.1
(Tier
%
1)
$0triamcinolone acetonide
$2.95
(topical) oint 0.025 %, 0.1
(Tier
%
1)
TRIDESILON CREA
NF
(Desonide)
ULTRAVATE CREA
NF
(Halobetasol Propionate)
ULTRAVATE OINT
NF
(Halobetasol Propionate)
WESTCORT OINT
NF
(Hydrocortisone Valerate)
Emollient/Keratolytic Agents
CARMOL 20 CREA (Urea)
Necessary
actions,
restrictions, or
limits on use
MO
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO
NF
NF RX/OTC; MO
$0$2.95
(Tier
1)
$0$2.95
lactic acid (ammonium
(Tier
lactate) lotn 12 %
1)
$0
lactic acid (ammonium
(Tier
lactate) lotn 5 %
3)
$0
(Tier
PANTHODERM CREA
3)
$0
(Tier
PETROLATUM OINT
3)
$0
(Tier
SUPER E CREA
3)
$0
(Tier
SUPER E DAY CREA
3)
$0
(Tier
SUPER E EYE CREA
3)
$0
(Tier
SUPER E NIGHT CREA
3)
$0
vitamin e (topical) crea
1000 unit, 1500 unit/30gm, (Tier
30000 unit/60gm, 6000 unit 3)
RX/OTC; MO
lactic acid (ammonium
lactate) crea 12 %
MO
MO
MO
MO
MO
MO
NF MO; NT
$0 NT
(Tier
3)
NF MO; NT
$0 MO; NT
(Tier
3)
RX/OTC; MO
MO; NT
NT
NT
NT
NT
NT
NT
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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106
Name of drug
vitamin e (topical) oil 100
unit/5drop, 12000 unit,
20000 unit, 28000 unit,
28000 unit/29ml, 400
unit/ml, 4000 unit, 49000
unit/52ml, 933.333 unit/ml
Enzymes - Topical
SANTYL OINT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NT
$0
(Tier
3)
$0- MO
$7.40
(Tier
2)
Immunomodulating Agents - Topical
ALDARA CREA
NF MO
(Imiquimod)
$0- MO
$2.95
imiquimod crea ex
(Tier
1)
$0- MO
$7.40
ZYCLARA CREA
(Tier
2)
$0- MO
$7.40
ZYCLARA PUMP CREA
(Tier
2)
Immunosuppressive Agents - Topical
$0- MO
$7.40
ELIDEL CREA
(Tier
2)
PROTOPIC OINT
NF MO
(Tacrolimus (Topical))
$0- MO
$2.95
tacrolimus (topical) oint
(Tier
1)
Keratolytic/Antimitotic Agents
CONDYLOX SOLN
NF MO
(Podofilox)
Name of drug
KERALYT GEL 6 %
(Salicylic Acid)
MEDIPLAST MISC
MOSCO CALLUS/CORN
REMOVER SOLN
P & S SHAM
podofilox soln ex
salicylic acid gel ex 6 %
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
Liniments
$0
ARTHRICARE DOUBLE
ICE PAIN RELIEVING RUB (Tier
3)
GEL
$0
ARTHRICARE PAIN
(Tier
RELIEVINGRUB GEL
3)
$0
ARTHRICARE TRIPLE
(Tier
MEDICATED PAIN
3)
RELIEVING RUB GEL
$0
(Tier
BIOFLEXOR GEL
3)
$0
BLUE-EMU SUPER
(Tier
STRENGTH CREA
3)
$0
DEEP BLUE RELIEF GEL (Tier
3)
liniments & rubs crea
$0
0.01%-5%-10%, 1.2%(Tier
2.6%-4.7%, 10%-0.025%3)
15%
NT
NT
NT
MO
MO; NT
NT
NT
NT
NT
MO; NT
NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
107
Name of drug
liniments & rubs oint
0.25%, 8%-2%
SM PAIN
RELIEF/MENTHOL GEL
VICKS BABYRUB CREA
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
lidocaine hcl soln ex 4 %
NT
MO; NT
AXSAIN CREA
DERMOPLAST AERO
DERMOPLAST PAIN
RELIEVINGSPRAY AERO
EMLA CREA (LidocainePrilocaine)
ITCH-X GEL
LANACANE CREA
lidocaine hcl gel ex 0.5 %
lidocaine hcl gel ex 2 %
lidocaine hcl gel ex 2 %
lidocaine oint ex 5 %
lidocaine ptch ex 5 %
Local Anesthetics - Topical
AMERICAINE AERO EX
Name of drug
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
NT
lidocaine-prilocaine crea
NT
LIDODERM PTCH
(Lidocaine)
NT
pramoxine-camphor-zinc
acetate lotn
NF MO
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0$2.95
(Tier
1)
MO; NT
NT
NT
OTC;RX/OTC;
MO; NT
RX/OTC; MO
REGENECARE HA LIQD
XYLOCAINE SOLN EX 4
% (Lidocaine HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
PA; MO
MO
NF PA; MO
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NF MO
Misc. Dermatological Products
$0
(Tier
ATOPICLAIR CREA
3)
$0
AURSTAT ANTI-ITCH
(Tier
HYDROGEL GEL
3)
$0
(Tier
BURN SPRAY AERO
3)
$0
(Tier
CALICYLIC CREA
3)
$0
(Tier
CURE-ALL CREA
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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108
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
DERMAGRAN AERO
3)
$0
DERMAREST ROSACEA (Tier
CREA
3)
$0
(Tier
DEXERYL CREA
3)
$0
(Tier
ELETONE CREA
3)
$0
ELETONE TWINPACK
(Tier
CREA
3)
$0
FRESH'N FEMININE
(Tier
DEODORANT AERO
3)
$0
(Tier
HEAL AID PLUS CREA
3)
$0
(Tier
HPR PLUS CREA
3)
$0
HYLATOPIC PLUS CREA (Tier
3)
$0
MOISTURE CREAM CREA (Tier
3)
$0
(Tier
NASALGUARD GEL
3)
$0
(Tier
NEOSALUS CP CREA
3)
$0
(Tier
NEOSALUS CREA
3)
$0
(Tier
NEW SKIN AERO
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
NIVATOPIC PLUS CREA
RX/OTC; MO;
NT
NONYX GEL
RX/OTC; MO;
NT
OC8 GEL
RX/OTC; MO;
NT
PRUCLAIR CREA
RX/OTC; MO;
NT
PRUMYX CREA
MO; NT
SEBUDERM GEL
RX/OTC; MO;
NT
RX/OTC; MO;
NT
SUMMERS EVE
DEODORANT SPRAY
AERO
SUMMERS EVE
DEODORANT SPRAY
ULTRA AERO
RX/OTC; MO;
NT
TETRIX CREA
RX/OTC; MO;
NT
XERALUX CREA
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
YODORA DEODORANT
CREA
Misc. Topical
A & D ZINC OXIDE CREA
(Dimethicone-Zinc OxideVitamin A-Vitamin D)
A-MANTLE CREA
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
NF
$0 MO; NT
(Tier
3)
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
109
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
ACNE-AID BAR
3)
$0
ACUICYN DAILY EYELID
(Tier
& EYELASH CLEANSER
3)
LIQD
$0
ALOE VESTA MULTI
(Tier
PURPOSECLEANSING
3)
FOAM
$0
ALUMINUM ACETATE
(Tier
SOLN
3)
$0
aluminum hydroxide oint ex (Tier
3)
$0
aluminum sulfate & calcium (Tier
acetate pack
3)
$0
ANTI-BACTERIAL HAND
(Tier
LOTION LOTN
3)
$0
AQUANIL SKIN
(Tier
CLEANSER LOTN
3)
$0
AVEENO MOISTURIZING (Tier
BAR
3)
AVEENO POSITIVELY
$0
AGELESSDAILY
(Tier
EXFOLIATING CLEANSER 3)
LOTN
$0
AVEENO POSITIVELY
(Tier
RADIANTCLEANSER
3)
LOTN
$0
AVEENO ULTRA(Tier
CALMING CLEANSER
3)
FOAM
$0
(Tier
AVENOVA SOLN
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO;
NT
NT
MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
RX/OTC; MO;
NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
AVENOVA/NEUTROX
(Tier
SOLN
3)
$0
(Tier
BASIS ALL CLEAR BAR
3)
$0
BASIS COMBINATION
(Tier
BAR
3)
$0
(Tier
BASIS EXTRA DRY BAR
3)
$0
BASIS NORMAL/DRY BAR (Tier
3)
$0
BASIS SENSITIVE SKIN
(Tier
BAR
3)
$0
BODY WASH &
(Tier
SHAMPOO FOAM
3)
$0
(Tier
CALAMINE LOTN EX
3)
$0
(Tier
CALAMINE LOTN EX
3)
$0
CALAMINE PHENOLATED (Tier
LOTN
3)
$0
(Tier
CARRAFOAM FOAM
3)
$0
CAVILON NO STING
(Tier
BARRIERFILM MISC
3)
$0
CETAPHIL GENTLE
(Tier
CLEANSING BAR
3)
$0
CONTI CASTILE SOAP
(Tier
BAR
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
NT
NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
110
Name of drug
CVS SALINE WOUND
WASH SOLN
DERMAGRAN OINT
(Aluminum Hydroxide)
DIABETIDERM
CLEANSING LOTN
dimethicone-zinc oxidevitamin a-vitamin d crea
DOMEBORO PACK
(Aluminum Sulfate &
Calcium Acetate)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
NT
NF NT
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
NT
NF
$0
(Tier
3)
$0
EQL DEODORANT BAR
(Tier
SOAP BAR
3)
$0
EQL MOISTURIZING
(Tier
BEAUTY BAR BAR
3)
$0
EQL MOISTURIZING
BEAUTY BAR/SENSITIVE (Tier
3)
SKIN BAR
$0
FORMULA 405 FACIAL & (Tier
BODYCLEANSING LOTN
3)
$0
FORMULA 405
(Tier
MOISTURIZINGSOAP
3)
BAR
$0
GENTLE SKIN CLEANSER (Tier
LOTN
3)
$0
(Tier
GNP CALAMINE LOTN
3)
$0
GNP CALAMINE
(Tier
PHENOLATED LOTN
3)
ELTA CLEANSE FOAM
FOAM
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
MO; NT
MO; NT
MO; NT
Name of drug
GNP SALINE WOUND
WASH SOLN
GRANDPAS BAKING
SODA SOAP BAR
GRANDPAS INDIAN
CORN SOAP BAR
GRANDPAS LOVE MY
LOOFAH SOAP BAR
GRANDPAS OATMEAL
SOAP BAR
GRANDPAS ORANGE
ESSENCE SOAP BAR
GRANDPAS PATCHOULI
SOAP BAR
GRANDPAS SHEA
BUTTER SOAP BAR
GRANDPAS WITCH
HAZEL SOAP BAR
HM CALAMINE LOTN
MO; NT
HYDROPEL OINT
MO; NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
JOHNSONS BABY BAR
BAR
JOHNSONS BUDDIES
EASY-GRIP SUDZING
BAR
lanolin (topical) crea
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
MO; NT
MO; NT
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
LOBOB CONTACT LENS (Tier
WEARERS SOAP BAR
3)
$0
(Tier
LOWILA BAR
3)
$0
MEIJER CALAMINE LOTN (Tier
3)
$0
NATURE DE FRANCE
(Tier
ALGOLI SOAP BAR
3)
$0
NATURE DE FRANCE
ARGILE BLANCHE SOAP (Tier
3)
BAR
$0
NATURE DE FRANCE
(Tier
ARGIMIEL SOAP BAR
3)
$0
NEUTROGENA ACNE
(Tier
CLEANSING SOAP BAR
3)
$0
NEUTROGENA FACIAL
(Tier
SOAP ORIGINAL
3)
FORMULA BAR
$0
NEUTROGENA
NATURALS FACE& BODY (Tier
3)
BAR
$0
NIVEA MOISTURIZING
(Tier
BODY WASH 2 IN 1 LOTN 3)
$0
NIVEA MOISTURIZING
(Tier
BODY WASH LOTN
3)
NIVEA TOUCH OF
$0
SMOOTHNESS
(Tier
MOISTURIZING BODY
3)
WASH LOTN
$0
NIVEA VISAGE GENTLE
(Tier
CLEANSING LOTN
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
NO-STING SKIN-PREP
(Tier
MISC
3)
$0
OCUSOFT HAND SOAP
(Tier
LOTN
3)
$0
OCUSOFT HYPOCHLOR (Tier
LIQD
3)
$0
OCUSOFT LID SCRUB
(Tier
FOAMING SOLN
3)
$0
OCUSOFT LID SCRUB
(Tier
ORIGINAL LIQD
3)
$0
(Tier
OILATUM BAR
3)
$0
PROSHIELD FOAM &
(Tier
SPRAY CLEANSER FOAM 3)
$0
(Tier
PX CALAMINE LOTN
3)
$0
(Tier
QC CALAMINE LOTN
3)
$0
(Tier
RA BEAUTY BAR BAR
3)
$0
RA CALAMINE LOTN
(Tier
6.971%-6.971%
3)
$0
RA SALINE WOUND
(Tier
WASH SOLN
3)
$0
(Tier
SAFE WASH SOLN
3)
$0
SALINE WOUND WASH
(Tier
SOLN
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
MO; NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
NT
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
SALJET RINSE SOLN
3)
$0
(Tier
SALJET SOLN
3)
$0
(Tier
SAYMAN LANOLIN BAR
3)
$0
SAYMAN WITCH HAZEL
(Tier
BAR
3)
$0
skin protectants, misc. liqd (Tier
3)
$0
(Tier
SM CALAMINE LOTN
3)
$0
SM CALAMINE
(Tier
PHENOLATED LOTN
3)
$0
SM SKIN CLEANSER
GENTLE/SENSITIVE SKIN (Tier
3)
LOTN
$0
STYGIENE STERILE
(Tier
EYELID CLEANSER LIQD
3)
SUMMERS EVE NIGHT$0
TIME
(Tier
CLEANSING/SENSITIVE
3)
SKIN BAR
$0
TERSASEPTIC
GLYCERINE CLEANSING (Tier
3)
BAR
$0
(Tier
TOPICLEAR LOTN
3)
$0
UNIVERSAL REMOVER
(Tier
WIPES MISC
3)
Necessary
actions,
restrictions, or
limits on use
NT
NT
MO; NT
MO; NT
NT
NT
NT
MO; NT
RX/OTC; MO;
NT
MO; NT
MO; NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
URO-PREP PROTECTIVE (Tier
SKINWIPES MISC
3)
$0
(Tier
VANICREAM BAR
3)
$0
(Tier
witch hazel-glycerin pads
3)
$0
WOUND WASH SALINE
(Tier
SOLN
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
NT
NT
Rosacea Agents
FINACEA GEL
METROCREAM CREA
(Metronidazole (Topical))
METROGEL GEL
(Metronidazole (Topical))
METROLOTION LOTN
(Metronidazole (Topical))
$0- MO
$7.40
(Tier
2)
NF MO
NF MO
NF MO
$0$2.95
(Tier
1)
$0metronidazole (topical) gel $2.95
(Tier
1)
$0$2.95
metronidazole (topical) lotn (Tier
1)
$0$7.40
MIRVASO GEL
(Tier
2)
MO
metronidazole (topical)
crea
MO
MO
PA; MO
Scabicides & Pediculicides
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
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113
Name of drug
lindane lotn
LYCELLE GEL
malathion lotn
nit remover gel
NIX CREME RINSE LIQD
(Permethrin)
permethrin aero xx 0.5 %
permethrin crea ex 5 %
permethrin liqd ex 1 %
permethrin lotn ex 1 %
PRONTO SHAM EX
0.33%-4% (PyrethrinsPiperonyl Butoxide)
pyrethrins-piperonyl
butoxide liqd 0.33%-4%,
1.2%-0.3%-0.3%-2.4%-3%
pyrethrins-piperonyl
butoxide sham 0.3%0.33%-4%, 0.33%-4%
pyrethrins-piperonyl
butoxide sham 0.33%-4%
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NF NT
RID LIQD (PyrethrinsPiperonyl Butoxide)
NF NT
Sunscreens
MO
BULL FROG QUIK GEL
SPF 36 GEL
RX/OTC; NT
NT
MO
MO; NT
NT
MO; NT
NF
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RID AERO (Permethrin)
RX/OTC; NT
NF MO; NT
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
BULL FROG QUIK GEL
(Tier
SPF 50 GEL
3)
$0
BULL FROG QUIK GEL
(Tier
SPORTSPF 36 GEL
3)
$0
BULL FROG QUIK GEL
(Tier
SPORTSPRAY SPF 50
3)
GEL
$0
BULL FROG SPF 36 GEL (Tier
3)
$0
BULL FROG WATER
(Tier
ARMOR SPORT QUIK
3)
GEL SPF 50 GEL
$0
BULL FROG WATER
(Tier
ARMOR SPORT QUIK
3)
SPRAY SPF 50 GEL
$0
NIVEA VISAGE EYE
(Tier
CONTOUR GEL
3)
$0
PRESUN ULTRA/PARSOL (Tier
GEL 3%-5%-7.5%-6%
3)
$0
SHADE OIL FREE CLEAR (Tier
GELSPF 25 GEL
3)
$0
SOLBAR PF LIQUID/GEL (Tier
SPF30 GEL
3)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
Tar Products
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
114
Name of drug
coal tar extract sham 1 %
COAL TAR SOLN EX
CUTAR OIL
ELTA LITE TAR LOTN
ELTA TAR CREA
GRANDPAS PINE TAR
SOAP BAR
MG217 MEDICATED TAR
LOTN
MG217 MEDICATED TAR
OINT
MG217 MEDICATED TAR
SHAMPOO SHAM
POLYTAR BAR
TARSUM SHAM
THERAPLEX T SHAM
(Coal Tar Extract)
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
Name of drug
NT
Diagnostic Drugs
NT
DIAGNOSTIC PRODUCTS
Necessary
actions,
restrictions, or
limits on use
$0 NT
(Tier
3)
Diagnostic Tests
MO; NT
NT
NT
NT
NT
NT
MO; NT
NT
MO; NT
NF NT
Wound Care Products
REGRANEX GEL
GLUTOL LIQD
What
the
drug
will
cost
you
(tier
level)
$0- MO
$7.40
(Tier
2)
$0
(Tier
ALBUSTIX STRP
3)
$0
CHEK-STIX COMBO PAK
(Tier
URINALYSIS CONTROL
3)
STRP
$0
CHEK-STIX CONTROL
(Tier
STRP
3)
$0
CHEMSTRIP -10 WITH SG (Tier
STRP
3)
$0
CHEMSTRIP 10 MD STRP (Tier
3)
$0
CHEMSTRIP 2 GP
(Tier
STRIPS STRP
3)
$0
CHEMSTRIP 2 LN STRIPS (Tier
STRP
3)
$0
(Tier
CHEMSTRIP 5 OB STRP
3)
$0
(Tier
CHEMSTRIP 7 STRP
3)
$0
CHEMSTRIP 9 STRIPS
(Tier
STRP
3)
$0
(Tier
CHEMSTRIP UGK STRP
3)
$0
(Tier
CHEMSTRIP-K STRP
3)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
CHEMSTRIP-MICRAL
STRP
CLINISTIX STRP
CLINITEST REAGENT
TABS
CLINITEST TABS
COMBISTIX STRP
CVS KETONE CARE
STRP
DIASTIX STRP
HEMA-COMBISTIX STRP
KETO-DIASTIX STRP
KETOCARE STRP
KETONE TEST STRIPS
STRP
KETOSTIX STRP
LABSTIX STRP
MULTISTIX 10 SG STRP
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
MULTISTIX 5 STRP
3)
$0
(Tier
MULTISTIX 7 STRP
3)
$0
(Tier
MULTISTIX 8 SG STRP
3)
$0
(Tier
MULTISTIX 9 SG STRP
3)
$0
(Tier
MULTISTIX 9 STRP
3)
$0
(Tier
MULTISTIX STRP
3)
$0
NITRATEST PAPER TEST (Tier
3)
$0
NOVA MAX PLUS
(Tier
KETONE TESTSTRIPS
3)
STRP
$0
(Tier
PRECISION XTRA STRP
3)
$0
PTS PANELS KETONE
(Tier
TEST STRP
3)
$0
(Tier
RELION KETONE STRP
3)
$0
RELION KETONE TEST
(Tier
STRIPS STRP
3)
$0
UNIVERSAL PH STRIPS
(Tier
STRP
3)
$0
(Tier
URISTIX 4 STRP
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
URISTIX STRP
WFHC PH PAPER TEST
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
CREON CPEP
MO; NT
Nutritional Supplements
DEXATRIM MAX PACK
1MG-5.5UNIT-34MCG72MG-75MG-0.35MG70MG-45MG-0.263MG10MG-1.8MG-3.5MG0.3MG-3MCG-70MCG0.35MG-25MG-30MG
Necessary
actions,
restrictions, or
limits on use
MO
$0$7.40
(Tier
2)
MO; NT
PANCREAZE CPEP
10000UNIT-4200UNIT17500UNIT, 25000UNIT10500UNIT-43750UNIT,
37000UNIT-21000UNIT61000UNIT, 40000UNIT16800UNIT-70000UNIT
MO; NT
PANCREAZE CPEP
6200UNIT-2600UNIT10850UNIT
$0$7.40
(Tier
2)
MO; NT
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure
DIETARY PRODUCTS/DIETARY MANAGEMENT
PRODUCTS
Dietary Management Products
$0
(Tier
CEREFOLIN TABS
3)
$0
folic acid-pyridoxine(Tier
cyanocobalamin tabs
3)
$0
(Tier
L-METHYL-MC TABS
3)
$0
(Tier
METAFOLBIC TABS
3)
$0
(Tier
NEOKE BCAA4 POWD
3)
$0
SULFZIX POWD
(Tier
500MCG/0.25GM
3)
$0
XIZFLUS POWD
(Tier
500MCG/0.25GM
3)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
MO; NT
RX/OTC; NT
RX/OTC; NT
RX/OTC; NT
NT
$0
(Tier
3)
DIGESTIVE AIDS - Drugs to Treat Low Digestive
Enzymes
MO
Carbonic Anhydrase Inhibitors
$0acetazolamide cp12 or 500 $2.95
(Tier
mg
1)
$0acetazolamide tabs or 250 $2.95
(Tier
mg
1)
DIAMOX CP12
NF
(Acetazolamide)
$0methazolamide tabs or 25 $2.95
(Tier
mg, 50 mg
1)
Diuretic Combinations
ALDACTAZIDE TABS
25MG-25MG
(Spironolactone &
Hydrochlorothiazide)
amiloride &
hydrochlorothiazide tabs
MO
MO
MO
MO
MO
NF
$0- MO
$2.95
(Tier
1)
Digestive Enzymes
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Name of drug
DYAZIDE CAPS
(Triamterene &
Hydrochlorothiazide)
MAXZIDE TABS
(Triamterene &
Hydrochlorothiazide)
MAXZIDE-25 TABS
(Triamterene &
Hydrochlorothiazide)
spironolactone &
hydrochlorothiazide tabs
triamterene &
hydrochlorothiazide caps
triamterene &
hydrochlorothiazide tabs
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
LASIX TABS (Furosemide)
MO
torsemide tabs or 10 mg,
100 mg, 20 mg, 5 mg
MO
Potassium Sparing Diuretics
ALDACTONE TABS
NF MO
(Spironolactone)
$0- MO
$2.95
amiloride hcl tabs or
(Tier
1)
$0- MO
spironolactone tabs or 100 $2.95
(Tier
mg, 25 mg, 50 mg
1)
NF
NF
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Loop Diuretics
$0bumetanide tabs or 0.5 mg, $2.95
(Tier
1 mg, 2 mg
1)
BUMEX TABS
NF
(Bumetanide)
DEMADEX TABS
NF
(Torsemide)
$0$2.95
furosemide soln ij 10 mg/ml (Tier
1)
$0$2.95
furosemide soln or 10
(Tier
mg/ml
1)
$0furosemide tabs or 20 mg, $2.95
(Tier
40 mg, 80 mg
1)
What
the
drug
will
cost
you
(tier
level)
MO
MO
MO
MO
MO
MO
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
Thiazides and Thiazide-Like Diuretics
$0- MO
$2.95
chlorothiazide tabs 500 mg (Tier
1)
$0- MO
$2.95
chlorthalidone tabs 25 mg (Tier
1)
$0- MO
hydrochlorothiazide caps or $2.95
(Tier
12.5 mg
1)
$0- MO
hydrochlorothiazide tabs or $2.95
(Tier
12.5 mg, 25 mg, 50 mg
1)
$0- MO
$2.95
indapamide tabs
(Tier
1)
$0- MO
$2.95
metolazone tabs
(Tier
1)
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Name of drug
MICROZIDE CAPS
(Hydrochlorothiazide)
ZAROXOLYN TABS
(Metolazone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF MO
ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
Bone Density Regulators
$0- MO
$2.95
alendronate sodium tabs
(Tier
10 mg, 5 mg
1)
$0- QL(0.15 ea
$2.95 daily); MO
alendronate sodium tabs
(Tier
35 mg, 70 mg
1)
Limit 3mls per
BONIVA SOLN IV 3
NF 3
MG/3ML (Ibandronate
months;QL(0.0
Sodium)
4 ml daily); MO
Limit 1 tab per
BONIVA TABS OR 150 MG NF 28 days (3 per
(Ibandronate Sodium)
84);QL(0.036
ea daily); MO
$0- MO
$2.95
calcitonin (salmon) soln
(Tier
1)
$0- Limit 2.4mls
$7.40 per 28
FORTEO SOLN
(Tier days;QL(0.09
2) ml daily)
$0- MO
$7.40
FORTICAL SOLN
(Tier
2)
FOSAMAX TABS
NF QL(0.15 ea
(Alendronate Sodium)
daily); MO
$0- Limit 3mls per
ibandronate sodium soln iv $2.95 3
(Tier months;QL(0.0
3 mg/3ml
1) 4 ml daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0ibandronate sodium tabs or $2.95
(Tier
150 mg
1)
$0MIACALCIN SOLN IJ 200 $7.40
(Tier
UNIT/ML
2)
MIACALCIN SOLN NA 200
NF
UNIT/ACT (Calcitonin
(Salmon))
$0$7.40
NATPARA CART
(Tier
2)
$0$7.40
PROLIA SOLN
(Tier
2)
RECLAST SOLN
(Zoledronic Acid)
XGEVA SOLN
zoledronic acid conc 4
mg/5ml
zoledronic acid soln 5
mg/100ml
zoledronic acid solr 4 mg
ZOMETA CONC 4
MG/5ML (Zoledronic Acid)
NF
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Limit 1 tab per
28 days (3 per
84);QL(0.036
ea daily); MO
MO
MO
PA; LA
Limit 1 ml per 6
months;QL(0.0
1 ml daily)
Limit 100mls
per
year;QL(0.28
ml daily)
Limit 6.8mls
per 28
days;QL(0.243
ml daily)
Limit 100mls
per
year;QL(0.28
ml daily)
NF
Corticotropin
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119
Name of drug
H.P. ACTHAR GEL
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; LA
Fertility Regulators
$0chorionic gonadotropin solr $2.95
(Tier
im
1)
Growth Hormone Receptor Antagonists
$0- LA
$7.40
SOMAVERT SOLR
(Tier
2)
Growth Hormone Releasing Hormones (GHRH)
$0$7.40
EGRIFTA SOLR 2 MG
(Tier
2)
Growth Hormones
$0- PA
GENOTROPIN MINIQUICK $7.40
(Tier
SOLR 0.4 MG
2)
$0- PA
$7.40
GENOTROPIN SOLR 5
(Tier
MG
2)
$0- PA
$7.40
HUMATROPE COMBO
(Tier
PACK SOLR
2)
$0- PA
$7.40
HUMATROPE SOLR
(Tier
2)
$0NORDITROPIN FLEXPRO $7.40 PA
SOLN 10 MG/1.5ML, 5
(Tier
MG/1.5ML
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
NUTROPIN AQ NUSPIN
(Tier
20 SOLN
2)
$0NUTROPIN AQ PEN SOLN $7.40
(Tier
20 MG/2ML
2)
$0$7.40
OMNITROPE SOLN 10
(Tier
MG/1.5ML, 5 MG/1.5ML
2)
$0SEROSTIM SOLR 4 MG, 6 $7.40
(Tier
MG
2)
$0$7.40
ZOMACTON SOLR 5 MG
(Tier
2)
Hormone Receptor Modulators
EVISTA TABS (Raloxifene
NF
HCl)
$0$2.95
raloxifene hcl tabs
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
PA
QL(1 ea daily);
MO
QL(1 ea daily);
MO
Insulin-Like Growth Factors (Somatomedins)
$0- LA
$7.40
INCRELEX SOLN
(Tier
2)
LHRH/GnRH Agonist Analog Pituitary
$0- 3 month kit
LUPRON DEPOT-PED KIT $7.40
(Tier
11.25 MG
2)
$0LUPRON DEPOT-PED KIT $7.40
11.25 MG, 15 MG, 7.5 MG (Tier
2)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0LUPRON DEPOT-PED KIT $7.40
(Tier
30 MG
2)
$0$7.40
SYNAREL SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Metabolic Modifiers
$0calcitriol caps or 0.25 mcg, $2.95
(Tier
0.5 mcg
1)
$0$2.95
calcitriol soln or 1 mcg/ml
(Tier
1)
$0$7.40
CARBAGLU TABS
(Tier
2)
$0$7.40
FABRAZYME SOLR 35
(Tier
MG
2)
$0$7.40
KANUMA SOLN
(Tier
2)
$0$7.40
KUVAN PACK
(Tier
2)
$0$7.40
KUVAN TBSO
(Tier
2)
$0$2.95
levocarnitine (metabolic
(Tier
modifiers) tabs or 330 mg
1)
MO
MO
LA
LA
LA
LA
LA
RX/OTC; MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
LUMIZYME SOLR
(Tier
2)
$0$7.40
MYALEPT SOLR
(Tier
2)
$0$7.40
MYOZYME SOLR
(Tier
2)
$0$7.40
NAGLAZYME SOLN
(Tier
2)
$0ORFADIN CAPS 10 MG, 2 $7.40
(Tier
MG, 20 MG, 5 MG
2)
$0paricalcitol caps or 1 mcg, $2.95
(Tier
2 mcg, 4 mcg
1)
$0$7.40
RAVICTI LIQD
(Tier
2)
ROCALTROL CAPS
NF
(Calcitriol)
ROCALTROL SOLN
NF
(Calcitriol)
$0$7.40
SENSIPAR TABS
(Tier
2)
$0$7.40
STRENSIQ SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
LA
LA
LA
LA
MO
LA
MO
MO
PA; LA
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Name of drug
VIMIZIM SOLN
ZEMPLAR CAPS OR 1
MCG, 2 MCG (Paricalcitol)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
MO
Prolactin Inhibitors
cabergoline tabs
Necessary
actions,
restrictions, or
limits on use
Somatostatic Agents
NF MO
Posterior Pituitary Hormones
DDAVP SOLN
NF
(Desmopressin Acetate
Refrigerated)
DDAVP SOLN
NF
(Desmopressin Acetate
Spray)
DDAVP SOLN
NF
(Desmopressin Acetate)
DDAVP TABS
NF
(Desmopressin Acetate)
$0$2.95
desmopressin acetate
(Tier
refrigerated soln
1)
$0desmopressin acetate soln $2.95
(Tier
ij 4 mcg/ml
1)
$0$2.95
desmopressin acetate
(Tier
spray refrigerated soln
1)
$0$2.95
desmopressin acetate
(Tier
spray soln
1)
$0desmopressin acetate tabs $2.95
(Tier
or 0.1 mg, 0.2 mg
1)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0- MO
$2.95
(Tier
1)
$0octreotide acetate soln 100 $2.95
mcg/ml, 200 mcg/ml, 50
(Tier
mcg/ml
1)
$0$7.40
SANDOSTATIN LAR
DEPOT KIT 20 MG, 30 MG (Tier
2)
SANDOSTATIN SOLN 100
MCG/ML, 200 MCG/ML, 50 NF
MCG/ML (Octreotide
Acetate)
$0- Limit 3 vials per
SIGNIFOR LAR SUSR 20 $7.40 28
(Tier days;SL(0.11
MG
2) ea daily); LA
$0- Limit 3 vials per
SIGNIFOR LAR SUSR 40 $7.40 56
(Tier days;SL(0.054
MG
2) ea daily); LA
$0- Limit 1 vial per
SIGNIFOR LAR SUSR 60 $7.40 28
(Tier days;SL(0.036
MG
2) ea daily); LA
$0- LA
$7.40
SIGNIFOR SOLN
(Tier
2)
$0$7.40
SOMATULINE DEPOT
(Tier
SOLN
2)
Vasopressin Receptor Antagonists
$0$7.40
SAMSCA TABS
(Tier
2)
ESTROGENS - Hormone Replacement/Modifying
Drugs
Estrogen Combinations
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122
Name of drug
ACTIVELLA TABS
(Estradiol & Norethindrone
Acetate)
estradiol & norethindrone
acetate tabs
PREMPHASE TABS
PREMPRO TABS
Estrogens
CLIMARA PTWK
(Estradiol)
DELESTROGEN OIL 10
MG/ML
DELESTROGEN OIL 20
MG/ML, 40 MG/ML
(Estradiol Valerate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
AL; MO
NF
$0- AL; MO
$2.95
(Tier
1)
$0- AL; MO
$7.40
(Tier
2)
$0- AL; MO
$7.40
(Tier
2)
NF AL; MO
$0- MO
$7.40
(Tier
2)
MO
NF
$0- AL; MO
$7.40
DIVIGEL GEL
(Tier
2)
estradiol ptwk td 0.025
$0- AL; MO
mg/24hr, 0.05 mg/24hr,
$2.95
0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5 (Tier
1)
mcg/24hr
$0- AL; MO
estradiol tabs or 0.5 mg, 1 $2.95
(Tier
mg, 2 mg
1)
$0- MO
estradiol valerate oil im 20 $2.95
(Tier
mg/ml, 40 mg/ml
1)
estropipate tabs 0.75 mg,
1.5 mg
PREMARIN TABS OR 0.3
MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; MO
FLUOROQUINOLONES - Drugs to Treat Bacterial
Infections
Fluoroquinolones
CIPRO I.V.-IN D5W SOLN
(Ciprofloxacin in D5W)
CIPRO TABS 250 MG, 500
MG (Ciprofloxacin HCl)
CIPRO XR TB24
(Ciprofloxacin-Ciprofloxacin
HCl)
ciprofloxacin hcl tabs or
100 mg, 250 mg, 500 mg,
750 mg
ciprofloxacin in d5w soln
200mg/100ml-5%
ciprofloxacin in d5w soln
400mg/200ml-5%
ciprofloxacin soln iv 400
mg/40ml
ciprofloxacin-ciprofloxacin
hcl tb24
NF MO
NF MO
MO
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
MO
MO
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123
Name of drug
LEVAQUIN SOLN IV
250MG/50ML-5%,
500MG/100ML-5%,
750MG/150ML-5%
(Levofloxacin in D5W)
LEVAQUIN SOLN OR 25
MG/ML (Levofloxacin)
LEVAQUIN TABS OR 250
MG, 500 MG, 750 MG
(Levofloxacin)
levofloxacin in d5w soln
levofloxacin soln iv 25
mg/ml
levofloxacin soln or 25
mg/ml
levofloxacin tabs or 250
mg, 500 mg, 750 mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
simethicone chew or 125
mg
NF
NF MO
MO
NF
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs
Antiflatulents
GAS-X EXTRA
STRENGTH CHEW 125
MG (Simethicone)
MYLANTA GAS CHEW
(Simethicone)
MYLANTA GAS RELIEF
MAXIMUM STRENGTH
CAPS (Simethicone)
simethicone caps or 125
mg, 125mg
Name of drug
MO; NT
NF
NF MO; NT
MO; NT
NF
$0 MO; NT
(Tier
3)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
Farnesoid X Receptor (FXR) Agonists
$0- PA; SL(1 ea
$7.40 daily)
OCALIVA TABS 10 MG
(Tier
2)
$0- PA; SL(2 ea
$7.40 daily)
OCALIVA TABS 5 MG
(Tier
2)
Gallstone Solubilizing Agents
ACTIGALL CAPS
NF
(Ursodiol)
$0$2.95
chenodiol tabs
(Tier
1)
URSO 250 TABS
NF
(Ursodiol)
URSO FORTE TABS
NF
(Ursodiol)
$0$2.95
ursodiol caps or 300 mg
(Tier
1)
$0$2.95
ursodiol tabs or 250 mg,
(Tier
500 mg
1)
MO
LA
MO
MO
MO
MO
Gastrointestinal Antiallergy Agents
$0- MO
$2.95
cromolyn sodium
(Tier
(mastocytosis) conc
1)
GASTROCROM CONC
MO
NF
(Cromolyn Sodium
(Mastocytosis))
Gastrointestinal Stimulants
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124
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0metoclopramide hcl soln ij $2.95
(Tier
5 mg/ml
1)
$0metoclopramide hcl soln or $2.95
(Tier
10 mg/10ml, 5 mg/5ml
1)
$0metoclopramide hcl tabs or $2.95
(Tier
10 mg, 5 mg
1)
REGLAN TABS
NF
(Metoclopramide HCl)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
Inflammatory Bowel Agents
APRISO CP24
ASACOL HD TBEC
AZULFIDINE EN-TABS
TBEC (Sulfasalazine)
AZULFIDINE TABS
(Sulfasalazine)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
NF MO
NF MO
$0- MO
$2.95
balsalazide disodium caps (Tier
1)
$0- PA
$7.40
CIMZIA KIT
(Tier
2)
$0- PA
$7.40
CIMZIA STARTER KIT KIT (Tier
2)
COLAZAL CAPS
NF MO
(Balsalazide Disodium)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
DELZICOL CPDR
(Tier
2)
$0$7.40
DIPENTUM CAPS
(Tier
2)
$0$7.40
ENTYVIO SOLR
(Tier
2)
$0$7.40
MESALAMINE DR TBEC
(Tier
2)
$0$2.95
mesalamine enem re
(Tier
1)
$0$2.95
mesalamine w/ cleanser kit (Tier
1)
$0$7.40
REMICADE SOLR
(Tier
2)
ROWASA KIT (Mesalamine NF
w/ Cleanser)
$0$2.95
sulfasalazine tabs or
(Tier
1)
$0$2.95
sulfasalazine tbec or
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
PA
MO
MO
MO
PA
MO
MO
MO
Intestinal Acidifiers
$0- MO
lactulose (encephalopathy) $2.95
(Tier
soln
1)
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Irritable Bowel Syndrome (IBS) Agents
$0- MO
$2.95
alosetron hcl tabs
(Tier
1)
$0- MO
$7.40
LINZESS CAPS
(Tier
2)
$0- MO
$7.40
LOTRONEX TABS
(Tier
(Alosetron HCl)
2)
$0- PA; MO
$7.40
VIBERZI TABS
(Tier
2)
Peripheral Opioid Receptor Antagonists
$0- MO
$7.40
MOVANTIK TABS
(Tier
2)
$0- MO
$7.40
RELISTOR SOLN SC 12
(Tier
MG/0.6ML, 8 MG/0.4ML
2)
Phosphate Binder Agents
$0- MO
calcium acetate (phosphate $2.95
(Tier
binder) caps
1)
$0- MO
FOSRENOL CHEW 1000 $7.40
(Tier
MG, 500 MG, 750 MG
2)
PHOSLO CAPS (Calcium
MO
NF
Acetate (Phosphate
Binder))
$0- MO
$7.40
RENVELA PACK 2.4 GM
(Tier
2)
Name of drug
RENVELA TABS 800 MG
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Short Bowel Syndrome (SBS) Agents
$0- PA; LA
$7.40
GATTEX KIT
(Tier
2)
GENITOURINARY AGENTS - MISCELLANEOUS
- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System
Alkalinizers
potassium citrate
(alkalinizer) tbcr 1080 mg,
540 mg
UROCIT-K 10 TBCR
(Potassium Citrate
(Alkalinizer))
UROCIT-K 5 TBCR
(Potassium Citrate
(Alkalinizer))
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
Genitourinary Irrigants
acetic acid soln
neomycin/polymyxin b gu
soln
sodium chloride (gu
irrigant) soln
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Prostatic Hypertrophy Agents
You can find information on what the symbols and abbreviations in this table mean by going to
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126
Name of drug
alfuzosin hcl tb24
AVODART CAPS
(Dutasteride)
dutasteride caps
dutasteride-tamsulosin hcl
caps
finasteride tabs or
FLOMAX CAPS
(Tamsulosin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
Gout Agent Combinations
GL; MO
Necessary
actions,
restrictions, or
limits on use
$0- MO
$2.95
(Tier
1)
Gout Agents
GL; MO
GL; MO
GL; MO
NF MO
$0JALYN CAPS (Dutasteride- $7.40
(Tier
Tamsulosin HCl)
2)
PROSCAR TABS
NF
(Finasteride)
$0$2.95
tamsulosin hcl caps
(Tier
1)
UROXATRAL TB24
NF
(Alfuzosin HCl)
colchicine w/ probenecid
tabs
What
the
drug
will
cost
you
(tier
level)
GL; MO
GL; MO
allopurinol tabs or 100 mg
allopurinol tabs or 300 mg
COLCHICINE TABS OR
COLCRYS TABS
ZYLOPRIM TABS 100 MG
(Allopurinol)
ZYLOPRIM TABS 300 MG
(Allopurinol)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
SL(8 ea daily);
MO
SL(2.66 ea
daily); MO
MO
MO
NF SL(8 ea daily);
MO
NF SL(2.66 ea
daily); MO
Uricosurics
MO
probenecid tabs
MO
Urinary Analgesics
$0 MO; NT
phenazopyridine hcl tabs or (Tier
100 mg, 200 mg
3)
PYRIDIUM TABS
NF MO; NT
(Phenazopyridine HCl)
$0- MO
$2.95
(Tier
1)
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders
Bradykinin B2 Receptor Antagonists
$0$7.40
FIRAZYR SOLN
(Tier
2)
Complement Inhibitors
GOUT AGENTS - Drugs to Treat Gout
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127
Name of drug
BERINERT KIT
CINRYZE SOLR
RUCONEST SOLR
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
cilostazol tabs
LA
clopidogrel bisulfate tabs
