As of July 1, 2020mybhhealthplan.com/formulary/formulary 20200701v1.pdf · The following is the formulary for the Beaumont Health Employee Health Plan (BHEHP) As of July 1, 2020 To

The following is the formulary for the Beaumont Health Employee Health Plan (BHEHP)

As of July 1, 2020

To search for a drug:

Symbol Guideline Description

AGE Age Edit Drug may not be recommended for

some patients based on age

G Gender Edit Drug may not be recommended for

some patients based on gender

PA Prior

Authorization

Requires your doctor to request

prior authorization to support use of

this drug

QL Quantity

Limit

Coverage may be limited to specific

quantities per prescription and/or

time period

ST Step Therapy Coverage may depend on previous

use of another drug

This document is the Beaumont Health Formulary, a list of

generic and brand name drugs covered by Beaumont Health

under your outpatient prescription drug benefit. The formulary

helps you and your doctor determine the right drug to prescribe

to treat your needs.

The drugs on the formulary are selected by the Beaumont

Health Pharmacy and Therapeutics (P & T) Committee. The

committee is made up of doctors and pharmacists who meet

regularly to decide which drugs should be included. Drugs on

the formulary are chosen for their safety, effectiveness and

value.

Beaumont Health updates the formulary on a monthly basis and

its contents may change. You can get the most current

formulary on the Beaumont Health website at

http://mybhhealthplan.com.

How to Use the Formulary The formulary is a list of preferred drugs available to Beaumont

Health members under their pharmacy benefit. All drugs on the

formulary are listed by their generic names and most common

brand name. The formulary may be accessed by using the index,

either by generic or brand name (in capital letters) and by

therapeutic drug category. In situations where a Food and Drug

Administration (FDA) approved generic drug is available,

brand names are listed for reference purposes only. Brand

names usually cost more and are not preferred over generic

alternatives. Any drugs not found in this formulary listing or

any formulary updates published by Beaumont Health are

considered non-formulary drugs and require prior authorization.

All drugs are listed in each category in alphabetical order by

generic name. All drugs have a generic name. If the generic

drug is FDA approved it will appear Italicized in the

formulary listing.

Some drugs on the formulary have certain process requirements

or limitations for coverage. These are identified by the letters

listed and explained in the following box. Your Prescription

Drug Guide explains the details of the process requirements

and limitations and how you can ask for exceptions.

Benefit Coverage and Limitations This printed formulary does not provide information regarding

the specific coverage and limitations an individual member may

have. Many members have specific benefit inclusions,

exclusions, copays, or a lack of coverage, which are not

reflected in the formulary. For example, over the counter drugs

are not covered. Refer to your Prescription Drug Guide for

more information regarding your specific coverage.

The formulary applies only to outpatient drugs provided to

members, and does not apply to drugs used in inpatient settings

or administered by a health care provider in a clinic or office

setting. If you have any specific questions regarding your

prescription coverage, refer to your Prescription Drug Guide

or contact

Beaumont Health at 1-947-522-1623 or MedImpact

at 1-844-863-0365.

Depending upon a member’s specific benefit, the following

topics may apply:

1. Generic Substitution

When available, FDA approved generic drugs are used in

most situations, regardless of the brand name indicated.

Members have lower copays when they use generic drugs.

If a member or Doctor requests a brand name drug instead

of an approved generic, the member is required to pay the

difference in cost between the brand and the generic.

http://mybhhealthplan.com/

2. Four Tier Benefit

The formulary is a five tier benefit design. Tiers are the

different cost levels you pay for a drug. Each tier is

assigned a member cost share. This is how much you pay

when you fill a prescription. The five tiers are:

• Tier 1 – Most generic drugs and low-cost preferred

brands are covered at the lowest cost share level

• Tier 2 – Preferred brand name and non-preferred

generic drugs are covered at the second lowest tier cost

share level

• Tier 3 – Preferred Brand name drugs are covered at

the third-tier cost share level. These brand-name drugs

are preferred under the plan’s formulary and have

lower copays than their non-preferred brand-name

alternatives.

• Tier 4 – Non-preferred brand name drugs are covered

at the fourth-tier cost share level. These brand name

drugs are have a higher copay than their generic and

preferred brand-name alternatives.

• Tier 5 – Specialty drugs, self-administered drugs that

require training or clinical monitoring, and

bioengineered drugs are covered at the fourth-tier cost

share level

If your drug is in Tier 2 or 3, look to see if there is a Tier 1

option available. Discuss these options with your doctor.

All preventive care drug categories have products that are

covered with $0 cost share.

Preventive care drugs and products are covered at $0 cost

share when prescribed by a participating doctor and

obtained at a network pharmacy. Preventive care drugs and

products are listed in the print formulary as Tier 0 to help

differentiate this group of drugs that have a $0 cost share.

Refer to your Prescription Drug Guide for more

information regarding coverage of preventive care drugs

and products.

Refer to your plan documents for infertility drug coverage

(if applicable) and cost share information.

Your pharmacy benefits, including tiers and restrictions, are

based on plan year. During your plan year, any changes to

the formulary that benefit you, such as moving a drug to a

lower tier for lower cost share, take effect right away. Most

changes that increase cost share or impose new limits or

processes on a drug you take do not affect you until the

start of your next plan year.

It is important to note that drug costs change frequently. If

you have a percent-of-cost coinsurance or deductible,

confirm your cost share by calling your pharmacy or

MedImpact before picking up your prescription.

3. Drug Prior Authorization Process

Depending upon plan benefit design, a medication prior

authorization request process may apply as follows:

A. Formulary Drugs

There are a number of drugs listed in the formulary

that may require prior authorization to ensure

appropriate use based on criteria set by the P&T

Committees. Examples include drugs used for non-

FDA-approved indications (off label use) and step

therapy. MedImpact reviews Each request is

reviewedeon an individual patient need basis. If the

request does not meet established guidelines it is not

approved and MedImpact may recommend an

alternative drug.

B. Non-Formulary Drugs

Drugs not found in the formulary listing are

considered non-formulary drugs. All non-formulary

drugs require prior authorization for coverage.

MedImpact reviews each prior authorization request

on an individual patient need basis. MedImpact

approves requests if a documented medical need

exists. The following basic guidelines are used:

• The use of formulary drugs is contraindicated in

the patient.

• The patient has failed an appropriate trial of

formulary or related agents.

• The choices available in the formulary are not

suited for the present patient care need, and the

drug selected is required for patient safety.

• The use of a formulary drug may provoke an

underlying condition, which would be detrimental

to patient care.

If the request does not meet the guidelines established

by the P&T Committees, MedImpact will not approve

and may recommend an alternative therapy.

C. Requesting Prior Authorizations

For drugs that require prior authorization for coverage, providers

must submit a request to MedImpact using one of the following

methods:

1. Fax a completed Prescription Drug Prior Authorization

Request Form to MedImpact at 1-858-790-7100.

2. Call MedImpact at 1-844-282-5330 (option 3) and provide all

necessary information requested.

3. Online at https://mp.medimpact.com/webtocase/EMRF2.asp

x?client=MI&state=CA

1

Table of Contents

Allergy.......................................................................................................................................................................................3Antiemesis/Antivertigo.............................................................................................................................................................. 3Asthma And Copd.................................................................................................................................................................... 4Autonomic Nervous System Disorders.....................................................................................................................................9Behavioral Health - Antidepressants...................................................................................................................................... 10Behavioral Health - Other....................................................................................................................................................... 13Cardiovascular Disease - Arrhythmia..................................................................................................................................... 19Cardiovascular Disease - Cardiac Stimulant.......................................................................................................................... 20Cardiovascular Disease - Hypertension................................................................................................................................. 20Cardiovascular Disease - Lipid Irregularity.............................................................................................................................28Cardiovascular Disease - Miscellaneous Agents................................................................................................................... 31Cardiovascular Disease - Vasodilation...................................................................................................................................31Contraception/Oxytocics.........................................................................................................................................................32Cough And Cold..................................................................................................................................................................... 40Dermatology - Acne................................................................................................................................................................42Dermatology - Antiinfective.....................................................................................................................................................43Dermatology - Antiinflammatory............................................................................................................................................. 46Dermatology - Miscellaneous................................................................................................................................................. 49Dermatology - Psoriasis/Eczema........................................................................................................................................... 51Diabetes................................................................................................................................................................................. 52Ear - General Disorders..........................................................................................................................................................58Electrolyte Regulation.............................................................................................................................................................59Endocrine Disorder - Fertility .................................................................................................................................................. 60Endocrine Disorder - Other.....................................................................................................................................................61Endocrine Disorder - Thyroid..................................................................................................................................................65Eye - General Disorders......................................................................................................................................................... 66Eye - Glaucoma......................................................................................................................................................................70Eye - Miscellaneous............................................................................................................................................................... 71Fluid Replacement..................................................................................................................................................................72Gout And Related Diseases................................................................................................................................................... 72Hematological Disorders........................................................................................................................................................ 72Hormonal Deficiency.............................................................................................................................................................. 75Immunization.......................................................................................................................................................................... 77Immunosuppression/Modulation.............................................................................................................................................78Infectious Disease - Bacterial ................................................................................................................................................. 79Infectious Disease - Fungal .................................................................................................................................................... 83Infectious Disease - Miscellaneous........................................................................................................................................ 84Infectious Disease - Parasitic ................................................................................................................................................. 85Infectious Disease - Viral ........................................................................................................................................................86Inflammatory Disease.............................................................................................................................................................90Local Anesthesia.................................................................................................................................................................... 95Lower Gastrointestinal Disorders - Bowel Inflammat..............................................................................................................95Lower Gastrointestinal Disorders - Other............................................................................................................................... 96

1

Medical Supplies.................................................................................................................................................................... 98Miscellaneous Agents...........................................................................................................................................................115Neoplastic Disease...............................................................................................................................................................115Neurological Disease - Miscellaneous..................................................................................................................................119Oral/Pharyngeal Disorders................................................................................................................................................... 121Other Drugs..........................................................................................................................................................................121Other Respiratory Disorders.................................................................................................................................................127Pain Management - Analgesics............................................................................................................................................127Parkinsons Disease..............................................................................................................................................................133Seizure Disorder...................................................................................................................................................................134Skeletal Muscle Disorder......................................................................................................................................................140Smoking Cessation...............................................................................................................................................................140Upper Gastrointestinal Disorders - Digestive....................................................................................................................... 141Upper Gastrointestinal Disorders - Spastic Disease............................................................................................................ 141Upper Gastrointestinal Disorders - Ulcer Disease................................................................................................................142Urinary Tract - Functional Disorders.....................................................................................................................................143Vaginal Disorders................................................................................................................................................................. 145Vitamin And/Or Mineral Deficiency.......................................................................................................................................145Weight Reduction................................................................................................................................................................. 147

2

Drug Status Notes

Allergy

2Nd Gen Antihistamine & Decongestant CombinationsCLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG

Tier 3 QL (2 EA per 1 day)

SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3Antihistamines - 1St Generationcarbinoxamine maleate oral tablet 4 mg Tier 2

clemastine oral tablet 2.68 mg Tier 2

cyproheptadine oral syrup 2 mg/5 ml Tier 2

cyproheptadine oral tablet 4 mg Tier 2

hydroxyzine hcl oral solution 10 mg/5 ml Tier 2

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

Tier 2

hydroxyzine pamoate oral capsule 25 mg, 50 mg

(Vistaril) Tier 2

KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 HR 4 MG/5 ML

Tier 3 QL (960 ML per 30 days)

promethazine oral syrup 6.25 mg/5 ml Tier 2

promethazine oral tablet 12.5 mg, 25 mg, 50 mg

Tier 2

Nasal Antihistamineazelastine nasal aerosol,spray 137 mcg (0.1 %)


azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg)


olopatadine nasal spray,non-aerosol 0.6 %

(Patanase) Tier 2 QL (30.5 GM per 30 days)

Nasal Anti-Inflammatory Steroidsflunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


mometasone nasal spray,non-aerosol 50 mcg/actuation

(Nasonex) Tier 2 QL (17 GM per 30 days)

OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG

Tier 3 QL (5 GM per 12 days)

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION

Tier 3 QL (6.8 GM per 30 days)

QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION


ZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION


Antiemesis/Antivertigo

Antiemetic, Cannibinoid-TypeCESAMET ORAL CAPSULE 1 MG Tier 3 QL (6 EA per 1 day)

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

(Marinol) Tier 2 QL (2 EA per 1 day)

Beaumont Health Employee Health Plan 07/01/2020

3

Drug Status Notes

SYNDROS ORAL SOLUTION 5 MG/ML Tier 4 ST; ST: Prior prescription for generic Dronabinol capsules in the last 120 days; QL (60 ML per 30 days)

Antiemetic/Antivertigo AgentsAKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG

Tier 3 QL (1 EA per 28 days)

aprepitant oral capsule 125 mg Tier 2 QL (1 EA per 21 days)

aprepitant oral capsule 40 mg (Emend) Tier 2 QL (1 EA per 28 days)

aprepitant oral capsule 80 mg (Emend) Tier 2 QL (2 EA per 21 days)

COMPRO RECTAL SUPPOSITORY 25 MG

Tier 2

doxylamine-pyridoxine (vit b6) oral tablet,delayed release (dr/ec) 10-10 mg

(Diclegis) Tier 2 QL (4 EA per 1 day)

granisetron hcl oral tablet 1 mg Tier 5 QL (8 EA per 30 days)

meclizine oral tablet 12.5 mg Tier 2

meclizine oral tablet 25 mg (Dramamine Less Drowsy) Tier 2

ondansetron hcl oral solution 4 mg/5 ml Tier 2 QL (50 ML per 15 days)

ondansetron hcl oral tablet 4 mg, 8 mg (Zofran) Tier 2

ondansetron oral tablet,disintegrating 4 mg, 8 mg

Tier 2

prochlorperazine maleate oral tablet 10 mg, 5 mg

(Compazine) Tier 2

prochlorperazine rectal suppository 25 mg

(Compro) Tier 2

promethazine rectal suppository 12.5 mg, 25 mg, 50 mg

(Promethegan) Tier 2

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG

Tier 2

SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR


scopolamine base transdermal patch 3 day 1 mg over 3 days

(Transderm-Scop) Tier 2

trimethobenzamide oral capsule 300 mg (Tigan) Tier 2

VARUBI ORAL TABLET 90 MG Tier 3 QL (2 EA per 14 days)Asthma And Copd

Anticholinergic, Orally Inhaled Short ActingATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION


ipratropium bromide inhalation solution0.02 %

Tier 2


4

Drug Status Notes

Anticholinergics, Orally Inhaled Long ActingINCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION


SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION


Beta-Adrenergic Agentsalbuterol sulfate oral syrup 2 mg/5 ml Tier 2

albuterol sulfate oral tablet 2 mg, 4 mg Tier 2

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

Tier 2

terbutaline oral tablet 2.5 mg, 5 mg Tier 2Beta-Adrenergic Agents, Inhaled, Short Actingalbuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation

(ProAir HFA) Tier 2

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

Tier 2

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml

(Xopenex) Tier 2

levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml

(Xopenex Concentrate) Tier 2

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation

(Xopenex HFA) Tier 2

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

Tier 3

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION

Tier 3

PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

Tier 4

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

Tier 3


5

Drug Status Notes

Beta-Adrenergic Agents, Inhaled, Ultra-Long ActingARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG


STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION


Beta-Adrenergic Agents, Orally Inhaled,Long ActingPERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE


Beta-Adrenergic And Anticholinergic CombinationsANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

Tier 3

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

Tier 2

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION


Beta-Adrenergic And Glucocorticoid CombinationsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE


DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

(AirDuo RespiClick) Tier 2 QL (1 EA per 30 days)


6

Drug Status Notes

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION


Beta-Adrenergic-Anticholinergic-Glucocort, InhaledTRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG


Glucocorticoids, Orally InhaledALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION


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


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)


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

(Pulmicort) Tier 2 QL (120 ML per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml

(Pulmicort) Tier 2 QL (60 ML per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION



7

Drug Status Notes





PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION


QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION


Interleukin-4(Il-4) Receptor Alpha Antagonist, MabDUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML, 300 MG/2 ML

Tier 5 PA

Leukotriene Receptor Antagonistsmontelukast oral granules in packet 4 mg

(Singulair) Tier 2

montelukast oral tablet 10 mg (Singulair) Tier 2

montelukast oral tablet,chewable 4 mg, 5 mg

(Singulair) Tier 2

zafirlukast oral tablet 10 mg, 20 mg (Accolate) Tier 2Mast Cell Stabilizerscromolyn oral concentrate 100 mg/5 ml (Gastrocrom) Tier 2

Monoclonal Antibodies To Immunoglobulin E(Ige)XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

Tier 5 PA

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.5 ML

Tier 5 PA

Phosphodiesterase-4 (Pde4) InhibitorsDALIRESP ORAL TABLET 250 MCG, 500 MCG


Respiratory Aids,Devices,EquipmentAEROCHAMBER MINI SPACER Tier 3 QL (2 EA per 365 days)

AEROCHAMBER MV SPACER Tier 3 QL (2 EA per 365 days)

AEROCHAMBER PLUS FLOW-VU SPACER


AEROCHAMBER PLUS FLOW-VU,L MSK SPACER


AEROCHAMBER PLUS FLOW-VU,M MSK SPACER


AEROCHAMBER PLUS FLOW-VU,S MSK SPACER



8

Drug Status Notes

AEROCHAMBER PLUS Z STAT LG MSK SPACER


AEROCHAMBER PLUS Z STAT MD MSK SPACER


AEROCHAMBER PLUS Z STAT SM MSK SPACER


AEROCHAMBER PLUS Z STAT SPACER


AEROCHAMBER WITH FLOWSIGNAL SPACER


AEROCHAMBER Z-STAT PLUS-FLW SG SPACER


EASIVENT HOLDING CHAMBER SPACER


EASIVENT MASK LARGE DEVICE Tier 3 QL (2 EA per 365 days)

EASIVENT MASK MEDIUM DEVICE Tier 3 QL (2 EA per 365 days)

EASIVENT MASK SMALL DEVICE Tier 3 QL (2 EA per 365 days)XanthinesELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

Tier 2

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG

Tier 3

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG

Tier 2

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

Tier 2

theophylline oral tablet extended release 24 hr 400 mg, 600 mg

Tier 2

Autonomic Nervous System Disorders

Alzheimer's Therapy, Nmda Receptor Antagonistsmemantine oral capsule,sprinkle,er 24hr14 mg, 21 mg, 28 mg, 7 mg

(Namenda XR) Tier 2 QL (30 EA per 30 days)

memantine oral solution 2 mg/ml Tier 2 QL (300 ML per 30 days)

memantine oral tablet 10 mg, 5 mg (Namenda) Tier 2 QL (60 EA per 30 days)

memantine oral tablets,dose pack 5-10 mg

(Namenda Titration Pak) Tier 2 QL (49 EA per 28 days)

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG


Alzheimer's Thx,Nmda Recept Antag & Cholines InhibNAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG



9

Drug Status Notes

Cholinesterase Inhibitorsdonepezil oral tablet 10 mg, 23 mg, 5 mg (Aricept) Tier 2

donepezil oral tablet,disintegrating 10 mg, 5 mg

Tier 2

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg

(Razadyne ER) Tier 2 QL (30 EA per 30 days)

galantamine oral tablet 12 mg, 4 mg, 8 mg

(Razadyne) Tier 2 QL (60 EA per 30 days)

pyridostigmine bromide oral tablet 30 mg Tier 2

pyridostigmine bromide oral tablet 60 mg (Mestinon) Tier 2

pyridostigmine bromide oral tablet extended release 180 mg

(Mestinon Timespan) Tier 2

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

Tier 2

rivastigmine transdermal patch 24 hour13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

(Exelon) Tier 2 QL (30 EA per 30 days)

Behavioral Health - Antidepressants

Alpha-2 Receptor Antagonist Antidepressantsmirtazapine oral tablet 15 mg, 30 mg (Remeron) Tier 2

mirtazapine oral tablet 45 mg, 7.5 mg Tier 2

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg

(Remeron SolTab) Tier 2

Maois - Non-Selective & IrreversibleMARPLAN ORAL TABLET 10 MG Tier 3

phenelzine oral tablet 15 mg (Nardil) Tier 2

tranylcypromine oral tablet 10 mg (Parnate) Tier 2Norepinephrine And Dopamine Reuptake Inhib (Ndris)bupropion hcl oral tablet 100 mg, 75 mg Tier 2

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

(Wellbutrin XL) Tier 2

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg

(Wellbutrin SR) Tier 2

Selective Serotonin Reuptake Inhibitor (Ssris)citalopram oral tablet 10 mg, 20 mg, 40 mg

(Celexa) Tier 2

escitalopram oxalate oral solution 5 mg/5 ml

Tier 2

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

(Lexapro) Tier 2

fluoxetine oral capsule 40 mg (Prozac) Tier 2

fluoxetine oral capsule,delayed release(dr/ec) 90 mg

Tier 2

fluoxetine oral solution 20 mg/5 ml (4 mg/ml)

Tier 2


10

Drug Status Notes

fluoxetine oral tablet 10 mg, 20 mg (Sarafem) Tier 2

fluoxetine oral tablet 60 mg Tier 2

fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg


fluvoxamine oral tablet 100 mg, 25 mg, 50 mg

Tier 2

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

(Paxil) Tier 2

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

(Paxil CR) Tier 2

PROZAC ORAL CAPSULE 10 MG, 20 MG

Tier 4

sertraline oral concentrate 20 mg/ml (Zoloft) Tier 2

sertraline oral tablet 100 mg, 25 mg, 50 mg

(Zoloft) Tier 2

Serotonin-2 Antagonist/Reuptake Inhibitors (Saris)nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

Tier 2

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg

Tier 2

Serotonin-Norepinephrine Reuptake-Inhib (Snris)desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg


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

(Pristiq) Tier 2 QL (1 EA per 1 day)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

(Cymbalta) Tier 2 QL (2 EA per 1 day)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

Tier 3 ST; ST: At least 2 prior prescriptions for Bupropion HCL, Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in the last 365 days; QL (1 EA per 1 day)


11

Drug Status Notes

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG


venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

(Effexor XR) Tier 2

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Tier 2

venlafaxine oral tablet extended release 24hr 225 mg, 37.5 mg, 75 mg

Tier 2

Ssri & 5Ht1a Partial Agonist AntidepressantVIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


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


Ssri & Serotonin Receptor Modulator AntidepressantTRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG


Tricyclic Antidepressant/Phenothiazine Combinatnsperphenazine-amitriptyline oral tablet 4-10 mg, 4-50 mg

Tier 2


12

Drug Status Notes

Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhibamitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 2

clomipramine oral capsule 25 mg, 50 mg, 75 mg

(Anafranil) Tier 2

desipramine oral tablet 10 mg, 25 mg (Norpramin) Tier 2

desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg

Tier 2

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 2

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

Tier 2

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

Tier 2

maprotiline oral tablet 25 mg Tier 2

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg

(Pamelor) Tier 2

protriptyline oral tablet 10 mg, 5 mg Tier 2

trimipramine oral capsule 100 mg, 25 mg, 50 mg

Tier 2

Behavioral Health - Other

Adrenergics, Aromatic, Non-Catecholamineamphetamine sulfate oral tablet 10 mg, 5 mg

(Evekeo) Tier 2 PA

dextroamphetamine oral capsule, extended release 10 mg, 5 mg

(Dexedrine Spansule) Tier 2 QL (60 EA per 30 days)

dextroamphetamine oral capsule, extended release 15 mg

(Dexedrine Spansule) Tier 2 QL (120 EA per 30 days)

dextroamphetamine oral solution 5 mg/5 ml

(ProCentra) Tier 2 QL (1800 ML per 30 days)

dextroamphetamine oral tablet 10 mg (Zenzedi) Tier 2 QL (180 EA per 30 days)

dextroamphetamine oral tablet 5 mg (Zenzedi) Tier 2 QL (90 EA per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg

(Adderall XR) Tier 2 QL (1 EA per 1 day)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg

(Adderall XR) Tier 2 QL (2 EA per 1 day)

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

(Adderall) Tier 2 QL (2 EA per 1 day)

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML


methamphetamine oral tablet 5 mg (Desoxyn) Tier 2 QL (150 EA per 30 days)


13

Drug Status Notes

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


ZENZEDI ORAL TABLET 10 MG Tier 2 QL (180 EA per 30 days)

ZENZEDI ORAL TABLET 15 MG Tier 3 QL (3 EA per 1 day)

ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG


ZENZEDI ORAL TABLET 20 MG, 30 MG Tier 3 QL (2 EA per 1 day)

ZENZEDI ORAL TABLET 5 MG Tier 2 QL (90 EA per 30 days)Anti-Alcoholic Preparationsacamprosate oral tablet,delayed release (dr/ec) 333 mg

Tier 2

disulfiram oral tablet 250 mg, 500 mg (Antabuse) Tier 2Anti-Anxiety - BenzodiazepinesALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

Tier 3

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

(Xanax) Tier 2

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

(Xanax XR) Tier 2

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 2

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

Tier 2

clorazepate dipotassium oral tablet 15 mg, 3.75 mg

Tier 2

clorazepate dipotassium oral tablet 7.5 mg

(Tranxene T-Tab) Tier 2

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

Tier 2

diazepam oral concentrate 5 mg/ml (Diazepam Intensol) Tier 2

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

Tier 2

diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) Tier 2

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

Tier 2

lorazepam oral concentrate 2 mg/ml (Lorazepam Intensol) Tier 2

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

(Ativan) Tier 2

oxazepam oral capsule 10 mg, 15 mg, 30 mg

Tier 2

Anti-Anxiety Drugsbuspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

Tier 2

meprobamate oral tablet 200 mg, 400 mg

Tier 2


14

Drug Status Notes

Anti-Mania DrugsEQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

Tier 3

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

Tier 2

lithium carbonate oral tablet 300 mg Tier 2

lithium carbonate oral tablet extended release 300 mg

(Lithobid) Tier 2

lithium carbonate oral tablet extended release 450 mg

Tier 2

lithium citrate oral solution 8 meq/5 ml Tier 2

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

Tier 4

Anti-Narcolepsy & Anti-Cataplexy,Sedative-Type AgtXYREM ORAL SOLUTION 500 MG/ML Tier 5 PA

Antipsych,Dopamine Antag.,Diphenylbutylpiperidinespimozide oral tablet 1 mg, 2 mg Tier 2

Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht MixedVRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

Tier 3 ST; ST: At least 2 prior prescriptions for Abilify Maintena, Abilify Mycite, Aripiprazole, Clozapine, Olanzapine, Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in the last 365 days

Antipsychotics, Atyp, D2 Partial Agonist/5Ht Mixedaripiprazole oral solution 1 mg/ml Tier 2

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

(Abilify) Tier 2

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

Tier 3

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

Tier 4

Antipsychotics, Dopamine & Serotonin AntagonistsADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED 10 MG

Tier 3

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

Tier 2


15

Drug Status Notes

Antipsychotics,Atypical,Dopamine,& Serotonin Antagclozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

(Clozaril) Tier 2

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

Tier 2

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)


LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG


olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

(Zyprexa) Tier 2

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

(Zyprexa Zydis) Tier 2

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg

(Invega) Tier 2

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

(Seroquel) Tier 2

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

(Seroquel XR) Tier 2

risperidone oral solution 1 mg/ml (Risperdal) Tier 2

risperidone oral tablet 0.25 mg Tier 2

risperidone oral tablet 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

(Risperdal) Tier 2

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 2


16

Drug Status Notes

VERSACLOZ ORAL SUSPENSION 50 MG/ML

Tier 3

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

(Geodon) Tier 2

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG

Tier 3

Antipsychotics,Dopamine Antagonists, Thioxanthenesthiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

Tier 2

Antipsychotics,Dopamine Antagonists,Butyrophenoneshaloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

Tier 2

Antipsychotics,Dopamine Antagonst,Dihydroindolonesmolindone oral tablet 10 mg, 25 mg, 5 mg

Tier 2

Anti-Psychotics,Phenothiazinesfluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

Tier 2

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

Tier 2

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

Tier 2

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg

Tier 2

Barbituratesphenobarbital oral tablet 100 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

Tier 2

SECONAL SODIUM ORAL CAPSULE 100 MG

Tier 3

Hypnotics, Melatonin Mt1/Mt2 Receptor AgonistsHETLIOZ ORAL CAPSULE 20 MG Tier 5 PA

Menopausal Symptoms Suppressant - Ssrisparoxetine mesylate(menop.sym) oral capsule 7.5 mg

(Brisdelle) Tier 2 QL (1 EA per 1 day)

Monoamine Oxidase(Mao) InhibitorsEMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR



17

Drug Status Notes

Narcolepsy And Sleep Disorder Therapy Agentsarmodafinil oral tablet 150 mg, 200 mg, 250 mg

(Nuvigil) Tier 2 QL (1 EA per 1 day)

armodafinil oral tablet 50 mg (Nuvigil) Tier 2 QL (3 EA per 1 day)

modafinil oral tablet 100 mg, 200 mg (Provigil) Tier 2 QL (2 EA per 1 day)Narcotic Antagonistsnaloxone injection auto-injector 2 mg/0.4 ml

(Evzio) Tier 2 QL (0.8 ML per 365 days)

naloxone injection solution 0.4 mg/ml Tier 2

naltrexone oral tablet 50 mg Tier 2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


Sedative-Hypnotics - Benzodiazepinesestazolam oral tablet 1 mg, 2 mg Tier 2

quazepam oral tablet 15 mg (Doral) Tier 2

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

(Restoril) Tier 2

triazolam oral tablet 0.125 mg Tier 2

triazolam oral tablet 0.25 mg (Halcion) Tier 2Sedative-Hypnotics,Non-BarbiturateBELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

Tier 4 ST; ST: Prior prescription for Eszopiclone, Zaleplon, or Zolpidem Tartrate in the last 120 days; QL (1 EA per 1 day)

eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) Tier 2 QL (1 EA per 1 day)

SILENOR ORAL TABLET 3 MG, 6 MG Tier 3 QL (1 EA per 1 day)

zaleplon oral capsule 10 mg, 5 mg Tier 2 QL (1 EA per 1 day)

zolpidem oral tablet 10 mg, 5 mg (Ambien) Tier 2 QL (1 EA per 1 day)

zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg

(Ambien CR) Tier 2 QL (1 EA per 1 day)

zolpidem sublingual tablet 1.75 mg, 3.5 mg

(Intermezzo) Tier 2 QL (1 EA per 1 day)

Ssri &Antipsych,Atyp,Dopamine&Serotonin Antag Combolanzapine-fluoxetine oral capsule 12-25 mg

Tier 2

olanzapine-fluoxetine oral capsule 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

(Symbyax) Tier 2

Tx For Adhd - Selective Alpha-2A Receptor Agonistclonidine hcl oral tablet extended release 12 hr 0.1 mg

(Kapvay) Tier 2 QL (120 EA per 30 days)

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

(Intuniv ER) Tier 2 QL (1 EA per 1 day)


18

Drug Status Notes

Tx For Attention Deficit-Hyperact(Adhd)/NarcolepsyAPTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

(Focalin XR) Tier 2 QL (1 EA per 1 day)

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

(Focalin) Tier 2 QL (2 EA per 1 day)

METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG


methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl oral capsule, er biphasic 30-70 30 mg


methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 40 mg

(Ritalin LA) Tier 2 QL (1 EA per 1 day)

methylphenidate hcl oral capsule,er biphasic 50-50 30 mg

(Ritalin LA) Tier 2 QL (2 EA per 1 day)

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml

(Methylin) Tier 2

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

(Ritalin) Tier 2 QL (90 EA per 30 days)

methylphenidate hcl oral tablet extended release 10 mg


methylphenidate hcl oral tablet extended release 20 mg

(Metadate ER) Tier 2 QL (90 EA per 30 days)

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

(Concerta) Tier 2 QL (1 EA per 1 day)

methylphenidate hcl oral tablet extended release 24hr 36 mg

(Concerta) Tier 2 QL (2 EA per 1 day)

methylphenidate hcl oral tablet,chewable10 mg, 2.5 mg, 5 mg


QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)

Tier 3

Tx For Attention Deficit-Hyperact.(Adhd), Nri-Typeatomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

(Strattera) Tier 2 QL (60 EA per 30 days)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

(Strattera) Tier 2 QL (30 EA per 30 days)

Cardiovascular Disease - Arrhythmia

Antiarrhythmicsamiodarone oral tablet 100 mg, 200 mg, 400 mg

(Pacerone) Tier 2


19

Drug Status Notes

disopyramide phosphate oral capsule100 mg, 150 mg

(Norpace) Tier 2

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

(Tikosyn) Tier 2

flecainide oral tablet 100 mg, 150 mg, 50 mg

Tier 2

mexiletine oral capsule 150 mg, 200 mg, 250 mg

Tier 2

MULTAQ ORAL TABLET 400 MG Tier 4

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG

Tier 3

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

Tier 2

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg

(Rythmol SR) Tier 2

propafenone oral tablet 150 mg, 225 mg, 300 mg

Tier 2

quinidine gluconate oral tablet extended release 324 mg

Tier 2

quinidine sulfate oral tablet 200 mg, 300 mg

Tier 2

Cardiovascular Disease - Cardiac Stimulant

Adrenergic Agents,Catecholaminesepinephrine injection syringe 0.1 mg/ml Tier 2

Digitalis GlycosidesDIGITEK ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG)

Tier 2

DIGOX ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG)

Tier 2

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg)

(Digitek) Tier 2

LANOXIN ORAL TABLET 125 MCG (0.125 MG), 187.5 MCG (0.1875 MG), 250 MCG (0.25 MG)

Tier 4

LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG)

Tier 3

Cardiovascular Disease - Hypertension

Ace Inhibitor/Calcium Channel Blocker Combinationamlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

(Lotrel) Tier 1

amlodipine-benazepril oral capsule 2.5-10 mg

Tier 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg

Tier 2


20

Drug Status Notes

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

(Tarka) Tier 2

Ace Inhibitor/Thiazide & Thiazide-Like Diureticbenazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

(Lotensin HCT) Tier 1

benazepril-hydrochlorothiazide oral tablet 5-6.25 mg

Tier 1

captopril-hydrochlorothiazide oral tablet25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

Tier 1

enalapril-hydrochlorothiazide oral tablet10-25 mg

(Vaseretic) Tier 1

enalapril-hydrochlorothiazide oral tablet5-12.5 mg

Tier 1

fosinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg

Tier 1

lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg

(Zestoretic) Tier 1

quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg

(Accuretic) Tier 1

Alpha/Beta-Adrenergic Blocking Agentscarvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

(Coreg) Tier 2

carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg

(Coreg CR) Tier 2

labetalol oral tablet 100 mg, 200 mg, 300 mg

Tier 2

Alpha-Adrenergic Blocking AgentsCARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG

Tier 3

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg

(Cardura) Tier 2

phenoxybenzamine oral capsule 10 mg (Dibenzyline) Tier 2

prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Tier 2

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

Tier 2

Angioten.Receptr Antag./Cal.Chanl Blkr/Thiazide Cbamlodipine-valsartan-hcthiazid oral tablet10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

(Exforge HCT) Tier 2

olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

(Tribenzor) Tier 2


21

Drug Status Notes

Angiotensin Receptor Antag./Thiazide Diuretic Combcandesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

(Atacand HCT) Tier 2

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

Tier 4

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

Tier 4

irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg

(Avalide) Tier 1

losartan-hydrochlorothiazide oral tablet100-12.5 mg, 100-25 mg, 50-12.5 mg

(Hyzaar) Tier 1

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

(Benicar HCT) Tier 2

telmisartan-hydrochlorothiazid oral tablet40-12.5 mg, 80-12.5 mg, 80-25 mg

(Micardis HCT) Tier 2

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

(Diovan HCT) Tier 1

Angiotensin Receptor Antgnst & Calc.Channel Blockramlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

(Azor) Tier 2

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

(Exforge) Tier 1

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

(Twynsta) Tier 2

Antihypertensives, Ace Inhibitorsbenazepril oral tablet 10 mg, 20 mg, 40 mg

(Lotensin) Tier 1

benazepril oral tablet 5 mg Tier 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

Tier 2

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

(Vasotec) Tier 1

fosinopril oral tablet 10 mg, 20 mg, 40 mg

Tier 1

lisinopril oral tablet 10 mg, 20 mg (Prinivil) Tier 1

lisinopril oral tablet 2.5 mg, 30 mg, 40 mg, 5 mg

(Zestril) Tier 1

moexipril oral tablet 15 mg, 7.5 mg Tier 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

Tier 1

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

(Accupril) Tier 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

(Altace) Tier 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1


22

Drug Status Notes

Antihypertensives, Angiotensin Receptor Antagonistcandesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg

(Atacand) Tier 2

EDARBI ORAL TABLET 40 MG, 80 MG Tier 4

eprosartan oral tablet 600 mg Tier 2

irbesartan oral tablet 150 mg, 300 mg, 75 mg

(Avapro) Tier 1

losartan oral tablet 100 mg, 25 mg, 50 mg

(Cozaar) Tier 1

olmesartan oral tablet 20 mg, 40 mg, 5 mg

(Benicar) Tier 2

telmisartan oral tablet 20 mg, 40 mg, 80 mg

(Micardis) Tier 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

(Diovan) Tier 1

Antihypertensives, Ganglionic BlockersVECAMYL ORAL TABLET 2.5 MG Tier 3 PA

Antihypertensives, MiscellaneousDEMSER ORAL CAPSULE 250 MG Tier 3

Antihypertensives, Sympatholyticclonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

