Partnership 2017 Formulary List of Covered Drugs FOR ... · PDF filePartnership 2017 Formulary List of Covered Drugs FOR MEMBERS ENROLLED IN MEDICAID ONLY ... process that addresses

Medicaid Only_DHS Approved 12/15/2016

Partnership 2017 Formulary

List of Covered Drugs

FOR MEMBERS ENROLLED IN MEDICAID ONLY

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID: 17379, Version Number 26

This formulary was updated on 10/24/2017. For more recent information or other questions, please contact

Family Care Customer Service at 1-800-963-0035 or, for TTY users, Wisconsin Relay 711, 8 a.m. – 8 p.m.,

7 days a week, or visit www.carewisc.org.

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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 Care Wisconsin Health Plan, Inc.

When it refers to “plan” or “our plan,” it means Partnership.

This document includes a list of the drugs (formulary) for our plan which is current as of 10/24/2017. For an

updated formulary, please contact us. Our contact information, along with the date we last updated the

formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time

during the year.

Care Wisconsin Health Plan, Inc., contracts with the Wisconsin Department of Health Services (DHS) to

offer the Partnership Program.

To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin

Customer Service at 1-800-963-0035 (TTY/TDD Wisconsin Relay System 711).

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What is the Care Wisconsin Formulary?

A formulary is a list of covered drugs selected by Care Wisconsin 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. Care Wisconsin will generally cover the drugs listed in our formulary as long as the drug is

medically necessary, the prescription is filled at a Care Wisconsin network pharmacy, and other plan rules

are followed. For more information on how to fill your prescriptions, please review your Member

Handbook.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we

will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less

expensive generic drug becomes available or when new adverse information about the safety or effectiveness

of a drug is released.

Other types of 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, 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 10/24/2017. To get updated

information about the drugs covered by Care Wisconsin, please contact us. Our contact information appears

on the front and back cover pages.

In the event of a mid-year non-maintenance formulary change, we will mail you updates to the formulary as

needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or

printing them from our Web site.

How do I use the Formulary?

To find your drug within the formulary:

Alphabetical Listing

The formulary begins on page 1. You should look for your drug in the listing that begins on page 2. The

formulary provides an alphabetical list of all of the drugs included in this document. Both brand name

drugs and generic drugs are listed in the formulary. Look in the formulary and find your drug.

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What are generic drugs?

Partnership 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: Partnership requires you [or your physician] to get prior authorization for

certain drugs. This means that you will need to get approval from Partnership before you fill your

prescriptions. If you don’t get approval, Partnership may not cover the drug.

• Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will

cover. For example, Partnership provides 62 tablets per prescription for Xifaxan. This may be in

addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B

both treat your medical condition, Partnership may not cover Drug B unless you try Drug A first. If

Drug A does not work for you, Partnership will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 1. 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 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.

You can ask Partnership 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 Partnership

formulary?” on page iv 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 Partnership does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Partnership. When you

receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered

by Partnership.

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• You can ask Partnership to make an exception and cover your drug. See below for information about

how to request an exception.

How do I request an exception to the Partnership Formulary?

You can ask Partnership 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.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Partnership 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, Partnership 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.

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 30-day supply (unless you have a prescription written for fewer days) when you go to a

network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a

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 91 to 98-day transition supply, consistent with dispensing increment, (unless you have a

prescription written for fewer days). We will cover more than one refill of these drugs for the first 90days

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

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emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary

exception.

Current members with a change in where they receive care

Partnership has a transition process that addresses unplanned transitions as members change treatment

settings due to changes in the type of care they require. Changes in where you live or receive care may

warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of

program enrollment. Examples of situations include:

• You were discharged from the hospital and were provided a discharge list of medications based upon

the formulary of the hospital.

• Beneficiaries who give up Hospice Status to revert back to standard Medicaid benefits.

• Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of

medications that are highly individualized.

Please note that our transition policy applies only to those drugs that are on our formulary and are

supplied by a network pharmacy.

For more information

For more detailed information about your Partnership prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about Partnership, please contact us. Our contact information, along with the date we

last updated the formulary, appears on the front and back cover pages.

For more information about Medicaid, please contact the Wisconsin Department of Health Services by

calling 1-800-362-3002. You can also get information by visiting their website at

www.dhs.wisconsin.gov/Medicaid.

Partnership Formulary

The formulary that begins on the next page provides coverage information about the drugs covered by

Partnership.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EMBEDA) and

generic drugs are listed in lower-case italics (e.g., fentanyl).

The information in the Requirements/Limits column tells you if Partnership has any special requirements for

coverage of your drug.

You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the

drug table. Last Updated 10/26/2017 Effective Date: 11/01/2017

1

LEGEND

1: Covered Medications

1(CW): CW OTC

1(ND): Non D RX

1(SO): State OTC

HR: High Risk Medication (PA required for ages 65 or over)

LA: This prescription drug is limited to certain pharmacies.

PA: You (or your physician) are required to get prior authorization before you fill your prescription for this drug.

Without prior approval, we may not cover this drug.

QL: There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.

ST: In some cases, you may be required to first try certain drugs to treat your medical condition before we will

cover another drug for that condition.



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Care Wisconsin Medicaid (List of Covered Drugs)

Drug Tier Notes

abacavir sulfate oral tablet 300 mg 1 QL (62 EA per 31 days)

abacavir sulfate-lamivudine oral tablet 600-300

mg 1 QL (31 EA per 31 days)

abacavir-lamivudine-zidovudine oral tablet 300-

150-300 mg 1 QL (62 EA per 31 days)

ABELCET INTRAVENOUS SUSPENSION 5

MG/ML 1

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION RECONSTITUTED 300 MG, 400

MG

1 ST; QL (1 EA per 26 days)

ABRAXANE INTRAVENOUS SUSPENSION

RECONSTITUTED 100 MG 1

ABSORICA ORAL CAPSULE 10 MG, 20 MG,

25 MG, 30 MG, 35 MG, 40 MG 1

acamprosate calcium oral tablet delayed release

333 mg 1

acarbose oral tablet 100 mg, 25 mg, 50 mg 1 QL (93 EA per 31 days)

acebutolol hcl oral capsule 200 mg, 400 mg 1

acetaminophen er oral tablet extended release

650 mg 1(SO)

acetaminophen extra strength oral liquid 500

mg/15ml 1(SO)

acetaminophen extra strength oral tablet 500 mg 1(SO)

acetaminophen oral capsule 500 mg 1(SO)

acetaminophen oral elixir 160 mg/5ml 1(SO)

acetaminophen oral liquid 160 mg/5ml 1(SO)

acetaminophen oral solution 160 mg/5ml 1(SO)

acetaminophen oral suspension 160 mg/5ml 1(SO)

acetaminophen oral tablet 325 mg 1(SO)

acetaminophen oral tablet chewable 80 mg 1(SO)

acetaminophen rectal suppository 120 mg, 650

mg 1(SO)

acetaminophen-codeine #2 oral tablet 300-15 mg 1 QL (413 EA per 31 days)





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Drug Tier Notes

acetaminophen-codeine oral solution 120-12

mg/5ml 1 QL (5167 ML per 31 days)

acetazolamide oral tablet 125 mg, 250 mg 1

acetic acid otic solution 2 % 1

acetylcysteine inhalation solution 10 %, 20 % 1

ACID GONE ORAL SUSPENSION 95-358

MG/15ML 1(SO)

ACID GONE ORAL TABLET CHEWABLE

160-105 MG 1(SO)

acidophilus extra strength oral capsule 1(CW)

acidophilus oral tablet chewable 1(CW)

acidophilus probiotic oral capsule 100 mg 1(CW)

acidophilus probiotic oral tablet 1(SO)

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1

acne maximum strength external cream 10 % 1(SO)

acne medication 10 external lotion 10 % 1(SO)

acne medication 5 external lotion 5 % 1(SO)

acne treatment external bar 10 % 1(SO)

ACTEMRA INTRAVENOUS SOLUTION 200

MG/10ML, 400 MG/20ML, 80 MG/4ML 1 ST

ACTEMRA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 162 MG/0.9ML 1 ST

ACTHIB INTRAMUSCULAR SOLUTION

RECONSTITUTED 1

ACTIMMUNE SUBCUTANEOUS SOLUTION

2000000 UNIT/0.5ML 1 PA; LA

acyclovir external ointment 5 % 1

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5ml 1

acyclovir oral tablet 400 mg, 800 mg 1

acyclovir sodium intravenous solution 50 mg/ml 1

ADACEL INTRAMUSCULAR SUSPENSION

5-2-15.5 LF-MCG/0.5 1

ADAGEN INTRAMUSCULAR SOLUTION 250

UNIT/ML 1 PA; LA

adapalene external cream 0.1 % 1

adapalene external gel 0.1 %, 0.3 % 1



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Drug Tier Notes

ADCIRCA ORAL TABLET 20 MG 1 PA

adefovir dipivoxil oral tablet 10 mg 1

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5

MG, 2 MG, 2.5 MG 1 QL (93 EA per 31 days)

adriamycin intravenous solution 2 mg/ml 1

adrucil intravenous solution 500 mg/10ml 1

ADVAIR DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-50

MCG/DOSE, 250-50 MCG/DOSE, 500-50

MCG/DOSE

1 QL (62 EA per 31 days)

ADVAIR HFA INHALATION AEROSOL 115-

21 MCG/ACT, 230-21 MCG/ACT, 45-21

MCG/ACT

1 QL (12 GM per 30 days)

ADVIL JUNIOR STRENGTH ORAL TABLET

100 MG 1(SO)

ADVIL ORAL CAPSULE 200 MG 1(SO)

AFEDITAB CR ORAL TABLET EXTENDED

RELEASE 24 HOUR 30 MG, 60 MG 1 QL (62 EA per 31 days)

AFINITOR DISPERZ ORAL TABLET

SOLUBLE 2 MG, 3 MG 1 PA; QL (31 EA per 31 days)

AFINITOR DISPERZ ORAL TABLET

SOLUBLE 5 MG 1 PA; QL (62 EA per 31 days)

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5

MG, 7.5 MG 1 PA; QL (31 EA per 31 days)

AFTERA ORAL TABLET 1.5 MG 1(SO)

ALBENZA ORAL TABLET 200 MG 1

albuterol sulfate er oral tablet extended release

12 hour 4 mg, 8 mg 1

albuterol sulfate inhalation nebulization solution

(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63

mg/3ml, 1.25 mg/3ml

1

albuterol sulfate oral syrup 2 mg/5ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

alclometasone dipropionate external cream 0.05

% 1

alclometasone dipropionate external ointment

0.05 % 1

ALDURAZYME INTRAVENOUS SOLUTION

2.9 MG/5ML 1 PA; LA



5

Drug Tier Notes

ALECENSA ORAL CAPSULE 150 MG 1 PA

alendronate sodium oral tablet 10 mg, 40 mg, 5


alendronate sodium oral tablet 35 mg, 70 mg 1 QL (4 EA per 28 days)

alevazol external ointment 1 % 1(SO)

ALEVE ORAL CAPSULE 220 MG 1(SO)

ALIMTA INTRAVENOUS SOLUTION

RECONSTITUTED 500 MG 1 PA

ALINIA ORAL SUSPENSION

RECONSTITUTED 100 MG/5ML 1 QL (155 ML per 31 days)

ALINIA ORAL TABLET 500 MG 1 QL (41 EA per 31 days)

ALIVIO EXTERNAL PATCH 0.03-5 % 1(CW)

all day allergy oral capsule 10 mg 1(SO)

allergy medication oral tablet 25 mg 1(SO)

allergy relief oral tablet dispersible 10 mg 1(SO)

allergy relief-d oral tablet extended release 12

hour 5-120 mg 1(SO)

allopurinol oral tablet 100 mg, 300 mg 1

ALMACONE ORAL TABLET CHEWABLE

200-200-25 MG 1(SO)

alosetron hcl oral tablet 0.5 mg, 1 mg 1 QL (62 EA per 31 days)

ALPHAGAN P OPHTHALMIC SOLUTION 0.1

%, 0.15 % 1

alprazolam er oral tablet extended release 24

hour 0.5 mg, 1 mg, 2 mg, 3 mg 1 QL (124 EA per 31 days)

ALPRAZOLAM INTENSOL ORAL

CONCENTRATE 1 MG/ML 1

alprazolam oral tablet 0.25 mg, 0.5 mg 1 QL (124 EA per 31 days)

alprazolam oral tablet 1 mg 1 QL (248 EA per 31 days)

alprazolam oral tablet 2 mg 1 QL (155 EA per 31 days)

alprazolam oral tablet dispersible 0.25 mg, 0.5

mg, 1 mg, 2 mg 1 QL (186 EA per 31 days)

alprazolam xr oral tablet extended release 24

hour 0.5 mg 1 QL (124 EA per 31 days)

aluminum hydroxide gel oral suspension 320

mg/5ml 1(SO)

ALUNBRIG ORAL TABLET 30 MG 1 PA; QL (186 EA per 31 days)

alyacen 1/35 oral tablet 1-35 mg-mcg 1



6

Drug Tier Notes

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral syrup 50 mg/5ml 1

amantadine hcl oral tablet 100 mg 1

AMBISOME INTRAVENOUS SUSPENSION


amcinonide external cream 0.1 % 1

amcinonide external lotion 0.1 % 1

amcinonide external ointment 0.1 % 1

AMETHIA ORAL TABLET 0.15-0.03 &0.01

MG 1

amikacin sulfate injection solution 500 mg/2ml 1

amiloride hcl oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet 5-50

mg 1

aminophylline intravenous solution 25 mg/ml 1

AMINOSYN II INTRAVENOUS SOLUTION 10

%, 8.5 % 1

AMINOSYN II/ELECTROLYTES

INTRAVENOUS SOLUTION 8.5 % 1

AMINOSYN/ELECTROLYTES

INTRAVENOUS SOLUTION 7 %, 8.5 % 1

AMINOSYN-HBC INTRAVENOUS

SOLUTION 7 % 1

AMINOSYN-PF INTRAVENOUS SOLUTION

10 %, 7 % 1

AMINOSYN-RF INTRAVENOUS SOLUTION

5.2 % 1

amiodarone hcl intravenous solution 150 mg/3ml 1

amiodarone hcl oral tablet 100 mg, 200 mg, 400

mg 1

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 1

amitriptyline hcl oral tablet 10 mg, 100 mg, 150

mg, 25 mg, 50 mg, 75 mg 1 PA; HR

amlodipine besy-benazepril hcl oral capsule 10-

20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg,

5-40 mg

1

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5




7

Drug Tier Notes

amlodipine besylate-valsartan oral tablet 10-160

mg, 10-320 mg, 5-160 mg, 5-320 mg 1 QL (31 EA per 31 days)

amlodipine-atorvastatin oral tablet 10-10 mg, 10-

20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20

mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80

mg

1

amlodipine-olmesartan oral tablet 10-20 mg, 10-

40 mg, 5-20 mg, 5-40 mg 1 QL (31 EA per 31 days)

amlodipine-valsartan-hctz oral tablet 10-160-12.5

mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg,

5-160-25 mg


ammonium lactate external cream 12 % 1

ammonium lactate external lotion 12 % 1

amnesteem oral capsule 10 mg, 20 mg, 40 mg 1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50

mg 1 PA; HR

amoxicill-clarithro-lansopraz oral 1

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension reconstituted 125

mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet chewable 125 mg, 250 mg 1

amoxicillin-pot clavulanate oral suspension

reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml,

400-57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-pot clavulanate oral tablet 250-125

mg, 500-125 mg, 875-125 mg 1

amoxicillin-pot clavulanate oral tablet chewable

200-28.5 mg, 400-57 mg 1

amphetamine-dextroamphetamine oral tablet 10

mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg 1 QL (93 EA per 31 days)

amphetamine-dextroamphetamine oral tablet 30


amphotericin b injection solution reconstituted 50

mg 1

ampicillin oral capsule 250 mg, 500 mg 1

ampicillin sodium injection solution reconstituted

1 gm, 125 mg 1



8

Drug Tier Notes

ampicillin sodium intravenous solution

reconstituted 10 gm 1

ampicillin-sulbactam sodium injection solution

reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm 1

ampicillin-sulbactam sodium intravenous solution

reconstituted 15 (10-5) gm 1

AMPYRA ORAL TABLET EXTENDED

RELEASE 12 HOUR 10 MG 1 PA; ST; QL (62 EA per 31 days)