300 mg
clopidogrel bisulfate tabs
75 mg
Hematorheologic Agents
pentoxifylline tbcr or
$0- MO
$2.95
(Tier
1)
dipyridamole tabs or 25
mg, 50 mg, 75 mg
EFFIENT TABS
Plasma Kallikrein Inhibitors
KALBITOR SOLN
Name of drug
$0$7.40
(Tier
2)
Platelet Aggregation Inhibitors
$0$7.40
AGGRENOX CP12
(Tier
2)
AGRYLIN CAPS
NF
(Anagrelide HCl)
$0$2.95
anagrelide hcl caps
(Tier
1)
$0ASPIRIN/DIPYRIDAMOLE $7.40
(Tier
CP12
2)
$0$7.40
BRILINTA TABS
(Tier
2)
MO
MO
MO
Necessary
actions,
restrictions, or
limits on use
MO
MO
AL; MO
MO
PERSANTINE TABS
(Dipyridamole)
PLAVIX TABS 300 MG
(Clopidogrel Bisulfate)
PLAVIX TABS 75 MG
(Clopidogrel Bisulfate)
NF AL; MO
PLETAL TABS (Cilostazol)
NF MO
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
ticlopidine hcl tabs
ZONTIVITY TABS
NF
NF MO
$0- AL
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Agents for Gaucher Disease
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128
Name of drug
CERDELGA CAPS
CEREZYME SOLR
ELELYSO SOLR
VPRIV SOLR
ZAVESCA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
folic acid tabs or 1 mg
LA
LA
Agents for Sickle Cell Anemia
$0- MO
$7.40
DROXIA CAPS
(Tier
2)
Cobalamins
cyanocobalamin subl sl
1000 mcg
cyanocobalamin tabs or
250 mcg
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
Folic Acid/Folates
folic acid caps or 0.8 mg,
800 mcg
FOLIC ACID CAPS OR 20
MG
FOLIC ACID CAPS OR 5
MG
Name of drug
$0 NT
(Tier
3)
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
folic acid tabs or 400 mcg,
800 mcg
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Hematopoietic Growth Factors
$0$7.40
ARANESP ALBUMIN
(Tier
FREE SOLN
2)
$0$7.40
ARANESP ALBUMIN
(Tier
FREE SOSY
2)
$0$7.40
EPOGEN SOLN
(Tier
2)
$0$7.40
GRANIX SOSY
(Tier
2)
$0$7.40
LEUKINE SOLR
(Tier
2)
$0$7.40
NEULASTA ONPRO KIT
(Tier
PSKT
2)
$0$7.40
NEULASTA SOSY
(Tier
2)
$0$7.40
NEUMEGA SOLR
(Tier
2)
$0$7.40
NEUPOGEN SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
MO; NT
PA
PA
PA; B/D
PA
PA
PA
PA
PA
PA
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Name of drug
NEUPOGEN SOSY
PROCRIT SOLN 10000
UNIT/ML, 2000 UNIT/ML,
20000 UNIT/ML, 3000
UNIT/ML, 4000 UNIT/ML,
40000 UNIT/ML
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
PA
$0- PA; B/D
$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
PROMACTA TABS 25 MG (Tier
2)
$0$7.40
PROMACTA TABS 50 MG (Tier
2)
$0$7.40
PROMACTA TABS 75 MG (Tier
2)
$0$7.40
ZARXIO SOSY
(Tier
2)
PROMACTA TABS 12.5
MG
Necessary
actions,
restrictions, or
limits on use
SL(12 ea daily);
LA
SL(6 ea daily);
LA
SL(3 ea daily);
LA
SL(2 ea daily);
LA
PA
Hematopoietic Mixtures
$0 NT
(Tier
B-6 FOLIC ACID CAPS
3)
FOLGARD RX TABS (Folic
MO; NT
NF
Acid-Vitamin B6-Vitamin
B12)
$0 RX/OTC; MO;
(Tier NT
FOLIC + B12 TABS
3)
$0 MO; NT
folic acid-vitamin b6(Tier
vitamin b12 tabs
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
FOLTRATE TABS
3)
$0
(Tier
HEMOCYTE-F ELIX
3)
$0
(Tier
I.L.X. B-12 ELIX
3)
$0
(Tier
iron combinations caps
3)
$0
(Tier
MTX SUPPORT TABS
3)
$0
OPURITY B12/FOLIC
(Tier
ACID TABS
3)
$0
(Tier
PRE-FOLIC TABS
3)
$0
VITAMIN B12/FOLIC ACID (Tier
TABS
3)
Iron
FER-IN-SOL SOLN
(Ferrous Sulfate)
FERGON TABS (Ferrous
Gluconate)
FERRETTS TABS
ferrous fumarate tabs or
324 mg
FERROUS FUMARATE
TABS OR 90 MG
FERROUS GLUCONATE
TABS OR 225 MG
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
RX/OTC; NT
RX/OTC; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
NT
RX/OTC; MO;
NT
NF MO; NT
NF NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
NT
NT
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
ferrous gluconate tabs or
(Tier
240 mg, 27 mg
3)
$0
ferrous sulfate dried tbcr
(Tier
160 mg
3)
$0
ferrous sulfate elix or 220
(Tier
mg/5ml
3)
$0
FERROUS SULFATE LIQD (Tier
OR 220 MG/5ML
3)
$0
ferrous sulfate soln or 15
(Tier
mg/ml
3)
$0
FERROUS SULFATE
(Tier
SYRP OR 300 MG/5ML
3)
$0
ferrous sulfate tabs or 325 (Tier
mg, 65 mg
3)
$0
ferrous sulfate tbcr or 50
(Tier
mg
3)
$0
FERROUS SULFATE
(Tier
TBEC OR 324 MG
3)
$0
ferrous sulfate tbec or 325 (Tier
mg
3)
HEMOCYTE TABS
NF
(Ferrous Fumarate)
$0
IRON CHEWS PEDIATRIC (Tier
CHEW
3)
$0
(Tier
IRON TABS 256 MG
3)
$0
(Tier
IRON TABS 28 MG
3)
Necessary
actions,
restrictions, or
limits on use
NT
Name of drug
polysaccharide iron
complex caps 150 mg
NT
PROFERRIN ES TABS
MO; NT
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
Stem Cell Mobilizers
$0$7.40
(Tier
2)
NT
MOZOBIL SOLN
MO; NT
HEMOSTATICS - Drugs to Stop Bleeding/Treat
Blood Disorders
Hemostatics - Systemic
NT
AMICAR SOLN 0.25
GM/ML
MO; NT
NT
AMICAR TABS 500 MG
MO; NT
aminocaproic acid tabs or
500 mg
NT
CYKLOKAPRON SOLN
(Tranexamic Acid)
LYSTEDA TABS
(Tranexamic Acid)
MO; NT
MO; NT
NT
NT
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
$0- MO
$2.95
(Tier
1)
NF
NF MO
$0$2.95
(Tier
1)
$0- MO
tranexamic acid tabs or 650 $2.95
(Tier
mg
1)
tranexamic acid soln iv
1000 mg/10ml
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
Barbiturate Hypnotics
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Name of drug
BUTISOL SODIUM TABS
30 MG
phenobarbital elix or 20
mg/5ml
phenobarbital soln or 20
mg/5ml
phenobarbital tabs or 100
mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8
mg, 97.2 mg
Hypnotics - Tricyclic Agents
SILENOR TABS
Non-Barbiturate Hypnotics
AMBIEN CR TBCR 12.5
MG (Zolpidem Tartrate)
AMBIEN CR TBCR 6.25
MG (Zolpidem Tartrate)
AMBIEN TABS 10 MG
(Zolpidem Tartrate)
AMBIEN TABS 5 MG
(Zolpidem Tartrate)
HALCION TABS
(Triazolam)
RESTORIL CAPS
(Temazepam)
SONATA CAPS (Zaleplon)
temazepam caps
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; MO
AL; MO
AL; MO
$0- MO
$7.40
(Tier
2)
NF AL; SL(1 ea
daily); MO
NF AL; SL(2 ea
daily); MO
NF AL; SL(1 ea
daily); MO
NF AL; SL(2 ea
daily); MO
NF MO
NF MO
NF AL; MO
$0- MO
$2.95
(Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
triazolam tabs 0.125 mg,
(Tier
0.25 mg
1)
$0$2.95
zaleplon caps
(Tier
1)
$0zolpidem tartrate tabs or 10 $2.95
(Tier
mg
1)
$0zolpidem tartrate tabs or 5 $2.95
(Tier
mg
1)
$0$2.95
zolpidem tartrate tbcr or
(Tier
12.5 mg
1)
$0$2.95
zolpidem tartrate tbcr or
(Tier
6.25 mg
1)
Necessary
actions,
restrictions, or
limits on use
MO
AL; MO
AL; SL(1 ea
daily); MO
AL; SL(2 ea
daily); MO
AL; SL(1 ea
daily); MO
AL; SL(2 ea
daily); MO
Orexin Receptor Antagonists
BELSOMRA TABS 10 MG
BELSOMRA TABS 15 MG
BELSOMRA TABS 20 MG
BELSOMRA TABS 5 MG
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
PA; SL(2 ea
daily); MO
PA; SL(1.33 ea
daily); MO
PA; SL(1 ea
daily); MO
PA; SL(4 ea
daily); MO
Selective Melatonin Receptor Agonists
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
132
Name of drug
HETLIOZ CAPS
ROZEREM TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
MO
Bulk Laxatives
CITRUCEL FIBER
LAXATIVE POWD
(Methylcellulose (Laxative))
CVS NATURAL FIBER
SUPPLEMENT PACK
EQL NATURAL FIBER
POWD
EQUALACTIN CHEW
EVAC POWD (Psyllium)
$0 MO; NT
(Tier
3)
MO; NT
NF
$0 NT
(Tier
3)
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
NF MO; NT
FIBERCON TABS (Calcium NF
Polycarbophil)
$0
HYDROCIL INSTANT
(Tier
PACK
3)
HYDROCIL INSTANT
NF
POWD (Psyllium)
$0
(Tier
KONSYL PACK 100 %
3)
$0
KONSYL PACK 28.3 %,
(Tier
60.3 %
3)
Necessary
actions,
restrictions, or
limits on use
KONSYL POWD 100 %
(Psyllium)
NF MO; NT
KONSYL POWD 60.3 %,
71.67 %
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NF MO; NT
KONSYL-D POWD
LAXATIVES - Bowel Treatment Drugs
calcium polycarbophil tabs
Name of drug
What
the
drug
will
cost
you
(tier
level)
METAMUCIL CAPS 0.52
GM (Psyllium)
$0 NT
METAMUCIL
(Tier
MULTIHEALTH FIBER
3)
POWD 55.46 %
METAMUCIL ORIGINAL
MO; NT
NF
TEXTURE POWD
(Psyllium)
METAMUCIL POWD 48.57 NF MO; NT
% (Psyllium)
$0 MO; NT
METAMUCIL SMOOTH
TEXTUREFIBER SINGLES (Tier
3)
PACK
$0 MO; NT
methylcellulose (laxative)
(Tier
powd 2 gm/10.2gm, 2
3)
gm/19gm
$0 MO; NT
psyllium caps 0.52 gm, 520 (Tier
mg
3)
MO; NT
psyllium powd 100 %,
48.57 %, 58.6 %, 95 %
MO; NT
psyllium powd 28.3 %, 30
%, 30.9 %, 33 %, 49 %, 68
%
MO; NT
UNIFIBER POWD
MO; NT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Laxative Combinations
NT
$0COLYTE-FLAVOR PACKS $7.40
SOLR 227.1GM-21.5GM(Tier
5.53GM-2.82GM-6.36GM
2)
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133
Name of drug
COLYTE-FLAVOR PACKS
SOLR 240GM-22.72GM5.84GM-2.98GM-6.72GM
(PEG 3350-KCl-Sod
Bicarb-Sod Chloride-Sod
Sulfate)
GOLYTELY SOLR 236GM22.74GM-5.86GM-2.97GM6.74GM (PEG 3350-KClSod Bicarb-Sod ChlorideSod Sulfate)
NULYTELY/FLAVOR
PACKS SOLR (PEG 3350Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
peg 3350-kcl-sod bicarbsod chloride-sod sulfate
solr
peg 3350-potassium
chloride-sod bicarbonatesod chloride solr
SUPREP BOWEL PREP
SOLN
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
polyethylene glycol 3350
powd or
NF
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO
Saline Laxatives
MO
magnesium hydroxide
chew or 311 mg
NF
MILK OF MAGNESIA
CONCENTRATE SUSP
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
Laxatives - Miscellaneous
$0
(Tier
3)
$0
FLEET LIQUID GLYCERIN (Tier
SUPPOSITORIES ENEM
3)
$0$2.95
lactulose soln
(Tier
1)
$0$2.95
polyethylene glycol 3350
(Tier
pack or
1)
MO; NT
CEO-TWO SUPP
MO; NT
MO
RX/OTC; MO
PHILLIPS MILK OF
MAGNESIA CHEWABLE
CHEW
PHILLIPS MILK OF
MAGNESIA
CONCENTRATED SUSP
PHILLIPS MILK OF
MAGNESIA SUSP
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
MO; NT
NT
NT
NT
Stimulant Laxatives
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
bisacodyl tbec or 5 mg
3)
$0
DULCOLAX BOWEL PREP (Tier NT
KIT KIT
3)
DULCOLAX SUPP
NF MO; NT
(Bisacodyl)
DULCOLAX TBEC
NF MO; NT
(Bisacodyl)
EX-LAX TABS
NF MO; NT
(Sennosides)
$0 MO; NT
FLEET BISACODYL ENEM (Tier
3)
bisacodyl supp re 10 mg
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
134
Name of drug
sennosides tabs 15 mg
Surfactant Laxatives
COLACE CAPS (Docusate
Sodium)
COLACE CLEAR CAPS
(Docusate Sodium)
docusate calcium caps
docusate sodium caps or
100 mg, 250 mg, 50 mg
docusate sodium liqd or
150 mg/15ml, 50 mg/5ml
docusate sodium syrp or
60 mg/15ml
docusate sodium tabs or
100 mg
DOCUSOL KIDS ENEM
DOCUSOL MINI ENEM
DOCUSOL PLUS MINIENEMA ENEM
ENEMEEZ MINI ENEM
ENEMEEZ PLUS ENEM
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NF MO; NT
NF MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0lidocaine hcl (local anesth.) $2.95
(Tier
soln 1 %, 2 %
1)
XYLOCAINE SOLN IJ 1 %,
NF
2 % (Lidocaine HCl (Local
Anesth.))
XYLOCAINE-MPF SOLN 1
NF
% (Lidocaine HCl (Local
Anesth.))
Necessary
actions,
restrictions, or
limits on use
MACROLIDES - Drugs to Treat Bacterial
Infections
Azithromycin
MO; NT
MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
LOCAL ANESTHETICS-Parenteral - Drugs for
Numbing
$0- MO
$2.95
azithromycin solr iv 500 mg (Tier
1)
$0- MO
$2.95
azithromycin susr or 100
(Tier
mg/5ml, 200 mg/5ml
1)
$0- MO
$2.95
azithromycin tabs or 250
(Tier
mg, 500 mg, 600 mg
1)
ZITHROMAX SOLR IV 500 NF MO
MG (Azithromycin)
ZITHROMAX SUSR OR
MO
100 MG/5ML, 200 MG/5ML NF
(Azithromycin)
ZITHROMAX TABS OR
MO
NF
250 MG, 500 MG, 600 MG
(Azithromycin)
ZITHROMAX TRI-PAK
NF MO
TABS (Azithromycin)
ZITHROMAX Z-PAK TABS NF MO
(Azithromycin)
Clarithromycin
BIAXIN SUSR
(Clarithromycin)
NF MO
Local Anesthetics - Amides
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
135
Name of drug
BIAXIN TABS
(Clarithromycin)
clarithromycin susr or 250
mg/5ml
clarithromycin tabs or 250
mg, 500 mg
clarithromycin tb24 or 500
mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Erythromycins
$0$2.95
(Tier
1)
$0$2.95
erythromycin base tabs
(Tier
500 mg
1)
$0erythromycin
$2.95
ethylsuccinate tabs or 400 (Tier
mg
1)
$0erythromycin lactobionate $2.95
(Tier
solr
1)
$0erythromycin stearate tabs $2.95
(Tier
1)
erythromycin base tabs
250 mg
SL(16 ea daily);
MO
SL(8 ea daily);
MO
Necessary
actions,
restrictions, or
limits on use
Contraceptives
$0
(Tier
3)
CONDOMS
MEDICAL DEVICES AND SUPPLIES
Bandages-Dressings-Tape
gauze pads 2" x 2"
$0- RX/OTC;MO
$2.95
(Tier
1)
Contraceptives
$0 NT
(Tier
3)
OMNIFLEX DIAPHRAGM
DPRH
Misc. Devices
ALCOHOL PADS
$0- RX/OTC; MO
$7.40
(Tier
2)
Parenteral Therapy Supplies
SL(10 ea daily);
MO
$0- MO
INSULIN SYRINGES AND $7.40
(Tier
PEN NEEDLES
2)
SL(8 ea daily)
Respiratory Therapy Supplies
SL(16 ea daily);
MO
Fidaxomicin
DIFICID TABS
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0- MO
$7.40
(Tier
2)
AEROCHAMBER MINI
AEROSOLCHAMBER
DEVI
AEROCHAMBER MV
MISC
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
MEDICAL DEVICES
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
136
Name of drug
What
the
drug
will
cost
you
(tier
level)
AEROCHAMBER PLUS
FLOW VU MISC
$0
(Tier
3)
AEROCHAMBER PLUS
FLOW-VU MISC
$0
(Tier
3)
AEROCHAMBER PLUS
FLOW-VU/LARGE MASK
MISC
$0
(Tier
3)
AEROCHAMBER PLUS
FLOW-VU/MASK MISC
$0
(Tier
3)
$0
AEROCHAMBER PLUS
FLOW-VU/MEDIUM MASK (Tier
3)
MISC
AEROCHAMBER PLUS
FLOW-VU/SMALL MASK
MISC
AEROCHAMBER Z-STAT
PLUS VALVED HOLDING
CHAMBER W/FLOW VU
MISC
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
AEROCHAMBER Z-STAT (Tier
PLUS/FLOWSIGNAL MISC 3)
$0
AEROCHAMBER Z-STAT (Tier
PLUS/LARGE MASK MISC 3)
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
MISC
$0
(Tier
3)
$0
AEROCHAMBER Z-STAT (Tier
PLUS/SMALL MASK MISC 3)
AEROCHAMBER/FLOWSI
GNAL MISC
$0
(Tier
3)
AEROVENT PLUS
$0
HOLDING
(Tier
CHAMBER/COLLAPSIBLE 3)
DEVI
AIRZONE PEAK FLOW
METER DEVI
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
137
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
ARIAL CHAMBER DEVI
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
ASSESS FULL RANGE
(Tier NT
PEAK FLOW METER DEVI 3)
$0 RX/OTC; MO;
ASSESS LOW RANGE
(Tier NT
PEAK FLOW METER DEVI 3)
ASSESS PEAK FLOW
METER FULL RANGE
DEVI
ASSESS PEAK FLOW
METER LOW RANGE
DEVI
$0
(Tier
3)
$0
(Tier
3)
$0
ASTHMA CHECK METER- (Tier
ZONE SYSTEM DEVI
3)
$0
(Tier
ASTHMAMENTOR DEVI
3)
BREATHERITE
COLLAPSIBLEADULT
SPACER W/MASK MISC
BREATHERITE
COLLAPSIBLECHILD
SPACER W/MASK MISC
BREATHERITE
COLLAPSIBLEINFANT
SPACER W/MASK MISC
Name of drug
BREATHERITE
COLLAPSIBLESMALL
CHILD SPACER W/MASK
MISC
BREATHERITE MISC
$0
(Tier
3)
BREATHERITE RIGID
SPACERW/MASK MISC
$0
(Tier
3)
BREATHERITE W/LARGE
MASK MISC
$0
(Tier
3)
BREATHERITE
W/MEDIUM MASK MISC
$0
(Tier
3)
BREATHERITE W/SMALL
MASK MISC
$0
(Tier
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0
(Tier
3)
$0
BREATHERITE
(Tier
COLLAPSIBLESPACER
W/ NEONATE MASK MISC 3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
138
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
CLEVER CHOICE ANTI$0 365 days
STATICVALVED
(Tier retail,1 ea per
HOLDING
days mail);
CHAMBER/ADULT LARGE 3) 365
RX/OTC;
MO;
DEVI
NT
QL(1 ea per
CLEVER CHOICE ANTI$0 365 days
STATICVALVED
(Tier retail,1 ea per
HOLDING
3) 365 days mail);
CHAMBER/MEDIUM DEVI
RX/OTC; MO;
NT
QL(1 ea per
CLEVER CHOICE ANTI$0 365 days
STATICVALVED
(Tier retail,1 ea per
HOLDING
3) 365 days mail);
CHAMBER/SMALL DEVI
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
COMPACT SPACE
ea per
CHAMBER/ANTI-STATIC (Tier retail,1
365
days
mail);
3)
DEVI
RX/OTC; MO;
NT
QL(1 ea per
COMPACT SPACE
$0 365 days
CHAMBER/ANTI(Tier retail,1 ea per
STATIC/LARGE MASK
3) 365 days mail);
DEVI
RX/OTC; MO;
NT
QL(1 ea per
COMPACT SPACE
$0 365 days
CHAMBER/ANTI(Tier retail,1 ea per
STATIC/MEDIUM MASK
3) 365 days mail);
DEVI
RX/OTC; MO;
NT
QL(1 ea per
COMPACT SPACE
$0 365 days
CHAMBER/ANTI(Tier retail,1 ea per
STATIC/SMALL MASK
3) 365 days mail);
DEVI
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
E-Z SPACER DEVI
$0
(Tier
3)
E-Z SPACER THE BODY
GUARDS PACK DEVI
$0
(Tier
3)
EASIVENT MISC
$0
(Tier
3)
EASIVENT/MASK-LARGE
MISC
$0
(Tier
3)
EASIVENT/MASKMEDIUM MISC
$0
(Tier
3)
EASIVENT/MASK-SMALL
MISC
$0
(Tier
3)
FLEXICHAMBER DEVI
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations in this table mean by going to
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139
Name of drug
INSPIRACHAMBER/ANTISTATIC
VALVED/MOUTHPIECE
DEVI
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
INSPIRACHAMBER/LARG (Tier
E DEVI
3)
INSPIRACHAMBER/SOOT $0
HERMASK/INSPIRAMASK (Tier
3)
/MEDIUM DEVI
INSPIRACHAMBER/SOOT $0
HERMASK/INSPIRAMASK (Tier
3)
/SMALL DEVI
INSPIREASE DRUG
DELIVERYSYSTEM MISC
LITEAIRE DEVI
MICROCHAMBER MISC
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
MICROLIFE DIGITAL
(Tier
PEAK FLOW METER DEVI 3)
MICROSPACER MISC
MINI WRIGHT AFS PEAK
FLOWMETER LOW
RANGE DEVI
MINI WRIGHT PEAK
FLOW METER DEVI
NESSI SPACER/LARGE
MASK DEVI
NESSI
SPACER/MOUTHPIECE
DEVI
NESSI
SPACER/SMALL/MED
MASK DEVI
OPTICHAMBER
ADVANTAGE MISC
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
$0 RX/OTC; MO;
(Tier NT
3)
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
140
Name of drug
What
the
drug
will
cost
you
(tier
level)
OPTICHAMBER
ADVANTAGE/LARGE
MASK MISC
$0
(Tier
3)
OPTICHAMBER
ADVANTAGE/MEDIUM
FACE MASK MISC
$0
(Tier
3)
OPTICHAMBER
ADVANTAGE/SMALL
FACE MASK MISC
$0
(Tier
3)
OPTICHAMBER
DIAMOND DEVI
$0
(Tier
3)
OPTICHAMBER
DIAMOND MISC
$0
(Tier
3)
OPTICHAMBER
DIAMOND/LARGEFACE
MASK DEVI
$0
(Tier
3)
$0
OPTICHAMBER
DIAMOND/MEDIUM FACE (Tier
3)
MASK MISC
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
OPTICHAMBER
DIAMOND/SMALLFACE
MASK MISC
$0
(Tier
3)
OPTICHAMBER FACE
MASK/LARGE MISC
$0
(Tier
3)
OPTICHAMBER FACE
MASK/MEDIUM MISC
$0
(Tier
3)
OPTICHAMBER FACE
MASK/SMALL MISC
$0
(Tier
3)
OPTIHALER MDI DRUG
DELIVERY SYSTEM DEVI
$0
(Tier
3)
OPTIHALER MISC
$0
(Tier
3)
PEAK AIR PEAK FLOW
METERADULT/PEDIATRI
C DEVI
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
RX/OTC; MO;
NT
$0
(Tier
3)
$0 RX/OTC; MO;
PEAK FLOW METER DEVI (Tier NT
3)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
141
Name of drug
PERSONAL BEST FULL
RANGE DEVI
PERSONAL BEST LOW
RANGE DEVI
PIKO 1 ELECTRONIC
DEVI
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
RX/OTC; MO;
NT
TRUZONE PEAK FLOW
METER DEVI
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
ea per
POCKET CHAMBER DEVI (Tier retail,1
365
days
mail);
3)
RX/OTC; MO;
NT
$0 RX/OTC; MO;
POCKET PEAK FLOW
(Tier NT
METER DEVI
3)
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
POCKET SPACER DEVI
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
POCKETPEAK PEAK
(Tier NT
FLOW METER LOW
3)
RANGE DEVI
POCKETPEAK PEAK
$0 RX/OTC; MO;
FLOW
(Tier NT
METER/UNIVERSAL
3)
RANGE 50-720 LPM DEVI
POCKETPEAK PEAK
$0 RX/OTC; MO;
FLOW
(Tier NT
METER/UNIVERSAL
3)
RANGE DEVI
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
RITEFLO DEVI
3) 365 days mail);
RX/OTC; MO;
NT
VALVED HOLDING
CHAMBER DEVI
VORTEX VALVED
HOLDING CHAMBER
DEVI
WATCHHALER DEVI
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
MIGRAINE PRODUCTS - Drugs to Treat Migraine
Headaches
Migraine Products
D.H.E. 45 SOLN
(Dihydroergotamine
Mesylate)
dihydroergotamine
mesylate soln ij 1 mg/ml
ergotamine tartrate subl sl
Serotonin Agonists
AMERGE TABS
(Naratriptan HCl)
IMITREX SOLN SC 6
MG/0.5ML (Sumatriptan
Succinate)
MO
NF
$0- MO
$2.95
(Tier
1)
$0$2.95
(Tier
1)
NF QL(0.3 ea
daily); MO
Limit 8mls per
NF month;QL(0.27
ml daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
142
Name of drug
IMITREX STATDOSE
REFILL SOCT 4 MG/0.5ML
(Sumatriptan Succinate)
IMITREX STATDOSE
REFILL SOCT 6 MG/0.5ML
(Sumatriptan Succinate)
IMITREX STATDOSE
SYSTEM SOAJ 4
MG/0.5ML (Sumatriptan
Succinate)
IMITREX TABS OR 100
MG (Sumatriptan
Succinate)
IMITREX TABS OR 25 MG
(Sumatriptan Succinate)
IMITREX TABS OR 50 MG
(Sumatriptan Succinate)
MAXALT TABS 10 MG
(Rizatriptan Benzoate)
MAXALT TABS 5 MG
(Rizatriptan Benzoate)
MAXALT-MLT TBDP 10
MG (Rizatriptan Benzoate)
MAXALT-MLT TBDP 5 MG
(Rizatriptan Benzoate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Limit 4mls per
NF month;QL(0.14
ml daily); MO
Limit 8mls per
NF month;QL(0.27
ml daily); MO
Limit 4mls per
NF month;QL(0.14
ml daily); MO
QL(0.3 ea
NF daily); MO
NF QL(0.9 ea
daily); MO
NF QL(0.6 ea
daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
$0- QL(0.3 ea
$2.95 daily); MO
naratriptan hcl tabs
(Tier
1)
$0- QL(0.4 ea
$2.95 daily); MO
rizatriptan benzoate tabs
(Tier
10 mg
1)
$0- QL(0.8 ea
rizatriptan benzoate tabs 5 $2.95 daily); MO
(Tier
mg
1)
$0- QL(0.4 ea
$2.95 daily); MO
rizatriptan benzoate tbdp
(Tier
10 mg
1)
Name of drug
rizatriptan benzoate tbdp 5
mg
sumatriptan succinate soaj
sc 4 mg/0.5ml
sumatriptan succinate soaj
sc 6 mg/0.5ml
sumatriptan succinate soct
sc 4 mg/0.5ml
sumatriptan succinate soct
sc 6 mg/0.5ml
sumatriptan succinate soln
sc 6 mg/0.5ml
sumatriptan succinate tabs
or 100 mg
sumatriptan succinate tabs
or 25 mg
sumatriptan succinate tabs
or 50 mg
zolmitriptan tabs 2.5 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(0.8 ea
daily); MO
Limit 4mls per
month;QL(0.14
ml daily); MO
Limit 8mls per
month;QL(0.27
ml daily); MO
Limit 4mls per
month;QL(0.14
ml daily); MO
Limit 8mls per
month;QL(0.27
ml daily); MO
Limit 8mls per
month;QL(0.27
ml daily); MO
QL(0.3 ea
daily); MO
QL(0.9 ea
daily); MO
QL(0.6 ea
daily); MO
SL(4 ea daily);
MO
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
143
Name of drug
zolmitriptan tabs 5 mg
zolmitriptan tbdp 2.5 mg
zolmitriptan tbdp 5 mg
ZOMIG TABS OR 2.5 MG
(Zolmitriptan)
ZOMIG TABS OR 5 MG
(Zolmitriptan)
ZOMIG ZMT TBDP 2.5 MG
(Zolmitriptan)
ZOMIG ZMT TBDP 5 MG
(Zolmitriptan)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
SL(2 ea daily);
MO
SL(4 ea daily);
MO
SL(2 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(2 ea daily);
MO
NF SL(4 ea daily);
MO
NF SL(2 ea daily);
MO
MINERALS & ELECTROLYTES
Bicarbonates
$0- MO
sodium bicarbonate soln iv $2.95
(Tier
8.4 %
1)
Calcium
CALCI-CHEW CHEW
CALCI-MIX CAPS
CALCIONATE SYRP
CALCIUM & MAGNESIUM
TABS
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
MO; NT
MO; NT
NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
calcium & phosphorus w/
(Tier
vitamin d tabs
3)
$0
calcium carbonate tabs or
(Tier
1250 mg, 1500 mg, 500
3)
mg, 600 mg, 600mg
$0
calcium carbonate(Tier
cholecalciferol caps
3)
600mg-500unit
$0
calcium carbonate(Tier
cholecalciferol chew
3)
500mg-100unit
$0
calcium carbonatecholecalciferol tabs 500mg- (Tier
3)
200unit
calcium carbonate-vitamin
$0
d tabs 125unit-250mg,
(Tier
125unit-500mg, 250mg3)
125unit, 500mg-125unit
calcium carbonate-vitamin
$0
d tabs 200unit-500mg,
(Tier
500mg-200unit, 500mg3)
500mg-200unit-200unit
$0
CALCIUM CITRATE
(Tier
MALATE/VITAMIN D TABS 3)
$0
calcium citrate tabs or 200 (Tier
mg, 950 mg
3)
$0
CALCIUM CITRATE TABS (Tier
OR 250 MG
3)
$0
calcium citrate-vitamin d
(Tier
tabs 250mg-200unit
3)
$0
calcium citrate-vitamin d
(Tier
tabs 315mg-200unit
3)
$0
calcium gluconate soln iv
(Tier
10 %
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
MO; NT
MO; NT
NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
144
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
CALCIUM GLUCONATE
(Tier
TABS OR 500 MG
3)
$0
CALCIUM LACTATE TABS (Tier
648 MG
3)
$0
CALCIUM LACTATE TABS (Tier
750 MG
3)
$0
(Tier
calcium tabs 600 mg
3)
$0
calcium w/ magnesium
(Tier
tabs 500mg-250mg
3)
$0
CALCIUM/VITAMIN D
(Tier
CAPS
3)
CITRACAL/VITAMIN D
NF
TABS (Calcium CitrateVitamin D)
$0
CORAL CALCIUM TABS
(Tier
OR 500 MG
3)
$0
EQL CALCIUM/VITAMIN D (Tier
CAPS
3)
$0
GNP VITAMIN D-400
(Tier
TABS
3)
$0
(Tier
MAGNEBIND 200 TABS
3)
$0
(Tier
oyster shell tabs
3)
$0
RA OYSTER SHELL
(Tier
CALCIUM/VITAMIN D
3)
TABS 250MG-125UNIT
$0
(Tier
RISACAL-D TABS
3)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NT
Chloride
MO; NT
$0- MO
$2.95
ammonium chloride soln iv (Tier
1)
NT
NT
NT
NT
NT
NT
NT
NT
NT
MO; NT
NT
Electrolyte Mixtures
CERALYTE 70 SOLN
60MEQ/L-70MEQ/L20MEQ/L-30MEQ/L
$0
(Tier
3)
$0
(Tier
CERASPORT EX1 SOLN
3)
$0
CERASPORT SOLN
(Tier
4MEQ/L-18MEQ/L3)
20MEQ/L-6MEQ/L
$0dextrose in lactated ringers $2.95
(Tier
soln
1)
$0dextrose w/ sodium
$2.95
chloride soln 0.45%-2.5%, (Tier
0.45%-5%
1)
$0$2.95
dextrose w/ sodium
(Tier
chloride soln 0.9%-5%
1)
$0
ENFAMIL ENFALYTE
(Tier
SOLN
3)
$0$2.95
lactated ringer's soln
(Tier
1)
$0
(Tier
MEDI-LYTE TABS
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO
MO; NT
NT
NT
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
145
Name of drug
oral electrolytes soln
18.8meq/l-42.4meq/l33.2meq/l-4.8gm/l18.8gm/l, 20meq/1000ml45meq/1000ml35meq/1000ml25gm/1000ml, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-25gm/l, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-35meq/l-30meq/l30meq/l-25gm/l-25gm/l,
20meq/l-20meq/l-45meq/l45meq/l-35meq/l-35meq/l30meq/l-30meq/l-5gm/l20gm/l, 20meq/l-45meq/l35meq/l-25gm/l, 20meq/l45meq/l-35meq/l-30meq/l25gm/l, 20meq/l-45meq/l35meq/l-30meq/l-5gm/l20gm/l, 20meq/l-45meq/l35meq/l-30meq/l-5gm/l25gm/l, 20meq/l-45meq/l35meq/l-5gm/l-20gm/l,
20meq/l-45meq/l-35meq/l7.8mg/l-25gm, 20meq/l45meq/l-35meq/l-7.8mg/l25gm/l, 20meq/l-45meq/l35meq/l-7.8mg/l-25meq/l,
20meq/l-45meq/l-45meq/l35meq/l-5gm/l-20gm/l,
35meq/l-45meq/l-20meq/l25gm/l, 35meq/l-45meq/l20meq/l-30meq/l-25gm/l,
35meq/l-45meq/l-20meq/l30meq/l-30gm/l, 35meq/l45meq/l-20meq/l-30meq/l5gm/l-20gm/l, 35meq/l45meq/l-20meq/l-5gm/l20gm/l, 35meq/l-45meq/l20meq/l-7.5mg/l-25meq/l,
35meq/l-45meq/l-20meq/l7.8mg/l-25gm/l, 35meq/l7.8mg/l-45meq/l-20meq/l25gm/l, 65meq/l-75meq/l20meq/l-30meq/l-2
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
$0
(Tier
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
oral electrolytes tabs
(Tier
287mg-180mg-15mg
3)
$0parenteral electrolytes conc $2.95
(Tier
1)
$0$2.95
parenteral electrolytes soln (Tier
1)
PEDIALYTE FREEZER
NF
POPS SOLN (Oral
Electrolytes)
PEDIALYTE SOLN
20MEQ/L-45MEQ/L35MEQ/L-30MEQ/LNF
25GM/L, 20MEQ/L45MEQ/L-35MEQ/L5GM/L-20GM/L (Oral
Electrolytes)
$0potassium chloride in
$2.95
dextrose & sodium chloride (Tier
soln 0.45%-20meq/l-5%
1)
$0
(Tier
THERMOTABS TABS
3)
Necessary
actions,
restrictions, or
limits on use
NT
B/D
B/D
MO; NT
MO; NT
NT
Fluoride
FLORICAL CAPS
MONOCAL TABS
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
Iodine Products
IODINE STRONG SOLN
POTASSIUM IODIDE
TABS OR
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
146
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MICRO-K CPCR
(Potassium Chloride)
NT
potassium chloride cpcr or
10 meq, 8 meq
Magnesium
$0
(Tier
3)
$0
(Tier
MAGINEX DS PACK
3)
$0
(Tier
MAGINEX TBEC
3)
$0
MAGNESIUM CHLORIDE (Tier
HEXAHYDRATE CRYS
3)
$0
magnesium chloride tbcr or (Tier
535 mg, 64 mg
3)
$0
MAGNESIUM
(Tier
ELEMENTAL TABS 30 MG 3)
$0
MAGNESIUM
(Tier
GLUCONATE TABS OR
3)
250 MG, 500 MG, 550 MG
$0magnesium sulfate soln ij $2.95
(Tier
50 %
1)
$0
magnesium tabs 250 mg,
(Tier
250mg
3)
MAG-TAB SR TBCR
NT
NT
MO; NT
NT
NT
MO
NT
Phosphate
PHOS-NAK POWDER
CONCENTRATE PACK
Name of drug
$0 MO; NT
(Tier
3)
Potassium
K-TAB TBCR 10 MEQ
(Potassium Chloride)
NF MO
K-TAB TBCR 8 MEQ
$0- MO
$7.40
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$2.95
(Tier
1)
$0POTASSIUM CHLORIDE $2.95
(Tier
ER TBCR
1)
$0potassium chloride
$2.95
microencapsulated crystals (Tier
cr tbcr
1)
$0potassium chloride soln iv 2 $2.95
(Tier
meq/ml
1)
$0potassium chloride soln or $2.95
(Tier
10 %, 20 %
1)
$0potassium chloride tbcr or $2.95
(Tier
10 meq, 20 meq, 8 meq
1)
MO
MO
MO
MO
MO
MO
Sodium
$0$2.95
(Tier
1)
$0- MO
sodium chloride soln iv 0.9 $2.95
(Tier
%
1)
sodium chloride soln iv
0.45 %
Trace Minerals
$0 NT
(Tier
3)
$0 MO; NT
chromium picolinate tabs or (Tier
200 mcg
3)
chromium picolinate caps
or 200 mcg
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
147
Name of drug
chromium tabs 200 mcg
MULTITRACE-4 SOLN
SELENIUM SOLN IV 40
MCG/ML
selenium tabs or 100 mcg
selenium tabs or 50 mcg
trace minerals (cr-cu-mnzn) soln
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
NT
MO; NT
MO; NT
NT
MO; NT
NT
Zinc
$0
(Tier
3)
$0
(Tier
ZINC 15 TABS
3)
$0
zinc gluconate tabs or 50
(Tier
mg
3)
$0
(Tier
ZINC LOZG MT 10 MG
3)
$0
ZINC SULFATE SOLN IV 1 (Tier
MG/ML, 5 MG/ML
3)
$0
(Tier
zinc tabs or 25 mg
3)
$0
(Tier
zinc tabs or 50 mg
3)
MO; NT
ORAZINC TABS
NT
MO; NT
NT
MO; NT
NT
MO; NT
Name of drug
Anesthetics Topical Oral
BABY ANBESOL GEL
(Benzocaine (Dental))
BABY ORAJEL GEL
(Benzocaine (Dental))
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF NT
NF NT
$0
(Tier
3)
$0
benzocaine (dental) gel 7.5 (Tier
%
3)
$0
benzocaine (dental) pste
(Tier
20 %
3)
$0
benzocaine (dental) soln 20 (Tier
%
3)
HURRICAINE ONE SOLN
NF
(Benzocaine (Dental))
HURRICAINE SOLN
NF
(Benzocaine (Dental))
$0lidocaine hcl (mouth-throat) $2.95
(Tier
soln
1)
ORABASE PSTE
NF
(Benzocaine (Dental))
$0
(Tier
ZILACTIN GEL
3)
NT
BABY ORAJEL LIQD
NT
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO
MO; NT
MO; NT
Anti-infectives - Throat
$0 MO; NT
carbamide peroxide soln mt (Tier
3)
$0- MO
$2.95
clotrimazole lozg mt
(Tier
1)
MOUTH/THROAT/DENTAL AGENTS
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
148
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
clotrimazole troc mt
(Tier
1)
$0
hydrogen peroxide (mouth- (Tier
throat) soln
3)
$0
hydrogen peroxide-benzyl (Tier
alcohol soln
3)
$0$2.95
nystatin (mouth-throat)
(Tier
susp
1)
PEROXYL SOLN EX 1.5%NF
6% (Hydrogen PeroxideBenzyl Alcohol)
$0
ULCEREASE SOLN 1.5%- (Tier
1.5%-0.6%-1.5%
3)
Necessary
actions,
restrictions, or
limits on use
MO
PERIDEX SOLN
(Chlorhexidine Gluconate
(Mouth-Throat))
pilocarpine hcl (oral) tabs
MO; NT
SALAGEN TABS
(Pilocarpine HCl (Oral))
MO
MO; NT
MO; NT
$0- MO
$2.95
(Tier
1)
MO
NF
$0- MO
$2.95
(Tier
1)
Throat Products - Misc.
