2018 PreferredOne Primary

2018 Formulary Primary

Effective 01/01/18

LAST REVISED 12/28/2018

Introduction

This closed formulary is a list of generic and brand medications covered by your prescription drug

benefit. Please note that this formulary is not a complete list of medications and not all listed drugs

may be covered by your plan. It is designed to offer you and your doctor cost-effective choices for safe

and clinically effective prescription drugs.

Coverage for the drugs included on the 2018 PreferredOne Formulary is determined by your

benefit plan design. Please refer to the benefit documents provided by your employer or health

plan for information on your specific benefit coverage. You may also contact the PreferredOne

Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for more information.

How is the formulary developed?

This formulary was developed based on the recommendations of an independent Pharmacy and

Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several

times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing

review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to

determine whether a drug should be included in the formulary.

Does the formulary change throughout the year?

The 2018 PreferredOne Formulary may change throughout the year as new drugs or clinical information

becomes available. Drugs may be added as they are introduced to the marketplace and other drugs

may change tier status as generics become available.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit

PreferredOne.com for the most current formulary information.

What are formulary tiers?

This formulary is made up of different cost levels or tiers. Your health plan or employer determines your

out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit

structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative

lower tier options with your doctor to help save money on your out of pocket costs.

Are generic drugs different than brand drugs?

Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and

effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost

significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if a

generic medication is right for you.

How do I fill my specialty medication?

Specialty medications are typically used to treat rare or chronic conditions and often require special

handling.

To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications, your

plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty pharmacies

provide personalized care and offer convenient delivery to your home or other approved location.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit

PreferredOne.com for the most current formulary information.

Are there any restrictions on my coverage?

Some medications on the formulary may have additional requirements or limits on coverage. These

requirements or limits may include:

Prior Authorization — Your benefit plan may require that the medication you have been prescribed

receive prior authorization. This means that you will need to get approval from your plan before you fill

your prescription. If you don’t get approval, the medication may not be covered by your drug benefit.

Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your

benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by your

plan before coverage will apply.

Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your medical

condition before another drug for that condition will be covered. For example, if two drugs are used to

treat the same medical condition, you may be required to first try one drug before the second drug is

covered.

For more information about the 2018 PreferredOne Formulary:

Call the PreferredOne Customer Service Department at 1-800-997-1750

Or, visit PreferredOne.com

TIER DESCRIPTION

1 $0 Cost Share

2 Preferred Generics

3 Non-Preferred Generics

4 Brands

5Preferred

Specialty/Injectables

6Non-Preferred

Specialty/Injectables

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered

per prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get prior

authorization before you fill your prescription for this drug.

Without prior approval, we may not cover this drug.

ST Step Therapy

In some cases, you may be required to first try certain drugs

to treat your medical condition before we will cover another

drug for that condition.

AL1 Age LimitThis prescription drug may only be covered if you meet the

minimum or maximum age limit.

Preferred Drug Preferred Drug.

QLC Quantity Limit (Custom)There is a limit on the amount of this drug that is covered

per prescription, or within a specific time frame.

PAGE 4 LAST UPDATED 12/2018

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICSNONSTEROIDAL ANTI-INFLAMMATORY DRUGS

adult aspirin (tablet dr) 1

adult aspirin regimen (tablet dr) 1

adult low dose aspirin ec (tablet dr) 1

aspir 81 (tablet dr) 1

aspir-low (tablet dr) 1

aspirin (81 mg tablet, cvs 81 mg tab, eq 81 mg tab,eql 81 mg tab, gnp 81 mg tab, gs 81 mg tab, hm 81mg tab, kro 81 mg tab, pub 81 mg tab, qc 81 mg tab,ra 81 mg tab, sm 81 mg tab)

1

aspirin ec (cvs ec 81 mg tablet, ec 81 mg tablet, eqec 81 mg tablet, eql ec 81 mg tablet, gnp ec 81 mgtablet, gs ec 81 mg tablet, hm ec 81 mg tablet, kroec 81 mg tablet, qc ec 81 mg tablet, ra ec 81 mgtablet, sb ec 81 mg tablet, sm ec 81 mg tablet, v-r ec81 mg tablet)

1

celecoxib (capsule) 3 QL 2 / DAY

children's aspirin (tab chew) 1

choline mag trisalicylate (liquid) 2

diclofenac potassium (tablet) 2

diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75mg tab, ec 25 mg tab, ec 50 mg tab, ec 75 mg tab)

2

diclofenac sodium er (tab er 24h) 2

diflunisal (tablet) 2

ecotrin ec 81 mg tablet 1

etodolac (200 mg capsule, 300 mg capsule, 400 mgtablet, 500 mg tablet)

2

etodolac er (tab er 24h) 2

fenoprofen 400 mg capsule 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fenoprofen 600 mg tablet 2

flurbiprofen (tablet) 2

ibu (tablet) 2

ibuprofen (400 mg tablet, 600 mg tablet, 800 mgtablet)

2

ibuprofen 100 mg/5 ml susp 3

indomethacin (25 mg capsule, 50 mg capsule) 2

indomethacin er (capsule er) 2

isomethept-caff-acetaminophen (tablet) 3

isomethept-dichloralp-acetamin (capsule) 2

ketoprofen (25 mg capsule, 50 mg capsule, 75 mgcapsule, er 200 mg capsule)

2

ketorolac 10 mg tablet 2 QL 20 TABLETS / 30DAYS

ketorolac tromethamine (15 mg/ml carpuject, 15mg/ml isecure syr, 30 mg/ml carpuject, 60 mg/2 mlcarpuject)

3

lo-dose aspirin ec (tablet dr) 1

low dose aspirin ec (tablet dr) 1

meclofenamate sodium (capsule) 2

mefenamic acid (capsule) 3

meloxicam (7.5 mg tablet, 7.5 mg/5 ml susp, 15 mgtablet)

2

nabumetone (tablet) 2

naproxen (125 mg/5 ml suspen, 250 mg tablet, 375mg tablet, dr 375 mg tablet, 500 mg kit, 500 mgtablet, dr 500 mg tablet)

2

naproxen sodium (275 mg tab, 550 mg tab) 2

naproxen sodium cr (tbmp 24hr) 3



naproxen sodium ds (tablet) 2

naproxen sodium er (tbmp 24hr) 3

nodolor (capsule) 2

oxaprozin (tablet) 2

piroxicam (capsule) 2

salsalate (tablet) 2

st. joseph aspirin (tab chew) 1

st. joseph aspirin ec (tablet dr) 1

sulindac (tablet) 2

tolmetin sodium (200 mg tab, 400 mg cap, 600 mgtab)

2

OPIOID ANALGESICS, LONG-ACTING

EMBEDA (CAP ER PO) 4QL 2 / DAY

PA

hydromorphone er (tab er 24h) 2QL 2 / DAY

PA

methadone hcl (5 mg tablet, 10 mg tablet) 2 PA

methadone hcl (5 mg/5 ml solution, 10 mg/5 mlsolution, 10 mg/ml oral conc)

2

methadose 40 mg tablet dispr 2

morphine sulfate er (er 10 mg cap, er 20 mg cap, er50 mg cap, er 80 mg cap, er 100 mg cap, er 120 mgcap)

2QL 2 / DAY

PA

morphine sulfate er (er 15 mg tablet, er 30 mgtablet, er 60 mg tablet, er 100 mg tablet, er 200 mgtablet)

2QL 3 / DAY

PA

morphine sulfate er (er 30 mg cap, er 45 mg cap, er60 mg cap, er 75 mg cap, er 90 mg cap)

2QL 1 / DAY

PA

OXYCONTIN (TAB ER 12H) 4QL 4 / DAY

PA



oxymorphone hcl er (tab er 12h) 2QL 4 / DAY

PA

tramadol hcl er (er 100 mg tablet, er 200 mg tablet,er 300 mg tablet)

3 QL 1 / DAY

tramadol hcl er 150 mg capsule 3QL 1 / DAY

PA

OPIOID ANALGESICS, SHORT-ACTING

acetamin-caff-dihydrocod 320.5 3

PA

QLC

QUANTITY LIMITSMAY APPLY BASEDON SHORT-ACTINGOPIOID PROGRAM.

acetaminophen-codeine (acetamin-codein 300-30mg/12.5, acetaminop-codeine 120-12 mg/5,acetaminophen-cod #2 tablet, acetaminophen-cod#3 tablet, acetaminophen-cod #4 tablet)

2

PA

QLC


ascomp with codeine (capsule) 2

PA

QLC


aspirin-caffeine-dihydrocodein (capsule) 3

PA

QLC


belladonna-opium (supp.rect) 3

butalb-acetaminoph-caff-codein (capsule) 3

PA

QLC


butalb-caff-acetaminoph-codein (capsule) 2

PA

QLC




butalbital compound-codeine (capsule) 2

PA

QLC


carisoprodol compound-codeine (tablet) 2

PA

QLC


carisoprodol-aspirin-codeine (tablet) 2

PA

QLC


codeine sulfate (tablet) 2

PA

QLC


endocet (tablet) 2

PA

QLC


hydrocodone-acetaminophen (5-325 mg, 7.5-325,10-325 mg)

2

PA

QLC


hydrocodone-acetaminophen (hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin 2.5-325,hydrocodone-acetamin 5-163/7.5, hydrocodone-acetamin 5-217/10, hydrocodone-acetamin 5-300mg, hydrocodone-acetamin 7.5-300, hydrocodone-acetamin 10-300 mg, hydrocodone-acetamn 7.5-325/15)

3

PA

QLC


hydrocodone-ibuprofen (5-200 mg, 10-200) 3

PA

QLC




hydrocodone-ibuprofen 7.5-200 2

PA

QLC


hydromorphone 3 mg suppos 2

hydromorphone hcl (0.5 mg/0.5 ml, 1 mg/mlcarpujct, 1 mg/ml syringe, 2 mg/ml carpujct, 2mg/ml isecure, 4 mg/ml carpujct, hcl 4 mg/ml amp)

3

hydromorphone hcl (1 mg/ml solution, 5 mg/5 mlsoln)

3

PA

QLC


hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mgtablet)

2

PA

QLC


ibudone 5-200 mg tablet 3

PA

QLC


lorcet (tablet) 2

PA

QLC


lorcet hd (tablet) 2

PA

QLC


lorcet plus (tablet) 2

PA

QLC




lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325mg tablet)

2

PA

QLC


meperidine hcl (50 mg tablet, 50 mg/5 ml solution,100 mg tablet)

2

PA

QLC


morphine sulfate (5 mg suppos, 10 mg suppos, 20mg suppos, 30 mg suppos)

2

morphine sulfate (5 mg/ml syringe, 10 mg/0.7 mlauto-inj)

3

morphine sulfate (sulf 10 mg/5 ml soln, sulf 20 mg/5ml soln, sulf 100 mg/5 ml soln, sulfate ir 15 mg tab,sulfate ir 30 mg tab)

2

PA

QLC


oxycodone hcl (5 mg capsule, 5 mg tablet, 10 mgtablet, 15 mg tablet, 30 mg tablet)

2

PA

QLC


oxycodone hcl (5 mg/5 ml soln, 20 mg tablet, 100mg/5 ml soln)

3

PA

QLC


oxycodone hcl-aspirin (tablet) 2

PA

QLC


oxycodone hcl-ibuprofen (tablet) 2

PA

QLC




oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen7.5-325, oxycodone-acetaminophen 5-325,oxycodone-acetaminophen 10-325)

2

PA

QLC


oxymorphone hcl (tablet) 3

PA

QLC


pentazocine-naloxone hcl (tablet) 2

PA

QLC


reprexain 10-200 mg tablet 3

PA

QLC


tramadol hcl (tablet) 2

QL 8 TABLETS / DAY

PA

QLC


tramadol hcl-acetaminophen (tablet) 2

QL 8 TABLETS / DAY

PA

QLC


verdrocet (tablet) 3

PA

QLC


vicodin (tablet) 3

PA

QLC




vicodin es (tablet) 3

PA

QLC


vicodin hp (tablet) 3

PA

QLC


xylon 10 (tablet) 3

PA

QLC


ANESTHETICSLOCAL ANESTHETICS

bupivacaine 0.5% vial 3

glydo (jel/pf app) 2

isoflurane (liquid) 3

lidocaine 5% patch 2

lidocaine hcl (0.5% vial, 1% 20 mg/2 ml, 1% 20 mg/2ml vl, 1% 300 mg/30 ml, 1% 50 mg/5 ml, 1% 50mg/5 ml vl, 1% ampul, 1% vial, 1.5% ampul, 2% 100mg/5 ml, 2% 40 mg/2 ml, 2% 40 mg/2 ml vl, 2%ampul, 2% vial, 4% ampul)

3

lidocaine hcl (2% jelly, 4% solution) 2

lidocaine hcl viscous (solution) 2

lidocaine hcl-epinephrine (ampul, vial) 3

lidocaine-epinephrine (cartridge) 3

lidocaine-prilocaine (cream , kit) 2

mepivacaine hcl (cartridge) 3

polocaine-mpf (vial) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSropivacaine hcl (0.2% 20 mg/10 ml, 0.2% 200mg/100 ml, 0.2% 40 mg/20 ml, 0.5% 100 mg/20 ml,0.5% 150 mg/30 ml, 0.75% 150 mg/20 ml, 1% 100mg/10 ml vl, 1% 200 mg/20 ml vl)

3

sevoflurane (liquid) 3

terrell (liquid) 3

tetracaine hcl 1% ampul 3

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTSALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium (tablet dr) 3

disulfiram (tablet) 2

naltrexone hcl (tablet) 2

VIVITROL (SUS ER REC) 6

OPIOID DEPENDENCE TREATMENTS

buprenorphin-naloxon 8-2 mg sl 3 QL 3 / DAY

buprenorphine 2 mg tablet sl 3 QL 12 / DAY

buprenorphine 8 mg tablet sl 3 QL 3 / DAY

buprenorphn-naloxn 2-0.5 mg sl 3 QL 12 / DAY

OPIOID REVERSAL AGENTSnaloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2mg/2 ml syringe, 4 mg/10 ml vial)

3

SMOKING CESSATION AGENTS

buproban (tab er 12h) 1QL 2 / DAY

AL1 18 to 999 yrs old

bupropion hcl sr 150 mg tab 1QL 2 / DAY


CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX,1 MG TABLET)

1QL 2 / DAY


CHANTIX STARTING MONTH BOX 1QL 1 BOX (53 TABLETS) /

28 DAYSAL1 18 to 999 yrs old



NICOTROL (CARTRIDGE) 1QL 16 / DAY


NICOTROL NS (SPRAY) 1QL 12 BOTTLES (120 ML)

/ 30 DAYSAL1 18 to 999 yrs old

ANTIBACTERIALSAMINOGLYCOSIDES

gentak (oint. (g)) 2

gentamicin sulfate (0.1% cream, 0.1% ointment,0.3% eye drop, 0.3% eye ointment, 3 mg/ml eyedrop)

2

KITABIS PAK (AMPUL-NEB) 6 ST

neomycin sulfate (tablet) 2

paromomycin sulfate (capsule) 2

TOBRADEX EYE OINTMENT 4

tobramycin 0.3% eye drop 2

tobramycin pak 300 mg/5 ml 6 ST

ANTIBACTERIALS, OTHER

acetic acid 0.25% irrig soln 3

avar cleanser 3

bacitracin 500 unit/gm ophth 2

bp 10-1 (cleanser) 3

bp cleansing wash 3

clindamycin hcl (capsule) 2

clindamycin palmitate hcl (soln recon) 3

clindamycin pediatric (soln recon) 3

clindamycin phosphate (ph 1% gel, ph 1% solution,phosp 1% lotion, 2% vaginal cream)

2



clindamycin phosphate 1% foam 3

colistimethate (vial) 3

hyophen (tablet) 3

linezolid 100 mg/5 ml susp 3 QL 6 BOTTLES (900 mL)/ 28 DAYS

linezolid 600 mg tablet 2 QL 28 / 30 DAYS

me-naphos-mb-hyo 1 (tablet) 3

methenamine hippurate (tablet) 3

methenamine md 500 mg tablet 2

metronidazole (0.75% cream, 0.75% lotion, topical0.75% gl, vaginal 0.75% gl, 250 mg tablet, 500 mgtablet)

2

metronidazole (top 1% gel pump, topical 1% gel, 375mg capsule)

3

mupirocin (cream, ointment) 2

neomycin-polymyxin b (40 mg/ml amp, 40 mg/ml vl) 3

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr50 mg cap, mcr 100 mg cap)

2

nitrofurantoin mono-macro (capsule) 2

phosphasal (tablet) 2

rosadan (cream, gel) 2

rosanil (cleanser) 3

sod sulfacetamide-sulfur lotn 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSsodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8% crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulface-sulfur 9-4.5% wash,sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacet-sulfur 10-5% clsr, sodium sulf-sulfur cleanser, sodium sulfacet-sulfur wash,sulfacetamide-sulfur 8-4% susp, sulfacetamide-sulfur10-2% crm)

3

sss 10-5 (10-5 cream, 10-5 foam) 3

sulfacetamide sodium-sulfur (med. pad) 3

tinidazole (tablet) 3

trimethoprim (tablet) 2

ur n-c (tablet) 2

uramit mb (capsule) 3

urin d.s. (tablet) 2

uro-458 (tablet) 3

uro-mp (capsule) 3

ustell (capsule) 3

utira-c (tablet) 2

vancomycin hcl (125 mg capsule, 250 mg capsule) 3

vilamit mb (capsule) 3

vilevev mb (tablet) 3

zencia (cleanser) 3

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5 ml susp, 375 mg/5 ml suspen) 4

cefaclor (250 mg capsule, 250 mg/5 ml susp, 500 mgcapsule)

2

cefaclor er (tab er 12h) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONScefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp)

2

cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300mg capsule)

2

cefditoren pivoxil (tablet) 3

cefixime (susp recon) 3

cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 2

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)

3

cefprozil (125 mg/5 ml susp, 250 mg tablet, 250mg/5 ml susp, 500 mg tablet)

2

ceftibuten (180 mg/5 ml susp, 400 mg capsule) 3

cefuroxime (tablet) 2

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500mg tablet, 750 mg capsule)

2

BETA-LACTAM, PENICILLINSamoxicillin (125 mg tab chew, 125 mg/5 ml susp,200 mg/5 ml susp, 250 mg capsule, 250 mg tabchew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mgcapsule, 500 mg tablet, 875 mg tablet)

2

amoxicillin-clavulanate pot er (tab er 12h) 2

amoxicillin-clavulanate potass (200-28.5 mg tabchew, 200-28.5 mg/5 ml sus, 250-125 mg tablet,250-62.5 mg/5 ml sus, 400-57 mg tab chew, 400-57mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 mlsus, 875-125 mg tablet)

2

ampicillin trihydrate (125 mg/5 ml susp, 250 mgcapsule, 250 mg/5 ml susp, 500 mg capsule)

2

dicloxacillin sodium (capsule) 2

penicillin v potassium (125 mg/5 ml soln, 250 mgtablet, 250 mg/5 ml soln, 500 mg tablet)

2



MACROLIDESazithromycin (1 gm pwd packet, 100 mg/5 ml susp,200 mg/5 ml susp, 250 mg tablet, 500 mg tablet,600 mg tablet)

2

clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250mg/5 ml sus, 500 mg tablet)

2

clarithromycin er (tab er 24h) 2

DIFICID (TABLET) 4

ery (med. swab) 2

erythromycin (0.5% eye ointment, 2% gel, 2%pledgets, 2% solution, 250 mg filmtab, dr 250 mgcap, 500 mg filmtab)

2

erythromycin 200 mg/5 ml gran 3

erythromycin es 400 mg tab 2

QUINOLONES

ciprofloxacin (250 mg/5 ml susp, 500 mg/5 ml susp) 3

ciprofloxacin 0.2% otic soln 3 ST

ciprofloxacin er (tbmp 24hr) 2

ciprofloxacin hcl (0.3% eye drop, hcl 100 mg tab, hcl250 mg tab, hcl 500 mg tab, hcl 750 mg tab)

2

gatifloxacin (drops) 3

levofloxacin (25 mg/ml solution, 250 mg tablet, 250mg/10 ml soln, 500 mg tablet, 500 mg/20 ml soln,750 mg tablet)

2

levofloxacin 0.5% eye drops 3

MOXEZA (DROPS VISC) 4

moxifloxacin 0.5% eye drops 2

moxifloxacin hcl (tablet) 2

ofloxacin (ear drops, eye drops) 2



ofloxacin 400 mg tablet 3

VIGAMOX (DROPS) 4

ZYMAXID (DROPS) 4

SULFONAMIDES

silver sulfadiazine (cream (g)) 2

sulfacetamide sodium (drops, ointment) 2

sulfadiazine (tablet) 2

sulfamethoxazole-trimethoprim (ds tablet, ss tablet,susp)

2

TETRACYCLINES

avidoxy (tablet) 3

demeclocycline hcl (tablet) 2

doxycycline hyclate (20 mg tab, 50 mg cap, 100 mgcap, 100 mg tab)

2

doxycycline monohydrate (25 mg/5 ml susp, mono50 mg tablet, mono 75 mg tablet, mono 100 mgtablet, mono 150 mg tablet)

3

doxycycline monohydrate (50 mg cap, 75 mgcapsule, 100 mg cap, 150 mg cap)

2

minocycline hcl (50 mg capsule, 75 mg capsule, 100mg capsule)

2

minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet)

3

minocycline hcl er (er 45 mg tablet, er 90 mg tablet,er 135 mg tablet)

3

mondoxyne nl (capsule) 2

morgidox (50 mg capsule, 100 mg capsule) 2

okebo (capsule) 2

tetracycline hcl (capsule) 2



ANTICONVULSANTSANTICONVULSANTS, OTHER

levetiracetam (100 mg/ml soln, 250 mg tablet, 500mg tablet, 750 mg tablet, 1,000 mg tablet)

2

levetiracetam er (tab er 24h) 2

POTIGA (TABLET) 4

roweepra (tablet) 2

roweepra xr (tab er 24h) 2

CALCIUM CHANNEL MODIFYING AGENTS

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 2

zonisamide (capsule) 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSdiazepam (2.5 mg rectal gel sys, 10 mg rectal gelsyst, 20 mg rectal gel syst)