ANADROL-50 ORAL TABLET 50 MG 1

anastrozole oral tablet 1 mg 1 QL (31 EA per 31 days)

ANDRODERM TRANSDERMAL PATCH 24

HOUR 2 MG/24HR, 4 MG/24HR 1

ANDROGEL TRANSDERMAL GEL 20.25

MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) 1

antacid & antigas oral suspension 200-200-20

mg/5ml, 400-400-40 mg/5ml 1(SO)

antacid extra strength oral tablet chewable 675-

135 mg 1(CW)

antacid oral tablet chewable 1177 mg, 420 mg,

500 mg, 550-110 mg 1(CW)

antacid ultra strength oral tablet chewable 1000

mg, 1000-200 mg 1(CW)

anti-diarrheal oral capsule 2 mg 1(CW)

anti-diarrheal oral tablet 2 mg 1(CW)

antifungal external cream 2 % 1(SO)

anti-itch maximum strength external cream 1 % 1(CW)

anti-oxidant formula oral capsule 1(CW)

antiseptic skin cleanser external solution 4 % 1(CW)

ANUSOL-HC RECTAL SUPPOSITORY 25 MG 1(CW)

apraclonidine hcl ophthalmic solution 0.5 % 1

aprepitant oral capsule 125 mg, 40 mg, 80 mg 1 QL (31 EA per 31 days)

aprepitant oral capsule 80 & 125 mg 1 QL (12 EA per 31 days)

APRI ORAL TABLET 0.15-30 MG-MCG 1

APRISO ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 0.375 GM 1 QL (124 EA per 31 days)

APTIOM ORAL TABLET 200 MG, 400 MG,

800 MG 1 QL (31 EA per 31 days)

APTIOM ORAL TABLET 600 MG 1 QL (62 EA per 31 days)



9

Drug Tier Notes

APTIVUS ORAL CAPSULE 250 MG 1 QL (124 EA per 31 days)

APTIVUS ORAL SOLUTION 100 MG/ML 1 QL (295 ML per 28 days)

AQUORAL MOUTH/THROAT AEROSOL

SOLUTION 1(CW)

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-

MCG 1

ARCALYST SUBCUTANEOUS SOLUTION


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

mg, 30 mg, 5 mg 1

aripiprazole oral tablet dispersible 10 mg 1

ARIPIPRAZOLE ORAL TABLET

DISPERSIBLE 15 MG 1

ARISTADA INTRAMUSCULAR PREFILLED

SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML,

662 MG/2.4ML, 882 MG/3.2ML

1 ST

ARNUITY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100

MCG/ACT, 200 MCG/ACT


arthricream rub external cream 10 % 1(CW)

ARTHRITIS HOT EXTERNAL CREAM 10-15

% 1(CW)

arthritis pain relief oral tablet extended release

650 mg 1(SO)

arthritis relief/aloe external aerosol 10 % 1(CW)

artificial tears ophthalmic ointment 83-15 % 1(SO)

artificial tears ophthalmic solution 0.1-0.3 %, 1-

0.3 %, 1.4 %, 5-6 mg/ml 1(SO)

ARZOL SILVER NIT APPLICATORS

EXTERNAL 75-25 % 1(ND)

ASCOMP-CODEINE ORAL CAPSULE 50-325-

40-30 MG 1 PA; HR; QL (382 EA per 31 days)

ASPERCREME EXTERNAL LOTION 10 % 1(CW)

ASPERCREME HEAT EXTERNAL GEL 10 % 1(CW)

ASPERCREME LIDOCAINE EXTERNAL

PATCH 4 % 1(CW) QL (90 EA per 30 days)

aspirin ec low strength oral tablet delayed release

81 mg 1(SO)

aspirin ec oral tablet delayed release 325 mg 1(SO)



10

Drug Tier Notes

aspirin oral tablet 325 mg 1(SO)

aspirin oral tablet chewable 81 mg 1(SO)

aspirin-dipyridamole er oral capsule extended

release 12 hour 25-200 mg 1

ASSURE ID INSULIN SAFETY SYR 29G X

1/2" 1 ML 1

ASTAGRAF XL ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG 1 ST

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg,

50-25 mg 1

athletes foot external cream 1 % 1(CW)

athletes foot external powder 2 % 1(SO)

athletes foot powder spray external aerosol

powder 2 % 1(SO)

athletes foot spray external aerosol 1 % 1(SO)

ATOMOXETINE HCL ORAL CAPSULE 10

MG, 18 MG, 25 MG 1 QL (93 EA per 31 days)

ATOMOXETINE HCL ORAL CAPSULE 100

MG, 40 MG, 60 MG, 80 MG 1 QL (31 EA per 31 days)

atorvastatin calcium oral tablet 10 mg, 20 mg, 40

mg, 80 mg 1 QL (31 EA per 31 days)

atovaquone oral suspension 750 mg/5ml 1

atovaquone-proguanil hcl oral tablet 250-100 mg,

62.5-25 mg 1

ATRIPLA ORAL TABLET 600-200-300 MG 1 QL (31 EA per 31 days)

atropine sulfate ophthalmic solution 1 % 1

ATROVENT HFA INHALATION AEROSOL

SOLUTION 17 MCG/ACT 1 QL (31 GM per 31 days)

AUBAGIO ORAL TABLET 14 MG, 7 MG 1 PA; ST; LA; QL (30 EA per 30

days)

AUBRA ORAL TABLET 0.1-20 MG-MCG 1

AVASTIN INTRAVENOUS SOLUTION 100

MG/4ML 1 PA

AVASTIN INTRAVENOUS SOLUTION 400

MG/16ML 1

AVIANE ORAL TABLET 0.1-20 MG-MCG 1

AVONEX INTRAMUSCULAR KIT 30 MCG 1 PA



11

Drug Tier Notes

AVONEX PEN INTRAMUSCULAR AUTO-

INJECTOR KIT 30 MCG/0.5ML 1 PA

AVONEX PREFILLED INTRAMUSCULAR

PREFILLED SYRINGE KIT 30 MCG/0.5ML 1 PA

AYR NASAL MIST ALLERGY/SINUS NASAL

SOLUTION 2.65 % 1(CW)

AYR NASAL SOLUTION 0.65 % 1(CW)

AYR SALINE NASAL NASAL GEL 1(CW)

azacitidine injection suspension reconstituted 100

mg 1

AZASAN ORAL TABLET 100 MG, 75 MG 1 ST

AZASITE OPHTHALMIC SOLUTION 1 % 1

azathioprine oral tablet 50 mg 1

azathioprine sodium injection solution

reconstituted 100 mg 1

azelastine hcl nasal solution 0.1 %, 0.15 % 1

azelastine hcl ophthalmic solution 0.05 % 1

azithromycin intravenous solution reconstituted

500 mg 1

azithromycin oral packet 1 gm 1

azithromycin oral suspension reconstituted 100

mg/5ml, 200 mg/5ml 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

AZOLEN TINCTURE EXTERNAL SOLUTION

2 % 1(SO)

AZOPT OPHTHALMIC SUSPENSION 1 % 1

aztreonam injection solution reconstituted 1 gm 1

b-12 compliance injection injection kit 1000

mcg/ml 1(ND)

B-12 DOTS ORAL TABLET DISPERSIBLE 500

MCG 1(CW)

b-12 oral tablet 2000 mcg, 2500 mcg 1(CW)

b-12 sublingual tablet sublingual 100-5000 mcg,

3000 mcg 1(CW)

b-6 oral tablet 100 mg 1(CW) QL (31 EA per 31 days)

bacitracin external ointment 500 unit/gm 1(SO)

bacitracin intramuscular solution reconstituted

50000 unit 1



12

Drug Tier Notes

bacitracin ophthalmic ointment 500 unit/gm 1

bacitracin-neomycin-polymyxin external ointment

400-5-5000 1(SO)

bacitracin-polymyxin b external ointment 500-

10000 unit/gm 1(SO)

bacitracin-polymyxin b ophthalmic ointment 500-

10000 unit/gm 1

bacitra-neomycin-polymyxin-hc ophthalmic

ointment 1 % 1

baclofen oral tablet 10 mg, 20 mg 1

balsalazide disodium oral capsule 750 mg 1

BALZIVA ORAL TABLET 0.4-35 MG-MCG 1

BANZEL ORAL SUSPENSION 40 MG/ML 1 QL (2852 ML per 31 days)

BANZEL ORAL TABLET 200 MG 1 QL (496 EA per 31 days)

BANZEL ORAL TABLET 400 MG 1 QL (248 EA per 31 days)

BARACLUDE ORAL SOLUTION 0.05 MG/ML 1 PA

BAVENCIO INTRAVENOUS SOLUTION 200

MG/10ML 1 PA

BAYER ADVANCED ASPIRIN EX ST ORAL

TABLET 500 MG 1(SO)

BAYER ASPIRIN EC LOW DOSE ORAL

TABLET DELAYED RELEASE 81 MG 1(SO)

BAYER ASPIRIN ORAL TABLET 325 MG 1(SO)

BAYER ASPIRIN ORAL TABLET DELAYED

RELEASE 325 MG 1(SO)

bcg vaccine injection injectable 1

bedding spray lice treatment aerosol 0.5 % 1(SO)

BELEODAQ INTRAVENOUS SOLUTION


BENADRYL ALLERGY CHILDRENS ORAL

LIQUID 12.5 MG/5ML 1(SO)

BENADRYL ALLERGY ORAL CAPSULE 25

MG 1(SO)

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5

mg 1

benazepril-hydrochlorothiazide oral tablet 10-

12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg 1

BENEFIBER ON THE GO ORAL PACKET 1(CW)



13

Drug Tier Notes

BENEFIBER ORAL POWDER 1(CW)

BENGAY COLD THERAPY EXTERNAL GEL

5 % 1(CW)

BENGAY ULTRA STRENGTH EXTERNAL

CREAM 4-10-30 % 1(CW)

BENGAY VANISHING SCENT EXTERNAL

GEL 2.5 % 1(CW)

BENLYSTA INTRAVENOUS SOLUTION

RECONSTITUTED 120 MG, 400 MG 1

BENLYSTA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 200 MG/ML 1

BENLYSTA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 200 MG/ML 1

benzonatate oral capsule 100 mg, 150 mg, 200

mg 1(ND)

benzoyl peroxide external gel 10 %, 2.5 %, 5 % 1(SO)

benzoyl peroxide wash external liquid 10 %, 5 % 1(SO)

benzoyl peroxide-erythromycin external gel 5-3 % 1

benztropine mesylate injection solution 1 mg/ml 1

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2

mg 1 PA; HR

BERRI-FREEZ PAIN RELIEVING EXTERNAL

GEL 4.5 % 1(CW)

betamethasone dipropionate aug external cream

0.05 % 1

betamethasone dipropionate aug external gel 0.05

% 1

betamethasone dipropionate aug external lotion

0.05 % 1

betamethasone dipropionate aug external

ointment 0.05 % 1

betamethasone dipropionate external cream 0.05

% 1

betamethasone dipropionate external lotion 0.05

% 1

betamethasone dipropionate external ointment

0.05 % 1

betamethasone valerate external cream 0.1 % 1

betamethasone valerate external foam 0.12 % 1



14

Drug Tier Notes

betamethasone valerate external lotion 0.1 % 1

betamethasone valerate external ointment 0.1 % 1

BETASERON SUBCUTANEOUS KIT 0.3 MG 1 PA; QL (15 EA per 31 days)

betaxolol hcl ophthalmic solution 0.5 % 1

betaxolol hcl oral tablet 10 mg, 20 mg 1

bethanechol chloride oral tablet 10 mg, 25 mg, 5

mg, 50 mg 1

bexarotene oral capsule 75 mg 1 PA

BEXSERO INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 1

bicalutamide oral tablet 50 mg 1 QL (31 EA per 31 days)

BICILLIN C-R 900/300 INTRAMUSCULAR

SUSPENSION 900000-300000 UNIT/2ML 1

BICILLIN C-R INTRAMUSCULAR

SUSPENSION 1200000 UNIT/2ML 1

BICILLIN L-A INTRAMUSCULAR

SUSPENSION 1200000 UNIT/2ML, 2400000

UNIT/4ML, 600000 UNIT/ML

1

BICNU INTRAVENOUS SOLUTION


BIOFREEZE EXTERNAL GEL 4 % 1(CW)

biospec dmx oral liquid 15-25 mg/5ml 1(SO)

BIOTENE MOISTURIZING MOUTH

MOUTH/THROAT SOLUTION 1(CW)

BIOTENE ORALBALANCE DRY MOUTH

MOUTH/THROAT GEL 1(CW)

bisacodyl ec oral tablet delayed release 5 mg 1(CW)

bisacodyl laxative rectal suppository 10 mg 1(CW)

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet 10-

6.25 mg, 2.5-6.25 mg, 5-6.25 mg 1

bleomycin sulfate injection solution reconstituted

30 unit 1

BLEPHAMIDE OPHTHALMIC SUSPENSION

10-0.2 % 1

BLEPHAMIDE S.O.P. OPHTHALMIC

OINTMENT 10-0.2 % 1



15

Drug Tier Notes

BOOSTRIX INTRAMUSCULAR

SUSPENSION 5-2.5-18.5 1

BOSULIF ORAL TABLET 100 MG 1 PA; QL (124 EA per 31 days)

BOSULIF ORAL TABLET 500 MG 1 PA; QL (31 EA per 31 days)

bp wash external liquid 2.5 % 1(SO)

BREO ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-25

MCG/INH, 200-25 MCG/INH

1

briellyn oral tablet 0.4-35 mg-mcg 1

BRILINTA ORAL TABLET 60 MG, 90 MG 1

brimonidine tartrate ophthalmic solution 0.15 %,

0.2 % 1

BRIVIACT INTRAVENOUS SOLUTION 50

MG/5ML 1 PA

BRIVIACT ORAL SOLUTION 10 MG/ML 1 PA

BRIVIACT ORAL TABLET 10 MG, 100 MG,

25 MG, 50 MG, 75 MG 1 PA

bromfenac sodium ophthalmic solution 0.09 % 1

bromocriptine mesylate oral capsule 5 mg 1

bromocriptine mesylate oral tablet 2.5 mg 1

budesonide inhalation suspension 0.25 mg/2ml,

0.5 mg/2ml, 1 mg/2ml 1

budesonide nasal suspension 32 mcg/act 1

bumetanide injection solution 0.25 mg/ml 1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

buprenorphine hcl sublingual tablet sublingual 2

mg, 8 mg 1 PA

bupropion hcl er (smoking det) oral tablet

extended release 12 hour 150 mg 1 QL (93 EA per 31 days)

bupropion hcl er (sr) oral tablet extended release

12 hour 100 mg 1 QL (124 EA per 31 days)





bupropion hcl er (xl) oral tablet extended release

24 hour 150 mg, 300 mg 1 QL (93 EA per 31 days)

bupropion hcl oral tablet 100 mg 1 QL (186 EA per 31 days)



16

Drug Tier Notes

bupropion hcl oral tablet 75 mg 1

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5

mg, 7.5 mg 1

busulfan intravenous solution 6 mg/ml 1

butalbital-apap-caff-cod oral capsule 50-300-40-

30 mg, 50-325-40-30 mg 1 PA; HR; QL (381 EA per 31 days)

BYDUREON SUBCUTANEOUS PEN-

INJECTOR 2 MG 1

BYDUREON SUBCUTANEOUS SUSPENSION

RECONSTITUTED ER 2 MG 1

BYETTA 10 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 10 MCG/0.04ML 1

BYETTA 5 MCG PEN SUBCUTANEOUS


cabergoline oral tablet 0.5 mg 1

CABOMETYX ORAL TABLET 20 MG, 40 MG,

60 MG 1

CAFERGOT ORAL TABLET 1-100 MG 1

CALCET CREAMY BITES ORAL TABLET

CHEWABLE 500-400 MG-UNIT 1(CW)