AQUORAL AERS
cevimeline hcl caps
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
NF MO
MULTIVITAMINS
Steroids - Mouth/Throat
triamcinolone acetonide
(mouth) pste
EVOXAC CAPS
(Cevimeline HCl)
NT
Antiseptics - Mouth/Throat
chlorhexidine gluconate
(mouth-throat) soln
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0 MO; NT
(Tier
3)
$0- MO
$2.95
(Tier
1)
B-Complex Vitamins
b-complex vitamins caps or
60mg-60mg-3mg-5mg20mg-3mg-1mcg-0.5mg,
60mg-60mg-5mg-20mg3mg-1mcg-3mg-0.5mg,
70mg-100mg-1mg-10mg2mg-1.5mg-100mcg
b-complex vitamins inj ij
2mg/ml-100mg/ml-2mg/ml100mg/ml-2mg/ml
b-complex vitamins soln ij
2mg/ml-2%-100mg/ml2mg/ml-100mg/ml-2mg/ml
b-complex vitamins tabs or
0.1mg-20mg-2mg-5mcg3mg-1mg, 100mg-50mg40mg-10mg-20mg-5mg4.6mg-1mcg-5mg-1mg,
10mg-10mg-2mg-1.5mg0.2mg, 10mg-14mg25mcg-7mg-4.5mg, 15mg2mg-5mg-2mcg-2mg-2mg,
30mg-50mg-50mg-50mg50mg-50mg-50mcg-50mg100mcg-50mcg-50mg,
3mg-10mg-20mg-3mg6mcg-2mg, 3mg-20mg3mg-10mg-6mcg-2mg,
3mg-3mg-20mg-20mg3mg-3mg-10mg-10mg6mcg-6mcg-2mg-2mg,
83mg-3mg-20mg-2mg5mcg-1mg
MO; NT
$0
(Tier
3)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
MO; NT
$0
(Tier
3)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
149
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
B-Complex w/ C
b complex w/ c caps
NT
10.2mg-10mg-15mg-50mg$0
5mg-300mg, 10mg-50mg10.2mg-15mg-5mg-300mg, (Tier
3)
10mg-50mg-10mg-15mg5mg-300mg, 15mg-10mg50mg-10mg-5mg-300mg
b complex w/ c tabs
NT
10.2mg-10.2mg-10mg10mg-50mg-50mg-15mg15mg-5mg-5mg-300mg300mg, 100mg-100mg25mg-20mg-6mg-15mcg100mg-5mcg-2mg-150mg,
100mg-100mg-5.5mg20mg-15mcg-25mg400mcg-5mcg-2mg150mg, 100mg-10mg20mg-10mcg-15mg-5mg500mg, 100mg-20mg5.5mg-15mcg-2mg-25mg150mg-400mcg-5mcg150mg, 10mg-10mg-15mg- $0
50mg-5mg-300mg, 15mg- (Tier
10.2mg-10mg-50mg-5mg300mg, 15mg-10mg-50mg- 3)
10.2mg-5mg-300mg,
15mg-10mg-50mg-10.2mg6mcg-400mcg-5mg300mg, 15mg-10mg-50mg10mg-5mg-300mg, 15mg150mg-10mg-50mg10.2mg-5mg-300mg,
15mg-20mg-50mg-10mg10mcg-5mg-300mg, 15mg50mg-10.2mg-10mg-5mg300mg, 50mg-10.2mg10mg-15mg-5mg-300mg,
50mg-10mg-10mg-15mg5mg-300mg, 50mg-15mg10mg-10.2mg-5mg-300mg
B-Complex w/ Folic Acid
Name of drug
B-100 COMPLEX TABS
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
b-complex w/ c & folic acid
MO; NT
tabs 10mg-20mg-1.5mg$0
1mg-1.5mg-5mg-300mcg- (Tier
50mg-60mg, 20mg-1.5mg3)
10mg-1mg-1.5mg-5mg300mcg-50mg-60mg
b-complex w/ folic acid tabs
MO; NT
1.5mg-20mg-1.7mg-6mcg400mcg-2mg, 1.7mg10mg-6mcg-1.2mg-20mg0.4mg-2mg, 100mg100mg-100mg-100mcg400mcg-100mg, 100mg100mg-100mg-100mg10mcg-400mcg-100mcg100mg, 10mg-10mg-50mg$0
10mg-10mg-10mg-10mcg(Tier
10mg-400mcg-10mcg3)
10mg, 10mg-20mg-1.7mg6mcg-1.5mg-400mcg-2mg,
15mg-100mg-200mg17mg-60mcg-400mcg20mg, 30mg-20mg-50mg30mg-10mg-10mcg400mcg-8mg, 40mcg-1mg6mg-5mcg-3mg-2mcg19mcg, 50mg-50mg-50mg50mcg-50mg-400mcg50mcg-50mg
b-complex w/ folic acid tbcr
NT
100mg-100mg-100mg100mg-100mcg-400mcg100mcg-100mg, 125mg125mg-125mg-125mg$0
125mcg-125mg-125mg(Tier
400mcg-125mcg-125mg,
3)
50mg-50mg-50mg-50mg50mcg-0.4mg-50mcg50mg, 50mg-50mg-50mg50mg-50mcg-100mcg50mcg-50mg
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
150
Name of drug
NERVO B-12 SL LOZG
Ped MV w/ Fluoride
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
pediatric multivitamins w/fl
chew 0.25mg-15unit1.2mg-2500unit-4.5mcg400unit-1.05mg-13.5mg1.05mg-0.3mg-60mg,
0.25mg-15unit-400unit2500unit-1.2mg-4.5mcg13.5mg-1.05mg-0.3mg1.05mg-60mg, 0.5mg15unit-1.2mg-2500unit4.5mcg-400unit-1.05mg13.5mg-1.05mg-0.3mg60mg, 0.5mg-15unit400unit-2500unit-1.2mg4.5mcg-13.5mg-1.05mg0.3mg-1.05mg-60mg,
0.5mg-2500unit-13.5mg1.2mg-4.5mcg-400unit1.05mg-0.3mg-15unit1.05mg-60mg, 15unit0.25mg-1.05mg-13.5mg1.2mg-2500unit-4.5mcg$0
400unit-0.3mg-1.05mg(Tier
60mg, 15unit-0.25mg3)
2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg0.3mg-1.05mg-60mg,
15unit-0.5mg-1.05mg13.5mg-1.2mg-2500unit4.5mcg-400unit-0.3mg1.05mg-60mg, 15unit0.5mg-2500unit-13.5mg1.2mg-4.5mcg-400unit1.05mg-0.3mg-1.05mg60mg, 15unit-1mg-1.05mg13.5mg-1.2mg-2500unit4.5mcg-400unit-0.3mg1.05mg-60mg, 15unit-1mg2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg0.3mg-1.05mg-60mg, 1mg15unit-1.2mg-2500unit4.5mcg-400unit-1.05mg13.5mg-1.05mg-0.3mg60mg, 1mg-15unit-400unit2500unit-1.2mg-4.5mcg-
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
151
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
13.5mg-1.05mg-0.3mg1.05mg-60mg
pediatric multivitamins w/fl
MO; NT
soln 0.5mg/ml-5unit/ml0.6mg/ml-8mg/ml1500unit/ml-2mcg/ml400unit/ml-0.5mg/ml0.4mg/ml-35mg/ml,
0.5mg/ml-5unit/ml-8mg/ml- $0
0.6mg/ml-1500unit/ml(Tier
2mcg/ml-400unit/ml3)
0.5mg/ml-0.4mg/ml35mg/ml, 5unit/ml0.5mg/ml-8mg/ml0.6mg/ml-1500unit/ml2mcg/ml-400unit/ml0.5mg/ml-0.4mg/ml35mg/ml
$0 MO; NT
pediatric vitamins acd w/
(Tier
fluoride soln
3)
POLY-VI-FLOR CHEW
$0 MO; NT
(Tier
3)
MO; NT
QUFLORA PEDIATRIC
CHEW 108MCG-1MG15UNIT-0.25MG-15MG1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG,
$0
108MCG-1MG-15UNIT(Tier
0.5MG-15MG-1200UNIT3)
5MG-1.3MG-4MCG400UNIT-1.2MG-100MCG1.5MG-60MG, 108MCG1MG-15UNIT-1MG-15MG1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG
Name of drug
QUFLORA PEDIATRIC
SOLN 150MCG/ML1MG/ML-0.5MG/ML12MG/ML-1100UNIT/ML2MG/ML-1MG/ML3MCG/ML-400UNIT/ML1MG/ML-81MCG/ML12UNIT/ML-1MG/ML45MG/ML
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
$0
(Tier
3)
Ped MV w/ Iron
$0 NT
MULTI-DELYN/IRON LIQD (Tier
3)
pediatric multiple vitamins
MO; NT
w/ iron liqd 1500unit/ml$0
10mg/ml-5unit/ml(Tier
400unit/ml-8mg/ml3)
0.6mg/ml-0.5mg/ml0.4mg/ml-35mg/ml
pediatric multiple vitamins
MO; NT
w/ iron soln 0.6mg/ml$0
10mg/ml-5unit/ml-8mg/ml- (Tier
1500unit/ml-400unit/ml3)
0.5mg/ml-0.4mg/ml35mg/ml
Ped Multi Vitamins w/Fl & FE
ped multivitamins w/fl &
iron soln
TRI-VIT/FLUORIDE/IRON
SOLN
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
Pediatric Multiple Vitamins
$0 NT
(Tier
3)
$0 MO; NT
pediatric multiple vitamin w/ (Tier
c soln
3)
$0 NT
pediatric multiple vitamin w/ (Tier
extra c & fa chew
3)
EQL CHILDRENS
MULTIVITAMINS CHEW
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
152
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
Pediatric Vitamins
pediatric vitamins adc soln
$0 MO; NT
(Tier
3)
ONE A DAY WOMENS
PRENATAL/DHA MISC
Necessary
actions,
restrictions, or
limits on use
MO
Specialty Vitamins Products
Prenatal Vitamins
MULTI PRENATAL TABS
VINATE ONE TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
NT
PRENATAL FORMULA
CAPS 35MG-30UNIT$0
4000UNIT-200MG-25MG(Tier
1.8MG-200MG-28MG3)
20MG-1.7MG-8MCG400UNIT-800MCG-2.6MG120MG
$0
PRENATAL LOW IRON
(Tier
TABS
3)
$0
PRENATAL ONE DAILY
(Tier
TABS
3)
PRENATAL TABS 11UNIT$0
263MG-25MG-1.5MG(Tier
27MG-4000UNIT-18MG3)
1.7MG-4MCG-400UNIT0.8MG-2.6MG-100MG
$0
PRENATAL VITAMIN
(Tier
TABS
3)
$0
RIGHT STEP PRENATAL (Tier
TABS
3)
$0$7.40
TRINATAL RX 1 TABS
(Tier
2)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO
ULTRA MAN TBCR
ULTRA WOMAN TBCR
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Vitamin Mixtures
cod liver oil caps 10 minim,
110mg-2664unit-1000mg100mg-200unit, 1250unit130unit, 1250unit133.33unit, 1250unit133unit, 1250unit-135unit,
200unit-4000unit, 20mg$0
35mg-1250unit-45mg(Tier
133.333unit, 34mg3)
1250unit-415mg-32mg135unit, 50mg-110mg250unit-110mg-100unit10unit, 52mg-2500unit600mg-52mg-270unit,
530mg-1250unit-130unit,
90mg-37mg-415mg-36mg1250unit-135unit
$0
COD LIVER OIL FOR KIDS (Tier
OIL
3)
COD LIVER OIL OIL
$0
4000UNIT/5ML(Tier
400UNIT/5ML,
3)
5000UNIT/5ML500UNIT/5ML
$0
CVS COD LIVER OIL OIL (Tier
3)
$0
NORWEGIAN COD LIVER (Tier
OIL OIL
3)
NT
RX/OTC; NT
RX/OTC; NT
RX/OTC; NT
RX/OTC; NT
You can find information on what the symbols and abbreviations in this table mean by going to
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Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
153
Name of drug
QC COD LIVER OIL OIL
RA COD LIVER OIL OIL
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; NT
RX/OTC; NT
vitamins a & d caps
MO; NT
10000unit-400unit,
$0
10000unit-5000unit,
1250unit-133unit, 1250unit- (Tier
3)
135unit, 5000unit-400unit,
700unit-400unit, 8000unit400unit
Vitamins w/ Lipotropics
$0 MO; NT
ACTIFLOVIT EAR
(Tier
HEALTH TABS
3)
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
vitamins w/ lipotropics tabs
10000unit-10mg-18mg100unit-225mcg-10mg150mg-100mg-30mg10mg-25mg-25mg-50mg50mg-10mg-50mg-50mg200mcg-400unit-50mg400mcg-50mg-250mg,
100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg100mg-100mg-100mg100mg-100mg-100mcg100mg-100mcg-100mcg100mg, 100mg-100mg100mg-100mg-100mg100mg-100mg-100mcg100mcg-100mcg-100mg,
100mg-100mg-100mg100mg-100mg-100mg100mg-100mcg-100mg200mcg-100mcg-100mg,
$0
100mg-111.3mg-0.33mg(Tier
1.7mg-1.7mcg-0.33mg3)
111.3mg-3.3mg-0.33mg100mg, 100mg-43.33mg111.3mg-0.33mg-1.7mg1.7mcg-0.33mg-111.3mg3.3mg-0.33mg-100mg,
200mg-29mg-0.333mg1.666mg-3.33mg111.333mg-111.333mg1mg-1.666mcg-0.333mg100mg, 200mg-29mg0.33mg-1.67mg-3.33mg111.33mg-111.33mg-1mg1.67mcg-0.33mg-100mg,
200mg-29mg-0.34mg1.67mg-3.34mg-111mg111mg-1mg-1.67mcg0.34mg-100mg, 20mg50mg-30mg-10mg-10mcg30mg-8mg, 25mg-40mg20mg-3.4mg-20mg-12mcg3mg-20mg-400mcg30mcg-4mg-150mg, 25mg-
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
154
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
40mg-20mg-3.4mg-20mg12mcg-3mg-20mg-400mg30mcg-4mg, 266.667mg29mg-0.333mg-1.667mg3.333mg-111.333mg111.333mg-1mg1.667mcg-0.33
MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms
Central Muscle Relaxants
$0- SL(8 ea daily);
$2.95 MO
baclofen tabs or 10 mg
(Tier
1)
$0- SL(4 ea daily);
$2.95 MO
baclofen tabs or 20 mg
(Tier
1)
$0- AL; MO
$2.95
carisoprodol tabs or 350
(Tier
mg
1)
$0- AL; MO
$2.95
chlorzoxazone tabs
(Tier
1)
$0- AL; MO
cyclobenzaprine hcl tabs or $2.95
(Tier
10 mg, 5 mg
1)
$0- AL; MO
$2.95
metaxalone tabs
(Tier
1)
$0- AL; MO
methocarbamol tabs or 500 $2.95
(Tier
mg, 750 mg
1)
PARAFON FORTE DSC
NF AL; MO
TABS (Chlorzoxazone)
ROBAXIN TABS OR 500
NF AL; MO
MG (Methocarbamol)
Name of drug
ROBAXIN-750 TABS
(Methocarbamol)
SKELAXIN TABS
(Metaxalone)
SOMA TABS 350 MG
(Carisoprodol)
What
the
drug
will
cost
you
(tier
level)
NF AL; MO
NF AL; MO
NF AL; MO
$0$2.95
tizanidine hcl caps or 2 mg (Tier
1)
$0$2.95
tizanidine hcl caps or 4 mg (Tier
1)
$0$2.95
tizanidine hcl caps or 6 mg (Tier
1)
$0tizanidine hcl tabs or 2 mg $2.95
(Tier
1)
$0$2.95
tizanidine hcl tabs or 4 mg (Tier
1)
ZANAFLEX CAPS 2 MG
NF
(Tizanidine HCl)
ZANAFLEX CAPS 4 MG
NF
(Tizanidine HCl)
ZANAFLEX CAPS 6 MG
NF
(Tizanidine HCl)
ZANAFLEX TABS 4 MG
NF
(Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM CAPS
(Dantrolene Sodium)
Necessary
actions,
restrictions, or
limits on use
SL(18 ea daily);
MO
SL(9 ea daily);
MO
SL(6 ea daily);
MO
SL(18 ea daily);
MO
SL(9 ea daily);
MO
SL(18 ea daily);
MO
SL(9 ea daily);
MO
SL(6 ea daily);
MO
SL(9 ea daily);
MO
NF MO
$0- MO
dantrolene sodium caps or $2.95
(Tier
100 mg, 25 mg, 50 mg
1)
You can find information on what the symbols and abbreviations in this table mean by going to
page viii.
Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016
155
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus
PATANASE SOLN
(Olopatadine HCl (Nasal))
Nasal Agents - Misc.
Nasal Anticholinergics
ATROVENT SOLN
(Ipratropium Bromide
(Nasal))
$0
(Tier
3)
$0
ENTSOL HYPERTONIC
NASAL IRRIGATION MIST (Tier
3)
SOLN
$0
ENTSOL NASAL SPRAY
(Tier
SOLN
3)
$0
ENTSOL NASAL WASH
(Tier
SOLN
3)
$0
(Tier
GELONASAL SOLN
3)
OCEAN NASAL SPRAY
NF
SOLN (Saline)
$0
(Tier
PONARIS SOLN
3)
$0
(Tier
saline gel na
3)
$0
saline soln na 0.65 %,
(Tier
0.65%, 0.65%-0.002%
3)
$0
(Tier
SALTAIRE SOLN
3)
AYR NASAL DROPS
SOLN
NT
NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
Nasal Antiallergy
$0- MO
$2.95
azelastine hcl soln 0.1 %
(Tier
1)
$0- MO
$2.95
olopatadine hcl (nasal) soln (Tier
1)
What
the
drug
will
cost
you
(tier
level)
NF MO
MO
NF
$0ipratropium bromide (nasal) $2.95
(Tier
soln
1)
Nasal Steroids
$0$2.95
budesonide (nasal) susp
(Tier
1)
$0$2.95
flunisolide (nasal) soln
(Tier
1)
$0$2.95
fluticasone propionate
(Tier
(nasal) susp
1)
RHINOCORT AQUA SUSP NF
(Budesonide (Nasal))
$0$2.95
triamcinolone acetonide
(Tier
(nasal) aero
1)
Sympathomimetic Decongestants
$0
BENZEDREX INHALER
(Tier
INHA
3)
NASAL DECONGESTANT
LIQD
NASAL DECONGESTANT
SYRP
Necessary
actions,
restrictions, or
limits on use
MO
RX/OTC; MO
MO
RX/OTC; MO
RX/OTC; MO
RX/OTC; MO
NT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
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Name of drug
NEO-SYNEPHRINE COLD
& SINUS MILD SOLN
(Phenylephrine HCl)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
NF
$0
NEO-SYNEPHRINE COLD (Tier
& SINUS REGULAR SOLN 3)
NEO-SYNEPHRINE SOLN
NF
0.25 % (Phenylephrine
HCl)
$0
NEO-SYNEPHRINE SOLN (Tier
0.5 %
3)
$0
phenylephrine hcl soln na
(Tier
0.25 %
3)
$0
pseudoephedrine hcl liqd
(Tier
or 15 mg/5ml
3)
$0
pseudoephedrine hcl tabs (Tier
or 30 mg, 60 mg
3)
SUDAFED CHILDRENS
NF
LIQD (Pseudoephedrine
HCl)
SUDAFED CONGESTION
NF
TABS (Pseudoephedrine
HCl)
SUDAFED NASAL
DECONGESTANT
NF
MAXIMUM STRENGTH
TABS (Pseudoephedrine
HCl)
$0
SUDAFED PE
(Tier
CHILDRENS NASAL
3)
DECONGESTANT SOLN
SUDAFED TABS
NF
(Pseudoephedrine HCl)
riluzole tabs
MO; NT
MO; NT
MO; NT
MO; NT
Necessary
actions,
restrictions, or
limits on use
MO
Neuromuscular Blocking Agent - Neurotoxins
$0- PA
$7.40
BOTOX SOLR
(Tier
2)
$0- PA
$7.40
XEOMIN SOLR
(Tier
2)
NUTRIENTS
MO; NT
MO; NT
MO; NT
Carbohydrates
dextrose soln iv 10 %
dextrose soln iv 5 %
MO; NT
GLUCOSE NURSETTE
SOLN (Glucose)
MO; NT
glucose soln 5 %
POLYCOSE LIQD
NT
MO; NT
NEUROMUSCULAR AGENTS - Drugs to
Relax/Paralyze Muscles
$0- B/D
$2.95
(Tier
1)
$0- MO; B/D
$2.95
(Tier
1)
NF NT
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Lipids
fat emulsion emul 20
gm/100ml
MCT OIL OIL
ALS Agents
RILUTEK TABS (Riluzole)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0- B/D
$2.95
(Tier
1)
$0 NT
(Tier
3)
NF MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
MICROLIPID EMUL
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
amino acid infusion 15%
Lipotropics
INOSITOL TABS OR 500
MG
lecithin caps or
LECITHIN
CONCENTRATE CAPS
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
amino acids caps 130mg10mg-130mg-130mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
B/D
RX/OTC; NT
Misc. Nutritional Substances
docosahexaenoic acid
caps 200 mg
EXPECTA LIPIL CAPS
(Docosahexaenoic Acid)
omega-3 fatty acids caps
180mg-120mg, 300mg,
300mg-160mg-1000mg100mg-5unit, 300mg772.5mg-90mg-180mg
omega-3 fatty acids caps
180mg-500mg-120mg,
27mg-244mg-500mg89mg, 300mg-1000mg200mg, 300mg-200mg,
500 mg, 500mg, 500mg270mg-135mg, 500mg300mg-1000mg-200mg1unit, 500mg-320mg130mg, 90mg-500mg60mg
$0 NT
(Tier
3)
NF NT
NT
$0
(Tier
3)
MO; NT
$0
(Tier
3)
Proteins
ADD-INS COMPLETE
PACK
$0 MO; NT
(Tier
3)
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
amino acids tabs 100mgMO; NT
6.15mg-2.1mg-0.85mg1.95mg-0.55mg-2.3mg1.95mg-0.75mg-1.15mg0.6mg-3.65mg-0.65mg3.25mg-3.8mg-1.95mg1.7mg-0.7mg-1.05mg,
115.333mg-54.667mg21mg-33.333mg33.333mg-46.667mg14.167mg-46.667mg40mg-53.333mg18.167mg-41mg66.667mg-40mg30.667mg-17.333mg14mg, 115.3mg-54.7mg21mg-33.3mg-13.3mg33.3mg-63.3mg-14.2mg46.7mg-40mg-53.3mg18.2mg-41mg-66.7mg$0
40mg-30.7mg-17.3mg(Tier
14mg, 1200mg-100mg,
3)
18.33mg-200mg-33.33mg50mg-23.16mg-58.33mg18.33mg-75mg-108.33mg,
200mg-33.33mg-50mg23.16mg-18.33mg58.33mg-18.33mg-75mg108.33mg, 35mg-29.5mg24.667mg-4.833mg17.667mg-24.667mg12.5mg-24mg-19mg-36mg17.5mg-4.667mg-75mg15mg, 74mg-50mg-0.7mg77mg-1.4mg-72mg-64mg27mg-54mg-70mg-41mg17mg-109mg-7mg-27mg68mg-47mg-41mg-64mg,
74mg-5mg-0.7mg-77mg1.4mg-72mg-64mg-22mg54mg-7mg-41mg-17mg109mg-97mg-27mg-68mg47mg-41mg-64mg
Name of drug
amino acids-protein
hydrolysate liqd
AMINOSYN II 15% (Use
amino acid infusion)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NF B/D
$0
(Tier
3)
$0
(Tier
ARGIMENT PACK
3)
$0
(Tier
arginine tabs 500 mg
3)
$0
COMPLEX MSUD AMINO (Tier
ACID BAR BAR
3)
$0
(Tier
GLUTAMENT PACK
3)
$0
(Tier
HEPAMENT PACK
3)
$0
L-CARNITINE TABS OR
(Tier
250 MG
3)
$0
L-CITRULLINE CAPS OR (Tier
3)
$0
levocarnitine caps or 250
(Tier
mg
3)
$0
PHENYLADE AMINO ACID (Tier
BAR
3)
$0
PHENYLADE AMINO ACID (Tier
BLEND PACK
3)
$0
PHENYLADE MTE AMINO (Tier
ACIDBLEND PACK
3)
MO; NT
ARGIMENT AT PACK
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
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159
Name of drug
PHENYLADE PHEBLOC
TABS
PHENYLADE40 DRINK
MIX PACK
PHLEXY-10 CAPS
PROTEINEX LIQD
SOLVIL PACK
SUPER-AMINO 1600
TABS
TRIAMINO TABS
tyrosine tabs 500 mg
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
RX/OTC; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
XPHE MAXAMUM PACK
MO; NT
153MG-280MG-41MCG1114UNIT-29MCG13MCG-0.9MG-410MCG4.5MG-569MG-7.4MG9.2UNIT-18.5MCG65.5MCG-592MG-280MG350MG-2.9MG-40MG215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG- $0
246MCG-12.3MCG-0.8MG- (Tier
31MG, 153MG-280MG3)
41MCG-29MCG-13MCG0.9MG-410MCG-4.5MG569MG-7.4MG-9.2UNIT18.5MCG-65.5MCG592MG-280MG-350MG1114UNIT-2.9MG-40MG215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG246MCG-12.3MCG-0.8MG31MG
OPHTHALMIC AGENTS - Drugs to Treat the Eye
Artificial Tears and Lubricants
GENTEAL MILD TO
NF
MODERATE SOLN
(Hypromellose (Ophth))
$0
hypromellose (ophth) soln (Tier
0.3 %, 3 mg/ml
3)
$0
(Tier
ISOPTO TEARS SOLN
3)
$0
(Tier
NUTRATEAR SOLN
3)
$0
(Tier
polyvinyl alcohol soln op
3)
$0
TEARS AGAIN NIGHT &
(Tier
DAY GEL
3)
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
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Name of drug
TGT LUBRICANT EYE
DROPS SOLN
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Beta-blockers - Ophthalmic
BETAGAN SOLN
NF
(Levobunolol HCl)
$0$2.95
betaxolol hcl (ophth) soln
(Tier
1)
$0$2.95
carteolol hcl (ophth) soln
(Tier
1)
COSOPT SOLN
NF
(Dorzolamide HCl-Timolol
Maleate)
$0$2.95
dorzolamide hcl-timolol
(Tier
maleate soln
1)
$0$2.95
levobunolol hcl soln
(Tier
1)
$0$2.95
timolol maleate (ophth)
(Tier
solg
1)
$0$2.95
timolol maleate (ophth)
(Tier
soln
1)
TIMOPTIC SOLN (Timolol
NF
Maleate (Ophth))
TIMOPTIC-XE SOLG
NF
(Timolol Maleate (Ophth))
Necessary
actions,
restrictions, or
limits on use
Name of drug
NT
Miotics
Necessary
actions,
restrictions, or
limits on use
$0- MO
$7.40
(Tier
2)
$0$7.40
PHOSPHOLINE IODIDE
(Tier
SOLR
2)
$0- MO
pilocarpine hcl soln op 1 %, $2.95
(Tier
2 %, 4 %
1)
ISOPTO CARPINE SOLN
(Pilocarpine HCl)
MO
MO
MO
MO
MO
MO
MO
MO
Ophthalmic Adrenergic Agents
$0$7.40
ALPHAGAN P SOLN 0.1 % (Tier
2)
ALPHAGAN P SOLN 0.15
NF
% (Brimonidine Tartrate)
$0$2.95
apraclonidine hcl soln
(Tier
1)
$0$2.95
brimonidine tartrate soln
(Tier
1)
IOPIDINE SOLN 0.5 %
NF
(Apraclonidine HCl)
MO
MO
MO
MO
MO
Ophthalmic Anti-infectives
MO
MO
Cycloplegic Mydriatics
cyclopentolate hcl soln op
1%
What
the
drug
will
cost
you
(tier
level)
$0- MO
$2.95
(Tier
1)
bacitracin-polymyxin b
(ophth) oint
BLEPH-10 SOLN
(Sulfacetamide Sodium
(Ophth))
CILOXAN SOLN
(Ciprofloxacin HCl (Ophth))
$0- MO
$2.95
(Tier
1)
MO
NF
NF MO
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161
Name of drug
ciprofloxacin hcl (ophth)
soln
erythromycin (ophth) oint
gatifloxacin (ophth) soln
gentamicin sulfate (ophth)
oint
gentamicin sulfate (ophth)
soln
levofloxacin (ophth) soln
neomycin-bacitracin znpolymyxin oint
neomycin-polymyxingramicidin soln
OCUFLOX SOLN
(Ofloxacin (Ophth))
ofloxacin (ophth) soln
polymyxin b-trimethoprim
soln
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Name of drug
POLYTRIM SOLN
(Polymyxin BTrimethoprim)
MO
sulfacetamide sodium
(ophth) soln
MO
tobramycin (ophth) soln
MO
TOBREX SOLN
(Tobramycin (Ophth))
trifluridine soln op
MO
VIGAMOX SOLN
MO
VIROPTIC SOLN
(Trifluridine)
MO
MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
ZIRGAN GEL
ZYMAXID SOLN
(Gatifloxacin (Ophth))
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
NF MO
$0- MO
$7.40
(Tier
2)
NF MO
Ophthalmic Decongestants
$0 MO; NT
naphazoline w/
pheniramine soln 0.025%- (Tier
3)
0.3%
NAPHCON-A SOLN
MO; NT
NF
(Naphazoline w/
Pheniramine)
Ophthalmic Immunomodulators
$0- MO
$7.40
RESTASIS EMUL
(Tier
2)
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Name of drug
RESTASIS MULTIDOSE
EMUL
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
neomycin-polymydexameth susp
Ophthalmic Local Anesthetics
$0- MO
$2.95
proparacaine hcl soln op
(Tier
1)
Ophthalmic Steroids
bacitracin-poly-neomycinhc oint
dexamethasone sodium
phosphate (ophth) soln
DUREZOL EMUL
fluorometholone (ophth)
susp
FML LIQUIFILM SUSP
(Fluorometholone (Ophth))
LOTEMAX OINT
MAXITROL OINT
(Neomycin-PolymyDexameth)
MAXITROL SUSP
(Neomycin-PolymyDexameth)
neomycin-polymydexameth oint
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
Name of drug
OMNIPRED SUSP
(Prednisolone Acetate
(Ophth))
PRED FORTE SUSP
(Prednisolone Acetate
(Ophth))
MO
prednisolone acetate
(ophth) susp
MO
sulfacetamide sodprednisolone soln
MO
MO
NF MO
$0- MO
$7.40
(Tier
2)
MO
NF
TOBRADEX SUSP
(TobramycinDexamethasone)
tobramycindexamethasone susp
Ophthalmics - Misc.
