2020 Comprehensive List of Covered Drugs · To find your drug on the comprehensive drug list follow the instructions below. You can look for your drug in the Index that starts on

Healthcare Marketplace Comprehensive Exchange Drug List: CY2020

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2020 Comprehensive List of Covered Drugs

PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Members must use network pharmacies to get their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change.

What is the Network Health Comprehensive Drug List? A comprehensive drug list is a list of drugs that are covered by your plan. Network Health works with a team of health care providers to choose drugs that provide quality treatment. Network Health covers drugs on our comprehensive drug list, as long as:

• The drug is medically necessary.• The prescription is filled at a Network Health network pharmacy.• Other plan rules are followed.

For more information on how to fill your prescriptions, please review your plan document or other plan materials.

Are all drugs covered by my benefit plan included on this Comprehensive Drug List? Yes. This comprehensive drug list is a list of drugs specifically covered by your plan. If you have questions about a medication that is not on the comprehensive drug list, please call customer service at 800-340-1305, 24 hours a day, seven days a week. TTY/TDD users, please call 800-716-3231.

Can the Comprehensive Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed comprehensive drug list is up to date as of 5/1/2020. To get updated information about the drugs covered by Network Health, please visit https://www.networkhealth.com/__assets/pdf/pharmacy-drug-lists/2020individualdruglist6tier.pdf or call customer service at 800-340-1305, 24 hours a day, seven days a week.

What else could result in changes to the covered drug list?


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We remove drugs from our drug list right away and will let members know when: • The U.S. Food and Drug Administration (FDA) decides that a drug is unsafe. • The drug maker removes the drug from the market.

How do I use the Comprehensive Drug List?

To find your drug on the comprehensive drug list follow the instructions below.

You can look for your drug in the Index that starts on page 76. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.

• Look in the Index and find your drug. • Next to your drug, see the page number where you can find coverage information. • Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Network Health covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs, but provide the same quality of treatment.

Are there any restrictions on my coverage?

Some covered drugs may have more requirements or limits on coverage. These requirements and limits may include the following.

Prior Authorization: Network Health needs you (or your prescriber) to get prior approval or authorization for certain drugs. This means that you need to get approval from Network Health before you fill your prescriptions. If you don’t get approval, Network Health may not cover the drug.

Quantity Limits: For certain drugs, Network Health limits the amount of the drug that it will cover. For example, Network Health provides 9 tablets per prescription for Sumatriptan tablets.

Fill Limits: For certain drugs, Network Health limits the number of fills that it will cover for a drug. For example, Network Health allows 2 treatment cycles of Chantix in a 365 day period.

Step Therapy: Network Health needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Network Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Network Health will then cover Drug B.

You can find out if your drug has any special requirements or limits by looking on the comprehensive drug list that starts on page 3 after this preface. You can also get more information about the restrictions for specific covered drugs by visiting https://www.networkhealth.com/_assets/pdf/pharmacy-drug-lists/2020individualdruglist6tier.pdf.

You can ask Network Health to make an exception to these restrictions or limits. See the section, “What if my drug is not on the Comprehensive Drug List?” on page III (3).


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Does the Plan cover prescription drugs that are considered “Preventive Services” under the Affordable Care Act?

The U.S. Department of Health and Human Services (HHS) has adopted Guidelines for Preventive Services under the Affordable Care Act (ACA). Under the ACA, some pharmacy benefit plans may provide a range of preventive services for $0 member cost share and are designated as tier 0 on this document. These items may include: • Aspirin to Prevent Cardiovascular Disease • Fluoride Supplementation in Children • Folic Acid Supplementation for Members Expecting or Planning to be Pregnant • Tobacco Use Counseling and Cessation Intervention • Immunizations • Women’s Health Preventive Services (i.e., birth control, emergency contraception)

• Low Dosed Statin Medications to Prevent Cardiovascular Disease and Stroke (age restrictions apply) (designated at either tier 0 or tier 1 in this document)

A list of the preventive services covered under the plan is available on the member portal at login.networkhealth.com, or will be mailed to you upon request. You may request the list by calling the Network Health Customer Service number on your identification card.

What if my drug is not on the Comprehensive Drug List?

If your drug is not on this drug list, call customer service to confirm that your drug is not covered. If you learn that Network Health does not cover your drug, you have two choices:

Ask customer service for a list of similar drugs that are covered by Network Health. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Network Health. Similar drugs that are preferred and covered by your plan’s formulary may be easier to obtain and lower cost to you than non-preferred drugs.

Ask Network Health to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for

certain drugs, Network Health limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more.

Generally, Network Health will only approve your request for an exception if the preferred drugs included on the plan’s drug list are not as effective in treating your condition or cause you to have adverse medical effects.

How do I find out if my exception is granted? When you ask for a drug list utilization restriction exception, please send a statement from your prescriber that supports your request.

• For utilization restriction exception requests received pre-service we will make our decision within fifteen business days of receipt of the information necessary to make a decision.

• You can ask for an expedited (fast) pre-service utilization restriction exception if you or your prescriber believes that your health could be seriously harmed by waiting up to fifteen business days for a decision.


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• If your pre-service utilization restriction expedited (fast) request is granted, we will give you a decision no later than 72 hours after we get your prescriber’s supporting statement.

For more information

For more information about your Network Health prescription drug coverage, please view your policy.

Network Health’s Comprehensive Drug List

The drug list gives coverage information for all drugs covered by Network Health. If you have trouble finding your drug on the list, turn to the Index that starts on page 76. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ELIQUIS). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Network Health has any special requirements for coverage of your drug.

Tier Name Tier Definition

Tier 0 Preventive Prescription Drugs

Tier 1 Adherence Generics (limited to certain conditions)

Tier 2 Generic Prescription Drugs

Tier 3 Brand Prescription Drugs

Tier 4 Non-Preferred Prescription Drugs

Tier 5 Preferred Specialty Prescription Drugs

Tier 6 Non-Preferred Specialty Prescription Drugs


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Network Health Prestige Bronze 20 HDHP

This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy.

DRUG TIER 30-Day Supply 90-Day Supply

Tier 0 $0.00 $0.00

Tier 1 0% after deductible 0% after deductible




Tier 5 35% after deductible N/A


Network Health Prestige Bronze Essential

This table defines the standard copayment and/or coinsurance structure. Depending on your

income level, your actual cost-share may be less. For more information, consult your policy.


Tier 0 $0.00 $0.00

Tier 1 $0.00 $0.00

Tier 2 $20.00 $55.00

Tier 3 $80.00 after deductible $225.00 after deductible





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Network Health Prestige Bronze 0 This table defines the standard copayment and/or coinsurance structure. Depending on

your income level, your actual cost-share may be less. For more information, consult your

policy.


Tier 0 $0.00 $0.00

Tier 1 $0.00 $0.00

Tier 2 $20.00 $55.00

Tier 3 $70.00 after deductible $195.00 after deductible




Network Health Prestige Bronze 50 HDHP This table defines the standard copayment and/or coinsurance structure. Depending on

your income level, your actual cost-share may be less. For more information, consult your

policy.


Tier 0 $0.00 $0.00








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Network Health Prestige Silver Essential



Tier 0 $0.00 $0.00

Tier 1 $0.00 $0.00

Tier 2 $20.00 $55.00

Tier 3 $80.00 $225.00




Network Health Prestige Silver 20 HDHP



Tier 0 $0.00 $0.00








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Network Health Prestige Gold Essential



Tier 0 $0.00 $0.00

Tier 1 $0.00 $0.00

Tier 2 $15.00 $40.00

Tier 3 $60.00 $165.00




Network Health Prestige Gold 50



Tier 0 $0.00 $0.00

Tier 1 $0.00 $0.00

Tier 2 $15.00 $40.00

Tier 3 $50.00 $135.00





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Network Health Prestige Gold 0 HDHP



Tier 0 $0.00 $0.00

Tier 1 No charge after deductible No charge after deductible







Native American Benefit


DRUG TIER Retail 30-Day Supply I/T/U Pharmacy 30-Day Supply

90-Day Supply I/T/U Pharmacy 90-Day Supply

Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 0% after deductible $0.00 0% after deductible N/A




Tier 5 $0.00 N/A N/A N/A



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Network Health Prestige Bronze Essential



DRUG TIER Retail 30-Day Supply I/T/U Pharmacy 30-Day Supply


Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 $0.00 $0.00 $0.00 N/A

Tier 2 $20.00 $0.00 $55.00 N/A

Tier 3 $80.00 after deductible $0.00 $225.00 after deductible N/A




Network Health Prestige Bronze 0



DRUG TIER 30-Day Supply I/T/U Pharmacy 30-Day Supply


Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 $0.00 $0.00 $0.00 N/A

Tier 2 $20.00 $0.00 $55.00 N/A

Tier 3 $70.00 after deductible $0.00 $195.00 after deductible N/A





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Tier 0 $0.00 $0.00 $0.00 N/A







Network Health Prestige Silver Essential





Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 $0.00 $0.00 $0.00 N/A

Tier 2 $20.00 $0.00 $55.00 N/A

Tier 3 $80.00 $0.00 $225.00 N/A





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Network Health Prestige Silver 20 HDHP





Tier 0 $0.00 $0.00 $0.00 N/A







Network Health Prestige Gold Essential





Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 $0.00 $0.00 $0.00 N/A

Tier 2 $15.00 $0.00 $40.00 N/A

Tier 3 $60.00 $0.00 $165.00 N/A





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Network Health Prestige Gold 50





Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 $0.00 $0.00 $0.00 N/A

Tier 2 $15.00 $0.00 $40.00 N/A

Tier 3 $50.00 $0.00 $135.00 N/A




Network Health Prestige Gold 0 HDHP


This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less.

For more information, consult your policy.



Tier 0 $0.00 $0.00 $0.00 N/A

Tier 1 No charge after deductible $0.00

No charge after deductible N/A









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The information listed in this document was current at the time of posting, however, changes occur frequently. The actual copay/coinsurance will be determined at the time the prescription is filled. For more information about your benefits contact Network Health Customer Service at 855-275-1400. For additional prescription drug information, log onto express-scripts.com or call Express Scripts at 800-340-1305.

HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan.

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Table of Contents

ANTI - INFECTIVES ........................................................................................................................................ 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 10

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 17

CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 29

DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 37

DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 42

EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 44

ENDOCRINE/DIABETES .............................................................................................................................. 44

GASTROENTEROLOGY .............................................................................................................................. 51

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 56

MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 59

OBSTETRICS & GYNECOLOGY ................................................................................................................ 61

OPHTHALMOLOGY ..................................................................................................................................... 66

RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 68

UROLOGICALS .............................................................................................................................................. 72

VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 72

Index .................................................................................................................................................................. 76

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List of Abbreviations

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

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

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

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Drug Name Drug Tier

Requirements / Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

amphotericin b 2

caspofungin 2

clotrimazole mucous membrane

2

CRESEMBA INTRAVENOUS

3

CRESEMBA ORAL 3 PA

fluconazole in nacl (iso-osm)

2

fluconazole oral suspension for reconstitution

2

fluconazole oral tablet 100 mg, 200 mg, 50 mg

2

fluconazole oral tablet 150 mg

2 QL (2 per 30 days)

flucytosine 2

griseofulvin microsize

2

griseofulvin ultramicrosize

2

itraconazole oral capsule


itraconazole oral solution

2

ketoconazole oral 2

MYCAMINE 3

NOXAFIL INTRAVENOUS

3

NOXAFIL ORAL SUSPENSION

3 PA

nystatin oral suspension

2

Drug Name Drug Tier


nystatin oral tablet 2

ORAVIG 4

posaconazole oral tablet,delayed release (dr/ec)

2 PA

terbinafine hcl oral 2

voriconazole intravenous

2

voriconazole oral 2 PA

ANTIVIRALS

abacavir 2

abacavir-lamivudine 2

abacavir-lamivudine-zidovudine

2

acyclovir oral capsule

2

acyclovir oral suspension 200 mg/5 ml

2

acyclovir oral tablet 2

acyclovir sodium 2

adefovir 2

amantadine hcl 2

APTIVUS 3

APTIVUS (WITH VITAMIN E)

3

atazanavir 2

BARACLUDE ORAL SOLUTION

3

BIKTARVY 3

cidofovir 2

CIMDUO 3


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Drug Name Drug Tier


CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

DESCOVY 3

didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg

2

DOVATO 3

EDURANT 3

efavirenz 2

EMTRIVA 3

entecavir 2

EPCLUSA 5 PA; QL (84 per 365 days)

EPIVIR HBV ORAL SOLUTION

3

famciclovir oral tablet 125 mg, 500 mg


famciclovir oral tablet 250 mg


fosamprenavir 2

FUZEON SUBCUTANEOUS RECON SOLN

3

ganciclovir sodium 2

GENVOYA 3

HARVONI 5 PA; QL (56 per 365 days)

INTELENCE 3

INVIRASE ORAL TABLET

3

ISENTRESS 3

ISENTRESS HD 3

JULUCA 3

Drug Name Drug Tier


KALETRA ORAL TABLET 100-25 MG

3 QL (112 per 274 days)

KALETRA ORAL TABLET 200-50 MG


lamivudine 2

lamivudine-zidovudine

2

LEXIVA ORAL SUSPENSION

3

lopinavir-ritonavir 2 QL (160 per 274 days)

nevirapine 2

NORVIR ORAL POWDER IN PACKET

3

NORVIR ORAL SOLUTION

3

ODEFSEY 3

oseltamivir oral capsule 30 mg


oseltamivir oral capsule 45 mg, 75 mg


oseltamivir oral suspension for reconstitution


PREVYMIS INTRAVENOUS

3

PREVYMIS ORAL 3 QL (100 per 365 days)

PREZISTA ORAL SUSPENSION

3

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

3


5

Drug Name Drug Tier


RAPIVAB (PF) 3

RELENZA DISKHALER


RETROVIR INTRAVENOUS

3

REYATAZ ORAL POWDER IN PACKET

3

ribavirin inhalation 2

rimantadine 2

ritonavir 2

SELZENTRY 3

stavudine oral capsule

2

SYMFI 3

SYMFI LO 3

SYNAGIS 5 PA

TEMIXYS 3

tenofovir disoproxil fumarate

2

TIVICAY 3

TRIUMEQ 3

TROGARZO 5 PA

TRUVADA 3

valacyclovir 2 QL (30 per 30 days)

valganciclovir 2

VEMLIDY 3

VIDEX 2 GRAM PEDIATRIC

3

VIRACEPT ORAL TABLET

3

VIREAD ORAL POWDER

3

Drug Name Drug Tier


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

3

ZEPATIER 5 PA; QL (84 per 365 days)

zidovudine 2

CEPHALOSPORINS

AVYCAZ 3

cefaclor oral capsule 2

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

2

cefaclor oral tablet extended release 12 hr

2

cefadroxil oral capsule

2

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

2

cefadroxil oral tablet 2

cefazolin 2

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

2

cefdinir 2

cefditoren pivoxil 2

cefepime in dextrose,iso-osm

2

cefepime injection 2

cefixime 2


6

Drug Name Drug Tier


cefotaxime injection recon soln 1 gram

2

cefotetan 2

cefoxitin 2

cefoxitin in dextrose, iso-osm

2

cefpodoxime 2

cefprozil 2

ceftazidime 2

ceftriaxone in dextrose,iso-os

2

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

2

ceftriaxone intravenous

2

cefuroxime axetil oral tablet

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous

2

cephalexin 2

tazicef 2

ZERBAXA 3

ERYTHROMYCINS & OTHER MACROLIDES

azithromycin intravenous

2

azithromycin oral packet


azithromycin oral suspension for reconstitution 100 mg/5 ml


Drug Name Drug Tier


azithromycin oral suspension for reconstitution 200 mg/5 ml


azithromycin oral tablet 250 mg, 500 mg


azithromycin oral tablet 600 mg


clarithromycin 2

DIFICID 4

e.e.s. 400 oral tablet 2

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

2

erythrocin (as stearate) oral tablet 250 mg

2

erythromycin ethylsuccinate oral suspension for reconstitution

2

erythromycin ethylsuccinate oral tablet

2

erythromycin oral 2

MISCELLANEOUS ANTIINFECTIVES

albendazole 2 QL (120 per 23 days)

ALINIA ORAL SUSPENSION FOR RECONSTITUTION


ALINIA ORAL TABLET



7

Drug Name Drug Tier


amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

2

ARIKAYCE 5 PA

atovaquone 2

atovaquone-proguanil oral tablet 250-100 mg


atovaquone-proguanil oral tablet 62.5-25 mg

2 QL (180 per 180 days)

aztreonam 2

bacitracin intramuscular

2

BENZNIDAZOLE 3 QL (720 per 365 days)

CAYSTON 5 QL (84 per 30 days)

chloramphenicol sod succinate

2

chloroquine phosphate oral tablet 250 mg


chloroquine phosphate oral tablet 500 mg


cleocin intravenous solution 300 mg/2 ml

2

clindamycin hcl 2

clindamycin in 5 % dextrose

2

clindamycin palmitate hcl

2

clindamycin pediatric

2

clindamycin phosphate injection

2

Drug Name Drug Tier


COARTEM 3 QL (24 per 23 days)

colistin (colistimethate na)

2

DALVANCE 3

dapsone oral 2

daptomycin intravenous recon soln 500 mg

2

DARAPRIM 5 PA

EMVERM 3 QL (6 per 23 days)

ertapenem 2

ethambutol 2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

2

gentamicin injection 2

gentamicin sulfate (ped) (pf)

2

gentamicin sulfate (pf) intravenous solution 100 mg/10 ml

2

hydroxychloroquine 2 QL (30 per 274 days)

imipenem-cilastatin 2

IMPAVIDO 3 QL (84 per 23 days)

isoniazid 2

ivermectin oral 2 QL (20 per 23 days)


8

Drug Name Drug Tier


KITABIS PAK 5 PA; QL (280 per 30 days)

lincomycin 2

linezolid 2 PA

linezolid in dextrose 5%

2

linezolid-0.9% sodium chloride

2

mefloquine 2 QL (13 per 180 days)

meropenem 2

MEROPENEM-0.9% SODIUM CHLORIDE

3

metro i.v. 2

metronidazole in nacl (iso-os)

2

metronidazole oral 2

NEBUPENT 3 QL (1 per 21 days)

neomycin 2

ORBACTIV 3

paromomycin 2

PASER 4

pentamidine inhalation


pentamidine injection

2

polymyxin b sulfate 2

praziquantel 2

PRIFTIN 3

primaquine 2 QL (120 per 180 days)

pyrazinamide 2

pyrimethamine 2 PA

Drug Name Drug Tier


quinine sulfate 2 QL (42 per 23 days)

rifabutin 2

rifampin 2

RIFATER 4

SIRTURO 3 PA; LA

tigecycline 2

tinidazole oral tablet 250 mg


tinidazole oral tablet 500 mg


tobramycin in 0.225 % nacl

5 PA; QL (280 per 30 days)

tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml

2

tobramycin sulfate 2

TRECATOR 4

XIFAXAN ORAL TABLET 200 MG


XIFAXAN ORAL TABLET 550 MG


PENICILLINS

amoxicillin oral capsule

2

amoxicillin oral suspension for reconstitution

2

amoxicillin oral tablet

2

amoxicillin oral tablet,chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate

2


9

Drug Name Drug Tier


ampicillin oral capsule

2

ampicillin sodium 2

ampicillin-sulbactam 2

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

3

dicloxacillin 2

nafcillin 2

nafcillin in dextrose iso-osm

2

oxacillin 2

oxacillin in dextrose(iso-osm)

2

penicillin g potassium

2

penicillin g procaine 2

penicillin g sodium 2

penicillin v potassium

2

pfizerpen-g 2

piperacillin-tazobactam

2

QUINOLONES

ciprofloxacin 2

ciprofloxacin hcl oral

2

ciprofloxacin in 5 % dextrose

2

FACTIVE 4

levofloxacin in d5w 2

levofloxacin intravenous

2

Drug Name Drug Tier


levofloxacin oral 2

moxifloxacin oral 2

MOXIFLOXACIN-SOD.ACE,SUL-WATER

3

moxifloxacin-sod.chloride(iso)

2

ofloxacin oral tablet 300 mg, 400 mg

2

SULFA'S & RELATED AGENTS

sulfadiazine 2

sulfamethoxazole-trimethoprim

2

sulfatrim 2

TETRACYCLINES

avidoxy 2

coremino 2

demeclocycline 2

doxy-100 2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet

2

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

2

doxycycline monohydrate oral capsule

2

doxycycline monohydrate oral suspension for reconstitution

2


10

Drug Name Drug Tier


doxycycline monohydrate oral tablet

2

minocycline oral capsule

2

minocycline oral tablet

2

minocycline oral tablet extended release 24 hr

2 ST

mondoxyne nl oral capsule 100 mg, 75 mg

2

morgidox oral capsule 100 mg

2

okebo oral capsule 75 mg

2

tetracycline 2

URINARY TRACT AGENTS

methenamine hippurate

2

methenamine mandelate

2

nitrofurantoin 2

nitrofurantoin macrocrystal

2

nitrofurantoin monohyd/m-cryst

2

trimethoprim 2

VANCOMYCIN

VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK

3

Drug Name Drug Tier


VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS SOLUTION 1 GRAM/250 ML, 1.25 GRAM/250 ML, 1.5 GRAM/250 ML, 1.5 GRAM/300 ML, 1.5 GRAM/500 ML, 1.75 GRAM/250 ML, 1.75 GRAM/500 ML, 2 GRAM/500 ML, 750 MG/150 ML

3

VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML, 500 MG/100 ML

3

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg

2

vancomycin oral capsule 125 mg


vancomycin oral capsule 250 mg


vancomycin oral recon soln


ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

dexrazoxane hcl 2

ELITEK 3

KEPIVANCE 5


11

Drug Name Drug Tier


leucovorin calcium injection recon soln

2 PA

leucovorin calcium injection solution 10 mg/ml

2 PA

leucovorin calcium oral

2 PA

levoleucovorin calcium intravenous recon soln 50 mg

2 PA

levoleucovorin calcium intravenous solution

2 PA

mesna 2

MESNEX ORAL 3

VISTOGARD 5 PA

XGEVA 5

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

abiraterone 5 PA; QL (120 per 30 days)

ABRAXANE 5 PA

ADAKVEO 5 PA

ADCETRIS 5 PA

adriamycin intravenous recon soln 10 mg

2 PA

adriamycin intravenous solution

2 PA

adrucil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml

2

AFINITOR 5 PA

AFINITOR DISPERZ

5 PA

ALECENSA 5 PA; QL (240 per 30 days)

Drug Name Drug Tier


ALIMTA 3 PA

ALIQOPA 5 PA

anastrozole 2

ARRANON 5 PA

arsenic trioxide intravenous solution 2 mg/ml

2 PA

AVASTIN 5 PA

azacitidine 5 PA

azathioprine 2

azathioprine sodium 2

BALVERSA 5 PA

BAVENCIO 5 PA

BENDEKA 5 PA

BESPONSA 5 PA

bexarotene 5 PA

bicalutamide 2

bleomycin 2 PA

BLINCYTO INTRAVENOUS KIT

5 PA

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG, 500 MG


busulfan 2

CABOMETYX ORAL TABLET 20 MG


CABOMETYX ORAL TABLET 40 MG, 60 MG

5 PA

capecitabine 5 PA


12

Drug Name Drug Tier


CAPRELSA ORAL TABLET 100 MG


CAPRELSA ORAL TABLET 300 MG


carboplatin intravenous solution

2 PA

carmustine 2 PA

cisplatin intravenous solution

2 PA

cladribine 2 PA

clofarabine 2 PA

COMETRIQ 5 PA

COTELLIC 5 PA; QL (63 per 30 days)

cyclophosphamide intravenous

2 PA

cyclophosphamide oral capsule

2

cyclosporine intravenous

2

cyclosporine modified

2

cyclosporine oral capsule

2

CYRAMZA 5 PA

cytarabine 2 PA

cytarabine (pf) injection solution

2

dacarbazine 2 PA

dactinomycin 2 PA

DARZALEX 5 PA

daunorubicin 2 PA

decitabine 5 PA

Drug Name Drug Tier


docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

2 PA

DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML

3 PA

doxorubicin intravenous recon soln 50 mg

2 PA

doxorubicin intravenous solution

2 PA

doxorubicin, peg-liposomal

2 PA

DROXIA 3

ELIGARD 5 PA

ELIGARD (3 MONTH)

