Sharp Health Plan: Covered
California Drug List
January 2017
How to use this document
This document is a list of the approved drugs covered for Sharp Health Plan members. All drugs are listed by their generic names
and most common proprietary (brand) name. Generic drugs are listed in lower case italic letters on this document. Brand name
drugs are listed in all capitalized letters. If a drug is only available as a brand name drug, both the generic and brand names are
listed in all capitalized letters. The brand names listed are for reference only and are not an indication that the brand name drug is
covered by Sharp Health Plan, unless specifically noted. The outpatient pharmacy benefit only covers outpatient drugs provided to
members through a network retail or mail order pharmacy. Drugs are listed alphabetically by generic name within each category.
This document is updated monthly and then posted to the Sharp Health Plan website where it can be accessed by current and
prospective members.
Medication Tiers
Each drug is assigned to a specific tier. The tier indicates what your copayment or coinsurance will be for the specific drug. A
deductible may also apply. The tier for each medication is marked throughout this document using one of the following codes:
Code
Tier
Description
T1
Tier 1
Most generic drugs and low-cost preferred brand name drugs
T2
Tier 2
Nonpreferred generic drugs, preferred brand name drugs, and any other drugs
recommended by Sharp Health Plan’s Pharmacy and Therapeutics committee based on
safety, efficacy, and cost
T3
Tier 3
Nonpreferred brand name drugs or drugs that are recommended by Sharp Health Plan’s
Pharmacy and Therapeutics committee based on safety, efficacy, and cost, or that
generally have a preferred and often less costly therapeutic alternative at a lower tier
T4
Tier 4
Biologics, drugs that the FDA or the manufacturer requires to be distributed through a
specialty pharmacy, drugs that require the enrollee to have special training or clinical
monitoring for self-administration, or drugs that cost the health plan more than six
hundred dollars ($600) net of rebates for a one-month supply
PV
PV
Select drugs covered with no copayment, including certain generic and over-thecounter contraceptives for women
MB
MB
Drugs covered under the Medical Benefit, please refer to your medical benefit
coverage information
A preferred drug is a drug that the Sharp Health Plan Pharmacy and Therapeutic Committee has determined provides greater value
than its alternatives when considering clinical effectiveness, safety and overall value.
For information about your copayments, coinsurance and/or deductible, please consult the benefits information available online by
logging onto SharpConnect at www.sharphealthplan.com. When you create an account at SharpConnect, you can access your
benefits information online 24 hours a day, 7 days a week.
What is the Drug List?
The Sharp Health Plan Drug List was developed to identify the safest and most effective drugs for members while maintaining
affordable benefits. The Drug List is updated regularly, based on input from the Sharp Health Plan Pharmacy & Therapeutics
(P&T) Committee, which meets quarterly. The Committee members are clinical pharmacists and actively practicing physicians of
Sharp Health Plan: Covered California
various medical specialties. Voting members are recruited from the Plan’s provider network based on experience, knowledge and
expertise. In addition, the P&T Committee frequently consults with other medical experts to provide input to the Committee.
Updates to the Drug List and drug usage guidelines are made as new clinical information and new drugs become available. In
order to keep the Drug List current, the P&T Committee evaluates clinical effectiveness, safety and overall value through:
• Medical and scientific publications
• Relevant utilization experience
• Physician recommendations
Some drugs are commercially available as both a brand and a generic version. It is the policy of Sharp Health Plan that when a
generic is available, Sharp Health Plan does not cover the corresponding brand-name medication. If a generic version of a drug is
available, the brand version will require prior authorization. The Plan requires the dispensing pharmacy to dispense the generic
medication unless prior authorization for the brand is obtained.
The Drug List is current as of the date listed on the front cover and subject to change. If an unlisted outpatient drug is approved
for coverage it will be covered on Tier 3 or Tier 4 if the cost exceeds $600 for a one-month supply.
Are There Any Restrictions On Drug Coverage?
Utilization management criteria may apply to either generic or brand name drugs. These are marked throughout the document
using the following codes.
Symbol
Guideline
Description
AGE
Age Edit
Coverage depends on patient age. Prior authorization is required for other ages.
PA
Prior
Authorization
Requires prior authorization by Sharp Health Plan based on specific clinical criteria.
See Prior Authorization below for additional information
QL
Quantity
Limit
Coverage is limited to specific quantities per prescription and/or time period. Prior
authorization is required for other quantities.
ST
Step Therapy
Coverage depends on previous use of another drug. Prior authorization may be required.
See Step Therapy below for additional information.
Refer to the Appendix at the end of this document for additional information about specific drug benefit exclusions, mail order
limitations, specialty drug restrictions and other utilization management criteria for the Sharp Health Plan Outpatient Prescription
Drug Benefit.
A specialty drug is a drug that the FDA or the manufacturer requires to be distributed through a specialty pharmacy, drugs that
require the enrollee to have special training or clinical monitoring for self-administration, or drugs that the Pharmacy and
Therapeutics Committee determines to be a specialty medication based on high-cost.
What is Quantity Limit?
Drugs with the QL symbol next to the drug name in the Drug List are subject to quantity limits. It is the policy of Sharp Health Plan
to maintain effective drug utilization management procedures. Such procedures include quantity limits on prescription drugs. The
Plan ensures appropriate review when determining whether or not to authorize a quantity of medication that exceeds the quantity
limit. Quantity limits exist when drugs are limited to a determined number of doses based on criteria including, but not limited to,
safety, potential overdose hazard, abuse potential, or approximation of usual doses per month, not to exceed the FDA maximally
approved dose. Your doctor may follow the prior authorization process when requesting an exception to the Sharp Health Plan
quantity limit for a drug.
What is Step Therapy?
Drugs with the ST symbol next to the drug name in the Drug List are subject to step therapy. The step therapy program encourages
safe and cost-effective medication use. Under this program, a “step” approach is required to receive coverage for certain high-cost
drugs. This means that to receive coverage you may need to first try a proven, cost-effective drug before using a more costly
Sharp Health Plan: Covered California
treatment, if needed. Remember, treatment decisions are always between you and your doctor. There may be a situation when it is
medically necessary for you to receive certain drugs without first trying the alternative drug. In these instances, your doctor may
request prior authorization as described below.
How does the program work? The step therapy program requires that you have a prescription history for a “first-line” medication
before your benefit plan will cover a “second-line” medication. A first-line medication is recognized as safe and effective in
treating a specific medical condition, as well as being cost-effective. A second-line medication is a less-preferred or sometimes
more costly treatment option.
If you have moved from another insurance plan to Sharp Health Plan and are taking a medication that your previous insurer
covered, Sharp Health Plan will not require you to follow step-therapy in order to obtain that medication. Your physician may
need to submit a request to Sharp Health Plan in order to provide you with this continuity of coverage.
What is Therapeutic Interchange?
Sharp Health Plan employs therapeutic interchange as part of its prescription drug benefit. Therapeutic interchange is the practice
of replacing (with the prescribing physician's approval) a prescription drug originally prescribed for a patient with a prescription
drug that is its therapeutic equivalent. Using therapeutic interchange may offer advantages such as value through
improved convenience and affordability or improved outcomes or fewer side effects. Two or more drugs are considered
therapeutically equivalent if they can be expected to produce similar levels of clinical effectiveness and sound medical outcomes
in patients. If during the prior authorization process, the requested medication has a preferred therapeutic equivalent on the Plan
Drug List, a request to consider the preferred drug(s) may be faxed to the prescribing physician. The prescribing physician may
choose to use therapeutic interchange and select a pharmaceutical that that does not require a prior authorization.
What is Generic Substitution?
The Food and Drug Administration (FDA) applies rigorous standards for identity, strength, quality, purity and potency before
approving a generic drug. Generics are required to have the same active ingredient, strength, dosage form, and route of
administration as their brand-name equivalents. When a generic is available, the pharmacy is required to switch a brand name drug
to the generic equivalent unless Sharp Health Plan has authorized the brand name drug due to medical necessity.
What is Prior Authorization?
Drugs with the PA symbol next to the drug name in the Drug List are subject to prior authorization. This means that your doctor
must contact Sharp Health Plan to obtain advance approval for coverage of the medication. To request prior authorization, your
doctor must fill out a prior authorization form including information to demonstrate medical necessity and submit it to Sharp
Health Plan. Sharp Health Plan processes routine and urgent requests from doctors in a timely fashion. Sharp Health Plan
processes routine requests within 72 hours and urgent request within 24 hours of Sharp Health Plan’s receipt of the information
reasonably necessary and requested by Sharp Health Plan to make the determination. Urgent circumstances exist when a member
is suffering from a health condition that may seriously jeopardize the member’s life, health, or ability to regain maximum
function. Upon receiving your physician’s request for prior authorization, Sharp Health Plan will evaluate the information
submitted and make a determination based on established clinical criteria for the particular medication.
What if a Drug is Not Listed on the Drug List?
SHP offers an open formulary which means unless your drugs is listed as a plan exclusion it will be included in our formulary.
New drugs that are not yet listed in the Drug List are not excluded from coverage and are available on Tier 3 or Tier 4 unless the
drug is specifically identified as a plan exclusion. In some cases, these drugs may require prior authorization. If you do not see
your drug on our formulary, you can contact Customer Care to find out how your drug is covered. There may be times when it is
medically necessary for you to receive a medication that is not listed on Sharp Health Plan’s Drug List. In these instances, your
doctor may request prior authorization as described above.
Sharp Health Plan: Covered California
Additional information about specific prescription drug benefits and drug benefit exclusions can be found in your Sharp Health Plan
Summary of Benefits and Evidence of Coverage.
You Have the Right to Appeal
If you don’t agree with a coverage decision, you or your doctor may request an appeal. You must submit your request within 180
days from the postmark date of the denial notice. There are two kinds of appeals you can request.
Standard (30 days): Your or your doctor can request a standard appeal. Sharp Health Plan must make a decision no later than 30
days after receipt of a standard request.
Urgent (72 hours): You or your doctor can request an urgent appeal if you or your doctor believes that your health could be
seriously harmed by waiting up to 30 days for a decision. Sharp Health Plan must make a decision no later than 72 hours after
receipt of an urgent request.
Participating Pharmacies
Prescriptions can be filled at participating network retail or mail pharmacies, unless it is a specialty drug or for a drug covered under
the Medical Benefit (MB). Most maintenance drugs in Tier 1, Tier 2, Tier 3 and PV can be obtained for a 90-day supply at mail or
retail. Maintenance drugs are those prescribed on a regular, ongoing basis to maintain health.
How to Obtain Specialty Drugs
All specialty drugs require prior authorization. Upon approval of your specialty drug, you will receive information on which retail
and mail pharmacies can supply your medication.
How to Obtain MB Drugs
Drugs listed as MB in this document are not covered under the Outpatient Prescription Drug Benefit but may be provided under
your medical benefit, subject to medical necessity and other guidelines. Please consult your Outpatient Prescription Drug Benefit
Document, your Member Handbook and Health Plan Benefits and Coverage Matrix for more information about your benefits and
how medical benefits are obtained.
Questions
If you have any questions, please contact Sharp Health Plan Customer Care at 1-800-359-2002 or email
[email protected]. If you, or somebody who you are helping, have questions about Sharp Health Plan, you have the
right to obtain assistance and information in your language without any cost to you. To speak with an interpreter, call (800) 8749426.
Sharp Health Plan: Covered California
APPENDIX A: EXCLUSIONS AND LIMITATIONS TO THE OUTPATIENT PRESCRIPTION DRUG BENEFIT
The services and supplies listed below are exclusions and limitations to your outpatient prescription drug benefits and are not covered
by Sharp Health Plan:
1. Drugs dispensed by other than a Plan Pharmacy, except as Medically Necessary for treatment of an Emergency or
urgent care condition.
2. Drugs when prescribed by non-contracting providers that are not authorized by the Plan except when coverage is
otherwise required in the context of Emergency Services.
3. Over-the-counter Items: Drugs, devices and products, or Prescription Legend Drugs with over-the-counter equivalents
and any drugs, devices or products that are therapeutically comparable to an over-the-counter drug, device or product.
This includes Prescription Legend Drugs when any version or strength becomes available over-the-counter. This
Exclusion does not apply to over-the-counter products that we must cover as a “Preventative Care” benefit under federal
law with a prescription or if the prescription legend drug is medically necessary due a documented failure or intolerance
to the over-the-counter equivalent or therapeutically comparable drug.
4. Drugs dispensed in institutional packaging (such as unit dose) and drugs that are repackaged.
5. Drugs that are packaged with over the counter medications or other non-prescription items/supplies.
6. Vitamins (other than pediatric or prenatal vitamins listed on the Drug Formulary).
7. Drugs and supplies prescribed solely for the treatment of hair loss, sexual dysfunction, athletic performance, cosmetic
purposes, anti-aging for cosmetic purposes, and mental performance. (Drugs for mental performance are not excluded
from coverage when they are used to treat diagnosed mental illness or medical conditions affecting memory, including,
but not limited to, treatment of the conditions or symptoms of dementia or Alzheimer’s disease.)
8. Herbal, nutritional and dietary supplements.
9. Drugs prescribed solely for the purpose of shortening the duration of the common cold.
10. Drugs prescribed by a dentist or when prescribed for a dental treatment.
11. Drugs and supplies prescribed in connection with a service or supply that is not a covered benefit unless required to treat
a complication that arises as a result of the service or supply.
12. Travel and/or required work related immunizations.
13. Infertility drugs are excluded, unless added by the employer as a supplemental benefit.
14. Drugs obtained outside of the United States unless they are furnished in connection with urgent care or an Emergency.
15. Drugs that are prescribed solely for the purposes of losing weight, except when medically necessary for the treatment of
morbid obesity. Members must be enrolled in a Sharp Health Plan approved comprehensive weight loss program prior
to or concurrent with receiving the weight loss drug and meet Plan criteria for coverage.
16. Off-label use of FDA approved prescription drugs unless the drug is recognized for treatment of such indication in one
of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical
Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or the safety and
effectiveness of use for this indication has been adequately demonstrated by at least two studies published in a
nationally recognized, major peer reviewed journal.
17. Smoking cessation prescription drugs unless the Member is concurrently enrolled in or has completed a Sharp Health
Plan approved smoking cessation program.
18. Replacement of lost, stolen, or destroyed medications.
19. Compounded medications, unless prior authorization is obtained and determined to be medically necessary.
20. Brand name drugs when a generic equivalent is available. Some drugs are commercially available as both a brand and a
generic version. It is the policy of Sharp Health Plan that when a generic is available, Sharp Health Plan does not cover
the corresponding brand-name drug. If a generic version of a drug is available, the brand version will not be listed in this
document and will require prior authorization. The Plan requires the dispensing pharmacy to dispense the generic drug
unless prior authorization for the brand is obtained.
Sharp Health Plan: Covered California
Español (Spanish)
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Sharp Health Plan, tiene derecho a obtener
ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-359-2002.
繁體中文 (Chinese)
如果您，或是您正在協助的對象，有關Sharp Health Plan代碼及範圍方面有疑問，您有權利
免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 (800) 359-2002。
Tiếng Việt (Vietnamese)
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Sharp Health Plan, quý vị sẽ có quyền được giúp và có
thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi (800) 359-2002.
Tagalog (Tagalog – Filipino)
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Sharp Health Plan, may karapatan ka na
makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa
(800) 359-2002.
한국어(Korean)
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Sharp Health Plan 에 관해서 질문이 있다면 귀하는 그러한
도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기
위해서는 (800) 359-2002로 전화하십시오.
Հայերեն (Armenian)
Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի Sharp Health Plan մասին, Դուք իրավունք
ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ
խոսելու համար զանգահարե՛ք (800) 359-2002։
Persian
‫ﺷﻣﺎ اﮔر‬، ‫ ﻣﯾﮑﻧﯾد ﮐﻣﮏ او ﺑﮫ ﺷﻣﺎ ﮐﮫ ﮐﺳﯽ ﯾﺎ‬، ‫ ﻣورد در ﺳوال‬Sharp Health Plan ، ‫ﮐﻣﮏ ﮐﮫ دارﯾد را اﯾن ﺣق ﺑﺎﺷﯾد داﺷﺗﮫ‬
‫( ﻧﻣﺎﯾﯾد درﯾﺎﻓت راﯾﮕﺎن طور ﺑﮫ را ﺧود زﺑﺎن ﺑﮫ اطﻼﻋﺎت و‬800) 359-2002. ‫ ﻧﻣﺎﯾﯾد ﺣﺎﺻل ﺗﻣﺎس‬.
Русский (Russian)
Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Sharp Health Plan, то вы имеете право
на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по
телефону (800) 359-2002.
日本語 (Japanese)
ご本人様、またはお客様の身の回りの方でも、Sharp Health Planについてご質問がございましたら、ご希望の
言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話され
る場合、(800) 359-2002までお電話ください。
‫( اﻟﻌرﺑﯾﺔ‬Arabic)
‫ ﺑﺧﺻوص أﺳﺋﻠﺔ ﺗﺳﺎﻋده ﺷﺧص ﻟدى أو ﻟدﯾك ﻛﺎن إن‬Sharp Health Plan ، ‫واﻟﻣﻌﻠوﻣﺎت اﻟﻣﺳﺎﻋدة ﻋﻠﻰ اﻟﺣﺻول ﻓﻲ اﻟﺣق ﻓﻠدﯾك‬
‫ﺗﻛﻠﻔﺔ اﯾﺔ دون ﻣن ﺑﻠﻐﺗك اﻟﺿرورﯾﺔ‬. ‫( ) ب اﺗﺻل ﻣﺗرﺟم ﻣﻊ ﻟﻠﺗﺣدث‬800) 359-2002.
ਪੰ ਜਾਬੀ (Punjabi)
ਜੇ ਤੁਹਾਨੂੰ , ਜ� ਤੁਸੀ ਿਜਸ ਦੀ ਮਦਦ ਕਰ ਰਹੇ ਹੋ , Sharp Health Plan ਕੋਈ ਸਵਾਲ ਹੈ ਤ�, ਤੁਹਾਨੂੰ ਿਬਨਾ ਿਕਸੇ ਕੀਮਤ 'ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਮਦਦ
ਅਤੇ ਜਾਣਕਾਰੀ ਪ�ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ . ਦੁਭਾਸ਼ੀਏ ਨਾਲ ਗੱ ਲ ਕਰਨ ਲਈ, (800) 359-2002 ਤੇ ਕਾਲ ਕਰੋ .
Sharp Health Plan: Covered California
ែខ� រ (Mon Khmer, Cambodian)
្របសិនបេរ�អ�ក ឬនរណ‌ម�នក់ែដលអ�កកំពងុ ែដជួយ ម�នសំណួរអ្◌ពំ ី Sharp Health Plan េប, អ�កម�នសិេ◌ធិេ◌េ◌◌ួលជំនួយនិងព័ែ◌◌៌មន� េ�កនុងភាសា ររស់អ�ក េបាយមិនអ្សប់ ្◌ាក់ ។ ែបេ◌ើមបីនយ‌
ិ យជ‌មួយអ�ករកដ្រប សូម
(800) 359-2002 ។
Hmoob (Hmong)
Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Sharp Health Plan, koj muaj cai kom lawv muab cov
ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau
(800) 359-2002.
�हंद� (Hindi)
य�द आपके ,या आप द्वारा सहायता �कए जा रहे �कसी व्यिक्त के Sharp Health Plan के बारे म� प्रश्न ह� ,तो आपके पास
अपनी भाषा म� मफ्
ु त म� सहायता और सच
ू ना प्राप्त करने का अ�धकार है । �कसी दभ
ु ा�षए से बात करने के �लए , (800)
359-2002 पर कॉल कर� ।
ภาษาไทย (Thai)
หากคุณ หรื อคนที่คณ
ุ กาลังช่วยเหลือมีคาถามเกี่ยวกับ Sharp Health Plan คุณมีสทิ ธิที่จะได้ รับความช่วยเหลือและข้ อมูลในภาษาของคุณได้ โดยไม่มีคา่ ใช้ จ่าย พูดคุยกับล่าม โทร (800)
359-2002
Nondiscrimination Notice
Sharp Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Sharp Health Plan does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.
Sharp Health Plan:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (such as large print, audio, accessible electronic formats, or other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Jamie Ryan, Director of Operations at (858) 499-8275.
If you believe that Sharp Health Plan has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Sharp Health Plan
Appeal/Grievance Department
Attn: Jamie Ryan, Director of Operations
8520 Tech Way, Suite 200
San Diego, CA 92123-1450
Toll-free: 1-800-359-2002
1-800-735-2929 TTY
Fax: (619) 740-8572
Sharp Health Plan: Covered California
You can file a grievance in person or by mail, fax, or you can also complete the online Grievance/Appeal form on
the Plan’s website sharphealthplan.com. If you need help filing a grievance, Jamie Ryan, Director of Operations is
available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,
800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Sharp Health Plan: Covered California
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ALLERGY
2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS
DESLORATADINE/PSEUDOEPHEDRINE
PSEUDOEPHEDRINE HCL/ACRIVAS
(CLARINEX-D 12
HOUR (2.5-120 MG)
(TBMP 12HR) )
(SEMPREX-D (608MG) (CAPSULE) )
3
ST
3
ALLERGENIC EXTRACTS, THERAPEUTICS
GR POL-ORC/SW VER/RYE/KENT/TIM
GR POL-ORC/SW VER/RYE/KENT/TIM
GR POL-ORC/SW VER/RYE/KENT/TIM
GRASS POLLEN-TIMOTHY, STANDARD
GRASS POLLEN-TIMOTHY, STANDARD
GRASS POLLEN-TIMOTHY, STANDARD
WEED POLLEN-SHORT RAGWEED
WEED POLLEN-SHORT RAGWEED
(ORALAIR (100 IR)
(TAB SUBL) )
(ORALAIR (100-300
IR) (TAB SUBL) )
(ORALAIR (300 IR)
(TAB SUBL) )
(GRASTEK (2800
UNIT) (TAB SUBL) )
(STANDARDIZED
TIMOTHY GRASS
(100K/ML) (VIAL) )
(STANDARDIZED
TIMOTHY GRASS
(10K UNIT/1)
(VIAL) )
(RAGWITEK (12
UNIT) (TAB SUBL) )
(SHORT RAGWEED
(1:20) (VIAL) )
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
ANTIHISTAMINES - 1ST GENERATION
carbinoxamine maleate
carbinoxamine maleate
CARBINOXAMINE MALEATE
clemastine fumarate
cyproheptadine hcl
cyproheptadine hcl
diphenhydramine hcl
hydroxyzine hcl
hydroxyzine hcl
hydroxyzine hcl
hydroxyzine hcl
hydroxyzine pamoate
hydroxyzine pamoate
hydroxyzine pamoate
Sharp Health Plan: Covered California
(CLISTIN (4 MG)
(TABLET) )
(CLISTIN (4 MG/5
ML) (LIQUID) )
(KARBINAL ER (4
MG/5 ML) (SUS ER
12H) )
(TAVIST (2.68 MG)
(TABLET) )
(PERIACTIN (2
MG/5 ML)
(SYRUP) )
(PERIACTIN (4 MG)
(TABLET) )
(BENADRYL (50
MG/ML) (VIAL) )
(ATARAX (10 MG)
(TABLET) )
(ATARAX (10 MG/5
ML) (SOLUTION) )
(ATARAX (25 MG)
(TABLET) )
(ATARAX (50 MG)
(TABLET) )
(VISTARIL (100
MG) (CAPSULE) )
(VISTARIL (25 MG)
(CAPSULE) )
(VISTARIL (50 MG)
(CAPSULE) )
2
2
3
1
1
1
MB
1
1
1
1
1
1
1
Page 10 of 224
Sharp Health Plan: Covered California
Drug Name
promethazine hcl
promethazine hcl
promethazine hcl
promethazine hcl
Drug Tier Requirements/Limits
(PHENERGAN (12.5
MG) (TABLET) )
(PHENERGAN (25
MG) (TABLET) )
(PHENERGAN (50
MG) (TABLET) )
(PHENERGAN VC
(6.25MG/5ML)
(SYRUP) )
1
1
1
1
ANTIHISTAMINES - 2ND GENERATION
cetirizine hcl
desloratadine
DESLORATADINE
desloratadine
desloratadine
levocetirizine dihydrochloride
levocetirizine dihydrochloride
(ZYRTEC (1
MG/ML)
(SOLUTION) )
(CLARINEX (2.5
MG) (TAB
RAPDIS) )
(CLARINEX (2.5
MG/5ML) (SYRUP) )
(CLARINEX (5 MG)
(TAB RAPDIS) )
(CLARINEX (5 MG)
(TABLET) )
(XYZAL (2.5
MG/5ML)
(SOLUTION) )
(XYZAL (5 MG)
(TABLET) )
2
ST
2
ST
3
ST
2
ST
2
ST
2
ST
2
ST
NASAL ANTIHISTAMINE
azelastine hcl
azelastine hcl
olopatadine hcl
(ASTELIN (137
MCG)
(SPRAY/PUMP) )
(ASTEPRO
(205.5MCG)
(SPRAY/PUMP) )
(PATANASE (0.6 %)
(SPRAY/PUMP) )
2
2
2
NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB.
AZELASTINE/FLUTICASONE
(DYMISTA (137-50
MCG)
(SPRAY/PUMP) )
3
ST, QL: 23 IN 30 DAYS
3
ST, QL: 25 IN 30 DAYS
3
ST, QL: 8.7 IN 30 DAYS
3
ST, QL: 3 IN 63 DAYS
2
ST, QL: 17.2 IN 30 DAYS
3
ST, QL: 5 IN 12 DAYS
3
ST, QL: 6.1 IN 30 DAYS
NASAL ANTI-INFLAMMATORY STEROIDS
BECLOMETHASONE DIPROPIONATE
BECLOMETHASONE DIPROPIONATE
BECLOMETHASONE DIPROPIONATE
budesonide
CICLESONIDE
CICLESONIDE
flunisolide
Sharp Health Plan: Covered California
(BECONASE AQ (42
MCG) (SPRAY) )
(QNASL (80 MCG)
(HFA AER AD) )
(QNASL CHILDREN
(40 MCG) (HFA AER
AD) )
(RHINOCORT
AQUA (32MCG)
(SPRAY/PUMP) )
(OMNARIS (50
MCG)
(SPRAY/PUMP) )
(ZETONNA (37
MCG) (HFA AER
AD) )
(NASALIDE (25
MCG) (SPRAY) )
1
Page 11 of 224
Sharp Health Plan: Covered California
Drug Name
FLUTICASONE FUROATE
fluticasone propionate
mometasone furoate
Drug Tier Requirements/Limits
(VERAMYST (27.5
MCG) (SPRAY
SUSP) )
(FLONASE (50
MCG) (SPRAY
SUSP) )
(NASONEX (50
MCG)
(SPRAY/PUMP) )
3
ST, QL: 10 IN 30 DAYS
1
QL: 3 IN 63 DAYS
1
ST, QL: 17 IN 30 DAYS
2
PA
2
PA, QL: 3 IN 21 DAYS
2
PA
2
PA
2
PA
ANTIEMESIS/ANTIVERTIGO
ANTIEMETIC/ANTIVERTIGO AGENTS
APREPITANT
APREPITANT
APREPITANT
APREPITANT
APREPITANT
DOLASETRON MESYLATE
DOLASETRON MESYLATE
DOXYLAMINE/PYRIDOXINE HCL
dronabinol
dronabinol
dronabinol
GRANISETRON
granisetron hcl
meclizine hcl
meclizine hcl
NABILONE
NETUPITANT/PALONOSETRON HCL
ondansetron
ondansetron
ONDANSETRON
ONDANSETRON
ondansetron hcl
Sharp Health Plan: Covered California
(EMEND (125 MG)
(CAPSULE) )
(EMEND (125 MG)
(SUSP RECON) )
(EMEND (125MG80MG) (CAP DS
PK) )
(EMEND (40 MG)
(CAPSULE) )
(EMEND (80 MG)
(CAPSULE) )
(ANZEMET (100
MG) (TABLET) )
(ANZEMET (50 MG)
(TABLET) )
(DICLEGIS (10 MG10MG) (TABLET
DR) )
(MARINOL (10 MG)
(CAPSULE) )
(MARINOL (2.5
MG) (CAPSULE) )
(MARINOL (5 MG)
(CAPSULE) )
(SANCUSO
(3.1MG/24HR)
(PATCH TDWK) )
(KYTRIL (1 MG)
(TABLET) )
(ANTIVERT (12.5
MG) (TABLET) )
(ANTIVERT (25
MG) (TABLET) )
(CESAMET (1 MG)
(CAPSULE) )
(AKYNZEO (300-0.5
MG) (CAPSULE) )
(ZOFRAN ODT (4
MG) (TAB
RAPDIS) )
(ZOFRAN ODT (8
MG) (TAB
RAPDIS) )
(ZUPLENZ (4 MG)
(FILM) )
(ZUPLENZ (8 MG)
(FILM) )
(ZOFRAN (24 MG)
(TABLET) )
3
4
3
2
PA
2
PA
2
PA
3
2
QL: 6 IN 30 DAYS
2
2
3
PA
3
QL: 1 IN 28 DAYS
1
1
3
PA
3
PA
1
PA
Page 12 of 224
Sharp Health Plan: Covered California
Drug Name
ondansetron hcl
ondansetron hcl
ondansetron hcl
prochlorperazine
prochlorperazine maleate
prochlorperazine maleate
promethazine hcl
promethazine hcl
promethazine hcl
ROLAPITANT HCL
SCOPOLAMINE
trimethobenzamide hcl
Drug Tier Requirements/Limits
(ZOFRAN (4 MG)
(TABLET) )
(ZOFRAN (4 MG/5
ML) (SOLUTION) )
(ZOFRAN (8 MG)
(TABLET) )
(COMPAZINE (25
MG) (SUPP.RECT) )
(COMPAZINE (10
MG) (TABLET) )
(COMPAZINE (5
MG) (TABLET) )
(PHENERGAN (12.5
MG) (SUPP.RECT) )
(PHENERGAN (25
MG) (SUPP.RECT) )
(PHENERGAN (50
MG) (SUPP.RECT) )
(VARUBI (90 MG)
(TABLET) )
(TRANSDERMSCOP
(1.5MG/3DAY)
(PATCH TD 3) )
(TIGAN (300 MG)
(CAPSULE) )
1
1
1
1
1
1
1
1
1
4
3
1
ASTHMA AND COPD
5-LIPOXYGENASE INHIBITORS
ZILEUTON
ZILEUTON
(ZYFLO (600 MG)
(TABLET) )
(ZYFLO CR (600
MG) (TBMP 12HR) )
3
3
ANTICHOLINERGIC, ORALLY INHALED SHORT ACTING
ipratropium bromide
IPRATROPIUM BROMIDE
(ATROVENT (0.2
MG/ML)
(SOLUTION) )
(ATROVENT HFA
(17MCG) (HFA AER
AD) )
1
2
QL: 6 IN 63 DAYS
ANTICHOLINERGICS, ORALLY INHALED LONG ACTING
ACLIDINIUM BROMIDE
TIOTROPIUM BROMIDE
TIOTROPIUM BROMIDE
TIOTROPIUM BROMIDE
UMECLIDINIUM BROMIDE
Sharp Health Plan: Covered California
(TUDORZA
PRESSAIR (400
MCG) (AER POW
BA) )
(SPIRIVA (18 MCG)
(CAP W/DEV) )
(SPIRIVA
RESPIMAT (1.25
MCG) (MIST
INHAL) )
(SPIRIVA
RESPIMAT (2.5
MCG) (MIST
INHAL) )
(INCRUSE ELLIPTA
(62.5 MCG) (BLST
W/DEV) )
3
ST, QL: 3 IN 63 DAYS
2
QL: 3 IN 63 DAYS
2
ST, AGE: >= 12 YEARS, QL: 4
IN 30 DAYS
2
QL: 3 IN 63 DAYS
3
ST, QL: 3 IN 63 DAYS
Page 13 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
BETA-ADRENERGIC AGENTS
metaproterenol sulfate
metaproterenol sulfate
metaproterenol sulfate
(ALUPENT (10 MG)
(TABLET) )
(ALUPENT (10
MG/5 ML)
(SYRUP) )
(ALUPENT (20 MG)
(TABLET) )
1
1
1
BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING
albuterol sulfate
albuterol sulfate
(ACCUNEB
(0.63MG/3ML)
(VIAL-NEB) )
(ACCUNEB
(1.25MG/3ML)
(VIAL-NEB) )
albuterol sulfate (2.5 mg/0.5) (vial-neb)
ALBUTEROL SULFATE
ALBUTEROL SULFATE
albuterol sulfate
albuterol sulfate
albuterol sulfate
albuterol sulfate
albuterol sulfate
ALBUTEROL SULFATE
ALBUTEROL SULFATE
albuterol sulfate
albuterol sulfate
levalbuterol hcl
levalbuterol hcl
levalbuterol hcl
levalbuterol hcl
Sharp Health Plan: Covered California
1
1
1
(PROAIR HFA (90
MCG) (HFA AER
AD) )
(PROAIR
RESPICLICK (90
MCG) (AER POW
BA) )
(PROVENTIL (2
MG) (TABLET) )
(PROVENTIL (2
MG/5 ML)
(SYRUP) )
(PROVENTIL (2.5
MG/3ML) (VIALNEB) )
(PROVENTIL (4
MG) (TABLET) )
(PROVENTIL (5
MG/ML)
(SOLUTION) )
(PROVENTIL HFA
(90 MCG) (HFA AER
AD) )
(VENTOLIN HFA
(90 MCG) (HFA AER
AD) )
(VOSPIRE ER (4
MG) (TAB ER 12H) )
(VOSPIRE ER (8
MG) (TAB ER 12H) )
(XOPENEX
(0.31MG/3ML)
(VIAL-NEB) )
(XOPENEX
(0.63MG/3ML)
(VIAL-NEB) )
(XOPENEX
(1.25MG/3ML)
(VIAL-NEB) )
(XOPENEX
CONCENTRATE
(1.25MG/0.5) (VIALNEB) )
1
1
1
1
1
1
1
3
ST, QL: 6 IN 63 DAYS
3
ST, QL: 6 IN 63 DAYS
1
1
1
AGE: <= 12 YEARS
1
AGE: <= 12 YEARS
1
AGE: <= 12 YEARS
1
AGE: <= 12 YEARS
Page 14 of 224
Sharp Health Plan: Covered California
Drug Name
levalbuterol tartrate
terbutaline sulfate
terbutaline sulfate
Drug Tier Requirements/Limits
(XOPENEX HFA (45
MCG) (HFA AER
AD) )
(BRETHINE (2.5
MG) (TABLET) )
(BRETHINE (5 MG)
(TABLET) )
2
ST, QL: 6 IN 63 DAYS
1
1
BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING
INDACATEROL MALEATE
OLODATEROL HCL
(ARCAPTA
NEOHALER (75
MCG) (CAP
W/DEV) )
(STRIVERDI
RESPIMAT (2.5
MCG) (MIST
INHAL) )
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 3 IN 63 DAYS
BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTING
ARFORMOTEROL TARTRATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
SALMETEROL XINAFOATE
(BROVANA
(15MCG/2ML)
(VIAL-NEB) )
(FORADIL (12
MCG) (CAP
W/DEV) )
(PERFOROMIST (20
MCG/2ML) (VIALNEB) )
(SEREVENT
DISKUS (50 MCG)
(BLST W/DEV) )
3
QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
QL: 360 IN 63 DAYS
2
QL: 2 IN 1 DAY
BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS
GLYCOPYRROLATE/FORMOTEROL FUM
IPRATROPIUM/ALBUTEROL SULFATE
ipratropium/albuterol sulfate
TIOTROPIUM BR/OLODATEROL HCL
UMECLIDINIUM BRM/VILANTEROL TR
(BEVESPI
AEROSPHERE (94.8 MCG) (HFA AER
AD) )
(COMBIVENT
RESPIMAT (20-100
MCG) (MIST
INHAL) )
(DUONEB (0.53MG/3) (AMPULNEB) )
(STIOLTO
RESPIMAT (2.52.5MCG) (MIST
INHAL) )
(ANORO ELLIPTA
(62.5-25MCG)
(BLST W/DEV) )
3
ST, QL: 1 IN 30 DAYS
2
2
2
QL: 3 IN 63 DAYS
3
ST, QL: 2 IN 1 DAY
BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS
BUDESONIDE/FORMOTEROL FUMARATE
BUDESONIDE/FORMOTEROL FUMARATE
FLUTICASONE/SALMETEROL
Sharp Health Plan: Covered California
(SYMBICORT (1604.5MCG) (HFA AER
AD) )
(SYMBICORT (804.5 MCG) (HFA AER
AD) )
(ADVAIR DISKUS
(100-50 MCG)
(BLST W/DEV) )
3
ST, QL: 10.2 IN 30 DAYS
3
ST, QL: 10.2 IN 30 DAYS
2
QL: 60 IN 30 DAYS
Page 15 of 224
Sharp Health Plan: Covered California
Drug Name
FLUTICASONE/SALMETEROL
FLUTICASONE/SALMETEROL
FLUTICASONE/SALMETEROL
FLUTICASONE/SALMETEROL
FLUTICASONE/SALMETEROL
FLUTICASONE/VILANTEROL
FLUTICASONE/VILANTEROL
MOMETASONE/FORMOTEROL
MOMETASONE/FORMOTEROL
Drug Tier Requirements/Limits
(ADVAIR DISKUS
(250-50 MCG)
(BLST W/DEV) )
(ADVAIR DISKUS
(500-50 MCG)
(BLST W/DEV) )
(ADVAIR HFA (11521MCG) (HFA AER
AD) )
(ADVAIR HFA (23021MCG) (HFA AER
AD) )
(ADVAIR HFA (4521MCG) (HFA AER
AD) )
(BREO ELLIPTA
(100-25MCG) (BLST
W/DEV) )
(BREO ELLIPTA
(200-25 MCG)
(BLST W/DEV) )
(DULERA (100-5
MCG) (HFA AER
AD) )
(DULERA (200-5
MCG) (HFA AER
AD) )
2
QL: 60 IN 30 DAYS
2
QL: 60 IN 30 DAYS
2
QL: 12 IN 30 DAYS
2
QL: 12 IN 30 DAYS
2
QL: 12 IN 30 DAYS
2
QL: 60 IN 30 DAYS
2
QL: 60 IN 30 DAYS
3
ST, QL: 13 IN 30 DAYS
3
ST, QL: 13 IN 30 DAYS
1
QL: 17.4 IN 30 DAYS
1
QL: 17.4 IN 30 DAYS
2
QL: 60 IN 15 DAYS
2
QL: 60 IN 15 DAYS
2
QL: 60 IN 15 DAYS
3
QL: 1 IN 21 DAYS
3
QL: 1 IN 21 DAYS
3
QL: 6 IN 63 DAYS
3
QL: 6 IN 63 DAYS
3
QL: 6 IN 63 DAYS
3
QL: 30 IN 30 DAYS
GLUCOCORTICOIDS, ORALLY INHALED
BECLOMETHASONE DIPROPIONATE
BECLOMETHASONE DIPROPIONATE
budesonide
budesonide
budesonide
BUDESONIDE
BUDESONIDE
CICLESONIDE
CICLESONIDE
FLUNISOLIDE
FLUTICASONE FUROATE
Sharp Health Plan: Covered California
(QVAR (40 MCG)
(AER W/ADAP) )
(QVAR (80 MCG)
(AER W/ADAP) )
(PULMICORT
(0.25MG/2ML)
(AMPUL-NEB) )
(PULMICORT (0.5
MG/2ML) (AMPULNEB) )
(PULMICORT (1
MG/2 ML) (AMPULNEB) )
(PULMICORT
FLEXHALER (180
MCG) (AER POW
BA) )
(PULMICORT
FLEXHALER (90
MCG) (AER POW
BA) )
(ALVESCO (160
MCG) (HFA AER
AD) )
(ALVESCO (80
MCG) (HFA AER
AD) )
(AEROSPAN (80
MCG) (HFA AER
AD) )
(ARNUITY
ELLIPTA (100 MCG)
(BLST W/DEV) )
Page 16 of 224
Sharp Health Plan: Covered California
Drug Name
FLUTICASONE FUROATE
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
Drug Tier Requirements/Limits
(ARNUITY
ELLIPTA (200 MCG)
(BLST W/DEV) )
(FLOVENT DISKUS
(100 MCG) (BLST
W/DEV) )
(FLOVENT DISKUS
(250 MCG) (BLST
W/DEV) )
(FLOVENT DISKUS
(50 MCG) (BLST
W/DEV) )
(FLOVENT HFA
(110 MCG) (AER
W/ADAP) )
(FLOVENT HFA
(220 MCG) (AER
W/ADAP) )
(FLOVENT HFA (44
MCG) (AER
W/ADAP) )
(ASMANEX
(110MCG(30)) (AER
POW BA) )
(ASMANEX
(220MCG 120) (AER
POW BA) )
(ASMANEX
(220MCG(14)) (AER
POW BA) )
(ASMANEX
(220MCG(30)) (AER
POW BA) )
(ASMANEX
(220MCG(60)) (AER
POW BA) )
(ASMANEX HFA
(100 MCG) (HFA
AER AD) )
(ASMANEX HFA
(200 MCG) (HFA
AER AD) )
3
QL: 30 IN 30 DAYS
1
QL: 3 IN 63 DAYS
1
QL: 6 IN 63 DAYS
1
QL: 3 IN 63 DAYS
1
QL: 3 IN 63 DAYS
1
QL: 6 IN 63 DAYS
1
QL: 6 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
3
QL: 3 IN 63 DAYS
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium
montelukast sodium
montelukast sodium
montelukast sodium
zafirlukast
zafirlukast
(SINGULAIR (10
MG) (TABLET) )
(SINGULAIR (4
MG) (GRAN
PACK) )
(SINGULAIR (4
MG) (TAB CHEW) )
(SINGULAIR (5
MG) (TAB CHEW) )
(ACCOLATE (10
MG) (TABLET) )
(ACCOLATE (20
MG) (TABLET) )
1
1
1
1
1
PA
1
PA
MAST CELL STABILIZERS
cromolyn sodium
Sharp Health Plan: Covered California
(GASTROCROM (20
MG/ML) (ORAL
CONC) )
2
Page 17 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
MAST CELL STABILIZERS, ORALLY INHALED
cromolyn sodium (20 mg/2 ml) (ampul-neb)
1
PHOSPHODIESTERASE-4 (PDE4) INHIBITORS
ROFLUMILAST
(DALIRESP (500
MCG) (TABLET) )
2
QL: 1 IN 1 DAY
2
QL: 1 PER FILL
2
QL: 1 PER FILL
RESPIRATORY AIDS,DEVICES,EQUIPMENT
INHALER, ASSIST DEVICES
INHALER,ASSIST DEVICE,ACCESORY
(SPACER)
(PEDIATRIC MASK
(OTC))
XANTHINES
theophylline anhydrous
theophylline anhydrous
THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ANHYDROUS
theophylline anhydrous
theophylline anhydrous
theophylline anhydrous
theophylline anhydrous
theophylline anhydrous
theophylline anhydrous
(ELIXOPHYLLIN
(80 MG/15ML)
(ELIXIR) )
(SLO-PHYLLIN (80
MG/15ML)
(SOLUTION) )
(THEO-24 (100 MG)
(CAP ER 24H) )
(THEO-24 (200 MG)
(CAP ER 24H) )
(THEO-24 (300 MG)
(CAP ER 24H) )
(THEO-24 (400 MG)
(CAP ER 24H) )
(THEO-DUR (100
MG) (TAB ER 12H) )
(THEO-DUR (200
MG) (TAB ER 12H) )
(THEO-DUR (300
MG) (TAB ER 12H) )
(THEO-DUR (450
MG) (TAB ER 12H) )
(UNIPHYL (400
MG) (TAB ER 24H) )
(UNIPHYL (600
MG) (TAB ER 24H) )
1
2
2
2
2
2
1
1
1
1
1
1
AUTONOMIC NERVOUS SYSTEM DISORDERS
ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS
memantine hcl
memantine hcl
memantine hcl
memantine hcl
MEMANTINE HCL
MEMANTINE HCL
MEMANTINE HCL
MEMANTINE HCL
MEMANTINE HCL
Sharp Health Plan: Covered California
(NAMENDA (10
MG) (TABLET) )
(NAMENDA (2
MG/ML)
(SOLUTION) )
(NAMENDA (5 MG)
(TABLET) )
(NAMENDA (5 MG10 MG) (TAB DS
PK) )
(NAMENDA XR (14
MG) (CAP SPR 24) )
(NAMENDA XR (21
MG) (CAP SPR 24) )
(NAMENDA XR (28
MG) (CAP SPR 24) )
(NAMENDA XR (7
MG) (CAP SPR 24) )
(NAMENDA XR (714-21-28) (CAP24
DSPK) )
1
1
1
1
QL: 49 IN 365 DAYS
3
3
3
3
3
Page 18 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB
MEMANTINE HCL/DONEPEZIL HCL
MEMANTINE HCL/DONEPEZIL HCL
MEMANTINE HCL/DONEPEZIL HCL
MEMANTINE HCL/DONEPEZIL HCL
(NAMZARIC
(14MG-10MG) (CAP
SPR 24) )
(NAMZARIC (21
MG-10MG) (CAP
SPR 24) )
(NAMZARIC (28
MG-10MG) (CAP
SPR 24) )
(NAMZARIC (7 MG10 MG) (CAP SPR
24) )
3
ST, QL: 1 IN 1 DAY
3
3
ST, QL: 1 IN 1 DAY
3
CHOLINESTERASE INHIBITORS
donepezil hcl
donepezil hcl
donepezil hcl
donepezil hcl
donepezil hcl
galantamine hbr
galantamine hbr
galantamine hbr
galantamine hbr
galantamine hbr
galantamine hbr
galantamine hbr
pyridostigmine bromide
pyridostigmine bromide
PYRIDOSTIGMINE BROMIDE
rivastigmine
rivastigmine
rivastigmine
Sharp Health Plan: Covered California
(ARICEPT (10 MG)
(TABLET) )
(ARICEPT (23 MG)
(TABLET) )
(ARICEPT (5 MG)
(TABLET) )
(ARICEPT ODT (10
MG) (TAB
RAPDIS) )
(ARICEPT ODT (5
MG) (TAB
RAPDIS) )
(RAZADYNE (12
MG) (TABLET) )
(RAZADYNE (4
MG) (TABLET) )
(RAZADYNE (4
MG/ML)
(SOLUTION) )
(RAZADYNE (8
MG) (TABLET) )
(RAZADYNE ER (16
MG) (CAP24H
PEL) )
(RAZADYNE ER (24
MG) (CAP24H
PEL) )
(RAZADYNE ER (8
MG) (CAP24H
PEL) )
(MESTINON (180
MG) (TABLET ER) )
(MESTINON (60
MG) (TABLET) )
(MESTINON (60
MG/5 ML)
(SYRUP) )
(EXELON
(13.3MG/24H)
(PATCH TD24) )
(EXELON
(4.6MG/24HR)
(PATCH TD24) )
(EXELON
(9.5MG/24HR)
(PATCH TD24) )
1
1
1
1
1
2
2
2
2
2
2
2
1
1
2
2
2
2
Page 19 of 224
Sharp Health Plan: Covered California
Drug Name
rivastigmine tartrate
rivastigmine tartrate
rivastigmine tartrate
rivastigmine tartrate
Drug Tier Requirements/Limits
(EXELON (1.5 MG)
(CAPSULE) )
(EXELON (3 MG)
(CAPSULE) )
(EXELON (4.5 MG)
(CAPSULE) )
(EXELON (6 MG)
(CAPSULE) )
2
2
2
2
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS
mirtazapine (7.5 mg) (tablet)
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
1
(REMERON (15 MG)
(TAB RAPDIS) )
(REMERON (15 MG)
(TABLET) )
(REMERON (30 MG)
(TAB RAPDIS) )
(REMERON (30 MG)
(TABLET) )
(REMERON (45 MG)
(TAB RAPDIS) )
(REMERON (45 MG)
(TABLET) )
1
1
1
1
1
1
MAOIS - NON-SELECTIVE & IRREVERSIBLE
ISOCARBOXAZID
phenelzine sulfate
tranylcypromine sulfate
(MARPLAN (10
MG) (TABLET) )
(NARDIL (15 MG)
(TABLET) )
(PARNATE (10 MG)
(TABLET) )
3
1
1
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)
BUPROPION HBR
BUPROPION HBR
BUPROPION HBR
BUPROPION HCL
bupropion hcl
bupropion hcl
bupropion hcl
bupropion hcl
bupropion hcl
bupropion hcl
Sharp Health Plan: Covered California
(APLENZIN
(174MG) (TAB ER
24H) )
(APLENZIN
(348MG) (TAB ER
24H) )
(APLENZIN
(522MG) (TAB ER
24H) )
(FORFIVO XL (450
MG) (TAB ER 24H) )
(WELLBUTRIN (100
MG) (TABLET) )
(WELLBUTRIN (75
MG) (TABLET) )
(WELLBUTRIN SR
(100 MG) (TABLET
ER) )
(WELLBUTRIN SR
(150 MG) (TABLET
ER) )
(WELLBUTRIN SR
(200 MG) (TABLET
ER) )
(WELLBUTRIN XL
(150 MG) (TAB ER
24H) )
3
3
3
3
1
1
1
1
1
1
QL: 1 IN 1 DAY
Page 20 of 224
Sharp Health Plan: Covered California
Drug Name
bupropion hcl
Drug Tier Requirements/Limits
(WELLBUTRIN XL
(300 MG) (TAB ER
24H) )
1
QL: 1 IN 1 DAY
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)
citalopram hydrobromide
citalopram hydrobromide
citalopram hydrobromide
citalopram hydrobromide
escitalopram oxalate
escitalopram oxalate
escitalopram oxalate
escitalopram oxalate
(CELEXA (10 MG)
(TABLET) )
(CELEXA (10 MG/5
ML) (SOLUTION) )
(CELEXA (20 MG)
(TABLET) )
(CELEXA (40 MG)
(TABLET) )
(LEXAPRO (10 MG)
(TABLET) )
(LEXAPRO (20 MG)
(TABLET) )
(LEXAPRO (5 MG)
(TABLET) )
(LEXAPRO (5 MG/5
ML) (SOLUTION) )
FLUOXETINE HCL (60 MG) (TABLET)
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
FLUOXETINE HCL
FLUOXETINE HCL
fluvoxamine maleate
fluvoxamine maleate
fluvoxamine maleate
fluvoxamine maleate
fluvoxamine maleate
paroxetine hcl
PAROXETINE HCL
paroxetine hcl
paroxetine hcl
paroxetine hcl
Sharp Health Plan: Covered California
1
1
1
1
1
1
1
1
3
(PROZAC (10 MG)
(CAPSULE) )
(PROZAC (10 MG)
(TABLET) )
(PROZAC (20 MG)
(CAPSULE) )
(PROZAC (20 MG)
(TABLET) )
(PROZAC (20 MG/5
ML) (SOLUTION) )
(PROZAC (40 MG)
(CAPSULE) )
(PROZAC WEEKLY
(90 MG) (CAPSULE
DR) )
(SARAFEM (10 MG)
(TABLET) )
(SARAFEM (20 MG)
(TABLET) )
(LUVOX (100 MG)
(TABLET) )
(LUVOX (25 MG)
(TABLET) )
(LUVOX (50 MG)
(TABLET) )
(LUVOX CR (100
MG) (CAP ER 24H) )
(LUVOX CR (150
MG) (CAP ER 24H) )
(PAXIL (10 MG)
(TABLET) )
(PAXIL (10 MG/5
ML) (ORAL SUSP) )
(PAXIL (20 MG)
(TABLET) )
(PAXIL (30 MG)
(TABLET) )
(PAXIL (40 MG)
(TABLET) )
1
1
1
1
1
1
2
3
PA
3
PA
1
1
1
2
2
1
3
1
1
1
Page 21 of 224
Sharp Health Plan: Covered California
Drug Name
paroxetine hcl
paroxetine hcl
paroxetine hcl
PAROXETINE MESYLATE
PAROXETINE MESYLATE
PAROXETINE MESYLATE
PAROXETINE MESYLATE
PAROXETINE MESYLATE
sertraline hcl
sertraline hcl
sertraline hcl
sertraline hcl
Drug Tier Requirements/Limits
(PAXIL CR (12.5
MG) (TAB ER 24H) )
(PAXIL CR (25 MG)
(TAB ER 24H) )
(PAXIL CR (37.5
MG) (TAB ER 24H) )
(BRISDELLE (7.5
MG) (CAPSULE) )
(PEXEVA (10 MG)
(TABLET) )
(PEXEVA (20 MG)
(TABLET) )
(PEXEVA (30 MG)
(TABLET) )
(PEXEVA (40 MG)
(TABLET) )
(ZOLOFT (100 MG)
(TABLET) )
(ZOLOFT (20
MG/ML) (ORAL
CONC) )
(ZOLOFT (25 MG)
(TABLET) )
(ZOLOFT (50 MG)
(TABLET) )
2
PA
2
PA
2
PA
3
ST, QL: 1 IN 1 DAY
3
3
3
3
1
1
1
1
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)
nefazodone hcl
nefazodone hcl
nefazodone hcl
nefazodone hcl
nefazodone hcl
trazodone hcl
trazodone hcl
trazodone hcl
trazodone hcl
TRAZODONE HCL
TRAZODONE HCL
(SERZONE (100
MG) (TABLET) )
(SERZONE (150
MG) (TABLET) )
(SERZONE (200
MG) (TABLET) )
(SERZONE (250
MG) (TABLET) )
(SERZONE (50 MG)
(TABLET) )
(DESYREL (100
MG) (TABLET) )
(DESYREL (150
MG) (TABLET) )
(DESYREL (300
MG) (TABLET) )
(DESYREL (50 MG)
(TABLET) )
(OLEPTRO ER (150
MG) (TAB ER 24H) )
(OLEPTRO ER (300
MG) (TAB ER 24H) )
2
2
2
2
2
1
1
1
1
3
ST
3
ST
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
DESVENLAFAXINE ER (100 MG) (TAB ER 24H)
DESVENLAFAXINE ER (50 MG) (TAB ER 24H)
desvenlafaxine
desvenlafaxine
DESVENLAFAXINE FUMARATE ER (100 MG)
(TAB ER 24)
DESVENLAFAXINE FUMARATE ER (50 MG)
(TAB ER 24)
Sharp Health Plan: Covered California
(KHEDEZLA (100
MG) (TAB ER 24) )
(KHEDEZLA (50
MG) (TAB ER 24) )
3
3
ST, QL: 1 IN 1 DAY
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
Page 22 of 224
Sharp Health Plan: Covered California
Drug Name
DESVENLAFAXINE SUCCINATE
DESVENLAFAXINE SUCCINATE
DESVENLAFAXINE SUCCINATE
duloxetine hcl
duloxetine hcl
duloxetine hcl
duloxetine hcl
LEVOMILNACIPRAN HCL
LEVOMILNACIPRAN HCL
LEVOMILNACIPRAN HCL
LEVOMILNACIPRAN HCL
LEVOMILNACIPRAN HCL
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
Drug Tier Requirements/Limits
(PRISTIQ ER (100
MG) (TAB ER 24H) )
(PRISTIQ ER (25
MG) (TAB ER 24H) )
(PRISTIQ ER (50
MG) (TAB ER 24H) )
(CYMBALTA (20
MG) (CAPSULE
DR) )
(CYMBALTA (30
MG) (CAPSULE
DR) )
(CYMBALTA (60
MG) (CAPSULE
DR) )
(IRENKA (40 MG)
(CAPSULE DR) )
(FETZIMA (120 MG)
(CAP SA 24H) )
(FETZIMA (20 MG)
(CAP SA 24H) )
(FETZIMA (2040MG)
(CAP24HDSPK) )
(FETZIMA (40 MG)
(CAP SA 24H) )
(FETZIMA (80 MG)
(CAP SA 24H) )
(EFFEXOR (100
MG) (TABLET) )
(EFFEXOR (25 MG)
(TABLET) )
(EFFEXOR (37.5
MG) (TABLET) )
(EFFEXOR (50 MG)
(TABLET) )
(EFFEXOR (75 MG)
(TABLET) )
(EFFEXOR XR (150
MG) (CAP ER 24H) )
(EFFEXOR XR (37.5
MG) (CAP ER 24H) )
(EFFEXOR XR (75
MG) (CAP ER 24H) )
venlafaxine hcl er (150 mg) (tab er 24)
venlafaxine hcl er (225 mg) (tab er 24)
venlafaxine hcl er (37.5 mg) (tab er 24)
venlafaxine hcl er (75 mg) (tab er 24)
3
ST, QL: 1 IN 1 DAY
3
3
ST, QL: 1 IN 1 DAY
1
1
1
1
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
2
2
2
2
ST, QL: 1 IN 1 DAY
ST, QL: 1 IN 1 DAY
ST, QL: 1 IN 1 DAY
ST, QL: 1 IN 1 DAY
3
ST
3
ST
3
ST
3
ST
SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT
VILAZODONE HCL
VILAZODONE HCL
VILAZODONE HCL
VILAZODONE HCL
Sharp Health Plan: Covered California
(VIIBRYD (10 MG)
(TABLET) )
(VIIBRYD (10 MG20MG) (TAB DS
PK) )
(VIIBRYD (20 MG)
(TABLET) )
(VIIBRYD (40 MG)
(TABLET) )
Page 23 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANT
VORTIOXETINE HYDROBROMIDE
VORTIOXETINE HYDROBROMIDE
VORTIOXETINE HYDROBROMIDE
(TRINTELLIX (10
MG) (TABLET) )
(TRINTELLIX (20
MG) (TABLET) )
(TRINTELLIX (5
MG) (TABLET) )
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS
amitriptyline/chlordiazepoxide
amitriptyline/chlordiazepoxide
(LIMBITROL
(12.5MG-5MG)
(TABLET) )
(LIMBITROL DS (25
MG-10MG)
(TABLET) )
2
2
TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS
perphenazine/amitriptyline hcl
perphenazine/amitriptyline hcl
perphenazine/amitriptyline hcl
perphenazine/amitriptyline hcl
perphenazine/amitriptyline hcl
(ETRAFON-A
(4MG-10MG)
(TABLET) )
(TRIAVIL 2-10 (2
MG-10 MG)
(TABLET) )
(TRIAVIL 2-25 (2
MG-25 MG)
(TABLET) )
(TRIAVIL 4-25 (4
MG-25 MG)
(TABLET) )
(TRIAVIL 4-50 (4
MG-50 MG)
(TABLET) )
2
2
2
2
2
TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB
amitriptyline hcl
amitriptyline hcl
amitriptyline hcl
amitriptyline hcl
amitriptyline hcl
amitriptyline hcl
amoxapine
amoxapine
amoxapine
amoxapine
clomipramine hcl
clomipramine hcl
clomipramine hcl
desipramine hcl
Sharp Health Plan: Covered California
(ELAVIL (10 MG)
(TABLET) )
(ELAVIL (100 MG)
(TABLET) )
(ELAVIL (150 MG)
(TABLET) )
(ELAVIL (25 MG)
(TABLET) )
(ELAVIL (50 MG)
(TABLET) )
(ELAVIL (75 MG)
(TABLET) )
(ASENDIN (100
MG) (TABLET) )
(ASENDIN (150
MG) (TABLET) )
(ASENDIN (25 MG)
(TABLET) )
(ASENDIN (50 MG)
(TABLET) )
(ANAFRANIL (25
MG) (CAPSULE) )
(ANAFRANIL (50
MG) (CAPSULE) )
(ANAFRANIL (75
MG) (CAPSULE) )
(NORPRAMIN (10
MG) (TABLET) )
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 24 of 224
Sharp Health Plan: Covered California
Drug Name
desipramine hcl
desipramine hcl
desipramine hcl
desipramine hcl
desipramine hcl
doxepin hcl
doxepin hcl
doxepin hcl
doxepin hcl
doxepin hcl
doxepin hcl
doxepin hcl
imipramine hcl
imipramine hcl
imipramine hcl
imipramine pamoate
imipramine pamoate
imipramine pamoate
imipramine pamoate
maprotiline hcl
maprotiline hcl
maprotiline hcl
nortriptyline hcl
nortriptyline hcl
nortriptyline hcl
nortriptyline hcl
nortriptyline hcl
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(NORPRAMIN (100
MG) (TABLET) )
(NORPRAMIN (150
MG) (TABLET) )
(NORPRAMIN (25
MG) (TABLET) )
(NORPRAMIN (50
MG) (TABLET) )
(NORPRAMIN (75
MG) (TABLET) )
(SINEQUAN (10
MG) (CAPSULE) )
(SINEQUAN (10
MG/ML) (ORAL
CONC) )
(SINEQUAN (100
MG) (CAPSULE) )
(SINEQUAN (150
MG) (CAPSULE) )
(SINEQUAN (25
MG) (CAPSULE) )
(SINEQUAN (50
MG) (CAPSULE) )
(SINEQUAN (75
MG) (CAPSULE) )
(TOFRANIL (10
MG) (TABLET) )
(TOFRANIL (25
MG) (TABLET) )
(TOFRANIL (50
MG) (TABLET) )
(TOFRANIL-PM
(100 MG)
(CAPSULE) )
(TOFRANIL-PM
(125 MG)
(CAPSULE) )
(TOFRANIL-PM
(150 MG)
(CAPSULE) )
(TOFRANIL-PM (75
MG) (CAPSULE) )
(LUDIOMIL (25
MG) (TABLET) )
(LUDIOMIL (50
MG) (TABLET) )
(LUDIOMIL (75
MG) (TABLET) )
(PAMELOR (10 MG)
(CAPSULE) )
(PAMELOR (10
MG/5 ML)
(SOLUTION) )
(PAMELOR (25 MG)
(CAPSULE) )
(PAMELOR (50 MG)
(CAPSULE) )
(PAMELOR (75 MG)
(CAPSULE) )
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
1
1
1
1
1
Page 25 of 224
Sharp Health Plan: Covered California
Drug Name
protriptyline hcl
protriptyline hcl
trimipramine maleate
TRIMIPRAMINE MALEATE
trimipramine maleate
TRIMIPRAMINE MALEATE
trimipramine maleate
TRIMIPRAMINE MALEATE
Drug Tier Requirements/Limits
(VIVACTIL (10 MG)
(TABLET) )
(VIVACTIL (5 MG)
(TABLET) )
(SURMONTIL (100
MG) (CAPSULE) )
(SURMONTIL (100
MG) (CAPSULE) )
(SURMONTIL (25
MG) (CAPSULE) )
(SURMONTIL (25
MG) (CAPSULE) )
(SURMONTIL (50
MG) (CAPSULE) )
(SURMONTIL (50
MG) (CAPSULE) )
2
2
2
3
2
3
2
3
BEHAVIORAL HEALTH - OTHER
ADRENERGICS, AROMATIC, NON-CATECHOLAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE
AMPHETAMINE SULFATE
AMPHETAMINE SULFATE
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
Sharp Health Plan: Covered California
(ADZENYS XRODT (12.5 MG)
(TAB RAP BP) )
(ADZENYS XRODT (15.7 MG)
(TAB RAP BP) )
(ADZENYS XRODT (18.8 MG)
(TAB RAP BP) )
(ADZENYS XRODT (3.1 MG) (TAB
RAP BP) )
(ADZENYS XRODT (6.3 MG) (TAB
RAP BP) )
(ADZENYS XRODT (9.4 MG) (TAB
RAP BP) )
(DYANAVEL XR
(2.5 MG/ML) (SUS
BP 24H) )
(EVEKEO (10 MG)
(TABLET) )
(EVEKEO (5 MG)
(TABLET) )
(DEXEDRINE (10
MG) (CAPSULE
ER) )
(DEXEDRINE (10
MG) (TABLET) )
(DEXEDRINE (15
MG) (CAPSULE
ER) )
(DEXEDRINE (5
MG) (CAPSULE
ER) )
(DEXEDRINE (5
MG) (TABLET) )
(PROCENTRA (5
MG/5 ML)
(SOLUTION) )
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
3
ST, AGE: > 5 YEARS|<= 17
YEARS, QL: 240 IN 30 DAYS
3
PA
3
PA
1
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
2
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
1
AGE: <= 17 YEARS, QL: 4 IN
1 DAY
1
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
2
AGE: <= 17 YEARS, QL: 12
IN 1 DAY
2
AGE: <= 17 YEARS
Page 26 of 224
Sharp Health Plan: Covered California
Drug Name
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
dextroamphetamine/amphetamine
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
LISDEXAMFETAMINE DIMESYLATE
methamphetamine hcl
Drug Tier Requirements/Limits
(ZENZEDI (15 MG)
(TABLET) )
(ZENZEDI (2.5 MG)
(TABLET) )
(ZENZEDI (20 MG)
(TABLET) )
(ZENZEDI (30 MG)
(TABLET) )
(ZENZEDI (7.5 MG)
(TABLET) )
(ADDERALL (10
MG) (TABLET) )
(ADDERALL (12.5
MG) (TABLET) )
(ADDERALL (15
MG) (TABLET) )
(ADDERALL (20
MG) (TABLET) )
(ADDERALL (30
MG) (TABLET) )
(ADDERALL (5
MG) (TABLET) )
(ADDERALL (7.5
MG) (TABLET) )
(ADDERALL XR (10
MG) (CAP ER 24H) )
(ADDERALL XR (15
MG) (CAP ER 24H) )
(ADDERALL XR (20
MG) (CAP ER 24H) )
(ADDERALL XR (25
MG) (CAP ER 24H) )
(ADDERALL XR (30
MG) (CAP ER 24H) )
(ADDERALL XR (5
MG) (CAP ER 24H) )
(VYVANSE (10 MG)
(CAPSULE) )
(VYVANSE (20 MG)
(CAPSULE) )
(VYVANSE (30 MG)
(CAPSULE) )
(VYVANSE (40 MG)
(CAPSULE) )
(VYVANSE (50 MG)
(CAPSULE) )
(VYVANSE (60 MG)
(CAPSULE) )
(VYVANSE (70 MG)
(CAPSULE) )
(DESOXYN (5 MG)
(TABLET) )
4
3
4
4
3
AGE: <= 17 YEARS, QL: 4 IN
1 DAY
AGE: <= 17 YEARS, QL: 24
IN 1 DAY
AGE: <= 17 YEARS, QL: 3 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 8 IN
1 DAY
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS
1
1
1
1
1
1
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
2
AGE: <= 17 YEARS
ANTI-ALCOHOLIC PREPARATIONS
acamprosate calcium
disulfiram
disulfiram
Sharp Health Plan: Covered California
(CAMPRAL (333
MG) (TABLET DR) )
(ANTABUSE (250
MG) (TABLET) )
(ANTABUSE (500
MG) (TABLET) )
2
1
1
Page 27 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ANTI-ANXIETY DRUGS
ALPRAZOLAM INTENSOL (1 MG/ML) (ORAL
CONC)
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
buspirone hcl
buspirone hcl
buspirone hcl
buspirone hcl
buspirone hcl
chlordiazepoxide hcl
chlordiazepoxide hcl
chlordiazepoxide hcl
2
(NIRAVAM (0.25
MG) (TAB
RAPDIS) )
(NIRAVAM (0.5 MG)
(TAB RAPDIS) )
(NIRAVAM (1 MG)
(TAB RAPDIS) )
(NIRAVAM (2 MG)
(TAB RAPDIS) )
(XANAX (0.25 MG)
(TABLET) )
(XANAX (0.5 MG)
(TABLET) )
(XANAX (1 MG)
(TABLET) )
(XANAX (2 MG)
(TABLET) )
(XANAX XR (0.5
MG) (TAB ER 24H) )
(XANAX XR (1 MG)
(TAB ER 24H) )
(XANAX XR (2 MG)
(TAB ER 24H) )
(XANAX XR (3 MG)
(TAB ER 24H) )
(BUSPAR (10 MG)
(TABLET) )
(BUSPAR (15 MG)
(TABLET) )
(BUSPAR (30 MG)
(TABLET) )
(BUSPAR (5 MG)
(TABLET) )
(BUSPAR (7.5 MG)
(TABLET) )
(LIBRIUM (10 MG)
(CAPSULE) )
(LIBRIUM (25 MG)
(CAPSULE) )
(LIBRIUM (5 MG)
(CAPSULE) )
clorazepate dipotassium (3.75 mg) (tablet)
clorazepate dipotassium
clorazepate dipotassium
diazepam
diazepam
diazepam
Sharp Health Plan: Covered California
2
2
2
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
(TRANXENE T-TAB
(15 MG) (TABLET) )
(TRANXENE T-TAB
(7.5 MG)
(TABLET) )
diazepam intensol (5 mg/ml) (oral conc)
diazepam
2
1
1
1
(VALIUM (10 MG)
(TABLET) )
(VALIUM (2 MG)
(TABLET) )
(VALIUM (5 MG)
(TABLET) )
(VALIUM (5 MG/5
ML) (SOLUTION) )
1
1
1
1
Page 28 of 224
Sharp Health Plan: Covered California
Drug Name
lorazepam
lorazepam
lorazepam
Drug Tier Requirements/Limits
(ATIVAN (0.5 MG)
(TABLET) )
(ATIVAN (1 MG)
(TABLET) )
(ATIVAN (2 MG)
(TABLET) )
lorazepam intensol (2 mg/ml) (oral conc)
meprobamate (200 mg) (tablet)
meprobamate (400 mg) (tablet)
oxazepam
oxazepam
oxazepam
1
1
1
1
2
2
(SERAX (10 MG)
(CAPSULE) )
(SERAX (15 MG)
(CAPSULE) )
(SERAX (30 MG)
(CAPSULE) )
1
1
1
ANTI-MANIA DRUGS
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
lithium carbonate
lithium carbonate
(EQUETRO (100
MG) (CPMP 12HR) )
(EQUETRO (200
MG) (CPMP 12HR) )
(EQUETRO (300
MG) (CPMP 12HR) )
(ESKALITH (300
MG) (CAPSULE) )
(ESKALITH CR (450
MG) (TABLET ER) )
lithium carbonate (150 mg) (capsule)
lithium carbonate (600 mg) (capsule)
lithium carbonate
lithium carbonate
3
3
3
1
1
1
1
(LITHOBID (300
MG) (TABLET ER) )
(LITHOTABS (300
MG) (TABLET) )
lithium citrate (8 meq/5 ml) (solution)
1
1
2
ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGT
SODIUM OXYBATE
(XYREM (500
MG/ML)
(SOLUTION) )
3
PA
ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES
pimozide
pimozide
(ORAP (1 MG)
(TABLET) )
(ORAP (2 MG)
(TABLET) )
2
2
ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED
CARIPRAZINE HCL
CARIPRAZINE HCL
CARIPRAZINE HCL
CARIPRAZINE HCL
CARIPRAZINE HCL
(VRAYLAR (1.5
MG) (CAPSULE) )
(VRAYLAR (1.5
MG-3MG) (CAP DS
PK) )
(VRAYLAR (3 MG)
(CAPSULE) )
(VRAYLAR (4.5
MG) (CAPSULE) )
(VRAYLAR (6 MG)
(CAPSULE) )
4
PA
4
PA
4
PA
4
PA
4
PA
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED
aripiprazole
Sharp Health Plan: Covered California
(ABILIFY (1
MG/ML)
(SOLUTION) )
2
ST, QL: 16 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
Page 29 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
aripiprazole
(ABILIFY (10 MG)
(TABLET) )
2
aripiprazole
(ABILIFY (15 MG)
(TABLET) )
2
aripiprazole
(ABILIFY (2 MG)
(TABLET) )
2
aripiprazole
(ABILIFY (20 MG)
(TABLET) )
2
aripiprazole
(ABILIFY (30 MG)
(TABLET) )
2
aripiprazole
(ABILIFY (5 MG)
(TABLET) )
2
aripiprazole
aripiprazole
(ABILIFY
DISCMELT (10 MG)
(TAB RAPDIS) )
(ABILIFY
DISCMELT (15 MG)
(TAB RAPDIS) )
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
BREXPIPRAZOLE
(REXULTI (0.25
MG) (TABLET) )
4
BREXPIPRAZOLE
(REXULTI (0.5 MG)
(TABLET) )
4
BREXPIPRAZOLE
(REXULTI (1 MG)
(TABLET) )
4
BREXPIPRAZOLE
(REXULTI (2 MG)
(TABLET) )
4
BREXPIPRAZOLE
(REXULTI (3 MG)
(TABLET) )
4
BREXPIPRAZOLE
(REXULTI (4 MG)
(TABLET) )
4
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS
LOXAPINE
loxapine succinate
loxapine succinate
Sharp Health Plan: Covered California
(ADASUVE (10 MG)
(AER POW BA) )
(LOXITANE (10
MG) (CAPSULE) )
(LOXITANE (25
MG) (CAPSULE) )
3
ST, QL: 1 IN 1 DAY
2
QL: 5 IN 1 DAY
2
QL: 5 IN 1 DAY
Page 30 of 224
Sharp Health Plan: Covered California
Drug Name
loxapine succinate
loxapine succinate
Drug Tier Requirements/Limits
(LOXITANE (5 MG)
(CAPSULE) )
(LOXITANE (50
MG) (CAPSULE) )
2
QL: 5 IN 1 DAY
2
QL: 5 IN 1 DAY
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG
1
1
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 4 IN 1 DAY
QL: 9 IN 1 DAY
1
QL: 9 IN 1 DAY
1
QL: 9 IN 1 DAY
2
QL: 9 IN 1 DAY
2
QL: 9 IN 1 DAY
2
QL: 9 IN 1 DAY
2
QL: 4 IN 1 DAY
2
QL: 9 IN 1 DAY
4
ST, QL: 18 IN 1 DAY
ASENAPINE MALEATE
(SAPHRIS (10 MG)
(TAB SUBL) )
3
ASENAPINE MALEATE
(SAPHRIS (2.5 MG)
(TAB SUBL) )
3
ASENAPINE MALEATE
(SAPHRIS (5 MG)
(TAB SUBL) )
3
clozapine (200 mg) (tablet)
clozapine (50 mg) (tablet)
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
CLOZAPINE
(CLOZARIL (100
MG) (TABLET) )
(CLOZARIL (25
MG) (TABLET) )
(FAZACLO (100
MG) (TAB
RAPDIS) )
(FAZACLO (12.5
MG) (TAB
RAPDIS) )
(FAZACLO (150
MG) (TAB
RAPDIS) )
(FAZACLO (200
MG) (TAB
RAPDIS) )
(FAZACLO (25 MG)
(TAB RAPDIS) )
(VERSACLOZ (50
MG/ML) (ORAL
SUSP) )
ILOPERIDONE
(FANAPT (1 MG)
(TABLET) )
3
ILOPERIDONE
(FANAPT (10 MG)
(TABLET) )
3
ILOPERIDONE
(FANAPT (12 MG)
(TABLET) )
3
ILOPERIDONE
(FANAPT (1-2-46MG) (TAB DS PK) )
3
ILOPERIDONE
(FANAPT (2 MG)
(TABLET) )
3
Sharp Health Plan: Covered California
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
Page 31 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ILOPERIDONE
(FANAPT (4 MG)
(TABLET) )
3
ILOPERIDONE
(FANAPT (6 MG)
(TABLET) )
3
ILOPERIDONE
(FANAPT (8 MG)
(TABLET) )
3
LURASIDONE HCL
(LATUDA (120 MG)
(TABLET) )
3
LURASIDONE HCL
(LATUDA (20 MG)
(TABLET) )
3
LURASIDONE HCL
(LATUDA (40 MG)
(TABLET) )
3
LURASIDONE HCL
(LATUDA (60 MG)
(TABLET) )
3
LURASIDONE HCL
(LATUDA (80 MG)
(TABLET) )
3
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
olanzapine
paliperidone
Sharp Health Plan: Covered California
(ZYPREXA (10 MG)
(TABLET) )
(ZYPREXA (15 MG)
(TABLET) )
(ZYPREXA (2.5 MG)
(TABLET) )
(ZYPREXA (20 MG)
(TABLET) )
(ZYPREXA (5 MG)
(TABLET) )
(ZYPREXA (7.5 MG)
(TABLET) )
(ZYPREXA ZYDIS
(10 MG) (TAB
RAPDIS) )
(ZYPREXA ZYDIS
(15 MG) (TAB
RAPDIS) )
(ZYPREXA ZYDIS
(20 MG) (TAB
RAPDIS) )
(ZYPREXA ZYDIS
(5 MG) (TAB
RAPDIS) )
(INVEGA (1.5 MG)
(TAB ER 24) )
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
Page 32 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
paliperidone
(INVEGA (3 MG)
(TAB ER 24) )
2
paliperidone
(INVEGA (6 MG)
(TAB ER 24) )
2
paliperidone
(INVEGA (9 MG)
(TAB ER 24) )
2
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
(SEROQUEL (100
MG) (TABLET) )
(SEROQUEL (200
MG) (TABLET) )
(SEROQUEL (25
MG) (TABLET) )
(SEROQUEL (300
MG) (TABLET) )
(SEROQUEL (400
MG) (TABLET) )
(SEROQUEL (50
MG) (TABLET) )
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
QUETIAPINE FUMARATE
(SEROQUEL XR
(150 MG) (TAB ER
24H) )
3
QUETIAPINE FUMARATE
(SEROQUEL XR
(200 MG) (TAB ER
24H) )
3
QUETIAPINE FUMARATE
(SEROQUEL XR
(300 MG) (TAB ER
24H) )
3
QUETIAPINE FUMARATE
(SEROQUEL XR
(400 MG) (TAB ER
24H) )
3
QUETIAPINE FUMARATE
(SEROQUEL XR (50
MG) (TAB ER 24H) )
3
QUETIAPINE FUMARATE
(SEROQUEL XR
(50-200-300)
(TAB24HDSPK) )
3
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
Sharp Health Plan: Covered California
(RISPERDAL (0.25
MG) (TABLET) )
(RISPERDAL (0.5
MG) (TABLET) )
(RISPERDAL (1
MG) (TABLET) )
(RISPERDAL (1
MG/ML)
(SOLUTION) )
(RISPERDAL (2
MG) (TABLET) )
(RISPERDAL (3
MG) (TABLET) )
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 1 FILL PER 365 DAYS;
USE RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 16 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
Page 33 of 224
Sharp Health Plan: Covered California
Drug Name
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
Drug Tier Requirements/Limits
(RISPERDAL (4
MG) (TABLET) )
(RISPERDAL MTAB (0.5 MG) (TAB
RAPDIS) )
(RISPERDAL MTAB (1 MG) (TAB
RAPDIS) )
(RISPERDAL MTAB (2 MG) (TAB
RAPDIS) )
(RISPERDAL MTAB (3 MG) (TAB
RAPDIS) )
(RISPERDAL MTAB (4 MG) (TAB
RAPDIS) )
risperidone odt (0.25 mg) (tab rapdis)
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 4 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ziprasidone hcl
(GEODON (20 MG)
(CAPSULE) )
1
ziprasidone hcl
(GEODON (40 MG)
(CAPSULE) )
1
ziprasidone hcl
(GEODON (60 MG)
(CAPSULE) )
1
ziprasidone hcl
(GEODON (80 MG)
(CAPSULE) )
1
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES
thiothixene
thiothixene
thiothixene
thiothixene
(NAVANE (1 MG)
(CAPSULE) )
(NAVANE (10 MG)
(CAPSULE) )
(NAVANE (2 MG)
(CAPSULE) )
(NAVANE (5 MG)
(CAPSULE) )
1
1
1
1
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol lactate
Sharp Health Plan: Covered California
(HALDOL (0.5 MG)
(TABLET) )
(HALDOL (1 MG)
(TABLET) )
(HALDOL (10 MG)
(TABLET) )
(HALDOL (2 MG)
(TABLET) )
(HALDOL (20 MG)
(TABLET) )
(HALDOL (5 MG)
(TABLET) )
(HALDOL (2
MG/ML) (ORAL
CONC) )
1
1
1
1
1
1
1
Page 34 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES
molindone hcl
(MOBAN (10 MG)
(TABLET) )
2
molindone hcl
(MOBAN (25 MG)
(TABLET) )
2
molindone hcl
(MOBAN (5 MG)
(TABLET) )
2
QL: 8 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 9 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
QL: 4 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRIST OR PCSD
NURSE
ANTI-PSYCHOTICS,PHENOTHIAZINES
chlorpromazine hcl
chlorpromazine hcl
chlorpromazine hcl
chlorpromazine hcl
chlorpromazine hcl
fluphenazine hcl
fluphenazine hcl
fluphenazine hcl
fluphenazine hcl
fluphenazine hcl
fluphenazine hcl
perphenazine
perphenazine
perphenazine
perphenazine
thioridazine hcl
thioridazine hcl
thioridazine hcl
thioridazine hcl
trifluoperazine hcl
trifluoperazine hcl
trifluoperazine hcl
Sharp Health Plan: Covered California
(THORAZINE (10
MG) (TABLET) )
(THORAZINE (100
MG) (TABLET) )
(THORAZINE (200
MG) (TABLET) )
(THORAZINE (25
MG) (TABLET) )
(THORAZINE (50
MG) (TABLET) )
(PROLIXIN (1 MG)
(TABLET) )
(PROLIXIN (10 MG)
(TABLET) )
(PROLIXIN (2.5
MG) (TABLET) )
(PROLIXIN (2.5
MG/5ML)
(ELIXIR) )
(PROLIXIN (5 MG)
(TABLET) )
(PROLIXIN (5
MG/ML) (ORAL
CONC) )
(TRILAFON (16
MG) (TABLET) )
(TRILAFON (2 MG)
(TABLET) )
(TRILAFON (4 MG)
(TABLET) )
(TRILAFON (8 MG)
(TABLET) )
(MELLARIL (10
MG) (TABLET) )
(MELLARIL (100
MG) (TABLET) )
(MELLARIL (25
MG) (TABLET) )
(MELLARIL (50
MG) (TABLET) )
(STELAZINE (1
MG) (TABLET) )
(STELAZINE (10
MG) (TABLET) )
(STELAZINE (2
MG) (TABLET) )
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 35 of 224
Sharp Health Plan: Covered California
Drug Name
trifluoperazine hcl
Drug Tier Requirements/Limits
(STELAZINE (5
MG) (TABLET) )
1
(BUTISOL SODIUM
(30 MG) (TABLET) )
3
BARBITURATES
BUTABARBITAL SODIUM
phenobarbital (100 mg) (tablet)
phenobarbital (15 mg) (tablet)
phenobarbital (16.2 mg) (tablet)
phenobarbital (20 mg/5 ml) (elixir)
phenobarbital (30 mg) (tablet)
phenobarbital (32.4 mg) (tablet)
phenobarbital (60 mg) (tablet)
phenobarbital (64.8 mg) (tablet)
phenobarbital (97.2mg) (tablet)
SECOBARBITAL SODIUM
1
1
1
1
1
1
1
1
1
(SECONAL
SODIUM (100 MG)
(CAPSULE) )
3
PA
HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS
RAMELTEON
TASIMELTEON
(ROZEREM (8 MG)
(TABLET) )
(HETLIOZ (20 MG)
(CAPSULE) )
2
ST
3
MONOAMINE OXIDASE(MAO) INHIBITORS
SELEGILINE
SELEGILINE
SELEGILINE
(EMSAM
(12MG/24HR)
(PATCH TD24) )
(EMSAM (6 MG/24
HR) (PATCH TD24) )
(EMSAM (9 MG/24
HR) (PATCH TD24) )
3
PA
3
PA
3
PA
NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS
armodafinil
armodafinil
armodafinil
armodafinil
modafinil
modafinil
(NUVIGIL (150 MG)
(TABLET) )
(NUVIGIL (200 MG)
(TABLET) )
(NUVIGIL (250 MG)
(TABLET) )
(NUVIGIL (50 MG)
(TABLET) )
(PROVIGIL (100
MG) (TABLET) )
(PROVIGIL (200
MG) (TABLET) )
2
PA, QL: 30 IN 30 DAYS
2
PA, QL: 30 IN 30 DAYS
2
PA, QL: 30 IN 30 DAYS
2
PA, QL: 60 IN 30 DAYS
2
PA, QL: 1 IN 1 DAY
2
PA, QL: 1 IN 1 DAY
NARCOTIC ANTAGONISTS
naloxone hcl
naloxone hcl
NALOXONE HCL
naltrexone hcl
(NARCAN (0.4
MG/ML)
(SYRINGE) )
(NARCAN (1
MG/ML)
(SYRINGE) )
(NARCAN (4 MG)
(SPRAY) )
(REVIA (50 MG)
(TABLET) )
MB
MB
3
QL: 4 IN 30 DAYS
1
PA
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
SEDATIVE-HYPNOTICS,NON-BARBITURATE
DOXEPIN HCL
DOXEPIN HCL
Sharp Health Plan: Covered California
(SILENOR (3 MG)
(TABLET) )
(SILENOR (6 MG)
(TABLET) )
Page 36 of 224
Sharp Health Plan: Covered California
Drug Name
estazolam
estazolam
eszopiclone
eszopiclone
eszopiclone
flurazepam hcl
flurazepam hcl
midazolam hcl
quazepam
SUVOREXANT
SUVOREXANT
SUVOREXANT
SUVOREXANT
temazepam
temazepam
temazepam
temazepam
triazolam
triazolam
zaleplon
zaleplon
zolpidem tartrate
zolpidem tartrate
zolpidem tartrate
zolpidem tartrate
zolpidem tartrate
zolpidem tartrate
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(PROSOM (1 MG)
(TABLET) )
(PROSOM (2 MG)
(TABLET) )
(LUNESTA (1 MG)
(TABLET) )
(LUNESTA (2 MG)
(TABLET) )
(LUNESTA (3 MG)
(TABLET) )
(DALMANE (15
MG) (CAPSULE) )
(DALMANE (30
MG) (CAPSULE) )
(VERSED (2
MG/ML) (SYRUP) )
(DORAL (15 MG)
(TABLET) )
(BELSOMRA (10
MG) (TABLET) )
(BELSOMRA (15
MG) (TABLET) )
(BELSOMRA (20
MG) (TABLET) )
(BELSOMRA (5
MG) (TABLET) )
(RESTORIL (15 MG)
(CAPSULE) )
(RESTORIL (22.5
MG) (CAPSULE) )
(RESTORIL (30 MG)
(CAPSULE) )
(RESTORIL (7.5
MG) (CAPSULE) )
(HALCION (0.125
MG) (TABLET) )
(HALCION (0.25
MG) (TABLET) )
(SONATA (10 MG)
(CAPSULE) )
(SONATA (5 MG)
(CAPSULE) )
(AMBIEN (10 MG)
(TABLET) )
(AMBIEN (10MG)
(TABLET) )
(AMBIEN (5 MG)
(TABLET) )
(AMBIEN (5MG)
(TABLET) )
(AMBIEN CR (12.5
MG) (TAB
MPHASE) )
(AMBIEN CR (6.25
MG) (TAB
MPHASE) )
(EDLUAR (10 MG)
(TAB SUBL) )
(EDLUAR (5 MG)
(TAB SUBL) )
2
2
1
1
1
2
2
2
2
PA
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
1
1
1
2
2
1
1
1
1
1
1
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
Page 37 of 224
Sharp Health Plan: Covered California
Drug Name
zolpidem tartrate
zolpidem tartrate
ZOLPIDEM TARTRATE
Drug Tier Requirements/Limits
(INTERMEZZO
(1.75 MG) (TAB
SUBL) )
(INTERMEZZO (3.5
MG) (TAB SUBL) )
(ZOLPIMIST (5
MG/SPRAY)
(SPRAY/PUMP) )
2
ST
2
ST
3
ST, QL: 7.7 IN 28 DAYS
SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA)
PIMAVANSERIN TARTRATE
(NUPLAZID (17
MG) (TABLET) )
4
PA
SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMB
olanzapine/fluoxetine hcl
olanzapine/fluoxetine hcl
olanzapine/fluoxetine hcl
olanzapine/fluoxetine hcl
olanzapine/fluoxetine hcl
(SYMBYAX (12MG25MG) (CAPSULE) )
(SYMBYAX (12MG50MG) (CAPSULE) )
(SYMBYAX (3 MG25 MG)
(CAPSULE) )
(SYMBYAX (6MG25MG) (CAPSULE) )
(SYMBYAX (6MG50MG) (CAPSULE) )
2
QL: 1 IN 1 DAY
2
QL: 1 IN 1 DAY
2
QL: 1 IN 1 DAY
2
QL: 1 IN 1 DAY
2
QL: 1 IN 1 DAY
TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONIST
clonidine hcl
guanfacine hcl
guanfacine hcl
guanfacine hcl
guanfacine hcl
(KAPVAY (0.1 MG)
(TAB ER 12H) )
(INTUNIV (1 MG)
(TAB ER 24H) )
(INTUNIV (2 MG)
(TAB ER 24H) )
(INTUNIV (3 MG)
(TAB ER 24H) )
(INTUNIV (4 MG)
(TAB ER 24H) )
2
2
2
2
2
AGE: >= 6 YEARS|<= 17
YEARS
AGE: >= 6 YEARS|<= 17
YEARS
AGE: >= 6 YEARS|<= 17
YEARS
AGE: >= 6 YEARS|<= 17
YEARS
AGE: >= 6 YEARS|<= 17
YEARS
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL
dexmethylphenidate hcl
dexmethylphenidate hcl
METHYLPHENIDATE
Sharp Health Plan: Covered California
(FOCALIN (10 MG)
(TABLET) )
(FOCALIN (2.5 MG)
(TABLET) )
(FOCALIN (5 MG)
(TABLET) )
(FOCALIN XR (10
MG) (CPBP 50-50) )
(FOCALIN XR (15
MG) (CPBP 50-50) )
(FOCALIN XR (20
MG) (CPBP 50-50) )
(FOCALIN XR (25
MG) (CPBP 50-50) )
(FOCALIN XR (30
MG) (CPBP 50-50) )
(FOCALIN XR (35
MG) (CPBP 50-50) )
(FOCALIN XR (40
MG) (CPBP 50-50) )
(FOCALIN XR (5
MG) (CPBP 50-50) )
(DAYTRANA
(10MG/9HR)
(PATCH TD24) )
1
PA, AGE: <= 17 YEARS
1
PA, AGE: <= 17 YEARS
1
PA, AGE: <= 17 YEARS
2
2
2
3
2
3
2
2
3
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
PA, QL: 1 IN 1 DAY
Page 38 of 224
Sharp Health Plan: Covered California
Drug Name
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(DAYTRANA
(15MG/9HR)
(PATCH TD24) )
(DAYTRANA (20
MG/9 HR) (PATCH
TD24) )
(DAYTRANA
(30MG/9HR)
(PATCH TD24) )
(APTENSIO XR (10
MG) (CSBP 40-60) )
(APTENSIO XR (15
MG) (CSBP 40-60) )
(APTENSIO XR (20
MG) (CSBP 40-60) )
(APTENSIO XR (30
MG) (CSBP 40-60) )
(APTENSIO XR (40
MG) (CSBP 40-60) )
(APTENSIO XR (50
MG) (CSBP 40-60) )
(APTENSIO XR (60
MG) (CSBP 40-60) )
(CONCERTA (18
MG) (TAB ER 24) )
(CONCERTA (27
MG) (TAB ER 24) )
(CONCERTA (36
MG) (TAB ER 24) )
(CONCERTA (54
MG) (TAB ER 24) )
(METADATE CD (10
MG) (CPBP 30-70) )
(METADATE CD (20
MG) (CPBP 30-70) )
(METADATE CD (30
MG) (CPBP 30-70) )
(METADATE CD (40
MG) (CPBP 30-70) )
(METADATE CD (50
MG) (CPBP 30-70) )
(METADATE CD (60
MG) (CPBP 30-70) )
(METADATE ER (10
MG) (TABLET ER) )
(METADATE ER (20
MG) (TABLET ER) )
(METHYLIN (10
MG) (TAB CHEW) )
(METHYLIN (10
MG/5 ML)
(SOLUTION) )
(METHYLIN (2.5
MG) (TAB CHEW) )
(METHYLIN (5 MG)
(TAB CHEW) )
(METHYLIN (5
MG/5 ML)
(SOLUTION) )
3
PA, QL: 1 IN 1 DAY
3
PA, QL: 1 IN 1 DAY
3
PA, QL: 1 IN 1 DAY
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 3 IN
1 DAY
AGE: <= 17 YEARS, QL: 3 IN
1 DAY
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
AGE: <= 17 YEARS, QL: 30
IN 1 DAY
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
AGE: <= 17 YEARS, QL: 30
IN 1 DAY
Page 39 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
METHYLPHENIDATE HCL
(QUILLICHEW ER
(20 MG) (TAB
CBP24H) )
3
METHYLPHENIDATE HCL
(QUILLICHEW ER
(30 MG) (TAB
CBP24H) )
3
METHYLPHENIDATE HCL
(QUILLICHEW ER
(40 MG) (TAB
CBP24H) )
3
METHYLPHENIDATE HCL
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
METHYLPHENIDATE HCL
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
METHYLPHENIDATE HCL
methylphenidate hcl
(QUILLIVANT XR
(5 MG/ML) (SU ER
RC24) )
(RITALIN (10 MG)
(TABLET) )
(RITALIN (20 MG)
(TABLET) )
(RITALIN (5 MG)
(TABLET) )
(RITALIN LA (10
MG) (CPBP 50-50) )
(RITALIN LA (20
MG) (CPBP 50-50) )
(RITALIN LA (30
MG) (CPBP 50-50) )
(RITALIN LA (40
MG) (CPBP 50-50) )
(RITALIN LA (60
MG) (CPBP 50-50) )
(RITALIN-SR (20
MG) (TABLET ER) )
3
1
1
1
2
1
1
1
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY; USE RESTRICTED
TO PSYCHIATRIST OR PCSD
NURSE
ST, AGE: <= 17 YEARS, QL: 2
IN 1 DAY; USE RESTRICTED
TO PSYCHIATRIST OR PCSD
NURSE
ST, AGE: <= 17 YEARS, QL: 1
IN 1 DAY; USE RESTRICTED
TO PSYCHIATRIST OR PCSD
NURSE
ST, AGE: <= 17 YEARS
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
AGE: <= 17 YEARS, QL: 3 IN
1 DAY
AGE: <= 17 YEARS, QL: 6 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
3
AGE: <= 17 YEARS
1
AGE: <= 17 YEARS, QL: 3 IN
1 DAY
TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE
ATOMOXETINE HCL
ATOMOXETINE HCL
ATOMOXETINE HCL
ATOMOXETINE HCL
ATOMOXETINE HCL
ATOMOXETINE HCL
ATOMOXETINE HCL
(STRATTERA (10
MG) (CAPSULE) )
(STRATTERA (100
MG) (CAPSULE) )
(STRATTERA (18
MG) (CAPSULE) )
(STRATTERA (25
MG) (CAPSULE) )
(STRATTERA (40
MG) (CAPSULE) )
(STRATTERA (60
MG) (CAPSULE) )
(STRATTERA (80
MG) (CAPSULE) )
2
2
2
2
2
2
2
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 2 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
AGE: <= 17 YEARS, QL: 1 IN
1 DAY
CARDIOVASCULAR DISEASE - ARRHYTHMIA
ANTIARRHYTHMICS
amiodarone hcl
amiodarone hcl
amiodarone hcl
disopyramide phosphate
disopyramide phosphate
Sharp Health Plan: Covered California
(CORDARONE (200
MG) (TABLET) )
(PACERONE (100
MG) (TABLET) )
(PACERONE (400
MG) (TABLET) )
(NORPACE (100
MG) (CAPSULE) )
(NORPACE (150
MG) (CAPSULE) )
1
1
1
1
1
Page 40 of 224
Sharp Health Plan: Covered California
Drug Name
DISOPYRAMIDE PHOSPHATE
DISOPYRAMIDE PHOSPHATE
dofetilide
dofetilide
dofetilide
DRONEDARONE HCL
flecainide acetate
flecainide acetate
flecainide acetate
mexiletine hcl
mexiletine hcl
mexiletine hcl
propafenone hcl
propafenone hcl
propafenone hcl
propafenone hcl
propafenone hcl
propafenone hcl
quinidine gluconate
Drug Tier Requirements/Limits
(NORPACE CR (100
MG) (CAPSULE
ER) )
(NORPACE CR (150
MG) (CAPSULE
ER) )
(TIKOSYN (125
MCG) (CAPSULE) )
(TIKOSYN (250
MCG) (CAPSULE) )
(TIKOSYN (500
MCG) (CAPSULE) )
(MULTAQ (400 MG)
(TABLET) )
(TAMBOCOR (100
MG) (TABLET) )
(TAMBOCOR (150
MG) (TABLET) )
(TAMBOCOR (50
MG) (TABLET) )
(MEXITIL (150 MG)
(CAPSULE) )
(MEXITIL (200 MG)
(CAPSULE) )
(MEXITIL (250 MG)
(CAPSULE) )
(RYTHMOL (150
MG) (TABLET) )
(RYTHMOL (225
MG) (TABLET) )
(RYTHMOL (300
MG) (TABLET) )
(RYTHMOL SR (225
MG) (CAP ER 12H) )
(RYTHMOL SR (325
MG) (CAP ER 12H) )
(RYTHMOL SR (425
MG) (CAP ER 12H) )
(QUINAGLUTE (324
MG) (TABLET ER) )
quinidine sulfate (200 mg) (tablet)
quinidine sulfate
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
2
2
1
1
(QUINORA (300
MG) (TABLET) )
1
CARDIOVASCULAR DISEASE - CARDIAC STIMULANT
DIGITALIS GLYCOSIDES
DIGOXIN (50 MCG/ML) (SOLUTION)
digoxin
DIGOXIN
digoxin
DIGOXIN
1
(LANOXIN (125
MCG) (TABLET) )
(LANOXIN (187.5
MCG) (TABLET) )
(LANOXIN (250
MCG) (TABLET) )
(LANOXIN (62.5
MCG) (TABLET) )
1
1
1
1
CARDIOVASCULAR DISEASE - HYPERTENSION
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION
amlodipine besylate/benazepril
Sharp Health Plan: Covered California
(LOTREL (10 MG20MG) (CAPSULE) )
1
Page 41 of 224
Sharp Health Plan: Covered California
Drug Name
amlodipine besylate/benazepril
amlodipine besylate/benazepril
amlodipine besylate/benazepril
amlodipine besylate/benazepril
amlodipine besylate/benazepril
PERINDOPRIL ARG/AMLODIPINE BES
PERINDOPRIL ARG/AMLODIPINE BES
PERINDOPRIL ARG/AMLODIPINE BES
trandolapril/verapamil hcl
trandolapril/verapamil hcl
trandolapril/verapamil hcl
trandolapril/verapamil hcl
Drug Tier Requirements/Limits
(LOTREL (10 MG40MG) (CAPSULE) )
(LOTREL (2.5MG10MG) (CAPSULE) )
(LOTREL (5 MG-10
MG) (CAPSULE) )
(LOTREL (5 MG-20
MG) (CAPSULE) )
(LOTREL (5 MG-40
MG) (CAPSULE) )
(PRESTALIA
(14MG-10MG)
(TABLET) )
(PRESTALIA (3.52.5 MG) (TABLET) )
(PRESTALIA (7 MG5 MG) (TABLET) )
(TARKA (1-240MG)
(TAB BP 24H) )
(TARKA (2 MG180MG) (TAB BP
24H) )
(TARKA (2-240MG)
(TAB BP 24H) )
(TARKA (4-240MG)
(TAB BP 24H) )
1
1
1
1
1
3
ST
3
ST
3
ST
2
2
2
2
ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC
benazepril/hydrochlorothiazide
benazepril/hydrochlorothiazide
benazepril/hydrochlorothiazide
benazepril/hydrochlorothiazide
captopril/hydrochlorothiazide
captopril/hydrochlorothiazide
captopril/hydrochlorothiazide
captopril/hydrochlorothiazide
enalapril/hydrochlorothiazide
enalapril/hydrochlorothiazide
fosinopril/hydrochlorothiazide
Sharp Health Plan: Covered California
(LOTENSIN HCT
(10-12.5MG)
(TABLET) )
(LOTENSIN HCT
(20 MG-25MG)
(TABLET) )
(LOTENSIN HCT
(20-12.5 MG)
(TABLET) )
(LOTENSIN HCT (56.25MG) (TABLET) )
(CAPOZIDE (25
MG-15MG)
(TABLET) )
(CAPOZIDE (25
MG-25MG)
(TABLET) )
(CAPOZIDE (50
MG-15MG)
(TABLET) )
(CAPOZIDE (50
MG-25MG)
(TABLET) )
(VASERETIC (10
MG-25MG)
(TABLET) )
(VASERETIC (5MG12.5MG) (TABLET) )
(MONOPRIL-HCT
(10-12.5MG)
(TABLET) )
1
1
1
1
2
2
2
2
2
2
2
Page 42 of 224
Sharp Health Plan: Covered California
Drug Name
fosinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
moexipril/hydrochlorothiazide
moexipril/hydrochlorothiazide
moexipril/hydrochlorothiazide
quinapril/hydrochlorothiazide
quinapril/hydrochlorothiazide
quinapril/hydrochlorothiazide
Drug Tier Requirements/Limits
(MONOPRIL-HCT
(20-12.5 MG)
(TABLET) )
(ZESTORETIC (1012.5MG) (TABLET) )
(ZESTORETIC (20
MG-25MG)
(TABLET) )
(ZESTORETIC (2012.5 MG)
(TABLET) )
(UNIRETIC (1512.5MG) (TABLET) )
(UNIRETIC (1525MG) (TABLET) )
(UNIRETIC (7.512.5MG) (TABLET) )
(ACCURETIC (1012.5MG) (TABLET) )
(ACCURETIC (20
MG-25MG)
(TABLET) )
(ACCURETIC (2012.5 MG)
(TABLET) )
2
2
2
2
2
2
2
2
2
2
ALPHA/BETA-ADRENERGIC BLOCKING AGENTS
carvedilol
carvedilol
carvedilol
carvedilol
CARVEDILOL PHOSPHATE
CARVEDILOL PHOSPHATE
CARVEDILOL PHOSPHATE
CARVEDILOL PHOSPHATE
labetalol hcl
labetalol hcl
labetalol hcl
(COREG (12.5 MG)
(TABLET) )
(COREG (25 MG)
(TABLET) )
(COREG (3.125 MG)
(TABLET) )
(COREG (6.25 MG)
(TABLET) )
(COREG CR (10
MG) (CPMP 24HR) )
(COREG CR (20
MG) (CPMP 24HR) )
(COREG CR (40
MG) (CPMP 24HR) )
(COREG CR (80
MG) (CPMP 24HR) )
(TRANDATE (100
MG) (TABLET) )
(TRANDATE (200
MG) (TABLET) )
(TRANDATE (300
MG) (TABLET) )
1
1
1
1
3
3
3
3
1
1
1
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate
doxazosin mesylate
doxazosin mesylate
doxazosin mesylate
DOXAZOSIN MESYLATE
Sharp Health Plan: Covered California
(CARDURA (1 MG)
(TABLET) )
(CARDURA (2 MG)
(TABLET) )
(CARDURA (4 MG)
(TABLET) )
(CARDURA (8 MG)
(TABLET) )
(CARDURA XL (4
MG) (TAB ER 24) )
1
1
1
1
3
Page 43 of 224
Sharp Health Plan: Covered California
Drug Name
DOXAZOSIN MESYLATE
phenoxybenzamine hcl
prazosin hcl
prazosin hcl
prazosin hcl
terazosin hcl
terazosin hcl
terazosin hcl
terazosin hcl
Drug Tier Requirements/Limits
(CARDURA XL (8
MG) (TAB ER 24) )
(DIBENZYLINE (10
MG) (CAPSULE) )
(MINIPRESS (1 MG)
(CAPSULE) )
(MINIPRESS (2 MG)
(CAPSULE) )
(MINIPRESS (5 MG)
(CAPSULE) )
(HYTRIN (1 MG)
(CAPSULE) )
(HYTRIN (10 MG)
(CAPSULE) )
(HYTRIN (2 MG)
(CAPSULE) )
(HYTRIN (5 MG)
(CAPSULE) )
3
2
1
1
1
1
1
1
1
ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CB
amlodipine/valsartan/hcthiazid
amlodipine/valsartan/hcthiazid
amlodipine/valsartan/hcthiazid
amlodipine/valsartan/hcthiazid
amlodipine/valsartan/hcthiazid
OLMESARTAN/AMLODIPIN/HCTHIAZID
OLMESARTAN/AMLODIPIN/HCTHIAZID
OLMESARTAN/AMLODIPIN/HCTHIAZID
OLMESARTAN/AMLODIPIN/HCTHIAZID
OLMESARTAN/AMLODIPIN/HCTHIAZID
(EXFORGE HCT
(10-160-25)
(TABLET) )
(EXFORGE HCT
(10-320-25)
(TABLET) )
(EXFORGE HCT
(10MG-160MG)
(TABLET) )
(EXFORGE HCT (5160-12.5)
(TABLET) )
(EXFORGE HCT (5160-25MG)
(TABLET) )
(TRIBENZOR (20-512.5) (TABLET) )
(TRIBENZOR (4010-12.5) (TABLET) )
(TRIBENZOR (4010-25MG)
(TABLET) )
(TRIBENZOR (40-512.5) (TABLET) )
(TRIBENZOR (40-525 MG) (TABLET) )
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
ANGIOTENSIN II RECEPTOR BLOCKER-BETA BLOCKER COMB.
