2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary) · 2017. 11. 1. · Covered Drug Index If you are not sure what category to look under, you should look for your drug in

Plans coveredCigna-HealthSpring Primary (HMO)Cigna-HealthSpring TotalCare (HMO SNP)Cigna-HealthSpring TotalCare AR (HMO SNP)Cigna-HealthSpring TotalCare ETN (HMO SNP)Cigna-HealthSpring TotalCare SMS (HMO SNP)Cigna-HealthSpring Traditions (HMO SNP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT ALL OF THE DRUGS WE COVER IN THIS PLAN.

2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated on November 1, 2017. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 17134, Version Number 18 Y0036_17_42746_Final_4i Populated Template 08052016

1

What is the Cigna-HealthSpring Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna-HealthSpring in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2017 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a

60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2017. To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 11. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 11. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 52. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Primary (HMO), Cigna-HealthSpring TotalCare (HMO SNP), Cigna-HealthSpring TotalCare AR (HMO SNP), Cigna-HealthSpring TotalCare ETN (HMO SNP), Cigna-HealthSpring TotalCare SMS (HMO SNP) and Cigna-HealthSpring Traditions (HMO SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.

2

What are generic drugs?Cigna-HealthSpring covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Cigna-HealthSpring requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna-HealthSpring before you fill your prescriptions. If you don’t get approval, Cigna-HealthSpring may not cover the drug.

• Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover. For example, Cigna-HealthSpring allows for 1 tablet per day for VESICARE. This applies to standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna-HealthSpring requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 11. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring drug list?” on this page for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to

coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can ensure that you don’t miss a dose.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications which are covered in the drug list.

• What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna-HealthSpring. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.

• You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Cigna-HealthSpring’s Drug List?You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not in our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

3

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list or utilization restriction exception. When you request a drug list or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days

you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 52. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VESICARE) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 11 along with the amount dispensed per the days supplied. (For example: VESICARE QL 30/30; this means the drug VESICARE is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

4

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Your plan has one tier named “Covered Drugs”. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.

Note for customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

For more information

For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

5

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.

Service Area: Alabama, Arkansas H0150-007Cigna-HealthSpring TotalCare (HMO SNP) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, AlabamaH4454-034Cigna-HealthSpring TotalCare AR (HMO)Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, Arkansas

Standard Retail Cost-Sharing*

Standard Mail Order Cost-Sharing*

30, 60, 90 Days 30, 90 Days

Tier 1: Covered Drugs 25% or 25% or$0 / $1.20 / $3.30 / 15%

(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Georgia H0439-002Cigna-HealthSpring TotalCare (HMO SNP)Baldwin, Banks, Barrow, Bartow, Butts, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Elbert, Fayette, Floyd, Forsyth, Franklin, Fulton, Gordon, Greene, Gwinnett, Habersham, Hall, Hart, Jackson, Jasper, Lamar, Lumpkin, Madison, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Putnam, Rabun, Rockdale, Spalding, Stephens, Walton, White and Wilkes, Georgia



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

*Cost-sharing is based on your level of “Extra Help”

6

Service Area: Illinois H1415-005Cigna-HealthSpring TotalCare (HMO SNP)Cook, DuPage, Kane and Will, Illinois



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Illinois, Indiana H1415-024Cigna-HealthSpring Primary (HMO)Cook, DuPage, Kane and Will, IllinoisH3945-002Cigna-HealthSpring Primary (HMO)Lake, Indiana



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Florida H5410-013Cigna-HealthSpring TotalCare (HMO SNP)Bay, Escambia, Okaloosa, Santa Rosa and Walton, Florida



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)


7

Service Area: Mississippi H4407-004Cigna-HealthSpring TotalCare SMS (HMO SNP)Attala, Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Leake, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: North Carolina H9725-003Cigna-HealthSpring TotalCare (HMO SNP)Alexander, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Lincoln, Polk, Rowan, Stokes, Yadkin and Union, North Carolina



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Mid-Atlantic H2108-001Cigna-HealthSpring TotalCare (HMO SNP)Anne Arundel, Baltimore, Baltimore City, Caroline, Dorchester, Harford, Howard, Kent, Montgomery, Prince George’s, Queen Anne’s and Talbot, Maryland; Washington, DC; Kent, New Castle and Sussex, Delaware



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)


8

Service Area: Mid-Atlantic H2108-020Cigna-HealthSpring Traditions (HMO SNP)Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery and Prince George’s, Maryland; Washington, DC; Kent, New Castle and Sussex, Delaware



30, 60, 90 Days 30, 90 Days

Tier 1: Covered Drugs 25% or Not covered$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Pennsylvania H3949-009Cigna-HealthSpring TotalCare (HMO SNP)Berks, Bucks, Chester, Cumberland, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia and York, Pennsylvania



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)

Service Area: Pennsylvania H3949-016Cigna-HealthSpring Traditions (HMO SNP)Bucks, Chester, Delaware, Montgomery and Philadelphia, Pennsylvania



30, 60, 90 Days 30, 90 Days

Tier 1: Covered Drugs 25% or Not covered$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)


9

Service Area: Tennessee H4454-020Cigna-HealthSpring TotalCare (HMO SNP)Bedford, Benton, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marshall, Maury, McNairy, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, TennesseeH4454-035Cigna-HealthSpring TotalCare ETN (HMO SNP)Bledsoe, Bradley, Grundy, Hamilton, Marion, Polk, Rhea and Sequatchie, TennesseeH4454-028Cigna-HealthSpring Primary (HMO)Bradley, Grundy, Hamilton, Marion, McMinn, Meigs and Sequatchie, Tennessee



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)


10

Service Area: Texas H4513-010Cigna-HealthSpring TotalCare (HMO SNP)Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591 and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, Texas H2165-019Cigna-HealthSpring TotalCare (HMO SNP)Cherokee, Grayson, Gregg, Henderson, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt and Wood, TexasH4528-002Cigna-HealthSpring TotalCare (HMO SNP)Bexar, Collin, Dallas, Denton, El Paso, Hood, Johnson, Parker, Tarrant and Wise, Texas



30, 60, 90 Days 30, 90 Days


(generics)$0 / $1.20 / $3.30 / 15%

(generics)$0 / $3.70 / $8.25 / 15%

(all other drugs)$0 / $3.70 / $8.25 / 15%

(all other drugs)


My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. - 8 p.m. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring

Generic Available?

Generic Cost-Share

11

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen/caffeine caps

1 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

1 PA QL(180/30)

butalbital/aspirin/caffeine caps 1 PA QL(180/30)capacet 1 PA QL(180/30)esgic caps 1 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

1 PA QL(180/30)

NonsteroidalAnti-inflammatoryDrugscelecoxib caps 400mg 1 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

1 QL(60/30)

diclofenac potassium 1diclofenac sodium dr 1diclofenac sodium er 1diflunisal 1etodolac 1etodolac er 1fenoprofen calcium caps 400mg

1

fenoprofen calcium tabs 1flurbiprofen 1ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

ketoprofen 1ketoprofen er 1 QL(30/30)meclofenamate sodium 1meloxicam 1 QL(30/30)nabumetone 1naproxen 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

naproxen dr 1naproxen sodium tabs 275mg, 550mg

1

oxaprozin 1piroxicam 1salsalate 1sulindac 1tolmetin sodium 1Opioid Analgesics, Long-actingbuprenorphine hcl inj 1 QL(150/30)DURAMORPH 1 QL(180/30)fentanyl 1 QL(10/30)INFUMORPH 200 1 QL(200/30)INFUMORPH 500 1 QL(200/30)levorphanol tartrate 1 QL(120/30)methadone hcl conc 1 QL(500/30)methadone hcl inj 1 QL(150/30)methadone hcl intensol 1 QL(500/30)methadone hcl oral soln 10mg/5ml

1 QL(450/30)

methadone hcl oral soln 5mg/5ml

1 QL(600/30)

methadone hcl tabs 10mg 1 QL(120/30)methadone hcl tabs 5mg 1 QL(180/30)morphine sulfate er tbcr 1 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

1 QL(180/30)

Opioid Analgesics, Short-actingacetaminophen/caffeine/dihydrocodeine

1 QL(300/30)

acetaminophen/codeine oral soln

1 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

1 QL(180/30)

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

1 QL(360/30)

12


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lorcet hd 1 QL(180/30)lorcet plus tabs 325mg; 7.5mg 1 QL(180/30)MORPHINE SULFATE INJ 150MG/30ML, 15MG/ML, 50MG/ML

1

morphine sulfate inj 5mg/ml 1morphine sulfate inj 1mg/ml 1 QL(180/30)MORPHINE SULFATE INJ 10MG/ML

1 QL(200/30)

morphine sulfate inj 10mg/ml 1 QL(200/30)MORPHINE SULFATE INJ 2MG/ML, 4MG/ML

1 QL(240/30)

MORPHINE SULFATE INJ 8MG/ML

1 QL(250/30)

morphine sulfate inj 8mg/ml 1 QL(250/30)morphine sulfate oral soln 100mg/5ml

1 QL(180/30)

morphine sulfate oral soln 20mg/5ml

1 QL(300/30)

morphine sulfate oral soln 10mg/5ml

1 QL(700/30)

MORPHINE SULFATE TABS 1 QL(120/30)nalbuphine hcl inj 20mg/ml 1 QL(90/30)nalbuphine hcl inj 10mg/ml 1 QL(180/30)oxycodone hcl caps 1 QL(120/30)oxycodone hcl conc 1 QL(120/30)oxycodone hcl oral soln 1 QL(1200/30)oxycodone hcl tabs 30mg 1 QL(90/30)oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg

1 QL(120/30)

oxycodone/acetaminophen tabs 325mg; 10mg

1 QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

1 QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

1 QL(360/30)

oxycodone/aspirin 1 QL(180/30)oxycodone/ibuprofen 1 QL(28/30)TALWIN 1tramadol hcl 1 QL(240/30)tramadol hydrochloride/acetaminophen

1 QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ascomp/codeine 1 PA QL(180/30)butalbital/acetaminophen/caffeine/codeine

1 PA QL(180/30)

butalbital/aspirin/caffeine/codeine

1 PA QL(180/30)

butorphanol tartrate inj 2mg/ml 1 QL(240/30)butorphanol tartrate inj 1mg/ml 1 QL(480/30)butorphanol tartrate nasal soln 1 QL(5/30)endocet tabs 325mg; 10mg 1 QL(180/30)endocet tabs 325mg; 7.5mg 1 QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

1 QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

1 B/D PA

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

1 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

1 PA NDS QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

1 QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg

1 QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg

1 QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

1 QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

1 QL(360/30)

hydrocodone/ibuprofen 1 QL(150/30)hydromorphone hcl dosette 1hydromorphone hcl inj 1hydromorphone hcl liqd 1 QL(1200/30)hydromorphone hcl tabs 8mg 1 QL(120/30)hydromorphone hcl tabs 2mg, 4mg

1 QL(180/30)

ibudone tabs 5mg; 200mg 1 QL(150/30)lorcet 1 QL(360/30)

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Opioid Reversal Agentsnaloxone hcl 1narcan 1 QL(4/30)Smoking Cessation Agentsbupropion hcl sr 1 QL(60/30)CHANTIX 1 QL(336/365)CHANTIX CONTINUING MONTH PAK

1 QL(336/365)

CHANTIX STARTING MONTH PAK

1 QL(336/365)

NICOTROL INHALER 1 QL(1008/90)NICOTROL NS 1 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 1gentak 1gentamicin sulfate crea 1GENTAMICIN SULFATE INJ 10MG/ML

1

gentamicin sulfate inj 10mg/ml, 40mg/ml

1

gentamicin sulfate oint 1gentamicin sulfate ophthalmic soln

1

gentamicin sulfate pediatric 1gentamicin sulfate/0.9% sodium chloride

1

isotonic gentamicin 1neomycin sulfate 1neomycin/polymyxin b sulfates 1paromomycin sulfate 1streptomycin sulfate 1tobramycin ophthalmic soln 1tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trezix caps 320.5mg; 30mg; 16mg

1 QL(300/30)

vicodin es tabs 300mg; 7.5mg 1 QL(180/30)vicodin hp tabs 300mg; 10mg 1 QL(180/30)vicodin tabs 300mg; 5mg 1 QL(360/30)xylon 1 QL(150/30)

Anesthetics

Local Anestheticsglydo 1lidocaine hcl external soln 1lidocaine hcl gel 1lidocaine hcl inj 1lidocaine hcl jelly 1lidocaine hcl mouth/throat soln 1lidocaine hcl viscous 1lidocaine oint 1 QL(120/30)lidocaine ptch 1 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 1 PAdisulfiram 1Opioid Dependence Treatmentsbuprenorphine hcl inj 1 QL(150/30)buprenorphine hcl subl 1 PA QL(90/30)buprenorphine hcl/naloxone hcl 1 PA QL(90/30)naltrexone hcl 1SUBOXONE 1 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

1 PA QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

1 PA QL(90/30)

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metronidazole in nacl 0.79% 1metronidazole inj 1metronidazole lotn 1metronidazole tabs 1metronidazole vaginal 1mupirocin 1neo-polycin 1neo-polycin hc 1neomycin/bacitracin/polymyxin 1neomycin/polymyxin/bacitracin/hydrocortisone

1

neomycin/polymyxin/gramicidin 1neomycin/polymyxin/hydrocortisone

1

nitrofurantoin 1nitrofurantoin macrocrystals 1nitrofurantoin monohydrate 1nitrofurantoin monohydrate/macrocrystals

1

polycin 1polymyxin b sulfate 1polymyxin b sulfate/trimethoprim sulfate

1

PRIMSOL 1rosadan 1silver sulfadiazine 1SSD 1SYNERCID 1 NDStigecycline 1 NDStrimethoprim 1trimethoprim sulfate/polymyxin b sulfate

1

TYGACIL 1 NDSvancomycin 1vancomycin hcl caps 125mg 1 QL(40/10)vancomycin hcl caps 250mg 1 QL(80/10)vancomycin hcl in dextrose 1vancomycin hcl inj 1vandazole 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tobramycin sulfate ophthalmic soln

1

TOBREX OINT 1ZYLET 1Antibacterials, Otheralcohol prep pads 1baciim 1bacitracin inj 1bacitracin ophthalmic oint 1bacitracin/polymyxin b 1BACTROBAN NASAL 1chloramphenicol sodium succinate

1

clindacin etz pledgets 1clindacin-p 1clindamycin 1clindamycin hcl 1clindamycin phosphate crea 1clindamycin phosphate external soln

1

clindamycin phosphate gel 1clindamycin phosphate in d5w 1clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

1

clindamycin phosphate lotn 1clindamycin phosphate pharmacy bulk package

1

clindamycin phosphate swab 1clindamycin/sodium chloride 1colistimethate sodium 1CUBICIN 1 B/D PA NDSdaptomycin 1 B/D PA NDSlincomycin hcl 1linezolid inj 1linezolid susr 1 NDS QL(1800/30)linezolid tabs 1 NDS QL(60/30)methenamine hippurate 1metronidazole crea 1metronidazole gel 1

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, OtherAZACTAM IN ISO-OSMOTIC DEXTROSE

1

aztreonam inj 1gm 1aztreonam inj 2gm 1 NDScefotetan 1imipenem/cilastatin 1INVANZ 1meropenem 1meropenem/sodium chloride 1Beta-lactam, Penicillinsamoxicillin 1amoxicillin/clavulanate potassium

1

amoxicillin/clavulanate potassium er

1

ampicillin 1ampicillin sodium 1ampicillin-sulbactam 1AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

1

BICILLIN L-A 1dicloxacillin sodium 1nafcillin sodium inj 10gm, 1gm, 2gm

1

nafcillin sodium inj 2gm 1 NDSoxacillin sodium inj 10gm 1penicillin g potassium inj 20000000unit, 5000000unit

1

penicillin v potassium 1pfizerpen-g 1piperacillin sodium/tazobactam sodium

1

piperacillin/tazobactam 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XIFAXAN TABS 200MG 1 PA QL(9/30)XIFAXAN TABS 550MG 1 PA NDS QL(90/30)Beta-lactam, Cephalosporinscefaclor 1cefaclor er 1cefadroxil 1CEFAZOLIN 1cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg

1

cefazolin sodium/dextrose inj 2gm; 3%

1

cefdinir 1cefepime 1cefepime/dextrose 1cefixime 1cefotaxime sodium inj 1gm, 2gm, 500mg

1

cefoxitin sodium inj 10gm, 1gm, 2gm

1

cefpodoxime proxetil 1cefprozil 1ceftazidime 1ceftazidime/dextrose 1ceftriaxone in iso-osmotic dextrose

1

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

1

cefuroxime axetil 1cefuroxime sodium 1cephalexin caps 250mg, 500mg 1cephalexin susr 1cephalexin tabs 1SUPRAX SUSR 500MG/5ML 1tazicef inj 1gm, 2gm, 6gm 1TEFLARO 1 NDS

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciprofloxacin hcl 1ciprofloxacin i.v.-in d5w 1ciprofloxacin inj 1ciprofloxacin susr 1levofloxacin in d5w 1levofloxacin inj 1levofloxacin oral soln 1levofloxacin tabs 1 QL(30/30)moxifloxacin hcl inj 1moxifloxacin hcl ophthalmic soln

1

moxifloxacin hcl tabs 1 QL(30/30)ofloxacin 1VIGAMOX 1SulfonamidesBLEPHAMIDE 1BLEPHAMIDE S.O.P. 1sodium sulfacetamide ophthalmic soln

1

sulfacetamide sodium ophthalmic soln

1

sulfacetamide sodium susp 1sulfacetamide sodium/prednisolone sodium phosphate

1

sulfadiazine 1sulfamethoxazole/trimethoprim 1sulfamethoxazole/trimethoprim ds

1

sulfatrim pediatric 1Tetracyclinesdemeclocycline hcl 1doxy 100 1doxycycline hyclate caps 1doxycycline hyclate inj 1doxycycline hyclate tabs 100mg, 20mg

1

doxycycline monohydrate caps 100mg, 50mg, 75mg

1 QL(60/30)

doxycycline monohydrate tabs 1doxycycline susr 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

1

MacrolidesAZASITE 1azithromycin inj 1azithromycin pack 1azithromycin susr 200mg/5ml 1 QL(75/30)azithromycin susr 100mg/5ml 1 QL(150/30)azithromycin tabs 250mg, 500mg

1 QL(12/28)

azithromycin tabs 600mg 1 QL(60/30)clarithromycin er 1 QL(60/30)clarithromycin susr 1clarithromycin tabs 1 QL(42/14)e.e.s. 400 1E.E.S. GRANULES 1ery 1ERY-TAB 1ERYPED 200 1ERYPED 400 1ERYTHROCIN LACTOBIONATE

1

erythrocin stearate 1erythromycin base 1erythromycin ethylsuccinate 1erythromycin external soln 1erythromycin gel 1erythromycin oint 1erythromycin pads 1ZMAX 1 QL(60/30)QuinolonesAVELOX INJ 1BESIVANCE 1CILOXAN OINT 1CIPRO HC 1CIPRODEX 1ciprofloxacin er tb24 500mg; 0 1 QL(3/3)ciprofloxacin er tb24 1000mg; 0 1 QL(14/14)

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

1 QL(90/30)

LYRICA ORAL SOLN 1 QL(900/30)zonisamide 1Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

1 QL(90/30)

clonazepam odt tbdp 2mg 1 QL(300/30)clonazepam tabs 0.5mg, 1mg 1 QL(90/30)clonazepam tabs 2mg 1 QL(300/30)DIASTAT ACUDIAL GEL 10MG 1 QL(20/30)DIASTAT ACUDIAL GEL 20MG 1 QL(40/30)DIASTAT PEDIATRIC 1 QL(5/30)diazepam rectal gel gel 2.5mg 1 QL(5/30)diazepam rectal gel gel 10mg 1 QL(20/30)divalproex sodium 1divalproex sodium dr 1divalproex sodium er 1gabapentin caps 100mg 1 QL(180/30)gabapentin caps 300mg, 400mg

1 QL(270/30)

gabapentin oral soln 1 QL(2160/30)gabapentin tabs 800mg 1 QL(90/30)gabapentin tabs 600mg 1 QL(180/30)GABITRIL TABS 16MG 1 QL(90/30)GABITRIL TABS 12MG 1 QL(120/30)ONFI SUSP 1 NDS QL(480/30)ONFI TABS 10MG 1 QL(30/30)ONFI TABS 20MG 1 NDS QL(60/30)phenobarbital elix 1 QL(1500/30)phenobarbital tabs 1 QL(90/30)primidone 1SABRIL PACK 1 PA NDS QL(200/30)SABRIL TABS 1 PA NDS QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

minocycline hcl 1mondoxyne nl 1 QL(60/30)morgidox 1x100mg caps 1morgidox 1x50mg 1morgidox 2x100mg caps 1tetracycline hcl 1tetracycline hydrochloride caps 500mg

1

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG 1 QL(30/30)APTIOM TABS 400MG, 800MG 1 NDS QL(30/30)APTIOM TABS 600MG 1 NDS QL(60/30)BRIVIACT INJ 1 NDS QL(600/30)BRIVIACT ORAL SOLN 1 NDS QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

1 NDS QL(60/30)

BRIVIACT TABS 100MG 1 NDS QL(120/30)FYCOMPA SUSP 1 QL(720/30)FYCOMPA TABS 1 QL(30/30)levetiracetam 1levetiracetam er tb24 750mg 1 QL(120/30)levetiracetam er tb24 500mg 1 QL(180/30)magnesium sulfate in d5w inj 5%; 1gm/100ml

1 B/D PA

roweepra 1SPRITAM TB3D 1000MG, 250MG, 500MG

1 QL(60/30)

SPRITAM TB3D 750MG 1 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 1ethosuximide 1LYRICA CAPS 225MG, 300MG 1 QL(60/30)

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 1 PANAMZARIC C4PK 1 QL(56/365)NAMZARIC CP24 1 QL(30/30)Cholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 1 QL(30/30)donepezil hcl tabs 10mg 1 QL(60/30)donepezil hcl tbdp 5mg 1 QL(30/30)donepezil hcl tbdp 10mg 1 QL(60/30)galantamine hydrobromide er 1 QL(30/30)galantamine hydrobromide oral soln

1 QL(200/30)

galantamine hydrobromide tabs 1 QL(60/30)rivastigmine tartrate 1 QL(60/30)rivastigmine transdermal system

1 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 1 PA QL(60/30)memantine hcl tabs 5mg 1 PA QL(90/30)memantine hcl titration pak 1 PA QL(49/28)memantine hydrochloride 1 PA QL(300/30)NAMENDA XR 1 PA QL(30/30)NAMENDA XR TITRATION PACK

1 PA QL(56/365)

Antidepressants

Antidepressants, Otherbupropion hcl er tb12 100mg, 200mg

1 QL(60/30)

bupropion hcl sr 1 QL(60/30)bupropion hcl tabs 75mg 1 QL(60/30)bupropion hcl tabs 100mg 1 QL(120/30)bupropion hcl xl 1 QL(30/30)maprotiline hcl 1 QL(90/30)mirtazapine 1 QL(30/30)mirtazapine odt 1 QL(30/30)nefazodone hcl 1 QL(60/30)trazodone hcl 1TRINTELLIX 1 QL(30/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tiagabine hydrochloride tabs 4mg

1

tiagabine hydrochloride tabs 2mg

1 QL(240/30)

valproate sodium 1valproic acid 1vigabatrin 1 PA NDS QL(200/30)Glutamate Reducing Agentsfelbamate 1lamotrigine 1lamotrigine er 1lamotrigine odt 1topiramate cpsp 1topiramate tabs 200mg 1 QL(60/30)topiramate tabs 100mg, 25mg, 50mg

1 QL(90/30)

TROKENDI XR CP24 100MG, 25MG, 50MG

1 QL(30/30)

TROKENDI XR CP24 200MG 1 NDS QL(60/30)Sodium Channel AgentsBANZEL SUSP 1 PA NDS

QL(2400/30)BANZEL TABS 200MG 1 PA NDS QL(60/30)BANZEL TABS 400MG 1 PA NDS QL(240/30)carbamazepine 1carbamazepine er 1DILANTIN CAPS 30MG 1epitol 1fosphenytoin sodium 1oxcarbazepine 1PEGANONE 1phenytoin 1phenytoin infatabs 1phenytoin sodium 1phenytoin sodium extended 1VIMPAT INJ 1 QL(1200/30)VIMPAT ORAL SOLN 1 QL(1200/30)VIMPAT TABS 1 QL(60/30)

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

paroxetine hcl tabs 10mg, 20mg, 40mg

1 QL(30/30)

paroxetine hcl tabs 30mg 1 QL(60/30)PAXIL SUSP 1 QL(900/30) STPRISTIQ 1 QL(30/30)sertraline hcl conc 1 QL(300/30)sertraline hcl tabs 25mg, 50mg 1 QL(30/30)sertraline hcl tabs 100mg 1 QL(60/30)venlafaxine hcl 1 QL(90/30)venlafaxine hcl er cp24 37.5mg, 75mg