(Catapres) Tier 2

clonidine transdermal patch weekly 0.1 mg/24 hr

(Catapres-TTS-1) Tier 2





guanfacine oral tablet 1 mg, 2 mg Tier 2

methyldopa oral tablet 250 mg, 500 mg Tier 2Antihypertensives, Vasodilatorshydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 2

minoxidil oral tablet 10 mg, 2.5 mg Tier 2Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg, 400 mg Tier 2

atenolol oral tablet 100 mg, 25 mg, 50 mg

(Tenormin) Tier 2

betaxolol oral tablet 10 mg, 20 mg Tier 2

bisoprolol fumarate oral tablet 10 mg, 5 mg

Tier 2

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

Tier 4

HEMANGEOL ORAL SOLUTION 4.28 MG/ML

Tier 2


23

Drug Status Notes

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

(Toprol XL) Tier 2

metoprolol tartrate oral tablet 100 mg, 50 mg

(Lopressor) Tier 2

metoprolol tartrate oral tablet 25 mg, 75 mg

Tier 2

nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) Tier 2

pindolol oral tablet 10 mg, 5 mg Tier 2

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg

(Inderal LA) Tier 2

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Tier 2

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

Tier 2

SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG

Tier 2

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

(Sorine) Tier 2

SOTYLIZE ORAL SOLUTION 5 MG/ML Tier 3

timolol maleate oral tablet 20 mg Tier 2Beta-Adrenergic Blocking Agents/Thiazide & Relatedatenolol-chlorthalidone oral tablet 100-25 mg

(Tenoretic 100) Tier 2

atenolol-chlorthalidone oral tablet 50-25 mg

(Tenoretic 50) Tier 2

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

(Ziac) Tier 2

metoprolol ta-hydrochlorothiaz oral tablet100-25 mg, 100-50 mg

Tier 2

metoprolol ta-hydrochlorothiaz oral tablet50-25 mg

(Lopressor HCT) Tier 2

nadolol-bendroflumethiazide oral tablet80-5 mg

Tier 2

Calcium Channel Blocking Agentsamlodipine oral tablet 10 mg, 2.5 mg, 5 mg

(Norvasc) Tier 2

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

Tier 4

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG

Tier 2

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg

Tier 2


24

Drug Status Notes

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

(Taztia XT) Tier 2

diltiazem hcl oral capsule,extended release 24 hr 420 mg

(Tiadylt ER) Tier 2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

(Cartia XT) Tier 2

diltiazem hcl oral capsule,extended release 24hr 360 mg

(Cardizem CD) Tier 2

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg

(Cardizem) Tier 2

diltiazem hcl oral tablet 90 mg Tier 2

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

(Matzim LA) Tier 2

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG

Tier 2

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg

Tier 2

isradipine oral capsule 2.5 mg, 5 mg Tier 2

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

Tier 2

nicardipine oral capsule 20 mg, 30 mg Tier 2

nifedipine oral capsule 10 mg (Procardia) Tier 2

nifedipine oral capsule 20 mg Tier 2

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

(Procardia XL) Tier 2

nifedipine oral tablet extended release30 mg, 60 mg, 90 mg

(Adalat CC) Tier 2

nisoldipine oral tablet extended release 24 hr 17 mg, 34 mg, 8.5 mg

(Sular) Tier 2

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

Tier 2

TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

Tier 2

verapamil oral capsule, 24 hr er pellet ct100 mg, 200 mg, 300 mg

(Verelan PM) Tier 2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg

(Verelan) Tier 2

verapamil oral tablet 120 mg, 40 mg, 80 mg

Tier 2


25

Drug Status Notes

verapamil oral tablet extended release120 mg, 180 mg, 240 mg

(Calan SR) Tier 2

Loop Diureticsbumetanide oral tablet 0.5 mg, 1 mg, 2 mg

Tier 2

ethacrynic acid oral tablet 25 mg (Edecrin) Tier 2

furosemide oral solution 10 mg/ml Tier 2

furosemide oral tablet 20 mg, 40 mg, 80 mg

(Lasix) Tier 2

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

Tier 2

Potassium Sparing Diureticsamiloride oral tablet 5 mg Tier 2

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

Tier 3

eplerenone oral tablet 25 mg, 50 mg (Inspra) Tier 2

spironolactone oral tablet 100 mg, 25 mg, 50 mg

(Aldactone) Tier 2

Potassium Sparing Diuretics In CombinationALDACTAZIDE ORAL TABLET 50-50 MG

Tier 4

amiloride-hydrochlorothiazide oral tablet5-50 mg

Tier 2

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

(Aldactazide) Tier 2

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

(Dyazide) Tier 2

triamterene-hydrochlorothiazid oral tablet37.5-25 mg

(Maxzide-25mg) Tier 2

triamterene-hydrochlorothiazid oral tablet75-50 mg

(Maxzide) Tier 2

Pulm Anti-Htn,Soluble Guanylate Cyclase StimulatorADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

Tier 5 PA

Pulm.Anti-Htn,Sel.C-Gmp Phosphodiesterase T5 InhibALYQ ORAL TABLET 20 MG Tier 5 PA

sildenafil (pulm.hypertension) oral suspension for reconstitution 10 mg/ml

(Revatio) Tier 2 PA

sildenafil (pulm.hypertension) oral tablet20 mg

(Revatio) Tier 2 PA

tadalafil (pulm. hypertension) oral tablet20 mg

(Alyq) Tier 5 PA

Pulmonary Anti-Htn, Endothelin Receptor Antagonistambrisentan oral tablet 10 mg, 5 mg (Letairis) Tier 5 PA


26

Drug Status Notes

bosentan oral tablet 125 mg, 62.5 mg (Tracleer) Tier 5 PA

LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 5 PA

OPSUMIT ORAL TABLET 10 MG Tier 5 PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG

Tier 5 PA

Pulmonary Antihypertensives, Prostacyclin-TypeORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

Tier 5 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier 3 PA

TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

Tier 5 PA

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

Tier 5 PA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

Tier 5 PA

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

Tier 5 PA

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

Tier 5 PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)

Tier 5 PA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML

Tier 5 PA

Renin Inhibitor, Directaliskiren oral tablet 150 mg, 300 mg (Tekturna) Tier 2

Thiazide And Related Diureticschlorothiazide oral tablet 500 mg Tier 2

chlorthalidone oral tablet 25 mg, 50 mg Tier 2

DIURIL ORAL SUSPENSION 250 MG/5 ML

Tier 3

hydrochlorothiazide oral capsule 12.5 mg

Tier 2

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Tier 2

indapamide oral tablet 1.25 mg, 2.5 mg Tier 2

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

Tier 2


27

Drug Status Notes

Vasodilators, CombinationBIDIL ORAL TABLET 20-37.5 MG Tier 3

Cardiovascular Disease - Lipid Irregularity

Antihyperlip.Hmg Coa Reduct Inhib&Cholest.Ab.Inhibezetimibe-simvastatin oral tablet 10-10 mg

(Vytorin 10-10) Tier 2 QL (1 EA per 1 day)

ezetimibe-simvastatin oral tablet 10-20 mg






Antihyperlipidemic - Hmg Coa Reductase Inhibitorsatorvastatin oral tablet 10 mg, 20 mg (Lipitor) Tier 1 $0 COPAY IF AGE 40-75

YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

atorvastatin oral tablet 40 mg, 80 mg (Lipitor) Tier 1 QL (1 EA per 1 day)

EZALLOR SPRINKLE ORAL CAPSULE, SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG


fluvastatin oral capsule 20 mg, 40 mg (Lescol) Tier 2 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (2 EA per 1 day)

fluvastatin oral tablet extended release 24 hr 80 mg

(Lescol XL) Tier 2 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

Tier 4 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)


28

Drug Status Notes

lovastatin oral tablet 10 mg, 20 mg, 40 mg

Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (2 EA per 1 day)

pravastatin oral tablet 10 mg, 80 mg Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

pravastatin oral tablet 20 mg, 40 mg (Pravachol) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

rosuvastatin oral tablet 10 mg, 5 mg (Crestor) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

rosuvastatin oral tablet 20 mg, 40 mg (Crestor) Tier 1 QL (1 EA per 1 day)

simvastatin oral tablet 10 mg, 20 mg, 40 mg

(Zocor) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

simvastatin oral tablet 5 mg Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF SECONDARY CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

simvastatin oral tablet 80 mg (Zocor) Tier 1 QL (1 EA per 1 day)Antihyperlipidemic - Mtp InhibitorJUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

Tier 5 PA

Antihyperlipidemic - Pcsk9 InhibitorsPRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML

Tier 3 PA


29

Drug Status Notes

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML

Tier 3 PA

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML

Tier 3 PA

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML

Tier 5 PA

Bile Salt Sequestrantscholestyramine (with sugar) oral powder4 gram

(Questran) Tier 2

cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) Tier 2

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM

Tier 2

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM

Tier 2

colesevelam oral powder in packet 3.75 gram

(WelChol) Tier 2

colesevelam oral tablet 625 mg (WelChol) Tier 2

COLESTID FLAVORED ORAL PACKET 7.5 GRAM

Tier 4

colestipol oral granules 5 gram (Colestid) Tier 2

colestipol oral packet 5 gram (Colestid) Tier 2

colestipol oral tablet 1 gram (Colestid) Tier 2

PREVALITE ORAL POWDER 4 GRAM Tier 2

PREVALITE ORAL POWDER IN PACKET 4 GRAM

Tier 2

Lipotropicsezetimibe oral tablet 10 mg (Zetia) Tier 2 QL (1 EA per 1 day)

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 2

fenofibrate nanocrystallized oral tablet145 mg, 48 mg

(Tricor) Tier 2

fenofibrate oral capsule 150 mg, 50 mg (Lipofen) Tier 2

fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) Tier 2

fenofibrate oral tablet 160 mg, 54 mg Tier 2

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

(Trilipix) Tier 2

fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) Tier 2

gemfibrozil oral tablet 600 mg (Lopid) Tier 2

niacin oral tablet extended release 24 hr1,000 mg, 500 mg, 750 mg

(Niaspan Extended-Release)

Tier 2

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza) Tier 2 QL (4 EA per 1 day)

TRIGLIDE ORAL TABLET 160 MG Tier 4

VASCEPA ORAL CAPSULE 0.5 GRAM Tier 4 QL (8 EA per 1 day)


30

Drug Status Notes

VASCEPA ORAL CAPSULE 1 GRAM Tier 4 QL (4 EA per 1 day)Cardiovascular Disease - Miscellaneous Agents

Adrenergic Vasopressor Agentsmidodrine oral tablet 10 mg, 2.5 mg, 5 mg

Tier 2

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

Tier 5 PA

Angiotensin Recept-Neprilysin Inhibitor Comb(Arni)ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

Tier 3

Antianginal & Anti-Ischemic Agents,Non-Hemodynamicranolazine oral tablet extended release 12 hr 1,000 mg

(Ranexa) Tier 2 QL (60 EA per 30 days)

ranolazine oral tablet extended release 12 hr 500 mg

(Ranexa) Tier 2 QL (120 EA per 30 days)

Antianginal, Heart Rate Reducing, I(F) InhibitorCORLANOR ORAL SOLUTION 5 MG/5 ML

Tier 3 PA

CORLANOR ORAL TABLET 5 MG, 7.5 MG

Tier 3 PA

Antihyperlip - Hmg-Coa&Calcium Channel Blocker Cbamlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

(Caduet) Tier 2 QL (1 EA per 1 day)

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg


Protein StabilizersVYNDAMAX ORAL CAPSULE 61 MG Tier 5 PA

VYNDAQEL ORAL CAPSULE 20 MG Tier 5 PACardiovascular Disease - Vasodilation

Vasodilators,CoronaryDILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG

Tier 3

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg

Tier 2

isosorbide dinitrate oral tablet 40 mg (Isordil) Tier 2

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) Tier 2

isosorbide dinitrate oral tablet extended release 40 mg

(ISOCHRON) Tier 2

isosorbide mononitrate oral tablet 10 mg, 20 mg

Tier 2


31

Drug Status Notes

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

Tier 2

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

Tier 2

NITRO-BID TRANSDERMAL OINTMENT 2 %

Tier 3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

Tier 3

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

(Nitrostat) Tier 2

nitroglycerin transdermal patch 24 hour0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

(Minitran) Tier 2

nitroglycerin translingual spray,non-aerosol 400 mcg/spray

(Nitrolingual) Tier 2

NITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 MCG/SPRAY

Tier 4

NITRO-TIME ORAL CAPSULE, EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG

Tier 2

Vasodilators,Peripheralisoxsuprine oral tablet 10 mg, 20 mg Tier 2

Contraception/Oxytocics

Contraceptives, Intravaginal, SystemicELURYNG VAGINAL RING 0.12-0.015 MG/24 HR


etonogestrel-ethinyl estradiol vaginal ring0.12-0.015 mg/24 hr

(EluRyng) Tier 2 QL (1 EA per 28 days)

Contraceptives,InjectableDEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

Tier 2 QL (0.65 ML per 84 days)

medroxyprogesterone intramuscular suspension 150 mg/ml

(Depo-Provera) Tier 2 QL (1 ML per 84 days)

medroxyprogesterone intramuscular syringe 150 mg/ml

(Depo-Provera) Tier 2 QL (1 ML per 84 days)

Contraceptives,OralAFIRMELLE ORAL TABLET 0.1-20 MG-MCG

Tier 2

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG

Tier 2

ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 2

ALYACEN 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

Tier 2


32

Drug Status Notes

AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)


AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


AMETHYST (28) ORAL TABLET 90-20 MCG (28)

Tier 2

APRI ORAL TABLET 0.15-0.03 MG Tier 2

ARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

Tier 2

ASHLYNA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


AUBRA EQ ORAL TABLET 0.1-20 MG-MCG

Tier 2

AUBRA ORAL TABLET 0.1-20 MG-MCG Tier 2

AUROVELA 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 2

AUROVELA 1/20 (21) ORAL TABLET 1-20 MG-MCG

Tier 2

AUROVELA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2

AUROVELA FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

Tier 2

AUROVELA FE 1-20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

AVIANE ORAL TABLET 0.1-20 MG-MCG

Tier 2

AYUNA ORAL TABLET 0.15-0.03 MG Tier 2

AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG

Tier 2

BEKYREE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

Tier 2

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

BRIELLYN ORAL TABLET 0.4-35 MG-MCG

Tier 2

CAMILA ORAL TABLET 0.35 MG Tier 2


33

Drug Status Notes

CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)


CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

Tier 2

CHATEAL (28) ORAL TABLET 0.15-0.03 MG

Tier 2

CHATEAL EQ (28) ORAL TABLET 0.15-0.03 MG

Tier 2

CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG

Tier 2

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 2

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

Tier 2

CYRED EQ ORAL TABLET 0.15-0.03 MG

Tier 2

CYRED ORAL TABLET 0.15-0.03 MG Tier 2

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 2

DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

Tier 2

DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


DEBLITANE ORAL TABLET 0.35 MG Tier 2

desog-e.estradiol/e.estradiol oral tablet0.15-0.02 mgx21 /0.01 mg x 5

(Azurette (28)) Tier 2

desogestrel-ethinyl estradiol oral tablet0.15-0.03 mg

(Apri) Tier 2

drospirenone-e.estradiol-lm.fa oral tablet3-0.02-0.451 mg (24) (4)

(Beyaz) Tier 2

drospirenone-e.estradiol-lm.fa oral tablet3-0.03-0.451 mg (21) (7)

(Tydemy) Tier 2

drospirenone-ethinyl estradiol oral tablet3-0.02 mg

(Gianvi (28)) Tier 2

drospirenone-ethinyl estradiol oral tablet3-0.03 mg

(Ocella) Tier 2

ELINEST ORAL TABLET 0.3-30 MG-MCG

Tier 2

ELLA ORAL TABLET 30 MG Tier 3

EMOQUETTE ORAL TABLET 0.15-0.03 MG

Tier 2

ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

Tier 2


34

Drug Status Notes

ENSKYCE ORAL TABLET 0.15-0.03 MG

Tier 2

ERRIN ORAL TABLET 0.35 MG Tier 2

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

Tier 2

ethynodiol diac-eth estradiol oral tablet1-35 mg-mcg

(Kelnor 1/35 (28)) Tier 2

ethynodiol diac-eth estradiol oral tablet1-50 mg-mcg

(Kelnor 1-50) Tier 2

FALMINA (28) ORAL TABLET 0.1-20 MG-MCG

Tier 2

FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

Tier 2

FEMYNOR ORAL TABLET 0.25-35 MG-MCG

Tier 2

GIANVI (28) ORAL TABLET 3-0.02 MG Tier 2

HAILEY 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2

HAILEY FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

HAILEY ORAL TABLET 1.5-30 MG-MCG

Tier 2

HEATHER ORAL TABLET 0.35 MG Tier 2

INCASSIA ORAL TABLET 0.35 MG Tier 2

INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


ISIBLOOM ORAL TABLET 0.15-0.03 MG

Tier 2

JAIMIESS ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


JASMIEL (28) ORAL TABLET 3-0.02 MG

Tier 2

JENCYCLA ORAL TABLET 0.35 MG Tier 2

JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


JULEBER ORAL TABLET 0.15-0.03 MG Tier 2

JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 2

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG

Tier 2

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

Tier 2

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2


35

Drug Status Notes

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

Tier 2

KALLIGA ORAL TABLET 0.15-0.03 MG Tier 2

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 2

KELNOR 1-50 ORAL TABLET 1-50 MG-MCG

Tier 2

KURVELO (28) ORAL TABLET 0.15-0.03 MG

Tier 2

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

(Amethia Lo) Tier 2 QL (91 EA per 84 days)

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

(Fayosim) Tier 2

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

(Amethia) Tier 2 QL (91 EA per 84 days)

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 2

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

Tier 2

LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

Tier 2

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

LARISSIA ORAL TABLET 0.1-20 MG-MCG

Tier 2

LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

Tier 2

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG

Tier 2

LESSINA ORAL TABLET 0.1-20 MG-MCG

Tier 2

LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

Tier 2

levonorgestrel-ethinyl estrad oral tablet0.1-20 mg-mcg

(Afirmelle) Tier 2

levonorgestrel-ethinyl estrad oral tablet0.15-0.03 mg

(Altavera (28)) Tier 2

levonorgestrel-ethinyl estrad oral tablet90-20 mcg (28)

(Amethyst (28)) Tier 2


36

Drug Status Notes

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

(Introvale) Tier 2 QL (91 EA per 84 days)

levonorg-eth estrad triphasic oral tablet50-30 (6)/75-40 (5)/125-30(10)

(Enpresse) Tier 2

LEVORA-28 ORAL TABLET 0.15-0.03 MG

Tier 2

LILLOW (28) ORAL TABLET 0.15-0.03 MG

Tier 2

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2)

Tier 3

LOJAIMIESS ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)


LORYNA (28) ORAL TABLET 3-0.02 MG

Tier 2

LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG

Tier 2

LO-ZUMANDIMINE (28) ORAL TABLET 3-0.02 MG

Tier 2

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG

Tier 2

LYZA ORAL TABLET 0.35 MG Tier 2

MARLISSA (28) ORAL TABLET 0.15-0.03 MG

Tier 2

MELODETTA 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

Tier 2

MIBELAS 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

Tier 2

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 2

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

Tier 2

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

Tier 2

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

MILI ORAL TABLET 0.25-35 MG-MCG Tier 2

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG

Tier 2

NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG

Tier 3

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

Tier 2

NIKKI (28) ORAL TABLET 3-0.02 MG Tier 2


37

Drug Status Notes

NORA-BE ORAL TABLET 0.35 MG Tier 2

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

(Wymzya Fe) Tier 2

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

(Kaitlib Fe) Tier 2

norethindrone (contraceptive) oral tablet0.35 mg

(Camila) Tier 2

norethindrone ac-eth estradiol oral tablet1.5-30 mg-mcg

(Aurovela 1.5/30 (21)) Tier 2

norethindrone ac-eth estradiol oral tablet1-20 mg-mcg

(Aurovela 1/20 (21)) Tier 2

norethindrone-e.estradiol-iron oral tablet1 mg-20 mcg (21)/75 mg (7)

(Aurovela Fe 1-20 (28)) Tier 2

norethindrone-e.estradiol-iron oral tablet1.5 mg-30 mcg (21)/75 mg (7)

(Aurovela Fe 1.5/30 (28)) Tier 2

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

(Melodetta 24 Fe) Tier 2

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg

(Tri-Lo-Estarylla) Tier 2

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-35 mcg (28)

(Tri Femynor) Tier 2

norgestimate-ethinyl estradiol oral tablet0.25-35 mg-mcg

(Estarylla) Tier 2

NORLYDA ORAL TABLET 0.35 MG Tier 2

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

Tier 2

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21)

Tier 2

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 2

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

Tier 2

OCELLA ORAL TABLET 3-0.03 MG Tier 2

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG

Tier 2

PHILITH ORAL TABLET 0.4-35 MG-MCG

Tier 2

PIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG

Tier 2

PORTIA 28 ORAL TABLET 0.15-0.03 MG

Tier 2

PREVIFEM ORAL TABLET 0.25-35 MG-MCG

Tier 2


38

Drug Status Notes

RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG

Tier 2

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

Tier 2

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


SHAROBEL ORAL TABLET 0.35 MG Tier 2

SIMLIYA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

SIMPESSE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)


SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG

Tier 2

SRONYX ORAL TABLET 0.1-20 MG-MCG

Tier 2

SYEDA ORAL TABLET 3-0.03 MG Tier 2

TARINA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

Tier 2

TARINA FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

TARINA FE 1-20 EQ (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

Tier 2

TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

Tier 2

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

Tier 2

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2

TRI-LO-MARZIA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2

TRI-LO-MILI ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2

TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2


39

Drug Status Notes

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

Tier 2

TRI-VYLIBRA LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

Tier 2

TULANA ORAL TABLET 0.35 MG Tier 2

TYDEMY ORAL TABLET 3-0.03-0.451 MG (21) (7)

Tier 2

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

Tier 2

VIENVA ORAL TABLET 0.1-20 MG-MCG

Tier 2

VIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

VOLNEA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

Tier 2

VYFEMLA (28) ORAL TABLET 0.4-35 MG-MCG

Tier 2

VYLIBRA ORAL TABLET 0.25-35 MG-MCG

Tier 2

WERA (28) ORAL TABLET 0.5-35 MG-MCG

Tier 2

WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

Tier 2

ZARAH ORAL TABLET 3-0.03 MG Tier 2

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

Tier 2

ZUMANDIMINE (28) ORAL TABLET 3-0.03 MG

Tier 2

Contraceptives,TransdermalXULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR


OxytocicsCERVIDIL VAGINAL INSERT, EXTENDED RELEASE 10 MG

Tier 3

methylergonovine oral tablet 0.2 mg (Methergine) Tier 2

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG

Tier 3

Cough And Cold

1St Gen Antihistamine & Decongestant Combinationspromethazine-phenylephrine oral syrup6.25-5 mg/5 ml

(Promethazine VC) Tier 2

Antitussives,Non-Narcoticbenzonatate oral capsule 100 mg (Tessalon Perles) Tier 2


40

Drug Status Notes

benzonatate oral capsule 200 mg Tier 2Narcotic Antituss-1St Gen. Antihistamine-Decongestpromethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5 ml

Tier 2

Narcotic Antitussive-1St Generation Antihistaminehydrocodone-chlorpheniramine oral suspension,extended rel 12 hr 10-8 mg/5 ml

Tier 2

promethazine-codeine oral syrup 6.25-10 mg/5 ml

Tier 2

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR 10-8 MG

Tier 3

Narcotic Antitussive-Anticholinergic Comb.hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

(Hydromet) Tier 2

hydrocodone-homatropine oral tablet 5-1.5 mg

Tier 2

HYDROMET ORAL SYRUP 5-1.5 MG/5 ML

Tier 2

Narcotic Antitussive-Expectorant Combinationcodeine-guaifenesin oral liquid 10-100 mg/5 ml

(G Tussin AC) Tier 2

G TUSSIN AC ORAL LIQUID 10-100 MG/5 ML

Tier 2

GUAIATUSSIN AC ORAL LIQUID 10-100 MG/5 ML

Tier 2

GUAIFENESIN AC ORAL LIQUID 10-100 MG/5 ML

Tier 2

M-CLEAR WC ORAL LIQUID 6.3-100 MG/5 ML

Tier 4

VIRTUSSIN AC ORAL LIQUID 10-100 MG/5 ML

Tier 2

Non-Narc Antituss-1St Gen. Antihistamine-DecongestBROMFED DM ORAL SYRUP 2-30-10 MG/5 ML

Tier 2

brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg/5 ml

(Bromfed DM) Tier 2

Non-Narc Antitussive-1St Gen Antihistamine Comb.promethazine-dm oral syrup 6.25-15 mg/5 ml

Tier 2


41

Drug Status Notes

Nose Preparations, Vasoconstrictors (Rx)ADRENALIN NASAL SOLUTION 1 MG/ML

Tier 3

Dermatology - Acne

Acne Agents,SystemicAMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG

Tier 2 Age (Max 35 Years)

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG


isotretinoin oral capsule 10 mg, 20 mg, 40 mg

(Amnesteem) Tier 2 Age (Max 35 Years)

isotretinoin oral capsule 30 mg (Claravis) Tier 2 Age (Max 35 Years)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG


ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG


Acne Agents,TopicalAZELEX TOPICAL CREAM 20 % Tier 3 Age (Max 35 Years)

clindamycin-benzoyl peroxide topical gel1.2 %(1 % base) -5 %

(Neuac) Tier 2 Age (Max 35 Years)

clindamycin-benzoyl peroxide topical gel1-5 %

(Benzaclin) Tier 2 Age (Max 35 Years)

dapsone topical gel 5 % (Aczone) Tier 2

dapsone topical gel with pump 7.5 % (Aczone) Tier 2 Age (Max 35 Years)

NEUAC TOPICAL GEL 1.2 %(1 % BASE) -5 %


sulfacetamide sodium (acne) topical suspension 10 %

(Klaron) Tier 2 Age (Max 35 Years)

Keratolytic-Glucocorticoid CombinationsVANOXIDE-HC TOPICAL SUSPENSION 5-0.5 %


Rosacea Agents, Topicalazelaic acid topical gel 15 % (Finacea) Tier 2

ivermectin topical cream 1 % (Soolantra) Tier 2

metronidazole topical cream 0.75 % (Rosadan) Tier 2

metronidazole topical gel 0.75 % (Rosadan) Tier 2

metronidazole topical gel 1 % (Metrogel) Tier 2

metronidazole topical gel with pump 1 % (Metrogel) Tier 2

metronidazole topical lotion 0.75 % (MetroLotion) Tier 2

MIRVASO TOPICAL GEL 0.33 % Tier 3

MIRVASO TOPICAL GEL WITH PUMP 0.33 %

Tier 3

ROSADAN TOPICAL CREAM 0.75 % Tier 2Topical Preparations,AntibacterialsALA-QUIN TOPICAL CREAM 3-0.5 % Tier 3


42

Drug Status Notes

hydrocortisone-iodoquinol topical cream1-1 %

Tier 2

hydrocortisone-iodoquinol-aloe topical cream in packet 1.9-1 %

(Vytone) Tier 2

IODOFLEX TOPICAL PADS, MEDICATED 0.9 %

Tier 3

Vitamin A Derivativesadapalene topical cream 0.1 % (Differin) Tier 2 Age (Max 35 Years)

adapalene topical gel 0.1 %, 0.3 % (Differin) Tier 2 Age (Max 35 Years)

adapalene topical gel with pump 0.3 % (Differin) Tier 2 Age (Max 35 Years)

adapalene topical lotion 0.1 % (Differin) Tier 2 Age (Max 35 Years)

AKLIEF TOPICAL CREAM 0.005 % Tier 5

AVITA TOPICAL CREAM 0.025 % Tier 2 Age (Max 35 Years)

AVITA TOPICAL GEL 0.025 % Tier 2 Age (Max 35 Years)

DIFFERIN TOPICAL LOTION 0.1 % Tier 4 Age (Max 35 Years)

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %


tretinoin microspheres topical gel 0.04 %, 0.1 %

(Retin-A Micro) Tier 2 Age (Max 35 Years)

tretinoin microspheres topical gel with pump 0.04 %, 0.1 %

(Retin-A Micro Pump) Tier 2 Age (Max 35 Years)

tretinoin topical cream 0.025 % (Avita) Tier 2 Age (Max 35 Years)

tretinoin topical cream 0.05 %, 0.1 % (Retin-A) Tier 2 Age (Max 35 Years)

tretinoin topical gel 0.01 % (Retin-A) Tier 2 Age (Max 35 Years)

tretinoin topical gel 0.025 % (Avita) Tier 2 Age (Max 35 Years)

tretinoin topical gel 0.05 % (Atralin) Tier 2 Age (Max 35 Years)

TRETIN-X TOPICAL CREAM 0.075 % Tier 3 Age (Max 35 Years)Dermatology - Antiinfective

Topical AntibioticsCENTANY AT TOPICAL OINTMENT KIT 2 %

Tier 3

clindamycin phosphate topical foam 1 % (Evoclin) Tier 2 Age (Max 35 Years)

clindamycin phosphate topical gel 1 % (Cleocin T) Tier 2 Age (Max 35 Years)

clindamycin phosphate topical gel, once daily 1 %

(Clindagel) Tier 2 Age (Max 35 Years)

clindamycin phosphate topical lotion 1 % (Cleocin T) Tier 2 Age (Max 35 Years)

clindamycin phosphate topical solution 1 %

(Cleocin T) Tier 2 Age (Max 35 Years)

clindamycin phosphate topical swab 1 % (Clindacin ETZ) Tier 2 Age (Max 35 Years)

ERY PADS TOPICAL SWAB 2 % Tier 2 Age (Max 35 Years)

erythromycin with ethanol topical gel 2 % (Erygel) Tier 2 Age (Max 35 Years)

erythromycin with ethanol topical solution 2 %


erythromycin-benzoyl peroxide topical gel 3-5 %

(Benzamycin) Tier 2 Age (Max 35 Years)

gentamicin topical cream 0.1 % Tier 2

gentamicin topical ointment 0.1 % Tier 2


43

Drug Status Notes

mupirocin calcium topical cream 2 % Tier 2

mupirocin topical ointment 2 % (Centany) Tier 2Topical Antifungal/Antiinflammatory,Steriod Agentclotrimazole-betamethasone topical cream 1-0.05 %

Tier 2

clotrimazole-betamethasone topical lotion 1-0.05 %

Tier 2

Topical AntifungalsCICLODAN KIT TOPICAL COMBO PACK 0.77 %

Tier 3

ciclopirox topical cream 0.77 % (Ciclodan) Tier 2

ciclopirox topical gel 0.77 % Tier 2

ciclopirox topical shampoo 1 % (Loprox) Tier 2

ciclopirox topical solution 8 % (Ciclodan) Tier 2

ciclopirox topical suspension 0.77 % (Loprox (as olamine)) Tier 2

ciclopirox-ure-camph-menth-euc topical solution 8 %

(Ciclodan Kit) Tier 2

clotrimazole topical cream 1 % (Antifungal (clotrimazole)) Tier 2

clotrimazole topical solution 1 % Tier 2

econazole topical cream 1 % Tier 2

ECOZA TOPICAL FOAM 1 % Tier 4

EXELDERM TOPICAL SOLUTION 1 % Tier 3

EXODERM TOPICAL LOTION 25-1 % Tier 2

ketoconazole topical cream 2 % Tier 2

ketoconazole topical shampoo 2 % (Nizoral) Tier 2

KETODAN KIT TOPICAL COMBO PACK 2 %

Tier 3

luliconazole topical cream 1 % (Luzu) Tier 2 QL (60 GM per 28 days)

MENTAX TOPICAL CREAM 1 % Tier 3

miconazole nitrate-zinc ox-pet topical ointment 0.25-15-81.35 %

(Vusion) Tier 2

naftifine topical cream 1 % Tier 2

naftifine topical cream 2 % (Naftin) Tier 2

naftifine topical gel 1 % (Naftin) Tier 2

NAFTIN TOPICAL GEL 2 % Tier 3

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM

Tier 2

nystatin topical cream 100,000 unit/gram Tier 2

nystatin topical ointment 100,000 unit/gram

Tier 2

nystatin topical powder 100,000 unit/gram

(Nyamyc) Tier 2

nystatin-triamcinolone topical cream100,000-0.1 unit/g-%

Tier 2


44

Drug Status Notes

nystatin-triamcinolone topical ointment100,000-0.1 unit/gram-%

Tier 2

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM

Tier 2

oxiconazole topical cream 1 % (Oxistat) Tier 2Topical Antiparasiticslindane topical shampoo 1 % Tier 2

malathion topical lotion 0.5 % (Ovide) Tier 2

permethrin topical cream 5 % (Elimite) Tier 2

SKLICE TOPICAL LOTION 0.5 % Tier 3

spinosad topical suspension 0.9 % (Natroba) Tier 2

ULESFIA TOPICAL LOTION 5 % Tier 3Topical Antiviralsacyclovir topical ointment 5 % (Zovirax) Tier 2

Topical SulfonamidesBP 10-1 TOPICAL CLEANSER 10-1 % Tier 2 Age (Max 35 Years)

mafenide acetate topical packet 50 gram (Sulfamylon) Tier 2

ROSANIL TOPICAL CLEANSER 10-5 % (W/W)


ROSULA CLEANSING CLOTHS TOPICAL PADS, MEDICATED 10-5 %


silver sulfadiazine topical cream 1 % (SSD) Tier 2

SSD TOPICAL CREAM 1 % Tier 2

SSS 10-5 TOPICAL FOAM 10-5 % Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical cleanser 10-2 %

(Avar LS) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

(Rosanil) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical cleanser 9.8-4.8 %

(Plexion) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical cleanser 9-4 %

(Sumaxin) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical cleanser 9-4.5 %

(Sumadan) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

(Sumaxin) Tier 2 Age (Max 35 Years)

sulfacetamide sodium-sulfur topical suspension 10-5 %


sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 %


sulfacetamide-sulfur-cleansr23 topical kit9-4.5 %

(Sumadan) Tier 2 Age (Max 35 Years)

SULFAMYLON TOPICAL PACKET 50 GRAM

Tier 4


45

Drug Status Notes

Dermatology - Antiinflammatory

Topical Antibiotics/Antiinflammatory,SteroidalCORTISPORIN TOPICAL OINTMENT 1 %

Tier 3

NEO-SYNALAR KIT TOPICAL CREAM 0.5 % (0.35 % BASE)-0.025 %

Tier 3

NEO-SYNALAR TOPICAL CREAM 0.5 % (0.35 % BASE)-0.025 %

Tier 3

Topical Anti-Inflammatory SteroidalADVANCED ALLERGY COLLECT KIT TOPICAL KIT 2.5 %

Tier 2

ALA-CORT TOPICAL CREAM 1 % Tier 2

ALA-SCALP TOPICAL LOTION 2 % Tier 2

alclometasone topical cream 0.05 % Tier 2

alclometasone topical ointment 0.05 % Tier 2

amcinonide topical cream 0.1 % Tier 2

betamethasone dipropionate topical cream 0.05 %

Tier 2

betamethasone dipropionate topical lotion 0.05 %

Tier 2

betamethasone dipropionate topical ointment 0.05 %

Tier 2

betamethasone valerate topical cream0.1 %

Tier 2

betamethasone valerate topical foam0.12 %

(Luxiq) Tier 2

betamethasone valerate topical lotion0.1 %

Tier 2

betamethasone valerate topical ointment0.1 %

Tier 2

betamethasone, augmented topical cream 0.05 %

Tier 2

betamethasone, augmented topical gel0.05 %

Tier 2

betamethasone, augmented topical lotion 0.05 %

Tier 2

betamethasone, augmented topical ointment 0.05 %

(Diprolene) Tier 2

CAPEX TOPICAL SHAMPOO 0.01 % Tier 3

clobetasol scalp solution 0.05 % Tier 2

clobetasol topical cream 0.05 % (Temovate) Tier 2

clobetasol topical foam 0.05 % (Olux) Tier 2

clobetasol topical gel 0.05 % Tier 2

clobetasol topical lotion 0.05 % (Clobex) Tier 2

clobetasol topical ointment 0.05 % (Temovate) Tier 2

clobetasol topical shampoo 0.05 % (Clobex) Tier 2


46

Drug Status Notes

clobetasol topical spray,non-aerosol 0.05 %

(Clobex) Tier 2

clobetasol-emollient topical cream 0.05 %

Tier 2

clobetasol-emollient topical foam 0.05 % (Olux-E) Tier 2

clocortolone pivalate topical cream 0.1 % (Cloderm) Tier 2

CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER 0.05 %

Tier 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2


DESONATE TOPICAL GEL 0.05 % Tier 4

desonide topical lotion 0.05 % (DesOwen) Tier 2

desonide topical ointment 0.05 % Tier 2

DESOWEN TOPICAL CREAM 0.05 % Tier 4

desoximetasone topical cream 0.05 %, 0.25 %

(Topicort) Tier 2

desoximetasone topical gel 0.05 % (Topicort) Tier 2

desoximetasone topical ointment 0.05 %, 0.25 %

(Topicort) Tier 2

fluocinolone and shower cap scalp oil0.01 %

(Derma-Smoothe/FS Scalp Oil)

