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H6351_2018_drug01 Accepted
Liberty Advantage
2018 Comprehensive Formulary
List of Covered Drugs
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID, 00018338 Version 13
This formulary was updated on 08/01/2018. For more recent information or other questions, please contact Liberty Advantage Member Services at 1-844-854-6884 or, for TTY users, 711, Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 13, andMonday to Friday (except holidays) from February 14 through September 30, orvisit www.libertyadvantage.com.
Liberty Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Liberty Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
Liberty Advantage 遵守適用的聯邦民權法律規定,不因種族、膚色、民族血統、年齡、殘障 或性別而歧視任何人。
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-854-6884 TTY: 711.
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-888-854-6884 TTY:711。
1
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Liberty Advantage. When it refers to “plan” or “our plan,” it means Liberty Advantage.
This document includes a list of the drugs (formulary) for our plan which is current as of 08/01/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.
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What is the Liberty Advantage Formulary? A formulary is a list of covered drugs selected by Liberty Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Liberty Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Liberty Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 08/01/2018. To get updated information about the drugs covered by Liberty Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event that Liberty Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, Liberty Advantage will update our formulary and post in on our website.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents-Misc.” If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 109. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
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What are generic drugs? Liberty Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization (PA): Liberty Advantage requires you [or your physician] to get priorauthorization for certain drugs. This means that you will need to get approval from LibertyAdvantage before you fill your prescriptions. If you don’t get approval, Liberty Advantage may notcover the drug.
• Prior Authorization Restriction for Part B vs Part D Determination (PA BvD): This drug may beeligible for payment under Medicare Part B or Part D. You (or your physician) are required to get priorauthorization from Liberty Advantage to determine that this drug is covered under Medicare Part Dbefore you fill your prescription for this drug. Without prior approval, Liberty Advantage may notcover this drug.
• Prior Authorization Restriction for New Starts Only (PA NSO): If you are a new member, you (oryour physician) are required to get prior authorization from Liberty Advantage before you fill yourprescription for this drug. Without prior approval, Liberty Advantage may not cover this drug.
• Quantity Limits (QL): For certain drugs, Liberty Advantage limits the amount of the drug that LibertyAdvantage will cover. For example, Liberty Advantage provides 9 tabs per prescription for sumatriptantab. This may be in addition to a standard one month or three-month supply.
• Step Therapy (ST): In some cases, Liberty Advantage requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Liberty Advantage may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, Liberty Advantage will then cover Drug B.
• Non-Mail-Order Drug (NM): You may be able to receive greater than a 1-month supply of most of thedrugs on your Formulary via mail order at a reduced cost share. Drugs not available via your mail-orderbenefit are noted with “NM” in the notes column of your Formulary.
• Limited Distribution (LD): The symbol (LD) next to a drug name indicates that the drug has beennoted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs canonly be obtained at specialty designated pharmacies able to appropriately handle the drugs.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
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You can ask Liberty Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Liberty Advantage’s formulary?” on this page for information about how to request an exception.
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Liberty Advantage does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by Liberty Advantage.When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by Liberty Advantage.
• You can ask Liberty Advantage to make an exception and cover your drug. See below forinformation about how to request an exception.
How do I request an exception to the Liberty Advantage Formulary? You can ask Liberty Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be coveredat a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at alower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialtytier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Liberty Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit,you can ask us to waive the limit and cover a greater amount.
Generally, Liberty Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
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What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
We will provide a one-time 31-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level of care change may include:
• Entering or leaving a LTC facility• Discharged from a hospital to a home• End a Medicare Part A skilled nursing facility stay• Give up Hospice status and revert back to standard Medicare benefits• End an LTC facility stay and return to their home
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
For more information For more detailed information about your Liberty Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Liberty Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
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Liberty Advantage’s Formulary The formulary below provides coverage information about the drugs covered by Liberty Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 109. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., lidocaine).
The second column of the chart lists the Drug Tier.
The information in the Notes column tells you if Liberty Advantage has any special requirements for coverage of your drug.
• The symbol LD in the Notes column next to a drug name indicates that the drug has been noted asbeing restricted to certain pharmacies by the Food and Drug Administration. These drugs can onlybe obtained at specialty designated pharmacies able to appropriately handle the drugs.
• The symbol PA in the Notes column indicates that prior authorization may apply.• The symbol PA BvD in the Notes column indicates that prior authorization may apply for
medications that could be eligible for payment under either Medicare Part B or Part D.• The symbol PA NSO in the Notes column indicates that prior authorization may apply on certain
medications for new members of the plan.• The symbol QL in the Notes column indicates that quantities dispensed may be limited.• The symbol ST in the Notes column indicates that step therapy may apply.• The symbol NM in the Notes column indicates that the drug is not available via your mail-order
benefit.
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAMPHETAMINES
1amphetamine 10mg er cap
1amphetamine 10mg tab
1amphetamine 12.5mg tab
1amphetamine 15mg er cap
1amphetamine 15mg tab
1amphetamine 20mg er cap
1amphetamine 20mg tab
1amphetamine 25mg er cap
1amphetamine 30mg er cap
1amphetamine 30mg tab
1amphetamine 5mg er cap
1amphetamine 5mg tab
1amphetamine 7.5mg tab
1dextroamphetamine sulfate 10mg er cap
1dextroamphetamine sulfate 10mg tab
1dextroamphetamine sulfate 15mg er cap
1dextroamphetamine sulfate 5mg er cap
1dextroamphetamine sulfate 5mg tab
1methamphetamine 5mg tab PA
1VYVANSE 10MG CAP
1VYVANSE 10MG CHEW TAB
1VYVANSE 20MG CAP
1VYVANSE 20MG CHEW TAB
1VYVANSE 30MG CAP
1VYVANSE 30MG CHEW TAB
1VYVANSE 40MG CAP
1VYVANSE 40MG CHEW TAB
1VYVANSE 50MG CAP
1VYVANSE 50MG CHEW TAB
1VYVANSE 60MG CAP
1VYVANSE 60MG CHEW TAB
1VYVANSE 70MG CAPATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS
1atomoxetine 100mg cap QL=60 EA/30 Days
1atomoxetine 10mg cap QL=60 EA/30 Days
1atomoxetine 18mg cap QL=60 EA/30 Days
1atomoxetine 25mg cap QL=60 EA/30 Days
1atomoxetine 40mg cap QL=60 EA/30 Days
1atomoxetine 60mg cap QL=60 EA/30 Days
1atomoxetine 80mg cap QL=60 EA/30 Days
1guanfacine 1mg er tab
1guanfacine 2mg er tab
1guanfacine 3mg er tab
1guanfacine 4mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
7
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
STIMULANTS - MISC.
1armodafinil 150mg tab PA QL=30 EA/30 Days
1armodafinil 200mg tab PA QL=30 EA/30 Days
1armodafinil 250mg tab PA QL=30 EA/30 Days
1armodafinil 50mg tab PA QL=30 EA/30 Days
1dexmethylphenidate 10mg er cap
1dexmethylphenidate 10mg tab
1dexmethylphenidate 15mg er cap
1dexmethylphenidate 2.5mg tab
1dexmethylphenidate 20mg er cap
1dexmethylphenidate 30mg er cap
1dexmethylphenidate 40mg er cap
1dexmethylphenidate 5mg er cap
1dexmethylphenidate 5mg tab
1metadate 20mg er tab
1methylphenidate 10mg cd cap
1methylphenidate 10mg chew tab
1methylphenidate 10mg er tab
1methylphenidate 10mg la cap
1methylphenidate 10mg tab
1METHYLPHENIDATE 18MG SR TAB
1methylphenidate 1mg/ml oral soln
1methylphenidate 2.5mg chew tab
1methylphenidate 20mg cd cap
1methylphenidate 20mg er tab
1methylphenidate 20mg la cap
1methylphenidate 20mg tab
1METHYLPHENIDATE 27MG SR TAB
1methylphenidate 2mg/ml oral soln
1methylphenidate 30mg cd cap
1methylphenidate 30mg la cap
1METHYLPHENIDATE 36MG SR TAB
1methylphenidate 40mg cd cap
1methylphenidate 40mg la cap
1methylphenidate 50mg cd cap
1METHYLPHENIDATE 54MG SR TAB
1methylphenidate 5mg chew tab
1methylphenidate 5mg tab
1methylphenidate 60mg cd cap
1modafinil 100mg tab PA QL=60 EA/30 Days
1modafinil 200mg tab PA QL=60 EA/30 Days
AMINOGLYCOSIDESAMINOGLYCOSIDES
1amikacin 250mg/ml inj
1gentamicin 1.2mg/ml inj
1gentamicin 40mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1gentamicin sulfate 0.8mg/ml inj
1gentamicin sulfate 1.6mg/ml inj
1gentamicin sulfate 1mg/ml inj
1neomycin sulfate 500mg tab
1paromomycin 250mg cap
1STREPTOMYCIN 100MG INJ
1TOBI PODHALER KIT 28MG PACK NDS PA
1TOBRAMYCIN 10MG/ML INJ
1tobramycin 40mg/ml inj
1tobramycin 60mg/ml inh soln NDS PA
ANALGESICS - ANTI-INFLAMMATORYANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
1HUMIRA 10MG/0.1ML SYRINGE NDS PA
1HUMIRA 10MG/0.2ML SYRINGE NDS PA
1HUMIRA 20MG/0.2ML SYRINGE NDS PA
1HUMIRA 20MG/0.4ML SYRINGE NDS PA
1HUMIRA 40MG/0.4ML AUTO-INJECTOR NDS PA
1HUMIRA 40MG/0.4ML SYRINGE NDS PA
1HUMIRA 40MG/0.8ML AUTO-INJECTOR NDS PA
1HUMIRA 40MG/0.8ML SYRINGE NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 40MG/0.8ML INJ
NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML INJ
NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK (6) 40MG/0.8ML INJ
NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML
NDS PA
1HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ
NDS PA
1HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML INJ
NDS PA
1SIMPONI ARIA 50MG/4ML INJ NDS PAGOLD COMPOUNDS
1RIDAURA 3MG CAPINTERLEUKIN-1 BLOCKERS
1ARCALYST 220MG INJ NDS PAINTERLEUKIN-1BETA BLOCKERS
1ILARIS 150MG/ML INJ NDS PANONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
1celecoxib 100mg cap QL=60 EA/30 Days
1celecoxib 200mg cap QL=60 EA/30 Days
1celecoxib 400mg cap QL=60 EA/30 Days
1celecoxib 50mg cap QL=60 EA/30 Days
1diclofenac potassium 50mg tab
1diclofenac sodium 100mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
9
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1diclofenac sodium 25mg dr tab
1diclofenac sodium 50mg dr tab
1diclofenac sodium 50mg/misoprostol 0.2mg tab
1diclofenac sodium 75mg dr tab
1diclofenac sodium 75mg/misoprostol 0.2mg tab
1etodolac 200mg cap
1etodolac 300mg cap
1etodolac 400mg er tab
1etodolac 400mg tab
1etodolac 500mg er tab
1etodolac 500mg tab
1etodolac 600mg er tab
1FENOPROFEN 400MG CAP
1flurbiprofen 100mg tab
1flurbiprofen 50mg tab
1ibu 600mg tab
1ibu 800mg tab
1ibuprofen 20mg/ml oral susp
1ibuprofen 400mg tab
1ibuprofen 600mg tab
1ibuprofen 800mg tab
1INDOCIN 25MG/5ML ORAL SUSP
1indomethacin 25mg cap
1indomethacin 50mg cap
1indomethacin 75mg er cap
1ketoprofen 50mg cap
1ketoprofen 75mg cap
1ketorolac tromethamine 10mg tab QL=20 EA/5 Days
1ketorolac tromethamine 15mg/ml inj
1ketorolac tromethamine 30mg/ml cartridge
1ketorolac tromethamine 30mg/ml inj
1MECLOFENAMATE 100MG CAP
1MECLOFENAMATE 50MG CAP
1mefenamic acid 250mg cap
1meloxicam 15mg tab
1meloxicam 7.5mg tab
1nabumetone 500mg tab
1nabumetone 750mg tab
1naproxen 250mg tab
1naproxen 25mg/ml oral susp
1naproxen 375mg dr tab
1naproxen 375mg tab
1naproxen 500mg dr tab
1naproxen 500mg tab
1naproxen sodium 275mg tab
1naproxen sodium 550mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
10
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1oxaprozin 600mg tab
1piroxicam 10mg cap
1piroxicam 20mg cap
1sulindac 150mg tab
1sulindac 200mg tabPYRIMIDINE SYNTHESIS INHIBITORS
1leflunomide 10mg tab
1leflunomide 20mg tabSELECTIVE COSTIMULATION MODULATORS
1ORENCIA 125MG/ML AUTO-INJECTOR NDS PA
1ORENCIA 125MG/ML SYRINGE NDS PA
1ORENCIA 250MG INJ NDS PA
1ORENCIA 50MG/0.4ML SYRINGE NDS PA
1ORENCIA 87.5MG/0.7ML SYRINGE NDS PASOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
1ENBREL 25MG INJ NDS PA
1ENBREL 25MG/0.5ML SYRINGE NDS PA
1ENBREL 50MG/ML SURECLICK INJ NDS PA
1ENBREL 50MG/ML SYRINGE NDS PA
ANALGESICS - NONNARCOTICSALICYLATES
1diflunisal 500mg tab
ANALGESICS - OPIOIDOPIOID AGONISTS
1codeine sulfate 15mg tab QL=240 EA/30 Days
1codeine sulfate 30mg tab QL=240 EA/30 Days
1codeine sulfate 60mg tab QL=180 EA/30 Days
1duramorph 0.5mg/ml inj PA BvD
1duramorph 1mg/ml inj PA BvD
1EMBEDA 100-4MG ER CAP QL=60 EA/30 Days
1EMBEDA 20-0.8MG ER CAP QL=60 EA/30 Days
1EMBEDA 30-1.2MG ER CAP QL=60 EA/30 Days
1EMBEDA 50-2MG ER CAP QL=60 EA/30 Days
1EMBEDA 60-2.4MG ER CAP QL=60 EA/30 Days
1EMBEDA 80-3.2MG ER CAP QL=60 EA/30 Days
1fentanyl 0.012mg/hr patch QL=10 EA/30 Days
1fentanyl 0.025mg/hr patch QL=10 EA/30 Days
1FENTANYL 0.0375MG/HR PATCH QL=10 EA/30 Days
1fentanyl 0.05mg/hr patch QL=10 EA/30 Days
1FENTANYL 0.0625MG/HR PATCH QL=10 EA/30 Days
1fentanyl 0.075mg/hr patch QL=10 EA/30 Days
1fentanyl 0.1mg/hr patch QL=10 EA/30 Days
1fentanyl 0.2mg lozenge PA QL=120 EA/30 Days
1fentanyl 0.4mg lozenge PA QL=120 EA/30 Days
1fentanyl 0.6mg lozenge PA QL=120 EA/30 Days
1fentanyl 0.8mg lozenge PA QL=120 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
11
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1fentanyl 1.2mg lozenge PA QL=120 EA/30 Days
1fentanyl 1.6mg lozenge PA QL=120 EA/30 Days
1FENTORA 100MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 200MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 400MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 600MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 800MCG BUCCAL TAB PA QL=120 EA/30 Days
1hydromorphone 10mg/ml (1ml) inj
1hydromorphone 10mg/ml (5ml) inj
1hydromorphone 12mg er tab QL=60 EA/30 Days
1hydromorphone 16mg er tab QL=60 EA/30 Days
1hydromorphone 1mg/ml oral soln QL=2400 ML/30 Days
1hydromorphone 2mg tab QL=450 EA/30 Days
1hydromorphone 2mg/ml syringe
1hydromorphone 32mg er tab QL=60 EA/30 Days
1hydromorphone 4mg tab QL=240 EA/30 Days
1hydromorphone 8mg er tab QL=60 EA/30 Days
1hydromorphone 8mg tab QL=120 EA/30 Days
1HYSINGLA 100MG ER TAB QL=30 EA/30 Days
1HYSINGLA 120MG ER TAB QL=30 EA/30 Days
1HYSINGLA 20MG ER TAB QL=30 EA/30 Days
1HYSINGLA 30MG ER TAB QL=30 EA/30 Days
1HYSINGLA 40MG ER TAB QL=30 EA/30 Days
1HYSINGLA 60MG ER TAB QL=30 EA/30 Days
1HYSINGLA 80MG ER TAB QL=30 EA/30 Days
1LEVORPHANOL 2MG TAB QL=240 EA/30 Days
1meperidine 100mg tab QL=360 EA/30 Days
1meperidine 50mg tab QL=720 EA/30 Days
1methadone 10mg tab QL=360 EA/30 Days
1methadone 1mg/ml oral soln QL=3600 ML/30 Days
1methadone 2mg/ml oral soln QL=1800 ML/30 Days
1methadone 5mg tab QL=360 EA/30 Days
1morphine sulfate 100mg er cap QL=60 EA/30 Days
1morphine sulfate 100mg er tab QL=120 EA/30 Days
1morphine sulfate 10mg er cap QL=60 EA/30 Days
1MORPHINE SULFATE 120MG ER (24HR) CAP QL=60 EA/30 Days
1morphine sulfate 15mg er tab QL=120 EA/30 Days
1morphine sulfate 15mg tab QL=180 EA/30 Days
1morphine sulfate 200mg er tab QL=120 EA/30 Days
1morphine sulfate 20mg er cap QL=60 EA/30 Days
1morphine sulfate 20mg/ml oral soln QL=180 ML/30 Days
1morphine sulfate 2mg/ml oral soln QL=1800 ML/30 Days
1MORPHINE SULFATE 2MG/ML SYRINGE
1MORPHINE SULFATE 30MG ER (24 HR) CAP QL=60 EA/30 Days
1morphine sulfate 30mg er cap QL=60 EA/30 Days
1morphine sulfate 30mg er tab QL=120 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
12
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1morphine sulfate 30mg tab QL=180 EA/30 Days
1MORPHINE SULFATE 45MG ER (24HR) CAP QL=60 EA/30 Days
1morphine sulfate 4mg/ml oral soln QL=900 ML/30 Days
1morphine sulfate 50mg er cap QL=60 EA/30 Days
1MORPHINE SULFATE 5MG/ML SYRINGE
1MORPHINE SULFATE 60MG (24HR) ER CAP QL=60 EA/30 Days
1morphine sulfate 60mg er cap QL=60 EA/30 Days
1morphine sulfate 60mg er tab QL=120 EA/30 Days
1MORPHINE SULFATE 75MG ER (24HR) CAP QL=60 EA/30 Days
1morphine sulfate 80mg er cap QL=60 EA/30 Days
1MORPHINE SULFATE 90MG ER (24HR) CAP QL=60 EA/30 Days
1NUCYNTA 100MG ER TAB QL=60 EA/30 Days
1NUCYNTA 150MG ER TAB QL=60 EA/30 Days
1NUCYNTA 200MG ER TAB QL=60 EA/30 Days
1NUCYNTA 250MG ER TAB QL=60 EA/30 Days
1NUCYNTA 50MG ER TAB QL=60 EA/30 Days
1oxycodone 10mg tab QL=180 EA/30 Days
1oxycodone 15mg tab QL=180 EA/30 Days
1oxycodone 1mg/ml oral soln QL=5400 ML/30 Days
1oxycodone 20mg tab QL=180 EA/30 Days
1oxycodone 20mg/ml oral soln QL=270 ML/30 Days
1oxycodone 30mg tab QL=180 EA/30 Days
1oxycodone 5mg cap QL=360 EA/30 Days
1oxycodone 5mg tab QL=360 EA/30 Days
1OXYCONTIN 10MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 15MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 20MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 30MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 40MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 60MG ER TAB QL=60 EA/30 Days
1OXYCONTIN 80MG ER TAB QL=120 EA/30 Days
1oxymorphone 10mg tab QL=360 EA/30 Days
1oxymorphone 5mg tab QL=360 EA/30 Days
1tramadol 100mg er tab QL=60 EA/30 Days
1tramadol 100mg er tab (matrix delivery) QL=60 EA/30 Days
1tramadol 200mg er tab QL=60 EA/30 Days
1tramadol 200mg er tab (matrix delivery) QL=60 EA/30 Days
1tramadol 300mg er tab QL=60 EA/30 Days
1tramadol 300mg er tab (matrix delivery) QL=60 EA/30 Days
1tramadol 50mg tab QL=240 EA/30 Days
1XTAMPZA 13.5MG ER CAP QL=120 EA/30 Days
1XTAMPZA 18MG ER CAP QL=120 EA/30 Days
1XTAMPZA 27MG ER CAP QL=120 EA/30 Days
1XTAMPZA 36MG ER CAP QL=120 EA/30 Days
1XTAMPZA 9MG ER CAP QL=120 EA/30 DaysOPIOID COMBINATIONS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
13
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln
QL=5400 ML/30 Days
1acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln
QL=4980 ML/30 Days
1acetaminophen 300mg/codeine phosphate 15mg tab QL=390 EA/30 Days
1acetaminophen 300mg/codeine phosphate 30mg tab QL=390 EA/30 Days
1acetaminophen 300mg/codeine phosphate 60mg tab QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 10mg tab
QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 5mg tab
QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab
QL=390 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 10mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 2.5mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 5mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 10mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 2.5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 7.5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/tramadol 37.5mg tab QL=360 EA/30 Days
1aspirin 325mg/oxycodone 4.84mg tab QL=360 EA/30 Days
1endocet 10-325mg tab QL=360 EA/30 Days
1endocet 5-325mg tab QL=360 EA/30 Days
1endocet 7.5-325mg tab QL=360 EA/30 Days
1hydrocodone 10mg/ibuprofen 200mg tab QL=480 EA/30 Days
1hydrocodone 5mg/ibuprofen 200mg tab QL=480 EA/30 Days
1hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab QL=480 EA/30 Days
1IBUPROFEN 400MG/OXYCODONE 5MG TAB QL=240 EA/30 Days
1lorcet 10-325mg tab QL=360 EA/30 Days
1lorcet 5-325mg tab QL=360 EA/30 Days
1lorcet 7.5-325mg tab QL=360 EA/30 Days
1vicodin 10-300mg tab QL=390 EA/30 Days
1vicodin 5-300mg tab QL=390 EA/30 Days
1vicodin 7.5-300mg tab QL=390 EA/30 DaysOPIOID PARTIAL AGONISTS
1BUNAVAIL 2.1-0.3MG FILM
1BUNAVAIL 4.2-0.7MG FILM
1BUNAVAIL 6.3-1MG FILM
1buprenorphine 0.3mg/ml cartridge
1buprenorphine 0.3mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
14
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1buprenorphine 2mg sl tab PA
1buprenorphine 8mg sl tab PA
1butorphanol tartrate 10mg/ml nasal spray QL=10 ML/30 Days
1BUTORPHANOL TARTRATE 1MG/ML INJ
1butorphanol tartrate 2mg/ml inj
1naloxone 0.5mg/pentazocine 50mg tab QL=360 EA/30 Days
1SUBOXONE 12-3MG STRIP
1SUBOXONE 2-0.5MG STRIP
1SUBOXONE 4-1MG STRIP
1SUBOXONE 8-2MG STRIP
1ZUBSOLV 11.4-2.9MG SL TAB QL=60 EA/30 Days
1ZUBSOLV 1.4-0.36MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 2.9-0.71MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 5.7-1.4MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 8.6-2.1MG SL TAB QL=60 EA/30 Days
ANDROGENS-ANABOLICANABOLIC STEROIDS
1ANADROL-50 50MG TAB
1oxandrolone 10mg tab
1oxandrolone 2.5mg tabANDROGENS
1ANDRODERM 2MG/24HR PATCH PA QL=60 EA/30 Days
1ANDRODERM 4MG/24HR PATCH PA QL=30 EA/30 Days
1ANDROGEL 1% (25MG) GEL PA QL=300 GM/30 Days
1ANDROGEL 1% (50MG) GEL PA QL=300 GM/30 Days
1ANDROGEL 1.62% (1.25GM) GEL PA QL=37.50 GM/30 Days
1ANDROGEL 1.62% (2.5GM) GEL PA QL=150 GM/30 Days
1ANDROGEL 1.62% GEL PA QL=150 GM/30 Days
1danazol 100mg cap
1danazol 200mg cap
1danazol 50mg cap
1testosterone 1% (25mg) gel PA QL=300 GM/30 Days
1testosterone 1% (50mg) gel PA QL=300 GM/30 Days
1testosterone 1% gel pump PA QL=300 GM/30 Days
1testosterone cypionate 100mg/ml inj
1testosterone cypionate 200mg/ml inj
1testosterone enanthate 200mg/ml inj
ANORECTAL AGENTSINTRARECTAL STEROIDS
1colocort 100mg/60ml enema
1hydrocortisone 1.67mg/ml enema
1UCERIS 2MG/ACT FOAM PARECTAL COMBINATIONS
1hydrocortisone/pramoxine 1-1% rectal creamRECTAL STEROIDS
1procto-med 2.5% cream
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
15
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1procto-pak 1% rectal cream
1proctosol 2.5% cream
1proctozone hc 2.5% cream
ANTHELMINTICSANTHELMINTICS
1ALBENZA 200MG TAB NDS
1ivermectin 3mg tab
ANTIANGINAL AGENTSANTIANGINALS-OTHER
1RANEXA 1000MG ER TAB
1RANEXA 500MG ER TABNITRATES
1isosorbide dinitrate 10mg tab
1isosorbide dinitrate 20mg tab
1isosorbide dinitrate 30mg tab
1ISOSORBIDE DINITRATE 40MG ER TAB
1isosorbide dinitrate 5mg tab
1isosorbide mononitrate 10mg tab
1isosorbide mononitrate 120mg er tab
1isosorbide mononitrate 20mg tab
1isosorbide mononitrate 30mg er tab
1isosorbide mononitrate 60mg er tab
1minitran 0.1mg/hr patch
1minitran 0.2mg/hr patch
1minitran 0.4mg/hr patch
1minitran 0.6mg/hr patch
1NITRO-DUR 0.3MG/HR PATCH
1NITRO-DUR 0.8MG/HR PATCH
1nitroglycerin 0.1mg/hr patch
1nitroglycerin 0.2mg/hr patch
1nitroglycerin 0.3mg sl tab
1nitroglycerin 0.4mg sl tab
1nitroglycerin 0.4mg/act pump spray
1nitroglycerin 0.4mg/hr patch
1nitroglycerin 0.6mg sl tab
1nitroglycerin 0.6mg/hr patch
ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.
1buspirone 10mg tab
1buspirone 15mg tab
1buspirone 30mg tab
1buspirone 5mg tab
1buspirone 7.5mg tab
1hydroxyzine 10mg tab
1hydroxyzine 25mg tab
1HYDROXYZINE 25MG/ML INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
16
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydroxyzine 2mg/ml oral soln
1hydroxyzine 50mg tab
1hydroxyzine 50mg/ml inj
1HYDROXYZINE PAMOATE 100MG CAP
1hydroxyzine pamoate 25mg cap
1hydroxyzine pamoate 50mg cap
1meprobamate 200mg tab
1meprobamate 400mg tabBENZODIAZEPINES
1alprazolam 0.25mg odt
1alprazolam 0.25mg tab
1alprazolam 0.5mg er tab
1alprazolam 0.5mg odt
1alprazolam 0.5mg tab
1alprazolam 1mg er tab
1alprazolam 1mg odt
1alprazolam 1mg tab
1alprazolam 2mg er tab
1alprazolam 2mg odt
1alprazolam 2mg tab
1alprazolam 3mg er tab
1chlordiazepoxide 10mg cap
1chlordiazepoxide 25mg cap
1chlordiazepoxide 5mg cap
1clorazepate dipotassium 15mg tab
1clorazepate dipotassium 3.75mg tab
1clorazepate dipotassium 7.5mg tab
1diazepam 10mg tab
1DIAZEPAM 1MG/ML ORAL SOLN
1diazepam 2mg tab
1diazepam 5mg tab
1diazepam 5mg/ml oral soln
1lorazepam 0.5mg tab
1lorazepam 1mg tab
1lorazepam 2mg tab
1lorazepam 2mg/ml oral conc
1oxazepam 10mg cap
1oxazepam 15mg cap
1oxazepam 30mg cap
ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A
1disopyramide 100mg cap
1disopyramide 150mg cap
1NORPACE 100MG ER CAP
1NORPACE 150MG ER CAP
1PROCAINAMIDE 100MG/ML INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
17
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1PROCAINAMIDE 500MG/ML INJ
1quinidine gluconate 324mg er tab
1QUINIDINE GLUCONATE 80MG/ML INJ
1QUINIDINE SULFATE 200MG TAB
1QUINIDINE SULFATE 300MG TABANTIARRHYTHMICS TYPE I-B
1mexiletine 150mg cap
1mexiletine 200mg cap
1mexiletine 250mg capANTIARRHYTHMICS TYPE I-C
1flecainide acetate 100mg tab
1flecainide acetate 150mg tab
1flecainide acetate 50mg tab
1propafenone 150mg tab
1propafenone 225mg er cap
1propafenone 225mg tab
1propafenone 300mg tab
1propafenone 325mg er cap
1propafenone 425mg er capANTIARRHYTHMICS TYPE III
1amiodarone 200mg tab
1amiodarone 400mg tab
1amiodarone 50mg/ml inj
1amiodarone hydrochloride 100mg tab
1dofetilide 125mcg cap
1dofetilide 250mcg cap
1dofetilide 500mcg cap
1MULTAQ 400MG TAB
1NEXTERONE 150MG/100ML INJ
1NEXTERONE 360MG/200ML INJ
1pacerone 200mg tab
1pacerone 400mg tab
ANTIASTHMATIC AND BRONCHODILATOR AGENTSANTIASTHMATIC - MONOCLONAL ANTIBODIES
1NUCALA 100MG INJ NDS PA
1XOLAIR 150MG INJ NDS PAANTI-INFLAMMATORY AGENTS
1CROMOLYN SODIUM 10MG/ML INH SOLN PA BvDBRONCHODILATORS - ANTICHOLINERGICS
1ATROVENT 17MCG INH
1INCRUSE 62.5MCG INH
1ipratropium bromide 0.02% inh soln PA BvD
1SPIRIVA 1.25MCG RESPIMAT INH ST QL=4 GM/30 Days
1SPIRIVA 18MCG HANDIHALER
1SPIRIVA 2.5MCG RESPIMAT INHLEUKOTRIENE MODULATORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
18
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1montelukast 10mg tab
1montelukast 4mg chew tab
1montelukast 4mg granules
1montelukast 5mg chew tab
1zafirlukast 10mg tab
1zafirlukast 20mg tab
1zileuton 600mg er tabSELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
1DALIRESP 250MCG TAB
1DALIRESP 500MCG TABSTEROID INHALANTS
1ARNUITY 100MCG INH QL=30 EA/30 Days
1ARNUITY 200MCG INH QL=30 EA/30 Days
1ASMANEX 100MCG (120ACT) HFA INH QL=13 GM/30 Days
1ASMANEX 110MCG (30ACT) INH QL=1 EA/30 Days
1ASMANEX 200MCG (120ACT) HFA INH QL=13 GM/30 Days
1ASMANEX 220MCG (120ACT) INH QL=1 EA/30 Days
1ASMANEX 220MCG (30ACT) INH QL=1 EA/30 Days
1ASMANEX 220MCG (60ACT) INH QL=1 EA/30 Days
1budesonide 0.125mg/ml inh soln PA BvD QL=120 ML/30 Days
1budesonide 0.25mg/ml inh soln PA BvD QL=120 ML/30 Days
1budesonide 0.5mg/ml inh soln PA BvD QL=120 ML/30 Days
1FLOVENT 100MCG DISKUS QL=60 EA/30 Days
1FLOVENT 110MCG HFA INH QL=24 GM/30 Days
1FLOVENT 220MCG HFA INH QL=24 GM/30 Days
1FLOVENT 250MCG DISKUS QL=60 EA/30 Days
1FLOVENT 44MCG HFA INH QL=21.20 GM/30 Days
1FLOVENT 50MCG DISKUS QL=60 EA/30 DaysSYMPATHOMIMETICS
1ADVAIR 100-50MCG DISKUS QL=60 EA/30 Days
1ADVAIR 115-21MCG HFA INH QL=12 GM/30 Days
1ADVAIR 230-21MCG HFA INH QL=12 GM/30 Days
1ADVAIR 250-50MCG DISKUS QL=60 EA/30 Days
1ADVAIR 45-21MCG HFA INH QL=12 GM/30 Days
1ADVAIR 500-50MCG DISKUS QL=60 EA/30 Days
1albuterol 0.21mg/ml (0.63mg/3ml) inh soln PA BvD
1albuterol 0.417mg/ml (1.25mg/3ml) inh soln PA BvD
1albuterol 0.4mg/ml (2mg/5ml) oral soln
1albuterol 0.83mg/ml (0.083%) inh soln PA BvD
1albuterol 1mg/ml (0.5%) inh soln PA BvD
1albuterol 2mg tab
1albuterol 4mg er tab
1albuterol 4mg tab
1albuterol 8mg er tab
1ANORO 62.5-25MCG ELLIPTA INH QL=60 EA/30 Days
1BREO 100-25MCG ELLIPTA INH QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
19
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1BREO 200-25MCG ELLIPTA INH QL=60 EA/30 Days
1BROVANA 15MCG/2ML INH SOLN PA BvD
1COMBIVENT RESPIMAT 20-100MCG INH
1DULERA 100-5MCG INH QL=13 GM/30 Days
1DULERA 200-5MCG INH QL=13 GM/30 Days
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 113-14MCG/ACT POWDER INH
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-14MCG/ACT POWDER INH
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-14MCG/ACT POWDER INH
1ipratropium/albuterol 0.5-2.5mg/3ml inh soln PA BvD
1levalbuterol 0.31mg inh soln PA BvD
1levalbuterol 0.63mg inh soln PA BvD
1levalbuterol 1.25mg inh soln PA BvD
1levalbuterol 2.5mg inh soln PA BvD
1METAPROTERENOL SULFATE 10MG TAB
1METAPROTERENOL SULFATE 20MG TAB
1METAPROTERENOL SULFATE 2MG/ML ORAL SOLN
1SEREVENT 50MCG/DOSE INH
1STIOLTO 2.5-2.5MCG INH QL=4 GM/30 Days
1terbutaline sulfate 1mg/ml inj
1terbutaline sulfate 2.5mg tab
1terbutaline sulfate 5mg tab
1TRELEGY 62.5-25MCG ELLIPTA INH
1VENTOLIN 108MCG INH QL=36 GM/30 DaysXANTHINES
1aminophylline 25mg/ml inj
1theophylline 100mg er tab
1theophylline 200mg er tab
1theophylline 300mg er tab
1theophylline 400mg er tab
1theophylline 5.33mg/ml oral soln
1theophylline 600mg er tab
ANTICOAGULANTSCOUMARIN ANTICOAGULANTS
1jantoven 10mg tab
1jantoven 1mg tab
1jantoven 2.5mg tab
1jantoven 2mg tab
1jantoven 3mg tab
1jantoven 4mg tab
1jantoven 5mg tab
1jantoven 6mg tab
1jantoven 7.5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
20
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1warfarin sodium 10mg tab
1warfarin sodium 1mg tab
1warfarin sodium 2.5mg tab
1warfarin sodium 2mg tab
1warfarin sodium 3mg tab
1warfarin sodium 4mg tab
1warfarin sodium 5mg tab
1warfarin sodium 6mg tab
1warfarin sodium 7.5mg tabDIRECT FACTOR XA INHIBITORS
1ELIQUIS 2.5MG TAB
1ELIQUIS 30-DAY STARTER PACK
1ELIQUIS 5MG TAB
1XARELTO 10MG TAB
1XARELTO 15MG TAB
1XARELTO 20MG TAB
1XARELTO STARTER PACKHEPARINS AND HEPARINOID-LIKE AGENTS
1enoxaparin sodium 100mg/1ml syringe QL=34 ML/17 Days
1enoxaparin sodium 120mg/0.8ml syringe QL=27.20 ML/17 Days
1enoxaparin sodium 150mg/1ml syringe QL=34 ML/17 Days
1enoxaparin sodium 300mg/3ml syringe QL=51 ML/17 Days
1enoxaparin sodium 30mg/0.3ml syringe QL=10.20 ML/17 Days
1enoxaparin sodium 40mg/0.4ml syringe QL=13.60 ML/17 Days
1enoxaparin sodium 60mg/0.6ml syringe QL=20.40 ML/17 Days
1enoxaparin sodium 80mg/0.8ml syringe QL=27.20 ML/17 Days
1fondaparinux sodium 12.5mg/ml (0.4ml) syringe PA
1fondaparinux sodium 12.5mg/ml (0.6ml) syringe PA
1fondaparinux sodium 12.5mg/ml (0.8ml) syringe PA
1fondaparinux sodium 5mg/ml syringe PA
1FRAGMIN 10000UNIT/ML SYRINGE
1FRAGMIN 12500UNIT/0.5ML SYRINGE
1FRAGMIN 15000UNIT/0.6ML SYRINGE
1FRAGMIN 18000UNIT/0.72ML SYRINGE
1FRAGMIN 2500UNIT/0.2ML SYRINGE
1FRAGMIN 5000UNIT/0.2ML SYRINGE
1FRAGMIN 7500UNIT/0.3ML SYRINGE
1FRAGMIN 95000UNIT/3.8ML INJ NDS
1heparin sodium, porcine 10000unit/ml inj PA BvD
1heparin sodium, porcine 1000unit/ml inj PA BvD
1HEPARIN SODIUM, PORCINE 100UNIT/ML INJ PA BvD
1heparin sodium, porcine 20000unit/ml inj PA BvD
1heparin sodium, porcine 40unit/ml inj PA BvD
1heparin sodium, porcine 5000unit/ml inj PA BvD
1heparin sodium, porcine 50unit/ml inj PA BvDTHROMBIN INHIBITORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
21
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1argatroban 100mg/ml inj
1ARGATROBAN 1MG/ML INJ PA BvD
1PRADAXA 110MG CAP
1PRADAXA 150MG CAP
1PRADAXA 75MG CAP
ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS
1FYCOMPA 0.5MG/ML ORAL SUSP PA NSO
1FYCOMPA 10MG TAB PA NSO
1FYCOMPA 12MG TAB PA NSO
1FYCOMPA 2MG TAB PA NSO
1FYCOMPA 4MG TAB PA NSO
1FYCOMPA 6MG TAB PA NSO
1FYCOMPA 8MG TAB PA NSOANTICONVULSANTS - BENZODIAZEPINES
1clonazepam 0.125mg odt
1clonazepam 0.25mg odt
1clonazepam 0.5mg odt
1clonazepam 0.5mg tab
1clonazepam 1mg odt
1clonazepam 1mg tab
1clonazepam 2mg odt
1clonazepam 2mg tab
1DIASTAT 10MG APPLICATOR
1DIASTAT 2.5MG APPLICATOR
1DIASTAT 20MG PF APPLICATOR
1ONFI 10MG TAB PA NSO
1ONFI 2.5MG/ML ORAL SUSP PA NSO
1ONFI 20MG TAB PA NSOANTICONVULSANTS - MISC.
1APTIOM 200MG TAB PA NSO
1APTIOM 400MG TAB PA NSO
1APTIOM 600MG TAB PA NSO
1APTIOM 800MG TAB PA NSO
1BANZEL 200MG TAB
1BANZEL 400MG TAB
1BANZEL 40MG/ML ORAL SUSP
1BRIVIACT 100MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 10MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 10MG/ML INJ PA NSO
1BRIVIACT 10MG/ML ORAL SOLN PA NSO
1BRIVIACT 25MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 50MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 75MG TAB PA NSO QL=60 EA/30 Days
1carbamazepine 100mg chew tab
1carbamazepine 100mg er cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
22
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1carbamazepine 100mg er tab
1carbamazepine 200mg er cap
1carbamazepine 200mg er tab
1carbamazepine 200mg tab
1carbamazepine 20mg/ml oral susp
1carbamazepine 300mg er cap
1carbamazepine 400mg er tab
1epitol 200mg tab
1gabapentin 100mg cap
1gabapentin 300mg cap
1gabapentin 400mg cap
1gabapentin 50mg/ml oral soln
1gabapentin 600mg tab
1gabapentin 800mg tab
1LAMICTAL BLUE KIT
1LAMICTAL GREEN KIT
1LAMICTAL ORANGE KIT
1LAMICTAL XR BLUE KIT
1LAMICTAL XR GREEN KIT
1LAMICTAL XR ORANGE KIT
1lamotrigine 100mg er tab
1lamotrigine 100mg odt
1lamotrigine 100mg tab
1lamotrigine 150mg tab
1lamotrigine 200mg er tab
1lamotrigine 200mg odt
1lamotrigine 200mg tab
1lamotrigine 250mg er tab
1lamotrigine 25mg chew tab
1lamotrigine 25mg er tab
1lamotrigine 25mg odt
1lamotrigine 25mg tab
1lamotrigine 300mg er tab
1lamotrigine 50mg er tab
1lamotrigine 50mg odt
1lamotrigine 5mg chew tab
1lamotrigine tab 25mg (35) starter pack
1lamotrigine tab 25mg (42)/100mg (7) starter pack
1lamotrigine tab 25mg (84)/100mg (14) starter pack
1levetiracetam 1000mg tab
1levetiracetam 100mg/ml inj
1levetiracetam 100mg/ml oral soln
1levetiracetam 10mg/ml inj
1levetiracetam 15mg/ml inj
1levetiracetam 250mg tab
1levetiracetam 500mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
23
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1levetiracetam 500mg tab
1levetiracetam 5mg/ml inj
1levetiracetam 750mg er tab
1levetiracetam 750mg tab
1LYRICA 100MG CAP
1LYRICA 150MG CAP
1LYRICA 200MG CAP
1LYRICA 20MG/ML ORAL SOLN
1LYRICA 225MG CAP
1LYRICA 25MG CAP
1LYRICA 300MG CAP
1LYRICA 50MG CAP
1LYRICA 75MG CAP
1oxcarbazepine 150mg tab
1oxcarbazepine 300mg tab
1oxcarbazepine 600mg tab
1oxcarbazepine 60mg/ml oral susp
1OXTELLAR 150MG XR TAB
1OXTELLAR 300MG XR TAB
1OXTELLAR 600MG XR TAB
1primidone 250mg tab
1primidone 50mg tab
1QUDEXY 100MG XR CAP PA NSO
1QUDEXY 150MG XR CAP PA NSO
1QUDEXY 200MG XR CAP PA NSO
1QUDEXY 25MG XR CAP PA NSO
1QUDEXY 50MG XR CAP PA NSO
1roweepra 1000mg tab
1roweepra 500mg er tab
1roweepra 500mg tab
1roweepra 750mg er tab
1roweepra 750mg tab
1SPRITAM 1000MG ODT PA NSO
1SPRITAM 250MG ODT PA NSO
1SPRITAM 500MG ODT PA NSO
1SPRITAM 750MG ODT PA NSO
1TOPIRAMATE 100MG ER CAP PA NSO
1topiramate 100mg tab
1TOPIRAMATE 150MG ER CAP PA NSO
1topiramate 15mg cap
1TOPIRAMATE 200MG ER CAP PA NSO
1topiramate 200mg tab
1topiramate 25mg cap
1TOPIRAMATE 25MG ER CAP PA NSO
1topiramate 25mg tab
1TOPIRAMATE 50MG ER CAP PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
24
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1topiramate 50mg tab
1TROKENDI 100MG XR CAP PA NSO
1TROKENDI 200MG XR CAP PA NSO
1TROKENDI 25MG XR CAP PA NSO
1TROKENDI 50MG XR CAP PA NSO
1VIMPAT 100MG TAB QL=60 EA/30 Days
1VIMPAT 10MG/ML ORAL SOLN
1VIMPAT 150MG TAB QL=60 EA/30 Days
1VIMPAT 200MG TAB QL=60 EA/30 Days
1VIMPAT 200MG/20ML INJ
1VIMPAT 50MG TAB QL=60 EA/30 Days
1zonisamide 100mg cap
1zonisamide 25mg cap
1zonisamide 50mg capCARBAMATES
1felbamate 120mg/ml oral susp
1felbamate 400mg tab
1felbamate 600mg tabGABA MODULATORS
1GABITRIL 12MG TAB
1GABITRIL 16MG TAB
1SABRIL 500MG ORAL SOLN NDS PA NSO
1SABRIL 500MG TAB NDS PA NSO
1tiagabine 12mg tab
1tiagabine 16mg tab
1tiagabine 2mg tab
1tiagabine 4mg tab
1vigabatrin 50mg/ml oral soln NDS PA NSOHYDANTOINS
1DILANTIN 30MG ER CAP
1fosphenytoin sodium 75mg/ml inj
1PEGANONE 250MG TAB
1phenytoin 25mg/ml oral susp
1phenytoin 50mg chew tab
1phenytoin sodium 100mg er cap
1phenytoin sodium 200mg er cap
1phenytoin sodium 300mg er cap
1phenytoin sodium 50mg/ml injSUCCINIMIDES
1CELONTIN 300MG CAP
1ethosuximide 250mg cap
1ethosuximide 50mg/ml oral solnVALPROIC ACID
1divalproex sodium 125mg dr cap
1divalproex sodium 125mg dr tab
1divalproex sodium 250mg dr tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
25
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1divalproex sodium 250mg er tab
1divalproex sodium 500mg dr tab
1divalproex sodium 500mg er tab
1valproic acid 100mg/ml inj
1valproic acid 250mg cap
1valproic acid 50mg/ml oral soln
ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
1mirtazapine 15mg odt
1mirtazapine 15mg tab
1mirtazapine 30mg odt
1mirtazapine 30mg tab
1mirtazapine 45mg odt
1mirtazapine 45mg tab
1mirtazapine 7.5mg tabANTIDEPRESSANTS - MISC.