2 QL 2 PACKAGES / RX

divalproex sodium (dr 125 mg cap sprnk, sod dr 125mg tab, sod dr 250 mg tab, sod dr 500 mg tab)

2

divalproex sodium er (tab er 24h) 2

gabapentin (100 mg capsule, 250 mg/5 ml soln, 300mg capsule, 400 mg capsule, 600 mg tablet, 800 mgtablet)

2

phenobarbital (15 mg tablet, 16.2 mg tablet, 20mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mgtablet, 100 mg tablet)

2

phenobarbital sodium (vial) 3

primidone (tablet) 2

SABRIL 500 MG TABLET 6 PA

tiagabine hcl (2 mg tablet, 4 mg tablet) 3

valproic acid (250 mg capsule, 250 mg/5 ml soln) 2

vigabatrin (powd pack) 5 PA



vigadrone (powd pack) 5 PA

GLUTAMATE REDUCING AGENTSfelbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml susp)

3

lamotrigine (5 mg disper tablet, 25 mg disper tab, 25mg tablet, 100 mg tablet, 150 mg tablet, 200 mgtablet)

2

lamotrigine er (tab er 24) 2

lamotrigine odt (tab rapdis) 2

subvenite (tablet) 2

topiramate (15 mg sprinkle cap, 25 mg sprinkle cap,25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mgtablet)

2

topiramate er (cap spr 24) 3

SODIUM CHANNEL AGENTS

APTIOM (TABLET) 4

carbamazepine (100 mg tab chew, 100 mg/5 mlsusp, 200 mg tablet)

2

carbamazepine er (er 100 mg cap, er 100 mg tablet,er 200 mg cap, er 300 mg cap)

3

carbamazepine er (er 200 mg tablet, er 400 mgtablet)

2

epitol (tablet) 2

fosphenytoin sodium (vial) 3

oxcarbazepine (150 mg tablet, 300 mg tablet, 300mg/5 ml susp, 600 mg tablet)

2

PEGANONE (TABLET) 4

phenytoin (50 mg infatab, 50 mg tablet chew, 125mg/5 ml susp)

2

phenytoin sodium extended (capsule) 2

VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

4



ANTIDEMENTIA AGENTSANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates (tablet) 2

isoxsuprine hcl (tablet) 2

papaverine hcl (vial) 3

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tablet, 10 mg tablet) 2

donepezil hcl odt (tab rapdis) 2

galantamine er (cap24h pel) 2

galantamine hbr (tablet) 2

galantamine hydrobromide (solution) 2

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 6 mg capsule)

2

rivastigmine (4.6 mg/24hr patch, 9.5 mg/24hr patch,13.3 mg/24hr ptch)

3

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (hcl 2 mg/ml solution, 5-10 mgtitration pk, hcl 5 mg tablet, hcl 10 mg tablet)

2

NAMENDA (5 MG TABLET, 10 MG TABLET) 4

ANTIDEPRESSANTSANTIDEPRESSANTS, OTHER

bupropion hcl (tablet) 2

bupropion hcl sr (100 mg tablet, 150 mg tablet, 200mg tablet)

2 QL 2 / DAY

bupropion hcl xl 150 mg tablet 2 QL 3 / DAY

bupropion hcl xl 300 mg tablet 2 QL 1 / DAY

chlordiazepoxide-amitriptyline (tablet) 2

mirtazapine (7.5 mg tablet, 15 mg odt, 15 mg tablet,30 mg odt, 30 mg tablet, 45 mg odt, 45 mg tablet)

2



olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) 3 QL 3 / DAY

olanzapine-fluoxetine hcl (6-50 mg, 12-25 mg, 12-50mg)

3 QL 1 / DAY

perphenazine-amitriptyline (tablet) 2

MONOAMINE OXIDASE INHIBITORS

phenelzine sulfate (tablet) 2

tranylcypromine sulfate (tablet) 2

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR

citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20mg tablet, 40 mg tablet)

2

desvenlafaxine suc er 100 mg 2 QL 4 / DAY

desvenlafaxine succinate er (er 25 mg, er 50 mg) 2 QL 1 / DAY

escitalopram oxalate (5 mg tablet, 10 mg tablet, 20mg tablet)

2

escitalopram oxalate 5 mg/5 ml 3

fluoxetine dr (capsule dr) 3 QL 4 / 28 DAYS

fluoxetine hcl (hcl 10 mg capsule, hcl 10 mg tablet,20 mg/5 ml solution, hcl 20 mg capsule, hcl 40 mgcapsule)

2

fluvoxamine maleate (tablet) 2

fluvoxamine maleate er (cap er 24h) 3 QL 2 / DAY

maprotiline hcl (tablet) 2

nefazodone hcl (tablet) 3

paroxetine cr (tab er 24h) 2

paroxetine er (tab er 24h) 2

paroxetine hcl (tablet) 2

sertraline hcl (20 mg/ml oral conc, 20 mg/ml oralsoln, hcl 25 mg tablet, hcl 50 mg tablet, hcl 100 mgtablet)

2



trazodone hcl (tablet) 2

venlafaxine hcl (tablet) 2

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er150 mg cap)

2

TRICYCLICS

amitriptyline hcl (tablet) 2

amoxapine (tablet) 2

clomipramine hcl (capsule) 2

desipramine hcl (tablet) 2

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25mg capsule, 50 mg capsule, 75 mg capsule, 100 mgcapsule, 150 mg capsule)

2

imipramine hcl (tablet) 2

imipramine pamoate (capsule) 2

nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, 20mg/10 ml soln, hcl 25 mg cap, hcl 50 mg cap, hcl 75mg cap)

2

protriptyline hcl (tablet) 2

trimipramine maleate (capsule) 3

ANTIEMETICSANTIEMETICS, OTHER

compro (supp.rect) 2

dimenhydrinate 50 mg/ml vial 3

meclizine hcl (12.5 mg tablet, 25 mg tablet) 3

metoclopramide hcl (10 mg/2 ml syr, 10 mg/2 mlvial)

3

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10mg tablet, 10 mg/10 ml sol)

2

metoclopramide hcl odt (tab rapdis) 3



perphenazine (tablet) 2

prochlorperazine (supp.rect) 2

prochlorperazine maleate (tablet) 2

trimethobenzamide hcl (capsule) 2

EMETOGENIC THERAPY ADJUNCTS

dronabinol (2.5 mg capsule, 5 mg capsule, 10 mgcapsule)

2QL 2 / DAY

PA

granisetron hcl 1 mg tablet 3 QL 4 / 30 DAYS

ondansetron 4 mg/5 ml solution 2 QL 120 ML / 30 DAYS

ondansetron hcl (4 mg tablet, 8 mg tablet) 2

ondansetron hcl (4 mg/2 ml amp, 4 mg/2 ml vial) 3 QL 60 VIALS (120 ML) /30 DAYS

ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 mlsyr)

3 QL 60 SYRINGES (120ML) / 30 DAYS

ondansetron hcl 24 mg tablet 2 QL 2 / 30 DAYS

ondansetron odt (tab rapdis) 2

VARUBI 90 MG TABLET 4 QL 4 / 30 DAYS

ANTIFUNGALS

ciclodan 0.77% cream 2

ciclopirox (0.77% cream, 0.77% gel, 0.77% topicalsusp, 1% shampoo)

2

clotrimazole (cream, solution) 3

clotrimazole 10 mg troche 2

econazole nitrate (cream (g)) 2

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mgtablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

2

flucytosine (capsule) 3



griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 2

griseofulvin ultramicrosize (tablet) 2

itraconazole 100 mg capsule 2 PA

ketoconazole (2% foam, 200 mg tablet) 3

ketoconazole (cream, shampoo) 2

miconazole 3 200 mg vag supp 3

naftifine hcl (cream ) 3

nyamyc (powder) 2

nyata (powder) 2

nystatin (100,000 unit/gm cream, 100,000 unit/gmoint, 100,000 unit/gm powd, 100,000 unit/ml susp,500,000 unit oral tab, 500,000 unit/5 ml sus)

2

nystatin-triamcinolone (cream, ointm) 2

nystop (powder) 2

oxiconazole nitrate (cream (g)) 3

terbinafine hcl (tablet) 2 QL 84 DAY SUPPLY / 180DAYS

terconazole (0.4% cream, 0.8% cream) 2

terconazole 80 mg suppository 3

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)

3

ANTIGOUT AGENTS

allopurinol (tablet) 2

colchicine 0.6 mg tablet 4

COLCRYS (TABLET) 4

probenecid (tablet) 2

probenecid-colchicine (tablet) 2



ULORIC (40 MG TABLET, 80 MG TABLET) 4 ST

ANTIMIGRAINE AGENTSERGOT ALKALOIDS

dihydroergotamine mesylate (1 mg/ml amp, 1mg/ml vl)

3

ergotamine-caffeine (tablet) 3

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate (tablet) 3 QL 12 / 30 DAYS

AXERT (TABLET) 4 QL 12 / 30 DAYS

eletriptan hbr (tablet) 3 QL 12 / 30 DAYS

frovatriptan succinate (tablet) 3 QL 12 / 30 DAYS

naratriptan (tablet) 3 QL 9 / 30 DAYS

naratriptan hcl (tablet) 3 QL 9 / 30 DAYS

rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mgtablet)

2 QL 18 / 30 DAYS

sumatriptan (spray) 2 QL 2 PACKS (12 UNITS) /30 DAYS

sumatriptan 4 mg/0.5 ml inject 3 QL 10 PENS (5 ML) / 30DAYS

sumatriptan 6 mg/0.5 ml vial 3 QL 8 VIALS (4 ML) / 30DAYS

sumatriptan succinate (25 mg tablet, 50 mg tablet,100 mg tablet)

2 QL 9 / 30 DAYS

sumatriptan succinate (6 mg/0.5 ml inject, 6 mg/0.5ml syrng)

3 QL 10 SYRINGES (5 ML) /30 DAYS

zolmitriptan (tablet) 2 QL 12 / 30 DAYS

zolmitriptan 2.5 mg odt 2 QL 12 / 30 DAYS

zolmitriptan 5 mg odt 2 QL 9 / 30 DAYS

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 4 QL 2 BOXES (12 UNITS) /30 DAYS



ZOMIG (2.5 MG TABLET, 5 MG TABLET) 4 QL 12 / 30 DAYS

ZOMIG ZMT 2.5 MG TABLET 4 QL 12 / 30 DAYS

ZOMIG ZMT 5 MG TABLET 4 QL 9 / 30 DAYS

ANTIMYASTHENIC AGENTSPARASYMPATHOMIMETICS

guanidine hcl (tablet) 4

pyridostigmine bromide (tablet) 2

pyridostigmine bromide er (tablet er) 2

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 2

rifabutin (capsule) 2

ANTITUBERCULARS

cycloserine (capsule) 3

ethambutol hcl (tablet) 2

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300mg tablet)

2

pyrazinamide (tablet) 2

rifampin (150 mg capsule, 300 mg capsule) 2

ANTINEOPLASTICSALKYLATING AGENTS

ALKERAN 2 MG TABLET 4

cyclophosphamide (25 mg capsule, 50 mg capsule) 4

HEXALEN (CAPSULE) 4

LEUKERAN (TABLET) 4

LONSURF 15 MG-6.14 MG TABLET 6QL 100 / 28 DAYS

PA



LONSURF 20 MG-8.19 MG TABLET 6QL 168 / 84 DAYS

PA

MATULANE (CAPSULE) 5

melphalan (tablet) 2

MYLERAN (TABLET) 4

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100MG CAPSULE, 140 MG CAPSULE, 180 MG CAPSULE,250 MG CAPSULE)

6 PA

temozolomide (5 mg capsule, 20 mg capsule, 100 mgcapsule, 140 mg capsule, 180 mg capsule, 250 mgcapsule)

5 PA

VALCHLOR (GEL (GRAM)) 6 PA

ANTIANDROGENS

abiraterone acetate (tablet) 5 PA

bicalutamide (tablet) 2

flutamide (capsule) 2

NILANDRON (TABLET) 6

nilutamide (tablet) 5

XTANDI (CAPSULE) 6 PA

ZYTIGA (TABLET) 6 PA

ANTIANGIOGENIC AGENTSPOMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MGCAPSULE, 4 MG CAPSULE)

6 PA

REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MGCAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MGCAPSULE)

6 PA

THALOMID (50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)

5 PA

ANTIESTROGENS/MODIFIERS

EMCYT (CAPSULE) 4



FARESTON (TABLET) 4

FASLODEX (SYRINGE) 6

SOLTAMOX (SOLUTION) 1

tamoxifen citrate (tablet) 1

ANTIMETABOLITES

capecitabine (150 mg tablet, 500 mg tablet) 5 PA

floxuridine (vial) 6

hydroxyurea (capsule) 2

mercaptopurine (tablet) 5

TABLOID (TABLET) 5

XELODA (150 MG TABLET, 500 MG TABLET) 6 PA

ANTINEOPLASTICS, OTHER

azacitidine (vial) 6

bleo 15k (vial) 6

bleomycin sulfate (vial) 6

COTELLIC (TABLET) 6 PA

FARYDAK (CAPSULE) 6QL 6 / 30 DAYS

PA

IMLYGIC (VIAL) 6

leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab,25 mg tab)

2

leucovorin calcium 350 mg vial 3

LYNPARZA 50 MG CAPSULE 6 PA

LYSODREN (TABLET) 4

NINLARO (CAPSULE) 6QL 3 / 28 DAYS

PA



thiotepa (vial) 6

ZOLINZA (CAPSULE) 5 PA

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole (tablet) 2

exemestane (tablet) 2

letrozole (tablet) 2

ENZYME INHIBITORS

etoposide 50 mg capsule 5

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 6

MOLECULAR TARGET INHIBITORS

AFINITOR (TABLET) 6QL 1 / DAY

PA

AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5MG TABLET)

6 PA

BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MGTABLET)

6 PA

CAPRELSA 100 MG TABLET 5QL 2 / DAY

PA

CAPRELSA 300 MG TABLET 5 PA

COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 6 PA

GLEEVEC (100 MG TABLET, 400 MG TABLET) 6 PA

IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125MG CAPSULE)

6 PA

imatinib mesylate (tablet) 5 PA

IRESSA (TABLET) 6 PA

JAKAFI (5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 25 MG TABLET)

5 PA

JAKAFI 10 MG TABLET 5QL 2 / DAY

PA



MEKINIST (0.5 MG TABLET, 2 MG TABLET) 5 PA

SPRYCEL (TABLET) 5 PA

STIVARGA (TABLET) 6 PA

SUTENT (CAPSULE) 6 PA

TARCEVA (100 MG TABLET, 150 MG TABLET) 6QL 1 / DAY

PA

TARCEVA 25 MG TABLET 6QL 3 / DAY

PA

TASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200MG CAPSULE)

6 PA

TYKERB (TABLET) 5 PA

ZYDELIG (100 MG TABLET, 150 MG TABLET) 6 PA

ZYKADIA (CAPSULE) 6QL 5 / DAY

PA

MONOCLONAL ANTIBODIES

BLINCYTO (KIT) 6 PA

UNITUXIN (VIAL) 6 PA

RETINOIDS

bexarotene (capsule) 5 PA

tretinoin 10 mg capsule 5

ANTIPARASITICSANTIHELMINTHICS

ivermectin (tablet) 3

praziquantel (tablet) 2

STROMECTOL (TABLET) 4



ANTIPROTOZOALS

atovaquone (oral susp) 3

atovaquone-proguanil hcl (tablet) 3

chloroquine phosphate (tablet) 2

hydroxychloroquine sulfate (tablet) 2

mefloquine hcl (tablet) 2

primaquine (tablet) 2

quinine sulfate (capsule) 3 PA

PEDICULICIDES/SCABICIDES

lindane (lotion, shampoo) 2

malathion (lotion) 3

permethrin 5% cream 2

spinosad (suspension) 3

ANTIPARKINSON AGENTSANTICHOLINERGICS

benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)

2

benztropine mesylate (2 mg/2 ml ampule, 2 mg/2 mlvial)

3

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mgtablet)

2

ANTIPARKINSON AGENTS, OTHERamantadine (50 mg/5 ml solution, 100 mg capsule,100 mg/10 ml soln)

2

amantadine 100 mg tablet 3

carbidopa-levodopa-entacapone (tablet) 3

entacapone (tablet) 2

tolcapone (tablet) 3



DOPAMINE AGONISTS

APOKYN (CARTRIDGE) 6QL 20 CARTRIDGES (60

ML) / 30 DAYSPA

bromocriptine mesylate (2.5 mg tablet, 5 mgcapsule)

2

pramipexole dihydrochloride (tablet) 2

pramipexole er (tab er 24h) 3

ropinirole er (tab er 24h) 3

ropinirole hcl (tablet) 2

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa (tablet) 3

carbidopa-levodopa (10-100 mg odt, 25-100 mg odt,25-250 mg odt)

3

carbidopa-levodopa (10-100 tab, 25-100 tab, 25-250tab)

2

carbidopa-levodopa er (tablet er) 2

LODOSYN (TABLET) 4

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

selegiline hcl 5 mg capsule 3

selegiline hcl 5 mg tablet 2

ANTIPSYCHOTICS1ST GENERATION/TYPICAL

chlorpromazine 25 mg/ml amp 3

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50mg tablet, 100 mg tablet, 200 mg tablet)

2

droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 3

fluphenazine 2.5 mg/ml vial 3

fluphenazine decanoate (vial) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5mg/5 ml elix, 5 mg tablet, 5 mg/ml conc, 10 mgtablet)

2

haloperidol (tablet) 2

haloperidol decanoate (dec 50 mg/ml vial, dec 100mg/ml amp, dec 100 mg/ml vial, dec 500 mg/5 ml vl,decan 50 mg/ml amp)

3

haloperidol decanoate 100 (ampul) 3

haloperidol lac 2 mg/ml conc 2

haloperidol lactate (5 mg/ml ampul, 5 mg/ml vial, 50mg/10 ml vl)

3

loxapine (capsule) 2

molindone hcl (tablet) 3

pimozide (tablet) 3

thioridazine hcl (tablet) 2

thiothixene (capsule) 2

trifluoperazine hcl (tablet) 2

2ND GENERATION/ATYPICALaripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet,15 mg tablet, 20 mg tablet, 30 mg tablet)

2 QL 1 / DAY

aripiprazole 1 mg/ml solution 2 QL 5 BOTTLES (750 ML)/ 30 DAYS

aripiprazole odt (tab rapdis) 2 QL 2 / DAY

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET,6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MGTABLET)

4QL 2 / DAY

ST

FANAPT TITRATION PACK 4QL 1 PACK (8 TABLETS) /

180 DAYSST

INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 9MG TABLET)

4 QL 1 / DAY



INVEGA ER 6 MG TABLET 4 QL 2 / DAY

NUPLAZID (10 MG TABLET, 17 MG TABLET, 34 MGCAPSULE)

4 PA

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mgtablet, 10 mg tablet, 15 mg tablet, 20 mg tablet)

2 QL 1 / DAY

olanzapine 10 mg vial 3

olanzapine odt (tab rapdis) 2 QL 1 / DAY

paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9mg tablet)

3 QL 1 / DAY

paliperidone er 6 mg tablet 3 QL 2 / DAY

quetiapine er 200 mg tablet 2 QL 3 / DAY

quetiapine fumarate (25 mg tab, 50 mg tab, 100 mgtab, 200 mg tab)

2 QL 3 / DAY

quetiapine fumarate (300 mg tab, 400 mg tab) 2 QL 2 / DAY

quetiapine fumarate er (er 50 mg tablet, er 150 mgtablet, er 300 mg tablet, er 400 mg tablet)

2 QL 2 / DAY

REXULTI (TABLET) 4 QL 1 / DAY

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mgtablet, 2 mg tablet, 3 mg tablet, 4 mg tablet)

2 QL 2 / DAY

risperidone 0.25 mg odt 3 QL 2 / DAY

risperidone 1 mg/ml solution 2 QL 8 BOTTLES (240 ML)/ 30 DAYS

risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3mg odt, 4 mg odt)

2 QL 2 / DAY

SAPHRIS (TAB SUBL) 4 QL 2 / DAY

ziprasidone hcl (capsule) 3 QL 2 / DAY

TREATMENT-RESISTANT

clozapine (25 mg tablet, 100 mg tablet) 2 QL 9 / DAY

clozapine 200 mg tablet 2 QL 4 / DAY

clozapine 50 mg tablet 2 QL 6 / DAY



clozapine odt (odt 25 mg tablet, odt 100 mg tablet) 3 QL 9 / DAY

clozapine odt 12.5 mg tablet 3 QL 3 / DAY

clozapine odt 150 mg tablet 3 QL 6 / DAY

clozapine odt 200 mg tablet 3 QL 4 / DAY

ANTIVIRALSANTI-CYTOMEGALOVIRUS (CMV) AGENTS

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 4

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 2

ZIRGAN (GEL (GRAM)) 4

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil (tablet) 5

BARACLUDE 0.05 MG/ML SOLUTION 6 QL 3 BOTTLES (630 ML)/ 30 DAYS

entecavir (tablet) 5

EPIVIR HBV 25 MG/5 ML SOLN 5

HEPSERA (TABLET) 6

lamivudine 100 mg tablet 5

lamivudine hbv (tablet) 5

TYZEKA (TABLET) 6

ANTI-HEPATITIS C (HCV) AGENTS

EPCLUSA (TABLET) 5QL 1 / DAY

PA

HARVONI (TABLET) 5QL 1 / DAY

PA

INTRON A (10 MILLION UNITS VIL, 18 MILLIONUNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLIONUNIT/2.5ML, 50 MILLION UNITS VIL)

6 PA



ledipasvir-sofosbuvir (tablet) 5QL 1 / DAY

PA

MAVYRET (TABLET) 5QL 3 / DAY

PA

moderiba (200 mg tablet, 200-400 mg dosepack,400-400 mg dosepack, 600-400 mg dosepack, 600-600 mg dosepack)

6

OLYSIO (CAPSULE) 6QL 1 / DAY

PA

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/MLVIAL)

5 PA

PEGASYS PROCLICK (135 MCG/0.5, 180 MCG/0.5) 5 PA

PEGINTRON (50 MCG KIT, 80 MCG KIT, 120 MCG KIT,150 MCG KIT)