NEBIVOLOL HCL/VALSARTAN
(BYVALSON (5 MG80 MG) (TABLET) )
3
ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB
AZILSARTAN MED/CHLORTHALIDONE
AZILSARTAN MED/CHLORTHALIDONE
candesartan/hydrochlorothiazid
Sharp Health Plan: Covered California
(EDARBYCLOR (40
MG-25MG)
(TABLET) )
(EDARBYCLOR
(40-12.5 MG)
(TABLET) )
(ATACAND HCT
(16-12.5MG)
(TABLET) )
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
Page 44 of 224
Sharp Health Plan: Covered California
Drug Name
candesartan/hydrochlorothiazid
candesartan/hydrochlorothiazid
irbesartan/hydrochlorothiazide
irbesartan/hydrochlorothiazide
losartan/hydrochlorothiazide
losartan/hydrochlorothiazide
losartan/hydrochlorothiazide
OLMESARTAN/HYDROCHLOROTHIAZIDE
OLMESARTAN/HYDROCHLOROTHIAZIDE
OLMESARTAN/HYDROCHLOROTHIAZIDE
telmisartan/hydrochlorothiazid
telmisartan/hydrochlorothiazid
telmisartan/hydrochlorothiazid
valsartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
Drug Tier Requirements/Limits
(ATACAND HCT
(32-12.5MG)
(TABLET) )
(ATACAND HCT
(32MG-25MG)
(TABLET) )
(AVALIDE (15012.5MG) (TABLET) )
(AVALIDE (30012.5MG) (TABLET) )
(HYZAAR (10012.5MG) (TABLET) )
(HYZAAR (100MG25MG) (TABLET) )
(HYZAAR (50-12.5
MG) (TABLET) )
(BENICAR HCT (2012.5 MG)
(TABLET) )
(BENICAR HCT (40
MG-25MG)
(TABLET) )
(BENICAR HCT (4012.5 MG)
(TABLET) )
(MICARDIS HCT
(40-12.5 MG)
(TABLET) )
(MICARDIS HCT
(80 MG-25MG)
(TABLET) )
(MICARDIS HCT
(80-12.5MG)
(TABLET) )
(DIOVAN HCT (16012.5MG) (TABLET) )
(DIOVAN HCT (16025MG) (TABLET) )
(DIOVAN HCT (32012.5MG) (TABLET) )
(DIOVAN HCT
(320MG-25MG)
(TABLET) )
(DIOVAN HCT (8012.5MG) (TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR
AMLODIPINE BES/OLMESARTAN MED
AMLODIPINE BES/OLMESARTAN MED
AMLODIPINE BES/OLMESARTAN MED
AMLODIPINE BES/OLMESARTAN MED
amlodipine/valsartan
amlodipine/valsartan
amlodipine/valsartan
Sharp Health Plan: Covered California
(AZOR (10 MG20MG) (TABLET) )
(AZOR (10 MG40MG) (TABLET) )
(AZOR (5 MG-20
MG) (TABLET) )
(AZOR (5 MG-40
MG) (TABLET) )
(EXFORGE (10MG160MG) (TABLET) )
(EXFORGE (10MG320MG) (TABLET) )
(EXFORGE (5 MG160MG) (TABLET) )
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
Page 45 of 224
Sharp Health Plan: Covered California
Drug Name
amlodipine/valsartan
telmisartan/amlodipine
telmisartan/amlodipine
telmisartan/amlodipine
telmisartan/amlodipine
Drug Tier Requirements/Limits
(EXFORGE (5MG320MG) (TABLET) )
(TWYNSTA (40 MG10MG) (TABLET) )
(TWYNSTA (40 MG5 MG) (TABLET) )
(TWYNSTA (80 MG10MG) (TABLET) )
(TWYNSTA (80 MG5 MG) (TABLET) )
2
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
ANTIHYPERTENSIVES, ACE INHIBITORS
benazepril hcl
benazepril hcl
benazepril hcl
benazepril hcl
captopril
captopril
captopril
captopril
ENALAPRIL MALEATE
enalapril maleate
enalapril maleate
enalapril maleate
enalapril maleate
fosinopril sodium
fosinopril sodium
fosinopril sodium
lisinopril
lisinopril
lisinopril
LISINOPRIL
lisinopril
lisinopril
lisinopril
Sharp Health Plan: Covered California
(LOTENSIN (10 MG)
(TABLET) )
(LOTENSIN (20 MG)
(TABLET) )
(LOTENSIN (40 MG)
(TABLET) )
(LOTENSIN (5 MG)
(TABLET) )
(CAPOTEN (100
MG) (TABLET) )
(CAPOTEN (12.5
MG) (TABLET) )
(CAPOTEN (25 MG)
(TABLET) )
(CAPOTEN (50 MG)
(TABLET) )
(EPANED (1
MG/ML) (SOLN
RECON) )
(VASOTEC (10 MG)
(TABLET) )
(VASOTEC (2.5 MG)
(TABLET) )
(VASOTEC (20 MG)
(TABLET) )
(VASOTEC (5 MG)
(TABLET) )
(MONOPRIL (10
MG) (TABLET) )
(MONOPRIL (20
MG) (TABLET) )
(MONOPRIL (40
MG) (TABLET) )
(PRINIVIL (10 MG)
(TABLET) )
(PRINIVIL (20 MG)
(TABLET) )
(PRINIVIL (5 MG)
(TABLET) )
(QBRELIS (1
MG/ML)
(SOLUTION) )
(ZESTRIL (10 MG)
(TABLET) )
(ZESTRIL (2.5 MG)
(TABLET) )
(ZESTRIL (20 MG)
(TABLET) )
1
1
1
1
1
1
1
1
3
AGE: <= 6 YEARS, QL: 1200
IN 30 DAYS
1
1
1
1
1
1
1
1
1
1
3
ST, QL: 1200 IN 30 DAYS
1
1
1
Page 46 of 224
Sharp Health Plan: Covered California
Drug Name
lisinopril
lisinopril
lisinopril
moexipril hcl
moexipril hcl
perindopril erbumine
perindopril erbumine
perindopril erbumine
quinapril hcl
quinapril hcl
quinapril hcl
quinapril hcl
ramipril
ramipril
ramipril
ramipril
trandolapril
trandolapril
trandolapril
Drug Tier Requirements/Limits
(ZESTRIL (30 MG)
(TABLET) )
(ZESTRIL (40 MG)
(TABLET) )
(ZESTRIL (5 MG)
(TABLET) )
(UNIVASC (15 MG)
(TABLET) )
(UNIVASC (7.5 MG)
(TABLET) )
(ACEON (2 MG)
(TABLET) )
(ACEON (4 MG)
(TABLET) )
(ACEON (8 MG)
(TABLET) )
(ACCUPRIL (10
MG) (TABLET) )
(ACCUPRIL (20
MG) (TABLET) )
(ACCUPRIL (40
MG) (TABLET) )
(ACCUPRIL (5 MG)
(TABLET) )
(ALTACE (1.25 MG)
(CAPSULE) )
(ALTACE (10 MG)
(CAPSULE) )
(ALTACE (2.5 MG)
(CAPSULE) )
(ALTACE (5 MG)
(CAPSULE) )
(MAVIK (1 MG)
(TABLET) )
(MAVIK (2 MG)
(TABLET) )
(MAVIK (4 MG)
(TABLET) )
1
1
1
1
1
2
2
2
2
2
2
2
1
1
1
1
1
1
1
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST
AZILSARTAN MEDOXOMIL
AZILSARTAN MEDOXOMIL
candesartan cilexetil
candesartan cilexetil
candesartan cilexetil
candesartan cilexetil
eprosartan mesylate
irbesartan
irbesartan
irbesartan
Sharp Health Plan: Covered California
(EDARBI (40 MG)
(TABLET) )
(EDARBI (80 MG)
(TABLET) )
(ATACAND (16 MG)
(TABLET) )
(ATACAND (32 MG)
(TABLET) )
(ATACAND (4 MG)
(TABLET) )
(ATACAND (8 MG)
(TABLET) )
(TEVETEN (600
MG) (TABLET) )
(AVAPRO (150 MG)
(TABLET) )
(AVAPRO (300 MG)
(TABLET) )
(AVAPRO (75 MG)
(TABLET) )
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
Page 47 of 224
Sharp Health Plan: Covered California
Drug Name
losartan potassium
losartan potassium
losartan potassium
OLMESARTAN MEDOXOMIL
OLMESARTAN MEDOXOMIL
OLMESARTAN MEDOXOMIL
telmisartan
telmisartan
telmisartan
valsartan
valsartan
valsartan
valsartan
Drug Tier Requirements/Limits
(COZAAR (100 MG)
(TABLET) )
(COZAAR (25 MG)
(TABLET) )
(COZAAR (50 MG)
(TABLET) )
(BENICAR (20 MG)
(TABLET) )
(BENICAR (40 MG)
(TABLET) )
(BENICAR (5 MG)
(TABLET) )
(MICARDIS (20
MG) (TABLET) )
(MICARDIS (40
MG) (TABLET) )
(MICARDIS (80
MG) (TABLET) )
(DIOVAN (160 MG)
(TABLET) )
(DIOVAN (320 MG)
(TABLET) )
(DIOVAN (40 MG)
(TABLET) )
(DIOVAN (80 MG)
(TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS
MECAMYLAMINE HCL
(VECAMYL (2.5
MG) (TABLET) )
3
ANTIHYPERTENSIVES, MISCELLANEOUS
METYROSINE
(DEMSER (250 MG)
(CAPSULE) )
3
ANTIHYPERTENSIVES, SYMPATHOLYTIC
clonidine
clonidine
clonidine
clonidine hcl
clonidine hcl
clonidine hcl
clonidine hcl/chlorthalidone
clonidine hcl/chlorthalidone
clonidine hcl/chlorthalidone
guanfacine hcl
guanfacine hcl
Sharp Health Plan: Covered California
(CATAPRES-TTS 1
(0.1MG/24HR)
(PATCH TDWK) )
(CATAPRES-TTS 2
(0.2MG/24HR)
(PATCH TDWK) )
(CATAPRES-TTS 3
(0.3MG/24HR)
(PATCH TDWK) )
(CATAPRES (0.1
MG) (TABLET) )
(CATAPRES (0.2
MG) (TABLET) )
(CATAPRES (0.3
MG) (TABLET) )
(COMBIPRES
(0.1MG-15MG)
(TABLET) )
(COMBIPRES (0.215MG) (TABLET) )
(COMBIPRES
(0.3MG-15MG)
(TABLET) )
(TENEX (1 MG)
(TABLET) )
(TENEX (2 MG)
(TABLET) )
2
2
2
1
1
1
2
2
2
1
1
Page 48 of 224
Sharp Health Plan: Covered California
Drug Name
methyldopa
methyldopa
methyldopa/hydrochlorothiazide
methyldopa/hydrochlorothiazide
reserpine
reserpine
Drug Tier Requirements/Limits
(ALDOMET (250
MG) (TABLET) )
(ALDOMET (500
MG) (TABLET) )
(ALDORIL 15
(250MG-15MG)
(TABLET) )
(ALDORIL 25
(250MG-25MG)
(TABLET) )
(SANDRIL (0.1 MG)
(TABLET) )
(SANDRIL (0.25
MG) (TABLET) )
1
1
2
2
2
2
ANTIHYPERTENSIVES, VASODILATORS
hydralazine hcl
hydralazine hcl
hydralazine hcl
hydralazine hcl
minoxidil
minoxidil
(APRESOLINE (10
MG) (TABLET) )
(APRESOLINE (100
MG) (TABLET) )
(APRESOLINE (25
MG) (TABLET) )
(APRESOLINE (50
MG) (TABLET) )
(LONITEN (10 MG)
(TABLET) )
(LONITEN (2.5 MG)
(TABLET) )
1
1
1
1
1
1
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl
acebutolol hcl
atenolol
atenolol
atenolol
betaxolol hcl
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate
metoprolol succinate
metoprolol succinate
metoprolol succinate
metoprolol succinate
metoprolol tartrate
metoprolol tartrate
metoprolol tartrate (25 mg) (tablet)
metoprolol tartrate (37.5 mg) (tablet)
Sharp Health Plan: Covered California
(SECTRAL (200
MG) (CAPSULE) )
(SECTRAL (400
MG) (CAPSULE) )
(TENORMIN (100
MG) (TABLET) )
(TENORMIN (25
MG) (TABLET) )
(TENORMIN (50
MG) (TABLET) )
(KERLONE (10 MG)
(TABLET) )
(KERLONE (20 MG)
(TABLET) )
(ZEBETA (10 MG)
(TABLET) )
(ZEBETA (5 MG)
(TABLET) )
(TOPROL XL (100
MG) (TAB ER 24H) )
(TOPROL XL (200
MG) (TAB ER 24H) )
(TOPROL XL (25
MG) (TAB ER 24H) )
(TOPROL XL (50
MG) (TAB ER 24H) )
(LOPRESSOR (100
MG) (TABLET) )
(LOPRESSOR (50
MG) (TABLET) )
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 49 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
metoprolol tartrate (75 mg) (tablet)
nadolol
nadolol
nadolol
NEBIVOLOL HCL
NEBIVOLOL HCL
NEBIVOLOL HCL
NEBIVOLOL HCL
PENBUTOLOL SULFATE
pindolol
pindolol
PROPRANOLOL HCL
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
propranolol hcl
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
sotalol hcl (120 mg) (tablet)
sotalol hcl (160 mg) (tablet)
sotalol hcl (240 mg) (tablet)
sotalol hcl (80 mg) (tablet)
Sharp Health Plan: Covered California
1
(CORGARD (20
MG) (TABLET) )
(CORGARD (40
MG) (TABLET) )
(CORGARD (80
MG) (TABLET) )
(BYSTOLIC (10
MG) (TABLET) )
(BYSTOLIC (2.5
MG) (TABLET) )
(BYSTOLIC (20
MG) (TABLET) )
(BYSTOLIC (5 MG)
(TABLET) )
(LEVATOL (20 MG)
(TABLET) )
(VISKEN (10 MG)
(TABLET) )
(VISKEN (5 MG)
(TABLET) )
(HEMANGEOL
(4.28 MG/ML)
(SOLUTION) )
(INDERAL (10 MG)
(TABLET) )
(INDERAL (20 MG)
(TABLET) )
(INDERAL (20 MG/5
ML) (SOLUTION) )
(INDERAL (40 MG)
(TABLET) )
(INDERAL
(40MG/5ML)
(SOLUTION) )
(INDERAL (60 MG)
(TABLET) )
(INDERAL (80 MG)
(TABLET) )
(INDERAL LA (120
MG) (CAP SA 24H) )
(INDERAL LA (160
MG) (CAP SA 24H) )
(INDERAL LA (60
MG) (CAP SA 24H) )
(INDERAL LA (80
MG) (CAP SA 24H) )
(INDERAL XL (120
MG) (CAP ER 24H) )
(INDERAL XL (80
MG) (CAP ER 24H) )
(INNOPRAN XL
(120 MG) (CAP ER
24H) )
(INNOPRAN XL (80
MG) (CAP ER 24H) )
1
1
1
3
3
3
3
3
2
2
3
ST, AGE: <= 1 YEAR, QL: 12
IN 1 DAY
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
1
1
1
1
Page 50 of 224
Sharp Health Plan: Covered California
Drug Name
SOTALOL HCL
timolol maleate
timolol maleate
timolol maleate
Drug Tier Requirements/Limits
(SOTYLIZE (5
MG/ML)
(SOLUTION) )
(BLOCADREN (10
MG) (TABLET) )
(BLOCADREN (20
MG) (TABLET) )
(BLOCADREN (5
MG) (TABLET) )
3
PA
2
2
2
BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED
atenolol/chlorthalidone
atenolol/chlorthalidone
bisoprolol fumarate/hctz
bisoprolol fumarate/hctz
bisoprolol fumarate/hctz
METOPROLOL SUCCINATE/HCTZ
METOPROLOL SUCCINATE/HCTZ
METOPROLOL SUCCINATE/HCTZ
metoprolol/hydrochlorothiazide
metoprolol/hydrochlorothiazide
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol/bendroflumethiazide
propranolol/hydrochlorothiazid
propranolol/hydrochlorothiazid
(TENORETIC 100
(100MG-25MG)
(TABLET) )
(TENORETIC 50 (50
MG-25MG)
(TABLET) )
(ZIAC (10-6.25MG)
(TABLET) )
(ZIAC (2.5-6.25MG)
(TABLET) )
(ZIAC (5-6.25MG)
(TABLET) )
(DUTOPROL (10012.5MG) (TAB ER
24H) )
(DUTOPROL (2512.5 MG) (TAB ER
24H) )
(DUTOPROL (5012.5 MG) (TAB ER
24H) )
(LOPRESSOR HCT
(100MG-25MG)
(TABLET) )
(LOPRESSOR HCT
(100MG-50MG)
(TABLET) )
(LOPRESSOR HCT
(50 MG-25MG)
(TABLET) )
(CORZIDE (40 MG-5
MG) (TABLET) )
(CORZIDE (80 MG-5
MG) (TABLET) )
(INDERIDE-40/25
(40 MG-25MG)
(TABLET) )
(INDERIDE-80/25
(80 MG-25MG)
(TABLET) )
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate
amlodipine besylate
amlodipine besylate
diltiazem hcl
Sharp Health Plan: Covered California
(NORVASC (10 MG)
(TABLET) )
(NORVASC (2.5 MG)
(TABLET) )
(NORVASC (5 MG)
(TABLET) )
(CARDIZEM (120
MG) (TABLET) )
1
1
1
1
Page 51 of 224
Sharp Health Plan: Covered California
Drug Name
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
DILTIAZEM HCL
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
diltiazem hcl
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(CARDIZEM (30
MG) (TABLET) )
(CARDIZEM (60
MG) (TABLET) )
(CARDIZEM (90
MG) (TABLET) )
(CARDIZEM CD
(120 MG) (CAP ER
24H) )
(CARDIZEM CD
(180 MG) (CAP ER
24H) )
(CARDIZEM CD
(240 MG) (CAP ER
24H) )
(CARDIZEM CD
(300 MG) (CAP ER
24H) )
(CARDIZEM CD
(360 MG) (CAP ER
24H) )
(CARDIZEM LA
(120 MG) (TAB ER
24H) )
(CARDIZEM LA
(180 MG) (TAB ER
24H) )
(CARDIZEM LA
(240 MG) (TAB ER
24H) )
(CARDIZEM LA
(300 MG) (TAB ER
24H) )
(CARDIZEM LA
(360 MG) (TAB ER
24H) )
(CARDIZEM LA
(420 MG) (TAB ER
24H) )
(CARDIZEM SR
(120 MG) (CAP ER
12H) )
(CARDIZEM SR (60
MG) (CAP ER 12H) )
(CARDIZEM SR (90
MG) (CAP ER 12H) )
(DILACOR XR (120
MG) (CAP ER
DEG) )
(DILACOR XR (180
MG) (CAP ER
DEG) )
(DILACOR XR (240
MG) (CAP ER
DEG) )
(TIAZAC (120 MG)
(CAPSULE ER) )
(TIAZAC (180 MG)
(CAPSULE ER) )
(TIAZAC (240 MG)
(CAPSULE ER) )
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 52 of 224
Sharp Health Plan: Covered California
Drug Name
diltiazem hcl
diltiazem hcl
diltiazem hcl
felodipine
felodipine
felodipine
isradipine
isradipine
nicardipine hcl
nicardipine hcl
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nimodipine
NIMODIPINE
nisoldipine
nisoldipine
nisoldipine
nisoldipine
nisoldipine
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(TIAZAC (300 MG)
(CAPSULE ER) )
(TIAZAC (360 MG)
(CAPSULE ER) )
(TIAZAC (420 MG)
(CAPSULE ER) )
(PLENDIL (10 MG)
(TAB ER 24H) )
(PLENDIL (2.5 MG)
(TAB ER 24H) )
(PLENDIL (5 MG)
(TAB ER 24H) )
(DYNACIRC (2.5
MG) (CAPSULE) )
(DYNACIRC (5 MG)
(CAPSULE) )
(CARDENE (20 MG)
(CAPSULE) )
(CARDENE (30 MG)
(CAPSULE) )
(ADALAT CC (30
MG) (TABLET ER) )
(ADALAT CC (60
MG) (TABLET ER) )
(ADALAT CC (90
MG) (TABLET ER) )
(PROCARDIA (10
MG) (CAPSULE) )
(PROCARDIA (20
MG) (CAPSULE) )
(PROCARDIA XL
(30 MG) (TAB ER
24) )
(PROCARDIA XL
(60 MG) (TAB ER
24) )
(PROCARDIA XL
(60 MG) (TABLET
ER) )
(PROCARDIA XL
(90 MG) (TAB ER
24) )
(PROCARDIA XL
(90 MG) (TABLET
ER) )
(NIMOTOP (30 MG)
(CAPSULE) )
(NYMALIZE (60
MG/20ML)
(SOLUTION) )
(SULAR (17 MG)
(TAB ER 24H) )
(SULAR (20 MG)
(TAB ER 24H) )
(SULAR (25.5 MG)
(TAB ER 24H) )
(SULAR (30 MG)
(TAB ER 24H) )
(SULAR (34 MG)
(TAB ER 24H) )
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
2
1
2
2
4
1
1
1
1
1
Page 53 of 224
Sharp Health Plan: Covered California
Drug Name
nisoldipine
nisoldipine
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
verapamil hcl
Drug Tier Requirements/Limits
(SULAR (40 MG)
(TAB ER 24H) )
(SULAR (8.5MG)
(TAB ER 24H) )
(CALAN (120 MG)
(TABLET) )
(CALAN (40 MG)
(TABLET) )
(CALAN (80 MG)
(TABLET) )
(CALAN SR (120
MG) (TABLET ER) )
(CALAN SR (180
MG) (TABLET ER) )
(CALAN SR (240
MG) (TABLET ER) )
(VERELAN (120
MG) (CAP24H
PEL) )
(VERELAN (180
MG) (CAP24H
PEL) )
(VERELAN (240
MG) (CAP24H
PEL) )
(VERELAN (360
MG) (CAP24H
PEL) )
(VERELAN PM (100
MG) (CAP24H
PCT) )
(VERELAN PM (200
MG) (CAP24H
PCT) )
(VERELAN PM (300
MG) (CAP24H
PCT) )
1
1
1
1
1
1
1
1
2
2
1
2
2
2
2
LOOP DIURETICS
bumetanide
bumetanide
bumetanide
ethacrynic acid
furosemide
furosemide
furosemide
furosemide
furosemide
torsemide
Sharp Health Plan: Covered California
(BUMEX (0.5 MG)
(TABLET) )
(BUMEX (1 MG)
(TABLET) )
(BUMEX (2 MG)
(TABLET) )
(EDECRIN (25 MG)
(TABLET) )
(LASIX (10 MG/ML)
(SOLUTION) )
(LASIX (20 MG)
(TABLET) )
(LASIX (40 MG)
(TABLET) )
(LASIX
(40MG/5ML)
(SOLUTION) )
(LASIX (80 MG)
(TABLET) )
(DEMADEX (10
MG) (TABLET) )
1
1
1
2
1
1
1
1
1
2
Page 54 of 224
Sharp Health Plan: Covered California
Drug Name
torsemide
torsemide
torsemide
Drug Tier Requirements/Limits
(DEMADEX (100
MG) (TABLET) )
(DEMADEX (20
MG) (TABLET) )
(DEMADEX (5 MG)
(TABLET) )
2
2
2
POTASSIUM SPARING DIURETICS
amiloride hcl
eplerenone
eplerenone
spironolactone
spironolactone
spironolactone
TRIAMTERENE
TRIAMTERENE
(MIDAMOR (5 MG)
(TABLET) )
(INSPRA (25 MG)
(TABLET) )
(INSPRA (50 MG)
(TABLET) )
(ALDACTONE (100
MG) (TABLET) )
(ALDACTONE (25
MG) (TABLET) )
(ALDACTONE (50
MG) (TABLET) )
(DYRENIUM (100
MG) (CAPSULE) )
(DYRENIUM (50
MG) (CAPSULE) )
1
2
2
1
1
1
2
2
POTASSIUM SPARING DIURETICS IN COMBINATION
amiloride/hydrochlorothiazide
spironolact/hydrochlorothiazid
SPIRONOLACT/HYDROCHLOROTHIAZID
triamterene/hydrochlorothiazid
triamterene/hydrochlorothiazid
triamterene/hydrochlorothiazid
triamterene/hydrochlorothiazid
(MODURETIC 5-50
(5 MG-50 MG)
(TABLET) )
(ALDACTAZIDE (25
MG-25MG)
(TABLET) )
(ALDACTAZIDE (50
MG-50MG)
(TABLET) )
(DYAZIDE (37.5-25
MG) (CAPSULE) )
(DYAZIDE (50 MG25MG) (CAPSULE) )
(MAXZIDE (75 MG50MG) (TABLET) )
(MAXZIDE-25 MG
(37.5-25 MG)
(TABLET) )
1
1
2
1
1
1
1
PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR
RIOCIGUAT
RIOCIGUAT
RIOCIGUAT
RIOCIGUAT
RIOCIGUAT
(ADEMPAS (0.5
MG) (TABLET) )
(ADEMPAS (1 MG)
(TABLET) )
(ADEMPAS (1.5
MG) (TABLET) )
(ADEMPAS (2 MG)
(TABLET) )
(ADEMPAS (2.5
MG) (TABLET) )
4
PA, QL: 3 IN 1 DAY
4
PA, QL: 3 IN 1 DAY
4
PA, QL: 3 IN 1 DAY
4
PA, QL: 3 IN 1 DAY
4
PA, QL: 3 IN 1 DAY
PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB
SILDENAFIL CITRATE
sildenafil citrate
Sharp Health Plan: Covered California
(REVATIO (10
MG/ML) (SUSP
RECON) )
(REVATIO (20 MG)
(TABLET) )
4
PA, QL: 2 IN 21 DAYS
4
PA, QL: 90 IN 30 DAYS
Page 55 of 224
Sharp Health Plan: Covered California
Drug Name
TADALAFIL
Drug Tier Requirements/Limits
(ADCIRCA (20 MG)
(TABLET) )
4
PA, QL: 60 IN 30 DAYS
PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST
AMBRISENTAN
AMBRISENTAN
BOSENTAN
BOSENTAN
MACITENTAN
(LETAIRIS (10 MG)
(TABLET) )
(LETAIRIS (5 MG)
(TABLET) )
(TRACLEER (125
MG) (TABLET) )
(TRACLEER (62.5
MG) (TABLET) )
(OPSUMIT (10 MG)
(TABLET) )
4
PA
4
PA
4
PA
4
PA
4
PA, QL: 1 IN 1 DAY
PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE
ILOPROST TROMETHAMINE
ILOPROST TROMETHAMINE
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
SELEXIPAG
TREPROSTINIL
TREPROSTINIL DIOLAMINE
TREPROSTINIL DIOLAMINE
TREPROSTINIL DIOLAMINE
TREPROSTINIL DIOLAMINE
TREPROSTINIL/NEB ACCESSORIES
TREPROSTINIL/NEBULIZER/ACCESOR
Sharp Health Plan: Covered California
(VENTAVIS (10
MCG/ML) (AMPULNEB) )
(VENTAVIS (20
MCG/ML) (AMPULNEB) )
(UPTRAVI (1000
MCG) (TABLET) )
(UPTRAVI (1200
MCG) (TABLET) )
(UPTRAVI (1400
MCG) (TABLET) )
(UPTRAVI (1600
MCG) (TABLET) )
(UPTRAVI (200
MCG) (TABLET) )
(UPTRAVI (200800MCG) (TAB DS
PK) )
(UPTRAVI (400
MCG) (TABLET) )
(UPTRAVI (600
MCG) (TABLET) )
(UPTRAVI (800
MCG) (TABLET) )
(TYVASO
(1.74MG/2.9)
(AMPUL-NEB) )
(ORENITRAM ER
(0.125 MG)
(TABLET ER) )
(ORENITRAM ER
(0.25 MG) (TABLET
ER) )
(ORENITRAM ER (1
MG) (TABLET ER) )
(ORENITRAM ER
(2.5 MG) (TABLET
ER) )
(TYVASO REFILL
KIT (1.74MG/2.9)
(AMPUL-NEB) )
(TYVASO
INSTITUTIONAL
START KIT
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
Page 56 of 224
Sharp Health Plan: Covered California
Drug Name
TREPROSTINIL/NEBULIZER/ACCESOR
Drug Tier Requirements/Limits
(1.74MG/2.9)
(AMPUL-NEB) )
(TYVASO STARTER
KIT (1.74MG/2.9)
(AMPUL-NEB) )
4
PA
3
PA
3
PA
RENIN INHIBITOR, DIRECT
ALISKIREN HEMIFUMARATE
ALISKIREN HEMIFUMARATE
(TEKTURNA (150
MG) (TABLET) )
(TEKTURNA (300
MG) (TABLET) )
RENIN INHIBITOR, DIRECT & CALCIUM CHANNEL BLOCKER
ALISKIREN/AMLODIPINE BESYLATE
ALISKIREN/AMLODIPINE BESYLATE
ALISKIREN/AMLODIPINE BESYLATE
ALISKIREN/AMLODIPINE BESYLATE
(TEKAMLO (150
MG-5MG)
(TABLET) )
(TEKAMLO
(150MG-10MG)
(TABLET) )
(TEKAMLO
(300MG-10MG)
(TABLET) )
(TEKAMLO
(300MG-5MG)
(TABLET) )
3
3
3
3
RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMB
ALISKIREN/HYDROCHLOROTHIAZIDE
ALISKIREN/HYDROCHLOROTHIAZIDE
ALISKIREN/HYDROCHLOROTHIAZIDE
ALISKIREN/HYDROCHLOROTHIAZIDE
(TEKTURNA HCT
(150-12.5MG)
(TABLET) )
(TEKTURNA HCT
(150MG-25MG)
(TABLET) )
(TEKTURNA HCT
(300-12.5MG)
(TABLET) )
(TEKTURNA HCT
(300MG-25MG)
(TABLET) )
3
PA
3
PA
3
PA
3
PA
THIAZIDE AND RELATED DIURETICS
chlorothiazide
chlorothiazide
CHLOROTHIAZIDE
chlorthalidone
chlorthalidone
(DIURIL (250 MG)
(TABLET) )
(DIURIL (500 MG)
(TABLET) )
(DIURIL (250
MG/5ML) (ORAL
SUSP) )
(HYGROTON (25
MG) (TABLET) )
(HYGROTON (50
MG) (TABLET) )
hydrochlorothiazide (12.5 mg) (tablet)
hydrochlorothiazide
hydrochlorothiazide
hydrochlorothiazide
indapamide
indapamide
methyclothiazide (5 mg) (tablet)
Sharp Health Plan: Covered California
2
2
3
1
1
1
(HYDRODIURIL (25
MG) (TABLET) )
(HYDRODIURIL (50
MG) (TABLET) )
(MICROZIDE (12.5
MG) (CAPSULE) )
(LOZOL (1.25 MG)
(TABLET) )
(LOZOL (2.5 MG)
(TABLET) )
1
1
1
2
2
2
Page 57 of 224
Sharp Health Plan: Covered California
Drug Name
metolazone
metolazone
metolazone
Drug Tier Requirements/Limits
(ZAROXOLYN (10
MG) (TABLET) )
(ZAROXOLYN (2.5
MG) (TABLET) )
(ZAROXOLYN (5
MG) (TABLET) )
1
1
1
VASODILATORS, COMBINATION
ISOSORB DINIT/HYDRALAZINE HCL
(BIDIL (20-37.5MG)
(TABLET) )
3
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
ANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIB
EZETIMIBE/SIMVASTATIN
EZETIMIBE/SIMVASTATIN
EZETIMIBE/SIMVASTATIN
EZETIMIBE/SIMVASTATIN
(VYTORIN (10 MG10MG) (TABLET) )
(VYTORIN (10 MG20MG) (TABLET) )
(VYTORIN (10 MG40MG) (TABLET) )
(VYTORIN (10 MG80MG) (TABLET) )
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS
atorvastatin calcium
atorvastatin calcium
atorvastatin calcium
atorvastatin calcium
fluvastatin sodium
fluvastatin sodium
fluvastatin sodium
LOVASTATIN
LOVASTATIN
LOVASTATIN
lovastatin
lovastatin
lovastatin
PITAVASTATIN CALCIUM
PITAVASTATIN CALCIUM
PITAVASTATIN CALCIUM
pravastatin sodium
pravastatin sodium
pravastatin sodium
Sharp Health Plan: Covered California
(LIPITOR (10 MG)
(TABLET) )
(LIPITOR (20 MG)
(TABLET) )
(LIPITOR (40 MG)
(TABLET) )
(LIPITOR (80 MG)
(TABLET) )
(LESCOL (20 MG)
(CAPSULE) )
(LESCOL (40 MG)
(CAPSULE) )
(LESCOL XL (80
MG) (TAB ER 24H) )
(ALTOPREV (20
MG) (TAB ER 24H) )
(ALTOPREV (40
MG) (TAB ER 24H) )
(ALTOPREV (60
MG) (TAB ER 24H) )
(MEVACOR (10 MG)
(TABLET) )
(MEVACOR (20 MG)
(TABLET) )
(MEVACOR (40 MG)
(TABLET) )
(LIVALO (1 MG)
(TABLET) )
(LIVALO (2 MG)
(TABLET) )
(LIVALO (4 MG)
(TABLET) )
(PRAVACHOL (10
MG) (TABLET) )
(PRAVACHOL (20
MG) (TABLET) )
(PRAVACHOL (40
MG) (TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
Page 58 of 224
Sharp Health Plan: Covered California
Drug Name
pravastatin sodium
rosuvastatin calcium
rosuvastatin calcium
rosuvastatin calcium
rosuvastatin calcium
simvastatin
simvastatin
simvastatin
simvastatin
simvastatin
Drug Tier Requirements/Limits
(PRAVACHOL (80
MG) (TABLET) )
(CRESTOR (10 MG)
(TABLET) )
(CRESTOR (20 MG)
(TABLET) )
(CRESTOR (40 MG)
(TABLET) )
(CRESTOR (5 MG)
(TABLET) )
(ZOCOR (10 MG)
(TABLET) )
(ZOCOR (20 MG)
(TABLET) )
(ZOCOR (40 MG)
(TABLET) )
(ZOCOR (5 MG)
(TABLET) )
(ZOCOR (80 MG)
(TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
PA, QL: 1 IN 1 DAY
ANTIHYPERLIPIDEMIC - MTP INHIBITOR
LOMITAPIDE MESYLATE
LOMITAPIDE MESYLATE
LOMITAPIDE MESYLATE
LOMITAPIDE MESYLATE
LOMITAPIDE MESYLATE
LOMITAPIDE MESYLATE
(JUXTAPID (10 MG)
(CAPSULE) )
(JUXTAPID (20 MG)
(CAPSULE) )
(JUXTAPID (30 MG)
(CAPSULE) )
(JUXTAPID (40 MG)
(CAPSULE) )
(JUXTAPID (5 MG)
(CAPSULE) )
(JUXTAPID (60 MG)
(CAPSULE) )
4
4
4
4
4
4
BILE SALT SEQUESTRANTS
cholestyramine (with sugar)
cholestyramine (with sugar)
cholestyramine/aspartame
cholestyramine/aspartame
COLESEVELAM HCL
COLESEVELAM HCL
colestipol hcl
colestipol hcl
colestipol hcl
COLESTIPOL HCL
(QUESTRAN (4 G)
(POWD PACK) )
(QUESTRAN (4 G)
(POWDER) )
(QUESTRAN LIGHT
(4 G) (POWD
PACK) )
(QUESTRAN LIGHT
(4 G) (POWDER) )
(WELCHOL (3.75 G)
(POWD PACK) )
(WELCHOL (625
MG) (TABLET) )
(COLESTID (1 G)
(TABLET) )
(COLESTID (5 G)
(GRANULES) )
(COLESTID (5 G)
(PACKET) )
(COLESTID (7.5 G)
(PACKET) )
1
1
1
1
3
3
1
1
1
2
LIPOTROPICS
EZETIMIBE
fenofibrate
Sharp Health Plan: Covered California
(ZETIA (10 MG)
(TABLET) )
(FENOGLIDE (120
MG) (TABLET) )
2
QL: 1 IN 1 DAY
2
ST
Page 59 of 224
Sharp Health Plan: Covered California
Drug Name
fenofibrate
fenofibrate
fenofibrate
fenofibrate
fenofibrate
fenofibrate nanocrystallized
fenofibrate nanocrystallized
FENOFIBRATE NANOCRYSTALLIZED
fenofibrate,micronized
FENOFIBRATE,MICRONIZED
fenofibrate,micronized
FENOFIBRATE,MICRONIZED
fenofibrate,micronized
fenofibrate,micronized
fenofibrate,micronized
fenofibric acid
fenofibric acid
fenofibric acid (choline)
fenofibric acid (choline)
gemfibrozil
ICOSAPENT ETHYL
METHIONINE/INOSITOL/CHOLINE/FA
niacin
niacin
niacin
niacin
omega-3 acid ethyl esters
Drug Tier Requirements/Limits
(FENOGLIDE (40
MG) (TABLET) )
(LIPOFEN (150 MG)
(CAPSULE) )
(LIPOFEN (50 MG)
(CAPSULE) )
(LOFIBRA (160 MG)
(TABLET) )
(LOFIBRA (54 MG)
(TABLET) )
(TRICOR (145MG)
(TABLET) )
(TRICOR (48 MG)
(TABLET) )
(TRIGLIDE (160
MG) (TABLET) )
(ANTARA (130 MG)
(CAPSULE) )
(ANTARA (30 MG)
(CAPSULE) )
(ANTARA (43 MG)
(CAPSULE) )
(ANTARA (90 MG)
(CAPSULE) )
(LOFIBRA (134MG)
(CAPSULE) )
(LOFIBRA (200 MG)
(CAPSULE) )
(LOFIBRA (67 MG)
(CAPSULE) )
(FIBRICOR (105
MG) (TABLET) )
(FIBRICOR (35 MG)
(TABLET) )
(TRILIPIX (135 MG)
(CAPSULE DR) )
(TRILIPIX (45 MG)
(CAPSULE DR) )
(LOPID (600 MG)
(TABLET) )
(VASCEPA (1 G)
(CAPSULE) )
(LIPOCHOL PLUS
(0.5 MG)
(TABLET) )
(NIACOR (500 MG)
(TABLET) )
(NIASPAN (1000
MG) (TAB ER 24H) )
(NIASPAN (500 MG)
(TAB ER 24H) )
(NIASPAN (750 MG)
(TAB ER 24H) )
(LOVAZA (1 G)
(CAPSULE) )
2
ST
1
1
1
1
1
1
3
ST
2
ST
3
ST
1
3
ST
1
1
1
1
1
1
1
1
3
PA
3
1
1
1
1
2
PA
4
PA
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
ADRENERGIC VASOPRESSOR AGENTS
DROXIDOPA
Sharp Health Plan: Covered California
(NORTHERA (100
MG) (CAPSULE) )
Page 60 of 224
Sharp Health Plan: Covered California
Drug Name
DROXIDOPA
DROXIDOPA
midodrine hcl
midodrine hcl
midodrine hcl
Drug Tier Requirements/Limits
(NORTHERA (200
MG) (CAPSULE) )
(NORTHERA (300
MG) (CAPSULE) )
(PROAMATINE (10
MG) (TABLET) )
(PROAMATINE (2.5
MG) (TABLET) )
(PROAMATINE (5
MG) (TABLET) )
4
PA
4
PA
2
2
2
ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)
SACUBITRIL/VALSARTAN
SACUBITRIL/VALSARTAN
SACUBITRIL/VALSARTAN
(ENTRESTO (24
MG-26MG)
(TABLET) )
(ENTRESTO (49
MG-51MG)
(TABLET) )
(ENTRESTO (97MG103MG) (TABLET) )
3
ST
3
ST
3
ST
ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC
RANOLAZINE
RANOLAZINE
(RANEXA (1000
MG) (TAB ER 12H) )
(RANEXA (500 MG)
(TAB ER 12H) )
3
3
ANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITOR
IVABRADINE HCL
IVABRADINE HCL
(CORLANOR (5
MG) (TABLET) )
(CORLANOR (7.5
MG) (TABLET) )
3
ST
3
ST
ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CB
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
amlodipine/atorvastatin
(CADUET (10 MG10MG) (TABLET) )
(CADUET (10 MG20MG) (TABLET) )
(CADUET (10 MG40MG) (TABLET) )
(CADUET (10 MG80MG) (TABLET) )
(CADUET (2.5MG10MG) (TABLET) )
(CADUET (2.5MG20MG) (TABLET) )
(CADUET (2.5MG40MG) (TABLET) )
(CADUET (5 MG-10
MG) (TABLET) )
(CADUET (5 MG-20
MG) (TABLET) )
(CADUET (5 MG-40
MG) (TABLET) )
(CADUET (5 MG-80
MG) (TABLET) )
2
2
2
2
2
2
2
2
2
2
2
CARDIOVASCULAR DISEASE - VASODILATION
VASODILATORS,CORONARY
ISOSORBIDE DINITRATE
isosorbide dinitrate
Sharp Health Plan: Covered California
(DILATRATE-SR (40
MG) (CAPSULE
ER) )
(ISOCHRON (40
MG) (TABLET ER) )
2
1
Page 61 of 224
Sharp Health Plan: Covered California
Drug Name
isosorbide dinitrate
isosorbide dinitrate
isosorbide dinitrate
ISOSORBIDE DINITRATE
isosorbide dinitrate
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
NITROGLYCERIN
NITROGLYCERIN
nitroglycerin
nitroglycerin
NITROGLYCERIN
nitroglycerin
nitroglycerin
NITROGLYCERIN
nitroglycerin
nitroglycerin
nitroglycerin
nitroglycerin
nitroglycerin
nitroglycerin
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(ISORDIL (10 MG)
(TABLET) )
(ISORDIL (20 MG)
(TABLET) )
(ISORDIL (30 MG)
(TABLET) )
(ISORDIL (40 MG)
(TABLET) )
(ISORDIL
TITRADOSE (5 MG)
(TABLET) )
(IMDUR (120 MG)
(TAB ER 24H) )
(IMDUR (30 MG)
(TAB ER 24H) )
(IMDUR (60 MG)
(TAB ER 24H) )
(MONOKET (10
MG) (TABLET) )
(MONOKET (20
MG) (TABLET) )
(GONITRO (400
MCG) (POWD
PACK) )
(NITRO-BID (2 %)
(OINT. (G)) )
(NITRO-DUR
(0.1MG/HR) (PATCH
TD24) )
(NITRO-DUR
(0.2MG/HR) (PATCH
TD24) )
(NITRO-DUR (0.3
MG/HR) (PATCH
TD24) )
(NITRO-DUR
(0.4MG/HR) (PATCH
TD24) )
(NITRO-DUR
(0.6MG/HR) (PATCH
TD24) )
(NITRO-DUR
(0.8MG/HR) (PATCH
TD24) )
(NITROLINGUAL
(400MCG/SPR)
(SPRAY) )
(NITROMIST
(400MCG/SPR)
(SPRAY) )
(NITROSTAT (0.3
MG) (TAB SUBL) )
(NITROSTAT (0.4
MG) (TAB SUBL) )
(NITROSTAT (0.6
MG) (TAB SUBL) )
(NITRO-TIME (2.5
MG) (CAPSULE
ER) )
1
1
1
2
1
1
1
1
1
1
4
2
1
1
2
1
1
2
2
2
1
1
1
1
Page 62 of 224
Sharp Health Plan: Covered California
Drug Name
nitroglycerin
nitroglycerin
Drug Tier Requirements/Limits
(NITRO-TIME (6.5
MG) (CAPSULE
ER) )
(NITRO-TIME (9
MG) (CAPSULE
ER) )
1
1
VASODILATORS,PERIPHERAL
ergoloid mesylates
(HYDERGINE (1
MG) (TABLET) )
isoxsuprine hcl (20 mg) (tablet)
isoxsuprine hcl
2
2
(VASODILAN (10
MG) (TABLET) )
2
CONTRACEPTION/OXYTOCICS
CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC
ETONOGESTREL/ETHINYL ESTRADIOL
(NUVARING (.12.015MG) (VAG
RING) )
PV
CONTRACEPTIVES,INTRAVAGINAL
nonoxynol 9
NONOXYNOL 9
NONOXYNOL 9
NONOXYNOL 9
(DELFEN (12.5 %)
(FOAM/APPL)
(OTC))
(GYNOL II (3 %)
(JELLY/APPL)
(OTC))
(TODAY
CONTRACEPTIVE
SPONGE (1000 MG)
(CON.SPONGE)
(OTC))
(VCF (28 %) (FILM)
(OTC))
PV
QL: 210 IN 30 DAYS
PV
QL: 5 IN 30 DAYS
PV
QL: 24 IN 30 DAYS
PV
QL: 45 IN 30 DAYS
CONTRACEPTIVES,ORAL
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
desogestrel-ethinyl estradiol
DROSPIR/ETH ESTRA/LEVOMEFOL CA
DROSPIR/ETH ESTRA/LEVOMEFOL CA
ESTRADIOL VALERATE/DIENOGEST
ethinyl estradiol/drospirenone
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
ethynodiol d-ethinyl estradiol
(MIRCETTE (21-5)
(TABLET) )
(CYCLESSA (7
DAYS X 3)
(TABLET) )
(DESOGEN (0.150.03) (TABLET) )
(BEYAZ (3-0.02(24))
(TABLET) )
(SAFYRAL (30.03(21))
(TABLET) )
(NATAZIA (3-21(28)) (TABLET) )
(YASMIN 28
(0.03MG-3MG)
(TABLET) )
(YAZ (0.02-3(24))
(TABLET) )
(DEMULEN (1 MG35MCG) (TABLET) )
(DEMULEN 1-50-21
(1 MG-50MCG)
(TABLET) )
ethynodiol d-ethinyl estradiol (1 mg-35mcg) (tablet)
levonorgestrel
Sharp Health Plan: Covered California
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
(AFTERA (1.5 MG)
(TABLET) (OTC))
PV
Page 63 of 224
Sharp Health Plan: Covered California
Drug Name
levonorgestrel
levonorgestrel
levonorgestrel-ethin estradiol
levonorgestrel-ethin estradiol
Drug Tier Requirements/Limits
(PLAN B ONE-STEP
(1.5 MG) (TABLET)
(OTC))
(TAKE ACTION (1.5
MG) (TABLET)
(OTC))
(AMETHYST (9020MCG) (TABLET) )
(AVIANE (0.1-0.02)
(TABLET) )
levonorgestrel-ethin estradiol (0.1-0.02) (tablet)
levonorgestrel-ethin estradiol (6-5-10) (tablet)
levonorgestrel-ethin estradiol
levonorgestrel-ethin estradiol
levonorgestrel-ethin estradiol
l-norgest/e.estradiol-e.estrad
L-NORGEST/E.ESTRADIOL-E.ESTRAD
l-norgest/e.estradiol-e.estrad
noreth-ethinyl estradiol/iron
noreth-ethinyl estradiol/iron
norethindrone
norethindrone
norethindrone ac-eth estradiol
norethindrone ac-eth estradiol
norethindrone-e.estradiol-iron
NORETHINDRONE-E.ESTRADIOL-IRON
norethindrone-e.estradiol-iron
norethindrone-e.estradiol-iron
norethindrone-e.estradiol-iron
NORETHINDRONE-E.ESTRADIOL-IRON
Sharp Health Plan: Covered California
PV
PV
PV
PV
PV
PV
(NORDETTE-28
(0.15-0.03)
(TABLET) )
(SEASONALE (0.150.03) (TBDSPK
3MO) )
(TRIVORA (6-5-10)
(TABLET) )
(LOSEASONIQUE
(100-20(84))
(TBDSPK 3MO) )
(QUARTETTE
(0.15MG(84))
(TBDSPK 3MO) )
(SEASONIQUE
(150-30(84))
(TBDSPK 3MO) )
(FEMCON FE (0.435(21)) (TAB
CHEW) )
(GENERESS FE (0.825(24)) (TAB
CHEW) )
(NOR-Q-D (0.35
MG) (TABLET) )
(ORTHO
MICRONOR (0.35
MG) (TABLET) )
(LOESTRIN (1.50.03MG) (TABLET) )
(LOESTRIN (1MG20MCG) (TABLET) )
(ESTROSTEP FE (57-9-7) (TABLET) )
(LO LOESTRIN FE
(1MG-10(24))
(TABLET) )
(LOESTRIN FE (1.530(21)) (TABLET) )
(LOESTRIN FE
(1MG-20(21))
(TABLET) )
(MICROGESTIN 24
FE (1MG-20(24))
(TABLET) )
(MINASTRIN 24 FE
(1MG-20(24)) (TAB
CHEW) )
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
PV
Page 64 of 224
Sharp Health Plan: Covered California
Drug Name
NORETHINDRONE-E.ESTRADIOL-IRON
Drug Tier Requirements/Limits
(TAYTULLA (1MG20(24)) (CAPSULE) )
norethindrone-ethinyl estrad (0.4-0.035) (tablet)
norethindrone-ethinyl estrad (0.5-0.035) (tablet)
norethindrone-ethinyl estrad (1 mg-35mcg) (tablet)
norethindrone-ethinyl estrad (10-11) (tablet)
norethindrone-ethinyl estrad (7 days x 3) (tablet)
norethindrone-ethinyl estrad (7-9-5) (tablet)
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
norgestrel-ethinyl estradiol
PV
PV
PV
PV
PV
PV
(NORINYL 1+50 (1
MG-50MCG)
(TABLET) )
(ORTHO TRICYCLEN (7DAYSX3
28) (TABLET) )
(ORTHO TRICYCLEN LO
(7DAYSX3 LO)
(TABLET) )
(ORTHO-CYCLEN
(0.25-0.035)
(TABLET) )
(LO-OVRAL-28 (0.30.03MG) (TABLET) )
(LO-OVRAL-8 (0.30.03MG) (TABLET) )
norgestrel-ethinyl estradiol (0.5 mg-50) (tablet)
ULIPRISTAL ACETATE
PV
PV
PV
PV
PV
PV
PV
PV
(ELLA (30 MG)
(TABLET) )
PV
CONTRACEPTIVES,TRANSDERMAL
norelgestromin/ethin.estradiol
(ORTHO EVRA
(150-35/24H)
(PATCH TDWK) )
PV
COUGH AND COLD
1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS
chlorpheniramine/phenylephrine (1mg-2mg/ml)
(drops)
phenylephrine hcl/prometh hcl
phenylephrine hcl/prometh hcl
2
(PHENERGAN VC
(5-6.25MG/5)
(SYRUP) )
(PHEN-TUSS AD (56.25MG/5)
(SYRUP) )
1
1
1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMB
p-ephed hcl/chlor-mal/bell alk (90-8-0.24) (tab er
12h)
2
ANTITUSSIVES,NON-NARCOTIC
benzonatate
benzonatate
benzonatate
(TESSALON (200
MG) (CAPSULE) )
(TESSALON PERLE
(100 MG)
(CAPSULE) )
(ZONATUSS (150
MG) (CAPSULE) )
1
1
1
NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST
hydrocodone/cpm/pseudoephed
promethazine/phenyleph/codeine
Sharp Health Plan: Covered California
(ZUTRIPRO (5-460MG/5)
(SOLUTION) )
(PENTAZINE VC
WITH CODEINE
2
1
Page 65 of 224
Sharp Health Plan: Covered California
Drug Name
promethazine/phenyleph/codeine
Drug Tier Requirements/Limits
(6.25-5-10)
(SYRUP) )
(PHENERGAN VC
WITH CODEINE
(6.25-5-10)
(SYRUP) )
1
NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB
HYDROCODONE/PSEUDOEPHED/GUAIF
P-EPHED HCL/CODEINE/GUAIFEN
(HYCOFENIX (2.530-200)
(SOLUTION) )
(CODITUSSIN DAC
(30-10-200)
(LIQUID) (OTC))
3
ST, QL: 473 IN 30 DAYS
3
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE
CODEINE POLI/CHLORPHENIR POLIS
HYDROCODONE/CHLORPHEN P-STIREX
HYDROCODONE/CHLORPHEN P-STIREX
hydrocodone/chlorphen p-stirex
HYDROCODONE/CHLORPHENIRAMINE
promethazine hcl/codeine
(TUZISTRA XR
(14.7-2.8/5) (SUS ER
12H) )
(TUSSICAPS
(10MG-8MG) (CAP
ER 12H) )
(TUSSICAPS (5MG4MG) (CAP ER
12H) )
(TUSSIONEX (108MG/5ML) (SUS ER
12H) )
(VITUZ (5MG4MG/5)
(SOLUTION) )
(PHENERGAN
WITH CODEINE
(6.25-10/5)
(SYRUP) )
3
ST, QL: 20 IN 1 DAY
3
3
2
3
1
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.
hydrocodone bit/homatrop me-br (5-1.5 mg/5)
(syrup)
hydrocodone bit/homatrop me-br
hydrocodone bit/homatrop me-br
1
(HYDROMET (5-1.5
MG/5) (SYRUP) )
(TUSSIGON (5 MG1.5MG) (TABLET) )
1
1
NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS
P-EPHED HCL/HYDROCODONE
(REZIRA (605MG/5ML)
(SOLUTION) )
3
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION
guaifenesin/codeine phosphate (100-10mg/5) (liquid)
(otc)
guaifenesin/codeine phosphate (200-10mg/5) (liquid)
(otc)
GUAIFENESIN/HYDROCODONE
GUAIFENESIN/HYDROCODONE
3
3
(FLOWTUSS (2002.5/5) (SOLUTION) )
(OBREDON (2002.5/5) (SOLUTION) )
3
3
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST
brompheniramine/pseudoephed/dm
brompheniramine/pseudoephed/dm (2-30-10/5)
(syrup)
Sharp Health Plan: Covered California
(BROMFED DM (230-10/5) (SYRUP) )
2
2
Page 66 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
chlorpheniramine/phenyleph/dm (1-2-3mg/ml)
(drops)
2
NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.
promethazine/dextromethorphan
(PHEN TUSS DM
(6.25-15/5)
(SYRUP) )
1
NOSE PREPARATIONS, VASOCONSTRICTORS (RX)
TETRAHYDROZOLINE HCL
TETRAHYDROZOLINE HCL
(TYZINE (0.1 %)
(DROPS) )
(TYZINE (0.1 %)
(SPRAY) )
3
3
DERMATOLOGY - ACNE
ACNE AGENTS,SYSTEMIC
ISOTRETINOIN
ISOTRETINOIN
ISOTRETINOIN
ISOTRETINOIN
ISOTRETINOIN
ISOTRETINOIN
isotretinoin
isotretinoin
isotretinoin
isotretinoin
(ABSORICA (10
MG) (CAPSULE) )
(ABSORICA (20
MG) (CAPSULE) )
(ABSORICA (25
MG) (CAPSULE) )
(ABSORICA (30
MG) (CAPSULE) )
(ABSORICA (35
MG) (CAPSULE) )
(ABSORICA (40
MG) (CAPSULE) )
(ABSORICA 30MG
(30 MG)
(CAPSULE) )
(ACCUTANE (10
MG) (CAPSULE) )
(ACCUTANE (20
MG) (CAPSULE) )
(ACCUTANE (40
MG) (CAPSULE) )
2
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
3
ST
3
ST
3
ST
3
ST
3
ST
ACNE AGENTS,TOPICAL
ADAPALENE/BENZOYL PEROXIDE
ADAPALENE/BENZOYL PEROXIDE
ADAPALENE/BENZOYL PEROXIDE
AZELAIC ACID
CLINDAMYCIN PHOS/BENZOYL PEROX
clindamycin phos/benzoyl perox
clindamycin phos/benzoyl perox
clindamycin phos/benzoyl perox
CLINDAMYCIN PHOS/BENZOYL PEROX
Sharp Health Plan: Covered California
(EPIDUO (0.1 %2.5%) (GEL
(GRAM)) )
(EPIDUO (0.1 %2.5%) (GEL
W/PUMP) )
(EPIDUO FORTE
(0.3 %-2.5%) (GEL
W/PUMP) )
(AZELEX (20 %)
(CREAM (G)) )
(ACANYA (1.2%2.5%) (GEL
W/PUMP) )
(BENZACLIN (1 %-5
%) (GEL (GRAM)) )
(BENZACLIN (1 %-5
%) (GEL W/PUMP) )
(DUAC (1.2(1)%-5%)
(GEL (GRAM)) )
(ONEXTON (1.2%3.75%) (GEL
W/PUMP) )
1
2
2
3
Page 67 of 224
Sharp Health Plan: Covered California
Drug Name
CLINDAMYCIN/TRETINOIN
clindamycin/tretinoin
DAPSONE
DAPSONE
sulfacetamide sodium
Drug Tier Requirements/Limits
(VELTIN (1.20.025%) (GEL
(GRAM)) )
(ZIANA (1.20.025%) (GEL
(GRAM)) )
(ACZONE (5 %)
(GEL (GRAM)) )
(ACZONE (7.5 %)
(GEL W/PUMP) )
(KLARON (10 %)
(SUSPENSION) )
3
ST, QL: 1 IN 30 DAYS
2
ST, QL: 1 IN 30 DAYS
3
3
2
KERATOLYTIC-GLUCOCORTICOID COMBINATIONS
BENZOYL PEROXIDE/HYDROCORTISON
(VANOXIDE-HC (5
%-0.5 %)
(SUSPENSION) )
3
ROSACEA AGENTS, TOPICAL
AZELAIC ACID
AZELAIC ACID
BRIMONIDINE TARTRATE
BRIMONIDINE TARTRATE
IVERMECTIN
metronidazole
metronidazole
metronidazole
metronidazole
METRONIDAZOLE
metronidazole
(FINACEA (15 %)
(FOAM) )
(FINACEA (15 %)
(GEL (GRAM)) )
(MIRVASO (0.33 %)
(GEL (GRAM)) )
(MIRVASO (0.33 %)
(GEL W/PUMP) )
(SOOLANTRA (1 %)
(CREAM (G)) )
(METROCREAM
(0.75 %) (CREAM
(G)) )
(METROGEL (1 %)
(GEL (GRAM)) )
(METROGEL (1 %)
(GEL W/PUMP) )
(METROLOTION
(0.75 %) (LOTION) )
(NORITATE (1 %)
(CREAM (G)) )
(ROSADAN (0.75 %)
(GEL (GRAM)) )
3
3
3
ST, QL: 30 IN 30 DAYS
3
4
1
1
1
2
2
1
TOPICAL PREPARATIONS,ANTIBACTERIALS
CADEXOMER IODINE
CADEXOMER IODINE
CLIOQUINOL/HYDROCORTISONE
HYDROCORTISONE/IODOQUIN/ALOE#2
hydrocortisone/iodoquinol
(IODOFLEX (0.9 %)
(MED. PAD) )
(IODOSORB (0.9 %)
(GEL (GRAM)) )
(ALA-QUIN (3 %-0.5
%) (CREAM (G)) )
(ALCORTIN A (2 %1 %-1%) (GEL
PACKET) )
(DERMAZENE (1
%-1 %) (CREAM
(G)) )
hydrocortisone/iodoquinol (1 %-1 %) (cream (g))
hydrocortisone/iodoquinol/aloe
IODOQUINOL/ALOE POLYSACCHAR #1
Sharp Health Plan: Covered California
3
3
3
3
2
2
(VYTONE (1.9 %-1
%) (CREAM
PACK) )
(ALOQUIN (1.25%1%) (GEL
(GRAM)) )
2
3
Page 68 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
VITAMIN A DERIVATIVES
adapalene
adapalene
adapalene
adapalene
adapalene
tretinoin
tretinoin
tretinoin
tretinoin
tretinoin
tretinoin microspheres
tretinoin microspheres
TRETINOIN MICROSPHERES
(DIFFERIN (0.1 %)
(CREAM (G)) )
(DIFFERIN (0.1 %)
(GEL (GRAM)) )
(DIFFERIN (0.1 %)
(LOTION) )
(DIFFERIN (0.3 %)
(GEL (GRAM)) )
(DIFFERIN (0.3 %)
(GEL W/PUMP) )
(RETIN-A (0.01 %)
(GEL (GRAM)) )
(RETIN-A (0.025 %)
(CREAM (G)) )
(RETIN-A (0.025 %)
(GEL (GRAM)) )
(RETIN-A (0.05 %)
(CREAM (G)) )
(RETIN-A (0.1 %)
(CREAM (G)) )
(RETIN-A MICRO
(0.04 %) (GEL
(GRAM)) )
(RETIN-A MICRO
(0.1 %) (GEL
(GRAM)) )
(RETIN-A MICRO
PUMP (0.08 %)
(GEL W/PUMP) )
2
ST
2
ST
2
ST
2
ST
2
ST
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
2
PA
2
PA
3
PA
3
ST, AGE: >= 12 YEARS
VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTS
TAZAROTENE
(FABIOR (0.1 %)
(FOAM) )
DERMATOLOGY - ANTIINFECTIVE
ANTIPARASITICS
NITAZOXANIDE
NITAZOXANIDE
(ALINIA (100
MG/5ML) (SUSP
RECON) )
(ALINIA (500 MG)
(TABLET) )
3
3
TOPICAL ANTIBIOTICS
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
CLINDAMYCIN PHOSPHATE
clindamycin phosphate
erythromycin base/ethanol
Sharp Health Plan: Covered California
(CLEOCIN T (1 %)
(GEL (GRAM)) )
(CLEOCIN T (1 %)
(LOTION) )
(CLEOCIN T (1 %)
(MED. SWAB) )
(CLEOCIN T (1 %)
(SOLUTION) )
(CLINDACIN ETZ (1
%) (MED. SWAB) )
(CLINDACIN P (1
%) (MED. SWAB) )
(CLINDAGEL (1 %)
(GEL (ML)) )
(EVOCLIN (1 %)
(FOAM) )
(ERY (2 %) (MED.
SWAB) )
1
1
1
1
1
1
2
2
2
Page 69 of 224
Sharp Health Plan: Covered California
Drug Name
erythromycin base/ethanol
erythromycin base/ethanol
erythromycin/benzoyl peroxide
ERYTHROMYCIN/BENZOYL PEROXIDE
Drug Tier Requirements/Limits
(ERYGEL (2 %)
(GEL (GRAM)) )
(ERYMAX (2 %)
(SOLUTION) )
(BENZAMYCIN (3
%-5 %) (GEL
(GRAM)) )
(BENZAMYCINPAK
(3 %-5 %) (GEL
(EA)) )
gentamicin sulfate (0.1 %) (cream (g))
gentamicin sulfate (0.1 %) (oint. (g))
mupirocin
MUPIROCIN
mupirocin calcium
1
1
2
3
1
1
(CENTANY (2 %)
(OINT. (G)) )
(CENTANY AT (2
%) (KIT) )
(BACTROBAN (2 %)
(CREAM (G)) )
1
3
1
TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENT
clotrimazole/betamethasone dip
clotrimazole/betamethasone dip
(LOTRISONE (1 %0.05 %) (CREAM
(G)) )
(LOTRISONE (1 %0.05 %) (LOTION) )
1
2
TOPICAL ANTIFUNGALS
BUTENAFINE HCL
ciclopirox
ciclopirox
ciclopirox
ciclopirox
ciclopirox olamine
ciclopirox olamine
ciclopirox olamine
clotrimazole
clotrimazole
ECONAZOLE NITRATE
econazole nitrate
EFINACONAZOLE
ketoconazole
KETOCONAZOLE
ketoconazole
ketoconazole
Sharp Health Plan: Covered California
(MENTAX (1 %)
(CREAM (G)) )
(CICLODAN (8 %)
(SOLUTION) )
(LOPROX (0.77 %)
(GEL (GRAM)) )
(LOPROX (1 %)
(SHAMPOO) )
(PENLAC (8 %)
(SOLUTION) )
(CICLODAN (0.77
%) (CREAM (G)) )
(LOPROX (0.77 %)
(CREAM (G)) )
(LOPROX (0.77 %)
(SUSPENSION) )
(LOTRIMIN (1 %)
(CREAM (G)) )
(LOTRIMIN (1 %)
(SOLUTION) )
(ECOZA (1 %)
(FOAM) )
(SPECTAZOLE (1
%) (CREAM (G)) )
(JUBLIA (10 %)
(SOL W/APPL) )
(EXTINA (2 %)
(FOAM) )
(EXTINA (2 %)
(FOAM) )
(NIZORAL (2 %)
(CREAM (G)) )
(NIZORAL (2 %)
(SHAMPOO) )
3
2
2
2
2
2
2
2
2
2
3
1
4
PA
4
4
1
1
Page 70 of 224
Sharp Health Plan: Covered California
Drug Name
KETOCONAZOLE
LULICONAZOLE
MICONAZOLE NITRATE/ZINC OX/PET
naftifine hcl
NAFTIFINE HCL
naftifine hcl
NAFTIFINE HCL
nystatin
nystatin
nystatin
nystatin
nystatin/triamcin
nystatin/triamcin
oxiconazole nitrate
OXICONAZOLE NITRATE
SERTACONAZOLE NITRATE
sodium thiosulfate/sal acid
SULCONAZOLE NITRATE
SULCONAZOLE NITRATE
TAVABOROLE
Drug Tier Requirements/Limits
(XOLEGEL (2 %)
(GEL (GRAM)) )
(LUZU (1 %)
(CREAM (G)) )
(VUSION (0.25 %15%) (OINT. (G)) )
(NAFTIN (1 %)
(CREAM (G)) )
(NAFTIN (1 %)
(GEL (GRAM)) )
(NAFTIN (2 %)
(CREAM (G)) )
(NAFTIN (2 %)
(GEL (GRAM)) )
(MYCOSTATIN
(100000/G) (CREAM
(G)) )
(NYAMYC
(100000/G)
(POWDER) )
(NYSTEX
(100000/G) (OINT.
(G)) )
(NYSTOP
(100000/G)
(POWDER) )
(MYCOGEN II
(100000-0.1)
(CREAM (G)) )
(MYCOGEN II
(100000-0.1) (OINT.
(G)) )
(OXISTAT (1 %)
(CREAM (G)) )
(OXISTAT (1 %)
(LOTION) )
(ERTACZO (2 %)
(CREAM (G)) )
(VERSICLEAR (251%) (LOTION) )
(EXELDERM (1 %)
(CREAM (G)) )
(EXELDERM (1 %)
(SOLUTION) )
(KERYDIN (5 %)
(SOL W/APPL) )
3
3
ST, QL: 60 IN 28 DAYS
3
2
3
2
3
1
1
1
1
1
1
2
3
3
2
3
3
3
PA
3
PA
TOPICAL ANTIPARASITICS
BENZYL ALCOHOL
CROTAMITON
CROTAMITON
IVERMECTIN
lindane
malathion
permethrin (5 %) (cream (g))
Sharp Health Plan: Covered California
(ULESFIA (5 %)
(LOTION) )
(EURAX (10 %)
(CREAM (G)) )
(EURAX (10 %)
(LOTION) )
(SKLICE (0.5 %)
(LOTION) )
(KWELL (1 %)
(SHAMPOO) )
(OVIDE (0.5 %)
(LOTION) )
3
3
3
PA
2
2
PA
1
Page 71 of 224
Sharp Health Plan: Covered California
Drug Name
spinosad
Drug Tier Requirements/Limits
(NATROBA (0.9 %)
(SUSPENSION) )
2
PA
3
PA
2
PA
TOPICAL ANTIVIRALS
ACYCLOVIR
acyclovir
PENCICLOVIR
(ZOVIRAX (5 %)
(CREAM (G)) )
(ZOVIRAX (5 %)
(OINT. (G)) )
(DENAVIR (1 %)
(CREAM (G)) )
3
TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT
ACYCLOVIR/HYDROCORTISONE
(XERESE (5 %-1 %)
(CREAM (G)) )
3
ST, QL: 4 FILLS PER YEAR
3
PA
TOPICAL GENITAL WART-HPV TREATMENT AGENTS
SINECATECHINS
(VEREGEN (15 %)
(OINT. (G)) )
TOPICAL PLEUROMUTILIN DERIVATIVES
RETAPAMULIN
(ALTABAX (1 %)
(OINT. (G)) )
3
TOPICAL SULFONAMIDES
MAFENIDE ACETATE
MAFENIDE ACETATE
silver sulfadiazine
silver sulfadiazine
sulfacetamide sod/sulfur/urea
(SULFAMYLON (50
G) (PACKET) )
(SULFAMYLON (8.5
%) (CREAM (G)) )
(SILVADENE (1 %)
(CREAM (G)) )
(THERMAZENE (1
%) (CREAM (G)) )
(CLARIS (10%-4%10%) (CLEANSER) )
sulfacetamide sod/sulfur/urea (10%-5%-10%)
(cleanser)
sulfacetamide sodium/sulfur
SULFACETAMIDE SODIUM/SULFUR
SULFACETAMIDE SODIUM/SULFUR
sulfacetamide sodium/sulfur
SULFACETAMIDE SODIUM/SULFUR
SULFACETAMIDE SODIUM/SULFUR
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
Sharp Health Plan: Covered California
3
3
1
1
2
2
(AVAR (105%(W/W))
(CLEANSER) )
(AVAR (9.5 %-5 %)
(FOAM) )
(AVAR (9.5 %-5 %)
(MED. PAD) )
(AVAR LS (10 %-2
%) (CLEANSER) )
(AVAR LS (10 %-2
%) (FOAM) )
(AVAR LS (10 %-2
%) (MED. PAD) )
(AVAR-E (105%(W/W)) (CREAM
(G)) )
(AVAR-E GREEN
(10-5%(W/W))
(CREAM (G)) )
(AVAR-E LS (10 %-2
%) (CREAM (G)) )
(BP 10-1 (10 %-1 %)
(CLEANSER) )
(CLARIFOAM EF
(10 %-5 %)
(FOAM) )
2
3
3
2
3
3
2
2
2
2
2
Page 72 of 224
Sharp Health Plan: Covered California
Drug Name
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
SULFACETAMIDE SODIUM/SULFUR
sulfacetamide sodium/sulfur
SULFACETAMIDE SODIUM/SULFUR
SULFACETAMIDE SODIUM/SULFUR
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfacetamide sodium/sulfur
sulfact sod/sulur/avob/otn/oct
Drug Tier Requirements/Limits
(PLEXION (105%(W/W))
(LOTION) )
(PLEXION (9.8%4.8%)
(CLEANSER) )
(PLEXION (9.8%4.8%) (CREAM
(G)) )
(PLEXION (9.8%4.8%) (LOTION) )
(PLEXION (9.8%4.8%) (MED. PAD) )
(PLEXION TS (105%(W/W))
(SUSPENSION) )
(ROSANIL (105%(W/W))
(CLEANSER) )
(ROSULA (10 %-4.5
%) (CLEANSER) )
(SS 10-2 (10 %-2 %)
(CLEANSER) )
(SULFACET-R (105%(W/V))
(LOTION) )
(SUMADAN (9 %4.5 %)
(CLEANSER) )
(SUMAXIN (10 %-4
%) (MED. PAD) )
(SUMAXIN (9 %-4
%) (CLEANSER) )
(SUMAXIN TS (8 %4 %)
(SUSPENSION) )
(ZENCIA (9 %-4 %)
(CLEANSER) )
(SUMADAN XLT (9
%-4.5 %) (CMB CLN
CR) )
1
2
2
2
3
2
3
3
2
1
2
2
2
2
2
2
DERMATOLOGY - ANTIINFLAMMATORY
RECTAL PREPARATIONS
hydrocortisone (1 %) (crm/pe app)
hydrocortisone (2.5 %) (crm/pe app)
hydrocortisone (2.5 %) (crm/pe app)
2
1
2
TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL
NEOMYCIN SULFATE/FLUOCINOLONE
NEOMYCIN/BACITRA/POLYMYXIN/HC
NEOMYCIN/FLUOCINOLONE/EMOL #65
NEOMYCIN/POLYMYXIN B SULF/HC
Sharp Health Plan: Covered California
(NEO-SYNALAR
(0.5-0.025%)
(CREAM (G)) )
(CORTISPORIN (1
%) (OINT. (G)) )
(NEO-SYNALAR
(0.5-0.025%)
(CREAM (G)) )
(CORTISPORIN (0.5
%) (CREAM (G)) )
3
ST
3
3
ST
3
Page 73 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
TOPICAL ANTI-INFLAMMATORY STEROIDAL
alclometasone dipropionate
alclometasone dipropionate
amcinonide
amcinonide
amcinonide
betamethasone dipropionate
betamethasone dipropionate
betamethasone dipropionate
betamethasone dipropionate
BETAMETHASONE DIPROPIONATE
betamethasone valerate
betamethasone valerate
betamethasone valerate
betamethasone valerate
betamethasone/propylene glyc
betamethasone/propylene glyc
betamethasone/propylene glyc
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate
clobetasol propionate/emoll
clobetasol propionate/emoll
clocortolone pivalate
Sharp Health Plan: Covered California
(ACLOVATE (0.05
%) (CREAM (G)) )
(ACLOVATE (0.05
%) (OINT. (G)) )
(CYCLOCORT (0.1
%) (CREAM (G)) )
(CYCLOCORT (0.1
%) (LOTION) )
(CYCLOCORT (0.1
%) (OINT. (G)) )
(DIPROLENE (0.05
%) (CREAM (G)) )
(DIPROLENE (0.05
%) (GEL (GRAM)) )
(DIPROLENE (0.05
%) (LOTION) )
(DIPROLENE (0.05
%) (OINT. (G)) )
(SERNIVO (0.05 %)
(SPRAY/PUMP) )
(LUXIQ (0.12 %)
(FOAM) )
(VALISONE (0.1 %)
(CREAM (G)) )
(VALISONE (0.1 %)
(LOTION) )
(VALISONE (0.1 %)
(OINT. (G)) )
(DIPROLENE (0.05
%) (LOTION) )
(DIPROLENE (0.05
%) (OINT. (G)) )
(DIPROLENE AF
(0.05 %) (CREAM
(G)) )
(CLOBEX (0.05 %)
(LOTION) )
(CLOBEX (0.05 %)
(SHAMPOO) )
(CLOBEX (0.05 %)
(SPRAY) )
(CLODAN (0.05 %)
(SHAMPOO) )
(OLUX (0.05 %)
(FOAM) )
(TEMOVATE (0.05
%) (CREAM (G)) )
(TEMOVATE (0.05
%) (GEL (GRAM)) )
(TEMOVATE (0.05
%) (OINT. (G)) )
(TEMOVATE (0.05
%) (SOLUTION) )
(OLUX-E (0.05 %)
(FOAM) )
(TEMOVATE E (0.05
%) (CREAM (G)) )
(CLODERM (0.1 %)
(CREAM (G)) )
2
2
2
2
2
1
PA
1
PA
1
PA
1
PA
3
ST
2
1
1
1
1
PA
1
PA
1
PA
2
2
2
2
2
1
1
1
1
2
2
2
Page 74 of 224
Sharp Health Plan: Covered California
Drug Name
DESONIDE
Drug Tier Requirements/Limits
(DESONATE (0.05
%) (GEL (GRAM)) )
desonide (0.05 %) (oint. (g))
desonide
desonide
DESONIDE
desoximetasone
desoximetasone
desoximetasone
desoximetasone
desoximetasone
DESOXIMETASONE
diflorasone diacetate
diflorasone diacetate
DIFLORASONE DIACETATE/EMOLL
FLUOCINOLONE ACETONIDE
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide
fluocinolone/shower cap
fluocinonide
fluocinonide
fluocinonide
fluocinonide
fluocinonide
fluocinonide/emollient base
flurandrenolide
flurandrenolide
Sharp Health Plan: Covered California
3
2
(DESOWEN (0.05 %)
(CREAM (G)) )
(DESOWEN (0.05 %)
(LOTION) )
(VERDESO (0.05 %)
(FOAM) )
(TOPICORT (0.05 %)
(CREAM (G)) )
(TOPICORT (0.05 %)
(GEL (GRAM)) )
(TOPICORT (0.05 %)
(OINT. (G)) )
(TOPICORT (0.25 %)
(CREAM (G)) )
(TOPICORT (0.25 %)
(OINT. (G)) )
(TOPICORT (0.25 %)
(SPRAY) )
(APEXICON (0.05
%) (OINT. (G)) )
(PSORCON (0.05 %)
(CREAM (G)) )
(APEXICON E (0.05
%) (CREAM (G)) )
(CAPEX SHAMPOO
(0.01 %)
(SHAMPOO) )
(DERMASMOOTHE-FS (0.01
%) (OIL) )
(SYNALAR (0.01 %)
(CREAM (G)) )
(SYNALAR (0.01 %)
(SOLUTION) )
(SYNALAR (0.025
%) (CREAM (G)) )
(SYNALAR (0.025
%) (OINT. (G)) )
(DERMASMOOTHE-FS (0.01
%) (OIL) )
(LIDEX (0.05 %)
(CREAM (G)) )
(LIDEX (0.05 %)
(GEL (GRAM)) )
(LIDEX (0.05 %)
(OINT. (G)) )
(LIDEX (0.05 %)
(SOLUTION) )
(VANOS (0.1 %)
(CREAM (G)) )
(LIDEX-E (0.05 %)
(CREAM (G)) )
(CORDRAN (0.05 %)
(CREAM (G)) )
(CORDRAN (0.05 %)
(LOTION) )
2
2
3
2
2
2
2
2
3
2
2
3
2
1
1
1
1
1
1
1
1
1
1
4
2
2
2
Page 75 of 224
Sharp Health Plan: Covered California
Drug Name
FLURANDRENOLIDE
FLURANDRENOLIDE
fluticasone propionate
fluticasone propionate
fluticasone propionate
HALCINONIDE
HALCINONIDE
halobetasol propionate
HALOBETASOL PROPIONATE
halobetasol propionate
HALOBETASOL/LACTIC ACID
HALOBETASOL/LACTIC ACID
hydrocortisone
hydrocortisone
hydrocortisone
Drug Tier Requirements/Limits
(CORDRAN (0.05 %)
(OINT. (G)) )
(CORDRAN
(4MCG/SQ CM)
(MED. TAPE) )
(CUTIVATE (0.005
%) (OINT. (G)) )
(CUTIVATE (0.05 %)
(CREAM (G)) )
(CUTIVATE (0.05 %)
(LOTION) )
(HALOG (0.1 %)
(CREAM (G)) )
(HALOG (0.1 %)
(OINT. (G)) )
(ULTRAVATE (0.05
%) (CREAM (G)) )
(ULTRAVATE (0.05
%) (LOTION) )
(ULTRAVATE (0.05
%) (OINT. (G)) )
(ULTRAVATE X
(0.05%-10%) (CMB
ONT CR) )
(ULTRAVATE X
(0.05%-10%)
(COMBO. PKG) )
(ALACORT (1 %)
(CREAM (G)) )
(ANUSOL HC (2.5
%) (CREAM (G)) )
(CORTAID (1 %)
(OINT. (G)) )
hydrocortisone (1 %) (cream (g))
hydrocortisone
hydrocortisone
hydrocortisone
HYDROCORTISONE
hydrocortisone butyrate
HYDROCORTISONE BUTYRATE
hydrocortisone butyrate
hydrocortisone butyrate
hydrocortisone butyrate/emoll
HYDROCORTISONE PROBUTATE
mometasone furoate
Sharp Health Plan: Covered California
3
2
2
2
3
3
2
4
2
3
3
2
1
1
2
(HYTONE (2.5 %)
(OINT. (G)) )
(NUCORT (2.5 %)
(LOTION) )
(SCALACORT (2 %)
(LOTION) )
(TEXACORT (2.5 %)
(SOLUTION) )
(LOCOID (0.1 %)
(CREAM (G)) )
(LOCOID (0.1 %)
(LOTION) )
(LOCOID (0.1 %)
(OINT. (G)) )
(LOCOID (0.1 %)
(SOLUTION) )
(LOCOID
LIPOCREAM (0.1
%) (CREAM (G)) )
(PANDEL (0.1 %)
(CREAM (G)) )
hydrocortisone valerate (0.2 %) (cream (g))
hydrocortisone valerate
3
1
1
1
2
2
3
2
2
2
3
1
(WESTCORT (0.2 %)
(OINT. (G)) )
(ELOCON (0.1 %)
(CREAM (G)) )
2
2
Page 76 of 224
Sharp Health Plan: Covered California
Drug Name
mometasone furoate
mometasone furoate
prednicarbate
prednicarbate
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
Drug Tier Requirements/Limits
(ELOCON (0.1 %)
(OINT. (G)) )
(ELOCON (0.1 %)
(SOLUTION) )
(DERMATOP (0.1 %)
(CREAM (G)) )
(DERMATOP (0.1 %)
(OINT. (G)) )
(KENALOG (0.025
%) (CREAM (G)) )
(KENALOG (0.025
%) (LOTION) )
(KENALOG (0.025
%) (OINT. (G)) )
(KENALOG (0.1 %)
(CREAM (G)) )
(KENALOG (0.1 %)
(LOTION) )
(KENALOG (0.1 %)
(OINT. (G)) )
(KENALOG
(0.147MG/G)
(AEROSOL) )
(KENALOG (0.5 %)
(CREAM (G)) )
(KENALOG (0.5 %)
(OINT. (G)) )
triamcinolone acetonide (0.05 %) (oint. (g))
2
2
2
2
1
1
1
1
1
1
1
1
1
1
TOPICAL ANTI-INFLAMMATORY, NSAIDS
DICLOFENAC EPOLAMINE
diclofenac sodium
diclofenac sodium
DICLOFENAC SODIUM
diclofenac sodium
DICLOFENAC SODIUM/CAPSAICIN
(FLECTOR (1.3 %)
(PATCH TD12) )
(PENNSAID (1.5 %)
(DROPS) )
(PENNSAID (1.5 %)
(DROPS) )
(PENNSAID
(20MG/G(2%)) (SOL
MD PMP) )
(VOLTAREN (1 %)
(GEL (GRAM)) )
(NUDICLO (1.50.025%) (KIT CRSOL) )
3
ST
2
2
ST
3
ST
2
4
DERMATOLOGY - ANTIPRURITIC DRUGS
ANTIPRURITICS,TOPICAL
doxepin hcl
doxepin hcl
(PRUDOXIN (5 %)
(CREAM (G)) )
(ZONALON (5 %)
(CREAM (G)) )
2
2
DERMATOLOGY - MISCELLANEOUS
ANTIPERSPIRANTS
ALUMINUM CHLORIDE
(DRYSOL (20 %)
(SOLUTION) )
3
ANTISEBORRHEIC AGENTS
selenium sulfide (2.25 %) (shampoo)
SELENIUM SULFIDE
Sharp Health Plan: Covered California
2
(SELRX (2.3 %)
(SHAMPOO) )
3
Page 77 of 224
Sharp Health Plan: Covered California
Drug Name
selenium sulfide
SELENIUM SULFIDE
sulfacetamide sodium
SULFACETAMIDE SODIUM
SULFACETAMIDE SODIUM
SULFACETAMIDE SODIUM
SULFACETAMIDE SODIUM
SULFACETAMIDE SODIUM
Drug Tier Requirements/Limits
(SELSUN (2.5 %)
(LOTION) )
(TERSI FOAM (2.25
%) (FOAM) )
(OVACE (10 %)
(CLEANSER) )
(OVACE PLUS (10
%) (CLEANSR ER) )
(OVACE PLUS (10
%) (CREAM (G)) )
(OVACE PLUS (10
%) (SHAMPOO) )
(OVACE PLUS (9.8
%) (FOAM) )
(OVACE PLUS (9.8
%) (LOTION) )
sulfacetamide sodium (10 %) (cleanser)
sulfacetamide sodium (10 %) (clnsr gel)
sulfacetamide sodium (10 %) (shampoo)
1
3
2
PA
3
PA
3
PA
3
PA
3
PA
3
PA
2
2
2
PA
PA
PA
EMOLLIENTS
ammonium lactate
ammonium lactate
(LAC-HYDRIN (12
%) (CREAM (G)) )
(LAC-HYDRIN (12
%) (LOTION) )
lactic acid (10 %) (cream (g))
lactic acid (10 %) (lotion)
2
2
2
2
KERATOLYTICS
benzoyl peroxide (4 %) (gel (gram))
benzoyl peroxide (5.3%) (foam)
benzoyl peroxide (6 %) (towelette)
benzoyl peroxide (8 %) (gel (gram))
benzoyl peroxide (9.8 %) (foam)
BENZOYL PEROXIDE
BENZOYL PEROXIDE
BENZOYL PEROXIDE
2
2
2
2
2
(PACNEX HP (7 %)
(MED. PAD) )
(PACNEX LP (4.25
%) (MED. PAD) )
(PACNEX MX (4.25
%) (CLEANSER) )
benzoyl peroxide microspheres (7 %) (cleanser)
BENZOYL PEROXIDE/SULFUR
PODOFILOX
podofilox
SALICYLIC ACID
salicylic acid (26 %) (liquid)
salicylic acid (27.5 %) (liq-film)
salicylic acid (28.5 %) (sol-filmer)
salicylic acid (6 %) (cream (g))
salicylic acid (6 %) (crm er (g))
salicylic acid (6 %) (foam)
salicylic acid (6 %) (gel (gram))
Sharp Health Plan: Covered California
3
3
1
(NUOX (6%-3%)
(GEL (GRAM)) )
(CONDYLOX (0.5
%) (GEL (GRAM)) )
(CONDYLOX (0.5
%) (SOLUTION) )
podophyllum resin (25 %) (liquid)
potassium hydroxide (5 %) (solution)
SALICYLIC ACID
3
3
2
1
2
2
(BENSAL HP (3 %)
(OINT. (G)) )
(KERALYT SCALP
(6 %-6 %) (KT SHM
GEL) )
3
3
2
2
2
2
2
2
2
Page 78 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
salicylic acid (6 %) (lotion er)
salicylic acid (6 %) (lotion)
salicylic acid (6 %) (shampoo)
SALICYLIC ACID
salicylic acid/ammon lact/aloe
SALICYLIC ACID/UREA
UREA
UREA
urea
UREA
UREA
urea
urea
urea
urea
UREA
UREA
UREA
UREA
urea
urea
urea
urea
2
2
2
(ULTRASAL-ER
(28.5 %) (SOLFILMER) )
(SALKERA (6 %)
(FOAM) )
(SALVAX DUO
PLUS (6 %-35 %)
(FOAM) )
(GORDO-UREA (40
%) (OINT. (G)) )
(HYDRO 35 (35 %)
(FOAM) )
(HYDRO 40 (40 %)
(FOAM) )
(KERAFOAM (30 %)
(FOAM) )
(KERAFOAM (42 %)
(FOAM) )
(KERALAC (47 %)
(CREAM (G)) )
(REA LO 39 (39 %)
(CREAM (G)) )
(REA LO 40 (40 %)
(CREAM (G)) )
(REA LO 40 (40 %)
(LOTION) )
(UMECTA (40 %)
(EMULSN(G)) )
(UMECTA PD (40
%) (EMUL
ADHES) )
(UMECTA PD (40
%) (SUSP ADHES) )
(URAMAXIN (20 %)
(FOAM) )
(URAMAXIN (45 %)
(CREAM (G)) )
(URAMAXIN (45 %)
(GEL (ML)) )
(URAMAXIN (45 %)
(LOTION) )
(URAMAXIN GT
(45 %) (GEL/PF
APP) )
urea (35 %) (foam)
urea (50 %) (sol/pf app)
urea
UREA
UREA
urea
Sharp Health Plan: Covered California
3
2
3
3
3
2
3
3
2
2
2
2
3
3
3
3
2
2
2
2
2
2
(URE-K (50 %)
(CREAM (G)) )
(UREVAZ (44 %)
(CREAM (G)) )
(UTOPIC (41 %)
(CREAM (G)) )
(X-VIATE (40 %)
(GEL (ML)) )
2
3
3
2
Page 79 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
hydrocortisone/pramoxine
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE/ALOE
HYDROCORTISONE/PRAMOXINE/EMOLL
lidocaine/hydrocortisone ac
(ANALPRAM HC
(2.5 %-1 %)
(LOTION) )
(EPIFOAM (1 %-1
%) (FOAM) )
(PRAMOSONE (1
%-1 %) (CREAM
(G)) )
(PRAMOSONE (1
%-1 %) (LOTION) )
(PRAMOSONE (1
%-1 %) (OINT. (G)) )
(PRAMOSONE (2.5
%-1 %) (CREAM
(G)) )
(PRAMOSONE (2.5
%-1 %) (LOTION) )
(PRAMOSONE (2.5
%-1 %) (OINT. (G)) )
(NOVACORT (2 %-1
%-1%) (GEL
(GRAM)) )
(PRAMOSONE E
(2.5 %-1 %)
(CREAM (G)) )
(LIDAMANTLE HC
(3 %-0.5 %)
(CREAM (G)) )
3
3
3
3
3
2
3
3
3
3
2
TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS
ALITRETINOIN
BEXAROTENE
diclofenac sodium
fluorouracil
fluorouracil
fluorouracil
fluorouracil
FLUOROURACIL
FLUOROURACIL
INGENOL MEBUTATE
INGENOL MEBUTATE
MECHLORETHAMINE HCL
(PANRETIN (0.1 %)
(GEL (GRAM)) )
(TARGRETIN (1 %)
(GEL (GRAM)) )
(SOLARAZE (3 %)
(GEL (GRAM)) )
(CARAC (0.5 %)
(CREAM (G)) )
(EFUDEX (2 %)
(SOLUTION) )
(EFUDEX (5 %)
(CREAM (G)) )
(EFUDEX (5 %)
(SOLUTION) )
(FLUOROPLEX (1
%) (CREAM (G)) )
(TOLAK (4 %)
(CREAM (G)) )
(PICATO (0.015 %)
(GEL (EA)) )
(PICATO (0.05 %)
(GEL (EA)) )
(VALCHLOR (0.016
%) (GEL (GRAM)) )
4
PA
4
PA
4
1
1
1
1
2
3
3
PA
3
PA
4
PA
TOPICAL LOCAL ANESTHETICS
BENZOCAINE
(ANACAINE (10 %)
(OINT. (G)) )
ethyl chloride (100 %) (spray)
lidocaine
Sharp Health Plan: Covered California
3
2
(LIDODERM (5 %)
(ADH. PATCH) )
2
Page 80 of 224
Sharp Health Plan: Covered California
Drug Name
LIDOCAINE
lidocaine
LIDOCAINE HCL
LIDOCAINE HCL
lidocaine hcl
lidocaine hcl
LIDOCAINE HCL
LIDOCAINE HCL
lidocaine hcl
LIDOCAINE HCL/MENTHOL
lidocaine/prilocaine
lidocaine/tetracaine
Drug Tier Requirements/Limits
(LIDOVEX (3.75 %)
(CREAM (G)) )
(XYLOCAINE (5 %)
(OINT. (G)) )
(ASTERO (4 %)
(GEL W/PUMP) )
(LDO PLUS (4 %)
(GEL W/PUMP) )
(LIDO-K (3 %)
(LOTION) )
(LIDOPIN (3 %)
(CREAM (G)) )
(LIDOPIN (3.25 %)
(CREAM (G)) )
(LIDORX (3 %)
(GEL W/PUMP) )
(PRE-ATTACHED
LTA KIT (4 %)
(SOLUTION) )
(SYNVEXIA TC (4
%-1 %) (CREAM
(G)) )
(EMLA (2.5 %-2.5%)
(CREAM (G)) )
(PLIAGLIS (7 %-7
%) (CREAM (G)) )
3
1
3
3
2
2
3
3
2
3
2
2
TOPICAL PREPARATIONS,MISCELLANEOUS
POVIDONE-IODINE
(BETADINE (5 %)
(SOLUTION) )
3
TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES
COLLAGENASE CLOSTRIDIUM HIST.
HYALURONIDASE, HUMAN RECOMB.
HYALURONIDASE, HUMAN RECOMB.
HYALURONIDASE, HUMAN RECOMB.
HYALURONIDASE, HUMAN RECOMB.
HYALURONIDASE, HUMAN RECOMB.
(SANTYL (250
UNIT/G) (OINT.
(G)) )
(HYQVIA HY
COMPONENT
(1600/10 ML)
(VIAL) )
(HYQVIA HY
COMPONENT
(200/1.25ML)
(VIAL) )
(HYQVIA HY
COMPONENT
(2400/15 ML)
(VIAL) )
(HYQVIA HY
COMPONENT
(400/2.5 ML)
(VIAL) )
(HYQVIA HY
COMPONENT
(800/5 ML) (VIAL) )
3
MB
MB
MB
MB
MB
DERMATOLOGY - PSORIASIS/ECZEMA
ANTIPSORIATIC AGENTS,SYSTEMIC
acitretin
acitretin
acitretin
Sharp Health Plan: Covered California
(SORIATANE (10
MG) (CAPSULE) )
(SORIATANE (17.5
MG) (CAPSULE) )
(SORIATANE (25
MG) (CAPSULE) )
2
2
2
Page 81 of 224
Sharp Health Plan: Covered California
Drug Name
METHOXSALEN
Drug Tier Requirements/Limits
(8-MOP (10 MG)
(CAPSULE) )
methoxsalen, rapid (10 mg) (capsule)
methoxsalen, rapid (10 mg) (capsule)
2
1
4
ANTIPSORIATICS AGENTS
ANTHRALIN
ANTHRALIN
ANTHRALIN MICRONIZED
calcipotriene
calcipotriene
calcipotriene
CALCIPOTRIENE
calcitriol
TAZAROTENE
TAZAROTENE
TAZAROTENE
TAZAROTENE
(DRITHOCREME
HP (1 %) (CREAM
(G)) )
(ZITHRANOL-RR
(1.2 %) (CRM RR
(G)) )
(ZITHRANOL (1 %)
(SHAMPOO(G)) )
(DOVONEX (0.005
%) (CREAM (G)) )
(DOVONEX (0.005
%) (OINT. (G)) )
(DOVONEX (0.005
%) (SOLUTION) )
(SORILUX (0.005 %)
(FOAM) )
(VECTICAL (3
MCG/G) (OINT.
(G)) )
(TAZORAC (0.05 %)
(CREAM (G)) )
(TAZORAC (0.05 %)
(GEL (GRAM)) )
(TAZORAC (0.1 %)
(CREAM (G)) )
(TAZORAC (0.1 %)
(GEL (GRAM)) )
2
ST
3
ST
3
1
ST
2
ST
1
ST
3
ST
2
ST
3
ST
3
ST
3
ST
3
ST
TOPICAL AGENTS,MISCELLANEOUS
PYROGALLOL
UREA
(PYROGALLIC
ACID (25 %) (OINT.
(G)) )
(GORDO-UREA (22
%) (OINT. (G)) )
3
3
TOPICAL IMMUNOSUPPRESSIVE AGENTS
PIMECROLIMUS
tacrolimus
tacrolimus
(ELIDEL (1 %)
(CREAM (G)) )
(PROTOPIC (0.03 %)
(OINT. (G)) )
(PROTOPIC (0.1 %)
(OINT. (G)) )
2
ST
1
ST
1
ST
TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDAL
CALCIPOTRIENE/BETAMETHASONE
calcipotriene/betamethasone
CALCIPOTRIENE/BETAMETHASONE
(ENSTILAR (0.005.064) (FOAM) )
(TACLONEX (0.005.064) (OINT. (G)) )
(TACLONEX (0.005.064)
(SUSPENSION) )
3
ST
2
ST
3
ST
DIABETES
ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.
alogliptin benz/metformin hcl
alogliptin benz/metformin hcl
Sharp Health Plan: Covered California
(KAZANO (12.51000) (TABLET) )
(KAZANO (12.5500MG) (TABLET) )
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
Page 82 of 224
Sharp Health Plan: Covered California
Drug Name
LINAGLIPTIN/METFORMIN HCL
LINAGLIPTIN/METFORMIN HCL
LINAGLIPTIN/METFORMIN HCL
LINAGLIPTIN/METFORMIN HCL
LINAGLIPTIN/METFORMIN HCL
SAXAGLIPTIN HCL/METFORMIN HCL
SAXAGLIPTIN HCL/METFORMIN HCL
SAXAGLIPTIN HCL/METFORMIN HCL
SITAGLIPTIN PHOS/METFORMIN HCL
SITAGLIPTIN PHOS/METFORMIN HCL
SITAGLIPTIN PHOS/METFORMIN HCL
SITAGLIPTIN PHOS/METFORMIN HCL
SITAGLIPTIN PHOS/METFORMIN HCL
Drug Tier Requirements/Limits
(JENTADUETO (2.51000MG)
(TABLET) )
(JENTADUETO (2.5500 MG) (TABLET) )
(JENTADUETO (2.5850 MG) (TABLET) )
(JENTADUETO XR
(2.5-1000MG) (TAB
BP 24H) )
(JENTADUETO XR
(5MG-1000MG)
(TAB BP 24H) )
(KOMBIGLYZE XR
(2.5-1000MG)
(TBMP 24HR) )
(KOMBIGLYZE XR
(5 MG-500MG)
(TBMP 24HR) )
(KOMBIGLYZE XR
(5MG-1000MG)
(TBMP 24HR) )
(JANUMET (50-1000
MG) (TABLET) )
(JANUMET (50MG500MG) (TABLET) )
(JANUMET XR
(100-1000MG)
(TBMP 24HR) )
(JANUMET XR (501000 MG) (TBMP
24HR) )
(JANUMET XR
(50MG-500MG)
(TBMP 24HR) )
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONE
alogliptin benz/pioglitazone
alogliptin benz/pioglitazone
alogliptin benz/pioglitazone
alogliptin benz/pioglitazone
alogliptin benz/pioglitazone
alogliptin benz/pioglitazone
(OSENI (12.5-15
MG) (TABLET) )
(OSENI (12.5-30
MG) (TABLET) )
(OSENI (12.5-45
MG) (TABLET) )
(OSENI (25 MG15MG) (TABLET) )
(OSENI (25 MG30MG) (TABLET) )
(OSENI (25 MG45MG) (TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)
ALBIGLUTIDE
ALBIGLUTIDE
DULAGLUTIDE
Sharp Health Plan: Covered California
(TANZEUM
(30MG/0.5ML) (PEN
INJCTR) )
(TANZEUM
(50MG/0.5ML) (PEN
INJCTR) )
(TRULICITY
(0.75MG/0.5) (PEN
INJCTR) )
3
ST, QL: 4 IN 28 DAYS
3
ST, QL: 4 IN 28 DAYS
3
ST, QL: 4 IN 28 DAYS
Page 83 of 224
Sharp Health Plan: Covered California
Drug Name
DULAGLUTIDE
EXENATIDE
EXENATIDE
EXENATIDE MICROSPHERES
EXENATIDE MICROSPHERES
LIRAGLUTIDE
LIRAGLUTIDE
Drug Tier Requirements/Limits
(TRULICITY (1.5
MG/0.5) (PEN
INJCTR) )
(BYETTA
(10MCG/0.04) (PEN
INJCTR) )
(BYETTA
(5MCG/0.02) (PEN
INJCTR) )
(BYDUREON (2
MG) (VIAL) )
(BYDUREON PEN
(2MG/0.65ML) (PEN
INJCTR) )
(VICTOZA 2-PAK
(0.6 MG/0.1) (PEN
INJCTR) )
(VICTOZA 3-PAK
(0.6 MG/0.1) (PEN
INJCTR) )
3
ST, QL: 4 IN 28 DAYS
2
ST, QL: 2.4 IN 28 DAYS
2
ST, QL: 1.2 IN 28 DAYS
2
ST, QL: 1 IN 7 DAYS
2
ST, QL: 1 IN 7 DAYS
2
ST, QL: 9 IN 30 DAYS
2
ST, QL: 9 IN 30 DAYS
ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB
CANAGLIFLOZIN
CANAGLIFLOZIN
DAPAGLIFLOZIN PROPANEDIOL
DAPAGLIFLOZIN PROPANEDIOL
EMPAGLIFLOZIN
EMPAGLIFLOZIN
(INVOKANA (100
MG) (TABLET) )
(INVOKANA (300
MG) (TABLET) )
(FARXIGA (10 MG)
(TABLET) )
(FARXIGA (5 MG)
(TABLET) )
(JARDIANCE (10
MG) (TABLET) )
(JARDIANCE (25
MG) (TABLET) )
2
QL: 1 IN 1 DAY
2
QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS
BROMOCRIPTINE MESYLATE
(CYCLOSET (0.8
MG) (TABLET) )
3
ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)
acarbose
acarbose
acarbose
miglitol
miglitol
miglitol
(PRECOSE (100
MG) (TABLET) )
(PRECOSE (25 MG)
(TABLET) )
(PRECOSE (50 MG)
(TABLET) )
(GLYSET (100 MG)
(TABLET) )
(GLYSET (25 MG)
(TABLET) )
(GLYSET (50 MG)
(TABLET) )
2
2
2
2
2
2
ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE
PRAMLINTIDE ACETATE
PRAMLINTIDE ACETATE
(SYMLINPEN 120
(2700/2.7ML) (PEN
INJCTR) )
(SYMLINPEN 60
(1500/1.5ML) (PEN
INJCTR) )
2
2
ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS
alogliptin benzoate
Sharp Health Plan: Covered California
(NESINA (12.5 MG)
(TABLET) )
1
QL: 1 IN 1 DAY
Page 84 of 224
Sharp Health Plan: Covered California
Drug Name
alogliptin benzoate
alogliptin benzoate
LINAGLIPTIN
SAXAGLIPTIN HCL
SAXAGLIPTIN HCL
SITAGLIPTIN PHOSPHATE
SITAGLIPTIN PHOSPHATE
SITAGLIPTIN PHOSPHATE
Drug Tier Requirements/Limits
(NESINA (25 MG)
(TABLET) )
(NESINA (6.25 MG)
(TABLET) )
(TRADJENTA (5
MG) (TABLET) )
(ONGLYZA (2.5
MG) (TABLET) )
(ONGLYZA (5 MG)
(TABLET) )
(JANUVIA (100 MG)
(TABLET) )
(JANUVIA (25 MG)
(TABLET) )
(JANUVIA (50 MG)
(TABLET) )
1
QL: 1 IN 1 DAY
1
QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE
chlorpropamide
chlorpropamide
glimepiride
glimepiride
glimepiride
glipizide
glipizide
glipizide
glipizide
glipizide
(DIABINESE (100
MG) (TABLET) )
(DIABINESE (250
MG) (TABLET) )
(AMARYL (1 MG)
(TABLET) )
(AMARYL (2 MG)
(TABLET) )
(AMARYL (4 MG)
(TABLET) )
(GLUCOTROL (10
MG) (TABLET) )
(GLUCOTROL (5
MG) (TABLET) )
(GLUCOTROL XL
(10 MG) (TAB ER
24) )
(GLUCOTROL XL
(2.5 MG) (TAB ER
24) )
(GLUCOTROL XL (5
MG) (TAB ER 24) )
glyburide (1.25 mg) (tablet)
glyburide (2.5 mg) (tablet)
glyburide (5 mg) (tablet)
glyburide,micronized
glyburide,micronized
glyburide,micronized
nateglinide
nateglinide
repaglinide
repaglinide
repaglinide
tolazamide
Sharp Health Plan: Covered California
1
1
1
1
1
1
1
1
1
1
1
1
1
(GLYNASE (1.5 MG)
(TABLET) )
(GLYNASE (3 MG)
(TABLET) )
(GLYNASE (6 MG)
(TABLET) )
(STARLIX (120 MG)
(TABLET) )
(STARLIX (60 MG)
(TABLET) )
(PRANDIN (0.5 MG)
(TABLET) )
(PRANDIN (1 MG)
(TABLET) )
(PRANDIN (2 MG)
(TABLET) )
(TOLINASE (250
MG) (TABLET) )
1
1
1
2
2
2
2
2
1
Page 85 of 224
Sharp Health Plan: Covered California
Drug Name
tolazamide
tolbutamide
Drug Tier Requirements/Limits
(TOLINASE (500
MG) (TABLET) )
(ORINASE (500 MG)
(TABLET) )
1
1
ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)
pioglitazone hcl
pioglitazone hcl
pioglitazone hcl
ROSIGLITAZONE MALEATE
ROSIGLITAZONE MALEATE
(ACTOS (15 MG)
(TABLET) )
(ACTOS (30 MG)
(TABLET) )
(ACTOS (45 MG)
(TABLET) )
(AVANDIA (2 MG)
(TABLET) )
(AVANDIA (4 MG)
(TABLET) )
1
ST
1
ST
1
ST
3
ST
3
ST
ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.
EMPAGLIFLOZIN/LINAGLIPTIN
EMPAGLIFLOZIN/LINAGLIPTIN
(GLYXAMBI (10
MG-5 MG)
(TABLET) )
(GLYXAMBI (25
MG-5 MG)
(TABLET) )
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
METFORMIN HCL
(FORTAMET (1000
MG) (TAB ER 24) )
(FORTAMET (500
MG) (TAB ER 24) )
(GLUCOPHAGE
(1000 MG)
(TABLET) )
(GLUCOPHAGE
(500 MG)
(TABLET) )
(GLUCOPHAGE
(850 MG)
(TABLET) )
(GLUCOPHAGE XR
(500 MG) (TAB ER
24H) )
(GLUCOPHAGE XR
(750 MG) (TAB ER
24H) )
(GLUMETZA (1000
MG)
(TABERGR24H) )
(GLUMETZA (500
MG)
(TABERGR24H) )
(RIOMET (500
MG/5ML)
(SOLUTION) )
2
PA
2
PA
1
1
1
1
1
2
PA
2
PA
3
ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB
glipizide/metformin hcl
glipizide/metformin hcl
glipizide/metformin hcl
Sharp Health Plan: Covered California
(METAGLIP (2.5-250
MG) (TABLET) )
(METAGLIP (2.5-500
MG) (TABLET) )
(METAGLIP (5 MG500MG) (TABLET) )
2
2
2
Page 86 of 224
Sharp Health Plan: Covered California
Drug Name
glyburide/metformin hcl
glyburide/metformin hcl
glyburide/metformin hcl
repaglinide/metformin hcl
repaglinide/metformin hcl
Drug Tier Requirements/Limits
(GLUCOVANCE
(1.25-250MG)
(TABLET) )
(GLUCOVANCE
(2.5-500 MG)
(TABLET) )
(GLUCOVANCE (5
MG-500MG)
(TABLET) )
(PRANDIMET
(1MG-500MG)
(TABLET) )
(PRANDIMET (2
MG-500MG)
(TABLET) )
1
1
1
2
2
ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB.
pioglitazone hcl/glimepiride
pioglitazone hcl/glimepiride
(DUETACT (30 MG2 MG) (TABLET) )
(DUETACT (30 MG4 MG) (TABLET) )
2
ST
2
ST
ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKER
MIFEPRISTONE
(KORLYM (300 MG)
(TABLET) )
4
PA
ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMB
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
CANAGLIFLOZIN/METFORMIN HCL
DAPAGLIFLOZIN/METFORMIN HCL
DAPAGLIFLOZIN/METFORMIN HCL
DAPAGLIFLOZIN/METFORMIN HCL
DAPAGLIFLOZIN/METFORMIN HCL
Sharp Health Plan: Covered California
(INVOKAMET (1501000MG)
(TABLET) )
(INVOKAMET (150500 MG) (TABLET) )
(INVOKAMET (501000 MG)
(TABLET) )
(INVOKAMET
(50MG-500MG)
(TABLET) )
(INVOKAMET XR
(150-1000MG) (TAB
BP 24H) )
(INVOKAMET XR
(150-500 MG) (TAB
BP 24H) )
(INVOKAMET XR
(50-1000 MG) (TAB
BP 24H) )
(INVOKAMET XR
(50MG-500MG)
(TAB BP 24H) )
(XIGDUO XR (101000 MG) (TAB BP
24H) )
(XIGDUO XR
(10MG-500MG)
(TAB BP 24H) )
(XIGDUO XR (5
MG-500MG) (TAB
BP 24H) )
(XIGDUO XR (5MG1000MG) (TAB BP
24H) )
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
4
QL: 2 IN 1 DAY
4
QL: 2 IN 1 DAY
4
QL: 2 IN 1 DAY
4
QL: 2 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
Page 87 of 224
Sharp Health Plan: Covered California
Drug Name
EMPAGLIFLOZIN/METFORMIN HCL
EMPAGLIFLOZIN/METFORMIN HCL
EMPAGLIFLOZIN/METFORMIN HCL
EMPAGLIFLOZIN/METFORMIN HCL
Drug Tier Requirements/Limits
(SYNJARDY (12.51000) (TABLET) )
(SYNJARDY (12.5500MG) (TABLET) )
(SYNJARDY (5 MG500MG) (TABLET) )
(SYNJARDY (5MG1000MG)
(TABLET) )
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB
pioglitazone hcl/metformin hcl
pioglitazone hcl/metformin hcl
PIOGLITAZONE HCL/METFORMIN HCL
PIOGLITAZONE HCL/METFORMIN HCL
ROSIGLITAZONE/METFORMIN HCL
ROSIGLITAZONE/METFORMIN HCL
(ACTOPLUS MET
(15MG-500MG)
(TABLET) )
(ACTOPLUS MET
(15MG-850MG)
(TABLET) )
(ACTOPLUS MET
XR (15-1000 MG)
(TBMP 24HR) )
(ACTOPLUS MET
XR (30-1000 MG)
(TBMP 24HR) )
(AVANDAMET (2
MG-500MG)
(TABLET) )
(AVANDAMET (21000MG)
(TABLET) )
1
ST
1
ST
3
ST
3
ST
3
ST
3
ST
DIABETIC ULCER PREPARATIONS,TOPICAL
BECAPLERMIN
(REGRANEX (0.01
%) (GEL (GRAM)) )
3
HYPERGLYCEMICS
DIAZOXIDE
GLUCAGON,HUMAN RECOMBINANT
(PROGLYCEM (50
MG/ML) (ORAL
SUSP) )
(GLUCAGON
EMERGENCY KIT
(1 MG) (KIT) )
3
2
INSULINS
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART PROT/INSULN ASP
INSULIN ASPART PROT/INSULN ASP
INSULIN DEGLUDEC
INSULIN DEGLUDEC
Sharp Health Plan: Covered California
(NOVOLOG
(100/ML)
(CARTRIDGE) )
(NOVOLOG
(100/ML) (VIAL) )
(NOVOLOG
FLEXPEN (100/ML)
(INSULN PEN) )
(NOVOLOG MIX 7030 (70-30/ML)
(VIAL) )
(NOVOLOG MIX 7030 FLEXPEN (7030/ML) (INSULN
PEN) )
(TRESIBA
FLEXTOUCH U-100
(100/ML (3))
(INSULN PEN) )
(TRESIBA
FLEXTOUCH U-200
3
ST, QL: 30 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
Page 88 of 224
Sharp Health Plan: Covered California
Drug Name
INSULIN DETEMIR
INSULIN DETEMIR
INSULIN GLARGINE,HUM.REC.ANLOG
INSULIN GLARGINE,HUM.REC.ANLOG
INSULIN GLARGINE,HUM.REC.ANLOG
INSULIN GLULISINE
INSULIN GLULISINE
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO PROTAMIN/LISPRO
INSULIN LISPRO PROTAMIN/LISPRO
INSULIN LISPRO PROTAMIN/LISPRO
INSULIN LISPRO PROTAMIN/LISPRO
INSULIN NPH HUM/REG INSULIN HM
INSULIN NPH HUM/REG INSULIN HM
INSULIN NPH HUM/REG INSULIN HM
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(200/ML (3))
(INSULN PEN) )
(LEVEMIR (100/ML)
(VIAL) )
(LEVEMIR
FLEXTOUCH
(100/ML (3))
(INSULN PEN) )
(LANTUS (100/ML)
(VIAL) )
(LANTUS
SOLOSTAR (100/ML
(3)) (INSULN PEN) )
(TOUJEO
SOLOSTAR
(300/ML) (INSULN
PEN) )
(APIDRA (100/ML)
(VIAL) )
(APIDRA
SOLOSTAR
(100/ML) (INSULN
PEN) )
(HUMALOG
(100/ML)
(CARTRIDGE) )
(HUMALOG
(100/ML) (VIAL) )
(HUMALOG
KWIKPEN U-100
(100/ML) (INSULN
PEN) )
(HUMALOG
KWIKPEN U-200
(200/ML (3))
(INSULN PEN) )
(HUMALOG MIX
50-50 (50-50/ML)
(VIAL) )
(HUMALOG MIX
50-50 KWIKPEN
(50-50/ML)
(INSULN PEN) )
(HUMALOG MIX
75-25 (75-25/ML)
(VIAL) )
(HUMALOG MIX
75-25 KWIKPEN
(75-25/ML)
(INSULN PEN) )
(HUMULIN 70/30
KWIKPEN (7030/ML) (INSULN
PEN) (OTC))
(HUMULIN 70-30
(70-30/ML) (VIAL)
(OTC))
(NOVOLIN 70-30
(70-30/ML) (VIAL)
(OTC))
3
ST, QL: 40 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
2
QL: 40 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
QL: 7.5 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
3
ST, QL: 30 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
QL: 40 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
2
QL: 40 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
QL: 40 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
QL: 30 IN 28 DAYS
2
QL: 40 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
Page 89 of 224
Sharp Health Plan: Covered California
Drug Name
INSULIN NPH HUMAN ISOPHANE
INSULIN NPH HUMAN ISOPHANE
INSULIN NPH HUMAN ISOPHANE
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
INSULIN REGULAR, HUMAN
Drug Tier Requirements/Limits
(HUMULIN N
(100/ML) (VIAL)
(OTC))
(HUMULIN N
KWIKPEN (100/ML
(3)) (INSULN PEN)
(OTC))
(NOVOLIN N
(100/ML) (VIAL)
(OTC))
(AFREZZA (4
UNIT(30)) (CART
INHAL) )
(AFREZZA (4
UNIT(60)) (CART
INHAL) )
(AFREZZA (4
UNIT(90)) (CART
INHAL) )
(AFREZZA (4 UNIT)
(CART INHAL) )
(AFREZZA (8
UNIT(60)) (CART
INHAL) )
(HUMULIN R
(100/ML) (VIAL)
(OTC))
(HUMULIN R U-500
(500/ML) (VIAL) )
(HUMULIN R U-500
KWIKPEN (500/ML
(3)) (INSULN PEN) )
(NOVOLIN R
(100/ML) (VIAL)
(OTC))
2
QL: 40 IN 28 DAYS
2
QL: 30 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
3
PA, QL: 180 IN 28 DAYS
3
PA, QL: 180 IN 28 DAYS
3
PA, QL: 180 IN 28 DAYS
3
PA, QL: 180 IN 28 DAYS
3
PA, QL: 180 IN 28 DAYS
2
QL: 40 IN 28 DAYS
2
QL: 40 IN 28 DAYS
2
QL: 8 IN 28 DAYS
3
ST, QL: 40 IN 28 DAYS
EAR - GENERAL DISORDERS
EAR PREPARATIONS ANTI-INFLAMMATORY
fluocinolone acetonide oil
(DERMOTIC (0.01
%) (DROPS) )
2
EAR PREPARATIONS, MISC. ANTI-INFECTIVES
acetic acid
(VOSOL (2 %)
(SOLUTION) )
acetic acid/aluminum acetate (2 %) (drops)
acetic acid/hydrocortisone
HC/PRAMOXINE HCL/CHLOROXYLENOL
2
2
(VOSOL HC (2 %-1
%) (DROPS) )
(CORTANE-B (1-10.1%) (LOTION) )
1
3
EAR PREPARATIONS,ANTIBIOTICS
CIPROFLOXACIN
ciprofloxacin hcl
NEOMYCIN SU/COLIST/HC/THONZON
neomycin/polymyxin b sulf/hc
Sharp Health Plan: Covered California
(OTIPRIO (6 %)
(VIAL) )
(CETRAXAL (0.2 %)
(DROPERETTE) )
(COLY-MYCIN S
(3.3-3-10/1) (DROPS
SUSP) )
(ANTIBIOTIC EAR
SOLUTION (3.510K-1)
(SOLUTION) )
3
2
3
1
Page 90 of 224
Sharp Health Plan: Covered California
Drug Name
neomycin/polymyxin b sulf/hc
neomycin/polymyxin b sulf/hc
neomycin/polymyxin b sulf/hc
ofloxacin
Drug Tier Requirements/Limits
(CORTISPORIN
(3.5-10K-1) (DROPS
SUSP) )
(CORTISPORIN
(3.5-10K-1)
(SOLUTION) )
(NEOMYCINPOLYMYXINHYDROCORT (3.510K-1)
(SOLUTION) )
(FLOXIN (0.3 %)
(DROPS) )
1
1
1
1
PA
OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS
CIPROFLOXACIN HCL/DEXAMETH
CIPROFLOXACIN HCL/FLUOCINOLONE
CIPROFLOXACIN/HYDROCORTISONE
(CIPRODEX (0.3 %0.1%) (DROPS
SUSP) )
(OTOVEL (0.30.025%) (VIAL) )
(CIPRO HC (0.2 %-1
%) (DROPS SUSP) )
2
PA
3
PA
2
ELECTROLYTE REGULATION
ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS
TOLVAPTAN
TOLVAPTAN
(SAMSCA (15 MG)
(TABLET) )
(SAMSCA (30 MG)
(TABLET) )
4
4
ELECTROLYTE DEPLETERS
calcium acetate
calcium acetate
calcium acetate
CALCIUM ACETATE
(ELIPHOS (667 MG)
(TABLET) )
(PHOSLO (667 MG)
(CAPSULE) )
(PHOSLO (667 MG)
(TABLET) )
(PHOSLYRA (667
MG/5ML)
(SOLUTION) )
calcium carbonate/mag carb/fa (200-400-1) (tablet)
FERRIC CITRATE
LANTHANUM CARBONATE
LANTHANUM CARBONATE
LANTHANUM CARBONATE
LANTHANUM CARBONATE
LANTHANUM CARBONATE
PATIROMER CALCIUM SORBITEX
PATIROMER CALCIUM SORBITEX
Sharp Health Plan: Covered California
1
1
1
3
2
(AURYXIA (210MG
IRON) (TABLET) )
(FOSRENOL (1000
MG) (POWD
PACK) )
(FOSRENOL (1000
MG) (TAB CHEW) )
(FOSRENOL (500
MG) (TAB CHEW) )
(FOSRENOL (750
MG) (POWD
PACK) )
(FOSRENOL (750
MG) (TAB CHEW) )
(VELTASSA (16.8
GRAM) (POWD
PACK) )
(VELTASSA (25.2
GRAM) (POWD
PACK) )
3
QL: 12 IN 1 DAY
3
3
3
3
3
4
4
Page 91 of 224
Sharp Health Plan: Covered California
Drug Name
PATIROMER CALCIUM SORBITEX
SEVELAMER CARBONATE
SEVELAMER CARBONATE
SEVELAMER CARBONATE
SEVELAMER HCL
SEVELAMER HCL
Drug Tier Requirements/Limits
(VELTASSA (8.4
GRAM) (POWD
PACK) )
(RENVELA (0.8 G)
(POWD PACK) )
(RENVELA (2.4 G)
(POWD PACK) )
(RENVELA (800
MG) (TABLET) )
(RENAGEL (400
MG) (TABLET) )
(RENAGEL (800
MG) (TABLET) )
sodium polystyrene sulfon/sorb (15 g/60 ml) (oral
susp)
sodium polystyrene sulfonate ( ) (powder)
sodium polystyrene sulfonate (15 g/60 ml) (oral susp)
sodium polystyrene sulfonate (30 g/120ml) (enema)
sodium polystyrene sulfonate (50 g/200ml) (enema)
SUCROFERRIC OXYHYDROXIDE
4
3
3
3
3
3
2
2
2
2
2
(VELPHORO
(500MG IRON) (TAB
CHEW) )
3
PA
POTASSIUM REPLACEMENT
pot chloride/pot bicarb/cit ac (25 meq) (tablet eff)
POTASSIUM BICARBONATE/CIT AC
POTASSIUM BICARBONATE/CIT AC
potassium bicarbonate/cit ac
potassium chloride
POTASSIUM CHLORIDE
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
Sharp Health Plan: Covered California
2
(EFFER-K (10 MEQ)
(TABLET EFF) )
(EFFER-K (20 MEQ)
(TABLET EFF) )
(KLOR-CON-EF (25
MEQ) (TABLET
EFF) )
(KLOR-CON (20
MEQ) (PACKET) )
(KLOR-CON (25
MEQ) (PACKET) )
(KLOR-CON 10 (10
MEQ) (TABLET
ER) )
(KLOR-CON 8 (8
MEQ) (TABLET
ER) )
(K-SOL
(20MEQ/15ML)
(LIQUID) )
(K-SOL
(40MEQ/15ML)
(LIQUID) )
(K-TAB ER (10
MEQ) (TABLET
ER) )
(K-TAB ER (20
MEQ) (TABLET
ER) )
(K-TAB ER (8 MEQ)
(TABLET ER) )
(MICRO-K (10
MEQ) (CAPSULE
ER) )
(MICRO-K (8 MEQ)
(CAPSULE ER) )
3
3
2
1
3
1
1
1
1
1
1
1
1
1
Page 92 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
potassium chloride (10 meq) (tab er prt)
potassium chloride (15 meq) (tab er prt)
potassium chloride (20 meq) (tab er prt)
1
1
1
ENDOCRINE DISORDER - FERTILITY
DRUGS TO TREAT IMPOTENCY
TADALAFIL
(CIALIS (5 MG)
(TABLET) )
3
ST, QL: 1 IN 1 DAY; USE
RESTRICTED TO
UROLOGIST
1
PA
FERTILITY STIMULATING PREPARATIONS,NON-FSH
clomiphene citrate
(SEROPHENE (50
MG) (TABLET) )
PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL
PROGESTERONE,MICRONIZED
(CRINONE (8 %)
(GEL/PF APP) )
2
PA
ENDOCRINE DISORDER - OTHER
ANTIDIURETIC AND VASOPRESSOR HORMONES
desmopressin (nonrefrigerated) (10/spray)
(spray/pump)
desmopressin acetate (0.1 mg) (tablet)
desmopressin acetate (0.1 mg/ml) (solution)
desmopressin acetate (0.2 mg) (tablet)
desmopressin acetate (10/spray) (spray/pump)
DESMOPRESSIN ACETATE
2
1
2
1
2
(STIMATE
(150/SPRAY)
(SPRAY/PUMP) )
3
BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE
TERIPARATIDE
(FORTEO
(20MCG/DOSE)
(PEN INJCTR) )
MB
BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS
ALENDRONATE SODIUM/VITAMIN D3
ALENDRONATE SODIUM/VITAMIN D3
(FOSAMAX PLUS D
(70 MG-2800)
(TABLET) )
(FOSAMAX PLUS D
(70 MG-5600)
(TABLET) )
3
PA
3
PA
BONE RESORPTION INHIBITORS
ALENDRONATE SODIUM
alendronate sodium
alendronate sodium
alendronate sodium
alendronate sodium
alendronate sodium
alendronate sodium
calcitonin,salmon,synthetic
DENOSUMAB
Sharp Health Plan: Covered California
(BINOSTO (70 MG)
(TABLET EFF) )
(FOSAMAX (10
MG) (TABLET) )
(FOSAMAX (35
MG) (TABLET) )
(FOSAMAX (40
MG) (TABLET) )
(FOSAMAX (5 MG)
(TABLET) )
(FOSAMAX (70
MG) (TABLET) )
(FOSAMAX (70
MG/75ML)
(SOLUTION) )
(MIACALCIN
(200/SPRAY)
(SPRAY/PUMP) )
(PROLIA (60
MG/ML)
(SYRINGE) )
3
1
1
1
1
1
2
PA
1
PA
MB
Page 93 of 224
Sharp Health Plan: Covered California
Drug Name
DENOSUMAB
etidronate disodium
etidronate disodium
ibandronate sodium
raloxifene hcl
risedronate sodium
risedronate sodium
risedronate sodium
risedronate sodium
risedronate sodium
Drug Tier Requirements/Limits
(XGEVA (120
MG/1.7) (VIAL) )
(DIDRONEL (200
MG) (TABLET) )
(DIDRONEL (400
MG) (TABLET) )
(BONIVA (150 MG)
(TABLET) )
(EVISTA (60 MG)
(TABLET) )
(ACTONEL (150
MG) (TABLET) )
(ACTONEL (30 MG)
(TABLET) )
(ACTONEL (35 MG)
(TABLET) )
(ACTONEL (5 MG)
(TABLET) )
(ATELVIA (35 MG)
(TABLET DR) )
MB
1
1
2
PA
PV
2
PA
2
PA
2
PA
2
PA
2
PA
CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER
CINACALCET HCL
CINACALCET HCL
CINACALCET HCL
(SENSIPAR (30 MG)
(TABLET) )
(SENSIPAR (60 MG)
(TABLET) )
(SENSIPAR (90 MG)
(TABLET) )
3
PA
4
PA
4
PA
GROWTH HORMONES
SOMATROPIN
(SEROSTIM (4 MG)
(VIAL) )
MB
HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE
doxercalciferol
doxercalciferol
doxercalciferol
paricalcitol
paricalcitol
paricalcitol
(HECTOROL (0.5
MCG) (CAPSULE) )
(HECTOROL (1
MCG) (CAPSULE) )
(HECTOROL (2.5
MCG) (CAPSULE) )
(ZEMPLAR (1 MCG)
(CAPSULE) )
(ZEMPLAR (2 MCG)
(CAPSULE) )
(ZEMPLAR (4MCG)
(CAPSULE) )
1
1
1
2
2
2
INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES
MECASERMIN
(INCRELEX (10
MG/ML) (VIAL) )
MB
LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS
NAFARELIN ACETATE
(SYNAREL (2
MG/ML) (SPRAY) )
4
PA
MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR
OSPEMIFENE
(OSPHENA (60 MG)
(TABLET) )
3
ST
PITUITARY SUPPRESSIVE AGENTS
cabergoline
danazol
danazol
Sharp Health Plan: Covered California
(DOSTINEX (0.5
MG) (TABLET) )
(DANOCRINE (100
MG) (CAPSULE) )
(DANOCRINE (200
MG) (CAPSULE) )
2
1
1
Page 94 of 224
Sharp Health Plan: Covered California
Drug Name
danazol
Drug Tier Requirements/Limits
(DANOCRINE (50
MG) (CAPSULE) )
1
ENDOCRINE DISORDER - THYROID
ANTITHYROID PREPARATIONS
methimazole
methimazole
(TAPAZOLE (10
MG) (TABLET) )
(TAPAZOLE (5 MG)
(TABLET) )
propylthiouracil (50 mg) (tablet)
1
1
1
IODINE CONTAINING AGENTS
potassium iodide (1 g/ml) (solution)
potassium iodide/iodine (5 %) (solution)
2
2
THYROID HORMONES
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
Sharp Health Plan: Covered California
(LEVO-T (100 MCG)
(TABLET) )
(LEVO-T (112 MCG)
(TABLET) )
(LEVO-T (125 MCG)
(TABLET) )
(LEVO-T (137 MCG)
(TABLET) )
(LEVO-T (150 MCG)
(TABLET) )
(LEVO-T (175MCG)
(TABLET) )
(LEVO-T (200 MCG)
(TABLET) )
(LEVO-T (25 MCG)
(TABLET) )
(LEVO-T (300 MCG)
(TABLET) )
(LEVO-T (50 MCG)
(TABLET) )
(LEVO-T (75 MCG)
(TABLET) )
(LEVO-T (88 MCG)
(TABLET) )
(LEVOXYL (100
MCG) (TABLET) )
(LEVOXYL (112
MCG) (TABLET) )
(LEVOXYL (125
MCG) (TABLET) )
(LEVOXYL (137
MCG) (TABLET) )
(LEVOXYL (150
MCG) (TABLET) )
(LEVOXYL
(175MCG)
(TABLET) )
(LEVOXYL (200
MCG) (TABLET) )
(LEVOXYL (25
MCG) (TABLET) )
(LEVOXYL (50
MCG) (TABLET) )
(LEVOXYL (75
MCG) (TABLET) )
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 95 of 224
Sharp Health Plan: Covered California
Drug Name
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
LEVOTHYROXINE SODIUM
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(LEVOXYL (88
MCG) (TABLET) )
(SYNTHROID (100
MCG) (TABLET) )
(SYNTHROID (112
MCG) (TABLET) )
(SYNTHROID (125
MCG) (TABLET) )
(SYNTHROID (137
MCG) (TABLET) )
(SYNTHROID (150
MCG) (TABLET) )
(SYNTHROID
(175MCG)
(TABLET) )
(SYNTHROID (200
MCG) (TABLET) )
(SYNTHROID (25
MCG) (TABLET) )
(SYNTHROID (300
MCG) (TABLET) )
(SYNTHROID (50
MCG) (TABLET) )
(SYNTHROID (75
MCG) (TABLET) )
(SYNTHROID (88
MCG) (TABLET) )
(TIROSINT (100
MCG) (CAPSULE) )
(TIROSINT (112
MCG) (CAPSULE) )
(TIROSINT (125
MCG) (CAPSULE) )
(TIROSINT (13
MCG) (CAPSULE) )
(TIROSINT (137
MCG) (CAPSULE) )
(TIROSINT (150
MCG) (CAPSULE) )
(TIROSINT (25
MCG) (CAPSULE) )
(TIROSINT (50
MCG) (CAPSULE) )
(TIROSINT (75
MCG) (CAPSULE) )
(TIROSINT (88
MCG) (CAPSULE) )
(UNITHROID (100
MCG) (TABLET) )
(UNITHROID (112
MCG) (TABLET) )
(UNITHROID (125
MCG) (TABLET) )
(UNITHROID (137
MCG) (TABLET) )
(UNITHROID (150
MCG) (TABLET) )
(UNITHROID
(175MCG)
(TABLET) )
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
Page 96 of 224
Sharp Health Plan: Covered California
Drug Name
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
liothyronine sodium
liothyronine sodium
liothyronine sodium
LIOTRIX
LIOTRIX
LIOTRIX
LIOTRIX
LIOTRIX
THYROID,PORK
THYROID,PORK
THYROID,PORK
THYROID,PORK
thyroid,pork
THYROID,PORK
THYROID,PORK
thyroid,pork
THYROID,PORK
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(UNITHROID (200
MCG) (TABLET) )
(UNITHROID (25
MCG) (TABLET) )
(UNITHROID (300
MCG) (TABLET) )
(UNITHROID (50
MCG) (TABLET) )
(UNITHROID (75
MCG) (TABLET) )
(UNITHROID (88
MCG) (TABLET) )
(CYTOMEL (25
MCG) (TABLET) )
(CYTOMEL (5
MCG) (TABLET) )
(CYTOMEL (50
MCG) (TABLET) )
(THYROLAR-1
(12.5-50MCG)
(TABLET) )
(THYROLAR-1/2
(6.25-25MCG)
(TABLET) )
(THYROLAR-1/4
(3.1-12.5)
(TABLET) )
(THYROLAR-2 (25100MCG)
(TABLET) )
(THYROLAR-3
(37.5-150)
(TABLET) )
(ARMOUR
THYROID (120 MG)
(TABLET) )
(ARMOUR
THYROID (15 MG)
(TABLET) )
(ARMOUR
THYROID (180 MG)
(TABLET) )
(ARMOUR
THYROID (240 MG)
(TABLET) )
(ARMOUR
THYROID (30 MG)
(TABLET) )
(ARMOUR
THYROID (30 MG)
(TABLET) )
(ARMOUR
THYROID (300 MG)
(TABLET) )
(ARMOUR
THYROID (60 MG)
(TABLET) )
(ARMOUR
THYROID (60 MG)
(TABLET) )
1
1
1
1
1
1
1
1
1
3
3
3
3
3
2
2
2
2
1
2
2
1
2
Page 97 of 224
Sharp Health Plan: Covered California
Drug Name
thyroid,pork
THYROID,PORK
Drug Tier Requirements/Limits
(ARMOUR
THYROID (90 MG)
(TABLET) )
(ARMOUR
THYROID (90 MG)
(TABLET) )
thyroid,pork (113.75 mg) (tablet)
thyroid,pork (130 mg) (tablet)
thyroid,pork (146.25 mg) (tablet)
thyroid,pork (16.25 mg) (tablet)
thyroid,pork (162.5 mg) (tablet)
thyroid,pork (195 mg) (tablet)
thyroid,pork (260 mg) (tablet)
thyroid,pork (32.5 mg) (tablet)
thyroid,pork (325 mg) (tablet)
thyroid,pork (48.75 mg) (tablet)
thyroid,pork (65 mg) (tablet)
thyroid,pork (81.25 mg) (tablet)
thyroid,pork (97.5 mg) (tablet)
thyroid,pork
thyroid,pork
thyroid,pork
thyroid,pork
thyroid,pork
thyroid,pork
thyroid,pork
thyroid,pork
1
2
2
2
2
2
2
1
2
2
2
2
2
2
2
(WP THYROID
(113.75 MG)
(TABLET) )
(WP THYROID (130
MG) (TABLET) )
(WP THYROID
(16.25 MG)
(TABLET) )
(WP THYROID (32.5
MG) (TABLET) )
(WP THYROID
(48.75 MG)
(TABLET) )
(WP THYROID (65
MG) (TABLET) )
(WP THYROID
(81.25 MG)
(TABLET) )
(WP THYROID (97.5
MG) (TABLET) )
2
2
2
2
2
2
2
2
EYE - GENERAL DISORDERS
EYE ANTIBIOTIC-CORTICOID COMBINATIONS
GENTAMICIN/PREDNISOL AC
GENTAMICIN/PREDNISOL AC
neo/polymyx b sulf/dexameth
neo/polymyx b sulf/dexameth
neo/polymyx b sulf/dexameth
(PRED-G (0.3%-1%)
(DROPS SUSP) )
(PRED-G (0.3-0.6%)
(OINT. (G)) )
(MAXITROL (0.1 %)
(DROPS SUSP) )
(MAXITROL (3.510K-.1) (OINT. (G)) )
(MAXITROL (3.510K-.1) (OINT. (G)) )
neomycin su/baci zn/poly/hc (3.5-10k-1) (oint. (g))
neomycin/polymyxin b sulf/hc (3.5-10k-10) (drops
susp)
tobramycin/dexamethasone
Sharp Health Plan: Covered California
2
2
1
1
2
1
1
(TOBRADEX (0.3
%-0.1%) (DROPS
SUSP) )
1
Page 98 of 224
Sharp Health Plan: Covered California
Drug Name
TOBRAMYCIN/DEXAMETHASONE
TOBRAMYCIN/DEXAMETHASONE
TOBRAMYCIN/LOTEPRED ETAB
Drug Tier Requirements/Limits
(TOBRADEX (0.3
%-0.1%) (OINT.