CALCI-MIX ORAL CAPSULE 1250 (500 CA)

MG 1(CW)

calcipotriene external cream 0.005 % 1

calcipotriene external ointment 0.005 % 1

calcipotriene external solution 0.005 % 1

calcipotriene-betameth diprop external ointment

0.005-0.064 % 1

calcitonin (salmon) nasal solution 200 unit/act 1 QL (4 ML per 28 days)

cal-citrate plus vitamin d oral tablet 250-100 mg-

unit 1(CW)

calcitriol intravenous solution 1 mcg/ml 1

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

calcium + d3 oral tablet 600-200 mg-unit 1(CW)

calcium 1000 + d oral tablet 1000-800 mg-unit 1(CW)

calcium 500 + d oral tablet 500-125 mg-unit 1(CW)

calcium 500 + d3 oral tablet 500-600 mg-unit 1(CW)

calcium 500 +d oral tablet 500-400 mg-unit 1(CW)



17

Drug Tier Notes

calcium 500/d oral tablet chewable 500-400 mg-

unit 1(CW)

calcium 500+d oral tablet 500-200 mg-unit 1(CW)

calcium 600 oral tablet 1500 (600 ca) mg, 600 mg 1(CW)

calcium 600/vitamin d oral tablet chewable 600-

400 mg-unit 1(CW)

calcium 600+d oral tablet 600-200 mg-unit, 600-

400 mg-unit, 600-800 mg-unit 1(CW)

calcium 600-d oral tablet 600-400 mg-unit 1(CW)

calcium acetate (phos binder) oral capsule 667

mg 1

calcium acetate (phos binder) oral tablet 667 mg 1

calcium antacid extra strength oral tablet

chewable 750 mg 1(CW)

calcium carbonate antacid oral tablet 648 mg,

650 mg 1(CW)

calcium carbonate antacid oral tablet chewable

500 mg 1(CW)

calcium carbonate oral suspension 1250 (500 ca)

mg/5ml 1(SO)

calcium carbonate oral tablet 1250 (500 ca) mg 1(CW)

calcium carbonate oral tablet chewable 1250

(500 ca) mg, 260 mg 1(CW)

calcium carbonate-vitamin d oral capsule 600-

200 mg-unit 1(CW)

calcium carbonate-vitamin d oral tablet 500-400

mg-unit 1(CW)

calcium citrate + d oral tablet 250-200 mg-unit,

315-200 mg-unit, 315-250 mg-unit 1(CW)

calcium citrate + d3 oral tablet 200-250 mg-unit 1(CW)

calcium citrate oral tablet 200 mg 1(CW)

calcium citrate-vitamin d oral tablet 200-125 mg-

unit 1(CW)

calcium oral tablet 500 mg, 600 mg 1(CW)

calcium oral tablet chewable 500-100 mg-unit 1(CW)

calcium plus vitamin d3 oral capsule 600-500

mg-unit 1(CW)

calcium-vitamin d oral tablet 600-200 mg-unit 1(CW)



18

Drug Tier Notes

calcium-vitamin d3 oral capsule 600-400 mg-unit 1(CW)

CALTRATE 600+D3 SOFT ORAL TABLET

CHEWABLE 600-800 MG-UNIT 1(CW)

CAMILA ORAL TABLET 0.35 MG 1

CANCIDAS INTRAVENOUS SOLUTION


candesartan cilexetil oral tablet 16 mg, 4 mg, 8


candesartan cilexetil oral tablet 32 mg 1 QL (31 EA per 31 days)

candesartan cilexetil-hctz oral tablet 16-12.5 mg,

32-12.5 mg, 32-25 mg 1 QL (31 EA per 31 days)

CAPASTAT SULFATE INJECTION

SOLUTION RECONSTITUTED 1 GM 1

CAPRELSA ORAL TABLET 100 MG 1 PA; QL (62 EA per 31 days)

CAPRELSA ORAL TABLET 300 MG 1 PA; QL (31 EA per 31 days)

capsaicin arthritis relief external liquid 0.15 % 1(SO)

capsaicin external cream 0.025 %, 0.075 % 1(SO)

capsaicin hot patch external pad 0.025 % 1(CW)

capsaicin hp external cream 0.1 % 1(SO)

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

mg 1

captopril-hydrochlorothiazide oral tablet 25-15

mg, 25-25 mg, 50-15 mg, 50-25 mg 1

CAPZASIN-P EXTERNAL CREAM 0.035 % 1(CW)

CARBAGLU ORAL TABLET 200 MG 1

carbamazepine er oral capsule extended release

12 hour 100 mg, 200 mg, 300 mg 1

carbamazepine er oral tablet extended release 12

hour 100 mg, 200 mg, 400 mg 1

carbamazepine oral suspension 100 mg/5ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet chewable 100 mg 1

carbidopa-levodopa er oral tablet extended

release 25-100 mg, 50-200 mg 1

carbidopa-levodopa oral tablet 10-100 mg, 25-

100 mg, 25-250 mg 1

carbidopa-levodopa oral tablet dispersible 10-

100 mg, 25-100 mg, 25-250 mg 1



19

Drug Tier Notes

carbidopa-levodopa-entacapone oral tablet 12.5-

50-200 mg, 18.75-75-200 mg, 25-100-200 mg,

31.25-125-200 mg, 37.5-150-200 mg, 50-200-200

mg

1

carbinoxamine maleate oral solution 4 mg/5ml 1

carbinoxamine maleate oral tablet 4 mg 1

carboplatin intravenous solution 150 mg/15ml 1

carisoprodol-aspirin oral tablet 200-325 mg 1 PA; HR; QL (248 EA per 31 days)

carisoprodol-aspirin-codeine oral tablet 200-325-

16 mg 1 PA; HR; QL (248 EA per 31 days)

carteolol hcl ophthalmic solution 1 % 1

CARTIA XT ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 180 MG, 240 MG 1 QL (186 EA per 31 days)

CARTIA XT ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 300 MG 1 QL (31 EA per 31 days)

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,

6.25 mg 1

CASPOFUNGIN ACETATE INTRAVENOUS

SOLUTION RECONSTITUTED 50 MG, 70 MG 1

CASTIVA COOLING EXTERNAL LOTION 5-

14 % 1(CW)

CASTIVA WARMING EXTERNAL LOTION

0.035 % 1(CW)

castor oil oil 1(CW)

castor oil oral oil 100 % 1(CW)

CAYSTON INHALATION SOLUTION

RECONSTITUTED 75 MG 1 PA; QL (84 ML per 28 days)

caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1

cefaclor er oral tablet extended release 12 hour

500 mg 1

cefaclor oral capsule 250 mg, 500 mg 1

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension reconstituted 250


cefadroxil oral tablet 1 gm 1

cefazolin sodium injection solution reconstituted

1 gm, 10 gm, 500 mg 1

cefdinir oral capsule 300 mg 1



20

Drug Tier Notes

cefdinir oral suspension reconstituted 125


cefepime hcl injection solution reconstituted 1

gm, 2 gm 1

cefotaxime sodium injection solution reconstituted

1 gm, 2 gm, 500 mg 1

cefotetan disodium injection solution

reconstituted 1 gm, 2 gm 1

cefoxitin sodium injection solution reconstituted

10 gm 1

cefoxitin sodium intravenous solution

reconstituted 1 gm, 2 gm 1

cefpodoxime proxetil oral suspension

reconstituted 100 mg/5ml, 50 mg/5ml 1

cefpodoxime proxetil oral tablet 100 mg, 200 mg 1

cefprozil oral suspension reconstituted 125


cefprozil oral tablet 250 mg, 500 mg 1

ceftazidime injection solution reconstituted 1 gm,

2 gm, 6 gm 1

ceftriaxone sodium injection solution

reconstituted 250 mg, 500 mg 1

ceftriaxone sodium intravenous solution

reconstituted 1 gm, 10 gm, 2 gm 1

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection solution

reconstituted 1.5 gm, 7.5 gm, 750 mg 1

celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 QL (62 EA per 31 days)

celecoxib oral capsule 400 mg 1 QL (31 EA per 31 days)

CELONTIN ORAL CAPSULE 300 MG 1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension reconstituted 125


cephalexin oral tablet 250 mg, 500 mg 1

CEREZYME INTRAVENOUS SOLUTION

RECONSTITUTED 400 UNIT 1 PA

cetirizine hcl allergy child oral solution 5 mg/5ml 1(SO)

cetirizine hcl oral syrup 1 mg/ml 1(SO) QL (310 ML per 31 days)



21

Drug Tier Notes

cetirizine hcl oral tablet 10 mg, 5 mg 1(SO)

cetirizine hcl oral tablet chewable 10 mg, 5 mg 1(SO)

cetirizine-pseudoephedrine er oral tablet

extended release 12 hour 5-120 mg 1(SO)

cevimeline hcl oral capsule 30 mg 1

CHANTIX CONTINUING MONTH PAK ORAL

TABLET 1 MG 1 PA

CHANTIX ORAL TABLET 0.5 MG 1 PA; QL (11 EA per 31 days)

CHANTIX ORAL TABLET 1 MG 1 PA; QL (174 EA per 84 days)

CHANTIX STARTING MONTH PAK ORAL

TABLET 0.5 MG X 11 & 1 MG X 42 1 PA; QL (53 EA per 28 days)

cheratussin ac oral solution 100-10 mg/5ml 1(ND)

chest rub external ointment 4.8-1.2-2.6 % 1(CW)

childrens acetaminophen oral suspension 160

mg/5ml 1(SO)

childrens acetaminophen oral tablet dispersible

80 mg 1(SO)

childrens ibuprofen 100 oral suspension 100

mg/5ml 1(SO)

childrens loratadine oral syrup 5 mg/5ml 1(SO)

childrens mucus relief cough oral liquid 5-100

mg/5ml 1(SO)

childrens pepto oral tablet chewable 400 mg 1(CW)

childrens silfedrine oral liquid 15 mg/5ml 1(SO)

CHILDRENS SOOTHE ORAL TABLET

CHEWABLE 400 MG 1(CW)

childs ibuprofen oral suspension 100 mg/5ml 1(SO)

chloramphenicol sod succinate intravenous

solution reconstituted 1 gm 1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg,

5 mg 1 QL (124 EA per 31 days)

chlorhexidine gluconate external liquid 4 % 1(CW)

chlorhexidine gluconate mouth/throat solution

0.12 % 1

chloroquine phosphate oral tablet 250 mg, 500

mg 1

chlorothiazide oral tablet 250 mg, 500 mg 1



22

Drug Tier Notes

chlorothiazide sodium intravenous solution


chlorpromazine hcl injection solution 50 mg/2ml 1

chlorpromazine hcl oral tablet 10 mg, 100 mg,

200 mg, 25 mg, 50 mg 1

chlorpropamide oral tablet 100 mg, 250 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

chlorzoxazone oral tablet 500 mg 1 PA; HR; QL (186 EA per 31 days)

cholestyramine light oral packet 4 gm 1

cholestyramine light oral powder 4 gm/dose 1

chorionic gonadotropin intramuscular solution

reconstituted 10000 unit 1 PA

CIALIS ORAL TABLET 2.5 MG, 5 MG 1 PA; QL (31 EA per 31 days)

ciclopirox external shampoo 1 % 1

ciclopirox external solution 8 % 1

ciclopirox olamine external cream 0.77 % 1

ciclopirox olamine external suspension 0.77 % 1

cilostazol oral tablet 100 mg, 50 mg 1

CIMZIA PREFILLED SUBCUTANEOUS KIT 2

X 200 MG/ML 1 ST

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG 1 ST

CINRYZE INTRAVENOUS SOLUTION

RECONSTITUTED 500 UNIT 1 PA; QL (100 EA per 31 days)

ciprofloxacin hcl ophthalmic solution 0.3 % 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500

mg, 750 mg 1

ciprofloxacin in d5w intravenous solution 200

mg/100ml 1

ciprofloxacin intravenous solution 400 mg/40ml 1

ciprofloxacin oral suspension reconstituted 250

mg/5ml (5%), 500 mg/5ml (10%) 1

cisplatin intravenous solution 100 mg/100ml 1

citalopram hydrobromide oral solution 10


citalopram hydrobromide oral tablet 10 mg, 40


citalopram hydrobromide oral tablet 20 mg 1 QL (186 EA per 31 days)



23

Drug Tier Notes

CITRUCEL ORAL TABLET 500 MG 1(CW)

cladribine intravenous solution 10 mg/10ml 1

CLARAVIS ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG 1

clarithromycin er oral tablet extended release 24

hour 500 mg 1

clarithromycin oral suspension reconstituted 125


clarithromycin oral tablet 250 mg, 500 mg 1

CLARITIN ALLERGY CHILDRENS ORAL

SYRUP 5 MG/5ML 1(SO)

CLARITIN CHILDRENS ORAL TABLET

CHEWABLE 5 MG 1(SO)

CLARITIN ORAL CAPSULE 10 MG 1(SO)

CLARITIN ORAL TABLET 10 MG 1(SO)

CLARITIN-D 12 HOUR ORAL TABLET

EXTENDED RELEASE 12 HOUR 5-120 MG 1(SO)

CLARITIN-D 24 HOUR ORAL TABLET

EXTENDED RELEASE 24 HOUR 10-240 MG 1(SO)

clemastine fumarate oral tablet 2.68 mg 1

clindamycin hcl oral capsule 150 mg, 300 mg, 75

mg 1

clindamycin palmitate hcl oral solution

reconstituted 75 mg/5ml 1

clindamycin phos-benzoyl perox external gel 1-5

% 1

clindamycin phosphate external gel 1 % 1

clindamycin phosphate external lotion 1 % 1

clindamycin phosphate external solution 1 % 1

clindamycin phosphate external swab 1 % 1

clindamycin phosphate in d5w intravenous

solution 600 mg/50ml 1

clindamycin phosphate injection solution 300

mg/2ml, 600 mg/4ml, 900 mg/6ml 1

clindamycin phosphate vaginal cream 2 % 1

CLINIMIX E/DEXTROSE (2.75/5)




24

Drug Tier Notes





CLINIMIX E/DEXTROSE (5/15)

INTRAVENOUS SOLUTION 5 % 1

CLINIMIX/DEXTROSE (2.75/5)










CLINIMIX/DEXTROSE (5/15) INTRAVENOUS

SOLUTION 5 % 1


SOLUTION 5 % 1


SOLUTION 5 % 1

clobetasol propionate e external cream 0.05 % 1

clobetasol propionate external foam 0.05 % 1

clobetasol propionate external gel 0.05 % 1

clobetasol propionate external lotion 0.05 % 1

clobetasol propionate external ointment 0.05 % 1

clobetasol propionate external shampoo 0.05 % 1

clobetasol propionate external solution 0.05 % 1

clofarabine intravenous solution 1 mg/ml 1

clomipramine hcl oral capsule 25 mg, 50 mg, 75

mg 1 PA; HR

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

clonazepam oral tablet dispersible 0.125 mg, 0.25

mg, 0.5 mg, 1 mg, 2 mg 1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine hcl transdermal patch weekly 0.1

mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 1 QL (4 EA per 28 days)



25

Drug Tier Notes

clopidogrel bisulfate oral tablet 75 mg 1 QL (31 EA per 31 days)

clorazepate dipotassium oral tablet 15 mg 1 QL (186 EA per 31 days)

clorazepate dipotassium oral tablet 3.75 mg 1 QL (744 EA per 31 days)

clorazepate dipotassium oral tablet 7.5 mg 1 QL (372 EA per 31 days)

clotrimazole 3 vaginal cream 2 % 1(SO)

clotrimazole af external cream 1 % 1(SO)

clotrimazole external cream 1 % 1

clotrimazole external solution 1 % 1

clotrimazole mouth/throat troche 10 mg 1

clotrimazole-7 vaginal cream 1 % 1(SO)

clotrimazole-betamethasone external cream 1-

0.05 % 1

clotrimazole-betamethasone external lotion 1-

0.05 % 1

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

mg 1

clozapine oral tablet dispersible 100 mg, 150 mg,

200 mg, 25 mg 1 ST

clozapine oral tablet dispersible 12.5 mg 1

COARTEM ORAL TABLET 20-120 MG 1 QL (24 EA per 31 days)

