1441 Main Street
1441 Main Street
Suite 900
Suite 900
Columbia, SC 29201
Columbia, SC 29201
1-855-735-4398
1-855-735-4398
TTY: 711
TTY: 711
2017
2017
http://mmp.absolutetotalcare.com
http://mmp.absolutetotalcare.com
FOR MORE INFORMATION,
FOR MORE INFORMATION,
contact Member Services at
contact Member Services at
1-855-735-4398 from 8 a.m. to 8 p.m.,
1-855-735-4398 from 8 a.m. to 8 p.m.,
Monday through Friday. TTY users call 711.
Monday through Friday. TTY users call 711.
After hours, on weekends and on holidays,
After hours, on weekends and on holidays,
you may be asked to leave a message.
you may be asked to leave a message.
Your call will be returned within the next
Your call will be returned within the next
business day.
business day.
http://mmp.absolutetotalcare.com
http://mmp.absolutetotalcare.com
<XXXXXXXXX>, Version Number <X>
00017411, Version 5
[Updated] [No changes made since] mm/yyyy
Updated 08/23/2016
© 2017 Absolute Total Care, Inc. All rights reserved.
© 2017 Absolute Total Care, Inc. All rights reserved.
FORMULARY
(LIST
OF
COVERED
DRUGS)
�
FORMULARY
(LIST
OF
COVERED
DRUGS)
Absolute Total Care (MMP)
Absolute Total Care (MMP)
Note to existing members:
This formulary has changed since last year. Please review this
Note to existing
document
to makemembers:
sure that it still contains the drugs you take.
This formulary has changed since last year. Please review this
PLEASE
READ:
THIS sure
DOCUMENT
CONTAINS
ABOUT
document
to make
that it still
containsINFORMATION
the drugs you take.
THE DRUGS WE COVER IN THIS PLAN.
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGSVersion
WE COVER
00017411,
11 IN THIS PLAN.
<XXXXXXXXX>,
Version <X>
Updated
06/01/2017.
For more recent information or other
questions, please contact Absolute Total Care Member Services
[Updated]
[No changes
made Member
since] <mm/yyyy>.
For more
recent
at
1-855-735-4398,
TTY:711.
Service hours
are from
8
information
or other
questions,
contact Absolute Total
a.m.
to 8 p.m.,
Monday
throughplease
Friday.
Care Member Services at 1-855-735-4398, TTY:711. Member Service
After
on weekends
on holidays,
you mayFriday.
be asked
hourshours,
are from
<8 a.m. to 8and
p.m.,
Monday through
to leave a message. Your call will be returned within the next
After hours,
business
day.on weekends and on holidays, you may be asked
to leave a message. Your call will be returned within the next
Or
visit http://mmp.absolutetotalcare.com
business
day.>
H1723_LOD17_Approved_09072016
Or visit http://mmp.absolutetotalcare.com
H1723_LOD17
H1723_LOD17_Approved_09072016
Absolute Total Care (ATC) | 2017 List of Covered Drugs
(Formulary)
This is a list of drugs that members can get in Absolute Total Care (ATC).
 Absolute Total Care (ATC) is a health plan that contracts with both Medicare and South
Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees.
 The List of Covered Drugs and/or pharmacy and provider networks may change
throughout the year. We will send you a notice before we make a change that affects you.
 Benefits may change on January 1 of each year. You can always check ATC’s up-to-date
List of Covered Drugs online at http://mmp.absolutetotalcare.com.
 Limitations and restrictions may apply. For more information, call ATC Member Services or
read the ATC Member Handbook.
 You can get this information for free in other languages. Please call our customer service
number at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After
hours, on weekends and on federal holidays, you may be asked to leave a message. Your
call will be returned within the next business day. TTY users call 711. The call is free.
 Usted puede obtener esta información gratuitamente en otros idiomas. Llame al 1-866­
896-1844. El horario de atención es de 8 a.m. a 8 p.m., de lunes a viernes. Luego del
horario de atención, los fines de semana y los días feriado, es posible que se le pida que
deje un mensaje. Le devolveremos la llamada el próximo día hábil. Los usuarios de TTY
deben llamar al 711. La llamada es gratuita.
 You can get this information for free in other formats, such as large print, braille, or audio.
Call 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After
hours, on weekends and on federal holidays, you may be asked to leave a message. Your
call will be returned within the next business day. TTY users call 711. The call is free.
 If you would like this information in a format other than English or in an alternate format,
please call 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After
hours, on weekends and on federal holidays, you may be asked to leave a message. Your
call will be returned within the next business day. TTY users call 711. You can also email
[email protected].
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8
a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. The call is free. For more information, visit http://mmp.absolutetotalcare.com.
1
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 11 are the drugs covered by ATC.
These drugs are available at pharmacies within our network. A pharmacy is in our network if
we have an agreement with them to work with us and provide you services. We refer to these
pharmacies as “network pharmacies.”
→ ATC will cover all medically necessary drugs on the Drug List if:
 your doctor or other prescriber says you need them to get better or stay healthy, and
 you fill the prescription at an ATC network pharmacy.
 ATC may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website listed at the bottom of
the page or by calling Member Services at the number at the bottom of the page.
2. Does the Drug List ever change?
Yes. ATC may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
 a cheaper drug comes along that works as well as a drug on the Drug List now, or
 we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
 Decide to require or not require prior approval for a drug. (Prior approval is permission from
ATC before you can get a drug.)
 Add or change the amount of a drug you can get (called “quantity limits”).
 Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
2
(For more information on these drug rules, see page 4.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
 You can always check ATC’s up to date Drug List on our website listed at the bottom of the
page. You can also call Member Services to check the current Drug List at the number at the
bottom of the page.
3. What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the
Drug List is made.
We will mail you a notice if you are taking a drug and we change our rules for covering it. You will
receive the notice by mail at least 60 days before we change the drug rules or remove the drug
from our Drug List. For example, if you are taking a drug, and we add prior authorization
(approval), quantity limits, and/or step therapy, the notice you receive will explain the new rules.
For more information on these drug rules, see page 4. If you have questions about the notice you
receive from ATC, call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m.,
Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to
leave a message. Your call will be returned within the next business day. TTY users call 711.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. If you have any
questions after being notified of the change, you should contact the doctor who prescribed the
drug for you.
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
3
5. Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you or your doctor or other prescriber must do something before you can get the drug. For
example:
 Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from ATC before you fill your prescription. If you don’t get
approval, ATC may not cover the drug.
 Quantity limits: Sometimes ATC limits the amount of a drug you can get.
 Step therapy: Sometimes ATC requires you to do step therapy. This means you will have
to try drugs in a certain order for your medical condition. You might have to try one drug
before we will cover another drug. If your doctor thinks the first drug doesn’t work for you,
then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on
pages 9. You can also get more information by visiting our web site at
http://mmp.absolutetotalcare.com. We have posted online documents that explain our prior
authorization and step therapy restrictions. You may also ask us to send you a copy by calling
member services at the number below.
You can ask for an “exception” from these limits. Please see question 11 for more information on
exceptions.
→ If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new ATC member. This will give you time to talk to your doctor or
other prescriber. He or she can help you decide if there is a similar drug on the Drug List you
can take instead or whether to ask for an exception. Please see question 11 for more
information about exceptions.
6. How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions,
or limits on use.”
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
4
7. What happens if we change our rules on how we cover some
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask for a refill.
Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This
gives you time to talk to your doctor or other prescriber about what to do next.
8. How can you find a drug on the Drug List?
There are two ways to find a drug:
 You can search alphabetically (if you know how to spell the drug), or
 You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the
index of drugs that begins on page 108.
To search by medical condition, find the section labeled “List of drugs by medical condition” on
page 11. The drugs in this section are grouped into categories depending on the type of medical
conditions they are used to treat. For example, if you have a heart condition, you should look in
the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.
9. What if you are a current member and the drug you want to take is
not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at the number at the bottom of
the page and ask about it. If you learn that ATC will not cover the drug, you can do one of these
things:
 Ask Member Services for a list of drugs like the one you want to take. Then show the list to
your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like
the one you want to take. Or
 You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
5
Throughout the plan year, you may have a change in your treatment setting (the place where you
get and take your medicine) because of the level of care you require. Such transitions may
include, but are not limited to:
 Members who are discharged from a hospital or skilled-nursing facility to a home setting.
 Members who are admitted to a hospital or skilled-nursing facility from a home setting.
 Members who transfer from one skilled-nursing facility to another and are served by a different
pharmacy.
 Members who end their skilled-nursing facility Medicare Part A stay (where payments include
all pharmacy charges) and who now need to use their Part D plan benefit.
 Members who give up Hospice Status and go back to standard Medicare Part A and B
coverage.
 Members discharged from psychiatric hospitals with highly individualized drug regimens.
For these changes in treatment settings, ATC will cover as much as a 31-day temporary supply of
a Part D-covered drug when you fill your prescription at a network pharmacy. If you change
treatment settings multiple times within the same month, you may have to request an exception or
prior approval and get approval for continued coverage of your drug. We will review these
requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug
regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call
Member Services.
10. What if you are a new ATC member and can’t find your drug on the
Drug List or have a problem getting your drug?
We can help. We will cover a temporary 30-day supply of your Part D drug and a 90-day supply of
your Healthy Connections Medicaid drug during the first 180 days you are a member of ATC. This
will give you time to talk to your doctor or other prescriber. He or she will determine if there is a
similar drug on the Drug List you can take instead or whether to ask for an exception.
We will cover a temporary supply of your drug if:
?

you are taking a drug that is not on our Drug List, or

health plan rules do not let you get the amount ordered by your prescriber, or

the drug requires prior approval by ATC, or

you are taking a drug that is part of a step therapy restriction.
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
6
If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 91 to 98 days for Part D drugs and 90 days for non-Part D drugs. You may refill the
drug multiple times during this time period. This gives your prescriber time to change your drugs
to ones on the Drug List or ask for an exception.
11. Can you ask for an exception to cover your drug?
Yes. You can ask ATC to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.

For example, ATC may limit the amount of a drug we will cover. If your drug has
a limit, you can ask us to change the limit and cover more.

Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
12. How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an
exception. After we get the statement, we will give you a decision on your exception request
within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of getting your prescriber’s
supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services at 1-855-735-4398. TTY users call 711. A
Member Services representative will work with you and your provider to help you ask for an
exception.
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
7
14. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually
cost less than the brand name drug and usually don’t have well-known names. Generic drugs are
approved by the Food and Drug Administration (FDA).
ATC covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. ATC covers some OTC drugs when they are written as
prescriptions by your provider.
You can read the ATC Drug List to see what OTC drugs are covered.
16. What is your copay?
As an ATC member, you have no copays for prescription or OTC drugs as long as you follow ATC’s rules.
Copays are listed by tiers. Tiers are groups of drugs with the same copay. 
Tier 1 drugs are generic drugs. The copay is $0. 
Tier 2 drugs are brand name drugs. The copay is $0. 
Tier 3 drugs are Non-Medicare prescription or over-the-counter drugs. The copay is $0. 17. What are drug tiers?
Tiers are groups of drugs on our Drug List. ?

Tier 1 drugs are generic drugs. The copay is $0. 
Tier 2 drugs are brand name drugs. The copay is $0. 
Tier 3 drugs are Non-Medicare prescription or over-the-counter drugs. The copay is $0. If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
8
List of Covered Drugs
The list of covered drugs that begins on page 11 gives you information about the drugs covered
by ATC. If you have trouble finding your drug in the list, turn to the Index that begins on page 108.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin).
The information in the necessary actions, restrictions, or limits on use column tells you if ATC has
any rules for covering your drug.
Abbreviations Descriptions
?
B/D
This prescription drug has a Part B versus Part D administrative prior
authorization requirement. This drug may be covered under Medicare Part B
or Part D depending upon the circumstances. Information may need to be
submitted describing the use and setting of the drug to make the
determination.
DP
This drug is not a Medicare Part D drug. This item is covered under your
Medicaid benefits. This drug also has different rules for appeals.
LA
Limited Access. This prescription may be available only at certain pharmacies.
For more information call Member Services at 1-866-549-8289. TTY users
should call 711.
PA
Prior Approval (or prior authorization). ATC requires your doctor or you to get
prior approval for certain drugs. This means that you will need to get approval
from ATC before you fill your prescriptions. If you don’t get approval, ATC may
not cover the drug.
QL
Quantity Limit. For certain drugs, ATC limits the amount of the drug that will
be covered. For example, only 30 tablets of JANUVIA per 30 days. This may
be in addition to a standard one-month or three-month supply.
MO
Maintenance Drug. This prescription drug is eligible for a 90-day supply
through our mail order service as well as through certain retail network
pharmacies. Consider using mail order for your long-term (maintenance)
medications (such as high blood pressure medications). Retail network
pharmacies may be more appropriate for short- term prescriptions (such as
antibiotics).
NDS
Non-Extended Day Supply. This prescription drug is not available for an
extended days' supply.
ST
Step Therapy. Sometimes ATC requires you to do step therapy. This means
you might have to try one drug before we will cover another drug.
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
9
Note: The DP next to a drug means the drug is not a “Part D drug.” The amount you pay when
you fill a prescription for this drug does not count towards your total drug costs (that is, the
amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these
drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us
to review a coverage decision and to change it if you think we made a mistake. For example, we
might decide that a drug that you want is not covered or is no longer covered by Medicare or
Healthy Connections Medicaid. If you or your doctor disagrees with our decision, you can appeal.
To ask for instructions on how to appeal, call Member Services at the number at the bottom of the
page. You can also read the Member Handbook to learn how to appeal a decision.
?
If you have questions, please call Absolute Total Care at 1-855-735-4398. Hours are from 8
a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you
may be asked to leave a message. Your call will be returned within the next business day. TTY
users call 711. For more information, visit http://mmp.absolutetotalcare.com.
10 Name of drug
Analgesics
Analgesics
allzital
butalbital/acetaminophen
butalbital/acetaminophen/caffeine/codeine capsule 325mg;
50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine capsule 325mg; 50mg;
40mg
butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg
butalbital/aspirin/caffeine capsule
GRALISE
GRALISE STARTER
tencon tablet 325mg; 50mg
Nonsteroidal Anti-inflammatory Drugs
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal tablet 500mg
etodolac er
etodolac capsule, tablet
fenoprofen calcium capsule 400mg
fenoprofen calcium tablet
flogen
flurbiprofen tablet
ibuprofen suspension
ibuprofen tablet 400mg, 600mg, 800mg
indomethacin er
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
indomethacin capsule
$0(Tier 1)
ketoprofen er capsule extended release 24 hour 200mg
$0(Tier 1)
ketoprofen capsule 50mg, 75mg
ketorolac tromethamine injection 15mg/ml, 30mg/ml
meclofenamate sodium capsule
meloxicam suspension
meloxicam tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
nabumetone
naproxen dr
naproxen sodium tablet 275mg, 550mg
naproxen suspension, tablet
oxaprozin
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
DP
MO
MO
MO
PA (High Risk
Medication-Anti
inflammatory Agents) MO
PA (High Risk
Medication-Anti
inflammatory Agents) MO
QL (30 EA per 30 days)
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
11
Name of drug
piroxicam capsule
sulindac tablet
tolmetin sodium capsule
tolmetin sodium tablet 600mg
Opioid Analgesics, Long-acting
fentanyl
levorphanol tartrate tablet
METHADONE HCL INJECTION
methadone hcl oral solution 5mg/5ml
methadone hcl oral solution 10mg/5ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
morphine sulfate er tablet extended release 60mg
morphine sulfate er tablet extended release 15mg, 30mg
morphine sulfate er tablet extended release 200mg
morphine sulfate er tablet extended release 100mg
Opioid Analgesics, Short-acting
acetaminophen/codeine tablet 300mg; 60mg
acetaminophen/codeine tablet 300mg; 15mg, 300mg; 30mg
ascomp/codeine
butorphanol tartrate nasal solution
butorphanol tartrate injection 2mg/ml
butorphanol tartrate injection 1mg/ml
duramorph injection 1mg/ml
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
QL (10 EA per 30 days)
QL (120 EA per 30 days)
QL (160 ML per 30 days)
QL (1200 ML per 30
days)
QL (600 ML per 30 days)
QL (120 EA per 30 days)
QL (240 EA per 30 days)
QL (100 EA per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (5 ML per 28 days)
QL (360 ML per 30 days)
QL (720 ML per 30 days)
QL (2000 ML per 30
days)
QL (4000 ML per 30
days)
QL (360 EA per 30 days)
QL (120 EA per 30 days)
PA (Fentanyl Citrate Oral
Transmucosal) NDS
QL (5550 ML per 30
days)
QL (360 EA per 30 days)
$0(Tier 1)
QL (360 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (150 ML per 30 days)
QL (750 ML per 30 days)
QL (150 EA per 30 days)
PA (Lazanda)
QL (30 EA per 30 days)
PA (Lazanda)
duramorph injection 0.5mg/ml
$0(Tier 1)
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
fentanyl citrate oral transmucosal
$0(Tier 1)
$0(Tier 1)
hydrocodone bitartrate/acetaminophen solution 325mg/15ml;
7.5mg/15ml
hydrocodone bitartrate/acetaminophen tablet 300mg; 7.5mg,
325mg; 2.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tablet 10mg; 200mg, 5mg; 200mg
hydromorphone hcl tablet
hydromorphone hcl injection 10mg/ml, 50mg/5ml
hydromorphone hcl injection 2mg/ml
LAZANDA SOLUTION 300MCG/ACT
$0(Tier 1)
LAZANDA SOLUTION 100MCG/ACT, 400MCG/ACT
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
12
Name of drug
morphine sulfate tablet
morphine sulfate solution 100mg/5ml
morphine sulfate solution 10mg/5ml, 20mg/5ml
nalbuphine hcl injection 20mg/ml
nalbuphine hcl injection 10mg/ml
oxycodone hcl tablet 30mg
oxycodone hcl tablet 10mg, 15mg, 20mg
oxycodone hcl tablet 5mg
oxycodone/acetaminophen solution
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, $0(Tier 1)
325mg; 7.5mg
TALWIN
$0(Tier 2)
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
Anesthetics
Local Anesthetics
lidocaine hcl jelly
lidocaine hcl external solution
lidocaine hcl injection 0.5%, 2%
lidocaine viscous
lidocaine/prilocaine cream
lidocaine ointment
lidocaine patch
$0(Tier 1)
$0(Tier 1)
$0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram tablet
Opioid Dependence Treatments
buprenorphine hcl injection
buprenorphine hcl tablet sublingual 2mg
PA (High Risk
Medications)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (90 EA per 30 days) PA (Anesthetics)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
buprenorphine hcl tablet sublingual 8mg
$0(Tier 1)
naltrexone hcl tablet
SUBOXONE FILM 12MG; 3MG
$0(Tier 1)
$0(Tier 2)
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG $0(Tier 2)
ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG,
11.4MG; 2.9MG, 2.9MG; 0.71MG
ZUBSOLV TABLET SUBLINGUAL 8.6MG; 2.1MG
Necessary actions,
restrictions, or limits on
use
QL (180 EA per 30 days)
QL (300 ML per 30 days)
QL (900 ML per 30 days)
QL (100 ML per 30 days)
QL (200 ML per 30 days)
QL (134 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (1800 ML per 30
days)
QL (360 EA per 30 days)
$0(Tier 2)
$0(Tier 2)
QL (267 ML per 30 days)
QL (300 EA per 30 days)
PA (Suboxone)
QL (75 EA per 30 days)
PA (Suboxone)
QL (60 EA per 30 days)
PA (Suboxone)
QL (90 EA per 30 days)
PA (Suboxone)
QL (30 EA per 30 days)
PA (Zubsolv)
QL (60 EA per 30 days)
PA (Zubsolv)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
13
Name of drug
ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG
Opioid Reversal Agents
naloxone hcl injection 0.4mg/ml, 2mg/2ml
Smoking Cessation Agents
buproban
bupropion hcl sr tablet extended release 12 hour 150mg
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
NICOTROL NS
Antibacterials
Aminoglycosides
amikacin sulfate injection 500mg/2ml
gentak ointment
gentamicin sulfate/0.9% sodium chloride injection 1.2mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%
gentamicin sulfate cream, external ointment, ophthalmic
ointment, ophthalmic solution
gentamicin sulfate injection 10mg/ml, 40mg/ml
isotonic gentamicin
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
streptomycin sulfate injection 1gm
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
Antibacterials, Other
alcohol prep pads
baciim
BACITRACIN INJECTION
bacitracin ointment
CHLORAMPHENICOL SODIUM SUCCINATE
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
clindamax gel
clindamycin hcl capsule
clindamycin palmitate hcl
clindamycin phosphate in d5w
clindamycin phosphate cream, gel, lotion, external solution,
swab
clindamycin phosphate injection 300mg/2ml, 600mg/4ml,
900mg/6ml
colistimethate sodium
CUBICIN
daptomycin
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
PA (Zubsolv)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (56 EA per 28 days)
QL (56 EA per 28 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
B/D
NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
14
Name of drug
LINCOCIN INJECTION
lincomycin hcl injection
linezolid tablet
linezolid suspension reconstituted
linezolid injection 600mg/300ml
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole gel 0.75%
metronidazole cream, lotion, tablet
mupirocin ointment
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/hydrocortisone ophthalmic suspension
1%; 3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals
nitrofurantoin monohydrate/macrocrystals
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
PA (High Risk Medication
- Nitrofurantoin)
PA (High Risk Medication
- Nitrofurantoin)
$0(Tier 1)
polymyxin b sulfate injection
silver sulfadiazine cream
ssd
SYNERCID INJECTION 350MG; 150MG
trimethoprim tablet
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm, 500mg
vandazole
XIFAXAN TABLET 200MG
XIFAXAN TABLET 550MG
Beta-lactam, Cephalosporins
cefaclor er tablet extended release 12 hour 500mg
cefaclor capsule
cefadroxil
cefazolin sodium injection 10gm, 1gm, 500mg
cefdinir
cefepime injection 1gm, 2gm
cefotaxime sodium injection 1gm, 2gm, 500mg
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil tablet
cefprozil
ceftazidime injection 1gm, 2gm, 6gm
ceftriaxone sodium injection 10gm, 1gm, 250mg, 2gm, 500mg
cefuroxime axetil tablet
cefuroxime sodium injection 1.5gm, 7.5gm, 750mg
cephalexin capsule 250mg, 500mg
cephalexin suspension reconstituted, tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QL (20 EA per 10 days)
QL (600 ML per 10 days)
NDS
QL (60 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
15
Name of drug
CLAFORAN INJECTION 10GM, 500MG
FORTAZ INJECTION 1GM, 2GM
SUPRAX CAPSULE, TABLET CHEWABLE,
SUSPENSION RECONSTITUTED
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE
aztreonam injection 1gm
imipenem/cilastatin
INVANZ
meropenem injection 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin capsule, suspension reconstituted, tablet