ACULAR LS SOLN
(Ketorolac Tromethamine
(Ophth))
ACULAR SOLN (Ketorolac
Tromethamine (Ophth))
azelastine hcl (ophth) soln
MO
NF
AZOPT SUSP
$0- MO
$2.95
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
MO
NF
$0- MO
$2.95
(Tier
1)
MO
NF
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
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163
Name of drug
bromfenac sodium (ophth)
soln
cromolyn sodium (ophth)
soln
CYSTARAN SOLN
diclofenac sodium (ophth)
soln
dorzolamide hcl soln
ELESTAT SOLN
(Epinastine HCl (Ophth))
ENUCLENE SOLN
epinastine hcl (ophth) soln
EYE STREAM SOLN
flurbiprofen sodium soln
ILEVRO SUSP
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Once daily
dosing;MO
MO
Limit 60mls per
28
days;QL(2.15
ml daily); LA
MO
ketorolac tromethamine
(ophth) soln
ketotifen fumarate (ophth)
soln
MURO 128 OINT 5 %
(Sodium Chloride
Hypertonic)
NEVANAC SUSP
MO; NT
MO
MO; NT
MO
MO
OCUFEN SOLN
(Flurbiprofen Sodium)
OPTIVAR SOLN
(Azelastine HCl (Ophth))
MO
MO; NT
MO; NT
$0 MO; NT
(Tier
3)
MO; NT
NF
MURO 128 SOLN 2 %
MO
Necessary
actions,
restrictions, or
limits on use
NF
MURO 128 SOLN 5 %
(Sodium Chloride
Hypertonic)
NF MO
$0
(Tier
3)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0
(Tier
3)
$0- MO
$7.40
(Tier
2)
NF MO
NF MO
$0- MO
$7.40
PATADAY SOLN
(Tier
2)
$0 MO; NT
sodium chloride hypertonic (Tier
oint
3)
$0 MO; NT
sodium chloride hypertonic (Tier
soln
3)
TRUSOPT SOLN
NF MO
(Dorzolamide HCl)
ZADITOR SOLN (Ketotifen NF MO; NT
Fumarate (Ophth))
Prostaglandins - Ophthalmic
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164
Name of drug
BIMATOPROST SOLN
latanoprost soln
LUMIGAN SOLN
TRAVATAN Z SOLN
XALATAN SOLN
(Latanoprost)
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
Otic Combinations
boric acid in isopropyl soln
MO
CIPRODEX SUSP
MO
neomycin-polymyxin-hc
(otic) soln
MO
NF MO
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
acetic acid (otic) soln
acetic acid-aluminum
acetate soln
carbamide peroxide (otic)
soln
DEBROX SOLN
(Carbamide Peroxide
(Otic))
Otic Anti-infectives
FLOXIN OTIC SOLN
(Ofloxacin (Otic))
ofloxacin (otic) soln
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0 MO; NT
(Tier
3)
MO; NT
NF
NF MO
$0- MO
$2.95
(Tier
1)
neomycin-polymyxin-hc
(otic) susp
Otic Steroids
DERMOTIC OIL
(Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
(otic) oil
hydrocortisone w/acetic
acid soln
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
NT
MO
MO
MO
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding
Oxytocics
$0- MO
methylergonovine maleate $2.95
(Tier
tabs or 0.2 mg
1)
PASSIVE IMMUNIZING AGENTS - Antibody
Drugs to Treat Low Immune System
Immune Serums
You can find information on what the symbols and abbreviations in this table mean by going to
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
BIVIGAM SOLN
(Tier
2)
$0$7.40
CUVITRU SOLN
(Tier
2)
$0FLEBOGAMMA DIF SOLN $7.40
(Tier
10 %
2)
$0$7.40
GAMASTAN S/D INJ
(Tier
2)
$0$7.40
GAMMAGARD LIQUID
(Tier
SOLN
2)
$0$7.40
GAMMAKED SOLN
(Tier
2)
$0$7.40
GAMUNEX-C SOLN
(Tier
2)
$0$7.40
HIZENTRA SOLN
(Tier
2)
$0OCTAGAM SOLN 10
$7.40
GM/100ML, 2 GM/20ML,
(Tier
20 GM/200ML, 5 GM/50ML 2)
$0$7.40
PRIVIGEN SOLN
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
B/D
VARIZIG SOLN 125
UNIT/1.2ML
B/D
B/D
B/D
B/D
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Monoclonal Antibodies
SYNAGIS SOLN 50
MG/0.5ML
$0$7.40
(Tier
2)
Passive Immunizing Agents - Combinations
$0- B/D
$7.40
HYQVIA KIT
(Tier
2)
PENICILLINS - Drugs to Treat Bacterial Infections
Aminopenicillins
B/D
B/D
B/D
B/D
B/D
$0$2.95
(Tier
1)
$0amoxicillin susr 125
$2.95
mg/5ml, 200 mg/5ml, 250
(Tier
mg/5ml, 400 mg/5ml
1)
$0$2.95
amoxicillin tabs 500 mg,
(Tier
875 mg
1)
$0$2.95
ampicillin caps 250 mg,
(Tier
500 mg
1)
$0$2.95
ampicillin sodium solr ij 1
(Tier
gm, 2 gm
1)
$0ampicillin sodium solr iv 10 $2.95
(Tier
gm
1)
MO
amoxicillin caps 250 mg,
500 mg
MO
MO
MO
MO
Natural Penicillins
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
BICILLIN L-A SUSP
penicillin g potassium solr
20 mu, 20000000 unit,
5000000 unit
penicillin v potassium solr
250 mg/5ml
penicillin v potassium tabs
250 mg, 500 mg
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
Penicillin Combinations
amoxicillin & pot
clavulanate chew 200mg28.5mg, 400mg-57mg
amoxicillin & pot
clavulanate susr
200mg/5ml-28.5mg/5ml,
250mg/5ml-62.5mg/5ml,
400mg/5ml-57mg/5ml,
600mg/5ml-42.9mg/5ml
amoxicillin & pot
clavulanate tabs 250mg125mg, 500mg-125mg,
875mg-125mg
amoxicillin & pot
clavulanate tb12 1000mg62.5mg
ampicillin & sulbactam
sodium solr ij 1gm-2gm
ampicillin & sulbactam
sodium solr iv 5gm-10gm
$0- MO
$2.95
(Tier
1)
MO
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0$2.95
(Tier
1)
Name of drug
AUGMENTIN ES-600
SUSR (Amoxicillin & Pot
Clavulanate)
AUGMENTIN SUSR
250MG/5ML-62.5MG/5ML
(Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS
500MG-125MG, 875MG125MG (Amoxicillin & Pot
Clavulanate)
AUGMENTIN XR TB12
(Amoxicillin & Pot
Clavulanate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
MO
NF
MO
NF
NF
$0- MO
$7.40
(Tier
2)
$0BICILLIN C-R SUSP
$7.40
900000UNIT/2ML(Tier
300000UNIT/2ML
2)
$0$2.95
piperacillin sodium(Tier
tazobactam sodium solr
1)
UNASYN SOLR 1GM-2GM
MO
NF
(Ampicillin & Sulbactam
Sodium)
ZOSYN SOLR 0.25GM2GM, 0.375GM-3GM,
0.5GM-4GM, 4.5GM-36GM NF
(Piperacillin SodiumTazobactam Sodium)
BICILLIN C-R SUSP
300000UNIT/ML300000UNIT/ML
Penicillinase-Resistant Penicillins
$0- MO
$2.95
dicloxacillin sodium caps
(Tier
1)
$0$2.95
nafcillin sodium solr ij 10
(Tier
gm
1)
You can find information on what the symbols and abbreviations in this table mean by going to
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167
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
nafcillin sodium solr ij 2 gm (Tier
1)
$0oxacillin sodium solr 10 gm $2.95
(Tier
1)
$0$2.95
oxacillin sodium solr 2 gm (Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; NT
Pharmaceutical Excipients
$0 RX/OTC; MO;
(Tier NT
3)
Semi Solid Vehicles
LANOLIN ANHYDROUS
OINT
LANOLIN ANHYDROUSGRX OINT
lanolin oint ex
PROGESTINS - Hormone Replacement/Modifying
Drugs
$0$2.95
(Tier
1)
$0MEGACE ES SUSP
$7.40
(Megestrol Acetate
(Tier
(Appetite))
2)
$0$2.95
megestrol acetate
(Tier
(appetite) susp
1)
$0norethindrone acetate tabs $2.95
(Tier
or
1)
$0$2.95
progesterone micronized
(Tier
caps or 100 mg, 200 mg
1)
PROMETRIUM CAPS
NF
(Progesterone Micronized)
PROVERA TABS
NF
(Medroxyprogesterone
Acetate)
medroxyprogesterone
acetate tabs or 10 mg, 2.5
mg, 5 mg
Liquid Vehicles
KARAYA GUM GUM
Necessary
actions,
restrictions, or
limits on use
Progestins
PHARMACEUTICAL ADJUVANTS
$0
CHERRY CONCENTRATE (Tier
SYRP
3)
$0
(Tier
CHERRY SYRUP SYRP
3)
$0
PROPYLENE GLYCOL
(Tier
SOLN EX
3)
$0
RASPBERRY SYRUP
(Tier
SYRP
3)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0 RX/OTC; NT
(Tier
3)
$0 RX/OTC; NT
(Tier
3)
$0 RX/OTC; NT
(Tier
3)
MO
AL; MO
AL; MO
MO
MO
MO
MO
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
Agents for Chemical Dependency
$0- MO
$2.95
acamprosate calcium tbec (Tier
1)
CAMPRAL TBEC
NF MO
(Acamprosate Calcium)
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Name of drug
disulfiram tabs or 250 mg,
500 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Anti-Cataplectic Agents
XYREM SOLN
Name of drug
$0- LA
$7.40
(Tier
2)
Antidementia Agents
ARICEPT ODT TBDP
NF MO
(Donepezil Hydrochloride)
ARICEPT TABS (Donepezil NF MO
Hydrochloride)
$0- MO
$2.95
donepezil hydrochloride
(Tier
tabs
1)
$0- MO
$2.95
donepezil hydrochloride
(Tier
tbdp
1)
EXELON CAPS OR 1.5
MO
NF
MG, 3 MG, 4.5 MG, 6 MG
(Rivastigmine Tartrate)
$0- MO
EXELON PT24 TD 13.3
MG/24HR, 4.6 MG/24HR, $7.40
(Tier
9.5 MG/24HR
2)
(Rivastigmine)
$0- MO
galantamine hydrobromide $2.95
(Tier
cp24
1)
$0- MO
galantamine hydrobromide $2.95
(Tier
soln
1)
$0- MO
galantamine hydrobromide $2.95
(Tier
tabs
1)
memantine hcl soln 2
mg/ml
memantine hcl tabs 10 mg,
5 mg
NAMENDA SOLN 10
MG/5ML (Memantine HCl)
NAMENDA TABS 10 MG, 5
MG (Memantine HCl)
NAMENDA TITRATION
PAK TABS (Memantine
HCl)
NAMENDA XR CP24 14
MG
NAMENDA XR CP24 21
MG
NAMENDA XR CP24 28
MG
NAMENDA XR CP24 7 MG
NAMENDA XR TITRATION
PACK CP24
RAZADYNE ER CP24
(Galantamine
Hydrobromide)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
AL; MO
MO
AL; MO
MO
MO
SL(2 ea daily);
MO
SL(1.33 ea
daily); MO
SL(1 ea daily);
MO
SL(4 ea daily);
MO
MO
MO
NF
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Name of drug
RAZADYNE SOLN
(Galantamine
Hydrobromide)
RAZADYNE TABS
(Galantamine
Hydrobromide)
rivastigmine pt24
rivastigmine tartrate caps
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NF
AMPYRA TB12
MO
NF
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Combination Psychotherapeutics
$0$2.95
chlordiazepoxide(Tier
amitriptyline tabs
1)
$0$2.95
olanzapine-fluoxetine hcl
(Tier
caps
1)
$0perphenazine-amitriptyline $2.95
(Tier
tabs
1)
SYMBYAX CAPS
NF
(Olanzapine-Fluoxetine
HCl)
AUBAGIO TABS
AVONEX KIT
AVONEX PEN AJKT
AL; MO
AVONEX PSKT
MO
BETASERON KIT
AL; MO
COPAXONE SOSY 20
MG/ML (Glatiramer
Acetate)
MO
Movement Disorder Drug Therapy
$0$2.95
tetrabenazine tabs
(Tier
1)
$0- LA
$7.40
XENAZINE TABS
(Tier
(Tetrabenazine)
2)
COPAXONE SOSY 40
MG/ML
EXTAVIA KIT
GILENYA CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
PA
PA
PA
PA
PA
Multiple Sclerosis Agents
You can find information on what the symbols and abbreviations in this table mean by going to
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170
Name of drug
glatiramer acetate sosy
LEMTRADA SOLN
PLEGRIDY SOPN
PLEGRIDY SOSY
PLEGRIDY STARTER
PACK SOPN
PLEGRIDY STARTER
PACK SOSY
REBIF REBIDOSE SOAJ
REBIF REBIDOSE
TITRATIONPACK SOAJ
REBIF SOSY
REBIF TITRATION PACK
SOSY
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
PA
TECFIDERA CPDR
PA; LA
TECFIDERA STARTER
PACK MISC
PA
TYSABRI CONC
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
Premenstrual Dysphoric Disorder (PMDD) Agents
fluoxetine hcl (pmdd) cap
NF
10 mg, 20 mg
PA
Pseudobulbar Affect (PBA) Agents
$0- MO
$7.40
NUEDEXTA CAPS
(Tier
2)
PA
PA
PA
PA
Psychotherapeutic and Neurological Agents $0- AL; MO
$2.95
ergoloid mesylates tabs or (Tier
1)
$0- MO
$7.40
ORAP TABS (Pimozide)
(Tier
2)
$0- MO
$2.95
pimozide tabs
(Tier
1)
Smoking Deterrents
PA
bupropion hcl (smoking
deterrent) tb12
$0- SL(2 ea daily);
$2.95 MO
(Tier
1)
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Name of drug
CHANTIX CONTINUING
MONTHPAK TABS
CHANTIX TABS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
NICODERM CQ PT24
(Nicotine)
NICORETTE GUM
(Nicotine Polacrilex)
NICORETTE LOZG
(Nicotine Polacrilex)
NICORETTE MINI LOZG
(Nicotine Polacrilex)
NICORETTE STARTER
KIT GUM (Nicotine
Polacrilex)
Name of drug
PA; MO
BRISDELLE CAPS
PA; MO
NF MO; NT
NF PA; MO; NT
NF PA; MO; NT
NF PA; MO; NT
PA; MO; NT
NF
$0
(Tier
3)
$0
nicotine polacrilex lozg mt (Tier
2 mg, 4 mg
3)
$0
(Tier
nicotine pt24
3)
$0
NICOTINE
TRANSDERMAL SYSTEM (Tier
3)
KIT
$0$7.40
NICOTROL INHALER
(Tier
INHA
2)
$0$7.40
NICOTROL NS SOLN
(Tier
2)
ZYBAN TB12 (Bupropion
NF
HCl (Smoking Deterrent))
nicotine polacrilex gum mt
2 mg, 4 mg
Necessary
actions,
restrictions, or
limits on use
PA; MO; NT
PA; MO; NT
MO; NT
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Alpha-Proteinase Inhibitor (Human)
$0- LA
ARALAST NP SOLR 1000 $7.40
(Tier
MG
2)
$0- LA
$7.40
PROLASTIN-C SOLR
(Tier
2)
$0- LA
$7.40
ZEMAIRA SOLR
(Tier
2)
Cystic Fibrosis Agents
KALYDECO PACK
KALYDECO TABS
NT
ORKAMBI TABS
SL(17 ea daily);
MO
PULMOZYME SOLN
MO
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
PA
PA
PA; LA
B/D
Pulmonary Fibrosis Agents
SL(2 ea daily);
MO
ESBRIET CAPS
Vasomotor Symptom Agents
$0- PA; LA
$7.40
(Tier
2)
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
OFEV CAPS
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; LA
SULFONAMIDES - Drugs to Treat Bacterial
Infections
Sulfonamides
sulfadiazine tabs or
$0- MO
$2.95
(Tier
1)
TETRACYCLINES - Drugs to Treat Bacterial
Infections
Tetracyclines
ADOXA PAK 1/100 TABS
(Doxycycline
(Monohydrate))
ADOXA PAK 1/150 TABS
(Doxycycline
(Monohydrate))
ADOXA PAK 2/100 TABS
(Doxycycline
(Monohydrate))
ADOXA TABS 100 MG, 50
MG, 75 MG (Doxycycline
(Monohydrate))
Name of drug
doxycycline (monohydrate)
tabs 100 mg, 150 mg, 50
mg, 75 mg
doxycycline hyclate caps or
100 mg, 50 mg
doxycycline hyclate solr iv
100 mg
doxycycline hyclate tabs or
100 mg, 20 mg
MO
NF
MO
NF
MO
NF
MO
NF
$0- MO
$2.95
demeclocycline hcl tabs
(Tier
1)
$0- MO
doxycycline (monohydrate) $2.95
caps 100 mg, 50 mg, 75
(Tier
mg
1)
$0- MO
doxycycline (monohydrate) $2.95
(Tier
susr 25 mg/5ml
1)
doxycycline hyclate tbec or
150 mg
MINOCIN CAPS OR 100
MG, 50 MG, 75 MG
(Minocycline HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
NF
$0minocycline hcl caps or 100 $2.95
(Tier
mg, 50 mg, 75 mg
1)
$0minocycline hcl tabs or 100 $2.95
(Tier
mg, 50 mg
1)
MONODOX CAPS
NF
(Doxycycline
(Monohydrate))
$0tetracycline hcl caps or 250 $2.95
(Tier
mg, 500 mg
1)
VIBRAMYCIN CAPS 100
NF
MG (Doxycycline Hyclate)
VIBRAMYCIN SUSR 25
NF
MG/5ML (Doxycycline
(Monohydrate))
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones
Antithyroid Agents
methimazole tabs or 10
mg, 5 mg
propylthiouracil tabs or
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
Thyroid Hormones
CYTOMEL TABS
NF
(Liothyronine Sodium)
levothyroxine sodium tabs
$0or 100 mcg, 112 mcg, 125
$2.95
mcg, 137 mcg, 150 mcg,
(Tier
175 mcg, 200 mcg, 25
1)
mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
$0liothyronine sodium tabs or $2.95
(Tier
25 mcg, 5 mcg, 50 mcg
1)
SYNTHROID TABS
NF
(Levothyroxine Sodium)
TOXOIDS
Toxoid Combinations
ADACEL SUSP
BOOSTRIX SUSP
DAPTACEL SUSP
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
MO
Name of drug
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC SUSP
INFANRIX SUSP
TENIVAC INJ
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT SUSP
MO
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
SUSP
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
B/D
ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
Antispasmodics
BENTYL CAPS OR 10 MG
(Dicyclomine HCl)
BENTYL TABS OR 20 MG
(Dicyclomine HCl)
NF MO
NF MO
$0- MO
dicyclomine hcl caps or 10 $2.95
(Tier
mg
1)
$0- MO
dicyclomine hcl tabs or 20 $2.95
(Tier
mg
1)
$0- MO
$2.95
glycopyrrolate soln ij 0.2
(Tier
mg/ml
1)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.95
glycopyrrolate tabs or 1 mg (Tier
1)
$0glycopyrrolate tabs or 2 mg $2.95
(Tier
1)
$0methscopolamine bromide $2.95
(Tier
tabs or 2.5 mg, 5 mg
1)
PAMINE FORTE TABS
NF
(Methscopolamine
Bromide)
PAMINE TABS
NF
(Methscopolamine
Bromide)
ROBINUL FORTE TABS
NF
(Glycopyrrolate)
ROBINUL SOLN IJ 0.2
NF
MG/ML (Glycopyrrolate)
ROBINUL TABS OR 1 MG NF
(Glycopyrrolate)
Necessary
actions,
restrictions, or
limits on use
Name of drug
SL(8 ea daily);
MO
famotidine tabs or 10 mg
SL(4 ea daily);
MO
famotidine tabs or 20 mg
MO
famotidine tabs or 40 mg
MO
nizatidine caps 150 mg,
300 mg
MO
PEPCID AC CHEW
SL(4 ea daily);
MO
MO
SL(8 ea daily);
MO
H-2 Antagonists
$0- RX/OTC; MO
$2.95
cimetidine tabs or 200 mg (Tier
1)
$0- MO
cimetidine tabs or 300 mg, $2.95
(Tier
400 mg, 800 mg
1)
$0famotidine soln iv 20
$2.95
mg/2ml, 200 mg/20ml, 40
(Tier
mg/4ml
1)
$0- MO
$2.95
famotidine susr or 40
(Tier
mg/5ml
1)
PEPCID AC TABS
(Famotidine)
PEPCID SUSR
(Famotidine)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO
MO
MO
NT
NF MO; NT
NF MO
$0$2.95
(Tier
1)
$0ranitidine hcl syrp or 15
$2.95
mg/ml, 150 mg/10ml, 75
(Tier
mg/5ml
1)
$0$2.95
ranitidine hcl tabs or 150
(Tier
mg
1)
$0$2.95
ranitidine hcl tabs or 300
(Tier
mg
1)
$0
ranitidine hcl tabs or 75 mg (Tier
3)
ZANTAC 75 TABS
NF
(Ranitidine HCl)
MO
ranitidine hcl caps or 150
mg, 300 mg
MO
RX/OTC; MO
MO
MO; NT
MO; NT
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Name of drug
ZANTAC TABS OR 150
MG (Ranitidine HCl)
ZANTAC TABS OR 300
MG (Ranitidine HCl)
Misc. Anti-Ulcer
CARAFATE TABS 1 GM
(Sucralfate)
sucralfate tabs or
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF RX/OTC; MO
NF MO
NEXIUM CPDR 20 MG
(Esomeprazole
Magnesium)
NF MO
NEXIUM CPDR 40 MG
(Esomeprazole
Magnesium)
$0- MO
$2.95
(Tier
1)
Proton Pump Inhibitors
DEXILANT CPDR
esomeprazole magnesium
cpdr 20 mg
esomeprazole magnesium
cpdr 40 mg
esomeprazole sodium solr
40 mg
ESOMEPRAZOLE
STRONTIUM CPDR 49.3
MG
lansoprazole cpdr or 15 mg
lansoprazole cpdr or 30 mg
Name of drug
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
ST; MO
ST; RX/OTC;
MO
ST; MO
ST
RX/OTC; MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
NEXIUM I.V. SOLR
(Esomeprazole Sodium)
Necessary
actions,
restrictions, or
limits on use
ST; RX/OTC;
MO
ST; MO
NF
$0NEXIUM PACK 10 MG, 2.5 $7.40
MG, 20 MG, 40 MG, 5 MG (Tier
2)
$0omeprazole cpdr or 10 mg, $2.95
(Tier
20 mg, 40 mg
1)
$0pantoprazole sodium solr iv $2.95
(Tier
40 mg
1)
$0pantoprazole sodium tbec $2.95
(Tier
or 20 mg, 40 mg
1)
PREVACID CPDR 15 MG
NF
(Lansoprazole)
PREVACID CPDR 30 MG
NF
(Lansoprazole)
PRILOSEC CPDR 10 MG,
NF
20 MG, 40 MG
(Omeprazole)
$0$7.40
PROTONIX SOLR IV 40
(Tier
MG
2)
PROTONIX TBEC OR 20
NF
MG, 40 MG (Pantoprazole
Sodium)
ST; MO
MO
MO
RX/OTC; MO
MO
MO
MO
Ulcer Drugs - Prostaglandins
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Name of drug
What
the
drug
will
cost
you
(tier
level)
CYTOTEC TABS
(Misoprostol)
misoprostol tabs or 100
mcg, 200 mcg
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.95
(Tier
1)
Ulcer Therapy Combinations
amoxicillin-clarithromycin
w/ lansoprazole misc
OMECLAMOX-PAK MISC
omeprazole-sodium
bicarbonate caps 20mg1100mg
omeprazole-sodium
bicarbonate caps 40mg1100mg
omeprazole-sodium
bicarbonate pack 20mg1680mg
PREVPAC MISC
(Amoxicillin-Clarithromycin
w/ Lansoprazole)
ZEGERID CAPS 20MG1100MG (OmeprazoleSodium Bicarbonate)
ZEGERID CAPS 40MG1100MG (OmeprazoleSodium Bicarbonate)
ZEGERID PACK 20MG1680MG (OmeprazoleSodium Bicarbonate)
$0$2.95
(Tier
1)
$0$7.40
(Tier
2)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
MO
MO
RX/OTC; MO
MO
ST; MO
MO
NF
RX/OTC; MO
NF
MO
NF
$0- ST; MO
$7.40
(Tier
2)
Name of drug
Urinary Anti-infectives
HIPREX TABS
(Methenamine Hippurate)
MACROBID CAPS
(Nitrofurantoin Monohyd
Macro)
MACRODANTIN CAPS
100 MG, 50 MG
(Nitrofurantoin
Macrocrystal)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
MO
NF
AL; MO
NF
$0- MO
$2.95
(Tier
1)
$0- AL; MO
nitrofurantoin macrocrystal $2.95
(Tier
caps or 100 mg, 50 mg
1)
$0- MO
$2.95
nitrofurantoin monohyd
(Tier
macro caps
1)
methenamine hippurate
tabs
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms
Urinary Antispasmodic - Antimuscarinics
DETROL LA CP24
NF MO
(Tolterodine Tartrate)
DETROL TABS
NF MO
(Tolterodine Tartrate)
DITROPAN XL TB24
NF MO
(Oxybutynin Chloride)
$0- MO
$2.95
oxybutynin chloride syrp
(Tier
1)
$0- MO
$2.95
oxybutynin chloride tabs
(Tier
1)
URINARY ANTI-INFECTIVES - Drugs to Treat
Bladder/Kidney Infections
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177
Name of drug
oxybutynin chloride tb24
tolterodine tartrate cp24
tolterodine tartrate tabs
trospium chloride cp24
trospium chloride tabs
What
the
drug
will
cost
you
(tier
level)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
$0$2.95
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
Urinary Antispasmodics - Beta-3 Adrenergic
$0- MO
$7.40
MYRBETRIQ TB24
(Tier
2)
Urinary Antispasmodics - Cholinergic Agonists
$0- MO
bethanechol chloride tabs $2.95
10 mg, 25 mg, 5 mg, 50 mg (Tier
1)
Urinary Antispasmodics - Direct Muscle Relaxants
$0- MO
$2.95
flavoxate hcl tabs
(Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$7.40
MENACTRA INJ
(Tier
2)
$0MENOMUNE-A/C/Y/W-135 $7.40
(Tier
INJ
2)
$0$7.40
MENVEO SOLR
(Tier
2)
$0$7.40
PEDVAX HIB SUSP
(Tier
2)
$0$7.40
TYPHIM VI SOLN
(Tier
2)
Mixed Vaccine Combinations
COMVAX SUSP
CERVARIX SUSP
ENGERIX-B SUSP IJ 10
MCG/0.5ML, 20 MCG/ML
Bacterial Vaccines
ACTHIB SOLR
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Viral Vaccines
GARDASIL 9 SUSP
VACCINES
Necessary
actions,
restrictions, or
limits on use
GARDASIL 9 SUSY
$0$7.40
(Tier
2)
$0- B/D
$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
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Name of drug
GARDASIL SUSP
HAVRIX SUSP
IMOVAX RABIES
(H.D.C.V.) INJ
IPOL INACTIVATED IPV
INJ
IXIARO SUSP
M-M-R II INJ
PROQUAD INJ
RABAVERT SUSR
RECOMBIVAX HB SUSP
ROTARIX SUSR
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
ROTATEQ SOLN
TWINRIX SUSP
B/D
VAQTA SUSP
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX SOLR
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
VAGINAL PRODUCTS - Drugs to Treat Vaginal
Infections and Low Hormones
B/D
B/D
Miscellaneous Vaginal Products
$0 NT
benzocaine-resorcinol
(Tier
vaginal crea 2%-5%
3)
$0 NT
(Tier
FEMINEASE CREA
3)
VAGISIL CREA
NT
NF
(Benzocaine-Resorcinol
Vaginal)
Spermicides
ENCARE SUPP
$0 NT
(Tier
3)
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179
Name of drug
nonoxynol-9 gel
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
OPTIONS CONCEPTROL
$0 NT
VAGINAL
(Tier
CONTRACEPTIVE GEL
3)
(Nonoxynol-9)
$0 MO; NT
OPTIONS GYNOL II
VAGINALCONTRACEPTIV (Tier
3)
E GEL
$0 NT
(Tier
SHUR-SEAL GEL
3)
$0 NT
VCF VAGINAL
(Tier
CONTRACEPTIVE FILM
3)
FILM
$0 NT
VCF VAGINAL
CONTRACEPTIVE FOAM (Tier
3)
FOAM
Vaginal Anti-infectives
CLEOCIN CREA VA 2 %
(Clindamycin Phosphate
Vaginal)
MO
TERAZOL 3 CREA
(Terconazole Vaginal)
TERAZOL 7 CREA
(Terconazole Vaginal)
terconazole vaginal crea
terconazole vaginal supp
tioconazole vaginal oint
VAGISTAT-1 OINT
(Tioconazole Vaginal)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF MO
$0- MO
$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
$0 NT
(Tier
3)
NF NT
Vaginal Estrogens
estradiol vaginal crea 0.1
mg/gm
NF
$0- MO
$2.95
(Tier
1)
$0 MO; NT
clotrimazole vaginal crea 1 (Tier
%
3)
GYNE-LOTRIMIN CREA
NF MO; NT
(Clotrimazole Vaginal)
METROGEL-VAGINAL
MO
NF
GEL (Metronidazole
Vaginal)
$0- MO
$2.95
metronidazole vaginal gel
(Tier
1)
$0 MO; NT
miconazole nitrate vaginal (Tier
supp 100 mg
3)
clindamycin phosphate
vaginal crea
Name of drug
What
the
drug
will
cost
you
(tier
level)
PREMARIN CREA VA
0.625 MG/GM
$0- MO
$2.95
(Tier
1)
$0- MO
$7.40
(Tier
2)
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
Anaphylaxis Therapy Agents
ADRENACLICK SOAJ
AUVI-Q SOAJ
EPINEPHRINE SOAJ IJ
0.15 MG/0.15ML, 0.3
MG/0.3ML
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
$0- MO
$7.40
(Tier
2)
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180
Name of drug
EPIPEN 2-PAK SOAJ
EPIPEN-JR 2-PAK SOAJ
What
the
drug
will
cost
you
(tier
level)
$0$7.40
(Tier
2)
$0$7.40
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
Neurogenic Orthostatic Hypotension (NOH) $0- PA; SL(18 ea
$7.40 daily)
NORTHERA CAPS 100
(Tier
MG
2)
$0- PA; SL(9 ea
$7.40 daily)
NORTHERA CAPS 200
(Tier
MG
2)
$0- PA; SL(6 ea
$7.40 daily)
NORTHERA CAPS 300
(Tier
MG
2)
Vasopressors
dobutamine hcl soln
midodrine hcl tabs
$0$2.95
(Tier
1)
$0- MO
$2.95
(Tier
1)
VITAMINS
Oil Soluble Vitamins
A-25 CAPS
BABY DDROPS LIQD
(Cholecalciferol)
BETA CAROTENE CAPS
OR 10000 UNIT
$0 NT
(Tier
3)
NF NT
$0 NT
(Tier
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
beta carotene caps or
(Tier
25000 unit
3)
$0
cholecalciferol caps or
(Tier
1000 unit, 2000 unit, 400
3)
unit, 5000 unit
$0
cholecalciferol liqd or 400
(Tier
unit/ml
3)
$0
cholecalciferol liqd or 400
(Tier
unt/0.03ml
3)
$0
cholecalciferol tabs or 1000 (Tier
unit, 2000 unit, 400 unit
3)
$0
cholecalciferol tabs or 5000 (Tier
unit, 50000 unit
3)
D-VI-SOL LIQD
NF
(Cholecalciferol)
DRISDOL CAPS
NF
(Ergocalciferol)
DRISDOL SOLN
NF
(Ergocalciferol)
$0
ergocalciferol caps or
(Tier
50000 unit
3)
$0
ergocalciferol soln or 8000 (Tier
unit/ml
3)
$0
(Tier
MEPHYTON TABS
3)
$0
phytonadione tabs or 100
(Tier
mcg
3)
$0
(Tier
vitamin a caps 10000 unit
3)
$0
VITAMIN A CAPS 25000
(Tier
UNIT