5 PA

ELIGARD (4 MONTH)

5 PA

ELIGARD (6 MONTH)

5 PA

ELZONRIS 5 PA

EMCYT 3 PA

epirubicin intravenous recon soln 200 mg

2 PA

epirubicin intravenous solution

2 PA

ERBITUX 5 PA

ERIVEDGE 5 PA; QL (30 per 30 days)


13

Drug Name Drug Tier


ERLEADA 5 PA

erlotinib oral tablet 100 mg, 150 mg


erlotinib oral tablet 25 mg


ETOPOPHOS 3

etoposide 2 PA

everolimus (antineoplastic)

5 PA

everolimus (immunosuppressive)

2 ST

exemestane 2 PA

floxuridine 2 PA

fludarabine 2 PA

fluorouracil intravenous

2

flutamide 2

FOLOTYN 5 PA

fulvestrant 2 PA

GAMIFANT 5 PA

GAZYVA 5 PA

gemcitabine intravenous recon soln

2 PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

2 PA

gengraf oral capsule 100 mg, 25 mg

2

gengraf oral solution 2

Drug Name Drug Tier


GILOTRIF 5 PA; QL (30 per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

3 PA

HALAVEN 5 PA

HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA

HYCAMTIN ORAL 5 PA

hydroxyurea 2

IBRANCE ORAL CAPSULE


ICLUSIG ORAL TABLET 15 MG


ICLUSIG ORAL TABLET 45 MG


idarubicin 2 PA

IDHIFA 5 PA; QL (30 per 30 days)

ifosfamide 2 PA

imatinib oral tablet 100 mg


imatinib oral tablet 400 mg


IMBRUVICA ORAL CAPSULE 140 MG


IMBRUVICA ORAL CAPSULE 70 MG


IMBRUVICA ORAL TABLET


IMFINZI 5 PA

INLYTA ORAL TABLET 1 MG



14

Drug Name Drug Tier


INLYTA ORAL TABLET 5 MG


IRESSA 5 PA; QL (30 per 30 days)

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml

2 PA

irinotecan intravenous solution 300 mg/15 ml

2 ST

ISTODAX 5 PA

IXEMPRA 5 PA

JAKAFI 5 PA; QL (60 per 30 days)

KADCYLA 5 PA

KANJINTI 5 PA

KEYTRUDA INTRAVENOUS SOLUTION

5 PA

KYMRIAH 5 PA

KYPROLIS 5 PA

LENVIMA 5 PA

letrozole 2

LEUKERAN 3 PA

leuprolide subcutaneous kit

5 PA

LIBTAYO 5 PA

LONSURF 5 PA

LORBRENA ORAL TABLET 100 MG


LORBRENA ORAL TABLET 25 MG


Drug Name Drug Tier


LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

5 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG

5 PA

LUPRON DEPOT-PED

5 PA

LUPRON DEPOT-PED (3 MONTH)

5 PA

LYNPARZA ORAL TABLET


LYSODREN 3 PA

MARQIBO 5 PA

MATULANE 5 PA

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

2

megestrol oral tablet 2

MEKINIST ORAL TABLET 0.5 MG


MEKINIST ORAL TABLET 2 MG


melphalan 2

melphalan hcl 2 PA

mercaptopurine 2

methotrexate sodium 2

methotrexate sodium (pf)

2

mitomycin intravenous

2 PA

mitoxantrone 5

MVASI 5 PA


15

Drug Name Drug Tier


mycophenolate mofetil

2

mycophenolate mofetil (hcl)

2

mycophenolate sodium

2

MYLERAN 3

MYLOTARG 5 PA

NERLYNX 5 PA

NEXAVAR 5 PA; QL (120 per 30 days)

nilutamide 2

NINLARO 5 PA; QL (9 per 30 days)

NUBEQA 5 PA

NULOJIX 3 PA

octreotide acetate 5

ODOMZO 5 PA; QL (30 per 30 days)

OGIVRI 5 PA

ONCASPAR 3 PA

ONIVYDE 5 PA

OPDIVO 5 PA

oxaliplatin 2 PA

paclitaxel 2 PA

paraplatin 2 ST

PERJETA 5 PA

PHOTOFRIN 3 PA

POTELIGEO 5 PA

PROGRAF INTRAVENOUS

3

PROGRAF ORAL GRANULES IN PACKET

3

Drug Name Drug Tier


PURIXAN 5

RITUXAN 5 PA

RITUXAN HYCELA

5 PA

ROZLYTREK ORAL CAPSULE 100 MG


ROZLYTREK ORAL CAPSULE 200 MG


RUBRACA 5 PA; QL (120 per 30 days)

RUXIENCE 5 PA

RYDAPT 5 PA

SANDIMMUNE ORAL SOLUTION

3

SIGNIFOR 5 PA

SIMULECT 3

sirolimus 2

SOMATULINE DEPOT

5 PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG


SPRYCEL ORAL TABLET 20 MG


SPRYCEL ORAL TABLET 70 MG


STIVARGA 5 PA; QL (84 per 30 days)

SUTENT ORAL CAPSULE 12.5 MG


SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG


SYLVANT 5 PA


16

Drug Name Drug Tier


tacrolimus oral 2

TAFINLAR 5 PA; QL (120 per 30 days)

TAGRISSO 5 PA; QL (30 per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG


TALZENNA ORAL CAPSULE 1 MG


tamoxifen 0

TARGRETIN TOPICAL

5 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG


TASIGNA ORAL CAPSULE 50 MG


TECENTRIQ 5 PA

TEMODAR INTRAVENOUS

5 PA

temozolomide 5 PA

temsirolimus 5 PA

TENIPOSIDE 3 PA

THALOMID 5 PA

thiotepa injection recon soln 15 mg

2 PA

TIBSOVO 5 PA

toposar 2 PA

topotecan 5 PA

toremifene 2

TRAZIMERA 3 PA

TREANDA INTRAVENOUS RECON SOLN

5 PA

Drug Name Drug Tier


tretinoin (chemotherapy)

2 PA

TRIPTODUR 5 PA

TRISENOX INTRAVENOUS SOLUTION 2 MG/ML

3 PA

TRUXIMA 5 PA

TYKERB 5 PA; QL (180 per 30 days)

UNITUXIN 5 PA

VANTAS 5 PA

VECTIBIX 5 PA

VELCADE 5 PA

VENCLEXTA 5 PA

VENCLEXTA STARTING PACK


VERZENIO 5 PA; QL (60 per 30 days)

vinblastine intravenous solution

2 PA

vincasar pfs intravenous solution 1 mg/ml

2 PA

vincristine 2 PA

vinorelbine 2 PA

VITRAKVI 5 PA

VIZIMPRO 5 PA; QL (30 per 30 days)

VOTRIENT 5 PA; QL (120 per 30 days)

VYXEOS 5 PA

XALKORI 5 PA; QL (60 per 30 days)

XERMELO 5 PA; QL (90 per 30 days)


17

Drug Name Drug Tier


XOSPATA 5 PA

YERVOY 5 PA

YESCARTA 5 PA

YONDELIS 5 PA

YONSA 5 PA; QL (120 per 30 days)

ZANOSAR 3 PA

ZEJULA 5 PA; QL (90 per 30 days)

ZELBORAF 5 PA; QL (240 per 30 days)

ZEVALIN (Y-90) 3

ZIRABEV 5 PA

ZOLADEX 5 PA

ZOLINZA 5 PA

ZORTRESS 3 PA

ZYDELIG 5 PA; QL (60 per 30 days)

ZYKADIA ORAL TABLET


ZYTIGA ORAL TABLET 500 MG


AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

BANZEL 3

carbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet

2

Drug Name Drug Tier


carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet,chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam 2 PA

clonazepam 2

DIACOMIT 5

diazepam rectal 2

DILANTIN 3

divalproex 2

EPIDIOLEX 5 PA

epitol 2

ethosuximide 2

felbamate 2

fosphenytoin 2

gabapentin oral capsule

2

gabapentin oral solution 250 mg/5 ml, 300 mg/6 ml (6 ml)

2

gabapentin oral tablet 600 mg, 800 mg

2

lamotrigine 2

levetiracetam 2

levetiracetam in nacl (iso-os)

2

NAYZILAM 3 QL (2 per 30 days)

oxcarbazepine 2

PEGANONE 3


18

Drug Name Drug Tier


phenobarbital 2

phenytoin oral suspension

2

phenytoin oral tablet,chewable

2

phenytoin sodium 2

phenytoin sodium extended

2

pregabalin 2

primidone 2

roweepra 2

roweepra xr 2

subvenite 2

subvenite starter (blue) kit

2

subvenite starter (green) kit

2

subvenite starter (orange) kit

2

tiagabine 2

topiramate oral capsule, sprinkle

2

topiramate oral tablet

2

valproate sodium 2

valproic acid 2

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)

2

vigabatrin 5

vigadrone 5

VIMPAT INTRAVENOUS

3

Drug Name Drug Tier


VIMPAT ORAL SOLUTION

3

VIMPAT ORAL TABLET

3

zonisamide 2

ANTIPARKINSONISM AGENTS

APOKYN 5

benztropine 2

bromocriptine 2

carbidopa 2

carbidopa-levodopa 2

carbidopa-levodopa-entacapone

2

entacapone 2

INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE

5 PA

pramipexole 2

rasagiline 2

ropinirole 2

selegiline hcl 2

tolcapone 2

trihexyphenidyl 2

MIGRAINE & CLUSTER HEADACHE THERAPY

almotriptan malate oral tablet 12.5 mg


almotriptan malate oral tablet 6.25 mg


dihydroergotamine injection

2

dihydroergotamine nasal

2 ST; QL (8 per 30 days)


19

Drug Name Drug Tier


eletriptan 2 QL (6 per 30 days)

ergotamine-caffeine 2

frovatriptan 2 QL (9 per 30 days)

migergot 2

naratriptan 2 QL (9 per 30 days)

rizatriptan 2 QL (18 per 30 days)

sumatriptan 2 QL (6 per 30 days)

sumatriptan succinate oral


sumatriptan succinate subcutaneous cartridge


sumatriptan succinate subcutaneous pen injector


sumatriptan succinate subcutaneous solution


sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

2 QL (0.5 per 30 days)

sumatriptan-naproxen


zolmitriptan 2 QL (6 per 30 days)

MISCELLANEOUS NEUROLOGICAL THERAPY

dalfampridine 5 PA

Drug Name Drug Tier


donepezil oral tablet 10 mg, 5 mg

2

donepezil oral tablet 23 mg

2 ST

donepezil oral tablet,disintegrating

2

galantamine 2

memantine oral capsule,sprinkle,er 24hr

2

memantine oral solution

2

memantine oral tablet

2

NUEDEXTA 3 PA

RADICAVA 5 PA

rivastigmine 2

rivastigmine tartrate 2

RUZURGI 5 PA

tetrabenazine oral tablet 12.5 mg


tetrabenazine oral tablet 25 mg


TYSABRI 5 PA

ZOLGENSMA 5 PA

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

atracurium 2

baclofen oral tablet 10 mg

1

baclofen oral tablet 20 mg

2

chlorzoxazone 2

cisatracurium intravenous solution 2 mg/ml

2


20

Drug Name Drug Tier


cyclobenzaprine 2

dantrolene 2

metaxall 2

metaxalone 2

methocarbamol 2

orphenadrine citrate 2

orphenadrine-asa-caffeine oral tablet 50-770-60 mg

2

orphengesic forte 2

pyridostigmine bromide oral syrup

2

pyridostigmine bromide oral tablet 60 mg

2

pyridostigmine bromide oral tablet extended release

2

regonol 2

revonto 2

tizanidine 2

NARCOTIC ANALGESICS

acetaminophen-caff-dihydrocod oral capsule

2 ST

acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg

2 ST

acetaminophen-codeine oral solution 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 ST

acetaminophen-codeine oral tablet

2 ST

ascomp with codeine 2 ST

Drug Name Drug Tier


buprenorphine hcl injection

2 ST

buprenorphine hcl sublingual

2

buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour

2 ST

butalbital compound w/codeine

2 ST

butalbital-acetaminop-caf-cod

2 ST

butalbital-acetaminophen

2

butalbital-acetaminophen-caff oral capsule

2

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

2

butalbital-aspirin-caffeine

2

codeine sulfate oral tablet

2 ST

codeine-butalbital-asa-caff

2 ST

diskets 2 ST

duramorph (pf) 2 ST

dvorah 2 ST

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 ST

fentanyl 2 ST; QL (15 per 23 days)


21

Drug Name Drug Tier


fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)

2 ST

fentanyl citrate (pf)-0.9%nacl intravenous solution 5 mcg/ml

2 ST

fentanyl citrate (pf)-0.9%nacl intravenous syringe 10 mcg/ml

2 ST

fentanyl citrate buccal lozenge on a handle


hydrocodone bitartrate


hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 7.5-325 mg/15 ml

2 ST

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

2 ST

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

2 ST

hydromorphone (pf) injection solution 10 mg/ml, 2 mg/ml

2 ST

Drug Name Drug Tier


hydromorphone (pf)-0.9 % nacl intravenous pt controlled analgesia syring 10 mg/50 ml (0.2 mg/ml)

2 ST

hydromorphone in 0.9 % nacl intravenous pt controlled analgesia syring 15 mg/30 ml (0.5 mg/ml)

2 ST

hydromorphone injection solution

2 ST

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

2 ST

hydromorphone oral liquid

2 ST

hydromorphone oral tablet

2 ST

hydromorphone oral tablet extended release 24 hr


hydromorphone rectal

2 ST

HYSINGLA ER 4 ST; QL (60 per 23 days)

ibuprofen-oxycodone 2 ST

levorphanol tartrate oral tablet 2 mg

2 ST

lorcet (hydrocodone) 2 ST

lorcet hd 2 ST

lorcet plus oral tablet 7.5-325 mg

2 ST

methadone injection solution

2


22

Drug Name Drug Tier


methadone oral concentrate

2 ST

methadone oral solution

2 ST

methadone oral tablet

2 ST

methadone oral tablet,soluble

2 ST

methadose oral concentrate

2 ST

methadose oral tablet,soluble

2 ST

morphine (pf) in 0.9 % sod chl intravenous pt controlled analgesia syring 30 mg/30 ml (1 mg/ml)

2 ST

morphine (pf) in 0.9 % sod chl intravenous solution 1 mg/ml

2 ST

morphine (pf) in 0.9 % sod chl intravenous syringe 0.5 mg/ml, 2 mg/2 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml)

2 ST

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

2 ST

morphine (pf) intravenous patient control.analgesia soln

2 ST

morphine concentrate oral solution

2 ST

morphine injection solution 8 mg/ml

2 ST

Drug Name Drug Tier


morphine injection syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

2 ST

morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml

2 ST

morphine oral capsule, er multiphase 24 hr


morphine oral capsule,extend.release pellets


morphine oral solution

2 ST

morphine oral tablet 2 ST

morphine oral tablet extended release


morphine rectal 2 ST

oxycodone oral capsule

2 ST

oxycodone oral concentrate

2 ST

oxycodone oral solution

2 ST

oxycodone oral tablet

2 ST

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR


oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 ST


23

Drug Name Drug Tier


oxycodone-aspirin 2 ST

oxymorphone oral tablet

2 ST

oxymorphone oral tablet extended release 12 hr


prolate 2 ST

SUBLOCADE 5

tencon oral tablet 50-325 mg

2

vicodin hp 2 ST

vtol lq 2

zebutal oral capsule 50-325-40 mg

2

NON-NARCOTIC ANALGESICS

aspir-81 0 OTC

aspirin low dose 0 OTC

aspirin oral tablet 0 OTC

aspirin oral tablet,chewable

0 OTC

aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg

0 OTC

aspir-trin 0 OTC

bayer aspirin 0 OTC

buprenorphine-naloxone sublingual film 12-3 mg

2

buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg


buprenorphine-naloxone sublingual tablet 2-0.5 mg


Drug Name Drug Tier


buprenorphine-naloxone sublingual tablet 8-2 mg

2

butorphanol tartrate 2 ST

celecoxib 2 ST

children's aspirin 0 OTC

diclofenac potassium 2

diclofenac sodium oral

2

diclofenac sodium topical drops


diclofenac sodium topical gel 1 %


diclofenac-misoprostol

2

diflunisal 2

e.c. prin 0 OTC

ecotrin 0 OTC

ecotrin low strength 0 OTC

etodolac 2

EUFLEXXA 5 PA

fenoprofen oral tablet

2 ST

flurbiprofen oral tablet 100 mg

2

ibu 2

ibuprofen oral suspension

2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

2

indomethacin oral 2

ketoprofen oral capsule 25 mg

2 ST


24

Drug Name Drug Tier


ketoprofen oral capsule 50 mg, 75 mg

2

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

2 ST

ketorolac injection 2

ketorolac intramuscular

2

ketorolac oral 2 QL (20 per 30 days)

lite coat aspirin 0 OTC

meclofenamate 2

mefenamic acid 2

meloxicam oral tablet 15 mg

2

meloxicam oral tablet 7.5 mg


nabumetone 2

nalbuphine 2 ST

naloxone injection solution

2

naloxone injection syringe

2

naltrexone 2

naproxen oral suspension

2 ST

naproxen oral tablet 2

naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

2

naproxen sodium oral tablet, er multiphase 24 hr

2 ST

Drug Name Drug Tier


naproxen-esomeprazole

2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


oxaprozin 2

piroxicam 2

salsalate 2

st joseph aspirin 0 OTC

SUBOXONE SUBLINGUAL FILM 12-3 MG

3

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG


sulindac 2

tolmetin oral capsule 2 ST

tolmetin oral tablet 200 mg

2

tolmetin oral tablet 600 mg

2 ST

tramadol oral tablet 50 mg

2 ST

tramadol oral tablet extended release 24 hr


tramadol oral tablet, er multiphase 24 hr


tramadol-acetaminophen

2 ST

VIVITROL 5


25

Drug Name Drug Tier


ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET 11.4-2.9 MG

3

ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG


PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA

3

alprazolam 2

alprazolam intensol 2

amitriptyline oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

amitriptyline oral tablet 150 mg, 75 mg

2

amitriptyline-chlordiazepoxide

2

amoxapine 2

amphetamine sulfate 2

aripiprazole oral solution

2

aripiprazole oral tablet


aripiprazole oral tablet,disintegrating


ARISTADA 3

ARISTADA INITIO 3

armodafinil 2 QL (30 per 30 days)

Drug Name Drug Tier


atomoxetine 2

bupropion hcl oral tablet 100 mg

1

bupropion hcl oral tablet 75 mg

2

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg


bupropion hcl oral tablet sustained-release 12 hr


buspirone 2

chlordiazepoxide hcl 2

chlorpromazine 2

citalopram oral solution

2

citalopram oral tablet


clomipramine 2

clonidine hcl oral tablet extended release 12 hr

2

clorazepate dipotassium

2

clozapine oral tablet 2

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

2

desipramine 2

desvenlafaxine succinate


dexmethylphenidate 2

dextroamphetamine 2

dextroamphetamine-amphetamine

2


26

Drug Name Drug Tier


diazepam injection 2

diazepam intensol 2

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2

diazepam oral tablet 2

doxepin oral capsule 2

doxepin oral concentrate

2

doxepin oral tablet 2 QL (30 per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg


duloxetine oral capsule,delayed release(dr/ec) 30 mg


duloxetine oral capsule,delayed release(dr/ec) 40 mg


EMSAM 4

ergoloid 2

escitalopram oxalate oral solution

2

escitalopram oxalate oral tablet


estazolam 2

eszopiclone 2 QL (30 per 30 days)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR


Drug Name Drug Tier


flumazenil 2

fluoxetine oral capsule 10 mg



1



fluoxetine oral capsule,delayed release(dr/ec)


fluoxetine oral solution

2

fluoxetine oral tablet 10 mg


fluoxetine oral tablet 20 mg, 60 mg

2 ST

fluphenazine decanoate

2

fluphenazine hcl 2

flurazepam 2

fluvoxamine oral capsule,extended release 24hr


fluvoxamine oral tablet 100 mg






guanfacine oral tablet extended release 24 hr

2

guanidine 2

haloperidol 2

haloperidol decanoate

2

haloperidol lactate 2


27

Drug Name Drug Tier


imipramine hcl 2

imipramine pamoate 2

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG


LATUDA ORAL TABLET 80 MG


lithium carbonate 2

lithium citrate oral solution 8 meq/5 ml

2

lorazepam 2

lorazepam intensol 2

loxapine succinate 2

maprotiline 2

MARPLAN 4

metadate er 2

methamphetamine 2

methylphenidate hcl oral capsule, er biphasic 30-70

2

methylphenidate hcl oral capsule,er biphasic 50-50

2

methylphenidate hcl oral solution

2

methylphenidate hcl oral tablet

2

methylphenidate hcl oral tablet extended release

2

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

2

methylphenidate hcl oral tablet,chewable

2

Drug Name Drug Tier


midazolam oral syrup 2 mg/ml

2

mirtazapine oral tablet

1

mirtazapine oral tablet,disintegrating

2

modafinil oral tablet 100 mg


modafinil oral tablet 200 mg


molindone 2

nefazodone 2

nortriptyline oral capsule 10 mg, 25 mg, 50 mg

1

nortriptyline oral capsule 75 mg

2

nortriptyline oral solution

2

olanzapine intramuscular

2

olanzapine oral 2 QL (30 per 30 days)

olanzapine-fluoxetine

2

oxazepam 2

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6 mg


paroxetine hcl oral tablet 10 mg, 40 mg


paroxetine hcl oral tablet 20 mg, 30 mg



28

Drug Name Drug Tier


paroxetine hcl oral tablet extended release 24 hr


paroxetine mesylate(menop.sym)


perphenazine 2

perphenazine-amitriptyline

2

phenelzine 2

pimozide 2

procentra 2

protriptyline 2

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg


quetiapine oral tablet 300 mg, 400 mg


quetiapine oral tablet extended release 24 hr 150 mg, 200 mg


quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg


ramelteon 2 ST; QL (30 per 30 days)

REXULTI 4 QL (30 per 30 days)

RISPERDAL CONSTA

3

risperidone oral solution

2

risperidone oral tablet


Drug Name Drug Tier


risperidone oral tablet,disintegrating


SAPHRIS 4 QL (60 per 30 days)

seconal sodium 2 QL (30 per 30 days)

sertraline oral concentrate

2

sertraline oral tablet 100 mg, 50 mg


sertraline oral tablet 25 mg


SUNOSI 3 QL (30 per 30 days)

thioridazine 2

thiothixene 2

tranylcypromine 2

trazodone oral tablet 100 mg, 150 mg, 50 mg

1

trazodone oral tablet 300 mg

2

triazolam 2

trifluoperazine 2

trimipramine 2

TRINTELLIX 4 ST; QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg


venlafaxine oral capsule,extended release 24hr 75 mg


venlafaxine oral tablet 100 mg, 25 mg, 50 mg



29

Drug Name Drug Tier


venlafaxine oral tablet 37.5 mg, 75 mg


venlafaxine oral tablet extended release 24hr


VIIBRYD ORAL TABLET


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


VYVANSE 3

XYREM 5 ST

zaleplon oral capsule 10 mg


zaleplon oral capsule 5 mg


zenzedi oral tablet 10 mg, 5 mg

2

ziprasidone hcl 2 QL (60 per 30 days)

ziprasidone mesylate 2

zolpidem 2 QL (30 per 30 days)