amoxicillin tablet chewable 125mg, 250mg
ampicillin
ampicillin sodium injection 10gm, 125mg, 1gm
ampicillin-sulbactam
BACTOCILL IN DEXTROSE
BICILLIN C-R INJECTION 300000UNIT/ML;
300000UNIT/ML, 900000UNIT/2ML; 300000UNIT/2ML
BICILLIN L-A INJECTION 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML
dicloxacillin sodium
nafcillin sodium injection 10gm, 1gm
oxacillin sodium injection 10gm, 2gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 40000UNIT/ML, 0;
60000UNIT/ML
penicillin g potassium injection 5000000unit
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
piperacillin/tazobactam injection 4gm; 0.5gm
ZOSYN INJECTION 36GM; 4.5GM, 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML
Macrolides
AZASITE
azithromycin injection 500mg
azithromycin suspension reconstituted 100mg/5ml
azithromycin suspension reconstituted 200mg/5ml
azithromycin tablet 500mg
azithromycin tablet 250mg
azithromycin tablet 600mg
clarithromycin er
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (15 ML per 5 days)
QL (22.5 ML per 5 days)
QL (3 EA per 3 days)
QL (6 EA per 5 days)
QL (8 EA per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
16
Name of drug
clarithromycin suspension reconstituted
clarithromycin tablet 250mg
clarithromycin tablet 500mg
e.e.s. 400 tablet
e.e.s. granules
ERY-TAB
ERYPED 400
ERYTHROCIN LACTOBIONATE INJECTION 500MG
erythrocin stearate tablet 250mg
erythromycin base
erythromycin ethylsuccinate suspension reconstituted
erythromycin capsule delayed release particles, ointment
erythromycin solution 2%
KETEK
ZMAX
Quinolones
AVELOX INJECTION
ciprofloxacin hcl solution, tablet
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin injection 400mg/40ml
levofloxacin in d5w injection 5%; 500mg/100ml, 5%;
750mg/150ml
levofloxacin injection, oral solution
levofloxacin tablet 250mg
levofloxacin tablet 500mg, 750mg
moxifloxacin hcl injection
ofloxacin ophthalmic solution, otic solution
ofloxacin tablet 300mg, 400mg
Sulfonamides
sodium sulfacetamide solution
sulfacetamide sodium suspension
sulfadiazine tablet
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
Tetracyclines
demeclocycline hcl tablet
doxy 100
doxycycline hyclate capsule, injection, tablet
doxycycline monohydrate capsule 100mg, 50mg
minocycline hcl capsule
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG, 400MG, 800MG
APTIOM TABLET 600MG
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (28 EA per 14 days)
QL (42 EA per 21 days)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (10 EA per 10 days)
QL (14 EA per 14 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
17
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
Name of drug
BRIVIACT INJECTION
BRIVIACT TABLET
BRIVIACT ORAL SOLUTION
$0(Tier 2)
FYCOMPA TABLET
$0(Tier 2)
FYCOMPA SUSPENSION
$0(Tier 2)
levetiracetam injection
levetiracetam oral solution, tablet
POTIGA TABLET 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
POTIGA TABLET 200MG, 300MG, 400MG
$0(Tier 2)
SPRITAM
Calcium Channel Modifying Agents
CELONTIN CAPSULE 300MG
ethosuximide
LYRICA SOLUTION
LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG
$0(Tier 2)
LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
zonisamide
$0(Tier 1)
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tablet disintegrating 0.125mg, 0.25mg, 0.5mg, $0(Tier 1)
1mg
clonazepam odt tablet disintegrating 2mg
$0(Tier 1)
clonazepam tablet 0.5mg, 1mg
$0(Tier 1)
clonazepam tablet 2mg
$0(Tier 1)
diazepam gel 20mg
$0(Tier 1)
diazepam gel 2.5mg
$0(Tier 1)
diazepam gel 10mg
$0(Tier 1)
divalproex sodium dr
$0(Tier 1)
divalproex sodium er
$0(Tier 1)
divalproex sodium capsule delayed release sprinkle
$0(Tier 1)
gabapentin capsule, solution
$0(Tier 1)
gabapentin tablet 600mg, 800mg
$0(Tier 1)
GABITRIL TABLET 12MG, 16MG
$0(Tier 2)
ONFI SUSPENSION
ONFI TABLET 10MG, 20MG
phenobarbital elixir
phenobarbital tablet 100mg, 15mg, 16.2mg, 30mg, 32.4mg,
60mg, 64.8mg, 97.2mg
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
MO
QL (600 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (720 ML per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (100 EA per 30 days)
QL (24.9 EA per 30 days)
QL (50 EA per 30 days)
MO
MO
MO
MO
MO
QL (90 EA per 30 days)
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
18
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Name of drug
primidone tablet
SABRIL
tiagabine hydrochloride
valproate sodium injection
valproic acid capsule, solution
Glutamate Reducing Agents
felbamate
lamotrigine odt
lamotrigine tablet chewable, tablet
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG $0(Tier 2)
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG, $0(Tier 2)
200MG
topiramate er capsule er 24 hour sprinkle 100mg, 25mg, 50mg$0(Tier 1)
topiramate er capsule er 24 hour sprinkle 150mg, 200mg
$0(Tier 1)
topiramate capsule sprinkle, tablet
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 25MG, 50MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 100MG
Sodium Channel Agents
BANZEL SUSPENSION
BANZEL TABLET 200MG
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
BANZEL TABLET 400MG
$0(Tier 2)
carbamazepine er
carbamazepine tablet chewable, suspension, tablet
CARBATROL
CEREBYX INJECTION 500MG PE/10ML
DILANTIN INFATABS
DILANTIN-125
DILANTIN CAPSULE
epitol
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 600MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
QL (360 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
NDS
QL (240 EA per 30 days)
MO
QL (240 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
19
Name of drug
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
PEGANONE TABLET 250MG
PHENYTEK
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
TEGRETOL-XR
TEGRETOL SUSPENSION, TABLET
VIMPAT INJECTION
VIMPAT ORAL SOLUTION
VIMPAT TABLET 50MG
VIMPAT TABLET 100MG, 150MG, 200MG
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates tablet
Cholinesterase Inhibitors
donepezil hcl tablet disintegrating
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
PA (High Risk
Medications) MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 1)
galantamine hydrobromide er
$0(Tier 1)
galantamine hydrobromide solution
galantamine hydrobromide tablet 4mg
$0(Tier 1)
$0(Tier 1)
galantamine hydrobromide tablet 12mg
$0(Tier 1)
galantamine hydrobromide tablet 8mg
$0(Tier 1)
rivastigmine tartrate
$0(Tier 1)
rivastigmine transdermal system
$0(Tier 1)
memantine hcl titration pak
memantine hydrochloride solution
MO
MO
MO
$0(Tier 1)
donepezil hcl tablet 10mg, 5mg
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl
Necessary actions,
restrictions, or limits on
use
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (60 EA per 30 days)
MO
MO
QL (360 ML per 30 days)
MO
Antidepressants
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
20
Name of drug
Antidepressants, Other
bupropion hcl sr tablet extended release 12 hour 100mg,
150mg, 200mg
bupropion hcl xl
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (180 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
$0(Tier 1)
bupropion hcl tablet 75mg
bupropion hcl tablet 100mg
$0(Tier 1)
$0(Tier 1)
maprotiline hcl
mirtazapine odt
$0(Tier 1)
$0(Tier 1)
mirtazapine tablet
nefazodone hcl
trazodone hcl tablet
TRINTELLIX
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Monoamine Oxidase Inhibitors
EMSAM
$0(Tier 2)
MARPLAN
$0(Tier 2)
phenelzine sulfate
$0(Tier 1)
tranylcypromine sulfate
$0(Tier 1)
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide solution
$0(Tier 1)
citalopram hydrobromide tablet 10mg
$0(Tier 1)
citalopram hydrobromide tablet 40mg
$0(Tier 1)
citalopram hydrobromide tablet 20mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 100mg
$0(Tier 1)
desvenlafaxine er tablet extended release 24 hour 25mg, 50mg$0(Tier 1)
duloxetine hcl capsule delayed release particles
$0(Tier 1)
escitalopram oxalate solution
escitalopram oxalate tablet
$0(Tier 1)
$0(Tier 1)
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) NDS
MO
MO
MO
QL (600 ML per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
21
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
FETZIMA
FETZIMA TITRATION PACK
$0(Tier 2)
fluoxetine hcl capsule, solution
fluoxetine hcl tablet 10mg
fluvoxamine maleate
paroxetine hcl
paroxetine hcl er tablet extended release 24 hour 37.5mg
PAXIL SUSPENSION
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
25MG, 50MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
100MG
$0(Tier 2)
sertraline hcl concentrate, tablet
venlafaxine hcl
$0(Tier 1)
$0(Tier 1)
venlafaxine hcl er
$0(Tier 1)
VIIBRYD STARTER PACK
$0(Tier 2)
VIIBRYD TABLET
$0(Tier 2)
Tricyclics
amitriptyline hcl tablet
amoxapine
chlordiazepoxide/amitriptyline
clomipramine hcl capsule
desipramine hcl tablet
doxepin hcl capsule, concentrate
imipramine hcl tablet
imipramine pamoate
nortriptyline hcl capsule, solution
perphenazine/amitriptyline
protriptyline hcl
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 180 days)
ST
(ANTIDEPRESSANTS
#2, new starts only)
QL (30 EA per 30 days)
ST
(ANTIDEPRESSANTS
#2, new starts only) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
22
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
trimipramine maleate capsule
Antiemetics
Antiemetics, Other
meclizine hcl tablet
phenadoz suppository 12.5mg
$0(Tier 1)
$0(Tier 1)
promethazine hcl injection, suppository, syrup, tablet
$0(Tier 1)
promethegan suppository 25mg, 50mg
$0(Tier 1)
TRANSDERM-SCOP
trimethobenzamide hcl capsule 300mg
$0(Tier 2)
$0(Tier 1)
Emetogenic Therapy Adjuncts
aprepitant capsule 40mg
$0(Tier 1)
aprepitant capsule 0
$0(Tier 1)
aprepitant capsule 125mg
$0(Tier 1)
aprepitant capsule 80mg
$0(Tier 1)
dronabinol
$0(Tier 1)
EMEND CAPSULE 40MG
$0(Tier 2)
EMEND CAPSULE 0
$0(Tier 2)
EMEND CAPSULE 125MG
$0(Tier 2)
EMEND CAPSULE 80MG
$0(Tier 2)
granisetron hcl injection 0.1mg/ml, 1mg/ml
ondansetron hcl oral solution
ondansetron hcl injection 4mg/2ml
ondansetron hcl tablet 24mg
ondansetron hcl tablet 4mg, 8mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
ondansetron odt
$0(Tier 1)
Antifungals
Antifungals
ABELCET
AMBISOME
amphotericin b
CANCIDAS
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
QL (10 EA per 30 days)
PA (High Risk
Medications)
QL (1 EA per 14 days)
B/D
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
QL (60 EA per 30 days)
B/D
QL (1 EA per 14 days)
B/D
QL (3 EA per 14 days)
B/D
QL (4 EA per 30 days)
B/D
QL (8 EA per 30 days)
B/D
B/D
B/D
QL (90 EA per 30 days)
B/D
QL (90 EA per 30 days)
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
23
Name of drug
ciclopirox olamine cream
ciclopirox suspension
clotrimazole cream, solution, troche
econazole nitrate cream
fluconazole in nacl injection 200mg/100ml; 0.9%,
400mg/200ml; 0.9%
fluconazole suspension reconstituted, tablet
flucytosine
griseofulvin microsize tablet
griseofulvin ultramicrosize tablet 125mg, 250mg
itraconazole capsule
ketoconazole cream, shampoo, tablet
miconazole 3 suppository
MYCAMINE
naftifine hcl
naftifine hydrochloride
NAFTIN GEL 1%
NATACYN
NOXAFIL SUSPENSION, TABLET DELAYED RELEASE
nyamyc
nystatin/triamcinolone
nystatin cream, ointment, powder, suspension, tablet
nystop
SPORANOX SOLUTION
terbinafine hcl tablet
terconazole cream
terconazole suppository
voriconazole injection
voriconazole suspension reconstituted, tablet
Antigout Agents
Antigout Agents
allopurinol sodium
allopurinol tablet
ALOPRIM
colchicine capsule
colchicine tablet 0.6mg
COLCRYS
probenecid/colchicine
probenecid tablet
Antimigraine Agents
Antimigraine Agents
BOTOX INJECTION 100UNIT
Ergot Alkaloids
dihydroergotamine mesylate injection
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (12 EA per 30 days)
NDS
QL (3 EA per 30 days)
NDS
MO
MO
MO
MO
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
24
Name of drug
dihydroergotamine mesylate nasal solution
ERGOMAR
migergot
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML
IMITREX SOLUTION
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan succinate refill
sumatriptan succinate injection
sumatriptan succinate tablet
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON SYRUP
pyridostigmine bromide er
pyridostigmine bromide tablet
Antimycobacterials
Antimycobacterials, Other
DAPSONE TABLET
MYCOBUTIN
rifabutin
Antituberculars
CAPASTAT SULFATE
ethambutol hcl tablet
isoniazid injection
isoniazid syrup, tablet
PASER
PRIFTIN
pyrazinamide tablet
rifampin capsule, injection
RIFATER
SIRTURO
TRECATOR
Antineoplastics
Alkylating Agents
ALKERAN INJECTION
BICNU
BUSULFEX
cyclophosphamide capsule
dacarbazine injection 200mg
GLEOSTINE
HEXALEN
IFEX INJECTION 1GM
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (8 ML per 28 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (4 ML per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
QL (9 EA per 30 days)
QL (12 EA per 30 days)
QL (12 EA per 30 days)
QL (4 ML per 30 days)
QL (4 ML per 30 days)
QL (9 EA per 30 days)
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
QL (120 EA per 30 days)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
B/D
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
25
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Name of drug
ifosfamide injection 1gm
LEUKERAN
MATULANE
melphalan hydrochloride
MUSTARGEN
THIOTEPA INJECTION 15MG
TREANDA INJECTION 100MG
VALCHLOR
YONDELIS
ZANOSAR
Antiandrogens
bicalutamide
Necessary actions,
restrictions, or limits on
use
NDS
PA (Valchlor, new starts
only)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
flutamide
NILANDRON TABLET 150MG
$0(Tier 1)
$0(Tier 2)
nilutamide
XTANDI
$0(Tier 1)
$0(Tier 2)
ZYTIGA
$0(Tier 2)
Antiangiogenic Agents
POMALYST
REVLIMID CAPSULE 2.5MG, 20MG
$0(Tier 2)
$0(Tier 2)
REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJECTION 250MG/5ML
SOLTAMOX
tamoxifen citrate tablet
Antimetabolites
adrucil injection 500mg/10ml
ALIMTA INJECTION 500MG
ARRANON
cladribine
CLOLAR
cytarabine aqueous
DROXIA
ELITEK
fluorouracil injection 2.5gm/50ml
FOLOTYN INJECTION 40MG/2ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
QL (30 EA per 30 days)
MO
MO
QL (60 EA per 30 days)
NDS
QL (60 EA per 30 days)
QL (120 EA per 30 days)
NDS
PA (zytiga, new starts
only) NDS
NDS
PA (revlimid, new starts
only)
PA (revlimid, new starts
only) LA
NDS
MO
MO
MO
B/D
NDS
B/D
B/D
MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
26
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Name of drug
gemcitabine hcl injection 1gm
hydroxyurea capsule
LONSURF
mercaptopurine tablet
PURIXAN
TABLOID
Antineoplastics, Other
ABRAXANE
adriamycin injection 2mg/ml
amifostine
azacitidine
BELEODAQ
Necessary actions,
restrictions, or limits on
use
PA (LONSURF, new
starts only) NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
bleomycin sulfate injection 30unit
CAMPTOSAR INJECTION 100MG/5ML
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COSMEGEN
COTELLIC
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
DACOGEN
daunorubicin hcl injection 5mg/ml
decitabine
dexrazoxane injection 250mg
DOCEFREZ INJECTION 20MG
DOCETAXEL INJECTION 80MG/8ML
docetaxel injection 80mg/4ml
doxorubicin hcl liposome
doxorubicin hcl injection 2mg/ml
ELLENCE INJECTION 200MG/100ML
epirubicin hcl injection 200mg/100ml
ERWINAZE
fludarabine phosphate injection 50mg
FUSILEV
GILOTRIF
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
HALAVEN
IBRANCE
$0(Tier 2)
$0(Tier 2)
IDAMYCIN PFS INJECTION 20MG/20ML
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
ISTODAX
ISTODAX (OVERFILL)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
PA (beleodaq, new starts
only)
B/D
NDS
QL (63 EA per 21 days)
PA (Cotellic, new starts
only) NDS
NDS
PA (gilotrif, new starts
only) NDS
QL (30 EA per 30 days)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
27
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
Name of drug
JEVTANA
KISQALI
LARTRUVO INJECTION 500MG/50ML
$0(Tier 2)
leucovorin calcium tablet
leucovorin calcium injection 100mg, 350mg
levoleucovorin calcium
LYNPARZA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
mesna
MESNEX
mitomycin injection
mitoxantrone hcl injection 2mg/ml
NINLARO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ODOMZO
$0(Tier 2)
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PROLEUKIN
RUBRACA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
SYLATRON
SYNRIBO
TAGRISSO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TRISENOX
VELCADE
VENCLEXTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
VENCLEXTA STARTING PACK
$0(Tier 2)
VINBLASTINE SULFATE INJECTION 1MG/ML
vincristine sulfate
vinorelbine tartrate injection 50mg/5ml
ZINECARD INJECTION 250MG
ZOLINZA
Antineoplastics
FARYDAK
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Kisqali, new starts
only) NDS
PA (Lartruvo, new starts
only) NDS
QL (480 EA per 30 days)
NDS
QL (4 EA per 28 days) PA
(Ninlaro, new starts only)
NDS
QL (30 EA per 30 days)
PA (Odomzo, new starts
only) NDS
QL (120 EA per 30 days)
PA (Rubraca, new starts
only) NDS
NDS
QL (30 EA per 30 days)
PA (Tagrisso, new starts
only)
NDS
PA (Venclexta, new starts
only)
PA (Venclexta, new starts
only)
B/D
B/D
NDS
QL (6 EA per 21 days) PA
(Farydak, new starts only)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
28
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
ZALTRAP INJECTION 100MG/4ML
ZYKADIA
$0(Tier 2)
Aromatase Inhibitors, 3rd Generation
anastrozole tablet
$0(Tier 1)
exemestane
letrozole
Enzyme Inhibitors
ETOPOPHOS
etoposide injection 500mg/25ml
KYPROLIS
$0(Tier 1)
$0(Tier 1)
toposar injection 1gm/50ml
topotecan hcl injection 4mg
ZYDELIG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
Molecular Target Inhibitors
AFINITOR
$0(Tier 2)
AFINITOR DISPERZ
$0(Tier 2)
ALECENSA
$0(Tier 2)
BOSULIF
$0(Tier 2)
CABOMETYX TABLET 20MG, 60MG
$0(Tier 2)
CABOMETYX TABLET 40MG
$0(Tier 2)
CAPRELSA
$0(Tier 2)
COMETRIQ
$0(Tier 2)
ERIVEDGE
ICLUSIG TABLET 45MG
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (zaltrap, new starts
only)
QL (150 EA per 30 days)
PA (zykadia, new starts
only) NDS
QL (30 EA per 30 days)
MO
MO
MO
PA (KYPROLIS, new
starts only) NDS
QL (60 EA per 30 days)
PA (zydelig, new starts
only) NDS
QL (30 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (60 EA per 30 days)
PA (afinitor, new starts
only) NDS
QL (240 EA per 30 days)
PA (Alecensa, new starts
only)
PA (bosulif, new starts
only) NDS
QL (30 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
QL (60 EA per 30 days)
PA (Cabometyx, new
starts only) NDS
PA (caprelsa, new starts
only) NDS
PA (cometriq, new starts
only) NDS
NDS
QL (30 EA per 30 days)
PA (iclusig, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
29
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
ICLUSIG TABLET 15MG
imatinib mesylate tablet 400mg
$0(Tier 1)
imatinib mesylate tablet 100mg
$0(Tier 1)
IMBRUVICA
$0(Tier 2)
INLYTA
$0(Tier 2)
IRESSA
JAKAFI
$0(Tier 2)
$0(Tier 2)
LENVIMA 10 MG DAILY DOSE
$0(Tier 2)
LENVIMA 14 MG DAILY DOSE
$0(Tier 2)
LENVIMA 18 MG DAILY DOSE
$0(Tier 2)
LENVIMA 20 MG DAILY DOSE
$0(Tier 2)
LENVIMA 24 MG DAILY DOSE
$0(Tier 2)
LENVIMA 8 MG DAILY DOSE
$0(Tier 2)
MEKINIST
$0(Tier 2)
NEXAVAR
$0(Tier 2)
SPRYCEL
$0(Tier 2)
STIVARGA
$0(Tier 2)
SUTENT
$0(Tier 2)
TAFINLAR
TARCEVA
$0(Tier 2)
$0(Tier 2)
TASIGNA
$0(Tier 2)
TYKERB
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
PA (iclusig, new starts
only) NDS
QL (60 EA per 30 days)
PA (Imatinib, new starts
only)
QL (90 EA per 30 days)
PA (Imatinib, new starts
only)
QL (120 EA per 30 days)
PA (imbruvica, new starts
only) NDS
PA (inlyta, new starts
only) NDS
QL (60 EA per 30 days)
PA (jakafi, new starts
only) NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
QL (90 EA per 30 days)
NDS
QL (60 EA per 30 days)
NDS
PA (mekinist, new starts
only) NDS
PA (nexavar, new starts
only) NDS
PA (sprycel, new starts
only) NDS
PA (stivarga, new starts
only) NDS
PA (sutent, new starts
only) NDS
NDS
PA (tarceva, new starts
only) NDS
PA (tarceva, new starts
only) NDS
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
30
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
VOTRIENT
XALKORI
$0(Tier 2)
ZELBORAF
$0(Tier 2)
Monoclonal Antibodies
AVASTIN
$0(Tier 2)
CYRAMZA
DARZALEX INJECTION 100MG/5ML
EMPLICITI
ERBITUX INJECTION 100MG/50ML
HERCEPTIN
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
KADCYLA INJECTION 100MG
$0(Tier 2)
KEYTRUDA INJECTION 50MG
$0(Tier 2)
KEYTRUDA INJECTION 100MG/4ML
$0(Tier 2)
OPDIVO INJECTION 40MG/4ML
PERJETA
RITUXAN INJECTION 500MG/50ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
SYLVANT INJECTION 100MG
TECENTRIQ
$0(Tier 2)
$0(Tier 2)
VECTIBIX INJECTION 100MG/5ML
YERVOY INJECTION 50MG/10ML
$0(Tier 2)
$0(Tier 2)
Retinoids
bexarotene
PANRETIN
TARGRETIN GEL
tretinoin capsule 10mg
Antiparasitics
Anthelmintics
ALBENZA
ivermectin tablet
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tablet
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (120 EA per 30 days)
PA (votrient, new starts
only) NDS
PA (xalkori, new starts
only) NDS
PA (zelboraf, new starts
only) NDS
PA (avastin, new starts
only) NDS
NDS
NDS
NDS
PA (herceptin, new starts
only) NDS
PA (kadcyla, new starts
only) NDS
PA (keytruda, new starts
only)
PA (keytruda, new starts
only) NDS
PA (rituxan, new starts
only) NDS
PA (Tecentriq, new starts
only) NDS
PA (yervoy, new starts
only)
NDS
NDS
NDS
NDS
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
31
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Name of drug
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
MEPRON SUSPENSION
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE TABLET
quinine sulfate capsule 324mg
tinidazole tablet
Pediculicides/Scabicides
malathion
permethrin cream
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection
benztropine mesylate tablet
Necessary actions,
restrictions, or limits on
use
MO
B/D
PA (Quinine)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
trihexyphenidyl hcl
$0(Tier 1)
Antiparkinson Agents, Other
entacapone
$0(Tier 1)
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
QL (240 EA per 30 days)
MO
MO
tolcapone
Dopamine Agonists
APOKYN INJECTION 30MG/3ML
bromocriptine mesylate capsule, tablet
NEUPRO
$0(Tier 1)
pramipexole dihydrochloride
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
$0(Tier 1)
$0(Tier 1)
NDS
MO
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
ELDEPRYL CAPSULE
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
32
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
rasagiline mesylate tablet
selegiline hcl capsule, tablet
ZELAPAR
Antipsychotics
1st Generation/Typical
chlorpromazine hcl tablet
CHLORPROMAZINE HCL INJECTION 50MG/2ML
compro
fluphenazine decanoate injection
FLUPHENAZINE HCL INJECTION
fluphenazine hcl concentrate, elixir
fluphenazine hcl tablet
haloperidol decanoate
haloperidol lactate
haloperidol concentrate
haloperidol tablet
loxapine succinate capsule
perphenazine tablet
pimozide
prochlorperazine edisylate injection
prochlorperazine maleate tablet
prochlorperazine suppository 25mg
thioridazine hcl tablet 100mg, 10mg, 25mg, 50mg
thiothixene capsule 10mg, 1mg, 2mg, 5mg
trifluoperazine hcl tablet
2nd Generation/Atypical
ABILIFY MAINTENA
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
$0(Tier 2)
QL (1 EA per 30 days)
NDS
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (1.6 ML per 30 days)
NDS
QL (2.4 ML per 30 days)
NDS
QL (3.2 ML per 30 days)
NDS
QL (60 EA per 30 days)
MO
aripiprazole odt
$0(Tier 1)
aripiprazole tablet
$0(Tier 1)
ARISTADA INJECTION 441MG/1.6ML
$0(Tier 2)
ARISTADA INJECTION 662MG/2.4ML
$0(Tier 2)
ARISTADA INJECTION 882MG/3.2ML
$0(Tier 2)
FANAPT
$0(Tier 2)
FANAPT TITRATION PACK
GEODON INJECTION
INVEGA SUSTENNA INJECTION 39MG/0.25ML
INVEGA SUSTENNA INJECTION 78MG/0.5ML
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (0.25 ML per 28 days)
QL (0.5 ML per 28 days)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
33
Name of drug
INVEGA SUSTENNA INJECTION 117MG/0.75ML
What the drug
will cost you
(tier level)
$0(Tier 2)
INVEGA SUSTENNA INJECTION 156MG/ML
$0(Tier 2)
INVEGA SUSTENNA INJECTION 234MG/1.5ML
$0(Tier 2)
INVEGA TRINZA INJECTION 273MG/0.875ML
$0(Tier 2)
INVEGA TRINZA INJECTION 410MG/1.315ML
$0(Tier 2)
INVEGA TRINZA INJECTION 546MG/1.75ML
$0(Tier 2)
INVEGA TRINZA INJECTION 819MG/2.625ML
$0(Tier 2)
LATUDA
$0(Tier 2)
NUPLAZID
$0(Tier 2)
olanzapine odt
olanzapine injection
olanzapine tablet
paliperidone er tablet extended release 24 hour 1.5mg, 3mg,
9mg
paliperidone er tablet extended release 24 hour 6mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
quetiapine fumarate
REXULTI
$0(Tier 1)
$0(Tier 2)
RISPERDAL CONSTA
risperidone odt
risperidone solution
risperidone tablet
SAPHRIS
VRAYLAR CAPSULE THERAPY PACK
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
VRAYLAR CAPSULE 1.5MG
$0(Tier 2)
VRAYLAR CAPSULE 4.5MG, 6MG
$0(Tier 2)
VRAYLAR CAPSULE 3MG
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (0.75 ML per 28 days)
NDS
QL (1 ML per 28 days)
NDS
QL (1.5 ML per 28 days)
NDS
QL (0.88 ML per 90 days)
NDS
QL (1.32 ML per 90 days)
NDS
QL (1.75 ML per 90 days)
NDS
QL (2.63 ML per 90 days)
NDS
QL (30 EA per 30 days)
PA (Latuda, new starts
only) MO
QL (60 EA per 30 days)
NDS
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
PA (Rexulti, new starts
only) MO
MO
MO
QL (60 EA per 30 days)
PA (Vraylar, new starts
only)
QL (120 EA per 30 days)
PA (Vraylar, new starts
only) NDS
QL (30 EA per 30 days)
PA (Vraylar, new starts
only) NDS
QL (60 EA per 30 days)
PA (Vraylar, new starts
only) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
34
Name of drug
ziprasidone hcl
ZYPREXA RELPREVV INJECTION 210MG
Antipsychotics
molindone hydrochloride
Treatment-Resistant
clozapine odt tablet disintegrating 12.5mg, 25mg
clozapine odt tablet disintegrating 200mg
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 1)
MO
$0(Tier 1)
$0(Tier 1)
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (270 EA per 30 days)
MO
MO
QL (120 EA per 30 days)
MO
QL (180 EA per 30 days)
MO
QL (90 EA per 30 days) MO
clozapine odt tablet disintegrating 150mg
$0(Tier 1)
clozapine odt tablet disintegrating 100mg
$0(Tier 1)
clozapine tablet 100mg, 200mg, 25mg, 50mg
FAZACLO TABLET DISINTEGRATING 200MG
$0(Tier 1)
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 150MG
$0(Tier 2)
FAZACLO TABLET DISINTEGRATING 100MG, 12.5MG,
25MG
VERSACLOZ
Antispasticity Agents
Antispasticity Agents
baclofen tablet
dantrolene sodium capsule
tizanidine hcl tablet
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir
ganciclovir injection
VALCYTE
valganciclovir
valganciclovir hydrochlorde
ZIRGAN
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE SOLUTION
entecavir
EPIVIR HBV SOLUTION
INTRON A W/DILUENT INJECTION 10MU
INTRON A INJECTION 10MU, 18MU, 50MU,
6000000UNIT/ML
lamivudine tablet 100mg
TYZEKA
Anti-hepatitis C (HCV) Agents
HARVONI
$0(Tier 2)
$0(Tier 2) $0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
B/D
NDS
MO
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
MO
$0(Tier 1)
$0(Tier 2)
MO
NDS
$0(Tier 2) QL (30 EA per 30 days)
PA (harvoni) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
35