Tier 2

fluocinolone topical cream 0.01 % Tier 2

fluocinolone topical cream 0.025 % (Synalar) Tier 2

fluocinolone topical oil 0.01 % (Derma-Smoothe/FS Body Oil)

Tier 2

fluocinolone topical ointment 0.025 % (Synalar) Tier 2

fluocinolone topical solution 0.01 % (Synalar) Tier 2

fluocinonide topical cream 0.05 % Tier 2

fluocinonide topical cream 0.1 % (Vanos) Tier 2

fluocinonide topical gel 0.05 % Tier 2

fluocinonide topical ointment 0.05 % Tier 2

fluocinonide topical solution 0.05 % Tier 2

FLUOCINONIDE-E TOPICAL CREAM 0.05 %

Tier 2

fluocinonide-emollient topical cream 0.05 %

(Fluocinonide-E) Tier 2

flurandrenolide topical cream 0.05 % (Cordran) Tier 2

flurandrenolide topical lotion 0.05 % (Cordran) Tier 2

flurandrenolide topical ointment 0.05 % (Cordran) Tier 2

fluticasone propionate topical cream0.05 %

(Cutivate) Tier 2

fluticasone propionate topical lotion 0.05 %

(Beser) Tier 2

fluticasone propionate topical ointment0.005 %

Tier 2

halobetasol propionate topical cream0.05 %

Tier 2


47

Drug Status Notes

halobetasol propionate topical ointment0.05 %

Tier 2

HALOG TOPICAL OINTMENT 0.1 % Tier 3

hydrocortisone butyrate topical cream0.1 %

(Locoid) Tier 2

hydrocortisone butyrate topical lotion 0.1 %

(Locoid) Tier 2

hydrocortisone butyrate topical ointment0.1 %

Tier 2

hydrocortisone butyrate topical solution0.1 %

(Locoid) Tier 2

hydrocortisone butyr-emollient topical cream 0.1 %

(Locoid Lipocream) Tier 2

hydrocortisone topical cream 1 % (Ala-Cort) Tier 2

hydrocortisone topical cream 2.5 % Tier 2

hydrocortisone topical cream with perineal applicator 1 %

(Procto-Pak) Tier 2

hydrocortisone topical cream with perineal applicator 2.5 %

(Procto-Med HC) Tier 2

hydrocortisone topical lotion 2.5 % Tier 2

hydrocortisone topical ointment 2.5 % Tier 2

hydrocortisone valerate topical cream0.2 %

Tier 2

hydrocortisone valerate topical ointment0.2 %

Tier 2

mometasone topical cream 0.1 % Tier 2

mometasone topical ointment 0.1 % Tier 2

mometasone topical solution 0.1 % Tier 2

NUCORT TOPICAL LOTION 2 % Tier 3

PANDEL TOPICAL CREAM 0.1 % Tier 3

prednicarbate topical cream 0.1 % Tier 2

prednicarbate topical ointment 0.1 % Tier 2

PROCTO-MED HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

Tier 2

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 %

Tier 2

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

Tier 2

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

Tier 2

SCALACORT DK TOPICAL COMBO PACK 2-2-2 %

Tier 3

SYNALAR CREAM KIT TOPICAL CREAM 0.025 %

Tier 3

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM 0.025 %

Tier 3

SYNALAR TS TOPICAL KIT 0.01 % Tier 3


48

Drug Status Notes

TEXACORT TOPICAL SOLUTION 2.5 %

Tier 3

triamcinolone acetonide topical aerosol0.147 mg/gram

(Kenalog) Tier 2

triamcinolone acetonide topical cream0.025 %

Tier 2

triamcinolone acetonide topical cream0.1 %, 0.5 %

(Triderm) Tier 2

triamcinolone acetonide topical lotion0.025 %, 0.1 %

Tier 2

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %

Tier 2

TRIDERM TOPICAL CREAM 0.1 %, 0.5 %

Tier 2

TRIDESILON TOPICAL CREAM 0.05 % Tier 2Topical Anti-Inflammatory, Nsaidsdiclofenac epolamine transdermal patch 12 hour 1.3 %

(Flector) Tier 2

diclofenac sodium topical drops 1.5 % Tier 2

diclofenac sodium topical gel 1 % (Voltaren) Tier 2Dermatology - Miscellaneous

AntiperspirantsDRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 %

Tier 2

DRYSOL TOPICAL SOLUTION 20 % Tier 2Antiseborrheic AgentsOVACE PLUS SHAMPOO TOPICAL SHAMPOO 10 %


selenium sulfide topical lotion 2.5 % Tier 2

selenium sulfide topical shampoo 2.25 % Tier 2

sulfacetamide sodium topical cleanser10 %

(Ovace) Tier 2 Age (Max 35 Years)

sulfacetamide sodium topical cleanser, gel 10 %

(Ovace Plus Wash) Tier 2 Age (Max 35 Years)

sulfacetamide sodium topical shampoo10 %

(Ovace Plus Shampoo) Tier 2 Age (Max 35 Years)

TERSI FOAM TOPICAL FOAM 2.25 % Tier 3Emollientsammonium lactate topical cream 12 % (Geri-Hydrolac) Tier 2

ammonium lactate topical lotion 12 % (Geri-Hydrolac) Tier 2Iodine AntisepticsBETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) SOLUTION 5 %

Tier 4

Keratolyticsbenzoyl peroxide topical foam 9.8 % (BenzePrO) Tier 2 Age (Max 35 Years)

CONDYLOX TOPICAL GEL 0.5 % Tier 3

INOVA 4-1 TOPICAL COMBO PACK 1-4-5 %



49

Drug Status Notes

INOVA 8-2 TOPICAL COMBO PACK 2-8-5 %


INOVA TOPICAL COMBO PACK 4-5 %, 8-5 %


KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO AND GEL 6-6 %


PODOCON TOPICAL LIQUID 25 % Tier 2

podofilox topical solution 0.5 % Tier 2

PR BENZOYL PEROXIDE TOPICAL CLEANSER 7 %


salicylic acid topical film forming liquid w/appl 27.5 %

(Virasal) Tier 2 Age (Max 35 Years)

salicylic acid topical film-forming soln er w/ appl 28.5 %

(UltraSal-ER) Tier 2 Age (Max 35 Years)

salicylic acid topical liquid 26 % Tier 2 Age (Max 35 Years)

SALVAX DUO PLUS TOPICAL FOAM 6-35 %

Tier 3

URAMAXIN GT TOPICAL KIT,CREAM AND GEL 45 %

Tier 3

Topical Anti-Inflammatory Steroid-Local AnestheticEPIFOAM TOPICAL FOAM 1-1 % Tier 3

hydrocortisone-pramoxine topical cream2.5-1 %

(Pramosone) Tier 2

Topical Antineoplastic & Premalignant Lesion Agntsdiclofenac sodium topical gel 3 % (Solaraze) Tier 2 PA; QL (100 GM per 1

FILL)

FLUOROPLEX TOPICAL CREAM 1 % Tier 3

fluorouracil topical cream 0.5 % (Carac) Tier 2

fluorouracil topical cream 5 % (Efudex) Tier 2

fluorouracil topical solution 2 %, 5 % Tier 2

PANRETIN TOPICAL GEL 0.1 % Tier 3

PICATO TOPICAL GEL 0.015 % Tier 4 QL (3 EA per 28 days)

PICATO TOPICAL GEL 0.05 % Tier 4 QL (2 EA per 28 days)

TARGRETIN TOPICAL GEL 1 % Tier 5 PA

TOLAK TOPICAL CREAM 4 % Tier 3

VALCHLOR TOPICAL GEL 0.016 % Tier 5 PATopical Local AnestheticsANACAINE TOPICAL OINTMENT 10 % Tier 3

ANASTIA TOPICAL LOTION 2.75 % Tier 3

lidocaine hcl laryngotracheal solution 4 %

(LTA Pre-Attached) Tier 2

lidocaine hcl topical cream 3 % (Lidopin) Tier 2

lidocaine topical adhesive patch,medicated 5 %

(Lidoderm) Tier 2


50

Drug Status Notes

lidocaine topical ointment 5 % Tier 2 QL (240 GM per 30 days)

lidocaine-prilocaine topical cream 2.5-2.5 %

Tier 2

LIDOPIN TOPICAL CREAM 3.25 % Tier 3

NUMBONEX TOPICAL LOTION 2.75 % Tier 3

TRANZAREL TOPICAL GEL 4 % Tier 3Topical/Mucous Membr./Subcut. EnzymesSANTYL TOPICAL OINTMENT 250 UNIT/GRAM

Tier 3

Dermatology - Psoriasis/Eczema

Antipsoriatic Agents,Systemicacitretin oral capsule 10 mg, 25 mg (Soriatane) Tier 2

acitretin oral capsule 17.5 mg Tier 2

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML

Tier 5 PA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML

Tier 5 PA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML

Tier 5 PA

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML

Tier 5 PA

methoxsalen oral capsule,liqd-filled,rapid rel 10 mg

(Oxsoralen Ultra) Tier 2

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

Tier 5 PA

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

Tier 5 PA

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

Tier 5 PA

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML

Tier 5 PA

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML

Tier 5 PA

TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML

Tier 5 PA

Antipsoriatics Agentscalcipotriene scalp solution 0.005 % Tier 2

calcipotriene topical cream 0.005 % (Dovonex) Tier 2

calcipotriene topical ointment 0.005 % Tier 2

calcitriol topical ointment 3 mcg/gram (Vectical) Tier 2

DRITHOCREME HP TOPICAL CREAM 1 %

Tier 3


51

Drug Status Notes

tazarotene topical cream 0.1 % (Tazorac) Tier 2 Age (Max 35 Years)

ZITHRANOL TOPICAL SHAMPOO 1 % Tier 3Topical Immunosuppressive Agentspimecrolimus topical cream 1 % (Elidel) Tier 2

tacrolimus topical ointment 0.03 %, 0.1 %

(Protopic) Tier 2

Topical Vit D Analog/Antiinflammatory, Steroidalcalcipotriene-betamethasone topical ointment 0.005-0.064 %

(Taclonex) Tier 2

calcipotriene-betamethasone topical suspension 0.005-0.064 %

(Taclonex) Tier 2

ENSTILAR TOPICAL FOAM 0.005-0.064 %

Tier 3

Diabetes

Antihypergly, (Dpp-4) Inhibitor & Biguanide Comb.JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG


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


JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG

Tier 4 ST; ST: Prior prescriptiion for Janumet XR, Janumet, or Januvia in the last 120 days; QL (2 EA per 1 day)

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


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG


Antihypergly,Incretin Mimetic(Glp-1 Recep.Agonist)BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML



52

Drug Status Notes

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML


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


OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML)


RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG


TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


Antihyperglycemc-Sod/Gluc Cotransport2(Sglt2)InhibFARXIGA ORAL TABLET 10 MG, 5 MG Tier 3 QL (1 EA per 1 day)

INVOKANA ORAL TABLET 100 MG, 300 MG


JARDIANCE ORAL TABLET 10 MG, 25 MG



53

Drug Status Notes

STEGLATRO ORAL TABLET 15 MG, 5 MG

Tier 4 ST; ST: At least 2 prior prescriptions for Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/Metformin HCL, Glyburide, Glyburide micronized, Glyburide/Metformin HCL, Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/Glimepiride, Pioglitazone HCL/Metformin HCL, Riomet ER, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in the last 365 days; QL (30 EA per 30 days)

Antihyperglycemic - Dopamine Receptor AgonistsCYCLOSET ORAL TABLET 0.8 MG Tier 3

Antihyperglycemic, Alpha-Glucosidase Inhib (N-S)acarbose oral tablet 100 mg, 25 mg, 50 mg

(Precose) Tier 2

miglitol oral tablet 100 mg, 25 mg, 50 mg (Glyset) Tier 2Antihyperglycemic, Amylin Analog-TypeSYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML

Tier 3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML

Tier 4

Antihyperglycemic, Dpp-4 InhibitorsJANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


ONGLYZA ORAL TABLET 2.5 MG, 5 MG


TRADJENTA ORAL TABLET 5 MG Tier 4 ST; ST: Prior prescriptiion for Janumet XR, Janumet, or Januvia in the last 120 days; QL (1 EA per 1 day)

Antihyperglycemic, Insulin-Release Stimulant Typeglimepiride oral tablet 1 mg, 2 mg, 4 mg (Amaryl) Tier 1

glipizide oral tablet 10 mg, 5 mg (Glucotrol) Tier 1


54

Drug Status Notes

glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg

(Glucotrol XL) Tier 1

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

(Glynase) Tier 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

Tier 1

nateglinide oral tablet 120 mg, 60 mg (Starlix) Tier 1

repaglinide oral tablet 0.5 mg Tier 1

repaglinide oral tablet 1 mg, 2 mg (Prandin) Tier 1Antihyperglycemic, Insulin-Response Enhancer (N-S)AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3

pioglitazone oral tablet 15 mg, 30 mg, 45 mg

(Actos) Tier 1

Antihyperglycemic,Biguanide Type(Non-Sulfonylurea)metformin oral solution 500 mg/5 ml (Riomet) Tier 2

metformin oral tablet 1,000 mg, 500 mg, 850 mg

(Glucophage) Tier 1

metformin oral tablet extended release 24 hr 500 mg, 750 mg

(Glucophage XR) Tier 1

RIOMET ORAL SOLUTION 500 MG/5 ML

Tier 4

Antihyperglycemic,Insulin & Glp-1 Receptor AgonistSOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML


XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML)


Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmbglipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

Tier 1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

Tier 1

Antihyperglycemic,Insulin-Response & Release Comb.pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg

(DUETACT) Tier 2

Antihyperglycemic-Glucocorticoid Receptor BlockerKORLYM ORAL TABLET 300 MG Tier 5 PA

Antihyperglycemic-Sglt2 Inhibitor & Biguanide CombINVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG



55

Drug Status Notes

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG

Tier 4 ST; ST: At least 2 prior prescriptions for Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/Metformin HCL, Glyburide, Glyburide micronized, Glyburide/Metformin HCL, Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/Glimepiride, Pioglitazone HCL/Metformin HCL, Riomet ER, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in the last 365 days; QL (60 EA per 30 days)

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG


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


Antihyperglycm,Insul-Resp.Enhancer & Biguanide CmbACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG

Tier 3

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg

(Actoplus MET) Tier 2

Hyperglycemicsdiazoxide oral suspension 50 mg/ml (Proglycem) Tier 2

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

Tier 3

GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG

Tier 3

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG

Tier 3


56

Drug Status Notes

InsulinsAFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT

Tier 3 PA; QL (180 EA per 28 days)

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML


HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML


HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)


HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)


HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)


HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)


HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)


HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML


HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)


HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML


HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML



57

Drug Status Notes

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)


LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)


TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)


TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)


TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML


Ear - General Disorders

Ear Preparations Anti-Inflammatoryfluocinolone acetonide oil otic (ear) drops 0.01 %

(DermOtic Oil) Tier 2

Ear Preparations, Misc. Anti-Infectivesacetic acid otic (ear) solution 2 % Tier 2

CORTANE-B TOPICAL LOTION 1-1-0.1 %

Tier 3

hydrocortisone-acetic acid otic (ear) drops 1-2 %

Tier 2

Ear Preparations,Antibioticsciprofloxacin hcl otic (ear) dropperette0.2 %

(Cetraxal) Tier 2

CORTISPORIN-TC OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML

Tier 3


58

Drug Status Notes

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

Tier 2

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

Tier 2

ofloxacin otic (ear) drops 0.3 % Tier 2Otic Preparations,Anti-Inflammatory-AntibioticsCIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %

Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

Tier 3

Electrolyte Regulation

Arginine Vasopressin (Avp) Receptor AntagonistsJYNARQUE ORAL TABLET 15 MG Tier 5 PA; QL (30 EA per 365

days)

JYNARQUE ORAL TABLET 30 MG Tier 5 PA; QL (60 EA per 365 days)

JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)


SAMSCA ORAL TABLET 15 MG Tier 5 PA; QL (30 EA per 365 days)

SAMSCA ORAL TABLET 30 MG Tier 5 PA; QL (60 EA per 365 days)

Electrolyte Depleterscalcium acetate(phosphat bind) oral capsule 667 mg

Tier 2

calcium acetate(phosphat bind) oral tablet 667 mg

Tier 2

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML

Tier 2

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

(Fosrenol) Tier 2

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML

Tier 3

sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram

(Renvela) Tier 2

sevelamer carbonate oral tablet 800 mg (Renvela) Tier 2

sevelamer hcl oral tablet 400 mg Tier 2

sevelamer hcl oral tablet 800 mg (Renagel) Tier 2

SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 15 GRAM/60 ML

Tier 2

sodium polystyrene sulfonate oral powder

Tier 2


59

Drug Status Notes

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML

Tier 2

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML

Tier 2

VELPHORO ORAL TABLET,CHEWABLE 500 MG

Tier 3

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM

Tier 3 PA; QL (1 EA per 1 day)

Potassium ReplacementEFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ, 25 MEQ

Tier 2

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ

Tier 2


Tier 2


Tier 2

potassium chloride oral capsule, extended release 10 meq, 8 meq

Tier 2

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

Tier 2

potassium chloride oral packet 20 meq (Klor-Con) Tier 2

potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq

(K-Tab) Tier 2

potassium chloride oral tablet,er particles/crystals 10 meq

(Klor-Con M10) Tier 2

potassium chloride oral tablet,er particles/crystals 20 meq

(Klor-Con M20) Tier 2

Sodium/Saline PreparationsBD POSIFLUSH NORMAL SALINE 0.9 INJECTION SYRINGE

Tier 2

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE

Tier 2

BD PRE-FILLED SALINE BLUNT CAN INJECTION SYRINGE

Tier 2

NORMAL SALINE FLUSH INJECTION SYRINGE

Tier 2

sodium chlor 0.9% bacteriostat injection solution 0.9 %

Tier 2

sodium chloride 0.9 % (flush) injection syringe

(BD PosiFlush Normal Saline 0.9)

Tier 2

sodium chloride injection syringe 0.9 % Tier 2Endocrine Disorder - Fertility

Fertility Stimulating Preparations,Non-Fshclomiphene citrate oral tablet 50 mg (Serophene) Tier 2


60

Drug Status Notes

Follicle Stim./Luteinizing HormonesMENOPUR SUBCUTANEOUS RECON SOLN 75 UNIT

Tier 3

Follicle-Stimulating Hormone (Fsh)BRAVELLE INJECTION RECON SOLN 75 UNIT

Tier 3

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE 300 UNIT/0.36 ML, 600 UNIT/0.72 ML, 900 UNIT/1.08 ML

Tier 3

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML, 450/0.75 UNIT/ML, 900/1.5 UNIT/ML

Tier 3

GONAL-F RFF SUBCUTANEOUS RECON SOLN 75 UNIT

Tier 3

GONAL-F SUBCUTANEOUS RECON SOLN 1,050 UNIT, 450 UNIT

Tier 3

Human Chorionic Gonadotropin (Hcg)chorionic gonadotropin, human intramuscular recon soln 10,000 unit

(Novarel) Tier 5

NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT

Tier 5

OVIDREL SUBCUTANEOUS SYRINGE 250 MCG/0.5 ML

Tier 3

PREGNYL INTRAMUSCULAR RECON SOLN 10,000 UNIT

Tier 5

Pregnancy Facilitating/Maintaining Agent,HormonalCRINONE VAGINAL GEL 8 % Tier 3

ENDOMETRIN VAGINAL INSERT 100 MG

Tier 3

Endocrine Disorder - Other

Antidiuretic And Vasopressor HormonesDDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE)

Tier 4

desmopressin injection solution 4 mcg/ml

(DDAVP) Tier 2

desmopressin nasal spray with pump 10 mcg/spray (0.1 ml)

(DDAVP) Tier 2

desmopressin nasal spray,non-aerosol10 mcg/spray (0.1 ml)

Tier 2

desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) Tier 2Antineoplastic Lhrh(Gnrh) Agonist,Pituitary Suppr.ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG

Tier 5 PA

ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG

Tier 5 PA


61

Drug Status Notes

ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG

Tier 5 PA

ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH)

Tier 5 PA

leuprolide subcutaneous kit 1 mg/0.2 ml Tier 2

leuprolide subcutaneous solution 1 mg/0.2 ml

Tier 2

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG

Tier 5

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

Tier 5

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG

Tier 5

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG

Tier 5

Bone Formation Stim. Agents - Parathyroid HormoneFORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML

Tier 5 PA; QL (2.4 ML per 28 days)

Bone Formation Stimulating Agts - Pth Rel PeptidesTYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)

Tier 5 PA

Bone Resorption Inhibitor & Vitamin D CombinationsFOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT

Tier 3

Bone Resorption Inhibitorsalendronate oral tablet 10 mg, 35 mg, 5 mg

Tier 2

alendronate oral tablet 70 mg (Fosamax) Tier 2

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

Tier 2

ibandronate oral tablet 150 mg (Boniva) Tier 2

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

Tier 4

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML

Tier 5 PA

raloxifene oral tablet 60 mg (Evista) Tier 2 QL (1 EA per 1 day)

risedronate oral tablet 150 mg (Actonel) Tier 2 QL (1 EA per 30 days)

risedronate oral tablet 30 mg Tier 2 QL (1 EA per 1 day)

risedronate oral tablet 35 mg (Actonel) Tier 2 QL (1 EA per 7 days)

risedronate oral tablet 5 mg (Actonel) Tier 2 QL (1 EA per 1 day)


62

Drug Status Notes

risedronate oral tablet,delayed release (dr/ec) 35 mg

(Atelvia) Tier 2 QL (1 EA per 7 days)

Calcimimetic,Parathyroid Calcium Enhancercinacalcet oral tablet 30 mg, 60 mg, 90 mg

(Sensipar) Tier 2

Growth Hormone Receptor AntagonistsSOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

Tier 5

Growth Hormone Releasing Hormone (Ghrh) & AnalogsEGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

Tier 5 PA

EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG

Tier 5 PA

Growth HormonesGENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

Tier 5 PA; Age (Max 18 Years)

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)


HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)


HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG


NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)


NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)


OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)


OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG


SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.)



63

Drug Status Notes

SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG


SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG


ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG


ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG


Hyperparathyroid Tx Agents - Vitamin D Analog-Typedoxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

Tier 2

paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) Tier 2

paricalcitol oral capsule 4 mcg Tier 2Insulin-Like Growth Factor-1 (Igf-1) HormonesINCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML

Tier 5 PA

Leptin Hormone AnalogsMYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)


Lhrh(Gnrh) Agonist Analog Pituitary SuppressantsLUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

Tier 5

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG

Tier 5

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML

Tier 3

Lhrh(Gnrh) Antagonist,Pituitary Suppressant AgentsCETROTIDE SUBCUTANEOUS KIT 0.25 MG

Tier 3

ganirelix subcutaneous syringe 250 mcg/0.5 ml

Tier 3

Lhrh(Gnrh)Agnst Pit.Sup-Central Precocious PubertyLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 30 MG

Tier 5

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED)

Tier 5

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY)

Tier 3

Pituitary Suppressive Agentscabergoline oral tablet 0.5 mg Tier 2


64

Drug Status Notes

danazol oral capsule 100 mg, 200 mg, 50 mg

Tier 2

Endocrine Disorder - Thyroid

Antithyroid Preparationsmethimazole oral tablet 10 mg, 5 mg (Tapazole) Tier 2

propylthiouracil oral tablet 50 mg Tier 2Thyroid HormonesARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

Tier 3

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

Tier 4

EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 2

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3

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

(Euthyrox) Tier 2

levothyroxine oral tablet 300 mcg (Levo-T) Tier 2

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

Tier 3

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg

(Cytomel) Tier 2

NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 162.5 MG, 195 MG, 260 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG

Tier 3

NATURE-THROID ORAL TABLET 130 MG, 16.25 MG, 32.5 MG, 65 MG

Tier 2

NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG

Tier 2

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3

thyroid (pork) oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

(NP Thyroid) Tier 2

THYROLAR-1 ORAL TABLET 12.5-50 MCG

Tier 3

THYROLAR-1/2 ORAL TABLET 6.25-25 MCG

Tier 3


65

Drug Status Notes

THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG

Tier 3

THYROLAR-2 ORAL TABLET 25-100 MCG

Tier 3

THYROLAR-3 ORAL TABLET 37.5-150 MCG

Tier 3

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3

WESTHROID ORAL TABLET 130 MG, 32.5 MG, 65 MG

Tier 2

WESTHROID ORAL TABLET 195 MG, 97.5 MG

Tier 3

WP THYROID ORAL TABLET 113.75 MG, 48.75 MG, 81.25 MG, 97.5 MG

Tier 3

WP THYROID ORAL TABLET 130 MG, 16.25 MG, 32.5 MG, 65 MG

Tier 2

Eye - General Disorders

Eye Antibiotic-Corticoid Combinationsneomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

(Neo-Polycin HC) Tier 2

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension3.5mg/ml-10,000 unit/ml-0.1 %

(Maxitrol) Tier 2

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

(Maxitrol) Tier 2

NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT/G-1%

Tier 2

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-1 %

Tier 3

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT 0.3-0.6 %

Tier 3

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %

Tier 3

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.05 %

Tier 3

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

(TobraDex) Tier 2

ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 %

Tier 3

Eye Antihistaminesazelastine ophthalmic (eye) drops 0.05 %

Tier 2

BEPREVE OPHTHALMIC (EYE) DROPS 1.5 %



66

Drug Status Notes

epinastine ophthalmic (eye) drops 0.05 %

Tier 2

olopatadine ophthalmic (eye) drops 0.1 %

(Pataday) Tier 2

olopatadine ophthalmic (eye) drops 0.2 %

(Pataday) Tier 2 QL (3 ML per 30 days)

PAZEO OPHTHALMIC (EYE) DROPS 0.7 %


Eye Antiinflammatory AgentsACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 %

Tier 3

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 %

Tier 3

bromfenac ophthalmic (eye) drops 0.09 %

Tier 2

DUREZOL OPHTHALMIC (EYE) DROPS 0.05 %

Tier 4

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

Tier 3

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

(FML Liquifilm) Tier 2

flurbiprofen sodium ophthalmic (eye) drops 0.03 %

Tier 2

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

Tier 3

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 %

Tier 3

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 %

Tier 3

ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) Tier 2

ketorolac ophthalmic (eye) drops 0.5 % (Acular) Tier 2

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 %

Tier 3

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 %

Tier 3

loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 %

(Lotemax) Tier 2

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

Tier 3

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

Tier 3

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

Tier 3

prednisolone acetate (pf) ophthalmic (eye) drops,suspension 1 %

Tier 2

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

(Pred Forte) Tier 2


67

Drug Status Notes

PROLENSA OPHTHALMIC (EYE) DROPS 0.07 %

Tier 4

Eye Antiviralstrifluridine ophthalmic (eye) drops 1 % Tier 2

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 %

Tier 3

Eye Local AnestheticsAKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 %

Tier 3

ALCAINE OPHTHALMIC (EYE) DROPS 0.5 %

Tier 2

ALTACAINE OPHTHALMIC (EYE) DROPS 0.5 %

Tier 2

ALTAFLUOR BENOX OPHTHALMIC (EYE) DROPS 0.25-0.4 %

Tier 2

proparacaine ophthalmic (eye) drops 0.5 %

(Alcaine) Tier 2

tetracaine hcl (pf) ophthalmic (eye) drops0.5 %

Tier 2

tetracaine hcl ophthalmic (eye) drops 0.5 %

(Altacaine) Tier 2

Eye SulfonamidesBLEPH-10 OPHTHALMIC (EYE) DROPS 10 %

Tier 2

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 %

Tier 3

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %

Tier 3

sulfacetamide sodium ophthalmic (eye) drops 10 %

(Bleph-10) Tier 2

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)

Tier 2

Eye Vasoconstrictors (Rx Only)phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 %

Tier 2

Ophthalmic AntibioticsAK-POLY-BAC OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM

Tier 2

AZASITE OPHTHALMIC (EYE) DROPS 1 %

Tier 3

bacitracin ophthalmic (eye) ointment 500 unit/gram

Tier 2

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

(AK-Poly-Bac) Tier 2

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 %

Tier 3

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 %

Tier 3


68

Drug Status Notes

ciprofloxacin hcl ophthalmic (eye) drops0.3 %

(Ciloxan) Tier 2

erythromycin ophthalmic (eye) ointment5 mg/gram (0.5 %)

Tier 2

gatifloxacin ophthalmic (eye) drops 0.5 %

(Zymaxid) Tier 2

GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM)

Tier 2

gentamicin ophthalmic (eye) drops 0.3 % Tier 2

moxifloxacin ophthalmic (eye) drops 0.5 %

(Vigamox) Tier 2

moxifloxacin ophthalmic (eye) drops, viscous 0.5 %

(Moxeza) Tier 2

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 %

Tier 3

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

(Neo-Polycin) Tier 2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

Tier 2

NEO-POLYCIN OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT-UNIT/G

Tier 2

ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) Tier 2

POLYCIN OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM

Tier 2

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

(Polytrim) Tier 2

tobramycin ophthalmic (eye) drops 0.3 % (Tobrex) Tier 2

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 %

Tier 3

Ophthalmic Anti-Inflammatory Immunomodulator-TypeRESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 %


RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 %


Ophthalmic Human Nerve Growth Factor (Hngf)OXERVATE OPHTHALMIC (EYE) DROPS 0.002 %

Tier 5 PA

Ophthalmic Mast Cell StabilizersALOCRIL OPHTHALMIC (EYE) DROPS 2 %

Tier 3


69

Drug Status Notes

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 %

Tier 3

cromolyn ophthalmic (eye) drops 4 % Tier 2Eye - Glaucoma

Carbonic Anhydrase Inhibitorsacetazolamide oral capsule, extended release 500 mg

Tier 2

acetazolamide oral tablet 125 mg, 250 mg

Tier 2

methazolamide oral tablet 25 mg, 50 mg Tier 2Miotics/Other Intraoc. Pressure ReducersALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

Tier 3

apraclonidine ophthalmic (eye) drops 0.5 %

Tier 2

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

Tier 3

betaxolol ophthalmic (eye) drops 0.5 % Tier 2

BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 %

Tier 3

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

Tier 4

brimonidine ophthalmic (eye) drops 0.15 %

(Alphagan P) Tier 2

brimonidine ophthalmic (eye) drops 0.2 %

Tier 2

carteolol ophthalmic (eye) drops 1 % Tier 2

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 %

Tier 4

COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML

Tier 4

dorzolamide (pf) ophthalmic (eye) drops2 %

Tier 2

dorzolamide ophthalmic (eye) drops 2 % (Trusopt) Tier 2

dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 %

(Cosopt (PF)) Tier 2 QL (2 EA per 1 day)

dorzolamide-timolol (pf) ophthalmic (eye) drops 2-0.5 %

Tier 2

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

(Cosopt) Tier 2

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 %

Tier 3

latanoprost (pf) ophthalmic (eye) drops0.005 %

Tier 2

latanoprost ophthalmic (eye) drops 0.005 %

(Xalatan) Tier 2


70

Drug Status Notes

levobunolol ophthalmic (eye) drops 0.5 %

Tier 2

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %


metipranolol ophthalmic (eye) drops 0.3 %

Tier 2

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 %

Tier 3

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

(Isopto Carpine) Tier 2

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 %

Tier 4

timolol maleate ophthalmic (eye) drops0.25 %, 0.5 %

(Timoptic) Tier 2

timolol maleate ophthalmic (eye) drops, once daily 0.5 %

(Istalol) Tier 2

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

(Timoptic-XE) Tier 2

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.25 %, 0.5 %


travoprost ophthalmic (eye) drops 0.004 %

(Travatan Z) Tier 2 QL (1 ML per 12 days)

XELPROS OPHTHALMIC (EYE) DROPS, EMULSION 0.005 %

Tier 3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 0.0015 %


Mydriaticsatropine ophthalmic (eye) drops 1 % (Isopto Atropine) Tier 2

CYCLOMYDRIL OPHTHALMIC (EYE) DROPS 0.2-1 %

Tier 3

cyclopentolate ophthalmic (eye) drops0.5 %, 1 %, 2 %

(Cyclogyl) Tier 2

HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 %

Tier 2

tropicamide ophthalmic (eye) drops 0.5 %

Tier 2

tropicamide ophthalmic (eye) drops 1 % (Mydriacyl) Tier 2Ophthalmic Antifibrotic AgentsMITOSOL OPHTHALMIC (EYE) KIT 0.2 MG

Tier 3

Eye - Miscellaneous

Artificial TearsLACRISERT OPHTHALMIC (EYE) INSERT 5 MG

Tier 3

Eye Preparations, Miscellaneous (Otc)GELFILM OPHTHALMIC (EYE) FILM Tier 3


71

Drug Status Notes

Ophthalmic Cystine Depleting AgentsCYSTARAN OPHTHALMIC (EYE) DROPS 0.44 %

Tier 5 PA

Fluid Replacement

Nucleic Acid/Nucleotide SupplementsXURIDEN ORAL GRANULES IN PACKET 2 GRAM

Tier 5 PA

Gout And Related Diseases

Colchicinecolchicine oral capsule 0.6 mg (Mitigare) Tier 2 QL (2 EA per 1 day)

colchicine oral tablet 0.6 mg (Colcrys) Tier 2 QL (4 EA per 1 day)Hyperuricemia Tx - Purine Inhibitorsallopurinol oral tablet 100 mg, 300 mg (Zyloprim) Tier 2

febuxostat oral tablet 40 mg, 80 mg (Uloric) Tier 2 ST; ST: Prior prescription for Allopurinol in the last 120 days; QL (30 EA per 30 days)

Uricosuric Agentsprobenecid oral tablet 500 mg Tier 2

probenecid-colchicine oral tablet 500-0.5 mg

Tier 2

Hematological Disorders

Anticoagulants,Coumarin TypeCOUMADIN ORAL TABLET 1 MG, 2.5 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 3

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 2

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

(Jantoven) Tier 2

Antifibrinolytic Agentstranexamic acid oral tablet 650 mg (Lysteda) Tier 2

Direct Factor Xa InhibitorsELIQUIS ORAL TABLET 2.5 MG Tier 3 QL (2 EA per 1 day)

ELIQUIS ORAL TABLET 5 MG Tier 3 QL (74 EA per 30 days)

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG


XARELTO ORAL TABLET 10 MG, 20 MG


XARELTO ORAL TABLET 15 MG, 2.5 MG


XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)


Hematinics,OtherARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 3 PA


72

Drug Status Notes

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

Tier 3 PA

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 5 PA

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

Tier 5 PA

Hemorrheologic Agentspentoxifylline oral tablet extended release 400 mg

Tier 2

Heparin And Related Preparationsenoxaparin subcutaneous solution 300 mg/3 ml

(Lovenox) Tier 2 QL (30 ML per 30 days)

enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml


enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml


enoxaparin subcutaneous syringe 30 mg/0.3 ml






fondaparinux subcutaneous syringe 10 mg/0.8 ml

(Arixtra) Tier 2 QL (8 ML per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml


fondaparinux subcutaneous syringe 5 mg/0.4 ml


fondaparinux subcutaneous syringe 7.5 mg/0.6 ml


FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML


FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML


FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML







73

Drug Status Notes

FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML




heparin (porcine) injection cartridge5,000 unit/ml (1 ml)

Tier 2

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

Tier 2

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

Tier 2

heparin, porcine (pf) injection solution1,000 unit/ml

Tier 2

heparin, porcine (pf) injection syringe5,000 unit/0.5 ml

Tier 2

Leukocyte (Wbc) StimulantsGRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

Tier 5 PA

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 5 PA

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML

Tier 5 PA

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML

Tier 5 PA

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

Tier 5 PA

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 5 PA

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG/0.6 ML

Tier 5 PA

Platelet Aggregation Inhibitorsaspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

(Aggrenox) Tier 2

BRILINTA ORAL TABLET 60 MG, 90 MG


cilostazol oral tablet 100 mg, 50 mg Tier 2

clopidogrel oral tablet 300 mg Tier 2 QL (4 EA per 30 days)

clopidogrel oral tablet 75 mg (Plavix) Tier 2

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

Tier 2

prasugrel oral tablet 10 mg, 5 mg (Effient) Tier 2 QL (1 EA per 1 day)

ZONTIVITY ORAL TABLET 2.08 MG Tier 3 QL (1 EA per 1 day)Platelet Reducing Agentsanagrelide oral capsule 0.5 mg (Agrylin) Tier 2

anagrelide oral capsule 1 mg Tier 2


74

Drug Status Notes

Sickle Cell Anemia AgentsDROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

Tier 3

ENDARI ORAL POWDER IN PACKET 5 GRAM

Tier 5 PA

OXBRYTA ORAL TABLET 500 MG Tier 5 PAThrombin Inhibitors,Selective,Direct, & ReversiblePRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG


Thrombopoietin Receptor AgonistsMULPLETA ORAL TABLET 3 MG Tier 5 PA

Vitamin K Preparationsphytonadione (vitamin k1) oral tablet 5 mg

(Mephyton) Tier 2

Hormonal Deficiency

Androgenic AgentsANADROL-50 ORAL TABLET 50 MG Tier 3 PA

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR

Tier 4 PA

METHITEST ORAL TABLET 10 MG Tier 3 PA

methyltestosterone oral capsule 10 mg (Android) Tier 2 PA

oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) Tier 2 PA

testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml

(Depo-Testosterone) Tier 2 PA

testosterone enanthate intramuscular oil200 mg/ml

Tier 2 PA

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

(Testim) Tier 2 PA

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

(Fortesta) Tier 2 PA

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

(Vogelxo) Tier 2 PA

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

(AndroGel) Tier 2 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

(AndroGel) Tier 2 PA

Estrogen & Progestin With Antimineralocorticoid CbANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

Tier 3

Estrogen/Androgen CombinationsCOVARYX H.S. ORAL TABLET 0.625-1.25 MG

Tier 2

COVARYX ORAL TABLET 1.25-2.5 MG Tier 2


75

Drug Status Notes

EEMT HS ORAL TABLET 0.625-1.25 MG

Tier 2

EEMT ORAL TABLET 1.25-2.5 MG Tier 2

estrogens-methyltestosterone oral tablet0.625-1.25 mg

(Covaryx H.S.) Tier 2

estrogens-methyltestosterone oral tablet1.25-2.5 mg

(Covaryx) Tier 2

Estrogenic AgentsAMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

Tier 2

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/24 HR


COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR


DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

Tier 3

DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 0.75 MG/0.75 GRAM (0.1%), 1 MG/GRAM (0.1 %), 1.25 MG/1.25 GRAM (0.1 %)

Tier 3

DOTTI TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR


ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION

Tier 4

estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) Tier 2

estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Dotti) Tier 2 QL (2 EA per 7 days)

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Climara) Tier 2 QL (1 EA per 7 days)

estradiol-norethindrone acet oral tablet0.5-0.1 mg, 1-0.5 mg

(Amabelz) Tier 2

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ACTUATION

Tier 3

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%)

Tier 4

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG, 1-5 MG-MCG

Tier 2

JINTELI ORAL TABLET 1-5 MG-MCG Tier 2


76

Drug Status Notes

LOPREEZA ORAL TABLET 1-0.5 MG Tier 2

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG

Tier 3

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24 HR


MIMVEY ORAL TABLET 1-0.5 MG Tier 2

norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg, 1-5 mg-mcg

(Fyavolv) Tier 2

PREFEST ORAL TABLET 1 MG (15)/1 MG- 0.09 MG (15)

Tier 3

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

Tier 3

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)

Tier 3

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

Tier 3

Lhrh (Gnrh) Agonist Analog And Progestin CombLUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET 3.75 MG -5 MG (30)

Tier 5

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET 11.25 MG -5 MG (90)

Tier 5

Progestational AgentsCRINONE VAGINAL GEL 4 % Tier 3

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

(Provera) Tier 2

norethindrone acetate oral tablet 5 mg (Aygestin) Tier 2

progesterone intramuscular oil 50 mg/ml Tier 2

progesterone micronized oral capsule100 mg, 200 mg

(Prometrium) Tier 2

Immunization

AntiseraHYPERRHO S/D INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG)

Tier 3

HYPERRHO S/D INTRAMUSCULAR SYRINGE 250 UNIT (50 MCG)

Tier 5

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE 250 UNIT (50 MCG)

Tier 5

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG)

Tier 3

RHOPHYLAC INJECTION SYRINGE 1,500 UNIT (300 MCG)/2 ML

Tier 5


77

Drug Status Notes

WINRHO SDF INJECTION SOLUTION 1,500 UNIT (300 MCG)/1.3 ML, 15000 UNIT(3000 MCG)/13 ML, 2,500 UNIT (500 MCG)/2.2 ML, 5,000 UNIT(1000 MCG)/4.4 ML

Tier 5

Immunosuppression/Modulation

ImmunomodulatorsACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML

Tier 5 PA

ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML

Tier 5

imiquimod topical cream in packet 5 % (Aldara) Tier 2 QL (24 EA per 30 days)

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

Tier 5 PA

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML

Tier 5 PA

PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

Tier 5

ImmunosuppressivesASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG

Tier 3

AZASAN ORAL TABLET 100 MG, 75 MG

Tier 3

azathioprine oral tablet 50 mg (Imuran) Tier 2

cyclosporine modified oral capsule 100 mg, 25 mg

(Gengraf) Tier 2

cyclosporine modified oral capsule 50 mg

Tier 2

cyclosporine modified oral solution 100 mg/ml

(Gengraf) Tier 2

cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) Tier 2

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG

Tier 3

everolimus (immunosuppressive) oral tablet 0.25 mg, 0.5 mg, 0.75 mg

(Zortress) Tier 2

GENGRAF ORAL CAPSULE 100 MG, 25 MG

Tier 2

GENGRAF ORAL SOLUTION 100 MG/ML

Tier 2

mycophenolate mofetil oral capsule 250 mg

(CellCept) Tier 2

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

(CellCept) Tier 2

mycophenolate mofetil oral tablet 500 mg

(CellCept) Tier 2


78

Drug Status Notes

mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

(Myfortic) Tier 2

NEORAL ORAL CAPSULE 100 MG, 25 MG

Tier 4

NEORAL ORAL SOLUTION 100 MG/ML Tier 4

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

Tier 3

PROGRAF ORAL GRANULES IN PACKET 0.2 MG, 1 MG

Tier 3

RAPAMUNE ORAL SOLUTION 1 MG/ML

Tier 3

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

Tier 4

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

Tier 4

SANDIMMUNE ORAL SOLUTION 100 MG/ML

Tier 4

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune) Tier 2

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

(Prograf) Tier 2

ZORTRESS ORAL TABLET 1 MG Tier 3Infectious Disease - Bacterial

Absorbable Sulfonamidessulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

(Sulfatrim) Tier 2

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) Tier 2

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

(Bactrim DS) Tier 2

SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML

Tier 2

BetalactamsCAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

Tier 5 PA

Cephalosporins - 1St Generationcefadroxil oral capsule 500 mg Tier 2

cefadroxil oral tablet 1 gram Tier 2

cephalexin oral capsule 250 mg, 500 mg, 750 mg

(Keflex) Tier 2

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 2

Cephalosporins - 2Nd Generationcefaclor oral capsule 250 mg, 500 mg Tier 2

cefaclor oral tablet extended release 12 hr 500 mg

Tier 2

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 2


79

Drug Status Notes

cefprozil oral tablet 250 mg, 500 mg Tier 2

cefuroxime axetil oral tablet 250 mg, 500 mg

Tier 2

Cephalosporins - 3Rd Generationcefdinir oral capsule 300 mg Tier 2

cefdinir oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml

Tier 2

cefditoren pivoxil oral tablet 200 mg Tier 2

cefditoren pivoxil oral tablet 400 mg (Spectracef) Tier 2

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

(Suprax) Tier 2

cefpodoxime oral tablet 100 mg, 200 mg Tier 2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

Tier 4

Chemotherapeutics, Antibacterial, Misc.HYOPHEN ORAL TABLET 81.6-0.12-10.8 MG

Tier 2

methenamine hippurate oral tablet 1 gram

(Hiprex) Tier 2

methenamine mandelate oral tablet 1 gram

Tier 2

methen-sod phos-meth blue-hyos oral tablet 81.6-40.8-0.12 mg

(Urogesic-Blue) Tier 2

MONUROL ORAL PACKET 3 GRAM Tier 3

PHOSPHASAL ORAL TABLET 81.6-10.8-40.8 MG

Tier 2

PRIMSOL ORAL SOLUTION 50 MG/5 ML

Tier 3

trimethoprim oral tablet 100 mg Tier 2

URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG

Tier 2

URIMAR-T ORAL TABLET 120-0.12-10.8 MG

Tier 2

URIN DS ORAL TABLET 81.6-10.8-40.8 MG

Tier 2

URO-458 ORAL TABLET 81-10.8-40.8 MG

Tier 2

UROGESIC-BLUE ORAL TABLET 81.6-40.8-0.12 MG

Tier 2

URO-MP ORAL CAPSULE 118-10-40.8-36 MG

Tier 2

USTELL ORAL CAPSULE 120-0.12 MG Tier 2

UTIRA-C ORAL TABLET 81.6-10.8-40.8 MG

Tier 4

VILAMIT MB ORAL CAPSULE 118-10-40.8-36 MG

Tier 2


80

Drug Status Notes

Macrolidesazithromycin oral packet 1 gram (Zithromax) Tier 2

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

(Zithromax) Tier 2

azithromycin oral tablet 250 mg, 500 mg (Zithromax) Tier 2

azithromycin oral tablet 600 mg Tier 2

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 2

clarithromycin oral tablet 250 mg, 500 mg

Tier 2

clarithromycin oral tablet extended release 24 hr 500 mg

Tier 2

DIFICID ORAL TABLET 200 MG Tier 3 QL (20 EA per 30 days)

E.E.S. 400 ORAL TABLET 400 MG Tier 2

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 500 MG

Tier 2

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

(E.E.S. Granules) Tier 2

erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml

(EryPed 400) Tier 2

erythromycin ethylsuccinate oral tablet400 mg

(E.E.S. 400) Tier 2

erythromycin oral tablet,delayed release (dr/ec) 250 mg, 333 mg, 500 mg

(Ery-Tab) Tier 2

Nitrofuran Derivativesnitrofurantoin macrocrystal oral capsule100 mg, 25 mg, 50 mg

(Macrodantin) Tier 2

nitrofurantoin monohyd/m-cryst oral capsule 100 mg

(Macrobid) Tier 2

nitrofurantoin oral suspension 25 mg/5 ml

(Furadantin) Tier 2

Oxazolidinoneslinezolid oral suspension for reconstitution 100 mg/5 ml

(Zyvox) Tier 2

linezolid oral tablet 600 mg (Zyvox) Tier 2Penicillinsamoxicillin oral capsule 250 mg, 500 mg Tier 2

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

Tier 2

amoxicillin oral tablet 500 mg, 875 mg Tier 2

amoxicillin oral tablet,chewable 250 mg Tier 2

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml

Tier 2


81

Drug Status Notes

amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml

(Augmentin) Tier 2

amoxicillin-pot clavulanate oral suspension for reconstitution 600-42.9 mg/5 ml

(Augmentin ES-600) Tier 2

amoxicillin-pot clavulanate oral tablet250-125 mg

Tier 2

amoxicillin-pot clavulanate oral tablet500-125 mg, 875-125 mg

(Augmentin) Tier 2

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

(Augmentin XR) Tier 2

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg

Tier 2

ampicillin oral capsule 250 mg, 500 mg Tier 2

dicloxacillin oral capsule 250 mg, 500 mg

Tier 2

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR 775 MG

Tier 4

penicillin v potassium oral recon soln125 mg/5 ml, 250 mg/5 ml

Tier 2

penicillin v potassium oral tablet 250 mg, 500 mg

Tier 2

Pleuromutilin DerivativesXENLETA INTRAVENOUS SOLUTION 150 MG/15 ML

Tier 5

XENLETA ORAL TABLET 600 MG Tier 5QuinolonesBAXDELA ORAL TABLET 450 MG Tier 3 PA

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML

Tier 4

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 MG, 500 MG

Tier 4

ciprofloxacin hcl oral tablet 100 mg, 750 mg

Tier 2

ciprofloxacin hcl oral tablet 250 mg, 500 mg

(Cipro) Tier 2

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

(Cipro) Tier 2

FACTIVE ORAL TABLET 320 MG Tier 3

levofloxacin oral solution 250 mg/10 ml Tier 2

levofloxacin oral tablet 250 mg Tier 2

levofloxacin oral tablet 500 mg, 750 mg (Levaquin) Tier 2

moxifloxacin oral tablet 400 mg Tier 2


82

Drug Status Notes

Tetracyclinesdoxycycline hyclate oral capsule 100 mg, 50 mg

(Morgidox) Tier 2 QL (2 EA per 1 day)

doxycycline hyclate oral tablet 100 mg Tier 2 QL (2 EA per 1 day)

doxycycline hyclate oral tablet 150 mg, 75 mg

(Acticlate) Tier 2 QL (2 EA per 1 day)

doxycycline hyclate oral tablet 50 mg (Targadox) Tier 2 QL (4 EA per 1 day)

doxycycline monohydrate oral capsule100 mg, 75 mg

(Mondoxyne NL) Tier 2 QL (2 EA per 1 day)

doxycycline monohydrate oral capsule150 mg


doxycycline monohydrate oral capsule50 mg

(Monodox) Tier 2 QL (2 EA per 1 day)

doxycycline monohydrate oral capsule,ir - delay rel,biphase 40 mg

(Oracea) Tier 2 QL (1 EA per 1 day)

doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml

(Vibramycin) Tier 2

doxycycline monohydrate oral tablet 100 mg

(Avidoxy) Tier 2 QL (2 EA per 1 day)

doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg


minocycline oral capsule 100 mg, 75 mg Tier 2

minocycline oral capsule 50 mg (Minocin) Tier 2

minocycline oral tablet 100 mg, 50 mg, 75 mg

Tier 2

MONDOXYNE NL ORAL CAPSULE 100 MG, 75 MG


tetracycline oral capsule 250 mg, 500 mg

Tier 2

Infectious Disease - Fungal

Antifungal Agentsclotrimazole mucous membrane troche10 mg

Tier 2

CRESEMBA ORAL CAPSULE 186 MG Tier 3

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

(Diflucan) Tier 2

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

(Diflucan) Tier 2

flucytosine oral capsule 250 mg, 500 mg (Ancobon) Tier 2

itraconazole oral capsule 100 mg (Sporanox) Tier 2

itraconazole oral solution 10 mg/ml (Sporanox) Tier 2

ketoconazole oral tablet 200 mg Tier 2

NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)

Tier 3

ONMEL ORAL TABLET 200 MG Tier 3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG

Tier 3

terbinafine hcl oral tablet 250 mg Tier 2


83

Drug Status Notes

TOLSURA ORAL CAPSULE, SOLID DISPERSION 65 MG

Tier 4 PA

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)

(Vfend) Tier 2

voriconazole oral tablet 200 mg, 50 mg (Vfend) Tier 2Antifungal Antibioticsgriseofulvin microsize oral suspension125 mg/5 ml

Tier 2

griseofulvin microsize oral tablet 500 mg Tier 2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 2

nystatin oral suspension 100,000 unit/ml Tier 2

nystatin oral tablet 500,000 unit Tier 2Infectious Disease - Miscellaneous

AminoglycosidesARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML

Tier 5 PA

BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML

Tier 5 PA

neomycin oral tablet 500 mg Tier 2

TOBI PODHALER INHALATION CAPSULE 28 MG

Tier 5 PA

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG

Tier 5 PA

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

(Tobi) Tier 2 PA

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml

(Kitabis Pak) Tier 2 PA

Antileproticsdapsone oral tablet 100 mg, 25 mg Tier 2

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG


Anti-Mycobacterium Agentsethambutol oral tablet 100 mg Tier 2

ethambutol oral tablet 400 mg (Myambutol) Tier 2

isoniazid oral tablet 100 mg, 300 mg Tier 2

PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

Tier 3

pyrazinamide oral tablet 500 mg Tier 2

rifabutin oral capsule 150 mg (Mycobutin) Tier 2

TRECATOR ORAL TABLET 250 MG Tier 3Antitubercular Antibioticscycloserine oral capsule 250 mg Tier 2

PRIFTIN ORAL TABLET 150 MG Tier 3

RIFAMATE ORAL CAPSULE 300-150 MG

Tier 3

rifampin oral capsule 150 mg, 300 mg (Rifadin) Tier 2


84

Drug Status Notes

RIFATER ORAL TABLET 50-120-300 MG

Tier 3

SIRTURO ORAL TABLET 100 MG Tier 5 PALincosamidesclindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

(Cleocin HCl) Tier 2

clindamycin palmitate hcl oral recon soln75 mg/5 ml

(Clindamycin Pediatric) Tier 2

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML

Tier 2

Rifamycins And Related Derivative AntibioticsXIFAXAN ORAL TABLET 200 MG Tier 3 QL (9 EA per 1 FILL)

XIFAXAN ORAL TABLET 550 MG Tier 3 PAVancomycin And DerivativesFIRVANQ ORAL RECON SOLN 25 MG/ML

Tier 3

vancomycin oral capsule 125 mg, 250 mg

(Vancocin) Tier 2 QL (56 EA per 14 days)

Infectious Disease - Parasitic

2Nd Gen. Anaerobic Antiprotozoal-AntibacterialSOLOSEC ORAL GRANULES DEL RELEASE IN PACKET 2 GRAM

Tier 3 ST; ST: At least 2 prior prescriptions for Clindamycin HCL, Clindamycin Phosphate, Metronidazole, Tinidazole, or Vandazole in the last 120 days; QL (1 EA per 30 days)

tinidazole oral tablet 250 mg, 500 mg Tier 2Anaerobic Antiprotozoal-Antibacterial Agentsmetronidazole oral tablet 250 mg, 500 mg

(Flagyl) Tier 2

Anthelminticsalbendazole oral tablet 200 mg (Albenza) Tier 2

EMVERM ORAL TABLET,CHEWABLE 100 MG

Tier 3 PA

ivermectin oral tablet 3 mg (Stromectol) Tier 2

praziquantel oral tablet 600 mg (Biltricide) Tier 2Antimalarial Drugsatovaquone-proguanil oral tablet 250-100 mg

(Malarone) Tier 2

atovaquone-proguanil oral tablet 62.5-25 mg

(Malarone Pediatric) Tier 2

chloroquine phosphate oral tablet 250 mg, 500 mg

Tier 2


85

Drug Status Notes

COARTEM ORAL TABLET 20-120 MG Tier 3

hydroxychloroquine oral tablet 200 mg (Plaquenil) Tier 2 12 PER FILL; QL (12 EA per 5 days)

KRINTAFEL ORAL TABLET 150 MG Tier 4 QL (2 EA per 30 days)

mefloquine oral tablet 250 mg Tier 2

quinine sulfate oral capsule 324 mg (Qualaquin) Tier 2AntiparasiticsALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

Tier 3

ALINIA ORAL TABLET 500 MG Tier 3Antiprotozoal Drugs,Miscellaneousatovaquone oral suspension 750 mg/5 ml

(Mepron) Tier 2

NEBUPENT INHALATION RECON SOLN 300 MG

Tier 4

pentamidine inhalation recon soln 300 mg

(Nebupent) Tier 2

Infectious Disease - Viral

Antiretroviral-Integrase Inhibitor And Nrti Comb.DOVATO ORAL TABLET 50-300 MG Tier 3 QL (1 EA per 1 day)

Antiretroviral-Nucleoside,Nucleotide,Protease Inh.SYMTUZA ORAL TABLET 800-150-200-10 MG


Antivirals, Generalacyclovir oral capsule 200 mg Tier 2

acyclovir oral suspension 200 mg/5 ml (Zovirax) Tier 2

acyclovir oral tablet 400 mg, 800 mg Tier 2

famciclovir oral tablet 125 mg, 250 mg, 500 mg

Tier 2

oseltamivir oral capsule 30 mg (Tamiflu) Tier 2 QL (40 EA per 183 days)

oseltamivir oral capsule 45 mg, 75 mg (Tamiflu) Tier 2 QL (20 EA per 183 days)

oseltamivir oral suspension for reconstitution 6 mg/ml

(Tamiflu) Tier 2 QL (360 ML per 183 days)

PREVYMIS ORAL TABLET 240 MG, 480 MG

Tier 5 PA

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION


rimantadine oral tablet 100 mg (Flumadine) Tier 2

SITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG


valacyclovir oral tablet 1 gram, 500 mg (Valtrex) Tier 2

valganciclovir oral recon soln 50 mg/ml (Valcyte) Tier 2

valganciclovir oral tablet 450 mg (Valcyte) Tier 2


86

Drug Status Notes

Antivirals, Hiv-Spec, Non-Peptidic Protease InhibAPTIVUS ORAL CAPSULE 250 MG Tier 3 QL (4 EA per 1 day)

PREZCOBIX ORAL TABLET 800-150 MG-MG


PREZISTA ORAL TABLET 150 MG Tier 3 QL (8 EA per 1 day)



PREZISTA ORAL TABLET 800 MG Tier 3 QL (1 EA per 1 day)Antivirals, Hiv-Spec, Nucleoside-Nucleotide AnalogCIMDUO ORAL TABLET 300-300 MG Tier 3 QL (1 EA per 1 day)

DESCOVY ORAL TABLET 200-25 MG Tier 3 QL (1 EA per 1 day)

TEMIXYS ORAL TABLET 300-300 MG Tier 3 QL (1 EA per 1 day)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG


Antivirals, Hiv-Spec., Nucleoside Analog, Rti Combabacavir-lamivudine oral tablet 600-300 mg

(Epzicom) Tier 2 QL (1 EA per 1 day)

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) Tier 2 QL (2 EA per 1 day)

lamivudine-zidovudine oral tablet 150-300 mg

(Combivir) Tier 2 QL (2 EA per 1 day)

Antivirals, Hiv-Specific, Ccr5 Co-Receptor Antag.SELZENTRY ORAL TABLET 150 MG, 75 MG


SELZENTRY ORAL TABLET 25 MG, 300 MG


Antivirals, Hiv-Specific, Fusion InhibitorsFUZEON SUBCUTANEOUS RECON SOLN 90 MG


Antivirals, Hiv-Specific, Non-Nucleoside, RtiEDURANT ORAL TABLET 25 MG Tier 3 QL (1 EA per 1 day)

efavirenz oral capsule 200 mg, 50 mg (Sustiva) Tier 2

efavirenz oral tablet 600 mg (Sustiva) Tier 2

INTELENCE ORAL TABLET 100 MG, 25 MG


INTELENCE ORAL TABLET 200 MG Tier 3 QL (2 EA per 1 day)

nevirapine oral suspension 50 mg/5 ml (Viramune) Tier 2 QL (1200 ML per 30 days)

nevirapine oral tablet 200 mg (Viramune) Tier 2 QL (2 EA per 1 day)

nevirapine oral tablet extended release 24 hr 100 mg


nevirapine oral tablet extended release 24 hr 400 mg

(Viramune XR) Tier 2 QL (1 EA per 1 day)


87

Drug Status Notes

PIFELTRO ORAL TABLET 100 MG Tier 3 QL (2 EA per 1 day)

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

Tier 4

Antivirals, Hiv-Specific, Nucleoside Analog, Rtiabacavir oral solution 20 mg/ml (Ziagen) Tier 2 QL (960 ML per 30 days)

abacavir oral tablet 300 mg (Ziagen) Tier 2 QL (2 EA per 1 day)

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


EMTRIVA ORAL CAPSULE 200 MG Tier 3 QL (1 EA per 1 day)

lamivudine oral solution 10 mg/ml (Epivir) Tier 2 QL (960 ML per 30 days)

lamivudine oral tablet 150 mg (Epivir) Tier 2 QL (2 EA per 1 day)

lamivudine oral tablet 300 mg (Epivir) Tier 2 QL (1 EA per 1 day)

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg


zidovudine oral capsule 100 mg (Retrovir) Tier 2 QL (6 EA per 1 day)

zidovudine oral syrup 10 mg/ml (Retrovir) Tier 2 QL (1920 ML per 30 days)

zidovudine oral tablet 300 mg Tier 2 QL (2 EA per 1 day)Antivirals, Hiv-Specific, Nucleotide Analog, Rtitenofovir disoproxil fumarate oral tablet300 mg

(Viread) Tier 2 QL (1 EA per 1 day)

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


Antivirals, Hiv-Specific, Protease Inhibitorsatazanavir oral capsule 150 mg, 200 mg (Reyataz) Tier 2 QL (2 EA per 1 day)

atazanavir oral capsule 300 mg (Reyataz) Tier 2 QL (1 EA per 1 day)

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 3

EVOTAZ ORAL TABLET 300-150 MG Tier 3 QL (1 EA per 1 day)

fosamprenavir oral tablet 700 mg (Lexiva) Tier 2 QL (4 EA per 1 day)

NORVIR ORAL SOLUTION 80 MG/ML Tier 3 QL (480 ML per 30 days)

ritonavir oral tablet 100 mg (Norvir) Tier 2 QL (12 EA per 1 day)

VIRACEPT ORAL TABLET 250 MG, 625 MG

Tier 3

Antivirals,Hiv-1 Integrase Strand Transfer InhibtrISENTRESS HD ORAL TABLET 600 MG


ISENTRESS ORAL TABLET 400 MG Tier 3 QL (2 EA per 1 day)

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


Artv Cmb Nucleoside,Nucleotide,&Non-Nucleoside RtiATRIPLA ORAL TABLET 600-200-300 MG



88

Drug Status Notes

COMPLERA ORAL TABLET 200-25-300 MG


DELSTRIGO ORAL TABLET 100-300-300 MG


ODEFSEY ORAL TABLET 200-25-25 MG


SYMFI LO ORAL TABLET 400-300-300 MG


SYMFI ORAL TABLET 600-300-300 MG Tier 3 QL (1 EA per 1 day)Arv Cmb-Nrti,N(T)Rti, Integrase InhibitorBIKTARVY ORAL TABLET 50-200-25 MG


GENVOYA ORAL TABLET 150-150-200-10 MG


STRIBILD ORAL TABLET 150-150-200-300 MG


Arv Comb-Nrtis & Integrase InhibitorTRIUMEQ ORAL TABLET 600-50-300 MG


Cytochrome P450 InhibitorsTYBOST ORAL TABLET 150 MG Tier 3 QL (1 EA per 1 day)

Hep C - Ns5a, Ns3/4A, Nucleotide Ns5b Inhib ComboVOSEVI ORAL TABLET 400-100-100 MG

Tier 5 PA

Hep C Virus - Ns5a & Ns5b Polymerase Inhib. Combo.EPCLUSA ORAL TABLET 400-100 MG Tier 5 PA

HARVONI ORAL TABLET 45-200 MG, 90-400 MG

Tier 5 PA

Hepatitis B Treatment Agentsadefovir oral tablet 10 mg (Hepsera) Tier 5 QL (1 EA per 1 day)

entecavir oral tablet 0.5 mg, 1 mg (Baraclude) Tier 2 QL (1 EA per 1 day)

lamivudine oral tablet 100 mg (Epivir HBV) Tier 2 QL (1 EA per 1 day)

VEMLIDY ORAL TABLET 25 MG Tier 5 QL (1 EA per 1 day)Hepatitis C Treatment AgentsPEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

Tier 5 PA

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML

Tier 5 PA

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 5 PA

ribavirin oral capsule 200 mg Tier 5

ribavirin oral tablet 200 mg Tier 5Hepatitis C Virus- Ns5a And Ns3/4A Inhibitor CombMAVYRET ORAL TABLET 100-40 MG Tier 5 PA


89

Drug Status Notes

Inflammatory Disease

Anti-Arthritic And Chelating AgentsCUPRIMINE ORAL CAPSULE 250 MG Tier 4 PA

DEPEN TITRATABS ORAL TABLET 250 MG

Tier 3 PA

D-PENAMINE ORAL TABLET 125 MG Tier 3 PA

penicillamine oral capsule 250 mg (Cuprimine) Tier 2 PAAnti-Arthritic, Folate Antagonist AgentsOTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 12.5 MG/0.25 ML
















Anti-Inflammatory Tumor Necrosis Factor InhibitorCIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

Tier 5 PA

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

Tier 5 PA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

Tier 5 PA

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML)

Tier 5 PA

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

Tier 5 PA

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML)

Tier 5 PA


90

Drug Status Notes

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)

Tier 3 PA

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

Tier 5 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

Tier 5 PA

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

Tier 5 PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

Tier 5 PA

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

Tier 5 PA

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML

Tier 5 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML

Tier 5 PA

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 80 MG/0.8 ML

Tier 5 PA

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML

Tier 5 PA

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML

Tier 5 PA

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML

Tier 5 PA

Anti-Inflammatory, Interleukin-1 Beta BlockersILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML

Tier 5 PA

Anti-Inflammatory, Pyrimidine Synthesis Inhibitorleflunomide oral tablet 10 mg, 20 mg (Arava) Tier 2

Anti-Inflammatory,Phosphodiesterase-4(Pde4) Inhib.OTEZLA ORAL TABLET 30 MG Tier 5 PA

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)

Tier 5 PA


91

Drug Status Notes

Antinflammatory, Sel.Costim.Mod.,T-Cell InhibitorORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML

Tier 5 PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

Tier 5 PA

C1 Esterase InhibitorsHAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT

Tier 5 PA

Glucocorticoidsbudesonide oral capsule,delayed,extend.release 3 mg

(Entocort EC) Tier 2

budesonide oral tablet,delayed and ext.release 9 mg

(Uceris) Tier 2

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

Tier 2

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

Tier 3

dexamethasone oral solution 0.5 mg/5 ml

Tier 2

dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg

(Decadron) Tier 2

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg

Tier 2

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

(Cortef) Tier 2

MEDROL ORAL TABLET 2 MG Tier 4

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

(Medrol) Tier 2

methylprednisolone oral tablets,dose pack 4 mg

(Medrol (Pak)) Tier 2

MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS), 5 MG (48 TABS)

Tier 3

prednisolone oral solution 15 mg/5 ml Tier 2

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

Tier 2

prednisolone sodium phosphate oral solution 20 mg/5 ml (4 mg/ml)

(Veripred 20) Tier 2

prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml)

(Pediapred) Tier 2

prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg, 30 mg

(Orapred ODT) Tier 2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

Tier 3


92

Drug Status Notes

prednisone oral solution 5 mg/5 ml Tier 2

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

Tier 2

prednisone oral tablets,dose pack 10 mg, 5 mg

Tier 2

Gold SaltsRIDAURA ORAL CAPSULE 3 MG Tier 3

Immunomodulator,B-Lymphocyte Stim(Blys)-Spec InhibBENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML

Tier 5 PA

BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML

Tier 5 PA

Interleukin-6 (Il-6) Receptor InhibitorsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML

Tier 5 PA

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML

Tier 5 PA

Janus Kinase (Jak) InhibitorsRINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG

Tier 5

XELJANZ ORAL TABLET 10 MG Tier 5 PA; QL (2 EA per 1 day)

XELJANZ ORAL TABLET 5 MG Tier 5 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG, 22 MG

Tier 5 PA

Mineralocorticoidsfludrocortisone oral tablet 0.1 mg Tier 2

Monoclonal Antibody-Human Interleukin 12/23 InhibSTELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML

Tier 5 PA

Nsaid & Topical Irritant Counter-Irritant Comb.COMFORT PAC-IBUPROFEN KIT 800 MG

Tier 3

COMFORT PAC-MELOXICAM KIT 15 MG

Tier 3

COMFORT PAC-NAPROXEN KIT 500 MG

Tier 3

Nsaids (Cox Non-Specific Inhib)& Prostaglandin Cmbdiclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg

(Arthrotec 50) Tier 2

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 75-200 mg-mcg

(Arthrotec 75) Tier 2


93

Drug Status Notes

Nsaids, Cyclooxygenase 2 Inhibitor - Typecelecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

(Celebrex) Tier 2

Nsaids, Cyclooxygenase Inhibitor-Typediclofenac potassium oral tablet 50 mg Tier 2

diclofenac sodium oral tablet extended release 24 hr 100 mg

(Voltaren-XR) Tier 2

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

Tier 2

EC-NAPROXEN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG

Tier 2

etodolac oral capsule 200 mg, 300 mg Tier 2

etodolac oral tablet 400 mg (Lodine) Tier 2

etodolac oral tablet 500 mg Tier 2

etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

Tier 2

flurbiprofen oral tablet 100 mg Tier 2

IBU ORAL TABLET 400 MG, 600 MG, 800 MG

Tier 2

ibuprofen oral suspension 100 mg/5 ml (Children's Advil) Tier 2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

(IBU) Tier 2

INDOCIN ORAL SUSPENSION 25 MG/5 ML

Tier 3

indomethacin oral capsule 25 mg, 50 mg Tier 2

indomethacin oral capsule, extended release 75 mg

Tier 2

ketoprofen oral capsule 25 mg, 50 mg, 75 mg

Tier 2

ketorolac oral tablet 10 mg Tier 2

mefenamic acid oral capsule 250 mg Tier 2

meloxicam oral tablet 15 mg, 7.5 mg (Mobic) Tier 2

nabumetone oral tablet 500 mg, 750 mg Tier 2

naproxen oral suspension 125 mg/5 ml (Naprosyn) Tier 2

naproxen oral tablet 250 mg, 375 mg Tier 2

naproxen oral tablet 500 mg (Naprosyn) Tier 2

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg

(EC-Naproxen) Tier 2

naproxen sodium oral tablet 275 mg Tier 2

naproxen sodium oral tablet 550 mg (Anaprox DS) Tier 2

oxaprozin oral tablet 600 mg (Daypro) Tier 2

piroxicam oral capsule 10 mg, 20 mg (Feldene) Tier 2

sulindac oral tablet 150 mg, 200 mg Tier 2


94

Drug Status Notes

Local Anesthesia

Local AnestheticsGLYDO MUCOUS MEMBRANE JELLY IN APPLICATOR 2 %

Tier 2

lidocaine hcl mucous membrane jelly 2 %

Tier 2

lidocaine hcl mucous membrane jelly in applicator 2 %

(Glydo) Tier 2

lidocaine hcl mucous membrane solution4 % (40 mg/ml)

Tier 2

LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 %

Tier 2

Lower Gastrointestinal Disorders - Bowel Inflammat

Bowel Antiinflamatory Agentssulfadiazine oral tablet 500 mg Tier 2

Chronic Inflam. Colon Dx, 5-A-Salicylat,Rectal Txmesalamine rectal enema 4 gram/60 ml (Rowasa) Tier 2

mesalamine rectal suppository 1,000 mg (Canasa) Tier 2

mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml

(Rowasa) Tier 2

Drug Tx-Chronic Inflam. Colon Dx,5-AminosalicylatAPRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM

Tier 3

balsalazide oral capsule 750 mg (Colazal) Tier 2

DIPENTUM ORAL CAPSULE 250 MG Tier 3

mesalamine oral capsule (with del rel tablets) 400 mg

(Delzicol) Tier 2

mesalamine oral capsule,extended release 24hr 0.375 gram

(Apriso) Tier 2

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

(Lialda) Tier 2

mesalamine oral tablet,delayed release (dr/ec) 800 mg

(Asacol HD) Tier 2

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

Tier 3

sulfasalazine oral tablet 500 mg (Azulfidine) Tier 2

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

(Azulfidine EN-tabs) Tier 2

Hemorrhoidal Prep, Anti-Infam Steroid/Local Anesthhydrocortisone-pramoxine rectal cream1-1 %, 2.5-1 %

(Analpram-HC) Tier 2

hydrocortisone-pramoxine rectal cream2.5-1 % (4g)

(Analpram-HC Singles) Tier 2


95

Drug Status Notes

lidocaine-hydrocortisone-aloe rectal gel2.8-0.55 %

Tier 2

PROCTOFOAM HC RECTAL FOAM 1-1 %

Tier 3

Ibs Agents,Mixed Opioid Recep Agonists/AntagonistsVIBERZI ORAL TABLET 100 MG, 75 MG

Tier 4 PA

Irritable Bowel Agents,Guanylate Cylase-C AgonistLINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG


Local Anorectal Nitrate PreparationsRECTIV RECTAL OINTMENT 0.4 % (W/W)

Tier 3

Rectal PreparationsANUCORT-HC RECTAL SUPPOSITORY 25 MG

Tier 2

hydrocortisone acetate rectal suppository 25 mg

(Anucort-HC) Tier 2

hydrocortisone acetate rectal suppository 30 mg

(Proctocort) Tier 2

Rectal/Lower Bowel Prep.,Glucocort. (Non-Hemorr)COLOCORT RECTAL ENEMA 100 MG/60 ML

Tier 2

CORTIFOAM RECTAL FOAM 10 % (80 MG)

Tier 3

hydrocortisone rectal enema 100 mg/60 ml

(Colocort) Tier 2

Lower Gastrointestinal Disorders - Other

Ammonia InhibitorsCARBAGLU ORAL TABLET, DISPERSIBLE 200 MG

Tier 5

ENULOSE ORAL SOLUTION 10 GRAM/15 ML

Tier 2

GENERLAC ORAL SOLUTION 10 GRAM/15 ML

Tier 2

LITHOSTAT ORAL TABLET 250 MG Tier 3

RAVICTI ORAL LIQUID 1.1 GRAM/ML Tier 5 PA

sodium phenylbutyrate oral powder 0.94 gram/gram

(Buphenyl) Tier 5

sodium phenylbutyrate oral tablet 500 mg

(Buphenyl) Tier 5

Antidiarrhealsdiphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml

Tier 2


96

Drug Status Notes

diphenoxylate-atropine oral tablet 2.5-0.025 mg

(Lomotil) Tier 2

loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))