1APLENZIN 174MG ER TAB ST
1APLENZIN 348MG ER TAB ST
1APLENZIN 522MG ER TAB ST
1bupropion 100mg sr tab
1bupropion 100mg tab
1bupropion 150mg sr (12 hr) tab
1bupropion 150mg xl (24 hr) tab
1bupropion 200mg sr tab
1bupropion 300mg xl tab
1bupropion 75mg tab
1MAPROTILINE 25MG TAB
1MAPROTILINE 50MG TAB
1MAPROTILINE 75MG TABMONOAMINE OXIDASE INHIBITORS (MAOIS)
1EMSAM 12MG/24HR PATCH
1EMSAM 6MG/24HR PATCH
1EMSAM 9MG/24HR PATCH
1MARPLAN 10MG TAB
1phenelzine 15mg tab
1tranylcypromine 10mg tabSELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
1citalopram 10mg tab
1citalopram 20mg tab
1citalopram 2mg/ml oral soln
1citalopram 40mg tab
1escitalopram 10mg tab
1escitalopram 1mg/ml oral soln
1escitalopram 20mg tab
1escitalopram 5mg tab
1fluoxetine 10mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
26
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1fluoxetine 10mg tab
1fluoxetine 20mg cap
1fluoxetine 20mg tab
1fluoxetine 40mg cap
1fluoxetine 4mg/ml oral soln
1fluvoxamine maleate 100mg er cap ST
1fluvoxamine maleate 100mg tab
1fluvoxamine maleate 150mg er cap ST
1fluvoxamine maleate 25mg tab
1fluvoxamine maleate 50mg tab
1paroxetine 10mg tab
1paroxetine 12.5mg er tab
1paroxetine 20mg tab
1paroxetine 25mg er tab
1paroxetine 30mg tab
1paroxetine 37.5mg er tab
1paroxetine 40mg tab
1PAXIL 10MG/5ML ORAL SUSP
1PEXEVA 10MG TAB ST
1PEXEVA 20MG TAB ST
1PEXEVA 30MG TAB ST
1PEXEVA 40MG TAB ST
1sertraline 100mg tab
1sertraline 20mg/ml oral soln
1sertraline 25mg tab
1sertraline 50mg tabSEROTONIN MODULATORS
1NEFAZODONE 100MG TAB
1NEFAZODONE 150MG TAB
1NEFAZODONE 200MG TAB
1nefazodone 250mg tab
1nefazodone 50mg tab
1trazodone 100mg tab
1trazodone 150mg tab
1trazodone 300mg tab
1trazodone 50mg tab
1TRINTELLIX 10MG TAB ST QL=30 EA/30 Days
1TRINTELLIX 20MG TAB ST QL=30 EA/30 Days
1TRINTELLIX 5MG TAB ST QL=30 EA/30 Days
1VIIBRYD 10/20MG STARTER PACK ST QL=30 EA/30 Days
1VIIBRYD 10MG TAB ST QL=30 EA/30 Days
1VIIBRYD 20MG TAB ST QL=30 EA/30 Days
1VIIBRYD 40MG TAB ST QL=30 EA/30 DaysSEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
1DESVENLAFAXINE FUMARATE 100MG ER TAB ST
1DESVENLAFAXINE FUMARATE 50MG ER TAB ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
27
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1desvenlafaxine succinate 100mg er tab
1desvenlafaxine succinate 25mg er tab
1desvenlafaxine succinate 50mg er tab
1duloxetine 20mg dr cap
1duloxetine 30mg dr cap
1DULOXETINE 40MG DR CAP ST QL=30 EA/30 Days
1duloxetine 60mg dr cap
1FETZIMA 120MG ER CAP ST QL=30 EA/30 Days
1FETZIMA 20MG ER CAP ST QL=30 EA/30 Days
1FETZIMA 40MG ER CAP ST QL=30 EA/30 Days
1FETZIMA 80MG ER CAP ST QL=30 EA/30 Days
1FETZIMA PACK ST QL=30 EA/30 Days
1KHEDEZLA 100MG ER TAB ST
1KHEDEZLA 50MG ER TAB ST
1venlafaxine 100mg tab
1venlafaxine 150mg er cap
1venlafaxine 150mg er tab
1VENLAFAXINE 225MG ER TAB
1venlafaxine 25mg tab
1venlafaxine 37.5mg er cap
1venlafaxine 37.5mg er tab
1venlafaxine 37.5mg tab
1venlafaxine 50mg tab
1venlafaxine 75mg er cap
1venlafaxine 75mg er tab
1venlafaxine 75mg tabTRICYCLIC AGENTS
1amitriptyline 100mg tab
1amitriptyline 10mg tab
1amitriptyline 150mg tab
1amitriptyline 25mg tab
1amitriptyline 50mg tab
1amitriptyline 75mg tab
1AMOXAPINE 100MG TAB
1AMOXAPINE 150MG TAB
1AMOXAPINE 25MG TAB
1AMOXAPINE 50MG TAB
1clomipramine 25mg cap
1clomipramine 50mg cap
1clomipramine 75mg cap
1desipramine 100mg tab
1desipramine 10mg tab
1desipramine 150mg tab
1desipramine 25mg tab
1desipramine 50mg tab
1desipramine 75mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
28
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1doxepin 100mg cap
1doxepin 10mg cap
1doxepin 10mg/ml oral soln
1doxepin 150mg cap
1doxepin 25mg cap
1doxepin 50mg cap
1DOXEPIN 75MG CAP
1imipramine 10mg tab
1imipramine 25mg tab
1imipramine 50mg tab
1imipramine pamoate 100mg cap
1imipramine pamoate 125mg cap
1imipramine pamoate 150mg cap
1imipramine pamoate 75mg cap
1nortriptyline 10mg cap
1nortriptyline 25mg cap
1NORTRIPTYLINE 2MG/ML ORAL SOLN
1nortriptyline 50mg cap
1nortriptyline 75mg cap
1protriptyline 10mg tab
1protriptyline 5mg tab
1trimipramine 100mg cap
1trimipramine 25mg cap
1trimipramine 50mg cap
ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS
1acarbose 100mg tab
1acarbose 25mg tab
1acarbose 50mg tab
1miglitol 100mg tab
1miglitol 25mg tab
1miglitol 50mg tabANTIDIABETIC COMBINATIONS
1glimepiride 2mg/pioglitazone 30mg tab
1glimepiride 4mg/pioglitazone 30mg tab
1glipizide 2.5mg/metformin 250mg tab
1glipizide 2.5mg/metformin 500mg tab
1glipizide 5mg/metformin 500mg tab
1glyburide 1.25mg/metformin 250mg tab
1glyburide 2.5mg/metformin 500mg tab
1glyburide 5mg/metformin 500mg tab
1GLYXAMBI 10-5MG TAB QL=30 EA/30 Days
1GLYXAMBI 25-5MG TAB QL=30 EA/30 Days
1JANUMET 100-1000MG XR TAB QL=30 EA/30 Days
1JANUMET 50-1000MG TAB QL=60 EA/30 Days
1JANUMET 50-1000MG XR TAB QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
29
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1JANUMET 50-500MG TAB QL=60 EA/30 Days
1JANUMET 50-500MG XR TAB QL=60 EA/30 Days
1JENTADUETO 2.5-1000MG TAB QL=60 EA/30 Days
1JENTADUETO 2.5-1000MG XR TAB QL=30 EA/30 Days
1JENTADUETO 2.5-500MG TAB QL=60 EA/30 Days
1JENTADUETO 2.5-850MG TAB QL=60 EA/30 Days
1JENTADUETO 5-1000MG XR TAB QL=30 EA/30 Days
1metformin 500mg/pioglitazone 15mg tab
1metformin 850mg/pioglitazone 15mg tab
1SYNJARDY 12.5-1000MG TAB QL=60 EA/30 Days
1SYNJARDY 12.5-500MG TAB QL=60 EA/30 Days
1SYNJARDY 5-1000MG TAB QL=60 EA/30 Days
1SYNJARDY 5-500MG TAB QL=60 EA/30 Days
1SYNJARDY XR 10-1000MG TAB QL=30 EA/30 Days
1SYNJARDY XR 12.5-1000MG TAB QL=60 EA/30 Days
1SYNJARDY XR 25-1000MG TAB QL=30 EA/30 Days
1SYNJARDY XR 5-1000MG TAB QL=60 EA/30 Days
1XIGDUO 10-1000MG XR TAB QL=30 EA/30 Days
1XIGDUO 10-500MG XR TAB QL=30 EA/30 Days
1XIGDUO 2.5-1000MG XR TAB QL=60 EA/30 Days
1XIGDUO 5-1000MG XR TAB QL=60 EA/30 Days
1XIGDUO 5-500MG XR TAB QL=30 EA/30 Days
1XULTOPHY 100UNIT-3.6MG/ML PEN INJ PA QL=15 ML/30 DaysBIGUANIDES
1metformin 1000mg tab
1metformin 500mg er tab
1metformin 500mg tab
1metformin 750mg er tab
1metformin 850mg tabDIABETIC OTHER
1GLUCAGEN 1MG HYPOKIT
1GLUCAGON 1MG INJ
1KORLYM 300MG TAB NDS PA
1PROGLYCEM 50MG/ML ORAL SUSPDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
1JANUVIA 100MG TAB QL=30 EA/30 Days
1JANUVIA 25MG TAB QL=30 EA/30 Days
1JANUVIA 50MG TAB QL=30 EA/30 Days
1TRADJENTA 5MG TAB QL=30 EA/30 DaysINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
1BYDUREON 2.35MG/ML AUTO-INJECTOR
1BYDUREON 2MG INJ
1BYDUREON 2MG PEN INJ
1OZEMPIC 2MG/1.5ML PEN INJ
1OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE)
1VICTOZA 18MG/3ML PEN INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
30
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
INSULIN
1FIASP 100UNIT/ML INJ
1FIASP 100UNIT/ML PEN INJ
1HUMULIN R 500UNIT/ML INJ
1HUMULIN R 500UNIT/ML PEN INJ
1LANTUS 100UNIT/ML INJ
1LANTUS 100UNIT/ML SOLOSTAR
1LEVEMIR 100UNIT/ML FLEXTOUCH
1LEVEMIR 100UNIT/ML INJ
1NOVOLIN 100UNIT/ML INJ
1NOVOLIN N 100UNIT/ML INJ
1NOVOLIN R 100UNIT/ML INJ
1NOVOLOG 100UNIT/ML FLEXPEN
1NOVOLOG 100UNIT/ML INJ
1NOVOLOG 100UNIT/ML PENFILL
1NOVOLOG MIX 100UNIT/ML FLEXPEN
1NOVOLOG MIX 100UNIT/ML INJ
1TOUJEO 300UNIT/ML PEN INJ
1TOUJEO MAX 300UNIT/ML PEN INJ (3ML)
1TRESIBA 100UNIT/ML PEN INJ
1TRESIBA 200UNIT/ML PEN INJINSULIN SENSITIZING AGENTS
1AVANDIA 2MG TAB
1AVANDIA 4MG TAB
1pioglitazone 15mg tab
1pioglitazone 30mg tab
1pioglitazone 45mg tabMEGLITINIDE ANALOGUES
1nateglinide 120mg tab
1nateglinide 60mg tab
1repaglinide 0.5mg tab
1repaglinide 1mg tab
1repaglinide 2mg tabSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
1FARXIGA 10MG TAB QL=30 EA/30 Days
1FARXIGA 5MG TAB QL=30 EA/30 Days
1JARDIANCE 10MG TAB QL=30 EA/30 Days
1JARDIANCE 25MG TAB QL=30 EA/30 DaysSULFONYLUREAS
1CHLORPROPAMIDE 100MG TAB
1CHLORPROPAMIDE 250MG TAB
1glimepiride 1mg tab
1glimepiride 2mg tab
1glimepiride 4mg tab
1glipizide 10mg er tab
1glipizide 10mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
31
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1glipizide 2.5mg er tab
1glipizide 5mg er tab
1glipizide 5mg tab
1glyburide 1.25mg tab
1glyburide 1.5mg tab
1glyburide 2.5mg tab
1glyburide 3mg tab
1glyburide 5mg tab
1glyburide 6mg tab
1tolazamide 250mg tab
1tolazamide 500mg tab
1TOLBUTAMIDE 500MG TAB
ANTIDIARRHEALSANTIPERISTALTIC AGENTS
1atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln
1atropine sulfate 0.025mg/diphenoxylate 2.5mg tab
1loperamide 2mg cap
ANTIDOTESANTIDOTES
1fomepizole 1000mg/ml injANTIDOTES - CHELATING AGENTS
1CHEMET 100MG CAP
1FERRIPROX 100MG/ML ORAL SOLN NDS PA
1FERRIPROX 500MG TAB NDS PA
1JADENU 180MG TAB NDS
1JADENU 90MG TAB NDS
ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS
1EXJADE 125MG ORAL SUSP NDS
1EXJADE 250MG ORAL SUSP NDS
1EXJADE 500MG ORAL SUSP NDS
1JADENU 180MG GRANULE PACKET NDS
1JADENU 360MG GRANULE PACKET NDS
1JADENU 360MG TAB NDS
1JADENU 90MG GRANULE PACKET NDSOPIOID ANTAGONISTS
1NALOXONE 0.4MG/ML CARTRIDGE
1NALOXONE 1MG/ML SYRINGE QL=2 ML/2 Days
1naltrexone 50mg tab
1NARCAN 4MG/0.1ML NASAL SPRAY QL=2 EA/2 Days
ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS
1granisetron 0.1mg/ml inj
1granisetron 1mg tab PA BvD QL=60 EA/30 Days
1granisetron 1mg/ml (1ml) inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
32
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1granisetron 1mg/ml inj
1ondansetron 0.8mg/ml oral soln PA BvD
1ondansetron 24mg tab PA BvD
1ondansetron 2mg/ml inj
1ondansetron 2mg/ml syringe
1ondansetron 4mg odt PA BvD
1ondansetron 4mg tab PA BvD
1ondansetron 8mg odt PA BvD
1ondansetron 8mg tab PA BvDANTIEMETICS - ANTICHOLINERGIC
1meclizine 12.5mg tab
1meclizine 25mg tab
1scopolamine 1mg/3days patch
1TRANSDERM SCOP 1MG/3DAYS PATCH
1trimethobenzamide 300mg cap PAANTIEMETICS - MISCELLANEOUS
1CESAMET 1MG CAP PA
1dronabinol 10mg cap PA
1dronabinol 2.5mg cap PA
1dronabinol 5mg cap PASUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
1aprepitant 125mg cap PA BvD QL=3 EA/2 Days
1aprepitant 125mg/80mg pack PA BvD QL=3 EA/2 Days
1aprepitant 40mg cap PA BvD QL=3 EA/2 Days
1aprepitant 80mg cap PA BvD QL=3 EA/2 Days
1VARUBI 90MG TAB PA BvD QL=2 EA/14 Days
ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)
1CANCIDAS 50MG INJ NDS
1CANCIDAS 70MG INJ NDS
1CASPOFUNGIN ACETATE 50MG INJ NDS
1CASPOFUNGIN ACETATE 70MG INJ NDS
1ERAXIS 100MG INJ
1ERAXIS 50MG INJ
1MYCAMINE 100MG INJ
1MYCAMINE 50MG INJANTIFUNGALS
1ABELCET 5MG/ML INJ PA BvD
1AMBISOME 50MG INJ PA BvD
1AMPHOTERICIN B 50MG INJ PA BvD
1flucytosine 250mg cap
1flucytosine 500mg cap
1griseofulvin 125mg tab
1griseofulvin 250mg tab
1griseofulvin 25mg/ml oral susp
1griseofulvin 500mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
33
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1nystatin 500000unit tab
1terbinafine 250mg tabIMIDAZOLE-RELATED ANTIFUNGALS
1fluconazole 100mg tab
1fluconazole 10mg/ml oral susp
1fluconazole 150mg tab
1fluconazole 200mg tab
1fluconazole 2mg/ml (100ml) inj
1fluconazole 2mg/ml inj
1fluconazole 40mg/ml oral susp
1fluconazole 50mg tab
1itraconazole 100mg cap PA
1ketoconazole 200mg tab
1NOXAFIL 100MG DR TAB NDS PA
1NOXAFIL 40MG/ML ORAL SUSP PA
1voriconazole 200mg inj PA
1voriconazole 200mg tab NDS PA
1voriconazole 40mg/ml oral susp PA
1voriconazole 50mg tab NDS PA
ANTIHISTAMINESANTIHISTAMINES - ETHANOLAMINES
1carbinoxamine maleate 0.8mg/ml oral soln
1carbinoxamine maleate 4mg tab
1CLEMASTINE FUMARATE 2.68MG TAB
1diphenhydramine 50mg/ml injANTIHISTAMINES - NON-SEDATING
1cetirizine 1mg/ml oral soln
1desloratadine 5mg tab
1levocetirizine 0.5mg/ml oral soln
1levocetirizine 5mg tabANTIHISTAMINES - PHENOTHIAZINES
1phenadoz 12.5mg rectal supp
1promethazine 1.25mg/ml oral soln
1promethazine 12.5mg rectal supp
1promethazine 12.5mg tab
1promethazine 25mg rectal supp
1promethazine 25mg tab
1promethazine 25mg/ml inj
1promethazine 50mg rectal supp
1promethazine 50mg tab
1promethazine 50mg/ml inj
1promethegan 25mg rectal supp
1promethegan 50mg rectal suppANTIHISTAMINES - PIPERIDINES
1cyproheptadine 0.4mg/ml oral soln
1cyproheptadine 4mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
34
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ANTIHYPERLIPIDEMICSANTIHYPERLIPIDEMICS - MISC.
1KYNAMRO 200MG/ML SYRINGE NDS PA
1omega-3 acid ethyl esters (usp) 1000mg cap
1VASCEPA 1GM CAP PA
1VASCEPA 500MG CAP PABILE ACID SEQUESTRANTS
1cholestyramine resin 4gm sf powder for oral susp
1cholestyramine resin 66.7mg/ml oral susp
1colestipol 1000mg tab
1colestipol 5000mg granules
1prevalite 4gm/dose oral susp
1WELCHOL 3.75GM ORAL SUSP
1WELCHOL 625MG TABFIBRIC ACID DERIVATIVES
1fenofibrate 130mg cap
1fenofibrate 134mg cap
1fenofibrate 145mg tab
1FENOFIBRATE 150MG CAP
1fenofibrate 160mg tab
1fenofibrate 200mg cap
1fenofibrate 43mg cap
1fenofibrate 48mg tab
1FENOFIBRATE 50MG CAP
1fenofibrate 54mg tab
1fenofibrate 67mg cap
1fenofibric acid 135mg dr cap
1fenofibric acid 45mg dr cap
1gemfibrozil 600mg tabHMG COA REDUCTASE INHIBITORS
1atorvastatin 10mg tab
1atorvastatin 20mg tab
1atorvastatin 40mg tab
1atorvastatin 80mg tab
1fluvastatin 20mg cap
1fluvastatin 40mg cap
1fluvastatin 80mg er tab
1lovastatin 10mg tab
1lovastatin 20mg tab
1lovastatin 40mg tab
1pravastatin sodium 10mg tab
1pravastatin sodium 20mg tab
1pravastatin sodium 40mg tab
1pravastatin sodium 80mg tab
1rosuvastatin 10mg tab
1rosuvastatin 20mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
35
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1rosuvastatin 40mg tab
1rosuvastatin 5mg tab
1simvastatin 10mg tab
1simvastatin 20mg tab
1simvastatin 40mg tab
1simvastatin 5mg tab
1simvastatin 80mg tabINTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
1ezetimibe 10mg tab QL=30 EA/30 DaysMICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS
1JUXTAPID 10MG CAP NDS PA
1JUXTAPID 20MG CAP NDS PA
1JUXTAPID 30MG CAP NDS PA
1JUXTAPID 40MG CAP NDS PA
1JUXTAPID 5MG CAP NDS PA
1JUXTAPID 60MG CAP NDS PANICOTINIC ACID DERIVATIVES
1niacin 1000mg er tab
1niacin 500mg er tab
1niacin 750mg er tabPROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS
1PRALUENT 150MG/ML AUTO-INJECTOR NDS PA QL=2 ML/28 Days
1PRALUENT 75MG/ML AUTO-INJECTOR NDS PA QL=2 ML/28 Days
1REPATHA 120MG/ML CARTRIDGE NDS PA QL=3.50 ML/28 Days
1REPATHA 140MG/ML AUTO-INJECTOR NDS PA QL=2 ML/28 Days
1REPATHA 140MG/ML SYRINGE NDS PA QL=2 ML/28 Days
ANTIHYPERTENSIVESACE INHIBITORS
1benazepril 10mg tab
1benazepril 20mg tab
1benazepril 40mg tab
1benazepril 5mg tab
1captopril 100mg tab
1captopril 12.5mg tab
1captopril 25mg tab
1captopril 50mg tab
1enalapril maleate 10mg tab
1enalapril maleate 2.5mg tab
1enalapril maleate 20mg tab
1enalapril maleate 5mg tab
1fosinopril sodium 10mg tab
1fosinopril sodium 20mg tab
1fosinopril sodium 40mg tab
1lisinopril 10mg tab
1lisinopril 2.5mg tab
1lisinopril 20mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
36
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1lisinopril 30mg tab
1lisinopril 40mg tab
1lisinopril 5mg tab
1moexipril 15mg tab
1moexipril 7.5mg tab
1perindopril erbumine 2mg tab
1perindopril erbumine 4mg tab
1perindopril erbumine 8mg tab
1QBRELIS 1MG/ML ORAL SOLN PA
1quinapril 10mg tab
1quinapril 20mg tab
1quinapril 40mg tab
1quinapril 5mg tab
1ramipril 1.25mg cap
1ramipril 10mg cap
1ramipril 2.5mg cap
1ramipril 5mg cap
1trandolapril 1mg tab
1trandolapril 2mg tab
1trandolapril 4mg tabAGENTS FOR PHEOCHROMOCYTOMA
1DEMSER 250MG CAP NDS
1phenoxybenzamine 10mg capANGIOTENSIN II RECEPTOR ANTAGONISTS
1candesartan cilexetil 16mg tab
1candesartan cilexetil 32mg tab
1candesartan cilexetil 4mg tab
1candesartan cilexetil 8mg tab
1EPROSARTAN 600MG TAB
1irbesartan 150mg tab
1irbesartan 300mg tab
1irbesartan 75mg tab
1losartan potassium 100mg tab
1losartan potassium 25mg tab
1losartan potassium 50mg tab
1olmesartan medoxomil 20mg tab
1olmesartan medoxomil 40mg tab
1olmesartan medoxomil 5mg tab
1telmisartan 20mg tab
1telmisartan 40mg tab
1telmisartan 80mg tab
1valsartan 160mg tab
1valsartan 320mg tab
1valsartan 40mg tab
1valsartan 80mg tabANTIADRENERGIC ANTIHYPERTENSIVES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
37
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1clonidine 0.00417mg/hr patch
1clonidine 0.00833mg/hr patch
1clonidine 0.0125mg/hr patch
1clonidine 0.1mg tab
1clonidine 0.2mg tab
1clonidine 0.3mg tab
1doxazosin 1mg tab
1doxazosin 2mg tab
1doxazosin 4mg tab
1doxazosin 8mg tab
1guanfacine 1mg tab
1guanfacine 2mg tab
1methyldopa 250mg tab
1methyldopa 500mg tab
1prazosin 1mg cap
1prazosin 2mg cap
1prazosin 5mg cap
1terazosin 10mg cap
1terazosin 1mg cap
1terazosin 2mg cap
1terazosin 5mg capANTIHYPERTENSIVE COMBINATIONS
1amlodipine 10mg/benazepril 20mg cap
1amlodipine 10mg/benazepril 40mg cap
1amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
1amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab
1amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 320mg tab
1amlodipine 10mg/olmesartan medoxomil 20mg tab
1amlodipine 10mg/olmesartan medoxomil 40mg tab
1amlodipine 10mg/telmisartan 40mg tab
1amlodipine 10mg/telmisartan 80mg tab
1amlodipine 10mg/valsartan 160mg tab
1amlodipine 10mg/valsartan 320mg tab
1amlodipine 2.5mg/benazepril 10mg cap
1amlodipine 5mg/benazepril 10mg cap
1amlodipine 5mg/benazepril 20mg cap
1amlodipine 5mg/benazepril 40mg cap
1amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
1amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 160mg tab
1amlodipine 5mg/olmesartan medoxomil 20mg tab
1amlodipine 5mg/olmesartan medoxomil 40mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
38
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1amlodipine 5mg/telmisartan 40mg tab
1amlodipine 5mg/telmisartan 80mg tab
1amlodipine 5mg/valsartan 160mg tab
1amlodipine 5mg/valsartan 320mg tab
1atenolol 100mg/chlorthalidone 25mg tab
1atenolol 50mg/chlorthalidone 25mg tab
1benazepril 10mg/hydrochlorothiazide 12.5mg tab
1benazepril 20mg/hydrochlorothiazide 12.5mg tab
1benazepril 20mg/hydrochlorothiazide 25mg tab
1benazepril 5mg/hydrochlorothiazide 6.25mg tab
1bendroflumethiazide 5mg/nadolol 40mg tab
1bendroflumethiazide 5mg/nadolol 80mg tab
1bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab
1bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab
1bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab
1candesartan cilexetil 16mg/hydrochlorothiazide 12.5mg tab
1candesartan cilexetil 32mg/hydrochlorothiazide 12.5mg tab
1candesartan cilexetil 32mg/hydrochlorothiazide 25mg tab
1captopril 25mg/hydrochlorothiazide 15mg tab
1CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE 25MG TAB
1captopril 50mg/hydrochlorothiazide 15mg tab
1CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE 25MG TAB
1enalapril maleate 10mg/hydrochlorothiazide 25mg tab
1enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab
1fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab
1fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab
1hydrochlorothiazide 12.5mg/irbesartan 150mg tab
1hydrochlorothiazide 12.5mg/irbesartan 300mg tab
1hydrochlorothiazide 12.5mg/lisinopril 10mg tab
1hydrochlorothiazide 12.5mg/lisinopril 20mg tab
1hydrochlorothiazide 12.5mg/losartan potassium 100mg tab
1hydrochlorothiazide 12.5mg/losartan potassium 50mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
39
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydrochlorothiazide 12.5mg/moexipril 15mg tab
1hydrochlorothiazide 12.5mg/moexipril 7.5mg tab
1hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab
1hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab
1hydrochlorothiazide 12.5mg/quinapril 10mg tab
1hydrochlorothiazide 12.5mg/quinapril 20mg tab
1hydrochlorothiazide 12.5mg/telmisartan 40mg tab
1hydrochlorothiazide 12.5mg/telmisartan 80mg tab
1hydrochlorothiazide 12.5mg/valsartan 160mg tab
1hydrochlorothiazide 12.5mg/valsartan 320mg tab
1hydrochlorothiazide 12.5mg/valsartan 80mg tab
1hydrochlorothiazide 15mg/methyldopa 250mg tab
1hydrochlorothiazide 25mg/lisinopril 20mg tab
1hydrochlorothiazide 25mg/losartan potassium 100mg tab
1hydrochlorothiazide 25mg/methyldopa 250mg tab
1hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab
1hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab
1hydrochlorothiazide 25mg/moexipril 15mg tab
1hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab
1hydrochlorothiazide 25mg/propranolol 40mg tab
1hydrochlorothiazide 25mg/propranolol 80mg tab
1hydrochlorothiazide 25mg/quinapril 20mg tab
1hydrochlorothiazide 25mg/telmisartan 80mg tab
1hydrochlorothiazide 25mg/valsartan 160mg tab
1hydrochlorothiazide 25mg/valsartan 320mg tab
1hydrochlorothiazide 50mg/metoprolol tartrate 100mg tab
1trandolapril 1mg/verapamil 240mg er tab
1trandolapril 2mg/verapamil 180mg er tab
1trandolapril 2mg/verapamil 240mg er tab
1trandolapril 4mg/verapamil 240mg er tabSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)
1eplerenone 25mg tab
1eplerenone 50mg tabVASODILATORS
1hydralazine 100mg tab
1hydralazine 10mg tab
1hydralazine 20mg/ml inj
1hydralazine 25mg tab
1hydralazine 50mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
40
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1minoxidil 10mg tab
1minoxidil 2.5mg tab
ANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.
1AZACTAM 1GM/50ML INJ
1AZACTAM 2GM/50ML INJ
1aztreonam 333mg/ml inj
1baci-im 50000unit inj
1bacitracin 5000unit/ml inj
1CAYSTON 75MG INH SOLN NDS PA
1colistin 75mg/ml inj
1DALVANCE 500MG INJ NDS
1metronidazole 250mg tab
1metronidazole 375mg cap
1metronidazole 500mg tab
1metronidazole 5mg/ml inj
1NEBUPENT 300MG INH SOLN PA BvD
1PENTAM 300MG INJ
1tinidazole 250mg tab
1tinidazole 500mg tab
1trimethoprim 100mg tab
1vancomycin 1000mg inj
1vancomycin 100mg/ml inj
1vancomycin 125mg cap ST QL=56 EA/14 Days
1vancomycin 250mg cap ST QL=56 EA/14 Days
1vancomycin 500mg inj
1XIFAXAN 200MG TAB QL=9 EA/3 Days
1XIFAXAN 550MG TAB QL=3 EA/1 DaysANTI-INFECTIVE MISC. - COMBINATIONS
1sulfamethoxazole 400mg/trimethoprim 80mg tab
1sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml oral susp
1sulfamethoxazole 800mg/trimethoprim 160mg tab
1SULFAMETHOXAZOLE 80MG/ML/TRIMETHOPRIM 16MG/ML INJ
ANTIPROTOZOAL AGENTS
1ALINIA 100MG/5ML ORAL SUSP
1ALINIA 500MG TAB
1atovaquone 150mg/ml oral suspCARBAPENEMS
1cilastatin 2.5mg/ml/imipenem 2.5mg/ml inj
1cilastatin 5mg/ml/imipenem 5mg/ml inj
1DORIPENEM 500MG INJ
1INVANZ 1GM INJ
1meropenem 1gm inj
1meropenem 500mg inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
41
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
CHLORAMPHENICOLS
1CHLORAMPHENICOL 100MG/ML INJCYCLIC LIPOPEPTIDES
1CUBICIN 500MG INJ NDS
1daptomycin 500mg inj NDSGLYCYLCYCLINES
1TIGECYCLINE 50MG INJ NDS
1TYGACIL 50MG INJ NDSLEPROSTATICS
1dapsone 100mg tab
1dapsone 25mg tabLINCOSAMIDES
1clindamycin 12mg/ml inj
1clindamycin 150mg cap
1clindamycin 150mg/ml (2ml) inj
1clindamycin 150mg/ml (4ml) inj
1clindamycin 150mg/ml (6ml) inj
1clindamycin 15mg/ml oral soln
1clindamycin 18mg/ml inj
1clindamycin 300mg cap
1clindamycin 6mg/ml inj
1clindamycin 75mg cap
1lincomycin 300mg/ml injOXAZOLIDINONES
1linezolid 20mg/ml oral susp PA
1linezolid 2mg/ml inj NDS PA
1linezolid 600mg tab PA
1SIVEXTRO 200MG INJ NDS PA QL=6 EA/6 Days
1SIVEXTRO 200MG TAB NDS PA QL=6 EA/6 DaysPOLYMYXINS
1polymyxin b 250000unit/ml injSTREPTOGRAMINS
1SYNERCID 500MG INJ NDS
ANTIMALARIALSANTIMALARIAL COMBINATIONS
1atovaquone 250mg/proguanil 100mg tab
1atovaquone 62.5mg/proguanil 25mg tab
1COARTEM 20-120MG TABANTIMALARIALS
1CHLOROQUINE PHOSPHATE 250MG TAB
1chloroquine phosphate 500mg tab
1DARAPRIM 25MG TAB NDS
1hydroxychloroquine sulfate 200mg tab
1mefloquine 250mg tab
1PRIMAQUINE PHOSPHATE 26.3MG TAB
1quinine sulfate 324mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
42
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ANTIMYASTHENIC/CHOLINERGIC AGENTSANTIMYASTHENIC/CHOLINERGIC AGENTS
1GUANIDINE 125MG TAB
1pyridostigmine bromide 180mg er tab
1pyridostigmine bromide 60mg tab
ANTIMYCOBACTERIAL AGENTSANTI TB COMBINATIONS
1RIFAMATE 150-300MG CAP
1RIFATER 50-120-300MG TABANTIMYCOBACTERIAL AGENTS
1CAPASTAT 1GM INJ
1ethambutol 100mg tab
1ethambutol 400mg tab
1isoniazid 100mg tab
1ISONIAZID 100MG/ML INJ
1ISONIAZID 10MG/ML ORAL SOLN
1isoniazid 300mg tab
1PASER D/R 4GM GRANULES
1PRIFTIN 150MG TAB
1pyrazinamide 500mg tab
1rifabutin 150mg cap
1rifampin 150mg cap
1rifampin 300mg cap
1rifampin 60mg/ml inj
1SIRTURO 100MG TAB NDS PA
1TRECATOR 250MG TAB
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS
1BICNU 100MG INJ NDS
1busulfan 6mg/ml inj
1carboplatin 10mg/ml inj
1cisplatin 1mg/ml inj
1CYCLOPHOSPHAMIDE 25MG CAP PA BvD
1CYCLOPHOSPHAMIDE 50MG CAP PA BvD
1GLEOSTINE 100MG CAP
1GLEOSTINE 10MG CAP
1GLEOSTINE 40MG CAP
1GLEOSTINE 5MG CAP
1HEXALEN 50MG CAP NDS
1ifosfamide 1000mg inj
1LEUKERAN 2MG TAB
1melphalan 5mg/ml inj NDS
1MUSTARGEN 10MG INJ
1oxaliplatin 100mg inj
1oxaliplatin 5mg/ml inj
1thiotepa 15mg inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
43
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1TREANDA 100MG INJ NDS PA NSO
1TREANDA 25MG INJ NDS PA NSO
1YONDELIS 1MG INJ NDS PA NSO
1ZANOSAR 1GM INJANTIMETABOLITES
1adrucil 500mg/10ml inj PA BvD
1ALIMTA 100MG INJ NDS
1ALIMTA 500MG INJ NDS
1ARRANON 5MG/ML INJ
1azacitidine 100mg inj NDS
1cladribine 1mg/ml inj PA BvD
1clofarabine 1mg/ml inj
1CLOLAR 1MG/ML INJ
1cytarabine 100mg/ml inj PA BvD
1CYTARABINE 20MG/ML INJ PA BvD
1decitabine 5mg/ml inj NDS
1fludarabine phosphate 50mg inj
1fluorouracil 50mg/ml inj PA BvD
1FOLOTYN 40MG/2ML INJ NDS PA NSO
1gemcitabine 1000mg inj
1mercaptopurine 50mg tab
1methotrexate 1000mg inj
1methotrexate 2.5mg tab
1METHOTREXATE 250MG/10ML INJ
1methotrexate 250mg/10ml inj
1methotrexate 50mg/2ml inj
1PURIXAN 2000MG/100ML ORAL SUSP
1TABLOID 40MG TAB
1TREXALL 10MG TAB
1TREXALL 15MG TAB
1TREXALL 5MG TAB
1TREXALL 7.5MG TAB
1XATMEP 2.5MG/ML ORAL SOLN PAANTINEOPLASTIC - ANGIOGENESIS INHIBITORS
1AVASTIN 100MG/4ML INJ NDS
1AVASTIN 400MG/16ML INJ NDS
1CYRAMZA 100MG/10ML INJ NDS PA NSO
1CYRAMZA 500MG/50ML INJ NDS PA NSO
1ZALTRAP 100MG/4ML INJ NDS PA NSOANTINEOPLASTIC - ANTIBODIES
1BAVENCIO 20MG/ML INJ NDS
1DARZALEX 100MG/5ML INJ NDS PA NSO
1EMPLICITI 300MG INJ NDS PA NSO
1EMPLICITI 400MG INJ NDS PA NSO
1ERBITUX 100MG/50ML INJ NDS
1HERCEPTIN 150MG INJ NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
44
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1HERCEPTIN 440MG INJ NDS
1IMFINZI 120MG/2.4ML INJ NDS PA NSO
1IMFINZI 500MG/10ML INJ NDS PA NSO
1KADCYLA 100MG INJ NDS PA NSO
1KADCYLA 160MG INJ NDS PA NSO
1KEYTRUDA 100MG/4ML INJ NDS PA NSO
1LARTRUVO 10MG/ML INJ NDS PA NSO
1LARTRUVO 190MG/19ML INJ NDS PA NSO
1MYLOTARG 4.5MG INJ NDS PA NSO
1OPDIVO 100MG/10ML INJ NDS PA NSO
1OPDIVO 40MG/4ML INJ NDS PA NSO
1PERJETA 420MG/14ML INJ NDS PA NSO
1RITUXAN 100MG/10ML INJ NDS PA NSO
1RITUXAN 500MG/50ML INJ NDS PA NSO
1TECENTRIQ 60MG/ML INJ NDS PA NSO
1VECTIBIX 100MG/5ML INJ NDS
1YERVOY 50MG/10ML INJ NDS PA NSOANTINEOPLASTIC - BCL-2 INHIBITORS
1VENCLEXTA 10/100/50MG STARTING PACK NDS PA NSO
1VENCLEXTA 100MG TAB NDS PA NSO
1VENCLEXTA 10MG TAB NDS PA NSO
1VENCLEXTA 50MG TAB NDS PA NSOANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS
1ERIVEDGE 150MG CAP NDS PA NSO
1ODOMZO 200MG CAP NDS PA NSOANTINEOPLASTIC - HORMONAL AND RELATED AGENTS
1anastrozole 1mg tab
1bicalutamide 50mg tab
1DEPO-PROVERA 400MG/ML INJ
1ELIGARD 22.5MG SYRINGE
1ELIGARD 30MG SYRINGE
1ELIGARD 45MG SYRINGE
1ELIGARD 7.5MG SYRINGE
1EMCYT 140MG CAP
1ERLEADA 60MG TAB NDS PA NSO QL=120 EA/30 Days
1exemestane 25mg tab
1FARESTON 60MG TAB
1FASLODEX 250MG/5ML SYRINGE NDS
1FIRMAGON 120MG INJ PA NSO
1FIRMAGON 80MG INJ PA NSO
1flutamide 125mg cap
1HYDROXYPROGESTERONE CAPROATE 250MG/ML INJ
NDS PA NSO
1letrozole 2.5mg tab
1leuprolide acetate 5mg/ml inj
1LUPRON 11.25MG (1.5ML) SYRINGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
45
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1LUPRON 22.5MG SYRINGE
1LUPRON 3.75MG SYRINGE
1LUPRON 30MG SYRINGE
1LUPRON 45MG SYRINGE
1LUPRON 7.5MG SYRINGE
1LYSODREN 500MG TAB
1megestrol acetate 20mg tab PA NSO
1megestrol acetate 40mg tab PA NSO
1megestrol acetate 40mg/ml oral susp PA
1NILANDRON 150MG TAB
1nilutamide 150mg tab
1SOLTAMOX 10MG/5ML ORAL SOLN PA NSO
1tamoxifen 10mg tab
1tamoxifen 20mg tab
1TRELSTAR 11.25MG INJ
1TRELSTAR 22.5MG INJ
1TRELSTAR 3.75MG INJ
1XTANDI 40MG CAP NDS PA NSO QL=120 EA/30 Days
1ZYTIGA 250MG TAB NDS PA NSO QL=120 EA/30 Days
1ZYTIGA 500MG TAB NDS PA NSO QL=60 EA/30 DaysANTINEOPLASTIC - IMMUNOMODULATORS
1POMALYST 1MG CAP NDS PA NSO
1POMALYST 2MG CAP NDS PA NSO
1POMALYST 3MG CAP NDS PA NSO
1POMALYST 4MG CAP NDS PA NSOANTINEOPLASTIC ANTIBIOTICS
1adriamycin 2mg/ml inj PA BvD
1bleomycin 15unit/ml inj PA BvD
1COSMEGEN 0.5MG INJ NDS
1dactinomycin 0.5mg inj NDS
1daunorubicin 5mg/ml inj
1doxorubicin 2mg/ml liposome inj NDS
1doxorubicin hydrochloride 2mg/ml inj PA BvD
1epirubicin 2mg/ml inj
1idarubicin hydrochloride 1mg/ml inj
1mitomycin 20mg inj
1mitomycin 40mg inj
1MITOMYCIN 5MG INJ
1mitoxantrone 2mg/ml injANTINEOPLASTIC COMBINATIONS
1KISQALI/FEMARA TAB CO-PACK 200MG NDS PA NSO
1KISQALI/FEMARA TAB CO-PACK 400MG NDS PA NSO
1KISQALI/FEMARA TAB CO-PACK 600MG NDS PA NSO
1LONSURF 15-6.14MG TAB NDS PA NSO
1LONSURF 20-8.19MG TAB NDS PA NSO
1VYXEOS 44-100MG INJ NDS PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
46
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ANTINEOPLASTIC ENZYME INHIBITORS
1AFINITOR 10MG TAB NDS PA NSO QL=30 EA/30 Days
1AFINITOR 2.5MG TAB NDS PA NSO QL=30 EA/30 Days
1AFINITOR 2MG ORAL SUSP NDS PA NSO
1AFINITOR 3MG ORAL SUSP NDS PA NSO
1AFINITOR 5MG ORAL SUSP NDS PA NSO
1AFINITOR 5MG TAB NDS PA NSO QL=30 EA/30 Days
1AFINITOR 7.5MG TAB NDS PA NSO QL=30 EA/30 Days
1ALECENSA 150MG CAP NDS PA NSO QL=240 EA/30 Days
1ALIQOPA 60MG INJ NDS PA NSO
1ALUNBRIG 180MG TAB NDS PA NSO
1ALUNBRIG 30MG TAB NDS PA NSO
1ALUNBRIG 90MG TAB NDS PA NSO
1ALUNBRIG TAB STARTER PACK NDS PA NSO
1BELEODAQ 500MG INJ NDS PA NSO
1BORTEZOMIB 3.5MG INJ NDS
1BOSULIF 100MG TAB NDS PA NSO
1BOSULIF 400MG TAB NDS PA NSO
1BOSULIF 500MG TAB NDS PA NSO
1CABOMETYX 20MG TAB NDS PA NSO
1CABOMETYX 40MG TAB NDS PA NSO
1CABOMETYX 60MG TAB NDS PA NSO
1CALQUENCE 100MG CAP NDS PA NSO
1CAPRELSA 100MG TAB NDS PA NSO
1CAPRELSA 300MG TAB NDS PA NSO
1COMETRIQ 100MG DAILY DOSE CARTON PACK NDS PA NSO
1COMETRIQ 140MG DAILY DOSE CARTON PACK NDS PA NSO
1COMETRIQ 60MG DAILY DOSE CARTON PACK NDS PA NSO
1COTELLIC 20MG TAB NDS PA NSO
1FARYDAK 10MG CAP NDS PA NSO
1FARYDAK 15MG CAP NDS PA NSO
1FARYDAK 20MG CAP NDS PA NSO
1GILOTRIF 20MG TAB NDS PA NSO QL=30 EA/30 Days
1GILOTRIF 30MG TAB NDS PA NSO QL=30 EA/30 Days
1GILOTRIF 40MG TAB NDS PA NSO QL=30 EA/30 Days
1IBRANCE 100MG CAP NDS PA NSO
1IBRANCE 125MG CAP NDS PA NSO
1IBRANCE 75MG CAP NDS PA NSO
1ICLUSIG 15MG TAB NDS PA NSO
1ICLUSIG 45MG TAB NDS PA NSO
1IDHIFA 100MG TAB NDS PA NSO
1IDHIFA 50MG TAB NDS PA NSO
1imatinib 100mg tab PA NSO
1imatinib 400mg tab PA NSO
1IMBRUVICA 140MG CAP NDS PA NSO QL=120 EA/30 Days
1IMBRUVICA 140MG TAB NDS PA NSO QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
47
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1IMBRUVICA 280MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 420MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 560MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 70MG CAP NDS PA NSO QL=30 EA/30 Days
1INLYTA 1MG TAB NDS PA NSO QL=240 EA/30 Days
1INLYTA 5MG TAB NDS PA NSO QL=240 EA/30 Days
1IRESSA 250MG TAB NDS PA NSO
1ISTODAX 10MG INJ NDS PA NSO
1JAKAFI 10MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 15MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 20MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 25MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 5MG TAB NDS PA NSO QL=60 EA/30 Days
1KISQALI 200MG DAILY DOSE PACK NDS PA NSO
1KISQALI 400MG DAILY DOSE PACK NDS PA NSO
1KISQALI 600MG DAILY DOSE PACK NDS PA NSO
1KYPROLIS 30MG INJ NDS PA NSO
1KYPROLIS 60MG INJ NDS PA NSO
1LENVIMA (8) 4MG PACK NDS PA NSO
1LENVIMA 10 10MG PACK NDS PA NSO
1LENVIMA 14 PACK NDS PA NSO
1LENVIMA 18 PACK NDS PA NSO
1LENVIMA 20 10MG PACK NDS PA NSO
1LENVIMA 24 PACK NDS PA NSO
1LYNPARZA 100MG CAP NDS PA NSO
1LYNPARZA 150MG CAP NDS PA NSO
1LYNPARZA 50MG CAP NDS PA NSO
1MEKINIST 0.5MG TAB NDS PA NSO
1MEKINIST 2MG TAB NDS PA NSO
1NERLYNX 40MG TAB NDS PA NSO
1NEXAVAR 200MG TAB NDS PA NSO
1NINLARO 2.3MG CAP NDS PA NSO
1NINLARO 3MG CAP NDS PA NSO
1NINLARO 4MG CAP NDS PA NSO
1RUBRACA 200MG TAB NDS PA NSO QL=120 EA/30 Days
1RUBRACA 250MG TAB NDS PA NSO QL=120 EA/30 Days
1RUBRACA 300MG TAB NDS PA NSO QL=120 EA/30 Days
1RYDAPT 25MG CAP NDS PA NSO
1SPRYCEL 100MG TAB NDS PA NSO
1SPRYCEL 140MG TAB NDS PA NSO
1SPRYCEL 20MG TAB NDS PA NSO
1SPRYCEL 50MG TAB NDS PA NSO
1SPRYCEL 70MG TAB NDS PA NSO
1SPRYCEL 80MG TAB NDS PA NSO
1STIVARGA 40MG TAB NDS PA NSO QL=120 EA/30 Days
1SUTENT 12.5MG CAP NDS PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
48
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SUTENT 25MG CAP NDS PA NSO
1SUTENT 37.5MG CAP NDS PA NSO
1SUTENT 50MG CAP NDS PA NSO
1TAFINLAR 50MG CAP NDS PA NSO QL=120 EA/30 Days
1TAFINLAR 75MG CAP NDS PA NSO QL=120 EA/30 Days
1TAGRISSO 40MG TAB NDS PA NSO
1TAGRISSO 80MG TAB NDS PA NSO
1TARCEVA 100MG TAB NDS PA NSO
1TARCEVA 150MG TAB NDS PA NSO
1TARCEVA 25MG TAB NDS PA NSO
1TASIGNA 150MG CAP NDS PA NSO
1TASIGNA 200MG CAP NDS PA NSO
1TASIGNA 50MG CAP NDS PA NSO
1TORISEL 25MG/ML INJ NDS
1TYKERB 250MG TAB NDS PA NSO
1VELCADE 3.5MG INJ NDS
1VERZENIO 100MG TAB NDS PA NSO
1VERZENIO 150MG TAB NDS PA NSO
1VERZENIO 200MG TAB NDS PA NSO
1VERZENIO 50MG TAB NDS PA NSO
1VOTRIENT 200MG TAB NDS PA NSO
1XALKORI 200MG CAP NDS PA NSO
1XALKORI 250MG CAP NDS PA NSO
1ZEJULA 100MG CAP NDS PA NSO
1ZELBORAF 240MG TAB NDS PA NSO
1ZOLINZA 100MG CAP NDS PA NSO
1ZYDELIG 100MG TAB NDS PA NSO
1ZYDELIG 150MG TAB NDS PA NSO
1ZYKADIA 150MG CAP NDS PA NSOANTINEOPLASTIC ENZYMES
1ERWINAZE 10000UNIT INJ NDS PA NSOANTINEOPLASTICS MISC.
1ACTIMMUNE 2000000UNIT/0.5ML INJ NDS
1bexarotene 75mg cap NDS PA NSO
1dacarbazine 200mg inj
1hydroxyurea 500mg cap
1INTRON A 10MU INJ
1INTRON A 18MU INJ NDS
1INTRON A 25MU INJ
1INTRON A 50MU INJ NDS
1INTRON A 6000000UNIT/ML INJ
1MATULANE 50MG CAP NDS
1NIPENT 10MG INJ NDS
1PROLEUKIN 22000000UNIT INJ NDS
1SYLATRON 200MCG INJ NDS PA NSO
1SYLATRON 300MCG INJ NDS PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
49
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SYLATRON 600MCG INJ NDS PA NSO
1SYNRIBO 3.5MG INJ NDS
1tretinoin 10mg cap
1TRISENOX 12MG/6ML INJCHEMOTHERAPY ADJUNCTS
1ELITEK 1.5MG INJ NDS
1ELITEK 7.5MG INJ NDS
1KEPIVANCE 6.25MG INJ NDSCHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
1dexrazoxane 250mg inj NDS
1FUSILEV 50MG INJ NDS
1LEUCOVORIN 10MG TAB
1leucovorin 10mg/ml inj
1LEUCOVORIN 15MG TAB
1leucovorin 20mg/ml inj
1leucovorin 25mg tab
1leucovorin 5mg tab
1levoleucovorin 10mg/ml inj NDS
1levoleucovorin 50mg inj NDS
1mesna 100mg/ml inj
1MESNEX 400MG TABMITOTIC INHIBITORS
1ABRAXANE 100MG INJ NDS
1DOCETAXEL 10MG/ML INJ
1DOCETAXEL 20MG/ML INJ NDS
1ETOPOPHOS 100MG INJ
1etoposide 20mg/ml inj
1HALAVEN 1MG/2ML INJ NDS
1JEVTANA 60MG/1.5ML INJ NDS
1paclitaxel 6mg/ml inj
1toposar 1gm/50ml inj
1VINBLASTINE 1MG/ML INJ PA BvD
1vincasar 1mg/ml inj PA BvD
1vincristine sulfate 1mg/ml inj PA BvD
1vinorelbine 10mg/ml injTOPOISOMERASE I INHIBITORS
1irinotecan 20mg/ml inj
1topotecan 1mg/ml inj
ANTIPARKINSON AGENTSANTIPARKINSON ADJUVANTS
1carbidopa 25mg tabANTIPARKINSON ANTICHOLINERGICS
1benztropine mesylate 0.5mg tab
1benztropine mesylate 1mg tab
1benztropine mesylate 1mg/ml inj
1benztropine mesylate 2mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
50
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1trihexyphenidyl 0.4mg/ml oral soln
1trihexyphenidyl 2mg tab
1trihexyphenidyl 5mg tabANTIPARKINSON COMT INHIBITORS
1entacapone 200mg tab
1tolcapone 100mg tabANTIPARKINSON DOPAMINERGICS
1amantadine 100mg cap
1amantadine 100mg tab
1amantadine 10mg/ml oral soln
1APOKYN 10MG/ML CARTRIDGE NDS
1bromocriptine 2.5mg tab
1bromocriptine 5mg cap
1carbidopa 10mg/levodopa 100mg odt
1carbidopa 10mg/levodopa 100mg tab
1CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB
1CARBIDOPA 18.75MG/ENTACAPONE 200MG/LEVODOPA 75MG TAB
1CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB
1carbidopa 25mg/levodopa 100mg er tab
1carbidopa 25mg/levodopa 100mg odt
1carbidopa 25mg/levodopa 100mg tab
1carbidopa 25mg/levodopa 250mg odt
1carbidopa 25mg/levodopa 250mg tab
1CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB
1CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB
1CARBIDOPA 50MG/ENTACAPONE 200MG/LEVODOPA 200MG TAB
1carbidopa 50mg/levodopa 200mg er tab
1NEUPRO 1MG/24HR PATCH
1NEUPRO 2MG/24HR PATCH
1NEUPRO 3MG/24HR PATCH
1NEUPRO 4MG/24HR PATCH
1NEUPRO 6MG/24HR PATCH
1NEUPRO 8MG/24HR PATCH
1pramipexole 0.125mg tab
1pramipexole 0.25mg tab
1pramipexole 0.375mg er tab
1pramipexole 0.5mg tab
1pramipexole 0.75mg er tab
1pramipexole 0.75mg tab
1pramipexole 1.5mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
51
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1pramipexole 1.5mg tab
1pramipexole 1mg tab
1pramipexole 2.25mg er tab
1pramipexole 3.75mg er tab
1pramipexole 3mg er tab
1pramipexole 4.5mg er tab
1ropinirole 0.25mg tab
1ropinirole 0.5mg tab
1ropinirole 12mg er tab
1ropinirole 1mg tab
1ropinirole 2mg er tab
1ropinirole 2mg tab
1ropinirole 3mg tab
1ropinirole 4mg er tab
1ropinirole 4mg tab
1ropinirole 5mg tab
1ropinirole 6mg er tab
1ropinirole 8mg er tab
1STALEVO 12.5-50-200MG TAB
1STALEVO 18.75-75-200MG TAB
1STALEVO 25-100-200MG TAB
1STALEVO 31.25-125-200MG TAB
1STALEVO 37.5-150-200MG TAB
1STALEVO 50-200-200MG TABANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
1rasagiline 0.5mg tab
1rasagiline 1mg tab
1selegiline 5mg cap
1selegiline 5mg tab
ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS
1lithium carbonate 150mg cap
1lithium carbonate 300mg cap
1lithium carbonate 300mg er tab
1lithium carbonate 300mg tab
1lithium carbonate 450mg er tab
1lithium carbonate 600mg cap
1lithium citrate 60mg/ml oral solnANTIPSYCHOTICS - MISC.