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
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181
Name of drug
vitamin a caps 8000 unit
VITAMIN A TABS
10000UNIT-1000UNIT
vitamin e caps or 100 unit,
1000 unit
vitamin e liqd or 400
unit/15ml
vitamin e soln or 15
unit/0.3ml
WHEAT GERM OIL
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
NT
NT
MO; NT
NT
MO; NT
NT
Water Soluble Vitamins
ascorbic acid chew or 250
mg, 250mg
ascorbic acid cpcr or 500
mg
ASCORBIC ACID GRAN
OR
ascorbic acid soln ij 500
mg/ml
ascorbic acid tabs or 100
mg
ascorbic acid tabs or 250
mg
ascorbic acid tbcr or 1000
mg, 500 mg, 500mg
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
NT
MO; NT
NT
MO; NT
NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
B-1 TABS
3)
$0
(Tier
biotin tabs or 300 mcg
3)
$0
biotin tabs or 5 mg, 5000
(Tier
mcg, 800 mcg
3)
$0
BIOTIN TABS OR 800
(Tier
MCG
3)
$0
(Tier
calcium ascorbate tabs or
3)
$0
niacin cpcr or 250 mg, 500 (Tier
mg
3)
$0
niacin tabs or 100 mg, 250 (Tier
mg, 50 mg, 500 mg
3)
$0
niacin tbcr or 250 mg, 500 (Tier
mg, 750 mg
3)
$0
(Tier
NIACIN TR TBCR
3)
$0
niacinamide tabs or 100 mg (Tier
3)
$0
niacinamide tabs or 500 mg (Tier
3)
$0
pyridoxine hcl tabs or 100
(Tier
mg, 25 mg, 50 mg
3)
$0
riboflavin tabs or 100 mg,
(Tier
25 mg
3)
$0
(Tier
riboflavin tabs or 50 mg
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
NT
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182
Name of drug
SLO-NIACIN TBCR
(Niacin)
thiamine hcl tabs or 100
mg, 50 mg
thiamine hcl tabs or 250
mg
thiamine mononitrate tabs
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO; NT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations in this table mean by going to
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183
Index
A & D ZINC OXIDE
109
A-25
181
A-MANTLE
109
abacavir sulfate
74
abacavir sulfate-lamivudine 74
abacavir sulfate-lamivudinezidovudine
74
ABELCET
45
ABILIFY 1 MG/ML
73
ABILIFY 10 MG
73
ABILIFY 15 MG
73
ABILIFY 2 MG
73
ABILIFY 20 MG
73
ABILIFY 30 MG
73
ABILIFY 5 MG
73
ABILIFY 9.75 MG/1.3ML
73
ABILIFY DISCMELT 10 MG 73
ABILIFY DISCMELT 15 MG 73
ABILIFY MAINTENA
73
ABRAXANE
66
ABSORICA 10 MG, 20 MG, 25
MG, 35 MG, 40 MG
95
ABSORICA 30 MG
95
acamprosate calcium
168
acarbose
36
ACCOLATE
23
ACCUPRIL
51
ACCURETIC
53
acebutolol hcl 200 mg, 400
mg
83
ACEON 4 MG
51
ACEON 8 MG
51
acetaminophen 120 mg
8
acetaminophen 160 mg
8
acetaminophen 160 mg/5ml 8
acetaminophen 160 mg/5ml, 80
mg/0.8ml
8
acetaminophen 160 mg/5ml, 80
mg/2.5ml
8
acetaminophen 80 mg
8
acetaminophen 80 mg/0.8ml 8
acetaminophen w/ codeine
120mg/5ml-12mg/5ml
13
acetaminophen w/ codeine
300mg-15mg
13
acetaminophen w/ codeine
300mg-30mg, 300mg-60mg 13
acetaminophen-caffeinepyrilamine
8
acetazolamide 250 mg
117
Index 1
acetazolamide 500 mg 117
acetic acid
126
acetic acid (otic)
165
acetic acid-aluminum
acetate
165
acetylcysteine 10 %, 20 % 95
acitretin
100
ACNE MEDICATION
96
ACNE MEDICATION 10 96
ACNE-AID
110
ACTEMRA
5
ACTHIB
178
ACTIDOM DMX
93
ACTIFLOVIT EAR
HEALTH
154
ACTIGALL
124
ACTIMMUNE
65
ACTIQ 1200 MCG, 1600 MCG,
400 MCG, 600 MCG, 800
MCG
9
ACTIQ 200 MCG
9
ACTIVELLA
123
ACTOPLUS MET
36
ACTOS 15 MG
39
ACTOS 30 MG
39
ACTOS 45 MG
39
ACUICYN DAILY EYELID &
EYELASH CLEANSER 110
ACULAR
163
ACULAR LS
163
acyclovir 200 mg
79
acyclovir 200 mg/5ml
80
acyclovir 400 mg, 800 mg 80
acyclovir sodium 50 mg/ml 80
acyclovir sodium 500 mg 80
acyclovir topical
101
ADACEL
174
ADAGEN
84
ADALAT CC
84
adapalene 0.1 %
96
ADCIRCA
86
ADD-INS COMPLETE
158
ADDERALL XR
1
adefovir dipivoxil
78
ADEMPAS 0.5 MG
87
ADEMPAS 1 MG
87
ADEMPAS 1.5 MG
87
ADEMPAS 2 MG
87
ADEMPAS 2.5 MG
87
ADIPEX-P
1
ADOXA 100 MG, 50 MG, 75
MG
173
ADOXA PAK 1/100
173
ADOXA PAK 1/150
173
ADOXA PAK 2/100
173
ADRENACLICK
180
ADULT ACNOMEL
96
ADVAIR DISKUS
24
ADVAIR HFA
24
ADVIL
5
ADVIL ALLERGY &
CONGESTION
93
ADVIL MIGRAINE
5
AEROCHAMBER MINI
AEROSOLCHAMBER
136
AEROCHAMBER MV
136
AEROCHAMBER PLUS FLOW
VU
137
AEROCHAMBER PLUS FLOWVU
137
AEROCHAMBER PLUS FLOWVU/LARGE MASK
137
AEROCHAMBER PLUS FLOWVU/MASK
137
AEROCHAMBER PLUS FLOWVU/MEDIUM MASK
137
AEROCHAMBER PLUS FLOWVU/SMALL MASK
137
AEROCHAMBER Z-STAT PLUS
VALVED HOLDING CHAMBER
W/FLOW VU
137
AEROCHAMBER Z-STAT
PLUS/FLOWSIGNAL
137
AEROCHAMBER Z-STAT
PLUS/LARGE MASK
137
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
137
AEROCHAMBER Z-STAT
PLUS/SMALL MASK
137
AEROCHAMBER/FLOWSIGNAL
137
AEROSPAN
23
AEROVENT PLUS HOLDING
CHAMBER/COLLAPSIBLE 137
AFINITOR
62
AFINITOR DISPERZ
62
AGGRENOX
128
AGRYLIN
128
AIRZONE PEAK FLOW
METER
137
ALBENZA
16
ALBUSTIX
115
albuterol sulfate 0.083 %, 0.5 %,
0.63 mg/3ml, 1.25 mg/3ml 24
albuterol sulfate 2 mg, 4 mg 24
albuterol sulfate 2 mg/5ml 24
albuterol sulfate 4 mg, 8 mg 24
alclometasone dipropionate 102
ALCOHOL PADS
136
ALDACTAZIDE 25MG25MG
117
ALDACTONE
118
ALDARA
107
ALECENSA
62
alendronate sodium 10 mg, 5
mg
119
alendronate sodium 35 mg, 70
mg
119
ALER-DRYL
46
ALEVAZOL
98
ALEVE
5
alfuzosin hcl
127
ALIMTA 100 MG
58
ALIMTA 500 MG
58
ALINIA 500 MG
18
ALKERAN 2 MG
56
ALKERAN 50 MG
56
ALLI
1
allopurinol 100 mg
127
allopurinol 300 mg
127
ALOE VESTA MULTI
PURPOSECLEANSING
110
ALOGLIPTIN
39
ALOGLIPTIN/METFORMIN
HCL
36
ALOGLIPTIN/PIOGLITAZONE
12.5MG-15MG
36
ALOGLIPTIN/PIOGLITAZONE
12.5MG-30MG
36
ALOGLIPTIN/PIOGLITAZONE
12.5MG-45MG, 25MG-15MG,
25MG-30MG, 25MG-45MG 36
alosetron hcl
126
ALPHA LIPOIC ACID 50 MG 3
ALPHA-LIPOIC ACID
3
alpha-lipoic acid (thioctic acid)
100 mg
3
ALPHAGAN P 0.1 %
161
ALPHAGAN P 0.15 %
161
alprazolam 0.25 mg, 0.5 mg, 1
mg, 2 mg
21
alprazolam 0.5 mg, 1 mg, 2 mg, 3
mg
21
ALTACE
51
alum & mag hydroxsimethicone 200mg-25mg200mg
15
alum & mag hydroxsimethicone 200mg/5ml200mg/5ml-20mg/5ml20mg/5ml-200mg/5ml200mg/5ml, 200mg/5ml20mg/5ml-200mg/5ml,
400mg/5ml-400mg/5ml40mg/5ml-40mg/5ml400mg/5ml-400mg/5ml,
400mg/5ml-40mg/5ml400mg/5ml
15
alum & mag hydroxsimethicone 200mg/5ml20mg/5ml-200mg/5ml,
400mg/5ml-40mg/5ml400mg/5ml
15
ALUMINUM ACETATE 110
ALUMINUM HYDROXIDE 16
aluminum hydroxide
110
aluminum hydroxide-mag
trisil
15
aluminum sulfate & calcium
acetate
110
amantadine hcl 100 mg
68
amantadine hcl 50 mg/5ml 68
AMARYL 1 MG
41
AMARYL 2 MG
41
AMARYL 4 MG
41
AMBIEN 10 MG
132
AMBIEN 5 MG
132
AMBIEN CR 12.5 MG
132
AMBIEN CR 6.25 MG
132
AMBISOME
45
amcinonide
102
AMERGE
142
AMERICAINE
108
AMICAR 0.25 GM/ML
131
AMICAR 500 MG
131
amifostine crystalline
66
amikacin sulfate 1 gm/4ml, 500
mg/2ml
3
amiloride &
hydrochlorothiazide
117
amiloride hcl
118
amino acid infusion 15% 158
amino acids 100mg-6.15mg2.1mg-0.85mg-1.95mg-0.55mg2.3mg-1.95mg-0.75mg-1.15mg0.6mg-3.65mg-0.65mg-3.25mg3.8mg-1.95mg-1.7mg-0.7mg1.05mg, 115.333mg-54.667mg21mg-33.333mg-33.333mg46.667mg-14.167mg-46.667mg40mg-53.333mg-18.167mg41mg-66.667mg-40mg30.667mg-17.333mg-14mg,
115.3mg-54.7mg-21mg-33.3mg13.3mg-33.3mg-63.3mg-14.2mg46.7mg-40mg-53.3mg-18.2mg41mg-66.7mg-40mg-30.7mg17.3mg-14mg, 1200mg-100mg,
18.33mg-200mg-33.33mg-50mg23.16mg-58.33mg-18.33mg75mg-108.33mg, 200mg33.33mg-50mg-23.16mg18.33mg-58.33mg-18.33mg75mg-108.33mg, 35mg-29.5mg24.667mg-4.833mg-17.667mg24.667mg-12.5mg-24mg-19mg36mg-17.5mg-4.667mg-75mg15mg, 74mg-50mg-0.7mg-77mg1.4mg-72mg-64mg-27mg-54mg70mg-41mg-17mg-109mg-7mg27mg-68mg-47mg-41mg-64mg,
74mg-5mg-0.7mg-77mg-1.4mg72mg-64mg-22mg-54mg-7mg41mg-17mg-109mg-97mg-27mg68mg-47mg-41mg-64mg 159
amino acids 130mg-10mg130mg-130mg
158
amino acids-protein
hydrolysate
159
aminocaproic acid 500 mg 131
aminophylline
25
aminosalicylic acid
56
AMINOSYN II 15% (Use amino
acid infusion)
159
amiodarone hcl 100 mg, 200 mg,
400 mg
22
amitriptyline hcl
35
amlodipine besylate 10 mg 84
amlodipine besylate 2.5 mg 84
amlodipine besylate 5 mg
84
amlodipine besylate-benazepril
hcl
53
ammonium chloride
145
amoxapine
35
amoxicillin & pot clavulanate
1000mg-62.5mg
167
Index 2
amoxicillin & pot clavulanate
200mg-28.5mg, 400mg57mg
167
amoxicillin & pot clavulanate
200mg/5ml-28.5mg/5ml,
250mg/5ml-62.5mg/5ml,
400mg/5ml-57mg/5ml,
600mg/5ml-42.9mg/5ml
167
amoxicillin & pot clavulanate
250mg-125mg, 500mg-125mg,
875mg-125mg
167
amoxicillin 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400
mg/5ml
166
amoxicillin 250 mg, 500 mg 166
amoxicillin 500 mg, 875 mg 166
amoxicillin-clarithromycin w/
lansoprazole
177
amphetaminedextroamphetamine
1
amphotericin b 50 mg
45
ampicillin & sulbactam sodium
1gm-2gm
167
ampicillin & sulbactam sodium
5gm-10gm
167
ampicillin 250 mg, 500 mg 166
ampicillin sodium 1 gm, 2
gm
166
ampicillin sodium 10 gm
166
AMPYRA
170
ANADROL-50
14
ANAFRANIL
35
anagrelide hcl
128
ANAPROX DS
5
anastrozole
60
ANCOBON 500 MG
45
ANDRODERM
14
ANDROGEL 20.25 MG/1.25GM,
40.5 MG/2.5GM
14
ANDROGEL 25 MG/2.5GM, 50
MG/5GM
14
ANDROGEL PUMP 1.62 % 14
ANORO ELLIPTA
24
ANTARA 30 MG
49
ANTARA 90 MG
49
ANTI-BACTERIAL HAND
LOTION
110
APOKYN
68
apraclonidine hcl
161
APRISO
125
APTIOM
27
APTIVUS 100 MG/ML
75
APTIVUS 250 MG
75
Index 3
AQUANIL SKIN
CLEANSER
110
AQUORAL
149
ARALAST NP 1000 MG 172
ARALEN
55
ARANESP ALBUMIN
FREE
129
ARAVA
7
ARCALYST
5
argatroban 250 mg/2.5ml 26
ARGIMENT
159
ARGIMENT AT
159
arginine 500 mg
159
ARIAL CHAMBER
138
ARICEPT
169
ARICEPT ODT
169
ARIMIDEX
60
aripiprazole 1 mg/ml
73
aripiprazole 10 mg
73
aripiprazole 15 mg
73
aripiprazole 2 mg
73
aripiprazole 20 mg
74
aripiprazole 30 mg
74
aripiprazole 5 mg
74
ARISTADA
74
ARISTOSPAN INTRAARTICULAR
91
ARIXTRA
25
AROMASIN
60
ARRANON
58
ARTHRICARE DOUBLE ICE
PAIN RELIEVING RUB 107
ARTHRICARE PAIN
RELIEVINGRUB
107
ARTHRICARE TRIPLE
MEDICATED PAIN RELIEVING
RUB
107
ARTHROTEC 50
5
ARTHROTEC 75
5
ARZERRA
59
ASACOL HD
125
ASCORBIC ACID
182
ascorbic acid 100 mg
182
ascorbic acid 1000 mg, 500 mg,
500mg
182
ascorbic acid 250 mg
182
ascorbic acid 250 mg,
250mg
182
ascorbic acid 500 mg
182
ascorbic acid 500 mg/ml 182
ASCRIPTIN
9
ASPIRIN 120 MG, 200 MG
9
aspirin 300 mg, 600 mg
9
aspirin 324 mg, 325 mg, 500 mg,
81 mg
9
aspirin 325 mg
9
aspirin buffered (cal carb-mag
carb-mag oxide)
9
ASPIRIN LOW DOSE
9
ASPIRIN/DIPYRIDAMOLE 128
ASSESS FULL RANGE PEAK
FLOW METER
138
ASSESS LOW RANGE PEAK
FLOW METER
138
ASSESS PEAK FLOW METER
FULL RANGE
138
ASSESS PEAK FLOW METER
LOW RANGE
138
ASTAGRAF XL
81
ASTHMA CHECK METER-ZONE
SYSTEM
138
ASTHMAMENTOR
138
ATACAND
52
ATACAND HCT
53
atenolol & chlorthalidone
53
atenolol 100 mg, 25 mg, 50
mg
83
ATIVAN 0.5 MG, 1 MG, 2
MG
21
ATIVAN 2 MG/ML
21
ATIVAN 4 MG/ML
21
ATOPICLAIR
108
atorvastatin calcium
49
atovaquone
18
atovaquone-proguanil hcl 250mg100mg
55
ATRIPLA
75
ATROVENT
156
ATROVENT HFA
23
AUBAGIO
170
AUGMENTIN 250MG/5ML62.5MG/5ML
167
AUGMENTIN 500MG-125MG,
875MG-125MG
167
AUGMENTIN ES-600
167
AUGMENTIN XR
167
AURSTAT ANTI-ITCH
HYDROGEL
108
AUVI-Q
180
AVALIDE
53
AVANDIA 2 MG
39
AVANDIA 4 MG
40
AVAPRO
52
AVASTIN
59
AVEED
14
AVEENO MOISTURIZING 110
AVEENO POSITIVELY
AGELESSDAILY EXFOLIATING
CLEANSER
110
AVEENO POSITIVELY
RADIANTCLEANSER
110
AVEENO SKIN RELIEF
SHOWER& BATH
101
AVEENO ULTRA-CALMING
CLEANSER
110
AVENOVA
110
AVENOVA/NEUTROX
110
AVODART
127
AVONEX
170
AVONEX PEN
170
AXSAIN
108
AYR NASAL DROPS
156
azacitidine
58
AZACTAM
16
AZATHIOPRINE 100 MG
81
azathioprine 100 mg, 50 mg, 75
mg
81
azelastine hcl (ophth)
163
azelastine hcl 0.1 %
156
AZILECT
69
azithromycin 100 mg/5ml, 200
mg/5ml
135
azithromycin 250 mg, 500 mg,
600 mg
135
azithromycin 500 mg
135
AZOPT
163
aztreonam
16
AZULFIDINE
125
AZULFIDINE EN-TABS
125
b complex w/ c 10.2mg10.2mg-10mg-10mg-50mg50mg-15mg-15mg-5mg-5mg300mg-300mg, 100mg-100mg25mg-20mg-6mg-15mcg100mg-5mcg-2mg-150mg,
100mg-100mg-5.5mg-20mg15mcg-25mg-400mcg-5mcg2mg-150mg, 100mg-10mg20mg-10mcg-15mg-5mg500mg, 100mg-20mg-5.5mg15mcg-2mg-25mg-150mg400mcg-5mcg-150mg, 10mg10mg-15mg-50mg-5mg-300mg,
15mg-10.2mg-10mg-50mg5mg-300mg, 15mg-10mg50mg-10.2mg-5mg-300mg,
15mg-10mg-50mg-10.2mg6mcg-400mcg-5mg-300mg,
15mg-10mg-50mg-10mg-5mg300mg, 15mg-150mg-10mg50mg-10.2mg-5mg-300mg,
15mg-20mg-50mg-10mg10mcg-5mg-300mg, 15mg50mg-10.2mg-10mg-5mg300mg, 50mg-10.2mg-10mg15mg-5mg-300mg, 50mg10mg-10mg-15mg-5mg-300mg,
50mg-15mg-10mg-10.2mg5mg-300mg
150
b complex w/ c 10.2mg-10mg15mg-50mg-5mg-300mg,
10mg-50mg-10.2mg-15mg5mg-300mg, 10mg-50mg10mg-15mg-5mg-300mg,
15mg-10mg-50mg-10mg-5mg300mg
150
B-1
182
B-100 COMPLEX
150
B-6 FOLIC ACID
130
b-complex vitamins 0.1mg20mg-2mg-5mcg-3mg-1mg,
100mg-50mg-40mg-10mg20mg-5mg-4.6mg-1mcg-5mg1mg, 10mg-10mg-2mg-1.5mg0.2mg, 10mg-14mg-25mcg7mg-4.5mg, 15mg-2mg-5mg2mcg-2mg-2mg, 30mg-50mg50mg-50mg-50mg-50mg50mcg-50mg-100mcg-50mcg50mg, 3mg-10mg-20mg-3mg6mcg-2mg, 3mg-20mg-3mg10mg-6mcg-2mg, 3mg-3mg20mg-20mg-3mg-3mg-10mg10mg-6mcg-6mcg-2mg-2mg,
83mg-3mg-20mg-2mg-5mcg1mg
149
b-complex vitamins 2mg/ml100mg/ml-2mg/ml-100mg/ml2mg/ml
149
b-complex vitamins 2mg/ml-2%100mg/ml-2mg/ml-100mg/ml2mg/ml
149
b-complex vitamins 60mg-60mg3mg-5mg-20mg-3mg-1mcg0.5mg, 60mg-60mg-5mg-20mg3mg-1mcg-3mg-0.5mg, 70mg100mg-1mg-10mg-2mg-1.5mg100mcg
149
b-complex w/ c & folic acid 10mg20mg-1.5mg-1mg-1.5mg-5mg300mcg-50mg-60mg, 20mg1.5mg-10mg-1mg-1.5mg-5mg300mcg-50mg-60mg
150
b-complex w/ folic acid 1.5mg20mg-1.7mg-6mcg-400mcg-2mg,
1.7mg-10mg-6mcg-1.2mg-20mg0.4mg-2mg, 100mg-100mg100mg-100mcg-400mcg-100mg,
100mg-100mg-100mg-100mg10mcg-400mcg-100mcg-100mg,
10mg-10mg-50mg-10mg-10mg10mg-10mcg-10mg-400mcg10mcg-10mg, 10mg-20mg1.7mg-6mcg-1.5mg-400mcg2mg, 15mg-100mg-200mg-17mg60mcg-400mcg-20mg, 30mg20mg-50mg-30mg-10mg-10mcg400mcg-8mg, 40mcg-1mg-6mg5mcg-3mg-2mcg-19mcg, 50mg50mg-50mg-50mcg-50mg400mcg-50mcg-50mg
150
b-complex w/ folic acid 100mg100mg-100mg-100mg-100mcg400mcg-100mcg-100mg, 125mg125mg-125mg-125mg-125mcg125mg-125mg-400mcg-125mcg125mg, 50mg-50mg-50mg-50mg50mcg-0.4mg-50mcg-50mg,
50mg-50mg-50mg-50mg-50mcg100mcg-50mcg-50mg
150
BABY ANBESOL
148
BABY DDROPS
181
BABY ORAJEL
148
BACIGUENT
97
bacitracin (topical)
97
bacitracin zinc
97
bacitracin-poly-neomycin-hc
163
bacitracin-polymyxin b
97
bacitracin-polymyxin b
(ophth)
161
baclofen 10 mg
155
Index 4
baclofen 20 mg
155
BACTRIM
17
BACTRIM DS
17
BACTROBAN
97
balsalazide disodium
125
BANZEL
27
BARACLUDE 0.05 MG/ML 78
BARACLUDE 0.5 MG, 1 MG 78
BASIS ALL CLEAR
110
BASIS COMBINATION
110
BASIS EXTRA DRY
110
BASIS NORMAL/DRY
110
BASIS SENSITIVE SKIN 110
bath products 40%-40%-40%40%, 5%-5%-5%
101
BD GLUCOSE
38
BELEODAQ
62
BELSOMRA 10 MG
132
BELSOMRA 15 MG
132
BELSOMRA 20 MG
132
BELSOMRA 5 MG
132
BELVIQ
1
BELVIQ XR
1
BENADRYL ALLERGY
46
BENADRYL ALLERGY
CHILDRENS 12.5 MG
46
BENADRYL ALLERGY
CHILDRENS 12.5 MG/5ML 46
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS
46
benazepril &
hydrochlorothiazide
53
benazepril hcl 10 mg, 20 mg, 40
mg, 5 mg
51
BENDEKA
56
BENLYSTA 120 MG
83
BENSULFOID
96
BENTYL 10 MG
174
BENTYL 20 MG
174
BENZACLIN
96
BENZACLIN WITH PUMP 96
BENZALKONIUM
CHLORIDE
74
BENZAMYCIN
96
BENZEDREX INHALER
156
benzocaine (dental) 20 % 148
benzocaine (dental) 7.5 % 148
benzocaine-resorcinol vaginal
2%-5%
179
Index 5
benzonatate 100 mg, 200
mg
93
benzoyl peroxide 5 %
96
benzoyl peroxideerythromycin
96
benzphetamine hcl 25 mg 1
benztropine mesylate 0.5 mg, 1
mg, 2 mg
67
benztropine mesylate 1
mg/ml
67
BERINERT
128
BETA CAROTENE 10000
UNIT
181
beta carotene 25000 unit 181
BETAGAN
161
betamethasone dipropionate
(topical)
102
betamethasone dipropionate
augmented
102
betamethasone sod phosphate
& acetate
91
betamethasone valerate 0.1
%
102
betamethasone valerate 0.12
%
102
BETAPACE
84
BETAPACE AF
84
BETASERON
170
betaxolol hcl
83
betaxolol hcl (ophth)
161
bethanechol chloride 10 mg, 25
mg, 5 mg, 50 mg
178
BETHKIS
3
bexarotene
65
BIAXIN
135
bicalutamide
60
BICILLIN C-R 300000UNIT/ML300000UNIT/ML
167
BICILLIN C-R
900000UNIT/2ML300000UNIT/2ML
167
BICILLIN L-A
167
BICNU
56
BIMATOPROST
165
BIOFLEXOR
107
biotin 300 mcg
182
biotin 5 mg, 5000 mcg, 800
mcg
182
BIOTIN 800 MCG
182
BIPHENOX
8
bisacodyl 10 mg
134
bisacodyl 5 mg
134
bismuth subsalicylate 262
mg
42
bismuth subsalicylate 262
mg/15ml, 525 mg/30ml, 527
mg/30ml
43
bismuth subsalicylate 525
mg/15ml
43
bisoprolol &
hydrochlorothiazide
53
bisoprolol fumarate
83
BIVIGAM
166
bleomycin sulfate
61
BLEPH-10
161
BLINCYTO
59
BLUE-EMU SUPER
STRENGTH
107
BODI WHIRL OIL
101
BODY WASH &
SHAMPOO
110
BONIVA 150 MG
119
BONIVA 3 MG/3ML
119
BOOSTRIX
174
boric acid in isopropyl
165
BOSULIF
62
BOTOX
157
BREATHERITE
138
BREATHERITE
COLLAPSIBLEADULT SPACER
W/MASK
138
BREATHERITE
COLLAPSIBLECHILD SPACER
W/MASK
138
BREATHERITE
COLLAPSIBLEINFANT SPACER
W/MASK
138
BREATHERITE
COLLAPSIBLESMALL CHILD
SPACER W/MASK
138
BREATHERITE
COLLAPSIBLESPACER W/
NEONATE MASK
138
BREATHERITE RIGID
SPACERW/MASK
138
BREATHERITE W/LARGE
MASK
138
BREATHERITE W/MEDIUM
MASK
138
BREATHERITE W/SMALL
MASK
138
BREO ELLIPTA 25MCG/INH100MCG/INH, 25MCG/INH200MCG/INH
24
BREVICON-28
89
BRILINTA
128
brimonidine tartrate
161
BRINTELLIX 10 MG
33
BRINTELLIX 20 MG
33
BRINTELLIX 5 MG
34
BRISDELLE
172
BRIVIACT 10 MG
27
BRIVIACT 10 MG/ML
27
BRIVIACT 100 MG
27
BRIVIACT 25 MG
27
BRIVIACT 50 MG
27
BRIVIACT 50 MG/5ML
27
BRIVIACT 75 MG
27
bromfenac sodium (ophth) 164
bromocriptine mesylate 2.5
mg
68
bromocriptine mesylate 5 mg68
brompheniramine & phenyleph
1mg/5ml-1mg/5ml-2.5mg/5ml2.5mg/5ml, 1mg/5ml2.5mg/5ml
93
brompheniramine &
pseudoeph
93
budesonide
91
budesonide (inhalation) 0.25
mg/2ml, 0.5 mg/2ml
23
budesonide (nasal)
156
BUFFERIN
9
BULL FROG QUIK GEL SPF
36
114
BULL FROG QUIK GEL SPF
50
114
BULL FROG QUIK GEL
SPORTSPF 36
114
BULL FROG QUIK GEL
SPORTSPRAY SPF 50
114
BULL FROG SPF 36
114
BULL FROG WATER ARMOR
SPORT QUIK GEL SPF 50 114
BULL FROG WATER ARMOR
SPORT QUIK SPRAY SPF
50
114
bumetanide 0.5 mg, 1 mg, 2
mg
118
BUMEX
118
BUPRENEX
14
buprenorphine hcl 0.3 mg/ml 14
buprenorphine hcl 2 mg
14
buprenorphine hcl 8 mg
14
buprenorphine hcl-naloxone hcl
dihydrate 2mg-0.5mg
14
buprenorphine hcl-naloxone hcl
dihydrate 8mg-2mg
14
bupropion hcl (smoking
deterrent)
171
bupropion hcl 100 mg
31
bupropion hcl 150 mg
32
bupropion hcl 200 mg
32
bupropion hcl 300 mg
32
bupropion hcl 75 mg
31
BURN SPRAY
108
buspirone hcl 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
20
BUSULFEX
56
butalbital-aspirin-caffeine
w/cod
13
BUTISOL SODIUM 30
MG
132
butorphanol tartrate 10
mg/ml
14
butorphanol tartrate 2
mg/ml
14
BYDUREON
39
BYDUREON PEN
39
BYETTA
39
cabergoline
122
CABOMETYX
62
CALAMINE
110
CALAMINE
PHENOLATED
110
CALAN
84
CALAN SR
84
CALCI-CHEW
144
CALCI-MIX
144
CALCIONATE
144
calcipotriene
100
calcitonin (salmon)
119
calcitriol 0.25 mcg, 0.5
mcg
121
calcitriol 1 mcg/ml
121
CALCIUM &
MAGNESIUM
144
calcium & phosphorus w/
vitamin d
144
calcium 600 mg
145
calcium acetate (phosphate
binder)
126
calcium ascorbate
182
calcium carbonate (antacid)
500 mg, 750 mg
16
calcium carbonate (antacid)
600 mg
16
calcium carbonate (antacid)
648 mg
16
calcium carbonate 1250 mg,
1500 mg, 500 mg, 600 mg,
600mg
144
calcium carbonate-cholecalciferol
500mg-100unit
144
calcium carbonate-cholecalciferol
500mg-200unit
144
calcium carbonate-cholecalciferol
600mg-500unit
144
calcium carbonate-vitamin d
125unit-250mg, 125unit-500mg,
250mg-125unit, 500mg125unit
144
calcium carbonate-vitamin d
200unit-500mg, 500mg-200unit,
500mg-500mg-200unit-200unit
144
calcium citrate 200 mg, 950
mg
144
CALCIUM CITRATE 250
MG
144
CALCIUM CITRATE
MALATE/VITAMIN D
144
calcium citrate-vitamin d 250mg200unit
144
calcium citrate-vitamin d 315mg200unit
144
calcium gluconate 10 %
144
CALCIUM GLUCONATE 500
MG
145
CALCIUM LACTATE 648
MG
145
CALCIUM LACTATE 750
MG
145
calcium polycarbophil
133
calcium w/ magnesium 500mg250mg
145
CALCIUM/VITAMIN D
145
CALICYLIC
108
CAMPATH
59
CAMPRAL
168
CAMPTOSAR 100 MG/5ML, 40
MG/2ML
67
CAMPTOSAR 300
MG/15ML
67
CANCIDAS 50 MG
44
CANCIDAS 70 MG
44
candesartan cilexetil
52
candesartan cilexetilhydrochlorothiazide
53
CAPASTAT SULFATE
56
CAPRELSA
62
captopril &
hydrochlorothiazide
53
captopril 100 mg, 12.5 mg, 25
mg, 50 mg
51
CARAC
100
CARAFATE 1 GM
176
Index 6
CARBAGLU
121
carbamazepine 100 mg
27
carbamazepine 100 mg, 200 mg,
300 mg
27
carbamazepine 100 mg, 200 mg,
400 mg
27
carbamazepine 100 mg/5ml 27
carbamazepine 200 mg
27
carbamide peroxide
148
carbamide peroxide (otic) 165
CARBATROL
27
carbidopa
67
carbidopa-levodopa
68
carbinoxamine maleate
46
carboplatin
56
CARDIZEM
84
CARDIZEM CD
84
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG 84
CARDURA
52
carisoprodol 350 mg
155
CARMOL
106
CARMOL 20
106
CARRAFOAM
110
carteolol hcl (ophth)
161
carvedilol 12.5 mg
83
carvedilol 25 mg
83
carvedilol 3.125 mg
83
carvedilol 6.25 mg
83
CASODEX
60
CATAFLAM
5
CATAPRES
52
CATAPRES-TTS-1
52
CATAPRES-TTS-2
52
CATAPRES-TTS-3
52
CAVILON NO STING
BARRIERFILM
110
CAYSTON
16
cefaclor 250 mg, 500 mg
87
cefadroxil 1 gm
87
cefadroxil 500 mg
87
cefadroxil 500 mg/5ml
87
cefazolin sodium 1 gm, 10 gm,
500 mg
87
cefdinir
88
CEFEPIME 2 GM/100ML
89
cefepime hcl
89
cefixime
88
Index 7
cefoxitin sodium 1 gm
87
cefoxitin sodium 10 gm
87
cefoxitin sodium 2 gm
87
cefpodoxime proxetil 100 mg,
200 mg
88
cefpodoxime proxetil 100
mg/5ml
88
cefprozil 250 mg, 500 mg 87
cefprozil 250 mg/5ml
87
ceftazidime 1 gm, 2 gm
88
ceftazidime 6 gm
88
CEFTIN 250 MG, 500 MG 88
ceftriaxone sodium 1 gm 88
ceftriaxone sodium 10 gm 88
ceftriaxone sodium 2 gm 88
ceftriaxone sodium 250 mg88
ceftriaxone sodium 500 mg88
cefuroxime axetil
88
cefuroxime sodium 1.5 gm 88
CELEBREX
5
celecoxib
5
CELESTONE-SOLUSPAN 91
CELEXA 10 MG
32
CELEXA 20 MG
32
CELEXA 40 MG
32
CELLCEPT 200 MG/ML 81
CELLCEPT 250 MG
81
CELLCEPT 500 MG
81
CELLCEPT
INTRAVENOUS
81
CELONTIN
31
CENTANY
98
CEO-TWO
134
cephalexin 125 mg/5ml, 250
mg/5ml
87
cephalexin 250 mg, 500 mg,
750 mg
87
CERALYTE 70 60MEQ/L70MEQ/L-20MEQ/L-30MEQ/L
145
CERASPORT 4MEQ/L18MEQ/L-20MEQ/L-6MEQ/L
145
CERASPORT EX1
145
CERDELGA
129
CEREBYX 100 MG
PE/2ML
30
CEREBYX 500 MG
PE/10ML
30
CEREFOLIN
117
CEREZYME
129
CERVARIX
178
CESAMET
44
CETAPHIL GENTLE
CLEANSING
110
cetirizine hcl 1 mg/ml
47
cetirizine-pseudoephedrine 93
cevimeline hcl
149
CHANTIX
172
CHANTIX CONTINUING
MONTHPAK
172
CHEK-STIX COMBO PAK
URINALYSIS CONTROL 115
CHEK-STIX CONTROL
115
CHEMSTRIP -10 WITH SG 115
CHEMSTRIP 10 MD
115
CHEMSTRIP 2 GP STRIPS115
CHEMSTRIP 2 LN STRIPS 115
CHEMSTRIP 5 OB
115
CHEMSTRIP 7
115
CHEMSTRIP 9 STRIPS
115
CHEMSTRIP UGK
115
CHEMSTRIP-K
115
CHEMSTRIP-MICRAL
116
chenodiol
124
CHERRY CONCENTRATE 168
CHERRY SYRUP
168
CHEW Q 100 MG
3
CHILDRENS MOTRIN JUNIOR
STRENGTH
5
CHILDRENS PLUS COLD 94
CHLOR-TRIMETON 2
MG/5ML
46
CHLOR-TRIMETON 4 MG 46
chloramphenicol sodium
succinate
18
chlordiazepoxide-amitriptyline
170
chlorhexidine gluconate (mouththroat)
149
chloroquine phosphate 250 mg,
500 mg
55
chlorothiazide 500 mg
118
chlorpheniramine &
phenylephrine 4mg-10mg
94
chlorpheniramine & pseudoeph
15mg/5ml-1mg/5ml
94
chlorpheniramine maleate 2
mg/5ml
46
chlorpheniramine maleate 4
mg
46
chlorpheniramine w/ codeine 94
chlorpromazine hcl 10 mg, 100
mg, 200 mg, 25 mg, 50 mg 72
chlorpromazine hcl 25 mg/ml 72
chlorpromazine hcl 50
mg/2ml
72
chlorthalidone 25 mg
118
chlorzoxazone
155
cholecalciferol 1000 unit, 2000
unit, 400 unit
181
cholecalciferol 1000 unit, 2000
unit, 400 unit, 5000 unit
181
cholecalciferol 400 unit/ml 181
cholecalciferol 400
unt/0.03ml
181
cholecalciferol 5000 unit, 50000
unit
181
cholestyramine 4 gm
48
cholestyramine 4 gm/dose 48
cholestyramine light
48
choline fenofibrate
49
chorionic gonadotropin
120
chromium 200 mcg
148
chromium picolinate 200
mcg
147
ciclopirox 0.77 %
98
ciclopirox 1 %
98
ciclopirox 8 %
98
ciclopirox olamine
98
cidofovir
78
cilostazol
128
CILOXAN
161
cimetidine 200 mg
175
cimetidine 300 mg, 400 mg, 800
mg
175
CIMZIA
125
CIMZIA STARTER KIT
125
CINQAIR
22
CINRYZE
128
CIPRO 250 MG, 500 MG 123
CIPRO I.V.-IN D5W
123
CIPRO XR
123
CIPRODEX
165
ciprofloxacin 400 mg/40ml 123
ciprofloxacin hcl (ophth)
162
ciprofloxacin hcl 100 mg, 250 mg,
500 mg, 750 mg
123
ciprofloxacin in d5w
200mg/100ml-5%
123
ciprofloxacin in d5w
400mg/200ml-5%
123
ciprofloxacin-ciprofloxacin
hcl
123
cisplatin 100 mg/100ml, 200
mg/200ml, 50 mg/50ml
56
citalopram hydrobromide 10
mg
32
citalopram hydrobromide 10
mg/5ml
32
citalopram hydrobromide 20
mg
32
citalopram hydrobromide 40