Tier 2

opium tincture oral tincture 10 mg/ml (morphine)

Tier 2

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE 50-15 MG/ML (4)

Tier 5

Bile SaltsCHENODAL ORAL TABLET 250 MG Tier 3

CHOLBAM ORAL CAPSULE 250 MG, 50 MG

Tier 5 PA

ursodiol oral capsule 300 mg (Actigall) Tier 2

ursodiol oral tablet 250 mg (URSO 250) Tier 2

ursodiol oral tablet 500 mg (URSO Forte) Tier 2Irritable Bowel Synd. Agent,5Ht-3 Antagonist-Typealosetron oral tablet 0.5 mg, 1 mg (Lotronex) Tier 2

Irritable Bowel Synd. Agent,5Ht-4 Partial AgonistZELNORM ORAL TABLET 6 MG Tier 5

Laxatives And CatharticsAMITIZA ORAL CAPSULE 24 MCG, 8 MCG


CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML

Tier 2

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

Tier 2

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM

Tier 2

GAVILYTE-N ORAL RECON SOLN 420 GRAM

Tier 2

lactulose oral solution 10 gram/15 ml (Constulose) Tier 2

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

Tier 2

MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM

Tier 3

OSMOPREP ORAL TABLET 1.5 GRAM Tier 3

peg 3350-electrolytes oral recon soln236-22.74-6.74 -5.86 gram

(GaviLyte-G) Tier 2

peg-electrolyte soln oral recon soln 420 gram

(GaviLyte-N) Tier 2

PEG-PREP ORAL KIT 5-210 MG-GRAM Tier 2

PLENVU ORAL POWDER IN PACKET, SEQUENTIAL 140-9-5.2 GRAM

Tier 3

PREPOPIK ORAL POWDER IN PACKET 10 MG-3.5 GRAM-12 GRAM

Tier 3


97

Drug Status Notes

SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5-3.13-1.6 GRAM

Tier 3

TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM

Tier 2

Narcotic Antagonists, Peripherally-ActingMOVANTIK ORAL TABLET 12.5 MG, 25 MG


Medical Supplies

Catheters And Related DevicesDOVER BULB SYRINGE SYRINGE 60 ML

Tier 2

Syringes And AccessoriesADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

ALLERGIST TRAY 1/2 ML 27GX3/8" SYRINGE 1/2 ML 27 GAUGE X 3/8"

Tier 2

ALLERGIST TRAY INTRADERMAL BEV SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 3/8"

Tier 2

ALLERGIST TRAY REGULAR BEVEL SYRINGE 1 ML 27 GAUGE X 3/8"

Tier 2

ALLERGY SYRINGE SYRINGE 1 ML 27 GAUGE X 3/8", 1 ML 27 X 1/2"

Tier 2

ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

BD ALLERGIST TRAY REG BEVEL SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 27 X 1/2"

Tier 2

BD ALLERGIST TRAY REG BEVEL TRAY 1/2 ML 27 X 1/2"

Tier 2

BD ALLERGY SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2"

Tier 2

BD BLUNT PLASTIC CANNULA SYRINGE 17 X 3 ML

Tier 2

BD BULK SYRINGE SLIP TIP SYRINGE 1 ML, 5 ML

Tier 2

BD ECCENTRIC TIP SYRINGE SYRINGE 10 ML

Tier 2


98

Drug Status Notes

BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2", 1 ML 30 GAUGE X 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 X 5/8"

Tier 2

BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 5/16"

Tier 2

BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2"

Tier 2

BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2"

Tier 2

BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML

Tier 2

BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64"

Tier 2

BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16

Tier 2

BD INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8"

Tier 2

BD INTERLINK BLUNT PLASTIC CAN SYRINGE 17 X 5 ML

Tier 2

BD INTERLINK SYRINGE SYRINGE 17 X 10 ML

Tier 2

BD LAB ECCENTRIC NON-STERILE SYRINGE 10 ML

Tier 2

BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 GAUGE X 1/2"

Tier 2

BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE X 1/2"

Tier 2

BD LUER-LOK BULK SYRINGE SYRINGE 20 ML

Tier 2


99

Drug Status Notes

BD LUER-LOK SYRINGE SYRINGE 1 ML, 1 ML 20 GAUGE X 1", 10 ML, 10 ML 20 X 1 1/2", 10 ML 20 X 1", 10 ML 21 GAUGE X 1", 10 ML 21 X 1 1/2", 10 ML 22 X 1", 10 ML 23X 1 1/4 ", 20 ML, 3 ML, 3 ML 18 X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/2 ", 3 ML 25 X 5/8", 3 ML 26 X 5/8", 5 ML, 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1", 50 ML

Tier 2

BD LUER-LOK TIP CONTROL SYRING SYRINGE 10 ML

Tier 2

BD PRECISIONGLIDE SYRINGE 3 ML 22 GAUGE X 3/4"

Tier 2

BD SAFETYGLIDE ALLERGIST TRAY SYRINGE 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2"

Tier 2

BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64"

Tier 2

BD SAFETYGLIDE SHIELDING REG SYRINGE 1 ML 25 GAUGE X 5/8", 3 ML 21 GAUGE X 1 1/2"

Tier 2

BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE X 5/8", 10 ML 22 X 1 1/2", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 5 ML 22 GAUGE X 1 1/2"

Tier 2

BD SAFETYGLIDE TB REG BEVEL SYRINGE 1 ML 27 X 1/2"

Tier 2

BD SAFETYGLIDE TUBERCULIN SYRINGE 1 ML 26 GAUGE X 3/8"

Tier 2

BD SAFETY-LOK DETACHABLE NEEDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2"

Tier 2


100

Drug Status Notes

BD SAFETY-LOK TUBERCULIN SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2"

Tier 2

BD SAFETY-LOK WITH LUER-LOK SYRINGE 10 ML, 3 ML, 5 ML

Tier 2

BD SLIP TIP SYRINGE SYRINGE 1 ML 26 GAUGE X 5/8", 10 ML, 3 ML, 50 ML

Tier 2

B-D SLIP TIP SYRINGE SYRINGE 20 ML

Tier 2

BD SYRINGE CATH TIP NONSTERILE SYRINGE 50 ML

Tier 2

BD SYRINGE CATHETER TIP SYRINGE 50 ML

Tier 2

BD SYRINGE LUER-LOK NONSTERILE SYRINGE 10 ML, 20 ML, 5 ML, 50 ML

Tier 2

BD SYRINGE LUER-LOK STERILE SYRINGE 10 ML, 50 ML

Tier 2

BD SYRINGE SLIP TIP NONSTERILE SYRINGE 10 ML, 20 ML, 50 ML

Tier 2

BD SYRINGE SYRINGE 1 ML Tier 2

BD SYRINGE-DUAL CANNULA SYRINGE 10 ML 20 GAUGE AND 17 GAUGE

Tier 2

BD TUBERCULIN SLIP-TIP SYRINGE 1 ML

Tier 2

BD TUBERCULIN SYRINGE SYRINGE 1 ML 21 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2", 1/2 ML 27 X 1/2 "

Tier 2

BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 15/64"

Tier 2

BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64"

Tier 2

CAREPOINT LUER SLIP SYRINGE SYRINGE 1 ML

Tier 2

CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2


101

Drug Status Notes

COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

Tier 2

DAVOL IRRIGATION SYRINGE SYRINGE

Tier 2

DAVOL PISTON IRRIGATION SYRINGE

Tier 2

DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64"

Tier 2

DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16

Tier 2

EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1 ML 32 GAUGE X 5/16", 1/2 ML 32 GAUGE X 5/16"

Tier 2

EASY GLIDE CATHETER TIP SYRING SYRINGE 60 ML

Tier 2

EASY GLIDE DENTAL IRRIG SYRING SYRINGE 10 ML

Tier 2

EASY GLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64"

Tier 2

EASY GLIDE LUER LOCK SYRINGE SYRINGE 1 ML, 10 ML, 3 ML, 60 ML

Tier 2


102

Drug Status Notes

EASY GLIDE LUER SLIP TB SYRING SYRINGE 1 ML

Tier 2

EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"

Tier 2

EASY TOUCH FLIPLOCK SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 18 GAUGE X 1 1/2", 10 ML 18 GAUGE X 1", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 18 GAUGE X 1 1/2", 3 ML 18 GAUGE X 1", 3 ML 19 GAUGE X 1 1/2", 3 ML 19 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 18 GAUGE X 1", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1", 5 ML 25 GAUGE X 5/8"

Tier 2

EASY TOUCH FLURINGE FLIPLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8"

Tier 2

EASY TOUCH FLURINGE FLU TRAY TRAY 1 ML 25 GAUGE X 1"

Tier 2

EASY TOUCH FLURINGE SHEATHLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8"

Tier 2

EASY TOUCH FLURINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8"

Tier 2

EASY TOUCH INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2"

Tier 2


103

Drug Status Notes

EASY TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2"

Tier 2

EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML

Tier 2

EASY TOUCH LUER LOCK SYRINGE SYRINGE 1 ML, 10 ML, 3 ML, 5 ML

Tier 2

EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"

Tier 2

EASY TOUCH SHEATHLOCK SYRG-NDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1"

Tier 2

EASY TOUCH SHEATHLOCK SYRINGE SYRINGE 10 ML, 3 ML, 5 ML

Tier 2

EASY TOUCH SYR ALLERGY TRAY TRAY 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2"

Tier 2

EASY TOUCH SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8"

Tier 2

EASY TOUCH TUBERCULIN FLIPLOCK SYRINGE 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2"

Tier 2

EASY TOUCH TUBERCULIN SHEATHLK SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2"

Tier 2


104

Drug Status Notes

EASY TOUCH UNI-SLIP SYRINGE 1 ML, 10 ML, 3 ML, 5 ML

Tier 2

ECLIPSE SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 3 ML 21 GAUGE X 1", 3 ML 25 GAUGE X 1"

Tier 2

EXCEL SYRINGE SYRINGE 3 ML 23 X 1"

Tier 2

EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

Tier 2

EXEL SYRINGE SYRINGE 10 ML, 3 ML 23 GAUGE X 1 1/2", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4", 30 ML, 50 ML

Tier 2

FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x 1/4"

(UltiCare Insulin Syr Half Unit)

Tier 2

INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8", 1/2 ML 28 GAUGE X 1/2"

Tier 2

insulin syringe needleless syringe 1 ml (BD Insulin Syringe Slip Tip)

Tier 2

INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge

(Ultilet Insulin Syringe) Tier 2

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 29 gauge x 1/2", 1 ml 30 gauge x 5/16, 1 ml 31 gauge x 5/16

(Advocate Syringes) Tier 2

insulin syringe-needle u-100 syringe 0.3 ml 30

(Ultra Comfort Insulin Syringe)

Tier 2

insulin syringe-needle u-100 syringe 0.3 ml 30 gauge x 1/2", 0.5 ml 30 gauge x 1/2"

(BD Insulin Syringe Ultra-Fine)

Tier 2


105

Drug Status Notes

insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 31 gauge x 1/4", 1/2 ml 31 gauge x 1/4"

(Sure Comfort Insulin Syringe)

Tier 2

insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 15/64", 1 ml 31 gauge x 15/64", 1/2 ml 31 gauge x 15/64"

(BD Veo Insulin Syringe UF)

Tier 2

insulin syringe-needle u-100 syringe 1 ml 27 gauge x 1/2", 1 ml 28 gauge x 1/2"

(BD Insulin Syringe) Tier 2

insulin syringe-needle u-100 syringe 1 ml 28 gauge, 1 ml 30 gauge x 7/16", 1/2 ml 28 gauge, 1/2 ml 29 , 1/2 ml 30 gauge

(Lite Touch Insulin Syringe)

Tier 2

insulin syringe-needle u-100 syringe 1 ml 29 gauge x 7/16"

Tier 2


(BD Eclipse Luer-Lok) Tier 2


(Thinpro Insulin Syringe) Tier 2

insulin syringe-needle u-100 syringe 1/2 ml 27 gauge x 1/2"

(Easy Touch Insulin Syringe)

Tier 2

insulin syringe-needle u-100 syringe 1/2 ml 28 gauge x 1/2"

(BD Lo-Dose Micro-Fine IV)

Tier 2

INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1"

Tier 2

INTERLINK SYRINGE AND CANNULA SYRINGE 15 X 10 ML

Tier 2

IRRIGATION SYRINGE SYRINGE Tier 2

LIFESHIELD BLUNT CANNULA SYRINGE 1 ML 18 GAUGE X 1", 3 ML 18 X 1"

Tier 2

LITE TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE

Tier 2

LUER LOCK SYRINGE SYRINGE 30 ML, 60 ML

Tier 2

LUER SLIP TIP SYRINGE TRAY SYRINGE 1 ML

Tier 2

LUER-LOK TIP SYRINGE 30 ML Tier 2


106

Drug Status Notes

MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML 29 X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16"

Tier 2

MAGELLAN SAFETY SYRINGE SYRINGE 1 ML 23 GAUGE X 1"

Tier 2

MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 ML 30 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2"

Tier 2

MAGELLAN TUBERCULIN SAFETY SYR SYRINGE 1 ML 28 GAUGE X 1/2"

Tier 2

MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2"

Tier 2

MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2"

Tier 2

MONOJECT 140CC PISTON SYRINGE SYRINGE

Tier 2

MONOJECT 35CC SYRINGE CATH TIP SYRINGE 35 ML

Tier 2

MONOJECT 3CC SYR 25GX1" SYRINGE 3 ML 25 GAUGE X 1"

Tier 2

MONOJECT ALLERGY TRAY DETACH TRAY 1 ML 27 X 1/2"

Tier 2

MONOJECT ALLERGY TRAY TRAY 0.5 ML 28 X 1/2", 1 ML 28 X 1/2"

Tier 2

MONOJECT CONTROL SYRINGE LUER SYRINGE 12 ML

Tier 2

MONOJECT DISPOSABLE SYRINGE SYRINGE 20 ML

Tier 2

MONOJECT ECCENTRIC NON-STERILE SYRINGE 12 ML, 35 ML

Tier 2

MONOJECT ENFIT STERILE SYRINGE SYRINGE 1 ML, 3 ML, 35 ML, 6 ML, 60 ML

Tier 2

MONOJECT ENFIT SYRINGE CAP Tier 2

MONOJECT ENFIT SYRINGE SYRINGE 1 ML, 12 ML, 3 ML, 35 ML, 6 ML, 60 ML

Tier 2

MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 29 GAUGE X 1/2"

Tier 2


107

Drug Status Notes

MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML , 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

Tier 2

MONOJECT LUER-LOCK TIP SYRINGE 12 ML, 3 ML

Tier 2

MONOJECT MAGELLAN SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1"

Tier 2

MONOJECT PHARMACY TRAY LUER SYRINGE 12 ML, 20 ML, 3 ML, 35 ML, 6 ML, 60 ML

Tier 2

MONOJECT PHARMACY TRAY REG TIP SYRINGE 1 ML

Tier 2

MONOJECT REG TIP NON-STERILE SYRINGE 12 ML, 20 ML, 3 ML, 6 ML

Tier 2

MONOJECT REGULAR LUER SYRINGE 12 ML, 35 ML, 6 ML

Tier 2

MONOJECT SAFETY LUER LOCK TIP SYRINGE 3 ML

Tier 2

MONOJECT SAFETY SYRINGES SYRINGE , 12 ML, 12 ML 20 X 1 1/2", 12 ML 21X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 6 ML

Tier 2

MONOJECT SMARTIP CANNULA SYRINGE 12 ML, 3 ML, 6 ML

Tier 2

MONOJECT SYRINGE ECCENTRI LUER SYRINGE 60 ML

Tier 2

MONOJECT SYRINGE LUER LOK SYRINGE 35 ML, 6 ML, 60 ML

Tier 2

MONOJECT SYRINGE REGULAR LUER SYRINGE 60 ML

Tier 2


108

Drug Status Notes

MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE, 12 ML 18 GAUGE X 1", 12 ML 20 X 1 1/2", 12 ML 21 GAUGE X 1 1/2", 12 ML 21 GAUGE X 1", 140 ML, 3 ML, 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 20 X 3/4", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/4", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4", 6 ML, 6 ML 20 X 1 1/2", 6 ML 21 X 1 1/2", 6 ML 21 X 1", 6 ML 22 X 1 1/2"

Tier 2

MONOJECT SYRINGE TOOMEY TYPE SYRINGE 60 ML

Tier 2

MONOJECT TB LUER LOK SYRINGE 1 ML

Tier 2

MONOJECT TB REGULAR LUER TIP SYRINGE 1 ML

Tier 2

MONOJECT TB SAFETY SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 28 GAUGE X 1/2"

Tier 2

MONOJECT TB SYRINGE 1 ML 28 GAUGE X 1/2"

Tier 2

MONOJECT TUBERCULIN SYRINGE SYRINGE 1 ML, 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2", 1 ML 28 GAUGE X 1/2", 1/2 ML 28 X 1/2"

Tier 2

MONOJECT ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE

Tier 2

NORM-JECT SYRINGE 10 ML, 20 ML Tier 2

NORM-JECT TUBERKULIN SYRINGE 1 ML

Tier 2

PISTON SYRINGE WITH ENFIT SYRINGE 60 ML

Tier 2

PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2"

Tier 2


109

Drug Status Notes

SAFESNAP INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

SAFESNAP SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 10 ML, 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 GAUGE X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1", 3 ML, 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML, 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1"

Tier 2

SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 GAUGE X 1/2"

Tier 2

SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4"

Tier 2

SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

Tier 2


110

Drug Status Notes

SURGUARD2 SAFETY SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2"

Tier 2

syringe (disposable) syringe 20 ml (B-D Slip Tip Syringe) Tier 2

syringe (disposable) syringe 3 ml (BD Luer-Lok Syringe) Tier 2

syringe (disposable) syringe 30 ml (Exel Syringe) Tier 2

syringe (disposable) syringe 5 ml (BD Bulk Syringe Slip Tip) Tier 2

syringe (disposable) syringe 60 ml (Easy Glide Catheter Tip Syring)

Tier 2

SYRINGE 3CC/20GX1" SYRINGE 3 ML 20 GAUGE X 1"

Tier 2


Tier 2

SYRINGE 3CC/21GX1-1/2" SYRINGE 3 ML 21 GAUGE X 1 1/2"

Tier 2


Tier 2

SYRINGE 3CC/22GX3/4" SYRINGE 3 ML 22 GAUGE X 3/4"

Tier 2


Tier 2

syringe with needle syringe 1 ml 25 gauge x 1"

(Easy Touch) Tier 2

syringe with needle syringe 3 ml 20 gauge x 1 1/2", 3 ml 22 x 1 1/2", 3 ml 23 gauge x 1 1/2"

(BD Luer-Lok Syringe) Tier 2

syringe with needle syringe 3 ml 21 gauge x 1 1/2"

(BD Integra Syringe) Tier 2

syringe with needle, safety syringe 1 ml 25 gauge x 5/8"

(BD Safety-Lok Tuberculin) Tier 2

syringe with needle, safety syringe 3 ml 22 gauge x 1"

(BD Safety-Lok Detachable Needl)

Tier 2

SYRINGE WITHOUT NEEDLE SYRINGE

Tier 2


111

Drug Status Notes

TECHLITE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16"

Tier 2

TECHLITE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16

Tier 2

TERUMO ALLERGY SYRINGE SYRINGE 1 ML 27 X 1/2"

Tier 2

TERUMO HYPODERMIC NEEDLE/SYRIN SYRINGE 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1"

Tier 2

TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8", 0.5 ML 29 GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8"

Tier 2

TERUMO SYRINGE SYRINGE 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 30 ML

Tier 2

THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 ML 31 X 3/8", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8"

Tier 2

TOOMEY SYRINGE SYRINGE 70 ML Tier 2

TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16

Tier 2


112

Drug Status Notes

TRUEPLUS INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

Tier 2

TUBERCULIN SYRINGE SYRINGE 1 ML, 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2"

Tier 2

tuberculin-allergy syringes syringe 1 ml 26 gauge x 3/8"

(Allergist Tray Intradermal Bev)

Tier 2

ULTICARE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 1/4"

Tier 2

ULTICARE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE X 1/4"

Tier 2

ULTICARE SAFETY SYRINGE SYRINGE 3 ML, 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8"

Tier 2

ULTICARE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 25 GAUGE X 5/8", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16

Tier 2

ULTICARE TB SAFETY SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 27 GAUGE X 5/8", 1 ML 28 GAUGE X 1/2"

Tier 2

ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29

Tier 2

ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16"

Tier 2


113

Drug Status Notes

ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE

Tier 2

ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2"

Tier 2

ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

Tier 2

ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

VANISHPOINT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 3/16"

Tier 2

VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 1 ML 25 GAUGE X 1", 1 ML 29 GAUGE X 1/2", 10 ML 21 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2"

Tier 2

VANISHPOINT TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2"

Tier 2


114

Drug Status Notes

Miscellaneous Agents

Amyloidosis Agents-Transthyretin (Ttr) SuppressionTEGSEDI SUBCUTANEOUS SYRINGE 284 MG/1.5 ML

Tier 5 PA; QL (6 ML per 28 days)

Anaphylaxis Therapy Agentsepinephrine injection auto-injector 0.15 mg/0.15 ml

(Auvi-Q) Tier 2

epinephrine injection auto-injector 0.3 mg/0.3 ml

(EpiPen) Tier 2

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

Tier 3

EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

Tier 3

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML

Tier 3

EPIPEN JR INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML

Tier 3

SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 MG/0.3 ML

Tier 3 QL (2 EA per 1 FILL)

Miscellaneous AgentsNEXAVIR INJECTION SOLUTION 25.5 MG/ML

Tier 3

Parasympathetic Agentsbethanechol chloride oral tablet 10 mg, 5 mg

Tier 2

bethanechol chloride oral tablet 25 mg, 50 mg

(Urecholine) Tier 2

cevimeline oral capsule 30 mg (Evoxac) Tier 2

pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) Tier 2Pharmacological Chaperone-Alpha-Galactosid.A StabzGALAFOLD ORAL CAPSULE 123 MG Tier 5 PA

Pku Treatment Agents - Phenylalanine Ammonia LyasePALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML

Tier 5 PA

Pku Tx Agent-Cofactor Of Phenylalanine HydroxylaseKUVAN ORAL POWDER IN PACKET 100 MG, 500 MG

Tier 5 PA

KUVAN ORAL TABLET,SOLUBLE 100 MG

Tier 5 PA

Neoplastic Disease

Alkylating Agentscyclophosphamide oral capsule 25 mg, 50 mg

Tier 5


115

Drug Status Notes

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

Tier 3

GLIADEL WAFER IMPLANT WAFER 7.7 MG

Tier 3

hydroxyurea oral capsule 500 mg (Hydrea) Tier 2

LEUKERAN ORAL TABLET 2 MG Tier 3

MYLERAN ORAL TABLET 2 MG Tier 3

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

(Temodar) Tier 5 PA

Antiandrogenic Agentsabiraterone oral tablet 250 mg (Zytiga) Tier 5 PA; QL (4 EA per 1 day)

bicalutamide oral tablet 50 mg (Casodex) Tier 2

ERLEADA ORAL TABLET 60 MG Tier 5 PA

flutamide oral capsule 125 mg Tier 2

nilutamide oral tablet 150 mg (Nilandron) Tier 5 QL: 1 PER DAY AFTER 30 DAYS

NUBEQA ORAL TABLET 300 MG Tier 5 PA

XTANDI ORAL CAPSULE 40 MG Tier 5 PA; QL (4 EA per 1 day)

ZYTIGA ORAL TABLET 500 MG Tier 5 PA; QL (2 EA per 1 day)Antimetabolitescapecitabine oral tablet 150 mg (Xeloda) Tier 5 PA; QL (28 EA per 21

days)

capecitabine oral tablet 500 mg (Xeloda) Tier 5 PA; QL (112 EA per 21 days)

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

Tier 5 PA

mercaptopurine oral tablet 50 mg Tier 2

methotrexate sodium (pf) injection solution 25 mg/ml

Tier 2

methotrexate sodium injection solution25 mg/ml

Tier 2

methotrexate sodium oral tablet 2.5 mg Tier 2

PURIXAN ORAL SUSPENSION 20 MG/ML

Tier 5

TABLOID ORAL TABLET 40 MG Tier 3

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

Tier 3

XATMEP ORAL SOLUTION 2.5 MG/ML Tier 3 ST; ST: Prior prescription for Methotrexate tablets or injection solution in the last 120 days if 12 years of age or older; QL (120 ML per 60 days)

Antineoplastic Aromatase Inhibitorsanastrozole oral tablet 1 mg (Arimidex) Tier 2

exemestane oral tablet 25 mg (Aromasin) Tier 2

letrozole oral tablet 2.5 mg (Femara) Tier 2


116

Drug Status Notes

Antineoplastic - Braf Kinase InhibitorsTAFINLAR ORAL CAPSULE 50 MG, 75 MG

Tier 5 PA

Antineoplastic - Janus Kinase (Jak) InhibitorsJAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


Antineoplastic - Mek1 And Mek2 Kinase InhibitorsCOTELLIC ORAL TABLET 20 MG Tier 5 PA; QL (63 EA per 28

days)

MEKINIST ORAL TABLET 0.5 MG, 2 MG

Tier 5 PA

Antineoplastic - Mtor Kinase InhibitorsAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

Tier 5 PA

AFINITOR ORAL TABLET 10 MG Tier 5 PA; QL (2 EA per 1 day)

AFINITOR ORAL TABLET 2.5 MG Tier 5 PA; QL (1 EA per 1 day)

everolimus (antineoplastic) oral tablet 5 mg

(Afinitor) Tier 2 PA; QL (1 EA per 1 day)

everolimus (antineoplastic) oral tablet7.5 mg

(Afinitor) Tier 2 PA; QL (2 EA per 1 day)

Antineoplastic - Topoisomerase I InhibitorsHYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

Tier 5

Antineoplastic Immunomodulator AgentsPOMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

Tier 5 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG


SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

Tier 5

Antineoplastic Systemic Enzyme InhibitorsBOSULIF ORAL TABLET 100 MG Tier 5 PA; QL (4 EA per 1 day)

BOSULIF ORAL TABLET 500 MG Tier 5 PA; QL (1 EA per 1 day)

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

Tier 5 PA

CAPRELSA ORAL TABLET 100 MG Tier 5 PA; QL (2 EA per 1 day)

CAPRELSA ORAL TABLET 300 MG Tier 5 PA; QL (1 EA per 1 day)

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


erlotinib oral tablet 100 mg, 150 mg (Tarceva) Tier 5 PA; QL (3 EA per 1 day)

erlotinib oral tablet 25 mg (Tarceva) Tier 5 PA; QL (2 EA per 1 day)


117

Drug Status Notes

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

Tier 5 PA

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG

Tier 5 PA

ICLUSIG ORAL TABLET 15 MG Tier 5 PA; QL (2 EA per 1 day)

ICLUSIG ORAL TABLET 45 MG Tier 5 PA; QL (1 EA per 1 day)

imatinib oral tablet 100 mg (Gleevec) Tier 5 PA; QL (3 EA per 1 day)

imatinib oral tablet 400 mg (Gleevec) Tier 5 PA; QL (2 EA per 1 day)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

Tier 5 PA

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

Tier 5 PA

IRESSA ORAL TABLET 250 MG Tier 5 PA

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)

Tier 5 PA

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)

Tier 5 PA

LYNPARZA ORAL TABLET 100 MG, 150 MG


NEXAVAR ORAL TABLET 200 MG Tier 5 PA; QL (4 EA per 1 day)

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG

Tier 5 PA

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG


RYDAPT ORAL CAPSULE 25 MG Tier 5 PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG


SPRYCEL ORAL TABLET 20 MG Tier 5 PA; QL (2 EA per 1 day)

STIVARGA ORAL TABLET 40 MG Tier 5 PA; QL (3 EA per 1 day)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


TAGRISSO ORAL TABLET 40 MG, 80 MG


TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG


TYKERB ORAL TABLET 250 MG Tier 5 PA

VOTRIENT ORAL TABLET 200 MG Tier 5 PA; QL (4 EA per 1 day)

ZEJULA ORAL CAPSULE 100 MG Tier 5 PA

ZYKADIA ORAL TABLET 150 MG Tier 5 PA


118

Drug Status Notes

Antineoplastic,Histone Deacetylase Inhibitors,HdisFARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

Tier 5 PA

ZOLINZA ORAL CAPSULE 100 MG Tier 5 PAAntineoplastics,MiscellaneousLYSODREN ORAL TABLET 500 MG Tier 3

MATULANE ORAL CAPSULE 50 MG Tier 5

SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG

Tier 5 PA

tretinoin (antineoplastic) oral capsule 10 mg


Chemotherapy Rescue/Antidote Agentsleucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

Tier 2

MESNEX ORAL TABLET 400 MG Tier 3

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


Photoactivated, Antineopls. & Premalignant LesionsLEVULAN TOPICAL SOLUTION 20 % Tier 3

Selective Estrogen Receptor Modulators (Serm)FARESTON ORAL TABLET 60 MG Tier 3 PA

SOLTAMOX ORAL SOLUTION 10 MG/5 ML

Tier 3

tamoxifen oral tablet 10 mg, 20 mg Tier 2Selective Retinoid X Receptor Agonists (Rxr)bexarotene oral capsule 75 mg (Targretin) Tier 5 PA

Steroid AntineoplasticsEMCYT ORAL CAPSULE 140 MG Tier 3

megestrol oral tablet 20 mg, 40 mg Tier 2Neurological Disease - Miscellaneous

Agents To Treat Multiple SclerosisAUBAGIO ORAL TABLET 14 MG, 7 MG Tier 5 PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML

Tier 5 PA

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML

Tier 5 PA

BETASERON SUBCUTANEOUS KIT 0.3 MG

Tier 5 PA

BETASERON SUBCUTANEOUS RECON SOLN 0.3 MG

Tier 5 PA

EXTAVIA SUBCUTANEOUS KIT 0.3 MG

Tier 5 PA

EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG

Tier 5 PA


119

Drug Status Notes

GILENYA ORAL CAPSULE 0.5 MG Tier 5 PA

glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml

(Glatopa) Tier 5 PA

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML

Tier 5 PA

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

Tier 5 PA

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

Tier 5 PA

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

Tier 5 PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

Tier 5 PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

Tier 5 PA

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

Tier 5 PA

VUMERITY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 231 MG

Tier 5 PA

Agts Tx Neuromusc Transmission Dis,Pot-Chan Blkrdalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra) Tier 5 PA

Amyotrophic Lateral Sclerosis Agentsriluzole oral tablet 50 mg (Rilutek) Tier 2

Fibromyalgia Agents,Serotonin-Norepineph Ru InhibSAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

Tier 4

Movement Disorders(Drug Therapy)INGREZZA INITIATION PACK ORAL CAPSULE,DOSE PACK 40 MG (7)- 80 MG (21)

Tier 5 PA

INGREZZA ORAL CAPSULE 40 MG Tier 5 PA

tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Tier 2 PAPseudobulbar Affect (Pba) Agents, Nmda AntagonistsNUEDEXTA ORAL CAPSULE 20-10 MG Tier 4 PA


120

Drug Status Notes

Oral/Pharyngeal Disorders

Dental Aids And Preparationschlorhexidine gluconate mucous membrane mouthwash 0.12 %

(Paroex Oral Rinse) Tier 2

ORALONE DENTAL PASTE 0.1 % Tier 2

PAROEX ORAL RINSE MUCOUS MEMBRANE MOUTHWASH 0.12 %

Tier 2

PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 %

Tier 2

triamcinolone acetonide dental paste 0.1 %

(Oralone) Tier 2

Nose Preparations, Miscellaneous (Rx)ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %)

Tier 2

Periodontal Collagenase Inhibitorsdoxycycline hyclate oral tablet 20 mg Tier 2

Other Drugs

Abortifacient,Progesterone Receptor Antagonist-TypMIFEPREX ORAL TABLET 200 MG Tier 4

mifepristone oral tablet 200 mg (Mifeprex) Tier 2Agents For Stomatological UseDEBACTEROL MUCOUS MEMBRANE SOLUTION 30-50 %

Tier 3

DEBACTEROL MUCOUS MEMBRANE SWAB 30-50 %

Tier 3

Appetite Stim. For Anorexia,Cachexia,Wasting Synd.megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125 mg/ml)

Tier 2

Drugs To Tx Gaucher Dx-Type 1, Substrate Reducingmiglustat oral capsule 100 mg (Zavesca) Tier 5 PA

General Inhalation AgentsHYPER-SAL INHALATION SOLUTION FOR NEBULIZATION 3.5 %

Tier 3

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 3 %

Tier 2

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 6 %

Tier 3

sodium chloride inhalation solution for nebulization 0.9 %, 10 %

Tier 2

sodium chloride inhalation solution for nebulization 3 %

(NebuSal) Tier 2

sodium chloride inhalation solution for nebulization 7 %

(Hyper-Sal) Tier 2


121

Drug Status Notes

Metabolic Deficiency AgentsCARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML

Tier 4

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML

Tier 5

levocarnitine (with sugar) oral solution100 mg/ml

(Carnitor) Tier 2

levocarnitine oral solution 100 mg/ml (Carnitor (sugar-free)) Tier 2

levocarnitine oral tablet 330 mg (Carnitor) Tier 2Metallic Poison,Agents To TreatCHEMET ORAL CAPSULE 100 MG Tier 3

CLOVIQUE ORAL CAPSULE 250 MG Tier 2 PA

deferasirox oral tablet 180 mg, 360 mg, 90 mg

(Jadenu) Tier 2 PA

deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg

(Exjade) Tier 5 PA

GALZIN ORAL CAPSULE 25 MG (ZINC), 50 MG (ZINC)

Tier 3

RADIOGARDASE ORAL CAPSULE 0.5 GRAM

Tier 3

trientine oral capsule 250 mg (Clovique) Tier 2 PANeedles/Needleless Devices1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

1ST TIER UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

ABOUTTIME PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32"

Tier 2

ASSURE ID PEN NEEDLE NEEDLE 30 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16"

Tier 2

BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 GAUGE X 3/16"

Tier 2

BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X 5/32"

Tier 2

BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 GAUGE X 1/4"

Tier 2

BD ULTRA-FINE MINI PEN NEEDLE NEEDLE 31 GAUGE X 3/16"

Tier 2


122

Drug Status Notes

BD ULTRA-FINE NANO PEN NEEDLE NEEDLE 32 GAUGE X 5/32"

Tier 2

BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE 29 GAUGE X 1/2"

Tier 2

BD ULTRA-FINE SHORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16"

Tier 2

CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

CARETOUCH PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

CLICKFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/16", 33 GAUGE X 5/32"

Tier 2

DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"

Tier 2

EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32"

Tier 2

EASY GLIDE PEN NEEDLE NEEDLE 33 GAUGE X 5/32"

Tier 2

EASY TOUCH NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16"

Tier 2

EASY TOUCH SAFETY PEN NEEDLE NEEDLE 30 GAUGE X 3/16"

Tier 2


123

Drug Status Notes

HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

INSUPEN NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

Tier 2

LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16"

Tier 2

MAXICOMFORT II PEN NEEDLE NEEDLE 31 GAUGE X 1/4"

Tier 2

MAXICOMFORT SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 29 GAUGE X 5/16"

Tier 2

MICRODOT INSULIN PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

Tier 2

MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16"

Tier 2

NOVOFINE 32 NEEDLE 32 GAUGE X 1/4"

Tier 2

NOVOFINE AUTOCOVER NEEDLE 30 GAUGE X 1/3"

Tier 2

NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6"

Tier 2

NOVOTWIST NEEDLE 32 GAUGE X 1/5"

Tier 2

PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

pen needle, diabetic needle 29 gauge x 1/2", 31 gauge x 1/4", 31 gauge x 3/16", 31 gauge x 5/16", 32 gauge x 5/32"

(1st Tier Unifine Pentips) Tier 2

pen needle, diabetic needle 30 gauge x 5/16"

(AboutTime Pen Needle) Tier 2

pen needle, diabetic needle 31 gauge x 1/3", 31 gauge x 1/6"

Tier 2


124

Drug Status Notes


(BD Ultra-Fine Micro Pen Needle)

Tier 2


(CareFine Pen Needle) Tier 2


(Advocate Pen Needle) Tier 2

PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"

Tier 2

PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

PURE COMFORT PEN NEEDLE NEEDLE 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

RELION NEEDLES NEEDLE 31 GAUGE X 1/4"

Tier 2

RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32"

Tier 2

SAFETY PEN NEEDLE NEEDLE 31 GAUGE X 3/16"

Tier 2

SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"

Tier 2

SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16"

Tier 2

TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2

TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"

Tier 2

TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

TRUEPLUS PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

Tier 2


125

Drug Status Notes

ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"

Tier 2

ULTIGUARD SAFE PACK NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"

Tier 2

ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE X 5/32"

Tier 2

ULTRA FLO PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16"

Tier 2

ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32"

Tier 2

ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

Tier 2

ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X 5/16"

Tier 2

ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X 1/2"

Tier 2

UNIFINE PENTIPS MAXFLOW NEEDLE 30 GAUGE X 3/16"