COLACE CLEAR ORAL CAPSULE 50 MG 1(CW)

COLACE ORAL CAPSULE 100 MG 1(CW)

colchicine oral tablet 0.6 mg 1

colchicine-probenecid oral tablet 0.5-500 mg 1

colestipol hcl oral granules 5 gm 1

colestipol hcl oral tablet 1 gm 1

colistimethate sodium injection solution

reconstituted 150 mg 1 PA

COMBIGAN OPHTHALMIC SOLUTION 0.2-

0.5 % 1

COMBIVENT RESPIMAT INHALATION

AEROSOL SOLUTION 20-100 MCG/ACT 1

COMETRIQ (100 MG DAILY DOSE) ORAL

KIT 1 X 80 & 1 X 20 MG 1 PA; QL (56 EA per 28 days)

COMETRIQ (140 MG DAILY DOSE) ORAL

KIT 1 X 80 & 3 X 20 MG 1 PA; QL (112 EA per 28 days)



26

Drug Tier Notes

COMETRIQ (60 MG DAILY DOSE) ORAL KIT

20 MG 1 PA; QL (84 EA per 28 days)

COMFORT ASSIST INSULIN SYRINGE 29G

X 1/2" 1 ML 1

COMPLERA ORAL TABLET 200-25-300 MG 1 QL (31 EA per 31 days)

compro rectal suppository 25 mg 1

cool n heat external stick 10-30 % 1(CW)

COPAXONE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 20 MG/ML 1 PA; QL (31 ML per 31 days)

COPAXONE SUBCUTANEOUS SOLUTION


cortisone acetate oral tablet 25 mg 1

COSENTYX SENSOREADY PEN

SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 150 MG/ML

1 ST

COSENTYX SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 150 MG/ML 1 ST

COTELLIC ORAL TABLET 20 MG 1 PA; LA

cough relief oral liquid 15 mg/5ml 1(SO)

cough syrup oral syrup 100 mg/5ml 1(SO)

CREON ORAL CAPSULE DELAYED

RELEASE PARTICLES 12000 UNIT, 24000-

76000 UNIT, 3000-9500 UNIT, 36000 UNIT,

6000 UNIT

1

CREO-TERPIN ORAL SYRUP 10 MG/15ML 1(SO)

CRIXIVAN ORAL CAPSULE 200 MG 1 QL (465 EA per 31 days)

CRIXIVAN ORAL CAPSULE 400 MG 1 QL (279 EA per 31 days)

cromolyn sodium inhalation nebulization solution

20 mg/2ml 1

cromolyn sodium ophthalmic solution 4 % 1

cromolyn sodium oral concentrate 100 mg/5ml 1

CRYSELLE-28 ORAL TABLET 0.3-30 MG-

MCG 1

cvs antacid supreme oral suspension 400-135

mg/5ml 1(SO)

cvs b-12 oral tablet dispersible 1500 mcg 1(CW)

cvs fluticasone propionate nasal suspension 50

mcg/act 1(CW)



27

Drug Tier Notes

cvs gauze sterile pad 2"x2" 1

cvs glucose bits oral tablet chewable 1 gm 1(CW)

cvs hot steam inhalation liquid 6.2 % 1(CW)

cvs hydrocortisone acetate external cream 0.5 % 1(CW)

cvs laxative dietary supplemnt oral tablet 500 mg 1(CW)

cvs nasal mist nasal aerosol solution 0.9 % 1(CW)

cvs natural fiber supplement oral packet 58.6 % 1(CW)

cvs senna-extra oral tablet 17.2 mg 1(CW)

cvs slow release iron oral tablet extended release

143 (45 fe) mg 1(CW)

cvs sore muscle rub external gel 2.5 % 1(CW)

cvs stool softener oral capsule 50 mg 1(CW)

cvs targeted acne spot external cream 2.5 % 1(SO)

cyanocobalamin injection solution 1000 mcg/ml 1(ND)

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-

MCG 1

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-

35 MG-MCG 1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg 1 PA; HR; QL (93 EA per 31 days)

cyclobenzaprine hcl oral tablet 7.5 mg 1 PA; HR; QL (186 EA per 31 days)

cyclophosphamide oral capsule 25 mg, 50 mg 1

cyclosporine intravenous solution 50 mg/ml 1

cyclosporine modified oral capsule 100 mg, 25

mg, 50 mg 1

cyclosporine modified oral solution 100 mg/ml 1

cyclosporine oral capsule 100 mg, 25 mg 1

cyproheptadine hcl oral syrup 2 mg/5ml 1 PA; HR

cyproheptadine hcl oral tablet 4 mg 1 PA; HR

CYRAMZA INTRAVENOUS SOLUTION 100

MG/10ML, 500 MG/50ML 1

CYSTADANE ORAL POWDER 1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 1

CYSTARAN OPHTHALMIC SOLUTION 0.44

% 1 PA; QL (60 ML per 30 days)

cytarabine (pf) injection solution 100 mg/ml 1

cytarabine injection solution 20 mg/ml 1



28

Drug Tier Notes

D3 DOTS ORAL TABLET DISPERSIBLE 2000

UNIT 1(CW)

dacarbazine intravenous solution reconstituted

200 mg 1

DAKLINZA ORAL TABLET 30 MG, 60 MG,

90 MG 1 PA

DALIRESP ORAL TABLET 500 MCG 1 QL (31 EA per 31 days)

danazol oral capsule 100 mg, 200 mg, 50 mg 1

dapsone oral tablet 100 mg, 25 mg 1

DAPTACEL INTRAMUSCULAR

SUSPENSION 10-15-5 1

daptomycin intravenous solution reconstituted

500 mg 1

DARAPRIM ORAL TABLET 25 MG 1

daunorubicin hcl intravenous injectable 5 mg/ml 1

daytime cough oral liquid 15 mg/15ml 1(SO)

DEBLITANE ORAL TABLET 0.35 MG 1

DEBROX OTIC SOLUTION 6.5 % 1(CW)

DECARA ORAL CAPSULE 25000 UNIT 1(CW)

decitabine intravenous solution reconstituted 50

mg 1

DELSYM COUGH/CHEST CONGEST DM

ORAL LIQUID 5-100 MG/5ML 1(SO)

DELYLA ORAL TABLET 0.1-20 MG-MCG 1

DEMSER ORAL CAPSULE 250 MG 1

DEPEN TITRATABS ORAL TABLET 250 MG 1

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML 1

DERMAFUNGAL EXTERNAL OINTMENT 2

% 1(SO)

DESCOVY ORAL TABLET 200-25 MG 1

desipramine hcl oral tablet 10 mg, 100 mg, 150

mg, 25 mg, 50 mg, 75 mg 1 PA; HR

desloratadine oral tablet 5 mg 1

desloratadine oral tablet dispersible 2.5 mg, 5 mg 1

desmopressin ace spray refrig nasal solution 0.01

% 1

desmopressin acetate injection solution 4 mcg/ml 1



29

Drug Tier Notes

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1

desogestrel-ethinyl estradiol oral tablet 0.15-

0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1

desonide external cream 0.05 % 1

desonide external lotion 0.05 % 1

desonide external ointment 0.05 % 1

desoximetasone external cream 0.05 %, 0.25 % 1

desoximetasone external gel 0.05 % 1

desoximetasone external ointment 0.25 % 1

desvenlafaxine er oral tablet extended release 24

hour 100 mg, 50 mg 1

desvenlafaxine succinate er oral tablet extended

release 24 hour 100 mg, 25 mg, 50 mg 1

DEX4 GLUCOSE GO-POUCH ORAL GEL 15

GM/33GM 1(CW)

DEXAMETHASONE INTENSOL ORAL


dexamethasone oral elixir 0.5 mg/5ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,

1.5 mg, 2 mg, 4 mg, 6 mg 1

dexamethasone sodium phosphate injection

solution 10 mg/ml, 120 mg/30ml 1

dexamethasone sodium phosphate ophthalmic

solution 0.1 % 1

dexmethylphenidate hcl oral tablet 2.5 mg 1 QL (248 EA per 31 days)

dexmethylphenidate hcl oral tablet 5 mg 1 QL (124 EA per 31 days)

dexrazoxane intravenous solution reconstituted

250 mg 1

dextroamphetamine sulfate er oral capsule






dextroamphetamine sulfate oral tablet 10 mg 1 QL (186 EA per 31 days)

dextroamphetamine sulfate oral tablet 5 mg 1 QL (155 EA per 31 days)

dextrose in lactated ringers intravenous solution

5 % 1



30

Drug Tier Notes

dextrose intravenous solution 10 %, 5 % 1

dextrose-nacl intravenous solution 10-0.2 %, 10-

0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33

%, 5-0.45 %, 5-0.9 %

1

DIABETIC TUSSIN DM ORAL LIQUID 100-10

MG/5ML 1(SO)

DIABETIC TUSSIN ORAL LIQUID 100

MG/5ML 1(SO)

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20

MG 1

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 1

DIAZEPAM INTENSOL ORAL

CONCENTRATE 5 MG/ML 1 QL (248 ML per 31 days)

diazepam oral solution 1 mg/ml 1 QL (1240 ML per 31 days)

diazepam oral tablet 10 mg 1 QL (124 EA per 31 days)



diazepam rectal gel 10 mg, 2.5 mg 1

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium er oral tablet extended release

24 hour 100 mg 1

diclofenac sodium ophthalmic solution 0.1 % 1

diclofenac sodium oral tablet delayed release 25

mg, 50 mg, 75 mg 1

diclofenac sodium transdermal gel 1 % 1 PA

diclofenac sodium transdermal gel 3 % 1 PA; QL (100 GM per 31 days)

diclofenac sodium transdermal solution 1.5 % 1

dicloxacillin sodium oral capsule 250 mg, 500 mg 1

dicyclomine hcl intramuscular solution 10 mg/ml 1

dicyclomine hcl oral capsule 10 mg 1

dicyclomine hcl oral solution 10 mg/5ml 1

dicyclomine hcl oral tablet 20 mg 1

didanosine oral capsule delayed release 125 mg 1 QL (93 EA per 31 days)

didanosine oral capsule delayed release 200 mg 1 QL (62 EA per 31 days)

didanosine oral capsule delayed release 250 mg,


diflorasone diacetate external cream 0.05 % 1



31

Drug Tier Notes

diflorasone diacetate external ointment 0.05 % 1

diflunisal oral tablet 500 mg 1

DIGITEK ORAL TABLET 125 MCG 1 QL (31 EA per 31 days)

DIGITEK ORAL TABLET 250 MCG 1 PA; HR; QL (31 EA per 31 days)

digoxin injection solution 0.25 mg/ml 1 PA; HR

digoxin oral solution 0.05 mg/ml 1 PA; HR

digoxin oral tablet 125 mcg 1 QL (31 EA per 31 days)

digoxin oral tablet 250 mcg 1 PA; HR; QL (31 EA per 31 days)

dihydroergotamine mesylate injection solution 1

mg/ml 1

DILANTIN ORAL CAPSULE 30 MG 1

diltiazem hcl er beads oral capsule extended

release 24 hour 180 mg, 360 mg, 420 mg 1 QL (31 EA per 31 days)

diltiazem hcl er coated beads oral capsule

extended release 24 hour 120 mg, 240 mg, 300

mg


diltiazem hcl er oral capsule extended release 12

hour 120 mg, 60 mg, 90 mg 1

diltiazem hcl intravenous solution 50 mg/10ml 1

diltiazem hcl intravenous solution reconstituted

100 mg 1

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

90 mg 1

dilt-xr oral capsule extended release 24 hour 120

mg, 180 mg, 240 mg 1 QL (62 EA per 31 days)

DIPENTUM ORAL CAPSULE 250 MG 1

diphenhydramine hcl (sleep) oral tablet 50 mg 1(SO)

diphenhydramine hcl injection solution 50 mg/ml 1

diphenhydramine hcl oral capsule 25 mg, 50 mg 1(SO)

diphenhydramine hcl oral elixir 12.5 mg/5ml 1

diphenhydramine hcl oral liquid 12.5 mg/5ml 1(SO)

diphenhydramine hcl oral tablet 25 mg 1(SO)

diphenoxylate-atropine oral liquid 2.5-0.025

mg/5ml 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

diphtheria-tetanus toxoids dt intramuscular

suspension 25-5 lfu/0.5ml 1



32

Drug Tier Notes

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

disopyramide phosphate oral capsule 100 mg,

150 mg 1 PA; HR

disulfiram oral tablet 250 mg, 500 mg 1

divalproex sodium er oral tablet extended release

24 hour 250 mg, 500 mg 1

divalproex sodium oral capsule delayed release

sprinkle 125 mg 1

divalproex sodium oral tablet delayed release 125

mg, 250 mg, 500 mg 1

docetaxel intravenous concentrate 80 mg/4ml 1

docetaxel intravenous solution 80 mg/8ml 1

docusate sodium oral capsule 100 mg, 250 mg 1(CW)

docusate sodium oral liquid 50 mg/5ml 1(CW)

docusate sodium oral syrup 60 mg/15ml 1(CW)

docusate sodium oral tablet 100 mg 1(CW)

DOCUSOL KIDS RECTAL ENEMA 100

MG/5ML 1(CW)

dofetilide oral capsule 125 mcg, 250 mcg, 500

mcg 1

donepezil hcl oral tablet 10 mg 1 QL (62 EA per 31 days)

donepezil hcl oral tablet 5 mg 1 QL (31 EA per 31 days)

donepezil hcl oral tablet dispersible 10 mg 1 QL (62 EA per 31 days)

donepezil hcl oral tablet dispersible 5 mg 1 QL (31 EA per 31 days)

dorzolamide hcl ophthalmic solution 2 % 1 QL (10 ML per 31 days)

dorzolamide hcl-timolol mal ophthalmic solution

22.3-6.8 mg/ml 1 QL (10 ML per 28 days)

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

8 mg 1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg 1 PA; HR

doxepin hcl oral concentrate 10 mg/ml 1 PA; HR

doxercalciferol intravenous solution 4 mcg/2ml 1

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5

mcg 1

doxorubicin hcl intravenous solution 2 mg/ml 1

doxorubicin hcl liposomal intravenous injectable

2 mg/ml 1



33

Drug Tier Notes

DOXY 100 INTRAVENOUS SOLUTION


doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline hyclate oral tablet delayed release 50

mg 1

doxycycline monohydrate oral capsule 100 mg,

50 mg 1

doxycycline monohydrate oral tablet 100 mg, 150

mg, 50 mg, 75 mg 1

DRAMAMINE LESS DROWSY ORAL

TABLET 25 MG 1(SO)

DRAMAMINE ORAL TABLET 50 MG 1(SO)

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 PA; QL (62 EA per 31 days)

drospirenone-ethinyl estradiol oral tablet 3-0.03

mg 1

DROXIA ORAL CAPSULE 200 MG, 300 MG,

400 MG 1

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 40 mg, 60 mg 1 QL (62 EA per 31 days)

DURAFLEX COMFORT EXTERNAL GEL 1(CW)

duramorph injection solution 0.5 mg/ml, 1 mg/ml 1

DUREZOL OPHTHALMIC EMULSION 0.05 % 1

dutasteride oral capsule 0.5 mg 1 QL (31 EA per 31 days)

dutasteride-tamsulosin hcl oral capsule 0.5-0.4


ear wax drops otic solution 6.5 % 1(CW)

econazole nitrate external cream 1 % 1

ECONTRA EZ ORAL TABLET 1.5 MG 1(SO)

EDURANT ORAL TABLET 25 MG 1 QL (31 EA per 31 days)