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
PEG-INTRON REDIPEN
PEGASYS
$0(Tier 2)
PEGASYS PROCLICK
$0(Tier 2)
PEGINTRON
$0(Tier 2)
REBETOL SOLUTION
ribasphere ribapak
ribasphere tablet
ribavirin capsule
ribavirin tablet 200mg
SOVALDI
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
VIRAZOLE
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
QL (28 EA per 28 days)
PA (Immunological
Agents - Sovaldi) NDS
$0(Tier 2)
$0(Tier 2)
ISENTRESS TABLET CHEWABLE, PACKET
ISENTRESS TABLET
TIVICAY TABLET 10MG
TIVICAY TABLET 25MG, 50MG
VITEKTA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABLET 25MG
INTELENCE TABLET 100MG, 200MG
nevirapine
nevirapine er
ODEFSEY
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
RESCRIPTOR
STRIBILD
SUSTIVA TABLET
SUSTIVA CAPSULE 50MG
SUSTIVA CAPSULE 200MG
Necessary actions,
restrictions, or limits on
use
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
PA (Immunological
Agents - Peg-Intron,
Pegasys) NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
MO
MO
QL (30 EA per 30 days)
NDS
MO
NDS
NDS
MO
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
36
Name of drug
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
DESCOVY
didanosine
EMTRIVA
EPZICOM
lamivudine/zidovudine
lamivudine solution 10mg/ml
lamivudine tablet 150mg, 300mg
RETROVIR IV INFUSION
stavudine
TRIUMEQ
TRUVADA TABLET 200MG; 300MG
TRUVADA TABLET 100MG; 150MG, 133MG; 200MG,
167MG; 250MG
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM
VIREAD
ZERIT SOLUTION RECONSTITUTED
ZIAGEN SOLUTION
zidovudine
Anti-HIV Agents, Other
FUZEON
SELZENTRY TABLET 25MG, 75MG
SELZENTRY TABLET 150MG, 300MG
TYBOST
Anti-HIV Agents, Protease Inhibitors
APTIVUS
CRIXIVAN CAPSULE 200MG, 400MG
EVOTAZ
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
QL (30 EA per 30 days)
NDS
MO
MO
NDS
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
MO
MO
MO
NDS
NDS
QL (30 EA per 30 days)
NDS
MO
NDS
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
NDS
MO
NDS
MO
NDS
MO
QL (30 EA per 30 days)
NDS
NDS
NDS
NDS
INVIRASE
KALETRA SOLUTION
KALETRA TABLET 100MG; 25MG
KALETRA TABLET 200MG; 50MG
LEXIVA
lopinavir/ritonavir
NORVIR
PREZCOBIX
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
PREZISTA SUSPENSION
PREZISTA TABLET 150MG, 600MG, 75MG, 800MG
REYATAZ
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
37
Name of drug
VIRACEPT
Anti-influenza Agents
amantadine hcl capsule, syrup, tablet
oseltamivir phosphate capsule 75mg
oseltamivir phosphate capsule 45mg
oseltamivir phosphate capsule 30mg
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPSULE 75MG
TAMIFLU CAPSULE 45MG
TAMIFLU CAPSULE 30MG
TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule, suspension, tablet
acyclovir ointment
DENAVIR
famciclovir tablet
trifluridine solution
valacyclovir hcl
ZOVIRAX CREAM, OINTMENT
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
buspirone hcl tablet
meprobamate
Benzodiazepines
alprazolam intensol
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg, 1mg, 2mg
clorazepate dipotassium tablet 15mg
clorazepate dipotassium tablet 3.75mg, 7.5mg
diazepam intensol
diazepam solution 1mg/ml
diazepam tablet 10mg, 2mg, 5mg
LORAZEPAM INTENSOL
lorazepam tablet 0.5mg
lorazepam tablet 1mg, 2mg
triazolam
Bipolar Agents
Mood Stabilizers
lithium
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
NDS
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
B/D
MO
QL (30 GM per 30 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (56 EA per 180 days)
QL (28 EA per 180 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (540 ML per 180
days)
QL (60 EA per 30 days)
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 GM per 30 days)
$0(Tier 2)
NDS
$0(Tier 1)
$0(Tier 1)
MO
PA (High Risk
Medications)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
38
Name of drug
lithium carbonate er
lithium carbonate capsule, tablet
LITHOBID
Blood Glucose Regulators
Antidiabetic Agents
acarbose
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
$0(Tier 1)
QL (90 EA per 30 days)
MO
QL (2.4 ML per 30 days)
ST (INCRETIN
MIMETICS #2) MO
ST (INCRETIN
MIMETICS #2) MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (240 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (60 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
QL (120 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
PA (High Risk Medication
- Glyburide) MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Glyburide) MO
BYETTA INJECTION 10MCG/0.04ML
$0(Tier 2)
BYETTA INJECTION 5MCG/0.02ML
$0(Tier 2)
CYCLOSET
FARXIGA
$0(Tier 2)
$0(Tier 2)
glimepiride tablet 1mg, 2mg
$0(Tier 1)
glimepiride tablet 4mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 2.5mg
$0(Tier 1)
glipizide er tablet extended release 24 hour 10mg
$0(Tier 1)
glipizide/metformin hcl
$0(Tier 1)
glipizide tablet 10mg
$0(Tier 1)
glipizide tablet 5mg
$0(Tier 1)
glyburide micronized tablet 1.5mg, 3mg
$0(Tier 1)
glyburide micronized tablet 6mg
$0(Tier 1)
glyburide/metformin hcl
$0(Tier 1)
glyburide tablet 5mg
$0(Tier 1)
glyburide tablet 1.25mg, 2.5mg
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
39
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
JANUVIA
JENTADUETO
$0(Tier 2)
JENTADUETO XR
$0(Tier 2)
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG, 500MG; 5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
metformin hcl er tablet extended release 24 hour 500mg
$0(Tier 2)
metformin hcl er tablet extended release 24 hour 750mg
$0(Tier 1)
metformin hcl tablet 500mg
$0(Tier 1)
metformin hcl tablet 1000mg
$0(Tier 1)
metformin hcl tablet 850mg
$0(Tier 1)
miglitol
$0(Tier 1)
nateglinide
$0(Tier 1)
ONGLYZA
$0(Tier 2)
pioglitazone hcl
$0(Tier 1)
pioglitazone hcl-glimepiride
$0(Tier 1)
pioglitazone hcl/metformin hcl
$0(Tier 1)
repaglinide
SYMLINPEN 120
$0(Tier 1)
$0(Tier 2)
SYMLINPEN 60
$0(Tier 2)
tolbutamide
TRADJENTA
$0(Tier 1)
$0(Tier 2)
VICTOZA
$0(Tier 2)
Glycemic Agents
GLUCAGEN HYPOKIT
$0(Tier 2)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
PA (Blood Glucose
Regulators Amylinomimetics) MO
PA (Blood Glucose
Regulators Amylinomimetics) MO
MO
QL (30 EA per 30 days)
MO
ST (INCRETIN
MIMETICS #2) MO
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
40
Name of drug
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insulins
APIDRA
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
APIDRA SOLOSTAR
$0(Tier 2)
HUMALOG KWIKPEN
$0(Tier 2)
HUMALOG MIX 50/50
$0(Tier 2)
HUMALOG MIX 50/50 KWIKPEN
$0(Tier 2)
HUMALOG MIX 75/25
$0(Tier 2)
HUMALOG MIX 75/25 KWIKPEN
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMALOG INJECTION 100UNIT/ML
$0(Tier 2)
HUMULIN 70/30
$0(Tier 2)
HUMULIN 70/30 KWIKPEN
$0(Tier 2)
HUMULIN N
$0(Tier 2)
HUMULIN N KWIKPEN
$0(Tier 2)
HUMULIN R
$0(Tier 2)
HUMULIN R U-500 (CONCENTRATED)
$0(Tier 2)
HUMULIN R U-500 KWIKPEN
$0(Tier 2)
LANTUS
$0(Tier 2)
LANTUS SOLOSTAR
$0(Tier 2)
LEVEMIR
$0(Tier 2)
LEVEMIR FLEXTOUCH
$0(Tier 2)
NOVOLIN 70/30
$0(Tier 2)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
41
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
NOVOLIN N
NOVOLIN R
$0(Tier 2)
NOVOLOG
$0(Tier 2)
NOVOLOG FLEXPEN
$0(Tier 2)
NOVOLOG MIX 70/30
$0(Tier 2)
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
$0(Tier 2)
NOVOLOG PENFILL
$0(Tier 2)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN TABLET
$0(Tier 2)
enoxaparin sodium
$0(Tier 1)
FONDAPARINUX SODIUM INJECTION 10MG/0.8ML,
$0(Tier 1)
5MG/0.4ML, 7.5MG/0.6ML
fondaparinux sodium injection 2.5mg/0.5ml
$0(Tier 1)
FRAGMIN INJECTION 10000UNIT/ML, 2500UNIT/0.2ML, $0(Tier 2) 5000UNIT/0.2ML
heparin sodium/d5w
$0(Tier 1) heparin sodium injection 10000unit/ml, 1000unit/ml,
$0(Tier 1) 20000unit/ml, 5000unit/ml
jantoven
$0(Tier 1)
PRADAXA CAPSULE 150MG, 75MG
$0(Tier 2)
PRADAXA CAPSULE 110MG
$0(Tier 2)
warfarin sodium tablet
$0(Tier 1)
XARELTO STARTER PACK
$0(Tier 2) XARELTO TABLET 10MG
$0(Tier 2) XARELTO TABLET 15MG, 20MG
$0(Tier 2)
Blood Formation Modifiers
anagrelide hydrochloride
$0(Tier 1)
ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML, $0(Tier 2)
25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML, $0(Tier 2)
100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML
EPOGEN INJECTION 10000UNIT/ML, 20000UNIT/ML,
$0(Tier 2)
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
GRANIX
LEUKINE INJECTION 250MCG
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (40 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
QL (45 ML per 30 days)
MO
MO
NDS
MO
MO
QL (60 EA per 30 days)
MO
MO
MO
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Blood
Products/Modifiers/
Volume Expanders) NDS
PA (Blood
Products/Modifiers/
Volume Expanders)
PA (Granix)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
42
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 2)
Name of drug
NEUPOGEN
PROCRIT
PROMACTA TABLET 50MG
$0(Tier 2)
PROMACTA TABLET 25MG
$0(Tier 2)
Coagulants
tranexamic acid injection
tranexamic acid tablet
Platelet Modifying Agents
aspirin/dipyridamole
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
BRILINTA
$0(Tier 2)
cilostazol
clopidogrel tablet 300mg
clopidogrel tablet 75mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dipyridamole tablet
$0(Tier 1)
EFFIENT
$0(Tier 2)
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er
clonidine hcl tablet
clonidine hcl patch weekly
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
guanfacine hcl
$0(Tier 1)
methyldopa/hydrochlorothiazide
$0(Tier 1)
methyldopa tablet 250mg, 500mg
$0(Tier 1)
methyldopate hcl
midodrine hcl
Alpha-adrenergic Blocking Agents
prazosin hcl capsule
Necessary actions,
restrictions, or limits on
use
PA (Neupogen) NDS
PA (Blood
Products/Modifiers/
Volume Expanders)
QL (30 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
QL (90 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Promacta) NDS
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
MO
MO
MO
QL (4 EA per 28 days)
MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
43
Name of drug
reserpine tablet 0.25mg
Angiotensin II Receptor Antagonists
BENICAR
What the drug
will cost you
(tier level)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
PA (High Risk
Medications) MO
$0(Tier 2)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
BENICAR HCT
$0(Tier 2)
candesartan cilexetil
$0(Tier 1)
candesartan cilexetil/hydrochlorothiazide
$0(Tier 1)
eprosartan mesylate
$0(Tier 1)
ezetimibe
$0(Tier 1)
irbesartan
$0(Tier 1)
irbesartan/hydrochlorothiazide
$0(Tier 1)
losartan potassium
$0(Tier 1)
losartan potassium/hydrochlorothiazide
$0(Tier 1)
olmesartan medoxomil
$0(Tier 1)
olmesartan medoxomil/hydrochlorothiazide
$0(Tier 1)
telmisartan
$0(Tier 1)
telmisartan/amlodipine
$0(Tier 1)
telmisartan/hydrochlorothiazide
$0(Tier 1)
valsartan
$0(Tier 1)
valsartan/hydrochlorothiazide
$0(Tier 1)
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
benazepril hcl tablet 10mg, 20mg, 5mg
$0(Tier 1)
$0(Tier 1)
benazepril hcl tablet 40mg
$0(Tier 1)
captopril/hydrochlorothiazide
captopril tablet
enalapril maleate/hydrochlorothiazide
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
44
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Name of drug
enalapril maleate tablet
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
$0(Tier 1)
ramipril
$0(Tier 1)
trandolapril tablet 1mg, 2mg
$0(Tier 1)
trandolapril tablet 4mg
$0(Tier 1)
Antiarrhythmics
amiodarone hcl tablet
amiodarone hcl injection 50mg/ml
disopyramide phosphate capsule
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
dofetilide
$0(Tier 1)
flecainide acetate
mexiletine hcl
MULTAQ
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
pacerone tablet 100mg, 200mg, 400mg
PROCAINAMIDE HCL INJECTION
propafenone hcl
quinidine gluconate cr
QUINIDINE GLUCONATE INJECTION
quinidine sulfate tablet
sorine
sotalol hcl (af) tablet 120mg
sotalol hcl tablet 160mg, 240mg, 80mg
Beta-adrenergic Blocking Agents
acebutolol hcl capsule
atenolol/chlorthalidone
atenolol tablet
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
carvedilol
labetalol hcl injection
labetalol hcl tablet
metoprolol succinate er
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
PA (High Risk
Medications) MO
QL (60 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
45
Name of drug
metoprolol tartrate injection
metoprolol tartrate tablet 100mg, 25mg, 50mg
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol tablet 20mg, 40mg, 80mg
pindolol tablet
propranolol hcl er
propranolol hcl injection
propranolol hcl oral solution, tablet
propranolol/hydrochlorothiazide
timolol maleate tablet 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
afeditab cr
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
amlodipine besylate/benazepril hydrochloride
$0(Tier 1)
amlodipine besylate/valsartan
$0(Tier 1)
amlodipine besylate tablet
$0(Tier 1)
amlodipine/valsartan/hctz
$0(Tier 1)
cartia xt
$0(Tier 1)
dilt-xr capsule extended release 24 hour 120mg, 240mg
$0(Tier 1)
dilt-xr capsule extended release 24 hour 180mg
$0(Tier 1)
diltiazem cd capsule extended release 24 hour 240mg
$0(Tier 1)
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 120mg,
300mg, 360mg, 420mg
diltiazem hcl er capsule extended release 12 hour
diltiazem hcl tablet
DILTIAZEM HCL INJECTION 100MG
diltiazem hcl injection 50mg/10ml
felodipine er
$0(Tier 1)
$0(Tier 1)
matzim la tablet extended release 24 hour 180mg, 240mg,
300mg
matzim la tablet extended release 24 hour 360mg, 420mg
$0(Tier 1)
nicardipine hcl capsule
nifedical xl
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
46
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
nifedipine er
taztia xt
$0(Tier 1)
verapamil hcl er tablet extended release
verapamil hcl er capsule extended release 24 hour
$0(Tier 1)
$0(Tier 1)
verapamil hcl sr capsule extended release 24 hour 360mg
verapamil hcl injection
verapamil hcl tablet
Cardiovascular Agents, Other
DEMSER
digitek tablet 0.125mg
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
digitek tablet 0.25mg
$0(Tier 1)
digoxin oral solution
$0(Tier 1)
digoxin injection 0.25mg/ml
$0(Tier 1)
digoxin tablet 125mcg
$0(Tier 1)
digoxin tablet 250mcg
$0(Tier 1)
LANOXIN INJECTION
$0(Tier 2)
LANOXIN TABLET 125MCG
$0(Tier 2)
LANOXIN TABLET 250MCG
$0(Tier 2)
NORTHERA CAPSULE 200MG, 300MG
$0(Tier 2)
NORTHERA CAPSULE 100MG
$0(Tier 2)
pentoxifylline er
RANEXA TABLET EXTENDED RELEASE 12 HOUR
1000MG
$0(Tier 1)
$0(Tier 2)
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
$0(Tier 2)
REPATHA
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
PA (High Risk Medication
- Digoxin)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
PA (High Risk Medication
- Digoxin) MO
QL (180 EA per 30 days)
PA (Northera)
QL (90 EA per 30 days)
PA (Northera)
MO
QL (60 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (90 EA per 30 days)
PA (Cardiovascular
Agents) MO
QL (3 ML per 30 days)
PA (Repatha)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
47
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
$0(Tier 2)
TEKTURNA
$0(Tier 2)
TEKTURNA HCT
$0(Tier 2)
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium
acetazolamide tablet
Diuretics, Loop
bumetanide injection
bumetanide tablet
furosemide injection
furosemide oral solution, tablet
torsemide tablet
Diuretics, Potassium-sparing
amiloride hcl tablet
amiloride/hydrochlorothiazide
DYRENIUM
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tablet
triamterene/hydrochlorothiazide
Diuretics, Thiazide
chlorothiazide
chlorothiazide sodium
chlorthalidone tablet 25mg, 50mg
hydrochlorothiazide capsule, tablet
indapamide tablet
methyclothiazide tablet
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (3.5 ML per 28 days)
PA (Repatha) NDS
QL (3 ML per 30 days)
PA (Repatha)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
fenofibrate capsule 130mg, 43mg
$0(Tier 1)
fenofibrate tablet
$0(Tier 1)
fenofibric acid tablet 105mg
$0(Tier 1)
fenofibric acid tablet 35mg
$0(Tier 1)
gemfibrozil tablet
$0(Tier 1)
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
48
Name of drug
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
fluvastatin sodium er
$0(Tier 1)
fluvastatin capsule 40mg
$0(Tier 1)
fluvastatin capsule 20mg
$0(Tier 1)
lovastatin tablet 10mg, 20mg
$0(Tier 1)
lovastatin tablet 40mg
$0(Tier 1)
pravastatin sodium
$0(Tier 1)
rosuvastatin calcium
$0(Tier 1)
simvastatin tablet
$0(Tier 1)
Dyslipidemics, Other
cholestyramine light
colestipol hcl granules, tablet
cvs niacin flush free
eql niacin
gnp niacin
gnp niacin flush free
JUXTAPID CAPSULE 10MG, 40MG, 5MG, 60MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
JUXTAPID CAPSULE 30MG
$0(Tier 2)
JUXTAPID CAPSULE 20MG
$0(Tier 2)
KYNAMRO
$0(Tier 2)
niacin er tablet extended release 500mg
$0(Tier 1)
niacin er tablet extended release 1000mg, 750mg
$0(Tier 1)
niacin flush free formula
niacin flush free capsule 100mg; 400mg, 500mg
NIACIN FLUSH-FREE EXTRA STRENGTH
niacin tablet 100mg, 250mg, 500mg, 50mg
niacor
no flush niacin capsule
omega-3-acid ethyl esters
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
MO
MO
DP
DP
DP
DP
QL (30 EA per 30 days)
PA (Juxtapid) MO
QL (60 EA per 30 days)
PA (Juxtapid) MO
QL (90 EA per 30 days)
PA (Juxtapid) MO
QL (4 ML per 28 days)
PA (Kynamro)
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
DP
DP
DP
DP
MO
DP
QL (120 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
49
Name of drug
prevalite powder
ra niacin tablet 100mg
th niacin flush free
WELCHOL
ZETIA
Vasodilators, Direct-acting Arterial/Venous
BIDIL
isosorbide dinitrate er
isosorbide dinitrate tablet 10mg, 20mg, 30mg, 5mg
isosorbide mononitrate
isosorbide mononitrate er
NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR
nitroglycerin transdermal
nitroglycerin injection 5mg/ml
nitroglycerin tablet sublingual 0.3mg, 0.4mg, 0.6mg
NITROSTAT TABLET SUBLINGUAL
Vasodilators, Direct-acting Arterial
hydralazine hcl injection
hydralazine hcl tablet
minoxidil tablet
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg;
5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg
dextroamphetamine sulfate tablet
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
guanfacine er
INTUNIV
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
MO
DP
DP
MO
QL (30 EA per 30 days)
MO
$0(Tier 2)
QL (180 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (60 EA per 30 days)
$0(Tier 1)
QL (90 EA per 30 days)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 30MG $0(Tier 2)
METADATE CD CAPSULE EXTENDED RELEASE 20MG $0(Tier 2)
methylphenidate hcl cd capsule extended release 30mg
$0(Tier 1)
methylphenidate hcl cd capsule extended release 10mg, 50mg, $0(Tier 1)
60mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
40mg
methylphenidate hcl er capsule extended release 24 hour
$0(Tier 1)
20mg
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
50
Name of drug
methylphenidate hcl er tablet extended release 20mg
methylphenidate hcl tablet
STRATTERA
Central Nervous System, Other
HETLIOZ
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
$0(Tier 2)
QL (30 EA per 30 days)
PA (Hetlioz) NDS
QL (60 EA per 30 days)
NUEDEXTA
riluzole
tetrabenazine tablet 25mg
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
tetrabenazine tablet 12.5mg
$0(Tier 1)
Fibromyalgia Agents
SAVELLA
$0(Tier 2)
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AMPYRA
QL (120 EA per 30 days)
PA (Tetrabenazine)
QL (180 EA per 30 days)
PA (Tetrabenazine)
QL (60 EA per 30 days)
MO
$0(Tier 2)
$0(Tier 2)
AUBAGIO
$0(Tier 2)
AVONEX
AVONEX PEN
BETASERON
GILENYA
glatopa
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
TECFIDERA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
TECFIDERA STARTER PACK
TYSABRI
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse
chlorhexidine gluconate solution
KEPIVANCE
periogard
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride
triamcinolone in orabase
Dermatological Agents
Dermatological Agents
adapalene gel 0.1%
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (60 EA per 30 days)
PA (Ampyra) NDS
QL (30 EA per 30 days)
PA (Aubagio) NDS
PA (Avonex) NDS
PA (Avonex) NDS
PA (Betaseron) NDS
PA (Gilenya) NDS
PA (Copaxone) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
PA (Rebif) NDS
QL (60 EA per 30 days)
PA (Tecfidera)
PA (Tecfidera)
PA (Tysabri) NDS
MO
MO
$0(Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
51
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
Name of drug
adapalene cream
ammonium lactate cream, lotion
calcipotriene cream, ointment
calcipotriene solution
claravis
clindamycin/benzoyl peroxide gel 5%; 1%
clotrimazole/betamethasone dipropionate
curity gauze pads 2"x2"
diclofenac sodium gel 1%
e-oil external oil 100unit/5drop
ELIDEL
erythromycin/benzoyl peroxide
fluorouracil cream 5%
fluorouracil cream 0.5%
fluorouracil external solution 2%, 5%
imiquimod cream
methoxsalen capsule
PICATO
podofilox solution
SANTYL
selenium sulfide lotion
SORIATANE CAPSULE 10MG, 17.5MG, 25MG
tacrolimus ointment 0.03%, 0.1%
TAZORAC
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%, 0.05%
UVADEX
VEREGEN
VOLTAREN
ZONALON
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CEREZYME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME INJECTION 35MG
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (240 GM per 30 days)
QL (60 ML per 30 days)
QL (204 EA per 30 days)
DP
QL (60 GM per 30 days)
PA (Dermatological
Agents)
NDS
QL (24 EA per 30 days)
NDS
QL (60 GM per 30 days)
PA (Dermatological
Agents)
QL (90 GM per 30 days)
QL (15 GM per 30 days)
NDS
PA (cerezyme) NDS
MO
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
52
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
KUVAN
LUMIZYME
NAGLAZYME
PANCREAZE
RAVICTI
sodium phenylbutyrate powder
SUCRAID
VPRIV
ZAVESCA
ZENPEP
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE INJECTION 0.25MG/5ML
atropine sulfate injection 0.5mg/5ml
dicyclomine hcl
glycopyrrolate tablet
glycopyrrolate injection 4mg/20ml
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
cromolyn sodium concentrate 100mg/5ml
diphenoxylate/atropine tablet
GATTEX
gavilyte-h
loperamide hcl capsule
magnesium oxide tablet 400mg
metoclopramide hcl injection, oral solution, tablet
RELISTOR INJECTION
RELISTOR TABLET
ursodiol capsule, tablet
Histamine2 (H2) Receptor Antagonists
cimetidine hcl solution
cimetidine tablet
FAMOTIDINE PREMIXED
famotidine injection 20mg/2ml
famotidine tablet 20mg, 40mg
ranitidine hcl capsule, syrup
ranitidine hcl injection 150mg/6ml, 50mg/2ml
ranitidine hcl tablet 150mg, 300mg
ZANTAC INJECTION 25MG/ML
Irritable Bowel Syndrome Agents
alosetron hydrochloride
AMITIZA
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Enzyme
Replacements/ Modifiers Kuvan) NDS
NDS
MO
NDS
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
PA (Gattex) NDS
MO
DP
QL (90 EA per 30 days)
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
MO
MO
$0(Tier 1)
QL (60 EA per 30 days)
PA (Irritable Bowel
Syndrome Agents) NDS
MO
$0(Tier 2)
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
53
Name of drug
Laxatives
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
lactulose solution
NULYTELY/FLAVOR PACKS
peg-3350/nacl/na bicarbonate/kcl
polyethylene glycol 3350 powder
trilyte
Protectants
misoprostol
sucralfate tablet
Proton Pump Inhibitors
esomeprazole magnesium
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (90 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
esomeprazole sodium
lansoprazole capsule delayed release 15mg
$0(Tier 1)
$0(Tier 1)
lansoprazole capsule delayed release 30mg
$0(Tier 1)
omeprazole capsule delayed release 10mg
$0(Tier 1)
omeprazole capsule delayed release 20mg, 40mg
$0(Tier 1)
pantoprazole sodium injection
pantoprazole sodium tablet delayed release 20mg
$0(Tier 1)
$0(Tier 1)
pantoprazole sodium tablet delayed release 40mg
$0(Tier 1)
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide er
$0(Tier 1)
flavoxate hcl
MYRBETRIQ
$0(Tier 1)
$0(Tier 2)
oxybutynin chloride er
oxybutynin chloride tablet
tolterodine tartrate
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
tolterodine tartrate er
$0(Tier 1)
MO
MO
QL (30 EA per 30 days)
MO
MO
QL (30 EA per 30 days)
MO
MO
MO
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
Benign Prostatic Hypertrophy Agents
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
54
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
alfuzosin hcl er
doxazosin
doxazosin mesylate tablet 1mg, 2mg, 8mg
dutasteride
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
finasteride tablet 5mg
$0(Tier 1)
tamsulosin hcl
$0(Tier 1)
terazosin hcl capsule
Genitourinary Agents, Other
bethanechol chloride
ELMIRON
Phosphate Binders
calcium acetate capsule
calcium acetate tablet 667mg
ELIPHOS
FOSRENOL TABLET CHEWABLE 1000MG, 500MG,
750MG
RENVELA TABLET
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
A-HYDROCORT INJECTION 100MG
alclometasone dipropionate cream, ointment
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate cream, lotion, ointment
betamethasone valerate cream, lotion, ointment
budesonide capsule delayed release particles 3mg
clobetasol propionate e
clobetasol propionate gel, ointment, shampoo, solution
clodan
cortisone acetate tablet 25mg
DEPO-MEDROL INJECTION 20MG/ML
desonide cream, lotion, ointment
desoximetasone cream, gel, ointment
dexamethasone sodium phosphate injection 120mg/30ml
dexamethasone elixir
dexamethasone tablet 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg,
6mg
fludrocortisone acetate tablet
fluocinolone acetonide cream, oil, ointment, solution
fluocinonide-e
fluocinonide gel, ointment, solution
fluticasone propionate cream 0.05%
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (30 EA per 30 days)
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
MO
$0(Tier 2)
NDS
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1) $0(Tier 1)
$0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
55
Name of drug
fluticasone propionate ointment 0.005%
halobetasol propionate
hydrocortisone butyrate ointment, solution
hydrocortisone valerate cream, ointment
hydrocortisone cream 1%, 2.5%
hydrocortisone enema
hydrocortisone tablet
hydrocortisone lotion 2.5%
hydrocortisone ointment 1%, 2.5%
methylprednisolone acetate injection 40mg/ml, 80mg/ml
methylprednisolone dose pack tablet therapy pack
methylprednisolone sodiumsuccinate injection 1000mg,
125mg, 40mg
methylprednisolone tablet
mometasone furoate cream 0.1%
mometasone furoate ointment 0.1%
prednicarbate cream
prednisolone sodium phosphate oral solution 10mg/5ml,
15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml
prednisone solution
prednisone tablet 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg
procto-med hc
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF INJECTION 100MG, 250MG
SOLU-MEDROL INJECTION 125MG, 2GM, 40MG,
500MG
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5%
triderm
UCERIS FOAM
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
desmopressin acetate injection
desmopressin acetate tablet
INCRELEX
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML,
30MG/3ML, 5MG/1.5ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
pregnyl w/diluent benzyl alcohol/nacl
