Preferred Drug List
(List of Covered Drugs)
This document includes Passport Health Plan’s
complete 2016 formulary.
What is the Passport Health Plan formulary?
The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must:
• Be a Passport member;
• Need a drug that is medically necessary;
• Get the prescription filled at a Passport Health Plan network pharmacy. A network pharmacy is one that is signed up with
Passport; and
• Follow all Passport rules (see limits below).
The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary.
These drugs may or may not need prior-authorization.
How do I find my drug on the formulary?
• You can search for a drug using the online searchable formulary on our website at www.passporthealthplan.com.
Are there any limits to the drugs you have been prescribed?
Some covered drugs may have limits on them. This could include:
• Prior-Authorization: Some medicines must be approved by Passport before Passport will cover or pay for them. This means
your provider will need to get approval before you can have your prescriptions filled. If you do not get approval, Passport may
not cover the drug.
• Quantity Limits: For some drugs, there are limits on the amount Passport will cover. This means you may not get the
standard one month supply.
• Step Therapy: Sometimes Passport requires you to try certain drugs first to treat your medical condition before we will
cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Passport may not
cover drug B unless you try Drug A first. If Drug A does not work for you, Passport will then cover Drug B.
• Too Early to Refill: If you are given a month supply of a medicine, Passport will not cover a refill of the prescription until
30 days has passed.
What if my drug is not on the formulary?
Remember, not all drugs are listed on the formulary. If Passport does not cover your drug, you have 3 options:
1. Work with your pharmacy or provider to find the preferred drug.
2. You can call Member Services at 1-800-578-0603 and ask for a list of similar drugs that are on Passport’s Preferred Drug List.
3. If a drug is not covered by Passport or is not listed on our Preferred Drug List, your doctor can request approval for it.
i
Can the formulary change?
Yes. Passport may add or remove drugs from the formulary during the year. To get updated information about covered drugs,
please visit our website at www.passporthealthplan.com or call Member Services at 1-800-578-0603.
What are generic drugs?
Passport covers both brand-name and generic drugs. A generic drug has the same active ingredient as the brand-name drug.
This means they work the same and have the same effect. Generic drugs usually cost less than brand name drugs and are
approved by the Food and Drug Administration (FDA).
How much are my copays?
As long as you take generic medicines, you will pay $0. If you take a preferred brand name medicine, your copay will be $2. If you
take a non-preferred name brand medicine, your copay will be $4.
ii
LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
PA
Prior Authorization
Your provider is required to get prior authorization before you fill your
prescription, which ensures appropriate use of the selected drug.
Without prior approval, we may not cover this drug.
ST
Step Therapy
In some cases, you may be required to first try certain drugs to treat
your medical condition before you move up a “step” to other drug
options.
GL
Gender Limit
This prescription drug is restricted for a single gender. .
AL
Age Limit
This prescription drug may only be covered if you meet the minimum
or maximum age limit.
C
Custom
This drug has unique restrictions.
S
Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare
conditions. Some examples of the diseases include; multiple sclerosis,
rheumatoid arthritis, hepatitis C, and hemophilia.
Medical Drug
This medication is not on our drug list. Click on the THERAPEUTIC
CLASS or sub class to find covered alternative medications. If you
have questions, please contact member services.
MED
PAGE 4
LAST UPDATED 02/2016
LIST OF COVERED PRESCRIPTION MEDICATIONS
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
CELEBREX 50 MG CAPSULE
celecoxib
BRAND
choline sal/mag salicylate 500 mg/5ml liquid
generic
diclofenac potassium 50 mg tablet
generic
DICLOFENAC SODIUM (50 MG TABLET DR, 100 MG
TAB ER 24H, 25 MG TABLET DR, 75 MG TABLET DR)
generic
DICLOFENAC SODIUM/MISOPROSTOL (50 IR, 75 IR)
generic
PA
QL
PA
diflunisal 500 mg tablet
generic
ETODOLAC (200 MG CAPSULE, 400 MG TAB ER 24H,
400 MG TABLET, 300 MG CAPSULE, 500 MG TABLET,
500 MG TAB ER 24H, 600 MG TAB ER 24H)
generic
FENOPROFEN CALCIUM (400 MG CAPSULE, 600 MG
TABLET)
generic
FLURBIPROFEN (50 MG, 100 MG)
generic
IBUPROFEN (400 MG, 600 MG, 800 MG)
generic
INDOMETHACIN (25 MG, 75 MG ER, 50 MG)
generic
indomethacin sodium 1 mg vial
generic
KETOPROFEN (75 MG CAPSULE, 50 MG CAPSULE, 200
MG CAP24H PEL)
generic
KETOROLAC TROMETHAMINE (15 MG/ML VIAL,
30MG/ML(1) VIAL, 30 MG/ML CARTRIDGE, 10 MG
TABLET, 30 MG/ML VIAL, 15 MG/ML CARTRIDGE, 60
MG/2 ML VIAL, 60 MG/2 ML SYRINGE)
generic
MECLOFENAMATE SODIUM (50 MG, 100 MG)
generic
mefenamic acid 250 mg capsule
generic
MELOXICAM (7.5 MG TABLET, 7.5 MG/5ML ORAL
SUSP)
generic
meloxicam 15 mg tablet
generic
NABUMETONE (500 MG, 750 MG)
generic
NAPROXEN (125 MG/5ML ORAL SUSP, 500 MG TABLET
DR, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET,
375 MG TABLET DR)
generic
PAGE 5
GL
Male
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
NAPROXEN SODIUM (550 MG, 275 MG)
generic
oxaprozin 600 mg tablet
generic
PIROXICAM (20 MG, 10 MG)
generic
SALSALATE (750 MG, 500 MG)
generic
SULINDAC (200 MG, 150 MG)
generic
TOLMETIN SODIUM (600 MG TABLET, 400 MG
CAPSULE, 200 MG TABLET)
generic
LIMITS & RESTRICTIONS
OPIOID ANALGESICS, LONG-ACTING
DISKETS 40 MG TABLET DISPR
methadone hcl
BRAND
FENTANYL (100, 12)
generic
QL
PA
C
12 patches/28 days
QL
FENTANYL (37.5MCG/HR, 87.5MCG/HR, 62.5MCG/HR)
generic
PA
C
12 patches/28 days
QL
FENTANYL (50MCG/HR, 25MCG/HR, 75MCG/HR)
generic
PA
C
HYDROMORPHONE HCL (16 MG ER, 12 MG ER)
generic
QL
hydromorphone hcl 32 mg tab er 24h
generic
QL
hydromorphone hcl 8 mg tab er 24h
generic
QL
levorphanol tartrate 2 mg tablet
generic
methadone hcl 10 mg tablet
generic
methadone hcl 10 mg/5 ml solution
generic
12 patches/28 days
QL
QL
C
40ml/day
QL
methadone hcl 10 mg/ml oral conc
generic
C
methadone hcl 10 mg/ml syringe
generic
methadone hcl 10 mg/ml vial
generic
methadone hcl 40 mg tablet sol
generic
QL
methadone hcl 5 mg tablet
generic
QL
PAGE 6
80ml/day
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
methadone hcl 5 mg/5 ml solution
generic
LIMITS & RESTRICTIONS
QL
C
METHADONE INTENSOL 10 MG/ML
methadone hcl
BRAND
QL
METHADOSE 10 MG/ML ORAL CONC
methadone hcl
BRAND
QL
METHADOSE 40 MG TABLET DISPR
methadone hcl
BRAND
QL
MORPHINE SULFATE (100 MG ER, 200 MG ER)
generic
80ml/day
QL
PA
MORPHINE SULFATE (100 MG ER, 80 MG ER)
generic
QL
MORPHINE SULFATE (30 MG CPMP 24HR, 30 MG CAP
ER PEL)
generic
QL
MORPHINE SULFATE (60 MG CPMP 24HR, 60 MG CAP
ER PEL, 50 MG CAP ER PEL)
generic
QL
MORPHINE SULFATE (90 MG CPMP 24HR, 45 MG
CPMP 24HR, 120 MG CPMP 24HR, 60 MG TABLET ER,
75 MG CPMP 24HR)
generic
morphine sulfate 10 mg cap er pel
generic
morphine sulfate 15 mg tablet er
generic
QL
PA
QL
QL
PA
morphine sulfate 20 mg cap er pel
generic
morphine sulfate 30 mg tablet er
generic
QL
QL
PA
QL
oxycodone hcl 10 mg tab er 12h
generic
PA
QL
oxycodone hcl 20 mg tab er 12h
generic
PA
QL
oxycodone hcl 40 mg tab er 12h
generic
PA
QL
oxycodone hcl 80 mg tab er 12h
generic
PA
OXYCONTIN (30 MG, 40 MG)
oxycodone hcl
PAGE 7
QL
BRAND
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
OXYCONTIN (60 MG, 80 MG)
oxycodone hcl
BRAND
OXYCONTIN 10 MG TABLET
oxycodone hcl
BRAND
OXYCONTIN 15 MG TABLET
oxycodone hcl
BRAND
OXYCONTIN 20 MG TABLET
oxycodone hcl
BRAND
OXYMORPHONE HCL (20 MG ER, 15 MG ER)
generic
LIMITS & RESTRICTIONS
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
OXYMORPHONE HCL (40 MG ER, 30 MG ER)
generic
PA
QL
oxymorphone hcl 10 mg tab er 12h
generic
PA
QL
oxymorphone hcl 5 mg tab er 12h
generic
PA
QL
oxymorphone hcl 7.5 mg tab er 12h
generic
PA
TRAMADOL HCL (100 MG CPBP 25-75, 100 MG TAB ER
24H)
generic
TRAMADOL HCL (200 MG TBMP 24HR, 150 MG CPBP
25-75, 100 MG TBMP 24HR, 300 MG TBMP 24HR)
generic
TRAMADOL HCL (300 MG TAB ER 24H, 300 MG CPBP
17-83, 200 MG TAB ER 24H, 200 MG CPBP 25-75)
generic
QL
acetaminophen with codeine 300mg-15mg tablet
generic
QL
acetaminophen with codeine 300mg-30mg tablet
generic
QL
acetaminophen with codeine 300mg-60mg tablet
generic
QL
ACETAMINOPHEN WITH CODEINE PHOSPHATE
(300MG/12.5, 120-12MG/5)
generic
C
alfentanil hcl 500 mcg/ml ampul
generic
ASCOMP WITH CODEINE CAPSULE
BRAND
QL
QL
PA
OPIOID ANALGESICS, SHORT-ACTING
PAGE 8
150 ml/day
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
codeine phosphate/butalbital/aspirin/caffeine
ASTRAMORPH-PF 1 MG/ML AMPUL
morphine sulfate/pf
BRAND
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE
PHOSPHATE (50-325-30, 50-300-30)
generic
BUTORPHANOL TARTRATE (2 MG/ML, 1 MG/ML)
generic
butorphanol tartrate 10 mg/ml spray
generic
QL
QL
C
codeine sulfate 15 mg tablet
generic
QL
codeine sulfate 30 mg tablet
generic
QL
codeine sulfate 60 mg tablet
generic
QL
codeine/butalbital/asa/caffein 30-50-325 capsule
generic
QL
dhcodeine bt/acetaminophn/caff 16-320.5mg capsule
generic
dihydrocodeine/aspirin/caffein 16-356-30 capsule
generic
DURAMORPH (5 ML, 10 ML)
morphine sulfate/pf
BRAND
ENDOCET (5-325, 2.5-325 MG)
oxycodone hcl/acetaminophen
BRAND
QL
ENDOCET 10-325 MG TABLET
oxycodone hcl/acetaminophen
BRAND
QL
ENDOCET 7.5-325 MG TABLET
oxycodone hcl/acetaminophen
BRAND
QL
ENDODAN 4.8355-325 MG TABLET
oxycodone hcl/aspirin
BRAND
QL
FENTANYL CITRATE (800 MCG, 1600 MCG, 1200 MCG)
generic
QL
fentanyl citrate 200 mcg lozenge hd
generic
QL
fentanyl citrate 400 mcg lozenge hd
generic
QL
fentanyl citrate 600 mcg lozenge hd
generic
QL
FENTANYL CITRATE IN 0.9 % SODIUM CHLORIDE/PF
(10 MCG/ML SYRINGE, 20 MCG/ML PLAST. BAG)
generic
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 %
SODIUM CHLORIDE/PF (4MCG/ML-.1, 2MCG/ML-.1, 2625MCG/1, 2-1250MCG)
generic
FENTANYL CITRATE/PF (50 MCG/ML AMPUL,
100MCG/2ML SYRINGE, 50 MCG/ML VIAL)
generic
PAGE 9
2 nasal sprayers or
5ml/month
QL
GL
Female
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
HYDROCODONE BITARTRATE/ACETAMINOPHEN (2.5167/5, 7.5-325/15, 5-217MG/10, 2.5-108/5)
generic
C
HYDROCODONE BITARTRATE/ACETAMINOPHEN (5
MG-325MG, 10MG-325MG, 5MG-300MG, 10MG-300MG,
7.5-325MG, 7.5-300MG)
generic
QL
hydrocodone/acetaminophen 2.5-325mg tablet
generic
QL
HYDROCODONE/IBUPROFEN (10MG-200MG, 5MG200MG)
generic
hydrocodone/ibuprofen 2.5-200mg tablet
generic
QL
hydrocodone/ibuprofen 7.5-200 mg tablet
generic
QL
HYDROMORPHONE HCL (1 MG/ML SYRINGE, 2 MG/ML
SYRINGE, 4 MG/ML SYRINGE, 2 MG/ML VIAL)
generic
hydromorphone hcl 1 mg/ml liquid
generic
QL
hydromorphone hcl 2 mg tablet
generic
QL
hydromorphone hcl 3 mg supp.rect
generic
QL
hydromorphone hcl 4 mg tablet
generic
QL
hydromorphone hcl 8 mg tablet
generic
QL
HYDROMORPHONE HCL/PF (1 MG/ML AMPUL, 10
MG/ML AMPUL, 2 MG/ML AMPUL, 10 MG/ML VIAL, 4
MG/ML AMPUL)
generic
ibuprofen/oxycodone hcl 400mg-5mg tablet
generic
QL
LORCET 5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
LORCET HD 10-325 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
LORCET PLUS 7.5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
LORTAB (10-325 MG, 5-325 MG, 7.5-325 MG)
hydrocodone bitartrate/acetaminophen
BRAND
QL
meperidine hcl 50 mg/5 ml solution
generic
LIMITS & RESTRICTIONS
32ml/day
QL
C
MORPHINE SULFATE (2 MG/ML CARTRIDGE,
250MG/10ML VIAL PORT, 8 MG/ML VIAL, 4 MG/ML VIAL,
25 MG/ML VIAL, 10 MG SUPP.RECT, 30 MG
SUPP.RECT, 10 MG/ML VIAL, 10 MG/ML SYRINGE, 100
MG/4ML VIAL PORT, 20 MG SUPP.RECT, 50 MG/ML
VIAL, 15 MG/ML CARTRIDGE, 5 MG/ML VIAL, 15 MG/ML
PAGE 10
20ml/day
generic
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
VIAL, 8 MG/ML SYRINGE, 4 MG/ML SYRINGE, 4 MG/ML
CARTRIDGE, 2 MG/ML SYRINGE, 10 MG/ML
CARTRIDGE, 30 MG/30ML PCA SYRING, 5 MG/ML
SYRINGE, 5 MG SUPP.RECT)
QL
morphine sulfate 10 mg/5 ml solution
generic
C
45ml/day
QL
morphine sulfate 100 mg/5ml solution
generic
C
morphine sulfate 15 mg tablet
generic
morphine sulfate 20 mg/5 ml solution
generic
9ml/day
QL
QL
C
morphine sulfate 30 mg tablet
generic
MORPHINE SULFATE/PF (0.5 MG/ML, 1 MG/ML, 30
MG/30ML PCA, 150MG/30ML PCA)
generic
morphine sulfate/pf 1 mg/2 ml syringe
generic
NALBUPHINE HCL (10 MG/ML VIAL, 20 MG/ML VIAL, 10
MG/ML AMPUL, 20 MG/ML AMPUL)
generic
OPIUM/BELLADONNA ALKALOIDS (60-16.2MG, 3016.2MG)
generic
OXYCODONE HCL (5 MG CAPSULE, 5 MG TABLET)
generic
QL
oxycodone hcl 10 mg tablet
generic
QL
oxycodone hcl 15 mg tablet
generic
QL
oxycodone hcl 20 mg tablet
generic
QL
oxycodone hcl 20 mg/ml oral conc
generic
45ml/day
QL
GL
Male
QL
C
oxycodone hcl 30 mg tablet
generic
oxycodone hcl 5 mg/5 ml solution
generic
8ml/day
QL
QL
C
OXYCODONE HCL/ACETAMINOPHEN (2.5-325MG, 5
MG-325MG)
generic
QL
oxycodone hcl/acetaminophen 10mg-325mg tablet
generic
QL
oxycodone hcl/acetaminophen 7.5-325mg tablet
generic
QL
oxycodone hcl/aspirin 4.8355-325 tablet
generic
QL
PAGE 11
80ml/day
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
oxymorphone hcl 10 mg tablet
generic
QL
oxymorphone hcl 5 mg tablet
generic
QL
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet
generic
QL
REPREXAIN (10-200 MG, 2.5-200 MG, 5-200 MG)
hydrocodone/ibuprofen
BRAND
QL
ROXICET 5-325 TABLET
oxycodone hcl/acetaminophen
BRAND
QL
SUBLIMAZE 50 MCG/ML AMPULE
fentanyl citrate/pf
BRAND
SUFENTA (50 MCG/ML AMPUL, 250 MCG/5 ML
AMPULE, 100 MCG/2 ML AMPUL)
sufentanil citrate
BRAND
sufentanil citrate 50 mcg/ml ampul
generic
tramadol hcl 50 mg tablet
generic
QL
tramadol hcl/acetaminophen 37.5-325mg tablet
generic
QL
VERDROCET 2.5-325 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
VICODIN 5-300 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
VICODIN ES 7.5-300 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
VICODIN HP 10-300 MG TABLET
hydrocodone bitartrate/acetaminophen
BRAND
QL
ZAMICET 10-325 MG/15 ML SOLN
hydrocodone bitartrate/acetaminophen
BRAND
C
LIMITS & RESTRICTIONS
32ml/day
ANESTHETICS
LOCAL ANESTHETICS
BUFFERED LIDOCAINE 1% SYRINGE
lidocaine hcl buffered with 8.4 % sodium bicarbonate
BRAND
BUPIVACAINE HCL (2.5 MG/ML, 5 MG/ML)
generic
bupivacaine hcl/dex-water/pf 0.75 % ampul
generic
BUPIVACAINE HCL/EPINEPHRINE (0.25-.0005, 0.51:200K)
generic
BUPIVACAINE HCL/EPINEPHRINE/PF (0.5-1:200K, 0.25.0005)
generic
PAGE 12
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
BUPIVACAINE HCL/PF (2.5 MG/ML VIAL, 2.5 MG/ML
AMPUL, 7.5 MG/ML VIAL, 5 MG/ML VIAL, 5 MG/ML
AMPUL, 7.5 MG/ML AMPUL)
generic
CARBOCAINE 1.5% VIAL
mepivacaine hcl/pf
BRAND
CHLOROPROCAINE HCL/PF (30 MG/ML, 20 MG/ML)
generic
COMPOUND 347 INHALATION
enflurane
BRAND
etomidate 2 mg/ml vial
generic
FORANE LIQUID
isoflurane
BRAND
isoflurane 99.9 % liquid
generic
KETAMINE HCL (10 MG/ML, 50 MG/ML, 100 MG/ML)
generic
LIDOCAINE HCL (20 MG/ML DISP SYRIN, 40 MG/ML
SOLUTION, 100MG/10ML DISP SYRIN, 10 MG/ML DISP
SYRIN, 30 MG/3 ML SYRINGE, 2 % SOLUTION)
generic
lidocaine hcl/d7.5w/pf 5 % ampul
generic
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF (8 MG/ML,
4 MG/ML)
generic
LIDOCAINE HCL/EPINEPHRINE (2 %-1:100K, 1%1:100K, 0.5-1:200K)
generic
LIDOCAINE HCL/EPINEPHRINE/PF (2%-1:200K VIAL,
1.5-1:200K VIAL, 1.5-1:200K AMPUL)
generic
LIDOCAINE HCL/PF (50 MG/5 ML SYRINGE, 15 MG/ML
AMPUL, 5 MG/ML VIAL, 10 MG/ML VIAL, 20 MG/ML
AMPUL LUER, 100 MG/5ML SYRINGE, 10 MG/ML
AMPUL, 40 MG/ML AMPUL, 20 MG/ML VIAL)
generic
NAROPIN (2 MG/ML INFUSION, 200 MG/100 ML INF,
0.2% 400 MG/200 ML)
ropivacaine hcl/pf
BRAND
POLOCAINE 1% VIAL
mepivacaine hcl
BRAND
POLOCAINE-MPF (1.5%, 2%, 1%)
mepivacaine hcl/pf
BRAND
propofol 10 mg/ml vial
generic
SENSORCAINE 0.5% VIAL
bupivacaine hcl
BRAND
SENSORCAINE-EPINEPHRINE (0.25%-EPI 1:200000,
0.5%-EPI 1:200,000)
bupivacaine hcl/epinephrine
BRAND
PAGE 13
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
SENSORCAINE-MPF 0.5% VIAL
bupivacaine hcl/pf
BRAND
sevoflurane liquid
generic
SOJOURN INHALATION LIQUID
sevoflurane
BRAND
TERRELL LIQUID
isoflurane
BRAND
tetracaine hcl/pf 10 mg/ml ampul
generic
LIMITS & RESTRICTIONS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 333 mg tablet dr
generic
DEPADE 50 MG TABLET
naltrexone hcl
BRAND
DISULFIRAM (500 MG, 250 MG)
generic
naltrexone hcl 50 mg tablet
generic
OPIOID DEPENDENCE TREATMENTS
QL
BUPRENORPHINE HCL (2 MG, 8 MG)
generic
PA
buprenorphine hcl 0.3 mg/ml syringe
generic
buprenorphine hcl 0.3 mg/ml vial
generic
BUPRENORPHINE HCL/NALOXONE HCL (/NALOXONE
8 MG-2 MG, /NALOXONE 2 MG-0.5MG)
generic
SUBOXONE (12 MG-3 MG, 2 MG-0.5 MG, 4 MG-1 MG, 8
MG-2 MG)
buprenorphine hcl/naloxone hcl
BRAND
PA
QL
PA
QL
PA
OPIOID REVERSAL AGENTS
NALOXONE HCL (1 MG/ML, 0.4 MG/ML)
generic
QL
SMOKING CESSATION AGENTS
BUPROBAN 150 MG TABLET
bupropion hcl
BRAND
bupropion hcl 150 mg tablet er
generic
CHANTIX (0.5 MG, 1 MG)
varenicline tartrate
BRAND
CHANTIX (1 MG CONT, STARTING)
varenicline tartrate
BRAND
PAGE 14
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
ANTIBACTERIALS
AMINOGLYCOSIDES
AMIKACIN SULFATE (1000MG/4ML, 500 MG/2ML)
generic
GENTAMICIN SULFATE (20 MG/2 ML, 40 MG/ML)
generic
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISOOSMOTIC (GENTAMIC90MG/100ML,
GENTAMIC100MG/0.1L, GENTAMIC80 MG/50ML,
GENTAMIC80MG/100ML, GENTAMIC60 MG/50ML,
GENTAMIC70 MG/50ML)
generic
GENTAMICIN SULFATE/PF (20 MG/2 ML, 100MG/10ML
PORT)
generic
neomycin sulfate 500 mg tablet
generic
paromomycin sulfate 250 mg capsule
generic
TOBRAMYCIN SULFATE (10 MG/ML, 40 MG/ML, 1.2 G)
generic
S
Specialty Drug
TOBRAMYCIN SULFATE/SODIUM CHLORIDE (60
MG/50ML, 80MG/100ML)
generic
S
Specialty Drug
ANTIBACTERIALS, OTHER
acetic acid 0.25 % irrig soln
generic
BACIIM 50,000 UNITS VIAL
bacitracin
BRAND
bacitracin 50000 unit vial
generic
BACTROBAN NASAL 2% OINTMENT
mupirocin calcium
BRAND
chloramphenicol sod succ 1 g vial
generic
CLINDAMYCIN HCL (150 MG, 75 MG, 300 MG)
generic
clindamycin palmitate hcl 75 mg/5 ml soln recon
generic
CLINDAMYCIN PHOSPHATE (300 MG/2ML VIAL PORT,
2 % CREAM/APPL, 900MG/6ML VIAL PORT, 600
MG/4ML VIAL PORT, 150 MG/ML VIAL)
generic
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN
WATER (300MG/50ML, 900MG/50ML, 600MG/50ML)
generic
colistin (colistimethate na) 150 mg vial
generic
HYOPHEN TABLET
methenamine/methylene blue/benzoic
acid/salicylate/hyoscy
BRAND
lincomycin hcl 300 mg/ml vial
generic
LINEZOLID (600MG/300 IV SOLN, 600 MG TABLET, 100
generic
PAGE 15
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
MG/5ML SUSP RECON)
linezolid-0.9% sodium chloride 600mg/300 iv soln
generic
methenamine hippurate 1 g tablet
generic
METHENAMINE MANDELATE (500 MG, 1 G)
generic
METRO IV 500 MG/100 ML
metronidazole in sodium chloride
BRAND
METRONIDAZOLE (250 MG TABLET, 0.75 % GEL
W/APPL, 500 MG TABLET, 375 MG CAPSULE)
generic
metronidazole/sodium chloride 500mg/0.1l piggyback
generic
NEOMYCIN SULFATE/POLYMYXIN B SULFATE
(AMPUL, VIAL)
generic
NITROFURANTOIN (25 MG/5 ML ORAL SUSP, 50 MG
CAPSULE)
generic
NITROFURANTOIN MACROCRYSTAL (50 MG, 25 MG,
100 MG)
generic
nitrofurantoin monohyd/m-cryst 100 mg capsule
generic
PHOSPHASAL TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc
sul
BRAND
polymyxin b sulfate 500k unit vial
generic
SULFAMYLON 8.5% CREAM
mafenide acetate
BRAND
TINIDAZOLE (250 MG, 500 MG)
generic
trimethoprim 100 mg tablet
generic
TYGACIL 50 MG VIAL
tigecycline
BRAND
UR N-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc
sul
BRAND
URETRON D-S TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc
sul
BRAND
URIMAR-T TABLET
methenamine/methylene blue/salicylate/sodium
phos/hyoscy
BRAND
URIN D.S. TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc
sul
BRAND
URO-BLUE TABLETS
BRAND
PAGE 16
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
methenamine/sodium phosphate,monobasic/meth
blue/hyosc sul
UROGESIC-BLUE TABLET
methenamine/sodium phosphate,monobasic/meth
blue/hyosc sul
BRAND
UROLET MB TABLET
methenamine/sodium phosphate,monobasic/meth
blue/hyosc sul
BRAND
UROPHEN MB TABLET
methenamine/methylene blue/benzoic
acid/salicylate/hyoscy
BRAND
URYL TABLET
methenamine/sodium phosphate,monobasic/meth
blue/hyosc sul
BRAND
USTELL CAPSULE
methenamine/methylene blue/salicylate/sodium
phos/hyoscy
BRAND
UTIRA-C TABLET
methenamine/methylene blue/sodium phos/pnyl sal/hyosc
sul
BRAND
VANCOMYCIN HCL (10 G VIAL, 250 MG CAPSULE, 500
MG VIAL, 750 MG VIAL PORT, 125 MG CAPSULE, 1 G
VIAL, 750 MG VIAL, 5 G VIAL, 1 G VIAL PORT, 500 MG
VIAL PORT)
generic
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER
(500MG/0.1L FROZ.PIGGY, 1G/200ML FROZ.PIGGY,
1.25 G/250 PLAST. BAG, 1.5G/250ML PLAST. BAG)
generic
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE
(1.5G/250ML, 750MG/.15L, 1.25 G/250)
generic
vancomycin in dextrose,iso-osm 750mg/.15l froz.piggy
generic
VANDAZOLE VAGINAL 0.75% GEL
metronidazole
BRAND
XIFAXAN (550 MG, 200 MG)
rifaximin
BRAND
ZYVOX 100 MG/5 ML SUSPENSION
linezolid
BRAND
PA
BETA-LACTAM, CEPHALOSPORINS
CEFACLOR (500 MG TAB ER 12H, 125 MG/5ML SUSP
RECON, 500 MG CAPSULE, 250 MG/5ML SUSP RECON,
250 MG CAPSULE, 375 MG/5ML SUSP RECON)
generic
CEFADROXIL (500 MG CAPSULE, 500 MG/5ML SUSP
RECON, 250 MG/5ML SUSP RECON, 1 G TABLET)
generic
PAGE 17
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CEFAZOLIN SODIUM (300G BULKBAGINJ, 1 G VIAL, 20
G VIAL, 10 G VIAL, 500 MG VIAL, 1 G VIAL PORT, 100 G
BULKBAGINJ)
generic
CEFAZOLIN SODIUM IN 0.9 % SODIUM CHLORIDE (0.9
2 G/100 ML PLAST. BAG, 0.9 2 G/50 ML PIGGYBACK,
0.9 2 G/10 ML SYRGE)
generic
cefazolin sodium/d5w 2 g/100 ml plast. bag
generic
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML
PIGGYBACK, 1 ML FROZ.PIGGY, 1 ML PIGGYBACK)
generic
CEFDINIR (125 MG/5ML SUSP RECON, 300 MG
CAPSULE, 250 MG/5ML SUSP RECON)
generic
CEFDITOREN PIVOXIL (200 MG, 400 MG)
generic
CEFEPIME HCL (2, 1)
generic
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC (1 G/50 ML,
2 G/100 ML)
generic
CEFIXIME (200, 100)
generic
CEFOTAXIME SODIUM (10 G, 2 G, 1 G, 500 MG)
generic
CEFOTETAN DISODIUM (2, 10, 1)
generic
CEFOXITIN SODIUM (2, 1, 10)
generic
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,
1 ML)
generic
CEFPODOXIME PROXETIL (100 MG TABLET, 100
MG/5ML SUSP RECON, 50 MG/5 ML SUSP RECON, 200
MG TABLET)
generic
CEFPROZIL (250 MG TABLET, 250 MG/5ML SUSP
RECON, 125 MG/5ML SUSP RECON, 500 MG TABLET)
generic
CEFTAZIDIME (1, 2, 6)
generic
CEFTIBUTEN (400 MG CAPSULE, 180 MG/5ML SUSP
RECON)
generic
CEFTRIAXONE SODIUM (1 G, 2 G PORT, 1 G PORT, 10
G, 500 MG, 250 MG, 2 G)
generic
CEFTRIAXONE SODIUM/DEXTROSE, ISO-OSMOTIC (2
ML FROZ.PIGGY, 2 ML PIGGYBACK, 1 ML PIGGYBACK,
1 ML FROZ.PIGGY)
generic
CEFUROXIME AXETIL (250 MG, 500 MG)
generic
CEFUROXIME SODIUM (7.5G, 750 MG, 7.5 G, 1.5 G)
generic
CEFUROXIME SODIUM/DEXTROSE, ISO-OSMOTIC
(750MG/50ML, 1.5G/50ML)
generic
CEPHALEXIN (250 MG TABLET, 250 MG CAPSULE, 750
generic
PAGE 18
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
MG CAPSULE, 500 MG TABLET, 250 MG/5ML SUSP
RECON, 125 MG/5ML SUSP RECON, 500 MG CAPSULE)
BETA-LACTAM, OTHER
AZTREONAM (2, 1)
generic
IMIPENEM/CILASTATIN SODIUM (250 MG, 500 MG)
generic
MEROPENEM (500 MG, 1 G)
generic
MEROPENEM IN 0.9 % SODIUM CHLORIDE (1 G/50 ML,
500MG/50ML)
generic
BETA-LACTAM, PENICILLINS
AMOXICILLIN (250 MG CAPSULE, 500 MG TABLET, 400
MG/5ML SUSP RECON, 500 MG CAPSULE, 125 MG TAB
CHEW, 250 MG TAB CHEW, 125 MG/5ML SUSP RECON,
875 MG TABLET, 250 MG/5ML SUSP RECON, 200
MG/5ML SUSP RECON)
generic
AMOXICILLIN/POTASSIUM CLAVULANATE (600-42.9/5
SUSP RECON, 400-57MG TAB CHEW, 200-28.5MG TAB
CHEW, 875-125 MG TABLET, 400-57MG/5 SUSP
RECON, 250-62.5/5 SUSP RECON, 250-125 MG
TABLET, 200-28.5/5 SUSP RECON, 1000-62.5 TAB ER
12H, 500-125 MG TABLET)
generic
AMPICILLIN SODIUM (500 MG, 10 G, 1 G, 2 G PORT, 2
G, 1 G PORT, 250 MG, 125 MG)
generic
AMPICILLIN SODIUM/SULBACTAM SODIUM (15, 1.5
PORT, 3, 3 PORT, 1.5)
generic
AMPICILLIN TRIHYDRATE (250 MG CAPSULE, 500 MG
CAPSULE, 250 MG/5ML SUSP RECON, 125 MG/5ML
SUSP RECON)
generic
DICLOXACILLIN SODIUM (500 MG, 250 MG)
generic
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC (1 G/50 ML, 2
G/100 ML)
generic
NAFCILLIN SODIUM (2 PORT, 2, 1 PORT, 1, 10)
generic
OXACILLIN SODIUM (10, 2 PORT, 1, 2, 1 PORT)
generic
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,
1 ML)
generic
PENICILLIN G POTASSIUM (5MM, 20MM)
generic
PENICILLIN G PROCAINE (1.2MM/2 ML SYRINE,
600000/ML SYRINE)
generic
penicillin g sodium 5mm unit vial
generic
PENICILLIN V POTASSIUM (500 MG TABLET, 250 MG
TABLET, 250 MG/5ML SOLN RECON, 125 MG/5ML
generic
PAGE 19
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
SOLN RECON)
PFIZERPEN (20 UNIT, 5 UNITS)
penicillin g potassium
BRAND
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM (40.5,
4.5, 3.375, 4.5 PORT, 3.375 PORT, 2.25 PORT, 2.25)
generic
MACROLIDES
AZITHROMYCIN (200 MG/5ML SUSP RECON, 500 MG
VIAL PORT, 100 MG/5ML SUSP RECON, 500 MG VIAL, 1
G PACKET, 250 MG TABLET)
generic
AZITHROMYCIN (500 MG, 600 MG)
generic
QL
CLARITHROMYCIN (250, 125)
generic
C
CLARITHROMYCIN (500 MG TAB ER 24H, 500 MG
TABLET, 250 MG TABLET)
generic
QL
E.E.S. 200 MG/5 ML GRANULES
erythromycin ethylsuccinate
BRAND
E.E.S. 400 FILMTAB
erythromycin ethylsuccinate
BRAND
ery e-succ/sulfisoxazole 200-600/5 susp recon
generic
ERY-TAB (250 MG, 500 MG, 333 MG)
erythromycin base
BRAND
ERYPED 200 MG/5 ML SUSPENSION
erythromycin ethylsuccinate
BRAND
ERYPED 400 MG/5 ML SUSPENSION
erythromycin ethylsuccinate
BRAND
ERYTHROCIN 250 MG FILMTAB
erythromycin stearate
BRAND
ERYTHROMYCIN BASE (500 MG TABLET, 250 MG
TABLET, 250 MG CAPSULE DR)
generic
erythromycin ethylsuccinate 400 mg tablet
generic
150ml/fill
QUINOLONES
AVELOX IV 400 MG/250 ML
moxifloxacin hcl/sodium chloride, iso-osmotic
BRAND
CIPRO (5%, 10%)
ciprofloxacin
BRAND
C
CIPROFLOXACIN HCL (100 MG, 500 MG, 750 MG)
generic
QL
ciprofloxacin hcl 0.2 % droperette
generic
ciprofloxacin hcl 250 mg tablet
generic
PAGE 20
10ml/day; 150ml/fill
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CIPROFLOXACIN LACTATE (400MG/40ML,
200MG/20ML)
generic
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER
(400MG/0.2L, 200MG/0.1L)
generic
CIPROFLOXACIN/CIPROFLOXACIN HCL (500 MG, 1000
MG)
generic
QL
LEVOFLOXACIN (500 MG, 750 MG, 250 MG)
generic
C
5 tablets/30 days
levofloxacin 25 mg/ml vial
generic
levofloxacin 250mg/10ml solution
generic
C
480ml/fill
LEVOFLOXACIN/DEXTROSE 5 % IN WATER
(750MG/.15L, 250MG/50ML, 500MG/0.1L)
generic
moxifloxacin hcl 400 mg tablet
generic
moxifloxacin/sod.ace,sul/water 400mg/.25l piggyback
generic
OFLOXACIN (400 MG, 300 MG, 200 MG)
generic
LIMITS & RESTRICTIONS
QL
SULFONAMIDES
sulfadiazine 500 mg tablet
generic
SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20
ORAL SUSP, 200-40MG/5 ORAL SUSP, 80-16MG/ML
VIAL, 400MG-80MG TABLET, 800-160 MG TABLET)
generic
SULFATRIM PEDIATRIC SUSPENSION
sulfamethoxazole/trimethoprim
BRAND
TETRACYCLINES
AVIDOXY 100 MG TABLET
doxycycline monohydrate
BRAND
DEMECLOCYCLINE HCL (150 MG, 300 MG)
generic
DOXYCYCLINE MONOHYDRATE (150 MG TABLET, 75
MG CAPSULE, 50 MG CAPSULE, 100 MG TABLET, 75
MG TABLET, 100 MG CAPSULE, 40 MG CAP IR DR, 150
MG CAPSULE, 50 MG TABLET, 25 MG/5 ML SUSP
RECON)
generic
MINOCYCLINE HCL (135 MG TAB ER 24H, 100 MG
CAPSULE, 90 MG TAB ER 24H, 75 MG CAPSULE, 45
MG TAB ER 24H, 100 MG TABLET, 50 MG TABLET, 75
MG TABLET, 50 MG CAPSULE)
generic
MONDOXYNE NL (50 MG, 75 MG, 100 MG)
doxycycline monohydrate
BRAND
OCUDOX CONVENIENCE KIT
doxycycline hyclate/eyelid clns no.3/eyelid emollient no.1
BRAND
PAGE 21
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
TETRACYCLINE HCL (500 MG, 250 MG)
generic
LIMITS & RESTRICTIONS
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
LEVETIRACETAM (1000 MG TABLET, 500 MG/5ML
SOLUTION, 500 MG TAB ER 24H, 100 MG/ML
SOLUTION, 500 MG TABLET, 750 MG TABLET, 750 MG
TAB ER 24H, 500 MG/5ML VIAL, 250 MG TABLET)
generic
POTIGA (50 MG, 300 MG, 200 MG, 400 MG)
ezogabine
BRAND
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 300 MG KAPSEAL
methsuximide
BRAND
ETHOSUXIMIDE (250 MG/5ML SOLUTION, 250 MG
CAPSULE)
generic
ZONISAMIDE (50 MG, 100 MG, 25 MG)