ELIDEL EXTERNAL CREAM 1 % 1 ST

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 1

ELITEK INTRAVENOUS SOLUTION

RECONSTITUTED 1.5 MG 1 PA

ELITEK INTRAVENOUS SOLUTION

RECONSTITUTED 7.5 MG 1



34

Drug Tier Notes

EMBEDA ORAL CAPSULE EXTENDED

RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG,

50-2 MG, 60-2.4 MG, 80-3.2 MG


EMCYT ORAL CAPSULE 140 MG 1 PA

EMEND ORAL SUSPENSION


EMOQUETTE ORAL TABLET 0.15-30 MG-

MCG 1

EMSAM TRANSDERMAL PATCH 24 HOUR

12 MG/24HR, 6 MG/24HR, 9 MG/24HR 1 ST; QL (31 EA per 31 days)

EMTRIVA ORAL CAPSULE 200 MG 1 QL (31 EA per 31 days)

EMTRIVA ORAL SOLUTION 10 MG/ML 1 QL (705 ML per 28 days)

EMVERM ORAL TABLET CHEWABLE 100

MG 1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20

mg, 5 mg 1

enalapril-hydrochlorothiazide oral tablet 10-25

mg, 5-12.5 mg 1

ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 25 MG/0.5ML, 50

MG/ML

1

ENBREL SUBCUTANEOUS SOLUTION


ENBREL SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 50 MG/ML 1

ENDOCET ORAL TABLET 10-325 MG, 5-325

MG, 7.5-325 MG 1 QL (382 EA per 31 days)

ENEMEEZ MINI RECTAL ENEMA 283 MG 1(CW)

ENGERIX-B INJECTION SUSPENSION 10

MCG/0.5ML, 20 MCG/ML 1

enoxaparin sodium injection solution 300 mg/3ml 1 QL (35 ML per 31 days)

enoxaparin sodium subcutaneous solution 100

mg/ml, 150 mg/ml 1 QL (31 ML per 31 days)


mg/0.8ml, 80 mg/0.8ml 1 QL (24 ML per 31 days)


mg/0.3ml 1 QL (9 ML per 31 days)





35

Drug Tier Notes



ENPRESSE-28 ORAL TABLET 1

entacapone oral tablet 200 mg 1 QL (310 EA per 31 days)

entecavir oral tablet 0.5 mg, 1 mg 1 PA

enulose oral solution 10 gm/15ml 1

EPCLUSA ORAL TABLET 400-100 MG 1 PA

epinastine hcl ophthalmic solution 0.05 % 1

EPINEPHRINE INJECTION SOLUTION

AUTO-INJECTOR 0.15 MG/0.3ML 1

EPINEPHRINE INJECTION SOLUTION

AUTO-INJECTOR 0.3 MG/0.3ML 1 QL (2 EA per 60 days)

EPIPEN 2-PAK INJECTION SOLUTION


EPIPEN JR 2-PAK INJECTION SOLUTION


epirubicin hcl intravenous solution 200 mg/100ml 1

epitol oral tablet 200 mg 1

EPIVIR HBV ORAL SOLUTION 5 MG/ML 1

eplerenone oral tablet 25 mg, 50 mg 1

EPOGEN INJECTION SOLUTION 10000

UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML,

3000 UNIT/ML, 4000 UNIT/ML

1 PA

eprosartan mesylate oral tablet 600 mg 1 QL (31 EA per 31 days)

eq allergy relief (cetirizine) oral solution 1 mg/ml 1(SO)

eq allergy relief childrens oral elixir 12.5 mg/5ml 1(SO)

eq aspirin oral tablet delayed release 500 mg 1(SO)

eql calcium/vitamin d oral capsule 600-100 mg-

unit 1(CW)

EQUALACTIN ORAL TABLET CHEWABLE

625 MG 1(CW)

ERAXIS INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG, 50 MG 1 PA

ergoloid mesylates oral tablet 1 mg 1

ERIVEDGE ORAL CAPSULE 150 MG 1 PA; QL (28 EA per 28 days)

ERRIN ORAL TABLET 0.35 MG 1

ERWINAZE INJECTION SOLUTION

RECONSTITUTED 10000 UNIT 1 PA; QL (62 EA per 28 days)



36

Drug Tier Notes

ERY-TAB ORAL TABLET DELAYED

RELEASE 250 MG, 333 MG, 500 MG 1

ERYTHROCIN LACTOBIONATE

INTRAVENOUS SOLUTION

RECONSTITUTED 500 MG

1

ERYTHROCIN STEARATE ORAL TABLET

250 MG 1

erythromycin base oral tablet 250 mg, 500 mg 1

erythromycin ethylsuccinate oral suspension

reconstituted 200 mg/5ml 1

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin external gel 2 % 1

erythromycin external solution 2 % 1

erythromycin ophthalmic ointment 5 mg/gm 1

ESBRIET ORAL CAPSULE 267 MG 1 PA

ESBRIET ORAL TABLET 267 MG, 801 MG 1 PA

escitalopram oxalate oral solution 5 mg/5ml 1 QL (620 ML per 31 days)

escitalopram oxalate oral tablet 10 mg 1 QL (47 EA per 31 days)

escitalopram oxalate oral tablet 20 mg, 5 mg 1 QL (31 EA per 31 days)

esomeprazole magnesium oral capsule delayed

release 20 mg, 40 mg 1

esomeprazole sodium intravenous solution


ESTRACE VAGINAL CREAM 0.1 MG/GM 1

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA; HR

estradiol transdermal patch weekly 0.025

mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06

mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

estradiol vaginal tablet 10 mcg 1

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml 1

estradiol-norethindrone acet oral tablet 0.5-0.1

mg, 1-0.5 mg 1

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1

ethambutol hcl oral tablet 100 mg, 400 mg 1

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5ml 1



37

Drug Tier Notes

ethynodiol diac-eth estradiol oral tablet 1-50 mg-

mcg 1

etodolac oral capsule 200 mg 1 QL (62 EA per 31 days)

etodolac oral capsule 300 mg 1 QL (93 EA per 31 days)

etodolac oral tablet 400 mg, 500 mg 1 QL (62 EA per 31 days)

etoposide intravenous solution 500 mg/25ml 1

EURAX EXTERNAL CREAM 10 % 1

EURAX EXTERNAL LOTION 10 % 1

EVOTAZ ORAL TABLET 300-150 MG 1

EXEL COMFORT POINT PEN NEEDLE 29G X

12MM 1

exemestane oral tablet 25 mg 1 QL (62 EA per 31 days)

EXJADE ORAL TABLET SOLUBLE 125 MG,

250 MG, 500 MG 1 PA

extra strength acetaminophen oral capsule 500

mg 1(SO)

eye itch relief ophthalmic solution 0.025 % 1(SO)

ezetimibe oral tablet 10 mg 1 QL (31 EA per 31 days)

FABRAZYME INTRAVENOUS SOLUTION


FALLBACK SOLO ORAL TABLET 1.5 MG 1(SO)

FALMINA ORAL TABLET 0.1-20 MG-MCG 1

famciclovir oral tablet 125 mg, 250 mg, 500 mg 1

famotidine intravenous solution 20 mg/2ml 1

famotidine oral suspension reconstituted 40

mg/5ml 1

famotidine oral tablet 20 mg, 40 mg 1

famotidine premixed intravenous solution 20-0.9

mg/50ml-% 1

FANAPT ORAL TABLET 1 MG, 10 MG, 12

MG, 2 MG, 4 MG, 6 MG, 8 MG 1 ST; QL (62 EA per 31 days)

FANAPT TITRATION PACK ORAL TABLET

1 & 2 & 4 & 6 MG 1 ST; QL (62 EA per 31 days)

FARESTON ORAL TABLET 60 MG 1 PA; QL (31 EA per 31 days)

FARXIGA ORAL TABLET 10 MG, 5 MG 1 QL (31 EA per 31 days)

FARYDAK ORAL CAPSULE 10 MG, 15 MG,

20 MG 1 PA



38

Drug Tier Notes

FASLODEX INTRAMUSCULAR SOLUTION

250 MG/5ML 1 QL (31 ML per 31 days)

felbamate oral suspension 600 mg/5ml 1

felbamate oral tablet 400 mg, 600 mg 1

felodipine er oral tablet extended release 24 hour

10 mg, 2.5 mg, 5 mg 1 QL (31 EA per 31 days)

femynor oral tablet 0.25-35 mg-mcg 1

fenofibrate micronized oral capsule 130 mg, 134

mg, 200 mg, 43 mg, 67 mg 1 QL (31 EA per 31 days)

fenofibrate oral capsule 150 mg, 50 mg 1

fenofibrate oral tablet 145 mg, 160 mg 1 QL (31 EA per 31 days)

fenofibrate oral tablet 48 mg, 54 mg 1 QL (62 EA per 31 days)

fenofibric acid oral capsule delayed release 135

mg, 45 mg 1

fentanyl citrate buccal lozenge on a handle 1200

mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800

mcg

1 PA; QL (186 EA per 31 days)

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr 1 PA; ST; QL (11 EA per 33 days)

FERRIPROX ORAL TABLET 500 MG 1

ferrous gluconate oral tablet 240 (27 fe) mg, 324

(37.5 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg 1(CW)

ferrous sulfate er oral tablet extended release 140

(45 fe) mg 1(CW)

ferrous sulfate oral syrup 300 (60 fe) mg/5ml 1(CW)

ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg 1(CW)

ferrous sulfate oral tablet delayed release 324 (65

fe) mg, 325 (65 fe) mg 1(CW)

FETZIMA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 20 MG, 40 MG,

80 MG

1 ST

FETZIMA TITRATION ORAL CAPSULE ER

24 HOUR THERAPY PACK 20 & 40 MG 1 ST

FEVERALL ADULTS RECTAL

SUPPOSITORY 650 MG 1(SO)

FEVERALL CHILDRENS RECTAL


FEVERALL INFANTS RECTAL




39

Drug Tier Notes

FEVERALL JUNIOR STRENGTH RECTAL


fexofenadine hcl oral tablet 180 mg, 60 mg 1(CW)

fiber laxative oral capsule 0.52 gm 1(CW)

fiber oral powder 1(CW)

fiber oral tablet 625 mg 1(CW)

fiber therapy oral tablet 500 mg 1(CW)

finasteride oral tablet 5 mg 1 QL (31 EA per 31 days)

FIRAZYR SUBCUTANEOUS SOLUTION 30

MG/3ML 1 PA

fish oil maximum strength oral capsule delayed

release 1200 mg 1(CW)

fish oil oral capsule 1000 mg, 1200 mg, 435 mg 1(CW)

fish oil oral tablet chewable 875 mg 1(CW)

FISH OIL PEARLS ORAL CAPSULE 150 MG,

180 MG, 183.33 MG 1(CW)

flecainide acetate oral tablet 100 mg, 150 mg, 50

mg 1

FLEET ENEMA RECTAL ENEMA 7-19

GM/118ML 1(CW)

FLEXALL EXTERNAL GEL 16 %, 7 % 1(CW)

FLEXALL ULTRA PLUS EXTERNAL GEL

3.1-16-10 % 1(CW)

FLONASE ALLERGY RELIEF NASAL

SUSPENSION 50 MCG/ACT 1(CW)

FLOVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 100

MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL 110

MCG/ACT, 220 MCG/ACT 1 QL (24 GM per 24 days)

FLOVENT HFA INHALATION AEROSOL 44

MCG/ACT 1 QL (11 GM per 31 days)

fluconazole in sodium chloride intravenous

solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-

%

1

fluconazole oral suspension reconstituted 10

mg/ml, 40 mg/ml 1

fluconazole oral tablet 100 mg, 150 mg, 50 mg 1

flucytosine oral capsule 250 mg, 500 mg 1



40

Drug Tier Notes

fludarabine phosphate intravenous solution


fludrocortisone acetate oral tablet 0.1 mg 1

flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (50 ML per 31 days)

fluocinolone acetonide body external oil 0.01 % 1

fluocinolone acetonide external cream 0.01 %,

0.025 % 1

fluocinolone acetonide external ointment 0.025 % 1

fluocinolone acetonide external solution 0.01 % 1

fluocinolone acetonide otic oil 0.01 % 1

fluocinonide external cream 0.1 % 1

fluocinonide external gel 0.05 % 1

fluocinonide external ointment 0.05 % 1

fluocinonide external solution 0.05 % 1

fluorometholone ophthalmic suspension 0.1 % 1

fluorouracil external cream 5 % 1

fluorouracil external solution 2 %, 5 % 1

fluorouracil intravenous solution 2.5 gm/50ml 1

fluoxetine hcl oral capsule 10 mg 1 QL (186 EA per 31 days)



fluoxetine hcl oral capsule delayed release 90 mg 1 QL (4 EA per 28 days)

fluoxetine hcl oral solution 20 mg/5ml 1 QL (620 ML per 31 days)

fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg 1 QL (31 EA per 31 days)

fluphenazine decanoate injection solution 25

mg/ml 1

fluphenazine hcl injection solution 2.5 mg/ml 1

fluphenazine hcl oral concentrate 5 mg/ml 1

fluphenazine hcl oral elixir 2.5 mg/5ml 1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg,

5 mg 1

flurazepam hcl oral capsule 15 mg, 30 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1 QL (93 EA per 31 days)

flurbiprofen sodium ophthalmic solution 0.03 % 1

flutamide oral capsule 125 mg 1

fluticasone propionate external cream 0.05 % 1



41

Drug Tier Notes

fluticasone propionate external lotion 0.05 % 1

fluticasone propionate external ointment 0.005 % 1

fluticasone propionate nasal suspension 50

mcg/act 1 QL (32 GM per 30 days)

FLUTICASONE-SALMETEROL

INHALATION AEROSOL POWDER BREATH

ACTIVATED 113-14 MCG/ACT, 232-14

MCG/ACT, 55-14 MCG/ACT


fluvoxamine maleate er oral capsule extended

release 24 hour 100 mg, 150 mg 1 QL (62 EA per 31 days)

fluvoxamine maleate oral tablet 100 mg, 25 mg,


folic acid oral tablet 1 mg 1(ND)

folic acid oral tablet 400 mcg, 800 mcg 1(CW)

fomepizole intravenous solution 1 gm/ml 1

fondaparinux sodium subcutaneous solution 10

mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5

mg/0.6ml

1 QL (14 ML per 31 days)

FORTEO SUBCUTANEOUS SOLUTION 600

MCG/2.4ML 1 PA; QL (2.4 ML per 28 days)

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-

12.5 mg 1

fosphenytoin sodium injection solution 100 mg

pe/2ml 1

FRAGMIN SUBCUTANEOUS SOLUTION

10000 UNIT/ML, 12500 UNIT/0.5ML, 15000

UNIT/0.6ML, 18000 UNT/0.72ML, 2500

UNIT/0.2ML, 5000 UNIT/0.2ML, 7500

UNIT/0.3ML, 95000 UNIT/3.8ML

1

FREAMINE HBC INTRAVENOUS SOLUTION

6.9 % 1

FUNGICURE INTENSIVE/NAILGUARD

EXTERNAL SOLUTION 1 % 1(SO)

FUNGOID TINCTURE EXTERNAL KIT 2 % 1(SO)

FUNGOID TINCTURE EXTERNAL

SOLUTION 2 % 1(SO)

furosemide injection solution 10 mg/ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1



42

Drug Tier Notes

FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED 90 MG 1 QL (62 EA per 31 days)

FYCOMPA ORAL SUSPENSION 0.5 MG/ML 1 QL (744 ML per 31 days)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2

MG, 4 MG, 6 MG, 8 MG 1 QL (31 EA per 31 days)

gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 QL (279 EA per 31 days)

gabapentin oral solution 250 mg/5ml 1

gabapentin oral tablet 600 mg, 800 mg 1 QL (186 EA per 31 days)