$0(Tier 1)
PA (Chorionic
Gonadotropin)
MO
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Chorionic
Gonadotropin)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
56
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
SAIZEN
SAIZEN CLICK.EASY
$0(Tier 2)
SEROSTIM INJECTION 4MG, 5MG, 6MG
$0(Tier 2)
STIMATE SOLUTION
ZORBTIVE
$0(Tier 2)
$0(Tier 2)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
oxandrolone tablet
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR, 4MG/24HR
danazol capsule
METHITEST
testosterone cypionate injection
testosterone enanthate injection
Estrogens
ALORA
apri
aranelle
aubra
aviane
balziva
bekyree
blisovi fe 1.5/30
caziant
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary))
NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Serostim) NDS
PA (Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary) Zorbtive)
QL (120 EA per 30 days)
PA (Korlym)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
QL (8 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
57
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
CLIMARA PRO
cryselle-28
cyclafem 1/35
delyla
DEPO-ESTRADIOL INJECTION 5MG/ML
desogestrel/ethinyl estradiol tablet 0; 0
drospirenone/ethinyl estradiol tablet 3mg; 0.02mg
enpresse-28
ESTRACE CREAM
estradiol valerate injection 20mg/ml, 40mg/ml
estradiol tablet
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
estradiol patch weekly
$0(Tier 1)
estropipate tablet
$0(Tier 1)
ethynodiol diacetate/ethinyl estradiol
falmina
gildess 1.5/30
introvale
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kariva
kelnor 1/35
kimidess
larin 1.5/30
leena
lessina
levonorgestrel/ethinyl estradiol tablet 0; 0
levora 0.15/30-28
low-ogestrel
lutera
marlissa
MENEST
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
MO
MO
MO
MO
MO
MO
MO
PA (High Risk
Medications) MO
QL (4 EA per 28 days) PA
(High Risk Medications)
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA (High Risk
Medications) MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
58
What the drug
will cost you
Name of drug
(tier level)
mononessa
$0(Tier 1)
necon 0.5/35-28
$0(Tier 1)
necon 1/35
$0(Tier 1)
necon 10/11-28
$0(Tier 1)
necon 7/7/7
$0(Tier 1)
norethindrone acetate/ethinyl estradiol
$0(Tier 1)
norgestimate/ethinyl estradiol
$0(Tier 1)
nortrel 0.5/35 (28)
$0(Tier 1)
nortrel 1/35
$0(Tier 1)
nortrel 7/7/7
$0(Tier 1)
OGESTREL
$0(Tier 2)
portia-28
$0(Tier 1)
PREMARIN INJECTION
$0(Tier 2)
PREMARIN CREAM
$0(Tier 2)
PREMARIN TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, $0(Tier 2)
1.25MG
$0(Tier 1)
$0(Tier 1)
MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
PA (High Risk
Medications) MO
QL (30 EA per 30 days)
PA (High Risk
Medications) MO
MO
QL (91 EA per 91 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (3 EA per 28 days)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
NDS
MO
PREMPHASE
$0(Tier 2)
PREMPRO
$0(Tier 2)
previfem
quasense
$0(Tier 1)
$0(Tier 1)
sprintec 28
sronyx
tri-lo-estarylla
tri-lo-sprintec
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vienva
xulane
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zovia 1/35e
zovia 1/50e
Progestins
camila
deblitane
DEPO-SUBQ PROVERA 104
errin
hydroxyprogesterone caproate injection
jolivette
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
59
Name of drug
lyza
medroxyprogesterone acetate injection, tablet
megestrol acetate tablet
megestrol acetate suspension 625mg/5ml
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
megestrol acetate suspension 40mg/ml
$0(Tier 1)
nora-be
norethindrone acetate tablet
norethindrone tablet
norlyroc
progesterone capsule
PROMETRIUM
sharobel
Selective Estrogen Receptor Modifying Agents
EVISTA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
raloxifene hydrochloride
$0(Tier 1)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL
levothyroxine sodium tablet
levoxyl tablet 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg
liothyronine sodium injection
liothyronine sodium tablet
POTASSIUM IODIDE
SYNTHROID TABLET
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
unithroid tablet 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 90MG
SENSIPAR TABLET 30MG
SENSIPAR TABLET 60MG
Necessary actions,
restrictions, or limits on
use
MO
MO
PA (High Risk
Medications)
PA (High Risk
Medications) MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days)
MO
QL (30 EA per 30 days)
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
MO
DP
MO
MO
MO
MO
MO
MO
MO
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
QL (120 EA per 30 days)
NDS
QL (60 EA per 30 days)
QL (60 EA per 30 days)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
60
Name of drug
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
ELIGARD
FIRMAGON
leuprolide acetate injection
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT-PED (1-MONTH) INJECTION 11.25MG,
15MG
octreotide acetate
SIGNIFOR
SOMATULINE DEPOT INJECTION 120MG/0.5ML,
90MG/0.3ML
SOMAVERT
SYNAREL
TRELSTAR MIXJECT
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet 10mg, 5mg
propylthiouracil tablet
Immunological Agents
Angioedema (HAE) Agents
CINRYZE
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
FIRAZYR
Immune Suppressants
AZASAN
azathioprine tablet
BENLYSTA
CELLCEPT INTRAVENOUS
cyclosporine modified
cyclosporine capsule, injection
ENBREL
NDS
NDS
PA (Hormonal Agents,
Suppressant (Pituitary) Somavert) NDS
NDS
$0(Tier 1)
$0(Tier 1)
MO
MO
$0(Tier 2) QL (100 EA per 30 days)
PA (Blood
Products/Modifiers/
Volume Expanders Cinryze) NDS
PA (FIRAZYR) NDS
$0(Tier 2) $0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
ENBREL SURECLICK
$0(Tier 2)
ENVARSUS XR
gengraf
$0(Tier 2)
$0(Tier 1)
B/D
B/D MO
PA (Benlysta) NDS
B/D
B/D
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
61
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
HUMIRA
HUMIRA PEN
$0(Tier 2)
HUMIRA PEN-CROHNS DISEASESTARTER
$0(Tier 2)
HUMIRA PEN-PSORIASIS STARTER
$0(Tier 2)
KINERET
$0(Tier 2)
methotrexate sodium injection 1gm/40ml, 1gm, 50mg/2ml
methotrexate tablet
mycophenolate mofetil
mycophenolic acid dr
NULOJIX
ORENCIA
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
ORENCIA CLICKJECT
$0(Tier 2)
PROGRAF INJECTION
RAPAMUNE SOLUTION
REMICADE
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
sirolimus tablet
tacrolimus capsule 0.5mg, 1mg, 5mg
TORISEL
ZORTRESS
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D
GAMMAGARD LIQUID INJECTION 2.5GM/25ML
GAMUNEX-C INJECTION 1GM/10ML
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS INJECTION 180MG
leflunomide
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
B/D
B/D MO
B/D
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
B/D
B/D NDS
PA (Immunological
Agents) NDS
B/D
B/D
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
B/D
B/D NDS
B/D NDS
B/D
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
NDS
$0(Tier 1)
SIMULECT INJECTION 20MG
SYNAGIS INJECTION 50MG/0.5ML
Vaccines
ACTHIB INJECTION 0
Necessary actions,
restrictions, or limits on
use
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
PA (Immunological
Agents) NDS
QL (28 ML per 28 days)
PA (Immunological
Agents) NDS
$0(Tier 2)
$0(Tier 2)
QL (2.4 EA per 28 days)
PA (Immunological
Agents - Ilaris)
QL (30 EA per 30 days)
MO
B/D
$0(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
62
Name of drug
ADACEL
bcg vaccine
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX INJECTION 1440ELU/ML, 720ELU/0.5ML
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB INJECTION 7.5MCG/0.5ML
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ SOLUTION
TENIVAC
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VARIZIG
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
DELZICOL
DIPENTUM
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
B/D
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
MO
MO
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
63
What the drug
will cost you
(tier level)
$0(Tier 1)
Name of drug
mesalamine dr
mesalamine kit
Sulfonamides
sulfasalazine tablet, tablet delayed release
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tablet 10mg, 40mg, 5mg
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
QL (180 EA per 30 days)
MO
MO
$0(Tier 1)
MO
$0(Tier 1)
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
QL (8 EA per 28 days)
QL (4 ML per 30 days)
MO
MO
alendronate sodium tablet 70mg
$0(Tier 1)
alendronate sodium tablet 35mg
calcitonin-salmon solution
$0(Tier 1)
$0(Tier 1)
calcitriol capsule, oral solution
calcitriol injection 1mcg/ml
doxercalciferol capsule 0.5mcg, 1mcg
doxercalciferol capsule 2.5mcg
doxercalciferol injection
etidronate disodium
FORTEO INJECTION 600MCG/2.4ML
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
fortical
$0(Tier 1)
ibandronate sodium tablet
$0(Tier 1)
MIACALCIN INJECTION
PAMIDRONATE DISODIUM INJECTION 6MG/ML
pamidronate disodium injection 30mg/10ml, 90mg/10ml
PROLIA
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
risedronate sodium dr
$0(Tier 1)
risedronate sodium tablet 30mg, 5mg
$0(Tier 1)
risedronate sodium tablet 35mg
$0(Tier 1)
XGEVA
zoledronic acid injection 4mg/5ml, 5mg/100ml
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
MO
NDS
MO
PA (metabolic bone
disease agents - IV
osteoporosis)
QL (4 ML per 30 days)
MO
QL (1 EA per 30 days)
MO
QL (1 ML per 180 days)
PA (Metabolic Bone
Disease Agents - Prolia)
QL (4 EA per 28 days)
MO
QL (30 EA per 30 days)
MO
QL (4 EA per 28 days)
MO
NDS
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
64
What the drug
will cost you
Name of drug
(tier level)
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" $0(Tier 2)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
$0(Tier 2)
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
$0(Tier 1)
$0(Tier 2)
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
bd pen needles short/ultrafine/31g x 5/16"
BOTOX INJECTION 200UNIT
$0(Tier 1)
$0(Tier 2)
CALCIUM PANTOTHENATE TABLET 100MG, 200MG
calcium pantothenate tablet 500mg
CARNITOR INJECTION
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
exel comfort point insulin pen needles 31g x 8mm
FERRIPROX TABLET
insupen ultrafin 31gx8mm
INTRALIPID INJECTION 30GM/100ML
intralipid injection 20gm/100ml
IOSAT
kp fish oil
lactated ringers irrigation
levocarnitine solution, tablet
lite touch pen needles/31g x 3/16"
methylergonovine maleate tablet
monoject insulin syringe/detach needle/1ml/25g x 5/8"
NATPARA
novofine 32gx6mm
nutrilipid
pantothenic acid
physiolyte
physiosol irrigation
prostamen
ringers irrigation
sterile water irrigation
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
THYROSAFE
THYROSHIELD
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
QL (200 EA per 30 days)
MO
QL (200 EA per 30 days)
MO
MO
QL (200 EA per 30 days)
MO
MO
MO
MO
QL (200 EA per 30 days)
MO
MO
PA (Miscellaneous
Therapeutic Agents Botox)
DP
DP
MO
MO
MO
MO
B/D
B/D
DP
DP
MO
MO
MO
PA (Natpara) NDS
MO
B/D
DP
DP
MO
MO
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
65
Name of drug
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
VENALIV
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN
latanoprost
LUMIGAN
Ophthalmic Agents, Other
bacitracin/polymyxin b
CYSTARAN
naphazoline hcl
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
polymyxin b sulfate/trimethoprim sulfate
RESTASIS
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
olopatadine hcl ophthalmic solution 0.1%
PATANOL
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic solution 0.1%
diclofenac sodium solution 0.1%
DUREZOL
fluorometholone
flurbiprofen sodium
ketorolac tromethamine ophthalmic solution 0.4%, 0.5%
LOTEMAX SUSPENSION
neomycin/polymyxin/dexamethasone
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate ophthalmic solution 1%
sulfacetamide sodium/prednisolone sodium phosphate
TOBRADEX OINTMENT
tobramycin/dexamethasone
Ophthalmic Antiglaucoma Agents
acetazolamide er
ALPHAGAN P SOLUTION 0.1%
betaxolol hcl solution 0.5%
brimonidine tartrate
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
levobunolol hcl solution 0.5%
What the drug
will cost you
(tier level)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
MO
MO
DP
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
MO
MO
MO
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
QL (60 EA per 30 days)
MO
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
66
What the drug
will cost you
Name of drug
(tier level)
methazolamide tablet
$0(Tier 1)
metipranolol
$0(Tier 1)
PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED $0(Tier 2)
0.125%
pilocarpine hcl solution 1%, 2%, 4%
$0(Tier 1)
timolol maleate ophthalmic gel forming
$0(Tier 1)
timolol maleate solution 0.25%, 0.5%
$0(Tier 1)
Otic Agents
Otic Agents
acetasol hc
$0(Tier 1)
acetic acid
$0(Tier 1)
CIPRODEX
$0(Tier 2)
hydrocortisone/acetic acid
$0(Tier 1)
neomycin/polymyxin/hc
$0(Tier 1)
neomycin/polymyxin/hydrocortisone otic suspension 1%;
$0(Tier 1)
3.5mg/ml; 10000unit/ml
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
$0(Tier 2)
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT,
45MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT
$0(Tier 2)
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
budesonide inhalation suspension 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml
budesonide nasal suspension 32mcg/act
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
DULERA
FLOVENT DISKUS
FLOVENT HFA AEROSOL 44MCG/ACT
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT $0(Tier 2)
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
$0(Tier 1)
$0(Tier 1)
mometasone furoate suspension 50mcg/act
SYMBICORT
$0(Tier 1)
$0(Tier 2)
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
MO
MO
QL (12 GM per 30 days)
MO
MO
MO
MO
MO
B/D MO
QL (17.2 GM per 30 days)
MO
MO
MO
QL (21.2 GM per 30 days)
MO
QL (24 GM per 30 days)
MO
MO
QL (32 GM per 30 days)
MO
QL (34 GM per 30 days)
QL (10.2 GM per 30 days)
MO
QL (33 GM per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
67
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 1)
Name of drug
ALA-HIST PE
all day allergy childrens solution 5mg/5ml
azelastine hcl solution 0.15%
azelastine hcl solution 0.1%
cetirizine hcl tablet chewable 10mg
cetirizine hcl tablet 10mg
cvs indoor/outdoor allergy relief
cyproheptadine hcl syrup, tablet
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
DALLERGY TABLET 1MG; 5MG
diphenhydramine hcl injection 50mg/ml
eql all day allergy
hydroxyzine hcl injection, syrup, tablet
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
hydroxyzine pamoate capsule
$0(Tier 1)
levocetirizine dihydrochloride solution
levocetirizine dihydrochloride tablet
$0(Tier 1)
$0(Tier 1)
NASOPEN PE
olopatadine hcl nasal solution 0.6%
RYMED TABLET 2MG; 10MG
wal-zyr all day allergy childrens
Antileukotrienes
montelukast sodium
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
zafirlukast
$0(Tier 1)
ZYFLO CR
$0(Tier 2)
Bronchodilators, Anticholinergic
ATROVENT HFA
$0(Tier 2)
COMBIVENT RESPIMAT
$0(Tier 2)
ipratropium bromide/albuterol sulfate
$0(Tier 1)
ipratropium bromide inhalation solution
$0(Tier 1)
ipratropium bromide nasal solution 0.06%
$0(Tier 1)
ipratropium bromide nasal solution 0.03%
$0(Tier 1)
SPIRIVA HANDIHALER
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
DP
MO
QL (30 ML per 30 days)
MO
DP
DP
DP
PA (High Risk
Medications) MO
DP
DP
PA (High Risk
Medications)
PA (High Risk
Medications)
MO
QL (30 EA per 30 days)
MO
DP
DP
DP
QL (30 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
QL (120 EA per 30 days)
MO
QL (39 GM per 30 days)
MO
QL (8 GM per 30 days)
MO
QL (540 ML per 30 days)
B/D MO
QL (300 ML per 30 days)
B/D MO
QL (15 ML per 30 days)
MO
QL (30 ML per 30 days)
MO
QL (30 EA per 30 days)
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
68
Name of drug
SPIRIVA RESPIMAT
Bronchodilators, Sympathomimetic
ADRENACLICK
albuterol sulfate er
albuterol sulfate syrup, tablet
albuterol sulfate nebulization solution 0.083%
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (8 GM per 30 days)
MO
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
albuterol sulfate nebulization solution 0.63mg/3ml,
1.25mg/3ml
albuterol sulfate nebulization solution 0.5%
$0(Tier 1)
EPINEPHRINE INJECTION 0.15MG/0.15ML,
0.3MG/0.3ML
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
levalbuterol hcl nebulization solution 0.31mg/3ml,
0.63mg/3ml
levalbuterol tartrate hfa
$0(Tier 2)
QL (4 EA per 30 days)
MO
MO
QL (1170 ML per 30
days) B/D MO
QL (1200 ML per 30
days) B/D MO
QL (200 ML per 30 days)
B/D MO
QL (4 EA per 30 days)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
QL (4 EA per 30 days)
QL (4 EA per 30 days)
B/D MO
$0(Tier 1)
levalbuterol nebulization solution
metaproterenol sulfate syrup, tablet
PROAIR HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
PROAIR RESPICLICK
$0(Tier 2)
SEREVENT DISKUS
$0(Tier 2)
QL (45 GM per 30 days)
MO
B/D MO
MO
QL (36 GM per 30 days)
MO
QL (2 EA per 30 days)
MO
QL (60 EA per 30 days)
MO
terbutaline sulfate injection
terbutaline sulfate tablet
VENTOLIN HFA
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
XOPENEX HFA
$0(Tier 2)
XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML
$0(Tier 2)
Cystic Fibrosis Agents
CAYSTON
$0(Tier 1)
$0(Tier 2)
KALYDECO PACKET
$0(Tier 2)
KALYDECO TABLET
$0(Tier 2)
ORKAMBI TABLET 125MG; 200MG
$0(Tier 2)
MO
QL (36 GM per 30 days)
MO
QL (45 GM per 30 days)
MO
QL (450 ML per 30 days)
B/D MO
PA (Antibacterials - Beta
lactam, Other) NDS
QL (56 EA per 28 days)
PA (Kalydeco) NDS
QL (60 EA per 30 days)
PA (Kalydeco) NDS
QL (112 EA per 28 days)
PA (Orkambi)
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
69
What the drug
will cost you
(tier level)
$0(Tier 2)
Name of drug
ORKAMBI TABLET 125MG; 100MG
PULMOZYME
TOBI PODHALER
tobramycin
Mast Cell Stabilizers
cromolyn sodium nebulization solution 20mg/2ml
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection
$0(Tier 1)
DALIRESP
$0(Tier 2)
ELIXOPHYLLIN
$0(Tier 2)
THEO-24
$0(Tier 2)
theophylline cr tablet extended release 12 hour 100mg, 200mg$0(Tier 1)
theophylline er tablet extended release 24 hour
$0(Tier 1)
theophylline er tablet extended release 12 hour 300mg, 450mg$0(Tier 1)
theophylline solution
$0(Tier 1)
Pulmonary Antihypertensives
ADCIRCA
$0(Tier 2)
ADEMPAS
$0(Tier 2)
LETAIRIS
OPSUMIT
$0(Tier 2)
$0(Tier 2)
ORENITRAM
sildenafil injection
sildenafil tablet
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
TRACLEER
$0(Tier 2)
TYVASO
UPTRAVI TABLET THERAPY PACK
UPTRAVI TABLET
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
Respiratory Tract Agents, Other
acetylcysteine solution
ARALAST NP INJECTION 500MG
ESBRIET CAPSULE
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
OFEV
$0(Tier 2)
PROLASTIN-C
promethazine vc plain
XOLAIR
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
QL (112 EA per 28 days)
PA (Orkambi) NDS
B/D
B/D
QL (305 ML per 30 days)
B/D MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days)
PA (Adcirca)
QL (90 EA per 30 days)
PA (Adempas) NDS
NDS
QL (30 EA per 30 days)
PA (Opsumit)
PA (Orenitram)
PA (Sildenafil - IV)
QL (90 EA per 30 days)
PA (Sildenafil - PAH)
QL (60 EA per 30 days)
LA NDS
B/D
PA (Uptravi)
QL (60 EA per 30 days)
PA (Uptravi)
B/D
NDS
QL (270 EA per 30 days)
PA (Esbriet) NDS
QL (60 EA per 30 days)
PA (Ofev) NDS
NDS
PA (Respiratory Tract
Agents) NDS
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
70
Name of drug
ZEMAIRA
ZINC W/A&C
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet 500mg
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
NDS
DP
$0(Tier 1)
PA (High Risk
Medications)
QL (90 EA per 30 days)
PA (High Risk
Medications)
PA (High Risk
Medications)
PA (High Risk
Medications)
cyclobenzaprine hcl tablet 10mg, 5mg
$0(Tier 1)
methocarbamol tablet
$0(Tier 1)
orphenadrine citrate er
$0(Tier 1)
orphenadrine citrate injection
Sleep Disorder Agents
GABA Receptor Modulators
flurazepam hcl
temazepam capsule 15mg, 30mg
zaleplon
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
zolpidem tartrate er
$0(Tier 1)
zolpidem tartrate tablet
$0(Tier 1)
Sleep Disorders, Other
modafinil tablet 200mg
$0(Tier 1)
ROZEREM
XYREM
$0(Tier 2)
$0(Tier 2)
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CARBAGLU
CHEMET
DEPEN TITRATABS
EXJADE
kionex powder
MYKIDZ IRON 10
sm iron slow release tablet extended release 142mg
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (30 EA per 30 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (90 EA per 365 days)
PA (High Risk Medication
- Nonbenzodiazepine
Hypnotics)
QL (30 EA per 30 days)
PA (Central Nervous
System Agents) MO
QL (30 EA per 30 days)
QL (540 ML per 30 days)
LA NDS
NDS
MO
NDS
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
71
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
Name of drug
SODIUM LACTATE INJECTION 5MEQ/ML
sodium polystyrene sulfonate suspension
sps
SYPRINE
Electrolyte/Mineral Replacement
abatron
$0(Tier 3)
abatron af
$0(Tier 3)
AMINOSYN 7%/ELECTROLYTES
$0(Tier 2)
aminosyn 8.5%/electrolytes
$0(Tier 1)
aminosyn ii 8.5%/electrolytes
$0(Tier 1)
AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; $0(Tier 2)
1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML
AMINOSYN-HBC
$0(Tier 2)
AMINOSYN-PF 7%
$0(Tier 2)
AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; $0(Tier 2)
1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML
AMINOSYN-RF
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
DP
DP
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
72
Name of drug
AMMONIUM CHLORIDE
calcium carbonate/vitamin d tablet 600mg; 400unit
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
DEXTROSE 10%/NACL 0.45%
dextrose 10%
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
DUOFER
eql iron supplement therapy
eql slow release iron
ezfe 200
fe c tab plus
FEOSOL BIFERA
FEOSOL TABLET 200MG, 45MG
FER-IN-SOL SOLUTION
fer-iron
ferate tablet 27mg
FERGON TABLET 240MG
ferosul
FERRETTS
FERRETTS IPS
ferrex 150
FERRIMIN 150
FERRLECIT
What the drug
will cost you
(tier level)
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
73
Name of drug
ferro-bob
ferrous drops
ferrous fumarate 324
FERROUS FUMARATE TABLET 29MG
FERROUS GLUCONATE TABLET 225MG, 324MG
ferrous gluconate tablet 240mg, 324mg, 325mg
ferrous sulfate elixir 220mg/5ml
FERROUS SULFATE LIQUID 220MG/5ML
ferrous sulfate solution 15mg/ml
FERROUS SULFATE SYRUP 300MG/5ML
FERROUS SULFATE TABLET DELAYED RELEASE
324MG
ferrous sulfate tablet delayed release 325mg
FERROUS SULFATE TABLET EXTENDED RELEASE
140MG
ferrous sulfate tablet 325mg
ferrousul
FOLITAB 500
FREAMINE HBC 6.9%
gnp iron tablet extended release 45mg
gnp iron tablet 200mg
gnp slow release iron tablet extended release 47.5mg
HEMOCYTE
hepatamine
hm iron
iferex 150
INFED
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iron 100 plus
iron complex
IRON FORMULA CAPSULE 100MCG; 400MCG; 27MG
iron supplement
iron supplement childrens
IRON UP
IRON TABLET 256MG, 90MG
iron tablet 27mg
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelp tablet 150mcg
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 2)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 1)
$0(Tier 1)
$0(Tier 2)
$0(Tier 3)
DP
DP
DP
B/D
DP
DP
DP
DP
B/D
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
74
What the drug
will cost you
Name of drug
(tier level)
klor-con 10
$0(Tier 1)
klor-con 8
$0(Tier 1)
klor-con m10
$0(Tier 1)
klor-con m15
$0(Tier 1)
klor-con m20
$0(Tier 1)
kp ferrous gluconate
$0(Tier 3)
kp ferrous sulfate
$0(Tier 3)
lactated ringers viaflex
$0(Tier 1)
magnesium sulfate injection 50%
$0(Tier 1)
MOZOBIL
$0(Tier 2)
myferon 150
$0(Tier 3)
NEPHRAMINE
$0(Tier 2)
normosol-m in d5w
$0(Tier 1)
NORMOSOL-R
$0(Tier 2)
NORMOSOL-R IN D5W
$0(Tier 2)
NOVAFERRUM 125
$0(Tier 3)
NOVAFERRUM 50
$0(Tier 3)
NOVAFERRUM PEDIATRIC DROPS
$0(Tier 3)
nu-iron 150
$0(Tier 3)
PLASMA-LYTE A
$0(Tier 2)
PLASMA-LYTE-148
$0(Tier 2)
PLASMA-LYTE-56/D5W
$0(Tier 2)
PLENAMINE
$0(Tier 1)
poly-iron 150
$0(Tier 3)
potassium chloride 0.15% d5w/nacl 0.33%
$0(Tier 1)
potassium chloride 0.15% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride 0.22% d5w/nacl 0.45%
$0(Tier 1)
potassium chloride er capsule extended release
$0(Tier 1)
potassium chloride er tablet extended release 10meq, 20meq, $0(Tier 1)
8meq
potassium chloride/dextrose
$0(Tier 1)
POTASSIUM CHLORIDE/DEXTROSE/LACTATED
$0(Tier 2)
RINGERS INJECTION 3MEQ/L; 149MEQ/L; 5%;
28MEQ/L; 24MEQ/L; 130MEQ/L
POTASSIUM CHLORIDE/SODIUM CHLORIDE
$0(Tier 1)
INJECTION 40MEQ/L; 0.9%
potassium chloride/sodium chloride injection 20meq/l; 0.45%, $0(Tier 1) 20meq/l; 0.9%
potassium chloride oral solution
$0(Tier 1) potassium chloride injection 10meq/100ml, 20meq/100ml,
$0(Tier 1) 2meq/ml, 40meq/100ml
potassium citrate er
$0(Tier 1)
Necessary actions,
restrictions, or limits on
use
MO
MO
MO
MO
MO
DP
DP
PA (Mozobil)
DP
B/D
DP
DP
DP
DP
B/D
DP
MO
MO
MO
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
75
Name of drug
PREMASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
premasol injection 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml; 470mg/100ml
PROCALAMINE
PROFE
PROSOL
qc ferrous sulfate
ra high potency iron
ra iron tablet 325mg
ra slow release iron tablet extended release 47.5mg
ringers injection
slow release iron
sm iron slow release tablet extended release 160mg
sm iron tablet 325mg
SM SLOW RELEASE IRON TABLET EXTENDED
RELEASE 143MG
sodium chloride 0.45% injection
sodium chloride 0.9% solution
sodium chloride injection 0.9%, 2.5meq/ml, 3%, 5%
sodium ferric gluconate complex/sucrose
sodium fluoride tablet 1mg
TANDEM
th iron
tpn electrolytes
TRAVASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
TROPHAMINE
What the drug
will cost you
(tier level)
$0(Tier 2)
Necessary actions,
restrictions, or limits on
use
B/D
$0(Tier 1)
B/D
$0(Tier 2)
$0(Tier 3)
$0(Tier 2)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
B/D
DP
B/D
DP
DP
DP
DP
$0(Tier 1)
$0(Tier 1)
$0(Tier 1)
$0(Tier 3)
$0(Tier 1)
$0(Tier 3)
$0(Tier 3)
$0(Tier 1)
$0(Tier 2)
$0(Tier 2)
DP
DP
DP
DP
DP
MO
DP
DP
B/D
B/D
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
76
Name of drug
TYR COOLER LIQUID 0; 36MCG/130ML; 0; 0;
27MG/130ML; 0; 46.8MCG/130ML; 279MG/130ML;
2MG/130ML; 219MG/130ML; 21.5MCG/130ML;
0.6MG/130ML; 1.2MCG/130ML; 0; 132UNIT/130ML;
5.4MG/130ML; 100MCG/130ML; 0; 0; 0; 0; 0; 0;
104MG/130ML; 0.8MG/130ML; 0; 6.3MG/130ML;
276MG/130ML; 25.3MCG/130ML; 261MG/130ML;
63MCG/130ML; 0; 0.7MG/130ML; 0.6MG/130ML; 0;
142MG/130ML; 21.5MCG/130ML; 0; 0.5MG/130ML; 0;
5.9UNIT/130ML; 0; 0; 832UNIT/130ML; 5.4MG/130ML
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
VENOFER
Vitamins
a thru z advanced tablet 60mg; 0; 30mcg; 200mg; 10mg;
20mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg;
50mg; 2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg;
1.7mg; 2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg;
30unit; 3500unit; 11mg, 60mg; 0; 30mcg; 200mg; 10mg;
72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;
2.3mg; 20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg;
1.7mg; 75mcg; 2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg;