6 PA

PEGINTRON REDIPEN (50 MCG, 80 MCG, 120 MCG,120 MCG 4PK, 150 MCG)

6 PA

REBETOL 40 MG/ML SOLUTION 6

ribasphere (200 mg capsule, 400 mg tablet, 600 mgtablet)

6

ribasphere 200 mg tablet 5

ribavirin 200 mg capsule 6

ribavirin 200 mg tablet 5

sofosbuvir-velpatasvir (tablet) 5QL 1 / DAY

PA

SOVALDI (TABLET) 6QL 1 / DAY

PA

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)ISENTRESS (25 MG TABLET CHEW, 100 MG POWDERPACKET, 100 MG TABLET CHEW, 400 MG TABLET)

5

ISENTRESS HD (TABLET) 6

STRIBILD (TABLET) 5



TIVICAY (TABLET) 5

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA (TABLET) 5

COMPLERA (TABLET) 5

EDURANT (TABLET) 5

efavirenz (50 mg capsule, 200 mg capsule, 600 mgtablet)

5

INTELENCE (TABLET) 5

nevirapine (50 mg/5 ml susp, 200 mg tablet) 5

nevirapine er (tab er 24h) 5

RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 5

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)

abacavir (20 mg/ml solution, 300 mg tablet) 5

abacavir-lamivudine (tablet) 5

abacavir-lamivudine-zidovudine (tablet) 5

didanosine (capsule dr) 5

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 5

EPZICOM (TABLET) 6

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300mg tablet)

5

lamivudine-zidovudine (tablet) 5

stavudine (1 mg/ml solution, 15 mg capsule, 20 mgcapsule, 30 mg capsule, 40 mg capsule)

5

tenofovir disoproxil fumarate (tablet) 5

TRUVADA (TABLET) 5

VIDEX (SOLN RECON) 5


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSVIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)

5

ZIAGEN 20 MG/ML SOLUTION 5

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300mg tablet)

5

ANTI-HIV AGENTS, OTHER

FUZEON (VIAL) 6 QL 2 VIALS / DAY

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET,75 MG TABLET, 150 MG TABLET, 300 MG TABLET)

5 PA

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 5

atazanavir sulfate (capsule) 5

CRIXIVAN (CAPSULE) 5

fosamprenavir calcium (tablet) 5

INVIRASE (200 MG CAPSULE, 500 MG TABLET) 5

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 5

KALETRA 80 MG-20 MG/ML SOLN 6

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 5

lopinavir-ritonavir (solution) 5

NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGELCAP)

5

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION,150 MG TABLET, 400 MG TABLET, 600 MG TABLET,800 MG TABLET)

5

REYATAZ 50 MG POWDER PACKET 5

ritonavir (tablet) 5

VIRACEPT (TABLET) 5



ANTI-INFLUENZA AGENTS

oseltamivir 6 mg/ml suspension 3 QL 6 BOTTLES (360 ML)/ 365 DAYS

oseltamivir phos 30 mg capsule 3 QL 40 / 365 DAYS

oseltamivir phosphate (45 mg capsule, 75 mgcapsule)

3 QL 20 / 365 DAYS

RELENZA (BLST W/DEV) 4 QL 2 INHALERS (40DISKS) / 365 DAYS

rimantadine hcl (tablet) 2

ANTIHERPETIC AGENTSacyclovir (5% ointment, 200 mg capsule, 200 mg/5ml susp, 400 mg tablet, 800 mg tablet)

2

famciclovir (tablet) 2

trifluridine (drops) 2

valacyclovir (tablet) 2 QL 4 / DAY

ANXIOLYTICSANXIOLYTICS, OTHER

buspirone hcl (tablet) 2

ketamine hcl (100 mg/ml vial, 200 mg/20 ml vial,500 mg/10 ml vial, 500 mg/5 ml vial, 1,000 mg/10ml vial)

3

meprobamate (tablet) 2

midazolam hcl (hcl 1 mg/ml vial, 2 mg/2 ml isecure,2 mg/2 ml syringe, hcl 2 mg/2 ml vial, hcl 2 mg/mlsyrup, 5 mg/ml isecure syr, 5 mg/ml syringe, hcl 5mg/5 ml vial, hcl 5 mg/ml vial, 10 mg/2 ml syringe,hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, hcl 25mg/5 ml vial, hcl 50 mg/10 ml vial)

3

quazepam (tablet) 3 QL 1 / DAY

BENZODIAZEPINESalprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mgtablet)

2 QL 4 / DAY



alprazolam 2 mg tablet 2 QL 5 / DAY

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 2 QL 1 / DAY

alprazolam er 2 mg tablet 2 QL 5 / DAY

alprazolam er 3 mg tablet 2 QL 3 / DAY

alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt1 mg tab)

3 QL 4 / DAY

alprazolam odt 2 mg tab 3 QL 5 / DAY

alprazolam xr (0.5 mg tablet, 1 mg tablet) 2 QL 1 / DAY

alprazolam xr 2 mg tablet 2 QL 5 / DAY

alprazolam xr 3 mg tablet 2 QL 3 / DAY

chlordiazepoxide 10 mg capsule 2 QL 30 / DAY



clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25mg odt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet,1 mg dis tablet, 1 mg odt, 1 mg tablet, 2 mg tablet)

2 QL 3 / DAY

clonazepam 2 mg odt 2 QL 10 / DAY

clorazepate 15 mg tablet 2 QL 6 / DAY

clorazepate 3.75 mg tablet 2 QL 24 / DAY

clorazepate 7.5 mg tablet 2 QL 12 / DAY

diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oralsoln, 5 mg/5 ml solution, 10 mg tablet)

2

diazepam (5 mg/ml oral conc, 10 mg/2 ml carpuject,10 mg/2 ml syringe)

3

lorazepam (0.5 mg tablet, 1 mg tablet) 2 QL 3 / DAY

lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20mg/10 ml vial, 40 mg/10 ml vial)

3



lorazepam 2 mg tablet 2 QL 5 / DAY

lorazepam 2 mg/ml oral concent 3 QL 5 BOTTLES (150 ML)/ 30 DAYS

lorazepam intensol (oral conc) 3 QL 5 BOTTLES (150 ML)/ 30 DAYS

oxazepam (capsule) 2 QL 4 / DAY

BIPOLAR AGENTSMOOD STABILIZERS

lithium (solution) 2

lithium carbonate (150 mg cap, 300 mg cap, 300 mgtab, 600 mg cap)

2

lithium carbonate er (tablet er) 2

BLOOD GLUCOSE REGULATORSANTIDIABETIC AGENTS

acarbose (tablet) 2

BYDUREON (VIAL) 4QL 4 VIALS / 28 DAYS

ST

BYDUREON BCISE (AUTO INJCT) 4QL 4 AUTO-INJECTOR

(3.4 ML) / 28 DAYSST

BYDUREON PEN (PEN INJCTR) 4QL 4 PENS / 28 DAYS

ST

BYETTA 10 MCG DOSE PEN INJ 4QL 1 PEN (2.4 ML) / 30

DAYSST

BYETTA 5 MCG DOSE PEN INJ 4QL 1 PEN (1.2 ML) / 30

DAYSST

chlorpropamide (tablet) 2

glimepiride (tablet) 2



glipizide (tablet) 2

glipizide er (tab er 24) 2

glipizide xl (tab er 24) 2

glipizide-metformin (tablet) 2

glyburide (tablet) 2

glyburide micronized (tablet) 2

glyburide-metformin hcl (tablet) 2

INVOKAMET (50-1,000 MG TABLET, 50-500 MGTABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)

4 ST

INVOKAMET XR (50-1,000 MG TAB, 50-500 MGTABLET, 150-1,000 MG TAB, 150-500 MG TABLET)

4 ST

INVOKANA (100 MG TABLET, 300 MG TABLET) 4 ST

JANUMET (50-1,000 MG TABLET, 50-500 MGTABLET)

4 ST

JANUMET XR (50-1,000 MG TABLET, 50-500 MGTABLET, 100-1,000 MG TABLET)

4 ST

JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MGTABLET)

4 ST

JARDIANCE (10 MG TABLET, 25 MG TABLET) 4 ST

JENTADUETO (2.5 MG-1000 MG TAB, 2.5 MG-500MG TAB, 2.5 MG-850 MG TAB)

4 ST

metformin hcl (500 mg tablet, 850 mg tablet, 1,000mg tablet)

2

metformin hcl er 500 (generic for glucophage xr) 2

metformin hcl er 750 mg tablet 2

nateglinide (tablet) 2

pioglitazone hcl (tablet) 2

pioglitazone-glimepiride (tablet) 2

pioglitazone-metformin (tablet) 2



repaglinide (tablet) 2

repaglinide-metformin hcl (tablet) 3

SYNJARDY (5-1,000 MG TABLET, 5-500 MG TABLET,12.5-1,000 MG TABLET, 12.5-500 MG TABLET)

4 ST

tolazamide (tablet) 2

tolbutamide (tablet) 2

TRADJENTA (TABLET) 4 ST

TRULICITY (0.75 MG/0.5 ML PEN, 1.5 MG/0.5 MLPEN)

4QL 4 PENS (2 ML) / 28

DAYSST

VICTOZA 2-PAK (PEN INJCTR) 4QL 3 PENS (9 ML) / 30

DAYSST

GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 4

GLUCAGON EMERGENCY KIT (VIAL) 4

glucagon hcl (vial) 3

INSULINSHUMALOG (100 UNITS/ML CARTRIDGE, 100UNITS/ML VIAL)

4

HUMALOG JUNIOR KWIKPEN (INS PEN HF) 4

HUMALOG KWIKPEN U-100 (INSULN PEN) 4

HUMALOG KWIKPEN U-200 (INSULN PEN) 4

HUMALOG MIX 50-50 (VIAL) 4

HUMALOG MIX 50-50 KWIKPEN (INSULN PEN) 4

HUMALOG MIX 75-25 (VIAL) 4

HUMALOG MIX 75-25 KWIKPEN (INSULN PEN) 4

HUMULIN 70-30 (VIAL) 4



HUMULIN 70/30 KWIKPEN (INSULN PEN) 4

HUMULIN N (VIAL) 4

HUMULIN N KWIKPEN (INSULN PEN) 4

HUMULIN R (VIAL) 4

HUMULIN R U-500 (VIAL) 4

LANTUS (VIAL) 4

LANTUS SOLOSTAR (INSULN PEN) 4

NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/MLVIAL)

4

NOVOLOG FLEXPEN (INSULN PEN) 4

NOVOLOG MIX 70-30 (VIAL) 4

NOVOLOG MIX 70-30 FLEXPEN (INSULN PEN) 4

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERSANTICOAGULANTS

ARIXTRA (SYRINGE) 6 QL 35 DAY SUPPLY / 180DAYS

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 mlsyr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/mlsyringe, 120 mg/0.8 ml syr, 150 mg/ml syringe, 300mg/3 ml vial)

6 QL 35 DAY SUPPLY / 180DAYS

fondaparinux sodium (syringe) 6 QL 35 DAY SUPPLY / 180DAYS

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/MLSYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 MLVL)



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSheparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2ml vial, 5,000 unit/ml carpujct, sod 5,000 unit/ 0.5ml, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod10,000 unit/ml vl, sod 20,000 unit/ml vl, 30,000unit/30 ml vial, 40,000 unit/4 ml vial, 50,000 unit/10ml vial, 50,000 unit/5 ml vial)

3

jantoven (tablet) 2

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 MLSYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 MLSYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL)


PRADAXA (CAPSULE) 4 QL 2 / DAY

warfarin sodium (tablet) 2

XARELTO (10 MG TABLET, 20 MG TABLET) 4 QL 1 / DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 4 QL 2 / DAY

XARELTO STARTER PACK 4 QL 1 PACK (51 TABLETS)/ 30 DAYS

BLOOD FORMATION MODIFIERS

anagrelide hcl (capsule) 2

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 MLSYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 MLSYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 MLSYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 MLSYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 MLSYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 MLSYRINGE, 300 MCG/ML VIAL, 500 MCG/1 MLSYRINGE)

5 PA

EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/MLVIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL,20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL)

6 PA

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5ML SYRINGE, 300 MCG/ML VIAL, 480 MCG/0.8 MLSAFE SYR, 480 MCG/0.8 ML SYRINGE, 480 MCG/1.6ML VIAL)

5 PA



LEUKINE (VIAL) 6 PA

MIRCERA (30 MCG/0.3 ML SYRINGE, 50 MCG/0.3 MLSYRINGE, 75 MCG/0.3 ML SYRINGE, 100 MCG/0.3ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 200MCG/0.3 ML SYRINGE)

6 PA

NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6MG/0.6 ML KIT)

6 PA

NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/MLVIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL)

5 PA

PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/MLVIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL,20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)

5 PA

PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50MG TABLET, 75 MG TABLET)

6 PA

ZARXIO (300 MCG/0.5 ML SYRINGE, 480 MCG/0.8ML SYRINGE)

5 PA

COAGULANTS

aminocaproic acid (500 mg tab, 1,000 mg tab) 3

tranexamic acid 650 mg tablet 3

PLATELET MODIFYING AGENTS

BRILINTA (TABLET) 4

cilostazol (tablet) 2

clopidogrel (tablet) 2

dipyridamole (25 mg tablet, 50 mg tablet, 75 mgtablet)

2

EFFIENT (TABLET) 4

prasugrel hcl (tablet) 2

ticlopidine hcl (tablet) 2

CARDIOVASCULAR AGENTSALPHA-ADRENERGIC AGONISTS

clonidine (patch tdwk) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSclonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mgtablet)

2

guanfacine hcl (tablet) 2

methyldopa (tablet) 2

midodrine hcl (tablet) 2

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (tablet) 2

phenoxybenzamine hcl (capsule) 2

prazosin hcl (capsule) 2

reserpine (tablet) 2

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil (tablet) 2

eprosartan mesylate (tablet) 3

irbesartan (tablet) 2

losartan potassium (tablet) 2

olmesartan medoxomil (tablet) 2

telmisartan (tablet) 2

valsartan (tablet) 2

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (tablet) 2

captopril (tablet) 2

enalapril maleate (tablet) 2

fosinopril sodium (tablet) 2

lisinopril (tablet) 2

moexipril hcl (tablet) 2



perindopril erbumine (tablet) 2

quinapril hcl (tablet) 2

ramipril (capsule) 2

trandolapril (tablet) 2

ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400mg tablet)

2

disopyramide phosphate (capsule) 2

dofetilide (capsule) 3

flecainide acetate (tablet) 2

mexiletine hcl (capsule) 2

MULTAQ (TABLET) 4

pacerone 200 mg tablet 2

propafenone hcl (tablet) 2

propafenone hcl er (cap er 12h) 3

quinidine gluc 80 mg/ml vial 3

quinidine gluc er 324 mg tab 2

quinidine sulfate (sulf er 300 mg tab, sulfate 200 mgtab, sulfate 300 mg tab)

2

sorine (tablet) 3

sotalol (tablet) 2

TIKOSYN (CAPSULE) 4

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (capsule) 2

atenolol (tablet) 2

betaxolol hcl (10 mg tablet, 20 mg tablet) 2



bisoprolol fumarate (tablet) 2

carvedilol (tablet) 2

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)

2

metoprolol succinate (tab er 24h) 2

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mgtab)

2

nadolol (tablet) 2

pindolol (tablet) 2

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet,80 mg tablet)

2

propranolol hcl er (cap sa 24h) 2

timolol maleate (5 mg tablet, 10 mg tablet, 20 mgtablet)

2

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr (tablet er) 2

amlodipine besylate (tablet) 2

cartia xt (cap er 24h) 2

dilt-xr (cap er deg) 2

diltiazem 12hr er (cap er 12h) 2

diltiazem 24hr cd (120 mg cap, 180 mg cap, 240 mgcap, 300 mg cap)

2

diltiazem 24hr cd 360 mg cap 3

diltiazem 24hr er (er 120 mg cap, er 180 mg cap, er240 mg cap, er 300 mg cap, er 420 mg cap)

2

diltiazem 24hr er (er 180 mg tab, er 240 mg tab, er300 mg tab, er 360 mg cap, er 360 mg tab, er 420mg tab)

3

diltiazem er (cap er deg) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSdiltiazem hcl (30 mg tablet, 60 mg tablet, 90 mgtablet, 120 mg tablet)

2

felodipine er (tab er 24h) 2

isradipine (capsule) 2

matzim la (tab er 24h) 3

nicardipine hcl (20 mg capsule, 30 mg capsule) 2

nifedical xl (tab er 24) 2

nifedipine (capsule) 2

nifedipine er (tab er 24, tablet er) 2

nimodipine (capsule) 3

nisoldipine (tab er 24h) 3

taztia xt (cap sa 24h) 2

verapamil er (er 120 mg capsule, er 120 mg tablet,er 180 mg capsule, er 180 mg tablet, er 240 mgcapsule, er 240 mg tablet)

2

verapamil er pm (cap24h pct) 2

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mgtablet, 360 mg cap pellet)

2

verapamil sr (cap24h pel) 2

CARDIOVASCULAR AGENTS, OTHER

alprostadil (vial) 3

amiloride-hydrochlorothiazide (tablet) 2

amlodipine besylate-benazepril (capsule) 2

atenolol-chlorthalidone (tablet) 2

benazepril-hydrochlorothiazide (tablet) 2

bisoprolol-hydrochlorothiazide (tablet) 2

BYVALSON (TABLET) 4



candesartan-hydrochlorothiazid (tablet) 3

captopril-hydrochlorothiazide (tablet) 2

digitek (tablet) 2

digox (tablet) 2

digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25mg tablet, 125 mcg tablet, 250 mcg tablet)

2

digoxin 0.25 mg/ml syringe 3

enalapril-hydrochlorothiazide (tablet) 2

fosinopril-hydrochlorothiazide (tablet) 2

irbesartan-hydrochlorothiazide (tablet) 2

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET,187.5 MCG TABLET, 250 MCG TABLET)

4

lisinopril-hydrochlorothiazide (tablet) 2

losartan-hydrochlorothiazide (tablet) 2

methyldopa-hydrochlorothiazide (tablet) 2

metoprolol-hydrochlorothiazide (tablet) 2

moexipril-hydrochlorothiazide (tablet) 2

nadolol-bendroflumethiazide (tablet) 3

olmesartan-hydrochlorothiazide (tablet) 2

pentoxifylline (tablet er) 2

phenylephrine hcl (10 mg/ml vial, 50 mg/5 ml vial,100 mg/10 ml vl)

3

propranolol-hydrochlorothiazid (tablet) 2

quinapril-hydrochlorothiazide (tablet) 2

spironolactone-hctz (tablet) 2

TEKTURNA (150 MG TABLET, 300 MG TABLET) 4 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTEKTURNA HCT (150-12.5 MG TAB, 150-25 MGTABLET, 300-12.5 MG TAB, 300-25 MG TABLET)

4 ST

telmisartan-hydrochlorothiazid (tablet) 2

trandolapril-verapamil er (tab bp 24h) 2

triamterene-hydrochlorothiazid (37.5-25 mg cp,37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab)

2

valsartan-hydrochlorothiazide (tablet) 2

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tablet, 250 mg tablet) 2

acetazolamide er 500 mg cap 3

KEVEYIS (TABLET) 6QL 4 / DAY

PA

DIURETICS, LOOPbumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5mg/10 ml vial)

3

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 2

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)

2

furosemide (20 mg/2 ml vial, 40 mg/4 ml syringe, 40mg/4 ml vial, 100 mg/10 ml syring, 100 mg/10 mlvial)

3

torsemide (tablet) 2

DIURETICS, POTASSIUM-SPARING

amiloride hcl (tablet) 2

eplerenone (tablet) 3

spironolactone (tablet) 2

DIURETICS, THIAZIDE

chlorothiazide (tablet) 2

chlorthalidone (tablet) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONShydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 25 mgtab, 50 mg tab)

2

indapamide (tablet) 2

methyclothiazide (tablet) 2

metolazone (tablet) 2

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (40 mg tablet, 120 mg tablet) 3

fenofibrate (43 mg capsule, 48 mg tablet, 50 mgcapsule, 54 mg tablet, 67 mg capsule, 130 mgcapsule, 134 mg capsule, 145 mg tablet, 150 mgcapsule, 160 mg tablet, 200 mg capsule)

2

fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mgtablet, dr 135 mg cap)

2

gemfibrozil (tablet) 2

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin 10 mg tablet 1

atorvastatin calcium (20 mg tablet, 40 mg tablet, 80mg tablet)

2

fluvastatin er (tab er 24h) 3

fluvastatin sodium (capsule) 3

lovastatin (10 mg tablet, 40 mg tablet) 2

lovastatin 20 mg tablet 1

pravastatin sodium (tablet) 2

rosuvastatin calcium (tablet) 2

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet,40 mg tablet)

2

simvastatin 80 mg tablet 2 PA

DYSLIPIDEMICS, OTHER

cholestyramine light powder 2



colesevelam hcl (hcl 3.75 g packet, 625 mg tablet) 2

colestipol hcl (hcl 1 gm tablet, hcl granules, hclgranules packet, micronized 1 gm tab)

2

ezetimibe (tablet) 3

JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MGCAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE)

6QL 1 / DAY

PA

KYNAMRO (SYRINGE) 6QL 4 SYRINGES (4 ML) /

28 DAYSPA

niacin er (tab er 24h) 2

niacor (tablet) 2

omega-3 acid ethyl esters (capsule) 2

PRALUENT PEN (PEN INJCTR) 5QL 2 PENS (2 ML) / 28

DAYSPA

PRALUENT SYRINGE (SYRINGE) 5QL 2 SYRINGES (2 ML) /

28 DAYSPA

prevalite powder 2

REPATHA PUSHTRONEX (WEAR INJCT) 5QL 1 CARTRIDGE (3.5

ML) / 28 DAYSPA

REPATHA SURECLICK (PEN INJCTR) 5QL 3 PENS (3 ML) / 28

DAYSPA

REPATHA SYRINGE (SYRINGE) 5QL 3 SYRINGES (3 ML) /

28 DAYSPA

triklo (capsule) 2

VASCEPA (CAPSULE) 4



VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine 20 mg/ml vial 3

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mgtablet, 100 mg tablet)