(G)) )
(TOBRADEX ST
(0.3%-0.05%)
(DROPS SUSP) )
(ZYLET (0.3%-0.5%)
(DROPS SUSP) )
2
3
3
EYE ANTIHISTAMINES
ALCAFTADINE
BEPOTASTINE BESILATE
EMEDASTINE DIFUMARATE
OLOPATADINE HCL
olopatadine hcl
OLOPATADINE HCL
(LASTACAFT (0.25
%) (DROPS) )
(BEPREVE (1.5 %)
(DROPS) )
(EMADINE (0.05 %)
(DROPS) )
(PATADAY (0.2 %)
(DROPS) )
(PATANOL (0.1 %)
(DROPS) )
(PAZEO (0.7 %)
(DROPS) )
3
ST, QL: 3 IN 30 DAYS
3
ST, QL: 10 IN 30 DAYS
3
ST, QL: 10 IN 30 DAYS
3
2
3
QL: 3 IN 63 DAYS
2
PA
EYE ANTIINFLAMMATORY AGENTS
bromfenac sodium (0.09%) (drops)
BROMFENAC SODIUM
BROMFENAC SODIUM
DEXAMETHASONE
dexamethasone sod phosphate
diclofenac sodium
DIFLUPREDNATE
fluorometholone
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE ACETATE
flurbiprofen sodium
ketorolac tromethamine
ketorolac tromethamine
KETOROLAC TROMETHAMINE/PF
LOTEPREDNOL ETABONATE
LOTEPREDNOL ETABONATE
LOTEPREDNOL ETABONATE
LOTEPREDNOL ETABONATE
Sharp Health Plan: Covered California
(BROMSITE (0.075
%) (DROPS) )
(PROLENSA (0.07
%) (DROPS) )
(MAXIDEX (0.1 %)
(DROPS SUSP) )
(DEXASOL (0.1 %)
(DROPS) )
(VOLTAREN (0.1 %)
(DROPS) )
(DUREZOL (0.05 %)
(DROPS) )
(FML (0.1 %)
(DROPS SUSP) )
(FML FORTE (0.25
%) (DROPS SUSP) )
(FML S.O.P. (0.1 %)
(OINT. (G)) )
(FLAREX (0.1 %)
(DROPS SUSP) )
(OCUFEN (0.03 %)
(DROPS) )
(ACULAR (0.5 %)
(DROPS) )
(ACULAR LS (0.4
%) (DROPS) )
(ACUVAIL (0.45 %)
(DROPERETTE) )
(ALREX (0.2 %)
(DROPS SUSP) )
(LOTEMAX (0.5 %)
(DROPS GEL) )
(LOTEMAX (0.5 %)
(DROPS SUSP) )
(LOTEMAX (0.5 %)
(OINT. (G)) )
4
3
2
1
2
3
PA
1
2
2
2
1
2
2
3
3
3
3
3
Page 99 of 224
Sharp Health Plan: Covered California
Drug Name
NEPAFENAC
NEPAFENAC
prednisolone acetate
prednisolone acetate
PREDNISOLONE ACETATE
Drug Tier Requirements/Limits
(ILEVRO (0.3 %)
(DROPS SUSP) )
(NEVANAC (0.1 %)
(DROPS SUSP) )
(OMNIPRED (1 %)
(DROPS SUSP) )
(PRED FORTE (1 %)
(DROPS SUSP) )
(PRED MILD (0.12
%) (DROPS SUSP) )
prednisolone sod phosphate (1 %) (drops)
3
3
PA
1
1
2
1
EYE ANTIVIRALS
GANCICLOVIR
trifluridine
(ZIRGAN (0.15 %)
(GEL (GRAM)) )
(VIROPTIC (1 %)
(DROPS) )
3
1
EYE SULFONAMIDES
sulfacetamide sodium
sulfacetamide sodium
(SODIUM
SULAMYD (10 %)
(DROPS) )
(SODIUM
SULAMYD (10 %)
(OINT. (G)) )
sulfacetamide/prednisolone sp (10 %-0.23%) (drops)
SULFACETM NA/PREDNISOL AC
SULFACETM NA/PREDNISOL AC
1
1
1
(BLEPHAMIDE (10
%-0.2 %) (DROPS
SUSP) )
(BLEPHAMIDE
S.O.P. (10 %-0.2 %)
(OINT. (G)) )
2
2
EYE VASOCONSTRICTORS (RX ONLY)
phenylephrine hcl
(MYDFRIN (2.5 %)
(DROPS) )
phenylephrine hcl (10 %) (drops)
2
2
OPHTHALMIC ANTIBIOTICS
AZITHROMYCIN
(AZASITE (1 %)
(DROPS) )
bacitracin (500 unit/g) (oint. (g))
bacitracin/polymyxin b sulfate (500-10k/g) (oint. (g))
BESIFLOXACIN HCL
ciprofloxacin hcl
CIPROFLOXACIN HCL
erythromycin base
gatifloxacin
gentamicin sulfate
gentamicin sulfate
1
1
(BESIVANCE (0.6
%) (DROPS SUSP) )
(CILOXAN (0.3 %)
(DROPS) )
(CILOXAN (0.3 %)
(OINT. (G)) )
(ILOTYCIN (5
MG/G) (OINT. (G)) )
(ZYMAXID (0.5 %)
(DROPS) )
(GARAMYCIN (0.3
%) (DROPS) )
(GARAMYCIN (0.3
%) (OINT. (G)) )
levofloxacin (0.5 %) (drops)
MOXIFLOXACIN HCL
MOXIFLOXACIN HCL
Sharp Health Plan: Covered California
3
3
1
2
1
2
1
1
1
(MOXEZA (0.5 %)
(DROPS VISC) )
(VIGAMOX (0.5 %)
(DROPS) )
3
3
Page 100 of 224
Sharp Health Plan: Covered California
Drug Name
NATAMYCIN
neomycin su/bacitra/polymyxin
Drug Tier Requirements/Limits
(NATACYN (5 %)
(DROPS SUSP) )
(NEO-POLYCIN
(3.5MG-400) (OINT.
(G)) )
neomycin/polymyxn b/gramicidin (1.75mg-10k)
(drops)
ofloxacin
polymyxin b sulf/trimethoprim
tobramycin
TOBRAMYCIN
3
1
1
(OCUFLOX (0.3 %)
(DROPS) )
(POLYTRIM (100001/ML) (DROPS) )
(TOBREX (0.3 %)
(DROPS) )
(TOBREX (0.3 %)
(OINT. (G)) )
1
1
1
2
OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE
CYCLOSPORINE
LIFITEGRAST
(RESTASIS (0.05 %)
(DROPERETTE) )
(XIIDRA (5 %)
(DROPERETTE) )
2
3
PA, QL: 60 IN 30 DAYS
OPHTHALMIC MAST CELL STABILIZERS
cromolyn sodium
LODOXAMIDE TROMETHAMINE
NEDOCROMIL SODIUM
(OPTICROM (4 %)
(DROPS) )
(ALOMIDE (0.1 %)
(DROPS) )
(ALOCRIL (2 %)
(DROPS) )
1
2
3
EYE - GLAUCOMA
CARBONIC ANHYDRASE INHIBITORS
acetazolamide
acetazolamide
acetazolamide
methazolamide
methazolamide
(DIAMOX (125 MG)
(TABLET) )
(DIAMOX (250 MG)
(TABLET) )
(DIAMOX
SEQUELS (500 MG)
(CAPSULE ER) )
(NEPTAZANE (25
MG) (TABLET) )
(NEPTAZANE (50
MG) (TABLET) )
1
1
1
1
1
MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS
apraclonidine hcl
APRACLONIDINE HCL
betaxolol hcl
BETAXOLOL HCL
BIMATOPROST
bimatoprost
brimonidine tartrate
BRIMONIDINE TARTRATE
brimonidine tartrate
Sharp Health Plan: Covered California
(IOPIDINE (0.5 %)
(DROPS) )
(IOPIDINE (1 %)
(DROPERETTE) )
(BETOPTIC (0.5 %)
(DROPS) )
(BETOPTIC S (0.25
%) (DROPS SUSP) )
(LUMIGAN (0.01 %)
(DROPS) )
(LUMIGAN (0.03 %)
(DROPS) )
(ALPHAGAN (0.2
%) (DROPS) )
(ALPHAGAN P (0.1
%) (DROPS) )
(ALPHAGAN P (0.15
%) (DROPS) )
2
3
1
2
2
1
1
2
1
Page 101 of 224
Sharp Health Plan: Covered California
Drug Name
BRIMONIDINE TARTRATE/TIMOLOL
BRINZOLAMIDE
BRINZOLAMIDE/BRIMONIDINE TART
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleat
DORZOLAMIDE/TIMOLOL/PF
ECHOTHIOPHATE IODIDE
latanoprost
levobunolol hcl
metipranolol
pilocarpine hcl
pilocarpine hcl
pilocarpine hcl
TAFLUPROST/PF
TIMOLOL
TIMOLOL
TIMOLOL MALEATE
timolol maleate
timolol maleate
timolol maleate
timolol maleate
TIMOLOL MALEATE/PF
TIMOLOL MALEATE/PF
TRAVOPROST
Drug Tier Requirements/Limits
(COMBIGAN (0.2%0.5%) (DROPS) )
(AZOPT (1 %)
(DROPS SUSP) )
(SIMBRINZA (1 %0.2 %) (DROPS
SUSP) )
(OCUPRESS (1 %)
(DROPS) )
(TRUSOPT (2 %)
(DROPS) )
(COSOPT (22.36.8/1) (DROPS) )
(COSOPT PF (2 %0.5 %)
(DROPERETTE) )
(PHOSPHOLINE
IODIDE (0.125 %)
(DROPS) )
(XALATAN (0.005
%) (DROPS) )
(BETAGAN (0.5 %)
(DROPS) )
(OPTIPRANOLOL
(0.3 %) (DROPS) )
(ISOPTO CARPINE
(1 %) (DROPS) )
(ISOPTO CARPINE
(2 %) (DROPS) )
(ISOPTO CARPINE
(4 %) (DROPS) )
(ZIOPTAN (0.0015
%)
(DROPERETTE) )
(BETIMOL (0.25 %)
(DROPS) )
(BETIMOL (0.5 %)
(DROPS) )
(ISTALOL (0.5 %)
(DROP DAILY) )
(TIMOPTIC (0.25 %)
(DROPS) )
(TIMOPTIC (0.5 %)
(DROPS) )
(TIMOPTIC-XE
(0.25 %) (SOLGEL) )
(TIMOPTIC-XE (0.5
%) (SOL-GEL) )
(TIMOPTIC
OCUDOSE (0.25 %)
(DROPERETTE) )
(TIMOPTIC
OCUDOSE (0.5 %)
(DROPERETTE) )
(TRAVATAN Z
(0.004 %) (DROPS) )
3
3
3
2
1
2
3
2
1
1
2
1
1
1
3
2
2
2
1
1
1
1
2
2
3
MYDRIATICS
atropine sulfate (1 %) (drops)
atropine sulfate (1 %) (oint. (g))
Sharp Health Plan: Covered California
1
1
Page 102 of 224
Sharp Health Plan: Covered California
Drug Name
cyclopentolate hcl
cyclopentolate hcl
cyclopentolate hcl
CYCLOPENTOLATE/PHENYLEPHRINE
homatropine hbr
HYDROXYAMPHETAMINE/TROPICAMIDE
tropicamide
tropicamide
Drug Tier Requirements/Limits
(CYCLOGYL (0.5
%) (DROPS) )
(CYCLOGYL (1 %)
(DROPS) )
(CYCLOGYL (2 %)
(DROPS) )
(CYCLOMYDRIL
(0.2 %-1 %)
(DROPS) )
(ISOPTO
HOMATROPINE (5
%) (DROPS) )
(PAREMYD (1 %0.25 %) (DROPS) )
(MYDRIACYL (0.5
%) (DROPS) )
(MYDRIACYL (1 %)
(DROPS) )
2
2
2
3
1
3
1
1
OPHTHALMIC ANTIFIBROTIC AGENTS
MITOMYCIN
(MITOSOL (0.2 MG)
(KIT) )
3
(LACRISERT (5 MG)
(INSERT) )
3
PA
EYE - MISCELLANEOUS
ARTIFICIAL TEARS
HYDROXYPROPYL CELLULOSE
EYE PREPARATIONS, MISCELLANEOUS (OTC)
GELATIN
(GELFILM
(25X50MM)
(EACH) )
3
OPHTHALMIC CYSTINE DEPLETING AGENTS
CYSTEAMINE HCL
(CYSTARAN (0.44
%) (DROPS) )
4
FLUID REPLACEMENT
NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTS
URIDINE TRIACETATE
(XURIDEN (2 G)
(GRAN PACK) )
4
PA, QL: 4 IN 1 DAY
1
QL: 20 PER FILL
2
QL: 20 PER FILL
GOUT AND RELATED DISEASES
COLCHICINE
colchicine
colchicine
colchicine/probenecid
(COLCRYS (0.6 MG)
(TABLET) )
(MITIGARE (0.6
MG) (CAPSULE) )
(COLBENEMID
(0.5-500MG)
(TABLET) )
1
HYPERURICEMIA TX - PURINE INHIBITORS
allopurinol
allopurinol
FEBUXOSTAT
FEBUXOSTAT
(ZYLOPRIM (100
MG) (TABLET) )
(ZYLOPRIM (300
MG) (TABLET) )
(ULORIC (40 MG)
(TABLET) )
(ULORIC (80 MG)
(TABLET) )
1
1
3
ST
3
ST
4
ST, QL: 1 IN 1 DAY
URICOSURIC AGENTS
LESINURAD
Sharp Health Plan: Covered California
(ZURAMPIC (200
MG) (TABLET) )
Page 103 of 224
Sharp Health Plan: Covered California
Drug Name
probenecid
Drug Tier Requirements/Limits
(BENEMID (500
MG) (TABLET) )
1
HEMATOLOGICAL DISORDERS
ANTICOAGULANTS,COUMARIN TYPE
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
warfarin sodium
(COUMADIN (1
MG) (TABLET) )
(COUMADIN (10
MG) (TABLET) )
(COUMADIN (2
MG) (TABLET) )
(COUMADIN (2.5
MG) (TABLET) )
(COUMADIN (3
MG) (TABLET) )
(COUMADIN (4
MG) (TABLET) )
(COUMADIN (5
MG) (TABLET) )
(COUMADIN (6
MG) (TABLET) )
(COUMADIN (7.5
MG) (TABLET) )
1
1
1
1
1
1
1
1
1
ANTIFIBRINOLYTIC AGENTS
AMINOCAPROIC ACID
AMINOCAPROIC ACID
AMINOCAPROIC ACID
tranexamic acid
(AMICAR (1000
MG) (TABLET) )
(AMICAR (250
MG/ML)
(SOLUTION) )
(AMICAR (500 MG)
(TABLET) )
(LYSTEDA (650
MG) (TABLET) )
3
3
3
2
CITRATES AS ANTICOAGULANTS
citrate phosphate dextros soln (2.63 g/100) (solution)
DEXTROSE/SOD CITRATE/CITRIC AC
2
(ACD (2.45G-2.2G)
(SOLUTION) )
sodium citrate (4 g/100 ml) (solution)
3
2
DIRECT FACTOR XA INHIBITORS
APIXABAN
APIXABAN
EDOXABAN TOSYLATE
EDOXABAN TOSYLATE
EDOXABAN TOSYLATE
RIVAROXABAN
RIVAROXABAN
RIVAROXABAN
RIVAROXABAN
Sharp Health Plan: Covered California
(ELIQUIS (2.5 MG)
(TABLET) )
(ELIQUIS (5 MG)
(TABLET) )
(SAVAYSA (15 MG)
(TABLET) )
(SAVAYSA (30 MG)
(TABLET) )
(SAVAYSA (60 MG)
(TABLET) )
(XARELTO (10 MG)
(TABLET) )
(XARELTO (15 MG)
(TABLET) )
(XARELTO (15 MG20MG) (TAB DS
PK) )
(XARELTO (20 MG)
(TABLET) )
2
2
3
ST
3
ST
3
ST
2
2
2
2
Page 104 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
HEMATINICS,OTHER
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
DARBEPOETIN ALFA IN POLYSORBAT
(ARANESP (100
MCG/ML) (VIAL) )
(ARANESP
(100MCG/0.5)
(SYRINGE) )
(ARANESP
(10MCG/0.4)
(SYRINGE) )
(ARANESP
(150MCG/.75)
(VIAL) )
(ARANESP
(150MCG/0.3)
(SYRINGE) )
(ARANESP (200
MCG/ML) (VIAL) )
(ARANESP
(200MCG/0.4)
(SYRINGE) )
(ARANESP (25
MCG/ML) (VIAL) )
(ARANESP
(25MCG/0.42)
(SYRINGE) )
(ARANESP (300
MCG/ML) (VIAL) )
(ARANESP
(300MCG/0.6)
(SYRINGE) )
(ARANESP (40
MCG/0.4)
(SYRINGE) )
(ARANESP (40
MCG/ML) (VIAL) )
(ARANESP (500
MCG/ML)
(SYRINGE) )
(ARANESP
(60MCG/0.3)
(SYRINGE) )
(ARANESP
(60MCG/ML)
(VIAL) )
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
HEMORRHEOLOGIC AGENTS
pentoxifylline
(TRENTAL (400
MG) (TABLET ER) )
1
HEPARIN AND RELATED PREPARATIONS
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
Sharp Health Plan: Covered California
(LOVENOX (100
MG/ML)
(SYRINGE) )
(LOVENOX
(120MG/.8ML)
(SYRINGE) )
(LOVENOX (150
MG/ML)
(SYRINGE) )
(LOVENOX
(300MG/3ML)
(VIAL) )
MB
MB
MB
MB
Page 105 of 224
Sharp Health Plan: Covered California
Drug Name
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
Drug Tier Requirements/Limits
(LOVENOX
(30MG/0.3ML)
(SYRINGE) )
(LOVENOX
(40MG/0.4ML)
(SYRINGE) )
(LOVENOX
(60MG/0.6ML)
(SYRINGE) )
(LOVENOX
(80MG/0.8ML)
(SYRINGE) )
MB
MB
MB
MB
LEUKOCYTE (WBC) STIMULANTS
PEGFILGRASTIM
PEGFILGRASTIM
TBO-FILGRASTIM
TBO-FILGRASTIM
(NEULASTA
(6MG/0.6ML) (SYR
W/ INJ) )
(NEULASTA
(6MG/0.6ML)
(SYRINGE) )
(GRANIX
(300MCG/0.5)
(SYRINGE) )
(GRANIX
(480MCG/0.8)
(SYRINGE) )
MB
MB
MB
MB
PLATELET AGGREGATION INHIBITORS
ASPIRIN
aspirin/dipyridamole
ASPIRIN/OMEPRAZOLE
ASPIRIN/OMEPRAZOLE
cilostazol
cilostazol
clopidogrel bisulfate
clopidogrel bisulfate
dipyridamole
dipyridamole
dipyridamole
PRASUGREL HCL
PRASUGREL HCL
TICAGRELOR
TICAGRELOR
Sharp Health Plan: Covered California
(DURLAZA (162.5
MG) (CAP ER 24H) )
(AGGRENOX
(25MG-200MG)
(CPMP 12HR) )
(YOSPRALA
(325MG-40MG)
(TAB IR DR) )
(YOSPRALA (81
MG-40MG) (TAB IR
DR) )
(PLETAL (100 MG)
(TABLET) )
(PLETAL (50 MG)
(TABLET) )
(PLAVIX (300 MG)
(TABLET) )
(PLAVIX (75 MG)
(TABLET) )
(PERSANTINE (25
MG) (TABLET) )
(PERSANTINE (50
MG) (TABLET) )
(PERSANTINE (75
MG) (TABLET) )
(EFFIENT (10 MG)
(TABLET) )
(EFFIENT (5 MG)
(TABLET) )
(BRILINTA (60 MG)
(TABLET) )
(BRILINTA (90 MG)
(TABLET) )
3
PA
2
4
4
1
1
2
1
QL: 4 IN 1 DAY
1
1
1
2
QL: 30 IN 30 DAYS
2
QL: 30 IN 30 DAYS
3
ST
3
ST, QL: 2 IN 1 DAY; USE
RESTRICTED TO
CARDIOLOGIST
Page 106 of 224
Sharp Health Plan: Covered California
Drug Name
ticlopidine hcl
VORAPAXAR SULFATE
Drug Tier Requirements/Limits
(TICLID (250 MG)
(TABLET) )
(ZONTIVITY (2.08
MG) (TABLET) )
1
4
PA
PLATELET REDUCING AGENTS
anagrelide hcl
anagrelide hcl
(AGRYLIN (0.5 MG)
(CAPSULE) )
(AGRYLIN (1 MG)
(CAPSULE) )
2
2
SICKLE CELL ANEMIA AGENTS
HYDROXYUREA
HYDROXYUREA
HYDROXYUREA
(DROXIA (200 MG)
(CAPSULE) )
(DROXIA (300 MG)
(CAPSULE) )
(DROXIA (400 MG)
(CAPSULE) )
3
3
3
THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLE
DABIGATRAN ETEXILATE MESYLATE
DABIGATRAN ETEXILATE MESYLATE
DABIGATRAN ETEXILATE MESYLATE
(PRADAXA (110
MG) (CAPSULE) )
(PRADAXA (150
MG) (CAPSULE) )
(PRADAXA (75 MG)
(CAPSULE) )
3
ST
3
ST
3
ST
4
PA
4
PA
4
PA
4
PA
THROMBOPOIETIN RECEPTOR AGONISTS
ELTROMBOPAG OLAMINE
ELTROMBOPAG OLAMINE
ELTROMBOPAG OLAMINE
ELTROMBOPAG OLAMINE
(PROMACTA (12.5
MG) (TABLET) )
(PROMACTA (25
MG) (TABLET) )
(PROMACTA (50
MG) (TABLET) )
(PROMACTA (75
MG) (TABLET) )
VITAMIN K PREPARATIONS
PHYTONADIONE
(MEPHYTON (5
MG) (TABLET) )
2
HORMONAL DEFICIENCY
ANDROGENIC AGENTS
fluoxymesterone
methyltestosterone
METHYLTESTOSTERONE
methyltestosterone
oxandrolone
oxandrolone
OXYMETHOLONE
TESTOSTERONE
TESTOSTERONE
Sharp Health Plan: Covered California
(HALOTESTIN (10
MG) (TABLET) )
(ANDROID (10 MG)
(CAPSULE) )
(METHITEST (10
MG) (TABLET) )
(TESTRED (10 MG)
(CAPSULE) )
(OXANDRIN (10
MG) (TABLET) )
(OXANDRIN (2.5
MG) (TABLET) )
(ANADROL-50 (50
MG) (TABLET) )
(ANDRODERM (2
MG/24 HR) (PATCH
TD24) )
(ANDRODERM (4
MG/24 HR) (PATCH
TD24) )
1
1
PA
2
PA
1
PA
2
2
4
3
PA
3
PA
Page 107 of 224
Sharp Health Plan: Covered California
Drug Name
testosterone
TESTOSTERONE
TESTOSTERONE
TESTOSTERONE
testosterone
testosterone
TESTOSTERONE
testosterone
TESTOSTERONE
TESTOSTERONE
testosterone
testosterone
testosterone
testosterone
Drug Tier Requirements/Limits
(ANDROGEL (1.25
G(1%)) (GEL MD
PMP) )
(ANDROGEL
(1.25G-1.62) (GEL
PACKET) )
(ANDROGEL (2.5G1.62%) (GEL
PACKET) )
(ANDROGEL
(20.25/1.25) (GEL
MD PMP) )
(ANDROGEL
(25MG(1%)) (GEL
PACKET) )
(ANDROGEL (50
MG (1%)) (GEL
PACKET) )
(AXIRON
(30MG/1.5ML) (SOL
MD PMP) )
(FORTESTA (10 MG
(2%)) (GEL MD
PMP) )
(NATESTO
(5.5/0.122) (GEL MD
PMP) )
(STRIANT (30 MG)
(MUC ER 12H) )
(TESTIM (50 MG
(1%)) (GEL
(GRAM)) )
(VOGELXO (1.25
G(1%)) (GEL MD
PMP) )
(VOGELXO (50 MG
(1%)) (GEL
(GRAM)) )
(VOGELXO (50 MG
(1%)) (GEL
PACKET) )
1
PA
2
PA
2
PA
2
PA
1
PA
1
PA
3
PA
2
PA
3
3
PA
1
PA
1
PA
1
PA
1
PA
ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB
DROSPIRENONE/ESTRADIOL
DROSPIRENONE/ESTRADIOL
(ANGELIQ (0.250.5MG) (TABLET) )
(ANGELIQ (0.5 MG1MG) (TABLET) )
3
3
ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB
ESTROGENS,CONJ/BAZEDOXIFENE
(DUAVEE (0.45-20
MG) (TABLET) )
3
QL: 1 IN 1 DAY
ESTROGEN/ANDROGEN COMBINATIONS
estrogen,ester/me-testosterone
estrogen,ester/me-testosterone
estrogen,ester/me-testosterone
estrogen,ester/me-testosterone (0.625-1.25) (tablet)
estrogen,ester/me-testosterone (1.25-2.5mg) (tablet)
Sharp Health Plan: Covered California
(COVARYX (1.252.5MG) (TABLET) )
(COVARYX (1.252.5MG) (TABLET) )
(COVARYX H.S.
(0.625-1.25)
(TABLET) )
1
2
1
1
1
Page 108 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ESTROGENIC AGENTS
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
estradiol
estradiol
estradiol
estradiol
estradiol
estradiol
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
estradiol
estradiol
estradiol
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
Sharp Health Plan: Covered California
(ALORA
(.025MG/24H)
(PATCH TDSW) )
(ALORA
(.075MG/24H)
(PATCH TDSW) )
(ALORA
(0.05MG/24H)
(PATCH TDSW) )
(ALORA
(0.1MG/24HR)
(PATCH TDSW) )
(CLIMARA
(.025MG/24H)
(PATCH TDWK) )
(CLIMARA
(.0375MG/24)
(PATCH TDWK) )
(CLIMARA
(.075MG/24H)
(PATCH TDWK) )
(CLIMARA
(0.05MG/24H)
(PATCH TDWK) )
(CLIMARA
(0.06MG/24H)
(PATCH TDWK) )
(CLIMARA
(0.1MG/24HR)
(PATCH TDWK) )
(DIVIGEL
(0.25(0.1%)) (GEL
PACKET) )
(DIVIGEL
(0.5MG(0.1)) (GEL
PACKET) )
(DIVIGEL
(1MG(0.1%)) (GEL
PACKET) )
(ELESTRIN (0.87G)
(GEL MD PMP) )
(ESTRACE (0.5 MG)
(TABLET) )
(ESTRACE (1 MG)
(TABLET) )
(ESTRACE (2 MG)
(TABLET) )
(ESTROGEL (1.25
G) (GEL MD PMP) )
(EVAMIST
(1.53/SPRAY)
(SPRAY) )
(MENOSTAR
(14MCG/24HR)
(PATCH TDWK) )
(MINIVELLE
(.025MG/24H)
(PATCH TDSW) )
2
2
2
2
2
2
2
2
2
2
3
3
3
3
1
1
1
3
3
3
2
Page 109 of 224
Sharp Health Plan: Covered California
Drug Name
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
estradiol
estradiol
estradiol
estradiol
estradiol
ESTRADIOL/LEVONORGESTREL
estradiol/norethindrone acet
estradiol/norethindrone acet
ESTRADIOL/NORETHINDRONE ACET
ESTRADIOL/NORETHINDRONE ACET
ESTRADIOL/NORGESTIMATE
ESTROGEN,CON/M-PROGEST ACET
ESTROGEN,CON/M-PROGEST ACET
ESTROGEN,CON/M-PROGEST ACET
ESTROGEN,CON/M-PROGEST ACET
ESTROGEN,CON/M-PROGEST ACET
ESTROGENS, CONJUGATED
ESTROGENS, CONJUGATED
ESTROGENS, CONJUGATED
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(MINIVELLE
(.0375MG/24)
(PATCH TDSW) )
(MINIVELLE
(.075MG/24H)
(PATCH TDSW) )
(MINIVELLE
(0.05MG/24H)
(PATCH TDSW) )
(MINIVELLE
(0.1MG/24HR)
(PATCH TDSW) )
(VIVELLE-DOT
(.025MG/24H)
(PATCH TDSW) )
(VIVELLE-DOT
(.0375MG/24)
(PATCH TDSW) )
(VIVELLE-DOT
(.075MG/24H)
(PATCH TDSW) )
(VIVELLE-DOT
(0.05MG/24H)
(PATCH TDSW) )
(VIVELLE-DOT
(0.1MG/24HR)
(PATCH TDSW) )
(CLIMARA PRO
(45-15/24H) (PATCH
TDWK) )
(ACTIVELLA (0.50.1MG) (TABLET) )
(ACTIVELLA (1
MG-0.5MG)
(TABLET) )
(COMBIPATCH (.05.14/24) (PATCH
TDSW) )
(COMBIPATCH (.05.25/24) (PATCH
TDSW) )
(PREFEST (1-10.09MG) (TABLET) )
(PREMPHASE
(0.625 (14))
(TABLET) )
(PREMPRO (0.31.5MG) (TABLET) )
(PREMPRO (0.451.5MG) (TABLET) )
(PREMPRO (0.6252.5) (TABLET) )
(PREMPRO (0.625-5
MG) (TABLET) )
(PREMARIN (0.3
MG) (TABLET) )
(PREMARIN
(0.45MG)
(TABLET) )
(PREMARIN (0.625
MG) (TABLET) )
2
2
2
2
1
1
1
1
1
3
2
2
2
2
3
2
2
2
2
2
2
2
2
Page 110 of 224
Sharp Health Plan: Covered California
Drug Name
ESTROGENS, CONJUGATED
ESTROGENS, CONJUGATED
ESTROGENS,ESTERIFIED
ESTROGENS,ESTERIFIED
ESTROGENS,ESTERIFIED
ESTROGENS,ESTERIFIED
estropipate
estropipate
estropipate
norethindrone ac-eth estradiol
norethindrone ac-eth estradiol
norethindrone ac-eth estradiol
norethindrone ac-eth estradiol
Drug Tier Requirements/Limits
(PREMARIN (0.9
MG) (TABLET) )
(PREMARIN (1.25
MG) (TABLET) )
(MENEST (0.3 MG)
(TABLET) )
(MENEST (0.625
MG) (TABLET) )
(MENEST (1.25 MG)
(TABLET) )
(MENEST (2.5 MG)
(TABLET) )
(OGEN 2.5 (3 MG)
(TABLET) )
(ORTHO-EST (0.75
MG) (TABLET) )
(ORTHO-EST (1.5
MG) (TABLET) )
(FEMHRT (0.5MG2.5) (TABLET) )
(FEMHRT (1MG5MCG) (TABLET) )
(JEVANTIQUE
(1MG-5MCG)
(TABLET) )
(JEVANTIQUE LO
(0.5MG-2.5)
(TABLET) )
2
2
2
2
2
2
1
1
1
1
1
1
1
PROGESTATIONAL AGENTS
medroxyprogesterone acetate
medroxyprogesterone acetate
medroxyprogesterone acetate
norethindrone acetate
PROGESTERONE,MICRONIZED
progesterone,micronized
progesterone,micronized
(PROVERA (10 MG)
(TABLET) )
(PROVERA (2.5 MG)
(TABLET) )
(PROVERA (5 MG)
(TABLET) )
(AYGESTIN (5 MG)
(TABLET) )
(CRINONE (4 %)
(GEL/PF APP) )
(PROMETRIUM
(100 MG)
(CAPSULE) )
(PROMETRIUM
(200 MG)
(CAPSULE) )
1
1
1
2
3
2
2
IMMUNIZATION
ANTISERA
IGG/HYALURONIDASE,RECOMBINANT
IGG/HYALURONIDASE,RECOMBINANT
IGG/HYALURONIDASE,RECOMBINANT
IGG/HYALURONIDASE,RECOMBINANT
IGG/HYALURONIDASE,RECOMBINANT
IMMUN GLOB G(IGG)/PRO/IGA 0-50
Sharp Health Plan: Covered California
(HYQVIA (10
G/100ML) (VIAL) )
(HYQVIA
(2.5G/25ML)
(VIAL) )
(HYQVIA (20
G/200ML) (VIAL) )
(HYQVIA (30
G/300ML) (VIAL) )
(HYQVIA (5 G/50
ML) (VIAL) )
(HIZENTRA (1 G/5
ML) (VIAL) )
MB
MB
MB
MB
MB
MB
Page 111 of 224
Sharp Health Plan: Covered California
Drug Name
IMMUN GLOB G(IGG)/PRO/IGA 0-50
IMMUN GLOB G(IGG)/PRO/IGA 0-50
IMMUN GLOB G(IGG)/PRO/IGA 0-50
Drug Tier Requirements/Limits
(HIZENTRA (10
G/50 ML) (VIAL) )
(HIZENTRA (2 G/10
ML) (VIAL) )
(HIZENTRA (4 G/20
ML) (VIAL) )
MB
MB
MB
IMMUNOSUPPRESSION/MODULATION
IMMUNOMODULATORS
imiquimod
IMIQUIMOD
IMIQUIMOD
IMIQUIMOD
INTERFERON ALFA-2B,RECOMB.
INTERFERON ALFA-2B,RECOMB.
INTERFERON ALFA-2B,RECOMB.
INTERFERON ALFA-2B,RECOMB.
INTERFERON ALFA-2B,RECOMB.
(ALDARA (5 %)
(CREAM PACK) )
(ZYCLARA (2.5 %)
(CRM MD PMP) )
(ZYCLARA (3.75 %)
(CREAM PACK) )
(ZYCLARA (3.75 %)
(CRM MD PMP) )
(INTRON A (10MM
UNIT) (VIAL) )
(INTRON A
(10MM/ML)
(VIAL) )
(INTRON A (18MM
UNIT) (VIAL) )
(INTRON A (50MM
UNIT) (VIAL) )
(INTRON A
(6MMUNIT/ML)
(VIAL) )
1
QL: 24 IN 30 DAYS
3
PA
3
PA
3
PA
MB
MB
MB
MB
MB
IMMUNOSUPPRESSIVES
AZATHIOPRINE
AZATHIOPRINE
azathioprine
cyclosporine
CYCLOSPORINE
cyclosporine
CYCLOSPORINE
(AZASAN (100 MG)
(TABLET) )
(AZASAN (75 MG)
(TABLET) )
(IMURAN (50 MG)
(TABLET) )
(SANDIMMUNE
(100 MG)
(CAPSULE) )
(SANDIMMUNE
(100 MG/ML)
(SOLUTION) )
(SANDIMMUNE (25
MG) (CAPSULE) )
(SANDIMMUNE (25
MG) (CAPSULE) )
cyclosporine, modified (50 mg) (capsule)
cyclosporine, modified
cyclosporine, modified
cyclosporine, modified
cyclosporine, modified
EVEROLIMUS
EVEROLIMUS
Sharp Health Plan: Covered California
2
2
1
1
1
1
1
1
(GENGRAF (50 MG)
(CAPSULE) )
(NEORAL (100 MG)
(CAPSULE) )
(NEORAL (100
MG/ML)
(SOLUTION) )
(NEORAL (25 MG)
(CAPSULE) )
(ZORTRESS (0.25
MG) (TABLET) )
(ZORTRESS (0.5
MG) (TABLET) )
1
1
1
1
3
PA
4
PA
Page 112 of 224
Sharp Health Plan: Covered California
Drug Name
EVEROLIMUS
mycophenolate mofetil
mycophenolate mofetil
mycophenolate mofetil
mycophenolate sodium
mycophenolate sodium
sirolimus
sirolimus
SIROLIMUS
sirolimus
TACROLIMUS
TACROLIMUS
TACROLIMUS
TACROLIMUS
TACROLIMUS
TACROLIMUS
tacrolimus
tacrolimus
tacrolimus
Drug Tier Requirements/Limits
(ZORTRESS (0.75
MG) (TABLET) )
(CELLCEPT (200
MG/ML) (SUSP
RECON) )
(CELLCEPT (250
MG) (CAPSULE) )
(CELLCEPT (500
MG) (TABLET) )
(MYFORTIC (180
MG) (TABLET DR) )
(MYFORTIC (360
MG) (TABLET DR) )
(RAPAMUNE (0.5
MG) (TABLET) )
(RAPAMUNE (1
MG) (TABLET) )
(RAPAMUNE (1
MG/ML)
(SOLUTION) )
(RAPAMUNE (2
MG) (TABLET) )
(ASTAGRAF XL (0.5
MG) (CAP ER 24H) )
(ASTAGRAF XL (1
MG) (CAP ER 24H) )
(ASTAGRAF XL (5
MG) (CAP ER 24H) )
(ENVARSUS XR
(0.75 MG) (TAB ER
24H) )
(ENVARSUS XR (1
MG) (TAB ER 24H) )
(ENVARSUS XR (4
MG) (TAB ER 24H) )
(PROGRAF (0.5 MG)
(CAPSULE) )
(PROGRAF (1 MG)
(CAPSULE) )
(PROGRAF (5 MG)
(CAPSULE) )
4
PA
4
PA
1
PA
4
PA
2
2
2
PA
4
PA
4
PA
4
PA
3
3
3
4
4
4
1
1
1
INFECTIOUS DISEASE - BACTERIAL
ABSORBABLE SULFONAMIDES
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
(BACTRIM (400MG80MG) (TABLET) )
(BACTRIM DS (800160 MG) (TABLET) )
sulfamethoxazole/trimethoprim (200-40mg/5) (oral
susp)
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
1
1
1
(SULFATRIM (20040MG/5) (ORAL
SUSP) )
(SULFATRIM (800160/20) (ORAL
SUSP) )
1
2
BETALACTAMS
aztreonam
Sharp Health Plan: Covered California
(AZACTAM (1 G)
(VIAL) )
MB
Page 113 of 224
Sharp Health Plan: Covered California
Drug Name
AZTREONAM LYSINE
Drug Tier Requirements/Limits
(CAYSTON (75
MG/ML) (VIALNEB) )
4
CARBAPENEMS (THIENAMYCINS)
ERTAPENEM SODIUM
ERTAPENEM SODIUM
(INVANZ (1 G)
(VIAL PORT) )
(INVANZ (1 G)
(VIAL) )
MB
MB
CEPHALOSPORINS - 1ST GENERATION
cefadroxil
cefadroxil
cefadroxil
cefadroxil
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
(DURICEF (1 G)
(TABLET) )
(DURICEF (250
MG/5ML) (SUSP
RECON) )
(DURICEF (500 MG)
(CAPSULE) )
(DURICEF (500
MG/5ML) (SUSP
RECON) )
(KEFLEX (125
MG/5ML) (SUSP
RECON) )
(KEFLEX (250 MG)
(CAPSULE) )
(KEFLEX (250 MG)
(TABLET) )
(KEFLEX (250
MG/5ML) (SUSP
RECON) )
(KEFLEX (500 MG)
(CAPSULE) )
(KEFLEX (500 MG)
(TABLET) )
(KEFLEX (750 MG)
(CAPSULE) )
2
2
2
2
1
1
1
1
1
1
1
CEPHALOSPORINS - 2ND GENERATION
cefaclor
cefaclor
cefaclor
cefaclor
cefaclor
cefaclor
cefprozil
cefprozil
cefprozil
Sharp Health Plan: Covered California
(CECLOR (125
MG/5ML) (SUSP
RECON) )
(CECLOR (250 MG)
(CAPSULE) )
(CECLOR (250
MG/5ML) (SUSP
RECON) )
(CECLOR (375
MG/5ML) (SUSP
RECON) )
(CECLOR (500 MG)
(CAPSULE) )
(CECLOR CD (500
MG) (TAB ER 12H) )
(CEFZIL (125
MG/5ML) (SUSP
RECON) )
(CEFZIL (250 MG)
(TABLET) )
(CEFZIL (250
MG/5ML) (SUSP
RECON) )
2
2
2
2
2
2
1
1
1
Page 114 of 224
Sharp Health Plan: Covered California
Drug Name
cefprozil
CEFUROXIME AXETIL
cefuroxime axetil
CEFUROXIME AXETIL
cefuroxime axetil
Drug Tier Requirements/Limits
(CEFZIL (500 MG)
(TABLET) )
(CEFTIN (125
MG/5ML) (SUSP
RECON) )
(CEFTIN (250 MG)
(TABLET) )
(CEFTIN (250
MG/5ML) (SUSP
RECON) )
(CEFTIN (500 MG)
(TABLET) )
1
2
1
2
1
CEPHALOSPORINS - 3RD GENERATION
cefdinir
cefdinir
cefdinir
cefditoren pivoxil
cefditoren pivoxil
CEFIXIME
cefixime
CEFIXIME
cefixime
CEFIXIME
CEFIXIME
cefpodoxime proxetil
cefpodoxime proxetil
cefpodoxime proxetil
cefpodoxime proxetil
ceftibuten
ceftibuten
(OMNICEF (125
MG/5ML) (SUSP
RECON) )
(OMNICEF (250
MG/5ML) (SUSP
RECON) )
(OMNICEF (300
MG) (CAPSULE) )
(SPECTRACEF (200
MG) (TABLET) )
(SPECTRACEF (400
MG) (TABLET) )
(SUPRAX (100 MG)
(TAB CHEW) )
(SUPRAX (100
MG/5ML) (SUSP
RECON) )
(SUPRAX (200 MG)
(TAB CHEW) )
(SUPRAX (200
MG/5ML) (SUSP
RECON) )
(SUPRAX (400 MG)
(CAPSULE) )
(SUPRAX (500
MG/5ML) (SUSP
RECON) )
(VANTIN (100 MG)
(TABLET) )
(VANTIN (100
MG/5ML) (SUSP
RECON) )
(VANTIN (200 MG)
(TABLET) )
(VANTIN (50 MG/5
ML) (SUSP
RECON) )
(CEDAX (180
MG/5ML) (SUSP
RECON) )
(CEDAX (400 MG)
(CAPSULE) )
1
1
1
2
2
3
2
3
2
3
3
2
2
2
2
2
2
CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.
FOSFOMYCIN TROMETHAMINE
meth/meblue/sod phos/psal/hyos (118-10-36)
(capsule)
Sharp Health Plan: Covered California
(MONUROL (3 G)
(PACKET) )
3
2
Page 115 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
meth/meblue/sod phos/psal/hyos (81.6-10.8) (tablet)
meth/meblue/sod phos/psal/hyos (81-0.12mg) (tablet)
METH/MEBLUE/SOD PHOS/PSAL/HYOS
METH/MEBLUE/SOD PHOS/PSAL/HYOS
METH/MEBLUE/SOD PHOS/PSAL/HYOS
1
2
(PHOSPHASAL
(81.6-10.8)
(TABLET) )
(URETRON D-S
(81.6-10.8)
(TABLET) )
(URIN D.S. (81.610.8) (TABLET) )
methen/m-blue/sal/na phos/hyos (120-0.12mg)
(tablet)
methen/m-blue/sal/na phos/hyos
methen/sod phos/meth blue/hyos
methen/sod phos/meth blue/hyos
methenamine mandelate
methenamine mandelate
TRIMETHOPRIM
trimethoprim
2
2
2
(UTA (120-0.12MG)
(CAPSULE) )
(URYL (81.6-.12MG)
(TABLET) )
(UTA (120-40.8MG)
(CAPSULE) )
methenam/me blue/ba/salicy/hyo (81.6-0.12) (tablet)
methenamine hippurate
2
2
2
2
2
(HIPREX (1 G)
(TABLET) )
(MANDELAMINE (1
G) (TABLET) )
(MANDELAMINE
(500 MG)
(TABLET) )
(PRIMSOL (50 MG/5
ML) (SOLUTION) )
(PROLOPRIM (100
MG) (TABLET) )
1
2
2
3
2
KETOLIDES
TELITHROMYCIN
TELITHROMYCIN
(KETEK (300 MG)
(TABLET) )
(KETEK (400 MG)
(TABLET) )
3
3
MACROLIDES
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
AZITHROMYCIN
clarithromycin
clarithromycin
Sharp Health Plan: Covered California
(ZITHROMAX (1 G)
(PACKET) )
(ZITHROMAX (100
MG/5ML) (SUSP
RECON) )
(ZITHROMAX (200
MG/5ML) (SUSP
RECON) )
(ZITHROMAX (250
MG) (TABLET) )
(ZITHROMAX (500
MG) (TABLET) )
(ZITHROMAX (600
MG) (TABLET) )
(ZITHROMAX TRIPAK (500 MG)
(TABLET) )
(ZMAX (2 G/60 ML)
(SUS ER REC) )
(BIAXIN (125
MG/5ML) (SUSP
RECON) )
(BIAXIN (250 MG)
(TABLET) )
1
QL: 9 IN 30 DAYS
1
QL: 15 PER FILL
1
QL: 1 IN 5 DAYS
1
QL: 6 PER FILL
1
1
QL: 8 IN 30 DAYS
1
3
1
1
Page 116 of 224
Sharp Health Plan: Covered California
Drug Name
clarithromycin
clarithromycin
clarithromycin
erythromycin base
ERYTHROMYCIN BASE
erythromycin base
erythromycin base
Drug Tier Requirements/Limits
(BIAXIN (250
MG/5ML) (SUSP
RECON) )
(BIAXIN (500 MG)
(TABLET) )
(BIAXIN XL (500
MG) (TAB ER 24H) )
(ERYC (250 MG)
(CAPSULE DR) )
(ERY-TAB (333 MG)
(TABLET DR) )
(ERYTHRCIN
STEARATE (250
MG) (TABLET) )
(ERYTHRCIN
STEARATE (500
MG) (TABLET) )
erythromycin base (250 mg) (tablet dr)
erythromycin base (500 mg) (tablet dr)
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
erythromycin ethylsuccinate
erythromycin ethylsuccinate
ERYTHROMYCIN ETHYLSUCCINATE
FIDAXOMICIN
1
1
1
2
1
1
1
1
(PCE (333 MG) (TAB
PART) )
(PCE (500 MG) (TAB
PART) )
(E.E.S. 400 (400 MG)
(TABLET) )
(ERYPED 200 (200
MG/5ML) (SUSP
RECON) )
(ERYPED 400 (400
MG/5ML) (SUSP
RECON) )
erythromycin ethylsuccinate (400 mg) (tablet)
erythromycin stearate
1
2
2
1
2
2
1
(ERYTHRCIN
STEARATE (250
MG) (TABLET) )
(DIFICID (200 MG)
(TABLET) )
1
3
PA
NITROFURAN DERIVATIVES
nitrofurantoin
nitrofurantoin macrocrystal
nitrofurantoin macrocrystal
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst
(FURADANTIN (25
MG/5 ML) (ORAL
SUSP) )
(MACRODANTIN
(100 MG)
(CAPSULE) )
(MACRODANTIN
(25 MG)
(CAPSULE) )
(MACRODANTIN
(50 MG)
(CAPSULE) )
(MACROBID (100
MG) (CAPSULE) )
1
1
1
1
1
OXAZOLIDINONES
linezolid
linezolid
TEDIZOLID PHOSPHATE
Sharp Health Plan: Covered California
(ZYVOX (100
MG/5ML) (SUSP
RECON) )
(ZYVOX (600 MG)
(TABLET) )
(SIVEXTRO (200
MG) (TABLET) )
4
PA
4
PA
4
PA
Page 117 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
PENICILLINS
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
AMOXICILLIN/POTASSIUM CLAV
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
amoxicillin/potassium clav
ampicillin trihydrate
Sharp Health Plan: Covered California
(AMOXIL (125 MG)
(TAB CHEW) )
(AMOXIL (125
MG/5ML) (SUSP
RECON) )
(AMOXIL (200
MG/5ML) (SUSP
RECON) )
(AMOXIL (250 MG)
(CAPSULE) )
(AMOXIL (250 MG)
(TAB CHEW) )
(AMOXIL (250
MG/5ML) (SUSP
RECON) )
(AMOXIL (400
MG/5ML) (SUSP
RECON) )
(AMOXIL (500 MG)
(CAPSULE) )
(AMOXIL (500 MG)
(TABLET) )
(AMOXIL (875 MG)
(TABLET) )
(MOXATAG (775
MG) (TBMP 24HR) )
(AUGMENTIN (12531.25/) (SUSP
RECON) )
(AUGMENTIN (20028.5/5) (SUSP
RECON) )
(AUGMENTIN (20028.5MG) (TAB
CHEW) )
(AUGMENTIN (250125 MG) (TABLET) )
(AUGMENTIN (25062.5/5) (SUSP
RECON) )
(AUGMENTIN (40057MG) (TAB
CHEW) )
(AUGMENTIN (40057MG/5) (SUSP
RECON) )
(AUGMENTIN (500125 MG) (TABLET) )
(AUGMENTIN (875125 MG) (TABLET) )
(AUGMENTIN ES600 (600-42.9/5)
(SUSP RECON) )
(AUGMENTIN XR
(1000-62.5) (TAB ER
12H) )
(AMPICILLIN (125
MG/5ML) (SUSP
RECON) )
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
2
1
Page 118 of 224
Sharp Health Plan: Covered California
Drug Name
ampicillin trihydrate
ampicillin trihydrate
ampicillin trihydrate
dicloxacillin sodium
dicloxacillin sodium
Drug Tier Requirements/Limits
(AMPICILLIN (250
MG) (CAPSULE) )
(AMPICILLIN (250
MG/5ML) (SUSP
RECON) )
(AMPICILLIN (500
MG) (CAPSULE) )
(PATHOCIL (250
MG) (CAPSULE) )
(PATHOCIL (500
MG) (CAPSULE) )
penicillin v potassium (500 mg) (tablet)
penicillin v potassium
penicillin v potassium
penicillin v potassium
1
1
1
1
1
1
(VEETIDS (125
MG/5ML) (SOLN
RECON) )
(VEETIDS (250 MG)
(TABLET) )
(VEETIDS (250
MG/5ML) (SOLN
RECON) )
1
1
1
QUINOLONES
ciprofloxacin
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin/ciprofloxa hcl
ciprofloxacin/ciprofloxa hcl
GEMIFLOXACIN MESYLATE
levofloxacin
levofloxacin
levofloxacin
levofloxacin
moxifloxacin hcl
moxifloxacin hcl
ofloxacin
Sharp Health Plan: Covered California
(CIPRO (250
MG/5ML) (SUS MC
REC) )
(CIPRO (500
MG/5ML) (SUS MC
REC) )
(CIPRO (100 MG)
(TABLET) )
(CIPRO (250 MG)
(TABLET) )
(CIPRO (500 MG)
(TABLET) )
(CIPRO (750 MG)
(TABLET) )
(CIPRO XR (1000
MG) (TBMP 24HR) )
(CIPRO XR (500
MG) (TBMP 24HR) )
(FACTIVE (320 MG)
(TABLET) )
(LEVAQUIN (250
MG) (TABLET) )
(LEVAQUIN
(250MG/10ML)
(SOLUTION) )
(LEVAQUIN (500
MG) (TABLET) )
(LEVAQUIN (750
MG) (TABLET) )
(AVELOX (400 MG)
(TABLET) )
(AVELOX ABC
PACK (400 MG)
(TABLET) )
(FLOXIN (400 MG)
(TABLET) )
1
1
1
1
1
1
2
2
3
1
1
1
1
1
PA
1
PA
2
Page 119 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
TETRACYCLINES
demeclocycline hcl
demeclocycline hcl
DOXYCYCLINE CALCIUM
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
doxycycline hyclate
doxycycline hyclate
doxycycline hyclate
doxycycline hyclate
doxycycline hyclate
DOXYCYCLINE HYCLATE
doxycycline hyclate
doxycycline hyclate
DOXYCYCLINE HYCLATE
doxycycline hyclate
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
Sharp Health Plan: Covered California
(DECLOMYCIN
(150 MG)
(TABLET) )
(DECLOMYCIN
(300 MG)
(TABLET) )
(VIBRAMYCIN (50
MG/5 ML)
(SYRUP) )
(ACTICLATE (150
MG) (TABLET) )
(ACTICLATE (75
MG) (TABLET) )
(DORYX (100 MG)
(TABLET DR) )
(DORYX (150 MG)
(TABLET DR) )
(DORYX (200 MG)
(TABLET DR) )
(DORYX (50 MG)
(TABLET DR) )
(DORYX (75 MG)
(TABLET DR) )
(DORYX MPC (120
MG) (TABLET DR) )
(MORGIDOX (100
MG) (CAPSULE) )
(MORGIDOX (50
MG) (CAPSULE) )
(TARGADOX (50
MG) (TABLET) )
(VIBRAMYCIN (100
MG) (CAPSULE) )
(VIBRA-TABS (100
MG) (TABLET) )
(ADOXA (150 MG)
(CAPSULE) )
(ADOXA (150 MG)
(TABLET) )
(AVIDOXY (100
MG) (TABLET) )
(MONDOXYNE NL
(100 MG)
(CAPSULE) )
(MONDOXYNE NL
(50 MG)
(CAPSULE) )
(MONDOXYNE NL
(75 MG)
(CAPSULE) )
(MONODOX (100
MG) (CAPSULE) )
(MONODOX (50
MG) (CAPSULE) )
(MONODOX (50
MG) (TABLET) )
(MONODOX (75
MG) (CAPSULE) )
1
1
3
3
3
2
2
2
QL: 30 IN 30 DAYS
2
QL: 60 IN 30 DAYS
2
3
QL: 60 IN 30 DAYS
1
1
3
ST, QL: 4 IN 1 DAY
1
1
2
2
2
2
2
2
2
2
2
2
Page 120 of 224
Sharp Health Plan: Covered California
Drug Name
doxycycline monohydrate
doxycycline monohydrate
doxycycline monohydrate
minocycline hcl
minocycline hcl
minocycline hcl
minocycline hcl
minocycline hcl
minocycline hcl
MINOCYCLINE HCL
MINOCYCLINE HCL
minocycline hcl
minocycline hcl
MINOCYCLINE HCL
MINOCYCLINE HCL
MINOCYCLINE HCL
minocycline hcl
tetracycline hcl
tetracycline hcl
Drug Tier Requirements/Limits
(MONODOX (75
MG) (TABLET) )
(ORACEA (40 MG)
(CAP IR DR) )
(VIBRAMYCIN (25
MG/5 ML) (SUSP
RECON) )
(DYNACIN (100
MG) (TABLET) )
(DYNACIN (50 MG)
(TABLET) )
(DYNACIN (75 MG)
(TABLET) )
(MINOCIN (100
MG) (CAPSULE) )
(MINOCIN (50 MG)
(CAPSULE) )
(MINOCIN (75 MG)
(CAPSULE) )
(SOLODYN (105
MG) (TAB ER 24H) )
(SOLODYN
(115MG) (TAB ER
24H) )
(SOLODYN (135
MG) (TAB ER 24H) )
(SOLODYN (45 MG)
(TAB ER 24H) )
(SOLODYN (55 MG)
(TAB ER 24H) )
(SOLODYN (65 MG)
(TAB ER 24H) )
(SOLODYN (80 MG)
(TAB ER 24H) )
(SOLODYN (90 MG)
(TAB ER 24H) )
(PANMYCIN (250
MG) (CAPSULE) )
(SUMYCIN (500
MG) (CAPSULE) )
2
2
1
2
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
1
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
4
AGE: <= 26 YEARS
2
AGE: <= 26 YEARS
1
1
INFECTIOUS DISEASE - FUNGAL
ANTIFUNGAL AGENTS
clotrimazole
fluconazole
fluconazole
fluconazole
fluconazole
fluconazole
fluconazole
flucytosine
Sharp Health Plan: Covered California
(MYCELEX (10 MG)
(TROCHE) )
(DIFLUCAN (10
MG/ML) (SUSP
RECON) )
(DIFLUCAN (100
MG) (TABLET) )
(DIFLUCAN (150
MG) (TABLET) )
(DIFLUCAN (200
MG) (TABLET) )
(DIFLUCAN (40
MG/ML) (SUSP
RECON) )
(DIFLUCAN (50
MG) (TABLET) )
(ANCOBON (250
MG) (CAPSULE) )
1
1
1
QL: 4 IN 30 DAYS
1
QL: 3 IN 30 DAYS
1
1
2
1
Page 121 of 224
Sharp Health Plan: Covered California
Drug Name
flucytosine
ISAVUCONAZONIUM SULFATE
ITRACONAZOLE
ITRACONAZOLE
itraconazole
ketoconazole
MICONAZOLE
POSACONAZOLE
POSACONAZOLE
terbinafine hcl
voriconazole
voriconazole
voriconazole
Drug Tier Requirements/Limits
(ANCOBON (500
MG) (CAPSULE) )
(CRESEMBA (186
MG) (CAPSULE) )
(ONMEL (200 MG)
(TABLET) )
(SPORANOX (10
MG/ML)
(SOLUTION) )
(SPORANOX (100
MG) (CAPSULE) )
(NIZORAL (200
MG) (TABLET) )
(ORAVIG (50 MG)
(MA BUC TAB) )
(NOXAFIL (100 MG)
(TABLET DR) )
(NOXAFIL (200
MG/5ML) (ORAL
SUSP) )
(LAMISIL (250 MG)
(TABLET) )
(VFEND (200 MG)
(TABLET) )
(VFEND (200
MG/5ML) (SUSP
RECON) )
(VFEND (50 MG)
(TABLET) )
1
4
3
3
2
1
3
4
PA
4
PA
1
4
PA
4
PA
4
PA
ANTIFUNGAL ANTIBIOTICS
griseofulvin ultramicrosize
griseofulvin ultramicrosize
griseofulvin, microsize
griseofulvin, microsize
nystatin
nystatin
nystatin
(GRIS-PEG (125
MG) (TABLET) )
(GRIS-PEG (250
MG) (TABLET) )
(GRIFULVIN V (125
MG/5ML) (ORAL
SUSP) )
(GRIFULVIN V (500
MG) (TABLET) )
(MYCOSTATIN
(100000/ML) (ORAL
SUSP) )
(MYCOSTATIN
(150MM UNIT)
(POWDER(EA)) )
(MYCOSTATIN
(500K UNIT)
(TABLET) )
nystatin (500mm unit) (powder(ea))
nystatin (50mm unit) (powder(ea))
1
1
1
1
1
2
1
2
2
INFECTIOUS DISEASE - MISCELLANEOUS
AMINOGLYCOSIDES
neomycin sulfate (500 mg) (tablet)
TOBRAMYCIN
TOBRAMYCIN
Sharp Health Plan: Covered California
1
(BETHKIS (300
MG/4ML) (AMPULNEB) )
(TOBI PODHALER
(28 MG) (CAP
W/DEV) )
3
PA
3
Page 122 of 224
Sharp Health Plan: Covered California
Drug Name
TOBRAMYCIN
tobramycin in 0.225% nacl
Drug Tier Requirements/Limits
(TOBI PODHALER
(28 MG)
(CAPSULE) )
(TOBI (300
MG/5ML) (AMPULNEB) )
tobramycin sulfate (1.2 g) (vial)
tobramycin sulfate (10 mg/ml) (vial)
tobramycin sulfate (40 mg/ml) (vial)
TOBRAMYCIN/NEBULIZER
(KITABIS PAK (300
MG/5ML) (AMPULNEB) )
3
2
PA
4
4
4
PA
PA
PA
3
PA
ANTILEPROTICS
dapsone (100 mg) (tablet)
dapsone (25 mg) (tablet)
THALIDOMIDE
THALIDOMIDE
THALIDOMIDE
THALIDOMIDE
1
1
(THALOMID (100
MG) (CAPSULE) )
(THALOMID (150
MG) (CAPSULE) )
(THALOMID (200
MG) (CAPSULE) )
(THALOMID (50
MG) (CAPSULE) )
2
PA
2
PA
2
PA
2
PA
ANTI-MYCOBACTERIUM AGENTS
AMINOSALICYLIC ACID
ethambutol hcl
ethambutol hcl
ETHIONAMIDE
isoniazid
isoniazid
isoniazid
(PASER (4 G)
(GRANPKT DR) )
(MYAMBUTOL (100
MG) (TABLET) )
(MYAMBUTOL (400
MG) (TABLET) )
(TRECATOR (250
MG) (TABLET) )
(HYZYD (100 MG)
(TABLET) )
(HYZYD (300 MG)
(TABLET) )
(RIMIFON (50 MG/5
ML) (SOLUTION) )
pyrazinamide (500 mg) (tablet)
rifabutin
3
1
1
3
1
1
1
1
(MYCOBUTIN (150
MG) (CAPSULE) )
2
ANTITUBERCULAR ANTIBIOTICS
BEDAQUILINE FUMARATE
cycloserine
RIFAMP/ISONIAZID/PYRAZINAMIDE
rifampin
rifampin
RIFAMPIN/ISONIAZID
RIFAPENTINE
Sharp Health Plan: Covered California
(SIRTURO (100 MG)
(TABLET) )
(SEROMYCIN (250
MG) (CAPSULE) )
(RIFATER (120-50300) (TABLET) )
(RIFADIN (150 MG)
(CAPSULE) )
(RIFADIN (300 MG)
(CAPSULE) )
(RIFAMATE (300150 MG)
(CAPSULE) )
(PRIFTIN (150 MG)
(TABLET) )
3
2
3
1
1
3
3
Page 123 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
LINCOSAMIDES
clindamycin hcl
clindamycin hcl
clindamycin hcl
clindamycin palmitate hcl
(CLEOCIN HCL
(150 MG)
(CAPSULE) )
(CLEOCIN HCL
(300 MG)
(CAPSULE) )
(CLEOCIN HCL (75
MG) (CAPSULE) )
(CLEOCIN
PALMITATE (75
MG/5 ML) (SOLN
RECON) )
1
1
1
2
RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS
RIFAXIMIN
RIFAXIMIN
(XIFAXAN (200
MG) (TABLET) )
(XIFAXAN (550
MG) (TABLET) )
4
4
PA
4
PA
4
PA
VANCOMYCIN AND DERIVATIVES
vancomycin hcl
vancomycin hcl
(VANCOCIN HCL
(125 MG)
(CAPSULE) )
(VANCOCIN HCL
(250 MG)
(CAPSULE) )
INFECTIOUS DISEASE - PARASITIC
2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL
tinidazole
tinidazole
(TINDAMAX (250
MG) (TABLET) )
(TINDAMAX (500
MG) (TABLET) )
2
2
AMEBACIDES
paromomycin sulfate
(HUMATIN (250
MG) (CAPSULE) )
2
ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS
metronidazole
metronidazole
metronidazole
METRONIDAZOLE
(FLAGYL (250 MG)
(TABLET) )
(FLAGYL (375 MG)
(CAPSULE) )
(FLAGYL (500 MG)
(TABLET) )
(FLAGYL ER (750
MG) (TABLET ER) )
1
2
1
3
ANTHELMINTICS
ALBENDAZOLE
ivermectin
MEBENDAZOLE
PRAZIQUANTEL
(ALBENZA (200
MG) (TABLET) )
(STROMECTOL (3
MG) (TABLET) )
(EMVERM (100
MG) (TAB CHEW) )
(BILTRICIDE (600
MG) (TABLET) )
3
2
3
PA
2
ANTIMALARIAL DRUGS
ARTEMETHER/LUMEFANTRINE
atovaquone/proguanil hcl
Sharp Health Plan: Covered California
(COARTEM (20MG120MG) (TABLET) )
(MALARONE (250100 MG) (TABLET) )
3
2
Page 124 of 224
Sharp Health Plan: Covered California
Drug Name
atovaquone/proguanil hcl
chloroquine phosphate
Drug Tier Requirements/Limits
(MALARONE (62.525 MG) (TABLET) )
(ARALEN (500 MG)
(TABLET) )
chloroquine phosphate (250 mg) (tablet)
hydroxychloroquine sulfate
mefloquine hcl
PRIMAQUINE PHOSPHATE
PYRIMETHAMINE
quinine sulfate
2
1
1
(PLAQUENIL (200
MG) (TABLET) )
(LARIAM (250 MG)
(TABLET) )
(PRIMAQUINE (26.3
MG) (TABLET) )
(DARAPRIM (25
MG) (TABLET) )
(QUALAQUIN (324
MG) (CAPSULE) )
1
2
2
4
PA
1
ANTIPROTOZOAL DRUGS,MISCELLANEOUS
atovaquone
MILTEFOSINE
PENTAMIDINE ISETHIONATE
(MEPRON (750
MG/5ML) (ORAL
SUSP) )
(IMPAVIDO (50 MG)
(CAPSULE) )
(NEBUPENT (300
MG) (VIAL-NEB) )
2
4
PA, QL: 84 IN 28 DAYS
3
INFECTIOUS DISEASE - VIRAL
ANTIVIRALS, GENERAL
ACYCLOVIR
acyclovir
acyclovir
acyclovir
acyclovir
famciclovir
famciclovir
famciclovir
OSELTAMIVIR PHOSPHATE
OSELTAMIVIR PHOSPHATE
OSELTAMIVIR PHOSPHATE
OSELTAMIVIR PHOSPHATE
rimantadine hcl
valacyclovir hcl
valacyclovir hcl
valganciclovir hcl
Sharp Health Plan: Covered California
(SITAVIG (50 MG)
(MA BUC TAB) )
(ZOVIRAX (200
MG) (CAPSULE) )
(ZOVIRAX (200
MG/5ML) (ORAL
SUSP) )
(ZOVIRAX (400
MG) (TABLET) )
(ZOVIRAX (800
MG) (TABLET) )
(FAMVIR (125 MG)
(TABLET) )
(FAMVIR (250 MG)
(TABLET) )
(FAMVIR (500 MG)
(TABLET) )
(TAMIFLU (30 MG)
(CAPSULE) )
(TAMIFLU (45 MG)
(CAPSULE) )
(TAMIFLU (6
MG/ML) (SUSP
RECON) )
(TAMIFLU (75 MG)
(CAPSULE) )
(FLUMADINE (100
MG) (TABLET) )
(VALTREX (1000
MG) (TABLET) )
(VALTREX (500
MG) (TABLET) )
(VALCYTE (450
MG) (TABLET) )
3
ST, QL: 4 FILLS PER YEAR
1
1
1
1
1
ST
1
ST
1
ST
2
2
2
2
2
1
ST
1
ST
1
Page 125 of 224
Sharp Health Plan: Covered California
Drug Name
valganciclovir hcl
ZANAMIVIR
Drug Tier Requirements/Limits
(VALCYTE (50
MG/ML) (SOLN
RECON) )
(RELENZA (5 MG)
(BLST W/DEV) )
1
PA
2
QL: 1 IN 365 DAYS
ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB
DARUNAVIR ETHANOLATE
DARUNAVIR ETHANOLATE
DARUNAVIR ETHANOLATE
DARUNAVIR ETHANOLATE
DARUNAVIR ETHANOLATE
DARUNAVIR/COBICISTAT
TIPRANAVIR
TIPRANAVIR/VITAMIN E TPGS
(PREZISTA (100
MG/ML) (ORAL
SUSP) )
(PREZISTA (150
MG) (TABLET) )
(PREZISTA (600
MG) (TABLET) )
(PREZISTA (75 MG)
(TABLET) )
(PREZISTA (800
MG) (TABLET) )
(PREZCOBIX (800150 MG) (TABLET) )
(APTIVUS (250 MG)
(CAPSULE) )
(APTIVUS (100
MG/ML)
(SOLUTION) )
3
PA
3
PA
4
PA
3
PA
4
PA
4
4
PA
3
PA
ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG
EMTRICITABINE/TENOFOV ALAFENAM
EMTRICITABINE/TENOFOVIR
EMTRICITABINE/TENOFOVIR
EMTRICITABINE/TENOFOVIR
EMTRICITABINE/TENOFOVIR
(DESCOVY
(200MG-25MG)
(TABLET) )
(TRUVADA (100-150
MG) (TABLET) )
(TRUVADA (133-200
MG) (TABLET) )
(TRUVADA (167-250
MG) (TABLET) )
(TRUVADA (200-300
MG) (TABLET) )
4
PA, QL: 1 IN 1 DAY
2
PA
2
PA
2
PA
2
PA
ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB
abacavir sulfate/lamivudine
abacavir/lamivudine/zidovudine
lamivudine/zidovudine
(EPZICOM (600300MG) (TABLET) )
(TRIZIVIR (150300MG) (TABLET) )
(COMBIVIR (150300MG) (TABLET) )
4
PA
4
PA
4
PA
ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.
MARAVIROC
MARAVIROC
(SELZENTRY (150
MG) (TABLET) )
(SELZENTRY (300
MG) (TABLET) )
2
PA, QL: 2 IN 1 DAY
2
PA, QL: 4 IN 1 DAY
ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS
ENFUVIRTIDE
(FUZEON (90 MG)
(VIAL) )
MB
ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI
DELAVIRDINE MESYLATE
DELAVIRDINE MESYLATE
EFAVIRENZ
Sharp Health Plan: Covered California
(RESCRIPTOR (100
MG) (TAB
DISPER) )
(RESCRIPTOR (200
MG) (TABLET) )
(SUSTIVA (200 MG)
(CAPSULE) )
2
2
3
PA
Page 126 of 224
Sharp Health Plan: Covered California
Drug Name
EFAVIRENZ
EFAVIRENZ
ETRAVIRINE
ETRAVIRINE
ETRAVIRINE
nevirapine
nevirapine
nevirapine
nevirapine
RILPIVIRINE HCL
Drug Tier Requirements/Limits
(SUSTIVA (50 MG)
(CAPSULE) )
(SUSTIVA (600 MG)
(TABLET) )
(INTELENCE (100
MG) (TABLET) )
(INTELENCE (200
MG) (TABLET) )
(INTELENCE (25
MG) (TABLET) )
(VIRAMUNE (200
MG) (TABLET) )
(VIRAMUNE (50
MG/5 ML) (ORAL
SUSP) )
(VIRAMUNE XR
(100 MG) (TAB ER
24H) )
(VIRAMUNE XR
(400 MG) (TAB ER
24H) )
(EDURANT (25 MG)
(TABLET) )
3
PA
3
PA
4
PA
4
PA
3
PA
2
PA
2
PA
2
PA
2
PA
4
PA
ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI
ABACAVIR SULFATE
abacavir sulfate
DIDANOSINE
didanosine
didanosine
didanosine
didanosine
EMTRICITABINE
EMTRICITABINE
lamivudine
lamivudine
lamivudine
stavudine
stavudine
Sharp Health Plan: Covered California
(ZIAGEN (20
MG/ML)
(SOLUTION) )
(ZIAGEN (300 MG)
(TABLET) )
(VIDEX
(FNL10MG/ML)
(SOLN RECON) )
(VIDEX EC (125
MG) (CAPSULE
DR) )
(VIDEX EC (200
MG) (CAPSULE
DR) )
(VIDEX EC (250
MG) (CAPSULE
DR) )
(VIDEX EC (400
MG) (CAPSULE
DR) )
(EMTRIVA (10
MG/ML)
(SOLUTION) )
(EMTRIVA (200
MG) (CAPSULE) )
(EPIVIR (10
MG/ML)
(SOLUTION) )
(EPIVIR (150 MG)
(TABLET) )
(EPIVIR (300 MG)
(TABLET) )
(ZERIT (1 MG/ML)
(SOLN RECON) )
(ZERIT (15 MG)
(CAPSULE) )
3
PA
2
PA
2
1
1
1
1
3
3
1
1
1
1
1
Page 127 of 224
Sharp Health Plan: Covered California
Drug Name
stavudine
stavudine
stavudine
zidovudine
zidovudine
zidovudine
Drug Tier Requirements/Limits
(ZERIT (20 MG)
(CAPSULE) )
(ZERIT (30 MG)
(CAPSULE) )
(ZERIT (40 MG)
(CAPSULE) )
(RETROVIR (10
MG/ML) (SYRUP) )
(RETROVIR (100
MG) (CAPSULE) )
(RETROVIR (300
MG) (TABLET) )
1
1
1
1
1
1
ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI
TENOFOVIR DISOPROXIL FUMARATE
TENOFOVIR DISOPROXIL FUMARATE
TENOFOVIR DISOPROXIL FUMARATE
TENOFOVIR DISOPROXIL FUMARATE
TENOFOVIR DISOPROXIL FUMARATE
(VIREAD (150 MG)
(TABLET) )
(VIREAD (200 MG)
(TABLET) )
(VIREAD (250 MG)
(TABLET) )
(VIREAD (300 MG)
(TABLET) )
(VIREAD
(40MG/SCOOP)
(POWDER) )
4
PA
4
PA
4
PA
4
PA
4
PA
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB
LOPINAVIR/RITONAVIR
LOPINAVIR/RITONAVIR
LOPINAVIR/RITONAVIR
(KALETRA
(100MG-25MG)
(TABLET) )
(KALETRA
(200MG-50MG)
(TABLET) )
(KALETRA (400100/5)
(SOLUTION) )
2
PA
2
PA
2
PA
4
PA
4
PA
4
PA
4
PA
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS
ATAZANAVIR SULFATE
ATAZANAVIR SULFATE
ATAZANAVIR SULFATE
ATAZANAVIR SULFATE
ATAZANAVIR SULFATE/COBICISTAT
FOSAMPRENAVIR CALCIUM
FOSAMPRENAVIR CALCIUM
INDINAVIR SULFATE
INDINAVIR SULFATE
NELFINAVIR MESYLATE
NELFINAVIR MESYLATE
RITONAVIR
Sharp Health Plan: Covered California
(REYATAZ (150 MG)
(CAPSULE) )
(REYATAZ (200 MG)
(CAPSULE) )
(REYATAZ (300 MG)
(CAPSULE) )
(REYATAZ (50 MG)
(POWD PACK) )
(EVOTAZ (300-150
MG) (TABLET) )
(LEXIVA (50
MG/ML) (ORAL
SUSP) )
(LEXIVA (700 MG)
(TABLET) )
(CRIXIVAN (200
MG) (CAPSULE) )
(CRIXIVAN (400
MG) (CAPSULE) )
(VIRACEPT (250
MG) (TABLET) )
(VIRACEPT (625
MG) (TABLET) )
(NORVIR (100 MG)
(CAPSULE) )
4
3
PA
4
PA
2
2
3
PA
3
PA
2
Page 128 of 224
Sharp Health Plan: Covered California
Drug Name
RITONAVIR
RITONAVIR
SAQUINAVIR MESYLATE
SAQUINAVIR MESYLATE
Drug Tier Requirements/Limits
(NORVIR (100 MG)
(TABLET) )
(NORVIR (80
MG/ML)
(SOLUTION) )
(INVIRASE (200
MG) (CAPSULE) )
(INVIRASE (500
MG) (TABLET) )
2
2
4
PA
4
PA
ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR
DOLUTEGRAVIR SODIUM
DOLUTEGRAVIR SODIUM
DOLUTEGRAVIR SODIUM
ELVITEGRAVIR
ELVITEGRAVIR
RALTEGRAVIR POTASSIUM
RALTEGRAVIR POTASSIUM
RALTEGRAVIR POTASSIUM
RALTEGRAVIR POTASSIUM
(TIVICAY (10 MG)
(TABLET) )
(TIVICAY (25 MG)
(TABLET) )
(TIVICAY (50 MG)
(TABLET) )
(VITEKTA (150 MG)
(TABLET) )
(VITEKTA (85 MG)
(TABLET) )
(ISENTRESS (100
MG) (POWD
PACK) )
(ISENTRESS (100
MG) (TAB CHEW) )
(ISENTRESS (25
MG) (TAB CHEW) )
(ISENTRESS (400
MG) (TABLET) )
4
PA, QL: 60 IN 30 DAYS
4
PA, QL: 60 IN 30 DAYS
4
PA
4
PA, QL: 1 IN 1 DAY
4
PA, QL: 1 IN 1 DAY
2
PA
2
PA
2
PA
2
PA
ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI
EFAVIRENZ/EMTRICITAB/TENOFOVIR
EMTRICITAB/RILPIVIRI/TENOF ALA
EMTRICITAB/RILPIVIRINE/TENOFOV
(ATRIPLA (600200MG) (TABLET) )
(ODEFSEY (200-2525) (TABLET) )
(COMPLERA (20025-300) (TABLET) )
4
PA
4
PA, QL: 1 IN 1 DAY
4
PA
4
PA, QL: 1 IN 1 DAY
4
PA
2
PA, QL: 1 IN 1 DAY
3
PA
ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITOR
ELVITEG/COBI/EMTRIC/TENOFO ALA
ELVITEG/COBI/EMTRIC/TENOFO DIS
(GENVOYA (150200-10) (TABLET) )
(STRIBILD (150-200
MG) (TABLET) )
ARV COMB-NRTIS & INTEGRASE INHIBITOR
ABACAVIR/DOLUTEGRAVIR/LAMIVUDI
(TRIUMEQ (600-50300) (TABLET) )
CYTOCHROME P450 INHIBITORS
COBICISTAT
(TYBOST (150 MG)
(TABLET) )
HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.
LEDIPASVIR/SOFOSBUVIR
SOFOSBUVIR/VELPATASVIR
(HARVONI (90MG400MG) (TABLET) )
(EPCLUSA (400100MG) (TABLET) )
2
PA
2
PA
HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INH
SOFOSBUVIR
(SOVALDI (400 MG)
(TABLET) )
2
PA
4
PA
HEPATITIS B TREATMENT AGENTS
adefovir dipivoxil
Sharp Health Plan: Covered California
(HEPSERA (10 MG)
(TABLET) )
Page 129 of 224
Sharp Health Plan: Covered California
Drug Name
ENTECAVIR
entecavir
entecavir
lamivudine
LAMIVUDINE
TELBIVUDINE
Drug Tier Requirements/Limits
(BARACLUDE (0.05
MG/ML)
(SOLUTION) )
(BARACLUDE (0.5
MG) (TABLET) )
(BARACLUDE (1
MG) (TABLET) )
(EPIVIR HBV (100
MG) (TABLET) )
(EPIVIR HBV (25
MG/5 ML)
(SOLUTION) )
(TYZEKA (600 MG)
(TABLET) )
3
PA
4
PA
4
PA
1
2
4
PA
HEPATITIS C TREATMENT AGENTS
PEGINTERFERON ALFA-2A
PEGINTERFERON ALFA-2A
PEGINTERFERON ALFA-2A
PEGINTERFERON ALFA-2A
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
ribavirin
ribavirin
Sharp Health Plan: Covered California
(PEGASYS
(180MCG/0.5)
(SYRINGE) )
(PEGASYS
(180MCG/ML)
(VIAL) )
(PEGASYS
PROCLICK
(135MCG/0.5) (PEN
INJCTR) )
(PEGASYS
PROCLICK
(180MCG/0.5) (PEN
INJCTR) )
(PEGINTRON
(120MCG/0.5)
(KIT) )
(PEGINTRON
(150MCG/0.5)
(KIT) )
(PEGINTRON (50
MCG/0.5) (KIT) )
(PEGINTRON
(80MCG/0.5) (KIT) )
(PEGINTRON
REDIPEN
(120MCG/0.5) (PEN
IJ KIT) )
(PEGINTRON
REDIPEN
(150MCG/0.5) (PEN
IJ KIT) )
(PEGINTRON
REDIPEN (50
MCG/0.5) (PEN IJ
KIT) )
(PEGINTRON
REDIPEN
(80MCG/0.5) (PEN IJ
KIT) )
(COPEGUS (200
MG) (TABLET) )
(MODERIBA (200
MG) (TABLET) )
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
2
PA
2
PA
Page 130 of 224
Sharp Health Plan: Covered California
Drug Name
ribavirin
ribavirin
ribavirin
ribavirin
ribavirin
RIBAVIRIN
ribavirin
ribavirin
ribavirin
ribavirin
ribavirin
ribavirin
Drug Tier Requirements/Limits
(MODERIBA (200400(7)) (TAB DS
PK) )
(MODERIBA (400400(7)) (TAB DS
PK) )
(MODERIBA (600400(7)) (TAB DS
PK) )
(MODERIBA (600600(7)) (TAB DS
PK) )
(REBETOL (200
MG) (CAPSULE) )
(REBETOL (40
MG/ML)
(SOLUTION) )
(RIBATAB (400-400
MG) (TAB DS PK) )
(RIBATAB (400400(7)) (TAB DS
PK) )
(RIBATAB (600-400
MG) (TAB DS PK) )
(RIBATAB (600400(7)) (TAB DS
PK) )
(RIBATAB (600-600
MG) (TAB DS PK) )
(RIBATAB (600600(7)) (TAB DS
PK) )
ribavirin (200-400mg) (tab ds pk)
ribavirin (400 mg) (tablet)
ribavirin (600 mg) (tablet)
2
PA
4
PA
2
PA
2
PA
1
PA
3
PA
4
PA
4
PA
2
PA
2
PA
2
PA
2
PA
2
2
2
PA
PA
PA
HEPATITIS C VIRUS - NS5A REPLICATION COMPLEX INHIB
DACLATASVIR DIHYDROCHLORIDE
DACLATASVIR DIHYDROCHLORIDE
DACLATASVIR DIHYDROCHLORIDE
(DAKLINZA (30
MG) (TABLET) )
(DAKLINZA (60
MG) (TABLET) )
(DAKLINZA (90
MG) (TABLET) )
4
PA
4
PA
4
PA
4
PA
4
PA, QL: 84 IN 28 DAYS
4
PA
HEPATITIS C VIRUS - NS5A, NS3/4A, NS5B INHIB CMB.
OMBITA/PARITAP/RITON/DASABUVIR
OMBITA/PARITAP/RITON/DASABUVIR
(VIEKIRA PAK
(12.5-75-50) (TAB
DS PK) )
(VIEKIRA XR (8.3350 MG) (TAB BP
24H) )
HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB.
SIMEPREVIR SODIUM
(OLYSIO (150 MG)
(CAPSULE) )
HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB
ELBASVIR/GRAZOPREVIR
OMBITASVIR/PARITAPREV/RITONAV
Sharp Health Plan: Covered California
(ZEPATIER (50MG100MG) (TABLET) )
(TECHNIVIE (12.575 MG) (TABLET) )
4
PA
4
PA
Page 131 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
INFLAMMATORY DISEASE
ANTI-ARTHRITIC AND CHELATING AGENTS
PENICILLAMINE
PENICILLAMINE
(CUPRIMINE (250
MG) (CAPSULE) )
(DEPEN (250 MG)
(TABLET) )
4
PA
3
ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
METHOTREXATE/PF
Sharp Health Plan: Covered California
(OTREXUP
(10MG/0.4ML)
(AUTO INJCT) )
(OTREXUP
(12.5MG/0.4) (AUTO
INJCT) )
(OTREXUP
(15MG/0.4ML)
(AUTO INJCT) )
(OTREXUP
(17.5MG/0.4) (AUTO
INJCT) )
(OTREXUP
(20MG/0.4ML)
(AUTO INJCT) )
(OTREXUP
(22.5MG/0.4) (AUTO
INJCT) )
(OTREXUP
(25MG/0.4ML)
(AUTO INJCT) )
(OTREXUP (7.5
MG/0.4) (AUTO
INJCT) )
(RASUVO
(10MG/0.2ML)
(AUTO INJCT) )
(RASUVO
(12.5/0.25) (AUTO
INJCT) )
(RASUVO
(15MG/0.3ML)
(AUTO INJCT) )
(RASUVO
(17.5/0.35) (AUTO
INJCT) )
(RASUVO
(20MG/0.4ML)
(AUTO INJCT) )
(RASUVO
(22.5/0.45) (AUTO
INJCT) )
(RASUVO
(25MG/0.5ML)
(AUTO INJCT) )
(RASUVO
(27.5/0.55) (AUTO
INJCT) )
(RASUVO
(30MG/0.6ML)
(AUTO INJCT) )
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
Page 132 of 224
Sharp Health Plan: Covered California
Drug Name
METHOTREXATE/PF
Drug Tier Requirements/Limits
(RASUVO
(7.5MG/0.15) (AUTO
INJCT) )
MB
ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST
ANAKINRA
(KINERET
(100MG/0.67)
(SYRINGE) )
MB
ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR
ADALIMUMAB
ADALIMUMAB
ADALIMUMAB
ADALIMUMAB
ADALIMUMAB
ADALIMUMAB
ADALIMUMAB
ETANERCEPT
ETANERCEPT
ETANERCEPT
ETANERCEPT
GOLIMUMAB
GOLIMUMAB
GOLIMUMAB
GOLIMUMAB
GOLIMUMAB
Sharp Health Plan: Covered California
(HUMIRA
(10MG/0.2ML)
(SYRINGEKIT) )
(HUMIRA
(20MG/0.4ML)
(SYRINGEKIT) )
(HUMIRA
(40MG/0.8ML)
(SYRINGEKIT) )
(HUMIRA
PEDIATRIC
CROHN'S
(40MG/0.8ML)
(SYRINGEKIT) )
(HUMIRA PEN
(40MG/0.8ML) (PEN
IJ KIT) )
(HUMIRA PEN
CROHN-UC-HS
STARTER
(40MG/0.8ML) (PEN
IJ KIT) )
(HUMIRA PEN
PSORIASISUVEITIS
(40MG/0.8ML) (PEN
IJ KIT) )
(ENBREL (25 MG)
(VIAL) )
(ENBREL
(25MG/0.5ML)
(SYRINGE) )
(ENBREL (50
MG/ML) (PEN
INJCTR) )
(ENBREL (50
MG/ML)
(SYRINGE) )
(SIMPONI (100
MG/ML) (PEN
INJCTR) )
(SIMPONI (100
MG/ML)
(SYRINGE) )
(SIMPONI
(50MG/0.5ML) (PEN
INJCTR) )
(SIMPONI
(50MG/0.5ML)
(SYRINGE) )
(SIMPONI ARIA (50
MG/4 ML) (VIAL) )
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
Page 133 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR
leflunomide
leflunomide
(ARAVA (10 MG)
(TABLET) )
(ARAVA (20 MG)
(TABLET) )
2
2
ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.
APREMILAST
APREMILAST
(OTEZLA (10-2030MG) (TAB DS
PK) )
(OTEZLA (30 MG)
(TABLET) )
4
PA
4
PA
GLUCOCORTICOIDS
budesonide
BUDESONIDE
cortisone acetate
dexamethasone
dexamethasone
dexamethasone
dexamethasone
dexamethasone
dexamethasone
dexamethasone
(ENTOCORT EC (3
MG) (CAPDR - ER) )
(UCERIS (9 MG)
(TABDR - ER) )
(CORTONE (25 MG)
(TABLET) )
(DECADRON (0.5
MG) (TABLET) )
(DECADRON (0.75
MG) (TABLET) )
(DECADRON (1
MG) (TABLET) )
(DECADRON (1.5
MG) (TABLET) )
(DECADRON (2
MG) (TABLET) )
(DECADRON (4
MG) (TABLET) )
(DECADRON (6
MG) (TABLET) )
dexamethasone (0.5 mg/5ml) (solution)
DEXAMETHASONE INTENSOL (1 MG/ML)
(DROPS)
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
dexamethasone
hydrocortisone
hydrocortisone
hydrocortisone
methylprednisolone
METHYLPREDNISOLONE
methylprednisolone
methylprednisolone
methylprednisolone
Sharp Health Plan: Covered California
4
3
1
1
1
1
1
1
1
1
1
3
(DEXPAK (1.5MG
(21)) (TAB DS PK) )
(DEXPAK (1.5MG
(35)) (TAB DS PK) )
(DEXPAK (1.5MG
(51)) (TAB DS PK) )
(HEXADROL (0.5
MG/5ML)
(ELIXIR) )
(CORTEF (10 MG)
(TABLET) )
(CORTEF (20 MG)
(TABLET) )
(CORTEF (5 MG)
(TABLET) )
(MEDROL (16 MG)
(TABLET) )
(MEDROL (2 MG)
(TABLET) )
(MEDROL (32 MG)
(TABLET) )
(MEDROL (4 MG)
(TAB DS PK) )
(MEDROL (4 MG)
(TABLET) )
2
2
2
1
1
1
1
1
2
1
1
1
Page 134 of 224
Sharp Health Plan: Covered California
Drug Name
methylprednisolone
PREDNISOLONE
PREDNISOLONE
PREDNISOLONE
prednisolone
PREDNISOLONE SOD PHOSPHATE
prednisolone sod phosphate
prednisolone sod phosphate
prednisolone sod phosphate
prednisolone sod phosphate
prednisolone sod phosphate
Drug Tier Requirements/Limits
(MEDROL (8 MG)
(TABLET) )
(MILLIPRED (5 MG)
(TABLET) )
(MILLIPRED DP (5
MG (21)) (TAB DS
PK) )
(MILLIPRED DP (5
MG (48)) (TAB DS
PK) )
(ORAPRED (15
MG/5 ML)
(SOLUTION) )
(MILLIPRED (10
MG/5 ML)
(SOLUTION) )
(ORAPRED (15
MG/5 ML)
(SOLUTION) )
(ORAPRED ODT (10
MG) (TAB
RAPDIS) )
(ORAPRED ODT (15
MG) (TAB
RAPDIS) )
(ORAPRED ODT (30
MG) (TAB
RAPDIS) )
(PEDIAPRED (5
MG/5 ML)
(SOLUTION) )
prednisolone sod phosphate (25 mg/5 ml) (solution)
PREDNISOLONE SOD PHOSPHATE
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
PREDNISONE
PREDNISONE
Sharp Health Plan: Covered California
3
3
3
1
3
2
2
2
2
2
2
(VERIPRED 20 (20
MG/5 ML)
(SOLUTION) )
(DELTASONE (1
MG) (TABLET) )
(DELTASONE (10
MG) (TAB DS PK) )
(DELTASONE (10
MG) (TABLET) )
(DELTASONE (2.5
MG) (TABLET) )
(DELTASONE (20
MG) (TABLET) )
(DELTASONE (5
MG) (TAB DS PK) )
(DELTASONE (5
MG) (TABLET) )
(DELTASONE (50
MG) (TABLET) )
prednisone (20 mg) (tablet)
prednisone (5 mg/5 ml) (solution)
PREDNISONE INTENSOL (5 MG/ML) (ORAL
CONC)
PREDNISONE
1
3
1
1
1
1
1
1
1
1
1
1
2
(RAYOS (1 MG)
(TABLET DR) )
(RAYOS (2 MG)
(TABLET DR) )
(RAYOS (5 MG)
(TABLET DR) )
4
PA
4
PA
4
PA
Page 135 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
GOLD SALTS
AURANOFIN
(RIDAURA (3 MG)
(CAPSULE) )
4
INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS
TOCILIZUMAB
TOCILIZUMAB
TOCILIZUMAB
TOCILIZUMAB
(ACTEMRA (162
MG/0.9)
(SYRINGE) )
(ACTEMRA
(200MG/10ML)
(VIAL) )
(ACTEMRA
(400MG/20ML)
(VIAL) )
(ACTEMRA (80
MG/4 ML) (VIAL) )
MB
MB
MB
MB
JANUS KINASE (JAK) INHIBITORS
TOFACITINIB CITRATE
TOFACITINIB CITRATE
(XELJANZ (5 MG)
(TABLET) )
(XELJANZ XR (11
MG) (TAB ER 24H) )
4
PA
4
PA
MINERALOCORTICOIDS
fludrocortisone acetate
(FLORINEF (0.1
MG) (TABLET) )
1
MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB
USTEKINUMAB
USTEKINUMAB
(STELARA
(45MG/0.5ML)
(SYRINGE) )
(STELARA (90
MG/ML)
(SYRINGE) )
MB
MB
NASAL NSAIDS, COX NON-SELECTIVE,SYSTEMIC ANALGESIC
KETOROLAC TROMETHAMINE
(SPRIX (15.75 MG)
(SPRAY) )
3
NSAID & HISTAMINE H2 RECEPTOR ANTAGONIST COMB.