30unit; 3500unit; 11mg, 90mg; 0; 30mcg; 150mcg; 200mg;
10mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg;
150mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg;
109mg; 80mg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 25mcg; 11mg, 90mg; 0;
30mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg;
18mg; 500mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg;
5mcg; 109mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 150mcg;
2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
a thru z select 50+ advanced formula
a thru z select advanced
a thru z select tablet
a-caro-25
abc plus senior adults 50+
ACEROLA C 500
acerola c-500
actical
ADULT ONE DAILY GUMMIES
advanced stress formula/zinc
animal chews
animal shapes + iron
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 2)
$0(Tier 2)
$0(Tier 2)
$0(Tier 3)
MO
MO
MO
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
77
Name of drug
animal shapes tablet chewable 60mg; 0; 4.5mcg; 400unit;
300mcg; 13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit
antioxidant vitamins tablet
APATATE FORTE
APATATE LIQUID
APETEX
APETIGEN
APETIGEN-PLUS
AQUA-E
AQUADEKS CAPSULE, TABLET CHEWABLE
aquadeks liquid
AQUASOL A PARENTERAL
aqueous vitamin d infants
aqueous vitamin e
asco-tabs-1000
ascorbic acid/rose hips tablet 500mg
ASCORBIC ACID POWDER
ascorbic acid tablet chewable 250mg
ascorbic acid tablet 250mg, 500mg
b complete
b complex/c tablet 300mg; 150mg; 10mg; 50mg; 5mg;
10.2mg; 15mg, 300mg; 50mg; 10mg; 5mg; 10.2mg; 15mg,
300mg; 50mg; 10mg; 5mg; 10mg; 15mg
B COMPLEX/FOLIC ACID
b complex/vitamin c
b complex capsule 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;
3mg; 60mg
b complex tablet 6mcg; 0.4mg; 20mg; 10mg; 2mg; 1.7mg;
1.2mg
b-100 complex tablet 0; 100mcg; 0; 100mg; 100mg; 100mcg;
100mcg; 100mg; 0; 100mg; 100mg; 0; 100mg; 100mg;
100mg; 0
b-100 tr tablet extended release 100mcg; 100mg; 100mcg;
400mcg; 100mg; 100mg; 100mg; 100mg
B-12 1000
B-12 DOTS
b-12 microlozenge
B-12 SUPER STRENGTH
b-12 tr tablet extended release 1000mcg
b-12 tablet extended release 1000mcg
B-12 TABLET SUBLINGUAL 100MCG; 5000MCG
b-12 tablet sublingual 1000mcg, 2500mcg, 3000mcg,
5000mcg
b-12 tablet 100mcg, 250mcg, 500mcg
b-1 tablet 100mg
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
78
What the drug
will cost you
Name of drug
(tier level)
b-50 complex tablet extended release 50mcg; 50mg; 50mcg; $0(Tier 3)
400mcg; 50mcg; 50mg; 50mg; 30mg; 50mg; 50mg; 50mg
b-50 complex tablet 0; 50mcg; 0; 50mg; 50mg; 50mcg;
$0(Tier 3)
100mcg; 50mg; 0; 50mg; 50mg; 0; 50mg; 50mg; 50mg; 0
b-6 tablet 100mg, 250mg
$0(Tier 3)
b-complex +c
$0(Tier 3)
b-complex balanced
$0(Tier 3)
b-complex formula 1
$0(Tier 3)
b-complex plus vitamin c tablet 300mg; 150mg; 10mg; 50mg; $0(Tier 3)
5mg; 10.2mg; 15mg
b-complex w/c capsule 300mg; 10mg; 50mg; 5mg; 10mg;
$0(Tier 3)
15mg
b-complex w/c tablet 300mg; 50mg; 10mg; 5mg; 10.2mg;
$0(Tier 3)
15mg
b-complex with b-12
$0(Tier 3)
b-complex/c tablet 300mg; 10mg; 50mg; 5mg; 10.2mg; 15mg, $0(Tier 3)
300mg; 50mg; 10mg; 5mg; 10.2mg; 15mg, 500mg; 50mcg;
50mg; 50mcg; 400mcg; 50mg; 50mg; 50mg; 50mg
B-COMPLEX/VITAMIN C/FOLIC ACID/ BIOTIN
$0(Tier 3)
b-complex capsule 5mg; 1mcg; 400mcg; 60mg; 20mg; 0.5mg;
$0(Tier 3)
3mg; 3mg; 60mg, 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg; 60mg
b-complex tablet 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg
$0(Tier 3)
B-NATAL
$0(Tier 3)
balance b-100
$0(Tier 3)
balance b-50 tablet 50mcg; 50mg; 50mcg; 400mcg; 50mg;
$0(Tier 3)
50mg; 50mg; 50mg
balanced b complex tr
$0(Tier 3)
balanced b-100 tablet extended release 100mcg; 100mg;
$0(Tier 3)
100mcg; 0.4mg; 100mg; 100mg; 100mg; 100mg
balanced b-100 tablet 100mcg; 100mg; 100mcg; 100mcg;
$0(Tier 3)
100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg
balanced b-50 complex tablet
$0(Tier 3)
balanced b-50 tablet 50mcg; 50mg; 50mcg; 100mcg; 50mg; $0(Tier 3)
50mg; 50mg; 50mg; 50mg; 50mg; 50mg
bec/zinc
$0(Tier 3)
bee zee
$0(Tier 3)
beta carotene capsule 25000unit
$0(Tier 3)
better b complex
$0(Tier 3)
BIO-35 GLUTEN-FREE
$0(Tier 3)
biotin 5000
$0(Tier 3)
biotin plus/calcium/vit d3
$0(Tier 3)
biotin/maximum strength
$0(Tier 3)
biotin capsule 2500mcg, 5000mcg
$0(Tier 3)
BIOTIN TABLET 10MG
$0(Tier 3)
biotin tablet 1000mcg, 300mcg, 5000mcg, 800mcg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
79
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
body/hair/skin/nails
BRAIN MIGHT/DHA & CO Q10
brewers yeast tablet 487.5mg, 500mg, 680mg; 240mcg;
70mcg; 150mcg
c 1000
$0(Tier 3)
c 1000/bioflavonoids/rosehips
$0(Tier 3)
c 250
$0(Tier 3)
c 500
$0(Tier 3)
c 500/rose hips tablet 500mg; 37mg
$0(Tier 3)
c complex
$0(Tier 3)
c-1000
$0(Tier 3)
c-1000 prolonged release
$0(Tier 3)
c-1000 sr
$0(Tier 3)
c-1000/rose hips sr
$0(Tier 3)
c-1000/rose hips tablet 1000mg; 37mg
$0(Tier 3)
c-250 tablet
$0(Tier 3)
c-250 tablet chewable 250mg
$0(Tier 3)
c-500
$0(Tier 3)
c-500 prolonged release
$0(Tier 3)
c-500 sr tablet extended release
$0(Tier 3)
c-500/rose hips tablet 500mg; 37mg
$0(Tier 3)
calcidol
$0(Tier 3)
calciferol solution
$0(Tier 3)
calcium ascorbate tablet 500mg
$0(Tier 3)
cemill
$0(Tier 3)
cemill sr
$0(Tier 3)
centamin
$0(Tier 3)
centavite a-z complete multivitamin/minerals
$0(Tier 3)
centravites
$0(Tier 3)
centravites 50 plus tablet 60mg; 30mcg; 150mcg; 200mg;
$0(Tier 3)
72mg; 130mcg; 2mg; 25mcg; 400mcg; 150mcg; 4mg; 100mg;
3.5mg; 160mcg; 20mg; 5mcg; 10mg; 48mg; 80mg; 3mg;
1.7mg; 20mcg; 2mg; 1.5mg; 45unit; 10mcg; 5000unit;
400unit; 10mcg; 15mg
CENTRUM ADULTS
$0(Tier 3)
CENTRUM CARDIO
$0(Tier 3)
CENTRUM FLAVOR BURST ADULT
$0(Tier 3)
CENTRUM FLAVOR BURST KIDS
$0(Tier 3)
centrum kids complete tablet chewable 60mg; 0; 45mcg;
$0(Tier 3)
108mg; 10mg; 20mcg; 2mg; 6mcg; 400unit; 400mcg; 18mg;
40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg;
20mcg; 1.5mg; 30unit; 3500unit; 15mg
CENTRUM PERFORMANCE
$0(Tier 3)
CENTRUM SILVER
$0(Tier 3)
CENTRUM SILVER ADULT 50+
$0(Tier 3)
CENTRUM SILVER ULTRA MENS
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
80
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)
Name of drug
CENTRUM SILVER ULTRA WOMENS
CENTRUM SPECIALIST ENERGY
CENTRUM SPECIALIST HEART
CENTRUM SPECIALIST VISION
CENTRUM ULTRA MENS
CENTRUM ULTRA WOMENS
CENTRUM TABLET CHEWABLE, LIQUID
CENTRUM TABLET 60MG; 0; 0; 30MCG; 75MCG;
200MG; 10MG; 72MG; 400UNIT; 35MCG; 0.5MG; 6MCG;
18MG; 400MCG; 50MG; 2.3MG; 20MG; 5MCG; 20MG;
25MCG; 80MG; 150MCG; 2MG; 1.7MG; 2MG; 0; 10MCG;
45MCG; 55MCG; 10MCG; 1.5MG; 30UNIT; 3500UNIT;
11MG
century mature
$0(Tier 3)
century tablet 90mg; 0; 30mcg; 200mg; 10mg; 72mg;
$0(Tier 3)
400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg;
300mcg; 100mg; 2.3mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
cerovite advanced formula
$0(Tier 3)
cerovite jr
$0(Tier 3)
cerovite senior
$0(Tier 3)
certa plus
$0(Tier 3)
certa-vite liquid
$0(Tier 3)
CERTAVITE SENIOR/ANTIOXIDANT NUTRIENTS
$0(Tier 3)
certavite/antioxidants
$0(Tier 3)
chew-c
$0(Tier 3)
chewable vitamin c tablet chewable 250mg, 500mg
$0(Tier 3)
chewable vite childrens
$0(Tier 3)
childrens chewable vitamin
$0(Tier 3)
childrens chewable vitamins/iron tablet chewable 400unit;
$0(Tier 3)
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit, 50mg; 4mcg; 300mcg; 15mg;
13.5mg; 1.05mg; 1.2mg; 1.05mg; 2500unit; 400unit; 15unit
childrens chewable vitamins tablet chewable 400unit; 4.5mcg; $0(Tier 3)
0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit;
2500unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0;
2500unit; 400unit; 15unit
childrens gummies
$0(Tier 3)
CITRUS BIOFLAVONOIDS POWDER
$0(Tier 3)
COD LIVER OIL PLUS VITAMIN C
$0(Tier 3)
cod liver oil w/vitamins a&d
$0(Tier 3)
cod liver oil w/vitamins a, c, & d
$0(Tier 3)
cod liver oil capsule 0, 0; 1250unit; 130unit, 1250unit;
$0(Tier 3)
130unit, 1250unit; 135unit, 4000unit; 200unit, 600mg; 52mg;
52mg; 2500unit; 270unit
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
81
Name of drug
COD LIVER OIL OIL 5000UNIT/5ML; 500UNIT/5ML
companion
compete
complete
COMPLETE FORMULATION MULTIVITAMIN
SUPPLEMENT CAPSULE 100MG; 0; 100MCG; 12MG;
1500UNIT; 6MCG; 200MCG; 20MG; 800MCG; 1.9MG;
1.7MG; 1.5MG; 200UNIT; 16000UNIT; 10MG
complete formulation multivitamin supplement tablet
chewable
complete multivitamin/multimineral supplement
complete senior
complex b-100
complex b-50 prolonged release
cvs b complex plus c
cvs b-12 tablet sublingual 5000mcg, 500mcg
cvs balanced b-100 tablet 100mcg; 100mg; 100mcg; 400mcg;
100mg; 100mg; 100mg; 100mg
cvs balanced b-50
cvs beta carotene
cvs biotin capsule 5000mcg
cvs childrens chewable complete tablet chewable 60mg; 0;
40mcg; 100mg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 20mg;
20mg; 10mg; 100mg; 150mcg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit; 15mg
cvs childrens chewable multivitamin/iron
CVS COD LIVER OIL OIL
cvs cod liver oil capsule
cvs daily energy
cvs daily gummies
cvs daily multiple
cvs daily multiple for men
cvs daily multiple for men 50+
cvs daily multiple for women 50+
cvs daily multiple for women tablet 60mg; 0; 450mg; 5mg;
400unit; 6mcg; 18mg; 400mcg; 50mg; 10mg; 2mg; 1.7mg;
1.5mg; 30unit; 2500unit; 15mg
cvs daily multiple plus iron/calcium/zinc
CVS DIABETES HEALTH SUPPORT
cvs e
cvs e oil
cvs folic acid tablet 800mcg
cvs gummy dinos tablet chewable 30mg; 75mcg; 5mg;
200unit; 38mg; 5mcg; 200mcg; 20mcg; 40mcg; 1mg; 20unit;
2000unit; 2.5mg
cvs hair skin & nails/an tioxidants
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
82
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
CVS SPECTRAVITE ADULT 50+
CVS SPECTRAVITE ADULT GUMMIES
cvs spectravite advanced formula
cvs spectravite senior tablet 60mg; 0; 30mcg; 150mcg;
220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg;
400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg;
30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg;
55mcg; 1.5mg; 50unit; 2500unit; 11mg
cvs spectravite ultra health mens
$0(Tier 3)
CVS SPECTRAVITE ULTRA MEN50+
$0(Tier 3)
CVS SPECTRAVITE ULTRA MENS HEALTH
$0(Tier 3)
CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMEN
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMENS HEALTH
$0(Tier 3)
CVS SPECTRAVITE ULTRA WOMENS HEALTH
$0(Tier 3)
SENIOR TABLET 100MG; 0; 30MCG; 150MCG; 500MG;
5MG; 20MG; 72MG; 800UNIT; 50MCG; 0.5MG; 50MCG;
8MG; 400MCG; 300MCG; 50MG; 2.3MG; 14MG; 5MCG;
50MCG; 80MG; 150MCG; 5MG; 1.1MG; 2MG; 10MCG;
50MCG; 55MCG; 1.1MG; 35UNIT; 3500UNIT; 15MG
cvs spectravite ultra womens health senior tablet 100mg; 0; $0(Tier 3)
30mcg; 150mcg; 500mg; 5mg; 72mg; 800unit; 50mcg; 0.5mg;
50mcg; 8mg; 400mcg; 300mcg; 50mg; 2.3mg; 14mg; 5mcg;
20mg; 50mcg; 80mg; 150mcg; 5mg; 1.1mg; 2mg; 10mcg;
50mcg; 55mcg; 1.1mg; 35unit; 3500unit; 15mg
cvs stress formula/zinc
$0(Tier 3)
cvs super b complex/c tablet 150mg; 5mcg; 15mcg; 400mcg; $0(Tier 3)
25mg; 5.5mg; 2mg; 20mg; 150mg; 100mg
cvs vision formula
$0(Tier 3)
cvs vitamin a
$0(Tier 3)
cvs vitamin b-12 tablet 2000mcg
$0(Tier 3)
cvs vitamin b-6 tablet 100mg
$0(Tier 3)
cvs vitamin c/rose hips
$0(Tier 3)
CVS VITAMIN C TABLET CHEWABLE 1000MG
$0(Tier 3)
cvs vitamin c tablet 1000mg, 500mg
$0(Tier 3)
cvs vitamin d 5000 high-potency
$0(Tier 3)
cvs vitamin e capsule 1000unit, 400unit
$0(Tier 3)
cvs womens active daily
$0(Tier 3)
cyanocobalamin injection 1000mcg/ml
$0(Tier 3)
CYTO B2
$0(Tier 3)
d 10000
$0(Tier 3)
d 1000 capsule 1000unit
$0(Tier 3)
d 1000 tablet chewable 1000unit
$0(Tier 3)
d 1000 tablet 1000unit
$0(Tier 3)
d 2000
$0(Tier 3)
d 400 tablet chewable 400unit
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
83
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
d 400 tablet 400unit
d 5000
d-1000 extra strength
d-2000 maximum strength
d-400
d-5000
D-VI-SOL
d-vita
d2000 ultra strength
d3
d3 adult
d3 high potency capsule 1000unit
d3 super strength
d3-1000
d3-50
daily combo multi vitamin tablet 60mg; 450mg; 6mcg;
400unit; 0.4mg; 27mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg;
5000unit; 30unit; 15mg
daily multi-vitamins + iron
$0(Tier 3)
daily multiple vitamin/iron
$0(Tier 3)
daily multiple vitamins w/iron tablet 60mcg; 6mcg; 4mg;
$0(Tier 3)
18mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit;
15unit
daily multiple vitamins/minerals tablet 60mg; 0; 30mcg;
$0(Tier 3)
162mg; 10mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg;
400mcg; 100mg; 3.5mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 160mcg; 20mcg;
10mcg; 1.5mg; 30unit; 2500unit; 15mg
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit;
$0(Tier 3)
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily multiple vitamin tablet 60mg; 0; 10mg; 6mcg; 400unit; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg;
0; 45mg; 10mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg; 30unit; 3000unit
daily multiple weight loss
$0(Tier 3)
daily multivitamin capsule
$0(Tier 3)
daily value multivitamin
$0(Tier 3)
daily vitamin formula
$0(Tier 3)
daily vitamin formula+iron
$0(Tier 3)
daily vitamin formula+minerals
$0(Tier 3)
daily vitamins tablet 60mg; 400unit; 6mcg; 0.4mg; 20mg;
$0(Tier 3)
2mg; 1.7mg; 1.5mg; 5000unit
daily vitamin tablet 60mg; 0; 20mg; 400unit; 6mcg; 400mcg; $0(Tier 3)
20mg; 2mg; 1.7mg; 1.5mg; 15unit; 5000unit
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
84
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
daily vite tablet 60mg; 10mg; 400unit; 6mcg; 20mg; 2mg;
1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 6mcg; 0.4mg; 20mg;
10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit
daily-vite/iron/beta-carotene
$0(Tier 3)
daily-vite tablet 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit
DECARA CAPSULE 25000UNIT
$0(Tier 3)
decara capsule 50000unit
$0(Tier 3)
DECUBI-VITE
$0(Tier 3)
delta d3
$0(Tier 3)
diabetes health formula
$0(Tier 3)
DIABETES HEALTH PACK
$0(Tier 3)
dialyvite 800/ultra d
$0(Tier 3)
DIALYVITE 800/ZINC
$0(Tier 3)
DIALYVITE 800/ZINC 15
$0(Tier 3)
dialyvite 800 tablet
$0(Tier 3)
dialyvite vitamin d 5000
$0(Tier 3)
dialyvite vitamin d3 max
$0(Tier 3)
dino-life
$0(Tier 3)
dino-life w extra c
$0(Tier 3)
DINO-LIFE W/IRON & ZINC
$0(Tier 3)
disney cars gummies
$0(Tier 3)
disney princess gummies
$0(Tier 3)
DRISDOL
$0(Tier 3)
e-400
$0(Tier 3)
e-oil oral oil 100unt/0.25ml
$0(Tier 3)
e400
$0(Tier 3)
ear health formula
$0(Tier 3)
ear health plus tablet 100mg; 1.67mg; 29mg; 111mg;
$0(Tier 3)
1.67mcg; 111mg; 200mg; 3.34mg; 0.34mg; 1mg; 0.34mg
ecee plus
$0(Tier 3)
ELDERTONIC ELIXIR 13.5%; 2MCG/15ML; 3MG/15ML; $0(Tier 3)
0; 0.7MG/15ML; 7MG/15ML; 0.7MG/15ML; 0.6MG/15ML;
0.5MG/15ML; 5MG/15ML
eq complete chewable multivitamin childrens
$0(Tier 3)
eq complete multivitamin adults 50+
$0(Tier 3)
EQ COMPLETE MULTIVITAMIN ADULTS UNDER 50 $0(Tier 3)
eq multivitamin gummies childrens tablet chewable 15mg;
$0(Tier 3)
38mcg; 2.5mg; 200unit; 19mg; 1.5mcg; 100mcg; 15mcg;
0.5mg; 9unit; 1000unit; 1.3mg
EQ ONE DAILY MENS HEALTH
$0(Tier 3)
EQ ONE DAILY WOMENS HEALTH TABLET 60MG; 0; $0(Tier 3)
30MCG; 500MG; 5MG; 1000UNIT; 120MCG; 2MG; 6MCG;
18MG; 400MCG; 50MG; 2MG; 10MG; 25MCG; 2MG;
1.7MG; 20MCG; 1.5MG; 22.5UNIT; 2500UNIT; 15MG
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
85
What the drug
will cost you
Name of drug
(tier level)
eql b complex
$0(Tier 3)
eql b complex 100
$0(Tier 3)
eql b complex 50
$0(Tier 3)
eql b-12 tablet extended release
$0(Tier 3)
eql b-6
$0(Tier 3)
eql beta carotene
$0(Tier 3)
eql central-vite
$0(Tier 3)
eql central-vite performance
$0(Tier 3)
eql central-vite select
$0(Tier 3)
eql century
$0(Tier 3)
eql century cardio healthformula
$0(Tier 3)
eql century mature
$0(Tier 3)
eql childrens c
$0(Tier 3)
EQL CHILDRENS MULTIVITAMINS
$0(Tier 3)
eql childrens multivitamins/minerals
$0(Tier 3)
eql folic acid
$0(Tier 3)
eql one daily 50 plus
$0(Tier 3)
EQL ONE DAILY DIET SUPPORT
$0(Tier 3)
eql one daily energy
$0(Tier 3)
eql one daily essential
$0(Tier 3)
eql one daily maximum
$0(Tier 3)
eql one daily mens health formula
$0(Tier 3)
eql one daily womens
$0(Tier 3)
eql sour gummies childrens
$0(Tier 3)
EQL SUPER ENERGY BOOSTER
$0(Tier 3)
eql ultimate womens century
$0(Tier 3)
eql vision formula
$0(Tier 3)
eql vitamin b-12
$0(Tier 3)
eql vitamin c
$0(Tier 3)
eql vitamin c/rose hips tablet 1000mg, 500mg
$0(Tier 3)
eql vitamin d3 tablet
$0(Tier 3)
eql vitamin e
$0(Tier 3)
ergocalciferol solution
$0(Tier 3)
essentia
$0(Tier 3)
essential balance tablet 120mg; 30mcg; 100mg; 10mg; 36mg; $0(Tier 3)
400unit; 120mcg; 2mg; 6mcg; 9mg; 400mcg; 250mcg;
100mg; 2mg; 20mg; 5mcg; 77mg; 40mg; 150mcg; 2mg;
1.7mg; 2mg; 150mcg; 10mcg; 25mcg; 25mcg; 10mcg; 1.5mg;
50unit; 3000unit; 25mcg; 15mg
flintstones complete
$0(Tier 3)
flintstones gummies plus bone building support
$0(Tier 3)
FLINTSTONES GUMMIES PLUS IMMUNITY
$0(Tier 3)
SUPPORT/EXTRA C
flintstones gummies plus omega-3 dha
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
86
What the drug
will cost you
Name of drug
(tier level)
FLINTSTONES GUMMIES TABLET CHEWABLE 15MG; $0(Tier 3)
1000UNIT; 37.5MCG; 2.5MG; 100UNIT; 19MG; 2.5MCG;
100MCG; 10MCG; 20MCG; 0.5MG; 10UNIT; 1.25MG,
15MG; 37.5MCG; 2.5MG; 100UNIT; 15MCG; 2.5MCG;
100MCG; 10MCG; 20MCG; 0.5MG; 1000UNIT; 10UNIT;
1.25MG
flintstones plus calcium
$0(Tier 3)
flintstones plus extra c
$0(Tier 3)
flintstones plus iron
$0(Tier 3)
FLINTSTONES SOUR GUMMIES
$0(Tier 3)
flintstones/my first
$0(Tier 3)
FOLGARD TABLET 40MG; 2000UNIT; 120MCG;
$0(Tier 3)
800MCG; 31MG; 12MG; 0.32MG
FOLIC + B12
$0(Tier 3)
FOLIC ACID INJECTION
$0(Tier 3)
FOLIC ACID CAPSULE 20MG
$0(Tier 3)
folic acid tablet 1mg, 400mcg, 800mcg
$0(Tier 3)
foltabs 800
$0(Tier 3)
FREEDAVITE
$0(Tier 3)
fruit c 500
$0(Tier 3)
fruit c-100
$0(Tier 3)
fruity c
$0(Tier 3)
fruity chewables multivitamin
$0(Tier 3)
fruity chews
$0(Tier 3)
FULL SPECTRUM B/VITAMIN C
$0(Tier 3)
geravim
$0(Tier 3)
geriaton
$0(Tier 3)
GERITOL COMPLETE TABLET 57MG; 6100UNIT;
$0(Tier 3)
44MCG; 13MG; 148MG; 20MG; 400UNIT; 12MCG; 1.8MG;
6.7MCG; 0.38MG; 16MG; 86MG; 2.4MG; 20MG; 0; 118MG; 24MCG; 36MG; 120MCG; 2MG; 1.7MG; 1MCG; 1MCG; 1.5MG; 30UNIT; 13.5MG, 57MG; 6100UNIT; 44MCG; 13MG; 148MG; 20MG; 400UNIT; 12MCG; 1.8MG;
6.7MCG; 0.38MG; 16MG; 86MG; 2.4MG; 20MG; 118MG; 24MCG; 36MG; 120MCG; 2MG; 1.7MG; 1MCG; 1MCG; 1.5MG; 30UNIT; 13.5MG
gnp animal shapes plus extra c tablet chewable 0; 400unit; $0(Tier 3)
4.5mcg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 250mg; 1.05mg;
15unit; 2500unit
gnp animal shapes plus iron tablet chewable 0; 400unit;
$0(Tier 3)
4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
gnp animal shapes tablet chewable 0; 400unit; 4.5mcg;
$0(Tier 3)
300mcg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit; 2500unit
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
87
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
gnp b-100 balanced tr tablet extended release 100mcg;
100mg; 100mcg; 400mcg; 100mg; 100mg; 100mg; 100mg
gnp b-100 complex prolonged release
$0(Tier 3)
gnp b-12
$0(Tier 3)
gnp b-50 balanced tablet 50mcg; 50mg; 50mcg; 400mcg;
$0(Tier 3)
50mg; 50mg; 50mg; 50mg
gnp b-50 complex prolonged release
$0(Tier 3)
gnp biotin
$0(Tier 3)
gnp century
$0(Tier 3)
gnp century active performance
$0(Tier 3)
gnp century adults 50+ senior tablet 60mg; 0; 30mcg; 220mg; $0(Tier 3)
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
1.5mg; 50unit; 2500unit; 11mg
gnp century cardio healthformula
$0(Tier 3)
gnp century mature
$0(Tier 3)
gnp century ultimate mens complete
$0(Tier 3)
gnp century ultimate mens senior formula
$0(Tier 3)
gnp century ultimate womens complete
$0(Tier 3)
gnp century ultimate womens senior formula
$0(Tier 3)
gnp childrens chewables w/extra c
$0(Tier 3)
gnp childrens chewables/iron tablet chewable 60mg; 0;
$0(Tier 3)
400unit; 4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg;
1.05mg; 15unit; 2500unit
GNP CHILDRENS COMPLETE CHEWABLES
$0(Tier 3)
gnp cod liver oil
$0(Tier 3)
gnp essential one daily tablet 60mg; 0; 400unit; 6mcg;
$0(Tier 3)
400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
gnp folic acid
$0(Tier 3)
gnp hair/skin/nails tablet 60mg; 1250mcg; 0.5mg; 100mg;
$0(Tier 3)
100unit; 50mg; 30unit; 1mg; 100mcg; 50mg; 250mcg; 25mg;
50mg; 10mg; 50mg; 0.85mg; 0.75mg; 2500unit; 7.5mg
gnp healthy eyes
$0(Tier 3)
gnp healthy eyes supervision
$0(Tier 3)
gnp little ones childrens tablet chewable 60mg; 0; 400unit; $0(Tier 3)
4.5mcg; 300mcg; 10mg; 1.05mg; 1.2mg; 1.05mg; 15unit;
1998unit
gnp maximum one daily tablet 60mg; 0; 30mcg; 162mg;
$0(Tier 3)
10mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg; 400mcg;
100mg; 3.5mg; 20mg; 109mg; 25mcg; 80mg; 150mcg; 2mg;
1.7mg; 2mg; 150mcg; 10mcg; 160mcg; 20mcg; 10mcg;
1.5mg; 30unit; 2500unit; 15mg
gnp mega multi for men
$0(Tier 3)
gnp mega multi for women
$0(Tier 3)
gnp niacin tr tablet extended release 250mg
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
88
What the drug
will cost you
Name of drug
(tier level)
gnp norwegian cod liver oil
$0(Tier 3)
gnp one daily maximum
$0(Tier 3)
gnp one daily mens 50+ advanced
$0(Tier 3)
gnp one daily mens health 50+
$0(Tier 3)
gnp one daily mens health/lycopene
$0(Tier 3)
gnp one daily plus iron tablet 60mg; 0; 10mg; 400unit; 6mcg; $0(Tier 3)
18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
gnp one daily womens 50+ advanced
$0(Tier 3)
gnp one daily womens health 50+
$0(Tier 3)
gnp opti-vitamins tablet 200mg; 1000unit; 2mg; 2mg; 55mcg; $0(Tier 3)
60unit; 40mg
gnp therapeutic-m
$0(Tier 3)
gnp vitamin a
$0(Tier 3)
gnp vitamin b-1
$0(Tier 3)
gnp vitamin b-12
$0(Tier 3)
gnp vitamin b-12 prolonged release
$0(Tier 3)
gnp vitamin b-12 tr
$0(Tier 3)
gnp vitamin b-6 tablet 100mg
$0(Tier 3)
gnp vitamin c
$0(Tier 3)
gnp vitamin c drops lozenge 60mg
$0(Tier 3)
gnp vitamin c pr
$0(Tier 3)
gnp vitamin c tr
$0(Tier 3)
gnp vitamin c w/rose hips tr
$0(Tier 3)
gnp vitamin c w/rose hips tablet 500mg, 500mg; 37mg
$0(Tier 3)
gnp vitamin c/rose hips
$0(Tier 3)
gnp vitamin d maximum strength
$0(Tier 3)
gnp vitamin d super strength
$0(Tier 3)
gnp vitamin d3 extra strength
$0(Tier 3)
gnp vitamin d tablet 1000unit
$0(Tier 3)
gnp vitamin e
$0(Tier 3)
gnp vitamin e water dispersible
$0(Tier 3)
gnp womens one daily
$0(Tier 3)
gnp zoochews gummies
$0(Tier 3)
gummi bear multivitamin/mineral
$0(Tier 3)
hair/skin/nails/biotin
$0(Tier 3)
hair/skin/nails tablet 25mg; 300mcg; 20mg; 170mg; 200mg; $0(Tier 3)
6mcg; 1.8mg; 400mcg; 25mg; 10mg; 16mg; 150mcg; 5unit
halls defense vitamin c drops
$0(Tier 3)
HARD NAILS
$0(Tier 3)
healthy eyes tablet 60mg; 2mg; 6mg; 30unit; 15mg
$0(Tier 3)
healthy kids cod liver oil/vitamin d
$0(Tier 3)
HEALTHY KIDS GUMMIES
$0(Tier 3)
healthy kids vitamin d3
$0(Tier 3)
hm animal shapes
$0(Tier 3)
hm antioxidant vitamins
$0(Tier 3)
hm complete 50+
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
89
Name of drug
HM COMPLETE 50+ MENS ULTIMATE
HM COMPLETE 50+ WOMENS ULTIMATE
HM COMPLETE TABLET 60MG; 0; 30MCG; 200MG;
10MG; 72MG; 400UNIT; 35MCG; 0.5MG; 6MCG; 18MG;
400MCG; 50MG; 2.3MG; 20MG; 5MCG; 20MG; 25MCG;
80MG; 150MCG; 2MG; 1.7MG; 2MG; 75MCG; 10MCG;
45MCG; 55MCG; 10MCG; 1.5MG; 30UNIT; 3500UNIT;
11MG
hm complete tablet 60mg; 0; 30mcg; 200mg; 10mg; 72mg;
400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
hm folic acid
HM HAIR/SKIN/NAILS
hm niacin tablet extended release
HM ONE DAILY MENS
HM ONE DAILY WOMENS
hm vitamin d
HM VITAMIN D3 CAPSULE 4000UNIT
hm vitamin d3 capsule 2000unit
hm vitamin e
HONEY BEARS
HONEY BEARS W/IRON AND ZINC
HYDROXOCOBALAMIN INJECTION
i-vite
i-vite protect
icaps
ICAPS AREDS FORMULA
icaps lutein & omega-3
icaps mv
ICAPS PLUS
infuvite
infuvite adult
infuvite pediatric
INTEGRA
iromin-g
iron 100/c
IRON 21/7
just d
K-PAX IMMUNE SUPPORT FORMULA DOUBLE
STRENGTH
K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL
STRENGTH
K-PAX IMMUNE SUPPORT FORMULA SINGLE
STRENGTH
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
90
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
kids gummy bear vitamins
kids vitamins
kids vitamins complete
kids vitamins plus extra c
kids vitamins plus iron
kobee
kp adults 50+ daily formula
kp adults daily formula
kp b complex/c
kp mens 50+ daily formula
kp mens daily formula
kp vitamin d capsule 1000unit
kp vitamin e
kp womens 50+ daily formula
kp womens daily formula
LIFE PACK MENS
LIFE PACK WOMENS
lipo-flavonoid plus
lipoflavovit
LIPOTRIAD
liqui-e
liquid b12 liquid 1000mcg/15ml
LIQUID C 500
lysiplex plus liquid
M.V.I. ADULT
M.V.I. PEDIATRIC
M.V.I.-12 WITHOUT VITAMIN K
macuvite
macuvite eye care
MAXIMIN PACK
maximum d3
mega multiple w/chelated minerals
MEGA MULTIVITAMIN FOR MEN
MEGA MULTIVITAMIN FOR WOMEN
meijer c
MENS 50+ ADVANCED
mens daily formula/lycopene
MENS PACK
MEPHYTON
meribin
MG-PLUS PROTEIN
MH MACULAR HEALTH
milltrium senior
MTX SUPPORT
multi complete/iron
multi for her 50+ tablet
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
91
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
multi for her tablet
multi for him 50+
multi for him tablet
multi vitamin mens
multi-day plus iron
multi-day vitamins
multi-delyn
MULTI-DELYN/IRON
multi-vitamin daily
multi-vitamin gummies
multi-vitamin hp/minerals
MULTI-VITAMIN MONOCAPS
multi-vitamin/minerals tablet 60mg; 160mg; 6mcg; 18mg;
0.4mg; 150mcg; 100mg; 20mg; 125mg; 2mg; 1.7mg; 1.2mg;
5000unit; 400unit; 15mg
multi-vitamins
$0(Tier 3)
multi-vitamins/iron
$0(Tier 3)
multi-vitamin tablet 60mg; 0; 30mcg; 10mg; 400unit; 6mcg; $0(Tier 3)
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
multilex
$0(Tier 3)
multiple vitamin/minerals/no iron
$0(Tier 3)
multiple vitamins essential
$0(Tier 3)
multiple vitamins plain
$0(Tier 3)
multiple vitamins/iron tablet chewable 60mg; 4.5mcg;
$0(Tier 3)
400unit; 15mg; 0.3mg; 13.5mg; 1.04mg; 1.2mg; 1.05mg;
2500unit; 15unit
multiple vitamins/iron tablet 60mg; 0; 10mg; 400unit; 6mcg; $0(Tier 3)
18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit,
60mg; 400unit; 6mcg; 18mg; 400mcg; 20mg; 10mg; 2mg;
1.7mg; 1.5mg; 30unit; 5000unit
multiple vitamins/womens
$0(Tier 3)
multiple vitamins tablet 50mg; 1mcg; 20mg; 1mg; 1mg;
$0(Tier 3)
2.5mg; 2mg; 5000unit; 400unit, 60mg; 0; 10mg; 400unit;
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg;
0; 400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit, 60mg; 0; 6mcg; 400mcg; 20mg; 10mg;
2mg; 1.7mg; 1.5mg; 30unit; 5000unit; 400unit, 60mg; 20mg;
8mcg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit
multivital performance
$0(Tier 3)
multivital platinum tablet 60mg; 0; 30mcg; 200mg; 10mg;
$0(Tier 3)
72mg; 400unit; 150mcg; 2mg; 25mcg; 18mg; 400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 48mg; 10mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg; 20mcg; 1.5mg; 45unit; 3500unit; 15mg
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
92
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
multivital tablet
multivitamin & mineral
multivitamin gummies adult tablet chewable 30mg; 75mcg;
5mg; 200unit; 30mcg; 5mcg; 200mcg; 20mcg; 40mcg; 1mg;
0; 2000unit; 20unit; 2.5mg
multivitamins capsule
$0(Tier 3)
my-vitalife
$0(Tier 3)
MYKIDZ IRON
$0(Tier 3)
NANOVM 1-3 YEARS POWDER
$0(Tier 3)
NANOVM 4-8 YEARS POWDER
$0(Tier 3)
NANOVM T/F LIQUID
$0(Tier 3)
NASCOBAL SOLUTION
$0(Tier 3)
natural vitamin e capsule 1000unit, 400unit
$0(Tier 3)