ZULRESSO 5 PA

CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral 2

bretylium tosylate 2

dofetilide 2

flecainide 2

mexiletine 2

Drug Name Drug Tier


pacerone oral tablet 100 mg, 200 mg, 400 mg

2

procainamide injection

2

propafenone 2

quinidine gluconate oral

2

quinidine sulfate oral tablet

2

sotalol af 2

sotalol oral 2

SOTYLIZE 3

ANTIHYPERTENSIVE THERAPY

acebutolol 2

aliskiren 2

amiloride 2

amiloride-hydrochlorothiazide

2

amlodipine 1

amlodipine-benazepril

2

amlodipine-olmesartan

2

amlodipine-valsartan

2

amlodipine-valsartan-hcthiazid

2

atenolol 1

atenolol-chlorthalidone oral tablet 100-25 mg

2

atenolol-chlorthalidone oral tablet 50-25 mg

1

benazepril 1


30

Drug Name Drug Tier


benazepril-hydrochlorothiazide

2

betaxolol oral 2

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

2

bumetanide 2

candesartan 1

candesartan-hydrochlorothiazid

2

captopril oral tablet 100 mg, 12.5 mg, 50 mg

2

captopril oral tablet 25 mg

1

captopril-hydrochlorothiazide

2

cartia xt oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg

2

cartia xt oral capsule,extended release 24hr 180 mg

1

carvedilol 1

carvedilol phosphate 2

chlorothiazide oral tablet 500 mg

2

chlorothiazide sodium

2

chlorthalidone oral tablet 25 mg, 50 mg

1

clonidine 2 QL (4 per 21 days)

clonidine hcl oral tablet 0.1 mg

1

Drug Name Drug Tier


clonidine hcl oral tablet 0.2 mg, 0.3 mg

2

DEMSER 3 PA

diltiazem hcl oral capsule,ext.rel 24h degradable

1

diltiazem hcl oral capsule,extended release 12 hr

2

diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 420 mg

2

diltiazem hcl oral capsule,extended release 24 hr 240 mg, 360 mg

1

diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg, 360 mg

2

diltiazem hcl oral capsule,extended release 24hr 180 mg

1

diltiazem hcl oral tablet 120 mg

1

diltiazem hcl oral tablet 30 mg, 60 mg, 90 mg

2

diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg


doxazosin oral tablet 8 mg


EDARBI 4 ST


31

Drug Name Drug Tier


enalapril maleate 1

enalaprilat intravenous solution

2

enalapril-hydrochlorothiazide

2

eplerenone 2

epoprostenol (glycine)

5 PA

eprosartan 2

esmolol in nacl (iso-osm)

2

esmolol intravenous solution

2

ethacrynate sodium 2

ethacrynic acid 2

felodipine 2

fosinopril oral tablet 10 mg

2

fosinopril oral tablet 20 mg, 40 mg

1

fosinopril-hydrochlorothiazide

2

furosemide injection 2

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 20 mg, 40 mg

1

furosemide oral tablet 80 mg

2

guanfacine oral tablet

2

hydralazine injection 2

hydralazine oral tablet 10 mg, 100 mg

2

Drug Name Drug Tier


hydralazine oral tablet 25 mg, 50 mg

1

hydrochlorothiazide 1

indapamide 1

irbesartan oral tablet 150 mg, 300 mg

1

irbesartan oral tablet 75 mg

2

irbesartan-hydrochlorothiazide

2

isradipine 2

labetalol intravenous solution

2

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)

2

labetalol oral 2

lisinopril 1

lisinopril-hydrochlorothiazide

1

losartan 1

losartan-hydrochlorothiazide

2

mannitol 20 % 2

matzim la 2

methyldopa 2

methyldopa-hydrochlorothiazide

2

methyldopate 2

metolazone oral tablet 10 mg

2

metolazone oral tablet 2.5 mg, 5 mg

1


32

Drug Name Drug Tier


metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

1

metoprolol succinate oral tablet extended release 24 hr 200 mg

2

metoprolol ta-hydrochlorothiaz

2

metoprolol tartrate intravenous

2

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

metoprolol tartrate oral tablet 37.5 mg, 75 mg

2

minoxidil oral 2

moexipril 2

nadolol 2

nadolol-bendroflumethiazide oral tablet 80-5 mg

2

nicardipine oral 2

nifedipine oral tablet extended release 24hr 30 mg

2

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

1

nifedipine oral tablet extended release 30 mg

1

nifedipine oral tablet extended release 60 mg, 90 mg

2

nimodipine 2

nisoldipine 2

Drug Name Drug Tier


olmesartan 2

olmesartan-amlodipin-hcthiazid

2

olmesartan-hydrochlorothiazide

2

osmitrol 20 % 2

perindopril erbumine

2

phenoxybenzamine 2 PA

phentolamine injection recon soln

2

pindolol 2

prazosin 1

propranolol intravenous

2

propranolol oral capsule,extended release 24 hr

1

propranolol oral solution

2

propranolol oral tablet

1

propranolol-hydrochlorothiazid

2

quinapril 1

quinapril-hydrochlorothiazide

2

ramipril oral capsule 1.25 mg

2

ramipril oral capsule 10 mg, 2.5 mg, 5 mg

1

REMODULIN 5 PA

spironolactone 1

spironolacton-hydrochlorothiaz

2


33

Drug Name Drug Tier


taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 300 mg

2

taztia xt oral capsule,extended release 24 hr 240 mg, 360 mg

1

telmisartan 1

telmisartan-amlodipine

2

telmisartan-hydrochlorothiazid

2

terazosin oral capsule 1 mg, 2 mg, 5 mg


terazosin oral capsule 10 mg


tiadylt er oral capsule,extended release 24 hr 120 mg, 180 mg, 300 mg, 420 mg

2

tiadylt er oral capsule,extended release 24 hr 240 mg, 360 mg

1

timolol maleate oral 2

torsemide oral tablet 10 mg, 5 mg

2

torsemide oral tablet 100 mg, 20 mg

1

trandolapril 2

trandolapril-verapamil

2

treprostinil sodium 5 PA

triamterene 2

Drug Name Drug Tier


triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 5 PA

valsartan oral tablet 160 mg, 40 mg, 80 mg

1

valsartan oral tablet 320 mg

2

valsartan-hydrochlorothiazide

2

veletri 5 PA

verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 240 mg, 360 mg

2

verapamil oral capsule,ext rel. pellets 24 hr 180 mg

1

verapamil oral tablet 120 mg

1

verapamil oral tablet 40 mg, 80 mg

2

verapamil oral tablet extended release 120 mg, 240 mg

1

verapamil oral tablet extended release 180 mg

2

CARDIAC GLYCOSIDES

digitek 2


34

Drug Name Drug Tier


digox 2

digoxin oral solution 50 mcg/ml (0.05 mg/ml)

2

digoxin oral tablet 2

COAGULATION THERAPY

ADVATE 5 PA

ADYNOVATE 5 PA

AFSTYLA 5 PA

ALPHANATE 5 PA

ALPROLIX 5 PA

AMICAR ORAL SOLUTION

3

aminocaproic acid 2

aspirin-dipyridamole 2

BENEFIX 5 PA

bivalirudin intravenous recon soln

2

BRILINTA 3

CABLIVI INJECTION KIT

5 PA

CEPROTIN (BLUE BAR)

5

CEPROTIN (GREEN BAR)

5

cilostazol 2

clopidogrel 2

COAGADEX 5 PA

CORIFACT 5 PA

dipyridamole oral 2

DOPTELET (15 TAB PACK)


ELIQUIS 3

Drug Name Drug Tier


ELIQUIS DVT-PE TREAT 30D START

3

ELOCTATE 5 PA

enoxaparin 5

ESPEROCT 5 PA

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 700-1,300 UNIT

5 PA

fondaparinux 5

HEMLIBRA 5 PA

HEMOFIL M HIGH 5 PA

HEMOFIL M LOW 5 PA

HEMOFIL M MID 5 PA

HEMOFIL M SUPER HIGH

5 PA

hep flush-10 (pf) 2

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

2

heparin (porcine) in nacl (pf)

2

heparin (porcine) injection cartridge

2

heparin (porcine) injection solution

2

heparin (porcine) injection syringe 5,000 unit/ml

2


35

Drug Name Drug Tier


heparin flush(porcine)-0.9nacl

2

heparin lock flush 2

heparin lock flush (porcine) intravenous solution 100 unit/ml

2

heparin lockflush(porcine)(pf)

2

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

2

heparin, porcine (pf) injection solution

2

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

2

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

2

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml

2

HUMATE-P 5 PA

IXINITY 5 PA

jantoven 1

JIVI 5 PA

KOGENATE FS 5 PA

KOVALTRY 5 PA

MONONINE 5 PA

NOVOEIGHT 5 PA

NOVOSEVEN RT 5 PA

Drug Name Drug Tier


NPLATE 5 PA

OBIZUR 5 PA

pentoxifylline 2

phytonadione (vitamin k1) injection solution

2

phytonadione (vitamin k1) oral tablet 5 mg


prasugrel 2

PROFILNINE 5 PA

PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA

PROMACTA ORAL TABLET

5 PA

protamine 2

RIASTAP 5

tranexamic acid intravenous

2

TRETTEN 5 PA

vitamin k 2

vitamin k1 injection 2

VONVENDI 5 PA

warfarin 1

XARELTO 3

LIPID/CHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin


atorvastatin oral tablet 10 mg, 20 mg


atorvastatin oral tablet 40 mg, 80 mg



36

Drug Name Drug Tier


cholestyramine (with sugar)

2

cholestyramine light 2

colesevelam 2

colestipol 2

ezetimibe 2

ezetimibe-simvastatin


fenofibrate micronized

2

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

2

fenofibrate oral tablet 120 mg, 40 mg

2 ST

fenofibrate oral tablet 160 mg, 54 mg

2

fenofibric acid 2

fenofibric acid (choline)

2

fluvastatin oral capsule 20 mg


fluvastatin oral capsule 40 mg


fluvastatin oral tablet extended release 24 hr


gemfibrozil 1

JUXTAPID 5 PA

lovastatin oral tablet 10 mg


lovastatin oral tablet 20 mg, 40 mg


niacin oral tablet 500 mg

2

Drug Name Drug Tier


niacin oral tablet extended release 24 hr

2

omega-3 acid ethyl esters

2 PA

PRALUENT PEN 3 PA; QL (2 per 21 days)

pravastatin 0 QL (30 per 30 days)

prevalite 2

rosuvastatin oral tablet 10 mg, 5 mg


rosuvastatin oral tablet 20 mg, 40 mg


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg


simvastatin oral tablet 80 mg


triklo 2 PA

VASCEPA 3 PA

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR 3 PA

ENTRESTO 3 QL (60 per 30 days)

ranolazine 2

VYNDAMAX 5 PA

VYNDAQEL 5 PA

NITRATES

isosorbide dinitrate oral

2

isosorbide mononitrate

2

nitro-bid 2


37

Drug Name Drug Tier


nitroglycerin in 5 % dextrose

2

nitroglycerin intravenous

2

nitroglycerin sublingual

2

nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual spray,non-aerosol

2

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 2

calcipotriene scalp 2 QL (120 per 23 days)

calcipotriene topical cream


calcipotriene topical ointment


calcipotriene-betamethasone topical ointment


calcitriol topical 2

COSENTYX 5 PA; QL (2 per 21 days)

COSENTYX (2 SYRINGES)


COSENTYX PEN 5 PA; QL (10 per 21 days)

COSENTYX PEN (2 PENS)


hydrocortisone-pramoxine topical

2

Drug Name Drug Tier


selenium sulfide topical lotion

2

SKYRIZI SUBCUTANEOUS SYRINGE KIT


STELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5 per 63 days)

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML


STELARA SUBCUTANEOUS SYRINGE 90 MG/ML


TREMFYA SUBCUTANEOUS AUTO-INJECTOR


TREMFYA SUBCUTANEOUS SYRINGE


BURN THERAPY

silver sulfadiazine 2

ssd 2

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate 2

diclofenac sodium topical gel 3 %


doxepin topical 2 ST; QL (45 per 23 days)

DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML



38

Drug Name Drug Tier


DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML


fluorouracil topical cream 5 %

2

fluorouracil topical solution

2

iodine-sodium iodide topical tincture 2 %

2

methoxsalen 2

methyl salicylate 2

methyl salicylate topical liquid

2

pimecrolimus 2 ST; QL (100 per 23 days)

podofilox 2

prudoxin 2 ST; QL (45 per 23 days)

REGRANEX 3 QL (15 per 30 days)

tacrolimus topical 2 ST; QL (100 per 23 days)

UVADEX 3

VALCHLOR 5 PA

wintergreen oil 2

THERAPY FOR ACNE

adapalene topical cream

2

adapalene topical gel

2

adapalene topical gel with pump

2

adapalene topical solution

2

Drug Name Drug Tier


adapalene topical swab

2

adapalene-benzoyl peroxide

2

amnesteem 2

avita topical cream 2 PA

azelaic acid 2

benzepro topical towelette

2

benzoyl peroxide topical foam 9.8 %

2

claravis 2

clindacin p 2

clindamycin phosphate topical foam

2

clindamycin phosphate topical gel


clindamycin phosphate topical lotion


clindamycin phosphate topical solution


clindamycin phosphate topical swab

2

clindamycin-benzoyl peroxide

2

clindamycin-tretinoin

2 PA

dapsone topical gel 2

ery pads 2

erygel 2

erythromycin with ethanol topical gel

2


39

Drug Name Drug Tier


erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide

2

isotretinoin 2

ivermectin topical 2 QL (60 per 23 days)

metronidazole topical

2

MIRVASO 4

myorisan 2

neuac 2

rosadan topical cream

2

rosadan topical gel 2

SOOLANTRA 4 ST; QL (60 per 23 days)

tazarotene 2 PA

TAZORAC TOPICAL CREAM 0.05 %

3 PA

TAZORAC TOPICAL GEL

3 PA

tretinoin 2 PA

tretinoin microspheres

2 PA

zenatane 2

TOPICAL ANESTHETICS

lidocaine hcl laryngotracheal

2

lidocaine hcl-hydrocortison ac topical

2

Drug Name Drug Tier


lidocaine topical adhesive patch,medicated 5 %

2 PA

lidocaine viscous 2

lidocaine-prilocaine topical cream


ZTLIDO 3 PA

TOPICAL ANTIBACTERIALS

CORTISPORIN TOPICAL

4

gentamicin topical 2

lugols topical 2

mafenide acetate 2

mupirocin 2 QL (44 per 30 days)

mupirocin calcium 2 ST; QL (30 per 30 days)

strong iodine topical 2

SULFAMYLON TOPICAL CREAM

3

TOPICAL ANTIFUNGALS

ciclodan topical cream


ciclodan topical solution

2

ciclopirox topical cream


ciclopirox topical gel


ciclopirox topical shampoo


ciclopirox topical solution

2

ciclopirox topical suspension



40

Drug Name Drug Tier


clotrimazole topical cream


clotrimazole topical solution


clotrimazole-betamethasone topical cream


clotrimazole-betamethasone topical lotion


econazole 2 QL (85 per 21 days)

ketoconazole topical cream


ketoconazole topical foam


ketoconazole topical shampoo


ketodan 2 QL (100 per 21 days)

ketodan kit 2

MENTAX 4 QL (30 per 21 days)

naftifine 2 QL (60 per 21 days)

nyamyc 2

nystatin topical cream


nystatin topical ointment


nystatin topical powder

2

nystatin-triamcinolone


nystop 2

oxiconazole 2 QL (60 per 21 days)

Drug Name Drug Tier


TOPICAL ANTIVIRALS

acyclovir topical cream


acyclovir topical ointment


DENAVIR 4

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 %

2

alclometasone 2

amcinonide 2 ST

apexicon e 2 ST

beser 2

betamethasone dipropionate

2

betamethasone valerate topical cream

2

betamethasone valerate topical foam

2 ST

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented

2

clobetasol scalp 2 QL (100 per 23 days)

clobetasol topical cream


clobetasol topical foam


clobetasol topical gel



41

Drug Name Drug Tier


clobetasol topical lotion


clobetasol topical ointment


clobetasol topical shampoo


clobetasol topical spray,non-aerosol


clobetasol-emollient topical cream


clobetasol-emollient topical foam


clodan 2 ST; QL (236 per 23 days)

desonide topical cream

2

desonide topical lotion

2 ST

desonide topical ointment

2

desoximetasone 2 ST

diflorasone 2 ST; QL (120 per 23 days)

fluocinolone 2

fluocinolone and shower cap

2

fluocinonide topical cream 0.05 %


fluocinonide topical cream 0.1 %


fluocinonide topical gel


fluocinonide topical ointment


fluocinonide topical solution


Drug Name Drug Tier


fluocinonide-e 2 QL (120 per 23 days)

flurandrenolide 2 QL (120 per 23 days)

fluticasone propionate topical

2

halcinonide 2

halobetasol propionate topical cream

2

halobetasol propionate topical ointment

2

HALOG TOPICAL OINTMENT

4 ST

hydrocortisone butyrate topical cream


hydrocortisone butyrate topical lotion


hydrocortisone butyrate topical ointment

2

hydrocortisone butyrate topical solution


hydrocortisone butyr-emollient


hydrocortisone topical cream 1 %, 2.5 %

2

hydrocortisone topical lotion 2.5 %

2

hydrocortisone topical ointment 1 %, 2.5 %

2

hydrocortisone valerate

2


42

Drug Name Drug Tier


hydrocortisone-min oil-wht pet

2

mometasone topical 2

nolix 2 QL (120 per 23 days)

prednicarbate 2

scalacort 2

tovet emollient 2 ST; QL (100 per 23 days)

triamcinolone acetonide topical aerosol


triamcinolone acetonide topical cream

2

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

2

triamcinolone acetonide topical ointment 0.05 %

2 ST

trianex 2 ST

triderm topical cream

2

TOPICAL ENZYMES

SANTYL 3 QL (180 per 30 days)

TOPICAL SCABICIDES / PEDICULICIDES

crotan 2

lindane topical shampoo

2

malathion 2

Drug Name Drug Tier


permethrin topical cream

2

SKLICE 4

spinosad 2

DIAGNOSTICS & MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers irrigation

2

neomycin-polymyxin b gu

2

ringer's irrigation 2

tis-u-sol pentalyte 2

MISCELLANEOUS AGENTS

acamprosate 2

acetic acid irrigation 2

anagrelide 2

aqua care sodium chloride

2

aqua care sterile water

2

ARALAST NP 5 PA

caffeine citrate oral 2

CARBAGLU 5

cevimeline 2

CHEMET 3 PA

clovique 2 PA

deferasirox oral tablet 360 mg, 90 mg

5 PA

deferasirox oral tablet, dispersible

5 PA

disulfiram 2

etidronate disodium oral tablet 200 mg

2


43

Drug Name Drug Tier


FERRIPROX 5 PA

GLASSIA 5 PA

ic green 2

INCRELEX 5 PA

indocyanine green 2

levocarnitine (with sugar)

2

levocarnitine oral solution 100 mg/ml

2

levocarnitine oral tablet

2

midodrine 2

nitisinone 5 PA

NITYR 5 PA

pilocarpine hcl oral tablet 5 mg

2

PROLASTIN-C 5 PA

RAVICTI 5

REVCOVI 5 PA

riluzole 2 PA

risedronate oral tablet 30 mg


sodium benzoate-sod phenylacet

2

sodium chloride 0.9 % (flush) injection syringe

2

sodium chloride irrigation

2

sodium ferric gluconat-sucrose

2

sodium phenylbutyrate

2

SOLIRIS 5 PA

trientine 2 PA

Drug Name Drug Tier


water for irrigation, sterile

2

XURIDEN 5

ZEMAIRA 5 PA

zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

5 PA

SMOKING DETERRENTS

bupropion hcl (smoking deter)

0 QL (180 per 365 days)

CHANTIX 0 QL (180 per 365 days)

CHANTIX CONTINUING MONTH BOX

0 QL (180 per 365 days)

CHANTIX STARTING MONTH BOX

0 QL (180 per 365 days)

NICODERM CQ 0 OTC; QL (180 per 365 days)

nicorelief buccal gum 2 mg

0 OTC; QL (180 per 365 days)

NICORETTE BUCCAL GUM 2 MG


nicorette buccal gum 4 mg


NICORETTE BUCCAL LOZENGE


NICORETTE BUCCAL MINI LOZENGE


nicotine (polacrilex) 0 OTC; QL (180 per 365 days)


44

Drug Name Drug Tier


nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr


nicotine transdermal patch, td daily, sequential


quit 2 0 OTC; QL (180 per 365 days)

quit 4 0 OTC; QL (180 per 365 days)

stop smoking aid 0 OTC; QL (180 per 365 days)

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal aerosol,spray


azelastine nasal spray,non-aerosol

2

chlorhexidine gluconate mucous membrane

2

denta 5000 plus 2

dentagel 2

fluoride (sodium) dental cream

2

fluoride (sodium) dental gel

2

ipratropium bromide nasal


olopatadine nasal 2 QL (31 per 30 days)

oralone 2

paroex oral rinse 2

periogard 2

Drug Name Drug Tier


pilocarpine hcl oral tablet 7.5 mg

2

sf 2

sf 5000 plus 2

sodium fluoride 5000 plus

2

triamcinolone acetonide dental

2

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) 2

ciprofloxacin hcl otic (ear)

2

flac otic oil 2

fluocinolone acetonide oil

2

hydrocortisone-acetic acid

2

ofloxacin otic (ear) 2

OTIC STEROID / ANTIBIOTIC

CIPRO HC 4

CIPRODEX 3

neomycin-polymyxin-hc otic (ear)

2

ENDOCRINE/DIABETES

ADRENAL HORMONES

betamethasone acet,sod phos

2

cortisone 2

cosyntropin injection 2

decadron oral tablet 2

dexamethasone 2


45

Drug Name Drug Tier


dexamethasone intensol

2

dexamethasone sodium phos (pf) injection solution

2

dexamethasone sodium phosphate injection

2

fludrocortisone 2

hidex 2

hydrocortisone oral 2

methylprednisolone 2

methylprednisolone acetate

2

millipred dp 2

millipred oral tablet 2

prednisolone oral solution 15 mg/5 ml

2

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone sodium phosphate oral tablet,disintegrating

2

prednisone intensol 2

prednisone oral solution

2

prednisone oral tablet

1

prednisone oral tablets,dose pack

2

Drug Name Drug Tier


triamcinolone acetonide injection

2

veripred 20 2

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 2

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES

FREESTYLE INSULINX STRIP

3 OTC

FREESTYLE INSULINX TEST STRIPS

3 OTC

FREESTYLE LITE STRIPS

3 OTC

FREESTYLE TEST 3 OTC

PRECISION XTRA TEST

3 OTC

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT

ACE AEROSOL CLOUD ENHANCER

3

AEROCHAMBER MINI

3

AEROCHAMBER PLUS FLOW-VU

3

AEROCHAMBER PLUS Z STAT

3

AEROTRACH PLUS

3

AEROVENT PLUS 3

BREATHERITE MDI SPACER

3


46

Drug Name Drug Tier


COMPACT SPACE CHAMBER

3

EASIVENT HOLDING CHAMBER

3

FLEXICHAMBER 3

GLUCAGEN DIAGNOSTIC KIT

3

INSPIRACHAMBER

3

LITEAIRE MDI CHAMBER

3

MICROCHAMBER 3

MICROSPACER 3

OPTICHAMBER DIAMOND VHC

3

POCKET CHAMBER

3

PRIMEAIRE 3

PROCHAMBER 3

RITEFLO AEROCHAMBER

3

VORTEX HOLDING CHAMBER

3

GLUCOSE ELEVATING AGENTS

BAQSIMI 3 QL (2 per 30 days)