IBUPROFEN/FAMOTIDINE
(DUEXIS (80026.6MG) (TABLET) )
3
NSAID, COX INHIBITOR-TYPE & PROTON PUMP INHIB COMB
NAPROXEN/ESOMEPRAZOLE MAG
NAPROXEN/ESOMEPRAZOLE MAG
(VIMOVO (375MG20MG) (TAB IR
DR) )
(VIMOVO (500MG20MG) (TAB IR
DR) )
3
PA
3
PA
NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMB
diclofenac sodium/misoprostol
diclofenac sodium/misoprostol
(ARTHROTEC 50
(50 MG-200) (TAB
IR DR) )
(ARTHROTEC 75
(75 MG-200) (TAB
IR DR) )
2
2
NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE
celecoxib
celecoxib
celecoxib
Sharp Health Plan: Covered California
(CELEBREX (100
MG) (CAPSULE) )
(CELEBREX (200
MG) (CAPSULE) )
(CELEBREX (400
MG) (CAPSULE) )
1
1
1
Page 136 of 224
Sharp Health Plan: Covered California
Drug Name
celecoxib
Drug Tier Requirements/Limits
(CELEBREX (50
MG) (CAPSULE) )
1
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
diclofenac potassium
DICLOFENAC POTASSIUM
diclofenac sodium
diclofenac sodium
diclofenac sodium
diclofenac sodium
DICLOFENAC SUBMICRONIZED
DICLOFENAC SUBMICRONIZED
etodolac
etodolac
etodolac
etodolac
etodolac
etodolac
etodolac
fenoprofen calcium
fenoprofen calcium
fenoprofen calcium
fenoprofen calcium
flurbiprofen
flurbiprofen
ibuprofen
ibuprofen
ibuprofen
ibuprofen
indomethacin
INDOMETHACIN
Sharp Health Plan: Covered California
(CATAFLAM (50
MG) (TABLET) )
(ZIPSOR (25 MG)
(CAPSULE) )
(VOLTAREN (25
MG) (TABLET DR) )
(VOLTAREN (50
MG) (TABLET DR) )
(VOLTAREN (75
MG) (TABLET DR) )
(VOLTAREN-XR
(100 MG) (TAB ER
24H) )
(ZORVOLEX (18
MG) (CAPSULE) )
(ZORVOLEX (35
MG) (CAPSULE) )
(LODINE (200 MG)
(CAPSULE) )
(LODINE (300 MG)
(CAPSULE) )
(LODINE (400 MG)
(TABLET) )
(LODINE (500 MG)
(TABLET) )
(LODINE XL (400
MG) (TAB ER 24H) )
(LODINE XL (500
MG) (TAB ER 24H) )
(LODINE XL (600
MG) (TAB ER 24H) )
(FENORTHO (200
MG) (CAPSULE) )
(FENORTHO (400
MG) (CAPSULE) )
(NALFON (400 MG)
(CAPSULE) )
(NALFON (600 MG)
(TABLET) )
(ANSAID (100 MG)
(TABLET) )
(ANSAID (50 MG)
(TABLET) )
(MOTRIN (100
MG/5ML) (ORAL
SUSP) )
(MOTRIN (400 MG)
(TABLET) )
(MOTRIN (600 MG)
(TABLET) )
(MOTRIN (800 MG)
(TABLET) )
(INDOCIN (25 MG)
(CAPSULE) )
(INDOCIN (25 MG/5
ML) (ORAL SUSP) )
2
3
ST, QL: 4 IN 1 DAY
1
1
1
1
3
ST, QL: 3 IN 1 DAY
3
ST, QL: 3 IN 1 DAY
2
2
2
2
2
2
2
2
2
2
2
1
1
2
1
1
1
1
2
Page 137 of 224
Sharp Health Plan: Covered California
Drug Name
indomethacin
INDOMETHACIN
indomethacin
INDOMETHACIN, SUBMICRONIZED
INDOMETHACIN, SUBMICRONIZED
ketoprofen
ketoprofen
ketoprofen
ketorolac tromethamine
meclofenamate sodium
meclofenamate sodium
mefenamic acid
meloxicam
meloxicam
meloxicam
MELOXICAM, SUBMICRONIZED
MELOXICAM, SUBMICRONIZED
nabumetone
nabumetone
naproxen
naproxen
naproxen
naproxen
naproxen
naproxen
naproxen sodium
naproxen sodium
naproxen sodium
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(INDOCIN (50 MG)
(CAPSULE) )
(INDOCIN (50 MG)
(SUPP.RECT) )
(INDOCIN (75 MG)
(CAPSULE ER) )
(TIVORBEX (20
MG) (CAPSULE) )
(TIVORBEX (40
MG) (CAPSULE) )
(ORUDIS (50 MG)
(CAPSULE) )
(ORUDIS (75 MG)
(CAPSULE) )
(ORUVAIL (200 MG)
(CAP24H PEL) )
(TORADOL (10 MG)
(TABLET) )
(MECLOMEN (100
MG) (CAPSULE) )
(MECLOMEN (50
MG) (CAPSULE) )
(PONSTEL (250
MG) (CAPSULE) )
(MOBIC (15 MG)
(TABLET) )
(MOBIC (7.5 MG)
(TABLET) )
(MOBIC (7.5
MG/5ML) (ORAL
SUSP) )
(VIVLODEX (10
MG) (CAPSULE) )
(VIVLODEX (5 MG)
(CAPSULE) )
(RELAFEN (500
MG) (TABLET) )
(RELAFEN (750
MG) (TABLET) )
(EC-NAPROSYN
(375 MG) (TABLET
DR) )
(EC-NAPROSYN
(500 MG) (TABLET
DR) )
(NAPROSYN (125
MG/5ML) (ORAL
SUSP) )
(NAPROSYN (250
MG) (TABLET) )
(NAPROSYN (375
MG) (TABLET) )
(NAPROSYN (500
MG) (TABLET) )
(ANAPROX (275
MG) (TABLET) )
(ANAPROX DS (550
MG) (TABLET) )
(NAPRELAN (375
MG) (TBMP 24HR) )
1
2
1
3
PA, QL: 3 IN 1 DAY
3
PA, QL: 3 IN 1 DAY
1
1
2
2
2
2
2
1
1
1
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
1
1
1
1
1
1
1
1
1
2
ST, QL: 1 IN 1 DAY
Page 138 of 224
Sharp Health Plan: Covered California
Drug Name
naproxen sodium
NAPROXEN SODIUM
oxaprozin
piroxicam
piroxicam
sulindac
sulindac
tolmetin sodium
tolmetin sodium
tolmetin sodium
Drug Tier Requirements/Limits
(NAPRELAN (500
MG) (TBMP 24HR) )
(NAPRELAN (750
MG) (TBMP 24HR) )
(DAYPRO (600 MG)
(TABLET) )
(FELDENE (10 MG)
(CAPSULE) )
(FELDENE (20 MG)
(CAPSULE) )
(CLINORIL (150
MG) (TABLET) )
(CLINORIL (200
MG) (TABLET) )
(TOLECTIN (200
MG) (TABLET) )
(TOLECTIN (600
MG) (TABLET) )
(TOLECTIN DS (400
MG) (CAPSULE) )
2
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
2
1
1
1
1
2
2
2
LOCAL ANESTHESIA
LOCAL ANESTHETICS
lidocaine hcl
(GLYDO (2 %)
(JEL/PF APP) )
lidocaine hcl (2 %) (jel/pf app)
lidocaine hcl
lidocaine hcl
lidocaine hcl
2
2
(XYLOCAINE (2 %)
(JEL (ML)) )
(XYLOCAINE (40
MG/ML)
(SOLUTION) )
(XYLOCAINE VISC
OUS (2 %)
(SOLUTION) )
2
2
1
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
BOWEL ANTIINFLAMATORY AGENTS
sulfadiazine (500 mg) (tablet)
2
CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX
MESALAMINE
mesalamine
(CANASA (1000
MG) (SUPP.RECT) )
(SFROWASA (4 G/60
ML) (ENEMA) )
3
1
DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT
balsalazide disodium
BALSALAZIDE DISODIUM
MESALAMINE
mesalamine
MESALAMINE
MESALAMINE
MESALAMINE
Sharp Health Plan: Covered California
(COLAZAL (750
MG) (CAPSULE) )
(GIAZO (1.1 G)
(TABLET) )
(APRISO (0.375G)
(CAP ER 24H) )
(ASACOL HD (800
MG) (TABLET DR) )
(DELZICOL (400
MG)
(CAP(DRTAB)) )
(LIALDA (1.2 G)
(TABLET DR) )
(PENTASA (250
MG) (CAPSULE
ER) )
1
3
2
2
ST
3
ST, QL: 180 IN 30 DAYS
3
3
ST
Page 139 of 224
Sharp Health Plan: Covered California
Drug Name
MESALAMINE
OLSALAZINE SODIUM
sulfasalazine
sulfasalazine
Drug Tier Requirements/Limits
(PENTASA (500
MG) (CAPSULE
ER) )
(DIPENTUM (250
MG) (CAPSULE) )
(AZULFIDINE (500
MG) (TABLET DR) )
(AZULFIDINE (500
MG) (TABLET) )
3
ST
3
ST
1
1
DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLON
CERTOLIZUMAB PEGOL
CERTOLIZUMAB PEGOL
(CIMZIA (400 MG)
(KIT) )
(CIMZIA
(400MG/2ML)
(SYRINGEKIT) )
MB
MB
HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTH
hydrocortisone/lidocaine/aloe
HYDROCORTISONE/PRAMOXINE
hydrocortisone/pramoxine
hydrocortisone/pramoxine
hydrocortisone/pramoxine
HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE/PRAMOXINE
lidocaine/hydrocortisone ac
lidocaine/hydrocortisone ac
lidocaine/hydrocortisone ac
lidocaine/hydrocortisone ac
lidocaine/hydrocortisone ac
(RECTAGEL HC
(0.55%-2.8%) (GEL
W/APPL) )
(ANALPRAM HC (1
%-1 %)
(CREAM/APPL) )
(ANALPRAM HC
(2.5 %-1 %)
(CREAM/APPL) )
(ANALPRAM HC
(2.5-1%(4G))
(CREAM/APPL) )
(PRAMCORT (1 %-1
%) (CREAM/APPL) )
(PROCORT (1.851.15%)
(CREAM/APPL) )
(PROCTOFOAM-HC
(1 %-1 %) (FOAM) )
(ANAMANTLE HC
(3 %-0.5 %)
(CREAM (G)) )
(ANAMANTLE HC
(3 %-0.5 %)
(CREAM/APPL) )
(ANAMANTLE HC
(3-2.5%(7G)) (GEL
W/APPL) )
(ANAMANTLE HC
FORTE (3%-1%(7
G))
(CREAM/APPL) )
(LIDAZONE HC (3
%-0.5 %) (CREAM
(G)) )
2
3
2
2
2
3
2
2
2
2
2
2
IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTS
ELUXADOLINE
ELUXADOLINE
(VIBERZI (100 MG)
(TABLET) )
(VIBERZI (75 MG)
(TABLET) )
4
PA
4
PA
IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONIST
LINACLOTIDE
Sharp Health Plan: Covered California
(LINZESS (145
MCG) (CAPSULE) )
2
Page 140 of 224
Sharp Health Plan: Covered California
Drug Name
LINACLOTIDE
Drug Tier Requirements/Limits
(LINZESS (290
MCG) (CAPSULE) )
2
LOCAL ANORECTAL NITRATE PREPARATIONS
NITROGLYCERIN
(RECTIV (0.4%
(W/W)) (OINT. (G)) )
3
RECTAL PREPARATIONS
hydrocortisone acetate (25 mg) (supp.rect)
hydrocortisone acetate (30 mg) (supp.rect)
HYDROCORTISONE ACETATE
1
2
(MICORT-HC (2.5
%) (CREAM/APPL) )
4
RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)
BUDESONIDE
hydrocortisone
HYDROCORTISONE ACETATE
(UCERIS (2 MG)
(FOAM/APPL) )
(CORTENEMA
(100MG/60ML)
(ENEMA) )
(CORTIFOAM (10
%) (FOAM/APPL) )
4
ST
1
3
LOWER GASTROINTESTINAL DISORDERS - OTHER
AMMONIA INHIBITORS
ACETOHYDROXAMIC ACID
CARGLUMIC ACID
GLYCEROL PHENYLBUTYRATE
lactulose
sodium phenylbutyrate
SODIUM PHENYLBUTYRATE
(LITHOSTAT (250
MG) (TABLET) )
(CARBAGLU (200
MG) (TAB
DISPER) )
(RAVICTI
(1.1GRAM/ML)
(LIQUID) )
(CHRONULAC (10
G/15 ML)
(SOLUTION) )
(BUPHENYL (0.94
G/G) (POWDER) )
(BUPHENYL (500
MG) (TABLET) )
3
4
3
1
2
3
ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORS
CROFELEMER
(MYTESI (125 MG)
(TABLET DR) )
3
ANTIDIARRHEALS
DIFENOXIN HCL/ATROPINE SULFATE
diphenoxylate hcl/atropine
diphenoxylate hcl/atropine
loperamide hcl
(MOTOFEN (10.025MG)
(TABLET) )
(LOMOTIL (2.5.025/5) (LIQUID) )
(LOMOTIL (2.5.025MG) (TABLET) )
(IMODIUM (2 MG)
(CAPSULE) )
opium tincture (10 mg/ml) (tincture)
paregoric (2 mg/5 ml) (liquid)
3
1
1
2
2
2
BILE SALTS
CHENODIOL
CHOLIC ACID
CHOLIC ACID
Sharp Health Plan: Covered California
(CHENODAL (250
MG) (TABLET) )
(CHOLBAM (250
MG) (CAPSULE) )
(CHOLBAM (50
MG) (CAPSULE) )
3
4
PA
4
PA
Page 141 of 224
Sharp Health Plan: Covered California
Drug Name
ursodiol
ursodiol
ursodiol
Drug Tier Requirements/Limits
(ACTIGALL (300
MG) (CAPSULE) )
(URSO (250 MG)
(TABLET) )
(URSO FORTE (500
MG) (TABLET) )
1
2
2
FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG
OBETICHOLIC ACID
OBETICHOLIC ACID
(OCALIVA (10 MG)
(TABLET) )
(OCALIVA (5 MG)
(TABLET) )
4
PA, QL: 30 IN 30 DAYS
4
PA, QL: 30 IN 30 DAYS
IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPE
alosetron hcl
alosetron hcl
(LOTRONEX (0.5
MG) (TABLET) )
(LOTRONEX (1 MG)
(TABLET) )
4
PA
4
PA
LAXATIVES AND CATHARTICS
bisac/nacl/nahco3/kcl/peg 3350
lactulose
lactulose
LACTULOSE
LACTULOSE
LUBIPROSTONE
LUBIPROSTONE
NAPHOS M-B M-H/NA PHOS,DI-BA
peg 3350/na sulf,bicarb,cl/kcl
PEG 3350/NA SULF,BICARB,CL/KCL
peg 3350/na sulf,bicarb,cl/kcl
PEG 3350/SOD CHLOR/POTASS CIT
PEG3350/SOD SUL/NACL/ASB/C/KCL
polyethylene glycol 3350
polyethylene glycol 3350
polyethylene glycol 3350
Sharp Health Plan: Covered California
(PEG-PREP (5 MG210 G) (KIT) )
(CHRONULAC (10
G/15 ML)
(SOLUTION) )
(CHRONULAC (20
G/30 ML)
(SOLUTION) )
(KRISTALOSE (10
G) (PACKET) )
(KRISTALOSE (20
G) (PACKET) )
(AMITIZA (24MCG)
(CAPSULE) )
(AMITIZA (8 MCG)
(CAPSULE) )
(OSMOPREP (1.5 G)
(TABLET) )
(COLYTE WITH
FLAVOR PACKETS
(240-22.72G) (SOLN
RECON) )
(GOLYTELY (227.121.5) (POWD
PACK) )
(GOLYTELY (23622.74G) (SOLN
RECON) )
(GIALAX (17
G/SCOOP) (KIT) )
(MOVIPREP (7.52.691G) (POWD
PACK) )
(GAVILAX
(17G/DOSE)
(POWDER) (OTC))
(MIRALAX (17G)
(POWD PACK) )
(MIRALAX (17G)
(POWD PACK)
(OTC))
PV
1
1
3
3
3
3
PV
PV
PV
PV
PV
PV
PV
PV
PV
Page 142 of 224
Sharp Health Plan: Covered California
Drug Name
polyethylene glycol 3350
polyethylene glycol 3350
SOD PICOSULF/MAG OX/CITRIC AC
sodium chloride/nahco3/kcl/peg
SODIUM, POTASSIUM,MAG SULFATES
Drug Tier Requirements/Limits
(MIRALAX
(17G/DOSE)
(POWDER) )
(MIRALAX
(17G/DOSE)
(POWDER) (OTC))
(PREPOPIK (10 MG12 G) (POWD
PACK) )
(NULYTELY WITH
FLAVOR PACKS
(420G) (SOLN
RECON) )
(SUPREP (17.53.13G) (SOLN
RECON) )
PV
PV
PV
PV
PV
NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING
METHYLNALTREXONE BROMIDE
NALOXEGOL OXALATE
NALOXEGOL OXALATE
(RELISTOR (150
MG) (TABLET) )
(MOVANTIK (12.5
MG) (TABLET) )
(MOVANTIK (25
MG) (TABLET) )
3
PA, QL: 3 IN 1 DAY
4
PA
4
PA
MEDICAL SUPPLIES
SYRINGES AND ACCESSORIES
SYRINGE AND NEEDLE,INSULIN
(INSULIN
SYRINGE)
1
MISCELLANEOUS AGENTS
ANAPHYLAXIS THERAPY AGENTS
epinephrine
epinephrine
EPINEPHRINE
EPINEPHRINE
(ADRENACLICK
(0.15/0.15) (AUTO
INJCT) )
(ADRENACLICK
(0.3MG/0.3) (AUTO
INJCT) )
(EPIPEN 2-PAK
(0.3MG/0.3) (AUTO
INJCT) )
(EPIPEN JR 2-PAK
(0.15MG/0.3) (AUTO
INJCT) )
1
1
2
2
PARASYMPATHETIC AGENTS
bethanechol chloride
bethanechol chloride
bethanechol chloride
bethanechol chloride
cevimeline hcl
guanidine hcl
pilocarpine hcl
pilocarpine hcl
Sharp Health Plan: Covered California
(URECHOLINE (10
MG) (TABLET) )
(URECHOLINE (25
MG) (TABLET) )
(URECHOLINE (5
MG) (TABLET) )
(URECHOLINE (50
MG) (TABLET) )
(EVOXAC (30 MG)
(CAPSULE) )
(GUANIDINE (125
MG) (TABLET) )
(SALAGEN (5 MG)
(TABLET) )
(SALAGEN (7.5
MG) (TABLET) )
1
1
1
1
2
2
2
2
Page 143 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
NEOPLASTIC DISEASE
ALKYLATING AGENTS
ALTRETAMINE
BUSULFAN
CHLORAMBUCIL
(HEXALEN (50 MG)
(CAPSULE) )
(MYLERAN (2 MG)
(TABLET) )
(LEUKERAN (2
MG) (TABLET) )
CYCLOPHOSPHAMIDE (25 MG) (CAPSULE)
CYCLOPHOSPHAMIDE (50 MG) (CAPSULE)
hydroxyurea
LOMUSTINE
LOMUSTINE
LOMUSTINE
LOMUSTINE
MELPHALAN
temozolomide
temozolomide
temozolomide
temozolomide
temozolomide
temozolomide
(HYDREA (500 MG)
(CAPSULE) )
(GLEOSTINE (10
MG) (CAPSULE) )
(GLEOSTINE (100
MG) (CAPSULE) )
(GLEOSTINE (40
MG) (CAPSULE) )
(GLEOSTINE (5
MG) (CAPSULE) )
(ALKERAN (2 MG)
(TABLET) )
(TEMODAR (100
MG) (CAPSULE) )
(TEMODAR (140
MG) (CAPSULE) )
(TEMODAR (180
MG) (CAPSULE) )
(TEMODAR (20
MG) (CAPSULE) )
(TEMODAR (250
MG) (CAPSULE) )
(TEMODAR (5 MG)
(CAPSULE) )
4
PA
3
PA
3
PA
2
2
PA
PA
1
3
3
3
3
3
2
PA
2
PA
2
PA
2
PA
2
PA
2
PA
4
PA
ANTIANDROGENIC AGENTS
ABIRATERONE ACETATE
bicalutamide
ENZALUTAMIDE
flutamide
nilutamide
(ZYTIGA (250 MG)
(TABLET) )
(CASODEX (50 MG)
(TABLET) )
(XTANDI (40 MG)
(CAPSULE) )
(EULEXIN (125 MG)
(CAPSULE) )
(NILANDRON (150
MG) (TABLET) )
2
4
PA
1
2
PA, QL: 60 IN 30 DAYS
ANTIBIOTIC ANTINEOPLASTICS
daunorubicin hcl
epirubicin hcl
(CERUBIDINE (5
MG/ML) (VIAL) )
(ELLENCE
(200MG/0.1L)
(VIAL) )
MB
MB
ANTIMETABOLITES
capecitabine
capecitabine
mercaptopurine
Sharp Health Plan: Covered California
(XELODA (150 MG)
(TABLET) )
(XELODA (500 MG)
(TABLET) )
(PURINETHOL (50
MG) (TABLET) )
2
PA
2
PA
1
Page 144 of 224
Sharp Health Plan: Covered California
Drug Name
MERCAPTOPURINE
METHOTREXATE SODIUM
METHOTREXATE SODIUM
methotrexate sodium
METHOTREXATE SODIUM
METHOTREXATE SODIUM
THIOGUANINE
TRIFLURIDINE/TIPIRACIL HCL
TRIFLURIDINE/TIPIRACIL HCL
Drug Tier Requirements/Limits
(PURIXAN (20
MG/ML) (ORAL
SUSP) )
(TREXALL (10 MG)
(TABLET) )
(TREXALL (15 MG)
(TABLET) )
(TREXALL (2.5 MG)
(TABLET) )
(TREXALL (5 MG)
(TABLET) )
(TREXALL (7.5 MG)
(TABLET) )
(TABLOID (40 MG)
(TABLET) )
(LONSURF (15-6.14
MG) (TABLET) )
(LONSURF (20-8.19
MG) (TABLET) )
3
3
3
1
3
3
3
PA
4
PA
4
PA
ANTINEOPLASTIC AROMATASE INHIBITORS
anastrozole
exemestane
letrozole
(ARIMIDEX (1 MG)
(TABLET) )
(AROMASIN (25
MG) (TABLET) )
(FEMARA (2.5 MG)
(TABLET) )
1
2
ST
2
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR
SONIDEGIB PHOSPHATE
VISMODEGIB
(ODOMZO (200
MG) (CAPSULE) )
(ERIVEDGE (150
MG) (CAPSULE) )
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS
RUXOLITINIB PHOSPHATE
RUXOLITINIB PHOSPHATE
RUXOLITINIB PHOSPHATE
RUXOLITINIB PHOSPHATE
RUXOLITINIB PHOSPHATE
(JAKAFI (10 MG)
(TABLET) )
(JAKAFI (15 MG)
(TABLET) )
(JAKAFI (20 MG)
(TABLET) )
(JAKAFI (25 MG)
(TABLET) )
(JAKAFI (5 MG)
(TABLET) )
ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS
COBIMETINIB FUMARATE
TRAMETINIB DIMETHYL SULFOXIDE
TRAMETINIB DIMETHYL SULFOXIDE
(COTELLIC (20 MG)
(TABLET) )
(MEKINIST (0.5
MG) (TABLET) )
(MEKINIST (2 MG)
(TABLET) )
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
ANTINEOPLASTIC - MTOR KINASE INHIBITORS
EVEROLIMUS
EVEROLIMUS
EVEROLIMUS
EVEROLIMUS
Sharp Health Plan: Covered California
(AFINITOR (10 MG)
(TABLET) )
(AFINITOR (2.5
MG) (TABLET) )
(AFINITOR (5 MG)
(TABLET) )
(AFINITOR (7.5
MG) (TABLET) )
Page 145 of 224
Sharp Health Plan: Covered California
Drug Name
EVEROLIMUS
EVEROLIMUS
EVEROLIMUS
Drug Tier Requirements/Limits
(AFINITOR
DISPERZ (2 MG)
(TAB SUSP) )
(AFINITOR
DISPERZ (3 MG)
(TAB SUSP) )
(AFINITOR
DISPERZ (5 MG)
(TAB SUSP) )
4
PA
4
PA
4
PA
3
PA
3
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS
TOPOTECAN HCL
TOPOTECAN HCL
(HYCAMTIN (0.25
MG) (CAPSULE) )
(HYCAMTIN (1
MG) (CAPSULE) )
ANTINEOPLASTIC IMMUNOMODULATOR AGENTS
LENALIDOMIDE
LENALIDOMIDE
LENALIDOMIDE
LENALIDOMIDE
LENALIDOMIDE
LENALIDOMIDE
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
PEGINTERFERON ALFA-2B
POMALIDOMIDE
POMALIDOMIDE
POMALIDOMIDE
POMALIDOMIDE
(REVLIMID (10
MG) (CAPSULE) )
(REVLIMID (15
MG) (CAPSULE) )
(REVLIMID (2.5
MG) (CAPSULE) )
(REVLIMID (20
MG) (CAPSULE) )
(REVLIMID (25
MG) (CAPSULE) )
(REVLIMID (5 MG)
(CAPSULE) )
(SYLATRON (200
MCG) (KIT) )
(SYLATRON (300
MCG) (KIT) )
(SYLATRON (600
MCG) (KIT) )
(POMALYST (1 MG)
(CAPSULE) )
(POMALYST (2 MG)
(CAPSULE) )
(POMALYST (3 MG)
(CAPSULE) )
(POMALYST (4 MG)
(CAPSULE) )
MB
MB
MB
3
3
3
3
ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS
AFATINIB DIMALEATE
AFATINIB DIMALEATE
AFATINIB DIMALEATE
ALECTINIB HCL
AXITINIB
AXITINIB
BOSUTINIB
BOSUTINIB
CABOZANTINIB S-MALATE
Sharp Health Plan: Covered California
(GILOTRIF (20 MG)
(TABLET) )
(GILOTRIF (30 MG)
(TABLET) )
(GILOTRIF (40 MG)
(TABLET) )
(ALECENSA (150
MG) (CAPSULE) )
(INLYTA (1 MG)
(TABLET) )
(INLYTA (5 MG)
(TABLET) )
(BOSULIF (100 MG)
(TABLET) )
(BOSULIF (500 MG)
(TABLET) )
(CABOMETYX (20
MG) (TABLET) )
4
4
4
4
PA
4
PA
4
PA
4
PA
4
PA
4
Page 146 of 224
Sharp Health Plan: Covered California
Drug Name
CABOZANTINIB S-MALATE
CABOZANTINIB S-MALATE
CABOZANTINIB S-MALATE
CABOZANTINIB S-MALATE
CABOZANTINIB S-MALATE
CERITINIB
CRIZOTINIB
CRIZOTINIB
DABRAFENIB MESYLATE
DABRAFENIB MESYLATE
DASATINIB
DASATINIB
DASATINIB
DASATINIB
DASATINIB
DASATINIB
ERLOTINIB HCL
ERLOTINIB HCL
ERLOTINIB HCL
GEFITINIB
IBRUTINIB
IDELALISIB
IDELALISIB
imatinib mesylate
imatinib mesylate
IXAZOMIB CITRATE
IXAZOMIB CITRATE
IXAZOMIB CITRATE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(CABOMETYX (40
MG) (TABLET) )
(CABOMETYX (60
MG) (TABLET) )
(COMETRIQ (100
MG/DAY)
(CAPSULE) )
(COMETRIQ (140
MG/DAY)
(CAPSULE) )
(COMETRIQ (60
MG/DAY)
(CAPSULE) )
(ZYKADIA (150
MG) (CAPSULE) )
(XALKORI (200
MG) (CAPSULE) )
(XALKORI (250
MG) (CAPSULE) )
(TAFINLAR (50 MG)
(CAPSULE) )
(TAFINLAR (75 MG)
(CAPSULE) )
(SPRYCEL (100 MG)
(TABLET) )
(SPRYCEL (140 MG)
(TABLET) )
(SPRYCEL (20 MG)
(TABLET) )
(SPRYCEL (50 MG)
(TABLET) )
(SPRYCEL (70 MG)
(TABLET) )
(SPRYCEL (80 MG)
(TABLET) )
(TARCEVA (100
MG) (TABLET) )
(TARCEVA (150
MG) (TABLET) )
(TARCEVA (25 MG)
(TABLET) )
(IRESSA (250 MG)
(TABLET) )
(IMBRUVICA (140
MG) (CAPSULE) )
(ZYDELIG (100 MG)
(TABLET) )
(ZYDELIG (150 MG)
(TABLET) )
(GLEEVEC (100
MG) (TABLET) )
(GLEEVEC (400
MG) (TABLET) )
(NINLARO (2.3 MG)
(CAPSULE) )
(NINLARO (3 MG)
(CAPSULE) )
(NINLARO (4 MG)
(CAPSULE) )
4
4
4
4
4
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
2
2
4
PA
4
PA
4
PA
4
PA
4
PA
Page 147 of 224
Sharp Health Plan: Covered California
Drug Name
LAPATINIB DITOSYLATE
LENVATINIB MESYLATE
LENVATINIB MESYLATE
LENVATINIB MESYLATE
LENVATINIB MESYLATE
LENVATINIB MESYLATE
LENVATINIB MESYLATE
NILOTINIB HCL
NILOTINIB HCL
OLAPARIB
OSIMERTINIB MESYLATE
OSIMERTINIB MESYLATE
PALBOCICLIB
PALBOCICLIB
PALBOCICLIB
PAZOPANIB HCL
PONATINIB HCL
PONATINIB HCL
REGORAFENIB
SORAFENIB TOSYLATE
SUNITINIB MALATE
SUNITINIB MALATE
SUNITINIB MALATE
SUNITINIB MALATE
VANDETANIB
VANDETANIB
VEMURAFENIB
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(TYKERB (250 MG)
(TABLET) )
(LENVIMA (10
MG/DAY)
(CAPSULE) )
(LENVIMA (14
MG/DAY)
(CAPSULE) )
(LENVIMA (18
MG/DAY)
(CAPSULE) )
(LENVIMA (20
MG/DAY)
(CAPSULE) )
(LENVIMA (24
MG/DAY)
(CAPSULE) )
(LENVIMA (8
MG/DAY)
(CAPSULE) )
(TASIGNA (150 MG)
(CAPSULE) )
(TASIGNA (200 MG)
(CAPSULE) )
(LYNPARZA (50
MG) (CAPSULE) )
(TAGRISSO (40 MG)
(TABLET) )
(TAGRISSO (80 MG)
(TABLET) )
(IBRANCE (100
MG) (CAPSULE) )
(IBRANCE (125
MG) (CAPSULE) )
(IBRANCE (75 MG)
(CAPSULE) )
(VOTRIENT (200
MG) (TABLET) )
(ICLUSIG (15 MG)
(TABLET) )
(ICLUSIG (45 MG)
(TABLET) )
(STIVARGA (40
MG) (TABLET) )
(NEXAVAR (200
MG) (TABLET) )
(SUTENT (12.5 MG)
(CAPSULE) )
(SUTENT (25 MG)
(CAPSULE) )
(SUTENT (37.5 MG)
(CAPSULE) )
(SUTENT (50 MG)
(CAPSULE) )
(CAPRELSA (100
MG) (TABLET) )
(CAPRELSA (300
MG) (TABLET) )
(ZELBORAF (240
MG) (TABLET) )
4
PA
4
PA
4
PA
4
PA, QL: 60 IN 30 DAYS
4
PA
4
PA
4
PA, QL: 60 IN 30 DAYS
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA, QL: 1 IN 1 DAY
4
PA, QL: 2 IN 1 DAY
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
Page 148 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDIS
PANOBINOSTAT LACTATE
PANOBINOSTAT LACTATE
PANOBINOSTAT LACTATE
VORINOSTAT
(FARYDAK (10 MG)
(CAPSULE) )
(FARYDAK (15 MG)
(CAPSULE) )
(FARYDAK (20 MG)
(CAPSULE) )
(ZOLINZA (100 MG)
(CAPSULE) )
4
PA
4
PA
4
PA
4
PA
ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS
VENETOCLAX
VENETOCLAX
VENETOCLAX
VENETOCLAX
(VENCLEXTA (10
MG) (TABLET) )
(VENCLEXTA (100
MG) (TABLET) )
(VENCLEXTA (50
MG) (TABLET) )
(VENCLEXTA
STARTING PACK
(10-50-100) (TAB DS
PK) )
4
PA, QL: 2 IN 1 DAY
4
PA, QL: 4 IN 1 DAY
4
PA, QL: 1 IN 1 DAY
4
PA, QL: 42 IN 28 DAYS
ANTINEOPLASTICS,MISCELLANEOUS
etoposide
MITOTANE
PROCARBAZINE HCL
tretinoin
(VEPESID (50 MG)
(CAPSULE) )
(LYSODREN (500
MG) (TABLET) )
(MATULANE (50
MG) (CAPSULE) )
(VESANOID (10
MG) (CAPSULE) )
2
3
4
PA
2
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
leucovorin calcium
leucovorin calcium
leucovorin calcium
leucovorin calcium
MESNA
URIDINE TRIACETATE
(WELLCOVORIN
(10 MG) (TABLET) )
(WELLCOVORIN
(15 MG) (TABLET) )
(WELLCOVORIN
(25 MG) (TABLET) )
(WELLCOVORIN (5
MG) (TABLET) )
(MESNEX (400 MG)
(TABLET) )
(VISTOGARD (10
G) (GRAN PACK) )
2
2
2
2
4
4
PA
PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONS
AMINOLEVULINIC ACID HCL
(AMELUZ (10 %)
(GEL (GRAM)) )
4
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)
tamoxifen citrate
tamoxifen citrate
TAMOXIFEN CITRATE
TOREMIFENE CITRATE
(NOLVADEX (10
MG) (TABLET) )
(NOLVADEX (20
MG) (TABLET) )
(SOLTAMOX (10
MG/5 ML)
(SOLUTION) )
(FARESTON (60
MG) (TABLET) )
PV
PV
PV
3
SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)
bexarotene
Sharp Health Plan: Covered California
(TARGRETIN (75
MG) (CAPSULE) )
4
PA
Page 149 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
STEROID ANTINEOPLASTICS
ESTRAMUSTINE PHOSPHATE SODIUM
megestrol acetate
megestrol acetate
(EMCYT (140 MG)
(CAPSULE) )
(MEGACE (20 MG)
(TABLET) )
(MEGACE (40 MG)
(TABLET) )
3
PA
1
1
VINCA ALKALOIDS
vinorelbine tartrate
(NAVELBINE (50
MG/5 ML) (VIAL) )
MB
NEUROLOGICAL DISEASE - MISCELLANEOUS
AGENTS TO TREAT MULTIPLE SCLEROSIS
DIMETHYL FUMARATE
DIMETHYL FUMARATE
DIMETHYL FUMARATE
FINGOLIMOD HCL
glatiramer acetate
GLATIRAMER ACETATE
INTERFERON BETA-1A
INTERFERON BETA-1A
INTERFERON BETA-1A
INTERFERON BETA-1A
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
INTERFERON BETA-1A/ALBUMIN
Sharp Health Plan: Covered California
(TECFIDERA (120
MG) (CAPSULE
DR) )
(TECFIDERA (120240 MG) (CAPSULE
DR) )
(TECFIDERA (240
MG) (CAPSULE
DR) )
(GILENYA (0.5 MG)
(CAPSULE) )
(COPAXONE (20
MG/ML)
(SYRINGE) )
(COPAXONE (40
MG/ML)
(SYRINGE) )
(AVONEX
(30MCG/.5ML)
(SYRINGE) )
(AVONEX
(30MCG/.5ML)
(SYRINGEKIT) )
(AVONEX PEN
(30MCG/.5ML) (PEN
IJ KIT) )
(AVONEX PEN
(30MCG/.5ML) (PEN
INJCTR) )
(AVONEX (30 MCG)
(KIT) )
(REBIF
(22MCG/.5ML)
(SYRINGE) )
(REBIF
(44MCG/.5ML)
(SYRINGE) )
(REBIF (8.8-22(6))
(SYRINGE) )
(REBIF REBIDOSE
(22MCG/.5ML) (PEN
INJCTR) )
(REBIF REBIDOSE
(44MCG/.5ML) (PEN
INJCTR) )
(REBIF REBIDOSE
(8.8-22(6)) (PEN
INJCTR) )
4
PA, QL: 60 IN 30 DAYS
4
PA, QL: 60 IN 30 DAYS
4
PA, QL: 60 IN 30 DAYS
2
PA
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
Page 150 of 224
Sharp Health Plan: Covered California
Drug Name
INTERFERON BETA-1B
INTERFERON BETA-1B
INTERFERON BETA-1B
INTERFERON BETA-1B
TERIFLUNOMIDE
TERIFLUNOMIDE
Drug Tier Requirements/Limits
(BETASERON (0.3
MG) (KIT) )
(BETASERON (0.3
MG) (VIAL) )
(EXTAVIA (0.3 MG)
(KIT) )
(EXTAVIA (0.3 MG)
(VIAL) )
(AUBAGIO (14 MG)
(TABLET) )
(AUBAGIO (7 MG)
(TABLET) )
MB
MB
MB
MB
4
PA, QL: 1 IN 1 DAY
4
PA, QL: 1 IN 1 DAY
AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR
DALFAMPRIDINE
(AMPYRA (10 MG)
(TAB ER 12H) )
4
PA
1
PA
AMYOTROPHIC LATERAL SCLEROSIS AGENTS
riluzole
(RILUTEK (50 MG)
(TABLET) )
FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB
MILNACIPRAN HCL
MILNACIPRAN HCL
MILNACIPRAN HCL
MILNACIPRAN HCL
MILNACIPRAN HCL
(SAVELLA (100
MG) (TABLET) )
(SAVELLA (12.5
MG) (TABLET) )
(SAVELLA (12.5-2550) (TAB DS PK) )
(SAVELLA (25 MG)
(TABLET) )
(SAVELLA (50 MG)
(TABLET) )
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
4
PA
4
PA
3
ST, QL: 3 IN 1 DAY
3
QL: 78 IN 30 DAYS
3
QL: 3 IN 1 DAY
MOVEMENT DISORDERS(DRUG THERAPY)
GABAPENTIN ENACARBIL
GABAPENTIN ENACARBIL
tetrabenazine
tetrabenazine
(HORIZANT (300
MG) (TABLET ER) )
(HORIZANT (600
MG) (TABLET ER) )
(XENAZINE (12.5
MG) (TABLET) )
(XENAZINE (25
MG) (TABLET) )
POSTHERPETIC NEURALGIA AGENTS
GABAPENTIN
GABAPENTIN
GABAPENTIN
(GRALISE (300 MG)
(TAB ER 24H) )
(GRALISE (300-600
MG) (TAB ER 24H) )
(GRALISE (600 MG)
(TAB ER 24H) )
PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS
DEXTROMETHORPHAN HBR/QUINIDINE
(NUEDEXTA (20
MG-10MG)
(CAPSULE) )
3
ORAL/PHARYNGEAL DISORDERS
DENTAL AIDS AND PREPARATIONS
triamcinolone acetonide
(KENALOG IN
ORABASE (0.1 %)
(PASTE (G)) )
1
NOSE PREPARATIONS ANTIBIOTICS
MUPIROCIN CALCIUM
Sharp Health Plan: Covered California
(BACTROBAN
NASAL (2 %) (OINT.
(G)) )
2
Page 151 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
NOSE PREPARATIONS, MISCELLANEOUS (RX)
ipratropium bromide
ipratropium bromide
(ATROVENT (21
MCG) (SPRAY) )
(ATROVENT (42
MCG) (SPRAY) )
1
1
OTHER DRUGS
ABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYP
MIFEPRISTONE
(MIFEPREX (200
MG) (TABLET) )
3
APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.
megestrol acetate
megestrol acetate
(MEGACE
(400MG/10ML)
(ORAL SUSP) )
(MEGACE ES
(625MG/5ML)
(ORAL SUSP) )
1
2
CONDOMS
CONDOMS, FEMALE
CONDOMS, LATEX, LUBRICATED
(FEMALE
CONDOM (OTC))
(CONDOMS (OTC))
PV
QL: 6 IN 30 DAYS
PV
QL: 30 IN 30 DAYS
CXCR4 CHEMOKINE RECEPTOR ANTAGONIST
PLERIXAFOR
(MOZOBIL
(24MG/1.2ML)
(VIAL) )
MB
DRUGS TO TREAT HEREDITARY TYROSINEMIA
NITISINONE
NITISINONE
NITISINONE
NITISINONE
NITISINONE
(ORFADIN (10 MG)
(CAPSULE) )
(ORFADIN (2 MG)
(CAPSULE) )
(ORFADIN (20 MG)
(CAPSULE) )
(ORFADIN (4
MG/ML) (ORAL
SUSP) )
(ORFADIN (5 MG)
(CAPSULE) )
3
3
3
PA
4
PA
3
DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING
ELIGLUSTAT TARTRATE
MIGLUSTAT
(CERDELGA (84
MG) (CAPSULE) )
(ZAVESCA (100
MG) (CAPSULE) )
4
4
METABOLIC DEFICIENCY AGENTS
BETAINE
LEVOCARNITINE
(CYSTADANE (1
G/1.7 ML)
(POWDER) )
(CARNITOR SF (100
MG/ML)
(SOLUTION) )
levocarnitine (330 mg) (tablet)
levocarnitine (with sugar) (100 mg/ml) (solution)
sulfur/sod sul/sod thiosulf/fa (400 mg-1mg) (capsule)
4
3
2
2
2
METALLIC POISON,AGENTS TO TREAT
DEFERASIROX
DEFERASIROX
DEFERASIROX
Sharp Health Plan: Covered California
(EXJADE (125 MG)
(TAB DISPER) )
(EXJADE (250 MG)
(TAB DISPER) )
(EXJADE (500 MG)
(TAB DISPER) )
4
4
4
Page 152 of 224
Sharp Health Plan: Covered California
Drug Name
DEFERASIROX
DEFERASIROX
DEFERASIROX
DEFERIPRONE
DEFERIPRONE
PRUSSIAN BLUE (INSOLUBLE)
SUCCIMER
TRIENTINE HCL
ZINC ACETATE
ZINC ACETATE
Drug Tier Requirements/Limits
(JADENU (180 MG)
(TABLET) )
(JADENU (360 MG)
(TABLET) )
(JADENU (90 MG)
(TABLET) )
(FERRIPROX (100
MG/ML)
(SOLUTION) )
(FERRIPROX (500
MG) (TABLET) )
(RADIOGARDASE
(0.5 G) (CAPSULE) )
(CHEMET (100 MG)
(CAPSULE) )
(SYPRINE (250 MG)
(CAPSULE) )
(GALZIN (25 MG)
(CAPSULE) )
(GALZIN (50 MG)
(CAPSULE) )
4
4
4
4
PA
4
PA
3
3
3
3
3
NEEDLES/NEEDLELESS DEVICES
PEN NEEDLE, DIABETIC
(PEN NEEDLES
(OTC))
1
ST
PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE
SAPROPTERIN DIHYDROCHLORIDE
SAPROPTERIN DIHYDROCHLORIDE
SAPROPTERIN DIHYDROCHLORIDE
(KUVAN (100 MG)
(POWD PACK) )
(KUVAN (100 MG)
(TABLET SOL) )
(KUVAN (500 MG)
(POWD PACK) )
4
PA
4
PA
4
PA
SOMATOSTATIC AGENTS
LANREOTIDE ACETATE
LANREOTIDE ACETATE
LANREOTIDE ACETATE
(SOMATULINE
DEPOT (120MG/0.5)
(SYRINGE) )
(SOMATULINE
DEPOT
(60MG/0.2ML)
(SYRINGE) )
(SOMATULINE
DEPOT
(90MG/0.3ML)
(SYRINGE) )
octreotide acetate (100 mcg/ml) (ampul)
octreotide acetate (100 mcg/ml) (syringe)
octreotide acetate (100 mcg/ml) (vial)
octreotide acetate (1000mcg/ml) (vial)
octreotide acetate (200 mcg/ml) (vial)
octreotide acetate (50 mcg/ml) (ampul)
octreotide acetate (50 mcg/ml) (syringe)
octreotide acetate (50 mcg/ml) (vial)
octreotide acetate (500 mcg/ml) (ampul)
octreotide acetate (500 mcg/ml) (syringe)
octreotide acetate (500 mcg/ml) (vial)
OCTREOTIDE ACETATE,MI-SPHERES
OCTREOTIDE ACETATE,MI-SPHERES
Sharp Health Plan: Covered California
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
MB
(SANDOSTATIN
LAR (10 MG) (KIT) )
(SANDOSTATIN
LAR (20 MG) (KIT) )
MB
MB
Page 153 of 224
Sharp Health Plan: Covered California
Drug Name
OCTREOTIDE ACETATE,MI-SPHERES
Drug Tier Requirements/Limits
(SANDOSTATIN
LAR (30 MG) (KIT) )
MB
OTHER RESPIRATORY DISORDERS
ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS
PIRFENIDONE
(ESBRIET (267 MG)
(CAPSULE) )
4
PA
CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR
IVACAFTOR
IVACAFTOR
IVACAFTOR
(KALYDECO (150
MG) (TABLET) )
(KALYDECO (50
MG) (GRAN
PACK) )
(KALYDECO (75
MG) (GRAN
PACK) )
4
PA
4
PA
4
PA
CYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.
LUMACAFTOR/IVACAFTOR
LUMACAFTOR/IVACAFTOR
(ORKAMBI (100-125
MG) (TABLET) )
(ORKAMBI (200125MG) (TABLET) )
4
PA
4
PA
MUCOLYTICS
acetylcysteine
acetylcysteine
DORNASE ALFA
(MUCOMYST (100
MG/ML) (VIAL) )
(MUCOMYST (200
MG/ML) (VIAL) )
(PULMOZYME (1
MG/ML)
(SOLUTION) )
2
2
3
PA
PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS
NINTEDANIB ESYLATE
NINTEDANIB ESYLATE
(OFEV (100 MG)
(CAPSULE) )
(OFEV (150 MG)
(CAPSULE) )
4
PA
4
PA
PAIN MANAGEMENT - ANALGESICS
ANALGESIC, NON-SALICYLATE & BARBITURATE COMB.
BUTALBITAL/ACETAMINOPHEN
BUTALBITAL/ACETAMINOPHEN
butalbital/acetaminophen
(ALLZITAL (25MG325MG) (TABLET) )
(BUPAP (50MG300MG) (TABLET) )
(BUTAPAP (50MG325MG) (TABLET) )
3
PA, QL: 12 IN 1 DAY
3
PA, QL: 6 IN 1 DAY
2
ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB
butalbital/aspirin/caffeine
(FIORINAL (50-32540) (CAPSULE) )
1
ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB
butalb/acetaminophen/caffeine
butalb/acetaminophen/caffeine
butalb/acetaminophen/caffeine
BUTALB/ACETAMINOPHEN/CAFFEINE
(ESGIC (50-325-40)
(CAPSULE) )
(ESGIC (50-325-40)
(TABLET) )
(FIORICET (50-30040) (CAPSULE) )
(VANATOL LQ (50325/15)
(SOLUTION) )
1
1
2
3
ANALGESIC/ANTIPYRETICS, SALICYLATES
aspirin (325 mg) (tablet dr) (otc)
aspirin (325 mg) (tablet) (otc)
Sharp Health Plan: Covered California
PV
PV
Page 154 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
aspirin (81 mg) (tab chew) (otc)
aspirin
aspirin
choline sal/mag salicylate
diflunisal
salsalate
salsalate
PV
(BAYER
CHEWABLE
ASPIRIN (81 MG)
(TAB CHEW)
(OTC))
(ECOTRIN (81 MG)
(TABLET DR)
(OTC))
(CHOLINE MAG
TRISALICYLATE
(500 MG/5ML)
(LIQUID) )
(DOLOBID (500
MG) (TABLET) )
(DISALCID (500
MG) (TABLET) )
(DISALCID (750
MG) (TABLET) )
PV
PV
1
2
1
1
ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION
hydrocodone/ibuprofen
hydrocodone/ibuprofen
hydrocodone/ibuprofen
hydrocodone/ibuprofen
ibuprofen/oxycodone hcl
(IBUDONE (10MG200MG) (TABLET) )
(IBUDONE (5MG200MG) (TABLET) )
(REPREXAIN (2.5200MG) (TABLET) )
(VICOPROFEN (7.5200 MG) (TABLET) )
(COMBUNOX
(400MG-5MG)
(TABLET) )
2
2
2
2
2
ANALGESICS,NARCOTICS
acetaminophen/caff/dihydrocod
aspirin/caffein/dihydrocodeine
BUPRENORPHINE
BUPRENORPHINE
BUPRENORPHINE
BUPRENORPHINE
BUPRENORPHINE
BUPRENORPHINE HCL
BUPRENORPHINE HCL
BUPRENORPHINE HCL
BUPRENORPHINE HCL
Sharp Health Plan: Covered California
(TREZIX (320.530MG) (CAPSULE) )
(SYNALGOS-DC
(356-30-16)
(CAPSULE) )
(BUTRANS (10
MCG/HR) (PATCH
TDWK) )
(BUTRANS (15
MCG/HR) (PATCH
TDWK) )
(BUTRANS (20
MCG/HR) (PATCH
TDWK) )
(BUTRANS (5
MCG/HR) (PATCH
TDWK) )
(BUTRANS (7.5
MCG/HR) (PATCH
TDWK) )
(BELBUCA (150
MCG) (FILM) )
(BELBUCA (300
MCG) (FILM) )
(BELBUCA (450
MCG) (FILM) )
(BELBUCA (600
MCG) (FILM) )
2
QL: 10 IN 1 DAY
2
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
Page 155 of 224
Sharp Health Plan: Covered California
Drug Name
BUPRENORPHINE HCL
BUPRENORPHINE HCL
BUPRENORPHINE HCL
butorphanol tartrate
Drug Tier Requirements/Limits
(BELBUCA (75
MCG) (FILM) )
(BELBUCA (750
MCG) (FILM) )
(BELBUCA (900
MCG) (FILM) )
(STADOL (10
MG/ML) (SPRAY) )
carisoprodol/aspirin/codeine (200-325-16) (tablet)
codeine sulfate
codeine sulfate
codeine sulfate
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
Sharp Health Plan: Covered California
3
PA
3
PA
3
PA
2
1
(CODEINE (15 MG)
(TABLET) )
(CODEINE (30 MG)
(TABLET) )
(CODEINE (60 MG)
(TABLET) )
(DURAGESIC (100
MCG/HR) (PATCH
TD72) )
(DURAGESIC (12
MCG/HR) (PATCH
TD72) )
(DURAGESIC (25
MCG/HR) (PATCH
TD72) )
(DURAGESIC
(37.5MCG/HR)
(PATCH TD72) )
(DURAGESIC
(50MCG/HR)
(PATCH TD72) )
(DURAGESIC
(62.5MCG/HR)
(PATCH TD72) )
(DURAGESIC
(75MCG/HR)
(PATCH TD72) )
(DURAGESIC
(87.5MCG/HR)
(PATCH TD72) )
(SUBSYS
(100MCG/SPR)
(SPRAY) )
(SUBSYS (1200
MCG) (SPRAY) )
(SUBSYS (1600
MCG) (SPRAY) )
(SUBSYS (200
MCG) (SPRAY) )
(SUBSYS
(400MCG/SPR)
(SPRAY) )
(SUBSYS (600
MCG) (SPRAY) )
(SUBSYS (800
MCG) (SPRAY) )
(ABSTRAL (100
MCG) (TAB SUBL) )
(ABSTRAL (200
MCG) (TAB SUBL) )
(ABSTRAL (300
MCG) (TAB SUBL) )
1
1
1
4
PA
1
PA
1
PA
4
PA
1
PA
4
PA
4
PA
4
PA
4
PA
3
PA
3
PA
4
PA
4
PA
4
PA
4
PA
3
PA
3
PA
3
PA
Page 156 of 224
Sharp Health Plan: Covered California
Drug Name
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(ABSTRAL (400
MCG) (TAB SUBL) )
(ABSTRAL (600
MCG) (TAB SUBL) )
(ABSTRAL (800
MCG) (TAB SUBL) )
(ACTIQ (1200 MCG)
(LOZENGE HD) )
(ACTIQ (1600 MCG)
(LOZENGE HD) )
(ACTIQ (200 MCG)
(LOZENGE HD) )
(ACTIQ (400 MCG)
(LOZENGE HD) )
(ACTIQ (600 MCG)
(LOZENGE HD) )
(ACTIQ (800 MCG)
(LOZENGE HD) )
(FENTORA (100
MCG) (TABLET
EFF) )
(FENTORA (200
MCG) (TABLET
EFF) )
(FENTORA (400
MCG) (TABLET
EFF) )
(FENTORA (600
MCG) (TABLET
EFF) )
(FENTORA (800
MCG) (TABLET
EFF) )
(LAZANDA
(100MCG/SPR)
(SPRAY/PUMP) )
(LAZANDA
(300MCG/SPR)
(SPRAY/PUMP) )
(LAZANDA
(400MCG/SPR)
(SPRAY/PUMP) )
(HYSINGLA ER
(100 MG) (TAB ER
24H) )
(HYSINGLA ER
(120 MG) (TAB ER
24H) )
(HYSINGLA ER (20
MG) (TAB ER 24H) )
(HYSINGLA ER (30
MG) (TAB ER 24H) )
(HYSINGLA ER (40
MG) (TAB ER 24H) )
(HYSINGLA ER (60
MG) (TAB ER 24H) )
(HYSINGLA ER (80
MG) (TAB ER 24H) )
(ZOHYDRO ER (10
MG) (CAP ER 12H) )
3
PA
3
PA
3
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
3
PA
3
PA
3
PA
3
PA
3
PA
4
PA
4
PA, QL: 15 IN 21 DAYS
4
PA
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
QL: 1 IN 1 DAY
3
Page 157 of 224
Sharp Health Plan: Covered California
Drug Name
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
HYDROCODONE BITARTRATE
hydrocodone/acetaminophen
Drug Tier Requirements/Limits
(ZOHYDRO ER (15
MG) (CAP ER 12H) )
(ZOHYDRO ER (20
MG) (CAP ER 12H) )
(ZOHYDRO ER (30
MG) (CAP ER 12H) )
(ZOHYDRO ER (40
MG) (CAP ER 12H) )
(ZOHYDRO ER (50
MG) (CAP ER 12H) )
(HYCET (7.5-325/15)
(SOLUTION) )
hydrocodone/acetaminophen (2.5-167/5) (solution)
HYDROCODONE/ACETAMINOPHEN
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
HYDROCODONE/ACETAMINOPHEN
hydrocodone/acetaminophen
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
Sharp Health Plan: Covered California
3
3
3
3
3
1
1
(LORTAB (10300/15)
(SOLUTION) )
(LORTAB (10MG325MG) (TABLET) )
(LORTAB (5 MG325MG) (TABLET) )
(LORTAB (7.5-325
MG) (TABLET) )
(NORCO (10MG325MG) (TABLET) )
(NORCO (5 MG325MG) (TABLET) )
(NORCO (7.5-325
MG) (TABLET) )
(VERDROCET (2.5325 MG) (TABLET) )
(XODOL 10-300
(10MG-300MG)
(TABLET) )
(XODOL 5-300 (5
MG-300MG)
(TABLET) )
(XODOL 7.5-300
(7.5-300 MG)
(TABLET) )
(ZAMICET (10325/15)
(SOLUTION) )
(ZAMICET (10325/15)
(SOLUTION) )
(ZAMICET (5163/7.5)
(SOLUTION) )
(DILAUDID (1
MG/ML) (LIQUID) )
(DILAUDID (2 MG)
(TABLET) )
(DILAUDID (3 MG)
(SUPP.RECT) )
(DILAUDID (4 MG)
(TABLET) )
(DILAUDID (8 MG)
(TABLET) )
(EXALGO (12 MG)
(TAB ER 24H) )
3
1
1
1
1
1
1
2
1
1
1
2
3
2
1
1
1
1
1
2
PA
Page 158 of 224
Sharp Health Plan: Covered California
Drug Name
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
levorphanol tartrate
meperidine hcl
meperidine hcl
meperidine hcl
methadone hcl
methadone hcl
methadone hcl
Drug Tier Requirements/Limits
(EXALGO (16 MG)
(TAB ER 24H) )
(EXALGO (32 MG)
(TAB ER 24H) )
(EXALGO (8 MG)
(TAB ER 24H) )
(LEVODROMORAN (2
MG) (TABLET) )
(DEMEROL (100
MG) (TABLET) )
(DEMEROL (50 MG)
(TABLET) )
(DEMEROL (50
MG/5 ML)
(SOLUTION) )
(DISKETS (40 MG)
(TABLET SOL) )
(DOLOPHINE HCL
(10 MG) (TABLET) )
(DOLOPHINE HCL
(5 MG) (TABLET) )
methadone hcl (10 mg/5 ml) (solution)
methadone hcl (5 mg/5 ml) (solution)
methadone hcl
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
MORPHINE SULFATE
morphine sulfate
MORPHINE SULFATE
morphine sulfate
morphine sulfate
morphine sulfate
MORPHINE SULFATE (15 MG) (TABLET)
MORPHINE SULFATE (30 MG) (TABLET)
Sharp Health Plan: Covered California
2
PA
2
PA
2
PA
2
1
1
2
1
1
1
2
2
(METHADOSE (10
MG/ML) (ORAL
CONC) )
(AVINZA (120 MG)
(CPMP 24HR) )
(AVINZA (30 MG)
(CPMP 24HR) )
(AVINZA (45 MG)
(CPMP 24HR) )
(AVINZA (60 MG)
(CPMP 24HR) )
(AVINZA (75 MG)
(CPMP 24HR) )
(AVINZA (90 MG)
(CPMP 24HR) )
(KADIAN (10 MG)
(CAP ER PEL) )
(KADIAN (100 MG)
(CAP ER PEL) )
(KADIAN (20 MG)
(CAP ER PEL) )
(KADIAN (200 MG)
(CAP ER PEL) )
(KADIAN (30 MG)
(CAP ER PEL) )
(KADIAN (40 MG)
(CAP ER PEL) )
(KADIAN (50 MG)
(CAP ER PEL) )
(KADIAN (60 MG)
(CAP ER PEL) )
(KADIAN (80 MG)
(CAP ER PEL) )
1
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 1 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
3
ST, QL: 4 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
2
ST, QL: 2 IN 1 DAY
3
3
Page 159 of 224
Sharp Health Plan: Covered California
Drug Name
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
MORPHINE SULFATE/NALTREXONE
MORPHINE SULFATE/NALTREXONE
MORPHINE SULFATE/NALTREXONE
MORPHINE SULFATE/NALTREXONE
MORPHINE SULFATE/NALTREXONE
MORPHINE SULFATE/NALTREXONE
Drug Tier Requirements/Limits
(MS CONTIN (100
MG) (TABLET ER) )
(MS CONTIN (15
MG) (TABLET ER) )
(MS CONTIN (200
MG) (TABLET ER) )
(MS CONTIN (30
MG) (TABLET ER) )
(MS CONTIN (60
MG) (TABLET ER) )
(MSIR (10 MG/5
ML) (SOLUTION) )
(MSIR (20 MG/5
ML) (SOLUTION) )
(RMS (10 MG)
(SUPP.RECT) )
(RMS (20 MG)
(SUPP.RECT) )
(RMS (30 MG)
(SUPP.RECT) )
(RMS (5 MG)
(SUPP.RECT) )
(ROXANOL (100
MG/5ML)
(SOLUTION) )
(EMBEDA (100MG4MG) (CAP ER PO) )
(EMBEDA (20MG0.8MG) (CAP ER
PO) )
(EMBEDA (30MG1.2MG) (CAP ER
PO) )
(EMBEDA (50 MG-2
MG) (CAP ER PO) )
(EMBEDA (60MG2.4MG) (CAP ER
PO) )
(EMBEDA (80MG3.2MG) (CAP ER
PO) )
opium/belladonna alkaloids (30-16.2mg) (supp.rect)
opium/belladonna alkaloids (60-16.2mg) (supp.rect)
oxycodone hcl
OXYCODONE HCL
OXYCODONE HCL
oxycodone hcl
oxycodone hcl
OXYCODONE HCL
Sharp Health Plan: Covered California
1
1
1
1
2
2
1
1
1
1
2
3
3
3
3
3
3
2
2
(ETH-OXYDOSE (20
MG/ML) (ORAL
CONC) )
(OXAYDO (5 MG)
(TABLET ORL) )
(OXAYDO (7.5 MG)
(TABLET ORL) )
(OXY IR (5 MG)
(CAPSULE) )
oxycodone hcl (10mg/0.5ml) (syringe)
oxycodone hcl
1
(OXYCONTIN (10
MG) (TAB ER 12H) )
(OXYCONTIN (15
MG) (TAB ER 12H) )
(OXYCONTIN (15
MG) (TAB ER 12H) )
1
PA
3
PA
3
PA
1
PA
4
PA
1
PA
2
PA
3
PA
Page 160 of 224
Sharp Health Plan: Covered California
Drug Name
oxycodone hcl
oxycodone hcl
OXYCODONE HCL
oxycodone hcl
oxycodone hcl
OXYCODONE HCL
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
OXYCODONE HCL/ACETAMINOPHEN
OXYCODONE HCL/ACETAMINOPHEN
OXYCODONE HCL/ACETAMINOPHEN
oxycodone hcl/acetaminophen
OXYCODONE HCL/ACETAMINOPHEN
oxycodone hcl/aspirin
oxycodone hcl/aspirin
OXYCODONE MYRISTATE
OXYCODONE MYRISTATE
OXYCODONE MYRISTATE
OXYCODONE MYRISTATE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(OXYCONTIN (20
MG) (TAB ER 12H) )
(OXYCONTIN (30
MG) (TAB ER 12H) )
(OXYCONTIN (30
MG) (TAB ER 12H) )
(OXYCONTIN (40
MG) (TAB ER 12H) )
(OXYCONTIN (60
MG) (TAB ER 12H) )
(OXYCONTIN (60
MG) (TAB ER 12H) )
(OXYCONTIN (80
MG) (TAB ER 12H) )
(ROXICODONE (10
MG) (TABLET) )
(ROXICODONE (15
MG) (TABLET) )
(ROXICODONE (20
MG) (TABLET) )
(ROXICODONE (30
MG) (TABLET) )
(ROXICODONE (5
MG) (TABLET) )
(ROXICODONE (5
MG/5 ML)
(SOLUTION) )
(PERCOCET (10MG325MG) (TABLET) )
(PERCOCET (2.5325 MG) (TABLET) )
(PERCOCET (5 MG325MG) (TABLET) )
(PERCOCET (7.5325 MG) (TABLET) )
(PRIMLEV (10MG300MG) (TABLET) )
(PRIMLEV (5 MG300MG) (TABLET) )
(PRIMLEV (7.5-300
MG) (TABLET) )
(ROXICET (5-325/5
ML) (SOLUTION) )
(XARTEMIS XR
(7.5-325 MG) (TAB
IR ERO) )
(ENDODAN (4.8355325) (TABLET) )
(PERCODAN
(4.8355-325)
(TABLET) )
(XTAMPZA ER (13.5
MG) (CAP SPR 12) )
(XTAMPZA ER (18
MG) (CAP SPR 12) )
(XTAMPZA ER (27
MG) (CAP SPR 12) )
(XTAMPZA ER (36
MG) (CAP SPR 12) )
1
PA
2
PA
3
PA
1
PA
2
PA
3
PA
1
PA
1
PA
1
PA
1
PA
1
PA
1
PA
1
PA
1
1
1
1
2
2
2
1
3
QL: 12 IN 1 DAY
1
1
3
3
3
3
Page 161 of 224
Sharp Health Plan: Covered California
Drug Name
OXYCODONE MYRISTATE
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
pentazocine hcl/naloxone hcl
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
TAPENTADOL HCL
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
tramadol hcl
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(XTAMPZA ER (9
MG) (CAP SPR 12) )
(OPANA (10 MG)
(TABLET) )
(OPANA (5 MG)
(TABLET) )
(OPANA ER (10 MG)
(TAB ER 12H) )
(OPANA ER (15 MG)
(TAB ER 12H) )
(OPANA ER (20 MG)
(TAB ER 12H) )
(OPANA ER (30 MG)
(TAB ER 12H) )
(OPANA ER (40 MG)
(TAB ER 12H) )
(OPANA ER (5 MG)
(TAB ER 12H) )
(OPANA ER (7.5
MG) (TAB ER 12H) )
(TALWIN NX
(50MG-0.5MG)
(TABLET) )
(NUCYNTA (100
MG) (TABLET) )
(NUCYNTA (50 MG)
(TABLET) )
(NUCYNTA (75 MG)
(TABLET) )
(NUCYNTA ER (100
MG) (TAB ER 12H) )
(NUCYNTA ER (150
MG) (TAB ER 12H) )
(NUCYNTA ER (200
MG) (TAB ER 12H) )
(NUCYNTA ER (250
MG) (TAB ER 12H) )
(NUCYNTA ER (50
MG) (TAB ER 12H) )
(CONZIP (100 MG)
(CPBP 25-75) )
(CONZIP (150 MG)
(CPBP 25-75) )
(CONZIP (200 MG)
(CPBP 25-75) )
(CONZIP (300 MG)
(CPBP 17-83) )
(RYZOLT (100 MG)
(TBMP 24HR) )
(RYZOLT (200 MG)
(TBMP 24HR) )
(RYZOLT (300 MG)
(TBMP 24HR) )
(ULTRAM (50 MG)
(TABLET) )
(ULTRAM ER (100
MG) (TAB ER 24H) )
(ULTRAM ER (200
MG) (TAB ER 24H) )
3
2
2
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
2
QL: 4 IN 1 DAY
2
QL: 4 IN 1 DAY
2
QL: 2 IN 1 DAY
2
QL: 2 IN 1 DAY
1
3
PA, QL: 180 IN 30 DAYS
3
PA, QL: 180 IN 30 DAYS
3
PA, QL: 180 IN 30 DAYS
3
PA, QL: 2 IN 1 DAY
3
PA, QL: 2 IN 1 DAY
3
PA, QL: 2 IN 1 DAY
3
PA, QL: 2 IN 1 DAY
3
PA, QL: 2 IN 1 DAY
2
PA
2
PA
2
PA
2
PA
2
PA
2
PA
2
PA
1
2
PA
2
PA
Page 162 of 224
Sharp Health Plan: Covered California
Drug Name
tramadol hcl
tramadol hcl/acetaminophen
Drug Tier Requirements/Limits
(ULTRAM ER (300
MG) (TAB ER 24H) )
(ULTRACET (37.5325MG) (TABLET) )
2
PA
2
ANTIMIGRAINE PREPARATIONS
almotriptan malate
almotriptan malate
DICLOFENAC POTASSIUM
dihydroergotamine mesylate
ELETRIPTAN HBR
ELETRIPTAN HBR
ERGOTAMINE TARTRATE
ERGOTAMINE TARTRATE/CAFFEINE
ERGOTAMINE TARTRATE/CAFFEINE
frovatriptan succinate
isomethept/dichlphn/acetaminop
isomethepten/caf/acetaminophen
naratriptan hcl
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate
rizatriptan benzoate
rizatriptan benzoate
SUMATRIPTAN SUCC/NAPROXEN SOD
SUMATRIPTAN SUCC/NAPROXEN SOD
SUMATRIPTAN SUCCINATE
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
Sharp Health Plan: Covered California
(AXERT (12.5 MG)
(TABLET) )
(AXERT (6.25 MG)
(TABLET) )
(CAMBIA (50 MG)
(POWD PACK) )
(MIGRANAL
(0.5MG/SPRY)
(SPRAY/PUMP) )
(RELPAX (20 MG)
(TABLET) )
(RELPAX (40 MG)
(TABLET) )
(ERGOMAR (2 MG)
(TAB SUBL) )
(CAFERGOT (1 MG100MG) (TABLET) )
(MIGERGOT (2100MG)
(SUPP.RECT) )
(FROVA (2.5 MG)
(TABLET) )
(MIDRIN (65-100325) (CAPSULE) )
(PRODRIN (65-20325) (TABLET) )
(AMERGE (1 MG)
(TABLET) )
(AMERGE (2.5 MG)
(TABLET) )
(MAXALT (10 MG)
(TABLET) )
(MAXALT (5 MG)
(TABLET) )
(MAXALT MLT (10
MG) (TAB
RAPDIS) )
(MAXALT MLT (5
MG) (TAB
RAPDIS) )
(TREXIMET (10
MG-60MG)
(TABLET) )
(TREXIMET (85MG500MG) (TABLET) )
(ALSUMA (6
MG/0.5ML) (PEN
INJCTR) )
(IMITREX (100 MG)
(TABLET) )
(IMITREX (25 MG)
(TABLET) )
(IMITREX (4
MG/0.5ML)
(CARTRIDGE) )
2
ST, QL: 12 IN 30 DAYS
2
ST, QL: 6 IN 30 DAYS
3
ST, QL: 9 IN 30 DAYS
4
ST, QL: 8 IN 28 DAYS
3
ST, QL: 6 IN 30 DAYS
3
ST, QL: 6 IN 30 DAYS
2
2
3
2
ST, QL: 9 IN 30 DAYS
1
2
2
ST, QL: 9 IN 30 DAYS
2
ST, QL: 9 IN 30 DAYS
1
QL: 9 IN 30 DAYS
1
QL: 9 IN 30 DAYS
1
QL: 9 IN 30 DAYS
1
QL: 9 IN 30 DAYS
4
3
ST, QL: 2 IN 23 DAYS
2
QL: 1 PER FILL
1
QL: 9 PER FILL
1
QL: 9 PER FILL
1
QL: 2 PER FILL
Page 163 of 224
Sharp Health Plan: Covered California
Drug Name
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
ZOLMITRIPTAN
zolmitriptan
ZOLMITRIPTAN
zolmitriptan
zolmitriptan
zolmitriptan
Drug Tier Requirements/Limits
(IMITREX (4
MG/0.5ML) (PEN
INJCTR) )
(IMITREX (50 MG)
(TABLET) )
(IMITREX (6
MG/0.5ML)
(CARTRIDGE) )
(IMITREX (6
MG/0.5ML) (PEN
INJCTR) )
(IMITREX (6
MG/0.5ML)
(SYRINGE) )
(IMITREX (6
MG/0.5ML) (VIAL) )
(ONZETRA XSAIL
(11 MG) (AER POW
BA) )
(SUMAVEL
DOSEPRO (4
MG/0.5ML) (NDL
FR INJ) )
(SUMAVEL
DOSEPRO (6
MG/0.5ML) (NDL
FR INJ) )
(ZEMBRACE
SYMTOUCH (3
MG/0.5ML) (PEN
INJCTR) )
(ZOMIG (2.5 MG)
(SPRAY) )
(ZOMIG (2.5 MG)
(TABLET) )
(ZOMIG (5 MG)
(SPRAY) )
(ZOMIG (5 MG)
(TABLET) )
(ZOMIG ZMT (2.5
MG) (TAB
RAPDIS) )
(ZOMIG ZMT (5
MG) (TAB
RAPDIS) )
1
QL: 2 PER FILL
1
QL: 9 PER FILL
1
QL: 1 PER FILL
1
QL: 1 PER FILL
1
QL: 1 PER FILL
1
QL: 1 PER FILL
3
ST, QL: 16 IN 30 DAYS
3
ST, QL: 4 IN 30 DAYS
3
ST, QL: 4 IN 30 DAYS
3
PA
3
ST, QL: 6 IN 30 DAYS
2
ST, QL: 6 IN 30 DAYS
3
ST, QL: 6 IN 30 DAYS
2
ST, QL: 6 IN 30 DAYS
2
ST, QL: 6 IN 30 DAYS
2
ST, QL: 6 IN 30 DAYS
NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB
butalbit/acetamin/caff/codeine
butalbit/acetamin/caff/codeine
(FIORICET WITH
CODEINE (50-30030) (CAPSULE) )
(FIORICET WITH
CODEINE (50-32530) (CAPSULE) )
2
1
NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE
codeine/butalbital/asa/caffein
(FIORINAL WITH
CODEINE #3 (30-50325) (CAPSULE) )
1
NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB
acetaminophen with codeine (300mg/12.5) (solution)
acetaminophen with codeine (300mg-15mg) (tablet)
Sharp Health Plan: Covered California
2
1
Page 164 of 224
Sharp Health Plan: Covered California
Drug Name
ACETAMINOPHEN WITH CODEINE
acetaminophen with codeine
acetaminophen with codeine
acetaminophen with codeine
Drug Tier Requirements/Limits
(CAPITAL WCODEINE (12012MG/5) (ORAL
SUSP) )
(TYLENOL WITH
CODEINE (12012MG/5)
(SOLUTION) )
(TYLENOLCODEINE NO.3
(300MG-30MG)
(TABLET) )
(TYLENOLCODEINE NO.4
(300MG-60MG)
(TABLET) )
2
2
1
1
NARCOTIC WITHDRAWAL THERAPY AGENTS
buprenorphine hcl
buprenorphine hcl
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
buprenorphine hcl/naloxone hcl
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
buprenorphine hcl/naloxone hcl
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HCL/NALOXONE HCL
(SUBUTEX (2 MG)
(TAB SUBL) )
(SUBUTEX (8 MG)
(TAB SUBL) )
(BUNAVAIL (2.1-0.3
MG) (FILM) )
(BUNAVAIL (4.2-0.7
MG) (FILM) )
(BUNAVAIL
(6.3MG-1MG)
(FILM) )
(SUBOXONE (12
MG-3 MG) (FILM) )
(SUBOXONE (2
MG-0.5MG)
(FILM) )
(SUBOXONE (2
MG-0.5MG) (TAB
SUBL) )
(SUBOXONE (4MG1MG) (FILM) )
(SUBOXONE (8
MG-2 MG) (FILM) )
(SUBOXONE (8
MG-2 MG) (TAB
SUBL) )
(ZUBSOLV (1.40.36MG) (TAB
SUBL) )
(ZUBSOLV (11.42.9MG) (TAB
SUBL) )
(ZUBSOLV (2.90.71MG) (TAB
SUBL) )
(ZUBSOLV (5.7-1.4
MG) (TAB SUBL) )
(ZUBSOLV (8.6-2.1
MG) (TAB SUBL) )
2
PA, QL: 20 IN 30 DAYS
2
PA, QL: 20 IN 30 DAYS
3
PA
3
PA
3
PA
3
PA
3
PA
2
PA
3
PA
3
PA
2
PA
3
PA
3
PA
3
PA
3
PA
3
PA
PARKINSONS DISEASE
ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC
benztropine mesylate
Sharp Health Plan: Covered California
(COGENTIN (0.5
MG) (TABLET) )
1
Page 165 of 224
Sharp Health Plan: Covered California
Drug Name
benztropine mesylate
benztropine mesylate
trihexyphenidyl hcl
trihexyphenidyl hcl
trihexyphenidyl hcl
Drug Tier Requirements/Limits
(COGENTIN (1 MG)
(TABLET) )
(COGENTIN (2 MG)
(TABLET) )
(ARTANE (2 MG)
(TABLET) )
(ARTANE (2 MG/5
ML) (ELIXIR) )
(ARTANE (5 MG)
(TABLET) )
1
1
1
1
1
ANTIPARKINSONISM DRUGS,OTHER
amantadine hcl
amantadine hcl
amantadine hcl
APOMORPHINE HCL
bromocriptine mesylate
bromocriptine mesylate
CARBIDOPA/LEVODOPA
carbidopa/levodopa
carbidopa/levodopa
carbidopa/levodopa
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
carbidopa/levodopa
carbidopa/levodopa
carbidopa/levodopa
carbidopa/levodopa
Sharp Health Plan: Covered California
(SYMMETREL (100
MG) (CAPSULE) )
(SYMMETREL (100
MG) (TABLET) )
(SYMMETREL (50
MG/5 ML)
(SOLUTION) )
(APOKYN (10
MG/ML)
(CARTRIDGE) )
(PARLODEL (2.5
MG) (TABLET) )
(PARLODEL (5 MG)
(CAPSULE) )
(DUOPA (4.6320/ML) (INT PMP
SP) )
(PARCOPA (10MG100MG) (TAB
RAPDIS) )
(PARCOPA (25MG100MG) (TAB
RAPDIS) )
(PARCOPA (25MG250MG) (TAB
RAPDIS) )
(RYTARY (23.7595MG) (CAPSULE
ER) )
(RYTARY (36.25145) (CAPSULE
ER) )
(RYTARY (48.75195) (CAPSULE
ER) )
(RYTARY (61.25245) (CAPSULE
ER) )
(SINEMET 10-100
(10MG-100MG)
(TABLET) )
(SINEMET 25-100
(25MG-100MG)
(TABLET) )
(SINEMET 25-250
(25MG-250MG)
(TABLET) )
(SINEMET CR
(25MG-100MG)
(TABLET ER) )
1
1
1
MB
1
1
4
2
2
2
4
ST, QL: 10 IN 1 DAY
4
ST, QL: 10 IN 1 DAY
4
ST, QL: 10 IN 1 DAY
4
ST, QL: 10 IN 1 DAY
1
1
1
1
Page 166 of 224
Sharp Health Plan: Covered California
Drug Name
carbidopa/levodopa
carbidopa/levodopa/entacapone
carbidopa/levodopa/entacapone
carbidopa/levodopa/entacapone
carbidopa/levodopa/entacapone
carbidopa/levodopa/entacapone
carbidopa/levodopa/entacapone
entacapone
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
pramipexole di-hcl
RASAGILINE MESYLATE
RASAGILINE MESYLATE
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(SINEMET CR
(50MG-200MG)
(TABLET ER) )
(STALEVO 100 (25100-200) (TABLET) )
(STALEVO 125
(31.25-125)
(TABLET) )
(STALEVO 150
(37.5-150MG)
(TABLET) )
(STALEVO 200 (50200-200) (TABLET) )
(STALEVO 50 (12.550 MG) (TABLET) )
(STALEVO 75
(18.75-75MG)
(TABLET) )
(COMTAN (200 MG)
(TABLET) )
(MIRAPEX (0.125
MG) (TABLET) )
(MIRAPEX (0.25
MG) (TABLET) )
(MIRAPEX (0.5 MG)
(TABLET) )
(MIRAPEX (0.75
MG) (TABLET) )
(MIRAPEX (1 MG)
(TABLET) )
(MIRAPEX (1.5 MG)
(TABLET) )
(MIRAPEX ER
(0.375 MG) (TAB ER
24H) )
(MIRAPEX ER (0.75
MG) (TAB ER 24H) )
(MIRAPEX ER (1.5
MG) (TAB ER 24H) )
(MIRAPEX ER (2.25
MG) (TAB ER 24H) )
(MIRAPEX ER (3
MG) (TAB ER 24H) )
(MIRAPEX ER (3.75
MG) (TAB ER 24H) )
(MIRAPEX ER (4.5
MG) (TAB ER 24H) )
(AZILECT (0.5 MG)
(TABLET) )
(AZILECT (1 MG)
(TABLET) )
(REQUIP (0.25 MG)
(TABLET) )
(REQUIP (0.5 MG)
(TABLET) )
(REQUIP (1 MG)
(TABLET) )
(REQUIP (2 MG)
(TABLET) )
1
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
2
2
2
2
Page 167 of 224
Sharp Health Plan: Covered California
Drug Name
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
ropinirole hcl
ROTIGOTINE
ROTIGOTINE
ROTIGOTINE
ROTIGOTINE
ROTIGOTINE
ROTIGOTINE
selegiline hcl
selegiline hcl
SELEGILINE HCL
tolcapone
Drug Tier Requirements/Limits
(REQUIP (3 MG)
(TABLET) )
(REQUIP (4 MG)
(TABLET) )
(REQUIP (5 MG)
(TABLET) )
(REQUIP XL (12
MG) (TAB ER 24H) )
(REQUIP XL (2 MG)
(TAB ER 24H) )
(REQUIP XL (4 MG)
(TAB ER 24H) )
(REQUIP XL (6 MG)
(TAB ER 24H) )
(REQUIP XL (8 MG)
(TAB ER 24H) )
(NEUPRO (1 MG/24
HR) (PATCH TD24) )
(NEUPRO (2 MG/24
HR) (PATCH TD24) )
(NEUPRO (3 MG/24
HR) (PATCH TD24) )
(NEUPRO (4 MG/24
HR) (PATCH TD24) )
(NEUPRO (6 MG/24
HR) (PATCH TD24) )
(NEUPRO (8 MG/24
HR) (PATCH TD24) )
(ELDEPRYL (5 MG)
(CAPSULE) )
(ELDEPRYL (5 MG)
(TABLET) )
(ZELAPAR (1.25
MG) (TAB
RAPDIS) )
(TASMAR (100 MG)
(TABLET) )
2
2
2
2
2
2
2
2
3
3
3
3
3
3
1
PA
2
PA
3
PA
2
DECARBOXYLASE INHIBITORS
carbidopa
(LODOSYN (25 MG)
(TABLET) )
2
SEIZURE DISORDER
ANTICONVULSANTS
BRIVARACETAM
BRIVARACETAM
BRIVARACETAM
BRIVARACETAM
BRIVARACETAM
BRIVARACETAM
carbamazepine
carbamazepine
Sharp Health Plan: Covered California
(BRIVIACT (10 MG)
(TABLET) )
(BRIVIACT (10
MG/ML)
(SOLUTION) )
(BRIVIACT (100
MG) (TABLET) )
(BRIVIACT (25 MG)
(TABLET) )
(BRIVIACT (50 MG)
(TABLET) )
(BRIVIACT (75 MG)
(TABLET) )
(CARBATROL (100
MG) (CPMP 12HR) )
(CARBATROL (200
MG) (CPMP 12HR) )
4
4
4
4
4
4
2
2
Page 168 of 224
Sharp Health Plan: Covered California
Drug Name
carbamazepine
carbamazepine
carbamazepine
carbamazepine
carbamazepine
carbamazepine
carbamazepine
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
diazepam
diazepam
diazepam
divalproex sodium
divalproex sodium
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(CARBATROL (300
MG) (CPMP 12HR) )
(TEGRETOL (100
MG) (TAB CHEW) )
(TEGRETOL (100
MG/5ML) (ORAL
SUSP) )
(TEGRETOL (200
MG) (TABLET) )
(TEGRETOL XR
(100 MG) (TAB ER
12H) )
(TEGRETOL XR
(200 MG) (TAB ER
12H) )
(TEGRETOL XR
(400 MG) (TAB ER
12H) )
(KLONOPIN (0.5
MG) (TABLET) )
(KLONOPIN (1 MG)
(TABLET) )
(KLONOPIN (2 MG)
(TABLET) )
(KLONOPIN
RAPIDLY
DISINTEGRATING
(0.125 MG) (TAB
RAPDIS) )
(KLONOPIN
RAPIDLY
DISINTEGRATING
(0.25 MG) (TAB
RAPDIS) )
(KLONOPIN
RAPIDLY
DISINTEGRATING
(0.5 MG) (TAB
RAPDIS) )
(KLONOPIN
RAPIDLY
DISINTEGRATING
(1 MG) (TAB
RAPDIS) )
(KLONOPIN
RAPIDLY
DISINTEGRATING
(2 MG) (TAB
RAPDIS) )
(DIASTAT (2.5 MG)
(KIT) )
(DIASTAT
ACUDIAL (12.5-1520) (KIT) )
(DIASTAT
ACUDIAL (5-7.510MG) (KIT) )
(DEPAKOTE (125
MG) (TABLET DR) )
(DEPAKOTE (250
MG) (TABLET DR) )
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
1
Page 169 of 224
Sharp Health Plan: Covered California
Drug Name
divalproex sodium
divalproex sodium
divalproex sodium
divalproex sodium
ESLICARBAZEPINE ACETATE
ESLICARBAZEPINE ACETATE
ESLICARBAZEPINE ACETATE
ESLICARBAZEPINE ACETATE
ethosuximide
ethosuximide
ETHOTOIN
EZOGABINE
EZOGABINE
EZOGABINE
EZOGABINE
felbamate
felbamate
felbamate
gabapentin
gabapentin
gabapentin
gabapentin
gabapentin
gabapentin
gabapentin
LACOSAMIDE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(DEPAKOTE (500
MG) (TABLET DR) )
(DEPAKOTE ER
(250 MG) (TAB ER
24H) )
(DEPAKOTE ER
(500 MG) (TAB ER
24H) )
(DEPAKOTE
SPRINKLE (125
MG) (CAP
SPRINK) )
(APTIOM (200 MG)
(TABLET) )
(APTIOM (400 MG)
(TABLET) )
(APTIOM (600 MG)
(TABLET) )
(APTIOM (800 MG)
(TABLET) )
(ZARONTIN (250
MG) (CAPSULE) )
(ZARONTIN (250
MG/5ML)
(SOLUTION) )
(PEGANONE (250
MG) (TABLET) )
(POTIGA (200 MG)
(TABLET) )
(POTIGA (300 MG)
(TABLET) )
(POTIGA (400 MG)
(TABLET) )
(POTIGA (50 MG)
(TABLET) )
(FELBATOL (400
MG) (TABLET) )
(FELBATOL (600
MG) (TABLET) )
(FELBATOL (600
MG/5ML) (ORAL
SUSP) )
(NEURONTIN (100
MG) (CAPSULE) )
(NEURONTIN (250
MG/5ML)
(SOLUTION) )
(NEURONTIN (300
MG) (CAPSULE) )
(NEURONTIN (300
MG/6ML)
(SOLUTION) )
(NEURONTIN (400
MG) (CAPSULE) )
(NEURONTIN (600
MG) (TABLET) )
(NEURONTIN (800
MG) (TABLET) )
(VIMPAT (10
MG/ML)
(SOLUTION) )
1
1
1
1
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
1
1
3
3
3
3
3
2
2
2
1
1
1
2
1
1
1
3
Page 170 of 224
Sharp Health Plan: Covered California
Drug Name
LACOSAMIDE
LACOSAMIDE
LACOSAMIDE
LACOSAMIDE
Drug Tier Requirements/Limits
(VIMPAT (100 MG)
(TABLET) )
(VIMPAT (150 MG)
(TABLET) )
(VIMPAT (200 MG)
(TABLET) )
(VIMPAT (50 MG)
(TABLET) )
3
QL: 2 IN 1 DAY
3
QL: 2 IN 1 DAY
3
QL: 2 IN 1 DAY
3
QL: 2 IN 1 DAY
lamotrigine
(LAMICTAL (100
MG) (TABLET) )
1
lamotrigine
(LAMICTAL (150
MG) (TABLET) )
1
lamotrigine
(LAMICTAL (200
MG) (TABLET) )
1
lamotrigine
(LAMICTAL (25
MG) (TABLET) )
1
lamotrigine
(LAMICTAL (25
MG) (TB CHW
DSP) )
1
lamotrigine
(LAMICTAL (5 MG)
(TB CHW DSP) )
1
lamotrigine
LAMOTRIGINE
LAMOTRIGINE
lamotrigine
lamotrigine
lamotrigine
lamotrigine
lamotrigine
lamotrigine
Sharp Health Plan: Covered California
(LAMICTAL (BLUE)
(25MG (35)) (TAB
DS PK) )
(LAMICTAL
(GREEN) (25(84)100) (TAB DS PK) )
(LAMICTAL
(ORANGE) (25(42)100) (TAB DS PK) )
(LAMICTAL ODT
(100 MG) (TAB
RAPDIS) )
(LAMICTAL ODT
(200 MG) (TAB
RAPDIS) )
(LAMICTAL ODT
(25 MG) (TAB
RAPDIS) )
(LAMICTAL ODT
(50 MG) (TAB
RAPDIS) )
(LAMICTAL ODT
(BLUE) (25(21)-50)
(TB RD DSPK) )
(LAMICTAL ODT
(GREEN) (50(42)100) (TB RD
DSPK) )
QL: 3 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
QL: 3 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
QL: 2 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
QL: 6 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
QL: 6 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
QL: 8 IN 1 DAY; USE
RESTRICTED TO
PSYCHIATRY AND
NEUROLOGY
1
QL: 6 IN 1 DAY
2
QL: 98 IN 180 DAYS
2
QL: 49 IN 180 DAYS
2
2
2
2
2
2
Page 171 of 224
Sharp Health Plan: Covered California
Drug Name
lamotrigine
lamotrigine
lamotrigine
lamotrigine
lamotrigine
lamotrigine
lamotrigine
LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
levetiracetam
levetiracetam
levetiracetam
levetiracetam
levetiracetam
levetiracetam
levetiracetam
levetiracetam
levetiracetam
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
METHSUXIMIDE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(LAMICTAL ODT
(ORANGE) (25-50100) (TB RD
DSPK) )
(LAMICTAL XR
(100 MG) (TAB ER
24) )
(LAMICTAL XR
(200 MG) (TAB ER
24) )
(LAMICTAL XR (25
MG) (TAB ER 24) )
(LAMICTAL XR
(250 MG) (TAB ER
24) )
(LAMICTAL XR
(300 MG) (TAB ER
24) )
(LAMICTAL XR (50
MG) (TAB ER 24) )
(LAMICTAL XR
(BLUE) (25(21)-50)
(TB ER DSPK) )
(LAMICTAL XR
(GREEN) (50-100200) (TB ER DSPK) )
(LAMICTAL XR
(ORANGE) (25-50100) (TB ER DSPK) )
(KEPPRA (100
MG/ML)
(SOLUTION) )
(KEPPRA (1000 MG)
(TABLET) )
(KEPPRA (250 MG)
(TABLET) )
(KEPPRA (500 MG)
(TABLET) )
(KEPPRA (500
MG/5ML)
(SOLUTION) )
(KEPPRA (750 MG)
(TABLET) )
(KEPPRA XR (500
MG) (TAB ER 24H) )
(KEPPRA XR (750
MG) (TAB ER 24H) )
(ROWEEPRA (500
MG) (TABLET) )
(SPRITAM (1000
MG) (TAB SUSP) )
(SPRITAM (250 MG)
(TAB SUSP) )
(SPRITAM (500 MG)
(TAB SUSP) )
(SPRITAM (750 MG)
(TAB SUSP) )
(CELONTIN (300
MG) (CAPSULE) )
2
2
2
2
2
2
2
3
3
3
1
PA
1
1
1
1
PA
1
2
PA
2
PA
1
3
ST, QL: 3 IN 1 DAY
3
ST, QL: 12 IN 1 DAY
3
ST, QL: 6 IN 1 DAY
3
ST, QL: 4 IN 1 DAY
3
Page 172 of 224
Sharp Health Plan: Covered California
Drug Name
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
oxcarbazepine
oxcarbazepine
oxcarbazepine
oxcarbazepine
PERAMPANEL
PERAMPANEL
PERAMPANEL
PERAMPANEL
PERAMPANEL
PERAMPANEL
PERAMPANEL
phenytoin
phenytoin
phenytoin
phenytoin sodium extended
PHENYTOIN SODIUM EXTENDED
phenytoin sodium extended
phenytoin sodium extended
PREGABALIN
PREGABALIN
PREGABALIN
PREGABALIN
PREGABALIN
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(OXTELLAR XR
(150 MG) (TAB ER
24H) )
(OXTELLAR XR
(300 MG) (TAB ER
24H) )
(OXTELLAR XR
(600 MG) (TAB ER
24H) )
(TRILEPTAL (150
MG) (TABLET) )
(TRILEPTAL (300
MG) (TABLET) )
(TRILEPTAL (300
MG/5ML) (ORAL
SUSP) )
(TRILEPTAL (600
MG) (TABLET) )
(FYCOMPA (0.5
MG/ML) (ORAL
SUSP) )
(FYCOMPA (10 MG)
(TABLET) )
(FYCOMPA (12 MG)
(TABLET) )
(FYCOMPA (2 MG)
(TABLET) )
(FYCOMPA (4 MG)
(TABLET) )
(FYCOMPA (6 MG)
(TABLET) )
(FYCOMPA (8 MG)
(TABLET) )
(DILANTIN (50 MG)
(TAB CHEW) )
(DILANTIN-125
(100 MG/4ML)
(ORAL SUSP) )
(DILANTIN-125
(125 MG/5ML)
(ORAL SUSP) )
(DILANTIN (100
MG) (CAPSULE) )
(DILANTIN (30 MG)
(CAPSULE) )
(PHENYTEK (200
MG) (CAPSULE) )
(PHENYTEK (300
MG) (CAPSULE) )
(LYRICA (100 MG)
(CAPSULE) )
(LYRICA (150 MG)
(CAPSULE) )
(LYRICA (20
MG/ML)
(SOLUTION) )
(LYRICA (200 MG)
(CAPSULE) )
(LYRICA (225 MG)
(CAPSULE) )
3
3
3
1
QL: 2 IN 1 DAY
1
QL: 2 IN 1 DAY
1
PA
1
QL: 4 IN 1 DAY
3
ST, QL: 680 IN 28 DAYS
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
3
ST, QL: 4 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 1 IN 1 DAY
1
1
1
1
1
1
1
3
ST
3
ST
3
ST
3
ST
3
ST
Page 173 of 224
Sharp Health Plan: Covered California
Drug Name
PREGABALIN
PREGABALIN
PREGABALIN
PREGABALIN
primidone
primidone
RUFINAMIDE
RUFINAMIDE
RUFINAMIDE
TIAGABINE HCL
TIAGABINE HCL
tiagabine hcl
tiagabine hcl
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
topiramate
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(LYRICA (25 MG)
(CAPSULE) )
(LYRICA (300 MG)
(CAPSULE) )
(LYRICA (50 MG)
(CAPSULE) )
(LYRICA (75 MG)
(CAPSULE) )
(MYSOLINE (250
MG) (TABLET) )
(MYSOLINE (50
MG) (TABLET) )
(BANZEL (200 MG)
(TABLET) )
(BANZEL (40
MG/ML) (ORAL
SUSP) )
(BANZEL (400 MG)
(TABLET) )
(GABITRIL (12 MG)
(TABLET) )
(GABITRIL (16 MG)
(TABLET) )
(GABITRIL (2 MG)
(TABLET) )
(GABITRIL (4 MG)
(TABLET) )
(QUDEXY XR (100
MG) (CAP SPR 24) )
(QUDEXY XR (150
MG) (CAP SPR 24) )
(QUDEXY XR (200
MG) (CAP SPR 24) )
(QUDEXY XR (25
MG) (CAP SPR 24) )
(QUDEXY XR (50
MG) (CAP SPR 24) )
(TOPAMAX (100
MG) (TABLET) )
(TOPAMAX (15 MG)
(CAP SPRINK) )
(TOPAMAX (200
MG) (TABLET) )
(TOPAMAX (25 MG)
(CAP SPRINK) )
(TOPAMAX (25 MG)
(TABLET) )
(TOPAMAX (50 MG)
(TABLET) )
(TROKENDI XR
(100 MG) (CAP ER
24H) )
(TROKENDI XR
(200 MG) (CAP ER
24H) )
(TROKENDI XR (25
MG) (CAP ER 24H) )
(TROKENDI XR (50
MG) (CAP ER 24H) )
3
ST
3
ST
3
ST
3
ST
1
1
3
3
3
3
3
2
2
2
2
2
2
2
1
QL: 3 IN 1 DAY
1
QL: 4 IN 1 DAY
1
QL: 2 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 3 IN 1 DAY
1
QL: 2 IN 1 DAY
3
PA, QL: 1 IN 1 DAY
3
PA, QL: 2 IN 1 DAY
3
PA, QL: 1 IN 1 DAY
3
PA, QL: 1 IN 1 DAY
Page 174 of 224
Sharp Health Plan: Covered California
Drug Name
valproic acid (as sodium salt)
VIGABATRIN
VIGABATRIN
zonisamide
zonisamide
zonisamide
Drug Tier Requirements/Limits
(DEPAKENE (250
MG/5ML)
(SOLUTION) )
(SABRIL (500 MG)
(POWD PACK) )
(SABRIL (500 MG)
(TABLET) )
(ZONEGRAN (100
MG) (CAPSULE) )
(ZONEGRAN (25
MG) (CAPSULE) )
(ZONEGRAN (50
MG) (CAPSULE) )
1
4
PA
4
PA
1
PA
1
PA
1
PA
3
ST, QL: 2 IN 1 DAY
3
ST, QL: 480 IN 30 DAYS
3
ST, QL: 2 IN 1 DAY
BENZODIAZEPINES
CLOBAZAM
CLOBAZAM
CLOBAZAM
(ONFI (10 MG)
(TABLET) )
(ONFI (2.5 MG/ML)
(ORAL SUSP) )
(ONFI (20 MG)
(TABLET) )
SKELETAL MUSCLE DISORDER
AGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH
DICHLORPHENAMIDE
(KEVEYIS (50 MG)
(TABLET) )
4
PA
SKELETAL MUSCLE RELAXANTS
baclofen
baclofen
carisoprodol
carisoprodol
carisoprodol/aspirin
CHLORZOXAZONE
CHLORZOXAZONE
chlorzoxazone
CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE HCL
cyclobenzaprine hcl
cyclobenzaprine hcl
cyclobenzaprine hcl
dantrolene sodium
dantrolene sodium
dantrolene sodium
Sharp Health Plan: Covered California
(LIORESAL (10 MG)
(TABLET) )
(LIORESAL (20 MG)
(TABLET) )
(SOMA (250 MG)
(TABLET) )
(SOMA (350 MG)
(TABLET) )
(SOMA
COMPOUND (200325 MG) (TABLET) )
(LORZONE (375
MG) (TABLET) )
(LORZONE (750
MG) (TABLET) )
(PARAFON FORTE
DSC (500 MG)
(TABLET) )
(AMRIX (15 MG)
(CAP ER 24H) )
(AMRIX (30 MG)
(CAP ER 24H) )
(FEXMID (7.5 MG)
(TABLET) )
(FLEXERIL (10 MG)
(TABLET) )
(FLEXERIL (5 MG)
(TABLET) )
(DANTRIUM (100
MG) (CAPSULE) )
(DANTRIUM (25
MG) (CAPSULE) )
(DANTRIUM (50
MG) (CAPSULE) )
1
2
1
1
1
3
3
1
3
3
2
1
1
2
2
2
Page 175 of 224
Sharp Health Plan: Covered California
Drug Name
metaxalone
metaxalone
methocarbamol
methocarbamol
orphenadrine citrate
tizanidine hcl
tizanidine hcl
tizanidine hcl
tizanidine hcl
tizanidine hcl
Drug Tier Requirements/Limits
(SKELAXIN (400
MG) (TABLET) )
(SKELAXIN (800
MG) (TABLET) )
(ROBAXIN (500
MG) (TABLET) )
(ROBAXIN-750 (750
MG) (TABLET) )
(NORFLEX (100
MG) (TABLET ER) )
(ZANAFLEX (2 MG)
(CAPSULE) )
(ZANAFLEX (2 MG)
(TABLET) )
(ZANAFLEX (4 MG)
(CAPSULE) )
(ZANAFLEX (4 MG)
(TABLET) )
(ZANAFLEX (6 MG)
(CAPSULE) )
2
2
1
1
2
2
2
2
2
2
SMOKING CESSATION
SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)
nicotine
nicotine
nicotine
(NICODERM CQ
(14MG/24HR)
(PATCH TD24)
(OTC))
(NICODERM CQ (21
MG/24HR) (PATCH
TD24) (OTC))
(NICODERM CQ
(7MG/24HR)
(PATCH TD24)
(OTC))
NICOTINE PATCH (21-14-7MG) (PATCH DYSQ)
(OTC)
NICOTINE
NICOTINE
nicotine
nicotine polacrilex
nicotine polacrilex
nicotine polacrilex
nicotine polacrilex
PV
PV
PV
PV
(NICOTROL (10
MG)
(CARTRIDGE) )
(NICOTROL NS (10
MG/ML) (SPRAY) )
(PROSTEP (22
MG/24HR) (PATCH
TD24) (OTC))
(NICORETTE (2
MG) (GUM) (OTC))
(NICORETTE (2
MG) (LOZENGE)
(OTC))
(NICORETTE (4
MG) (GUM) (OTC))
(NICORETTE (4
MG) (LOZENGE)
(OTC))
PV
PV
PV
PV
PV
PV
PV
SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST
VARENICLINE TARTRATE
VARENICLINE TARTRATE
VARENICLINE TARTRATE
Sharp Health Plan: Covered California
(CHANTIX (0.5 (11)1) (TAB DS PK) )
(CHANTIX (0.5 MG)
(TABLET) )
(CHANTIX (1 MG)
(TABLET) )
PV
PV
PV
Page 176 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
SMOKING DETERRENTS, OTHER
bupropion hcl
(ZYBAN (150 MG)
(TABLET ER) )
PV
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
GASTRIC ENZYMES
SACROSIDASE
(SUCRAID
(8500/ML)
(SOLUTION) )
4
PANCREATIC ENZYMES
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
(CREON (12K-38K60) (CAPSULE DR) )
(CREON (24-76120K) (CAPSULE
DR) )
(CREON (36-114180) (CAPSULE
DR) )
(CREON (3-9.5-15K)
(CAPSULE DR) )
(CREON (6K-19K30K) (CAPSULE
DR) )
(PERTZYE (16K57.5K) (CAPSULE
DR) )
(PERTZYE (8K28.75K) (CAPSULE
DR) )
(VIOKACE (10.439.2K) (TABLET) )
(VIOKACE (20.978.3K) (TABLET) )
(ZENPEP (10-3455K) (CAPSULE
DR) )
(ZENPEP (15-5182K) (CAPSULE
DR) )
(ZENPEP (20-68109K) (CAPSULE
DR) )
(ZENPEP (25-85136K) (CAPSULE
DR) )
(ZENPEP (3K-10K16K) (CAPSULE
DR) )
(ZENPEP (40K136K) (CAPSULE
DR) )
2
2
3
3
2
3
3
3
3
3
3
3
3
3
3
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
ANTICHOLINERGICS/ANTISPASMODICS
dicyclomine hcl
dicyclomine hcl
dicyclomine hcl
Sharp Health Plan: Covered California
(BENTYL (10 MG)
(CAPSULE) )
(BENTYL (10 MG/5
ML) (SOLUTION) )
(BENTYL (20 MG)
(TABLET) )
1
2
1
Page 177 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
BELLADONNA ALKALOIDS
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
HYOSCYAMINE SULFATE
hyoscyamine sulfate
hyoscyamine sulfate
methscopolamine bromide
methscopolamine bromide
PHENOBARB/HYOSCY/ATROPINE/SCOP
PHENOBARB/HYOSCY/ATROPINE/SCOP
PHENOBARB/HYOSCY/ATROPINE/SCOP
(HYOSYNE
(0.125MG/ML)
(DROPS) )
(HYOSYNE
(125MCG/5ML)
(ELIXIR) )
(LEVBID (0.375
MG) (TAB ER 12H) )
(LEVSIN (0.125 MG)
(TABLET) )
(LEVSIN-SL (0.125
MG) (TAB SUBL) )
(NULEV (0.125 MG)
(TAB RAPDIS) )
(SYMAX (0.125 MG)
(TAB RAPDIS) )
(SYMAX DUOTAB
(0.125-0.25) (TAB
MPHASE) )
(SYMAX-SL (0.125
MG) (TAB SUBL) )
(SYMAX-SR (0.375
MG) (TAB ER 12H) )
(PAMINE (2.5 MG)
(TABLET) )
(PAMINE FORTE (5
MG) (TABLET) )
(DONNATAL (16.2
MG) (TABLET) )
(DONNATAL
(16.2MG/5ML)
(ELIXIR) )
(PHENOHYTRO
(16.2 MG)
(TABLET) )
1
1
1
1
1
2
2
3
1
1
2
2
2
2
2
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
ANTICHOLINERGICS,QUATERNARY AMMONIUM
chlordiazepoxide/clidinium br
GLYCOPYRROLATE
glycopyrrolate
glycopyrrolate
propantheline bromide
(LIBRAX (5 MG2.5MG)
(CAPSULE) )
(CUVPOSA (1 MG/5
ML) (SOLUTION) )
(ROBINUL (1 MG)
(TABLET) )
(ROBINUL FORTE
(2 MG) (TABLET) )
(PRO-BANTHINE
(15 MG) (TABLET) )
2
3
1
1
1
ANTI-ULCER PREPARATIONS
misoprostol
misoprostol
sucralfate
SUCRALFATE
Sharp Health Plan: Covered California
(CYTOTEC (100
MCG) (TABLET) )
(CYTOTEC (200
MCG) (TABLET) )
(CARAFATE (1 G)
(TABLET) )
(CARAFATE (1 G/10
ML) (ORAL SUSP) )
1
1
1
2
Page 178 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
ANTI-ULCER-H.PYLORI AGENTS
BISMUTH/METRONID/TETRACYCLINE
lansoprazole/amoxiciln/clarith
OMEPRAZOLE/CLARITH/AMOXICILLIN
(PYLERA (125-125
MG) (CAPSULE) )
(PREVPAC (30-500500) (COMBO.
PKG) )
(OMECLAMOXPAK (20(20)-500)
(COMBO. PKG) )
3
1
3
HISTAMINE H2-RECEPTOR INHIBITORS
cimetidine
cimetidine
cimetidine
famotidine
famotidine
famotidine
nizatidine
nizatidine
nizatidine
ranitidine hcl
ranitidine hcl
ranitidine hcl
ranitidine hcl
ranitidine hcl
(TAGAMET (300
MG) (TABLET) )
(TAGAMET (400
MG) (TABLET) )
(TAGAMET (800
MG) (TABLET) )
(PEPCID (20 MG)
(TABLET) )
(PEPCID (40 MG)
(TABLET) )
(PEPCID
(40MG/5ML) (ORAL
SUSP) )
(AXID (150 MG)
(CAPSULE) )
(AXID
(150MG/10ML)
(SOLUTION) )
(AXID (300 MG)
(CAPSULE) )
(ZANTAC (15
MG/ML) (SYRUP) )
(ZANTAC (150 MG)
(CAPSULE) )
(ZANTAC (150 MG)
(TABLET) )
(ZANTAC (300 MG)
(CAPSULE) )
(ZANTAC (300 MG)
(TABLET) )
1
1
1
1
1
1
2
2
2
1
1
1
1
1
INTESTINAL MOTILITY STIMULANTS
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
(METOZOLV ODT
(10 MG) (TAB
RAPDIS) )
(METOZOLV ODT
(5 MG) (TAB
RAPDIS) )
(REGLAN (10 MG)
(TABLET) )
(REGLAN (10
MG/10ML)
(SOLUTION) )
(REGLAN (5 MG)
(TABLET) )
(REGLAN (5 MG/5
ML) (SOLUTION) )
2
2
1
1
1
1
PROTON-PUMP INHIBITORS
DEXLANSOPRAZOLE
Sharp Health Plan: Covered California
(DEXILANT (30
MG) (CAP DR BP) )
3
ST, QL: 1 IN 1 DAY
Page 179 of 224
Sharp Health Plan: Covered California
Drug Name
DEXLANSOPRAZOLE
ESOMEPRAZOLE MAGNESIUM
ESOMEPRAZOLE MAGNESIUM
esomeprazole magnesium
ESOMEPRAZOLE MAGNESIUM
esomeprazole magnesium
ESOMEPRAZOLE MAGNESIUM
ESOMEPRAZOLE MAGNESIUM
Drug Tier Requirements/Limits
(DEXILANT (60
MG) (CAP DR BP) )
(NEXIUM (10 MG)
(SUSPDR PKT) )
(NEXIUM (2.5 MG)
(SUSPDR PKT) )
(NEXIUM (20 MG)
(CAPSULE DR) )
(NEXIUM (20 MG)
(SUSPDR PKT) )
(NEXIUM (40 MG)
(CAPSULE DR) )
(NEXIUM (40 MG)
(SUSPDR PKT) )
(NEXIUM (5 MG)
(SUSPDR PKT) )
ESOMEPRAZOLE STRONTIUM (24.65 MG)
(CAPSULE DR)
esomeprazole strontium (49.3 mg) (capsule dr)
LANSOPRAZOLE
lansoprazole
LANSOPRAZOLE
(PREVACID (15 MG)
(TAB RAP DR) )
(PREVACID (30 MG)
(CAPSULE DR) )
(PREVACID (30 MG)
(TAB RAP DR) )
omeprazole (10 mg) (capsule dr)
omeprazole
omeprazole
omeprazole
omeprazole/sodium bicarbonate
omeprazole/sodium bicarbonate
omeprazole/sodium bicarbonate
omeprazole/sodium bicarbonate
pantoprazole sodium
PANTOPRAZOLE SODIUM
pantoprazole sodium
rabeprazole sodium
RABEPRAZOLE SODIUM
RABEPRAZOLE SODIUM
Sharp Health Plan: Covered California
3
ST, QL: 1 IN 1 DAY
3
ST
3
ST
2
ST
3
ST
2
ST
3
ST
3
ST
3
ST, QL: 1 IN 1 DAY
2
ST, QL: 4 IN 1 DAY
3
ST
2
ST
3
ST
2
(PRILOSEC (10 MG)
(CAPSULE DR) )
(PRILOSEC (20 MG)
(CAPSULE DR) )
(PRILOSEC (40 MG)
(CAPSULE DR) )
(ZEGERID (201680MG)
(PACKET) )
(ZEGERID (20MG1.1G) (CAPSULE) )
(ZEGERID (401680MG)
(PACKET) )
(ZEGERID (40MG1.1G) (CAPSULE) )
(PROTONIX (20
MG) (TABLET DR) )
(PROTONIX (40
MG) (GRANPKT
DR) )
(PROTONIX (40
MG) (TABLET DR) )
(ACIPHEX (20 MG)
(TABLET DR) )
(ACIPHEX
SPRINKLE (10 MG)
(CAP DR SPR) )
(ACIPHEX
SPRINKLE (5 MG)
(CAP DR SPR) )
1
1
1
2
ST
2
ST
2
ST
2
ST
1
3
PA, QL: 1 IN 1 DAY
1
1
2
2
Page 180 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
URINARY TRACT - FUNCTIONAL DISORDERS
BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS
alfuzosin hcl
dutasteride
finasteride
SILODOSIN
SILODOSIN
tamsulosin hcl
(UROXATRAL (10
MG) (TAB ER 24H) )
(AVODART (0.5 MG)
(CAPSULE) )
(PROSCAR (5 MG)
(TABLET) )
(RAPAFLO (4 MG)
(CAPSULE) )
(RAPAFLO (8 MG)
(CAPSULE) )
(FLOMAX (0.4 MG)
(CAP ER 24H) )
1
2
ST
1
PA
3
ST
3
ST
1
QL: 1 IN 1 DAY
BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMB
dutasteride/tamsulosin hcl
(JALYN (0.5-0.4 MG)
(CPMP 24HR) )
2
KIDNEY STONE AGENTS
CYSTEAMINE BITARTRATE
CYSTEAMINE BITARTRATE
CYSTEAMINE BITARTRATE
CYSTEAMINE BITARTRATE
TIOPRONIN
(CYSTAGON (150
MG) (CAPSULE) )
(CYSTAGON (50
MG) (CAPSULE) )
(PROCYSBI (25 MG)
(CAP DR SPR) )
(PROCYSBI (75 MG)
(CAP DR SPR) )
(THIOLA (100 MG)
(TABLET) )
3
3
4
PA
4
PA
3
OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP
MIRABEGRON
MIRABEGRON
(MYRBETRIQ (25
MG) (TAB ER 24H) )
(MYRBETRIQ (50
MG) (TAB ER 24H) )
3
3
URINARY PH MODIFIERS
citric acid/sodium citrate
CITRIC ACID/SODIUM CITRATE
CITRIC ACID/SODIUM CITRATE
METHEN MAND/NAPHOS M-B M-H
NA PHOS,M-B/K PHOS,MONOB
phosphorus #1
potassium citrate
potassium citrate
potassium citrate
Sharp Health Plan: Covered California
(CYTRA-2 (334500MG)
(SOLUTION) )
(ORACIT (640490MG)
(SOLUTION) )
(SHOHL'S
MODIFIED (300-500
MG) (SOLUTION) )
(UROQID-ACID
NO.2 (500-500 MG)
(TABLET) )
(K-PHOS NO.2 (700305MG) (TABLET) )
(K-PHOS NEUTRAL
(250 MG)
(TABLET) )
(UROCIT-K (10
MEQ) (TABLET
ER) )
(UROCIT-K (15
MEQ) (TABLET
ER) )
(UROCIT-K (5 MEQ)
(TABLET ER) )
2
3
3
3
3
2
2
2
2
Page 181 of 224
Sharp Health Plan: Covered California
Drug Name
potassium citrate/citric acid
potassium citrate/citric acid
POTASSIUM PHOSPHATE,MONOBASIC
sod/pot/k cit/sod cit/cit acid
sod/pot/k cit/sod cit/cit acid
Drug Tier Requirements/Limits
(CYTRA-K (1100334/5)
(SOLUTION) )
(CYTRA-K (33001002) (PACKET) )
(K-PHOS
ORIGINAL (500
MG) (TABLET
SOL) )
(CYTRA-3 (500550/5)
(SOLUTION) )
(TRICITRATES
(500-550/5)
(SOLUTION) )
2
2
3
2
2
URINARY TRACT ANALGESIC AGENTS
PENTOSAN POLYSULFATE SODIUM
(ELMIRON (100
MG) (CAPSULE) )
2
PA
URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)
phenazopyridine hcl
phenazopyridine hcl
(PYRIDIUM (100
MG) (TABLET) )
(PYRIDIUM (200
MG) (TABLET) )
1
1
URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.
darifenacin hydrobromide
darifenacin hydrobromide
SOLIFENACIN SUCCINATE
SOLIFENACIN SUCCINATE
(ENABLEX (15 MG)
(TAB ER 24H) )
(ENABLEX (7.5
MG) (TAB ER 24H) )
(VESICARE (10
MG) (TABLET) )
(VESICARE (5 MG)
(TABLET) )
2
ST
2
ST
3
ST
3
ST
URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT
FESOTERODINE FUMARATE
FESOTERODINE FUMARATE
flavoxate hcl
OXYBUTYNIN
oxybutynin chloride
oxybutynin chloride
oxybutynin chloride
oxybutynin chloride
oxybutynin chloride
OXYBUTYNIN CHLORIDE
tolterodine tartrate
tolterodine tartrate
Sharp Health Plan: Covered California
(TOVIAZ (4 MG)
(TAB ER 24H) )
(TOVIAZ (8 MG)
(TAB ER 24H) )
(URISPAS (100 MG)
(TABLET) )
(OXYTROL
(3.9MG/24HR)
(PATCH TDSW) )
(DITROPAN (5 MG)
(TABLET) )
(DITROPAN (5
MG/5 ML)
(SYRUP) )
(DITROPAN XL (10
MG) (TAB ER 24) )
(DITROPAN XL (15
MG) (TAB ER 24) )
(DITROPAN XL (5
MG) (TAB ER 24) )
(GELNIQUE (10 %)
(GEL PACKET) )
(DETROL (1 MG)
(TABLET) )
(DETROL (2 MG)
(TABLET) )
3
ST
3
ST
2
3
ST
1
1
1
ST
1
ST
1
ST
3
ST
1
ST
1
ST
Page 182 of 224
Sharp Health Plan: Covered California
Drug Name
tolterodine tartrate
tolterodine tartrate
trospium chloride
trospium chloride
Drug Tier Requirements/Limits
(DETROL LA (2
MG) (CAP ER 24H) )
(DETROL LA (4
MG) (CAP ER 24H) )
(SANCTURA (20
MG) (TABLET) )
(SANCTURA XR (60
MG) (CAP ER 24H) )
1
ST
1
ST
1
ST
1
ST
VAGINAL DISORDERS
VAGINAL ANTIBIOTICS
CLINDAMYCIN PHOSPHATE
clindamycin phosphate
CLINDAMYCIN PHOSPHATE
metronidazole
METRONIDAZOLE
METRONIDAZOLE
(CLEOCIN (100 MG)
(SUPP.VAG) )
(CLEOCIN (2 %)
(CREAM/APPL) )
(CLINDESSE (2 %)
(CRM ER (G)) )
(METROGELVAGINAL (0.75 %)
(GEL W/APPL) )
(NUVESSA (1.3 %)
(GEL W/APPL) )
(VANDAZOLE (0.75
%) (GEL W/APPL) )
3
1
ST
3
1
3
2
VAGINAL ANTIFUNGALS
BUTOCONAZOLE NITRATE
miconazole nitrate
terconazole
terconazole
terconazole
(GYNAZOLE 1 (2
%) (CRM/PF APP) )
(MONISTAT 3 (200
MG) (SUPP.VAG) )
(TERAZOL 3 (0.8 %)
(CREAM/APPL) )
(TERAZOL 3 (80
MG) (SUPP.VAG) )
(TERAZOL 7 (0.4 %)
(CREAM/APPL) )
3
1
1
1
1
VAGINAL ANTISEPTICS
ACETIC ACID/OXYQUINOLINE
ACETIC ACID/OXYQUINOLINE
(FEM PH (0.90.025%)
(JELLY/APPL) )
(RELAGARD (0.90.025%)
(JELLY/APPL) )
3
3
VAGINAL ESTROGEN PREPARATIONS
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL ACETATE
ESTRADIOL ACETATE
ESTROGENS, CONJUGATED
Sharp Health Plan: Covered California
(ESTRACE (0.01 %)
(CREAM/APPL) )
(ESTRING
(7.5MCG/24H) (VAG
RING) )
(VAGIFEM (10
MCG) (TABLET) )
(FEMRING
(0.05MG/24H) (VAG
RING) )
(FEMRING
(0.1MG/24HR) (VAG
RING) )
(PREMARIN (0.625
MG/G)
(CREAM/APPL) )
2
ST
3
2
3
3
2
ST
Page 183 of 224
Sharp Health Plan: Covered California
Drug Name
Drug Tier Requirements/Limits
VAGINAL SULFONAMIDES
SULFANILAMIDE
(AVC (15 %)
(CREAM/APPL) )
3
VITAMIN AND/OR MINERAL DEFICIENCY
CALCIUM REPLACEMENT
calcium/mag/d3/b12/fa/b6/boron (500-1.1mg)
(tablet)
calcium/mag/d3/b12/fa/b6/boron (500-300-1)
(wafer)
2
2
FLUORIDE PREPARATIONS
SODIUM FLUORIDE
SODIUM FLUORIDE
SODIUM FLUORIDE
SODIUM FLUORIDE
(FLUORABON
(0.25MG/0.6)
(DROPS) )
(FLUOR-A-DAY (2.5
MG/ML) (DROPS) )
(FLUORITAB
(0.125/DROP)
(DROPS) )
(FLURA-DROPS
(0.25MG/DRP)
(DROPS) )
sodium fluoride (0.2 %) (solution)
sodium fluoride (0.25(0.55)) (tab chew)
sodium fluoride (0.5 mg/ml) (drops)
sodium fluoride (0.5(1.1)mg) (tab chew)
sodium fluoride (1.1 %) (cream (g))
sodium fluoride (1.1 %) (gel (gram))
sodium fluoride (1mg(2.2mg)) (tab chew)
sodium fluoride/potassium nit (1.1%-5%) (gel
(gram))
SODIUM FLUORIDE/VITAMIN D3
SODIUM FLUORIDE/XYLITOL
SODIUM FLUORIDE/XYLITOL
PV
PV
PV
PV
PV
PV
PV
PV
2
2
PV
2
(FLORIVA (0.25400/1) (DROPS) )
(FLUOR-A-DAY
(0.25(0.55)) (TAB
CHEW) )
(FLUOR-A-DAY
(1MG(2.2MG)) (TAB
CHEW) )
PV
3
3
FOLIC ACID PREPARATIONS
FA#7/PC,PE DHA/NAC/PAP/IF/MV46
FE/FA/DHA/EPA/FAD/NADH/BE/MV47
(PURALOR CI (3.65-2.5) (TAB CH
BPH) )
(ENLYTE (1.58.73MG) (CAP IR
DR) )
folic acid (0.4 mg) (tablet) (otc)
folic acid (0.8 mg) (tablet) (otc)
3
3
PV
PV
IRON REPLACEMENT
fe fumarate/cal/e/fa/multivit (65 mg-1 mg) (tablet)
FE FUMARATE/FA/MV, MIN COMB#15
FERRIC AMCIT/LYS/VIT B COMP/FA
ferrous fumarate/folic acid
Sharp Health Plan: Covered California
2
(CENTRATEX (106
MG-1MG)
(CAPSULE) )
(HEMATRON (501MG/5ML)
(LIQUID) )
(HEMOCYTE-F (106
MG-1MG)
(TABLET) )
3
3
2
Page 184 of 224
Sharp Health Plan: Covered California
Drug Name
ferrous sulfate
Drug Tier Requirements/Limits
(FER-IN-SOL (15
MG/ML) (DROPS)
(OTC))
ferrous sulfate (220 (44)/5) (elixir) (otc)
ferrous sulfate (220 (44)/5) (solution) (otc)
ferrous sulfate (300 mg/5ml) (liquid) (otc)
ferrous sulfate (324(65)mg) (tablet dr) (otc)
ferrous sulfate (325(65) mg) (capsule er) (otc)
ferrous sulfate (325(65) mg) (tablet dr) (otc)
ferrous sulfate (325(65) mg) (tablet) (otc)
iron aspgly,ps/c/b12/fa/ca/suc (150-25-1) (capsule)
iron aspgly/c/b12/fa/ca-th/suc (70-150-1mg) (tablet)
IRON BG,PS/FOLIC/B,C NO.12/SUC
PV
PV
PV
PV
PV
PV
PV
2
2
(IROSPAN (651MG(24))
(TABLET) )
iron bg,ps/vitc/b12/fa/calcium (150-60-1) (capsule)
iron carb,gl/fa/b12/c/docusate
iron fm,ps no.1/folic/mv no.18
IRON FUM, PS/FA/VIT C/L. CASEI
iron fum,ps/folic acid/vitc/b3
IRON HEME POLYPEPTIDE/FOLIC AC
iron polysac/iron heme/fa/b12
iron ps cmplx/vit b12/fa
iron, carbonyl/fa/c/b-6/b12/zn
iron,carb/dss/b12if/fa/mv-mn
IRON,CARB/FA#6/MV, MIN NO.40
Sharp Health Plan: Covered California
2
2
3
2
(INTEGRA PLUS
(125MG-1MG)
(CAPSULE) )
(INTEGRA F (125-140-3) (CAPSULE) )
iron fum/docusate/fa/bcomp,c (66.6-1mg) (tablet)
iron fum/vit c/b12-if/fa (110-0.5mg) (capsule)
iron fum/vit c/vit b12/stomc (200-250-10) (capsule)
iron fumarate/vit c/vit b12/fa (200-250mg) (capsule)
iron fumarate/vit c/vit b12/fa (460-60mg) (capsule)
IRON GLY,FUM/C/B12/ME-THFOLATE
2
2
(PUREVIT DUALFE
PLUS (106 MG1MG) (CAPSULE) )
(TANDEM PLUS
(106 MG-1MG)
(CAPSULE) )
(FUSION
SPRINKLES (7MG250MCG) (POWD
PACK) )
iron fum,ag/c/b12/folic/ca/suc (151-60-1mg) (tablet)
iron fum,ps/fa/vit b with c #9
3
2
(FERRALET 90 (901-50 MG)
(TABLET) )
iron carb/fa#9/vit c/d3/b6/b12 (125-1-170) (tablet)
iron fm,ps no.1/folic/mv no.18
PV
2
2
2
2
2
2
2
(MAXARON FORTE
(150-200 MG)
(TABLET) )
(PROFERRINFORTE (12-1MG)
(TABLET) )
(BIFERA RX (22-61-25) (TABLET) )
(NIFEREX-150
FORTE (150-25-1)
(CAPSULE) )
(CORVITE 150 (1501.25MG) (TABLET) )
(HEMATRON-AF
(150-50-1MG) (TAB
ER 24H) )
(CORVITE FE (150
MG-1MG)
(TABLET) )
3
3
2
2
2
2
3
Page 185 of 224
Sharp Health Plan: Covered California
Drug Name
IRON,CARB/FA#6/MV, MIN NO.41
IRON,CARBONYL/FA/MULTIVIT-MIN
IRON,FM,PS/FOLIC/B,C18/L.CASEI
Drug Tier Requirements/Limits
(CORVITE 150 (150
MG-1MG)
(TABLET) )
(ACTIVE FE (751.25 MG)
(TABLET) )
(FUSION PLUS
(130-1.25MG)
(CAPSULE) )
iron/c/folic acd/mv cmb11/calc (151-200-1) (tablet)
IRON/FA#1/C/B12/BIOT/COPPR/DSS
IRON/FA#1/VIT C/B12/ZN/DSS/SUC
IRON/MFOLATE/B12/C/BIOT/ZN/DSS
3
3
2
(FERIVA FA (110
MG-1MG)
(CAPSULE) )
(FERIVA 21-7 (75-1175MG) (TABLET) )
iron/fa/b12/c/docusate sodium (90-1-50 mg) (tablet)
iron/fa/vit bcomp,c/minerals (106 mg-1mg) (tablet)
IRON/FOLIC ACID/C/B12/BIOTIN
3
3
3
2
2
(FERIVA (75-1175MG) (CAP
MPHASE) )
(MAXFE (160MG-160) (TABLET) )
3
3
PEDIATRIC VITAMIN PREPARATIONS
fluoride/iron/vitamins a,c,d (0.25 mg/ml) (drops)
ped mv a,c,d3 #21 w-fluoride (0.25 mg/ml) (drops)
ped mv a,c,d3 #21 w-fluoride (0.5 mg/ml) (drops)
2
1
1
PRENATAL VITAMIN PREPARATIONS
IRON,CARBONYL/FA/MULTIVIT-MIN
IRON,CARBONYL/FA/MULTIVIT-MIN
(ELITE-OB (501.25MG) (TABLET) )
(OB COMPLETE
(50-1.25MG)
(TABLET) )
iron,carbonyl/vit c/vit b12/fa (100-250-1) (tablet)
pn vit.w-o ca #7, iron,fa,dha (28-1.25mg) (capsule)
pnv #14/ferrous fum/folic acid (29 mg-1 mg) (tab
chew)
pnv 10/iron fps/folic acid/om3 (30-1-310.1) (capsule)
PNV 3/IRON FUM,GLUC/FOLIC ACID
PNV CMB#21/IRON/FOLIC ACID
Sharp Health Plan: Covered California
3
1
1
1
1
(MAXINATE
(20MG-0.8MG)
(TABLET) )
(PRENATAL
COMPLETE (14
MG-400) (TABLET)
(OTC))
pnv no.118/iron fumarate/fa (29 mg-1 mg) (tab chew)
pnv with ca#74/iron/folic acid (27 mg-1 mg) (tablet)
pnv with ca,no.72/iron/fa (27 mg-1 mg) (tablet)
pnv w-o ca no5/iron fum/fa (106.5-1mg) (capsule)
pnv,ca,no.35/iron/fa/ds/omeg-3 (27-1-50 mg)
(capsule)
pnv/ferrous fumarate/fa/se (27 mg-1 mg) (tablet)
pnv/iron fum/docusate/fa (90-50-1mg) (tablet er)
pnv/iron,carbonyl/docusate/fa (90-50-1mg) (tablet)
pnv119/iron fumarate/fa/dss (29-1-25 mg) (tablet)
pnv19/iron bd hc,s-p/folic/om3 (29-1-400mg)
(cmbpkgdrcp)
PNV2/IRON B-G SUC-P/FA/OMEGA-3
3
PV
PV
1
1
1
1
1
1
1
1
1
1
(COMPLETE
NATAL DHA (29-1250MG) (COMBO.
PKG) )
3
Page 186 of 224
Sharp Health Plan: Covered California
Drug Name
PNV2/IRON B-G SUC-P/FA/OMEGA-3
Drug Tier Requirements/Limits
(TRUST NATAL
DHA (29-1-250MG)
(COMBO. PKG) )
pnv53/iron b-g hcl-p/fa/omega3 (29-1-400mg)
(combo. pkg)
pnv7/fe asp gly/docusate/fa (30-50-1mg) (tablet)
pnv95/ferrous fumarate/fa (28mg-0.8mg) (tablet)
(otc)
prenat vit comb.10/iron/fa/dha (65-1-250mg)
(combo. pkg)
prenatal vit #105/iron/fa/dha
1
1
PV
1
(VITATRUE (30-1.4300) (COMBO.