mg
33
CITRACAL/VITAMIN D 145
CITRUCEL FIBER
LAXATIVE
133
cladribine
58
CLARINEX 5 MG
47
clarithromycin 250 mg, 500
mg
136
clarithromycin 250
mg/5ml
136
clarithromycin 500 mg
136
CLARITIN 10 MG
47
CLEARASIL DAILY
CLEAR
96
clemastine fumarate 2.68
mg
47
CLEOCIN 150 MG, 300 MG, 75
MG
18
CLEOCIN 2 %
180
CLEOCIN IN D5W
18
CLEOCIN PHOSPHATE
300MG/50ML-5%,
600MG/50ML-5%,
900MG/50ML-5%
19
CLEOCIN PHOSPHATE 600
MG/4ML, 900 MG/6ML
18
CLEOCIN-T
96
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/ADULT
LARGE
139
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/MEDIUM
139
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/SMALL
139
CLIMARA
123
CLINDAGEL
96
clindamycin hcl 150 mg, 300
mg, 75 mg
19
clindamycin palmitate
hydrochloride
19
clindamycin phosphate
(topical)
96
clindamycin phosphate 150
mg/ml, 600 mg/4ml
19
clindamycin phosphate 150
mg/ml, 9000 mg/60ml
19
clindamycin phosphate 600
mg/4ml, 900 mg/6ml
19
clindamycin phosphate in
d5w
19
clindamycin phosphate
vaginal
180
clindamycin phosphate-benzoyl
peroxide
96
clindamycin phosphate-benzoyl
peroxide (refrigerate)
96
CLINISTIX
116
CLINITEST
116
CLINITEST REAGENT
116
clobetasol propionate
102
clobetasol propionate emollient
base
102
clobetasol propionate
emulsion
103
CLOBEX
103
CLOLAR
58
clomipramine hcl 25 mg, 50 mg,
75 mg
35
clonazepam 0.125 mg, 0.25 mg,
0.5 mg, 1 mg, 2 mg
26
clonazepam 0.5 mg
26
clonazepam 1 mg
26
clonazepam 2 mg
26
clonidine hcl (adhd)
2
clonidine hcl 0.1 mg, 0.2 mg, 0.3
mg
53
clonidine hcl 0.1 mg/24hr, 0.2
mg/24hr, 0.3 mg/24hr
52
clopidogrel bisulfate 300
mg
128
clopidogrel bisulfate 75 mg 128
clorazepate dipotassium
21
clotrimazole
148
clotrimazole (topical)
98
clotrimazole vaginal 1 %
180
clotrimazole w/
betamethasone
98
CLOVERINE SALVE
98
clozapine
71
CLOZAPINE ODT
71
CLOZARIL
71
COAL TAR
89
coal tar extract 1 %
115
COARTEM
55
Index 8
cod liver oil 10 minim, 110mg2664unit-1000mg-100mg200unit, 1250unit-130unit,
1250unit-133.33unit, 1250unit133unit, 1250unit-135unit,
200unit-4000unit, 20mg-35mg1250unit-45mg-133.333unit,
34mg-1250unit-415mg-32mg135unit, 50mg-110mg-250unit110mg-100unit-10unit, 52mg2500unit-600mg-52mg-270unit,
530mg-1250unit-130unit, 90mg37mg-415mg-36mg-1250unit135unit
153
COD LIVER OIL 4000UNIT/5ML400UNIT/5ML, 5000UNIT/5ML500UNIT/5ML
153
COD LIVER OIL FOR KIDS153
CODITUSSIN AC
94
coenzyme q10 (ubidecarenone)
10 mg, 150 mg, 60 mg
3
coenzyme q10 (ubidecarenone)
30 mg
3
COENZYME Q10 25 MG
3
COENZYME Q10 60 MG
3
COGENTIN
67
COLACE
135
COLACE CLEAR
135
COLAZAL
125
COLCHICINE
127
colchicine w/ probenecid 127
COLCRYS
127
COLESTID
48
COLESTID FLAVORED 5
GM
48
colestipol hcl
48
colistimethate sodium
16
COLY-MYCIN M
16
COLYTE-FLAVOR PACKS
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
133
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM
134
COMBISTIX
116
COMBIVENT RESPIMAT
24
COMBIVIR
75
COMETRIQ
62
COMPACT SPACE
CHAMBER/ANTI-STATIC 139
COMPACT SPACE
CHAMBER/ANTISTATIC/LARGE MASK
139
Index 9
COMPACT SPACE
CHAMBER/ANTISTATIC/MEDIUM MASK 139
COMPACT SPACE
CHAMBER/ANTISTATIC/SMALL MASK 139
COMPLERA
75
COMPLEX MSUD AMINO
ACID BAR
159
COMTAN
68
COMVAX
178
CONCERTA 27 MG, 36 MG 2
CONDOMS
136
CONDYLOX
107
CONTI CASTILE SOAP 110
CONTRAVE
1
COPAXONE 20 MG/ML 170
COPAXONE 40 MG/ML 170
COPEGUS
78
CORAL CALCIUM 500
MG
145
CORDARONE
22
COREG 12.5 MG
83
COREG 25 MG
83
COREG 3.125 MG
83
COREG 6.25 MG
83
COREG CR
83
CORGARD
84
CORLANOR 5 MG
87
CORLANOR 7.5 MG
87
CORTEF
91
CORTENEMA
15
cortisone acetate
91
CORZIDE
53
COSENTYX
100
COSENTYX SENSOREADY
PEN
100
COSMEGEN
61
COSOPT
161
COTELLIC
62
COUMADIN
25
COZAAR
52
CREON
117
CRESEMBA 186 MG
45
CRESEMBA 372 MG
45
CRESTOR
49
CRIXIVAN
75
cromolyn sodium
22
cromolyn sodium
(mastocytosis)
124
cromolyn sodium (ophth) 164
CUBICIN
18
CUBICIN RF
18
CUPRIMINE
80
CURE-ALL
108
CUTAR
115
CUTIVATE
103
CUVITRU
166
CVS COD LIVER OIL
153
CVS GLUCOSE 4 GM
38
CVS HDYROCORTISONE
ACETATE
103
CVS KETONE CARE
116
CVS NATURAL FIBER
SUPPLEMENT
133
CVS SALINE WOUND
WASH
111
cyanocobalamin 1000 mcg 129
cyanocobalamin 250 mcg 129
cyclobenzaprine hcl 10 mg, 5
mg
155
cyclopentolate hcl 1 %
161
CYCLOPHOSPHAMIDE 25 MG,
50 MG
57
CYCLOSET
39
cyclosporine 100 mg, 25 mg 81
cyclosporine 50 mg/ml
81
cyclosporine modified (for
microemulsion) 100 mg, 25 mg,
50 mg
81
CYKLOKAPRON
131
CYMBALTA
34
cyproheptadine hcl 2 mg/5ml 48
cyproheptadine hcl 4 mg
48
CYRAMZA
59
CYSTARAN
164
cytarabine
58
CYTOMEL
174
CYTOTEC
177
CYTOVENE
78
D-VI-SOL
181
D.H.E. 45
142
dacarbazine
65
DACOGEN
58
dakin's solution 0.25 %, 0.5
%
74
DAKLINZA
78
DALIRESP
23
danazol 100 mg, 200 mg, 50
mg
14
DANTRIUM
155
dantrolene sodium 100 mg, 25
mg, 50 mg
155
dapsone 100 mg, 25 mg
18
DAPTACEL
174
daptomycin
18
DARAPRIM
55
DARZALEX
59
daunorubicin hcl
62
DAYPRO
5
DDAVP
122
DEBROX
165
decitabine
58
DECON-A 2MG/5ML5MG/5ML
94
DEEP BLUE RELIEF
107
DELESTROGEN 10
MG/ML
123
DELESTROGEN 20 MG/ML, 40
MG/ML
123
DELZICOL
125
DEMADEX
118
demeclocycline hcl
173
DEMEROL 100 MG/ML, 50
MG/ML
9
DEMEROL 25 MG/ML
9
DEMSER
52
DENAVIR
101
DEPACON
31
DEPAKENE
31
DEPAKOTE
31
DEPAKOTE ER
31
DEPAKOTE SPRINKLES
31
DEPEN TITRATABS
80
DEPO-MEDROL 20 MG/ML 91
DEPO-MEDROL 40 MG/ML, 80
MG/ML
91
DEPO-PROVERA
60
DEPO-PROVERA
CONTRACEPTIVE
91
DERMA-SMOOTHE/FS
BODY
103
DERMA-SMOOTHE/FS
SCALP
103
DERMAGRAN
109
DERMAREST ROSACEA 109
DERMATOP
103
DERMAZINC BABY
101
DERMAZINC SCALP
101
DERMAZINC SPRAY
101
DERMOPLAST
108
DERMOPLAST PAIN
RELIEVINGSPRAY
108
DERMOTIC
165
DESCOVY
75
desipramine hcl 10 mg, 100
mg, 150 mg, 25 mg, 50 mg, 75
mg
35
desloratadine
47
desmopressin acetate 0.1 mg,
0.2 mg
122
desmopressin acetate 4
mcg/ml
122
desmopressin acetate
refrigerated
122
desmopressin acetate
spray
122
desmopressin acetate spray
refrigerated
122
DESOGEN
89
desogestrel & ethinyl
estradiol
89
desogestrel-ethinyl estradiol
(biphasic)
89
desonide
103
DESOWEN
103
desoximetasone 0.05 % 103
desoximetasone 0.25 % 103
DESOXYN
1
DESVENLAFAXINE ER 100
MG, 50 MG
34
DETROL
177
DETROL LA
177
DEX4 QUICK DISSOLVE
GLUCOSE
38
dexamethasone 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg
92
dexamethasone 0.5
mg/5ml
92
dexamethasone 1.5 mg
92
dexamethasone sodium
phosphate (ophth)
163
dexamethasone sodium
phosphate 10 mg/ml
92
dexamethasone sodium
phosphate 100 mg/10ml, 120
mg/30ml, 20 mg/5ml, 4
mg/ml
92
DEXATRIM MAX 1MG-5.5UNIT34MCG-72MG-75MG-0.35MG70MG-45MG-0.263MG-10MG1.8MG-3.5MG-0.3MG-3MCG70MCG-0.35MG-25MG-30MG
117
dexbrompheniramine &
pseudoephedrine
94
DEXEDRINE
1
DEXERYL
109
DEXILANT
176
dexmethylphenidate hcl 10 mg,
2.5 mg, 5 mg
2
dexmethylphenidate hcl 15
mg
2
dexrazoxane 250 mg, 500
mg
66
dextroamphetamine sulfate 10
mg, 15 mg, 5 mg
1
dextroamphetamine sulfate 10
mg, 5 mg
1
dextrose (diabetic use) 15
gm/38gm, 40 %
38
dextrose 10 %
157
dextrose 5 %
157
dextrose in lactated ringers 145
dextrose w/ sodium chloride
0.45%-2.5%, 0.45%-5%
145
dextrose w/ sodium chloride
0.9%-5%
145
DHS ZINC
101
DIABETA 1.25 MG
41
DIABETA 2.5 MG
41
DIABETA 5 MG
41
DIABETIDERM
CLEANSING
111
DIAMOX
117
DIASTAT ACUDIAL
26
DIASTAT PEDIATRIC
26
DIASTIX
116
diazepam 1 mg/ml
21
diazepam 10 mg, 2 mg, 5
mg
21
DIAZEPAM 10 MG, 2.5 MG, 20
MG
26
diazepam 5 mg/ml
21
DIBENZYLINE
52
diclofenac potassium
5
diclofenac sodium (actinic
keratoses)
100
diclofenac sodium (ophth) 164
diclofenac sodium (topical) 1
%
97
diclofenac sodium 100 mg
5
Index 10
diclofenac sodium 25 mg, 50 mg,
75 mg
5
diclofenac w/ misoprostol
5
dicloxacillin sodium
167
dicyclomine hcl 10 mg
174
dicyclomine hcl 20 mg
174
didanosine
75
diethylpropion hcl 25 mg
1
DIETHYLPROPION HCL 25
MG
1
diethylpropion hcl 75 mg
1
DIFFERIN 0.1 %
96
DIFICID
136
diflorasone diacetate
103
DIFLUCAN
45
diflunisal
9
DIGOXIN 0.05 MG/ML
85
digoxin 0.125 mg, 125 mcg 85
digoxin 0.25 mg, 250 mcg 85
dihydroergotamine mesylate 1
mg/ml
142
DILANTIN-125
30
DILAUDID 1 MG/ML
9
DILAUDID 2 MG
9
DILAUDID 2 MG/ML
9
DILAUDID 4 MG
9
DILAUDID 8 MG
9
DILAUDID-HP 10 MG/ML
9
diltiazem hcl 120 mg, 180 mg,
240 mg
85
diltiazem hcl 120 mg, 30 mg, 60
mg, 90 mg
85
diltiazem hcl 120 mg, 60 mg, 90
mg
85
diltiazem hcl coated beads 84
diltiazem hcl extended release
beads
85
DIMETAPP COLD & ALLERGY
1MG/5ML-2.5MG/5ML
94
dimethicone-zinc oxide-vitamin avitamin d
111
DIOVAN
52
DIOVAN HCT
53
DIPENTUM
125
diphenhydramine hcl
(topical)
100
diphenhydramine hcl 12.5
mg
47
diphenhydramine hcl 12.5
mg/5ml
47
Index 11
diphenhydramine hcl 12.5
mg/5ml, 25 mg/10ml, 50
mg/20ml
47
diphenhydramine hcl 25
mg
47
diphenhydramine hcl 50
mg/ml
47
diphenhydraminephenylephrine 12.5mg/5ml5mg/5ml
94
diphenhydraminephenylephrine 25mg-10mg 94
diphenhydraminephenylephrine-acetaminophen
12.5mg-12.5mg-325mg-325mg5mg-5mg, 12.5mg-325mg5mg
94
diphenhydraminephenylephrine-acetaminophen
12.5mg/5ml-160mg/5ml2.5mg/5ml
94
diphenhydraminepseudoephedrineacetaminophen
94
diphenoxylate w/ atropine 43
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
174
DIPROLENE
103
DIPROLENE AF
103
dipyridamole 25 mg, 50 mg, 75
mg
128
disopyramide phosphate 21
disulfiram 250 mg, 500
mg
169
DITROPAN XL
177
divalproex sodium
31
DIVIGEL
123
dobutamine hcl
181
DOCEFREZ
66
docetaxel 140 mg/7ml, 20
mg/ml, 80 mg/4ml
66
DOCETAXEL 160 MG/16ML,
20 MG/2ML, 200 MG/20ML, 80
MG/8ML
66
DOCETAXEL 20 MG/ML, 80
MG/4ML
66
docosahexaenoic acid 200
mg
158
docusate calcium
135
docusate sodium 100 mg 135
docusate sodium 100 mg, 250
mg, 50 mg
135
docusate sodium 150 mg/15ml,
50 mg/5ml
135
docusate sodium 60
mg/15ml
135
DOCUSOL KIDS
135
DOCUSOL MINI
135
DOCUSOL PLUS MINIENEMA
135
dofetilide
22
DOLOPHINE 10 MG
9
DOLOPHINE 5 MG
9
DOMEBORO
111
DOMETUSS-DMX
94
donepezil hydrochloride
169
dorzolamide hcl
164
dorzolamide hcl-timolol
maleate
161
DOVONEX
100
doxazosin mesylate
53
doxepin hcl 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
35
doxepin hcl 10 mg/ml
35
DOXIL
62
doxorubicin hcl 10 mg, 50
mg
62
doxorubicin hcl 2 mg/ml
62
doxorubicin hcl liposomal
62
doxycycline (monohydrate) 100
mg, 150 mg, 50 mg, 75 mg 173
doxycycline (monohydrate) 100
mg, 50 mg, 75 mg
173
doxycycline (monohydrate) 25
mg/5ml
173
doxycycline hyclate 100 mg 173
doxycycline hyclate 100 mg, 20
mg
173
doxycycline hyclate 100 mg, 50
mg
173
doxycycline hyclate 150 mg 173
DRISDOL
181
DRIXORAL
COLD/ALLERGY
94
dronabinol
44
drospirenone-ethinyl
estradiol
89
DROXIA
129
DUAC
97
DUETACT
36
DULCOLAX
134
DULCOLAX BOWEL PREP
KIT
134
DULERA
24
duloxetine hcl 20 mg, 30 mg, 60
mg
34
DUOPA
68
DURAGESIC 100 MCG/HR 9
DURAGESIC 12 MCG/HR
9
DURAGESIC 25 MCG/HR 10
DURAGESIC 50 MCG/HR 10
DURAGESIC 75 MCG/HR 10
DUREZOL
163
dutasteride
127
dutasteride-tamsulosin hcl 127
DYAZIDE
118
dyphylline-guaifenesin
23
E-Z SPACER
139
E-Z SPACER THE BODY
GUARDS PACK
139
EASIVENT
139
EASIVENT/MASK-LARGE 139
EASIVENT/MASK-MEDIUM
139
EASIVENT/MASK-SMALL 139
EC-NAPROSYN
5
econazole nitrate
98
ECOTRIN MAXIMUM
STRENGTH
9
ECOTRIN REGULAR
STRENGTH
9
ED CHLORPED
46
ED CHLORPED D
94
EDURANT
75
EFFEXOR XR 150 MG
34
EFFEXOR XR 37.5 MG
34
EFFEXOR XR 75 MG
34
EFFIENT
128
EFUDEX
100
EGRIFTA 2 MG
120
ELAVIL
35
ELDEPRYL
69
ELELYSO
129
ELESTAT
164
ELETONE
109
ELETONE TWINPACK
109
ELIDEL
107
ELIGARD
60
ELIQUIS
25
ELITEK
65
ELIXSURE FEVER/PAIN
8
ELLA
91
ELLENCE
62
ELOCON
104
ELOXATIN
57
ELTA CLEANSE FOAM 111
ELTA LITE TAR
115
ELTA TAR
115
EMCYT
60
EMEND 125 MG, 80 MG 44
EMEND 40 MG
44
EMLA
108
EMPLICITI
59
EMSAM
32
EMTRIVA
75
enalapril maleate &
hydrochlorothiazide
53
enalapril maleate 10 mg 51
enalapril maleate 2.5 mg 51
enalapril maleate 20 mg 51
enalapril maleate 5 mg
51
ENBREL
8
ENBREL SURECLICK
8
ENCARE
179
ENEMEEZ MINI
135
ENEMEEZ PLUS
135
ENFAMIL ENFALYTE
145
ENGERIX-B 10 MCG/0.5ML,
20 MCG/ML
178
enoxaparin sodium
25
entacapone
68
entecavir
78
ENTOCORT EC
92
ENTRE-HIST PSE
94
ENTRESTO
86
ENTSOL HYPERTONIC
NASAL IRRIGATION
MIST
156
ENTSOL NASAL SPRAY 156
ENTSOL NASAL WASH 156
ENTYVIO
125
ENUCLENE
164
ENVARSUS XR
81
EPHEDRINE HCL
24
epinastine hcl (ophth)
164
EPINEPHRINE 0.15
MG/0.15ML, 0.3
MG/0.3ML
180
EPIPEN 2-PAK
181
EPIPEN-JR 2-PAK
181
epirubicin hcl
62
EPIVIR 10 MG/ML
75
EPIVIR 150 MG, 300 MG
75
EPIVIR HBV 100 MG
79
EPIVIR HBV 5 MG/ML
79
eplerenone
54
EPOGEN
129
eprosartan mesylate
52
EPZICOM
75
EQ TRIACTING
COLD/ALLERGY
94
EQL CALCIUM/VITAMIN D 145
EQL CHILDRENS
MULTIVITAMINS
152
EQL DEODORANT BAR
SOAP
111
EQL MOISTURIZING BEAUTY
BAR
111
EQL MOISTURIZING BEAUTY
BAR/SENSITIVE SKIN
111
EQL NATURAL FIBER
133
EQUALACTIN
133
EQUETRO
69
ERAXIS 100 MG
44
ERBITUX
59
ergocalciferol 50000 unit 181
ergocalciferol 8000 unit/ml 181
ergoloid mesylates
171
ergotamine tartrate
142
ERIVEDGE
60
ERWINAZE
64
erythromycin (acne aid)
97
erythromycin (ophth)
162
erythromycin base 250 mg 136
erythromycin base 500 mg 136
erythromycin ethylsuccinate 400
mg
136
erythromycin lactobionate 136
erythromycin stearate
136
ESBRIET
172
escitalopram oxalate
33
esomeprazole magnesium 20
mg
176
esomeprazole magnesium 40
mg
176
esomeprazole sodium 40
mg
176
ESOMEPRAZOLE STRONTIUM
49.3 MG
176
estradiol & norethindrone
acetate
123
Index 12
estradiol 0.025 mg/24hr, 0.05
mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
123
estradiol 0.5 mg, 1 mg, 2
mg
123
estradiol vaginal 0.1 mg/gm 180
estradiol valerate 20 mg/ml, 40
mg/ml
123
estropipate 0.75 mg, 1.5
mg
123
ethambutol hcl 100 mg, 400
mg
56
ethosuximide 250 mg
31
ethosuximide 250 mg/5ml 31
ethynodiol diacet & eth
estrad
89
ETHYOL
66
etodolac 200 mg, 300 mg
6
etodolac 400 mg, 500 mg
6
etodolac 400 mg, 500 mg, 600
mg
6
ETOPOPHOS
66
etoposide 1 gm/50ml, 100
mg/5ml, 500 mg/25ml
66
EVAC
133
EVISTA
120
EVOCLIN
97
EVOMELA
57
EVOTAZ
75
EVOXAC
149
EX-LAX
134
EXELON 1.5 MG, 3 MG, 4.5 MG,
6 MG
169
EXELON 13.3 MG/24HR, 4.6
MG/24HR, 9.5 MG/24HR 169
exemestane
60
EXJADE
43
EXPECTA LIPIL
158
EXTAVIA
170
EXTINA
98
EYE STREAM
164
FABRAZYME 35 MG
121
famciclovir
80
famotidine 10 mg
175
famotidine 20 mg
175
famotidine 20 mg/2ml, 200
mg/20ml, 40 mg/4ml
175
famotidine 40 mg
175
famotidine 40 mg/5ml
175
FAMVIR
80
Index 13
FANAPT
70
FARESTON
60
FARYDAK
63
FASLODEX
60
fat emulsion 20 gm/100ml157
FAZACLO 100 MG, 25 MG71
FAZACLO 12.5 MG, 150 MG,
200 MG
71
felbamate
30
FELBATOL
30
FELDENE
6
felodipine
85
FEMARA
60
FEMCON FE
89
FEMINEASE
179
fenofibrate 145 mg, 160 mg, 48
mg, 54 mg
49
fenofibrate micronized 130
mg
49
fenofibrate micronized 134 mg,
200 mg, 67 mg
49
fenofibrate micronized 43
mg
49
fentanyl 100 mcg/hr
10
fentanyl 12 mcg/hr
10
fentanyl 25 mcg/hr
10
fentanyl 50 mcg/hr
10
fentanyl 75 mcg/hr
10
fentanyl citrate 1200 mcg, 1600
mcg, 400 mcg, 600 mcg, 800
mcg
10
fentanyl citrate 200 mcg 10
FER-IN-SOL
130
FERGON
130
FERRETTS
130
FERRIPROX 500 MG
43
ferrous fumarate 324 mg 130
FERROUS FUMARATE 90
MG
130
FERROUS GLUCONATE 225
MG
130
ferrous gluconate 240 mg, 27
mg
131
ferrous sulfate 15 mg/ml 131
ferrous sulfate 220
mg/5ml
131
FERROUS SULFATE 220
MG/5ML
131
FERROUS SULFATE 300
MG/5ML
131
FERROUS SULFATE 324
MG
131
ferrous sulfate 325 mg
131
ferrous sulfate 325 mg, 65
mg
131
ferrous sulfate 50 mg
131
ferrous sulfate dried 160
mg
131
FETZIMA 120 MG, 40 MG, 80
MG
34
FETZIMA 20 MG
34
FETZIMA TITRATION PACK34
FEVERALL INFANTS
8
FIBERCON
133
FINACEA
113
finasteride
127
FIORINAL/CODEINE #3
13
FIRAZYR
127
FIRMAGON
60
FLAGYL 250 MG
17
FLAGYL 375 MG
17
FLAGYL 500 MG
17
flavoxate hcl
178
FLEBOGAMMA DIF 10 % 166
flecainide acetate 100 mg 22
flecainide acetate 150 mg 22
flecainide acetate 50 mg
22
FLECTOR
97
FLEET BISACODYL
134
FLEET LIQUID GLYCERIN
SUPPOSITORIES
134
FLEXICHAMBER
139
FLOMAX
127
FLORICAL
146
FLOVENT DISKUS 100
MCG/BLIST
23
FLOVENT DISKUS 250
MCG/BLIST
23
FLOVENT DISKUS 50
MCG/BLIST
23
FLOVENT HFA 110 MCG/ACT,
220 MCG/ACT
24
FLOVENT HFA 44
MCG/ACT
24
FLOXIN OTIC
165
fluconazole 10 mg/ml, 40
mg/ml
45
fluconazole 100 mg, 150 mg, 200
mg, 50 mg
45
fluconazole in dextrose
45
fluconazole in nacl 200mg/100ml0.9%, 400mg/200ml-0.9% 45
flucytosine 500 mg
45
FLUDARA
58
fludarabine phosphate 50
mg
58
fludrocortisone acetate
93
FLUMADINE
80
flunisolide (nasal)
156
fluocinolone acetonide
(otic)
165
fluocinolone acetonide 0.01
%
104
fluocinolone acetonide 0.01 %,
0.025 %
104
fluocinolone acetonide 0.025
%
104
fluocinonide 0.05 %
104
fluocinonide emulsified
base
104
fluorometholone (ophth)
163
fluorouracil (topical)
100
FLUOROURACIL 0.5 %
100
fluorouracil 1 gm/20ml, 2.5
gm/50ml, 500 mg/10ml
58
fluoxetine hcl (PMDD) cap 10 mg,
20 mg
171
fluoxetine hcl 10 mg, 20 mg 33
fluoxetine hcl 10 mg, 20 mg, 40
mg
33
fluoxetine hcl 20 mg/5ml
33
fluoxetine hcl 90 mg
33
fluoxymesterone
14
fluphenazine decanoate
72
fluphenazine hcl 1 mg, 10 mg, 2.5
mg, 5 mg
72
fluphenazine hcl 2.5 mg/ml 72
fluphenazine hcl 5 mg/ml
72
flurbiprofen 100 mg, 50 mg
6
flurbiprofen sodium
164
flutamide
60
fluticasone propionate
(nasal)
156
fluticasone propionate 0.005
%
104
fluticasone propionate 0.05
%
104
fluvastatin sodium 20 mg, 40
mg
49
fluvoxamine maleate
33
FML LIQUIFILM
163
FOCALIN
2
FOCALIN XR 15 MG
2
FOLGARD RX
130
FOLIC + B12
130
folic acid 0.8 mg, 800
mcg
129
folic acid 1 mg
129
FOLIC ACID 20 MG
129
folic acid 400 mcg, 800
mcg
129
FOLIC ACID 5 MG
129
folic acid-pyridoxinecyanocobalamin
117
folic acid-vitamin b6-vitamin
b12
130
FOLOTYN
58
FOLTRATE
130
fondaparinux sodium
25
FORADIL AEROLIZER
24
FORFIVO XL
32
FORMULA 405 FACIAL &
BODYCLEANSING
111
FORMULA 405
MOISTURIZINGSOAP 111
FORTAMET 1000 MG
38
FORTAMET 500 MG
38
FORTAZ 1 GM, 2 GM
88
FORTAZ 6 GM
88
FORTEO
119
FORTICAL
119
FOSAMAX
119
fosinopril sodium
51
fosinopril sodium &
hydrochlorothiazide
53
fosphenytoin sodium 100 mg
pe/2ml
30
fosphenytoin sodium 500 mg
pe/10ml
30
FOSRENOL 1000 MG, 500
MG, 750 MG
126
FRAGMIN 10000 UNIT/ML,
12500 UNIT/0.5ML, 15000
UNIT/0.6ML, 18000
UNT/0.72ML, 2500
UNIT/0.2ML, 5000 UNIT/0.2ML,
7500 UNIT/0.3ML, 95000
UNIT/3.8ML
25
FRAGMIN 25000 UNIT/ML 26
FRESH'N FEMININE
DEODORANT
109
furosemide 10 mg/ml
118
furosemide 20 mg, 40 mg, 80
mg
118
FUSILEV
66
FUZEON
75
FYCOMPA 0.5 MG/ML
26
FYCOMPA 10 MG, 12 MG, 2
MG, 4 MG, 6 MG, 8 MG
26
gabapentin 100 mg, 300 mg, 400
mg
27
gabapentin 250 mg/5ml, 300
mg/6ml
27
gabapentin 600 mg, 800 mg 27
GABITRIL 12 MG, 16 MG
30
GABITRIL 2 MG, 4 MG
30
galantamine hydrobromide 169
GAMASTAN S/D
166
GAMMAGARD LIQUID
166
GAMMAKED
166
GAMUNEX-C
166
ganciclovir sodium
78
GARDASIL
179
GARDASIL 9
178
GAS-X EXTRA STRENGTH 125
MG
124
GASTROCROM
124
gatifloxacin (ophth)
162
GATTEX
126
gauze pads 2" X 2"
136
GAZYVA
59
gelatin 650 mg
80
GELONASAL
156
GELUSIL 200MG-25MG200MG
16
gemcitabine hcl
58
gemfibrozil
49
GEMZAR
58
GENOTROPIN 5 MG
120
GENOTROPIN MINIQUICK 0.4
MG
120
gentamicin in saline 0.9%1mg/ml
4
gentamicin sulfate (ophth) 162
gentamicin sulfate (topical) 98
gentamicin sulfate 40 mg/ml 4
GENTEAL MILD TO
MODERATE
160
GENTLE SKIN CLEANSER111
GENVOYA
75
GEODON 20 MG
69
GEODON 20 MG, 40 MG, 60
MG, 80 MG
69
GERISILK BATH OIL
101
GILENYA
170
GILOTRIF
63
glatiramer acetate
171
Index 14
GLEEVEC 100 MG, 400 MG 63
GLEEVEC 400 MG
63
GLEOSTINE
57
glimepiride 1 mg
41
glimepiride 2 mg
41
glimepiride 4 mg
42
glipizide 10 mg
42
glipizide 2.5 mg
42
glipizide 5 mg
42
glipizide-metformin hcl 2.5mg250mg
36
glipizide-metformin hcl 2.5mg500mg, 5mg-500mg
36
GLUCAGEN HYPOKIT
38
glucagon (rdna)
38
GLUCOPHAGE 1000 MG 38
GLUCOPHAGE 500 MG
38
GLUCOPHAGE 850 MG
38
GLUCOPHAGE XR 500 MG 38
GLUCOPHAGE XR 750 MG 38
glucosamine sulfate 500 mg 3
glucosamine-chondroitin 200mg250mg
3
GLUCOSE 4 GM
39
glucose 5 %
157
GLUCOSE NURSETTE
157
GLUCOTROL 10 MG
42
GLUCOTROL 5 MG
42
GLUCOTROL XL 10 MG
42
GLUCOTROL XL 2.5 MG
42
GLUCOTROL XL 5 MG
42
GLUCOVANCE 1.25MG250MG
36
GLUCOVANCE 2.5MG-500MG,
5MG-500MG
36
GLUTAMENT
159
GLUTOL
115
glyburide 1.25 mg
42
glyburide 2.5 mg
42
glyburide 5 mg
42
glyburide micronized 1.5 mg 42
glyburide micronized 3 mg 42
glyburide micronized 6 mg 42
glyburide-metformin 1.25mg250mg
37
glyburide-metformin 2.5mg500mg, 5mg-500mg
37
GLYCERIN 99 %, 99.5 %
89
GLYCERINE
89
Index 15
GLYCEROL FORMAL
89
glycopyrrolate 0.2 mg/ml 174
glycopyrrolate 1 mg
175
glycopyrrolate 2 mg
175
GLYNASE 1.5 MG
42
GLYNASE 3 MG
42
GLYNASE 6 MG
42
GLYSET
36
GNP CALAMINE
111
GNP CALAMINE
PHENOLATED
111
GNP GLUCOSE 4 GM
39
GNP QUICK DISSOLVE
GLUCOSE
39
GNP SALINE WOUND
WASH
111
GNP VITAMIN D-400
145
GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM
134
GRANDPAS BAKING SODA
SOAP
111
GRANDPAS INDIAN CORN
SOAP
111
GRANDPAS LOVE MY
LOOFAH SOAP
111
GRANDPAS OATMEAL
SOAP
111
GRANDPAS ORANGE
ESSENCE SOAP
111
GRANDPAS PATCHOULI
SOAP
111
GRANDPAS PINE TAR
SOAP
115
GRANDPAS SHEA BUTTER
SOAP
111
GRANDPAS WITCH HAZEL
SOAP
111
granisetron hcl 1 mg
43
GRANIX
129
GRIS-PEG
45
griseofulvin microsize
45
griseofulvin ultramicrosize 45
guaifenesin-codeine
100mg/5ml-10mg/5ml
94
guanfacine hcl
53
guanfacine hcl (adhd)
2
guanidine hcl
55
GYNE-LOTRIMIN
180
H.P. ACTHAR
120
HALAVEN
66
HALCION
132
HALDOL
71
HALDOL DECANOATE 100 71
HALDOL DECANOATE 50 71
halobetasol propionate
104
haloperidol
71
haloperidol decanoate 100
mg/ml, 50 mg/ml
71
haloperidol lactate
71
HARVONI
79
HAVRIX
179
HEAL AID PLUS
109
HEMA-COMBISTIX
116
HEMOCYTE
131
HEMOCYTE-F
130
HEPAMENT
159
heparin sodium (porcine)
26
HEPSERA
79
HERCEPTIN
59
HETLIOZ
133
HEXALEN
57
HIPREX
177
HIZENTRA
166
HM CALAMINE
111
HPR PLUS
109
HUMALOG
40
HUMALOG KWIKPEN
40
HUMALOG MIX 50/50
40
HUMALOG MIX 50/50
KWIKPEN
40
HUMALOG MIX 75/25
40
HUMALOG MIX 75/25
KWIKPEN
40
HUMATROPE
120
HUMATROPE COMBO
PACK
120
HUMIRA
4
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK 4
HUMIRA PEN
4
HUMIRA PEN-CROHNS
DISEASESTARTER
4
HUMIRA PEN-PSORIASIS
STARTER
4
HUMULIN 70/30
40
HUMULIN 70/30 KWIKPEN 40
HUMULIN N
40
HUMULIN N KWIKPEN
40
HUMULIN R
40
HUMULIN R U-500
(CONCENTRATED)
40
HUMULIN R U-500
KWIKPEN
40
HURRICAINE
148
HURRICAINE ONE
148
HYCAMTIN
67
hydralazine hcl 10 mg, 100 mg,
25 mg, 50 mg
54
HYDREA
65
hydrochlorothiazide 12.5
mg
118
hydrochlorothiazide 12.5 mg, 25
mg, 50 mg
118
HYDROCIL INSTANT
133
hydrocodone polistirexchlorpheniramine polistirex 94
hydrocodone w/
homatropine
93
hydrocodone-acetaminophen
10mg-300mg, 5mg-300mg,
7.5mg-300mg
13
hydrocodone-acetaminophen
10mg-325mg, 5mg-325mg,
7.5mg-325mg
13
hydrocodone-acetaminophen
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
13
hydrocodone-ibuprofen
13
hydrocortisone (intrarectal) 15
hydrocortisone (rectal)
15
hydrocortisone (topical) 0.5
%
104
hydrocortisone (topical) 1
%
104
hydrocortisone (topical) 2.5
%
104
hydrocortisone 10 mg, 20 mg, 5
mg
92
hydrocortisone acetate
(topical)
105
hydrocortisone butyrate
105
hydrocortisone butyrate
hydrophilic lipo base
105
hydrocortisone valerate
105
hydrocortisone w/acetic
acid
165
hydrocortisone-aloe vera 105
hydrogen peroxide (mouththroat)
149
hydrogen peroxide-benzyl
alcohol
149
hydromorphone hcl 1 mg/ml 10
hydromorphone hcl 10 mg/ml, 50
mg/5ml, 500 mg/50ml
10
hydromorphone hcl 2 mg
10
hydromorphone hcl 2
mg/ml
10
hydromorphone hcl 4 mg 10
hydromorphone hcl 8 mg 10
HYDROPEL
111
hydroxychloroquine sulfate 55
HYDROXYPROGESTERONE
CAPROATE
61
hydroxyurea
65
hydroxyzine hcl 10 mg, 25 mg,
50 mg
21
hydroxyzine hcl 10 mg/5ml 20
hydroxyzine hcl 50 mg/ml 20
hydroxyzine pamoate 25 mg,
50 mg
21
HYLATOPIC PLUS
109
hypromellose (ophth) 0.3 %, 3
mg/ml
160
HYQVIA
166
HYVEE ADVANCED ANTACID
MAXIMUM STRENGTH 16
HYZAAR
53
I.L.X. B-12
130
ibandronate sodium 150
mg
119
ibandronate sodium 3
mg/3ml
119
IBRANCE
63
ibuprofen 100 mg
6
ibuprofen 100 mg/5ml
6
ibuprofen 200 mg
6
ibuprofen 40 mg/ml, 50
mg/1.25ml
6
ibuprofen 400 mg
6
ibuprofen 600 mg
6
ibuprofen 800 mg
6
ICLUSIG
63
IDAMYCIN PFS
62
idarubicin hcl
62
IFEX 1 GM
57
IFEX 3 GM
57
ifosfamide 1 gm
57
ifosfamide 1 gm/20ml, 3
gm/60ml
57
IFOSFAMIDE 3 GM
57
ILARIS
5
ILEVRO
164
imatinib mesylate
63
IMBRUVICA
63
imipenem-cilastatin
18
imipramine hcl 10 mg, 25 mg, 50
mg
35
imipramine pamoate
35
imiquimod
107
IMITREX 100 MG
143
IMITREX 25 MG
143
IMITREX 50 MG
143
IMITREX 6 MG/0.5ML
142
IMITREX STATDOSE REFILL 4
MG/0.5ML
143
IMITREX STATDOSE REFILL 6
MG/0.5ML
143
IMITREX STATDOSE SYSTEM 4
MG/0.5ML
143
IMOVAX RABIES
(H.D.C.V.)