NEPHRO-VITE
$0(Tier 3)
NEPHRONEX LIQUID
$0(Tier 3)
NEURO VITE
$0(Tier 3)
niacin er capsule extended release 125mg, 250mg
$0(Tier 3)
niacin sr capsule extended release 250mg, 500mg
$0(Tier 3)
niacin tr capsule extended release 250mg, 500mg
$0(Tier 3)
niacin tr tablet extended release 250mg, 500mg
$0(Tier 3)
niacinamide tablet 100mg, 500mg
$0(Tier 3)
niacin capsule extended release 250mg
$0(Tier 3)
NO IRON MULTIPLE VITAMIN/MINERALS
$0(Tier 3)
ocutabs
$0(Tier 3)
ocutabs/lutein
$0(Tier 3)
OCUVITE ADULT 50+
$0(Tier 3)
ocuvite/lutein
$0(Tier 3)
OMNICAP
$0(Tier 3)
once daily/iron
$0(Tier 3)
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg; $0(Tier 3)
5000unit; 400unit
ONCOVITE
$0(Tier 3)
one daily adults 50+
$0(Tier 3)
one daily complete
$0(Tier 3)
one daily for men 50+ advanced
$0(Tier 3)
one daily for men/lycopene
$0(Tier 3)
one daily for women
$0(Tier 3)
one daily for women 50+a dvanced
$0(Tier 3)
one daily healthy weight advanced
$0(Tier 3)
one daily maximum
$0(Tier 3)
one daily mens health/lycopene
$0(Tier 3)
one daily mens tablet 90mg; 0; 30mcg; 210mg; 120mcg; 2mg; $0(Tier 3)
3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg;
1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit;
20mcg; 15mg
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
93
What the drug
will cost you
Name of drug
(tier level)
one daily plus iron tablet 60mg; 75mg; 10mg; 400unit; 6mcg; $0(Tier 3)
18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
one daily plus minerals tablet 50mg; 19mg; 400unit; 5mcg; $0(Tier 3)
1mcg; 150mcg; 4.5mg; 10mg; 1mg; 20mg; 1mg; 10mg; 1mg;
2.5mg; 5mcg; 2mg; 5000unit; 3.75mg
one daily womens 50 plus
$0(Tier 3)
one daily womens 50+
$0(Tier 3)
one daily/iron/calcium
$0(Tier 3)
one daily/minerals tablet 50mg; 125mg; 1mg; 3mcg; 100mcg; $0(Tier 3)
150mcg; 5mg; 20mg; 1mg; 1.7mg; 1.5mg; 10unit; 5000unit;
400unit
one daily tablet 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg; $0(Tier 3)
1.7mg; 1.5mg; 5000unit; 400unit; 30unit
ONE-A-DAY CHOLESTEROL PLUS
$0(Tier 3)
ONE-A-DAY ENERGY
$0(Tier 3)
ONE-A-DAY ESSENTIAL
$0(Tier 3)
ONE-A-DAY MAXIMUM FORMULA
$0(Tier 3)
ONE-A-DAY MENOPAUSE FORMULA
$0(Tier 3)
ONE-A-DAY MENS
$0(Tier 3)
ONE-A-DAY MENS 50+ ADVANTAGE TABLET 60MG; $0(Tier 3)
0; 30MCG; 120MG; 15MG; 700UNIT; 180MCG; 2MG;
25MCG; 400MCG; 120MG; 300MCG; 100MG; 4MG;
20MG; 20MCG; 150MCG; 6MG; 3.4MG; 90MCG; 110MCG;
4.5MG; 22.5UNIT; 2500UNIT; 22.5MG
ONE-A-DAY MENS HEALTH FORMULA
$0(Tier 3)
ONE-A-DAY MENS VITACRAVES GUMMIES
$0(Tier 3)
ONE-A-DAY SCOOBY-DOO GUMMIES
$0(Tier 3)
one-a-day teen advantage for her
$0(Tier 3)
ONE-A-DAY TEEN ADVANTAGE FOR HIM
$0(Tier 3)
ONE-A-DAY VITACRAVES
$0(Tier 3)
ONE-A-DAY VITACRAVES GUMMIES+OMEGA-3 DHA $0(Tier 3)
ONE-A-DAY VITACRAVES GUMMIES/IMMUNITY
$0(Tier 3)
SUPPORT
ONE-A-DAY VITACRAVES SOURGUMMIES
$0(Tier 3)
ONE-A-DAY WEIGHT SMART ADVANCED
$0(Tier 3)
ONE-A-DAY WOMENS 50+ ADVANTAGE TABLET
$0(Tier 3)
60MG; 0; 0; 30MCG; 500MG; 15MG; 1000UNIT; 180MCG;
2MG; 25MCG; 400MCG; 120MG; 50MG; 4MG; 20MG;
20MCG; 150MCG; 6MG; 3.4MG; 0; 90MCG; 20MCG;
4.5MG; 22.5UNIT; 2500UNIT; 22.5MG
ONE-A-DAY WOMENS ACTIVE MIND & BODY
$0(Tier 3)
ONE-A-DAY WOMENS FORMULA
$0(Tier 3)
ONE-A-DAY WOMENS PETITES
$0(Tier 3)
ONE-A-DAY WOMENS PLUS HEALTHY SKIN
$0(Tier 3)
SUPPORT
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
94
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
ONE-A-DAY WOMENS VITACRAVES GUMMIES
TABLET CHEWABLE 15MG; 75MCG; 50MCG; 400UNIT;
4.5MCG; 200MCG; 20MCG; 1MG; 1250UNIT; 15UNIT;
1.25MG
ONE-A-DAY/JOLLY RANCHER
$0(Tier 3)
one-daily multi vitamins
$0(Tier 3)
optimal-d
$0(Tier 3)
optimal-d pack
$0(Tier 3)
OPTISOURCE POST BARIATRIC SURGERY
$0(Tier 3)
OPURITY B12/FOLIC ACID
$0(Tier 3)
pa b-complex with b-12
$0(Tier 3)
pa vitamin b-12 tr
$0(Tier 3)
pa vitamin d-3 gummy
$0(Tier 3)
pa vitamin d-3 capsule
$0(Tier 3)
pa vitamin e
$0(Tier 3)
PARVLEX
$0(Tier 3)
pediavit liquid 40mg/10ml; 150mcg/10ml; 3mcg/10ml;
$0(Tier 3)
200mcg/10ml; 10mg/10ml; 9mg/10ml; 5mg/10ml;
0.7mg/10ml; 0.8mg/10ml; 0.7mg/10ml; 10unit/10ml;
2500unit/10ml; 400unit/10ml; 8mg/10ml
PHYSICIANS EZ USE B-12 COMPLIANCE KIT
$0(Tier 3)
phytonadione injection 1mg/0.5ml
$0(Tier 3)
poly vitamin
$0(Tier 3)
POLY-VI-SOL/IRON SOLUTION
$0(Tier 3)
POLY-VI-SOL SOLUTION
$0(Tier 3)
poly-vita drops solution 35mg/ml; 400unit/ml; 2mcg/ml;
$0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
poly-vita/iron drops solution 35mg/ml; 400unit/ml; 10mg/ml; $0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
polyvitamin/iron tablet chewable
$0(Tier 3)
polyvitamin/iron solution 35mg/ml; 400unit/ml; 10mg/ml;
$0(Tier 3)
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
polyvitamin solution 35mg/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; $0(Tier 3)
0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml,
35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml
PRESERVISION AREDS
$0(Tier 3)
PRESERVISION/LUTEIN
$0(Tier 3)
prevent
$0(Tier 3)
PROCERV HP
$0(Tier 3)
prorenal+d
$0(Tier 3)
prorenal+d/omega-3
$0(Tier 3)
prosight
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
95
What the drug
will cost you
Name of drug
(tier level)
prosight w/lutein
$0(Tier 3)
PROTECT CARDIO AF
$0(Tier 3)
PROTEXIN
$0(Tier 3)
pureway-c
$0(Tier 3)
pyridoxine hcl injection 100mg/ml
$0(Tier 3)
pyridoxine hcl tablet 100mg, 25mg, 50mg
$0(Tier 3)
qc childrens chewable complete
$0(Tier 3)
qc childrens chewable vitamins/extra c
$0(Tier 3)
qc childrens chewable vitamins/iron
$0(Tier 3)
QC COD LIVER OIL
$0(Tier 3)
qc maximum daily multivitamin/multimineral
$0(Tier 3)
qc mens daily multivitamin
$0(Tier 3)
qc multi-vite
$0(Tier 3)
qc multi-vite 50 & over
$0(Tier 3)
qc womens daily multivitamin
$0(Tier 3)
QUIN B STRONG
$0(Tier 3)
QUINTABS
$0(Tier 3)
QUINTABS-M TABLET 0; 30MCG; 30MG; 300MG; 30MG;$0(Tier 3)
0.2MG; 30MCG; 50UNIT; 400UNIT; 400MCG; 15MG;
2MG; 100MG; 150MCG; 30MG; 30MG; 35MCG; 30MG;
5000UNIT; 7.5MG
quintabs-m tablet 300mg; 0; 30mcg; 30mg; 30mg; 0.2mg;
$0(Tier 3)
30mcg; 50unit; 400unit; 10mg; 400mcg; 15mg; 2mg; 100mg;
150mcg; 30mg; 30mg; 35mcg; 30mg; 5000unit; 7.5mg
ra b-complex
$0(Tier 3)
ra b-complex with b-12
$0(Tier 3)
ra b-complex/vitamin c tr
$0(Tier 3)
ra balanced b-100
$0(Tier 3)
ra balanced b-50 tablet 50mcg; 50mg; 50mg; 50mcg;
$0(Tier 3)
400mcg; 50mcg; 50mg; 50mg; 50mg; 50mg; 50mg
ra beta carotene
$0(Tier 3)
ra biotin capsule
$0(Tier 3)
ra central-vite cardio
$0(Tier 3)
ra central-vite energy
$0(Tier 3)
ra central-vite performance tablet 120mg; 0; 40mcg; 60mcg; $0(Tier 3)
100mg; 10mg; 72mg; 400unit; 120mcg; 2mg; 18mcg; 18mg;
400mcg; 60mg; 50mg; 40mg; 4mg; 40mg; 5mcg; 48mg;
25mcg; 80mg; 150mcg; 6mg; 5.1mg; 4mg; 10mcg; 75mcg;
70mcg; 10mcg; 4.5mg; 60unit; 5000unit; 15mg
ra central-vite select mature
$0(Tier 3)
ra central-vite select tablet 60mg; 0; 30mcg; 200mg; 10mg; $0(Tier 3)
48mg; 72mg; 400unit; 150mcg; 2mg; 25mcg; 400mcg;
250mcg; 100mg; 2mg; 20mg; 5mcg; 10mcg; 80mg; 150mcg;
3mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg; 20mcg; 1.5mg;
45unit; 3500unit; 15mg
ra central-vite senior
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
96
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
RA CENTRAL-VITE UNDER 50 MENS
RA CENTRAL-VITE UNDER 50 WOMENS
ra central-vite womens mature
ra central-vite/antioxidants tablet 60mg; 0; 30mcg; 162mg;
10mg; 72mg; 120mcg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg
ra central-vite tablet 60mg; 0; 30mcg; 200mg; 10mg; 20mg; $0(Tier 3)
72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;
2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
RA COD LIVER OIL OIL
$0(Tier 3)
ra cod liver oil capsule 1250unit; 133unit
$0(Tier 3)
RA ESSENCE-C
$0(Tier 3)
ra folic acid
$0(Tier 3)
ra gummy vitamins & minerals childrens
$0(Tier 3)
ra natural vitamin e
$0(Tier 3)
ra one daily energy formula
$0(Tier 3)
ra one daily essential
$0(Tier 3)
ra one daily gummy vites
$0(Tier 3)
ra one daily maximum
$0(Tier 3)
ra one daily mens 50+ with vitamin d-3
$0(Tier 3)
ra one daily mens/vitamind-3
$0(Tier 3)
ra one daily multi-vitamin plus iron tablet 60mg; 10mg;
$0(Tier 3)
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg;
30unit; 5000unit
ra one daily multi-vitamin tablet 60mg; 0; 10mg; 400unit;
$0(Tier 3)
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
ra one daily womens/vitamin d-3
$0(Tier 3)
ra stress formula advanced
$0(Tier 3)
ra stress formula energy
$0(Tier 3)
ra therapeutic m plus beta carotene tablet 90mg; 0; 30mcg; $0(Tier 3)
40mg; 10mg; 31mg; 7.5mg; 400unit; 26mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 28mcg; 7.5mg;
150mcg; 3mg; 3.4mg; 32mcg; 21mcg; 3mg; 30unit; 5000unit; 15mg
ra vitamin a capsule 10000unit
$0(Tier 3)
ra vitamin b-1
$0(Tier 3)
ra vitamin b-12 tr tablet extended release 1000mcg
$0(Tier 3)
RA VITAMIN B-12 LIQUID 1000MCG/ML
$0(Tier 3)
ra vitamin b-6 tablet 50mg
$0(Tier 3)
ra vitamin b12
$0(Tier 3)
ra vitamin c drops
$0(Tier 3)
ra vitamin c tr tablet extended release 1000mg; 25mg, 500mg $0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
97
What the drug
will cost you
(tier level)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
Name of drug
ra vitamin c/acerola
ra vitamin c/rose hips
ra vitamin c/rose hips tr
ra vitamin c tablet chewable 250mg, 500mg, 500mg; 0
ra vitamin c tablet 250mg, 500mg
ra vitamin d-3
ra vitamin e capsule 1000unit, 200unit, 400unit
RAPID B-12 ENERGY
rena-vite
REPLESTA
REPLESTA CHILDRENS
REPLESTA NX
risanoid plus
s.s.s. tonic tablet
SCOOBY-DOO ONE A DAY
sentry senior
SENTRY TABLET 60MG; 0; 30MCG; 75MCG; 200MG;
10MG; 20MG; 72MG; 400UNIT; 35MCG; 0.5MG; 6MCG;
18MG; 400MCG; 50MG; 2.3MG; 20MG; 5MCG; 25MCG;
80MG; 150MCG; 2MG; 1.7MG; 2MG; 10MCG; 45MCG;
55MCG; 10MCG; 1.5MG; 30UNIT; 3500UNIT; 11MG
sentry tablet 90mg; 0; 30mcg; 150mcg; 200mg; 10mg;
$0(Tier 3)
109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg;
250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 25mcg;
80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
slo-niacin tablet extended release 250mg
$0(Tier 3)
sm animal shapes complete tablet chewable 0; 40mcg; 10mg; $0(Tier 3)
100mg; 400unit; 38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg;
15mg; 100mg; 150mcg; 2mg; 1.7mg; 10mg; 60mg; 1.5mg;
30unit; 3000unit; 12mg
sm antioxidant vitamins
$0(Tier 3)
sm balanced b-50
$0(Tier 3)
sm ballanced b-100
$0(Tier 3)
sm chewable c
$0(Tier 3)
sm chewable vitamin c
$0(Tier 3)
sm cod liver oil
$0(Tier 3)
sm complete
$0(Tier 3)
sm complete 50+
$0(Tier 3)
sm complete 50+ ultimate mens
$0(Tier 3)
sm complete 50+ ultimate womens
$0(Tier 3)
sm complete advanced formula
$0(Tier 3)
sm complete senior formula
$0(Tier 3)
sm folic acid
$0(Tier 3)
sm hair/skin/nails
$0(Tier 3)
sm multiple vitamins essential
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
98
What the drug
will cost you
Name of drug
(tier level)
sm multiple vitamins/iron
$0(Tier 3)
sm niacin cr
$0(Tier 3)
SM ONE DAILY MENS
$0(Tier 3)
SM ONE DAILY WOMENS
$0(Tier 3)
sm opti-vitamins
$0(Tier 3)
sm super b complex-vitamin c
$0(Tier 3)
sm vit c/rose hips
$0(Tier 3)
sm vitamin b-12
$0(Tier 3)
sm vitamin b-6 tablet 100mg
$0(Tier 3)
sm vitamin b1
$0(Tier 3)
sm vitamin c/rose hips
$0(Tier 3)
sm vitamin c tablet chewable 500mg
$0(Tier 3)
sm vitamin c tablet 1000mg, 250mg
$0(Tier 3)
sm vitamin d
$0(Tier 3)
sm vitamin d3
$0(Tier 3)
SM VITAMIN D3 MAXIMUM STRENGTH
$0(Tier 3)
sm vitamin e
$0(Tier 3)
sm vitamin e blended
$0(Tier 3)
SOLO
$0(Tier 3)
stress 500 b-complex
$0(Tier 3)
stress 500 b-complex/zinc
$0(Tier 3)
stress b-complex/vitamin c/zinc
$0(Tier 3)
stress b/zinc tablet 500mg; 45mcg; 70mg; 20mg; 3mg; 12mcg;$0(Tier 3)
400mcg; 100mg; 5mg; 10mg; 10mg; 30unit; 23.9mg
stress formula w/iron
$0(Tier 3)
stress formula/iron tablet 500mg; 45mcg; 12mcg; 27mg;
$0(Tier 3)
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit, 600mg;
12mcg; 81mg; 0.4mg; 100mg; 20mg; 0; 15mg; 0; 30unit
stress formula/zinc tablet 500mg; 45mcg; 20mg; 3mg; 12mcg; $0(Tier 3)
400mcg; 100mg; 5mg; 10mg; 10mg; 30unit; 23.9mg, 500mg;
45mcg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg;
15mg; 30unit; 23.9mg, 600mg; 45mg; 3mg; 12mcg; 400mcg;
100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg
stress formula tablet 500mg; 45mcg; 12mcg; 400mcg; 100mg; $0(Tier 3)
20mg; 3mg; 10mg; 10mg; 30unit, 500mg; 45mcg; 12mcg;
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit
stress plus zinc
$0(Tier 3)
sunvite advanced
$0(Tier 3)
super b with c
$0(Tier 3)
super b-complex/vitamin c& folic acid
$0(Tier 3)
super b-complex/vitamin c tablet 300mg; 20mg; 10mcg;
$0(Tier 3)
50mg; 5mg; 10mg; 15mg
super biotin
$0(Tier 3)
super multiple capsule
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
99
What the drug
will cost you
Name of drug
(tier level)
super multiple tablet 150mg; 15mg; 30mcg; 0; 35mg; 50mg; $0(Tier 3)
150mcg; 100mcg; 25mg; 1mg; 100mcg; 50mg; 6mg; 0; 400mcg; 25mg; 5mg; 250mcg; 0; 5mg; 0; 10mg; 1mg; 0; 100mg; 25mcg; 0; 18mg; 75mcg; 25mg; 25mg; 25mg;
150mcg; 50mcg; 25mg; 25unit; 10000unit; 400unit; 0; 7.5mg
super quints b-50
$0(Tier 3)
super thera vite m
$0(Tier 3)
superplex-t
$0(Tier 3)
tab-a-vite maximum
$0(Tier 3)
tab-a-vite w/beta carotene
$0(Tier 3)
tab-a-vite/iron
$0(Tier 3)
tab-a-vite tablet 60mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; $0(Tier 3)
1.7mg; 0; 1.5mg; 5000unit
th b 100 complex
$0(Tier 3)
th b complex/iron/vitamin c/vitamin e
$0(Tier 3)
th childrens chewable multi vitamins
$0(Tier 3)
th cod liver oil
$0(Tier 3)
th complete multi
$0(Tier 3)
th complete multi 50+
$0(Tier 3)
th daily multiple vitamins
$0(Tier 3)
th daily multiple vitamins/iron
$0(Tier 3)
th premium daily multiple
$0(Tier 3)
th theradex-m
$0(Tier 3)
th vision vitamins/lutein
$0(Tier 3)
th vitamin b 50/b-complex
$0(Tier 3)
th vitamin b-12
$0(Tier 3)
th vitamin b-6
$0(Tier 3)
th vitamin b1
$0(Tier 3)
th vitamin b12
$0(Tier 3)
th vitamin b12 er
$0(Tier 3)
th vitamin c
$0(Tier 3)
th vitamin c/rose hips/bioflavonoids
$0(Tier 3)
th vitamin d3
$0(Tier 3)
th vitamin e
$0(Tier 3)
th vitamin e/d-alpha
$0(Tier 3)
th womens daily
$0(Tier 3)
THERA M PLUS
$0(Tier 3)
thera-d 2000
$0(Tier 3)
THERA-D 4000
$0(Tier 3)
thera-d rapid repletion
$0(Tier 3)
THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG;
$0(Tier 3)
50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG; 100MG;
2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG;
150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG;
70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
100
What the drug
will cost you
Name of drug
(tier level)
thera-m tablet 120mg; 15mcg; 40mg; 10mg; 7.5mg; 400unit; $0(Tier 3)
15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg;
31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg; 30unit; 5500unit; 15mg, 120mg; 15mcg; 44mg; 10mg; 7.5mg;
400unit; 15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg;
30mg; 31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg;
3mg; 30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg;
40mg; 7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg;
100mg; 3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg;
3mg; 3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit;
400unit; 30unit; 28mcg; 15mg
thera-tabs
$0(Tier 3)
THERA-TABS M
$0(Tier 3)
THERA/BETA-CAROTENE
$0(Tier 3)
THERAGRAN-M PREMIER 50 PLUS TABLET 120MG; 0; $0(Tier 3)
35MCG; 200MG; 15MG; 72MG; 1000UNIT; 150MCG;
250MCG; 2MG; 30MCG; 400MCG; 250MCG; 375MCG;
100MG; 3.5MG; 25MG; 50MG; 10MCG; 80MG; 150MCG;
6MG; 3MG; 2MG; 150MCG; 10MCG; 75MCG; 200MCG;
3MG; 60UNIT; 3500UNIT; 17MG
THERANATAL LACTATION SUPPORT
$0(Tier 3)
THERAPEUTIC LIQUID
$0(Tier 3)
therapeutic m tablet 90mg; 0; 30mcg; 150mcg; 40mg; 7.5mg; $0(Tier 3)
26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg; 3.5mg;
32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg;
21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit; 30unit;
28mcg; 15mg
therapeutic-m/lutein
$0(Tier 3)
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg; $0(Tier 3)
3.4mg; 3mg; 5000unit; 400unit; 30unit
theratrum complete 50 plus tablet 60mg; 0; 30mcg; 150mcg; $0(Tier 3)
200mg; 10mg; 72mg; 400unit; 150mcg; 2mg; 25mcg;
400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 48mg;
10mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 75mcg; 20mcg;
1.5mg; 45unit; 10mcg; 3500unit; 15mg
theratrum complete tablet 60mg; 0; 30mcg; 150mcg; 162mg; $0(Tier 3)
10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;
150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg;
2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg;
30unit; 5000unit; 25mcg; 15mg
therems
$0(Tier 3)
THEREMS-H
$0(Tier 3)
THEREMS-M
$0(Tier 3)
thiamine hcl injection, tablet
$0(Tier 3)
total b/c
$0(Tier 3)
totalday multiple
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
101
What the drug
will cost you
(tier level)
$0(Tier 3)
Name of drug
TRI-VI-SOL SOLUTION 35MG/ML; 400UNIT/ML;
750UNIT/ML
tri-vitamin solution 35mg/ml; 400unit/ml; 1500unit/ml
$0(Tier 3)
tri-vita solution 35mg/ml; 400unit/ml; 1500unit/ml
$0(Tier 3)
trueplus diabetic multivitamin
$0(Tier 3)
ultra freeda
$0(Tier 3)
ultra freeda/iron
$0(Tier 3)
UNICOMPLEX-M TABLET 60MG; 60MG; 10MG;
$0(Tier 3)
400UNIT; 2MG; 6MCG; 18MG; 400MCG; 1MG; 20MG; 0;
45MG; 150MCG; 5MG; 2MG; 1.7MG; 0; 1.5MG; 30UNIT;
5000UNIT; 15MG
vision formula/lutein
$0(Tier 3)
vision vitamins tablet 60mg; 0; 2mg; 40mcg; 30unit;
$0(Tier 3)
5000unit; 40mg
VITA-C
$0(Tier 3)
vita-plus e
$0(Tier 3)
vitalee
$0(Tier 3)
VITALETS CHILDRENS
$0(Tier 3)
VITALETS TABLET CHEWABLE 40MG; 0; 150MCG;
$0(Tier 3)
80MG; 3MCG; 200UNIT; 10MG; 200MCG; 20MG; 0.1MG;
10MG; 5MG; 60MG; 1MG; 0.85MG; 0.75MG; 2500UNIT;
15UNIT; 0.8MG
vitamelts energy vitamin b-12
$0(Tier 3)
vitamin a & d capsule 1250unit; 135unit, 400unit; 5000unit $0(Tier 3)
VITAMIN A PALMITATE TABLET 15000UNIT
$0(Tier 3)
vitamin a palmitate tablet 10000unit
$0(Tier 3)
VITAMIN A/BETA CAROTENE TABLET
$0(Tier 3)
vitamin a/beta carotene capsule
$0(Tier 3)
vitamin a capsule 10000unit, 8000unit
$0(Tier 3)
VITAMIN B 12 LOZENGE 250MCG
$0(Tier 3)
vitamin b 6
$0(Tier 3)
vitamin b complex-c
$0(Tier 3)
vitamin b complex tablet 10mg; 10mg; 0.2mg; 2mg; 1.5mg, $0(Tier 3)
2mcg; 15mg; 5mg; 2mg; 2mg; 2mg
vitamin b-12 cr
$0(Tier 3)
vitamin b-12 natural
$0(Tier 3)
vitamin b-12 tr tablet extended release 1000mcg, 2000mcg
$0(Tier 3)
vitamin b-12 lozenge 500mcg
$0(Tier 3)
vitamin b-12 tablet sublingual 1000mcg, 2500mcg
$0(Tier 3)
vitamin b-12 tablet 1000mcg, 100mcg, 250mcg, 500mcg
$0(Tier 3)
vitamin b-1 tablet 100mg, 250mg, 50mg
$0(Tier 3)
vitamin b-2
$0(Tier 3)
vitamin b-6 tablet extended release 200mg
$0(Tier 3)
vitamin b-6 tablet 100mg, 250mg, 25mg, 50mg
$0(Tier 3)
vitamin b-complex tablet 83mg; 5mcg; 20mg; 1mg; 2mg; 3mg $0(Tier 3)
vitamin b12 tr
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
102
What the drug
will cost you
Name of drug
(tier level)
VITAMIN B12/FOLIC ACID
$0(Tier 3)
vitamin b12 tablet extended release 1000mcg
$0(Tier 3)
vitamin b12 tablet 100mcg, 500mcg
$0(Tier 3)
vitamin b1 tablet 100mg, 250mg
$0(Tier 3)
vitamin b6 tablet 250mg
$0(Tier 3)
vitamin c drops lozenge 60mg
$0(Tier 3)
vitamin c sr capsule extended release
$0(Tier 3)
vitamin c tr/rose hips
$0(Tier 3)
vitamin c tr capsule extended release
$0(Tier 3)
vitamin c tr tablet extended release 1500mg, 500mg
$0(Tier 3)
vitamin c/acerola tablet chewable
$0(Tier 3)
vitamin c/rose hips tr tablet extended release 1000mg, 500mg, $0(Tier 3)
500mg; 0
vitamin c/rose hips/acerola tablet
$0(Tier 3)
vitamin c/rose hips tablet 1000mg, 1000mg; 0, 500mg,
$0(Tier 3)
500mg; 0
VITAMIN C POWDER 0
$0(Tier 3)
VITAMIN C SYRUP 500MG/5ML
$0(Tier 3)
VITAMIN C TABLET CHEWABLE 0; 500MG; 0; 0; 0; 0
$0(Tier 3)
vitamin c tablet chewable 250mg, 500mg, 500mg; 0
$0(Tier 3)
vitamin c tablet extended release 500mg
$0(Tier 3)
vitamin c tablet 1000mg, 100mg, 250mg, 500mg
$0(Tier 3)
vitamin d-1000
$0(Tier 3)
vitamin d-1000 maximum strength
$0(Tier 3)
vitamin d-3 capsule 1000unit
$0(Tier 3)
vitamin d-400
$0(Tier 3)
VITAMIN D2
$0(Tier 3)
vitamin d3 400
$0(Tier 3)
vitamin d3 maximum strength
$0(Tier 3)
vitamin d3 super strength tablet
$0(Tier 3)
vitamin d3 capsule 10000unit, 1000unit, 2000unit, 400unit, $0(Tier 3)
5000unit
VITAMIN D3 LIQUID 1000UNIT/SPRAY,
$0(Tier 3)
1200UNIT/15ML
vitamin d3 liquid 400unit/ml, 5000unit/ml
$0(Tier 3)
vitamin d3 tablet chewable 1000unit
$0(Tier 3)
VITAMIN D3 TABLET 3000UNIT
$0(Tier 3)
vitamin d3 tablet 1000unit, 2000unit, 400unit, 5000unit
$0(Tier 3)
vitamin d capsule, liquid
$0(Tier 3)
vitamin d tablet 1000unit, 2000unit, 400unit
$0(Tier 3)
vitamin e blend capsule 400unit
$0(Tier 3)
vitamin e mixed
$0(Tier 3)
vitamin e water dispersible
$0(Tier 3)
vitamin e water soluble
$0(Tier 3)
vitamin e-400
$0(Tier 3)
vitamin e/d-alpha
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
103
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)
Name of drug
vitamin e/d-alpha natural capsule 400unit
vitamin e/selenium
vitamin e capsule 1000unit, 100unit, 200unit, 400unit
vitamin e oil, solution
VITAMIN E TABLET 100UNIT
vitamin k
VITAMIN K1 INJECTION 10MG/ML
vitamin k1 injection 1mg/0.5ml
vitamins & minerals
vitamins a & d
vitamins a-d-e/selenium
vitamins for hair tablet 300mcg; 100mg; 250mg; 6mcg; 0;
4mg; 400mcg; 125mg; 35mg; 35mg; 150mcg; 2mg; 2mg; 0;
2mg; 5000unit; 15mg, 400mcg; 100mg; 250mg; 2mg; 6mcg;
18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg
vitatrum tablet chewable
$0(Tier 3)
VITATRUM TABLET 90MG; 0; 30MCG; 200MG; 10MG; $0(Tier 3)
109MG; 72MG; 400UNIT; 35MCG; 0.9MG; 6MCG; 18MG;
500MCG; 250MCG; 300MCG; 100MG; 2.3MG; 20MG;
5MCG; 25MCG; 80MG; 150MCG; 2MG; 1.7MG; 2MG;
150MCG; 10MCG; 45MCG; 55MCG; 10MCG; 1.5MG;
30UNIT; 3500UNIT; 11MG
VITRUM 50+ SENIOR MULTI
$0(Tier 3)
vitrum senior tablet 60mg; 0; 30mcg; 150mcg; 200mg; 10mg; $0(Tier 3)
48mg; 72mg; 400unit; 150mcg; 2mg; 25mcg; 400mcg;
250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 10mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 1.5mg;
45unit; 3500unit; 15mg
VP-PNV-DHA
$0(Tier 2)
womens 50+ advanced
$0(Tier 3)
WOMENS BIOMULTIPLE
$0(Tier 3)
womens daily formula/folic acid/calcium/iron
$0(Tier 3)
womens multi
$0(Tier 3)
womens one daily
$0(Tier 3)
YELETS TEENAGE FORMULA
$0(Tier 3)
ZINC LOZENGE 100MG; 10MG; 50MG; 500UNIT; 15MG $0(Tier 3)
zoo friends
$0(Tier 3)
ZOO FRIENDS COMPLETE TABLET CHEWABLE 30MG; $0(Tier 3)
0; 20MCG; 50MG; 5MG; 200UNIT; 1MG; 3MCG; 9MG;
200MCG; 10MG; 10MG; 50MG; 75MCG; 1MG; 0.85MG;
5MG; 0.75MG; 15UNIT; 2500UNIT; 7.5MG
zoo friends plus extra c
$0(Tier 3)
zoo friends plus iron
$0(Tier 3)
Unclassified
No Classification
ALBA-LYBE NR
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
104
Name of drug
b-100 tr tablet extended release 100mcg; 100mg; 100mcg;
400mcg; 100mg; 100mg; 100mg; 100mg
B-12 QUICK DISSOLVE
b-12 tr tablet extended release 1000mcg, 2000mcg
b-12 tablet 100mcg
b-complex/b-12
b-complex/vitamin c
balance b-50 tablet 50mcg; 50mg; 50mcg; 400mcg; 50mg;
50mg; 50mg; 50mg
BIOFLONEX
BIOTIN CAPSULE 1MG
biotin capsule 5000mcg, 5mg
brewers yeast tablet 500mg; 0.15mg; 0.02mg; 0.06mg
c-chewable
calcium ascorbate tablet 500mg
chewable vitamin c tablet chewable 500mg, 500mg; 0
CHOLECALCIFEROL
cod liver oil capsule 135unit; 415mg; 36mg; 37mg; 90mg;
1250unit
cvs b-12 liquid 1000mcg/15ml
cvs b-12 tablet disintegrating 1500mcg
cvs b-6
cvs biotin high potency
cvs iron
cvs slow release iron
cvs super b complex/c tablet 150mg; 5mcg; 100mg; 5.5mg;
15mcg; 400mcg; 25mg; 2mg; 20mg; 100mg
cvs vitamin b-12 tr
cvs vitamin b-12 tablet 1000mcg, 500mcg
D 1000 PLUS ALOE
d 1000 tablet 1000unit
d 400 tablet 400unit
D3 + K2 DOTS
eq allergy relief
eq slow-release iron
eql b-100 complex tr
eql vitamin c/rose hips tablet 500mg
essential one daily multivitamin
fe c
FERAHEME
ferrous sulfate elixir 220mg/5ml
ferrous sulfate solution 15mg/ml
ferrous sulfate tablet 325mg
GERITOL TONIC
gnp b-complex plus vitamin c
gnp childrens chewables/extra c
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
105
Name of drug
gnp childrens chewables/iron tablet chewable 60mg; 0;
400unit; 4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg;
1.05mg; 15unit; 2500unit
gnp essential one daily tablet 60mg; 0; 75mg; 10mg; 400unit;
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
gnp iron tablet extended release 45mg
gnp little ones childrens tablet chewable 60mg; 0; 400unit;
4.5mcg; 300mcg; 10mg; 1.05mg; 1.2mg; 1.05mg; 15unit;
1998unit
gnp one daily plus iron tablet 60mg; 75mg; 10mg; 400unit;
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
gnp one daily womens health
gnp vitamin b1
gnp vitamin c drops lozenge 60mg; 0
GNP VITAMIN D-400
gnp vitamin d tablet chewable 400unit
hm iron slow release
HM ONE DAILY ESSENTIAL TABLET 60MG; 0; 45MG;
10MG; 400UNIT; 6MCG; 400MCG; 20MG; 2MG; 1.7MG;
1.5MG; 30UNIT; 3000UNIT
hm one daily essential tablet 60mg; 0; 45mg; 10mg; 400unit;
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
hm one daily/iron
hm vitamin b complex/vitamin c
hm vitamin b1
hm vitamin b100 complex
hm vitamin b12
hm vitamin b12 tr
hm vitamin b50 complex
hm vitamin b6
hm vitamin c
hm vitamin c tr
I.L.X. B-12
ICAR PEDIATRIC
ICAR-C
INTRINSI B12/FOLATE
IRON CHEWS PEDIATRIC
IRON FORMULA CAPSULE 100MCG; 400MCG; 27MG
iron tablet 65mg
KELP/LECITHIN/B-6
liquid b12 liquid 1000mcg/15ml
LORTUSS LQ
multivitamin
natural c/rose hips
pa biotin
What the drug
will cost you
(tier level)
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
$0(Tier 3)
DP
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
$0(Tier 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
106
What the drug
will cost you
Name of drug
(tier level)
POLY HIST FORTE
$0(Tier 3)
PROFERRIN ES
$0(Tier 3)
pyridoxine hcl tablet 25mg
$0(Tier 3)
ra niacin tablet 500mg
$0(Tier 3)
ra slow release iron tablet extended release 45mg
$0(Tier 3)
ra vitamin b-12 tr tablet extended release 1000mcg
$0(Tier 3)
ra vitamin b-12 tablet 100mcg
$0(Tier 3)
ra vitamin b-6 tablet 100mg
$0(Tier 3)
ra vitamin c tablet chewable 500mg; 0
$0(Tier 3)
RX SUPPORT HEARTBURN/ACID REFLUX WITH ALOE $0(Tier 3)
RYMED TABLET 2MG; 10MG
$0(Tier 3)
sb vitamin c
$0(Tier 3)
sm b-complex
$0(Tier 3)
SM ONE DAILY ESSENTIAL
$0(Tier 3)
sm vitamin b100 complex
$0(Tier 3)
sm vitamin b12
$0(Tier 3)
sm vitamin b12 tr
$0(Tier 3)
sm vitamin b6
$0(Tier 3)
sm vitamin c tr
$0(Tier 3)
sm vitamin c tablet 1000mg, 500mg
$0(Tier 3)
STAHIST AD
$0(Tier 3)
V-R FATIGUE RELIEF COMPLEX
$0(Tier 3)
VASOFLEX D1
$0(Tier 3)
vitamin b-1 tablet 100mg
$0(Tier 3)
vitamin b-6 tablet 100mg
$0(Tier 3)
vitamin b12 tablet 100mcg, 500mcg
$0(Tier 3)
vitamin b1 tablet 100mg
$0(Tier 3)
vitamin c drops lozenge 60mg; 0
$0(Tier 3)
vitamin c/rose hips tr tablet extended release 1000mg
$0(Tier 3)
vitamin c/rose hips tablet 500mg, 500mg; 0
$0(Tier 3)
VITAMIN C SOLUTION RECONSTITUTED 0
$0(Tier 3)
vitamin c tablet 500mg
$0(Tier 3)
vitamin d-3 tablet 2000unit
$0(Tier 3)
VITRON-C
$0(Tier 3)
wee care
$0(Tier 3)
ZINC & C LOZENGES
$0(Tier 3)
zoo friends gummies
$0(Tier 3)
Necessary actions,
restrictions, or limits on
use
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
You can find information on what the symbols and abbreviations in this table mean by going to page 9.