2

minoxidil (2.5 mg tablet, 10 mg tablet) 2

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

amyl nitrite (ampul) 3

isochron (tablet er) 2

isosorbide dinitrate (tablet) 2

isosorbide dinitrate er (tablet er) 2

isosorbide mononitrate (tablet) 2

isosorbide mononitrate er (tab er 24h) 2

minitran (0.2 mg/hr patch, 0.4 mg/hr patch, 0.6mg/hr patch)

2

nitroglycerin (0.3 mg tablet sl, 0.4 mg tablet sl, 0.6mg tablet sl, er 2.5 mg cap, er 6.5 mg cap, er 9 mgcapsule)

2

nitroglycerin 400 mcg spray 3

nitroglycerin patch (patch td24) 2

CENTRAL NERVOUS SYSTEM AGENTSATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

dextroamp-amphetamin 30 mg tab 2QL 2 / DAY

PA

dextroamphetamine 10 mg tab 2QL 6 / DAY

PA

dextroamphetamine 5 mg tab 2QL 3 / DAY

PA

dextroamphetamine 5 mg/5 ml 2QL 1800 ML / 30 DAYS

PA



dextroamphetamine er 10 mg cap 2QL 6 / DAY

PA


PA


PA

dextroamphetamine-amphet er (cap er 24h) 2QL 1 / DAY

PA

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5mg tab, dextroamp-amphetamin 10 mg tab,dextroamp-amphetamin 15 mg tab, dextroamp-amphetamin 20 mg tab, dextroamp-amphetamine 5mg tab)

2QL 3 / DAY

PA

methamphetamine hcl (tablet) 2QL 5 / DAY

PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINESatomoxetine hcl (10 mg capsule, 18 mg capsule, 25mg capsule, 40 mg capsule)

2 QL 2 / DAY

atomoxetine hcl (60 mg capsule, 80 mg capsule, 100mg capsule)

2 QL 1 / DAY

clonidine hcl er (tab er 12h) 3

dexmethylphenidate er 20 mg cp 2QL 2 / DAY

PA

dexmethylphenidate hcl (tablet) 2QL 2 / DAY

PA

dexmethylphenidate hcl er (er 5 mg cap, er 10 mgcp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mgcp, er 40 mg cp)

2QL 1 / DAY

PA

guanfacine hcl er (tab er 24h) 2

metadate er (tablet er) 2QL 3 / DAY

PA



methylphenidate 10 mg chew tab 2QL 6 / DAY

PA

methylphenidate 10 mg/5 ml sol 2QL 900 ML / 30 DAYS

PA

methylphenidate 5 mg/5 ml soln 2QL 1800 ML / 30 DAYS

PA

methylphenidate er (er 10 mg tab, er 36 mg tab) 2QL 2 / DAY

PA

methylphenidate er (er 18 mg tab, er 27 mg tab, er54 mg tab)

2QL 1 / DAY

PA

methylphenidate er (la) (10mg, 20mg, 30mg, 40mg) 2QL 1 / DAY

PA

methylphenidate er 20 mg tab 2QL 3 / DAY

PA

methylphenidate hcl (2.5 mg chew tb, 5 mg chewtab, 5 mg tablet, 10 mg tablet, 20 mg tablet)

2QL 3 / DAY

PA

methylphenidate hcl cd (cpbp 30-70) 2QL 1 / DAY

PA

methylphenidate hcl er (cd) (cpbp 30-70) 2QL 1 / DAY

PA

methylphenidate la (10 mg cap, 20 mg cap, 30 mgcap, 40 mg cap)

2QL 1 / DAY

PA

methylphenidate la 60 mg cap 3QL 1 / DAY

PA

CENTRAL NERVOUS SYSTEM, OTHER

butalb-acetamin-caff 50-300-40 3

butalbital-acetaminophen-caffe (butalb-acetamin-caff 50-325-40, butalbit-acetaminophen-caff cp)

2

butalbital-acetaminophn 50-325 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSbutalbital-aspirin-caffeine (butalb-aspirin-caffe 50-325-40, butalbital-asa-caffeine cap)

2

capacet (capsule) 2

tencon (tablet) 2

tetrabenazine (12.5 mg tablet, 25 mg tablet) 5 PA

vanatol lq (solution) 3

vanatol s (solution) 3

FIBROMYALGIA AGENTS

duloxetine hcl (dr 20 mg cap, dr 60 mg cap) 2 QL 2 / DAY

duloxetine hcl dr 30 mg cap 2 QL 3 / DAY

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200MG CAPSULE, 225 MG CAPSULE)

4 QL 3 / DAY

LYRICA 300 MG CAPSULE 4 QL 2 / DAY

MULTIPLE SCLEROSIS AGENTS

AVONEX 30 MCG VIAL KIT 5QL 4 KITS (4 VIALS) / 28

DAYSPA

AVONEX PEN (PEN IJ KIT) 5QL 1 KIT / 28 DAYS

PA

AVONEX PREFILLED SYR 30 MCG KT 5QL 1 KIT / 28 DAYS

PA

BETASERON (KIT) 5QL 1 KIT (15 VIALS) / 30

DAYSPA

COPAXONE 20 MG/ML SYRINGE 5QL 1 KIT (30 SYRINGES) /

30 DAYSPA

COPAXONE 40 MG/ML SYRINGE 5QL 1 KIT (12 SYRINGES) /

28 DAYSPA



dalfampridine er (tab er 12h) 5QL 2 / DAY

PA

glatiramer 20 mg/ml syringe 5QL 1 KIT (30 SYRINGES) /

30 DAYSPA

glatiramer 40 mg/ml syringe 5QL 1 KIT (12 SYRINGES) /

28 DAYSPA

glatopa 20 mg/ml syringe 6QL 1 KIT (30 SYRINGES) /

30 DAYSPA

glatopa 40 mg/ml syringe 6QL 1 KIT (12 SYRINGES) /

28 DAYSPA

TECFIDERA (DR 120 MG CAPSULE, DR 240 MGCAPSULE)

5QL 2 / DAY

PA

TECFIDERA STARTER PACK 5QL

1 PACK (60CAPSULES) / 365DAYS

PA

DENTAL AND ORAL AGENTS

cevimeline hcl (capsule) 3

chlorhexidine 0.12% rinse 2

oralone (paste (g)) 2

paroex (mouthwash) 2

periogard (mouthwash) 2

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 2

triamcinolone 0.1% paste 2

DERMATOLOGICAL AGENTS

acitretin (capsule) 2



adapalene (cream, gel) 2 PA

adapalene (gel, gel pump) 3 PA

ammonium lactate (cream, lotion) 3

amnesteem (10 mg capsule, 20 mg capsule, 40 mgcapsule)

2 PA

benzepro (6% foaming cloths, 7% creamy wash) 3

bp-50% urea (emulsn(g)) 3

bpo (4% gel, 6% foaming cloths, 8% gel) 3

calcipotriene (cream, ointment, solution) 3

calcitriol 3 mcg/g ointment 2

claravis (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

2 PA

clind ph-benzoyl perox 1.2-5% 3

clindacin p (med. swab) 2

clindamycin phos 1% pledget 2

clindamycin-benzoyl perox 1-5% 2

clotrimazole-betamethasone (crm, lot) 2

COSENTYX (2 SYRINGES) (SYRINGE) 6 PA

COSENTYX PEN (2 PENS) (PEN INJCTR) 6 PA

COSENTYX PEN (PEN INJCTR) 6 PA

COSENTYX SYRINGE (SYRINGE) 6 PA

DUPIXENT 200 MG/1.14 ML SYRING 5QL 4 SYRINGES (4.6 ML)

/ 28 DAYSPA

DUPIXENT 300 MG/2 ML SAFE SYRG 5QL 4 SYRINGES (8 ML) /

28 DAYSPA



erythromycin-benzoyl peroxide (gel (gram)) 2

fluorouracil (2% soln, 5% soln) 3

fluorouracil 0.5% cream 4

fluorouracil 5% cream 2

hydrocortisone-pramoxine (1%-1%, 2.5-1%) 2

hydrocortisone-pramoxine hcl (cream (g)) 3

imiquimod 5% cream packet 2

isotretinoin (capsule) 2 PA

lactic acid (e cream, lotion) 3

lidocaine-hydrocortisone (3-0.5% cream, 3-0.5%cream kit)

3

lugol's strong iodine solution 3

melpaque hp (cream (g)) 3

methoxsalen (cap lq rap) 2

metopic (cream (g)) 3

MIRVASO (GEL, GEL PUMP) 4

myorisan (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

2 PA

neuac gel 3

podocon-25 (liquid) 2

podofilox (solution) 2

pramcort (cream/appl) 2

rea lo 39 (cream (g)) 3

rea lo 40 cream 3

rea lo 40 lotion 2



salacyn (cream, lotion) 3

salicylic acid (6% foam, 6% gel, 6% shampoo, 26%liquid, 27.5% liquid)

3

seb-prev (cleanser) 2

selenium sulfide 2.25% shampoo 3

selenium sulfide 2.5% lotion 2

silver nitrate (0.5% soln, 10% solution, 25% solution,50% solution)

2

silver nitrate 10% ointment 3

silver nitrate applicator (stick (ea)) 3

sod sulfacetamide 10% shampoo 3

sodium sulfacetamide 10% wash 2

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/MLSYRINGE)

5 PA

sulfacetamide sodium (sod top susp, sodium lotn) 3

tacrolimus (0.03% ointment, 0.1% ointment) 2

tretinoin (0.01% gel, 0.025% cream, 0.025% gel,0.05% cream, 0.05% gel, 0.1% cream)

2 PA

tretinoin microsphere (gel 0.04%, gel 0.1%) 2 PA

urea (35% foam, 39% cream, 40% cream, 40% gel,41% cream, 45% cream, 45% nail gel, 47% cream,50% nail stick)

3

urea 45% lotion 2

zenatane (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

2 PA

ENZYME REPLACEMENT/MODIFIERS

ADAGEN (VIAL) 6

BUPHENYL (500 MG TABLET, POWDER) 6

CERDELGA (CAPSULE) 6 PA



CREON (CAPSULE DR) 4

CYSTAGON (CAPSULE) 6

KUVAN (100 MG POWDER PACKET, 100 MG TABLET,500 MG POWDER PACKET)

5 PA

miglustat (capsule) 5 PA

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE)

6 PA

PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 6 PA

RAVICTI (LIQUID) 6 PA

sodium phenylbutyrate (500mg tb, powder) 6

STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 MLVIAL, 40 MG/ML VIAL, 80 MG/0.8 ML VIAL)

5 PA

SUCRAID (SOLUTION) 6

GASTROINTESTINAL AGENTSANTISPASMODICS, GASTROINTESTINAL

atropine sulfate (0.05 mg/ml syringe, 0.1 mg/mlsyringe, 0.4 mg/ml vial, 0.5 mg/5 ml abboject, 1mg/10 ml abboject, 1 mg/ml vial, 8 mg/20 ml vial)

3

belladonna-phenobarbital tab 3

chlordiazepoxide-clidinium (capsule) 2

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20mg tablet)

2

ed-spaz (tab rapdis) 3

glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1 mgtablet, 1 mg/5 ml vial, 1.5 mg tablet, 2 mg tablet, 4mg/20 ml vial)

3

hyoscyamine 0.125 mg odt 3

hyoscyamine sulfate (0.125 mg tab sl, 0.125 mg/5 mlelix, 0.125 mg/ml drop, sulf 0.125 mg tab)

2

hyoscyamine sulfate er (tab er 12h) 2



hyoscyamine sulfate sr (tab er 12h) 2

methscopolamine bromide (tablet) 3

oscimin 0.125 mg odt 3

oscimin 0.125 mg tablet 2

oscimin sl (tab subl) 2

oscimin sr (tab er 12h) 2

phenohytro tablet 2

propantheline bromide (tablet) 2

symax (tab rapdis) 2

symax-sl (tab subl) 2

symax-sr (tab er 12h) 2

GASTROINTESTINAL AGENTS, OTHER

CHOLBAM (50 MG CAPSULE, 250 MG CAPSULE) 6 PA

cromolyn 100 mg/5 ml oral conc 2

diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025)

2

FULYZAQ (TABLET DR) 4 QL 2 / DAY

GATTEX 5 MG 30-VIAL KIT 6 PA

lansoprazol-amoxicil-clarithro (combo. pkg) 3

loperamide 2 mg capsule 3

MOTOFEN (TABLET) 4

MOVANTIK (12.5 MG TABLET, 25 MG TABLET) 4QL 1 / DAY

ST

MYTESI (TABLET DR) 4 QL 2 / DAY

opium tincture (tincture) 3



paregoric (liquid) 2

PYLERA (CAPSULE) 4

RELISTOR (12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL)

4QL 1 SYRINGE (0.6 ML) /

DAYPA

RELISTOR 8 MG/0.4 ML SYRINGE 4QL 1 SYRINGE (0.4 ML) /

DAYPA

ursodiol (250 mg tablet, 300 mg capsule, 500 mgtablet)

2

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (300 mg tablet, 300 mg/5 ml soln, 400mg tablet, 800 mg tablet)

2

cimetidine 200 mg tablet 3

famotidine (20 mg tablet, 40 mg/5 ml susp) 3

famotidine 40 mg tablet 2

nizatidine (15 mg/ml solution, 150 mg capsule, 300mg capsule)

2

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150mg tablet, 150 mg/10 ml syrup, 300 mg capsule, 300mg tablet)

2

ranitidine hcl 150 mg/6 ml vl 3

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (0.5 mg tablet, 1 mg tablet) 3 PA

AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) 4QL 2 / DAY

ST

LINZESS (72 MCG CAPSULE, 145 MCG CAPSULE, 290MCG CAPSULE)

4QL 1 / DAY

ST

LOTRONEX (0.5 MG TABLET, 1 MG TABLET) 4 PA



LAXATIVESclearlax (eql powder, gnp powder, gs powder, hmpowder, powder, sm powder, sw powder)

1

constulose (solution) 2

cvs purelax powder 1

enulose (solution) 2

gavilax (powder) 1

gavilyte-c (soln recon) 1

gavilyte-g (soln recon) 1

gavilyte-n (soln recon) 1

generlac (solution) 2

gentlelax (powder) 1

glycolax (powder) 1

lactulose (10 gm/15 ml solution, 20 gm/30 mlsolution)

2

laxaclear (powder) 1

laxative peg 3350 (powder) 1

natura-lax (powder) 1

peg 3350-electrolyte (soln recon) 1

peg-3350 and electrolytes (soln recon) 1

polyethylene glycol 3350 (otc) 1

polyethylene glycol 3350 (powd pack, powder) 3

smoothlax powder 1

trilyte with flavor packets (soln recon) 1



PROTECTANTS

misoprostol (tablet) 2

sucralfate (tablet) 2

PROTON PUMP INHIBITORS

lansoprazole (dr 15 mg capsule, dr 30 mg capsule) 2 QL 2 / DAY

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr40 mg capsule)

2 QL 1 / DAY

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 2 QL 1 / DAY

rabeprazole sodium (tablet dr) 3 QL 1 / DAY

GENITOURINARY AGENTSANTISPASMODICS, URINARY

flavoxate hcl (tablet) 3

MYRBETRIQ (TAB ER 24H) 4

oxybutynin chloride (5 mg tablet, 5 mg/5 ml syrup) 2

oxybutynin chloride er (tab er 24) 2

tolterodine tartrate (tablet) 3

tolterodine tartrate er (cap er 24h) 3

trospium chloride (tablet) 3

trospium chloride er (cap er 24h) 3

VESICARE (TABLET) 4

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er (tab er 24h) 2

dutasteride (capsule) 2

finasteride 5 mg tablet 2

tadalafil (2.5 mg tablet, 5 mg tablet) 2 QL 1 / DAY

tamsulosin hcl (capsule) 2



terazosin hcl (capsule) 2

GENITOURINARY AGENTS, OTHER

bethanechol chloride (tablet) 2

CUPRIMINE (CAPSULE) 6 PA

ELMIRON (CAPSULE) 4

THIOLA (TABLET) 6

PHOSPHATE BINDERScalcium acetate (667 mg capsule, 667 mg gelcap,667 mg tablet)

2

eliphos (tablet) 2

sevelamer carbonate 800 mg tab 2

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

a-hydrocort (vial) 3

ala-cort 2.5% cream 2

alclometasone dipropionate (dipr oint, dipro crm) 2

amcinonide (cream, lotion, ointment) 3

anucort-hc (supp.rect) 2

betamethasone ac-sp 6 mg/ml vl 3

betamethasone diprop augmented (crm, gel, lot, oin) 2

betamethasone dipropionate (crm, lot, oint) 2

betamethasone valer 0.12% foam 3

betamethasone valerate (va cream, va lotion, valerointm)

2

clobetasol propionate (cream, gel, ointment,solution)

2

clobetasol propionate (prop foam, prop spray,shampoo, topical lotn)

3

clocortolone pivalate (cream ) 3



clodan 0.05% shampoo 3

cormax (solution) 2

cortisone acetate (tablet) 2

decadron 0.5 mg/5 ml elixir 2

desonide (cream, lotion, ointment) 2

desoximetasone (0.05% cream, 0.05% gel, 0.25%cream, 0.25% ointment)

2

desoximetasone 0.05% ointment 3

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mgtablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

2

dexamethasone sodium phosphate (4 mg/mlsyringe, 4 mg/ml vial, 10 mg/ml vial, 20 mg/5 mlvial, 100 mg/10 ml vl, 120 mg/30 ml vl)

3

diflorasone 0.05% cream 2

diflorasone 0.05% ointment 3

fludrocortisone acetate (tablet) 2

fluocinolone acetonide (0.01% body oil, 0.01%cream, 0.01% solution, 0.025% cream, 0.025%ointment)

2

fluocinonide (cream, gel, ointment, solution) 2

fluocinonide 0.1% cream 3

flurandrenolide (cream, lotion) 3

fluticasone prop 0.05% lotion 3

fluticasone propionate (0.005% oint, 0.05% cream) 2

halobetasol propionate (cream, ointmnt) 3

hemmorex-hc 25 mg suppository 2

hemmorex-hc 30 mg suppository 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONShydrocortisone (1% cream, 2.5% cream, 2.5% lotion,2.5% ointment, 5 mg tablet, 10 mg tablet, 20 mgtablet)

2

hydrocortisone 1% ointment 3

hydrocortisone ac 25 mg supp 2

hydrocortisone ac 30 mg supp 3

hydrocortisone butyrate (buty cream, butyr oint,butyr soln)

2

hydrocortisone valerate (cream, ointmt) 2

KORLYM (TABLET) 6QL 4 / DAY

PA

methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mgtab, 16 mg tab, 32 mg tab)

2

methylprednisolone acetate (40 mg/ml vl, 80 mg/mlvl)

3

methylprednisolone sodium succ (40 mg vl, 125 mg) 3

mometasone furoate (cream, oint, soln) 2

prednicarbate (cream, ointment) 3

prednisolone (solution) 2

prednisolone sod ph 25 mg/5 ml 3

prednisolone sodium phos odt (tab rapdis) 3

prednisolone sodium phosphate (5 mg/5 ml soln, 15mg/5 ml soln)

2

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tabdose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mgtab dose pack, 10 mg tablet, 20 mg tablet, 50 mgtablet)

2

psorcon (cream (g)) 2

scalacort (lotion) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONStriamcinolone acetonide (0.025% cream, 0.025%lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1%ointment, 0.5% cream, 0.5% ointment)

2

triamcinolone acetonide (0.147 mg/g spray, acet 40mg/ml vl, acet 40mg/ml vl, acet 50mg/5ml vl, 200mg/5 ml vial, 400 mg/10 ml vl)

3

triderm (cream ) 2

u-cort (cream (g)) 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

chorionic gonadotropin (vial) 6 PA

desmopressin acetate (0.01% solution, 0.01% spray,0.1 mg/ml sol, acetate 0.1 mg tb, acetate 0.2 mg tb,10 mcg/0.1 ml spr)

2

desmopressin acetate (ac 4 mcg/ml ampul, ac 4mcg/ml vial, 40 mcg/10 ml vial)

3

GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG,MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG,MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MGCARTRIDGE)

6 PA

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MGCARTRIDGE, 24 MG CARTRIDGE)

6 PA

INCRELEX (VIAL) 6 PA

NORDITROPIN FLEXPRO (PEN INJCTR) 5 PA

NOVAREL 10,000 UNITS VIAL 6 PA

NOVAREL 5,000 UNIT VIAL 6QL 1 VIAL / 30 DAYS

PA

NUTROPIN AQ (CARTRIDGE) 5 PA

NUTROPIN AQ NUSPIN (PEN INJCTR) 5 PA

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10MG/1.5 ML CRTG)

5 PA

PREGNYL (VIAL) 6 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8MG VIAL)

6 PA

SAIZEN-SAIZENPREP (CARTRIDGE) 6 PA

SEROSTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL) 6 PA

ZOMACTON (VIAL) 6 PA

ZORBTIVE (VIAL) 6 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)ANDROGENS

ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GELPCKT, 1.62%(2.5G) GEL PCKT)

4 PA

androxy (tablet) 2 PA

danazol (capsule) 2

methyltestosterone (capsule) 3 PA

oxandrolone 10 mg tablet 3QL 2 / DAY

PA

oxandrolone 2.5 mg tablet 3QL 8 / DAY

PA

testosterone (1.62% (2.5 g) pkt, 1.62% gel pump,1.62%(1.25 g) pkt, 25 mg/2.5 gm pkt, 50 mg/5 gramgel, 50 mg/5 gram pkt)

2 PA

testosterone 12.5 mg/1.25 gram 3 PA

testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100mg/ml, testosterone 200 mg/ml)