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DIAZEPAM (12.5-15-20, 2.5 MG, 5-7.5-10MG)
generic
DIVALPROEX SODIUM (125 MG TABLET DR, 250 MG
TAB ER 24H, 125 MG CAP SPRINK, 500 MG TABLET
DR, 500 MG TAB ER 24H, 250 MG TABLET DR)
generic
GABAPENTIN (250 MG/5ML SOLUTION, 800 MG
TABLET, 100 MG CAPSULE, 300 MG/6ML SOLUTION,
300 MG CAPSULE, 600 MG TABLET, 400 MG CAPSULE)
generic
GABITRIL (12 MG, 16 MG)
tiagabine hcl
BRAND
ONFI (2.5 MG/ML SUSPENSION, 5 MG TABLET, 20 MG
TABLET, 10 MG TABLET)
clobazam
BRAND
PHENOBARBITAL (60 MG TABLET, 15 MG TABLET, 100
MG TABLET, 64.8 MG TABLET, 30 MG TABLET, 97.2MG
TABLET, 16.2 MG TABLET, 32.4 MG TABLET, 20 MG/5
ML ELIXIR)
generic
PHENOBARBITAL SODIUM (130MG/ML, 65 MG/ML)
generic
PRIMIDONE (250 MG, 50 MG)
generic
SABRIL (500 MG TABLET, 500 MG POWDER PACKET)
vigabatrin
BRAND
TIAGABINE HCL (4 MG, 2 MG)
generic
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
SODIUM) (500 MG/5ML VIAL, 250 MG/5ML SOLUTION,
generic
PAGE 22
C
2 kits/30 days
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
500MG/10ML SOLUTION)
valproic acid 250 mg capsule
generic
GLUTAMATE REDUCING AGENTS
FELBAMATE (400 MG TABLET, 600 MG TABLET, 600
MG/5ML ORAL SUSP)
generic
LAMOTRIGINE (50 MG TAB RAPDIS, 100 MG TAB ER
24, 25-50-100 TB RD DSPK, 300 MG TAB ER 24, 5 MG
TB CHW DSP, 100 MG TAB RAPDIS, 25MG (35) TAB DS
PK, 200 MG TABLET, 200 MG TAB ER 24, 25(21)-50 TB
RD DSPK, 150 MG TABLET, 50 MG TAB ER 24, 100 MG
TABLET, 25 MG TABLET, 25 MG TAB ER 24, 250 MG
TAB ER 24, 200 MG TAB RAPDIS, 25 MG TAB RAPDIS,
50(42)-100 TB RD DSPK, 25 MG TB CHW DSP)
generic
TOPIRAGEN (200 MG, 50 MG, 25 MG, 100 MG)
topiramate
BRAND
TOPIRAMATE (25 MG CAP SPRINK, 200 MG TABLET,
50 MG TABLET, 25 MG TABLET, 100 MG TABLET, 15
MG CAP SPRINK)
generic
SODIUM CHANNEL AGENTS
BANZEL (400 MG TABLET, 40 MG/ML SUSPENSION,
200 MG TABLET)
rufinamide
BRAND
CARBAMAZEPINE (400 MG TAB ER 12H, 200 MG
TABLET, 300 MG CPMP 12HR, 200 MG TAB ER 12H, 200
MG CPMP 12HR, 100 MG CPMP 12HR, 100 MG/5ML
ORAL SUSP, 100 MG TAB CHEW)
generic
DILANTIN 30 MG CAPSULE
phenytoin sodium extended
BRAND
EPITOL 200 MG TABLET
carbamazepine
BRAND
FOSPHENYTOIN SODIUM (500 PE/10, 100MG PE/2)
generic
OXCARBAZEPINE (150 MG TABLET, 300 MG TABLET,
600 MG TABLET, 300 MG/5ML ORAL SUSP)
generic
PEGANONE 250 MG TABLET
ethotoin
BRAND
PHENYTOIN (50 MG TAB CHEW, 125 MG/5ML ORAL
SUSP, 100 MG/4ML ORAL SUSP)
generic
PHENYTOIN SODIUM (50 MG/ML SYRINGE, 50 MG/ML
VIAL, 50 MG/ML AMPUL)
generic
PHENYTOIN SODIUM EXTENDED (300 MG, 100 MG,
200 MG)
generic
PAGE 23
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
TEGRETOL XR 100 MG TABLET
carbamazepine
BRAND
VIMPAT (200 MG/20 ML VIAL, 10 MG/ML SOLUTION, 150
MG TABLET, 100 MG TABLET, 200 MG TABLET, 50 MG
TABLET)
lacosamide
BRAND
LIMITS & RESTRICTIONS
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1 mg tablet
generic
ISOXSUPRINE HCL (20 MG, 10 MG)
generic
papaverine hcl 30 mg/ml vial
generic
CHOLINESTERASE INHIBITORS
DONEPEZIL HCL (10 MG TABLET, 5 MG TAB RAPDIS,
10 MG TAB RAPDIS, 23 MG TABLET, 5 MG TABLET)
generic
GALANTAMINE HBR (12 MG TABLET, 24 MG CAP24H
PEL, 4 MG TABLET, 8 MG CAP24H PEL, 8 MG TABLET,
16 MG CAP24H PEL, 4 MG/ML SOLUTION)
generic
RIVASTIGMINE (13.3MG/24H, 9.5MG/24HR,
4.6MG/24HR)
generic
RIVASTIGMINE TARTRATE (1.5 MG, 6 MG, 4.5 MG, 3
MG)
generic
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
MEMANTINE HCL (10 MG, 5 MG)
generic
MEMANTINE HCL (5 MG-10 MG TAB DS PK, 2 MG/ML
SOLUTION)
generic
NAMENDA (10 MG TABLET, 5-10 MG TITRATION PK, 5
MG TABLET, 2 MG/ML SOLUTION)
memantine hcl
BRAND
GL
Male
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE (25 MG10MG, 12.5MG-5MG)
generic
BUDEPRION XL 300 MG TABLET
bupropion hcl
BRAND
BUPROPION HCL (75 MG TABLET, 200 MG TABLET ER,
150 MG TABLET ER, 100 MG TABLET ER, 300 MG TAB
ER 24H, 100 MG TABLET)
generic
PAGE 24
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
bupropion hcl 150 mg tab er 24h
generic
MIRTAZAPINE (15 MG TABLET, 45 MG TABLET, 7.5 MG
TABLET, 45 MG TAB RAPDIS, 15 MG TAB RAPDIS, 30
MG TABLET, 30 MG TAB RAPDIS)
generic
OLANZAPINE/FLUOXETINE HCL (6MG-50MG, 6MG25MG, 12MG-25MG, 12MG-50MG, 3 MG-25 MG)
generic
PERPHENAZINE/AMITRIPTYLINE HCL (4 MG-25 MG,
4MG-10MG, 2 MG-10 MG, 4 MG-50 MG, 2 MG-25 MG)
generic
LIMITS & RESTRICTIONS
QL
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate 15 mg tablet
generic
tranylcypromine sulfate 10 mg tablet
generic
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
CITALOPRAM HYDROBROMIDE (40 MG TABLET, 10
MG TABLET, 20 MG TABLET, 10 MG/5 ML SOLUTION)
generic
ESCITALOPRAM OXALATE (20 MG TABLET, 10 MG
TABLET, 5 MG/5 ML SOLUTION, 5 MG TABLET)
generic
FLUOXETINE HCL (20 MG TABLET, 40 MG CAPSULE,
20 MG/5 ML SOLUTION, 90 MG CAPSULE DR, 10 MG
TABLET, 20 MG CAPSULE, 10 MG CAPSULE)
generic
FLUVOXAMINE MALEATE (150 MG CAP ER 24H, 100
MG CAP ER 24H, 25 MG TABLET, 100 MG TABLET, 50
MG TABLET)
generic
MAPROTILINE HCL (25 MG, 75 MG, 50 MG)
generic
PAROXETINE HCL (12.5 MG TAB ER 24H, 10 MG
TABLET, 25 MG TAB ER 24H, 20 MG TABLET, 40 MG
TABLET, 30 MG TABLET, 37.5 MG TAB ER 24H)
generic
SERTRALINE HCL (50 MG TABLET, 25 MG TABLET, 20
MG/ML ORAL CONC, 100 MG TABLET)
generic
TRAZODONE HCL (100 MG, 50 MG, 300 MG, 150 MG)
generic
VENLAFAXINE HCL (37.5 MG ER, 150 MG ER)
generic
VENLAFAXINE HCL (50 MG, 25 MG, 37.5 MG, 100 MG)
generic
QL
venlafaxine hcl 225 mg tab er 24
generic
QL
venlafaxine hcl 75 mg cap er 24h
generic
QL
venlafaxine hcl 75 mg tablet
generic
QL
TRICYCLICS
PAGE 25
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
AMITRIPTYLINE HCL (50 MG, 75 MG, 100 MG, 25 MG,
10 MG, 150 MG)
generic
AMOXAPINE (25 MG, 100 MG, 50 MG, 150 MG)
generic
CLOMIPRAMINE HCL (50 MG, 75 MG, 25 MG)
generic
DESIPRAMINE HCL (10 MG, 75 MG, 100 MG, 25 MG, 50
MG, 150 MG)
generic
DOXEPIN HCL (150 MG CAPSULE, 75 MG CAPSULE, 50
MG CAPSULE, 25 MG CAPSULE, 100 MG CAPSULE, 10
MG/ML ORAL CONC, 10 MG CAPSULE)
generic
IMIPRAMINE HCL (25 MG, 10 MG, 50 MG)
generic
IMIPRAMINE PAMOATE (150 MG, 75 MG, 100 MG, 125
MG)
generic
NORTRIPTYLINE HCL (50 MG CAPSULE, 10 MG/5 ML
SOLUTION, 25 MG CAPSULE, 10 MG CAPSULE, 75 MG
CAPSULE)
generic
PROTRIPTYLINE HCL (5 MG, 10 MG)
generic
LIMITS & RESTRICTIONS
ANTIEMETICS
ANTIEMETICS, OTHER
COMPRO 25 MG SUPPOSITORY
prochlorperazine
BRAND
dimenhydrinate 50 mg/ml vial
generic
MECLIZINE HCL (25 MG, 12.5 MG)
generic
METOCLOPRAMIDE HCL (10 MG TABLET, 5 MG TAB
RAPDIS, 5 MG TABLET, 10 MG/10ML SOLUTION, 10 MG
TAB RAPDIS, 5 MG/ML VIAL, 5 MG/5 ML SOLUTION)
generic
PERPHENAZINE (16 MG, 2 MG, 4 MG, 8 MG)
generic
prochlorperazine 25 mg supp.rect
generic
PROCHLORPERAZINE EDISYLATE (10 MG/2 ML, 5
MG/ML)
generic
PROCHLORPERAZINE MALEATE (5 MG, 10 MG)
generic
TRIMETHOBENZAMIDE HCL (300 MG CAPSULE, 100
MG/ML VIAL)
generic
EMETOGENIC THERAPY ADJUNCTS
DRONABINOL (10 MG, 2.5 MG, 5 MG)
generic
EMEND (TRIPACK, 40 MG CAPSULE, 125 MG
CAPSULE, 80 MG CAPSULE, 150 MG VIAL)
aprepitant
BRAND
PAGE 26
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
GRANISETRON HCL (1 MG/ML(1), 1 MG/ML)
generic
LIMITS & RESTRICTIONS
PA
granisetron hcl 1 mg tablet
generic
GRANISETRON HCL/PF (100 MCG/ML, 1 MG/ML(1))
generic
S
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PA
GRANISOL 2 MG/10 ML SOLUTION
granisetron hcl
BRAND
ONDANSETRON (8 MG, 4 MG)
generic
ONDANSETRON HCL (4 MG/5 ML SOLUTION, 24 MG
TABLET)
generic
ONDANSETRON HCL (8 MG, 4 MG)
generic
QL
ondansetron hcl 2 mg/ml vial
generic
PA
ondansetron hcl/pf 4 mg/2 ml syringe
generic
C
50ml/30 days
QL
PA
ondansetron hcl/pf 4 mg/2 ml vial
generic
S
Specialty Drug
S
Specialty Drug
ANTIFUNGALS
amphotericin b 50 mg vial
generic
CANCIDAS (70 MG, 50 MG)
caspofungin acetate
BRAND
CICLODAN 0.77% CREAM
ciclopirox olamine
BRAND
CICLOPIROX (1 SHAMPOO, 0.77 GEL (GRAM), 8
SOLUTION)
generic
CICLOPIROX OLAMINE (0.77 CREAM (G), 0.77
SUSPENSION)
generic
ciclopirox/ure/camph/menth/euc 8 % solution
generic
econazole nitrate 1 % cream (g)
generic
FIRST-BXN MOUTHWASH
nystatin/lidocaine hcl/diphenhydramine hcl
BRAND
FLUCONAZOLE (10 MG/ML SUSP RECON, 50 MG
TABLET, 40 MG/ML SUSP RECON, 100 MG TABLET)
generic
FLUCONAZOLE (150 MG, 200 MG)
generic
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC
(400MG/0.2L, 200MG/0.1L)
generic
PAGE 27
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC
(200MG/0.1L PGGYBK BTL, 400MG/0.2L PGGYBK BTL,
100MG/50ML PGGYBK BTL, 200MG/0.1L PIGGYBACK,
400MG/0.2L PIGGYBACK)
generic
FLUCYTOSINE (500 MG, 250 MG)
generic
GRISEOFULVIN ULTRAMICROSIZE (125 MG, 250 MG)
generic
GRISEOFULVIN, MICROSIZE (500 MG TABLET, 125
MG/5ML ORAL SUSP)
generic
GYNAZOLE 1 2% CREAM
butoconazole nitrate
BRAND
itraconazole 100 mg capsule
generic
KETOCONAZOLE (2 CREAM (G), 2 FOAM, 2 SHAMPOO)
generic
ketoconazole 200 mg tablet
generic
KETODAN (KIT, )
ketoconazole/skin cleanser combination no.28
BRAND
LAMISIL (187.5 MG PACK, 125 MG PACKET)
terbinafine hcl
BRAND
miconazole nitrate 200 mg supp.vag
generic
MYCAMINE (50 MG, 100 MG)
micafungin sodium
BRAND
NATACYN EYE DROPS
natamycin
BRAND
NOXAFIL (40 MG/ML SUSPENSION, 300 MG/16.7 ML
VIAL, DR 100 MG TABLET)
posaconazole
BRAND
NYAMYC 100,000 UNITS/GM POWDER
nystatin
BRAND
NYSTATIN (100000/ML ORAL SUSP, 500MM UNIT
POWDER(EA), 150MM UNIT POWDER(EA), 100000/G
POWDER, 100000/G CREAM (G), 100000/G OINT. (G),
50MM UNIT POWDER(EA), 500K UNIT TABLET)
generic
NYSTATIN/TRIAMCINOLONE ACETONIDE (CREAM,
OINT.)
generic
NYSTOP 100,000 UNITS/GM POWDER
nystatin
BRAND
PEDI-DRI TOPICAL POWDER
nystatin
BRAND
SPORANOX 10 MG/ML SOLUTION
itraconazole
BRAND
terbinafine hcl 250 mg tablet
generic
PAGE 28
LIMITS & RESTRICTIONS
QL
C
max 84 days
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
therapy/365 days
TERCONAZOLE (0.4 % CREAM/APPL, 80 MG
SUPP.VAG, 0.8 % CREAM/APPL)
generic
triacetin 100 % liquid
generic
VORICONAZOLE (200 MG VIAL, 200 MG/5ML SUSP
RECON, 50 MG TABLET)
generic
voriconazole 200 mg tablet
generic
QL
ANTIGOUT AGENTS
ALLOPURINOL (300 MG, 100 MG)
generic
allopurinol sodium 500 mg vial
generic
ALOPRIM 500 MG VIAL
allopurinol sodium
BRAND
COLCHICINE (0.6 MG CAPSULE, 0.6 MG TABLET)
generic
colchicine/probenecid 0.5-500mg tablet
generic
COLCRYS 0.6 MG TABLET
colchicine
BRAND
probenecid 500 mg tablet
generic
ULORIC (40 MG, 80 MG)
febuxostat
BRAND
PA
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
DIHYDROERGOTAMINE MESYLATE (1 MG/ML AMPUL,
1 MG/ML VIAL, 0.5MG/SPRY SPRAY/PUMP)
generic
ergotamine tartrate/caffeine 1 mg-100mg tablet
generic
MIGERGOT SUPPOSITORY
ergotamine tartrate/caffeine
BRAND
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
ALMOTRIPTAN MALATE (12.5 MG, 6.25 MG)
generic
NARATRIPTAN HCL (2.5 MG, 1 MG)
generic
RIZATRIPTAN BENZOATE (10 MG TABLET, 5 MG
TABLET, 5 MG TAB RAPDIS, 10 MG TAB RAPDIS)
generic
SUMATRIPTAN (20 MG, 5 MG)
generic
SUMATRIPTAN SUCCINATE (50 MG, 100 MG, 25 MG)
generic
SUMATRIPTAN SUCCINATE (6 PEN INJCTR, 6
generic
PAGE 29
QL
C
6 nasal sprayers/month
C
4 injections (2
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
SYRINGE, 6 CARTRIDGE, 4 PEN INJCTR, 4
CARTRIDGE, 6 VIAL)
kits)/month
ZOLMITRIPTAN (5 MG TAB RAPDIS, 2.5 MG TAB
RAPDIS, 5 MG TABLET, 2.5 MG TABLET)
generic
ZOMIG (2.5 MG, 5 MG)
zolmitriptan
BRAND
C
6 nasal sprayers/month
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
ENLON 10 MG/ML VIAL
edrophonium chloride
BRAND
guanidine hcl 125 mg tablet
generic
MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP)
pyridostigmine bromide
BRAND
NEOSTIGMINE METHYLSULFATE (4 MG/4 ML
SYRINGE, 1 MG/ML VIAL, 2 MG/2 ML SYRINGE, 1:2000
VIAL, 1:1000 VIAL, 3 MG/3 ML SYRINGE, 0.5 MG/ML
VIAL)
generic
PROSTIGMIN 15 MG TABLET
neostigmine bromide
BRAND
PYRIDOSTIGMINE BROMIDE (180 MG ER, 60 MG)
generic
REGONOL 10 MG/2 ML AMPUL
pyridostigmine bromide
BRAND
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
DAPSONE (100 MG, 25 MG)
generic
MYCOBUTIN 150 MG CAPSULE
rifabutin
BRAND
rifabutin 150 mg capsule
generic
ANTITUBERCULARS
ETHAMBUTOL HCL (100 MG, 400 MG)
generic
ISONIAZID (50 MG/5 ML SOLUTION, 100 MG/ML VIAL,
300 MG TABLET, 100 MG TABLET)
generic
PRIFTIN 150 MG TABLET
rifapentine
BRAND
pyrazinamide 500 mg tablet
generic
RIFAMPIN (600 MG VIAL, 150 MG CAPSULE, 300 MG
CAPSULE)
generic
PAGE 30
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
SIRTURO 100 MG TABLET
bedaquiline fumarate
BRAND
LIMITS & RESTRICTIONS
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLET
melphalan
BRAND
BICNU 100 MG VIAL
carmustine
BRAND
BUSULFEX 60 MG/10 ML VIAL
busulfan
BRAND
CYCLOPHOSPHAMIDE (25 MG TABLET, 2 G VIAL, 50
MG TABLET, 500 MG VIAL, 1 G VIAL)
generic
DACARBAZINE (200 MG, 100 MG)
generic
DAUNOXOME (2 MG/ML, 50 MG (2 MG/ML))
daunorubicin citrate liposomal
BRAND
GLEOSTINE (40 MG, 100 MG, 10 MG, 5 MG)
lomustine
BRAND
HEXALEN 50 MG CAPSULE
altretamine
BRAND
IFOSFAMIDE (1 G/20 ML, 3G/60ML, 3 G, 1 G)
generic
IFOSFAMIDE/MESNA (1G-1G, 3G-1G)
generic
LEUKERAN 2 MG TABLET
chlorambucil
S
Specialty Drug
BRAND
S
Specialty Drug
LOMUSTINE (100 MG, 10 MG, 40 MG)
generic
S
Specialty Drug
MATULANE 50 MG CAPSULE
procarbazine hcl
BRAND
S
Specialty Drug
melphalan hcl 50 mg vial
generic
MUSTARGEN 10 MG VIAL
mechlorethamine hcl
BRAND
MYLERAN 2 MG TABLET
busulfan
BRAND
TEMODAR 100 MG VIAL
temozolomide
BRAND
S
Specialty Drug
TEMOZOLOMIDE (5 MG, 20 MG, 140 MG, 100 MG, 180
MG, 250 MG)
generic
S
Specialty Drug
TREANDA (100 MG, 25 MG)
bendamustine hcl
BRAND
VALCHLOR 0.016% GEL
BRAND
PAGE 31
MED
Medical Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
mechlorethamine hcl
ZANOSAR 1 GM POWDER VIAL
streptozocin
BRAND
ANTIANDROGENS
bicalutamide 50 mg tablet
generic
S
Specialty Drug
flutamide 125 mg capsule
generic
NILANDRON 150 MG TABLET
nilutamide
BRAND
S
Specialty Drug
XTANDI 40 MG CAPSULE
enzalutamide
BRAND
S
Specialty Drug
ZYTIGA 250 MG TABLET
abiraterone acetate
BRAND
S
Specialty Drug
POMALYST (3 MG, 2 MG, 4 MG, 1 MG)
pomalidomide
BRAND
S
Specialty Drug
REVLIMID (2.5 MG, 15 MG, 5 MG, 10 MG, 25 MG, 20 MG)
lenalidomide
BRAND
S
Specialty Drug
THALOMID (50 MG, 150 MG, 100 MG, 200 MG)
thalidomide
BRAND
S
Specialty Drug
S
Specialty Drug
S
Specialty Drug
S
Specialty Drug
ANTIANGIOGENIC AGENTS
ANTIESTROGENS/MODIFIERS
EMCYT 140 MG CAPSULE
estramustine phosphate sodium
BRAND
FARESTON 60 MG TABLET
toremifene citrate
BRAND
TAMOXIFEN CITRATE (10 MG, 20 MG)
generic
ANTIMETABOLITES
ADRUCIL (2,500 MG/50 ML, 500 MG/10 ML, 5 GRAM/100
ML)
fluorouracil
BRAND
ALIMTA (500 MG, 100 MG)
pemetrexed disodium
BRAND
CAPECITABINE (500 MG, 150 MG)
generic
cladribine 10 mg/10ml vial
generic
cytarabine 20 mg/ml vial
generic
S
Specialty Drug
CYTARABINE/PF (2 G/20 ML, 100 MG, 1 G, 500 MG, 20
MG/ML, 100 MG/5ML)
generic
S
Specialty Drug
DROXIA (400 MG, 200 MG, 300 MG)
BRAND
PAGE 32
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
hydroxyurea
ELITEK (1.5 MG, 7.5 MG)
rasburicase
BRAND
floxuridine 500 mg vial
generic
MED
FLUOROURACIL (2.5 G/50ML, 1 G/20 ML, 5 G/100 ML,
500MG/10ML)
generic
S
FLUOROURACIL (5 SOLUTION, 2 SOLUTION, 5 CREAM
(G))
generic
FOLOTYN (20 MG/ML, 40 MG/2 ML)
pralatrexate
BRAND
GEMCITABINE HCL (200 MG, 2 G, 1 G, 2 G/52.6ML,
200MG/5.26, 1 G/26.3ML)
generic
hydroxyurea 500 mg capsule
generic
mercaptopurine 50 mg tablet
generic
pentostatin 10 mg vial
generic
PURINETHOL 50 MG TABLET
mercaptopurine
BRAND
PA
TABLOID 40 MG TABLET
thioguanine
BRAND
S
Medical Drug
Specialty Drug
Specialty Drug
ANTINEOPLASTICS, OTHER
ABRAXANE 100 MG VIAL
paclitaxel protein-bound
BRAND
ADRIAMYCIN (50 MG, 10 MG, 2 MG/ML, 200 MG/100 ML,
20 MG)
doxorubicin hcl
BRAND
amifostine crystalline 500 mg vial
generic
ARRANON 250 MG VIAL
nelarabine
BRAND
CARBOPLATIN (10 MG/ML, 150 MG)
generic
CERUBIDINE 20 MG VIAL
daunorubicin hcl
BRAND
cisplatin 1 mg/ml vial
generic
dactinomycin 0.5 mg vial
generic
DAUNORUBICIN HCL (20 MG, 5 MG/ML)
generic
decitabine 50 mg vial
generic
DEXRAZOXANE HCL (250 MG, 500 MG)
generic
DOCETAXEL (20 MG/2 ML, 160 MG/8ML, FNL 20MG/2,
generic
PAGE 33
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
20MG/ML(1), 200MG/20ML, 160MG/16ML, 140 MG/7ML,
80 MG/8 ML, 80 MG/4 ML, FNL 80MG/8)
DOXIL 2 MG/ML VIAL
doxorubicin hcl pegylated liposomal
BRAND
DOXORUBICIN HCL (50 MG, 10 MG, 50 MG/25ML, 20
MG/10ML, 2 MG/ML, 10 MG/5 ML)
generic
doxorubicin hcl peg-liposomal 2 mg/ml vial
generic
ELOXATIN (200 MG/40 ML, 100 MG/20 ML, 50 MG/10
ML)
oxaliplatin
BRAND
EPIRUBICIN HCL (50 MG, 50 MG/25ML, 200 MG,
200MG/0.1L)
generic
FLUDARABINE PHOSPHATE (50 MG, 50 MG/2 ML)
generic
FUSILEV I.V. 50 MG VIAL
levoleucovorin calcium
BRAND
idarubicin hcl 1 mg/ml vial
generic
IRINOTECAN HCL (40 MG/2 ML, 100 MG/5ML,
500MG/25ML)
generic
ISTODAX 10 MG VIAL
romidepsin
BRAND
IXEMPRA (15 MG, 45 MG)
ixabepilone
BRAND
LEUCOVORIN CALCIUM (100 MG VIAL, 500MG/50ML
VIAL, 500 MG VIAL, 50 MG VIAL, 200 MG VIAL, 350 MG
VIAL, 10 MG TABLET, 5 MG TABLET, 25 MG TABLET, 15
MG TABLET)
generic
leucovorin calcium 10 mg/ml vial
generic
levoleucovorin calcium 10 mg/ml vial
generic
LIPODOX 2 MG/ML VIAL
doxorubicin hcl pegylated liposomal
BRAND
LIPODOX 50 2 MG/ML VIAL
doxorubicin hcl pegylated liposomal
BRAND
LYSODREN 500 MG TABLET
mitotane
BRAND
MARQIBO KIT
vincristine sulfate liposomal
BRAND
mesna 100 mg/ml vial
generic
MESNEX 400 MG TABLET
mesna
BRAND
MITOMYCIN (5 MG, 40 MG, 20 MG)
generic
PAGE 34
S
Specialty Drug
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
mitoxantrone hcl 2 mg/ml vial
generic
ONXOL 30 MG/5 ML VIAL
paclitaxel
BRAND
OXALIPLATIN (50 MG, 100 MG, 50 MG/10ML,
100MG/20ML)
generic
paclitaxel 6 mg/ml vial
generic
PHOTOFRIN 75 MG VIAL
porfimer sodium
BRAND
SYLATRON (200 MCG, 600 MCG, 300 MCG)
peginterferon alfa-2b
BRAND
S
Specialty Drug
SYLATRON 4-PACK (300 MCG, 200 MCG)
peginterferon alfa-2b
BRAND
S
Specialty Drug
SYLATRON 888 MCG 4-PACK
peginterferon alfa-2b
BRAND
teniposide 50 mg/5 ml ampul
generic
THERACYS 81 MG VIAL
bcg live
BRAND
thiotepa 15 mg vial
generic
TRISENOX 10 MG/10 ML AMPULE
arsenic trioxide
BRAND
VINBLASTINE SULFATE (1 MG/ML, 10 MG)
generic
VINCASAR PFS (2 MG/2 ML, 1 MG/ML)
vincristine sulfate
BRAND
VINCRISTINE SULFATE (2 MG/2 ML, 1 MG/ML)
generic
VINORELBINE TARTRATE (50 MG/5 ML, 10 MG/ML)
generic
VUMON 50 MG/5 ML AMPULE
teniposide
BRAND
ZOLINZA 100 MG CAPSULE
vorinostat
BRAND
S
Specialty Drug
anastrozole 1 mg tablet
generic
S
Specialty Drug
exemestane 25 mg tablet
generic
S
Specialty Drug
letrozole 2.5 mg tablet
generic
S
Specialty Drug
ETOPOSIDE (20 MG/ML VIAL, 50 MG CAPSULE)
generic
S
Specialty Drug
TOPOSAR (100 MG/5 ML, 500 MG/25 ML, 1,000 MG/50
BRAND
S
Specialty Drug
LIMITS & RESTRICTIONS
MED
Medical Drug
AROMATASE INHIBITORS, 3RD GENERATION
ENZYME INHIBITORS
PAGE 35
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
ML)
etoposide
MOLECULAR TARGET INHIBITORS
AFINITOR (10 MG, 7.5 MG, 2.5 MG, 5 MG)
everolimus
BRAND
S
Specialty Drug
AFINITOR DISPERZ (2 MG, 5 MG, 3 MG)
everolimus
BRAND
S
Specialty Drug
BOSULIF (500 MG, 100 MG)
bosutinib
BRAND
S
Specialty Drug
CAPRELSA (300 MG, 100 MG)
vandetanib
BRAND
S
Specialty Drug
ERIVEDGE 150 MG CAPSULE
vismodegib
BRAND
S
Specialty Drug
GILOTRIF (20 MG, 40 MG, 30 MG)
afatinib dimaleate
BRAND
S
Specialty Drug
GLEEVEC (100 MG, 400 MG)
imatinib mesylate
BRAND
S
Specialty Drug
IBRANCE (125 MG, 100 MG, 75 MG)
palbociclib
BRAND
ICLUSIG 15 MG TABLET
ponatinib hcl
BRAND
ICLUSIG 45 MG TABLET
ponatinib hcl
BRAND
IMATINIB MESYLATE (400 MG, 100 MG)
generic
PA
S
Specialty Drug
S
Specialty Drug
S
Specialty Drug
QL
IMBRUVICA 140 MG CAPSULE
ibrutinib
BRAND
PA
S
Specialty Drug
INLYTA (5 MG, 1 MG)
axitinib
BRAND
S
Specialty Drug
JAKAFI (10 MG, 15 MG, 5 MG, 25 MG, 20 MG)
ruxolitinib phosphate
BRAND
S
Specialty Drug
MEKINIST (2 MG, 0.5 MG)
trametinib dimethyl sulfoxide
BRAND
S
Specialty Drug
NEXAVAR 200 MG TABLET
sorafenib tosylate
BRAND
S
Specialty Drug
SPRYCEL (80 MG, 20 MG, 140 MG, 70 MG, 100 MG, 50
MG)
dasatinib
BRAND
S
Specialty Drug
PAGE 36
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
STIVARGA 40 MG TABLET
regorafenib
BRAND
S
Specialty Drug
SUTENT (50 MG, 12.5 MG, 25 MG)
sunitinib malate
BRAND
S
Specialty Drug
TAFINLAR (50 MG, 75 MG)
dabrafenib mesylate
BRAND
S
Specialty Drug
TARCEVA (150 MG, 100 MG, 25 MG)
erlotinib hcl
BRAND
S
Specialty Drug
TASIGNA (150 MG, 200 MG)
nilotinib hcl
BRAND
S
Specialty Drug
TORISEL 25 MG KIT
temsirolimus
BRAND
TYKERB 250 MG TABLET
lapatinib ditosylate
BRAND
VOTRIENT 200 MG TABLET
pazopanib hcl
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
BRAND
S
Specialty Drug
XALKORI (200 MG, 250 MG)
crizotinib
BRAND
S
Specialty Drug
ZELBORAF 240 MG TABLET
vemurafenib
BRAND
S
Specialty Drug
ZYDELIG (100 MG, 150 MG)
idelalisib
BRAND
PA
S
Specialty Drug
QL
ZYKADIA 150 MG CAPSULE
ceritinib
BRAND
PA
S
Specialty Drug
MONOCLONAL ANTIBODIES
ARZERRA (1,000 MG/50 ML, 100 MG/5 ML)
ofatumumab
BRAND
AVASTIN (100 MG/4 ML, 400 MG/16 ML)
bevacizumab
BRAND
BEXXAR (14 MG/ML DOSIMETRIC, 14 MG/ML
THERAPEUTIC)
tositumomab (with maltose)
BRAND
ERBITUX (100 MG/50 ML, 200 MG/100 ML)
cetuximab
BRAND
HERCEPTIN 440 MG VIAL
trastuzumab
BRAND
PA
BRAND
PA
KADCYLA (160 MG, 100 MG)
PAGE 37
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
ado-trastuzumab emtansine
PERJETA 420 MG/14 ML VIAL
pertuzumab
BRAND
RITUXAN 10 MG/ML VIAL
rituximab
BRAND
VECTIBIX (100 MG/5 ML, 400 MG/20 ML)
panitumumab
BRAND
ZEVALIN Y-90 VIAL
kit for prep yttrium-90/ibritumomab tiuxetan/albumin human
BRAND
PA
RETINOIDS
bexarotene 75 mg capsule
generic
TARGRETIN (1% GEL, 75 MG CAPSULE)
bexarotene
BRAND
TARGRETIN 75 MG SOFTGEL
bexarotene
BRAND
tretinoin 10 mg capsule
generic
S
Specialty Drug
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA 200 MG TABLET
albendazole
BRAND
STROMECTOL 3 MG TABLET
ivermectin
BRAND
ANTIPROTOZOALS
ALINIA (500 MG TABLET, 100 MG/5 ML SUSPENSION)
nitazoxanide
BRAND
atovaquone 750 mg/5ml oral susp
generic
ATOVAQUONE/PROGUANIL HCL (250-100 MG, 62.5-25
MG)
generic
CHLOROQUINE PHOSPHATE (500 MG, 250 MG)
generic
COARTEM TABLETS
artemether/lumefantrine
BRAND
DARAPRIM 25 MG TABLET
pyrimethamine
BRAND
hydroxychloroquine sulfate 200 mg tablet
generic
mefloquine hcl 250 mg tablet
generic
MEPRON 750 MG/5 ML SUSPENSION
atovaquone
BRAND
PAGE 38
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
NEBUPENT 300 MG INHAL POWDER
pentamidine isethionate
BRAND
quinine sulfate 324 mg capsule
generic
LIMITS & RESTRICTIONS
PEDICULICIDES/SCABICIDES
EURAX (CREAM, LOTION)
crotamiton
BRAND
ST
malathion 0.5 % lotion
C
60ml/fill; must try
permethrin and
piperonyl
butoxide/
pyrethrins
S
Specialty Drug
generic
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
BENZTROPINE MESYLATE (2 MG/2 ML VIAL, 2 MG/2 ML
AMPUL, 1 MG TABLET, 2 MG TABLET, 0.5 MG TABLET)
generic
TRIHEXYPHENIDYL HCL (2 MG/5 ML ELIXIR, 2 MG
TABLET, 5 MG TABLET)
generic
ANTIPARKINSON AGENTS, OTHER
AMANTADINE HCL (100 MG TABLET, 100 MG
CAPSULE, 50 MG/5 ML SOLUTION)
generic
CARBIDOPA/LEVODOPA/ENTACAPONE (50-200-200,
37.5-150MG, 18.75-75MG, 25-100-200, 31.25-125, 12.550 MG)
generic
entacapone 200 mg tablet
generic
TASMAR 100 MG TABLET
tolcapone
BRAND
tolcapone 100 mg tablet
generic
DOPAMINE AGONISTS
APOKYN 30 MG/3 ML CARTRIDGE
apomorphine hcl
BRAND
BROMOCRIPTINE MESYLATE (2.5 MG TABLET, 5 MG
CAPSULE)
generic
PRAMIPEXOLE DI-HCL (0.375 MG TAB ER 24H, 1.5 MG
TABLET, 0.125 MG TABLET, 2.25 MG TAB ER 24H, 0.5
MG TABLET, 1.5 MG TAB ER 24H, 4.5 MG TAB ER 24H,
0.25 MG TABLET, 0.75 MG TAB ER 24H, 3 MG TAB ER
24H, 0.75 MG TABLET, 1 MG TABLET)
generic
ROPINIROLE HCL (3 MG TABLET, 2 MG TAB ER 24H, 8
MG TAB ER 24H, 1 MG TABLET, 5 MG TABLET, 12 MG
generic
PAGE 39
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
TAB ER 24H, 6 MG TAB ER 24H, 0.5 MG TABLET, 4 MG
TABLET, 4 MG TAB ER 24H, 0.25 MG TABLET, 2 MG
TABLET)
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 25 mg tablet
generic
CARBIDOPA/LEVODOPA (25MG-250MG TAB RAPDIS,
25MG-250MG TABLET, 25MG-100MG TAB RAPDIS,
25MG-100MG TABLET ER, 10MG-100MG TAB RAPDIS,
50MG-200MG TABLET ER, 10MG-100MG TABLET,
25MG-100MG TABLET)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
SELEGILINE HCL (5 MG TABLET, 5 MG CAPSULE)
generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
CHLORPROMAZINE HCL (100 MG TABLET, 200 MG
TABLET, 25 MG TABLET, 10 MG TABLET, 25 MG/ML
AMPUL, 50 MG TABLET)
generic
DROPERIDOL (2.5 MG/ML AMPUL, 2.5 MG/ML VIAL)
generic
fluphenazine decanoate 25 mg/ml vial
generic
FLUPHENAZINE HCL (2.5 MG/5ML ELIXIR, 10 MG
TABLET, 5 MG TABLET, 2.5 MG TABLET, 5 MG/ML
ORAL CONC, 2.5 MG/ML VIAL, 1 MG TABLET)
generic
HALOPERIDOL (20 MG, 0.5 MG, 2 MG, 10 MG, 1 MG, 5
MG)
generic
HALOPERIDOL DECANOATE (50 MG/ML VIAL, 100
MG/ML AMPUL, 50 MG/ML AMPUL, 100 MG/ML VIAL)
generic
HALOPERIDOL LACTATE (2 MG/ML ORAL CONC, 5
MG/ML VIAL, 5 MG/ML AMPUL)
generic
LOXAPINE SUCCINATE (10 MG, 5 MG, 50 MG, 25 MG)
generic
MOLINDONE HCL (10 MG, 5 MG, 25 MG)
generic
PIMOZIDE (2 MG, 1 MG)
generic
THIORIDAZINE HCL (50 MG, 10 MG, 25 MG, 100 MG)
generic
THIOTHIXENE (1 MG, 10 MG, 2 MG, 5 MG)
generic
TRIFLUOPERAZINE HCL (10 MG, 1 MG, 2 MG, 5 MG)
generic
GL
Male
2ND GENERATION/ATYPICAL
ABILIFY (10 MG, 30 MG, 20 MG, 15 MG, 5 MG)
aripiprazole
PAGE 40
BRAND
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ABILIFY 1 MG/ML SOLUTION
aripiprazole
BRAND
C
ABILIFY 2 MG TABLET
aripiprazole
BRAND
QL
ABILIFY 9.7 MG/1.3 ML VIAL
aripiprazole
BRAND
C
ABILIFY DISCMELT (10 MG, 15 MG)
aripiprazole
BRAND
QL
ABILIFY MAINTENA ER 300 MG SYR
aripiprazole
BRAND
ABILIFY MAINTENA ER 300 MG VL
aripiprazole
BRAND
ABILIFY MAINTENA ER 400 MG SYR
aripiprazole
BRAND
ABILIFY MAINTENA ER 400 MG VL
aripiprazole
BRAND
ARIPIPRAZOLE (15 MG, 10 MG)
generic
QL
ARIPIPRAZOLE (15 MG, 10 MG, 30 MG, 5 MG, 20 MG, 2
MG)
generic
QL
aripiprazole 1 mg/ml solution
generic
QL
GEODON 20 MG/ML VIAL
ziprasidone mesylate
BRAND
INVEGA SUSTENNA (156 MG SY, 117 MG SY, 39 MG
SYR, 234 MG SY, 78 MG SYR)
paliperidone palmitate
BRAND
LIMITS & RESTRICTIONS
30ml/DAY
30ml/day
QL
PA
PA
C
30ml/day
QL
PA
PA
C
30ml/DAY
PA
C
must try 1 oral
antipsychotic
QL
INVEGA TRINZA (819 MG/2.625 ML, 546 MG/1.75 ML)
paliperidone palmitate
BRAND
PA
ST
QL
INVEGA TRINZA 273 MG/0.875 ML
paliperidone palmitate
BRAND
PA
ST
QL
INVEGA TRINZA 410 MG/1.315 ML
paliperidone palmitate
BRAND
PA
ST
OLANZAPINE (10 MG, 5 MG, 20 MG)
PAGE 41
generic
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
PA
OLANZAPINE (15 MG TAB RAPDIS, 10 MG VIAL)
generic
QL
OLANZAPINE (20 MG, 10 MG, 5 MG, 2.5 MG, 7.5 MG, 15
MG)
generic
QL
PALIPERIDONE (9 MG ER 24, 6 MG ER 24, 1.5 MG ER
24, 3 MG ER 24)
generic
QUETIAPINE FUMARATE (200 MG, 50 MG, 400 MG, 25
MG, 300 MG, 100 MG)
generic
QL
RISPERDAL CONSTA (25 MG, 12.5 MG, 50 MG, 37.5
MG)
risperidone microspheres
BRAND
PA
RISPERIDONE (1 MG TAB RAPDIS, 2 MG TABLET, 4 MG
TAB RAPDIS, 4 MG TABLET, 0.25 MG TABLET, 1 MG/ML
SOLUTION, 2 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 3
MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 1 MG TABLET, 3
MG TABLET, 0.5 MG TABLET)
generic
QL
SEROQUEL XR (200 MG, 150 MG, 400 MG, 300 MG)
quetiapine fumarate
BRAND
C
dosage <150mg/day
beyond initial 30 days
will require PA for
those
between 13-64yrs of
age
QL
SEROQUEL XR 50 MG TABLET
quetiapine fumarate
BRAND
SEROQUEL XR SAMPLE KIT
quetiapine fumarate
BRAND
ZIPRASIDONE HCL (80 MG, 60 MG, 20 MG, 40 MG)
generic
C
dosage <150mg/day
beyond initial 30 days
will require PA for
those
between 13-64yrs of
age
QL
TREATMENT-RESISTANT
CLOZAPINE (50 MG TABLET, 12.5 MG TAB RAPDIS, 200
MG TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG
TAB RAPDIS, 25 MG TAB RAPDIS, 200 MG TAB
RAPDIS, 100 MG TAB RAPDIS)
generic
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir 75 mg/ml vial
PAGE 42
generic
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
foscarnet sodium 24 mg/ml infus. btl
generic
ganciclovir sodium 500 mg vial
generic
VALCYTE (450 MG TABLET, 50 MG/ML SOLUTION)
valganciclovir hcl
BRAND
valganciclovir hcl 450 mg tablet
generic
LIMITS & RESTRICTIONS
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 10 mg tablet
generic
BARACLUDE 0.05 MG/ML SOLUTION
entecavir
BRAND
S
ENTECAVIR (0.5 MG, 1 MG)
generic
QL
EPIVIR HBV 25 MG/5 ML SOLN
lamivudine
BRAND
lamivudine 100 mg tablet
generic
TYZEKA 600 MG TABLET
telbivudine
BRAND
Specialty Drug
ANTI-HEPATITIS C (HCV) AGENTS
QL
HARVONI 90-400 MG TABLET
ledipasvir/sofosbuvir
BRAND
PA
S
PA
INCIVEK 375 MG TABLET
telaprevir
BRAND
INFERGEN (15 MCG/0.5 ML, 9 MCG/0.3 ML)
interferon alfacon-1
BRAND
INTRON A (50 UNITS VIL, 6 UNIT/ML VL, 10 UNIT/ML, 18
UNITS VIL, 10 UNITS VIL)
interferon alfa-2b,recomb.