1 QL(30/30)

venlafaxine hcl er cp24 150mg 1 QL(60/30)venlafaxine hcl er tb24 37.5mg, 75mg

1 QL(30/30)

venlafaxine hcl er tb24 150mg 1 QL(60/30)VIIBRYD 1 QL(30/30) STVIIBRYD STARTER PACK 1 STTricyclicsamitriptyline hcl 1 PAamoxapine 1clomipramine hcl 1 PAdesipramine hcl 1doxepin hcl 1 PAimipramine hcl 1 PAimipramine pamoate 1 PAnortriptyline hcl 1perphenazine/amitriptyline 1 PAprotriptyline hcl 1trimipramine maleate 1 PA

Antiemetics

Antiemetics, Othermeclizine hcl tabs 1phenadoz 1phenergan supp 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Monoamine Oxidase InhibitorsEMSAM 1 NDS QL(30/30)MARPLAN 1 QL(180/30)phenelzine sulfate 1tranylcypromine sulfate 1SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 1 QL(30/30)desvenlafaxine er 1 QL(30/30)duloxetine hcl cpep 20mg, 60mg

1 QL(60/30)

duloxetine hcl cpep 30mg 1 QL(90/30)escitalopram oxalate oral soln 1 QL(600/30)escitalopram oxalate tabs 1 QL(30/30)FETZIMA 1 QL(30/30) STFETZIMA TITRATION PACK 1 QL(56/365) STfluoxetine caps 10mg 1 QL(30/30)fluoxetine caps 20mg 1 QL(120/30)fluoxetine dr 1 QL(4/28)fluoxetine hcl caps 10mg 1 QL(30/30)fluoxetine hcl caps 40mg 1 QL(60/30)fluoxetine hcl caps 20mg 1 QL(120/30)fluoxetine hcl oral soln 1 QL(600/30)fluoxetine hcl tabs 10mg 1 QL(30/30)fluoxetine hcl tabs 20mg 1 QL(120/30)fluvoxamine maleate er 1 QL(60/30)fluvoxamine maleate tabs 25mg, 50mg

1 QL(30/30)

fluvoxamine maleate tabs 100mg

1 QL(90/30)

olanzapine/fluoxetine 1 QL(30/30)paroxetine hcl er tb24 12.5mg 1 QL(30/30)paroxetine hcl er tb24 25mg, 37.5mg

1 QL(60/30)

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciclopirox sham 1ciclopirox susp 1clotrimazole external crea 1clotrimazole external soln 1clotrimazole troc 1clotrimazole/betamethasone dipropionate

1

econazole nitrate 1fluconazole 1fluconazole in dextrose inj 56mg/ml; 400mg/200ml

1

fluconazole in nacl 1flucytosine 1 NDSgriseofulvin microsize 1griseofulvin ultramicrosize 1itraconazole 1 PA QL(120/30)ketoconazole crea 1ketoconazole sham 1ketoconazole tabs 1naftifine hcl 1naftifine hydrochloride 1NAFTIN 1NATACYN 1NOXAFIL SUSP 1 PA NDS QL(600/30)NOXAFIL TBEC 1 PA NDS QL(93/30)nyamyc 1nystatin 1nystatin/triamcinolone 1nystop 1SPORANOX ORAL SOLN 1 PAterbinafine hcl tabs 1 QL(90/365)terconazole 1voriconazole inj 1 PAvoriconazole susr 1 PA NDS QL(300/30)voriconazole tabs 1 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethazine hcl plain 1 PApromethazine hcl supp 1promethazine hcl syrp 1 PApromethazine hcl tabs 1 PApromethegan 1scopolamine 1 QL(10/30)TRANSDERM-SCOP 1 QL(10/30)Emetogenic Therapy AdjunctsALOXI 1 B/D PA NDSaprepitant caps 40mg 1 B/D PA QL(1/30)aprepitant caps 125mg 1 B/D PA QL(2/28)aprepitant caps 80mg 1 B/D PA QL(4/28)aprepitant caps 1 B/D PA QL(6/28)dronabinol 1 PA QL(60/30)EMEND CAPS 40MG 1 B/D PA QL(1/30)EMEND CAPS 125MG 1 B/D PA QL(2/28)EMEND CAPS 80MG 1 B/D PA QL(4/28)EMEND SUSR 1 B/D PA QL(6/28)EMEND TRIPACK 1 B/D PA QL(6/28)granisetron hcl inj 4mg/4ml 1 B/D PAgranisetron hcl inj 0.1mg/ml, 1mg/ml

1 B/D PA QL(60/30)

granisetron hcl tabs 1 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

1

ondansetron hcl oral soln 1 B/D PA QL(450/30)ondansetron hcl tabs 24mg 1 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(90/30)ondansetron odt 1 B/D PA QL(90/30)

Antifungals

AntifungalsABELCET 1 PA NDSAMBISOME 1 PA NDSamphotericin b 1 PACANCIDAS 1 PA NDScaspofungin acetate 1 PA NDSciclodan 1ciclopirox nail lacquer 1ciclopirox olamine 1

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimycobacterials

Antimycobacterials, Otherdapsone 1rifabutin 1AntitubercularsCAPASTAT SULFATE 1cycloserine 1ethambutol hcl 1isoniazid 1PASER 1PRIFTIN 1pyrazinamide 1rifampin 1RIFATER 1SIRTURO 1 PA QL(188/365)TRECATOR 1

Antineoplastics

Alkylating AgentsBENDEKA 1 B/D PA NDS

QL(8/21)BICNU 1 B/D PAbusulfan 1 B/D PA NDSBUSULFEX 1 B/D PA NDScyclophosphamide caps 1 B/D PAcyclophosphamide inj 1gm, 500mg

1 B/D PA

cyclophosphamide inj 2gm 1 B/D PA NDSdacarbazine 1 B/D PAEVOMELA 1 PA NDSGLEOSTINE 1HEXALEN 1 NDSifosfamide 1 B/D PAKISQALI FEMARA 200 DOSE 1 PA NDS QL(49/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALOPRIM 1colchicine caps 1 QL(60/30)colchicine tabs 1 QL(120/30)MITIGARE 1 QL(60/30)probenecid 1probenecid/colchicine 1ULORIC 1 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidscafergot 1 QL(40/28)dihydroergotamine mesylate inj 1 QL(30/28)ergotamine tartrate/caffeine 1 QL(40/28)migergot 1 NDS QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 1 QL(9/30)rizatriptan benzoate 1 QL(12/30)rizatriptan benzoate odt 1 QL(12/30)sumatriptan 1 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

1 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

1 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

1 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

1 QL(8/30)

sumatriptan succinate tabs 1 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 1pyridostigmine bromide 1pyridostigmine bromide er 1REGONOL 1

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARRANON 1cladribine 1 B/D PAclofarabine 1 B/D PACLOLAR 1 B/D PAcytarabine 1 B/D PAcytarabine aqueous 1 B/D PADROXIA 1ELITEK 1 B/D PA NDSfluorouracil inj 1 B/D PAFOLOTYN 1 B/D PA NDSgemcitabine 1 B/D PAgemcitabine hcl inj 200mg, 2gm 1 B/D PAgemcitabine hcl inj 1gm 1 B/D PA NDShydroxyurea 1LONSURF TABS 8.19MG; 20MG

1 PA NDS QL(80/28)

LONSURF TABS 6.14MG; 15MG

1 PA NDS QL(100/28)

mercaptopurine 1NIPENT 1 B/D PA NDSPURIXAN 1 PA NDS QL(300/30)TABLOID 1VYXEOS 1 B/D PA NDSAntineoplasticsdocetaxel inj 200mg/10ml 1 B/D PA NDSAntineoplastics, OtherABRAXANE 1 B/D PA NDSazacitidine 1 B/D PA NDSBELEODAQ 1 PA NDSbleomycin sulfate 1 B/D PAcarboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

1 B/D PA

cisplatin 1 B/D PACOSMEGEN 1 B/D PA NDSdaunorubicin hcl 1 B/D PAdecitabine 1 NDSdexrazoxane 1 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

1 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KISQALI FEMARA 400 DOSE 1 PA NDS QL(70/28)KISQALI FEMARA 600 DOSE 1 PA NDS QL(91/28)LEUKERAN 1MATULANE 1 NDSmelphalan hydrochloride 1 B/D PA NDSMUSTARGEN 1 B/D PATEPADINA 1 PAthiotepa 1 PATREANDA 1 B/D PA NDS

QL(8/21)VALCHLOR 1 PA NDS QL(60/30)YONDELIS 1 PA NDSZANOSAR 1 B/D PAAntiandrogensbicalutamide 1 QL(30/30)flutamide 1NILANDRON 1 NDS QL(60/30)nilutamide 1 NDS QL(60/30)XTANDI 1 PA NDS QL(120/30)ZYTIGA TABS 500MG 1 PA NDS QL(60/30)ZYTIGA TABS 250MG 1 PA NDS QL(120/30)Antiangiogenic AgentsPOMALYST 1 PA NDS QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

1 PA NDS QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

1 PA NDS QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

1 PA NDS QL(30/30)

THALOMID CAPS 200MG 1 PA NDS QL(60/30)Antiestrogens/ModifiersEMCYT 1FARESTON 1 NDS QL(30/30)FASLODEX 1 B/D PA NDS

QL(30/30)SOLTAMOX 1 NDStamoxifen citrate 1Antimetabolitesadrucil 1 B/D PAALIMTA 1 B/D PA NDS

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxaliplatin inj 100mg/20ml, 50mg/10ml

1 B/D PA

oxaliplatin inj 100mg 1 B/D PA NDSpaclitaxel 1 B/D PAPORTRAZZA 1 PA NDS QL(100/21)PROLEUKIN 1 B/D PA NDSRUBRACA 1 PA NDS QL(120/30)RYDAPT 1 PA NDS QL(224/28)SYLATRON 1 PA NDS QL(4/28)SYNRIBO 1 PA NDS QL(28/28)TRISENOX 1 B/D PAVELCADE 1 B/D PA NDS

QL(14/21)VENCLEXTA STARTING PACK 1 PA NDS QL(84/365)VENCLEXTA TABS 50MG 1 PA QL(30/30)VENCLEXTA TABS 10MG 1 PA QL(60/30)VENCLEXTA TABS 100MG 1 PA NDS QL(120/30)vinblastine sulfate 1 B/D PAvincasar pfs 1 B/D PAvincristine sulfate 1 B/D PAvinorelbine tartrate 1 B/D PAZEJULA 1 PA NDS QL(90/30)ZOLINZA 1 NDS QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 1 QL(30/30)exemestane 1 QL(60/30)letrozole 1 QL(30/30)Enzyme Inhibitorsetoposide inj 1 B/D PAKYPROLIS 1 B/D PA NDStoposar 1 B/D PAtopotecan hcl inj 4mg 1 NDSMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

1 PA NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxorubicin hcl 1 B/D PAdoxorubicin hcl liposome 1 B/D PA NDSepirubicin hcl inj 200mg/100ml 1 B/D PA NDSERWINAZE 1 B/D PA NDS

QL(60/28)ETHYOL 1 B/D PA NDSfludarabine phosphate 1 B/D PAFUSILEV 1 NDSHALAVEN 1 PA NDSidarubicin hcl inj 10mg/10ml 1 B/D PA NDSirinotecan 1 B/D PAirinotecan hcl 1 B/D PAISTODAX (OVERFILL) 1 PA NDSIXEMPRA KIT 1 B/D PA NDSJEVTANA 1 B/D PA NDSKISQALI 1 PA NDS QL(63/21)LARTRUVO 1 PA NDSleucovorin calcium inj 100mg, 350mg, 500mg, 50mg

1

leucovorin calcium tabs 1levoleucovorin calcium 1 NDSlevoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

1 NDS

LYNPARZA TABS 1 PA NDS QL(120/30)mesna 1 B/D PAMESNEX TABS 1 NDSmitomycin inj 20mg, 5mg 1 B/D PAmitomycin inj 40mg 1 B/D PA NDSMITOXANTRONE HCL INJ 2MG/ML

1 B/D PA

mitoxantrone hcl inj 2mg/ml 1 B/D PANERLYNX 1 PA NDS QL(180/30)NINLARO 1 PA NDS QL(3/28)ODOMZO 1 PA NDS QL(30/30)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NEXAVAR 1 PA NDS QL(120/30)SPRYCEL 1 PA NDS QL(30/30)STIVARGA 1 PA NDS QL(84/28)SUTENT 1 PA NDS QL(28/28)TAFINLAR 1 PA NDS QL(120/30)TAGRISSO 1 PA NDS QL(30/30)TARCEVA TABS 100MG, 150MG

1 PA NDS QL(30/30)

TARCEVA TABS 25MG 1 PA NDS QL(60/30)TASIGNA 1 PA NDS QL(120/30)TYKERB 1 PA NDS QL(180/30)VOTRIENT 1 PA NDS QL(120/30)XALKORI 1 PA NDS QL(60/30)ZALTRAP 1 PA NDS QL(40/28)ZELBORAF 1 PA NDS QL(240/30)ZYDELIG 1 PA NDS QL(60/30)ZYKADIA 1 PA NDS QL(150/30)Monoclonal AntibodiesAVASTIN 1 B/D PA NDSBAVENCIO 1 PA NDSBESPONSA 1 PA NDSCYRAMZA 1 PA NDSDARZALEX 1 PA NDSEMPLICITI 1 PA NDSERBITUX 1 B/D PA NDSGAZYVA 1 PA NDSHERCEPTIN 1 B/D PA NDSIMFINZI 1 PA NDSKADCYLA 1 PA NDSKEYTRUDA 1 PA NDSMYLOTARG 1 PA NDSOPDIVO 1 PA NDS QL(80/28)PERJETA 1 PA NDSRITUXAN 1 PA NDSRITUXAN HYCELA 1 PA NDSTECENTRIQ 1 PA NDS QL(20/21)UNITUXIN 1 PA NDSVECTIBIX 1 B/D PA NDSYERVOY INJ 200MG/40ML 1 B/D PA NDS

QL(80/21)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AFINITOR DISPERZ TBSO 5MG

1 PA NDS QL(120/30)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

1 PA NDS QL(30/30)

AFINITOR TABS 10MG 1 PA NDS QL(60/30)ALECENSA 1 PA NDS QL(240/30)ALIQOPA 1 PA NDS QL(3/28)ALUNBRIG 1 PA NDS QL(180/30)BOSULIF TABS 500MG 1 PA NDS QL(30/30)BOSULIF TABS 100MG 1 PA NDS QL(120/30)CABOMETYX TABS 20MG, 60MG

1 PA NDS QL(30/30)

CABOMETYX TABS 40MG 1 PA NDS QL(60/30)CAPRELSA TABS 300MG 1 PA NDS QL(30/30)CAPRELSA TABS 100MG 1 PA NDS QL(60/30)COMETRIQ KIT 1 PA NDS QL(56/28)COMETRIQ KIT 20MG 1 PA NDS QL(84/28)COMETRIQ KIT 1 PA NDS QL(112/28)COTELLIC 1 PA NDS QL(63/28)ERIVEDGE 1 PA NDS QL(30/30)FARYDAK 1 PA NDS QL(6/21)GILOTRIF 1 PA NDS QL(30/30)IBRANCE 1 PA NDS QL(21/28)ICLUSIG TABS 45MG 1 PA NDS QL(30/30)ICLUSIG TABS 15MG 1 PA NDS QL(60/30)IDHIFA 1 PA NDS QL(30/30)imatinib mesylate 1 PA NDS QL(60/30)IMBRUVICA 1 PA NDS QL(120/30)INLYTA 1 PA NDS QL(120/30)IRESSA 1 PA NDS QL(30/30)JAKAFI 1 PA NDS QL(60/30)LENVIMA 10 MG DAILY DOSE 1 PA NDS QL(30/30)LENVIMA 14 MG DAILY DOSE 1 PA NDS QL(60/30)LENVIMA 18 MG DAILY DOSE 1 PA NDS QL(90/30)LENVIMA 20 MG DAILY DOSE 1 PA NDS QL(60/30)LENVIMA 24 MG DAILY DOSE 1 PA NDS QL(90/30)LENVIMA 8 MG DAILY DOSE 1 PA NDS QL(60/30)LYNPARZA CAPS 1 PA NDS QL(480/30)MEKINIST TABS 2MG 1 PA NDS QL(30/30)MEKINIST TABS 0.5MG 1 PA NDS QL(90/30)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

benztropine mesylate tabs 1 PAtrihexyphenidyl hcl 1 PAAntiparkinson Agents, Otherentacapone 1 QL(240/30)tolcapone 1 NDSDopamine AgonistsAPOKYN 1 PA NDS QL(60/30)bromocriptine mesylate 1NEUPRO 1 QL(30/30)pramipexole dihydrochloride 1 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

1 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

1 QL(90/30)

ropinirole hcl 1Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 1carbidopa/levodopa 1carbidopa/levodopa er 1carbidopa/levodopa odt 1carbidopa/levodopa/entacapone

1

RYTARY 1 STMonoamine Oxidase B (MAO-B) InhibitorsAZILECT 1 QL(30/30)rasagiline mesylate 1 QL(30/30)selegiline hcl 1

Antipsychotics

1st Generation/Typicalchlorpromazine hcl 1compro 1fluphenazine decanoate 1fluphenazine hcl 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

YERVOY INJ 50MG/10ML 1 B/D PA NDS QL(300/21)

Retinoidsbexarotene 1 NDSPANRETIN 1 NDSTARGRETIN GEL 1 NDS QL(60/30)tretinoin caps 1 NDS

Antiparasitics

AnthelminticsALBENZA 1BILTRICIDE 1ivermectin 1AntiprotozoalsALINIA SUSR 1 QL(150/30)ALINIA TABS 1 QL(20/30)atovaquone 1atovaquone/proguanil hcl 1chloroquine phosphate 1COARTEM 1 QL(24/30)DARAPRIM 1 NDS QL(90/30)hydroxychloroquine sulfate 1mefloquine hcl 1NEBUPENT 1 B/D PA QL(6/28)PENTAM 300 1PRIMAQUINE PHOSPHATE 1 QL(90/30)quinine sulfate 1 QL(42/7)Pediculicides/Scabicideslindane 1malathion 1permethrin 1

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 1

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA SUSTENNA INJ 234MG/1.5ML

1 NDS QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

1 NDS QL(0.88/90)


1 NDS QL(1.32/90)


1 NDS QL(1.75/90)


1 NDS QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

1 NDS QL(30/30) ST

LATUDA TABS 80MG 1 NDS QL(60/30) STNUPLAZID 1 PA NDS QL(60/30)olanzapine 1 QL(30/30)olanzapine 1 QL(30/30)olanzapine odt 1 QL(30/30)paliperidone er tb24 1.5mg, 3mg

1 QL(30/30) ST

paliperidone er tb24 9mg 1 NDS QL(30/30) STpaliperidone er tb24 6mg 1 QL(60/30) STquetiapine fumarate 1 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

1 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

1 QL(60/30)

REXULTI 1 NDS QL(30/30) STRISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

1 QL(2/28)

RISPERDAL CONSTA INJ 50MG

1 NDS QL(2/28)

risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg

1 QL(60/30)

risperidone m-tab tbdp 4mg 1 QL(120/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

1 QL(60/30)

risperidone odt tbdp 4mg 1 QL(120/30)risperidone oral soln 1 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

1 QL(60/30)

risperidone tabs 4mg 1 QL(120/30)SAPHRIS 1 QL(60/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

haloperidol 1haloperidol decanoate 1haloperidol lactate 1loxapine caps 25mg, 50mg 1loxapine caps 10mg, 5mg 1 QL(120/30)loxapine succinate caps 25mg, 50mg

1

loxapine succinate caps 10mg, 5mg

1 QL(120/30)

perphenazine 1pimozide 1prochlorperazine 1prochlorperazine edisylate 1prochlorperazine maleate 1thioridazine hcl 1thiothixene 1trifluoperazine hcl 12nd Generation/AtypicalABILIFY MAINTENA 1 PA NDS QL(1/30)aripiprazole odt 1 NDS QL(60/30) STaripiprazole oral soln 1 QL(900/30) STaripiprazole tabs 1 QL(30/30) STARISTADA INJ 441MG/1.6ML 1 NDS QL(1.6/30)ARISTADA INJ 662MG/2.4ML 1 NDS QL(2.4/30)ARISTADA INJ 882MG/3.2ML 1 NDS QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 1 NDS QL(3.9/60)FANAPT TABS 1MG, 2MG, 4MG

1 QL(60/30) ST

FANAPT TABS 10MG, 12MG, 6MG, 8MG

1 NDS QL(60/30) ST

FANAPT TITRATION PACK 1 QL(16/365) STGEODON INJ 1 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

1 QL(0.25/28)


1 NDS QL(0.5/28)


1 NDS QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

1 NDS QL(1/28)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 1 NDS QL(30/30)BARACLUDE ORAL SOLN 1 QL(630/30)entecavir 1 QL(30/30)EPIVIR HBV ORAL SOLN 1INTRON A INJ 6000000UNIT/ML

1

INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU

1 NDS

INTRON A W/DILUENT 1 NDSlamivudine tabs 100mg 1Anti-hepatitis C (HCV) AgentsEPCLUSA 1 PA NDS QL(28/28)HARVONI 1 PA NDS QL(28/28)PEG-INTRON REDIPEN 1 PA NDS QL(4/28)PEGASYS INJ 180MCG/0.5ML 1 PA NDS QL(2/28)PEGASYS INJ 180MCG/ML 1 PA NDS QL(4/28)PEGASYS PROCLICK 1 PA NDS QL(2/28)PEGINTRON 1 PA NDS QL(4/28)ribavirin caps 1 QL(168/28)ribavirin tabs 1 QL(168/28)SOVALDI 1 PA NDS QL(28/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)GENVOYA 1 NDS QL(30/30)ISENTRESS CHEW 25MG 1 QL(180/30)ISENTRESS CHEW 100MG 1 NDS QL(180/30)ISENTRESS HD 1 NDS QL(60/30)ISENTRESS PACK 1 NDS QL(180/30)ISENTRESS TABS 1 NDS QL(60/30)TIVICAY TABS 10MG, 25MG 1 QL(60/30)TIVICAY TABS 50MG 1 NDS QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 1 NDS QL(30/30)EDURANT 1 NDS QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VRAYLAR CAPS 1 NDS QL(30/30) STVRAYLAR CPPK 1 QL(14/365) STziprasidone hcl 1 QL(60/30)ZYPREXA RELPREVV INJ 405MG

1 NDS QL(1/28)

ZYPREXA RELPREVV INJ 210MG

1 QL(2/28)

ZYPREXA RELPREVV INJ 300MG

1 NDS QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

1

clozapine odt tbdp 200mg 1 NDS QL(120/30)clozapine odt tbdp 150mg 1 QL(180/30)clozapine odt tbdp 100mg 1 QL(270/30)clozapine tabs 25mg, 50mg 1clozapine tabs 200mg 1 QL(120/30)clozapine tabs 100mg 1 QL(270/30)VERSACLOZ 1 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 1dantrolene sodium 1tizanidine hcl 1

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 1 NDSFOSCAVIR 1ganciclovir inj 500mg 1 B/D PAVALCYTE ORAL SOLN 1 NDSvalganciclovir 1 NDSvalganciclovir hydrochlorde 1 NDSZIRGAN 1 ST

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZERIT ORAL SOLN 1 QL(2400/30)ZIAGEN ORAL SOLN 1 QL(960/30)zidovudine caps 1 QL(180/30)zidovudine syrp 1 QL(1680/28)zidovudine tabs 1 QL(60/30)Anti-HIV Agents, OtherATRIPLA 1 NDS QL(30/30)FUZEON 1 NDS QL(60/30)SELZENTRY ORAL SOLN 1 NDS QL(1610/26)SELZENTRY TABS 150MG, 75MG

1 NDS QL(60/30)

SELZENTRY TABS 300MG 1 NDS QL(120/30)SELZENTRY TABS 25MG 1 QL(240/30)TYBOST 1 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 1 NDS QL(120/30)APTIVUS ORAL SOLN 1 NDS QL(285/28)CRIXIVAN CAPS 400MG 1 QL(180/30)CRIXIVAN CAPS 200MG 1 QL(270/30)EVOTAZ 1 NDS QL(30/30)fosamprenavir calcium 1 NDS QL(120/30)INVIRASE CAPS 1 NDS QL(300/30)INVIRASE TABS 1 NDS QL(120/30)KALETRA ORAL SOLN 1 QL(480/30)KALETRA TABS 200MG; 50MG

1 NDS QL(120/30)

KALETRA TABS 100MG; 25MG

1 QL(300/30)

LEXIVA SUSP 1 QL(1575/28)LEXIVA TABS 1 NDS QL(120/30)lopinavir/ritonavir 1 QL(480/30)NORVIR CAPS 1 QL(360/30)NORVIR ORAL SOLN 1 QL(480/30)NORVIR TABS 1 QL(360/30)PREZCOBIX 1 NDS QL(30/30)PREZISTA SUSP 1 NDS QL(400/30)PREZISTA TABS 800MG 1 NDS QL(30/30)PREZISTA TABS 600MG 1 NDS QL(60/30)PREZISTA TABS 150MG 1 QL(180/30)PREZISTA TABS 75MG 1 QL(210/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTELENCE TABS 100MG, 200MG