1EQUETRO 100MG ER CAP
1EQUETRO 200MG ER CAP
1EQUETRO 300MG ER CAP
1GEODON 20MG INJ
1LATUDA 120MG TAB PA NSO QL=30 EA/30 Days
1LATUDA 20MG TAB PA NSO QL=30 EA/30 Days
1LATUDA 40MG TAB PA NSO QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
52
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1LATUDA 60MG TAB PA NSO QL=30 EA/30 Days
1LATUDA 80MG TAB PA NSO QL=30 EA/30 Days
1NUPLAZID 17MG TAB PA NSO
1VRAYLAR 1.5/3MG MIXED PACK PA NSO QL=30 EA/30 Days
1VRAYLAR 1.5MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 3MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 4.5MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 6MG CAP PA NSO QL=30 EA/30 Days
1ziprasidone 20mg cap
1ziprasidone 40mg cap
1ziprasidone 60mg cap
1ziprasidone 80mg capBENZISOXAZOLES
1FANAPT 10MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 12MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 1MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 2MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 4MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 6MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 8MG TAB PA NSO QL=60 EA/30 Days
1FANAPT TITRATION PACK PA NSO QL=60 EA/30 Days
1INVEGA 117MG/0.75ML SYRINGE PA NSO
1INVEGA 156MG/ML SYRINGE PA NSO
1INVEGA 234MG/1.5ML SYRINGE PA NSO
1INVEGA 273MG/0.875ML SYRINGE PA NSO
1INVEGA 39MG/0.25ML SYRINGE PA NSO
1INVEGA 410MG/1.315ML SYRINGE PA NSO
1INVEGA 546MG/1.75ML SYRINGE PA NSO
1INVEGA 78MG/0.5ML SYRINGE PA NSO
1INVEGA 819MG/2.625ML SYRINGE PA NSO
1paliperidone 1.5mg er tab PA NSO
1paliperidone 3mg er tab PA NSO
1paliperidone 6mg er tab PA NSO
1paliperidone 9mg er tab PA NSO
1RISPERDAL 12.5MG INJ PA NSO
1RISPERDAL 25MG INJ PA NSO
1RISPERDAL 37.5MG INJ PA NSO
1RISPERDAL 50MG INJ PA NSO
1risperidone 0.25mg odt
1risperidone 0.25mg tab
1risperidone 0.5mg odt
1risperidone 0.5mg tab
1risperidone 1mg odt
1risperidone 1mg tab
1risperidone 1mg/ml oral soln
1risperidone 2mg odt
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
53
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1risperidone 2mg tab
1risperidone 3mg odt
1risperidone 3mg tab
1risperidone 4mg odt
1risperidone 4mg tabBUTYROPHENONES
1haloperidol 0.5mg tab
1haloperidol 10mg tab
1haloperidol 1mg tab
1haloperidol 20mg tab
1haloperidol 2mg tab
1haloperidol 2mg/ml oral soln
1haloperidol 5mg tab
1haloperidol 5mg/ml inj
1haloperidol 5mg/ml syringe
1haloperidol decanoate 100mg/ml inj
1haloperidol decanoate 500mg/5ml inj
1haloperidol decanoate 50mg/ml injDIBENZAPINES
1clozapine 100mg odt
1clozapine 100mg tab
1CLOZAPINE 12.5MG ODT
1CLOZAPINE 150MG ODT
1CLOZAPINE 200MG ODT
1clozapine 200mg tab
1clozapine 25mg odt
1clozapine 25mg tab
1clozapine 50mg tab
1FAZACLO 12.5MG ODT
1FAZACLO 150MG ODT
1FAZACLO 200MG ODT
1loxapine 10mg cap
1loxapine 25mg cap
1loxapine 50mg cap
1loxapine 5mg cap
1olanzapine 10mg inj
1olanzapine 10mg odt QL=30 EA/30 Days
1olanzapine 10mg tab QL=30 EA/30 Days
1olanzapine 15mg odt QL=30 EA/30 Days
1olanzapine 15mg tab QL=30 EA/30 Days
1olanzapine 2.5mg tab QL=30 EA/30 Days
1olanzapine 20mg odt QL=30 EA/30 Days
1olanzapine 20mg tab QL=30 EA/30 Days
1olanzapine 5mg odt QL=30 EA/30 Days
1olanzapine 5mg tab QL=30 EA/30 Days
1olanzapine 7.5mg tab QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
54
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1quetiapine 100mg tab
1quetiapine 150mg xr tab QL=30 EA/30 Days
1quetiapine 200mg tab
1quetiapine 200mg xr tab QL=30 EA/30 Days
1quetiapine 25mg tab
1quetiapine 300mg tab
1quetiapine 300mg xr tab
1quetiapine 400mg tab
1quetiapine 400mg xr tab
1quetiapine 50mg tab
1quetiapine 50mg xr tab QL=30 EA/30 Days
1SAPHRIS 10MG SL TAB PA NSO QL=60 EA/30 Days
1SAPHRIS 2.5MG SL TAB PA NSO QL=60 EA/30 Days
1SAPHRIS 5MG SL TAB PA NSO QL=60 EA/30 Days
1VERSACLOZ 50MG/ML ORAL SUSP
1ZYPREXA 210MG INJPHENOTHIAZINES
1chlorpromazine 100mg tab
1chlorpromazine 10mg tab
1chlorpromazine 200mg tab
1chlorpromazine 25mg tab
1CHLORPROMAZINE 25MG/ML INJ
1chlorpromazine 50mg tab
1compro 25mg rectal supp
1FLUPHENAZINE 0.5MG/ML ORAL SOLN
1fluphenazine 10mg tab
1fluphenazine 1mg tab
1fluphenazine 2.5mg tab
1FLUPHENAZINE 2.5MG/ML INJ
1fluphenazine 5mg tab
1FLUPHENAZINE 5MG/ML ORAL SOLN
1fluphenazine decanoate 25mg/ml inj
1perphenazine 16mg tab
1perphenazine 2mg tab
1perphenazine 4mg tab
1perphenazine 8mg tab
1prochlorperazine 10mg tab
1prochlorperazine 25mg rectal supp
1prochlorperazine 5mg tab
1prochlorperazine 5mg/ml inj
1thioridazine 100mg tab
1thioridazine 10mg tab
1thioridazine 25mg tab
1thioridazine 50mg tab
1trifluoperazine 10mg tab
1trifluoperazine 1mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
55
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1trifluoperazine 2mg tab
1trifluoperazine 5mg tabQUINOLINONE DERIVATIVES
1ABILIFY 300MG MAINTENA INJ NDS PA NSO
1ABILIFY 300MG MAINTENA PF SYRINGE NDS PA NSO
1ABILIFY 400MG MAINTENA INJ NDS PA NSO
1ABILIFY 400MG MAINTENA PF SYRINGE NDS PA NSO
1aripiprazole 10mg odt PA NSO QL=60 EA/30 Days
1aripiprazole 10mg tab QL=30 EA/30 Days
1aripiprazole 15mg odt PA NSO QL=60 EA/30 Days
1aripiprazole 15mg tab QL=30 EA/30 Days
1aripiprazole 1mg/ml oral soln PA NSO
1aripiprazole 20mg tab QL=30 EA/30 Days
1aripiprazole 2mg tab QL=30 EA/30 Days
1aripiprazole 30mg tab QL=30 EA/30 Days
1aripiprazole 5mg tab QL=30 EA/30 Days
1ARISTADA 273MG/ML SYRINGE PA NSO
1ARISTADA 441MG/1.6ML SYRINGE NDS PA NSO
1ARISTADA 662MG/2.4ML SYRINGE NDS PA NSO
1ARISTADA 882MG/3.2ML SYRINGE NDS PA NSO
1REXULTI 0.25MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 0.5MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 1MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 2MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 3MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 4MG TAB PA NSO QL=30 EA/30 DaysTHIOXANTHENES
1thiothixene 10mg cap
1thiothixene 1mg cap
1thiothixene 2mg cap
1thiothixene 5mg cap
ANTIVIRALSANTIRETROVIRALS
1abacavir 20mg/ml oral soln
1abacavir 300mg tab
1abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab
1abacavir 600mg/lamivudine 300mg tab NDS
1APTIVUS 100MG/ML ORAL SOLN NDS
1APTIVUS 250MG CAP NDS
1atazanavir 150mg cap NDS
1atazanavir 200mg cap NDS
1atazanavir 300mg cap NDS
1ATRIPLA 600-200-300MG TAB NDS
1BIKTARVY 50-200-25MG TAB NDS
1COMPLERA 200-25-300MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
56
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CRIXIVAN 200MG CAP
1CRIXIVAN 400MG CAP
1DESCOVY 200-25MG TAB NDS
1didanosine 200mg dr cap
1didanosine 250mg dr cap
1didanosine 400mg dr cap
1EDURANT 25MG TAB NDS
1efavirenz 200mg cap
1efavirenz 50mg cap
1efavirenz 600mg cap
1EMTRIVA 10MG/ML ORAL SOLN
1EMTRIVA 200MG CAP
1EPZICOM 600-300MG TAB NDS
1EVOTAZ 300-150MG TAB NDS
1fosamprenavir 700mg tab NDS
1FUZEON 90MG INJ NDS
1GENVOYA 150-150-200-10MG TAB NDS
1INTELENCE 100MG TAB NDS
1INTELENCE 200MG TAB NDS
1INTELENCE 25MG TAB
1INVIRASE 200MG CAP
1INVIRASE 500MG TAB NDS
1ISENTRESS 100MG CHEW TAB NDS
1ISENTRESS 100MG ORAL SUSP
1ISENTRESS 25MG CHEW TAB
1ISENTRESS 400MG TAB NDS
1ISENTRESS 600MG TAB NDS
1JULUCA 50-25MG TAB NDS
1KALETRA 100-25MG TAB
1KALETRA 200-50MG TAB NDS
1KALETRA 400-100MG/5ML ORAL SOLN NDS
1lamivudine 10mg/ml oral soln
1lamivudine 150mg tab
1lamivudine 150mg/zidovudine 300mg tab NDS
1lamivudine 300mg tab
1LEXIVA 50MG/ML ORAL SUSP
1LEXIVA 700MG TAB NDS
1lopinavir 80mg/ml/ritonavir 20mg/ml oral solution NDS
1nevirapine 100mg er tab
1nevirapine 200mg tab
1nevirapine 400mg er tab
1NORVIR 100MG CAP
1NORVIR 100MG POWDER PACKET
1NORVIR 100MG TAB
1NORVIR 80MG/ML ORAL SOLN
1ODEFSEY 200-25-25MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
57
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1PREZCOBIX 800-150MG TAB NDS
1PREZISTA 100MG/ML ORAL SUSP
1PREZISTA 150MG TAB
1PREZISTA 600MG TAB NDS
1PREZISTA 75MG TAB
1PREZISTA 800MG TAB NDS
1RESCRIPTOR 100MG TAB
1RESCRIPTOR 200MG TAB
1RETROVIR 10MG/ML INJ
1REYATAZ 150MG CAP NDS
1REYATAZ 200MG CAP NDS
1REYATAZ 300MG CAP NDS
1REYATAZ 50MG ORAL POWDER NDS
1ritonavir 100mg tab
1SELZENTRY 150MG TAB NDS
1SELZENTRY 20MG/ML ORAL SOLN NDS
1SELZENTRY 25MG TAB NDS
1SELZENTRY 300MG TAB NDS
1SELZENTRY 75MG TAB NDS
1stavudine 15mg cap
1stavudine 20mg cap
1stavudine 30mg cap
1stavudine 40mg cap
1STRIBILD 150-150-200-300MG TAB NDS
1SUSTIVA 200MG CAP
1SUSTIVA 50MG CAP
1SUSTIVA 600MG TAB
1SYMFI 600-300-300MG TAB
1SYMFI LO 400-300-300MG TAB
1tenofovir disoproxil fumarate 300mg tab NDS
1TIVICAY 10MG TAB
1TIVICAY 25MG TAB
1TIVICAY 50MG TAB NDS
1TRIUMEQ 600-50-300MG TAB NDS
1TRUVADA 100-150MG TAB NDS
1TRUVADA 133-200MG TAB NDS
1TRUVADA 167-250MG TAB NDS
1TRUVADA 200-300MG TAB NDS
1TYBOST 150MG TAB
1VIDEX 125MG DR CAP
1VIDEX 2GM ORAL SOLN
1VIRACEPT 250MG TAB NDS
1VIRACEPT 625MG TAB NDS
1VIRAMUNE 50MG/5ML ORAL SUSP
1VIREAD 150MG TAB NDS
1VIREAD 200MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
58
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1VIREAD 250MG TAB NDS
1VIREAD 300MG TAB NDS
1VIREAD 40MG/GM ORAL POWDER
1ZERIT 1MG/ML ORAL SOLN
1ZIAGEN 20MG/ML ORAL SOLN
1zidovudine 100mg cap
1zidovudine 10mg/ml oral soln
1zidovudine 300mg tabCMV AGENTS
1cidofovir 75mg/ml inj
1ganciclovir 500mg inj PA BvD
1VALCYTE 50MG/ML ORAL SOLN NDS
1valganciclovir 450mg tab NDS
1valganciclovir 50mg/ml oral soln NDSHEPATITIS AGENTS
1adefovir dipivoxil 10mg tab
1BARACLUDE 0.05MG/ML ORAL SOLN
1entecavir 0.5mg tab
1entecavir 1mg tab
1EPCLUSA 400-100MG TAB NDS PA QL=30 EA/30 Days
1EPIVIR HBV 5MG/ML ORAL SOLN
1lamivudine 100mg tab
1MAVYRET 100-40MG TAB NDS PA QL=84 EA/28 Days
1MODERIBA 1200/DAY DOSE PACK NDS
1moderiba 200mg tab
1MODERIBA 800/DAY DOSE PACK NDS
1PEGASYS 135MCG/0.5ML AUTO-INJECTOR NDS
1PEGASYS 180MCG/0.5ML AUTO-INJECTOR NDS
1PEGASYS 180MCG/0.5ML SYRINGE NDS
1PEGASYS 180MCG/ML INJ NDS
1ribasphere 200mg cap
1ribasphere 200mg tab
1ribasphere 400mg tab
1ribasphere 600mg tab NDS
1ribasphere ribapak 1200/day NDS
1ribasphere ribapak 800/day
1ribavirin 200mg cap
1ribavirin 200mg tab
1VEMLIDY 25MG TAB NDS
1ZEPATIER 50-100MG TAB NDS PA QL=30 EA/30 DaysHERPES AGENTS
1acyclovir 200mg cap
1acyclovir 400mg tab
1acyclovir 40mg/ml oral susp
1acyclovir 50mg/ml inj PA BvD
1acyclovir 800mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
59
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1famciclovir 125mg tab
1famciclovir 250mg tab
1famciclovir 500mg tab
1valacyclovir 1000mg tab
1valacyclovir 500mg tabINFLUENZA AGENTS
1oseltamivir 30mg cap QL=84 EA/180 Days
1oseltamivir 45mg cap QL=28 EA/180 Days
1oseltamivir 6mg/ml oral susp QL=550 ML/180 Days
1oseltamivir 75mg cap QL=28 EA/180 Days
1RELENZA 5MG/BLISTER INH QL=56 EA/180 Days
1rimantadine 100mg tab
1TAMIFLU 6MG/ML ORAL SUSP QL=550 ML/180 Days
ASSORTED CLASSESCHELATING AGENTS
1DEPEN 250MG TAB
1SYPRINE 250MG CAP PAIMMUNOMODULATORS
1REVLIMID 10MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 15MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 2.5MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 20MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 25MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 5MG CAP NDS PA NSO QL=30 EA/30 Days
1THALOMID 100MG CAP NDS PA NSO
1THALOMID 150MG CAP NDS PA NSO
1THALOMID 200MG CAP NDS PA NSO
1THALOMID 50MG CAP NDS PA NSOIMMUNOSUPPRESSIVE AGENTS
1ASTAGRAF 0.5MG XL CAP PA BvD
1ASTAGRAF 1MG XL CAP PA BvD
1ASTAGRAF 5MG XL CAP PA BvD
1ATGAM 50MG/ML INJ NDS PA BvD
1AZASAN 100MG TAB PA BvD
1AZASAN 75MG TAB PA BvD
1azathioprine 50mg tab PA BvD
1cyclosporine 100mg cap PA BvD
1cyclosporine 25mg cap PA BvD
1cyclosporine 50mg/ml inj PA BvD
1cyclosporine, modified 100mg cap PA BvD
1cyclosporine, modified 100mg/ml oral soln PA BvD
1cyclosporine, modified 25mg cap PA BvD
1ENVARSUS 0.75MG ER TAB PA BvD
1ENVARSUS 1MG ER TAB PA BvD
1ENVARSUS 4MG ER TAB PA BvD
1gengraf 100mg cap PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
60
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1gengraf 100mg/ml oral soln PA BvD
1gengraf 25mg cap PA BvD
1mycophenolate mofetil 200mg/ml oral susp PA BvD
1mycophenolate mofetil 250mg cap PA BvD
1mycophenolate mofetil 500mg tab PA BvD
1mycophenolic acid 180mg dr tab PA BvD
1mycophenolic acid 360mg dr tab PA BvD
1NULOJIX 250MG INJ NDS PA BvD
1PROGRAF 5MG/ML INJ PA BvD
1RAPAMUNE 1MG/ML ORAL SOLN PA BvD
1SANDIMMUNE 100MG/ML ORAL SOLN PA BvD
1SIMULECT 20MG INJ NDS
1sirolimus 0.5mg tab PA BvD
1sirolimus 1mg tab PA BvD
1sirolimus 2mg tab PA BvD
1tacrolimus 0.5mg cap PA BvD
1tacrolimus 1mg cap PA BvD
1tacrolimus 5mg cap PA BvD
1THYMOGLOBULIN 25MG INJ NDS PA BvD
1ZORTRESS 0.25MG TAB PA BvD
1ZORTRESS 0.5MG TAB PA BvD
1ZORTRESS 0.75MG TAB PA BvDIRRIGATION SOLUTIONS
1calcium chloride 0.002 meq/ml/potassium chloride 0.004 meq/ml/sodium chloride 0.147 meq/ml soln
1lactated ringers irrigation
1physiolyte soln
1physiosol soln
1water 1000mg/ml solnLYMPHATIC AGENTS
1SYLVANT 100MG INJ NDS
1SYLVANT 400MG INJ NDSPOTASSIUM REMOVING RESINS
1kionex 250mg/ml oral susp
1sodium polystyrene sulfonate 250mg/ml oral susp
1sps 250mg/ml oral susp
1VELTASSA 16.8GM POWDER FOR ORAL SUSP PA
1VELTASSA 25.2GM POWDER FOR ORAL SUSP PA
1VELTASSA 8.4GM POWDER FOR ORAL SUSP PASYSTEMIC LUPUS ERYTHEMATOSUS AGENTS
1BENLYSTA 120MG INJ NDS
1BENLYSTA 400MG INJ NDS
BETA BLOCKERSALPHA-BETA BLOCKERS
1carvedilol 12.5mg tab
1carvedilol 25mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
61
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1carvedilol 3.125mg tab
1carvedilol 6.25mg tab
1labetalol 100mg tab
1labetalol 200mg tab
1labetalol 300mg tab
1labetalol 5mg/ml injBETA BLOCKERS CARDIO-SELECTIVE
1acebutolol 200mg cap
1acebutolol 400mg cap
1atenolol 100mg tab
1atenolol 25mg tab
1atenolol 50mg tab
1betaxolol 10mg tab
1betaxolol 20mg tab
1bisoprolol fumarate 10mg tab
1bisoprolol fumarate 5mg tab
1BYSTOLIC 10MG TAB
1BYSTOLIC 2.5MG TAB
1BYSTOLIC 20MG TAB
1BYSTOLIC 5MG TAB
1metoprolol succinate 100mg er tab
1metoprolol succinate 200mg er tab
1metoprolol succinate 25mg er tab
1metoprolol succinate 50mg er tab
1metoprolol tartrate 100mg tab
1metoprolol tartrate 1mg/ml cartridge
1metoprolol tartrate 1mg/ml inj
1metoprolol tartrate 25mg tab
1metoprolol tartrate 50mg tabBETA BLOCKERS NON-SELECTIVE
1INNOPRAN 120MG XL CAP
1INNOPRAN 80MG XL CAP
1nadolol 20mg tab
1nadolol 40mg tab
1nadolol 80mg tab
1pindolol 10mg tab
1pindolol 5mg tab
1propranolol 10mg tab
1propranolol 120mg er cap
1propranolol 160mg er cap
1propranolol 1mg/ml inj
1propranolol 20mg tab
1propranolol 40mg tab
1PROPRANOLOL 4MG/ML ORAL SOLN
1propranolol 60mg er cap
1propranolol 60mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
62
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1propranolol 80mg er cap
1propranolol 80mg tab
1PROPRANOLOL 8MG/ML ORAL SOLN
1sorine 120mg tab
1sorine 160mg tab
1sorine 240mg tab
1sorine 80mg tab
1sotalol 120mg tab
1sotalol 160mg tab
1sotalol 240mg tab
1sotalol 80mg tab
1timolol 10mg tab
1timolol 20mg tab
1timolol 5mg tab
BIOLOGICALS MISCBIOLOGICALS MISC
1ADAGEN 250UNIT/ML INJ NDS PA
CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS
1afeditab 30mg cr tab
1afeditab 60mg cr tab
1amlodipine 10mg tab
1amlodipine 2.5mg tab
1amlodipine 5mg tab
1CARDENE 20MG/200ML INJ
1CARDENE 40MG/200ML INJ
1cartia 120mg er cap
1cartia 180mg er cap
1cartia 240mg er cap
1cartia 300mg er cap
1dilt 120mg xr cap
1dilt 180mg xr cap
1dilt 240mg xr cap
1diltiazem 120mg er (12 hr) cap
1diltiazem 120mg er (24 hr) cap
1diltiazem 120mg tab
1diltiazem 180mg er cap
1DILTIAZEM 1MG/ML INJ
1diltiazem 240mg er cap
1diltiazem 300mg er cap
1diltiazem 30mg tab
1diltiazem 360mg er cap
1diltiazem 420mg er cap
1diltiazem 5mg/ml inj
1diltiazem 60mg er cap
1diltiazem 60mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
63
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1diltiazem 90mg er cap
1diltiazem 90mg tab
1felodipine 10mg er tab
1felodipine 2.5mg er tab
1felodipine 5mg er tab
1isradipine 2.5mg cap
1isradipine 5mg cap
1matzim 180mg er tab
1matzim 240mg er tab
1matzim 300mg er tab
1matzim 360mg er tab
1matzim 420mg er tab
1nicardipine 2.5mg/ml inj
1nicardipine 20mg cap
1nicardipine 30mg cap
1nifedipine 10mg cap
1nifedipine 20mg cap
1nifedipine 30mg er tab
1nifedipine 30mg osmotic er tab
1nifedipine 60mg er tab
1nifedipine 60mg osmotic er tab
1nifedipine 90mg er tab
1nifedipine 90mg osmotic er tab
1nimodipine 30mg cap
1nisoldipine 17mg er tab
1nisoldipine 20mg er tab
1nisoldipine 30mg er tab
1nisoldipine 34mg er tab
1nisoldipine 40mg er tab
1nisoldipine 8.5mg er tab
1taztia 120mg er cap
1taztia 180mg er cap
1taztia 240mg er cap
1taztia 300mg er cap
1taztia 360mg er cap
1verapamil 100mg er cap
1verapamil 120mg er cap
1verapamil 120mg er tab
1verapamil 120mg tab
1verapamil 180mg er cap
1verapamil 180mg er tab
1verapamil 2.5mg/ml inj
1verapamil 200mg er cap
1verapamil 240mg er cap
1verapamil 240mg er tab
1verapamil 300mg er cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
64
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1verapamil 360mg sr cap
1verapamil 40mg tab
1verapamil 80mg tab
CARDIOTONICSCARDIAC GLYCOSIDES
1digitek 0.125mg tab
1digitek 0.25mg tab
1digox 0.125mg tab
1digox 0.25mg tab
1digoxin 0.05mg/ml oral soln
1digoxin 0.125mg tab
1digoxin 0.25mg tab
1digoxin 0.25mg/ml inj
CARDIOVASCULAR AGENTS - MISC.CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
1amlodipine 10mg/atorvastatin 10mg tab
1amlodipine 10mg/atorvastatin 20mg tab
1amlodipine 10mg/atorvastatin 40mg tab
1amlodipine 10mg/atorvastatin 80mg tab
1amlodipine 2.5mg/atorvastatin 10mg tab
1amlodipine 2.5mg/atorvastatin 20mg tab
1amlodipine 2.5mg/atorvastatin 40mg tab
1amlodipine 5mg/atorvastatin 10mg tab
1amlodipine 5mg/atorvastatin 20mg tab
1amlodipine 5mg/atorvastatin 40mg tab
1amlodipine 5mg/atorvastatin 80mg tab
1BIDIL 20-37.5MG TAB
1ENTRESTO 24-26MG TAB PA QL=60 EA/30 Days
1ENTRESTO 49-51MG TAB PA QL=60 EA/30 Days
1ENTRESTO 97-103MG TAB PA QL=60 EA/30 DaysPROSTAGLANDIN VASODILATORS
1REMODULIN 10MG/ML INJ NDS PA BvD
1REMODULIN 1MG/ML INJ NDS PA BvD
1REMODULIN 2.5MG/ML INJ NDS PA BvD
1REMODULIN 5MG/ML INJ NDS PA BvD
1VENTAVIS 10MCG/ML INH SOLN NDS PA
1VENTAVIS 20MCG/ML INH SOLN NDS PAPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
1LETAIRIS 10MG TAB NDS PA QL=30 EA/30 Days
1LETAIRIS 5MG TAB NDS PA QL=30 EA/30 Days
1OPSUMIT 10MG TAB NDS PA QL=30 EA/30 Days
1TRACLEER 125MG TAB NDS PA QL=60 EA/30 Days
1TRACLEER 32MG TAB FOR ORAL SUSP NDS PA QL=120 EA/30 Days
1TRACLEER 62.5MG TAB NDS PA QL=60 EA/30 DaysPULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS
1sildenafil 20mg tab PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
65
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST
1UPTRAVI 1000MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 1200MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 1400MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 1600MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 200MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 400MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 600MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI 800MCG TAB NDS PA QL=60 EA/30 Days
1UPTRAVI TITRATION PACK NDS PA QL=200 EA/30 DaysPULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR
1ADEMPAS 0.5MG TAB NDS PA
1ADEMPAS 1.5MG TAB NDS PA
1ADEMPAS 1MG TAB NDS PA
1ADEMPAS 2.5MG TAB NDS PA
1ADEMPAS 2MG TAB NDS PASINUS NODE INHIBITORS
1CORLANOR 5MG TAB PA
1CORLANOR 7.5MG TAB PA
CEPHALOSPORINSCEPHALOSPORIN COMBINATIONS
1AVYCAZ 2-0.5GM INJ NDS
1ZERBAXA 1.5GM INJ NDSCEPHALOSPORINS - 1ST GENERATION
1cefadroxil 1000mg tab
1cefadroxil 100mg/ml oral susp
1cefadroxil 500mg cap
1cefadroxil 50mg/ml oral susp
1cefazolin 1gm inj
1cefazolin 200mg/ml inj
1cefazolin 500mg inj
1cephalexin 250mg cap
1cephalexin 25mg/ml oral susp
1cephalexin 500mg cap
1cephalexin 50mg/ml oral suspCEPHALOSPORINS - 2ND GENERATION
1cefaclor 250mg cap
1CEFACLOR 25MG/ML ORAL SUSP
1cefaclor 500mg cap
1cefaclor 50mg/ml oral susp
1CEFACLOR 75MG/ML ORAL SUSP
1cefotetan 1000mg inj
1cefotetan 2000mg inj
1cefoxitin 1000mg inj
1cefoxitin 2000mg inj
1cefoxitin 200mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
66
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1cefprozil 250mg tab
1cefprozil 25mg/ml oral susp
1cefprozil 500mg tab
1cefprozil 50mg/ml oral susp
1cefuroxime 1.5gm inj
1cefuroxime 250mg tab
1cefuroxime 500mg tab
1cefuroxime 750mg inj
1cefuroxime 95mg/ml injCEPHALOSPORINS - 3RD GENERATION
1cefdinir 25mg/ml oral susp
1cefdinir 300mg cap
1cefdinir 50mg/ml oral susp
1cefixime 20mg/ml oral susp
1cefixime 40mg/ml oral susp
1CEFOTAXIME 1GM INJ
1CEFOTAXIME 2GM INJ
1CEFOTAXIME 500MG INJ
1cefpodoxime 100mg tab
1cefpodoxime 10mg/ml oral susp
1cefpodoxime 200mg tab
1cefpodoxime 20mg/ml oral susp
1ceftazidime 1000mg inj
1ceftazidime 2000mg inj
1ceftazidime 200mg/ml inj
1ceftriaxone 1000mg inj
1ceftriaxone 100mg/ml inj
1ceftriaxone 2000mg inj
1ceftriaxone 250mg inj
1ceftriaxone 500mg inj
1SUPRAX 400MG CAP
1tazicef 1gm inj
1tazicef 2gm inj
1tazicef 6gm injCEPHALOSPORINS - 4TH GENERATION
1cefepime 1gm inj
1cefepime 2gm injCEPHALOSPORINS - 5TH GENERATION
1TEFLARO 400MG INJ NDS
1TEFLARO 600MG INJ NDS
CONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORAL
1altavera 28 day pack
1alyacen 1/35 28 day pack
1amethia 91 day pack
1amethia lo 91 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
67
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1apri 28 day pack
1aranelle 28 pack
1ashlyna 91 day pack
1aubra 28 day pack
1aviane 28 pack
1balziva 28 day pack
1bekyree 28 day pack
1blisovi 21 fe 1.5/30 28 day
1blisovi 21 fe 1/20 28 day pack
1blisovi 24 fe 1/20 28 day pack
1briellyn 28 day pack
1camrese lo 91 day pack
1caziant 28 day pack
1cryselle 28 pack
1cyclafem 1/35 28 day pack
1cyclafem 7/7/7 28 day pack
1delyla 28 day pack
1desogestrel/ethinyl estradiol 28 day pack
1desogestrel/ethinyl estradiol pack
1drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg pack
1drospirenone 3mg/ethinyl estradiol 0.02mg/levomefolate calcium 0.451mg pack
1drospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg pack
1emoquette pack
1enpresse 28 day pack
1enskyce 28 day pack
1estarylla 28 day pack
1ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack
1ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack
1ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack
1ethinyl estradiol 0.025mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
1ethinyl estradiol 0.02mg/ferrous fumarate 75mg/norethindrone acetate 1mg pack
1ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack
1ethinyl estradiol 0.02mg/levonorgestrel 0.09mg pack
1ethinyl estradiol 0.02mg/norethindrone 1mg 21 day pack
1ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
68
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack
1ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
1ethinyl estradiol 0.035mg/norgestimate 0.25mg pack
1ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 0.05mg/ 0.075mg pack
1ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack
1ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 day pack
1ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack
1ethinyl estradiol/levonorgestrel 91 day pack
1falmina 28 day pack
1fayosim 91 day pack
1femynor 28 day pack
1gianvi 28-day pack
1introvale 91 day pack
1isibloom 28 day pack
1juleber 28 day pack
1junel 1.5/30 21 day pack
1junel 1/20 21 day pack
1junel fe 1.5/30 28 day pack
1junel fe 1/20 28 day pack
1junel fe 24 1/20 28 day pack
1kaitlib fe 28 day pack
1kariva 28 day pack
1kelnor 1/35 28 day pack
1kelnor 1/50 28 day pack
1kimidess 28 day pack
1kurvelo 28 day pack
1larin 1.5/30 pack
1larin 1/20 pack
1larin fe 1.5/30 pack
1larin fe 1/20 pack
1larissia 28 day pack
1layolis fe 28 pack
1leena 28 day pack
1lessina 28 day pack
1levonest 28 day pack
1levora 0.15/30 28 day pack
1loryna 28 day pack
1low-ogestrel 28 day pack
1lutera 28 day pack
1marlissa 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
69
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1microgestin 1.5/30 21 day pack
1microgestin 1/20 21 day pack
1microgestin fe 1.5/30 28 day pack
1microgestin fe 1/20 28 day pack
1mili 28 day pack
1mononessa 28 day pack
1NATAZIA 28 DAY PACK
1necon 0.5/35 28 day pack
1necon 7/7/7 28 day pack
1nikki 28 day pack
1nortrel 0.5/35 28 day pack
1nortrel 1/35 21 day pack
1nortrel 1/35 28 day pack
1nortrel 7/7/7 28 day pack
1ocella 28 day pack
1orsythia 28 day pack
1pimtrea pack
1pirmella 1/35 28 day pack
1portia 28 day pack
1previfem 28 day pack
1quasense 91 day pack
1reclipsen 28 day pack
1rivelsa 91 day pack
1setlakin 91 day pack
1sprintec 28 day pack
1sronyx 28 day pack
1syeda 28 day pack
1tarina fe 1/20 28 day pack
1tri-legest 28 day pack
1tri-lo-estarylla 28 day pack
1tri-lo-sprintec 28 day pack
1tri-mili 28 day pack
1tri-previfem 28 day pack
1tri-sprintec 28 day pack
1tri-vylibra 28 day pack
1trinessa 28 day pack
1trivora 28 day pack
1velivet 28 day pack
1vestura 3-0.02mg pack
1vienva 28 day pack
1vyfemla 28 day pack
1vylibra 28 day pack
1wymzya fe 28 day pack
1zarah 3-0.03mg pack
1zenchent 28 day pack
1zovia 1/35e 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
70
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
COMBINATION CONTRACEPTIVES - TRANSDERMAL
1XULANE 150-35MCG PATCHCOMBINATION CONTRACEPTIVES - VAGINAL
1NUVARING VAGINAL RINGPROGESTIN CONTRACEPTIVES - INJECTABLE
1medroxyprogesterone acetate 150mg/ml inj
1medroxyprogesterone acetate 150mg/ml syringePROGESTIN CONTRACEPTIVES - ORAL
1camila 28 day 0.35mg pack
1deblitane 28 day 0.35mg pack
1errin 28 day 0.35mg pack
1jolivette 28 day 0.35mg pack
1lyza 0.35mg pack
1nora-be 28 day 0.35mg pack
1norethindrone 0.35mg pack
1norlyroc 28 day 0.35mg pack
1sharobel 28 day 0.35mg pack
CORTICOSTEROIDSGLUCOCORTICOSTEROIDS
1budesonide 3mg dr cap NDS
1CORTISONE ACETATE 25MG TAB
1dexamethasone 0.1mg/ml oral soln
1dexamethasone 0.5mg tab
1dexamethasone 0.75mg tab
1dexamethasone 1.5mg tab
1DEXAMETHASONE 10MG/ML INJ
1DEXAMETHASONE 1MG TAB
1DEXAMETHASONE 1MG/ML ORAL SOLN
1DEXAMETHASONE 2MG TAB
1dexamethasone 4mg tab
1dexamethasone 6mg tab
1dexamethasone phosphate 4mg/ml inj
1hydrocortisone 10mg tab
1hydrocortisone 20mg tab
1hydrocortisone 5mg tab
1KENALOG 10MG/ML INJ
1KENALOG 40MG/ML INJ
1MEDROL 2MG TAB
1methylprednisolone 125mg inj PA BvD
1methylprednisolone 16mg tab
1methylprednisolone 32mg tab
1methylprednisolone 40mg/ml inj PA BvD
1methylprednisolone 4mg pack
1methylprednisolone 4mg tab
1methylprednisolone 62.5mg/ml inj PA BvD
1methylprednisolone 8mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
71
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1methylprednisolone acetate 40mg/ml inj
1methylprednisolone acetate 80mg/ml inj
1prednisolone 10mg odt
1prednisolone 15mg odt
1prednisolone 1mg/ml oral soln
1prednisolone 30mg odt
1prednisolone 3mg/ml oral soln
1PREDNISONE 10MG (21) TAB PACK
1PREDNISONE 10MG (48) TAB PACK
1prednisone 10mg tab
1prednisone 1mg tab
1PREDNISONE 1MG/ML ORAL SOLN
1prednisone 2.5mg tab
1prednisone 20mg tab
1PREDNISONE 50MG TAB
1PREDNISONE 5MG (21) TAB PACK
1PREDNISONE 5MG (48) TAB PACK
1prednisone 5mg tab
1PREDNISONE 5MG/ML ORAL SOLN
1SOLU-CORTEF 100MG INJ
1SOLU-CORTEF 250MG INJ
1triamcinolone acetonide 40mg/ml inj
1UCERIS 9MG ER TAB PA QL=30 EA/30 DaysMINERALOCORTICOIDS
1fludrocortisone 0.1mg tab
COUGH/COLD/ALLERGYCOUGH/COLD/ALLERGY COMBINATIONS
1CLARINEX-D 2.5-120MG ER TAB
1phenylephrine 1mg/ml/promethazine 1.25mg/ml oral soln
MUCOLYTICS
1acetylcysteine 10% inh soln PA BvD
1acetylcysteine 20% inh soln PA BvD
DERMATOLOGICALSACNE PRODUCTS
1adapalene 0.1% cream PA
1adapalene 0.1% gel PA
1adapalene 0.3% gel PA
1adapalene/benzoyl peroxide 0.1-2.5% gel PA
1amnesteem 10mg cap
1amnesteem 20mg cap
1amnesteem 40mg cap
1avita 0.025% cream PA
1avita 0.025% gel PA
1claravis 10mg cap
1claravis 20mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
72
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1claravis 30mg cap
1claravis 40mg cap
1clindacin 1% pad
1clindamycin 1% foam
1clindamycin 1% gel
1clindamycin 1% lotion
1clindamycin 1% pad
1clindamycin 1% topical soln
1clindamycin/benzoyl peroxide 1-5% gel
1DIFFERIN 0.1% LOTION PA
1EPIDUO 0.3-2.5% GEL PA
1EPIDUO 0.1-2.5% GEL PA
1ery 2% pad
1erythromycin 2% gel
1erythromycin 2% topical soln
1erythromycin/benzoyl peroxide 5-3% gel
1isotretinoin 10mg cap
1isotretinoin 20mg cap
1isotretinoin 30mg cap
1isotretinoin 40mg cap
1myorisan 10mg cap
1myorisan 20mg cap
1myorisan 30mg cap
1myorisan 40mg cap
1sulfacetamide sodium 10% lotion
1tretinoin 0.01% gel PA
1tretinoin 0.025% cream PA
1tretinoin 0.025% gel PA
1tretinoin 0.04% gel PA
1tretinoin 0.05% cream PA
1tretinoin 0.05% gel PA
1tretinoin 0.1% cream PA
1tretinoin 0.1% gel PA
1zenatane 10mg cap
1zenatane 20mg cap
1zenatane 30mg cap
1zenatane 40mg capANTIBIOTICS - TOPICAL
1gentamicin sulfate 0.1% cream
1gentamicin sulfate 0.1% ointment
1mupirocin 2% cream
1mupirocin 2% ointmentANTIFUNGALS - TOPICAL
1betamethasone/clotrimazole 1-0.05% cream
1betamethasone/clotrimazole 1-0.05% lotion
1ciclopirox 0.77% cream
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
73
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ciclopirox 0.77% gel
1ciclopirox 0.77% lotion
1ciclopirox 1% shampoo
1ciclopirox 8% topical soln
1clotrimazole 1% cream
1clotrimazole 1% topical soln
1econazole nitrate 1% cream
1ERTACZO 2% CREAM
1ketoconazole 2% cream
1ketoconazole 2% shampoo
1ketoconazole 20mg/ml foam
1naftifine 2% cream
1nyamyc 100000unit/gm powder
1nystatin 100000unit/ml cream
1nystatin 100000unit/ml/triamcinolone acetonide 1mg/ml cream
1nystatin 100unit/mg ointment
1nystatin 100unit/mg powder
1nystatin 100unit/mg/triamcinolone acetonide 0.001mg/mg ointment
1nystop 100000unit/gm powderANTI-INFLAMMATORY AGENTS - TOPICAL
1diclofenac sodium 1% gel QL=1000 GM/30 Days
1diclofenac sodium 1.5% topical solnANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL
1diclofenac sodium 3% gel PA NSO
1FLUOROURACIL 0.5% CREAM
1fluorouracil 2% topical soln
1fluorouracil 5% cream
1fluorouracil 5% topical soln
1PANRETIN 0.1% GEL NDS
1PICATO 0.015% GEL NDS QL=3 EA/10 Days
1PICATO 0.05% GEL NDS QL=2 EA/10 Days
1TARGRETIN 1% GEL NDS
1TOLAK 4% CREAM
1VALCHLOR 0.016% GEL NDS PA NSO QL=240 GM/30 DaysANTIPSORIATICS
1acitretin 10mg cap
1acitretin 17.5mg cap
1acitretin 25mg cap
1calcipotriene 0.005% cream
1calcipotriene 0.005% ointment
1calcipotriene 0.005% topical soln
1COSENTYX 150MG/ML AUTO-INJECTOR NDS PA
1COSENTYX 150MG/ML SYRINGE NDS PA
1methoxsalen 10mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
74
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1tazarotene 0.1% cream
1TAZORAC 0.05% CREAM
1TAZORAC 0.05% GEL
1TAZORAC 0.1% GELANTISEBORRHEIC PRODUCTS
1selenium sulfide 2.5% shampooANTIVIRALS - TOPICAL
1acyclovir 5% ointment