Tier 2

UNIFINE PENTIPS NEEDLE 29 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

Tier 2

UNIFINE PENTIPS PLUS MAXFLOW NEEDLE 30 GAUGE X 3/16"

Tier 2

UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

Tier 2

VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32"

Tier 2

Somatostatic AgentsSIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

Tier 5 PA

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML

Tier 5


126

Drug Status Notes

Other Respiratory Disorders

Antifibrotic Therapy - Pyridone AnalogsESBRIET ORAL CAPSULE 267 MG Tier 5 PA

ESBRIET ORAL TABLET 267 MG, 801 MG

Tier 5 PA

Cystic Fib.Transmemb Conduct.Reg.(Cftr)PotentiatorKALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG

Tier 5 PA

KALYDECO ORAL TABLET 150 MG Tier 5 PACystic Fibrosis-Cftr Potentiator & Corrector Comb.ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG

Tier 5 PA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

Tier 5 PA

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N)

Tier 5 PA

Mucolyticsacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

Tier 2

PULMOZYME INHALATION SOLUTION 1 MG/ML

Tier 5 PA

Pulmonary Fibrosis - Systemic Enzyme InhibitorsOFEV ORAL CAPSULE 100 MG, 150 MG

Tier 5 PA

Pain Management - Analgesics

Analgesic, Non-Salicylate & Barbiturate Comb.butalbital-acetaminophen oral tablet 50-300 mg

(Bupap) Tier 2 QL (6 EA per 1 day)

butalbital-acetaminophen oral tablet 50-325 mg

(Tencon) Tier 2

TENCON ORAL TABLET 50-325 MG Tier 2Analgesic, Salicylate, Barbiturate,& Xanthine Cmbbutalbital-aspirin-caffeine oral capsule50-325-40 mg

(Fiorinal) Tier 2

Analgesic,Non-Salicylate,Barbiturate,&Xanthine Cmbbutalbital-acetaminophen-caff oral capsule 50-300-40 mg

(Fioricet) Tier 2

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

(Zebutal) Tier 2

butalbital-acetaminophen-caff oral tablet50-325-40 mg

(Esgic) Tier 2


127

Drug Status Notes

FIORICET ORAL CAPSULE 50-300-40 MG

Tier 2

ZEBUTAL ORAL CAPSULE 50-325-40 MG

Tier 2

Analgesic/Antipyretics, Salicylatesdiflunisal oral tablet 500 mg Tier 2

salsalate oral tablet 500 mg, 750 mg (Disalcid) Tier 2Analgesics, Narcotic Agonist And Nsaid Combinationhydrocodone-ibuprofen oral tablet 10-200 mg

(Ibudone) Tier 2

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

Tier 2

ibuprofen-oxycodone oral tablet 400-5 mg

Tier 2

Analgesics,NarcoticsBELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG


belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg

Tier 2

buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour

(Butrans) Tier 2 QL (1 EA per 7 days)

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml

Tier 2

carisoprodol-aspirin-codeine oral tablet200-325-16 mg

Tier 2

DEMEROL (PF) INJECTION SYRINGE 75 MG/ML

Tier 4

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

(Actiq) Tier 2 PA

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

(Duragesic) Tier 2 PA; QL (1 EA per 3 days)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg

(Dilaudid) Tier 2

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg


hydromorphone oral tablet extended release 24 hr 32 mg


HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG



128

Drug Status Notes

meperidine oral solution 50 mg/5 ml Tier 2 QL (30 ML per 1 day)

meperidine oral tablet 100 mg (Demerol) Tier 2 QL (6 EA per 1 day)

METHADONE INTENSOL ORAL CONCENTRATE 10 MG/ML

Tier 2 QL (4 ML per 1 day)

methadone oral concentrate 10 mg/ml (Methadone Intensol) Tier 2 QL (4 ML per 1 day)

methadone oral tablet 10 mg (Dolophine) Tier 2 QL (4 EA per 1 day)

methadone oral tablet 5 mg (Dolophine) Tier 2 QL (8 EA per 1 day)

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)

Tier 2

morphine oral capsule, er multiphase 24 hr 120 mg


morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

(Kadian) Tier 2 QL (2 EA per 1 day)

morphine oral capsule,extend.release pellets 40 mg

(Kadian) Tier 2 QL (1 EA per 1 day)

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

Tier 2

morphine oral tablet 15 mg Tier 2

morphine oral tablet extended release100 mg, 15 mg, 200 mg, 30 mg, 60 mg

(MS Contin) Tier 2 QL (3 EA per 1 day)

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG


NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG


OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG

Tier 3

oxycodone oral capsule 5 mg Tier 2

oxycodone oral concentrate 20 mg/ml Tier 2

oxycodone oral solution 5 mg/5 ml Tier 2

oxycodone oral tablet 10 mg, 20 mg Tier 2

oxycodone oral tablet 15 mg, 30 mg, 5 mg

(Roxicodone) Tier 2

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg

(OxyContin) Tier 2 QL (2 EA per 1 day)

oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg

(OxyContin) Tier 2 QL (4 EA per 1 day)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG



129

Drug Status Notes

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


oxymorphone oral tablet 10 mg, 5 mg Tier 2

oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg


oxymorphone oral tablet extended release 12 hr 30 mg, 40 mg


pentazocine-naloxone oral tablet 50-0.5 mg

Tier 2

tramadol oral tablet 50 mg (Ultram) Tier 2

tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg

Tier 2

tramadol oral tablet, er multiphase 24 hr100 mg, 200 mg, 300 mg

Tier 2

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG


Antimigraine PreparationsAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML

Tier 3 PA

almotriptan malate oral tablet 12.5 mg, 6.25 mg


CAMBIA ORAL POWDER IN PACKET 50 MG


dihydroergotamine injection solution 1 mg/ml

(D.H.E.45) Tier 2 QL (15 ML per 14 days)

dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

(Migranal) Tier 2 QL (8 ML per 28 days)

eletriptan oral tablet 20 mg, 40 mg (Relpax) Tier 2 QL (2 EA per 5 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML

Tier 3 PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML

Tier 3 PA

ERGOMAR SUBLINGUAL TABLET 2 MG


ergotamine-caffeine oral tablet 1-100 mg (Cafergot) Tier 2 QL (10 EA per 7 days)

frovatriptan oral tablet 2.5 mg (Frova) Tier 2 QL (3 EA per 5 days)

MIGERGOT RECTAL SUPPOSITORY 2-100 MG


naratriptan oral tablet 1 mg, 2.5 mg (Amerge) Tier 2 QL (3 EA per 5 days)

rizatriptan oral tablet 10 mg (Maxalt) Tier 2 QL (3 EA per 5 days)

rizatriptan oral tablet 5 mg Tier 2 QL (3 EA per 5 days)

rizatriptan oral tablet,disintegrating 10 mg

(Maxalt-MLT) Tier 2 QL (3 EA per 5 days)

rizatriptan oral tablet,disintegrating 5 mg Tier 2 QL (3 EA per 5 days)


130

Drug Status Notes

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

(Imitrex) Tier 2 QL (6 EA per 15 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

(Imitrex) Tier 2 QL (3 EA per 5 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Refill) Tier 2 QL (1 ML per 14 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Pen) Tier 2 QL (1 ML per 14 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml

(Imitrex) Tier 2 QL (1 ML per 14 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) Tier 2 QL (2 EA per 5 days)

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg

(Zomig ZMT) Tier 2 QL (2 EA per 5 days)

ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG


ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG


Calcitonin Gene-Related Peptide (Cgrp) InhibitorsEMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3)

Tier 3 PA

Narc.& Non-Sal.Analgesic,Barbiturate &Xanthine Cmbbutalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg

(Fioricet with Codeine) Tier 2

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg

Tier 2

Narcotic & Salicylate Analgesics, Barb.& XanthineASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG

Tier 2

BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG

Tier 2

codeine-butalbital-asa-caff oral capsule30-50-325-40 mg

(Ascomp with Codeine) Tier 2

Narcotic Analgesic & Non-Salicylate Analgesic Combacetaminophen-codeine oral solution120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

Tier 2

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

Tier 2

acetaminophen-codeine oral tablet 300-30 mg

(Tylenol-Codeine #3) Tier 2


131

Drug Status Notes

ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


hydrocodone-acetaminophen oral tablet10-300 mg

(Vicodin HP) Tier 2 QL (13 EA per 1 day)


(Lorcet HD) Tier 2 QL (12 EA per 1 day)

hydrocodone-acetaminophen oral tablet2.5-325 mg

Tier 2

hydrocodone-acetaminophen oral tablet5-300 mg, 7.5-300 mg



(Lorcet (hydrocodone)) Tier 2 QL (12 EA per 1 day)

hydrocodone-acetaminophen oral tablet7.5-325 mg

(Lorcet Plus) Tier 2 QL (12 EA per 1 day)

LORCET (HYDROCODONE) ORAL TABLET 5-325 MG


LORCET HD ORAL TABLET 10-325 MG Tier 2 QL (12 EA per 1 day)

LORCET PLUS ORAL TABLET 7.5-325 MG


LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML

Tier 3

oxycodone-acetaminophen oral tablet10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

(Endocet) Tier 2 QL (12 EA per 1 day)

PRIMLEV ORAL TABLET 5-300 MG, 7.5-300 MG


tramadol-acetaminophen oral tablet37.5-325 mg

(Ultracet) Tier 2

VICODIN HP ORAL TABLET 10-300 MG Tier 2 QL (13 EA per 1 day)Narcotic And Salicylate Analgesic Combinationoxycodone-aspirin oral tablet 4.8355-325 mg

Tier 2

Narcotic Withdrawal Therapy AgentsBUNAVAIL BUCCAL FILM 2.1-0.3 MG Tier 3 QL (1 EA per 1 day)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG


buprenorphine hcl sublingual tablet 2 mg, 8 mg


buprenorphine-naloxone sublingual film12-3 mg, 8-2 mg

(Suboxone) Tier 2 QL (2 EA per 1 day)

buprenorphine-naloxone sublingual film2-0.5 mg, 4-1 mg

(Suboxone) Tier 2 QL (1 EA per 1 day)

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg



132

Drug Status Notes

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG


Parkinsons Disease

Antiparkinsonism Drugs,Anticholinergicbenztropine oral tablet 0.5 mg, 1 mg, 2 mg

Tier 2

trihexyphenidyl oral tablet 2 mg, 5 mg Tier 2Antiparkinsonism Drugs,Otheramantadine hcl oral capsule 100 mg Tier 2

amantadine hcl oral tablet 100 mg Tier 2

bromocriptine oral capsule 5 mg (Parlodel) Tier 2

bromocriptine oral tablet 2.5 mg (Parlodel) Tier 2

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

(Sinemet) Tier 2

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg

Tier 2

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

Tier 2

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

(Stalevo 50) Tier 2


(Stalevo 75) Tier 2

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

(Stalevo 100) Tier 2





carbidopa-levodopa-entacapone oral tablet 50-200-200 mg


DUOPA J-TUBE INTESTINAL PUMP SUSPENSION 4.63-20 MG/ML

Tier 3 PA

entacapone oral tablet 200 mg (Comtan) Tier 2

INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 MG

Tier 5 PA

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR


pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

(Mirapex) Tier 2


133

Drug Status Notes

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

(Mirapex ER) Tier 2 QL (1 EA per 1 day)

rasagiline oral tablet 0.5 mg, 1 mg (Azilect) Tier 2 QL (1 EA per 1 day)

ropinirole oral tablet 0.25 mg, 3 mg, 5 mg

(Requip) Tier 2

ropinirole oral tablet 0.5 mg, 1 mg, 2 mg, 4 mg

Tier 2

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 6 mg

(Requip XL) Tier 2 QL (1 EA per 1 day)

ropinirole oral tablet extended release 24 hr 4 mg, 8 mg


RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG


selegiline hcl oral capsule 5 mg Tier 2

tolcapone oral tablet 100 mg (Tasmar) Tier 2 QL (3 EA per 1 day)

ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG


Decarboxylase Inhibitorscarbidopa oral tablet 25 mg (Lodosyn) Tier 2

Seizure Disorder

Anticonvulsant - Benzodiazepine Typeclobazam oral suspension 2.5 mg/ml (Onfi) Tier 2 QL (480 ML per 30 days)

clobazam oral tablet 10 mg, 20 mg (Onfi) Tier 2 QL (2 EA per 1 day)

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

(Klonopin) Tier 2

clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 2

DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG

Tier 3 QL (1 EA per 1 FILL)

DIASTAT RECTAL KIT 2.5 MG Tier 3 QL (1 EA per 1 FILL)

diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg

(Diastat AcuDial) Tier 2 QL (1 EA per 1 FILL)

diazepam rectal kit 2.5 mg (Diastat) Tier 2 QL (1 EA per 1 FILL)

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

Tier 3

NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)

Tier 4

AnticonvulsantsAPTIOM ORAL TABLET 400 MG Tier 3 QL (1 EA per 1 day)

APTIOM ORAL TABLET 600 MG, 800 MG


BANZEL ORAL SUSPENSION 40 MG/ML


BANZEL ORAL TABLET 200 MG Tier 3 QL (16 EA per 1 day)

BANZEL ORAL TABLET 400 MG Tier 3 QL (8 EA per 1 day)

BRIVIACT ORAL SOLUTION 10 MG/ML Tier 3 QL (600 ML per 30 days)


134

Drug Status Notes

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG


carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

(Carbatrol) Tier 2

carbamazepine oral tablet 200 mg (Epitol) Tier 2

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

(Tegretol XR) Tier 2

carbamazepine oral tablet,chewable 100 mg

Tier 2

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

Tier 3

CELONTIN ORAL CAPSULE 300 MG Tier 3

CEREBYX INJECTION SOLUTION 100 MG PE/2 ML, 500 MG PE/10 ML

Tier 3

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG

Tier 3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG

Tier 3

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG

Tier 3

DILANTIN EXTENDED ORAL CAPSULE 100 MG

Tier 3

DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG

Tier 3

DILANTIN ORAL CAPSULE 30 MG Tier 3

DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML

Tier 3

divalproex oral capsule, delayed rel sprinkle 125 mg

(Depakote Sprinkles) Tier 2

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

(Depakote ER) Tier 2

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

(Depakote) Tier 2

EPITOL ORAL TABLET 200 MG Tier 2

ethosuximide oral capsule 250 mg (Zarontin) Tier 2

ethosuximide oral solution 250 mg/5 ml (Zarontin) Tier 2

felbamate oral tablet 400 mg (Felbatol) Tier 2 QL (9 EA per 1 day)

felbamate oral tablet 600 mg (Felbatol) Tier 2 QL (6 EA per 1 day)

FELBATOL ORAL SUSPENSION 600 MG/5 ML


FELBATOL ORAL TABLET 400 MG Tier 3 QL (9 EA per 1 day)

FELBATOL ORAL TABLET 600 MG Tier 3 QL (6 EA per 1 day)


135

Drug Status Notes

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG


FYCOMPA ORAL TABLET 2 MG Tier 3 QL (120 EA per 30 days)

FYCOMPA ORAL TABLET 4 MG, 6 MG Tier 3 QL (60 EA per 30 days)

gabapentin oral capsule 100 mg, 300 mg, 400 mg

(Neurontin) Tier 2

gabapentin oral solution 250 mg/5 ml (Neurontin) Tier 2

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

Tier 2

gabapentin oral tablet 600 mg, 800 mg (Neurontin) Tier 2

GABITRIL ORAL TABLET 12 MG Tier 4 QL (4 EA per 1 day)

GABITRIL ORAL TABLET 16 MG Tier 4 QL (3 EA per 1 day)

GABITRIL ORAL TABLET 2 MG, 4 MG Tier 3 QL (4 EA per 1 day)

KEPPRA ORAL SOLUTION 100 MG/ML Tier 3

KEPPRA ORAL TABLET 1,000 MG, 250 MG, 500 MG, 750 MG

Tier 3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG

Tier 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG


LAMICTAL ODT ORAL TABLET,DISINTEGRATING 200 MG


LAMICTAL ODT ORAL TABLET,DISINTEGRATING 25 MG, 50 MG


LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG (21) -50 MG (7)

Tier 3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (42) -100 MG (14)

Tier 3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG(14)-50 MG (14)-100 MG (7)

Tier 3

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

Tier 3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

Tier 3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)

Tier 4

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)

Tier 4


136

Drug Status Notes

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)

Tier 4

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG


LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 200 MG, 250 MG, 300 MG


LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 25 MG, 50 MG


LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7)

Tier 3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)

Tier 3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7)

Tier 3

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

(Subvenite) Tier 2

lamotrigine oral tablet extended release 24hr 100 mg

(Lamictal XR) Tier 2 QL (3 EA per 1 day)

lamotrigine oral tablet extended release 24hr 200 mg, 250 mg, 300 mg


lamotrigine oral tablet extended release 24hr 25 mg, 50 mg


lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

(Lamictal) Tier 2

lamotrigine oral tablet,disintegrating 100 mg

(Lamictal ODT) Tier 2 QL (3 EA per 1 day)

lamotrigine oral tablet,disintegrating 200 mg


lamotrigine oral tablet,disintegrating 25 mg, 50 mg


lamotrigine oral tablets,dose pack 25 mg (35)

(Subvenite Starter (Blue) Kit)

Tier 2

lamotrigine oral tablets,dose pack 25 mg (42) -100 mg (7)

(Subvenite Starter (Orange) Kit)

Tier 2

lamotrigine oral tablets,dose pack 25 mg (84) -100 mg (14)

(Subvenite Starter (Green) Kit)

Tier 2

levetiracetam oral solution 100 mg/ml (Keppra) Tier 2

levetiracetam oral solution 500 mg/5 ml (5 ml)

Tier 2

levetiracetam oral tablet 1,000 mg, 750 mg

(Roweepra) Tier 2


137

Drug Status Notes

levetiracetam oral tablet 250 mg, 500 mg (Keppra) Tier 2

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg

(Keppra XR) Tier 2

MYSOLINE ORAL TABLET 250 MG, 50 MG

Tier 3

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

Tier 3

NEURONTIN ORAL SOLUTION 250 MG/5 ML

Tier 3

NEURONTIN ORAL TABLET 600 MG, 800 MG

Tier 3

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

(Trileptal) Tier 2

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

(Trileptal) Tier 2

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG


PEGANONE ORAL TABLET 250 MG Tier 3

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

Tier 3

phenytoin oral suspension 100 mg/4 ml Tier 2

phenytoin oral suspension 125 mg/5 ml (Dilantin-125) Tier 2

phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) Tier 2

phenytoin sodium extended oral capsule100 mg

(Dilantin Extended) Tier 2

phenytoin sodium extended oral capsule200 mg, 300 mg

(Phenytek) Tier 2

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

(Lyrica) Tier 2

primidone oral tablet 250 mg, 50 mg (Mysoline) Tier 2

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 25 MG, 50 MG


QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 150 MG, 200 MG


ROWEEPRA ORAL TABLET 1,000 MG, 750 MG

Tier 2

ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG

Tier 3

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG



138

Drug Status Notes

SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG


SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

Tier 2

SUBVENITE STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)

Tier 2

SUBVENITE STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)

Tier 2

SUBVENITE STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)

Tier 2

TEGRETOL ORAL SUSPENSION 100 MG/5 ML

Tier 3

TEGRETOL ORAL TABLET 200 MG Tier 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG

Tier 3

tiagabine oral tablet 12 mg, 2 mg, 4 mg (Gabitril) Tier 2 QL (4 EA per 1 day)

tiagabine oral tablet 16 mg (Gabitril) Tier 2 QL (3 EA per 1 day)

TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG

Tier 3

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

Tier 3

topiramate oral capsule, sprinkle 15 mg, 25 mg

(Topamax) Tier 2

topiramate oral capsule,sprinkle,er 24hr100 mg, 25 mg, 50 mg

(Qudexy XR) Tier 2 QL (1 EA per 1 day)

topiramate oral capsule,sprinkle,er 24hr150 mg, 200 mg

(Qudexy XR) Tier 2 QL (2 EA per 1 day)

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

(Topamax) Tier 2

TRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 MG/ML)

Tier 3

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

Tier 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG

Tier 3 ST; ST: Prior prescription for immediate release Topiramate in the last 120 days; QL (1 EA per 1 day)

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG

Tier 3 ST; ST: Prior prescription for immediate release Topiramate in the last 120 days; QL (2 EA per 1 day)

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

Tier 2


139

Drug Status Notes

valproic acid oral capsule 250 mg Tier 2

VIMPAT ORAL SOLUTION 10 MG/ML Tier 3 QL (1200 ML per 30 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


ZARONTIN ORAL CAPSULE 250 MG Tier 3

ZARONTIN ORAL SOLUTION 250 MG/5 ML

Tier 3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

Tier 3

zonisamide oral capsule 100 mg, 25 mg (Zonegran) Tier 2

zonisamide oral capsule 50 mg Tier 2Skeletal Muscle Disorder

Agents To Tx Periodic Paralysis - Carbon Anhyd InhKEVEYIS ORAL TABLET 50 MG Tier 5 PA

Skeletal Muscle Relax.& Top.Irritant Counter-IrritantCOMFORT PAC-TIZANIDINE KIT 4 MG Tier 3

Skeletal Muscle Relaxantsbaclofen oral tablet 10 mg, 20 mg, 5 mg Tier 2

carisoprodol oral tablet 250 mg, 350 mg (Soma) Tier 2 QL (4 EA per 1 day)

carisoprodol-aspirin oral tablet 200-325 mg

Tier 2

chlorzoxazone oral tablet 500 mg Tier 2

cyclobenzaprine oral tablet 10 mg, 5 mg Tier 2

dantrolene oral capsule 100 mg Tier 2

dantrolene oral capsule 25 mg, 50 mg (Dantrium) Tier 2

METAXALL ORAL TABLET 800 MG Tier 2

metaxalone oral tablet 800 mg (Metaxall) Tier 2

methocarbamol oral tablet 500 mg Tier 2

methocarbamol oral tablet 750 mg (Robaxin-750) Tier 2

orphenadrine citrate oral tablet extended release 100 mg

Tier 2

tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) Tier 2

tizanidine oral tablet 2 mg Tier 2

tizanidine oral tablet 4 mg (Zanaflex) Tier 2Smoking Cessation

Smoking Deterrent Agents (Ganglionic Stim,Others)NICOTROL INHALATION CARTRIDGE 10 MG

Tier 3 QL (1008 EA per 90 days); Age (Min 12 Years)

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML

Tier 3 QL (160 ML per 90 days); Age (Min 12 Years)

Smoking Deterrent-Nicotinic Recept.Partial AgonistCHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

Tier 3 QL (2 EA per 1 day); Age (Min 18 Years)


140

Drug Status Notes

CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 3 QL (2 EA per 1 day); Age (Min 18 Years)

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

Tier 3 QL (2 EA per 1 day); Age (Min 18 Years)

Smoking Deterrents, Otherbupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

Tier 2 Age (Min 18 Years)

Upper Gastrointestinal Disorders - Digestive

Gastric EnzymesSUCRAID ORAL SOLUTION 8,500 UNIT/ML

Tier 5 PA

Pancreatic EnzymesCREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

Tier 3

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

Tier 3

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT

Tier 3

VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT

Tier 3

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

Tier 3

Upper Gastrointestinal Disorders - Spastic Disease

Anticholinergics/Antispasmodicsdicyclomine oral capsule 10 mg Tier 2

dicyclomine oral solution 10 mg/5 ml Tier 2

dicyclomine oral tablet 20 mg Tier 2


141

Drug Status Notes

Belladonna AlkaloidsED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG

Tier 2

hyoscyamine sulfate oral drops 0.125 mg/ml

(Hyosyne) Tier 2

hyoscyamine sulfate oral elixir 0.125 mg/5 ml

(Hyosyne) Tier 2

hyoscyamine sulfate oral tablet 0.125 mg (Oscimin) Tier 2

hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg

(Oscimin SR) Tier 2

hyoscyamine sulfate oral tablet,disintegrating 0.125 mg

(Ed-Spaz) Tier 2

hyoscyamine sulfate sublingual tablet0.125 mg

(Oscimin SL) Tier 2

HYOSYNE ORAL DROPS 0.125 MG/ML Tier 2

HYOSYNE ORAL ELIXIR 0.125 MG/5 ML

Tier 2

methscopolamine oral tablet 2.5 mg, 5 mg

Tier 2

OSCIMIN ORAL TABLET 0.125 MG Tier 2

OSCIMIN SL SUBLINGUAL TABLET 0.125 MG

Tier 2

OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 HR 0.375 MG

Tier 2

SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG)

Tier 3

Upper Gastrointestinal Disorders - Ulcer Disease

Anticholinergics,Quaternary Ammoniumchlordiazepoxide-clidinium oral capsule5-2.5 mg

(Librax (with clidinium)) Tier 2

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML)

Tier 3

glycopyrrolate oral tablet 1 mg, 2 mg Tier 2

propantheline oral tablet 15 mg Tier 2Anti-Ulcer Preparationsmisoprostol oral tablet 100 mcg, 200 mcg

(Cytotec) Tier 2

sucralfate oral suspension 100 mg/ml (Carafate) Tier 2

sucralfate oral tablet 1 gram (Carafate) Tier 2Anti-Ulcer-H.Pylori Agentsamoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg


OMECLAMOX-PAK ORAL COMBO PACK 20 MG-500 MG- 500 MG (40)

Tier 3


142

Drug Status Notes

PYLERA ORAL CAPSULE 140-125-125 MG

Tier 3

Histamine H2-Receptor Inhibitorscimetidine oral tablet 200 mg (Acid Reducer

(cimetidine))Tier 2

cimetidine oral tablet 300 mg, 400 mg, 800 mg

Tier 2

famotidine oral suspension 40 mg/5 ml (8 mg/ml)

Tier 2

famotidine oral tablet 20 mg (Acid Controller) Tier 2

famotidine oral tablet 40 mg (Pepcid) Tier 2

nizatidine oral capsule 150 mg, 300 mg Tier 2Intestinal Motility Stimulantsmetoclopramide hcl oral tablet 10 mg, 5 mg

(Reglan) Tier 2

metoclopramide hcl oral tablet,disintegrating 10 mg

Tier 2

Proton-Pump Inhibitorsesomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

(Nexium) Tier 2 QL (1 EA per 1 day)

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

(Nexium) Tier 2 QL (2 EA per 1 day)

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

(Heartburn Treatment 24 Hour)

Tier 2

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

(Prevacid) Tier 2

lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg

(Prevacid SoluTab) Tier 2 Age (Max 12 Years)

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg

Tier 2

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

(Zegerid) Tier 2 QL (1 EA per 1 day)

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg

(Protonix) Tier 2

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

(AcipHex) Tier 2 QL (1 EA per 1 day)

Urinary Tract - Functional Disorders

Benign Prostatic Hypertrophy/Micturition Agentsalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) Tier 2

dutasteride oral capsule 0.5 mg (Avodart) Tier 2

finasteride oral tablet 5 mg (Proscar) Tier 2

silodosin oral capsule 4 mg, 8 mg (Rapaflo) Tier 2

tamsulosin oral capsule 0.4 mg (Flomax) Tier 2


143

Drug Status Notes

Bph Agents,5-Alpha-Red Inh & Alpha-1-Adr Antg Cmbdutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg

(Jalyn) Tier 2

Cystine-Depleting Agents, Nephropathic CystinosisCYSTAGON ORAL CAPSULE 150 MG, 50 MG

Tier 5

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG

Tier 5 PA

Kidney Stone AgentsTHIOLA ORAL TABLET 100 MG Tier 5

Overactive Bladder Agents, Beta-3 Adrenergic RecepMYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG

Tier 3

Urinary Ph ModifiersK-PHOS NO 2 ORAL TABLET 305-700 MG

Tier 3

potassium citrate oral tablet extended release 10 meq (1,080 mg)

(Urocit-K 10) Tier 2

potassium citrate oral tablet extended release 15 meq

(Urocit-K 15) Tier 2

potassium citrate oral tablet extended release 5 meq (540 mg)

(Urocit-K 5) Tier 2

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

Tier 3

Urinary Tract Analgesic AgentsELMIRON ORAL CAPSULE 100 MG Tier 4

Urinary Tract Anesthetic/Analgesic Agnt (Azo-Dye)phenazopyridine oral tablet 100 mg, 200 mg

(Pyridium) Tier 2

Urinary Tract Antispasmodic, M(3) Selective Antag.darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg

Tier 2

solifenacin oral tablet 10 mg, 5 mg (Vesicare) Tier 2Urinary Tract Antispasmodic/Antiincontinence Agentflavoxate oral tablet 100 mg Tier 2

GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 MG/GRAM)

Tier 3

oxybutynin chloride oral syrup 5 mg/5 ml Tier 2

oxybutynin chloride oral tablet 5 mg Tier 2

oxybutynin chloride oral tablet extended release 24hr 10 mg, 5 mg

(Ditropan XL) Tier 2


144

Drug Status Notes

oxybutynin chloride oral tablet extended release 24hr 15 mg

Tier 2

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 MG/24 HR

Tier 3

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

(Detrol LA) Tier 2

tolterodine oral tablet 1 mg, 2 mg (Detrol) Tier 2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG

Tier 3

trospium oral capsule,extended release 24hr 60 mg

Tier 2

trospium oral tablet 20 mg Tier 2Vaginal Disorders

Vaginal AntibioticsCLEOCIN VAGINAL SUPPOSITORY 100 MG

Tier 3

clindamycin phosphate vaginal cream 2 %

(Cleocin) Tier 2

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE 2 %

Tier 3

metronidazole vaginal gel 0.75 % (Vandazole) Tier 2

NUVESSA VAGINAL GEL 1.3 % Tier 4

VANDAZOLE VAGINAL GEL 0.75 % Tier 2Vaginal AntifungalsGYNAZOLE-1 VAGINAL CREAM 2 % Tier 3

terconazole vaginal cream 0.4 %, 0.8 % Tier 2

terconazole vaginal suppository 80 mg Tier 2Vaginal AntisepticsFEM PH VAGINAL GEL 0.9-0.025 % Tier 4

RELAGARD VAGINAL GEL 0.9-0.025 % Tier 4Vaginal Estrogen Preparationsestradiol vaginal cream 0.01 % (0.1 mg/gram)

(Estrace) Tier 2

estradiol vaginal tablet 10 mcg (Yuvafem) Tier 2

ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR)


FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR


PREMARIN VAGINAL CREAM 0.625 MG/GRAM

Tier 3

YUVAFEM VAGINAL TABLET 10 MCG Tier 2Vitamin And/Or Mineral Deficiency

Fluoride PreparationsCLINPRO 5000 DENTAL PASTE 1.1 % Tier 2

DENTA 5000 PLUS DENTAL CREAM 1.1 %

Tier 2

DENTAGEL DENTAL GEL 1.1 % Tier 2


145

Drug Status Notes

fluoride (sodium) dental cream 1.1 % (Denta 5000 Plus) Tier 2

fluoride (sodium) dental gel 1.1 % (DentaGel) Tier 2

FLUORIDEX DAILY DEFENSE DENTAL PASTE 1.1 %

Tier 2

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 %

Tier 3

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

Tier 3

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 %

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 %

Tier 3

PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 %

Tier 3

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

Tier 3

PREVIDENT DENTAL SOLUTION 0.2 % Tier 3

SF 5000 PLUS DENTAL CREAM 1.1 % Tier 2

SF DENTAL GEL 1.1 % Tier 2

SODIUM FLUORIDE 5000 PLUS DENTAL CREAM 1.1 %

Tier 2

Folic Acid Preparationsfolic acid injection solution 5 mg/ml Tier 2 $0 COPAY IF FEMALE 0-

50 YEARS OF AGE

folic acid oral tablet 1 mg Tier 2 $0 COPAY IF FEMALE 0-50 YEARS OF AGE

Multivitamin PreparationsFOLET ONE ORAL CAPSULE 38 MG IRON-1 MG -25 MG-225 MG

Tier 3

OBSTETRIX ONE ORAL CAPSULE 38 MG IRON-1 MG -25 MG-225 MG

Tier 3

Prenatal Vitamin PreparationsCITRANATAL (DUAL-IRON) ORAL TABLET 27 MG IRON-1 MG -50 MG

Tier 3

CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK 90 MG IRON-1 MG -50 MG-300 MG

Tier 4

CITRANATAL ASSURE ORAL COMBO PACK 35 MG IRON-1 MG -50 MG-300 MG

Tier 4

CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK 27 MG IRON-1 MG -50 MG-250 MG

Tier 3

CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE 27 MG IRON-1 MG -50 MG-260 MG

Tier 4

PNV-DHA + DOCUSATE ORAL CAPSULE 27-1.25-55-300 MG

Tier 2


146

Drug Status Notes

PRENAISSANCE ORAL CAPSULE 29-1.25-55-325 MG

Tier 2

PRENAISSANCE PLUS ORAL CAPSULE 28-1-50-250 MG

Tier 2

PRENATABS RX ORAL TABLET 29 MG IRON- 1 MG

Tier 2

PRENATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG IRON- 1 MG-25 MG

Tier 2

PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG

Tier 2

PREPLUS ORAL TABLET 27 MG IRON- 1 MG

Tier 2

TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-1.2 MG-55 MG-265 MG

Tier 2

VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-200 MG

Tier 3

ZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

Tier 2

Vitamin B PreparationsPOTABA ORAL CAPSULE 500 MG Tier 3

Vitamin B12 Preparationscyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml

Tier 2

NASCOBAL NASAL SPRAY,NON-AEROSOL 500 MCG/SPRAY

Tier 3

Vitamin D Preparationscalcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) Tier 2

ergocalciferol (vitamin d2) oral capsule1,250 mcg (50,000 unit)

(Vitamin D2) Tier 2 $0 COPAY IF AGE 65 YEARS OR OLDER

VITAMIN D2 ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 2 $0 COPAY IF AGE 65 YEARS OR OLDER

Weight Reduction

Anorexic Agentsbenzphetamine oral tablet 50 mg Tier 2

diethylpropion oral tablet 25 mg Tier 2

diethylpropion oral tablet extended release 75 mg

Tier 2

LOMAIRA ORAL TABLET 8 MG Tier 2

phendimetrazine tartrate oral tablet 35 mg

Tier 2

phentermine oral capsule 15 mg, 30 mg Tier 2

phentermine oral capsule 37.5 mg (Adipex-P) Tier 2

phentermine oral tablet 37.5 mg (Adipex-P) Tier 2


147

Drug Status Notes

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG

Tier 4

Anti-Obesity - Opioid Antag/Norepi & Da Reup InhibCONTRAVE ORAL TABLET EXTENDED RELEASE 8-90 MG

Tier 3

Anti-Obesity Glucagon-Like Peptide-1 Recep AgonistSAXENDA SUBCUTANEOUS PEN INJECTOR 3 MG/0.5 ML (18 MG/3 ML)

Tier 3

Fat Absorption Decreasing AgentsXENICAL ORAL CAPSULE 120 MG Tier 3


148

Index

1ST TIER UNIFINE PENTIPS....... 1221ST TIER UNIFINE PENTIPS PLUS............................................. 122abacavir ........................................... 88abacavir-lamivudine .........................87abacavir-lamivudine-zidovudine ...... 87abiraterone .....................................116ABOUTTIME PEN NEEDLE.......... 122acamprosate ....................................14acarbose ..........................................54acebutolol ........................................ 23acetaminophen-codeine ................ 131acetazolamide ..................................70acetic acid ........................................58acetylcysteine ................................ 127acitretin ............................................ 51ACTEMRA....................................... 93ACTEMRA ACTPEN........................93ACTIMMUNE...................................78ACTOPLUS MET XR.......................56ACUVAIL (PF)................................. 67acyclovir .....................................45, 86adapalene ........................................43ADASUVE........................................15adefovir ............................................89ADEMPAS....................................... 26ADRENALIN.................................... 42ADVAIR DISKUS...............................6ADVAIR HFA..................................... 6ADVANCED ALLERGY COLLECT KIT................................................... 46ADVOCATE PEN NEEDLE........... 122ADVOCATE SYRINGES................. 98AEROCHAMBER MINI...................... 8AEROCHAMBER MV........................ 8AEROCHAMBER PLUS FLOW-VU...8AEROCHAMBER PLUS FLOW-VU,L MSK..........................................8AEROCHAMBER PLUS FLOW-VU,M MSK.........................................8AEROCHAMBER PLUS FLOW-VU,S MSK..........................................8AEROCHAMBER PLUS Z STAT.......9AEROCHAMBER PLUS Z STAT LG MSK............................................. 9