3 PA

testosterone enanthate (vial) 3 PA

ESTROGENS

altavera (tablet) 1

alyacen (tablet) 1

amabelz (tablet) 3



amethia (tbdspk 3mo) 1

amethia lo (tbdspk 3mo) 1

amethyst (tablet) 1

apri (tablet) 1

aranelle (tablet) 1

ashlyna (tbdspk 3mo) 1

aubra (tablet) 1

aubra eq (tablet) 1

aviane (tablet) 1

azurette (tablet) 1

balziva (tablet) 1

bekyree (tablet) 1

blisovi 24 fe (tablet) 1

blisovi fe (tablet) 1

briellyn (tablet) 1

camrese (tbdspk 3mo) 1

camrese lo (tbdspk 3mo) 1

caziant (tablet) 1

chateal (tablet) 1

chateal eq (tablet) 1

covaryx (tablet) 2

covaryx h.s. (tablet) 2

cryselle (tablet) 1

cyclafem (tablet) 1



cyred (tablet) 1

cyred eq (tablet) 1

dasetta (tablet) 1

daysee (tbdspk 3mo) 1

delyla (tablet) 1

desogestr-eth estrad eth estra (tablet) 1

desogestrel-ethinyl estradiol (tablet) 1

drospirenone-eth estra-levomef (tablet) 1

drospirenone-ethinyl estradiol (tablet) 1

eemt (tablet) 2

eemt h.s. (tablet) 2

elinest (tablet) 1

emoquette (tablet) 1

enpresse (tablet) 1

enskyce (tablet) 1

estarylla (tablet) 1

estradiol (0.025 mg patch, tds 0.025 mg/day, 0.0375mg patch, 0.0375 mg/day patch, tds 0.0375 mg/day,0.05 mg patch, tds 0.05 mg/day, 0.06 mg/day patch,tds 0.06 mg/day, 0.075 mg patch, 0.075 mg/daypatch, tds 0.075 mg/day, 0.1 mg patch, tds 0.1mg/day, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

2

estradiol 0.01% cream 3

estradiol-norethindrone acetat (tablet) 3

estrogen-methyltestosterone (tablet) 2

estropipate (tablet) 2



ethynodiol-ethinyl estradiol (tablet) 1

falmina (tablet) 1

fayosim (tbdspk 3mo) 1

femynor (tablet) 1

fyavolv (tablet) 3

gianvi (tablet) 1

gildagia (tablet) 1

gildess (tablet) 1

gildess 24 fe (tablet) 1

hailey 24 fe (tablet) 1

introvale (tbdspk 3mo) 1

isibloom (tablet) 1

jevantique lo (tablet) 3

jinteli (tablet) 3

jolessa (tbdspk 3mo) 1

juleber (tablet) 1

junel (tablet) 1

junel fe (tablet) 1

junel fe 24 (tablet) 1

kaitlib fe (tab chew) 1

kariva (tablet) 1

kelnor 1-35 (tablet) 1

kelnor 1-50 (tablet) 1

kimidess (tablet) 1



kurvelo (tablet) 1

larin (tablet) 1

larin 24 fe (tablet) 1

larin fe (tablet) 1

larissia (tablet) 1

leena (tablet) 1

lessina (tablet) 1

levonest (tablet) 1

levonorg-eth estrad eth estrad (tbdspk 3mo) 1

levonorgestrel-eth estradiol (tablet, tbdspk 3mo) 1

levora-28 (tablet) 1

lillow (tablet) 1

lomedia 24 fe (tablet) 1

lopreeza (tablet) 3

loryna (tablet) 1

low-ogestrel (tablet) 1

lutera (tablet) 1

marlissa (tablet) 1

melodetta 24 fe (tab chew) 1

mibelas 24 fe (tab chew) 1

microgestin (tablet) 1

microgestin fe (tablet) 1

mili (tablet) 1

mimvey (tablet) 3



mimvey lo (tablet) 3

mono-linyah (tablet) 1

mononessa (tablet) 1

myzilra (tablet) 1

necon (tablet) 1

nikki (tablet) 1

norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, noreth-estrad-fe 1-0.02(21)-75,noreth-estrad-fe 1-0.02(24)-75, norethin-estra-fe0.8-0.025 mg)

1

norethind-eth estrad 1-0.02 mg 1

norethindron-ethinyl estradiol (norethin-eth 1 mg-5mcg, norethind-eth 0.5-2.5)

3

norgestimate-ethinyl estradiol (tablet) 1

nortrel (tablet) 1

NUVARING (VAG RING) 1

ocella (tablet) 1

ogestrel (tablet) 1

orsythia (tablet) 1

philith (tablet) 1

pimtrea (tablet) 1

pirmella (tablet) 1

portia (tablet) 1

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)

4

PREMPHASE (TABLET) 4

PREMPRO (TABLET) 4



previfem (tablet) 1

quasense (tbdspk 3mo) 1

rajani (tablet) 1

reclipsen (tablet) 1

rivelsa (tbdspk 3mo) 1

setlakin (tbdspk 3mo) 1

sprintec (tablet) 1

sronyx (tablet) 1

syeda (tablet) 1

tarina fe (tablet) 1

tarina fe 1-20 eq (tablet) 1

tilia fe (tablet) 1

tri femynor (tablet) 1

tri-estarylla (tablet) 1

tri-legest fe (tablet) 1

tri-linyah (tablet) 1

tri-lo-estarylla (tablet) 1

tri-lo-marzia (tablet) 1

tri-lo-sprintec (tablet) 1

tri-mili (tablet) 1

tri-previfem (tablet) 1

tri-sprintec (tablet) 1

tri-vylibra (tablet) 1

trinessa (tablet) 1



trinessa lo (tablet) 1

trivora-28 (tablet) 1

tydemy (tablet) 1

velivet (tablet) 1

vestura (tablet) 1

vienva (tablet) 1

viorele (tablet) 1

vyfemla (tablet) 1

vylibra (tablet) 1

wera (tablet) 1

wymzya fe (tab chew) 1

xulane (patch tdwk) 1

zarah (tablet) 1

zenchent (tablet) 1

zenchent fe (tab chew) 1

zovia 1-35e (tablet) 1

zovia 1-50e (tablet) 1

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA (TABLET) 1

PROGESTINS

camila (tablet) 1

deblitane (tablet) 1

errin (tablet) 1

heather (tablet) 1



incassia (tablet) 1

jencycla (tablet) 1

jolivette (tablet) 1

lyza (tablet) 1

medroxyprogesterone 150 mg/ml 1

medroxyprogesterone acetate (2.5 mg tab, 5 mgtab, 10 mg tab)

2

megestrol 625 mg/5 ml susp 3

megestrol acetate (20 mg tablet, 40 mg tablet, acet40 mg/ml susp)

2

nora-be (tablet) 1

norethindrone (tablet) 1

norethindrone acetate (tablet) 2

norlyda (tablet) 1

norlyroc (tablet) 1

progesterone (oil 50 mg/ml vl, 100 mg capsule, 200mg capsule)

3

progesterone in oil (vial) 3

sharobel (tablet) 1

tulana (tablet) 1

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl (tablet) 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

EUTHYROX (TABLET) 2

LEVO-T (TABLET) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlevothyroxine sodium (25 mcg tablet, 50 mcg tablet,75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcg tablet, 300 mcgtablet)

2

LEVOXYL (TABLET) 2

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcgtab)

2

np thyroid (tablet) 3

thyroid (tablet) 3

UNITHROID (TABLET) 2

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR (TABLET) 4 PA

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline (tablet) 3

EGRIFTA 1 MG VIAL 6QL 2 VIALS / DAY

PA

EGRIFTA 2 MG VIAL 6QL 1 VIAL / DAY

PA

ELIGARD 22.5 MG SYRINGE KIT 6QL 1 SYRINGE / 84 DAYS

PA

ELIGARD 30 MG SYRINGE KIT 6QL 1 SYRINGE / 112

DAYSPA

ELIGARD 45 MG SYRINGE KIT 6QL 1 SYRINGE / 168

DAYSPA

ELIGARD 7.5 MG SYRINGE KIT 6QL 1 SYRINGE / 28 DAYS

PA

leuprolide acetate (kit) 6 PA



LUPANETA PK 11.25-5 MG 3MO KIT 6QL 1 KIT / 90 DAYS

PA

LUPANETA PK 3.75-5 MG 1MO KIT 6QL 1 KIT / 30 DAYS

PA

LUPRON DEPOT (3.75 MG KIT, 11.25 MG 3MO KIT) 6 PA

LUPRON DEPOT (7.5 MG KIT, 45 MG 6MO KIT) 5 PA

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 22.5MG 3MO KIT)

5 PA

LUPRON DEPOT-PED (7.5 MG KIT, 15 MG KIT, 30 MG3MO KIT)

5 PA

LUPRON DEPOT-PED 11.25 MG 3MO 6 PA

LUPRON DEPOT-PED 11.25 MG KIT 6 PA

octreotide acetate (acet 0.05 mg/ml vl, acet 50mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/mlvial, acet 100 mcg/ml amp, acet 100 mcg/ml syr,acet 100 mcg/ml vl, acet 200 mcg/ml vl, acet 500mcg/ml amp, acet 500 mcg/ml syr, acet 500 mcg/mlvl, 1,000 mcg/5 ml vial, 1,000 mcg/ml vial, 5,000mcg/5 ml vial)

6 PA

SIGNIFOR (AMPUL) 6QL 2 AMPULES / DAY

PA

SOMATULINE DEPOT (60 MG/0.2 ML, 90 MG/0.3ML, 120 MG/0.5 ML)

6 PA

SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL,25 MG VIAL, 30 MG VIAL)

6 PA

SYNAREL (SPRAY) 4

ZOLADEX 10.8 MG IMPLANT SYRN 6 QL 1 IMPLANT / 84DAYS

ZOLADEX 3.6 MG IMPLANT SYRN 6 QL 1 IMPLANT / 28DAYS



HORMONAL AGENTS, SUPPRESSANT (THYROID)ANTITHYROID AGENTS

methimazole (tablet) 2

propylthiouracil (tablet) 2

IMMUNOLOGICAL AGENTSANGIOEDEMA (HAE) AGENTS

FIRAZYR (SYRINGE) 6 PA

KALBITOR (VIAL) 6 PA

IMMUNE SUPPRESSANTS

azathioprine (tablet) 2

azathioprine sodium (vial) 3

CIMZIA (200 MG VIAL KIT, 200 MG/ML STARTER KIT,200 MG/ML SYRINGE KIT)

5 PA

cyclosporine (25 mg capsule, 100 mg capsule) 5

cyclosporine modified (25 mg, 50 mg, 100 mg,100mg/ml)

5

gengraf (25 mg capsule, 50 mg capsule, 100 mgcapsule, 100 mg/ml solution)

5

HUMIRA (SYRINGEKIT) 5 PA

HUMIRA PEDIATRIC CROHN'S (SYRINGEKIT) 5 PA

HUMIRA PEN (PEN IJ KIT) 5 PA

HUMIRA PEN CROHN'S-UC-HS (PEN IJ KIT) 5 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS (PEN IJ KIT) 5 PA

HUMIRA(CF) (SYRINGEKIT) 5 PA

HUMIRA(CF) PEDIATRIC CROHN'S (SYRINGEKIT) 5 PA

HUMIRA(CF) PEN (PEN IJ KIT) 5 PA

HUMIRA(CF) PEN CROHN'S-UC-HS (PEN IJ KIT) 5 PA



HUMIRA(CF) PEN PSOR-UV-ADOL HS (PEN IJ KIT) 5 PA

methotrexate (50 mg/2 ml vial, 250 mg/10 ml vial) 3

methotrexate 2.5 mg tablet 2

methotrexate sodium (vial) 3

mycophenolate 200 mg/ml susp 6

mycophenolate mofetil (250 mg capsule, 500 mgtablet)

5

mycophenolic acid (tablet dr) 6

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE)

6 PA

ORENCIA CLICKJECT (AUTO INJCT) 6 PA

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/MLSYRINGE)

5 PA

SIMPONI ARIA (VIAL) 5 PA

sirolimus (tablet) 6

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mgcapsule)

5

XELJANZ (5 MG TABLET, 10 MG TABLET) 6 PA

XELJANZ XR (TAB ER 24H) 6 PA

IMMUNIZING AGENTS, PASSIVE

GAMASTAN (VIAL) 6 PA

GAMASTAN S-D (VIAL) 6 PA

GAMMAKED 1 GRAM/10 ML VIAL 6 PA

GAMUNEX-C 1 GRAM/10 ML VIAL 6 PA

HYQVIA (2.5 GM-200, 5 GM-400, 10 GM-800, 20GM-1,600, 30 GM-2,400)

6 PA



IMMUNOMODULATORS

leflunomide (tablet) 2

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET,STARTER PACK)

5 PA

VACCINES

ACTHIB (VIAL) 1

ADACEL TDAP (SYRINGE, VIAL) 1

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL)

1

AFLURIA 2018-2019 (2018-2019 SYRINGE, 2018-2019 VIAL)

1

AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE,2017-2018 VIAL)

1

AFLURIA QUAD 2018-2019 (2018-2019 SYRINGE,2018-2019 VIAL)

1

BEXSERO (SYRINGE) 1

BOOSTRIX TDAP (SYRINGE, VIAL) 1

DAPTACEL DTAP (VIAL) 1

DIPHTHERIA-TETANUS TOXOIDS-PED (VIAL) 1

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/MLVIAL)

1

ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5ML PED VL, PEDI 10 MCG/0.5 SYRN)

1

FLUAD 2017-2018 (SYRINGE) 1

FLUAD 2018-2019 (SYRINGE) 1

FLUARIX QUAD 2017-2018 (SYRINGE) 1

FLUARIX QUAD 2018-2019 (SYRINGE) 1

FLUBLOK 2017-2018 (VIAL) 1

FLUBLOK QUAD 2017-2018 (SYRINGE) 1

FLUBLOK QUAD 2018-2019 (SYRINGE) 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL)

1

FLUCELVAX QUAD 2018-2019 (2018-2019 SYR, 2018-2019 VIAL)

1

FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL)

1

FLULAVAL QUAD 2018-2019 (2018-2019 SYR, 2018-2019 VIAL)

1

FLUMIST QUAD 2018-2019 (NAS SP SYR) 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL)

1

FLUZONE HIGH-DOSE 2017-2018 (SYRINGE) 1

FLUZONE HIGH-DOSE 2018-2019 (SYRINGE) 1

FLUZONE INTRADERM QUAD 2017-18 (SYRINGE) 1

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE,2017-2018 VIAL)

1

FLUZONE QUAD 2018-2019 (2018-2019 SYRINGE,2018-2019 VIAL)

1

FLUZONE QUAD PEDI 2017-2018 (SYRINGE) 1

FLUZONE QUAD PEDI 2018-2019 (SYRINGE) 1

GARDASIL (SYRINGE, VIAL) 1

GARDASIL 9 (9 SYRINGE, 9 VIAL) 1

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/MLVIAL)

1

HEPLISAV-B (20 MCG/0.5 ML SYRNG, 20 MCG/0.5ML VIAL)

1

HIBERIX (VIAL) 1

INFANRIX DTAP (SYRINGE, VIAL) 1

IPOL (VIAL) 1

KINRIX (TIP-LOK SYRINGE, VIAL) 1



M-M-R II VACCINE (VIAL) 1

MENACTRA (VIAL) 1

MENOMUNE-A-C-Y-W-135 (VIAL) 1

MENVEO A-C-Y-W-135-DIP (KIT) 1

PEDVAXHIB (VIAL) 1

PENTACEL (KIT) 1

PENTACEL ACTHIB COMPONENT (VIAL) 1

PENTACEL DTAP-IPV COMPONENT (VIAL) 1

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 1

PREVNAR 13 (SYRINGE) 1

PROQUAD (VIAL) 1

QUADRACEL DTAP-IPV (VIAL) 1

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 MLVL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/MLVIAL)

1

ROTARIX (SUSP RECON) 1

ROTATEQ (SOLUTION) 1

SHINGRIX (KIT) 1

TENIVAC (SYRINGE, VIAL) 1

TETANUS DIPHTHERIA TOXOIDS (VIAL) 1

TRUMENBA (SYRINGE) 1

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)

1

VARIVAX VACCINE (VIAL) 1

ZOSTAVAX (VIAL) 1



INFLAMMATORY BOWEL DISEASE AGENTSAMINOSALICYLATES

APRISO (CAP ER 24H) 4

balsalazide disodium (capsule) 2

CANASA (SUPP.RECT) 4

mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema) 2

mesalamine 1,000 mg supp 4

GLUCOCORTICOIDS

budesonide ec (capdr - er) 2

colocort (enema) 2

hydrocortisone 100 mg/60 ml 2

procto-med hc (crm/pe app) 2

procto-pak (crm/pe app) 2

proctosol-hc (crm/pe app) 2

proctozone-hc (crm/pe app) 2

SULFONAMIDES

sulfasalazine (tablet) 2

METABOLIC BONE DISEASE AGENTS

alendronate sodium (35 mg tab, 70 mg tab) 2 QL 4 / 28 DAYS

alendronate sodium (sod 70 mg/75 ml, sodium 5 mgtablet, sodium 10 mg tab, sodium 40 mg tab)

2

calcitonin-salmon (spray/pump) 2 QL 1 BOTTLE (3.7 ML) /30 DAYS

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1mcg/ml solution)

2

d3-2000 (capsule) 1

d3-50 (capsule) 3



decara 50,000 unit softgel 3

doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcgcap)

3

etidronate disodium (tablet) 3

FORTEO (PEN INJCTR) 5 PA

ibandronate sodium 150 mg tab 2 QL 1 / 28 DAYS

NATPARA (CARTRIDGE) 6QL 2 CARTRIDGES / 28

DAYSPA

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcgcapsule)

2

PROLIA (SYRINGE) 6QL 2 SYRINGES (2 ML) /

365 DAYSPA

RECLAST (PGGYBK BTL) 6

risedronate sodium (5 mg tablet, 30 mg tab) 2

risedronate sodium 150 mg tab 3 QL 1 / 28 DAYS

risedronate sodium 35 mg tab 2 QL 4 / 28 DAYS

vitamin d2 1.25mg(50,000 unit) 2

vitamin d3 (400 softgel, cvs 400 sftgl, eql 400 sftgl,1,000 softgel, cvs 1,000 sfgl, 2,000 softgel, cvs 2,000sfgl, eql 1,000 sfgl, eql 2,000 sfgl, hm 2,000 sftgl, ra2,000 sfgl, ra 2,000 sftgl, sm 2,000 sftgl, sv 400softgel, sv 1,000 sftgl, sv 2,000 sftgl)

1

vitamin d3 50,000 unit capsule 3

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4

MISCELLANEOUS THERAPEUTIC AGENTS

accu-chek aviva connect (each) 4

accu-chek aviva plus meter 4

accu-chek aviva plus test strp 4 QL 10 / DAY



accu-chek compact plus kit 4

accu-chek compact plus strips (strip) 4 QL 10 / DAY

accu-chek guide monitor system (each) 4

accu-chek guide test strip (strip) 4 QL 10 / DAY

accu-chek nano smartview (each) 4

accu-chek smartview test strip 4 QL 10 / DAY

ADYNOVATE (VIAL) 6

aftera (tablet) 1

alcohol,dehydrated (ampule, vial) 3

alophen pills (tablet dr) 1

aqua care sterile water irrig (irrig soln) 3

ascorbic acid 500 mg/ml vial 3

b-complex 100 injection 3

benzonatate (100 mg capsule, 200 mg capsule) 2

benzonatate 150 mg capsule 3

benzphetamine hcl (25 mg tablet, 50 mg tablet) 3 PA

bisa-lax (tablet dr) 1

bisacodyl (cvs ec 5 mg tablet, ec 5 mg tablet, fleet ec5 mg tab, ra ec 5 mg tablet, sb ec 5 mg tablet)

1

bromfed dm (syrup) 3

brompheniramine-pseudoephed-dm (syrup) 3

c-lax laxative (tablet dr) 1

caffeine and sodium benzoate (vial) 3

calcium disodium versenate (ampul) 3

caya contoured (diaphragm) 1



centergy (drops) 3

centergy dm (drops) 3

CETROTIDE (KIT) 5 PA

children's vitamin d3 (tab chew) 1

citrate of magnesia (solution) 1

citrate phosphate dextrose (solution) 3

clomiphene citrate (tablet) 2

cocaine 4% solution 3

CONCEPTROL (GEL/PF APP) 1

cyanocobalamin injection (vial) 3

d3 dots (tablet) 1

deferoxamine 500 mg vial 3

delta d3 (tablet) 1

diethylpropion hcl (tablet) 3 PA

diethylpropion hcl er (tablet er) 3 PA

ducodyl (tablet dr) 1

DUROLANE (SYRINGE) 6 PA

econtra ez (tablet) 1

econtra one-step (tablet) 1

ELOCTATE (VIAL) 6

enlon (vial) 3

ephedrine sulfate (50 mg/ml ampul, sulfate 50mg/ml vl)

3

eq clearlax powder 1

ethyl chloride (spray) 3



EUFLEXXA (SYRINGE) 5 PA

exoderm (lotion) 2

fa-8 (capsule) 1

fallback solo (tablet) 1

fc2 female condom (each) 1

femcap (each) 1

folic acid (0.4 mg tablet, 0.8 mg tablet, 400 mcgtablet, 800 mcg capsule, 800 mcg tablet, cvs 800mcg tablet, gnp 400 mcg tablet, hm 400 mcg tablet,ra 0.4 mg tablet, ra 800 mcg tablet, sm 0.4 mgtablet, sm 400 mcg tablet, sv 800 mcg tablet)

1

folic acid 1 mg tablet 2

folic acid 5 mg/ml vial 3

FOLLISTIM AQ (75 VIAL, 300 CARTRIDG, 600CARTRIDG, 900 CARTRIDG)

6 PA

formaldehyde (sol w/appl) 3

GANIRELIX ACETATE (SYRINGE) 6 PA

gel-one (syringe) 6 PA

gentle laxative (5 mg tablet, cvs ec 5 mg tb, ec 5 mgtablet, eq dr 5 mg tab, eql ec 5 mg tb, sm ec 5 mgtab)

1

genvisc 850 (syringe) 6 PA

glycine 1.5% irrigation 3

GONAL-F (450 VIAL, 1,050 VIAL) 5 PA

GONAL-F RFF (VIAL) 5 PA

GONAL-F RFF REDI-JECT (300, 450, 900) 5 PA

gynol ii (jelly/appl) 1

HUMULIN R U-500 KWIKPEN (INSULN PEN) 4



HYALGAN 20 MG/2 ML VIAL 6 PA

hydrocod-cpm-pseudoephedrine (solution) 3

PA

QLC

Limited to 240 mlper prescription.Limited to 2 fills per60 days.