1 NDS QL(60/30)

INTELENCE TABS 25MG 1 QL(120/30)nevirapine er tb24 400mg 1 QL(30/30)nevirapine er tb24 100mg 1 QL(90/30)nevirapine susp 1 QL(1200/30)nevirapine tabs 1 QL(60/30)ODEFSEY 1 NDS QL(30/30)RESCRIPTOR TABS 200MG 1 QL(180/30)RESCRIPTOR TABS 100MG 1 QL(270/30)STRIBILD 1 NDS QL(30/30)SUSTIVA CAPS 200MG 1 NDS QL(60/30)SUSTIVA CAPS 50MG 1 QL(90/30)SUSTIVA TABS 1 NDS QL(30/30)VIRAMUNE SUSP 1 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir sulfate/lamivudine/zidovudine

1 NDS QL(60/30)

abacavir tabs 1 QL(60/30)abacavir/lamivudine 1 NDS QL(30/30)DESCOVY 1 NDS QL(30/30)didanosine 1 QL(30/30)EMTRIVA CAPS 1 QL(30/30)EMTRIVA ORAL SOLN 1 QL(680/28)EPZICOM 1 NDS QL(30/30)lamivudine oral soln 1 QL(900/30)lamivudine tabs 300mg 1 QL(30/30)lamivudine tabs 150mg 1 QL(60/30)lamivudine/zidovudine 1 QL(60/30)RETROVIR IV INFUSION 1stavudine 1 QL(60/30)TRIUMEQ 1 NDS QL(30/30)TRUVADA 1 NDS QL(30/30)VIDEX PEDIATRIC ORAL SOLN 2GM

1 QL(900/30)

VIDEX PEDIATRIC ORAL SOLN 4GM

1 QL(1200/30)

VIREAD POWD 1 NDS QL(240/30)VIREAD TABS 1 NDS QL(30/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alprazolam tabs 0.25mg, 0.5mg, 1mg

1 QL(90/30)

alprazolam tabs 2mg 1 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

1 QL(90/30)

clorazepate dipotassium tabs 15mg

1 QL(180/30)

diazepam inj 5mg/ml 1diazepam oral soln 1 QL(1200/30)diazepam tabs 1 QL(120/30)lorazepam conc 1 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 1lorazepam intensol 1 QL(150/30)lorazepam tabs 0.5mg, 1mg 1 QL(90/30)lorazepam tabs 2mg 1 QL(150/30)oxazepam 1 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate 1lithium carbonate er 1

Blood Glucose Regulators

Antidiabetic Agentsacarbose 1 QL(90/30)BYDUREON 1 QL(4/28)BYDUREON PEN 1 QL(4/28)BYETTA INJ 5MCG/0.02ML 1 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 1 QL(2.4/30)CYCLOSET 1 QL(180/30)FARXIGA 1 QL(30/30)glimepiride 1 QL(60/30)glipizide er tb24 2.5mg, 5mg 1 QL(30/30)glipizide er tb24 10mg 1 QL(60/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REYATAZ CAPS 150MG, 300MG

1 NDS QL(30/30)

REYATAZ CAPS 200MG 1 NDS QL(60/30)REYATAZ PACK 1 NDS QL(180/30)VIRACEPT TABS 625MG 1 NDS QL(120/30)VIRACEPT TABS 250MG 1 NDS QL(270/30)Anti-influenzaAgentsamantadine hcl 1oseltamivir phosphate caps 45mg, 75mg

1 QL(56/365)

oseltamivir phosphate caps 30mg

1 QL(112/365)

rimantadine hcl 1TAMIFLU CAPS 45MG, 75MG 1 QL(56/365)TAMIFLU CAPS 30MG 1 QL(112/365)TAMIFLU SUSR 1 QL(700/365)Antiherpetic Agentsacyclovir caps 1acyclovir oint 1 QL(30/30)acyclovir sodium inj 50mg/ml 1 B/D PAacyclovir susp 1acyclovir tabs 1DENAVIR 1 NDS QL(5/30)famciclovir 1 QL(60/30)trifluridine 1valacyclovir hcl 1 QL(30/30)ZOVIRAX CREA 1 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl 1Benzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

1 QL(90/30)

alprazolam odt tbdp 2mg 1 QL(150/30)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RIOMET 1 QL(750/30)SYMLINPEN 120 1 PA NDS

QL(10.8/28)SYMLINPEN 60 1 PA QL(6/30)SYNJARDY 1 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

1 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

1 QL(60/30)

TRADJENTA 1 QL(30/30)TRULICITY 1 QL(2/28)VICTOZA 1 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 5MG; 500MG

1 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

1 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 1 QL(4/30)GLUCAGON EMERGENCY KIT

1 QL(4/30)

PROGLYCEM 1InsulinsHUMALOG 1HUMALOG KWIKPEN 1humalog mix 50/50 1humalog mix 50/50 kwikpen 1humalog mix 75/25 1humalog mix 75/25 kwikpen 1humulin 70/30 1humulin 70/30 kwikpen 1humulin n 1humulin n kwikpen 1humulin r 1humulin r u-500 (concentrated) 1HUMULIN R U-500 KWIKPEN 1lantus 1lantus solostar 1levemir 1levemir flextouch 1SOLIQUA 100/33 1 QL(18/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide xl tb24 2.5mg, 5mg 1 QL(30/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hcl tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 1 QL(30/30)INVOKAMET 1 QL(60/30)INVOKAMET XR 1 QL(60/30)INVOKANA 1 QL(30/30)JANUMET 1 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

1 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

1 QL(60/30)

JANUVIA 1 QL(30/30)JARDIANCE 1 QL(30/30)JENTADUETO 1 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

1 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

1 QL(60/30)

Metformin hcl er tb24 500mg, 1000mg (generic for Fortamet)

1 QL(60/30)

Metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

Metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl tabs 1000mg 1 QL(60/30)metformin hcl tabs 850mg 1 QL(90/30)metformin hcl tabs 500mg 1 QL(150/30)miglitol 1 QL(90/30)nateglinide 1 QL(90/30)PIOGLITAZONE HCL TABS 45MG

1 QL(30/30)

pioglitazone hcl tabs 15mg, 30mg

1 QL(30/30)

pioglitazone hcl-glimepiride 1 QL(30/30)pioglitazone hcl/metformin hcl 1 QL(90/30)repaglinide tabs 0.5mg, 1mg 1 QL(120/30)repaglinide tabs 2mg 1 QL(240/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SAVAYSA 1 QL(30/30)warfarin sodium 1XARELTO STARTER PACK 1 QL(102/365)XARELTO TABS 20MG 1 QL(30/30)XARELTO TABS 10MG 1 QL(35/90)XARELTO TABS 15MG 1 QL(60/30)BloodFormationModifiersanagrelide hydrochloride 1ARANESP ALBUMIN FREE INJ 500MCG/ML

1 PA NDS QL(1/21)

ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

1 PA QL(1.2/28)


1 PA NDS QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

1 PA QL(1.6/28)


1 PA NDS QL(1.6/28)


1 PA QL(1.68/28)


1 PA NDS QL(2/28)


1 PA NDS QL(2.4/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

1 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

1 PA NDS QL(4/28)

LEUKINE INJ 250MCG 1 PA NDSMOZOBIL 1 NDS QL(9.6/30)NEULASTA 1 PA NDS QL(1.2/28)NEULASTA ONPRO KIT 1 PA NDS QL(1.2/28)NEUPOGEN INJ 300MCG/0.5ML

1 PA NDS QL(7/28)

NEUPOGEN INJ 480MCG/0.8ML

1 PA NDS QL(11.2/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TOUJEO SOLOSTAR 1 QL(9/30)TRESIBA FLEXTOUCH 1XULTOPHY 100/3.6 1 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 1enoxaparin sodium inj 30mg/0.3ml

1 QL(9/90)

enoxaparin sodium inj 40mg/0.4ml

1 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

1 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

1 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

1 QL(30/90)

fondaparinux sodium inj 5mg/0.4ml

1 NDS QL(12/90)

fondaparinux sodium inj 2.5mg/0.5ml

1 QL(15/90)

fondaparinux sodium inj 7.5mg/0.6ml

1 NDS QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

1 NDS QL(24/90)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

1

heparin sodium/d5w 1heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%

1

heparin sodium/nacl 0.9% 1heparin sodium/sodium chloride 0.9%

1

heparin sodium/sodium chloride 0.9% premix

1

jantoven 1PRADAXA 1 QL(60/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg, 25mg

1 QL(30/30)

losartan potassium tabs 50mg 1 QL(60/30)losartan potassium/hydrochlorothiazide

1 QL(30/30)

olmesartan medoxomil 1 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

1 QL(30/30)

telmisartan 1 QL(30/30)telmisartan/amlodipine 1 QL(30/30)telmisartan/hydrochlorothiazide 1 QL(30/30)valsartan 1 QL(30/30)valsartan/hydrochlorothiazide 1 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl tabs 10mg, 20mg, 5mg

1 QL(30/30)

benazepril hcl tabs 40mg 1 QL(60/30)benazepril hcl/hydrochlorothiazide

1 QL(30/30)

captopril tabs 12.5mg, 25mg 1 QL(90/30)captopril tabs 100mg 1 QL(120/30)captopril tabs 50mg 1 QL(270/30)captopril/hydrochlorothiazide tabs 25mg; 25mg, 50mg; 25mg

1 QL(60/30)

captopril/hydrochlorothiazide tabs 25mg; 15mg, 50mg; 15mg

1 QL(90/30)

enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg

1 QL(30/30)

enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg

1 QL(60/30)

fosinopril sodium 1 QL(60/30)fosinopril sodium/hydrochlorothiazide

1 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

lisinopril/hydrochlorothiazide tabs 25mg; 20mg

1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NEUPOGEN INJ 300MCG/ML 1 PA NDS QL(14/28)NEUPOGEN INJ 480MCG/1.6ML

1 PA NDS QL(22.4/30)

PROCRIT INJ 40000UNIT/ML 1 PA NDS QL(6/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

1 PA QL(12/28)

PROCRIT INJ 20000UNIT/ML 1 PA NDS QL(12/28)PROMACTA 1 PA NDS QL(30/30)Coagulantstranexamic acid inj 1 PAtranexamic acid tabs 1 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 1 QL(60/30)BRILINTA 1 QL(60/30)cilostazol 1clopidogrel tabs 300mg 1 QL(2/365)clopidogrel tabs 75mg 1 QL(30/30)EFFIENT 1 QL(30/30)prasugrel 1 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

1 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 1 QL(8/28)clonidine hcl tabs 1midodrine hcl 1Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

1 NDS

prazosin hcl 1Angiotensin II Receptor AntagonistsBENICAR 1 QL(30/30) STBENICAR HCT 1 QL(30/30) STcandesartan cilexetil 1 QL(30/30)candesartan cilexetil/hydrochlorothiazide

1 QL(30/30)

ENTRESTO 1 QL(60/30)irbesartan 1 QL(30/30)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-adrenergic Blocking Agentsacebutolol hcl 1atenolol 1atenolol/chlorthalidone 1betaxolol hcl 1bisoprolol fumarate 1bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

1 QL(30/30)

BYSTOLIC TABS 20MG 1 QL(60/30)BYVALSON 1 QL(30/30)carvedilol 1COREG CR 1 QL(30/30)labetalol hcl 1metoprolol succinate er 1 QL(60/30)metoprolol tartrate 1metoprolol/hydrochlorothiazide 1nadolol 1nadolol/bendroflumethiazide tabs 5mg; 80mg

1

nadolol/bendroflumethiazide tabs 5mg; 40mg

1 QL(30/30)

pindolol 1propranolol hcl 1propranolol hcl er 1propranolol/hydrochlorothiazide 1timolol maleate 1Calcium Channel Blocking Agentsafeditab cr tb24 30mg 1 QL(30/30)afeditab cr tb24 60mg 1 QL(60/30)amlodipine besylate tabs 10mg, 2.5mg

1 QL(30/30)

amlodipine besylate tabs 5mg 1 QL(45/30)amlodipine besylate/benazepril hydrochloride

1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 1moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

1 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

1 QL(60/30)

perindopril erbumine tabs 2mg, 4mg

1 QL(30/30)

perindopril erbumine tabs 8mg 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

1 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg, 2mg 1 QL(30/30)trandolapril tabs 4mg 1 QL(60/30)Antiarrhythmicsamiodarone hcl 1dofetilide 1 QL(60/30)flecainide acetate 1lidocaine hcl inj 1mexiletine hcl 1MULTAQ 1 QL(60/30)pacerone 1propafenone hcl 1propafenone hcl er 1quinidine sulfate 1sorine 1sotalol hcl 1sotalol hcl (af) 1TIKOSYN 1 QL(60/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

verapamil hcl er tbcr 1verapamil hcl sr cp24 360mg 1 QL(30/30)Cardiovascular Agents, OtherDEMSER 1 NDSdigitek tabs 0.125mg 1 QL(30/30)digitek tabs 0.25mg 1 PAdigox tabs 125mcg 1 QL(30/30)digox tabs 250mcg 1 PAdigoxin inj 1 PAdigoxin tabs 125mcg 1 QL(30/30)digoxin tabs 250mcg 1 PALANOXIN PEDIATRIC 1 PANORTHERA CAPS 100MG 1 PA NDS QL(90/30)NORTHERA CAPS 200MG, 300MG

1 PA NDS QL(180/30)

pentoxifylline er 1RANEXA 1 QL(60/30)TEKTURNA 1 QL(30/30) STTEKTURNA HCT 1 QL(30/30) STDiuretics, Carbonic Anhydrase Inhibitorsacetazolamide 1acetazolamide sodium 1Diuretics, Loopbumetanide 1ethacrynate sodium 1furosemide 1torsemide 1Diuretics, Potassium-sparingamiloride hcl 1amiloride/hydrochlorothiazide 1spironolactone 1spironolactone/hydrochlorothiazide

1

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 1chlorothiazide sodium 1chlorthalidone 1hydrochlorothiazide 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amlodipine besylate/valsartan 1 QL(30/30)amlodipine/olmesartan medoxomil

1 QL(30/30)

amlodipine/valsartan/hctz 1 QL(30/30)AZOR 1 QL(30/30) STcartia xt cp24 120mg, 300mg 1 QL(30/30)cartia xt cp24 180mg, 240mg 1 QL(60/30)dilt-xr cp24 120mg 1 QL(30/30)dilt-xr cp24 180mg, 240mg 1 QL(60/30)diltiazem cd cp24 240mg 1 QL(60/30)diltiazem hcl 1diltiazem hcl cd 1 QL(30/30)diltiazem hcl er cp12 1diltiazem hcl er cp24 120mg, 300mg, 360mg, 420mg

1 QL(30/30)

diltiazem hcl er cp24 180mg, 240mg

1 QL(60/30)

diltiazem hcl er tb24 300mg, 360mg, 420mg

1 QL(30/30)

diltiazem hcl er tb24 180mg, 240mg

1 QL(60/30)

felodipine er 1 QL(30/30)isradipine 1matzim la tb24 300mg, 360mg, 420mg

1 QL(30/30)

matzim la tb24 180mg, 240mg 1 QL(60/30)nicardipine hcl 1nifedipine er tb24 30mg, 90mg 1 QL(30/30)nifedipine er tb24 60mg 1 QL(60/30)nimodipine 1nisoldipine er tb24 20mg, 30mg, 40mg

1

nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg

1 QL(30/30)

taztia xt cp24 120mg, 300mg, 360mg

1 QL(30/30)

taztia xt cp24 180mg, 240mg 1 QL(60/30)verapamil hcl 1verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

1 QL(30/30)

verapamil hcl er cp24 200mg 1 QL(60/30)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prevalite 1REPATHA 1 PA NDS QL(3/30)REPATHA PUSHTRONEX SYSTEM

1 PA NDS QL(3.5/30)

REPATHA SURECLICK 1 PA NDS QL(3/30)VASCEPA CAPS 1GM 1 QL(120/30)VASCEPA CAPS 0.5GM 1 QL(240/30)VYTORIN 1 QL(30/30)WELCHOL 1ZETIA 1 QL(30/30)Vasodilators, Direct-acting Arterialhydralazine hcl 1minoxidil 1Vasodilators, Direct-acting Arterial/VenousBIDIL 1 QL(180/30)isosorbide dinitrate er 1isosorbide dinitrate tabs 1isosorbide mononitrate 1isosorbide mononitrate er 1minitran 1 QL(30/30)nitroglycerin 1nitroglycerin lingual translingual soln

1

nitroglycerin transdermal 1 QL(30/30)NITROSTAT 1

Central Nervous System Agents

AttentionDeficitHyperactivityDisorderAgents,Amphetaminesamphetamine/dextroamphetamine cp24

1 QL(30/30)

amphetamine/dextroamphetamine tabs

1 QL(60/30)

dextroamphetamine sulfate er cp24 5mg

1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

indapamide 1metolazone 1Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 1 QL(30/30)fenofibrate caps 43mg, 50mg 1 QL(60/30)fenofibrate micronized caps 134mg, 200mg

1 QL(30/30)

fenofibrate micronized caps 67mg

1 QL(60/30)

fenofibrate tabs 145mg, 160mg 1 QL(30/30)fenofibrate tabs 48mg, 54mg 1 QL(60/30)fenofibric acid dr cpdr 135mg 1 QL(30/30)fenofibric acid dr cpdr 45mg 1 QL(60/30)gemfibrozil 1 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 1 QL(30/30) STLIVALO 1 QL(30/30) STlovastatin tabs 10mg, 20mg 1 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 1 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 1cholestyramine light 1colestipol hcl gran 1colestipol hcl tabs 1ezetimibe 1 QL(30/30)ezetimibe/simvastatin 1 QL(30/30)KYNAMRO 1 PA NDS QL(4/28)niacin er tbcr 500mg 1 QL(30/30)niacin er tbcr 1000mg, 750mg 1 QL(60/30)niacor 1omega-3-acid ethyl esters 1 QL(120/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AVONEX 1 PA NDS QL(4/28)AVONEX PEN 1 PA NDS QL(4/28)BETASERON 1 PA NDS QL(14/28)COPAXONE INJ 40MG/ML 1 PA NDS QL(12/28)COPAXONE INJ 20MG/ML 1 PA NDS QL(30/30)GILENYA 1 PA NDS QL(30/30)REBIF 1 PA NDS QL(6/28)REBIF REBIDOSE 1 PA NDS QL(6/28)REBIF REBIDOSE TITRATION PACK

1 PA NDS QL(4.2/28)

REBIF TITRATION PACK 1 PA NDS QL(4.2/28)TECFIDERA CPDR 120MG 1 PA NDS QL(14/30)TECFIDERA CPDR 240MG 1 PA NDS QL(60/30)TECFIDERA STARTER PACK 1 PA NDS

QL(120/365)TYSABRI 1 PA NDS QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 1paroex 1periogard 1pilocarpine hcl 1pilocarpine hydrochloride 1triamcinolone acetonide dental paste

1

Dermatological Agents

Dermatological Agentsacitretin 1 PAammonium lactate 1amnesteem 1calcipotriene crea 1 QL(120/30)calcipotriene external soln 1calcipotriene oint 1 QL(120/30)calcitrene 1 QL(120/30)calcitriol oint 1 QL(800/30)CARAC 1 NDSclaravis 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


1 QL(90/30)


1 QL(120/30)

dextroamphetamine sulfate oral soln

1 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

1 QL(60/30)

dextroamphetamine sulfate tabs 10mg

1 QL(180/30)

AttentionDeficitHyperactivityDisorderAgents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

1 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

1 QL(60/30)

clonidine hcl er 1 QL(120/30)dexmethylphenidate hcl 1 QL(60/30)metadate er 1 QL(90/30)methylphenidate hcl er tbcr 10mg, 27mg, 54mg

1 QL(30/30)

methylphenidate hcl er tbcr 36mg

1 QL(60/30)


1 QL(90/30)


1 QL(120/30)

methylphenidate hcl tabs 10mg, 5mg

1 QL(60/30)

methylphenidate hcl tabs 20mg 1 QL(90/30)STRATTERA CAPS 100MG, 60MG, 80MG

1 QL(30/30)

STRATTERA CAPS 10MG, 18MG, 25MG, 40MG

1 QL(60/30)

Central Nervous System, OtherHETLIOZ 1 PA NDS QL(30/30)NUEDEXTA 1 QL(60/30)riluzole 1tetrabenazine tabs 12.5mg 1 PA NDS QL(90/30)tetrabenazine tabs 25mg 1 PA NDS QL(120/30)Multiple Sclerosis AgentsAMPYRA 1 PA NDS QL(60/30)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALDURAZYME 1 PA NDSBUPHENYL TABS 1 NDSCEREZYME 1 B/D PA NDSCREON 1CYSTADANE 1 NDSCYSTAGON 1ELAPRASE 1 PA NDSFABRAZYME 1 B/D PA NDSKUVAN PACK 500MG 1 PA NDS QL(150/30)KUVAN PACK 100MG 1 PA NDS QL(750/30)KUVAN TBSO 1 PA NDS QL(750/30)LUMIZYME 1 PA NDSNAGLAZYME 1 PA NDSORFADIN 1 NDSsodium phenylbutyrate 1 NDSVPRIV 1 PA NDSZAVESCA 1 NDS QL(90/30)ZENPEP 1

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 1atropine sulfate inj 0.25mg/5ml, 1mg/10ml, 1mg/ml, 8mg/20ml

1

dicyclomine hcl caps 1dicyclomine hcl oral soln 1dicyclomine hcl tabs 1ed-spaz 1glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

1

glycopyrrolate tabs 1hyoscyamine sulfate elix 1hyoscyamine sulfate odt 1hyoscyamine sulfate subl 1hyoscyamine sulfate tabs 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

curity gauze pads 2”x2” 1diclofenac sodium transdermal soln

1 QL(1050/30)

doxepin hydrochloride 1ELIDEL 1 QL(100/90)erythromycin/benzoyl peroxide 1fluorouracil crea 1fluorouracil external soln 1imiquimod 1 QL(12/30)methoxsalen 1 NDSmyorisan 1PICATO GEL 0.05% 1 QL(2/56) STPICATO GEL 0.015% 1 QL(3/56) STpodofilox 1REGRANEX 1 PA NDS QL(15/30)SANTYL 1selenium sulfide lotn 1tacrolimus oint 1 QL(100/90)tazarotene 1 QL(120/30)TAZORAC CREA 1 QL(120/30)TAZORAC GEL 1 QL(100/30)tretinoin crea 1 PA QL(45/30)tretinoin gel 1 PA QL(45/30)tretinoin microsphere 1 PAtretinoin microsphere pump gel 0.1%

1 PA

UVADEX 1 B/D PAVOLTAREN GEL 1 QL(1000/30)zenatane 1ZYCLARA 1 NDS QL(56/30)ZYCLARA PUMP CREA 2.5% 1 NDS QL(15/30)

EnzymeReplacement/Modifiers

EnzymeReplacement/ModifiersADAGEN 1 PA NDS

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

generlac 1lactulose 1MOVIPREP 1peg 3350/electrolytes 1peg-3350/electrolytes 1peg-3350/nacl/na bicarbonate/kcl

1

polyethylene glycol 3350 powd 1SUPREP BOWEL PREP KIT 1trilyte 1ProtectantsCARAFATE SUSP 1MISOPROSTOL TABS 200MCG

1

misoprostol tabs 100mcg 1sucralfate 1Proton Pump InhibitorsDEXILANT 1 QL(60/30) STesomeprazole magnesium 1 QL(60/30)ESOMEPRAZOLE SODIUM 1omeprazole cpdr 1 QL(60/30)pantoprazole sodium tbec 1 QL(60/30)

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 1 QL(30/30)ENABLEX 1 QL(30/30) STflavoxate hcl 1MYRBETRIQ 1 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

1 QL(30/30)

oxybutynin chloride er tb24 15mg

1 QL(60/30)

oxybutynin chloride syrp 1 QL(600/30)oxybutynin chloride tabs 1 QL(120/30)tolterodine tartrate 1 QL(60/30)tolterodine tartrate er 1 QL(30/30)VESICARE 1 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hyoscyamine sulfate tbdp 1methscopolamine bromide 1nulev 1oscimin 1propantheline bromide 1Gastrointestinal AgentsTRULANCE 1 QL(30/30)Gastrointestinal Agents, Othercromolyn sodium conc 1diphenoxylate/atropine 1GATTEX 1 PA NDS QL(30/30)loperamide hcl caps 1metoclopramide hcl 1OSMOPREP 1RELISTOR INJ 8MG/0.4ML 1 PA NDS QL(12/30)RELISTOR INJ 12MG/0.6ML 1 PA NDS QL(18/30)ursodiol 1Histamine2 (H2) Receptor Antagonistscimetidine 1cimetidine hcl 1famotidine inj 1famotidine premixed 1famotidine tabs 20mg, 40mg 1nizatidine caps 1ranitidine hcl 1Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

1 PA QL(60/30)

alosetron hydrochloride tabs 1mg

1 PA NDS QL(60/30)

AMITIZA 1 QL(60/30)LINZESS 1 QL(30/30)VIBERZI 1 PA QL(60/30)Laxativesconstulose 1enulose 1gavilyte-c 1gavilyte-g 1gavilyte-n/flavor pack 1