179
IMURAN
81
INCRELEX
120
indapamide
118
INDERAL LA
84
indomethacin 25 mg, 50 mg 6
indomethacin 75 mg
6
INFANRIX
174
INFANTS ADVIL
6
INFANTS SILAPAP
8
INLYTA
63
INOSITOL 500 MG
158
INSPIRACHAMBER/ANTISTATIC
VALVED/MOUTHPIECE 140
INSPIRACHAMBER/LARGE
140
INSPIRACHAMBER/SOOTHER
MASK/INSPIRAMASK/MEDIUM
140
INSPIRACHAMBER/SOOTHER
MASK/INSPIRAMASK/SMALL
140
INSPIREASE DRUG
DELIVERYSYSTEM
140
INSPRA
54
INSULIN SYRINGES AND PEN
NEEDLES
136
INTELENCE 100 MG, 200
MG
75
INTELENCE 25 MG
75
INTRON A
65
INTRON A W/DILUENT
65
INTUNIV
2
INVANZ
18
INVEGA 1.5 MG
70
INVEGA 3 MG
70
Index 16
INVEGA 6 MG
70
INVEGA 9 MG
70
INVEGA SUSTENNA
70
INVEGA TRINZA
70
INVIRASE
75
INVOKAMET 150MG-1000MG,
150MG-500MG, 50MG1000MG
37
INVOKAMET 50MG-500MG 37
INVOKANA
41
IODINE STRONG
146
IOPIDINE 0.5 %
161
IPOL INACTIVATED IPV 179
ipratropium bromide
23
ipratropium bromide (nasal) 156
ipratropium-albuterol
24
IPRIVASK
26
irbesartan
52
irbesartan-hydrochlorothiazide
54
IRESSA
63
irinotecan hcl
67
IRON 256 MG
131
IRON 28 MG
131
IRON CHEWS PEDIATRIC 131
iron combinations
130
irrigation solutions,
physiological
82
ISENTRESS 100 MG
75
ISENTRESS 25 MG
76
ISENTRESS 400 MG
76
isoniazid & rifampin
55
isoniazid 100 mg, 300 mg 56
ISOPTO CARPINE
161
ISOPTO TEARS
160
ISORDIL TITRADOSE 5 MG 20
isosorbide dinitrate
20
isosorbide mononitrate 10 mg, 20
mg
20
isosorbide mononitrate 120 mg,
30 mg, 60 mg
20
isotretinoin 10 mg, 20 mg, 30 mg,
40 mg
97
ISTODAX
63
ISTODAX (OVERFILL)
63
ITCH-X
108
itraconazole
45
ivermectin
16
IXEMPRA KIT
67
Index 17
IXIARO
179
JADENU
43
JAKAFI
63
JALYN
127
JANUMET
37
JANUMET XR 100MG1000MG
37
JANUMET XR 50MG-1000MG,
50MG-500MG
37
JANUVIA
39
JARDIANCE
41
JENTADUETO
37
JENTADUETO XR 2.5MG1000MG
37
JENTADUETO XR 5MG1000MG
37
JEVTANA
67
JOHNSONS BABY BAR 111
JOHNSONS BUDDIES EASYGRIP SUDZING
111
JUXTAPID 10 MG
50
JUXTAPID 20 MG
50
JUXTAPID 30 MG
50
JUXTAPID 40 MG
50
JUXTAPID 5 MG
50
JUXTAPID 60 MG
50
K-TAB 10 MEQ
147
K-TAB 8 MEQ
147
KADCYLA
59
KADIAN 10 MG
10
KADIAN 100 MG
10
KADIAN 20 MG, 30 MG, 50
MG, 60 MG, 80 MG
10
KALBITOR
128
KALETRA
76
KALYDECO
172
KANUMA
121
KAPVAY
2
KARAYA GUM
168
KAYEXALATE
82
KAZANO
37
KEFLEX
87
KENALOG-10
92
KENALOG-40
92
KEPIVANCE
65
KEPPRA
27
KEPPRA XR
27
KERALYT 6 %
107
KERLONE
83
KETO-DIASTIX
116
KETOCARE
116
ketoconazole
45
ketoconazole (topical)
98
KETONE TEST STRIPS
116
ketoprofen 50 mg, 75 mg
6
ketorolac tromethamine
(ophth)
164
ketorolac tromethamine 15
mg/ml, 30 mg/ml
6
ketorolac tromethamine 30
mg/ml, 60 mg/2ml
6
KETOSTIX
116
ketotifen fumarate (ophth) 164
KEYTRUDA
59
KHEDEZLA
34
KINERET
5
KITABIS PAK
4
KLARON
97
KLONOPIN 0.5 MG
26
KLONOPIN 1 MG
26
KLONOPIN 2 MG
26
KOMBIGLYZE XR 2.5MG1000MG
37
KOMBIGLYZE XR 5MG1000MG, 5MG-500MG
37
KONSYL 100 %
133
KONSYL 28.3 %, 60.3 % 133
KONSYL 60.3 %, 71.67 % 133
KONSYL-D
133
KORLYM
39
KUVAN
121
KYNAMRO
48
L-CARNITINE 250 MG
159
L-CITRULLINE
159
L-METHYL-MC
117
labetalol hcl 100 mg, 200 mg, 300
mg
83
LABSTIX
116
LAC-HYDRIN
106
lactated ringer's
145
LACTIC ACID
89
lactic acid (ammonium lactate) 12
%
106
lactic acid (ammonium lactate) 5
%
106
LACTIC ACID RACEMIC
89
lactulose
134
lactulose (encephalopathy) 125
LAMICTAL
28
LAMICTAL CHEWABLE
DISPERSIBLE
27
LAMICTAL XR
28
LAMICTAL XR 100 MG, 200 MG,
25 MG, 250 MG, 300 MG, 50
MG
28
LAMISIL 250 MG
45
LAMISIL AT
99
LAMISIL AT JOCK ITCH
99
lamivudine
76
lamivudine (hbv)
79
lamivudine-zidovudine
76
lamotrigine 100 mg, 150 mg, 200
mg, 25 mg
28
lamotrigine 100 mg, 200 mg, 25
mg, 250 mg, 300 mg, 50 mg 28
lamotrigine 25 mg, 5 mg
28
LANACANE
108
lanolin
168
lanolin (topical)
111
LANOLIN ANHYDROUS 168
LANOLIN ANHYDROUSGRX
168
LANOXIN 125 MCG
86
LANOXIN 187.5 MCG
86
LANOXIN 250 MCG
86
LANOXIN 62.5 MCG
86
lansoprazole 15 mg
176
lansoprazole 30 mg
176
LANTUS
40
LANTUS SOLOSTAR
40
LARTRUVO
59
LASIX
118
latanoprost
165
LATUDA 120 MG
69
LATUDA 20 MG
69
LATUDA 40 MG
69
LATUDA 60 MG
69
LATUDA 80 MG
70
LAZANDA 100 MCG/ACT 10
LAZANDA 300 MCG/ACT 10
LAZANDA 400 MCG/ACT 10
LEADER QUICK DISSOLVE
GLUCOSE
39
lecithin
158
LECITHIN
CONCENTRATE
158
leflunomide 10 mg, 20 mg
7
LEMTRADA
171
LENVIMA 10 MG DAILY
DOSE
63
LENVIMA 14 MG DAILY
DOSE
63
LENVIMA 18 MG DAILY
DOSE
63
LENVIMA 20 MG DAILY
DOSE
63
LENVIMA 24 MG DAILY
DOSE
63
LENVIMA 8 MG DAILY
DOSE
63
LESCOL
49
LETAIRIS
86
letrozole
61
leucovorin calcium 10 mg, 15
mg, 25 mg, 5 mg
66
leucovorin calcium 100 mg, 350
mg
66
leucovorin calcium 200 mg, 50
mg, 500 mg
66
LEUKERAN
57
LEUKINE
129
leuprolide acetate
61
levalbuterol hcl 0.31 mg/3ml,
0.63 mg/3ml, 1.25 mg/0.5ml,
1.25 mg/3ml
24
LEVAQUIN 25 MG/ML
124
LEVAQUIN 250 MG, 500 MG,
750 MG
124
LEVAQUIN 250MG/50ML-5%,
500MG/100ML-5%,
750MG/150ML-5%
124
LEVEMIR
41
LEVEMIR FLEXTOUCH 41
levetiracetam 100 mg/ml, 500
mg/5ml
28
levetiracetam 1000 mg, 250
mg, 500 mg, 750 mg
28
LEVETIRACETAM
1000MG/100ML750MG/100ML,
1500MG/100ML540MG/100ML, 500MG/100ML820MG/100ML
28
levetiracetam 500 mg, 750
mg
28
levetiracetam 500 mg/5ml 28
levobunolol hcl
161
levocarnitine (metabolic
modifiers) 330 mg
121
levocarnitine 250 mg
159
levocetirizine
dihydrochloride
47
levofloxacin (ophth)
162
levofloxacin 25 mg/ml
124
levofloxacin 250 mg, 500 mg, 750
mg
124
levofloxacin in d5w
124
LEVOLEUCOVORIN
66
levoleucovorin calcium
66
levonorgestrel & eth
estradiol
89
levonorgestrel (emergency oc)
0.75 mg
91
levonorgestrel (emergency oc)
1.5 mg
91
levonorgestrel-eth estradiol
(triphasic)
90
levonorgestrel-ethinyl estradiol
(91-day)
90
levothyroxine sodium 100 mcg,
112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg,
300 mcg, 50 mcg, 75 mcg, 88
mcg
174
LEXAPRO
33
LEXIVA
76
LEXUSS 210
94
lidocaine 5 %
108
lidocaine hcl (local anesth.) 1 %,
2%
135
lidocaine hcl (mouth-throat) 148
lidocaine hcl 0.5 %
108
lidocaine hcl 2 %
108
lidocaine hcl 4 %
108
lidocaine-prilocaine
108
LIDODERM
108
LINCOCIN
19
lincomycin hcl
19
lindane
114
linezolid 100 mg/5ml
19
linezolid 600 mg
19
linezolid 600 mg/300ml
19
linezolid in sodium chloride 19
liniments & rubs 0.01%-5%-10%,
1.2%-2.6%-4.7%, 10%-0.025%15%
107
liniments & rubs 0.25%, 8%2%
108
LINZESS
126
liothyronine sodium 25 mcg, 5
mcg, 50 mcg
174
LIPITOR
49
LIQ-10 50MG/5ML15UNIT/5ML
3
lisinopril &
hydrochlorothiazide
54
Index 18
lisinopril 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
51
LITEAIRE
140
lithium
69
lithium carbonate 150 mg, 300
mg, 600 mg
69
lithium carbonate 300 mg
69
lithium carbonate 300 mg, 450
mg
69
LITHIUM CARBONATE 600
MG
69
LITHOBID
69
LOBOB CONTACT LENS
WEARERS SOAP
112
LOCOID
105
LOCOID LIPOCREAM
105
LODOSYN
67
LOMOTIL
43
LONSURF
62
loperamide hcl 2 mg
43
LOPID
49
LOPRESSOR 100 MG, 50
MG
83
LOPRESSOR HCT
54
LOPROX 0.77 %
99
LOPROX SHAMPOO
99
loratadine 10 mg
47
lorazepam 0.5 mg, 1 mg, 2
mg
21
lorazepam 2 mg/ml
21
lorazepam 2 mg/ml, 20
mg/10ml
21
lorazepam 4 mg/ml
21
losartan potassium
52
losartan potassium &
hydrochlorothiazide
54
LOSEASONIQUE
90
LOTEMAX
163
LOTENSIN
51
LOTENSIN HCT
54
LOTREL
54
LOTRISONE
99
LOTRONEX
126
lovastatin
49
LOVAZA
48
LOVENOX
26
LOWILA
112
loxapine succinate
71
LUMIGAN
165
LUMIZYME
121
Index 19
LUPRON DEPOT
61
LUPRON DEPOT-PED 11.25
MG
120
LUPRON DEPOT-PED 11.25
MG, 15 MG, 7.5 MG
120
LUPRON DEPOT-PED 30
MG
121
lutein 6 mg
3
LUXIQ
105
LYCELLE
114
LYNPARZA
63
LYRICA 100 MG
28
LYRICA 150 MG
28
LYRICA 20 MG/ML
28
LYRICA 200 MG
28
LYRICA 225 MG
28
LYRICA 25 MG
28
LYRICA 300 MG
28
LYRICA 50 MG
28
LYRICA 75 MG
28
LYSODREN
61
LYSTEDA
131
M-M-R II
179
MAALOX
16
MACROBID
177
MACRODANTIN 100 MG, 50
MG
177
mafenide acetate
102
MAG-TAB SR
147
MAGINEX
147
MAGINEX DS
147
MAGNEBIND 200
145
magnesium 250 mg,
250mg
147
magnesium chloride 535 mg,
64 mg
147
MAGNESIUM CHLORIDE
HEXAHYDRATE
147
MAGNESIUM ELEMENTAL 30
MG
147
MAGNESIUM GLUCONATE
250 MG, 500 MG, 550
MG
147
magnesium hydroxide 311
mg
134
magnesium sulfate 50 % 147
MALARONE 250MG100MG
55
malathion
114
maprotiline hcl
32
MARINOL
44
MARPLAN
32
MARQIBO
67
MATULANE
65
MAVIK
51
MAXALT 10 MG
143
MAXALT 5 MG
143
MAXALT-MLT 10 MG
143
MAXALT-MLT 5 MG
143
MAXIPIME 1 GM, 2 GM
89
MAXITROL
163
MAXZIDE
118
MAXZIDE-25
118
MCT OIL
157
meclizine hcl 12.5 mg, 25
mg
44
meclizine hcl 25 mg
44
MEDI-LYTE
145
MEDIPLAST
107
MEDROL 16 MG, 32 MG, 4 MG,
8 MG
92
MEDROL 2 MG
92
MEDROL DOSEPAK
92
medroxyprogesterone acetate
(contraceptive)
91
medroxyprogesterone acetate 10
mg, 2.5 mg, 5 mg
168
mefenamic acid
6
mefloquine hcl
55
MEGACE ES
168
MEGACE ORAL
61
megestrol acetate
(appetite)
168
megestrol acetate 20 mg, 40
mg
61
megestrol acetate 40 mg/ml, 400
mg/10ml
61
MEIJER CALAMINE
112
MEKINIST
64
meloxicam 15 mg, 7.5 mg
6
melphalan hcl
57
memantine hcl 10 mg, 5 mg169
memantine hcl 2 mg/ml
169
MENACTRA
178
MENOMUNE-A/C/Y/W-135
178
menthol (topical analgesic) 5
%
97
MENVEO
178
meperidine hcl 100 mg/ml, 50
mg/ml
11
meperidine hcl 25 mg/ml
11
MEPHYTON
181
MEPRON
18
mercaptopurine
58
meropenem
18
MERREM
18
mesalamine
125
MESALAMINE DR
125
mesalamine w/ cleanser
125
mesna
66
MESNEX 100 MG/ML
66
MESNEX 400 MG
66
MESTINON 60 MG
55
MESTINON TIMESPAN
55
METADATE CD
2
METAFOLBIC
117
METAMUCIL 0.52 GM
133
METAMUCIL 48.57 %
133
METAMUCIL MULTIHEALTH
FIBER 55.46 %
133
METAMUCIL ORIGINAL
TEXTURE
133
METAMUCIL SMOOTH
TEXTUREFIBER SINGLES 133
metaxalone
155
metformin hcl 1000 mg
38
metformin hcl 500 mg
38
metformin hcl 750 mg
38
metformin hcl 850 mg
38
methadone hcl 10 mg
11
methadone hcl 10 mg/5ml 11
methadone hcl 10 mg/ml
11
methadone hcl 5 mg
11
methadone hcl 5 mg/5ml
11
METHADOSE
11
METHADOSE SUGARFREE
11
methamphetamine hcl
1
methazolamide 25 mg, 50
mg
117
methenamine hippurate
177
methimazole 10 mg, 5 mg 174
methocarbamol 500 mg, 750
mg
155
methotrexate sodium 1 gm 58
methotrexate sodium 1 gm/40ml,
100 mg/4ml, 200 mg/8ml, 250
mg/10ml, 50 mg/2ml
58
methotrexate sodium 10 mg, 15
mg, 2.5 mg, 5 mg, 7.5 mg
58
methoxsalen rapid
100
methscopolamine bromide 2.5
mg, 5 mg
175
methylcellulose (laxative) 2
gm/10.2gm, 2 gm/19gm 133
methylergonovine maleate 0.2
mg
165
methylphenidate hcl 10 mg, 20
mg, 30 mg, 40 mg, 50 mg, 60
mg
2
methylphenidate hcl 10 mg, 20
mg, 5 mg
2
methylphenidate hcl 20 mg, 27
mg, 36 mg
2
methylphenidate hcl 20 mg, 30
mg, 40 mg
2
methylphenidate hcl 27 mg, 36
mg
2
methylprednisolone 16 mg, 32
mg, 4 mg, 8 mg
92
methylprednisolone 4 mg 92
methylprednisolone acetate 40
mg/ml, 80 mg/ml
92
methylprednisolone sod
succ
92
metoclopramide hcl 10 mg, 5
mg
125
metoclopramide hcl 10
mg/10ml, 5 mg/5ml
125
metoclopramide hcl 5
mg/ml
125
metolazone
118
metoprolol &
hydrochlorothiazide
54
metoprolol succinate
83
metoprolol tartrate 100 mg, 25
mg, 50 mg
83
METOPROLOL TARTRATE
37.5 MG, 75 MG
83
METROCREAM
113
METROGEL
113
METROGEL-VAGINAL 180
METROLOTION
113
metronidazole (topical) 113
metronidazole 250 mg
17
metronidazole 375 mg
17
metronidazole 500 mg
17
metronidazole in nacl
17
metronidazole vaginal
180
MEVACOR
49
mexiletine hcl
22
MG217 MEDICATED
TAR
115
MG217 MEDICATED TAR
SHAMPOO
115
MIACALCIN 200 UNIT/ACT119
MIACALCIN 200 UNIT/ML 119
MICATIN
99
miconazole nitrate (topical) 99
miconazole nitrate vaginal 100
mg
180
MICRO-K
147
MICROCHAMBER
140
MICROLIFE DIGITAL PEAK
FLOW METER
140
MICROLIPID
158
MICROSPACER
140
MICROZIDE
119
midodrine hcl
181
MIDOL COMPLETE 500MG15MG-60MG
8
MIDOL MAXIMUM STRENGTH
MENSTRUAL
8
MIDOL MAXIMUM STRENGTH
MENSTRUAL FORMULA
8
miglitol
36
MILK OF MAGNESIA
CONCENTRATE
134
MINI WRIGHT AFS PEAK
FLOWMETER LOW
RANGE
140
MINI WRIGHT PEAK FLOW
METER
140
MINIPRESS
53
MINOCIN 100 MG, 50 MG, 75
MG
173
minocycline hcl 100 mg, 50
mg
173
minocycline hcl 100 mg, 50 mg,
75 mg
173
minoxidil 10 mg, 2.5 mg
54
MIRAPEX
68
mirtazapine
31
MIRVASO
113
misoprostol 100 mcg, 200
mcg
177
mitomycin 20 mg, 40 mg, 5
mg
62
mitoxantrone hcl
62
MOBIC 15 MG, 7.5 MG
6
modafinil
3
MODICON
90
moexipril hcl
51
moexipril-hydrochlorothiazide
54
MOISTURE CREAM
109
molindone hcl
72
Index 20
mometasone furoate
105
MONOCAL
146
MONODOX
173
montelukast sodium 10 mg 23
montelukast sodium 4 mg, 5
mg
23
morphine sulfate 0.5 mg/ml 11
morphine sulfate 1 mg/ml
11
morphine sulfate 10 mg
11
morphine sulfate 10 mg/5ml 11
morphine sulfate 100 mg
11
morphine sulfate 100 mg/5ml, 20
mg/ml
11
MORPHINE SULFATE 15
MG
11
morphine sulfate 15 mg
11
morphine sulfate 20 mg, 30 mg,
50 mg, 60 mg, 80 mg
11
morphine sulfate 20 mg/5ml 11
morphine sulfate 200 mg
12
MORPHINE SULFATE 30
MG
11
morphine sulfate 30 mg, 60
mg
12
MOSCO CALLUS/CORN
REMOVER
107
MOTRIN INFANTS
7
MOTRIN INFANTS DROPS 6
MOTRIN JUNIOR
STRENGTH
7
MOVANTIK
126
MOZOBIL
131
MS CONTIN 100 MG
12
MS CONTIN 15 MG
12
MS CONTIN 200 MG
12
MS CONTIN 30 MG, 60 MG 12
MTX SUPPORT
130
MULTAQ
22
MULTI PRENATAL
153
MULTI-DELYN/IRON
152
MULTISTIX
116
MULTISTIX 10 SG
116
MULTISTIX 5
116
MULTISTIX 7
116
MULTISTIX 8 SG
116
MULTISTIX 9
116
MULTISTIX 9 SG
116
MULTITRACE-4
148
mupirocin
98
mupirocin calcium (topical) 98
Index 21
MURO 128 2 %
164
MURO 128 5 %
164
MUSTARGEN
57
MYALEPT
121
MYAMBUTOL
56
MYCAMINE
44
MYCOBUTIN
56
mycophenolate mofetil
81
mycophenolate mofetil hcl 81
mycophenolate sodium
81
MYFORTIC
81
MYLANTA 200MG/5ML20MG/5ML-200MG/5ML 16
MYLANTA DOUBLESTRENGTH
16
MYLANTA GAS
124
MYLANTA GAS RELIEF
MAXIMUM STRENGTH 124
MYOZYME
121
MYRBETRIQ
178
MYSOLINE
28
nabumetone
7
nadolol &
bendroflumethiazide
54
nadolol 20 mg, 40 mg, 80
mg
84
nafcillin sodium 10 gm
167
nafcillin sodium 2 gm
168
naftifine hcl 2 %
99
NAFTIN 2 %
99
NAGLAZYME
121
nalbuphine hcl 10 mg/ml, 20
mg/ml
14
naloxone hcl 2 mg/2ml
43
naltrexone hcl
43
NAMENDA 10 MG, 5 MG 169
NAMENDA 10 MG/5ML 169
NAMENDA TITRATION
PAK
169
NAMENDA XR 14 MG
169
NAMENDA XR 21 MG
169
NAMENDA XR 28 MG
169
NAMENDA XR 7 MG
169
NAMENDA XR TITRATION
PACK
169
naphazoline w/ pheniramine
0.025%-0.3%
162
NAPHCON-A
162
NAPROSYN 250 MG, 375 MG,
500 MG
7
naproxen 250 mg, 375 mg, 500
mg
7
naproxen 375 mg, 500 mg
7
naproxen sodium 220 mg
7
naproxen sodium 275 mg, 550
mg
7
naratriptan hcl
143
NARDIL
32
NASAL DECONGESTANT 156
NASALGUARD
109
nateglinide
41
NATPARA
119
NATURE DE FRANCE ALGOLI
SOAP
112
NATURE DE FRANCE ARGILE
BLANCHE SOAP
112
NATURE DE FRANCE
ARGIMIEL SOAP
112
NAVELBINE
67
NEBUPENT
17
nefazodone hcl
34
NEO-SYNEPHRINE 0.25
%
157
NEO-SYNEPHRINE 0.5 % 157
NEO-SYNEPHRINE COLD &
SINUS MILD
157
NEO-SYNEPHRINE COLD &
SINUS REGULAR
157
NEOKE BCAA4
117
neomycin sulfate
4
neomycin-bacitracin znpolymyxin
162
neomycin-bacitracin-polymyxin w/
lidocaine
98
neomycin-polymydexameth
163
neomycin-polymyxin-gramicidin
162
neomycin-polymyxin-hc
(otic)
165
neomycin/polymyxin b gu 126
NEORAL 100 MG, 25 MG 81
NEOSALUS
109
NEOSALUS CP
109
NERVO B-12 SL
151
NESINA
39
NESSI SPACER/LARGE
MASK
140
NESSI
SPACER/MOUTHPIECE 140
NESSI SPACER/SMALL/MED
MASK
140
NEULASTA
129
NEULASTA ONPRO KIT 129
NEUMEGA
129
NEUPOGEN
129
NEUPRO
68
NEURONTIN
29
NEUTROGENA ACNE
CLEANSING SOAP
112
NEUTROGENA FACIAL SOAP
ORIGINAL FORMULA
112
NEUTROGENA NATURALS
FACE& BODY
112
NEVANAC
164
nevirapine 100 mg, 400 mg 76
nevirapine 200 mg
76
NEVIRAPINE 50 MG/5ML 76
NEW SKIN
109
NEXAFED SINUS PRESSURE
+PAIN
94
NEXAVAR
64
NEXIUM 10 MG, 2.5 MG, 20 MG,
40 MG, 5 MG
176
NEXIUM 20 MG
176
NEXIUM 40 MG
176
NEXIUM I.V.
176
niacin (antihyperlipidemic) 50
niacin 100 mg, 250 mg, 50 mg,
500 mg
182
niacin 250 mg, 500 mg
182
niacin 250 mg, 500 mg, 750
mg
182
NIACIN TR
182
niacinamide 100 mg
182
niacinamide 500 mg
182
NIASPAN
50
nicardipine hcl 20 mg, 30 mg 85
NICODERM CQ
172
NICORETTE
172
NICORETTE MINI
172
NICORETTE STARTER
KIT
172
nicotine
172
nicotine polacrilex 2 mg, 4
mg
172
NICOTINE TRANSDERMAL
SYSTEM
172
NICOTROL INHALER
172
NICOTROL NS
172
nifedipine 30 mg, 60 mg, 90
mg
85
NILANDRON
61
nilutamide
61
nimodipine 30 mg, 30mg 85
NINLARO
64
nisoldipine 17 mg, 34 mg, 8.5
mg
85
nit remover
114
NITRATEST PAPER
116
NITRO-DUR 0.1 MG/HR, 0.2
MG/HR, 0.4 MG/HR, 0.6
MG/HR
20
nitrofurantoin macrocrystal 100
mg, 50 mg
177
nitrofurantoin monohyd
macro
177
nitroglycerin 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6
mg/hr
20
nitroglycerin 0.3 mg, 0.4 mg,
0.6 mg
20
nitroglycerin 0.4 mg/spray 20
NITROGLYCERIN
LINGUAL
20
NITROLINGUAL
PUMPSPRAY
20
NITROMIST
20
NITROSTAT
20
NIVATOPIC PLUS
109
NIVEA MOISTURIZING BODY
WASH
112
NIVEA MOISTURIZING BODY
WASH 2 IN 1
112
NIVEA TOUCH OF
SMOOTHNESS
MOISTURIZING BODY
WASH
112
NIVEA VISAGE EYE
CONTOUR
114
NIVEA VISAGE GENTLE
CLEANSING
112
NIX CREME RINSE
114
nizatidine 150 mg, 300
mg
175
NIZORAL
99
NIZORAL A-D
99
NO-STING SKIN-PREP 112
NOBLE FORMULA 2 % 101
nonoxynol-9
180
NONYX
109
NOR-QD
91
NORDITROPIN FLEXPRO 10
MG/1.5ML, 5 MG/1.5ML 120
norelgestromin-ethinyl
estradiol
90
norethin acet & estrad-fe 75mg20mcg-1mg, 75mg-30mcg1.5mg
90
norethindrone & eth estradiol90
norethindrone & ethinyl estradiolfe 0.4mg-35mcg
90
norethindrone
(contraceptive)
91
norethindrone acet & eth estra
20mcg-1mg, 30mcg-1.5mg 90
norethindrone acetate
168
norethindrone-eth estradiol
(triphasic)
90
norgestimate-ethinyl
estradiol
90
norgestimate-ethinyl estradiol
(triphasic)
90
norgestrel & ethinyl estradiol 90
NORINYL 1+35
90
NORPACE
21
NORPRAMIN
35
NORTHERA 100 MG
181
NORTHERA 200 MG
181
NORTHERA 300 MG
181
nortriptyline hcl 10 mg, 25 mg, 50
mg, 75 mg
35
nortriptyline hcl 10 mg/5ml 36
NORVASC 10 MG
85
NORVASC 2.5 MG
85
NORVASC 5 MG
85
NORVIR
76
NORWEGIAN COD LIVER
OIL
153
NOVA MAX PLUS KETONE
TESTSTRIPS
116
NOXAFIL 100 MG
46
NOXAFIL 300 MG/16.7ML 46
NOXAFIL 40 MG/ML
46
NUCALA
22
NUEDEXTA
171
NULLO
80
NULOJIX
82
NULYTELY/FLAVOR
PACKS
134
NUPLAZID
70
NUTRATEAR
160
NUTROPIN AQ NUSPIN
20
120
NUTROPIN AQ PEN 20
MG/2ML
120
NUVARING
91
NYMALIZE
85
nystatin
45
nystatin (mouth-throat)
149
Index 22
nystatin (topical)
99
nystatin-triamcinolone
99
OC8
109
OCALIVA 10 MG
124
OCALIVA 5 MG
124
OCEAN NASAL SPRAY
156
OCTAGAM 10 GM/100ML, 2
GM/20ML, 20 GM/200ML, 5
GM/50ML
166
octreotide acetate 100 mcg/ml,
200 mcg/ml, 50 mcg/ml
122
OCUFEN
164
OCUFLOX
162
OCUSOFT HAND SOAP 112
OCUSOFT HYPOCHLOR 112
OCUSOFT LID SCRUB
FOAMING
112
OCUSOFT LID SCRUB
ORIGINAL
112
ODEFSEY
76
ODOMZO
60
OFEV
173
ofloxacin (ophth)
162
ofloxacin (otic)
165
OILATUM
112
olanzapine
72
olanzapine-fluoxetine hcl 170
olopatadine hcl (nasal)
156
OLUX
105
OLUX-E
105
OLYSIO
79
OMECLAMOX-PAK
177
omega-3 fatty acids 180mg120mg, 300mg, 300mg-160mg1000mg-100mg-5unit, 300mg772.5mg-90mg-180mg
158
omega-3 fatty acids 180mg500mg-120mg, 27mg-244mg500mg-89mg, 300mg-1000mg200mg, 300mg-200mg, 500 mg,
500mg, 500mg-270mg-135mg,
500mg-300mg-1000mg-200mg1unit, 500mg-320mg-130mg,
90mg-500mg-60mg
158
omega-3-acid ethyl esters 48
omeprazole 10 mg, 20 mg, 40
mg
176
omeprazole-sodium bicarbonate
20mg-1100mg
177
omeprazole-sodium bicarbonate
20mg-1680mg
177
Index 23
omeprazole-sodium
bicarbonate 40mg1100mg
177
OMNIFLEX DIAPHRAGM136
OMNIPRED
163
OMNITROPE 10 MG/1.5ML, 5
MG/1.5ML
120
ONCASPAR
65
ondansetron
44
ondansetron hcl 24 mg, 4 mg, 8
mg
44
ondansetron hcl 4 mg/2ml, 40
mg/20ml
43
ondansetron hcl 4 mg/5ml 44
ONE A DAY WOMENS
PRENATAL/DHA
153
ONFI
26
ONGLYZA
39
OPANA 10 MG
12
OPANA 5 MG
12
OPDIVO
59
OPSUMIT
86
OPTICHAMBER
ADVANTAGE
140
OPTICHAMBER
ADVANTAGE/LARGE
MASK
141
OPTICHAMBER
ADVANTAGE/MEDIUM FACE
MASK
141
OPTICHAMBER
ADVANTAGE/SMALL FACE
MASK
141
OPTICHAMBER
DIAMOND
141
OPTICHAMBER
DIAMOND/LARGEFACE
MASK
141
OPTICHAMBER
DIAMOND/MEDIUM FACE
MASK
141
OPTICHAMBER
DIAMOND/SMALLFACE
MASK
141
OPTICHAMBER FACE
MASK/LARGE
141
OPTICHAMBER FACE
MASK/MEDIUM
141
OPTICHAMBER FACE
MASK/SMALL
141
OPTIHALER
141
OPTIHALER MDI DRUG
DELIVERY SYSTEM
141
OPTIONS CONCEPTROL
VAGINAL
CONTRACEPTIVE
180
OPTIONS GYNOL II
VAGINALCONTRACEPTIVE
180
OPTIVAR
164
OPURITY B12/FOLIC
ACID
130
ORABASE
148
oral electrolytes 18.8meq/l42.4meq/l-33.2meq/l-4.8gm/l18.8gm/l, 20meq/1000ml45meq/1000ml-35meq/1000ml25gm/1000ml, 20meq/l-20meq/l45meq/l-45meq/l-35meq/l-25gm/l,
20meq/l-20meq/l-45meq/l45meq/l-35meq/l-35meq/l30meq/l-30meq/l-25gm/l-25gm/l,
20meq/l-20meq/l-45meq/l45meq/l-35meq/l-35meq/l30meq/l-30meq/l-5gm/l-20gm/l,
20meq/l-45meq/l-35meq/l-25gm/l,
20meq/l-45meq/l-35meq/l30meq/l-25gm/l, 20meq/l45meq/l-35meq/l-30meq/l-5gm/l20gm/l, 20meq/l-45meq/l35meq/l-30meq/l-5gm/l-25gm/l,
20meq/l-45meq/l-35meq/l-5gm/l20gm/l, 20meq/l-45meq/l35meq/l-7.8mg/l-25gm, 20meq/l45meq/l-35meq/l-7.8mg/l-25gm/l,
20meq/l-45meq/l-35meq/l7.8mg/l-25meq/l, 20meq/l45meq/l-45meq/l-35meq/l-5gm/l20gm/l, 35meq/l-45meq/l20meq/l-25gm/l, 35meq/l45meq/l-20meq/l-30meq/l-25gm/l,
35meq/l-45meq/l-20meq/l30meq/l-30gm/l, 35meq/l45meq/l-20meq/l-30meq/l-5gm/l20gm/l, 35meq/l-45meq/l20meq/l-5gm/l-20gm/l, 35meq/l45meq/l-20meq/l-7.5mg/l25meq/l, 35meq/l-45meq/l20meq/l-7.8mg/l-25gm/l, 35meq/l7.8mg/l-45meq/l-20meq/l-25gm/l,
65meq/l-75meq/l-20meq/l30meq/l-2
146
oral electrolytes 287mg-180mg15mg
146
ORAP
171
ORAPRED ODT
92
ORAZINC
148
ORBACTIV
17
ORENCIA
7
ORENCIA CLICKJECT
7
ORFADIN 10 MG, 2 MG, 20 MG,
5 MG
121
ORKAMBI
172
ORTHO EVRA
90
ORTHO MICRONOR
91
ORTHO TRI-CYCLEN
90
ORTHO-CEPT
90
ORTHO-CYCLEN
90
ORTHO-NOVUM 1/35
90
ORTHO-NOVUM 7/7/7
90
OSENI 12.5MG-15MG
37
OSENI 12.5MG-30MG
37
OSENI 12.5MG-45MG, 25MG15MG, 25MG-30MG, 25MG45MG
37
OTEZLA
7
OTREXUP
4
oxacillin sodium 10 gm
168
oxacillin sodium 2 gm
168
oxaliplatin
57
OXANDRIN
14
oxandrolone 10 mg, 2.5 mg 14
oxaprozin
7
oxazepam
21
oxcarbazepine
29
OXSORALEN ULTRA
100
oxybutynin chloride
177
oxycodone hcl 100 mg/5ml 12
oxycodone hcl 15 mg
12
oxycodone hcl 30 mg
12
oxycodone hcl 5 mg
12
oxycodone w/ acetaminophen
10mg-325mg, 2.5mg-325mg,
5mg-325mg, 7.5mg-325mg 13
oxycodone w/ acetaminophen
5mg/5ml-325mg/5ml
13
oxycodone-aspirin
13
oxymorphone hcl 10 mg
12
oxymorphone hcl 15 mg
12
oxymorphone hcl 5 mg
12
oxymorphone hcl 7.5 mg
12
oyster shell
145
P&S
101
paclitaxel 100 mg/16.7ml, 150
mg/25ml
67
paclitaxel 30 mg/5ml, 300
mg/50ml
67
paliperidone 1.5 mg
70
paliperidone 3 mg
70
paliperidone 6 mg
70
paliperidone 9 mg
70
PAMELOR
36
PAMINE
175
PAMINE FORTE
175
PANCREAZE 10000UNIT4200UNIT-17500UNIT,
25000UNIT-10500UNIT43750UNIT, 37000UNIT21000UNIT-61000UNIT,
40000UNIT-16800UNIT70000UNIT
117
PANCREAZE 6200UNIT2600UNIT-10850UNIT 117
PANRETIN
100
PANTHODERM
106
pantoprazole sodium 20 mg, 40
mg
176
pantoprazole sodium 40
mg
176
papaya 5mg-5mg-3mg-2mg20mg
81
PARAFON FORTE DSC 155
parenteral electrolytes
146
paricalcitol 1 mcg, 2 mcg, 4
mcg
121
PARLODEL
68
PARNATE
32
paromomycin sulfate
4
paroxetine hcl
33
PATADAY
164
PATANASE
156
PAXIL 10 MG, 20 MG, 30 MG,
40 MG
33
PAXIL 10 MG/5ML
33
PAXIL CR
33
PEAK AIR PEAK FLOW
METERADULT/PEDIATRIC
141
PEAK FLOW METER
141
ped multivitamins w/fl &
iron
152
PEDIALYTE 20MEQ/L45MEQ/L-35MEQ/L-30MEQ/L25GM/L, 20MEQ/L-45MEQ/L35MEQ/L-5GM/L-20GM/L
146
PEDIALYTE FREEZER
POPS
146
pediatric multiple vitamin w/
c
152
pediatric multiple vitamin w/
extra c & fa
152
pediatric multiple vitamins w/ iron
0.6mg/ml-10mg/ml-5unit/ml8mg/ml-1500unit/ml-400unit/ml0.5mg/ml-0.4mg/ml-35mg/ml
152
pediatric multiple vitamins w/ iron
1500unit/ml-10mg/ml-5unit/ml400unit/ml-8mg/ml-0.6mg/ml0.5mg/ml-0.4mg/ml-35mg/ml
152
pediatric multivitamins w/fl
0.25mg-15unit-1.2mg-2500unit4.5mcg-400unit-1.05mg-13.5mg1.05mg-0.3mg-60mg, 0.25mg15unit-400unit-2500unit-1.2mg4.5mcg-13.5mg-1.05mg-0.3mg1.05mg-60mg, 0.5mg-15unit1.2mg-2500unit-4.5mcg-400unit1.05mg-13.5mg-1.05mg-0.3mg60mg, 0.5mg-15unit-400unit2500unit-1.2mg-4.5mcg-13.5mg1.05mg-0.3mg-1.05mg-60mg,
0.5mg-2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg-0.3mg15unit-1.05mg-60mg, 15unit0.25mg-1.05mg-13.5mg-1.2mg2500unit-4.5mcg-400unit-0.3mg1.05mg-60mg, 15unit-0.25mg2500unit-13.5mg-1.2mg-4.5mcg400unit-1.05mg-0.3mg-1.05mg60mg, 15unit-0.5mg-1.05mg13.5mg-1.2mg-2500unit-4.5mcg400unit-0.3mg-1.05mg-60mg,
15unit-0.5mg-2500unit-13.5mg1.2mg-4.5mcg-400unit-1.05mg0.3mg-1.05mg-60mg, 15unit1mg-1.05mg-13.5mg-1.2mg2500unit-4.5mcg-400unit-0.3mg1.05mg-60mg, 15unit-1mg2500unit-13.5mg-1.2mg-4.5mcg400unit-1.05mg-0.3mg-1.05mg60mg, 1mg-15unit-1.2mg2500unit-4.5mcg-400unit1.05mg-13.5mg-1.05mg-0.3mg60mg, 1mg-15unit-400unit2500unit-1.2mg-4.5mcg-13.5mg1.05mg-0.3mg-1.05mg-60mg
151
Index 24
pediatric multivitamins w/fl
0.5mg/ml-5unit/ml-0.6mg/ml8mg/ml-1500unit/ml-2mcg/ml400unit/ml-0.5mg/ml-0.4mg/ml35mg/ml, 0.5mg/ml-5unit/ml8mg/ml-0.6mg/ml-1500unit/ml2mcg/ml-400unit/ml-0.5mg/ml0.4mg/ml-35mg/ml, 5unit/ml0.5mg/ml-8mg/ml-0.6mg/ml1500unit/ml-2mcg/ml-400unit/ml0.5mg/ml-0.4mg/ml-35mg/ml
152
pediatric vitamins acd w/
fluoride
152
pediatric vitamins adc
153
PEDVAX HIB
178
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate
134
peg 3350-potassium chloride-sod
bicarbonate-sod chloride 134
PEG-INTRON
79
PEG-INTRON REDIPEN
79
PEG-INTRON REDIPEN PAK
4
79
PEGANONE
30
PEGASYS
79
PEGASYS PROCLICK
79
PEGINTRON
79
penicillin g potassium 20 mu,
20000000 unit, 5000000
unit
167
penicillin v potassium 250 mg,
500 mg
167
penicillin v potassium 250
mg/5ml
167
PENLAC NAIL LACQUER 99
PENTAM 300
17
pentoxifylline
128
PEPCID
175
PEPCID AC
175
PEPTO BISMOL
43
PEPTO-BISMOL 262 MG
43
PEPTO-BISMOL 262
MG/15ML
43
PEPTO-BISMOL
INSTACOOL
43
PEPTO-BISMOL MAX
STRENGTH
43
PEPTO-BISMOL TO-GO
43
PERCODAN
13
PERIDEX
149
perindopril erbumine 2 mg 51
perindopril erbumine 4 mg 51
Index 25
perindopril erbumine 8 mg 51
PERJETA
59
permethrin 0.5 %
114
permethrin 1 %
114
permethrin 5 %
114
PEROXYL 1.5%-6%
149
perphenazine 16 mg, 2 mg, 4
mg, 8 mg
72
perphenazine-amitriptyline
170
PERSANTINE
128
PERSONAL BEST FULL
RANGE
142