BRAND
MODERIBA 200 MG TABLET
ribavirin
BRAND
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML
SYRINGE)
peginterferon alfa-2a
BRAND
PEGASYS PROCLICK (180, 135)
peginterferon alfa-2a
BRAND
RIBASPHERE (600 MG TABLET, 400 MG TABLET, 200
MG TABLET, 200 MG CAPSULE)
ribavirin
BRAND
PAGE 43
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
RIBASPHERE RIBAPAK (200-400 MG, 600-600 MG, 600400 MG, 400-400 MG)
ribavirin
BRAND
RIBAVIRIN (200 MG CAPSULE, 200 MG TABLET)
generic
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
PA
S
Specialty Drug
QL
SOVALDI 400 MG TABLET
sofosbuvir
BRAND
PA
S
Specialty Drug
QL
TECHNIVIE DOSE PACK
ombitasvir/paritaprevir/ritonavir
BRAND
PA
S
VICTRELIS 200 MG CAPSULE
boceprevir
Specialty Drug
PA
BRAND
S
Specialty Drug
QL
VIEKIRA PAK
ombitasvir/paritaprevir/ritonavir/dasabuvir sodium
BRAND
PA
S
Specialty Drug
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
ISENTRESS (100 MG POWDER PACKET, 25 MG
TABLET CHEW, 400 MG TABLET, 100 MG TABLET
CHEW)
raltegravir potassium
BRAND
STRIBILD TABLET
elvitegravir/cobicistat/emtricitabine/tenofovir
BRAND
TIVICAY 50 MG TABLET
dolutegravir sodium
BRAND
PA
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TABLET
efavirenz/emtricitabine/tenofovir disoproxil fumarate
BRAND
COMPLERA TABLET
emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
BRAND
EDURANT 25 MG TABLET
rilpivirine hcl
BRAND
INTELENCE (25 MG, 200 MG, 100 MG)
etravirine
BRAND
NEVIRAPINE (100 MG TAB ER 24H, 50 MG/5 ML ORAL
SUSP, 200 MG TABLET, 400 MG TAB ER 24H)
generic
RESCRIPTOR (100 MG, 200 MG)
BRAND
PAGE 44
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
delavirdine mesylate
SUSTIVA (200 MG CAPSULE, 600 MG TABLET, 50 MG
CAPSULE)
efavirenz
BRAND
VIRAMUNE XR (400 MG, 100 MG)
nevirapine
BRAND
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 300 mg tablet
generic
abacavir/lamivudine/zidovudine 150-300mg tablet
generic
DIDANOSINE (250 MG, 400 MG, 200 MG, 125 MG)
generic
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
emtricitabine
BRAND
EPIVIR 10 MG/ML ORAL SOLN
lamivudine
BRAND
EPZICOM TABLET
abacavir sulfate/lamivudine
BRAND
LAMIVUDINE (300 MG TABLET, 10 MG/ML SOLUTION,
150 MG TABLET)
generic
lamivudine/zidovudine 150-300mg tablet
generic
STAVUDINE (30 MG CAPSULE, 40 MG CAPSULE, 15
MG CAPSULE, 20 MG CAPSULE, 1 MG/ML SOLN
RECON)
generic
TRUVADA 200 MG-300 MG TABLET
emtricitabine/tenofovir disoproxil fumarate
BRAND
VIDEX (2, 4)
didanosine
BRAND
VIREAD (POWDER, 300 MG TABLET, 200 MG TABLET,
150 MG TABLET, 250 MG TABLET)
tenofovir disoproxil fumarate
BRAND
ZIAGEN 20 MG/ML SOLUTION
abacavir sulfate
BRAND
ZIDOVUDINE (10 MG/ML SYRUP, 300 MG TABLET, 100
MG CAPSULE)
generic
ANTI-HIV AGENTS, OTHER
FUZEON (90 MG VIAL, CONVENIENCE KIT)
enfuvirtide
BRAND
SELZENTRY (300 MG, 150 MG)
maraviroc
BRAND
PA
ANTI-HIV AGENTS, PROTEASE INHIBITORS
PAGE 45
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)
tipranavir
BRAND
CRIXIVAN (400 MG, 200 MG)
indinavir sulfate
BRAND
INVIRASE (500 MG TABLET, 200 MG CAPSULE)
saquinavir mesylate
BRAND
KALETRA (100-25 MG TABLET, 400-100/5 ML ORAL
SOLU, 200-50 MG TABLET)
lopinavir/ritonavir
BRAND
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
fosamprenavir calcium
BRAND
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100
MG SOFTGEL CAP)
ritonavir
BRAND
PREZISTA (600 MG TABLET, 100 MG/ML SUSPENSION,
150 MG TABLET, 400 MG TABLET, 800 MG TABLET, 75
MG TABLET)
darunavir ethanolate
BRAND
REYATAZ (200 MG, 100 MG, 300 MG, 150 MG)
atazanavir sulfate
BRAND
VIRACEPT (625 MG, 250 MG)
nelfinavir mesylate
BRAND
LIMITS & RESTRICTIONS
ANTI-INFLUENZA AGENTS
QL
RELENZA 5 MG DISKHALER
zanamivir
BRAND
rimantadine hcl 100 mg tablet
generic
TAMIFLU (45 MG, 30 MG)
oseltamivir phosphate
BRAND
TAMIFLU 6 MG/ML SUSPENSION
oseltamivir phosphate
TAMIFLU 75 MG CAPSULE
oseltamivir phosphate
C
max 10 day supply/fill
BRAND
C
25ml/day
BRAND
C
20 capsules/180 days
C
15gm/fill
ANTIHERPETIC AGENTS
ACYCLOVIR (200 MG CAPSULE, 400 MG TABLET, 800
MG TABLET, 200 MG/5ML ORAL SUSP)
generic
acyclovir 5 % oint. (g)
generic
ACYCLOVIR SODIUM (500 MG, 50 MG/ML, 1000 MG)
generic
FAMCICLOVIR (500 MG, 250 MG, 125 MG)
generic
trifluridine 1 % drops
generic
PAGE 46
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
VALACYCLOVIR HCL (500 MG, 1000 MG)
generic
ZOVIRAX 5% CREAM
acyclovir
BRAND
LIMITS & RESTRICTIONS
C
5gm/fill
ANXIOLYTICS
ANXIOLYTICS, OTHER
BUSPIRONE HCL (5 MG, 30 MG, 7.5 MG, 10 MG, 15 MG)
generic
MIDAZOLAM HCL (5 MG/ML(1) VIAL, 2 MG/ML SYRUP, 2
MG/2 ML VIAL, 5 MG/ML VIAL, 5 MG/5 ML VIAL, 10 MG/2
ML VIAL, 10 MG/10ML VIAL)
generic
MIDAZOLAM HCL/PF (5 MG/ML SYRINGE, 5 MG/ML
CARTRIDGE, 5 MG/5 ML VIAL, 2 MG/2 ML CARTRIDGE,
10 MG/2 ML VIAL, 2 MG/2 ML VIAL, 10 MG/2 ML
SYRINGE, 5 MG/ML(1) VIAL, 2 MG/2 ML SYRINGE)
generic
BENZODIAZEPINES
ALPRAZOLAM (2 MG TAB RAPDIS, 1 MG TABLET, 0.25
MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 0.5 MG TAB ER
24H, 2 MG TABLET, 3 MG TAB ER 24H, 1 MG TAB
RAPDIS, 1 MG TAB ER 24H, 0.25 MG TABLET, 2 MG
TAB ER 24H, 0.5 MG TABLET)
generic
ALPRAZOLAM 1 MG/ML ORAL CONC
alprazolam
BRAND
CHLORDIAZEPOXIDE HCL (25 MG, 5 MG, 10 MG)
generic
CLONAZEPAM (0.125 MG TAB RAPDIS, 0.5 MG
TABLET, 1 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 1
MG TABLET, 0.5 MG TAB RAPDIS, 2 MG TAB RAPDIS, 2
MG TABLET)
generic
CLORAZEPATE DIPOTASSIUM (7.5 MG, 3.75 MG, 15
MG)
generic
DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5 MG/5 ML
SOLUTION, 5 MG/ML SYRINGE, 5 MG/ML ORAL CONC,
5 MG TABLET, 5 MG/ML VIAL)
generic
LORAZEPAM (4 MG/ML SYRINGE, 2 MG/ML SYRINGE,
0.5 MG TABLET, 4 MG/ML VIAL, 2 MG/ML VIAL, 1 MG
TABLET, 2 MG/ML ORAL CONC, 2 MG TABLET)
generic
LORAZEPAM INTENSOL 2 MG/ML
lorazepam
BRAND
OXAZEPAM (10 MG, 15 MG, 30 MG)
generic
BIPOLAR AGENTS
MOOD STABILIZERS
PAGE 47
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LITHIUM CARBONATE (300 MG TABLET ER, 300 MG
TABLET, 300 MG CAPSULE, 600 MG CAPSULE, 150 MG
CAPSULE, 450 MG TABLET ER)
generic
lithium citrate 8 meq/5 ml solution
generic
LIMITS & RESTRICTIONS
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
ACARBOSE (50 MG, 25 MG, 100 MG)
generic
ACTOPLUS MET XR (30-1,000 MG, 15-1,000 MG)
pioglitazone hcl/metformin hcl
BRAND
BYDUREON 2 MG PEN INJECT
exenatide microspheres
BRAND
BYDUREON 2 MG VIAL
exenatide microspheres
BRAND
BYETTA (5 MCG, 10 MCG)
exenatide
BRAND
GLIMEPIRIDE (1 MG, 4 MG, 2 MG)
generic
GLIPIZIDE (10 MG TAB ER 24, 5 MG TABLET, 10 MG
TABLET, 5 MG TAB ER 24, 2.5 MG TAB ER 24)
generic
GLIPIZIDE/METFORMIN HCL (2.5-250 MG, 5 MG-500MG,
2.5-500 MG)
generic
GLYBURIDE (2.5 MG, 5 MG, 1.25 MG)
generic
GLYBURIDE,MICRONIZED (3 MG, 6 MG, 1.5 MG)
generic
GLYBURIDE/METFORMIN HCL (2.5-500 MG, 1.25250MG, 5 MG-500MG)
generic
INVOKAMET (50-1,000 MG, 50-500 MG, 150-500 MG,
150-1,000 MG)
canagliflozin/metformin hcl
BRAND
INVOKANA (100 MG, 300 MG)
canagliflozin
BRAND
JANUMET (50-1,000 MG, 50-500 MG)
sitagliptin phosphate/metformin hcl
BRAND
JANUMET XR (50-500 MG, 50-1,000 MG, 100-1,000 MG)
sitagliptin phosphate/metformin hcl
BRAND
JANUVIA (25 MG, 100 MG)
sitagliptin phosphate
BRAND
PAGE 48
PA
PA
C
1 unit/7 days
PA
C
1 unit/7 days
QL
PA
QL
C
must try metformin for
6 months
ST
C
must try metformin for
6 mos
ST
C
must try metformin for
6 mos
ST
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
C
must try metformin for
6 mos
PA
JANUVIA 50 MG TABLET
sitagliptin phosphate
BRAND
ST
C
JENTADUETO (2.5 MG-850 MG, 2.5 MG-1000 MG, 2.5
MG-500 MG)
linagliptin/metformin hcl
BRAND
METFORMIN HCL (850 MG TABLET, 750 MG TAB ER
24H, 1000 MG TABLET, 500 MG TAB ER 24, 500 MG
TAB ER 24H)
generic
metformin hcl 500 mg tablet
generic
GL
NATEGLINIDE (120 MG, 60 MG)
generic
PA
PIOGLITAZONE HCL (30 MG, 15 MG, 45 MG)
generic
PIOGLITAZONE HCL/GLIMEPIRIDE (30 MG-4 MG, 30
MG-2 MG)
generic
PIOGLITAZONE HCL/METFORMIN HCL (15MG-500MG,
15MG-850MG)
generic
REPAGLINIDE (1 MG, 2 MG, 0.5 MG)
generic
REPAGLINIDE/METFORMIN HCL (1MG-500MG, 2 MG500MG)
generic
RIOMET 500 MG/5 ML SOLUTION
metformin hcl
BRAND
SYMLINPEN 120 PEN INJECTOR
pramlintide acetate
BRAND
PA
SYMLINPEN 60 PEN INJECTOR
pramlintide acetate
BRAND
PA
TOLAZAMIDE (250 MG, 500 MG)
generic
tolbutamide 500 mg tablet
generic
TRADJENTA 5 MG TABLET
linagliptin
BRAND
VICTOZA 2-PAK 18 MG/3 ML PEN
liraglutide
BRAND
VICTOZA 3-PAK 18 MG/3 ML PEN
liraglutide
BRAND
PAGE 49
must try metformin for
6 mos
ST
C
must try metformin for
6 mos
Male
ST
C
must try metformin for
6 mos
QL
PA
QL
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
GLYCEMIC AGENTS
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL,
1 MG HYPOKIT 2-PACK)
glucagon,human recombinant
BRAND
GLUCAGON 1 MG EMERGENCY KIT
glucagon,human recombinant
BRAND
glucagon hcl 1 mg vial
generic
PROGLYCEM 50 MG/ML ORAL SUSP
diazoxide
BRAND
INSULINS
HUMALOG 200 UNITS/ML KWIKPEN
insulin lispro
BRAND
HUMULIN R 500 UNITS/ML VIAL
insulin regular, human
BRAND
LANTUS 100 UNITS/ML VIAL
insulin glargine,human recombinant analog
BRAND
LANTUS SOLOSTAR 100 UNITS/ML
insulin glargine,human recombinant analog
BRAND
LEVEMIR 100 UNITS/ML VIAL
insulin detemir
BRAND
LEVEMIR FLEXPEN 100 UNITS/ML
insulin detemir
BRAND
LEVEMIR FLEXTOUCH 100 UNITS/ML
insulin detemir
BRAND
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ACD INJECTION SOLUTION
dextrose-water/sodium citrate/citric acid
BRAND
ACD-A SOLUTION
citrate dextrose solution
BRAND
argatroban in nacl,iso-osmotic 50 mg/50ml vial
generic
citrate phosphate dextros soln 2.63 g/100 solution
generic
ENOXAPARIN SODIUM (300MG/3ML VIAL, 150 MG/ML
SYRINGE, 120MG/.8ML SYRINGE, 100 MG/ML
SYRINGE, 40MG/0.4ML SYRINGE, 30MG/0.3ML
SYRINGE, 80MG/0.8ML SYRINGE, 60MG/0.6ML
SYRINGE)
generic
FONDAPARINUX SODIUM (10MG/0.8ML, 2.5 MG/0.5,
5MG/0.4ML, 7.5MG/0.6)
generic
PAGE 50
C
PA required if days'
supply > or =11 days
PA
C
PA required if days'
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
supply > or =11 days
S
HEPARIN 50 UNITS/5 ML (10/ML)
heparin sodium,porcine/pf
BRAND
HEPARIN SODIUM,PORCINE (20000/ML VIAL, 10
UNIT/ML VIAL, 1000/ML VIAL, 100/ML (1) SYRINGE, 10
UNIT/ML SYRINGE, 300/3 ML SYRINGE, 100/ML VIAL,
5000/ML VIAL, 200/2 ML SYRINGE, 5000/ML(1)
CARTRIDGE, 500/5 ML SYRINGE, 10000/ML VIAL)
generic
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM
CHLORIDE (HEPAR25000/500, HEPAR25000/250)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE (1K/1000 ML IV SOLN, 100/ML KIT, 10
UNIT/ML KIT, 6K/1000 ML IV SOLN)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE/PF (2K/1000ML, 1000/500ML)
generic
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN
WATER (25000/250, 20K/500ML, 12500/250, 25000/500)
generic
HEPARIN SODIUM,PORCINE/PF (5000/0.5ML SYRINGE,
500/5 ML SYRINGE, 300/3 ML SYRINGE, 100/ML (1)
VIAL, 10 UNIT/ML SYRINGE, 100/ML (1) SYRINGE,
5000/0.5ML VIAL, 1000/10 ML SYRINGE, 200/2 ML
SYRINGE, 1000/ML VIAL, 10 UNIT/ML VIAL, 1 UNIT/ML
SYRINGE)
generic
JANTOVEN (7.5 MG, 6 MG, 5 MG, 2.5 MG, 2 MG, 4 MG, 3
MG, 1 MG, 10 MG)
warfarin sodium
BRAND
MONOJECT PREFILL ADVANCED (500 UNIT/5 ML
(100/ML), 50 UNITS/5 ML (10/ML), 30 UNITS/3 ML
(10/ML), 300 UNIT/3 ML (100/ML), 1,000 UNIT/10
(100/ML), 100 UNIT/10 ML (10/ML))
heparin sodium,porcine/pf
BRAND
PRADAXA (75 MG, 150 MG)
dabigatran etexilate mesylate
BRAND
protamine sulfate 10 mg/ml vial
generic
TRICITRASOL 46.7% VIAL
sodium citrate dihydrate
BRAND
WARFARIN SODIUM (5 MG, 2.5 MG, 7.5 MG, 1 MG, 2
MG, 10 MG, 6 MG, 3 MG, 4 MG)
generic
XARELTO (15 MG, 20 MG, 10 MG)
rivaroxaban
BRAND
Specialty Drug
PA
BLOOD FORMATION MODIFIERS
PAGE 51
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ANAGRELIDE HCL (1 MG, 0.5 MG)
generic
LEUKINE (250 MCG, 500 MCG/ML)
sargramostim
BRAND
MOZOBIL (24 MG/1.2 ML, 20 MG/ML)
plerixafor
BRAND
NEULASTA (6 ML SYRINGE, ONPRO 6 ML KIT)
pegfilgrastim
BRAND
NEUMEGA 5 MG VIAL
oprelvekin
BRAND
PROCRIT (20,000, 10,000, 2,000, 3,000, 40,000, 4,000)
epoetin alfa
BRAND
PROMACTA (75 MG, 50 MG, 25 MG, 12.5 MG)
eltrombopag olamine
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
BRAND
S
Specialty Drug
ADVATE (801-1,200, 401-800, 200-400, 3,601-4,800,
1,201-1,800, 1,801-2,400)
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ADVATE 1,201-1,800 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ADVATE 1,801-2,400 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ADVATE 200-400 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ADVATE 401-800 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ADVATE 801-1,200 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
S
Specialty Drug
ALPHANATE (1,500-600, 1,000-400, 250-100, 500-200,
2,000-800)
antihemophilic factor, human/von willebrand factor,human
BRAND
S
Specialty Drug
AMINOCAPROIC ACID (250 MG/ML VIAL, 250 MG/ML
SOLUTION, 500 MG TABLET)
generic
BEBULIN 200-1,200 UNITS VIAL
factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor
BRAND
BEBULIN VH IMMU 200-1,200 UNIT
factor ix complex human
BRAND
S
Specialty Drug
BENEFIX (3,000 KIT, 2,000 VIAL, 1,000 KIT, 250 KIT,
2,000 KIT, 1,000 VIAL, 500 KIT, 250 VIAL, 500 VIAL)
factor ix human recombinant
BRAND
S
Specialty Drug
COAGULANTS
PAGE 52
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CORIFACT KIT
factor xiii
BRAND
ELOCTATE (1,000, 250, 2,000, 3,000, 500, 1,500, 750)
antihemophilic factor (fviii) recombinant, fc fusion protein
BRAND
FEIBA NF (651-1,200 VIAL, 500 (NOMINAL), 1,750-3,250
VIAL, 1,000 (NOMINAL), 2,500 (NOMINAL), 400-650
VIAL)
anti-inhibitor coagulant complex
BRAND
FEIBA VH IMMUNO 651-1,200 UNIT
anti-inhibitor coagulant complex
BRAND
HELIXATE FS (1,000, 250, 500, 2,000)
antihemophilic factor viii, human recombinant
BRAND
HELIXATE FS 3,000 UNITS VIAL
antihemophilic factor (fviii) recomb,full length (alb-free)
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
PA
S
Specialty Drug
BRAND
S
Specialty Drug
HUMATE-P (2,400, 1,200, 600)
antihemophilic factor, human/von willebrand factor,human
BRAND
S
Specialty Drug
IXINITY (1,000, 1,000 -2 VLS, 1,500, 1,500 -2 VLS, 500)
factor ix human recombinant, threonine 148
BRAND
S
Specialty Drug
KOATE-DVI (250 VIAL, 1,000 VIAL, 500 KIT)
antihemophilic factor, human
BRAND
S
Specialty Drug
KOATE-DVI 500 UNITS VIAL
antihemophilic factor, human
BRAND
KOGENATE FS (2,000 UNIT VIAL, 1,000 UNITADAPTER, 2,000 UNIT-ADAPTER, 3,000 UNITS VIAL,
250 UNIT VL-BIOSET, 500 UNIT VIAL, 1,000 UNITBIOSET, 500 UNIT VL-ADAPTR, 500 UNIT VL-BIOSET,
1,000 UNITS VIAL)
antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND
KOGENATE FS (250 UNIT VIAL, 250 UNIT VL-ADAPTR,
2,000 UNIT-BIOSET)
antihemophilic factor (fviii) recomb,full length (alb-free)
PA
S
Specialty Drug
PA
S
Specialty Drug
BRAND
S
Specialty Drug
MONONINE 1,000 UNITS KIT
factor ix
BRAND
S
Specialty Drug
MONSEL'S FERRIC SUBSULFATE SOL
ferric subsulfate
BRAND
NOVOEIGHT (250, 2,000, 1,000, 1,500, 500, 3,000)
antihemophilic factor viii recombinant, b-domain truncated
BRAND
NOVOSEVEN RT (8 MG, 5 MG, 1 MG, 2 MG)
coagulation factor viia (recombinant)
BRAND
PROFILNINE (500, 1,500, 1,000)
PAGE 53
BRAND
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor
LIMITS & RESTRICTIONS
S
Specialty Drug
PA
PROFILNINE SD (1,500, 1,000, 500)
factor ix complex human
BRAND
RECOMBINATE (1,801-2,400, 1,241-1,800)
antihemophilic factor viii, human recombinant
BRAND
RECOMBINATE (801-1,240 VL, 401-800 VIAL, 220-400
VIAL)
antihemophilic factor viii, human recombinant
BRAND
RIASTAP VIAL
fibrinogen
BRAND
tranexamic acid 650 mg tablet
generic
TRETTEN 2,500 UNIT VIAL
factor xiii a-subunit, recombinant
BRAND
XYNTHA (500, 2,000, 250, 1,000)
antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
XYNTHA SOLOFUSE (500 KIT, 3,000 KIT, 1,000 SYR,
500 SYR, 3,000 SYR, 1,000 KIT, 2,000 SYR, 250 SYR,
250 KIT, 2,000 KIT)
antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
S
Specialty Drug
S
Specialty Drug
PLATELET MODIFYING AGENTS
aspirin/dipyridamole 25mg-200mg cpmp 12hr
generic
BRILINTA (90 MG, 60 MG)
ticagrelor
BRAND
CILOSTAZOL (50 MG, 100 MG)
generic
CLOPIDOGREL BISULFATE (75 MG, 300 MG)
generic
DIPYRIDAMOLE (75 MG TABLET, 25 MG TABLET, 50
MG TABLET, 5 MG/ML VIAL)
generic
EFFIENT (10 MG, 5 MG)
prasugrel hcl
BRAND
EPTIFIBATIDE (0.75 MG/ML, 2 MG/ML)
generic
ZONTIVITY 2.08 MG TABLET
vorapaxar sulfate
BRAND
PA
QL
PA
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CLONIDINE (0.1MG/24HR, 0.2MG/24HR, 0.3MG/24HR)
generic
CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG)
generic
PAGE 54
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CLONIDINE HCL/PF (1000MCG/10, 5000MCG/10)
generic
GUANFACINE HCL (2 MG, 1 MG)
generic
METHYLDOPA (500 MG, 250 MG)
generic
methyldopate hcl 250 mg/5ml vial
generic
MIDODRINE HCL (5 MG, 2.5 MG, 10 MG)
generic
LIMITS & RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENTS
DIBENZYLINE 10 MG CAPSULE
phenoxybenzamine hcl
BRAND
DOXAZOSIN MESYLATE (4 MG, 1 MG, 2 MG, 8 MG)
generic
phenoxybenzamine hcl 10 mg capsule
generic
phentolamine mesylate 5 mg vial
generic
PRAZOSIN HCL (1 MG, 2 MG, 5 MG)
generic
RESERPINE (0.1 MG, 0.25 MG)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
CANDESARTAN CILEXETIL (4 MG, 32 MG, 16 MG, 8
MG)
generic
eprosartan mesylate 600 mg tablet
generic
IRBESARTAN (75 MG, 300 MG, 150 MG)
generic
LOSARTAN POTASSIUM (50 MG, 100 MG, 25 MG)
generic
TELMISARTAN (80 MG, 20 MG, 40 MG)
generic
VALSARTAN (80 MG, 320 MG, 40 MG, 160 MG)
generic
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
BENAZEPRIL HCL (20 MG, 5 MG, 40 MG, 10 MG)
generic
CAPTOPRIL (50 MG, 25 MG, 100 MG, 12.5 MG)
generic
ENALAPRIL MALEATE (5 MG, 20 MG, 2.5 MG, 10 MG)
generic
enalaprilat dihydrate 1.25 mg/ml vial
generic
FOSINOPRIL SODIUM (40 MG, 20 MG, 10 MG)
generic
LISINOPRIL (10 MG, 30 MG, 40 MG, 2.5 MG, 5 MG, 20
MG)
generic
MOEXIPRIL HCL (15 MG, 7.5 MG)
generic
PERINDOPRIL ERBUMINE (4 MG, 8 MG, 2 MG)
generic
QUINAPRIL HCL (5 MG, 10 MG, 40 MG, 20 MG)
generic
RAMIPRIL (5 MG, 10 MG, 2.5 MG, 1.25 MG)
generic
PAGE 55
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
TRANDOLAPRIL (2 MG, 4 MG, 1 MG)
generic
LIMITS & RESTRICTIONS
ANTIARRHYTHMICS
ADENOSINE (3 MG/ML SYRINGE, 3 MG/ML VIAL)
generic
AMIODARONE HCL (50 MG/ML VIAL, 200 MG TABLET,
100 MG TABLET, 50 MG/ML AMPUL, 400 MG TABLET,
150 MG/3ML SYRINGE)
generic
FLECAINIDE ACETATE (50 MG, 150 MG, 100 MG)
generic
ibutilide fumarate 0.1 mg/ml vial
generic
MEXILETINE HCL (150 MG, 200 MG, 250 MG)
generic
PACERONE (100 MG, 200 MG, 400 MG)
amiodarone hcl
BRAND
PROCAINAMIDE HCL (500 MG/ML, 100 MG/ML)
generic
PROPAFENONE HCL (300 MG TABLET, 425 MG CAP
ER 12H, 225 MG CAP ER 12H, 325 MG CAP ER 12H, 225
MG TABLET, 150 MG TABLET)
generic
QUINIDINE GLUCONATE (80 MG/ML VIAL, 324 MG
TABLET ER)
generic
QUINIDINE SULFATE (300 MG ER, 300 MG, 200 MG)
generic
SORINE (80 MG, 160 MG, 240 MG, 120 MG)
sotalol hcl
BRAND
SOTALOL HCL (240 MG, 160 MG, 120 MG, 80 MG)
generic
TIKOSYN (500 MCG, 250 MCG, 125 MCG)
dofetilide
BRAND
BETA-ADRENERGIC BLOCKING AGENTS
ACEBUTOLOL HCL (400 MG, 200 MG)
generic
ATENOLOL (25 MG, 50 MG, 100 MG)
generic
BETAXOLOL HCL (20 MG, 10 MG)
generic
BISOPROLOL FUMARATE (5 MG, 10 MG)
generic
CARVEDILOL (12.5 MG, 25 MG, 6.25 MG, 3.125 MG)
generic
esmolol hcl 100mg/10ml vial
generic
LABETALOL HCL (100 MG TABLET, 20 MG/4 ML
SYRINGE, 5 MG/ML VIAL, 200 MG TABLET, 300 MG
TABLET)
generic
METOPROLOL SUCCINATE (25 MG ER, 50 MG ER, 100
MG ER, 200 MG ER)
generic
METOPROLOL TARTRATE (5 MG/5 ML SYRINGE, 5
MG/5 ML AMPUL, 5 MG/5 ML VIAL, 50 MG TABLET, 25
generic
PAGE 56
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
MG TABLET, 100 MG TABLET)
NADOLOL (20 MG, 80 MG, 40 MG)
generic
PINDOLOL (5 MG, 10 MG)
generic
PROPRANOLOL HCL (60 MG CAP SA 24H, 80 MG
TABLET, 80 MG CAP SA 24H, 60 MG TABLET, 10 MG
TABLET, 20 MG/5 ML SOLUTION, 40 MG TABLET, 20
MG TABLET, 120 MG CAP SA 24H, 1 MG/ML VIAL, 160
MG CAP SA 24H, 40MG/5ML SOLUTION)
generic
TIMOLOL MALEATE (10 MG, 20 MG, 5 MG)
generic
CALCIUM CHANNEL BLOCKING AGENTS
AFEDITAB CR (30 MG, 60 MG)
nifedipine
BRAND
AMLODIPINE BESYLATE (5 MG, 2.5 MG, 10 MG)
generic
CARTIA XT (120 MG, 300 MG, 180 MG, 240 MG)
diltiazem hcl
BRAND
DILT-XR (120 MG, 180 MG, 240 MG)
diltiazem hcl
BRAND
DILTIAZEM HCL (120 MG CAP ER 12H, 180 MG CAP ER
24H, 30 MG TABLET, 120 MG CAP ER 24H, 420MG
CAPSULE ER, 60 MG CAP ER 12H, 240 MG TAB ER
24H, 5 MG/ML VIAL, 240 MG CAP ER DEG, 240 MG CAP
ER 24H, 100 MG VIAL PORT, 300 MG CAP ER 24H, 60
MG TABLET, 120 MG CAP ER DEG, 240 MG CAPSULE
ER, 180 MG CAP ER DEG, 300 MG CAPSULE ER, 180
MG TAB ER 24H, 180 MG CAPSULE ER, 420MG TAB ER
24H, 300 MG TAB ER 24H, 360 MG CAP ER 24H, 90 MG
CAP ER 12H, 360 MG CAPSULE ER, 120 MG CAPSULE
ER, 90 MG TABLET, 360 MG TAB ER 24H, 120 MG
TABLET)
generic
FELODIPINE (5 MG ER, 2.5 MG ER, 10 MG ER)
generic
ISRADIPINE (2.5 MG, 5 MG)
generic
MATZIM LA (180 MG, 300 MG, 360 MG, 240 MG, 420
MG)
diltiazem hcl
BRAND
NICARDIPINE HCL (25 MG/10ML VIAL, 25 MG/10ML
AMPUL, 20 MG CAPSULE, 30 MG CAPSULE)
generic
nicardipine hcl in 0.9% nacl 1 mg/10 ml syringe
generic
NIFEDIAC CC 30 MG TABLET
nifedipine
BRAND
NIFEDICAL XL (30 MG, 60 MG)
nifedipine
BRAND
PAGE 57
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
NIFEDIPINE (60 MG TABLET ER, 30 MG TAB ER 24, 60
MG TAB ER 24, 30 MG TABLET ER, 90 MG TAB ER 24,
90 MG TABLET ER)
generic
nimodipine 30 mg capsule
generic
NISOLDIPINE (25.5 MG ER, 30 MG ER, 8.5MG ER, 40
MG ER, 17 MG ER, 20 MG ER, 34 MG ER)
generic
TAZTIA XT (300 MG, 120 MG, 180 MG, 240 MG)
diltiazem hcl
BRAND
VERAPAMIL HCL (300 MG CAP24H PCT, 2.5 MG/ML
AMPUL, 2.5 MG/ML VIAL, 240 MG CAP24H PEL, 200 MG
CAP24H PCT, 2.5 MG/ML SYRINGE, 180 MG TABLET
ER, 120 MG CAP24H PEL, 40 MG TABLET, 80 MG
TABLET, 120 MG TABLET, 120 MG TABLET ER, 240 MG
TABLET ER, 180 MG CAP24H PEL, 360 MG CAP24H
PEL, 100 MG CAP24H PCT)
generic
LIMITS & RESTRICTIONS
CARDIOVASCULAR AGENTS, OTHER
alprostadil 500 mcg/ml vial
generic
amiloride/hydrochlorothiazide 5 mg-50 mg tablet
generic
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM (10
MG-80MG, 10 MG-20MG, 2.5MG-20MG, 5 MG-20 MG,
2.5MG-40MG, 2.5MG-10MG, 5 MG-80 MG, 10 MG-40MG,
5 MG-40 MG, 5 MG-10 MG, 10 MG-10MG)
generic
AMLODIPINE BESYLATE/BENAZEPRIL HCL (2.5MG10MG, 10 MG-40MG, 5 MG-40 MG, 10 MG-20MG, 5 MG10 MG, 5 MG-20 MG)
generic
AMLODIPINE BESYLATE/VALSARTAN (10MG-160MG,
5MG-320MG, 10MG-320MG)
generic
AMLODIPINE
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE (5160-25MG, 10MG-160MG, 5-160-12.5, 10-320-25, 10-16025)
generic
amlodipine/valsartan 5 mg-160mg tablet
generic
ATENOLOL/CHLORTHALIDONE (50 MG-25MG, 100MG25MG)
generic
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE (20-12.5
MG, 10-12.5MG, 20-25MG, 5-6.25MG)
generic
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE
(10-6.25MG, 2.5-6.25MG, 5-6.25MG)
generic
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE
(16-12.5MG, 32-12.5MG, 32MG-25MG)
generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE (25 MG-25MG,
25 MG-15MG, 50 MG-15MG, 50 MG-25MG)
generic
PAGE 58
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
cardioplegic solution no.1 k+=16meq/l plst bg pf
generic
CLORPRES (0.1-15, 0.2-15)
clonidine hcl/chlorthalidone
BRAND
CORLANOR (5 MG, 7.5 MG)
ivabradine hcl
BRAND
DEMSER 250 MG CAPSULE
metyrosine
BRAND
DIGITEK 250 MCG TABLET
digoxin
BRAND
DIGOX (250 MCG, 125 MCG)
digoxin
BRAND
DIGOXIN (250 MCG/ML AMPUL, 125 MCG TABLET, 50
MCG/ML SOLUTION, 250 MCG TABLET, 250 MCG/ML
SYRINGE)
generic
DOBUTAMINE HCL (500MG/40ML, 250MG/20ML)
generic
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER
(500MG/250, 250MG/250, 500 MG/500, 1000MG/250)
generic
DOPAMINE HCL (200 MG/5ML, 400 MG/5ML,
800MG/10ML, 400MG/10ML, 800MG/5ML)
generic
DOPAMINE HCL/DEXTROSE 5 % IN WATER
(400MG/0.5L, 200MG/.25L, 800MG/0.5L, 400MG/.25L,
800MG/.25L)
generic
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE
(5MG-12.5MG, 10 MG-25MG)
generic
ephedrine sulfate 50 mg/ml vial
generic
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE (2012.5 MG, 10-12.5MG)
generic
IRBESARTAN/HYDROCHLOROTHIAZIDE (300-12.5MG,
150-12.5MG)
generic
LISINOPRIL/HYDROCHLOROTHIAZIDE (20-12.5 MG, 1012.5MG, 20-25MG)
generic
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
(50-12.5 MG, 100-12.5MG, 100MG-25MG)
generic
MANNITOL (25 VIAL, 20 IV SOLN, 5 IV SOLN, 10 IV
SOLN)
generic
METHYLDOPA/HYDROCHLOROTHIAZIDE (250MG25MG, 250MG-15MG)
generic
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE
(50 MG-25MG, 100MG-50MG, 100MG-25MG)
generic
milrinone lactate 1 mg/ml vial
generic
PAGE 59
LIMITS & RESTRICTIONS
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
MILRINONE LACTATE/DEXTROSE 5 % IN WATER
(40MG/200ML, 20MG/100ML)
generic
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE (15-25MG,
15-12.5MG, 7.5-12.5MG)
generic
NADOLOL/BENDROFLUMETHIAZIDE (40 MG, 80 MG)
generic
NOREPINEPHRINE BITARTRATE (1 MG/ML AMPUL, 1
MG/ML VIAL)
generic
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUM
CHLORIDE (8 MG/250ML, 4MG/250ML)
generic
NORTHERA (200 MG, 300 MG, 100 MG)
droxidopa
BRAND
OSMITROL (20%, 15%)
mannitol
BRAND
pentoxifylline 400 mg tablet er
generic
phenylephrine hcl 10 mg/ml vial
generic
PHENYLEPHRINE HCL IN 0.9 % SODIUM CHLORIDE/PF
(1 MG/10 ML SYRINGE, 80MG/250ML PLAST. BAG)
generic
phenylephrine hcl in 0.9% nacl 1 mg/10 ml syringe
generic
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE (80,
40)
generic
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE (1012.5MG, 20-12.5 MG, 20-25MG)
generic
spironolact/hydrochlorothiazid 25 mg-25mg tablet
generic
TELMISARTAN/AMLODIPINE BESYLATE (80 MG-10MG,
40 MG-10MG, 80 MG-5 MG, 40 MG-5 MG)
generic
TELMISARTAN/HYDROCHLOROTHIAZIDE (40-12.5 MG,
80-12.5MG, 80 MG-25MG)
generic
TRANDOLAPRIL/VERAPAMIL HCL (1-240MG, 4-240MG,
2-240MG, 2 MG-180MG)
generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE (50 MG25MG CAPSULE, 37.5-25 MG CAPSULE, 75 MG-50MG
TABLET, 37.5-25 MG TABLET)
generic
VALSARTAN/HYDROCHLOROTHIAZIDE (160-12.5MG,
160-25MG, 320MG-25MG, 80-12.5MG, 320-12.5MG)
generic
LIMITS & RESTRICTIONS
QL
PA
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE (125 MG TABLET, 500 MG CAPSULE
ER, 250 MG TABLET)
generic
acetazolamide sodium 500 mg vial
generic
PAGE 60
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
DIURETICS, LOOP
BUMETANIDE (1 MG TABLET, 0.5 MG TABLET, 2 MG
TABLET, 0.25 MG/ML VIAL)
generic
ethacrynate sodium 50 mg vial
generic
FUROSEMIDE (80 MG TABLET, 20 MG TABLET, 10
MG/ML SYRINGE, 40 MG TABLET, 10 MG/ML
SOLUTION, 40MG/5ML SOLUTION, 10 MG/ML VIAL)
generic
TORSEMIDE (5 MG TABLET, 20 MG/2 ML VIAL, 10 MG
TABLET, 20 MG TABLET, 100 MG TABLET)
generic
DIURETICS, POTASSIUM-SPARING
amiloride hcl 5 mg tablet
generic
EPLERENONE (25 MG, 50 MG)
generic
SPIRONOLACTONE (50 MG, 100 MG, 25 MG)
generic
DIURETICS, THIAZIDE
CHLOROTHIAZIDE (250 MG, 500 MG)
generic
chlorothiazide sodium 500 mg vial
generic
CHLORTHALIDONE (25 MG, 50 MG)
generic
HYDROCHLOROTHIAZIDE (12.5 MG CAPSULE, 50 MG
TABLET, 12.5 MG TABLET, 25 MG TABLET)
generic
INDAPAMIDE (2.5 MG, 1.25 MG)
generic
methyclothiazide 5 mg tablet
generic
METOLAZONE (10 MG, 2.5 MG, 5 MG)
generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
FENOFIBRATE (50 MG CAPSULE, 40 MG TABLET, 54
MG TABLET, 160 MG TABLET, 150 MG CAPSULE, 120
MG TABLET)
generic
FENOFIBRATE NANOCRYSTALLIZED (145MG, 48 MG)
generic
FENOFIBRATE,MICRONIZED (43 MG, 130 MG, 67 MG,
134MG, 200 MG)
generic
FENOFIBRIC ACID (35 MG, 105 MG)
generic
FENOFIBRIC ACID (CHOLINE) (45 MG, 135 MG)
generic
gemfibrozil 600 mg tablet
generic
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ATORVASTATIN CALCIUM (20 MG, 40 MG, 80 MG, 10
MG)
PAGE 61
generic
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
FLUVASTATIN SODIUM (40 MG CAPSULE, 80 MG TAB
ER 24H, 20 MG CAPSULE)
generic
LOVASTATIN (10 MG, 40 MG, 20 MG)
generic
PRAVASTATIN SODIUM (20 MG, 80 MG, 40 MG, 10 MG)
generic
SIMVASTATIN (20 MG, 40 MG, 5 MG, 80 MG, 10 MG)
generic
LIMITS & RESTRICTIONS
DYSLIPIDEMICS, OTHER
CHOLESTYRAMINE (WITH SUGAR) (SUAR) 4 POWDER,
SUAR) 4 POWD PACK)
generic
CHOLESTYRAMINE/ASPARTAME (4 POWD PACK, 4
POWDER)
generic
COLESTIPOL HCL (5 PACKET, 1 TABLET, 5 RANULES)
generic
JUXTAPID (60 MG, 40 MG, 30 MG, 5 MG, 20 MG, 10 MG)
lomitapide mesylate
BRAND
NIACIN (1000 MG ER, 750 MG ER, 500 MG ER)
generic
omega-3 acid ethyl esters 1 g capsule
generic
PREVALITE (PACKET, POWDER)
cholestyramine/aspartame
BRAND
VASCEPA 1 GM CAPSULE
icosapent ethyl
BRAND
ZETIA 10 MG TABLET
ezetimibe
BRAND
PA
S
Specialty Drug
PA
VASODILATORS, DIRECT-ACTING ARTERIAL
CORLOPAM 10 MG/ML VIAL
fenoldopam mesylate
BRAND
HYDRALAZINE HCL (50 MG TABLET, 10 MG TABLET, 25
MG TABLET, 20 MG/ML VIAL, 100 MG TABLET)
generic
MINOXIDIL (10 MG, 2.5 MG)
generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
amyl nitrite 0.3 ml ampul
generic
ISOSORBIDE DINITRATE (40 MG ER, 5 MG, 10 MG, 20
MG, 30 MG)
generic
ISOSORBIDE MONONITRATE (10 MG TABLET, 60 MG
TAB ER 24H, 30 MG TAB ER 24H, 20 MG TABLET, 120
MG TAB ER 24H)
generic
NITRO-BID 2% OINTMENT
nitroglycerin
BRAND
NITRO-TIME (ER 9 MG, ER 6.5 MG, ER 2.5 MG)
BRAND
PAGE 62
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
nitroglycerin
NITROGLYCERIN (2.5 MG CAPSULE ER, 0.2MG/HR
PATCH TD24, 0.6MG/HR PATCH TD24, 400MCG/SPR
SPRAY, 50 MG/10ML VIAL, 9 MG CAPSULE ER,
0.4MG/HR PATCH TD24, 6.5 MG CAPSULE ER,
0.1MG/HR PATCH TD24)
generic
NITROGLYCERIN/DEXTROSE 5 % IN WATER
(50MG/500ML, 100MG/250, 200MG/500, 25MG/250ML,
50MG/250ML)
generic
NITROSTAT (0.4 MG, 0.6 MG, 0.3 MG)
nitroglycerin
BRAND
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
DEXEDRINE 10 MG TABLET
dextroamphetamine sulfate
BRAND
DEXTROAMPHETAMINE SULFSACCHARATE/AMPHETAMINE SULF-ASPARTATE (30
MG TABLET, 20 MG TABLET, 10 MG TABLET, 30 MG
CAP ER 24H, 7.5 MG TABLET, 12.5 MG TABLET, 15 MG
TABLET, 10 MG CAP ER 24H, 20 MG CAP ER 24H, 15
MG CAP ER 24H, 5 MG CAP ER 24H, 25 MG CAP ER
24H, 5 MG TABLET)
generic
DEXTROAMPHETAMINE SULFATE (15 MG CAPSULE
ER, 5 MG/5 ML SOLUTION, 5 MG TABLET, 5 MG
CAPSULE ER, 10 MG TABLET, 10 MG CAPSULE ER)
generic
methamphetamine hcl 5 mg tablet
generic
PROCENTRA 5 MG/5 ML SOLUTION
dextroamphetamine sulfate
BRAND
VYVANSE (60 MG, 20 MG, 50 MG, 30 MG, 10 MG, 70
MG, 40 MG)
lisdexamfetamine dimesylate
BRAND
PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
clonidine hcl 0.1 mg tab er 12h
generic
DEXMETHYLPHENIDATE HCL (30 MG CPBP 50-50, 5
MG TABLET, 20 MG CPBP 50-50, 15 MG CPBP 50-50, 10
MG CPBP 50-50, 40 MG CPBP 50-50, 5 MG CPBP 50-50,
10 MG TABLET, 2.5 MG TABLET)
generic
GUANFACINE HCL (1 MG ER, 3 MG ER, 4 MG ER, 2 MG
ER)
generic
METADATE ER 20 MG TABLET
methylphenidate hcl
BRAND
PAGE 63
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
METHYLPHENIDATE HCL (54 MG TAB ER 24, 10 MG
TABLET, 10 MG TABLET ER, 27 MG TAB ER 24, 20 MG
CPBP 30-70, 50 MG CPBP 30-70, 5 MG TABLET, 30 MG
CPBP 50-50, 10 MG/5 ML SOLUTION, 5 MG/5 ML
SOLUTION, 10 MG CPBP 30-70, 5 MG TAB CHEW, 40
MG CPBP 50-50, 20 MG TABLET, 20 MG CPBP 50-50,
2.5 MG TAB CHEW, 18 MG TAB ER 24, 40 MG CPBP 3070, 10 MG TAB CHEW, 36 MG TAB ER 24, 60 MG CPBP
30-70, 20 MG TABLET ER, 30 MG CPBP 30-70)
generic
STRATTERA (100 MG, 25 MG, 40 MG, 18 MG, 80 MG, 60
MG, 10 MG)
atomoxetine hcl
BRAND
LIMITS & RESTRICTIONS
CENTRAL NERVOUS SYSTEM, OTHER
ALAGESIC LQ ORAL SOLUTION
butalbital/acetaminophen/caffeine
BRAND
atracurium besylate 10 mg/ml vial
generic
benzphetamine hcl 50 mg tablet
generic
butalbital/acetaminophen 50mg-325mg tablet
generic
BUTALBITAL/ACETAMINOPHEN/CAFFEINE (50-300-40
CAPSULE, 50-325-40 TABLET, 50-325-40 CAPSULE)
generic
QL
butalbital/aspirin/caffeine 50-325-40 capsule
generic
QL
CAPACET CAPSULE
butalbital/acetaminophen/caffeine
BRAND
QL
DIETHYLPROPION HCL (75 MG ER, 25 MG)
generic
PA
ESGIC CAPSULE
butalbital/acetaminophen/caffeine
BRAND
QL
MARGESIC CAPSULE
butalbital/acetaminophen/caffeine
BRAND
QL
MARTEN-TAB 325-50 TABLET
butalbital/acetaminophen
BRAND
metformin hcl 1000 mg tab er 24
generic
NUEDEXTA 20-10 MG CAPSULE
dextromethorphan hbr/quinidine sulfate
BRAND
pancuronium bromide 1 mg/ml vial
generic
PHENDIMETRAZINE TARTRATE (35 MG TABLET, 105
MG CAPSULE ER)
generic
PA
PHENTERMINE HCL (30 MG CAPSULE, 37.5 MG
CAPSULE, 15 MG CAPSULE, 37.5 MG TABLET)
generic
PA
riluzole 50 mg tablet
generic
PAGE 64
QL
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ROCURONIUM BROMIDE (10 MG/ML VIAL,
100MG/10ML SYRINGE, 50 MG/5 ML SYRINGE)
generic
succinylcholine chloride 200mg/10ml syringe
generic
TENCON 50-325 MG TABLET
butalbital/acetaminophen
BRAND
TETRABENAZINE (12.5 MG, 25 MG)
generic
VECURONIUM BROMIDE (20 MG, 10 MG)
generic
XENAZINE (25 MG, 12.5 MG)
tetrabenazine
BRAND
S
ZEBUTAL 50-325-40 MG CAPSULE
butalbital/acetaminophen/caffeine
BRAND
QL
LIMITS & RESTRICTIONS
Specialty Drug
FIBROMYALGIA AGENTS
PA
DULOXETINE HCL (30 MG, 20 MG)
generic
ST
C
PA depends on
indicaton. 60mg max
daily
PA
duloxetine hcl 60 mg capsule dr
generic
ST
C
LYRICA (50 MG CAPSULE, 100 MG CAPSULE, 300 MG
CAPSULE, 225 MG CAPSULE, 150 MG CAPSULE, 200
MG CAPSULE, 20 MG/ML ORAL SOLUTION, 75 MG
CAPSULE, 25 MG CAPSULE)
pregabalin
BRAND
PA
SAVELLA (50 MG TABLET, 100 MG TABLET, TITRATION
PACK, 25 MG TABLET, 12.5 MG TABLET)
milnacipran hcl
BRAND
PA
2/ day .