hydrocodone-chlorpheniramne er (sus er 12h) 3

PA

QLC


hydrocodone-homatropine 5-1.5 2

PA

QLC

Limited to 6 tabs perday up to 7 dayssupply.Limited to 2 fills per60 days.

hydrocodone-homatropine mbr (soln, syrup) 2

PA

QLC


hydromet (syrup) 2

PA

QLC


hydroxocobalamin (vial) 3

HYMOVIS (SYRINGE) 6 PA

indocyanine green (vial) 3

kids first vitamin d3 (tab chew) 1

kids vitamin d3 (tab chew) 1

laxative (5 mg tablet, ec 5 mg tablet, gnp ec 5 mgtablet, hm ec 5 mg tablet, pub ec 5 mg tablet, ra ec 5mg tablet, sm tablet)

1

laxative feminine (tablet) 1



levonorgestrel (tablet) 1

magnesium citrate (cvs magnesium soln, cvs ofmagnesia soln, eq magnesium solution, eqlmagnesium solution, gs magnesium solution, hmmagnesium solution, magnesium solution, qcmagnesium solution, sm magnesium solution)

1

md-gastroview (solution) 3

MENOPUR (VIAL) 6 PA

methylergonovine 0.2 mg tablet 2

methylergonovine maleate (0.2 mg/ml amp, 0.2mg/ml vl)

3

metoprolol tartrate (37.5 mg tb, 75 mg tab) 3

MONOVISC (SYRINGE) 6 PA

my choice (tablet) 1

my way (tablet) 1

MYALEPT (VIAL) 6 PA

new day (tablet) 1

NEXT CHOICE ONE DOSE (TABLET) 1

nicoderm cq (patch td24) 1 QL 1 / DAY

nicorelief (gum) 1 QL 24 / DAY

nicotine gum (gum) 1 QL 24 / DAY

nicotine lozenge (2 mg, 2 mg mini, cvs 2 mg, cvs 2mg mini, 4 mg, 4 mg mini, cvs 4 mg, cvs 4 mg mini,eq 2 mg, eq 4 mg, eql 2 mg, eql 4 mg, gnp 2 mg, gnp2 mg mini, gnp 4 mg, gnp 4 mg mini, hm 2 mg, hm 4mg, kro 2 mg, kro 2 mg mini, kro 4 mg, kro 4 mgmini, ra 2 mg, ra 2 mg mini, ra 4 mg, ra 4 mg mini,sm 2 mg, sm 4 mg, sw 2 mg, sw 4 mg)

1 QL 20 / DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine patch (7 mg/24hr patch, cvs 7 mg/24hrpatch, eq 7 mg/24hr patch, hm 7 mg/24hr patch, 14mg/24hr patch, cvs 14 mg/24hr patch, eq 14mg/24hr patch, hm 14 mg/24hr patch, 21 mg/24hrpatch, cvs 21 mg/24hr patch, eq 21 mg/24hr patch,gnp 7 mg/24hr patch, gnp 14 mg/24hr patch, gnp 21mg/24hr patch, hm 21 mg/24hr patch, kro 7mg/24hr patch, kro 14 mg/24hr patch, kro 21mg/24hr patch, ra 7 mg/24hr patch, ra 14 mg/24hrpatch, ra 21 mg/24hr patch, sm 7 mg/24hr patch,sm 14 mg/24hr patch, sm 21 mg/24hr patch, 22mg/24hr patch, transdermal system)

1 QL 1 / DAY

NOVOEIGHT (VIAL) 6

nts (patch td24) 1 QL 1 / DAY

NUCALA (VIAL) 6QL 1 VIAL / 30 DAYS

PA

NUWIQ (VIAL) 5

OBIZUR (VIAL) 6

onetouch ultra blue test strp (strip) 4 QL 10 / DAY

onetouch ultra2 (kit) 4

onetouch ultramini (kit) 4

onetouch verio flex (each) 4

onetouch verio iq (each) 4

onetouch verio meter system 4

onetouch verio sync (kit) 4

onetouch verio test strip 4 QL 10 / DAY

opcicon one-step (tablet) 1

option 2 (tablet) 1

ORTHOVISC (SYRINGE) 6 PA



OVIDREL (SYRINGE) 5

oxytocin (vial) 3

phenazopyridine hcl (tablet) 2

phendimetrazine tartrate (tablet) 3 PA

phendimetrazine tartrate er (capsule er) 3 PA

phentermine hcl (15 mg capsule, 30 mg capsule, 37.5mg capsule, 37.5 mg tablet)

3 PA

physostigmine salicylate (ampul) 3

phytonadione 1 mg/0.5 ml syr 3

powderlax (powder) 1

pralidoxime chloride (pen injctr) 3

promethazine vc-codeine (syrup) 2

PA

QLC


promethazine-codeine (syrup) 2

PA

QLC


promethazine-dm (syrup) 2

promethazine-phenyleph-codeine (syrup) 2

PA

QLC


pyridoxine 100 mg/ml vial 3

quit 2 mg chewing gum 1 QL 24 / DAY

quit 2 mg lozenge 1 QL 20 / DAY

quit 4 mg chewing gum 1 QL 24 / DAY



quit 4 mg lozenge 1 QL 20 / DAY

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mgtablet)

2 QL 6 / 30 DAYS

sodium citrate 4% soln 3

sterile water for irrigation 3

stop smoking aid (lozenge) 1 QL 20 / DAY

supartz fx (syringe) 6 PA

SYNVISC (SYRINGE) 5 PA

SYNVISC-ONE (SYRINGE) 5 PA

tadalafil 10 mg tablet 2 QL 6 / 30 DAYS

tadalafil 20 mg tablet (generic for cialis) 2 QL 6 / 30 DAYS

tc99m sulfur colloid prep (vial) 3

thera-d (2000 tablet, rapid repletion tablet, sport2,000 unit tab)

1

thiamine 200 mg/2 ml vial 3

TODAY CONTRACEPTIVE SPONGE (CON.SPONGE) 1 QL 12 / 30 DAYS

TRETTEN (VIAL) 6

trivisc (syringe) 6 PA

tussigon (tablet) 2

PA

QLC

Limited to 6 tabs perday up to 7 dayssupply.Limited to 2 fills per60 days.

vaseline white petroleum (oint pack) 3

vcf (film, foam, gel) 1

visco-3 (syringe) 6 PA

vitajoy daily d (tab chew) 1



vitamin d-400 (tablet) 1

vitamin d2 (400 tablet, 2,000 tablet) 1

vitamin d3 (cvs vit 1,000 unit gummies, cvs vit 1,000unit soft chw, cvs vit 1,000 unit tab chew, gnp vit 400unit tab chew, gnp vitamin 400 unit tablet, gnpvitamin 1,000 unit tab, gnp vitamin 2,000 unit tab,hm vitamin 400 unit tablet, hm vitamin 1,000 unittab, ra vitamin 1,000 unit tab, sm vitamin 1,000 unittab, vitamin 400 unit tab chew, vitamin 400 unittablet, vitamin 400 unit/5 ml liq, vitamin 800 unitgummy, vitamin 1,000 unit gummies, vitamin 1,000unit tab chew, vitamin 1,000 unit tablet, vitamin1,000 unit/10 ml lq, vitamin 2,000 unit tab chew,vitamin 2,000 unit tablet)

1

vitamin k1 (ampul) 3

wide seal diaphragm (diaphragm) 1

woman's laxative (tablet) 1

women's gentle laxative (tablet dr) 1

women's laxative (eq women's 5 mg tab, eqwomen's ec 5 mg tb, ra women's tablet, womanstablet, women's 5 mg tablet, women's ec 5 mb tab)

1

XURIDEN (GRAN PACK) 6QL 4 / DAY

PA

OPHTHALMIC AGENTSOPHTHALMIC AGENTS, OTHER

ak-poly-bac (oint. (g)) 2

altacaine (drops) 2

ALTAFLUOR (DROPS) 3

atropine 1% eye drops 2

balanced salt (irrig soln) 3

bioglo (strip) 3



cyclopentolate hcl (drops) 2

CYSTARAN (DROPS) 6QL 4 BOTTLES (60 ML) /

28 DAYSPA

fluorescein-proparacaine (drops) 3

flurox (drops) 3

ful-glo 1 mg opth strip 3

glostrips (strip) 3

green glo (strip) 3

homatropaire (drops) 2

homatropine hydrobromide (drops) 2

naphazoline hcl (drops) 2

neo-polycin (oint. (g)) 2

neo-polycin hc (oint. (g)) 2

neomycin-bacitracin-poly-hc (oint. (g)) 2

neomycin-bacitracin-polymyxin (oint. (g)) 2

neomycin-poly-hc eye drops 3

neomycin-polymyxin-dexameth (neomyc-polym-dexamet ointm, neomyc-polym-dexameth drop)

2

phenylephrine hcl (2.5% drop, 10% drops) 2

polycin (oint. (g)) 2

polymyxin b sul-trimethoprim (drops) 2

proparacaine hcl (drops) 2

provisc (syringe) 3

sulfacetamide-prednisolone (drops) 2

tetcaine (drops) 2



tetracaine hcl (eye drop, steri-unit sol) 2

tobramycin-dexamethasone (drops susp) 2

tropicamide (drops) 2

OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine hcl 0.05% drops 2

cromolyn 4% eye drops 2

epinastine hcl (drops) 3

olopatadine hcl 0.1% eye drops 2

OPHTHALMIC ANTI-INFLAMMATORIES

bromfenac sodium (drops) 3 QL 1 BOTTLE / RX

diclofenac 0.1% eye drops 2

fluorometholone (drops susp) 2

flurbiprofen sodium (drops) 2

FML FORTE (DROPS SUSP) 4

FML S.O.P. (OINT. (G)) 4

ketorolac tromethamine (0.4% solution, 0.5%solution)

2

prednisolone ac 1% eye drop 2

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1% DROPS 4

apraclonidine hcl (drops) 3

AZOPT (DROPS SUSP) 4

betaxolol hcl 0.5% eye drop 2

BETOPTIC S (DROPS SUSP) 4

brimonidine tartrate (drops) 2



carteolol hcl (drops) 2

dorzolamide hcl (drops) 2

dorzolamide-timolol eye drops 2

levobunolol hcl (drops) 2

methazolamide (tablet) 2

metipranolol (drops) 2

pilocarpine hcl (1% drops, 2% drops, 4% drops) 2

timolol 0.5% eye drop 3

timolol maleate (0.25% gel-solution, 0.25% gfs gel-solution, maleate 0.25% eye drop, 0.5% gel-solution,0.5% gfs gel-solution, maleate 0.5% eye drops)

2

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 0.03% eye drops 2 QL 2.5 ML / 25 DAYS

latanoprost 0.005% eye drops 2 QL 2.5 ML / 30 DAYS

LUMIGAN (DROPS) 4 QL 2.5 ML / 30 DAYS

TRAVATAN Z (DROPS) 4 QL 2.5 ML / 25 DAYS

OTIC AGENTS

acetic acid 2% ear solution 2

CIPRO HC (DROPS SUSP) 4

CIPRODEX (DROPS SUSP) 4

flac otic oil (drops) 3

fluocinolone acetonide oil (drops) 3

hydrocortisone-acetic acid (drops) 2

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort (solution) 2

OTOVEL (VIAL) 4



RESPIRATORY TRACT/PULMONARY AGENTSANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1mg/2 ml inh susp)

3 QL 60 AMPULES (120ML) / 30 DAYS

budesonide 32 mcg nasal spray 3 QL 2 BOTTLES (16.9 G) /30 DAYS

FLOVENT 250 MCG DISKUS 4 QL 4 INHALERS (240BLISTERS) / 30 DAYS

FLOVENT DISKUS (50 MCG, 100 MCG) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

FLOVENT HFA (110 MCG, 220 MCG) 4 QL 2 INHALERS (24 G) /30 DAYS

FLOVENT HFA 44 MCG INHALER 4 QL 2 INHALERS (21.2 G)/ 30 DAYS

fluticasone prop 50 mcg spray 3

mometasone furoate 50 mcg spry 2 QL 2 BOTTLES (34 G) /30 DAYS

NASONEX (SPRAY/PUMP) 4 QL 2 BOTTLES (34 G) /30 DAYS

PULMICORT FLEXHALER (AER POW BA) 4 QL 2 INHALERS / 30DAYS

QVAR 40 MCG ORAL INHALER 4 QL 2 INHALERS (17.4 G)/ 30 DAYS

QVAR 80 MCG ORAL INHALER 4 QL 3 INHALERS (26.1 G)/ 30 DAYS

QVAR REDIHALER (HFA AEROBA) 4 QL 2 INHALERS (21.2 G)/ 30 DAYS

triamcinolone 55 mcg nasal spr 3

ANTIHISTAMINES

arbinoxa 4 mg tablet 2

azelastine hcl (0.1% (137 mcg) spry, 0.15% nasalspray)

2 QL 2 BOTTLES (60 ML) /30 DAYS

carbinoxamine maleate (4 mg/5 ml liquid, maleate 4mg tab)

2



cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 3

clemastine fumarate (tablet) 2

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4mg/10 ml syrp)

2

desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 3

diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 2

diphenhydramine hcl (50 mg/ml crpjt, 50 mg/mlsyrng)

3

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup,hcl 10 mg tablet, hcl 25 mg tablet, 50 mg/25 mlsyrup, hcl 50 mg tablet)

2

hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100mg/2 ml vial, 500 mg/10 ml vial)

3

hydroxyzine pamoate (capsule) 2

levocetirizine dihydrochloride (2.5 mg/5 ml sol, 5 mgtablet)

2

olopatadine 665 mcg nasal spry 3 QL 1 BOTTLE (30.5 G) /30 DAYS

phenadoz (supp.rect) 2

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 mlsyrp, 12.5 mg tablet, 25 mg tablet, 50 mgsuppository, 50 mg tablet)

2

promethegan (supp.rect) 2

ANTILEUKOTRIENESmontelukast sodium (4 mg granules, 4 mg tab chew,5 mg tab chew, 10 mg tablet)

2

zafirlukast (tablet) 2

BRONCHODILATORS, ANTICHOLINERGIC

INCRUSE ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (30BLISTERS) / 30 DAYS

ipratropium br 0.02% soln 2 QL 125 VIALS (312.5 ML)/ 30 DAYS



ipratropium bromide (0.03% spray, 0.06% spray) 2

SPIRIVA (CAP W/DEV) 4 QL 1 CAPSULE / DAY

SPIRIVA RESPIMAT (MIST INHAL) 4 QL 1 INHALER (4 G) / 30DAYS

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol 2.5 mg/0.5 ml sol 2 QL 150 VIALS / 30 DAYS

albuterol sul 2.5 mg/3 ml soln 2 QL 180 VIALS (540 ML) /30 DAYS

albuterol sulfate (0.63 mg/3 ml, 1.25 mg/3 ml) 2 QL 125 VIALS (375 ML) /30 DAYS

albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate 2 mgtab, sulfate 4 mg tab, sulfate er 4 mg tab, sulfate er8 mg tab)

2

epinephrine (0.1 mg/ml syringe, 1 mg/ml ampul, 1mg/ml vial)

3

epinephrine 0.15 mg auto-injct - impax generics 3 ST

epinephrine 0.15 mg auto-injct - lineage impax g 3 ST

EPINEPHRINE 0.15 MG AUTO-INJCT - MYLANSPECIALTY

2

epinephrine 0.3 mg auto-inject 2 ST

epinephrine 0.3 mg auto-inject - lineage impax g 2

epinephrine 0.3 mg auto-inject - impax generics 2

epinephrine 0.3 mg auto-inject - lineage impax g 2

EPINEPHRINE 0.3 MG AUTO-INJECT - MYLANSPECIALTY

2

EPIPEN 2-PAK 0.3 MG AUTO-INJCT - MYLANSPECIALTY

4

levalbuterol 1.25 mg/3 ml sol 3 QL 90 VIALS (270 ML) /30 DAYS

levalbuterol concentrate (vial-neb) 3 QL 90 VIALS (45 ML) /30 DAYS



levalbuterol hcl (0.31 mg/3 ml, 0.63 mg/3 ml) 3 QL 180 VIALS (540 ML) /30 DAYS

metaproterenol sulfate (10 mg tablet, 10 mg/5 mlsyr, 20 mg tablet)

3

PROAIR HFA (HFA AER AD) 4 QL 2 INHALERS (17 G) /30 DAYS

SEREVENT DISKUS (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

terbutaline sulf 1 mg/ml vial 3

terbutaline sulfate (2.5 mg tab, 5 mg tab) 2

VENTOLIN HFA (HFA AER AD) 4 QL 6 INHALERS (48 G) /30 DAYS

CYSTIC FIBROSIS AGENTS

BETHKIS (AMPUL-NEB) 5

CAYSTON (VIAL-NEB) 6 PA

KALYDECO (50 MG GRANULES PACKET, 75 MGGRANULES PACKET, 150 MG TABLET)

6 PA

ORKAMBI (100 MG TABLET, 200 MG TABLET) 6QL 4 / DAY

PA

TOBI (AMPUL-NEB) 6 ST

TOBI PODHALER (CAP W/DEV, CAPSULE) 6QL 1 KIT (224 CAPSULES)

/ 56 DAYSST

tobramycin 300 mg/5 ml ampule 6 ST

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine cit 60 mg/3 ml oral 3

theochron (tab er 12h) 2

theophylline (80 mg/15 ml soln, er 400 mg tablet, er600 mg tablet)

2

theophylline anhydrous (tab er 12h) 2



PULMONARY ANTIHYPERTENSIVES

ADCIRCA (TABLET) 6QL 2 / DAY

PA

ADEMPAS (TABLET) 5QL 3 / DAY

PA

LETAIRIS (5 MG TABLET, 10 MG TABLET) 5QL 1 / DAY

PA

OPSUMIT (TABLET) 5QL 1 / DAY

PA

ORENITRAM ER (ER 0.125 MG TABLET, ER 0.25 MGTABLET, ER 1 MG TABLET, ER 2.5 MG TABLET, ER 5MG TABLET)

6 PA

REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5MG/ML VIAL, 10 MG/ML VIAL)

6 PA

REVATIO 10 MG/ML ORAL SUSP 6QL 2 BOTTLES (224 ML)

/ 30 DAYSPA

REVATIO 20 MG TABLET 6QL 3 / DAY

PA

sildenafil (tablet) 5QL 3 / DAY

PA

tadalafil 20 mg tablet (generic for adcirca) 5QL 2 / DAY

PA

TRACLEER (62.5 MG TABLET, 125 MG TABLET) 5QL 2 / DAY

PA

TRACLEER 32 MG TABLET FOR SUSP 5QL 4 TABLETS / DAY

PA

TYVASO (AMPUL-NEB) 6QL 1 AMPULE (2.9 ML) /

DAYPA

TYVASO INSTITUTIONAL START KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA



TYVASO REFILL KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA

TYVASO STARTER KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA

UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET,1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCGTABLET)

6QL 2 / DAY

PA

UPTRAVI 200-800 TITRATION PACK 6QL 2 PACKS (400

TABLETS) / 365 DAYSPA

VENTAVIS (10 MCG/1 ML SOLUTION, 20 MCG/1 MLSOLUTION)

6QL 9 AMPULES / DAY

PA

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (10% vial, 20% vial) 2

ADVAIR DISKUS (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

ADVAIR HFA (HFA AER AD) 4 QL 1 INHALER (12 G) /30 DAYS

ANORO ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

BREO ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

COMBIVENT RESPIMAT (MIST INHAL) 4 QL 2 INHALERS (8 G) /30 DAYS

cromolyn 20 mg/2 ml neb soln 2

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801MG TABLET)

6 PA

fluticasone-salmeterol (aer pow ba) 2 QL 1 INHALER / 30 DAYS

ipratropium-albuterol (ampul-neb) 2 QL 180 VIALS (540 ML) /30 DAYS

OFEV (100 MG CAPSULE, 150 MG CAPSULE) 6 PA



promethazine vc (syrup) 2 AL1 2 to 999 yrs old

PULMOZYME (SOLUTION) 6 PA

STIOLTO RESPIMAT (MIST INHAL) 4 QL 1 INHALER (4 G) / 30DAYS

SYMBICORT (HFA AER AD) 4 QL 1 INHALER (10.2 G) /30 DAYS

XOLAIR (75 MG/0.5 ML SYRINGE, 150 MG VIAL, 150MG/ML SYRINGE)

6 PA

SKELETAL MUSCLE RELAXANTS

baclofen (tablet) 2

carisoprodol 250 mg tablet 3

carisoprodol 350 mg tablet 2

carisoprodol compound (tablet) 2

carisoprodol-aspirin (tablet) 2

chlorzoxazone (tablet) 2

cyclobenzaprine 7.5 mg tablet 3

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2

dantrolene sodium (capsule) 2

metaxall (tablet) 3

metaxalone (tablet) 3

methocarbamol (500 mg tablet, 750 mg tablet) 2

methocarbamol 1,000 mg/10 ml 3

orphenadrine citrate (30 mg/ml vial, 60 mg/2 mlampule, 60 mg/2 ml vial)

3

orphenadrine citrate er (tablet er) 2

tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mgcapsule)

3

tizanidine hcl (2 mg tablet, 4 mg tablet) 2



SLEEP DISORDER AGENTSGABA RECEPTOR MODULATORS

estazolam (tablet) 2 QL 1 / DAY

eszopiclone (tablet) 2 QL 1 / DAY

temazepam (capsule) 2 QL 1 / DAY

triazolam (tablet) 2 QL 2 / DAY

zaleplon 10 mg capsule 2 QL 2 / DAY

zaleplon 5 mg capsule 2 QL 1 / DAY

zolpidem tartrate (5 mg tablet, 10 mg tablet) 2 QL 1 / DAY

zolpidem tartrate er (tab mphase) 2 QL 1 / DAY

SLEEP DISORDERS, OTHER

flurazepam hcl (15 mg capsule, 30 mg capsule) 2QL 1 / DAY

PA

HETLIOZ (CAPSULE) 6QL 1 / DAY

PA

modafinil (tablet) 3QL 1 / DAY

PA

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTESELECTROLYTE/MINERAL MODIFIERS

EXJADE (125 MG TABLET, 250 MG TABLET, 500 MGTABLET)