107
Index Drug Name
a thru z advanced
a thru z select
a thru z select 50+ advanced formula
a thru z select advanced
abacavir
abacavir sulfate/lamivudine/zidovudine
abacavir/lamivudine
abatron
abatron af
abc plus senior adults 50+
ABELCET
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
a-caro-25
acebutolol hcl
ACEROLA C 500
acerola c-500
acetaminophen/codeine
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
ACTHIB
actical
ACTIMMUNE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
ADCIRCA
adefovir dipivoxil
ADEMPAS
ADRENACLICK
adriamycin
adrucil
ADULT ONE DAILY GUMMIES
ADVAIR DISKUS
ADVAIR HFA
advanced stress formula/zinc
afeditab cr
AFINITOR
AFINITOR DISPERZ
Page #
77
77
77
77
37
37
37
72
72
77
23
33
27
13
39
77
45
77
77
12
67
48
66
48
67
70
62
77
62
38
38
63
52
51
70
35
70
69
27
26
77
67
67
77
46
29
29
108
Drug Name
A-HYDROCORT
ALA-HIST PE
ALBA-LYBE NR
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
alcohol prep pads
ALDURAZYME
ALECENSA
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all day allergy childrens
allopurinol
allopurinol sodium
allzital
ALOPRIM
ALORA
alosetron hydrochloride
ALPHAGAN P
alprazolam
alprazolam intensol
amantadine hcl
AMBISOME
amcinonide
amifostine
amikacin sulfate
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
AMMONIUM CHLORIDE
Page #
55
68
104
31
69
69
55
14
52
29
64
55
26
31
25
68
24
24
11
24
57
53
66
38
38
38
23
55
27
14
48
48
70
72
72
72
72
72
72
72
72
45
53
22
46
46
46
46
73
Drug Name
ammonium lactate
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
amphotericin b
ampicillin
ampicillin sodium
ampicillin-sulbactam
AMPYRA
ANADROL-50
anagrelide hydrochloride
anastrozole
ANDRODERM
animal chews
animal shapes
animal shapes + iron
antioxidant vitamins
APATATE
APATATE FORTE
APETEX
APETIGEN
APETIGEN-PLUS
APIDRA
APIDRA SOLOSTAR
APOKYN
aprepitant
apri
APTIOM
APTIVUS
AQUADEKS
AQUA-E
AQUASOL A PARENTERAL
aqueous vitamin d infants
aqueous vitamin e
ARALAST NP
aranelle
ARANESP ALBUMIN FREE
ARCALYST
aripiprazole
aripiprazole odt
ARISTADA
ARRANON
ascomp/codeine
ASCORBIC ACID
ascorbic acid/rose hips
asco-tabs-1000
ASMANEX HFA
Page #
52
22
16
16
16
50
23
16
16
16
51
57
42
29
57
77
78
77
78
78
78
78
78
78
41
41
32
23
57
17
37
78
78
78
78
78
70
57
42
62
33
33
33
26
12
78
78
78
67
109
Drug Name
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspirin/dipyridamole
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone dipropionate
AVASTIN
AVELOX
aviane
AVONEX
AVONEX PEN
azacitidine
AZACTAM IN ISO-OSMOTIC
DEXTROSE
AZASAN
AZASITE
azathioprine
azelastine hcl
AZILECT
azithromycin
aztreonam
b complete
b complex
b complex/c
B COMPLEX/FOLIC ACID
b complex/vitamin c
b-1
b-100 complex
b-100 tr
b-100 tr
b-12
b-12
B-12 1000
B-12 DOTS
b-12 microlozenge
B-12 QUICK DISSOLVE
B-12 SUPER STRENGTH
b-12 tr
Page #
67
67
67
43
45
45
49
31
31
38
53
68
51
57
55
31
17
57
51
51
27
16
61
16
61
68
32
16
16
78
78
78
78
78
78
78
105
78
105
78
78
78
78
105
78
105
Drug Name
b-12 tr
b-50 complex
b-6
baciim
BACITRACIN
bacitracin/polymyxin b
baclofen
BACTOCILL IN DEXTROSE
balance b-100
balance b-50
balance b-50
balanced b complex tr
balanced b-100
balanced b-50
balanced b-50 complex
balsalazide disodium
balziva
BANZEL
BARACLUDE
bcg vaccine
b-complex
b-complex +c
b-complex balanced
b-complex formula 1
b-complex plus vitamin c
b-complex w/c
b-complex with b-12
b-complex/b-12
b-complex/c
b-complex/vitamin c
B-COMPLEX/VITAMIN C/FOLIC ACID/ BIOTIN
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
bd insulin syringe/detachable
needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
bd pen needles short/ultrafine/31g x 5/16"
bec/zinc
bee zee
Page #
78
79
79
14
14
66
35
16
79
105
79
79
79
79
79
63
57
19
35
63
79
79
79
79
79
79
79
105
79
105
79
64
65
65
65
65
65
65
65
65
65
79
79
110
Drug Name
bekyree
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENICAR
BENICAR HCT
BENLYSTA
benztropine mesylate
beta carotene
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
betaxolol hcl
bethanechol chloride
better b complex
bexarotene
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
BICNU
BIDIL
BIO-35 GLUTEN-FREE
BIOFLONEX
BIOTIN
biotin
biotin 5000
biotin plus/calcium/vit d3
biotin/maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
blisovi fe 1.5/30
B-NATAL
body/hair/skin/nails
BOOSTRIX
BOSULIF
BOTOX
BOTOX
BRAIN MIGHT/DHA & CO Q10
brewers yeast
brewers yeast
BRILINTA
brimonidine tartrate
BRIVIACT
bromocriptine mesylate
budesonide
budesonide
bumetanide
Page #
57
27
44
44
44
44
61
32
79
55
55
51
45
66
55
79
31
63
26
16
16
25
50
79
105
105
79
79
79
79
45
45
27
57
79
80
63
29
24
65
80
105
80
43
66
18
32
55
67
48
Drug Name
BUPHENYL
buprenorphine hcl
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYETTA
c 1000
c 1000/bioflavonoids/rosehips
c 250
c 500
c 500/rose hips
c complex
c-1000
c-1000 prolonged release
c-1000 sr
c-1000/rose hips
c-1000/rose hips sr
c-250
c-500
c-500 prolonged release
c-500 sr
c-500/rose hips
cabergoline
CABOMETYX
calcidol
calciferol
calcipotriene
calcitonin-salmon
calcitriol
calcium acetate
calcium ascorbate
calcium ascorbate
calcium carbonate/vitamin d
CALCIUM PANTOTHENATE
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
Page #
52
13
14
21
14
21
21
38
25
11
11
11
11
12
39
80
80
80
80
80
80
80
80
80
80
80
80
80
80
80
80
61
29
80
80
52
64
64
55
105
80
73
65
59
27
23
44
44
25
29
111
Drug Name
captopril
captopril/hydrochlorothiazide
CARBAGLU
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
CARIMUNE NANOFILTERED
CARNITOR
carteolol hcl
cartia xt
carvedilol
CAYSTON
caziant
c-chewable
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT INTRAVENOUS
CELONTIN
cemill
cemill sr
centamin
centavite a-z complete
multivitamin/minerals
centravites
centravites 50 plus
CENTRUM
CENTRUM ADULTS
CENTRUM CARDIO
CENTRUM FLAVOR BURST ADULT
CENTRUM FLAVOR BURST KIDS
centrum kids complete
CENTRUM PERFORMANCE
CENTRUM SILVER
CENTRUM SILVER ADULT 50+
Page #
44
44
71
19
19
19
32
32
32
27
62
65
66
46
45
69
57
105
15
15
15
15
15
15
15
15
15
15
15
15
15
15
61
18
80
80
80
80
80
80
81
80
80
80
80
80
80
80
80
Drug Name
CENTRUM SILVER ULTRA MENS
CENTRUM SILVER ULTRA WOMENS
CENTRUM SPECIALIST ENERGY
CENTRUM SPECIALIST HEART
CENTRUM SPECIALIST VISION
CENTRUM ULTRA MENS
CENTRUM ULTRA WOMENS
century
century mature
cephalexin
CEREBYX
CEREZYME
cerovite advanced formula
cerovite jr
cerovite senior
certa plus
certa-vite
CERTAVITE SENIOR/ANTIOXIDANT
NUTRIENTS
certavite/antioxidants
CERVARIX
cetirizine hcl
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHEMET
chewable vitamin c
chewable vitamin c
chewable vite childrens
chew-c
childrens chewable vitamin
childrens chewable vitamins
childrens chewable vitamins/iron
childrens gummies
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpromazine hcl
chlorthalidone
chlorzoxazone
CHOLECALCIFEROL
cholestyramine light
chorionic gonadotropin
ciclopirox
ciclopirox olamine
Page #
80
81
81
81
81
81
81
81
81
15
19
52
81
81
81
81
81
81
81
63
68
14
14
14
71
105
81
81
81
81
81
81
81
14
22
51
51
31
48
48
33
48
71
105
49
56
24
24
112
Drug Name
cidofovir
cilostazol
cimetidine
cimetidine hcl
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
CITRUS BIOFLAVONOIDS
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
CLIMARA PRO
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clobetasol propionate
clobetasol propionate e
clodan
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
Page #
35
43
53
53
61
67
17
17
17
27
21
81
26
16
52
17
16
14
14
58
14
14
14
14
14
52
73
73
73
73
73
73
73
73
73
73
73
73
73
73
73
73
55
55
55
26
22
18
18
43
Drug Name
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
cod liver oil
cod liver oil
COD LIVER OIL PLUS VITAMIN C
cod liver oil w/vitamins a&d
cod liver oil w/vitamins a, c, & d
colchicine
COLCRYS
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
companion
compete
COMPLERA
complete
COMPLETE FORMULATION
MULTIVITAMIN SUPPLEMENT
complete multivitamin/multimineral
supplement
complete senior
complex b-100
complex b-50 prolonged release
compro
constulose
cortisone acetate
COSMEGEN
COTELLIC
COUMADIN
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cvs b complex plus c
cvs b-12
cvs b-12
cvs b-6
cvs balanced b-100
Page #
43
43
38
24
52
35
35
32
105
81
81
81
81
24
24
49
14
66
68
29
82
82
36
82
82
82
82
82
82
33
54
55
27
27
42
52
37
53
66
70
58
14
52
82
105
82
105
82
113
Drug Name
cvs balanced b-50
cvs beta carotene
cvs biotin
cvs biotin high potency
cvs childrens chewable complete
cvs childrens chewable multivitamin/iron
CVS COD LIVER OIL
cvs daily energy
cvs daily gummies
cvs daily multiple
cvs daily multiple for men
cvs daily multiple for men 50+
cvs daily multiple for women
cvs daily multiple for women 50+
cvs daily multiple plus iron/calcium/zinc
CVS DIABETES HEALTH SUPPORT
cvs e
cvs e oil
cvs folic acid
cvs gummy dinos
cvs hair skin & nails/an tioxidants
cvs indoor/outdoor allergy relief
cvs iron
cvs niacin flush free
cvs slow release iron
CVS SPECTRAVITE ADULT 50+
CVS SPECTRAVITE ADULT GUMMIES
cvs spectravite advanced formula
cvs spectravite senior
cvs spectravite ultra health mens
CVS SPECTRAVITE ULTRA MEN50+
CVS SPECTRAVITE ULTRA MENS
HEALTH
CVS SPECTRAVITE ULTRA MENS
HEALTH SENIOR
CVS SPECTRAVITE ULTRA WOMEN
CVS SPECTRAVITE ULTRA WOMENS
HEALTH
CVS SPECTRAVITE ULTRA WOMENS
HEALTH SENIOR
cvs stress formula/zinc
cvs super b complex/c
cvs super b complex/c
cvs vision formula
cvs vitamin a
cvs vitamin b-12
cvs vitamin b-12
cvs vitamin b-12 tr
cvs vitamin b-6
CVS VITAMIN C
Page #
82
82
82
105
82
82
82
82
82
82
82
82
82
82
82
82
82
82
82
82
82
68
105
49
105
83
83
83
83
83
83
83
83
83
83
83
83
105
83
83
83
105
83
105
83
83
Drug Name
cvs vitamin c/rose hips
cvs vitamin d 5000 high-potency
cvs vitamin e
cvs womens active daily
cyanocobalamin
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYRAMZA
CYSTADANE
CYSTAGON
CYSTARAN
cytarabine aqueous
CYTO B2
CYTOMEL
d 1000
d 1000
D 1000 PLUS ALOE
d 10000
d 2000
d 400
d 400
d 5000
d-1000 extra strength
d-2000 maximum strength
d2000 ultra strength
d3
D3 + K2 DOTS
d3 adult
d3 high potency
d3 super strength
d3-1000
d3-50
d-400
d-5000
dacarbazine
DACOGEN
daily combo multi vitamin
daily multiple vitamin
daily multiple vitamin/iron
daily multiple vitamins
daily multiple vitamins w/iron
daily multiple vitamins/minerals
daily multiple weight loss
daily multivitamin
daily multi-vitamins + iron
Page #
83
83
83
83
83
58
71
25
39
61
61
68
31
52
52
66
26
83
60
105
83
105
83
83
105
83
84
84
84
84
84
105
84
84
84
84
84
84
84
25
27
84
84
84
84
84
84
84
84
84
114
Drug Name
daily value multivitamin
daily vitamin
daily vitamin formula
daily vitamin formula+iron
daily vitamin formula+minerals
daily vitamins
daily vite
daily-vite
daily-vite/iron/beta-carotene
DALIRESP
DALLERGY
danazol
dantrolene sodium
DAPSONE
DAPTACEL
daptomycin
DARAPRIM
darifenacin hydrobromide er
DARZALEX
daunorubicin hcl
deblitane
DECARA
decitabine
DECUBI-VITE
delta d3
delyla
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
DESCOVY
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexrazoxane
dextroamphetamine sulfate
DEXTROSE 10%/NACL 0.45%
dextrose 10%
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/nacl 0.45%
Page #
84
84
84
84
84
84
85
85
85
70
68
57
35
25
63
14
32
54
31
27
59
85
27
85
85
58
63
17
47
38
71
58
55
59
37
22
56
58
55
55
21
55
55
66
27
50
73
73
73
73
Drug Name
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
diabetes health formula
DIABETES HEALTH PACK
dialyvite 800
dialyvite 800/ultra d
DIALYVITE 800/ZINC
DIALYVITE 800/ZINC 15
dialyvite vitamin d 5000
dialyvite vitamin d3 max
diazepam
diazepam
diazepam intensol
diclofenac potassium
diclofenac sodium
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
diltiazem cd
diltiazem hcl
diltiazem hcl er
dilt-xr
dino-life
dino-life w extra c
DINO-LIFE W/IRON & ZINC
DIPENTUM
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disney cars gummies
disney princess gummies
disopyramide phosphate
disulfiram
Page #
73
73
73
73
73
73
73
85
85
85
85
85
85
85
85
18
38
38
11
52
66
11
11
16
53
37
11
47
47
24
19
19
19
46
46
46
46
85
85
85
63
68
53
63
43
85
85
45
13
115
Drug Name
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
DOCETAXEL
dofetilide
donepezil hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
doxazosin
doxazosin mesylate
doxepin hcl
doxercalciferol
doxorubicin hcl
doxorubicin hcl liposome
doxy 100
doxycycline hyclate
doxycycline monohydrate
DRISDOL
dronabinol
drospirenone/ethinyl estradiol
DROXIA
DULERA
duloxetine hcl
DUOFER
duramorph
DUREZOL
dutasteride
D-VI-SOL
d-vita
DYRENIUM
e.e.s. 400
e.e.s. granules
e400
e-400
ear health formula
ear health plus
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
ecee plus
econazole nitrate
EDURANT
EFFIENT
ELAPRASE
ELDEPRYL
ELDERTONIC
ELELYSO
ELIDEL
ELIGARD
ELIPHOS
Page #
18
18
18
27
27
45
20
66
66
55
55
22
64
27
27
17
17
17
85
23
58
26
67
21
73
12
66
55
84
84
48
17
17
85
85
85
85
65
65
85
24
36
43
52
32
85
52
52
61
55
Drug Name
ELITEK
ELIXOPHYLLIN
ELLENCE
ELMIRON
EMCYT
EMEND
EMPLICITI
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
ENBREL SURECLICK
endocet
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
enulose
ENVARSUS XR
e-oil
e-oil
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
eq allergy relief
eq complete chewable multivitamin
childrens
eq complete multivitamin adults 50+
EQ COMPLETE MULTIVITAMIN
ADULTS UNDER 50
eq multivitamin gummies childrens
EQ ONE DAILY MENS HEALTH
EQ ONE DAILY WOMENS HEALTH
eq slow-release iron
eql all day allergy
eql b complex
eql b complex 100
eql b complex 50
eql b-100 complex tr
eql b-12
eql b-6
Page #
26
70
27
55
26
23
31
21
37
45
44
61
61
12
63
42
58
32
35
54
61
52
85
69
69
69
27
19
35
48
42
44
37
105
85
85
85
85
85
85
105
68
86
86
86
105
86
86
116
Drug Name
eql beta carotene
eql central-vite
eql central-vite performance
eql central-vite select
eql century
eql century cardio healthformula
eql century mature
eql childrens c
EQL CHILDRENS MULTIVITAMINS
eql childrens multivitamins/minerals
eql folic acid
eql iron supplement therapy
eql niacin
eql one daily 50 plus
EQL ONE DAILY DIET SUPPORT
eql one daily energy
eql one daily essential
eql one daily maximum
eql one daily mens health formula
eql one daily womens
eql slow release iron
eql sour gummies childrens
EQL SUPER ENERGY BOOSTER
eql ultimate womens century
eql vision formula
eql vitamin b-12
eql vitamin c
eql vitamin c/rose hips
eql vitamin c/rose hips
eql vitamin d3
eql vitamin e
ERBITUX
ergocalciferol
ergoloid mesylates
ERGOMAR
ERIVEDGE
errin
ERWINAZE
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
erythromycin/benzoyl peroxide
ESBRIET
escitalopram oxalate
esomeprazole magnesium
esomeprazole sodium
Page #
86
86
86
86
86
86
86
86
86
86
86
73
49
86
86
86
86
86
86
86
73
86
86
86
86
86
86
105
86
86
86
31
86
20
25
29
59
27
17
17
17
17
17
17
17
52
70
21
54
54
Drug Name
essentia
essential balance
essential one daily multivitamin
ESTRACE
estradiol
estradiol valerate
estropipate
ethambutol hcl
ethosuximide
ethynodiol diacetate/ethinyl estradiol
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
etoposide
EVISTA
EVOTAZ
exel comfort point insulin pen needles 31g x
8mm
exemestane
EXJADE
ezetimibe
ezfe 200
FABRAZYME
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FARESTON
FARXIGA
FARYDAK
FASLODEX
FAZACLO
fe c
fe c tab plus
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenofibric acid
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
FEOSOL
FEOSOL BIFERA
FERAHEME
ferate
FERGON
Page #
86
86
105
58
58
58
58
25
18
58
64
11
11
29
29
60
37
65
29
71
44
73
52
58
38
53
53
33
33
26
39
28
26
35
105
73
19
46
48
48
48
11
12
12
73
73
105
73
73
117
Drug Name
FER-IN-SOL
fer-iron
ferosul
FERRETTS
FERRETTS IPS
ferrex 150
FERRIMIN 150
FERRIPROX
FERRLECIT
ferro-bob
ferrous drops
FERROUS FUMARATE
ferrous fumarate 324
FERROUS GLUCONATE
ferrous sulfate
ferrous sulfate
ferrousul
FETZIMA
FETZIMA TITRATION PACK
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
flintstones complete
FLINTSTONES GUMMIES
flintstones gummies plus bone building
support
FLINTSTONES GUMMIES PLUS
IMMUNITY SUPPORT/EXTRA C
flintstones gummies plus omega-3 dha
flintstones plus calcium
flintstones plus extra c
flintstones plus iron
FLINTSTONES SOUR GUMMIES
flintstones/my first
flogen
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in nacl
flucytosine
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorometholone
fluorouracil
Page #
73
73
73
73
73
73
73
65
73
74
74
74
74
74
105
74
74
22
22
55
61
61
54
45
86
87
86
86
86
87
87
87
87
87
11
67
67
24
24
24
27
55
67
55
55
55
66
26
Drug Name
fluorouracil
fluoxetine hcl
fluphenazine decanoate
FLUPHENAZINE HCL
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvastatin
fluvastatin sodium er
fluvoxamine maleate
FOLGARD
FOLIC + B12
FOLIC ACID
FOLITAB 500
FOLOTYN
foltabs 800
FONDAPARINUX SODIUM
FORTAZ
FORTEO
fortical
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC 6.9%
FREEDAVITE
fruit c 500
fruit c-100
fruity c
fruity chewables multivitamin
fruity chews
FULL SPECTRUM B/VITAMIN C
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
galantamine hydrobromide er
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
Page #
52
22
33
33
71
11
66
26
55
67
49
49
22
87
87
87
74
26
87
42
16
64
64
45
45
19
55
42
74
87
87
87
87
87
87
87
48
27
37
18
18
18
20
20
62
62
62
35
63
63
118
Drug Name
GATTEX
gavilyte-c
gavilyte-g
gavilyte-h
gavilyte-n/flavor pack
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate/0.9% sodium chloride
GENVOYA
GEODON
geravim
geriaton
GERITOL COMPLETE
GERITOL TONIC
gildess 1.5/30
GILENYA
GILOTRIF
glatopa
GLEOSTINE
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glyburide
glyburide micronized
glyburide/metformin hcl
glycopyrrolate
gnp animal shapes
gnp animal shapes plus extra c
gnp animal shapes plus iron
gnp b-100 balanced tr
gnp b-100 complex prolonged release
gnp b-12
gnp b-50 balanced
gnp b-50 complex prolonged release
gnp b-complex plus vitamin c
gnp biotin
gnp century
gnp century active performance
gnp century adults 50+ senior
gnp century cardio healthformula
gnp century mature
gnp century ultimate mens complete
gnp century ultimate mens senior formula
Page #
53
54
54
53
54
27
48
54
61
14
14
14
36
33
87
87
87
105
58
51
27
51
25
39
39
39
39
40
41
39
39
39
53
87
87
87
88
88
88
88
88
105
88
88
88
88
88
88
88
88
Drug Name
gnp century ultimate womens complete
gnp century ultimate womens senior formula
gnp childrens chewables w/extra c
gnp childrens chewables/extra c
gnp childrens chewables/iron
gnp childrens chewables/iron
GNP CHILDRENS COMPLETE
CHEWABLES
gnp cod liver oil
gnp essential one daily
gnp essential one daily
gnp folic acid
gnp hair/skin/nails
gnp healthy eyes
gnp healthy eyes supervision
gnp iron
gnp iron
gnp little ones childrens
gnp little ones childrens
gnp maximum one daily
gnp mega multi for men
gnp mega multi for women
gnp niacin
gnp niacin flush free
gnp niacin tr
gnp norwegian cod liver oil
gnp one daily maximum
gnp one daily mens 50+ advanced
gnp one daily mens health 50+
gnp one daily mens health/lycopene
gnp one daily plus iron
gnp one daily plus iron
gnp one daily womens 50+ advanced
gnp one daily womens health
gnp one daily womens health 50+
gnp opti-vitamins
gnp slow release iron
gnp therapeutic-m
gnp vitamin a
gnp vitamin b1
gnp vitamin b-1
gnp vitamin b-12
gnp vitamin b-12 prolonged release
gnp vitamin b-12 tr
gnp vitamin b-6
gnp vitamin c
gnp vitamin c drops
gnp vitamin c drops
gnp vitamin c pr
gnp vitamin c tr
Page #
88
88
88
105
106
88
88
88
106
88
88
88
88
88
106
74
106
88
88
88
88
49
49
88
89
89
89
89
89
106
89
89
106
89
89
74
89
89
106
89
89
89
89
89
89
106
89
89
89
119
Drug Name
gnp vitamin c w/rose hips
gnp vitamin c w/rose hips tr
gnp vitamin c/rose hips
gnp vitamin d
gnp vitamin d
gnp vitamin d maximum strength
gnp vitamin d super strength
gnp vitamin d3 extra strength
GNP VITAMIN D-400
gnp vitamin e
gnp vitamin e water dispersible
gnp womens one daily
gnp zoochews gummies
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guanfacine er
guanfacine hcl
GUANIDINE HCL
gummi bear multivitamin/mineral
hair/skin/nails
hair/skin/nails/biotin
HALAVEN
halls defense vitamin c drops
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HARD NAILS
HARVONI
HAVRIX
healthy eyes
healthy kids cod liver oil/vitamin d
HEALTHY KIDS GUMMIES
healthy kids vitamin d3
HEMOCYTE
heparin sodium
heparin sodium/d5w
hepatamine
HERCEPTIN
HETLIOZ
HEXALEN
HIBERIX
hm animal shapes
hm antioxidant vitamins
HM COMPLETE
hm complete 50+
Page #
89
89
89
106
89
89
89
89
106
89
89
89
89
11
11
23
42
24
24
50
43
25
89
89
89
27
89
56
33
33
33
89
35
63
89
89
89
89
74
42
42
74
31
51
25
63
89
89
90
89
Drug Name
HM COMPLETE 50+ MENS ULTIMATE
HM COMPLETE 50+ WOMENS
ULTIMATE
hm folic acid
HM HAIR/SKIN/NAILS
hm iron
hm iron slow release
hm niacin
HM ONE DAILY ESSENTIAL
HM ONE DAILY MENS
HM ONE DAILY WOMENS
hm one daily/iron
hm vitamin b complex/vitamin c
hm vitamin b1
hm vitamin b100 complex
hm vitamin b12
hm vitamin b12 tr
hm vitamin b50 complex
hm vitamin b6
hm vitamin c
hm vitamin c tr
hm vitamin d
HM VITAMIN D3
hm vitamin e
HONEY BEARS
HONEY BEARS W/IRON AND ZINC
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
HUMULIN R U-500 KWIKPEN
hydralazine hcl
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrocortisone
Page #
90
90
90
90
74
106
90
106
90
90
106
106
106
106
106
106
106
106
106
106
90
90
90
90
90
41
41
41
41
41
41
62
62
62
62
41
41
41
41
41
41
41
50
48
12
12
12
56
120
Drug Name
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone/acetic acid
hydromorphone hcl
HYDROXOCOBALAMIN
hydroxychloroquine sulfate
hydroxyprogesterone caproate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
I.L.X. B-12
ibandronate sodium
IBRANCE
ibuprofen
icaps
ICAPS AREDS FORMULA
icaps lutein & omega-3
icaps mv
ICAPS PLUS
ICAR PEDIATRIC
ICAR-C
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
iferex 150
IFEX
ifosfamide
ILARIS
imatinib mesylate
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMITREX STATDOSE REFILL
IMOVAX RABIES (H.D.C.V.)