MULTIPLE SCLEROSIS AGENTS
PA
AMPYRA ER 10 MG TABLET
dalfampridine
BRAND
AVONEX (30 MCG KT, 30 MCG)
interferon beta-1a
BRAND
AVONEX ADMIN PACK 30 MCG VL
interferon beta-1a/albumin human
BRAND
AVONEX PEN (30 ML, 30 ML KIT)
interferon beta-1a
BRAND
PAGE 65
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
COPAXONE (20 MG/ML, 40 MG/ML)
glatiramer acetate
BRAND
EXTAVIA 0.3 MG KIT
interferon beta-1b
BRAND
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
PA
S
Specialty Drug
QL
GILENYA 0.5 MG CAPSULE
fingolimod hcl
BRAND
PA
S
Specialty Drug
PA
GLATOPA 20 MG/ML SYRINGE
glatiramer acetate
BRAND
REBIF (TITRATION PACK, 44 MCG/0.5 ML SYRINGE)
interferon beta-1a/albumin human
BRAND
REBIF 22 MCG/0.5 ML SYRINGE
interferon beta-1a/albumin human
S
Specialty Drug
PA
S
Specialty Drug
BRAND
S
Specialty Drug
REBIF REBIDOSE (44 ML, 22 ML)
interferon beta-1a/albumin human
BRAND
S
Specialty Drug
REBIF REBIDOSE TITRATION PACK
interferon beta-1a/albumin human
BRAND
TECFIDERA (DR 240 MG CAPSULE, STARTER PACK,
DR 120 MG CAPSULE)
dimethyl fumarate
BRAND
PA
S
Specialty Drug
PA
S
Specialty Drug
DENTAL AND ORAL AGENTS
cevimeline hcl 30 mg capsule
generic
chlorhexidine gluconate 0.12 % mouthwash
generic
DEBACTEROL SOLUTION
sulfuric acid/sulfonated phenol
BRAND
FIRST-MOUTHWASH BLM SUSPENSION
mag hydroxide/al
hydroxide/simeth/diphenhydramine/lidocaine
BRAND
KEPIVANCE 6.25 MG VIAL
palifermin
BRAND
lidocaine hcl 4 % solution
generic
PAROEX 0.12% ORAL RINSE
chlorhexidine gluconate
BRAND
PERIOGARD 0.12% ORAL RINSE
chlorhexidine gluconate
BRAND
PAGE 66
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
PILOCARPINE HCL (7.5 MG, 5 MG)
generic
PRE-ATTACHED LTA KIT
lidocaine hcl
BRAND
LIMITS & RESTRICTIONS
DERMATOLOGICAL AGENTS
8-MOP 10 MG CAPSULE
methoxsalen
BRAND
ABSORICA (30 MG, 20 MG, 10 MG, 40 MG)
isotretinoin
BRAND
ACITRETIN (17.5 MG, 10 MG, 25 MG)
generic
ADAPALENE (0.1 (GRAM), 0.3 W/PUMP)
generic
QL
C
45gm/30 days
ADAPALENE (0.3 GEL (GRAM), 0.1 CREAM (G))
generic
C
45gm/30 days
adapalene 0.1 % lotion
generic
C
59gm/30 days
ALCLOMETASONE DIPROPIONATE (0.05 OINT., 0.05
CREAM)
generic
ALPHAQUIN HP 4% CREAM
oxybenzone/octinoxate/hydroquinone
BRAND
AMCINONIDE (0.1 CREAM (G), 0.1 LOTION, 0.1 OINT.
(G))
generic
ammonium lactate 12 % cream (g)
generic
AMNESTEEM (10 MG, 20 MG, 40 MG)
isotretinoin
BRAND
APEXICON 0.05% OINTMENT
diflorasone diacetate
BRAND
APEXICON E 0.05% CREAM
diflorasone diacetate/emollient base
BRAND
AVAR CLEANSER
sulfacetamide sodium/sulfur
BRAND
AVITA 0.025% CREAM
tretinoin
BRAND
C
20gm/30 days
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY
WASH)
benzoyl peroxide microspheres
BRAND
BENZOYL PEROXIDE (5 % GEL (GRAM), 7 %
CLEANSER, 5 % GEL ALCOHL, 9.8 % FOAM, 5.3%
FOAM)
generic
BETAMETHASONE DIPROPIONATE (0.05 LOTION, 0.05
GEL (GRAM), 0.05 CREAM (G), 0.05 OINT. (G))
generic
PAGE 67
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL (0.05 CREAM (G), 0.05 OINT. (G), 0.05 LOTION)
generic
BETAMETHASONE VALERATE (0.1 CREAM (G), 0.1
LOTION, 0.12 FOAM, 0.1 OINT. (G))
generic
BP 10-1 WASH
sulfacetamide sodium/sulfur
BRAND
BP CLEANSING WASH
sulfacetamide sodium/sulfur/urea
BRAND
BP-50% UREA EMULSION
urea/lactic acid/zinc undecylenate
BRAND
BPO (8% GEL, 4% GEL, 3% FOAMING CLOTHS, 9%
FOAMING CLOTHS, 6% FOAMING CLOTHS)
benzoyl peroxide
BRAND
CALCIPOTRIENE (0.005 CREAM (G), 0.005 OINT. (G),
0.005 SOLUTION)
generic
calcipotriene/betamethasone 0.005-.064 oint. (g)
generic
CALCITRENE 0.005% OINTMENT
calcipotriene
BRAND
calcitriol 3 mcg/g oint. (g)
generic
CARB-O-PHILIC (GEL, CREAM)
urea
BRAND
CEM-UREA 45% PRE-FILLED APPL
urea
BRAND
CLARAVIS (40 MG, 30 MG, 20 MG, 10 MG)
isotretinoin
BRAND
CLARIS CLARIFYING WASH
sulfacetamide sodium/sulfur/urea
BRAND
CLINDACIN ETZ 1% PLEDGET
clindamycin phosphate
BRAND
CLINDACIN P 1% PLEDGETS
clindamycin phosphate
BRAND
CLINDAMYCIN PHOSPHATE (1 FOAM, 1 LOTION, 1
MED. SWAB, 1 GEL (GRAM), 1 SOLUTION)
generic
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE (1
%-5 %, 1.2(1)%-5%)
generic
CLOBETASOL PROPIONATE (0.05 SOLUTION, 0.05
LOTION, 0.05 SHAMPOO, 0.05 SPRAY, 0.05 CREAM (G),
0.05 FOAM, 0.05 OINT. (G), 0.05 GEL (GRAM))
generic
CLOBETASOL PROPIONATE/EMOLLIENT BASE (0.05
FOAM, 0.05 CREAM (G))
generic
PAGE 68
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CLODAN 0.05% SHAMPOO
clobetasol propionate
BRAND
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE (1
-0.05 LOTION, 1 -0.05 CREAM (G))
generic
cocaine hcl 4 % solution
generic
CORMAX 0.05% SOLUTION
clobetasol propionate
BRAND
DERMAZENE CREAM
hydrocortisone/iodoquinol
BRAND
DESONIDE (0.05 LOTION, 0.05 CREAM (G), 0.05 OINT.
(G))
generic
DESOXIMETASONE (0.05 CREAM (G), 0.25 OINT. (G),
0.25 CREAM (G), 0.05 GEL (GRAM), 0.05 OINT. (G))
generic
DICLOFENAC SODIUM (1.5 DROPS, 3 GEL (GRAM))
generic
DIFLORASONE DIACETATE (0.05 OINT., 0.05 CREAM)
generic
DRITHOCREME HP 1% CREAM
anthralin
BRAND
DRYSOL (DAB-O-MATIC, )
aluminum chloride
BRAND
ERY 2% PADS
erythromycin base/ethyl alcohol
BRAND
ERYGEL 2% GEL
erythromycin base/ethyl alcohol
BRAND
ERYTHROMYCIN BASE/ETHYL ALCOHOL (2 MED.
SWAB, 2 SOLUTION, 2 GEL (GRAM))
generic
erythromycin/benzoyl peroxide 3 %-5 % gel (gram)
generic
ethyl chloride 100 % spray
generic
FLUOCINOLONE ACETONIDE (0.025 OINT. (G), 0.01
CREAM (G), 0.025 CREAM (G), 0.01 OIL, 0.01
SOLUTION)
generic
fluocinolone/shower cap 0.01 % oil
generic
FLUOCINONIDE (0.05 GEL (GRAM), 0.05 SOLUTION, 0.1
CREAM (G), 0.05 CREAM (G), 0.05 OINT. (G))
generic
fluocinonide/emollient base 0.05 % cream (g)
generic
FLUTICASONE PROPIONATE (0.005 OINT. (G), 0.05
LOTION, 0.05 CREAM (G))
generic
FORMA-RAY 20% SOLUTION
formaldehyde
BRAND
GENTAMICIN SULFATE (0.1 OINT., 0.1 CREAM)
generic
PAGE 69
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
GLYDO 2% JELLY SYRINGE
lidocaine hcl
BRAND
HALOBETASOL PROPIONATE (0.05 OINT., 0.05
CREAM)
generic
HALONATE COMBO PACK
halobetasol propionate/ammonium lactate
BRAND
HALONATE PAC COMBO PACK
halobetasol propionate/ammonium lactate
BRAND
hc/mineral oil/petrolat,wht 1 % oint. (g)
generic
HYDROCORTISONE (2.5 LOTION, 2.5 CREAM (G), 1
CREAM (G), 2.5 OINT. (G))
generic
hydrocortisone acetate/aloe v 2 % gel (gram)
generic
HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOE
VERA (2 %-2 % KIT, 0.55%-2.8% GEL W/APPL, 2.53%(7G) KIT)
generic
HYDROCORTISONE ACETATE/PRAMOXINE HCL (1 %-1
% CREAM/APPL, 2.5 %-1 % CREAM/APPL, 2.5 %-1 %
CREAM (G), 2.5-1%(4G) CREAM/APPL)
generic
HYDROCORTISONE
ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE
COMB#1 (2.5%-1%-1%, 2.5-1%(4G))
generic
HYDROCORTISONE BUTYRATE (0.1 OINT. (G), 0.1
SOLUTION, 0.1 CREAM (G))
generic
hydrocortisone butyrate/emoll 0.1 % cream (g)
generic
HYDROCORTISONE VALERATE (0.2 CREAM, 0.2 OINT.)
generic
hydrocortisone/iodoquinol 1 %-1 % cream (g)
generic
hydroquinone 4 % cream (g)
generic
hydroquinone microspheres 4 % crm er (g)
generic
HYPERCARE 20% SOLUTION
aluminum chloride
BRAND
imiquimod 5 % cream pack
generic
LACLOTION 12% LOTION
ammonium lactate
BRAND
LATRIX 50% TOPICAL SUSPENSION
urea/lactic acid/salicylic acid
BRAND
LATRIX XM 45% EMULSION
urea/lactic acid/zinc undecylenate
BRAND
lidocaine 5 % adh. patch
generic
lidocaine 5 % oint. (g)
generic
PAGE 70
LIMITS & RESTRICTIONS
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIDOCAINE HCL (3 CREAM (G), 2 JEL/PF APP, 3
LOTION, 2 JEL (ML))
generic
LIDOCAINE HCL/HYDROCORTISONE ACETATE (3 %0.5 % KIT, 3%-1%(7 G) KIT, 3 %-0.5 % CREAM (G), 3 %0.5 % CREAM/APPL)
generic
LIDOCAINE/PRILOCAINE (2.5 CREAM (G), 2.5 KIT)
generic
LIMITS & RESTRICTIONS
ST
LINDANE (1 LOTION, 1 SHAMPOO)
generic
C
LORENZA 4%-1% PATCH
lidocaine/menthol
BRAND
LUSTRA-ULTRA 4% CREAM
vitamin a/vitamin e/avobenzone/octinoxate/hydroquinone
BRAND
mafenide acetate 50 g packet
generic
MELPAQUE HP 4% CREAM
hydroquinone/ferric oxide
BRAND
MELQUIN HP 4% CREAM
hydroquinone
BRAND
MELQUIN-3 SOLUTION
hydroquinone
BRAND
METRONIDAZOLE (0.75 GEL (GRAM), 0.75 CREAM (G),
1 GEL W/PUMP, 0.75 LOTION, 1 GEL (GRAM))
generic
MOMETASONE FUROATE (0.1 CREAM (G), 0.1 OINT.
(G), 0.1 SOLUTION)
generic
mupirocin 2 % oint. (g)
generic
mupirocin calcium 2 % cream (g)
generic
MYORISAN (10 MG, 30 MG, 20 MG, 40 MG)
isotretinoin
BRAND
NEUAC GEL
clindamycin phosphate/benzoyl peroxide
BRAND
NU-DERM (BLENDER, CLEAR)
hydroquinone
BRAND
NUQUIN HP (GEL, CREAM)
dioxybenzone/padimate o/hydroquinone
BRAND
OBAGI ELASTIDERM SKIN 4% CREAM
hydroquinone
BRAND
OXSORALEN-ULTRA 10 MG CAP
methoxsalen, rapid
BRAND
PAGE 71
60ml/fill; must try
permethrin and
piperonyl
butoxide/
pyrethrins
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
PAIN RELIEF 5%-1% PATCH
lidocaine hcl/menthol
BRAND
permethrin 5 % cream (g)
generic
podofilox 0.5 % solution
generic
PR BENZOYL PEROXIDE 7% WASH
benzoyl peroxide microspheres
BRAND
PR CREAM KIT
protectives combination no.2/ceramides 1,3,6-11
BRAND
PRAMCORT 1% CREAM
hydrocortisone acetate/pramoxine hcl
BRAND
PREDNICARBATE (0.1 CREAM, 0.1 OINT.)
generic
REA LO 39 CREAM
urea
BRAND
REA LO 40 (40 CM, 40 TION)
urea
BRAND
RECTIV 0.4% OINTMENT
nitroglycerin
BRAND
REGRANEX 0.01% GEL
becaplermin
BRAND
RELADOR PAK 2.5-2.5% CRM-DRESS
lidocaine/prilocaine
BRAND
RELADOR PAK PLUS 2.5%-2.5%
lidocaine/prilocaine
BRAND
REMEVEN 50% CREAM
urea
BRAND
ROSADAN (GEL, CREAM)
metronidazole
BRAND
ROSULA 10%-5% CLOTHS
sulfacetamide sodium/sulfur
BRAND
SALACYN (CREAM, LOTION)
salicylic acid
BRAND
SALICYLIC ACID (6 CREAM (G), 28.5 LIQ-FILM, 6 GEL
(GRAM), 6 SHAMPOO, 27.5 LIQ-FILM, 6 CRM ER (G), 26
LIQUID, 6 LOTION ER, 6 LOTION)
generic
salicylic acid/ammon lact/aloe 6 % foam
generic
SALICYLIC ACID/CERAMIDES 1,3,6-11 (6 KIT CLCMER,
6 COMBO. PKG)
generic
SALVAX 6% FOAM
salicylic acid
BRAND
PAGE 72
LIMITS & RESTRICTIONS
C
120ml/fill
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
SANTYL OINTMENT
collagenase clostridium histolyticum
BRAND
SCALACORT 2% LOTION
hydrocortisone
BRAND
SE 10-5 SS CREAM
sulfacetamide sodium/sulfur/witch hazel
BRAND
SE BPO 7% WASH
benzoyl peroxide microspheres
BRAND
SEB-PREV 10% WASH
sulfacetamide sodium
BRAND
SELENIUM SULFIDE (2.5 SUSPENSION, 2.5 LOTION,
2.25 SHAMPOO)
generic
SILVER NITRATE (50 SOLUTION, 10 OINT. (G), 10
SOLUTION, 0.5 SOLUTION, 25 SOLUTION)
generic
silver nitrate applicator 75%-25% stick (ea)
generic
silver sulfadiazine 1 % cream (g)
generic
LIMITS & RESTRICTIONS
ST
spinosad 0.9 % suspension
generic
C
SS 10-2 CLEANSER
sulfacetamide sodium/sulfur
BRAND
SSD 1% CREAM
silver sulfadiazine
BRAND
SSS 10-5 (FOAM, CREAM)
sulfacetamide sodium/sulfur
BRAND
sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser
generic
SULFACETAMIDE SODIUM (10 SUSPENSION, 10
CLNSGEL ER, 10 SHAMPOO, 10 CLEANSER)
generic
SULFACETAMIDE SODIUM/SULFUR (10 %-4 % MED.
PAD, 8 %-4 % SUSPENSION, 10 %-5 % MED. PAD,
9.8%-4.8% CLEANSER, 9 %-4.5 % CLEANSER, 105%(W/W) LOTION, 10-5%(W/V) LOTION, 10-5%(W/W)
CREAM (G), 10-5%(W/W) CLEANSER, 10-5%(W/W)
SUSPENSION, 9 %-4 % CLEANSER, 10 %-2 %
CLEANSER, 10 %-5 % FOAM)
generic
sulfacetamide/sulfur/cleansr23 9 %-4.5 % kit
generic
SULFACLEANSE 8-4 SUSPENSION
sulfacetamide sodium/sulfur
BRAND
TACROLIMUS (0.1, 0.03)
generic
PAGE 73
1420ml/fill; must try
permethrin and
piperonyl butoxide/
pyrethrins and
malathion
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
PA
TAZORAC (0.05% CREAM, 0.1% GEL, 0.05% GEL, 0.1%
CREAM)
tazarotene
BRAND
THERMAZENE 1% CREAM
silver sulfadiazine
BRAND
TRETINOIN (0.025 GEL (GRAM), 0.05 GEL (GRAM),
0.025 CREAM (G), 0.01 GEL (GRAM))
generic
QL
TRETINOIN (0.05, 0.1)
generic
QL
TRETINOIN MICROSPHERES (0.1 (GRAM), 0.04
W/PUMP, 0.1 W/PUMP, 0.04 (GRAM))
generic
QL
TRI-CHLOR 80% SOLUTION
trichloroacetic acid
BRAND
TRIAMCINOLONE ACETONIDE (0.5 % OINT. (G), 0.1 %
LOTION, 0.025 % CREAM (G), 0.5 % CREAM (G), 0.1 %
OINT. (G), 0.1 % CREAM (G), 0.147MG/G AEROSOL,
0.025 % OINT. (G), 0.025 % LOTION)
generic
TRIANEX 0.05% OINTMENT
triamcinolone acetonide
BRAND
TRIDERM 0.1% CREAM
triamcinolone acetonide
BRAND
UMECTA 40% MOUSSE
urea
BRAND
UREA (35 FOAM, 45 LOTION, 45 GEL (ML), 45 CREAM
(G), 40 LOTION, 39 CREAM (G), 50 SOL/PF APP, 40 GEL
(ML), 40 CREAM (G), 40 NL FM SUSP, 50 CREAM (G))
generic
urea/hyaluronate sodium 40%-0.2% kit
generic
urea/lactic ac/zn undecylenate 50 % emulsn(g)
generic
urea/lactic acid/salicylic ac 50 % suspension
generic
VASHE WOUND THERAPY SOLUTION
sodium chloride irrigating solution/hypochlorous acid
BRAND
VASOLEX OINTMENT
trypsin/balsam peru/castor oil
BRAND
VIRTI-SULF EMOLLIENT CREAM
sulfacetamide sodium/sulfur
BRAND
X-VIATE (CREAM, LOTION, GEL)
urea
BRAND
ZENCIA WASH
sulfacetamide sodium/sulfur
BRAND
PAGE 74
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
ENZYME REPLACEMENT/MODIFIERS
ALDURAZYME 2.9 MG/5 ML VIAL
laronidase
BRAND
BUPHENYL 500 MG TABLET
sodium phenylbutyrate
BRAND
CREON (12,000, 36,000, 24,000, 6,000, 3,000)
lipase/protease/amylase
BRAND
CYSTADANE POWDER
betaine
BRAND
CYSTAGON (150 MG, 50 MG)
cysteamine bitartrate
BRAND
ELAPRASE 6 MG/3 ML VIAL
idursulfase
BRAND
ELELYSO 200 UNITS VIAL
taliglucerase alfa
BRAND
FABRAZYME (35 MG, 5 MG)
agalsidase beta
BRAND
KUVAN (100 MG TABLET, 100 MG POWDER PACKET,
500 MG POWDER PACKET)
sapropterin dihydrochloride
BRAND
LUMIZYME 50 MG VIAL
alglucosidase alfa
BRAND
MYOZYME 50 MG VIAL
alglucosidase alfa
BRAND
NAGLAZYME 5 MG/5 ML VIAL
galsulfase
BRAND
ORFADIN (5 MG, 2 MG, 10 MG)
nitisinone
BRAND
RAVICTI 1.1 GRAM/ML LIQUID
glycerol phenylbutyrate
BRAND
sodium phenylbutyrate 0.94 g/g powder
generic
STRENSIQ (18 MG/0.45 ML, 28 MG/0.7 ML, 80 MG/0.8
ML, 40 MG/ML)
asfotase alfa
BRAND
SUCRAID 8,500 UNITS/ML SOLN
sacrosidase
BRAND
VPRIV 400 UNITS VIAL
velaglucerase alfa
BRAND
ZAVESCA 100 MG CAPSULE
miglustat
BRAND
PAGE 75
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ANASPAZ 0.125 MG TABLET ODT
hyoscyamine sulfate
BRAND
ATROPINE SULFATE (1 MG/ML VIAL, 0.4 MG/ML VIAL,
0.1 MG/ML DISP SYRIN, 0.05MG/ML SYRINGE, 0.1
MG/ML SYRINGE)
generic
B-DONNA TABLET
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine
hb
BRAND
chlordiazepoxide/clidinium br 5 mg-2.5mg capsule
generic
DICYCLOMINE HCL (10 MG CAPSULE, 10 MG/5 ML
SOLUTION, 20 MG TABLET)
generic
ED-SPAZ 0.125 MG ODT
hyoscyamine sulfate
BRAND
GLYCOPYRROLATE (1 MG/5 ML SYRINGE, 0.2 MG/ML
VIAL, 0.6MG/3ML SYRINGE, 0.4MG/2ML SYRINGE, 1
MG TABLET, 2 MG TABLET)
generic
HYOSCYAMINE SULFATE (125MCG/5ML ELIXIR,
0.125MG/ML DROPS, 0.125 MG TABLET, 0.375 MG TAB
ER 12H, 0.125 MG TAB RAPDIS)
generic
HYOSYNE (125 MCG/5 ML ELIXIR, 0.125 MG/ML DROP)
hyoscyamine sulfate
BRAND
ME-PB-HYOS TABLET
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine
hb
BRAND
OSCIMIN (0.125 MG TABLET, 0.125 MG ODT)
hyoscyamine sulfate
BRAND
OSCIMIN SL 0.125 MG TABLET
hyoscyamine sulfate
BRAND
OSCIMIN SR 0.375 MG TABLET
hyoscyamine sulfate
BRAND
SYMAX FASTABS 0.125 MG TABLET
hyoscyamine sulfate
BRAND
SYMAX-SL 0.125 MG TABLET SL
hyoscyamine sulfate
BRAND
SYMAX-SR 0.375 MG TABLET
hyoscyamine sulfate
BRAND
GASTROINTESTINAL AGENTS, OTHER
PAGE 76
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CHENODAL 250 MG TABLET
chenodiol
BRAND
cromolyn sodium 20 mg/ml oral conc
generic
dexpanthenol 250 mg/ml vial
generic
DIPHENOXYLATE HCL/ATROPINE SULFATE (2.5.025MG TABLET, 2.5-.025/5 LIQUID)
generic
GASTROCROM 100 MG/5 ML CONC
cromolyn sodium
BRAND
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg
generic
opium tincture 10 mg/ml tincture
generic
paregoric 2 mg/5 ml liquid
generic
RELISTOR (12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL, 12
MG/0.6 ML SYRINGE, 8 MG/0.4 ML SYRINGE)
methylnaltrexone bromide
BRAND
URSODIOL (250 MG TABLET, 300 MG CAPSULE, 500
MG TABLET)
generic
VSL#3 DS PACKET
lactobacillus combination no.2/s.thermophl/bif cmb no.1
BRAND
LIMITS & RESTRICTIONS
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
CIMETIDINE (300 MG, 800 MG, 400 MG)
generic
cimetidine hcl 300 mg/5ml solution
generic
FAMOTIDINE (40MG/5ML ORAL SUSP, 10 MG/ML VIAL,
40 MG TABLET)
generic
famotidine/pf 20 mg/2 ml vial
generic
NIZATIDINE (150MG/10ML SOLUTION, 300 MG
CAPSULE, 150 MG CAPSULE)
generic
RANITIDINE HCL (25 MG/ML VIAL, 150 MG CAPSULE,
50 MG/2 ML VIAL, 300 MG TABLET, 300 MG CAPSULE,
150 MG TABLET, 15 MG/ML SYRUP)
generic
IRRITABLE BOWEL SYNDROME AGENTS
ALOSETRON HCL (0.5 MG, 1 MG)
generic
LINZESS (290 MCG, 145 MCG)
linaclotide
BRAND
LOTRONEX (1 MG, 0.5 MG)
alosetron hcl
BRAND
LAXATIVES
ENULOSE 10 GM/15 ML SOLUTION
lactulose
PAGE 77
BRAND
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
GAVILYTE-H AND BISACODYL KIT
bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg
3350
BRAND
GENERLAC 10 GM/15 ML SOLUTION
lactulose
BRAND
POLYETHYLENE GLYCOL 3350 (3350 17G POWD
PACK, 3350 17G/DOSE POWDER)
generic
LIMITS & RESTRICTIONS
PROTECTANTS
CARAFATE 1 GM/10 ML SUSP
sucralfate
BRAND
MISOPROSTOL (200 MCG, 100 MCG)
generic
sucralfate 1 g tablet
generic
PROTON PUMP INHIBITORS
esomeprazole magnesium 20 mg capsule dr
generic
esomeprazole magnesium 40 mg capsule dr
generic
ESOMEPRAZOLE SODIUM (20 MG, 40 MG)
generic
esomeprazole strontium 49.3 mg capsule dr
generic
C
must try 3 wks of
therapy within the last
12 mos of omeprazole,
omeprazole OTC or
pantoprazole
ST
FIRST-LANSOPRAZOLE 3 MG/ML
lansoprazole
BRAND
C
no STEP required if
<12 yrs old; must try 3
weeks of therapy within
last 12 months of
omeprazole,
omeprazole OTC or
pantoprazole
ST
FIRST-OMEPRAZOLE 2 MG/ML SUSP
omeprazole
BRAND
lansoprazole 15 mg capsule dr
generic
C
no PA required if <12
yrs old; must try 3
weeks of therapy within
last 12 months of
omeprazole,
omeprazole OTC or
pantoprazole
PA
ST
ST
lansoprazole 30 mg capsule dr
generic
C
PAGE 78
must try 3 weeks of
therapy within
the last 12
months of
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
omeprazole,
omeprazole OTC or
pantoprazole
OMEPRAZOLE (10 MG, 40 MG, 20 MG)
generic
PA
ST
OMEPRAZOLE/SODIUM BICARBONATE (20MG-1.1G,
40MG-1.1G)
generic
C
PANTOPRAZOLE SODIUM (20 MG TABLET DR, 40 MG
VIAL, 40 MG TABLET DR)
must try 3 weeks of
therapy within
the last 12
months of
omeprazole,
omeprazole OTC or
pantoprazole
generic
PA
ST
rabeprazole sodium 20 mg tablet dr
generic
C
must try 3 weeks of
therapy within
the last 12
months of
omeprazole,
omeprazole OTC or
pantoprazole
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl 100 mg tablet
generic
OXYBUTYNIN CHLORIDE (5 MG/5 ML SYRUP, 10 MG
TAB ER 24, 5 MG TABLET, 5 MG TAB ER 24, 15 MG TAB
ER 24)
generic
TOLTERODINE TARTRATE (4 MG CAP ER 24H, 1 MG
TABLET, 2 MG TABLET, 2 MG CAP ER 24H)
generic
TROSPIUM CHLORIDE (60 MG CAP ER 24H, 20 MG
TABLET)
generic
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 10 mg tab er 24h
generic
dutasteride 0.5 mg capsule
generic
dutasteride/tamsulosin hcl 0.5-0.4 mg cpmp 24hr
generic
finasteride 5 mg tablet
generic
tamsulosin hcl 0.4 mg cap er 24h
generic
TERAZOSIN HCL (5 MG, 10 MG, 1 MG, 2 MG)
generic
PAGE 79
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
GENITOURINARY AGENTS, OTHER
AMINOACETIC ACID 1.5% IRRIG
glycine urologic solution
BRAND
BETHANECHOL CHLORIDE (5 MG, 25 MG, 10 MG, 50
MG)
generic
citric acid/sodium citrate 334-500mg solution
generic
CUPRIMINE 250 MG CAPSULE
penicillamine
BRAND
CYTRA-2 ORAL SOLUTION
citric acid/sodium citrate
BRAND
CYTRA-3 SYRUP
sodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
CYTRA-K (ORAL SOLUTION, CRYSTALS PACKET)
potassium citrate/citric acid
BRAND
ELMIRON 100 MG CAPSULE
pentosan polysulfate sodium
BRAND
FEM PH VAGINAL JELLY
acetic acid/oxyquinoline sulfate
BRAND
glycine urologic solution 1.5 % irrig soln
generic
HEMABATE 250 MCG/ML AMPUL
carboprost tromethamine
BRAND
K-PHOS #2 TABLET
sodium phosphate,monobasic/potassium
phosphate,monobasic
BRAND
K-PHOS NEUTRAL TABLET
phosphorus #1
BRAND
PHENAZOPYRIDINE HCL (200 MG, 100 MG)
generic
PHOSPHA 250 NEUTRAL TABLET
phosphorus #1
BRAND
POTASSIUM CITRATE (15 ER, 10 ER, 5 ER)
generic
POTASSIUM CITRATE/CITRIC ACID (1100-334/5
SOLUTION, 3300-1002 PACKET)
generic
RENACIDIN IRRIGATION SOLN
citric acid/gluconolactone/magnesium carbonate
BRAND
sod/pot/k cit/sod cit/cit acid 500-550/5 solution
generic
sodium chloride irrig solution 0.9 % irrig soln
generic
TARON-CRYSTALS PACKET
potassium citrate/citric acid
BRAND
TRICITRATES ORAL SOLUTION
BRAND
PAGE 80
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
sodium/potassium/potassium citrate/sodium citrate/cit ac
VIRT-PHOS 250 NEUTRAL TABLET
phosphorus #1
BRAND
VIRTRATE-2 SOLUTION
citric acid/sodium citrate
BRAND
VIRTRATE-3 SOLUTION
sodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
VIRTRATE-K SOLUTION
potassium citrate/citric acid
BRAND
PHOSPHATE BINDERS
CALCIUM ACETATE (667 MG CAPSULE, 667 MG
TABLET)
generic
ELIPHOS 667 MG TABLET
calcium acetate
BRAND
RENVELA (800 MG TABLET, 0.8 GM POWDER PACKET,
2.4 GM POWDER PACKET)
sevelamer carbonate
BRAND
sevelamer carbonate 800 mg tablet
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
A-HYDROCORT 100 MG VIAL
hydrocortisone sod succinate
BRAND
A-METHAPRED 40 MG UNIVIAL
methylprednisolone sodium succinate
BRAND
betamet acet/betamet na ph 6 mg/ml vial
generic
cortisone acetate 25 mg tablet
generic
DELTASONE 20 MG TABLET
prednisone
BRAND
DEXAMETHASONE (6 MG TABLET, 0.5 MG TABLET, 2
MG TABLET, 0.75 MG TABLET, 4 MG TABLET, 1.5 MG
TABLET, 0.5 MG/5ML ELIXIR, 1 MG TABLET, 0.5
MG/5ML SOLUTION)
generic
DEXAMETHASONE INTENSOL 1MG/1ML
dexamethasone
BRAND
DEXAMETHASONE SOD PHOSPHATE (10 MG/ML VIAL,
4 MG/ML VIAL, 4 MG/ML SYRINGE)
generic
dexamethasone sod phosphate/pf 10 mg/ml vial
generic
fludrocortisone acetate 0.1 mg tablet
generic
GRX HICORT 25 MG SUPPOSITORY
hydrocortisone acetate
BRAND
PAGE 81
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
HEMMOREX-HC (25 MG, 30 MG)
hydrocortisone acetate
BRAND
HEMRIL-30 30 MG SUPPOSITORY
hydrocortisone acetate
BRAND
HYDROCORTISONE (5 MG, 10 MG, 20 MG)
generic
hydrocortisone acetate 25 mg supp.rect
generic
hydrocortisone acetate 30 mg supp.rect
generic
METHYLPREDNISOLONE (4 MG TABLET, 16 MG
TABLET, 8 MG TABLET, 4 MG TAB DS PK, 32 MG
TABLET)
generic
METHYLPREDNISOLONE ACETATE (80 MG/ML, 40
MG/ML)
generic
METHYLPREDNISOLONE SODIUM SUCCINATE (40 MG,
1000 MG, 125 MG)
generic
MILLIPRED DP (5 MG 6-DAY, 5 MG 12-DAY)
prednisolone
BRAND
prednisolone 15 mg/5 ml solution
generic
PREDNISOLONE SOD PHOSPHATE (5 MG/5 ML
SOLUTION, 10 MG TAB RAPDIS, 15 MG TAB RAPDIS,
15 MG/5 ML SOLUTION, 30 MG TAB RAPDIS, 25 MG/5
ML SOLUTION)
generic
PREDNISONE (2.5 MG TABLET, 5 MG TABLET, 1 MG
TABLET, 50 MG TABLET, 5 MG/5 ML SOLUTION, 20 MG
TABLET, 10 MG TABLET, 10 MG TAB DS PK, 5 MG TAB
DS PK)
generic
PREDNISONE 5 MG/ML SOLUTION
prednisone
BRAND
RECTACORT-HC 25 MG SUPPOSITORY
hydrocortisone acetate
BRAND
TRIAMCINOLONE ACETONIDE (10 MG/ML, 40 MG/ML)
generic
VERIPRED 20 20 MG/5 ML SOLN
prednisolone sod phosphate
BRAND
LIMITS & RESTRICTIONS
C
only non-DESI NDCs
are covered
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
chorionic gonadotropin, human 10000 unit vial
generic
cosyntropin 0.25 mg vial
generic
desmopressin (nonrefrigerated) 10/spray spray/pump
generic
DESMOPRESSIN ACETATE (4MCG/ML AMPUL, 0.1 MG
TABLET, 0.2 MG TABLET, 0.1 MG/ML SOLUTION,
4MCG/ML VIAL, 10/SPRAY SPRAY/PUMP)
generic
PAGE 82
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
GONAL-F RFF (900, 450, 300)
follitropin alfa, recomb
BRAND
GONAL-F RFF REDI-JECT (900, 300, 450)
follitropin alfa, recomb
BRAND
HP ACTHAR GEL 80 UNIT/ML VIAL
corticotropin
BRAND
INCRELEX 40 MG/4 ML VIAL
mecasermin
BRAND
NORDITROPIN (5 ML, 15 ML)
somatropin
BRAND
NORDITROPIN FLEXPRO (10 MG/1.5, 5 MG/1.5, 30
MG/3 ML, 15 MG/1.5)
somatropin
BRAND
NORDITROPIN NORDIFLEX (NORDIFLX 15 MG/1.5,
NORDIFLX 10 MG/1.5, NORDIFLEX 5 MG/1.5,
NORDIFLEX 30 MG/3)
somatropin
BRAND
NOVAREL 10,000 UNITS VIAL
chorionic gonadotropin, human
BRAND
STIMATE 1.5 MG/ML NASAL SPRAY
desmopressin acetate
BRAND
vasopressin 20 unit/ml vial
generic
LIMITS & RESTRICTIONS
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDROGEL (1%(5G) PACKET, 1% PUMP)
testosterone
BRAND
ANDROGEL (1.62%(1.25G) PCKT, 1.62% PUMP,
1.62%(2.5G) PCKT, 1%(2.5G) PACKET)
testosterone
BRAND
ANDROXY 10 MG TABLET
fluoxymesterone
BRAND
DANAZOL (200 MG, 50 MG, 100 MG)
generic
METHITEST 10 MG TABLET
methyltestosterone
BRAND
methyltestosterone 10 mg capsule
generic
OXANDROLONE (2.5 MG, 10 MG)
generic
TESTOPEL 75 MG PELLETS
BRAND
PAGE 83
QL
S
GL
Specialty Drug
Male
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
testosterone
TESTOSTERONE (1.25G (1%) MD PMP, 50 MG (1%)
PACKET, 25MG(1%) PACKET)
generic
QL
testosterone 10 mg (2%) gel md pmp
generic
PA
TESTOSTERONE CYPIONATE (100 MG/ML, 200 MG/ML)
generic