GLUCAGEN HYPOKIT


GLUCAGON EMERGENCY KIT (HUMAN)


GVOKE SYRINGE 3 QL (2 per 30 days)

PROGLYCEM 3

Drug Name Drug Tier


INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU

AUTOJECT 2 INJECTION DEVICE

3 OTC

AUTOPEN 1 TO 21 UNITS

3 OTC

BD INTEGRA NEEDLE

3

BD MICROTAINER LANCET 30 GAUGE

3 OTC

BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X 1/2"

3

BD ULTRA FINE LANCETS

3 OTC

BD ULTRA-FINE NANO PEN NEEDLE

3 OTC

FREESTYLE CONTROL

3 OTC

FREESTYLE FLASH SYSTEM

3 OTC

FREESTYLE FREEDOM

3 OTC

FREESTYLE FREEDOM LITE

3 OTC

FREESTYLE INSULINX

3 OTC

FREESTYLE LIBRE 10 DAY READER

3

FREESTYLE LIBRE 10 DAY SENSOR

3


47

Drug Name Drug Tier


FREESTYLE LITE METER

3 OTC

FREESTYLE SIDEKICK II

3 OTC

FREESTYLE SYSTEM KIT

3 OTC

LANCETS 33 GAUGE

3 OTC

LANCING DEVICE 3 OTC

MEDISENSE 3 OTC

MEDISENSE GLUCOSE KETONE

3 OTC

PRECISION XTRA MONITOR

3 OTC

SAFE-CLIP BY MAIL

3 OTC

V-GO 20 3

V-GO 30 3

V-GO 40 3

INSULIN THERAPY

HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN INSULIN

3

HUMALOG MIX 50-50 INSULN U-100

3

HUMALOG MIX 50-50 KWIKPEN

3

HUMALOG MIX 75-25 KWIKPEN

3

HUMALOG MIX 75-25(U-100)INSULN

3

Drug Name Drug Tier


HUMALOG U-100 INSULIN

3

HUMULIN 70/30 U-100 INSULIN

3

HUMULIN 70/30 U-100 KWIKPEN

3

HUMULIN N NPH INSULIN KWIKPEN

3

HUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

HUMULIN R U-500 (CONC) INSULIN

3

HUMULIN R U-500 (CONC) KWIKPEN

3

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN

3

LEVEMIR FLEXTOUCH U-100 INSULN

4

LEVEMIR U-100 INSULIN

4

NOVOLOG FLEXPEN U-100 INSULIN

4

NOVOLOG MIX 70-30 U-100 INSULN

4

NOVOLOG MIX 70-30FLEXPEN U-100

4


48

Drug Name Drug Tier


NOVOLOG PENFILL U-100 INSULIN

4

NOVOLOG U-100 INSULIN ASPART

4

RELION NOVOLIN 70/30

4

RELION NOVOLIN N

4

RELION NOVOLIN R

4

SOLIQUA 100/33 4 QL (15 per 30 days)

TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

MISCELLANEOUS HORMONES

ALDURAZYME 5 PA

ANADROL-50 4

BRINEURA INTRAVENTRICULAR KIT

5 PA

cabergoline 2 QL (8 per 21 days)

calcitonin (salmon) 2

calcitriol intravenous solution 1 mcg/ml

2

calcitriol oral 2

CERDELGA 5 PA

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 PA

cinacalcet 2 PA

Drug Name Drug Tier


CRYSVITA 5 PA; QL (90 per 21 days)

danazol 2

DDAVP NASAL SOLUTION

3

desmopressin nasal spray,non-aerosol

2

desmopressin oral 2

doxercalciferol intravenous

2

doxercalciferol oral 2 ST

ELAPRASE 5 PA

FABRAZYME 5 PA

KANUMA 5 PA

KUVAN 5 PA

LUMIZYME 5 PA

MEPSEVII 5 PA

METHITEST 3

methyltestosterone oral capsule

2

miglustat 5 PA

MYALEPT 5 PA

NAGLAZYME 5 PA

NATPARA 5 PA

ORILISSA ORAL TABLET 150 MG


ORILISSA ORAL TABLET 200 MG


oxandrolone 2

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML



49

Drug Name Drug Tier


PALYNZIQ SUBCUTANEOUS SYRINGE 2.5 MG/0.5 ML


PALYNZIQ SUBCUTANEOUS SYRINGE 20 MG/ML


pamidronate 2

paricalcitol intravenous

2

paricalcitol oral 2 ST

SAMSCA 5 PA; QL (30 per 30 days)

SOMAVERT 5

STIMATE 5

STRENSIQ 5 PA

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

2 PA

testosterone enanthate

2 PA

testosterone transdermal gel


testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation


testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)


Drug Name Drug Tier


testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %)


testosterone transdermal gel in packet 1 % (25 mg/2.5gram)


testosterone transdermal gel in packet 1 % (50 mg/5 gram)


testosterone transdermal gel in packet 1.62 % (20.25 mg/1.25 gram)


testosterone transdermal gel in packet 1.62 % (40.5 mg/2.5 gram)


testosterone transdermal solution in metered pump w/app


VIMIZIM 5 PA

zoledronic acid 5

zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml

5

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose 2

BYDUREON BCISE



50

Drug Name Drug Tier


BYDUREON SUBCUTANEOUS PEN INJECTOR


BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML


BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML


FARXIGA 3 ST; QL (30 per 30 days)

glimepiride 1

glipizide 1

glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg

2

glipizide-metformin oral tablet 5-500 mg

1

glyburide micronized

2

glyburide oral tablet 1.25 mg, 2.5 mg

2

glyburide oral tablet 5 mg

1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg

2

glyburide-metformin oral tablet 5-500 mg

1

GLYXAMBI 3 ST; QL (30 per 30 days)

JANUMET 3 ST; QL (60 per 30 days)

Drug Name Drug Tier


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA 3 ST; QL (30 per 30 days)

JARDIANCE 3 ST; QL (30 per 30 days)

JENTADUETO 3 ST; QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG


metformin oral tablet

1

metformin oral tablet extended release 24 hr 500 mg


metformin oral tablet extended release 24 hr 750 mg


miglitol 2

nateglinide 2

pioglitazone 2 QL (30 per 30 days)

pioglitazone-glimepiride



51

Drug Name Drug Tier


pioglitazone-metformin


repaglinide 2

repaglinide-metformin


SYMLINPEN 120 3 ST; QL (19 per 30 days)

SYMLINPEN 60 3 ST; QL (11 per 30 days)

SYNJARDY 3 ST; QL (60 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG


TRADJENTA 3 ST; QL (30 per 30 days)

TRULICITY 3 ST; QL (1 per 30 days)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-500 MG


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG


THYROID HORMONES

ARMOUR THYROID

3

Drug Name Drug Tier


levothyroxine intravenous recon soln

2

levothyroxine oral 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine 2

nature-throid 2

np thyroid 2

thyroid (pork) 2

THYROLAR-1 4

THYROLAR-1/2 4

THYROLAR-1/4 4

THYROLAR-2 4

THYROLAR-3 4

unithroid 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

2

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz 2

atropine in 0.9 % sod chloride intravenous syringe 0.8 mg/2 ml (0.4 mg/ml)

2

atropine injection syringe 0.05 mg/ml

2


52

Drug Name Drug Tier


belladonna alkaloids-opium

2 ST

dicyclomine intramuscular

2

dicyclomine oral capsule

2

dicyclomine oral solution

2

dicyclomine oral tablet

2

diphenoxylate-atropine

2

ed-spaz 2

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml), 1 mg/5 ml (0.2 mg/ml)

2

glycopyrrolate injection

2

glycopyrrolate oral 2

hyoscyamine sulfate oral

2

hyoscyamine sulfate sublingual

2

hyosyne 2

loperamide oral capsule

2

methscopolamine 2

opium tincture 2

oscimin 2

oscimin sl 2

oscimin sr 2

phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 -0.0194 mg/5 ml

2

Drug Name Drug Tier


symax fastabs 2

symax-sl 2

symax-sr 2

MISCELLANEOUS GASTROINTESTINAL AGENTS

alophen (bisacodyl) 0 OTC

alosetron 2

aprepitant oral capsule 125 mg, 40 mg


aprepitant oral capsule 80 mg


aprepitant oral capsule,dose pack


balsalazide 2

bisacodyl oral 0 OTC

bisa-lax (bisacodyl) 0 OTC

budesonide oral 2

calcium acetate(phosphat bind)

2

CHENODAL 5 PA

CHOLBAM ORAL CAPSULE 250 MG

5 PA

CHOLBAM ORAL CAPSULE 50 MG


CINVANTI 3 PA

citrate of magnesia 0 OTC

citroma 0 OTC

clearlax 0 OTC

colocort 2

compro 2

constulose 2

CREON 3


53

Drug Name Drug Tier


cromolyn oral 2

CYSTADANE 5

dimenhydrinate injection solution

2

DIPENTUM 4

doxylamine-pyridoxine (vit b6)

2 QL (720 per 365 days)

dronabinol 2 PA

droperidol injection solution

2

ducodyl (bisacodyl) 0 OTC

ENTYVIO 5 PA

enulose 2

fleet laxative (bisacodyl)

0 OTC

fosaprepitant 2 PA

gavilax oral powder 0 OTC

gavilyte-c 0

gavilyte-g 0

gavilyte-n 0

generlac 2

gentle laxative (bisacodyl) oral

0 OTC

gentlelax 0 OTC

glycolax oral powder

0 OTC

granisetron (pf) 2

granisetron hcl intravenous

2 PA

granisetron hcl oral 2 QL (6 per 30 days)

healthylax 0 OTC

hydrocortisone rectal

2

Drug Name Drug Tier


hydrocortisone topical cream with perineal applicator

2

hydrocortisone-pramoxine rectal

2

INFLECTRA 5 PA

kionex (with sorbitol)

2

lactulose oral packet 2

lactulose oral solution 10 gram/15 ml, 20 gram/30 ml

2

lanthanum 2

laxaclear 0 OTC

laxative (bisacodyl) oral

0 OTC

laxative peg 3350 oral powder

0 OTC

LOKELMA 3 QL (30 per 30 days)

magnesium citrate oral solution

0 OTC

meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine 2

mesalamine with cleansing wipe

2

metoclopramide hcl 2

milk of magnesia 0 OTC

milk of magnesia concentrated

0 OTC

miralax oral powder in packet

0 OTC

MOVANTIK 3 QL (30 per 30 days)

natura-lax 0 OTC


54

Drug Name Drug Tier


OCALIVA 5 PA; QL (30 per 30 days)

ondansetron 2 QL (9 per 30 days)

ondansetron hcl (pf) 2

ondansetron hcl intravenous

2

ondansetron hcl oral solution


ondansetron hcl oral tablet 24 mg


ondansetron hcl oral tablet 4 mg, 8 mg


oral saline laxative oral liquid

0 OTC

palonosetron intravenous solution 0.25 mg/5 ml

2 PA

palonosetron intravenous syringe

2 PA

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

0

peg-electrolyte soln 0

peg-prep 0

PENTASA 3

phosphate laxative oral liquid

0 OTC

polyethylene glycol 3350

0 OTC

powderlax 0 OTC

prochlorperazine 2

prochlorperazine edisylate

2

Drug Name Drug Tier


prochlorperazine maleate

2

procto-med hc 2

procto-pak 2

proctosol hc topical 2

proctozone-hc 2

purelax 0 OTC

RECTIV 3

RELISTOR ORAL 3 ST

RELISTOR SUBCUTANEOUS SOLUTION

3 ST

RELISTOR SUBCUTANEOUS SYRINGE

3 ST

scopolamine base 2

sevelamer carbonate 2

sevelamer hcl 2

smoothlax 0 OTC

sodium polystyrene (sorb free)

2

sodium polystyrene sulfonate oral powder

2

sps (with sorbitol) 2

SUCRAID 5

sulfasalazine 2

trilyte with flavor packets

0

trimethobenzamide oral

2

TRULANCE 3

UCERIS RECTAL 3

ursodiol 2


55

Drug Name Drug Tier


VARUBI ORAL 3 PA; QL (2 per 30 days)

VIBERZI 3

VIOKACE 3

women's gentle laxative(bisac)

0 OTC

women's laxative (bisacodyl)

0 OTC

ULCER THERAPY

amoxicil-clarithromy-lansopraz


CARAFATE ORAL SUSPENSION

3

cimetidine 2

cimetidine hcl oral 2

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg


esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

2

esomeprazole sodium

2

famotidine (pf) 2

famotidine (pf)-nacl (iso-os)

2

famotidine intravenous solution

2

famotidine oral suspension

2

famotidine oral tablet 20 mg, 40 mg

2

Drug Name Drug Tier


lansoprazole oral capsule,delayed release(dr/ec) 15 mg


lansoprazole oral capsule,delayed release(dr/ec) 30 mg

2

lansoprazole oral tablet,disintegrat, delay rel 15 mg


lansoprazole oral tablet,disintegrat, delay rel 30 mg

2

misoprostol 2

nizatidine 2

omeprazole oral capsule,delayed release(dr/ec) 10 mg


omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg

1

omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram


omeprazole-sodium bicarbonate oral capsule 40-1.1 mg-gram

2 PA

omeprazole-sodium bicarbonate oral packet 20-1,680 mg


omeprazole-sodium bicarbonate oral packet 40-1,680 mg

2 PA

pantoprazole intravenous

2


56

Drug Name Drug Tier


pantoprazole oral tablet,delayed release (dr/ec) 20 mg


pantoprazole oral tablet,delayed release (dr/ec) 40 mg

1

rabeprazole oral tablet,delayed release (dr/ec)

2

ranitidine hcl oral syrup

2

ranitidine hcl oral tablet 150 mg

1

ranitidine hcl oral tablet 300 mg

2

sucralfate 2

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

LEUKINE INJECTION RECON SOLN

5 PA

MOZOBIL 5

NEULASTA 5 PA; QL (1.2 per 23 days)

NIVESTYM 5 PA

PROCRIT 5 PA

RETACRIT 5 PA

UDENYCA 5 PA; QL (1.2 per 23 days)

ZARXIO 5 PA

ZIEXTENZO 5 PA

GROWTH HORMONES

Drug Name Drug Tier


EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

5 PA

EGRIFTA SV 5 PA

OMNITROPE 5 PA

INTERFERONS

AVONEX INTRAMUSCULAR PEN INJECTOR KIT


AVONEX INTRAMUSCULAR SYRINGE KIT


BETASERON SUBCUTANEOUS KIT


GILENYA ORAL CAPSULE 0.5 MG

5 PA

glatiramer subcutaneous syringe 20 mg/ml


glatiramer subcutaneous syringe 40 mg/ml


glatopa subcutaneous syringe 20 mg/ml


glatopa subcutaneous syringe 40 mg/ml


OCREVUS 5 PA

PEGASYS SUBCUTANEOUS SOLUTION


PEGASYS SUBCUTANEOUS SYRINGE



57

Drug Name Drug Tier


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML


POMALYST 5 PA

REBIF (WITH ALBUMIN)


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK


REVLIMID 5 PA

ribavirin oral capsule

5 ST

ribavirin oral tablet 200 mg

5 ST

Drug Name Drug Tier


SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5 PA

TECFIDERA 5 PA

VUMERITY 5 PA

INTERLEUKINS

ACTIMMUNE 5

ALFERON N 3 PA

ILARIS (PF) SUBCUTANEOUS SOLUTION

5 PA

imiquimod topical cream in packet

2

INTRON A INJECTION

5 PA

PROLEUKIN 5 PA

VACCINES & MISCELLANEOUS IMMUNOLOGICALS

ADACEL(TDAP ADOLESN/ADULT)(PF)

0

AFLURIA QD 2019-20(3YR UP)(PF)

0

AFLURIA QD 2019-20(6-35MO)(PF)

0

AFLURIA QUAD 2019-20(6MO UP)

0

BEXSERO 0

BIOTHRAX 0

BOOSTRIX TDAP 0

BOTOX 5 PA

DAPTACEL (DTAP PEDIATRIC) (PF)

0


58

Drug Name Drug Tier


ENGERIX-B (PF) 0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

0

FLUAD 2019-2020 (65 YR UP)(PF)

0

FLUARIX QUAD 2019-2020 (PF)

0

FLUBLOK QUAD 2019-2020 (PF)

0

FLUCELVAX QUAD 2019-2020

0

FLUCELVAX QUAD 2019-2020 (PF)

0

FLULAVAL QUAD 2019-2020

0

FLULAVAL QUAD 2019-2020 (PF)

0

FLUZONE HIGH-DOSE 2019-20 (PF)

0

FLUZONE QUAD 2019-2020

0

FLUZONE QUAD 2019-2020 (PF)

0

FLUZONE QUAD PEDI 2019-20 (PF)

0

GAMASTAN 5

GAMASTAN S/D 5 PA

GAMMAGARD LIQUID

5 PA

GAMMAGARD S-D (IGA < 1 MCG/ML)

5 PA

GAMUNEX-C 5 PA

GARDASIL 9 (PF) 0

Drug Name Drug Tier


HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

0

HIBERIX (PF) 0

HIZENTRA SUBCUTANEOUS SOLUTION

5 PA

HYPERHEP B S/D 3

HYPERHEP B S-D NEONATAL

3

HYPERRAB (PF) 3

HYPERRAB S/D (PF)

3

IMOGAM RABIES-HT (PF)

3

IMOVAX RABIES VACCINE (PF)

0

INFANRIX (DTAP) (PF)

0

IPOL 0

IXIARO (PF) 0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

0

M-M-R II (PF) 0

PEDVAX HIB (PF) 0

PNEUMOVAX-23 0

PREVNAR 13 (PF) 0

PRIVIGEN 5 PA

PROQUAD (PF) 0

PROVENGE 5 PA


59

Drug Name Drug Tier


QUADRACEL (PF) 0

RABAVERT (PF) 0

RECOMBIVAX HB (PF)

0

ROTATEQ VACCINE

0

SHINGRIX (PF) 0

STAMARIL (PF) 0

TDVAX 0

TETANUS,DIPHTHERIA TOX PED(PF)

0

TRUMENBA 0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

0

TYPHIM VI 0

VARIVAX (PF) 0

VARIZIG INTRAMUSCULAR SOLUTION

0

VAXCHORA VACCINE

0

VIVOTIF 0

YF-VAX (PF) 0

MUSCULOSKELETAL & RHEUMATOLOGY

GOUT THERAPY

allopurinol 1

allopurinol sodium 2

aloprim 2

colchicine oral tablet

2

febuxostat 2 ST

Drug Name Drug Tier


KRYSTEXXA 5 PA

MITIGARE 3

probenecid 2

probenecid-colchicine

2

OSTEOPOROSIS THERAPY

alendronate oral solution


alendronate oral tablet 10 mg, 5 mg


alendronate oral tablet 35 mg, 70 mg


ibandronate intravenous

5 PA

ibandronate oral 2 QL (1 per 23 days)

raloxifene 2







risedronate oral tablet,delayed release (dr/ec)


TYMLOS 5 PA; QL (1 per 30 days)

OTHER RHEUMATOLOGICALS

ACTEMRA ACTPEN


ACTEMRA INTRAVENOUS

5 PA

ACTEMRA SUBCUTANEOUS



60

Drug Name Drug Tier


BENLYSTA INTRAVENOUS

5 PA

BENLYSTA SUBCUTANEOUS


D-PENAMINE 3 PA

ENBREL MINI 5 PA; QL (4 per 21 days)

ENBREL SUBCUTANEOUS RECON SOLN


ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

5 PA; QL (4.5 per 21 days)

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)


ENBREL SURECLICK


HUMIRA 5 PA; QL (2 per 21 days)

HUMIRA PEN 5 PA; QL (2 per 21 days)

HUMIRA PEN CROHNS-UC-HS START


HUMIRA PEN PSOR-UVEITS-ADOL HS


HUMIRA(CF) 5 PA; QL (2 per 21 days)

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML


Drug Name Drug Tier


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS


HUMIRA(CF) PEN PSOR-UV-ADOL HS


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML


leflunomide 2 QL (30 per 30 days)

OTEZLA 5 PA; QL (60 per 23 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)


OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)


penicillamine 2 PA

RIDAURA 3

RINVOQ 5 PA; QL (30 per 30 days)

SAVELLA ORAL TABLET



61

Drug Name Drug Tier


SAVELLA ORAL TABLETS,DOSE PACK


SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML


SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML


XELJANZ 5 PA; QL (60 per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG


XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 22 MG

5 PA

OBSTETRICS & GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED

0

FC2 FEMALE CONDOM

0 OTC

FEMCAP VAGINAL DEVICE 22 MM

0

MIRENA 0

PARAGARD T 380A

0

ESTROGENS & PROGESTINS

Drug Name Drug Tier


amabelz 2

camila 0

CRINONE VAGINAL GEL 4 %

3

deblitane 0

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

3

dotti 2 QL (8 per 21 days)

errin 0

estradiol oral 1

estradiol transdermal patch semiweekly


estradiol transdermal patch weekly


estradiol vaginal 2

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

2

estradiol-norethindrone acet

2

fyavolv 2

heather 0

hydroxyprogest(pf)(preg presv)

5 PA

hydroxyprogesterone cap(ppres)

5 PA

hydroxyprogesterone caproate

2 PA

incassia 0

jencycla 0


62

Drug Name Drug Tier


jinteli 2

lopreeza oral tablet 1-0.5 mg

2

lyza 0

medroxyprogesterone intramuscular


medroxyprogesterone oral

2

MENEST 3

mimvey 2

nora-be 0

norethindrone (contraceptive)

0

norethindrone acetate

2

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

norlyda 0

progesterone 5

progesterone micronized

2

sharobel 0

tulana 0

yuvafem 2

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal

2

eluryng 0

etonogestrel-ethinyl estradiol

0

GYNAZOLE-1 4

gynol ii 0 OTC

INTRAROSA 4

Drug Name Drug Tier


isoxsuprine oral tablet 20 mg

2

metronidazole vaginal

2

miconazole-3 vaginal suppository

2

NEXPLANON 0

terconazole 2

TODAY CONTRACEPTIVE SPONGE

0 OTC

tranexamic acid oral 2

vaginal contraceptive foam

0 OTC

vandazole 2

VCF CONTRACEPTIVE FILM

0 OTC

VCF CONTRACEPTIVE GEL

0 OTC

xulane 0

ORAL CONTRACEPTIVES & RELATED AGENTS

afirmelle 0

altavera (28) 0

alyacen 1/35 (28) 0

alyacen 7/7/7 (28) 0

amethia 0

amethia lo 0

amethyst (28) 0

apri 0

aranelle (28) 0

ashlyna 0

aubra 0


63

Drug Name Drug Tier


aubra eq 0

aurovela 1.5/30 (21) 0

aurovela 1/20 (21) 0

aurovela 24 fe 0

aurovela fe 1.5/30 (28)

0

aurovela fe 1-20 (28)