PKG) )
prenatal vit #76/iron,carb/fa (29 mg-1 mg) (tablet)
prenatal vit #76/iron,carb/fa (29 mg-1 mg) (tablet)
PRENATAL VIT #76/IRON,CARB/FA
(THRIVITE RX (29
MG-1 MG)
(TABLET) )
PV W-O CAL/FERROUS FUMARATE/FA
PV
1
1
PV
PV
1
(LACTOCAL-F (65
MG-1 MG)
(TABLET) )
1
PV
PV
1
1
(TRINATAL RX 1
(60 MG-1 MG)
(TABLET) )
(M-VIT (27 MG-1
MG) (TABLET) )
pv w-o cal/iron ps cplx/fa (29 mg-1 mg) (tab chew)
PV W-O CAL/IRON,CARB/DOCUS/FA
1
1
1
1
1
1
prenatal vit/iron fumarate/fa (27mg-0.8mg) (tablet)
(otc)
prenatal vit/iron fumarate/fa (28mg-0.8mg) (tablet)
(otc)
prenatal vit/iron fumarate/fa (65 mg-1 mg) (capsule)
prenatal vit/iron fumarate/fa (66-1mg) (tablet)
prenatal vit27,calcium/iron/fa
1
1
PV
prenatal vit 15/iron cb/fa/dss (90-1-50 mg) (tablet)
prenatal vit 16/iron cb/fa/dss (90-1-50 mg) (tablet)
prenatal vit 18/iron cb/fa/dss (90-1-50 mg) (tablet)
prenatal vit no.109/iron/fa (40-1mg) (tab chew)
prenatal vit no.127/iron/fa (15 mg-1 mg) (tablet)
prenatal vit no.129/iron/fa (27mg-0.8mg) (tablet)
(otc)
prenatal vit no.73/iron/fa (28 mg-1 mg) (tablet)
prenatal vit no.78/iron/fa (29 mg-1 mg) (tablet)
prenatal vit no.78/iron/fa (29 mg-1 mg) (tablet)
prenatal vit#96/ferrous fum/fa (27mg-0.8mg) (tablet)
(otc)
prenatal vit/iron bisglycin/fa (29 mg-1 mg) (tablet)
prenatal vit/iron fumarate/fa
3
1
3
1
(OBSTETRIX EC
(29-50-1MG)
(TABLET DR) )
3
PRENATAL VITAMINS WITHOUT IRON
pnv w-o iron/fa/calcium/b6/b12
(PREMESIS RX (1200-75) (TBMP
24HR) )
1
(POTABA (500 MG)
(CAPSULE) )
3
(ROCALTROL (0.25
MCG) (CAPSULE) )
1
VITAMIN B PREPARATIONS
POTASSIUM AMINOBENZOATE
VITAMIN D PREPARATIONS
calcitriol
Sharp Health Plan: Covered California
Page 187 of 224
Sharp Health Plan: Covered California
Drug Name
calcitriol
calcitriol
cholecalciferol (vitamin d3) (400 unit) (capsule) (otc)
cholecalciferol (vitamin d3) (400 unit) (tab chew)
(otc)
cholecalciferol (vitamin d3) (400 unit) (tablet) (otc)
cholecalciferol (vitamin d3) (400 unit/5) (liquid)
(otc)
ergocalciferol (vitamin d2) (400 unit) (tablet) (otc)
ergocalciferol (vitamin d2) (50000 unit) (capsule)
Sharp Health Plan: Covered California
Drug Tier Requirements/Limits
(ROCALTROL (0.5
MCG) (CAPSULE) )
(ROCALTROL (1
MCG/ML)
(SOLUTION) )
1
1
PV
AGE: >= 65 YEARS
PV
AGE: >= 65 YEARS
PV
AGE: >= 65 YEARS
PV
AGE: >= 65 YEARS
PV
1
AGE: >= 65 YEARS
Page 188 of 224
Medication Prescribing Limitations
STEP THERAPY EDITS
• ABILIFY (1 MG/ML) (SOLUTION)
• ABILIFY (10 MG) (TABLET)
• ABILIFY (15 MG) (TABLET)
• ABILIFY (2 MG) (TABLET)
• ABILIFY (20 MG) (TABLET)
• ABILIFY (30 MG) (TABLET)
• ABILIFY (5 MG) (TABLET)
• ABILIFY DISCMELT (10 MG) (TAB
RAPDIS)
• ABILIFY DISCMELT (15 MG) (TAB
RAPDIS)
• ACANYA (1.2%-2.5%) (GEL W/PUMP)
• ACTOPLUS MET (15MG-500MG)
(TABLET)
• ACTOPLUS MET (15MG-850MG)
(TABLET)
• ACTOPLUS MET XR (15-1000 MG)
(TBMP 24HR)
• ACTOPLUS MET XR (30-1000 MG)
(TBMP 24HR)
• ACTOS (15 MG) (TABLET)
• ACTOS (30 MG) (TABLET)
• ACTOS (45 MG) (TABLET)
• ADASUVE (10 MG) (AER POW BA)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) in
180 days or Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 180 days or
Ziprasidone HCL in 180 days
Prior prescription for topical tretinoin in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• ALTOPREV (20 MG) (TAB ER 24H)
Prior prescription for Lovastatin, Simvastatin, Atorvastatin, or Pravastatin in 120
days
• ALTOPREV (40 MG) (TAB ER 24H)
Prior prescription for Lovastatin, Simvastatin, Atorvastatin, or Pravastatin in 120
days
• ALTOPREV (60 MG) (TAB ER 24H)
Prior prescription for Lovastatin, Simvastatin, Atorvastatin, or Pravastatin in 120
days
• AMBIEN CR (12.5 MG) (TAB MPHASE) Prior prescription for Zolpidem Tartrate in 120 days
• AMBIEN CR (6.25 MG) (TAB MPHASE) Prior prescription for Zolpidem Tartrate in 120 days
• AMERGE (1 MG) (TABLET)
Prior prescription for sumatriptan or rizatriptan in 120 days
• AMERGE (2.5 MG) (TABLET)
Prior prescription for sumatriptan or rizatriptan in 120 days
• ANORO ELLIPTA (62.5-25MCG) (BLST
W/DEV)
Prior prescription for Stiolto Respimat in 120 days
• ANTARA (130 MG) (CAPSULE)
Prior prescription for preferred fenofibrate product in 120 days
• ANTARA (30 MG) (CAPSULE)
Prior prescription for preferred fenofibrate product in 120 days
• ANTARA (90 MG) (CAPSULE)
Prior prescription for preferred fenofibrate product in 120 days
• APIDRA (100/ML) (VIAL)
Prior prescription for Humalog in 120 days
• APIDRA SOLOSTAR (100/ML) (INSULN
PEN)
Prior prescription for Humalog in 120 days
Sharp Health Plan: Covered California
Page 189 of 224
Medication Prescribing Limitations
• APTENSIO XR (10 MG) (CSBP 40-60)
• APTENSIO XR (15 MG) (CSBP 40-60)
• APTENSIO XR (20 MG) (CSBP 40-60)
• APTENSIO XR (30 MG) (CSBP 40-60)
• APTENSIO XR (40 MG) (CSBP 40-60)
• APTENSIO XR (50 MG) (CSBP 40-60)
• APTENSIO XR (60 MG) (CSBP 40-60)
• APTIOM (200 MG) (TABLET)
• APTIOM (400 MG) (TABLET)
• APTIOM (600 MG) (TABLET)
• APTIOM (800 MG) (TABLET)
• ARCAPTA NEOHALER (75 MCG) (CAP
W/DEV)
• AROMASIN (25 MG) (TABLET)
• ASACOL HD (800 MG) (TABLET DR)
• AVANDAMET (2 MG-500MG) (TABLET)
• AVANDAMET (2-1000MG) (TABLET)
• AVANDIA (2 MG) (TABLET)
• AVANDIA (4 MG) (TABLET)
• AVINZA (120 MG) (CPMP 24HR)
• AVINZA (30 MG) (CPMP 24HR)
• AVINZA (45 MG) (CPMP 24HR)
• AVINZA (60 MG) (CPMP 24HR)
• AVINZA (75 MG) (CPMP 24HR)
• AVINZA (90 MG) (CPMP 24HR)
• AVODART (0.5 MG) (CAPSULE)
• AXERT (12.5 MG) (TABLET)
• AXERT (6.25 MG) (TABLET)
• AZELEX (20 %) (CREAM (G))
• AZOR (10 MG-20MG) (TABLET)
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
Prior prescription for methylphenidate IR, generic/multisource mixed amphetamine
salts (Adderall) or long acting formulation of methylphenidate (ER, LA, CD) in 120
days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or
zonisamide in 365 days
Prior prescription for Serevent Diskus in 120 days
Prior prescription for Anastrozole orLetrozole in 120 days
Prior prescription for Apriso, Balsalazide, Dipentum, Giazo, or Pentasa in 120 days
Prior prescription for Avandaryl, Fortamet, Metformin HCL, Riomet, Avandia, or
Pioglitazone HCL in 120 days
Prior prescription for Avandaryl, Fortamet, Metformin HCL, Riomet, Avandia, or
Pioglitazone HCL in 120 days
Prior prescription for metformin, pioglitazone, Avandamet, or Avandaryl in 120 days
Prior prescription for metformin, pioglitazone, Avandamet, or Avandaryl in 120 days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
Prior prescription for Finasteride in 120 days
Prior prescription for sumatriptan or rizatriptan in 120 days
Prior prescription for sumatriptan or rizatriptan in 120 days
Prior prescription for topical tretinoin in 120 days
At least 2 prior prescriptions for a Calcium ChannelBblocker, Ace Inhibitor, or
Angiotensin Receptor Blocker in 120 days
Sharp Health Plan: Covered California
Page 190 of 224
Medication Prescribing Limitations
• AZOR (10 MG-40MG) (TABLET)
At least 2 prior prescriptions for a Calcium ChannelBblocker, Ace Inhibitor, or
Angiotensin Receptor Blocker in 120 days
• AZOR (5 MG-20 MG) (TABLET)
At least 2 prior prescriptions for a Calcium ChannelBblocker, Ace Inhibitor, or
Angiotensin Receptor Blocker in 120 days
• AZOR (5 MG-40 MG) (TABLET)
At least 2 prior prescriptions for a Calcium ChannelBblocker, Ace Inhibitor, or
Angiotensin Receptor Blocker in 120 days
• BECONASE AQ (42 MCG) (SPRAY)
Prior prescription for Fluticasone Propionate in 120 days
• BELSOMRA (10 MG) (TABLET)
Prior prescription for Zolpidem Tartrate, Eszopiclone, Zaleplon, Rozerem, or Silenor
in 120 days
• BELSOMRA (15 MG) (TABLET)
Prior prescription for Zolpidem Tartrate, Eszopiclone, Zaleplon, Rozerem, or Silenor
in 120 days
• BELSOMRA (20 MG) (TABLET)
Prior prescription for Zolpidem Tartrate, Eszopiclone, Zaleplon, Rozerem, or Silenor
in 120 days
• BELSOMRA (5 MG) (TABLET)
Prior prescription for Zolpidem Tartrate, Eszopiclone, Zaleplon, Rozerem, or Silenor
in 120 days
• BENICAR (20 MG) (TABLET)
Prior prescription for one of the following: generic losartan, candesartan, irbesartan,
telmisartan, valsartan, eprosartan in 120 days
• BENICAR (40 MG) (TABLET)
Prior prescription for one of the following: generic losartan, candesartan, irbesartan,
telmisartan, valsartan, eprosartan in 120 days
• BENICAR (5 MG) (TABLET)
Prior prescription for one of the following: generic losartan, candesartan, irbesartan,
telmisartan, valsartan, eprosartan in 120 days
• BENICAR HCT (20-12.5 MG) (TABLET) Prior prescription for Benicar or losartan HCL in 120 days
• BENICAR HCT (40 MG-25MG)
(TABLET)
Prior prescription for Benicar or losartan HCL in 120 days
• BENICAR HCT (40-12.5 MG) (TABLET) Prior prescription for Benicar or losartan HCL in 120 days
• BEPREVE (1.5 %) (DROPS)
Prior prescription for Olopatadine HCL, Azelastine HCL, Epinastine HCL, or
Ketotifen in 120 days
• BEVESPI AEROSPHERE (9-4.8 MCG)
(HFA AER AD)
Prior prescription for Stiolto Respimat in 120 days
• BRILINTA (60 MG) (TABLET)
Prior prescription for Effient or Clopidogrel in 120 days
• BRILINTA (90 MG) (TABLET)
Prior prescription for Effient or Clopidogrel in 120 days
• BRISDELLE (7.5 MG) (CAPSULE)
Prior prescription for paroxetine or venlafaxine in 120 days
• BYDUREON (2 MG) (VIAL)
Prior prescription for Fortamet, Metformin HCL, Riomet, or Bydureon Pen in 120
days
• BYDUREON PEN (2MG/0.65ML) (PEN
INJCTR)
Prior prescription for Bydureon, Fortamet, Metformin HCL, or Riomet in 120 days
• BYETTA (10MCG/0.04) (PEN INJCTR) Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• BYETTA (5MCG/0.02) (PEN INJCTR)
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• CAMBIA (50 MG) (POWD PACK)
Prior prescription for Sumatriptan in 120 days
• CIALIS (5 MG) (TABLET)
At least 2 prior prescriptions for Alfuzosin HCL, Cardura XL, Doxazosin, Rapaflo,
Tamsulosin HCL, Terazosin HCL, Dutasteride, or Finasteride in 120 days
• CLARINEX (2.5 MG) (TAB RAPDIS)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• CLARINEX (2.5 MG/5ML) (SYRUP)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• CLARINEX (5 MG) (TAB RAPDIS)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• CLARINEX (5 MG) (TABLET)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• CLARINEX-D 12 HOUR (2.5-120 MG)
(TBMP 12HR)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• CLEOCIN (2 %) (CREAM/APPL)
Prior prescription for Metronidazole or Vandazole in 120 days
• CORLANOR (5 MG) (TABLET)
Prior prescription for a Beta-adrenergic Blocking Agent in 120 days
• CORLANOR (7.5 MG) (TABLET)
Prior prescription for a Beta-adrenergic Blocking Agent in 120 days
• DELZICOL (400 MG) (CAP(DRTAB))
Prior prescription for Apriso or Balsalazide in 120 days
• DESVENLAFAXINE ER (100 MG) (TAB At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
ER 24H)
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• DESVENLAFAXINE ER (50 MG) (TAB At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
ER 24H)
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• DESVENLAFAXINE FUMARATE ER
At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
(100 MG) (TAB ER 24)
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• DESVENLAFAXINE FUMARATE ER (50 At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
MG) (TAB ER 24)
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• DETROL (1 MG) (TABLET)
Prior presciption for Gelnique or Oxybutynin in 120 days
• DETROL (2 MG) (TABLET)
Prior presciption for Gelnique or Oxybutynin in 120 days
Sharp Health Plan: Covered California
Page 191 of 224
Medication Prescribing Limitations
• DETROL LA (2 MG) (CAP ER 24H)
• DETROL LA (4 MG) (CAP ER 24H)
• DEXILANT (30 MG) (CAP DR BP)
Prior presciption for Gelnique or Oxybutynin in 120 days
Prior presciption for Gelnique or Oxybutynin in 120 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
• DEXILANT (60 MG) (CAP DR BP)
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
• DIFFERIN (0.1 %) (CREAM (G))
Prior prescription for topical tretinoin in 120 days
• DIFFERIN (0.1 %) (GEL (GRAM))
Prior prescription for topical tretinoin in 120 days
• DIFFERIN (0.1 %) (LOTION)
Prior prescription for topical tretinoin in 120 days
• DIFFERIN (0.3 %) (GEL (GRAM))
Prior prescription for topical tretinoin in 120 days
• DIFFERIN (0.3 %) (GEL W/PUMP)
Prior prescription for topical tretinoin in 120 days
• DIPENTUM (250 MG) (CAPSULE)
Prior prescription for Apriso, Balsalazide, Giazo, Mesalamine, or Pentasa in 120
days
• DITROPAN XL (10 MG) (TAB ER 24)
Prior prescription for Gelnique, Tolterodine Tartrate, or Oxybutynin in 120 days
• DITROPAN XL (15 MG) (TAB ER 24)
Prior prescription for Gelnique, Tolterodine Tartrate, or Oxybutynin in 120 days
• DITROPAN XL (5 MG) (TAB ER 24)
Prior prescription for Gelnique, Tolterodine Tartrate, or Oxybutynin in 120 days
• DOVONEX (0.005 %) (CREAM (G))
Prior prescription for generic topical corticosteroid in 120 days
• DOVONEX (0.005 %) (OINT. (G))
Prior prescription for generic topical corticosteroid in 120 days
• DOVONEX (0.005 %) (SOLUTION)
Prior prescription for generic topical corticosteroid in 120 days
• DRITHOCREME HP (1 %) (CREAM (G)) Prior prescription for generic topical corticosteroid in 120 days
• DUETACT (30 MG-2 MG) (TABLET)
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• DUETACT (30 MG-4 MG) (TABLET)
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• DULERA (100-5 MCG) (HFA AER AD) At least 2 prior prescriptions for Advair Diskus and Breo Ellipta in the 365 days
• DULERA (200-5 MCG) (HFA AER AD) At least 2 prior prescriptions for Advair Diskus and Breo Ellipta in the 365 days
• DYANAVEL XR (2.5 MG/ML) (SUS BP
24H)
Prior prescription for Dextroamphetamine-amphet ER in 120 days
• DYMISTA (137-50 MCG) (SPRAY/PUMP) Prior prescription for Fluticasone Propionate in 120 days
• EDARBI (40 MG) (TABLET)
Prior prescription for one of the following: generic losartan, candesartan, irbesartan,
telmisartan, valsartan, eprosartan in 120 days
• EDARBI (80 MG) (TABLET)
Prior prescription for one of the following: generic losartan, candesartan, irbesartan,
telmisartan, valsartan, eprosartan in 120 days
• EDARBYCLOR (40 MG-25MG)
(TABLET)
Prior prescription for losartan or Edarbi in 120 days
• EDARBYCLOR (40-12.5 MG) (TABLET) Prior prescription for losartan or Edarbi in 120 days
• EDLUAR (10 MG) (TAB SUBL)
Prior prescription for Ambien IR in 120 days
• EDLUAR (5 MG) (TAB SUBL)
Prior prescription for Ambien IR in 120 days
• ELIDEL (1 %) (CREAM (G))
Prior prescription for generic topical corticosteroid in 120 days
• EMADINE (0.05 %) (DROPS)
Prior prescription for Olopatadine HCL, Azelastine HCL, Epinastine HCL, or
Ketotifen in 120 days
• ENABLEX (15 MG) (TAB ER 24H)
Prior presciption for Gelnique or Oxybutynin in 120 days
• ENABLEX (7.5 MG) (TAB ER 24H)
Prior presciption for Gelnique or Oxybutynin in 120 days
• ENSTILAR (0.005-.064) (FOAM)
Prior prescription for topical anti-inflammatory steroidal in 120 days
• ENTRESTO (24 MG-26MG) (TABLET) Prior prescription for of ACE Inhibitor or ARB in 12 days. May not be on an ACE
Inhibitor at the same time.
• ENTRESTO (49 MG-51MG) (TABLET) Prior prescription for of ACE Inhibitor or ARB in 12 days. May not be on an ACE
Inhibitor at the same time.
• ENTRESTO (97MG-103MG) (TABLET) Prior prescription for of ACE Inhibitor or ARB in 12 days. May not be on an ACE
Inhibitor at the same time.
• EPIDUO (0.1 %-2.5%) (GEL (GRAM))
Prior prescription for topical tretinoin in 120 days
• EPIDUO (0.1 %-2.5%) (GEL W/PUMP) Prior prescription for topical tretinoin in 120 days
• EPIDUO FORTE (0.3 %-2.5%) (GEL
W/PUMP)
Prior prescription for topical tretinoin in 120 days
• ESOMEPRAZOLE STRONTIUM (24.65 At least 3 prior prescriptions fo lansoprazole, pantoprazole, Protonix, omeprazole,
MG) (CAPSULE DR)
and Prilosec OTC in 365 days
• ESOMEPRAZOLE STRONTIUM (49.3
At least 3 prior prescriptions fo lansoprazole, pantoprazole, Protonix, omeprazole,
MG) (CAPSULE DR)
and Prilosec OTC in 365 days
• ESTRACE (0.01 %) (CREAM/APPL)
Prior prescription for Vagifem or Premarin in 120 days
• EXFORGE (10MG-160MG) (TABLET)
Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE (10MG-320MG) (TABLET)
Prior prescription for valsartan and amlodipine in 120 days
Sharp Health Plan: Covered California
Page 192 of 224
Medication Prescribing Limitations
• EXFORGE (5 MG-160MG) (TABLET)
Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE (5MG-320MG) (TABLET)
Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE HCT (10-160-25) (TABLET) Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE HCT (10-320-25) (TABLET) Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE HCT (10MG-160MG)
(TABLET)
Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE HCT (5-160-12.5) (TABLET) Prior prescription for valsartan and amlodipine in 120 days
• EXFORGE HCT (5-160-25MG) (TABLET) Prior prescription for valsartan and amlodipine in 120 days
• FABIOR (0.1 %) (FOAM)
Prior prescription for topical tretinoin in 120 days
• FAMVIR (125 MG) (TABLET)
At least 2 prior prescriptions for Acyclovir, Sitavig, Zovirax, or Valacyclovir HCL in
120 days
• FAMVIR (250 MG) (TABLET)
At least 2 prior prescriptions for Acyclovir, Sitavig, Zovirax, or Valacyclovir HCL in
120 days
• FAMVIR (500 MG) (TABLET)
At least 2 prior prescriptions for Acyclovir, Sitavig, Zovirax, or Valacyclovir HCL in
120 days
• FANAPT (1 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (10 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (12 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (1-2-4-6MG) (TAB DS PK)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (2 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (4 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (6 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FANAPT (8 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• FARXIGA (10 MG) (TABLET)
Prior prescription for Invokamet or Invokana in 365 days
• FARXIGA (5 MG) (TABLET)
Prior prescription for Invokamet or Invokana in 365 days
• FENOGLIDE (120 MG) (TABLET)
Prior prescription for preferred fenofibrate product in 120 days
• FENOGLIDE (40 MG) (TABLET)
Prior prescription for preferred fenofibrate product in 120 days
• FETZIMA (120 MG) (CAP SA 24H)
At least 2 of Prior prescription for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• FETZIMA (20 MG) (CAP SA 24H)
At least 2 of Prior prescription for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• FETZIMA (20-40MG) (CAP24HDSPK)
At least 2 of Prior prescription for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• FETZIMA (40 MG) (CAP SA 24H)
At least 2 of Prior prescription for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• FETZIMA (80 MG) (CAP SA 24H)
At least 2 of Prior prescription for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• FLECTOR (1.3 %) (PATCH TD12)
Prior prescription for Diclofenac in 120 days
• FORADIL (12 MCG) (CAP W/DEV)
Prior prescription for Serevent Diskus in 120 days
• FROVA (2.5 MG) (TABLET)
Prior prescription for sumatriptan or rizatriptan in 120 days
• FYCOMPA (0.5 MG/ML) (ORAL SUSP) At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
• FYCOMPA (10 MG) (TABLET)
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
Sharp Health Plan: Covered California
Page 193 of 224
Medication Prescribing Limitations
• FYCOMPA (12 MG) (TABLET)
• FYCOMPA (2 MG) (TABLET)
• FYCOMPA (4 MG) (TABLET)
• FYCOMPA (6 MG) (TABLET)
• FYCOMPA (8 MG) (TABLET)
• GELNIQUE (10 %) (GEL PACKET)
• GLYXAMBI (10 MG-5 MG) (TABLET)
• GLYXAMBI (25 MG-5 MG) (TABLET)
• GRALISE (300 MG) (TAB ER 24H)
• HEMANGEOL (4.28 MG/ML)
(SOLUTION)
• HORIZANT (300 MG) (TABLET ER)
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
At least 2 prior prescriptions for carbamazepine, gabapentin, lamotrigine,
levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or
zonisamide in 365 days
Prior prescription for oxybutynin in 120 days
Prior Prescription for a formulary SGLT2 (Invokana/Invokamet) or DPP4 inhibitor
(Tradjenta, Jentadueto, Januvia Janumet, Janumet XR) in 120 days
Prior Prescription for a formulary SGLT2 (Invokana/Invokamet) or DPP4 inhibitor
(Tradjenta, Jentadueto, Januvia Janumet, Janumet XR) in 120 days
Prior prescription for Gabapentin in 120 days
Prior prescripton for generic propranolol oral solution in 120 days
Prior prescription for Gabapentin, Pramipexole DI-HCL, or Ropinirole HCL in 120
days
• HORIZANT (600 MG) (TABLET ER)
Prior prescription for Gabapentin, Pramipexole DI-HCL, or Ropinirole HCL in 120
days
• HYCOFENIX (2.5-30-200) (SOLUTION) Prior prescription for Lortuss EX in 120 days
• INCRUSE ELLIPTA (62.5 MCG) (BLST
W/DEV)
Prior prescription for Spiriva Respimat 2.5 mcg or Spiriva HandiHaler in 120 days
• INTERMEZZO (1.75 MG) (TAB SUBL) Prior prescription for Zolpimist or Edluar in 120 days
• INTERMEZZO (3.5 MG) (TAB SUBL)
Prior prescription for Zolpimist or Edluar in 120 days
• INVEGA (1.5 MG) (TAB ER 24)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• INVEGA (3 MG) (TAB ER 24)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• INVEGA (6 MG) (TAB ER 24)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• INVEGA (9 MG) (TAB ER 24)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• JANUMET (50-1000 MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUMET (50MG-500MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUMET XR (100-1000MG) (TBMP
24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUMET XR (50-1000 MG) (TBMP
24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUMET XR (50MG-500MG) (TBMP
24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUVIA (100 MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUVIA (25 MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• JANUVIA (50 MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• JARDIANCE (10 MG) (TABLET)
Prior prescription for Invokamet or Invokana in 365 days
• JARDIANCE (25 MG) (TABLET)
Prior prescription for Invokamet or Invokana in 365 days
• JENTADUETO (2.5-1000MG) (TABLET) Prior prescription for preferred generic alogliptin products in 120 days
• JENTADUETO (2.5-500 MG) (TABLET) Prior prescription for preferred generic alogliptin products in 120 days
• JENTADUETO (2.5-850 MG) (TABLET) Prior prescription for preferred generic alogliptin products in 120 days
• JENTADUETO XR (2.5-1000MG) (TAB
BP 24H)
Prior prescription for preferred generic alogliptin products in 120 days
Sharp Health Plan: Covered California
Page 194 of 224
Medication Prescribing Limitations
• JENTADUETO XR (5MG-1000MG) (TAB
BP 24H)
Prior prescription for preferred generic alogliptin products in 120 days
• KADIAN (10 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
• KADIAN (100 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
• KADIAN (20 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/amitriptyline HCL in 120
days
• KADIAN (200 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KADIAN (30 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KADIAN (40 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KADIAN (50 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KADIAN (60 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KADIAN (80 MG) (CAP ER PEL)
Prior prescription for Morphine Sulfate or Perphenazine/Amitriptyline in 120 days
• KHEDEZLA (100 MG) (TAB ER 24)
At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• KHEDEZLA (50 MG) (TAB ER 24)
At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• KOMBIGLYZE XR (2.5-1000MG) (TBMP
24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• KOMBIGLYZE XR (5 MG-500MG)
(TBMP 24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• KOMBIGLYZE XR (5MG-1000MG)
(TBMP 24HR)
Prior prescription for preferred generic alogliptin products in 120 days
• LASTACAFT (0.25 %) (DROPS)
Prior prescription for Olopatadine HCL, Azelastine HCL, Epinastine HCL, or
Ketotifen in 120 days
• LATUDA (120 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• LATUDA (20 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• LATUDA (40 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• LATUDA (60 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• LATUDA (80 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• LESCOL XL (80 MG) (TAB ER 24H)
Prior prescription for Simvastatin, Pravastatin, Altoprev, Lovastatin, or Atorvastatin
in 120 days
• LEVEMIR (100/ML) (VIAL)
Prior prescription for Lantus or Lantus Solostar in 120 days
• LEVEMIR FLEXTOUCH (100/ML (3))
(INSULN PEN)
Prior prescription for Lantus or Lantus Solostar in 120 days
• LIVALO (1 MG) (TABLET)
Prior prescription for Simvastatin, Pravastatin, Altoprev, Lovastatin, or Atorvastatin
in 120 days
• LIVALO (2 MG) (TABLET)
Prior prescription for Simvastatin, Pravastatin, Altoprev, Lovastatin, or Atorvastatin
in 120 days
• LIVALO (4 MG) (TABLET)
Prior prescription for Simvastatin, Pravastatin, Altoprev, Lovastatin, or Atorvastatin
in 120 days
• LUZU (1 %) (CREAM (G))
Prior prescription for Clotrimazole and Ketoconazole in 120 days
• LYRICA (100 MG) (CAPSULE)
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
• LYRICA (150 MG) (CAPSULE)
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
• LYRICA (20 MG/ML) (SOLUTION)
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
• LYRICA (200 MG) (CAPSULE)
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
Sharp Health Plan: Covered California
Page 195 of 224
Medication Prescribing Limitations
• LYRICA (225 MG) (CAPSULE)
• LYRICA (25 MG) (CAPSULE)
• LYRICA (300 MG) (CAPSULE)
• LYRICA (50 MG) (CAPSULE)
• LYRICA (75 MG) (CAPSULE)
• MIGRANAL (0.5MG/SPRY)
(SPRAY/PUMP)
• MIRVASO (0.33 %) (GEL (GRAM))
• NAMZARIC (14MG-10MG) (CAP SPR
24)
• NAMZARIC (28 MG-10MG) (CAP SPR
24)
• NAPRELAN (375 MG) (TBMP 24HR)
• NAPRELAN (500 MG) (TBMP 24HR)
• NAPRELAN (750 MG) (TBMP 24HR)
• NASONEX (50 MCG) (SPRAY/PUMP)
• NEO-SYNALAR (0.5-0.025%) (CREAM
(G))
• NEXIUM (10 MG) (SUSPDR PKT)
• NEXIUM (2.5 MG) (SUSPDR PKT)
• NEXIUM (20 MG) (CAPSULE DR)
• NEXIUM (20 MG) (SUSPDR PKT)
• NEXIUM (40 MG) (CAPSULE DR)
• NEXIUM (40 MG) (SUSPDR PKT)
• NEXIUM (5 MG) (SUSPDR PKT)
• NOVOLIN 70-30 (70-30/ML) (VIAL)
(OTC)
• NOVOLIN N (100/ML) (VIAL) (OTC)
• NOVOLIN R (100/ML) (VIAL) (OTC)
• NOVOLOG (100/ML) (CARTRIDGE)
• NOVOLOG (100/ML) (VIAL)
• NOVOLOG FLEXPEN (100/ML)
(INSULN PEN)
• NOVOLOG MIX 70-30 (70-30/ML)
(VIAL)
• NOVOLOG MIX 70-30 FLEXPEN (7030/ML) (INSULN PEN)
• OLEPTRO ER (150 MG) (TAB ER 24H)
• OLEPTRO ER (300 MG) (TAB ER 24H)
• OMNARIS (50 MCG) (SPRAY/PUMP)
• ONFI (10 MG) (TABLET)
• ONFI (2.5 MG/ML) (ORAL SUSP)
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
At least 3 prior prescriptions for amitriptyline, Savella, Fanatrex, Gabapentin, and
Gralise in 120 days
Prior prescription for sumatriptan or rizatriptan in 120 days
Prior prescription for Flagyl ER, Metronidazole, Noritate, Nuvessa, or Vandazole in
120 days
At least 2 of prior prescriptions for donepezil and memantine in 120 days
At least 2 of prior prescriptions for donepezil and memantine in 120 days
At least 2 prior prescriptions for Naproxen Sodium ER or Naproxen in 120 days
At least 2 prior prescriptions for Naproxen Sodium ER or Naproxen in 120 days
At least 2 prior prescriptions for Naproxen Sodium ER or Naproxen in 120 days
Prior prescription for Fluticasone Propionate in 120 days
Prior prescription for Capex Shampoo, Fluocinolone, Fluocinolone/shower cap,
Iluvien, or Retisert in 120 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
Prior prescription for Humulin 70/30 IN 120 days
Prior prescription for Humulin N or Humulin N Kwikpen in 120 days
Prior prescription for Humulin R in 120 days
Prior prescription for Humalog in 120 days
Prior prescription for Humalog in 120 days
Prior prescription for Humalog in 120 days
Prior prescription for Humalog in 120 days
Prior prescription for Humalog in 120 days
Prior prescription for Trazodone HCL in 120 days
Prior prescription for Trazodone HCL in 120 days
Prior prescription for Fluticasone Propionate in 120 days
Prior prescription for Lamotrigine or Topiramate in 120 days
Prior prescription for Lamotrigine or Topiramate in 120 days
Sharp Health Plan: Covered California
Page 196 of 224
Medication Prescribing Limitations
• ONFI (20 MG) (TABLET)
• ONGLYZA (2.5 MG) (TABLET)
• ONGLYZA (5 MG) (TABLET)
• ONZETRA XSAIL (11 MG) (AER POW
BA)
• OSPHENA (60 MG) (TABLET)
• OXYTROL (3.9MG/24HR) (PATCH
TDSW)
• PEN NEEDLES (OTC)
• PENNSAID (1.5 %) (DROPS)
• PENNSAID (20MG/G(2%)) (SOL MD
PMP)
• PENTASA (250 MG) (CAPSULE ER)
• PENTASA (500 MG) (CAPSULE ER)
• PRADAXA (110 MG) (CAPSULE)
• PRADAXA (150 MG) (CAPSULE)
• PRADAXA (75 MG) (CAPSULE)
• PREMARIN (0.625 MG/G)
(CREAM/APPL)
• PRESTALIA (14MG-10MG) (TABLET)
• PRESTALIA (3.5-2.5 MG) (TABLET)
• PRESTALIA (7 MG-5 MG) (TABLET)
• PREVACID (15 MG) (TAB RAP DR)
• PREVACID (30 MG) (CAPSULE DR)
• PREVACID (30 MG) (TAB RAP DR)
• PRISTIQ ER (100 MG) (TAB ER 24H)
• PRISTIQ ER (50 MG) (TAB ER 24H)
Prior prescription for Lamotrigine or Topiramate in 120 days
Prior prescription for preferred generic alogliptin products in 120 days
Prior prescription for preferred generic alogliptin products in 120 days
Prior prescription for Sumatriptan in 120 days
Prior prescription for Vagifem in 120 days
Prior presciption for Gelnique or Oxybutynin in 120 days
Prior prescription for an insulin or GLP-1 Agonist
Prior prescription for Diclofenac in 120 days
Prior prescription for Diclofenac in 120 days
Prior prescription for Apriso, Balsalazide, Dipentum, Giazo, or Mesalamine in 120
days
Prior prescription for Apriso, Balsalazide, Dipentum, Giazo, or Mesalamine in 120
days
Prior prescription for Eliquis or Xarelto in 120 days
Prior prescription for Eliquis or Xarelto in 120 days
Prior prescription for Eliquis or Xarelto in 120 days
Prior prescription for Estrace or Vagifem in 120 days
Prior prescription for perindopril and amlodipine required.
Prior prescription for perindopril and amlodipine required.
Prior prescription for perindopril and amlodipine required.
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
At least 2 prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) and
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
Prior prescription for generic topical corticosteroid in 120 days
Prior prescription for generic topical corticosteroid in 120 days
• PROTOPIC (0.03 %) (OINT. (G))
• PROTOPIC (0.1 %) (OINT. (G))
• PROVENTIL HFA (90 MCG) (HFA AER
AD)
Prior prescription for Proair HFA in 120 days
• QBRELIS (1 MG/ML) (SOLUTION)
Prior prescription for lisonopril in 120 days
• QNASL (80 MCG) (HFA AER AD)
Prior prescription for Fluticasone Propionate in 120 days
• QNASL CHILDREN (40 MCG) (HFA AER
AD)
Prior prescription for Fluticasone Propionate in 120 days
• QUILLICHEW ER (20 MG) (TAB
Prior prescription for long acting formulation of methylphenidate (LA,CD) in 120
CBP24H)
days
• QUILLICHEW ER (30 MG) (TAB
Prior prescription for long acting formulation of methylphenidate (LA,CD) in 120
CBP24H)
days
• QUILLICHEW ER (40 MG) (TAB
Prior prescription for long acting formulation of methylphenidate (LA,CD) in 120
CBP24H)
days
• QUILLIVANT XR (5 MG/ML) (SU ER
Prior prescription for Methylphenidate HCL CD, Methylphenidate HCL ER, or
RC24)
Ritalin LA in 120 days
• RAPAFLO (4 MG) (CAPSULE)
Prior prescription for Terazosin HCL, Cardura XL, or Doxazosin in 120 days
• RAPAFLO (8 MG) (CAPSULE)
Prior prescription for Terazosin HCL, Cardura XL, or Doxazosin in 120 days
• RELPAX (20 MG) (TABLET)
Prior prescription for sumatriptan or rizatriptan in 120 days
• RELPAX (40 MG) (TABLET)
Prior prescription for sumatriptan or rizatriptan in 120 days
• REXULTI (0.25 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
Sharp Health Plan: Covered California
Page 197 of 224
Medication Prescribing Limitations
• REXULTI (0.5 MG) (TABLET)
• REXULTI (1 MG) (TABLET)
• REXULTI (2 MG) (TABLET)
• REXULTI (3 MG) (TABLET)
• REXULTI (4 MG) (TABLET)
• RHINOCORT AQUA (32MCG)
(SPRAY/PUMP)
• ROZEREM (8 MG) (TABLET)
• RYTARY (23.75-95MG) (CAPSULE ER)
• RYTARY (36.25-145) (CAPSULE ER)
• RYTARY (48.75-195) (CAPSULE ER)
• RYTARY (61.25-245) (CAPSULE ER)
• SANCTURA (20 MG) (TABLET)
• SANCTURA XR (60 MG) (CAP ER 24H)
• SAPHRIS (10 MG) (TAB SUBL)
• SAPHRIS (2.5 MG) (TAB SUBL)
• SAPHRIS (5 MG) (TAB SUBL)
• SAVAYSA (15 MG) (TABLET)
• SAVAYSA (30 MG) (TABLET)
• SAVAYSA (60 MG) (TABLET)
• SAVELLA (100 MG) (TABLET)
• SAVELLA (12.5 MG) (TABLET)
• SAVELLA (12.5-25-50) (TAB DS PK)
• SAVELLA (25 MG) (TABLET)
• SAVELLA (50 MG) (TABLET)
• SERNIVO (0.05 %) (SPRAY/PUMP)
• SEROQUEL XR (150 MG) (TAB ER 24H)
• SEROQUEL XR (200 MG) (TAB ER 24H)
• SEROQUEL XR (300 MG) (TAB ER 24H)
• SEROQUEL XR (400 MG) (TAB ER 24H)
• SEROQUEL XR (50 MG) (TAB ER 24H)
• SILENOR (3 MG) (TABLET)
• SILENOR (6 MG) (TABLET)
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
Prior prescription for Fluticasone Propionate in 120 days
Prior prescription for Silenor, Zaleplon, Eszopiclone, Belsomra, or Zolpidem Tartrate
in 120 days
Prior prescription for Sinemet CR in 120 days
Prior prescription for Sinemet CR in 120 days
Prior prescription for Sinemet CR in 120 days
Prior prescription for Sinemet CR in 120 days
Prior presciption for Gelnique or Oxybutynin in 120 days
Prior presciption for Gelnique or Oxybutynin in 120 days
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
Prior prescription for Xarelto or Eliquis in 120 days
Prior prescription for Xarelto or Eliquis in 120 days
Prior prescription for Xarelto or Eliquis in 120 days
At least 2 prior prescriptions for Amitriptyline HCL, Fanatrex, Gabapentin, or
Gralise in 120 days
At least 2 prior prescriptions for Amitriptyline HCL, Fanatrex, Gabapentin, or
Gralise in 120 days
At least 2 prior prescriptions for Amitriptyline HCL, Fanatrex, Gabapentin, or
Gralise in 120 days
At least 2 prior prescriptions for Amitriptyline HCL, Fanatrex, Gabapentin, or
Gralise in 120 days
At least 2 prior prescriptions for Amitriptyline HCL, Fanatrex, Gabapentin, or
Gralise in 120 days
Prior prescription for Triamcinolone Acetonide in 120 days
At least 2 prior prescriptions for a formulary preferred atypical antipsychotic, SSRI,
or SNRI IN 180 days
At least 2 prior prescriptions for a formulary preferred atypical antipsychotic, SSRI,
or SNRI IN 180 days
At least 2 prior prescriptions for a formulary preferred atypical antipsychotic, SSRI,
or SNRI IN 180 days
At least 2 prior prescriptions for a formulary preferred atypical antipsychotic, SSRI,
or SNRI IN 180 days
At least 2 prior prescriptions for a formulary preferred atypical antipsychotic, SSRI,
or SNRI IN 180 days
Prior prescription for Rozerem, Belsomra, Zolpidem Tartrate, Eszopiclone, or
Zaleplon in 120 days
Prior prescription for Rozerem, Belsomra, Zolpidem Tartrate, Eszopiclone, or
Zaleplon in 120 days
Sharp Health Plan: Covered California
Page 198 of 224
Medication Prescribing Limitations
• SITAVIG (50 MG) (MA BUC TAB)
Prior prescription for acyclovir, valacyclovir, famciclovir and Zovirax ointment in
120 days
• SORILUX (0.005 %) (FOAM)
Prior prescription for generic topical corticosteroid in 120 days
• SPIRIVA RESPIMAT (1.25 MCG) (MIST Prior prescription for Beta-adrenergic and Glucocorticoid Combinations or orally
INHAL)
inhaled Glucocorticoids in 120 days
• SPRITAM (1000 MG) (TAB SUSP)
Prior prescription for levetiracetam in 120 days
• SPRITAM (250 MG) (TAB SUSP)
Prior prescription for levetiracetam in 120 days
• SPRITAM (500 MG) (TAB SUSP)
Prior prescription for levetiracetam in 120 days
• SPRITAM (750 MG) (TAB SUSP)
Prior prescription for levetiracetam in 120 days
• STRIVERDI RESPIMAT (2.5 MCG)
(MIST INHAL)
Prior prescription for Serevent Diskus in 120 days
• SUMAVEL DOSEPRO (4 MG/0.5ML)
(NDL FR INJ)
Prior prescription for Sumatriptan or rizatriptan in 120 days
• SUMAVEL DOSEPRO (6 MG/0.5ML)
(NDL FR INJ)
Prior prescription for Sumatriptan or rizatriptan in 120 days
• SYMBICORT (160-4.5MCG) (HFA AER
AD)
At least 2 prior prescriptions for Advair Diskus and Breo Ellipta in the 365 days
• SYMBICORT (80-4.5 MCG) (HFA AER
AD)
At least 2 prior prescriptions for Advair Diskus and Breo Ellipta in the 365 days
• SYNJARDY (12.5-1000) (TABLET)
Prior prescription for Invokana or Invokamet in 120 days
• SYNJARDY (12.5-500MG) (TABLET)
Prior prescription for Invokana or Invokamet in 120 days
• SYNJARDY (5 MG-500MG) (TABLET) Prior prescription for Invokana or Invokamet in 120 days
• SYNJARDY (5MG-1000MG) (TABLET) Prior prescription for Invokana or Invokamet in 120 days
• TACLONEX (0.005-.064) (OINT. (G))
Prior prescription for topical anti-inflammatory steroidal in 120 days
• TACLONEX (0.005-.064) (SUSPENSION) Prior prescription for topical anti-inflammatory steroidal in 120 days
• TANZEUM (30MG/0.5ML) (PEN INJCTR)At least 2 prior prescriptions for Fortamet, Metformin HCL, Riomet, Bydureon.
Byetta, or Victoza in 365 days
• TANZEUM (50MG/0.5ML) (PEN INJCTR)At least 2 prior prescriptions for Fortamet, Metformin HCL, Riomet, Bydureon.
Byetta, or Victoza in 365 days
• TARGADOX (50 MG) (TABLET)
Prior prescription for doxycycline in 120 days
• TAZORAC (0.05 %) (CREAM (G))
Prior prescription for generic topical corticosteroid in 120 days
• TAZORAC (0.05 %) (GEL (GRAM))
Prior prescription for generic topical corticosteroid in 120 days
• TAZORAC (0.1 %) (CREAM (G))
Prior prescription for generic topical corticosteroid in 120 days
• TAZORAC (0.1 %) (GEL (GRAM))
Prior prescription for generic topical corticosteroid in 120 days
• TOVIAZ (4 MG) (TAB ER 24H)
Prior presciption for Gelnique or Oxybutynin in 120 days
• TOVIAZ (8 MG) (TAB ER 24H)
Prior presciption for Gelnique or Oxybutynin in 120 days
• TRADJENTA (5 MG) (TABLET)
Prior prescription for preferred generic alogliptin products in 120 days
• TRESIBA FLEXTOUCH U-100 (100/ML
(3)) (INSULN PEN)
Prior prescription for Lantus or Lantus Solostar in 120 days
• TRESIBA FLEXTOUCH U-200 (200/ML
(3)) (INSULN PEN)
Prior prescription for Lantus or Lantus Solostar in 120 days
• TREXIMET (85MG-500MG) (TABLET) Prior prescription for Sumatriptan or Rizatriptan in 120 days
• TRIBENZOR (20-5-12.5) (TABLET)
Prior prescription for Benicar and amlodipine required.
• TRIBENZOR (40-10-12.5) (TABLET)
Prior prescription for Benicar and amlodipine required.
• TRIBENZOR (40-10-25MG) (TABLET) Prior prescription for Benicar and amlodipine required.
• TRIBENZOR (40-5-12.5) (TABLET)
Prior prescription for Benicar and amlodipine required.
• TRIBENZOR (40-5-25 MG) (TABLET)
Prior prescription for Benicar and amlodipine required.
• TRIGLIDE (160 MG) (TABLET)
Prior prescription for preferred fenofibrate product in 120 days
• TRINTELLIX (10 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• TRINTELLIX (20 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• TRINTELLIX (5 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• TRULICITY (0.75MG/0.5) (PEN INJCTR) At least 2 prior prescriptions for Fortamet, Metformin HCL, Riomet, Bydureon.
Byetta, or Victoza in 365 days
• TRULICITY (1.5 MG/0.5) (PEN INJCTR) At least 2 prior prescriptions for Fortamet, Metformin HCL, Riomet, Bydureon.
Byetta, or Victoza in 365 days
• TUDORZA PRESSAIR (400 MCG) (AER
POW BA)
Prior presciption for Spiriva in 120 days
• TUZISTRA XR (14.7-2.8/5) (SUS ER 12H)Prior presciption for Promethazine HCL/codeine in 60 days
Sharp Health Plan: Covered California
Page 199 of 224
Medication Prescribing Limitations
• UCERIS (2 MG) (FOAM/APPL)
• ULORIC (40 MG) (TABLET)
• ULORIC (80 MG) (TABLET)
• VALTREX (1000 MG) (TABLET)
• VALTREX (500 MG) (TABLET)
• VECTICAL (3 MCG/G) (OINT. (G))
• VELTIN (1.2-0.025%) (GEL (GRAM))
• VENLAFAXINE HCL ER (150 MG) (TAB
ER 24)
Prior prescription for Mesalamine in 120 days
Prior prescription for Allopurinol in 120 days
Prior prescription for Allopurinol in 120 days
Prior presciption for Acyclovir, Sitavig, Zovirax, or Valacyclovir HCL in 120 days
Prior presciption for Acyclovir, Sitavig, Zovirax, or Valacyclovir HCL in 120 days
Prior prescription for generic topical corticosteroid in 120 days
Prior prescription for topical tretinoin in 120 days
Prior prescription for Citalopram HBR, Sertraline HCL, Fluoxetine HCL,
Venlafaxine HCL, Fluovoxamine Maleate, Escitalopram, or Paroxetine HCL in 365
days
• VENLAFAXINE HCL ER (225 MG) (TAB Prior prescription for Citalopram HBR, Sertraline HCL, Fluoxetine HCL,
ER 24)
Venlafaxine HCL, Fluovoxamine Maleate, Escitalopram, or Paroxetine HCL in 365
days
• VENLAFAXINE HCL ER (37.5 MG) (TAB Prior prescription for Citalopram HBR, Sertraline HCL, Fluoxetine HCL,
ER 24)
Venlafaxine HCL, Fluovoxamine Maleate, Escitalopram, or Paroxetine HCL in 365
days
• VENLAFAXINE HCL ER (75 MG) (TAB Prior prescription for Citalopram HBR, Sertraline HCL, Fluoxetine HCL,
ER 24)
Venlafaxine HCL, Fluovoxamine Maleate, Escitalopram, or Paroxetine HCL in 365
days
• VENTOLIN HFA (90 MCG) (HFA AER
AD)
Prior prescription for Proair HFA in 120 days
• VERAMYST (27.5 MCG) (SPRAY SUSP) Prior prescription for Fluticasone Propionate in 120 days
• VERSACLOZ (50 MG/ML) (ORAL SUSP) At least 2 prior prescriptions for plan preferred atypical antipsychotics, SSRIs, or
SNRIs within the previous 180 days required. Must be written by a psychiatrist or
PCSD NP.
• VESICARE (10 MG) (TABLET)
Prior presciption for Gelnique or Oxybutynin in 120 days
• VESICARE (5 MG) (TABLET)
Prior presciption for Gelnique or Oxybutynin in 120 days
• VICTOZA 2-PAK (0.6 MG/0.1) (PEN
INJCTR)
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• VICTOZA 3-PAK (0.6 MG/0.1) (PEN
INJCTR)
Prior prescription for Fortamet, Metformin HCL, or Riomet in 120 days
• VIIBRYD (10 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• VIIBRYD (10 MG-20MG) (TAB DS PK) At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• VIIBRYD (20 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• VIIBRYD (40 MG) (TABLET)
At least 2 of prior prescriptions for Selective Serotonin Reuptake Inhibitor (SSRIs) or
Serotonin-norepinephrine Reuptake-inhib (SNRIs) in 120 days
• VIVLODEX (10 MG) (CAPSULE)
Prior prescription for Meloxicam in 120 days
• VIVLODEX (5 MG) (CAPSULE)
Prior prescription for Meloxicam in 120 days
• VYTORIN (10 MG-10MG) (TABLET)
Prior prescription for Simvastatin, Rosuvastatin, or Atorvastatin in 120 days
• VYTORIN (10 MG-20MG) (TABLET)
Prior prescription for Simvastatin, Rosuvastatin, or Atorvastatin in 120 days
• VYTORIN (10 MG-40MG) (TABLET)
Prior prescription for Simvastatin, Rosuvastatin, or Atorvastatin in 120 days
• VYTORIN (10 MG-80MG) (TABLET)
Prior prescription for Simvastatin, Rosuvastatin, or Atorvastatin in 120 days
• XERESE (5 %-1 %) (CREAM (G))
Prior prescription for acyclovir, valacyclovir, famciclovir and Zovirax ointment in
365 days
• XIGDUO XR (10-1000 MG) (TAB BP
24H)
Prior prescription for Invokana or Invokamet in 365 days
• XIGDUO XR (10MG-500MG) (TAB BP
24H)
Prior prescription for Invokana or Invokamet in 365 days
• XIGDUO XR (5 MG-500MG) (TAB BP
24H)
Prior prescription for Invokana or Invokamet in 365 days
• XIGDUO XR (5MG-1000MG) (TAB BP
24H)
Prior prescription for Invokana or Invokamet in 365 days
• XOPENEX HFA (45 MCG) (HFA AER
AD)
Prior prescription for Proair HFA in 120 days
• XYZAL (2.5 MG/5ML) (SOLUTION)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• XYZAL (5 MG) (TABLET)
At least 3 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
• ZEGERID (20-1680MG) (PACKET)
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
Sharp Health Plan: Covered California
Page 200 of 224
Medication Prescribing Limitations
• ZEGERID (20MG-1.1G) (CAPSULE)
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
• ZEGERID (40-1680MG) (PACKET)
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
• ZEGERID (40MG-1.1G) (CAPSULE)
At least 3 prior prescriptions for Protonix, pantoprazole, omeprazole, Prilosec OTC,
Prilosec, Prevacid 24 hour, Nexium OTC, Aciphex, First-lansoprazole, or Prilosec
DR in 365 days
• ZETONNA (37 MCG) (HFA AER AD)
Prior prescription for Fluticasone Propionate in 120 days
• ZIANA (1.2-0.025%) (GEL (GRAM))
Prior prescription for topical tretinoin in 120 days
• ZIPSOR (25 MG) (CAPSULE)
Prior prescription for diclofenac sodium and an NSAID (such as Naprosyn) in 120
days
• ZITHRANOL-RR (1.2 %) (CRM RR (G)) Prior prescription for generic topical corticosteroid in 120 days
• ZOLPIMIST (5 MG/SPRAY)
(SPRAY/PUMP)
Prior prescription for Zolpimist or Edluar in 120 days
• ZOMIG (2.5 MG) (SPRAY)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZOMIG (2.5 MG) (TABLET)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZOMIG (5 MG) (SPRAY)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZOMIG (5 MG) (TABLET)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZOMIG ZMT (2.5 MG) (TAB RAPDIS)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZOMIG ZMT (5 MG) (TAB RAPDIS)
Prior prescription for Sumatriptan or Rizatriptan in 120 days
• ZORVOLEX (18 MG) (CAPSULE)
Prior prescription for diclofenac sodium and an NSAID (such as Naprosyn) in 120
days
• ZORVOLEX (35 MG) (CAPSULE)
Prior prescription for diclofenac sodium and an NSAID (such as Naprosyn) in 120
days
• ZURAMPIC (200 MG) (TABLET)
Prior prescription for Allopurinol or Uloric in 120 days
• ZYRTEC (1 MG/ML) (SOLUTION)
At least 2 prior prescriptions for Claritin OTC and Zyrtec OTC in 120 days
Sharp Health Plan: Covered California
Page 201 of 224
Index
-#8-MOP (10 MG) (CAPSULE) ..........................................82
-AABACAVIR SULFATE................................................... 127
ABACAVIR SULFATE/LAMIVUDINE.........................126
ABACAVIR/DOLUTEGRAVIR/LAMIVUDI................ 129
ABACAVIR/LAMIVUDINE/ZIDOVUDINE.................126
ABILIFY (1 MG/ML) (SOLUTION) .......................29, 189
ABILIFY (10 MG) (TABLET) .................................30, 189
ABILIFY (15 MG) (TABLET) .................................30, 189
ABILIFY (2 MG) (TABLET) ...................................30, 189
ABILIFY (20 MG) (TABLET) .................................30, 189
ABILIFY (30 MG) (TABLET) .................................30, 189
ABILIFY (5 MG) (TABLET) ...................................30, 189
ABILIFY DISCMELT (10 MG) (TAB RAPDIS) ...... 30,
189
ABILIFY DISCMELT (15 MG) (TAB RAPDIS) ...... 30,
189
ABIRATERONE ACETATE........................................... 144
ABSORICA (10 MG) (CAPSULE) ..................................67
ABSORICA (20 MG) (CAPSULE) ..................................67
ABSORICA (25 MG) (CAPSULE) ..................................67
ABSORICA (30 MG) (CAPSULE) ..................................67
ABSORICA (35 MG) (CAPSULE) ..................................67
ABSORICA (40 MG) (CAPSULE) ..................................67
ABSORICA 30MG (30 MG) (CAPSULE) ...................... 67
ABSTRAL (100 MCG) (TAB SUBL) ............................156
ABSTRAL (200 MCG) (TAB SUBL) ............................156
ABSTRAL (300 MCG) (TAB SUBL) ............................156
ABSTRAL (400 MCG) (TAB SUBL) ............................157
ABSTRAL (600 MCG) (TAB SUBL) ............................157
ABSTRAL (800 MCG) (TAB SUBL) ............................157
ACAMPROSATE CALCIUM...........................................27
ACANYA (1.2%-2.5%) (GEL W/PUMP) ................ 67, 189
ACARBOSE...................................................................... 84
ACCOLATE (10 MG) (TABLET) ....................................17
ACCOLATE (20 MG) (TABLET) ....................................17
ACCUNEB (0.63MG/3ML) (VIAL-NEB) .......................14
ACCUNEB (1.25MG/3ML) (VIAL-NEB) .......................14
ACCUPRIL (10 MG) (TABLET) ..................................... 47
ACCUPRIL (20 MG) (TABLET) ..................................... 47
ACCUPRIL (40 MG) (TABLET) ..................................... 47
ACCUPRIL (5 MG) (TABLET) ....................................... 47
ACCURETIC (10-12.5MG) (TABLET) ...........................43
ACCURETIC (20 MG-25MG) (TABLET) ...................... 43
ACCURETIC (20-12.5 MG) (TABLET) ..........................43
ACCUTANE (10 MG) (CAPSULE) .................................67
ACCUTANE (20 MG) (CAPSULE) .................................67
ACCUTANE (40 MG) (CAPSULE) .................................67
ACD (2.45G-2.2G) (SOLUTION) ..................................104
ACEBUTOLOL HCL........................................................ 49
ACEON (2 MG) (TABLET) ............................................. 47
ACEON (4 MG) (TABLET) ............................................. 47
ACEON (8 MG) (TABLET) ............................................. 47
ACETAMINOPHEN WITH CODEINE................. 164, 165
ACETAMINOPHEN WITH CODEINE (300MG/12.5)
(SOLUTION) ........................................................................
ACETAMINOPHEN WITH CODEINE (300MG-15MG)
(TABLET) .............................................................................
ACETAMINOPHEN/CAFF/DIHYDROCOD................ 155
ACETAZOLAMIDE........................................................101
ACETIC ACID.................................................................. 90
ACETIC ACID/ALUMINUM ACETATE .........................90
ACETIC ACID/ALUMINUM ACETATE (2 %) (DROPS)
...............................................................................................
ACETIC ACID/HYDROCORTISONE............................. 90
ACETIC ACID/OXYQUINOLINE.................................183
ACETOHYDROXAMIC ACID...................................... 141
ACETYLCYSTEINE...................................................... 154
ACIPHEX (20 MG) (TABLET DR) ...............................180
ACIPHEX SPRINKLE (10 MG) (CAP DR SPR) ..........180
ACIPHEX SPRINKLE (5 MG) (CAP DR SPR) ............180
ACITRETIN...................................................................... 81
ACLIDINIUM BROMIDE................................................ 13
ACLOVATE (0.05 %) (CREAM (G)) ...............................74
ACLOVATE (0.05 %) (OINT. (G)) ...................................74
ACTEMRA (162 MG/0.9) (SYRINGE) .........................136
ACTEMRA (200MG/10ML) (VIAL) ............................ 136
ACTEMRA (400MG/20ML) (VIAL) ............................ 136
ACTEMRA (80 MG/4 ML) (VIAL) .............................. 136
ACTICLATE (150 MG) (TABLET) ............................... 120
ACTICLATE (75 MG) (TABLET) ................................. 120
ACTIGALL (300 MG) (CAPSULE) .............................. 142
ACTIQ (1200 MCG) (LOZENGE HD) ..........................157
ACTIQ (1600 MCG) (LOZENGE HD) ..........................157
ACTIQ (200 MCG) (LOZENGE HD) ............................157
ACTIQ (400 MCG) (LOZENGE HD) ............................157
ACTIQ (600 MCG) (LOZENGE HD) ............................157
ACTIQ (800 MCG) (LOZENGE HD) ............................157
ACTIVE FE (75-1.25 MG) (TABLET) .......................... 186
ACTIVELLA (0.5-0.1MG) (TABLET) .......................... 110
ACTIVELLA (1 MG-0.5MG) (TABLET) ......................110
ACTONEL (150 MG) (TABLET) .................................... 94
ACTONEL (30 MG) (TABLET) ...................................... 94
ACTONEL (35 MG) (TABLET) ...................................... 94
ACTONEL (5 MG) (TABLET) ........................................ 94
ACTOPLUS MET (15MG-500MG) (TABLET) ...... 88,
189
ACTOPLUS MET (15MG-850MG) (TABLET) ...... 88,
189
ACTOPLUS MET XR (15-1000 MG) (TBMP 24HR) ......
88,
189
ACTOPLUS MET XR (30-1000 MG) (TBMP 24HR) ......
88,
189
ACTOS (15 MG) (TABLET) ....................................86, 189
ACTOS (30 MG) (TABLET) ....................................86, 189
ACTOS (45 MG) (TABLET) ....................................86, 189
ACULAR (0.5 %) (DROPS) .............................................99
ACULAR LS (0.4 %) (DROPS) ....................................... 99
ACUVAIL (0.45 %) (DROPERETTE) ............................. 99
ACYCLOVIR............................................................ 72, 125
ACYCLOVIR/HYDROCORTISONE............................... 72
ACZONE (5 %) (GEL (GRAM)) ..................................... 68
ACZONE (7.5 %) (GEL W/PUMP) ................................. 68
ADALAT CC (30 MG) (TABLET ER) ............................ 53
ADALAT CC (60 MG) (TABLET ER) ............................ 53
ADALAT CC (90 MG) (TABLET ER) ............................ 53
ADALIMUMAB............................................................. 133
ADAPALENE....................................................................69
ADAPALENE/BENZOYL PEROXIDE............................67
ADASUVE (10 MG) (AER POW BA) .................... 30, 189
ADCIRCA (20 MG) (TABLET) .......................................56
ADDERALL (10 MG) (TABLET) ................................... 27
ADDERALL (12.5 MG) (TABLET) ................................ 27
ADDERALL (15 MG) (TABLET) ................................... 27
ADDERALL (20 MG) (TABLET) ................................... 27
ADDERALL (30 MG) (TABLET) ................................... 27
ADDERALL (5 MG) (TABLET) ..................................... 27
ADDERALL (7.5 MG) (TABLET) .................................. 27
ADDERALL XR (10 MG) (CAP ER 24H) ......................27
ADDERALL XR (15 MG) (CAP ER 24H) ......................27
ADDERALL XR (20 MG) (CAP ER 24H) ......................27
ADDERALL XR (25 MG) (CAP ER 24H) ......................27
ADDERALL XR (30 MG) (CAP ER 24H) ......................27
ADDERALL XR (5 MG) (CAP ER 24H) ........................27
ADEFOVIR DIPIVOXIL................................................ 129
ADEMPAS (0.5 MG) (TABLET) .....................................55
ADEMPAS (1 MG) (TABLET) ........................................55
ADEMPAS (1.5 MG) (TABLET) .....................................55
ADEMPAS (2 MG) (TABLET) ........................................55
ADEMPAS (2.5 MG) (TABLET) .....................................55
ADOXA (150 MG) (CAPSULE) ................................... 120
ADOXA (150 MG) (TABLET) ...................................... 120
ADRENACLICK (0.15/0.15) (AUTO INJCT) ...............143
ADRENACLICK (0.3MG/0.3) (AUTO INJCT) ............ 143
ADVAIR DISKUS (100-50 MCG) (BLST W/DEV) ....... 15
ADVAIR DISKUS (250-50 MCG) (BLST W/DEV) ....... 16
ADVAIR DISKUS (500-50 MCG) (BLST W/DEV) ....... 16
ADVAIR HFA (115-21MCG) (HFA AER AD) ............... 16
ADVAIR HFA (230-21MCG) (HFA AER AD) ............... 16
ADVAIR HFA (45-21MCG) (HFA AER AD) ................. 16
ADZENYS XR-ODT (12.5 MG) (TAB RAP BP) ........... 26
ADZENYS XR-ODT (15.7 MG) (TAB RAP BP) ........... 26
ADZENYS XR-ODT (18.8 MG) (TAB RAP BP) ........... 26
ADZENYS XR-ODT (3.1 MG) (TAB RAP BP) ............. 26
ADZENYS XR-ODT (6.3 MG) (TAB RAP BP) ............. 26
ADZENYS XR-ODT (9.4 MG) (TAB RAP BP) ............. 26
AEROSPAN (80 MCG) (HFA AER AD) .........................16
AFATINIB DIMALEATE............................................... 146
AFINITOR (10 MG) (TABLET) .................................... 145
AFINITOR (2.5 MG) (TABLET) ................................... 145
AFINITOR (5 MG) (TABLET) ...................................... 145
AFINITOR (7.5 MG) (TABLET) ................................... 145
AFINITOR DISPERZ (2 MG) (TAB SUSP) ..................146
AFINITOR DISPERZ (3 MG) (TAB SUSP) ..................146
AFINITOR DISPERZ (5 MG) (TAB SUSP) ..................146
AFREZZA (4 UNIT(30)) (CART INHAL) ......................90
AFREZZA (4 UNIT(60)) (CART INHAL) ......................90
AFREZZA (4 UNIT(90)) (CART INHAL) ......................90
AFREZZA (4 UNIT) (CART INHAL) .............................90
AFREZZA (8 UNIT(60)) (CART INHAL) ......................90
AFTERA (1.5 MG) (TABLET) (OTC)..............................63
AGGRENOX (25MG-200MG) (CPMP 12HR) ............. 106
AGRYLIN (0.5 MG) (CAPSULE) ................................. 107
AGRYLIN (1 MG) (CAPSULE) .................................... 107
AKYNZEO (300-0.5 MG) (CAPSULE) .......................... 12
ALACORT (1 %) (CREAM (G)) ..................................... 76
ALA-QUIN (3 %-0.5 %) (CREAM (G)) ..........................68
ALBENDAZOLE............................................................ 124
ALBENZA (200 MG) (TABLET) .................................. 124
ALBIGLUTIDE.................................................................83
ALBUTEROL SULFATE.................................................. 14
ALBUTEROL SULFATE (2.5 MG/0.5) (VIAL-NEB) ........
Sharp Health Plan: Covered California
ALCAFTADINE................................................................99
ALCLOMETASONE DIPROPIONATE........................... 74
ALCORTIN A (2 %-1 %-1%) (GEL PACKET) ...............68
ALDACTAZIDE (25 MG-25MG) (TABLET) ................. 55
ALDACTAZIDE (50 MG-50MG) (TABLET) ................. 55
ALDACTONE (100 MG) (TABLET) ...............................55
ALDACTONE (25 MG) (TABLET) .................................55
ALDACTONE (50 MG) (TABLET) .................................55
ALDARA (5 %) (CREAM PACK) .................................112
ALDOMET (250 MG) (TABLET) ................................... 49
ALDOMET (500 MG) (TABLET) ................................... 49
ALDORIL 15 (250MG-15MG) (TABLET) ..................... 49
ALDORIL 25 (250MG-25MG) (TABLET) ..................... 49
ALECENSA (150 MG) (CAPSULE) .............................146
ALECTINIB HCL........................................................... 146
ALENDRONATE SODIUM............................................. 93
ALENDRONATE SODIUM/VITAMIN D3......................93
ALFUZOSIN HCL.......................................................... 181
ALINIA (100 MG/5ML) (SUSP RECON) .......................69
ALINIA (500 MG) (TABLET) .........................................69
ALISKIREN HEMIFUMARATE..................................... 57
ALISKIREN/AMLODIPINE BESYLATE....................... 57
ALISKIREN/HYDROCHLOROTHIAZIDE.................... 57
ALITRETINOIN............................................................... 80
ALKERAN (2 MG) (TABLET) ..................................... 144
ALLOPURINOL............................................................. 103
ALLZITAL (25MG-325MG) (TABLET) .......................154
ALMOTRIPTAN MALATE............................................ 163
ALOCRIL (2 %) (DROPS) .............................................101
ALOGLIPTIN BENZ/METFORMIN HCL...................... 82
ALOGLIPTIN BENZ/PIOGLITAZONE.......................... 83
ALOGLIPTIN BENZOATE........................................ 84, 85
ALOMIDE (0.1 %) (DROPS) ........................................ 101
ALOQUIN (1.25%-1%) (GEL (GRAM)) ........................ 68
ALORA (.025MG/24H) (PATCH TDSW) ..................... 109
ALORA (.075MG/24H) (PATCH TDSW) ..................... 109
ALORA (0.05MG/24H) (PATCH TDSW) ..................... 109
ALORA (0.1MG/24HR) (PATCH TDSW) .................... 109
ALOSETRON HCL.........................................................142
ALPHAGAN (0.2 %) (DROPS) ..................................... 101
ALPHAGAN P (0.1 %) (DROPS) ..................................101
ALPHAGAN P (0.15 %) (DROPS) ................................101
ALPRAZOLAM................................................................ 28
ALPRAZOLAM INTENSOL (1 MG/ML) (ORAL CONC)
...............................................................................................
ALREX (0.2 %) (DROPS SUSP) ..................................... 99
ALSUMA (6 MG/0.5ML) (PEN INJCTR) .................... 163
ALTABAX (1 %) (OINT. (G)) ..........................................72
ALTACE (1.25 MG) (CAPSULE) ....................................47
ALTACE (10 MG) (CAPSULE) .......................................47
ALTACE (2.5 MG) (CAPSULE) ......................................47
ALTACE (5 MG) (CAPSULE) .........................................47
ALTOPREV (20 MG) (TAB ER 24H) ..................... 58, 189
ALTOPREV (40 MG) (TAB ER 24H) ..................... 58, 189
ALTOPREV (60 MG) (TAB ER 24H) ..................... 58, 189
ALTRETAMINE..............................................................144
ALUMINUM CHLORIDE................................................77
ALUPENT (10 MG) (TABLET) ...................................... 14
ALUPENT (10 MG/5 ML) (SYRUP) .............................. 14
ALUPENT (20 MG) (TABLET) ...................................... 14
ALVESCO (160 MCG) (HFA AER AD) ......................... 16
ALVESCO (80 MCG) (HFA AER AD) ........................... 16
AMANTADINE HCL......................................................166
AMARYL (1 MG) (TABLET) ......................................... 85
AMARYL (2 MG) (TABLET) ......................................... 85
AMARYL (4 MG) (TABLET) ......................................... 85
AMBIEN (10 MG) (TABLET) .........................................37
AMBIEN (10MG) (TABLET) ..........................................37
AMBIEN (5 MG) (TABLET) ...........................................37
AMBIEN (5MG) (TABLET) ............................................37
AMBIEN CR (12.5 MG) (TAB MPHASE) ..............37, 189
AMBIEN CR (6.25 MG) (TAB MPHASE) ..............37, 189
AMBRISENTAN...............................................................56
AMCINONIDE..................................................................74
AMELUZ (10 %) (GEL (GRAM)) .................................149
AMERGE (1 MG) (TABLET) ................................163, 189
AMERGE (2.5 MG) (TABLET) .............................163, 189
AMETHYST (90-20MCG) (TABLET) ............................64
AMICAR (1000 MG) (TABLET) ...................................104
AMICAR (250 MG/ML) (SOLUTION) ........................ 104
AMICAR (500 MG) (TABLET) .....................................104
AMILORIDE HCL............................................................55
AMILORIDE/HYDROCHLOROTHIAZIDE................... 55
AMINOCAPROIC ACID................................................ 104
AMINOLEVULINIC ACID HCL...................................149
AMINOSALICYLIC ACID............................................ 123
AMIODARONE HCL....................................................... 40
AMITIZA (24MCG) (CAPSULE) ................................. 142
AMITIZA (8 MCG) (CAPSULE) .................................. 142
AMITRIPTYLINE HCL................................................... 24
AMITRIPTYLINE/CHLORDIAZEPOXIDE................... 24
AMLODIPINE BES/OLMESARTAN MED.................... 45
Page 202 of 224
Index
AMLODIPINE BESYLATE............................................. 51
AMLODIPINE BESYLATE/BENAZEPRIL.............. 41, 42
AMLODIPINE/ATORVASTATIN.....................................61
AMLODIPINE/VALSARTAN.................................... 45, 46
AMLODIPINE/VALSARTAN/HCTHIAZID................... 44
AMMONIUM LACTATE..................................................78
AMOXAPINE................................................................... 24
AMOXICILLIN...............................................................118
AMOXICILLIN/POTASSIUM CLAV............................ 118
AMOXIL (125 MG) (TAB CHEW) ............................... 118
AMOXIL (125 MG/5ML) (SUSP RECON) .................. 118
AMOXIL (200 MG/5ML) (SUSP RECON) .................. 118
AMOXIL (250 MG) (CAPSULE) .................................. 118
AMOXIL (250 MG) (TAB CHEW) ............................... 118
AMOXIL (250 MG/5ML) (SUSP RECON) .................. 118
AMOXIL (400 MG/5ML) (SUSP RECON) .................. 118
AMOXIL (500 MG) (CAPSULE) .................................. 118
AMOXIL (500 MG) (TABLET) .....................................118
AMOXIL (875 MG) (TABLET) .....................................118
AMPHETAMINE.............................................................. 26
AMPHETAMINE SULFATE............................................ 26
AMPICILLIN (125 MG/5ML) (SUSP RECON) ........... 118
AMPICILLIN (250 MG) (CAPSULE) ...........................119
AMPICILLIN (250 MG/5ML) (SUSP RECON) ........... 119
AMPICILLIN (500 MG) (CAPSULE) ...........................119
AMPICILLIN TRIHYDRATE................................ 118, 119
AMPYRA (10 MG) (TAB ER 12H) ...............................151
AMRIX (15 MG) (CAP ER 24H) .................................. 175
AMRIX (30 MG) (CAP ER 24H) .................................. 175
ANACAINE (10 %) (OINT. (G)) ..................................... 80
ANADROL-50 (50 MG) (TABLET) .............................. 107
ANAFRANIL (25 MG) (CAPSULE) ...............................24
ANAFRANIL (50 MG) (CAPSULE) ...............................24
ANAFRANIL (75 MG) (CAPSULE) ...............................24
ANAGRELIDE HCL.......................................................107
ANAKINRA.................................................................... 133
ANALPRAM HC (1 %-1 %) (CREAM/APPL) ............. 140
ANALPRAM HC (2.5 %-1 %) (CREAM/APPL) .......... 140
ANALPRAM HC (2.5 %-1 %) (LOTION) ...................... 80
ANALPRAM HC (2.5-1%(4G)) (CREAM/APPL) ........140
ANAMANTLE HC (3 %-0.5 %) (CREAM (G)) ........... 140
ANAMANTLE HC (3 %-0.5 %) (CREAM/APPL) ....... 140
ANAMANTLE HC (3-2.5%(7G)) (GEL W/APPL) .......140
ANAMANTLE HC FORTE (3%-1%(7 G))
(CREAM/APPL) .............................................................140
ANAPROX (275 MG) (TABLET) ..................................138
ANAPROX DS (550 MG) (TABLET) ............................138
ANASTROZOLE............................................................ 145
ANCOBON (250 MG) (CAPSULE) .............................. 121
ANCOBON (500 MG) (CAPSULE) .............................. 122
ANDRODERM (2 MG/24 HR) (PATCH TD24) ............107
ANDRODERM (4 MG/24 HR) (PATCH TD24) ............107
ANDROGEL (1.25 G(1%)) (GEL MD PMP) ................ 108
ANDROGEL (1.25G-1.62) (GEL PACKET) ................. 108
ANDROGEL (2.5G-1.62%) (GEL PACKET) ................108
ANDROGEL (20.25/1.25) (GEL MD PMP) ..................108
ANDROGEL (25MG(1%)) (GEL PACKET) .................108
ANDROGEL (50 MG (1%)) (GEL PACKET) ...............108
ANDROID (10 MG) (CAPSULE) ................................. 107
ANGELIQ (0.25-0.5MG) (TABLET) ............................ 108
ANGELIQ (0.5 MG-1MG) (TABLET) .......................... 108
ANORO ELLIPTA (62.5-25MCG) (BLST W/DEV) ......
15,
189
ANSAID (100 MG) (TABLET) ..................................... 137
ANSAID (50 MG) (TABLET) ....................................... 137
ANTABUSE (250 MG) (TABLET) ..................................27
ANTABUSE (500 MG) (TABLET) ..................................27
ANTARA (130 MG) (CAPSULE) ........................... 60, 189
ANTARA (30 MG) (CAPSULE) ............................. 60, 189
ANTARA (43 MG) (CAPSULE) ..................................... 60
ANTARA (90 MG) (CAPSULE) ............................. 60, 189
ANTHRALIN.................................................................... 82
ANTHRALIN MICRONIZED.......................................... 82
ANTIBIOTIC EAR SOLUTION (3.5-10K-1)
(SOLUTION) ....................................................................90
ANTIVERT (12.5 MG) (TABLET) ..................................12
ANTIVERT (25 MG) (TABLET) .....................................12
ANUSOL HC (2.5 %) (CREAM (G)) .............................. 76
ANZEMET (100 MG) (TABLET) ................................... 12
ANZEMET (50 MG) (TABLET) ..................................... 12
APEXICON (0.05 %) (OINT. (G)) ...................................75
APEXICON E (0.05 %) (CREAM (G)) ........................... 75
APIDRA (100/ML) (VIAL) ..................................... 89, 189
APIDRA SOLOSTAR (100/ML) (INSULN PEN) ...... 89,
189
APIXABAN.....................................................................104
APLENZIN (174MG) (TAB ER 24H) ............................. 20
APLENZIN (348MG) (TAB ER 24H) ............................. 20
APLENZIN (522MG) (TAB ER 24H) ............................. 20
APOKYN (10 MG/ML) (CARTRIDGE) ....................... 166
APOMORPHINE HCL................................................... 166
APRACLONIDINE HCL................................................ 101
APREMILAST................................................................ 134
APREPITANT................................................................... 12
APRESOLINE (10 MG) (TABLET) ................................ 49
APRESOLINE (100 MG) (TABLET) .............................. 49
APRESOLINE (25 MG) (TABLET) ................................ 49
APRESOLINE (50 MG) (TABLET) ................................ 49
APRISO (0.375G) (CAP ER 24H) ................................. 139
APTENSIO XR (10 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (15 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (20 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (30 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (40 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (50 MG) (CSBP 40-60) ..................39, 190
APTENSIO XR (60 MG) (CSBP 40-60) ..................39, 190
APTIOM (200 MG) (TABLET) ............................. 170, 190
APTIOM (400 MG) (TABLET) ............................. 170, 190
APTIOM (600 MG) (TABLET) ............................. 170, 190
APTIOM (800 MG) (TABLET) ............................. 170, 190
APTIVUS (100 MG/ML) (SOLUTION) ........................126
APTIVUS (250 MG) (CAPSULE) .................................126
ARALEN (500 MG) (TABLET) .................................... 125
ARANESP (100 MCG/ML) (VIAL) .............................. 105
ARANESP (100MCG/0.5) (SYRINGE) ........................ 105
ARANESP (10MCG/0.4) (SYRINGE) .......................... 105
ARANESP (150MCG/.75) (VIAL) ................................ 105
ARANESP (150MCG/0.3) (SYRINGE) ........................ 105
ARANESP (200 MCG/ML) (VIAL) .............................. 105
ARANESP (200MCG/0.4) (SYRINGE) ........................ 105
ARANESP (25 MCG/ML) (VIAL) ................................ 105
ARANESP (25MCG/0.42) (SYRINGE) ........................ 105
ARANESP (300 MCG/ML) (VIAL) .............................. 105
ARANESP (300MCG/0.6) (SYRINGE) ........................ 105
ARANESP (40 MCG/0.4) (SYRINGE) ......................... 105
ARANESP (40 MCG/ML) (VIAL) ................................ 105
ARANESP (500 MCG/ML) (SYRINGE) ...................... 105
ARANESP (60MCG/0.3) (SYRINGE) .......................... 105
ARANESP (60MCG/ML) (VIAL) ................................. 105
ARAVA (10 MG) (TABLET) ......................................... 134
ARAVA (20 MG) (TABLET) ......................................... 134
ARCAPTA NEOHALER (75 MCG) (CAP W/DEV) ......
15,
190
ARFORMOTEROL TARTRATE...................................... 15
ARICEPT (10 MG) (TABLET) ........................................ 19
ARICEPT (23 MG) (TABLET) ........................................ 19
ARICEPT (5 MG) (TABLET) .......................................... 19
ARICEPT ODT (10 MG) (TAB RAPDIS) .......................19
ARICEPT ODT (5 MG) (TAB RAPDIS) .........................19
ARIMIDEX (1 MG) (TABLET) .....................................145
ARIPIPRAZOLE.........................................................29, 30
ARMODAFINIL............................................................... 36
ARMOUR THYROID (120 MG) (TABLET) .................. 97
ARMOUR THYROID (15 MG) (TABLET) .................... 97
ARMOUR THYROID (180 MG) (TABLET) .................. 97
ARMOUR THYROID (240 MG) (TABLET) .................. 97
ARMOUR THYROID (30 MG) (TABLET) .................... 97
ARMOUR THYROID (300 MG) (TABLET) .................. 97
ARMOUR THYROID (60 MG) (TABLET) .................... 97
ARMOUR THYROID (90 MG) (TABLET) .................... 98
ARNUITY ELLIPTA (100 MCG) (BLST W/DEV) ........ 16
ARNUITY ELLIPTA (200 MCG) (BLST W/DEV) ........ 17
AROMASIN (25 MG) (TABLET) ......................... 145, 190
ARTANE (2 MG) (TABLET) ......................................... 166
ARTANE (2 MG/5 ML) (ELIXIR) .................................166
ARTANE (5 MG) (TABLET) ......................................... 166
ARTEMETHER/LUMEFANTRINE...............................124
ARTHROTEC 50 (50 MG-200) (TAB IR DR) ...............136
ARTHROTEC 75 (75 MG-200) (TAB IR DR) ...............136
ASACOL HD (800 MG) (TABLET DR) ............... 139, 190
ASENAPINE MALEATE..................................................31
ASENDIN (100 MG) (TABLET) ..................................... 24
ASENDIN (150 MG) (TABLET) ..................................... 24
ASENDIN (25 MG) (TABLET) ....................................... 24
ASENDIN (50 MG) (TABLET) ....................................... 24
ASMANEX (110MCG(30)) (AER POW BA) ................. 17
ASMANEX (220MCG 120) (AER POW BA) ................. 17
ASMANEX (220MCG(14)) (AER POW BA) ................. 17
ASMANEX (220MCG(30)) (AER POW BA) ................. 17
ASMANEX (220MCG(60)) (AER POW BA) ................. 17
ASMANEX HFA (100 MCG) (HFA AER AD) ............... 17
ASMANEX HFA (200 MCG) (HFA AER AD) ............... 17
ASPIRIN..........................................................106, 154, 155
ASPIRIN (325 MG) (TABLET DR) (OTC)..........................
ASPIRIN (325 MG) (TABLET) (OTC).................................
ASPIRIN (81 MG) (TAB CHEW) (OTC).............................
ASPIRIN/CAFFEIN/DIHYDROCODEINE................... 155
ASPIRIN/DIPYRIDAMOLE.......................................... 106
ASPIRIN/OMEPRAZOLE..............................................106
ASTAGRAF XL (0.5 MG) (CAP ER 24H) ....................113
ASTAGRAF XL (1 MG) (CAP ER 24H) .......................113
ASTAGRAF XL (5 MG) (CAP ER 24H) .......................113
ASTELIN (137 MCG) (SPRAY/PUMP) ..........................11
ASTEPRO (205.5MCG) (SPRAY/PUMP) .......................11
Sharp Health Plan: Covered California
ASTERO (4 %) (GEL W/PUMP) .....................................81
ATACAND (16 MG) (TABLET) ...................................... 47
ATACAND (32 MG) (TABLET) ...................................... 47
ATACAND (4 MG) (TABLET) ........................................ 47
ATACAND (8 MG) (TABLET) ........................................ 47
ATACAND HCT (16-12.5MG) (TABLET) ......................44
ATACAND HCT (32-12.5MG) (TABLET) ......................45
ATACAND HCT (32MG-25MG) (TABLET) .................. 45
ATARAX (10 MG) (TABLET) .........................................10
ATARAX (10 MG/5 ML) (SOLUTION) ..........................10
ATARAX (25 MG) (TABLET) .........................................10
ATARAX (50 MG) (TABLET) .........................................10
ATAZANAVIR SULFATE...............................................128
ATAZANAVIR SULFATE/COBICISTAT....................... 128
ATELVIA (35 MG) (TABLET DR) ..................................94
ATENOLOL...................................................................... 49
ATENOLOL/CHLORTHALIDONE.................................51
ATIVAN (0.5 MG) (TABLET) ......................................... 29
ATIVAN (1 MG) (TABLET) ............................................ 29
ATIVAN (2 MG) (TABLET) ............................................ 29
ATOMOXETINE HCL......................................................40
ATORVASTATIN CALCIUM........................................... 58
ATOVAQUONE...............................................................125
ATOVAQUONE/PROGUANIL HCL...................... 124, 125
ATRIPLA (600-200MG) (TABLET) ..............................129
ATROPINE SULFATE.................................................... 102
ATROPINE SULFATE (1 %) (DROPS) ...............................
ATROPINE SULFATE (1 %) (OINT. (G)) ...........................
ATROVENT (0.2 MG/ML) (SOLUTION) .......................13
ATROVENT (21 MCG) (SPRAY) ..................................152
ATROVENT (42 MCG) (SPRAY) ..................................152
ATROVENT HFA (17MCG) (HFA AER AD) ................. 13
AUBAGIO (14 MG) (TABLET) .....................................151
AUBAGIO (7 MG) (TABLET) .......................................151
AUGMENTIN (125-31.25/) (SUSP RECON) ............... 118
AUGMENTIN (200-28.5/5) (SUSP RECON) ............... 118
AUGMENTIN (200-28.5MG) (TAB CHEW) ................118
AUGMENTIN (250-125 MG) (TABLET) ..................... 118
AUGMENTIN (250-62.5/5) (SUSP RECON) ............... 118
AUGMENTIN (400-57MG) (TAB CHEW) ...................118
AUGMENTIN (400-57MG/5) (SUSP RECON) ............ 118
AUGMENTIN (500-125 MG) (TABLET) ..................... 118
AUGMENTIN (875-125 MG) (TABLET) ..................... 118
AUGMENTIN ES-600 (600-42.9/5) (SUSP RECON) ......
118
AUGMENTIN XR (1000-62.5) (TAB ER 12H) ............ 118
AURANOFIN.................................................................. 136
AURYXIA (210MG IRON) (TABLET) ........................... 91
AVALIDE (150-12.5MG) (TABLET) ...............................45
AVALIDE (300-12.5MG) (TABLET) ...............................45
AVANDAMET (2 MG-500MG) (TABLET) ............ 88, 190
AVANDAMET (2-1000MG) (TABLET) ..................88, 190
AVANDIA (2 MG) (TABLET) ................................. 86, 190
AVANDIA (4 MG) (TABLET) ................................. 86, 190
AVAPRO (150 MG) (TABLET) ....................................... 47
AVAPRO (300 MG) (TABLET) ....................................... 47
AVAPRO (75 MG) (TABLET) ......................................... 47
AVAR (10-5%(W/W)) (CLEANSER) .............................. 72
AVAR (9.5 %-5 %) (FOAM) ............................................ 72
AVAR (9.5 %-5 %) (MED. PAD) ..................................... 72
AVAR LS (10 %-2 %) (CLEANSER) .............................. 72
AVAR LS (10 %-2 %) (FOAM) ........................................72
AVAR LS (10 %-2 %) (MED. PAD) .................................72
AVAR-E (10-5%(W/W)) (CREAM (G)) .......................... 72
AVAR-E GREEN (10-5%(W/W)) (CREAM (G)) ............72
AVAR-E LS (10 %-2 %) (CREAM (G)) ...........................72
AVC (15 %) (CREAM/APPL) ........................................184
AVELOX (400 MG) (TABLET) .....................................119
AVELOX ABC PACK (400 MG) (TABLET) ................ 119
AVIANE (0.1-0.02) (TABLET) ........................................64
AVIDOXY (100 MG) (TABLET) ...................................120
AVINZA (120 MG) (CPMP 24HR) ........................159, 190
AVINZA (30 MG) (CPMP 24HR) ..........................159, 190
AVINZA (45 MG) (CPMP 24HR) ..........................159, 190
AVINZA (60 MG) (CPMP 24HR) ..........................159, 190
AVINZA (75 MG) (CPMP 24HR) ..........................159, 190
AVINZA (90 MG) (CPMP 24HR) ..........................159, 190
AVODART (0.5 MG) (CAPSULE) ........................ 181, 190
AVONEX (30 MCG) (KIT) ............................................ 150
AVONEX (30MCG/.5ML) (SYRINGE) ........................ 150
AVONEX (30MCG/.5ML) (SYRINGEKIT) ..................150
AVONEX PEN (30MCG/.5ML) (PEN IJ KIT) .............. 150
AVONEX PEN (30MCG/.5ML) (PEN INJCTR) ...........150
AXERT (12.5 MG) (TABLET) .............................. 163, 190
AXERT (6.25 MG) (TABLET) .............................. 163, 190
AXID (150 MG) (CAPSULE) ........................................179
AXID (150MG/10ML) (SOLUTION) ........................... 179
AXID (300 MG) (CAPSULE) ........................................179
AXIRON (30MG/1.5ML) (SOL MD PMP) ................... 108
AXITINIB........................................................................146
AYGESTIN (5 MG) (TABLET) ..................................... 111
AZACTAM (1 G) (VIAL) .............................................. 113
Page 203 of 224
Index
AZASAN (100 MG) (TABLET) .................................... 112
AZASAN (75 MG) (TABLET) ...................................... 112
AZASITE (1 %) (DROPS) ............................................. 100
AZATHIOPRINE............................................................ 112
AZELAIC ACID..........................................................67, 68
AZELASTINE HCL..........................................................11
AZELASTINE/FLUTICASONE...................................... 11
AZELEX (20 %) (CREAM (G)) .............................. 67, 190
AZILECT (0.5 MG) (TABLET) ..................................... 167
AZILECT (1 MG) (TABLET) ........................................ 167
AZILSARTAN MED/CHLORTHALIDONE................... 44
AZILSARTAN MEDOXOMIL......................................... 47
AZITHROMYCIN...................................................100, 116
AZOPT (1 %) (DROPS SUSP) ...................................... 102
AZOR (10 MG-20MG) (TABLET) .......................... 45, 190
AZOR (10 MG-40MG) (TABLET) .......................... 45, 191
AZOR (5 MG-20 MG) (TABLET) ........................... 45, 191
AZOR (5 MG-40 MG) (TABLET) ........................... 45, 191
AZTREONAM................................................................ 113
AZTREONAM LYSINE..................................................114
AZULFIDINE (500 MG) (TABLET DR) ...................... 140
AZULFIDINE (500 MG) (TABLET) .............................140
-BBACITRACIN................................................................. 100
BACITRACIN (500 UNIT/G) (OINT. (G)) ..........................
BACITRACIN/POLYMYXIN B SULFATE................... 100
BACITRACIN/POLYMYXIN B SULFATE (500-10K/G)
(OINT. (G)) ...........................................................................
BACLOFEN.................................................................... 175
BACTRIM (400MG-80MG) (TABLET) ........................113
BACTRIM DS (800-160 MG) (TABLET) ..................... 113
BACTROBAN (2 %) (CREAM (G)) ................................70
BACTROBAN NASAL (2 %) (OINT. (G)) ....................151
BALSALAZIDE DISODIUM.........................................139
BANZEL (200 MG) (TABLET) ..................................... 174
BANZEL (40 MG/ML) (ORAL SUSP) ......................... 174
BANZEL (400 MG) (TABLET) ..................................... 174
BARACLUDE (0.05 MG/ML) (SOLUTION) ............... 130
BARACLUDE (0.5 MG) (TABLET) ............................. 130
BARACLUDE (1 MG) (TABLET) ................................ 130
BAYER CHEWABLE ASPIRIN (81 MG) (TAB CHEW)
(OTC)...............................................................................155
BECAPLERMIN............................................................... 88
BECLOMETHASONE DIPROPIONATE.................. 11, 16
BECONASE AQ (42 MCG) (SPRAY) .....................11, 191
BEDAQUILINE FUMARATE........................................ 123
BELBUCA (150 MCG) (FILM) .....................................155
BELBUCA (300 MCG) (FILM) .....................................155
BELBUCA (450 MCG) (FILM) .....................................155
BELBUCA (600 MCG) (FILM) .....................................155
BELBUCA (75 MCG) (FILM) .......................................156
BELBUCA (750 MCG) (FILM) .....................................156
BELBUCA (900 MCG) (FILM) .....................................156
BELSOMRA (10 MG) (TABLET) ...........................37, 191
BELSOMRA (15 MG) (TABLET) ...........................37, 191
BELSOMRA (20 MG) (TABLET) ...........................37, 191
BELSOMRA (5 MG) (TABLET) .............................37, 191
BENADRYL (50 MG/ML) (VIAL) ................................. 10
BENAZEPRIL HCL.......................................................... 46
BENAZEPRIL/HYDROCHLOROTHIAZIDE................. 42
BENEMID (500 MG) (TABLET) .................................. 104
BENICAR (20 MG) (TABLET) ............................... 48, 191
BENICAR (40 MG) (TABLET) ............................... 48, 191
BENICAR (5 MG) (TABLET) ................................. 48, 191
BENICAR HCT (20-12.5 MG) (TABLET) ..............45, 191
BENICAR HCT (40 MG-25MG) (TABLET) .......... 45, 191
BENICAR HCT (40-12.5 MG) (TABLET) ..............45, 191
BENSAL HP (3 %) (OINT. (G)) ...................................... 78
BENTYL (10 MG) (CAPSULE) .................................... 177
BENTYL (10 MG/5 ML) (SOLUTION) ........................177
BENTYL (20 MG) (TABLET) .......................................177
BENZACLIN (1 %-5 %) (GEL (GRAM)) ....................... 67
BENZACLIN (1 %-5 %) (GEL W/PUMP) ...................... 67
BENZAMYCIN (3 %-5 %) (GEL (GRAM)) ...................70
BENZAMYCINPAK (3 %-5 %) (GEL (EA)) .................. 70
BENZOCAINE..................................................................80
BENZONATATE............................................................... 65
BENZOYL PEROXIDE.................................................... 78
BENZOYL PEROXIDE (4 %) (GEL (GRAM)) ..................
BENZOYL PEROXIDE (5.3%) (FOAM) ............................
BENZOYL PEROXIDE (6 %) (TOWELETTE) ..................
BENZOYL PEROXIDE (8 %) (GEL (GRAM)) ..................
BENZOYL PEROXIDE (9.8 %) (FOAM) ...........................
BENZOYL PEROXIDE MICROSPHERES..................... 78
BENZOYL PEROXIDE MICROSPHERES (7 %)
(CLEANSER) .......................................................................
BENZOYL PEROXIDE/HYDROCORTISON................. 68
BENZOYL PEROXIDE/SULFUR.................................... 78
BENZTROPINE MESYLATE................................ 165, 166
BENZYL ALCOHOL....................................................... 71
BEPOTASTINE BESILATE..............................................99
BEPREVE (1.5 %) (DROPS) ................................... 99, 191
BESIFLOXACIN HCL....................................................100
BESIVANCE (0.6 %) (DROPS SUSP) .......................... 100
BETADINE (5 %) (SOLUTION) ..................................... 81
BETAGAN (0.5 %) (DROPS) ........................................ 102
BETAINE.........................................................................152
BETAMETHASONE DIPROPIONATE........................... 74
BETAMETHASONE VALERATE................................... 74
BETAMETHASONE/PROPYLENE GLYC..................... 74
BETASERON (0.3 MG) (KIT) .......................................151
BETASERON (0.3 MG) (VIAL) .................................... 151
BETAXOLOL HCL...................................................49, 101
BETHANECHOL CHLORIDE.......................................143
BETHKIS (300 MG/4ML) (AMPUL-NEB) .................. 122
BETIMOL (0.25 %) (DROPS) ....................................... 102
BETIMOL (0.5 %) (DROPS) ......................................... 102
BETOPTIC (0.5 %) (DROPS) ........................................101
BETOPTIC S (0.25 %) (DROPS SUSP) ........................ 101
BEVESPI AEROSPHERE (9-4.8 MCG) (HFA AER AD)
................................................................................... 15, 191
BEXAROTENE......................................................... 80, 149
BEYAZ (3-0.02(24)) (TABLET) ...................................... 63
BIAXIN (125 MG/5ML) (SUSP RECON) .................... 116
BIAXIN (250 MG) (TABLET) .......................................116
BIAXIN (250 MG/5ML) (SUSP RECON) .................... 117
BIAXIN (500 MG) (TABLET) .......................................117
BIAXIN XL (500 MG) (TAB ER 24H) ..........................117
BICALUTAMIDE........................................................... 144
BIDIL (20-37.5MG) (TABLET) .......................................58
BIFERA RX (22-6-1-25) (TABLET) ............................. 185
BILTRICIDE (600 MG) (TABLET) ...............................124
BIMATOPROST..............................................................101
BINOSTO (70 MG) (TABLET EFF) ............................... 93
BISAC/NACL/NAHCO3/KCL/PEG 3350...................... 142
BISMUTH/METRONID/TETRACYCLINE.................. 179
BISOPROLOL FUMARATE............................................ 49
BISOPROLOL FUMARATE/HCTZ.................................51
BLEPHAMIDE (10 %-0.2 %) (DROPS SUSP) ............. 100
BLEPHAMIDE S.O.P. (10 %-0.2 %) (OINT. (G)) .........100
BLOCADREN (10 MG) (TABLET) ................................ 51
BLOCADREN (20 MG) (TABLET) ................................ 51
BLOCADREN (5 MG) (TABLET) .................................. 51
BONIVA (150 MG) (TABLET) ........................................94
BOSENTAN...................................................................... 56
BOSULIF (100 MG) (TABLET) .................................... 146
BOSULIF (500 MG) (TABLET) .................................... 146
BOSUTINIB.................................................................... 146
BP 10-1 (10 %-1 %) (CLEANSER) ................................. 72
BREO ELLIPTA (100-25MCG) (BLST W/DEV) ........... 16
BREO ELLIPTA (200-25 MCG) (BLST W/DEV) .......... 16
BRETHINE (2.5 MG) (TABLET) ....................................15
BRETHINE (5 MG) (TABLET) .......................................15
BREXPIPRAZOLE........................................................... 30
BRILINTA (60 MG) (TABLET) ............................ 106, 191
BRILINTA (90 MG) (TABLET) ............................ 106, 191
BRIMONIDINE TARTRATE....................................68, 101
BRIMONIDINE TARTRATE/TIMOLOL...................... 102
BRINZOLAMIDE...........................................................102
BRINZOLAMIDE/BRIMONIDINE TART.................... 102
BRISDELLE (7.5 MG) (CAPSULE) ....................... 22, 191
BRIVARACETAM.......................................................... 168
BRIVIACT (10 MG) (TABLET) ....................................168
BRIVIACT (10 MG/ML) (SOLUTION) ........................168
BRIVIACT (100 MG) (TABLET) ..................................168
BRIVIACT (25 MG) (TABLET) ....................................168
BRIVIACT (50 MG) (TABLET) ....................................168
BRIVIACT (75 MG) (TABLET) ....................................168
BROMFED DM (2-30-10/5) (SYRUP) ............................66
BROMFENAC SODIUM.................................................. 99
BROMFENAC SODIUM (0.09%) (DROPS) .......................
BROMOCRIPTINE MESYLATE............................. 84, 166
BROMPHENIRAMINE/PSEUDOEPHED/DM............... 66
BROMPHENIRAMINE/PSEUDOEPHED/DM (2-30-10/5)
(SYRUP) ...............................................................................
BROMSITE (0.075 %) (DROPS) .....................................99
BROVANA (15MCG/2ML) (VIAL-NEB) ....................... 15
BUDESONIDE............................................11, 16, 134, 141
BUDESONIDE/FORMOTEROL FUMARATE............... 15
BUMETANIDE................................................................. 54
BUMEX (0.5 MG) (TABLET) ......................................... 54
BUMEX (1 MG) (TABLET) ............................................ 54
BUMEX (2 MG) (TABLET) ............................................ 54
BUNAVAIL (2.1-0.3 MG) (FILM) ................................. 165
BUNAVAIL (4.2-0.7 MG) (FILM) ................................. 165
BUNAVAIL (6.3MG-1MG) (FILM) ...............................165
BUPAP (50MG-300MG) (TABLET) ............................. 154
BUPHENYL (0.94 G/G) (POWDER) ............................ 141
BUPHENYL (500 MG) (TABLET) ............................... 141
BUPRENORPHINE........................................................ 155
BUPRENORPHINE HCL............................... 155, 156, 165
BUPRENORPHINE HCL/NALOXONE HCL............... 165
BUPROPION HBR............................................................20
Sharp Health Plan: Covered California
BUPROPION HCL..............................................20, 21, 177
BUSPAR (10 MG) (TABLET) ......................................... 28
BUSPAR (15 MG) (TABLET) ......................................... 28
BUSPAR (30 MG) (TABLET) ......................................... 28
BUSPAR (5 MG) (TABLET) ........................................... 28
BUSPAR (7.5 MG) (TABLET) ........................................ 28
BUSPIRONE HCL............................................................ 28
BUSULFAN.....................................................................144
BUTABARBITAL SODIUM.............................................36
BUTALB/ACETAMINOPHEN/CAFFEINE.................. 154
BUTALBIT/ACETAMIN/CAFF/CODEINE.................. 164
BUTALBITAL/ACETAMINOPHEN.............................. 154
BUTALBITAL/ASPIRIN/CAFFEINE............................ 154
BUTAPAP (50MG-325MG) (TABLET) ........................ 154
BUTENAFINE HCL......................................................... 70
BUTISOL SODIUM (30 MG) (TABLET) ....................... 36
BUTOCONAZOLE NITRATE....................................... 183
BUTORPHANOL TARTRATE.......................................156
BUTRANS (10 MCG/HR) (PATCH TDWK) ................ 155
BUTRANS (15 MCG/HR) (PATCH TDWK) ................ 155
BUTRANS (20 MCG/HR) (PATCH TDWK) ................ 155
BUTRANS (5 MCG/HR) (PATCH TDWK) .................. 155
BUTRANS (7.5 MCG/HR) (PATCH TDWK) ............... 155
BYDUREON (2 MG) (VIAL) ..................................84, 191
BYDUREON PEN (2MG/0.65ML) (PEN INJCTR) ...... 84,
191
BYETTA (10MCG/0.04) (PEN INJCTR) ................ 84, 191
BYETTA (5MCG/0.02) (PEN INJCTR) .................. 84, 191
BYSTOLIC (10 MG) (TABLET) ..................................... 50
BYSTOLIC (2.5 MG) (TABLET) .................................... 50
BYSTOLIC (20 MG) (TABLET) ..................................... 50
BYSTOLIC (5 MG) (TABLET) ....................................... 50
BYVALSON (5 MG-80 MG) (TABLET) .........................44
-CCABERGOLINE............................................................... 94
CABOMETYX (20 MG) (TABLET) ............................. 146
CABOMETYX (40 MG) (TABLET) ............................. 147
CABOMETYX (60 MG) (TABLET) ............................. 147
CABOZANTINIB S-MALATE...............................146, 147
CADEXOMER IODINE................................................... 68
CADUET (10 MG-10MG) (TABLET) .............................61
CADUET (10 MG-20MG) (TABLET) .............................61
CADUET (10 MG-40MG) (TABLET) .............................61
CADUET (10 MG-80MG) (TABLET) .............................61
CADUET (2.5MG-10MG) (TABLET) .............................61
CADUET (2.5MG-20MG) (TABLET) .............................61
CADUET (2.5MG-40MG) (TABLET) .............................61
CADUET (5 MG-10 MG) (TABLET) ..............................61
CADUET (5 MG-20 MG) (TABLET) ..............................61
CADUET (5 MG-40 MG) (TABLET) ..............................61
CADUET (5 MG-80 MG) (TABLET) ..............................61
CAFERGOT (1 MG-100MG) (TABLET) ......................163
CALAN (120 MG) (TABLET) .........................................54
CALAN (40 MG) (TABLET) ...........................................54
CALAN (80 MG) (TABLET) ...........................................54
CALAN SR (120 MG) (TABLET ER) .............................54
CALAN SR (180 MG) (TABLET ER) .............................54
CALAN SR (240 MG) (TABLET ER) .............................54
CALCIPOTRIENE............................................................ 82
CALCIPOTRIENE/BETAMETHASONE........................ 82
CALCITONIN,SALMON,SYNTHETIC..........................93
CALCITRIOL....................................................82, 187, 188
CALCIUM ACETATE.......................................................91
CALCIUM CARBONATE/MAG CARB/FA....................91
CALCIUM CARBONATE/MAG CARB/FA (200-400-1)
(TABLET) .............................................................................
CALCIUM/MAG/D3/B12/FA/B6/BORON.................... 184
CALCIUM/MAG/D3/B12/FA/B6/BORON (500-1.1MG)
(TABLET) .............................................................................
CALCIUM/MAG/D3/B12/FA/B6/BORON (500-300-1)
(WAFER) ..............................................................................
CAMBIA (50 MG) (POWD PACK) .......................163, 191
CAMPRAL (333 MG) (TABLET DR) .............................27
CANAGLIFLOZIN........................................................... 84
CANAGLIFLOZIN/METFORMIN HCL......................... 87
CANASA (1000 MG) (SUPP.RECT) .............................139
CANDESARTAN CILEXETIL.........................................47
CANDESARTAN/HYDROCHLOROTHIAZID.........44, 45
CAPECITABINE.............................................................144
CAPEX SHAMPOO (0.01 %) (SHAMPOO) .................. 75
CAPITAL W-CODEINE (120-12MG/5) (ORAL SUSP)
......................................................................................... 165
CAPOTEN (100 MG) (TABLET) .................................... 46
CAPOTEN (12.5 MG) (TABLET) ................................... 46
CAPOTEN (25 MG) (TABLET) ...................................... 46
CAPOTEN (50 MG) (TABLET) ...................................... 46
CAPOZIDE (25 MG-15MG) (TABLET) ......................... 42
CAPOZIDE (25 MG-25MG) (TABLET) ......................... 42
CAPOZIDE (50 MG-15MG) (TABLET) ......................... 42
CAPOZIDE (50 MG-25MG) (TABLET) ......................... 42
CAPRELSA (100 MG) (TABLET) ................................ 148
Page 204 of 224
Index
CAPRELSA (300 MG) (TABLET) ................................ 148
CAPTOPRIL......................................................................46
CAPTOPRIL/HYDROCHLOROTHIAZIDE....................42
CARAC (0.5 %) (CREAM (G)) ....................................... 80
CARAFATE (1 G) (TABLET) ........................................178
CARAFATE (1 G/10 ML) (ORAL SUSP) ..................... 178
CARBAGLU (200 MG) (TAB DISPER) ....................... 141
CARBAMAZEPINE......................................... 29, 168, 169
CARBATROL (100 MG) (CPMP 12HR) .......................168
CARBATROL (200 MG) (CPMP 12HR) .......................168
CARBATROL (300 MG) (CPMP 12HR) .......................169
CARBIDOPA...................................................................168
CARBIDOPA/LEVODOPA.................................... 166, 167
CARBIDOPA/LEVODOPA/ENTACAPONE................. 167
CARBINOXAMINE MALEATE......................................10
CARDENE (20 MG) (CAPSULE) ...................................53
CARDENE (30 MG) (CAPSULE) ...................................53
CARDIZEM (120 MG) (TABLET) ..................................51
CARDIZEM (30 MG) (TABLET) ....................................52
CARDIZEM (60 MG) (TABLET) ....................................52
CARDIZEM (90 MG) (TABLET) ....................................52
CARDIZEM CD (120 MG) (CAP ER 24H) .................... 52
CARDIZEM CD (180 MG) (CAP ER 24H) .................... 52
CARDIZEM CD (240 MG) (CAP ER 24H) .................... 52
CARDIZEM CD (300 MG) (CAP ER 24H) .................... 52
CARDIZEM CD (360 MG) (CAP ER 24H) .................... 52
CARDIZEM LA (120 MG) (TAB ER 24H) .....................52
CARDIZEM LA (180 MG) (TAB ER 24H) .....................52
CARDIZEM LA (240 MG) (TAB ER 24H) .....................52
CARDIZEM LA (300 MG) (TAB ER 24H) .....................52
CARDIZEM LA (360 MG) (TAB ER 24H) .....................52
CARDIZEM LA (420 MG) (TAB ER 24H) .....................52
CARDIZEM SR (120 MG) (CAP ER 12H) ..................... 52
CARDIZEM SR (60 MG) (CAP ER 12H) ....................... 52
CARDIZEM SR (90 MG) (CAP ER 12H) ....................... 52
CARDURA (1 MG) (TABLET) ....................................... 43
CARDURA (2 MG) (TABLET) ....................................... 43
CARDURA (4 MG) (TABLET) ....................................... 43
CARDURA (8 MG) (TABLET) ....................................... 43
CARDURA XL (4 MG) (TAB ER 24) ............................. 43
CARDURA XL (8 MG) (TAB ER 24) ............................. 44
CARGLUMIC ACID.......................................................141
CARIPRAZINE HCL........................................................29
CARISOPRODOL...........................................................175
CARISOPRODOL/ASPIRIN.......................................... 175
CARISOPRODOL/ASPIRIN/CODEINE....................... 156
CARISOPRODOL/ASPIRIN/CODEINE (200-325-16)
(TABLET) .............................................................................
CARNITOR SF (100 MG/ML) (SOLUTION) ...............152
CARTEOLOL HCL.........................................................102
CARVEDILOL.................................................................. 43
CARVEDILOL PHOSPHATE.......................................... 43
CASODEX (50 MG) (TABLET) ....................................144
CATAFLAM (50 MG) (TABLET) ................................. 137
CATAPRES (0.1 MG) (TABLET) .................................... 48
CATAPRES (0.2 MG) (TABLET) .................................... 48
CATAPRES (0.3 MG) (TABLET) .................................... 48
CATAPRES-TTS 1 (0.1MG/24HR) (PATCH TDWK) ......
48
CATAPRES-TTS 2 (0.2MG/24HR) (PATCH TDWK) ......
48
CATAPRES-TTS 3 (0.3MG/24HR) (PATCH TDWK) ......
48
CAYSTON (75 MG/ML) (VIAL-NEB) ......................... 114
CECLOR (125 MG/5ML) (SUSP RECON) ...................114
CECLOR (250 MG) (CAPSULE) .................................. 114
CECLOR (250 MG/5ML) (SUSP RECON) ...................114
CECLOR (375 MG/5ML) (SUSP RECON) ...................114
CECLOR (500 MG) (CAPSULE) .................................. 114
CECLOR CD (500 MG) (TAB ER 12H) ........................114
CEDAX (180 MG/5ML) (SUSP RECON) .....................115
CEDAX (400 MG) (CAPSULE) .................................... 115
CEFACLOR.....................................................................114
CEFADROXIL.................................................................114
CEFDINIR.......................................................................115
CEFDITOREN PIVOXIL................................................115
CEFIXIME...................................................................... 115
CEFPODOXIME PROXETIL......................................... 115
CEFPROZIL............................................................ 114, 115
CEFTIBUTEN.................................................................115
CEFTIN (125 MG/5ML) (SUSP RECON) .................... 115
CEFTIN (250 MG) (TABLET) .......................................115
CEFTIN (250 MG/5ML) (SUSP RECON) .................... 115
CEFTIN (500 MG) (TABLET) .......................................115
CEFUROXIME AXETIL................................................ 115
CEFZIL (125 MG/5ML) (SUSP RECON) .....................114
CEFZIL (250 MG) (TABLET) ....................................... 114
CEFZIL (250 MG/5ML) (SUSP RECON) .....................114
CEFZIL (500 MG) (TABLET) ....................................... 115
CELEBREX (100 MG) (CAPSULE) ............................. 136
CELEBREX (200 MG) (CAPSULE) ............................. 136
CELEBREX (400 MG) (CAPSULE) ............................. 136
CELEBREX (50 MG) (CAPSULE) ............................... 137
CELECOXIB........................................................... 136, 137
CELEXA (10 MG) (TABLET) .........................................21
CELEXA (10 MG/5 ML) (SOLUTION) ..........................21
CELEXA (20 MG) (TABLET) .........................................21
CELEXA (40 MG) (TABLET) .........................................21
CELLCEPT (200 MG/ML) (SUSP RECON) .................113
CELLCEPT (250 MG) (CAPSULE) .............................. 113
CELLCEPT (500 MG) (TABLET) .................................113
CELONTIN (300 MG) (CAPSULE) ..............................172
CENTANY (2 %) (OINT. (G)) ......................................... 70
CENTANY AT (2 %) (KIT) ............................................. 70
CENTRATEX (106 MG-1MG) (CAPSULE) .................184
CEPHALEXIN................................................................ 114
CERDELGA (84 MG) (CAPSULE) .............................. 152
CERITINIB......................................................................147
CERTOLIZUMAB PEGOL............................................ 140
CERUBIDINE (5 MG/ML) (VIAL) ...............................144
CESAMET (1 MG) (CAPSULE) ..................................... 12
CETIRIZINE HCL............................................................ 11
CETRAXAL (0.2 %) (DROPERETTE) ........................... 90
CEVIMELINE HCL........................................................143
CHANTIX (0.5 (11)-1) (TAB DS PK) ........................... 176
CHANTIX (0.5 MG) (TABLET) ....................................176
CHANTIX (1 MG) (TABLET) .......................................176
CHEMET (100 MG) (CAPSULE) ................................. 153
CHENODAL (250 MG) (TABLET) ...............................141
CHENODIOL.................................................................. 141
CHLORAMBUCIL......................................................... 144
CHLORDIAZEPOXIDE HCL.......................................... 28
CHLORDIAZEPOXIDE/CLIDINIUM BR.................... 178
CHLOROQUINE PHOSPHATE..................................... 125
CHLOROQUINE PHOSPHATE (250 MG) (TABLET) ......
CHLOROTHIAZIDE.........................................................57
CHLORPHENIRAMINE/PHENYLEPH/DM.................. 67
CHLORPHENIRAMINE/PHENYLEPH/DM (1-23MG/ML) (DROPS) .............................................................
CHLORPHENIRAMINE/PHENYLEPHRINE................ 65
CHLORPHENIRAMINE/PHENYLEPHRINE (1MG2MG/ML) (DROPS) .............................................................
CHLORPROMAZINE HCL..............................................35
CHLORPROPAMIDE....................................................... 85
CHLORTHALIDONE.......................................................57
CHLORZOXAZONE...................................................... 175
CHOLBAM (250 MG) (CAPSULE) ..............................141
CHOLBAM (50 MG) (CAPSULE) ................................141
CHOLECALCIFEROL (VITAMIN D3)......................... 188
CHOLECALCIFEROL (VITAMIN D3) (400 UNIT)
(CAPSULE) (OTC)...............................................................
CHOLECALCIFEROL (VITAMIN D3) (400 UNIT) (TAB
CHEW) (OTC).......................................................................
CHOLECALCIFEROL (VITAMIN D3) (400 UNIT)
(TABLET) (OTC)..................................................................
CHOLECALCIFEROL (VITAMIN D3) (400 UNIT/5)
(LIQUID) (OTC)...................................................................
CHOLESTYRAMINE (WITH SUGAR).......................... 59
CHOLESTYRAMINE/ASPARTAME.............................. 59
CHOLIC ACID................................................................141
CHOLINE MAG TRISALICYLATE (500 MG/5ML)
(LIQUID) ........................................................................ 155
CHOLINE SAL/MAG SALICYLATE............................155
CHRONULAC (10 G/15 ML) (SOLUTION) ........ 141, 142
CHRONULAC (20 G/30 ML) (SOLUTION) ................ 142
CIALIS (5 MG) (TABLET) ......................................93, 191
CICLESONIDE........................................................... 11, 16
CICLODAN (0.77 %) (CREAM (G)) .............................. 70
CICLODAN (8 %) (SOLUTION) .................................... 70
CICLOPIROX....................................................................70
CICLOPIROX OLAMINE................................................ 70
CILOSTAZOL................................................................. 106
CILOXAN (0.3 %) (DROPS) ......................................... 100
CILOXAN (0.3 %) (OINT. (G)) ..................................... 100
CIMETIDINE.................................................................. 179
CIMZIA (400 MG) (KIT) ...............................................140
CIMZIA (400MG/2ML) (SYRINGEKIT) ..................... 140
CINACALCET HCL......................................................... 94
CIPRO (100 MG) (TABLET) ......................................... 119
CIPRO (250 MG) (TABLET) ......................................... 119
CIPRO (250 MG/5ML) (SUS MC REC) ....................... 119
CIPRO (500 MG) (TABLET) ......................................... 119
CIPRO (500 MG/5ML) (SUS MC REC) ....................... 119
CIPRO (750 MG) (TABLET) ......................................... 119
CIPRO HC (0.2 %-1 %) (DROPS SUSP) .........................91
CIPRO XR (1000 MG) (TBMP 24HR) .......................... 119
CIPRO XR (500 MG) (TBMP 24HR) ............................ 119
CIPRODEX (0.3 %-0.1%) (DROPS SUSP) .....................91
CIPROFLOXACIN....................................................90, 119
CIPROFLOXACIN HCL...................................90, 100, 119
CIPROFLOXACIN HCL/DEXAMETH........................... 91
CIPROFLOXACIN HCL/FLUOCINOLONE...................91
CIPROFLOXACIN/CIPROFLOXA HCL.......................119
CIPROFLOXACIN/HYDROCORTISONE...................... 91
Sharp Health Plan: Covered California
CITALOPRAM HYDROBROMIDE................................ 21
CITRATE PHOSPHATE DEXTROS SOLN.................. 104
CITRATE PHOSPHATE DEXTROS SOLN (2.63 G/100)
(SOLUTION) ........................................................................
CITRIC ACID/SODIUM CITRATE............................... 181
CLARIFOAM EF (10 %-5 %) (FOAM) .......................... 72
CLARINEX (2.5 MG) (TAB RAPDIS) ................... 11, 191
CLARINEX (2.5 MG/5ML) (SYRUP) .................... 11, 191
CLARINEX (5 MG) (TAB RAPDIS) ...................... 11, 191
CLARINEX (5 MG) (TABLET) .............................. 11, 191
CLARINEX-D 12 HOUR (2.5-120 MG) (TBMP 12HR)
................................................................................... 10, 191
CLARIS (10%-4%-10%) (CLEANSER) ......................... 72
CLARITHROMYCIN............................................. 116, 117
CLEMASTINE FUMARATE........................................... 10
CLEOCIN (100 MG) (SUPP.VAG) ................................ 183
CLEOCIN (2 %) (CREAM/APPL) ........................ 183, 191
CLEOCIN HCL (150 MG) (CAPSULE) ....................... 124
CLEOCIN HCL (300 MG) (CAPSULE) ....................... 124
CLEOCIN HCL (75 MG) (CAPSULE) ......................... 124
CLEOCIN PALMITATE (75 MG/5 ML) (SOLN RECON)
......................................................................................... 124
CLEOCIN T (1 %) (GEL (GRAM)) ................................ 69
CLEOCIN T (1 %) (LOTION) ......................................... 69
CLEOCIN T (1 %) (MED. SWAB) .................................. 69
CLEOCIN T (1 %) (SOLUTION) ....................................69
CLIMARA (.025MG/24H) (PATCH TDWK) ................ 109
CLIMARA (.0375MG/24) (PATCH TDWK) .................109
CLIMARA (.075MG/24H) (PATCH TDWK) ................ 109
CLIMARA (0.05MG/24H) (PATCH TDWK) ................ 109
CLIMARA (0.06MG/24H) (PATCH TDWK) ................ 109
CLIMARA (0.1MG/24HR) (PATCH TDWK) ............... 109
CLIMARA PRO (45-15/24H) (PATCH TDWK) ........... 110
CLINDACIN ETZ (1 %) (MED. SWAB) .........................69
CLINDACIN P (1 %) (MED. SWAB) ..............................69
CLINDAGEL (1 %) (GEL (ML)) .....................................69
CLINDAMYCIN HCL.................................................... 124
CLINDAMYCIN PALMITATE HCL..............................124
CLINDAMYCIN PHOS/BENZOYL PEROX.................. 67
CLINDAMYCIN PHOSPHATE............................... 69, 183
CLINDAMYCIN/TRETINOIN.........................................68
CLINDESSE (2 %) (CRM ER (G)) ................................183
CLINORIL (150 MG) (TABLET) .................................. 139
CLINORIL (200 MG) (TABLET) .................................. 139
CLIOQUINOL/HYDROCORTISONE............................. 68
CLISTIN (4 MG) (TABLET) ........................................... 10
CLISTIN (4 MG/5 ML) (LIQUID) .................................. 10
CLOBAZAM................................................................... 175
CLOBETASOL PROPIONATE.........................................74
CLOBETASOL PROPIONATE/EMOLL..........................74
CLOBEX (0.05 %) (LOTION) ......................................... 74
CLOBEX (0.05 %) (SHAMPOO) .................................... 74
CLOBEX (0.05 %) (SPRAY) ........................................... 74
CLOCORTOLONE PIVALATE........................................74
CLODAN (0.05 %) (SHAMPOO) ....................................74
CLODERM (0.1 %) (CREAM (G)) ................................. 74
CLOMIPHENE CITRATE................................................ 93
CLOMIPRAMINE HCL................................................... 24
CLONAZEPAM.............................................................. 169
CLONIDINE......................................................................48
CLONIDINE HCL.......................................................38, 48
CLONIDINE HCL/CHLORTHALIDONE....................... 48
CLOPIDOGREL BISULFATE........................................106
CLORAZEPATE DIPOTASSIUM.................................... 28
CLORAZEPATE DIPOTASSIUM (3.75 MG) (TABLET)
...............................................................................................
CLOTRIMAZOLE.................................................... 70, 121
CLOTRIMAZOLE/BETAMETHASONE DIP................. 70
CLOZAPINE..................................................................... 31
CLOZAPINE (200 MG) (TABLET) ....................................
CLOZAPINE (50 MG) (TABLET) ......................................
CLOZARIL (100 MG) (TABLET) ...................................31
CLOZARIL (25 MG) (TABLET) .....................................31
COARTEM (20MG-120MG) (TABLET) .......................124
COBICISTAT...................................................................129
COBIMETINIB FUMARATE.........................................145
CODEINE (15 MG) (TABLET) ..................................... 156
CODEINE (30 MG) (TABLET) ..................................... 156
CODEINE (60 MG) (TABLET) ..................................... 156
CODEINE POLI/CHLORPHENIR POLIS.......................66
CODEINE SULFATE...................................................... 156
CODEINE/BUTALBITAL/ASA/CAFFEIN................... 164
CODITUSSIN DAC (30-10-200) (LIQUID) (OTC)......... 66
COGENTIN (0.5 MG) (TABLET) ................................. 165
COGENTIN (1 MG) (TABLET) .................................... 166
COGENTIN (2 MG) (TABLET) .................................... 166
COLAZAL (750 MG) (CAPSULE) ............................... 139
COLBENEMID (0.5-500MG) (TABLET) ..................... 103
COLCHICINE................................................................. 103
COLCHICINE/PROBENECID....................................... 103
COLCRYS (0.6 MG) (TABLET) ................................... 103
COLESEVELAM HCL..................................................... 59
Page 205 of 224
Index
COLESTID (1 G) (TABLET) ...........................................59
COLESTID (5 G) (GRANULES) .................................... 59
COLESTID (5 G) (PACKET) ...........................................59
COLESTID (7.5 G) (PACKET) ........................................59
COLESTIPOL HCL.......................................................... 59
COLLAGENASE CLOSTRIDIUM HIST.........................81
COLY-MYCIN S (3.3-3-10/1) (DROPS SUSP) ............... 90
COLYTE WITH FLAVOR PACKETS (240-22.72G)
(SOLN RECON) .............................................................142
COMBIGAN (0.2%-0.5%) (DROPS) ............................ 102
COMBIPATCH (.05-.14/24) (PATCH TDSW) .............. 110
COMBIPATCH (.05-.25/24) (PATCH TDSW) .............. 110
COMBIPRES (0.1MG-15MG) (TABLET) ...................... 48
COMBIPRES (0.2-15MG) (TABLET) .............................48
COMBIPRES (0.3MG-15MG) (TABLET) ...................... 48
COMBIVENT RESPIMAT (20-100 MCG) (MIST
INHAL) .............................................................................15
COMBIVIR (150-300MG) (TABLET) .......................... 126
COMBUNOX (400MG-5MG) (TABLET) .....................155
COMETRIQ (100 MG/DAY) (CAPSULE) ....................147
COMETRIQ (140 MG/DAY) (CAPSULE) ....................147
COMETRIQ (60 MG/DAY) (CAPSULE) ......................147
COMPAZINE (10 MG) (TABLET) ..................................13
COMPAZINE (25 MG) (SUPP.RECT) ............................ 13
COMPAZINE (5 MG) (TABLET) ....................................13
COMPLERA (200-25-300) (TABLET) ..........................129
COMPLETE NATAL DHA (29-1-250MG) (COMBO.