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate crea 1clobetasol propionate e 1clobetasol propionate emollient 1clobetasol propionate external soln

1

clobetasol propionate foam 1clobetasol propionate gel 1clobetasol propionate oint 1clobetasol propionate sham 1clodan 1cormax scalp application 1cortisone acetate 1DEPO-MEDROL INJ 20MG/ML 1desonide lotn 1desonide oint 1desoximetasone 1dexamethasone 1dexamethasone intensol 1dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

1

diflorasone diacetate 1fludrocortisone acetate 1fluocinolone acetonide 1fluocinolone acetonide body 1fluocinolone acetonide scalp 1fluocinonide 1fluocinonide emulsified base 1fluticasone propionate crea 1fluticasone propionate oint 1halobetasol propionate 1hydrocortisone butyrate 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxazosin 1 QL(30/30)doxazosin mesylate tabs 1mg, 2mg

1 QL(30/30)

doxazosin mesylate tabs 8mg 1 QL(60/30)dutasteride 1 QL(30/30)dutasteride/tamsulosin hydrochloride

1 QL(30/30)

finasteride tabs 5mg 1 QL(30/30)tamsulosin hcl 1 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

1 QL(30/30)

terazosin hcl caps 10mg 1 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 1ELMIRON 1phenazopyridine hcl 1Phosphate BindersAURYXIA 1 QL(360/30)calcium acetate caps 1calcium acetate tabs 667mg 1PHOSLYRA 1RENVELA PACK 1 QL(180/30)RENVELA TABS 1 QL(540/30)VELPHORO 1 QL(180/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 1ALA SCALP 1ala-cort crea 1% 1alclometasone dipropionate 1amcinonide 1augmented betamethasone dipropionate

1

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 1 PAdesmopressin acetate inj 1desmopressin acetate nasal soln

1 QL(15/30)

desmopressin acetate tabs 1INCRELEX 1 PANOVAREL 1 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL

1 PA

SAIZEN 1 PA NDSSAIZEN CLICK.EASY 1 PA NDSSTIMATE 1

Hormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)

Anabolic SteroidsANADROL-50 1 PA NDSoxandrolone tabs 10mg 1 PA NDS QL(60/30)oxandrolone tabs 2.5mg 1 PA QL(120/30)Androgensdanazol 1testosterone cypionate 1 PAtestosterone enanthate 1 PA QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

1 PA QL(300/30)

testosterone pump 1 PA QL(300/30)EstrogensALORA 1 PA QL(8/28)altavera 1alyacen 1/35 1alyacen 7/7/7 1amethia 1 QL(91/91)amethia lo 1 QL(91/91)apri 1aranelle 1ashlyna 1 QL(91/91)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocortisone butyrate (lipid) 1hydrocortisone butyrate (lipophilic)

1

hydrocortisone external crea 1hydrocortisone lotn 2.5% 1hydrocortisone oint 1%, 2.5% 1hydrocortisone rectal crea 1hydrocortisone tabs 1hydrocortisone valerate 1MEDROL TABS 2MG 1methylprednisolone 1methylprednisolone acetate 1methylprednisolone dose pack 1methylprednisolone sodiumsuccinate

1

mometasone furoate crea 1mometasone furoate external soln

1

mometasone furoate oint 1prednicarbate oint 1prednisolone oral soln 1prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

1

prednisone 1prednisone intensol 1procto-med hc 1procto-pak 1proctosol hc 1proctozone-hc 1SOLU-CORTEF 1TEXACORT 1triamcinolone acetonide crea 1triamcinolone acetonide lotn 1triamcinolone acetonide oint 1trianex 1triderm crea 0.1% 1

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

1

falmina 1FEMRING 1 QL(1/90)femynor 1fyavolv tabs 2.5mcg; 0.5mg 1 PAgildagia 1introvale 1 QL(91/91)isibloom 1jevantique lo 1 PAjolessa 1 QL(91/91)juleber 1junel 1.5/30 1junel 1/20 1junel fe 1.5/30 1junel fe 1/20 1kariva 1kelnor 1/35 1kimidess 1kurvelo 1larin 1.5/30 1larin 1/20 1larin fe 1.5/30 1larin fe 1/20 1larissia 1lessina 1levonest 1levonorgestrel and ethinyl estradiol tabs 0; 0

1 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

1

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

1 QL(91/91)

levora 0.15/30-28 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

aubra 1aviane 1balziva 1bekyree 1blisovi fe 1.5/30 1blisovi fe 1/20 1briellyn 1camrese 1 QL(91/91)camrese lo 1 QL(91/91)caziant 1chateal 1cryselle-28 1cyclafem 1/35 1cyclafem 7/7/7 1cyred 1dasetta 1/35 1dasetta 7/7/7 1daysee 1 QL(91/91)DELESTROGEN INJ 10MG/ML 1delyla 1DEPO-ESTRADIOL 1desogestrel/ethinyl estradiol 1elinest 1emoquette 1enpresse-28 1enskyce 1estarylla 1estradiol pttw 1 PA QL(8/28)estradiol ptwk 1 PA QL(4/28)estradiol tabs 10mcg 1 QL(18/28)estradiol tabs 0.5mg, 1mg, 2mg 1 PAestradiol valerate 1ESTRING 1 QL(1/90)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sronyx 1tarina fe 1/20 1tilia fe 1tri-estarylla 1tri-legest fe 1tri-linyah 1tri-previfem 1tri-sprintec 1trivora-28 1VAGIFEM 1 QL(18/28)velivet 1vienva 1viorele 1vyfemla 1wera 1yuvafem 1 QL(18/28)zenchent 1zovia 1/35e 1zovia 1/50e 1Progesterone Agonists/Antagonistsella 1Progestinscamila 1deblitane 1DEPO-PROVERA 1 QL(10/28)errin 1heather 1hydroxyprogesterone caproate 1 PA NDSjencycla 1jolivette 1lyza 1MAKENA 1 PA NDSmedroxyprogesterone acetate inj

1 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

1 PA

megestrol acetate tabs 1 PAnora-be 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

low-ogestrel 1lutera 1marlissa 1MENEST 1 PAMENOSTAR 1 PA QL(4/28)microgestin 1.5/30 1microgestin 1/20 1microgestin fe 1microgestin fe 1.5/30 1MINIVELLE 1 PA QL(8/28)mono-linyah 1myzilra 1necon 0.5/35-28 1necon 1/50-28 1necon 7/7/7 1norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

1

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

1 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

1

norgestimate/ethinyl estradiol 1nortrel 0.5/35 (28) 1nortrel 1/35 1nortrel 7/7/7 1ogestrel 1orsythia 1philith 1pimtrea 1pirmella 1/35 1pirmella 7/7/7 1portia-28 1PREMARIN CREA 1PREMARIN INJ 1PREMARIN TABS 1 PA QL(30/30)previfem 1quasense 1 QL(91/91)reclipsen 1setlakin 1 QL(91/91)sprintec 28 1

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELIGARD INJ 30MG 1 PA QL(1/120)ELIGARD INJ 45MG 1 PA QL(1/180)ELIGARD INJ 7.5MG 1 PA QL(1/30)ELIGARD INJ 22.5MG 1 PA QL(1/90)FIRMAGON INJ 80MG 1 B/D PA QL(1/28)FIRMAGON INJ 120MG 1 B/D PA NDS

QL(4/365)leuprolide acetate 1 PALUPRON DEPOT (1-MONTH) 1 PA NDS QL(1/30)LUPRON DEPOT (3-MONTH) INJ 22.5MG

1 PA NDS QL(1/84)

LUPRON DEPOT (3-MONTH) INJ 11.25MG

1 PA NDS QL(1/90)

LUPRON DEPOT (4-MONTH) 1 PA NDS QL(1/112)LUPRON DEPOT (6-MONTH) 1 PA NDS QL(1/168)LUPRON DEPOT-PED (1-MONTH)

1 PA NDS QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

1 PA NDS QL(1/30)

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml

1 PA

octreotide acetate inj 500mcg/ml

1 PA NDS

SANDOSTATIN LAR DEPOT 1 PA NDSSIGNIFOR 1 PA NDS QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

1 PA NDS QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

1 PA NDS QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

1 PA NDS QL(0.5/28)

SOMAVERT 1 PA NDS QL(30/30)SYNAREL 1 PA NDSTRELSTAR MIXJECT INJ 22.5MG

1 PA NDS QL(1/168)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone 1norethindrone acetate 1norlyroc 1progesterone caps 1sharobel 1Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 1 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL 1liothyronine sodium 1SYNTHROID 1THYROLAR-1 1THYROLAR-1/2 1THYROLAR-1/4 1THYROLAR-2 1THYROLAR-3 1UNITHROID 1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 1 NDS

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)SENSIPAR TABS 30MG 1 QL(60/30)SENSIPAR TABS 60MG 1 NDS QL(60/30)SENSIPAR TABS 90MG 1 NDS QL(120/30)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 1 QL(16/30)

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methotrexate sodium 1mycophenolate mofetil caps 1 PAmycophenolate mofetil inj 1 PAmycophenolate mofetil susr 1 PA NDSmycophenolate mofetil tabs 1 PAmycophenolic acid dr 1 PANULOJIX 1 PA NDS QL(150/30)PROGRAF INJ 1 PARAPAMUNE ORAL SOLN 1 PA NDSREMICADE 1 PA NDSSANDIMMUNE ORAL SOLN 1 PA NDSsirolimus 1 PAtacrolimus caps 1 PATORISEL 1 B/D PA NDS

QL(4/28)XATMEP 1 PAZORTRESS TABS 0.25MG, 0.75MG

1 PA NDS QL(60/30)

ZORTRESS TABS 0.5MG 1 PA NDS QL(120/30)Immunizing Agents, PassiveATGAM 1 PAGAMMAKED INJ 1GM/10ML 1 B/D PAGAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

1 B/D PA NDS

GAMUNEX-C INJ 1GM/10ML 1 B/D PAGAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

1 B/D PA NDS

THYMOGLOBULIN 1 B/D PAImmunomodulatorsACTEMRA INJ 162MG/0.9ML 1 PA NDS QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

1 PA NDS QL(40/28)

ACTIMMUNE 1 PA NDSARCALYST 1 PA NDSBENLYSTA INJ 400MG 1 PA NDS QL(9/28)BENLYSTA INJ 120MG 1 PA NDS QL(30/28)ILARIS 1 PA NDS QL(2/28)leflunomide 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRELSTAR MIXJECT INJ 3.75MG

1 PA NDS QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

1 PA NDS QL(1/84)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 1propylthiouracil 1

Immunological Agents

Angioedema (HAE) AgentsCINRYZE 1 PA NDS QL(100/30)FIRAZYR 1 PA NDS QL(18/30)Immune SuppressantsASTAGRAF XL CP24 0.5MG, 1MG

1 PA

ASTAGRAF XL CP24 5MG 1 PA NDSAZASAN 1 PAazathioprine 1 PACELLCEPT INTRAVENOUS 1 PAcyclosporine 1 PAcyclosporine modified 1 PAENBREL INJ 25MG/0.5ML 1 PA NDS

QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 1 PA NDS QL(8/28)ENBREL SURECLICK 1 PA NDS QL(8/28)ENVARSUS XR 1 PAgengraf 1 PAHUMIRA INJ 10MG/0.2ML, 20MG/0.4ML

1 PA NDS QL(2/28)

HUMIRA INJ 40MG/0.8ML 1 PA NDS QL(4/28)HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

1 PA NDS QL(6/365)

HUMIRA PEN 1 PA NDS QL(4/28)HUMIRA PEN-CROHNS DISEASESTARTER

1 PA NDS QL(12/365)

HUMIRA PEN-PSORIASIS STARTER

1 PA NDS QL(8/365)

KINERET 1 PA NDS QL(20.1/30)

methotrexate 1

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STAMARIL 1 QL(1/999)TENIVAC 1 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

1

TRUMENBA 1TWINRIX 1TYPHIM VI 1VAQTA 1VARIVAX 1 QL(1/365)VARIZIG 1 QL(12/30)VAXCHORA 1YF-VAX 1ZOSTAVAX 1 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 1 QL(120/30)balsalazide disodium 1mesalamine kit 1Glucocorticoidsbudesonide cpep 1colocort 1hydrocortisone enem 1Sulfonamidessulfasalazine 1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

calcitonin-salmon 1 QL(3.7/30)calcitriol caps 1calcitriol inj 1calcitriol oral soln 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RIDAURA 1SIMULECT 1 B/D PA NDSSYNAGIS INJ 50MG/0.5ML 1 PA NDSsynagis inj 100mg/ml 1 PA NDSVaccinesACTHIB 1ADACEL 1 QL(0.5/365)BEXSERO 1BOOSTRIX 1 QL(0.5/365)DAPTACEL 1DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

1

ENGERIX-B INJ 10MCG/0.5ML 1 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 1 B/D PA QL(8/365)GARDASIL 1 QL(1.5/365)GARDASIL 9 1 QL(1.5/365)HAVRIX 1HIBERIX 1IMOVAX RABIES (H.D.C.V.) 1INFANRIX 1IPOL INACTIVATED IPV 1IXIARO 1KINRIX 1M-M-R II 1 QL(2/365)MENACTRA 1MENVEO 1PEDIARIX 1PEDVAX HIB 1PROQUAD 1 QL(2/365)QUADRACEL 1RABAVERT 1RECOMBIVAX HB 1 B/D PA QL(3/365)ROTARIX 1ROTATEQ 1

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTRALIPID 1 B/D PAKORLYM 1 PA NDS QL(120/30)LACTATED RINGERS IRRIGATION

1

levocarnitine 1LIPOSYN III 1 B/D PANATPARA 1 PA NDS QL(2/28)novofine 30gx8mm 1 QL(200/30)novofine 31 1 QL(200/30)novofine 32gx6mm 1 QL(200/30)novofine autocover 30gx8mm 1 QL(200/30)novotwist 32gx5mm 1 QL(200/30)NUTRILIPID 1 B/D PAPHYSIOLYTE 1PHYSIOSOL IRRIGATION 1RINGERS IRRIGATION 1sodium chloride 0.9% 1sterile water irrigation 1techlite pen needles/31g x 6 mm

1 QL(200/30)

techlite pen needles/31g x 8mm 1 QL(200/30)techlite pen needles/32g x 4mm 1 QL(200/30)techlite pen needles/32g x 6mm 1 QL(200/30)techlite pen needles/32g x 8mm 1 QL(200/30)TIS-U-SOL 1

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 1 QL(5/30)COMBIGAN 1latanoprost 1 QL(5/30)LUMIGAN 1 QL(5/30) STTRAVATAN Z 1 QL(5/30)ZIOPTAN 1 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 1CYSTARAN 1 PA NDS QL(60/30)LACRISERT 1proparacaine hcl 1RESTASIS 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxercalciferol caps 0.5mcg 1 QL(90/30)doxercalciferol caps 2.5mcg 1 QL(120/30)doxercalciferol caps 1mcg 1 QL(240/30)doxercalciferol inj 1etidronate disodium 1FORTEO 1 PA NDS QL(2.4/28)ibandronate sodium tabs 1 QL(1/28)MIACALCIN 1 NDSpamidronate disodium 1 B/D PAparicalcitol caps 4mcg 1 QL(60/30)paricalcitol caps 1mcg, 2mcg 1 QL(90/30)PROLIA 1 QL(1/180) STrisedronate sodium tabs 150mg 1 QL(1/30)risedronate sodium tabs 35mg 1 QL(4/28)risedronate sodium tabs 30mg, 5mg

1 QL(30/30)

XGEVA 1 PA NDS QL(1.7/28)zoledronic acid inj 4mg/5ml 1 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 1 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 1 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

1 QL(200/30)

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

1 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

1 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16”

1 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16”

1 QL(200/30)

bd pen needle/nano/ultra fine/32g x 4mm

1 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

1 QL(200/30)

bd safetyglide 27g x 5/8” 1 QL(200/30)CARNITOR INJ 1 B/D PAFERRIPROX 1 PA NDSfomepizole 1 NDS

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

apraclonidine 1AZOPT 1betaxolol hcl 1brimonidine tartrate 1carteolol hcl 1dorzolamide hcl 1 QL(10/30)dorzolamide hcl/timolol maleate 1 QL(10/30)levobunolol hcl 1methazolamide 1metipranolol 1PHOSPHOLINE IODIDE 1pilocarpine hcl 1SIMBRINZA 1timolol maleate 1

Otic Agents

Otic Agentsacetasol hc 1acetic acid 1COLY-MYCIN S 1fluocinolone acetonide 1fluocinolone acetonide ear drops

1

hydrocortisone/acetic acid 1neomycin/polymyxin/hc 1neomycin/polymyxin/hydrocortisone

1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories,InhaledCorticosteroidsADVAIR DISKUS 1 QL(60/30)ADVAIR HFA 1 QL(12/30)ARNUITY ELLIPTA 1 QL(30/30)BREO ELLIPTA 1 QL(60/30)budesonide nasal spray 1 QL(17.2/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tropicamide 1Ophthalmic Anti-allergy AgentsALOCRIL 1azelastine hcl ophthalmic soln 1cromolyn sodium ophthalmic soln

1

epinastine hcl 1olopatadine hcl ophthalmic soln 1 QL(5/30)PATADAY 1 QL(2.5/30)PAZEO 1 QL(2.5/30)OphthalmicAnti-inflammatoriesbromfenac 1dexamethasone sodium phosphate ophthalmic soln

1

diclofenac sodium ophthalmic soln

1

DUREZOL 1fluorometholone 1flurbiprofen sodium 1ILEVRO 1ketorolac tromethamine ophthalmic soln

1

LOTEMAX 1neomycin/polymyxin/dexamethasone

1

PRED MILD 1PRED-G 1PRED-G S.O.P. 1prednisolone acetate 1prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 1TOBRADEX OINT 1tobramycin/dexamethasone 1Ophthalmic Antiglaucoma Agentsacetazolamide er 1

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

albuterol sulfate syrp 1albuterol sulfate tabs 1ANORO ELLIPTA 1 QL(60/30)epinephrine hcl inj 1mg/10ml, 1mg/ml

1

epinephrine inj 0.15mg/0.3ml, 0.3mg/0.3ml

1 QL(2/30)

EPIPEN 2-PAK 1 QL(2/30)EPIPEN-JR 2-PAK 1 QL(2/30)metaproterenol sulfate 1PERFOROMIST 1 B/D PA QL(120/30)PROAIR HFA 1 QL(17/30)PROAIR RESPICLICK 1 QL(2/30)SEREVENT DISKUS 1 QL(60/30)terbutaline sulfate 1VENTOLIN HFA 1 QL(36/30)Cystic Fibrosis AgentsCAYSTON 1 PA NDS QL(84/56)KALYDECO 1 PA NDS QL(60/30)ORKAMBI 1 PA NDS QL(120/30)PULMOZYME 1 B/D PA NDS

QL(150/30)TOBI PODHALER 1 NDS QL(1568/365)tobramycin nebu 1 B/D PA NDS

QL(280/56)Mast Cell Stabilizerscromolyn sodium nebu 1 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 1DALIRESP 1 PA QL(30/30)THEO-24 1theophylline cr 1theophylline er tb12 300mg, 450mg

1

theophylline er tb24 1Pulmonary AntihypertensivesADEMPAS 1 PA NDS QL(90/30)LETAIRIS 1 PA NDS QL(30/30)OPSUMIT 1 PA NDS QL(30/30)REMODULIN 1 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

budesonide susp 1 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

1 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

1 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

1 QL(10.6/30)


1 QL(12/30)


1 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 1 QL(16/30)mometasone furoate susp 1 QL(34/30)NASONEX 1 QL(34/30) STAntihistaminesazelastine hcl nasal soln 1 QL(30/25)desloratadine 1 QL(30/30)desloratadine odt 1 QL(30/30)diphenhydramine hcl inj 1levocetirizine dihydrochloride oral soln

1 QL(300/30)

levocetirizine dihydrochloride tabs

1 QL(30/30)

Antileukotrienesmontelukast sodium 1 QL(30/30)zafirlukast 1 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 1 QL(25.8/30)COMBIVENT RESPIMAT 1 QL(8/30)INCRUSE ELLIPTA 1 QL(30/30)ipratropium bromide inhalation soln

1 B/D PA QL(300/30)

ipratropium bromide nasal soln 1 QL(30/30)ipratropium bromide/albuterol sulfate

1 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 1albuterol sulfate nebu 0.5% 1 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

1 B/D PA QL(360/30)

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/MineralModifiersCHEMET 1 NDSCUPRIMINE 1 NDSDEPEN TITRATABS 1 NDSEXJADE 1 NDSJADENU 1 NDSJADENU SPRINKLE 1 NDSkionex 1SAMSCA TABS 15MG 1 PA NDS QL(30/30)SAMSCA TABS 30MG 1 PA NDS QL(60/30)sodium bicarbonate inj 1sodium bicarbonate partial fill 1SODIUM LACTATE INJ 5MEQ/ML

1 B/D PA

sodium polystyrene sulfonate powd

1

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

1

sps 1SYPRINE 1 NDSVELTASSA 1Electrolyte/Mineral ReplacementAMINOSYN 1 B/D PAAMINOSYN 7%/ELECTROLYTES

1 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

1 B/D PA

AMINOSYN II 1 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

1 B/D PA

AMINOSYN M 1 B/D PAAMINOSYN-HBC 1 B/D PAAMINOSYN-PF 1 B/D PAAMINOSYN-PF 7% 1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SILDENAFIL TABS 1 PA QL(90/30)TRACLEER 1 PA NDS QL(60/30)VENTAVIS 1 PA NDS QL(270/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 1 B/D PAARALAST NP INJ 500MG 1 B/D PAESBRIET CAPS 1 PA NDS QL(270/30)ESBRIET TABS 801MG 1 PA NDS QL(90/30)ESBRIET TABS 267MG 1 PA NDS QL(270/30)OFEV 1 PA NDS QL(60/30)PROLASTIN-C 1 B/D PA NDSribavirin inhalation soln 1 B/D PA NDSVIRAZOLE 1 B/D PA NDSXOLAIR 1 PA NDS QL(6/28)ZEMAIRA 1 B/D PA NDS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

1 PA QL(90/30)

orphenadrine citrate er 1 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 1 QL(60/365)zaleplon 1 QL(90/365)zolpidem tartrate tabs 1 PA QL(30/30)Sleep Disorders, Otherarmodafinil 1 PA QL(30/30)MODAFINIL TABS 100MG 1 PA QL(30/30)modafinil tabs 200mg 1 PA QL(30/30)NUVIGIL 1 PA QL(30/30)ROZEREM 1 QL(30/30)SILENOR 1 QL(30/30)XYREM 1 PA NDS QL(540/30)

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 5%/nacl 0.33% 1dextrose 5%/nacl 0.45% 1dextrose 5%/nacl 0.9% 1DEXTROSE 50% 1 B/D PADEXTROSE 70% 1fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 1 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

1 B/D PA

HEPATAMINE 1 B/D PAKABIVEN 1 B/D PAkcl 0.075%/d5w/nacl 0.45% 1 B/D PAkcl 0.15%/d5w/nacl 0.2% 1 B/D PAkcl 0.15%/d5w/nacl 0.225% 1 B/D PAkcl 0.15%/d5w/nacl 0.45% 1 B/D PAkcl 0.15%/d5w/nacl 0.9% 1 B/D PAkcl 0.3%/d5w/nacl 0.45% 1 B/D PAkcl 0.3%/d5w/nacl 0.9% 1 B/D PAklor-con 10 1klor-con 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 1LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

1 B/D PA

LACTATED RINGERS VIAFLEX

1 B/D PA

ludent 1magnesium sulfate inj 1 B/D PANEPHRAMINE 1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMINOSYN-RF 1 B/D PAav-phos 250 neutral 1CARBAGLU 1 NDSCLINIMIX 2.75%/DEXTROSE 5%

1 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

1 B/D PA


1 B/D PA


1 B/D PA


1 B/D PA

CLINIMIX 5%/DEXTROSE 15% 1 B/D PACLINIMIX 5%/DEXTROSE 20% 1 B/D PACLINIMIX 5%/DEXTROSE 25% 1 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

1 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

1 B/D PA

CLINIMIX E 4.25%/DEXTROSE 25%

1 B/D PA

CLINIMIX E 5%/DEXTROSE 25%

1 B/D PA

CLINISOL SF 15% 1 B/D PAdextrose10%/nacl 0.45% 1 B/D PAdextrose5% /electrolyte #48 viaflex

1 B/D PA

DEXTROSE 10% 1 B/D PAdextrose 10%/nacl 0.2% 1 B/D PAdextrose 2.5%/nacl 0.45% 1 B/D PADEXTROSE 20% 1 B/D PADEXTROSE 25% 1 B/D PADEXTROSE 30% 1 B/D PADEXTROSE 40% 1 B/D PADEXTROSE 5% 1DEXTROSE 5%/LACTATED RINGERS

1 B/D PA

dextrose 5%/nacl 0.2% 1dextrose 5%/nacl 0.225% 1DEXTROSE 5%/NACL 0.3% 1

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 40MEQ/L; 0.9%

1 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%

1 B/D PA

potassium citrate er 1PREMASOL 1 B/D PAPROCALAMINE 1 B/D PAPROSOL 1 B/D PARINGERS INJECTION 1 B/D PAsodium chloride 0.45% 1sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