0

aviane 0

ayuna 0

azurette (28) 0

balziva (28) 0

bekyree (28) 0

blisovi 24 fe 0

blisovi fe 1.5/30 (28) 0

blisovi fe 1/20 (28) 0

briellyn 0

camrese 0

camrese lo 0

caziant (28) 0

chateal (28) 0

chateal eq (28) 0

cryselle (28) 0

cyclafem 1/35 (28) 0

cyclafem 7/7/7 (28) 0

cyred 0

cyred eq 0

dasetta 1/35 (28) 0

dasetta 7/7/7 (28) 0

daysee 0

desog-e.estradiol/e.estradiol

0

Drug Name Drug Tier


desogestrel-ethinyl estradiol

0

drospirenone-e.estradiol-lm.fa

0

drospirenone-ethinyl estradiol

0

econtra ez 0 OTC; QL (1 per 30 days)

econtra one-step 0 OTC; QL (1 per 30 days)

elinest 0

ELLA 0 QL (1 per 30 days)

emoquette 0

enpresse 0

enskyce 0

estarylla 0

ethynodiol diac-eth estradiol

0

falmina (28) 0

fayosim 0

femynor 0

gianvi (28) 0

hailey 0

hailey 24 fe 0

introvale 0

isibloom 0

jaimiess 0 ACA

jasmiel (28) 0

jolessa 0

juleber 0

junel 1.5/30 (21) 0

junel 1/20 (21) 0


64

Drug Name Drug Tier


junel fe 1.5/30 (28) 0

junel fe 1/20 (28) 0

junel fe 24 0

kaitlib fe 0

kalliga 0

kariva (28) 0

kelnor 1/35 (28) 0

kelnor 1-50 0

kurvelo (28) 0

l norgest/e.estradiol-e.estrad

0

larin 1.5/30 (21) 0

larin 1/20 (21) 0

larin 24 fe 0

larin fe 1.5/30 (28) 0

larin fe 1/20 (28) 0

larissia 0

layolis fe 0

leena 28 0

lessina 0

levonest (28) 0

levonorgestrel oral tablet 1.5 mg


levonorgestrel-ethinyl estrad

0

levonorg-eth estrad triphasic

0

levora-28 0

lillow (28) 0

lojaimiess 0 ACA

loryna (28) 0

low-ogestrel (28) 0

lo-zumandimine (28) 0

Drug Name Drug Tier


lutera (28) 0

marlissa (28) 0

melodetta 24 fe 0

mibelas 24 fe 0

microgestin 1.5/30 (21)

0

microgestin 1/20 (21)

0

microgestin fe 1.5/30 (28)

0

microgestin fe 1/20 (28)

0

mili 0

mono-linyah 0

my choice 0 OTC; QL (1 per 30 days)

my way 0 OTC; QL (1 per 30 days)

necon 0.5/35 (28) 0

new day 0 OTC; QL (1 per 30 days)

nikki (28) 0

noreth-ethinyl estradiol-iron

0

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

0

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

0

norethindrone-e.estradiol-iron oral tablet,chewable

0


65

Drug Name Drug Tier


norgestimate-ethinyl estradiol

0

nortrel 0.5/35 (28) 0

nortrel 1/35 (21) 0

nortrel 1/35 (28) 0

nortrel 7/7/7 (28) 0

ocella 0

ogestrel (28) 0

opcicon one-step 0 OTC; QL (1 per 30 days)

option-2 0 OTC; QL (1 per 30 days)

orsythia 0

philith 0

pimtrea (28) 0

pirmella 0

PLAN B ONE-STEP 0 OTC; QL (1 per 30 days)

portia 28 0

previfem 0

reclipsen (28) 0

rivelsa 0

setlakin 0

simliya (28) 0

simpesse 0

sprintec (28) 0

sronyx 0

syeda 0

tarina 24 fe 0

tarina fe 1/20 (28) 0

tilia fe 0

tri femynor 0

tri-estarylla 0

Drug Name Drug Tier


tri-legest fe 0

tri-linyah 0

tri-lo-estarylla 0

tri-lo-marzia 0

tri-lo-mili 0

tri-lo-sprintec 0

tri-mili 0

tri-previfem (28) 0

tri-sprintec (28) 0

trivora (28) 0

tri-vylibra 0

tri-vylibra lo 0

tydemy 0

velivet triphasic regimen (28)

0

vienva 0

viorele (28) 0

volnea (28) 0 ACA

vyfemla (28) 0

vylibra 0

wera (28) 0

wymzya fe 0

zarah 0

zovia 1/35e (28) 0

zumandimine (28) 0

OXYTOCICS

methergine 2 QL (240 per 30 days)

methylergonovine oral


oxytocin injection solution

2


66

Drug Name Drug Tier


OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac 2

bacitracin ophthalmic (eye)

2

bacitracin-polymyxin b ophthalmic (eye)

2

ciprofloxacin hcl ophthalmic (eye)

2

erythromycin ophthalmic (eye)

2

gatifloxacin 2

gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

2

levofloxacin ophthalmic (eye)

2

moxifloxacin ophthalmic (eye)

2

NATACYN 3

neomycin-bacitracin-polymyxin

2

neomycin-polymyxin-gramicidin

2

neo-polycin 2

ofloxacin ophthalmic (eye)

2

polycin 2

polymyxin b sulf-trimethoprim

2

tobramycin 2

Drug Name Drug Tier


ANTIVIRALS

trifluridine 2

BETA-BLOCKERS

betaxolol ophthalmic (eye)

2

carteolol 2

levobunolol ophthalmic (eye) drops 0.5 %

2

metipranolol 2

timolol maleate ophthalmic (eye)

2

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE

3

CYCLOPLEGIC MYDRIATICS

atropine ophthalmic (eye) drops

2

atropine ophthalmic (eye) ointment

2

cyclopentolate 2

tropicamide 2

DIRECT ACTING MIOTICS

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

2

MISCELLANEOUS OPHTHALMOLOGICS

ALOMIDE 4 ST

altacaine 2

azelastine ophthalmic (eye)

2

cromolyn ophthalmic (eye)

2


67

Drug Name Drug Tier


CYSTARAN 5

epinastine 2

EYLEA 5 PA

JETREA (PF) INTRAVITREAL SOLUTION 0.125 MG/0.1 ML (1.25 MG/ML)

5 PA

LASTACAFT 4 ST

lidocaine-phenylephrn in water

2

LUXTURNA 5 PA

olopatadine ophthalmic (eye)

2

OXERVATE 5 PA

proparacaine 2

RESTASIS 3 PA; QL (60 per 30 days)

RESTASIS MULTIDOSE


tetracaine hcl 2

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac 2

diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2

ketorolac ophthalmic (eye)

2

NEVANAC 4

ORAL DRUGS FOR GLAUCOMA

acetazolamide 2

acetazolamide sodium

2

Drug Name Drug Tier


methazolamide 2

OTHER GLAUCOMA DRUGS

AZOPT 4

bimatoprost ophthalmic (eye)

2

COMBIGAN 4

dorzolamide 2

dorzolamide-timolol 2

dorzolamide-timolol (pf) ophthalmic (eye) dropperette

2

latanoprost 1

miostat 2

travoprost 2

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc

2

neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-hc ophthalmic (eye)

2

neo-polycin hc 2

tobramycin-dexamethasone

2

STEROIDS

dexamethasone sodium phosphate ophthalmic (eye)

2

fluorometholone 2

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

4


68

Drug Name Drug Tier


LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

3

LOTEMAX OPHTHALMIC (EYE) OINTMENT

4

LOTEMAX SM 4

loteprednol etabonate

2

OZURDEX 5

prednisolone acetate 2

prednisolone sodium phosphate ophthalmic (eye)

2

STEROID-SULFONAMIDE COMBINATIONS

sulfacetamide-prednisolone

2

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

3

apraclonidine 2

brimonidine 2

VASOCONSTRICTOR DECONGESTANTS

phenylephrine hcl ophthalmic (eye)

2

RESPIRATORY, ALLERGY, COUGH & COLD

ANTIHISTAMINE & ANTIALLERGENIC AGENTS

adrenalin injection 2

Drug Name Drug Tier


carbinoxamine maleate oral liquid

2

carbinoxamine maleate oral tablet 4 mg

2

carbinoxamine maleate oral tablet 6 mg

2 ST

cetirizine oral solution 1 mg/ml

2

clemastine oral tablet 2.68 mg

2

cyproheptadine 2

desloratadine 2 QL (30 per 30 days)

dexchlorpheniramine maleate oral solution

2

diphenhydramine hcl injection solution 50 mg/ml

2

diphenhydramine hcl injection syringe

2

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml


EPIPEN 2-PAK 3 PA; QL (2 per 30 days)

EPIPEN JR 2-PAK 3 PA; QL (2 per 30 days)

hydroxyzine hcl intramuscular

2

hydroxyzine hcl oral solution 10 mg/5 ml

2

hydroxyzine hcl oral tablet

2


69

Drug Name Drug Tier


hydroxyzine pamoate

2

levocetirizine oral solution

2

levocetirizine oral tablet


phenadoz 2

promethazine injection solution

2

promethazine oral 2

promethazine rectal 2

promethegan 2

COUGH & COLD THERAPY

benzonatate 2

brompheniramine-pseudoeph-dm oral syrup

2

codeine-guaifenesin 2

g tussin ac 2

guaiatussin ac 2

hydrocodone-chlorpheniramine

2

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

2

hydrocodone-homatropine oral tablet

2

hydromet 2

lortuss ex oral syrup 2

m-clear wc 2

promethazine-codeine

2

promethazine-dm 2

Drug Name Drug Tier


promethazine-phenyleph-codeine

2

promethazine-phenylephrine

2

virtussin ac 2

virtussin dac 2

PULMONARY AGENTS

acetylcysteine 2

ADEMPAS 5 PA

albuterol sulfate inhalation hfa aerosol inhaler


albuterol sulfate inhalation solution for nebulization

2

albuterol sulfate oral 2

alyq 2 PA; QL (60 per 30 days)

ambrisentan 5 PA

aminophylline intravenous solution 250 mg/10 ml

2

ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION


azelastine-fluticasone


BEVESPI AEROSPHERE


bosentan 5 PA


70

Drug Name Drug Tier


budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml


budesonide inhalation suspension for nebulization 1 mg/2 ml


CINRYZE 5 PA

COMBIVENT RESPIMAT


cromolyn inhalation 2

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION





3 ST

ESBRIET ORAL CAPSULE


ESBRIET ORAL TABLET 267 MG


ESBRIET ORAL TABLET 801 MG

5 PA

FASENRA 5 PA

FASENRA PEN 5 PA

Drug Name Drug Tier


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


fluticasone propionate nasal


FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED


fluticasone propion-salmeterol inhalation blister with device


icatibant 5 PA

INCRUSE ELLIPTA


ipratropium bromide inhalation

2

ipratropium-albuterol


KALYDECO ORAL GRANULES IN PACKET 25 MG

5 PA

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG


KALYDECO ORAL TABLET


levalbuterol hcl 2

metaproterenol oral syrup

2

mometasone nasal 2 ST; QL (17 per 30 days)

montelukast oral granules in packet

2


71

Drug Name Drug Tier


montelukast oral tablet

1

montelukast oral tablet,chewable

1

nebusal inhalation solution for nebulization 3 %

2

NUCALA 5 PA; QL (1 per 21 days)

OFEV 5 PA; QL (60 per 30 days)

OPSUMIT 5 PA

ORKAMBI ORAL GRANULES IN PACKET


ORKAMBI ORAL TABLET


PERFOROMIST 3 QL (120 per 30 days)

PROAIR HFA 3 QL (17 per 30 days)

PROAIR RESPICLICK


pulmosal 2

PULMOZYME 5 PA

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION


QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION


Drug Name Drug Tier


RUCONEST 5 PA

sildenafil (pulm.hypertension) intravenous

5 PA

sildenafil (pulm.hypertension) oral suspension for reconstitution


sildenafil (pulm.hypertension) oral tablet


sodium chloride inhalation

2

STRIVERDI RESPIMAT


SYMBICORT 3 ST; QL (11 per 30 days)

SYMDEKO 5 PA; QL (56 per 30 days)

tadalafil (pulm. hypertension)


terbutaline 2

theochron oral tablet extended release 12 hr 100 mg, 200 mg

2

theophylline oral elixir

2

theophylline oral solution

2

theophylline oral tablet extended release 12 hr

2

theophylline oral tablet extended release 24 hr

2

TRACLEER ORAL TABLET FOR SUSPENSION

5 PA


72

Drug Name Drug Tier


TRELEGY ELLIPTA


TRIKAFTA 5 PA

TYVASO 5 PA

TYVASO REFILL KIT

5 PA

TYVASO STARTER KIT

5 PA

UTIBRON NEOHALER


wixela inhub 2 QL (1 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN


XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML


XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML


zafirlukast 2

zileuton 2

UROLOGICALS

ANTICHOLINERGICS & ANTISPASMODICS

darifenacin 2

flavoxate 2

oxybutynin chloride 2

solifenacin 2

tolterodine 2

trospium 2

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

Drug Name Drug Tier


alfuzosin 2

dutasteride 2 ST

dutasteride-tamsulosin

2 ST

finasteride oral tablet 5 mg

2

silodosin 2

tamsulosin 2

CHOLINERGIC STIMULANTS

bethanechol chloride 2

MISCELLANEOUS UROLOGICALS

alprostadil 2

CYSTAGON 5

ELMIRON 3

K-PHOS ORIGINAL

3

potassium citrate 2

RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

3

VITAMINS, HEMATINICS & ELECTROLYTES

ELECTROLYTES

calcium gluconate in 0.9% nacl intravenous solution 1 gram/100 ml

2

effer-k oral tablet, effervescent 25 meq

2

klor-con 2

klor-con 10 2

klor-con 8 2

klor-con m10 2


73

Drug Name Drug Tier


klor-con m15 2

klor-con m20 2

klor-con/ef 2

k-tab oral tablet extended release 8 meq

2

potassium chloride oral

2

sodium chloride 0.45 % intravenous parenteral solution

2

sodium chloride 3 % 2

sodium chloride 5 % 2

VITAMINS & HEMATINICS

b complex 1 (with folic acid)

0 OTC

b complex-vitamin b12

0 OTC

b complex-vitamin c-folic acid oral tablet

0 OTC

balanced b-100 complex oral tablet extended release 100 mg

0 OTC

balanced b-100 oral tablet 0.4 mg

0 OTC

balanced b-50 oral tablet

0 OTC

bal-care dha 2

b-complex with vitamin c oral tablet

0 OTC

classic prenatal 0 OTC

c-nate dha 2

complete natal dha 2

Drug Name Drug Tier


complex b-100 oral tablet extended release

0 OTC

cyanocobalamin (vitamin b-12) injection

2

dialyvite 800 oral tablet

0 OTC

elite-ob 2

ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 unit)

2

fluoride (sodium) oral drops

0 OTC

fluoride (sodium) oral tablet,chewable

0 OTC

fluoritab oral tablet,chewable

0 OTC

folic acid injection 2

folic acid oral tablet 400 mcg, 800 mcg

0 OTC

folivane-ob 2

foltabs 800 0 OTC

full spectrum b-vitamin c

0 OTC

hydroxocobalamin 2

INFED 3

kobee 0 OTC

kpn oral tablet 0 OTC

ludent fluoride 0 OTC

m.v.i. adult 2

m-natal plus 2

multi-vitamin with fluoride

0 OTC


74

Drug Name Drug Tier


multivitamins with fluoride

0 OTC

mvc-fluoride 0 OTC

mynatal 2

mynatal advance 2

mynatal plus 2

mynatal-z 2

mynate 90 plus 2

natural b-100 complex

0 OTC

newgen 2

obstetrix dha 2

one daily prenatal oral combo pack 28-800-440 mg-mcg-mg

0 OTC

perry prenatal 0 OTC

pnv 29-1 2

pnv-dha 2

pnv-dha + docusate 2

pnv-omega 2

pnv-select 2

pr natal 400 2

pr natal 400 ec 2

pr natal 430 2

pr natal 430 ec 2

prena1 chew 2

prena1 pearl 2

prena1 true 2

prenaissance 2

prenaissance plus 2

prenatabs fa 2

prenatabs rx 2

prenatal complete 0 OTC

Drug Name Drug Tier


prenatal formula oral tablet 28 mg iron- 800 mcg

0 OTC

prenatal multi-dha (algal oil)

0 OTC

prenatal one daily 0 OTC

prenatal oral tablet 28 mg iron- 800 mcg

0 OTC

prenatal plus 2

prenatal plus (calcium carb)

2

prenatal vitamin oral tablet 27 mg iron- 0.8 mg

0 OTC

prenatal vitamin plus low iron

2

prenatal vitamin with minerals

0 OTC

prenatal vits96-iron fum-folic

0 OTC

prenatal-u 2

preplus 2

pretab 2

rena-vite 0 OTC

se-natal 19 chewable 2

se-natal-19 2

stress formula 0 OTC

stress formula with iron

0 OTC

stress formula with iron(sulf)

0 OTC

super b complex-vitamin c

0 OTC

super b maxi complex

0 OTC

super quints 0 OTC


75

Drug Name Drug Tier


super quints b-50 0 OTC

taron-c dha 2

taron-prex prenatal-dha

2

total b/c 0 OTC

trinatal rx 1 2

trinate 2

triveen-duo dha 2

tri-vitamin with fluoride

0 OTC

trust natal dha 2

VENOFER 3

virt-c dha 2

Drug Name Drug Tier


virt-nate dha 2

virt-pn dha 2

virt-pn plus 2

vitamin b complex oral tablet

0 OTC

vitamin b complex-folic acid oral tablet

0 OTC

vitamins a,c,d and fluoride

0 OTC

vp-ch-pnv 2

zatean-pn dha 2

zatean-pn plus 2

zingiber 2


76

Index

A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-

zidovudine .......................... 3 ABILIFY MAINTENA ........ 25 abiraterone ............................ 11 ABRAXANE ........................ 11 acamprosate .......................... 42 acarbose ................................ 49 ACE AEROSOL CLOUD

ENHANCER .................... 45 acebutolol ............................. 29 acetaminophen-caff-

dihydrocod ........................ 20 acetaminophen-codeine ........ 20 acetazolamide ....................... 67 acetazolamide sodium .......... 67 acetic acid ....................... 42, 44 acetylcysteine ....................... 69 acitretin ................................. 37 ACTEMRA .......................... 59 ACTEMRA ACTPEN .......... 59 ACTIMMUNE ..................... 57 acyclovir ........................... 3, 40 acyclovir sodium .................... 3 ADACEL(TDAP

ADOLESN/ADULT)(PF) 57 ADAKVEO .......................... 11 adapalene .............................. 38 adapalene-benzoyl peroxide . 38 ADCETRIS .......................... 11 adefovir................................... 3 ADEMPAS ........................... 69 adrenalin ............................... 68 adriamycin ............................ 11 adrucil ................................... 11 ADVATE ............................. 34 ADYNOVATE ..................... 34 AEROCHAMBER MINI ..... 45 AEROCHAMBER PLUS

FLOW-VU ....................... 45 AEROCHAMBER PLUS Z

STAT ................................ 45 AEROTRACH PLUS ........... 45 AEROVENT PLUS.............. 45

AFINITOR ........................... 11 AFINITOR DISPERZ .......... 11 afirmelle................................ 62 AFLURIA QD 2019-20(3YR

UP)(PF) ............................ 57 AFLURIA QD 2019-20(6-

35MO)(PF) ....................... 57 AFLURIA QUAD 2019-

20(6MO UP) ..................... 57 AFSTYLA ............................ 34 ak-poly-bac ........................... 66 ala-cort .................................. 40 albendazole ............................. 6 albuterol sulfate .................... 69 alclometasone ....................... 40 ALDURAZYME .................. 48 ALECENSA ......................... 11 alendronate ........................... 59 ALFERON N ........................ 57 alfuzosin ............................... 72 ALIMTA .............................. 11 ALINIA .................................. 6 ALIQOPA ............................ 11 aliskiren ................................ 29 allopurinol ............................ 59 allopurinol sodium ................ 59 almotriptan malate ................ 18 ALOMIDE............................ 66 alophen (bisacodyl) .............. 52 aloprim.................................. 59 alosetron ............................... 52 ALPHAGAN P ..................... 68 ALPHANATE ...................... 34 alprazolam ............................ 25 alprazolam intensol............... 25 ALPROLIX .......................... 34 alprostadil ............................. 72 altacaine ................................ 66 altavera (28) .......................... 62 alyacen 1/35 (28) .................. 62 alyacen 7/7/7 (28) ................. 62 alyq ....................................... 69 amabelz ................................. 61 amantadine hcl ........................ 3 ambrisentan .......................... 69 amcinonide ........................... 40

amethia ................................. 62 amethia lo ............................. 62 amethyst (28) ........................ 62 AMICAR .............................. 34 amikacin ................................. 7 amiloride ............................... 29 amiloride-hydrochlorothiazide

.......................................... 29 aminocaproic acid ................. 34 aminophylline ....................... 69 amiodarone ........................... 29 amitriptyline ......................... 25 amitriptyline-chlordiazepoxide

.......................................... 25 amlodipine ............................ 29 amlodipine-atorvastatin ........ 35 amlodipine-benazepril .......... 29 amlodipine-olmesartan ......... 29 amlodipine-valsartan ............ 29 amlodipine-valsartan-hcthiazid

.......................................... 29 ammonium lactate ................ 37 amnesteem ............................ 38 amoxapine ............................. 25 amoxicil-clarithromy-lansopraz

.......................................... 55 amoxicillin .............................. 8 amoxicillin-pot clavulanate .... 8 amphetamine sulfate ............. 25 amphotericin b ........................ 3 ampicillin ................................ 9 ampicillin sodium ................... 9 ampicillin-sulbactam .............. 9 ANADROL-50 ..................... 48 anagrelide ............................. 42 anaspaz ................................. 51 anastrozole ............................ 11 apexicon e ............................. 40 APOKYN ............................. 18 apraclonidine ........................ 68 aprepitant .............................. 52 apri ........................................ 62 APTIVUS ............................... 3 APTIVUS (WITH VITAMIN

E) ........................................ 3 aqua care sodium chloride .... 42


77

aqua care sterile water .......... 42 ARALAST NP ..................... 42 aranelle (28).......................... 62 ARIKAYCE ........................... 7 aripiprazole ........................... 25 ARISTADA .......................... 25 ARISTADA INITIO ............ 25 armodafinil ........................... 25 ARMONAIR RESPICLICK 69 ARMOUR THYROID ......... 51 ARRANON .......................... 11 arsenic trioxide ..................... 11 ascomp with codeine ............ 20 ashlyna .................................. 62 aspir-81 ................................. 23 aspirin ................................... 23 aspirin low dose .................... 23 aspirin-dipyridamole ............ 34 aspir-trin ............................... 23 atazanavir ............................... 3 atenolol ................................. 29 atenolol-chlorthalidone......... 29 atomoxetine .......................... 25 atorvastatin ........................... 35 atovaquone ............................. 7 atovaquone-proguanil ............. 7 atracurium............................. 19 atropine ........................... 51, 66 atropine in 0.9 % sod chloride

.......................................... 51 aubra ..................................... 62 aubra eq ................................ 63 AUGMENTIN ........................ 9 aurovela 1.5/30 (21) ............. 63 aurovela 1/20 (21) ................ 63 aurovela 24 fe ....................... 63 aurovela fe 1.5/30 (28) ......... 63 aurovela fe 1-20 (28) ............ 63 AUTOJECT 2 INJECTION

DEVICE ........................... 46 AUTOPEN 1 TO 21 UNITS 46 AVASTIN ............................ 11 aviane ................................... 63 avidoxy ................................... 9 avita ...................................... 38 AVONEX ............................. 56 AVYCAZ ............................... 5 ayuna .................................... 63

azacitidine ............................. 11 azathioprine .......................... 11 azathioprine sodium ............. 11 azelaic acid ........................... 38 azelastine ........................ 44, 66 azelastine-fluticasone ........... 69 azithromycin ........................... 6 AZOPT ................................. 67 aztreonam ............................... 7 azurette (28) .......................... 63 B b complex 1 (with folic acid) 73 b complex-vitamin b12 ......... 73 b complex-vitamin c-folic acid