testosterone enanthate 200 mg/ml vial
generic
ESTROGENS
ALTAVERA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
ALYACEN (7-7-7-28, 1-35-28)
norethindrone-ethinyl estradiol
BRAND
AMETHIA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHIA LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHYST 90-20 MCG TABLET
levonorgestrel-ethinyl estradiol
BRAND
APRI 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
ARANELLE 28 TABLET
norethindrone-ethinyl estradiol
BRAND
ASHLYNA 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AUBRA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
AVIANE-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
AZURETTE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BALZIVA 28 TABLET
norethindrone-ethinyl estradiol
BRAND
BEKYREE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BLISOVI 24 FE TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BLISOVI FE (1.5-30, 1-20)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BRIELLYN TABLET
norethindrone-ethinyl estradiol
BRAND
PAGE 84
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
CAMRESE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAMRESE LO TABLET
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAZIANT 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
CHATEAL-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
CRYSELLE-28 TABLET
norgestrel-ethinyl estradiol
BRAND
CYCLAFEM (7-7-7-28, 1-35-28)
norethindrone-ethinyl estradiol
BRAND
CYRED 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
DASETTA (7/7/7-28, 1-35-28)
norethindrone-ethinyl estradiol
BRAND
DAYSEE 0.15-0.03-0.01 MG TAB
levonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
DELYLA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
desog-e.estradiol/e.estradiol 21-5 tablet
generic
desogestrel-ethinyl estradiol 0.15-0.03 tablet
generic
ELINEST-28 TABLET
norgestrel-ethinyl estradiol
BRAND
EMOQUETTE 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
ENPRESSE-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
ENSKYCE 28 TABLET
desogestrel-ethinyl estradiol
BRAND
ESTARYLLA 0.25-0.035 MG TABLET
norgestimate-ethinyl estradiol
BRAND
ESTRADIOL (.0375MG/24 PATCH TDWK, 0.05MG/24H
PATCH TDSW, .075MG/24H PATCH TDWK, 2 MG
TABLET, .025MG/24H PATCH TDWK, 0.5 MG TABLET,
.025MG/24H PATCH TDSW, 0.06MG/24H PATCH TDWK,
0.1MG/24HR PATCH TDWK, 1 MG TABLET, .0375MG/24
PATCH TDSW, 0.05MG/24H PATCH TDWK, .075MG/24H
PATCH TDSW)
generic
ESTRADIOL VALERATE (40 MG/ML, 20 MG/ML, 10
MG/ML)
generic
PAGE 85
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ESTRADIOL/NORETHINDRONE ACETATE (0.5-0.1MG, 1
MG-0.5MG)
generic
ESTROPIPATE (0.75 MG, 3 MG, 1.5 MG)
generic
ETHINYL ESTRADIOL/DROSPIRENONE (0.03MG-3MG,
0.02-3(24))
generic
FALMINA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
GIANVI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
BRAND
GILDAGIA 0.4 MG-0.035 MG TAB
norethindrone-ethinyl estradiol
BRAND
GILDESS (1.5 MG-30 MCG, 1 MG-20 MCG)
norethindrone acetate-ethinyl estradiol
BRAND
GILDESS 24 FE 1-0.02 MG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
GILDESS FE (1-20, 1.5-30)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
INTROVALE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
BRAND
JINTELI 1 MG-5 MCG TABLET
norethindrone acetate-ethinyl estradiol
BRAND
JOLESSA 0.15 MG-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
BRAND
JUNEL (1 MG-20 MCG, 1.5 MG-30 MCG)
norethindrone acetate-ethinyl estradiol
BRAND
JUNEL FE (1.5 MG-30 MCG, 1 MG-20 MCG)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
JUNEL FE 24 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
KAITLIB FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
BRAND
KARIVA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KELNOR 1-35 28 TABLET
ethynodiol diacetate-ethinyl estradiol
BRAND
KIMIDESS 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KURVELO TABLET
levonorgestrel-ethinyl estradiol
BRAND
LARIN (21 1-20, 1.5 MG-30 MCG)
BRAND
PAGE 86
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
norethindrone acetate-ethinyl estradiol
LARIN 24 FE 1 MG-20 MCG TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LARIN FE (1.5-30, 1-20)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LEENA 28 TABLET
norethindrone-ethinyl estradiol
BRAND
LESSINA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
LEVONEST-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
LEVONORGESTREL (1.5 MG, 0.75 MG)
generic
LEVONORGESTREL-ETHINYL ESTRADIOL (90-20MCG
TABLET, 0.15-0.03 TBDSPK 3MO, 0.1-0.02 TABLET, 6-510 TABLET, 0.15-0.03 TABLET)
generic
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL (150-30(84), 100-20(84))
generic
LEVORA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
LOMEDIA 24 FE 1 MG-20 MCG TAB
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LOPREEZA 1 MG-0.5 MG TABLET
estradiol/norethindrone acetate
BRAND
LORYNA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
BRAND
LOW-OGESTREL-28 TABLET
norgestrel-ethinyl estradiol
BRAND
LUTERA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
MARLISSA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
MENEST (1.25 MG, 0.625 MG, 2.5 MG, 0.3 MG)
estrogens,esterified
BRAND
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)
norethindrone acetate-ethinyl estradiol
BRAND
MICROGESTIN 24 FE 1 MG-20 MCG
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MICROGESTIN FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MIMVEY 1-0.5 MG TABLET
BRAND
PAGE 87
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
estradiol/norethindrone acetate
MIMVEY LO 0.5-0.1 MG TABLET
estradiol/norethindrone acetate
BRAND
MONO-LINYAH 28 TABLET
norgestimate-ethinyl estradiol
BRAND
MONONESSA 28 TABLET
norgestimate-ethinyl estradiol
BRAND
MY WAY 1.5 MG TABLET
levonorgestrel
BRAND
MYZILRA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
NECON (1-35-28, 7-7-7-28, 10-11-28, 1-50-28, 0.5-35-28)
norethindrone-ethinyl estradiol
BRAND
NEXT CHOICE ONE DOSE 1.5 MG TB
levonorgestrel
BRAND
NIKKI 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
BRAND
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew
generic
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL
(0.5MG-2.5, 1MG-20MCG, 1MG-5MCG)
generic
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL/FERROUS FUMARATE (1MG-20(24), 1MG20(21))
generic
NORGESTIMATE-ETHINYL ESTRADIOL (0.25-0.035,
7DAYSX3 28, 7DAYSX3 LO)
generic
NORTREL (7-7-7-28, 1-35, 0.5-35)
norethindrone-ethinyl estradiol
BRAND
OCELLA 3 MG-0.03 MG TABLET
ethinyl estradiol/drospirenone
BRAND
OGEN 2.5 TABLET
estropipate
BRAND
OGESTREL TABLET
norgestrel-ethinyl estradiol
BRAND
ORSYTHIA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
PHILITH 0.4-0.035 MG TABLET
norethindrone-ethinyl estradiol
BRAND
PIMTREA 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
PIRMELLA (1-35-28, 7-7-7-28)
BRAND
PAGE 88
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
norethindrone-ethinyl estradiol
PORTIA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
PREMPHASE 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
BRAND
PREMPRO (0.625-5 MG, 0.625-2.5 MG, 0.45-1.5 MG, 0.3
MG-1.5 MG)
estrogens, conjugated/medroxyprogesterone acetate
BRAND
PREVIFEM TABLET
norgestimate-ethinyl estradiol
BRAND
QUASENSE 0.15-0.03 MG TABLET
levonorgestrel-ethinyl estradiol
BRAND
RECLIPSEN 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
SETLAKIN 0.15 MG-0.03 MG TAB
levonorgestrel-ethinyl estradiol
BRAND
SPRINTEC 28 DAY TABLET
norgestimate-ethinyl estradiol
BRAND
SRONYX 0.10-0.02 MG TABLET
levonorgestrel-ethinyl estradiol
BRAND
SYEDA 28 TABLET
ethinyl estradiol/drospirenone
BRAND
TARINA FE 1-20 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-ESTARYLLA TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-LEGEST FE-28 DAY TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-LINYAH TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-LO-ESTARYLLA TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-LO-MARZIA TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-LO-SPRINTEC TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-PREVIFEM TABLET
norgestimate-ethinyl estradiol
BRAND
TRI-SPRINTEC TABLET
norgestimate-ethinyl estradiol
BRAND
PAGE 89
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
TRINESSA TABLET
norgestimate-ethinyl estradiol
BRAND
TRIVORA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
VAGIFEM 10 MCG VAGINAL TAB
estradiol
BRAND
VELIVET 28 DAY TABLET
desogestrel-ethinyl estradiol
BRAND
VESTURA 3 MG-0.02 MG TABLET
ethinyl estradiol/drospirenone
BRAND
VIENVA-28 TABLET
levonorgestrel-ethinyl estradiol
BRAND
VIORELE 28 DAY TABLET
desogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
VYFEMLA 28 TABLET
norethindrone-ethinyl estradiol
BRAND
WERA 0.5/0.035 MG 28 TABLET
norethindrone-ethinyl estradiol
BRAND
WYMZYA FE CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZARAH TABLET
ethinyl estradiol/drospirenone
BRAND
ZENCHENT 0.4 MG-35 MCG TABLET
norethindrone-ethinyl estradiol
BRAND
ZENCHENT FE TABLET CHEWABLE
norethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZEOSA CHEWABLE TABLET
norethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZOVIA 1-35E TABLET
ethynodiol diacetate-ethinyl estradiol
BRAND
ZOVIA 1-50E TABLET
ethynodiol diacetate-ethinyl estradiol
BRAND
LIMITS & RESTRICTIONS
PROGESTINS
CAMILA TABLET
norethindrone
BRAND
DEBLITANE 0.35 MG TABLET
norethindrone
BRAND
DEPO-PROVERA 400 MG/ML VIAL
medroxyprogesterone acetate
BRAND
ENDOMETRIN 100 MG SUPPOSITORY
BRAND
PAGE 90
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
progesterone,micronized
ERRIN 0.35 MG TABLET
norethindrone
BRAND
HEATHER TABLET
norethindrone
BRAND
IMPLANON 68 MG IMPLANT
etonogestrel
BRAND
JENCYCLA 0.35 MG TABLET
norethindrone
BRAND
JOLIVETTE TABLET
norethindrone
BRAND
LYZA 0.35 MG TABLET
norethindrone
BRAND
MAKENA 1,250 MG/5 ML VIAL
hydroxyprogesterone caproate
BRAND
MEDROXYPROGESTERONE ACETATE (2.5 MG
TABLET, 150 MG/ML VIAL, 5 MG TABLET, 150 MG/ML
SYRINGE, 10 MG TABLET)
generic
MEGESTROL ACETATE (20 MG TABLET, 625MG/5ML
ORAL SUSP, 400MG/10ML ORAL SUSP, 40 MG
TABLET)
generic
NORA-BE TABLET
norethindrone
BRAND
norethindrone 0.35 mg tablet
generic
norethindrone acetate 5 mg tablet
generic
NORLYROC 0.35 MG TABLET
norethindrone
BRAND
progesterone 50 mg/ml vial
generic
PROGESTERONE,MICRONIZED (100 MG, 200 MG)
generic
SHAROBEL 0.35 MG TABLET
norethindrone
BRAND
PA
GL
Male
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 60 mg tablet
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (60 MG, 300 MG, 120 MG, 30 MG,
90 MG, 240 MG, 180 MG, 15 MG)
thyroid,pork
BRAND
LEVOTHYROXINE SODIUM (75 MCG, 300 MCG, 25
generic
PAGE 91
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
MCG, 112 MCG, 137 MCG, 125 MCG, 100 MCG, 200
MCG, 50 MCG, 175MCG, 88 MCG, 150 MCG)
LEVOXYL (112 MCG, 125 MCG, 88 MCG, 50 MCG, 200
MCG, 137 MCG, 75 MCG, 100 MCG, 150 MCG, 175 MCG,
25 MCG)
levothyroxine sodium
BRAND
LIOTHYRONINE SODIUM (25 MCG TABLET, 5 MCG
TABLET, 50 MCG TABLET, 10 MCG/ML VIAL)
generic
NATURE-THROID (146.25 MG, 65 MG, 113.75 MG, 32.5
MG, 81.25 MG, 162.5 MG, 130 MG, 16.25 MG, 325 MG,
195 MG, 97.5 MG, 48.75 MG, 260 MG)
thyroid,pork
BRAND
NP THYROID (90 MG, 30 MG, 60 MG)
thyroid,pork
BRAND
THYROLAR-1 STRENGTH TABLET
liotrix
BRAND
THYROLAR-1/2 STRENGTH TAB
liotrix
BRAND
THYROLAR-1/4 STRENGTH TAB
liotrix
BRAND
THYROLAR-2 STRENGTH TABLET
liotrix
BRAND
THYROLAR-3 STRENGTH TABLET
liotrix
BRAND
UNITHROID (137 MCG, 88 MCG)
levothyroxine sodium
BRAND
WESTHROID (130 MG, 97.5 MG, 16.25 MG, 65 MG, 48.75
MG, 32.5 MG, 195 MG)
thyroid,pork
BRAND
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
QL
SENSIPAR (30 MG, 60 MG)
cinacalcet hcl
BRAND
PA
S
Specialty Drug
QL
SENSIPAR 90 MG TABLET
cinacalcet hcl
BRAND
PA
S
Specialty Drug
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 0.5 mg tablet
PAGE 92
generic
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
EGRIFTA 1 MG VIAL
tesamorelin acetate
BRAND
PA
EGRIFTA 2 MG VIAL
tesamorelin acetate
BRAND
S
LEUPROLIDE ACETATE (1 KIT, 1 VIAL)
generic
LUPRON DEPOT (DEPOT 7.5 MG, DEPOT 22.5 MG
3MO, DEPOT 11.25 MG 3MO, DEPOT-4 MONTH, DEPOT
3.75 MG, DEPOT 45 MG 6MO)
leuprolide acetate
BRAND
LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT,
7.5 MG KIT, 11.25 MG KIT, 15 MG KIT)
leuprolide acetate
BRAND
OCTREOTIDE ACETATE (500 MCG/ML, 50 MCG/ML, 100
MCG/ML)
generic
SIGNIFOR (0.6 MG/ML, 0.9 MG/ML, 0.3 MG/ML)
pasireotide diaspartate
VANTAS 50 MG KIT
histrelin acetate
LIMITS & RESTRICTIONS
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
BRAND
S
Specialty Drug
BRAND
PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
METHIMAZOLE (5 MG, 10 MG)
generic
propylthiouracil 50 mg tablet
generic
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
FIRAZYR 30 MG/3 ML SYRINGE
icatibant acetate
BRAND
IMMUNE SUPPRESSANTS
AZASAN (75 MG, 100 MG)
azathioprine
BRAND
azathioprine 50 mg tablet
generic
CELLCEPT (200 MG/ML ORAL SUSP, 500 MG VIAL)
mycophenolate mofetil hcl
BRAND
CYCLOSPORINE (100 MG CAPSULE, 250 MG/5ML VIAL,
250 MG/5ML AMPUL, 25 MG CAPSULE)
generic
CYCLOSPORINE, MODIFIED (50 MG CAPSULE, 100
MG/ML SOLUTION, 100 MG CAPSULE, 25 MG
CAPSULE)
generic
PAGE 93
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 50 MG/ML
SURECLICK SYR, 25 MG/0.5 ML SYRINGE)
etanercept
BRAND
GENGRAF (25 MG CAPSULE, 100 MG/ML SOLUTION,
100 MG CAPSULE)
cyclosporine, modified
BRAND
HECORIA (1 MG, 5 MG, 0.5 MG)
tacrolimus
BRAND
HUMIRA (10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML)
adalimumab
BRAND
HUMIRA 40 MG/0.8 ML PEN
adalimumab
BRAND
HUMIRA PEDIATRIC CROHN'S START
adalimumab
BRAND
HUMIRA PEN CROHN'S-UC-HS START
adalimumab
BRAND
HUMIRA PEN PSORIASIS START PK
adalimumab
BRAND
METHOTREXATE SODIUM (25 MG/ML VIAL, 2.5 MG
TABLET)
generic
methotrexate sodium/pf 1 g vial
generic
methotrexate sodium/pf 25 mg/ml vial
generic
MYCOPHENOLATE MOFETIL (500 MG TABLET, 250 MG
CAPSULE)
generic
MYCOPHENOLATE SODIUM (180 MG, 360 MG)
generic
MYFORTIC (360 MG, 180 MG)
mycophenolate sodium
BRAND
NULOJIX 250 MG VIAL
belatacept
BRAND
PROGRAF 5 MG/ML AMPULE
tacrolimus
BRAND
RAPAMUNE (1 MG TABLET, 1 MG/ML ORAL SOLN, 2
MG TABLET)
sirolimus
BRAND
REMICADE 100 MG VIAL
infliximab
BRAND
SIROLIMUS (1 MG, 0.5 MG)
generic
PAGE 94
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
TACROLIMUS (1 MG, 5 MG, 0.5 MG)
generic
TREXALL (15 MG, 10 MG, 7.5 MG, 5 MG)
methotrexate sodium
BRAND
ZORTRESS (0.75 MG, 0.5 MG, 0.25 MG)
everolimus
BRAND
S
BIVIGAM LIQUID 10% VIAL
immune globulin,gamm(igg)/glycine/iga greater than 50
mcg/ml
BRAND
PA
FLEBOGAMMA DIF (10%, 5%)
immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml
BRAND
PA
GAMMAGARD LIQUID 10% VIAL
immune globulin,gamm(igg)/glycine/iga greater than 50
mcg/ml
BRAND
PA
GAMMAPLEX 5% VIAL
immune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50
mcg/ml
BRAND
PA
GAMUNEX 10% VIAL
immune globulin,gamma caprylate (igg)
BRAND
PA
GAMUNEX-C (2.5 GRAM/25 ML, 1 GRAM/10 ML, 10
GRAM/100 ML, 20 GRAM/200 ML, 5 GRAM/50 ML)
immune globulin,gamm(igg)/glycine/iga greater than 50
mcg/ml
BRAND
PA
HIZENTRA (10 GRAM/50 ML, 2 GRAM/10 ML, 1 GRAM/5
ML, 4 GRAM/20 ML)
immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND
HYPERRHO S-D 250 UNITS SYRINGE
rho(d) immune globulin
BRAND
PRIVIGEN 10% VIAL
immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND
VARIZIG 125 UNIT VIAL
varicella-zoster immune globulin (human)
BRAND
LIMITS & RESTRICTIONS
Specialty Drug
IMMUNIZING AGENTS, PASSIVE
PA
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGE
tocilizumab
BRAND
PA
ACTIMMUNE 100 MCG/0.5 ML VIAL
interferon gamma-1b,recomb.
BRAND
S
Specialty Drug
ARCALYST 220 MG INJECTION
rilonacept
BRAND
S
Specialty Drug
BENLYSTA (120 MG, 400 MG)
belimumab
BRAND
PAGE 95
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
ILARIS 180 MG VIAL
canakinumab/pf
BRAND
LEFLUNOMIDE (20 MG, 10 MG)
generic
RIDAURA 3 MG CAPSULE
auranofin
BRAND
SYNAGIS (50 MG/0.5 ML, 100 MG/1 ML)
palivizumab
BRAND
LIMITS & RESTRICTIONS
PA
VACCINES
ADACEL TDAP VIAL
diphtheria,pertussis(acell),tetanus vaccine/pf
BRAND
EZ FLU 2015-16 (FLUVIRIN) KIT
influenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf
BRAND
PNEUMOVAX 23 SYRINGE
pneumococcal 23-valent polysaccharide vaccine
BRAND
PNEUMOVAX 23 VIAL
pneumococcal 23-valent polysaccharide vaccine
BRAND
ZOSTAVAX VIAL
zoster vaccine live/pf
BRAND
AL
1 to 65 yrs old
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ER 0.375 GRAM CAPSULE
mesalamine
BRAND
balsalazide disodium 750 mg capsule
generic
CANASA 1,000 MG SUPPOSITORY
mesalamine
BRAND
mesalamine 4 g/60 ml enema
generic
mesalamine w/cleansing wipes 4 g/60 ml enema kit
generic
PENTASA (500 MG, 250 MG)
mesalamine
BRAND
GLUCOCORTICOIDS
budesonide 3 mg capdr - er
generic
COLOCORT 100 MG ENEMA
hydrocortisone
BRAND
CORTIFOAM 10% AEROSOL
hydrocortisone acetate
BRAND
hydrocortisone 100mg/60ml enema
generic
PROCTO-PAK 1% CREAM
BRAND
PAGE 96
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
hydrocortisone
PROCTOSOL-HC 2.5% CREAM
hydrocortisone
BRAND
PROCTOZONE-HC 2.5% CREAM
hydrocortisone
BRAND
UCERIS 9 MG ER TABLET
budesonide
BRAND
SULFONAMIDES
SULFASALAZINE (500 MG, 500 MG DR)
generic
SULFAZINE 500 MG TABLET
sulfasalazine
BRAND
SULFAZINE EC 500 MG TAB
sulfasalazine
BRAND
METABOLIC BONE DISEASE AGENTS
ALENDRONATE SODIUM (10 MG TABLET, 70 MG/75ML
SOLUTION, 40 MG TABLET, 35 MG TABLET, 70 MG
TABLET, 5 MG TABLET)
generic
calcitonin,salmon,synthetic 200/spray spray/pump
generic
CALCITRIOL (1 MCG/ML SOLUTION, 0.5 MCG
CAPSULE, 0.25 MCG CAPSULE, 1 MCG/ML AMPUL)
generic
DOXERCALCIFEROL (1 MCG, 2.5 MCG, 0.5 MCG)
generic
ETIDRONATE DISODIUM (200 MG, 400 MG)
generic
FORTEO 600 MCG/2.4 ML PEN INJ
teriparatide
BRAND
FORTICAL 200 UNITS NASAL SPRAY
calcitonin,salmon,synthetic
BRAND
HECTOROL (2 MCG/ML, 4 MCG/2 ML)
doxercalciferol
BRAND
ibandronate sodium 150 mg tablet
generic
PARICALCITOL (2 MCG/ML VIAL, 2 MCG CAPSULE, 5
MCG/ML VIAL, 4MCG CAPSULE, 1 MCG CAPSULE)
generic
RISEDRONATE SODIUM (5 MG, 30 MG, 35 MG DR, 150
MG, 35 MG)
generic
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine 200 mg/ml vial
generic
ALBUTEIN 25% VIAL
BRAND
PAGE 97
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
albumin human
APLIGRAF DISK
cult skin subst,human-bovine
BRAND
AVITENE SHEET 70MMX70MM
microfibrillar collagen
BRAND
coal tar 20 % solution
generic
DEFEROXAMINE MESYLATE (2 G, 500 MG)
generic
dexmedetomidine hcl 200mcg/2ml vial
generic
ENDO-AVITENE 5MM SHEET
microfibrillar collagen
BRAND
EUFLEXXA 20 MG/2 ML SYRINGE
hyaluronate sodium
BRAND
flumazenil 0.1 mg/ml vial
generic
fomepizole 1 g/ml vial
generic
FORMADON 10% SOLUTION
formaldehyde
BRAND
formaldehyde 10 % sol w/appl
generic
glutaraldehyde 25 % solution
generic
glycine/sod/water/sod hydrox vial
generic
IC GREEN 25 MG VIAL
indocyanine green
BRAND
isomethept/dichlphn/acetaminop 65-100-325 capsule
generic
isomethepten/caf/acetaminophen 65-20-325 tablet
generic
isosulfan blue 1 % vial
generic
LMD 10% WITH 0.9% SOD CHL SOLN
dextran 40 in 0.9 % sodium chloride
BRAND
LMD 10% WITH 5% DEXT SOLN
dextran 40/dextrose 5 % in water
BRAND
LUGOL'S SOLUTION
potassium iodide/iodine
BRAND
MD-GASTROVIEW 66%-10% SOLN
diatrizoate meglumine/diatrizoate sodium
BRAND
METHYLENE BLUE (1 VIAL, 1 AMPUL)
generic
METHYLERGONOVINE MALEATE (0.2 MG TABLET,
.2MG/ML(1) AMPUL)
generic
MIGRAGESIC IDA CAPSULE
isometheptene mucate/dichloralphenazone/acetaminophen
BRAND
PAGE 98
PA
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
NODOLOR CAPSULE
isometheptene mucate/dichloralphenazone/acetaminophen
BRAND
oxytocin 10 unit/ml vial
generic
PANHEMATIN 313 MG VIAL
hemin
BRAND
phenol liquid
generic
physostigmine salicylate 1 mg/ml ampul
generic
potassium iodide/iodine 5 % solution
generic
PROTOPAM CHLORIDE 1 GM VIAL
pralidoxime chloride
BRAND
SITZMARKS CAPSULE
radiopaque pvc markers/barium sulfate
BRAND
sodium morrhuate 50 mg/ml vial
generic
SODIUM THIOSULFATE (1 G/10 ML, 12.5G/50ML)
generic
SOLIRIS 300 MG/30 ML VIAL
eculizumab
BRAND
SOTRADECOL 3% VIAL
sodium tetradecyl sulfate
BRAND
water for inj.,bacteriostatic vial
generic
WATER FOR INJECTION,STERILE (IVSOLN, AMPUL,
VIAL)
generic
water for irrigation,sterile irrig soln
generic
water/me-paraben/propylparaben vial
generic
LIMITS & RESTRICTIONS
PA
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AKORN BALANCED SALT SOLN
balanced salt irrig soln no.2
BRAND
ALTACAINE 0.5% EYE DROPS
tetracaine hcl
BRAND
ALTAFLUOR EYE DROPS
benoxinate hcl/fluorescein sodium
BRAND
ATROPINE CARE 1% EYE DROPS
atropine sulfate
BRAND
ATROPINE SULFATE (1 DROPS, 1 OINT. (G))
generic
balanced salt irrig soln no.2 irrig soln
generic
benoxinate hcl/fluorescein na 0.4%-0.25% drops
generic
PAGE 99
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
BIOGLO 1 MG OPHTHALMIC STRIPS
fluorescein sodium
BRAND
BSS EYE SOLUTION
balanced salt irrig soln no.2
BRAND
ciprofloxacin hcl 0.3 % drops
generic
CYCLOPENTOLATE HCL (2, 1)
generic
CYSTARAN 0.44% EYE DROPS
cysteamine hcl
BRAND
ERYTHROMYCIN BASE (5 MG/G, 5MG/G)
generic
FLUCAINE EYE DROPS
proparacaine hcl/fluorescein sodium
BRAND
FLUOR-I-STRIP AT
fluorescein sodium
BRAND
FLUORESCITE 10% VIAL
fluorescein sodium
BRAND
FLUORETS 1 MG OPTH STRIPS
fluorescein sodium
BRAND
FLUROX EYE DROPS
benoxinate hcl/fluorescein sodium
BRAND
FUL-GLO 1 MG OPTH STRIPS
fluorescein sodium
BRAND
GARAMYCIN (0.3%, 3 MG/ML)
gentamicin sulfate
BRAND
gatifloxacin 0.5 % drops
generic
GENTAK 0.3 % EYE OINTMENT
gentamicin sulfate
BRAND
GENTAMICIN SULFATE (0.3 OINT. (G), 0.3 DROPS)
generic
HOMATROPAIRE 5% EYE DROPS
homatropine hbr
BRAND
homatropine hbr 5 % drops
generic
levofloxacin 0.5 % drops
generic
MOXEZA 0.5% EYE DROPS
moxifloxacin hcl
BRAND
naphazoline hcl 0.1 % drops
generic
NEO-POLYCIN EYE OINTMENT
neomycin sulfate/bacitracin/polymyxin b
BRAND
NEO-POLYCIN HC EYE OINTMENT
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
BRAND
PAGE 100
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g)
generic
neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g)
generic
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
generic
NEOMYCIN/POLYMYXIN B
SULFATE/DEXAMETHASONE (0.1 % DROPS SUSP, 3.510K-.1 OINT. (G))
generic
neomycin/polymyxn b/gramicidin 1.75mg-10k drops
generic
OCUCOAT VISCOADHERENT SYRINGE
hypromellose
BRAND
ofloxacin 0.3 % drops
generic
PHENYLEPHRINE HCL (10, 2.5)
generic
POLYCIN EYE OINTMENT
bacitracin/polymyxin b sulfate
BRAND
polymyxin b sulf/trimethoprim 10000-1/ml drops
generic
proparacaine hcl 0.5 % drops
generic
proparacaine/fluorescein sod 0.5%-0.25% drops
generic
RESTASIS 0.05% EYE EMULSION
cyclosporine
BRAND
SULFACETAMIDE SODIUM (10 DROPS, 10 OINT. (G))
generic
sulfacetamide/prednisolone sp 10 %-0.23% drops
generic
TETCAINE 0.5% EYE DROPS
tetracaine hcl
BRAND
tetracaine hcl 0.5 % drops
generic
tetracaine hcl/pf 0.5 % drops
generic
tobramycin 0.3 % drops
generic
tobramycin/dexamethasone 0.3 %-0.1% drops susp
generic
TROPICAMIDE (0.5, 1)
generic
LIMITS & RESTRICTIONS
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine hcl 0.05 % drops
generic
cromolyn sodium 4 % drops
generic
epinastine hcl 0.05 % drops
generic
olopatadine hcl 0.1 % drops
generic
OPHTHALMIC ANTI-INFLAMMATORIES
bromfenac sodium 0.09% drops
generic
dexamethasone sod phosphate 0.1 % drops
generic
PAGE 101
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
diclofenac sodium 0.1 % drops
generic
fluorometholone 0.1 % drops susp
generic
flurbiprofen sodium 0.03 % drops
generic
KETOROLAC TROMETHAMINE (0.5, 0.4)
generic
PRED MILD 0.12% EYE DROPS
prednisolone acetate
BRAND
prednisolone acetate 1 % drops susp
generic
prednisolone sod phosphate 1 % drops
generic
LIMITS & RESTRICTIONS
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 0.1% DROPS
brimonidine tartrate
BRAND
apraclonidine hcl 0.5 % drops
generic
betaxolol hcl 0.5 % drops
generic
BRIMONIDINE TARTRATE (0.2, 0.15)
generic
carteolol hcl 1 % drops
generic
dorzolamide hcl 2 % drops
generic
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops
generic
levobunolol hcl 0.5 % drops
generic
METHAZOLAMIDE (50 MG, 25 MG)
generic
metipranolol 0.3 % drops
generic
MIOSTAT VIAL
carbachol
BRAND
PHOSPHOLINE IODIDE 0.125%
echothiophate iodide
BRAND
PILOCARPINE HCL (4, 2, 1)
generic
TIMOLOL MALEATE (0.25 DROPS, 0.5 SOL-GEL, 0.5
DROPS, 0.25 SOL-GEL)
generic
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost 0.03 % drops
generic
latanoprost 0.005 % drops
generic