1DENAVIR 1% CREAMBURN PRODUCTS
1silver sulfadiazine 1% cream
1ssd 1% cream
1SULFAMYLON 85MG/GM CREAMCORTICOSTEROIDS - TOPICAL
1ala-cort 1% cream
1ala-cort 2.5% cream
1alclometasone dipropionate 0.05% cream
1alclometasone dipropionate 0.05% ointment
1AMCINONIDE 0.1% CREAM PA
1AMCINONIDE 0.1% OINTMENT PA
1betamethasone 0.05% aug cream
1betamethasone 0.05% aug gel
1betamethasone 0.05% aug lotion
1betamethasone 0.05% aug ointment
1betamethasone 0.05% cream
1betamethasone 0.05% lotion
1betamethasone 0.05% ointment
1betamethasone 0.1% cream
1betamethasone 0.1% lotion
1betamethasone 0.1% ointment
1betamethasone valerate 0.12% foam PA
1calcipotriene/betamethasone 0.005-0.064% ointment
1clobetasol propionate 0.05% cream PA
1clobetasol propionate 0.05% foam PA
1clobetasol propionate 0.05% gel PA
1clobetasol propionate 0.05% lotion PA
1clobetasol propionate 0.05% ointment PA
1clobetasol propionate 0.05% shampoo PA
1clobetasol propionate 0.05% spray PA
1clobetasol propionate 0.05% topical soln PA
1clodan 0.05% shampoo PA
1desonide 0.05% cream PA
1desonide 0.05% lotion PA
1desonide 0.05% ointment
1desoximetasone 0.05% cream
1desoximetasone 0.05% gel
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
75
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1desoximetasone 0.25% cream
1desoximetasone 0.25% ointment
1DIFLORASONE DIACETATE 0.05% CREAM PA
1DIFLORASONE DIACETATE 0.05% OINTMENT PA
1fluocinolone acetonide 0.01% cream
1fluocinolone acetonide 0.01% topical soln
1fluocinolone acetonide 0.025% cream
1fluocinolone acetonide 0.025% ointment
1fluocinolone acetonide 0.1mg/ml oil
1fluocinonide 0.05% e cream
1fluocinonide 0.05% gel
1fluocinonide 0.05% ointment
1fluocinonide 0.05% topical soln
1fluticasone propionate 0.005% ointment
1fluticasone propionate 0.05% cream
1fluticasone propionate 0.05% lotion PA
1halobetasol propionate 0.05% cream
1halobetasol propionate 0.05% ointment
1hydrocortisone 1% cream
1hydrocortisone 1% ointment
1hydrocortisone 2.5% cream
1hydrocortisone 2.5% lotion
1hydrocortisone 2.5% ointment
1hydrocortisone valerate 0.2% cream
1hydrocortisone valerate 0.2% ointment
1mometasone furoate 0.1% cream
1mometasone furoate 0.1% lotion
1mometasone furoate 0.1% ointment
1prednicarbate 0.1% cream
1prednicarbate 0.1% ointment
1PSORCON 0.05% CREAM PA
1TOPICORT 0.05% CREAM
1triamcinolone acetonide 0.025% cream
1triamcinolone acetonide 0.025% lotion
1triamcinolone acetonide 0.025% ointment
1triamcinolone acetonide 0.1% cream
1triamcinolone acetonide 0.1% lotion
1triamcinolone acetonide 0.1% ointment
1triamcinolone acetonide 0.147mg/ml spray
1triamcinolone acetonide 0.5% cream
1triamcinolone acetonide 0.5% ointment
1triderm 0.1% creamECZEMA AGENTS
1DUPIXENT 300MG/2ML SYRINGE NDS PAEMOLLIENTS
1ammonium lactate 12% cream
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
76
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ammonium lactate 12% lotionENZYMES - TOPICAL
1SANTYL 250UNIT/GM OINTMENTIMMUNOMODULATING AGENTS - TOPICAL
1imiquimod 5% cream
1ZYCLARA 2.5% CREAMIMMUNOSUPPRESSIVE AGENTS - TOPICAL
1ELIDEL 1% CREAM
1tacrolimus 0.03% ointment
1tacrolimus 0.1% ointmentKERATOLYTIC/ANTIMITOTIC AGENTS
1podofilox 0.5% topical solnLOCAL ANESTHETICS - TOPICAL
1lidocaine 2% gel
1lidocaine 4% topical soln
1lidocaine 5% ointment ST QL=107 GM/30 Days
1lidocaine 5% patch PA QL=90 EA/30 Days
1lidocaine/prilocaine 2.5-2.5% creamROSACEA AGENTS
1FINACEA 15% FOAM
1FINACEA 15% GEL
1metronidazole 0.75% cream
1metronidazole 0.75% gel
1metronidazole 0.75% lotion
1metronidazole 1% gelSCABICIDES & PEDICULICIDES
1EURAX 10% CREAM
1lindane 1% shampoo
1malathion 0.5% lotion
1permethrin 5% creamWOUND CARE PRODUCTS
1REGRANEX 0.01% GEL NDS QL=30 GM/15 Days
DIGESTIVE AIDSDIGESTIVE ENZYMES
1CREON 12000-38000-60000UNIT DR CAP
1CREON 24000-76000-120000UNIT DR CAP
1CREON 3000-9500-15000UNIT DR CAP
1CREON 36000-114000-180000UNIT DR CAP
1CREON 6000-19000-30000UNIT DR CAP
1PANCREAZE 10500-25000-43750UNIT DR CAP ST
1PANCREAZE 16800-40000-70000UNIT DR CAP ST
1PANCREAZE 21000-37000-61000UNIT DR CAP ST
1PANCREAZE 2600-6200-10850UNIT DR CAP ST
1PANCREAZE 4200-10000-17500UNIT DR CAP ST
1SUCRAID 8500UNIT/ML ORAL SOLN NDS PA
DIURETICS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
77
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
CARBONIC ANHYDRASE INHIBITORS
1acetazolamide 100mg/ml inj
1acetazolamide 125mg tab
1acetazolamide 250mg tab
1acetazolamide 500mg er cap
1methazolamide 25mg tab
1methazolamide 50mg tabDIURETIC COMBINATIONS
1amiloride 5mg/hydrochlorothiazide 50mg tab
1hydrochlorothiazide 25mg/spironolactone 25mg tab
1hydrochlorothiazide 25mg/triamterene 37.5mg cap
1hydrochlorothiazide 25mg/triamterene 37.5mg tab
1hydrochlorothiazide 50mg/triamterene 75mg tabLOOP DIURETICS
1bumetanide 0.25mg/ml inj
1bumetanide 0.5mg tab
1bumetanide 1mg tab
1bumetanide 2mg tab
1ethacrynic acid 25mg tab
1furosemide 10mg/ml inj
1furosemide 10mg/ml oral soln
1furosemide 10mg/ml syringe
1furosemide 20mg tab
1furosemide 40mg tab
1furosemide 80mg tab
1FUROSEMIDE 8MG/ML ORAL SOLN
1torsemide 100mg tab
1torsemide 10mg tab
1torsemide 20mg tab
1torsemide 5mg tabPOTASSIUM SPARING DIURETICS
1amiloride 5mg tab
1DYRENIUM 100MG CAP
1DYRENIUM 50MG CAP
1spironolactone 100mg tab
1spironolactone 25mg tab
1spironolactone 50mg tabTHIAZIDES AND THIAZIDE-LIKE DIURETICS
1CHLOROTHIAZIDE 250MG TAB
1chlorothiazide 500mg inj
1chlorothiazide 500mg tab
1chlorthalidone 25mg tab
1chlorthalidone 50mg tab
1DIURIL 250MG/5ML ORAL SUSP
1hydrochlorothiazide 12.5mg cap
1hydrochlorothiazide 12.5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
78
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydrochlorothiazide 25mg tab
1hydrochlorothiazide 50mg tab
1indapamide 1.25mg tab
1indapamide 2.5mg tab
1METHYCLOTHIAZIDE 5MG TAB
1metolazone 10mg tab
1metolazone 2.5mg tab
1metolazone 5mg tab
ENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORS
1ALENDRONATE 0.933MG/ML ORAL SOLN
1alendronate 10mg tab
1alendronate 35mg tab
1ALENDRONATE 40MG TAB
1alendronate 5mg tab
1alendronate 70mg tab
1etidronate disodium 200mg tab
1ETIDRONATE DISODIUM 400MG TAB
1FORTEO 600MCG/2.4ML PEN INJ NDS
1ibandronate 150mg tab QL=1 EA/30 Days
1ibandronate 1mg/ml inj PA BvD
1MIACALCIN 200UNIT/ML INJ PA BvD
1NATPARA 100MCG CARTRIDGE NDS PA
1NATPARA 25MCG CARTRIDGE NDS PA
1NATPARA 50MCG CARTRIDGE NDS PA
1NATPARA 75MCG CARTRIDGE NDS PA
1pamidronate disodium 3mg/ml inj PA BvD
1PAMIDRONATE DISODIUM 6MG/ML INJ PA BvD
1pamidronate disodium 9mg/ml inj PA BvD
1PROLIA 60MG/ML SYRINGE
1risedronate sodium 150mg tab
1risedronate sodium 30mg tab
1risedronate sodium 35mg (12) pack
1risedronate sodium 35mg (4) pack
1risedronate sodium 35mg tab
1risedronate sodium 5mg tab
1salmon calcitonin 200unit/act nasal spray
1TYMLOS 2MG/ML PEN INJECTOR NDS
1XGEVA 120MG/1.7ML INJ NDS PA
1zoledronic acid 0.05mg/ml inj
1zoledronic acid 0.8mg/ml inj
1ZOMETA 4MG/100ML INJ NDSGROWTH HORMONE RECEPTOR ANTAGONISTS
1SOMAVERT 10MG INJ NDS PA
1SOMAVERT 15MG INJ NDS PA
1SOMAVERT 20MG INJ NDS PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
79
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SOMAVERT 25MG INJ NDS PA
1SOMAVERT 30MG INJ NDS PAGROWTH HORMONES
1GENOTROPIN 0.2MG SYRINGE NDS PA
1GENOTROPIN 0.4MG SYRINGE NDS PA
1GENOTROPIN 0.6MG SYRINGE NDS PA
1GENOTROPIN 0.8MG SYRINGE NDS PA
1GENOTROPIN 1.2MG SYRINGE NDS PA
1GENOTROPIN 1.4MG SYRINGE NDS PA
1GENOTROPIN 1.6MG SYRINGE NDS PA
1GENOTROPIN 1.8MG SYRINGE NDS PA
1GENOTROPIN 12MG CARTRIDGE NDS PA
1GENOTROPIN 1MG SYRINGE NDS PA
1GENOTROPIN 2MG SYRINGE NDS PA
1GENOTROPIN 5MG CARTRIDGE NDS PA
1NORDITROPIN 10MG/1.5ML PEN INJ NDS PA
1NORDITROPIN 15MG/1.5ML PEN INJ NDS PA
1NORDITROPIN 30MG/3ML PEN INJ NDS PA
1NORDITROPIN 5MG/1.5ML PEN INJ NDS PAHORMONE RECEPTOR MODULATORS
1raloxifene 60mg tabINSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
1INCRELEX 40MG/4ML INJ NDS PALHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS
1LUPRON 11.25MG (1ML) SYRINGE NDS
1LUPRON 15MG SYRINGE NDS
1LUPRON 30MG SYRINGE (3 MONTH)
1SYNAREL 2MG/ML NASAL SPRAY NDSMETABOLIC MODIFIERS
1ALDURAZYME 2.9MG/5ML INJ NDS
1calcitriol 0.00025mg cap PA BvD
1calcitriol 0.0005mg cap PA BvD
1calcitriol 0.001mg/ml inj PA BvD
1calcitriol 0.001mg/ml oral soln PA BvD
1CARBAGLU 200MG ORAL SUSP PA
1doxercalciferol 0.0005mg cap PA BvD
1doxercalciferol 0.001mg cap PA BvD
1doxercalciferol 0.0025mg cap PA BvD
1doxercalciferol 0.002mg/ml inj PA BvD
1ELAPRASE 6MG/3ML INJ NDS
1FABRAZYME 35MG INJ NDS
1FABRAZYME 5MG INJ NDS
1KUVAN 100MG POWDER FOR ORAL SOLN NDS PA
1KUVAN 100MG TAB NDS PA
1KUVAN 500MG POWDER FOR ORAL SOLN NDS PA
1levocarnitine 100mg/ml oral soln PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
80
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1levocarnitine 330mg tab PA BvD
1LUMIZYME 50MG INJ NDS
1NAGLAZYME 1MG/ML INJ NDS
1ORFADIN 10MG CAP NDS PA
1ORFADIN 20MG CAP NDS PA
1ORFADIN 2MG CAP NDS PA
1ORFADIN 4MG/ML ORAL SUSP NDS PA
1ORFADIN 5MG CAP NDS PA
1paricalcitol 0.001mg cap PA BvD
1paricalcitol 0.002mg cap PA BvD
1paricalcitol 0.002mg/ml inj PA BvD
1paricalcitol 0.004mg cap PA BvD
1paricalcitol 0.005mg/ml inj PA BvD
1RAVICTI 1.1GM/ML ORAL SOLN NDS PA
1SENSIPAR 30MG TAB PA BvD
1SENSIPAR 60MG TAB PA BvD
1SENSIPAR 90MG TAB PA BvD
1sodium phenylbutyrate 0.94mg/mg oral powder
1STRENSIQ 40MG/ML INJ NDS PA
1STRENSIQ 80MG/0.8ML INJ NDS PAPOSTERIOR PITUITARY HORMONES
1desmopressin acetate 0.004mg/ml inj
1desmopressin acetate 0.01% nasal soln
1desmopressin acetate 0.01% nasal spray
1desmopressin acetate 0.1mg tab
1desmopressin acetate 0.2mg tab
1STIMATE 1.5MG/ML NASAL SPRAYPROLACTIN INHIBITORS
1cabergoline 0.5mg tabSOMATOSTATIC AGENTS
1octreotide 0.05mg/ml inj
1octreotide 0.1mg/ml inj
1octreotide 0.2mg/ml inj
1octreotide 0.5mg/ml inj
1octreotide 1mg/ml inj
1SIGNIFOR 0.3MG/ML INJ NDS PA QL=60 ML/30 Days
1SIGNIFOR 0.6MG/ML INJ NDS PA QL=60 ML/30 Days
1SIGNIFOR 0.9MG/ML INJ NDS PA QL=60 ML/30 Days
1SOMATULINE 120MG/0.5ML SYRINGE NDS
1SOMATULINE 60MG/0.2ML SYRINGE NDS
1SOMATULINE 90MG/0.3ML SYRINGE NDSVASOPRESSIN RECEPTOR ANTAGONISTS
1JYNARQUE 45/15 THERAPY PACK NDS PA QL=60 EA/30 Days
1JYNARQUE 60/30 THERAPY PACK NDS PA QL=60 EA/30 Days
1JYNARQUE 90/30 THERAPY PACK NDS PA QL=60 EA/30 Days
ESTROGENS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
81
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ESTROGEN COMBINATIONS
1amabelz 0.5/0.1mg 28 day pack
1amabelz 1/0.5mg 28 day pack
1COMBIPATCH 0.05-0.14MG PATCH
1COMBIPATCH 0.05-0.25MG PATCH
1estradiol 0.5mg/norethindrone acetate 0.1mg pack
1estradiol 1mg/norethindrone acetate 0.5mg pack
1ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mg tab
1ethinyl estradiol 0.005mg/norethindrone acetate 1mg tab
1fyavolv 0.5mg-2.5mcg tab
1fyavolv 1mg-5mcg tab
1jinteli tab
1mimvey lo 28 day pack
1mimvey pack
1PREMPHASE 28 DAY PACK
1PREMPRO 0.3/1.5MG 28 DAY PACK
1PREMPRO 0.45/1.5 28 DAY PACK
1PREMPRO 0.625/2.5MG 28 DAY PACK
1PREMPRO 0.625/5MG 28 DAY PACKESTROGENS
1estradiol 0.00104mg/hr twice weekly patch
1estradiol 0.00104mg/hr weekly patch
1estradiol 0.00156mg/hr twice weekly patch
1estradiol 0.00156mg/hr weekly patch
1estradiol 0.00208mg/hr twice weekly patch
1estradiol 0.00208mg/hr weekly patch
1estradiol 0.0025mg/hr weekly patch
1estradiol 0.00312mg/hr weekly patch
1estradiol 0.00313mg/hr twice weekly patch
1estradiol 0.00417mg/hr twice weekly patch
1estradiol 0.00417mg/hr weekly patch
1estradiol 0.5mg tab
1estradiol 1mg tab
1estradiol 20mg/ml inj
1estradiol 2mg tab
1estradiol 40mg/ml inj
1ESTROPIPATE 0.75MG TAB
1ESTROPIPATE 1.5MG TAB
1ESTROPIPATE 3MG TAB
1PREMARIN 0.3MG TAB
1PREMARIN 0.45MG TAB
1PREMARIN 0.625MG TAB
1PREMARIN 0.9MG TAB
1PREMARIN 1.25MG TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
82
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
FLUOROQUINOLONESFLUOROQUINOLONES
1AVELOX 400MG/250ML INJ
1BAXDELA 450MG TAB PA QL=60 EA/30 Days
1ciprofloxacin 100mg/ml oral susp
1ciprofloxacin 250mg tab
1ciprofloxacin 2mg/ml inj
1ciprofloxacin 500mg tab
1ciprofloxacin 50mg/ml oral susp
1ciprofloxacin 750mg tab
1levofloxacin 250mg tab
1levofloxacin 25mg/ml inj
1levofloxacin 25mg/ml oral soln
1levofloxacin 500mg tab
1levofloxacin 5mg/ml (150ml) inj
1levofloxacin 5mg/ml inj
1levofloxacin 750mg tab
1MOXIFLOXACIN 1.6MG/ML INJ
1moxifloxacin 400mg tab
1ofloxacin 400mg tab
GASTROINTESTINAL AGENTS - MISC.BILE ACID SYNTHESIS DISORDER AGENTS
1CHOLBAM 250MG CAP NDS PA
1CHOLBAM 50MG CAP NDS PAFARNESOID X RECEPTOR (FXR) AGONISTS
1OCALIVA 10MG TAB NDS PA QL=30 EA/30 Days
1OCALIVA 5MG TAB NDS PA QL=30 EA/30 DaysGALLSTONE SOLUBILIZING AGENTS
1CHENODAL 250MG TAB NDS
1ursodiol 250mg tab
1ursodiol 300mg cap
1ursodiol 500mg tabGASTROINTESTINAL ANTIALLERGY AGENTS
1cromolyn sodium 20mg/ml oral solnGASTROINTESTINAL STIMULANTS
1metoclopramide 10mg tab
1metoclopramide 1mg/ml oral soln
1metoclopramide 5mg tab
1metoclopramide 5mg/ml injINFLAMMATORY BOWEL AGENTS
1APRISO 0.375GM ER CAP
1balsalazide disodium 750mg cap
1CANASA 1000MG RECTAL SUPP
1DIPENTUM 250MG CAP
1LIALDA 1.2GM DR TAB
1mesalamine 66.7mg/ml enema
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
83
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1sulfasalazine 500mg dr tab
1sulfasalazine 500mg tabINTESTINAL ACIDIFIERS
1enulose 10gm/15ml oral soln
1generlac 10gm/15ml oral solnIRRITABLE BOWEL SYNDROME (IBS) AGENTS
1alosetron 0.5mg tab
1alosetron 1mg tab
1LINZESS 145MCG CAP PA
1LINZESS 290MCG CAP PA
1LINZESS 72MCG CAP PAPERIPHERAL OPIOID RECEPTOR ANTAGONISTS
1MOVANTIK 12.5MG TAB PA
1MOVANTIK 25MG TAB PA
1RELISTOR 12MG/0.6ML INJ PA
1RELISTOR 12MG/0.6ML SYRINGE PA
1RELISTOR 8MG/0.4ML SYRINGE PA
1SYMPROIC 0.2MG TAB PAPHOSPHATE BINDER AGENTS
1AURYXIA 210MG TAB
1calcium acetate 667mg cap
1calcium acetate 667mg tab
1FOSRENOL 1000MG CHEW TAB
1FOSRENOL 1000MG ORAL POWDER
1FOSRENOL 500MG CHEW TAB
1FOSRENOL 750MG CHEW TAB
1FOSRENOL 750MG ORAL POWDER
1lanthanum carbonate 1000mg chew tab
1lanthanum carbonate 500mg chew tab
1lanthanum carbonate 750mg chew tab
1PHOSLYRA 667MG/5ML ORAL SOLN
1RENVELA 800MG TAB
1sevelamer carbonate 2400mg oral susp
1sevelamer carbonate 800mg oral susp
1sevelamer carbonate 800mg tabSHORT BOWEL SYNDROME (SBS) AGENTS
1GATTEX 5MG INJ NDS PA
GENITOURINARY AGENTS - MISCELLANEOUSALKALINIZERS
1potassium citrate 10meq er tab
1potassium citrate 15 meq er tab
1potassium citrate 5 meq er tabCYSTINOSIS AGENTS
1CYSTAGON 150MG CAP PA
1CYSTAGON 50MG CAP PAGENITOURINARY IRRIGANTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
84
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1neomycin 40mg/ml/polymyxin b 200000unit/ml soln
1sodium chloride 0.9% solnINTERSTITIAL CYSTITIS AGENTS
1ELMIRON 100MG CAPPROSTATIC HYPERTROPHY AGENTS
1alfuzosin 10mg er tab
1dutasteride 0.5mg cap
1dutasteride 0.5mg/tamsulosin 0.4mg cap
1finasteride 5mg tab
1RAPAFLO 4MG CAP
1RAPAFLO 8MG CAP
1tamsulosin 0.4mg capURINARY STONE AGENTS
1LITHOSTAT 250MG TAB
1THIOLA 100MG TAB
GOUT AGENTSGOUT AGENT COMBINATIONS
1colchicine 0.5mg/probenecid 500mg tabGOUT AGENTS
1allopurinol 100mg tab
1allopurinol 300mg tab
1COLCHICINE 0.6MG CAP
1COLCHICINE 0.6MG TAB
1MITIGARE 0.6MG CAP
1ULORIC 40MG TAB ST
1ULORIC 80MG TAB STURICOSURICS
1probenecid 500mg tab
HEMATOLOGICAL AGENTS - MISC.BRADYKININ B2 RECEPTOR ANTAGONISTS
1FIRAZYR 30MG/3ML SYRINGE NDS PACOMPLEMENT INHIBITORS
1BERINERT 500UNIT INJ NDS PA
1CINRYZE 500UNIT INJ NDS PA
1HAEGARDA 2000UNT INJ NDS PA
1HAEGARDA 3000UNT INJ NDS PA
1RUCONEST 2100UNIT INJ NDS PAHEMATORHEOLOGIC AGENTS
1pentoxifylline 400mg er tabPLATELET AGGREGATION INHIBITORS
1anagrelide 0.5mg cap
1anagrelide 1mg cap
1aspirin 25mg/dipyridamole 200mg cap
1BRILINTA 60MG TAB
1BRILINTA 90MG TAB
1cilostazol 100mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
85
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1cilostazol 50mg tab
1clopidogrel 75mg tab
1dipyridamole 25mg tab
1dipyridamole 50mg tab
1dipyridamole 75mg tab
1prasugrel 10mg tab
1prasugrel 5mg tab
HEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASE
1CEREZYME 400UNIT INJ NDS
1VPRIV 400UNIT INJ NDS
1ZAVESCA 100MG CAP NDS PAAGENTS FOR SICKLE CELL ANEMIA
1DROXIA 200MG CAP
1DROXIA 300MG CAP
1DROXIA 400MG CAPHEMATOPOIETIC GROWTH FACTORS
1ARANESP 100MCG/0.5ML SYRINGE PA BvD ST
1ARANESP 100MCG/ML INJ PA BvD ST
1ARANESP 10MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 150MCG/0.3ML SYRINGE PA BvD ST
1ARANESP 200MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 200MCG/ML INJ PA BvD ST
1ARANESP 25MCG/0.42ML SYRINGE PA BvD ST
1ARANESP 25MCG/ML INJ PA BvD ST
1ARANESP 300MCG/0.6ML SYRINGE PA BvD ST
1ARANESP 300MCG/ML INJ PA BvD ST
1ARANESP 40MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 40MCG/ML INJ PA BvD ST
1ARANESP 500MCG/ML SYRINGE PA BvD ST
1ARANESP 60MCG/0.3ML SYRINGE PA BvD ST
1ARANESP 60MCG/ML INJ PA BvD ST
1EPOGEN 10000UNIT/ML INJ PA BvD
1EPOGEN 20000UNIT/ML INJ PA BvD
1EPOGEN 2000UNIT/ML INJ PA BvD
1EPOGEN 3000UNIT/ML INJ PA BvD
1EPOGEN 4000UNIT/ML INJ PA BvD
1GRANIX 300MCG/0.5ML SYRINGE NDS
1GRANIX 480MCG/0.8ML SYRINGE NDS
1LEUKINE 250MCG INJ NDS PA
1NEULASTA 6MG/0.6ML SYRINGE NDS
1PROCRIT 10000UNIT/ML INJ PA BvD
1PROCRIT 20000UNIT/ML INJ PA BvD
1PROCRIT 2000UNIT/ML INJ PA BvD
1PROCRIT 3000UNIT/ML INJ PA BvD
1PROCRIT 40000UNIT/ML INJ PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
86
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1PROCRIT 4000UNIT/ML INJ PA BvD
1PROMACTA 12.5MG TAB NDS PA
1PROMACTA 25MG TAB NDS PA
1PROMACTA 50MG TAB NDS PA
1PROMACTA 75MG TAB NDS PA
1ZARXIO 300MCG/0.5ML SYRINGE NDS
1ZARXIO 480MCG/0.8ML SYRINGE NDSSTEM CELL MOBILIZERS
1MOZOBIL 24MG/1.2ML INJ NDS
HEMOSTATICSHEMOSTATICS - SYSTEMIC
1tranexamic acid 100mg/ml inj
1tranexamic acid 650mg tab
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTSBARBITURATE HYPNOTICS
1BUTISOL 30MG TAB
1PHENOBARBITAL 100MG TAB
1PHENOBARBITAL 15MG TAB
1phenobarbital 16.2mg tab
1PHENOBARBITAL 30MG TAB
1phenobarbital 32.4mg tab
1phenobarbital 4mg/ml oral soln
1PHENOBARBITAL 60MG TAB
1phenobarbital 64.8mg tab
1phenobarbital 97.2mg tabNON-BARBITURATE HYPNOTICS
1estazolam 1mg tab
1estazolam 2mg tab
1eszopiclone 1mg tab QL=30 EA/30 Days
1eszopiclone 2mg tab QL=30 EA/30 Days
1eszopiclone 3mg tab QL=30 EA/30 Days
1FLURAZEPAM 15MG CAP
1FLURAZEPAM 30MG CAP
1temazepam 15mg cap
1temazepam 22.5mg cap
1temazepam 30mg cap
1temazepam 7.5mg cap
1TRIAZOLAM 0.125MG TAB
1triazolam 0.25mg tab
1zaleplon 10mg cap QL=30 EA/30 Days
1zaleplon 5mg cap QL=30 EA/30 Days
1zolpidem tartrate 10mg tab QL=30 EA/30 Days
1zolpidem tartrate 5mg tab QL=60 EA/30 DaysSELECTIVE MELATONIN RECEPTOR AGONISTS
1HETLIOZ 20MG CAP NDS PA QL=30 EA/30 Days
1ROZEREM 8MG TAB PA QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
87
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
LAXATIVESLAXATIVE COMBINATIONS
1gavilyte-c oral soln
1gavilyte-g oral soln
1gavilyte-n powder for oral soln
1MOVIPREP ORAL SOLN
1peg 3350/electrolyte oral soln
1peg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral soln
1polyethylene glycol 3350/kcl/sodium bicarbonate/sodium chloride/sodium sulfate powder for oral soln
1trilyte powder for oral solnLAXATIVES - MISCELLANEOUS
1constulose 10gm/15ml oral soln
1lactulose 667mg/ml oral soln
1polyethylene glycol 3350 142mg/ml oral soln
LOCAL ANESTHETICS-PARENTERALLOCAL ANESTHETICS - AMIDES
1lidocaine 0.5% inj
1lidocaine 1% inj
1lidocaine 2% inj
MACROLIDESAZITHROMYCIN
1azithromycin 20mg/ml oral susp
1azithromycin 250mg pack
1azithromycin 250mg tab
1azithromycin 2mg/ml inj
1azithromycin 40mg/ml oral susp
1azithromycin 500mg (3) tab pack
1azithromycin 500mg tab
1azithromycin 600mg tabCLARITHROMYCIN
1clarithromycin 250mg tab
1clarithromycin 25mg/ml oral susp
1clarithromycin 500mg er tab
1clarithromycin 500mg tab
1clarithromycin 50mg/ml oral suspERYTHROMYCINS
1ERY-TAB 250MG DR TAB
1ERY-TAB 333MG DR TAB
1ERY-TAB 500MG DR TAB
1ERYPED 400MG/5ML ORAL SUSP
1ERYTHROCIN LACTOBIONATE 500MG INJ
1erythromycin 250mg dr cap
1ERYTHROMYCIN 250MG TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
88
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ERYTHROMYCIN 500MG TAB
1erythromycin ethylsuccinate 40mg/ml oral susp
MEDICAL DEVICESPARENTERAL THERAPY SUPPLIES
1INSULIN SYRINGE (DISP) U-100 1/2ML
MEDICAL DEVICES AND SUPPLIESBANDAGES-DRESSINGS-TAPE
1GAUZE PADMISC. DEVICES
1ALCOHOL SWAB 1"X1" (DIABETIC)PARENTERAL THERAPY SUPPLIES
1INSULIN PEN NEEDLE
1INSULIN SYRINGE (DISP) U-100 0.3ML
1INSULIN SYRINGE (DISP) U-100 1ML
1INSULIN SYRINGE MIS 1ML/29G
MIGRAINE PRODUCTSMIGRAINE PRODUCTS
1DIHYDROERGOTAMINE MESYLATE 0.5MG/ACT NASAL SPRAY
QL=16 ML/30 Days
1MIGRANAL 4MG/ML NASAL SPRAY QL=16 ML/30 DaysSEROTONIN AGONISTS
1naratriptan 1mg tab QL=18 EA/30 Days
1naratriptan 2.5mg tab QL=18 EA/30 Days
1rizatriptan 10mg odt QL=36 EA/60 Days
1rizatriptan 10mg tab QL=36 EA/60 Days
1rizatriptan 5mg odt QL=36 EA/60 Days
1rizatriptan 5mg tab QL=36 EA/60 Days
1sumatriptan 100mg tab QL=18 EA/30 Days
1sumatriptan 12mg/ml auto-injector QL=5 ML/30 Days
1sumatriptan 12mg/ml inj QL=5 ML/30 Days
1sumatriptan 20mg/act nasal spray QL=12 EA/30 Days
1sumatriptan 25mg tab QL=18 EA/30 Days
1sumatriptan 4mg cartridge QL=5 ML/30 Days
1sumatriptan 50mg tab QL=18 EA/30 Days
1sumatriptan 5mg/act nasal spray QL=12 EA/30 Days
1sumatriptan 6mg cartridge QL=5 ML/30 Days
1sumatriptan 8mg/ml auto-injector QL=5 ML/30 Days
1zolmitriptan 2.5mg odt QL=18 EA/30 Days
1zolmitriptan 2.5mg tab QL=18 EA/30 Days
1zolmitriptan 5mg odt QL=18 EA/30 Days
1zolmitriptan 5mg tab QL=18 EA/30 Days
1ZOMIG 2.5MG NASAL SPRAY QL=16 EA/30 Days
1ZOMIG 5MG NASAL SPRAY QL=12 EA/30 Days
MINERALS & ELECTROLYTESBICARBONATES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
89
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1sodium lactate 5 meq/ml injELECTROLYTE MIXTURES
1calcium chloride 0.002 meq/ml/potassium chloride 0.004 meq/ml/sodium chloride 0.147 meq/ml inj
1d5w/lactated ringers inj
1GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342MEQ/ML INJ
1GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769MEQ/ML INJ
1glucose 25mg/ml/sodium chloride 0.0769 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.01meq/ml/sodium chloride 0.0769meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.0342meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.056meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.0769meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.154meq/ml inj
1glucose 50mg/ml/potassium chloride 0.03meq/ml/sodium chloride 0.0769meq/ml inj
1GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
1GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04MEQ/ML INJ
1glucose 50mg/ml/potassium chloride 0.04meq/ml/sodium chloride 0.0769meq/ml inj
1glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj
1GLUCOSE 50MG/ML/SODIUM CHLORIDE 0.0385MEQ/ML INJ
1glucose 50mg/ml/sodium chloride 0.0564 meq/ml inj
1glucose 50mg/ml/sodium chloride 0.0769 meq/ml inj
1glucose 50mg/ml/sodium chloride 0.154 meq/ml inj
1IONOSOL-MB INJ
1ISOLYTE P INJ
1ISOLYTE S INJ
1KCL/D5W/LR INJ 0.15%
1lactated ringers inj
1NORMOSOL-M INJ
1NORMOSOL-R IN 5% DEXTROSE INJ
1NORMOSOL-R INJ
1PLASMA-LYTE 148 INJ
1PLASMALYTE A INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
90
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj
1potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
1tpn electrolytes injMAGNESIUM
1magnesium sulfate 50% inj
1magnesium sulfate 50% syringePOTASSIUM
1K-TAB 20MEQ ER TAB
1K-TAB 8MEQ ER TAB
1klor-con 10meq er cap
1klor-con 10meq er micro tab
1klor-con 10meq er tab
1KLOR-CON 15MEQ ER TAB
1klor-con 20meq er micro tab
1klor-con 8meq er cap
1klor-con 8meq er tab
1potassium chloride 0.1meq/ml inj
1potassium chloride 10% oral soln
1potassium chloride 10meq er cap
1potassium chloride 10meq er micro tab
1potassium chloride 10meq er tab
1potassium chloride 2 meq/ml inj
1potassium chloride 20% oral soln
1potassium chloride 20meq er micro tab
1POTASSIUM CHLORIDE 20MEQ ER TAB
1potassium chloride 40meq/20ml inj
1potassium chloride 8meq er cap
1potassium chloride 8meq er tabSODIUM
1sodium chloride 0.45% inj
1sodium chloride 0.9% inj
1sodium chloride 2.5 meq/ml inj
1sodium chloride 3% inj
1sodium chloride 5% inj
MISCELLANEOUS THERAPEUTIC CLASSESCHELATING AGENTS
1trientine 250mg tab PAIMMUNOSUPPRESSIVE AGENTS
1AZATHIOPRINE 10MG/ML INJ PA BvD
1mycophenolate mofetil 500mg inj PA BvDSYSTEMIC LUPUS ERYTHEMATOSUS AGENTS
1BENLYSTA 200MG/ML AUTO-INJECTOR NDS PA QL=4 ML/28 Days
1BENLYSTA 200MG/ML SYRINGE NDS PA QL=4 ML/28 Days
MOUTH/THROAT/DENTAL AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
91
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ANESTHETICS TOPICAL ORAL
1lidocaine 2% topical solnANTI-INFECTIVES - THROAT
1clotrimazole 10mg lozenge
1nystatin 100000unit/ml oral suspANTISEPTICS - MOUTH/THROAT
1chlorhexidine gluconate 0.12% mouthwash
1periogard 0.12% mouthwashSTEROIDS - MOUTH/THROAT
1triamcinolone acetonide 0.1% oral pasteTHROAT PRODUCTS - MISC.
1cevimeline 30mg cap
1pilocarpine 5mg tab
1pilocarpine 7.5mg tab
MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS
1baclofen 10mg tab
1baclofen 20mg tab
1carisoprodol 350mg tab
1chlorzoxazone 500mg tab
1cyclobenzaprine 10mg tab
1cyclobenzaprine 5mg tab
1cyclobenzaprine 7.5mg tab
1metaxall 800mg tab
1METAXALONE 400MG TAB
1metaxalone 800mg tab
1methocarbamol 500mg tab
1methocarbamol 750mg tab
1orphenadrine citrate 100mg er tab
1orphenadrine citrate 30mg/ml inj
1tizanidine 2mg cap
1tizanidine 2mg tab
1tizanidine 4mg cap
1tizanidine 4mg tab
1tizanidine 6mg capDIRECT MUSCLE RELAXANTS
1dantrolene sodium 100mg cap
1dantrolene sodium 25mg cap
1dantrolene sodium 50mg capMUSCLE RELAXANT COMBINATIONS
1aspirin 325mg/carisoprodol 200mg tab
1aspirin 325mg/carisoprodol 200mg/codeine phosphate 16mg tab
NASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGY
1azelastine 0.1% (137mcg) nasal inhaler
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
92
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1azelastine 0.15% (205.5mcg) nasal inhaler
1olopatadine 0.6% nasal inhalerNASAL ANTICHOLINERGICS
1ipratropium bromide 0.03% nasal inhaler
1ipratropium bromide 0.06% nasal inhalerNASAL STEROIDS
1flunisolide 25mcg nasal inhaler QL=50 ML/15 Days
1fluticasone propionate 50mcg nasal inhaler QL=32 GM/15 Days
1triamcinolone 55mcg nasal spray QL=33 GM/15 Days
NEUROMUSCULAR AGENTSALS AGENTS
1riluzole 50mg tabMUSCULAR DYSTROPHY AGENTS
1EXONDYS 100MG/2ML INJ NDS PA
1EXONDYS 500MG/10ML INJ NDS PA
NUTRIENTSCARBOHYDRATES
1glucose 10% inj
1glucose 5% injLIPIDS
1intralipid 200mg/ml inj PA BvD
1nutrilipid 20% iv soln PA BvDPROTEINS
1AMINOSYN 7% WITH ELECTROLYTES, SULFITE-FREE INJ
PA BvD
1aminosyn 8.5% with electrolytes, sulfite-free inj PA BvD
1AMINOSYN II 10% INJ PA BvD
1aminosyn ii 8.5% with electrolytes, sulfite-free inj PA BvD
1AMINOSYN II 8.5%, SULFITE-FREE INJ PA BvD
1AMINOSYN-HBC 7%, SULFITE-FREE INJ PA BvD
1AMINOSYN-PF 10%, SULFITE-FREE INJ PA BvD
1AMINOSYN-PF 7% INJ PA BvD
1AMINOSYN-RF 5.2%, SULFITE-FREE INJ PA BvD
1CLINIMIX 4.25/10 INJ PA BvD
1CLINIMIX 4.25/20 INJ PA BvD
1CLINIMIX 4.25/25 INJ PA BvD
1CLINIMIX 4.25/5 INJ PA BvD
1CLINIMIX 5/15 INJ PA BvD
1CLINIMIX 5/20 INJ PA BvD
1CLINIMIX 5/25 INJ PA BvD
1CLINIMIX E 2.75/10 INJ PA BvD
1CLINIMIX E 2.75/5 INJ PA BvD
1CLINIMIX E 4.25/10 INJ PA BvD
1CLINIMIX E 4.25/25 INJ PA BvD
1CLINIMIX E 4.25/5 INJ PA BvD
1CLINIMIX E 5/15 INJ PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
93
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CLINIMIX E 5/20 INJ PA BvD
1CLINIMIX E 5/25 INJ PA BvD
1clinisol 15% inj PA BvD
1FREAMINE 6.9% INJ PA BvD
1HEPATAMINE 8% INJ PA BvD
1NEPHRAMINE 5.4% INJ PA BvD
1plenamine 15% inj PA BvD
1PREMASOL 10% INJ PA BvD
1premasol 6% inj PA BvD
1PROCALAMINE 3% INJ PA BvD
1PROSOL 20% INJ PA BvD
1TRAVASOL 10% INJ PA BvD
1TROPHAMINE 10% INJ PA BvD
OPHTHALMIC AGENTSARTIFICIAL TEARS AND LUBRICANTS
1LACRISERT 5MG IMPLANTBETA-BLOCKERS - OPHTHALMIC
1betaxolol 0.5% ophth soln
1BETIMOL 0.25% OPHTH SOLN
1BETIMOL 0.5% OPHTH SOLN
1BETOPTIC S 0.25% OPHTH SUSP
1carteolol 1% ophth soln
1COMBIGAN 0.2-0.5% OPHTH SOLN
1dorzolamide 20mg/ml/timolol 5mg/ml ophth soln
1ISTALOL 0.5% OPHTH SOLN
1levobunolol 0.5% ophth soln
1METIPRANOLOL 0.3% OPHTH SOLN
1timolol 0.25% ophth gel
1timolol 0.25% ophth soln
1timolol 0.5% 24hr ophth soln
1timolol 0.5% ophth gel
1timolol 0.5% ophth soln
1TIMOPTIC-XE 0.25% OPHTH GELCYCLOPLEGIC MYDRIATICS
1ATROPINE SULFATE 1% OPHTH SOLNMIOTICS
1PHOSPHOLINE IODIDE 0.125% OPHTH SOLN
1pilocarpine 1% ophth soln
1pilocarpine 2% ophth soln
1pilocarpine 4% ophth solnOPHTHALMIC ADRENERGIC AGENTS
1ALPHAGAN P 0.1% OPHTH SOLN
1apraclonidine 0.5% ophth soln
1brimonidine tartrate 0.15% ophth soln
1brimonidine tartrate 0.2% ophth soln
1IOPIDINE 1% OPHTH SOLN
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
94
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SIMBRINZA 1-0.2% OPHTH SUSPOPHTHALMIC ANTI-INFECTIVES
1AZASITE 1% OPHTH SOLN
1BACITRACIN 0.5UNIT/MG OPHTH OINTMENT
1bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment
1BESIVANCE 0.6% OPHTH SUSP ST
1ciprofloxacin 0.3% ophth soln
1erythromycin 0.005mg/mg ophth ointment
1gatifloxacin 0.5% ophth soln
1gentak 0.3% ophth ointment
1gentamicin sulfate 0.3% ophth soln
1gramicidin 0.025mg/ml/neomycin 1.75mg/ml/polymyxin b 10000unit/ml ophth soln
1levofloxacin 0.5% ophth soln
1moxifloxacin 0.5% ophth soln
1NATACYN 5% OPHTH SUSP
1neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit
1ofloxacin 0.3% ophth soln
1polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln
1SULFACETAMIDE SODIUM 10% OPHTH OINTMENT
1sulfacetamide sodium 10% ophth soln
1tobramycin 0.3% ophth soln
1trifluridine 1% soln
1VIGAMOX 0.5% OPHTH SOLN
1ZIRGAN 0.15% OPHTH GELOPHTHALMIC IMMUNOMODULATORS
1RESTASIS 0.05% OPHTH SUSPOPHTHALMIC LOCAL ANESTHETICS
1proparacaine 0.5% ophth solnOPHTHALMIC STEROIDS
1ALREX 0.2% OPHTH SUSP
1BLEPHAMIDE 10-0.2% OPHTH SUSP
1DEXAMETHASONE 0.1% OPHTH SOLN
1dexamethasone/neomycin/polymyxin b 0.1% ophth ointment
1dexamethasone/neomycin/polymyxin b 0.1% ophth susp
1dexamethasone/tobramycin 0.3-0.1% ophth susp
1DUREZOL 0.05% OPHTH SUSP
1fluorometholone 0.1% ophth susp
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susp
1LOTEMAX 0.5% OPHTH GEL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
95
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1LOTEMAX 0.5% OPHTH OINTMENT
1LOTEMAX 0.5% OPHTH SUSP
1MAXIDEX 0.1% OPHTH SUSP
1neomycin/polymyxin/bacitracin/hydrocortisone ophth ointmentment 1%
1PRED MILD 0.12% OPHTH SUSP
1PRED-G 0.3-1% OPHTH SUSP
1prednisolone 1% ophth soln
1prednisolone acetate 1% ophth susp
1prednisolone sodium phosphate 2.5mg/ml/sulfacetamide sodium 100mg/ml ophth soln
1TOBRADEX 0.3-0.1% OPHTH OINTMENT
1ZYLET 0.5-0.3% OPHTH SUSPOPHTHALMICS - MISC.