.......................................... 73 bacitracin .......................... 7, 66 bacitracin-polymyxin b......... 66 baclofen ................................ 19 balanced b-100 ..................... 73 balanced b-100 complex ....... 73 balanced b-50 ....................... 73 bal-care dha .......................... 73 balsalazide ............................ 52 BALVERSA ......................... 11 balziva (28) ........................... 63 BANZEL .............................. 17 BAQSIMI ............................. 46 BARACLUDE ....................... 3 BAVENCIO ......................... 11 bayer aspirin ......................... 23 b-complex with vitamin c ..... 73 BD INTEGRA NEEDLE ..... 46 BD MICROTAINER

LANCET .......................... 46 BD SPECIALTY USE

NEEDLES ........................ 46 BD ULTRA FINE LANCETS

.......................................... 46 BD ULTRA-FINE NANO

PEN NEEDLE .................. 46 bekyree (28) .......................... 63 belladonna alkaloids-opium . 52 benazepril ............................. 29 benazepril-hydrochlorothiazide

.......................................... 30 BENDEKA ........................... 11 BENEFIX ............................. 34 BENLYSTA ......................... 60

benzepro ............................... 38 BENZNIDAZOLE ................. 7 benzonatate ........................... 69 benzoyl peroxide .................. 38 benztropine ........................... 18 beser ...................................... 40 BESPONSA .......................... 11 betamethasone acet,sod phos 44 betamethasone dipropionate . 40 betamethasone valerate ......... 40 betamethasone, augmented ... 40 BETASERON ....................... 56 betaxolol ......................... 30, 66 bethanechol chloride ............. 72 BEVESPI AEROSPHERE ... 69 bexarotene ............................. 11 BEXSERO ............................ 57 bicalutamide ......................... 11 BIKTARVY ........................... 3 bimatoprost ........................... 67 BIOTHRAX ......................... 57 bisacodyl ............................... 52 bisa-lax (bisacodyl) .............. 52 bisoprolol fumarate ............... 30 bisoprolol-hydrochlorothiazide

.......................................... 30 bivalirudin ............................. 34 bleomycin ............................. 11 BLINCYTO .......................... 11 blisovi 24 fe .......................... 63 blisovi fe 1.5/30 (28) ............ 63 blisovi fe 1/20 (28) ............... 63 BOOSTRIX TDAP ............... 57 bosentan ................................ 69 BOSULIF ............................. 11 BOTOX ................................ 57 BREATHERITE MDI

SPACER ........................... 45 bretylium tosylate ................. 29 briellyn .................................. 63 BRILINTA ........................... 34 brimonidine ........................... 68 BRINEURA .......................... 48 bromfenac ............................. 67 bromocriptine ....................... 18 brompheniramine-pseudoeph-

dm ..................................... 69 budesonide ...................... 52, 70


78

bumetanide ........................... 30 buprenorphine ...................... 20 buprenorphine hcl ................. 20 buprenorphine-naloxone....... 23 bupropion hcl........................ 25 bupropion hcl (smoking deter)

.......................................... 43 buspirone .............................. 25 busulfan ................................ 11 butalbital compound w/codeine

.......................................... 20 butalbital-acetaminop-caf-cod

.......................................... 20 butalbital-acetaminophen ..... 20 butalbital-acetaminophen-caff

.......................................... 20 butalbital-aspirin-caffeine .... 20 butorphanol tartrate .............. 23 BYDUREON ........................ 50 BYDUREON BCISE ........... 49 BYETTA .............................. 50 C cabergoline ........................... 48 CABLIVI .............................. 34 CABOMETYX .................... 11 caffeine citrate ...................... 42 calcipotriene ......................... 37 calcipotriene-betamethasone 37 calcitonin (salmon) ............... 48 calcitriol .......................... 37, 48 calcium acetate(phosphat bind)

.......................................... 52 calcium gluconate in 0.9% nacl

.......................................... 72 camila ................................... 61 camrese ................................. 63 camrese lo ............................. 63 candesartan ........................... 30 candesartan-hydrochlorothiazid

.......................................... 30 capecitabine .......................... 11 CAPRELSA ......................... 12 captopril ................................ 30 captopril-hydrochlorothiazide

.......................................... 30 CARAFATE ......................... 55 CARBAGLU ........................ 42 carbamazepine ...................... 17

carbidopa .............................. 18 carbidopa-levodopa .............. 18 carbidopa-levodopa-

entacapone ........................ 18 carbinoxamine maleate ......... 68 carboplatin ............................ 12 carmustine ............................ 12 carteolol ................................ 66 cartia xt ................................. 30 carvedilol .............................. 30 carvedilol phosphate ............. 30 caspofungin ............................ 3 CAYA CONTOURED ......... 61 CAYSTON ............................. 7 caziant (28) ........................... 63 cefaclor ................................... 5 cefadroxil ................................ 5 cefazolin ................................. 5 cefazolin in dextrose (iso-os) . 5 cefdinir.................................... 5 cefditoren pivoxil ................... 5 cefepime ................................. 5 cefepime in dextrose,iso-osm . 5 cefixime .................................. 5 cefotaxime .............................. 6 cefotetan ................................. 6 cefoxitin .................................. 6 cefoxitin in dextrose, iso-osm 6 cefpodoxime ........................... 6 cefprozil .................................. 6 ceftazidime ............................. 6 ceftriaxone .............................. 6 ceftriaxone in dextrose,iso-os . 6 cefuroxime axetil .................... 6 cefuroxime sodium ................. 6 celecoxib ............................... 23 CELONTIN .......................... 17 cephalexin ............................... 6 CEPROTIN (BLUE BAR) ... 34 CEPROTIN (GREEN BAR) 34 CERDELGA ......................... 48 CEREZYME ........................ 48 cetirizine ............................... 68 cevimeline ............................ 42 CHANTIX ............................ 43 CHANTIX CONTINUING

MONTH BOX .................. 43

CHANTIX STARTING MONTH BOX .................. 43

chateal (28) ........................... 63 chateal eq (28) ...................... 63 CHEMET .............................. 42 CHENODAL ........................ 52 children's aspirin ................... 23 chloramphenicol sod succinate

............................................ 7 chlordiazepoxide hcl ............. 25 chlorhexidine gluconate ........ 44 chloroquine phosphate ............ 7 chlorothiazide ....................... 30 chlorothiazide sodium .......... 30 chlorpromazine ..................... 25 chlorthalidone ....................... 30 chlorzoxazone ....................... 19 CHOLBAM .......................... 52 cholestyramine (with sugar) . 36 cholestyramine light ............. 36 ciclodan ................................. 39 ciclopirox .............................. 39 cidofovir ................................. 3 cilostazol ............................... 34 CIMDUO ................................ 3 cimetidine ............................. 55 cimetidine hcl ....................... 55 cinacalcet .............................. 48 CINRYZE ............................. 70 CINVANTI ........................... 52 CIPRO HC ............................ 44 CIPRODEX .......................... 44 ciprofloxacin ........................... 9 ciprofloxacin hcl ......... 9, 44, 66 ciprofloxacin in 5 % dextrose . 9 cisatracurium ........................ 19 cisplatin ................................. 12 citalopram ............................. 25 citrate of magnesia ................ 52 citroma .................................. 52 cladribine .............................. 12 claravis .................................. 38 clarithromycin ......................... 6 classic prenatal ...................... 73 clearlax ................................. 52 clemastine ............................. 68 cleocin ..................................... 7 clindacin p ............................ 38


79

clindamycin hcl ...................... 7 clindamycin in 5 % dextrose .. 7 clindamycin palmitate hcl ...... 7 clindamycin pediatric ............. 7 clindamycin phosphate .... 7, 38,

62 clindamycin-benzoyl peroxide

.......................................... 38 clindamycin-tretinoin ........... 38 clobazam............................... 17 clobetasol ........................ 40, 41 clobetasol-emollient ............. 41 clodan ................................... 41 clofarabine ............................ 12 clomipramine ........................ 25 clonazepam ........................... 17 clonidine ............................... 30 clonidine hcl ................... 25, 30 clopidogrel ............................ 34 clorazepate dipotassium ....... 25 clotrimazole ...................... 3, 40 clotrimazole-betamethasone . 40 clovique ................................ 42 clozapine............................... 25 c-nate dha ............................. 73 COAGADEX ....................... 34 COARTEM ............................ 7 codeine sulfate ...................... 20 codeine-butalbital-asa-caff ... 20 codeine-guaifenesin .............. 69 colchicine ............................. 59 colesevelam .......................... 36 colestipol .............................. 36 colistin (colistimethate na) ..... 7 colocort ................................. 52 COMBIGAN ........................ 67 COMBIVENT RESPIMAT . 70 COMETRIQ ......................... 12 COMPACT SPACE

CHAMBER ...................... 46 complete natal dha ................ 73 complex b-100 ...................... 73 compro .................................. 52 constulose ............................. 52 coremino ................................. 9 CORIFACT .......................... 34 CORLANOR ........................ 36 cortisone ............................... 44

CORTISPORIN .................... 39 COSENTYX ......................... 37 COSENTYX (2 SYRINGES)

.......................................... 37 COSENTYX PEN ................ 37 COSENTYX PEN (2 PENS) 37 cosyntropin ........................... 44 COTELLIC ........................... 12 CREON ................................ 52 CRESEMBA .......................... 3 CRINONE ............................ 61 CRIXIVAN ............................ 4 cromolyn ................... 53, 66, 70 crotan .................................... 42 cryselle (28) .......................... 63 CRYSVITA .......................... 48 cyanocobalamin (vitamin b-12)

.......................................... 73 cyclafem 1/35 (28) ................ 63 cyclafem 7/7/7 (28) .............. 63 cyclobenzaprine .................... 20 cyclopentolate ....................... 66 cyclophosphamide ................ 12 cyclosporine.......................... 12 cyclosporine modified .......... 12 cyproheptadine ..................... 68 CYRAMZA .......................... 12 cyred ..................................... 63 cyred eq ................................ 63 CYSTADANE ...................... 53 CYSTAGON ........................ 72 CYSTARAN ........................ 67 cytarabine ............................. 12 cytarabine (pf) ...................... 12 D dacarbazine ........................... 12 dactinomycin ........................ 12 dalfampridine........................ 19 DALVANCE .......................... 7 danazol.................................. 48 dantrolene ............................. 20 dapsone ............................. 7, 38 DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 57 daptomycin ............................. 7 DARAPRIM ........................... 7 darifenacin ............................ 72 DARZALEX ........................ 12

dasetta 1/35 (28) ................... 63 dasetta 7/7/7 (28) .................. 63 daunorubicin ......................... 12 daysee ................................... 63 DDAVP ................................ 48 deblitane ............................... 61 decadron ............................... 44 decitabine .............................. 12 deferasirox ............................ 42 demeclocycline ....................... 9 DEMSER .............................. 30 DENAVIR ............................ 40 denta 5000 plus ..................... 44 dentagel ................................. 44 DEPO-PROVERA ................ 61 DESCOVY ............................. 4 desipramine ........................... 25 desloratadine ......................... 68 desmopressin ........................ 48 desog-e.estradiol/e.estradiol . 63 desogestrel-ethinyl estradiol . 63 desonide ................................ 41 desoximetasone ..................... 41 desvenlafaxine succinate ...... 25 dexamethasone ..................... 44 dexamethasone intensol ........ 45 dexamethasone sodium phos

(pf) .................................... 45 dexamethasone sodium

phosphate .................... 45, 67 dexchlorpheniramine maleate

.......................................... 68 dexmethylphenidate .............. 25 dexrazoxane hcl .................... 10 dextroamphetamine .............. 25 dextroamphetamine-

amphetamine ..................... 25 DIACOMIT .......................... 17 dialyvite 800 ......................... 73 diazepam ......................... 17, 26 diazepam intensol ................. 26 diclofenac potassium ............ 23 diclofenac sodium ..... 23, 37, 67 diclofenac-misoprostol ......... 23 dicloxacillin ............................ 9 dicyclomine .......................... 52 didanosine ............................... 4 DIFICID ................................. 6


80

diflorasone ............................ 41 diflunisal ............................... 23 digitek ................................... 33 digox ..................................... 34 digoxin .................................. 34 dihydroergotamine ............... 18 DILANTIN ........................... 17 diltiazem ............................... 30 dilt-xr .................................... 30 dimenhydrinate ..................... 53 DIPENTUM ......................... 53 diphenhydramine hcl ............ 68 diphenoxylate-atropine ......... 52 dipyridamole ........................ 34 diskets ................................... 20 disulfiram ............................. 42 divalproex ............................. 17 docetaxel............................... 12 DOCETAXEL ...................... 12 dofetilide............................... 29 donepezil .............................. 19 DOPTELET (15 TAB PACK)

.......................................... 34 dorzolamide .......................... 67 dorzolamide-timolol ............. 67 dorzolamide-timolol (pf) ...... 67 dotti ...................................... 61 DOVATO ............................... 4 doxazosin .............................. 30 doxepin ........................... 26, 37 doxercalciferol ...................... 48 doxorubicin........................... 12 doxorubicin, peg-liposomal .. 12 doxy-100 ................................ 9 doxycycline hyclate ................ 9 doxycycline monohydrate 9, 10 doxylamine-pyridoxine (vit b6)

.......................................... 53 D-PENAMINE ..................... 60 dronabinol............................. 53 droperidol ............................. 53 drospirenone-e.estradiol-lm.fa

.......................................... 63 drospirenone-ethinyl estradiol

.......................................... 63 DROXIA .............................. 12 ducodyl (bisacodyl) .............. 53 DULERA .............................. 70

duloxetine ............................. 26 DUPIXENT .................... 37, 38 duramorph (pf) ..................... 20 dutasteride ............................ 72 dutasteride-tamsulosin .......... 72 dvorah ................................... 20 E e.c. prin ................................. 23 e.e.s. 400 ................................. 6 EASIVENT HOLDING

CHAMBER ...................... 46 econazole .............................. 40 econtra ez .............................. 63 econtra one-step .................... 63 ecotrin ................................... 23 ecotrin low strength .............. 23 EDARBI ............................... 30 ed-spaz .................................. 52 EDURANT ............................. 4 efavirenz ................................. 4 effer-k ................................... 72 EGRIFTA ............................. 56 EGRIFTA SV ....................... 56 ELAPRASE .......................... 48 eletriptan ............................... 19 ELIGARD ............................ 12 ELIGARD (3 MONTH) ....... 12 ELIGARD (4 MONTH) ....... 12 ELIGARD (6 MONTH) ....... 12 elinest.................................... 63 ELIQUIS .............................. 34 ELIQUIS DVT-PE TREAT

30D START ..................... 34 ELITEK ................................ 10 elite-ob .................................. 73 ELLA .................................... 63 ELMIRON ............................ 72 ELOCTATE ......................... 34 eluryng .................................. 62 ELZONRIS ........................... 12 EMCYT ................................ 12 emoquette ............................. 63 EMSAM ............................... 26 EMTRIVA .............................. 4 EMVERM .............................. 7 enalapril maleate ................... 31 enalaprilat ............................. 31

enalapril-hydrochlorothiazide .......................................... 31

ENBREL ............................... 60 ENBREL MINI .................... 60 ENBREL SURECLICK ....... 60 endocet .................................. 20 ENGERIX-B (PF) ................ 58 ENGERIX-B PEDIATRIC

(PF) ................................... 58 enoxaparin ............................ 34 enpresse ................................ 63 enskyce ................................. 63 entacapone ............................ 18 entecavir ................................. 4 ENTRESTO .......................... 36 ENTYVIO ............................ 53 enulose .................................. 53 EPCLUSA .............................. 4 EPIDIOLEX ......................... 17 epinastine .............................. 67 epinephrine ........................... 68 EPIPEN 2-PAK .................... 68 EPIPEN JR 2-PAK ............... 68 epirubicin .............................. 12 epitol ..................................... 17 EPIVIR HBV .......................... 4 eplerenone ............................. 31 epoprostenol (glycine) .......... 31 eprosartan ............................. 31 ERBITUX ............................. 12 ergocalciferol (vitamin d2) ... 73 ergoloid ................................. 26 ergotamine-caffeine .............. 19 ERIVEDGE .......................... 12 ERLEADA ........................... 13 erlotinib ................................. 13 errin ....................................... 61 ertapenem ............................... 7 ery pads ................................. 38 erygel .................................... 38 ery-tab ..................................... 6 erythrocin (as stearate) ........... 6 erythromycin ..................... 6, 66 erythromycin ethylsuccinate ... 6 erythromycin with ethanol ... 38,

39 erythromycin-benzoyl peroxide

.......................................... 39


81

ESBRIET .............................. 70 escitalopram oxalate ............. 26 esmolol ................................. 31 esmolol in nacl (iso-osm) ..... 31 esomeprazole magnesium .... 55 esomeprazole sodium ........... 55 ESPEROCT .......................... 34 estarylla ................................ 63 estazolam .............................. 26 estradiol ................................ 61 estradiol valerate .................. 61 estradiol-norethindrone acet . 61 eszopiclone ........................... 26 ethacrynate sodium ............... 31 ethacrynic acid...................... 31 ethambutol .............................. 7 ethosuximide ........................ 17 ethynodiol diac-eth estradiol 63 etidronate disodium .............. 42 etodolac ................................ 23 etonogestrel-ethinyl estradiol62 ETOPOPHOS ....................... 13 etoposide............................... 13 EUFLEXXA ......................... 23 everolimus (antineoplastic) .. 13 everolimus

(immunosuppressive) ....... 13 exemestane ........................... 13 EYLEA ................................. 67 ezetimibe .............................. 36 ezetimibe-simvastatin ........... 36 F FABRAZYME ..................... 48 FACTIVE ............................... 9 falmina (28) .......................... 63 famciclovir ............................. 4 famotidine............................. 55 famotidine (pf)...................... 55 famotidine (pf)-nacl (iso-os) 55 FARXIGA ............................ 50 FASENRA ............................ 70 FASENRA PEN ................... 70 fayosim ................................. 63 FC2 FEMALE CONDOM ... 61 febuxostat ............................. 59 FEIBA NF ............................ 34 felbamate .............................. 17 felodipine .............................. 31

FEMCAP .............................. 61 femynor ................................ 63 fenofibrate ............................ 36 fenofibrate micronized ......... 36 fenofibrate nanocrystallized . 36 fenofibric acid....................... 36 fenofibric acid (choline) ....... 36 fenoprofen ............................ 23 fentanyl ................................. 20 fentanyl citrate ...................... 21 fentanyl citrate (pf) ............... 21 fentanyl citrate (pf)-0.9%nacl

.......................................... 21 FERRIPROX ........................ 43 FETZIMA ............................. 26 finasteride ............................. 72 flac otic oil ............................ 44 flavoxate ............................... 72 flecainide .............................. 29 fleet laxative (bisacodyl) ...... 53 FLEXICHAMBER ............... 46 floxuridine ............................ 13 FLUAD 2019-2020 (65 YR

UP)(PF) ............................ 58 FLUARIX QUAD 2019-2020

(PF) ................................... 58 FLUBLOK QUAD 2019-2020

(PF) ................................... 58 FLUCELVAX QUAD 2019-

2020 .................................. 58 FLUCELVAX QUAD 2019-

2020 (PF) .......................... 58 fluconazole ............................. 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 13 fludrocortisone...................... 45 FLULAVAL QUAD 2019-

2020 .................................. 58 FLULAVAL QUAD 2019-

2020 (PF) .......................... 58 flumazenil ............................. 26 flunisolide ............................. 70 fluocinolone .......................... 41 fluocinolone acetonide oil .... 44 fluocinolone and shower cap 41 fluocinonide .......................... 41 fluocinonide-e ....................... 41

fluoride (sodium) ............ 44, 73 fluoritab ................................ 73 fluorometholone ................... 67 fluorouracil ..................... 13, 38 fluoxetine .............................. 26 fluphenazine decanoate ........ 26 fluphenazine hcl .................... 26 flurandrenolide ..................... 41 flurazepam ............................ 26 flurbiprofen ........................... 23 flurbiprofen sodium .............. 67 flutamide ............................... 13 fluticasone propionate .... 41, 70 fluticasone propion-salmeterol

.......................................... 70 FLUTICASONE PROPION-

SALMETEROL ................ 70 fluvastatin ............................. 36 fluvoxamine .......................... 26 FLUZONE HIGH-DOSE

2019-20 (PF) ..................... 58 FLUZONE QUAD 2019-2020

.......................................... 58 FLUZONE QUAD 2019-2020

(PF) ................................... 58 FLUZONE QUAD PEDI

2019-20 (PF) ..................... 58 folic acid ............................... 73 folivane-ob ............................ 73 FOLOTYN ........................... 13 foltabs 800 ............................ 73 fondaparinux ......................... 34 fosamprenavir ......................... 4 fosaprepitant ......................... 53 fosinopril ............................... 31 fosinopril-hydrochlorothiazide

.......................................... 31 fosphenytoin ......................... 17 FREESTYLE CONTROL .... 46 FREESTYLE FLASH

SYSTEM .......................... 46 FREESTYLE FREEDOM .... 46 FREESTYLE FREEDOM

LITE ................................. 46 FREESTYLE INSULINX ... 45,

46 FREESTYLE INSULINX

TEST STRIPS .................. 45


82

FREESTYLE LIBRE 10 DAY READER .......................... 46

FREESTYLE LIBRE 10 DAY SENSOR .......................... 46

FREESTYLE LITE METER 47 FREESTYLE LITE STRIPS 45 FREESTYLE SIDEKICK II 47 FREESTYLE SYSTEM KIT 47 FREESTYLE TEST ............. 45 frovatriptan ........................... 19 full spectrum b-vitamin c ..... 73 fulvestrant ............................. 13 furosemide ............................ 31 FUZEON ................................ 4 fyavolv .................................. 61 G g tussin ac ............................. 69 gabapentin ............................ 17 galantamine .......................... 19 GAMASTAN ....................... 58 GAMASTAN S/D ................ 58 GAMIFANT ......................... 13 GAMMAGARD LIQUID .... 58 GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 58 GAMUNEX-C ..................... 58 ganciclovir sodium ................. 4 GARDASIL 9 (PF) .............. 58 gatifloxacin ........................... 66 gavilax .................................. 53 gavilyte-c .............................. 53 gavilyte-g .............................. 53 gavilyte-n .............................. 53 GAZYVA ............................. 13 gemcitabine .......................... 13 gemfibrozil ........................... 36 generlac ................................ 53 gengraf .................................. 13 gentak ................................... 66 gentamicin .................. 7, 39, 66 gentamicin in nacl (iso-osm) .. 7 gentamicin sulfate (ped) (pf) .. 7 gentamicin sulfate (pf) ........... 7 gentle laxative (bisacodyl) ... 53 gentlelax ............................... 53 GENVOYA ............................ 4 gianvi (28) ............................ 63 GILENYA ............................ 56

GILOTRIF ............................ 13 GLASSIA ............................. 43 glatiramer.............................. 56 glatopa .................................. 56 GLEOSTINE ........................ 13 glimepiride............................ 50 glipizide ................................ 50 glipizide-metformin .............. 50 GLUCAGEN DIAGNOSTIC

KIT ................................... 46 GLUCAGEN HYPOKIT ..... 46 GLUCAGON EMERGENCY

KIT (HUMAN) ................. 46 glyburide ............................... 50 glyburide micronized ............ 50 glyburide-metformin ............ 50 glycolax ................................ 53 glycopyrrolate ....................... 52 glycopyrrolate (pf) in water .. 52 GLYXAMBI ........................ 50 granisetron (pf) ..................... 53 granisetron hcl ...................... 53 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guaiatussin ac ....................... 69 guanfacine ...................... 26, 31 guanidine .............................. 26 GVOKE SYRINGE .............. 46 GYNAZOLE-1 ..................... 62 gynol ii .................................. 62 H hailey .................................... 63 hailey 24 fe ........................... 63 HALAVEN ........................... 13 halcinonide ........................... 41 halobetasol propionate .......... 41 HALOG ................................ 41 haloperidol ............................ 26 haloperidol decanoate ........... 26 haloperidol lactate ................ 26 HARVONI.............................. 4 HAVRIX (PF) ...................... 58 healthylax ............................. 53 heather .................................. 61 HEMLIBRA ......................... 34 HEMOFIL M HIGH ............. 34 HEMOFIL M LOW.............. 34 HEMOFIL M MID ............... 34