GABITRIL ORAL TABLET 12 MG, 16 MG 1

galantamine hydrobromide er oral capsule

extended release 24 hour 16 mg, 24 mg, 8 mg 1

galantamine hydrobromide oral solution 4 mg/ml 1

galantamine hydrobromide oral tablet 12 mg, 4

mg, 8 mg 1

GAMASTAN S/D INTRAMUSCULAR

INJECTABLE 1

GAMMAGARD INJECTION SOLUTION 2.5

GM/25ML 1

ganciclovir sodium intravenous solution


GARDASIL 9 INTRAMUSCULAR

SUSPENSION 1

GARDASIL 9 INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 1

GARLIFE ORAL TABLET 500 MG 1(CW)

gatifloxacin ophthalmic solution 0.5 % 1

GATTEX SUBCUTANEOUS KIT 5 MG 1

GAVILYTE-C ORAL SOLUTION

RECONSTITUTED 240 GM 1

GAVILYTE-G ORAL SOLUTION


GAVILYTE-N WITH FLAVOR PACK ORAL

SOLUTION RECONSTITUTED 420 GM 1

GAVISCON EXTRA STRENGTH ORAL

SUSPENSION 254-237.5 MG/5ML 1(SO)

GAVISCON ORAL SUSPENSION 95-358

MG/15ML 1(SO)

GELUSIL ORAL TABLET CHEWABLE 200-

200-25 MG 1(SO)



43

Drug Tier Notes

gemcitabine hcl intravenous solution


gemfibrozil oral tablet 600 mg 1 QL (62 EA per 31 days)

generlac oral solution 10 gm/15ml 1

GENGRAF ORAL CAPSULE 100 MG, 25 MG 1

gengraf oral capsule 50 mg 1

GENGRAF ORAL SOLUTION 100 MG/ML 1

gentamicin in saline intravenous solution 0.8-0.9

mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-

0.9 mg/ml-%

1

gentamicin sulfate external cream 0.1 % 1

gentamicin sulfate external ointment 0.1 % 1

gentamicin sulfate injection solution 40 mg/ml 1

gentamicin sulfate intravenous solution 10 mg/ml 1

gentamicin sulfate ophthalmic solution 0.3 % 1

GENTEAL SEVERE OPHTHALMIC GEL 0.3

% 1(SO)

GEODON INTRAMUSCULAR SOLUTION

RECONSTITUTED 20 MG 1 ST

GERI-HYDROLAC 5 EXTERNAL LOTION 5

% 1(CW)

geri-mucil oral powder 68 % 1(CW)

GIANVI ORAL TABLET 3-0.02 MG 1

GILDAGIA ORAL TABLET 0.4-35 MG-MCG 1

GILENYA ORAL CAPSULE 0.5 MG 1 PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40

MG 1 PA; QL (31 EA per 31 days)

GLEEVEC ORAL TABLET 100 MG 1 PA; QL (186 EA per 31 days)

GLEEVEC ORAL TABLET 400 MG 1 PA; QL (62 EA per 31 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100

MG, 40 MG, 5 MG 1

glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide er oral tablet extended release 24 hour

10 mg, 2.5 mg, 5 mg 1

glipizide oral tablet 10 mg, 5 mg 1

glipizide-metformin hcl oral tablet 2.5-250 mg,

2.5-500 mg, 5-500 mg 1



44

Drug Tier Notes

global alcohol prep ease pad 70 % 1

GLUCAGEN HYPOKIT INJECTION

SOLUTION RECONSTITUTED 1 MG 1

GLUCAGON EMERGENCY INJECTION KIT 1

MG 1

glucose oral gel 40 % 1(CW)

glucose oral liquid , 15 gm/59ml 1(CW)

glucose oral tablet chewable 4 gm, 4-6 gm-mg 1(CW)

glycopyrrolate injection solution 4 mg/20ml 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

gnp cold & hot extra strength external ointment

7.6-29 % 1(CW)

gnp fish oil oral capsule delayed release 840 mg 1(CW)

gnp iron oral tablet 200 (65 fe) mg 1(CW)

gnp melatonin maximum strength oral tablet 5 mg 1(CW)

gnp motion sickness relief oral tablet 25 mg 1(SO)

gnp vitamin d-400 oral tablet 90-400 mg-unit 1(CW)

GOLD BOND PAIN RELIEVING FOOT

EXTERNAL CREAM 16 % 1(CW)

GORDONS UREA EXTERNAL OINTMENT 22

%, 40 % 1(CW)

granisetron hcl intravenous solution 0.1 mg/ml, 1

mg/ml 1 QL (62 ML per 31 days)

granisetron hcl oral tablet 1 mg 1 QL (62 EA per 31 days)

griseofulvin microsize oral suspension 125

mg/5ml 1

griseofulvin microsize oral tablet 500 mg 1

guaifenesin oral syrup 100 mg/5ml 1(SO)

guaifenesin oral tablet 200 mg, 400 mg 1(CW)

guaifenesin-codeine oral syrup 100-10 mg/5ml 1(ND)

guaifenesin-dm oral syrup 100-10 mg/5ml 1(SO)

guanfacine hcl er oral tablet extended release 24

hour 1 mg, 2 mg, 3 mg, 4 mg 1 PA

guanfacine hcl oral tablet 1 mg, 2 mg 1

guanidine hcl oral tablet 125 mg 1

GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % 1(SO)

GYNE-LOTRIMIN VAGINAL CREAM 1 % 1(SO)



45

Drug Tier Notes

HALAVEN INTRAVENOUS SOLUTION 1

MG/2ML 1 PA

halobetasol propionate external cream 0.05 % 1

halobetasol propionate external ointment 0.05 % 1

haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml 1

haloperidol lactate injection solution 5 mg/ml 1

haloperidol lactate oral concentrate 2 mg/ml 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2

mg, 20 mg, 5 mg 1

HARVONI ORAL TABLET 90-400 MG 1 PA

HAVRIX INTRAMUSCULAR SUSPENSION

1440 EL U/ML, 720 EL U/0.5ML 1

hemorrhoidal cooling rectal gel 0.25-50 % 1(CW)

hemorrhoidal external pad 50 % 1(CW)

hemorrhoidal rectal cream 1-0.25-14.4-15 % 1(CW)

hemorrhoidal rectal ointment 0.25-14-74.9 %,

0.25-3-14-71.9 % 1(CW)

hemorrhoidal rectal suppository 0.25-3-85.5 %,

0.25-88.44 % 1(CW)

heparin (porcine) in d5w intravenous solution 40-

5 unit/ml-%, 50-5 unit/ml-% 1

heparin sod (porcine) in d5w intravenous solution

100 unit/ml 1

heparin sodium (porcine) injection solution 1000

unit/ml, 10000 unit/ml, 20000 unit/ml, 5000

unit/ml

1

HEPATAMINE INTRAVENOUS SOLUTION 8

% 1

HERCEPTIN INTRAVENOUS SOLUTION


HETLIOZ ORAL CAPSULE 20 MG 1 QL (31 EA per 31 days)

HEXALEN ORAL CAPSULE 50 MG 1 PA

HIBERIX INJECTION SOLUTION

RECONSTITUTED 10 MCG 1

HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS PREFILLED SYRINGE KIT

40 MG/0.8ML

1



46

Drug Tier Notes

HUMIRA PEN SUBCUTANEOUS PEN-

INJECTOR KIT 40 MG/0.8ML 1

HUMIRA PEN-CROHNS STARTER

SUBCUTANEOUS PEN-INJECTOR KIT 40

MG/0.8ML

1

HUMIRA PEN-PSORIASIS STARTER

SUBCUTANEOUS PEN-INJECTOR KIT 40

MG/0.8ML

1

HUMIRA SUBCUTANEOUS PREFILLED

SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML,

40 MG/0.8ML

1

hydralazine hcl injection solution 20 mg/ml 1

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg,

50 mg 1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg,

50 mg 1

HYDROCIL ORAL PACKET 95 % 1(CW)

HYDROCIL ORAL POWDER 95 % 1(CW)

hydrocodone-acetaminophen oral solution 7.5-

325 mg/15ml 1 QL (5683 ML per 31 days)

hydrocodone-acetaminophen oral tablet 10-300

mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg,

7.5-300 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 QL (186 EA per 31 days)

hydrocortisone acetate external cream 1 % 1(CW)

hydrocortisone acetate rectal suppository 25 mg,

30 mg 1(CW)

hydrocortisone butyr lipo base external cream 0.1

% 1

hydrocortisone butyrate external ointment 0.1 % 1

hydrocortisone butyrate external solution 0.1 % 1

hydrocortisone external cream 0.5 % 1(CW)

hydrocortisone external cream 1 %, 2.5 % 1

hydrocortisone external lotion 1 % 1(SO)

hydrocortisone external lotion 2.5 % 1

hydrocortisone external ointment 0.5 % 1(SO)

hydrocortisone external ointment 1 %, 2.5 % 1



47

Drug Tier Notes

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

hydrocortisone rectal cream 1 % 1(SO)

hydrocortisone rectal enema 100 mg/60ml 1

hydrocortisone valerate external cream 0.2 % 1

hydrocortisone valerate external ointment 0.2 % 1

hydrocortisone-acetic acid otic solution 1-2 % 1

hydrocortisone-aloe external cream 1 % 1(SO)

hydromorphone hcl er oral tablet er 24 hour

abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg 1 QL (31 EA per 31 days)

hydromorphone hcl injection solution 2 mg/ml 1

hydromorphone hcl oral liquid 1 mg/ml 1 QL (1984 ML per 31 days)

hydromorphone hcl oral tablet 2 mg, 4 mg 1 QL (372 EA per 31 days)

hydromorphone hcl oral tablet 8 mg 1 QL (248 EA per 31 days)

hydromorphone hcl pf injection solution 10

mg/ml, 50 mg/5ml 1

hydroxychloroquine sulfate oral tablet 200 mg 1

hydroxyprogesterone caproate intramuscular

solution 1.25 gm/5ml 1 PA

hydroxyurea oral capsule 500 mg 1

hydroxyzine hcl intramuscular solution 25 mg/ml,

50 mg/ml 1 PA; HR

hydroxyzine hcl oral syrup 10 mg/5ml 1 PA; HR

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; HR

hydroxyzine pamoate oral capsule 100 mg, 25

mg, 50 mg 1 PA; HR

HYPERRAB S/D INTRAMUSCULAR

INJECTABLE 150 UNIT/ML 1

HYSINGLA ER ORAL TABLET ER 24 HOUR

ABUSE-DETERRENT 100 MG, 120 MG, 20

MG, 30 MG, 40 MG, 60 MG, 80 MG

1 PA; QL (124 EA per 31 days)

ibandronate sodium intravenous solution 3

mg/3ml 1

ibandronate sodium oral tablet 150 mg 1 QL (1 EA per 28 days)

IBRANCE ORAL CAPSULE 100 MG, 125 MG,

75 MG 1 PA

ibuprofen junior strength oral tablet chewable

100 mg 1(SO)

ibuprofen oral capsule 200 mg 1(SO)



48

Drug Tier Notes

ibuprofen oral suspension 100 mg/5ml 1 QL (5000 ML per 31 days)

ibuprofen oral tablet 200 mg 1(SO)

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 QL (124 EA per 31 days)

ICAPS LUTEIN & OMEGA-3 ORAL CAPSULE 1(CW)

ICAPS LUTEIN & ZEAXANTHIN ORAL

TABLET DELAYED RELEASE 1(CW)

ice blue external gel 2 % 1(CW)

ICLUSIG ORAL TABLET 15 MG, 45 MG 1 PA

ICY HOT EXTERNAL STICK 10-30 % 1(CW)

ICY HOT NATURALS EXTERNAL CREAM

7.5 % 1(CW)

ICY HOT PAIN RELIEVING EXTERNAL GEL

2.5 % 1(CW)

ICY HOT PM EXTERNAL PATCH 0.025-5 % 1(CW)

ICY HOT POWER EXTERNAL GEL 16 % 1(CW)

idarubicin hcl intravenous solution 10 mg/10ml 1

IDHIFA ORAL TABLET 100 MG 1 PA; QL (31 EA per 31 days)

IDHIFA ORAL TABLET 50 MG 1 PA; QL (62 EA per 31 days)

ifosfamide intravenous solution reconstituted 1

gm 1

ILARIS (150MG DELIVERED)

SUBCUTANEOUS SOLUTION

RECONSTITUTED 180 MG

1 PA

ILEVRO OPHTHALMIC SUSPENSION 0.3 % 1

IMBRUVICA ORAL CAPSULE 140 MG 1 PA; QL (124 EA per 31 days)

IMFINZI INTRAVENOUS SOLUTION 120

MG/2.4ML, 500 MG/10ML 1 PA

imipenem-cilastatin intravenous solution


imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; HR

imipramine pamoate oral capsule 100 mg, 125

mg, 150 mg, 75 mg 1 PA; HR

imiquimod external cream 5 % 1

IMODIUM A-D ORAL CAPSULE 2 MG 1(CW)

IMODIUM A-D ORAL TABLET 2 MG 1(CW)

IMOVAX RABIES INTRAMUSCULAR

INJECTABLE 2.5 UNIT/ML 1



49

Drug Tier Notes

INCRELEX SUBCUTANEOUS SOLUTION 40

MG/4ML 1 PA

indapamide oral tablet 1.25 mg, 2.5 mg 1

indomethacin er oral capsule extended release 75

mg 1 PA; HR; QL (62 EA per 31 days)

indomethacin oral capsule 25 mg, 50 mg 1 PA; HR

INFANRIX INTRAMUSCULAR SUSPENSION

25-58-10 1

INLYTA ORAL TABLET 1 MG 1 PA; QL (186 EA per 31 days)

INLYTA ORAL TABLET 5 MG 1 PA; QL (62 EA per 31 days)

INTELENCE ORAL TABLET 100 MG, 25 MG 1 QL (124 EA per 31 days)

INTELENCE ORAL TABLET 200 MG 1 QL (62 EA per 31 days)

intense cough reliever oral liquid 20-300 mg/5ml,

30-200 mg/5ml 1(SO)

INTRON A INJECTION SOLUTION 10000000

UNIT/ML, 6000000 UNIT/ML 1 PA

INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000

UNIT, 50000000 UNIT

1 PA

INTROVALE ORAL TABLET 0.15-0.03 MG 1

INVANZ INJECTION SOLUTION


INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION 117 MG/0.75ML, 156 MG/ML,

39 MG/0.25ML, 78 MG/0.5ML

1 ST; QL (1 ML per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION 234 MG/1.5ML 1 ST; QL (2 ML per 28 days)

INVIRASE ORAL CAPSULE 200 MG 1 QL (310 EA per 31 days)

INVIRASE ORAL TABLET 500 MG 1 QL (124 EA per 31 days)

INVOKAMET ORAL TABLET 150-1000 MG,

150-500 MG, 50-1000 MG, 50-500 MG 1 QL (62 EA per 31 days)

INVOKAMET XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 150-1000

MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG 1 QL (31 EA per 31 days)

IPOL INJECTION INJECTABLE 1

ipratropium bromide inhalation solution 0.02 % 1

ipratropium bromide nasal solution 0.03 % 1 QL (62 ML per 31 days)



50

Drug Tier Notes

ipratropium bromide nasal solution 0.06 % 1 QL (31 ML per 31 days)

ipratropium-albuterol inhalation solution 0.5-2.5

(3) mg/3ml 1

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 QL (31 EA per 31 days)

irbesartan-hydrochlorothiazide oral tablet 150-

12.5 mg, 300-12.5 mg 1 QL (31 EA per 31 days)

IRESSA ORAL TABLET 250 MG 1 PA

irinotecan hcl intravenous solution 100 mg/5ml 1

iron (ferrous gluconate) oral tablet 256 (28 fe)

mg 1(CW)

iron oral tablet 90 (18 fe) mg 1(CW)

ISENTRESS HD ORAL TABLET 600 MG 1 QL (62 EA per 31 days)

ISENTRESS ORAL PACKET 100 MG 1

ISENTRESS ORAL TABLET 400 MG 1 QL (124 EA per 31 days)