PKG) ............................................................................... 186
COMTAN (200 MG) (TABLET) ....................................167
CONCERTA (18 MG) (TAB ER 24) ................................39
CONCERTA (27 MG) (TAB ER 24) ................................39
CONCERTA (36 MG) (TAB ER 24) ................................39
CONCERTA (54 MG) (TAB ER 24) ................................39
CONDOMS (OTC)..........................................................152
CONDOMS, FEMALE................................................... 152
CONDOMS, LATEX, LUBRICATED............................152
CONDYLOX (0.5 %) (GEL (GRAM)) ............................ 78
CONDYLOX (0.5 %) (SOLUTION) ................................78
CONZIP (100 MG) (CPBP 25-75) ................................. 162
CONZIP (150 MG) (CPBP 25-75) ................................. 162
CONZIP (200 MG) (CPBP 25-75) ................................. 162
CONZIP (300 MG) (CPBP 17-83) ................................. 162
COPAXONE (20 MG/ML) (SYRINGE) ........................150
COPAXONE (40 MG/ML) (SYRINGE) ........................150
COPEGUS (200 MG) (TABLET) .................................. 130
CORDARONE (200 MG) (TABLET) .............................. 40
CORDRAN (0.05 %) (CREAM (G)) ............................... 75
CORDRAN (0.05 %) (LOTION) ..................................... 75
CORDRAN (0.05 %) (OINT. (G)) ................................... 76
CORDRAN (4MCG/SQ CM) (MED. TAPE) .................. 76
COREG (12.5 MG) (TABLET) ........................................ 43
COREG (25 MG) (TABLET) ........................................... 43
COREG (3.125 MG) (TABLET) ...................................... 43
COREG (6.25 MG) (TABLET) ........................................ 43
COREG CR (10 MG) (CPMP 24HR) .............................. 43
COREG CR (20 MG) (CPMP 24HR) .............................. 43
COREG CR (40 MG) (CPMP 24HR) .............................. 43
COREG CR (80 MG) (CPMP 24HR) .............................. 43
CORGARD (20 MG) (TABLET) ..................................... 50
CORGARD (40 MG) (TABLET) ..................................... 50
CORGARD (80 MG) (TABLET) ..................................... 50
CORLANOR (5 MG) (TABLET) .............................61, 191
CORLANOR (7.5 MG) (TABLET) ..........................61, 191
CORTAID (1 %) (OINT. (G)) ...........................................76
CORTANE-B (1-1-0.1%) (LOTION) ............................... 90
CORTEF (10 MG) (TABLET) ....................................... 134
CORTEF (20 MG) (TABLET) ....................................... 134
CORTEF (5 MG) (TABLET) ......................................... 134
CORTENEMA (100MG/60ML) (ENEMA) ...................141
CORTIFOAM (10 %) (FOAM/APPL) ........................... 141
CORTISONE ACETATE.................................................134
CORTISPORIN (0.5 %) (CREAM (G)) ...........................73
CORTISPORIN (1 %) (OINT. (G)) ..................................73
CORTISPORIN (3.5-10K-1) (DROPS SUSP) ................. 91
CORTISPORIN (3.5-10K-1) (SOLUTION) .................... 91
CORTONE (25 MG) (TABLET) .................................... 134
CORVITE 150 (150 MG-1MG) (TABLET) ...................186
CORVITE 150 (150-1.25MG) (TABLET) ..................... 185
CORVITE FE (150 MG-1MG) (TABLET) .................... 185
CORZIDE (40 MG-5 MG) (TABLET) ............................ 51
CORZIDE (80 MG-5 MG) (TABLET) ............................ 51
COSOPT (22.3-6.8/1) (DROPS) .................................... 102
COSOPT PF (2 %-0.5 %) (DROPERETTE) ..................102
COTELLIC (20 MG) (TABLET) ................................... 145
COUMADIN (1 MG) (TABLET) ...................................104
COUMADIN (10 MG) (TABLET) .................................104
COUMADIN (2 MG) (TABLET) ...................................104
COUMADIN (2.5 MG) (TABLET) ................................104
COUMADIN (3 MG) (TABLET) ...................................104
COUMADIN (4 MG) (TABLET) ...................................104
COUMADIN (5 MG) (TABLET) ...................................104
COUMADIN (6 MG) (TABLET) ...................................104
COUMADIN (7.5 MG) (TABLET) ................................104
COVARYX (1.25-2.5MG) (TABLET) ........................... 108
COVARYX H.S. (0.625-1.25) (TABLET) ......................108
COZAAR (100 MG) (TABLET) ...................................... 48
COZAAR (25 MG) (TABLET) ........................................ 48
COZAAR (50 MG) (TABLET) ........................................ 48
CREON (12K-38K-60) (CAPSULE DR) .......................177
CREON (24-76-120K) (CAPSULE DR) ........................177
CREON (36-114-180) (CAPSULE DR) ........................ 177
CREON (3-9.5-15K) (CAPSULE DR) ...........................177
CREON (6K-19K-30K) (CAPSULE DR) ......................177
CRESEMBA (186 MG) (CAPSULE) ............................ 122
CRESTOR (10 MG) (TABLET) .......................................59
CRESTOR (20 MG) (TABLET) .......................................59
CRESTOR (40 MG) (TABLET) .......................................59
CRESTOR (5 MG) (TABLET) .........................................59
CRINONE (4 %) (GEL/PF APP) ................................... 111
CRINONE (8 %) (GEL/PF APP) ..................................... 93
CRIXIVAN (200 MG) (CAPSULE) ...............................128
CRIXIVAN (400 MG) (CAPSULE) ...............................128
CRIZOTINIB...................................................................147
CROFELEMER............................................................... 141
CROMOLYN SODIUM...................................... 17, 18, 101
CROMOLYN SODIUM (20 MG/2 ML) (AMPUL-NEB)
...............................................................................................
CROTAMITON................................................................. 71
CUPRIMINE (250 MG) (CAPSULE) ............................132
CUTIVATE (0.005 %) (OINT. (G)) ..................................76
CUTIVATE (0.05 %) (CREAM (G)) ................................76
CUTIVATE (0.05 %) (LOTION) ...................................... 76
CUVPOSA (1 MG/5 ML) (SOLUTION) .......................178
CYCLESSA (7 DAYS X 3) (TABLET) ........................... 63
CYCLOBENZAPRINE HCL..........................................175
CYCLOCORT (0.1 %) (CREAM (G)) .............................74
CYCLOCORT (0.1 %) (LOTION) ................................... 74
CYCLOCORT (0.1 %) (OINT. (G)) .................................74
CYCLOGYL (0.5 %) (DROPS) ..................................... 103
CYCLOGYL (1 %) (DROPS) ........................................ 103
CYCLOGYL (2 %) (DROPS) ........................................ 103
CYCLOMYDRIL (0.2 %-1 %) (DROPS) ...................... 103
CYCLOPENTOLATE HCL............................................ 103
CYCLOPENTOLATE/PHENYLEPHRINE................... 103
CYCLOPHOSPHAMIDE............................................... 144
CYCLOPHOSPHAMIDE (25 MG) (CAPSULE) ................
CYCLOPHOSPHAMIDE (50 MG) (CAPSULE) ................
CYCLOSERINE..............................................................123
CYCLOSET (0.8 MG) (TABLET) ................................... 84
CYCLOSPORINE................................................... 101, 112
CYCLOSPORINE, MODIFIED......................................112
CYCLOSPORINE, MODIFIED (50 MG) (CAPSULE) ......
CYMBALTA (20 MG) (CAPSULE DR) ..........................23
CYMBALTA (30 MG) (CAPSULE DR) ..........................23
CYMBALTA (60 MG) (CAPSULE DR) ..........................23
CYPROHEPTADINE HCL............................................... 10
CYSTADANE (1 G/1.7 ML) (POWDER) ......................152
CYSTAGON (150 MG) (CAPSULE) .............................181
CYSTAGON (50 MG) (CAPSULE) ...............................181
CYSTARAN (0.44 %) (DROPS) ....................................103
CYSTEAMINE BITARTRATE.......................................181
CYSTEAMINE HCL.......................................................103
CYTOMEL (25 MCG) (TABLET) ...................................97
CYTOMEL (5 MCG) (TABLET) .....................................97
CYTOMEL (50 MCG) (TABLET) ...................................97
CYTOTEC (100 MCG) (TABLET) ................................178
CYTOTEC (200 MCG) (TABLET) ................................178
CYTRA-2 (334-500MG) (SOLUTION) ........................ 181
CYTRA-3 (500-550/5) (SOLUTION) ............................182
CYTRA-K (1100-334/5) (SOLUTION) .........................182
CYTRA-K (3300-1002) (PACKET) ...............................182
-DDABIGATRAN ETEXILATE MESYLATE................... 107
DABRAFENIB MESYLATE.......................................... 147
DACLATASVIR DIHYDROCHLORIDE.......................131
DAKLINZA (30 MG) (TABLET) .................................. 131
DAKLINZA (60 MG) (TABLET) .................................. 131
DAKLINZA (90 MG) (TABLET) .................................. 131
DALFAMPRIDINE......................................................... 151
DALIRESP (500 MCG) (TABLET) ................................. 18
DALMANE (15 MG) (CAPSULE) .................................. 37
DALMANE (30 MG) (CAPSULE) .................................. 37
DANAZOL.................................................................. 94, 95
DANOCRINE (100 MG) (CAPSULE) ............................ 94
DANOCRINE (200 MG) (CAPSULE) ............................ 94
DANOCRINE (50 MG) (CAPSULE) .............................. 95
DANTRIUM (100 MG) (CAPSULE) ............................ 175
DANTRIUM (25 MG) (CAPSULE) .............................. 175
DANTRIUM (50 MG) (CAPSULE) .............................. 175
DANTROLENE SODIUM.............................................. 175
DAPAGLIFLOZIN PROPANEDIOL................................ 84
DAPAGLIFLOZIN/METFORMIN HCL.......................... 87
DAPSONE................................................................. 68, 123
Sharp Health Plan: Covered California
DAPSONE (100 MG) (TABLET) ........................................
DAPSONE (25 MG) (TABLET) ..........................................
DARAPRIM (25 MG) (TABLET) ..................................125
DARBEPOETIN ALFA IN POLYSORBAT................... 105
DARIFENACIN HYDROBROMIDE............................. 182
DARUNAVIR ETHANOLATE....................................... 126
DARUNAVIR/COBICISTAT.......................................... 126
DASATINIB.................................................................... 147
DAUNORUBICIN HCL.................................................. 144
DAYPRO (600 MG) (TABLET) .....................................139
DAYTRANA (10MG/9HR) (PATCH TD24) ....................38
DAYTRANA (15MG/9HR) (PATCH TD24) ....................39
DAYTRANA (20 MG/9 HR) (PATCH TD24) ..................39
DAYTRANA (30MG/9HR) (PATCH TD24) ....................39
DECADRON (0.5 MG) (TABLET) ................................134
DECADRON (0.75 MG) (TABLET) ..............................134
DECADRON (1 MG) (TABLET) ...................................134
DECADRON (1.5 MG) (TABLET) ................................134
DECADRON (2 MG) (TABLET) ...................................134
DECADRON (4 MG) (TABLET) ...................................134
DECADRON (6 MG) (TABLET) ...................................134
DECLOMYCIN (150 MG) (TABLET) .......................... 120
DECLOMYCIN (300 MG) (TABLET) .......................... 120
DEFERASIROX...................................................... 152, 153
DEFERIPRONE.............................................................. 153
DELAVIRDINE MESYLATE.........................................126
DELFEN (12.5 %) (FOAM/APPL) (OTC)....................... 63
DELTASONE (1 MG) (TABLET) ..................................135
DELTASONE (10 MG) (TAB DS PK) ...........................135
DELTASONE (10 MG) (TABLET) ................................135
DELTASONE (2.5 MG) (TABLET) ...............................135
DELTASONE (20 MG) (TABLET) ................................135
DELTASONE (5 MG) (TAB DS PK) .............................135
DELTASONE (5 MG) (TABLET) ..................................135
DELTASONE (50 MG) (TABLET) ................................135
DELZICOL (400 MG) (CAP(DRTAB)) .................139, 191
DEMADEX (10 MG) (TABLET) .....................................54
DEMADEX (100 MG) (TABLET) ...................................55
DEMADEX (20 MG) (TABLET) .....................................55
DEMADEX (5 MG) (TABLET) .......................................55
DEMECLOCYCLINE HCL............................................120
DEMEROL (100 MG) (TABLET) ................................. 159
DEMEROL (50 MG) (TABLET) ................................... 159
DEMEROL (50 MG/5 ML) (SOLUTION) .................... 159
DEMSER (250 MG) (CAPSULE) ....................................48
DEMULEN (1 MG-35MCG) (TABLET) .........................63
DEMULEN 1-50-21 (1 MG-50MCG) (TABLET) ........... 63
DENAVIR (1 %) (CREAM (G)) .......................................72
DENOSUMAB............................................................ 93, 94
DEPAKENE (250 MG/5ML) (SOLUTION) ..................175
DEPAKOTE (125 MG) (TABLET DR) ..........................169
DEPAKOTE (250 MG) (TABLET DR) ..........................169
DEPAKOTE (500 MG) (TABLET DR) ..........................170
DEPAKOTE ER (250 MG) (TAB ER 24H) ................... 170
DEPAKOTE ER (500 MG) (TAB ER 24H) ................... 170
DEPAKOTE SPRINKLE (125 MG) (CAP SPRINK) ......
170
DEPEN (250 MG) (TABLET) ........................................132
DERMA-SMOOTHE-FS (0.01 %) (OIL) ........................ 75
DERMATOP (0.1 %) (CREAM (G)) ............................... 77
DERMATOP (0.1 %) (OINT. (G)) ................................... 77
DERMAZENE (1 %-1 %) (CREAM (G)) ........................68
DERMOTIC (0.01 %) (DROPS) ...................................... 90
DESCOVY (200MG-25MG) (TABLET) ....................... 126
DESIPRAMINE HCL................................................. 24, 25
DESLORATADINE...........................................................11
DESLORATADINE/PSEUDOEPHEDRINE.................... 10
DESMOPRESSIN (NONREFRIGERATED)................... 93
DESMOPRESSIN (NONREFRIGERATED) (10/SPRAY)
(SPRAY/PUMP) ...................................................................
DESMOPRESSIN ACETATE........................................... 93
DESMOPRESSIN ACETATE (0.1 MG) (TABLET) ...........
DESMOPRESSIN ACETATE (0.1 MG/ML) (SOLUTION)
...............................................................................................
DESMOPRESSIN ACETATE (0.2 MG) (TABLET) ...........
DESMOPRESSIN ACETATE (10/SPRAY)
(SPRAY/PUMP) ...................................................................
DESOG-E.ESTRADIOL/E.ESTRADIOL........................ 63
DESOGEN (0.15-0.03) (TABLET) .................................. 63
DESOGESTREL-ETHINYL ESTRADIOL..................... 63
DESONATE (0.05 %) (GEL (GRAM)) ............................75
DESONIDE....................................................................... 75
DESONIDE (0.05 %) (OINT. (G)) .......................................
DESOWEN (0.05 %) (CREAM (G)) ............................... 75
DESOWEN (0.05 %) (LOTION) ......................................75
DESOXIMETASONE....................................................... 75
DESOXYN (5 MG) (TABLET) ........................................27
DESVENLAFAXINE........................................................22
DESVENLAFAXINE ER (100 MG) (TAB ER 24H) ......
191
DESVENLAFAXINE ER (50 MG) (TAB ER 24H) ......
191
Page 206 of 224
Index
DESVENLAFAXINE FUMARATE................................. 22
DESVENLAFAXINE FUMARATE ER (100 MG) (TAB
ER 24) .............................................................................191
DESVENLAFAXINE FUMARATE ER (50 MG) (TAB ER
24) ................................................................................... 191
DESVENLAFAXINE SUCCINATE................................. 23
DESYREL (100 MG) (TABLET) .....................................22
DESYREL (150 MG) (TABLET) .....................................22
DESYREL (300 MG) (TABLET) .....................................22
DESYREL (50 MG) (TABLET) .......................................22
DETROL (1 MG) (TABLET) ................................. 182, 191
DETROL (2 MG) (TABLET) ................................. 182, 191
DETROL LA (2 MG) (CAP ER 24H) ....................183, 192
DETROL LA (4 MG) (CAP ER 24H) ....................183, 192
DEXAMETHASONE................................................99, 134
DEXAMETHASONE (0.5 MG/5ML) (SOLUTION) ..........
DEXAMETHASONE INTENSOL (1 MG/ML) (DROPS)
...............................................................................................
DEXAMETHASONE SOD PHOSPHATE.......................99
DEXASOL (0.1 %) (DROPS) .......................................... 99
DEXEDRINE (10 MG) (CAPSULE ER) .........................26
DEXEDRINE (10 MG) (TABLET) ..................................26
DEXEDRINE (15 MG) (CAPSULE ER) .........................26
DEXEDRINE (5 MG) (CAPSULE ER) ...........................26
DEXEDRINE (5 MG) (TABLET) ....................................26
DEXILANT (30 MG) (CAP DR BP) ..................... 179, 192
DEXILANT (60 MG) (CAP DR BP) ..................... 180, 192
DEXLANSOPRAZOLE..........................................179, 180
DEXMETHYLPHENIDATE HCL....................................38
DEXPAK (1.5MG (21)) (TAB DS PK) .......................... 134
DEXPAK (1.5MG (35)) (TAB DS PK) .......................... 134
DEXPAK (1.5MG (51)) (TAB DS PK) .......................... 134
DEXTROAMPHETAMINE SULFATE...................... 26, 27
DEXTROAMPHETAMINE/AMPHETAMINE................ 27
DEXTROMETHORPHAN HBR/QUINIDINE.............. 151
DEXTROSE/SOD CITRATE/CITRIC AC..................... 104
DIABINESE (100 MG) (TABLET) ................................. 85
DIABINESE (250 MG) (TABLET) ................................. 85
DIAMOX (125 MG) (TABLET) .................................... 101
DIAMOX (250 MG) (TABLET) .................................... 101
DIAMOX SEQUELS (500 MG) (CAPSULE ER) .........101
DIASTAT (2.5 MG) (KIT) ..............................................169
DIASTAT ACUDIAL (12.5-15-20) (KIT) ......................169
DIASTAT ACUDIAL (5-7.5-10MG) (KIT) ................... 169
DIAZEPAM............................................................... 28, 169
DIAZEPAM INTENSOL (5 MG/ML) (ORAL CONC) .......
DIAZOXIDE..................................................................... 88
DIBENZYLINE (10 MG) (CAPSULE) ........................... 44
DICHLORPHENAMIDE................................................ 175
DICLEGIS (10 MG-10MG) (TABLET DR) .................... 12
DICLOFENAC EPOLAMINE.......................................... 77
DICLOFENAC POTASSIUM................................. 137, 163
DICLOFENAC SODIUM............................. 77, 80, 99, 137
DICLOFENAC SODIUM/CAPSAICIN........................... 77
DICLOFENAC SODIUM/MISOPROSTOL...................136
DICLOFENAC SUBMICRONIZED...............................137
DICLOXACILLIN SODIUM..........................................119
DICYCLOMINE HCL.................................................... 177
DIDANOSINE.................................................................127
DIDRONEL (200 MG) (TABLET) .................................. 94
DIDRONEL (400 MG) (TABLET) .................................. 94
DIFENOXIN HCL/ATROPINE SULFATE.....................141
DIFFERIN (0.1 %) (CREAM (G)) ...........................69, 192
DIFFERIN (0.1 %) (GEL (GRAM)) ........................ 69, 192
DIFFERIN (0.1 %) (LOTION) ................................. 69, 192
DIFFERIN (0.3 %) (GEL (GRAM)) ........................ 69, 192
DIFFERIN (0.3 %) (GEL W/PUMP) ....................... 69, 192
DIFICID (200 MG) (TABLET) ...................................... 117
DIFLORASONE DIACETATE......................................... 75
DIFLORASONE DIACETATE/EMOLL.......................... 75
DIFLUCAN (10 MG/ML) (SUSP RECON) .................. 121
DIFLUCAN (100 MG) (TABLET) ................................ 121
DIFLUCAN (150 MG) (TABLET) ................................ 121
DIFLUCAN (200 MG) (TABLET) ................................ 121
DIFLUCAN (40 MG/ML) (SUSP RECON) .................. 121
DIFLUCAN (50 MG) (TABLET) .................................. 121
DIFLUNISAL..................................................................155
DIFLUPREDNATE........................................................... 99
DIGOXIN.......................................................................... 41
DIGOXIN (50 MCG/ML) (SOLUTION) .............................
DIHYDROERGOTAMINE MESYLATE....................... 163
DILACOR XR (120 MG) (CAP ER DEG) ...................... 52
DILACOR XR (180 MG) (CAP ER DEG) ...................... 52
DILACOR XR (240 MG) (CAP ER DEG) ...................... 52
DILANTIN (100 MG) (CAPSULE) ...............................173
DILANTIN (30 MG) (CAPSULE) .................................173
DILANTIN (50 MG) (TAB CHEW) .............................. 173
DILANTIN-125 (100 MG/4ML) (ORAL SUSP) ...........173
DILANTIN-125 (125 MG/5ML) (ORAL SUSP) ...........173
DILATRATE-SR (40 MG) (CAPSULE ER) ....................61
DILAUDID (1 MG/ML) (LIQUID) ............................... 158
DILAUDID (2 MG) (TABLET) ..................................... 158
DILAUDID (3 MG) (SUPP.RECT) ................................158
DILAUDID (4 MG) (TABLET) ..................................... 158
DILAUDID (8 MG) (TABLET) ..................................... 158
DILTIAZEM HCL........................................................51-53
DIMETHYL FUMARATE..............................................150
DIOVAN (160 MG) (TABLET) ........................................48
DIOVAN (320 MG) (TABLET) ........................................48
DIOVAN (40 MG) (TABLET) ..........................................48
DIOVAN (80 MG) (TABLET) ..........................................48
DIOVAN HCT (160-12.5MG) (TABLET) ....................... 45
DIOVAN HCT (160-25MG) (TABLET) .......................... 45
DIOVAN HCT (320-12.5MG) (TABLET) ....................... 45
DIOVAN HCT (320MG-25MG) (TABLET) ....................45
DIOVAN HCT (80-12.5MG) (TABLET) ......................... 45
DIPENTUM (250 MG) (CAPSULE) ..................... 140, 192
DIPHENHYDRAMINE HCL........................................... 10
DIPHENOXYLATE HCL/ATROPINE........................... 141
DIPROLENE (0.05 %) (CREAM (G)) .............................74
DIPROLENE (0.05 %) (GEL (GRAM)) .......................... 74
DIPROLENE (0.05 %) (LOTION) ...................................74
DIPROLENE (0.05 %) (OINT. (G)) .................................74
DIPROLENE AF (0.05 %) (CREAM (G)) .......................74
DIPYRIDAMOLE........................................................... 106
DISALCID (500 MG) (TABLET) .................................. 155
DISALCID (750 MG) (TABLET) .................................. 155
DISKETS (40 MG) (TABLET SOL) ..............................159
DISOPYRAMIDE PHOSPHATE............................... 40, 41
DISULFIRAM...................................................................27
DITROPAN (5 MG) (TABLET) .....................................182
DITROPAN (5 MG/5 ML) (SYRUP) ............................. 182
DITROPAN XL (10 MG) (TAB ER 24) .................182, 192
DITROPAN XL (15 MG) (TAB ER 24) .................182, 192
DITROPAN XL (5 MG) (TAB ER 24) ...................182, 192
DIURIL (250 MG) (TABLET) ......................................... 57
DIURIL (500 MG) (TABLET) ......................................... 57
DIURIL (250 MG/5ML) (ORAL SUSP) ......................... 57
DIVALPROEX SODIUM........................................169, 170
DIVIGEL (0.25(0.1%)) (GEL PACKET) ....................... 109
DIVIGEL (0.5MG(0.1)) (GEL PACKET) ......................109
DIVIGEL (1MG(0.1%)) (GEL PACKET) ......................109
DOFETILIDE.................................................................... 41
DOLASETRON MESYLATE........................................... 12
DOLOBID (500 MG) (TABLET) ...................................155
DOLOPHINE HCL (10 MG) (TABLET) .......................159
DOLOPHINE HCL (5 MG) (TABLET) .........................159
DOLUTEGRAVIR SODIUM..........................................129
DONEPEZIL HCL............................................................ 19
DONNATAL (16.2 MG) (TABLET) .............................. 178
DONNATAL (16.2MG/5ML) (ELIXIR) ........................ 178
DORAL (15 MG) (TABLET) ...........................................37
DORNASE ALFA........................................................... 154
DORYX (100 MG) (TABLET DR) ................................ 120
DORYX (150 MG) (TABLET DR) ................................ 120
DORYX (200 MG) (TABLET DR) ................................ 120
DORYX (50 MG) (TABLET DR) .................................. 120
DORYX (75 MG) (TABLET DR) .................................. 120
DORYX MPC (120 MG) (TABLET DR) .......................120
DORZOLAMIDE HCL................................................... 102
DORZOLAMIDE HCL/TIMOLOL MALEAT...............102
DORZOLAMIDE/TIMOLOL/PF................................... 102
DOSTINEX (0.5 MG) (TABLET) ....................................94
DOVONEX (0.005 %) (CREAM (G)) ..................... 82, 192
DOVONEX (0.005 %) (OINT. (G)) ......................... 82, 192
DOVONEX (0.005 %) (SOLUTION) ...................... 82, 192
DOXAZOSIN MESYLATE........................................ 43, 44
DOXEPIN HCL..................................................... 25, 36, 77
DOXERCALCIFEROL..................................................... 94
DOXYCYCLINE CALCIUM......................................... 120
DOXYCYCLINE HYCLATE......................................... 120
DOXYCYCLINE MONOHYDRATE.....................120, 121
DOXYLAMINE/PYRIDOXINE HCL.............................. 12
DRITHOCREME HP (1 %) (CREAM (G)) .............82, 192
DRONABINOL................................................................. 12
DRONEDARONE HCL.................................................... 41
DROSPIR/ETH ESTRA/LEVOMEFOL CA.................... 63
DROSPIRENONE/ESTRADIOL....................................108
DROXIA (200 MG) (CAPSULE) ...................................107
DROXIA (300 MG) (CAPSULE) ...................................107
DROXIA (400 MG) (CAPSULE) ...................................107
DROXIDOPA.............................................................. 60, 61
DRYSOL (20 %) (SOLUTION) ....................................... 77
DUAC (1.2(1)%-5%) (GEL (GRAM)) .............................67
DUAVEE (0.45-20 MG) (TABLET) .............................. 108
DUETACT (30 MG-2 MG) (TABLET) ....................87, 192
DUETACT (30 MG-4 MG) (TABLET) ....................87, 192
DUEXIS (800-26.6MG) (TABLET) ...............................136
DULAGLUTIDE......................................................... 83, 84
DULERA (100-5 MCG) (HFA AER AD) ................16, 192
DULERA (200-5 MCG) (HFA AER AD) ................16, 192
DULOXETINE HCL......................................................... 23
DUONEB (0.5-3MG/3) (AMPUL-NEB) ......................... 15
DUOPA (4.63-20/ML) (INT PMP SP) ........................... 166
Sharp Health Plan: Covered California
DURAGESIC (100 MCG/HR) (PATCH TD72) .............156
DURAGESIC (12 MCG/HR) (PATCH TD72) ...............156
DURAGESIC (25 MCG/HR) (PATCH TD72) ...............156
DURAGESIC (37.5MCG/HR) (PATCH TD72) .............156
DURAGESIC (50MCG/HR) (PATCH TD72) ................156
DURAGESIC (62.5MCG/HR) (PATCH TD72) .............156
DURAGESIC (75MCG/HR) (PATCH TD72) ................156
DURAGESIC (87.5MCG/HR) (PATCH TD72) .............156
DUREZOL (0.05 %) (DROPS) ........................................ 99
DURICEF (1 G) (TABLET) ........................................... 114
DURICEF (250 MG/5ML) (SUSP RECON) ................. 114
DURICEF (500 MG) (CAPSULE) .................................114
DURICEF (500 MG/5ML) (SUSP RECON) ................. 114
DURLAZA (162.5 MG) (CAP ER 24H) ........................106
DUTASTERIDE.............................................................. 181
DUTASTERIDE/TAMSULOSIN HCL...........................181
DUTOPROL (100-12.5MG) (TAB ER 24H) ................... 51
DUTOPROL (25-12.5 MG) (TAB ER 24H) .................... 51
DUTOPROL (50-12.5 MG) (TAB ER 24H) .................... 51
DYANAVEL XR (2.5 MG/ML) (SUS BP 24H) ....... 26, 192
DYAZIDE (37.5-25 MG) (CAPSULE) ............................ 55
DYAZIDE (50 MG-25MG) (CAPSULE) ......................... 55
DYMISTA (137-50 MCG) (SPRAY/PUMP) ........... 11, 192
DYNACIN (100 MG) (TABLET) ...................................121
DYNACIN (50 MG) (TABLET) .....................................121
DYNACIN (75 MG) (TABLET) .....................................121
DYNACIRC (2.5 MG) (CAPSULE) ................................ 53
DYNACIRC (5 MG) (CAPSULE) ................................... 53
DYRENIUM (100 MG) (CAPSULE) .............................. 55
DYRENIUM (50 MG) (CAPSULE) ................................ 55
-EE.E.S. 400 (400 MG) (TABLET) ................................... 117
ECHOTHIOPHATE IODIDE..........................................102
EC-NAPROSYN (375 MG) (TABLET DR) .................. 138
EC-NAPROSYN (500 MG) (TABLET DR) .................. 138
ECONAZOLE NITRATE..................................................70
ECOTRIN (81 MG) (TABLET DR) (OTC).................... 155
ECOZA (1 %) (FOAM) ....................................................70
EDARBI (40 MG) (TABLET) ..................................47, 192
EDARBI (80 MG) (TABLET) ..................................47, 192
EDARBYCLOR (40 MG-25MG) (TABLET) ..........44, 192
EDARBYCLOR (40-12.5 MG) (TABLET) ............. 44, 192
EDECRIN (25 MG) (TABLET) ....................................... 54
EDLUAR (10 MG) (TAB SUBL) .............................37, 192
EDLUAR (5 MG) (TAB SUBL) ...............................37, 192
EDOXABAN TOSYLATE.............................................. 104
EDURANT (25 MG) (TABLET) ................................... 127
EFAVIRENZ............................................................ 126, 127
EFAVIRENZ/EMTRICITAB/TENOFOVIR................... 129
EFFER-K (10 MEQ) (TABLET EFF) .............................. 92
EFFER-K (20 MEQ) (TABLET EFF) .............................. 92
EFFEXOR (100 MG) (TABLET) .....................................23
EFFEXOR (25 MG) (TABLET) .......................................23
EFFEXOR (37.5 MG) (TABLET) ....................................23
EFFEXOR (50 MG) (TABLET) .......................................23
EFFEXOR (75 MG) (TABLET) .......................................23
EFFEXOR XR (150 MG) (CAP ER 24H) ....................... 23
EFFEXOR XR (37.5 MG) (CAP ER 24H) ...................... 23
EFFEXOR XR (75 MG) (CAP ER 24H) ......................... 23
EFFIENT (10 MG) (TABLET) .......................................106
EFFIENT (5 MG) (TABLET) .........................................106
EFINACONAZOLE.......................................................... 70
EFUDEX (2 %) (SOLUTION) .........................................80
EFUDEX (5 %) (CREAM (G)) ........................................ 80
EFUDEX (5 %) (SOLUTION) .........................................80
ELAVIL (10 MG) (TABLET) ...........................................24
ELAVIL (100 MG) (TABLET) .........................................24
ELAVIL (150 MG) (TABLET) .........................................24
ELAVIL (25 MG) (TABLET) ...........................................24
ELAVIL (50 MG) (TABLET) ...........................................24
ELAVIL (75 MG) (TABLET) ...........................................24
ELBASVIR/GRAZOPREVIR.........................................131
ELDEPRYL (5 MG) (CAPSULE) ..................................168
ELDEPRYL (5 MG) (TABLET) .................................... 168
ELESTRIN (0.87G) (GEL MD PMP) ............................ 109
ELETRIPTAN HBR........................................................ 163
ELIDEL (1 %) (CREAM (G)) ..................................82, 192
ELIGLUSTAT TARTRATE.............................................152
ELIPHOS (667 MG) (TABLET) ...................................... 91
ELIQUIS (2.5 MG) (TABLET) ...................................... 104
ELIQUIS (5 MG) (TABLET) ......................................... 104
ELITE-OB (50-1.25MG) (TABLET) ............................. 186
ELIXOPHYLLIN (80 MG/15ML) (ELIXIR) .................. 18
ELLA (30 MG) (TABLET) .............................................. 65
ELLENCE (200MG/0.1L) (VIAL) .................................144
ELMIRON (100 MG) (CAPSULE) ................................182
ELOCON (0.1 %) (CREAM (G)) .....................................76
ELOCON (0.1 %) (OINT. (G)) .........................................77
ELOCON (0.1 %) (SOLUTION) ..................................... 77
ELTROMBOPAG OLAMINE......................................... 107
ELUXADOLINE.............................................................140
Page 207 of 224
Index
ELVITEG/COBI/EMTRIC/TENOFO ALA....................129
ELVITEG/COBI/EMTRIC/TENOFO DIS......................129
ELVITEGRAVIR............................................................. 129
EMADINE (0.05 %) (DROPS) ................................ 99, 192
EMBEDA (100MG-4MG) (CAP ER PO) ...................... 160
EMBEDA (20MG-0.8MG) (CAP ER PO) ..................... 160
EMBEDA (30MG-1.2MG) (CAP ER PO) ..................... 160
EMBEDA (50 MG-2 MG) (CAP ER PO) ...................... 160
EMBEDA (60MG-2.4MG) (CAP ER PO) ..................... 160
EMBEDA (80MG-3.2MG) (CAP ER PO) ..................... 160
EMCYT (140 MG) (CAPSULE) ....................................150
EMEDASTINE DIFUMARATE....................................... 99
EMEND (125 MG) (CAPSULE) ......................................12
EMEND (125 MG) (SUSP RECON) ............................... 12
EMEND (125MG-80MG) (CAP DS PK) .........................12
EMEND (40 MG) (CAPSULE) ........................................12
EMEND (80 MG) (CAPSULE) ........................................12
EMLA (2.5 %-2.5%) (CREAM (G)) ................................81
EMPAGLIFLOZIN............................................................84
EMPAGLIFLOZIN/LINAGLIPTIN.................................. 86
EMPAGLIFLOZIN/METFORMIN HCL..........................88
EMSAM (12MG/24HR) (PATCH TD24) .........................36
EMSAM (6 MG/24 HR) (PATCH TD24) .........................36
EMSAM (9 MG/24 HR) (PATCH TD24) .........................36
EMTRICITAB/RILPIVIRI/TENOF ALA.......................129
EMTRICITAB/RILPIVIRINE/TENOFOV..................... 129
EMTRICITABINE...........................................................127
EMTRICITABINE/TENOFOV ALAFENAM................ 126
EMTRICITABINE/TENOFOVIR................................... 126
EMTRIVA (10 MG/ML) (SOLUTION) .........................127
EMTRIVA (200 MG) (CAPSULE) ................................ 127
EMVERM (100 MG) (TAB CHEW) ..............................124
ENABLEX (15 MG) (TAB ER 24H) ..................... 182, 192
ENABLEX (7.5 MG) (TAB ER 24H) .................... 182, 192
ENALAPRIL MALEATE..................................................46
ENALAPRIL/HYDROCHLOROTHIAZIDE................... 42
ENBREL (25 MG) (VIAL) ............................................ 133
ENBREL (25MG/0.5ML) (SYRINGE) ..........................133
ENBREL (50 MG/ML) (PEN INJCTR) .........................133
ENBREL (50 MG/ML) (SYRINGE) ..............................133
ENDODAN (4.8355-325) (TABLET) ............................ 161
ENFUVIRTIDE............................................................... 126
ENLYTE (1.5-8.73MG) (CAP IR DR) ...........................184
ENOXAPARIN SODIUM....................................... 105, 106
ENSTILAR (0.005-.064) (FOAM) ...........................82, 192
ENTACAPONE............................................................... 167
ENTECAVIR................................................................... 130
ENTOCORT EC (3 MG) (CAPDR - ER) .......................134
ENTRESTO (24 MG-26MG) (TABLET) ................ 61, 192
ENTRESTO (49 MG-51MG) (TABLET) ................ 61, 192
ENTRESTO (97MG-103MG) (TABLET) ............... 61, 192
ENVARSUS XR (0.75 MG) (TAB ER 24H) ..................113
ENVARSUS XR (1 MG) (TAB ER 24H) .......................113
ENVARSUS XR (4 MG) (TAB ER 24H) .......................113
ENZALUTAMIDE.......................................................... 144
EPANED (1 MG/ML) (SOLN RECON) .......................... 46
EPCLUSA (400-100MG) (TABLET) ............................ 129
EPIDUO (0.1 %-2.5%) (GEL (GRAM)) ..................67, 192
EPIDUO (0.1 %-2.5%) (GEL W/PUMP) .................67, 192
EPIDUO FORTE (0.3 %-2.5%) (GEL W/PUMP) ...... 67,
192
EPIFOAM (1 %-1 %) (FOAM) ........................................ 80
EPINEPHRINE................................................................143
EPIPEN 2-PAK (0.3MG/0.3) (AUTO INJCT) ............... 143
EPIPEN JR 2-PAK (0.15MG/0.3) (AUTO INJCT) ........ 143
EPIRUBICIN HCL.......................................................... 144
EPIVIR (10 MG/ML) (SOLUTION) ..............................127
EPIVIR (150 MG) (TABLET) ........................................127
EPIVIR (300 MG) (TABLET) ........................................127
EPIVIR HBV (100 MG) (TABLET) .............................. 130
EPIVIR HBV (25 MG/5 ML) (SOLUTION) ................. 130
EPLERENONE..................................................................55
EPROSARTAN MESYLATE............................................ 47
EPZICOM (600-300MG) (TABLET) .............................126
EQUETRO (100 MG) (CPMP 12HR) ..............................29
EQUETRO (200 MG) (CPMP 12HR) ..............................29
EQUETRO (300 MG) (CPMP 12HR) ..............................29
ERGOCALCIFEROL (VITAMIN D2)........................... 188
ERGOCALCIFEROL (VITAMIN D2) (400 UNIT)
(TABLET) (OTC)..................................................................
ERGOCALCIFEROL (VITAMIN D2) (50000 UNIT)
(CAPSULE) ..........................................................................
ERGOLOID MESYLATES...............................................63
ERGOMAR (2 MG) (TAB SUBL) .................................163
ERGOTAMINE TARTRATE...........................................163
ERGOTAMINE TARTRATE/CAFFEINE...................... 163
ERIVEDGE (150 MG) (CAPSULE) ..............................145
ERLOTINIB HCL........................................................... 147
ERTACZO (2 %) (CREAM (G)) ...................................... 71
ERTAPENEM SODIUM................................................. 114
ERY (2 %) (MED. SWAB) ............................................... 69
ERYC (250 MG) (CAPSULE DR) .................................117
ERYGEL (2 %) (GEL (GRAM)) ......................................70
ERYMAX (2 %) (SOLUTION) ........................................70
ERYPED 200 (200 MG/5ML) (SUSP RECON) ............ 117
ERYPED 400 (400 MG/5ML) (SUSP RECON) ............ 117
ERY-TAB (333 MG) (TABLET DR) ..............................117
ERYTHRCIN STEARATE (250 MG) (TABLET) ......... 117
ERYTHRCIN STEARATE (500 MG) (TABLET) ......... 117
ERYTHROMYCIN BASE...................................... 100, 117
ERYTHROMYCIN BASE (250 MG) (TABLET DR) .........
ERYTHROMYCIN BASE (500 MG) (TABLET DR) .........
ERYTHROMYCIN BASE/ETHANOL...................... 69, 70
ERYTHROMYCIN ETHYLSUCCINATE......................117
ERYTHROMYCIN ETHYLSUCCINATE (400 MG)
(TABLET) .............................................................................
ERYTHROMYCIN STEARATE.....................................117
ERYTHROMYCIN/BENZOYL PEROXIDE................... 70
ESBRIET (267 MG) (CAPSULE) ..................................154
ESCITALOPRAM OXALATE..........................................21
ESGIC (50-325-40) (CAPSULE) ................................... 154
ESGIC (50-325-40) (TABLET) ......................................154
ESKALITH (300 MG) (CAPSULE) ................................ 29
ESKALITH CR (450 MG) (TABLET ER) .......................29
ESLICARBAZEPINE ACETATE................................... 170
ESOMEPRAZOLE MAGNESIUM................................ 180
ESOMEPRAZOLE STRONTIUM..................................180
ESOMEPRAZOLE STRONTIUM (24.65 MG)
(CAPSULE DR) ............................................................. 192
ESOMEPRAZOLE STRONTIUM (49.3 MG) (CAPSULE
DR) ................................................................................. 192
ESTAZOLAM................................................................... 37
ESTRACE (0.01 %) (CREAM/APPL) ................... 183, 192
ESTRACE (0.5 MG) (TABLET) .................................... 109
ESTRACE (1 MG) (TABLET) ....................................... 109
ESTRACE (2 MG) (TABLET) ....................................... 109
ESTRADIOL................................................... 109, 110, 183
ESTRADIOL ACETATE.................................................183
ESTRADIOL VALERATE/DIENOGEST........................ 63
ESTRADIOL/LEVONORGESTREL............................. 110
ESTRADIOL/NORETHINDRONE ACET.....................110
ESTRADIOL/NORGESTIMATE................................... 110
ESTRAMUSTINE PHOSPHATE SODIUM.................. 150
ESTRING (7.5MCG/24H) (VAG RING) ....................... 183
ESTROGEL (1.25 G) (GEL MD PMP) ..........................109
ESTROGEN,CON/M-PROGEST ACET........................ 110
ESTROGEN,ESTER/ME-TESTOSTERONE.................108
ESTROGEN,ESTER/ME-TESTOSTERONE (0.625-1.25)
(TABLET) .............................................................................
ESTROGEN,ESTER/ME-TESTOSTERONE (1.252.5MG) (TABLET) ...............................................................
ESTROGENS, CONJUGATED...................... 110, 111, 183
ESTROGENS,CONJ/BAZEDOXIFENE........................ 108
ESTROGENS,ESTERIFIED........................................... 111
ESTROPIPATE................................................................ 111
ESTROSTEP FE (5-7-9-7) (TABLET) .............................64
ESZOPICLONE................................................................ 37
ETANERCEPT................................................................ 133
ETHACRYNIC ACID....................................................... 54
ETHAMBUTOL HCL.....................................................123
ETHINYL ESTRADIOL/DROSPIRENONE................... 63
ETHIONAMIDE............................................................. 123
ETHOSUXIMIDE........................................................... 170
ETHOTOIN..................................................................... 170
ETH-OXYDOSE (20 MG/ML) (ORAL CONC) ........... 160
ETHYL CHLORIDE......................................................... 80
ETHYL CHLORIDE (100 %) (SPRAY) ..............................
ETHYNODIOL D-ETHINYL ESTRADIOL....................63
ETHYNODIOL D-ETHINYL ESTRADIOL (1 MG35MCG) (TABLET) .............................................................
ETIDRONATE DISODIUM..............................................94
ETODOLAC.................................................................... 137
ETONOGESTREL/ETHINYL ESTRADIOL...................63
ETOPOSIDE....................................................................149
ETRAFON-A (4MG-10MG) (TABLET) ......................... 24
ETRAVIRINE..................................................................127
EULEXIN (125 MG) (CAPSULE) ................................ 144
EURAX (10 %) (CREAM (G)) ........................................ 71
EURAX (10 %) (LOTION) .............................................. 71
EVAMIST (1.53/SPRAY) (SPRAY) ...............................109
EVEKEO (10 MG) (TABLET) .........................................26
EVEKEO (5 MG) (TABLET) ...........................................26
EVEROLIMUS........................................112, 113, 145, 146
EVISTA (60 MG) (TABLET) ...........................................94
EVOCLIN (1 %) (FOAM) ................................................69
EVOTAZ (300-150 MG) (TABLET) .............................. 128
EVOXAC (30 MG) (CAPSULE) ....................................143
EXALGO (12 MG) (TAB ER 24H) ............................... 158
EXALGO (16 MG) (TAB ER 24H) ............................... 159
EXALGO (32 MG) (TAB ER 24H) ............................... 159
EXALGO (8 MG) (TAB ER 24H) ................................. 159
EXELDERM (1 %) (CREAM (G)) .................................. 71
EXELDERM (1 %) (SOLUTION) ...................................71
EXELON (1.5 MG) (CAPSULE) .....................................20
Sharp Health Plan: Covered California
EXELON (13.3MG/24H) (PATCH TD24) ....................... 19
EXELON (3 MG) (CAPSULE) ........................................20
EXELON (4.5 MG) (CAPSULE) .....................................20
EXELON (4.6MG/24HR) (PATCH TD24) ...................... 19
EXELON (6 MG) (CAPSULE) ........................................20
EXELON (9.5MG/24HR) (PATCH TD24) ...................... 19
EXEMESTANE............................................................... 145
EXENATIDE..................................................................... 84
EXENATIDE MICROSPHERES...................................... 84
EXFORGE (10MG-160MG) (TABLET) ................. 45, 192
EXFORGE (10MG-320MG) (TABLET) ................. 45, 192
EXFORGE (5 MG-160MG) (TABLET) .................. 45, 193
EXFORGE (5MG-320MG) (TABLET) ................... 46, 193
EXFORGE HCT (10-160-25) (TABLET) ................ 44, 193
EXFORGE HCT (10-320-25) (TABLET) ................ 44, 193
EXFORGE HCT (10MG-160MG) (TABLET) ........ 44, 193
EXFORGE HCT (5-160-12.5) (TABLET) ............... 44, 193
EXFORGE HCT (5-160-25MG) (TABLET) ........... 44, 193
EXJADE (125 MG) (TAB DISPER) .............................. 152
EXJADE (250 MG) (TAB DISPER) .............................. 152
EXJADE (500 MG) (TAB DISPER) .............................. 152
EXTAVIA (0.3 MG) (KIT) ............................................. 151
EXTAVIA (0.3 MG) (VIAL) .......................................... 151
EXTINA (2 %) (FOAM) .................................................. 70
EZETIMIBE...................................................................... 59
EZETIMIBE/SIMVASTATIN........................................... 58
EZOGABINE.................................................................. 170
-FFA#7/PC,PE DHA/NAC/PAP/IF/MV46..........................184
FABIOR (0.1 %) (FOAM) ........................................69, 193
FACTIVE (320 MG) (TABLET) .................................... 119
FAMCICLOVIR.............................................................. 125
FAMOTIDINE.................................................................179
FAMVIR (125 MG) (TABLET) ............................. 125, 193
FAMVIR (250 MG) (TABLET) ............................. 125, 193
FAMVIR (500 MG) (TABLET) ............................. 125, 193
FANAPT (1 MG) (TABLET) ................................... 31, 193
FANAPT (10 MG) (TABLET) ................................. 31, 193
FANAPT (12 MG) (TABLET) ................................. 31, 193
FANAPT (1-2-4-6MG) (TAB DS PK) ......................31, 193
FANAPT (2 MG) (TABLET) ................................... 31, 193
FANAPT (4 MG) (TABLET) ................................... 32, 193
FANAPT (6 MG) (TABLET) ................................... 32, 193
FANAPT (8 MG) (TABLET) ................................... 32, 193
FARESTON (60 MG) (TABLET) .................................. 149
FARXIGA (10 MG) (TABLET) ............................... 84, 193
FARXIGA (5 MG) (TABLET) ................................. 84, 193
FARYDAK (10 MG) (CAPSULE) ................................. 149
FARYDAK (15 MG) (CAPSULE) ................................. 149
FARYDAK (20 MG) (CAPSULE) ................................. 149
FAZACLO (100 MG) (TAB RAPDIS) .............................31
FAZACLO (12.5 MG) (TAB RAPDIS) ............................31
FAZACLO (150 MG) (TAB RAPDIS) .............................31
FAZACLO (200 MG) (TAB RAPDIS) .............................31
FAZACLO (25 MG) (TAB RAPDIS) ...............................31
FE FUMARATE/CAL/E/FA/MULTIVIT....................... 184
FE FUMARATE/CAL/E/FA/MULTIVIT (65 MG-1 MG)
(TABLET) .............................................................................
FE FUMARATE/FA/MV, MIN COMB#15.....................184
FE/FA/DHA/EPA/FAD/NADH/BE/MV47......................184
FEBUXOSTAT................................................................ 103
FELBAMATE..................................................................170
FELBATOL (400 MG) (TABLET) .................................170
FELBATOL (600 MG) (TABLET) .................................170
FELBATOL (600 MG/5ML) (ORAL SUSP) ................. 170
FELDENE (10 MG) (CAPSULE) .................................. 139
FELDENE (20 MG) (CAPSULE) .................................. 139
FELODIPINE.................................................................... 53
FEM PH (0.9-0.025%) (JELLY/APPL) ..........................183
FEMALE CONDOM (OTC)........................................... 152
FEMARA (2.5 MG) (TABLET) ..................................... 145
FEMCON FE (0.4-35(21)) (TAB CHEW) ....................... 64
FEMHRT (0.5MG-2.5) (TABLET) ................................ 111
FEMHRT (1MG-5MCG) (TABLET) ............................. 111
FEMRING (0.05MG/24H) (VAG RING) .......................183
FEMRING (0.1MG/24HR) (VAG RING) ...................... 183
FENOFIBRATE...........................................................59, 60
FENOFIBRATE NANOCRYSTALLIZED....................... 60
FENOFIBRATE,MICRONIZED.......................................60
FENOFIBRIC ACID......................................................... 60
FENOFIBRIC ACID (CHOLINE).................................... 60
FENOGLIDE (120 MG) (TABLET) ........................ 59, 193
FENOGLIDE (40 MG) (TABLET) .......................... 60, 193
FENOPROFEN CALCIUM............................................ 137
FENORTHO (200 MG) (CAPSULE) .............................137
FENORTHO (400 MG) (CAPSULE) .............................137
FENTANYL.....................................................................156
FENTANYL CITRATE........................................... 156, 157
FENTORA (100 MCG) (TABLET EFF) ........................157
FENTORA (200 MCG) (TABLET EFF) ........................157
FENTORA (400 MCG) (TABLET EFF) ........................157
Page 208 of 224
Index
FENTORA (600 MCG) (TABLET EFF) ........................157
FENTORA (800 MCG) (TABLET EFF) ........................157
FER-IN-SOL (15 MG/ML) (DROPS) (OTC)................. 185
FERIVA (75-1-175MG) (CAP MPHASE) ..................... 186
FERIVA 21-7 (75-1-175MG) (TABLET) .......................186
FERIVA FA (110 MG-1MG) (CAPSULE) .................... 186
FERRALET 90 (90-1-50 MG) (TABLET) .....................185
FERRIC AMCIT/LYS/VIT B COMP/FA....................... 184
FERRIC CITRATE............................................................91
FERRIPROX (100 MG/ML) (SOLUTION) ...................153
FERRIPROX (500 MG) (TABLET) ...............................153
FERROUS FUMARATE/FOLIC ACID..........................184
FERROUS SULFATE......................................................185
FERROUS SULFATE (220 (44)/5) (ELIXIR) (OTC)...........
FERROUS SULFATE (220 (44)/5) (SOLUTION) (OTC)
...............................................................................................
FERROUS SULFATE (300 MG/5ML) (LIQUID) (OTC)
...............................................................................................
FERROUS SULFATE (324(65)MG) (TABLET DR) (OTC)
...............................................................................................
FERROUS SULFATE (325(65) MG) (CAPSULE ER)
(OTC).....................................................................................
FERROUS SULFATE (325(65) MG) (TABLET DR)
(OTC).....................................................................................
FERROUS SULFATE (325(65) MG) (TABLET) (OTC)
...............................................................................................
FESOTERODINE FUMARATE..................................... 182
FETZIMA (120 MG) (CAP SA 24H) ...................... 23, 193
FETZIMA (20 MG) (CAP SA 24H) ........................ 23, 193
FETZIMA (20-40MG) (CAP24HDSPK) ................. 23, 193
FETZIMA (40 MG) (CAP SA 24H) ........................ 23, 193
FETZIMA (80 MG) (CAP SA 24H) ........................ 23, 193
FEXMID (7.5 MG) (TABLET) ...................................... 175
FIBRICOR (105 MG) (TABLET) .................................... 60
FIBRICOR (35 MG) (TABLET) ...................................... 60
FIDAXOMICIN...............................................................117
FINACEA (15 %) (FOAM) .............................................. 68
FINACEA (15 %) (GEL (GRAM)) .................................. 68
FINASTERIDE................................................................181
FINGOLIMOD HCL....................................................... 150
FIORICET (50-300-40) (CAPSULE) .............................154
FIORICET WITH CODEINE (50-300-30) (CAPSULE)
......................................................................................... 164
FIORICET WITH CODEINE (50-325-30) (CAPSULE)
......................................................................................... 164
FIORINAL (50-325-40) (CAPSULE) ............................ 154
FIORINAL WITH CODEINE #3 (30-50-325) (CAPSULE)
......................................................................................... 164
FLAGYL (250 MG) (TABLET) ..................................... 124
FLAGYL (375 MG) (CAPSULE) .................................. 124
FLAGYL (500 MG) (TABLET) ..................................... 124
FLAGYL ER (750 MG) (TABLET ER) .........................124
FLAREX (0.1 %) (DROPS SUSP) ...................................99
FLAVOXATE HCL..........................................................182
FLECAINIDE ACETATE..................................................41
FLECTOR (1.3 %) (PATCH TD12) ......................... 77, 193
FLEXERIL (10 MG) (TABLET) ....................................175
FLEXERIL (5 MG) (TABLET) ......................................175
FLOMAX (0.4 MG) (CAP ER 24H) ..............................181
FLONASE (50 MCG) (SPRAY SUSP) ............................ 12
FLORINEF (0.1 MG) (TABLET) .................................. 136
FLORIVA (0.25-400/1) (DROPS) .................................. 184
FLOVENT DISKUS (100 MCG) (BLST W/DEV) ..........17
FLOVENT DISKUS (250 MCG) (BLST W/DEV) ..........17
FLOVENT DISKUS (50 MCG) (BLST W/DEV) ............17
FLOVENT HFA (110 MCG) (AER W/ADAP) ................17
FLOVENT HFA (220 MCG) (AER W/ADAP) ................17
FLOVENT HFA (44 MCG) (AER W/ADAP) ..................17
FLOWTUSS (200-2.5/5) (SOLUTION) ...........................66
FLOXIN (0.3 %) (DROPS) .............................................. 91
FLOXIN (400 MG) (TABLET) ...................................... 119
FLUCONAZOLE............................................................ 121
FLUCYTOSINE...................................................... 121, 122
FLUDROCORTISONE ACETATE................................. 136
FLUMADINE (100 MG) (TABLET) ............................. 125
FLUNISOLIDE........................................................... 11, 16
FLUOCINOLONE ACETONIDE.....................................75
FLUOCINOLONE ACETONIDE OIL............................. 90
FLUOCINOLONE/SHOWER CAP..................................75
FLUOCINONIDE..............................................................75
FLUOCINONIDE/EMOLLIENT BASE.......................... 75
FLUORABON (0.25MG/0.6) (DROPS) ........................ 184
FLUOR-A-DAY (0.25(0.55)) (TAB CHEW) ................. 184
FLUOR-A-DAY (1MG(2.2MG)) (TAB CHEW) ........... 184
FLUOR-A-DAY (2.5 MG/ML) (DROPS) ...................... 184
FLUORIDE/IRON/VITAMINS A,C,D........................... 186
FLUORIDE/IRON/VITAMINS A,C,D (0.25 MG/ML)
(DROPS) ...............................................................................
FLUORITAB (0.125/DROP) (DROPS) ..........................184
FLUOROMETHOLONE...................................................99
FLUOROMETHOLONE ACETATE................................ 99
FLUOROPLEX (1 %) (CREAM (G)) .............................. 80
FLUOROURACIL.............................................................80
FLUOXETINE HCL..........................................................21
FLUOXETINE HCL (60 MG) (TABLET) ...........................
FLUOXYMESTERONE................................................. 107
FLUPHENAZINE HCL.................................................... 35
FLURA-DROPS (0.25MG/DRP) (DROPS) ...................184
FLURANDRENOLIDE.............................................. 75, 76
FLURAZEPAM HCL........................................................ 37
FLURBIPROFEN............................................................ 137
FLURBIPROFEN SODIUM............................................. 99
FLUTAMIDE...................................................................144
FLUTICASONE FUROATE................................. 12, 16, 17
FLUTICASONE PROPIONATE...........................12, 17, 76
FLUTICASONE/SALMETEROL...............................15, 16
FLUTICASONE/VILANTEROL......................................16
FLUVASTATIN SODIUM................................................ 58
FLUVOXAMINE MALEATE...........................................21
FML (0.1 %) (DROPS SUSP) .......................................... 99
FML FORTE (0.25 %) (DROPS SUSP) ...........................99
FML S.O.P. (0.1 %) (OINT. (G)) ......................................99
FOCALIN (10 MG) (TABLET) ....................................... 38
FOCALIN (2.5 MG) (TABLET) ...................................... 38
FOCALIN (5 MG) (TABLET) ......................................... 38
FOCALIN XR (10 MG) (CPBP 50-50) ............................38
FOCALIN XR (15 MG) (CPBP 50-50) ............................38
FOCALIN XR (20 MG) (CPBP 50-50) ............................38
FOCALIN XR (25 MG) (CPBP 50-50) ............................38
FOCALIN XR (30 MG) (CPBP 50-50) ............................38
FOCALIN XR (35 MG) (CPBP 50-50) ............................38
FOCALIN XR (40 MG) (CPBP 50-50) ............................38
FOCALIN XR (5 MG) (CPBP 50-50) ..............................38
FOLIC ACID................................................................... 184
FOLIC ACID (0.4 MG) (TABLET) (OTC)...........................
FOLIC ACID (0.8 MG) (TABLET) (OTC)...........................
FORADIL (12 MCG) (CAP W/DEV) ......................15, 193
FORFIVO XL (450 MG) (TAB ER 24H) .........................20
FORMOTEROL FUMARATE.......................................... 15
FORTAMET (1000 MG) (TAB ER 24) ............................86
FORTAMET (500 MG) (TAB ER 24) ..............................86
FORTEO (20MCG/DOSE) (PEN INJCTR) .....................93
FORTESTA (10 MG (2%)) (GEL MD PMP) .................108
FOSAMAX (10 MG) (TABLET) ..................................... 93
FOSAMAX (35 MG) (TABLET) ..................................... 93
FOSAMAX (40 MG) (TABLET) ..................................... 93
FOSAMAX (5 MG) (TABLET) ....................................... 93
FOSAMAX (70 MG) (TABLET) ..................................... 93
FOSAMAX (70 MG/75ML) (SOLUTION) .....................93
FOSAMAX PLUS D (70 MG-2800) (TABLET) ............. 93
FOSAMAX PLUS D (70 MG-5600) (TABLET) ............. 93
FOSAMPRENAVIR CALCIUM.....................................128
FOSFOMYCIN TROMETHAMINE.............................. 115
FOSINOPRIL SODIUM................................................... 46
FOSINOPRIL/HYDROCHLOROTHIAZIDE............ 42, 43
FOSRENOL (1000 MG) (POWD PACK) ........................ 91
FOSRENOL (1000 MG) (TAB CHEW) .......................... 91
FOSRENOL (500 MG) (TAB CHEW) ............................ 91
FOSRENOL (750 MG) (POWD PACK) .......................... 91
FOSRENOL (750 MG) (TAB CHEW) ............................ 91
FROVA (2.5 MG) (TABLET) ................................. 163, 193
FROVATRIPTAN SUCCINATE......................................163
FURADANTIN (25 MG/5 ML) (ORAL SUSP) ............ 117
FUROSEMIDE.................................................................. 54
FUSION PLUS (130-1.25MG) (CAPSULE) ................. 186
FUSION SPRINKLES (7MG-250MCG) (POWD PACK)
......................................................................................... 185
FUZEON (90 MG) (VIAL) ............................................ 126
FYCOMPA (0.5 MG/ML) (ORAL SUSP) ............. 173, 193
FYCOMPA (10 MG) (TABLET) ............................173, 193
FYCOMPA (12 MG) (TABLET) ............................173, 194
FYCOMPA (2 MG) (TABLET) ..............................173, 194
FYCOMPA (4 MG) (TABLET) ..............................173, 194
FYCOMPA (6 MG) (TABLET) ..............................173, 194
FYCOMPA (8 MG) (TABLET) ..............................173, 194
-GGABAPENTIN........................................................151, 170
GABAPENTIN ENACARBIL........................................ 151
GABITRIL (12 MG) (TABLET) .................................... 174
GABITRIL (16 MG) (TABLET) .................................... 174
GABITRIL (2 MG) (TABLET) ...................................... 174
GABITRIL (4 MG) (TABLET) ...................................... 174
GALANTAMINE HBR..................................................... 19
GALZIN (25 MG) (CAPSULE) .....................................153
GALZIN (50 MG) (CAPSULE) .....................................153
GANCICLOVIR.............................................................. 100
GARAMYCIN (0.3 %) (DROPS) .................................. 100
GARAMYCIN (0.3 %) (OINT. (G)) .............................. 100
GASTROCROM (20 MG/ML) (ORAL CONC) .............. 17
GATIFLOXACIN............................................................ 100
GAVILAX (17G/DOSE) (POWDER) (OTC)..................142
GEFITINIB......................................................................147
GELATIN........................................................................ 103
Sharp Health Plan: Covered California
GELFILM (25X50MM) (EACH) ................................... 103
GELNIQUE (10 %) (GEL PACKET) .....................182, 194
GEMFIBROZIL.................................................................60
GEMIFLOXACIN MESYLATE..................................... 119
GENERESS FE (0.8-25(24)) (TAB CHEW) ....................64
GENGRAF (50 MG) (CAPSULE) .................................112
GENTAMICIN SULFATE.........................................70, 100
GENTAMICIN SULFATE (0.1 %) (CREAM (G)) ..............
GENTAMICIN SULFATE (0.1 %) (OINT. (G)) ..................
GENTAMICIN/PREDNISOL AC.....................................98
GENVOYA (150-200-10) (TABLET) ............................ 129
GEODON (20 MG) (CAPSULE) .....................................34
GEODON (40 MG) (CAPSULE) .....................................34
GEODON (60 MG) (CAPSULE) .....................................34
GEODON (80 MG) (CAPSULE) .....................................34
GIALAX (17 G/SCOOP) (KIT) ..................................... 142
GIAZO (1.1 G) (TABLET) .............................................139
GILENYA (0.5 MG) (CAPSULE) ................................. 150
GILOTRIF (20 MG) (TABLET) .....................................146
GILOTRIF (30 MG) (TABLET) .....................................146
GILOTRIF (40 MG) (TABLET) .....................................146
GLATIRAMER ACETATE............................................. 150
GLEEVEC (100 MG) (TABLET) .................................. 147
GLEEVEC (400 MG) (TABLET) .................................. 147
GLEOSTINE (10 MG) (CAPSULE) ..............................144
GLEOSTINE (100 MG) (CAPSULE) ............................144
GLEOSTINE (40 MG) (CAPSULE) ..............................144
GLEOSTINE (5 MG) (CAPSULE) ................................144
GLIMEPIRIDE..................................................................85
GLIPIZIDE........................................................................ 85
GLIPIZIDE/METFORMIN HCL......................................86
GLUCAGON EMERGENCY KIT (1 MG) (KIT) ........... 88
GLUCAGON,HUMAN RECOMBINANT.......................88
GLUCOPHAGE (1000 MG) (TABLET) ..........................86
GLUCOPHAGE (500 MG) (TABLET) ............................86
GLUCOPHAGE (850 MG) (TABLET) ............................86
GLUCOPHAGE XR (500 MG) (TAB ER 24H) .............. 86
GLUCOPHAGE XR (750 MG) (TAB ER 24H) .............. 86
GLUCOTROL (10 MG) (TABLET) .................................85
GLUCOTROL (5 MG) (TABLET) ...................................85
GLUCOTROL XL (10 MG) (TAB ER 24) .......................85
GLUCOTROL XL (2.5 MG) (TAB ER 24) ......................85
GLUCOTROL XL (5 MG) (TAB ER 24) .........................85
GLUCOVANCE (1.25-250MG) (TABLET) .................... 87
GLUCOVANCE (2.5-500 MG) (TABLET) ..................... 87
GLUCOVANCE (5 MG-500MG) (TABLET) .................. 87
GLUMETZA (1000 MG) (TABERGR24H) .................... 86
GLUMETZA (500 MG) (TABERGR24H) ...................... 86
GLYBURIDE.....................................................................85
GLYBURIDE (1.25 MG) (TABLET) ...................................
GLYBURIDE (2.5 MG) (TABLET) .....................................
GLYBURIDE (5 MG) (TABLET) ........................................
GLYBURIDE,MICRONIZED...........................................85
GLYBURIDE/METFORMIN HCL...................................87
GLYCEROL PHENYLBUTYRATE............................... 141
GLYCOPYRROLATE..................................................... 178
GLYCOPYRROLATE/FORMOTEROL FUM................. 15
GLYDO (2 %) (JEL/PF APP) .........................................139
GLYNASE (1.5 MG) (TABLET) ..................................... 85
GLYNASE (3 MG) (TABLET) ........................................ 85
GLYNASE (6 MG) (TABLET) ........................................ 85
GLYSET (100 MG) (TABLET) ........................................84
GLYSET (25 MG) (TABLET) ..........................................84
GLYSET (50 MG) (TABLET) ..........................................84
GLYXAMBI (10 MG-5 MG) (TABLET) .................86, 194
GLYXAMBI (25 MG-5 MG) (TABLET) .................86, 194
GOLIMUMAB................................................................ 133
GOLYTELY (227.1-21.5) (POWD PACK) .................... 142
GOLYTELY (236-22.74G) (SOLN RECON) ................ 142
GONITRO (400 MCG) (POWD PACK) .......................... 62
GORDO-UREA (22 %) (OINT. (G)) ............................... 82
GORDO-UREA (40 %) (OINT. (G)) ............................... 79
GR POL-ORC/SW VER/RYE/KENT/TIM...................... 10
GRALISE (300 MG) (TAB ER 24H) ..................... 151, 194
GRALISE (300-600 MG) (TAB ER 24H) ......................151
GRALISE (600 MG) (TAB ER 24H) ............................. 151
GRANISETRON............................................................... 12
GRANISETRON HCL...................................................... 12
GRANIX (300MCG/0.5) (SYRINGE) ...........................106
GRANIX (480MCG/0.8) (SYRINGE) ...........................106
GRASS POLLEN-TIMOTHY, STANDARD....................10
GRASTEK (2800 UNIT) (TAB SUBL) ........................... 10
GRIFULVIN V (125 MG/5ML) (ORAL SUSP) ............ 122
GRIFULVIN V (500 MG) (TABLET) ............................122
GRISEOFULVIN ULTRAMICROSIZE......................... 122
GRISEOFULVIN, MICROSIZE..................................... 122
GRIS-PEG (125 MG) (TABLET) ...................................122
GRIS-PEG (250 MG) (TABLET) ...................................122
GUAIFENESIN/CODEINE PHOSPHATE.......................66
GUAIFENESIN/CODEINE PHOSPHATE (100-10MG/5)
(LIQUID) (OTC)...................................................................
Page 209 of 224
Index
GUAIFENESIN/CODEINE PHOSPHATE (200-10MG/5)
(LIQUID) (OTC)...................................................................
GUAIFENESIN/HYDROCODONE................................. 66
GUANFACINE HCL................................................... 38, 48
GUANIDINE (125 MG) (TABLET) .............................. 143
GUANIDINE HCL.......................................................... 143
GYNAZOLE 1 (2 %) (CRM/PF APP) ........................... 183
GYNOL II (3 %) (JELLY/APPL) (OTC).......................... 63
-HHALCINONIDE................................................................76
HALCION (0.125 MG) (TABLET) ..................................37
HALCION (0.25 MG) (TABLET) ....................................37
HALDOL (0.5 MG) (TABLET) ....................................... 34
HALDOL (1 MG) (TABLET) .......................................... 34
HALDOL (10 MG) (TABLET) ........................................ 34
HALDOL (2 MG) (TABLET) .......................................... 34
HALDOL (2 MG/ML) (ORAL CONC) ........................... 34
HALDOL (20 MG) (TABLET) ........................................ 34
HALDOL (5 MG) (TABLET) .......................................... 34
HALOBETASOL PROPIONATE..................................... 76
HALOBETASOL/LACTIC ACID.....................................76
HALOG (0.1 %) (CREAM (G)) .......................................76
HALOG (0.1 %) (OINT. (G)) ...........................................76
HALOPERIDOL............................................................... 34
HALOPERIDOL LACTATE............................................. 34
HALOTESTIN (10 MG) (TABLET) ..............................107
HARVONI (90MG-400MG) (TABLET) ........................129
HC/PRAMOXINE HCL/CHLOROXYLENOL................90
HECTOROL (0.5 MCG) (CAPSULE) ............................. 94
HECTOROL (1 MCG) (CAPSULE) ................................ 94
HECTOROL (2.5 MCG) (CAPSULE) ............................. 94
HEMANGEOL (4.28 MG/ML) (SOLUTION) ........ 50, 194
HEMATRON (50-1MG/5ML) (LIQUID) ...................... 184
HEMATRON-AF (150-50-1MG) (TAB ER 24H) ..........185
HEMOCYTE-F (106 MG-1MG) (TABLET) ................. 184
HEPSERA (10 MG) (TABLET) .....................................129
HETLIOZ (20 MG) (CAPSULE) .....................................36
HEXADROL (0.5 MG/5ML) (ELIXIR) ........................ 134
HEXALEN (50 MG) (CAPSULE) .................................144
HIPREX (1 G) (TABLET) ..............................................116
HIZENTRA (1 G/5 ML) (VIAL) ................................... 111
HIZENTRA (10 G/50 ML) (VIAL) ............................... 112
HIZENTRA (2 G/10 ML) (VIAL) ................................. 112
HIZENTRA (4 G/20 ML) (VIAL) ................................. 112
HOMATROPINE HBR....................................................103
HORIZANT (300 MG) (TABLET ER) .................. 151, 194
HORIZANT (600 MG) (TABLET ER) .................. 151, 194
HUMALOG (100/ML) (CARTRIDGE) ...........................89
HUMALOG (100/ML) (VIAL) ........................................89
HUMALOG KWIKPEN U-100 (100/ML) (INSULN PEN)
........................................................................................... 89
HUMALOG KWIKPEN U-200 (200/ML (3)) (INSULN
PEN) ................................................................................. 89
HUMALOG MIX 50-50 (50-50/ML) (VIAL) ................. 89
HUMALOG MIX 50-50 KWIKPEN (50-50/ML)
(INSULN PEN) ................................................................ 89
HUMALOG MIX 75-25 (75-25/ML) (VIAL) ................. 89
HUMALOG MIX 75-25 KWIKPEN (75-25/ML)
(INSULN PEN) ................................................................ 89
HUMATIN (250 MG) (CAPSULE) ............................... 124
HUMIRA (10MG/0.2ML) (SYRINGEKIT) .................. 133
HUMIRA (20MG/0.4ML) (SYRINGEKIT) .................. 133
HUMIRA (40MG/0.8ML) (SYRINGEKIT) .................. 133
HUMIRA PEDIATRIC CROHN'S (40MG/0.8ML)
(SYRINGEKIT) ..............................................................133
HUMIRA PEN (40MG/0.8ML) (PEN IJ KIT) ...............133
HUMIRA PEN CROHN-UC-HS STARTER
(40MG/0.8ML) (PEN IJ KIT) ........................................ 133
HUMIRA PEN PSORIASIS-UVEITIS (40MG/0.8ML)
(PEN IJ KIT) ...................................................................133
HUMULIN 70/30 KWIKPEN (70-30/ML) (INSULN PEN)
(OTC).................................................................................89
HUMULIN 70-30 (70-30/ML) (VIAL) (OTC)................. 89
HUMULIN N (100/ML) (VIAL) (OTC)........................... 90
HUMULIN N KWIKPEN (100/ML (3)) (INSULN PEN)
(OTC).................................................................................90
HUMULIN R (100/ML) (VIAL) (OTC)........................... 90
HUMULIN R U-500 (500/ML) (VIAL) ...........................90
HUMULIN R U-500 KWIKPEN (500/ML (3)) (INSULN
PEN) ................................................................................. 90
HYALURONIDASE, HUMAN RECOMB.......................81
HYCAMTIN (0.25 MG) (CAPSULE) ........................... 146
HYCAMTIN (1 MG) (CAPSULE) ................................ 146
HYCET (7.5-325/15) (SOLUTION) .............................. 158
HYCOFENIX (2.5-30-200) (SOLUTION) .............. 66, 194
HYDERGINE (1 MG) (TABLET) ................................... 63
HYDRALAZINE HCL......................................................49
HYDREA (500 MG) (CAPSULE) ................................. 144
HYDRO 35 (35 %) (FOAM) ............................................ 79
HYDRO 40 (40 %) (FOAM) ............................................ 79
HYDROCHLOROTHIAZIDE.......................................... 57
HYDROCHLOROTHIAZIDE (12.5 MG) (TABLET) .........
HYDROCODONE BIT/HOMATROP ME-BR.................66
HYDROCODONE BIT/HOMATROP ME-BR (5-1.5
MG/5) (SYRUP) ...................................................................
HYDROCODONE BITARTRATE..........................157, 158
HYDROCODONE/ACETAMINOPHEN........................158
HYDROCODONE/ACETAMINOPHEN (2.5-167/5)
(SOLUTION) ........................................................................
HYDROCODONE/CHLORPHEN P-STIREX................. 66
HYDROCODONE/CHLORPHENIRAMINE.................. 66
HYDROCODONE/CPM/PSEUDOEPHED..................... 65
HYDROCODONE/IBUPROFEN................................... 155
HYDROCODONE/PSEUDOEPHED/GUAIF..................66
HYDROCORTISONE................................. 73, 76, 134, 141
HYDROCORTISONE (1 %) (CREAM (G)) ........................
HYDROCORTISONE (1 %) (CRM/PE APP) .....................
HYDROCORTISONE (2.5 %) (CRM/PE APP) ..................
HYDROCORTISONE ACETATE...................................141
HYDROCORTISONE ACETATE (25 MG) (SUPP.RECT)
...............................................................................................
HYDROCORTISONE ACETATE (30 MG) (SUPP.RECT)
...............................................................................................
HYDROCORTISONE BUTYRATE................................. 76
HYDROCORTISONE BUTYRATE/EMOLL.................. 76
HYDROCORTISONE PROBUTATE............................... 76
HYDROCORTISONE VALERATE.................................. 76
HYDROCORTISONE VALERATE (0.2 %) (CREAM (G))
...............................................................................................
HYDROCORTISONE/IODOQUIN/ALOE#2.................. 68
HYDROCORTISONE/IODOQUINOL.............................68
HYDROCORTISONE/IODOQUINOL (1 %-1 %)
(CREAM (G)) .......................................................................
HYDROCORTISONE/IODOQUINOL/ALOE.................68
HYDROCORTISONE/LIDOCAINE/ALOE.................. 140
HYDROCORTISONE/PRAMOXINE...................... 80, 140
HYDROCORTISONE/PRAMOXINE/ALOE...................80
HYDROCORTISONE/PRAMOXINE/EMOLL............... 80
HYDRODIURIL (25 MG) (TABLET) ............................. 57
HYDRODIURIL (50 MG) (TABLET) ............................. 57
HYDROMET (5-1.5 MG/5) (SYRUP) .............................66
HYDROMORPHONE HCL....................................158, 159
HYDROXYAMPHETAMINE/TROPICAMIDE.............103
HYDROXYCHLOROQUINE SULFATE....................... 125
HYDROXYPROPYL CELLULOSE...............................103
HYDROXYUREA...................................................107, 144
HYDROXYZINE HCL......................................................10
HYDROXYZINE PAMOATE........................................... 10
HYGROTON (25 MG) (TABLET) ...................................57
HYGROTON (50 MG) (TABLET) ...................................57
HYOSCYAMINE SULFATE...........................................178
HYOSYNE (0.125MG/ML) (DROPS) ...........................178
HYOSYNE (125MCG/5ML) (ELIXIR) .........................178
HYQVIA (10 G/100ML) (VIAL) ...................................111
HYQVIA (2.5G/25ML) (VIAL) .....................................111
HYQVIA (20 G/200ML) (VIAL) ...................................111
HYQVIA (30 G/300ML) (VIAL) ...................................111
HYQVIA (5 G/50 ML) (VIAL) ......................................111
HYQVIA HY COMPONENT (1600/10 ML) (VIAL) ......
81
HYQVIA HY COMPONENT (200/1.25ML) (VIAL) ......
81
HYQVIA HY COMPONENT (2400/15 ML) (VIAL) ......
81
HYQVIA HY COMPONENT (400/2.5 ML) (VIAL) ......
81
HYQVIA HY COMPONENT (800/5 ML) (VIAL) .........81
HYSINGLA ER (100 MG) (TAB ER 24H) ................... 157
HYSINGLA ER (120 MG) (TAB ER 24H) ................... 157
HYSINGLA ER (20 MG) (TAB ER 24H) ..................... 157
HYSINGLA ER (30 MG) (TAB ER 24H) ..................... 157
HYSINGLA ER (40 MG) (TAB ER 24H) ..................... 157
HYSINGLA ER (60 MG) (TAB ER 24H) ..................... 157
HYSINGLA ER (80 MG) (TAB ER 24H) ..................... 157
HYTONE (2.5 %) (OINT. (G)) ........................................ 76
HYTRIN (1 MG) (CAPSULE) .........................................44
HYTRIN (10 MG) (CAPSULE) .......................................44
HYTRIN (2 MG) (CAPSULE) .........................................44
HYTRIN (5 MG) (CAPSULE) .........................................44
HYZAAR (100-12.5MG) (TABLET) ...............................45
HYZAAR (100MG-25MG) (TABLET) ........................... 45
HYZAAR (50-12.5 MG) (TABLET) ................................45
HYZYD (100 MG) (TABLET) .......................................123
HYZYD (300 MG) (TABLET) .......................................123
-IIBANDRONATE SODIUM...............................................94
IBRANCE (100 MG) (CAPSULE) ................................ 148
IBRANCE (125 MG) (CAPSULE) ................................ 148
IBRANCE (75 MG) (CAPSULE) .................................. 148
IBRUTINIB..................................................................... 147
IBUDONE (10MG-200MG) (TABLET) ........................155
IBUDONE (5MG-200MG) (TABLET) ..........................155
Sharp Health Plan: Covered California
IBUPROFEN................................................................... 137
IBUPROFEN/FAMOTIDINE..........................................136
IBUPROFEN/OXYCODONE HCL................................ 155
ICLUSIG (15 MG) (TABLET) .......................................148
ICLUSIG (45 MG) (TABLET) .......................................148
ICOSAPENT ETHYL....................................................... 60
IDELALISIB................................................................... 147
IGG/HYALURONIDASE,RECOMBINANT................. 111
ILEVRO (0.3 %) (DROPS SUSP) ..................................100
ILOPERIDONE...........................................................31, 32
ILOPROST TROMETHAMINE....................................... 56
ILOTYCIN (5 MG/G) (OINT. (G)) ................................ 100
IMATINIB MESYLATE................................................. 147
IMBRUVICA (140 MG) (CAPSULE) ........................... 147
IMDUR (120 MG) (TAB ER 24H) ...................................62
IMDUR (30 MG) (TAB ER 24H) .....................................62
IMDUR (60 MG) (TAB ER 24H) .....................................62
IMIPRAMINE HCL.......................................................... 25
IMIPRAMINE PAMOATE................................................25
IMIQUIMOD...................................................................112
IMITREX (100 MG) (TABLET) .................................... 163
IMITREX (25 MG) (TABLET) ...................................... 163
IMITREX (4 MG/0.5ML) (CARTRIDGE) .................... 163
IMITREX (4 MG/0.5ML) (PEN INJCTR) .....................164
IMITREX (50 MG) (TABLET) ...................................... 164
IMITREX (6 MG/0.5ML) (CARTRIDGE) .................... 164
IMITREX (6 MG/0.5ML) (PEN INJCTR) .....................164
IMITREX (6 MG/0.5ML) (SYRINGE) ......................... 164
IMITREX (6 MG/0.5ML) (VIAL) ................................. 164
IMMUN GLOB G(IGG)/PRO/IGA 0-50................ 111, 112
IMODIUM (2 MG) (CAPSULE) ................................... 141
IMPAVIDO (50 MG) (CAPSULE) .................................125
IMURAN (50 MG) (TABLET) ...................................... 112
INCRELEX (10 MG/ML) (VIAL) ................................... 94
INCRUSE ELLIPTA (62.5 MCG) (BLST W/DEV) ...... 13,
194
INDACATEROL MALEATE............................................ 15
INDAPAMIDE...................................................................57
INDERAL (10 MG) (TABLET) ....................................... 50
INDERAL (20 MG) (TABLET) ....................................... 50
INDERAL (20 MG/5 ML) (SOLUTION) ........................50
INDERAL (40 MG) (TABLET) ....................................... 50
INDERAL (40MG/5ML) (SOLUTION) ..........................50
INDERAL (60 MG) (TABLET) ....................................... 50
INDERAL (80 MG) (TABLET) ....................................... 50
INDERAL LA (120 MG) (CAP SA 24H) ........................50
INDERAL LA (160 MG) (CAP SA 24H) ........................50
INDERAL LA (60 MG) (CAP SA 24H) ..........................50
INDERAL LA (80 MG) (CAP SA 24H) ..........................50
INDERAL XL (120 MG) (CAP ER 24H) ........................50
INDERAL XL (80 MG) (CAP ER 24H) ..........................50
INDERIDE-40/25 (40 MG-25MG) (TABLET) ............... 51
INDERIDE-80/25 (80 MG-25MG) (TABLET) ............... 51
INDINAVIR SULFATE................................................... 128
INDOCIN (25 MG) (CAPSULE) ...................................137
INDOCIN (25 MG/5 ML) (ORAL SUSP) ..................... 137
INDOCIN (50 MG) (CAPSULE) ...................................138
INDOCIN (50 MG) (SUPP.RECT) ................................ 138
INDOCIN (75 MG) (CAPSULE ER) .............................138
INDOMETHACIN.................................................. 137, 138
INDOMETHACIN, SUBMICRONIZED........................138
INGENOL MEBUTATE....................................................80
INHALER, ASSIST DEVICES.........................................18
INHALER,ASSIST DEVICE,ACCESORY......................18
INLYTA (1 MG) (TABLET) .......................................... 146
INLYTA (5 MG) (TABLET) .......................................... 146
INNOPRAN XL (120 MG) (CAP ER 24H) .....................50
INNOPRAN XL (80 MG) (CAP ER 24H) .......................50
INSPRA (25 MG) (TABLET) .......................................... 55
INSPRA (50 MG) (TABLET) .......................................... 55
INSULIN ASPART............................................................88
INSULIN ASPART PROT/INSULN ASP .........................88
INSULIN DEGLUDEC.....................................................88
INSULIN DETEMIR.........................................................89
INSULIN GLARGINE,HUM.REC.ANLOG....................89
INSULIN GLULISINE..................................................... 89
INSULIN LISPRO.............................................................89
INSULIN LISPRO PROTAMIN/LISPRO.........................89
INSULIN NPH HUM/REG INSULIN HM...................... 89
INSULIN NPH HUMAN ISOPHANE............................. 90
INSULIN REGULAR, HUMAN...................................... 90
INSULIN SYRINGE....................................................... 143
INTEGRA F (125-1-40-3) (CAPSULE) ........................ 185
INTEGRA PLUS (125MG-1MG) (CAPSULE) .............185
INTELENCE (100 MG) (TABLET) ...............................127
INTELENCE (200 MG) (TABLET) ...............................127
INTELENCE (25 MG) (TABLET) .................................127
INTERFERON ALFA-2B,RECOMB..............................112
INTERFERON BETA-1A............................................... 150
INTERFERON BETA-1A/ALBUMIN............................150
INTERFERON BETA-1B................................................151
INTERMEZZO (1.75 MG) (TAB SUBL) ................ 38, 194
Page 210 of 224
Index
INTERMEZZO (3.5 MG) (TAB SUBL) .................. 38, 194
INTRON A (10MM UNIT) (VIAL) ............................... 112
INTRON A (10MM/ML) (VIAL) .................................. 112
INTRON A (18MM UNIT) (VIAL) ............................... 112
INTRON A (50MM UNIT) (VIAL) ............................... 112
INTRON A (6MMUNIT/ML) (VIAL) ...........................112
INTUNIV (1 MG) (TAB ER 24H) ................................... 38
INTUNIV (2 MG) (TAB ER 24H) ................................... 38
INTUNIV (3 MG) (TAB ER 24H) ................................... 38
INTUNIV (4 MG) (TAB ER 24H) ................................... 38
INVANZ (1 G) (VIAL PORT) ........................................114
INVANZ (1 G) (VIAL) ...................................................114
INVEGA (1.5 MG) (TAB ER 24) ............................ 32, 194
INVEGA (3 MG) (TAB ER 24) ............................... 33, 194
INVEGA (6 MG) (TAB ER 24) ............................... 33, 194
INVEGA (9 MG) (TAB ER 24) ............................... 33, 194
INVIRASE (200 MG) (CAPSULE) ............................... 129
INVIRASE (500 MG) (TABLET) .................................. 129
INVOKAMET (150-1000MG) (TABLET) ...................... 87
INVOKAMET (150-500 MG) (TABLET) ....................... 87
INVOKAMET (50-1000 MG) (TABLET) ....................... 87
INVOKAMET (50MG-500MG) (TABLET) ....................87
INVOKAMET XR (150-1000MG) (TAB BP 24H) ......... 87
INVOKAMET XR (150-500 MG) (TAB BP 24H) .......... 87
INVOKAMET XR (50-1000 MG) (TAB BP 24H) .......... 87
INVOKAMET XR (50MG-500MG) (TAB BP 24H) .......87
INVOKANA (100 MG) (TABLET) ................................. 84
INVOKANA (300 MG) (TABLET) ................................. 84
IODOFLEX (0.9 %) (MED. PAD) ................................... 68
IODOQUINOL/ALOE POLYSACCHAR #1................... 68
IODOSORB (0.9 %) (GEL (GRAM)) ..............................68
IOPIDINE (0.5 %) (DROPS) ..........................................101
IOPIDINE (1 %) (DROPERETTE) ................................ 101
IPRATROPIUM BROMIDE......................................13, 152
IPRATROPIUM/ALBUTEROL SULFATE...................... 15
IRBESARTAN...................................................................47
IRBESARTAN/HYDROCHLOROTHIAZIDE.................45
IRENKA (40 MG) (CAPSULE DR) ................................ 23
IRESSA (250 MG) (TABLET) .......................................147
IRON ASPGLY,PS/C/B12/FA/CA/SUC..........................185
IRON ASPGLY,PS/C/B12/FA/CA/SUC (150-25-1)
(CAPSULE) ..........................................................................
IRON ASPGLY/C/B12/FA/CA-TH/SUC........................185
IRON ASPGLY/C/B12/FA/CA-TH/SUC (70-150-1MG)
(TABLET) .............................................................................
IRON BG,PS/FOLIC/B,C NO.12/SUC...........................185
IRON BG,PS/VITC/B12/FA/CALCIUM........................ 185
IRON BG,PS/VITC/B12/FA/CALCIUM (150-60-1)
(CAPSULE) ..........................................................................
IRON CARB,GL/FA/B12/C/DOCUSATE...................... 185
IRON CARB/FA#9/VIT C/D3/B6/B12...........................185
IRON CARB/FA#9/VIT C/D3/B6/B12 (125-1-170)
(TABLET) .............................................................................
IRON FM,PS NO.1/FOLIC/MV NO.18..........................185
IRON FUM, PS/FA/VIT C/L. CASEI............................. 185
IRON FUM,AG/C/B12/FOLIC/CA/SUC........................185
IRON FUM,AG/C/B12/FOLIC/CA/SUC (151-60-1MG)
(TABLET) .............................................................................
IRON FUM,PS/FA/VIT B WITH C #9........................... 185
IRON FUM,PS/FOLIC ACID/VITC/B3......................... 185
IRON FUM/DOCUSATE/FA/BCOMP,C........................185
IRON FUM/DOCUSATE/FA/BCOMP,C (66.6-1MG)
(TABLET) .............................................................................
IRON FUM/VIT C/B12-IF/FA........................................ 185
IRON FUM/VIT C/B12-IF/FA (110-0.5MG) (CAPSULE)
...............................................................................................
IRON FUM/VIT C/VIT B12/STOMC............................ 185
IRON FUM/VIT C/VIT B12/STOMC (200-250-10)
(CAPSULE) ..........................................................................
IRON FUMARATE/VIT C/VIT B12/FA........................ 185
IRON FUMARATE/VIT C/VIT B12/FA (200-250MG)
(CAPSULE) ..........................................................................
IRON FUMARATE/VIT C/VIT B12/FA (460-60MG)
(CAPSULE) ..........................................................................
IRON GLY,FUM/C/B12/ME-THFOLATE..................... 185
IRON HEME POLYPEPTIDE/FOLIC AC..................... 185
IRON POLYSAC/IRON HEME/FA/B12........................ 185
IRON PS CMPLX/VIT B12/FA...................................... 185
IRON, CARBONYL/FA/C/B-6/B12/ZN.........................185
IRON,CARB/DSS/B12IF/FA/MV-MN........................... 185
IRON,CARB/FA#6/MV, MIN NO.40............................. 185
IRON,CARB/FA#6/MV, MIN NO.41............................. 186
IRON,CARBONYL/FA/MULTIVIT-MIN...................... 186
IRON,CARBONYL/VIT C/VIT B12/FA........................186
IRON,CARBONYL/VIT C/VIT B12/FA (100-250-1)
(TABLET) .............................................................................
IRON,FM,PS/FOLIC/B,C18/L.CASEI........................... 186
IRON/C/FOLIC ACD/MV CMB11/CALC.....................186
IRON/C/FOLIC ACD/MV CMB11/CALC (151-200-1)
(TABLET) .............................................................................
IRON/FA#1/C/B12/BIOT/COPPR/DSS..........................186
IRON/FA#1/VIT C/B12/ZN/DSS/SUC...........................186
IRON/FA/B12/C/DOCUSATE SODIUM....................... 186
IRON/FA/B12/C/DOCUSATE SODIUM (90-1-50 MG)
(TABLET) .............................................................................
IRON/FA/VIT BCOMP,C/MINERALS.......................... 186
IRON/FA/VIT BCOMP,C/MINERALS (106 MG-1MG)
(TABLET) .............................................................................
IRON/FOLIC ACID/C/B12/BIOTIN.............................. 186
IRON/MFOLATE/B12/C/BIOT/ZN/DSS....................... 186
IROSPAN (65-1MG(24)) (TABLET) ............................. 185
ISAVUCONAZONIUM SULFATE.................................122
ISENTRESS (100 MG) (POWD PACK) ........................129
ISENTRESS (100 MG) (TAB CHEW) .......................... 129
ISENTRESS (25 MG) (TAB CHEW) ............................ 129
ISENTRESS (400 MG) (TABLET) ................................129
ISOCARBOXAZID...........................................................20
ISOCHRON (40 MG) (TABLET ER) .............................. 61
ISOMETHEPT/DICHLPHN/ACETAMINOP................ 163
ISOMETHEPTEN/CAF/ACETAMINOPHEN............... 163
ISONIAZID..................................................................... 123
ISOPTO CARPINE (1 %) (DROPS) ..............................102
ISOPTO CARPINE (2 %) (DROPS) ..............................102
ISOPTO CARPINE (4 %) (DROPS) ..............................102
ISOPTO HOMATROPINE (5 %) (DROPS) .................. 103
ISORDIL (10 MG) (TABLET) .........................................62
ISORDIL (20 MG) (TABLET) .........................................62
ISORDIL (30 MG) (TABLET) .........................................62
ISORDIL (40 MG) (TABLET) .........................................62
ISORDIL TITRADOSE (5 MG) (TABLET) ....................62
ISOSORB DINIT/HYDRALAZINE HCL........................58
ISOSORBIDE DINITRATE........................................61, 62
ISOSORBIDE MONONITRATE......................................62
ISOTRETINOIN................................................................67
ISOXSUPRINE HCL........................................................ 63
ISOXSUPRINE HCL (20 MG) (TABLET) ..........................
ISRADIPINE..................................................................... 53
ISTALOL (0.5 %) (DROP DAILY) ................................ 102
ITRACONAZOLE...........................................................122
IVABRADINE HCL.......................................................... 61
IVACAFTOR................................................................... 154
IVERMECTIN.....................................................68, 71, 124
IXAZOMIB CITRATE....................................................147
-JJADENU (180 MG) (TABLET) ..................................... 153
JADENU (360 MG) (TABLET) ..................................... 153
JADENU (90 MG) (TABLET) ....................................... 153
JAKAFI (10 MG) (TABLET) ......................................... 145
JAKAFI (15 MG) (TABLET) ......................................... 145
JAKAFI (20 MG) (TABLET) ......................................... 145
JAKAFI (25 MG) (TABLET) ......................................... 145
JAKAFI (5 MG) (TABLET) ........................................... 145
JALYN (0.5-0.4 MG) (CPMP 24HR) ............................. 181
JANUMET (50-1000 MG) (TABLET) .....................83, 194
JANUMET (50MG-500MG) (TABLET) ................. 83, 194
JANUMET XR (100-1000MG) (TBMP 24HR) .......83, 194
JANUMET XR (50-1000 MG) (TBMP 24HR) ........83, 194
JANUMET XR (50MG-500MG) (TBMP 24HR) ...... 83,
194
JANUVIA (100 MG) (TABLET) ............................. 85, 194
JANUVIA (25 MG) (TABLET) ............................... 85, 194
JANUVIA (50 MG) (TABLET) ............................... 85, 194
JARDIANCE (10 MG) (TABLET) ...........................84, 194
JARDIANCE (25 MG) (TABLET) ...........................84, 194
JENTADUETO (2.5-1000MG) (TABLET) .............. 83, 194
JENTADUETO (2.5-500 MG) (TABLET) ............... 83, 194
JENTADUETO (2.5-850 MG) (TABLET) ............... 83, 194
JENTADUETO XR (2.5-1000MG) (TAB BP 24H) ...... 83,
194
JENTADUETO XR (5MG-1000MG) (TAB BP 24H) ......
83,
195
JEVANTIQUE (1MG-5MCG) (TABLET) ..................... 111
JEVANTIQUE LO (0.5MG-2.5) (TABLET) ..................111
JUBLIA (10 %) (SOL W/APPL) ......................................70
JUXTAPID (10 MG) (CAPSULE) ................................... 59
JUXTAPID (20 MG) (CAPSULE) ................................... 59
JUXTAPID (30 MG) (CAPSULE) ................................... 59
JUXTAPID (40 MG) (CAPSULE) ................................... 59
JUXTAPID (5 MG) (CAPSULE) ..................................... 59
JUXTAPID (60 MG) (CAPSULE) ................................... 59
-KKADIAN (10 MG) (CAP ER PEL) ........................159, 195
KADIAN (100 MG) (CAP ER PEL) ......................159, 195
KADIAN (20 MG) (CAP ER PEL) ........................159, 195
KADIAN (200 MG) (CAP ER PEL) ......................159, 195
KADIAN (30 MG) (CAP ER PEL) ........................159, 195
KADIAN (40 MG) (CAP ER PEL) ........................159, 195
KADIAN (50 MG) (CAP ER PEL) ........................159, 195
KADIAN (60 MG) (CAP ER PEL) ........................159, 195
KADIAN (80 MG) (CAP ER PEL) ........................159, 195
KALETRA (100MG-25MG) (TABLET) ....................... 128
KALETRA (200MG-50MG) (TABLET) ....................... 128
KALETRA (400-100/5) (SOLUTION) ..........................128
Sharp Health Plan: Covered California
KALYDECO (150 MG) (TABLET) ............................... 154
KALYDECO (50 MG) (GRAN PACK) ......................... 154
KALYDECO (75 MG) (GRAN PACK) ......................... 154
KAPVAY (0.1 MG) (TAB ER 12H) ................................. 38
KARBINAL ER (4 MG/5 ML) (SUS ER 12H) ............... 10
KAZANO (12.5-1000) (TABLET) ...................................82
KAZANO (12.5-500MG) (TABLET) .............................. 82
KEFLEX (125 MG/5ML) (SUSP RECON) ................... 114
KEFLEX (250 MG) (CAPSULE) .................................. 114
KEFLEX (250 MG) (TABLET) ..................................... 114
KEFLEX (250 MG/5ML) (SUSP RECON) ................... 114
KEFLEX (500 MG) (CAPSULE) .................................. 114
KEFLEX (500 MG) (TABLET) ..................................... 114
KEFLEX (750 MG) (CAPSULE) .................................. 114
KENALOG (0.025 %) (CREAM (G)) ..............................77
KENALOG (0.025 %) (LOTION) ....................................77
KENALOG (0.025 %) (OINT. (G)) ..................................77
KENALOG (0.1 %) (CREAM (G)) ..................................77
KENALOG (0.1 %) (LOTION) ........................................77
KENALOG (0.1 %) (OINT. (G)) ......................................77
KENALOG (0.147MG/G) (AEROSOL) .......................... 77
KENALOG (0.5 %) (CREAM (G)) ..................................77
KENALOG (0.5 %) (OINT. (G)) ......................................77
KENALOG IN ORABASE (0.1 %) (PASTE (G)) ......... 151
KEPPRA (100 MG/ML) (SOLUTION) ......................... 172
KEPPRA (1000 MG) (TABLET) ................................... 172
KEPPRA (250 MG) (TABLET) ..................................... 172
KEPPRA (500 MG) (TABLET) ..................................... 172
KEPPRA (500 MG/5ML) (SOLUTION) ....................... 172
KEPPRA (750 MG) (TABLET) ..................................... 172
KEPPRA XR (500 MG) (TAB ER 24H) ........................ 172
KEPPRA XR (750 MG) (TAB ER 24H) ........................ 172
KERAFOAM (30 %) (FOAM) ......................................... 79
KERAFOAM (42 %) (FOAM) ......................................... 79
KERALAC (47 %) (CREAM (G)) ................................... 79
KERALYT SCALP (6 %-6 %) (KT SHM GEL) ............. 78
KERLONE (10 MG) (TABLET) ...................................... 49
KERLONE (20 MG) (TABLET) ...................................... 49
KERYDIN (5 %) (SOL W/APPL) ....................................71
KETEK (300 MG) (TABLET) ....................................... 116
KETEK (400 MG) (TABLET) ....................................... 116
KETOCONAZOLE............................................. 70, 71, 122
KETOPROFEN................................................................138
KETOROLAC TROMETHAMINE.................. 99, 136, 138
KETOROLAC TROMETHAMINE/PF.............................99
KEVEYIS (50 MG) (TABLET) ..................................... 175
KHEDEZLA (100 MG) (TAB ER 24) ..................... 22, 195
KHEDEZLA (50 MG) (TAB ER 24) ....................... 22, 195
KINERET (100MG/0.67) (SYRINGE) .......................... 133
KITABIS PAK (300 MG/5ML) (AMPUL-NEB) ........... 123
KLARON (10 %) (SUSPENSION) .................................. 68
KLONOPIN (0.5 MG) (TABLET) ................................. 169
KLONOPIN (1 MG) (TABLET) .................................... 169
KLONOPIN (2 MG) (TABLET) .................................... 169
KLONOPIN RAPIDLY DISINTEGRATING (0.125 MG)
(TAB RAPDIS) ...............................................................169
KLONOPIN RAPIDLY DISINTEGRATING (0.25 MG)
(TAB RAPDIS) ...............................................................169
KLONOPIN RAPIDLY DISINTEGRATING (0.5 MG)
(TAB RAPDIS) ...............................................................169
KLONOPIN RAPIDLY DISINTEGRATING (1 MG) (TAB
RAPDIS) .........................................................................169
KLONOPIN RAPIDLY DISINTEGRATING (2 MG) (TAB
RAPDIS) .........................................................................169
KLOR-CON (20 MEQ) (PACKET) ................................. 92
KLOR-CON (25 MEQ) (PACKET) ................................. 92
KLOR-CON 10 (10 MEQ) (TABLET ER) ...................... 92
KLOR-CON 8 (8 MEQ) (TABLET ER) .......................... 92
KLOR-CON-EF (25 MEQ) (TABLET EFF) ....................92
KOMBIGLYZE XR (2.5-1000MG) (TBMP 24HR) ...... 83,
195
KOMBIGLYZE XR (5 MG-500MG) (TBMP 24HR) ......
83,
195
KOMBIGLYZE XR (5MG-1000MG) (TBMP 24HR) ......
83,
195
KORLYM (300 MG) (TABLET) ......................................87
K-PHOS NEUTRAL (250 MG) (TABLET) .................. 181
K-PHOS NO.2 (700-305MG) (TABLET) ...................... 181
K-PHOS ORIGINAL (500 MG) (TABLET SOL) ......... 182
KRISTALOSE (10 G) (PACKET) .................................. 142
KRISTALOSE (20 G) (PACKET) .................................. 142
K-SOL (20MEQ/15ML) (LIQUID) ................................. 92
K-SOL (40MEQ/15ML) (LIQUID) ................................. 92
K-TAB ER (10 MEQ) (TABLET ER) .............................. 92
K-TAB ER (20 MEQ) (TABLET ER) .............................. 92
K-TAB ER (8 MEQ) (TABLET ER) ................................ 92
KUVAN (100 MG) (POWD PACK) ...............................153
KUVAN (100 MG) (TABLET SOL) .............................. 153
KUVAN (500 MG) (POWD PACK) ...............................153
KWELL (1 %) (SHAMPOO) ........................................... 71
KYTRIL (1 MG) (TABLET) ............................................ 12
Page 211 of 224
Index
-LLABETALOL HCL........................................................... 43
LAC-HYDRIN (12 %) (CREAM (G)) ............................. 78
LAC-HYDRIN (12 %) (LOTION) ................................... 78
LACOSAMIDE....................................................... 170, 171
LACRISERT (5 MG) (INSERT) .................................... 103
LACTIC ACID.................................................................. 78
LACTIC ACID (10 %) (CREAM (G)) .................................
LACTIC ACID (10 %) (LOTION) .......................................
LACTOCAL-F (65 MG-1 MG) (TABLET) ................... 187
LACTULOSE.......................................................... 141, 142
LAMICTAL (100 MG) (TABLET) ................................ 171
LAMICTAL (150 MG) (TABLET) ................................ 171
LAMICTAL (200 MG) (TABLET) ................................ 171
LAMICTAL (25 MG) (TABLET) .................................. 171
LAMICTAL (25 MG) (TB CHW DSP) ......................... 171
LAMICTAL (5 MG) (TB CHW DSP) ........................... 171
LAMICTAL (BLUE) (25MG (35)) (TAB DS PK) .........171
LAMICTAL (GREEN) (25(84)-100) (TAB DS PK) ......
171
LAMICTAL (ORANGE) (25(42)-100) (TAB DS PK) ......
171
LAMICTAL ODT (100 MG) (TAB RAPDIS) ............... 171
LAMICTAL ODT (200 MG) (TAB RAPDIS) ............... 171
LAMICTAL ODT (25 MG) (TAB RAPDIS) ................. 171
LAMICTAL ODT (50 MG) (TAB RAPDIS) ................. 171
LAMICTAL ODT (BLUE) (25(21)-50) (TB RD DSPK)
......................................................................................... 171
LAMICTAL ODT (GREEN) (50(42)-100) (TB RD DSPK)
......................................................................................... 171
LAMICTAL ODT (ORANGE) (25-50-100) (TB RD
DSPK) .............................................................................172
LAMICTAL XR (100 MG) (TAB ER 24) ...................... 172
LAMICTAL XR (200 MG) (TAB ER 24) ...................... 172
LAMICTAL XR (25 MG) (TAB ER 24) ........................ 172
LAMICTAL XR (250 MG) (TAB ER 24) ...................... 172
LAMICTAL XR (300 MG) (TAB ER 24) ...................... 172
LAMICTAL XR (50 MG) (TAB ER 24) ........................ 172
LAMICTAL XR (BLUE) (25(21)-50) (TB ER DSPK) ......
172
LAMICTAL XR (GREEN) (50-100-200) (TB ER DSPK)
......................................................................................... 172
LAMICTAL XR (ORANGE) (25-50-100) (TB ER DSPK)
......................................................................................... 172
LAMISIL (250 MG) (TABLET) .................................... 122
LAMIVUDINE........................................................127, 130
LAMIVUDINE/ZIDOVUDINE...................................... 126
LAMOTRIGINE......................................................171, 172
LANOXIN (125 MCG) (TABLET) ..................................41
LANOXIN (187.5 MCG) (TABLET) ...............................41
LANOXIN (250 MCG) (TABLET) ..................................41
LANOXIN (62.5 MCG) (TABLET) .................................41
LANREOTIDE ACETATE..............................................153
LANSOPRAZOLE.......................................................... 180
LANSOPRAZOLE/AMOXICILN/CLARITH................179
LANTHANUM CARBONATE.........................................91
LANTUS (100/ML) (VIAL) .............................................89
LANTUS SOLOSTAR (100/ML (3)) (INSULN PEN) ......
89
LAPATINIB DITOSYLATE............................................148
LARIAM (250 MG) (TABLET) .....................................125
LASIX (10 MG/ML) (SOLUTION) .................................54
LASIX (20 MG) (TABLET) .............................................54
LASIX (40 MG) (TABLET) .............................................54
LASIX (40MG/5ML) (SOLUTION) ................................54
LASIX (80 MG) (TABLET) .............................................54
LASTACAFT (0.25 %) (DROPS) ............................ 99, 195
LATANOPROST............................................................. 102
LATUDA (120 MG) (TABLET) ...............................32, 195
LATUDA (20 MG) (TABLET) .................................32, 195
LATUDA (40 MG) (TABLET) .................................32, 195
LATUDA (60 MG) (TABLET) .................................32, 195
LATUDA (80 MG) (TABLET) .................................32, 195
LAZANDA (100MCG/SPR) (SPRAY/PUMP) .............. 157
LAZANDA (300MCG/SPR) (SPRAY/PUMP) .............. 157
LAZANDA (400MCG/SPR) (SPRAY/PUMP) .............. 157
LDO PLUS (4 %) (GEL W/PUMP) ................................. 81
LEDIPASVIR/SOFOSBUVIR........................................ 129
LEFLUNOMIDE.............................................................134
LENALIDOMIDE........................................................... 146
LENVATINIB MESYLATE............................................ 148
LENVIMA (10 MG/DAY) (CAPSULE) ........................ 148
LENVIMA (14 MG/DAY) (CAPSULE) ........................ 148
LENVIMA (18 MG/DAY) (CAPSULE) ........................ 148
LENVIMA (20 MG/DAY) (CAPSULE) ........................ 148
LENVIMA (24 MG/DAY) (CAPSULE) ........................ 148
LENVIMA (8 MG/DAY) (CAPSULE) .......................... 148
LESCOL (20 MG) (CAPSULE) .......................................58
LESCOL (40 MG) (CAPSULE) .......................................58
LESCOL XL (80 MG) (TAB ER 24H) .................... 58, 195
LESINURAD...................................................................103
LETAIRIS (10 MG) (TABLET) ....................................... 56
LETAIRIS (5 MG) (TABLET) ......................................... 56
LETROZOLE.................................................................. 145
LEUCOVORIN CALCIUM............................................ 149
LEUKERAN (2 MG) (TABLET) ................................... 144
LEVALBUTEROL HCL................................................... 14
LEVALBUTEROL TARTRATE........................................15
LEVAQUIN (250 MG) (TABLET) .................................119
LEVAQUIN (250MG/10ML) (SOLUTION) ..................119
LEVAQUIN (500 MG) (TABLET) .................................119
LEVAQUIN (750 MG) (TABLET) .................................119
LEVATOL (20 MG) (TABLET) ....................................... 50
LEVBID (0.375 MG) (TAB ER 12H) ............................ 178
LEVEMIR (100/ML) (VIAL) ...................................89, 195
LEVEMIR FLEXTOUCH (100/ML (3)) (INSULN PEN)
................................................................................... 89, 195
LEVETIRACETAM........................................................ 172
LEVOBUNOLOL HCL...................................................102
LEVOCARNITINE......................................................... 152
LEVOCARNITINE (330 MG) (TABLET) ...........................
LEVOCARNITINE (WITH SUGAR).............................152
LEVOCARNITINE (WITH SUGAR) (100 MG/ML)
(SOLUTION) ........................................................................
LEVOCETIRIZINE DIHYDROCHLORIDE................... 11
LEVO-DROMORAN (2 MG) (TABLET) ......................159
LEVOFLOXACIN...................................................100, 119
LEVOFLOXACIN (0.5 %) (DROPS) ...................................
LEVOMILNACIPRAN HCL............................................ 23
LEVONORGESTREL.................................................63, 64
LEVONORGESTREL-ETHIN ESTRADIOL.................. 64
LEVONORGESTREL-ETHIN ESTRADIOL (0.1-0.02)
(TABLET) .............................................................................
LEVONORGESTREL-ETHIN ESTRADIOL (6-5-10)
(TABLET) .............................................................................
LEVORPHANOL TARTRATE....................................... 159
LEVO-T (100 MCG) (TABLET) ......................................95
LEVO-T (112 MCG) (TABLET) ......................................95
LEVO-T (125 MCG) (TABLET) ......................................95
LEVO-T (137 MCG) (TABLET) ......................................95
LEVO-T (150 MCG) (TABLET) ......................................95
LEVO-T (175MCG) (TABLET) .......................................95
LEVO-T (200 MCG) (TABLET) ......................................95
LEVO-T (25 MCG) (TABLET) ........................................95
LEVO-T (300 MCG) (TABLET) ......................................95
LEVO-T (50 MCG) (TABLET) ........................................95
LEVO-T (75 MCG) (TABLET) ........................................95
LEVO-T (88 MCG) (TABLET) ........................................95
LEVOTHYROXINE SODIUM....................................95-97
LEVOXYL (100 MCG) (TABLET) ................................. 95
LEVOXYL (112 MCG) (TABLET) ................................. 95
LEVOXYL (125 MCG) (TABLET) ................................. 95
LEVOXYL (137 MCG) (TABLET) ................................. 95
LEVOXYL (150 MCG) (TABLET) ................................. 95
LEVOXYL (175MCG) (TABLET) .................................. 95
LEVOXYL (200 MCG) (TABLET) ................................. 95
LEVOXYL (25 MCG) (TABLET) ................................... 95
LEVOXYL (50 MCG) (TABLET) ................................... 95
LEVOXYL (75 MCG) (TABLET) ................................... 95
LEVOXYL (88 MCG) (TABLET) ................................... 96
LEVSIN (0.125 MG) (TABLET) ................................... 178
LEVSIN-SL (0.125 MG) (TAB SUBL) ......................... 178
LEXAPRO (10 MG) (TABLET) ...................................... 21
LEXAPRO (20 MG) (TABLET) ...................................... 21
LEXAPRO (5 MG) (TABLET) ........................................ 21
LEXAPRO (5 MG/5 ML) (SOLUTION) ......................... 21
LEXIVA (50 MG/ML) (ORAL SUSP) ...........................128
LEXIVA (700 MG) (TABLET) ...................................... 128
LIALDA (1.2 G) (TABLET DR) ....................................139
LIBRAX (5 MG-2.5MG) (CAPSULE) .......................... 178
LIBRIUM (10 MG) (CAPSULE) .....................................28
LIBRIUM (25 MG) (CAPSULE) .....................................28
LIBRIUM (5 MG) (CAPSULE) .......................................28
LIDAMANTLE HC (3 %-0.5 %) (CREAM (G)) .............80
LIDAZONE HC (3 %-0.5 %) (CREAM (G)) .................140
LIDEX (0.05 %) (CREAM (G)) .......................................75
LIDEX (0.05 %) (GEL (GRAM)) .................................... 75
LIDEX (0.05 %) (OINT. (G)) ...........................................75
LIDEX (0.05 %) (SOLUTION) ........................................75
LIDEX-E (0.05 %) (CREAM (G)) ................................... 75
LIDOCAINE................................................................80, 81
LIDOCAINE HCL.....................................................81, 139
LIDOCAINE HCL (2 %) (JEL/PF APP) ..............................
LIDOCAINE HCL/MENTHOL........................................81
LIDOCAINE/HYDROCORTISONE AC..................80, 140
LIDOCAINE/PRILOCAINE.............................................81
LIDOCAINE/TETRACAINE........................................... 81
LIDODERM (5 %) (ADH. PATCH) .................................80
LIDO-K (3 %) (LOTION) ................................................ 81
LIDOPIN (3 %) (CREAM (G)) ........................................81
LIDOPIN (3.25 %) (CREAM (G)) ...................................81
LIDORX (3 %) (GEL W/PUMP) ..................................... 81
LIDOVEX (3.75 %) (CREAM (G)) ................................. 81
Sharp Health Plan: Covered California
LIFITEGRAST................................................................ 101
LIMBITROL (12.5MG-5MG) (TABLET) ....................... 24
LIMBITROL DS (25 MG-10MG) (TABLET) ................. 24
LINACLOTIDE....................................................... 140, 141
LINAGLIPTIN.................................................................. 85
LINAGLIPTIN/METFORMIN HCL................................ 83
LINDANE..........................................................................71
LINEZOLID.................................................................... 117
LINZESS (145 MCG) (CAPSULE) ............................... 140
LINZESS (290 MCG) (CAPSULE) ............................... 141
LIORESAL (10 MG) (TABLET) ................................... 175
LIORESAL (20 MG) (TABLET) ................................... 175
LIOTHYRONINE SODIUM.............................................97
LIOTRIX........................................................................... 97
LIPASE/PROTEASE/AMYLASE...................................177
LIPITOR (10 MG) (TABLET) ......................................... 58
LIPITOR (20 MG) (TABLET) ......................................... 58
LIPITOR (40 MG) (TABLET) ......................................... 58
LIPITOR (80 MG) (TABLET) ......................................... 58
LIPOCHOL PLUS (0.5 MG) (TABLET) ......................... 60
LIPOFEN (150 MG) (CAPSULE) ................................... 60
LIPOFEN (50 MG) (CAPSULE) ..................................... 60
LIRAGLUTIDE.................................................................84
LISDEXAMFETAMINE DIMESYLATE.........................27
LISINOPRIL................................................................46, 47
LISINOPRIL/HYDROCHLOROTHIAZIDE....................43
LITHIUM CARBONATE..................................................29
LITHIUM CARBONATE (150 MG) (CAPSULE) ..............
LITHIUM CARBONATE (600 MG) (CAPSULE) ..............
LITHIUM CITRATE......................................................... 29
LITHIUM CITRATE (8 MEQ/5 ML) (SOLUTION) ...........