HEMOFIL M SUPER HIGH34 hep flush-10 (pf) ................... 34 heparin (porcine) .................. 34 heparin (porcine) in 5 % dex 34 heparin (porcine) in nacl (pf) 34 heparin flush(porcine)-0.9nacl

.......................................... 35 heparin lock flush ................. 35 heparin lock flush (porcine) .. 35 heparin lockflush(porcine)(pf)

.......................................... 35 heparin(porcine) in 0.45% nacl

.......................................... 35 heparin, porcine (pf) ............. 35 HERCEPTIN ........................ 13 HIBERIX (PF) ...................... 58 hidex ..................................... 45 HIZENTRA .......................... 58 HUMALOG JUNIOR

KWIKPEN U-100 ............ 47 HUMALOG KWIKPEN

INSULIN .......................... 47 HUMALOG MIX 50-50

INSULN U-100 ................ 47 HUMALOG MIX 50-50

KWIKPEN ........................ 47 HUMALOG MIX 75-25

KWIKPEN ........................ 47 HUMALOG MIX 75-25(U-

100)INSULN .................... 47 HUMALOG U-100 INSULIN

.......................................... 47 HUMATE-P ......................... 35 HUMIRA .............................. 60 HUMIRA PEN ..................... 60 HUMIRA PEN CROHNS-UC-

HS START ....................... 60 HUMIRA PEN PSOR-

UVEITS-ADOL HS ......... 60 HUMIRA(CF) ...................... 60 HUMIRA(CF) PEDI

CROHNS STARTER ....... 60 HUMIRA(CF) PEN .............. 60 HUMIRA(CF) PEN

CROHNS-UC-HS ............. 60 HUMIRA(CF) PEN PSOR-

UV-ADOL HS .................. 60


83

HUMULIN 70/30 U-100 INSULIN .......................... 47

HUMULIN 70/30 U-100 KWIKPEN ....................... 47

HUMULIN N NPH INSULIN KWIKPEN ....................... 47

HUMULIN N NPH U-100 INSULIN .......................... 47

HUMULIN R REGULAR U-100 INSULN .................... 47

HUMULIN R U-500 (CONC) INSULIN .......................... 47

HUMULIN R U-500 (CONC) KWIKPEN ....................... 47

HYCAMTIN ........................ 13 hydralazine ........................... 31 hydrochlorothiazide .............. 31 hydrocodone bitartrate.......... 21 hydrocodone-acetaminophen 21 hydrocodone-chlorpheniramine

.......................................... 69 hydrocodone-homatropine ... 69 hydrocodone-ibuprofen ........ 21 hydrocortisone .......... 41, 45, 53 hydrocortisone butyrate ........ 41 hydrocortisone butyr-emollient

.......................................... 41 hydrocortisone valerate ........ 41 hydrocortisone-acetic acid.... 44 hydrocortisone-min oil-wht pet

.......................................... 42 hydrocortisone-pramoxine .. 37,

53 hydromet............................... 69 hydromorphone .................... 21 hydromorphone (pf) ............. 21 hydromorphone (pf)-0.9 %

nacl ................................... 21 hydromorphone in 0.9 % nacl

.......................................... 21 hydroxocobalamin ................ 73 hydroxychloroquine ............... 7 hydroxyprogest(pf)(preg presv)

.......................................... 61 hydroxyprogesterone

cap(ppres) ......................... 61 hydroxyprogesterone caproate

.......................................... 61

hydroxyurea .......................... 13 hydroxyzine hcl .................... 68 hydroxyzine pamoate ........... 69 hyoscyamine sulfate ............. 52 hyosyne ................................. 52 HYPERHEP B S/D .............. 58 HYPERHEP B S-D

NEONATAL .................... 58 HYPERRAB (PF)................. 58 HYPERRAB S/D (PF) ......... 58 HYSINGLA ER ................... 21 I ibandronate ........................... 59 IBRANCE ............................ 13 ibu ......................................... 23 ibuprofen .............................. 23 ibuprofen-oxycodone............ 21 ic green ................................. 43 icatibant ................................ 70 ICLUSIG .............................. 13 idarubicin .............................. 13 IDHIFA ................................ 13 ifosfamide ............................. 13 ILARIS (PF) ......................... 57 imatinib ................................. 13 IMBRUVICA ....................... 13 IMFINZI ............................... 13 imipenem-cilastatin ................ 7 imipramine hcl ...................... 27 imipramine pamoate ............. 27 imiquimod ............................ 57 IMOGAM RABIES-HT (PF)

.......................................... 58 IMOVAX RABIES VACCINE

(PF) ................................... 58 IMPAVIDO ............................ 7 INBRIJA ............................... 18 incassia ................................. 61 INCRELEX .......................... 43 INCRUSE ELLIPTA ............ 70 indapamide ........................... 31 indocyanine green ................. 43 indomethacin ........................ 23 INFANRIX (DTAP) (PF) ..... 58 INFED .................................. 73 INFLECTRA ........................ 53 INLYTA ......................... 13, 14 INSPIRACHAMBER ........... 46

INTELENCE .......................... 4 INTRAROSA ....................... 62 INTRON A ........................... 57 introvale ................................ 63 INVIRASE ............................. 4 iodine-sodium iodide ............ 38 IPOL ..................................... 58 ipratropium bromide ....... 44, 70 ipratropium-albuterol ............ 70 irbesartan .............................. 31 irbesartan-hydrochlorothiazide

.......................................... 31 IRESSA ................................ 14 irinotecan .............................. 14 ISENTRESS ........................... 4 ISENTRESS HD .................... 4 isibloom ................................ 63 isoniazid .................................. 7 isosorbide dinitrate ............... 36 isosorbide mononitrate ......... 36 isotretinoin ............................ 39 isoxsuprine ............................ 62 isradipine .............................. 31 ISTODAX ............................. 14 itraconazole ............................. 3 ivermectin ......................... 7, 39 IXEMPRA ............................ 14 IXIARO (PF) ........................ 58 IXINITY ............................... 35 J jaimiess ................................. 63 JAKAFI ................................ 14 jantoven ................................ 35 JANUMET ........................... 50 JANUMET XR ..................... 50 JANUVIA ............................. 50 JARDIANCE ........................ 50 jasmiel (28) ........................... 63 jencycla ................................. 61 JENTADUETO .................... 50 JENTADUETO XR .............. 50 JETREA (PF) ........................ 67 jinteli ..................................... 62 JIVI ....................................... 35 jolessa ................................... 63 juleber ................................... 63 JULUCA ................................. 4 junel 1.5/30 (21) ................... 63


84

junel 1/20 (21) ...................... 63 junel fe 1.5/30 (28) ............... 64 junel fe 1/20 (28) .................. 64 junel fe 24 ............................. 64 JUXTAPID ........................... 36 K KADCYLA .......................... 14 kaitlib fe................................ 64 KALETRA ............................. 4 kalliga ................................... 64 KALYDECO ........................ 70 KANJINTI ............................ 14 KANUMA ............................ 48 kariva (28) ............................ 64 kelnor 1/35 (28) .................... 64 kelnor 1-50 ........................... 64 KEPIVANCE ....................... 10 ketoconazole ..................... 3, 40 ketodan ................................. 40 ketodan kit ............................ 40 ketoprofen....................... 23, 24 ketorolac ......................... 24, 67 KEYTRUDA ........................ 14 kionex (with sorbitol) ........... 53 KITABIS PAK ....................... 8 klor-con ................................ 72 klor-con 10 ........................... 72 klor-con 8 ............................. 72 klor-con m10 ........................ 72 klor-con m15 ........................ 73 klor-con m20 ........................ 73 klor-con/ef ............................ 73 kobee .................................... 73 KOGENATE FS ................... 35 KOVALTRY ........................ 35 K-PHOS ORIGINAL ........... 72 kpn ........................................ 73 KRYSTEXXA ...................... 59 k-tab ...................................... 73 kurvelo (28) .......................... 64 KUVAN ............................... 48 KYMRIAH ........................... 14 KYPROLIS .......................... 14 L l norgest/e.estradiol-e.estrad . 64 labetalol ................................ 31 lactated ringers ..................... 42 lactulose ................................ 53

lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine............................ 17 LANCETS ............................ 47 LANCING DEVICE ............ 47 lansoprazole .......................... 55 lanthanum ............................. 53 LANTUS SOLOSTAR U-100

INSULIN .......................... 47 LANTUS U-100 INSULIN .. 47 larin 1.5/30 (21) .................... 64 larin 1/20 (21) ....................... 64 larin 24 fe.............................. 64 larin fe 1.5/30 (28) ................ 64 larin fe 1/20 (28) ................... 64 larissia ................................... 64 LASTACAFT ....................... 67 latanoprost ............................ 67 LATUDA.............................. 27 laxaclear................................ 53 laxative (bisacodyl) .............. 53 laxative peg 3350.................. 53 layolis fe ............................... 64 leena 28................................. 64 leflunomide ........................... 60 LENVIMA............................ 14 lessina ................................... 64 letrozole ................................ 14 leucovorin calcium ............... 11 LEUKERAN ........................ 14 LEUKINE ............................. 56 leuprolide .............................. 14 levalbuterol hcl ..................... 70 LEVEMIR FLEXTOUCH U-

100 INSULN .................... 47 LEVEMIR U-100 INSULIN 47 levetiracetam ........................ 17 levetiracetam in nacl (iso-os) 17 levobunolol ........................... 66 levocarnitine ......................... 43 levocarnitine (with sugar) ..... 43 levocetirizine ........................ 69 levofloxacin ...................... 9, 66 levofloxacin in d5w ................ 9 levoleucovorin calcium ........ 11 levonest (28) ......................... 64 levonorgestrel ....................... 64 levonorgestrel-ethinyl estrad 64

levonorg-eth estrad triphasic 64 levora-28 ............................... 64 levorphanol tartrate ............... 21 levothyroxine ........................ 51 levoxyl .................................. 51 LEXIVA ................................. 4 LIBTAYO ............................. 14 lidocaine ............................... 39 lidocaine hcl .......................... 39 lidocaine hcl-hydrocortison ac

.......................................... 39 lidocaine viscous .................. 39 lidocaine-phenylephrn in water

.......................................... 67 lidocaine-prilocaine .............. 39 lillow (28) ............................. 64 lincomycin .............................. 8 lindane .................................. 42 linezolid .................................. 8 linezolid in dextrose 5% ......... 8 linezolid-0.9% sodium chloride

............................................ 8 liothyronine ........................... 51 lisinopril ................................ 31 lisinopril-hydrochlorothiazide

.......................................... 31 lite coat aspirin ..................... 24 LITEAIRE MDI CHAMBER

.......................................... 46 lithium carbonate .................. 27 lithium citrate ........................ 27 lojaimiess .............................. 64 LOKELMA ........................... 53 LONSURF ............................ 14 loperamide ............................ 52 lopinavir-ritonavir ................... 4 lopreeza ................................. 62 lorazepam ............................. 27 lorazepam intensol ................ 27 LORBRENA ......................... 14 lorcet (hydrocodone) ............ 21 lorcet hd ................................ 21 lorcet plus ............................. 21 lortuss ex ............................... 69 loryna (28) ............................ 64 losartan ................................. 31 losartan-hydrochlorothiazide 31 LOTEMAX ..................... 67, 68


85

LOTEMAX SM ................... 68 loteprednol etabonate ........... 68 lovastatin .............................. 36 low-ogestrel (28) .................. 64 loxapine succinate ................ 27 lo-zumandimine (28) ............ 64 ludent fluoride ...................... 73 lugols .................................... 39 LUMIZYME ........................ 48 LUPRON DEPOT ................ 14 LUPRON DEPOT (3

MONTH) .......................... 14 LUPRON DEPOT-PED ....... 14 LUPRON DEPOT-PED (3

MONTH) .......................... 14 lutera (28) ............................. 64 LUXTURNA ........................ 67 LYNPARZA......................... 14 LYSODREN......................... 14 lyza ....................................... 62 M m.v.i. adult ............................ 73 mafenide acetate ................... 39 magnesium citrate ................ 53 malathion .............................. 42 mannitol 20 % ...................... 31 maprotiline ........................... 27 marlissa (28) ......................... 64 MARPLAN .......................... 27 MARQIBO ........................... 14 MATULANE ....................... 14 matzim la .............................. 31 m-clear wc ............................ 69 meclizine .............................. 53 meclofenamate ..................... 24 MEDISENSE ....................... 47 MEDISENSE GLUCOSE

KETONE .......................... 47 medroxyprogesterone ........... 62 mefenamic acid .................... 24 mefloquine .............................. 8 megestrol .............................. 14 MEKINIST ........................... 14 melodetta 24 fe ..................... 64 meloxicam ............................ 24 melphalan ............................. 14 melphalan hcl ....................... 14 memantine ............................ 19

MENACTRA (PF) ............... 58 MENEST .............................. 62 MENTAX ............................. 40 MEPSEVII............................ 48 mercaptopurine ..................... 14 meropenem ............................. 8 MEROPENEM-0.9%

SODIUM CHLORIDE ....... 8 mesalamine ........................... 53 mesalamine with cleansing

wipe .................................. 53 mesna .................................... 11 MESNEX.............................. 11 metadate er ........................... 27 metaproterenol ...................... 70 metaxall ................................ 20 metaxalone............................ 20 metformin ............................. 50 methadone ...................... 21, 22 methadose ............................. 22 methamphetamine ................ 27 methazolamide ...................... 67 methenamine hippurate ........ 10 methenamine mandelate ....... 10 methergine ............................ 65 methimazole ......................... 45 METHITEST ........................ 48 methocarbamol ..................... 20 methotrexate sodium ............ 14 methotrexate sodium (pf) ..... 14 methoxsalen .......................... 38 methscopolamine .................. 52 methyl salicylate ................... 38 methyldopa ........................... 31 methyldopa-

hydrochlorothiazide .......... 31 methyldopate ........................ 31 methylergonovine ................. 65 methylphenidate hcl ............. 27 methylprednisolone .............. 45 methylprednisolone acetate .. 45 methyltestosterone ................ 48 metipranolol.......................... 66 metoclopramide hcl .............. 53 metolazone............................ 31 metoprolol succinate ............. 32 metoprolol ta-hydrochlorothiaz

.......................................... 32

metoprolol tartrate ................ 32 metro i.v. ................................. 8 metronidazole ............. 8, 39, 62 metronidazole in nacl (iso-os) 8 mexiletine ............................. 29 mibelas 24 fe ......................... 64 miconazole-3 ........................ 62 MICROCHAMBER ............. 46 microgestin 1.5/30 (21) ........ 64 microgestin 1/20 (21) ........... 64 microgestin fe 1.5/30 (28) .... 64 microgestin fe 1/20 (28) ....... 64 MICROSPACER .................. 46 midazolam ............................ 27 midodrine .............................. 43 migergot ................................ 19 miglitol ................................. 50 miglustat ............................... 48 mili ........................................ 64 milk of magnesia .................. 53 milk of magnesia concentrated

.......................................... 53 millipred ............................... 45 millipred dp .......................... 45 mimvey ................................. 62 minocycline .......................... 10 minoxidil ............................... 32 miostat .................................. 67 miralax .................................. 53 MIRENA .............................. 61 mirtazapine ........................... 27 MIRVASO ............................ 39 misoprostol ........................... 55 MITIGARE ........................... 59 mitomycin ............................. 14 mitoxantrone ......................... 14 M-M-R II (PF) ...................... 58 m-natal plus .......................... 73 modafinil ............................... 27 moexipril ............................... 32 molindone ............................. 27 mometasone .................... 42, 70 mondoxyne nl ....................... 10 mono-linyah .......................... 64 MONONINE ........................ 35 montelukast ..................... 70, 71 morgidox ............................... 10 morphine ............................... 22


86

morphine (pf)........................ 22 morphine (pf) in 0.9 % sod chl

.......................................... 22 morphine concentrate ........... 22 MOVANTIK ........................ 53 moxifloxacin..................... 9, 66 MOXIFLOXACIN-

SOD.ACE,SUL-WATER ... 9 moxifloxacin-sod.chloride(iso)

............................................ 9 MOZOBIL ............................ 56 multi-vitamin with fluoride .. 73 multivitamins with fluoride .. 74 mupirocin ............................. 39 mupirocin calcium ................ 39 MVASI ................................. 14 mvc-fluoride ......................... 74 my choice ............................. 64 my way ................................. 64 MYALEPT ........................... 48 MYCAMINE .......................... 3 mycophenolate mofetil ......... 15 mycophenolate mofetil (hcl) 15 mycophenolate sodium ......... 15 MYLERAN .......................... 15 MYLOTARG ....................... 15 mynatal ................................. 74 mynatal advance ................... 74 mynatal plus ......................... 74 mynatal-z .............................. 74 mynate 90 plus ..................... 74 myorisan ............................... 39 N nabumetone .......................... 24 nadolol .................................. 32 nadolol-bendroflumethiazide 32 nafcillin................................... 9 nafcillin in dextrose iso-osm .. 9 naftifine ................................ 40 NAGLAZYME..................... 48 nalbuphine ............................ 24 naloxone ............................... 24 naltrexone ............................. 24 naproxen ............................... 24 naproxen sodium .................. 24 naproxen-esomeprazole ........ 24 naratriptan............................. 19 NARCAN ............................. 24

NATACYN .......................... 66 nateglinide ............................ 50 NATPARA ........................... 48 natural b-100 complex .......... 74 natura-lax .............................. 53 nature-throid ......................... 51 NAYZILAM ......................... 17 NEBUPENT ........................... 8 nebusal .................................. 71 necon 0.5/35 (28) .................. 64 nefazodone............................ 27 neomycin ................................ 8 neomycin-bacitracin-poly-hc 67 neomycin-bacitracin-

polymyxin ......................... 66 neomycin-polymyxin b gu.... 42 neomycin-polymyxin b-

dexameth .......................... 67 neomycin-polymyxin-

gramicidin ......................... 66 neomycin-polymyxin-hc 44, 67 neo-polycin ........................... 66 neo-polycin hc ...................... 67 NERLYNX ........................... 15 neuac ..................................... 39 NEULASTA ......................... 56 NEVANAC .......................... 67 nevirapine ............................... 4 new day................................. 64 newgen.................................. 74 NEXAVAR .......................... 15 NEXPLANON...................... 62 niacin .................................... 36 nicardipine ............................ 32 NICODERM CQ .................. 43 nicorelief ............................... 43 nicorette ................................ 43 NICORETTE ........................ 43 nicotine ................................. 44 nicotine (polacrilex) ............. 43 nifedipine .............................. 32 nikki (28) .............................. 64 nilutamide ............................. 15 nimodipine ............................ 32 NINLARO ............................ 15 nisoldipine ............................ 32 nitisinone .............................. 43 nitro-bid ................................ 36

nitrofurantoin ........................ 10 nitrofurantoin macrocrystal .. 10 nitrofurantoin monohyd/m-

cryst .................................. 10 nitroglycerin ......................... 37 nitroglycerin in 5 % dextrose 37 NITYR .................................. 43 NIVESTYM ......................... 56 nizatidine .............................. 55 nolix ...................................... 42 nora-be .................................. 62 noreth-ethinyl estradiol-iron . 64 norethindrone (contraceptive)

.......................................... 62 norethindrone acetate ............ 62 norethindrone ac-eth estradiol

.................................... 62, 64 norethindrone-e.estradiol-iron

.......................................... 64 norgestimate-ethinyl estradiol

.......................................... 65 norlyda .................................. 62 nortrel 0.5/35 (28) ................. 65 nortrel 1/35 (21) .................... 65 nortrel 1/35 (28) .................... 65 nortrel 7/7/7 (28) ................... 65 nortriptyline .......................... 27 NORVIR ................................. 4 NOVOEIGHT ....................... 35 NOVOLOG FLEXPEN U-100

INSULIN .......................... 47 NOVOLOG MIX 70-30 U-100

INSULN ........................... 47 NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 47 NOVOLOG PENFILL U-100

INSULIN .......................... 48 NOVOLOG U-100 INSULIN

ASPART ........................... 48 NOVOSEVEN RT ................ 35 NOXAFIL ............................... 3 np thyroid .............................. 51 NPLATE ............................... 35 NUBEQA ............................. 15 NUCALA ............................. 71 NUEDEXTA ........................ 19 NULOJIX ............................. 15 nyamyc ................................. 40


87

nystatin ............................. 3, 40 nystatin-triamcinolone .......... 40 nystop ................................... 40 O OBIZUR ............................... 35 obstetrix dha ......................... 74 OCALIVA ............................ 54 ocella .................................... 65 OCREVUS ........................... 56 octreotide acetate .................. 15 ODEFSEY .............................. 4 ODOMZO ............................ 15 OFEV ................................... 71 ofloxacin ..................... 9, 44, 66 ogestrel (28).......................... 65 OGIVRI ................................ 15 okebo .................................... 10 olanzapine............................. 27 olanzapine-fluoxetine ........... 27 olmesartan ............................ 32 olmesartan-amlodipin-

hcthiazid ........................... 32 olmesartan-

hydrochlorothiazide .......... 32 olopatadine ..................... 44, 67 omega-3 acid ethyl esters ..... 36 omeprazole ........................... 55 omeprazole-sodium

bicarbonate ....................... 55 OMNITROPE....................... 56 ONCASPAR ........................ 15 ondansetron .......................... 54 ondansetron hcl .................... 54 ondansetron hcl (pf) ............. 54 one daily prenatal ................. 74 ONIVYDE ............................ 15 opcicon one-step ................... 65 OPDIVO ............................... 15 opium tincture ...................... 52 OPSUMIT ............................ 71 OPTICHAMBER DIAMOND

VHC ................................. 46 option-2 ................................ 65 oral saline laxative ................ 54 oralone .................................. 44 ORAVIG ................................ 3 ORBACTIV ........................... 8 ORILISSA ............................ 48

ORKAMBI ........................... 71 orphenadrine citrate .............. 20 orphenadrine-asa-caffeine .... 20 orphengesic forte .................. 20 orsythia ................................. 65 oscimin ................................. 52 oscimin sl .............................. 52 oscimin sr ............................. 52 oseltamivir .............................. 4 osmitrol 20 % ....................... 32 OTEZLA .............................. 60 OTEZLA STARTER ............ 60 oxacillin .................................. 9 oxacillin in dextrose(iso-osm) 9 oxaliplatin ............................. 15 oxandrolone .......................... 48 oxaprozin .............................. 24 oxazepam .............................. 27 oxcarbazepine ....................... 17 OXERVATE ........................ 67 oxiconazole ........................... 40 oxybutynin chloride .............. 72 oxycodone ............................ 22 OXYCODONE ..................... 22 oxycodone-acetaminophen ... 22 oxycodone-aspirin ................ 23 oxymorphone ........................ 23 oxytocin ................................ 65 OZURDEX ........................... 68 P pacerone................................ 29 paclitaxel .............................. 15 paliperidone .......................... 27 palonosetron ......................... 54 PALYNZIQ .................... 48, 49 pamidronate .......................... 49 pantoprazole ................... 55, 56 PARAGARD T 380A ........... 61 paraplatin .............................. 15 paricalcitol ............................ 49 paroex oral rinse ................... 44 paromomycin .......................... 8 paroxetine hcl ................. 27, 28 paroxetine

mesylate(menop.sym)....... 28 PASER.................................... 8 PEDVAX HIB (PF) .............. 58 peg 3350-electrolytes ........... 54