travoprost (benzalkonium) 0.004 % drops
generic
OTIC AGENTS
ACETASOL HC EAR DROPS
acetic acid/hydrocortisone
PAGE 102
BRAND
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
acetic acid 2 % solution
generic
acetic acid/aluminum acetate 2 % drops
generic
acetic acid/hydrocortisone 2 %-1 % drops
generic
AERO OTIC HC EAR DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
ANTIPYRINE/BENZOCAINE (5.4, 5.5)
generic
AURODEX OTIC SOLUTION
antipyrine/benzocaine
BRAND
AUROGUARD OTIC SOLUTION
antipyrine/benzocaine
BRAND
CIPRODEX OTIC SUSPENSION
ciprofloxacin hcl/dexamethasone
BRAND
CORTANE-B OTIC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol/water
BRAND
EXOTIC-HC EAR DROP
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
fluocinolone acetonide oil 0.01 % drops
generic
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE (SOLUTION, DROPS
SUSP)
generic
ofloxacin 0.3 % drops
generic
OTICIN HC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTO-END 10 EAR DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOMAX-HC EAR DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOZIN EAR DROPS
antipyrine/benzocaine/glycerin/zinc acetate
BRAND
PRAMOXINE-HC OTIC DROPS
hydrocortisone/pramoxine hcl/chloroxylenol
BRAND
LIMITS & RESTRICTIONS
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARNUITY ELLIPTA (200 MCG, 100 MCG)
fluticasone furoate
BRAND
BUDESONIDE (1 MG/2 ML AMPUL-NEB, 32MCG
SPRAY/PUMP)
generic
budesonide 0.25mg/2ml ampul-neb
generic
PAGE 103
QL
QL
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
budesonide 0.5 mg/2ml ampul-neb
generic
flunisolide 25 mcg spray
generic
fluticasone propionate 50 mcg spray susp
generic
PULMICORT FLEXHALER (90 MCG, 180 MCG)
budesonide
BRAND
QVAR (80 MCG, 40 MCG)
beclomethasone dipropionate
BRAND
triamcinolone acetonide 55 mcg spray
generic
LIMITS & RESTRICTIONS
C
2 vials (4ml)/day
C
2 vials (4ml)/day
ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID)
carbinoxamine maleate
BRAND
AZELASTINE HCL (205.5MCG, 137 MCG)
generic
CARBINOXAMINE MALEATE (4 MG TABLET, 4 MG/5 ML
LIQUID)
generic
CLEMASTINE FUMARATE (2.68 MG TABLET,
0.67MG/5ML SYRUP)
generic
CYPROHEPTADINE HCL (4 MG TABLET, 2 MG/5 ML
SYRUP)
generic
ST
DESLORATADINE (2.5 MG, 5 MG)
generic
C
must try
cetirizine,
cetirizine/
pseudoephedrine,
loratadine,
loratadine/
pseudoephedrine
PA
ST
desloratadine 5 mg tablet
generic
C
diphenhydramine hcl 50 mg/ml vial
generic
HYDROXYZINE HCL (10 MG TABLET, 50 MG/ML VIAL,
25 MG/ML VIAL, 50 MG/25ML SOLUTION, 10 MG/5 ML
SOLUTION, 50 MG TABLET, 25 MG TABLET)
generic
HYDROXYZINE PAMOATE (100 MG, 50 MG, 25 MG)
generic
PAGE 104
must try
cetirizine,
cetirizine/
pseudoephedrine,
loratadine,
loratadine/
pseudoephedrine
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
PA
ST
levocetirizine dihydrochloride 2.5 mg/5ml solution
generic
C
must try cetirizine,
cetirizine/pseudoephed
rine, loratadine,
loratadine/pseudoephe
drine
PA
ST
levocetirizine dihydrochloride 5 mg tablet
generic
C
olopatadine hcl 0.6 % spray/pump
generic
PALGIC (4 MG/5 ML LIQUID, 4 MG TABLET)
carbinoxamine maleate
BRAND
PHENADOZ (12.5 MG, 25 MG)
promethazine hcl
BRAND
PHENERGAN (50 MG, 12.5 MG, 25 MG)
promethazine hcl
BRAND
PROMETHAZINE HCL (25 MG/ML VIAL, 25 MG TABLET,
50 MG/ML AMPUL, 50 MG SUPP.RECT, 12.5 MG
SUPP.RECT, 50 MG TABLET, 12.5 MG TABLET, 25
MG/ML AMPUL, 25 MG SUPP.RECT, 6.25MG/5ML
SYRUP, 50 MG/ML VIAL)
generic
PROMETHEGAN (50 MG SUPPOSITORY, 25 MG SUPP,
12.5 MG SUPPOS)
promethazine hcl
BRAND
must try cetirizine,
cetirizine/pseudoephed
rine, loratadine,
loratadine/pseudoephe
drine
ANTILEUKOTRIENES
MONTELUKAST SODIUM (4 MG GRAN PACK, 10 MG
TABLET, 4 MG TAB CHEW, 5 MG TAB CHEW)
generic
zafirlukast 10 mg tablet
generic
zafirlukast 20 mg tablet
generic
PA
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA INHALER
ipratropium bromide
BRAND
IPRATROPIUM BROMIDE (42 MCG SPRAY, 21 MCG
SPRAY, 0.2 MG/ML SOLUTION)
generic
SPIRIVA 18 MCG CP-HANDIHALER
tiotropium bromide
BRAND
SPIRIVA RESPIMAT 1.25 MCG INH
BRAND
PAGE 105
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
tiotropium bromide
TUDORZA PRESSAIR 400 MCG INH
aclidinium bromide
BRAND
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENALIN 1 MG/ML VIAL
epinephrine
BRAND
C
2 kits/fill
ADRENALIN CL 1 MG/ML VIAL
epinephrine
BRAND
C
2 kits/fill
ALBUTEROL SULFATE (2 MG/5 ML SYRUP,
1.25MG/3ML VIAL-NEB, 8 MG TAB ER 12H, 2.5 MG/3ML
VIAL-NEB, 2.5 MG/0.5 VIAL-NEB, 4 MG TAB ER 12H, 2
MG TABLET, 0.63MG/3ML VIAL-NEB, 5 MG/ML
SOLUTION, 4 MG TABLET)
generic
EPINEPHRINE (1 MG/ML VIAL, 0.1 MG/ML SYRINGE,
0.3MG/0.3 AUTO INJCT, 1 MG/ML(1) AMPUL, 0.15/0.15
AUTO INJCT)
generic
C
2 kits/fill
epinephrine hcl/pf 1 mg/ml(1) ampul
generic
C
2 kits/fill
epinephrine/pf 1 mg/ml(1) ampul
generic
C
2 kits/fill
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
epinephrine
BRAND
C
2 kits/fill
EPIPEN JR 2-PAK 0.15 MG INJCTR
epinephrine
BRAND
C
2 kits/fill
LEVALBUTEROL HCL (0.63MG/3ML, 1.25MG/0.5,
1.25MG/3ML, 0.31MG/3ML)
generic
C
24 vials/month
METAPROTERENOL SULFATE (10 MG TABLET, 20 MG
TABLET, 10 MG/5 ML SYRUP)
generic
PERFOROMIST 20 MCG/2 ML SOLN
formoterol fumarate
BRAND
STRIVERDI RESPIMAT INHAL SPRAY
olodaterol hcl
BRAND
TERBUTALINE SULFATE (5 MG TABLET, 2.5 MG
TABLET, 1 MG/ML VIAL)
generic
VENTOLIN HFA 90 MCG INHALER
albuterol sulfate
BRAND
QL
QL
CYSTIC FIBROSIS AGENTS
PAGE 106
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
QL
CAYSTON 75 MG INHAL SOLUTION
aztreonam lysine
PA
BRAND
C
S
3 vials/day; max 84
vials/56 days
Specialty Drug
QL
KALYDECO (75 MG, 50 MG)
ivacaftor
PA
BRAND
C
2 packets/day
S
Specialty Drug
QL
KALYDECO 150 MG TABLET
ivacaftor
BRAND
PA
S
Specialty Drug
QL
TOBI 300 MG/5 ML SOLUTION
tobramycin in 0.225 % sodium chloride
PA
BRAND
C
2 vials/day
S
Specialty Drug
QL
TOBI PODHALER 28 MG INHALE CAP
tobramycin
PA
BRAND
C
8 capsules/day
S
Specialty Drug
QL
PA
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb
generic
C
2 vials/day
S
Specialty Drug
QL
tobramycin/nebulizer 300 mg/5ml ampul-neb
generic
PA
S
Specialty Drug
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
AMINOPHYLLINE (500MG/20ML VIAL, 250MG/10ML
VIAL, 250MG/10ML AMPUL)
generic
CAFFEINE CITRATED (60 ML VIAL, 60 ML SOLUTION)
generic
DIFIL-G 400 TABLET
guaifenesin/dyphylline
BRAND
THEOCHRON (ER 300 MG, ER 200 MG, ER 100 MG)
theophylline anhydrous
BRAND
PAGE 107
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
THEOPHYLLINE ANHYDROUS (80 MG/15ML ELIXIR,
300 MG TAB ER 12H, 600 MG TABLET ER, 400 MG
TABLET ER, 100 MG TAB ER 12H, 450 MG TAB ER 12H,
80 MG/15ML SOLUTION, 200 MG TAB ER 12H)
generic
THEOPHYLLINE/DEXTROSE 5 % IN WATER
(800MG/.25L, 400MG/0.5L, 200MG/0.1L, 200MG/50ML,
400MG/.25L)
generic
LIMITS & RESTRICTIONS
PULMONARY ANTIHYPERTENSIVES
PA
ADCIRCA 20 MG TABLET
tadalafil
BRAND
ADEMPAS (0.5 MG, 1.5 MG, 1 MG, 2 MG, 2.5 MG)
riociguat
BRAND
EPOPROSTENOL SODIUM (GLYCINE) (1.5 MG, 0.5 MG)
generic
LETAIRIS (5 MG, 10 MG)
ambrisentan
BRAND
OPSUMIT 10 MG TABLET
macitentan
BRAND
REMODULIN (10 MG/ML, 5 MG/ML, 2.5 MG/ML, 1
MG/ML)
treprostinil sodium
BRAND
REVATIO 10 MG/12.5 ML VIAL
sildenafil citrate
BRAND
sildenafil citrate 10 mg/12.5 vial
generic
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
QL
sildenafil citrate 20 mg tablet
generic
PA
S
Specialty Drug
PA
TRACLEER (125 MG, 62.5 MG)
bosentan
BRAND
TYVASO (INHALATION REFILL KIT, INSTITUTIONAL
START KIT, INHALATION STARTER KIT, 1.74 MG/2.9 ML
SOLUTION)
treprostinil/nebulizer/nebulizer accessories
BRAND
VELETRI (1.5 MG, 0.5 MG)
epoprostenol sodium (arginine)
BRAND
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
PAGE 108
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
VENTAVIS (10 ML, 20 ML)
iloprost tromethamine
BRAND
LIMITS & RESTRICTIONS
S
Specialty Drug
RESPIRATORY TRACT AGENTS, OTHER
ACETYLCYSTEINE (100 MG/ML, 200 MG/ML)
generic
ARALAST 1,000 MG VIAL
alpha-1-proteinase inhibitor
BRAND
ARALAST NP (1,000 MG, 500 MG)
alpha-1-proteinase inhibitor
BRAND
BENZONATATE (150 MG, 200 MG, 100 MG)
generic
BREO ELLIPTA (200-25 MCG, 100-25 MCG)
fluticasone furoate/vilanterol trifenatate
BRAND
CENTERGY PEDIATRIC DROPS
chlorpheniramine maleate/phenylephrine hcl
BRAND
COMBIVENT RESPIMAT INHAL SPRAY
ipratropium bromide/albuterol sulfate
BRAND
cromolyn sodium 20 mg/2 ml ampul-neb
generic
doxapram hcl 20 mg/ml vial
generic
DULERA (200 MCG, 100 MCG)
mometasone furoate/formoterol fumarate
BRAND
PA
ST
fexofenadine/pseudoephedrine 180-240mg tab er 24h
generic
C
hydrocodone/chlorphen p-stirex 10-8mg/5ml sus er 12h
generic
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
generic
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup
generic
PROLASTIN (500 MG, 1,000 MG)
alpha-1-proteinase inhibitor
BRAND
PROLASTIN C 1,000 MG VIAL
alpha-1-proteinase inhibitor
BRAND
promethazine hcl/codeine 6.25-10/5 syrup
generic
promethazine/dextromethorphan 6.25-15/5 syrup
generic
PULMOZYME 1 MG/ML AMPUL
dornase alfa
BRAND
PAGE 109
must try cetirizine,
cetirizine/
pseudoephedrine,
loratadine, loratadine/
pseudoephedrine
PA
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
sodium chloride for inhalation 7 % vial-neb
generic
STIOLTO RESPIMAT INHAL SPRAY
tiotropium bromide/olodaterol hcl
BRAND
SYMBICORT (80-4.5 MCG, 160-4.5 MCG)
budesonide/formoterol fumarate
BRAND
TUSSIGON 5-1.5 MG TABLET
hydrocodone bitartrate/homatropine methylbromide
BRAND
XOLAIR 150 MG VIAL
omalizumab
BRAND
ZEMAIRA 1,000 MG VIAL
alpha-1-proteinase inhibitor
BRAND
LIMITS & RESTRICTIONS
QL
PA
S
Specialty Drug
S
Specialty Drug
SKELETAL MUSCLE RELAXANTS
ANECTINE 20 MG/ML VIAL
succinylcholine chloride
BRAND
BACLOFEN (20 MG, 10 MG)
generic
carisoprodol 250 mg tablet
generic
chlorzoxazone 500 mg tablet
generic
CYCLOBENZAPRINE HCL (10 MG, 5 MG, 7.5 MG)
generic
DANTROLENE SODIUM (100 MG, 50 MG, 25 MG)
generic
GABLOFEN (50 MCG/ML SYRINGE, 40,000 MCG/20 ML
VIAL, 10,000 MCG/20 ML VIAL)
baclofen
BRAND
METAXALONE (800 MG, 400 MG)
generic
METHOCARBAMOL (750 MG, 500 MG)
generic
ORPHENADRINE CITRATE (100 MG TABLET ER, 30
MG/ML AMPUL, 30 MG/ML VIAL)
generic
orphenadrine/aspirin/caffeine 50-770-60 tablet
generic
REVONTO 20 MG VIAL
dantrolene sodium
BRAND
TIZANIDINE HCL (6 MG CAPSULE, 4 MG TABLET, 2 MG
CAPSULE, 4 MG CAPSULE, 2 MG TABLET)
generic
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
ESTAZOLAM (1 MG, 2 MG)
generic
ESZOPICLONE (2 MG, 1 MG, 3 MG)
generic
PAGE 110
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
quazepam 15 mg tablet
generic
TEMAZEPAM (7.5 MG, 15 MG, 30 MG, 22.5 MG)
generic
TRIAZOLAM (0.25 MG, 0.125 MG)
generic
ZALEPLON (10 MG, 5 MG)
generic
ZOLPIDEM TARTRATE (6.25 MG TAB MPHASE, 10 MG
TABLET, 12.5 MG TAB MPHASE, 5 MG TABLET)
generic
LIMITS & RESTRICTIONS
C
must try zolpidem and
zaleplon for at least 2
weeks of therapy in the
past 90 days
SLEEP DISORDERS, OTHER
caffeine/sodium benzoate 250 mg/ml vial
generic
FLURAZEPAM HCL (15 MG, 30 MG)
generic
QL
HETLIOZ 20 MG CAPSULE
tasimelteon
BRAND
PA
S
MODAFINIL (100 MG, 200 MG)
generic
Specialty Drug
PA
ST
ROZEREM 8 MG TABLET
ramelteon
BRAND
SECONAL SODIUM 100 MG CAPSULE
secobarbital sodium
BRAND
XYREM 500 MG/ML ORAL SOLUTION
sodium oxybate
BRAND
C
must try zolpidem and
zoleplon for at least 2
weeks of therapy in the
past 90 days
S
Specialty Drug
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET 100 MG CAPSULE
succimer
BRAND
EXJADE (500 MG, 250 MG, 125 MG)
deferasirox
BRAND
PA
FERRIPROX 500 MG TABLET
deferiprone
BRAND
S
Specialty Drug
KIONEX (15 GM/60 ML SUSPENSION, POWDER)
sodium polystyrene sulfonate
BRAND
MARLEXATE POWDER
sodium polystyrene sulfonate
BRAND
SAMSCA (30 MG, 15 MG)
BRAND
S
Specialty Drug
PAGE 111
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
tolvaptan
SODIUM POLYSTYRENE SULFONATE (POWDER,
30G/120ML ENEMA, 15 G/60 ML ORAL SUSP)
generic
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML
ENEMA)
sodium polystyrene sulfonate
BRAND
ELECTROLYTE/MINERAL REPLACEMENT
0.9 % SODIUM CHLORIDE (0.9 0.9 IV SOLN, 0.9 0.9
SYRINGE, 0.9 PGGYBK PRT, 0.9 0.9 VIAL, 0.9 PGY VL
PRT)
generic
CALCIUM CHLORIDE (100 MG/ML VIAL, 100 MG/ML
SYRINGE)
generic
calcium gluconate 100 mg/ml vial
generic
calcium/mag/d3/b12/fa/b6/boron 500-300-1 wafer
generic
CARBAGLU 200 MG DISPER TABLET
carglumic acid
BRAND
CENTRATEX CAPSULE
ferrous fumarate/folic acid/multivitamins with min no. 15
BRAND
chromic chloride 4mcg/ml vial
generic
CORVITA 150 TABLET
iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc
BRAND
cupric chloride 0.4 mg/ml vial
generic
DELFLEX WITH 1.5% DEXTROSE
peritoneal dialysis no.6 with dextrose 1.5 %
BRAND
DELFLEX WITH 2.5% DEXTROSE
peritoneal dialysis no.7 with dextrose 2.5 %
BRAND
DELFLEX WITH 4.25% DEXTROSE
peritoneal dialysis no.8 with dextrose 4.25 %
BRAND
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE (10
0.2 10 DEHP FR BG, 10 0.2 10 IV SOLN)
generic
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln
generic
dextrose 10 % and 0.9 % nacl 10 %-0.9 % iv soln
generic
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln
generic
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln
generic
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln
generic
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln
generic
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln
generic
PAGE 112
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
dextrose 5% in ringers 5 % iv soln
generic
dextrose 5%-lactated ringers 5 % iv soln
generic
EFFER-K 25 MEQ TABLET EFF
potassium bicarbonate/citric acid
BRAND
electrolyte-48 solution/d5w 5 % iv soln
generic
FE 90 PLUS TABLET
iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FE C PLUS TABLET
iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
BRAND
FEROCON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FEROTRINSIC CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FERRAPLUS 90 TABLET
iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
BRAND
FERREX 150 FORTE CAPSULE
iron polysaccharide complex/cyanocobalamin/folic acid
BRAND
FERREX 150 FORTE PLUS CAPSULE
iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
FERREX 28 TABLET
iron asp.glycin & fumarate /vit c/fa/mv comb 11/cathreonate
BRAND
FERROCITE PLUS TABLET
iron/folic acid/vitamin b comp and c/minerals
BRAND
FERROGELS FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
FOCALGIN DSS TABLET
iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FOLIVANE-F CAPSULE
iron fumarate & polysac comp/folic acid/vitamin c/niacin
BRAND
FOLIVANE-PLUS CAPSULE
iron fumarate,polysac cplex/folic acid/vit b comp with c #9
BRAND
HEMATINIC-FOLIC ACID TABLET
ferrous fumarate/folic acid
BRAND
HEMATINIC-VITAMIN-MINERAL TAB
iron/folic acid/vitamin b comp and c/minerals
BRAND
HEMATOGEN FA SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
HEMATOGEN FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
PAGE 113
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
HEMATOGEN SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/stomach
conc
BRAND
HEMETAB IRON SUPPLEMENT TABLET
iron polysacchar complx/iron heme polypeptide/folic
acid/b12
BRAND
K EFFERVESCENT 25 MEQ TABLET
potassium bicarbonate/citric acid
BRAND
K-PHOS ORIGINAL TABLET
potassium phosphate,monobasic
BRAND
K-SOL (10% (20, 20% (40)
potassium chloride
BRAND
K-TAB ER 8 MEQ TABLET
potassium chloride
BRAND
KLOR-CON (25, 20)
potassium chloride
BRAND
KLOR-CON 10 MEQ TABLET
potassium chloride
BRAND
KLOR-CON 8 MEQ TABLET
potassium chloride
BRAND
KLOR-CON M10 TABLET
potassium chloride
BRAND
KLOR-CON M15 TABLET
potassium chloride
BRAND
KLOR-CON M20 TABLET
potassium chloride
BRAND
KLOR-CON SPRINKLE (ER 8 CAP, ER 10 CP)
potassium chloride
BRAND
KLOR-CON-EF 25 MEQ TAB EFF
potassium bicarbonate/citric acid
BRAND
magnesium chloride 200 mg/ml vial
generic
MAGNESIUM SULFATE (4 SYRINGE, 4 VIAL)
generic
MAGNESIUM SULFATE IN STERILE WATER (4 G/50 ML
PIGGYBACK, 20 G/500ML IV SOLN, 4 G/100 ML
PIGGYBACK, 40G/1000ML IV SOLN, 2 G/50 ML
PIGGYBACK)
generic
manganese chloride 0.1 mg/ml vial
generic
manganese sulfate 0.1 mg/ml vial
generic
molybdenum(ammonium molybdate) 25 mcg/ml vial
generic
MONOJECT 0.9% SODIUM CL SYRING
BRAND
PAGE 114
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
0.9 % sodium chloride
MONOJECT PREFILL 0.9% FLUSH
0.9 % sodium chloride
BRAND
MONOJECT PREFILL 0.9% NA SYR
0.9 % sodium chloride
BRAND
MULTIGEN CAPLET
iron aspgly/ascorb.cal/vit b12/calcium
thr/succ.acid/stomach
BRAND
MULTIGEN FOLIC CAPLET
iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
BRAND
MULTIGEN PLUS CAPLET
iron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
MULTITRACE-4 CONC VIAL
zinc sulfate/cupric sulfate/manganese sulf/chromic chloride
BRAND
MULTITRACE-5 CONC VIAL
zinc sulfate heptahydrate/cuso4 phyd/manganese/chromium/se
BRAND
NATALVIRT FLT TABLET
iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
NUTRILYTE II VIAL
sodium/potassium/magnesium/calcium/chloride/acetate
BRAND
NUTRILYTE VIAL
sodium/potassium/magnes/calcium/chloride/acetate/glucon
ate
BRAND
POLYSACCHARIDE IRON FORTE
iron polysaccharide complex/cyanocobalamin/folic acid
BRAND
pot chloride/pot bicarb/cit ac 25 meq tablet eff
generic
POTASSIUM ACETATE (2, 4)
generic
potassium bicarbonate/cit ac 25 meq tablet eff
generic
POTASSIUM CHLORIDE (40MEQ/0.1L PIGGYBACK, 10
MEQ TAB ER PRT, 8 MEQ CAPSULE ER, 8 MEQ
TABLET ER, 10 MEQ CAPSULE ER, 10MEQ/50ML
PIGGYBACK, 2 MEQ/ML VIAL, 20MEQ/50ML
PIGGYBACK, 20 MEQ PACKET, 20MEQ/15ML LIQUID,
10 MEQ TABLET ER, 30MEQ/0.1L PIGGYBACK,
20MEQ/0.1L PIGGYBACK, 2 MEQ/ML IV SOLN, 20 MEQ
TABLET ER, 20 MEQ TAB ER PRT, 40MEQ/15ML
LIQUID, 10MEQ/0.1L PIGGYBACK)
generic
POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE
(20, 40)
generic
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER
(40, 20, 30)
generic
PAGE 115
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 %
SODIUM CHLORIDE (40, 20)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %
SODIUM CHLORIDE (20, 10, 30, 40)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %
SODIUM CHLORIDE (10, 20, 40, 30)
generic
POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5
% DEXTROSE (40, 20)
generic
potassium chloride-0.45% nacl 20 meq/l iv soln
generic
potassium chloride/d5-0.3%nacl 20 meq/l iv soln
generic
potassium phos in 0.9 % nacl 15mmol/250 plast. bag
generic
potassium phos,m-basic-d-basic 3mmol/ml vial
generic
PROFERRIN-FORTE TABLET
iron heme polypeptide/folic acid
BRAND
PUREVIT DUALFE PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
ringers solution iv soln
generic
ringers solution,lactated iv soln
generic
SE-TAN PLUS CAPSULE
iron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
selenium 40 mcg/ml vial
generic
SODIUM ACETATE (4, 2)
generic
SODIUM BICARBONATE (1 MEQ/ML SYRINGE,
0.5MEQ/ML SYRINGE, 0.9MEQ/ML SYRINGE, 1 MEQ/ML
VIAL, 10MEQ/10ML SYRINGE, 0.5MEQ/ML VIAL)
generic
SODIUM CHLORIDE 0.45 % (0.45 PGGYBK PRT, 0.45
0.45 IV SOLN)
generic
sodium chloride 3 % 3 % iv soln
generic
sodium chloride 5 % 5 % iv soln
generic
sodium lactate 5 meq/ml vial
generic
sodium phos,m-basic-d-basic 3mmol/ml vial
generic
SYREX SODIUM CHL 0.9% SYR
0.9 % sodium chloride
BRAND
TARON FORTE CAPSULE
iron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo
BRAND
TL ICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TL-HEM 150 CAPLET
BRAND
PAGE 116
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
LIMITS & RESTRICTIONS
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
TRICON CAPSULE
ferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TRIGELS-F FORTE SOFTGEL
ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
zinc chloride 1 mg/ml vial
generic
ZINC SULFATE (1 MG/ML VIAL, 5 MG/ML VIAL,
220(50)MG CAPSULE)
generic
AMINO ACIDS 15% SOLUTION
parenteral amino acid 15% combination no.1
BRAND
ascorbic acid 500 mg/ml vial
generic
BAL-CARE DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron
poly/fa/omega3
BRAND
cyanocobalamin (vitamin b-12) 1000mcg/ml vial
generic
cysteine hcl 50 mg/ml vial
generic
DEXTROSE 10 % IN WATER (10 10 IV SOLN, 10 10
DEHP FR BG)
generic
dextrose 2.5 % in water 2.5 % iv soln
generic
dextrose 20 % in water 20 % iv soln
generic
dextrose 25 % in water 25 % syringe
generic
dextrose 30 % in water 30 % iv soln
generic
dextrose 40 % in water 40 % iv soln
generic
DEXTROSE 5 % IN WATER (5 5 IV SOLN, 5 PGY VL
PRT, 5 5 VIAL, 5 PGGYBK PRT)
generic
DEXTROSE 50 % IN WATER (50 50 IV SOLN, 50 50
VIAL, 50 50 SYRGE)
generic
dextrose 70 % in water 70 % iv soln
generic
DIALYVITE TABLET
folic acid/vitamin b comp and c
BRAND
ergocalciferol (vitamin d2) 50000 unit capsule
generic
ethyl alcohol 98 % ampul
generic
FLUOR-A-DAY (1 MG TABLET, 0.25 MG TAB, 0.5 MG
TAB)
sodium fluoride/xylitol
BRAND
FOLBEE PLUS TABLET
folic acid/vitamin b comp and c
BRAND
FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET)
generic
PAGE 117
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
FREAMINE III 10% IV SOLN.
parenteral amino acid 10% combination no. 4
BRAND
INFED 100 MG/2 ML VIAL
iron dextran complex
BRAND
levocarnitine (with sugar) 100 mg/ml solution
generic
levocarnitine 330 mg tablet
generic
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGAL
OIL (7.5-90.314, 15-90.314)
generic
LIPOSYN III (20%, 10%, 30%)
fat emulsions
BRAND
MEPHYTON 5 MG TABLET
phytonadione
BRAND
MYNATAL PLUS CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNATAL-Z CAPTAB
prenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNEPHROCAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
BRAND
NEPHPLEX RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin/znox
BRAND
NEPHRO-VITE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
NIVA-PLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
NUTRILIPID 20% IV FAT EMULSION
fat emulsions
BRAND
pedi mv #75/fluoride/iron 0.25-10/ml drops
generic
PHYTONADIONE (10 MG/ML, 1MG/0.5ML)
generic
PNV 29-1 TABLET
prenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
generic
pnv with ca,no.74/iron/fa 27 mg-1 mg tablet
generic
PNV-SELECT TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
PNV-VP-U CAPSULE
prenatal vits without calc no5/ferrous fumarate/folic acid
BRAND
PREMASOL 10% IV SOLUTION
parenteral amino acid 10% combination no.7
BRAND
PAGE 118
LIMITS & RESTRICTIONS
PA
S
Specialty Drug
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
PRENA1 CHEW TABLET
prenatal vitamins combination no.42/folic acid
BRAND
PRENAPLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
PRETAB 29 MG-1 MG TABLET
prenatal vits with calcium #78/ferrous fumarate/folic acid
BRAND
RENA-VITE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
RENAL CAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
BRAND
RENO CAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
BRAND
ringers solution irrig soln
generic
ringers solution,lactated irrig soln
generic
sodium fluoride 0.25(0.55) tab chew
generic
THERAPEUTIC VIT-MINERAL CAP
multivitamins with min no.7/folic acid
BRAND
thiamine hcl 100 mg/ml vial
generic
THRIVITE RX TABLET
prenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
TL G-FOL OS TABLET
calcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
BRAND
TRAVASOL 10% SOLN VIAFLEX
parenteral amino acid 10% combination no. 6
BRAND
ULTIMATE OB DHA COMBO PACK
prenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
BRAND
VENA-BAL DHA COMBO PACK
prenatal vitamin no.81/sodium feredetate-iron
poly/fa/omega3
BRAND
VIRT NATE TABLET
prenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
VIRT-ADVANCE TABLET
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
BRAND
VIRT-CAPS SOFTGEL
vitamin b complex & vitamin c no.20/folic acid
BRAND
VIRT-NATE DHA SOFTGEL
prenatal vitamins no.11/ferrous fumarate/folic acid/omega3
BRAND
VIRT-NATE TABLET
prenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
PAGE 119
LIMITS & RESTRICTIONS
PA
LAST UPDATED 02/2016
DRUG DESCRIPTION (RX)
BRAND/GEN
VIRT-PN TABLET
prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
VIRT-VITE GT TABLET
prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
BRAND
VIRTPREX CAPSULE
prenatal vit with calcium no.66/iron fum/folic acid/dss/dha
BRAND
VITAFOL-OB CAPLET
prenatal vitamins comb 10/ferrous fumarate/folic acid
BRAND
VITAFOL-PN CAPLET
prenatal vit with calcium cmb 11/ferrous fumarate/folic acid
BRAND
VOL-CARE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
VOL-PLUS TABLET
prenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
VP-VITE RX TABLET
vitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
PAGE 120
LIMITS & RESTRICTIONS