ISENTRESS ORAL TABLET CHEWABLE 100

MG, 25 MG 1 QL (186 EA per 31 days)

isibloom oral tablet 0.15-30 mg-mcg 1

isoniazid injection solution 100 mg/ml 1

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1

isosorbide dinitrate er oral tablet extended

release 40 mg 1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg 1

isosorbide mononitrate er oral tablet extended

release 24 hour 120 mg, 30 mg, 60 mg 1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

isradipine oral capsule 2.5 mg, 5 mg 1

ISTODAX INTRAVENOUS SOLUTION


itraconazole oral capsule 100 mg 1 PA

ivermectin oral tablet 3 mg 1

IXIARO INTRAMUSCULAR SUSPENSION 1

JAKAFI ORAL TABLET 10 MG, 15 MG, 20

MG, 25 MG, 5 MG 1 PA; QL (62 EA per 31 days)

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2

MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5

MG

1



51

Drug Tier Notes

JANUMET ORAL TABLET 50-1000 MG, 50-


JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 100-1000 MG, 50-1000

MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50

MG 1 QL (31 EA per 31 days)

JENTADUETO ORAL TABLET 2.5-1000 MG,

2.5-500 MG, 2.5-850 MG 1 QL (62 EA per 31 days)

JENTADUETO XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 2.5-1000 MG 1 QL (62 EA per 31 days)

JENTADUETO XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 5-1000 MG 1 QL (31 EA per 31 days)

JINTELI ORAL TABLET 1-5 MG-MCG 1

jock itch spray external aerosol powder 1 % 1(SO)

JOLIVETTE ORAL TABLET 0.35 MG 1

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-

MCG 1

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG 1

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-

MCG 1

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG, 5 MG, 60 MG 1 PA

KADCYLA INTRAVENOUS SOLUTION


KALETRA ORAL TABLET 100-25 MG 1 QL (310 EA per 31 days)

KALETRA ORAL TABLET 200-50 MG 1 QL (155 EA per 31 days)

KALYDECO ORAL PACKET 50 MG, 75 MG 1 PA

KALYDECO ORAL TABLET 150 MG 1 PA

KARIVA ORAL TABLET 0.15-0.02/0.01 MG

(21/5) 1

KAZANO ORAL TABLET 12.5-1000 MG, 12.5-




52

Drug Tier Notes

kcl in dextrose-nacl intravenous solution 10-5-

0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-

0.225 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-

0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45

meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9

meq/l-%-%

1

kcl-lactated ringers-d5w intravenous solution 20

meq/l 1

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG 1

KEPIVANCE INTRAVENOUS SOLUTION


ketoconazole external cream 2 % 1

ketoconazole external shampoo 2 % 1

ketoconazole oral tablet 200 mg 1

ketoprofen oral capsule 50 mg 1 QL (186 EA per 31 days)

ketoprofen oral capsule 75 mg 1 QL (124 EA per 31 days)

ketorolac tromethamine injection solution 15

mg/ml, 30 mg/ml 1 PA; HR

ketorolac tromethamine intramuscular solution

60 mg/2ml 1 PA; HR

ketorolac tromethamine ophthalmic solution 0.4

%, 0.5 % 1

ketorolac tromethamine oral tablet 10 mg 1 PA; HR; QL (20 EA per 5 days)

ketotifen fumarate ophthalmic solution 0.025 % 1(SO)

KEYTRUDA INTRAVENOUS SOLUTION 100

MG/4ML 1 PA

KEYTRUDA INTRAVENOUS SOLUTION


KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG

(21/5) 1

KINERET SUBCUTANEOUS SOLUTION


KINRIX INTRAMUSCULAR SUSPENSION 1

KIONEX ORAL POWDER 1

KISQALI 200 DOSE ORAL TABLET 200 MG 1 PA



KISQALI FEMARA 200 DOSE ORAL TABLET

THERAPY PACK 200 & 2.5 MG 1 PA



53

Drug Tier Notes





KLOR-CON 10 ORAL TABLET EXTENDED

RELEASE 10 MEQ 1

klor-con m10 oral tablet extended release 10 meq 1

KLOR-CON M15 ORAL TABLET EXTENDED

RELEASE 15 MEQ 1

klor-con m20 oral tablet extended release 20 meq 1

KONSYL ORAL PACKET 100 %, 28.3 %, 60.3

%, 71.67 % 1(CW)

KONSYL ORAL POWDER 60.3 %, 71.67 % 1(CW)

KONSYL-D ORAL POWDER 52.3 % 1(CW)

KORLYM ORAL TABLET 300 MG 1 PA

KUVAN ORAL PACKET 100 MG, 500 MG 1 PA

KUVAN ORAL TABLET SOLUBLE 100 MG 1 PA

KYNAMRO SUBCUTANEOUS SOLUTION


KYPROLIS INTRAVENOUS SOLUTION


labetalol hcl intravenous solution 5 mg/ml 1

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1

LAC-HYDRIN FIVE EXTERNAL LOTION 5 % 1(CW)

lactated ringers intravenous solution 1

lactated ringers irrigation solution 1

lactulose oral solution 10 gm/15ml 1

LAMISIL AF DEFENSE EXTERNAL

AEROSOL POWDER 1 % 1(SO)

lamivudine oral solution 10 mg/ml 1 QL (992 ML per 31 days)

lamivudine oral tablet 100 mg 1

lamivudine oral tablet 150 mg 1 QL (62 EA per 31 days)

lamivudine oral tablet 300 mg 1 QL (31 EA per 31 days)

lamivudine-zidovudine oral tablet 150-300 mg 1 QL (62 EA per 31 days)

lamotrigine er oral tablet extended release 24

hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50

mg

1



54

Drug Tier Notes

lamotrigine oral tablet 100 mg, 150 mg, 200 mg,

25 mg 1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

lamotrigine oral tablet dispersible 100 mg, 200

mg, 25 mg, 50 mg 1

lansoprazole capsule delayed release 15 mg oral

(rx) 15 mg 1(CW)

lansoprazole oral capsule delayed release 15 mg,

30 mg 1

LANTUS SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML 1

LANTUS SUBCUTANEOUS SOLUTION 100

UNIT/ML 1

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-

MCG 1

LARIN 1/20 ORAL TABLET 1-20 MG-MCG 1

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-

MCG 1

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG 1

larissia oral tablet 0.1-20 mg-mcg 1

LARTRUVO INTRAVENOUS SOLUTION 500

MG/50ML 1 PA

latanoprost ophthalmic solution 0.005 % 1

LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG, 80 MG 1

laxative pills oral tablet 15 mg, 25 mg 1(CW)

LAZANDA NASAL SOLUTION 100

MCG/ACT, 300 MCG/ACT, 400 MCG/ACT 1 PA; QL (31 EA per 31 days)

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

leflunomide oral tablet 10 mg, 20 mg 1 QL (31 EA per 31 days)

LENVIMA 10 MG DAILY DOSE ORAL

CAPSULE THERAPY PACK 10 MG 1 PA


CAPSULE THERAPY PACK 10 & 4 MG 1 PA


CAPSULE THERAPY PACK 10 & 4 (2) MG 1 PA


CAPSULE THERAPY PACK 10 (2) MG 1 PA



55

Drug Tier Notes


CAPSULE THERAPY PACK 10 (2) & 4 MG 1 PA


CAPSULE THERAPY PACK 4 (2) MG 1 PA

LESSINA ORAL TABLET 0.1-20 MG-MCG 1

LETAIRIS ORAL TABLET 10 MG, 5 MG 1 QL (31 EA per 31 days)

letrozole oral tablet 2.5 mg 1 QL (31 EA per 31 days)

leucovorin calcium injection solution


leucovorin calcium oral tablet 10 mg, 15 mg, 25

mg, 5 mg 1

LEUKERAN ORAL TABLET 2 MG 1

LEUKINE INTRAVENOUS SOLUTION

RECONSTITUTED 250 MCG 1

leuprolide acetate injection kit 1 mg/0.2ml 1

LEVEMIR FLEXTOUCH SUBCUTANEOUS


LEVEMIR SUBCUTANEOUS SOLUTION 100

UNIT/ML 1

levetiracetam er oral tablet extended release 24

hour 500 mg, 750 mg 1

levetiracetam intravenous solution 500 mg/5ml 1

levetiracetam oral solution 100 mg/ml 1

levetiracetam oral tablet 1000 mg, 250 mg, 500

mg, 750 mg 1

levobunolol hcl ophthalmic solution 0.5 % 1

levocarnitine oral solution 1 gm/10ml 1

levocarnitine oral tablet 330 mg 1

levocetirizine dihydrochloride oral solution 2.5

mg/5ml 1

levocetirizine dihydrochloride oral tablet 5 mg 1

levofloxacin in d5w intravenous solution 500

mg/100ml 1

levofloxacin intravenous solution 25 mg/ml 1

levofloxacin ophthalmic solution 0.5 % 1

levofloxacin oral solution 25 mg/ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1



56

Drug Tier Notes

levoleucovorin calcium intravenous solution 175

mg/17.5ml 1

levoleucovorin calcium intravenous solution


LEVONEST ORAL TABLET 1

levonorgest-eth estrad 91-day oral tablet 0.15-

0.03 mg 1

levonorgestrel oral tablet 1.5 mg 1(SO)

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30

MG-MCG 1

levorphanol tartrate oral tablet 2 mg 1 QL (186 EA per 31 days)

levothyroxine sodium oral tablet 100 mcg, 112

mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200

mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

LEVOXYL ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175

MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,

88 MCG

1

LEXIVA ORAL SUSPENSION 50 MG/ML 1 QL (1628 ML per 28 days)

LEXIVA ORAL TABLET 700 MG 1 QL (124 EA per 31 days)

LIALDA ORAL TABLET DELAYED

RELEASE 1.2 GM 1

lice treatment external liquid 0.33-4 %, 1 % 1(SO)

lice treatment external lotion 1 % 1(SO)

LICIDE AEROSOL 0.5 % 1(CW)

lidocaine external patch 5 % 1 PA; QL (93 EA per 31 days)

lidocaine hcl (pf) injection solution 0.5 %, 1 % 1

lidocaine hcl external gel 2 % 1

lidocaine hcl external solution 4 % 1

lidocaine hcl injection solution 2 % 1

lidocaine viscous mouth/throat solution 2 % 1

lidocaine-prilocaine external cream 2.5-2.5 % 1

LIDOCARE ARM/NECK/LEG EXTERNAL

PATCH 4 % 1(CW) QL (90 EA per 30 days)

LIDOCREAM EXTERNAL CREAM 4 % 1(CW) QL (120 GM per 30 days)

lindane external shampoo 1 % 1

linezolid intravenous solution 600 mg/300ml 1 PA



57

Drug Tier Notes

linezolid oral suspension reconstituted 100

mg/5ml 1 PA

linezolid oral tablet 600 mg 1 PA

LINZESS ORAL CAPSULE 145 MCG, 290

MCG, 72 MCG 1

liothyronine sodium intravenous solution 10

mcg/ml 1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50

mcg 1

liquid calcium with d3 oral capsule 600-1000 mg-

unit 1(CW)

liquituss gg oral liquid 200 mg/5ml 1(SO)

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30

mg, 40 mg, 5 mg 1

lisinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg 1

lithium carbonate er oral tablet extended release

300 mg, 450 mg 1

lithium carbonate oral capsule 150 mg, 300 mg,

600 mg 1

lithium carbonate oral tablet 300 mg 1

lithium oral solution 8 meq/5ml 1

LOMEDIA 24 FE ORAL TABLET 1-20 MG-

MCG(24) 1

LONSURF ORAL TABLET 15-6.14 MG, 20-

8.19 MG 1 PA

loperamide hcl oral capsule 2 mg 1

lopinavir-ritonavir oral solution 400-100 mg/5ml 1

loratadine allergy relief oral tablet dispersible 10

mg 1(SO)

loratadine oral tablet 10 mg 1(SO)

loratadine-d 24hr oral tablet extended release 24

hour 10-240 mg 1(SO)

LORAZEPAM INTENSOL ORAL

CONCENTRATE 2 MG/ML 1 QL (248 ML per 31 days)

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

lorcet hd oral tablet 10-325 mg 1 QL (381 EA per 31 days)

LORCET ORAL TABLET 5-325 MG 1 QL (382 EA per 31 days)



58

Drug Tier Notes

LORCET PLUS ORAL TABLET 7.5-325 MG 1 QL (382 EA per 31 days)

LORYNA ORAL TABLET 3-0.02 MG 1

losartan potassium oral tablet 100 mg, 25 mg, 50


losartan potassium-hctz oral tablet 100-12.5 mg,

100-25 mg, 50-12.5 mg 1 QL (62 EA per 31 days)

LOTEMAX OPHTHALMIC GEL 0.5 % 1

LOTEMAX OPHTHALMIC OINTMENT 0.5 % 1

LOTEMAX OPHTHALMIC SUSPENSION 0.5

% 1

LOTRIMIN AF EXTERNAL AEROSOL 2 % 1(SO)

LOTRIMIN AF EXTERNAL POWDER 2 % 1(SO)

LOTRIMIN AF JOCK ITCH POWDER

EXTERNAL AEROSOL POWDER 2 % 1(SO)

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1

low-ogestrel oral tablet 0.3-30 mg-mcg 1

loxapine succinate oral capsule 10 mg, 25 mg, 5

mg, 50 mg 1

lubricant eye drops ophthalmic solution 0.4-0.3

%, 0.5 % 1(SO)

lubricant eye ophthalmic ointment 1(SO)

LUMIGAN OPHTHALMIC SOLUTION 0.01 % 1

LUMIZYME INTRAVENOUS SOLUTION


LUPRON DEPOT (1-MONTH)

INTRAMUSCULAR KIT 3.75 MG, 7.5 MG 1 PA; QL (1 EA per 31 days)


INTRAMUSCULAR KIT 11.25 MG 1 PA; QL (1 EA per 28 days)




INTRAMUSCULAR KIT 30 MG 1 PA; QL (1 EA per 112 days)



LUPRON DEPOT-PED (1-MONTH)


LUPRON DEPOT-PED (1-MONTH)




59

Drug Tier Notes

LUTERA ORAL TABLET 0.1-20 MG-MCG 1

LUZU EXTERNAL CREAM 1 % 1

LYNPARZA ORAL CAPSULE 50 MG 1 PA

LYNPARZA ORAL TABLET 100 MG, 150 MG 1 PA; LA

LYRICA ORAL CAPSULE 100 MG, 150 MG,

200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75

MG

1

LYRICA ORAL SOLUTION 20 MG/ML 1

LYSODREN ORAL TABLET 500 MG 1

LYZA ORAL TABLET 0.35 MG 1

MAALOX ADVANCED MAX ST ORAL

SUSPENSION 400-400-40 MG/5ML 1(SO)

mag-al oral liquid 200-200 mg/5ml 1(SO)

magnesium citrate oral solution 1.745 gm/30ml 1(CW)

magnesium oral capsule 500 mg 1(CW)

magnesium oral tablet 250 mg, 400 mg 1(CW)

magnesium oxide (antacid) oral capsule 500 mg 1(SO)

magnesium oxide -mg supplement oral tablet 250

mg 1(CW)

magnesium oxide oral capsule 400 mg 1(CW)

magnesium oxide oral tablet 250 mg, 400 (240

mg) mg, 400 (241.3 mg) mg, 400 mg, 500 mg 1(CW)

magnesium sulfate injection solution 50 % 1

MAKENA INTRAMUSCULAR OIL 250

MG/ML 1 PA

malathion external lotion 0.5 % 1

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 1

MAR-COF CG EXPECTORANT ORAL

LIQUID 225-7.5 MG/5ML 1(ND)

marlissa oral tablet 0.15-30 mg-mcg 1

MARPLAN ORAL TABLET 10 MG 1 ST

MATULANE ORAL CAPSULE 50 MG 1 PA

MATZIM LA ORAL TABLET EXTENDED

RELEASE 24 HOUR 180 MG, 240 MG, 300

MG, 360 MG, 420 MG

1

MAVYRET ORAL TABLET 100-40 MG 1 PA

meclizine hcl oral tablet 12.5 mg, 25 mg 1



60

Drug Tier Notes

medicated pain relieving external patch 1.2-5.7-

6.3 % 1(CW)