1

sodium fluoride chew 0.5mg, 1mg

1

TPN ELECTROLYTES 1 B/D PATRAVASOL 1 B/D PATROPHAMINE 1 B/D PAvirt-phos 250 neutral 1Therapeutic Nutrients/Minerals/ElectrolytesLIPOSYN III 1 B/D PAVitaminsmultivitamin with fluoride chew 1VP-PNV-DHA 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NORMOSOL -R 1 B/D PANORMOSOL-M IN D5W 1 B/D PANORMOSOL-R 1 B/D PANORMOSOL-R IN D5W 1 B/D PANUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ

1 B/D PA

PERIKABIVEN 1 B/D PAphospha 250 neutral 1PLENAMINE 1 B/D PApotassium chloride /sodium chloride

1 B/D PA

potassium chloride 0.15% d5w/nacl 0.45%

1 B/D PA

potassium chloride 0.15% d5w/nacl 0.45%viaflex

1 B/D PA

potassium chloride 0.22% d5w/nacl 0.45%

1 B/D PA

potassium chloride cr 1potassium chloride er 1potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

1 B/D PA

potassium chloride oral soln 1POTASSIUM CHLORIDE SR TBCR 8MEQ

1

potassium chloride sr tbcr 8meq

1

POTASSIUM CHLORIDE/DEXTROSE INJ 5%; 40MEQ/L

1 B/D PA

potassium chloride/dextrose inj 5%; 20meq/l

1 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS

1 B/D PA

potassium chloride/dextrose/sodium chloride

1 B/D PA

52

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 28abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 28abacavir tabs . . . . . . . . . . . . . . . . . . . . . 28ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 20ABILIFY MAINTENA . . . . . . . . . . . . . . . 26ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 22acamprosate calcium dr . . . . . . . . . . . . 13acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 29acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 33acetaminophen/caffeine/ dihydrocodeine . . . . . . . . . . . . . . . . . . . . 11acetaminophen/codeine oral soln . . . 11acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 11acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 11acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . 47acetazolamide . . . . . . . . . . . . . . . . . . . . . 34acetazolamide er . . . . . . . . . . . . . . . . . . 47acetazolamide sodium . . . . . . . . . . . . . 34acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 47acetylcysteine inhalation soln . . . . . . 49acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 36ACTEMRA INJ 162MG/0.9ML . . . . . . 44ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 44ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 44acyclovir caps . . . . . . . . . . . . . . . . . . . . 29acyclovir oint . . . . . . . . . . . . . . . . . . . . . 29acyclovir sodium inj 50mg/ml . . . . . . . 29acyclovir susp . . . . . . . . . . . . . . . . . . . . 29acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 29ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 45ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 37adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 27ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 48adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 47ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 47afeditab cr tb24 30mg . . . . . . . . . . . . . . 33afeditab cr tb24 60mg . . . . . . . . . . . . . . 33AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 23AFINITOR DISPERZ TBSO 5MG . . . 24AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 24AFINITOR TABS 10MG . . . . . . . . . . . . 24ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 39ALA SCALP . . . . . . . . . . . . . . . . . . . . . . . 39ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 25albuterol sulfate er . . . . . . . . . . . . . . . . . 48albuterol sulfate nebu 0.5% . . . . . . . . 48albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 48albuterol sulfate syrp . . . . . . . . . . . . . . 48albuterol sulfate tabs . . . . . . . . . . . . . . 48alclometasone dipropionate . . . . . . . . 39alcohol prep pads . . . . . . . . . . . . . . . . . 14ALDURAZYME . . . . . . . . . . . . . . . . . . . . 37ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 24alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 45alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 45alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 38ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 25ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 25ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 24allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 20allopurinol sodium . . . . . . . . . . . . . . . . . 20ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 47ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . 21ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 40alosetron hydrochloride tabs 0.5mg . . . . . . . . . . . . . . . . . . . . . . . . 38alosetron hydrochloride tabs 1mg . . . 38ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 29alprazolam odt tbdp 2mg . . . . . . . . . . . 29alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 29alprazolam tabs 2mg . . . . . . . . . . . . . . 29altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ALUNBRIG . . . . . . . . . . . . . . . . . . . . . . . 24alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 40alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 40amantadine hcl . . . . . . . . . . . . . . . . . . . . 29AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 20amcinonide . . . . . . . . . . . . . . . . . . . . . . . 39a-methapred . . . . . . . . . . . . . . . . . . . . . . 39amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 40amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 40amikacin sulfate . . . . . . . . . . . . . . . . . . . 13amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 34amiloride/hydrochlorothiazide . . . . . . 34aminophylline . . . . . . . . . . . . . . . . . . . . . 48AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 49AMINOSYN 7%/ELECTROLYTES . . 49AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 49AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 49AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 49AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 49AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 49AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 49AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 49AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 50amiodarone hcl . . . . . . . . . . . . . . . . . . . . 33AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 38amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 19amlodipine besylate/ benazepril hydrochloride . . . . . . . . . . . 33amlodipine besylate tabs 5mg . . . . . . 33amlodipine besylate tabs 10mg, 2.5mg . . . . . . . . . . . . . . . . . . . . . . 33amlodipine besylate/valsartan . . . . . . 34

53


Covered Drugs Index

atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 36atorvastatin calcium . . . . . . . . . . . . . . . 35atovaquone . . . . . . . . . . . . . . . . . . . . . . . 25atovaquone/proguanil hcl . . . . . . . . . . 25ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 28atropine sulfate inj 0.25mg/5ml, 1mg/10ml, 1mg/ml, 8mg/20ml . . . . . . 37atropine sulfate ophthalmic soln . . . . 46ATROVENT HFA . . . . . . . . . . . . . . . . . . 48aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 39AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 15AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 39AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 24AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 16aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 36AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 36av-phos 250 neutral . . . . . . . . . . . . . . . 50azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 22AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 15AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 44AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 16azathioprine . . . . . . . . . . . . . . . . . . . . . . . 44azelastine hcl nasal soln . . . . . . . . . . . 48azelastine hcl ophthalmic soln . . . . . 47AZILECT . . . . . . . . . . . . . . . . . . . . . . . . . . 25azithromycin inj . . . . . . . . . . . . . . . . . . . 16azithromycin pack . . . . . . . . . . . . . . . . . 16azithromycin susr 100mg/5ml . . . . . . 16azithromycin susr 200mg/5ml . . . . . . 16azithromycin tabs 250mg, 500mg . . . 16azithromycin tabs 600mg . . . . . . . . . . . 16AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 47AZOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34aztreonam inj 1gm . . . . . . . . . . . . . . . . . 15aztreonam inj 2gm . . . . . . . . . . . . . . . . . 15

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 31ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 31ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 44aripiprazole odt . . . . . . . . . . . . . . . . . . . . 26aripiprazole oral soln . . . . . . . . . . . . . . 26aripiprazole tabs . . . . . . . . . . . . . . . . . . 26ARISTADA INJ 441MG/1.6ML . . . . . . 26ARISTADA INJ 662MG/2.4ML . . . . . . 26ARISTADA INJ 882MG/3.2ML . . . . . . 26ARISTADA INJ 1064MG/3.9ML . . . . . 26armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 49ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 47ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 22ascomp/codeine . . . . . . . . . . . . . . . . . . . 12ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 40aspirin/dipyridamole . . . . . . . . . . . . . . . 32ASTAGRAF XL CP24 0.5MG, 1MG . . . . . . . . . . . . . . . . . . . . . . 44ASTAGRAF XL CP24 5MG . . . . . . . . . 44atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 33atenolol/chlorthalidone . . . . . . . . . . . . . 33ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 44atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 36

amlodipine/olmesartan medoxomil . . . 34amlodipine/valsartan/hctz . . . . . . . . . . 34ammonium lactate . . . . . . . . . . . . . . . . . 36amnesteem . . . . . . . . . . . . . . . . . . . . . . . 36amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 19amoxicillin . . . . . . . . . . . . . . . . . . . . . . . . . 15amoxicillin/clavulanate potassium . . . 15amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 15amphetamine/ dextroamphetamine cp24 . . . . . . . . . . 35amphetamine/ dextroamphetamine tabs . . . . . . . . . . 35amphotericin b . . . . . . . . . . . . . . . . . . . . 20ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 15ampicillin sodium . . . . . . . . . . . . . . . . . . 15ampicillin-sulbactam . . . . . . . . . . . . . . . 15AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 36ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 40anagrelide hydrochloride . . . . . . . . . . . 31anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 37anastrozole . . . . . . . . . . . . . . . . . . . . . . . 23ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 48APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 25apraclonidine . . . . . . . . . . . . . . . . . . . . . . 47aprepitant caps . . . . . . . . . . . . . . . . . . . 20aprepitant caps 40mg . . . . . . . . . . . . . . 20aprepitant caps 80mg . . . . . . . . . . . . . . 20aprepitant caps 125mg . . . . . . . . . . . . . 20apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 45APTIOM TABS 200MG . . . . . . . . . . . . . 17APTIOM TABS 400MG, 800MG . . . . 17APTIOM TABS 600MG . . . . . . . . . . . . . 17APTIVUS CAPS . . . . . . . . . . . . . . . . . . 28APTIVUS ORAL SOLN . . . . . . . . . . . . 28ARALAST NP INJ 500MG . . . . . . . . . . 49aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 31

54


Covered Drugs Index

budesonide cpep . . . . . . . . . . . . . . . . . 45budesonide nasal spray . . . . . . . . . . . . 47budesonide susp . . . . . . . . . . . . . . . . . . 48bumetanide . . . . . . . . . . . . . . . . . . . . . . . 34BUPHENYL TABS . . . . . . . . . . . . . . . . 37buprenorphine hcl inj . . . . . . . . . . . . . . 11buprenorphine hcl inj . . . . . . . . . . . . . . 13buprenorphine hcl/naloxone hcl . . . . . 13buprenorphine hcl subl . . . . . . . . . . . . 13bupropion hcl er tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 18bupropion hcl sr . . . . . . . . . . . . . . . . . . . 13bupropion hcl sr . . . . . . . . . . . . . . . . . . . 18bupropion hcl tabs 75mg . . . . . . . . . . . 18bupropion hcl tabs 100mg . . . . . . . . . . 18bupropion hcl xl . . . . . . . . . . . . . . . . . . . 18buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 29busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 21BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 21butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 11butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 12butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 11butalbital/aspirin/caffeine caps . . . . . 11butalbital/aspirin/caffeine/codeine . . . 12butorphanol tartrate inj 1mg/ml . . . . . 12butorphanol tartrate inj 2mg/ml . . . . . 12butorphanol tartrate nasal soln . . . . . 12BYDUREON . . . . . . . . . . . . . . . . . . . . . . 29BYDUREON PEN . . . . . . . . . . . . . . . . . 29BYETTA INJ 5MCG/0.02ML . . . . . . . . 29BYETTA INJ 10MCG/0.04ML . . . . . . . 29BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 33BYSTOLIC TABS 20MG . . . . . . . . . . . 33BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 33

benztropine mesylate inj . . . . . . . . . . . 25benztropine mesylate tabs . . . . . . . . . 25BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 16BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 24betamethasone dipropionate . . . . . . . 39betamethasone valerate . . . . . . . . . . . 39BETASERON . . . . . . . . . . . . . . . . . . . . . 36betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 33betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 47bethanechol chloride . . . . . . . . . . . . . . . 39bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 25BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 45bicalutamide . . . . . . . . . . . . . . . . . . . . . . 22BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 15BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 25bimatoprost ophthalmic soln . . . . . . . 46bisoprolol fumarate . . . . . . . . . . . . . . . . 33bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 33bleomycin sulfate . . . . . . . . . . . . . . . . . . 22BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 16BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 16blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 41blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 41BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 45BOSULIF TABS 100MG . . . . . . . . . . . . 24BOSULIF TABS 500MG . . . . . . . . . . . . 24BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 47briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 32brimonidine tartrate . . . . . . . . . . . . . . . . 47BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 17BRIVIACT ORAL SOLN . . . . . . . . . . . 17BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 17BRIVIACT TABS 100MG . . . . . . . . . . . 17bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 47bromocriptine mesylate . . . . . . . . . . . . 25

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 14bacitracin ophthalmic oint . . . . . . . . . . 14bacitracin/polymyxin b . . . . . . . . . . . . . 14baclofen tabs . . . . . . . . . . . . . . . . . . . . . 27BACTROBAN NASAL . . . . . . . . . . . . . 14balsalazide disodium . . . . . . . . . . . . . . 45balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BANZEL SUSP . . . . . . . . . . . . . . . . . . . 18BANZEL TABS 200MG . . . . . . . . . . . . 18BANZEL TABS 400MG . . . . . . . . . . . . 18BARACLUDE ORAL SOLN . . . . . . . . 27BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 24bd eclipse syringe/1ml/30gx1/2” . . . . 46bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 46bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 46bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 46bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 46bd pen needle/mini/ultrafine/ 31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . . 46bd pen needle/nano/ultra fine/ 32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . . 46bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 46bd safetyglide 27g x 5/8” . . . . . . . . . . . 46bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 22benazepril hcl/hydrochlorothiazide . . . 32benazepril hcl tabs 10mg, 20mg, 5mg . . . . . . . . . . . . . . . . . 32benazepril hcl tabs 40mg . . . . . . . . . . . 32BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 21BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 32BENICAR HCT . . . . . . . . . . . . . . . . . . . . 32BENLYSTA INJ 120MG . . . . . . . . . . . . 44BENLYSTA INJ 400MG . . . . . . . . . . . . 44

55


Covered Drugs Index

cefuroxime sodium . . . . . . . . . . . . . . . . 15celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 11celecoxib caps 400mg . . . . . . . . . . . . . 11CELLCEPT INTRAVENOUS . . . . . . . 44CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 17cephalexin caps 250mg, 500mg . . . . 15cephalexin susr . . . . . . . . . . . . . . . . . . . 15cephalexin tabs . . . . . . . . . . . . . . . . . . . 15CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 37CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 13CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 13CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 13chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 49chloramphenicol sodium succinate . . 14chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 36chloroquine phosphate . . . . . . . . . . . . . 25chlorothiazide . . . . . . . . . . . . . . . . . . . . . 34chlorothiazide sodium . . . . . . . . . . . . . . 34chlorpromazine hcl . . . . . . . . . . . . . . . . 25chlorthalidone . . . . . . . . . . . . . . . . . . . . . 34cholestyramine . . . . . . . . . . . . . . . . . . . . 35cholestyramine light . . . . . . . . . . . . . . . 35chorionic gonadotropin . . . . . . . . . . . . . 40ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 20ciclopirox nail lacquer . . . . . . . . . . . . . . 20ciclopirox olamine . . . . . . . . . . . . . . . . . 20ciclopirox sham . . . . . . . . . . . . . . . . . . . 20ciclopirox susp . . . . . . . . . . . . . . . . . . . . 20cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 27cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 32CILOXAN OINT . . . . . . . . . . . . . . . . . . . 16cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 38cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 38CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 44CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 16

carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 25carbidopa/levodopa . . . . . . . . . . . . . . . . 25carbidopa/levodopa/entacapone . . . . 25carbidopa/levodopa er . . . . . . . . . . . . . 25carbidopa/levodopa odt . . . . . . . . . . . . 25carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 22CARNITOR INJ . . . . . . . . . . . . . . . . . . . 46carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 47cartia xt cp24 120mg, 300mg . . . . . . . 34cartia xt cp24 180mg, 240mg . . . . . . . 34carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 33caspofungin acetate . . . . . . . . . . . . . . . 20CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 48caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 15cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 15CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 15cefazolin sodium/dextrose inj 2gm; 3% . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg . . . . . . 15cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefepime/dextrose . . . . . . . . . . . . . . . . . 15cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefotaxime sodium inj 1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . 15cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 15cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 15cefpodoxime proxetil . . . . . . . . . . . . . . . 15cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 15ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 15ceftazidime/dextrose . . . . . . . . . . . . . . . 15ceftriaxone in iso-osmotic dextrose . . . . . . . . . . . . . . . 15ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . 15cefuroxime axetil . . . . . . . . . . . . . . . . . . 15

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 43CABOMETYX TABS 20MG, 60MG . . . 24CABOMETYX TABS 40MG . . . . . . . . 24cafergot . . . . . . . . . . . . . . . . . . . . . . . . . . . 21calcipotriene crea . . . . . . . . . . . . . . . . . 36calcipotriene external soln . . . . . . . . . 36calcipotriene oint . . . . . . . . . . . . . . . . . . 36calcitonin-salmon . . . . . . . . . . . . . . . . . . 45calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 36calcitriol caps . . . . . . . . . . . . . . . . . . . . . 45calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 45calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 36calcitriol oral soln . . . . . . . . . . . . . . . . . 45calcium acetate caps . . . . . . . . . . . . . . 39calcium acetate tabs 667mg . . . . . . . . 39camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 41camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 41CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 20candesartan cilexetil . . . . . . . . . . . . . . . 32candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 32capacet . . . . . . . . . . . . . . . . . . . . . . . . . . . 11CAPASTAT SULFATE . . . . . . . . . . . . . . 21CAPRELSA TABS 100MG . . . . . . . . . 24CAPRELSA TABS 300MG . . . . . . . . . 24captopril/hydrochlorothiazide tabs 25mg; 15mg, 50mg; 15mg . . . . . 32captopril/hydrochlorothiazide tabs 25mg; 25mg, 50mg; 25mg . . . . . 32captopril tabs 12.5mg, 25mg . . . . . . . 32captopril tabs 50mg . . . . . . . . . . . . . . . . 32captopril tabs 100mg . . . . . . . . . . . . . . 32CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . . 36CARAFATE SUSP . . . . . . . . . . . . . . . . 38CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 50carbamazepine . . . . . . . . . . . . . . . . . . . . 18carbamazepine er . . . . . . . . . . . . . . . . . 18

56


Covered Drugs Index

clozapine odt tbdp 12.5mg, 25mg . . . 27clozapine odt tbdp 100mg . . . . . . . . . . 27clozapine odt tbdp 150mg . . . . . . . . . . 27clozapine odt tbdp 200mg . . . . . . . . . . 27clozapine tabs 25mg, 50mg . . . . . . . . 27clozapine tabs 100mg . . . . . . . . . . . . . . 27clozapine tabs 200mg . . . . . . . . . . . . . . 27COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 25colchicine caps . . . . . . . . . . . . . . . . . . . 21colchicine tabs . . . . . . . . . . . . . . . . . . . . 21colestipol hcl gran . . . . . . . . . . . . . . . . . 35colestipol hcl tabs . . . . . . . . . . . . . . . . . 35colistimethate sodium . . . . . . . . . . . . . . 14colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 45COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 47COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 46COMBIVENT RESPIMAT . . . . . . . . . . 48COMETRIQ KIT . . . . . . . . . . . . . . . . . . 24COMETRIQ KIT . . . . . . . . . . . . . . . . . . 24COMETRIQ KIT 20MG . . . . . . . . . . . . 24COMPLERA . . . . . . . . . . . . . . . . . . . . . . 27compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 25constulose . . . . . . . . . . . . . . . . . . . . . . . . 38COPAXONE INJ 20MG/ML . . . . . . . . . 36COPAXONE INJ 40MG/ML . . . . . . . . . 36COREG CR . . . . . . . . . . . . . . . . . . . . . . . 33cormax scalp application . . . . . . . . . . . 39cortisone acetate . . . . . . . . . . . . . . . . . . 39COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 22COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 24COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 31CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 37CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 35CRIXIVAN CAPS 200MG . . . . . . . . . . 28CRIXIVAN CAPS 400MG . . . . . . . . . . 28cromolyn sodium conc . . . . . . . . . . . . 38cromolyn sodium nebu . . . . . . . . . . . . 48cromolyn sodium ophthalmic soln . . . 47cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 41CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . 14

CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 50CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 50CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 50CLINIMIX E 5%/DEXTROSE 25% . . . 50CLINISOL SF 15% . . . . . . . . . . . . . . . . 50clobetasol propionate crea . . . . . . . . . 39clobetasol propionate e . . . . . . . . . . . . 39clobetasol propionate emollient . . . . . 39clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 39clobetasol propionate foam . . . . . . . . 39clobetasol propionate gel . . . . . . . . . . 39clobetasol propionate oint . . . . . . . . . 39clobetasol propionate sham . . . . . . . . 39clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 22CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . . 22clomipramine hcl . . . . . . . . . . . . . . . . . . 19clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg . . . . . 17clonazepam odt tbdp 2mg . . . . . . . . . . 17clonazepam tabs 0.5mg, 1mg . . . . . . 17clonazepam tabs 2mg . . . . . . . . . . . . . 17clonidine hcl er . . . . . . . . . . . . . . . . . . . . 36clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 32clonidine hcl ptwk 0.3mg/24hr . . . . . . 32clonidine hcl tabs . . . . . . . . . . . . . . . . . 32clopidogrel tabs 75mg . . . . . . . . . . . . . 32clopidogrel tabs 300mg . . . . . . . . . . . . 32clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 29clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 29clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 20clotrimazole external crea . . . . . . . . . 20clotrimazole external soln . . . . . . . . . . 20clotrimazole troc . . . . . . . . . . . . . . . . . . 20

ciprofloxacin er tb24 500mg; 0 . . . . . . 16ciprofloxacin er tb24 1000mg; 0 . . . . 16ciprofloxacin hcl . . . . . . . . . . . . . . . . . . . 16ciprofloxacin inj . . . . . . . . . . . . . . . . . . . 16ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 16ciprofloxacin susr . . . . . . . . . . . . . . . . . 16CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 16cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 22citalopram hydrobromide oral soln . . . 19citalopram hydrobromide tabs . . . . . 19cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 22claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 36clarithromycin er . . . . . . . . . . . . . . . . . . . 16clarithromycin susr . . . . . . . . . . . . . . . . 16clarithromycin tabs . . . . . . . . . . . . . . . . 16clindacin etz pledgets . . . . . . . . . . . . . . 14clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 14clindamycin . . . . . . . . . . . . . . . . . . . . . . . 14clindamycin hcl . . . . . . . . . . . . . . . . . . . . 14clindamycin phosphate crea . . . . . . . 14clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 14clindamycin phosphate gel . . . . . . . . 14clindamycin phosphate in d5w . . . . . . 14clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 14clindamycin phosphate lotn . . . . . . . . 14clindamycin phosphate pharmacy bulk package . . . . . . . . . . . . 14clindamycin phosphate swab . . . . . . 14clindamycin/sodium chloride . . . . . . . . 14CLINIMIX 2.75%/DEXTROSE 5% . . . 50CLINIMIX 4.25%/DEXTROSE 5% . . . 50CLINIMIX 4.25%/DEXTROSE 10% . . 50CLINIMIX 4.25%/DEXTROSE 20% . . 50CLINIMIX 4.25%/DEXTROSE 25% . . 50CLINIMIX 5%/DEXTROSE 15% . . . . 50CLINIMIX 5%/DEXTROSE 20% . . . . 50CLINIMIX 5%/DEXTROSE 25% . . . . 50

57


Covered Drugs Index

dextrose 2.5%/nacl 0.45% . . . . . . . . . 50DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 50dextrose5% / electrolyte #48 viaflex . . . . . . . . . . . . . . 50DEXTROSE 5%/ LACTATED RINGERS . . . . . . . . . . . . . 50dextrose 5%/nacl 0.2% . . . . . . . . . . . . 50DEXTROSE 5%/NACL 0.3% . . . . . . . 50dextrose 5%/nacl 0.9% . . . . . . . . . . . . 50dextrose 5%/nacl 0.33% . . . . . . . . . . . 50dextrose 5%/nacl 0.45% . . . . . . . . . . . 50dextrose 5%/nacl 0.225% . . . . . . . . . . 50DEXTROSE 10% . . . . . . . . . . . . . . . . . . 50dextrose 10%/nacl 0.2% . . . . . . . . . . . 50dextrose10%/nacl 0.45% . . . . . . . . . . . 50DEXTROSE 20% . . . . . . . . . . . . . . . . . . 50DEXTROSE 25% . . . . . . . . . . . . . . . . . . 50DEXTROSE 30% . . . . . . . . . . . . . . . . . . 50DEXTROSE 40% . . . . . . . . . . . . . . . . . . 50DEXTROSE 50% . . . . . . . . . . . . . . . . . . 50DEXTROSE 70% . . . . . . . . . . . . . . . . . . 50DIASTAT ACUDIAL GEL 10MG . . . . . 17DIASTAT ACUDIAL GEL 20MG . . . . . 17DIASTAT PEDIATRIC . . . . . . . . . . . . . . 17diazepam inj 5mg/ml . . . . . . . . . . . . . . . 29diazepam oral soln . . . . . . . . . . . . . . . . 29diazepam rectal gel gel 2.5mg . . . . . . 17diazepam rectal gel gel 10mg . . . . . . 17diazepam tabs . . . . . . . . . . . . . . . . . . . . 29diclofenac potassium . . . . . . . . . . . . . . 11diclofenac sodium dr . . . . . . . . . . . . . . . 11diclofenac sodium er . . . . . . . . . . . . . . . 11diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 47diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 37dicloxacillin sodium . . . . . . . . . . . . . . . . 15dicyclomine hcl caps . . . . . . . . . . . . . . 37dicyclomine hcl oral soln . . . . . . . . . . . 37dicyclomine hcl tabs . . . . . . . . . . . . . . . 37

delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41demeclocycline hcl . . . . . . . . . . . . . . . . 16DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 34DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 29DEPEN TITRATABS . . . . . . . . . . . . . . . 49DEPO-ESTRADIOL . . . . . . . . . . . . . . . 41DEPO-MEDROL INJ 20MG/ML . . . . . 39DEPO-PROVERA . . . . . . . . . . . . . . . . . 42DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 28desipramine hcl . . . . . . . . . . . . . . . . . . . 19desloratadine . . . . . . . . . . . . . . . . . . . . . . 48desloratadine odt . . . . . . . . . . . . . . . . . . 48desmopressin acetate inj . . . . . . . . . . 40desmopressin acetate nasal soln . . 40desmopressin acetate tabs . . . . . . . . 40desogestrel/ethinyl estradiol . . . . . . . . 41desonide lotn . . . . . . . . . . . . . . . . . . . . . 39desonide oint . . . . . . . . . . . . . . . . . . . . . 39desoximetasone . . . . . . . . . . . . . . . . . . . 39desvenlafaxine er . . . . . . . . . . . . . . . . . . 19dexamethasone . . . . . . . . . . . . . . . . . . . 39dexamethasone intensol . . . . . . . . . . . 39dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 39dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 47DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 38dexmethylphenidate hcl . . . . . . . . . . . . 36dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 22dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . . . . 36dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . . . . 36dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 36dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 36dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 36

CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 49curity gauze pads 2”x2” . . . . . . . . . . . . 37cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 41cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 41cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 49cyclophosphamide caps . . . . . . . . . . . 21cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 21cyclophosphamide inj 2gm . . . . . . . . . 21cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 21CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 29cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 44cyclosporine modified . . . . . . . . . . . . . . 44CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 24cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41CYSTADANE . . . . . . . . . . . . . . . . . . . . . 37CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 37CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 46cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 22cytarabine aqueous . . . . . . . . . . . . . . . . 22

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 21DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 48danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 40dantrolene sodium . . . . . . . . . . . . . . . . . 27dapsone . . . . . . . . . . . . . . . . . . . . . . . . . . 21DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 45daptomycin . . . . . . . . . . . . . . . . . . . . . . . 14DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 25darifenacin hydrobromide er . . . . . . . . 38DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 24dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 41dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 41daunorubicin hcl . . . . . . . . . . . . . . . . . . . 22daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 42decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 22DELESTROGEN INJ 10MG/ML . . . . 41

58


Covered Drugs Index

E.E.S. GRANULES . . . . . . . . . . . . . . . . 16EFFIENT . . . . . . . . . . . . . . . . . . . . . . . . . . 32ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 37ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 43ELIGARD INJ 22.5MG . . . . . . . . . . . . . 43ELIGARD INJ 30MG . . . . . . . . . . . . . . . 43ELIGARD INJ 45MG . . . . . . . . . . . . . . . 43elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 39EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EMEND CAPS 40MG . . . . . . . . . . . . . . 20EMEND CAPS 80MG . . . . . . . . . . . . . . 20EMEND CAPS 125MG . . . . . . . . . . . . . 20EMEND SUSR . . . . . . . . . . . . . . . . . . . . 20EMEND TRIPACK . . . . . . . . . . . . . . . . . 20emoquette . . . . . . . . . . . . . . . . . . . . . . . . 41EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 24EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 19EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 28EMTRIVA ORAL SOLN . . . . . . . . . . . . 28ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . 38enalapril maleate . . . . . . . . . . . . . . . . . . 32enalapril maleate/ hydrochlorothiazide tabs 5mg; 12.5mg . . . . . . . . . . . . . . . . . . . . . . 32enalapril maleate/ hydrochlorothiazide tabs 10mg; 25mg . . . . . . . . . . . . . . . . . . . . . . . 32ENBREL INJ 25MG/0.5ML . . . . . . . . . 44ENBREL INJ 25MG, 50MG/ML . . . . . 44ENBREL SURECLICK . . . . . . . . . . . . . 44endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 12endocet tabs 325mg; 7.5mg . . . . . . . . 12endocet tabs 325mg; 10mg . . . . . . . . 12ENGERIX-B INJ 10MCG/0.5ML . . . . 45ENGERIX-B INJ 20MCG/ML . . . . . . . 45enoxaparin sodium inj 30mg/0.3ml . . 31

donepezil hcl tbdp 5mg . . . . . . . . . . . . 18donepezil hcl tbdp 10mg . . . . . . . . . . . 18dorzolamide hcl . . . . . . . . . . . . . . . . . . . 47dorzolamide hcl/timolol maleate . . . . 47doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 39doxazosin mesylate tabs 1mg, 2mg . . . . . . . . . . . . . . . . . . . . . . . . . 39doxazosin mesylate tabs 8mg . . . . . . 39doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 19doxepin hydrochloride . . . . . . . . . . . . . 37doxercalciferol caps 0.5mcg . . . . . . . . 46doxercalciferol caps 1mcg . . . . . . . . . . 46doxercalciferol caps 2.5mcg . . . . . . . . 46doxercalciferol inj . . . . . . . . . . . . . . . . . 46doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 23doxorubicin hcl liposome . . . . . . . . . . . 23doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 16doxycycline hyclate caps . . . . . . . . . . 16doxycycline hyclate inj . . . . . . . . . . . . . 16doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 16doxycycline monohydrate caps 100mg, 50mg, 75mg . . . . . . . . . . 16doxycycline monohydrate tabs . . . . . 16doxycycline susr . . . . . . . . . . . . . . . . . . 16dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 20DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 22duloxetine hcl cpep 20mg, 60mg . . . 19duloxetine hcl cpep 30mg . . . . . . . . . . 19DURAMORPH . . . . . . . . . . . . . . . . . . . . 11DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 47dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 39dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 39

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 20ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 37EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 27e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 16

didanosine . . . . . . . . . . . . . . . . . . . . . . . . 28diflorasone diacetate . . . . . . . . . . . . . . . 39diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 11digitek tabs 0.25mg . . . . . . . . . . . . . . . . 34digitek tabs 0.125mg . . . . . . . . . . . . . . . 34digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 34digoxin tabs 125mcg . . . . . . . . . . . . . . . 34digoxin tabs 250mcg . . . . . . . . . . . . . . . 34digox tabs 125mcg . . . . . . . . . . . . . . . . 34digox tabs 250mcg . . . . . . . . . . . . . . . . 34dihydroergotamine mesylate inj . . . . 21DILANTIN CAPS 30MG . . . . . . . . . . . . 18diltiazem cd cp24 240mg . . . . . . . . . . . 34diltiazem hcl . . . . . . . . . . . . . . . . . . . . . . . 34diltiazem hcl cd . . . . . . . . . . . . . . . . . . . . 34diltiazem hcl er cp12 . . . . . . . . . . . . . . 34diltiazem hcl er cp24 120mg, 300mg, 360mg, 420mg . . . . . 34diltiazem hcl er cp24 180mg, 240mg . . . . . . . . . . . . . . . . . . . . 34diltiazem hcl er tb24 180mg, 240mg . . . . . . . . . . . . . . . . . . . . 34diltiazem hcl er tb24 300mg, 360mg, 420mg . . . . . . . . . . . . 34dilt-xr cp24 120mg . . . . . . . . . . . . . . . . . 34dilt-xr cp24 180mg, 240mg . . . . . . . . . 34diphenhydramine hcl inj . . . . . . . . . . . 48diphenoxylate/atropine . . . . . . . . . . . . . 38DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 45disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 13divalproex sodium . . . . . . . . . . . . . . . . . 17divalproex sodium dr . . . . . . . . . . . . . . . 17divalproex sodium er . . . . . . . . . . . . . . . 17docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 22docetaxel inj 200mg/10ml . . . . . . . . . . 22dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 33donepezil hcl tabs 10mg . . . . . . . . . . . 18donepezil hcl tabs 23mg, 5mg . . . . . . 18

59


Covered Drugs Index

famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 29famotidine inj . . . . . . . . . . . . . . . . . . . . . 38famotidine premixed . . . . . . . . . . . . . . . 38famotidine tabs 20mg, 40mg . . . . . . . 38FANAPT TABS 1MG, 2MG, 4MG . . . 26FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 26FANAPT TITRATION PACK . . . . . . . . 26FARESTON . . . . . . . . . . . . . . . . . . . . . . . 22FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 29FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 24FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 22felbamate . . . . . . . . . . . . . . . . . . . . . . . . . 18felodipine er . . . . . . . . . . . . . . . . . . . . . . . 34FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 41femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 41fenofibrate caps 43mg, 50mg . . . . . . . 35fenofibrate caps 130mg, 150mg . . . . 35fenofibrate micronized caps 67mg . . . 35fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 35fenofibrate tabs 48mg, 54mg . . . . . . . 35fenofibrate tabs 145mg, 160mg . . . . . 35fenofibric acid dr cpdr 45mg . . . . . . . . 35fenofibric acid dr cpdr 135mg . . . . . . . 35fenoprofen calcium caps 400mg . . . . 11fenoprofen calcium tabs . . . . . . . . . . . 11fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 11fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 12fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 12fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 12FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 46FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 19FETZIMA TITRATION PACK . . . . . . . 19finasteride tabs 5mg . . . . . . . . . . . . . . . 39FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 44FIRMAGON INJ 80MG . . . . . . . . . . . . . 43

erythromycin external soln . . . . . . . . . 16erythromycin gel . . . . . . . . . . . . . . . . . . 16erythromycin oint . . . . . . . . . . . . . . . . . 16erythromycin pads . . . . . . . . . . . . . . . . 16ESBRIET CAPS . . . . . . . . . . . . . . . . . . 49ESBRIET TABS 267MG . . . . . . . . . . . . 49ESBRIET TABS 801MG . . . . . . . . . . . . 49escitalopram oxalate oral soln . . . . . 19escitalopram oxalate tabs . . . . . . . . . 19esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 11esomeprazole magnesium . . . . . . . . . 38ESOMEPRAZOLE SODIUM . . . . . . . 38estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 41estradiol pttw . . . . . . . . . . . . . . . . . . . . . 41estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 41estradiol tabs 0.5mg, 1mg, 2mg . . . . 41estradiol tabs 10mcg . . . . . . . . . . . . . . . 41estradiol valerate . . . . . . . . . . . . . . . . . . 41ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 41ethacrynate sodium . . . . . . . . . . . . . . . . 34ethambutol hcl . . . . . . . . . . . . . . . . . . . . 21ethosuximide . . . . . . . . . . . . . . . . . . . . . . 17ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 41ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 23etidronate disodium . . . . . . . . . . . . . . . . 46etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 11etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 11etoposide inj . . . . . . . . . . . . . . . . . . . . . . 23EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 21EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 28exemestane . . . . . . . . . . . . . . . . . . . . . . . 23EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 49ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 35ezetimibe/simvastatin . . . . . . . . . . . . . . 35

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 37falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

enoxaparin sodium inj 40mg/0.4ml . . 31enoxaparin sodium inj 60mg/0.6ml . . 31enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . 31enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 31enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 41enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 41entacapone . . . . . . . . . . . . . . . . . . . . . . . 25entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 27ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 32enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ENVARSUS XR . . . . . . . . . . . . . . . . . . . 44EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 27epinastine hcl . . . . . . . . . . . . . . . . . . . . . 47epinephrine hcl inj 1mg/10ml, 1mg/ml . . . . . . . . . . . . . . . . . 48epinephrine inj 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . 48EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 48EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 48epirubicin hcl inj 200mg/100ml . . . . . 23epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EPIVIR HBV ORAL SOLN . . . . . . . . . 27EPZICOM . . . . . . . . . . . . . . . . . . . . . . . . . 28ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 24ergoloid mesylates . . . . . . . . . . . . . . . . . 18ergotamine tartrate/caffeine . . . . . . . . 21ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 24errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 23ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ERYPED 200 . . . . . . . . . . . . . . . . . . . . . 16ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 16ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 16ERYTHROCIN LACTOBIONATE . . . 16erythrocin stearate . . . . . . . . . . . . . . . . . 16erythromycin base . . . . . . . . . . . . . . . . . 16erythromycin/benzoyl peroxide . . . . . 37erythromycin ethylsuccinate . . . . . . . . 16

60


Covered Drugs Index

furosemide . . . . . . . . . . . . . . . . . . . . . . . . 34FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 23FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 28fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 41FYCOMPA SUSP . . . . . . . . . . . . . . . . . 17FYCOMPA TABS . . . . . . . . . . . . . . . . . 17

Ggabapentin caps 100mg . . . . . . . . . . . 17gabapentin caps 300mg, 400mg . . . . 17gabapentin oral soln . . . . . . . . . . . . . . 17gabapentin tabs 600mg . . . . . . . . . . . . 17gabapentin tabs 800mg . . . . . . . . . . . . 17GABITRIL TABS 12MG . . . . . . . . . . . . 17GABITRIL TABS 16MG . . . . . . . . . . . . 17galantamine hydrobromide er . . . . . . 18galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 18galantamine hydrobromide tabs . . . . 18GAMMAKED INJ 1GM/10ML . . . . . . . 44GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 44GAMUNEX-C INJ 1GM/10ML . . . . . . 44GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 44ganciclovir inj 500mg . . . . . . . . . . . . . . 27GARDASIL . . . . . . . . . . . . . . . . . . . . . . . . 45GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 45GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-n/flavor pack . . . . . . . . . . . . . . 38GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 24gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 22gemcitabine hcl inj 1gm . . . . . . . . . . . . 22gemcitabine hcl inj 200mg, 2gm . . . . 22gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 35generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 38

fluoxetine hcl tabs 10mg . . . . . . . . . . . 19fluoxetine hcl tabs 20mg . . . . . . . . . . . 19fluphenazine decanoate . . . . . . . . . . . . 25fluphenazine hcl . . . . . . . . . . . . . . . . . . . 25flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 11flurbiprofen sodium . . . . . . . . . . . . . . . . 47flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 22fluticasone propionate crea . . . . . . . . 39fluticasone propionate oint . . . . . . . . . 39fluticasone propionate susp . . . . . . . . 48fluvoxamine maleate er . . . . . . . . . . . . 19fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 19fluvoxamine maleate tabs 100mg . . . 19FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 22fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 46fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 31fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 31fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 31fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 31FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 46fosamprenavir calcium . . . . . . . . . . . . . 28FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . 27fosinopril sodium . . . . . . . . . . . . . . . . . . 32fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 32fosphenytoin sodium . . . . . . . . . . . . . . . 18FREAMINE HBC 6.9% . . . . . . . . . . . . . 50FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 50

FIRMAGON INJ 120MG . . . . . . . . . . . 43flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 38flecainide acetate . . . . . . . . . . . . . . . . . . 33FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 48FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 48FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 48FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 48FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 48fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 20fluconazole in dextrose inj 56mg/ml; 400mg/200ml . . . . . . . . . . . . 20fluconazole in nacl . . . . . . . . . . . . . . . . . 20flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 20fludarabine phosphate . . . . . . . . . . . . . 23fludrocortisone acetate . . . . . . . . . . . . . 39flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 48fluocinolone acetonide . . . . . . . . . . . . . 39fluocinolone acetonide . . . . . . . . . . . . . 47fluocinolone acetonide body . . . . . . . . 39fluocinolone acetonide ear drops . . . 47fluocinolone acetonide scalp . . . . . . . 39fluocinonide . . . . . . . . . . . . . . . . . . . . . . . 39fluocinonide emulsified base . . . . . . . 39fluoride chew 0.25mg . . . . . . . . . . . . . . 50fluoritab chew 0.5mg, 1mg . . . . . . . . . 50fluorometholone . . . . . . . . . . . . . . . . . . . 47fluorouracil crea . . . . . . . . . . . . . . . . . . . 37fluorouracil external soln . . . . . . . . . . . 37fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 22fluoxetine caps 10mg . . . . . . . . . . . . . . 19fluoxetine caps 20mg . . . . . . . . . . . . . . 19fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 19fluoxetine hcl caps 10mg . . . . . . . . . . . 19fluoxetine hcl caps 20mg . . . . . . . . . . . 19fluoxetine hcl caps 40mg . . . . . . . . . . . 19fluoxetine hcl oral soln . . . . . . . . . . . . . 19

61


Covered Drugs Index

HUMIRA PEN-CROHNS DISEASE STARTER . . . . . . . . . . . . . . . 44HUMIRA PEN-PSORIASIS STARTER . . . . . . . . . . . . . . . . . . . . . . . . . 44humulin 70/30 . . . . . . . . . . . . . . . . . . . . . 30humulin 70/30 kwikpen . . . . . . . . . . . . . 30humulin n . . . . . . . . . . . . . . . . . . . . . . . . . 30humulin n kwikpen . . . . . . . . . . . . . . . . . 30humulin r . . . . . . . . . . . . . . . . . . . . . . . . . . 30humulin r u-500 (concentrated) . . . . . 30HUMULIN R U-500 KWIKPEN. . . . . . 30hydralazine hcl . . . . . . . . . . . . . . . . . . . . 35hydrochlorothiazide . . . . . . . . . . . . . . . . 34hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . 12hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . 12hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . 12hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg . . . . . . . . 12hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . 12hydrocodone/ibuprofen . . . . . . . . . . . . 12hydrocortisone/acetic acid . . . . . . . . . . 47hydrocortisone butyrate . . . . . . . . . . . . 39hydrocortisone butyrate (lipid) . . . . . . 40hydrocortisone butyrate (lipophilic) . . . 40hydrocortisone enem . . . . . . . . . . . . . . 45hydrocortisone external crea . . . . . . . 40hydrocortisone lotn 2.5% . . . . . . . . . . . 40hydrocortisone oint 1%, 2.5% . . . . . . 40hydrocortisone rectal crea . . . . . . . . . 40hydrocortisone tabs . . . . . . . . . . . . . . . 40hydrocortisone valerate . . . . . . . . . . . . 40hydromorphone hcl dosette . . . . . . . . 12hydromorphone hcl inj . . . . . . . . . . . . . 12hydromorphone hcl liqd . . . . . . . . . . . 12hydromorphone hcl tabs 2mg, 4mg . . . . . . . . . . . . . . . . . . . . . . . . . 12

griseofulvin microsize . . . . . . . . . . . . . . 20griseofulvin ultramicrosize . . . . . . . . . . 20GUANIDINE HCL . . . . . . . . . . . . . . . . . . 21

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 23halobetasol propionate . . . . . . . . . . . . . 39haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 26haloperidol decanoate . . . . . . . . . . . . . 26haloperidol lactate . . . . . . . . . . . . . . . . . 26HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 27HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 42heparin sodium/d5w . . . . . . . . . . . . . . . 31heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 31heparin sodium/nacl 0.9% . . . . . . . . . . 31heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% . . . . . . . . . . . . . . . . . . 31heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 31heparin sodium/ sodium chloride 0.9% premix . . . . . . . 31HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 50HERCEPTIN . . . . . . . . . . . . . . . . . . . . . . 24HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 36HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 21HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 45HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 30HUMALOG KWIKPEN . . . . . . . . . . . . . 30humalog mix 50/50 . . . . . . . . . . . . . . . . 30humalog mix 50/50 kwikpen . . . . . . . . 30humalog mix 75/25 . . . . . . . . . . . . . . . . 30humalog mix 75/25 kwikpen . . . . . . . . 30HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML . . . . . . . . 44HUMIRA INJ 40MG/0.8ML . . . . . . . . . 44HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK . . . . . . . . 44HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 44

gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 44gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 13gentamicin sulfate crea . . . . . . . . . . . . 13GENTAMICIN SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 13gentamicin sulfate inj 10mg/ml, 40mg/ml . . . . . . . . . . . . . . . . . 13gentamicin sulfate oint . . . . . . . . . . . . 13gentamicin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . 13gentamicin sulfate pediatric . . . . . . . . 13GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 27GEODON INJ . . . . . . . . . . . . . . . . . . . . 26gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . . 41GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 36GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 24GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 21glimepiride . . . . . . . . . . . . . . . . . . . . . . . . 29glipizide er tb24 2.5mg, 5mg . . . . . . . 29glipizide er tb24 10mg . . . . . . . . . . . . . 29glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 30glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 30glipizide tabs 5mg . . . . . . . . . . . . . . . . . 29glipizide tabs 10mg . . . . . . . . . . . . . . . . 29glipizide xl tb24 2.5mg, 5mg . . . . . . . . 30glipizide xl tb24 10mg . . . . . . . . . . . . . . 30GLUCAGEN HYPOKIT . . . . . . . . . . . . 30GLUCAGON EMERGENCY KIT . . . . 30glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 37glycopyrrolate tabs . . . . . . . . . . . . . . . . 37glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 30granisetron hcl inj 0.1mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 20granisetron hcl inj 4mg/4ml . . . . . . . . . 20granisetron hcl tabs . . . . . . . . . . . . . . . 20

62


Covered Drugs Index

irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 23irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 23ISENTRESS CHEW 25MG . . . . . . . . . 27ISENTRESS CHEW 100MG . . . . . . . 27ISENTRESS HD . . . . . . . . . . . . . . . . . . . 27ISENTRESS PACK . . . . . . . . . . . . . . . 27ISENTRESS TABS . . . . . . . . . . . . . . . . 27isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 41isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . . 21isosorbide dinitrate er . . . . . . . . . . . . . . 35isosorbide dinitrate tabs . . . . . . . . . . . 35isosorbide mononitrate . . . . . . . . . . . . . 35isosorbide mononitrate er . . . . . . . . . . 35isotonic gentamicin . . . . . . . . . . . . . . . . 13isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 34ISTODAX (OVERFILL) . . . . . . . . . . . . . 23itraconazole . . . . . . . . . . . . . . . . . . . . . . . 20ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 25IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . . 23IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 49JADENU SPRINKLE . . . . . . . . . . . . . . . 49JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 24jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 31JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 30JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 30JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 30JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 30JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 30jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 42JENTADUETO . . . . . . . . . . . . . . . . . . . . 30JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . 30JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . 30jevantique lo . . . . . . . . . . . . . . . . . . . . . . 41

INTELENCE TABS 25MG . . . . . . . . . . 28INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 28INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 46INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 27INTRON A INJ 6000000UNIT/ML . . . 27INTRON A W/DILUENT . . . . . . . . . . . . 27introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 41INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 15INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 26INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 26INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 26INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 26INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 26INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 26INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 26INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 26INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 26INVIRASE CAPS . . . . . . . . . . . . . . . . . 28INVIRASE TABS . . . . . . . . . . . . . . . . . . 28INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 30INVOKAMET XR . . . . . . . . . . . . . . . . . . 30INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 30IPOL INACTIVATED IPV . . . . . . . . . . . 45ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 48ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 48ipratropium bromide nasal soln . . . . . 48irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 32irbesartan/hydrochlorothiazide . . . . . . 32IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

hydromorphone hcl tabs 8mg . . . . . . . 12hydroxychloroquine sulfate . . . . . . . . . 25hydroxyprogesterone caproate . . . . . 42hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 22hyoscyamine sulfate elix . . . . . . . . . . . 37hyoscyamine sulfate odt . . . . . . . . . . . 37hyoscyamine sulfate subl . . . . . . . . . . 37hyoscyamine sulfate tabs . . . . . . . . . . 37hyoscyamine sulfate tbdp . . . . . . . . . . 38

Iibandronate sodium tabs . . . . . . . . . . 46IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 24ibudone tabs 5mg; 200mg . . . . . . . . . . 12ibuprofen susp . . . . . . . . . . . . . . . . . . . . 11ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 11ICLUSIG TABS 15MG . . . . . . . . . . . . . 24ICLUSIG TABS 45MG . . . . . . . . . . . . . 24idarubicin hcl inj 10mg/10ml . . . . . . . . 23IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . 21ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 47imatinib mesylate . . . . . . . . . . . . . . . . . . 24IMBRUVICA . . . . . . . . . . . . . . . . . . . . . . . 24IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 24imipenem/cilastatin . . . . . . . . . . . . . . . . 15imipramine hcl . . . . . . . . . . . . . . . . . . . . . 19imipramine pamoate . . . . . . . . . . . . . . . 19imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 37IMOVAX RABIES (H.D.C.V.) . . . . . . . 45INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 40INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 48indapamide . . . . . . . . . . . . . . . . . . . . . . . 35INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 45INFUMORPH 200 . . . . . . . . . . . . . . . . . 11INFUMORPH 500 . . . . . . . . . . . . . . . . . 11INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