AEROCHAMBER PLUS Z STAT MD MSK............................................ 9AEROCHAMBER PLUS Z STAT SM MSK.............................................9AEROCHAMBER WITH FLOWSIGNAL................................... 9AEROCHAMBER Z-STAT PLUS-FLW SG.............................................9AFINITOR......................................117AFINITOR DISPERZ..................... 117AFIRMELLE.....................................32AFREZZA........................................ 57AIMOVIG AUTOINJECTOR.......... 130AKLIEF............................................ 43AK-POLY-BAC.................................68AKTEN (PF).....................................68AKYNZEO (NETUPITANT)................4ALA-CORT.......................................46ALA-QUIN........................................42ALA-SCALP.....................................46albendazole ..................................... 85albuterol sulfate ................................. 5ALCAINE......................................... 68alclometasone ..................................46ALDACTAZIDE................................26alendronate ......................................62ALFERON N.................................... 78alfuzosin .........................................143ALINIA............................................. 86aliskiren ............................................27ALLERGIST TRAY 1/2 ML 27GX3/8"......................................... 98ALLERGIST TRAY INTRADERMAL BEV.......................98ALLERGIST TRAY REGULAR BEVEL............................................. 98ALLERGY SYRINGE.......................98allopurinol ........................................ 72almotriptan malate ......................... 130ALOCRIL......................................... 69ALOMIDE.........................................70alosetron ..........................................97ALPHAGAN P..................................70alprazolam ....................................... 14ALPRAZOLAM INTENSOL..............14

ALREX.............................................67ALTACAINE.....................................68ALTAFLUOR BENOX......................68ALTAVERA (28)...............................32ALVESCO..........................................7ALYACEN 1/35 (28).........................32ALYACEN 7/7/7 (28)........................32ALYQ............................................... 26AMABELZ........................................76amantadine hcl .............................. 133ambrisentan .....................................26amcinonide ...................................... 46AMETHIA.........................................33AMETHIA LO...................................33AMETHYST (28)..............................33amiloride .......................................... 26amiloride-hydrochlorothiazide ..........26amiodarone ......................................19AMITIZA...........................................97amitriptyline ......................................13amlodipine ....................................... 24amlodipine-atorvastatin ....................31amlodipine-benazepril ......................20amlodipine-olmesartan .................... 22amlodipine-valsartan ........................22amlodipine-valsartan-hcthiazid ........ 21ammonium lactate ........................... 49AMNESTEEM..................................42amoxicil-clarithromy-lansopraz ...... 142amoxicillin ........................................ 81amoxicillin-pot clavulanate .........81, 82amphetamine sulfate ....................... 13ampicillin ..........................................82ANACAINE...................................... 50ANADROL-50.................................. 75anagrelide ........................................74ANASTIA......................................... 50anastrozole .................................... 116ANDRODERM................................. 75ANGELIQ.........................................75ANORO ELLIPTA.............................. 6ANUCORT-HC.................................96apraclonidine ................................... 70aprepitant ...........................................4APRI................................................ 33

I-1

APRISO........................................... 95APTENSIO XR.................................19APTIOM.........................................134APTIVUS......................................... 87ARANELLE (28)...............................33ARANESP (IN POLYSORBATE)................................................... 72, 73ARCAPTA NEOHALER.....................6ARIKAYCE.......................................84aripiprazole ...................................... 15ARISTADA.......................................15armodafinil ....................................... 18ARMONAIR RESPICLICK................. 7ARMOUR THYROID........................65ARNUITY ELLIPTA............................7ASCOMP WITH CODEINE............131ASHLYNA........................................33ASMANEX HFA.................................7ASMANEX TWISTHALER................. 7aspirin-dipyridamole .........................74ASSURE ID INSULIN SAFETY....... 98ASSURE ID PEN NEEDLE............122ASTAGRAF XL................................78atazanavir ........................................ 88atenolol ............................................ 23atenolol-chlorthalidone .....................24atomoxetine ..................................... 19atorvastatin ...................................... 28atovaquone ......................................86atovaquone-proguanil ......................85ATRIPLA..........................................88atropine ............................................71ATROVENT HFA...............................4AUBAGIO...................................... 119AUBRA............................................ 33AUBRA EQ...................................... 33AUROVELA 1.5/30 (21)...................33AUROVELA 1/20 (21)......................33AUROVELA 24 FE...........................33AUROVELA FE 1.5/30 (28)............. 33AUROVELA FE 1-20 (28)................33AVANDIA.........................................55AVIANE............................................33AVITA.............................................. 43AVONEX........................................119AYUNA............................................ 33AZASAN.......................................... 78AZASITE..........................................68azathioprine ..................................... 78

azelaic acid ......................................42azelastine .....................................3, 66AZELEX...........................................42azithromycin .....................................81AZOPT.............................................70AZURETTE (28).............................. 33bacitracin ......................................... 68bacitracin-polymyxin b ..................... 68baclofen ......................................... 140balsalazide .......................................95BALZIVA (28)...................................33BANZEL.........................................134BASAGLAR KWIKPEN U-100 INSULIN...........................................57BAXDELA........................................ 82BD ALLERGIST TRAY REG BEVEL............................................. 98BD ALLERGY SYRINGE.................98BD AUTOSHIELD DUO PEN NEEDLE........................................ 122BD BLUNT PLASTIC CANNULA.....98BD BULK SYRINGE SLIP TIP.........98BD ECCENTRIC TIP SYRINGE...... 98BD ECLIPSE LUER-LOK.................99BD INSULIN SYRINGE................... 99BD INSULIN SYRINGE HALF UNIT................................................ 99BD INSULIN SYRINGE MICRO-FINE.................................................99BD INSULIN SYRINGE SAFETY-LOK..................................................99BD INSULIN SYRINGE SLIP TIP....99BD INSULIN SYRINGE U-500.........99BD INSULIN SYRINGE ULTRA-FINE.................................................99BD INTEGRA SYRINGE..................99BD INTERLINK BLUNT PLASTIC CAN................................................. 99BD INTERLINK SYRINGE...............99BD LAB ECCENTRIC NON-STERILE..........................................99BD LO-DOSE MICRO-FINE IV........99BD LO-DOSE ULTRA-FINE............ 99BD LUER-LOK BULK SYRINGE..... 99BD LUER-LOK SYRINGE..............100BD LUER-LOK TIP CONTROL SYRING.........................................100BD NANO 2ND GEN PEN NEEDLE........................................ 122

BD POSIFLUSH NORMAL SALINE 0.9....................................................60BD PRECISIONGLIDE.................. 100BD PRE-FILLED NORMAL SALINE............................................60BD PRE-FILLED SALINE BLUNT CAN................................................. 60BD SAFETYGLIDE ALLERGIST TRAY............................................. 100BD SAFETYGLIDE INSULIN SYRINGE.......................................100BD SAFETYGLIDE SHIELDING REG...............................................100BD SAFETYGLIDE SYRINGE.......100BD SAFETYGLIDE TB REG BEVEL........................................... 100BD SAFETYGLIDE TUBERCULIN 100BD SAFETY-LOK DETACHABLE NEEDL...........................................100BD SAFETY-LOK TUBERCULIN.. 101BD SAFETY-LOK WITH LUER-LOK................................................101BD SLIP TIP SYRINGE................. 101B-D SLIP TIP SYRINGE................101BD SYRINGE.................................101BD SYRINGE CATH TIP NONSTERILE................................101BD SYRINGE CATHETER TIP......101BD SYRINGE LUER-LOK NONSTERILE................................101BD SYRINGE LUER-LOK STERILE........................................101BD SYRINGE SLIP TIP NONSTERILE................................101BD SYRINGE-DUAL CANNULA....101BD TUBERCULIN SLIP-TIP.......... 101BD TUBERCULIN SYRINGE.........101BD ULTRA-FINE MICRO PEN NEEDLE........................................ 122BD ULTRA-FINE MINI PEN NEEDLE........................................ 122BD ULTRA-FINE NANO PEN NEEDLE........................................ 123BD ULTRA-FINE ORIG PEN NEEDLE........................................ 123BD ULTRA-FINE SHORT PEN NEEDLE........................................ 123BD VEO INSULIN SYR HALF UNIT.............................................. 101

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BD VEO INSULIN SYRINGE UF...101BEKYREE (28)................................ 33BELBUCA......................................128belladonna alkaloids-opium ........... 128BELSOMRA.....................................18benazepril ........................................ 22benazepril-hydrochlorothiazide ........21BENLYSTA......................................93benzonatate ...............................40, 41benzoyl peroxide ..............................49benzphetamine .............................. 147benztropine ....................................133BEPREVE........................................66BESIVANCE.................................... 68BETADINE OPHTHALMIC PREP... 49betamethasone dipropionate ........... 46betamethasone valerate .................. 46betamethasone, augmented ............46BETASERON.................................119betaxolol .................................... 23, 70bethanechol chloride ......................115BETHKIS......................................... 84BETIMOL.........................................70BETOPTIC S................................... 70bexarotene .....................................119bicalutamide ...................................116BIDIL................................................28BIKTARVY.......................................89bisoprolol fumarate .......................... 23bisoprolol-hydrochlorothiazide .........24BLEPH-10........................................68BLEPHAMIDE..................................68BLEPHAMIDE S.O.P.......................68BLISOVI 24 FE................................ 33BLISOVI FE 1.5/30 (28)...................33BLISOVI FE 1/20 (28)......................33bosentan ..........................................27BOSULIF....................................... 117BP 10-1............................................45BRAVELLE...................................... 61BREO ELLIPTA................................. 6BRIELLYN....................................... 33BRILINTA.........................................74brimonidine ...................................... 70BRIVIACT.............................. 134, 135BROMFED DM................................ 41bromfenac ........................................67bromocriptine .................................133brompheniramine-pseudoeph-dm ....41

budesonide .................................. 7, 92bumetanide ......................................26BUNAVAIL.....................................132buprenorphine ................................128buprenorphine hcl ..........................132buprenorphine-naloxone ................132bupropion hcl ................................... 10bupropion hcl (smoking deter) ....... 141buspirone .........................................14BUTALBITAL COMPOUND W/CODEINE..................................131butalbital-acetaminop-caf-cod ........131butalbital-acetaminophen ...............127butalbital-acetaminophen-caff ........127butalbital-aspirin-caffeine ...............127butorphanol tartrate ....................... 128BYDUREON.................................... 53BYDUREON BCISE.........................52BYETTA...........................................53BYSTOLIC.......................................23cabergoline ...................................... 64CABOMETYX................................ 117calcipotriene .....................................51calcipotriene-betamethasone ...........52calcitonin (salmon) ...........................62calcitriol ....................................51, 147calcium acetate(phosphat bind) .......59CAMBIA.........................................130CAMILA........................................... 33CAMRESE.......................................34CAMRESE LO................................. 34candesartan .....................................23candesartan-hydrochlorothiazid .......22capecitabine ...................................116CAPEX.............................................46CAPRELSA....................................117captopril ........................................... 22captopril-hydrochlorothiazide ...........21CARBAGLU.....................................96carbamazepine .............................. 135CARBATROL.................................135carbidopa .......................................134carbidopa-levodopa ....................... 133carbidopa-levodopa-entacapone ... 133carbinoxamine maleate ......................3CARDIZEM LA.................................24CARDURA XL..................................21CAREFINE PEN NEEDLE.............123

CAREPOINT LUER SLIP SYRINGE.......................................101CARETOUCH INSULIN SYRINGE101CARETOUCH PEN NEEDLE........ 123carisoprodol ................................... 140carisoprodol-aspirin ....................... 140carisoprodol-aspirin-codeine ..........128CARNITOR (SUGAR-FREE)......... 122carteolol ........................................... 70CARTIA XT......................................24carvedilol ..........................................21carvedilol phosphate ........................21CAYSTON....................................... 79CAZIANT (28)..................................34cefaclor ............................................ 79cefadroxil ......................................... 79cefdinir ............................................. 80cefditoren pivoxil ..............................80cefixime ............................................80cefpodoxime .................................... 80cefprozil ..................................... 79, 80cefuroxime axetil ..............................80celecoxib ..........................................94CELONTIN.....................................135CENTANY AT..................................43cephalexin ........................................79CEREBYX......................................135CERVIDIL........................................ 40CESAMET......................................... 3CETROTIDE....................................64cevimeline ......................................115CHANTIX.......................................141CHANTIX CONTINUING MONTH BOX............................................... 140CHANTIX STARTING MONTH BOX............................................... 141CHATEAL (28).................................34CHATEAL EQ (28)...........................34CHEMET........................................122CHENODAL.....................................97chlordiazepoxide hcl ........................ 14chlordiazepoxide-clidinium .............142chlorhexidine gluconate .................121chloroquine phosphate .................... 85chlorothiazide ...................................27chlorthalidone .................................. 27chlorzoxazone ................................140CHOLBAM.......................................97cholestyramine (with sugar) .............30

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CHOLESTYRAMINE LIGHT............30chorionic gonadotropin, human ....... 61CICLODAN KIT................................44ciclopirox ..........................................44ciclopirox-ure-camph-menth-euc ..... 44cilostazol ..........................................74CILOXAN.........................................68CIMDUO.......................................... 87cimetidine .......................................143CIMZIA.............................................90CIMZIA POWDER FOR RECONST 90CIMZIA STARTER KIT.................... 90cinacalcet .........................................63CIPRO............................................. 82CIPRO HC....................................... 59CIPRO XR....................................... 82CIPRODEX......................................59ciprofloxacin .....................................82ciprofloxacin hcl ................... 58, 69, 82citalopram ........................................ 10CITRANATAL (DUAL-IRON)......... 146CITRANATAL 90 DHA (ALGAL OIL)................................................146CITRANATAL ASSURE.................146CITRANATAL DHA (ALGAL OIL)..146CITRANATAL HARMONY (IRON FUM)..............................................146CLARAVIS.......................................42CLARINEX-D 12 HOUR.................... 3clarithromycin ...................................81clemastine ..........................................3CLEOCIN.......................................145CLICKFINE PEN NEEDLE............ 123CLIMARA PRO................................76clindamycin hcl ................................ 85clindamycin palmitate hcl .................85CLINDAMYCIN PEDIATRIC............85clindamycin phosphate ............ 43, 145clindamycin-benzoyl peroxide ..........42CLINDESSE.................................. 145CLINPRO 5000..............................145clobazam ....................................... 134clobetasol ...................................46, 47clobetasol-emollient .........................47clocortolone pivalate ........................47CLODAN KIT................................... 47clomiphene citrate ............................60clomipramine ................................... 13clonazepam ................................... 134

clonidine ...........................................23clonidine hcl ...............................18, 23clopidogrel ....................................... 74clorazepate dipotassium ..................14clotrimazole ................................44, 83clotrimazole-betamethasone ............44CLOVIQUE.................................... 122clozapine ..........................................16COARTEM.......................................86codeine-butalbital-asa-caff .............131codeine-guaifenesin .........................41colchicine .........................................72colesevelam .....................................30COLESTID FLAVORED.................. 30colestipol ..........................................30COLOCORT.................................... 96COMBIGAN..................................... 70COMBIPATCH.................................76COMBIVENT RESPIMAT.................. 6COMETRIQ................................... 117COMFORT EZ INSULIN SYRINGE....................................................... 102COMFORT EZ PEN NEEDLES.....123COMFORT PAC-IBUPROFEN........ 93COMFORT PAC-MELOXICAM....... 93COMFORT PAC-NAPROXEN.........93COMFORT PAC-TIZANIDINE....... 140COMPLERA.....................................89COMPRO...........................................4CONDYLOX.....................................49CONSTULOSE................................97CONTRAVE...................................148CORDRAN TAPE LARGE ROLL.....47CORLANOR.................................... 31CORTANE-B....................................58CORTIFOAM................................... 96CORTISPORIN................................46CORTISPORIN-TC..........................58COSENTYX.....................................51COSENTYX (2 SYRINGES)............ 51COSENTYX PEN.............................51COSENTYX PEN (2 PENS)............ 51COSOPT..........................................70COTELLIC..................................... 117COUMADIN..................................... 72COVARYX....................................... 75COVARYX H.S................................ 75CREON..........................................141CRESEMBA.....................................83

CRINONE.................................. 61, 77CRIXIVAN........................................88cromolyn ...................................... 8, 70CRYSELLE (28)...............................34CUPRIMINE.....................................90CUVPOSA..................................... 142cyanocobalamin (vitamin b-12) ......147CYCLAFEM 1/35 (28)......................34CYCLAFEM 7/7/7 (28).....................34cyclobenzaprine .............................140CYCLOMYDRIL...............................71cyclopentolate ..................................71cyclophosphamide .........................115cycloserine .......................................84CYCLOSET..................................... 54cyclosporine .....................................78cyclosporine modified ...................... 78cyproheptadine .................................. 3CYRED............................................ 34CYRED EQ......................................34CYSTADANE.................................122CYSTAGON...................................144CYSTARAN..................................... 72CYTOMEL....................................... 65dalfampridine ................................. 120DALIRESP.........................................8danazol ............................................ 65dantrolene ......................................140dapsone .....................................42, 84darifenacin ..................................... 144DASETTA 1/35 (28).........................34DASETTA 7/7/7 (28)........................34DAVOL IRRIGATION SYRINGE... 102DAVOL PISTON IRRIGATION...... 102DAYSEE.......................................... 34DDAVP............................................ 61DEBACTEROL.............................. 121DEBLITANE.....................................34DECADRON.................................... 92deferasirox .....................................122DELSTRIGO....................................89DEMEROL (PF).............................128DEMSER......................................... 23DENTA 5000 PLUS....................... 145DENTAGEL................................... 145DEPAKOTE................................... 135DEPAKOTE ER............................. 135DEPAKOTE SPRINKLES..............135DEPEN TITRATABS........................90

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DEPO-ESTRADIOL.........................76DEPO-SUBQ PROVERA 104..........32DESCOVY....................................... 87desipramine ..................................... 13desmopressin .................................. 61desog-e.estradiol/e.estradiol ............34desogestrel-ethinyl estradiol ............34DESONATE.....................................47desonide .......................................... 47DESOWEN...................................... 47desoximetasone ...............................47desvenlafaxine .................................11desvenlafaxine succinate .................11dexamethasone ............................... 92DEXAMETHASONE INTENSOL..... 92dexmethylphenidate .........................19dextroamphetamine .........................13dextroamphetamine-amphetamine ..13DIASTAT........................................134DIASTAT ACUDIAL.......................134diazepam ................................. 14, 134DIAZEPAM INTENSOL................... 14diazoxide ..........................................56diclofenac epolamine .......................49diclofenac potassium ....................... 94diclofenac sodium ................49, 50, 94diclofenac-misoprostol .....................93dicloxacillin .......................................82dicyclomine ....................................141didanosine ....................................... 88diethylpropion ................................ 147DIFFERIN........................................ 43DIFICID............................................81diflunisal .........................................128DIGITEK.......................................... 20DIGOX............................................. 20digoxin ............................................. 20dihydroergotamine .........................130DILANTIN...................................... 135DILANTIN EXTENDED..................135DILANTIN INFATABS....................135DILANTIN-125............................... 135DILATRATE-SR...............................31diltiazem hcl ...............................24, 25DILT-XR...........................................25DIPENTUM......................................95diphenoxylate-atropine .............. 96, 97dipyridamole .................................... 74disopyramide phosphate ..................20

disulfiram ......................................... 14DIURIL.............................................27divalproex ...................................... 135DIVIGEL...........................................76dofetilide .......................................... 20donepezil ......................................... 10dorzolamide ..................................... 70dorzolamide (pf) ...............................70dorzolamide-timolol ..........................70dorzolamide-timolol (pf) ................... 70DOTTI..............................................76DOVATO..........................................86DOVER BULB SYRINGE................ 98doxazosin .........................................21doxepin ............................................ 13doxercalciferol ..................................64doxycycline hyclate ..................83, 121doxycycline monohydrate ................ 83doxylamine-pyridoxine (vit b6) ........... 4D-PENAMINE.................................. 90DRITHOCREME HP........................ 51dronabinol ..........................................3DROPLET INSULIN SYR HALF UNIT.............................................. 102DROPLET INSULIN SYRINGE..... 102DROPLET PEN NEEDLE..............123DROPSAFE PEN NEEDLE........... 123drospirenone-e.estradiol-lm.fa .........34drospirenone-ethinyl estradiol ..........34DROXIA...........................................75DRYSOL..........................................49DRYSOL DAB-O-MATIC................. 49DULERA............................................ 6duloxetine ........................................ 11DUOPA..........................................133DUPIXENT.........................................8DUREZOL........................................67dutasteride .....................................143dutasteride-tamsulosin ...................144DYANAVEL XR................................13DYRENIUM......................................26E.E.S. 400........................................81EASIVENT HOLDING CHAMBER.....9EASIVENT MASK LARGE.................9EASIVENT MASK MEDIUM.............. 9EASIVENT MASK SMALL.................9EASY COMFORT INSULIN SYRINGE.......................................102EASY COMFORT PEN NEEDLES 123

EASY GLIDE CATHETER TIP SYRING.........................................102EASY GLIDE DENTAL IRRIG SYRING.........................................102EASY GLIDE INSULIN SYRINGE.102EASY GLIDE LUER LOCK SYRINGE.......................................102EASY GLIDE LUER SLIP TB SYRING.........................................103EASY GLIDE PEN NEEDLE..........123EASY TOUCH....................... 104, 123EASY TOUCH FLIPLOCK INSULIN.........................................103EASY TOUCH FLIPLOCK SYRINGE.......................................103EASY TOUCH FLURINGE............ 103EASY TOUCH FLURINGE FLIPLOCK..................................... 103EASY TOUCH FLURINGE FLU TRAY............................................. 103EASY TOUCH FLURINGE SHEATHLOCK.............................. 103EASY TOUCH INSULIN SAFETY SYR............................................... 103EASY TOUCH INSULIN SYRINGE....................................................... 104EASY TOUCH LUER LOCK INSULIN.........................................104EASY TOUCH LUER LOCK SYRINGE.......................................104EASY TOUCH PEN NEEDLE........123EASY TOUCH SAFETY PEN NEEDLE........................................ 123EASY TOUCH SHEATHLOCK INSULIN.........................................104EASY TOUCH SHEATHLOCK SYRG-NDL.................................... 104EASY TOUCH SHEATHLOCK SYRINGE.......................................104EASY TOUCH SYR ALLERGY TRAY............................................. 104EASY TOUCH TUBERCULIN FLIPLOCK..................................... 104EASY TOUCH TUBERCULIN SHEATHLK....................................104EASY TOUCH UNI-SLIP............... 105ECLIPSE SYRINGE...................... 105EC-NAPROXEN.............................. 94econazole ........................................ 44

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ECOZA............................................ 44EDARBI........................................... 23EDARBYCLOR................................22ED-SPAZ....................................... 142EDURANT....................................... 87EEMT...............................................76EEMT HS.........................................76efavirenz .......................................... 87EFFER-K......................................... 60EGRIFTA......................................... 63EGRIFTA SV................................... 63ELESTRIN....................................... 76eletriptan ........................................130ELIGARD.........................................62ELIGARD (3 MONTH)..................... 61ELIGARD (4 MONTH)..................... 61ELIGARD (6 MONTH)..................... 62ELINEST..........................................34ELIQUIS...........................................72ELIXOPHYLLIN................................. 9ELLA................................................34ELMIRON...................................... 144ELURYNG....................................... 32EMCYT.......................................... 119EMGALITY PEN............................ 130EMGALITY SYRINGE........... 130, 131EMOQUETTE..................................34EMSAM............................................17EMTRIVA.........................................88EMVERM.........................................85enalapril maleate ............................. 22enalapril-hydrochlorothiazide ...........21ENBREL.......................................... 90ENBREL MINI..................................90ENBREL SURECLICK.....................91ENDARI........................................... 75ENDOCET..................................... 132ENDOMETRIN.................................61enoxaparin .......................................73ENPRESSE..................................... 34ENSKYCE........................................35ENSTILAR....................................... 52entacapone ....................................133entecavir .......................................... 89ENTRESTO..................................... 31ENULOSE........................................96ENVARSUS XR...............................78EPCLUSA........................................89EPIFOAM.........................................50

epinastine ........................................ 67epinephrine ..............................20, 115EPIPEN..........................................115EPIPEN 2-PAK.............................. 115EPIPEN JR.................................... 115EPIPEN JR 2-PAK.........................115EPITOL..........................................135eplerenone .......................................26EPOGEN......................................... 73eprosartan ........................................23EQUETRO.......................................15ergocalciferol (vitamin d2) ..............147ERGOMAR.................................... 130ergotamine-caffeine .......................130ERLEADA......................................116erlotinib .......................................... 117ERRIN..............................................35ERY PADS.......................................43ERY-TAB......................................... 81erythromycin .............................. 69, 81erythromycin ethylsuccinate ............ 81erythromycin with ethanol ................43erythromycin-benzoyl peroxide ........43ESBRIET....................................... 127escitalopram oxalate ........................10esomeprazole magnesium .............143ESTARYLLA....................................35estazolam ........................................ 18estradiol ................................... 76, 145estradiol-norethindrone acet ............76ESTRING.......................................145ESTROGEL..................................... 76estrogens-methyltestosterone ......... 76eszopiclone ......................................18ethacrynic acid .................................26ethambutol .......................................84ethosuximide ..................................135ethynodiol diac-eth estradiol ............35etodolac ........................................... 94etonogestrel-ethinyl estradiol ...........32EUTHYROX.....................................65EVAMIST.........................................76everolimus (antineoplastic) ............117everolimus (immunosuppressive) .... 78EVOTAZ.......................................... 88EXCEL SYRINGE..........................105EXEL INSULIN.............................. 105EXEL SYRINGE............................ 105EXELDERM.....................................44

exemestane ................................... 116EXODERM.......................................44EXTAVIA........................................119EZALLOR SPRINKLE......................28ezetimibe ......................................... 30ezetimibe-simvastatin ...................... 28FACTIVE..........................................82FALMINA (28)..................................35famciclovir ........................................86famotidine ...................................... 143FANAPT...........................................16FARESTON................................... 119FARXIGA.........................................53FARYDAK......................................119FAYOSIM.........................................35febuxostat ........................................ 72felbamate .......................................135FELBATOL.................................... 135felodipine ......................................... 25FEM PH......................................... 145FEMRING...................................... 145FEMYNOR.......................................35fenofibrate ........................................30fenofibrate micronized ..................... 30fenofibrate nanocrystallized .............30fenofibric acid ...................................30fenofibric acid (choline) ....................30fentanyl .......................................... 128fentanyl citrate ............................... 128FETZIMA................................... 11, 12finasteride ...................................... 143FIORICET......................................128FIRVANQ.........................................85FLAREX...........................................67flavoxate ........................................ 144flecainide ..........................................20FLOVENT DISKUS............................7FLOVENT HFA..............................7, 8fluconazole .......................................83flucytosine ........................................83fludrocortisone ................................. 93flunisolide ...........................................3fluocinolone ......................................47fluocinolone acetonide oil ................ 58fluocinolone and shower cap ........... 47fluocinonide ......................................47FLUOCINONIDE-E..........................47fluocinonide-emollient ......................47fluoride (sodium) ............................146

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FLUORIDEX DAILY DEFENSE.....146FLUORIDEX SENSITIVITY RELIEF.......................................... 146fluorometholone ...............................67FLUOROPLEX.................................50fluorouracil ....................................... 50fluoxetine ................................... 10, 11fluphenazine hcl ...............................17flurandrenolide .................................47flurbiprofen .......................................94flurbiprofen sodium .......................... 67flutamide ........................................ 116fluticasone propionate ......................47fluticasone propion-salmeterol ...........6fluvastatin .........................................28fluvoxamine ......................................11FML FORTE.................................... 67FML S.O.P.......................................67FOLET ONE.................................. 146folic acid .........................................146FOLLISTIM AQ................................61fondaparinux ....................................73FORTEO..........................................62FOSAMAX PLUS D......................... 62fosamprenavir ..................................88fosinopril .......................................... 22fosinopril-hydrochlorothiazide ..........21FRAGMIN.................................. 73, 74FREESTYLE PRECISION.............105frovatriptan .....................................130furosemide .......................................26FUZEON..........................................87FYAVOLV........................................ 76FYCOMPA.....................................136G TUSSIN AC..................................41gabapentin .....................................136GABITRIL...................................... 136GALAFOLD....................................115galantamine ..................................... 10GALZIN..........................................122ganirelix ........................................... 64gatifloxacin .......................................69GAVILYTE-C................................... 97GAVILYTE-G................................... 97GAVILYTE-N................................... 97GELFILM......................................... 71GELNIQUE.................................... 144gemfibrozil ....................................... 30GENERLAC.....................................96

GENGRAF.......................................78GENOTROPIN.................................63GENOTROPIN MINIQUICK.............63GENTAK..........................................69gentamicin ................................. 43, 69GENVOYA.......................................89GIANVI (28)..................................... 35GILENYA....................................... 120glatiramer .......................................120GLATOPA......................................120GLEOSTINE.................................. 116GLIADEL WAFER..........................116glimepiride ....................................... 54glipizide ......................................54, 55glipizide-metformin ...........................55GLUCAGEN HYPOKIT....................56GLUCAGON (HCL) EMERGENCY KIT................................................... 56GLUCAGON EMERGENCY KIT (HUMAN)......................................... 56glyburide .......................................... 55glyburide micronized ........................55glyburide-metformin .........................55glycopyrrolate ................................ 142GLYDO............................................ 95GONAL-F.........................................61GONAL-F RFF.................................61GONAL-F RFF REDI-JECT............. 61granisetron hcl ................................... 4GRANIX...........................................74griseofulvin microsize ...................... 84griseofulvin ultramicrosize ............... 84GUAIATUSSIN AC.......................... 41GUAIFENESIN AC.......................... 41guanfacine ................................. 18, 23GYNAZOLE-1................................145HAEGARDA.....................................92HAILEY............................................35HAILEY 24 FE................................. 35HAILEY FE 1/20 (28).......................35halobetasol propionate .............. 47, 48HALOG............................................ 48haloperidol ....................................... 17HARVONI........................................ 89HEALTHWISE INSULIN SYRINGE....................................................... 105HEALTHWISE PEN NEEDLE........124HEALTHY ACCENTS UNIFINE PENTIP..........................................124

HEATHER........................................35HEMANGEOL..................................23heparin (porcine) ..............................74heparin, porcine (pf) .........................74HETLIOZ..........................................17HOMATROPAIRE............................71HUMALOG JUNIOR KWIKPEN U-100...................................................57HUMALOG KWIKPEN INSULIN......57HUMALOG MIX 50-50 INSULN U-100...................................................57HUMALOG MIX 50-50 KWIKPEN... 57HUMALOG MIX 75-25 KWIKPEN... 57HUMALOG MIX 75-25(U-100)INSULN.................................... 57HUMALOG U-100 INSULIN.............57HUMATROPE..................................63HUMIRA...........................................91HUMIRA PEN.................................. 91HUMIRA PEN CROHNS-UC-HS START.............................................91HUMIRA PEN PSOR-UVEITS-ADOL HS.........................................91HUMIRA(CF)................................... 91HUMIRA(CF) PEDI CROHNS STARTER........................................91HUMIRA(CF) PEN........................... 91HUMIRA(CF) PEN CROHNS-UC-HS....................................................91HUMIRA(CF) PEN PSOR-UV-ADOL HS.........................................91HUMULIN 70/30 U-100 INSULIN.... 57HUMULIN 70/30 U-100 KWIKPEN..57HUMULIN N NPH INSULIN KWIKPEN........................................ 57HUMULIN N NPH U-100 INSULIN.. 57HUMULIN R REGULAR U-100 INSULN............................................57HUMULIN R U-500 (CONC) INSULIN...........................................58HUMULIN R U-500 (CONC) KWIKPEN........................................ 58HYCAMTIN....................................117hydralazine ...................................... 23hydrochlorothiazide ..........................27hydrocodone-acetaminophen ........ 132hydrocodone-chlorpheniramine ....... 41hydrocodone-homatropine ...............41hydrocodone-ibuprofen ..................128

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hydrocortisone ..................... 48, 92, 96hydrocortisone acetate .................... 96hydrocortisone butyrate ................... 48hydrocortisone butyr-emollient .........48hydrocortisone valerate ................... 48hydrocortisone-acetic acid ...............58hydrocortisone-iodoquinol ................43hydrocortisone-iodoquinol-aloe ........43hydrocortisone-pramoxine ......... 50, 95HYDROMET.................................... 41hydromorphone ..............................128hydroxychloroquine ..........................86hydroxyurea ...................................116hydroxyzine hcl ..................................3hydroxyzine pamoate .........................3HYOPHEN.......................................80hyoscyamine sulfate ...................... 142HYOSYNE..................................... 142HYPERRHO S/D............................. 77HYPER-SAL.................................. 121HYSINGLA ER...............................128HYZAAR.......................................... 22ibandronate ......................................62IBRANCE.......................................118IBU...................................................94ibuprofen ..........................................94ibuprofen-oxycodone ..................... 128ICLUSIG........................................ 118ILARIS (PF)..................................... 91ILEVRO............................................67imatinib .......................................... 118IMBRUVICA...................................118imipramine hcl ..................................13imipramine pamoate ........................ 13imiquimod ........................................ 78INBRIJA.........................................133INCASSIA........................................35INCONTROL PEN NEEDLE..........124INCRELEX.......................................64INCRUSE ELLIPTA........................... 5indapamide ...................................... 27INDOCIN..........................................94indomethacin ................................... 94INGREZZA.....................................120INGREZZA INITIATION PACK...... 120INOVA..............................................50INOVA 4-1....................................... 49INOVA 8-2....................................... 50insulin syr/ndl u100 half mark ........ 105

INSULIN SYRINGE....................... 105INSULIN SYRINGE MICROFINE.. 105insulin syringe needleless ..............105insulin syringe-needle u-100 ..105, 106INSUPEN.......................................124INTEGRA SYRINGE......................106INTELENCE.....................................87INTERLINK SYRINGE AND CANNULA......................................106INTRON A........................................78INTROVALE.................................... 35INVOKAMET....................................55INVOKAMET XR..............................56INVOKANA...................................... 53IODOFLEX.......................................43IOPIDINE.........................................70ipratropium bromide ...................4, 121ipratropium-albuterol ..........................6irbesartan .........................................23irbesartan-hydrochlorothiazide ........ 22IRESSA..........................................118IRRIGATION SYRINGE.................106ISENTRESS.................................... 88ISENTRESS HD.............................. 88ISIBLOOM....................................... 35isoniazid ...........................................84isosorbide dinitrate ...........................31isosorbide mononitrate .............. 31, 32isotretinoin ....................................... 42isoxsuprine .......................................32isradipine ......................................... 25itraconazole ..................................... 83ivermectin .................................. 42, 85JAIMIESS........................................ 35JAKAFI...........................................117JANTOVEN......................................72JANUMET........................................52JANUMET XR..................................52JANUVIA..........................................54JARDIANCE.................................... 53JASMIEL (28).................................. 35JENCYCLA......................................35JENTADUETO.................................52JENTADUETO XR...........................52JINTELI............................................76JOLESSA.........................................35JULEBER.........................................35JUNEL 1.5/30 (21)...........................35JUNEL 1/20 (21)..............................35

JUNEL FE 1.5/30 (28)..................... 35JUNEL FE 1/20 (28)........................ 35JUNEL FE 24...................................35JUXTAPID....................................... 29JYNARQUE..................................... 59KADIAN......................................... 128KAITLIB FE......................................36KALLIGA..........................................36KALYDECO................................... 127KARBINAL ER...................................3KARIVA (28).................................... 36KELNOR 1/35 (28)...........................36KELNOR 1-50..................................36KEPPRA........................................ 136KEPPRA XR.................................. 136KERALYT SCALP COMPLETE.......50ketoconazole ..............................44, 83KETODAN KIT.................................44ketoprofen ........................................94ketorolac .................................... 67, 94KEVEYIS....................................... 140KIONEX (WITH SORBITOL)........... 59KISQALI.........................................118KLONOPIN.................................... 134KLOR-CON M10..............................60KLOR-CON M15..............................60KLOR-CON M20..............................60KOMBIGLYZE XR........................... 52KORLYM..........................................55K-PHOS NO 2................................144KRINTAFEL.....................................86KURVELO (28)................................ 36KUVAN.......................................... 115l norgest/e.estradiol-e.estrad ........... 36labetalol ........................................... 21LACRISERT.....................................71lactulose ...........................................97LAMICTAL..................................... 136LAMICTAL ODT.............................136LAMICTAL ODT STARTER (BLUE)...........................................136LAMICTAL ODT STARTER (GREEN)........................................136LAMICTAL ODT STARTER (ORANGE).....................................136LAMICTAL STARTER (BLUE) KIT 136LAMICTAL STARTER (GREEN) KIT................................................. 136

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LAMICTAL STARTER (ORANGE) KIT................................................. 137LAMICTAL XR............................... 137LAMICTAL XR STARTER (BLUE).137LAMICTAL XR STARTER (GREEN)........................................137LAMICTAL XR STARTER (ORANGE).....................................137lamivudine ..................................88, 89lamivudine-zidovudine ..................... 87lamotrigine ..................................... 137LANOXIN.........................................20lansoprazole .................................. 143lanthanum ........................................59LANTUS SOLOSTAR U-100 INSULIN...........................................58LANTUS U-100 INSULIN.................58LARIN 1.5/30 (21)............................36LARIN 1/20 (21)...............................36LARIN 24 FE....................................36LARIN FE 1.5/30 (28)...................... 36LARIN FE 1/20 (28)......................... 36LARISSIA.........................................36latanoprost .......................................70latanoprost (pf) .................................70LATUDA...........................................16LAYOLIS FE.................................... 36LEENA 28........................................36leflunomide ...................................... 91LENVIMA.......................................118LESSINA..........................................36LETAIRIS.........................................27letrozole ......................................... 116leucovorin calcium ......................... 119LEUKERAN................................... 116leuprolide ......................................... 62levalbuterol hcl ...................................5levalbuterol tartrate ............................5LEVEMIR FLEXTOUCH U-100 INSULN............................................58LEVEMIR U-100 INSULIN...............58levetiracetam ......................... 137, 138levobunolol .......................................71levocarnitine ...................................122levocarnitine (with sugar) ...............122levofloxacin ......................................82LEVONEST (28).............................. 36levonorgestrel-ethinyl estrad ......36, 37levonorg-eth estrad triphasic ........... 37