LITHOBID (300 MG) (TABLET ER) ..............................29
LITHOSTAT (250 MG) (TABLET) ............................... 141
LITHOTABS (300 MG) (TABLET) .................................29
LIVALO (1 MG) (TABLET) .................................... 58, 195
LIVALO (2 MG) (TABLET) .................................... 58, 195
LIVALO (4 MG) (TABLET) .................................... 58, 195
L-NORGEST/E.ESTRADIOL-E.ESTRAD...................... 64
LO LOESTRIN FE (1MG-10(24)) (TABLET) ................ 64
LOCOID (0.1 %) (CREAM (G)) ......................................76
LOCOID (0.1 %) (LOTION) ............................................76
LOCOID (0.1 %) (OINT. (G)) ..........................................76
LOCOID (0.1 %) (SOLUTION) .......................................76
LOCOID LIPOCREAM (0.1 %) (CREAM (G)) ..............76
LODINE (200 MG) (CAPSULE) ...................................137
LODINE (300 MG) (CAPSULE) ...................................137
LODINE (400 MG) (TABLET) ......................................137
LODINE (500 MG) (TABLET) ......................................137
LODINE XL (400 MG) (TAB ER 24H) .........................137
LODINE XL (500 MG) (TAB ER 24H) .........................137
LODINE XL (600 MG) (TAB ER 24H) .........................137
LODOSYN (25 MG) (TABLET) ................................... 168
LODOXAMIDE TROMETHAMINE............................. 101
LOESTRIN (1.5-0.03MG) (TABLET) ............................. 64
LOESTRIN (1MG-20MCG) (TABLET) ..........................64
LOESTRIN FE (1.5-30(21)) (TABLET) .......................... 64
LOESTRIN FE (1MG-20(21)) (TABLET) .......................64
LOFIBRA (134MG) (CAPSULE) ....................................60
LOFIBRA (160 MG) (TABLET) ..................................... 60
LOFIBRA (200 MG) (CAPSULE) ...................................60
LOFIBRA (54 MG) (TABLET) ....................................... 60
LOFIBRA (67 MG) (CAPSULE) .....................................60
LOMITAPIDE MESYLATE............................................. 59
LOMOTIL (2.5-.025/5) (LIQUID) ................................. 141
LOMOTIL (2.5-.025MG) (TABLET) ............................ 141
LOMUSTINE.................................................................. 144
LONITEN (10 MG) (TABLET) ....................................... 49
LONITEN (2.5 MG) (TABLET) ...................................... 49
LONSURF (15-6.14 MG) (TABLET) ............................ 145
LONSURF (20-8.19 MG) (TABLET) ............................ 145
LO-OVRAL-28 (0.3-0.03MG) (TABLET) .......................65
LO-OVRAL-8 (0.3-0.03MG) (TABLET) .........................65
LOPERAMIDE HCL.......................................................141
LOPID (600 MG) (TABLET) ...........................................60
LOPINAVIR/RITONAVIR.............................................. 128
LOPRESSOR (100 MG) (TABLET) ................................49
LOPRESSOR (50 MG) (TABLET) ..................................49
LOPRESSOR HCT (100MG-25MG) (TABLET) ............ 51
LOPRESSOR HCT (100MG-50MG) (TABLET) ............ 51
LOPRESSOR HCT (50 MG-25MG) (TABLET) ............. 51
LOPROX (0.77 %) (CREAM (G)) ................................... 70
LOPROX (0.77 %) (GEL (GRAM)) .................................70
LOPROX (0.77 %) (SUSPENSION) ................................70
LOPROX (1 %) (SHAMPOO) ......................................... 70
LORAZEPAM................................................................... 29
LORAZEPAM INTENSOL (2 MG/ML) (ORAL CONC)
...............................................................................................
LORTAB (10-300/15) (SOLUTION) ............................. 158
LORTAB (10MG-325MG) (TABLET) .......................... 158
LORTAB (5 MG-325MG) (TABLET) ........................... 158
LORTAB (7.5-325 MG) (TABLET) ...............................158
LORZONE (375 MG) (TABLET) .................................. 175
Page 212 of 224
Index
LORZONE (750 MG) (TABLET) .................................. 175
LOSARTAN POTASSIUM............................................... 48
LOSARTAN/HYDROCHLOROTHIAZIDE.....................45
LOSEASONIQUE (100-20(84)) (TBDSPK 3MO) ..........64
LOTEMAX (0.5 %) (DROPS GEL) .................................99
LOTEMAX (0.5 %) (DROPS SUSP) ............................... 99
LOTEMAX (0.5 %) (OINT. (G)) ..................................... 99
LOTENSIN (10 MG) (TABLET) ..................................... 46
LOTENSIN (20 MG) (TABLET) ..................................... 46
LOTENSIN (40 MG) (TABLET) ..................................... 46
LOTENSIN (5 MG) (TABLET) ....................................... 46
LOTENSIN HCT (10-12.5MG) (TABLET) .....................42
LOTENSIN HCT (20 MG-25MG) (TABLET) ................ 42
LOTENSIN HCT (20-12.5 MG) (TABLET) ....................42
LOTENSIN HCT (5-6.25MG) (TABLET) .......................42
LOTEPREDNOL ETABONATE.......................................99
LOTREL (10 MG-20MG) (CAPSULE) ...........................41
LOTREL (10 MG-40MG) (CAPSULE) ...........................42
LOTREL (2.5MG-10MG) (CAPSULE) ...........................42
LOTREL (5 MG-10 MG) (CAPSULE) ............................42
LOTREL (5 MG-20 MG) (CAPSULE) ............................42
LOTREL (5 MG-40 MG) (CAPSULE) ............................42
LOTRIMIN (1 %) (CREAM (G)) .................................... 70
LOTRIMIN (1 %) (SOLUTION) ..................................... 70
LOTRISONE (1 %-0.05 %) (CREAM (G)) ..................... 70
LOTRISONE (1 %-0.05 %) (LOTION) ........................... 70
LOTRONEX (0.5 MG) (TABLET) ................................ 142
LOTRONEX (1 MG) (TABLET) ................................... 142
LOVASTATIN....................................................................58
LOVAZA (1 G) (CAPSULE) ............................................60
LOVENOX (100 MG/ML) (SYRINGE) ........................ 105
LOVENOX (120MG/.8ML) (SYRINGE) ...................... 105
LOVENOX (150 MG/ML) (SYRINGE) ........................ 105
LOVENOX (300MG/3ML) (VIAL) ...............................105
LOVENOX (30MG/0.3ML) (SYRINGE) ...................... 106
LOVENOX (40MG/0.4ML) (SYRINGE) ...................... 106
LOVENOX (60MG/0.6ML) (SYRINGE) ...................... 106
LOVENOX (80MG/0.8ML) (SYRINGE) ...................... 106
LOXAPINE....................................................................... 30
LOXAPINE SUCCINATE...........................................30, 31
LOXITANE (10 MG) (CAPSULE) .................................. 30
LOXITANE (25 MG) (CAPSULE) .................................. 30
LOXITANE (5 MG) (CAPSULE) .................................... 31
LOXITANE (50 MG) (CAPSULE) .................................. 31
LOZOL (1.25 MG) (TABLET) ........................................ 57
LOZOL (2.5 MG) (TABLET) .......................................... 57
LUBIPROSTONE............................................................142
LUDIOMIL (25 MG) (TABLET) .....................................25
LUDIOMIL (50 MG) (TABLET) .....................................25
LUDIOMIL (75 MG) (TABLET) .....................................25
LULICONAZOLE.............................................................71
LUMACAFTOR/IVACAFTOR.......................................154
LUMIGAN (0.01 %) (DROPS) ...................................... 101
LUMIGAN (0.03 %) (DROPS) ...................................... 101
LUNESTA (1 MG) (TABLET) .........................................37
LUNESTA (2 MG) (TABLET) .........................................37
LUNESTA (3 MG) (TABLET) .........................................37
LURASIDONE HCL.........................................................32
LUVOX (100 MG) (TABLET) .........................................21
LUVOX (25 MG) (TABLET) ...........................................21
LUVOX (50 MG) (TABLET) ...........................................21
LUVOX CR (100 MG) (CAP ER 24H) ............................21
LUVOX CR (150 MG) (CAP ER 24H) ............................21
LUXIQ (0.12 %) (FOAM) ................................................74
LUZU (1 %) (CREAM (G)) ..................................... 71, 195
LYNPARZA (50 MG) (CAPSULE) ............................... 148
LYRICA (100 MG) (CAPSULE) ........................... 173, 195
LYRICA (150 MG) (CAPSULE) ........................... 173, 195
LYRICA (20 MG/ML) (SOLUTION) .................... 173, 195
LYRICA (200 MG) (CAPSULE) ........................... 173, 195
LYRICA (225 MG) (CAPSULE) ........................... 173, 196
LYRICA (25 MG) (CAPSULE) ............................. 174, 196
LYRICA (300 MG) (CAPSULE) ........................... 174, 196
LYRICA (50 MG) (CAPSULE) ............................. 174, 196
LYRICA (75 MG) (CAPSULE) ............................. 174, 196
LYSODREN (500 MG) (TABLET) ................................149
LYSTEDA (650 MG) (TABLET) ................................... 104
-MMACITENTAN................................................................. 56
MACROBID (100 MG) (CAPSULE) .............................117
MACRODANTIN (100 MG) (CAPSULE) .................... 117
MACRODANTIN (25 MG) (CAPSULE) ...................... 117
MACRODANTIN (50 MG) (CAPSULE) ...................... 117
MAFENIDE ACETATE.................................................... 72
MALARONE (250-100 MG) (TABLET) .......................124
MALARONE (62.5-25 MG) (TABLET) ........................125
MALATHION....................................................................71
MANDELAMINE (1 G) (TABLET) .............................. 116
MANDELAMINE (500 MG) (TABLET) ...................... 116
MAPROTILINE HCL........................................................25
MARAVIROC..................................................................126
MARINOL (10 MG) (CAPSULE) ................................... 12
MARINOL (2.5 MG) (CAPSULE) .................................. 12
MARINOL (5 MG) (CAPSULE) ..................................... 12
MARPLAN (10 MG) (TABLET) ..................................... 20
MATULANE (50 MG) (CAPSULE) ..............................149
MAVIK (1 MG) (TABLET) ..............................................47
MAVIK (2 MG) (TABLET) ..............................................47
MAVIK (4 MG) (TABLET) ..............................................47
MAXALT (10 MG) (TABLET) ......................................163
MAXALT (5 MG) (TABLET) ........................................163
MAXALT MLT (10 MG) (TAB RAPDIS) .....................163
MAXALT MLT (5 MG) (TAB RAPDIS) .......................163
MAXARON FORTE (150-200 MG) (TABLET) ........... 185
MAXFE (160MG-1-60) (TABLET) ............................... 186
MAXIDEX (0.1 %) (DROPS SUSP) ............................... 99
MAXINATE (20MG-0.8MG) (TABLET) ...................... 186
MAXITROL (0.1 %) (DROPS SUSP) ............................. 98
MAXITROL (3.5-10K-.1) (OINT. (G)) ............................98
MAXZIDE (75 MG-50MG) (TABLET) .......................... 55
MAXZIDE-25 MG (37.5-25 MG) (TABLET) ................. 55
MEBENDAZOLE........................................................... 124
MECAMYLAMINE HCL.................................................48
MECASERMIN.................................................................94
MECHLORETHAMINE HCL..........................................80
MECLIZINE HCL.............................................................12
MECLOFENAMATE SODIUM..................................... 138
MECLOMEN (100 MG) (CAPSULE) ...........................138
MECLOMEN (50 MG) (CAPSULE) .............................138
MEDROL (16 MG) (TABLET) ......................................134
MEDROL (2 MG) (TABLET) ........................................134
MEDROL (32 MG) (TABLET) ......................................134
MEDROL (4 MG) (TAB DS PK) ................................... 134
MEDROL (4 MG) (TABLET) ........................................134
MEDROL (8 MG) (TABLET) ........................................135
MEDROXYPROGESTERONE ACETATE.................... 111
MEFENAMIC ACID.......................................................138
MEFLOQUINE HCL...................................................... 125
MEGACE (20 MG) (TABLET) ......................................150
MEGACE (40 MG) (TABLET) ......................................150
MEGACE (400MG/10ML) (ORAL SUSP) ................... 152
MEGACE ES (625MG/5ML) (ORAL SUSP) ................152
MEGESTROL ACETATE....................................... 150, 152
MEKINIST (0.5 MG) (TABLET) .................................. 145
MEKINIST (2 MG) (TABLET) ..................................... 145
MELLARIL (10 MG) (TABLET) .................................... 35
MELLARIL (100 MG) (TABLET) .................................. 35
MELLARIL (25 MG) (TABLET) .................................... 35
MELLARIL (50 MG) (TABLET) .................................... 35
MELOXICAM.................................................................138
MELOXICAM, SUBMICRONIZED.............................. 138
MELPHALAN.................................................................144
MEMANTINE HCL..........................................................18
MEMANTINE HCL/DONEPEZIL HCL..........................19
MENEST (0.3 MG) (TABLET) ......................................111
MENEST (0.625 MG) (TABLET) ..................................111
MENEST (1.25 MG) (TABLET) ....................................111
MENEST (2.5 MG) (TABLET) ......................................111
MENOSTAR (14MCG/24HR) (PATCH TDWK) .......... 109
MENTAX (1 %) (CREAM (G)) ....................................... 70
MEPERIDINE HCL........................................................ 159
MEPHYTON (5 MG) (TABLET) .................................. 107
MEPROBAMATE............................................................. 29
MEPROBAMATE (200 MG) (TABLET) .............................
MEPROBAMATE (400 MG) (TABLET) .............................
MEPRON (750 MG/5ML) (ORAL SUSP) .................... 125
MERCAPTOPURINE............................................. 144, 145
MESALAMINE.......................................................139, 140
MESNA........................................................................... 149
MESNEX (400 MG) (TABLET) .................................... 149
MESTINON (180 MG) (TABLET ER) ............................19
MESTINON (60 MG) (TABLET) .................................... 19
MESTINON (60 MG/5 ML) (SYRUP) ............................ 19
METADATE CD (10 MG) (CPBP 30-70) ........................39
METADATE CD (20 MG) (CPBP 30-70) ........................39
METADATE CD (30 MG) (CPBP 30-70) ........................39
METADATE CD (40 MG) (CPBP 30-70) ........................39
METADATE CD (50 MG) (CPBP 30-70) ........................39
METADATE CD (60 MG) (CPBP 30-70) ........................39
METADATE ER (10 MG) (TABLET ER) ....................... 39
METADATE ER (20 MG) (TABLET ER) ....................... 39
METAGLIP (2.5-250 MG) (TABLET) .............................86
METAGLIP (2.5-500 MG) (TABLET) .............................86
METAGLIP (5 MG-500MG) (TABLET) ......................... 86
METAPROTERENOL SULFATE.....................................14
METAXALONE.............................................................. 176
METFORMIN HCL.......................................................... 86
METH/MEBLUE/SOD PHOS/PSAL/HYOS......... 115, 116
METH/MEBLUE/SOD PHOS/PSAL/HYOS (118-10-36)
(CAPSULE) ..........................................................................
METH/MEBLUE/SOD PHOS/PSAL/HYOS (81.6-10.8)
(TABLET) .............................................................................
Sharp Health Plan: Covered California
METH/MEBLUE/SOD PHOS/PSAL/HYOS (81-0.12MG)
(TABLET) .............................................................................
METHADONE HCL....................................................... 159
METHADONE HCL (10 MG/5 ML) (SOLUTION) ...........
METHADONE HCL (5 MG/5 ML) (SOLUTION) .............
METHADOSE (10 MG/ML) (ORAL CONC) ...............159
METHAMPHETAMINE HCL..........................................27
METHAZOLAMIDE...................................................... 101
METHEN MAND/NAPHOS M-B M-H......................... 181
METHEN/M-BLUE/SAL/NA PHOS/HYOS..................116
METHEN/M-BLUE/SAL/NA PHOS/HYOS (1200.12MG) (TABLET) .............................................................
METHEN/SOD PHOS/METH BLUE/HYOS.................116
METHENAM/ME BLUE/BA/SALICY/HYO................ 116
METHENAM/ME BLUE/BA/SALICY/HYO (81.6-0.12)
(TABLET) .............................................................................
METHENAMINE HIPPURATE..................................... 116
METHENAMINE MANDELATE.................................. 116
METHIMAZOLE.............................................................. 95
METHIONINE/INOSITOL/CHOLINE/FA...................... 60
METHITEST (10 MG) (TABLET) ................................ 107
METHOCARBAMOL.....................................................176
METHOTREXATE SODIUM.........................................145
METHOTREXATE/PF............................................ 132, 133
METHOXSALEN............................................................. 82
METHOXSALEN, RAPID............................................... 82
METHOXSALEN, RAPID (10 MG) (CAPSULE) ..............
METHSCOPOLAMINE BROMIDE.............................. 178
METHSUXIMIDE.......................................................... 172
METHYCLOTHIAZIDE...................................................57
METHYCLOTHIAZIDE (5 MG) (TABLET) ......................
METHYLDOPA................................................................ 49
METHYLDOPA/HYDROCHLOROTHIAZIDE.............. 49
METHYLIN (10 MG) (TAB CHEW) .............................. 39
METHYLIN (10 MG/5 ML) (SOLUTION) .....................39
METHYLIN (2.5 MG) (TAB CHEW) ............................. 39
METHYLIN (5 MG) (TAB CHEW) ................................ 39
METHYLIN (5 MG/5 ML) (SOLUTION) .......................39
METHYLNALTREXONE BROMIDE........................... 143
METHYLPHENIDATE...............................................38, 39
METHYLPHENIDATE HCL......................................39, 40
METHYLPREDNISOLONE.................................. 134, 135
METHYLTESTOSTERONE...........................................107
METIPRANOLOL.......................................................... 102
METOCLOPRAMIDE HCL........................................... 179
METOLAZONE................................................................ 58
METOPROLOL SUCCINATE..........................................49
METOPROLOL SUCCINATE/HCTZ.............................. 51
METOPROLOL TARTRATE......................................49, 50
METOPROLOL TARTRATE (25 MG) (TABLET) .............
METOPROLOL TARTRATE (37.5 MG) (TABLET) ..........
METOPROLOL TARTRATE (75 MG) (TABLET) .............
METOPROLOL/HYDROCHLOROTHIAZIDE...............51
METOZOLV ODT (10 MG) (TAB RAPDIS) ................ 179
METOZOLV ODT (5 MG) (TAB RAPDIS) .................. 179
METROCREAM (0.75 %) (CREAM (G)) .......................68
METROGEL (1 %) (GEL (GRAM)) ................................68
METROGEL (1 %) (GEL W/PUMP) .............................. 68
METROGEL-VAGINAL (0.75 %) (GEL W/APPL) ......
183
METROLOTION (0.75 %) (LOTION) ............................ 68
METRONIDAZOLE......................................... 68, 124, 183
METYROSINE..................................................................48
MEVACOR (10 MG) (TABLET) ..................................... 58
MEVACOR (20 MG) (TABLET) ..................................... 58
MEVACOR (40 MG) (TABLET) ..................................... 58
MEXILETINE HCL.......................................................... 41
MEXITIL (150 MG) (CAPSULE) ................................... 41
MEXITIL (200 MG) (CAPSULE) ................................... 41
MEXITIL (250 MG) (CAPSULE) ................................... 41
MIACALCIN (200/SPRAY) (SPRAY/PUMP) ................ 93
MICARDIS (20 MG) (TABLET) ..................................... 48
MICARDIS (40 MG) (TABLET) ..................................... 48
MICARDIS (80 MG) (TABLET) ..................................... 48
MICARDIS HCT (40-12.5 MG) (TABLET) ....................45
MICARDIS HCT (80 MG-25MG) (TABLET) ................ 45
MICARDIS HCT (80-12.5MG) (TABLET) .....................45
MICONAZOLE............................................................... 122
MICONAZOLE NITRATE............................................. 183
MICONAZOLE NITRATE/ZINC OX/PET...................... 71
MICORT-HC (2.5 %) (CREAM/APPL) .........................141
MICROGESTIN 24 FE (1MG-20(24)) (TABLET) ..........64
MICRO-K (10 MEQ) (CAPSULE ER) ............................ 92
MICRO-K (8 MEQ) (CAPSULE ER) .............................. 92
MICROZIDE (12.5 MG) (CAPSULE) .............................57
MIDAMOR (5 MG) (TABLET) ....................................... 55
MIDAZOLAM HCL..........................................................37
MIDODRINE HCL........................................................... 61
MIDRIN (65-100-325) (CAPSULE) ..............................163
MIFEPREX (200 MG) (TABLET) .................................152
MIFEPRISTONE.......................................................87, 152
MIGERGOT (2-100MG) (SUPP.RECT) ........................ 163
Page 213 of 224
Index
MIGLITOL........................................................................ 84
MIGLUSTAT................................................................... 152
MIGRANAL (0.5MG/SPRY) (SPRAY/PUMP) ...... 163,
196
MILLIPRED (10 MG/5 ML) (SOLUTION) .................. 135
MILLIPRED (5 MG) (TABLET) ................................... 135
MILLIPRED DP (5 MG (21)) (TAB DS PK) .................135
MILLIPRED DP (5 MG (48)) (TAB DS PK) .................135
MILNACIPRAN HCL.....................................................151
MILTEFOSINE............................................................... 125
MINASTRIN 24 FE (1MG-20(24)) (TAB CHEW) ......... 64
MINIPRESS (1 MG) (CAPSULE) ...................................44
MINIPRESS (2 MG) (CAPSULE) ...................................44
MINIPRESS (5 MG) (CAPSULE) ...................................44
MINIVELLE (.025MG/24H) (PATCH TDSW) ............. 109
MINIVELLE (.0375MG/24) (PATCH TDSW) .............. 110
MINIVELLE (.075MG/24H) (PATCH TDSW) ............. 110
MINIVELLE (0.05MG/24H) (PATCH TDSW) ............. 110
MINIVELLE (0.1MG/24HR) (PATCH TDSW) ............ 110
MINOCIN (100 MG) (CAPSULE) ................................ 121
MINOCIN (50 MG) (CAPSULE) .................................. 121
MINOCIN (75 MG) (CAPSULE) .................................. 121
MINOCYCLINE HCL.................................................... 121
MINOXIDIL...................................................................... 49
MIRABEGRON...............................................................181
MIRALAX (17G) (POWD PACK) .................................142
MIRALAX (17G) (POWD PACK) (OTC)...................... 142
MIRALAX (17G/DOSE) (POWDER) ........................... 143
MIRALAX (17G/DOSE) (POWDER) (OTC).................143
MIRAPEX (0.125 MG) (TABLET) ................................167
MIRAPEX (0.25 MG) (TABLET) ..................................167
MIRAPEX (0.5 MG) (TABLET) ....................................167
MIRAPEX (0.75 MG) (TABLET) ..................................167
MIRAPEX (1 MG) (TABLET) .......................................167
MIRAPEX (1.5 MG) (TABLET) ....................................167
MIRAPEX ER (0.375 MG) (TAB ER 24H) ...................167
MIRAPEX ER (0.75 MG) (TAB ER 24H) .....................167
MIRAPEX ER (1.5 MG) (TAB ER 24H) .......................167
MIRAPEX ER (2.25 MG) (TAB ER 24H) .....................167
MIRAPEX ER (3 MG) (TAB ER 24H) ..........................167
MIRAPEX ER (3.75 MG) (TAB ER 24H) .....................167
MIRAPEX ER (4.5 MG) (TAB ER 24H) .......................167
MIRCETTE (21-5) (TABLET) .........................................63
MIRTAZAPINE.................................................................20
MIRTAZAPINE (7.5 MG) (TABLET) .................................
MIRVASO (0.33 %) (GEL (GRAM)) .......................68, 196
MIRVASO (0.33 %) (GEL W/PUMP) ..............................68
MISOPROSTOL..............................................................178
MITIGARE (0.6 MG) (CAPSULE) ............................... 103
MITOMYCIN..................................................................103
MITOSOL (0.2 MG) (KIT) ............................................ 103
MITOTANE..................................................................... 149
MOBAN (10 MG) (TABLET) ..........................................35
MOBAN (25 MG) (TABLET) ..........................................35
MOBAN (5 MG) (TABLET) ............................................35
MOBIC (15 MG) (TABLET) ......................................... 138
MOBIC (7.5 MG) (TABLET) ........................................ 138
MOBIC (7.5 MG/5ML) (ORAL SUSP) .........................138
MODAFINIL..................................................................... 36
MODERIBA (200 MG) (TABLET) ............................... 130
MODERIBA (200-400(7)) (TAB DS PK) ...................... 131
MODERIBA (400-400(7)) (TAB DS PK) ...................... 131
MODERIBA (600-400(7)) (TAB DS PK) ...................... 131
MODERIBA (600-600(7)) (TAB DS PK) ...................... 131
MODURETIC 5-50 (5 MG-50 MG) (TABLET) ..............55
MOEXIPRIL HCL.............................................................47
MOEXIPRIL/HYDROCHLOROTHIAZIDE....................43
MOLINDONE HCL.......................................................... 35
MOMETASONE FUROATE...........................12, 17, 76, 77
MOMETASONE/FORMOTEROL....................................16
MONDOXYNE NL (100 MG) (CAPSULE) ................. 120
MONDOXYNE NL (50 MG) (CAPSULE) ................... 120
MONDOXYNE NL (75 MG) (CAPSULE) ................... 120
MONISTAT 3 (200 MG) (SUPP.VAG) ...........................183
MONODOX (100 MG) (CAPSULE) ............................. 120
MONODOX (50 MG) (CAPSULE) ............................... 120
MONODOX (50 MG) (TABLET) ..................................120
MONODOX (75 MG) (CAPSULE) ............................... 120
MONODOX (75 MG) (TABLET) ..................................121
MONOKET (10 MG) (TABLET) .....................................62
MONOKET (20 MG) (TABLET) .....................................62
MONOPRIL (10 MG) (TABLET) ....................................46
MONOPRIL (20 MG) (TABLET) ....................................46
MONOPRIL (40 MG) (TABLET) ....................................46
MONOPRIL-HCT (10-12.5MG) (TABLET) ................... 42
MONOPRIL-HCT (20-12.5 MG) (TABLET) .................. 43
MONTELUKAST SODIUM.............................................17
MONUROL (3 G) (PACKET) ........................................ 115
MORGIDOX (100 MG) (CAPSULE) ............................ 120
MORGIDOX (50 MG) (CAPSULE) .............................. 120
MORPHINE SULFATE...........................................159, 160
MORPHINE SULFATE (15 MG) (TABLET) ......................
MORPHINE SULFATE (30 MG) (TABLET) ......................
MORPHINE SULFATE/NALTREXONE....................... 160
MOTOFEN (1-0.025MG) (TABLET) ............................ 141
MOTRIN (100 MG/5ML) (ORAL SUSP) ..................... 137
MOTRIN (400 MG) (TABLET) ..................................... 137
MOTRIN (600 MG) (TABLET) ..................................... 137
MOTRIN (800 MG) (TABLET) ..................................... 137
MOVANTIK (12.5 MG) (TABLET) ...............................143
MOVANTIK (25 MG) (TABLET) ..................................143
MOVIPREP (7.5-2.691G) (POWD PACK) .................... 142
MOXATAG (775 MG) (TBMP 24HR) ...........................118
MOXEZA (0.5 %) (DROPS VISC) ................................100
MOXIFLOXACIN HCL..........................................100, 119
MOZOBIL (24MG/1.2ML) (VIAL) ...............................152
MS CONTIN (100 MG) (TABLET ER) .........................160
MS CONTIN (15 MG) (TABLET ER) ...........................160
MS CONTIN (200 MG) (TABLET ER) .........................160
MS CONTIN (30 MG) (TABLET ER) ...........................160
MS CONTIN (60 MG) (TABLET ER) ...........................160
MSIR (10 MG/5 ML) (SOLUTION) ..............................160
MSIR (20 MG/5 ML) (SOLUTION) ..............................160
MUCOMYST (100 MG/ML) (VIAL) ............................154
MUCOMYST (200 MG/ML) (VIAL) ............................154
MULTAQ (400 MG) (TABLET) ...................................... 41
MUPIROCIN..................................................................... 70
MUPIROCIN CALCIUM..........................................70, 151
M-VIT (27 MG-1 MG) (TABLET) ................................ 187
MYAMBUTOL (100 MG) (TABLET) ........................... 123
MYAMBUTOL (400 MG) (TABLET) ........................... 123
MYCELEX (10 MG) (TROCHE) .................................. 121
MYCOBUTIN (150 MG) (CAPSULE) ..........................123
MYCOGEN II (100000-0.1) (CREAM (G)) .................... 71
MYCOGEN II (100000-0.1) (OINT. (G)) ........................ 71
MYCOPHENOLATE MOFETIL....................................113
MYCOPHENOLATE SODIUM..................................... 113
MYCOSTATIN (100000/G) (CREAM (G)) .....................71
MYCOSTATIN (100000/ML) (ORAL SUSP) ............... 122
MYCOSTATIN (150MM UNIT) (POWDER(EA)) ....... 122
MYCOSTATIN (500K UNIT) (TABLET) ..................... 122
MYDFRIN (2.5 %) (DROPS) ........................................ 100
MYDRIACYL (0.5 %) (DROPS) ...................................103
MYDRIACYL (1 %) (DROPS) ......................................103
MYFORTIC (180 MG) (TABLET DR) ..........................113
MYFORTIC (360 MG) (TABLET DR) ..........................113
MYLERAN (2 MG) (TABLET) .....................................144
MYRBETRIQ (25 MG) (TAB ER 24H) ........................ 181
MYRBETRIQ (50 MG) (TAB ER 24H) ........................ 181
MYSOLINE (250 MG) (TABLET) ................................ 174
MYSOLINE (50 MG) (TABLET) .................................. 174
MYTESI (125 MG) (TABLET DR) ............................... 141
-NNA PHOS,M-B/K PHOS,MONOB.................................181
NABILONE....................................................................... 12
NABUMETONE..............................................................138
NADOLOL........................................................................ 50
NADOLOL/BENDROFLUMETHIAZIDE.......................51
NAFARELIN ACETATE...................................................94
NAFTIFINE HCL..............................................................71
NAFTIN (1 %) (CREAM (G)) ......................................... 71
NAFTIN (1 %) (GEL (GRAM)) .......................................71
NAFTIN (2 %) (CREAM (G)) ......................................... 71
NAFTIN (2 %) (GEL (GRAM)) .......................................71
NALFON (400 MG) (CAPSULE) ..................................137
NALFON (600 MG) (TABLET) .................................... 137
NALOXEGOL OXALATE..............................................143
NALOXONE HCL............................................................ 36
NALTREXONE HCL........................................................ 36
NAMENDA (10 MG) (TABLET) .................................... 18
NAMENDA (2 MG/ML) (SOLUTION) .......................... 18
NAMENDA (5 MG) (TABLET) ...................................... 18
NAMENDA (5 MG-10 MG) (TAB DS PK) .....................18
NAMENDA XR (14 MG) (CAP SPR 24) ........................ 18
NAMENDA XR (21 MG) (CAP SPR 24) ........................ 18
NAMENDA XR (28 MG) (CAP SPR 24) ........................ 18
NAMENDA XR (7 MG) (CAP SPR 24) .......................... 18
NAMENDA XR (7-14-21-28) (CAP24 DSPK) ............... 18
NAMZARIC (14MG-10MG) (CAP SPR 24) ...........19, 196
NAMZARIC (21 MG-10MG) (CAP SPR 24) ..................19
NAMZARIC (28 MG-10MG) (CAP SPR 24) ..........19, 196
NAMZARIC (7 MG-10 MG) (CAP SPR 24) ...................19
NAPHOS M-B M-H/NA PHOS,DI-BA.......................... 142
NAPRELAN (375 MG) (TBMP 24HR) .................138, 196
NAPRELAN (500 MG) (TBMP 24HR) .................139, 196
NAPRELAN (750 MG) (TBMP 24HR) .................139, 196
NAPROSYN (125 MG/5ML) (ORAL SUSP) ................138
NAPROSYN (250 MG) (TABLET) ............................... 138
NAPROSYN (375 MG) (TABLET) ............................... 138
NAPROSYN (500 MG) (TABLET) ............................... 138
NAPROXEN.................................................................... 138
NAPROXEN SODIUM........................................... 138, 139
NAPROXEN/ESOMEPRAZOLE MAG......................... 136
Sharp Health Plan: Covered California
NARATRIPTAN HCL..................................................... 163
NARCAN (0.4 MG/ML) (SYRINGE) ............................. 36
NARCAN (1 MG/ML) (SYRINGE) ................................ 36
NARCAN (4 MG) (SPRAY) ............................................ 36
NARDIL (15 MG) (TABLET) ..........................................20
NASALIDE (25 MCG) (SPRAY) .....................................11
NASONEX (50 MCG) (SPRAY/PUMP) ................. 12, 196
NATACYN (5 %) (DROPS SUSP) ................................. 101
NATAMYCIN..................................................................101
NATAZIA (3-2-1(28)) (TABLET) ....................................63
NATEGLINIDE................................................................. 85
NATESTO (5.5/0.122) (GEL MD PMP) ........................ 108
NATROBA (0.9 %) (SUSPENSION) ............................... 72
NAVANE (1 MG) (CAPSULE) ........................................ 34
NAVANE (10 MG) (CAPSULE) ...................................... 34
NAVANE (2 MG) (CAPSULE) ........................................ 34
NAVANE (5 MG) (CAPSULE) ........................................ 34
NAVELBINE (50 MG/5 ML) (VIAL) ............................150
NEBIVOLOL HCL............................................................50
NEBIVOLOL HCL/VALSARTAN................................... 44
NEBUPENT (300 MG) (VIAL-NEB) ............................125
NEDOCROMIL SODIUM.............................................. 101
NEFAZODONE HCL........................................................22
NELFINAVIR MESYLATE............................................ 128
NEO/POLYMYX B SULF/DEXAMETH.........................98
NEOMYCIN SU/BACI ZN/POLY/HC............................. 98
NEOMYCIN SU/BACI ZN/POLY/HC (3.5-10K-1) (OINT.
(G)) .......................................................................................
NEOMYCIN SU/BACITRA/POLYMYXIN...................101
NEOMYCIN SU/COLIST/HC/THONZON..................... 90
NEOMYCIN SULFATE.................................................. 122
NEOMYCIN SULFATE (500 MG) (TABLET) ...................
NEOMYCIN SULFATE/FLUOCINOLONE.................... 73
NEOMYCIN/BACITRA/POLYMYXIN/HC.................... 73
NEOMYCIN/FLUOCINOLONE/EMOL #65.................. 73
NEOMYCIN/POLYMYXIN B SULF/HC...... 73, 90, 91,
98
NEOMYCIN/POLYMYXIN B SULF/HC (3.5-10K-10)
(DROPS SUSP) ....................................................................
NEOMYCIN/POLYMYXN B/GRAMICIDIN............... 101
NEOMYCIN/POLYMYXN B/GRAMICIDIN (1.75MG10K) (DROPS) ......................................................................
NEOMYCIN-POLYMYXIN-HYDROCORT (3.5-10K-1)
(SOLUTION) ....................................................................91
NEO-POLYCIN (3.5MG-400) (OINT. (G)) ................... 101
NEORAL (100 MG) (CAPSULE) ..................................112
NEORAL (100 MG/ML) (SOLUTION) ........................ 112
NEORAL (25 MG) (CAPSULE) ....................................112
NEO-SYNALAR (0.5-0.025%) (CREAM (G)) ....... 73, 196
NEPAFENAC.................................................................. 100
NEPTAZANE (25 MG) (TABLET) ............................... 101
NEPTAZANE (50 MG) (TABLET) ............................... 101
NESINA (12.5 MG) (TABLET) ....................................... 84
NESINA (25 MG) (TABLET) .......................................... 85
NESINA (6.25 MG) (TABLET) ....................................... 85
NETUPITANT/PALONOSETRON HCL......................... 12
NEULASTA (6MG/0.6ML) (SYR W/ INJ) ................... 106
NEULASTA (6MG/0.6ML) (SYRINGE) ...................... 106
NEUPRO (1 MG/24 HR) (PATCH TD24) ..................... 168
NEUPRO (2 MG/24 HR) (PATCH TD24) ..................... 168
NEUPRO (3 MG/24 HR) (PATCH TD24) ..................... 168
NEUPRO (4 MG/24 HR) (PATCH TD24) ..................... 168
NEUPRO (6 MG/24 HR) (PATCH TD24) ..................... 168
NEUPRO (8 MG/24 HR) (PATCH TD24) ..................... 168
NEURONTIN (100 MG) (CAPSULE) ...........................170
NEURONTIN (250 MG/5ML) (SOLUTION) ............... 170
NEURONTIN (300 MG) (CAPSULE) ...........................170
NEURONTIN (300 MG/6ML) (SOLUTION) ............... 170
NEURONTIN (400 MG) (CAPSULE) ...........................170
NEURONTIN (600 MG) (TABLET) ............................. 170
NEURONTIN (800 MG) (TABLET) ............................. 170
NEVANAC (0.1 %) (DROPS SUSP) ..............................100
NEVIRAPINE................................................................. 127
NEXAVAR (200 MG) (TABLET) .................................. 148
NEXIUM (10 MG) (SUSPDR PKT) ......................180, 196
NEXIUM (2.5 MG) (SUSPDR PKT) .....................180, 196
NEXIUM (20 MG) (CAPSULE DR) ..................... 180, 196
NEXIUM (20 MG) (SUSPDR PKT) ......................180, 196
NEXIUM (40 MG) (CAPSULE DR) ..................... 180, 196
NEXIUM (40 MG) (SUSPDR PKT) ......................180, 196
NEXIUM (5 MG) (SUSPDR PKT) ........................180, 196
NIACIN............................................................................. 60
NIACOR (500 MG) (TABLET) ....................................... 60
NIASPAN (1000 MG) (TAB ER 24H) ............................. 60
NIASPAN (500 MG) (TAB ER 24H) ............................... 60
NIASPAN (750 MG) (TAB ER 24H) ............................... 60
NICARDIPINE HCL.........................................................53
NICODERM CQ (14MG/24HR) (PATCH TD24) (OTC)
......................................................................................... 176
NICODERM CQ (21 MG/24HR) (PATCH TD24) (OTC)
......................................................................................... 176
Page 214 of 224
Index
NICODERM CQ (7MG/24HR) (PATCH TD24) (OTC)......
176
NICORETTE (2 MG) (GUM) (OTC)............................. 176
NICORETTE (2 MG) (LOZENGE) (OTC).................... 176
NICORETTE (4 MG) (GUM) (OTC)............................. 176
NICORETTE (4 MG) (LOZENGE) (OTC).................... 176
NICOTINE.......................................................................176
NICOTINE PATCH (21-14-7MG) (PATCH DYSQ) (OTC)
...............................................................................................
NICOTINE POLACRILEX.............................................176
NICOTROL (10 MG) (CARTRIDGE) ........................... 176
NICOTROL NS (10 MG/ML) (SPRAY) ........................ 176
NIFEDIPINE..................................................................... 53
NIFEREX-150 FORTE (150-25-1) (CAPSULE) ...........185
NILANDRON (150 MG) (TABLET) ............................. 144
NILOTINIB HCL............................................................ 148
NILUTAMIDE.................................................................144
NIMODIPINE....................................................................53
NIMOTOP (30 MG) (CAPSULE) ....................................53
NINLARO (2.3 MG) (CAPSULE) ................................. 147
NINLARO (3 MG) (CAPSULE) .................................... 147
NINLARO (4 MG) (CAPSULE) .................................... 147
NINTEDANIB ESYLATE.............................................. 154
NIRAVAM (0.25 MG) (TAB RAPDIS) ............................28
NIRAVAM (0.5 MG) (TAB RAPDIS) ..............................28
NIRAVAM (1 MG) (TAB RAPDIS) .................................28
NIRAVAM (2 MG) (TAB RAPDIS) .................................28
NISOLDIPINE............................................................ 53, 54
NITAZOXANIDE..............................................................69
NITISINONE...................................................................152
NITRO-BID (2 %) (OINT. (G)) ........................................62
NITRO-DUR (0.1MG/HR) (PATCH TD24) .................... 62
NITRO-DUR (0.2MG/HR) (PATCH TD24) .................... 62
NITRO-DUR (0.3 MG/HR) (PATCH TD24) ................... 62
NITRO-DUR (0.4MG/HR) (PATCH TD24) .................... 62
NITRO-DUR (0.6MG/HR) (PATCH TD24) .................... 62
NITRO-DUR (0.8MG/HR) (PATCH TD24) .................... 62
NITROFURANTOIN...................................................... 117
NITROFURANTOIN MACROCRYSTAL..................... 117
NITROFURANTOIN MONOHYD/M-CRYST..............117
NITROGLYCERIN............................................. 62, 63, 141
NITROLINGUAL (400MCG/SPR) (SPRAY) ................. 62
NITROMIST (400MCG/SPR) (SPRAY) ..........................62
NITROSTAT (0.3 MG) (TAB SUBL) .............................. 62
NITROSTAT (0.4 MG) (TAB SUBL) .............................. 62
NITROSTAT (0.6 MG) (TAB SUBL) .............................. 62
NITRO-TIME (2.5 MG) (CAPSULE ER) ....................... 62
NITRO-TIME (6.5 MG) (CAPSULE ER) ....................... 63
NITRO-TIME (9 MG) (CAPSULE ER) .......................... 63
NIZATIDINE...................................................................179
NIZORAL (2 %) (CREAM (G)) ...................................... 70
NIZORAL (2 %) (SHAMPOO) ........................................70
NIZORAL (200 MG) (TABLET) ................................... 122
NOLVADEX (10 MG) (TABLET) ................................. 149
NOLVADEX (20 MG) (TABLET) ................................. 149
NONOXYNOL 9............................................................... 63
NORCO (10MG-325MG) (TABLET) ............................158
NORCO (5 MG-325MG) (TABLET) .............................158
NORCO (7.5-325 MG) (TABLET) ................................ 158
NORDETTE-28 (0.15-0.03) (TABLET) .......................... 64
NORELGESTROMIN/ETHIN.ESTRADIOL.................. 65
NORETH-ETHINYL ESTRADIOL/IRON...................... 64
NORETHINDRONE......................................................... 64
NORETHINDRONE ACETATE..................................... 111
NORETHINDRONE AC-ETH ESTRADIOL...........64, 111
NORETHINDRONE-E.ESTRADIOL-IRON............. 64, 65
NORETHINDRONE-ETHINYL ESTRAD...................... 65
NORETHINDRONE-ETHINYL ESTRAD (0.4-0.035)
(TABLET) .............................................................................
NORETHINDRONE-ETHINYL ESTRAD (0.5-0.035)
(TABLET) .............................................................................
NORETHINDRONE-ETHINYL ESTRAD (1 MG35MCG) (TABLET) .............................................................
NORETHINDRONE-ETHINYL ESTRAD (10-11)
(TABLET) .............................................................................
NORETHINDRONE-ETHINYL ESTRAD (7 DAYS X 3)
(TABLET) .............................................................................
NORETHINDRONE-ETHINYL ESTRAD (7-9-5)
(TABLET) .............................................................................
NORETHINDRONE-MESTRANOL............................... 65
NORFLEX (100 MG) (TABLET ER) ............................ 176
NORGESTIMATE-ETHINYL ESTRADIOL...................65
NORGESTREL-ETHINYL ESTRADIOL....................... 65
NORGESTREL-ETHINYL ESTRADIOL (0.5 MG-50)
(TABLET) .............................................................................
NORINYL 1+50 (1 MG-50MCG) (TABLET) .................65
NORITATE (1 %) (CREAM (G)) .....................................68
NORPACE (100 MG) (CAPSULE) ..................................40
NORPACE (150 MG) (CAPSULE) ..................................40
NORPACE CR (100 MG) (CAPSULE ER) ..................... 41
NORPACE CR (150 MG) (CAPSULE ER) ..................... 41
NORPRAMIN (10 MG) (TABLET) .................................24
NORPRAMIN (100 MG) (TABLET) ...............................25
NORPRAMIN (150 MG) (TABLET) ...............................25
NORPRAMIN (25 MG) (TABLET) .................................25
NORPRAMIN (50 MG) (TABLET) .................................25
NORPRAMIN (75 MG) (TABLET) .................................25
NOR-Q-D (0.35 MG) (TABLET) .....................................64
NORTHERA (100 MG) (CAPSULE) .............................. 60
NORTHERA (200 MG) (CAPSULE) .............................. 61
NORTHERA (300 MG) (CAPSULE) .............................. 61
NORTRIPTYLINE HCL................................................... 25
NORVASC (10 MG) (TABLET) ...................................... 51
NORVASC (2.5 MG) (TABLET) ..................................... 51
NORVASC (5 MG) (TABLET) ........................................ 51
NORVIR (100 MG) (CAPSULE) ...................................128
NORVIR (100 MG) (TABLET) ......................................129
NORVIR (80 MG/ML) (SOLUTION) ........................... 129
NOVACORT (2 %-1 %-1%) (GEL (GRAM)) ..................80
NOVOLIN 70-30 (70-30/ML) (VIAL) (OTC).......... 89, 196
NOVOLIN N (100/ML) (VIAL) (OTC).................... 90, 196
NOVOLIN R (100/ML) (VIAL) (OTC).................... 90, 196
NOVOLOG (100/ML) (CARTRIDGE) ....................88, 196
NOVOLOG (100/ML) (VIAL) .................................88, 196
NOVOLOG FLEXPEN (100/ML) (INSULN PEN) ...... 88,
196
NOVOLOG MIX 70-30 (70-30/ML) (VIAL) .......... 88, 196
NOVOLOG MIX 70-30 FLEXPEN (70-30/ML) (INSULN
PEN) ......................................................................... 88, 196
NOXAFIL (100 MG) (TABLET DR) .............................122
NOXAFIL (200 MG/5ML) (ORAL SUSP) ....................122
NUCORT (2.5 %) (LOTION) ...........................................76
NUCYNTA (100 MG) (TABLET) ................................. 162
NUCYNTA (50 MG) (TABLET) ................................... 162
NUCYNTA (75 MG) (TABLET) ................................... 162
NUCYNTA ER (100 MG) (TAB ER 12H) .....................162
NUCYNTA ER (150 MG) (TAB ER 12H) .....................162
NUCYNTA ER (200 MG) (TAB ER 12H) .....................162
NUCYNTA ER (250 MG) (TAB ER 12H) .....................162
NUCYNTA ER (50 MG) (TAB ER 12H) .......................162
NUDICLO (1.5-0.025%) (KIT CR-SOL) ........................ 77
NUEDEXTA (20 MG-10MG) (CAPSULE) ...................151
NULEV (0.125 MG) (TAB RAPDIS) ............................ 178
NULYTELY WITH FLAVOR PACKS (420G) (SOLN
RECON) ......................................................................... 143
NUOX (6%-3%) (GEL (GRAM)) .................................... 78
NUPLAZID (17 MG) (TABLET) .....................................38
NUVARING (.12-.015MG) (VAG RING) ........................63
NUVESSA (1.3 %) (GEL W/APPL) ..............................183
NUVIGIL (150 MG) (TABLET) ...................................... 36
NUVIGIL (200 MG) (TABLET) ...................................... 36
NUVIGIL (250 MG) (TABLET) ...................................... 36
NUVIGIL (50 MG) (TABLET) ........................................ 36
NYAMYC (100000/G) (POWDER) ................................. 71
NYMALIZE (60 MG/20ML) (SOLUTION) ....................53
NYSTATIN................................................................ 71, 122
NYSTATIN (500MM UNIT) (POWDER(EA)) ...................
NYSTATIN (50MM UNIT) (POWDER(EA)) .....................
NYSTATIN/TRIAMCIN................................................... 71
NYSTEX (100000/G) (OINT. (G)) .................................. 71
NYSTOP (100000/G) (POWDER) ...................................71
-OOB COMPLETE (50-1.25MG) (TABLET) ....................186
OBETICHOLIC ACID.................................................... 142
OBREDON (200-2.5/5) (SOLUTION) ............................ 66
OBSTETRIX EC (29-50-1MG) (TABLET DR) ............ 187
OCALIVA (10 MG) (TABLET) ..................................... 142
OCALIVA (5 MG) (TABLET) ....................................... 142
OCTREOTIDE ACETATE.............................................. 153
OCTREOTIDE ACETATE (100 MCG/ML) (AMPUL) .......
OCTREOTIDE ACETATE (100 MCG/ML) (SYRINGE)
...............................................................................................
OCTREOTIDE ACETATE (100 MCG/ML) (VIAL) ...........
OCTREOTIDE ACETATE (1000MCG/ML) (VIAL) ..........
OCTREOTIDE ACETATE (200 MCG/ML) (VIAL) ...........
OCTREOTIDE ACETATE (50 MCG/ML) (AMPUL) .........
OCTREOTIDE ACETATE (50 MCG/ML) (SYRINGE)
...............................................................................................
OCTREOTIDE ACETATE (50 MCG/ML) (VIAL) .............
OCTREOTIDE ACETATE (500 MCG/ML) (AMPUL) .......
OCTREOTIDE ACETATE (500 MCG/ML) (SYRINGE)
...............................................................................................
OCTREOTIDE ACETATE (500 MCG/ML) (VIAL) ...........
OCTREOTIDE ACETATE,MI-SPHERES..............153, 154
OCUFEN (0.03 %) (DROPS) ........................................... 99
OCUFLOX (0.3 %) (DROPS) ........................................ 101
OCUPRESS (1 %) (DROPS) ..........................................102
ODEFSEY (200-25-25) (TABLET) ............................... 129
ODOMZO (200 MG) (CAPSULE) ................................ 145
OFEV (100 MG) (CAPSULE) ....................................... 154
OFEV (150 MG) (CAPSULE) ....................................... 154
OFLOXACIN.....................................................91, 101, 119
OGEN 2.5 (3 MG) (TABLET) ....................................... 111
Sharp Health Plan: Covered California
OLANZAPINE.................................................................. 32
OLANZAPINE/FLUOXETINE HCL............................... 38
OLAPARIB......................................................................148
OLEPTRO ER (150 MG) (TAB ER 24H) ................ 22, 196
OLEPTRO ER (300 MG) (TAB ER 24H) ................ 22, 196
OLMESARTAN MEDOXOMIL.......................................48
OLMESARTAN/AMLODIPIN/HCTHIAZID.................. 44
OLMESARTAN/HYDROCHLOROTHIAZIDE...............45
OLODATEROL HCL........................................................ 15
OLOPATADINE HCL................................................. 11, 99
OLSALAZINE SODIUM................................................140
OLUX (0.05 %) (FOAM) ................................................. 74
OLUX-E (0.05 %) (FOAM) ............................................. 74
OLYSIO (150 MG) (CAPSULE) ................................... 131
OMBITA/PARITAP/RITON/DASABUVIR................... 131
OMBITASVIR/PARITAPREV/RITONAV..................... 131
OMECLAMOX-PAK (20(20)-500) (COMBO. PKG) ......
179
OMEGA-3 ACID ETHYL ESTERS................................. 60
OMEPRAZOLE.............................................................. 180
OMEPRAZOLE (10 MG) (CAPSULE DR) ........................
OMEPRAZOLE/CLARITH/AMOXICILLIN................ 179
OMEPRAZOLE/SODIUM BICARBONATE.................180
OMNARIS (50 MCG) (SPRAY/PUMP) .................. 11, 196
OMNICEF (125 MG/5ML) (SUSP RECON) ................ 115
OMNICEF (250 MG/5ML) (SUSP RECON) ................ 115
OMNICEF (300 MG) (CAPSULE) ................................115
OMNIPRED (1 %) (DROPS SUSP) .............................. 100
ONDANSETRON..............................................................12
ONDANSETRON HCL...............................................12, 13
ONEXTON (1.2%-3.75%) (GEL W/PUMP) ................... 67
ONFI (10 MG) (TABLET) ..................................... 175, 196
ONFI (2.5 MG/ML) (ORAL SUSP) .......................175, 196
ONFI (20 MG) (TABLET) ..................................... 175, 197
ONGLYZA (2.5 MG) (TABLET) .............................85, 197
ONGLYZA (5 MG) (TABLET) ................................85, 197
ONMEL (200 MG) (TABLET) ...................................... 122
ONZETRA XSAIL (11 MG) (AER POW BA) ...... 164,
197
OPANA (10 MG) (TABLET) ......................................... 162
OPANA (5 MG) (TABLET) ........................................... 162
OPANA ER (10 MG) (TAB ER 12H) .............................162
OPANA ER (15 MG) (TAB ER 12H) .............................162
OPANA ER (20 MG) (TAB ER 12H) .............................162
OPANA ER (30 MG) (TAB ER 12H) .............................162
OPANA ER (40 MG) (TAB ER 12H) .............................162
OPANA ER (5 MG) (TAB ER 12H) ...............................162
OPANA ER (7.5 MG) (TAB ER 12H) ............................162
OPIUM TINCTURE........................................................141
OPIUM TINCTURE (10 MG/ML) (TINCTURE) ...............
OPIUM/BELLADONNA ALKALOIDS........................ 160
OPIUM/BELLADONNA ALKALOIDS (30-16.2MG)
(SUPP.RECT) .......................................................................
OPIUM/BELLADONNA ALKALOIDS (60-16.2MG)
(SUPP.RECT) .......................................................................
OPSUMIT (10 MG) (TABLET) ....................................... 56
OPTICROM (4 %) (DROPS) ......................................... 101
OPTIPRANOLOL (0.3 %) (DROPS) .............................102
ORACEA (40 MG) (CAP IR DR) .................................. 121
ORACIT (640-490MG) (SOLUTION) .......................... 181
ORALAIR (100 IR) (TAB SUBL) ................................... 10
ORALAIR (100-300 IR) (TAB SUBL) ............................ 10
ORALAIR (300 IR) (TAB SUBL) ................................... 10
ORAP (1 MG) (TABLET) ................................................ 29
ORAP (2 MG) (TABLET) ................................................ 29
ORAPRED (15 MG/5 ML) (SOLUTION) .....................135
ORAPRED ODT (10 MG) (TAB RAPDIS) ...................135
ORAPRED ODT (15 MG) (TAB RAPDIS) ...................135
ORAPRED ODT (30 MG) (TAB RAPDIS) ...................135
ORAVIG (50 MG) (MA BUC TAB) .............................. 122
ORENITRAM ER (0.125 MG) (TABLET ER) ................56
ORENITRAM ER (0.25 MG) (TABLET ER) ..................56
ORENITRAM ER (1 MG) (TABLET ER) .......................56
ORENITRAM ER (2.5 MG) (TABLET ER) ....................56
ORFADIN (10 MG) (CAPSULE) .................................. 152
ORFADIN (2 MG) (CAPSULE) .................................... 152
ORFADIN (20 MG) (CAPSULE) .................................. 152
ORFADIN (4 MG/ML) (ORAL SUSP) ......................... 152
ORFADIN (5 MG) (CAPSULE) .................................... 152
ORINASE (500 MG) (TABLET) ..................................... 86
ORKAMBI (100-125 MG) (TABLET) .......................... 154
ORKAMBI (200-125MG) (TABLET) ........................... 154
ORPHENADRINE CITRATE.........................................176
ORTHO EVRA (150-35/24H) (PATCH TDWK) ............. 65
ORTHO MICRONOR (0.35 MG) (TABLET) ..................64
ORTHO TRI-CYCLEN (7DAYSX3 28) (TABLET) ........65
ORTHO TRI-CYCLEN LO (7DAYSX3 LO) (TABLET)
........................................................................................... 65
ORTHO-CYCLEN (0.25-0.035) (TABLET) ....................65
ORTHO-EST (0.75 MG) (TABLET) ..............................111
ORTHO-EST (1.5 MG) (TABLET) ................................111
ORUDIS (50 MG) (CAPSULE) ..................................... 138
Page 215 of 224
Index
ORUDIS (75 MG) (CAPSULE) ..................................... 138
ORUVAIL (200 MG) (CAP24H PEL) ........................... 138
OSELTAMIVIR PHOSPHATE....................................... 125
OSENI (12.5-15 MG) (TABLET) .................................... 83
OSENI (12.5-30 MG) (TABLET) .................................... 83
OSENI (12.5-45 MG) (TABLET) .................................... 83
OSENI (25 MG-15MG) (TABLET) ................................. 83
OSENI (25 MG-30MG) (TABLET) ................................. 83
OSENI (25 MG-45MG) (TABLET) ................................. 83
OSIMERTINIB MESYLATE..........................................148
OSMOPREP (1.5 G) (TABLET) .................................... 142
OSPEMIFENE...................................................................94
OSPHENA (60 MG) (TABLET) .............................. 94, 197
OTEZLA (10-20-30MG) (TAB DS PK) .........................134
OTEZLA (30 MG) (TABLET) ....................................... 134
OTIPRIO (6 %) (VIAL) ................................................... 90
OTOVEL (0.3-0.025%) (VIAL) ....................................... 91
OTREXUP (10MG/0.4ML) (AUTO INJCT) ................. 132
OTREXUP (12.5MG/0.4) (AUTO INJCT) .................... 132
OTREXUP (15MG/0.4ML) (AUTO INJCT) ................. 132
OTREXUP (17.5MG/0.4) (AUTO INJCT) .................... 132
OTREXUP (20MG/0.4ML) (AUTO INJCT) ................. 132
OTREXUP (22.5MG/0.4) (AUTO INJCT) .................... 132
OTREXUP (25MG/0.4ML) (AUTO INJCT) ................. 132
OTREXUP (7.5 MG/0.4) (AUTO INJCT) ..................... 132
OVACE (10 %) (CLEANSER) ......................................... 78
OVACE PLUS (10 %) (CLEANSR ER) ...........................78
OVACE PLUS (10 %) (CREAM (G)) .............................. 78
OVACE PLUS (10 %) (SHAMPOO) ............................... 78
OVACE PLUS (9.8 %) (FOAM) .......................................78
OVACE PLUS (9.8 %) (LOTION) ................................... 78
OVIDE (0.5 %) (LOTION) ...............................................71
OXANDRIN (10 MG) (TABLET) ................................. 107
OXANDRIN (2.5 MG) (TABLET) ................................ 107
OXANDROLONE........................................................... 107
OXAPROZIN...................................................................139
OXAYDO (5 MG) (TABLET ORL) ...............................160
OXAYDO (7.5 MG) (TABLET ORL) ............................160
OXAZEPAM......................................................................29
OXCARBAZEPINE........................................................ 173
OXICONAZOLE NITRATE............................................. 71
OXISTAT (1 %) (CREAM (G)) ........................................71
OXISTAT (1 %) (LOTION) ..............................................71
OXTELLAR XR (150 MG) (TAB ER 24H) .................. 173
OXTELLAR XR (300 MG) (TAB ER 24H) .................. 173
OXTELLAR XR (600 MG) (TAB ER 24H) .................. 173
OXY IR (5 MG) (CAPSULE) ........................................ 160
OXYBUTYNIN...............................................................182
OXYBUTYNIN CHLORIDE..........................................182
OXYCODONE HCL............................................... 160, 161
OXYCODONE HCL (10MG/0.5ML) (SYRINGE) .............
OXYCODONE HCL/ACETAMINOPHEN.................... 161
OXYCODONE HCL/ASPIRIN...................................... 161
OXYCODONE MYRISTATE................................. 161, 162
OXYCONTIN (10 MG) (TAB ER 12H) ........................ 160
OXYCONTIN (15 MG) (TAB ER 12H) ........................ 160
OXYCONTIN (20 MG) (TAB ER 12H) ........................ 161
OXYCONTIN (30 MG) (TAB ER 12H) ........................ 161
OXYCONTIN (40 MG) (TAB ER 12H) ........................ 161
OXYCONTIN (60 MG) (TAB ER 12H) ........................ 161
OXYCONTIN (80 MG) (TAB ER 12H) ........................ 161
OXYMETHOLONE........................................................ 107
OXYMORPHONE HCL................................................. 162
OXYTROL (3.9MG/24HR) (PATCH TDSW) ....... 182, 197
-PPACERONE (100 MG) (TABLET) .................................. 40
PACERONE (400 MG) (TABLET) .................................. 40
PACNEX HP (7 %) (MED. PAD) .....................................78
PACNEX LP (4.25 %) (MED. PAD) ................................ 78
PACNEX MX (4.25 %) (CLEANSER) ............................ 78
PALBOCICLIB............................................................... 148
PALIPERIDONE......................................................... 32, 33
PAMELOR (10 MG) (CAPSULE) ................................... 25
PAMELOR (10 MG/5 ML) (SOLUTION) .......................25
PAMELOR (25 MG) (CAPSULE) ................................... 25
PAMELOR (50 MG) (CAPSULE) ................................... 25
PAMELOR (75 MG) (CAPSULE) ................................... 25
PAMINE (2.5 MG) (TABLET) .......................................178
PAMINE FORTE (5 MG) (TABLET) ............................ 178
PANDEL (0.1 %) (CREAM (G)) ..................................... 76
PANMYCIN (250 MG) (CAPSULE) .............................121
PANOBINOSTAT LACTATE..........................................149
PANRETIN (0.1 %) (GEL (GRAM)) ...............................80
PANTOPRAZOLE SODIUM..........................................180
PARAFON FORTE DSC (500 MG) (TABLET) ............ 175
PARCOPA (10MG-100MG) (TAB RAPDIS) ................ 166
PARCOPA (25MG-100MG) (TAB RAPDIS) ................ 166
PARCOPA (25MG-250MG) (TAB RAPDIS) ................ 166
PAREGORIC................................................................... 141
PAREGORIC (2 MG/5 ML) (LIQUID) ...............................
PAREMYD (1 %-0.25 %) (DROPS) .............................. 103
PARICALCITOL...............................................................94
PARLODEL (2.5 MG) (TABLET) ................................. 166
PARLODEL (5 MG) (CAPSULE) ................................. 166
PARNATE (10 MG) (TABLET) ....................................... 20
PAROMOMYCIN SULFATE..........................................124
PAROXETINE HCL....................................................21, 22
PAROXETINE MESYLATE............................................. 22
PASER (4 G) (GRANPKT DR) ......................................123
PATADAY (0.2 %) (DROPS) ............................................99
PATANASE (0.6 %) (SPRAY/PUMP) ..............................11
PATANOL (0.1 %) (DROPS) ........................................... 99
PATHOCIL (250 MG) (CAPSULE) ...............................119
PATHOCIL (500 MG) (CAPSULE) ...............................119
PATIROMER CALCIUM SORBITEX....................... 91, 92
PAXIL (10 MG) (TABLET) ............................................. 21
PAXIL (10 MG/5 ML) (ORAL SUSP) .............................21
PAXIL (20 MG) (TABLET) ............................................. 21
PAXIL (30 MG) (TABLET) ............................................. 21
PAXIL (40 MG) (TABLET) ............................................. 21
PAXIL CR (12.5 MG) (TAB ER 24H) ............................. 22
PAXIL CR (25 MG) (TAB ER 24H) ................................ 22
PAXIL CR (37.5 MG) (TAB ER 24H) ............................. 22
PAZEO (0.7 %) (DROPS) ................................................ 99
PAZOPANIB HCL...........................................................148
PCE (333 MG) (TAB PART) .......................................... 117
PCE (500 MG) (TAB PART) .......................................... 117
PED MV A,C,D3 #21 W-FLUORIDE............................ 186
PED MV A,C,D3 #21 W-FLUORIDE (0.25 MG/ML)
(DROPS) ...............................................................................
PED MV A,C,D3 #21 W-FLUORIDE (0.5 MG/ML)
(DROPS) ...............................................................................
PEDIAPRED (5 MG/5 ML) (SOLUTION) ................... 135
PEDIATRIC MASK (OTC)...............................................18
PEG 3350/NA SULF,BICARB,CL/KCL........................ 142
PEG 3350/SOD CHLOR/POTASS CIT.......................... 142
PEG3350/SOD SUL/NACL/ASB/C/KCL.......................142
PEGANONE (250 MG) (TABLET) ............................... 170
PEGASYS (180MCG/0.5) (SYRINGE) .........................130
PEGASYS (180MCG/ML) (VIAL) ............................... 130
PEGASYS PROCLICK (135MCG/0.5) (PEN INJCTR)
......................................................................................... 130
PEGASYS PROCLICK (180MCG/0.5) (PEN INJCTR)
......................................................................................... 130
PEGFILGRASTIM..........................................................106
PEGINTERFERON ALFA-2A........................................130
PEGINTERFERON ALFA-2B................................130, 146
PEGINTRON (120MCG/0.5) (KIT) ...............................130
PEGINTRON (150MCG/0.5) (KIT) ...............................130
PEGINTRON (50 MCG/0.5) (KIT) ................................130
PEGINTRON (80MCG/0.5) (KIT) .................................130
PEGINTRON REDIPEN (120MCG/0.5) (PEN IJ KIT) ......
130
PEGINTRON REDIPEN (150MCG/0.5) (PEN IJ KIT) ......
130
PEGINTRON REDIPEN (50 MCG/0.5) (PEN IJ KIT) ......
130
PEGINTRON REDIPEN (80MCG/0.5) (PEN IJ KIT) ......
130
PEG-PREP (5 MG-210 G) (KIT) ................................... 142
PEN NEEDLE, DIABETIC.............................................153
PEN NEEDLES (OTC)........................................... 153, 197
PENBUTOLOL SULFATE............................................... 50
PENCICLOVIR................................................................. 72
PENICILLAMINE.......................................................... 132
PENICILLIN V POTASSIUM........................................ 119
PENICILLIN V POTASSIUM (500 MG) (TABLET) ..........
PENLAC (8 %) (SOLUTION) ......................................... 70
PENNSAID (1.5 %) (DROPS) ................................. 77, 197
PENNSAID (20MG/G(2%)) (SOL MD PMP) .........77, 197
PENTAMIDINE ISETHIONATE....................................125
PENTASA (250 MG) (CAPSULE ER) .................. 139, 197
PENTASA (500 MG) (CAPSULE ER) .................. 140, 197
PENTAZINE VC WITH CODEINE (6.25-5-10) (SYRUP)
..................................................................................... 65, 66
PENTAZOCINE HCL/NALOXONE HCL..................... 162
PENTOSAN POLYSULFATE SODIUM........................182
PENTOXIFYLLINE........................................................105
PEPCID (20 MG) (TABLET) .........................................179
PEPCID (40 MG) (TABLET) .........................................179
PEPCID (40MG/5ML) (ORAL SUSP) .......................... 179
P-EPHED HCL/CHLOR-MAL/BELL ALK.....................65
P-EPHED HCL/CHLOR-MAL/BELL ALK (90-8-0.24)
(TAB ER 12H) ......................................................................
P-EPHED HCL/CODEINE/GUAIFEN.............................66
P-EPHED HCL/HYDROCODONE.................................. 66
PERAMPANEL............................................................... 173
PERCOCET (10MG-325MG) (TABLET) ..................... 161
PERCOCET (2.5-325 MG) (TABLET) ..........................161
PERCOCET (5 MG-325MG) (TABLET) ...................... 161
PERCOCET (7.5-325 MG) (TABLET) ..........................161
PERCODAN (4.8355-325) (TABLET) .......................... 161
PERFOROMIST (20 MCG/2ML) (VIAL-NEB) ............. 15
Sharp Health Plan: Covered California
PERIACTIN (2 MG/5 ML) (SYRUP) .............................. 10
PERIACTIN (4 MG) (TABLET) ......................................10
PERINDOPRIL ARG/AMLODIPINE BES......................42
PERINDOPRIL ERBUMINE........................................... 47
PERMETHRIN..................................................................71
PERMETHRIN (5 %) (CREAM (G)) ..................................
PERPHENAZINE..............................................................35
PERPHENAZINE/AMITRIPTYLINE HCL.....................24
PERSANTINE (25 MG) (TABLET) .............................. 106
PERSANTINE (50 MG) (TABLET) .............................. 106
PERSANTINE (75 MG) (TABLET) .............................. 106
PERTZYE (16K-57.5K) (CAPSULE DR) ..................... 177
PERTZYE (8K-28.75K) (CAPSULE DR) ..................... 177
PEXEVA (10 MG) (TABLET) ......................................... 22
PEXEVA (20 MG) (TABLET) ......................................... 22
PEXEVA (30 MG) (TABLET) ......................................... 22
PEXEVA (40 MG) (TABLET) ......................................... 22
PHEN TUSS DM (6.25-15/5) (SYRUP) .......................... 67
PHENAZOPYRIDINE HCL........................................... 182
PHENELZINE SULFATE................................................. 20
PHENERGAN (12.5 MG) (TABLET) ............................. 11
PHENERGAN (25 MG) (TABLET) ................................ 11
PHENERGAN (50 MG) (TABLET) ................................ 11
PHENERGAN (12.5 MG) (SUPP.RECT) ........................ 13
PHENERGAN (25 MG) (SUPP.RECT) ........................... 13
PHENERGAN (50 MG) (SUPP.RECT) ........................... 13
PHENERGAN VC (5-6.25MG/5) (SYRUP) ....................65
PHENERGAN VC (6.25MG/5ML) (SYRUP) ................. 11
PHENERGAN VC WITH CODEINE (6.25-5-10)
(SYRUP) ........................................................................... 66
PHENERGAN WITH CODEINE (6.25-10/5) (SYRUP)
........................................................................................... 66
PHENOBARB/HYOSCY/ATROPINE/SCOP................ 178
PHENOBARBITAL.......................................................... 36
PHENOBARBITAL (100 MG) (TABLET) ..........................
PHENOBARBITAL (15 MG) (TABLET) ............................
PHENOBARBITAL (16.2 MG) (TABLET) .........................
PHENOBARBITAL (20 MG/5 ML) (ELIXIR) ...................
PHENOBARBITAL (30 MG) (TABLET) ............................
PHENOBARBITAL (32.4 MG) (TABLET) .........................
PHENOBARBITAL (60 MG) (TABLET) ............................
PHENOBARBITAL (64.8 MG) (TABLET) .........................
PHENOBARBITAL (97.2MG) (TABLET) ..........................
PHENOHYTRO (16.2 MG) (TABLET) .........................178
PHENOXYBENZAMINE HCL........................................44
PHEN-TUSS AD (5-6.25MG/5) (SYRUP) ...................... 65
PHENYLEPHRINE HCL................................................100
PHENYLEPHRINE HCL (10 %) (DROPS) ........................
PHENYLEPHRINE HCL/PROMETH HCL.....................65
PHENYTEK (200 MG) (CAPSULE) .............................173
PHENYTEK (300 MG) (CAPSULE) .............................173
PHENYTOIN.................................................................. 173
PHENYTOIN SODIUM EXTENDED........................... 173
PHOSLO (667 MG) (CAPSULE) .................................... 91
PHOSLO (667 MG) (TABLET) ....................................... 91
PHOSLYRA (667 MG/5ML) (SOLUTION) ....................91
PHOSPHASAL (81.6-10.8) (TABLET) ......................... 116
PHOSPHOLINE IODIDE (0.125 %) (DROPS) .............102
PHOSPHORUS #1.......................................................... 181
PHYTONADIONE.......................................................... 107
PICATO (0.015 %) (GEL (EA)) ....................................... 80
PICATO (0.05 %) (GEL (EA)) ......................................... 80
PILOCARPINE HCL.............................................. 102, 143
PIMAVANSERIN TARTRATE......................................... 38
PIMECROLIMUS............................................................. 82
PIMOZIDE........................................................................ 29
PINDOLOL....................................................................... 50
PIOGLITAZONE HCL......................................................86
PIOGLITAZONE HCL/GLIMEPIRIDE........................... 87
PIOGLITAZONE HCL/METFORMIN HCL................... 88
PIRFENIDONE............................................................... 154
PIROXICAM................................................................... 139
PITAVASTATIN CALCIUM............................................. 58
PLAN B ONE-STEP (1.5 MG) (TABLET) (OTC)........... 64
PLAQUENIL (200 MG) (TABLET) .............................. 125
PLAVIX (300 MG) (TABLET) ...................................... 106
PLAVIX (75 MG) (TABLET) ........................................ 106
PLENDIL (10 MG) (TAB ER 24H) ................................. 53
PLENDIL (2.5 MG) (TAB ER 24H) ................................ 53
PLENDIL (5 MG) (TAB ER 24H) ................................... 53
PLERIXAFOR.................................................................152
PLETAL (100 MG) (TABLET) ...................................... 106
PLETAL (50 MG) (TABLET) ........................................ 106
PLEXION (10-5%(W/W)) (LOTION) ............................. 73
PLEXION (9.8%-4.8%) (CLEANSER) ........................... 73
PLEXION (9.8%-4.8%) (CREAM (G)) ........................... 73
PLEXION (9.8%-4.8%) (LOTION) ................................. 73
PLEXION (9.8%-4.8%) (MED. PAD) ............................. 73
PLEXION TS (10-5%(W/W)) (SUSPENSION) .............. 73
PLIAGLIS (7 %-7 %) (CREAM (G)) ...............................81
PN VIT.W-O CA #7, IRON,FA,DHA............................. 186
Page 216 of 224
Index
PN VIT.W-O CA #7, IRON,FA,DHA (28-1.25MG)
(CAPSULE) ..........................................................................
PNV #14/FERROUS FUM/FOLIC ACID...................... 186
PNV #14/FERROUS FUM/FOLIC ACID (29 MG-1 MG)
(TAB CHEW) .......................................................................
PNV 10/IRON FPS/FOLIC ACID/OM3......................... 186
PNV 10/IRON FPS/FOLIC ACID/OM3 (30-1-310.1)
(CAPSULE) ..........................................................................
PNV 3/IRON FUM,GLUC/FOLIC ACID.......................186
PNV CMB#21/IRON/FOLIC ACID............................... 186
PNV NO.118/IRON FUMARATE/FA............................ 186
PNV NO.118/IRON FUMARATE/FA (29 MG-1 MG)
(TAB CHEW) .......................................................................
PNV WITH CA#74/IRON/FOLIC ACID....................... 186
PNV WITH CA#74/IRON/FOLIC ACID (27 MG-1 MG)
(TABLET) .............................................................................
PNV WITH CA,NO.72/IRON/FA...................................186
PNV WITH CA,NO.72/IRON/FA (27 MG-1 MG)
(TABLET) .............................................................................
PNV W-O CA NO5/IRON FUM/FA............................... 186
PNV W-O CA NO5/IRON FUM/FA (106.5-1MG)
(CAPSULE) ..........................................................................
PNV W-O IRON/FA/CALCIUM/B6/B12....................... 187
PNV,CA,NO.35/IRON/FA/DS/OMEG-3........................ 186
PNV,CA,NO.35/IRON/FA/DS/OMEG-3 (27-1-50 MG)
(CAPSULE) ..........................................................................
PNV/FERROUS FUMARATE/FA/SE............................ 186
PNV/FERROUS FUMARATE/FA/SE (27 MG-1 MG)
(TABLET) .............................................................................
PNV/IRON FUM/DOCUSATE/FA................................. 186
PNV/IRON FUM/DOCUSATE/FA (90-50-1MG)
(TABLET ER) .......................................................................
PNV/IRON,CARBONYL/DOCUSATE/FA....................186
PNV/IRON,CARBONYL/DOCUSATE/FA (90-50-1MG)
(TABLET) .............................................................................
PNV119/IRON FUMARATE/FA/DSS............................186
PNV119/IRON FUMARATE/FA/DSS (29-1-25 MG)
(TABLET) .............................................................................
PNV19/IRON BD HC,S-P/FOLIC/OM3........................ 186
PNV19/IRON BD HC,S-P/FOLIC/OM3 (29-1-400MG)
(CMBPKGDRCP) ................................................................
PNV2/IRON B-G SUC-P/FA/OMEGA-3............... 186, 187
PNV53/IRON B-G HCL-P/FA/OMEGA3...................... 187
PNV53/IRON B-G HCL-P/FA/OMEGA3 (29-1-400MG)
(COMBO. PKG) ...................................................................
PNV7/FE ASP GLY/DOCUSATE/FA............................ 187
PNV7/FE ASP GLY/DOCUSATE/FA (30-50-1MG)
(TABLET) .............................................................................
PNV95/FERROUS FUMARATE/FA..............................187
PNV95/FERROUS FUMARATE/FA (28MG-0.8MG)
(TABLET) (OTC)..................................................................
PODOFILOX.....................................................................78
PODOPHYLLUM RESIN.................................................78
PODOPHYLLUM RESIN (25 %) (LIQUID) ......................
POLYETHYLENE GLYCOL 3350.........................142, 143
POLYMYXIN B SULF/TRIMETHOPRIM....................101
POLYTRIM (10000-1/ML) (DROPS) ............................101
POMALIDOMIDE.......................................................... 146
POMALYST (1 MG) (CAPSULE) .................................146
POMALYST (2 MG) (CAPSULE) .................................146
POMALYST (3 MG) (CAPSULE) .................................146
POMALYST (4 MG) (CAPSULE) .................................146
PONATINIB HCL........................................................... 148
PONSTEL (250 MG) (CAPSULE) ................................ 138
POSACONAZOLE..........................................................122
POT CHLORIDE/POT BICARB/CIT AC........................ 92
POT CHLORIDE/POT BICARB/CIT AC (25 MEQ)
(TABLET EFF) .....................................................................
POTABA (500 MG) (CAPSULE) .................................. 187
POTASSIUM AMINOBENZOATE................................ 187
POTASSIUM BICARBONATE/CIT AC.......................... 92
POTASSIUM CHLORIDE.......................................... 92, 93
POTASSIUM CHLORIDE (10 MEQ) (TAB ER PRT) ........
POTASSIUM CHLORIDE (15 MEQ) (TAB ER PRT) ........
POTASSIUM CHLORIDE (20 MEQ) (TAB ER PRT) ........
POTASSIUM CITRATE..................................................181
POTASSIUM CITRATE/CITRIC ACID.........................182
POTASSIUM HYDROXIDE.............................................78
POTASSIUM HYDROXIDE (5 %) (SOLUTION) ..............
POTASSIUM IODIDE...................................................... 95
POTASSIUM IODIDE (1 G/ML) (SOLUTION) .................
POTASSIUM IODIDE/IODINE........................................95
POTASSIUM IODIDE/IODINE (5 %) (SOLUTION) .........
POTASSIUM PHOSPHATE,MONOBASIC...................182
POTIGA (200 MG) (TABLET) ...................................... 170
POTIGA (300 MG) (TABLET) ...................................... 170
POTIGA (400 MG) (TABLET) ...................................... 170
POTIGA (50 MG) (TABLET) ........................................ 170
POVIDONE-IODINE........................................................ 81
PRADAXA (110 MG) (CAPSULE) .......................107, 197
PRADAXA (150 MG) (CAPSULE) .......................107, 197
PRADAXA (75 MG) (CAPSULE) .........................107, 197
PRAMCORT (1 %-1 %) (CREAM/APPL) .................... 140
PRAMIPEXOLE DI-HCL...............................................167
PRAMLINTIDE ACETATE.............................................. 84
PRAMOSONE (1 %-1 %) (CREAM (G)) ........................80
PRAMOSONE (1 %-1 %) (LOTION) ..............................80
PRAMOSONE (1 %-1 %) (OINT. (G)) ............................80
PRAMOSONE (2.5 %-1 %) (CREAM (G)) .....................80
PRAMOSONE (2.5 %-1 %) (LOTION) ...........................80
PRAMOSONE (2.5 %-1 %) (OINT. (G)) .........................80
PRAMOSONE E (2.5 %-1 %) (CREAM (G)) ................. 80
PRANDIMET (1MG-500MG) (TABLET) ...................... 87
PRANDIMET (2 MG-500MG) (TABLET) ..................... 87
PRANDIN (0.5 MG) (TABLET) ......................................85
PRANDIN (1 MG) (TABLET) .........................................85
PRANDIN (2 MG) (TABLET) .........................................85
PRASUGREL HCL......................................................... 106
PRAVACHOL (10 MG) (TABLET) ................................. 58
PRAVACHOL (20 MG) (TABLET) ................................. 58
PRAVACHOL (40 MG) (TABLET) ................................. 58
PRAVACHOL (80 MG) (TABLET) ................................. 59
PRAVASTATIN SODIUM...........................................58, 59
PRAZIQUANTEL........................................................... 124
PRAZOSIN HCL...............................................................44
PRE-ATTACHED LTA KIT (4 %) (SOLUTION) ............81
PRECOSE (100 MG) (TABLET) ..................................... 84
PRECOSE (25 MG) (TABLET) ....................................... 84
PRECOSE (50 MG) (TABLET) ....................................... 84
PRED FORTE (1 %) (DROPS SUSP) ............................100
PRED MILD (0.12 %) (DROPS SUSP) ......................... 100
PRED-G (0.3%-1%) (DROPS SUSP) .............................. 98
PRED-G (0.3-0.6%) (OINT. (G)) ..................................... 98
PREDNICARBATE...........................................................77
PREDNISOLONE........................................................... 135
PREDNISOLONE ACETATE.........................................100
PREDNISOLONE SOD PHOSPHATE.................. 100, 135
PREDNISOLONE SOD PHOSPHATE (1 %) (DROPS)
...............................................................................................
PREDNISOLONE SOD PHOSPHATE (25 MG/5 ML)
(SOLUTION) ........................................................................
PREDNISONE................................................................ 135
PREDNISONE (20 MG) (TABLET) ....................................
PREDNISONE (5 MG/5 ML) (SOLUTION) .......................
PREDNISONE INTENSOL (5 MG/ML) (ORAL CONC)
...............................................................................................
PREFEST (1-1-0.09MG) (TABLET) ............................. 110
PREGABALIN........................................................ 173, 174
PREMARIN (0.3 MG) (TABLET) ................................. 110
PREMARIN (0.45MG) (TABLET) ................................ 110
PREMARIN (0.625 MG) (TABLET) ............................. 110
PREMARIN (0.625 MG/G) (CREAM/APPL) .......183, 197
PREMARIN (0.9 MG) (TABLET) ................................. 111
PREMARIN (1.25 MG) (TABLET) ............................... 111
PREMESIS RX (1-200-75) (TBMP 24HR) ................... 187
PREMPHASE (0.625 (14)) (TABLET) ..........................110
PREMPRO (0.3-1.5MG) (TABLET) ..............................110
PREMPRO (0.45-1.5MG) (TABLET) ............................110
PREMPRO (0.625-2.5) (TABLET) ................................ 110
PREMPRO (0.625-5 MG) (TABLET) ............................110
PRENAT VIT COMB.10/IRON/FA/DHA...................... 187
PRENAT VIT COMB.10/IRON/FA/DHA (65-1-250MG)
(COMBO. PKG) ...................................................................
PRENATAL COMPLETE (14 MG-400) (TABLET) (OTC)
......................................................................................... 186
PRENATAL VIT #105/IRON/FA/DHA.......................... 187
PRENATAL VIT #76/IRON,CARB/FA.......................... 187
PRENATAL VIT #76/IRON,CARB/FA (29 MG-1 MG)
(TABLET) .............................................................................
PRENATAL VIT 15/IRON CB/FA/DSS......................... 187
PRENATAL VIT 15/IRON CB/FA/DSS (90-1-50 MG)
(TABLET) .............................................................................
PRENATAL VIT 16/IRON CB/FA/DSS......................... 187
PRENATAL VIT 16/IRON CB/FA/DSS (90-1-50 MG)
(TABLET) .............................................................................
PRENATAL VIT 18/IRON CB/FA/DSS......................... 187
PRENATAL VIT 18/IRON CB/FA/DSS (90-1-50 MG)
(TABLET) .............................................................................
PRENATAL VIT NO.109/IRON/FA............................... 187
PRENATAL VIT NO.109/IRON/FA (40-1MG) (TAB
CHEW) .................................................................................
PRENATAL VIT NO.127/IRON/FA............................... 187
PRENATAL VIT NO.127/IRON/FA (15 MG-1 MG)
(TABLET) .............................................................................
PRENATAL VIT NO.129/IRON/FA............................... 187
PRENATAL VIT NO.129/IRON/FA (27MG-0.8MG)
(TABLET) (OTC)..................................................................
PRENATAL VIT NO.73/IRON/FA................................. 187
PRENATAL VIT NO.73/IRON/FA (28 MG-1 MG)
(TABLET) .............................................................................
PRENATAL VIT NO.78/IRON/FA................................. 187
PRENATAL VIT NO.78/IRON/FA (29 MG-1 MG)
(TABLET) .............................................................................
PRENATAL VIT#96/FERROUS FUM/FA..................... 187
Sharp Health Plan: Covered California
PRENATAL VIT#96/FERROUS FUM/FA (27MG-0.8MG)
(TABLET) (OTC)..................................................................
PRENATAL VIT/IRON BISGLYCIN/FA....................... 187
PRENATAL VIT/IRON BISGLYCIN/FA (29 MG-1 MG)
(TABLET) .............................................................................
PRENATAL VIT/IRON FUMARATE/FA...................... 187
PRENATAL VIT/IRON FUMARATE/FA (27MG-0.8MG)
(TABLET) (OTC)..................................................................
PRENATAL VIT/IRON FUMARATE/FA (28MG-0.8MG)
(TABLET) (OTC)..................................................................
PRENATAL VIT/IRON FUMARATE/FA (65 MG-1 MG)
(CAPSULE) ..........................................................................
PRENATAL VIT/IRON FUMARATE/FA (66-1MG)
(TABLET) .............................................................................
PRENATAL VIT27,CALCIUM/IRON/FA......................187
PREPOPIK (10 MG-12 G) (POWD PACK) ...................143
PRESTALIA (14MG-10MG) (TABLET) .................42, 197
PRESTALIA (3.5-2.5 MG) (TABLET) .................... 42, 197
PRESTALIA (7 MG-5 MG) (TABLET) ...................42, 197
PREVACID (15 MG) (TAB RAP DR) ................... 180, 197
PREVACID (30 MG) (CAPSULE DR) ..................180, 197
PREVACID (30 MG) (TAB RAP DR) ................... 180, 197
PREVPAC (30-500-500) (COMBO. PKG) .................... 179
PREZCOBIX (800-150 MG) (TABLET) ....................... 126
PREZISTA (100 MG/ML) (ORAL SUSP) .....................126
PREZISTA (150 MG) (TABLET) .................................. 126
PREZISTA (600 MG) (TABLET) .................................. 126
PREZISTA (75 MG) (TABLET) .................................... 126
PREZISTA (800 MG) (TABLET) .................................. 126
PRIFTIN (150 MG) (TABLET) ..................................... 123
PRILOSEC (10 MG) (CAPSULE DR) .......................... 180
PRILOSEC (20 MG) (CAPSULE DR) .......................... 180
PRILOSEC (40 MG) (CAPSULE DR) .......................... 180
PRIMAQUINE (26.3 MG) (TABLET) ...........................125
PRIMAQUINE PHOSPHATE.........................................125
PRIMIDONE................................................................... 174
PRIMLEV (10MG-300MG) (TABLET) ........................ 161
PRIMLEV (5 MG-300MG) (TABLET) ......................... 161
PRIMLEV (7.5-300 MG) (TABLET) .............................161
PRIMSOL (50 MG/5 ML) (SOLUTION) ...................... 116
PRINIVIL (10 MG) (TABLET) ....................................... 46
PRINIVIL (20 MG) (TABLET) ....................................... 46
PRINIVIL (5 MG) (TABLET) ......................................... 46
PRISTIQ ER (100 MG) (TAB ER 24H) ...................23, 197
PRISTIQ ER (25 MG) (TAB ER 24H) .............................23
PRISTIQ ER (50 MG) (TAB ER 24H) .....................23, 197
PROAIR HFA (90 MCG) (HFA AER AD) ...................... 14
PROAIR RESPICLICK (90 MCG) (AER POW BA) ...... 14
PROAMATINE (10 MG) (TABLET) ............................... 61
PROAMATINE (2.5 MG) (TABLET) .............................. 61
PROAMATINE (5 MG) (TABLET) ................................. 61
PRO-BANTHINE (15 MG) (TABLET) ......................... 178
PROBENECID................................................................ 104
PROCARBAZINE HCL.................................................. 149
PROCARDIA (10 MG) (CAPSULE) ...............................53
PROCARDIA (20 MG) (CAPSULE) ...............................53
PROCARDIA XL (30 MG) (TAB ER 24) ........................53
PROCARDIA XL (60 MG) (TAB ER 24) ........................53
PROCARDIA XL (60 MG) (TABLET ER) ..................... 53
PROCARDIA XL (90 MG) (TAB ER 24) ........................53
PROCARDIA XL (90 MG) (TABLET ER) ..................... 53
PROCENTRA (5 MG/5 ML) (SOLUTION) ....................26
PROCHLORPERAZINE...................................................13
PROCHLORPERAZINE MALEATE............................... 13
PROCORT (1.85-1.15%) (CREAM/APPL) ................... 140
PROCTOFOAM-HC (1 %-1 %) (FOAM) ......................140
PROCYSBI (25 MG) (CAP DR SPR) ............................181
PROCYSBI (75 MG) (CAP DR SPR) ............................181
PRODRIN (65-20-325) (TABLET) ................................ 163
PROFERRIN-FORTE (12-1MG) (TABLET) .................185
PROGESTERONE,MICRONIZED...........................93, 111
PROGLYCEM (50 MG/ML) (ORAL SUSP) ...................88
PROGRAF (0.5 MG) (CAPSULE) ................................ 113
PROGRAF (1 MG) (CAPSULE) ................................... 113
PROGRAF (5 MG) (CAPSULE) ................................... 113
PROLENSA (0.07 %) (DROPS) ...................................... 99
PROLIA (60 MG/ML) (SYRINGE) .................................93
PROLIXIN (1 MG) (TABLET) ........................................ 35
PROLIXIN (10 MG) (TABLET) ...................................... 35
PROLIXIN (2.5 MG) (TABLET) ..................................... 35
PROLIXIN (2.5 MG/5ML) (ELIXIR) ..............................35
PROLIXIN (5 MG) (TABLET) ........................................ 35
PROLIXIN (5 MG/ML) (ORAL CONC) ......................... 35
PROLOPRIM (100 MG) (TABLET) ..............................116
PROMACTA (12.5 MG) (TABLET) .............................. 107
PROMACTA (25 MG) (TABLET) ................................. 107
PROMACTA (50 MG) (TABLET) ................................. 107
PROMACTA (75 MG) (TABLET) ................................. 107
PROMETHAZINE HCL............................................. 11, 13
PROMETHAZINE HCL/CODEINE.................................66
PROMETHAZINE/DEXTROMETHORPHAN............... 67
PROMETHAZINE/PHENYLEPH/CODEINE........... 65, 66
Page 217 of 224
Index
PROMETRIUM (100 MG) (CAPSULE) ....................... 111
PROMETRIUM (200 MG) (CAPSULE) ....................... 111
PROPAFENONE HCL...................................................... 41
PROPANTHELINE BROMIDE......................................178
PROPRANOLOL HCL..................................................... 50
PROPRANOLOL/HYDROCHLOROTHIAZID...............51
PROPYLTHIOURACIL.................................................... 95
PROPYLTHIOURACIL (50 MG) (TABLET) .....................
PROSCAR (5 MG) (TABLET) .......................................181
PROSOM (1 MG) (TABLET) .......................................... 37
PROSOM (2 MG) (TABLET) .......................................... 37
PROSTEP (22 MG/24HR) (PATCH TD24) (OTC).........176
PROTONIX (20 MG) (TABLET DR) ............................ 180
PROTONIX (40 MG) (GRANPKT DR) ........................ 180
PROTONIX (40 MG) (TABLET DR) ............................ 180
PROTOPIC (0.03 %) (OINT. (G)) ............................82, 197
PROTOPIC (0.1 %) (OINT. (G)) ..............................82, 197
PROTRIPTYLINE HCL....................................................26
PROVENTIL (2 MG) (TABLET) .....................................14
PROVENTIL (2 MG/5 ML) (SYRUP) .............................14
PROVENTIL (2.5 MG/3ML) (VIAL-NEB) .....................14
PROVENTIL (4 MG) (TABLET) .....................................14
PROVENTIL (5 MG/ML) (SOLUTION) .........................14
PROVENTIL HFA (90 MCG) (HFA AER AD) .......14, 197
PROVERA (10 MG) (TABLET) .................................... 111
PROVERA (2.5 MG) (TABLET) ................................... 111
PROVERA (5 MG) (TABLET) ...................................... 111
PROVIGIL (100 MG) (TABLET) .................................... 36
PROVIGIL (200 MG) (TABLET) .................................... 36
PROZAC (10 MG) (CAPSULE) ...................................... 21
PROZAC (10 MG) (TABLET) ......................................... 21
PROZAC (20 MG) (CAPSULE) ...................................... 21
PROZAC (20 MG) (TABLET) ......................................... 21
PROZAC (20 MG/5 ML) (SOLUTION) .......................... 21
PROZAC (40 MG) (CAPSULE) ...................................... 21
PROZAC WEEKLY (90 MG) (CAPSULE DR) .............. 21
PRUDOXIN (5 %) (CREAM (G)) ....................................77
PRUSSIAN BLUE (INSOLUBLE).................................153
PSEUDOEPHEDRINE HCL/ACRIVAS...........................10
PSORCON (0.05 %) (CREAM (G)) ................................ 75
PULMICORT (0.25MG/2ML) (AMPUL-NEB) .............. 16
PULMICORT (0.5 MG/2ML) (AMPUL-NEB) ............... 16
PULMICORT (1 MG/2 ML) (AMPUL-NEB) ................. 16
PULMICORT FLEXHALER (180 MCG) (AER POW BA)
........................................................................................... 16
PULMICORT FLEXHALER (90 MCG) (AER POW BA)
........................................................................................... 16
PULMOZYME (1 MG/ML) (SOLUTION) ................... 154
PURALOR CI (3.6-5-2.5) (TAB CH BPH) ....................184
PUREVIT DUALFE PLUS (106 MG-1MG) (CAPSULE)
......................................................................................... 185
PURINETHOL (50 MG) (TABLET) ............................. 144
PURIXAN (20 MG/ML) (ORAL SUSP) ....................... 145
PV W-O CAL/FERROUS FUMARATE/FA................... 187
PV W-O CAL/IRON PS CPLX/FA................................. 187
PV W-O CAL/IRON PS CPLX/FA (29 MG-1 MG) (TAB
CHEW) .................................................................................
PV W-O CAL/IRON,CARB/DOCUS/FA....................... 187
PYLERA (125-125 MG) (CAPSULE) ...........................179
PYRAZINAMIDE........................................................... 123
PYRAZINAMIDE (500 MG) (TABLET) ............................
PYRIDIUM (100 MG) (TABLET) .................................182
PYRIDIUM (200 MG) (TABLET) .................................182
PYRIDOSTIGMINE BROMIDE...................................... 19
PYRIMETHAMINE........................................................125
PYROGALLIC ACID (25 %) (OINT. (G)) ...................... 82
PYROGALLOL.................................................................82
-QQBRELIS (1 MG/ML) (SOLUTION) ......................46, 197
QNASL (80 MCG) (HFA AER AD) ........................ 11, 197
QNASL CHILDREN (40 MCG) (HFA AER AD) ...... 11,
197
QUALAQUIN (324 MG) (CAPSULE) .......................... 125
QUARTETTE (0.15MG(84)) (TBDSPK 3MO) ............... 64
QUAZEPAM......................................................................37
QUDEXY XR (100 MG) (CAP SPR 24) ....................... 174
QUDEXY XR (150 MG) (CAP SPR 24) ....................... 174
QUDEXY XR (200 MG) (CAP SPR 24) ....................... 174
QUDEXY XR (25 MG) (CAP SPR 24) ......................... 174
QUDEXY XR (50 MG) (CAP SPR 24) ......................... 174
QUESTRAN (4 G) (POWD PACK) ................................. 59
QUESTRAN (4 G) (POWDER) ....................................... 59
QUESTRAN LIGHT (4 G) (POWD PACK) .................... 59
QUESTRAN LIGHT (4 G) (POWDER) .......................... 59
QUETIAPINE FUMARATE............................................. 33
QUILLICHEW ER (20 MG) (TAB CBP24H) ......... 40, 197
QUILLICHEW ER (30 MG) (TAB CBP24H) ......... 40, 197
QUILLICHEW ER (40 MG) (TAB CBP24H) ......... 40, 197
QUILLIVANT XR (5 MG/ML) (SU ER RC24) ...... 40, 197
QUINAGLUTE (324 MG) (TABLET ER) .......................41
QUINAPRIL HCL............................................................. 47
QUINAPRIL/HYDROCHLOROTHIAZIDE.................... 43
QUINIDINE GLUCONATE..............................................41
QUINIDINE SULFATE.....................................................41
QUINIDINE SULFATE (200 MG) (TABLET) ....................
QUININE SULFATE.......................................................125
QUINORA (300 MG) (TABLET) .................................... 41
QVAR (40 MCG) (AER W/ADAP) ................................. 16
QVAR (80 MCG) (AER W/ADAP) ................................. 16
-RRABEPRAZOLE SODIUM............................................180
RADIOGARDASE (0.5 G) (CAPSULE) ....................... 153
RAGWITEK (12 UNIT) (TAB SUBL) ............................ 10
RALOXIFENE HCL......................................................... 94
RALTEGRAVIR POTASSIUM.......................................129
RAMELTEON................................................................... 36
RAMIPRIL........................................................................ 47
RANEXA (1000 MG) (TAB ER 12H) ............................. 61
RANEXA (500 MG) (TAB ER 12H) ............................... 61
RANITIDINE HCL......................................................... 179
RANOLAZINE..................................................................61
RAPAFLO (4 MG) (CAPSULE) ............................181, 197
RAPAFLO (8 MG) (CAPSULE) ............................181, 197
RAPAMUNE (0.5 MG) (TABLET) ............................... 113
RAPAMUNE (1 MG) (TABLET) .................................. 113
RAPAMUNE (1 MG/ML) (SOLUTION) ...................... 113
RAPAMUNE (2 MG) (TABLET) .................................. 113
RASAGILINE MESYLATE............................................167
RASUVO (10MG/0.2ML) (AUTO INJCT) ................... 132
RASUVO (12.5/0.25) (AUTO INJCT) ...........................132
RASUVO (15MG/0.3ML) (AUTO INJCT) ................... 132
RASUVO (17.5/0.35) (AUTO INJCT) ...........................132
RASUVO (20MG/0.4ML) (AUTO INJCT) ................... 132
RASUVO (22.5/0.45) (AUTO INJCT) ...........................132
RASUVO (25MG/0.5ML) (AUTO INJCT) ................... 132
RASUVO (27.5/0.55) (AUTO INJCT) ...........................132
RASUVO (30MG/0.6ML) (AUTO INJCT) ................... 132
RASUVO (7.5MG/0.15) (AUTO INJCT) ...................... 133
RAVICTI (1.1GRAM/ML) (LIQUID) ........................... 141
RAYOS (1 MG) (TABLET DR) ..................................... 135
RAYOS (2 MG) (TABLET DR) ..................................... 135
RAYOS (5 MG) (TABLET DR) ..................................... 135
RAZADYNE (12 MG) (TABLET) ...................................19
RAZADYNE (4 MG) (TABLET) .....................................19
RAZADYNE (4 MG/ML) (SOLUTION) .........................19
RAZADYNE (8 MG) (TABLET) .....................................19
RAZADYNE ER (16 MG) (CAP24H PEL) .....................19
RAZADYNE ER (24 MG) (CAP24H PEL) .....................19
RAZADYNE ER (8 MG) (CAP24H PEL) .......................19
REA LO 39 (39 %) (CREAM (G)) ...................................79
REA LO 40 (40 %) (CREAM (G)) ...................................79
REA LO 40 (40 %) (LOTION) .........................................79
REBETOL (200 MG) (CAPSULE) ................................131
REBETOL (40 MG/ML) (SOLUTION) ........................ 131
REBIF (22MCG/.5ML) (SYRINGE) ............................. 150
REBIF (44MCG/.5ML) (SYRINGE) ............................. 150
REBIF (8.8-22(6)) (SYRINGE) ..................................... 150
REBIF REBIDOSE (22MCG/.5ML) (PEN INJCTR) ......
150
REBIF REBIDOSE (44MCG/.5ML) (PEN INJCTR) ......
150
REBIF REBIDOSE (8.8-22(6)) (PEN INJCTR) ............ 150
RECTAGEL HC (0.55%-2.8%) (GEL W/APPL) ...........140
RECTIV (0.4% (W/W)) (OINT. (G)) ............................. 141
REGLAN (10 MG) (TABLET) ...................................... 179
REGLAN (10 MG/10ML) (SOLUTION) ...................... 179
REGLAN (5 MG) (TABLET) ........................................ 179
REGLAN (5 MG/5 ML) (SOLUTION) ......................... 179
REGORAFENIB............................................................. 148
REGRANEX (0.01 %) (GEL (GRAM)) .......................... 88
RELAFEN (500 MG) (TABLET) ...................................138
RELAFEN (750 MG) (TABLET) ...................................138
RELAGARD (0.9-0.025%) (JELLY/APPL) .................. 183
RELENZA (5 MG) (BLST W/DEV) ............................. 126
RELISTOR (150 MG) (TABLET) ..................................143
RELPAX (20 MG) (TABLET) ............................... 163, 197
RELPAX (40 MG) (TABLET) ............................... 163, 197
REMERON (15 MG) (TAB RAPDIS) ............................. 20
REMERON (15 MG) (TABLET) ..................................... 20
REMERON (30 MG) (TAB RAPDIS) ............................. 20
REMERON (30 MG) (TABLET) ..................................... 20
REMERON (45 MG) (TAB RAPDIS) ............................. 20
REMERON (45 MG) (TABLET) ..................................... 20
RENAGEL (400 MG) (TABLET) .................................... 92
RENAGEL (800 MG) (TABLET) .................................... 92
RENVELA (0.8 G) (POWD PACK) .................................92
RENVELA (2.4 G) (POWD PACK) .................................92
RENVELA (800 MG) (TABLET) .................................... 92
REPAGLINIDE................................................................. 85
REPAGLINIDE/METFORMIN HCL............................... 87
REPREXAIN (2.5-200MG) (TABLET) .........................155
REQUIP (0.25 MG) (TABLET) ..................................... 167
Sharp Health Plan: Covered California
REQUIP (0.5 MG) (TABLET) ....................................... 167
REQUIP (1 MG) (TABLET) .......................................... 167
REQUIP (2 MG) (TABLET) .......................................... 167
REQUIP (3 MG) (TABLET) .......................................... 168
REQUIP (4 MG) (TABLET) .......................................... 168
REQUIP (5 MG) (TABLET) .......................................... 168
REQUIP XL (12 MG) (TAB ER 24H) ........................... 168
REQUIP XL (2 MG) (TAB ER 24H) ............................. 168
REQUIP XL (4 MG) (TAB ER 24H) ............................. 168
REQUIP XL (6 MG) (TAB ER 24H) ............................. 168
REQUIP XL (8 MG) (TAB ER 24H) ............................. 168
RESCRIPTOR (100 MG) (TAB DISPER) ..................... 126
RESCRIPTOR (200 MG) (TABLET) ............................ 126
RESERPINE...................................................................... 49
RESTASIS (0.05 %) (DROPERETTE) .......................... 101
RESTORIL (15 MG) (CAPSULE) ...................................37
RESTORIL (22.5 MG) (CAPSULE) ................................37
RESTORIL (30 MG) (CAPSULE) ...................................37
RESTORIL (7.5 MG) (CAPSULE) ..................................37
RETAPAMULIN............................................................... 72
RETIN-A (0.01 %) (GEL (GRAM)) ................................ 69
RETIN-A (0.025 %) (CREAM (G)) .................................69
RETIN-A (0.025 %) (GEL (GRAM)) .............................. 69
RETIN-A (0.05 %) (CREAM (G)) ...................................69
RETIN-A (0.1 %) (CREAM (G)) .....................................69
RETIN-A MICRO (0.04 %) (GEL (GRAM)) .................. 69
RETIN-A MICRO (0.1 %) (GEL (GRAM)) .................... 69
RETIN-A MICRO PUMP (0.08 %) (GEL W/PUMP) ......
69
RETROVIR (10 MG/ML) (SYRUP) .............................. 128
RETROVIR (100 MG) (CAPSULE) .............................. 128
RETROVIR (300 MG) (TABLET) ................................. 128
REVATIO (10 MG/ML) (SUSP RECON) ........................55
REVATIO (20 MG) (TABLET) ........................................ 55
REVIA (50 MG) (TABLET) ............................................ 36
REVLIMID (10 MG) (CAPSULE) ................................ 146
REVLIMID (15 MG) (CAPSULE) ................................ 146
REVLIMID (2.5 MG) (CAPSULE) ............................... 146
REVLIMID (20 MG) (CAPSULE) ................................ 146
REVLIMID (25 MG) (CAPSULE) ................................ 146
REVLIMID (5 MG) (CAPSULE) .................................. 146
REXULTI (0.25 MG) (TABLET) .............................30, 197
REXULTI (0.5 MG) (TABLET) ...............................30, 198
REXULTI (1 MG) (TABLET) ..................................30, 198
REXULTI (2 MG) (TABLET) ..................................30, 198
REXULTI (3 MG) (TABLET) ..................................30, 198
REXULTI (4 MG) (TABLET) ..................................30, 198
REYATAZ (150 MG) (CAPSULE) ................................ 128
REYATAZ (200 MG) (CAPSULE) ................................ 128
REYATAZ (300 MG) (CAPSULE) ................................ 128
REYATAZ (50 MG) (POWD PACK) ............................. 128
REZIRA (60-5MG/5ML) (SOLUTION) ..........................66
RHINOCORT AQUA (32MCG) (SPRAY/PUMP) ...... 11,
198
RIBATAB (400-400 MG) (TAB DS PK) ........................131
RIBATAB (400-400(7)) (TAB DS PK) ...........................131
RIBATAB (600-400 MG) (TAB DS PK) ........................131
RIBATAB (600-400(7)) (TAB DS PK) ...........................131
RIBATAB (600-600 MG) (TAB DS PK) ........................131
RIBATAB (600-600(7)) (TAB DS PK) ...........................131
RIBAVIRIN............................................................. 130, 131
RIBAVIRIN (200-400MG) (TAB DS PK) ...........................
RIBAVIRIN (400 MG) (TABLET) .......................................
RIBAVIRIN (600 MG) (TABLET) .......................................
RIDAURA (3 MG) (CAPSULE) .................................... 136
RIFABUTIN.................................................................... 123
RIFADIN (150 MG) (CAPSULE) ..................................123
RIFADIN (300 MG) (CAPSULE) ..................................123
RIFAMATE (300-150 MG) (CAPSULE) .......................123
RIFAMP/ISONIAZID/PYRAZINAMIDE...................... 123
RIFAMPIN...................................................................... 123
RIFAMPIN/ISONIAZID................................................. 123
RIFAPENTINE................................................................123
RIFATER (120-50-300) (TABLET) ............................... 123
RIFAXIMIN.................................................................... 124
RILPIVIRINE HCL.........................................................127
RILUTEK (50 MG) (TABLET) ..................................... 151
RILUZOLE......................................................................151
RIMANTADINE HCL.................................................... 125
RIMIFON (50 MG/5 ML) (SOLUTION) .......................123
RIOCIGUAT...................................................................... 55
RIOMET (500 MG/5ML) (SOLUTION) ......................... 86
RISEDRONATE SODIUM............................................... 94
RISPERDAL (0.25 MG) (TABLET) ................................ 33
RISPERDAL (0.5 MG) (TABLET) .................................. 33
RISPERDAL (1 MG) (TABLET) ..................................... 33
RISPERDAL (1 MG/ML) (SOLUTION) .........................33
RISPERDAL (2 MG) (TABLET) ..................................... 33
RISPERDAL (3 MG) (TABLET) ..................................... 33
RISPERDAL (4 MG) (TABLET) ..................................... 34
RISPERDAL M-TAB (0.5 MG) (TAB RAPDIS) .............34
RISPERDAL M-TAB (1 MG) (TAB RAPDIS) ................34
Page 218 of 224
Index
RISPERDAL M-TAB (2 MG) (TAB RAPDIS) ................34
RISPERDAL M-TAB (3 MG) (TAB RAPDIS) ................34
RISPERDAL M-TAB (4 MG) (TAB RAPDIS) ................34
RISPERIDONE........................................................... 33, 34
RISPERIDONE ODT (0.25 MG) (TAB RAPDIS) ..............
RITALIN (10 MG) (TABLET) ......................................... 40
RITALIN (20 MG) (TABLET) ......................................... 40
RITALIN (5 MG) (TABLET) ........................................... 40
RITALIN LA (10 MG) (CPBP 50-50) ............................. 40
RITALIN LA (20 MG) (CPBP 50-50) ............................. 40
RITALIN LA (30 MG) (CPBP 50-50) ............................. 40
RITALIN LA (40 MG) (CPBP 50-50) ............................. 40
RITALIN LA (60 MG) (CPBP 50-50) ............................. 40
RITALIN-SR (20 MG) (TABLET ER) .............................40
RITONAVIR............................................................ 128, 129
RIVAROXABAN.............................................................104
RIVASTIGMINE............................................................... 19
RIVASTIGMINE TARTRATE.......................................... 20
RIZATRIPTAN BENZOATE.......................................... 163
RMS (10 MG) (SUPP.RECT) .........................................160
RMS (20 MG) (SUPP.RECT) .........................................160
RMS (30 MG) (SUPP.RECT) .........................................160
RMS (5 MG) (SUPP.RECT) ...........................................160
ROBAXIN (500 MG) (TABLET) ...................................176
ROBAXIN-750 (750 MG) (TABLET) ........................... 176
ROBINUL (1 MG) (TABLET) ....................................... 178
ROBINUL FORTE (2 MG) (TABLET) ..........................178
ROCALTROL (0.25 MCG) (CAPSULE) .......................187
ROCALTROL (0.5 MCG) (CAPSULE) .........................188
ROCALTROL (1 MCG/ML) (SOLUTION) .................. 188
ROFLUMILAST............................................................... 18
ROLAPITANT HCL..........................................................13
ROPINIROLE HCL.................................................167, 168
ROSADAN (0.75 %) (GEL (GRAM)) ............................. 68
ROSANIL (10-5%(W/W)) (CLEANSER) ....................... 73
ROSIGLITAZONE MALEATE........................................ 86
ROSIGLITAZONE/METFORMIN HCL.......................... 88
ROSULA (10 %-4.5 %) (CLEANSER) ........................... 73
ROSUVASTATIN CALCIUM...........................................59
ROTIGOTINE..................................................................168
ROWEEPRA (500 MG) (TABLET) ...............................172
ROXANOL (100 MG/5ML) (SOLUTION) ................... 160
ROXICET (5-325/5 ML) (SOLUTION) .........................161
ROXICODONE (10 MG) (TABLET) ............................ 161
ROXICODONE (15 MG) (TABLET) ............................ 161
ROXICODONE (20 MG) (TABLET) ............................ 161
ROXICODONE (30 MG) (TABLET) ............................ 161
ROXICODONE (5 MG) (TABLET) .............................. 161
ROXICODONE (5 MG/5 ML) (SOLUTION) ............... 161
ROZEREM (8 MG) (TABLET) ................................36, 198
RUFINAMIDE................................................................ 174
RUXOLITINIB PHOSPHATE........................................ 145
RYTARY (23.75-95MG) (CAPSULE ER) .............166, 198
RYTARY (36.25-145) (CAPSULE ER) ................. 166, 198
RYTARY (48.75-195) (CAPSULE ER) ................. 166, 198
RYTARY (61.25-245) (CAPSULE ER) ................. 166, 198
RYTHMOL (150 MG) (TABLET) ................................... 41
RYTHMOL (225 MG) (TABLET) ................................... 41
RYTHMOL (300 MG) (TABLET) ................................... 41
RYTHMOL SR (225 MG) (CAP ER 12H) ...................... 41
RYTHMOL SR (325 MG) (CAP ER 12H) ...................... 41
RYTHMOL SR (425 MG) (CAP ER 12H) ...................... 41
RYZOLT (100 MG) (TBMP 24HR) ............................... 162
RYZOLT (200 MG) (TBMP 24HR) ............................... 162
RYZOLT (300 MG) (TBMP 24HR) ............................... 162
-SSABRIL (500 MG) (POWD PACK) ...............................175
SABRIL (500 MG) (TABLET) ...................................... 175
SACROSIDASE.............................................................. 177
SACUBITRIL/VALSARTAN............................................61
SAFYRAL (3-0.03(21)) (TABLET) .................................63
SALAGEN (5 MG) (TABLET) ...................................... 143
SALAGEN (7.5 MG) (TABLET) ................................... 143
SALICYLIC ACID......................................................78, 79
SALICYLIC ACID (26 %) (LIQUID) .................................
SALICYLIC ACID (27.5 %) (LIQ-FILM) ...........................
SALICYLIC ACID (28.5 %) (SOL-FILMER) .....................
SALICYLIC ACID (6 %) (CREAM (G)) ............................
SALICYLIC ACID (6 %) (CRM ER (G)) ............................
SALICYLIC ACID (6 %) (FOAM) ......................................
SALICYLIC ACID (6 %) (GEL (GRAM)) ..........................
SALICYLIC ACID (6 %) (LOTION ER) ............................
SALICYLIC ACID (6 %) (LOTION) ..................................
SALICYLIC ACID (6 %) (SHAMPOO) ..............................
SALICYLIC ACID/AMMON LACT/ALOE....................79
SALICYLIC ACID/UREA................................................79
SALKERA (6 %) (FOAM) ...............................................79
SALMETEROL XINAFOATE..........................................15
SALSALATE...................................................................155
SALVAX DUO PLUS (6 %-35 %) (FOAM) ....................79
SAMSCA (15 MG) (TABLET) ........................................ 91
SAMSCA (30 MG) (TABLET) ........................................ 91
SANCTURA (20 MG) (TABLET) ......................... 183, 198
SANCTURA XR (60 MG) (CAP ER 24H) ............183, 198
SANCUSO (3.1MG/24HR) (PATCH TDWK) ................. 12
SANDIMMUNE (100 MG) (CAPSULE) ...................... 112
SANDIMMUNE (100 MG/ML) (SOLUTION) .............112
SANDIMMUNE (25 MG) (CAPSULE) ........................ 112
SANDOSTATIN LAR (10 MG) (KIT) ...........................153
SANDOSTATIN LAR (20 MG) (KIT) ...........................153
SANDOSTATIN LAR (30 MG) (KIT) ...........................154
SANDRIL (0.1 MG) (TABLET) ...................................... 49
SANDRIL (0.25 MG) (TABLET) .................................... 49
SANTYL (250 UNIT/G) (OINT. (G)) ..............................81
SAPHRIS (10 MG) (TAB SUBL) ............................ 31, 198
SAPHRIS (2.5 MG) (TAB SUBL) ........................... 31, 198
SAPHRIS (5 MG) (TAB SUBL) .............................. 31, 198
SAPROPTERIN DIHYDROCHLORIDE....................... 153
SAQUINAVIR MESYLATE........................................... 129
SARAFEM (10 MG) (TABLET) ......................................21
SARAFEM (20 MG) (TABLET) ......................................21
SAVAYSA (15 MG) (TABLET) ............................. 104, 198
SAVAYSA (30 MG) (TABLET) ............................. 104, 198
SAVAYSA (60 MG) (TABLET) ............................. 104, 198
SAVELLA (100 MG) (TABLET) ...........................151, 198
SAVELLA (12.5 MG) (TABLET) ..........................151, 198
SAVELLA (12.5-25-50) (TAB DS PK) ..................151, 198
SAVELLA (25 MG) (TABLET) .............................151, 198
SAVELLA (50 MG) (TABLET) .............................151, 198
SAXAGLIPTIN HCL........................................................ 85
SAXAGLIPTIN HCL/METFORMIN HCL...................... 83
SCALACORT (2 %) (LOTION) .......................................76
SCOPOLAMINE...............................................................13
SEASONALE (0.15-0.03) (TBDSPK 3MO) ....................64
SEASONIQUE (150-30(84)) (TBDSPK 3MO) ............... 64
SECOBARBITAL SODIUM.............................................36
SECONAL SODIUM (100 MG) (CAPSULE) .................36
SECTRAL (200 MG) (CAPSULE) .................................. 49
SECTRAL (400 MG) (CAPSULE) .................................. 49
SELEGILINE.................................................................... 36
SELEGILINE HCL......................................................... 168
SELENIUM SULFIDE................................................77, 78
SELENIUM SULFIDE (2.25 %) (SHAMPOO) ..................
SELEXIPAG...................................................................... 56
SELRX (2.3 %) (SHAMPOO) ......................................... 77
SELSUN (2.5 %) (LOTION) ............................................78
SELZENTRY (150 MG) (TABLET) .............................. 126
SELZENTRY (300 MG) (TABLET) .............................. 126
SEMPREX-D (60-8MG) (CAPSULE) .............................10
SENSIPAR (30 MG) (TABLET) ...................................... 94
SENSIPAR (60 MG) (TABLET) ...................................... 94
SENSIPAR (90 MG) (TABLET) ...................................... 94
SERAX (10 MG) (CAPSULE) .........................................29
SERAX (15 MG) (CAPSULE) .........................................29
SERAX (30 MG) (CAPSULE) .........................................29
SEREVENT DISKUS (50 MCG) (BLST W/DEV) ......... 15
SERNIVO (0.05 %) (SPRAY/PUMP) ...................... 74, 198
SEROMYCIN (250 MG) (CAPSULE) .......................... 123
SEROPHENE (50 MG) (TABLET) ..................................93
SEROQUEL (100 MG) (TABLET) ..................................33
SEROQUEL (200 MG) (TABLET) ..................................33
SEROQUEL (25 MG) (TABLET) ....................................33
SEROQUEL (300 MG) (TABLET) ..................................33
SEROQUEL (400 MG) (TABLET) ..................................33
SEROQUEL (50 MG) (TABLET) ....................................33
SEROQUEL XR (150 MG) (TAB ER 24H) .............33, 198
SEROQUEL XR (200 MG) (TAB ER 24H) .............33, 198
SEROQUEL XR (300 MG) (TAB ER 24H) .............33, 198
SEROQUEL XR (400 MG) (TAB ER 24H) .............33, 198
SEROQUEL XR (50 MG) (TAB ER 24H) ...............33, 198
SEROQUEL XR (50-200-300) (TAB24HDSPK) ............ 33
SEROSTIM (4 MG) (VIAL) ............................................ 94
SERTACONAZOLE NITRATE........................................ 71
SERTRALINE HCL.......................................................... 22
SERZONE (100 MG) (TABLET) .....................................22
SERZONE (150 MG) (TABLET) .....................................22
SERZONE (200 MG) (TABLET) .....................................22
SERZONE (250 MG) (TABLET) .....................................22
SERZONE (50 MG) (TABLET) .......................................22
SEVELAMER CARBONATE.......................................... 92
SEVELAMER HCL.......................................................... 92
SFROWASA (4 G/60 ML) (ENEMA) ............................139
SHOHL'S MODIFIED (300-500 MG) (SOLUTION) ......