1ALOCRIL 2% OPHTH SOLN
1ALOMIDE 0.1% OPHTH SOLN
1azelastine 0.05% ophth soln
1AZOPT 1% OPHTH SUSP
1cromolyn sodium 4% ophth soln
1CYSTARAN 0.44% OPHTH SOLN NDS PA QL=60 ML/30 Days
1diclofenac sodium 0.1% ophth soln
1dorzolamide 2% ophth soln
1epinastine 0.05% ophth soln
1flurbiprofen sodium 0.03% ophth soln
1ILEVRO 0.3% OPHTH SUSP
1ketorolac tromethamine 0.4% ophth soln
1ketorolac tromethamine 0.5% ophth soln
1NEVANAC 0.1% OPHTH SUSP
1olopatadine 0.1% ophth soln
1olopatadine 0.2% ophth solnPROSTAGLANDINS - OPHTHALMIC
1BIMATOPROST 0.03% OPHTH SOLN QL=5 ML/30 Days
1latanoprost 0.005% ophth soln QL=5 ML/30 Days
1LUMIGAN 0.01% OPHTH SOLN QL=5 ML/30 Days
1TRAVATAN Z 0.004% OPHTH SOLN QL=5 ML/30 Days
OTIC AGENTSOTIC AGENTS - MISCELLANEOUS
1acetic acid 2% otic solnOTIC ANTI-INFECTIVES
1CETRAXAL 0.2% OTIC SOLN
1CIPROFLOXACIN 0.2% OTIC SOLN
1ofloxacin 0.3% otic solnOTIC COMBINATIONS
1CIPRODEX 0.3-0.1% OTIC SUSP
1COLY MYCIN S 3.3-3-10-0.5MG/ML OTIC SUSP
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
96
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp
OTIC STEROIDS
1acetic acid/hydrocortisone 1-2% otic soln
1fluocinolone acetonide 0.01% otic soln
PASSIVE IMMUNIZING AGENTSIMMUNE SERUMS
1BIVIGAM 10% INJ NDS PA
1CARIMUNE 6GM INJ NDS PA
1FLEBOGAMMA 10% INJ NDS PA
1GAMASTAN 1800UNIT/10ML INJ PA
1GAMASTAN 360UNIT/2ML INJ PA
1GAMMAGARD 10GM INJ NDS PA
1GAMMAGARD 2.5GM/25ML INJ NDS PA
1GAMMAGARD 5GM INJ NDS PA
1GAMMAKED 1GM/10ML INJ NDS PA
1GAMMAPLEX 10GM/200ML INJ NDS PA
1GAMUNEX 1GM/10ML INJ NDS PA
1OCTAGAM 25GM/500ML INJ NDS PA
1PRIVIGEN 20GM/200ML INJ NDS PAMONOCLONAL ANTIBODIES
1SYNAGIS 100MG/1ML INJ NDS PA
1SYNAGIS 50MG/0.5ML INJ NDS PA
PASSIVE IMMUNIZING AND TREATMENT AGENTSIMMUNE SERUMS
1GAMMAPLEX 10GM/100ML INJ NDS PA
1GAMMAPLEX 20GM/200ML INJ NDS PA
1GAMMAPLEX 5GM/50ML INJ NDS PA
1HYPERRAB 150UNIT/ML (10ML) INJ PA BvD
1HYPERRAB 150UNIT/ML (2ML) INJ PA BvD
1IMOGAM 150UNIT/ML (2ML) INJ PA BvD
1OCTAGAM 2GM/20ML INJ NDS PA
PENICILLINSAMINOPENICILLINS
1amoxicillin 125mg chew tab
1amoxicillin 250mg cap
1AMOXICILLIN 250MG CHEW TAB
1amoxicillin 25mg/ml oral susp
1amoxicillin 40mg/ml oral susp
1amoxicillin 500mg cap
1amoxicillin 500mg tab
1amoxicillin 50mg/ml oral susp
1amoxicillin 80mg/ml oral susp
1amoxicillin 875mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
97
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ampicillin 100mg/ml inj
1AMPICILLIN 125MG/ML INJ
1ampicillin 250mg/ml inj
1ampicillin 500mg capNATURAL PENICILLINS
1BICILLIN L-A 1200000UNIT/2ML SYRINGE
1BICILLIN L-A 2400000UNIT/4ML SYRINGE
1BICILLIN L-A 600000UNIT/ML SYRINGE
1penicillin g potassium 1000000unit/ml inj
1PENICILLIN G POTASSIUM 40000UNIT/ML INJ
1PENICILLIN G POTASSIUM 60000UNIT/ML INJ
1PENICILLIN G PROCAINE 600000UNIT/ML SYRINGE
1PENICILLIN G SODIUM 100000UNIT/ML INJ
1penicillin v potassium 250mg tab
1penicillin v potassium 25mg/ml oral soln
1penicillin v potassium 500mg tab
1penicillin v potassium 50mg/ml oral solnPENICILLIN COMBINATIONS
1amoxicillin 1000mg/clavulanate 62.5mg er tab
1amoxicillin 120mg/ml/clavulanate 8.58mg/ml oral susp
1AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB
1amoxicillin 250mg/clavulanate 125mg tab
1AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB
1amoxicillin 40mg/ml/clavulanate 5.7mg/ml oral susp
1amoxicillin 500mg/clavulanate 125mg tab
1amoxicillin 50mg/ml/clavulanate 12.5mg/ml oral susp
1amoxicillin 80mg/ml/clavulanate 11.4mg/ml oral susp
1amoxicillin 875mg/clavulanate 125mg tab
1ampicillin 100mg/ml/sulbactam 50mg/ml inj
1ampicillin 20mg/ml/sulbactam 10mg/ml inj
1ampicillin 250mg/ml/sulbactam 125mg/ml inj
1AUGMENTIN 125-31.25MG/5ML ORAL SUSP
1BICILLIN 300000-300000UNIT/ML SYRINGE
1BICILLIN 450000-150000UNIT/ML SYRINGE
1piperacillin 2000mg/tazobactam 250mg inj
1piperacillin 200mg/ml/tazobactam 25mg/ml inj
1piperacillin 3000mg/tazobactam 375mg inj
1piperacillin 4000mg/tazobactam 500mg inj
1UNASYN 10-5GM INJ
1UNASYN 2-1GM INJ
1ZOSYN 40-5MG/ML INJ
1ZOSYN 60-7.5MG/ML INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
98
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
PENICILLINASE-RESISTANT PENICILLINS
1dicloxacillin 250mg cap
1dicloxacillin 500mg cap
1nafcillin 100mg/ml inj
1nafcillin 1gm inj
1oxacillin 100mg/ml inj
1oxacillin 2000mg inj
1OXACILLIN 20MG/ML INJ
1OXACILLIN 40MG/ML INJ
PROGESTINSPROGESTINS
1medroxyprogesterone acetate 10mg tab
1medroxyprogesterone acetate 2.5mg tab
1medroxyprogesterone acetate 5mg tab
1megestrol acetate 125mg/ml oral susp PA
1norethindrone acetate 5mg tab
1progesterone 100mg cap
1progesterone 200mg cap
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.AGENTS FOR CHEMICAL DEPENDENCY
1acamprosate calcium 333mg dr tab
1disulfiram 250mg tab
1disulfiram 500mg tabANTI-CATAPLECTIC AGENTS
1XYREM 500MG/ML ORAL SOLN NDS PA QL=540 ML/30 DaysANTIDEMENTIA AGENTS
1donepezil 10mg odt QL=30 EA/30 Days
1donepezil 10mg tab QL=60 EA/30 Days
1donepezil 23mg tab ST QL=30 EA/30 Days
1donepezil 5mg odt QL=30 EA/30 Days
1donepezil 5mg tab QL=60 EA/30 Days
1galantamine 12mg tab
1galantamine 4mg tab
1galantamine 8mg tab
1galantamine hydrobromide 16mg er cap
1galantamine hydrobromide 24mg er cap
1GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN
1galantamine hydrobromide 8mg er cap
1memantine 10mg tab
1memantine 10mg/memantine 5mg pack
1memantine 14mg er cap
1memantine 21mg er cap
1memantine 28mg er cap
1memantine 2mg/ml oral soln
1memantine 5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
99
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1memantine 7mg er cap
1NAMENDA 14MG XR CAP
1NAMENDA 21MG XR CAP
1NAMENDA 28 TITRATION PACK
1NAMENDA 28MG XR CAP
1NAMENDA 7MG XR CAP
1NAMZARIC 10-21MG ER CAP ST
1NAMZARIC 10-7MG ER CAP ST
1NAMZARIC 14-10MG ER CAP ST
1NAMZARIC 28-10MG ER CAP ST
1NAMZARIC TITRATION PACK ST
1rivastigmine 1.5mg cap
1rivastigmine 13.3mg/24hr patch
1rivastigmine 3mg cap
1rivastigmine 4.5mg cap
1rivastigmine 4.6mg/24hr patch
1rivastigmine 6mg cap
1rivastigmine 9.5mg/24hr patchCOMBINATION PSYCHOTHERAPEUTICS
1AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB
1AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB
1amitriptyline 12.5mg/chlordiazepoxide 5mg tab
1amitriptyline 25mg/chlordiazepoxide 10mg tab
1AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB
1AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB
1AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB
1fluoxetine 25mg/olanzapine 12mg cap
1fluoxetine 25mg/olanzapine 3mg cap
1fluoxetine 25mg/olanzapine 6mg cap
1fluoxetine 50mg/olanzapine 12mg cap
1fluoxetine 50mg/olanzapine 6mg capFIBROMYALGIA AGENTS
1SAVELLA 100MG TAB QL=60 EA/30 Days
1SAVELLA 12.5MG TAB QL=60 EA/30 Days
1SAVELLA 25MG TAB QL=60 EA/30 Days
1SAVELLA 4-WEEK TITRATION PACK
1SAVELLA 50MG TAB QL=60 EA/30 DaysMOVEMENT DISORDER DRUG THERAPY
1AUSTEDO 12MG TAB NDS PA
1AUSTEDO 6MG TAB NDS PA
1AUSTEDO 9MG TAB NDS PA
1tetrabenazine 12.5mg tab NDS PA
1tetrabenazine 25mg tab NDS PAMULTIPLE SCLEROSIS AGENTS
1AMPYRA 10MG ER TAB NDS PA QL=60 EA/30 Days
1AUBAGIO 14MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
100
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1AUBAGIO 7MG TAB NDS
1AVONEX 30MCG/0.5ML AUTO-INJECTOR NDS
1AVONEX 30MCG/0.5ML SYRINGE NDS
1AVONEX 30MCG/VIAL INJ NDS
1COPAXONE 20MG/ML SYRINGE NDS
1COPAXONE 40MG/ML SYRINGE NDS
1EXTAVIA 0.3MG INJ NDS
1GILENYA 0.5MG CAP NDS
1glatiramer 20mg/ml syringe NDS
1glatiramer 40mg/ml syringe NDS
1glatopa 20mg/ml inj NDS
1glatopa 40mg/ml syringe NDS
1PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR NDS
1PLEGRIDY 125MCG/0.5ML SYRINGE NDS
1PLEGRIDY PEN STARTER PACK NDS
1PLEGRIDY STARTER PACK NDS
1REBIF 22MCG/0.5ML AUTO-INJECTOR NDS
1REBIF 22MCG/0.5ML SYRINGE NDS
1REBIF 44MCG/0.5ML AUTO-INJECTOR NDS
1REBIF 44MCG/0.5ML SYRINGE NDS
1REBIF REBIDOSE PACK NDS
1REBIF TITRATION PACK NDS
1TECFIDERA 120MG DR CAP NDS
1TECFIDERA 240MG DR CAP NDS
1TECFIDERA 30-DAY STARTER PACK NDS
1TYSABRI 300MG/15ML INJ NDS PAPSEUDOBULBAR AFFECT (PBA) AGENTS
1NUEDEXTA 20-10MG CAP QL=60 EA/30 DaysPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
1ERGOLOID MESYLATES 1MG TAB
1pimozide 1mg tab
1pimozide 2mg tabSMOKING DETERRENTS
1bupropion 150mg sr tab
1CHANTIX 0.5MG TAB
1CHANTIX 1MG TAB
1CHANTIX CONTINUING MONTHS OF THERAPY 1MG PACK
1CHANTIX FIRST MONTH OF THERAPY PACK
1NICOTROL 10MG INHALER
1NICOTROL 10MG/ML NASAL INHALER
RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)
1ARALAST 500MG INJ NDS
1GLASSIA 1000MG/50ML INJ NDS
1PROLASTIN 1000MG INJ NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
101
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ZEMAIRA 1000MG INJ NDSCYSTIC FIBROSIS AGENTS
1KALYDECO 150MG TAB NDS PA QL=60 EA/30 Days
1KALYDECO 50MG GRANULES PACKET NDS PA QL=60 EA/30 Days
1KALYDECO 75MG GRANULES PACKET NDS PA QL=60 EA/30 Days
1ORKAMBI 100-125MG TAB NDS PA QL=120 EA/30 Days
1ORKAMBI 200-125MG TAB NDS PA QL=120 EA/30 Days
1PULMOZYME 1MG/ML INH SOLN NDS PA BvDPULMONARY FIBROSIS AGENTS
1ESBRIET 267MG CAP NDS PA
1ESBRIET 267MG TAB NDS PA
1ESBRIET 801MG TAB NDS PA
1OFEV 100MG CAP NDS PA
1OFEV 150MG CAP NDS PA
SULFONAMIDESSULFONAMIDES
1SULFADIAZINE 500MG TAB
TETRACYCLINESTETRACYCLINES
1demeclocycline 150mg tab
1demeclocycline 300mg tab
1doxy 100mg inj
1doxycycline hyclate 100mg cap
1doxycycline hyclate 100mg tab
1doxycycline hyclate 20mg tab
1doxycycline hyclate 50mg cap
1doxycycline monohydrate 100mg cap
1doxycycline monohydrate 100mg tab
1doxycycline monohydrate 50mg cap
1doxycycline monohydrate 50mg tab
1doxycycline monohydrate 5mg/ml oral susp
1doxycycline monohydrate 75mg tab
1minocycline 100mg cap
1minocycline 100mg tab
1minocycline 50mg cap
1minocycline 50mg tab
1minocycline 75mg cap
1minocycline 75mg tab
1morgidox 50mg cap
1tetracycline 250mg cap
1tetracycline 500mg cap
THYROID AGENTSANTITHYROID AGENTS
1methimazole 10mg tab
1methimazole 5mg tab
1propylthiouracil 50mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
102
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
THYROID HORMONES
1levo-t 100mcg tab
1levo-t 112mcg tab
1levo-t 125mcg tab
1levo-t 137mcg tab
1levo-t 150mcg tab
1levo-t 175mcg tab
1levo-t 200mcg tab
1levo-t 25mcg tab
1levo-t 300mcg tab
1levo-t 50mcg tab
1levo-t 75mcg tab
1levo-t 88mcg tab
1levothyroxine sodium 100mcg tab
1levothyroxine sodium 112mcg tab
1levothyroxine sodium 125mcg tab
1levothyroxine sodium 137mcg tab
1levothyroxine sodium 150mcg tab
1levothyroxine sodium 175mcg tab
1levothyroxine sodium 200mcg tab
1levothyroxine sodium 25mcg tab
1levothyroxine sodium 300mcg tab
1levothyroxine sodium 50mcg tab
1levothyroxine sodium 75mcg tab
1levothyroxine sodium 88mcg tab
1levoxyl 100mcg tab
1levoxyl 112mcg tab
1levoxyl 125mcg tab
1levoxyl 137mcg tab
1levoxyl 150mcg tab
1levoxyl 175mcg tab
1levoxyl 200mcg tab
1levoxyl 25mcg tab
1levoxyl 50mcg tab
1levoxyl 75mcg tab
1levoxyl 88mcg tab
1liothyronine sodium 0.005mg tab
1liothyronine sodium 0.01mg/ml inj
1liothyronine sodium 0.025mg tab
1liothyronine sodium 0.05mg tab
1SYNTHROID 100MCG TAB
1SYNTHROID 112MCG TAB
1SYNTHROID 125MCG TAB
1SYNTHROID 137MCG TAB
1SYNTHROID 150MCG TAB
1SYNTHROID 175MCG TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
103
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SYNTHROID 200MCG TAB
1SYNTHROID 25MCG TAB
1SYNTHROID 300MCG TAB
1SYNTHROID 50MCG TAB
1SYNTHROID 75MCG TAB
1SYNTHROID 88MCG TAB
1THYROLAR 120MG TAB
1THYROLAR 15MG TAB
1THYROLAR 180MG TAB
1THYROLAR 30MG TAB
1THYROLAR 60MG TAB
1unithroid 100mcg tab
1unithroid 112mcg tab
1unithroid 125mcg tab
1unithroid 150mcg tab
1unithroid 175mcg tab
1unithroid 200mcg tab
1unithroid 25mcg tab
1unithroid 300mcg tab
1unithroid 50mcg tab
1unithroid 75mcg tab
1unithroid 88mcg tab
TOXOIDSTOXOID COMBINATIONS
1ADACEL INJ
1ADACEL SYRINGE
1BOOSTRIX INJ
1BOOSTRIX SYRINGE
1DAPTACEL INJ
1DIPHTHERIA/TETANUS TOXOID INJ PA BvD
1INFANRIX INJ
1KINRIX 0.05 MG/ML INJ
1KINRIX INJ
1PEDIARIX INJ
1QUADRACEL INJ
1TENIVAC SYRINGE PA BvD
1TETANUS/DIPHTHERIA TOXOID INJ PA BvD
ULCER DRUGSANTISPASMODICS
1ATROPINE SULFATE 0.05MG/ML SYRINGE
1dicyclomine 10mg cap
1dicyclomine 20mg tab
1dicyclomine 2mg/ml oral soln
1glycopyrrolate 0.2mg/ml inj
1glycopyrrolate 1mg tab
1glycopyrrolate 2mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
104
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1methscopolamine 2.5mg tab
1methscopolamine 5mg tab
1PROPANTHELINE 15MG TABH-2 ANTAGONISTS
1cimetidine 200mg tab
1cimetidine 300mg tab
1cimetidine 400mg tab
1cimetidine 60mg/ml oral soln
1cimetidine 800mg tab
1FAMOTIDINE 0.4MG/ML INJ
1famotidine 10mg/ml inj
1famotidine 20mg tab
1famotidine 40mg tab
1famotidine 8mg/ml oral susp
1nizatidine 150mg cap
1NIZATIDINE 15MG/ML ORAL SOLN
1nizatidine 300mg cap
1ranitidine 150mg cap
1ranitidine 150mg tab
1ranitidine 15mg/ml oral soln
1ranitidine 25mg/ml inj
1ranitidine 300mg cap
1ranitidine 300mg tabMISC. ANTI-ULCER
1sucralfate 1000mg tabPROTON PUMP INHIBITORS
1esomeprazole 20mg dr cap
1ESOMEPRAZOLE 20MG INJ
1esomeprazole 40mg dr cap
1esomeprazole 40mg inj
1lansoprazole 15mg dr cap
1lansoprazole 30mg dr cap
1NEXIUM 10MG GRANULES FOR ORAL SUSP
1NEXIUM 2.5MG GRANULES FOR ORAL SUSP
1NEXIUM 20MG GRANULES FOR ORAL SUSP
1NEXIUM 40MG GRANULES FOR ORAL SUSP
1NEXIUM 5MG GRANULES FOR ORAL SUSP
1omeprazole 10mg dr cap
1omeprazole 20mg dr cap
1omeprazole 40mg dr cap
1pantoprazole 20mg dr tab
1pantoprazole 40mg dr tab
1pantoprazole 40mg inj
1rabeprazole sodium 20mg dr tabULCER DRUGS - PROSTAGLANDINS
1misoprostol 0.1mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
105
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1misoprostol 0.2mg tabULCER THERAPY COMBINATIONS
1amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack
1PYLERA 140-125-125MG CAP
URINARY ANTI-INFECTIVESURINARY ANTI-INFECTIVES
1methenamine hippurate 1000mg tab
1nitrofurantoin 5mg/ml oral susp
1nitrofurantoin macro 25mg cap
1nitrofurantoin monohydrate/macrocrystalline 100mg cap
1nitrofurantoin, macro 100mg cap
1nitrofurantoin, macro 50mg cap
URINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)
1oxybutynin chloride 10mg er tab
1oxybutynin chloride 15mg er tab
1oxybutynin chloride 1mg/ml oral soln
1oxybutynin chloride 5mg er tab
1oxybutynin chloride 5mg tab
1tolterodine tartrate 1mg tab
1tolterodine tartrate 2mg er cap
1tolterodine tartrate 2mg tab
1tolterodine tartrate 4mg er cap
1trospium chloride 20mg tab
1trospium chloride 60mg er cap
1VESICARE 10MG TAB
1VESICARE 5MG TABURINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS
1MYRBETRIQ 25MG ER TAB
1MYRBETRIQ 50MG ER TABURINARY ANTISPASMODICS - CHOLINERGIC AGONISTS
1bethanechol chloride 10mg tab
1bethanechol chloride 25mg tab
1bethanechol chloride 50mg tab
1bethanechol chloride 5mg tabURINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS
1flavoxate 100mg tab
VACCINESBACTERIAL VACCINES
1ACTHIB INJ
1BCG, LIVE, TICE STRAIN 50MG/ML INJ
1BEXSERO SYRINGE
1HIBERIX INJ
1MENACTRA INJ
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
106
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1MENVEO INJ
1PEDVAXHIB 7.5MCG/0.5ML INJ
1TRUMENBA SYRINGE
1TYPHIM VI 25MCG/0.5ML INJ
1TYPHIM VI 25MCG/0.5ML SYRINGEVIRAL VACCINES
1ENGERIX-B 10MCG/0.5ML SYRINGE PA BvD
1ENGERIX-B 20MCG/ML SYRINGE PA BvD
1GARDASIL 9 INJ PA
1GARDASIL 9 SYRINGE PA
1HAVRIX 1440UNIT INJ
1HAVRIX 1440UNIT SYRINGE
1HAVRIX 720UNIT INJ
1HAVRIX 720UNIT SYRINGE
1IMOVAX 2.5UNIT/ML INJ PA BvD
1IPOL INJ
1IXIARO SYRINGE
1M-M-R II INJ
1PROQUAD INJ
1RABAVERT 2.5UNIT/ML INJ PA BvD
1RECOMBIVAX 10MCG/ML SYRINGE PA BvD
1RECOMBIVAX 40MCG/ML INJ PA BvD
1RECOMBIVAX 5MCG/0.5ML SYRINGE PA BvD
1RECOMBIVAX HB 10MCG/ML INJ PA BvD
1ROTARIX ORAL SUSP
1ROTATEQ ORAL SUSP
1SHINGRIX INJ PA
1TWINRIX 720UNIT SYRINGE
1VAQTA 25UNIT/0.5ML SYRINGE
1VAQTA 50UNIT/0.5ML INJ
1VAQTA 50UNIT/1ML INJ
1VAQTA 50UNIT/ML SYRINGE
1VARIVAX 1350PFU/0.5ML INJ
1YF-VAX 4000UNIT/ML INJ
1ZOSTAVAX 19400UNIT/0.65ML INJ PA
VAGINAL PRODUCTSVAGINAL ANTI-INFECTIVES
1AVC BRAND OF SULFANILAMIDE 15% VAGINAL CREAM
1clindamycin 2% vaginal cream
1metronidazole 0.75% vaginal gel
1terconazole 0.4% vaginal cream
1terconazole 0.8% vaginal cream
1terconazole 80mg vaginal supp
1vandazole 0.75% vaginal gelVAGINAL ESTROGENS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
107
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1estradiol 0.1mg/ml vaginal cream
1ESTRING 2MG VAGINAL RING ST
1PREMARIN 0.625MG/GM VAGINAL CREAMVAGINAL PROGESTINS
1CRINONE 4% VAGINAL GEL PA
1CRINONE 8% VAGINAL GEL PA
VASOPRESSORSANAPHYLAXIS THERAPY AGENTS
1EPINEPHRINE 0.15MG/0.3ML AUTO-INJECTOR QL=2 EA/15 Days
1EPINEPHRINE 0.3MG/0.3ML AUTO-INJECTOR QL=2 EA/15 DaysNEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS
1NORTHERA 100MG CAP NDS PA
1NORTHERA 200MG CAP NDS PA
1NORTHERA 300MG CAP NDS PAVASOPRESSORS
1midodrine 10mg tab
1midodrine 2.5mg tab
1midodrine 5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
108
ALPHABETICAL LISTING OF DRUGS
A
abacavir 20mg/ml oral soln
56
abacavir 300mg tab 56 abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab
56
abacavir 600mg/lamivudine 300mg tab
56
ABELCET 5MG/ML INJ 33 ABILIFY 300MG MAINTENA INJ
56
ABILIFY 300MG MAINTENA PF SYRINGE
56
ABILIFY 400MG MAINTENA INJ
56
ABILIFY 400MG MAINTENA PF SYRINGE
56
ABRAXANE 100MG INJ 50 acamprosate calcium 333mg dr tab
99
acarbose 100mg tab 29 acarbose 25mg tab 29 acarbose 50mg tab 29 acebutolol 200mg cap 62 acebutolol 400mg cap 62 acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln
14
acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln
14
acetaminophen 300mg/codeine phosphate 15mg tab
14
acetaminophen 300mg/codeine phosphate 30mg tab
14
acetaminophen 300mg/codeine phosphate 60mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 10mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 5mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 10mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 2.5mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 5mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab
14
acetaminophen 325mg/oxycodone 10mg tab
14
acetaminophen 325mg/oxycodone 2.5mg tab
14
acetaminophen 325mg/oxycodone 5mg tab
14
acetaminophen 325mg/oxycodone 7.5mg tab
14
acetaminophen 325mg/tramadol 37.5mg tab
14
acetazolamide 100mg/ml inj
78
acetazolamide 125mg tab 78 acetazolamide 250mg tab 78
acetazolamide 500mg er cap
78
acetic acid 2% otic soln 96 acetic acid/hydrocortisone 1-2% otic soln
97
acetylcysteine 10% inh soln
72
acetylcysteine 20% inh soln
72
acitretin 10mg cap 74 acitretin 17.5mg cap 74 acitretin 25mg cap 74 ACTHIB INJ 106 ACTIMMUNE 2000000UNIT/0.5ML INJ
49
acyclovir 200mg cap 59 acyclovir 400mg tab 59 acyclovir 40mg/ml oral susp
59
acyclovir 5% ointment 75 acyclovir 50mg/ml inj 59 acyclovir 800mg tab 59 ADACEL INJ 104 ADACEL SYRINGE 104 ADAGEN 250UNIT/ML INJ
63
adapalene 0.1% cream 72 adapalene 0.1% gel 72 adapalene 0.3% gel 72 adapalene/benzoyl peroxide 0.1-2.5% gel
72
adefovir dipivoxil 10mg tab
59
ADEMPAS 0.5MG TAB 66 ADEMPAS 1.5MG TAB 66 ADEMPAS 1MG TAB 66 ADEMPAS 2.5MG TAB 66 ADEMPAS 2MG TAB 66 adriamycin 2mg/ml inj 46 adrucil 500mg/10ml inj 44 ADVAIR 100-50MCG DISKUS
19
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
109
ALPHABETICAL LISTING OF DRUGS
ADVAIR 115-21MCG HFA INH
19
ADVAIR 230-21MCG HFA INH
19
ADVAIR 250-50MCG DISKUS
19
ADVAIR 45-21MCG HFA INH
19
ADVAIR 500-50MCG DISKUS
19
afeditab 30mg cr tab 63 afeditab 60mg cr tab 63 AFINITOR 10MG TAB 47 AFINITOR 2.5MG TAB 47 AFINITOR 2MG ORAL SUSP
47
AFINITOR 3MG ORAL SUSP
47
AFINITOR 5MG ORAL SUSP
47
AFINITOR 5MG TAB 47 AFINITOR 7.5MG TAB 47 ala-cort 1% cream 75 ala-cort 2.5% cream 75 ALBENZA 200MG TAB 16 albuterol 0.21mg/ml (0.63mg/3ml) inh soln
19
albuterol 0.417mg/ml (1.25mg/3ml) inh soln
19
albuterol 0.4mg/ml (2mg/5ml) oral soln
19
albuterol 0.83mg/ml (0.083%) inh soln
19
albuterol 1mg/ml (0.5%) inh soln
19
albuterol 2mg tab 19 albuterol 4mg er tab 19 albuterol 4mg tab 19 albuterol 8mg er tab 19 alclometasone dipropionate 0.05% cream
75
alclometasone dipropionate 0.05% ointment
75
ALCOHOL SWAB 1"X1" (DIABETIC)
89
ALDURAZYME 2.9MG/5ML INJ
80
ALECENSA 150MG CAP 47 ALENDRONATE 0.933MG/ML ORAL SOLN
79
alendronate 10mg tab 79 alendronate 35mg tab 79 ALENDRONATE 40MG TAB
79
alendronate 5mg tab 79 alendronate 70mg tab 79 alfuzosin 10mg er tab 85 ALIMTA 100MG INJ 44 ALIMTA 500MG INJ 44 ALINIA 100MG/5ML ORAL SUSP
41
ALINIA 500MG TAB 41 ALIQOPA 60MG INJ 47 allopurinol 100mg tab 85 allopurinol 300mg tab 85 ALOCRIL 2% OPHTH SOLN
96
ALOMIDE 0.1% OPHTH SOLN
96
alosetron 0.5mg tab 84 alosetron 1mg tab 84 ALPHAGAN P 0.1% OPHTH SOLN
94
alprazolam 0.25mg odt 17 alprazolam 0.25mg tab 17 alprazolam 0.5mg er tab 17 alprazolam 0.5mg odt 17 alprazolam 0.5mg tab 17 alprazolam 1mg er tab 17 alprazolam 1mg odt 17 alprazolam 1mg tab 17 alprazolam 2mg er tab 17 alprazolam 2mg odt 17 alprazolam 2mg tab 17 alprazolam 3mg er tab 17 ALREX 0.2% OPHTH SUSP
95
altavera 28 day pack 67 ALUNBRIG 180MG TAB 47 ALUNBRIG 30MG TAB 47 ALUNBRIG 90MG TAB 47 ALUNBRIG TAB STARTER PACK
47
alyacen 1/35 28 day pack 67 amabelz 0.5/0.1mg 28 day pack
82
amabelz 1/0.5mg 28 day pack
82
amantadine 100mg cap 51 amantadine 100mg tab 51 amantadine 10mg/ml oral soln
51
AMBISOME 50MG INJ 33 AMCINONIDE 0.1% CREAM
75
AMCINONIDE 0.1% OINTMENT
75
amethia 91 day pack 67 amethia lo 91 day pack 67 amikacin 250mg/ml inj 8 amiloride 5mg tab 78 amiloride 5mg/hydrochlorothiazide 50mg tab
78
aminophylline 25mg/ml inj
20
AMINOSYN 7% WITH ELECTROLYTES, SULFITE-FREE INJ
93
aminosyn 8.5% with electrolytes, sulfite-free inj
93
AMINOSYN II 10% INJ 93 aminosyn ii 8.5% with electrolytes, sulfite-free inj
93
AMINOSYN II 8.5%, SULFITE-FREE INJ
93
AMINOSYN-HBC 7%, SULFITE-FREE INJ
93
AMINOSYN-PF 10%, SULFITE-FREE INJ
93
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
110
ALPHABETICAL LISTING OF DRUGS
AMINOSYN-PF 7% INJ 93 AMINOSYN-RF 5.2%, SULFITE-FREE INJ
93
amiodarone 200mg tab 18 amiodarone 400mg tab 18 amiodarone 50mg/ml inj 18 amiodarone hydrochloride 100mg tab
18
amitriptyline 100mg tab 28 amitriptyline 10mg tab 28 AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB
100
AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB
100
amitriptyline 12.5mg/chlordiazepoxide 5mg tab
100
amitriptyline 150mg tab 28 amitriptyline 25mg tab 28 amitriptyline 25mg/chlordiazepoxide 10mg tab
100
AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB
100
AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB
100
amitriptyline 50mg tab 28 AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB
100
amitriptyline 75mg tab 28 amlodipine 10mg tab 63 amlodipine 10mg/atorvastatin 10mg tab
65
amlodipine 10mg/atorvastatin 20mg tab
65
amlodipine 10mg/atorvastatin 40mg tab
65
amlodipine 10mg/atorvastatin 80mg tab
65
amlodipine 10mg/benazepril 20mg cap
38
amlodipine 10mg/benazepril 40mg cap
38
amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
38
amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab
38
amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 320mg tab
38
amlodipine 10mg/olmesartan medoxomil 20mg tab
38
amlodipine 10mg/olmesartan medoxomil 40mg tab
38
amlodipine 10mg/telmisartan 40mg tab
38
amlodipine 10mg/telmisartan 80mg tab
38
amlodipine 10mg/valsartan 160mg tab
38
amlodipine 10mg/valsartan 320mg tab
38
amlodipine 2.5mg tab 63 amlodipine 2.5mg/atorvastatin 10mg tab
65
amlodipine 2.5mg/atorvastatin 20mg tab
65
amlodipine 2.5mg/atorvastatin 40mg tab
65
amlodipine 2.5mg/benazepril 10mg cap
38
amlodipine 5mg tab 63 amlodipine 5mg/atorvastatin 10mg tab
65
amlodipine 5mg/atorvastatin 20mg tab
65
amlodipine 5mg/atorvastatin 40mg tab
65
amlodipine 5mg/atorvastatin 80mg tab
65
amlodipine 5mg/benazepril 10mg cap
38
amlodipine 5mg/benazepril 20mg cap
38
amlodipine 5mg/benazepril 40mg cap
38
amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
38
amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 160mg tab
38
amlodipine 5mg/olmesartan medoxomil 20mg tab
38
amlodipine 5mg/olmesartan medoxomil 40mg tab
38
amlodipine 5mg/telmisartan 40mg tab
39
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
111
ALPHABETICAL LISTING OF DRUGS
amlodipine 5mg/telmisartan 80mg tab
39
amlodipine 5mg/valsartan 160mg tab
39
amlodipine 5mg/valsartan 320mg tab
39
ammonium lactate 12% cream
76
ammonium lactate 12% lotion
77
amnesteem 10mg cap 72 amnesteem 20mg cap 72 amnesteem 40mg cap 72 AMOXAPINE 100MG TAB
28
AMOXAPINE 150MG TAB
28
AMOXAPINE 25MG TAB 28 AMOXAPINE 50MG TAB 28 amoxicillin 1000mg/clavulanate 62.5mg er tab
98
amoxicillin 120mg/ml/clavulanate 8.58mg/ml oral susp
98
amoxicillin 125mg chew tab
97
AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB
98
amoxicillin 250mg cap 97 AMOXICILLIN 250MG CHEW TAB
97
amoxicillin 250mg/clavulanate 125mg tab
98
amoxicillin 25mg/ml oral susp
97
AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB
98
amoxicillin 40mg/ml oral susp
97
amoxicillin 40mg/ml/clavulanate 5.7mg/ml oral susp
98
amoxicillin 500mg cap 97 amoxicillin 500mg tab 97 amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack
106
amoxicillin 500mg/clavulanate 125mg tab
98
amoxicillin 50mg/ml oral susp
97
amoxicillin 50mg/ml/clavulanate 12.5mg/ml oral susp
98
amoxicillin 80mg/ml oral susp
97
amoxicillin 80mg/ml/clavulanate 11.4mg/ml oral susp
98
amoxicillin 875mg tab 97 amoxicillin 875mg/clavulanate 125mg tab
98
amphetamine 10mg er cap
7
amphetamine 10mg tab 7 amphetamine 12.5mg tab 7 amphetamine 15mg er cap
7
amphetamine 15mg tab 7 amphetamine 20mg er cap
7
amphetamine 20mg tab 7 amphetamine 25mg er cap
7
amphetamine 30mg er cap
7
amphetamine 30mg tab 7 amphetamine 5mg er cap 7 amphetamine 5mg tab 7 amphetamine 7.5mg tab 7
AMPHOTERICIN B 50MG INJ
33
ampicillin 100mg/ml inj 98 ampicillin 100mg/ml/sulbactam 50mg/ml inj
98
AMPICILLIN 125MG/ML INJ
98
ampicillin 20mg/ml/sulbactam 10mg/ml inj
98
ampicillin 250mg/ml inj 98 ampicillin 250mg/ml/sulbactam 125mg/ml inj
98
ampicillin 500mg cap 98 AMPYRA 10MG ER TAB 100 ANADROL-50 50MG TAB
15
anagrelide 0.5mg cap 85 anagrelide 1mg cap 85 anastrozole 1mg tab 45 ANDRODERM 2MG/24HR PATCH
15
ANDRODERM 4MG/24HR PATCH
15
ANDROGEL 1% (25MG) GEL
15
ANDROGEL 1% (50MG) GEL
15
ANDROGEL 1.62% (1.25GM) GEL
15
ANDROGEL 1.62% (2.5GM) GEL
15
ANDROGEL 1.62% GEL 15 ANORO 62.5-25MCG ELLIPTA INH
19
APLENZIN 174MG ER TAB
26
APLENZIN 348MG ER TAB
26
APLENZIN 522MG ER TAB
26
APOKYN 10MG/ML CARTRIDGE
51
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
112
ALPHABETICAL LISTING OF DRUGS
apraclonidine 0.5% ophth soln
94
aprepitant 125mg cap 33 aprepitant 125mg/80mg pack
33
aprepitant 40mg cap 33 aprepitant 80mg cap 33 apri 28 day pack 68 APRISO 0.375GM ER CAP
83
APTIOM 200MG TAB 22 APTIOM 400MG TAB 22 APTIOM 600MG TAB 22 APTIOM 800MG TAB 22 APTIVUS 100MG/ML ORAL SOLN
56
APTIVUS 250MG CAP 56 ARALAST 500MG INJ 101 aranelle 28 pack 68 ARANESP 100MCG/0.5ML SYRINGE
86
ARANESP 100MCG/ML INJ
86
ARANESP 10MCG/0.4ML SYRINGE
86
ARANESP 150MCG/0.3ML SYRINGE
86
ARANESP 200MCG/0.4ML SYRINGE
86
ARANESP 200MCG/ML INJ
86
ARANESP 25MCG/0.42ML SYRINGE
86
ARANESP 25MCG/ML INJ
86
ARANESP 300MCG/0.6ML SYRINGE
86
ARANESP 300MCG/ML INJ
86
ARANESP 40MCG/0.4ML SYRINGE
86
ARANESP 40MCG/ML INJ
86
ARANESP 500MCG/ML SYRINGE
86
ARANESP 60MCG/0.3ML SYRINGE
86
ARANESP 60MCG/ML INJ
86
ARCALYST 220MG INJ 9 argatroban 100mg/ml inj 22 ARGATROBAN 1MG/ML INJ
22
aripiprazole 10mg odt 56 aripiprazole 10mg tab 56 aripiprazole 15mg odt 56 aripiprazole 15mg tab 56 aripiprazole 1mg/ml oral soln
56
aripiprazole 20mg tab 56 aripiprazole 2mg tab 56 aripiprazole 30mg tab 56 aripiprazole 5mg tab 56 ARISTADA 273MG/ML SYRINGE
56
ARISTADA 441MG/1.6ML SYRINGE
56
ARISTADA 662MG/2.4ML SYRINGE
56
ARISTADA 882MG/3.2ML SYRINGE
56
armodafinil 150mg tab 8 armodafinil 200mg tab 8 armodafinil 250mg tab 8 armodafinil 50mg tab 8 ARNUITY 100MCG INH 19 ARNUITY 200MCG INH 19 ARRANON 5MG/ML INJ 44 ashlyna 91 day pack 68 ASMANEX 100MCG (120ACT) HFA INH
19
ASMANEX 110MCG (30ACT) INH
19
ASMANEX 200MCG (120ACT) HFA INH
19
ASMANEX 220MCG (120ACT) INH
19
ASMANEX 220MCG (30ACT) INH
19
ASMANEX 220MCG (60ACT) INH
19
aspirin 25mg/dipyridamole 200mg cap
85
aspirin 325mg/carisoprodol 200mg tab
92
aspirin 325mg/carisoprodol 200mg/codeine phosphate 16mg tab
92
aspirin 325mg/oxycodone 4.84mg tab
14
ASTAGRAF 0.5MG XL CAP
60
ASTAGRAF 1MG XL CAP 60 ASTAGRAF 5MG XL CAP 60 atazanavir 150mg cap 56 atazanavir 200mg cap 56 atazanavir 300mg cap 56 atenolol 100mg tab 62 atenolol 100mg/chlorthalidone 25mg tab
39
atenolol 25mg tab 62 atenolol 50mg tab 62 atenolol 50mg/chlorthalidone 25mg tab
39
ATGAM 50MG/ML INJ 60 atomoxetine 100mg cap 7 atomoxetine 10mg cap 7 atomoxetine 18mg cap 7 atomoxetine 25mg cap 7 atomoxetine 40mg cap 7 atomoxetine 60mg cap 7 atomoxetine 80mg cap 7 atorvastatin 10mg tab 35
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
113
ALPHABETICAL LISTING OF DRUGS
atorvastatin 20mg tab 35 atorvastatin 40mg tab 35 atorvastatin 80mg tab 35 atovaquone 150mg/ml oral susp
41
atovaquone 250mg/proguanil 100mg tab
42
atovaquone 62.5mg/proguanil 25mg tab
42
ATRIPLA 600-200-300MG TAB
56
atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln
32
atropine sulfate 0.025mg/diphenoxylate 2.5mg tab
32
ATROPINE SULFATE 0.05MG/ML SYRINGE
104
ATROPINE SULFATE 1% OPHTH SOLN
94
ATROVENT 17MCG INH 18 AUBAGIO 14MG TAB 100 AUBAGIO 7MG TAB 101 aubra 28 day pack 68 AUGMENTIN 125-31.25MG/5ML ORAL SUSP
98
AURYXIA 210MG TAB 84 AUSTEDO 12MG TAB 100 AUSTEDO 6MG TAB 100 AUSTEDO 9MG TAB 100 AVANDIA 2MG TAB 31 AVANDIA 4MG TAB 31 AVASTIN 100MG/4ML INJ
44
AVASTIN 400MG/16ML INJ
44
AVC BRAND OF SULFANILAMIDE 15% VAGINAL CREAM
107
AVELOX 400MG/250ML INJ
83
aviane 28 pack 68 avita 0.025% cream 72 avita 0.025% gel 72 AVONEX 30MCG/0.5ML AUTO-INJECTOR
101
AVONEX 30MCG/0.5ML SYRINGE
101
AVONEX 30MCG/VIAL INJ
101
AVYCAZ 2-0.5GM INJ 66 azacitidine 100mg inj 44 AZACTAM 1GM/50ML INJ
41
AZACTAM 2GM/50ML INJ
41
AZASAN 100MG TAB 60 AZASAN 75MG TAB 60 AZASITE 1% OPHTH SOLN
95
AZATHIOPRINE 10MG/ML INJ
91
azathioprine 50mg tab 60 azelastine 0.05% ophth soln
96
azelastine 0.1% (137mcg) nasal inhaler
92
azelastine 0.15% (205.5mcg) nasal inhaler
93
azithromycin 20mg/ml oral susp
88
azithromycin 250mg pack 88 azithromycin 250mg tab 88 azithromycin 2mg/ml inj 88 azithromycin 40mg/ml oral susp
88
azithromycin 500mg (3) tab pack
88
azithromycin 500mg tab 88 azithromycin 600mg tab 88 AZOPT 1% OPHTH SUSP 96 aztreonam 333mg/ml inj 41
B
baci-im 50000unit inj 41
BACITRACIN 0.5UNIT/MG OPHTH OINTMENT
95
bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment
95
bacitracin 5000unit/ml inj 41 baclofen 10mg tab 92 baclofen 20mg tab 92 balsalazide disodium 750mg cap
83
balziva 28 day pack 68 BANZEL 200MG TAB 22 BANZEL 400MG TAB 22 BANZEL 40MG/ML ORAL SUSP
22
BARACLUDE 0.05MG/ML ORAL SOLN
59
BAVENCIO 20MG/ML INJ
44
BAXDELA 450MG TAB 83 BCG, LIVE, TICE STRAIN 50MG/ML INJ
106
bekyree 28 day pack 68 BELEODAQ 500MG INJ 47 benazepril 10mg tab 36 benazepril 10mg/hydrochlorothiazide 12.5mg tab
39
benazepril 20mg tab 36 benazepril 20mg/hydrochlorothiazide 12.5mg tab
39
benazepril 20mg/hydrochlorothiazide 25mg tab
39
benazepril 40mg tab 36 benazepril 5mg tab 36 benazepril 5mg/hydrochlorothiazide 6.25mg tab
39
bendroflumethiazide 5mg/nadolol 40mg tab
39
bendroflumethiazide 5mg/nadolol 80mg tab
39
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
114
ALPHABETICAL LISTING OF DRUGS
BENLYSTA 120MG INJ 61 BENLYSTA 200MG/ML AUTO-INJECTOR
91
BENLYSTA 200MG/ML SYRINGE
91
BENLYSTA 400MG INJ 61 benztropine mesylate 0.5mg tab
50
benztropine mesylate 1mg tab
50
benztropine mesylate 1mg/ml inj
50
benztropine mesylate 2mg tab
50
BERINERT 500UNIT INJ 85 BESIVANCE 0.6% OPHTH SUSP
95
betamethasone 0.05% aug cream
75
betamethasone 0.05% aug gel
75
betamethasone 0.05% aug lotion
75
betamethasone 0.05% aug ointment
75
betamethasone 0.05% cream
75
betamethasone 0.05% lotion
75
betamethasone 0.05% ointment
75
betamethasone 0.1% cream
75
betamethasone 0.1% lotion
75
betamethasone 0.1% ointment
75
betamethasone valerate 0.12% foam
75
betamethasone/clotrimazole 1-0.05% cream
73
betamethasone/clotrimazole 1-0.05% lotion
73
betaxolol 0.5% ophth soln
94
betaxolol 10mg tab 62 betaxolol 20mg tab 62 bethanechol chloride 10mg tab
106
bethanechol chloride 25mg tab
106
bethanechol chloride 50mg tab
106
bethanechol chloride 5mg tab
106
BETIMOL 0.25% OPHTH SOLN
94
BETIMOL 0.5% OPHTH SOLN
94
BETOPTIC S 0.25% OPHTH SUSP
94
bexarotene 75mg cap 49 BEXSERO SYRINGE 106 bicalutamide 50mg tab 45 BICILLIN 300000-300000UNIT/ML SYRINGE
98
BICILLIN 450000-150000UNIT/ML SYRINGE
98
BICILLIN L-A 1200000UNIT/2ML SYRINGE
98
BICILLIN L-A 2400000UNIT/4ML SYRINGE
98
BICILLIN L-A 600000UNIT/ML SYRINGE
98
BICNU 100MG INJ 43 BIDIL 20-37.5MG TAB 65 BIKTARVY 50-200-25MG TAB
56
BIMATOPROST 0.03% OPHTH SOLN
96
bisoprolol fumarate 10mg tab
62
bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab
39
bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab
39
bisoprolol fumarate 5mg tab
62
bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab
39
BIVIGAM 10% INJ 97 bleomycin 15unit/ml inj 46 BLEPHAMIDE 10-0.2% OPHTH SUSP
95
blisovi 21 fe 1.5/30 28 day
68
blisovi 21 fe 1/20 28 day pack
68
blisovi 24 fe 1/20 28 day pack
68
BOOSTRIX INJ 104 BOOSTRIX SYRINGE 104 BORTEZOMIB 3.5MG INJ
47
BOSULIF 100MG TAB 47 BOSULIF 400MG TAB 47 BOSULIF 500MG TAB 47 BREO 100-25MCG ELLIPTA INH
19
BREO 200-25MCG ELLIPTA INH
20
briellyn 28 day pack 68 BRILINTA 60MG TAB 85 BRILINTA 90MG TAB 85 brimonidine tartrate 0.15% ophth soln
94
brimonidine tartrate 0.2% ophth soln
94
BRIVIACT 100MG TAB 22 BRIVIACT 10MG TAB 22 BRIVIACT 10MG/ML INJ 22 BRIVIACT 10MG/ML ORAL SOLN
22
BRIVIACT 25MG TAB 22 BRIVIACT 50MG TAB 22 BRIVIACT 75MG TAB 22 bromocriptine 2.5mg tab 51
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
115
ALPHABETICAL LISTING OF DRUGS
bromocriptine 5mg cap 51 BROVANA 15MCG/2ML INH SOLN
20
budesonide 0.125mg/ml inh soln
19
budesonide 0.25mg/ml inh soln
19
budesonide 0.5mg/ml inh soln
19
budesonide 3mg dr cap 71 bumetanide 0.25mg/ml inj 78 bumetanide 0.5mg tab 78 bumetanide 1mg tab 78 bumetanide 2mg tab 78 BUNAVAIL 2.1-0.3MG FILM
14
BUNAVAIL 4.2-0.7MG FILM
14
BUNAVAIL 6.3-1MG FILM
14
buprenorphine 0.3mg/ml cartridge
14
buprenorphine 0.3mg/ml inj
14
buprenorphine 2mg sl tab 15 buprenorphine 8mg sl tab 15 bupropion 100mg sr tab 26 bupropion 100mg tab 26 bupropion 150mg sr (12 hr) tab
26
bupropion 150mg sr tab 101 bupropion 150mg xl (24 hr) tab
26
bupropion 200mg sr tab 26 bupropion 300mg xl tab 26 bupropion 75mg tab 26 buspirone 10mg tab 16 buspirone 15mg tab 16 buspirone 30mg tab 16 buspirone 5mg tab 16 buspirone 7.5mg tab 16 busulfan 6mg/ml inj 43 BUTISOL 30MG TAB 87 butorphanol tartrate 10mg/ml nasal spray
15
BUTORPHANOL TARTRATE 1MG/ML INJ
15
butorphanol tartrate 2mg/ml inj
15
BYDUREON 2.35MG/ML AUTO-INJECTOR
30
BYDUREON 2MG INJ 30 BYDUREON 2MG PEN INJ
30
BYSTOLIC 10MG TAB 62 BYSTOLIC 2.5MG TAB 62 BYSTOLIC 20MG TAB 62 BYSTOLIC 5MG TAB 62
C
cabergoline 0.5mg tab 81 CABOMETYX 20MG TAB
47
CABOMETYX 40MG TAB
47
CABOMETYX 60MG TAB
47
calcipotriene 0.005% cream
74
calcipotriene 0.005% ointment
74
calcipotriene 0.005% topical soln
74
calcipotriene/betamethasone 0.005-0.064% ointment
75
calcitriol 0.00025mg cap 80 calcitriol 0.0005mg cap 80 calcitriol 0.001mg/ml inj 80 calcitriol 0.001mg/ml oral soln