6 PA

FERRIPROX 500 MG TABLET 6 PA

JADENU (90 MG TABLET, 180 MG TABLET, 360 MGTABLET)

4 PA

JADENU SPRINKLE (GRAN PACK) 4 PA

KIONEX (15 GM/60 ML SUSPENSION, POWDER) 2

SAMSCA (TABLET) 4 QL 30 DAY SUPPLY / 60DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSsodium polystyrene sulfonate (sod polystyren sulf 15g/60 ml, sodium polystyrene sulf powder, sps 15gm/60 ml suspension, sps 30 gm/120 ml enema, sps50 gm/200 ml enema)

2

trientine hcl (capsule) 5 PA

ELECTROLYTE/MINERAL REPLACEMENT

aqua care sodium chloride (irrig soln) 3

CARBAGLU (TAB DISPER) 5

cytra-k crystals packet 2

denta 5000 plus (cream (g)) 2

dentagel (gel (gram)) 2

effer-k 25 meq tablet eff 2

fluoride (tab chew) 1

fluoridex daily defense (gel (gram)) 2

fluoritab 0.5 mg tablet chew 1

flura-drops (drops) 1

k effervescent (tablet eff) 2

klor-con 20 meq packet 2

klor-con m10 (tab er prt) 2

klor-con m20 (tab er prt) 2

klor-con sprinkle (capsule er) 2

klor-con-ef (tablet eff) 2

ludent fluoride (tab chew) 1

magnesium chl 200 mg/ml vial 3

magnesium sulfate (syringe, vial) 3

nebusal 3% vial 3



pot citrate-citric acid packet 2

potassium bicarbonate (tablet eff) 2

potassium chloride (er 8 meq capsule, er 8 meqtablet, 10% (20 meq/15ml), 10% (40 meq/30ml), er10 meq capsule, er 10 meq tablet, 20 meq packet,20% (40 meq/15ml), er 20 meq tablet, 25 meq tabeff)

2

potassium citrate er (er 5 tab, er 10 tb) 2

potassium citrate er 15 meq tb 3

pulmosal (vial-neb) 3

sf 5000 plus (cream (g)) 2

sodium chloride (0.9% irrig., 3% vial, 7% vial, 10%vial)

3

sodium chloride 0.9% inhal vl 2

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))

1

lactated ringers irrigation 3

levocarnitine (1 g/10 ml soln, 330 mg tablet) 3

ringers irrigation (irrig soln) 3


Index of Covered Drugs

Aa-hydrocort 71abacavir 40abacavir-lamivudine 40abacavir-lamivudine-zidovudine 40abiraterone acetate 30acamprosate calcium 14acarbose 44accu-chek 93accu-chek aviva connect 92accu-chek aviva plus 92accu-chek compact plus strips 93accu-chek guide monitor system 93accu-chek guide test strip 93accu-chek nano smartview 93accu-chek smartview 93acebutolol hcl 51acetamin-caff-dihydrocodeine 8acetaminophen-codeine 8acetazolamide 55acetic acid 15,104acetylcysteine 110acitretin 62ACTHIB 88acyclovir 42ADACEL TDAP 88ADAGEN 65adapalene 63ADCIRCA 109adefovir dipivoxil 38ADEMPAS 109adult aspirin 5adult aspirin regimen 5adult low dose aspirin ec 5ADVAIR DISKUS 110ADVAIR HFA 110ADYNOVATE 93afeditab cr 52AFINITOR 32AFINITOR DISPERZ 32

AFLURIA 2017-2018 88AFLURIA 2018-2019 88AFLURIA QUAD 2017-2018 88AFLURIA QUAD 2018-2019 88aftera 93ak-poly-bac 101ala-cort 71albuterol sulfate 107alclometasone dipropionate 71alcohol,dehydrated 93alendronate sodium 91alfuzosin hcl er 70ALKERAN 29allopurinol 27almotriptan malate 28alophen pills 93alosetron hcl 68ALPHAGAN P 103alprazolam 42,43alprazolam er 43alprazolam odt 43alprazolam xr 43alprostadil 53altacaine 101ALTAFLUOR 101altavera 75alyacen 75amabelz 75amantadine 34amcinonide 71amethia 76amethia lo 76amethyst 76amiloride hcl 55amiloride-hydrochlorothiazide 53aminocaproic acid 49amiodarone hcl 51AMITIZA 68amitriptyline hcl 25amlodipine besylate 52amlodipine besylate-benazepril 53

ammonium lactate 63amnesteem 63amoxapine 25amoxicillin 18amoxicillin-clavulanate pot er 18amoxicillin-clavulanate potass 18ampicillin trihydrate 18amyl nitrite 58anagrelide hcl 48anastrozole 32ANDROGEL 75androxy 75ANORO ELLIPTA 110anucort-hc 71APOKYN 35apraclonidine hcl 103apri 76APRISO 91APTIOM 22APTIVUS 41aqua care sodium chloride 113aqua care sterile water irrig 93aranelle 76ARANESP 48arbinoxa 105aripiprazole 36aripiprazole odt 36ARIXTRA 47ascomp with codeine 8ascorbic acid 93ashlyna 76aspir 81 5aspir-low 5aspirin 5aspirin ec 5aspirin-caffeine-dihydrocodein 8atazanavir sulfate 41atenolol 51atenolol-chlorthalidone 53atomoxetine hcl 59atorvastatin calcium 56

atovaquone 34atovaquone-proguanil hcl 34ATRIPLA 40atropine sulfate 66,101aubra 76aubra eq 76avar 15aviane 76avidoxy 20AVONEX 61AVONEX PEN 61AXERT 28azacitidine 31azathioprine 86azathioprine sodium 86azelastine hcl 103,105azithromycin 19AZOPT 103azurette 76

Bb-complex 93bacitracin 15baclofen 111balanced salt 101balsalazide disodium 91balziva 76BARACLUDE 38bekyree 76belladonna-opium 8belladonna-phenobarbital 66benazepril hcl 50benazepril-hydrochlorothiazide 53benzepro 63benzonatate 93benzphetamine hcl 93benztropine mesylate 34betamethasone acetate-sod phos 71betamethasone diprop augmented 71betamethasone dipropionate 71betamethasone valerate 71

BETASERON 61betaxolol hcl 51,103bethanechol chloride 71BETHKIS 108BETOPTIC S 103bexarotene 33BEXSERO 88bicalutamide 30bimatoprost 104bioglo 101bisa-lax 93bisacodyl 93bisoprolol fumarate 52bisoprolol-hydrochlorothiazide 53bleo 15k 31bleomycin sulfate 31BLINCYTO 33blisovi 24 fe 76blisovi fe 76BOOSTRIX TDAP 88BOSULIF 32bp 10-1 15bp-50% urea 63bpo 63BREO ELLIPTA 110briellyn 76BRILINTA 49brimonidine tartrate 103bromfed dm 93bromfenac sodium 103bromocriptine mesylate 35brompheniramine-pseudoephed-dm 93budesonide 105budesonide ec 91bumetanide 55BUPHENYL 65bupivacaine hcl 13buprenorphine hcl 14buprenorphine-naloxone 14buproban 14bupropion hcl 23

bupropion hcl sr 23bupropion hcl sr 150 mg tab 14bupropion xl 23buspirone hcl 42butalb-acetaminoph-caff-codein 8butalb-caff-acetaminoph-codein 8butalbital compound-codeine 9butalbital-acetaminophen 60butalbital-acetaminophen-caffe 60butalbital-aspirin-caffeine 61BYDUREON 44BYDUREON BCISE 44BYDUREON PEN 44BYETTA 44BYVALSON 53

Cc-lax laxative 93cabergoline 84caffeine and sodium benzoate 93caffeine citrate 108calcipotriene 63calcitonin-salmon 91calcitriol 63,91calcium acetate 71calcium disodium versenate 93camila 82camrese 76camrese lo 76CANASA 91candesartan cilexetil 50candesartan-hydrochlorothiazid 54capacet 61capecitabine 31CAPRELSA 32captopril 50captopril-hydrochlorothiazide 54CARBAGLU 113carbamazepine 22carbamazepine er 22carbidopa 35

carbidopa-levodopa 35carbidopa-levodopa er 35carbidopa-levodopa-entacapone 34carbinoxamine maleate 105carisoprodol 111carisoprodol compound 111carisoprodol compound-codeine 9carisoprodol-aspirin 111carisoprodol-aspirin-codeine 9carteolol hcl 104cartia xt 52carvedilol 52caya contoured 93CAYSTON 108caziant 76cefaclor 17cefaclor er 17cefadroxil 18cefdinir 18cefditoren pivoxil 18cefixime 18cefpodoxime proxetil 18cefprozil 18ceftibuten 18cefuroxime 18celecoxib 5centergy 94centergy dm 94cephalexin 18CERDELGA 65cetirizine hcl 106CETROTIDE 94cevimeline hcl 62CHANTIX 14chateal 76chateal eq 76children's aspirin 5children's vitamin d3 94chlordiazepoxide hcl 43chlordiazepoxide-amitriptyline 23chlordiazepoxide-clidinium 66

chlorhexidine gluconate 62chloroquine phosphate 34chlorothiazide 55chlorpromazine hcl 35chlorpropamide 44chlorthalidone 55chlorzoxazone 111CHOLBAM 67cholestyramine light 56choline mag trisalicylate 5chorionic gonadotropin 74ciclodan 26ciclopirox 26cilostazol 49cimetidine 68CIMZIA 86CIPRO HC 104CIPRODEX 104ciprofloxacin 19ciprofloxacin er 19ciprofloxacin hcl 19citalopram hbr 24citrate of magnesia 94citrate phosphate dextrose 94claravis 63clarithromycin 19clarithromycin er 19cleansing wash 15clearlax 69,94clemastine fumarate 106clindacin p 63clindamycin hcl 15clindamycin palmitate hcl 15clindamycin pediatric 15clindamycin phos-benzoyl perox 63clindamycin phosphate 15,16,63clindamycin-benzoyl peroxide 63clobetasol propionate 71clocortolone pivalate 71clodan 72clomiphene citrate 94

clomipramine hcl 25clonazepam 43clonidine 49clonidine hcl 50clonidine hcl er 59clopidogrel 49clorazepate dipotassium 43clotrimazole 26clotrimazole-betamethasone 63clozapine 37clozapine odt 38cocaine hcl 94codeine sulfate 9colchicine 27COLCRYS 27colesevelam hcl 57colestipol hcl 57colistimethate 16colocort 91COMBIVENT RESPIMAT 110COMETRIQ 32COMPLERA 40compro 25CONCEPTROL 94constulose 69COPAXONE 61cormax 72cortisone acetate 72COSENTYX (2 SYRINGES) 63COSENTYX PEN 63COSENTYX PEN (2 PENS) 63COSENTYX SYRINGE 63COTELLIC 31covaryx 76covaryx h.s. 76CREON 66CRIXIVAN 41cromolyn sodium 67,103,110cryselle 76CUPRIMINE 71cyanocobalamin injection 94

cyclafem 76cyclobenzaprine hcl 111cyclopentolate hcl 102cyclophosphamide 29cycloserine 29cyclosporine 86cyclosporine modified 86cyproheptadine hcl 106cyred 77cyred eq 77CYSTAGON 66CYSTARAN 102cytra-k 113

Dd3 dots 94d3-2000 91d3-50 91dalfampridine er 62danazol 75dantrolene sodium 111dapsone 29DAPTACEL DTAP 88dasetta 77daysee 77deblitane 82decadron 72decara 92deferoxamine mesylate 94delta d3 94delyla 77demeclocycline hcl 20denta 5000 plus 113dentagel 113desipramine hcl 25desloratadine 106desmopressin acetate 74desogestr-eth estrad eth estra 77desogestrel-ethinyl estradiol 77desonide 72desoximetasone 72

desvenlafaxine succinate er 24dexamethasone 72dexamethasone sodium phosphate 72dexmethylphenidate hcl 59dexmethylphenidate hcl er 59dextroamphetamine sulfate 58dextroamphetamine sulfate er 59dextroamphetamine-amphet er 59dextroamphetamine-amphetamine 58,59diazepam 21,43diclofenac potassium 5diclofenac sodium 5,103diclofenac sodium er 5dicloxacillin sodium 18dicyclomine hcl 66didanosine 40diethylpropion hcl 94diethylpropion hcl er 94DIFICID 19diflorasone diacetate 72diflunisal 5digitek 54digox 54digoxin 54dihydroergotamine mesylate 28dilt-xr 52diltiazem 12hr er 52diltiazem 24hr cd 52diltiazem 24hr er 52diltiazem er 52diltiazem hcl 53dimenhydrinate 25diphenhydramine hcl 106diphenoxylate-atropine 67DIPHTHERIA-TETANUS TOXOIDS-PED 88dipyridamole 49disopyramide phosphate 51disulfiram 14divalproex sodium 21divalproex sodium er 21dofetilide 51

donepezil hcl 23donepezil hcl odt 23dorzolamide hcl 104dorzolamide-timolol 104doxazosin mesylate 50doxepin hcl 25doxercalciferol 92doxycycline hyclate 20doxycycline monohydrate 20dronabinol 26droperidol 35drospirenone-eth estra-levomef 77drospirenone-ethinyl estradiol 77ducodyl 94duloxetine hcl 61DUPIXENT 63DUROLANE 94dutasteride 70

Eeconazole nitrate 26econtra ez 94econtra one-step 94ecotrin 5ed-spaz 66EDURANT 40eemt 77eemt h.s. 77efavirenz 40effer-k 113EFFIENT 49EGRIFTA 84eletriptan hbr 28ELIGARD 84elinest 77eliphos 71ELLA 82ELMIRON 71ELOCTATE 94EMBEDA 7EMCYT 30

emoquette 77EMTRIVA 40enalapril maleate 50enalapril-hydrochlorothiazide 54endocet 9ENGERIX-B ADULT 88ENGERIX-B PEDIATRIC-ADOLESCENT 88enlon 94enoxaparin sodium 47enpresse 77enskyce 77entacapone 34entecavir 38enulose 69EPCLUSA 38ephedrine sulfate 94epinastine hcl 103epinephrine 107epinephrine 0.15 mg auto-injct - impaxgenerics 107epinephrine 0.15 mg auto-injct - lineage impaxg 107EPINEPHRINE 0.15 MG AUTO-INJCT - MYLANSPECIALTY 107epinephrine 0.3 mg auto-inject - lineage impaxg 107epinephrine 0.3 mg auto-inject - impaxgenerics 107epinephrine 0.3 mg auto-inject - lineage impaxg 107EPINEPHRINE 0.3 MG AUTO-INJECT - MYLANSPECIALTY 107EPIPEN 2-PAK 0.3 MG AUTO-INJCT - MYLANSPECIALTY 107epitol 22EPIVIR HBV 38eplerenone 55EPOGEN 48eprosartan mesylate 50EPZICOM 40ergoloid mesylates 23

ergotamine-caffeine 28errin 82ery 19erythromycin 19erythromycin ethylsuccinate 19erythromycin-benzoyl peroxide 64ESBRIET 110escitalopram oxalate 24estarylla 77estazolam 112estradiol 77estradiol-norethindrone acetat 77estrogen-methyltestosterone 77estropipate 77eszopiclone 112ethambutol hcl 29ethosuximide 21ethyl chloride 94ethynodiol-ethinyl estradiol 78etidronate disodium 92etodolac 5etodolac er 5etoposide 32EUFLEXXA 95EUTHYROX 83exemestane 32EXJADE 112exoderm 95ezetimibe 57

Ffa-8 95fallback solo 95falmina 78famciclovir 42famotidine 68FANAPT 36FARESTON 31FARYDAK 31FASLODEX 31fayosim 78

fc2 female condom 95felbamate 22felodipine er 53femcap 95femynor 78fenofibrate 56fenofibric acid 56fenoprofen calcium 5,6FERRIPROX 112finasteride 70FIRAZYR 86flac otic oil 104flavoxate hcl 70flecainide acetate 51FLOVENT DISKUS 105FLOVENT HFA 105floxuridine 31FLUAD 2017-2018 88FLUAD 2018-2019 88FLUARIX QUAD 2017-2018 88FLUARIX QUAD 2018-2019 88FLUBLOK 2017-2018 88FLUBLOK QUAD 2017-2018 88FLUBLOK QUAD 2018-2019 88FLUCELVAX QUAD 2017-2018 89FLUCELVAX QUAD 2018-2019 89fluconazole 26flucytosine 26fludrocortisone acetate 72FLULAVAL QUAD 2017-2018 89FLULAVAL QUAD 2018-2019 89FLUMIST QUAD 2018-2019 89fluocinolone acetonide 72fluocinolone acetonide oil 104fluocinonide 72fluorescein-proparacaine 102fluoride 113fluoridex daily defense 113fluoritab 113fluorometholone 103fluorouracil 64

fluoxetine dr 24fluoxetine hcl 24fluphenazine decanoate 35fluphenazine hcl 35,36flura-drops 113flurandrenolide 72flurazepam hcl 112flurbiprofen 6flurbiprofen sodium 103flurox 102flutamide 30fluticasone propionate 72,105fluticasone-salmeterol 110fluvastatin er 56fluvastatin sodium 56FLUVIRIN 2017-2018 89fluvoxamine maleate 24fluvoxamine maleate er 24FLUZONE HIGH-DOSE 2017-2018 89FLUZONE HIGH-DOSE 2018-2019 89FLUZONE INTRADERM QUAD 2017-18 89FLUZONE QUAD 2017-2018 89FLUZONE QUAD 2018-2019 89FLUZONE QUAD PEDI 2017-2018 89FLUZONE QUAD PEDI 2018-2019 89FML FORTE 103FML S.O.P. 103folic acid 95FOLLISTIM AQ 95fondaparinux sodium 47formaldehyde 95FORTEO 92fosamprenavir calcium 41fosinopril sodium 50fosinopril-hydrochlorothiazide 54fosphenytoin sodium 22FRAGMIN 47frovatriptan succinate 28ful-glo 102FULYZAQ 67furosemide 55

FUZEON 41fyavolv 78

Ggabapentin 21galantamine er 23galantamine hbr 23galantamine hydrobromide 23GAMASTAN 87GAMASTAN S-D 87GAMMAKED 87GAMUNEX-C 87GANIRELIX ACETATE 95GARDASIL 89GARDASIL 9 89gatifloxacin 19GATTEX 67gavilax 69gavilyte-c 69gavilyte-g 69gavilyte-n 69gel-one 95gemfibrozil 56generlac 69gengraf 86GENOTROPIN 74gentak 15gentamicin sulfate 15gentle laxative 95gentlelax 69genvisc 850 95gianvi 78gildagia 78gildess 78gildess 24 fe 78glatiramer acetate 62glatopa 62GLEEVEC 32glimepiride 44glipizide 45glipizide er 45

glipizide xl 45glipizide-metformin 45glostrips 102GLUCAGEN 46GLUCAGON EMERGENCY KIT 46glucagon hcl 46glyburide 45glyburide micronized 45glyburide-metformin hcl 45glycine 95glycolax 69glycopyrrolate 66glydo 13GONAL-F 95GONAL-F RFF 95GONAL-F RFF REDI-JECT 95granisetron hcl 26GRANIX 48green glo 102griseofulvin 27griseofulvin ultramicrosize 27guanfacine hcl 50guanfacine hcl er 59guanidine hcl 29gynol ii 95

Hhailey 24 fe 78halobetasol propionate 72haloperidol 36haloperidol decanoate 36haloperidol decanoate 100 36haloperidol lactate 36HARVONI 38HAVRIX 89heather 82hemmorex-hc 72heparin sodium 48HEPLISAV-B 89HEPSERA 38HETLIOZ 112

HEXALEN 29HIBERIX 89homatropaire 102homatropine hydrobromide 102HUMALOG 46HUMALOG JUNIOR KWIKPEN 46HUMALOG KWIKPEN U-100 46HUMALOG KWIKPEN U-200 46HUMALOG MIX 50-50 46HUMALOG MIX 50-50 KWIKPEN 46HUMALOG MIX 75-25 46HUMALOG MIX 75-25 KWIKPEN 46HUMATROPE 74HUMIRA 86HUMIRA PEDIATRIC CROHN'S 86HUMIRA PEN 86HUMIRA PEN CROHN'S-UC-HS 86HUMIRA PEN PSOR-UVEITS-ADOL HS 86HUMIRA(CF) 86HUMIRA(CF) PEDIATRIC CROHN'S 86HUMIRA(CF) PEN 86HUMIRA(CF) PEN CROHN'S-UC-HS 86HUMIRA(CF) PEN PSOR-UV-ADOL HS 87HUMULIN 70-30 46HUMULIN 70/30 KWIKPEN 47HUMULIN N 47HUMULIN N KWIKPEN 47HUMULIN R 47HUMULIN R U-500 47HUMULIN R U-500 KWIKPEN 95HYALGAN 96HYCAMTIN 32hydralazine hcl 58hydrochlorothiazide 56hydrocod-cpm-pseudoephedrine 96hydrocodone-acetaminophen 9hydrocodone-chlorpheniramne er 96hydrocodone-homatropine mbr 96hydrocodone-ibuprofen 9,10hydrocortisone 73,91hydrocortisone acetate 73

hydrocortisone butyrate 73hydrocortisone valerate 73hydrocortisone-acetic acid 104hydrocortisone-pramoxine 64hydrocortisone-pramoxine hcl 64hydromet 96hydromorphone er 7hydromorphone hcl 10hydroxocobalamin 96hydroxychloroquine sulfate 34hydroxyurea 31hydroxyzine hcl 106hydroxyzine pamoate 106HYMOVIS 96hyophen 16hyoscyamine sulfate 66hyoscyamine sulfate er 66hyoscyamine sulfate sr 67HYQVIA 87

Iibandronate sodium 92IBRANCE 32ibu 6ibudone 10ibuprofen 6imatinib mesylate 32imipramine hcl 25imipramine pamoate 25imiquimod 64IMLYGIC 31incassia 83INCRELEX 74INCRUSE ELLIPTA 106indapamide 56indocyanine green 96indomethacin 6indomethacin er 6INFANRIX DTAP 89INTELENCE 40INTRON A 38

introvale 78INVEGA 36,37INVIRASE 41INVOKAMET 45INVOKAMET XR 45INVOKANA 45IPOL 89ipratropium bromide 106,107ipratropium-albuterol 110irbesartan 50irbesartan-hydrochlorothiazide 54IRESSA 32ISENTRESS 39ISENTRESS HD 39isibloom 78isochron 58isoflurane 13isomethept-caff-acetaminophen 6isomethept-dichloralp-acetamin 6isoniazid 29isosorbide dinitrate 58isosorbide dinitrate er 58isosorbide mononitrate 58isosorbide mononitrate er 58isotretinoin 64isoxsuprine hcl 23isradipine 53itraconazole 27ivermectin 33