LEVORA-28.....................................37LEVO-T............................................65levothyroxine ....................................65LEVOXYL........................................ 65LEVULAN...................................... 119lidocaine .....................................50, 51lidocaine hcl ...............................50, 95LIDOCAINE VISCOUS.................... 95lidocaine-hydrocortisone-aloe ..........96lidocaine-prilocaine ..........................51LIDOPIN.......................................... 51LIFESHIELD BLUNT CANNULA... 106LILLOW (28).................................... 37lindane ............................................. 45linezolid ............................................81LINZESS..........................................96liothyronine ...................................... 65lisinopril ............................................22lisinopril-hydrochlorothiazide ........... 21LITE TOUCH INSULIN PEN NEEDLES......................................124LITE TOUCH INSULIN SYRINGE.106lithium carbonate ............................. 15lithium citrate ....................................15LITHOBID........................................ 15LITHOSTAT.....................................96LIVALO............................................ 28LO LOESTRIN FE........................... 37LOJAIMIESS....................................37LOMAIRA.......................................147LONSURF......................................116loperamide .......................................97LOPREEZA......................................77lorazepam ........................................14LORAZEPAM INTENSOL................14LORCET (HYDROCODONE)........ 132LORCET HD..................................132LORCET PLUS..............................132LORTAB ELIXIR............................132LORYNA (28)...................................37losartan ............................................23losartan-hydrochlorothiazide ............22LOTEMAX........................................67loteprednol etabonate ......................67lovastatin ..........................................29LOW-OGESTREL (28).................... 37loxapine succinate ........................... 15LO-ZUMANDIMINE (28).................. 37LUER LOCK SYRINGE................. 106

LUER SLIP TIP SYRINGE TRAY..106LUER-LOK TIP.............................. 106luliconazole ......................................44LUMIGAN........................................ 71LUPANETA PACK (1 MONTH)....... 77LUPANETA PACK (3 MONTH)....... 77LUPRON DEPOT...................... 62, 64LUPRON DEPOT (3 MONTH)...62, 64LUPRON DEPOT (4 MONTH).........62LUPRON DEPOT (6 MONTH).........62LUPRON DEPOT-PED....................64LUPRON DEPOT-PED (3 MONTH) 64LUTERA (28)................................... 37LYNPARZA....................................118LYSODREN...................................119LYZA................................................37mafenide acetate ............................. 45MAGELLAN INSULIN SAFETY SYRNG..........................................107MAGELLAN SAFETY SYRINGE...107MAGELLAN SYRINGE..................107MAGELLAN TUBERCULIN SAFETY SYR................................ 107malathion ......................................... 45maprotiline ....................................... 13MARLISSA (28)............................... 37MARPLAN....................................... 10MATULANE................................... 119MATZIM LA......................................25MAVYRET....................................... 89MAXICOMFORT II PEN NEEDLE.124MAXICOMFORT INSULIN SYRINGE.......................................107MAXI-COMFORT INSULIN SYRINGE.......................................107MAXICOMFORT SAFETY PEN NEEDLE........................................ 124MAXIDEX.........................................67M-CLEAR WC..................................41meclizine ............................................4MEDROL......................................... 92medroxyprogesterone ................32, 77mefenamic acid ................................94mefloquine ....................................... 86megestrol ...............................119, 121MEKINIST......................................117MELODETTA 24 FE........................ 37meloxicam ........................................94memantine .........................................9

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MENEST..........................................77MENOPUR...................................... 61MENOSTAR.................................... 77MENTAX..........................................44meperidine .....................................129meprobamate ...................................14mercaptopurine ..............................116mesalamine ..................................... 95mesalamine with cleansing wipe ..... 95MESNEX........................................119METADATE ER............................... 19METAXALL....................................140metaxalone .................................... 140metformin .........................................55methadone .....................................129METHADONE INTENSOL.............129methamphetamine ...........................13methazolamide ................................ 70methenamine hippurate ...................80methenamine mandelate ................. 80methen-sod phos-meth blue-hyos ... 80methimazole .................................... 65METHITEST.................................... 75methocarbamol ..............................140methotrexate sodium ..................... 116methotrexate sodium (pf) ...............116methoxsalen .................................... 51methscopolamine ...........................142methyldopa ...................................... 23methylergonovine ............................ 40methylphenidate hcl .........................19methylprednisolone ..........................92methyltestosterone .......................... 75metipranolol ..................................... 71metoclopramide hcl ........................143metolazone ...................................... 27metoprolol succinate ........................24metoprolol ta-hydrochlorothiaz ........ 24metoprolol tartrate ............................24metronidazole .................... 42, 85, 145mexiletine .........................................20MIACALCIN..................................... 62MIBELAS 24 FE...............................37miconazole nitrate-zinc ox-pet .........44MICRHOGAM ULTRA-FILTERED PLUS............................................... 77MICRODOT INSULIN PEN NEEDLE........................................ 124MICROGESTIN 1.5/30 (21).............37

MICROGESTIN 1/20 (21)................37MICROGESTIN FE 1.5/30 (28)....... 37MICROGESTIN FE 1/20 (28).......... 37midodrine .........................................31MIFEPREX.................................... 121mifepristone ................................... 121MIGERGOT................................... 130miglitol ..............................................54miglustat ........................................ 121MILI..................................................37MILLIPRED DP................................92MIMVEY...........................................77MINI ULTRA-THIN II ......................124MINITRAN....................................... 32minocycline ......................................83minoxidil ...........................................23mirtazapine ...................................... 10MIRVASO........................................ 42misoprostol .................................... 142MITOSOL.........................................71modafinil .......................................... 18moexipril .......................................... 22molindone ........................................ 17mometasone ................................3, 48MONDOXYNE NL............................83MONOJECT 140CC PISTON SYRINGE.......................................107MONOJECT 35CC SYRINGE CATH TIP...................................... 107MONOJECT 3CC SYR 25GX1".... 107MONOJECT ALLERGY TRAY...... 107MONOJECT ALLERGY TRAY DETACH........................................107MONOJECT CONTROL SYRINGE LUER............................................. 107MONOJECT DISPOSABLE SYRINGE.......................................107MONOJECT ECCENTRIC NON-STERILE........................................107MONOJECT ENFIT STERILE SYRINGE.......................................107MONOJECT ENFIT SYRINGE...... 107MONOJECT ENFIT SYRINGE CAP............................................... 107MONOJECT INSULIN SAFETY SYRING.........................................107MONOJECT INSULIN SYRINGE.. 108MONOJECT LUER-LOCK TIP...... 108

MONOJECT MAGELLAN SYRINGE.......................................108MONOJECT PHARMACY TRAY LUER............................................. 108MONOJECT PHARMACY TRAY REG TIP........................................ 108MONOJECT REG TIP NON-STERILE........................................108MONOJECT REGULAR LUER......108MONOJECT SAFETY LUER LOCK TIP................................................. 108MONOJECT SAFETY SYRINGES 108MONOJECT SMARTIP CANNULA108MONOJECT SYRINGE................. 109MONOJECT SYRINGE ECCENTRI LUER..........................108MONOJECT SYRINGE LUER LOK....................................................... 108MONOJECT SYRINGE REGULAR LUER............................................. 108MONOJECT SYRINGE TOOMEY TYPE............................................. 109MONOJECT TB.............................109MONOJECT TB LUER LOK.......... 109MONOJECT TB REGULAR LUER TIP................................................. 109MONOJECT TB SAFETY SYRINGE.......................................109MONOJECT TUBERCULIN SYRINGE.......................................109MONOJECT ULTRA COMFORT INSULIN.........................................109MONO-LINYAH............................... 37montelukast ....................................... 8MONUROL...................................... 80morphine ........................................129morphine concentrate ....................129MOVANTIK......................................98MOVIPREP......................................97MOXATAG.......................................82moxifloxacin ...............................69, 82MULPLETA......................................75MULTAQ..........................................20mupirocin ......................................... 44mupirocin calcium ............................44MYALEPT........................................64mycophenolate mofetil .....................78mycophenolate sodium ....................79MYLERAN..................................... 116

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MYORISAN......................................42MYRBETRIQ................................. 144MYSOLINE.................................... 138nabumetone .....................................94nadolol ............................................. 24nadolol-bendroflumethiazide ............24naftifine ............................................ 44NAFTIN............................................44naloxone .......................................... 18naltrexone ........................................18NAMENDA XR...................................9NAMZARIC........................................9naproxen ..........................................94naproxen sodium ............................. 94naratriptan ......................................130NARCAN..........................................18NASCOBAL................................... 147NATACYN........................................69NATAZIA..........................................37nateglinide ....................................... 55NATURE-THROID........................... 65NAYZILAM.....................................134NEBUPENT..................................... 86NEBUSAL......................................121NECON 0.5/35 (28)......................... 37nefazodone ......................................11neomycin ......................................... 84neomycin-bacitracin-poly-hc ............ 66neomycin-bacitracin-polymyxin ........69neomycin-polymyxin b-dexameth .... 66neomycin-polymyxin-gramicidin .......69neomycin-polymyxin-hc ................... 59NEO-POLYCIN................................69NEO-POLYCIN HC..........................66NEORAL..........................................79NEO-SYNALAR...............................46NEO-SYNALAR KIT........................ 46NEUAC............................................ 42NEULASTA......................................74NEUPOGEN.................................... 74NEUPRO....................................... 133NEURONTIN................................. 138NEVANAC....................................... 67nevirapine ........................................ 87NEXAVAR......................................118NEXAVIR.......................................115niacin ............................................... 30nicardipine ....................................... 25NICOTROL.................................... 140

NICOTROL NS.............................. 140nifedipine ......................................... 25NIKKI (28)........................................37nilutamide ...................................... 116nisoldipine ........................................25NITRO-BID...................................... 32NITRO-DUR.....................................32nitrofurantoin ....................................81nitrofurantoin macrocrystal .............. 81nitrofurantoin monohyd/m-cryst ....... 81nitroglycerin ..................................... 32NITROMIST.....................................32NITRO-TIME....................................32nizatidine ........................................143NORA-BE........................................ 38NORDITROPIN FLEXPRO..............63noreth-ethinyl estradiol-iron ............. 38norethindrone (contraceptive) ..........38norethindrone acetate ......................77norethindrone ac-eth estradiol ...38, 77norethindrone-e.estradiol-iron ..........38norgestimate-ethinyl estradiol ..........38NORLYDA....................................... 38NORMAL SALINE FLUSH...............60NORM-JECT..................................109NORM-JECT TUBERKULIN..........109NORPACE CR.................................20NORTHERA.....................................31NORTREL 0.5/35 (28)..................... 38NORTREL 1/35 (21)........................ 38NORTREL 1/35 (28)........................ 38NORTREL 7/7/7 (28)....................... 38nortriptyline ...................................... 13NORVIR...........................................88NOVAREL........................................61NOVOFINE 32...............................124NOVOFINE AUTOCOVER............ 124NOVOFINE PLUS..........................124NOVOTWIST.................................124NOXAFIL......................................... 83NP THYROID...................................65NUBEQA........................................116NUCORT......................................... 48NUCYNTA..................................... 129NUCYNTA ER............................... 129NUEDEXTA................................... 120NUMBONEX....................................51NUTROPIN AQ NUSPIN................. 63NUVESSA......................................145

NYAMYC......................................... 44nystatin ...................................... 44, 84nystatin-triamcinolone ................44, 45NYSTOP..........................................45OBSTETRIX ONE..........................146OCELLA...........................................38ODEFSEY........................................89OFEV.............................................127ofloxacin .....................................59, 69olanzapine ....................................... 16olanzapine-fluoxetine .......................18olmesartan .......................................23olmesartan-amlodipin-hcthiazid ....... 21olmesartan-hydrochlorothiazide .......22olopatadine .................................. 3, 67OMECLAMOX-PAK.......................142omega-3 acid ethyl esters ................30omeprazole ....................................143omeprazole-sodium bicarbonate ... 143OMNARIS..........................................3OMNITROPE...................................63ondansetron .......................................4ondansetron hcl ................................. 4ONGLYZA........................................54ONMEL............................................83opium tincture .................................. 97OPSUMIT........................................ 27ORALONE..................................... 121ORAVIG...........................................83ORENCIA........................................ 92ORENCIA CLICKJECT....................92ORENITRAM................................... 27ORKAMBI...................................... 127orphenadrine citrate .......................140ORSYTHIA...................................... 38OSCIMIN....................................... 142OSCIMIN SL..................................142OSCIMIN SR................................. 142oseltamivir ........................................86OSMOPREP....................................97OTEZLA...........................................91OTEZLA STARTER.........................91OTREXUP (PF)............................... 90OVACE PLUS SHAMPOO.............. 49OVIDREL.........................................61oxandrolone .....................................75oxaprozin ......................................... 94OXAYDO....................................... 129oxazepam ........................................ 14

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OXBRYTA........................................75oxcarbazepine ............................... 138OXERVATE..................................... 69oxiconazole ......................................45OXTELLAR XR..............................138oxybutynin chloride ................144, 145oxycodone ..................................... 129oxycodone-acetaminophen ............132oxycodone-aspirin ..........................132OXYCONTIN......................... 129, 130oxymorphone .................................130OXYTROL......................................145OZEMPIC........................................ 53PACERONE.....................................20paliperidone ..................................... 16PALYNZIQ.....................................115PANCREAZE.................................141PANDEL.......................................... 48PANRETIN.......................................50pantoprazole ..................................143paricalcitol ........................................64PAROEX ORAL RINSE.................121paroxetine hcl .................................. 11paroxetine mesylate(menop.sym) ....17PASER.............................................84PAZEO.............................................67peg 3350-electrolytes ...................... 97PEGANONE.................................. 138PEGASYS........................................89peg-electrolyte soln ..........................97PEGINTRON................................... 89PEG-PREP...................................... 97PEN NEEDLE................................124pen needle, diabetic ...............124, 125penicillamine ....................................90penicillin v potassium .......................82pentamidine ..................................... 86PENTASA........................................95pentazocine-naloxone ....................130PENTIPS....................................... 125pentoxifylline ....................................73PERFOROMIST................................ 6perindopril erbumine ........................22PERIOGARD................................. 121permethrin ........................................45perphenazine ...................................17perphenazine-amitriptyline ...............12PERTZYE...................................... 141phenazopyridine ............................ 144

phendimetrazine tartrate ................147phenelzine ....................................... 10phenobarbital ...................................17phenoxybenzamine ..........................21phentermine ...................................147phenylephrine hcl .............................68PHENYTEK................................... 138phenytoin ....................................... 138phenytoin sodium extended ...........138PHILITH...........................................38PHOSLYRA..................................... 59PHOSPHASAL................................ 80PHOSPHOLINE IODIDE................. 71phytonadione (vitamin k1) ................75PICATO........................................... 50PIFELTRO....................................... 88pilocarpine hcl ..........................71, 115pimecrolimus ....................................52pimozide .......................................... 15PIMTREA (28)................................. 38pindolol ............................................ 24pioglitazone ......................................55pioglitazone-glimepiride ...................55pioglitazone-metformin .................... 56PIRMELLA.......................................38piroxicam ......................................... 94PISTON SYRINGE WITH ENFIT...109PLEGRIDY.....................................120PLENVU.......................................... 97PNV-DHA + DOCUSATE.............. 146PODOCON...................................... 50podofilox .......................................... 50POLYCIN.........................................69polymyxin b sulf-trimethoprim .......... 69POMALYST................................... 117PORTIA 28...................................... 38POTABA........................................ 147potassium chloride ...........................60potassium citrate ............................144PR BENZOYL PEROXIDE.............. 50PRADAXA........................................75PRALUENT PEN............................. 29pramipexole ........................... 133, 134prasugrel ..........................................74pravastatin ....................................... 29praziquantel ..................................... 85prazosin ........................................... 21PRED MILD..................................... 67PRED-G...........................................66

PRED-G S.O.P................................ 66prednicarbate ...................................48prednisolone .................................... 92prednisolone acetate ....................... 67prednisolone acetate (pf) .................67prednisolone sodium phosphate ......92prednisone .......................................93PREDNISONE INTENSOL.............. 92PREFEST........................................ 77pregabalin ......................................138PREGNYL........................................61PREMARIN..............................77, 145PREMPHASE.................................. 77PREMPRO.......................................77PRENAISSANCE...........................147PRENAISSANCE PLUS................ 147PRENATABS RX...........................147PRENATAL 19 (WITH DOCUSATE)..................................147PRENATAL VITAMIN PLUS LOW IRON..............................................147PREPLUS......................................147PREPOPIK...................................... 97PREVALITE.....................................30PREVENT DROPSAFE PEN NEEDLE........................................ 125PREVIDENT.................................. 146PREVIDENT 5000 BOOSTER PLUS............................................. 146PREVIDENT 5000 DRY MOUTH.. 146PREVIDENT 5000 ENAMEL PROTECT......................................146PREVIDENT 5000 ORTHO DEFENSE......................................146PREVIDENT 5000 SENSITIVE..... 146PREVIFEM...................................... 38PREVYMIS...................................... 86PREZCOBIX....................................87PREZISTA....................................... 87PRIFTIN...........................................84primidone .......................................138PRIMLEV.......................................132PRIMSOL.........................................80PRO COMFORT INSULIN SYRINGE.......................................109PRO COMFORT PEN NEEDLE....125PROAIR HFA.....................................5PROAIR RESPICLICK.......................5probenecid .......................................72

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probenecid-colchicine ......................72prochlorperazine ................................4prochlorperazine maleate .................. 4PROCRIT.........................................73PROCTOFOAM HC.........................96PROCTO-MED HC.......................... 48PROCTO-PAK.................................48PROCTOSOL HC............................48PROCTOZONE-HC......................... 48PROCYSBI.................................... 144PRODIGY INSULIN SYRINGE......109progesterone ....................................77progesterone micronized ................. 77PROGRAF.......................................79PROLENSA..................................... 68PROLEUKIN....................................78PROLIA............................................62promethazine .................................3, 4promethazine-codeine ..................... 41promethazine-dm .............................41promethazine-phenyleph-codeine ... 41promethazine-phenylephrine ........... 40PROMETHEGAN...............................4propafenone .....................................20propantheline .................................142proparacaine ....................................68propranolol .......................................24propylthiouracil .................................65PROSTIN E2................................... 40protriptyline ...................................... 13PROVENTIL HFA.............................. 5PROZAC..........................................11PULMICORT FLEXHALER................8PULMOZYME................................127PURE COMFORT PEN NEEDLE..125PURIXAN.......................................116PYLERA.........................................143pyrazinamide ................................... 84pyridostigmine bromide ....................10QNASL...............................................3QSYMIA.........................................148quazepam ........................................18QUDEXY XR..................................138quetiapine ........................................ 16QUILLIVANT XR..............................19quinapril ........................................... 22quinapril-hydrochlorothiazide ...........21quinidine gluconate ..........................20quinidine sulfate ...............................20

quinine sulfate ..................................86QVAR REDIHALER...........................8rabeprazole ....................................143RADIOGARDASE..........................122raloxifene ......................................... 62ramipril .............................................22ranolazine ........................................ 31RAPAMUNE.................................... 79rasagiline ....................................... 134RASUVO (PF)..................................90RAVICTI...........................................96REBIF (WITH ALBUMIN)...............120REBIF REBIDOSE.........................120REBIF TITRATION PACK............. 120RECLIPSEN (28).............................39RECTIV............................................96RELAGARD...................................145RELENZA DISKHALER...................86RELION NEEDLES........................125RELION PEN NEEDLES............... 125RENACIDIN...................................144repaglinide ....................................... 55REPATHA PUSHTRONEX..............30REPATHA SURECLICK.................. 30REPATHA SYRINGE.......................30RESTASIS.......................................69RESTASIS MULTIDOSE.................69RETIN-A MICRO PUMP.................. 43REVLIMID......................................117REXULTI..........................................15RHOGAM ULTRA-FILTERED PLUS............................................... 77RHOPHYLAC.................................. 77ribavirin ............................................ 89RIDAURA.........................................93rifabutin ............................................84RIFAMATE.......................................84rifampin ............................................84RIFATER......................................... 85riluzole ........................................... 120rimantadine ......................................86RINVOQ...........................................93RIOMET...........................................55risedronate .................................62, 63risperidone .......................................16ritonavir ............................................88rivastigmine ......................................10rivastigmine tartrate ......................... 10RIVELSA..........................................39

rizatriptan .......................................130ropinirole ........................................134ROSADAN.......................................42ROSANIL.........................................45ROSULA CLEANSING CLOTHS.....45rosuvastatin ..................................... 29ROWEEPRA..................................138ROWEEPRA XR............................138ROZLYTREK................................. 118RUBRACA..................................... 118RYBELSUS......................................53RYDAPT........................................ 118RYTARY........................................ 134SAFESNAP INSULIN SYRINGE... 110SAFESNAP SYRINGE.................. 110SAFETY PEN NEEDLE.................125SAIZEN............................................64SAIZEN SAIZENPREP....................63salicylic acid .....................................50salsalate .........................................128SALVAX DUO PLUS....................... 50SAMSCA..........................................59SANCUSO.........................................4SANDIMMUNE................................ 79SANTYL...........................................51SAVAYSA........................................72SAVELLA.......................................120SAXENDA......................................148SCALACORT DK.............................48scopolamine base ..............................4SECONAL SODIUM........................ 17SEGLUROMET................................56selegiline hcl .................................. 134selenium sulfide ...............................49SELZENTRY....................................87SEMPREX-D..................................... 3SEREVENT DISKUS.........................6SEROSTIM......................................64sertraline ..........................................11SETLAKIN....................................... 39sevelamer carbonate ....................... 59sevelamer hcl ...................................59SF.................................................. 146SF 5000 PLUS...............................146SHAROBEL..................................... 39SIGNIFOR..................................... 126sildenafil (pulm.hypertension) ..........26SILENOR.........................................18silodosin .........................................143

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silver sulfadiazine ............................ 45SIMBRINZA..................................... 71SIMLIYA (28)................................... 39SIMPESSE...................................... 39SIMPONI..........................................91simvastatin .......................................29sirolimus ...........................................79SIRTURO.........................................85SITAVIG...........................................86SKLICE............................................45sodium chlor 0.9% bacteriostat ........60sodium chloride ........................60, 121sodium chloride 0.9 % (flush) .......... 60SODIUM FLUORIDE 5000 PLUS..146sodium phenylbutyrate .....................96SODIUM POLYSTYRENE (SORB FREE)..............................................59sodium polystyrene sulfonate .......... 59SOLESTA........................................ 97solifenacin ......................................144SOLIQUA 100/33.............................55SOLOSEC....................................... 85SOLTAMOX...................................119SOMATULINE DEPOT..................126SOMAVERT.....................................63SORINE...........................................24sotalol .............................................. 24SOTALOL AF...................................24SOTYLIZE....................................... 24spinosad .......................................... 45SPIRIVA RESPIMAT......................... 5SPIRIVA WITH HANDIHALER.......... 5spironolactone ................................. 26spironolacton-hydrochlorothiaz ........26SPRINTEC (28)............................... 39SPRITAM...............................138, 139SPRYCEL......................................118SPS (WITH SORBITOL)..................60SRONYX..........................................39SSD................................................. 45SSS 10-5......................................... 45stavudine ......................................... 88STEGLATRO...................................54STELARA........................................ 93STIOLTO RESPIMAT........................6STIVARGA.....................................118STRIBILD.........................................89STRIVERDI RESPIMAT.................... 6SUBVENITE.................................. 139

SUBVENITE STARTER (BLUE) KIT................................................. 139SUBVENITE STARTER (GREEN) KIT................................................. 139SUBVENITE STARTER (ORANGE) KIT.............................. 139SUCRAID.......................................141sucralfate ....................................... 142sulfacetamide sodium ................49, 68sulfacetamide sodium (acne) ...........42sulfacetamide sodium-sulfur ............45sulfacetamide sod-sulfur-urea ......... 45sulfacetamide-prednisolone .............68sulfacetamide-sulfur-cleansr23 ........45sulfadiazine ......................................95sulfamethoxazole-trimethoprim ........79SULFAMYLON................................ 45sulfasalazine ....................................95SULFATRIM.................................... 79sulindac ............................................94sumatriptan ....................................131sumatriptan succinate ....................131SUPPRELIN LA...............................64SUPRAX..........................................80SUPREP BOWEL PREP KIT...........98SURE COMFORT INS. SYR. U-100.................................................110SURE COMFORT INSULIN SYRINGE.......................................110SURE COMFORT PEN NEEDLE..125SURE-FINE PEN NEEDLES......... 125SURE-JECT INSULIN SYRINGE.. 110SURGUARD2 SAFETY................. 111SUSTIVA......................................... 88SUTENT........................................ 118SYEDA.............................................39SYLATRON................................... 117SYMAX DUOTAB.......................... 142SYMBICORT..................................... 7SYMFI..............................................89SYMFI LO........................................89SYMJEPI....................................... 115SYMLINPEN 120.............................54SYMLINPEN 60...............................54SYMTUZA........................................86SYNALAR CREAM KIT................... 48SYNALAR OINTMENT KIT..............48SYNALAR TS.................................. 48SYNAREL........................................64

SYNDROS.........................................4SYNJARDY......................................56SYNJARDY XR................................56SYNRIBO.......................................119SYNTHROID....................................65syringe (disposable) .......................111SYRINGE 3CC/20GX1".................111SYRINGE 3CC/21GX1".................111SYRINGE 3CC/21GX1-1/2"...........111SYRINGE 3CC/22GX1".................111SYRINGE 3CC/22GX3/4"..............111SYRINGE 3CC/25GX1".................111syringe with needle ........................111syringe with needle, safety ............ 111SYRINGE WITHOUT NEEDLE..... 111TABLOID....................................... 116tacrolimus .................................. 52, 79tadalafil (pulm. hypertension) ...........26TAFINLAR..................................... 117TAGRISSO.................................... 118TALTZ AUTOINJECTOR.................51TALTZ AUTOINJECTOR (2 PACK).51TALTZ AUTOINJECTOR (3 PACK).51TALTZ SYRINGE.............................51tamoxifen ....................................... 119tamsulosin ......................................143TARGRETIN....................................50TARINA 24 FE.................................39TARINA FE 1/20 (28).......................39TARINA FE 1-20 EQ (28)................ 39TARON-PREX PRENATAL-DHA.. 147TASIGNA.......................................118tazarotene ........................................52TAZTIA XT.......................................25TECFIDERA.................................. 120TECHLITE INSULIN SYR HALF UNIT.............................................. 112TECHLITE INSULIN SYRINGE..... 112TECHLITE PEN NEEDLE..............125TEGRETOL................................... 139TEGRETOL XR............................. 139TEGSEDI.......................................115telmisartan ....................................... 23telmisartan-amlodipine .....................22telmisartan-hydrochlorothiazid .........22temazepam ......................................18TEMIXYS.........................................87temozolomide ................................ 116TENCON........................................127

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tenofovir disoproxil fumarate ............88terazosin .......................................... 21terbinafine hcl .................................. 83terbutaline ..........................................5terconazole .................................... 145TERSI FOAM...................................49TERUMO ALLERGY SYRINGE.... 112TERUMO HYPODERMIC NEEDLE/SYRIN............................ 112TERUMO INSULIN SYRINGE.......112TERUMO SYRINGE......................112testosterone .....................................75testosterone cypionate .....................75testosterone enanthate ....................75tetrabenazine .................................120tetracaine hcl ................................... 68tetracaine hcl (pf) .............................68tetracycline .......................................83TEXACORT..................................... 49THALOMID...................................... 84THEO-24............................................9THEOCHRON....................................9theophylline ........................................9THINPRO INSULIN SYRINGE...... 112THIOLA..........................................144thioridazine ...................................... 17thiothixene ....................................... 17thyroid (pork) ....................................65THYROLAR-1..................................65THYROLAR-1/2...............................65THYROLAR-1/4...............................66THYROLAR-2..................................66THYROLAR-3..................................66TIADYLT ER....................................25tiagabine ........................................ 139TILIA FE...........................................39timolol maleate ...........................24, 71TIMOPTIC OCUDOSE (PF)............ 71tinidazole ..........................................85TIVICAY...........................................88tizanidine ........................................140TOBI PODHALER............................84TOBRADEX.....................................66TOBRADEX ST............................... 66tobramycin ....................................... 69tobramycin in 0.225 % nacl ..............84tobramycin with nebulizer ................ 84tobramycin-dexamethasone ............ 66TOBREX..........................................69

TOLAK.............................................50tolcapone ....................................... 134TOLSURA........................................84tolterodine ......................................145TOOMEY SYRINGE......................112TOPAMAX..................................... 139TOPCARE CLICKFINE..................125TOPCARE ULTRA COMFORT..... 112topiramate ......................................139torsemide .........................................26TOUJEO MAX U-300 SOLOSTAR..58TOUJEO SOLOSTAR U-300 INSULIN...........................................58TOVIAZ..........................................145TRACLEER......................................27TRADJENTA....................................54tramadol .........................................130tramadol-acetaminophen ...............132trandolapril .......................................22trandolapril-verapamil ................ 20, 21tranexamic acid ................................72tranylcypromine ............................... 10TRANZAREL................................... 51travoprost .........................................71trazodone .........................................11TRECATOR.....................................84TRELEGY ELLIPTA...........................7TREMFYA........................................51TRESIBA FLEXTOUCH U-100........58TRESIBA FLEXTOUCH U-200........58TRESIBA U-100 INSULIN............... 58tretinoin ............................................43tretinoin (antineoplastic) .................119tretinoin microspheres ..................... 43TRETIN-X........................................ 43TREXALL.......................................116TRI FEMYNOR................................39triamcinolone acetonide ...........49, 121triamterene-hydrochlorothiazid ........ 26triazolam .......................................... 18TRIDERM........................................ 49TRIDESILON................................... 49trientine ..........................................122TRI-ESTARYLLA.............................39trifluoperazine .................................. 17trifluridine ......................................... 68TRIGLIDE........................................ 30trihexyphenidyl ...............................133TRIKAFTA..................................... 127

TRI-LEGEST FE..............................39TRILEPTAL....................................139TRI-LINYAH.....................................39TRI-LO-ESTARYLLA.......................39TRI-LO-MARZIA.............................. 39TRI-LO-MILI.....................................39TRI-LO-SPRINTEC..........................39TRILYTE WITH FLAVOR PACKETS........................................98trimethobenzamide ............................ 4trimethoprim .....................................80TRI-MILI...........................................39trimipramine .....................................13TRINTELLIX.................................... 12TRI-PREVIFEM (28)........................39TRI-SPRINTEC (28)........................ 39TRIUMEQ........................................ 89TRIVORA (28)................................. 40TRI-VYLIBRA...................................40TRI-VYLIBRA LO.............................40TROKENDI XR.............................. 139tropicamide ...................................... 71trospium .........................................145TRUE COMFORT INSULIN SYRINGE.......................................112TRUE COMFORT PEN NEEDLE..125TRUEPLUS INSULIN.................... 113TRUEPLUS PEN NEEDLE............125TRULICITY...................................... 53TRUVADA........................................87TUBERCULIN SYRINGE...............113tuberculin-allergy syringes .............113TUDORZA PRESSAIR...................... 5TULANA...........................................40TUSSICAPS.................................... 41TYBOST.......................................... 89TYDEMY..........................................40TYKERB........................................ 118TYMLOS..........................................62TYVASO.......................................... 27TYVASO INSTITUTIONAL START KIT................................................... 27TYVASO REFILL KIT...................... 27TYVASO STARTER KIT..................27ULESFIA..........................................45ULTICARE.....................................113ULTICARE INSULIN SYR HALF UNIT.............................................. 113ULTICARE INSULIN SYRINGE.....113

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ULTICARE PEN NEEDLE............. 126ULTICARE SAFETY SYRINGE.....113ULTICARE TB SAFETY SYRINGE113ULTIGUARD SAFE PACK.............126ULTILET INSULIN SYRINGE........ 113ULTILET PEN NEEDLE.................126ULTRA CMFT INS SYR HALF UNIT.............................................. 113ULTRA COMFORT INSULIN SYRINGE.......................................114ULTRA FLO INSULIN SYRINGE...114ULTRA FLO PEN NEEDLE........... 126ULTRA THIN PEN NEEDLE..........126ULTRACARE INSULIN SYRINGE.114ULTRACARE PEN NEEDLE......... 126ULTRA-THIN II (SHORT) INS SYR....................................................... 114ULTRA-THIN II (SHORT) PEN NDL................................................126ULTRA-THIN II INS PEN NEEDLES......................................126ULTRA-THIN II INSULIN SYRINGE.......................................114UNIFINE PENTIPS........................126UNIFINE PENTIPS MAXFLOW.....126UNIFINE PENTIPS PLUS..............126UNIFINE PENTIPS PLUS MAXFLOW.....................................126UNITHROID.....................................66UPTRAVI......................................... 27URAMAXIN GT................................50URETRON D-S................................80URIMAR-T....................................... 80URIN DS..........................................80URO-458..........................................80UROGESIC-BLUE...........................80URO-MP.......................................... 80ursodiol ............................................ 97USTELL........................................... 80UTIRA-C.......................................... 80valacyclovir ...................................... 86VALCHLOR..................................... 50valganciclovir ................................... 86valproic acid ...................................140valproic acid (as sodium salt) ........ 139valsartan .......................................... 23valsartan-hydrochlorothiazide ..........22vancomycin ......................................85VANDAZOLE.................................145

VANISHPOINT INSULIN SYRINGE.......................................114VANISHPOINT SYRINGE............. 114VANISHPOINT TUBERCULIN SYRINGE.......................................114VANOXIDE-HC................................42VARUBI............................................. 4VASCEPA..................................30, 31VECAMYL........................................23VELIVET TRIPHASIC REGIMEN (28).................................................. 40VELPHORO.....................................60VELTASSA...................................... 60VEMLIDY.........................................89venlafaxine .......................................12VENTAVIS.......................................27VENTOLIN HFA.................................5verapamil ................................... 25, 26VERIFINE PEN NEEDLE.............. 126VERSACLOZ...................................17VIBERZI...........................................96VICODIN HP..................................132VICTOZA 2-PAK..............................53VICTOZA 3-PAK..............................53VIENVA............................................40VIIBRYD.......................................... 12VILAMIT MB.................................... 80VIMPAT......................................... 140VIOKACE.......................................141VIORELE (28)..................................40VIRACEPT.......................................88VIREAD........................................... 88VIRTUSSIN AC................................41VISTOGARD..................................119VITAFOL FE+ (WITH DOCUSATE)....................................................... 147VITAMIN D2...................................147VOLNEA (28)...................................40voriconazole .....................................84VOSEVI........................................... 89VOTRIENT.....................................118VRAYLAR........................................15VUMERITY.................................... 120VYFEMLA (28).................................40VYLIBRA..........................................40VYNDAMAX.....................................31VYNDAQEL..................................... 31VYVANSE........................................14warfarin ............................................72

WERA (28).......................................40WESTHROID...................................66WINRHO SDF..................................78WP THYROID..................................66WYMZYA FE................................... 40XARELTO........................................72XATMEP........................................116XELJANZ.........................................93XELJANZ XR...................................93XELPROS........................................71XENICAL....................................... 148XENLETA........................................ 82XIFAXAN......................................... 85XIGDUO XR.....................................56XIIDRA.............................................69XOLAIR..............................................8XTANDI..........................................116XULANE.......................................... 40XULTOPHY 100/3.6........................ 55XURIDEN.........................................72XYREM............................................15YUVAFEM..................................... 145zafirlukast ...........................................8zaleplon ........................................... 18ZARAH.............................................40ZARONTIN.................................... 140ZATEAN-PN DHA..........................147ZEBUTAL.......................................128ZEJULA......................................... 118ZELAPAR...................................... 134ZELNORM....................................... 97ZENATANE......................................42ZENPEP........................................ 141ZENZEDI......................................... 14ZETONNA..........................................3zidovudine ........................................88ZIEXTENZO.....................................74ZIOPTAN (PF)................................. 71ziprasidone hcl .................................17ZIRGAN........................................... 68ZITHRANOL.................................... 52ZOHYDRO ER...............................130ZOLINZA........................................119zolmitriptan .................................... 131zolpidem .......................................... 18ZOMACTON.................................... 64ZOMIG...........................................131ZONEGRAN.................................. 140zonisamide .....................................140

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ZONTIVITY......................................74ZORBTIVE.......................................64ZORTRESS..................................... 79ZOVIA 1/35E (28)............................ 40ZUBSOLV......................................133ZUMANDIMINE (28)........................ 40ZYKADIA....................................... 118ZYLET..............................................66ZYPREXA RELPREVV....................17ZYTIGA..........................................116

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Documents

As of July 1, 2020mybhhealthplan.com/formulary/formulary 20200701v1.pdf · The following is the formulary for the Beaumont Health Employee Health Plan (BHEHP) As of July 1, 2020 To