PERSONAL BEST LOW
RANGE
142
PETROLATUM
106
phenazopyridine hcl 100 mg,
200 mg
127
phenelzine sulfate
32
phenobarbital 100 mg, 15 mg,
16.2 mg, 30 mg, 32.4 mg, 60
mg, 64.8 mg, 97.2 mg
132
phenobarbital 20 mg/5ml 132
phenoxybenzamine hcl
52
phentermine hcl
1
PHENYLADE AMINO
ACID
159
PHENYLADE AMINO ACID
BLEND
159
PHENYLADE MTE AMINO
ACIDBLEND
159
PHENYLADE PHEBLOC 160
PHENYLADE40 DRINK
MIX
160
phenyleph-promethazine w/
cod
95
phenylephrine hcl 0.25 % 157
phenylephrine w/ dm-gg
30mg/5ml-200mg/5ml10mg/5ml
95
phenylephrinechlorpheniramine-dm w/ apap
5mg/5ml-1mg/5ml-160mg/5ml2.5mg/5ml, 5mg/5ml-5mg/5ml1mg/5ml-1mg/5ml-160mg/5ml160mg/5ml-2.5mg/5ml2.5mg/5ml
95
phenylephrine-shark liver oilglycerin-petrolatum
15
phenytoin 125 mg/5ml
30
phenytoin 50 mg
30
phenytoin sodium
30
phenytoin sodium
extended
30
PHILLIPS MILK OF
MAGNESIA
134
PHILLIPS MILK OF MAGNESIA
CHEWABLE
134
PHILLIPS MILK OF MAGNESIA
CONCENTRATED
134
PHLEXY-10
160
PHOS-NAK POWDER
CONCENTRATE
147
PHOSLO
126
PHOSPHOLINE IODIDE 161
phytonadione 100 mcg
181
PICATO
100
PIKO 1 ELECTRONIC
142
pilocarpine hcl (oral)
149
pilocarpine hcl 1 %, 2 %, 4
%
161
pimozide
171
pindolol
84
pioglitazone hcl 15 mg
40
pioglitazone hcl 30 mg
40
pioglitazone hcl 45 mg
40
pioglitazone hcl-glimepiride 37
pioglitazone hcl-metformin
hcl
37
piperacillin sodium-tazobactam
sodium
167
piroxicam 10 mg, 20 mg
7
PLAN B ONE-STEP
91
PLAQUENIL
55
PLAVIX 300 MG
128
PLAVIX 75 MG
128
PLEGRIDY
171
PLEGRIDY STARTER
PACK
171
PLETAL
128
POCKET CHAMBER
142
POCKET PEAK FLOW
METER
142
POCKET SPACER
142
POCKETPEAK PEAK FLOW
METER LOW RANGE
142
POCKETPEAK PEAK FLOW
METER/UNIVERSAL
RANGE
142
POCKETPEAK PEAK FLOW
METER/UNIVERSAL RANGE 50720 LPM
142
podofilox
107
POLY-VI-FLOR
152
POLYCOSE
157
polyethylene glycol 3350 134
polymyxin b sulfate
19
polymyxin b-trimethoprim 162
polysaccharide iron complex 150
mg
131
POLYSPORIN
98
POLYTAR
115
POLYTRIM
162
polyvinyl alcohol
160
POMALYST
61
PONARIS
156
PONSTEL
7
PORTRAZZA
59
potassium chloride 10 %, 20
%
147
potassium chloride 10 meq, 20
meq, 8 meq
147
potassium chloride 10 meq, 8
meq
147
potassium chloride 2
meq/ml
147
POTASSIUM CHLORIDE
ER
147
potassium chloride in dextrose &
sodium chloride 0.45%-20meq/l5%
146
potassium chloride
microencapsulated crystals
cr
147
potassium citrate (alkalinizer)
1080 mg, 540 mg
126
POTASSIUM IODIDE
146
POTIGA 200 MG
29
POTIGA 300 MG
29
POTIGA 400 MG
29
POTIGA 50 MG
29
PRADAXA
26
PRALUENT 150 MG/ML
50
PRALUENT 75 MG/ML
50
pramipexole dihydrochloride
0.125 mg, 0.25 mg, 0.5 mg, 0.75
mg, 1 mg, 1.5 mg
68
pramoxine-camphor-zinc
acetate
108
PRANDIMET
37
PRANDIN 0.5 MG
41
PRANDIN 1 MG
41
PRANDIN 2 MG
41
PRAVACHOL
49
pravastatin sodium
49
prazosin hcl
53
PRE-FOLIC
130
PRECISION XTRA
116
PRECOSE
36
PRED FORTE
163
prednicarbate
105
prednisolone 15 mg/5ml 92
prednisolone 5 mg
93
prednisolone acetate
(ophth)
163
prednisolone sodium
phosphate 10 mg, 15 mg, 30
mg
92
prednisolone sodium
phosphate 15 mg/5ml, 5
mg/5ml, 6.7 mg/5ml
92
prednisone 1 mg, 10 mg, 2.5
mg, 20 mg, 5 mg, 50 mg 93
prednisone 10 mg, 5 mg 93
prednisone 5 mg/5ml
93
prednisone 5 mg/ml
93
PREMARIN 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25
MG
123
PREMARIN 0.625
MG/GM
180
PREMPHASE
123
PREMPRO
123
PRENATAL 11UNIT-263MG25MG-1.5MG-27MG4000UNIT-18MG-1.7MG4MCG-400UNIT-0.8MG2.6MG-100MG
153
PRENATAL FORMULA 35MG30UNIT-4000UNIT-200MG25MG-1.8MG-200MG-28MG20MG-1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG 153
PRENATAL LOW IRON 153
PRENATAL ONE DAILY 153
PRENATAL VITAMIN
153
PRESUN ULTRA/PARSOL 3%5%-7.5%-6%
114
PREVACID 15 MG
176
PREVACID 30 MG
176
PREVPAC
177
PREZCOBIX
76
PREZISTA
76
PRIFTIN
56
PRILOSEC 10 MG, 20 MG, 40
MG
176
primaquine phosphate
55
PRIMAQUINE
PHOSPHATE
55
PRIMAXIN IV
18
primidone 250 mg, 50 mg 29
PRINIVIL
51
PRISTIQ
34
PRIVIGEN
166
PROAIR HFA
24
PROAIR RESPICLICK
25
probenecid
127
PROCARDIA XL
85
prochlorperazine
73
prochlorperazine edisylate 73
prochlorperazine maleate 10 mg,
5 mg
73
PROCRIT 10000 UNIT/ML, 2000
UNIT/ML, 20000 UNIT/ML, 3000
UNIT/ML, 4000 UNIT/ML, 40000
UNIT/ML
130
PROCTOCORT 1 %
15
PROFERRIN ES
131
progesterone micronized 100 mg,
200 mg
168
PROGLYCEM
39
PROGRAF 0.5 MG, 1 MG, 5
MG
82
PROGRAF 5 MG/ML
82
PROLASTIN-C
172
PROLEUKIN
65
PROLIA
119
PROMACTA 12.5 MG
130
PROMACTA 25 MG
130
PROMACTA 50 MG
130
PROMACTA 75 MG
130
promethazine hcl 12.5 mg, 25
mg
47
promethazine hcl 12.5 mg, 25
mg, 50 mg
48
promethazine hcl 25 mg/ml, 50
mg/ml
47
promethazine hcl 6.25
mg/5ml
47
promethazine w/codeine
95
promethazine-dm
95
PROMETRIUM
168
PRONTO 0.33%-4%
114
propafenone hcl
22
proparacaine hcl
163
propranolol hcl 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
84
propranolol hcl 120 mg, 160 mg,
60 mg, 80 mg
84
PROPYLENE GLYCOL
168
propylthiouracil
174
PROQUAD
179
Index 26
PROSCAR
127
PROSHIELD FOAM & SPRAY
CLEANSER
112
PROTEINEX
160
PROTONIX 20 MG, 40 MG 176
PROTONIX 40 MG
176
PROTOPIC
107
protriptyline hcl
36
PROVENTIL HFA
25
PROVERA
168
PROVIGIL
3
PROZAC
33
PROZAC WEEKLY
33
PRUCLAIR
109
PRUMYX
109
pseudoephedrine hcl 15
mg/5ml
157
pseudoephedrine hcl 30 mg, 60
mg
157
pseudoephedrine-acetaminophen
95
pseudoephedrine-ibuprofen
100mg/5ml-15mg/5ml
95
psyllium 0.52 gm, 520 mg 133
psyllium 100 %, 48.57 %, 58.6 %,
95 %
133
psyllium 28.3 %, 30 %, 30.9 %,
33 %, 49 %, 68 %
133
PTS PANELS KETONE
TEST
116
PULMICORT 0.25 MG/2ML, 0.5
MG/2ML
24
PULMOZYME
172
PURINETHOL
58
PURIXAN
58
PX CALAMINE
112
pyrazinamide
56
pyrethrins-piperonyl butoxide
0.3%-0.33%-4%, 0.33%4%
114
pyrethrins-piperonyl butoxide
0.33%-4%
114
pyrethrins-piperonyl butoxide
0.33%-4%, 1.2%-0.3%-0.3%2.4%-3%
114
PYRIDIUM
127
pyridostigmine bromide 180
mg
55
pyridostigmine bromide 60
mg
55
pyridoxine hcl 100 mg, 25 mg, 50
mg
182
pyrithione zinc 0.25 %
101
Index 27
pyrithione zinc 2 %
101
QC CALAMINE
112
QC COD LIVER OIL
154
QSYMIA
1
QUALAQUIN
55
quetiapine fumarate 100 mg,
200 mg, 25 mg, 300 mg, 400
mg, 50 mg
72
QUFLORA PEDIATRIC
108MCG-1MG-15UNIT0.25MG-15MG-1200UNIT5MG-1.3MG-4MCG-400UNIT1.2MG-100MCG-1.5MG-60MG,
108MCG-1MG-15UNIT-0.5MG15MG-1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG,
108MCG-1MG-15UNIT-1MG15MG-1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG 152
QUFLORA PEDIATRIC
150MCG/ML-1MG/ML0.5MG/ML-12MG/ML1100UNIT/ML-2MG/ML1MG/ML-3MCG/ML400UNIT/ML-1MG/ML81MCG/ML-12UNIT/ML1MG/ML-45MG/ML
152
quinapril hcl
52
quinapril-hydrochlorothiazide
54
quinidine gluconate 324
mg
22
quinidine sulfate
22
quinine sulfate
55
QVAR
24
RA BEAUTY BAR
112
RA CALAMINE 6.971%6.971%
112
RA COD LIVER OIL
154
RA OYSTER SHELL
CALCIUM/VITAMIN D 250MG125UNIT
145
RA SALINE WOUND
WASH
112
RABAVERT
179
raloxifene hcl
120
ramipril
52
RANEXA
20
ranitidine hcl 15 mg/ml, 150
mg/10ml, 75 mg/5ml
175
ranitidine hcl 150 mg
175
ranitidine hcl 150 mg, 300
mg
175
ranitidine hcl 300 mg
175
ranitidine hcl 75 mg
175
RAPAMUNE 0.5 MG
82
RAPAMUNE 1 MG, 2 MG
82
RAPAMUNE 1 MG/ML
82
RASPBERRY SYRUP
168
RASUVO
5
RAVICTI
121
RAZADYNE
170
RAZADYNE ER
169
REBETOL 200 MG
79
REBIF
171
REBIF REBIDOSE
171
REBIF REBIDOSE
TITRATIONPACK
171
REBIF TITRATION PACK 171
RECLAST
119
RECOMBIVAX HB
179
RECTIV
15
REGENECARE HA
108
REGIMEX
1
REGLAN
125
REGRANEX
115
RELENZA DISKHALER
80
RELION KETONE
116
RELION KETONE TEST
STRIPS
116
RELISTOR 12 MG/0.6ML, 8
MG/0.4ML
126
REMERON
31
REMERON SOLTAB
31
REMICADE
125
REMODULIN
86
RENVELA 2.4 GM
126
RENVELA 800 MG
126
repaglinide 0.5 mg
41
repaglinide 1 mg
41
repaglinide 2 mg
41
repaglinide-metformin hcl
37
REPATHA
51
REPATHA PUSHTRONEX
SYSTEM
51
REPATHA SURECLICK
51
REQUIP
68
REQUIP XL
68
RESCRIPTOR
77
RESERPINE 0.1 MG
53
RESERPINE 0.25 MG
53
RESTASIS
162
RESTASIS MULTIDOSE 163
RESTORIL
132
RETIN-A
97
RETIN-A MICRO
97
RETIN-A MICRO PUMP 0.04 %,
0.1 %
97
RETROVIR
77
RETROVIR IV INFUSION 77
REVATIO 10 MG/12.5ML
86
REVATIO 20 MG
86
REVIA
43
REVLIMID
81
REXULTI 0.25 MG
74
REXULTI 0.5 MG
74
REXULTI 1 MG
74
REXULTI 2 MG
74
REXULTI 3 MG
74
REXULTI 4 MG
74
REYATAZ
77
REZAMID
97
RHINOCORT AQUA
156
ribavirin (hepatitis c)
79
riboflavin 100 mg, 25 mg 182
riboflavin 50 mg
182
RID
114
RIDAURA
5
rifabutin
56
RIFADIN
56
rifampin 150 mg, 300 mg
56
rifampin 600 mg
56
RIFATER
55
RIGHT STEP PRENATAL 153
RILUTEK
157
riluzole
157
rimantadine hydrochloride 80
RISACAL-D
145
RISPERDAL
71
RISPERDAL CONSTA 12.5
MG
70
RISPERDAL CONSTA 25
MG
71
RISPERDAL CONSTA 37.5
MG
71
RISPERDAL CONSTA 50
MG
71
RISPERDAL M-TAB
71
risperidone
71
RITALIN
3
RITALIN LA 20 MG, 30 MG, 40
MG
3
RITALIN LA 60 MG
3
RITEFLO
142
RITUXAN
60
rivastigmine
170
rivastigmine tartrate
170
rizatriptan benzoate 10
mg
143
rizatriptan benzoate 5 mg 143
ROBAXIN 500 MG
155
ROBAXIN-750
155
ROBINUL 0.2 MG/ML
175
ROBINUL 1 MG
175
ROBINUL FORTE
175
ROCALTROL
121
ROCEPHIN
88
ropinirole hydrochloride
69
rosuvastatin calcium
49
ROTARIX
179
ROTATEQ
179
ROWASA
125
ROXICODONE 15 MG
12
ROXICODONE 30 MG
12
ROXICODONE 5 MG
12
ROZEREM
133
RUCONEST
128
RYMED
95
RYTARY
69
RYTHMOL
22
RYTHMOL SR
22
SABRIL
30
SAFE WASH
112
SALAGEN
149
salicylic acid 6 %
107
saline
156
saline 0.65 %, 0.65%, 0.65%0.002%
156
SALINE WOUND WASH 112
SALJET
113
SALJET RINSE
113
SALTAIRE
156
SAMSCA
122
SANDIMMUNE 100 MG, 25
MG
82
SANDIMMUNE 100 MG/ML 82
SANDIMMUNE 50 MG/ML 82
SANDOSTATIN 100 MCG/ML,
200 MCG/ML, 50 MCG/ML 122
SANDOSTATIN LAR DEPOT 20
MG, 30 MG
122
SANTYL
107
SAPHRIS 10 MG
72
SAPHRIS 2.5 MG
72
SAPHRIS 5 MG
72
SAXENDA
1
SAYMAN LANOLIN
113
SAYMAN WITCH HAZEL 113
SEASONIQUE
90
SEBUDERM
109
SECTRAL
83
selegiline hcl
69
selenium 100 mcg
148
SELENIUM 40 MCG/ML
148
selenium 50 mcg
148
selenium sulfide 2.5 %
101
SELZENTRY
77
sennosides 15 mg
135
SENSIPAR
121
SEREVENT DISKUS
25
SEROQUEL
72
SEROSTIM 4 MG, 6 MG 120
sertraline hcl 100 mg, 25 mg, 50
mg
33
sertraline hcl 20 mg/ml
33
SHADE OIL FREE CLEAR
GELSPF 25
114
SHUR-SEAL
180
SIGNIFOR
122
SIGNIFOR LAR 20 MG
122
SIGNIFOR LAR 40 MG
122
SIGNIFOR LAR 60 MG
122
sildenafil citrate (pulmonary
hypertension)
86
SILENOR
132
SILVADENE
102
silver sulfadiazine
102
simethicone 125 mg
124
simethicone 125 mg,
125mg
124
SIMPONI
4
SIMPONI ARIA
4
SIMULECT
82
simvastatin 10 mg
50
Index 28
simvastatin 20 mg
50
simvastatin 40 mg
50
simvastatin 5 mg
50
simvastatin 80 mg
50
SINEMET
69
SINEMET CR
69
SINGULAIR 10 MG
23
SINGULAIR 4 MG, 5 MG
23
sirolimus
82
SIRTURO
56
SIVEXTRO
19
SKELAXIN
155
skin protectants, misc.
113
SLO-NIACIN
183
SM CALAMINE
113
SM CALAMINE
PHENOLATED
113
SM GLUCOSE 4 GM
39
SM IPECAC SYRUP
43
SM PAIN
RELIEF/MENTHOL
108
SM SKIN CLEANSER
GENTLE/SENSITIVE SKIN 113
sodium bicarbonate 8.4 % 144
sodium chloride (gu
irrigant)
126
sodium chloride (inhalant) 95
sodium chloride 0.45 %
147
sodium chloride 0.9 %
147
sodium chloride hypertonic 164
SODIUM CHLORIDE/SODIUM
BICARBONATE
89
SODIUM CITRATE
DIHYDRATE
89
sodium polystyrene
sulfonate
82
sodium polystyrene sulfonate 15
gm/60ml
82
SOLARAZE
100
SOLBAR PF LIQUID/GEL
SPF30
114
SOLTAMOX
61
SOLU-CORTEF 100 MG, 250
MG, 500 MG
93
SOLU-CORTEF 1000 MG 93
SOLU-MEDROL 1000 MG, 125
MG, 40 MG
93
SOLU-MEDROL 500 MG
93
SOLVIL
160
SOMA 350 MG
155
SOMATULINE DEPOT
122
Index 29
SOMAVERT
120
SONATA
132
SORIATANE
101
sotalol hcl
84
sotalol hcl (afib/afl)
84
Sotalol Hcl IV Soln
84
SOTYLIZE
84
SOVALDI
79
SPIRIVA HANDIHALER 23
SPIRIVA RESPIMAT 1.25
MCG/ACT, 2.5 MCG/ACT 23
SPIRIVA RESPIMAT 2.5
MCG/ACT
23
spironolactone &
hydrochlorothiazide
118
spironolactone 100 mg, 25 mg,
50 mg
118
SPORANOX 100 MG
46
SPORANOX PULSEPAK 46
SPRITAM 1000 MG
29
SPRITAM 250 MG
29
SPRITAM 500 MG
29
SPRITAM 750 MG
29
SPRYCEL
64
ST JOSEPH ADULT
9
ST JOSEPH ADULT
ANALGESICLOW DOSE BITE
SIZE
9
starch (topical)
15
STARLIX
41
stavudine
77
STELARA 45 MG/0.5ML, 90
MG/ML
101
STIOLTO RESPIMAT
25
STIVARGA
64
STRATTERA 10 MG
2
STRATTERA 100 MG
2
STRATTERA 18 MG
2
STRATTERA 25 MG
2
STRATTERA 40 MG
2
STRATTERA 60 MG
2
STRATTERA 80 MG
2
STRENSIQ
121
STRIBILD
77
STRIVERDI RESPIMAT 25
STROMECTOL
16
STYGIENE STERILE EYELID
CLEANSER
113
SUBSYS 100 MCG, 200
MCG
12
SUBSYS 1200 MCG
12
SUBSYS 1600 MCG, 400 MCG,
600 MCG, 800 MCG
12
sucralfate
176
SUDAFED
157
SUDAFED CHILDRENS
157
SUDAFED CONGESTION 157
SUDAFED NASAL
DECONGESTANT MAXIMUM
STRENGTH
157
SUDAFED PE CHILDRENS
NASAL DECONGESTANT 157
SUDAFED PE SEVERE COLD
MULTI-SYMPTOM
95
SULAR
85
sulfacetamide sodprednisolone
163
sulfacetamide sodium (acne) 97
sulfacetamide sodium
(ophth)
162
sulfadiazine
173
sulfamethoxazole-trimethoprim
17
SULFAMYLON 5 %
102
SULFAMYLON 85 MG/GM 102
sulfasalazine
125
SULFZIX 500MCG/0.25GM 117
sulindac 150 mg, 200 mg
7
sumatriptan succinate 100
mg
143
sumatriptan succinate 25
mg
143
sumatriptan succinate 4
mg/0.5ml
143
sumatriptan succinate 50
mg
143
sumatriptan succinate 6
mg/0.5ml
143
SUMMERS EVE DEODORANT
SPRAY
109
SUMMERS EVE DEODORANT
SPRAY ULTRA
109
SUMMERS EVE NIGHT-TIME
CLEANSING/SENSITIVE
SKIN
113
SUPER E
106
SUPER E DAY
106
SUPER E EYE
106
SUPER E NIGHT
106
SUPER-AMINO 1600
160
SUPRAX 400 MG
88
SUPRENZA 15 MG, 30 MG 1
SUPREP BOWEL PREP 134
SURMONTIL
36
SUSTIVA
77
SUTENT
64
SYLATRON
65
SYMBYAX
170
SYMLINPEN 120
36
SYMLINPEN 60
36
SYNAGIS 50 MG/0.5ML
166
SYNALAR
105
SYNAREL
121
SYNERCID
20
SYNJARDY 12.5MG-1000MG,
5MG-1000MG
38
SYNJARDY 12.5MG-500MG,
5MG-500MG
38
SYNRIBO
65
SYNTHROID
174
SYPRINE
80
TABLOID
59
tacrolimus (topical)
107
tacrolimus 0.5 mg, 1 mg, 5
mg
82
TAFINLAR
64
TAGRISSO
64
TALTZ
101
TAMIFLU
80
tamoxifen citrate 10 mg, 20
mg
61
tamsulosin hcl
127
TARCEVA
64
TARGRETIN 1 %
100
TARGRETIN 75 MG
65
TARSUM
115
TASIGNA
64
TASMAR
68
TAXOL
67
TAXOTERE
67
TAZORAC
101
TEARS AGAIN NIGHT &
DAY
160
TECENTRIQ
60
TECFIDERA
171
TECFIDERA STARTER
PACK
171
TECHNIVIE
79
TEFLARO 600 MG
89
TEGRETOL
29
TEGRETOL-XR 100 MG
29
TEGRETOL-XR 200 MG, 400
MG
29
TEKTURNA
54
TEKTURNA HCT
54
temazepam
132
TEMODAR
57
TEMOVATE
105
TEMOVATE E
106
TENEX
53
TENIVAC
174
TENORETIC 100
54
TENORETIC 50
54
TENORMIN
83
TERAZOL 3
180
TERAZOL 7
180
terazosin hcl
53
terbinafine hcl
45
terbinafine hcl (topical)
99
terbutaline sulfate 2.5 mg, 5
mg
25
terconazole vaginal
180
TERSASEPTIC GLYCERINE
CLEANSING
113
TESSALON PERLES
93
testosterone 1 %, 25 mg/2.5gm,
50 mg/5gm
15
TESTOSTERONE 1 %, 25
MG/2.5GM, 50 MG/5GM 15
testosterone cypionate
14
testosterone enanthate
14
TESTOSTERONE PUMP 15
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED 174
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
174
tetrabenazine
170
tetracycline hcl 250 mg, 500
mg
173
TETRIX
109
TGT LUBRICANT EYE
DROPS
161
THALOMID
81
theophylline 100 mg, 200 mg,
300 mg, 450 mg
25
theophylline 400 mg, 600
mg
25
THERACYS
65
THERAPLEX T
115
THERMOTABS
146
thiamine hcl 100 mg, 50
mg
183
thiamine hcl 250 mg
183
thiamine mononitrate
183
thioridazine hcl 10 mg, 100 mg,
25 mg, 50 mg
73
THIOTEPA
57
thiothixene
74
THYMOGLOBULIN
82
THYMOL
89
tiagabine hcl
30
TIAZAC
85
TICE BCG
65
ticlopidine hcl
128
TIGAN 100 MG/ML
44
TIGECYCLINE
18
TIKOSYN
22
timolol maleate (ophth)
161
TIMOPTIC
161
TIMOPTIC-XE
161
TINACTIN
99
TINACTIN JOCK ITCH
99
TINDAMAX
17
tinidazole 250 mg, 500 mg 17
tioconazole vaginal
180
TIVICAY
77
tizanidine hcl 2 mg
155
tizanidine hcl 4 mg
155
tizanidine hcl 6 mg
155
TOBI
4
TOBI PODHALER
4
TOBRADEX
163
tobramycin
4
tobramycin (ophth)
162
tobramycin sulfate 1.2 gm
4
tobramycin sulfate 1.2 gm/30ml,
40 mg/ml, 80 mg/2ml
4
tobramycindexamethasone
163
TOBREX
162
TOFRANIL-PM
36
tolazamide 250 mg
42
tolazamide 500 mg
42
tolbutamide
42
tolcapone
68
tolmetin sodium 200 mg
7
tolmetin sodium 400 mg
7
tolnaftate
99
tolterodine tartrate
178
Index 30
TOPAMAX
29
TOPAMAX SPRINKLE
29
TOPICLEAR
113
topiramate 100 mg, 200 mg, 25
mg, 50 mg
29
topiramate 15 mg, 25 mg
29
topotecan hcl 4 mg
67
TOPOTECAN HCL 4
MG/4ML
67
TOPROL XL
83
TORISEL
64
torsemide 10 mg, 100 mg, 20 mg,
5 mg
118
TOUJEO SOLOSTAR
41
trace minerals (cr-cu-mnzn)
148
TRACLEER
86
TRADJENTA
39
tramadol hcl 100 mg
12
tramadol hcl 200 mg
13
tramadol hcl 300 mg
13
tramadol hcl 50 mg
12
tramadol-acetaminophen
13
trandolapril
52
tranexamic acid 1000
mg/10ml
131
tranexamic acid 650 mg
131
TRANSDERM-SCOP
44
TRANXENE T
21
tranylcypromine sulfate
32
TRAVATAN Z
165
trazodone hcl 100 mg, 150 mg,
300 mg, 50 mg
34
TREANDA
57
TRECATOR
56
TRELSTAR
61
TRELSTAR MIXJECT
61
TRESIBA FLEXTOUCH 100
UNIT/ML
41
TRESIBA FLEXTOUCH 200
UNIT/ML
41
tretinoin (chemotherapy)
65
tretinoin 0.01 %, 0.025 %
97
tretinoin 0.025 %, 0.05 %, 0.1
%
97
tretinoin microsphere
97
TRI-VIT/FLUORIDE/IRON 152
triamcinolone acetonide
(mouth)
149
triamcinolone acetonide
(nasal)
156
Index 31
triamcinolone acetonide
(topical) 0.025 %, 0.1 % 106
triamcinolone acetonide
(topical) 0.025 %, 0.1 %, 0.5
%
106
TRIAMINIC COUGH & RUNNY
NOSE
47
TRIAMINO
160
triamterene &
hydrochlorothiazide
118
triazolam 0.125 mg, 0.25
mg
132
triclosan 0.3 %
74
TRICOR
49
TRIDESILON
106
trifluoperazine hcl
73
trifluridine
162
TRIGLIDE
49
trihexyphenidyl hcl
68
TRILEPTAL
29
TRILIPIX
49
trimethoprim
17
trimipramine maleate 100 mg,
25 mg, 50 mg
36
TRINATAL RX 1
153
TRINTELLIX 10 MG
34
TRINTELLIX 20 MG
34
TRINTELLIX 5 MG
34
triprolidine & pseudoephedrine
0.938mg/ml-10mg/ml
95
triprolidine & pseudoephedrine
2.5mg-2.5mg-60mg-60mg,
2.5mg-60mg
95
TRISENOX
65
TRIUMEQ
77
TRIZIVIR
77
trospium chloride
178
TRUSOPT
164
TRUVADA
77
TRUZONE PEAK FLOW
METER
142
TUDORZA PRESSAIR
23
TUMS
16
TUMS E-X 750
16
TUMS KIDS
16
TUMS LASTING
EFFECTS
16
TUMS SMOOTHIES
16
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
95
TWINRIX
179
TYBOST
77
TYGACIL
18
TYKERB
64
TYLENOL CHILDRENS
8
TYLENOL CHILDRENS PLUS
FLU
95
TYLENOL CHILDRENS PLUS
MULTI-SYMPTOM COLD 95
TYLENOL INFANTS
8
TYLENOL INFANTS
PAIN+FEVER
8
TYPHIM VI
178
tyrosine 500 mg
160
TYSABRI
171
TYVASO
86
TYVASO REFILL
86
TYVASO STARTER
86
TYZEKA
79
UCERIS 2 MG/ACT
15
ULCEREASE 1.5%-1.5%-0.6%1.5%
149
ULTRA DERM BATH OIL 101
ULTRA MAN
153
ULTRA MIDE 25
106
ULTRA WOMAN
153
ULTRACET
13
ULTRAM
13
ULTRAM ER 100 MG
13
ULTRAM ER 200 MG
13
ULTRAM ER 300 MG
13
ULTRAVATE
106
UNASYN 1GM-2GM
167
UNDELENIC TINCTURE 100
UNIFIBER
133
UNIVERSAL PH STRIPS 116
UNIVERSAL REMOVER
WIPES
113
UPTRAVI
86
urea 20 %
106
urea 25 %
106
URISTIX
117
URISTIX 4
116
URO-PREP PROTECTIVE
SKINWIPES
113
UROCIT-K 10
126
UROCIT-K 5
126
UROXATRAL
127
URSO 250
124
URSO FORTE
124
ursodiol 250 mg, 500 mg 124
ursodiol 300 mg
124
UVADEX
65
VAGISIL
179
VAGISTAT-1
180
valacyclovir hcl 1 gm, 1000 mg,
500 mg
80
VALCHLOR
100
VALCYTE 450 MG
78
valganciclovir hcl 450 mg
78
VALIUM
21
valproate sodium 100 mg/ml, 500
mg/5ml
31
valproate sodium 250
mg/5ml
31
valproic acid
31
valsartan
52
valsartan-hydrochlorothiazide
54
VALSTAR
62
VALTREX
80
VALVED HOLDING
CHAMBER
142
VANCOCIN HCL
17
vancomycin hcl 10 gm, 1000 mg,
5000 mg
17
vancomycin hcl 125 mg, 250
mg
17
vancomycin hcl 500 mg
17
VANCOMYCIN HCL IN
DEXTROSE
17
VANICREAM
113
VANTAS
61
VAQTA
179
VARIVAX
179
VARIZIG 125 UNIT/1.2ML 166
VARUBI
44
VASCEPA 0.5 GM
48
VASCEPA 1 GM
48
VASERETIC
54
VASOTEC 10 MG
52
VASOTEC 2.5 MG
52
VASOTEC 20 MG
52
VASOTEC 5 MG
52
VCF VAGINAL
CONTRACEPTIVE FILM 180
VCF VAGINAL
CONTRACEPTIVE FOAM 180
VECTIBIX
60
VELCADE
64
VELTASSA 16.8 GM
82
VELTASSA 25.2 GM
82
VELTASSA 8.4 GM
82
VENCLEXTA
60
VENCLEXTA STARTING
PACK
60
venlafaxine hcl 100 mg
35
venlafaxine hcl 150 mg
34
venlafaxine hcl 25 mg
35
venlafaxine hcl 37.5 mg
34
venlafaxine hcl 50 mg
35
venlafaxine hcl 75 mg
35
VENLAFAXINE HCL ER 35
VENTAVIS
86
verapamil hcl 100 mg, 120 mg,
180 mg, 200 mg, 240 mg, 300
mg, 360 mg
85
verapamil hcl 120 mg, 180 mg,
240 mg
85
verapamil hcl 120 mg, 40 mg,
80 mg
85
VERELAN
85
VERELAN PM
85
VERSACLOZ
72
VFEND
46
VFEND IV
46
VIBERZI
126
VIBRAMYCIN 100 MG 173
VIBRAMYCIN 25
MG/5ML
173
VICKS BABYRUB
108
VICOPROFEN
13
VICTOZA
39
VICTRELIS
79
VIDAZA
59
VIDEX EC
77
VIDEXPEDIATRIC
77
VIEKIRA PAK
79
VIGAMOX
162
VIIBRYD
34
VIIBRYD 10 MG, 20 MG, 40
MG
34
VIIBRYD STARTER PACK 34
VIMIZIM
122
VIMPAT 10 MG/ML
30
VIMPAT 100 MG, 150 MG, 200
MG, 50 MG
30
VIMPAT 200 MG/20ML
29
VINATE ONE
153
vinblastine sulfate
67
vincristine sulfate
67
vinorelbine tartrate
67
VIRACEPT
77
VIRAMUNE 200 MG
77
VIRAMUNE 50 MG/5ML
77
VIRAMUNE XR 100 MG
78
VIRAMUNE XR 400 MG
78
VIRAZOLE
80
VIREAD
78
VIROPTIC
162
VISTARIL
21
VISTIDE
78
VITALINE COQ10/VITAMIN E
100MG-300UNIT
3
vitamin a 10000 unit
181
VITAMIN A 10000UNIT1000UNIT
182
VITAMIN A 25000 UNIT
181
vitamin a 8000 unit
182
VITAMIN B12/FOLIC ACID 130
vitamin e (topical) 100 unit/5drop,
12000 unit, 20000 unit, 28000
unit, 28000 unit/29ml, 400 unit/ml,
4000 unit, 49000 unit/52ml,
933.333 unit/ml
107
vitamin e (topical) 1000 unit, 1500
unit/30gm, 30000 unit/60gm,
6000 unit
106
vitamin e 100 unit, 1000
unit
182
vitamin e 15 unit/0.3ml
182
vitamin e 400 unit/15ml
182
vitamins a & d 10000unit-400unit,
10000unit-5000unit, 1250unit133unit, 1250unit-135unit,
5000unit-400unit, 700unit400unit, 8000unit-400unit 154
Index 32
vitamins w/ lipotropics 10000unit10mg-18mg-100unit-225mcg10mg-150mg-100mg-30mg10mg-25mg-25mg-50mg-50mg10mg-50mg-50mg-200mcg400unit-50mg-400mcg-50mg250mg, 100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mg-100mcg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mg-100mcg-100mg-200mcg100mcg-100mg, 100mg111.3mg-0.33mg-1.7mg-1.7mcg0.33mg-111.3mg-3.3mg-0.33mg100mg, 100mg-43.33mg111.3mg-0.33mg-1.7mg-1.7mcg0.33mg-111.3mg-3.3mg-0.33mg100mg, 200mg-29mg-0.333mg1.666mg-3.33mg-111.333mg111.333mg-1mg-1.666mcg0.333mg-100mg, 200mg-29mg0.33mg-1.67mg-3.33mg111.33mg-111.33mg-1mg1.67mcg-0.33mg-100mg, 200mg29mg-0.34mg-1.67mg-3.34mg111mg-111mg-1mg-1.67mcg0.34mg-100mg, 20mg-50mg30mg-10mg-10mcg-30mg-8mg,
25mg-40mg-20mg-3.4mg-20mg12mcg-3mg-20mg-400mcg30mcg-4mg-150mg, 25mg-40mg20mg-3.4mg-20mg-12mcg-3mg20mg-400mg-30mcg-4mg,
266.667mg-29mg-0.333mg1.667mg-3.333mg-111.333mg111.333mg-1mg-1.667mcg-0.33
154
VITEKTA
78
VOGELXO
15
VOGELXO PUMP
15
VOLTAREN
97
VOLTAREN-XR
7
voriconazole 200 mg
46
voriconazole 200 mg, 50 mg 46
voriconazole 40 mg/ml
46
VORTEX VALVED HOLDING
CHAMBER
142
VOTRIENT
64
VPRIV
129
Index 33
VRAYLAR
70
VRAYLAR 1.5 MG
70
VRAYLAR 3 MG
70
VRAYLAR 4.5 MG
70
VRAYLAR 6 MG
70
WALGREENS GLUCOSE 4
GM
39
warfarin sodium
25
WATCHHALER
142
water for irrigation, sterile 82
WELCHOL
48
WELLBUTRIN 100 MG
32
WELLBUTRIN 75 MG
32
WELLBUTRIN SR 100 MG 32
WELLBUTRIN SR 150 MG 32
WELLBUTRIN SR 200 MG 32
WELLBUTRIN XL 150 MG 32
WELLBUTRIN XL 300 MG 32
WESTCORT
106
WFHC PH PAPER
117
WHEAT GERM
182
witch hazel-glycerin
113
WOUND WASH SALINE 113
XALATAN
165
XALKORI
64
XANAX
21
XANAX XR
21
XARELTO
25
XARELTO STARTER
PACK
25
XELJANZ
4
XENAZINE
170
XENICAL
2
XEOMIN
157
XERALUX
109
XGEVA
119
XIFAXAN
17
XIZFLUS
500MCG/0.25GM
117
XOLAIR
22
XOPENEX
25
XOPENEX
CONCENTRATE
25
XPHE MAXAMUM 153MG280MG-41MCG-1114UNIT29MCG-13MCG-0.9MG410MCG-4.5MG-569MG-7.4MG9.2UNIT-18.5MCG-65.5MCG592MG-280MG-350MG-2.9MG40MG-215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG246MCG-12.3MCG-0.8MG31MG, 153MG-280MG-41MCG29MCG-13MCG-0.9MG410MCG-4.5MG-569MG-7.4MG9.2UNIT-18.5MCG-65.5MCG592MG-280MG-350MG1114UNIT-2.9MG-40MG-215MG0.49MG-2.5MG-1.6MCG166UNIT-0.46MG-246MCG12.3MCG-0.8MG-31MG
160
XTANDI
61
XYLOCAINE 1 %, 2 %
135
XYLOCAINE 4 %
108
XYLOCAINE-MPF 1 %
135
XYREM
169
XYZAL
47
YASMIN 28
90
YAZ
90
YERVOY
60
YF-VAX
179
YODORA DEODORANT 109
YONDELIS
57
ZADITOR
164
zafirlukast
23
zaleplon
132
ZALTRAP
59
ZANAFLEX 2 MG
155
ZANAFLEX 4 MG
155
ZANAFLEX 6 MG
155
ZANOSAR
57
ZANTAC 150 MG
176
ZANTAC 300 MG
176
ZANTAC 75
175
ZARONTIN
31
ZAROXOLYN
119
ZARXIO
130
ZAVESCA
129
ZEBETA
83
ZEGERID 20MG-1100MG 177
ZEGERID 20MG-1680MG 177
ZEGERID 40MG-1100MG 177
ZELBORAF
64
ZEMAIRA
172
ZEMPLAR 1 MCG, 2 MCG 122
ZEPATIER
79
ZERIT
78
ZESTORETIC
54
ZESTRIL
52
ZETIA
50
ZIAC
54
ZIAGEN 20 MG/ML
78
ZIAGEN 300 MG
78
zidovudine
78
ZILACTIN
148
ZINACEF 1.5 GM
88
ZINC 10 MG
148
ZINC 15
148
zinc 25 mg
148
zinc 50 mg
148
zinc gluconate 50 mg
148
ZINC SULFATE 1 MG/ML, 5
MG/ML
148
ZINECARD
66
ziprasidone hcl
70
ZIRGAN
162
ZITHROMAX 100 MG/5ML, 200
MG/5ML
135
ZITHROMAX 250 MG, 500 MG,
600 MG
135
ZITHROMAX 500 MG
135
ZITHROMAX TRI-PAK
135
ZITHROMAX Z-PAK
135
ZOCOR 10 MG
50
ZOCOR 20 MG
50
ZOCOR 40 MG
50
ZOCOR 5 MG
50
ZOCOR 80 MG
50
ZOFRAN 4 MG, 8 MG
44
ZOFRAN 4 MG/5ML
44
ZOFRAN 40 MG/20ML
44
ZOFRAN ODT
44
ZOHYDRO ER 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 50
MG
13
ZOLADEX
61
zoledronic acid 4 mg
119
zoledronic acid 4 mg/5ml 119
zoledronic acid 5 mg/100ml 119
ZOLINZA
64
zolmitriptan 2.5 mg
143
zolmitriptan 5 mg
144
ZOLOFT
33
zolpidem tartrate 10 mg 132
zolpidem tartrate 12.5 mg 132
zolpidem tartrate 5 mg
132
zolpidem tartrate 6.25 mg 132
ZOMACTON 5 MG
120
ZOMETA 4 MG/5ML
119
ZOMIG 2.5 MG
144
ZOMIG 5 MG
144
ZOMIG ZMT 2.5 MG
144
ZOMIG ZMT 5 MG
144
ZONEGRAN
30
zonisamide
30
ZONTIVITY
128
ZORTRESS
82
ZOSTAVAX
179
ZOSYN 0.25GM-2GM,
0.375GM-3GM, 0.5GM-4GM,
4.5GM-36GM
167
ZOVIRAX 200 MG
80
ZOVIRAX 200 MG/5ML
80
ZOVIRAX 400 MG, 800
MG
80
ZOVIRAX 5 %
101
ZYBAN
172
ZYCLARA
107
ZYCLARA PUMP
107
ZYDELIG
64
ZYKADIA
64
ZYLOPRIM 100 MG
127
ZYLOPRIM 300 MG
127
ZYMAXID
162
ZYPREXA
72
ZYPREXA RELPREVV 210
MG
72
ZYPREXA ZYDIS
72
ZYRTEC-D
ALLERGY/CONGESTION 95
ZYTIGA
61
ZYVOX 100 MG/5ML
19
ZYVOX 200 MG/100ML
19
ZYVOX 600 MG
19
ZYVOX 600 MG/300ML
19
Index 34
Esta lista de medicamentos fue actualizada el Si
tiene preguntas, llame a Health Net
12/1/2016.
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