181
SHORT RAGWEED (1:20) (VIAL) .................................10
SILDENAFIL CITRATE...................................................55
SILENOR (3 MG) (TABLET) ..................................36, 198
SILENOR (6 MG) (TABLET) ..................................36, 198
SILODOSIN.................................................................... 181
SILVADENE (1 %) (CREAM (G)) .................................. 72
SILVER SULFADIAZINE................................................ 72
SIMBRINZA (1 %-0.2 %) (DROPS SUSP) ...................102
SIMEPREVIR SODIUM.................................................131
Sharp Health Plan: Covered California
SIMPONI (100 MG/ML) (PEN INJCTR) ......................133
SIMPONI (100 MG/ML) (SYRINGE) ...........................133
SIMPONI (50MG/0.5ML) (PEN INJCTR) ....................133
SIMPONI (50MG/0.5ML) (SYRINGE) .........................133
SIMPONI ARIA (50 MG/4 ML) (VIAL) .......................133
SIMVASTATIN..................................................................59
SINECATECHINS............................................................ 72
SINEMET 10-100 (10MG-100MG) (TABLET) ............ 166
SINEMET 25-100 (25MG-100MG) (TABLET) ............ 166
SINEMET 25-250 (25MG-250MG) (TABLET) ............ 166
SINEMET CR (25MG-100MG) (TABLET ER) ............ 166
SINEMET CR (50MG-200MG) (TABLET ER) ............ 167
SINEQUAN (10 MG) (CAPSULE) ..................................25
SINEQUAN (10 MG/ML) (ORAL CONC) ..................... 25
SINEQUAN (100 MG) (CAPSULE) ................................25
SINEQUAN (150 MG) (CAPSULE) ................................25
SINEQUAN (25 MG) (CAPSULE) ..................................25
SINEQUAN (50 MG) (CAPSULE) ..................................25
SINEQUAN (75 MG) (CAPSULE) ..................................25
SINGULAIR (10 MG) (TABLET) ................................... 17
SINGULAIR (4 MG) (GRAN PACK) ..............................17
SINGULAIR (4 MG) (TAB CHEW) ................................17
SINGULAIR (5 MG) (TAB CHEW) ................................17
SIROLIMUS.................................................................... 113
SIRTURO (100 MG) (TABLET) ....................................123
SITAGLIPTIN PHOS/METFORMIN HCL...................... 83
SITAGLIPTIN PHOSPHATE............................................85
SITAVIG (50 MG) (MA BUC TAB) ...................... 125, 199
SIVEXTRO (200 MG) (TABLET) ................................. 117
SKELAXIN (400 MG) (TABLET) .................................176
SKELAXIN (800 MG) (TABLET) .................................176
SKLICE (0.5 %) (LOTION) ............................................. 71
SLO-PHYLLIN (80 MG/15ML) (SOLUTION) .............. 18
SOD PICOSULF/MAG OX/CITRIC AC........................143
SOD/POT/K CIT/SOD CIT/CIT ACID...........................182
SODIUM CHLORIDE/NAHCO3/KCL/PEG................. 143
SODIUM CITRATE........................................................ 104
SODIUM CITRATE (4 G/100 ML) (SOLUTION) ..............
SODIUM FLUORIDE.....................................................184
SODIUM FLUORIDE (0.2 %) (SOLUTION) .....................
SODIUM FLUORIDE (0.25(0.55)) (TAB CHEW) .............
SODIUM FLUORIDE (0.5 MG/ML) (DROPS) ..................
SODIUM FLUORIDE (0.5(1.1)MG) (TAB CHEW) ...........
SODIUM FLUORIDE (1.1 %) (CREAM (G)) ....................
SODIUM FLUORIDE (1.1 %) (GEL (GRAM)) ..................
SODIUM FLUORIDE (1MG(2.2MG)) (TAB CHEW) .......
SODIUM FLUORIDE/POTASSIUM NIT......................184
SODIUM FLUORIDE/POTASSIUM NIT (1.1%-5%)
(GEL (GRAM)) ....................................................................
SODIUM FLUORIDE/VITAMIN D3.............................184
SODIUM FLUORIDE/XYLITOL.................................. 184
SODIUM OXYBATE........................................................ 29
SODIUM PHENYLBUTYRATE.................................... 141
SODIUM POLYSTYRENE SULFON/SORB.................. 92
SODIUM POLYSTYRENE SULFON/SORB (15 G/60
ML) (ORAL SUSP) ..............................................................
SODIUM POLYSTYRENE SULFONATE.......................92
SODIUM POLYSTYRENE SULFONATE ( ) (POWDER)
...............................................................................................
SODIUM POLYSTYRENE SULFONATE (15 G/60 ML)
(ORAL SUSP) ......................................................................
SODIUM POLYSTYRENE SULFONATE (30 G/120ML)
(ENEMA) .............................................................................
SODIUM POLYSTYRENE SULFONATE (50 G/200ML)
(ENEMA) .............................................................................
SODIUM SULAMYD (10 %) (DROPS) ....................... 100
SODIUM SULAMYD (10 %) (OINT. (G)) ................... 100
SODIUM THIOSULFATE/SAL ACID.............................71
SODIUM, POTASSIUM,MAG SULFATES................... 143
SOFOSBUVIR................................................................ 129
SOFOSBUVIR/VELPATASVIR..................................... 129
SOLARAZE (3 %) (GEL (GRAM)) ................................ 80
SOLIFENACIN SUCCINATE.........................................182
SOLODYN (105 MG) (TAB ER 24H) ........................... 121
SOLODYN (115MG) (TAB ER 24H) ............................ 121
SOLODYN (135 MG) (TAB ER 24H) ........................... 121
SOLODYN (45 MG) (TAB ER 24H) ............................. 121
SOLODYN (55 MG) (TAB ER 24H) ............................. 121
SOLODYN (65 MG) (TAB ER 24H) ............................. 121
SOLODYN (80 MG) (TAB ER 24H) ............................. 121
SOLODYN (90 MG) (TAB ER 24H) ............................. 121
SOLTAMOX (10 MG/5 ML) (SOLUTION) .................. 149
SOMA (250 MG) (TABLET) ......................................... 175
SOMA (350 MG) (TABLET) ......................................... 175
SOMA COMPOUND (200-325 MG) (TABLET) ..........175
SOMATROPIN.................................................................. 94
SOMATULINE DEPOT (120MG/0.5) (SYRINGE) ......
153
SOMATULINE DEPOT (60MG/0.2ML) (SYRINGE) ......
153
SOMATULINE DEPOT (90MG/0.3ML) (SYRINGE) ......
153
Page 219 of 224
Index
SONATA (10 MG) (CAPSULE) ...................................... 37
SONATA (5 MG) (CAPSULE) ........................................ 37
SONIDEGIB PHOSPHATE............................................ 145
SOOLANTRA (1 %) (CREAM (G)) ................................68
SORAFENIB TOSYLATE.............................................. 148
SORIATANE (10 MG) (CAPSULE) ................................ 81
SORIATANE (17.5 MG) (CAPSULE) ............................. 81
SORIATANE (25 MG) (CAPSULE) ................................ 81
SORILUX (0.005 %) (FOAM) .................................82, 199
SOTALOL HCL...........................................................50, 51
SOTALOL HCL (120 MG) (TABLET) ................................
SOTALOL HCL (160 MG) (TABLET) ................................
SOTALOL HCL (240 MG) (TABLET) ................................
SOTALOL HCL (80 MG) (TABLET) ..................................
SOTYLIZE (5 MG/ML) (SOLUTION) ........................... 51
SOVALDI (400 MG) (TABLET) ....................................129
SPACER.............................................................................18
SPECTAZOLE (1 %) (CREAM (G)) ............................... 70
SPECTRACEF (200 MG) (TABLET) ............................115
SPECTRACEF (400 MG) (TABLET) ............................115
SPINOSAD........................................................................72
SPIRIVA (18 MCG) (CAP W/DEV) ................................ 13
SPIRIVA RESPIMAT (1.25 MCG) (MIST INHAL) ...... 13,
199
SPIRIVA RESPIMAT (2.5 MCG) (MIST INHAL) ..........13
SPIRONOLACT/HYDROCHLOROTHIAZID.................55
SPIRONOLACTONE........................................................ 55
SPORANOX (10 MG/ML) (SOLUTION) ..................... 122
SPORANOX (100 MG) (CAPSULE) ............................ 122
SPRITAM (1000 MG) (TAB SUSP) ...................... 172, 199
SPRITAM (250 MG) (TAB SUSP) ........................ 172, 199
SPRITAM (500 MG) (TAB SUSP) ........................ 172, 199
SPRITAM (750 MG) (TAB SUSP) ........................ 172, 199
SPRIX (15.75 MG) (SPRAY) .........................................136
SPRYCEL (100 MG) (TABLET) ................................... 147
SPRYCEL (140 MG) (TABLET) ................................... 147
SPRYCEL (20 MG) (TABLET) ..................................... 147
SPRYCEL (50 MG) (TABLET) ..................................... 147
SPRYCEL (70 MG) (TABLET) ..................................... 147
SPRYCEL (80 MG) (TABLET) ..................................... 147
SS 10-2 (10 %-2 %) (CLEANSER) ..................................73
STADOL (10 MG/ML) (SPRAY) ...................................156
STALEVO 100 (25-100-200) (TABLET) .......................167
STALEVO 125 (31.25-125) (TABLET) ......................... 167
STALEVO 150 (37.5-150MG) (TABLET) .....................167
STALEVO 200 (50-200-200) (TABLET) .......................167
STALEVO 50 (12.5-50 MG) (TABLET) ........................167
STALEVO 75 (18.75-75MG) (TABLET) .......................167
STANDARDIZED TIMOTHY GRASS (100K/ML)
(VIAL) .............................................................................. 10
STANDARDIZED TIMOTHY GRASS (10K UNIT/1)
(VIAL) .............................................................................. 10
STARLIX (120 MG) (TABLET) ...................................... 85
STARLIX (60 MG) (TABLET) ........................................ 85
STAVUDINE........................................................... 127, 128
STELARA (45MG/0.5ML) (SYRINGE) ....................... 136
STELARA (90 MG/ML) (SYRINGE) ........................... 136
STELAZINE (1 MG) (TABLET) ..................................... 35
STELAZINE (10 MG) (TABLET) ................................... 35
STELAZINE (2 MG) (TABLET) ..................................... 35
STELAZINE (5 MG) (TABLET) ..................................... 36
STIMATE (150/SPRAY) (SPRAY/PUMP) ...................... 93
STIOLTO RESPIMAT (2.5-2.5MCG) (MIST INHAL) ......
15
STIVARGA (40 MG) (TABLET) ...................................148
STRATTERA (10 MG) (CAPSULE) ............................... 40
STRATTERA (100 MG) (CAPSULE) ............................. 40
STRATTERA (18 MG) (CAPSULE) ............................... 40
STRATTERA (25 MG) (CAPSULE) ............................... 40
STRATTERA (40 MG) (CAPSULE) ............................... 40
STRATTERA (60 MG) (CAPSULE) ............................... 40
STRATTERA (80 MG) (CAPSULE) ............................... 40
STRIANT (30 MG) (MUC ER 12H) ..............................108
STRIBILD (150-200 MG) (TABLET) ........................... 129
STRIVERDI RESPIMAT (2.5 MCG) (MIST INHAL) ......
15,
199
STROMECTOL (3 MG) (TABLET) .............................. 124
SUBOXONE (12 MG-3 MG) (FILM) ............................165
SUBOXONE (2 MG-0.5MG) (FILM) ............................165
SUBOXONE (2 MG-0.5MG) (TAB SUBL) .................. 165
SUBOXONE (4MG-1MG) (FILM) ................................165
SUBOXONE (8 MG-2 MG) (FILM) ..............................165
SUBOXONE (8 MG-2 MG) (TAB SUBL) .................... 165
SUBSYS (100MCG/SPR) (SPRAY) .............................. 156
SUBSYS (1200 MCG) (SPRAY) ................................... 156
SUBSYS (1600 MCG) (SPRAY) ................................... 156
SUBSYS (200 MCG) (SPRAY) ..................................... 156
SUBSYS (400MCG/SPR) (SPRAY) .............................. 156
SUBSYS (600 MCG) (SPRAY) ..................................... 156
SUBSYS (800 MCG) (SPRAY) ..................................... 156
SUBUTEX (2 MG) (TAB SUBL) .................................. 165
SUBUTEX (8 MG) (TAB SUBL) .................................. 165
SUCCIMER.....................................................................153
SUCRAID (8500/ML) (SOLUTION) ............................ 177
SUCRALFATE................................................................ 178
SUCROFERRIC OXYHYDROXIDE............................... 92
SULAR (17 MG) (TAB ER 24H) .....................................53
SULAR (20 MG) (TAB ER 24H) .....................................53
SULAR (25.5 MG) (TAB ER 24H) ..................................53
SULAR (30 MG) (TAB ER 24H) .....................................53
SULAR (34 MG) (TAB ER 24H) .....................................53
SULAR (40 MG) (TAB ER 24H) .....................................54
SULAR (8.5MG) (TAB ER 24H) .....................................54
SULCONAZOLE NITRATE.............................................71
SULFACETAMIDE SOD/SULFUR/UREA..................... 72
SULFACETAMIDE SOD/SULFUR/UREA (10%-5%10%) (CLEANSER) .............................................................
SULFACETAMIDE SODIUM............................ 68, 78, 100
SULFACETAMIDE SODIUM (10 %) (CLEANSER) .........
SULFACETAMIDE SODIUM (10 %) (CLNSR GEL) ........
SULFACETAMIDE SODIUM (10 %) (SHAMPOO) ..........
SULFACETAMIDE SODIUM/SULFUR....................72, 73
SULFACETAMIDE/PREDNISOLONE SP.................... 100
SULFACETAMIDE/PREDNISOLONE SP (10 %-0.23%)
(DROPS) ...............................................................................
SULFACETM NA/PREDNISOL AC..............................100
SULFACET-R (10-5%(W/V)) (LOTION) ........................73
SULFACT SOD/SULUR/AVOB/OTN/OCT.....................73
SULFADIAZINE.............................................................139
SULFADIAZINE (500 MG) (TABLET) ..............................
SULFAMETHOXAZOLE/TRIMETHOPRIM............... 113
SULFAMETHOXAZOLE/TRIMETHOPRIM (20040MG/5) (ORAL SUSP) ......................................................
SULFAMYLON (50 G) (PACKET) ................................. 72
SULFAMYLON (8.5 %) (CREAM (G)) ..........................72
SULFANILAMIDE......................................................... 184
SULFASALAZINE......................................................... 140
SULFATRIM (200-40MG/5) (ORAL SUSP) .................113
SULFATRIM (800-160/20) (ORAL SUSP) ................... 113
SULFUR/SOD SUL/SOD THIOSULF/FA..................... 152
SULFUR/SOD SUL/SOD THIOSULF/FA (400 MG-1MG)
(CAPSULE) ..........................................................................
SULINDAC..................................................................... 139
SUMADAN (9 %-4.5 %) (CLEANSER) ......................... 73
SUMADAN XLT (9 %-4.5 %) (CMB CLN CR) ............. 73
SUMATRIPTAN SUCC/NAPROXEN SOD...................163
SUMATRIPTAN SUCCINATE...............................163, 164
SUMAVEL DOSEPRO (4 MG/0.5ML) (NDL FR INJ) ......
164,
199
SUMAVEL DOSEPRO (6 MG/0.5ML) (NDL FR INJ) ......
164,
199
SUMAXIN (10 %-4 %) (MED. PAD) ..............................73
SUMAXIN (9 %-4 %) (CLEANSER) ..............................73
SUMAXIN TS (8 %-4 %) (SUSPENSION) .................... 73
SUMYCIN (500 MG) (CAPSULE) ............................... 121
SUNITINIB MALATE.................................................... 148
SUPRAX (100 MG) (TAB CHEW) ............................... 115
SUPRAX (100 MG/5ML) (SUSP RECON) ...................115
SUPRAX (200 MG) (TAB CHEW) ............................... 115
SUPRAX (200 MG/5ML) (SUSP RECON) ...................115
SUPRAX (400 MG) (CAPSULE) .................................. 115
SUPRAX (500 MG/5ML) (SUSP RECON) ...................115
SUPREP (17.5-3.13G) (SOLN RECON) ....................... 143
SURMONTIL (100 MG) (CAPSULE) ............................ 26
SURMONTIL (25 MG) (CAPSULE) .............................. 26
SURMONTIL (50 MG) (CAPSULE) .............................. 26
SUSTIVA (200 MG) (CAPSULE) ................................. 126
SUSTIVA (50 MG) (CAPSULE) ................................... 127
SUSTIVA (600 MG) (TABLET) .................................... 127
SUTENT (12.5 MG) (CAPSULE) ................................. 148
SUTENT (25 MG) (CAPSULE) .................................... 148
SUTENT (37.5 MG) (CAPSULE) ................................. 148
SUTENT (50 MG) (CAPSULE) .................................... 148
SUVOREXANT................................................................ 37
SYLATRON (200 MCG) (KIT) ..................................... 146
SYLATRON (300 MCG) (KIT) ..................................... 146
SYLATRON (600 MCG) (KIT) ..................................... 146
SYMAX (0.125 MG) (TAB RAPDIS) ........................... 178
SYMAX DUOTAB (0.125-0.25) (TAB MPHASE) ....... 178
SYMAX-SL (0.125 MG) (TAB SUBL) ......................... 178
SYMAX-SR (0.375 MG) (TAB ER 12H) ...................... 178
SYMBICORT (160-4.5MCG) (HFA AER AD) ....... 15, 199
SYMBICORT (80-4.5 MCG) (HFA AER AD) ........ 15, 199
SYMBYAX (12MG-25MG) (CAPSULE) ....................... 38
SYMBYAX (12MG-50MG) (CAPSULE) ....................... 38
SYMBYAX (3 MG-25 MG) (CAPSULE) ....................... 38
SYMBYAX (6MG-25MG) (CAPSULE) ......................... 38
SYMBYAX (6MG-50MG) (CAPSULE) ......................... 38
SYMLINPEN 120 (2700/2.7ML) (PEN INJCTR) ...........84
SYMLINPEN 60 (1500/1.5ML) (PEN INJCTR) .............84
SYMMETREL (100 MG) (CAPSULE) ......................... 166
SYMMETREL (100 MG) (TABLET) ............................ 166
SYMMETREL (50 MG/5 ML) (SOLUTION) ...............166
SYNALAR (0.01 %) (CREAM (G)) ................................ 75
Sharp Health Plan: Covered California
SYNALAR (0.01 %) (SOLUTION) .................................75
SYNALAR (0.025 %) (CREAM (G)) .............................. 75
SYNALAR (0.025 %) (OINT. (G)) .................................. 75
SYNALGOS-DC (356-30-16) (CAPSULE) .................. 155
SYNAREL (2 MG/ML) (SPRAY) ....................................94
SYNJARDY (12.5-1000) (TABLET) ....................... 88, 199
SYNJARDY (12.5-500MG) (TABLET) ...................88, 199
SYNJARDY (5 MG-500MG) (TABLET) ................ 88, 199
SYNJARDY (5MG-1000MG) (TABLET) ............... 88, 199
SYNTHROID (100 MCG) (TABLET) ............................. 96
SYNTHROID (112 MCG) (TABLET) ............................. 96
SYNTHROID (125 MCG) (TABLET) ............................. 96
SYNTHROID (137 MCG) (TABLET) ............................. 96
SYNTHROID (150 MCG) (TABLET) ............................. 96
SYNTHROID (175MCG) (TABLET) .............................. 96
SYNTHROID (200 MCG) (TABLET) ............................. 96
SYNTHROID (25 MCG) (TABLET) ............................... 96
SYNTHROID (300 MCG) (TABLET) ............................. 96
SYNTHROID (50 MCG) (TABLET) ............................... 96
SYNTHROID (75 MCG) (TABLET) ............................... 96
SYNTHROID (88 MCG) (TABLET) ............................... 96
SYNVEXIA TC (4 %-1 %) (CREAM (G)) ......................81
SYPRINE (250 MG) (CAPSULE) ................................. 153
SYRINGE AND NEEDLE,INSULIN.............................143
-TTABLOID (40 MG) (TABLET) ..................................... 145
TACLONEX (0.005-.064) (OINT. (G)) ....................82, 199
TACLONEX (0.005-.064) (SUSPENSION) ............ 82, 199
TACROLIMUS.......................................................... 82, 113
TADALAFIL............................................................... 56, 93
TAFINLAR (50 MG) (CAPSULE) ................................ 147
TAFINLAR (75 MG) (CAPSULE) ................................ 147
TAFLUPROST/PF........................................................... 102
TAGAMET (300 MG) (TABLET) ..................................179
TAGAMET (400 MG) (TABLET) ..................................179
TAGAMET (800 MG) (TABLET) ..................................179
TAGRISSO (40 MG) (TABLET) ....................................148
TAGRISSO (80 MG) (TABLET) ....................................148
TAKE ACTION (1.5 MG) (TABLET) (OTC)...................64
TALWIN NX (50MG-0.5MG) (TABLET) ..................... 162
TAMBOCOR (100 MG) (TABLET) ................................ 41
TAMBOCOR (150 MG) (TABLET) ................................ 41
TAMBOCOR (50 MG) (TABLET) .................................. 41
TAMIFLU (30 MG) (CAPSULE) .................................. 125
TAMIFLU (45 MG) (CAPSULE) .................................. 125
TAMIFLU (6 MG/ML) (SUSP RECON) .......................125
TAMIFLU (75 MG) (CAPSULE) .................................. 125
TAMOXIFEN CITRATE.................................................149
TAMSULOSIN HCL.......................................................181
TANDEM PLUS (106 MG-1MG) (CAPSULE) ............ 185
TANZEUM (30MG/0.5ML) (PEN INJCTR) ........... 83, 199
TANZEUM (50MG/0.5ML) (PEN INJCTR) ........... 83, 199
TAPAZOLE (10 MG) (TABLET) .....................................95
TAPAZOLE (5 MG) (TABLET) .......................................95
TAPENTADOL HCL.......................................................162
TARCEVA (100 MG) (TABLET) ...................................147
TARCEVA (150 MG) (TABLET) ...................................147
TARCEVA (25 MG) (TABLET) .....................................147
TARGADOX (50 MG) (TABLET) .........................120, 199
TARGRETIN (1 %) (GEL (GRAM)) ............................... 80
TARGRETIN (75 MG) (CAPSULE) ............................. 149
TARKA (1-240MG) (TAB BP 24H) ................................ 42
TARKA (2 MG-180MG) (TAB BP 24H) ......................... 42
TARKA (2-240MG) (TAB BP 24H) ................................ 42
TARKA (4-240MG) (TAB BP 24H) ................................ 42
TASIGNA (150 MG) (CAPSULE) .................................148
TASIGNA (200 MG) (CAPSULE) .................................148
TASIMELTEON................................................................ 36
TASMAR (100 MG) (TABLET) .................................... 168
TAVABOROLE..................................................................71
TAVIST (2.68 MG) (TABLET) ........................................ 10
TAYTULLA (1MG-20(24)) (CAPSULE) ........................ 65
TAZAROTENE............................................................69, 82
TAZORAC (0.05 %) (CREAM (G)) .........................82, 199
TAZORAC (0.05 %) (GEL (GRAM)) ......................82, 199
TAZORAC (0.1 %) (CREAM (G)) ...........................82, 199
TAZORAC (0.1 %) (GEL (GRAM)) ........................82, 199
TBO-FILGRASTIM........................................................ 106
TECFIDERA (120 MG) (CAPSULE DR) ..................... 150
TECFIDERA (120-240 MG) (CAPSULE DR) ..............150
TECFIDERA (240 MG) (CAPSULE DR) ..................... 150
TECHNIVIE (12.5-75 MG) (TABLET) ......................... 131
TEDIZOLID PHOSPHATE.............................................117
TEGRETOL (100 MG) (TAB CHEW) ...........................169
TEGRETOL (100 MG/5ML) (ORAL SUSP) ................ 169
TEGRETOL (200 MG) (TABLET) ................................ 169
TEGRETOL XR (100 MG) (TAB ER 12H) ...................169
TEGRETOL XR (200 MG) (TAB ER 12H) ...................169
TEGRETOL XR (400 MG) (TAB ER 12H) ...................169
TEKAMLO (150 MG-5MG) (TABLET) ......................... 57
TEKAMLO (150MG-10MG) (TABLET) ........................ 57
Page 220 of 224
Index
TEKAMLO (300MG-10MG) (TABLET) ........................ 57
TEKAMLO (300MG-5MG) (TABLET) .......................... 57
TEKTURNA (150 MG) (TABLET) ................................. 57
TEKTURNA (300 MG) (TABLET) ................................. 57
TEKTURNA HCT (150-12.5MG) (TABLET) .................57
TEKTURNA HCT (150MG-25MG) (TABLET) ............. 57
TEKTURNA HCT (300-12.5MG) (TABLET) .................57
TEKTURNA HCT (300MG-25MG) (TABLET) ............. 57
TELBIVUDINE...............................................................130
TELITHROMYCIN.........................................................116
TELMISARTAN................................................................48
TELMISARTAN/AMLODIPINE......................................46
TELMISARTAN/HYDROCHLOROTHIAZID................ 45
TEMAZEPAM...................................................................37
TEMODAR (100 MG) (CAPSULE) .............................. 144
TEMODAR (140 MG) (CAPSULE) .............................. 144
TEMODAR (180 MG) (CAPSULE) .............................. 144
TEMODAR (20 MG) (CAPSULE) ................................ 144
TEMODAR (250 MG) (CAPSULE) .............................. 144
TEMODAR (5 MG) (CAPSULE) .................................. 144
TEMOVATE (0.05 %) (CREAM (G)) .............................. 74
TEMOVATE (0.05 %) (GEL (GRAM)) ........................... 74
TEMOVATE (0.05 %) (OINT. (G)) .................................. 74
TEMOVATE (0.05 %) (SOLUTION) ...............................74
TEMOVATE E (0.05 %) (CREAM (G)) ...........................74
TEMOZOLOMIDE......................................................... 144
TENEX (1 MG) (TABLET) ............................................. 48
TENEX (2 MG) (TABLET) ............................................. 48
TENOFOVIR DISOPROXIL FUMARATE....................128
TENORETIC 100 (100MG-25MG) (TABLET) ...............51
TENORETIC 50 (50 MG-25MG) (TABLET) ..................51
TENORMIN (100 MG) (TABLET) ................................. 49
TENORMIN (25 MG) (TABLET) ................................... 49
TENORMIN (50 MG) (TABLET) ................................... 49
TERAZOL 3 (0.8 %) (CREAM/APPL) ......................... 183
TERAZOL 3 (80 MG) (SUPP.VAG) .............................. 183
TERAZOL 7 (0.4 %) (CREAM/APPL) ......................... 183
TERAZOSIN HCL............................................................ 44
TERBINAFINE HCL...................................................... 122
TERBUTALINE SULFATE.............................................. 15
TERCONAZOLE............................................................ 183
TERIFLUNOMIDE.........................................................151
TERIPARATIDE............................................................... 93
TERSI FOAM (2.25 %) (FOAM) .....................................78
TESSALON (200 MG) (CAPSULE) ............................... 65
TESSALON PERLE (100 MG) (CAPSULE) .................. 65
TESTIM (50 MG (1%)) (GEL (GRAM)) .......................108
TESTOSTERONE................................................... 107, 108
TESTRED (10 MG) (CAPSULE) .................................. 107
TETRABENAZINE.........................................................151
TETRACYCLINE HCL.................................................. 121
TETRAHYDROZOLINE HCL......................................... 67
TEVETEN (600 MG) (TABLET) .....................................47
TEXACORT (2.5 %) (SOLUTION) .................................76
THALIDOMIDE............................................................. 123
THALOMID (100 MG) (CAPSULE) ............................ 123
THALOMID (150 MG) (CAPSULE) ............................ 123
THALOMID (200 MG) (CAPSULE) ............................ 123
THALOMID (50 MG) (CAPSULE) .............................. 123
THEO-24 (100 MG) (CAP ER 24H) ................................18
THEO-24 (200 MG) (CAP ER 24H) ................................18
THEO-24 (300 MG) (CAP ER 24H) ................................18
THEO-24 (400 MG) (CAP ER 24H) ................................18
THEO-DUR (100 MG) (TAB ER 12H) ........................... 18
THEO-DUR (200 MG) (TAB ER 12H) ........................... 18
THEO-DUR (300 MG) (TAB ER 12H) ........................... 18
THEO-DUR (450 MG) (TAB ER 12H) ........................... 18
THEOPHYLLINE ANHYDROUS................................... 18
THERMAZENE (1 %) (CREAM (G)) .............................72
THIOGUANINE..............................................................145
THIOLA (100 MG) (TABLET) ......................................181
THIORIDAZINE HCL...................................................... 35
THIOTHIXENE.................................................................34
THORAZINE (10 MG) (TABLET) ..................................35
THORAZINE (100 MG) (TABLET) ................................35
THORAZINE (200 MG) (TABLET) ................................35
THORAZINE (25 MG) (TABLET) ..................................35
THORAZINE (50 MG) (TABLET) ..................................35
THRIVITE RX (29 MG-1 MG) (TABLET) ...................187
THYROID,PORK........................................................97, 98
THYROID,PORK (113.75 MG) (TABLET) ........................
THYROID,PORK (130 MG) (TABLET) .............................
THYROID,PORK (146.25 MG) (TABLET) ........................
THYROID,PORK (16.25 MG) (TABLET) ..........................
THYROID,PORK (162.5 MG) (TABLET) ..........................
THYROID,PORK (195 MG) (TABLET) .............................
THYROID,PORK (260 MG) (TABLET) .............................
THYROID,PORK (32.5 MG) (TABLET) ............................
THYROID,PORK (325 MG) (TABLET) .............................
THYROID,PORK (48.75 MG) (TABLET) ..........................
THYROID,PORK (65 MG) (TABLET) ...............................
THYROID,PORK (81.25 MG) (TABLET) ..........................
THYROID,PORK (97.5 MG) (TABLET) ............................
THYROLAR-1 (12.5-50MCG) (TABLET) ......................97
THYROLAR-1/2 (6.25-25MCG) (TABLET) ...................97
THYROLAR-1/4 (3.1-12.5) (TABLET) ...........................97
THYROLAR-2 (25-100MCG) (TABLET) .......................97
THYROLAR-3 (37.5-150) (TABLET) .............................97
TIAGABINE HCL...........................................................174
TIAZAC (120 MG) (CAPSULE ER) ............................... 52
TIAZAC (180 MG) (CAPSULE ER) ............................... 52
TIAZAC (240 MG) (CAPSULE ER) ............................... 52
TIAZAC (300 MG) (CAPSULE ER) ............................... 53
TIAZAC (360 MG) (CAPSULE ER) ............................... 53
TIAZAC (420 MG) (CAPSULE ER) ............................... 53
TICAGRELOR................................................................ 106
TICLID (250 MG) (TABLET) ....................................... 107
TICLOPIDINE HCL....................................................... 107
TIGAN (300 MG) (CAPSULE) ....................................... 13
TIKOSYN (125 MCG) (CAPSULE) ................................41
TIKOSYN (250 MCG) (CAPSULE) ................................41
TIKOSYN (500 MCG) (CAPSULE) ................................41
TIMOLOL....................................................................... 102
TIMOLOL MALEATE..............................................51, 102
TIMOLOL MALEATE/PF.............................................. 102
TIMOPTIC (0.25 %) (DROPS) ...................................... 102
TIMOPTIC (0.5 %) (DROPS) ........................................ 102
TIMOPTIC OCUDOSE (0.25 %) (DROPERETTE) ......
102
TIMOPTIC OCUDOSE (0.5 %) (DROPERETTE) ....... 102
TIMOPTIC-XE (0.25 %) (SOL-GEL) ........................... 102
TIMOPTIC-XE (0.5 %) (SOL-GEL) ............................. 102
TINDAMAX (250 MG) (TABLET) ............................... 124
TINDAMAX (500 MG) (TABLET) ............................... 124
TINIDAZOLE................................................................. 124
TIOPRONIN.................................................................... 181
TIOTROPIUM BR/OLODATEROL HCL........................ 15
TIOTROPIUM BROMIDE................................................13
TIPRANAVIR..................................................................126
TIPRANAVIR/VITAMIN E TPGS................................. 126
TIROSINT (100 MCG) (CAPSULE) ............................... 96
TIROSINT (112 MCG) (CAPSULE) ............................... 96
TIROSINT (125 MCG) (CAPSULE) ............................... 96
TIROSINT (13 MCG) (CAPSULE) ................................. 96
TIROSINT (137 MCG) (CAPSULE) ............................... 96
TIROSINT (150 MCG) (CAPSULE) ............................... 96
TIROSINT (25 MCG) (CAPSULE) ................................. 96
TIROSINT (50 MCG) (CAPSULE) ................................. 96
TIROSINT (75 MCG) (CAPSULE) ................................. 96
TIROSINT (88 MCG) (CAPSULE) ................................. 96
TIVICAY (10 MG) (TABLET) .......................................129
TIVICAY (25 MG) (TABLET) .......................................129
TIVICAY (50 MG) (TABLET) .......................................129
TIVORBEX (20 MG) (CAPSULE) ................................138
TIVORBEX (40 MG) (CAPSULE) ................................138
TIZANIDINE HCL......................................................... 176
TOBI (300 MG/5ML) (AMPUL-NEB) ..........................123
TOBI PODHALER (28 MG) (CAP W/DEV) ................ 122
TOBI PODHALER (28 MG) (CAPSULE) .................... 123
TOBRADEX (0.3 %-0.1%) (DROPS SUSP) ................... 98
TOBRADEX (0.3 %-0.1%) (OINT. (G)) ......................... 99
TOBRADEX ST (0.3%-0.05%) (DROPS SUSP) ............ 99
TOBRAMYCIN.............................................. 101, 122, 123
TOBRAMYCIN IN 0.225% NACL................................ 123
TOBRAMYCIN SULFATE.............................................123
TOBRAMYCIN SULFATE (1.2 G) (VIAL) ........................
TOBRAMYCIN SULFATE (10 MG/ML) (VIAL) ..............
TOBRAMYCIN SULFATE (40 MG/ML) (VIAL) ..............
TOBRAMYCIN/DEXAMETHASONE......................98, 99
TOBRAMYCIN/LOTEPRED ETAB................................ 99
TOBRAMYCIN/NEBULIZER....................................... 123
TOBREX (0.3 %) (DROPS) ........................................... 101
TOBREX (0.3 %) (OINT. (G)) ....................................... 101
TOCILIZUMAB..............................................................136
TODAY CONTRACEPTIVE SPONGE (1000 MG)
(CON.SPONGE) (OTC).................................................... 63
TOFACITINIB CITRATE............................................... 136
TOFRANIL (10 MG) (TABLET) .....................................25
TOFRANIL (25 MG) (TABLET) .....................................25
TOFRANIL (50 MG) (TABLET) .....................................25
TOFRANIL-PM (100 MG) (CAPSULE) ......................... 25
TOFRANIL-PM (125 MG) (CAPSULE) ......................... 25
TOFRANIL-PM (150 MG) (CAPSULE) ......................... 25
TOFRANIL-PM (75 MG) (CAPSULE) ........................... 25
TOLAK (4 %) (CREAM (G)) .......................................... 80
TOLAZAMIDE........................................................... 85, 86
TOLBUTAMIDE............................................................... 86
TOLCAPONE..................................................................168
TOLECTIN (200 MG) (TABLET) ................................. 139
TOLECTIN (600 MG) (TABLET) ................................. 139
TOLECTIN DS (400 MG) (CAPSULE) ........................ 139
TOLINASE (250 MG) (TABLET) ................................... 85
TOLINASE (500 MG) (TABLET) ................................... 86
TOLMETIN SODIUM.................................................... 139
Sharp Health Plan: Covered California
TOLTERODINE TARTRATE................................. 182, 183
TOLVAPTAN.....................................................................91
TOPAMAX (100 MG) (TABLET) ................................. 174
TOPAMAX (15 MG) (CAP SPRINK) ........................... 174
TOPAMAX (200 MG) (TABLET) ................................. 174
TOPAMAX (25 MG) (CAP SPRINK) ........................... 174
TOPAMAX (25 MG) (TABLET) ................................... 174
TOPAMAX (50 MG) (TABLET) ................................... 174
TOPICORT (0.05 %) (CREAM (G)) ................................75
TOPICORT (0.05 %) (GEL (GRAM)) ............................. 75
TOPICORT (0.05 %) (OINT. (G)) ....................................75
TOPICORT (0.25 %) (CREAM (G)) ................................75
TOPICORT (0.25 %) (OINT. (G)) ....................................75
TOPICORT (0.25 %) (SPRAY) ........................................ 75
TOPIRAMATE................................................................ 174
TOPOTECAN HCL.........................................................146
TOPROL XL (100 MG) (TAB ER 24H) .......................... 49
TOPROL XL (200 MG) (TAB ER 24H) .......................... 49
TOPROL XL (25 MG) (TAB ER 24H) ............................ 49
TOPROL XL (50 MG) (TAB ER 24H) ............................ 49
TORADOL (10 MG) (TABLET) ....................................138
TOREMIFENE CITRATE...............................................149
TORSEMIDE.............................................................. 54, 55
TOUJEO SOLOSTAR (300/ML) (INSULN PEN) .......... 89
TOVIAZ (4 MG) (TAB ER 24H) ........................... 182, 199
TOVIAZ (8 MG) (TAB ER 24H) ........................... 182, 199
TRACLEER (125 MG) (TABLET) .................................. 56
TRACLEER (62.5 MG) (TABLET) ................................. 56
TRADJENTA (5 MG) (TABLET) ............................85, 199
TRAMADOL HCL..................................................162, 163
TRAMADOL HCL/ACETAMINOPHEN.......................163
TRAMETINIB DIMETHYL SULFOXIDE....................145
TRANDATE (100 MG) (TABLET) ..................................43
TRANDATE (200 MG) (TABLET) ..................................43
TRANDATE (300 MG) (TABLET) ..................................43
TRANDOLAPRIL.............................................................47
TRANDOLAPRIL/VERAPAMIL HCL............................42
TRANEXAMIC ACID.................................................... 104
TRANSDERM-SCOP (1.5MG/3DAY) (PATCH TD 3) ......
13
TRANXENE T-TAB (15 MG) (TABLET) ....................... 28
TRANXENE T-TAB (7.5 MG) (TABLET) ...................... 28
TRANYLCYPROMINE SULFATE..................................20
TRAVATAN Z (0.004 %) (DROPS) ............................... 102
TRAVOPROST................................................................ 102
TRAZODONE HCL..........................................................22
TRECATOR (250 MG) (TABLET) ................................ 123
TRENTAL (400 MG) (TABLET ER) .............................105
TREPROSTINIL............................................................... 56
TREPROSTINIL DIOLAMINE........................................56
TREPROSTINIL/NEB ACCESSORIES...........................56
TREPROSTINIL/NEBULIZER/ACCESOR...............56, 57
TRESIBA FLEXTOUCH U-100 (100/ML (3)) (INSULN
PEN) ......................................................................... 88, 199
TRESIBA FLEXTOUCH U-200 (200/ML (3)) (INSULN
PEN) ................................................................... 88, 89, 199
TRETINOIN.............................................................. 69, 149
TRETINOIN MICROSPHERES....................................... 69
TREXALL (10 MG) (TABLET) .................................... 145
TREXALL (15 MG) (TABLET) .................................... 145
TREXALL (2.5 MG) (TABLET) ................................... 145
TREXALL (5 MG) (TABLET) ...................................... 145
TREXALL (7.5 MG) (TABLET) ................................... 145
TREXIMET (10 MG-60MG) (TABLET) .......................163
TREXIMET (85MG-500MG) (TABLET) ..............163, 199
TREZIX (320.5-30MG) (CAPSULE) ............................ 155
TRIAMCINOLONE ACETONIDE.......................... 77, 151
TRIAMCINOLONE ACETONIDE (0.05 %) (OINT. (G))
...............................................................................................
TRIAMTERENE............................................................... 55
TRIAMTERENE/HYDROCHLOROTHIAZID................55
TRIAVIL 2-10 (2 MG-10 MG) (TABLET) ...................... 24
TRIAVIL 2-25 (2 MG-25 MG) (TABLET) ...................... 24
TRIAVIL 4-25 (4 MG-25 MG) (TABLET) ...................... 24
TRIAVIL 4-50 (4 MG-50 MG) (TABLET) ...................... 24
TRIAZOLAM....................................................................37
TRIBENZOR (20-5-12.5) (TABLET) ...................... 44, 199
TRIBENZOR (40-10-12.5) (TABLET) .................... 44, 199
TRIBENZOR (40-10-25MG) (TABLET) ................ 44, 199
TRIBENZOR (40-5-12.5) (TABLET) ...................... 44, 199
TRIBENZOR (40-5-25 MG) (TABLET) ................. 44, 199
TRICITRATES (500-550/5) (SOLUTION) ................... 182
TRICOR (145MG) (TABLET) ......................................... 60
TRICOR (48 MG) (TABLET) .......................................... 60
TRIENTINE HCL........................................................... 153
TRIFLUOPERAZINE HCL........................................ 35, 36
TRIFLURIDINE..............................................................100
TRIFLURIDINE/TIPIRACIL HCL................................ 145
TRIGLIDE (160 MG) (TABLET) ............................ 60, 199
TRIHEXYPHENIDYL HCL........................................... 166
TRILAFON (16 MG) (TABLET) .....................................35
TRILAFON (2 MG) (TABLET) .......................................35
Page 221 of 224
Index
TRILAFON (4 MG) (TABLET) .......................................35
TRILAFON (8 MG) (TABLET) .......................................35
TRILEPTAL (150 MG) (TABLET) ................................173
TRILEPTAL (300 MG) (TABLET) ................................173
TRILEPTAL (300 MG/5ML) (ORAL SUSP) ................ 173
TRILEPTAL (600 MG) (TABLET) ................................173
TRILIPIX (135 MG) (CAPSULE DR) .............................60
TRILIPIX (45 MG) (CAPSULE DR) ...............................60
TRIMETHOBENZAMIDE HCL...................................... 13
TRIMETHOPRIM...........................................................116
TRIMIPRAMINE MALEATE.......................................... 26
TRINATAL RX 1 (60 MG-1 MG) (TABLET) ............... 187
TRINTELLIX (10 MG) (TABLET) ......................... 24, 199
TRINTELLIX (20 MG) (TABLET) ......................... 24, 199
TRINTELLIX (5 MG) (TABLET) ........................... 24, 199
TRIUMEQ (600-50-300) (TABLET) ............................. 129
TRIVORA (6-5-10) (TABLET) ........................................64
TRIZIVIR (150-300MG) (TABLET) ............................. 126
TROKENDI XR (100 MG) (CAP ER 24H) ................... 174
TROKENDI XR (200 MG) (CAP ER 24H) ................... 174
TROKENDI XR (25 MG) (CAP ER 24H) ..................... 174
TROKENDI XR (50 MG) (CAP ER 24H) ..................... 174
TROPICAMIDE.............................................................. 103
TROSPIUM CHLORIDE................................................ 183
TRULICITY (0.75MG/0.5) (PEN INJCTR) ............ 83, 199
TRULICITY (1.5 MG/0.5) (PEN INJCTR) ............. 84, 199
TRUSOPT (2 %) (DROPS) ............................................ 102
TRUST NATAL DHA (29-1-250MG) (COMBO. PKG) ......
187
TRUVADA (100-150 MG) (TABLET) ...........................126
TRUVADA (133-200 MG) (TABLET) ...........................126
TRUVADA (167-250 MG) (TABLET) ...........................126
TRUVADA (200-300 MG) (TABLET) ...........................126
TUDORZA PRESSAIR (400 MCG) (AER POW BA) ......
13,
199
TUSSICAPS (10MG-8MG) (CAP ER 12H) ....................66
TUSSICAPS (5MG-4MG) (CAP ER 12H) ......................66
TUSSIGON (5 MG-1.5MG) (TABLET) .......................... 66
TUSSIONEX (10-8MG/5ML) (SUS ER 12H) .................66
TUZISTRA XR (14.7-2.8/5) (SUS ER 12H) ........... 66, 199
TWYNSTA (40 MG-10MG) (TABLET) ..........................46
TWYNSTA (40 MG-5 MG) (TABLET) ...........................46
TWYNSTA (80 MG-10MG) (TABLET) ..........................46
TWYNSTA (80 MG-5 MG) (TABLET) ...........................46
TYBOST (150 MG) (TABLET) ..................................... 129
TYKERB (250 MG) (TABLET) .....................................148
TYLENOL WITH CODEINE (120-12MG/5)
(SOLUTION) ..................................................................165
TYLENOL-CODEINE NO.3 (300MG-30MG) (TABLET)
......................................................................................... 165
TYLENOL-CODEINE NO.4 (300MG-60MG) (TABLET)
......................................................................................... 165
TYVASO (1.74MG/2.9) (AMPUL-NEB) ........................ 56
TYVASO INSTITUTIONAL START KIT (1.74MG/2.9)
(AMPUL-NEB) .......................................................... 56, 57
TYVASO REFILL KIT (1.74MG/2.9) (AMPUL-NEB) ......
56
TYVASO STARTER KIT (1.74MG/2.9) (AMPUL-NEB)
........................................................................................... 57
TYZEKA (600 MG) (TABLET) .....................................130
TYZINE (0.1 %) (DROPS) .............................................. 67
TYZINE (0.1 %) (SPRAY) ...............................................67
-UUCERIS (2 MG) (FOAM/APPL) ........................... 141, 200
UCERIS (9 MG) (TABDR - ER) ....................................134
ULESFIA (5 %) (LOTION) ............................................. 71
ULIPRISTAL ACETATE...................................................65
ULORIC (40 MG) (TABLET) ................................103, 200
ULORIC (80 MG) (TABLET) ................................103, 200
ULTRACET (37.5-325MG) (TABLET) .........................163
ULTRAM (50 MG) (TABLET) ...................................... 162
ULTRAM ER (100 MG) (TAB ER 24H) ....................... 162
ULTRAM ER (200 MG) (TAB ER 24H) ....................... 162
ULTRAM ER (300 MG) (TAB ER 24H) ....................... 163
ULTRASAL-ER (28.5 %) (SOL-FILMER) ..................... 79
ULTRAVATE (0.05 %) (CREAM (G)) .............................76
ULTRAVATE (0.05 %) (LOTION) ...................................76
ULTRAVATE (0.05 %) (OINT. (G)) .................................76
ULTRAVATE X (0.05%-10%) (CMB ONT CR) ..............76
ULTRAVATE X (0.05%-10%) (COMBO. PKG) ............. 76
UMECLIDINIUM BRM/VILANTEROL TR...................15
UMECLIDINIUM BROMIDE..........................................13
UMECTA (40 %) (EMULSN(G)) .................................... 79
UMECTA PD (40 %) (EMUL ADHES) .......................... 79
UMECTA PD (40 %) (SUSP ADHES) ............................ 79
UNIPHYL (400 MG) (TAB ER 24H) .............................. 18
UNIPHYL (600 MG) (TAB ER 24H) .............................. 18
UNIRETIC (15-12.5MG) (TABLET) ...............................43
UNIRETIC (15-25MG) (TABLET) ..................................43
UNIRETIC (7.5-12.5MG) (TABLET) ..............................43
UNITHROID (100 MCG) (TABLET) ..............................96
UNITHROID (112 MCG) (TABLET) ..............................96
UNITHROID (125 MCG) (TABLET) ..............................96
UNITHROID (137 MCG) (TABLET) ..............................96
UNITHROID (150 MCG) (TABLET) ..............................96
UNITHROID (175MCG) (TABLET) ...............................96
UNITHROID (200 MCG) (TABLET) ..............................97
UNITHROID (25 MCG) (TABLET) ................................97
UNITHROID (300 MCG) (TABLET) ..............................97
UNITHROID (50 MCG) (TABLET) ................................97
UNITHROID (75 MCG) (TABLET) ................................97
UNITHROID (88 MCG) (TABLET) ................................97
UNIVASC (15 MG) (TABLET) ....................................... 47
UNIVASC (7.5 MG) (TABLET) ...................................... 47
UPTRAVI (1000 MCG) (TABLET) ................................. 56
UPTRAVI (1200 MCG) (TABLET) ................................. 56
UPTRAVI (1400 MCG) (TABLET) ................................. 56
UPTRAVI (1600 MCG) (TABLET) ................................. 56
UPTRAVI (200 MCG) (TABLET) ................................... 56
UPTRAVI (200-800MCG) (TAB DS PK) ........................56
UPTRAVI (400 MCG) (TABLET) ................................... 56
UPTRAVI (600 MCG) (TABLET) ................................... 56
UPTRAVI (800 MCG) (TABLET) ................................... 56
URAMAXIN (20 %) (FOAM) ......................................... 79
URAMAXIN (45 %) (CREAM (G)) ................................79
URAMAXIN (45 %) (GEL (ML)) ................................... 79
URAMAXIN (45 %) (LOTION) ...................................... 79
URAMAXIN GT (45 %) (GEL/PF APP) .........................79
UREA.......................................................................... 79, 82
UREA (35 %) (FOAM) ........................................................
UREA (50 %) (SOL/PF APP) ..............................................
URECHOLINE (10 MG) (TABLET) ............................. 143
URECHOLINE (25 MG) (TABLET) ............................. 143
URECHOLINE (5 MG) (TABLET) ............................... 143
URECHOLINE (50 MG) (TABLET) ............................. 143
URE-K (50 %) (CREAM (G)) ..........................................79
URETRON D-S (81.6-10.8) (TABLET) .........................116
UREVAZ (44 %) (CREAM (G)) ...................................... 79
URIDINE TRIACETATE........................................ 103, 149
URIN D.S. (81.6-10.8) (TABLET) .................................116
URISPAS (100 MG) (TABLET) .................................... 182
UROCIT-K (10 MEQ) (TABLET ER) ........................... 181
UROCIT-K (15 MEQ) (TABLET ER) ........................... 181
UROCIT-K (5 MEQ) (TABLET ER) ............................. 181
UROQID-ACID NO.2 (500-500 MG) (TABLET) ......... 181
UROXATRAL (10 MG) (TAB ER 24H) ........................ 181
URSO (250 MG) (TABLET) .......................................... 142
URSO FORTE (500 MG) (TABLET) ............................ 142
URSODIOL..................................................................... 142
URYL (81.6-.12MG) (TABLET) ....................................116
USTEKINUMAB............................................................ 136
UTA (120-0.12MG) (CAPSULE) ...................................116
UTA (120-40.8MG) (CAPSULE) ...................................116
UTOPIC (41 %) (CREAM (G)) ....................................... 79
-VVAGIFEM (10 MCG) (TABLET) .................................. 183
VALACYCLOVIR HCL..................................................125
VALCHLOR (0.016 %) (GEL (GRAM)) ......................... 80
VALCYTE (450 MG) (TABLET) .................................. 125
VALCYTE (50 MG/ML) (SOLN RECON) ................... 126
VALGANCICLOVIR HCL..................................... 125, 126
VALISONE (0.1 %) (CREAM (G)) ................................. 74
VALISONE (0.1 %) (LOTION) ....................................... 74
VALISONE (0.1 %) (OINT. (G)) ..................................... 74
VALIUM (10 MG) (TABLET) ......................................... 28
VALIUM (2 MG) (TABLET) ........................................... 28
VALIUM (5 MG) (TABLET) ........................................... 28
VALIUM (5 MG/5 ML) (SOLUTION) ............................ 28
VALPROIC ACID (AS SODIUM SALT)....................... 175
VALSARTAN.................................................................... 48
VALSARTAN/HYDROCHLOROTHIAZIDE.................. 45
VALTREX (1000 MG) (TABLET) .........................125, 200
VALTREX (500 MG) (TABLET) ...........................125, 200
VANATOL LQ (50-325/15) (SOLUTION) .................... 154
VANCOCIN HCL (125 MG) (CAPSULE) .................... 124
VANCOCIN HCL (250 MG) (CAPSULE) .................... 124
VANCOMYCIN HCL..................................................... 124
VANDAZOLE (0.75 %) (GEL W/APPL) ...................... 183
VANDETANIB................................................................ 148
VANOS (0.1 %) (CREAM (G)) ........................................75
VANOXIDE-HC (5 %-0.5 %) (SUSPENSION) .............. 68
VANTIN (100 MG) (TABLET) ......................................115
VANTIN (100 MG/5ML) (SUSP RECON) ....................115
VANTIN (200 MG) (TABLET) ......................................115
VANTIN (50 MG/5 ML) (SUSP RECON) .....................115
VARENICLINE TARTRATE.......................................... 176
VARUBI (90 MG) (TABLET) .......................................... 13
VASCEPA (1 G) (CAPSULE) .......................................... 60
VASERETIC (10 MG-25MG) (TABLET) ....................... 42
VASERETIC (5MG-12.5MG) (TABLET) ....................... 42
VASODILAN (10 MG) (TABLET) ..................................63
VASOTEC (10 MG) (TABLET) .......................................46
Sharp Health Plan: Covered California
VASOTEC (2.5 MG) (TABLET) ......................................46
VASOTEC (20 MG) (TABLET) .......................................46
VASOTEC (5 MG) (TABLET) .........................................46
VCF (28 %) (FILM) (OTC)...............................................63
VECAMYL (2.5 MG) (TABLET) ....................................48
VECTICAL (3 MCG/G) (OINT. (G)) ...................... 82, 200
VEETIDS (125 MG/5ML) (SOLN RECON) .................119
VEETIDS (250 MG) (TABLET) .................................... 119
VEETIDS (250 MG/5ML) (SOLN RECON) .................119
VELPHORO (500MG IRON) (TAB CHEW) .................. 92
VELTASSA (16.8 GRAM) (POWD PACK) .................... 91
VELTASSA (25.2 GRAM) (POWD PACK) .................... 91
VELTASSA (8.4 GRAM) (POWD PACK) ...................... 92
VELTIN (1.2-0.025%) (GEL (GRAM)) ...................68, 200
VEMURAFENIB............................................................ 148
VENCLEXTA (10 MG) (TABLET) ............................... 149
VENCLEXTA (100 MG) (TABLET) ............................. 149
VENCLEXTA (50 MG) (TABLET) ............................... 149
VENCLEXTA STARTING PACK (10-50-100) (TAB DS
PK) ..................................................................................149
VENETOCLAX.............................................................. 149
VENLAFAXINE HCL...................................................... 23
VENLAFAXINE HCL ER (150 MG) (TAB ER 24) ......
200
VENLAFAXINE HCL ER (225 MG) (TAB ER 24) ......
200
VENLAFAXINE HCL ER (37.5 MG) (TAB ER 24) ......
200
VENLAFAXINE HCL ER (75 MG) (TAB ER 24) ........200
VENTAVIS (10 MCG/ML) (AMPUL-NEB) ................... 56
VENTAVIS (20 MCG/ML) (AMPUL-NEB) ................... 56
VENTOLIN HFA (90 MCG) (HFA AER AD) .........14, 200
VEPESID (50 MG) (CAPSULE) ................................... 149
VERAMYST (27.5 MCG) (SPRAY SUSP) .............12, 200
VERAPAMIL HCL........................................................... 54
VERDESO (0.05 %) (FOAM) ..........................................75
VERDROCET (2.5-325 MG) (TABLET) ...................... 158
VEREGEN (15 %) (OINT. (G)) ....................................... 72
VERELAN (120 MG) (CAP24H PEL) ............................ 54
VERELAN (180 MG) (CAP24H PEL) ............................ 54
VERELAN (240 MG) (CAP24H PEL) ............................ 54
VERELAN (360 MG) (CAP24H PEL) ............................ 54
VERELAN PM (100 MG) (CAP24H PCT) ..................... 54
VERELAN PM (200 MG) (CAP24H PCT) ..................... 54
VERELAN PM (300 MG) (CAP24H PCT) ..................... 54
VERIPRED 20 (20 MG/5 ML) (SOLUTION) ...............135
VERSACLOZ (50 MG/ML) (ORAL SUSP) ............31, 200
VERSED (2 MG/ML) (SYRUP) ...................................... 37
VERSICLEAR (25-1%) (LOTION) ................................. 71
VESANOID (10 MG) (CAPSULE) ............................... 149
VESICARE (10 MG) (TABLET) ........................... 182, 200
VESICARE (5 MG) (TABLET) ............................. 182, 200
VFEND (200 MG) (TABLET) ....................................... 122
VFEND (200 MG/5ML) (SUSP RECON) ..................... 122
VFEND (50 MG) (TABLET) ......................................... 122
VIBERZI (100 MG) (TABLET) .....................................140
VIBERZI (75 MG) (TABLET) .......................................140
VIBRAMYCIN (100 MG) (CAPSULE) ........................ 120
VIBRAMYCIN (25 MG/5 ML) (SUSP RECON) ..........121
VIBRAMYCIN (50 MG/5 ML) (SYRUP) ..................... 120
VIBRA-TABS (100 MG) (TABLET) ............................. 120
VICOPROFEN (7.5-200 MG) (TABLET) ..................... 155
VICTOZA 2-PAK (0.6 MG/0.1) (PEN INJCTR) ...... 84,
200
VICTOZA 3-PAK (0.6 MG/0.1) (PEN INJCTR) ...... 84,
200
VIDEX (FNL10MG/ML) (SOLN RECON) .................. 127
VIDEX EC (125 MG) (CAPSULE DR) .........................127
VIDEX EC (200 MG) (CAPSULE DR) .........................127
VIDEX EC (250 MG) (CAPSULE DR) .........................127
VIDEX EC (400 MG) (CAPSULE DR) .........................127
VIEKIRA PAK (12.5-75-50) (TAB DS PK) .................. 131
VIEKIRA XR (8.33-50 MG) (TAB BP 24H) .................131
VIGABATRIN................................................................. 175
VIGAMOX (0.5 %) (DROPS) ........................................100
VIIBRYD (10 MG) (TABLET) ................................ 23, 200
VIIBRYD (10 MG-20MG) (TAB DS PK) ............... 23, 200
VIIBRYD (20 MG) (TABLET) ................................ 23, 200
VIIBRYD (40 MG) (TABLET) ................................ 23, 200
VILAZODONE HCL........................................................ 23
VIMOVO (375MG-20MG) (TAB IR DR) ..................... 136
VIMOVO (500MG-20MG) (TAB IR DR) ..................... 136
VIMPAT (10 MG/ML) (SOLUTION) ............................ 170
VIMPAT (100 MG) (TABLET) ...................................... 171
VIMPAT (150 MG) (TABLET) ...................................... 171
VIMPAT (200 MG) (TABLET) ...................................... 171
VIMPAT (50 MG) (TABLET) ........................................ 171
VINORELBINE TARTRATE..........................................150
VIOKACE (10.4-39.2K) (TABLET) .............................. 177
VIOKACE (20.9-78.3K) (TABLET) .............................. 177
VIRACEPT (250 MG) (TABLET) ................................. 128
VIRACEPT (625 MG) (TABLET) ................................. 128
Page 222 of 224
Index
VIRAMUNE (200 MG) (TABLET) ............................... 127
VIRAMUNE (50 MG/5 ML) (ORAL SUSP) ................ 127
VIRAMUNE XR (100 MG) (TAB ER 24H) ..................127
VIRAMUNE XR (400 MG) (TAB ER 24H) ..................127
VIREAD (150 MG) (TABLET) ..................................... 128
VIREAD (200 MG) (TABLET) ..................................... 128
VIREAD (250 MG) (TABLET) ..................................... 128
VIREAD (300 MG) (TABLET) ..................................... 128
VIREAD (40MG/SCOOP) (POWDER) .........................128
VIROPTIC (1 %) (DROPS) ............................................100
VISKEN (10 MG) (TABLET) .......................................... 50
VISKEN (5 MG) (TABLET) ............................................ 50
VISMODEGIB................................................................ 145
VISTARIL (100 MG) (CAPSULE) .................................. 10
VISTARIL (25 MG) (CAPSULE) .................................... 10
VISTARIL (50 MG) (CAPSULE) .................................... 10
VISTOGARD (10 G) (GRAN PACK) ............................149
VITATRUE (30-1.4-300) (COMBO. PKG) ....................187
VITEKTA (150 MG) (TABLET) ....................................129
VITEKTA (85 MG) (TABLET) ......................................129
VITUZ (5MG-4MG/5) (SOLUTION) ..............................66
VIVACTIL (10 MG) (TABLET) ...................................... 26
VIVACTIL (5 MG) (TABLET) ........................................ 26
VIVELLE-DOT (.025MG/24H) (PATCH TDSW) .........110
VIVELLE-DOT (.0375MG/24) (PATCH TDSW) ..........110
VIVELLE-DOT (.075MG/24H) (PATCH TDSW) .........110
VIVELLE-DOT (0.05MG/24H) (PATCH TDSW) .........110
VIVELLE-DOT (0.1MG/24HR) (PATCH TDSW) ........ 110
VIVLODEX (10 MG) (CAPSULE) ....................... 138, 200
VIVLODEX (5 MG) (CAPSULE) ......................... 138, 200
VOGELXO (1.25 G(1%)) (GEL MD PMP) ...................108
VOGELXO (50 MG (1%)) (GEL (GRAM)) .................. 108
VOGELXO (50 MG (1%)) (GEL PACKET) ..................108
VOLTAREN (0.1 %) (DROPS) ........................................ 99
VOLTAREN (1 %) (GEL (GRAM)) .................................77
VOLTAREN (25 MG) (TABLET DR) ........................... 137
VOLTAREN (50 MG) (TABLET DR) ........................... 137
VOLTAREN (75 MG) (TABLET DR) ........................... 137
VOLTAREN-XR (100 MG) (TAB ER 24H) .................. 137
VORAPAXAR SULFATE............................................... 107
VORICONAZOLE.......................................................... 122
VORINOSTAT.................................................................149
VORTIOXETINE HYDROBROMIDE............................. 24
VOSOL (2 %) (SOLUTION) ........................................... 90
VOSOL HC (2 %-1 %) (DROPS) .....................................90
VOSPIRE ER (4 MG) (TAB ER 12H) ............................. 14
VOSPIRE ER (8 MG) (TAB ER 12H) ............................. 14
VOTRIENT (200 MG) (TABLET) .................................148
VRAYLAR (1.5 MG) (CAPSULE) ..................................29
VRAYLAR (1.5 MG-3MG) (CAP DS PK) ......................29
VRAYLAR (3 MG) (CAPSULE) .....................................29
VRAYLAR (4.5 MG) (CAPSULE) ..................................29
VRAYLAR (6 MG) (CAPSULE) .....................................29
VUSION (0.25 %-15%) (OINT. (G)) ............................... 71
VYTONE (1.9 %-1 %) (CREAM PACK) ........................ 68
VYTORIN (10 MG-10MG) (TABLET) ...................58, 200
VYTORIN (10 MG-20MG) (TABLET) ...................58, 200
VYTORIN (10 MG-40MG) (TABLET) ...................58, 200
VYTORIN (10 MG-80MG) (TABLET) ...................58, 200
VYVANSE (10 MG) (CAPSULE) ................................... 27
VYVANSE (20 MG) (CAPSULE) ................................... 27
VYVANSE (30 MG) (CAPSULE) ................................... 27
VYVANSE (40 MG) (CAPSULE) ................................... 27
VYVANSE (50 MG) (CAPSULE) ................................... 27
VYVANSE (60 MG) (CAPSULE) ................................... 27
VYVANSE (70 MG) (CAPSULE) ................................... 27
-WWARFARIN SODIUM.................................................... 104
WEED POLLEN-SHORT RAGWEED............................ 10
WELCHOL (3.75 G) (POWD PACK) ..............................59
WELCHOL (625 MG) (TABLET) ................................... 59
WELLBUTRIN (100 MG) (TABLET) .............................20
WELLBUTRIN (75 MG) (TABLET) ...............................20
WELLBUTRIN SR (100 MG) (TABLET ER) .................20
WELLBUTRIN SR (150 MG) (TABLET ER) .................20
WELLBUTRIN SR (200 MG) (TABLET ER) .................20
WELLBUTRIN XL (150 MG) (TAB ER 24H) ................20
WELLBUTRIN XL (300 MG) (TAB ER 24H) ................21
WELLCOVORIN (10 MG) (TABLET) ..........................149
WELLCOVORIN (15 MG) (TABLET) ..........................149
WELLCOVORIN (25 MG) (TABLET) ..........................149
WELLCOVORIN (5 MG) (TABLET) ............................149
WESTCORT (0.2 %) (OINT. (G)) ....................................76
WP THYROID (113.75 MG) (TABLET) .........................98
WP THYROID (130 MG) (TABLET) ..............................98
WP THYROID (16.25 MG) (TABLET) ...........................98
WP THYROID (32.5 MG) (TABLET) .............................98
WP THYROID (48.75 MG) (TABLET) ...........................98
WP THYROID (65 MG) (TABLET) ................................98
WP THYROID (81.25 MG) (TABLET) ...........................98
WP THYROID (97.5 MG) (TABLET) .............................98
-XXALATAN (0.005 %) (DROPS) .................................... 102
XALKORI (200 MG) (CAPSULE) ................................147
XALKORI (250 MG) (CAPSULE) ................................147
XANAX (0.25 MG) (TABLET) ....................................... 28
XANAX (0.5 MG) (TABLET) ......................................... 28
XANAX (1 MG) (TABLET) ............................................ 28
XANAX (2 MG) (TABLET) ............................................ 28
XANAX XR (0.5 MG) (TAB ER 24H) ............................ 28
XANAX XR (1 MG) (TAB ER 24H) ............................... 28
XANAX XR (2 MG) (TAB ER 24H) ............................... 28
XANAX XR (3 MG) (TAB ER 24H) ............................... 28
XARELTO (10 MG) (TABLET) .................................... 104
XARELTO (15 MG) (TABLET) .................................... 104
XARELTO (15 MG-20MG) (TAB DS PK) ....................104
XARELTO (20 MG) (TABLET) .................................... 104
XARTEMIS XR (7.5-325 MG) (TAB IR ERO) ............. 161
XELJANZ (5 MG) (TABLET) ....................................... 136
XELJANZ XR (11 MG) (TAB ER 24H) ........................ 136
XELODA (150 MG) (TABLET) .................................... 144
XELODA (500 MG) (TABLET) .................................... 144
XENAZINE (12.5 MG) (TABLET) ............................... 151
XENAZINE (25 MG) (TABLET) .................................. 151
XERESE (5 %-1 %) (CREAM (G)) ......................... 72, 200
XGEVA (120 MG/1.7) (VIAL) ........................................ 94
XIFAXAN (200 MG) (TABLET) ...................................124
XIFAXAN (550 MG) (TABLET) ...................................124
XIGDUO XR (10-1000 MG) (TAB BP 24H) .......... 87, 200
XIGDUO XR (10MG-500MG) (TAB BP 24H) ....... 87, 200
XIGDUO XR (5 MG-500MG) (TAB BP 24H) ........ 87, 200
XIGDUO XR (5MG-1000MG) (TAB BP 24H) ....... 87, 200
XIIDRA (5 %) (DROPERETTE) ................................... 101
XODOL 10-300 (10MG-300MG) (TABLET) ............... 158
XODOL 5-300 (5 MG-300MG) (TABLET) .................. 158
XODOL 7.5-300 (7.5-300 MG) (TABLET) ................... 158
XOLEGEL (2 %) (GEL (GRAM)) ...................................71
XOPENEX (0.31MG/3ML) (VIAL-NEB) .......................14
XOPENEX (0.63MG/3ML) (VIAL-NEB) .......................14
XOPENEX (1.25MG/3ML) (VIAL-NEB) .......................14
XOPENEX CONCENTRATE (1.25MG/0.5) (VIAL-NEB)
........................................................................................... 14
XOPENEX HFA (45 MCG) (HFA AER AD) .......... 15, 200
XTAMPZA ER (13.5 MG) (CAP SPR 12) .....................161
XTAMPZA ER (18 MG) (CAP SPR 12) ........................161
XTAMPZA ER (27 MG) (CAP SPR 12) ........................161
XTAMPZA ER (36 MG) (CAP SPR 12) ........................161
XTAMPZA ER (9 MG) (CAP SPR 12) ..........................162
XTANDI (40 MG) (CAPSULE) .....................................144
XURIDEN (2 G) (GRAN PACK) ...................................103
X-VIATE (40 %) (GEL (ML)) ......................................... 79
XYLOCAINE (2 %) (JEL (ML)) ................................... 139
XYLOCAINE (40 MG/ML) (SOLUTION) ................... 139
XYLOCAINE (5 %) (OINT. (G)) .....................................81
XYLOCAINE VISCOUS (2 %) (SOLUTION) ............. 139
XYREM (500 MG/ML) (SOLUTION) ............................ 29
XYZAL (2.5 MG/5ML) (SOLUTION) ....................11, 200
XYZAL (5 MG) (TABLET) ..................................... 11, 200
-YYASMIN 28 (0.03MG-3MG) (TABLET) ........................ 63
YAZ (0.02-3(24)) (TABLET) ........................................... 63
YOSPRALA (325MG-40MG) (TAB IR DR) .................106
YOSPRALA (81 MG-40MG) (TAB IR DR) ..................106
-ZZAFIRLUKAST................................................................ 17
ZALEPLON.......................................................................37
ZAMICET (10-325/15) (SOLUTION) ...........................158
ZAMICET (5-163/7.5) (SOLUTION) ............................158
ZANAFLEX (2 MG) (CAPSULE) .................................176
ZANAFLEX (2 MG) (TABLET) ....................................176
ZANAFLEX (4 MG) (CAPSULE) .................................176
ZANAFLEX (4 MG) (TABLET) ....................................176
ZANAFLEX (6 MG) (CAPSULE) .................................176
ZANAMIVIR...................................................................126
ZANTAC (15 MG/ML) (SYRUP) .................................. 179
ZANTAC (150 MG) (CAPSULE) .................................. 179
ZANTAC (150 MG) (TABLET) .....................................179
ZANTAC (300 MG) (CAPSULE) .................................. 179
ZANTAC (300 MG) (TABLET) .....................................179
ZARONTIN (250 MG) (CAPSULE) ............................. 170
ZARONTIN (250 MG/5ML) (SOLUTION) .................. 170
ZAROXOLYN (10 MG) (TABLET) ................................ 58
ZAROXOLYN (2.5 MG) (TABLET) ............................... 58
ZAROXOLYN (5 MG) (TABLET) .................................. 58
ZAVESCA (100 MG) (CAPSULE) ................................152
ZEBETA (10 MG) (TABLET) ..........................................49
ZEBETA (5 MG) (TABLET) ............................................49
ZEGERID (20-1680MG) (PACKET) ..................... 180, 200
ZEGERID (20MG-1.1G) (CAPSULE) .................. 180, 201
ZEGERID (40-1680MG) (PACKET) ..................... 180, 201
ZEGERID (40MG-1.1G) (CAPSULE) .................. 180, 201
Sharp Health Plan: Covered California
ZELAPAR (1.25 MG) (TAB RAPDIS) .......................... 168
ZELBORAF (240 MG) (TABLET) ................................ 148
ZEMBRACE SYMTOUCH (3 MG/0.5ML) (PEN
INJCTR) ......................................................................... 164
ZEMPLAR (1 MCG) (CAPSULE) .................................. 94
ZEMPLAR (2 MCG) (CAPSULE) .................................. 94
ZEMPLAR (4MCG) (CAPSULE) ................................... 94
ZENCIA (9 %-4 %) (CLEANSER) ..................................73
ZENPEP (10-34-55K) (CAPSULE DR) ........................ 177
ZENPEP (15-51-82K) (CAPSULE DR) ........................ 177
ZENPEP (20-68-109K) (CAPSULE DR) ...................... 177
ZENPEP (25-85-136K) (CAPSULE DR) ...................... 177
ZENPEP (3K-10K-16K) (CAPSULE DR) .....................177
ZENPEP (40K-136K) (CAPSULE DR) .........................177
ZENZEDI (15 MG) (TABLET) ........................................27
ZENZEDI (2.5 MG) (TABLET) .......................................27
ZENZEDI (20 MG) (TABLET) ........................................27
ZENZEDI (30 MG) (TABLET) ........................................27
ZENZEDI (7.5 MG) (TABLET) .......................................27
ZEPATIER (50MG-100MG) (TABLET) ........................131
ZERIT (1 MG/ML) (SOLN RECON) ............................ 127
ZERIT (15 MG) (CAPSULE) ........................................ 127
ZERIT (20 MG) (CAPSULE) ........................................ 128
ZERIT (30 MG) (CAPSULE) ........................................ 128
ZERIT (40 MG) (CAPSULE) ........................................ 128
ZESTORETIC (10-12.5MG) (TABLET) ......................... 43
ZESTORETIC (20 MG-25MG) (TABLET) .....................43
ZESTORETIC (20-12.5 MG) (TABLET) ........................ 43
ZESTRIL (10 MG) (TABLET) .........................................46
ZESTRIL (2.5 MG) (TABLET) ........................................46
ZESTRIL (20 MG) (TABLET) .........................................46
ZESTRIL (30 MG) (TABLET) .........................................47
ZESTRIL (40 MG) (TABLET) .........................................47
ZESTRIL (5 MG) (TABLET) ...........................................47
ZETIA (10 MG) (TABLET) ............................................. 59
ZETONNA (37 MCG) (HFA AER AD) ...................11, 201
ZIAC (10-6.25MG) (TABLET) ........................................ 51
ZIAC (2.5-6.25MG) (TABLET) ....................................... 51
ZIAC (5-6.25MG) (TABLET) .......................................... 51
ZIAGEN (20 MG/ML) (SOLUTION) ............................127
ZIAGEN (300 MG) (TABLET) ......................................127
ZIANA (1.2-0.025%) (GEL (GRAM)) .....................68, 201
ZIDOVUDINE.................................................................128
ZILEUTON........................................................................13
ZINC ACETATE..............................................................153
ZIOPTAN (0.0015 %) (DROPERETTE) ........................102
ZIPRASIDONE HCL........................................................ 34
ZIPSOR (25 MG) (CAPSULE) .............................. 137, 201
ZIRGAN (0.15 %) (GEL (GRAM)) ............................... 100
ZITHRANOL (1 %) (SHAMPOO(G)) .............................82
ZITHRANOL-RR (1.2 %) (CRM RR (G)) .............. 82, 201
ZITHROMAX (1 G) (PACKET) .................................... 116
ZITHROMAX (100 MG/5ML) (SUSP RECON) .......... 116
ZITHROMAX (200 MG/5ML) (SUSP RECON) .......... 116
ZITHROMAX (250 MG) (TABLET) .............................116
ZITHROMAX (500 MG) (TABLET) .............................116
ZITHROMAX (600 MG) (TABLET) .............................116
ZITHROMAX TRI-PAK (500 MG) (TABLET) ............ 116
ZMAX (2 G/60 ML) (SUS ER REC) ............................. 116
ZOCOR (10 MG) (TABLET) ........................................... 59
ZOCOR (20 MG) (TABLET) ........................................... 59
ZOCOR (40 MG) (TABLET) ........................................... 59
ZOCOR (5 MG) (TABLET) ............................................. 59
ZOCOR (80 MG) (TABLET) ........................................... 59
ZOFRAN (24 MG) (TABLET) .........................................12
ZOFRAN (4 MG) (TABLET) ...........................................13
ZOFRAN (4 MG/5 ML) (SOLUTION) ........................... 13
ZOFRAN (8 MG) (TABLET) ...........................................13
ZOFRAN ODT (4 MG) (TAB RAPDIS) ......................... 12
ZOFRAN ODT (8 MG) (TAB RAPDIS) ......................... 12
ZOHYDRO ER (10 MG) (CAP ER 12H) ...................... 157
ZOHYDRO ER (15 MG) (CAP ER 12H) ...................... 158
ZOHYDRO ER (20 MG) (CAP ER 12H) ...................... 158
ZOHYDRO ER (30 MG) (CAP ER 12H) ...................... 158
ZOHYDRO ER (40 MG) (CAP ER 12H) ...................... 158
ZOHYDRO ER (50 MG) (CAP ER 12H) ...................... 158
ZOLINZA (100 MG) (CAPSULE) ................................ 149
ZOLMITRIPTAN............................................................ 164
ZOLOFT (100 MG) (TABLET) ....................................... 22
ZOLOFT (20 MG/ML) (ORAL CONC) .......................... 22
ZOLOFT (25 MG) (TABLET) ......................................... 22
ZOLOFT (50 MG) (TABLET) ......................................... 22
ZOLPIDEM TARTRATE............................................ 37, 38
ZOLPIMIST (5 MG/SPRAY) (SPRAY/PUMP) .......38, 201
ZOMIG (2.5 MG) (SPRAY) ................................... 164, 201
ZOMIG (2.5 MG) (TABLET) ................................ 164, 201
ZOMIG (5 MG) (SPRAY) ...................................... 164, 201
ZOMIG (5 MG) (TABLET) ................................... 164, 201
ZOMIG ZMT (2.5 MG) (TAB RAPDIS) ............... 164, 201
ZOMIG ZMT (5 MG) (TAB RAPDIS) .................. 164, 201
ZONALON (5 %) (CREAM (G)) .....................................77
ZONATUSS (150 MG) (CAPSULE) ............................... 65
Page 223 of 224
Index
ZONEGRAN (100 MG) (CAPSULE) ............................175
ZONEGRAN (25 MG) (CAPSULE) ..............................175
ZONEGRAN (50 MG) (CAPSULE) ..............................175
ZONISAMIDE................................................................ 175
ZONTIVITY (2.08 MG) (TABLET) .............................. 107
ZORTRESS (0.25 MG) (TABLET) ................................112
ZORTRESS (0.5 MG) (TABLET) ..................................112
ZORTRESS (0.75 MG) (TABLET) ................................113
ZORVOLEX (18 MG) (CAPSULE) .......................137, 201
ZORVOLEX (35 MG) (CAPSULE) .......................137, 201
ZOVIRAX (200 MG) (CAPSULE) ................................ 125
ZOVIRAX (200 MG/5ML) (ORAL SUSP) ................... 125
ZOVIRAX (400 MG) (TABLET) ...................................125
ZOVIRAX (5 %) (CREAM (G)) ...................................... 72
ZOVIRAX (5 %) (OINT. (G)) .......................................... 72
ZOVIRAX (800 MG) (TABLET) ...................................125
ZUBSOLV (1.4-0.36MG) (TAB SUBL) ........................ 165
ZUBSOLV (11.4-2.9MG) (TAB SUBL) ........................ 165
ZUBSOLV (2.9-0.71MG) (TAB SUBL) ........................ 165
ZUBSOLV (5.7-1.4 MG) (TAB SUBL) ......................... 165
ZUBSOLV (8.6-2.1 MG) (TAB SUBL) ......................... 165
ZUPLENZ (4 MG) (FILM) .............................................. 12
ZUPLENZ (8 MG) (FILM) .............................................. 12
ZURAMPIC (200 MG) (TABLET) ........................ 103, 201
ZUTRIPRO (5-4-60MG/5) (SOLUTION) ....................... 65
ZYBAN (150 MG) (TABLET ER) .................................177
ZYCLARA (2.5 %) (CRM MD PMP) ........................... 112
ZYCLARA (3.75 %) (CREAM PACK) ......................... 112
ZYCLARA (3.75 %) (CRM MD PMP) ......................... 112
ZYDELIG (100 MG) (TABLET) ................................... 147
ZYDELIG (150 MG) (TABLET) ................................... 147
ZYFLO (600 MG) (TABLET) ..........................................13
ZYFLO CR (600 MG) (TBMP 12HR) .............................13
ZYKADIA (150 MG) (CAPSULE) ................................147
ZYLET (0.3%-0.5%) (DROPS SUSP) ............................. 99
ZYLOPRIM (100 MG) (TABLET) ................................ 103
ZYLOPRIM (300 MG) (TABLET) ................................ 103
ZYMAXID (0.5 %) (DROPS) ........................................ 100
ZYPREXA (10 MG) (TABLET) ...................................... 32
ZYPREXA (15 MG) (TABLET) ...................................... 32
ZYPREXA (2.5 MG) (TABLET) ..................................... 32
ZYPREXA (20 MG) (TABLET) ...................................... 32
ZYPREXA (5 MG) (TABLET) ........................................ 32
ZYPREXA (7.5 MG) (TABLET) ..................................... 32
ZYPREXA ZYDIS (10 MG) (TAB RAPDIS) ................. 32
ZYPREXA ZYDIS (15 MG) (TAB RAPDIS) ................. 32
ZYPREXA ZYDIS (20 MG) (TAB RAPDIS) ................. 32
ZYPREXA ZYDIS (5 MG) (TAB RAPDIS) ................... 32
ZYRTEC (1 MG/ML) (SOLUTION) ....................... 11, 201
ZYTIGA (250 MG) (TABLET) ......................................144
ZYVOX (100 MG/5ML) (SUSP RECON) .....................117
ZYVOX (600 MG) (TABLET) .......................................117
Sharp Health Plan: Covered California
Page 224 of 224
SPECIALTY DRUG LIST
Drugs listed on this list are designated as specialty drugs under the Sharp Health Plan Pharmacy
Benefit. All specialty drugs require prior authorization. Upon approval of your specialty drug,
you will receive information on which retail and mail pharmacies can supply your medication.
BRAND NAME
ADASUVE
ADCIRCA
GENERIC NAME
LOXAPINE
TADALAFIL
BRAND NAME
CYCLOPHOSPHAMIDE
CYSTADANE
ADEMPAS
RIOCIGUAT
CYSTARAN
AFINITOR
EVEROLIMUS
DAKLINZA
AFINITOR DISPERZ
EVEROLIMUS
DEPEN
AGRYLIN
ANAGRELIDE HCL
DESCOVY
ALECENSA
AMPYRA
ALECTINIB
HYDROCHLORIDE
FAMPRIDINE (4AMINOPYRIDINE)
DIBENZYLINE
EDURANT
APTIVUS
TIPRANAVIR
EMCYT
ASTAGRAF XL
TACROLIMUS
EFAVIRENZ/
EMTRICITAB/
TENOFOVIR
ENVARSUS XR
AUBAGIO
TERIFLUNOMIDE
EPZICOM
BARACLUDE
BOSULIF
ENTECAVIR
BOSUTINIB
SODIUM
PHENYLBUTYRATE
CABOZANTINIB SMALATE
ERIVEDGE
ESBRIET
CAPRELSA
VANDETANIB
FARESTON
CARBAGLU
CARGLUMIC ACID
FARYDAK
CAYSTON
AZTREONAM
LYSINE
FERRIPROX
CEENU
LOMUSTINE
GENVOYA
ATRIPLA
BUPHENYL
CABOMETYX
CERDELGA
CHOLBAM
COMBIVIR
COMETRIQ
COMPLERA
COTELLIC
CUPRIMINE
January 2017
ELIGLUSTAT
TARTRATE
CHOLIC ACID
LAMIVUDINE/ZIDOVU
DINE
CABOZANTINIB SMALATE
EMTRICITAB/RILPIVIR
INE/TENOFOV
COBIMETINIB
PENICILLAMINE
EPCLUSA
EVOTAZ
EXJADE
GENERIC NAME
CYCLOPHOSPHAMIDE
BETAINE
CYSTEAMINE
HYDROCHLORIDE
DACLATASVIR
DIHYDROCHLORIDE
PENICILLAMINE
EMTRICITABINE/TENO
FOV ALAFENAM
PHENOXYBENZAMINE
HCL
RILPIVIRINE
HYDROCHLORIDE
ESTRAMUSTINE
PHOSPHATE SODIUM
TACROLIMUS
SOFOSBUVIR/VELPAT
ASVIR
ABACAVIR
SULFATE/LAMIVUDIN
E
VISMODEGIB
PIRFENIDONE
ATAZANAVIR
SULFATE/COBICISTAT
DEFERASIROX
TOREMIFENE
CITRATE
PANOBINOSTAT
LACTATE
DEFERIPRONE
GILOTRIF
ELVITEG/COBI/EMTRI
C/TENOFO ALA
FINGOLIMOD
HYDROCHLORIDE
AFATINIB DIMALEATE
GLEEVEC
IMATINIB MESYLATE
GLEOSTINE
LOMUSTINE
GILENYA
HARVONI
HECORIA
HEPSERA
LEDIPASVIR/
SOFOSBUVIR
TACROLIMUS
ADEFOVIR DIPIVOXIL
BRAND NAME
HETLIOZ
GENERIC NAME
TASIMELTEON
BRAND NAME
OCALIVA
HEXALEN
ALTRETAMINE
ODEFSEY
HYCAMTIN
TOPOTECAN HCL
ODOMZO
IBRANCE
ICLUSIG
IMBRUVICA
INCIVEK
INLYTA
PALBOCICLIB
PONATINIB HCL
IBRUTINIB
TELAPREVIR
AXITINIB
OFEV
OLYSIO
OPSUMIT
ORENITRAM ER
ORFADIN
INTELENCE
ETRAVIRINE
ORKAMBI
INVIRASE
IRESSA
ISENTRESS
JADENU
SAQUINAVIR
MESYLATE
GEFITINIB
RALTEGRAVIR
POTASSIUM
DEFERASIROX
KORLYM
RUXOLITINIB
PHOSPHATE
LOMITAPIDE
MESYLATE
LOPINAVIR/
RITONAVIR
IVACAFTOR
DICHLORPHENAMIDE
TOBRAMYCIN/
NEBULIZER
MIFEPRISTONE
KUVAN
SAPROPTERIN
JAKAFI
JUXTAPID
KALETRA
KALYDECO
KEVEYIS
KITABIS PAK
OTEZLA
APREMILAST
PANRETIN
ALITRETINOIN
POMALYST
POMALIDOMIDE
PREZCOBIX
DARUNAVIR/
COBICISTAT
PREZISTA
DARUNAVIR
PROCYSBI
CYSTEAMINE
PROGRAF
TACROLIMUS
PROMACTA
PULMOZYME
ELTROMBOPAG
DORNASE ALFA
PURIXAN
MERCAPTOPURINE
RAPAMUNE
SIROLIMUS
GLYCEROL
PHENYLBUTYRATE
RAVICTI
NEUMEGA
LENVATINIB
MESYLATE
AMBRISENTAN
CHLORAMBUCIL
FOSAMPRENAVIR
TRIFLURIDINE/
TIPIRACIL
OLAPARIB
MITOTANE
PROCARBAZINE HCL
TRAMETINIB
MYCOPHENOLATE
BUSULFAN
CYCLOSPORINE,
MODIFIED
OPRELVEKIN
NEXAVAR
SORAFENIB
STRIBILD
NILANDRON
NINLARO
NORTHERA
NORVIR
NUPLAZID
NYMALIZE
NILUTAMIDE
IXAZOMIB
DROXIDOPA
RITONAVIR
PIMAVANSERIN
NIMODIPINE
SUCRAID
SUSTIVA
SUTENT
SYNAREL
TABLOID
TAFINLAR
LENVIMA
LETAIRIS
LEUKERAN
LEXIVA
LONSURF
LYNPARZA
LYSODREN
MATULANE
MEKINIST
MYFORTIC
MYLERAN
NEORAL
January 2017
GENERIC NAME
OBETICHOLIC ACID
EMTRICITAB/
RILPIVIRI/TENOF
SONIDEGIB
PHOSPHATE
NINTEDANIB
SIMEPREVIR
MACITENTAN
TREPROSTINIL
NITISINONE
LUMACAFTOR/
IVACAFTOR
REVATIO
SILDENAFIL CITRATE
REVLIMID
REYATAZ
RIDAURA
LENALIDOMIDE
ATAZANAVIR
AURANOFIN
RILUTEK
RILUZOLE
SANDIMMUNE
SELZENTRY
SENSIPAR
SIRTURO
SORIATANE
SOVALDI
CYCLOSPORINE
MARAVIROC
CINACALCET
BEDAQUILINE
ACITRETIN
SOFOSBUVIR
SPRYCEL
DASATINIB
STIVARGA
REGORAFENIB
ELVITEGR/COBICIST/E
MTRIC/TENOF
SACROSIDASE
EFAVIRENZ
SUNITINIB
NAFARELIN ACETATE
THIOGUANINE
DABRAFENIB
BRAND NAME
GENERIC NAME
BRAND NAME
TAGRISSO
OSIMERTINIB
ZEPATIER
TARCEVA
TARGRETIN
TASIGNA
ERLOTINIB HCL
BEXAROTENE
NILOTINIB
DIMETHYL
FUMARATE
OMBITASVIR/PARITAP
REV/RITONAV
TEMOZOLOMIDE
THALIDOMIDE
TIOPRONIN
DOLUTEGRAVIR
TOBRAMYCIN/0.25
NORMAL SALINE
TOBRAMYCIN
BOSENTAN
ABACAVIR/DOLUTEGR
AVIR/LAMIVUDI
ABACAVIR/LAMIVUDI
NE/ZIDOVUDINE
EMTRICITABINE/TENO
FOVIR
LAPATINIB
TREPROSTINIL
TELBIVUDINE
SELEXIPAG
MECHLORETHAMINE
HCL
VENETOCLAX
ZIAGEN
ZOLINZA
ZORTRESS
GENERIC NAME
ELBASVIR/GRAZOPRE
VIR
ABACAVIR SULFATE
VORINOSTAT
EVEROLIMUS
ZYDELIG
IDELALISIB
ZYKADIA
CERITINIB
ZYTIGA
ABIRATERONE
TECFIDERA
TECHNIVIE
TEMODAR
THALOMID
THIOLA
TIVICAY
TOBI
TOBI PODHALER
TRACLEER
TRIUMEQ
TRIZIVIR
TRUVADA
TYKERB
TYVASO
TYZEKA
UPTRAVI
VALCHLOR
VENCLEXTA
VENCLEXTA
STARTING PACK
VENTAVIS
VICTRELIS
VIEKIRA PAK
VIEKIRA XR
VIRACEPT
VIREAD
VISTOGARD
VITEKTA
VOTRIENT
XALKORI
XELJANZ
XELJANZ XR
XELODA
XENAZINE
XTANDI
XURIDEN
XYREM
ZAVESCA
ZELBORAF
January 2017
VENETOCLAX
ILOPROST
BOCEPREVIR
OMBITA/PARITAP/RIT
ON/DASABUVIR
OMBITA/PARITAP/RIT
ON/DASABUVIR
NELFINAVIR
TENOFOVIR
DISOPROXIL
FUMARATE
URIDINE TRIACETATE
ELVITEGRAVIR
PAZOPANIB
CRIZOTINIB
TOFACITINIB
TOFACITINIB
CAPECITABINE
TETRABENAZINE
ENZALUTAMIDE
URIDINE TRIACETATE
SODIUM OXYBATE
MIGLUSTAT
VEMURAFENIB
MAINTENANCE DRUG INFORMATION
The therapeutic categories on this list are considered to be maintenance medications. A ninety (90) day supply
can be filled at mail order or at retail according to the member’s benefit. However, if a medication is listed on
the Sharp Health Plan Specialty Drug List a maximum of a 30 day supply per fill can be obtained. Medications
to treat HIV, Hepatitis C and Multiple Sclerosis may not be on the Specialty Drug List but are also limited to a
30 day supply per fill.
Maintenance Drug Classes
5-LIPOXYGENASE INHIBITORS
ACE INHIBITOR-CALCIUM
CHANNEL BLOCKER COMBINATION
ACE INHIBITOR-THIAZIDE OR
THIAZIDE-LIKE DIURETIC
ADRENERGIC VASOPRESSOR
AGENTS
ADRENERGICS, AROMATIC, NONCATECHOLAMINE
AGENTS TO TREAT
HYPOGLYCEMIA
(HYPERGLYCEMICS)
AGENTS TO TREAT MULTIPLE
SCLEROSIS
AGENTS TO TX PERIODIC
PARALYSIS - CARBON ANHYD INH
AGTS TX NEUROMUSC
TRANSMISSION DIS,POT-CHAN
BLKR
ALLERGENIC EXTRACTS,
THERAPEUTIC
ALPHA/BETA-ADRENERGIC
BLOCKING AGENTS
ALPHA-2 RECEPTOR ANTAGONIST
ANTIDEPRESSANTS
ALPHA-ADRENERGIC BLOCKING
AGENTS
ALZHEIMER'S THERAPY, NMDA
RECEPTOR ANTAGONISTS
ALZHEIMER'S THX,NMDA RECEPT
ANTAG & CHOLINES INHIB
AMINOGLYCOSIDES
AMMONIA INHIBITORS
AMYOTROPHIC LATERAL
SCLEROSIS AGENTS
ANDROGENIC AGENTS
ANGIOTEN.RECEPTR
ANTAG./CAL.CHANL
BLKR/THIAZIDE CB
January 2017
ANTIPSYCHOTICS,DOPAMINE
ANTAGONISTS,BUTYROPHENONES
ANTIPSYCHOTICS,DOPAMINE
ANTAGONST,DIHYDROINDOLONES
LEPTIN HORMONE ANALOGS
ANTITHYROID PREPARATIONS
LEUKOCYTE ADHESION
INHIB,ALPHA4-MEDIAT IGG4K MC
AB
LEUKOTRIENE RECEPTOR
ANTAGONISTS
LHRH (GNRH) AGONIST ANALOG
PITUITARY SUPPRESSANTS
LIPOTROPICS
ANTI-ULCER PREPARATIONS
LIPOTROPICS (CONTINUED 1)
ANTIVIRALS, GENERAL
LOOP DIURETICS
ANTIVIRALS, GENERAL
(CONTINUED 1)
ANTIVIRALS, HIV-SPEC, NONPEPTIDIC PROTEASE INHIB
MAOIS - NON-SELECTIVE &
IRREVERSIBLE
MAST CELL STABILIZERS
ANTIVIRALS, HIV-SPEC,
NUCLEOSIDE-NUCLEOTIDE
ANALOG
ANTIVIRALS, HIV-SPEC.,
NUCLEOSIDE ANALOG, RTI COMB
ANTIVIRALS, HIV-SPECIFIC, CCR5
CO-RECEPTOR ANTAG.
ANTIVIRALS, HIV-SPECIFIC, FUSION
INHIBITORS
ANTIVIRALS, HIV-SPECIFIC, NONNUCLEOSIDE, RTI
ANTIVIRALS, HIV-SPECIFIC,
NUCLEOSIDE ANALOG, RTI
ANTIVIRALS, HIV-SPECIFIC,
NUCLEOTIDE ANALOG, RTI
ANTIVIRALS, HIV-SPECIFIC,
PROTEASE INHIBITOR COMB
ANTIVIRALS, HIV-SPECIFIC,
PROTEASE INHIBITORS
ANTIVIRALS,HIV-1 INTEGRASE
STRAND TRANSFER INHIBTR
APPETITE STIM. FOR
ANOREXIA,CACHEXIA,WASTING
SYND.
MENOPAUSAL SYMPT SUPP-SEL
ESTROGEN RECEP MODULATOR
ANTIPSYCHOTICS,PHENOTHIAZINES
ANTISERA
METABOLIC DEFICIENCY AGENTS
METABOLIC DISEASE ENZYME
REPLACE, HYPOPHOSPHATASIA
METABOLIC DISEASE ENZYME
REPLACEMENT, GAUCHER'S DX
METABOLIC DISEASE ENZYME
REPLACEMENT,POMPE DISEASE
METABOLIC DX ENZYME REPLACE,
MUCOPOLYSACCHARIDOSIS
METABOLIC DX ENZYME
REPLACEMENT,LYSO.ACID LIP.DEF.
METALLIC POISON,AGENTS TO
TREAT
MINERALOCORTICOIDS
MIOTICS/OTHER INTRAOC.
PRESSURE REDUCERS
MONOAMINE OXIDASE(MAO)
INHIBITORS
Maintenance Drug Classes
ANGIOTENSIN II RECEPTOR
BLOCKER-BETA BLOCKER COMB.
ANGIOTENSIN RECEPT-NEPRILYSIN
INHIBITOR COMB(ARNI)
ANGIOTENSIN RECEPTOR ANTAG.THIAZIDE DIURETIC COMB
ANGIOTENSIN RECEPTOR BLOCKRCALCIUM CHANNEL BLOCKR
ANP - SELECTIVE RETINOID X
RECEPTOR AGONISTS (RXR)
ANTI-ALCOHOLIC PREPARATIONS
ANTIANGINAL & ANTI-ISCHEMIC
AGENTS,NON-HEMODYNAMIC
ANTI-ANXIETY DRUGS
ANTIARRHYTHMICS
ANTI-ARTHRITIC AND CHELATING
AGENTS
ANTI-ARTHRITIC, FOLATE
ANTAGONIST AGENTS
ANTICHOLINERGICS, ORALLY
INHALED LONG ACTING
ANTICHOLINERGICS, ORALLY
INHALED SHORT ACTING
ANTICHOLINERGICS,QUATERNARY
AMMONIUM
ANTICOAGULANTS,COUMARIN
TYPE
ANTICONVULSANTS
ANTICONVULSANTS (CONTINUED
1)
ANTIDIARRHEALS
APPETITE STIMULANTS
ARTV CMB
NUCLEOSIDE,NUCLEOTIDE,&NONNUCLEOSIDE RTI
ARV CMB-NRTI,N(T)RTI, INTEGRASE
INHIBITOR
ARV COMB-NRTIS & INTEGRASE
INHIBITOR
BARBITURATES
MONOCLONAL ANTIBODY-HUMAN
INTERLEUKIN 12/23 INHIB
MOVEMENT DISORDERS (DRUG
THERAPY)
MUCOLYTICS
BELLADONNA ALKALOIDS
MYDRIATICS
BENIGN PROSTATIC
HYPERTROPHY/MICTURITION
AGENTS
BETA-ADRENERGIC AGENTS
NARCOLEPSY AND SLEEP DISORDER
THERAPY AGENTS
BETA-ADRENERGIC AGENTS,
INHALED, SHORT ACTING
BETA-ADRENERGIC AGENTS,
INHALED, ULTRA-LONG ACTING
BETA-ADRENERGIC AGENTS,
ORALLY INHALED,LONG ACTING
BETA-ADRENERGIC AND
ANTICHOLINERGIC COMBINATIONS
BETA-ADRENERGIC AND
ANTICHOLINERGIC COMBO,
INHALED
BETA-ADRENERGIC AND
GLUCOCORTICOID COMBINATIONS
BETA-ADRENERGIC BLOCKING
AGENTS
BETA-ADRENERGIC BLOCKING
AGENTS (CONTINUED 1)
BETA-ADRENERGIC BLOCKING
AGENTS/THIAZIDE & RELATED
BILE SALT SEQUESTRANTS
ANTIDIURETIC AND VASOPRESSOR
HORMONES
ANTIFIBRINOLYTIC AGENTS
BILE SALTS
ANTIFIBROTIC THERAPY PYRIDONE ANALOGS
ANTIHEMOPHILIC FACTORS
BLOOD FACTORS,MISCELLANEOUS
ANTIHISTAMINES - 2ND
GENERATION
BONE FORMATION STIM. AGENTS PARATHYROID HORMONE
ANTIHYPERGLY,DPP-4 ENZYME
INHIB &THIAZOLIDINEDIONE
ANTIHYPERGLY,INCRETIN
MIMETIC(GLP-1 RECEP.AGONIST)
ANTIHYPERGLYCEMC-SOD/GLUC
COTRANSPORT2(SGLT2)INHIB
BONE RESORPTION INHIBITOR &
VITAMIN D COMBINATIONS
BONE RESORPTION INHIBITORS
January 2017
MONOCLONAL ANTIBODIES TO
IMMUNOGLOBULIN E (IGE)
MONOCLONAL ANTIBODY INTERLEUKIN-5 ANTAGONISTS
BIPOLAR DISORDER DRUGS
BLOOD TESTING PREPARATIONS
BPH,5-ALPHA-REDUCTASE INH &
ALPHA-1-ADRENOCEP ANTG
NARCOTIC WITHDRAWAL THERAPY
AGENTS
NASAL ANTIHISTAMINE
NASAL ANTI-INFLAMMATORY
STEROIDS
NEEDLES/NEEDLELESS DEVICES
NIACIN PREPARATIONS
NOREPINEPHRINE AND DOPAMINE
REUPTAKE INHIB (NDRIS)
NOSE PREPARATIONS,
MISCELLANEOUS (RX)
NSAID & HISTAMINE H2 RECEPTOR
ANTAGONIST COMB.
NSAID, COX INHIBITOR-TYPE &
PROTON PUMP INHIB COMB
NSAIDS, CYCLOOXYGENASE
INHIBITOR - TYPE ANALGESICS
NSAIDS, CYCLOOXYGENASE
INHIBITOR-TYPE (CONT'D 2)
NSAIDS,CYCLOOXYGENASE-2(COX2) SELECTIVE INHIBITOR
NUCLEIC ACID/NUCLEOTIDE
SUPPLEMENTS
OPHTH VASC. ENDOTHELIAL
GROWTH FACTOR ANTAGONISTS
OPHTH. VEGF-A RECEPTOR ANTAG.
RCMB MC ANTIBODY
OPHTHALMIC ANTIINFLAMMATORY
IMMUNOMODULATOR-TYPE
OPHTHALMIC CYSTINE DEPLETING
AGENTS
OVERACTIVE BLADDER AGENTS,
BETA-3 ADRENERGIC RECEP
PANCREATIC ENZYMES
Maintenance Drug Classes
ANTIHYPERGLYCEMIC, ALPHAGLUCOSIDASE INHIBITORS
ANTIHYPERGLYCEMIC, AMYLIN
ANALOG-TYPE
ANTIHYPERGLYCEMIC, BIGUANIDE
TYPE
ANTIHYPERGLYCEMIC, DPP-4
INHIBITORS
ANTIHYPERGLYCEMIC, INSULINRELEASE STIMULANT TYPE
ANTIHYPERGLYCEMIC, SGLT-2 &
DPP-4 INHIBITOR COMB.
ANTIHYPERGLYCEMIC,DPP-4
INHIBITOR & BIGUANIDE COMB
ANTIHYPERGLYCEMIC,INSULINREL STIM.& BIGUANIDE CMB
ANTIHYPERGLYCEMIC,THIAZOLIDI
NEDIONE & BIGUANIDE
ANTIHYPERGLYCEMIC,THIAZOLIDI
NEDIONE & SULFONYLUREA
ANTIHYPERGLYCEMIC,THIAZOLIDI
NEDIONE(PPARG AGONIST)
ANTIHYPERGLYCEMICGLUCOCORTICOID RECEPTOR
BLOCKER
ANTIHYPERGLYCEMIC-SGLT2
INHIBITOR & BIGUANIDE COMB
ANTIHYPERLIP - HMGCOA&CALCIUM CHANNEL
BLOCKER CB
ANTIHYPERLIP.HMG COA REDUCT
INHIB&CHOLEST.AB.INHIB
ANTIHYPERLIPIDEMIC - APO B-100
SYNTHESIS INHIBITOR
ANTIHYPERLIPIDEMIC - HMG COA
REDUCTASE INHIBITORS
ANTIHYPERLIPIDEMIC - MTP
INHIBITOR
ANTIHYPERLIPIDEMIC - PCSK9
INHIBITORS
ANTIHYPERTENSIVES, ACE
INHIBITORS
ANTIHYPERTENSIVES,
ANGIOTENSIN RECEPTOR
ANTAGONIST
ANTIHYPERTENSIVES,
MISCELLANEOUS
ANTIHYPERTENSIVES,
SYMPATHOLYTIC
ANTIHYPERTENSIVES,
VASODILATORS
ANTI-INFLAM. INTERLEUKIN-1
RECEPTOR ANTAGONIST
January 2017
C1 ESTERASE INHIBITORS
PARASYMPATHETIC AGENTS
CALCIMIMETIC,PARATHYROID
CALCIUM ENHANCER
CALCIUM CHANNEL BLOCKING
AGENTS
CARBONIC ANHYDRASE
INHIBITORS
CHOLINESTERASE INHIBITORS
PARATHYROID HORMONES
CHRONIC INFLAM. COLON DX, 5-ASALICYLAT,RECTAL TX
COLCHICINE
CONTRACEPTIVES, INTRAVAGINAL,
SYSTEMIC
CONTRACEPTIVES,INJECTABLE
PKU TX AGENT-COFACTOR OF
PHENYLALANINE HYDROXYLASE
PLATELET AGGREGATION
INHIBITORS
PLATELET PROLIFERATION
STIMULANTS
PLATELET REDUCING AGENTS
CONTRACEPTIVES,ORAL
POTASSIUM REPLACEMENT
CONTRACEPTIVES,TRANSDERMAL
POTASSIUM SPARING DIURETICS
CYSTIC FIBROSIS-CFTR
POTENTIATOR & CORRECTOR
COMB.
CYSTIC FIB-TRANSMEMB
CONDUCT.REG.(CFTR)POTENTIATO
R
CYTOCHROME P450 INHIBITORS
POTASSIUM SPARING DIURETICS IN
COMBINATION
DECARBOXYLASE INHIBITORS
DIABETIC SUPPLIES
PRENATAL VITAMINS WITHOUT
IRON
PROGESTATIONAL AGENTS
DIGITALIS GLYCOSIDES
PROTEIN C PREPARATIONS
DILUENT SOLUTIONS
PROTON-PUMP INHIBITORS
DIRECT FACTOR XA INHIBITORS
PULM ANTI-HTN,SOLUBLE
GUANYLATE CYCLASE
STIMULATOR
PULM.ANTI-HTN,SEL.C-GMP
PHOSPHODIESTERASE T5 INHIB
PULMONARY ANTI-HTN,
ENDOTHELIN RECEPTOR
ANTAGONIST
PULMONARY ANTIHYPERTENSIVES,
PROSTACYCLIN-TYPE
PULMONARY FIBROSIS - SYSTEMIC
ENZYME INHIBITORS
DRUG TX-CHRONIC INFLAM.
COLON DX,5-AMINOSALICYLAT
DRUGS TO TREAT ERECTILE
DYSFUNCTION (ED)
DRUGS TO TREAT HEREDITARY
TYROSINEMIA
DRUGS TO TX CHRONIC
INFLAMMATORY DISEASE OF
COLON
DRUGS TO TX GAUCHER DX-TYPE 1,
SUBSTRATE REDUCING
ELECTROLYTE DEPLETERS
PARENTERAL ADMINISTRATION
SETS
PHOSPHODIESTERASE-4 (PDE4)
INHIBITORS
PITUITARY SUPPRESSIVE AGENTS
PRENATAL VITAMIN
PREPARATIONS
PRENATAL VITAMIN
PREPARATIONS (CONTINUED 1)
RENIN INHIBITOR, DIRECT
RENIN INHIBITOR, DIRECT &
CALCIUM CHANNEL BLOCKER
Maintenance Drug Classes
ANTI-INFLAMMATORY TUMOR
NECROSIS FACTOR INHIBITOR
ANTI-INFLAMMATORY,
INTERLEUKIN-1 BETA BLOCKERS
ANTI-INFLAMMATORY,
PYRIMIDINE SYNTHESIS INHIBITOR
ANTIINFLAMMATORY,PHOSPHODIESTER
ASE-4(PDE4) INHIB.
ANTILEPROTICS
ANTIMALARIAL DRUGS
ENZYME REPLACEMENTS
(UBIQUITOUS ENZYMES)
ERYTHROPOIESIS-STIMULATING
AGENTS
ESTROGEN & PROGESTIN WITH
ANTIMINERALOCORTICOID CB
ESTROGEN & SELECTIVE
ESTROGEN RECEPT
MOD(SERM)COMB
ESTROGEN/ANDROGEN
COMBINATIONS
ESTROGENIC AGENTS
ANTINEOPLAST,HISTONE
DEACETYLASE (HDAC) INHIBITORS
ANTINEOPLASTIC - ALKYLATING
AGENTS
ANTINEOPLASTIC ANTIANDROGENIC AGENTS
FACTOR IX COMPLEX (PCC)
PREPARATIONS
FACTOR IX PREPARATIONS
ANTINEOPLASTIC ANTIMETABOLITES
ANTINEOPLASTIC - AROMATASE
INHIBITORS
ANTINEOPLASTIC - HEDGEHOG
PATHWAY INHIBITOR
FARNESOID X RECEPTOR (FXR)
AGONIST, BILE AC ANALOG
FAT ABSORPTION DECREASING
AGENTS
FIBROMYALGIA
AGENTS,SEROTONIN-NOREPINEPH
RU INHIB
FLUORIDE PREPARATIONS
ANTINEOPLASTIC IMMUNOTHERAPY, VIRUS-BASED
AGENTS
ANTINEOPLASTIC - JANUS KINASE
(JAK) INHIBITORS
FACTOR XIII PREPARATIONS
SBS - GLUCAGON-LIKE PEPTIDE-2
(GLP-2) ANALOGS
SELECTIVE ESTROGEN RECEPTOR
MODULATORS (SERMS)
SELECTIVE SEROTONIN 5-HT2A
INVERSE AGONISTS (SSIA)
SELECTIVE SEROTONIN REUPTAKE
INHIBITOR (SSRIS)
SEROTONIN-2
ANTAGONIST/REUPTAKE
INHIBITORS (SARIS)
SEROTONIN-NOREPINEPHRINE
REUPTAKE-INHIB (SNRIS)
SKELETAL MUSCLE RELAXANTS
SOMATOSTATIC AGENTS
SSRI & 5HT1A PARTIAL AGONIST
ANTIDEPRESSANT
ANTINEOPLASTIC - MEK1 AND
MEK2 KINASE INHIBITORS
ANTINEOPLASTIC - MTOR KINASE
INHIBITORS
ANTINEOPLASTIC TOPOISOMERASE I INHIBITORS
ANTINEOPLASTIC - VEGF-A,B &
PLGF INHIBITOR
ANTINEOPLASTIC - VEGFR
ANTAGONIST
GASTRIC ACID SECRETION
REDUCERS
GASTRIC ENZYMES
SSRI &
ANTIPSYCH,ATYP,DOPAMINE&SERO
TONIN ANTAG CMB
SSRI & SEROTONIN RECEPTOR
MODULATOR ANTIDEPRESSANT
SYRINGES AND ACCESSORIES
GLUCOCORTICOIDS
SYSTEMIC ENZYME INHIBITORS
GLUCOCORTICOIDS (CONTINUED 2)
THIAZIDE AND RELATED DIURETICS
GLUCOCORTICOIDS, ORALLY
INHALED
ANTINEOPLASTIC
IMMUNOMODULATOR AGENTS
ANTINEOPLASTIC LHRH(GNRH)
ANTAGONIST,PITUIT.SUPPRS
ANTINEOPLASTIC SYSTEMIC
ENZYME INHIBITORS
ANTINEOPLASTIC,ANTIPROGRAMMED DEATH-1 (PD-1)
MAB
ANTINEOPLASTIC-B CELL
LYMPHOMA-2(BCL-2) INHIBITORS
ANTINEOPLASTIC-INTERLEUKIN-
GOLD SALTS
THROMBIN
INHIBITORS,SELECTIVE,DIRECT, &
REVERSIBLE
THROMBOPOIETIN RECEPTOR
AGONISTS
THYROID HORMONES
January 2017
FOLIC ACID PREPARATIONS
RENIN INHIBITOR,DIRECT AND
THIAZIDE DIURETIC COMB
RESPIRATORY
AIDS,DEVICES,EQUIPMENT
RIFAMYCINS AND RELATED
DERIVATIVE ANTIBIOTICS
ROSACEA AGENTS, TOPICAL
GROWTH HORMONE RECEPTOR
ANTAGONISTS
GROWTH HORMONE RELEASING
HORMONE (GHRH) & ANALOGS
GROWTH HORMONES
HEART RATE REDUCING,
SELECTIVE I(F) CURRENT INHIB.
HEMORRHEOLOGIC AGENTS
TOPICAL ANTI-INFLAMMATORY,
NSAIDS
TOPICAL ANTINEOPLASTIC &
PREMALIGNANT LESION AGNTS
TOPICAL/MUCOUS MEMBR./SUBCUT.
ENZYMES
TRICYCLIC
Maintenance Drug Classes
6(IL-6)INHIB,ANTIBODY
ANTINEOPLASTICS,MISCELLANEOU
S
HEPATITIS B TREATMENT AGENTS
ANTINEOPLASTICS,MISCELLANEOU
S (CONTINUED 1)
ANTINFLAMMATORY,
SEL.COSTIM.MOD.,T-CELL
INHIBITOR
ANTI-OBESITY - ANOREXIC
AGENTS
ANTI-OBESITY - OPIOID
ANTAG/NOREPI & DA REUP INHIB
ANTI-OBESITY GLUCAGON-LIKE
PEPTIDE-1 RECEP AGONIST
ANTI-OBESITY SEROTONIN 2C
RECEPTOR AGONISTS
ANTIOXIDANT MULTIVITAMIN
COMBINATIONS
ANTIPARKINSONISM
DRUGS,ANTICHOLINERGIC
HISTAMINE H2-RECEPTOR
INHIBITORS
HUMAN MONOCLONAL ANTIBODY
COMPLEMENT(C5) INHIBITOR
ANTIPARKINSONISM
DRUGS,OTHER
ANTI-PROGRAMMED CELL DEATHLIGAND 1 (PD-L1) MAB
ANTIPROTOZOAL
DRUGS,MISCELLANEOUS
ANTIPSORIATIC AGENTS,SYSTEMIC
ANTIPSYCH,DOPAMINE
ANTAG.,DIPHENYLBUTYLPIPERIDI
NES
ANTIPSYCHOTIC,ATYPICAL,DOPAM
INE,SEROTONIN ANTAGNST
ANTIPSYCHOTIC-ATYPICAL,D3/D2
PARTIAL AG-5HT MIXED
ANTIPSYCHOTICS, ATYP, D2
PARTIAL AGONIST/5HT MIXED
ANTIPSYCHOTICS, DOPAMINE &
SEROTONIN ANTAGONISTS
ANTIPSYCHOTICS,DOPAMINE
ANTAGONISTS, THIOXANTHENES
January 2017
HYPERPARATHYROID TX AGENTS VITAMIN D ANALOG-TYPE
HYPERURICEMIA TX - URATEOXIDASE ENZYME-TYPE
HYPERURICEMIA TX - XANTHINE
OXIDASE INHIBITORS
HYPNOTICS, MELATONIN MT1/MT2
RECEPTOR AGONISTS
IBS AGENTS,MIXED OPIOID RECEP
AGONISTS/ANTAGONISTS
IMMUNOMODULATOR,BLYMPHOCYTE STIM(BLYS)-SPEC
INHIB
IMMUNOSUPPRESSIVES
INSULINS
ANTIDEPRESSANT/BENZODIAZEPIN
E COMBINATNS
TRICYCLIC
ANTIDEPRESSANT/PHENOTHIAZINE
COMBINATNS
TRICYCLIC ANTIDEPRESSANTS &
REL. NON-SEL. RU-INHIB
TX FOR ADHD - SELECTIVE ALPHA-2
RECEPTOR AGONIST
TX FOR ATTENTION DEFICITHYPERACT(ADHD)/NARCOLEPSY
TX FOR ATTENTION DEFICITHYPERACT.(ADHD), NRI-TYPE
URICOSURIC AGENTS
URINARY PH MODIFIERS
URINARY TRACT ANTISPASMODIC,
M(3) SELECTIVE ANTAG.
URINARY TRACT
ANTISPASMODIC/ANTIINCONTINEN
CE AGENT
VAGINAL ESTROGEN
PREPARATIONS
VASODILATORS, COMBINATION
INTEGRIN RECEPTOR ANTAGONIST,
MONOCLONAL ANTIBODY
INTERLEUKIN-6 (IL-6) RECEPTOR
INHIBITORS
INTRA-UTERINE DEVICES (IUDS)
VASODILATORS,CORONARY
IRON REPLACEMENT
VITAMIN B12 PREPARATIONS
IRRITABLE BOWEL
AGENTS,GUANYLATE CYCLASE-C
AGONIST
JANUS KINASE (JAK) INHIBITORS
VITAMIN D PREPARATIONS
KIDNEY STONE AGENTS
LAXATIVES AND CATHARTICS
VASODILATORS,PERIPHERAL
VITAMIN B PREPARATIONS
XANTHINES