PEGANONE ......................... 17 PEGASYS ............................ 56 peg-electrolyte soln .............. 54 peg-prep ................................ 54 penicillamine ........................ 60 penicillin g potassium ............. 9 penicillin g procaine ............... 9 penicillin g sodium ................. 9 penicillin v potassium ............. 9 pentamidine ............................ 8 PENTASA ............................ 54 pentoxifylline ........................ 35 PERFOROMIST ................... 71 perindopril erbumine ............ 32 periogard ............................... 44 PERJETA ............................. 15 permethrin ............................. 42 perphenazine ......................... 28 perphenazine-amitriptyline ... 28 perry prenatal ........................ 74 pfizerpen-g .............................. 9 phenadoz ............................... 69 phenelzine ............................. 28 phenobarb-hyoscy-atropine-

scop ................................... 52 phenobarbital ........................ 18 phenoxybenzamine ............... 32 phentolamine ........................ 32 phenylephrine hcl ................. 68 phenytoin .............................. 18 phenytoin sodium ................. 18 phenytoin sodium extended .. 18 philith .................................... 65 phosphate laxative ................ 54 PHOSPHOLINE IODIDE .... 66 PHOTOFRIN ........................ 15 phytonadione (vitamin k1) ... 35 pilocarpine hcl .......... 43, 44, 66 pimecrolimus ........................ 38 pimozide ............................... 28 pimtrea (28) .......................... 65 pindolol ................................. 32 pioglitazone .......................... 50 pioglitazone-glimepiride ....... 50 pioglitazone-metformin ........ 51 piperacillin-tazobactam .......... 9 pirmella ................................. 65 piroxicam .............................. 24


88

PLAN B ONE-STEP ............ 65 PLEGRIDY .......................... 57 PNEUMOVAX-23 ............... 58 pnv 29-1 ............................... 74 pnv-dha ................................. 74 pnv-dha + docusate .............. 74 pnv-omega ............................ 74 pnv-select ............................. 74 POCKET CHAMBER ......... 46 podofilox .............................. 38 polycin .................................. 66 polyethylene glycol 3350 ..... 54 polymyxin b sulfate ................ 8 polymyxin b sulf-trimethoprim

.......................................... 66 POMALYST ........................ 57 portia 28................................ 65 posaconazole .......................... 3 potassium chloride................ 73 potassium citrate ................... 72 POTELIGEO ........................ 15 powderlax ............................. 54 pr natal 400 ........................... 74 pr natal 400 ec ...................... 74 pr natal 430 ........................... 74 pr natal 430 ec ...................... 74 PRALUENT PEN ................ 36 pramipexole .......................... 18 prasugrel ............................... 35 pravastatin ............................ 36 praziquantel ............................ 8 prazosin ................................ 32 PRECISION XTRA

MONITOR ....................... 47 PRECISION XTRA TEST ... 45 prednicarbate ........................ 42 prednisolone ......................... 45 prednisolone acetate ............. 68 prednisolone sodium phosphate

.................................... 45, 68 prednisone ............................ 45 prednisone intensol ............... 45 pregabalin ............................. 18 prena1 chew.......................... 74 prena1 pearl .......................... 74 prena1 true ............................ 74 prenaissance ......................... 74 prenaissance plus .................. 74

prenatabs fa........................... 74 prenatabs rx .......................... 74 prenatal ................................. 74 prenatal complete ................. 74 prenatal formula ................... 74 prenatal multi-dha (algal oil) 74 prenatal one daily ................. 74 prenatal plus ......................... 74 prenatal plus (calcium carb) . 74 prenatal vitamin .................... 74 prenatal vitamin plus low iron

.......................................... 74 prenatal vitamin with minerals

.......................................... 74 prenatal vits96-iron fum-folic

.......................................... 74 prenatal-u .............................. 74 preplus .................................. 74 pretab .................................... 74 prevalite ................................ 36 previfem................................ 65 PREVNAR 13 (PF) .............. 58 PREVYMIS ............................ 4 PREZISTA ............................. 4 PRIFTIN ................................. 8 primaquine .............................. 8 PRIMEAIRE ........................ 46 primidone.............................. 18 PRIVIGEN ........................... 58 PROAIR HFA ...................... 71 PROAIR RESPICLICK ....... 71 probenecid ............................ 59 probenecid-colchicine .......... 59 procainamide ........................ 29 procentra ............................... 28 PROCHAMBER .................. 46 prochlorperazine ................... 54 prochlorperazine edisylate .... 54 prochlorperazine maleate ..... 54 PROCRIT ............................. 56 procto-med hc ....................... 54 procto-pak ............................. 54 proctosol hc .......................... 54 proctozone-hc ....................... 54 PROFILNINE ....................... 35 progesterone ......................... 62 progesterone micronized ...... 62 PROGLYCEM ..................... 46

PROGRAF ............................ 15 PROLASTIN-C .................... 43 prolate ................................... 23 PROLEUKIN ....................... 57 PROMACTA ........................ 35 promethazine ........................ 69 promethazine-codeine ........... 69 promethazine-dm .................. 69 promethazine-phenyleph-

codeine .............................. 69 promethazine-phenylephrine 69 promethegan ......................... 69 propafenone .......................... 29 proparacaine ......................... 67 propranolol ........................... 32 propranolol-hydrochlorothiazid

.......................................... 32 propylthiouracil .................... 45 PROQUAD (PF) ................... 58 protamine .............................. 35 protriptyline .......................... 28 PROVENGE ......................... 58 prudoxin ................................ 38 pulmosal ............................... 71 PULMOZYME ..................... 71 purelax .................................. 54 PURIXAN ............................ 15 pyrazinamide .......................... 8 pyridostigmine bromide ........ 20 pyrimethamine ........................ 8 Q QUADRACEL (PF) ............. 59 quetiapine ............................. 28 quinapril ................................ 32 quinapril-hydrochlorothiazide

.......................................... 32 quinidine gluconate .............. 29 quinidine sulfate ................... 29 quinine sulfate ........................ 8 quit 2 ..................................... 44 quit 4 ..................................... 44 QVAR REDIHALER ........... 71 R RABAVERT (PF) ................ 59 rabeprazole ........................... 56 RADICAVA ......................... 19 raloxifene .............................. 59 ramelteon .............................. 28


89

ramipril ................................. 32 ranitidine hcl ......................... 56 ranolazine ............................. 36 RAPIVAB (PF) ...................... 5 rasagiline .............................. 18 RAVICTI .............................. 43 REBIF (WITH ALBUMIN) . 57 REBIF REBIDOSE .............. 57 REBIF TITRATION PACK 57 reclipsen (28) ........................ 65 RECOMBIVAX HB (PF) .... 59 RECTIV ............................... 54 regonol .................................. 20 REGRANEX ........................ 38 RELENZA DISKHALER ...... 5 RELION NOVOLIN 70/30 .. 48 RELION NOVOLIN N ........ 48 RELION NOVOLIN R ........ 48 RELISTOR ........................... 54 REMODULIN ...................... 32 RENACIDIN ........................ 72 rena-vite ................................ 74 repaglinide ............................ 51 repaglinide-metformin .......... 51 RESTASIS ........................... 67 RESTASIS MULTIDOSE ... 67 RETACRIT .......................... 56 RETROVIR ............................ 5 REVCOVI ............................ 43 REVLIMID .......................... 57 revonto .................................. 20 REXULTI ............................. 28 REYATAZ ............................. 5 RIASTAP ............................. 35 ribavirin ............................ 5, 57 RIDAURA ............................ 60 rifabutin .................................. 8 rifampin .................................. 8 RIFATER ............................... 8 riluzole .................................. 43 rimantadine ............................. 5 ringer's .................................. 42 RINVOQ .............................. 60 risedronate ...................... 43, 59 RISPERDAL CONSTA ....... 28 risperidone ............................ 28 RITEFLO AEROCHAMBER

.......................................... 46

ritonavir .................................. 5 RITUXAN ............................ 15 RITUXAN HYCELA ........... 15 rivastigmine .......................... 19 rivastigmine tartrate .............. 19 rivelsa ................................... 65 rizatriptan.............................. 19 ropinirole .............................. 18 rosadan.................................. 39 rosuvastatin ........................... 36 ROTATEQ VACCINE......... 59 roweepra ............................... 18 roweepra xr ........................... 18 ROZLYTREK ...................... 15 RUBRACA ........................... 15 RUCONEST ......................... 71 RUXIENCE .......................... 15 RUZURGI ............................ 19 RYDAPT .............................. 15 S SAFE-CLIP BY MAIL ........ 47 salsalate ................................ 24 SAMSCA ............................. 49 SANDIMMUNE .................. 15 SANTYL .............................. 42 SAPHRIS ............................. 28 SAVELLA ...................... 60, 61 scalacort ................................ 42 scopolamine base .................. 54 seconal sodium ..................... 28 selegiline hcl ......................... 18 selenium sulfide .................... 37 SELZENTRY ......................... 5 se-natal 19 chewable ............ 74 se-natal-19 ............................ 74 sertraline ............................... 28 setlakin.................................. 65 sevelamer carbonate ............. 54 sevelamer hcl ........................ 54 sf 44 sf 5000 plus .......................... 44 sharobel ................................ 62 SHINGRIX (PF) ................... 59 SIGNIFOR............................ 15 sildenafil (pulm.hypertension)

.......................................... 71 silodosin................................ 72 silver sulfadiazine ................. 37

simliya (28) ........................... 65 simpesse ................................ 65 SIMPONI .............................. 61 SIMULECT .......................... 15 simvastatin ............................ 36 sirolimus ............................... 15 SIRTURO ............................... 8 SKLICE ................................ 42 SKYRIZI .............................. 37 smoothlax ............................. 54 sodium benzoate-sod

phenylacet ......................... 43 sodium chloride .............. 43, 71 sodium chloride 0.45 % ........ 73 sodium chloride 0.9 % (flush)

.......................................... 43 sodium chloride 3 % ............. 73 sodium chloride 5 % ............. 73 sodium ferric gluconat-sucrose

.......................................... 43 sodium fluoride 5000 plus .... 44 sodium phenylbutyrate ......... 43 sodium polystyrene (sorb free)

.......................................... 54 sodium polystyrene sulfonate

.......................................... 54 solifenacin ............................. 72 SOLIQUA 100/33 ................ 48 SOLIRIS ............................... 43 SOMATULINE DEPOT ...... 15 SOMAVERT ........................ 49 SOOLANTRA ...................... 39 sotalol ................................... 29 sotalol af ............................... 29 SOTYLIZE ........................... 29 spinosad ................................ 42 spironolactone ....................... 32 spironolacton-hydrochlorothiaz

.......................................... 32 sprintec (28) .......................... 65 SPRYCEL ............................. 15 sps (with sorbitol) ................. 54 sronyx ................................... 65 ssd ......................................... 37 st joseph aspirin .................... 24 STAMARIL (PF) .................. 59 stavudine ................................. 5 STELARA ............................ 37


90

STIMATE ............................ 49 STIVARGA .......................... 15 stop smoking aid................... 44 STRENSIQ ........................... 49 stress formula ....................... 74 stress formula with iron ........ 74 stress formula with iron(sulf)74 STRIVERDI RESPIMAT .... 71 strong iodine ......................... 39 SUBLOCADE ...................... 23 SUBOXONE ........................ 24 subvenite............................... 18 subvenite starter (blue) kit .... 18 subvenite starter (green) kit .. 18 subvenite starter (orange) kit 18 SUCRAID ............................ 54 sucralfate .............................. 56 sulfacetamide-prednisolone .. 68 sulfadiazine............................. 9 sulfamethoxazole-trimethoprim

............................................ 9 SULFAMYLON .................. 39 sulfasalazine ......................... 54 sulfatrim ................................. 9 sulindac................................. 24 sumatriptan ........................... 19 sumatriptan succinate ........... 19 sumatriptan-naproxen ........... 19 SUNOSI ............................... 28 super b complex-vitamin c ... 74 super b maxi complex .......... 74 super quints .......................... 74 super quints b-50 .................. 75 SUTENT .............................. 15 syeda ..................................... 65 SYLATRON......................... 57 SYLVANT ........................... 15 symax fastabs ....................... 52 symax-sl ............................... 52 symax-sr ............................... 52 SYMBICORT ...................... 71 SYMDEKO .......................... 71 SYMFI .................................... 5 SYMFI LO ............................. 5 SYMLINPEN 120 ................ 51 SYMLINPEN 60 .................. 51 SYNAGIS .............................. 5 SYNJARDY ......................... 51

SYNJARDY XR................... 51 T tacrolimus ....................... 16, 38 tadalafil (pulm. hypertension)

.......................................... 71 TAFINLAR .......................... 16 TAGRISSO .......................... 16 TALZENNA ......................... 16 tamoxifen .............................. 16 tamsulosin ............................. 72 TARGRETIN ....................... 16 tarina 24 fe ............................ 65 tarina fe 1/20 (28) ................. 65 taron-c dha ............................ 75 taron-prex prenatal-dha ........ 75 TASIGNA ............................ 16 tazarotene.............................. 39 tazicef ..................................... 6 TAZORAC ........................... 39 taztia xt ................................. 33 TDVAX ................................ 59 TECENTRIQ ........................ 16 TECFIDERA ........................ 57 telmisartan ............................ 33 telmisartan-amlodipine ......... 33 telmisartan-hydrochlorothiazid

.......................................... 33 TEMIXYS .............................. 5 TEMODAR .......................... 16 temozolomide ....................... 16 temsirolimus ......................... 16 tencon ................................... 23 TENIPOSIDE ....................... 16 tenofovir disoproxil fumarate . 5 terazosin................................ 33 terbinafine hcl ......................... 3 terbutaline ............................. 71 terconazole............................ 62 testosterone ........................... 49 testosterone cypionate .......... 49 testosterone enanthate ........... 49 TETANUS,DIPHTHERIA

TOX PED(PF) .................. 59 tetrabenazine ......................... 19 tetracaine hcl......................... 67 tetracycline ........................... 10 THALOMID ......................... 16 theochron .............................. 71

theophylline .......................... 71 thioridazine ........................... 28 thiotepa ................................. 16 thiothixene ............................ 28 thyroid (pork) ........................ 51 THYROLAR-1 ..................... 51 THYROLAR-1/2 .................. 51 THYROLAR-1/4 .................. 51 THYROLAR-2 ..................... 51 THYROLAR-3 ..................... 51 tiadylt er ................................ 33 tiagabine ............................... 18 TIBSOVO ............................. 16 tigecycline ............................... 8 tilia fe .................................... 65 timolol maleate ............... 33, 66 tinidazole ................................ 8 tis-u-sol pentalyte ................. 42 TIVICAY ................................ 5 tizanidine .............................. 20 tobramycin ............................ 66 tobramycin in 0.225 % nacl .... 8 tobramycin in 0.9 % nacl ........ 8 tobramycin sulfate .................. 8 tobramycin-dexamethasone .. 67 TODAY CONTRACEPTIVE

SPONGE ........................... 62 tolcapone ............................... 18 tolmetin ................................. 24 tolterodine ............................. 72 topiramate ............................. 18 toposar .................................. 16 topotecan ............................... 16 toremifene ............................. 16 torsemide .............................. 33 total b/c ................................. 75 TOUJEO MAX U-300

SOLOSTAR ..................... 48 TOUJEO SOLOSTAR U-300

INSULIN .......................... 48 tovet emollient ...................... 42 TRACLEER ......................... 71 TRADJENTA ....................... 51 tramadol ................................ 24 tramadol-acetaminophen ...... 24 trandolapril ........................... 33 trandolapril-verapamil .......... 33 tranexamic acid ............... 35, 62


91

tranylcypromine ................... 28 travoprost .............................. 67 TRAZIMERA....................... 16 trazodone .............................. 28 TREANDA ........................... 16 TRECATOR ........................... 8 TRELEGY ELLIPTA .......... 72 TREMFYA ........................... 37 treprostinil sodium................ 33 tretinoin ................................ 39 tretinoin (chemotherapy) ...... 16 tretinoin microspheres .......... 39 TRETTEN ............................ 35 tri femynor ............................ 65 triamcinolone acetonide 42, 44,

45 triamterene ............................ 33 triamterene-hydrochlorothiazid

.......................................... 33 trianex ................................... 42 triazolam ............................... 28 triderm .................................. 42 trientine................................. 43 tri-estarylla ........................... 65 trifluoperazine ...................... 28 trifluridine............................. 66 trihexyphenidyl .................... 18 TRIKAFTA .......................... 72 triklo ..................................... 36 tri-legest fe............................ 65 tri-linyah ............................... 65 tri-lo-estarylla ....................... 65 tri-lo-marzia .......................... 65 tri-lo-mili .............................. 65 tri-lo-sprintec ........................ 65 trilyte with flavor packets ..... 54 trimethobenzamide ............... 54 trimethoprim ......................... 10 tri-mili .................................. 65 trimipramine ......................... 28 trinatal rx 1 ........................... 75 trinate .................................... 75 TRINTELLIX....................... 28 tri-previfem (28) ................... 65 TRIPTODUR ....................... 16 TRISENOX .......................... 16 tri-sprintec (28) ..................... 65 TRIUMEQ .............................. 5

triveen-duo dha ..................... 75 tri-vitamin with fluoride ....... 75 trivora (28) ............................ 65 tri-vylibra .............................. 65 tri-vylibra lo .......................... 65 TROGARZO .......................... 5 tropicamide ........................... 66 trospium ................................ 72 TRULANCE ......................... 54 TRULICITY ......................... 51 TRUMENBA........................ 59 trust natal dha ....................... 75 TRUVADA ............................ 5 TRUXIMA ........................... 16 tulana .................................... 62 TWINRIX (PF)..................... 59 tydemy .................................. 65 TYKERB .............................. 16 TYMLOS.............................. 59 TYPHIM VI ......................... 59 TYSABRI ............................. 19 TYVASO .............................. 72 TYVASO REFILL KIT........ 72 TYVASO STARTER KIT ... 72 U UCERIS ................................ 54 UDENYCA .......................... 56 unithroid ............................... 51 UNITUXIN .......................... 16 UPTRAVI ............................. 33 ursodiol ................................. 54 UTIBRON NEOHALER ...... 72 UVADEX ............................. 38 V vaginal contraceptive foam .. 62 valacyclovir ............................ 5 VALCHLOR ........................ 38 valganciclovir ......................... 5 valproate sodium .................. 18 valproic acid ......................... 18 valproic acid (as sodium salt)

.......................................... 18 valsartan................................ 33 valsartan-hydrochlorothiazide

.......................................... 33 vancomycin .......................... 10 VANCOMYCIN IN 0.9 %

SODIUM CHL ................. 10

VANCOMYCIN IN DEXTROSE 5 % .............. 10

vandazole .............................. 62 VANTAS .............................. 16 VARIVAX (PF) .................... 59 VARIZIG .............................. 59 VARUBI ............................... 55 VASCEPA ............................ 36 VAXCHORA VACCINE ..... 59 VCF CONTRACEPTIVE

FILM ................................. 62 VCF CONTRACEPTIVE GEL

.......................................... 62 VECTIBIX ........................... 16 VELCADE ........................... 16 veletri .................................... 33 velivet triphasic regimen (28)

.......................................... 65 VEMLIDY .............................. 5 VENCLEXTA ...................... 16 VENCLEXTA STARTING

PACK ............................... 16 venlafaxine ..................... 28, 29 VENOFER ............................ 75 verapamil .............................. 33 veripred 20 ............................ 45 VERZENIO .......................... 16 V-GO 20 ............................... 47 V-GO 30 ............................... 47 V-GO 40 ............................... 47 VIBERZI .............................. 55 vicodin hp ............................. 23 VIDEX 2 GRAM PEDIATRIC

............................................ 5 vienva ................................... 65 vigabatrin .............................. 18 vigadrone .............................. 18 VIIBRYD ............................. 29 VIMIZIM .............................. 49 VIMPAT ............................... 18 vinblastine ............................. 16 vincasar pfs ........................... 16 vincristine ............................. 16 vinorelbine ............................ 16 VIOKACE ............................ 55 viorele (28) ........................... 65 VIRACEPT ............................. 5 VIREAD ................................. 5


92

virt-c dha .............................. 75 virt-nate dha.......................... 75 virt-pn dha ............................ 75 virt-pn plus ........................... 75 virtussin ac............................ 69 virtussin dac.......................... 69 VISTOGARD ....................... 11 vitamin b complex ................ 75 vitamin b complex-folic acid 75 vitamin k ............................... 35 vitamin k1 ............................. 35 vitamins a,c,d and fluoride ... 75 VITRAKVI........................... 16 VIVITROL ........................... 24 VIVOTIF .............................. 59 VIZIMPRO .......................... 16 volnea (28)............................ 65 VONVENDI ......................... 35 voriconazole ........................... 3 VORTEX HOLDING

CHAMBER ...................... 46 VOTRIENT .......................... 16 vp-ch-pnv ............................. 75 vtol lq ................................... 23 VUMERITY ......................... 57 vyfemla (28) ......................... 65 vylibra................................... 65 VYNDAMAX ...................... 36 VYNDAQEL ........................ 36 VYVANSE ........................... 29 VYXEOS .............................. 16 W warfarin ................................ 35 water for irrigation, sterile .... 43 wera (28) .............................. 65

westhroid .............................. 51 wintergreen oil ...................... 38 wixela inhub ......................... 72 women's gentle laxative(bisac)

.......................................... 55 women's laxative (bisacodyl)55 wymzya fe ............................ 65 X XALKORI ............................ 16 XARELTO ........................... 35 XELJANZ ............................ 61 XELJANZ XR ...................... 61 XERMELO ........................... 16 XGEVA ................................ 11 XIFAXAN .............................. 8 XIGDUO XR ........................ 51 XOLAIR ............................... 72 XOSPATA............................ 17 xulane ................................... 62 XURIDEN ............................ 43 XYREM................................ 29 Y YERVOY ............................. 17 YESCARTA ......................... 17 YF-VAX (PF) ....................... 59 YONDELIS .......................... 17 YONSA ................................ 17 yuvafem ................................ 62 Z zafirlukast ............................. 72 zaleplon ................................ 29 ZANOSAR ........................... 17 zarah ..................................... 65 ZARXIO ............................... 56 zatean-pn dha ........................ 75

zatean-pn plus ....................... 75 zebutal ................................... 23 ZEJULA ............................... 17 ZELBORAF ......................... 17 ZEMAIRA ............................ 43 zenatane ................................ 39 zenzedi .................................. 29 ZEPATIER ............................. 5 ZERBAXA ............................. 6 ZEVALIN (Y-90) ................. 17 zidovudine .............................. 5 ZIEXTENZO ........................ 56 zileuton ................................. 72 zingiber ................................. 75 ziprasidone hcl ...................... 29 ziprasidone mesylate ............ 29 ZIRABEV ............................. 17 ZOLADEX ........................... 17 zoledronic acid ...................... 49 zoledronic acid-mannitol-water

.................................... 43, 49 ZOLGENSMA ..................... 19 ZOLINZA ............................. 17 zolmitriptan ........................... 19 zolpidem ............................... 29 zonisamide ............................ 18 ZORTRESS .......................... 17 zovia 1/35e (28) .................... 65 ZTLIDO ................................ 39 ZUBSOLV ............................ 25 ZULRESSO .......................... 29 zumandimine (28) ................. 65 ZYDELIG ............................. 17 ZYKADIA ............................ 17 ZYTIGA ............................... 17

Documents

2020 Comprehensive List of Covered Drugs · To find your drug on the comprehensive drug list follow the instructions below. You can look for your drug in the Index that starts on