LAST UPDATED 02/2016
Index of covered drugs
0
0.9 % SODIUM CHLORIDE
116
ADALIMUMAB
94
ADAPALENE
67
ADCIRCA
108
ADEFOVIR DIPIVOXIL
8
43
ADEMPAS
8-MOP
67
A
108
ADENOSINE
56
ADO-TRASTUZUMAB EMTANSINE
37
ADRENALIN
106
106
A-HYDROCORT
81
ADRENALIN CHLORIDE
A-METHAPRED
81
ADRIAMYCIN
33
ABACAVIR SULFATE
45
ADRUCIL
32
ABACAVIR SULFATE/LAMIVUDINE
45
ADVATE
52
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 45
ADVATE H
52
ABILIFY
41
ADVATE L
52
ABILIFY DISCMELT
41
ADVATE M
52
ABILIFY MAINTENA
41
ADVATE SH
52
ABIRATERONE ACETATE
32
ADVATE UH
52
ABRAXANE
33
AERO OTIC HC
ABSORICA
67
AFATINIB DIMALEATE
36
ACAMPROSATE CALCIUM
14
AFEDITAB CR
57
ACARBOSE
48
AFINITOR
36
ACD
50
AFINITOR DISPERZ
36
ACD-A
50
AGALSIDASE BETA
75
ACEBUTOLOL HCL
56
AKORN BALANCED SALT
99
ALAGESIC LQ
64
ALBENDAZOLE
38
ACETAMINOPHEN WITH CODEINE PHOSPHATE
ACETASOL HC
8
102
103
ACETAZOLAMIDE
60
ALBENZA
38
ACETAZOLAMIDE SODIUM
60
ALBUMIN HUMAN
97
97
ACETIC ACID
102
ALBUTEIN
ACETIC ACID/ALUMINUM ACETATE
103
ALBUTEROL SULFATE
ACETIC ACID/HYDROCORTISONE
103
ALCLOMETASONE DIPROPIONATE
67
ALDURAZYME
74
ALENDRONATE SODIUM
97
ACETIC ACID/OXYQUINOLINE SULFATE
ACETYLCYSTEINE
ACITRETIN
ACLIDINIUM BROMIDE
80
109
106
67
ALFENTANIL HCL
8
106
ALFUZOSIN HCL
79
ACTEMRA
95
ALGLUCOSIDASE ALFA
75
ACTIMMUNE
95
ALIMTA
32
ACTOPLUS MET XR
48
ALINIA
38
ACYCLOVIR
47
ALKERAN
31
ACYCLOVIR SODIUM
46
ALLOPURINOL
29
ADACEL TDAP
96
ALLOPURINOL SODIUM
29
PAGE 121
LAST UPDATED 02/2016
ALMOTRIPTAN MALATE
29
AMMONIUM LACTATE
70
ALOPRIM
29
AMNESTEEM
67
ALOSETRON HCL
77
AMOXAPINE
26
ALPHA-1-PROTEINASE INHIBITOR
110
AMOXICILLIN
19
ALPHAGAN P
102
AMOXICILLIN/POTASSIUM CLAVULANATE
19
ALPHANATE
52
AMPHOTERICIN B
27
ALPHAQUIN HP
67
AMPICILLIN SODIUM
19
ALPRAZOLAM
47
AMPICILLIN SODIUM/SULBACTAM SODIUM
19
ALPRAZOLAM INTENSOL
47
AMPICILLIN TRIHYDRATE
19
ALPROSTADIL
58
AMPYRA
65
ALTACAINE
99
AMYL NITRITE
62
ALTAFLUOR
99
ANAGRELIDE HCL
51
ALTAVERA
84
ANASPAZ
75
ALTRETAMINE
31
ANASTROZOLE
35
ALUMINUM CHLORIDE
70
ANDROGEL
83
ALYACEN
84
ANDROXY
83
AMANTADINE HCL
39
ANECTINE
110
AMBRISENTAN
108
ANTHRALIN
69
53
AMCINONIDE
67
ANTI-INHIBITOR COAGULANT COMPLEX
AMETHIA
84
ANTIHEMOPHILIC FACTOR (FACTOR VIII)
AMETHIA LO
84
RECOMB,B-DOMAIN DELETED
AMETHYST
84
ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL
AMIFOSTINE CRYSTALLINE
33
LENGTH (ALB-FREE)
AMIKACIN SULFATE
14
ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,
AMILORIDE HCL
61
FC FUSION PROTEIN
AMILORIDE HCL/HYDROCHLOROTHIAZIDE
58
ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-
AMINO ACIDS
117
54
53
53
DOMAIN TRUNCATED
53
AMINOACETIC ACID
79
ANTIHEMOPHILIC FACTOR VIII, HUMAN
AMINOCAPROIC ACID
52
RECOMBINANT
54
ANTIHEMOPHILIC FACTOR, HUMAN
53
AMINOPHYLLINE
107
AMIODARONE HCL
56
ANTIHEMOPHILIC FACTOR, HUMAN/VON
AMITRIPTYLINE HCL
25
WILLEBRAND FACTOR,HUMAN
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE
24
ANTIPYRINE/BENZOCAINE
AMLODIPINE BESYLATE
57
ANTIPYRINE/BENZOCAINE/GLYCERIN/ZINC
AMLODIPINE BESYLATE/ATORVASTATIN
53
103
ACETATE
103
CALCIUM
58
APEXICON
67
AMLODIPINE BESYLATE/BENAZEPRIL HCL
58
APEXICON E
67
AMLODIPINE BESYLATE/VALSARTAN
58
APLIGRAF
98
AMLODIPINE
APOKYN
39
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
APOMORPHINE HCL
39
58
APRACLONIDINE HCL
PAGE 122
102
LAST UPDATED 02/2016
APREPITANT
26
AVASTIN
37
APRI
84
AVELOX IV
20
APRISO
96
AVIANE
84
APTIVUS
45
AVIDOXY
21
ARALAST
109
AVITA
67
ARALAST NP
109
AVITENE
98
ARANELLE
84
AVONEX
65
ARBINOXA
104
AVONEX ADMINISTRATION PACK
65
ARCALYST
95
AVONEX PEN
65
AXITINIB
36
ARGATROBAN IN SODIUM CHLORIDE, ISOOSMOTIC
50
AZASAN
93
ARIPIPRAZOLE
41
AZATHIOPRINE
93
ARMOUR THYROID
91
AZELASTINE HCL
ARNUITY ELLIPTA
103
AZITHROMYCIN
20
19
ARRANON
33
AZTREONAM
ARSENIC TRIOXIDE
35
AZTREONAM LYSINE
ARTEMETHER/LUMEFANTRINE
38
AZURETTE
ARZERRA
37
ASCOMP WITH CODEINE
8
ASCORBIC ACID
117
ASFOTASE ALFA
104
106
84
B
B-DONNA
76
75
BACIIM
15
ASHLYNA
84
BACITRACIN
15
ASPIRIN/DIPYRIDAMOLE
54
BACITRACIN/POLYMYXIN B SULFATE
101
BACLOFEN
110
ASTRAMORPH-PF
9
ATAZANAVIR SULFATE
46
BACTROBAN NASAL
ATENOLOL
56
BAL-CARE DHA
117
ATENOLOL/CHLORTHALIDONE
58
BALANCED SALT IRRIG SOLN NO.2
100
ATOMOXETINE HCL
64
BALSALAZIDE DISODIUM
96
ATORVASTATIN CALCIUM
61
BALZIVA
84
ATOVAQUONE
38
BANZEL
23
ATOVAQUONE/PROGUANIL HCL
38
BARACLUDE
43
ATRACURIUM BESYLATE
64
BCG LIVE
35
ATRIPLA
44
BEBULIN
52
ATROPINE CARE
99
BEBULIN VH IMMUNO
52
ATROPINE SULFATE
99
BECAPLERMIN
72
ATROVENT HFA
105
15
BECLOMETHASONE DIPROPIONATE
104
AUBRA
84
BEDAQUILINE FUMARATE
30
AURANOFIN
96
BEKYREE
84
AURODEX
103
BELATACEPT
94
AUROGUARD
103
BELIMUMAB
95
BENAZEPRIL HCL
55
AVAR
PAGE 123
67
LAST UPDATED 02/2016
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
58
BPO
BENDAMUSTINE HCL
31
BREO ELLIPTA
BENEFIX
52
BRIELLYN
84
BENLYSTA
95
BRILINTA
54
BENOXINATE HCL/FLUORESCEIN SODIUM
100
BENZEPRO
BENZONATATE
67
109
68
109
BRIMONIDINE TARTRATE
102
BROMFENAC SODIUM
101
BROMOCRIPTINE MESYLATE
39
BENZOYL PEROXIDE
68
BSS
BENZOYL PEROXIDE MICROSPHERES
73
BUDEPRION XL
BENZPHETAMINE HCL
64
BUDESONIDE
104
BENZTROPINE MESYLATE
39
BUDESONIDE/FORMOTEROL FUMARATE
110
BETAINE
75
BUFFERED LIDOCAINE
12
BUMETANIDE
60
BETAMETHASONE ACETATE/BETAMETHASONE
100
24
SODIUM PHOSPHATE
81
BUPHENYL
75
BETAMETHASONE DIPROPIONATE
67
BUPIVACAINE HCL
13
BUPIVACAINE HCL/DEXTROSE-WATER/PF
12
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL
67
BUPIVACAINE HCL/EPINEPHRINE
13
BETAMETHASONE VALERATE
68
BUPIVACAINE HCL/EPINEPHRINE/PF
12
102
BUPIVACAINE HCL/PF
13
BETHANECHOL CHLORIDE
80
BUPRENORPHINE HCL
14
BEVACIZUMAB
37
BUPRENORPHINE HCL/NALOXONE HCL
14
BEXAROTENE
38
BUPROBAN
14
BEXXAR
37
BUPROPION HCL
24
BICALUTAMIDE
32
BUSPIRONE HCL
47
BICNU
31
BUSULFAN
31
102
BUSULFEX
31
BUTALBITAL/ACETAMINOPHEN
65
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
65
BETAXOLOL HCL
BIMATOPROST
BIOGLO
99
BISACODYL/SODIUM CHLOR/SODIUM
BICARB/POTASSIUM CHL/PEG 3350
77
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
BISOPROLOL FUMARATE
56
E PHOSPHATE
BISOPROLOL
9
BUTALBITAL/ASPIRIN/CAFFEINE
64
FUMARATE/HYDROCHLOROTHIAZIDE
58
BUTOCONAZOLE NITRATE
28
BIVIGAM
95
BUTORPHANOL TARTRATE
9
BLISOVI 24 FE
84
BYDUREON
48
BLISOVI FE
84
BYDUREON PEN
48
BOCEPREVIR
44
BYETTA
48
BOSENTAN
108
BOSULIF
36
C
BOSUTINIB
36
CABERGOLINE
BP 10-1
68
CAFFEINE CITRATED
107
BP-50% UREA
68
CAFFEINE/SODIUM BENZOATE
111
PAGE 124
92
LAST UPDATED 02/2016
CALCIPOTRIENE
68
CALCIPOTRIENE/BETAMETHASONE
CARISOPRODOL
110
CARMUSTINE
31
DIPROPIONATE
68
CARTEOLOL HCL
CALCITONIN,SALMON,SYNTHETIC
97
CARTIA XT
57
CALCITRENE
68
CARVEDILOL
56
CALCITRIOL
97
CASPOFUNGIN ACETATE
27
CALCIUM ACETATE
81
CAYSTON
106
CAZIANT
85
CALCIUM CARB/MAG OXIDE/VITAMIN D3/VIT
102
B12/FA/VIT B6/BORON
119
CEFACLOR
17
CALCIUM CHLORIDE
112
CEFADROXIL
17
CALCIUM GLUCONATE
112
CEFAZOLIN SODIUM
17
CAMILA
90
CEFAZOLIN SODIUM IN 0.9 % SODIUM
CAMRESE
84
CHLORIDE
CAMRESE LO
85
CEFAZOLIN SODIUM/DEXTROSE 5 % IN WATER 18
CANAGLIFLOZIN
48
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC 18
CANAGLIFLOZIN/METFORMIN HCL
48
CEFDINIR
18
CANAKINUMAB/PF
95
CEFDITOREN PIVOXIL
18
CANASA
96
CEFEPIME HCL
18
CANCIDAS
27
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC
18
CANDESARTAN CILEXETIL
55
CEFIXIME
18
CEFOTAXIME SODIUM
18
CANDESARTAN
18
CILEXETIL/HYDROCHLOROTHIAZIDE
58
CEFOTETAN DISODIUM
18
CAPACET
64
CEFOXITIN SODIUM
18
CAPECITABINE
32
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC 18
CAPRELSA
36
CEFPODOXIME PROXETIL
18
CAPTOPRIL
55
CEFPROZIL
18
CAPTOPRIL/HYDROCHLOROTHIAZIDE
58
CEFTAZIDIME
18
CARAFATE
78
CEFTIBUTEN
18
CARB-O-PHILIC
68
CEFTRIAXONE SODIUM
18
CARBACHOL
102
CEFTRIAXONE SODIUM/DEXTROSE, ISO-
CARBAGLU
112
OSMOTIC
18
CARBAMAZEPINE
23
CEFUROXIME AXETIL
18
CARBIDOPA
40
CEFUROXIME SODIUM
18
CARBIDOPA/LEVODOPA
40
CEFUROXIME SODIUM/DEXTROSE, ISO-
CARBIDOPA/LEVODOPA/ENTACAPONE
39
OSMOTIC
CARBINOXAMINE MALEATE
18
105
CELEBREX
5
CARBOCAINE
13
CELECOXIB
5
CARBOPLATIN
33
CELLCEPT
93
CARBOPROST TROMETHAMINE
80
CELONTIN
22
CARDIOPLEGIC SOLUTION NO.1
58
CEM-UREA
68
112
CENTERGY
109
CARGLUMIC ACID
PAGE 125
LAST UPDATED 02/2016
CENTRATEX
112
CIPRODEX
103
CEPHALEXIN
18
CIPROFLOXACIN
CERITINIB
37
CIPROFLOXACIN HCL
100
CERUBIDINE
33
CIPROFLOXACIN HCL/DEXAMETHASONE
103
CETUXIMAB
37
CIPROFLOXACIN LACTATE
CEVIMELINE HCL
66
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN
CHANTIX
14
WATER
21
CHATEAL
85
CIPROFLOXACIN/CIPROFLOXACIN HCL
21
CHEMET
111
CISPLATIN
33
20
20
CHENODAL
76
CITALOPRAM HYDROBROMIDE
25
CHENODIOL
76
CITRATE DEXTROSE SOLUTION
50
CHLORAMBUCIL
31
CITRATE PHOSPHATE DEXTROS SOLN
50
CHLORAMPHENICOL SOD SUCC
15
CITRIC ACID/GLUCONOLACTONE/MAGNESIUM
CHLORDIAZEPOXIDE HCL
47
CARBONATE
80
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE
76
CITRIC ACID/SODIUM CITRATE
81
CHLORHEXIDINE GLUCONATE
66
CLADRIBINE
32
CHLOROPROCAINE HCL/PF
13
CLARAVIS
68
CHLOROQUINE PHOSPHATE
38
CLARIS
68
CHLOROTHIAZIDE
61
CLARITHROMYCIN
20
CHLOROTHIAZIDE SODIUM
61
CLEANSING WASH
68
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE
CLEMASTINE FUMARATE
HCL
CLINDACIN ETZ
68
109
104
CHLORPROMAZINE HCL
40
CLINDACIN P
68
CHLORTHALIDONE
61
CLINDAMYCIN HCL
15
CHLORZOXAZONE
110
CLINDAMYCIN PALMITATE HCL
15
68
CHOLESTYRAMINE (WITH SUGAR)
62
CLINDAMYCIN PHOSPHATE
CHOLESTYRAMINE/ASPARTAME
62
CLINDAMYCIN PHOSPHATE/BENZOYL
CHOLINE SALICYLATE/MAGNESIUM SALICYLATE 5
PEROXIDE
CHORIONIC GONADOTROPIN, HUMAN
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN
CHROMIC CHLORIDE
83
112
71
WATER
15
CICLODAN
27
CLOBAZAM
22
CICLOPIROX
27
CLOBETASOL PROPIONATE
69
CICLOPIROX OLAMINE
27
CLOBETASOL PROPIONATE/EMOLLIENT BASE 68
CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALY
CLODAN
68
PTOL
27
CLOMIPRAMINE HCL
26
CIDOFOVIR
42
CLONAZEPAM
47
CILOSTAZOL
54
CLONIDINE
54
CIMETIDINE
77
CLONIDINE HCL
63
CIMETIDINE HCL
77
CLONIDINE HCL/CHLORTHALIDONE
59
CINACALCET HCL
92
CLONIDINE HCL/PF
54
CIPRO
20
CLOPIDOGREL BISULFATE
54
PAGE 126
LAST UPDATED 02/2016
CLORAZEPATE DIPOTASSIUM
47
CUPRIC CHLORIDE
CLORPRES
59
CUPRIMINE
CLOTRIMAZOLE/BETAMETHASONE
112
80
CYANOCOBALAMIN (VITAMIN B-12)
117
DIPROPIONATE
69
CYCLAFEM
CLOZAPINE
42
CYCLOBENZAPRINE HCL
110
COAGULATION FACTOR VIIA (RECOMBINANT)
53
CYCLOPENTOLATE HCL
100
COAL TAR
98
CYCLOPHOSPHAMIDE
COARTEM
38
CYCLOSPORINE
COCAINE HCL
69
CYCLOSPORINE, MODIFIED
CODEINE
85
31
101
CYPROHEPTADINE HCL
94
104
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE
9
CYRED
85
CODEINE SULFATE
9
CYSTADANE
75
COLCHICINE
29
CYSTAGON
75
COLCHICINE/PROBENECID
29
CYSTARAN
100
COLCRYS
29
CYSTEAMINE BITARTRATE
COLESTIPOL HCL
62
CYSTEAMINE HCL
100
COLISTIN (AS COLISTIMETHATE SODIUM)
15
CYSTEINE HCL
117
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM
72
CYTARABINE
32
COLOCORT
96
CYTARABINE/PF
32
109
CYTRA-2
80
COMPLERA
44
CYTRA-3
80
COMPOUND 347
13
CYTRA-K
80
COMPRO
26
COPAXONE
65
D
CORIFACT
52
DABIGATRAN ETEXILATE MESYLATE
51
CORLANOR
59
DABRAFENIB MESYLATE
37
CORLOPAM
62
DACARBAZINE
31
CORMAX
69
DACTINOMYCIN
33
103
DALFAMPRIDINE
65
83
COMBIVENT RESPIMAT
CORTANE-B
75
CORTICOTROPIN
83
DANAZOL
CORTIFOAM
96
DANTROLENE SODIUM
CORTISONE ACETATE
81
DAPSONE
30
112
DARAPRIM
38
CORVITA 150
110
COSYNTROPIN
82
DARUNAVIR ETHANOLATE
46
CREON
75
DASATINIB
36
CRIXIVAN
46
DASETTA
85
CRIZOTINIB
37
DAUNORUBICIN CITRATE LIPOSOMAL
31
DAUNORUBICIN HCL
33
CROMOLYN SODIUM
109
CROTAMITON
39
DAUNOXOME
31
CRYSELLE
85
DAYSEE
85
CULT SKIN SUBST,HUMAN-BOVINE
98
DEBACTEROL
66
PAGE 127
LAST UPDATED 02/2016
DEBLITANE
90
DEXTROMETHORPHAN HBR/QUINIDINE
DECITABINE
33
SULFATE
64
DEFERASIROX
111
DEXTROSE 10 % AND 0.2 % SODIUM
DEFERIPRONE
111
CHLORIDE
112
DEFEROXAMINE MESYLATE
98
DEXTROSE 10 % AND 0.45 % SODIUM
DELAVIRDINE MESYLATE
44
CHLORIDE
112
DELFLEX WITH 1.5% DEXTROSE
112
DEXTROSE 10 % AND 0.9 % SODIUM
DELFLEX WITH 2.5% DEXTROSE
112
CHLORIDE
112
DELFLEX WITH 4.25% DEXTROSE
112
DEXTROSE 10 % IN WATER
117
DELTASONE
81
DEXTROSE 2.5 % AND 0.45 % SODIUM
DELYLA
85
CHLORIDE
112
DEMECLOCYCLINE HCL
21
DEXTROSE 2.5 % IN WATER
117
DEMSER
59
DEXTROSE 20 % IN WATER
117
DEPADE
14
DEXTROSE 25 % IN WATER
117
DEPO-PROVERA
90
DEXTROSE 30 % IN WATER
117
DERMAZENE
69
DEXTROSE 40 % IN WATER
117
DESIPRAMINE HCL
26
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE 112
104
DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE 112
DESLORATADINE
DESMOPRESSIN ACETATE
83
DESMOPRESSIN ACETATE (NON-
DEXTROSE 5 % AND 0.45 % SODIUM
CHLORIDE
112
REFRIGERATED)
82
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 112
DESOGESTREL-ETHINYL ESTRADIOL
90
DEXTROSE 5 % IN LACTATED RINGERS
113
DEXTROSE 5 % IN WATER
117
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
ESTRADIOL
90
DEXTROSE 5% IN RINGERS
112
DESONIDE
69
DEXTROSE 50 % IN WATER
117
DESOXIMETASONE
69
DEXTROSE 70 % IN WATER
117
DEXAMETHASONE
81
DEXTROSE-WATER/SODIUM CITRATE/CITRIC
DEXAMETHASONE INTENSOL
81
ACID
DEXAMETHASONE SOD PHOSPHATE
101
50
DIALYVITE
117
DEXAMETHASONE SODIUM PHOSPHATE/PF
81
DIATRIZOATE MEGLUMINE/DIATRIZOATE
DEXEDRINE
63
SODIUM
98
DEXMEDETOMIDINE HCL
98
DIAZEPAM
47
DEXMETHYLPHENIDATE HCL
63
DIAZOXIDE
50
DEXPANTHENOL
77
DIBENZYLINE
55
DEXRAZOXANE HCL
33
DICLOFENAC POTASSIUM
DEXTRAN 40 IN 0.9 % SODIUM CHLORIDE
98
DICLOFENAC SODIUM
DEXTRAN 40/DEXTROSE 5 % IN WATER
98
DICLOFENAC SODIUM/MISOPROSTOL
5
101
5
DEXTROAMPHETAMINE SULF-
DICLOXACILLIN SODIUM
19
SACCHARATE/AMPHETAMINE SULF-
DICYCLOMINE HCL
76
ASPARTATE
63
DIDANOSINE
45
DEXTROAMPHETAMINE SULFATE
63
DIETHYLPROPION HCL
64
PAGE 128
LAST UPDATED 02/2016
DIFIL-G 400
107
DOXIL
34
DIFLORASONE DIACETATE
69
DOXORUBICIN HCL
34
DIFLORASONE DIACETATE/EMOLLIENT BASE
67
DOXORUBICIN HCL PEGYLATED LIPOSOMAL
34
DIFLUNISAL
5
DOXYCYCLINE HYCLATE/EYELID CLNS
DIGITEK
59
NO.3/EYELID EMOLLIENT NO.1
21
DIGOX
59
DOXYCYCLINE MONOHYDRATE
21
DIGOXIN
59
DRITHOCREME HP
69
DRONABINOL
26
DROPERIDOL
40
DROXIA
32
DROXIDOPA
60
DIHYDROCODEINE
BITARTRATE/ACETAMINOPHEN/CAFFEINE
9
DIHYDROCODEINE
BITARTRATE/ASPIRIN/CAFFEINE
9
DIHYDROERGOTAMINE MESYLATE
29
DRYSOL
69
DILANTIN
23
DULERA
109
DILT-XR
57
DULOXETINE HCL
DILTIAZEM HCL
58
DURAMORPH
9
DIMENHYDRINATE
26
DUTASTERIDE
79
DIMETHYL FUMARATE
66
DUTASTERIDE/TAMSULOSIN HCL
79
DIOXYBENZONE/PADIMATE O/HYDROQUINONE 71
DIPHENHYDRAMINE HCL
DIPHENOXYLATE HCL/ATROPINE SULFATE
104
77
DIPHTHERIA,PERTUSSIS(ACELL),TETANUS
65
E
E.E.S. 200
20
E.E.S. 400
20
VACCINE/PF
96
ECHOTHIOPHATE IODIDE
DIPYRIDAMOLE
54
ECONAZOLE NITRATE
27
ECULIZUMAB
99
DISKETS
6
102
DISULFIRAM
14
ED-SPAZ
76
DIVALPROEX SODIUM
22
EDROPHONIUM CHLORIDE
30
DOBUTAMINE HCL
59
EDURANT
44
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER
59
EFAVIRENZ
45
DOCETAXEL
33
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DOFETILIDE
56
DISOPROXIL FUMARATE
DOLUTEGRAVIR SODIUM
44
EFFER-K
113
DONEPEZIL HCL
24
EFFIENT
54
DOPAMINE HCL
59
EGRIFTA
93
DOPAMINE HCL/DEXTROSE 5 % IN WATER
59
ELAPRASE
75
71
44
DORNASE ALFA
109
ELASTIDERM
DORZOLAMIDE HCL
102
ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN
DORZOLAMIDE HCL/TIMOLOL MALEATE
102
WATER
DOXAPRAM HCL
109
ELELYSO
75
DOXAZOSIN MESYLATE
55
ELINEST
85
DOXEPIN HCL
26
ELIPHOS
81
DOXERCALCIFEROL
97
ELITEK
33
PAGE 129
113
LAST UPDATED 02/2016
ELMIRON
80
EPITOL
23
ELOCTATE
53
EPIVIR
45
ELOXATIN
34
EPIVIR HBV
43
ELTROMBOPAG OLAMINE
52
EPLERENONE
61
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
EPOETIN ALFA
52
OFOVIR
44
EPOPROSTENOL SODIUM (ARGININE)
108
EMCYT
32
EPOPROSTENOL SODIUM (GLYCINE)
108
EMEND
26
EPROSARTAN MESYLATE
55
EMOQUETTE
85
EPTIFIBATIDE
54
EMTRICITABINE
45
EPZICOM
45
ERBITUX
37
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE
44
EMTRICITABINE/TENOFOVIR DISOPROXIL
ERGOCALCIFEROL (VITAMIN D2)
117
ERGOLOID MESYLATES
24
FUMARATE
45
ERGOTAMINE TARTRATE/CAFFEINE
29
EMTRIVA
45
ERIVEDGE
36
ENALAPRIL MALEATE
55
ERLOTINIB HCL
37
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 59
ERRIN
91
ENALAPRILAT DIHYDRATE
55
ERY
69
ENBREL
93
ERY-TAB
20
ENDO-AVITENE
98
ERYGEL
69
ENDOCET
9
ERYPED 200
20
ENDODAN
9
ERYPED 400
20
20
ENDOMETRIN
90
ERYTHROCIN STEARATE
ENFLURANE
13
ERYTHROMYCIN BASE
ENFUVIRTIDE
45
ERYTHROMYCIN BASE/BENZOYL PEROXIDE
69
ENLON
30
ERYTHROMYCIN BASE/ETHYL ALCOHOL
69
ENOXAPARIN SODIUM
50
ERYTHROMYCIN ETHYLSUCCINATE
20
ENPRESSE
85
ERYTHROMYCIN
ENSKYCE
85
ETHYLSUCCINATE/SULFISOXAZOLE ACETYL
20
ENTACAPONE
39
ERYTHROMYCIN STEARATE
20
ENTECAVIR
43
ESCITALOPRAM OXALATE
25
ENULOSE
77
ESGIC
64
ENZALUTAMIDE
32
ESMOLOL HCL
56
EPHEDRINE SULFATE
59
ESOMEPRAZOLE MAGNESIUM
78
100
EPINASTINE HCL
101
ESOMEPRAZOLE SODIUM
78
EPINEPHRINE
106
ESOMEPRAZOLE STRONTIUM
78
EPINEPHRINE HCL/PF
106
ESTARYLLA
85
EPINEPHRINE/PF
106
ESTAZOLAM
110
EPIPEN 2-PAK
106
ESTRADIOL
90
EPIPEN JR 2-PAK
106
ESTRADIOL VALERATE
85
EPIRUBICIN HCL
34
ESTRADIOL/NORETHINDRONE ACETATE
88
PAGE 130
LAST UPDATED 02/2016
ESTRAMUSTINE PHOSPHATE SODIUM
32
FACTOR IX COMPLEX, PROTHROMBIN CPLX
ESTROGENS,
CONC(PCC) NO.6, 3-FACTOR
52
CONJUGATED/MEDROXYPROGESTERONE
FACTOR IX HUMAN RECOMBINANT
52
ACETATE
89
FACTOR IX HUMAN RECOMBINANT, THREONINE
ESTROGENS,ESTERIFIED
87
148
53
ESTROPIPATE
88
FACTOR XIII
52
ESZOPICLONE
110
FACTOR XIII A-SUBUNIT, RECOMBINANT
54
ETANERCEPT
93
FALMINA
86
ETHACRYNATE SODIUM
61
FAMCICLOVIR
46
ETHAMBUTOL HCL
30
FAMOTIDINE
77
ETHINYL ESTRADIOL/DROSPIRENONE
90
FAMOTIDINE/PF
77
ETHOSUXIMIDE
22
FARESTON
32
ETHOTOIN
23
FAT EMULSIONS
118
ETHYL ALCOHOL
117
FE 90 PLUS
113
ETHYL CHLORIDE
69
FE C PLUS
113
ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 90
FEBUXOSTAT
29
ETIDRONATE DISODIUM
FEIBA NF
53
FEIBA VH IMMUNO
53
97
ETODOLAC
5
ETOMIDATE
13
FELBAMATE
23
ETONOGESTREL
91
FELODIPINE
57
ETOPOSIDE
35
FEM PH
80
ETRAVIRINE
44
FENOFIBRATE
61
EUFLEXXA
98
FENOFIBRATE NANOCRYSTALLIZED
61
EURAX
39
FENOFIBRATE,MICRONIZED
61
EVEROLIMUS
95
FENOFIBRIC ACID
61
EXEMESTANE
35
FENOFIBRIC ACID (CHOLINE)
61
EXENATIDE
48
FENOLDOPAM MESYLATE
62
EXENATIDE MICROSPHERES
48
FENOPROFEN CALCIUM
5
EXJADE
111
FENTANYL
6
EXOTIC-HC
103
FENTANYL CITRATE
9
EXTAVIA
66
FENTANYL CITRATE IN 0.9 % SODIUM
EZ FLU 2015-2016 (FLUVIRIN)
96
CHLORIDE/PF
EZETIMIBE
62
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 %
EZOGABINE
22
SODIUM CHLORIDE/PF
9
FENTANYL CITRATE/PF
12
F
9
FEROCON
113
FABRAZYME
75
FEROTRINSIC
113
FACTOR IX
53
FERRAPLUS 90
113
FACTOR IX COMPLEX HUMAN
54
FERREX 150 FORTE
113
FERREX 150 FORTE PLUS
113
FERREX 28
113
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.4, 3-FACTOR
PAGE 131
53
LAST UPDATED 02/2016
FERRIC SUBSULFATE
53
FLUOR-A-DAY
117
FERRIPROX
111
FLUOR-I-STRIP AT
100
FERROCITE PLUS
113
FLUORESCEIN SODIUM
100
FERROGELS FORTE
113
FLUORESCITE
100
FLUORETS
100
FLUOROMETHOLONE
102
FERROUS FUMARATE/ASCORBIC ACID/B12IF/FOLIC ACID
117
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID
117
FERROUS FUMARATE/ASCORBIC
FLUOROURACIL
33
FLUOXETINE HCL
25
FLUOXYMESTERONE
83
ACID/CYANOCOBALAMIN/STOMACH CONC
113
FLUPHENAZINE DECANOATE
40
FERROUS FUMARATE/FOLIC ACID
113
FLUPHENAZINE HCL
40
FERROUS FUMARATE/FOLIC
ACID/MULTIVITAMINS WITH MIN NO. 15
FLURAZEPAM HCL
112
111
FLURBIPROFEN
5
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL 109
FLURBIPROFEN SODIUM
102
FIBRINOGEN
54
FLUROX
100
FINASTERIDE
79
FLUTAMIDE
FINGOLIMOD HCL
66
FLUTICASONE FUROATE
FIRAZYR
93
FLUTICASONE FUROATE/VILANTEROL
FIRST-BXN
27
TRIFENATATE
109
FIRST-LANSOPRAZOLE
78
FLUTICASONE PROPIONATE
104
FIRST-MOUTHWASH BLM
66
FLUVASTATIN SODIUM
61
FIRST-OMEPRAZOLE
78
FLUVOXAMINE MALEATE
25
FLAVOXATE HCL
79
FOCALGIN DSS
113
FLEBOGAMMA DIF
95
FOLBEE PLUS
117
FLECAINIDE ACETATE
56
FOLIC ACID
117
FLOXURIDINE
33
FOLIC ACID/VITAMIN B COMP AND C
117
FOLIVANE-F
113
113
FLUCAINE
100
32
103
FLUCONAZOLE
27
FOLIVANE-PLUS
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC
27
FOLLITROPIN ALFA, RECOMB
83
FOLOTYN
33
FLUCONAZOLE IN SODIUM CHLORIDE, ISOOSMOTIC
27
FOMEPIZOLE
98
FLUCYTOSINE
28
FONDAPARINUX SODIUM
50
FLUDARABINE PHOSPHATE
34
FORANE
13
FLUDROCORTISONE ACETATE
81
FORMA-RAY
69
FLUMAZENIL
98
FORMADON
98
FLUNISOLIDE
104
FORMALDEHYDE
98
FLUOCINOLONE ACETONIDE
FLUOCINOLONE ACETONIDE OIL
69
103
FORMOTEROL FUMARATE
106
FORTEO
97
FLUOCINOLONE ACETONIDE/SHOWER CAP
69
FORTICAL
97
FLUOCINONIDE
69
FOSAMPRENAVIR CALCIUM
46
FLUOCINONIDE/EMOLLIENT BASE
69
FOSCARNET SODIUM
42
PAGE 132
LAST UPDATED 02/2016
FOSINOPRIL SODIUM
55
GLATIRAMER ACETATE
66
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 59
GLATOPA
66
FOSPHENYTOIN SODIUM
GLEEVEC
36
23
FREAMINE III
117
GLEOSTINE
31
FUL-GLO
100
GLIMEPIRIDE
48
FUROSEMIDE
61
GLIPIZIDE
48
FUSILEV
34
GLIPIZIDE/METFORMIN HCL
48
FUZEON
45
GLUCAGEN
49
GLUCAGON EMERGENCY KIT
50
GLUCAGON HCL
50
G
GABAPENTIN
22
GLUCAGON,HUMAN RECOMBINANT
50
GABITRIL
22
GLUTARALDEHYDE
98
GLYBURIDE
48
GABLOFEN
110
GALANTAMINE HBR
24
GLYBURIDE,MICRONIZED
48
GALSULFASE
75
GLYBURIDE/METFORMIN HCL
48
GAMMAGARD LIQUID
95
GLYCEROL PHENYLBUTYRATE
75
GAMMAPLEX
95
GLYCINE UROLOGIC SOLUTION
80
GAMUNEX
95
GLYCINE/SODIUM/WATER FOR
GAMUNEX-C
95
INJECTION,STERILE/SODIUM HYDROXIDE
98
GANCICLOVIR SODIUM
43
GLYCOPYRROLATE
76
GLYDO
69
GONAL-F RFF
82
GONAL-F RFF REDI-JECT
83
GARAMYCIN
100
GASTROCROM
77
GATIFLOXACIN
100
GAVILYTE-H AND BISACODYL
77
GRANISETRON HCL
27
GEMCITABINE HCL
33
GRANISETRON HCL/PF
27
GEMFIBROZIL
61
GRANISOL
27
GENERLAC
78
GRISEOFULVIN ULTRAMICROSIZE
28
GENGRAF
94
GRISEOFULVIN, MICROSIZE
28
81
GENTAK
100
GRX HICORT 25
GENTAMICIN SULFATE
100
GUAIFENESIN/DYPHYLLINE
GENTAMICIN SULFATE IN SODIUM CHLORIDE,
107
GUANFACINE HCL
63
ISO-OSMOTIC
15
GUANIDINE HCL
30
GENTAMICIN SULFATE/PF
15
GYNAZOLE 1
28
GEODON
41
GIANVI
86
H
GILDAGIA
86
H.P. ACTHAR
83
GILDESS
86
HALOBETASOL PROPIONATE
70
GILDESS 24 FE
86
HALOBETASOL PROPIONATE/AMMONIUM
GILDESS FE
86
LACTATE
70
GILENYA
66
HALONATE
70
GILOTRIF
36
HALONATE PAC
70
PAGE 133
LAST UPDATED 02/2016
HALOPERIDOL
40
HUMIRA PEN PSORIASIS
94
HALOPERIDOL DECANOATE
40
HUMULIN R U-500
50
HALOPERIDOL LACTATE
40
HYALURONATE SODIUM
98
HARVONI
43
HYDRALAZINE HCL
62
HEATHER
91
HYDROCHLOROTHIAZIDE
61
HECORIA
94
HYDROCODONE
HECTOROL
97
BITARTRATE/ACETAMINOPHEN
HELIXATE FS
53
HYDROCODONE BITARTRATE/HOMATROPINE
HEMABATE
80
METHYLBROMIDE
12
110
HEMATINIC PLUS
113
HYDROCODONE
HEMATINIC WITH FOLIC ACID
113
POLISTIREX/CHLORPHENIRAMINE POLISTIREX109
HEMATOGEN
113
HYDROCODONE/IBUPROFEN
12
HEMATOGEN FA
113
HYDROCORTISONE
97
HEMATOGEN FORTE
113
HYDROCORTISONE ACETATE
96
HEMETAB
114
HYDROCORTISONE ACETATE/ALOE VERA
70
HEMIN
99
HYDROCORTISONE ACETATE/LIDOCAINE
HEMMOREX-HC
81
HCL/ALOE VERA
HEMRIL
82
HYDROCORTISONE ACETATE/PRAMOXINE HCL 72
HEPARIN SODIUM,PORCINE
51
HYDROCORTISONE
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM
CHLORIDE
ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE
51
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE
51
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE/PF
70
51
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN
COMB#1
70
HYDROCORTISONE BUTYRATE
70
HYDROCORTISONE BUTYRATE/EMOLLIENT
BASE
70
HYDROCORTISONE SOD SUCCINATE
81
HYDROCORTISONE VALERATE
70
70
WATER
51
HYDROCORTISONE/IODOQUINOL
HEPARIN SODIUM,PORCINE/PF
51
HYDROCORTISONE/MINERAL
HERCEPTIN
37
OIL/PETROLATUM,WHITE
HETLIOZ
111
HEXALEN
31
HCL/CHLOROXYLENOL
HISTRELIN ACETATE
93
HYDROCORTISONE/PRAMOXINE
HIZENTRA
95
HCL/CHLOROXYLENOL/WATER
70
HYDROCORTISONE/PRAMOXINE
103
103
HOMATROPAIRE
100
HYDROMORPHONE HCL
10
HOMATROPINE HBR
100
HYDROMORPHONE HCL/PF
10
HUMALOG KWIKPEN U-200
50
HYDROQUINONE
71
HUMATE-P
53
HYDROQUINONE MICROSPHERES
70
HUMIRA
94
HYDROQUINONE/FERRIC OXIDE
71
HUMIRA PEDIATRIC CROHN'S
94
HYDROXYCHLOROQUINE SULFATE
38
HUMIRA PEN
94
HYDROXYPROGESTERONE CAPROATE
91
HUMIRA PEN CROHN'S-UC-HS
94
HYDROXYUREA
33
PAGE 134
LAST UPDATED 02/2016
HYDROXYZINE HCL
104
IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0
HYDROXYZINE PAMOATE
104
TO 50 MCG/ML
95
HYOPHEN
15
IMMUNE GLOBULIN,GAMMA CAPRYLATE (IGG) 95
HYOSCYAMINE SULFATE
76
IMPLANON
91
HYOSYNE
76
INCIVEK
43
HYPERCARE
70
INCRELEX
83
HYPERRHO S-D
95
INDAPAMIDE
61
INDINAVIR SULFATE
46
INDOCYANINE GREEN
98
HYPROMELLOSE
101
I
INDOMETHACIN
5
5
IBANDRONATE SODIUM
97
INDOMETHACIN SODIUM
IBRANCE
36
INFED
IBRUTINIB
36
INFERGEN
43
5
INFLIXIMAB
94
IBUPROFEN
118
IBUPROFEN/OXYCODONE HCL
10
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
IBUTILIDE FUMARATE
56
(4 YR & OLDER)/PF
96
IC GREEN
98
INLYTA
36
ICATIBANT ACETATE
93
INSULIN DETEMIR
50
ICLUSIG
36
INSULIN GLARGINE,HUMAN RECOMBINANT
ICOSAPENT ETHYL
62
ANALOG
50
IDARUBICIN HCL
34
INSULIN LISPRO
50
IDELALISIB
37
INSULIN REGULAR, HUMAN
50
IDURSULFASE
75
INTELENCE
44
IFOSFAMIDE
31
INTERFERON ALFA-2B,RECOMB.
43
IFOSFAMIDE/MESNA
31
INTERFERON ALFACON-1
43
ILARIS
95
INTERFERON BETA-1A
65
INTERFERON BETA-1A/ALBUMIN HUMAN
66
ILOPROST TROMETHAMINE
108
IMATINIB MESYLATE
36
INTERFERON BETA-1B
66
IMBRUVICA
36
INTERFERON GAMMA-1B,RECOMB.