80
calcium acetate 667mg cap
84
calcium acetate 667mg tab
84
calcium chloride 0.002 meq/ml/potassium chloride 0.004 meq/ml/sodium chloride 0.147 meq/ml inj
90
calcium chloride 0.002 meq/ml/potassium chloride 0.004 meq/ml/sodium chloride 0.147 meq/ml soln
61
CALQUENCE 100MG CAP
47
camila 28 day 0.35mg pack
71
camrese lo 91 day pack 68 CANASA 1000MG RECTAL SUPP
83
CANCIDAS 50MG INJ 33 CANCIDAS 70MG INJ 33 candesartan cilexetil 16mg tab
37
candesartan cilexetil 16mg/hydrochlorothiazide 12.5mg tab
39
candesartan cilexetil 32mg tab
37
candesartan cilexetil 32mg/hydrochlorothiazide 12.5mg tab
39
candesartan cilexetil 32mg/hydrochlorothiazide 25mg tab
39
candesartan cilexetil 4mg tab
37
candesartan cilexetil 8mg tab
37
CAPASTAT 1GM INJ 43 CAPRELSA 100MG TAB 47 CAPRELSA 300MG TAB 47 captopril 100mg tab 36 captopril 12.5mg tab 36 captopril 25mg tab 36 captopril 25mg/hydrochlorothiazide 15mg tab
39
CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE 25MG TAB
39
captopril 50mg tab 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
116
ALPHABETICAL LISTING OF DRUGS
captopril 50mg/hydrochlorothiazide 15mg tab
39
CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE 25MG TAB
39
CARBAGLU 200MG ORAL SUSP
80
carbamazepine 100mg chew tab
22
carbamazepine 100mg er cap
22
carbamazepine 100mg er tab
23
carbamazepine 200mg er cap
23
carbamazepine 200mg er tab
23
carbamazepine 200mg tab
23
carbamazepine 20mg/ml oral susp
23
carbamazepine 300mg er cap
23
carbamazepine 400mg er tab
23
carbidopa 10mg/levodopa 100mg odt
51
carbidopa 10mg/levodopa 100mg tab
51
CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB
51
CARBIDOPA 18.75MG/ENTACAPONE 200MG/LEVODOPA 75MG TAB
51
carbidopa 25mg tab 50 CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB
51
carbidopa 25mg/levodopa 100mg er tab
51
carbidopa 25mg/levodopa 100mg odt
51
carbidopa 25mg/levodopa 100mg tab
51
carbidopa 25mg/levodopa 250mg odt
51
carbidopa 25mg/levodopa 250mg tab
51
CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB
51
CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB
51
CARBIDOPA 50MG/ENTACAPONE 200MG/LEVODOPA 200MG TAB
51
carbidopa 50mg/levodopa 200mg er tab
51
carbinoxamine maleate 0.8mg/ml oral soln
34
carbinoxamine maleate 4mg tab
34
carboplatin 10mg/ml inj 43 CARDENE 20MG/200ML INJ
63
CARDENE 40MG/200ML INJ
63
CARIMUNE 6GM INJ 97 carisoprodol 350mg tab 92 carteolol 1% ophth soln 94 cartia 120mg er cap 63 cartia 180mg er cap 63 cartia 240mg er cap 63
cartia 300mg er cap 63 carvedilol 12.5mg tab 61 carvedilol 25mg tab 61 carvedilol 3.125mg tab 62 carvedilol 6.25mg tab 62 CASPOFUNGIN ACETATE 50MG INJ
33
CASPOFUNGIN ACETATE 70MG INJ
33
CAYSTON 75MG INH SOLN
41
caziant 28 day pack 68 cefaclor 250mg cap 66 CEFACLOR 25MG/ML ORAL SUSP
66
cefaclor 500mg cap 66 cefaclor 50mg/ml oral susp
66
CEFACLOR 75MG/ML ORAL SUSP
66
cefadroxil 1000mg tab 66 cefadroxil 100mg/ml oral susp
66
cefadroxil 500mg cap 66 cefadroxil 50mg/ml oral susp
66
cefazolin 1gm inj 66 cefazolin 200mg/ml inj 66 cefazolin 500mg inj 66 cefdinir 25mg/ml oral susp
67
cefdinir 300mg cap 67 cefdinir 50mg/ml oral susp
67
cefepime 1gm inj 67 cefepime 2gm inj 67 cefixime 20mg/ml oral susp
67
cefixime 40mg/ml oral susp
67
CEFOTAXIME 1GM INJ 67 CEFOTAXIME 2GM INJ 67 CEFOTAXIME 500MG INJ
67
cefotetan 1000mg inj 66
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
117
ALPHABETICAL LISTING OF DRUGS
cefotetan 2000mg inj 66 cefoxitin 1000mg inj 66 cefoxitin 2000mg inj 66 cefoxitin 200mg/ml inj 66 cefpodoxime 100mg tab 67 cefpodoxime 10mg/ml oral susp
67
cefpodoxime 200mg tab 67 cefpodoxime 20mg/ml oral susp
67
cefprozil 250mg tab 67 cefprozil 25mg/ml oral susp
67
cefprozil 500mg tab 67 cefprozil 50mg/ml oral susp
67
ceftazidime 1000mg inj 67 ceftazidime 2000mg inj 67 ceftazidime 200mg/ml inj 67 ceftriaxone 1000mg inj 67 ceftriaxone 100mg/ml inj 67 ceftriaxone 2000mg inj 67 ceftriaxone 250mg inj 67 ceftriaxone 500mg inj 67 cefuroxime 1.5gm inj 67 cefuroxime 250mg tab 67 cefuroxime 500mg tab 67 cefuroxime 750mg inj 67 cefuroxime 95mg/ml inj 67 celecoxib 100mg cap 9 celecoxib 200mg cap 9 celecoxib 400mg cap 9 celecoxib 50mg cap 9 CELONTIN 300MG CAP 25 cephalexin 250mg cap 66 cephalexin 25mg/ml oral susp
66
cephalexin 500mg cap 66 cephalexin 50mg/ml oral susp
66
CEREZYME 400UNIT INJ 86 CESAMET 1MG CAP 33 cetirizine 1mg/ml oral soln
34
CETRAXAL 0.2% OTIC SOLN
96
cevimeline 30mg cap 92 CHANTIX 0.5MG TAB 101 CHANTIX 1MG TAB 101 CHANTIX CONTINUING MONTHS OF THERAPY 1MG PACK
101
CHANTIX FIRST MONTH OF THERAPY PACK
101
CHEMET 100MG CAP 32 CHENODAL 250MG TAB 83 CHLORAMPHENICOL 100MG/ML INJ
42
chlordiazepoxide 10mg cap
17
chlordiazepoxide 25mg cap
17
chlordiazepoxide 5mg cap
17
chlorhexidine gluconate 0.12% mouthwash
92
CHLOROQUINE PHOSPHATE 250MG TAB
42
chloroquine phosphate 500mg tab
42
CHLOROTHIAZIDE 250MG TAB
78
chlorothiazide 500mg inj 78 chlorothiazide 500mg tab 78 chlorpromazine 100mg tab
55
chlorpromazine 10mg tab 55 chlorpromazine 200mg tab
55
chlorpromazine 25mg tab 55 CHLORPROMAZINE 25MG/ML INJ
55
chlorpromazine 50mg tab 55 CHLORPROPAMIDE 100MG TAB
31
CHLORPROPAMIDE 250MG TAB
31
chlorthalidone 25mg tab 78
chlorthalidone 50mg tab 78 chlorzoxazone 500mg tab 92 CHOLBAM 250MG CAP 83 CHOLBAM 50MG CAP 83 cholestyramine resin 4gm sf powder for oral susp
35
cholestyramine resin 66.7mg/ml oral susp
35
ciclopirox 0.77% cream 73 ciclopirox 0.77% gel 74 ciclopirox 0.77% lotion 74 ciclopirox 1% shampoo 74 ciclopirox 8% topical soln 74 cidofovir 75mg/ml inj 59 cilastatin 2.5mg/ml/imipenem 2.5mg/ml inj
41
cilastatin 5mg/ml/imipenem 5mg/ml inj
41
cilostazol 100mg tab 85 cilostazol 50mg tab 86 cimetidine 200mg tab 105 cimetidine 300mg tab 105 cimetidine 400mg tab 105 cimetidine 60mg/ml oral soln
105
cimetidine 800mg tab 105 CINRYZE 500UNIT INJ 85 CIPRODEX 0.3-0.1% OTIC SUSP
96
CIPROFLOXACIN 0.2% OTIC SOLN
96
ciprofloxacin 0.3% ophth soln
95
ciprofloxacin 100mg/ml oral susp
83
ciprofloxacin 250mg tab 83 ciprofloxacin 2mg/ml inj 83 ciprofloxacin 500mg tab 83 ciprofloxacin 50mg/ml oral susp
83
ciprofloxacin 750mg tab 83 cisplatin 1mg/ml inj 43 citalopram 10mg tab 26
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
118
ALPHABETICAL LISTING OF DRUGS
citalopram 20mg tab 26 citalopram 2mg/ml oral soln
26
citalopram 40mg tab 26 cladribine 1mg/ml inj 44 claravis 10mg cap 72 claravis 20mg cap 72 claravis 30mg cap 73 claravis 40mg cap 73 CLARINEX-D 2.5-120MG ER TAB
72
clarithromycin 250mg tab 88 clarithromycin 25mg/ml oral susp
88
clarithromycin 500mg er tab
88
clarithromycin 500mg tab 88 clarithromycin 50mg/ml oral susp
88
CLEMASTINE FUMARATE 2.68MG TAB
34
clindacin 1% pad 73 clindamycin 1% foam 73 clindamycin 1% gel 73 clindamycin 1% lotion 73 clindamycin 1% pad 73 clindamycin 1% topical soln
73
clindamycin 12mg/ml inj 42 clindamycin 150mg cap 42 clindamycin 150mg/ml (2ml) inj
42
clindamycin 150mg/ml (4ml) inj
42
clindamycin 150mg/ml (6ml) inj
42
clindamycin 15mg/ml oral soln
42
clindamycin 18mg/ml inj 42 clindamycin 2% vaginal cream
107
clindamycin 300mg cap 42 clindamycin 6mg/ml inj 42 clindamycin 75mg cap 42
clindamycin/benzoyl peroxide 1-5% gel
73
CLINIMIX 4.25/10 INJ 93 CLINIMIX 4.25/20 INJ 93 CLINIMIX 4.25/25 INJ 93 CLINIMIX 4.25/5 INJ 93 CLINIMIX 5/15 INJ 93 CLINIMIX 5/20 INJ 93 CLINIMIX 5/25 INJ 93 CLINIMIX E 2.75/10 INJ 93 CLINIMIX E 2.75/5 INJ 93 CLINIMIX E 4.25/10 INJ 93 CLINIMIX E 4.25/25 INJ 93 CLINIMIX E 4.25/5 INJ 93 CLINIMIX E 5/15 INJ 93 CLINIMIX E 5/20 INJ 94 CLINIMIX E 5/25 INJ 94 clinisol 15% inj 94 clobetasol propionate 0.05% cream
75
clobetasol propionate 0.05% foam
75
clobetasol propionate 0.05% gel
75
clobetasol propionate 0.05% lotion
75
clobetasol propionate 0.05% ointment
75
clobetasol propionate 0.05% shampoo
75
clobetasol propionate 0.05% spray
75
clobetasol propionate 0.05% topical soln
75
clodan 0.05% shampoo 75 clofarabine 1mg/ml inj 44 CLOLAR 1MG/ML INJ 44 clomipramine 25mg cap 28 clomipramine 50mg cap 28 clomipramine 75mg cap 28 clonazepam 0.125mg odt 22 clonazepam 0.25mg odt 22 clonazepam 0.5mg odt 22 clonazepam 0.5mg tab 22 clonazepam 1mg odt 22
clonazepam 1mg tab 22 clonazepam 2mg odt 22 clonazepam 2mg tab 22 clonidine 0.00417mg/hr patch
38
clonidine 0.00833mg/hr patch
38
clonidine 0.0125mg/hr patch
38
clonidine 0.1mg tab 38 clonidine 0.2mg tab 38 clonidine 0.3mg tab 38 clopidogrel 75mg tab 86 clorazepate dipotassium 15mg tab
17
clorazepate dipotassium 3.75mg tab
17
clorazepate dipotassium 7.5mg tab
17
clotrimazole 1% cream 74 clotrimazole 1% topical soln
74
clotrimazole 10mg lozenge
92
clozapine 100mg odt 54 clozapine 100mg tab 54 CLOZAPINE 12.5MG ODT
54
CLOZAPINE 150MG ODT
54
CLOZAPINE 200MG ODT
54
clozapine 200mg tab 54 clozapine 25mg odt 54 clozapine 25mg tab 54 clozapine 50mg tab 54 COARTEM 20-120MG TAB
42
codeine sulfate 15mg tab 11 codeine sulfate 30mg tab 11 codeine sulfate 60mg tab 11 colchicine 0.5mg/probenecid 500mg tab
85
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
119
ALPHABETICAL LISTING OF DRUGS
COLCHICINE 0.6MG CAP
85
COLCHICINE 0.6MG TAB
85
colestipol 1000mg tab 35 colestipol 5000mg granules
35
colistin 75mg/ml inj 41 colocort 100mg/60ml enema
15
COLY MYCIN S 3.3-3-10-0.5MG/ML OTIC SUSP
96
COMBIGAN 0.2-0.5% OPHTH SOLN
94
COMBIPATCH 0.05-0.14MG PATCH
82
COMBIPATCH 0.05-0.25MG PATCH
82
COMBIVENT RESPIMAT 20-100MCG INH
20
COMETRIQ 100MG DAILY DOSE CARTON PACK
47
COMETRIQ 140MG DAILY DOSE CARTON PACK
47
COMETRIQ 60MG DAILY DOSE CARTON PACK
47
COMPLERA 200-25-300MG TAB
56
compro 25mg rectal supp 55 constulose 10gm/15ml oral soln
88
COPAXONE 20MG/ML SYRINGE
101
COPAXONE 40MG/ML SYRINGE
101
CORLANOR 5MG TAB 66 CORLANOR 7.5MG TAB 66 CORTISONE ACETATE 25MG TAB
71
COSENTYX 150MG/ML AUTO-INJECTOR
74
COSENTYX 150MG/ML SYRINGE
74
COSMEGEN 0.5MG INJ 46 COTELLIC 20MG TAB 47 CREON 12000-38000-60000UNIT DR CAP
77
CREON 24000-76000-120000UNIT DR CAP
77
CREON 3000-9500-15000UNIT DR CAP
77
CREON 36000-114000-180000UNIT DR CAP
77
CREON 6000-19000-30000UNIT DR CAP
77
CRINONE 4% VAGINAL GEL
108
CRINONE 8% VAGINAL GEL
108
CRIXIVAN 200MG CAP 57 CRIXIVAN 400MG CAP 57 CROMOLYN SODIUM 10MG/ML INH SOLN
18
cromolyn sodium 20mg/ml oral soln
83
cromolyn sodium 4% ophth soln
96
cryselle 28 pack 68 CUBICIN 500MG INJ 42 cyclafem 1/35 28 day pack
68
cyclafem 7/7/7 28 day pack
68
cyclobenzaprine 10mg tab
92
cyclobenzaprine 5mg tab 92 cyclobenzaprine 7.5mg tab
92
CYCLOPHOSPHAMIDE 25MG CAP
43
CYCLOPHOSPHAMIDE 50MG CAP
43
cyclosporine 100mg cap 60 cyclosporine 25mg cap 60 cyclosporine 50mg/ml inj 60 cyclosporine, modified 100mg cap
60
cyclosporine, modified 100mg/ml oral soln
60
cyclosporine, modified 25mg cap
60
cyproheptadine 0.4mg/ml oral soln
34
cyproheptadine 4mg tab 34 CYRAMZA 100MG/10ML INJ
44
CYRAMZA 500MG/50ML INJ
44
CYSTAGON 150MG CAP 84 CYSTAGON 50MG CAP 84 CYSTARAN 0.44% OPHTH SOLN
96
cytarabine 100mg/ml inj 44 CYTARABINE 20MG/ML INJ
44
D
d5w/lactated ringers inj 90 dacarbazine 200mg inj 49 dactinomycin 0.5mg inj 46 DALIRESP 250MCG TAB 19 DALIRESP 500MCG TAB 19 DALVANCE 500MG INJ 41 danazol 100mg cap 15 danazol 200mg cap 15 danazol 50mg cap 15 dantrolene sodium 100mg cap
92
dantrolene sodium 25mg cap
92
dantrolene sodium 50mg cap
92
dapsone 100mg tab 42 dapsone 25mg tab 42 DAPTACEL INJ 104
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
120
ALPHABETICAL LISTING OF DRUGS
daptomycin 500mg inj 42 DARAPRIM 25MG TAB 42 DARZALEX 100MG/5ML INJ
44
daunorubicin 5mg/ml inj 46 deblitane 28 day 0.35mg pack
71
decitabine 5mg/ml inj 44 delyla 28 day pack 68 demeclocycline 150mg tab
102
demeclocycline 300mg tab
102
DEMSER 250MG CAP 37 DENAVIR 1% CREAM 75 DEPEN 250MG TAB 60 DEPO-PROVERA 400MG/ML INJ
45
DESCOVY 200-25MG TAB
57
desipramine 100mg tab 28 desipramine 10mg tab 28 desipramine 150mg tab 28 desipramine 25mg tab 28 desipramine 50mg tab 28 desipramine 75mg tab 28 desloratadine 5mg tab 34 desmopressin acetate 0.004mg/ml inj
81
desmopressin acetate 0.01% nasal soln
81
desmopressin acetate 0.01% nasal spray
81
desmopressin acetate 0.1mg tab
81
desmopressin acetate 0.2mg tab
81
desogestrel/ethinyl estradiol 28 day pack
68
desogestrel/ethinyl estradiol pack
68
desonide 0.05% cream 75 desonide 0.05% lotion 75 desonide 0.05% ointment 75
desoximetasone 0.05% cream
75
desoximetasone 0.05% gel
75
desoximetasone 0.25% cream
76
desoximetasone 0.25% ointment
76
DESVENLAFAXINE FUMARATE 100MG ER TAB
27
DESVENLAFAXINE FUMARATE 50MG ER TAB
27
desvenlafaxine succinate 100mg er tab
28
desvenlafaxine succinate 25mg er tab
28
desvenlafaxine succinate 50mg er tab
28
DEXAMETHASONE 0.1% OPHTH SOLN
95
dexamethasone 0.1mg/ml oral soln
71
dexamethasone 0.5mg tab 71 dexamethasone 0.75mg tab
71
dexamethasone 1.5mg tab 71 DEXAMETHASONE 10MG/ML INJ
71
DEXAMETHASONE 1MG TAB
71
DEXAMETHASONE 1MG/ML ORAL SOLN
71
DEXAMETHASONE 2MG TAB
71
dexamethasone 4mg tab 71 dexamethasone 6mg tab 71 dexamethasone phosphate 4mg/ml inj
71
dexamethasone/neomycin/polymyxin b 0.1% ophth ointment
95
dexamethasone/neomycin/polymyxin b 0.1% ophth susp
95
dexamethasone/tobramycin 0.3-0.1% ophth susp
95
dexmethylphenidate 10mg er cap
8
dexmethylphenidate 10mg tab
8
dexmethylphenidate 15mg er cap
8
dexmethylphenidate 2.5mg tab
8
dexmethylphenidate 20mg er cap
8
dexmethylphenidate 30mg er cap
8
dexmethylphenidate 40mg er cap
8
dexmethylphenidate 5mg er cap
8
dexmethylphenidate 5mg tab
8
dexrazoxane 250mg inj 50 dextroamphetamine sulfate 10mg er cap
7
dextroamphetamine sulfate 10mg tab
7
dextroamphetamine sulfate 15mg er cap
7
dextroamphetamine sulfate 5mg er cap
7
dextroamphetamine sulfate 5mg tab
7
DIASTAT 10MG APPLICATOR
22
DIASTAT 2.5MG APPLICATOR
22
DIASTAT 20MG PF APPLICATOR
22
diazepam 10mg tab 17 DIAZEPAM 1MG/ML ORAL SOLN
17
diazepam 2mg tab 17 diazepam 5mg tab 17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
121
ALPHABETICAL LISTING OF DRUGS
diazepam 5mg/ml oral soln
17
diclofenac potassium 50mg tab
9
diclofenac sodium 0.1% ophth soln
96
diclofenac sodium 1% gel 74 diclofenac sodium 1.5% topical soln
74
diclofenac sodium 100mg er tab
9
diclofenac sodium 25mg dr tab
10
diclofenac sodium 3% gel 74 diclofenac sodium 50mg dr tab
10
diclofenac sodium 50mg/misoprostol 0.2mg tab
10
diclofenac sodium 75mg dr tab
10
diclofenac sodium 75mg/misoprostol 0.2mg tab
10
dicloxacillin 250mg cap 99 dicloxacillin 500mg cap 99 dicyclomine 10mg cap 104 dicyclomine 20mg tab 104 dicyclomine 2mg/ml oral soln
104
didanosine 200mg dr cap 57 didanosine 250mg dr cap 57 didanosine 400mg dr cap 57 DIFFERIN 0.1% LOTION 73 DIFLORASONE DIACETATE 0.05% CREAM
76
DIFLORASONE DIACETATE 0.05% OINTMENT
76
diflunisal 500mg tab 11 digitek 0.125mg tab 65 digitek 0.25mg tab 65 digox 0.125mg tab 65 digox 0.25mg tab 65
digoxin 0.05mg/ml oral soln
65
digoxin 0.125mg tab 65 digoxin 0.25mg tab 65 digoxin 0.25mg/ml inj 65 DIHYDROERGOTAMINE MESYLATE 0.5MG/ACT NASAL SPRAY
89
DILANTIN 30MG ER CAP
25
dilt 120mg xr cap 63 dilt 180mg xr cap 63 dilt 240mg xr cap 63 diltiazem 120mg er (12 hr) cap
63
diltiazem 120mg er (24 hr) cap
63
diltiazem 120mg tab 63 diltiazem 180mg er cap 63 DILTIAZEM 1MG/ML INJ 63 diltiazem 240mg er cap 63 diltiazem 300mg er cap 63 diltiazem 30mg tab 63 diltiazem 360mg er cap 63 diltiazem 420mg er cap 63 diltiazem 5mg/ml inj 63 diltiazem 60mg er cap 63 diltiazem 60mg tab 63 diltiazem 90mg er cap 64 diltiazem 90mg tab 64 DIPENTUM 250MG CAP 83 diphenhydramine 50mg/ml inj
34
DIPHTHERIA/TETANUS TOXOID INJ
104
dipyridamole 25mg tab 86 dipyridamole 50mg tab 86 dipyridamole 75mg tab 86 disopyramide 100mg cap 17 disopyramide 150mg cap 17 disulfiram 250mg tab 99 disulfiram 500mg tab 99 DIURIL 250MG/5ML ORAL SUSP
78
divalproex sodium 125mg dr cap
25
divalproex sodium 125mg dr tab
25
divalproex sodium 250mg dr tab
25
divalproex sodium 250mg er tab
26
divalproex sodium 500mg dr tab
26
divalproex sodium 500mg er tab
26
DOCETAXEL 10MG/ML INJ
50
DOCETAXEL 20MG/ML INJ
50
dofetilide 125mcg cap 18 dofetilide 250mcg cap 18 dofetilide 500mcg cap 18 donepezil 10mg odt 99 donepezil 10mg tab 99 donepezil 23mg tab 99 donepezil 5mg odt 99 donepezil 5mg tab 99 DORIPENEM 500MG INJ 41 dorzolamide 2% ophth soln
96
dorzolamide 20mg/ml/timolol 5mg/ml ophth soln
94
doxazosin 1mg tab 38 doxazosin 2mg tab 38 doxazosin 4mg tab 38 doxazosin 8mg tab 38 doxepin 100mg cap 29 doxepin 10mg cap 29 doxepin 10mg/ml oral soln
29
doxepin 150mg cap 29 doxepin 25mg cap 29 doxepin 50mg cap 29 DOXEPIN 75MG CAP 29 doxercalciferol 0.0005mg cap
80
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
122
ALPHABETICAL LISTING OF DRUGS
doxercalciferol 0.001mg cap
80
doxercalciferol 0.0025mg cap
80
doxercalciferol 0.002mg/ml inj
80
doxorubicin 2mg/ml liposome inj
46
doxorubicin hydrochloride 2mg/ml inj
46
doxy 100mg inj 102 doxycycline hyclate 100mg cap
102
doxycycline hyclate 100mg tab
102
doxycycline hyclate 20mg tab
102
doxycycline hyclate 50mg cap
102
doxycycline monohydrate 100mg cap
102
doxycycline monohydrate 100mg tab
102
doxycycline monohydrate 50mg cap
102
doxycycline monohydrate 50mg tab
102
doxycycline monohydrate 5mg/ml oral susp
102
doxycycline monohydrate 75mg tab
102
dronabinol 10mg cap 33 dronabinol 2.5mg cap 33 dronabinol 5mg cap 33 drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg pack
68
drospirenone 3mg/ethinyl estradiol 0.02mg/levomefolate calcium 0.451mg pack
68
drospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg pack
68
DROXIA 200MG CAP 86
DROXIA 300MG CAP 86 DROXIA 400MG CAP 86 DULERA 100-5MCG INH 20 DULERA 200-5MCG INH 20 duloxetine 20mg dr cap 28 duloxetine 30mg dr cap 28 DULOXETINE 40MG DR CAP
28
duloxetine 60mg dr cap 28 DUPIXENT 300MG/2ML SYRINGE
76
duramorph 0.5mg/ml inj 11 duramorph 1mg/ml inj 11 DUREZOL 0.05% OPHTH SUSP
95
dutasteride 0.5mg cap 85 dutasteride 0.5mg/tamsulosin 0.4mg cap
85
DYRENIUM 100MG CAP 78 DYRENIUM 50MG CAP 78
E
econazole nitrate 1% cream
74
EDURANT 25MG TAB 57 efavirenz 200mg cap 57 efavirenz 50mg cap 57 efavirenz 600mg cap 57 ELAPRASE 6MG/3ML INJ
80
ELIDEL 1% CREAM 77 ELIGARD 22.5MG SYRINGE
45
ELIGARD 30MG SYRINGE
45
ELIGARD 45MG SYRINGE
45
ELIGARD 7.5MG SYRINGE
45
ELIQUIS 2.5MG TAB 21 ELIQUIS 30-DAY STARTER PACK
21
ELIQUIS 5MG TAB 21 ELITEK 1.5MG INJ 50
ELITEK 7.5MG INJ 50 ELMIRON 100MG CAP 85 EMBEDA 100-4MG ER CAP
11
EMBEDA 20-0.8MG ER CAP
11
EMBEDA 30-1.2MG ER CAP
11
EMBEDA 50-2MG ER CAP
11
EMBEDA 60-2.4MG ER CAP
11
EMBEDA 80-3.2MG ER CAP
11
EMCYT 140MG CAP 45 emoquette pack 68 EMPLICITI 300MG INJ 44 EMPLICITI 400MG INJ 44 EMSAM 12MG/24HR PATCH
26
EMSAM 6MG/24HR PATCH
26
EMSAM 9MG/24HR PATCH
26
EMTRIVA 10MG/ML ORAL SOLN
57
EMTRIVA 200MG CAP 57 enalapril maleate 10mg tab
36
enalapril maleate 10mg/hydrochlorothiazide 25mg tab
39
enalapril maleate 2.5mg tab
36
enalapril maleate 20mg tab
36
enalapril maleate 5mg tab
36
enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab
39
ENBREL 25MG INJ 11 ENBREL 25MG/0.5ML SYRINGE
11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
123
ALPHABETICAL LISTING OF DRUGS
ENBREL 50MG/ML SURECLICK INJ
11
ENBREL 50MG/ML SYRINGE
11
endocet 10-325mg tab 14 endocet 5-325mg tab 14 endocet 7.5-325mg tab 14 ENGERIX-B 10MCG/0.5ML SYRINGE
107
ENGERIX-B 20MCG/ML SYRINGE
107
enoxaparin sodium 100mg/1ml syringe
21
enoxaparin sodium 120mg/0.8ml syringe
21
enoxaparin sodium 150mg/1ml syringe
21
enoxaparin sodium 300mg/3ml syringe
21
enoxaparin sodium 30mg/0.3ml syringe
21
enoxaparin sodium 40mg/0.4ml syringe
21
enoxaparin sodium 60mg/0.6ml syringe
21
enoxaparin sodium 80mg/0.8ml syringe
21
enpresse 28 day pack 68 enskyce 28 day pack 68 entacapone 200mg tab 51 entecavir 0.5mg tab 59 entecavir 1mg tab 59 ENTRESTO 24-26MG TAB
65
ENTRESTO 49-51MG TAB
65
ENTRESTO 97-103MG TAB
65
enulose 10gm/15ml oral soln
84
ENVARSUS 0.75MG ER TAB
60
ENVARSUS 1MG ER TAB 60 ENVARSUS 4MG ER TAB 60
EPCLUSA 400-100MG TAB
59
EPIDUO 0.3-2.5% GEL 73 EPIDUO 0.1-2.5% GEL 73 epinastine 0.05% ophth soln
96
EPINEPHRINE 0.15MG/0.3ML AUTO-INJECTOR
108
EPINEPHRINE 0.3MG/0.3ML AUTO-INJECTOR
108
epirubicin 2mg/ml inj 46 epitol 200mg tab 23 EPIVIR HBV 5MG/ML ORAL SOLN
59
eplerenone 25mg tab 40 eplerenone 50mg tab 40 EPOGEN 10000UNIT/ML INJ
86
EPOGEN 20000UNIT/ML INJ
86
EPOGEN 2000UNIT/ML INJ
86
EPOGEN 3000UNIT/ML INJ
86
EPOGEN 4000UNIT/ML INJ
86
EPROSARTAN 600MG TAB
37
EPZICOM 600-300MG TAB
57
EQUETRO 100MG ER CAP
52
EQUETRO 200MG ER CAP
52
EQUETRO 300MG ER CAP
52
ERAXIS 100MG INJ 33 ERAXIS 50MG INJ 33 ERBITUX 100MG/50ML INJ
44
ERGOLOID MESYLATES 1MG TAB
101
ERIVEDGE 150MG CAP 45
ERLEADA 60MG TAB 45 errin 28 day 0.35mg pack 71 ERTACZO 2% CREAM 74 ERWINAZE 10000UNIT INJ
49
ery 2% pad 73 ERYPED 400MG/5ML ORAL SUSP
88
ERY-TAB 250MG DR TAB
88
ERY-TAB 333MG DR TAB
88
ERY-TAB 500MG DR TAB
88
ERYTHROCIN LACTOBIONATE 500MG INJ
88
erythromycin 0.005mg/mg ophth ointment
95
erythromycin 2% gel 73 erythromycin 2% topical soln
73
erythromycin 250mg dr cap
88
ERYTHROMYCIN 250MG TAB
88
ERYTHROMYCIN 500MG TAB
89
erythromycin ethylsuccinate 40mg/ml oral susp
89
erythromycin/benzoyl peroxide 5-3% gel
73
ESBRIET 267MG CAP 102 ESBRIET 267MG TAB 102 ESBRIET 801MG TAB 102 escitalopram 10mg tab 26 escitalopram 1mg/ml oral soln
26
escitalopram 20mg tab 26 escitalopram 5mg tab 26 esomeprazole 20mg dr cap 105 ESOMEPRAZOLE 20MG INJ
105
esomeprazole 40mg dr cap 105
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
124
ALPHABETICAL LISTING OF DRUGS
esomeprazole 40mg inj 105 estarylla 28 day pack 68 estazolam 1mg tab 87 estazolam 2mg tab 87 estradiol 0.00104mg/hr twice weekly patch
82
estradiol 0.00104mg/hr weekly patch
82
estradiol 0.00156mg/hr twice weekly patch
82
estradiol 0.00156mg/hr weekly patch
82
estradiol 0.00208mg/hr twice weekly patch
82
estradiol 0.00208mg/hr weekly patch
82
estradiol 0.0025mg/hr weekly patch
82
estradiol 0.00312mg/hr weekly patch
82
estradiol 0.00313mg/hr twice weekly patch
82
estradiol 0.00417mg/hr twice weekly patch
82
estradiol 0.00417mg/hr weekly patch
82
estradiol 0.1mg/ml vaginal cream
108
estradiol 0.5mg tab 82 estradiol 0.5mg/norethindrone acetate 0.1mg pack
82
estradiol 1mg tab 82 estradiol 1mg/norethindrone acetate 0.5mg pack
82
estradiol 20mg/ml inj 82 estradiol 2mg tab 82 estradiol 40mg/ml inj 82 ESTRING 2MG VAGINAL RING
108
ESTROPIPATE 0.75MG TAB
82
ESTROPIPATE 1.5MG TAB
82
ESTROPIPATE 3MG TAB 82 eszopiclone 1mg tab 87 eszopiclone 2mg tab 87 eszopiclone 3mg tab 87 ethacrynic acid 25mg tab 78 ethambutol 100mg tab 43 ethambutol 400mg tab 43 ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mg tab
82
ethinyl estradiol 0.005mg/norethindrone acetate 1mg tab
82
ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack
68
ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack
68
ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack
68
ethinyl estradiol 0.025mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
68
ethinyl estradiol 0.02mg/ferrous fumarate 75mg/norethindrone acetate 1mg pack
68
ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack
68
ethinyl estradiol 0.02mg/levonorgestrel 0.09mg pack
68
ethinyl estradiol 0.02mg/norethindrone 1mg 21 day pack
68
ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack
68
ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack
69
ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
69
ethinyl estradiol 0.035mg/norgestimate 0.25mg pack
69
ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 0.05mg/ 0.075mg pack
69
ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack
69
ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 day pack
69
ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack
69
ethinyl estradiol/levonorgestrel 91 day pack
69
ethosuximide 250mg cap 25 ethosuximide 50mg/ml oral soln
25
etidronate disodium 200mg tab
79
ETIDRONATE DISODIUM 400MG TAB
79
etodolac 200mg cap 10 etodolac 300mg cap 10 etodolac 400mg er tab 10 etodolac 400mg tab 10
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
125
ALPHABETICAL LISTING OF DRUGS
etodolac 500mg er tab 10 etodolac 500mg tab 10 etodolac 600mg er tab 10 ETOPOPHOS 100MG INJ 50 etoposide 20mg/ml inj 50 EURAX 10% CREAM 77 EVOTAZ 300-150MG TAB
57
exemestane 25mg tab 45 EXJADE 125MG ORAL SUSP
32
EXJADE 250MG ORAL SUSP
32
EXJADE 500MG ORAL SUSP
32
EXONDYS 100MG/2ML INJ
93
EXONDYS 500MG/10ML INJ
93
EXTAVIA 0.3MG INJ 101 ezetimibe 10mg tab 36
F
FABRAZYME 35MG INJ 80 FABRAZYME 5MG INJ 80 falmina 28 day pack 69 famciclovir 125mg tab 60 famciclovir 250mg tab 60 famciclovir 500mg tab 60 FAMOTIDINE 0.4MG/ML INJ
105
famotidine 10mg/ml inj 105 famotidine 20mg tab 105 famotidine 40mg tab 105 famotidine 8mg/ml oral susp
105
FANAPT 10MG TAB 53 FANAPT 12MG TAB 53 FANAPT 1MG TAB 53 FANAPT 2MG TAB 53 FANAPT 4MG TAB 53 FANAPT 6MG TAB 53 FANAPT 8MG TAB 53 FANAPT TITRATION PACK
53
FARESTON 60MG TAB 45 FARXIGA 10MG TAB 31 FARXIGA 5MG TAB 31 FARYDAK 10MG CAP 47 FARYDAK 15MG CAP 47 FARYDAK 20MG CAP 47 FASLODEX 250MG/5ML SYRINGE
45
fayosim 91 day pack 69 FAZACLO 12.5MG ODT 54 FAZACLO 150MG ODT 54 FAZACLO 200MG ODT 54 felbamate 120mg/ml oral susp
25
felbamate 400mg tab 25 felbamate 600mg tab 25 felodipine 10mg er tab 64 felodipine 2.5mg er tab 64 felodipine 5mg er tab 64 femynor 28 day pack 69 fenofibrate 130mg cap 35 fenofibrate 134mg cap 35 fenofibrate 145mg tab 35 FENOFIBRATE 150MG CAP
35
fenofibrate 160mg tab 35 fenofibrate 200mg cap 35 fenofibrate 43mg cap 35 fenofibrate 48mg tab 35 FENOFIBRATE 50MG CAP
35
fenofibrate 54mg tab 35 fenofibrate 67mg cap 35 fenofibric acid 135mg dr cap
35
fenofibric acid 45mg dr cap
35
FENOPROFEN 400MG CAP
10
fentanyl 0.012mg/hr patch
11
fentanyl 0.025mg/hr patch
11
FENTANYL 0.0375MG/HR PATCH
11
fentanyl 0.05mg/hr patch 11 FENTANYL 0.0625MG/HR PATCH
11
fentanyl 0.075mg/hr patch
11
fentanyl 0.1mg/hr patch 11 fentanyl 0.2mg lozenge 11 fentanyl 0.4mg lozenge 11 fentanyl 0.6mg lozenge 11 fentanyl 0.8mg lozenge 11 fentanyl 1.2mg lozenge 12 fentanyl 1.6mg lozenge 12 FENTORA 100MCG BUCCAL TAB
12
FENTORA 200MCG BUCCAL TAB
12
FENTORA 400MCG BUCCAL TAB
12
FENTORA 600MCG BUCCAL TAB
12
FENTORA 800MCG BUCCAL TAB
12
FERRIPROX 100MG/ML ORAL SOLN
32
FERRIPROX 500MG TAB 32 FETZIMA 120MG ER CAP
28
FETZIMA 20MG ER CAP 28 FETZIMA 40MG ER CAP 28 FETZIMA 80MG ER CAP 28 FETZIMA PACK 28 FIASP 100UNIT/ML INJ 31 FIASP 100UNIT/ML PEN INJ
31
FINACEA 15% FOAM 77 FINACEA 15% GEL 77 finasteride 5mg tab 85 FIRAZYR 30MG/3ML SYRINGE
85
FIRMAGON 120MG INJ 45 FIRMAGON 80MG INJ 45 flavoxate 100mg tab 106 FLEBOGAMMA 10% INJ 97 flecainide acetate 100mg tab
18
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
126
ALPHABETICAL LISTING OF DRUGS
flecainide acetate 150mg tab
18
flecainide acetate 50mg tab
18
FLOVENT 100MCG DISKUS
19
FLOVENT 110MCG HFA INH
19
FLOVENT 220MCG HFA INH
19
FLOVENT 250MCG DISKUS
19
FLOVENT 44MCG HFA INH
19
FLOVENT 50MCG DISKUS
19
fluconazole 100mg tab 34 fluconazole 10mg/ml oral susp
34
fluconazole 150mg tab 34 fluconazole 200mg tab 34 fluconazole 2mg/ml (100ml) inj
34
fluconazole 2mg/ml inj 34 fluconazole 40mg/ml oral susp
34
fluconazole 50mg tab 34 flucytosine 250mg cap 33 flucytosine 500mg cap 33 fludarabine phosphate 50mg inj
44
fludrocortisone 0.1mg tab 72 flunisolide 25mcg nasal inhaler
93
fluocinolone acetonide 0.01% cream
76
fluocinolone acetonide 0.01% otic soln
97
fluocinolone acetonide 0.01% topical soln
76
fluocinolone acetonide 0.025% cream
76
fluocinolone acetonide 0.025% ointment
76
fluocinolone acetonide 0.1mg/ml oil
76
fluocinonide 0.05% e cream
76
fluocinonide 0.05% gel 76 fluocinonide 0.05% ointment
76
fluocinonide 0.05% topical soln
76
fluorometholone 0.1% ophth susp
95
FLUOROURACIL 0.5% CREAM
74
fluorouracil 2% topical soln
74
fluorouracil 5% cream 74 fluorouracil 5% topical soln
74
fluorouracil 50mg/ml inj 44 fluoxetine 10mg cap 26 fluoxetine 10mg tab 27 fluoxetine 20mg cap 27 fluoxetine 20mg tab 27 fluoxetine 25mg/olanzapine 12mg cap
100
fluoxetine 25mg/olanzapine 3mg cap
100
fluoxetine 25mg/olanzapine 6mg cap
100
fluoxetine 40mg cap 27 fluoxetine 4mg/ml oral soln
27
fluoxetine 50mg/olanzapine 12mg cap
100
fluoxetine 50mg/olanzapine 6mg cap
100
FLUPHENAZINE 0.5MG/ML ORAL SOLN
55
fluphenazine 10mg tab 55 fluphenazine 1mg tab 55
fluphenazine 2.5mg tab 55 FLUPHENAZINE 2.5MG/ML INJ
55
fluphenazine 5mg tab 55 FLUPHENAZINE 5MG/ML ORAL SOLN
55
fluphenazine decanoate 25mg/ml inj
55
FLURAZEPAM 15MG CAP
87
FLURAZEPAM 30MG CAP
87
flurbiprofen 100mg tab 10 flurbiprofen 50mg tab 10 flurbiprofen sodium 0.03% ophth soln
96
flutamide 125mg cap 45 fluticasone propionate 0.005% ointment
76
fluticasone propionate 0.05% cream
76
fluticasone propionate 0.05% lotion
76
fluticasone propionate 50mcg nasal inhaler
93
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 113-14MCG/ACT POWDER INH
20
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-14MCG/ACT POWDER INH
20
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-14MCG/ACT POWDER INH
20
fluvastatin 20mg cap 35 fluvastatin 40mg cap 35 fluvastatin 80mg er tab 35 fluvoxamine maleate 100mg er cap
27
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
127
ALPHABETICAL LISTING OF DRUGS
fluvoxamine maleate 100mg tab
27
fluvoxamine maleate 150mg er cap
27
fluvoxamine maleate 25mg tab
27
fluvoxamine maleate 50mg tab
27
FOLOTYN 40MG/2ML INJ
44
fomepizole 1000mg/ml inj 32 fondaparinux sodium 12.5mg/ml (0.4ml) syringe
21
fondaparinux sodium 12.5mg/ml (0.6ml) syringe
21
fondaparinux sodium 12.5mg/ml (0.8ml) syringe
21
fondaparinux sodium 5mg/ml syringe
21
FORTEO 600MCG/2.4ML PEN INJ
79
fosamprenavir 700mg tab 57 fosinopril sodium 10mg tab
36
fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab
39
fosinopril sodium 20mg tab
36
fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab
39
fosinopril sodium 40mg tab
36
fosphenytoin sodium 75mg/ml inj
25
FOSRENOL 1000MG CHEW TAB
84
FOSRENOL 1000MG ORAL POWDER
84
FOSRENOL 500MG CHEW TAB
84
FOSRENOL 750MG CHEW TAB
84
FOSRENOL 750MG ORAL POWDER
84
FRAGMIN 10000UNIT/ML SYRINGE
21
FRAGMIN 12500UNIT/0.5ML SYRINGE
21
FRAGMIN 15000UNIT/0.6ML SYRINGE
21
FRAGMIN 18000UNIT/0.72ML SYRINGE
21
FRAGMIN 2500UNIT/0.2ML SYRINGE
21
FRAGMIN 5000UNIT/0.2ML SYRINGE
21
FRAGMIN 7500UNIT/0.3ML SYRINGE
21
FRAGMIN 95000UNIT/3.8ML INJ
21
FREAMINE 6.9% INJ 94 furosemide 10mg/ml inj 78 furosemide 10mg/ml oral soln
78
furosemide 10mg/ml syringe
78
furosemide 20mg tab 78 furosemide 40mg tab 78 furosemide 80mg tab 78 FUROSEMIDE 8MG/ML ORAL SOLN
78
FUSILEV 50MG INJ 50 FUZEON 90MG INJ 57 fyavolv 0.5mg-2.5mcg tab 82 fyavolv 1mg-5mcg tab 82 FYCOMPA 0.5MG/ML ORAL SUSP
22
FYCOMPA 10MG TAB 22 FYCOMPA 12MG TAB 22 FYCOMPA 2MG TAB 22
FYCOMPA 4MG TAB 22 FYCOMPA 6MG TAB 22 FYCOMPA 8MG TAB 22
G
gabapentin 100mg cap 23 gabapentin 300mg cap 23 gabapentin 400mg cap 23 gabapentin 50mg/ml oral soln
23
gabapentin 600mg tab 23 gabapentin 800mg tab 23 GABITRIL 12MG TAB 25 GABITRIL 16MG TAB 25 galantamine 12mg tab 99 galantamine 4mg tab 99 galantamine 8mg tab 99 galantamine hydrobromide 16mg er cap
99
galantamine hydrobromide 24mg er cap
99
GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN
99
galantamine hydrobromide 8mg er cap
99
GAMASTAN 1800UNIT/10ML INJ
97
GAMASTAN 360UNIT/2ML INJ
97
GAMMAGARD 10GM INJ
97
GAMMAGARD 2.5GM/25ML INJ
97
GAMMAGARD 5GM INJ 97 GAMMAKED 1GM/10ML INJ
97
GAMMAPLEX 10GM/100ML INJ
97
GAMMAPLEX 10GM/200ML INJ
97
GAMMAPLEX 20GM/200ML INJ
97
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
128
ALPHABETICAL LISTING OF DRUGS
GAMMAPLEX 5GM/50ML INJ
97
GAMUNEX 1GM/10ML INJ
97
ganciclovir 500mg inj 59 GARDASIL 9 INJ 107 GARDASIL 9 SYRINGE 107 gatifloxacin 0.5% ophth soln
95
GATTEX 5MG INJ 84 GAUZE PAD 89 gavilyte-c oral soln 88 gavilyte-g oral soln 88 gavilyte-n powder for oral soln
88
gemcitabine 1000mg inj 44 gemfibrozil 600mg tab 35 generlac 10gm/15ml oral soln
84
gengraf 100mg cap 60 gengraf 100mg/ml oral soln
61
gengraf 25mg cap 61 GENOTROPIN 0.2MG SYRINGE
80
GENOTROPIN 0.4MG SYRINGE
80
GENOTROPIN 0.6MG SYRINGE
80
GENOTROPIN 0.8MG SYRINGE
80
GENOTROPIN 1.2MG SYRINGE
80
GENOTROPIN 1.4MG SYRINGE
80
GENOTROPIN 1.6MG SYRINGE
80
GENOTROPIN 1.8MG SYRINGE
80
GENOTROPIN 12MG CARTRIDGE
80
GENOTROPIN 1MG SYRINGE
80
GENOTROPIN 2MG SYRINGE
80
GENOTROPIN 5MG CARTRIDGE
80
gentak 0.3% ophth ointment
95
gentamicin 1.2mg/ml inj 8 gentamicin 40mg/ml inj 8 gentamicin sulfate 0.1% cream
73
gentamicin sulfate 0.1% ointment
73
gentamicin sulfate 0.3% ophth soln
95
gentamicin sulfate 0.8mg/ml inj
9
gentamicin sulfate 1.6mg/ml inj
9
gentamicin sulfate 1mg/ml inj
9
GENVOYA 150-150-200-10MG TAB
57
GEODON 20MG INJ 52 gianvi 28-day pack 69 GILENYA 0.5MG CAP 101 GILOTRIF 20MG TAB 47 GILOTRIF 30MG TAB 47 GILOTRIF 40MG TAB 47 GLASSIA 1000MG/50ML INJ
101
glatiramer 20mg/ml syringe
101
glatiramer 40mg/ml syringe
101
glatopa 20mg/ml inj 101 glatopa 40mg/ml syringe 101 GLEOSTINE 100MG CAP 43 GLEOSTINE 10MG CAP 43 GLEOSTINE 40MG CAP 43 GLEOSTINE 5MG CAP 43 glimepiride 1mg tab 31 glimepiride 2mg tab 31 glimepiride 2mg/pioglitazone 30mg tab
29
glimepiride 4mg tab 31
glimepiride 4mg/pioglitazone 30mg tab
29
glipizide 10mg er tab 31 glipizide 10mg tab 31 glipizide 2.5mg er tab 32 glipizide 2.5mg/metformin 250mg tab
29
glipizide 2.5mg/metformin 500mg tab
29
glipizide 5mg er tab 32 glipizide 5mg tab 32 glipizide 5mg/metformin 500mg tab
29
GLUCAGEN 1MG HYPOKIT
30
GLUCAGON 1MG INJ 30 glucose 10% inj 93 GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342MEQ/ML INJ
90
GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769MEQ/ML INJ
90
glucose 25mg/ml/sodium chloride 0.0769 meq/ml inj
90
glucose 5% inj 93 glucose 50mg/ml/potassium chloride 0.01meq/ml/sodium chloride 0.0769meq/ml inj
90
glucose 50mg/ml/potassium chloride 0.02 meq/ml inj
90
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
129
ALPHABETICAL LISTING OF DRUGS
glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.0342meq/ml inj
90
glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.056meq/ml inj
90
glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.0769meq/ml inj
90
glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 0.154meq/ml inj
90
glucose 50mg/ml/potassium chloride 0.03meq/ml/sodium chloride 0.0769meq/ml inj
90
GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
90
GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04MEQ/ML INJ
90
glucose 50mg/ml/potassium chloride 0.04meq/ml/sodium chloride 0.0769meq/ml inj
90
glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj
90
GLUCOSE 50MG/ML/SODIUM CHLORIDE 0.0385MEQ/ML INJ
90
glucose 50mg/ml/sodium chloride 0.0564 meq/ml inj
90
glucose 50mg/ml/sodium chloride 0.0769 meq/ml inj
90
glucose 50mg/ml/sodium chloride 0.154 meq/ml inj
90
glyburide 1.25mg tab 32 glyburide 1.25mg/metformin 250mg tab
29
glyburide 1.5mg tab 32 glyburide 2.5mg tab 32 glyburide 2.5mg/metformin 500mg tab
29
glyburide 3mg tab 32 glyburide 5mg tab 32 glyburide 5mg/metformin 500mg tab
29
glyburide 6mg tab 32 glycopyrrolate 0.2mg/ml inj
104
glycopyrrolate 1mg tab 104 glycopyrrolate 2mg tab 104 GLYXAMBI 10-5MG TAB
29
GLYXAMBI 25-5MG TAB
29
gramicidin 0.025mg/ml/neomycin 1.75mg/ml/polymyxin b 10000unit/ml ophth soln
95
granisetron 0.1mg/ml inj 32 granisetron 1mg tab 32 granisetron 1mg/ml (1ml) inj
32
granisetron 1mg/ml inj 33 GRANIX 300MCG/0.5ML SYRINGE
86
GRANIX 480MCG/0.8ML SYRINGE
86
griseofulvin 125mg tab 33 griseofulvin 250mg tab 33 griseofulvin 25mg/ml oral susp
33