INCRELEX
indapamide
indomethacin
indomethacin er
INFANRIX
INFED
infuvite
infuvite adult
infuvite pediatric
INLYTA
insupen ultrafin 31gx8mm
INTEGRA
INTELENCE
Page #
56
56
67
12
90
32
59
27
68
68
106
64
27
11
90
90
90
90
90
106
106
29
27
27
74
25
26
62
30
30
16
22
22
52
25
25
63
56
48
11
11
63
74
90
90
90
30
65
90
36
Drug Name
INTRALIPID
INTRINSI B12/FOLATE
INTRON A
INTRON A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA SUSTENNA
INVEGA TRINZA
INVIRASE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
IOSAT
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
IRESSA
irinotecan
iromin-g
iron
IRON
iron 100 plus
iron 100/c
IRON 21/7
IRON CHEWS PEDIATRIC
iron complex
IRON FORMULA
IRON FORMULA
iron supplement
iron supplement childrens
IRON UP
ISENTRESS
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
isoniazid
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTODAX
ISTODAX (OVERFILL)
itraconazole
ivermectin
i-vite
i-vite protect
IXIARO
JAKAFI
Page #
65
106
35
35
58
50
16
33
34
37
74
74
65
63
68
68
44
44
30
27
90
106
74
74
90
90
106
74
106
74
74
74
74
36
74
74
25
50
50
50
50
14
27
27
24
31
90
90
63
30
121
Drug Name
jantoven
JANUVIA
JENTADUETO
JENTADUETO XR
JEVTANA
jolivette
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
just d
JUXTAPID
KADCYLA
KALETRA
KALYDECO
kariva
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelnor 1/35
kelp
KELP/LECITHIN/B-6
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
KEYTRUDA
kids gummy bear vitamins
kids vitamins
kids vitamins complete
kids vitamins plus extra c
kids vitamins plus iron
kimidess
KINERET
KINRIX
kionex
KISQALI
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
Page #
42
40
40
40
28
59
58
58
58
58
58
58
90
49
31
37
69
58
74
74
74
74
74
74
58
74
106
51
17
24
11
11
11
66
31
91
91
91
91
91
58
62
63
71
28
75
75
75
75
75
Drug Name
kobee
KOMBIGLYZE XR
KORLYM
kp adults 50+ daily formula
kp adults daily formula
kp b complex/c
kp ferrous gluconate
kp ferrous sulfate
kp fish oil
kp mens 50+ daily formula
kp mens daily formula
kp vitamin d
kp vitamin e
kp womens 50+ daily formula
kp womens daily formula
K-PAX IMMUNE SUPPORT FORMULA
DOUBLE STRENGTH
K-PAX IMMUNE SUPPORT FORMULA
PROFESSIONAL STRENGTH
K-PAX IMMUNE SUPPORT FORMULA
SINGLE STRENGTH
KUVAN
KYNAMRO
KYPROLIS
labetalol hcl
lactated ringers irrigation
lactated ringers viaflex
lactulose
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
lamotrigine odt
LANOXIN
lansoprazole
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
LARTRUVO
latanoprost
LATUDA
LAZANDA
leena
leflunomide
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
Page #
91
40
57
91
91
91
75
75
65
91
91
91
91
91
91
90
90
90
53
49
29
45
65
75
54
35
37
37
19
19
47
54
41
41
58
28
66
34
12
58
62
30
30
30
30
30
30
122
Drug Name
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol
levalbuterol hcl
levalbuterol tartrate hfa
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levoleucovorin calcium
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium
levoxyl
LEXIVA
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
LIFE PACK MENS
LIFE PACK WOMENS
LINCOCIN
lincomycin hcl
linezolid
liothyronine sodium
lipo-flavonoid plus
lipoflavovit
LIPOTRIAD
liquid b12
liquid b12
LIQUID C 500
liqui-e
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
lithium carbonate er
LITHOBID
Page #
58
70
29
28
26
42
61
69
69
69
41
41
18
66
65
68
17
17
28
58
58
12
60
60
37
13
13
13
13
13
91
91
15
15
15
60
91
91
91
106
91
91
91
45
45
65
38
39
39
39
Drug Name
LONSURF
loperamide hcl
lopinavir/ritonavir
lorazepam
LORAZEPAM INTENSOL
LORTUSS LQ
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
lovastatin
low-ogestrel
loxapine succinate
LUMIGAN
LUMIZYME
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT-PED (1-MONTH)
lutera
LYNPARZA
LYRICA
lysiplex plus
LYSODREN
lyza
M.V.I. ADULT
M.V.I. PEDIATRIC
M.V.I.-12 WITHOUT VITAMIN K
macuvite
macuvite eye care
magnesium oxide
magnesium sulfate
malathion
maprotiline hcl
marlissa
MARPLAN
MATULANE
matzim la
MAXIMIN PACK
maximum d3
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefloquine hcl
mega multiple w/chelated minerals
MEGA MULTIVITAMIN FOR MEN
MEGA MULTIVITAMIN FOR WOMEN
megestrol acetate
meijer c
MEKINIST
meloxicam
Page #
27
53
37
38
38
106
44
44
66
49
58
33
66
53
61
61
61
61
58
28
18
91
60
60
91
91
91
91
91
53
75
32
21
58
21
26
46
91
91
23
11
60
32
91
91
91
60
91
30
11
123
Drug Name
melphalan hydrochloride
memantine hcl
memantine hcl titration pak
memantine hydrochloride
MENACTRA
MENEST
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENS 50+ ADVANCED
mens daily formula/lycopene
MENS PACK
MENVEO
MEPHYTON
meprobamate
MEPRON
mercaptopurine
meribin
meropenem
mesalamine
mesalamine dr
mesna
MESNEX
MESTINON
METADATE CD
metaproterenol sulfate
metformin hcl
metformin hcl er
METHADONE HCL
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
methyldopate hcl
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
Page #
26
20
20
20
63
58
63
63
91
91
91
63
91
38
32
27
91
16
64
64
28
28
25
50
69
40
40
12
67
15
61
57
71
62
62
52
53
48
43
43
43
65
51
50
50
56
56
56
56
67
Drug Name
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MG-PLUS PROTEIN
MH MACULAR HEALTH
MIACALCIN
miconazole 3
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
miglitol
milltrium senior
minocycline hcl
minoxidil
mirtazapine
mirtazapine odt
misoprostol
mitomycin
mitoxantrone hcl
M-M-R II
modafinil
molindone hydrochloride
mometasone furoate
mometasone furoate
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
moxifloxacin hcl
MOZOBIL
MTX SUPPORT
MULTAQ
multi complete/iron
multi for her
multi for her 50+
multi for him
multi for him 50+
multi vitamin mens
multi-day plus iron
Page #
53
48
45
46
46
15
15
15
45
91
91
64
24
58
58
58
58
43
25
40
91
17
50
21
21
54
28
28
63
71
35
56
67
65
59
68
13
12
17
75
91
45
91
92
91
92
92
92
92
124
Drug Name
multi-day vitamins
multi-delyn
MULTI-DELYN/IRON
multilex
multiple vitamin/minerals/no iron
multiple vitamins
multiple vitamins essential
multiple vitamins plain
multiple vitamins/iron
multiple vitamins/womens
multivital
multivital performance
multivital platinum
multivitamin
multi-vitamin
multivitamin & mineral
multi-vitamin daily
multi-vitamin gummies
multivitamin gummies adult
multi-vitamin hp/minerals
MULTI-VITAMIN MONOCAPS
multi-vitamin/minerals
multivitamins
multi-vitamins
multi-vitamins/iron
mupirocin
MUSTARGEN
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
mycophenolic acid dr
myferon 150
MYKIDZ IRON
MYKIDZ IRON 10
MYRBETRIQ
my-vitalife
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
naftifine hcl
naftifine hydrochloride
NAFTIN
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NANOVM 1-3 YEARS
NANOVM 4-8 YEARS
NANOVM T/F
Page #
92
92
92
92
92
92
92
92
92
92
93
92
92
106
92
93
92
92
93
92
92
92
93
92
92
15
26
24
25
62
62
75
93
71
54
93
11
46
46
16
24
24
24
53
13
14
13
93
93
93
Drug Name
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
NASCOBAL
NASOPEN PE
NATACYN
nateglinide
NATPARA
natural c/rose hips
natural vitamin e
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
one
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
NEPHRAMINE
NEPHRONEX
NEPHRO-VITE
NEUPOGEN
NEUPRO
NEURO VITE
nevirapine
nevirapine er
NEXAVAR
niacin
niacin
niacin er
niacin er
niacin flush free
niacin flush free formula
NIACIN FLUSH-FREE EXTRA
STRENGTH
niacin sr
niacin tr
niacinamide
niacor
nicardipine hcl
Page #
66
11
11
11
25
93
68
24
40
65
106
93
32
59
59
59
59
21
14
66
14
15
66
66
67
15
67
75
93
93
43
32
93
36
36
30
49
93
49
93
49
49
49
93
93
93
49
46
125
Drug Name
NICOTROL NS
nifedical xl
nifedipine er
NILANDRON
nilutamide
NINLARO
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate/macrocrystals
nitroglycerin
nitroglycerin transdermal
NITROSTAT
no flush niacin
NO IRON MULTIPLE
VITAMIN/MINERALS
nora-be
NORDITROPIN FLEXPRO
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
NORTHERA
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
NOVAFERRUM 125
NOVAFERRUM 50
NOVAFERRUM PEDIATRIC DROPS
novofine 32gx6mm
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
NOXAFIL
NUEDEXTA
nu-iron 150
NULOJIX
NULYTELY/FLAVOR PACKS
NUPLAZID
Page #
14
46
47
26
26
28
50
15
15
50
50
50
49
93
60
56
60
60
59
59
60
75
75
75
47
59
59
59
22
37
75
75
75
65
41
42
42
42
42
42
42
42
24
51
75
62
54
34
Drug Name
nutrilipid
nyamyc
nystatin
nystatin/triamcinolone
nystop
octreotide acetate
ocutabs
ocutabs/lutein
OCUVITE ADULT 50+
ocuvite/lutein
ODEFSEY
ODOMZO
OFEV
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olmesartan medoxomil
olmesartan medoxomil/hydrochlorothiazide
olopatadine hcl
olopatadine hcl
omega-3-acid ethyl esters
omeprazole
OMNICAP
once daily
once daily/iron
ONCOVITE
ondansetron hcl
ondansetron odt
one daily
one daily adults 50+
one daily complete
one daily for men 50+ advanced
one daily for men/lycopene
one daily for women
one daily for women 50+a dvanced
one daily healthy weight advanced
one daily maximum
one daily mens
one daily mens health/lycopene
one daily plus iron
one daily plus minerals
one daily womens 50 plus
one daily womens 50+
one daily/iron/calcium
one daily/minerals
ONE-A-DAY CHOLESTEROL PLUS
ONE-A-DAY ENERGY
ONE-A-DAY ESSENTIAL
ONE-A-DAY MAXIMUM FORMULA
Page #
65
24
24
24
24
61
93
93
93
93
36
28
70
17
59
34
34
44
44
66
68
49
54
93
93
93
93
23
23
94
93
93
93
93
93
93
93
93
93
93
94
94
94
94
94
94
94
94
94
94
126
Drug Name
ONE-A-DAY MENOPAUSE FORMULA
ONE-A-DAY MENS
ONE-A-DAY MENS 50+ ADVANTAGE
ONE-A-DAY MENS HEALTH
FORMULA
ONE-A-DAY MENS VITACRAVES
GUMMIES
ONE-A-DAY SCOOBY-DOO GUMMIES
one-a-day teen advantage for her
ONE-A-DAY TEEN ADVANTAGE FOR
HIM
ONE-A-DAY VITACRAVES
ONE-A-DAY VITACRAVES
GUMMIES/IMMUNITY SUPPORT
ONE-A-DAY VITACRAVES
GUMMIES+OMEGA-3 DHA
ONE-A-DAY VITACRAVES
SOURGUMMIES
ONE-A-DAY WEIGHT SMART
ADVANCED
ONE-A-DAY WOMENS 50+
ADVANTAGE
ONE-A-DAY WOMENS ACTIVE MIND
& BODY
ONE-A-DAY WOMENS FORMULA
ONE-A-DAY WOMENS PETITES
ONE-A-DAY WOMENS PLUS
HEALTHY SKIN SUPPORT
ONE-A-DAY WOMENS VITACRAVES
GUMMIES
ONE-A-DAY/JOLLY RANCHER
one-daily multi vitamins
ONFI
ONGLYZA
OPDIVO
OPSUMIT
optimal-d
optimal-d pack
OPTISOURCE POST BARIATRIC
SURGERY
OPURITY B12/FOLIC ACID
ORENCIA
ORENCIA CLICKJECT
ORENITRAM
ORKAMBI
orphenadrine citrate
orphenadrine citrate er
oseltamivir phosphate
oxacillin sodium
oxaliplatin
Page #
94
94
94
94
94
94
94
94
94
94
94
94
94
94
94
94
94
94
95
95
95
18
40
31
70
95
95
95
95
62
62
70
69
71
71
38
16
28
Drug Name
oxandrolone
oxaprozin
oxcarbazepine
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
pa b-complex with b-12
pa biotin
pa vitamin b-12 tr
pa vitamin d-3
pa vitamin d-3 gummy
pa vitamin e
pacerone
paclitaxel
paliperidone er
PAMIDRONATE DISODIUM
PANCREAZE
PANRETIN
pantoprazole sodium
pantothenic acid
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PARVLEX
PASER
PATANOL
PAXIL
PEDIARIX
pediavit
PEDVAX HIB
peg-3350/nacl/na bicarbonate/kcl
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEG-INTRON REDIPEN
penicillin g potassium
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
PENTAM 300
pentoxifylline er
periogard
PERJETA
permethrin
perphenazine
Page #
57
11
19
19
54
54
13
13
95
106
95
95
95
95
45
28
34
64
53
31
54
65
14
22
22
95
25
66
22
63
95
63
54
20
36
36
36
36
16
16
16
16
16
32
47
51
31
32
33
127
Drug Name
perphenazine/amitriptyline
phenadoz
phenelzine sulfate
phenobarbital
PHENYTEK
phenytoin
phenytoin sodium
phenytoin sodium extended
PHOSPHOLINE IODIDE
PHYSICIANS EZ USE B-12
COMPLIANCE KIT
physiolyte
physiosol irrigation
phytonadione
PICATO
pilocarpine hcl
pilocarpine hcl
pilocarpine hydrochloride
pimozide
pindolol
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin/tazobactam
piroxicam
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
PLENAMINE
podofilox
POLY HIST FORTE
poly vitamin
polyethylene glycol 3350
poly-iron 150
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
POLY-VI-SOL
POLY-VI-SOL/IRON
poly-vita drops
poly-vita/iron drops
polyvitamin
polyvitamin/iron
POMALYST
portia-28
potassium chloride
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride er
potassium chloride/dextrose
Page #
22
23
21
18
20
20
20
20
67
95
65
65
95
52
51
67
51
33
46
40
40
40
16
12
75
75
75
75
52
107
95
54
75
15
66
95
95
95
95
95
95
26
59
75
75
75
75
75
75
Drug Name
POTASSIUM
CHLORIDE/DEXTROSE/LACTATED
RINGERS
POTASSIUM CHLORIDE/SODIUM
CHLORIDE
potassium citrate er
POTASSIUM IODIDE
POTIGA
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
PRESERVISION AREDS
PRESERVISION/LUTEIN
prevalite
prevent
previfem
PREZCOBIX
PREZISTA
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRISTIQ
PROAIR HFA
PROAIR RESPICLICK
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
PROCERV HP
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
procto-med hc
procto-pak
proctosol hc
proctozone-hc
Page #
75
75
75
60
18
42
32
49
43
66
66
56
66
56
66
56
56
59
76
59
59
95
95
50
95
59
37
37
25
32
19
22
69
69
24
24
45
76
95
33
33
33
43
56
56
56
56
128
Drug Name
PROFE
PROFERRIN ES
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
promethegan
PROMETRIUM
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
prorenal+d
prorenal+d/omega-3
prosight
prosight w/lutein
PROSOL
prostamen
PROTECT CARDIO AF
PROTEXIN
protriptyline hcl
PULMOZYME
pureway-c
PURIXAN
pyrazinamide
pyridostigmine bromide
pyridostigmine bromide er
pyridoxine hcl
pyridoxine hcl
qc childrens chewable complete
qc childrens chewable vitamins/extra c
qc childrens chewable vitamins/iron
QC COD LIVER OIL
qc ferrous sulfate
qc maximum daily
multivitamin/multimineral
qc mens daily multivitamin
qc multi-vite
qc multi-vite 50 & over
qc womens daily multivitamin
QUADRACEL
quasense
QUDEXY XR
Page #
76
107
60
41
62
70
28
64
43
23
70
23
60
45
46
46
46
61
63
95
95
95
96
76
65
96
96
22
70
96
27
25
25
25
107
96
96
96
96
96
76
96
96
96
96
96
63
59
19
Drug Name
quetiapine fumarate
QUIN B STRONG
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinine sulfate
QUINTABS
QUINTABS-M
ra balanced b-100
ra balanced b-50
ra b-complex
ra b-complex with b-12
ra b-complex/vitamin c tr
ra beta carotene
ra biotin
ra central-vite
ra central-vite cardio
ra central-vite energy
ra central-vite performance
ra central-vite select
ra central-vite select mature
ra central-vite senior
RA CENTRAL-VITE UNDER 50 MENS
RA CENTRAL-VITE UNDER 50
WOMENS
ra central-vite womens mature
ra central-vite/antioxidants
RA COD LIVER OIL
RA ESSENCE-C
ra folic acid
ra gummy vitamins & minerals childrens
ra high potency iron
ra iron
ra natural vitamin e
ra niacin
ra niacin
ra one daily energy formula
ra one daily essential
ra one daily gummy vites
ra one daily maximum
ra one daily mens 50+ with vitamin d-3
ra one daily mens/vitamind-3
ra one daily multi-vitamin
ra one daily multi-vitamin plus iron
ra one daily womens/vitamin d-3
ra slow release iron
ra slow release iron
ra stress formula advanced
Page #
34
96
45
45
45
45
45
32
96
96
96
96
96
96
96
96
96
97
96
96
96
96
96
96
97
97
97
97
97
97
97
97
76
76
97
107
50
97
97
97
97
97
97
97
97
97
107
76
97
129
Drug Name
ra stress formula energy
ra therapeutic m plus beta carotene
ra vitamin a
ra vitamin b-1
ra vitamin b12
ra vitamin b-12
RA VITAMIN B-12
ra vitamin b-12 tr
ra vitamin b-12 tr
ra vitamin b-6
ra vitamin b-6
ra vitamin c
ra vitamin c
ra vitamin c drops
ra vitamin c tr
ra vitamin c/acerola
ra vitamin c/rose hips
ra vitamin c/rose hips tr
ra vitamin d-3
ra vitamin e
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine hcl
RAPAMUNE
RAPID B-12 ENERGY
rasagiline mesylate
RAVICTI
REBETOL
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB
RELENZA DISKHALER
RELISTOR
REMICADE
rena-vite
RENVELA
repaglinide
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
REPLESTA
REPLESTA CHILDRENS
REPLESTA NX
RESCRIPTOR
reserpine
RESTASIS
Page #
97
97
97
97
97
107
97
107
97
107
97
107
98
97
97
98
98
98
98
98
63
60
45
47
53
62
98
33
53
36
51
51
51
51
63
38
53
62
98
55
40
47
48
48
98
98
98
36
44
66
Drug Name
RETROVIR IV INFUSION
REVLIMID
REXULTI
REYATAZ
ribasphere
ribasphere ribapak
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
risanoid plus
risedronate sodium
risedronate sodium dr
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rivastigmine transdermal system
rizatriptan benzoate
rizatriptan benzoate odt
ropinirole hcl
rosuvastatin calcium
ROTARIX
ROTATEQ
ROZEREM
RUBRACA
RX SUPPORT HEARTBURN/ACID
REFLUX WITH ALOE
RYMED
RYMED
s.s.s. tonic
SABRIL
SAIZEN
SAIZEN CLICK.EASY
SANTYL
SAPHRIS
SAVELLA
SAVELLA TITRATION PACK
sb vitamin c
SCOOBY-DOO ONE A DAY
selegiline hcl
selenium sulfide
SELZENTRY
SENSIPAR
SENTRY
Page #
37
26
34
37
36
36
36
25
25
25
51
38
76
65
98
64
64
34
34
34
31
20
20
25
25
32
49
63
63
71
28
107
107
68
98
19
57
57
52
34
51
51
107
98
33
52
37
60
98
130
Drug Name
sentry senior
SEREVENT DISKUS
SEROSTIM
sertraline hcl
sharobel
SIGNIFOR
sildenafil
silver sulfadiazine
SIMULECT
simvastatin
sirolimus
SIRTURO
slo-niacin
slow release iron
sm animal shapes complete
sm antioxidant vitamins
sm balanced b-50
sm ballanced b-100
sm b-complex
sm chewable c
sm chewable vitamin c
sm cod liver oil
sm complete
sm complete 50+
sm complete 50+ ultimate mens
sm complete 50+ ultimate womens
sm complete advanced formula
sm complete senior formula
sm folic acid
sm hair/skin/nails
sm iron
sm iron slow release
sm iron slow release
sm multiple vitamins essential
sm multiple vitamins/iron
sm niacin cr
SM ONE DAILY ESSENTIAL
SM ONE DAILY MENS
SM ONE DAILY WOMENS
sm opti-vitamins
SM SLOW RELEASE IRON
sm super b complex-vitamin c
sm vit c/rose hips
sm vitamin b1
sm vitamin b100 complex
sm vitamin b12
sm vitamin b-12
sm vitamin b12 tr
sm vitamin b6
sm vitamin b-6
Page #
98
69
57
22
60
61
70
15
62
49
62
25
98
76
98
98
98
98
107
98
98
98
98
98
98
98
98
98
98
98
76
71
76
98
99
99
107
99
99
99
76
99
99
99
107
107
99
107
107
99
Drug Name
sm vitamin c
sm vitamin c
sm vitamin c tr
sm vitamin c/rose hips
sm vitamin d
sm vitamin d3
SM VITAMIN D3 MAXIMUM
STRENGTH
sm vitamin e
sm vitamin e blended
sodium chloride
sodium chloride 0.45%
sodium chloride 0.9%
sodium ferric gluconate complex/sucrose
sodium fluoride
SODIUM LACTATE
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
SOLO
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
SORIATANE
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28
SPRITAM
SPRYCEL
sps
sronyx
ssd
STAHIST AD
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
stavudine
sterile water irrigation
Page #
107
99
107
99
99
99
99
99
99
76
76
76
76
76
72
53
72
17
99
26
56
56
61
61
52
45
45
45
36
68
69
48
48
24
59
18
30
72
59
15
107
32
32
32
32
32
32
37
65
131
Drug Name
STIMATE
STIVARGA
STRATTERA
streptomycin sulfate
stress 500 b-complex
stress 500 b-complex/zinc
stress b/zinc
stress b-complex/vitamin c/zinc
stress formula
stress formula w/iron
stress formula/iron
stress formula/zinc
stress plus zinc
STRIBILD
SUBOXONE
SUCRAID
sucralfate
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulindac
sumatriptan succinate
sumatriptan succinate refill
sunvite advanced
super b with c
super b-complex/vitamin c
super b-complex/vitamin c& folic acid
super biotin
super multiple
super quints b-50
super thera vite m
superplex-t
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
SUSTIVA
SUTENT
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
Page #
57
30
51
14
99
99
99
99
99
99
99
99
99
36
13
53
54
17
66
17
17
17
64
12
25
25
99
99
99
99
99
99
100
100
100
16
65
65
36
30
28
31
67
40
40
62
61
15
28
Drug Name
SYNTHROID
SYPRINE
tab-a-vite
tab-a-vite maximum
tab-a-vite w/beta carotene
tab-a-vite/iron
TABLOID
tacrolimus
tacrolimus
TAFINLAR
TAGRISSO
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM
TARCEVA
TARGRETIN
TASIGNA
TAZORAC
taztia xt
TECENTRIQ
TECFIDERA
TECFIDERA STARTER PACK
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
temazepam
tencon
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
testosterone cypionate
testosterone enanthate
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
tetrabenazine
th b 100 complex
th b complex/iron/vitamin c/vitamin e
th childrens chewable multi vitamins
th cod liver oil
th complete multi
th complete multi 50+
Page #
60
72
100
100
100
100
27
52
62
30
28
13
38
26
55
76
30
31
30
52
47
31
51
51
16
20
20
48
48
44
44
44
71
11
63
55
24
69
24
57
57
63
51
100
100
100
100
100
100
132
Drug Name
th daily multiple vitamins
th daily multiple vitamins/iron
th iron
th niacin flush free
th premium daily multiple
th theradex-m
th vision vitamins/lutein
th vitamin b 50/b-complex
th vitamin b1
th vitamin b12
th vitamin b-12
th vitamin b12 er
th vitamin b-6
th vitamin c
th vitamin c/rose hips/bioflavonoids
th vitamin d3
th vitamin e
th vitamin e/d-alpha
th womens daily
THALOMID
THEO-24
theophylline
theophylline cr
theophylline er
thera
THERA M PLUS
THERA/BETA-CAROTENE
thera-d 2000
THERA-D 4000
thera-d rapid repletion
THERAGRAN-M PREMIER 50 PLUS
THERA-M
THERANATAL LACTATION SUPPORT
THERAPEUTIC LIQUID
therapeutic m
therapeutic-m/lutein
thera-tabs
THERA-TABS M
theratrum complete
theratrum complete 50 plus
therems
THEREMS-H
THEREMS-M
thiamine hcl
thioridazine hcl
THIOTEPA
thiothixene
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
Page #
100
100
76
50
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
26
70
70
70
70
101
100
101
100
100
100
101
100
101
101
101
101
101
101
101
101
101
101
101
101
33
26
33
62
60
60
Drug Name
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
THYROSAFE
THYROSHIELD
tiagabine hydrochloride
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
TIVICAY
tizanidine hcl
TOBI PODHALER
TOBRADEX
tobramycin
tobramycin sulfate
tobramycin/dexamethasone
tolbutamide
tolcapone
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
topiramate
topiramate er
toposar
topotecan hcl
TORISEL
torsemide
total b/c
totalday multiple
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
trazodone hcl
TREANDA
TRECATOR
TRELSTAR MIXJECT
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
Page #
60
60
60
65
65
19
46
67
67
32
36
35
70
66
70
14
66
40
32
12
54
54
19
19
29
29
62
48
101
101
76
70
40
13
13
45
43
23
21
76
21
26
25
61
31
52
56
67
51
48
133
Drug Name
triazolam
triderm
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-lo-estarylla
tri-lo-sprintec
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
TRINTELLIX
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
TRI-VI-SOL
tri-vita
tri-vitamin
trivora-28
TROKENDI XR
TROPHAMINE
trueplus diabetic multivitamin
TRUMENBA
TRUVADA
TWINRIX
TYBOST
TYGACIL
TYKERB
TYPHIM VI
TYR COOLER
TYSABRI
TYVASO
TYZEKA
UCERIS
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
ultra freeda
ultra freeda/iron
UNICOMPLEX-M
unithroid
UPTRAVI
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
valacyclovir hcl
VALCHLOR
Page #
38
56
33
38
32
59
59
54
23
15
23
59
21
59
28
59
37
102
102
102
59
19
76
102
63
37
63
37
15
30
63
77
51
70
35
56
66
66
102
102
102
60
70
77
77
77
53
52
38
26
Drug Name
VALCYTE
valganciclovir
valganciclovir hydrochlorde
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
vandazole
VAQTA
VARIVAX
VARIZIG
VASOFLEX D1
VECTIBIX
VELCADE
velivet
VENALIV
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
venlafaxine hcl er
VENOFER
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
VICTOZA
VIDEX PEDIATRIC
vienva
VIIBRYD
VIIBRYD STARTER PACK
VIMPAT
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAZOLE
VIREAD
vision formula/lutein
vision vitamins
VITA-C
vitalee
VITALETS
VITALETS CHILDRENS
vitamelts energy vitamin b-12
vitamin a
vitamin a & d
VITAMIN A PALMITATE
Page #
35
35
35
19
19
44
44
15
15
63
63
63
107
31
28
59
66
28
28
22
22
77
69
47
47
47
52
35
40
37
59
22
22
20
28
28
28
38
36
37
102
102
102
102
102
102
102
102
102
102
134
Drug Name
VITAMIN A/BETA CAROTENE
VITAMIN B 12
vitamin b 6
vitamin b complex
vitamin b complex-c
vitamin b1
vitamin b1
vitamin b-1
vitamin b-1
vitamin b12
vitamin b12
vitamin b-12
vitamin b-12 cr
vitamin b-12 natural
vitamin b12 tr
vitamin b-12 tr
VITAMIN B12/FOLIC ACID
vitamin b-2
vitamin b6
vitamin b-6
vitamin b-6
vitamin b-complex
VITAMIN C
VITAMIN C
vitamin c drops
vitamin c drops
vitamin c sr
vitamin c tr
vitamin c tr/rose hips
vitamin c/acerola
vitamin c/rose hips
vitamin c/rose hips
vitamin c/rose hips tr
vitamin c/rose hips tr
vitamin c/rose hips/acerola
vitamin d
vitamin d-1000
vitamin d-1000 maximum strength
VITAMIN D2
vitamin d3
vitamin d-3
vitamin d-3
vitamin d3 400
vitamin d3 maximum strength
vitamin d3 super strength
vitamin d-400
vitamin e
vitamin e blend
vitamin e mixed
vitamin e water dispersible
Page #
102
102
102
102
102
107
103
107
102
107
103
102
102
102
102
102
103
102
103
107
102
102
107
103
107
103
103
103
103
103
107
103
107
103
103
103
103
103
103
103
107
103
103
103
103
103
104
103
103
103
Drug Name
vitamin e water soluble
vitamin e/d-alpha
vitamin e/d-alpha natural
vitamin e/selenium
vitamin e-400
vitamin k
VITAMIN K1
vitamins & minerals
vitamins a & d
vitamins a-d-e/selenium
vitamins for hair
vita-plus e
vitatrum
VITEKTA
VITRON-C
VITRUM 50+ SENIOR MULTI
vitrum senior
VOLTAREN
voriconazole
VOTRIENT
VP-PNV-DHA
VPRIV
V-R FATIGUE RELIEF COMPLEX
VRAYLAR
wal-zyr all day allergy childrens
warfarin sodium
wee care
WELCHOL
womens 50+ advanced
WOMENS BIOMULTIPLE
womens daily formula/folic
acid/calcium/iron
womens multi
womens one daily
XALKORI
XARELTO
XARELTO STARTER PACK
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX HFA
XTANDI
xulane
XYREM
YELETS TEENAGE FORMULA
YERVOY
YF-VAX
YONDELIS
zafirlukast
Page #
103
103
104
104
103
104
104
104
104
104
104
102
104
36
107
104
104
52
24
31
104
53
107
34
68
42
107
50
104
104
104
104
104
31
42
42
64
15
70
69
69
26
59
71
104
31
63
26
68
135
Drug Name
zaleplon
ZALTRAP
ZANOSAR
ZANTAC
ZAVESCA
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
ZERIT
ZETIA
ZIAGEN
zidovudine
ZINC
ZINC & C LOZENGES
ZINC W/A&C
ZINECARD
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
zonisamide
zoo friends
ZOO FRIENDS COMPLETE
zoo friends gummies
zoo friends plus extra c
zoo friends plus iron
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
ZUBSOLV
ZYDELIG
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
Page #
71
29
26
53
53
33
31
71
53
37
50
37
37
104
107
71
28
35
35
17
64
28
71
71
64
52
18
104
104
107
104
104
57
62
63
16
59
59
38
13
29
68
29
35
26
Multi-language Interpreter Services
English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-735-4398 (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-735-4398 (TTY: 711). Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請 電 1-855-735­
4398（TTY：711)。
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-735-4398 (TTY: 711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-855-735-4398 (TTY: 711) 번으로 전화해 주십시오.
French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-735-4398 (ATS : 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-735-4398 (TTY:
711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
бесплатные услуги перевода. Звоните 1-855-735-4398 (TTY: 711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos
sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-735-4398 (TTY: 711). ુ
ુ
ુ ભાષા સહાય સેવાઓ તમારા માટ°
Gujarati: Ʌચના:
જો તમે Ȥજરાતી
બોલતા હો, તો િન:Ƀƣક
ઉપલƞધ છે . ફોન કરો 1-855-735-4398 (TTY: 711). Arabic:
‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﻳﺔ‬،‫ إذا آﻨﺖ ﺗﺘﺤﺪث اذآﺮ اﻟﻠﻐﺔ‬:‫ﻣﻠﺤﻮﻇﺔ‬
‫ )رﻗﻢ هﺎﺗﻒ اﻟﺼﻢ‬1-855-735-4398
‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬
.(711 :‫واﻟﺒﻜﻢ‬
Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços
linguísticos, grátis. Ligue para 1-855-735-4398 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます
。1-855-735-4398（TTY: 711）まで、お電話にてご連絡ください。
H1723_MLI17R_Approved_08262016
Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете
звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером
1-855-735-4398 (телетайп: 711).
Hindi: Úयान दɅ : यिद आप िहदी
ं बोलते हɇ तो आपके िलए मÝत
मɅ भाषा सहायता सवाएं
े
उपलÞध ह।ɇ
ु
1-855-735-4398 (TTY: 711) पर कॉल करɅ ।
Cambodian: របយ័តន៖ េបើសនជាអ
ិ
ន កនិយាយ ភាសាែខម រ, េសវាជំនួយែផន កភាសា
ូ ពទ 1-855-735-4398 (TTY: 711)។
េដាយមិនគិតឈល
ន ួ គអាចមានសំ
ឺ
រាប់បេរអក។
ំ ី ន
ចរូ ទរស័
Absolute Total Care complies with applicable federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. Absolute Total Care does not exclude people or treat them
differently because of race, color, national origin, age, disability, or sex.
Absolute Total Care:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as
qualified sign language interpreters and written information in other formats (large print, accessible electronic
formats, other formats).
• Provides free language services to people whose primary language is not English, such as qualified
interpreters and information written in other languages.
If you need these services, contact Absolute Total Care's Member Services at 1-855-735-4398, TTY 711.
If you believe that Absolute Total Care has failed to provide these services or discriminated in another way on
the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number
above and telling them you need help filing a grievance; Absolute Total Care's Member Services is available to
help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–
1019, (TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
1441 Main Street
1441 Main Street
Suite 900
Suite 900
Columbia, SC 29201
Columbia, SC 29201
1-855-735-4398
1-855-735-4398
TTY: 711
TTY: 711
2017
2017
http://mmp.absolutetotalcare.com
http://mmp.absolutetotalcare.com
FOR MORE INFORMATION,
FOR MORE INFORMATION,
contact Member Services at
contact Member Services at
1-855-735-4398 from 8 a.m. to 8 p.m.,
1-855-735-4398 from 8 a.m. to 8 p.m.,
Monday through Friday. TTY users call 711.
Monday through Friday. TTY users call 711.
After hours, on weekends and on holidays,
After hours, on weekends and on holidays,
you may be asked to leave a message.
you may be asked to leave a message.
Your call will be returned within the next
Your call will be returned within the next
business day.
business day.
http://mmp.absolutetotalcare.com
http://mmp.absolutetotalcare.com
<XXXXXXXXX>, Version Number <X>
00017411, Version 11
[Updated] [No changes made since] mm/yyyy
Updated 06/01/2017
© 2017 Absolute Total Care, Inc. All rights reserved.
© 2017 Absolute Total Care, Inc. All rights reserved.
�
FORMULARY
(LIST
OF
COVERED
DRUGS)
FORMULARY
(LIST
OF
COVERED
DRUGS)
Absolute Total Care (MMP)
Absolute Total Care (MMP)
Note to existing members:
to existing
members:
ThisNote
formulary
has changed
since last year. Please review this
This
formulary
has
changed
since
last year.
this
document to make sure that it still
contains
thePlease
drugs review
you take.
document to make sure that it still contains the drugs you take.
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THIS DOCUMENT
CONTAINS INFORMATION ABOUT
THEPLEASE
DRUGSREAD:
WE COVER
IN THIS PLAN.
THE DRUGS WE COVER IN THIS PLAN.
00017411, Version 5
<XXXXXXXXX>, Version <X>
Updated 08/23/2016. For more recent information or other
[Updated]
[No changes
made since]
<mm/yyyy>.
For more
recent
questions,
please
contact Absolute
Total
Care Member
Services
information or other
questions,
please
contact
Absolute
Total8
at 1-855-735-4398,
TTY:711.
Member
Service
hours
are from
Care
Member
Services
at
1-855-735-4398,
TTY:711.
Member
Service
a.m. to 8 p.m., Monday through Friday.
hours are from <8 a.m. to 8 p.m., Monday through Friday.
After hours, on weekends and on holidays, you may be asked
After ahours,
on weekends
on holidays,
you may
asked
to leave
message.
Your call and
will be
returned within
thebenext
to
leave
a
message.
Your
call
will
be
returned
within
the
next
business day.
business day.>
Or visit http://mmp.absolutetotalcare.com
Or visit http://mmp.absolutetotalcare.com
H1723_LOD17_Approved_09072016
H1723_LOD17