95
IMIPENEM/CILASTATIN SODIUM
19
INTRON A
43
IMIPRAMINE HCL
26
INTROVALE
86
IMIPRAMINE PAMOATE
26
INVEGA SUSTENNA
41
IMIQUIMOD
70
INVEGA TRINZA
41
INVIRASE
46
INVOKAMET
48
IMMUNE
INVOKANA
48
GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0
IPRATROPIUM BROMIDE
IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA
GREATER THAN 50 MCG/ML
TO 50 MCG/ML
95
95
105
IPRATROPIUM BROMIDE/ALBUTEROL
IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0
SULFATE
TO 50 MCG/ML
IRBESARTAN
55
IRBESARTAN/HYDROCHLOROTHIAZIDE
59
PAGE 135
95
109
LAST UPDATED 02/2016
IRINOTECAN HCL
34
IRON ASP GLY&PS CMPLX/ASCORB.CAL/VIT
B12/FA/CA-THR/SUCC.ACID
ISOMETHEPTENE
MUCATE/DICHLORALPHENAZONE/ACETAMINOPH
113
EN
98
ISONIAZID
30
ISOSORBIDE DINITRATE
62
ISOSORBIDE MONONITRATE
62
ISOSULFAN BLUE
98
ISOTRETINOIN
71
ISOXSUPRINE HCL
24
ISRADIPINE
57
ISTODAX
34
IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT
ITRACONAZOLE
28
C/DOCUSATE SODIUM
115
IVABRADINE HCL
59
IRON DEXTRAN COMPLEX
118
IVACAFTOR
107
IVERMECTIN
38
IXABEPILONE
34
IXEMPRA
34
113
IXINITY
53
116
J
IRON ASP GLY/ASCORB.CAL/VIT B12/FA/CATHREONTE/SUCCINIC ACID
115
IRON ASP.GLYCIN & FUMARATE /VIT C/FA/MV
COMB 11/CA-THREONATE
113
IRON ASPGLY/ASCORB.CAL/VIT B12/CALCIUM
THR/SUCC.ACID/STOMACH
115
IRON BISGLY,PSCMPLX/ASCORBATE
CALC/B12/FOLIC ACID/CALC-THREO
116
IRON FUMARATE & POLYSAC COMP/FOLIC
ACID/VITAMIN C/NIACIN
113
IRON FUMARATE,POLYSAC CPLEX/FOLIC
ACID/VIT B COMP WITH C #9
IRON FUMARATE-IRON POLYSACCHAR/FOLIC
ACID/MV COMB18
IRON FUMARTE &ASP GLY/ASCORB.CAL/VIT
JAKAFI
36
B12/FA/CA-THR/SUCC.ACID
115
JANTOVEN
51
IRON HEME POLYPEPTIDE/FOLIC ACID
116
JANUMET
48
JANUMET XR
48
JANUVIA
49
JENCYCLA
91
JENTADUETO
49
JINTELI
86
JOLESSA
86
JOLIVETTE
91
JUNEL
86
IRON,CARBONYL/FOLIC ACID/VIT C/PYRIDOXINE
JUNEL FE
86
HCL/VIT B12/ZINC
JUNEL FE 24
86
JUXTAPID
62
IRON POLYSACCHAR COMPLX/IRON HEME
POLYPEPTIDE/FOLIC ACID/B12
114
IRON POLYSACCHARIDE
COMPLEX/CYANOCOBALAMIN/FOLIC ACID
115
IRON,CARBONYL/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID
113
IRON,CARBONYL/DOCUSATE SODIUM/B12IF/FOLIC ACID/MULTIVIT-MIN
116
112
IRON,CARBONYL/FOLIC ACID/VITAMIN
B12/VITAMIN C/DOCUSATE NA
113
IRON/FOLIC ACID/VITAMIN B COMP AND
K
C/MINERALS
113
K EFFERVESCENT
114
ISENTRESS
44
K-PHOS NEUTRAL
80
ISOFLURANE
14
K-PHOS NO.2
80
ISOMETHEPTENE
MUCATE/CAFFEINE/ACETAMINOPHEN
PAGE 136
98
K-PHOS ORIGINAL
114
K-SOL
114
LAST UPDATED 02/2016
K-TAB ER
114
LAMIVUDINE/ZIDOVUDINE
45
KADCYLA
37
LAMOTRIGINE
23
KAITLIB FE
86
LANSOPRAZOLE
78
KALETRA
46
LANSOPRAZOLE/AMOXICILLIN
KALYDECO
107
TRIHYDRATE/CLARITHROMYCIN
77
KARIVA
86
LANTUS
50
KELNOR 1-35
86
LANTUS SOLOSTAR
50
KEPIVANCE
66
LAPATINIB DITOSYLATE
37
KETAMINE HCL
13
LARIN
86
KETOCONAZOLE
28
LARIN 24 FE
87
KETOCONAZOLE/SKIN CLEANSER COMBINATION
LARIN FE
87
NO.28
28
LARONIDASE
74
KETODAN
28
LATANOPROST
KETOPROFEN
KETOROLAC TROMETHAMINE
KIMIDESS
KIONEX
5
102
86
111
KIT FOR PREP YTTRIUM-90/IBRITUMOMAB
TIUXETAN/ALBUMIN HUMAN
38
102
LATRIX
70
LATRIX XM
70
LEDIPASVIR/SOFOSBUVIR
43
LEENA
87
LEFLUNOMIDE
96
LENALIDOMIDE
32
KLOR-CON
114
LESSINA
87
KLOR-CON 10
114
LETAIRIS
108
KLOR-CON 8
114
LETROZOLE
35
KLOR-CON M10
114
LEUCOVORIN CALCIUM
34
KLOR-CON M15
114
LEUKERAN
31
KLOR-CON M20
114
LEUKINE
52
KLOR-CON SPRINKLE
114
LEUPROLIDE ACETATE
93
KLOR-CON-EF
114
LEVALBUTEROL HCL
106
KOATE-DVI
53
LEVEMIR
50
KOGENATE FS
53
LEVEMIR FLEXPEN
50
KURVELO
86
LEVEMIR FLEXTOUCH
50
KUVAN
75
LEVETIRACETAM
22
L
LEVOBUNOLOL HCL
102
LEVOCARNITINE
118
LABETALOL HCL
56
LEVOCARNITINE (WITH SUGAR)
118
LACLOTION
70
LEVOCETIRIZINE DIHYDROCHLORIDE
105
LACOSAMIDE
24
LEVOFLOXACIN
100
LACTOBACILLUS COMBINATION
LEVOFLOXACIN/DEXTROSE 5 % IN WATER
21
34
NO.2/S.THERMOPHL/BIF CMB NO.1
77
LEVOLEUCOVORIN CALCIUM
LACTULOSE
78
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM
LAMISIL
28
ALGAL OIL
118
LAMIVUDINE
45
LEVONEST
87
PAGE 137
LAST UPDATED 02/2016
LEVONORGESTREL
88
LITHIUM CITRATE
48
LEVONORGESTREL-ETHINYL ESTRADIOL
90
LMD 10% WITH 0.9% SOD CHLORIDE
98
LMD 10% WITH 5% DEXTROSE
98
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL
87
LOMEDIA 24 FE
87
LEVORA-28
87
LOMITAPIDE MESYLATE
62
LOMUSTINE
31
LEVORPHANOL TARTRATE
6
LEVOTHYROXINE SODIUM
92
LOPINAVIR/RITONAVIR
46
LEVOXYL
92
LOPREEZA
87
LEXIVA
46
LORAZEPAM
47
LIDOCAINE
70
LORAZEPAM INTENSOL
47
LIDOCAINE HCL
70
LORCET
10
LORCET HD
10
LIDOCAINE HCL BUFFERED WITH 8.4 % SODIUM
BICARBONATE
12
LORCET PLUS
10
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF
13
LORENZA
71
LIDOCAINE HCL/DEXTROSE 7.5%-WATER/PF
13
LORTAB
10
LIDOCAINE HCL/EPINEPHRINE
13
LORYNA
87
LIDOCAINE HCL/EPINEPHRINE/PF
13
LOSARTAN POTASSIUM
55
LIDOCAINE HCL/HYDROCORTISONE ACETATE 71
LOSARTAN
LIDOCAINE HCL/MENTHOL
71
POTASSIUM/HYDROCHLOROTHIAZIDE
59
LIDOCAINE HCL/PF
13
LOTRONEX
77
LIDOCAINE/MENTHOL
71
LOVASTATIN
62
LIDOCAINE/PRILOCAINE
72
LOW-OGESTREL
87
LINACLOTIDE
77
LOXAPINE SUCCINATE
40
LINAGLIPTIN
49
LUGOL'S
98
LINAGLIPTIN/METFORMIN HCL
49
LUMIZYME
75
LINCOMYCIN HCL
15
LUPRON DEPOT
93
LINDANE
71
LUPRON DEPOT-PED
93
LINEZOLID
17
LUSTRA-ULTRA
71
LINEZOLID IN 0.9 % SODIUM CHLORIDE
16
LUTERA
87
LINZESS
77
LYRICA
65
LIOTHYRONINE SODIUM
92
LYSODREN
34
LIOTRIX
92
LYZA
91
LIPASE/PROTEASE/AMYLASE
75
LIPODOX
34
M
LIPODOX 50
34
MACITENTAN
LIPOSYN III
118
MAFENIDE ACETATE
LIRAGLUTIDE
49
MAG HYDROXIDE/AL
LISDEXAMFETAMINE DIMESYLATE
63
HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAI
LISINOPRIL
55
NE
LISINOPRIL/HYDROCHLOROTHIAZIDE
59
MAGNESIUM CHLORIDE
114
LITHIUM CARBONATE
47
MAGNESIUM SULFATE
114
PAGE 138
108
71
66
LAST UPDATED 02/2016
MAGNESIUM SULFATE IN STERILE WATER
114
MEROPENEM IN 0.9 % SODIUM CHLORIDE
19
MAKENA
91
MESALAMINE
96
MALATHION
39
MESALAMINE WITH CLEANSING WIPES
96
MANGANESE CHLORIDE
114
MESNA
34
MANGANESE SULFATE
114
MESNEX
34
MANNITOL
60
MESTINON
30
MAPROTILINE HCL
25
METADATE ER
63
MARAVIROC
45
METAPROTERENOL SULFATE
106
MARGESIC
64
METAXALONE
110
MARLEXATE
111
METFORMIN HCL
64
MARLISSA
87
METHADONE HCL
7
MARQIBO
34
METHADONE INTENSOL
7
MARTEN-TAB
64
METHADOSE
7
MATULANE
31
METHAMPHETAMINE HCL
MATZIM LA
57
METHAZOLAMIDE
MD-GASTROVIEW
98
METHENAMINE HIPPURATE
16
ME-PB-HYOS
76
METHENAMINE MANDELATE
16
MECASERMIN
83
METHENAMINE/METHYLENE BLUE/BENZOIC
MECHLORETHAMINE HCL
31
ACID/SALICYLATE/HYOSCY
MECLIZINE HCL
26
METHENAMINE/METHYLENE
MECLOFENAMATE SODIUM
MEDROXYPROGESTERONE ACETATE
63
102
5
BLUE/SALICYLATE/SODIUM PHOS/HYOSCY
91
METHENAMINE/METHYLENE BLUE/SODIUM
17
MEFENAMIC ACID
5
MEFLOQUINE HCL
38
METHENAMINE/SODIUM
MEGESTROL ACETATE
91
PHOSPHATE,MONOBASIC/METH BLUE/HYOSC
MEKINIST
36
SUL
17
METHIMAZOLE
93
83
MELOXICAM
5
PHOS/PNYL SAL/HYOSC SUL
17
17
MELPAQUE HP
71
METHITEST
MELPHALAN
31
METHOCARBAMOL
MELPHALAN HCL
31
METHOTREXATE SODIUM
95
MELQUIN HP
71
METHOTREXATE SODIUM/PF
94
MELQUIN-3
71
METHOXSALEN
67
MEMANTINE HCL
24
METHOXSALEN, RAPID
71
MENEST
87
METHSUXIMIDE
22
MEPERIDINE HCL
10
METHYCLOTHIAZIDE
61
METHYLDOPA
55
MEPHYTON
118
110
MEPIVACAINE HCL
13
METHYLDOPA/HYDROCHLOROTHIAZIDE
59
MEPIVACAINE HCL/PF
13
METHYLDOPATE HCL
55
MEPRON
38
METHYLENE BLUE
98
MERCAPTOPURINE
33
METHYLERGONOVINE MALEATE
98
MEROPENEM
19
METHYLNALTREXONE BROMIDE
77
PAGE 139
LAST UPDATED 02/2016
METHYLPHENIDATE HCL
63
MITOTANE
34
METHYLPREDNISOLONE
82
MITOXANTRONE HCL
34
METHYLPREDNISOLONE ACETATE
82
MODAFINIL
111
METHYLPREDNISOLONE SODIUM SUCCINATE
82
MODERIBA
43
METHYLTESTOSTERONE
83
MOEXIPRIL HCL
55
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE
60
40
METIPRANOLOL
102
METOCLOPRAMIDE HCL
26
MOLINDONE HCL
METOLAZONE
61
MOLYBDENUM (AMMONIUM MOLYBDATE)
METOPROLOL SUCCINATE
56
MOMETASONE FUROATE
METOPROLOL TARTRATE
56
MOMETASONE FUROATE/FORMOTEROL
METOPROLOL
FUMARATE
114
71
109
TARTRATE/HYDROCHLOROTHIAZIDE
59
MONDOXYNE NL
21
METRO IV
16
MONO-LINYAH
88
METRONIDAZOLE
72
MONOJECT 0.9% SODIUM CHLORIDE
114
METRONIDAZOLE IN SODIUM CHLORIDE
16
MONOJECT PREFILL
115
METYROSINE
59
MONOJECT PREFILL ADVANCED
115
MEXILETINE HCL
56
MONONESSA
88
MICAFUNGIN SODIUM
28
MONONINE
53
MICONAZOLE NITRATE
28
MONSEL'S
53
MICROFIBRILLAR COLLAGEN
98
MONTELUKAST SODIUM
MICROGESTIN
87
MORPHINE SULFATE
11
MICROGESTIN 24 FE
87
MORPHINE SULFATE/PF
11
MICROGESTIN FE
87
MOXEZA
100
MIDAZOLAM HCL
47
MOXIFLOXACIN HCL
100
MIDAZOLAM HCL/PF
47
MOXIFLOXACIN HCL IN SODIUM ACETATE AND
MIDODRINE HCL
55
SULFATE,WATER,ISO-OSM
MIGERGOT
29
MOXIFLOXACIN HCL/SODIUM CHLORIDE, ISO-
MIGLUSTAT
75
OSMOTIC
20
MIGRAGESIC IDA
98
MOZOBIL
52
MILLIPRED DP
82
MULTIGEN
115
MILNACIPRAN HCL
65
MULTIGEN FOLIC
115
MILRINONE LACTATE
59
MULTIGEN PLUS
115
MILRINONE LACTATE/DEXTROSE 5 % IN WATER 59
MULTITRACE-4
115
MIMVEY
87
MULTITRACE-5
115
MIMVEY LO
88
MULTIVITAMINS WITH MIN NO.7/FOLIC ACID
119
MINOCYCLINE HCL
21
MUPIROCIN
71
MINOXIDIL
62
MUPIROCIN CALCIUM
71
MUSTARGEN
31
MIOSTAT
102
105
21
MIRTAZAPINE
25
MY WAY
88
MISOPROSTOL
78
MYCAMINE
28
MITOMYCIN
34
MYCOBUTIN
30
PAGE 140
LAST UPDATED 02/2016
MYCOPHENOLATE MOFETIL
94
NEOMYCIN SULFATE/BACITRACIN
MYCOPHENOLATE MOFETIL HCL
93
ZINC/POLYMYXIN B/HYDROCORTISONE
MYCOPHENOLATE SODIUM
94
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
MYFORTIC
94
B
MYLERAN
31
NEOMYCIN SULFATE/POLYMYXIN B SULFATE
101
MYNATAL PLUS
118
NEOMYCIN SULFATE/POLYMYXIN B
MYNATAL-Z
118
SULFATE/GRAMICIDIN D
MYNEPHROCAPS
118
NEOMYCIN SULFATE/POLYMYXIN B
MYORISAN
71
SULFATE/HYDROCORTISONE
MYOZYME
75
NEOMYCIN/POLYMYXIN B
MYZILRA
88
SULFATE/DEXAMETHASONE
N
NABUMETONE
5
100
16
101
103
101
NEOSTIGMINE BROMIDE
30
NEOSTIGMINE METHYLSULFATE
30
NEPHPLEX RX
118
118
NADOLOL
57
NEPHRO-VITE RX
NADOLOL/BENDROFLUMETHIAZIDE
60
NEUAC
71
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC
19
NEULASTA
52
NAFCILLIN SODIUM
19
NEUMEGA
52
NAGLAZYME
75
NEVIRAPINE
45
NALBUPHINE HCL
11
NEXAVAR
36
NALOXONE HCL
14
NEXT CHOICE ONE DOSE
88
NALTREXONE HCL
14
NIACIN
62
NAMENDA
24
NICARDIPINE HCL
57
NAPHAZOLINE HCL
100
NICARDIPINE HCL IN 0.9 % SODIUM CHLORIDE 57
NAPROXEN
5
NIFEDIAC CC
57
NAPROXEN SODIUM
5
NIFEDICAL XL
57
NARATRIPTAN HCL
29
NIFEDIPINE
57
NAROPIN
13
NIKKI
88
NATACYN
28
NILANDRON
32
NILOTINIB HCL
37
NATALVIRT FLT
115
NATAMYCIN
28
NILUTAMIDE
32
NATEGLINIDE
49
NIMODIPINE
58
NATURE-THROID
92
NISOLDIPINE
58
NEBUPENT
38
NITAZOXANIDE
38
NECON
88
NITISINONE
75
NELARABINE
33
NITRO-BID
62
NELFINAVIR MESYLATE
46
NITRO-TIME
62
NEO-POLYCIN
100
NITROFURANTOIN
16
NEO-POLYCIN HC
100
NITROFURANTOIN MACROCRYSTAL
16
NEOMYCIN SULFATE
15
NITROFURANTOIN
MONOHYDRATE/MACROCRYSTALS
PAGE 141
16
LAST UPDATED 02/2016
NITROGLYCERIN
72
NYAMYC
28
NITROGLYCERIN/DEXTROSE 5 % IN WATER
63
NYSTATIN
28
NITROSTAT
63
NYSTATIN/LIDOCAINE HCL/DIPHENHYDRAMINE
NIVA-PLUS
118
NIZATIDINE
HCL
27
77
NYSTATIN/TRIAMCINOLONE ACETONIDE
28
NODOLOR
98
NYSTOP
28
NORA-BE
91
NORDITROPIN
83
O
NORDITROPIN FLEXPRO
83
OCELLA
88
NORDITROPIN NORDIFLEX
83
OCTREOTIDE ACETATE
93
NOREPINEPHRINE BITARTRATE
60
OCUCOAT
101
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUM
OCUDOX
21
CHLORIDE
60
OFATUMUMAB
37
NORETHINDRONE
91
OFLOXACIN
NORETHINDRONE ACETATE
91
OGEN
88
OGESTREL
88
OLANZAPINE
42
OLANZAPINE/FLUOXETINE HCL
25
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL
88
NORETHINDRONE ACETATE-ETHINYL
103
ESTRADIOL/FERROUS FUMARATE
89
OLODATEROL HCL
106
NORETHINDRONE-ETHINYL ESTRADIOL
90
OLOPATADINE HCL
105
OMALIZUMAB
110
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE
90
OMBITASVIR/PARITAPREVIR/RITONAVIR
NORGESTIMATE-ETHINYL ESTRADIOL
89
OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABU
NORGESTREL-ETHINYL ESTRADIOL
88
VIR SODIUM
44
NORLYROC
91
OMEGA-3 ACID ETHYL ESTERS
62
NORTHERA
60
OMEPRAZOLE
79
NORTREL
88
OMEPRAZOLE/SODIUM BICARBONATE
79
NORTRIPTYLINE HCL
26
ONDANSETRON
27
NORVIR
46
ONDANSETRON HCL
27
NOVAREL
83
ONDANSETRON HCL/PF
27
NOVOEIGHT
53
ONFI
22
NOVOSEVEN RT
53
ONXOL
35
NOXAFIL
28
OPIUM TINCTURE
77
NP THYROID
92
OPIUM/BELLADONNA ALKALOIDS
11
NU-DERM
71
OPRELVEKIN
52
NUEDEXTA
64
OPSUMIT
108
NULOJIX
94
ORFADIN
75
NUQUIN HP
71
ORPHENADRINE CITRATE
NUTRILIPID
118
ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE 110
NUTRILYTE
115
ORSYTHIA
88
NUTRILYTE II
115
OSCIMIN
76
PAGE 142
44
110
LAST UPDATED 02/2016
OSCIMIN SL
76
PAREGORIC
OSCIMIN SR
76
PARENTERAL AMINO ACID 10% COMBINATION
OSELTAMIVIR PHOSPHATE
46
NO. 4
OSMITROL
60
PARENTERAL AMINO ACID 10% COMBINATION
OTICIN HC
103
NO. 6
OTO-END 10
103
PARENTERAL AMINO ACID 10% COMBINATION
OTOMAX-HC
103
NO.7
OTOZIN
103
PARENTERAL AMINO ACID 15% COMBINATION
OXACILLIN SODIUM
19
77
117
119
118
NO.1
117
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC 19
PARICALCITOL
97
OXALIPLATIN
35
PAROEX
66
OXANDROLONE
83
PAROMOMYCIN SULFATE
15
PAROXETINE HCL
25
OXAPROZIN
6
OXAZEPAM
47
PASIREOTIDE DIASPARTATE
93
OXCARBAZEPINE
23
PAZOPANIB HCL
37
OXSORALEN-ULTRA
71
PEDI-DRI
28
OXYBENZONE/OCTINOXATE/HYDROQUINONE
67
PEDIATRIC MULTIVITAMIN COMBO
OXYBUTYNIN CHLORIDE
79
NO.75/FLUORIDE/FERROUS SULFATE
OXYCODONE HCL
11
PEGANONE
23
OXYCODONE HCL/ACETAMINOPHEN
12
PEGASYS
43
OXYCODONE HCL/ASPIRIN
11
PEGASYS PROCLICK
43
PEGFILGRASTIM
52
OXYCONTIN
8
118
OXYMORPHONE HCL
12
PEGINTERFERON ALFA-2A
43
OXYTOCIN
99
PEGINTERFERON ALFA-2B
35
PEMETREXED DISODIUM
32
PENICILLAMINE
80
P
PACERONE
56
PENICILLIN G POTASSIUM
20
PACLITAXEL
35
PENICILLIN G PROCAINE
19
PACLITAXEL PROTEIN-BOUND
33
PENICILLIN G SODIUM
19
PAIN RELIEF
71
PENICILLIN V POTASSIUM
19
PALBOCICLIB
36
PENTAMIDINE ISETHIONATE
38
PENTASA
96
PALGIC
105
PALIFERMIN
66
PENTAZOCINE HCL/NALOXONE HCL
12
PALIPERIDONE
42
PENTOSAN POLYSULFATE SODIUM
80
PALIPERIDONE PALMITATE
41
PENTOSTATIN
33
PALIVIZUMAB
96
PENTOXIFYLLINE
60
PANCURONIUM BROMIDE
64
PERFOROMIST
PANHEMATIN
99
PERINDOPRIL ERBUMINE
55
PANITUMUMAB
38
PERIOGARD
66
PANTOPRAZOLE SODIUM
79
PERITONEAL DIALYSIS NO.6 WITH DEXTROSE 1.5
PAPAVERINE HCL
24
%
PAGE 143
106
112
LAST UPDATED 02/2016
PERITONEAL DIALYSIS NO.7 WITH DEXTROSE 2.5
PIMOZIDE
40
%
PIMTREA
88
PINDOLOL
57
PIOGLITAZONE HCL
49
112
PERITONEAL DIALYSIS NO.8 WITH DEXTROSE
4.25 %
112
PERJETA
38
PIOGLITAZONE HCL/GLIMEPIRIDE
49
PERMETHRIN
72
PIOGLITAZONE HCL/METFORMIN HCL
49
PERPHENAZINE
26
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 20
PERPHENAZINE/AMITRIPTYLINE HCL
25
PIRMELLA
PERTUZUMAB
38
PIROXICAM
PFIZERPEN
20
PLERIXAFOR
PHENADOZ
105
88
6
52
PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE
PHENAZOPYRIDINE HCL
80
VACCINE
96
PHENDIMETRAZINE TARTRATE
64
PNEUMOVAX 23
96
PHENELZINE SULFATE
25
PNV 29-1
118
PNV-SELECT
118
118
PHENERGAN
105
PHENOBARBITAL
22
PNV-VP-U
PHENOBARBITAL SODIUM
22
PODOFILOX
72
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE
POLOCAINE
13
SULF/SCOPOLAMINE HB
76
POLOCAINE-MPF
13
PHENOL
99
POLYCIN
PHENOXYBENZAMINE HCL
55
POLYETHYLENE GLYCOL 3350
78
PHENTERMINE HCL
64
POLYMYXIN B SULFATE
16
PHENTOLAMINE MESYLATE
55
POLYMYXIN B SULFATE/TRIMETHOPRIM
101
POLYSACCHARIDE IRON FORTE
115
PHENYLEPHRINE HCL
101
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE
60
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE/PF
PHENYLEPHRINE HCL/PROMETHAZINE HCL
60
109
101
POMALIDOMIDE
32
POMALYST
32
PONATINIB HCL
36
PORFIMER SODIUM
35
PORTIA
89
28
PHENYTOIN
23
POSACONAZOLE
PHENYTOIN SODIUM
23
POTASSIUM ACETATE
115
PHENYTOIN SODIUM EXTENDED
23
POTASSIUM BICARBONATE/CITRIC ACID
115
PHILITH
88
POTASSIUM CHLORIDE
115
PHOSPHA 250 NEUTRAL
80
POTASSIUM CHLORIDE IN 0.45 % SODIUM
PHOSPHASAL
16
CHLORIDE
PHOSPHOLINE IODIDE
102
116
POTASSIUM CHLORIDE IN 0.9 % SODIUM
PHOSPHORUS #1
81
CHLORIDE
115
PHOTOFRIN
35
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN
PHYSOSTIGMINE SALICYLATE
99
WATER
115
PHYTONADIONE
118
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9
PILOCARPINE HCL
102
% SODIUM CHLORIDE
PAGE 144
115
LAST UPDATED 02/2016
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %
PREMPRO
SODIUM CHLORIDE
PRENA1 CHEW
118
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %
PRENAPLUS
119
SODIUM CHLORIDE
PRENATAL VIT WITH CALCIUM CMB 11/FERROUS
116
116
89
POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3
FUMARATE/FOLIC ACID
% SODIUM CHLORIDE
PRENATAL VIT WITH CALCIUM NO. 40/IRON
116
POTASSIUM CHLORIDE IN LACTATED RINGERS
FUMARATE/FA CMB NO.1
AND 5 % DEXTROSE
PRENATAL VIT WITH CALCIUM NO.66/IRON
116
POTASSIUM CHLORIDE/POTASSIUM
BICARBONATE/CITRIC ACID
FUM/FOLIC ACID/DSS/DHA
115
120
119
120
PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX
POTASSIUM CITRATE
80
& ASPGL/FA/DHA
POTASSIUM CITRATE/CITRIC ACID
81
PRENATAL VITAMIN
POTASSIUM IODIDE/IODINE
99
NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE
POTASSIUM PHOS,M-BASIC-D-BASIC
116
POTASSIUM PHOSPHATE IN 0.9 % SODIUM
119
SOD
119
PRENATAL VITAMIN
CHLORIDE
116
NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE
POTASSIUM PHOSPHATE,MONOBASIC
114
SOD
120
POTIGA
22
PRENATAL VITAMIN NO.81/SODIUM FEREDETATE-
PR BENZOYL PEROXIDE
72
IRON POLY/FA/OMEGA3
PR CREAM
72
PRENATAL VITAMINS COMB 10/FERROUS
PRADAXA
51
FUMARATE/FOLIC ACID
PRALATREXATE
33
PRENATAL VITAMINS COMBINATION NO.42/FOLIC
PRALIDOXIME CHLORIDE
99
ACID
PRAMCORT
72
PRENATAL VITAMINS NO.11/FERROUS
PRAMIPEXOLE DI-HCL
39
FUMARATE/FOLIC ACID/OMEGA-3
PRAMLINTIDE ACETATE
49
PRENATAL VITAMINS WITH CALCIUM/FERROUS
PRAMOXINE-HC
103
FUMARATE/FOLIC ACID
54
PRENATAL VITS WITH CALCIUM #72/FERROUS
PRAVASTATIN SODIUM
62
FUMARATE/FOLIC ACID
PRAZOSIN HCL
55
PRENATAL VITS WITH CALCIUM #73/FERROUS
PRE-ATTACHED LTA KIT
67
FUMARATE/FOLIC ACID
102
120
118
PRASUGREL HCL
PRED MILD
119
119
118
118
119
PRENATAL VITS WITH CALCIUM #74/FERROUS
PREDNICARBATE
72
FUMARATE/FOLIC ACID
PREDNISOLONE
82
PRENATAL VITS WITH CALCIUM
PREDNISOLONE ACETATE
102
#76/IRON,CARBONYL/FOLIC ACID
PREDNISOLONE SOD PHOSPHATE
102
PRENATAL VITS WITH CALCIUM #78/FERROUS
120
119
PREDNISONE
82
FUMARATE/FOLIC ACID
PREDNISONE INTENSOL
82
PRENATAL VITS WITHOUT CALC NO5/FERROUS
PREGABALIN
65
FUMARATE/FOLIC ACID
118
PRETAB
119
PREMASOL
PREMPHASE
PAGE 145
118
89
PREVALITE
119
62
LAST UPDATED 02/2016
PREVIFEM
89
PROTECTIVES COMBINATION NO.2/CERAMIDES
PREZISTA
46
1,3,6-11
72
PRIFTIN
30
PROTOPAM CHLORIDE
99
PRIMIDONE
22
PROTRIPTYLINE HCL
26
PRIVIGEN
95
PULMICORT FLEXHALER
104
PROBENECID
29
PULMOZYME
109
PROCAINAMIDE HCL
56
PUREVIT DUALFE PLUS
116
PROCARBAZINE HCL
31
PURINETHOL
33
PROCENTRA
63
PYRAZINAMIDE
30
PROCHLORPERAZINE
26
PYRIDOSTIGMINE BROMIDE
30
PROCHLORPERAZINE EDISYLATE
26
PYRIMETHAMINE
38
PROCHLORPERAZINE MALEATE
26
PROCRIT
52
Q
PROCTO-PAK
96
QUASENSE
89
PROCTOSOL-HC
97
QUAZEPAM
110
PROCTOZONE-HC
97
QUETIAPINE FUMARATE
42
QUINAPRIL HCL
55
PROFERRIN-FORTE
116
PROFILNINE
53
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE
60
PROFILNINE SD
54
QUINIDINE GLUCONATE
56
PROGESTERONE
91
QUINIDINE SULFATE
56
PROGESTERONE,MICRONIZED
91
QUININE SULFATE
39
PROGLYCEM
50
QVAR
PROGRAF
94
104
PROLASTIN
109
R
PROLASTIN C
109
RABEPRAZOLE SODIUM
PROMACTA
52
79
RADIOPAQUE PVC MARKERS/BARIUM SULFATE 99
PROMETHAZINE HCL
105
RALOXIFENE HCL
91
PROMETHAZINE HCL/CODEINE
109
RALTEGRAVIR POTASSIUM
44
PROMETHAZINE HCL/DEXTROMETHORPHAN
RAMELTEON
111
HBR
109
RAMIPRIL
55
PROMETHEGAN
105
RANITIDINE HCL
77
RAPAMUNE
94
RASBURICASE
33
PROPARACAINE HCL/FLUORESCEIN SODIUM 101
RAVICTI
75
PROPOFOL
13
REA LO 39
72
PROPRANOLOL HCL
57
REA LO 40
72
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 60
REBIF
66
PROPYLTHIOURACIL
93
REBIF REBIDOSE
66
PROSTIGMIN
30
RECLIPSEN
89
PROTAMINE SULFATE
51
RECOMBINATE
54
RECTACORT-HC
82
PROPAFENONE HCL
56
PROPARACAINE HCL
101
PAGE 146
LAST UPDATED 02/2016
RECTIV
72
RINGERS SOLUTION,LACTATED
119
REGONOL
30
RIOCIGUAT
108
REGORAFENIB
36
RIOMET
49
REGRANEX
72
RISEDRONATE SODIUM
97
RELADOR PAK
72
RISPERDAL CONSTA
42
RELADOR PAK PLUS
72
RISPERIDONE
42
RELENZA
46
RISPERIDONE MICROSPHERES
42
RELISTOR
77
RITONAVIR
46
REMEVEN
72
RITUXAN
38
REMICADE
94
RITUXIMAB
38
REMODULIN
108
RIVAROXABAN
51
RENA-VITE RX
119
RIVASTIGMINE
24
80
RIVASTIGMINE TARTRATE
24
RENAL CAPS
119
RIZATRIPTAN BENZOATE
29
RENO CAPS
119
ROCURONIUM BROMIDE
64
RENACIDIN
RENVELA
81
ROMIDEPSIN
34
REPAGLINIDE
49
ROPINIROLE HCL
39
REPAGLINIDE/METFORMIN HCL
49
ROPIVACAINE HCL/PF
13
REPREXAIN
12
ROSADAN
72
RESCRIPTOR
44
ROSULA
72
RESERPINE
55
ROXICET
12
RESTASIS
101
ROZEREM
111
REVATIO
108
RUFINAMIDE
23
REVLIMID
32
RUXOLITINIB PHOSPHATE
36
REVONTO
110
REYATAZ
46
S
RHO(D) IMMUNE GLOBULIN
95
SABRIL
22
RIASTAP
54
SACROSIDASE
75
RIBASPHERE
43
SALACYN
72
RIBASPHERE RIBAPAK
43
SALICYLIC ACID
72
RIBAVIRIN
44
SALICYLIC ACID/AMMONIUM LACTATE/ALOE
RIDAURA
96
VERA
72
RIFABUTIN
30
SALICYLIC ACID/CERAMIDES 1,3,6-11
72
RIFAMPIN
30
SALSALATE
RIFAPENTINE
30
SALVAX
72
RIFAXIMIN
17
SAMSCA
111
RILONACEPT
95
SANTYL
72
RILPIVIRINE HCL
44
SAPROPTERIN DIHYDROCHLORIDE
75
RILUZOLE
64
SAQUINAVIR MESYLATE
46
RIMANTADINE HCL
46
SARGRAMOSTIM
52
SAVELLA
65
RINGERS SOLUTION
PAGE 147
119
6
LAST UPDATED 02/2016
SCALACORT
73
SODIUM CITRATE DIHYDRATE
SE 10-5 SS
73
SODIUM FLUORIDE
119
SE BPO
73
SODIUM FLUORIDE/XYLITOL
117
SODIUM LACTATE
116
SE-TAN PLUS
SEB-PREV
116
73
SODIUM MORRHUATE
SECOBARBITAL SODIUM
111
SODIUM OXYBATE
SECONAL SODIUM
111
SODIUM PHENYLBUTYRATE
SELEGILINE HCL
SELENIUM
40
116
51
99
111
SODIUM PHOS,M-BASIC-D-BASIC
75
116
SODIUM PHOSPHATE,MONOBASIC/POTASSIUM
SELENIUM SULFIDE
73
PHOSPHATE,MONOBASIC
SELZENTRY
45
SODIUM POLYSTYRENE SULFONATE
SENSIPAR
92
SODIUM TETRADECYL SULFATE
99
SENSORCAINE
13
SODIUM THIOSULFATE
99
SENSORCAINE-EPINEPHRINE
13
SODIUM/POTASSIUM/MAGNES/CALCIUM/CHLORID
SENSORCAINE-MPF
13
E/ACETATE/GLUCONATE
SEROQUEL XR
42
SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO
SERTRALINE HCL
25
RIDE/ACETATE
SETLAKIN
89
SODIUM/POTASSIUM/POTASSIUM
SEVELAMER CARBONATE
81
CITRATE/SODIUM CITRATE/CIT AC
81
SEVOFLURANE
14
SOFOSBUVIR
44
SHAROBEL
91
SOJOURN
14
SIGNIFOR
93
SOLIRIS
99
SOMATROPIN
83
SILDENAFIL CITRATE
108
80
112
115
115
SILVER NITRATE
73
SORAFENIB TOSYLATE
36
SILVER NITRATE/POTASSIUM NITRATE
73
SORINE
56
SILVER SULFADIAZINE
74
SOTALOL HCL
56
SIMVASTATIN
62
SOTRADECOL
99
SIROLIMUS
94
SOVALDI
44
SIRTURO
30
SPINOSAD
73
SITAGLIPTIN PHOSPHATE
49
SPIRIVA
105
SITAGLIPTIN PHOSPHATE/METFORMIN HCL
48
SPIRIVA RESPIMAT
105
SITZMARKS
99
SPIRONOLACTONE
61
SODIUM ACETATE
116
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE
60
SODIUM BICARBONATE
116
SPORANOX
28
SODIUM CHLORIDE 0.45 %
116
SPRINTEC
89
SODIUM CHLORIDE 3 %
116
SPRYCEL
36
SODIUM CHLORIDE 5 %
116
SPS
SODIUM CHLORIDE FOR INHALATION
109
SRONYX
89
SS 10-2
73
SSD
73
SSS 10-5
73
SODIUM CHLORIDE IRRIGATING SOLUTION
80
SODIUM CHLORIDE IRRIGATING
SOLUTION/HYPOCHLOROUS ACID
PAGE 148
74
112
LAST UPDATED 02/2016
STAVUDINE
45
SUTENT
37
STIMATE
83
SYEDA
89
SYLATRON
35
STIOLTO RESPIMAT
110
STIVARGA
36
SYLATRON 4-PACK
35
STRATTERA
64
SYMAX
76
STRENSIQ
75
SYMAX-SL
76
STREPTOZOCIN
32
SYMAX-SR
76
STRIBILD
44
SYMBICORT
STRIVERDI RESPIMAT
110
106
SYMLINPEN 120
49
STROMECTOL
38
SYMLINPEN 60
49
SUBLIMAZE
12
SYNAGIS
96
SUBOXONE
14
SYREX
SUCCIMER
111
SUCCINYLCHOLINE CHLORIDE
110
116
T
SUCRAID
75
TABLOID
33
SUCRALFATE
78
TACROLIMUS
94
SUFENTA
12
TADALAFIL
108
SUFENTANIL CITRATE
12
TAFINLAR
37
TALIGLUCERASE ALFA
75
TAMIFLU
46
TAMOXIFEN CITRATE
32
TAMSULOSIN HCL
79
TARCEVA
37
SULFACETAMIDE SODIUM
101
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE
SULFACETAMIDE SODIUM/SULFUR
101
74
SULFACETAMIDE SODIUM/SULFUR/SKIN
CLEANSER COMB NO.23
73
TARGRETIN
38
SULFACETAMIDE SODIUM/SULFUR/UREA
73
TARINA FE
89
SULFACETAMIDE SODIUM/SULFUR/WITCH
TARON FORTE
116
HAZEL
73
TARON-CRYSTALS
80
SULFACLEANSE 8-4
73
TASIGNA
37
SULFADIAZINE
21
TASIMELTEON
SULFAMETHOXAZOLE/TRIMETHOPRIM
21
TASMAR
39
SULFAMYLON
16
TAZAROTENE
74
SULFASALAZINE
97
TAZORAC
74
SULFATRIM
21
TAZTIA XT
58
SULFAZINE
97
TECFIDERA
66
SULFAZINE EC
97
TECHNIVIE
44
SULFURIC ACID/SULFONATED PHENOL
66
TEGRETOL XR
23
6
TELAPREVIR
43
SUMATRIPTAN
29
TELBIVUDINE
43
SUMATRIPTAN SUCCINATE
29
TELMISARTAN
55
SUNITINIB MALATE
37
TELMISARTAN/AMLODIPINE BESYLATE
60
SUSTIVA
45
TELMISARTAN/HYDROCHLOROTHIAZIDE
60
SULINDAC
PAGE 149
111
LAST UPDATED 02/2016
TEMAZEPAM
111
THYROLAR-2
92
TEMODAR
31
THYROLAR-3
92
TEMOZOLOMIDE
31
TIAGABINE HCL
22
TEMSIROLIMUS
37
TICAGRELOR
54
TENCON
65
TIGECYCLINE
16
TENIPOSIDE
35
TIKOSYN
56
TENOFOVIR DISOPROXIL FUMARATE
45
TIMOLOL MALEATE
TERAZOSIN HCL
79
TINIDAZOLE
TERBINAFINE HCL
28
TIOTROPIUM BROMIDE
105
TIOTROPIUM BROMIDE/OLODATEROL HCL
110
TERBUTALINE SULFATE
106
102
16
TERCONAZOLE
29
TIPRANAVIR
45
TERIPARATIDE
97
TIVICAY
44
TERRELL
14
TIZANIDINE HCL
110
TESAMORELIN ACETATE
93
TL G-FOL OS
119
TESTOPEL
83
TL ICON
116
TESTOSTERONE
84
TL-HEM 150
116
TESTOSTERONE CYPIONATE
84
TOBI
107
TESTOSTERONE ENANTHATE
84
TOBI PODHALER
107
TOBRAMYCIN
107
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE
107
TETCAINE
101
TETRABENAZINE
65
TETRACAINE HCL
101
TOBRAMYCIN SULFATE
15
TETRACAINE HCL/PF
101
TOBRAMYCIN SULFATE/SODIUM CHLORIDE
15
TETRACYCLINE HCL
21
TOBRAMYCIN/DEXAMETHASONE
101
THALIDOMIDE
32
TOBRAMYCIN/NEBULIZER
107
THALOMID
32
TOCILIZUMAB
95
THEOCHRON
107
TOLAZAMIDE
49
THEOPHYLLINE ANHYDROUS
107
TOLBUTAMIDE
49
THEOPHYLLINE/DEXTROSE 5 % IN WATER
108
TOLCAPONE
39
THERACYS
THERAPEUTIC VITAMIN W-MINERALS
35
119
TOLMETIN SODIUM
6
TOLTERODINE TARTRATE
79
THERMAZENE
74
TOLVAPTAN
111
THIAMINE HCL
119
TOPIRAGEN
23
THIOGUANINE
33
TOPIRAMATE
23
THIORIDAZINE HCL
40
TOPOSAR
35
THIOTEPA
35
TOREMIFENE CITRATE
32
THIOTHIXENE
40
TORISEL
37
THRIVITE RX
119
TORSEMIDE
61
37
THYROID,PORK
92
TOSITUMOMAB (WITH MALTOSE)
THYROLAR-1
92
TRACLEER
108
THYROLAR-1/2
92
TRADJENTA
49
THYROLAR-1/4
92
TRAMADOL HCL
12
PAGE 150
LAST UPDATED 02/2016
TRAMADOL HCL/ACETAMINOPHEN
12
TRIMETHOBENZAMIDE HCL
26
TRAMETINIB DIMETHYL SULFOXIDE
36
TRIMETHOPRIM
16
TRANDOLAPRIL
55
TRINESSA
89
TRANDOLAPRIL/VERAPAMIL HCL
60
TRISENOX
35
TRANEXAMIC ACID
54
TRIVORA-28
90
TRANYLCYPROMINE SULFATE
25
TROPICAMIDE
TRASTUZUMAB
37
TROSPIUM CHLORIDE
79
101
TRAVASOL
119
TRUVADA
45
TRAVOPROST (BENZALKONIUM)
102
TRYPSIN/BALSAM PERU/CASTOR OIL
74
TRAZODONE HCL
25
TUDORZA PRESSAIR
106
TREANDA
31
TUSSIGON
110
TREPROSTINIL SODIUM
108
TYGACIL
16
TYKERB
37
108
TYVASO
108
TRETINOIN
74
TYZEKA
43
TRETINOIN MICROSPHERES
74
TRETTEN
54
U
TREXALL
95
UCERIS
97
TRI-CHLOR
74
ULORIC
29
TRI-ESTARYLLA
89
ULTIMATE OB DHA
TRI-LEGEST FE
89
UMECTA
74
TRI-LINYAH
89
UNITHROID
92
TRI-LO-ESTARYLLA
89
UR N-C
16
TRI-LO-MARZIA
89
UREA
74
TRI-LO-SPRINTEC
89
UREA/HYALURONATE SODIUM
74
TRI-PREVIFEM
89
UREA/LACTIC ACID/SALICYLIC ACID
74
TRI-SPRINTEC
89
UREA/LACTIC ACID/ZINC UNDECYLENATE
74
TRIACETIN
29
URETRON D-S
16
104
URIMAR-T
16
TRIAMTERENE/HYDROCHLOROTHIAZIDE
60
URIN D.S.
16
TRIANEX
74
URO-BLUE
16
UROGESIC-BLUE
17
TREPROSTINIL/NEBULIZER/NEBULIZER
ACCESSORIES
TRIAMCINOLONE ACETONIDE
TRIAZOLAM
111
119
TRICHLOROACETIC ACID
74
UROLET MB
17
TRICITRASOL
51
UROPHEN MB
17
TRICITRATES
80
URSODIOL
77
URYL
17
TRICON
117
TRIDERM
74
USTELL
17
TRIFLUOPERAZINE HCL
40
UTIRA-C
17
TRIFLURIDINE
46
TRIGELS-F FORTE
TRIHEXYPHENIDYL HCL
PAGE 151
117
39
V
VAGIFEM
90
LAST UPDATED 02/2016
VALACYCLOVIR HCL
46
VICTOZA 2-PAK
49
VALCHLOR
31
VICTOZA 3-PAK
49
VALCYTE
43
VICTRELIS
44
VALGANCICLOVIR HCL
43
VIDEX
45
VALPROIC ACID
23
VIEKIRA PAK
44
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
VIENVA
90
SODIUM)
22
VIGABATRIN
22
VALSARTAN
55
VIMPAT
24
VALSARTAN/HYDROCHLOROTHIAZIDE
60
VINBLASTINE SULFATE
35
VANCOMYCIN HCL
17
VINCASAR PFS
35
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER
17
VINCRISTINE SULFATE
35
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE
17
VINCRISTINE SULFATE LIPOSOMAL
34
VANCOMYCIN IN DEXTROSE, ISO-OSMOTIC
17
VINORELBINE TARTRATE
35
VANDAZOLE
17
VIORELE
90
VANDETANIB
36
VIRACEPT
46
VANTAS
93
VIRAMUNE XR
45
VARENICLINE TARTRATE
14
VIREAD
45
VARICELLA-ZOSTER IMMUNE GLOBULIN
VIRT NATE
119
(HUMAN)
95
VIRT-ADVANCE
119
VARIZIG
95
VIRT-CAPS
119
VASCEPA
62
VIRT-NATE
119
VASHE WOUND THERAPY
74
VIRT-NATE DHA
119
VASOLEX
74
VIRT-PHOS 250 NEUTRAL
VASOPRESSIN
83
VIRT-PN
119
VECTIBIX
38
VIRT-VITE GT
120
VECURONIUM BROMIDE
65
VIRTI-SULF
74
VELAGLUCERASE ALFA
75
VIRTPREX
120
81
VELETRI
108
VIRTRATE-2
81
VELIVET
90
VIRTRATE-3
81
VEMURAFENIB
37
VIRTRATE-K
81
VENA-BAL DHA
119
VISMODEGIB
36
25
VITAFOL-OB
120
VENTAVIS
108
VITAFOL-PN
120
VENTOLIN HFA
106
VITAMIN A/VITAMIN
VENLAFAXINE HCL
VERAPAMIL HCL
58
E/AVOBENZONE/OCTINOXATE/HYDROQUINONE 71
VERDROCET
12
VITAMIN B COMPLEX & VITAMIN C NO.20/FOLIC
VERIPRED 20
82
ACID
VESTURA
90
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
VICODIN
12
ACID/BIOTIN
VICODIN ES
12
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
VICODIN HP
12
ACID/BIOTIN/ZNOX
PAGE 152
119
120
118
LAST UPDATED 02/2016
VOL-CARE RX
120
ZANAMIVIR
46
VOL-PLUS
120
ZANOSAR
32
VORAPAXAR SULFATE
54
ZARAH
90
VORICONAZOLE
29
ZAVESCA
75
VORINOSTAT
35
ZEBUTAL
65
VOTRIENT
37
ZELBORAF
37
VP-VITE RX
120
ZEMAIRA
110
VPRIV
75
ZENCHENT
90
VSL#3 DS
77
ZENCHENT FE
90
VUMON
35
ZENCIA
74
VYFEMLA
90
ZEOSA
90
VYVANSE
63
ZETIA
62
ZEVALIN
38
ZIAGEN
45
45
W
WARFARIN SODIUM
51
ZIDOVUDINE
WATER FOR INJ.,BACTERIOSTATIC
99
ZINC CHLORIDE
117
WATER FOR
ZINC SULFATE
117
INJ.,BACTERIOSTATIC/METHYLPARABEN/PROPYL
ZINC SULFATE HEPTAHYDRATE/CUSO4 P-
PARABEN
99
HYD/MANGANESE/CHROMIUM/SE
WATER FOR INJECTION,STERILE
99
ZINC SULFATE/CUPRIC SULFATE/MANGANESE
WATER FOR IRRIGATION,STERILE
99
SULF/CHROMIC CHLORIDE
WERA
90
ZIPRASIDONE HCL
42
WESTHROID
92
ZIPRASIDONE MESYLATE
41
WYMZYA FE
90
ZOLINZA
35
ZOLMITRIPTAN
30
X
ZOLPIDEM TARTRATE
115
115
111
X-VIATE
74
ZOMIG
30
XALKORI
37
ZONISAMIDE
22
XARELTO
51
ZONTIVITY
54
XENAZINE
65
ZORTRESS
95
XIFAXAN
17
ZOSTAVAX
96
ZOSTER VACCINE LIVE/PF
96
XOLAIR
110
XTANDI
32
ZOVIA 1-35E
90
XYNTHA
54
ZOVIA 1-50E
90
XYNTHA SOLOFUSE
54
ZOVIRAX
47
111
ZYDELIG
37
ZYKADIA
37
ZYTIGA
32
ZYVOX
17
XYREM
Z
ZAFIRLUKAST
105
ZALEPLON
111
ZAMICET
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12
LAST UPDATED 02/2016