griseofulvin 500mg tab 33 guanfacine 1mg er tab 7 guanfacine 1mg tab 38 guanfacine 2mg er tab 7 guanfacine 2mg tab 38 guanfacine 3mg er tab 7 guanfacine 4mg er tab 7 GUANIDINE 125MG TAB 43
H
HAEGARDA 2000UNT INJ
85
HAEGARDA 3000UNT INJ
85
HALAVEN 1MG/2ML INJ 50 halobetasol propionate 0.05% cream
76
halobetasol propionate 0.05% ointment
76
haloperidol 0.5mg tab 54 haloperidol 10mg tab 54 haloperidol 1mg tab 54 haloperidol 20mg tab 54 haloperidol 2mg tab 54 haloperidol 2mg/ml oral soln
54
haloperidol 5mg tab 54 haloperidol 5mg/ml inj 54 haloperidol 5mg/ml syringe
54
haloperidol decanoate 100mg/ml inj
54
haloperidol decanoate 500mg/5ml inj
54
haloperidol decanoate 50mg/ml inj
54
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
130
ALPHABETICAL LISTING OF DRUGS
HAVRIX 1440UNIT INJ 107 HAVRIX 1440UNIT SYRINGE
107
HAVRIX 720UNIT INJ 107 HAVRIX 720UNIT SYRINGE
107
heparin sodium, porcine 10000unit/ml inj
21
heparin sodium, porcine 1000unit/ml inj
21
HEPARIN SODIUM, PORCINE 100UNIT/ML INJ
21
heparin sodium, porcine 20000unit/ml inj
21
heparin sodium, porcine 40unit/ml inj
21
heparin sodium, porcine 5000unit/ml inj
21
heparin sodium, porcine 50unit/ml inj
21
HEPATAMINE 8% INJ 94 HERCEPTIN 150MG INJ 44 HERCEPTIN 440MG INJ 45 HETLIOZ 20MG CAP 87 HEXALEN 50MG CAP 43 HIBERIX INJ 106 HUMIRA 10MG/0.1ML SYRINGE
9
HUMIRA 10MG/0.2ML SYRINGE
9
HUMIRA 20MG/0.2ML SYRINGE
9
HUMIRA 20MG/0.4ML SYRINGE
9
HUMIRA 40MG/0.4ML AUTO-INJECTOR
9
HUMIRA 40MG/0.4ML SYRINGE
9
HUMIRA 40MG/0.8ML AUTO-INJECTOR
9
HUMIRA 40MG/0.8ML SYRINGE
9
HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 40MG/0.8ML INJ
9
HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML INJ
9
HUMIRA PEDIATRIC CROHN'S STARTER PACK (6) 40MG/0.8ML INJ
9
HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML
9
HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ
9
HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML INJ
9
HUMULIN R 500UNIT/ML INJ
31
HUMULIN R 500UNIT/ML PEN INJ
31
hydralazine 100mg tab 40 hydralazine 10mg tab 40 hydralazine 20mg/ml inj 40 hydralazine 25mg tab 40 hydralazine 50mg tab 40 hydrochlorothiazide 12.5mg cap
78
hydrochlorothiazide 12.5mg tab
78
hydrochlorothiazide 12.5mg/irbesartan 150mg tab
39
hydrochlorothiazide 12.5mg/irbesartan 300mg tab
39
hydrochlorothiazide 12.5mg/lisinopril 10mg tab
39
hydrochlorothiazide 12.5mg/lisinopril 20mg tab
39
hydrochlorothiazide 12.5mg/losartan potassium 100mg tab
39
hydrochlorothiazide 12.5mg/losartan potassium 50mg tab
39
hydrochlorothiazide 12.5mg/moexipril 15mg tab
40
hydrochlorothiazide 12.5mg/moexipril 7.5mg tab
40
hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab
40
hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab
40
hydrochlorothiazide 12.5mg/quinapril 10mg tab
40
hydrochlorothiazide 12.5mg/quinapril 20mg tab
40
hydrochlorothiazide 12.5mg/telmisartan 40mg tab
40
hydrochlorothiazide 12.5mg/telmisartan 80mg tab
40
hydrochlorothiazide 12.5mg/valsartan 160mg tab
40
hydrochlorothiazide 12.5mg/valsartan 320mg tab
40
hydrochlorothiazide 12.5mg/valsartan 80mg tab
40
hydrochlorothiazide 15mg/methyldopa 250mg tab
40
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
131
ALPHABETICAL LISTING OF DRUGS
hydrochlorothiazide 25mg tab
79
hydrochlorothiazide 25mg/lisinopril 20mg tab
40
hydrochlorothiazide 25mg/losartan potassium 100mg tab
40
hydrochlorothiazide 25mg/methyldopa 250mg tab
40
hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab
40
hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab
40
hydrochlorothiazide 25mg/moexipril 15mg tab
40
hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab
40
hydrochlorothiazide 25mg/propranolol 40mg tab
40
hydrochlorothiazide 25mg/propranolol 80mg tab
40
hydrochlorothiazide 25mg/quinapril 20mg tab
40
hydrochlorothiazide 25mg/spironolactone 25mg tab
78
hydrochlorothiazide 25mg/telmisartan 80mg tab
40
hydrochlorothiazide 25mg/triamterene 37.5mg cap
78
hydrochlorothiazide 25mg/triamterene 37.5mg tab
78
hydrochlorothiazide 25mg/valsartan 160mg tab
40
hydrochlorothiazide 25mg/valsartan 320mg tab
40
hydrochlorothiazide 50mg tab
79
hydrochlorothiazide 50mg/metoprolol tartrate 100mg tab
40
hydrochlorothiazide 50mg/triamterene 75mg tab
78
hydrocodone 10mg/ibuprofen 200mg tab
14
hydrocodone 5mg/ibuprofen 200mg tab
14
hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab
14
hydrocortisone 1% cream 76 hydrocortisone 1% ointment
76
hydrocortisone 1.67mg/ml enema
15
hydrocortisone 10mg tab 71 hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susp
95
hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln
97
hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp
97
hydrocortisone 2.5% cream
76
hydrocortisone 2.5% lotion
76
hydrocortisone 2.5% ointment
76
hydrocortisone 20mg tab 71 hydrocortisone 5mg tab 71
hydrocortisone valerate 0.2% cream
76
hydrocortisone valerate 0.2% ointment
76
hydrocortisone/pramoxine 1-1% rectal cream
15
hydromorphone 10mg/ml (1ml) inj
12
hydromorphone 10mg/ml (5ml) inj
12
hydromorphone 12mg er tab
12
hydromorphone 16mg er tab
12
hydromorphone 1mg/ml oral soln
12
hydromorphone 2mg tab 12 hydromorphone 2mg/ml syringe
12
hydromorphone 32mg er tab
12
hydromorphone 4mg tab 12 hydromorphone 8mg er tab
12
hydromorphone 8mg tab 12 hydroxychloroquine sulfate 200mg tab
42
HYDROXYPROGESTERONE CAPROATE 250MG/ML INJ
45
hydroxyurea 500mg cap 49 hydroxyzine 10mg tab 16 hydroxyzine 25mg tab 16 HYDROXYZINE 25MG/ML INJ
16
hydroxyzine 2mg/ml oral soln
17
hydroxyzine 50mg tab 17 hydroxyzine 50mg/ml inj 17 HYDROXYZINE PAMOATE 100MG CAP
17
hydroxyzine pamoate 25mg cap
17
hydroxyzine pamoate 50mg cap
17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
132
ALPHABETICAL LISTING OF DRUGS
HYPERRAB 150UNIT/ML (10ML) INJ
97
HYPERRAB 150UNIT/ML (2ML) INJ
97
HYSINGLA 100MG ER TAB
12
HYSINGLA 120MG ER TAB
12
HYSINGLA 20MG ER TAB
12
HYSINGLA 30MG ER TAB
12
HYSINGLA 40MG ER TAB
12
HYSINGLA 60MG ER TAB
12
HYSINGLA 80MG ER TAB
12
I
ibandronate 150mg tab 79 ibandronate 1mg/ml inj 79 IBRANCE 100MG CAP 47 IBRANCE 125MG CAP 47 IBRANCE 75MG CAP 47 ibu 600mg tab 10 ibu 800mg tab 10 ibuprofen 20mg/ml oral susp
10
ibuprofen 400mg tab 10 IBUPROFEN 400MG/OXYCODONE 5MG TAB
14
ibuprofen 600mg tab 10 ibuprofen 800mg tab 10 ICLUSIG 15MG TAB 47 ICLUSIG 45MG TAB 47 idarubicin hydrochloride 1mg/ml inj
46
IDHIFA 100MG TAB 47 IDHIFA 50MG TAB 47 ifosfamide 1000mg inj 43 ILARIS 150MG/ML INJ 9 ILEVRO 0.3% OPHTH SUSP
96
imatinib 100mg tab 47 imatinib 400mg tab 47 IMBRUVICA 140MG CAP
47
IMBRUVICA 140MG TAB 47 IMBRUVICA 280MG TAB 48 IMBRUVICA 420MG TAB 48 IMBRUVICA 560MG TAB 48 IMBRUVICA 70MG CAP 48 IMFINZI 120MG/2.4ML INJ
45
IMFINZI 500MG/10ML INJ
45
imipramine 10mg tab 29 imipramine 25mg tab 29 imipramine 50mg tab 29 imipramine pamoate 100mg cap
29
imipramine pamoate 125mg cap
29
imipramine pamoate 150mg cap
29
imipramine pamoate 75mg cap
29
imiquimod 5% cream 77 IMOGAM 150UNIT/ML (2ML) INJ
97
IMOVAX 2.5UNIT/ML INJ
107
INCRELEX 40MG/4ML INJ
80
INCRUSE 62.5MCG INH 18 indapamide 1.25mg tab 79 indapamide 2.5mg tab 79 INDOCIN 25MG/5ML ORAL SUSP
10
indomethacin 25mg cap 10 indomethacin 50mg cap 10 indomethacin 75mg er cap
10
INFANRIX INJ 104 INLYTA 1MG TAB 48 INLYTA 5MG TAB 48 INNOPRAN 120MG XL CAP
62
INNOPRAN 80MG XL CAP
62
INSULIN PEN NEEDLE 89 INSULIN SYRINGE (DISP) U-100 0.3ML
89
INSULIN SYRINGE (DISP) U-100 1/2ML
89
INSULIN SYRINGE (DISP) U-100 1ML
89
INSULIN SYRINGE MIS 1ML/29G
89
INTELENCE 100MG TAB 57 INTELENCE 200MG TAB 57 INTELENCE 25MG TAB 57 intralipid 200mg/ml inj 93 INTRON A 10MU INJ 49 INTRON A 18MU INJ 49 INTRON A 25MU INJ 49 INTRON A 50MU INJ 49 INTRON A 6000000UNIT/ML INJ
49
introvale 91 day pack 69 INVANZ 1GM INJ 41 INVEGA 117MG/0.75ML SYRINGE
53
INVEGA 156MG/ML SYRINGE
53
INVEGA 234MG/1.5ML SYRINGE
53
INVEGA 273MG/0.875ML SYRINGE
53
INVEGA 39MG/0.25ML SYRINGE
53
INVEGA 410MG/1.315ML SYRINGE
53
INVEGA 546MG/1.75ML SYRINGE
53
INVEGA 78MG/0.5ML SYRINGE
53
INVEGA 819MG/2.625ML SYRINGE
53
INVIRASE 200MG CAP 57
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
133
ALPHABETICAL LISTING OF DRUGS
INVIRASE 500MG TAB 57 IONOSOL-MB INJ 90 IOPIDINE 1% OPHTH SOLN
94
IPOL INJ 107 ipratropium bromide 0.02% inh soln
18
ipratropium bromide 0.03% nasal inhaler
93
ipratropium bromide 0.06% nasal inhaler
93
ipratropium/albuterol 0.5-2.5mg/3ml inh soln
20
irbesartan 150mg tab 37 irbesartan 300mg tab 37 irbesartan 75mg tab 37 IRESSA 250MG TAB 48 irinotecan 20mg/ml inj 50 ISENTRESS 100MG CHEW TAB
57
ISENTRESS 100MG ORAL SUSP
57
ISENTRESS 25MG CHEW TAB
57
ISENTRESS 400MG TAB 57 ISENTRESS 600MG TAB 57 isibloom 28 day pack 69 ISOLYTE P INJ 90 ISOLYTE S INJ 90 isoniazid 100mg tab 43 ISONIAZID 100MG/ML INJ
43
ISONIAZID 10MG/ML ORAL SOLN
43
isoniazid 300mg tab 43 isosorbide dinitrate 10mg tab
16
isosorbide dinitrate 20mg tab
16
isosorbide dinitrate 30mg tab
16
ISOSORBIDE DINITRATE 40MG ER TAB
16
isosorbide dinitrate 5mg tab
16
isosorbide mononitrate 10mg tab
16
isosorbide mononitrate 120mg er tab
16
isosorbide mononitrate 20mg tab
16
isosorbide mononitrate 30mg er tab
16
isosorbide mononitrate 60mg er tab
16
isotretinoin 10mg cap 73 isotretinoin 20mg cap 73 isotretinoin 30mg cap 73 isotretinoin 40mg cap 73 isradipine 2.5mg cap 64 isradipine 5mg cap 64 ISTALOL 0.5% OPHTH SOLN
94
ISTODAX 10MG INJ 48 itraconazole 100mg cap 34 ivermectin 3mg tab 16 IXIARO SYRINGE 107
J
JADENU 180MG GRANULE PACKET
32
JADENU 180MG TAB 32 JADENU 360MG GRANULE PACKET
32
JADENU 360MG TAB 32 JADENU 90MG GRANULE PACKET
32
JADENU 90MG TAB 32 JAKAFI 10MG TAB 48 JAKAFI 15MG TAB 48 JAKAFI 20MG TAB 48 JAKAFI 25MG TAB 48 JAKAFI 5MG TAB 48 jantoven 10mg tab 20 jantoven 1mg tab 20 jantoven 2.5mg tab 20 jantoven 2mg tab 20 jantoven 3mg tab 20 jantoven 4mg tab 20 jantoven 5mg tab 20
jantoven 6mg tab 20 jantoven 7.5mg tab 20 JANUMET 100-1000MG XR TAB
29
JANUMET 50-1000MG TAB
29
JANUMET 50-1000MG XR TAB
29
JANUMET 50-500MG TAB
30
JANUMET 50-500MG XR TAB
30
JANUVIA 100MG TAB 30 JANUVIA 25MG TAB 30 JANUVIA 50MG TAB 30 JARDIANCE 10MG TAB 31 JARDIANCE 25MG TAB 31 JENTADUETO 2.5-1000MG TAB
30
JENTADUETO 2.5-1000MG XR TAB
30
JENTADUETO 2.5-500MG TAB
30
JENTADUETO 2.5-850MG TAB
30
JENTADUETO 5-1000MG XR TAB
30
JEVTANA 60MG/1.5ML INJ
50
jinteli tab 82 jolivette 28 day 0.35mg pack
71
juleber 28 day pack 69 JULUCA 50-25MG TAB 57 junel 1.5/30 21 day pack 69 junel 1/20 21 day pack 69 junel fe 1.5/30 28 day pack
69
junel fe 1/20 28 day pack 69 junel fe 24 1/20 28 day pack
69
JUXTAPID 10MG CAP 36 JUXTAPID 20MG CAP 36 JUXTAPID 30MG CAP 36 JUXTAPID 40MG CAP 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
134
ALPHABETICAL LISTING OF DRUGS
JUXTAPID 5MG CAP 36 JUXTAPID 60MG CAP 36 JYNARQUE 45/15 THERAPY PACK
81
JYNARQUE 60/30 THERAPY PACK
81
JYNARQUE 90/30 THERAPY PACK
81
K
KADCYLA 100MG INJ 45 KADCYLA 160MG INJ 45 kaitlib fe 28 day pack 69 KALETRA 100-25MG TAB
57
KALETRA 200-50MG TAB
57
KALETRA 400-100MG/5ML ORAL SOLN
57
KALYDECO 150MG TAB 102 KALYDECO 50MG GRANULES PACKET
102
KALYDECO 75MG GRANULES PACKET
102
kariva 28 day pack 69 KCL/D5W/LR INJ 0.15% 90 kelnor 1/35 28 day pack 69 kelnor 1/50 28 day pack 69 KENALOG 10MG/ML INJ
71
KENALOG 40MG/ML INJ
71
KEPIVANCE 6.25MG INJ 50 ketoconazole 2% cream 74 ketoconazole 2% shampoo
74
ketoconazole 200mg tab 34 ketoconazole 20mg/ml foam
74
ketoprofen 50mg cap 10 ketoprofen 75mg cap 10 ketorolac tromethamine 0.4% ophth soln
96
ketorolac tromethamine 0.5% ophth soln
96
ketorolac tromethamine 10mg tab
10
ketorolac tromethamine 15mg/ml inj
10
ketorolac tromethamine 30mg/ml cartridge
10
ketorolac tromethamine 30mg/ml inj
10
KEYTRUDA 100MG/4ML INJ
45
KHEDEZLA 100MG ER TAB
28
KHEDEZLA 50MG ER TAB
28
kimidess 28 day pack 69 KINRIX 0.05 MG/ML INJ 104 KINRIX INJ 104 kionex 250mg/ml oral susp
61
KISQALI 200MG DAILY DOSE PACK
48
KISQALI 400MG DAILY DOSE PACK
48
KISQALI 600MG DAILY DOSE PACK
48
KISQALI/FEMARA TAB CO-PACK 200MG
46
KISQALI/FEMARA TAB CO-PACK 400MG
46
KISQALI/FEMARA TAB CO-PACK 600MG
46
klor-con 10meq er cap 91 klor-con 10meq er micro tab
91
klor-con 10meq er tab 91 KLOR-CON 15MEQ ER TAB
91
klor-con 20meq er micro tab
91
klor-con 8meq er cap 91 klor-con 8meq er tab 91 KORLYM 300MG TAB 30 K-TAB 20MEQ ER TAB 91
K-TAB 8MEQ ER TAB 91 kurvelo 28 day pack 69 KUVAN 100MG POWDER FOR ORAL SOLN
80
KUVAN 100MG TAB 80 KUVAN 500MG POWDER FOR ORAL SOLN
80
KYNAMRO 200MG/ML SYRINGE
35
KYPROLIS 30MG INJ 48 KYPROLIS 60MG INJ 48
L
labetalol 100mg tab 62 labetalol 200mg tab 62 labetalol 300mg tab 62 labetalol 5mg/ml inj 62 LACRISERT 5MG IMPLANT
94
lactated ringers inj 90 lactated ringers irrigation
61
lactulose 667mg/ml oral soln
88
LAMICTAL BLUE KIT 23 LAMICTAL GREEN KIT 23 LAMICTAL ORANGE KIT 23 LAMICTAL XR BLUE KIT
23
LAMICTAL XR GREEN KIT
23
LAMICTAL XR ORANGE KIT
23
lamivudine 100mg tab 59 lamivudine 10mg/ml oral soln
57
lamivudine 150mg tab 57 lamivudine 150mg/zidovudine 300mg tab
57
lamivudine 300mg tab 57 lamotrigine 100mg er tab 23 lamotrigine 100mg odt 23
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
135
ALPHABETICAL LISTING OF DRUGS
lamotrigine 100mg tab 23 lamotrigine 150mg tab 23 lamotrigine 200mg er tab 23 lamotrigine 200mg odt 23 lamotrigine 200mg tab 23 lamotrigine 250mg er tab 23 lamotrigine 25mg chew tab
23
lamotrigine 25mg er tab 23 lamotrigine 25mg odt 23 lamotrigine 25mg tab 23 lamotrigine 300mg er tab 23 lamotrigine 50mg er tab 23 lamotrigine 50mg odt 23 lamotrigine 5mg chew tab 23 lamotrigine tab 25mg (35) starter pack
23
lamotrigine tab 25mg (42)/100mg (7) starter pack
23
lamotrigine tab 25mg (84)/100mg (14) starter pack
23
lansoprazole 15mg dr cap 105 lansoprazole 30mg dr cap 105 lanthanum carbonate 1000mg chew tab
84
lanthanum carbonate 500mg chew tab
84
lanthanum carbonate 750mg chew tab
84
LANTUS 100UNIT/ML INJ
31
LANTUS 100UNIT/ML SOLOSTAR
31
larin 1.5/30 pack 69 larin 1/20 pack 69 larin fe 1.5/30 pack 69 larin fe 1/20 pack 69 larissia 28 day pack 69 LARTRUVO 10MG/ML INJ
45
LARTRUVO 190MG/19ML INJ
45
latanoprost 0.005% ophth soln
96
LATUDA 120MG TAB 52 LATUDA 20MG TAB 52 LATUDA 40MG TAB 52 LATUDA 60MG TAB 53 LATUDA 80MG TAB 53 layolis fe 28 pack 69 leena 28 day pack 69 leflunomide 10mg tab 11 leflunomide 20mg tab 11 LENVIMA (8) 4MG PACK
48
LENVIMA 10 10MG PACK
48
LENVIMA 14 PACK 48 LENVIMA 18 PACK 48 LENVIMA 20 10MG PACK
48
LENVIMA 24 PACK 48 lessina 28 day pack 69 LETAIRIS 10MG TAB 65 LETAIRIS 5MG TAB 65 letrozole 2.5mg tab 45 LEUCOVORIN 10MG TAB
50
leucovorin 10mg/ml inj 50 LEUCOVORIN 15MG TAB
50
leucovorin 20mg/ml inj 50 leucovorin 25mg tab 50 leucovorin 5mg tab 50 LEUKERAN 2MG TAB 43 LEUKINE 250MCG INJ 86 leuprolide acetate 5mg/ml inj
45
levalbuterol 0.31mg inh soln
20
levalbuterol 0.63mg inh soln
20
levalbuterol 1.25mg inh soln
20
levalbuterol 2.5mg inh soln
20
LEVEMIR 100UNIT/ML FLEXTOUCH
31
LEVEMIR 100UNIT/ML INJ
31
levetiracetam 1000mg tab 23 levetiracetam 100mg/ml inj
23
levetiracetam 100mg/ml oral soln
23
levetiracetam 10mg/ml inj 23 levetiracetam 15mg/ml inj 23 levetiracetam 250mg tab 23 levetiracetam 500mg er tab
23
levetiracetam 500mg tab 24 levetiracetam 5mg/ml inj 24 levetiracetam 750mg er tab
24
levetiracetam 750mg tab 24 levobunolol 0.5% ophth soln
94
levocarnitine 100mg/ml oral soln
80
levocarnitine 330mg tab 81 levocetirizine 0.5mg/ml oral soln
34
levocetirizine 5mg tab 34 levofloxacin 0.5% ophth soln
95
levofloxacin 250mg tab 83 levofloxacin 25mg/ml inj 83 levofloxacin 25mg/ml oral soln
83
levofloxacin 500mg tab 83 levofloxacin 5mg/ml (150ml) inj
83
levofloxacin 5mg/ml inj 83 levofloxacin 750mg tab 83 levoleucovorin 10mg/ml inj
50
levoleucovorin 50mg inj 50 levonest 28 day pack 69 levora 0.15/30 28 day pack
69
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
136
ALPHABETICAL LISTING OF DRUGS
LEVORPHANOL 2MG TAB
12
levo-t 100mcg tab 103 levo-t 112mcg tab 103 levo-t 125mcg tab 103 levo-t 137mcg tab 103 levo-t 150mcg tab 103 levo-t 175mcg tab 103 levo-t 200mcg tab 103 levo-t 25mcg tab 103 levo-t 300mcg tab 103 levo-t 50mcg tab 103 levo-t 75mcg tab 103 levo-t 88mcg tab 103 levothyroxine sodium 100mcg tab
103
levothyroxine sodium 112mcg tab
103
levothyroxine sodium 125mcg tab
103
levothyroxine sodium 137mcg tab
103
levothyroxine sodium 150mcg tab
103
levothyroxine sodium 175mcg tab
103
levothyroxine sodium 200mcg tab
103
levothyroxine sodium 25mcg tab
103
levothyroxine sodium 300mcg tab
103
levothyroxine sodium 50mcg tab
103
levothyroxine sodium 75mcg tab
103
levothyroxine sodium 88mcg tab
103
levoxyl 100mcg tab 103 levoxyl 112mcg tab 103 levoxyl 125mcg tab 103 levoxyl 137mcg tab 103 levoxyl 150mcg tab 103 levoxyl 175mcg tab 103 levoxyl 200mcg tab 103
levoxyl 25mcg tab 103 levoxyl 50mcg tab 103 levoxyl 75mcg tab 103 levoxyl 88mcg tab 103 LEXIVA 50MG/ML ORAL SUSP
57
LEXIVA 700MG TAB 57 LIALDA 1.2GM DR TAB 83 lidocaine 0.5% inj 88 lidocaine 1% inj 88 lidocaine 2% gel 77 lidocaine 2% inj 88 lidocaine 2% topical soln 92 lidocaine 4% topical soln 77 lidocaine 5% ointment 77 lidocaine 5% patch 77 lidocaine/prilocaine 2.5-2.5% cream
77
lincomycin 300mg/ml inj 42 lindane 1% shampoo 77 linezolid 20mg/ml oral susp
42
linezolid 2mg/ml inj 42 linezolid 600mg tab 42 LINZESS 145MCG CAP 84 LINZESS 290MCG CAP 84 LINZESS 72MCG CAP 84 liothyronine sodium 0.005mg tab
103
liothyronine sodium 0.01mg/ml inj
103
liothyronine sodium 0.025mg tab
103
liothyronine sodium 0.05mg tab
103
lisinopril 10mg tab 36 lisinopril 2.5mg tab 36 lisinopril 20mg tab 36 lisinopril 30mg tab 37 lisinopril 40mg tab 37 lisinopril 5mg tab 37 lithium carbonate 150mg cap
52
lithium carbonate 300mg cap
52
lithium carbonate 300mg er tab
52
lithium carbonate 300mg tab
52
lithium carbonate 450mg er tab
52
lithium carbonate 600mg cap
52
lithium citrate 60mg/ml oral soln
52
LITHOSTAT 250MG TAB 85 LONSURF 15-6.14MG TAB
46
LONSURF 20-8.19MG TAB
46
loperamide 2mg cap 32 lopinavir 80mg/ml/ritonavir 20mg/ml oral solution
57
lorazepam 0.5mg tab 17 lorazepam 1mg tab 17 lorazepam 2mg tab 17 lorazepam 2mg/ml oral conc
17
lorcet 10-325mg tab 14 lorcet 5-325mg tab 14 lorcet 7.5-325mg tab 14 loryna 28 day pack 69 losartan potassium 100mg tab
37
losartan potassium 25mg tab
37
losartan potassium 50mg tab
37
LOTEMAX 0.5% OPHTH GEL
95
LOTEMAX 0.5% OPHTH OINTMENT
96
LOTEMAX 0.5% OPHTH SUSP
96
lovastatin 10mg tab 35 lovastatin 20mg tab 35 lovastatin 40mg tab 35 low-ogestrel 28 day pack 69 loxapine 10mg cap 54
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
137
ALPHABETICAL LISTING OF DRUGS
loxapine 25mg cap 54 loxapine 50mg cap 54 loxapine 5mg cap 54 LUMIGAN 0.01% OPHTH SOLN
96
LUMIZYME 50MG INJ 81 LUPRON 11.25MG (1.5ML) SYRINGE
45
LUPRON 11.25MG (1ML) SYRINGE
80
LUPRON 15MG SYRINGE
80
LUPRON 22.5MG SYRINGE
46
LUPRON 3.75MG SYRINGE
46
LUPRON 30MG SYRINGE
46
LUPRON 30MG SYRINGE (3 MONTH)
80
LUPRON 45MG SYRINGE
46
LUPRON 7.5MG SYRINGE
46
lutera 28 day pack 69 LYNPARZA 100MG CAP 48 LYNPARZA 150MG CAP 48 LYNPARZA 50MG CAP 48 LYRICA 100MG CAP 24 LYRICA 150MG CAP 24 LYRICA 200MG CAP 24 LYRICA 20MG/ML ORAL SOLN
24
LYRICA 225MG CAP 24 LYRICA 25MG CAP 24 LYRICA 300MG CAP 24 LYRICA 50MG CAP 24 LYRICA 75MG CAP 24 LYSODREN 500MG TAB 46 lyza 0.35mg pack 71
M
magnesium sulfate 50% inj
91
magnesium sulfate 50% syringe
91
malathion 0.5% lotion 77 MAPROTILINE 25MG TAB
26
MAPROTILINE 50MG TAB
26
MAPROTILINE 75MG TAB
26
marlissa 28 day pack 69 MARPLAN 10MG TAB 26 MATULANE 50MG CAP 49 matzim 180mg er tab 64 matzim 240mg er tab 64 matzim 300mg er tab 64 matzim 360mg er tab 64 matzim 420mg er tab 64 MAVYRET 100-40MG TAB
59
MAXIDEX 0.1% OPHTH SUSP
96
meclizine 12.5mg tab 33 meclizine 25mg tab 33 MECLOFENAMATE 100MG CAP
10
MECLOFENAMATE 50MG CAP
10
MEDROL 2MG TAB 71 medroxyprogesterone acetate 10mg tab
99
medroxyprogesterone acetate 150mg/ml inj
71
medroxyprogesterone acetate 150mg/ml syringe
71
medroxyprogesterone acetate 2.5mg tab
99
medroxyprogesterone acetate 5mg tab
99
mefenamic acid 250mg cap
10
mefloquine 250mg tab 42 megestrol acetate 125mg/ml oral susp
99
megestrol acetate 20mg tab
46
megestrol acetate 40mg tab
46
megestrol acetate 40mg/ml oral susp
46
MEKINIST 0.5MG TAB 48 MEKINIST 2MG TAB 48 meloxicam 15mg tab 10 meloxicam 7.5mg tab 10 melphalan 5mg/ml inj 43 memantine 10mg tab 99 memantine 10mg/memantine 5mg pack
99
memantine 14mg er cap 99 memantine 21mg er cap 99 memantine 28mg er cap 99 memantine 2mg/ml oral soln
99
memantine 5mg tab 99 memantine 7mg er cap 100 MENACTRA INJ 106 MENVEO INJ 107 meperidine 100mg tab 12 meperidine 50mg tab 12 meprobamate 200mg tab 17 meprobamate 400mg tab 17 mercaptopurine 50mg tab 44 meropenem 1gm inj 41 meropenem 500mg inj 41 mesalamine 66.7mg/ml enema
83
mesna 100mg/ml inj 50 MESNEX 400MG TAB 50 metadate 20mg er tab 8 METAPROTERENOL SULFATE 10MG TAB
20
METAPROTERENOL SULFATE 20MG TAB
20
METAPROTERENOL SULFATE 2MG/ML ORAL SOLN
20
metaxall 800mg tab 92 METAXALONE 400MG TAB
92
metaxalone 800mg tab 92
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
138
ALPHABETICAL LISTING OF DRUGS
metformin 1000mg tab 30 metformin 500mg er tab 30 metformin 500mg tab 30 metformin 500mg/pioglitazone 15mg tab
30
metformin 750mg er tab 30 metformin 850mg tab 30 metformin 850mg/pioglitazone 15mg tab
30
methadone 10mg tab 12 methadone 1mg/ml oral soln
12
methadone 2mg/ml oral soln
12
methadone 5mg tab 12 methamphetamine 5mg tab
7
methazolamide 25mg tab 78 methazolamide 50mg tab 78 methenamine hippurate 1000mg tab
106
methimazole 10mg tab 102 methimazole 5mg tab 102 methocarbamol 500mg tab
92
methocarbamol 750mg tab
92
methotrexate 1000mg inj 44 methotrexate 2.5mg tab 44 METHOTREXATE 250MG/10ML INJ
44
methotrexate 250mg/10ml inj
44
methotrexate 50mg/2ml inj
44
methoxsalen 10mg cap 74 methscopolamine 2.5mg tab
105
methscopolamine 5mg tab 105 METHYCLOTHIAZIDE 5MG TAB
79
methyldopa 250mg tab 38 methyldopa 500mg tab 38
methylphenidate 10mg cd cap
8
methylphenidate 10mg chew tab
8
methylphenidate 10mg er tab
8
methylphenidate 10mg la cap
8
methylphenidate 10mg tab
8
METHYLPHENIDATE 18MG SR TAB
8
methylphenidate 1mg/ml oral soln
8
methylphenidate 2.5mg chew tab
8
methylphenidate 20mg cd cap
8
methylphenidate 20mg er tab
8
methylphenidate 20mg la cap
8
methylphenidate 20mg tab
8
METHYLPHENIDATE 27MG SR TAB
8
methylphenidate 2mg/ml oral soln
8
methylphenidate 30mg cd cap
8
methylphenidate 30mg la cap
8
METHYLPHENIDATE 36MG SR TAB
8
methylphenidate 40mg cd cap
8
methylphenidate 40mg la cap
8
methylphenidate 50mg cd cap
8
METHYLPHENIDATE 54MG SR TAB
8
methylphenidate 5mg chew tab
8
methylphenidate 5mg tab 8
methylphenidate 60mg cd cap
8
methylprednisolone 125mg inj
71
methylprednisolone 16mg tab
71
methylprednisolone 32mg tab
71
methylprednisolone 40mg/ml inj
71
methylprednisolone 4mg pack
71
methylprednisolone 4mg tab
71
methylprednisolone 62.5mg/ml inj
71
methylprednisolone 8mg tab
71
methylprednisolone acetate 40mg/ml inj
72
methylprednisolone acetate 80mg/ml inj
72
METIPRANOLOL 0.3% OPHTH SOLN
94
metoclopramide 10mg tab 83 metoclopramide 1mg/ml oral soln
83
metoclopramide 5mg tab 83 metoclopramide 5mg/ml inj
83
metolazone 10mg tab 79 metolazone 2.5mg tab 79 metolazone 5mg tab 79 metoprolol succinate 100mg er tab
62
metoprolol succinate 200mg er tab
62
metoprolol succinate 25mg er tab
62
metoprolol succinate 50mg er tab
62
metoprolol tartrate 100mg tab
62
metoprolol tartrate 1mg/ml cartridge
62
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
139
ALPHABETICAL LISTING OF DRUGS
metoprolol tartrate 1mg/ml inj
62
metoprolol tartrate 25mg tab
62
metoprolol tartrate 50mg tab
62
metronidazole 0.75% cream
77
metronidazole 0.75% gel 77 metronidazole 0.75% lotion
77
metronidazole 0.75% vaginal gel
107
metronidazole 1% gel 77 metronidazole 250mg tab 41 metronidazole 375mg cap 41 metronidazole 500mg tab 41 metronidazole 5mg/ml inj 41 mexiletine 150mg cap 18 mexiletine 200mg cap 18 mexiletine 250mg cap 18 MIACALCIN 200UNIT/ML INJ
79
microgestin 1.5/30 21 day pack
70
microgestin 1/20 21 day pack
70
microgestin fe 1.5/30 28 day pack
70
microgestin fe 1/20 28 day pack
70
midodrine 10mg tab 108 midodrine 2.5mg tab 108 midodrine 5mg tab 108 miglitol 100mg tab 29 miglitol 25mg tab 29 miglitol 50mg tab 29 MIGRANAL 4MG/ML NASAL SPRAY
89
mili 28 day pack 70 mimvey lo 28 day pack 82 mimvey pack 82 minitran 0.1mg/hr patch 16 minitran 0.2mg/hr patch 16 minitran 0.4mg/hr patch 16
minitran 0.6mg/hr patch 16 minocycline 100mg cap 102 minocycline 100mg tab 102 minocycline 50mg cap 102 minocycline 50mg tab 102 minocycline 75mg cap 102 minocycline 75mg tab 102 minoxidil 10mg tab 41 minoxidil 2.5mg tab 41 mirtazapine 15mg odt 26 mirtazapine 15mg tab 26 mirtazapine 30mg odt 26 mirtazapine 30mg tab 26 mirtazapine 45mg odt 26 mirtazapine 45mg tab 26 mirtazapine 7.5mg tab 26 misoprostol 0.1mg tab 105 misoprostol 0.2mg tab 106 MITIGARE 0.6MG CAP 85 mitomycin 20mg inj 46 mitomycin 40mg inj 46 MITOMYCIN 5MG INJ 46 mitoxantrone 2mg/ml inj 46 M-M-R II INJ 107 modafinil 100mg tab 8 modafinil 200mg tab 8 MODERIBA 1200/DAY DOSE PACK
59
moderiba 200mg tab 59 MODERIBA 800/DAY DOSE PACK
59
moexipril 15mg tab 37 moexipril 7.5mg tab 37 mometasone furoate 0.1% cream
76
mometasone furoate 0.1% lotion
76
mometasone furoate 0.1% ointment
76
mononessa 28 day pack 70 montelukast 10mg tab 19 montelukast 4mg chew tab
19
montelukast 4mg granules
19
montelukast 5mg chew tab
19
morgidox 50mg cap 102 morphine sulfate 100mg er cap
12
morphine sulfate 100mg er tab
12
morphine sulfate 10mg er cap
12
MORPHINE SULFATE 120MG ER (24HR) CAP
12
morphine sulfate 15mg er tab
12
morphine sulfate 15mg tab
12
morphine sulfate 200mg er tab
12
morphine sulfate 20mg er cap
12
morphine sulfate 20mg/ml oral soln
12
morphine sulfate 2mg/ml oral soln
12
MORPHINE SULFATE 2MG/ML SYRINGE
12
MORPHINE SULFATE 30MG ER (24 HR) CAP
12
morphine sulfate 30mg er cap
12
morphine sulfate 30mg er tab
12
morphine sulfate 30mg tab
13
MORPHINE SULFATE 45MG ER (24HR) CAP
13
morphine sulfate 4mg/ml oral soln
13
morphine sulfate 50mg er cap
13
MORPHINE SULFATE 5MG/ML SYRINGE
13
MORPHINE SULFATE 60MG (24HR) ER CAP
13
morphine sulfate 60mg er cap
13
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
140
ALPHABETICAL LISTING OF DRUGS
morphine sulfate 60mg er tab
13
MORPHINE SULFATE 75MG ER (24HR) CAP
13
morphine sulfate 80mg er cap
13
MORPHINE SULFATE 90MG ER (24HR) CAP
13
MOVANTIK 12.5MG TAB 84 MOVANTIK 25MG TAB 84 MOVIPREP ORAL SOLN 88 moxifloxacin 0.5% ophth soln
95
MOXIFLOXACIN 1.6MG/ML INJ
83
moxifloxacin 400mg tab 83 MOZOBIL 24MG/1.2ML INJ
87
MULTAQ 400MG TAB 18 mupirocin 2% cream 73 mupirocin 2% ointment 73 MUSTARGEN 10MG INJ 43 MYCAMINE 100MG INJ 33 MYCAMINE 50MG INJ 33 mycophenolate mofetil 200mg/ml oral susp
61
mycophenolate mofetil 250mg cap
61
mycophenolate mofetil 500mg inj
91
mycophenolate mofetil 500mg tab
61
mycophenolic acid 180mg dr tab
61
mycophenolic acid 360mg dr tab
61
MYLOTARG 4.5MG INJ 45 myorisan 10mg cap 73 myorisan 20mg cap 73 myorisan 30mg cap 73 myorisan 40mg cap 73 MYRBETRIQ 25MG ER TAB
106
MYRBETRIQ 50MG ER TAB
106
N
nabumetone 500mg tab 10 nabumetone 750mg tab 10 nadolol 20mg tab 62 nadolol 40mg tab 62 nadolol 80mg tab 62 nafcillin 100mg/ml inj 99 nafcillin 1gm inj 99 naftifine 2% cream 74 NAGLAZYME 1MG/ML INJ
81
NALOXONE 0.4MG/ML CARTRIDGE
32
naloxone 0.5mg/pentazocine 50mg tab
15
NALOXONE 1MG/ML SYRINGE
32
naltrexone 50mg tab 32 NAMENDA 14MG XR CAP
100
NAMENDA 21MG XR CAP
100
NAMENDA 28 TITRATION PACK
100
NAMENDA 28MG XR CAP
100
NAMENDA 7MG XR CAP
100
NAMZARIC 10-21MG ER CAP
100
NAMZARIC 10-7MG ER CAP
100
NAMZARIC 14-10MG ER CAP
100
NAMZARIC 28-10MG ER CAP
100
NAMZARIC TITRATION PACK
100
naproxen 250mg tab 10 naproxen 25mg/ml oral susp
10
naproxen 375mg dr tab 10 naproxen 375mg tab 10 naproxen 500mg dr tab 10
naproxen 500mg tab 10 naproxen sodium 275mg tab
10
naproxen sodium 550mg tab
10
naratriptan 1mg tab 89 naratriptan 2.5mg tab 89 NARCAN 4MG/0.1ML NASAL SPRAY
32
NATACYN 5% OPHTH SUSP
95
NATAZIA 28 DAY PACK 70 nateglinide 120mg tab 31 nateglinide 60mg tab 31 NATPARA 100MCG CARTRIDGE
79
NATPARA 25MCG CARTRIDGE
79
NATPARA 50MCG CARTRIDGE
79
NATPARA 75MCG CARTRIDGE
79
NEBUPENT 300MG INH SOLN
41
necon 0.5/35 28 day pack 70 necon 7/7/7 28 day pack 70 NEFAZODONE 100MG TAB
27
NEFAZODONE 150MG TAB
27
NEFAZODONE 200MG TAB
27
nefazodone 250mg tab 27 nefazodone 50mg tab 27 neomycin 40mg/ml/polymyxin b 200000unit/ml soln
85
neomycin sulfate 500mg tab
9
neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit
95
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
141
ALPHABETICAL LISTING OF DRUGS
neomycin/polymyxin/bacitracin/hydrocortisone ophth ointmentment 1%
96
NEPHRAMINE 5.4% INJ 94 NERLYNX 40MG TAB 48 NEULASTA 6MG/0.6ML SYRINGE
86
NEUPRO 1MG/24HR PATCH
51
NEUPRO 2MG/24HR PATCH
51
NEUPRO 3MG/24HR PATCH
51
NEUPRO 4MG/24HR PATCH
51
NEUPRO 6MG/24HR PATCH
51
NEUPRO 8MG/24HR PATCH
51
NEVANAC 0.1% OPHTH SUSP
96
nevirapine 100mg er tab 57 nevirapine 200mg tab 57 nevirapine 400mg er tab 57 NEXAVAR 200MG TAB 48 NEXIUM 10MG GRANULES FOR ORAL SUSP
105
NEXIUM 2.5MG GRANULES FOR ORAL SUSP
105
NEXIUM 20MG GRANULES FOR ORAL SUSP
105
NEXIUM 40MG GRANULES FOR ORAL SUSP
105
NEXIUM 5MG GRANULES FOR ORAL SUSP
105
NEXTERONE 150MG/100ML INJ
18
NEXTERONE 360MG/200ML INJ
18
niacin 1000mg er tab 36
niacin 500mg er tab 36 niacin 750mg er tab 36 nicardipine 2.5mg/ml inj 64 nicardipine 20mg cap 64 nicardipine 30mg cap 64 NICOTROL 10MG INHALER
101
NICOTROL 10MG/ML NASAL INHALER
101
nifedipine 10mg cap 64 nifedipine 20mg cap 64 nifedipine 30mg er tab 64 nifedipine 30mg osmotic er tab
64
nifedipine 60mg er tab 64 nifedipine 60mg osmotic er tab
64
nifedipine 90mg er tab 64 nifedipine 90mg osmotic er tab
64
nikki 28 day pack 70 NILANDRON 150MG TAB
46
nilutamide 150mg tab 46 nimodipine 30mg cap 64 NINLARO 2.3MG CAP 48 NINLARO 3MG CAP 48 NINLARO 4MG CAP 48 NIPENT 10MG INJ 49 nisoldipine 17mg er tab 64 nisoldipine 20mg er tab 64 nisoldipine 30mg er tab 64 nisoldipine 34mg er tab 64 nisoldipine 40mg er tab 64 nisoldipine 8.5mg er tab 64 NITRO-DUR 0.3MG/HR PATCH
16
NITRO-DUR 0.8MG/HR PATCH
16
nitrofurantoin 5mg/ml oral susp
106
nitrofurantoin macro 25mg cap
106
nitrofurantoin monohydrate/macrocrystalline 100mg cap
106
nitrofurantoin, macro 100mg cap
106
nitrofurantoin, macro 50mg cap
106
nitroglycerin 0.1mg/hr patch
16
nitroglycerin 0.2mg/hr patch
16
nitroglycerin 0.3mg sl tab 16 nitroglycerin 0.4mg sl tab 16 nitroglycerin 0.4mg/act pump spray
16
nitroglycerin 0.4mg/hr patch
16
nitroglycerin 0.6mg sl tab 16 nitroglycerin 0.6mg/hr patch
16
nizatidine 150mg cap 105 NIZATIDINE 15MG/ML ORAL SOLN
105
nizatidine 300mg cap 105 nora-be 28 day 0.35mg pack
71
NORDITROPIN 10MG/1.5ML PEN INJ
80
NORDITROPIN 15MG/1.5ML PEN INJ
80
NORDITROPIN 30MG/3ML PEN INJ
80
NORDITROPIN 5MG/1.5ML PEN INJ
80
norethindrone 0.35mg pack
71
norethindrone acetate 5mg tab
99
norlyroc 28 day 0.35mg pack
71
NORMOSOL-M INJ 90 NORMOSOL-R IN 5% DEXTROSE INJ
90
NORMOSOL-R INJ 90
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
142
ALPHABETICAL LISTING OF DRUGS
NORPACE 100MG ER CAP
17
NORPACE 150MG ER CAP
17
NORTHERA 100MG CAP 108 NORTHERA 200MG CAP 108 NORTHERA 300MG CAP 108 nortrel 0.5/35 28 day pack
70
nortrel 1/35 21 day pack 70 nortrel 1/35 28 day pack 70 nortrel 7/7/7 28 day pack 70 nortriptyline 10mg cap 29 nortriptyline 25mg cap 29 NORTRIPTYLINE 2MG/ML ORAL SOLN
29
nortriptyline 50mg cap 29 nortriptyline 75mg cap 29 NORVIR 100MG CAP 57 NORVIR 100MG POWDER PACKET
57
NORVIR 100MG TAB 57 NORVIR 80MG/ML ORAL SOLN
57
NOVOLIN 100UNIT/ML INJ
31
NOVOLIN N 100UNIT/ML INJ
31
NOVOLIN R 100UNIT/ML INJ
31
NOVOLOG 100UNIT/ML FLEXPEN
31
NOVOLOG 100UNIT/ML INJ
31
NOVOLOG 100UNIT/ML PENFILL
31
NOVOLOG MIX 100UNIT/ML FLEXPEN
31
NOVOLOG MIX 100UNIT/ML INJ
31
NOXAFIL 100MG DR TAB
34
NOXAFIL 40MG/ML ORAL SUSP
34
NUCALA 100MG INJ 18
NUCYNTA 100MG ER TAB
13
NUCYNTA 150MG ER TAB
13
NUCYNTA 200MG ER TAB
13
NUCYNTA 250MG ER TAB
13
NUCYNTA 50MG ER TAB
13
NUEDEXTA 20-10MG CAP
101
NULOJIX 250MG INJ 61 NUPLAZID 17MG TAB 53 nutrilipid 20% iv soln 93 NUVARING VAGINAL RING
71
nyamyc 100000unit/gm powder
74
nystatin 100000unit/ml cream
74
nystatin 100000unit/ml oral susp
92
nystatin 100000unit/ml/triamcinolone acetonide 1mg/ml cream
74
nystatin 100unit/mg ointment
74
nystatin 100unit/mg powder
74
nystatin 100unit/mg/triamcinolone acetonide 0.001mg/mg ointment
74
nystatin 500000unit tab 34 nystop 100000unit/gm powder
74
O
OCALIVA 10MG TAB 83 OCALIVA 5MG TAB 83 ocella 28 day pack 70 OCTAGAM 25GM/500ML INJ
97
OCTAGAM 2GM/20ML INJ
97
octreotide 0.05mg/ml inj 81 octreotide 0.1mg/ml inj 81 octreotide 0.2mg/ml inj 81 octreotide 0.5mg/ml inj 81 octreotide 1mg/ml inj 81 ODEFSEY 200-25-25MG TAB
57
ODOMZO 200MG CAP 45 OFEV 100MG CAP 102 OFEV 150MG CAP 102 ofloxacin 0.3% ophth soln 95 ofloxacin 0.3% otic soln 96 ofloxacin 400mg tab 83 olanzapine 10mg inj 54 olanzapine 10mg odt 54 olanzapine 10mg tab 54 olanzapine 15mg odt 54 olanzapine 15mg tab 54 olanzapine 2.5mg tab 54 olanzapine 20mg odt 54 olanzapine 20mg tab 54 olanzapine 5mg odt 54 olanzapine 5mg tab 54 olanzapine 7.5mg tab 54 olmesartan medoxomil 20mg tab
37
olmesartan medoxomil 40mg tab
37
olmesartan medoxomil 5mg tab
37
olopatadine 0.1% ophth soln
96
olopatadine 0.2% ophth soln
96
olopatadine 0.6% nasal inhaler
93
omega-3 acid ethyl esters (usp) 1000mg cap
35
omeprazole 10mg dr cap 105 omeprazole 20mg dr cap 105 omeprazole 40mg dr cap 105 ondansetron 0.8mg/ml oral soln
33
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
143
ALPHABETICAL LISTING OF DRUGS
ondansetron 24mg tab 33 ondansetron 2mg/ml inj 33 ondansetron 2mg/ml syringe
33
ondansetron 4mg odt 33 ondansetron 4mg tab 33 ondansetron 8mg odt 33 ondansetron 8mg tab 33 ONFI 10MG TAB 22 ONFI 2.5MG/ML ORAL SUSP
22
ONFI 20MG TAB 22 OPDIVO 100MG/10ML INJ
45
OPDIVO 40MG/4ML INJ 45 OPSUMIT 10MG TAB 65 ORENCIA 125MG/ML AUTO-INJECTOR
11
ORENCIA 125MG/ML SYRINGE
11
ORENCIA 250MG INJ 11 ORENCIA 50MG/0.4ML SYRINGE
11
ORENCIA 87.5MG/0.7ML SYRINGE
11
ORFADIN 10MG CAP 81 ORFADIN 20MG CAP 81 ORFADIN 2MG CAP 81 ORFADIN 4MG/ML ORAL SUSP
81
ORFADIN 5MG CAP 81 ORKAMBI 100-125MG TAB
102
ORKAMBI 200-125MG TAB
102
orphenadrine citrate 100mg er tab
92
orphenadrine citrate 30mg/ml inj
92
orsythia 28 day pack 70 oseltamivir 30mg cap 60 oseltamivir 45mg cap 60 oseltamivir 6mg/ml oral susp
60
oseltamivir 75mg cap 60
oxacillin 100mg/ml inj 99 oxacillin 2000mg inj 99 OXACILLIN 20MG/ML INJ
99
OXACILLIN 40MG/ML INJ
99
oxaliplatin 100mg inj 43 oxaliplatin 5mg/ml inj 43 oxandrolone 10mg tab 15 oxandrolone 2.5mg tab 15 oxaprozin 600mg tab 11 oxazepam 10mg cap 17 oxazepam 15mg cap 17 oxazepam 30mg cap 17 oxcarbazepine 150mg tab 24 oxcarbazepine 300mg tab 24 oxcarbazepine 600mg tab 24 oxcarbazepine 60mg/ml oral susp
24
OXTELLAR 150MG XR TAB
24
OXTELLAR 300MG XR TAB
24
OXTELLAR 600MG XR TAB
24
oxybutynin chloride 10mg er tab
106
oxybutynin chloride 15mg er tab
106
oxybutynin chloride 1mg/ml oral soln
106
oxybutynin chloride 5mg er tab
106
oxybutynin chloride 5mg tab
106
oxycodone 10mg tab 13 oxycodone 15mg tab 13 oxycodone 1mg/ml oral soln
13
oxycodone 20mg tab 13 oxycodone 20mg/ml oral soln
13
oxycodone 30mg tab 13 oxycodone 5mg cap 13 oxycodone 5mg tab 13
OXYCONTIN 10MG ER TAB
13
OXYCONTIN 15MG ER TAB
13
OXYCONTIN 20MG ER TAB
13
OXYCONTIN 30MG ER TAB
13
OXYCONTIN 40MG ER TAB
13
OXYCONTIN 60MG ER TAB
13
OXYCONTIN 80MG ER TAB
13
oxymorphone 10mg tab 13 oxymorphone 5mg tab 13 OZEMPIC 2MG/1.5ML PEN INJ