63


Covered Drugs Index

larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 23latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 46LATUDA TABS 80MG . . . . . . . . . . . . . . 26LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 26leflunomide . . . . . . . . . . . . . . . . . . . . . . . 44LENVIMA 8 MG DAILY DOSE . . . . . . 24LENVIMA 10 MG DAILY DOSE . . . . . 24LENVIMA 14 MG DAILY DOSE . . . . . 24LENVIMA 18 MG DAILY DOSE . . . . . 24LENVIMA 20 MG DAILY DOSE . . . . . 24LENVIMA 24 MG DAILY DOSE . . . . . 24lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 48letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 23leucovorin calcium inj 100mg, 350mg, 500mg, 50mg . . . . . . 23leucovorin calcium tabs . . . . . . . . . . . 23LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 22LEUKINE INJ 250MCG . . . . . . . . . . . . 31leuprolide acetate . . . . . . . . . . . . . . . . . 43levemir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30levemir flextouch . . . . . . . . . . . . . . . . . . 30levetiracetam . . . . . . . . . . . . . . . . . . . . . . 17levetiracetam er tb24 500mg . . . . . . . 17levetiracetam er tb24 750mg . . . . . . . 17levobunolol hcl . . . . . . . . . . . . . . . . . . . . 47levocarnitine . . . . . . . . . . . . . . . . . . . . . . 46levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 48levocetirizine dihydrochloride tabs . . . 48levofloxacin in d5w . . . . . . . . . . . . . . . . 16levofloxacin inj . . . . . . . . . . . . . . . . . . . . 16levofloxacin oral soln . . . . . . . . . . . . . . 16levofloxacin tabs . . . . . . . . . . . . . . . . . . 16levoleucovorin calcium . . . . . . . . . . . . . 23levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . 23levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 41

KISQALI FEMARA 400 DOSE . . . . . . 22KISQALI FEMARA 600 DOSE . . . . . . 22klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 50klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 50klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 50klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 50klor-con sprinkle . . . . . . . . . . . . . . . . . . . 50KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 46kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41KUVAN PACK 100MG . . . . . . . . . . . . . 37KUVAN PACK 500MG . . . . . . . . . . . . . 37KUVAN TBSO . . . . . . . . . . . . . . . . . . . . 37KYNAMRO . . . . . . . . . . . . . . . . . . . . . . . . 35KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 23

Llabetalol hcl . . . . . . . . . . . . . . . . . . . . . . . 33LACRISERT . . . . . . . . . . . . . . . . . . . . . . 46LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 50LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 46LACTATED RINGERS VIAFLEX . . . . 50lactulose . . . . . . . . . . . . . . . . . . . . . . . . . . 38lamivudine oral soln . . . . . . . . . . . . . . . 28lamivudine tabs 100mg . . . . . . . . . . . . 27lamivudine tabs 150mg . . . . . . . . . . . . 28lamivudine tabs 300mg . . . . . . . . . . . . 28lamivudine/zidovudine . . . . . . . . . . . . . 28lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 18lamotrigine er . . . . . . . . . . . . . . . . . . . . . 18lamotrigine odt . . . . . . . . . . . . . . . . . . . . 18LANOXIN PEDIATRIC . . . . . . . . . . . . . 34lantus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30lantus solostar . . . . . . . . . . . . . . . . . . . . . 30larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 41larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 41larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 41larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 41

JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 23jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 42juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 41junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 41junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 41junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 41

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 50KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 24KALETRA ORAL SOLN . . . . . . . . . . . 28KALETRA TABS 100MG; 25MG . . . . 28KALETRA TABS 200MG; 50MG . . . . 28KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 48kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . . 50kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 50kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . . . 50kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 50kcl 0.15%/d5w/nacl 0.45% . . . . . . . . . 50kcl 0.15%/d5w/nacl 0.225% . . . . . . . . 50kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 50kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 41ketoconazole crea . . . . . . . . . . . . . . . . 20ketoconazole sham . . . . . . . . . . . . . . . 20ketoconazole tabs . . . . . . . . . . . . . . . . . 20ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . 11ketoprofen er . . . . . . . . . . . . . . . . . . . . . . 11ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 47KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 24kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 41KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 44KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 23KISQALI FEMARA 200 DOSE . . . . . . 21

64


Covered Drugs Index

LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 43lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42LYNPARZA CAPS . . . . . . . . . . . . . . . . 24LYNPARZA TABS . . . . . . . . . . . . . . . . . 23LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . . . . . . . . . 17LYRICA CAPS 225MG, 300MG . . . . . 17LYRICA ORAL SOLN . . . . . . . . . . . . . . 17LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 43lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Mmagnesium sulfate in d5w inj 5%; 1gm/100ml . . . . . . . . . . . . . . . . . . . . 17magnesium sulfate inj . . . . . . . . . . . . . 50MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 42malathion . . . . . . . . . . . . . . . . . . . . . . . . . 25maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 18marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 42MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 19MATULANE . . . . . . . . . . . . . . . . . . . . . . . 22matzim la tb24 180mg, 240mg . . . . . 34matzim la tb24 300mg, 360mg, 420mg . . . . . . . . . . . . 34meclizine hcl tabs . . . . . . . . . . . . . . . . . 19meclofenamate sodium . . . . . . . . . . . . 11MEDROL TABS 2MG . . . . . . . . . . . . . . 40medroxyprogesterone acetate inj . . . 42medroxyprogesterone acetate tabs . . . . . . . . . . . . . . . . . . . . . . 42mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 25megestrol acetate susp 40mg/ml . . . 42megestrol acetate tabs . . . . . . . . . . . . 42MEKINIST TABS 0.5MG . . . . . . . . . . . 24MEKINIST TABS 2MG . . . . . . . . . . . . . 24meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 11melphalan hydrochloride . . . . . . . . . . . 22memantine hcl tabs 5mg . . . . . . . . . . . 18memantine hcl tabs 10mg . . . . . . . . . . 18

lithium carbonate er . . . . . . . . . . . . . . . . 29LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 35LONSURF TABS 6.14MG; 15MG . . . 22LONSURF TABS 8.19MG; 20MG . . . 22loperamide hcl caps . . . . . . . . . . . . . . . 38lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 28lorazepam conc . . . . . . . . . . . . . . . . . . . 29lorazepam inj 2mg/ml, 4mg/ml . . . . . . 29lorazepam intensol . . . . . . . . . . . . . . . . 29lorazepam tabs 0.5mg, 1mg . . . . . . . . 29lorazepam tabs 2mg . . . . . . . . . . . . . . . 29lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 12lorcet plus tabs 325mg; 7.5mg . . . . . . 12losartan potassium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 32losartan potassium tabs 50mg . . . . . . 32losartan potassium tabs 100mg, 25mg . . . . . . . . . . . . . . . . . . . . . 32LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 47lovastatin tabs 10mg, 20mg . . . . . . . . 35lovastatin tabs 40mg . . . . . . . . . . . . . . . 35low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 42loxapine caps 10mg, 5mg . . . . . . . . . . 26loxapine caps 25mg, 50mg . . . . . . . . . 26loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 26loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 26ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 46LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 37LUPRON DEPOT (1-MONTH) . . . . . . 43LUPRON DEPOT (3-MONTH) INJ 11.25MG . . . . . . . . . . . . . . . . . . . . . . 43LUPRON DEPOT (3-MONTH) INJ 22.5MG . . . . . . . . . . . . . . . . . . . . . . . 43LUPRON DEPOT (4-MONTH) . . . . . . 43LUPRON DEPOT (6-MONTH) . . . . . . 43LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 43

levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 41levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 41levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 41levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 41levorphanol tartrate . . . . . . . . . . . . . . . . 11levothyroxine sodium tabs . . . . . . . . . 43LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . 43LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 28LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 28lidocaine hcl external soln . . . . . . . . . 13lidocaine hcl gel . . . . . . . . . . . . . . . . . . . 13lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 13lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 33lidocaine hcl jelly . . . . . . . . . . . . . . . . . . 13lidocaine hcl mouth/throat soln . . . . . 13lidocaine hcl viscous . . . . . . . . . . . . . . . 13lidocaine oint . . . . . . . . . . . . . . . . . . . . . 13lidocaine/prilocaine crea . . . . . . . . . . . 13lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 13lidocaine viscous . . . . . . . . . . . . . . . . . . 13lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 14lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 14linezolid susr . . . . . . . . . . . . . . . . . . . . . 14linezolid tabs . . . . . . . . . . . . . . . . . . . . . 14LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 38liothyronine sodium . . . . . . . . . . . . . . . . 43LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 46LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 51lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 32lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . 32lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . 33lisinopril/hydrochlorothiazide tabs 25mg; 20mg . . . . . . . . . . . . . . . . . . 32lithium carbonate . . . . . . . . . . . . . . . . . . 29

65


Covered Drugs Index

MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 21mitomycin inj 20mg, 5mg . . . . . . . . . . . 23mitomycin inj 40mg . . . . . . . . . . . . . . . . 23MITOXANTRONE HCL INJ 2MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 23mitoxantrone hcl inj 2mg/ml . . . . . . . . 23M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 45MODAFINIL TABS 100MG . . . . . . . . . 49modafinil tabs 200mg . . . . . . . . . . . . . . 49moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 33moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . 33moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . 33mometasone furoate crea . . . . . . . . . 40mometasone furoate external soln . . . 40mometasone furoate oint . . . . . . . . . . 40mometasone furoate susp . . . . . . . . . 48mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 17mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 42montelukast sodium . . . . . . . . . . . . . . . 48morgidox 1x50mg . . . . . . . . . . . . . . . . . 17morgidox 1x100mg caps . . . . . . . . . . 17morgidox 2x100mg caps . . . . . . . . . . 17morphine sulfate er tbcr . . . . . . . . . . . 11morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 11morphine sulfate inj 1mg/ml . . . . . . . . 12MORPHINE SULFATE INJ 2MG/ML, 4MG/ML . . . . . . . . . . . . . . . . . 12morphine sulfate inj 5mg/ml . . . . . . . . 12MORPHINE SULFATE INJ 8MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 12morphine sulfate inj 8mg/ml . . . . . . . . 12MORPHINE SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 12morphine sulfate inj 10mg/ml . . . . . . . 12MORPHINE SULFATE INJ 150MG/30ML, 15MG/ML, 50MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 12morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 12

methylphenidate hcl er tbcr 20mg . . . 36methylphenidate hcl er tbcr 36mg . . . 36methylphenidate hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 36methylphenidate hcl tabs 20mg . . . . . 36methylprednisolone . . . . . . . . . . . . . . . . 40methylprednisolone acetate . . . . . . . . 40methylprednisolone dose pack . . . . . 40methylprednisolone sodiumsuccinate . . . . . . . . . . . . . . . . . . 40metipranolol . . . . . . . . . . . . . . . . . . . . . . . 47metoclopramide hcl . . . . . . . . . . . . . . . . 38metolazone . . . . . . . . . . . . . . . . . . . . . . . 35metoprolol/hydrochlorothiazide . . . . . 33metoprolol succinate er . . . . . . . . . . . . 33metoprolol tartrate . . . . . . . . . . . . . . . . . 33metronidazole crea . . . . . . . . . . . . . . . . 14metronidazole gel . . . . . . . . . . . . . . . . . 14metronidazole inj . . . . . . . . . . . . . . . . . . 14metronidazole in nacl 0.79% . . . . . . . 14metronidazole lotn . . . . . . . . . . . . . . . . 14metronidazole tabs . . . . . . . . . . . . . . . . 14metronidazole vaginal . . . . . . . . . . . . . . 14mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 33MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 46microgestin 1.5/30 . . . . . . . . . . . . . . . . . 42microgestin 1/20 . . . . . . . . . . . . . . . . . . . 42microgestin fe . . . . . . . . . . . . . . . . . . . . . 42microgestin fe 1.5/30 . . . . . . . . . . . . . . 42midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 32migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 21miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 35MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 42minocycline hcl . . . . . . . . . . . . . . . . . . . . 17minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 35mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 18mirtazapine odt . . . . . . . . . . . . . . . . . . . . 18misoprostol tabs 100mcg . . . . . . . . . . . 38MISOPROSTOL TABS 200MCG . . . . 38

memantine hcl titration pak . . . . . . . . . 18memantine hydrochloride . . . . . . . . . . 18MENACTRA . . . . . . . . . . . . . . . . . . . . . . 45MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 42MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 42MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 45mercaptopurine . . . . . . . . . . . . . . . . . . . . 22meropenem . . . . . . . . . . . . . . . . . . . . . . . 15meropenem/sodium chloride . . . . . . . 15mesalamine kit . . . . . . . . . . . . . . . . . . . . 45mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23MESNEX TABS . . . . . . . . . . . . . . . . . . . 23metadate er . . . . . . . . . . . . . . . . . . . . . . . 36metaproterenol sulfate . . . . . . . . . . . . . 48Metformin hcl er tb24 500mg, 1000mg (generic for Fortamet) . . . . . 30Metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 30Metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 30metformin hcl tabs 500mg . . . . . . . . . . 30metformin hcl tabs 850mg . . . . . . . . . . 30metformin hcl tabs 1000mg . . . . . . . . 30methadone hcl conc . . . . . . . . . . . . . . . 11methadone hcl inj . . . . . . . . . . . . . . . . . 11methadone hcl intensol . . . . . . . . . . . . 11methadone hcl oral soln 5mg/5ml . . . 11methadone hcl oral soln 10mg/5ml . . 11methadone hcl tabs 5mg . . . . . . . . . . . 11methadone hcl tabs 10mg . . . . . . . . . . 11methazolamide . . . . . . . . . . . . . . . . . . . . 47methenamine hippurate . . . . . . . . . . . . 14methimazole . . . . . . . . . . . . . . . . . . . . . . 44methotrexate . . . . . . . . . . . . . . . . . . . . . . 44methotrexate sodium . . . . . . . . . . . . . . 44methoxsalen . . . . . . . . . . . . . . . . . . . . . . 37methscopolamine bromide . . . . . . . . . 38methylphenidate hcl er tbcr 10mg, 27mg, 54mg . . . . . . . . . . . . . . . . 36methylphenidate hcl er tbcr 18mg . . . 36

66


Covered Drugs Index

NEUPOGEN INJ 300MCG/ML. . . . . . 32NEUPOGEN INJ 480MCG/0.8ML. . . 31NEUPOGEN INJ 480MCG/1.6ML. . . 32NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 25nevirapine er tb24 100mg . . . . . . . . . . 28nevirapine er tb24 400mg . . . . . . . . . . 28nevirapine susp . . . . . . . . . . . . . . . . . . . 28nevirapine tabs . . . . . . . . . . . . . . . . . . . 28NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 24niacin er tbcr 500mg . . . . . . . . . . . . . . . 35niacin er tbcr 1000mg, 750mg . . . . . . 35niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 34NICOTROL INHALER. . . . . . . . . . . . . . 13NICOTROL NS . . . . . . . . . . . . . . . . . . . . 13nifedipine er tb24 30mg, 90mg . . . . . 34nifedipine er tb24 60mg . . . . . . . . . . . . 34NILANDRON . . . . . . . . . . . . . . . . . . . . . . 22nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 22nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 34NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 23NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 22nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg . . . . . . . 34nisoldipine er tb24 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 34nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 14nitrofurantoin macrocrystals . . . . . . . . 14nitrofurantoin monohydrate . . . . . . . . . 14nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 14nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . 35nitroglycerin lingual translingual soln . . . . . . . . . . . . . . . . . . 35nitroglycerin transdermal . . . . . . . . . . . 35NITROSTAT . . . . . . . . . . . . . . . . . . . . . . . 35nizatidine caps . . . . . . . . . . . . . . . . . . . . 38nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 42norethindrone . . . . . . . . . . . . . . . . . . . . . 43norethindrone acetate . . . . . . . . . . . . . . 43

naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 13naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 13NAMENDA XR . . . . . . . . . . . . . . . . . . . . 18NAMENDA XR TITRATION PACK . . . 18NAMZARIC C4PK . . . . . . . . . . . . . . . . 18NAMZARIC CP24 . . . . . . . . . . . . . . . . . 18naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . 11naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 11naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 11naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 21narcan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13NASONEX . . . . . . . . . . . . . . . . . . . . . . . . 48NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 20nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 30NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 46NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 25necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 42necon 1/50-28 . . . . . . . . . . . . . . . . . . . . . 42necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 42nefazodone hcl . . . . . . . . . . . . . . . . . . . . 18neomycin/bacitracin/polymyxin . . . . . 14neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 14neomycin/polymyxin b sulfates . . . . . 13neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 47neomycin/polymyxin/gramicidin . . . . . 14neomycin/polymyxin/hc . . . . . . . . . . . . 47neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 14neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 47neomycin sulfate . . . . . . . . . . . . . . . . . . 13neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 14neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 14NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 50NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 23NEULASTA . . . . . . . . . . . . . . . . . . . . . . . 31NEULASTA ONPRO KIT . . . . . . . . . . . 31NEUPOGEN INJ 300MCG/0.5ML . . . 31

morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 12morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 12MORPHINE SULFATE TABS . . . . . . . 12MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 38moxifloxacin hcl inj . . . . . . . . . . . . . . . . 16moxifloxacin hcl ophthalmic soln . . . . 16moxifloxacin hcl tabs . . . . . . . . . . . . . . 16MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 31MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 33multivitamin with fluoride chew . . . . . 51mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 14MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 22mycophenolate mofetil caps . . . . . . . . 44mycophenolate mofetil inj . . . . . . . . . . 44mycophenolate mofetil susr . . . . . . . . 44mycophenolate mofetil tabs . . . . . . . . 44mycophenolic acid dr . . . . . . . . . . . . . . 44MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 24myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 37MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 38myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 11nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33nadolol/bendroflumethiazide tabs 5mg; 40mg . . . . . . . . . . . . . . . . . . . 33nadolol/bendroflumethiazide tabs 5mg; 80mg . . . . . . . . . . . . . . . . . . . 33nafcillin sodium inj 2gm . . . . . . . . . . . . 15nafcillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 15naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 20naftifine hydrochloride . . . . . . . . . . . . . 20NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 20NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 37nalbuphine hcl inj 10mg/ml . . . . . . . . . 12nalbuphine hcl inj 20mg/ml . . . . . . . . . 12

67


Covered Drugs Index

oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 38oseltamivir phosphate caps 30mg . . 29oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 29OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 38oxacillin sodium inj 10gm . . . . . . . . . . . 15oxaliplatin inj 100mg . . . . . . . . . . . . . . . 23oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 23oxandrolone tabs 2.5mg . . . . . . . . . . . 40oxandrolone tabs 10mg . . . . . . . . . . . . 40oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 11oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 29oxcarbazepine . . . . . . . . . . . . . . . . . . . . 18oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 38oxybutynin chloride er tb24 15mg . . . 38oxybutynin chloride syrp . . . . . . . . . . . 38oxybutynin chloride tabs . . . . . . . . . . . 38oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 12oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 12oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 12oxycodone/aspirin . . . . . . . . . . . . . . . . . 12oxycodone hcl caps . . . . . . . . . . . . . . . 12oxycodone hcl conc . . . . . . . . . . . . . . . 12oxycodone hcl oral soln . . . . . . . . . . . 12oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . 12oxycodone hcl tabs 30mg . . . . . . . . . . 12oxycodone/ibuprofen . . . . . . . . . . . . . . 12

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 33paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 23paliperidone er tb24 1.5mg, 3mg . . . 26paliperidone er tb24 6mg . . . . . . . . . . . 26paliperidone er tb24 9mg . . . . . . . . . . . 26pamidronate disodium . . . . . . . . . . . . . 46

nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 20nystatin/triamcinolone . . . . . . . . . . . . . . 20nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ooctreotide acetate inj 500mcg/ml . . . 43octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 43ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 28ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 23OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 16ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 42olanzapine . . . . . . . . . . . . . . . . . . . . . . . . 26olanzapine . . . . . . . . . . . . . . . . . . . . . . . . 26olanzapine/fluoxetine . . . . . . . . . . . . . . 19olanzapine odt . . . . . . . . . . . . . . . . . . . . 26olmesartan medoxomil . . . . . . . . . . . . . 32olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 32olopatadine hcl ophthalmic soln . . . . 47omega-3-acid ethyl esters . . . . . . . . . . 35omeprazole cpdr . . . . . . . . . . . . . . . . . . 38ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 20ondansetron hcl oral soln . . . . . . . . . . 20ondansetron hcl tabs 4mg, 8mg . . . . 20ondansetron hcl tabs 24mg . . . . . . . . 20ondansetron odt . . . . . . . . . . . . . . . . . . . 20ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 17ONFI TABS 10MG . . . . . . . . . . . . . . . . . 17ONFI TABS 20MG . . . . . . . . . . . . . . . . . 17OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 24OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 48oralone dental paste . . . . . . . . . . . . . . . 36ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 37ORKAMBI . . . . . . . . . . . . . . . . . . . . . . . . . 48orphenadrine citrate er . . . . . . . . . . . . . 49orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 42norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 42norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 42norgestimate/ethinyl estradiol . . . . . . 42norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 43NORMOSOL-M IN D5W . . . . . . . . . . . 51NORMOSOL -R . . . . . . . . . . . . . . . . . . . 51NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 51NORMOSOL-R IN D5W. . . . . . . . . . . . 51NORTHERA CAPS 100MG . . . . . . . . 34NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 34nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 42nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 42nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 42nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 19NORVIR CAPS . . . . . . . . . . . . . . . . . . . 28NORVIR ORAL SOLN . . . . . . . . . . . . . 28NORVIR TABS . . . . . . . . . . . . . . . . . . . . 28NOVAREL . . . . . . . . . . . . . . . . . . . . . . . . 40novofine 30gx8mm . . . . . . . . . . . . . . . . 46novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 46novofine 32gx6mm . . . . . . . . . . . . . . . . 46novofine autocover 30gx8mm . . . . . . 46novotwist 32gx5mm . . . . . . . . . . . . . . . 46NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 20NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 20NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 36nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 44NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 26NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 46NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ . . . . . . . . . . . 51NUVIGIL . . . . . . . . . . . . . . . . . . . . . . . . . . 49nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

68


Covered Drugs Index

polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14polyethylene glycol 3350 powd . . . . . 38polymyxin b sulfate . . . . . . . . . . . . . . . . 14polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 14POMALYST . . . . . . . . . . . . . . . . . . . . . . . 22portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 42PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 23potassium chloride 0.15% d5w/ nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . . 51potassium chloride 0.15% d5w/ nacl 0.45%viaflex . . . . . . . . . . . . . . . . . . 51potassium chloride 0.22% d5w/ nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . . 51potassium chloride cr . . . . . . . . . . . . . . 51potassium chloride/dextrose inj 5%; 20meq/l . . . . . . . . . . . . . . . . . . . . . . . 51POTASSIUM CHLORIDE/ DEXTROSE INJ 5%; 40MEQ/L . . . . . 51POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS . . 51potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 51potassium chloride er . . . . . . . . . . . . . . 51potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 51potassium chloride oral soln . . . . . . . . 51potassium chloride / sodium chloride . . . . . . . . . . . . . . . . . . . 51potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9% . . . . . . . . . . . . . 51POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 40MEQ/L; 0.9% . . . . 51POTASSIUM CHLORIDE SR TBCR 8MEQ . . . . . . . . . . . . . . . . . . 51potassium chloride sr tbcr 8meq . . . . 51potassium citrate er . . . . . . . . . . . . . . . . 51PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 31pramipexole dihydrochloride . . . . . . . . 25pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 25

perphenazine . . . . . . . . . . . . . . . . . . . . . 26perphenazine/amitriptyline . . . . . . . . . 19pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 15phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 19phenazopyridine hcl . . . . . . . . . . . . . . . 39phenelzine sulfate . . . . . . . . . . . . . . . . . 19phenergan supp . . . . . . . . . . . . . . . . . . 19phenobarbital elix . . . . . . . . . . . . . . . . . 17phenobarbital tabs . . . . . . . . . . . . . . . . 17phenoxybenzamine hydrochloride . . . 32phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 18phenytoin infatabs . . . . . . . . . . . . . . . . . 18phenytoin sodium . . . . . . . . . . . . . . . . . . 18phenytoin sodium extended . . . . . . . . 18philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 39phospha 250 neutral . . . . . . . . . . . . . . . 51PHOSPHOLINE IODIDE . . . . . . . . . . . 47PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 46PHYSIOSOL IRRIGATION . . . . . . . . . 46PICATO GEL 0.05% . . . . . . . . . . . . . . . 37PICATO GEL 0.015% . . . . . . . . . . . . . . 37pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 36pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 47pilocarpine hydrochloride . . . . . . . . . . . 36pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 26pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 42pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 33pioglitazone hcl-glimepiride . . . . . . . . 30pioglitazone hcl/metformin hcl . . . . . . 30pioglitazone hcl tabs 15mg, 30mg . . . 30PIOGLITAZONE HCL TABS 45MG . . . 30piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 15piperacillin/tazobactam . . . . . . . . . . . . . 15pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 42pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 42piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . 11PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 51podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 37

PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 25pantoprazole sodium tbec . . . . . . . . . 38paricalcitol caps 1mcg, 2mcg . . . . . . . 46paricalcitol caps 4mcg . . . . . . . . . . . . . 46paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36paromomycin sulfate . . . . . . . . . . . . . . . 13paroxetine hcl er tb24 12.5mg . . . . . . 19paroxetine hcl er tb24 25mg, 37.5mg . . . . . . . . . . . . . . . . . . . . . 19paroxetine hcl tabs 10mg, 20mg, 40mg . . . . . . . . . . . . . . . . 19paroxetine hcl tabs 30mg . . . . . . . . . . 19PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 21PATADAY . . . . . . . . . . . . . . . . . . . . . . . . . 47PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 19PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 47PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 45PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 45peg 3350/electrolytes . . . . . . . . . . . . . . 38peg-3350/electrolytes . . . . . . . . . . . . . . 38peg-3350/nacl/na bicarbonate/kcl . . . 38PEGANONE . . . . . . . . . . . . . . . . . . . . . . 18PEGASYS INJ 180MCG/0.5ML . . . . . 27PEGASYS INJ 180MCG/ML . . . . . . . . 27PEGASYS PROCLICK . . . . . . . . . . . . . 27PEGINTRON . . . . . . . . . . . . . . . . . . . . . . 27PEG-INTRON REDIPEN . . . . . . . . . . . 27penicillin g potassium inj 20000000unit, 5000000unit . . . . . . . . 15penicillin v potassium . . . . . . . . . . . . . . 15PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 25pentoxifylline er . . . . . . . . . . . . . . . . . . . . 34PERFOROMIST . . . . . . . . . . . . . . . . . . . 48PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 51perindopril erbumine tabs 2mg, 4mg . . . . . . . . . . . . . . . . . . . . . . . . . 33perindopril erbumine tabs 8mg . . . . . 33periogard . . . . . . . . . . . . . . . . . . . . . . . . . 36PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 24permethrin . . . . . . . . . . . . . . . . . . . . . . . . 25

69


Covered Drugs Index

pyridostigmine bromide . . . . . . . . . . . . 21pyridostigmine bromide er . . . . . . . . . . 21

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 45quasense . . . . . . . . . . . . . . . . . . . . . . . . . 42quetiapine fumarate . . . . . . . . . . . . . . . 26quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 26quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 26quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 33quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . 33quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . 33quinidine sulfate . . . . . . . . . . . . . . . . . . . 33quinine sulfate . . . . . . . . . . . . . . . . . . . . . 25

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 45raloxifene hydrochloride . . . . . . . . . . . . 43ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 33RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 34ranitidine hcl . . . . . . . . . . . . . . . . . . . . . . 38RAPAMUNE ORAL SOLN . . . . . . . . . 44rasagiline mesylate . . . . . . . . . . . . . . . . 25REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36REBIF REBIDOSE . . . . . . . . . . . . . . . . 36REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 36REBIF TITRATION PACK . . . . . . . . . . 36reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 42RECOMBIVAX HB . . . . . . . . . . . . . . . . . 45REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 21REGRANEX . . . . . . . . . . . . . . . . . . . . . . 37RELISTOR INJ 8MG/0.4ML . . . . . . . . 38RELISTOR INJ 12MG/0.6ML . . . . . . . 38REMICADE . . . . . . . . . . . . . . . . . . . . . . . 44REMODULIN . . . . . . . . . . . . . . . . . . . . . . 48

PROCALAMINE . . . . . . . . . . . . . . . . . . . 51prochlorperazine . . . . . . . . . . . . . . . . . . 26prochlorperazine edisylate . . . . . . . . . 26prochlorperazine maleate . . . . . . . . . . 26PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 32PROCRIT INJ 20000UNIT/ML . . . . . . 32PROCRIT INJ 40000UNIT/ML . . . . . . 32procto-med hc . . . . . . . . . . . . . . . . . . . . . 40procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 40proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 40proctozone-hc . . . . . . . . . . . . . . . . . . . . . 40progesterone caps . . . . . . . . . . . . . . . . 43PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 30PROGRAF INJ . . . . . . . . . . . . . . . . . . . 44PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 49PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 47PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 23PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46PROMACTA . . . . . . . . . . . . . . . . . . . . . . 32promethazine hcl plain . . . . . . . . . . . . . 20promethazine hcl supp . . . . . . . . . . . . 20promethazine hcl syrp . . . . . . . . . . . . . 20promethazine hcl tabs . . . . . . . . . . . . . 20promethegan . . . . . . . . . . . . . . . . . . . . . . 20propafenone hcl . . . . . . . . . . . . . . . . . . . 33propafenone hcl er . . . . . . . . . . . . . . . . . 33propantheline bromide . . . . . . . . . . . . . 38proparacaine hcl . . . . . . . . . . . . . . . . . . . 46propranolol hcl . . . . . . . . . . . . . . . . . . . . 33propranolol hcl er . . . . . . . . . . . . . . . . . . 33propranolol/hydrochlorothiazide . . . . 33propylthiouracil . . . . . . . . . . . . . . . . . . . . 44PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 45PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 51protriptyline hcl . . . . . . . . . . . . . . . . . . . . 19PULMOZYME . . . . . . . . . . . . . . . . . . . . . 48PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 22pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 21

pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 25prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 32pravastatin sodium . . . . . . . . . . . . . . . . 35prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 32PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 47PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 47PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 47prednicarbate oint . . . . . . . . . . . . . . . . . 40prednisolone acetate . . . . . . . . . . . . . . 47prednisolone oral soln . . . . . . . . . . . . . 40prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 47prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 40prednisone . . . . . . . . . . . . . . . . . . . . . . . . 40prednisone intensol . . . . . . . . . . . . . . . . 40PREGNYL W/DILUENT BENZYL ALCOHOL/NACL . . . . . . . . . 40PREMARIN CREA . . . . . . . . . . . . . . . . 42PREMARIN INJ . . . . . . . . . . . . . . . . . . . 42PREMARIN TABS . . . . . . . . . . . . . . . . 42PREMASOL . . . . . . . . . . . . . . . . . . . . . . . 51prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 35previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 42PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 28PREZISTA SUSP . . . . . . . . . . . . . . . . . 28PREZISTA TABS 75MG . . . . . . . . . . . . 28PREZISTA TABS 150MG . . . . . . . . . . . 28PREZISTA TABS 600MG . . . . . . . . . . . 28PREZISTA TABS 800MG . . . . . . . . . . . 28PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 21PRIMAQUINE PHOSPHATE . . . . . . . 25primidone . . . . . . . . . . . . . . . . . . . . . . . . . 17PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . 14PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 19PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 48PROAIR RESPICLICK . . . . . . . . . . . . . 48probenecid . . . . . . . . . . . . . . . . . . . . . . . . 21probenecid/colchicine . . . . . . . . . . . . . . 21

70


Covered Drugs Index

selenium sulfide lotn . . . . . . . . . . . . . . 37SELZENTRY ORAL SOLN . . . . . . . . 28SELZENTRY TABS 25MG . . . . . . . . . 28SELZENTRY TABS 150MG, 75MG . . . . . . . . . . . . . . . . . . . . 28SELZENTRY TABS 300MG . . . . . . . . 28SENSIPAR TABS 30MG . . . . . . . . . . . 43SENSIPAR TABS 60MG . . . . . . . . . . . 43SENSIPAR TABS 90MG . . . . . . . . . . . 43SEREVENT DISKUS . . . . . . . . . . . . . . 48sertraline hcl conc . . . . . . . . . . . . . . . . . 19sertraline hcl tabs 25mg, 50mg . . . . . 19sertraline hcl tabs 100mg . . . . . . . . . . 19setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 42sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 43SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 43SILDENAFIL TABS . . . . . . . . . . . . . . . . 49SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 49silver sulfadiazine . . . . . . . . . . . . . . . . . 14SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 47SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 45simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 35sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 44SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 21sodium bicarbonate inj . . . . . . . . . . . . 49sodium bicarbonate partial fill . . . . . . . 49sodium chloride 0.9% . . . . . . . . . . . . . . 46sodium chloride 0.45% . . . . . . . . . . . . . 51sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 51sodium fluoride chew 0.5mg, 1mg . . . 51SODIUM LACTATE INJ 5MEQ/ML . . 49sodium phenylbutyrate . . . . . . . . . . . . . 37sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 49sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 49sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 16SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 30SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 22

risperidone m-tab tbdp 4mg . . . . . . . . 26risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 26risperidone odt tbdp 4mg . . . . . . . . . . . 26risperidone oral soln . . . . . . . . . . . . . . 26risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 26risperidone tabs 4mg . . . . . . . . . . . . . . 26RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 24RITUXAN HYCELA . . . . . . . . . . . . . . . . 24rivastigmine tartrate . . . . . . . . . . . . . . . . 18rivastigmine transdermal system . . . . 18rizatriptan benzoate . . . . . . . . . . . . . . . . 21rizatriptan benzoate odt . . . . . . . . . . . . 21ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 25rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 14rosuvastatin calcium . . . . . . . . . . . . . . . 35ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 45ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 45roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 17ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 49RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 23RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 23RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 25

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 17SABRIL TABS . . . . . . . . . . . . . . . . . . . . 17SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 40SAIZEN CLICK.EASY . . . . . . . . . . . . . 40salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 11SAMSCA TABS 15MG . . . . . . . . . . . . . 49SAMSCA TABS 30MG . . . . . . . . . . . . . 49SANDIMMUNE ORAL SOLN . . . . . . 44SANDOSTATIN LAR DEPOT . . . . . . . 43SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 37SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 26SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 31scopolamine . . . . . . . . . . . . . . . . . . . . . . 20selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 25

RENVELA PACK . . . . . . . . . . . . . . . . . . 39RENVELA TABS . . . . . . . . . . . . . . . . . . 39repaglinide tabs 0.5mg, 1mg . . . . . . . 30repaglinide tabs 2mg . . . . . . . . . . . . . . 30REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 35REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . 35REPATHA SURECLICK . . . . . . . . . . . . 35RESCRIPTOR TABS 100MG . . . . . . . 28RESCRIPTOR TABS 200MG . . . . . . . 28RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 46RETROVIR IV INFUSION . . . . . . . . . . 28REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 22REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 22REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 26REYATAZ CAPS 150MG, 300MG . . . 29REYATAZ CAPS 200MG . . . . . . . . . . . 29REYATAZ PACK . . . . . . . . . . . . . . . . . . 29ribavirin caps . . . . . . . . . . . . . . . . . . . . . 27ribavirin inhalation soln . . . . . . . . . . . . 49ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 27RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 45rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 21riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36rimantadine hcl . . . . . . . . . . . . . . . . . . . . 29RINGERS INJECTION . . . . . . . . . . . . . 51RINGERS IRRIGATION . . . . . . . . . . . . 46RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 30risedronate sodium tabs 30mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 46risedronate sodium tabs 35mg . . . . . 46risedronate sodium tabs 150mg . . . . 46RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 26RISPERDAL CONSTA INJ 50MG . . . 26risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . 26

71


Covered Drugs Index

tacrolimus oint . . . . . . . . . . . . . . . . . . . . 37TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 24TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 24TALWIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 12TAMIFLU CAPS 30MG . . . . . . . . . . . . 29TAMIFLU CAPS 45MG, 75MG . . . . . 29TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 29tamoxifen citrate . . . . . . . . . . . . . . . . . . . 22tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 39TARCEVA TABS 25MG . . . . . . . . . . . . 24TARCEVA TABS 100MG, 150MG . . . 24TARGRETIN GEL . . . . . . . . . . . . . . . . . 25tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 42TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . . 24tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 37tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 15TAZORAC CREA . . . . . . . . . . . . . . . . . 37TAZORAC GEL . . . . . . . . . . . . . . . . . . . 37taztia xt cp24 120mg, 300mg, 360mg . . . . . . . . . . . . 34taztia xt cp24 180mg, 240mg . . . . . . . 34TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 24TECFIDERA CPDR 120MG . . . . . . . . 36TECFIDERA CPDR 240MG . . . . . . . . 36TECFIDERA STARTER PACK . . . . . . 36techlite pen needles/31g x 6 mm . . . 46techlite pen needles/31g x 8mm . . . . 46techlite pen needles/32g x 4mm . . . . 46techlite pen needles/32g x 6mm . . . . 46techlite pen needles/32g x 8mm . . . . 46TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 15TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 34TEKTURNA HCT . . . . . . . . . . . . . . . . . . 34telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 32telmisartan/amlodipine . . . . . . . . . . . . . 32telmisartan/hydrochlorothiazide . . . . . 32temazepam . . . . . . . . . . . . . . . . . . . . . . . 49TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 45TEPADINA . . . . . . . . . . . . . . . . . . . . . . . . 22

sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 16sulfamethoxazole/trimethoprim . . . . . 16sulfamethoxazole/trimethoprim ds . . 16sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 45sulfatrim pediatric . . . . . . . . . . . . . . . . . . 16sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 11sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate tabs . . . . . . . . 21SUPRAX SUSR 500MG/5ML . . . . . . . 15SUPREP BOWEL PREP KIT . . . . . . . 38SUSTIVA CAPS 50MG . . . . . . . . . . . . . 28SUSTIVA CAPS 200MG . . . . . . . . . . . 28SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 28SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 24SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 23SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 30SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 30SYNAGIS INJ 50MG/0.5ML . . . . . . . . 45synagis inj 100mg/ml . . . . . . . . . . . . . . 45SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 43SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 14SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 30SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 30SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 30SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 23SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 43SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 49

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 22tacrolimus caps . . . . . . . . . . . . . . . . . . . 44

SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 40SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 43SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 43SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 43SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 43sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 33sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 33SOVALDI . . . . . . . . . . . . . . . . . . . . . . . . . 27spironolactone . . . . . . . . . . . . . . . . . . . . 34spironolactone/hydrochlorothiazide . . 34SPORANOX ORAL SOLN . . . . . . . . . 20sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 42SPRITAM TB3D 750MG . . . . . . . . . . . 17SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 17SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 24sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 45stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 28sterile water irrigation . . . . . . . . . . . . . . 46STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 40STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 24STRATTERA CAPS 10MG, 18MG, 25MG, 40MG . . . . . . . 36STRATTERA CAPS 100MG, 60MG, 80MG . . . . . . . . . . . . . 36streptomycin sulfate . . . . . . . . . . . . . . . 13STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 28SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 13sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 38sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 16sulfacetamide sodium/ prednisolone sodium phosphate . . . . 16sulfacetamide sodium susp . . . . . . . . 16

72


Covered Drugs Index

tranylcypromine sulfate . . . . . . . . . . . . 19TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 51TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 46trazodone hcl . . . . . . . . . . . . . . . . . . . . . . 18TREANDA . . . . . . . . . . . . . . . . . . . . . . . . 22TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 21TRELSTAR MIXJECT INJ 3.75MG . . 44TRELSTAR MIXJECT INJ 11.25MG . . 44TRELSTAR MIXJECT INJ 22.5MG . . 43TRESIBA FLEXTOUCH . . . . . . . . . . . . 31tretinoin caps . . . . . . . . . . . . . . . . . . . . . 25tretinoin crea . . . . . . . . . . . . . . . . . . . . . 37tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 37tretinoin microsphere . . . . . . . . . . . . . . 37tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 37trezix caps 320.5mg; 30mg; 16mg . . 13triamcinolone acetonide crea . . . . . . 40triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 36triamcinolone acetonide lotn . . . . . . . 40triamcinolone acetonide oint . . . . . . . 40triamterene/hydrochlorothiazide . . . . 34trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40triderm crea 0.1% . . . . . . . . . . . . . . . . . 40tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 42trifluoperazine hcl . . . . . . . . . . . . . . . . . . 26trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 29trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 25tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 42tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 42trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 14trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 14trimipramine maleate . . . . . . . . . . . . . . 19TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 18tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 42TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 23tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 42

timolol maleate . . . . . . . . . . . . . . . . . . . . 33timolol maleate . . . . . . . . . . . . . . . . . . . . 47TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 46TIVICAY TABS 10MG, 25MG . . . . . . . 27TIVICAY TABS 50MG . . . . . . . . . . . . . . 27tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 27TOBI PODHALER . . . . . . . . . . . . . . . . . 48TOBRADEX OINT . . . . . . . . . . . . . . . . 47tobramycin/dexamethasone . . . . . . . . 47tobramycin nebu . . . . . . . . . . . . . . . . . . 48tobramycin ophthalmic soln . . . . . . . . 13tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 13tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . 14TOBREX OINT . . . . . . . . . . . . . . . . . . . 14tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 25tolmetin sodium . . . . . . . . . . . . . . . . . . . 11tolterodine tartrate . . . . . . . . . . . . . . . . . 38tolterodine tartrate er . . . . . . . . . . . . . . 38topiramate cpsp . . . . . . . . . . . . . . . . . . . 18topiramate tabs 100mg, 25mg, 50mg . . . . . . . . . . . . . . . 18topiramate tabs 200mg . . . . . . . . . . . . 18toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 23topotecan hcl inj 4mg . . . . . . . . . . . . . . 23TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 44torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 34TOUJEO SOLOSTAR . . . . . . . . . . . . . . 31TPN ELECTROLYTES . . . . . . . . . . . . . 51TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 49TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 30tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 12tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 12trandolapril tabs 1mg, 2mg . . . . . . . . . 33trandolapril tabs 4mg . . . . . . . . . . . . . . 33tranexamic acid inj . . . . . . . . . . . . . . . . 32tranexamic acid tabs . . . . . . . . . . . . . . 32TRANSDERM-SCOP . . . . . . . . . . . . . . 20

terazosin hcl caps 1mg, 2mg, 5mg . . . . . . . . . . . . . . . . . . . . 39terazosin hcl caps 10mg . . . . . . . . . . . 39terbinafine hcl tabs . . . . . . . . . . . . . . . . 20terbutaline sulfate . . . . . . . . . . . . . . . . . 48terconazole . . . . . . . . . . . . . . . . . . . . . . . 20testosterone cypionate . . . . . . . . . . . . . 40testosterone enanthate . . . . . . . . . . . . 40testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 40testosterone pump . . . . . . . . . . . . . . . . . 40TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 45tetrabenazine tabs 12.5mg . . . . . . . . . 36tetrabenazine tabs 25mg . . . . . . . . . . . 36tetracycline hcl . . . . . . . . . . . . . . . . . . . . 17tetracycline hydrochloride caps 500mg . . . . . . . . . . . . . . . . . . . . . . . 17TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 40THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 22THALOMID CAPS 200MG . . . . . . . . . 22THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 48theophylline cr . . . . . . . . . . . . . . . . . . . . . 48theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 48theophylline er tb24 . . . . . . . . . . . . . . . 48thioridazine hcl . . . . . . . . . . . . . . . . . . . . 26thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 22thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 26THYMOGLOBULIN . . . . . . . . . . . . . . . . 44THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 43THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 43THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 43THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 43THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 43tiagabine hydrochloride tabs 2mg . . . 18tiagabine hydrochloride tabs 4mg . . . 18tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 14TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . . 33tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

73


Covered Drugs Index

VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 30VIDEX PEDIATRIC ORAL SOLN 2GM . . . . . . . . . . . . . . . . . 28VIDEX PEDIATRIC ORAL SOLN 4GM . . . . . . . . . . . . . . . . . 28vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 18VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 16VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 19VIIBRYD STARTER PACK . . . . . . . . . 19VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 18VIMPAT ORAL SOLN . . . . . . . . . . . . . 18VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 18vinblastine sulfate . . . . . . . . . . . . . . . . . 23vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 23vincristine sulfate . . . . . . . . . . . . . . . . . . 23vinorelbine tartrate . . . . . . . . . . . . . . . . . 23viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42VIRACEPT TABS 250MG . . . . . . . . . . 29VIRACEPT TABS 625MG . . . . . . . . . . 29VIRAMUNE SUSP . . . . . . . . . . . . . . . . 28VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . . 49VIREAD POWD . . . . . . . . . . . . . . . . . . . 28VIREAD TABS . . . . . . . . . . . . . . . . . . . . 28virt-phos 250 neutral . . . . . . . . . . . . . . . 51VOLTAREN GEL . . . . . . . . . . . . . . . . . . 37voriconazole inj . . . . . . . . . . . . . . . . . . . 20voriconazole susr . . . . . . . . . . . . . . . . . 20voriconazole tabs . . . . . . . . . . . . . . . . . 20VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 24VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 51VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 27VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 27vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 42VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . . 35VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 31

vancomycin hcl in dextrose . . . . . . . . . 14vancomycin hcl inj . . . . . . . . . . . . . . . . 14vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 14VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 45VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 45VASCEPA CAPS 0.5GM . . . . . . . . . . . 35VASCEPA CAPS 1GM . . . . . . . . . . . . . 35VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 45VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 24VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 23velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 39VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 49VENCLEXTA STARTING PACK . . . . 23VENCLEXTA TABS 10MG . . . . . . . . . 23VENCLEXTA TABS 50MG . . . . . . . . . 23VENCLEXTA TABS 100MG . . . . . . . . 23venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 19venlafaxine hcl er cp24 37.5mg, 75mg . . . . . . . . . . . . . . . . . . . . . 19venlafaxine hcl er cp24 150mg . . . . . 19venlafaxine hcl er tb24 37.5mg, 75mg . . . . . . . . . . . . . . . . . . . . . 19venlafaxine hcl er tb24 150mg . . . . . . 19VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 49VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 48verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 34verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . . . . . . . . . . . . . . . . 34verapamil hcl er cp24 200mg . . . . . . . 34verapamil hcl er tbcr . . . . . . . . . . . . . . 34verapamil hcl sr cp24 360mg . . . . . . . 34VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 27VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 38VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 38vicodin es tabs 300mg; 7.5mg . . . . . . 13vicodin hp tabs 300mg; 10mg . . . . . . 13vicodin tabs 300mg; 5mg . . . . . . . . . . . 13

TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 28trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 42TROKENDI XR CP24 100MG, 25MG, 50MG . . . . . . . . . . . . . 18TROKENDI XR CP24 200MG . . . . . . 18TROPHAMINE . . . . . . . . . . . . . . . . . . . . 51tropicamide . . . . . . . . . . . . . . . . . . . . . . . 47TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 38TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 30TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 45TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 28TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 45TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 28TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 14TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 24TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 45TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 36

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 21UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 43UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 24ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . . 37

VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . . 42valacyclovir hcl . . . . . . . . . . . . . . . . . . . . 29VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 22VALCYTE ORAL SOLN . . . . . . . . . . . 27valganciclovir . . . . . . . . . . . . . . . . . . . . . . 27valganciclovir hydrochlorde . . . . . . . . 27valproate sodium . . . . . . . . . . . . . . . . . . 18valproic acid . . . . . . . . . . . . . . . . . . . . . . . 18valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 32valsartan/hydrochlorothiazide . . . . . . 32vancomycin . . . . . . . . . . . . . . . . . . . . . . . 14vancomycin hcl caps 125mg . . . . . . . 14vancomycin hcl caps 250mg . . . . . . . 14

74


Covered Drugs Index

ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZYTIGA TABS 250MG . . . . . . . . . . . . . 22ZYTIGA TABS 500MG . . . . . . . . . . . . . 22

ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 24ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 49zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 37zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 42ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 37ZERIT ORAL SOLN . . . . . . . . . . . . . . . 28ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ZIAGEN ORAL SOLN . . . . . . . . . . . . . 28zidovudine caps . . . . . . . . . . . . . . . . . . 28zidovudine syrp . . . . . . . . . . . . . . . . . . . 28zidovudine tabs . . . . . . . . . . . . . . . . . . . 28ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 46ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 27ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16zoledronic acid inj 4mg/5ml . . . . . . . . 46zoledronic acid inj 5mg/100ml . . . . . . 46ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 23zolpidem tartrate tabs . . . . . . . . . . . . . 49zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 17ZORTRESS TABS 0.5MG . . . . . . . . . . 44ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 44ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 45ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 16zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 42zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . . 42ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 29ZUBSOLV SUBL 0.7MG; 0.18MG . . 13ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 13ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 37ZYCLARA PUMP CREA 2.5% . . . . . . 37ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 35wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 24XARELTO STARTER PACK . . . . . . . . 31XARELTO TABS 10MG . . . . . . . . . . . . 31XARELTO TABS 15MG . . . . . . . . . . . . 31XARELTO TABS 20MG . . . . . . . . . . . . 31XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 44XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46XIFAXAN TABS 200MG . . . . . . . . . . . . 15XIFAXAN TABS 550MG . . . . . . . . . . . . 15XIGDUO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 30XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 5MG; 500MG . . . . . . . . . . . . . 30XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 49XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 22XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 31xylon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

YYERVOY INJ 50MG/10ML . . . . . . . . . 25YERVOY INJ 200MG/40ML . . . . . . . . 24YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 22yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 48zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 49ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 24ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 22ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 37zebutal caps 325mg; 50mg; 40mg . . 11ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1-800-668-3813 (TTY 711) October 1 – February 14, 8 a.m. – 8 p.m. local time, 7 days a week. From February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m. local time, Saturday, 8 a.m. – 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

CignaHealthSpring.com

This drug list was updated on November 1, 2017. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. This information is available for free in other languages. Please call our customer service number at 1-800-668-3813 (TTY 711), 7 days a week, 8 a.m. - 8 p.m. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al 1-800-668-3813 (TTY 711), 7 dias de la semana, 8 a.m. - 8 p.m. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna

Documents

2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary) · 2017. 11. 1. · Covered Drug Index If you are not sure what category to look under, you should look for your drug in