JJADENU 112JADENU SPRINKLE 112JAKAFI 32jantoven 48JANUMET 45JANUMET XR 45JANUVIA 45JARDIANCE 45jencycla 83JENTADUETO 45

jevantique lo 78jinteli 78jolessa 78jolivette 83juleber 78junel 78junel fe 78junel fe 24 78JUXTAPID 57

Kk effervescent 113kaitlib fe 78KALBITOR 86KALETRA 41KALYDECO 108kariva 78kelnor 1-35 78kelnor 1-50 78ketamine hcl 42ketoconazole 27ketoprofen 6ketorolac tromethamine 6,103KEVEYIS 55kids first vitamin d3 96kids vitamin d3 96kimidess 78KINRIX 89KIONEX 112KITABIS PAK 15klor-con 113klor-con m10 113klor-con m20 113klor-con sprinkle 113klor-con-ef 113KORLYM 73kurvelo 79KUVAN 66KYNAMRO 57

Llabetalol hcl 52lactated ringers 114lactic acid 64lactulose 69lamivudine 38,40lamivudine hbv 38lamivudine-zidovudine 40lamotrigine 22lamotrigine er 22lamotrigine odt 22LANOXIN 54lansoprazol-amoxicil-clarithro 67lansoprazole 70LANTUS 47LANTUS SOLOSTAR 47larin 79larin 24 fe 79larin fe 79larissia 79latanoprost 104laxaclear 69laxative 96laxative feminine 96laxative peg 3350 69ledipasvir-sofosbuvir 39leena 79leflunomide 88lessina 79LETAIRIS 109letrozole 32leucovorin calcium 31LEUKERAN 29LEUKINE 49leuprolide acetate 84levalbuterol concentrate 107levalbuterol hcl 107,108levetiracetam 21levetiracetam er 21LEVO-T 83

levobunolol hcl 104levocarnitine 114levocetirizine dihydrochloride 106levofloxacin 19levonest 79levonorg-eth estrad eth estrad 79levonorgestrel 97levonorgestrel-eth estradiol 79levora-28 79levothyroxine sodium 84LEVOXYL 84LEXIVA 41lidocaine 13lidocaine hcl 13lidocaine hcl viscous 13lidocaine hcl-epinephrine 13lidocaine-epinephrine 13lidocaine-hydrocortisone 64lidocaine-prilocaine 13lillow 79lindane 34linezolid 16LINZESS 68liothyronine sodium 84lisinopril 50lisinopril-hydrochlorothiazide 54lithium 44lithium carbonate 44lithium carbonate er 44lo-dose aspirin ec 6LODOSYN 35lomedia 24 fe 79LONSURF 29,30loperamide 67lopinavir-ritonavir 41lopreeza 79lorazepam 43,44lorazepam intensol 44lorcet 10lorcet hd 10lorcet plus 10

lortab 11loryna 79losartan potassium 50losartan-hydrochlorothiazide 54LOTRONEX 68lovastatin 56LOVENOX 48low dose aspirin ec 6low-ogestrel 79loxapine 36ludent fluoride 113lugol's 64LUMIGAN 104LUPANETA PACK 85LUPRON DEPOT 85LUPRON DEPOT-PED 85lutera 79LYNPARZA 31LYRICA 61LYSODREN 31lyza 83

MM-M-R II VACCINE 90magnesium chloride 113magnesium citrate 97magnesium sulfate 113malathion 34maprotiline hcl 24marlissa 79MATULANE 30matzim la 53MAVYRET 39md-gastroview 97me-naphos-mb-hyo 1 16meclizine hcl 25meclofenamate sodium 6medroxyprogesterone acetate 83mefenamic acid 6mefloquine hcl 34megestrol acetate 83

MEKINIST 33melodetta 24 fe 79meloxicam 6melpaque hp 64melphalan 30memantine hcl 23MENACTRA 90MENOMUNE-A-C-Y-W-135 90MENOPUR 97MENVEO A-C-Y-W-135-DIP 90meperidine hcl 11mepivacaine hcl 13meprobamate 42mercaptopurine 31mesalamine 91metadate er 59metaproterenol sulfate 108metaxall 111metaxalone 111metformin hcl 45metformin hcl er 45metformin hcl er 500 (generic for glucophage xr)

45methadone hcl 7methadose 7methamphetamine hcl 59methazolamide 104methenamine hippurate 16methenamine mandelate 16methimazole 86methocarbamol 111methotrexate 87methotrexate sodium 87methoxsalen 64methscopolamine bromide 67methyclothiazide 56methyldopa 50methyldopa-hydrochlorothiazide 54methylergonovine maleate 97methylphenidate er 60methylphenidate er (la) 60

methylphenidate hcl 60methylphenidate hcl cd 60methylphenidate hcl er (cd) 60methylphenidate la 60methylprednisolone 73methylprednisolone acetate 73methylprednisolone sodium succ 73methyltestosterone 75metipranolol 104metoclopramide hcl 25metoclopramide hcl odt 25metolazone 56metopic 64metoprolol succinate 52metoprolol tartrate 52,97metoprolol-hydrochlorothiazide 54metronidazole 16mexiletine hcl 51mibelas 24 fe 79miconazole 3 27microgestin 79microgestin fe 79midazolam hcl 42midodrine hcl 50miglustat 66mili 79mimvey 79mimvey lo 80minitran 58minocycline hcl 20minocycline hcl er 20minoxidil 58MIRCERA 49mirtazapine 23MIRVASO 64misoprostol 70modafinil 112moderiba 39moexipril hcl 50moexipril-hydrochlorothiazide 54molindone hcl 36

mometasone furoate 73,105mondoxyne nl 20mono-linyah 80mononessa 80MONOVISC 97montelukast sodium 106morgidox 20morphine sulfate 11morphine sulfate er 7MOTOFEN 67MOVANTIK 67MOXEZA 19moxifloxacin 19moxifloxacin hcl 19MULTAQ 51mupirocin 16my choice 97my way 97MYALEPT 97mycophenolate mofetil 87mycophenolic acid 87MYLERAN 30myorisan 64MYRBETRIQ 70MYTESI 67myzilra 80

Nnabumetone 6nadolol 52nadolol-bendroflumethiazide 54naftifine hcl 27naloxone hcl 14naltrexone hcl 14NAMENDA 23naphazoline hcl 102naproxen 6naproxen sodium 6naproxen sodium cr 6naproxen sodium ds 7naproxen sodium er 7

naratriptan 28naratriptan hcl 28NASONEX 105nateglinide 45NATPARA 92natura-lax 69nebusal 113necon 80nefazodone hcl 24neo-polycin 102neo-polycin hc 102neomycin sulfate 15neomycin-bacitracin-poly-hc 102neomycin-bacitracin-polymyxin 102neomycin-polymyxin b 16neomycin-polymyxin-dexameth 102neomycin-polymyxin-hc 102,104neomycin-polymyxin-hydrocort 104neuac 64NEULASTA 49NEUPOGEN 49nevirapine 40nevirapine er 40new day 97NEXT CHOICE ONE DOSE 97niacin er 57niacor 57nicardipine hcl 53nicoderm cq 97nicorelief 97nicotine gum 97nicotine lozenge 97nicotine patch 98NICOTROL 15NICOTROL NS 15nifedical xl 53nifedipine 53nifedipine er 53nikki 80NILANDRON 30nilutamide 30

nimodipine 53NINLARO 31nisoldipine 53nitrofurantoin 16nitrofurantoin mono-macro 16nitroglycerin 58nitroglycerin patch 58nizatidine 68nodolor 7nora-be 83NORDITROPIN FLEXPRO 74norethin-eth estra-ferrous fum 80norethindron-ethinyl estradiol 80norethindrone 83norethindrone acetate 83norgestimate-ethinyl estradiol 80norlyda 83norlyroc 83nortrel 80nortriptyline hcl 25NORVIR 41NOVAREL 74NOVOEIGHT 98NOVOLOG 47NOVOLOG FLEXPEN 47NOVOLOG MIX 70-30 47NOVOLOG MIX 70-30 FLEXPEN 47np thyroid 84nts 98NUCALA 98NUPLAZID 37NUTROPIN AQ 74NUTROPIN AQ NUSPIN 74NUVARING 80NUWIQ 98nyamyc 27nyata 27nystatin 27nystatin-triamcinolone 27nystop 27

OOBIZUR 98ocella 80octreotide acetate 85OFEV 110ofloxacin 19,20ogestrel 80okebo 20olanzapine 37olanzapine odt 37olanzapine-fluoxetine hcl 24olmesartan medoxomil 50olmesartan-hydrochlorothiazide 54olopatadine hcl 103,106OLYSIO 39omega-3 acid ethyl esters 57omeprazole 70OMNITROPE 74ondansetron hcl 26ondansetron odt 26onetouch ultra blue test strp 98onetouch ultra2 98onetouch ultramini 98onetouch verio 98onetouch verio flex 98onetouch verio iq 98onetouch verio sync 98opcicon one-step 98opium tincture 67OPSUMIT 109option 2 98oralone 62ORENCIA 87ORENCIA CLICKJECT 87ORENITRAM ER 109ORFADIN 66ORKAMBI 108orphenadrine citrate 111orphenadrine citrate er 111orsythia 80

ORTHOVISC 98oscimin 67oscimin sl 67oscimin sr 67oseltamivir phosphate 42OTEZLA 88OTOVEL 104OVIDREL 99oxandrolone 75oxaprozin 7oxazepam 44oxcarbazepine 22oxiconazole nitrate 27oxybutynin chloride 70oxybutynin chloride er 70oxycodone hcl 11oxycodone hcl-aspirin 11oxycodone hcl-ibuprofen 11oxycodone-acetaminophen 12OXYCONTIN 7oxymorphone hcl 12oxymorphone hcl er 8oxytocin 99

Ppacerone 51paliperidone er 37pantoprazole sodium 70papaverine hcl 23paregoric 68paricalcitol 92paroex 62paromomycin sulfate 15paroxetine cr 24paroxetine er 24paroxetine hcl 24PEDVAXHIB 90peg 3350-electrolyte 69peg-3350 and electrolytes 69PEGANONE 22PEGASYS 39

PEGASYS PROCLICK 39PEGINTRON 39PEGINTRON REDIPEN 39penicillin v potassium 18PENTACEL 90PENTACEL ACTHIB COMPONENT 90PENTACEL DTAP-IPV COMPONENT 90pentazocine-naloxone hcl 12pentoxifylline 54perindopril erbumine 51periogard 62permethrin 34perphenazine 26perphenazine-amitriptyline 24phenadoz 106phenazopyridine hcl 99phendimetrazine tartrate 99phendimetrazine tartrate er 99phenelzine sulfate 24phenobarbital 21phenobarbital sodium 21phenohytro 67phenoxybenzamine hcl 50phentermine hcl 99phenylephrine hcl 54,102phenytoin 22phenytoin sodium extended 22philith 80phosphasal 16physostigmine salicylate 99phytonadione 99pilocarpine hcl 62,104pimozide 36pimtrea 80pindolol 52pioglitazone hcl 45pioglitazone-glimepiride 45pioglitazone-metformin 45pirmella 80piroxicam 7PNEUMOVAX 23 90

podocon-25 64podofilox 64polocaine-mpf 13polycin 102polyethylene glycol 3350 69polyethylene glycol 3350 (otc) 69polymyxin b sul-trimethoprim 102POMALYST 30portia 80potassium bicarbonate 114potassium chloride 114potassium citrate er 114potassium citrate-citric acid 114POTIGA 21powderlax 99PRADAXA 48pralidoxime chloride 99PRALUENT PEN 57PRALUENT SYRINGE 57pramcort 64pramipexole dihydrochloride 35pramipexole er 35prasugrel hcl 49pravastatin sodium 56praziquantel 33prazosin hcl 50prednicarbate 73prednisolone 73prednisolone acetate 103prednisolone sodium phos odt 73prednisolone sodium phosphate 73prednisone 73PREGNYL 74PREMARIN 80PREMPHASE 80PREMPRO 80prevalite 57previfem 81PREVNAR 13 90PREZISTA 41primaquine 34

primidone 21PROAIR HFA 108probenecid 27probenecid-colchicine 27prochlorperazine 26prochlorperazine maleate 26PROCRIT 49procto-med hc 91procto-pak 91proctosol-hc 91proctozone-hc 91PROCYSBI 66progesterone 83progesterone in oil 83PROLIA 92PROMACTA 49promethazine hcl 106promethazine vc 111promethazine vc-codeine 99promethazine-codeine 99promethazine-dm 99promethazine-phenyleph-codeine 99promethegan 106propafenone hcl 51propafenone hcl er 51propantheline bromide 67proparacaine hcl 102propranolol hcl 52propranolol hcl er 52propranolol-hydrochlorothiazid 54propylthiouracil 86PROQUAD 90protriptyline hcl 25provisc 102psorcon 73PULMICORT FLEXHALER 105pulmosal 114PULMOZYME 111purelax 69PYLERA 68pyrazinamide 29

pyridostigmine bromide 29pyridostigmine bromide er 29pyridoxine hcl 99

QQUADRACEL DTAP-IPV 90quasense 81quazepam 42quetiapine fumarate 37quetiapine fumarate er 37quinapril hcl 51quinapril-hydrochlorothiazide 54quinidine gluconate 51quinidine sulfate 51quinine sulfate 34quit 2 99quit 4 99,100QVAR 105QVAR REDIHALER 105

Rrabeprazole sodium 70rajani 81raloxifene hcl 83ramipril 51ranitidine hcl 68RAVICTI 66rea lo 39 64rea lo 40 64REBETOL 39RECLAST 92reclipsen 81RECOMBIVAX HB 90RELENZA 42RELISTOR 68REMODULIN 109repaglinide 46repaglinide-metformin hcl 46REPATHA PUSHTRONEX 57REPATHA SURECLICK 57REPATHA SYRINGE 57

reprexain 12RESCRIPTOR 40reserpine 50REVATIO 109REVLIMID 30REXULTI 37REYATAZ 41ribasphere 39ribavirin 39rifabutin 29rifampin 29rimantadine hcl 42ringers irrigation 114risedronate sodium 92risperidone 37risperidone odt 37ritonavir 41rivastigmine 23rivelsa 81rizatriptan 28ropinirole er 35ropinirole hcl 35ropivacaine hcl 14rosadan 16rosanil 16rosuvastatin calcium 56ROTARIX 90ROTATEQ 90roweepra 21roweepra xr 21

SSABRIL 21SAIZEN 75SAIZEN-SAIZENPREP 75salacyn 65salicylic acid 65salsalate 7SAMSCA 112SAPHRIS 37scalacort 73

seb-prev 65selegiline hcl 35selenium sulfide 65SELZENTRY 41SENSIPAR 84SEREVENT DISKUS 108SEROSTIM 75sertraline hcl 24setlakin 81sevelamer carbonate 71sevoflurane 14sf 5000 plus 114sharobel 83SHINGRIX 90SIGNIFOR 85sildenafil 109sildenafil citrate 100silver nitrate 65silver nitrate applicator 65silver sulfadiazine 20SIMPONI 87SIMPONI ARIA 87simvastatin 56sirolimus 87smoothlax 69sodium chloride 114sodium citrate 100sodium fluoride 114sodium phenylbutyrate 66sodium polystyrene sulfonate 113sodium sulfacetamide 65sodium sulfacetamide-sulfur 16,17sofosbuvir-velpatasvir 39SOLTAMOX 31SOMATULINE DEPOT 85SOMAVERT 85sorine 51sotalol 51SOVALDI 39spinosad 34SPIRIVA 107

SPIRIVA RESPIMAT 107spironolactone 55spironolactone-hctz 54sprintec 81SPRYCEL 33sronyx 81sss 10-5 17st. joseph aspirin 7st. joseph aspirin ec 7stavudine 40STELARA 65STIOLTO RESPIMAT 111STIVARGA 33stop smoking aid 100STRENSIQ 66STRIBILD 39STROMECTOL 33subvenite 22SUCRAID 66sucralfate 70sulfacetamide sodium 20,65sulfacetamide sodium-sulfur 17sulfacetamide-prednisolone 102sulfadiazine 20sulfamethoxazole-trimethoprim 20sulfasalazine 91sulindac 7sumatriptan 28sumatriptan succinate 28supartz fx 100SUTENT 33syeda 81symax 67symax-sl 67symax-sr 67SYMBICORT 111SYNAREL 85SYNJARDY 46SYNVISC 100SYNVISC-ONE 100

TTABLOID 31tacrolimus 65,87tadalafil 70,100tadalafil 20 mg tablet (generic for adcirca) 109tadalafil 20 mg tablet (generic for cialis) 100tamoxifen citrate 31tamsulosin hcl 70TARCEVA 33tarina fe 81tarina fe 1-20 eq 81TASIGNA 33taztia xt 53tc99m sulfur colloid prep 100TECFIDERA 62TEKTURNA 54TEKTURNA HCT 55telmisartan 50telmisartan-hydrochlorothiazid 55temazepam 112TEMODAR 30temozolomide 30tencon 61TENIVAC 90tenofovir disoproxil fumarate 40terazosin hcl 71terbinafine hcl 27terbutaline sulfate 108terconazole 27terrell 14testosterone 75testosterone cypionate 75testosterone enanthate 75TETANUS DIPHTHERIA TOXOIDS 90tetcaine 102tetrabenazine 61tetracaine hcl 14,103tetracycline hcl 20THALOMID 30theochron 108

theophylline 108theophylline anhydrous 108thera-d 100thiamine hcl 100THIOLA 71thioridazine hcl 36thiotepa 32thiothixene 36thyroid 84tiagabine hcl 21ticlopidine hcl 49TIKOSYN 51tilia fe 81timolol maleate 52,104tinidazole 17TIVICAY 40tizanidine hcl 111TOBI 108TOBI PODHALER 108TOBRADEX 15tobramycin 15,108tobramycin-dexamethasone 103TODAY CONTRACEPTIVE SPONGE 100tolazamide 46tolbutamide 46tolcapone 34tolmetin sodium 7tolterodine tartrate 70tolterodine tartrate er 70topiramate 22topiramate er 22torsemide 55TRACLEER 109TRADJENTA 46tramadol hcl 12tramadol hcl er 8tramadol hcl-acetaminophen 12trandolapril 51trandolapril-verapamil er 55tranexamic acid 49tranylcypromine sulfate 24

TRAVATAN Z 104trazodone hcl 25tretinoin 33,65tretinoin microsphere 65TRETTEN 100tri femynor 81tri-estarylla 81tri-legest fe 81tri-linyah 81tri-lo-estarylla 81tri-lo-marzia 81tri-lo-sprintec 81tri-mili 81tri-previfem 81tri-sprintec 81tri-vylibra 81triamcinolone acetonide 62,74,105triamterene-hydrochlorothiazid 55triazolam 112triderm 74trientine hcl 113trifluoperazine hcl 36trifluridine 42trihexyphenidyl hcl 34triklo 57trilyte with flavor packets 69trimethobenzamide hcl 26trimethoprim 17trimipramine maleate 25trinessa 81trinessa lo 82trivisc 100trivora-28 82tropicamide 103trospium chloride 70trospium chloride er 70TRULICITY 46TRUMENBA 90TRUVADA 40tulana 83tussigon 100

tydemy 82TYKERB 33TYVASO 109TYVASO INSTITUTIONAL START KIT 109TYVASO REFILL KIT 110TYVASO STARTER KIT 110TYZEKA 38

Uu-cort 74ULORIC 28UNITHROID 84UNITUXIN 33UPTRAVI 110ur n-c 17uramit mb 17urea 65urin d.s. 17uro-458 17uro-mp 17ursodiol 68ustell 17utira-c 17

Vvalacyclovir 42VALCHLOR 30VALCYTE 38valganciclovir hcl 38valproic acid 21valsartan 50valsartan-hydrochlorothiazide 55vanatol lq 61vanatol s 61vancomycin hcl 17VAQTA 90VARIVAX VACCINE 90VARUBI 26VASCEPA 57vaseline white petroleum 100vcf 100

velivet 82venlafaxine hcl 25venlafaxine hcl er 25VENTAVIS 110VENTOLIN HFA 108verapamil er 53verapamil er pm 53verapamil hcl 53verapamil sr 53verdrocet 12VESICARE 70vestura 82vicodin 12vicodin es 13vicodin hp 13VICTOZA 2-PAK 46VIDEX 40vienva 82vigabatrin 21vigadrone 22VIGAMOX 20vilamit mb 17vilevev mb 17VIMPAT 22viorele 82VIRACEPT 41VIREAD 41visco-3 100vitajoy daily d 100vitamin d-400 101vitamin d2 92,101vitamin d3 92,101vitamin k1 101VIVITROL 14voriconazole 27vyfemla 82vylibra 82

Wwarfarin sodium 48water 100

wera 82wide seal diaphragm 101woman's laxative 101women's gentle laxative 101women's laxative 101wymzya fe 82

XXARELTO 48XELJANZ 87XELJANZ XR 87XELODA 31XOLAIR 111XTANDI 30xulane 82XURIDEN 101xylon 10 13

Zzafirlukast 106zaleplon 112zarah 82ZARXIO 49ZEMPLAR 92zenatane 65zenchent 82zenchent fe 82zencia 17ZIAGEN 41zidovudine 41ziprasidone hcl 37ZIRGAN 38ZOLADEX 85ZOLINZA 32zolmitriptan 28zolmitriptan odt 28zolpidem tartrate 112zolpidem tartrate er 112ZOMACTON 75ZOMIG 28,29ZOMIG ZMT 29

zonisamide 21ZORBTIVE 75ZOSTAVAX 90zovia 1-35e 82zovia 1-50e 82ZYDELIG 33ZYKADIA 33ZYMAXID 20ZYTIGA 30

NDR PIC LV (1/18)

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2018 PreferredOne Primary