30
OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE)
30
P
pacerone 200mg tab 18 pacerone 400mg tab 18 paclitaxel 6mg/ml inj 50 paliperidone 1.5mg er tab 53 paliperidone 3mg er tab 53 paliperidone 6mg er tab 53 paliperidone 9mg er tab 53 pamidronate disodium 3mg/ml inj
79
PAMIDRONATE DISODIUM 6MG/ML INJ
79
pamidronate disodium 9mg/ml inj
79
PANCREAZE 10500-25000-43750UNIT DR CAP
77
PANCREAZE 16800-40000-70000UNIT DR CAP
77
PANCREAZE 21000-37000-61000UNIT DR CAP
77
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
144
ALPHABETICAL LISTING OF DRUGS
PANCREAZE 2600-6200-10850UNIT DR CAP
77
PANCREAZE 4200-10000-17500UNIT DR CAP
77
PANRETIN 0.1% GEL 74 pantoprazole 20mg dr tab 105 pantoprazole 40mg dr tab 105 pantoprazole 40mg inj 105 paricalcitol 0.001mg cap 81 paricalcitol 0.002mg cap 81 paricalcitol 0.002mg/ml inj
81
paricalcitol 0.004mg cap 81 paricalcitol 0.005mg/ml inj
81
paromomycin 250mg cap 9 paroxetine 10mg tab 27 paroxetine 12.5mg er tab 27 paroxetine 20mg tab 27 paroxetine 25mg er tab 27 paroxetine 30mg tab 27 paroxetine 37.5mg er tab 27 paroxetine 40mg tab 27 PASER D/R 4GM GRANULES
43
PAXIL 10MG/5ML ORAL SUSP
27
PEDIARIX INJ 104 PEDVAXHIB 7.5MCG/0.5ML INJ
107
peg 3350/electrolyte oral soln
88
peg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral soln
88
PEGANONE 250MG TAB 25 PEGASYS 135MCG/0.5ML AUTO-INJECTOR
59
PEGASYS 180MCG/0.5ML AUTO-INJECTOR
59
PEGASYS 180MCG/0.5ML SYRINGE
59
PEGASYS 180MCG/ML INJ
59
penicillin g potassium 1000000unit/ml inj
98
PENICILLIN G POTASSIUM 40000UNIT/ML INJ
98
PENICILLIN G POTASSIUM 60000UNIT/ML INJ
98
PENICILLIN G PROCAINE 600000UNIT/ML SYRINGE
98
PENICILLIN G SODIUM 100000UNIT/ML INJ
98
penicillin v potassium 250mg tab
98
penicillin v potassium 25mg/ml oral soln
98
penicillin v potassium 500mg tab
98
penicillin v potassium 50mg/ml oral soln
98
PENTAM 300MG INJ 41 pentoxifylline 400mg er tab
85
perindopril erbumine 2mg tab
37
perindopril erbumine 4mg tab
37
perindopril erbumine 8mg tab
37
periogard 0.12% mouthwash
92
PERJETA 420MG/14ML INJ
45
permethrin 5% cream 77 perphenazine 16mg tab 55 perphenazine 2mg tab 55 perphenazine 4mg tab 55 perphenazine 8mg tab 55
PEXEVA 10MG TAB 27 PEXEVA 20MG TAB 27 PEXEVA 30MG TAB 27 PEXEVA 40MG TAB 27 phenadoz 12.5mg rectal supp
34
phenelzine 15mg tab 26 PHENOBARBITAL 100MG TAB
87
PHENOBARBITAL 15MG TAB
87
phenobarbital 16.2mg tab 87 PHENOBARBITAL 30MG TAB
87
phenobarbital 32.4mg tab 87 phenobarbital 4mg/ml oral soln
87
PHENOBARBITAL 60MG TAB
87
phenobarbital 64.8mg tab 87 phenobarbital 97.2mg tab 87 phenoxybenzamine 10mg cap
37
phenylephrine 1mg/ml/promethazine 1.25mg/ml oral soln
72
phenytoin 25mg/ml oral susp
25
phenytoin 50mg chew tab 25 phenytoin sodium 100mg er cap
25
phenytoin sodium 200mg er cap
25
phenytoin sodium 300mg er cap
25
phenytoin sodium 50mg/ml inj
25
PHOSLYRA 667MG/5ML ORAL SOLN
84
PHOSPHOLINE IODIDE 0.125% OPHTH SOLN
94
physiolyte soln 61 physiosol soln 61 PICATO 0.015% GEL 74 PICATO 0.05% GEL 74
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
145
ALPHABETICAL LISTING OF DRUGS
pilocarpine 1% ophth soln
94
pilocarpine 2% ophth soln
94
pilocarpine 4% ophth soln
94
pilocarpine 5mg tab 92 pilocarpine 7.5mg tab 92 pimozide 1mg tab 101 pimozide 2mg tab 101 pimtrea pack 70 pindolol 10mg tab 62 pindolol 5mg tab 62 pioglitazone 15mg tab 31 pioglitazone 30mg tab 31 pioglitazone 45mg tab 31 piperacillin 2000mg/tazobactam 250mg inj
98
piperacillin 200mg/ml/tazobactam 25mg/ml inj
98
piperacillin 3000mg/tazobactam 375mg inj
98
piperacillin 4000mg/tazobactam 500mg inj
98
pirmella 1/35 28 day pack 70 piroxicam 10mg cap 11 piroxicam 20mg cap 11 PLASMA-LYTE 148 INJ 90 PLASMALYTE A INJ 90 PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR
101
PLEGRIDY 125MCG/0.5ML SYRINGE
101
PLEGRIDY PEN STARTER PACK
101
PLEGRIDY STARTER PACK
101
plenamine 15% inj 94
podofilox 0.5% topical soln
77
polyethylene glycol 3350 142mg/ml oral soln
88
polyethylene glycol 3350/kcl/sodium bicarbonate/sodium chloride/sodium sulfate powder for oral soln
88
polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln
95
polymyxin b 250000unit/ml inj
42
POMALYST 1MG CAP 46 POMALYST 2MG CAP 46 POMALYST 3MG CAP 46 POMALYST 4MG CAP 46 portia 28 day pack 70 potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj
91
potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
91
potassium chloride 0.1meq/ml inj
91
potassium chloride 10% oral soln
91
potassium chloride 10meq er cap
91
potassium chloride 10meq er micro tab
91
potassium chloride 10meq er tab
91
potassium chloride 2 meq/ml inj
91
potassium chloride 20% oral soln
91
potassium chloride 20meq er micro tab
91
POTASSIUM CHLORIDE 20MEQ ER TAB
91
potassium chloride 40meq/20ml inj
91
potassium chloride 8meq er cap
91
potassium chloride 8meq er tab
91
potassium citrate 10meq er tab
84
potassium citrate 15 meq er tab
84
potassium citrate 5 meq er tab
84
PRADAXA 110MG CAP 22 PRADAXA 150MG CAP 22 PRADAXA 75MG CAP 22 PRALUENT 150MG/ML AUTO-INJECTOR
36
PRALUENT 75MG/ML AUTO-INJECTOR
36
pramipexole 0.125mg tab 51 pramipexole 0.25mg tab 51 pramipexole 0.375mg er tab
51
pramipexole 0.5mg tab 51 pramipexole 0.75mg er tab
51
pramipexole 0.75mg tab 51 pramipexole 1.5mg er tab 51 pramipexole 1.5mg tab 52 pramipexole 1mg tab 52 pramipexole 2.25mg er tab
52
pramipexole 3.75mg er tab
52
pramipexole 3mg er tab 52 pramipexole 4.5mg er tab 52 prasugrel 10mg tab 86 prasugrel 5mg tab 86 pravastatin sodium 10mg tab
35
pravastatin sodium 20mg tab
35
pravastatin sodium 40mg tab
35
pravastatin sodium 80mg tab
35
prazosin 1mg cap 38
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
146
ALPHABETICAL LISTING OF DRUGS
prazosin 2mg cap 38 prazosin 5mg cap 38 PRED MILD 0.12% OPHTH SUSP
96
PRED-G 0.3-1% OPHTH SUSP
96
prednicarbate 0.1% cream
76
prednicarbate 0.1% ointment
76
prednisolone 1% ophth soln
96
prednisolone 10mg odt 72 prednisolone 15mg odt 72 prednisolone 1mg/ml oral soln
72
prednisolone 30mg odt 72 prednisolone 3mg/ml oral soln
72
prednisolone acetate 1% ophth susp
96
prednisolone sodium phosphate 2.5mg/ml/sulfacetamide sodium 100mg/ml ophth soln
96
PREDNISONE 10MG (21) TAB PACK
72
PREDNISONE 10MG (48) TAB PACK
72
prednisone 10mg tab 72 prednisone 1mg tab 72 PREDNISONE 1MG/ML ORAL SOLN
72
prednisone 2.5mg tab 72 prednisone 20mg tab 72 PREDNISONE 50MG TAB
72
PREDNISONE 5MG (21) TAB PACK
72
PREDNISONE 5MG (48) TAB PACK
72
prednisone 5mg tab 72 PREDNISONE 5MG/ML ORAL SOLN
72
PREMARIN 0.3MG TAB 82 PREMARIN 0.45MG TAB 82 PREMARIN 0.625MG TAB
82
PREMARIN 0.625MG/GM VAGINAL CREAM
108
PREMARIN 0.9MG TAB 82 PREMARIN 1.25MG TAB 82 PREMASOL 10% INJ 94 premasol 6% inj 94 PREMPHASE 28 DAY PACK
82
PREMPRO 0.3/1.5MG 28 DAY PACK
82
PREMPRO 0.45/1.5 28 DAY PACK
82
PREMPRO 0.625/2.5MG 28 DAY PACK
82
PREMPRO 0.625/5MG 28 DAY PACK
82
prevalite 4gm/dose oral susp
35
previfem 28 day pack 70 PREZCOBIX 800-150MG TAB
58
PREZISTA 100MG/ML ORAL SUSP
58
PREZISTA 150MG TAB 58 PREZISTA 600MG TAB 58 PREZISTA 75MG TAB 58 PREZISTA 800MG TAB 58 PRIFTIN 150MG TAB 43 PRIMAQUINE PHOSPHATE 26.3MG TAB
42
primidone 250mg tab 24 primidone 50mg tab 24 PRIVIGEN 20GM/200ML INJ
97
probenecid 500mg tab 85 PROCAINAMIDE 100MG/ML INJ
17
PROCAINAMIDE 500MG/ML INJ
18
PROCALAMINE 3% INJ 94 prochlorperazine 10mg tab
55
prochlorperazine 25mg rectal supp
55
prochlorperazine 5mg tab 55 prochlorperazine 5mg/ml inj
55
PROCRIT 10000UNIT/ML INJ
86
PROCRIT 20000UNIT/ML INJ
86
PROCRIT 2000UNIT/ML INJ
86
PROCRIT 3000UNIT/ML INJ
86
PROCRIT 40000UNIT/ML INJ
86
PROCRIT 4000UNIT/ML INJ
87
procto-med 2.5% cream 15 procto-pak 1% rectal cream
16
proctosol 2.5% cream 16 proctozone hc 2.5% cream
16
progesterone 100mg cap 99 progesterone 200mg cap 99 PROGLYCEM 50MG/ML ORAL SUSP
30
PROGRAF 5MG/ML INJ 61 PROLASTIN 1000MG INJ 101 PROLEUKIN 22000000UNIT INJ
49
PROLIA 60MG/ML SYRINGE
79
PROMACTA 12.5MG TAB
87
PROMACTA 25MG TAB 87 PROMACTA 50MG TAB 87 PROMACTA 75MG TAB 87 promethazine 1.25mg/ml oral soln
34
promethazine 12.5mg rectal supp
34
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
147
ALPHABETICAL LISTING OF DRUGS
promethazine 12.5mg tab 34 promethazine 25mg rectal supp
34
promethazine 25mg tab 34 promethazine 25mg/ml inj 34 promethazine 50mg rectal supp
34
promethazine 50mg tab 34 promethazine 50mg/ml inj 34 promethegan 25mg rectal supp
34
promethegan 50mg rectal supp
34
propafenone 150mg tab 18 propafenone 225mg er cap
18
propafenone 225mg tab 18 propafenone 300mg tab 18 propafenone 325mg er cap
18
propafenone 425mg er cap
18
PROPANTHELINE 15MG TAB
105
proparacaine 0.5% ophth soln
95
propranolol 10mg tab 62 propranolol 120mg er cap
62
propranolol 160mg er cap
62
propranolol 1mg/ml inj 62 propranolol 20mg tab 62 propranolol 40mg tab 62 PROPRANOLOL 4MG/ML ORAL SOLN
62
propranolol 60mg er cap 62 propranolol 60mg tab 62 propranolol 80mg er cap 63 propranolol 80mg tab 63 PROPRANOLOL 8MG/ML ORAL SOLN
63
propylthiouracil 50mg tab
102
PROQUAD INJ 107
PROSOL 20% INJ 94 protriptyline 10mg tab 29 protriptyline 5mg tab 29 PSORCON 0.05% CREAM
76
PULMOZYME 1MG/ML INH SOLN
102
PURIXAN 2000MG/100ML ORAL SUSP
44
PYLERA 140-125-125MG CAP
106
pyrazinamide 500mg tab 43 pyridostigmine bromide 180mg er tab
43
pyridostigmine bromide 60mg tab
43
Q
QBRELIS 1MG/ML ORAL SOLN
37
QUADRACEL INJ 104 quasense 91 day pack 70 QUDEXY 100MG XR CAP
24
QUDEXY 150MG XR CAP
24
QUDEXY 200MG XR CAP
24
QUDEXY 25MG XR CAP 24 QUDEXY 50MG XR CAP 24 quetiapine 100mg tab 55 quetiapine 150mg xr tab 55 quetiapine 200mg tab 55 quetiapine 200mg xr tab 55 quetiapine 25mg tab 55 quetiapine 300mg tab 55 quetiapine 300mg xr tab 55 quetiapine 400mg tab 55 quetiapine 400mg xr tab 55 quetiapine 50mg tab 55 quetiapine 50mg xr tab 55 quinapril 10mg tab 37 quinapril 20mg tab 37 quinapril 40mg tab 37
quinapril 5mg tab 37 quinidine gluconate 324mg er tab
18
QUINIDINE GLUCONATE 80MG/ML INJ
18
QUINIDINE SULFATE 200MG TAB
18
QUINIDINE SULFATE 300MG TAB
18
quinine sulfate 324mg cap
42
R
RABAVERT 2.5UNIT/ML INJ
107
rabeprazole sodium 20mg dr tab
105
raloxifene 60mg tab 80 ramipril 1.25mg cap 37 ramipril 10mg cap 37 ramipril 2.5mg cap 37 ramipril 5mg cap 37 RANEXA 1000MG ER TAB
16
RANEXA 500MG ER TAB 16 ranitidine 150mg cap 105 ranitidine 150mg tab 105 ranitidine 15mg/ml oral soln
105
ranitidine 25mg/ml inj 105 ranitidine 300mg cap 105 ranitidine 300mg tab 105 RAPAFLO 4MG CAP 85 RAPAFLO 8MG CAP 85 RAPAMUNE 1MG/ML ORAL SOLN
61
rasagiline 0.5mg tab 52 rasagiline 1mg tab 52 RAVICTI 1.1GM/ML ORAL SOLN
81
REBIF 22MCG/0.5ML AUTO-INJECTOR
101
REBIF 22MCG/0.5ML SYRINGE
101
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
148
ALPHABETICAL LISTING OF DRUGS
REBIF 44MCG/0.5ML AUTO-INJECTOR
101
REBIF 44MCG/0.5ML SYRINGE
101
REBIF REBIDOSE PACK 101 REBIF TITRATION PACK 101 reclipsen 28 day pack 70 RECOMBIVAX 10MCG/ML SYRINGE
107
RECOMBIVAX 40MCG/ML INJ
107
RECOMBIVAX 5MCG/0.5ML SYRINGE
107
RECOMBIVAX HB 10MCG/ML INJ
107
REGRANEX 0.01% GEL 77 RELENZA 5MG/BLISTER INH
60
RELISTOR 12MG/0.6ML INJ
84
RELISTOR 12MG/0.6ML SYRINGE
84
RELISTOR 8MG/0.4ML SYRINGE
84
REMODULIN 10MG/ML INJ
65
REMODULIN 1MG/ML INJ
65
REMODULIN 2.5MG/ML INJ
65
REMODULIN 5MG/ML INJ
65
RENVELA 800MG TAB 84 repaglinide 0.5mg tab 31 repaglinide 1mg tab 31 repaglinide 2mg tab 31 REPATHA 120MG/ML CARTRIDGE
36
REPATHA 140MG/ML AUTO-INJECTOR
36
REPATHA 140MG/ML SYRINGE
36
RESCRIPTOR 100MG TAB
58
RESCRIPTOR 200MG TAB
58
RESTASIS 0.05% OPHTH SUSP
95
RETROVIR 10MG/ML INJ
58
REVLIMID 10MG CAP 60 REVLIMID 15MG CAP 60 REVLIMID 2.5MG CAP 60 REVLIMID 20MG CAP 60 REVLIMID 25MG CAP 60 REVLIMID 5MG CAP 60 REXULTI 0.25MG TAB 56 REXULTI 0.5MG TAB 56 REXULTI 1MG TAB 56 REXULTI 2MG TAB 56 REXULTI 3MG TAB 56 REXULTI 4MG TAB 56 REYATAZ 150MG CAP 58 REYATAZ 200MG CAP 58 REYATAZ 300MG CAP 58 REYATAZ 50MG ORAL POWDER
58
ribasphere 200mg cap 59 ribasphere 200mg tab 59 ribasphere 400mg tab 59 ribasphere 600mg tab 59 ribasphere ribapak 1200/day
59
ribasphere ribapak 800/day
59
ribavirin 200mg cap 59 ribavirin 200mg tab 59 RIDAURA 3MG CAP 9 rifabutin 150mg cap 43 RIFAMATE 150-300MG CAP
43
rifampin 150mg cap 43 rifampin 300mg cap 43 rifampin 60mg/ml inj 43 RIFATER 50-120-300MG TAB
43
riluzole 50mg tab 93 rimantadine 100mg tab 60
risedronate sodium 150mg tab
79
risedronate sodium 30mg tab
79
risedronate sodium 35mg (12) pack
79
risedronate sodium 35mg (4) pack
79
risedronate sodium 35mg tab
79
risedronate sodium 5mg tab
79
RISPERDAL 12.5MG INJ 53 RISPERDAL 25MG INJ 53 RISPERDAL 37.5MG INJ 53 RISPERDAL 50MG INJ 53 risperidone 0.25mg odt 53 risperidone 0.25mg tab 53 risperidone 0.5mg odt 53 risperidone 0.5mg tab 53 risperidone 1mg odt 53 risperidone 1mg tab 53 risperidone 1mg/ml oral soln
53
risperidone 2mg odt 53 risperidone 2mg tab 54 risperidone 3mg odt 54 risperidone 3mg tab 54 risperidone 4mg odt 54 risperidone 4mg tab 54 ritonavir 100mg tab 58 RITUXAN 100MG/10ML INJ
45
RITUXAN 500MG/50ML INJ
45
rivastigmine 1.5mg cap 100 rivastigmine 13.3mg/24hr patch
100
rivastigmine 3mg cap 100 rivastigmine 4.5mg cap 100 rivastigmine 4.6mg/24hr patch
100
rivastigmine 6mg cap 100 rivastigmine 9.5mg/24hr patch
100
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
149
ALPHABETICAL LISTING OF DRUGS
rivelsa 91 day pack 70 rizatriptan 10mg odt 89 rizatriptan 10mg tab 89 rizatriptan 5mg odt 89 rizatriptan 5mg tab 89 ropinirole 0.25mg tab 52 ropinirole 0.5mg tab 52 ropinirole 12mg er tab 52 ropinirole 1mg tab 52 ropinirole 2mg er tab 52 ropinirole 2mg tab 52 ropinirole 3mg tab 52 ropinirole 4mg er tab 52 ropinirole 4mg tab 52 ropinirole 5mg tab 52 ropinirole 6mg er tab 52 ropinirole 8mg er tab 52 rosuvastatin 10mg tab 35 rosuvastatin 20mg tab 35 rosuvastatin 40mg tab 36 rosuvastatin 5mg tab 36 ROTARIX ORAL SUSP 107 ROTATEQ ORAL SUSP 107 roweepra 1000mg tab 24 roweepra 500mg er tab 24 roweepra 500mg tab 24 roweepra 750mg er tab 24 roweepra 750mg tab 24 ROZEREM 8MG TAB 87 RUBRACA 200MG TAB 48 RUBRACA 250MG TAB 48 RUBRACA 300MG TAB 48 RUCONEST 2100UNIT INJ
85
RYDAPT 25MG CAP 48
S
SABRIL 500MG ORAL SOLN
25
SABRIL 500MG TAB 25 salmon calcitonin 200unit/act nasal spray
79
SANDIMMUNE 100MG/ML ORAL SOLN
61
SANTYL 250UNIT/GM OINTMENT
77
SAPHRIS 10MG SL TAB 55 SAPHRIS 2.5MG SL TAB 55 SAPHRIS 5MG SL TAB 55 SAVELLA 100MG TAB 100 SAVELLA 12.5MG TAB 100 SAVELLA 25MG TAB 100 SAVELLA 4-WEEK TITRATION PACK
100
SAVELLA 50MG TAB 100 scopolamine 1mg/3days patch
33
selegiline 5mg cap 52 selegiline 5mg tab 52 selenium sulfide 2.5% shampoo
75
SELZENTRY 150MG TAB 58 SELZENTRY 20MG/ML ORAL SOLN
58
SELZENTRY 25MG TAB 58 SELZENTRY 300MG TAB 58 SELZENTRY 75MG TAB 58 SENSIPAR 30MG TAB 81 SENSIPAR 60MG TAB 81 SENSIPAR 90MG TAB 81 SEREVENT 50MCG/DOSE INH
20
sertraline 100mg tab 27 sertraline 20mg/ml oral soln
27
sertraline 25mg tab 27 sertraline 50mg tab 27 setlakin 91 day pack 70 sevelamer carbonate 2400mg oral susp
84
sevelamer carbonate 800mg oral susp
84
sevelamer carbonate 800mg tab
84
sharobel 28 day 0.35mg pack
71
SHINGRIX INJ 107 SIGNIFOR 0.3MG/ML INJ
81
SIGNIFOR 0.6MG/ML INJ
81
SIGNIFOR 0.9MG/ML INJ
81
sildenafil 20mg tab 65 silver sulfadiazine 1% cream
75
SIMBRINZA 1-0.2% OPHTH SUSP
95
SIMPONI ARIA 50MG/4ML INJ
9
SIMULECT 20MG INJ 61 simvastatin 10mg tab 36 simvastatin 20mg tab 36 simvastatin 40mg tab 36 simvastatin 5mg tab 36 simvastatin 80mg tab 36 sirolimus 0.5mg tab 61 sirolimus 1mg tab 61 sirolimus 2mg tab 61 SIRTURO 100MG TAB 43 SIVEXTRO 200MG INJ 42 SIVEXTRO 200MG TAB 42 sodium chloride 0.45% inj
91
sodium chloride 0.9% inj 91 sodium chloride 0.9% soln
85
sodium chloride 2.5 meq/ml inj
91
sodium chloride 3% inj 91 sodium chloride 5% inj 91 sodium lactate 5 meq/ml inj
90
sodium phenylbutyrate 0.94mg/mg oral powder
81
sodium polystyrene sulfonate 250mg/ml oral susp
61
SOLTAMOX 10MG/5ML ORAL SOLN
46
SOLU-CORTEF 100MG INJ
72
SOLU-CORTEF 250MG INJ
72
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
150
ALPHABETICAL LISTING OF DRUGS
SOMATULINE 120MG/0.5ML SYRINGE
81
SOMATULINE 60MG/0.2ML SYRINGE
81
SOMATULINE 90MG/0.3ML SYRINGE
81
SOMAVERT 10MG INJ 79 SOMAVERT 15MG INJ 79 SOMAVERT 20MG INJ 79 SOMAVERT 25MG INJ 80 SOMAVERT 30MG INJ 80 sorine 120mg tab 63 sorine 160mg tab 63 sorine 240mg tab 63 sorine 80mg tab 63 sotalol 120mg tab 63 sotalol 160mg tab 63 sotalol 240mg tab 63 sotalol 80mg tab 63 SPIRIVA 1.25MCG RESPIMAT INH
18
SPIRIVA 18MCG HANDIHALER
18
SPIRIVA 2.5MCG RESPIMAT INH
18
spironolactone 100mg tab
78
spironolactone 25mg tab 78 spironolactone 50mg tab 78 sprintec 28 day pack 70 SPRITAM 1000MG ODT 24 SPRITAM 250MG ODT 24 SPRITAM 500MG ODT 24 SPRITAM 750MG ODT 24 SPRYCEL 100MG TAB 48 SPRYCEL 140MG TAB 48 SPRYCEL 20MG TAB 48 SPRYCEL 50MG TAB 48 SPRYCEL 70MG TAB 48 SPRYCEL 80MG TAB 48 sps 250mg/ml oral susp 61 sronyx 28 day pack 70 ssd 1% cream 75 STALEVO 12.5-50-200MG TAB
52
STALEVO 18.75-75-200MG TAB
52
STALEVO 25-100-200MG TAB
52
STALEVO 31.25-125-200MG TAB
52
STALEVO 37.5-150-200MG TAB
52
STALEVO 50-200-200MG TAB
52
stavudine 15mg cap 58 stavudine 20mg cap 58 stavudine 30mg cap 58 stavudine 40mg cap 58 STIMATE 1.5MG/ML NASAL SPRAY
81
STIOLTO 2.5-2.5MCG INH
20
STIVARGA 40MG TAB 48 STRENSIQ 40MG/ML INJ 81 STRENSIQ 80MG/0.8ML INJ
81
STREPTOMYCIN 100MG INJ
9
STRIBILD 150-150-200-300MG TAB
58
SUBOXONE 12-3MG STRIP
15
SUBOXONE 2-0.5MG STRIP
15
SUBOXONE 4-1MG STRIP
15
SUBOXONE 8-2MG STRIP
15
SUCRAID 8500UNIT/ML ORAL SOLN
77
sucralfate 1000mg tab 105 sulfacetamide sodium 10% lotion
73
SULFACETAMIDE SODIUM 10% OPHTH OINTMENT
95
sulfacetamide sodium 10% ophth soln
95
SULFADIAZINE 500MG TAB
102
sulfamethoxazole 400mg/trimethoprim 80mg tab
41
sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml oral susp
41
sulfamethoxazole 800mg/trimethoprim 160mg tab
41
SULFAMETHOXAZOLE 80MG/ML/TRIMETHOPRIM 16MG/ML INJ
41
SULFAMYLON 85MG/GM CREAM
75
sulfasalazine 500mg dr tab
84
sulfasalazine 500mg tab 84 sulindac 150mg tab 11 sulindac 200mg tab 11 sumatriptan 100mg tab 89 sumatriptan 12mg/ml auto-injector
89
sumatriptan 12mg/ml inj 89 sumatriptan 20mg/act nasal spray
89
sumatriptan 25mg tab 89 sumatriptan 4mg cartridge
89
sumatriptan 50mg tab 89 sumatriptan 5mg/act nasal spray
89
sumatriptan 6mg cartridge
89
sumatriptan 8mg/ml auto-injector
89
SUPRAX 400MG CAP 67 SUSTIVA 200MG CAP 58 SUSTIVA 50MG CAP 58 SUSTIVA 600MG TAB 58 SUTENT 12.5MG CAP 48 SUTENT 25MG CAP 49 SUTENT 37.5MG CAP 49 SUTENT 50MG CAP 49
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
151
ALPHABETICAL LISTING OF DRUGS
syeda 28 day pack 70 SYLATRON 200MCG INJ 49 SYLATRON 300MCG INJ 49 SYLATRON 600MCG INJ 50 SYLVANT 100MG INJ 61 SYLVANT 400MG INJ 61 SYMFI 600-300-300MG TAB
58
SYMFI LO 400-300-300MG TAB
58
SYMPROIC 0.2MG TAB 84 SYNAGIS 100MG/1ML INJ
97
SYNAGIS 50MG/0.5ML INJ
97
SYNAREL 2MG/ML NASAL SPRAY
80
SYNERCID 500MG INJ 42 SYNJARDY 12.5-1000MG TAB
30
SYNJARDY 12.5-500MG TAB
30
SYNJARDY 5-1000MG TAB
30
SYNJARDY 5-500MG TAB
30
SYNJARDY XR 10-1000MG TAB
30
SYNJARDY XR 12.5-1000MG TAB
30
SYNJARDY XR 25-1000MG TAB
30
SYNJARDY XR 5-1000MG TAB
30
SYNRIBO 3.5MG INJ 50 SYNTHROID 100MCG TAB
103
SYNTHROID 112MCG TAB
103
SYNTHROID 125MCG TAB
103
SYNTHROID 137MCG TAB
103
SYNTHROID 150MCG TAB
103
SYNTHROID 175MCG TAB
103
SYNTHROID 200MCG TAB
104
SYNTHROID 25MCG TAB
104
SYNTHROID 300MCG TAB
104
SYNTHROID 50MCG TAB
104
SYNTHROID 75MCG TAB
104
SYNTHROID 88MCG TAB
104
SYPRINE 250MG CAP 60
T
TABLOID 40MG TAB 44 tacrolimus 0.03% ointment
77
tacrolimus 0.1% ointment 77 tacrolimus 0.5mg cap 61 tacrolimus 1mg cap 61 tacrolimus 5mg cap 61 TAFINLAR 50MG CAP 49 TAFINLAR 75MG CAP 49 TAGRISSO 40MG TAB 49 TAGRISSO 80MG TAB 49 TAMIFLU 6MG/ML ORAL SUSP
60
tamoxifen 10mg tab 46 tamoxifen 20mg tab 46 tamsulosin 0.4mg cap 85 TARCEVA 100MG TAB 49 TARCEVA 150MG TAB 49 TARCEVA 25MG TAB 49 TARGRETIN 1% GEL 74 tarina fe 1/20 28 day pack
70
TASIGNA 150MG CAP 49 TASIGNA 200MG CAP 49 TASIGNA 50MG CAP 49 tazarotene 0.1% cream 75 tazicef 1gm inj 67 tazicef 2gm inj 67
tazicef 6gm inj 67 TAZORAC 0.05% CREAM
75
TAZORAC 0.05% GEL 75 TAZORAC 0.1% GEL 75 taztia 120mg er cap 64 taztia 180mg er cap 64 taztia 240mg er cap 64 taztia 300mg er cap 64 taztia 360mg er cap 64 TECENTRIQ 60MG/ML INJ
45
TECFIDERA 120MG DR CAP
101
TECFIDERA 240MG DR CAP
101
TECFIDERA 30-DAY STARTER PACK
101
TEFLARO 400MG INJ 67 TEFLARO 600MG INJ 67 telmisartan 20mg tab 37 telmisartan 40mg tab 37 telmisartan 80mg tab 37 temazepam 15mg cap 87 temazepam 22.5mg cap 87 temazepam 30mg cap 87 temazepam 7.5mg cap 87 TENIVAC SYRINGE 104 tenofovir disoproxil fumarate 300mg tab
58
terazosin 10mg cap 38 terazosin 1mg cap 38 terazosin 2mg cap 38 terazosin 5mg cap 38 terbinafine 250mg tab 34 terbutaline sulfate 1mg/ml inj
20
terbutaline sulfate 2.5mg tab
20
terbutaline sulfate 5mg tab
20
terconazole 0.4% vaginal cream
107
terconazole 0.8% vaginal cream
107
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
152
ALPHABETICAL LISTING OF DRUGS
terconazole 80mg vaginal supp
107
testosterone 1% (25mg) gel
15
testosterone 1% (50mg) gel
15
testosterone 1% gel pump 15 testosterone cypionate 100mg/ml inj
15
testosterone cypionate 200mg/ml inj
15
testosterone enanthate 200mg/ml inj
15
TETANUS/DIPHTHERIA TOXOID INJ
104
tetrabenazine 12.5mg tab 100 tetrabenazine 25mg tab 100 tetracycline 250mg cap 102 tetracycline 500mg cap 102 THALOMID 100MG CAP 60 THALOMID 150MG CAP 60 THALOMID 200MG CAP 60 THALOMID 50MG CAP 60 theophylline 100mg er tab
20
theophylline 200mg er tab
20
theophylline 300mg er tab
20
theophylline 400mg er tab
20
theophylline 5.33mg/ml oral soln
20
theophylline 600mg er tab
20
THIOLA 100MG TAB 85 thioridazine 100mg tab 55 thioridazine 10mg tab 55 thioridazine 25mg tab 55 thioridazine 50mg tab 55 thiotepa 15mg inj 43 thiothixene 10mg cap 56 thiothixene 1mg cap 56 thiothixene 2mg cap 56 thiothixene 5mg cap 56
THYMOGLOBULIN 25MG INJ
61
THYROLAR 120MG TAB 104 THYROLAR 15MG TAB 104 THYROLAR 180MG TAB 104 THYROLAR 30MG TAB 104 THYROLAR 60MG TAB 104 tiagabine 12mg tab 25 tiagabine 16mg tab 25 tiagabine 2mg tab 25 tiagabine 4mg tab 25 TIGECYCLINE 50MG INJ 42 timolol 0.25% ophth gel 94 timolol 0.25% ophth soln 94 timolol 0.5% 24hr ophth soln
94
timolol 0.5% ophth gel 94 timolol 0.5% ophth soln 94 timolol 10mg tab 63 timolol 20mg tab 63 timolol 5mg tab 63 TIMOPTIC-XE 0.25% OPHTH GEL
94
tinidazole 250mg tab 41 tinidazole 500mg tab 41 TIVICAY 10MG TAB 58 TIVICAY 25MG TAB 58 TIVICAY 50MG TAB 58 tizanidine 2mg cap 92 tizanidine 2mg tab 92 tizanidine 4mg cap 92 tizanidine 4mg tab 92 tizanidine 6mg cap 92 TOBI PODHALER KIT 28MG PACK
9
TOBRADEX 0.3-0.1% OPHTH OINTMENT
96
tobramycin 0.3% ophth soln
95
TOBRAMYCIN 10MG/ML INJ
9
tobramycin 40mg/ml inj 9 tobramycin 60mg/ml inh soln
9
TOLAK 4% CREAM 74
tolazamide 250mg tab 32 tolazamide 500mg tab 32 TOLBUTAMIDE 500MG TAB
32
tolcapone 100mg tab 51 tolterodine tartrate 1mg tab
106
tolterodine tartrate 2mg er cap
106
tolterodine tartrate 2mg tab
106
tolterodine tartrate 4mg er cap
106
TOPICORT 0.05% CREAM
76
TOPIRAMATE 100MG ER CAP
24
topiramate 100mg tab 24 TOPIRAMATE 150MG ER CAP
24
topiramate 15mg cap 24 TOPIRAMATE 200MG ER CAP
24
topiramate 200mg tab 24 topiramate 25mg cap 24 TOPIRAMATE 25MG ER CAP
24
topiramate 25mg tab 24 TOPIRAMATE 50MG ER CAP
24
topiramate 50mg tab 25 toposar 1gm/50ml inj 50 topotecan 1mg/ml inj 50 TORISEL 25MG/ML INJ 49 torsemide 100mg tab 78 torsemide 10mg tab 78 torsemide 20mg tab 78 torsemide 5mg tab 78 TOUJEO 300UNIT/ML PEN INJ
31
TOUJEO MAX 300UNIT/ML PEN INJ (3ML)
31
tpn electrolytes inj 91 TRACLEER 125MG TAB 65
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
153
ALPHABETICAL LISTING OF DRUGS
TRACLEER 32MG TAB FOR ORAL SUSP
65
TRACLEER 62.5MG TAB 65 TRADJENTA 5MG TAB 30 tramadol 100mg er tab 13 tramadol 100mg er tab (matrix delivery)
13
tramadol 200mg er tab 13 tramadol 200mg er tab (matrix delivery)
13
tramadol 300mg er tab 13 tramadol 300mg er tab (matrix delivery)
13
tramadol 50mg tab 13 trandolapril 1mg tab 37 trandolapril 1mg/verapamil 240mg er tab
40
trandolapril 2mg tab 37 trandolapril 2mg/verapamil 180mg er tab
40
trandolapril 2mg/verapamil 240mg er tab
40
trandolapril 4mg tab 37 trandolapril 4mg/verapamil 240mg er tab
40
tranexamic acid 100mg/ml inj
87
tranexamic acid 650mg tab
87
TRANSDERM SCOP 1MG/3DAYS PATCH
33
tranylcypromine 10mg tab
26
TRAVASOL 10% INJ 94 TRAVATAN Z 0.004% OPHTH SOLN
96
trazodone 100mg tab 27 trazodone 150mg tab 27 trazodone 300mg tab 27 trazodone 50mg tab 27 TREANDA 100MG INJ 44
TREANDA 25MG INJ 44 TRECATOR 250MG TAB 43 TRELEGY 62.5-25MCG ELLIPTA INH
20
TRELSTAR 11.25MG INJ 46 TRELSTAR 22.5MG INJ 46 TRELSTAR 3.75MG INJ 46 TRESIBA 100UNIT/ML PEN INJ
31
TRESIBA 200UNIT/ML PEN INJ
31
tretinoin 0.01% gel 73 tretinoin 0.025% cream 73 tretinoin 0.025% gel 73 tretinoin 0.04% gel 73 tretinoin 0.05% cream 73 tretinoin 0.05% gel 73 tretinoin 0.1% cream 73 tretinoin 0.1% gel 73 tretinoin 10mg cap 50 TREXALL 10MG TAB 44 TREXALL 15MG TAB 44 TREXALL 5MG TAB 44 TREXALL 7.5MG TAB 44 triamcinolone 55mcg nasal spray
93
triamcinolone acetonide 0.025% cream
76
triamcinolone acetonide 0.025% lotion
76
triamcinolone acetonide 0.025% ointment
76
triamcinolone acetonide 0.1% cream
76
triamcinolone acetonide 0.1% lotion
76
triamcinolone acetonide 0.1% ointment
76
triamcinolone acetonide 0.1% oral paste
92
triamcinolone acetonide 0.147mg/ml spray
76
triamcinolone acetonide 0.5% cream
76
triamcinolone acetonide 0.5% ointment
76
triamcinolone acetonide 40mg/ml inj
72
TRIAZOLAM 0.125MG TAB
87
triazolam 0.25mg tab 87 triderm 0.1% cream 76 trientine 250mg tab 91 trifluoperazine 10mg tab 55 trifluoperazine 1mg tab 55 trifluoperazine 2mg tab 56 trifluoperazine 5mg tab 56 trifluridine 1% soln 95 trihexyphenidyl 0.4mg/ml oral soln
51
trihexyphenidyl 2mg tab 51 trihexyphenidyl 5mg tab 51 tri-legest 28 day pack 70 tri-lo-estarylla 28 day pack
70
tri-lo-sprintec 28 day pack
70
trilyte powder for oral soln
88
trimethobenzamide 300mg cap
33
trimethoprim 100mg tab 41 tri-mili 28 day pack 70 trimipramine 100mg cap 29 trimipramine 25mg cap 29 trimipramine 50mg cap 29 trinessa 28 day pack 70 TRINTELLIX 10MG TAB 27 TRINTELLIX 20MG TAB 27 TRINTELLIX 5MG TAB 27 tri-previfem 28 day pack 70 TRISENOX 12MG/6ML INJ
50
tri-sprintec 28 day pack 70 TRIUMEQ 600-50-300MG TAB
58
trivora 28 day pack 70 tri-vylibra 28 day pack 70
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
154
ALPHABETICAL LISTING OF DRUGS
TROKENDI 100MG XR CAP
25
TROKENDI 200MG XR CAP
25
TROKENDI 25MG XR CAP
25
TROKENDI 50MG XR CAP
25
TROPHAMINE 10% INJ 94 trospium chloride 20mg tab
106
trospium chloride 60mg er cap
106
TRUMENBA SYRINGE 107 TRUVADA 100-150MG TAB
58
TRUVADA 133-200MG TAB
58
TRUVADA 167-250MG TAB
58
TRUVADA 200-300MG TAB
58
TWINRIX 720UNIT SYRINGE
107
TYBOST 150MG TAB 58 TYGACIL 50MG INJ 42 TYKERB 250MG TAB 49 TYMLOS 2MG/ML PEN INJECTOR
79
TYPHIM VI 25MCG/0.5ML INJ
107
TYPHIM VI 25MCG/0.5ML SYRINGE
107
TYSABRI 300MG/15ML INJ
101
U
UCERIS 2MG/ACT FOAM 15 UCERIS 9MG ER TAB 72 ULORIC 40MG TAB 85 ULORIC 80MG TAB 85 UNASYN 10-5GM INJ 98 UNASYN 2-1GM INJ 98 unithroid 100mcg tab 104 unithroid 112mcg tab 104
unithroid 125mcg tab 104 unithroid 150mcg tab 104 unithroid 175mcg tab 104 unithroid 200mcg tab 104 unithroid 25mcg tab 104 unithroid 300mcg tab 104 unithroid 50mcg tab 104 unithroid 75mcg tab 104 unithroid 88mcg tab 104 UPTRAVI 1000MCG TAB 66 UPTRAVI 1200MCG TAB 66 UPTRAVI 1400MCG TAB 66 UPTRAVI 1600MCG TAB 66 UPTRAVI 200MCG TAB 66 UPTRAVI 400MCG TAB 66 UPTRAVI 600MCG TAB 66 UPTRAVI 800MCG TAB 66 UPTRAVI TITRATION PACK
66
ursodiol 250mg tab 83 ursodiol 300mg cap 83 ursodiol 500mg tab 83
V
valacyclovir 1000mg tab 60 valacyclovir 500mg tab 60 VALCHLOR 0.016% GEL 74 VALCYTE 50MG/ML ORAL SOLN
59
valganciclovir 450mg tab 59 valganciclovir 50mg/ml oral soln
59
valproic acid 100mg/ml inj
26
valproic acid 250mg cap 26 valproic acid 50mg/ml oral soln
26
valsartan 160mg tab 37 valsartan 320mg tab 37 valsartan 40mg tab 37 valsartan 80mg tab 37 vancomycin 1000mg inj 41 vancomycin 100mg/ml inj 41 vancomycin 125mg cap 41 vancomycin 250mg cap 41
vancomycin 500mg inj 41 vandazole 0.75% vaginal gel
107
VAQTA 25UNIT/0.5ML SYRINGE
107
VAQTA 50UNIT/0.5ML INJ
107
VAQTA 50UNIT/1ML INJ 107 VAQTA 50UNIT/ML SYRINGE
107
VARIVAX 1350PFU/0.5ML INJ
107
VARUBI 90MG TAB 33 VASCEPA 1GM CAP 35 VASCEPA 500MG CAP 35 VECTIBIX 100MG/5ML INJ
45
VELCADE 3.5MG INJ 49 velivet 28 day pack 70 VELTASSA 16.8GM POWDER FOR ORAL SUSP
61
VELTASSA 25.2GM POWDER FOR ORAL SUSP
61
VELTASSA 8.4GM POWDER FOR ORAL SUSP
61
VEMLIDY 25MG TAB 59 VENCLEXTA 10/100/50MG STARTING PACK
45
VENCLEXTA 100MG TAB
45
VENCLEXTA 10MG TAB 45 VENCLEXTA 50MG TAB 45 venlafaxine 100mg tab 28 venlafaxine 150mg er cap 28 venlafaxine 150mg er tab 28 VENLAFAXINE 225MG ER TAB
28
venlafaxine 25mg tab 28 venlafaxine 37.5mg er cap
28
venlafaxine 37.5mg er tab 28
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
155
ALPHABETICAL LISTING OF DRUGS
venlafaxine 37.5mg tab 28 venlafaxine 50mg tab 28 venlafaxine 75mg er cap 28 venlafaxine 75mg er tab 28 venlafaxine 75mg tab 28 VENTAVIS 10MCG/ML INH SOLN
65
VENTAVIS 20MCG/ML INH SOLN
65
VENTOLIN 108MCG INH 20 verapamil 100mg er cap 64 verapamil 120mg er cap 64 verapamil 120mg er tab 64 verapamil 120mg tab 64 verapamil 180mg er cap 64 verapamil 180mg er tab 64 verapamil 2.5mg/ml inj 64 verapamil 200mg er cap 64 verapamil 240mg er cap 64 verapamil 240mg er tab 64 verapamil 300mg er cap 64 verapamil 360mg sr cap 65 verapamil 40mg tab 65 verapamil 80mg tab 65 VERSACLOZ 50MG/ML ORAL SUSP
55
VERZENIO 100MG TAB 49 VERZENIO 150MG TAB 49 VERZENIO 200MG TAB 49 VERZENIO 50MG TAB 49 VESICARE 10MG TAB 106 VESICARE 5MG TAB 106 vestura 3-0.02mg pack 70 vicodin 10-300mg tab 14 vicodin 5-300mg tab 14 vicodin 7.5-300mg tab 14 VICTOZA 18MG/3ML PEN INJ
30
VIDEX 125MG DR CAP 58 VIDEX 2GM ORAL SOLN 58 vienva 28 day pack 70 vigabatrin 50mg/ml oral soln
25
VIGAMOX 0.5% OPHTH SOLN
95
VIIBRYD 10/20MG STARTER PACK
27
VIIBRYD 10MG TAB 27 VIIBRYD 20MG TAB 27 VIIBRYD 40MG TAB 27 VIMPAT 100MG TAB 25 VIMPAT 10MG/ML ORAL SOLN
25
VIMPAT 150MG TAB 25 VIMPAT 200MG TAB 25 VIMPAT 200MG/20ML INJ
25
VIMPAT 50MG TAB 25 VINBLASTINE 1MG/ML INJ
50
vincasar 1mg/ml inj 50 vincristine sulfate 1mg/ml inj
50
vinorelbine 10mg/ml inj 50 VIRACEPT 250MG TAB 58 VIRACEPT 625MG TAB 58 VIRAMUNE 50MG/5ML ORAL SUSP
58
VIREAD 150MG TAB 58 VIREAD 200MG TAB 58 VIREAD 250MG TAB 59 VIREAD 300MG TAB 59 VIREAD 40MG/GM ORAL POWDER
59
voriconazole 200mg inj 34 voriconazole 200mg tab 34 voriconazole 40mg/ml oral susp
34
voriconazole 50mg tab 34 VOTRIENT 200MG TAB 49 VPRIV 400UNIT INJ 86 VRAYLAR 1.5/3MG MIXED PACK
53
VRAYLAR 1.5MG CAP 53 VRAYLAR 3MG CAP 53 VRAYLAR 4.5MG CAP 53 VRAYLAR 6MG CAP 53 vyfemla 28 day pack 70 vylibra 28 day pack 70 VYVANSE 10MG CAP 7
VYVANSE 10MG CHEW TAB
7
VYVANSE 20MG CAP 7 VYVANSE 20MG CHEW TAB
7
VYVANSE 30MG CAP 7 VYVANSE 30MG CHEW TAB
7
VYVANSE 40MG CAP 7 VYVANSE 40MG CHEW TAB
7
VYVANSE 50MG CAP 7 VYVANSE 50MG CHEW TAB
7
VYVANSE 60MG CAP 7 VYVANSE 60MG CHEW TAB
7
VYVANSE 70MG CAP 7 VYXEOS 44-100MG INJ 46
W
warfarin sodium 10mg tab
21
warfarin sodium 1mg tab 21 warfarin sodium 2.5mg tab
21
warfarin sodium 2mg tab 21 warfarin sodium 3mg tab 21 warfarin sodium 4mg tab 21 warfarin sodium 5mg tab 21 warfarin sodium 6mg tab 21 warfarin sodium 7.5mg tab
21
water 1000mg/ml soln 61 WELCHOL 3.75GM ORAL SUSP
35
WELCHOL 625MG TAB 35 wymzya fe 28 day pack 70
X
XALKORI 200MG CAP 49 XALKORI 250MG CAP 49 XARELTO 10MG TAB 21 XARELTO 15MG TAB 21 XARELTO 20MG TAB 21
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
156
ALPHABETICAL LISTING OF DRUGS
XARELTO STARTER PACK
21
XATMEP 2.5MG/ML ORAL SOLN
44
XGEVA 120MG/1.7ML INJ
79
XIFAXAN 200MG TAB 41 XIFAXAN 550MG TAB 41 XIGDUO 10-1000MG XR TAB
30
XIGDUO 10-500MG XR TAB
30
XIGDUO 2.5-1000MG XR TAB
30
XIGDUO 5-1000MG XR TAB
30
XIGDUO 5-500MG XR TAB
30
XOLAIR 150MG INJ 18 XTAMPZA 13.5MG ER CAP
13
XTAMPZA 18MG ER CAP
13
XTAMPZA 27MG ER CAP
13
XTAMPZA 36MG ER CAP
13
XTAMPZA 9MG ER CAP 13 XTANDI 40MG CAP 46 XULANE 150-35MCG PATCH
71
XULTOPHY 100UNIT-3.6MG/ML PEN INJ
30
XYREM 500MG/ML ORAL SOLN
99
Y
YERVOY 50MG/10ML INJ
45
YF-VAX 4000UNIT/ML INJ
107
YONDELIS 1MG INJ 44
Z
zafirlukast 10mg tab 19
zafirlukast 20mg tab 19 zaleplon 10mg cap 87 zaleplon 5mg cap 87 ZALTRAP 100MG/4ML INJ
44
ZANOSAR 1GM INJ 44 zarah 3-0.03mg pack 70 ZARXIO 300MCG/0.5ML SYRINGE
87
ZARXIO 480MCG/0.8ML SYRINGE
87
ZAVESCA 100MG CAP 86 ZEJULA 100MG CAP 49 ZELBORAF 240MG TAB 49 ZEMAIRA 1000MG INJ 102 zenatane 10mg cap 73 zenatane 20mg cap 73 zenatane 30mg cap 73 zenatane 40mg cap 73 zenchent 28 day pack 70 ZEPATIER 50-100MG TAB
59
ZERBAXA 1.5GM INJ 66 ZERIT 1MG/ML ORAL SOLN
59
ZIAGEN 20MG/ML ORAL SOLN
59
zidovudine 100mg cap 59 zidovudine 10mg/ml oral soln
59
zidovudine 300mg tab 59 zileuton 600mg er tab 19 ziprasidone 20mg cap 53 ziprasidone 40mg cap 53 ziprasidone 60mg cap 53 ziprasidone 80mg cap 53 ZIRGAN 0.15% OPHTH GEL
95
zoledronic acid 0.05mg/ml inj
79
zoledronic acid 0.8mg/ml inj
79
ZOLINZA 100MG CAP 49 zolmitriptan 2.5mg odt 89 zolmitriptan 2.5mg tab 89
zolmitriptan 5mg odt 89 zolmitriptan 5mg tab 89 zolpidem tartrate 10mg tab
87
zolpidem tartrate 5mg tab 87 ZOMETA 4MG/100ML INJ
79
ZOMIG 2.5MG NASAL SPRAY
89
ZOMIG 5MG NASAL SPRAY
89
zonisamide 100mg cap 25 zonisamide 25mg cap 25 zonisamide 50mg cap 25 ZORTRESS 0.25MG TAB 61 ZORTRESS 0.5MG TAB 61 ZORTRESS 0.75MG TAB 61 ZOSTAVAX 19400UNIT/0.65ML INJ
107
ZOSYN 40-5MG/ML INJ 98 ZOSYN 60-7.5MG/ML INJ
98
zovia 1/35e 28 day pack 70 ZUBSOLV 11.4-2.9MG SL TAB
15
ZUBSOLV 1.4-0.36MG SL TAB
15
ZUBSOLV 2.9-0.71MG SL TAB
15
ZUBSOLV 5.7-1.4MG SL TAB
15
ZUBSOLV 8.6-2.1MG SL TAB
15
ZYCLARA 2.5% CREAM 77 ZYDELIG 100MG TAB 49 ZYDELIG 150MG TAB 49 ZYKADIA 150MG CAP 49 ZYLET 0.5-0.3% OPHTH SUSP
96
ZYPREXA 210MG INJ 55 ZYTIGA 250MG TAB 46 ZYTIGA 500MG TAB 46
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
157
Liberty Advantage is required by federal law to provide the following information.
Discrimination is Against the Law
Liberty Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Liberty Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Liberty Advantage:
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formats) • Provides free language services to people whose primary language is not English, suchas:
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If you need these services, contact our Corporate Compliance Officer.
If you believe that Liberty Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Corporate Compliance Officer, Liberty Advantage, 10900 Nuckols Road, Suite 110, Glen Allen, VA 23060, phone: 844-317-9059, TTY 711, fax: 804-299-4059, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance out Corporate Compliance Officer is available to help you.
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This formulary was updated on 08/01/2018. For more recent information or other questions, please contact Liberty Advantage Member Services at 1-844-854-6884 or, for TTY users, 711, Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30, or visit www.libertyadvantageplan.com.
Liberty Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Liberty Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
Liberty Advantage 遵守適用的聯邦民權法律規定,不因種族、膚色、民族血統、年齡、殘障 或性別而歧視任何人。
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注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-888-854-6884 TTY:711。