MEDROX EXTERNAL PATCH 0.0375-5 %,

0.0375-5-20 % 1(CW)

medroxyprogesterone acetate intramuscular

suspension 150 mg/ml 1 QL (1 ML per 90 days)

medroxyprogesterone acetate oral tablet 10 mg,

2.5 mg, 5 mg 1

mefloquine hcl oral tablet 250 mg 1

megestrol acetate oral suspension 40 mg/ml, 625

mg/5ml 1 PA; HR

megestrol acetate oral tablet 20 mg, 40 mg 1 PA; HR

MEKINIST ORAL TABLET 0.5 MG 1 PA; LA; QL (124 EA per 31 days)

MEKINIST ORAL TABLET 2 MG 1 PA; LA; QL (31 EA per 31 days)

melatonin er oral tablet extended release 10 mg,

3 mg 1(CW)

melatonin fast meltz oral tablet dispersible 500

mcg 1(CW)

melatonin gummies oral tablet chewable 2.5 mg 1(CW)

melatonin oral capsule 10 mg, 5 mg 1(CW)

melatonin oral tablet 1 mg, 10 mg, 3 mg, 3-10 mg,

3-2 mg, 300 mcg 1(CW)

melatonin oral tablet dispersible 3 mg, 5 mg 1(CW)

melatonin sublingual tablet sublingual 5 mg 1(CW)

melatonin tr with vitamin b6 oral tablet extended

release 3-10 mg 1(CW)

meloxicam oral tablet 15 mg 1 QL (31 EA per 31 days)

meloxicam oral tablet 7.5 mg 1 QL (62 EA per 31 days)

melphalan hcl intravenous solution reconstituted

50 mg 1

memantine hcl oral solution 2 mg/ml 1 QL (372 ML per 31 days)

memantine hcl oral tablet 10 mg, 5 mg 1 QL (62 EA per 31 days)

memantine hcl oral tablet 5 (28)-10 (21) mg 1

MENACTRA INTRAMUSCULAR

INJECTABLE 1

mencaps external patch 0.0225-4.5 % 1(CW)

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG 1 PA; HR



61

Drug Tier Notes

MENVEO INTRAMUSCULAR SOLUTION

RECONSTITUTED 1

meperidine hcl injection solution 100 mg/ml, 25

mg/ml, 50 mg/ml 1 PA; HR

meperidine hcl oral solution 50 mg/5ml 1

meperidine hcl oral tablet 100 mg, 50 mg 1 PA; HR; QL (372 EA per 31 days)

MEPHYTON ORAL TABLET 5 MG 1(CW)

mercaptopurine oral tablet 50 mg 1

meropenem intravenous solution reconstituted 1

gm, 500 mg 1

MESALAMINE ORAL TABLET DELAYED

RELEASE 800 MG 1

mesalamine-cleanser rectal kit 4 gm 1

mesna intravenous solution 100 mg/ml 1

MESNEX ORAL TABLET 400 MG 1

METADATE ER ORAL TABLET EXTENDED

RELEASE 20 MG 1 QL (93 EA per 31 days)

METAMUCIL MULTIHEALTH FIBER ORAL

PACKET 58.12 % 1(CW)

METAMUCIL MULTIHEALTH FIBER ORAL

POWDER 55.46 %, 63 % 1(CW)

METAMUCIL ORAL POWDER 28.3 %, 48.57

% 1(CW)

METAMUCIL ORAL WAFER 1(CW)

METAMUCIL SMOOTH TEXTURE ORAL

PACKET 28 % 1(CW)

METAMUCIL SMOOTH TEXTURE ORAL

POWDER 58.6 % 1(CW)

metaproterenol sulfate oral syrup 10 mg/5ml 1

metaproterenol sulfate oral tablet 10 mg, 20 mg 1

metaxalone oral tablet 800 mg 1 PA; HR; QL (124 EA per 31 days)

metformin hcl er oral tablet extended release 24

hour 500 mg 1 QL (124 EA per 31 days)

metformin hcl er oral tablet extended release 24


metformin hcl oral tablet 1000 mg, 850 mg 1 QL (62 EA per 31 days)

metformin hcl oral tablet 500 mg 1 QL (124 EA per 31 days)

methadone hcl injection solution 10 mg/ml 1



62

Drug Tier Notes

methadone hcl oral solution 10 mg/5ml 1 QL (500 ML per 31 days)

methadone hcl oral solution 5 mg/5ml 1 QL (992 ML per 31 days)

methadone hcl oral tablet 10 mg, 5 mg 1 QL (248 EA per 31 days)

methenamine hippurate oral tablet 1 gm 1

methimazole oral tablet 10 mg, 5 mg 1

methocarbamol injection solution 1000 mg/10ml 1 PA; HR

methocarbamol oral tablet 500 mg, 750 mg 1 PA; HR

methotrexate oral tablet 2.5 mg 1

methotrexate sodium (pf) injection solution 1

gm/40ml 1

methotrexate sodium injection solution 50 mg/2ml 1

methotrexate sodium injection solution


methoxsalen rapid oral capsule 10 mg 1

methscopolamine bromide oral tablet 2.5 mg, 5

mg 1

methyclothiazide oral tablet 5 mg 1

methyldopa oral tablet 250 mg, 500 mg 1 PA; HR

methyldopa-hydrochlorothiazide oral tablet 250-

15 mg, 250-25 mg 1 PA; HR

methyldopate hcl intravenous solution 250

mg/5ml 1 PA; HR

methylphenidate hcl er (cd) oral capsule extended

release 10 mg 1

methylphenidate hcl er oral tablet extended

release 10 mg, 20 mg 1 QL (93 EA per 31 days)

methylphenidate hcl oral solution 10 mg/5ml 1 QL (930 ML per 31 days)

methylphenidate hcl oral solution 5 mg/5ml 1 QL (1860 ML per 31 days)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5


methylprednisolone acetate injection suspension

40 mg/ml, 80 mg/ml 1

methylprednisolone oral tablet 16 mg, 32 mg, 4

mg, 8 mg 1

methylprednisolone oral tablet therapy pack 4 mg 1

methylprednisolone sodium succ injection

solution reconstituted 125 mg, 40 mg 1

metipranolol ophthalmic solution 0.3 % 1



63

Drug Tier Notes

metoclopramide hcl injection solution 5 mg/ml 1

metoclopramide hcl oral solution 5 mg/5ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

metoprolol succinate er oral tablet extended

release 24 hour 100 mg, 200 mg, 25 mg, 50 mg 1 QL (62 EA per 31 days)

metoprolol tartrate intravenous solution 5 mg/5ml 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg 1

metoprolol-hydrochlorothiazide oral tablet 100-

25 mg, 100-50 mg, 50-25 mg 1

metronidazole external cream 0.75 % 1

metronidazole external gel 0.75 %, 1 % 1

metronidazole external lotion 0.75 % 1

metronidazole in nacl intravenous solution 500-

0.79 mg/100ml-% 1

metronidazole oral tablet 250 mg, 500 mg 1

metronidazole vaginal gel 0.75 % 1

mexiletine hcl oral capsule 150 mg, 200 mg, 250

mg 1

MIACALCIN INJECTION SOLUTION 200

UNIT/ML 1

MI-ACID ORAL TABLET CHEWABLE 700-

300 MG 1(CW)

miconazole 3 combo pack app vaginal kit 200 & 2

mg-% (9gm) 1(SO)

miconazole 3 combo pack vaginal kit 200 & 2

mg-% (9gm) 1(SO)

miconazole 3 vaginal cream 4 % 1(SO)

miconazole 3 vaginal suppository 200 mg 1(SO)

miconazole 7 vaginal suppository 100 mg 1(SO)

miconazole nitrate external cream 2 % 1(SO)

miconazole nitrate powder 2 % 1(SO)

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30

MG-MCG 1

MICROGESTIN 1/20 ORAL TABLET 1-20

MG-MCG 1



64

Drug Tier Notes

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-

30 MG-MCG 1

MICROGESTIN FE 1/20 ORAL TABLET 1-20

MG-MCG 1

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1

milk of magnesia concentrate oral suspension

2400 mg/10ml 1(CW)

milk of magnesia oral suspension 400 mg/5ml 1(CW)

MIMVEY LO ORAL TABLET 0.5-0.1 MG 1

MIMVEY ORAL TABLET 1-0.5 MG 1

mineral freez external gel 2 % 1(CW)

MINITRAN TRANSDERMAL PATCH 24

HOUR 0.1 MG/HR, 0.2 MG/HR, 0.6 MG/HR 1 QL (31 EA per 31 days)

MINITRAN TRANSDERMAL PATCH 24

HOUR 0.4 MG/HR 1 QL (62 EA per 31 days)

minocycline hcl oral capsule 100 mg, 50 mg, 75

mg 1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1

minoxidil oral tablet 10 mg, 2.5 mg 1

mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1 QL (31 EA per 31 days)

mirtazapine oral tablet 7.5 mg 1

mirtazapine oral tablet dispersible 15 mg, 30 mg,


misoprostol oral tablet 100 mcg, 200 mcg 1

mitomycin intravenous solution reconstituted 20

mg, 40 mg, 5 mg 1

mitoxantrone hcl intravenous concentrate 25

mg/12.5ml 1

M-M-R II SUBCUTANEOUS INJECTABLE 1

modafinil oral tablet 100 mg, 200 mg 1 PA; QL (62 EA per 31 days)

moexipril hcl oral tablet 15 mg, 7.5 mg 1

moexipril-hydrochlorothiazide oral tablet 15-12.5

mg, 15-25 mg, 7.5-12.5 mg 1

MOI-STIR MOUTH/THROAT SOLUTION 1(CW)

mometasone furoate external cream 0.1 % 1

mometasone furoate external ointment 0.1 % 1

MONISTAT 1 COMBO PACK VAGINAL KIT

1200 & 2 MG & % 1(SO)



65

Drug Tier Notes

MONISTAT 1 DAY OR NIGHT VAGINAL KIT

1200 & 2 MG & % 1(SO)

MONISTAT 3 COMBINATION PACK

VAGINAL KIT 200 & 2 MG-% (9GM), 200-2

MG-%

1(SO)

MONISTAT 3 COMBO PACK APP VAGINAL

KIT 200 & 2 MG-% (9GM) 1(SO)

MONISTAT 3 VAGINAL CREAM 4 % 1(SO)

MONISTAT 7 COMBO PACK APP VAGINAL

KIT 100 & 2 MG-% (9GM) 1(SO)

MONISTAT 7 COMPLETE THERAPY

VAGINAL KIT 100-2 MG-% 1(SO)

MONONESSA ORAL TABLET 0.25-35 MG-

MCG 1

montelukast sodium oral packet 4 mg 1 QL (31 EA per 31 days)

montelukast sodium oral tablet 10 mg 1 QL (31 EA per 31 days)

montelukast sodium oral tablet chewable 4 mg, 5


morphine sulfate (concentrate) oral solution 100


morphine sulfate (pf) intravenous solution 2

mg/ml 1

morphine sulfate er beads oral capsule extended

release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75

mg, 90 mg


morphine sulfate er oral capsule extended release

24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60

mg, 80 mg


morphine sulfate er oral tablet extended release

100 mg, 15 mg, 200 mg, 30 mg, 60 mg 1 QL (93 EA per 31 days)

morphine sulfate oral solution 10 mg/5ml, 20


morphine sulfate oral tablet 15 mg, 30 mg 1 QL (186 EA per 31 days)

motion sickness relief oral tablet 50 mg 1(SO)

motion sickness relief oral tablet chewable 25 mg 1(SO)

MOVIPREP ORAL SOLUTION


MOXEZA OPHTHALMIC SOLUTION 0.5 % 1



66

Drug Tier Notes

moxifloxacin hcl intravenous solution 400

mg/250ml 1

moxifloxacin hcl ophthalmic solution 0.5 % 1

MOZOBIL SUBCUTANEOUS SOLUTION 24

MG/1.2ML 1 PA; QL (8 ML per 31 days)

mucus relief dm max oral liquid 5-100 mg/5ml 1(SO)

MULTAQ ORAL TABLET 400 MG 1

mupirocin external ointment 2 % 1

MURO 128 OPHTHALMIC OINTMENT 5 % 1(CW)

muscle rub external cream 10-15 % 1(CW)

muscle rub ultra strength external cream 4-10-30

% 1(CW)

MUSTARGEN INJECTION SOLUTION


MY WAY ORAL TABLET 1.5 MG 1(SO)

mycophenolate mofetil hcl intravenous solution


mycophenolate mofetil oral capsule 250 mg 1

mycophenolate mofetil oral suspension

reconstituted 200 mg/ml 1

mycophenolate mofetil oral tablet 500 mg 1

MYLANTA ORAL SUSPENSION 200-200-20

MG/5ML 1(SO)

MYORISAN ORAL CAPSULE 10 MG, 20 MG,

40 MG 1

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HOUR 25 MG, 50 MG 1

MYTESI ORAL TABLET DELAYED

RELEASE 125 MG 1

nabumetone oral tablet 500 mg 1 QL (124 EA per 31 days)

nabumetone oral tablet 750 mg 1 QL (62 EA per 31 days)

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

nadolol-bendroflumethiazide oral tablet 40-5 mg,

80-5 mg 1

nafcillin sodium injection solution reconstituted 1

gm, 10 gm 1

NAGLAZYME INTRAVENOUS SOLUTION 1

MG/ML 1 PA



67

Drug Tier Notes

naloxone hcl injection solution 0.4 mg/ml 1

naltrexone hcl oral tablet 50 mg 1

NAMZARIC ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 14-10 MG, 28-10 MG 1

naproxen dr oral tablet delayed release 375 mg,

500 mg 1

naproxen oral suspension 125 mg/5ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium oral capsule 220 mg 1(SO)

naproxen sodium oral tablet 220 mg 1(SO)

naproxen sodium oral tablet 275 mg, 550 mg 1

naratriptan hcl oral tablet 1 mg, 2.5 mg 1 QL (9 EA per 31 days)

NARCAN NASAL LIQUID 4 MG/0.1ML 1 QL (2 EA per 30 days)

NASADROPS SALINE ON THE GO NASAL

SOLUTION 0.9 % 1(CW)

nasal decongestant oral liquid 30 mg/5ml 1(SO)

nasal decongestant oral tablet 30 mg 1(SO)

NASAL MOIST NASAL SOLUTION 0.65 % 1(CW)

NASOGEL NASAL GEL 1(CW)

nateglinide oral tablet 120 mg, 60 mg 1

NATPARA SUBCUTANEOUS CARTRIDGE

100 MCG, 25 MCG, 50 MCG, 75 MCG 1 PA; HR

natural fiber laxative oral powder 28.3 %, 30.9

%, 48.57 %, 58.6 % 1(CW)

natural fiber therapy oral powder 30 % 1(CW)

natural psyllium seed oral powder 100 % 1(CW)

NEBUPENT INHALATION SOLUTION


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

MG-MCG 1

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35

MG-MCG 1

nefazodone hcl oral tablet 100 mg, 150 mg, 200

mg, 250 mg, 50 mg 1

neomycin sulfate oral tablet 500 mg 1

neomycin-bacitracin zn-polymyx ophthalmic

ointment 5-400-10000 1



68

Drug Tier Notes

neomycin-polymyxin b gu irrigation solution 40-

200000 1

neomycin-polymyxin-dexameth ophthalmic

ointment 3.5-10000-0.1 1

neomycin-polymyxin-dexameth ophthalmic

suspension 3.5-10000-0.1 1

neomycin-polymyxin-gramicidin ophthalmic

solution 1.75-10000-.025 1

neomycin-polymyxin-hc ophthalmic suspension

3.5-10000-1 1

neomycin-polymyxin-hc otic solution 1 % 1

neomycin-polymyxin-hc otic suspension 3.5-

10000-1 1

NEPHRAMINE INTRAVENOUS SOLUTION

5.4 % 1

NERLYNX ORAL TABLET 40 MG 1 PA; LA; QL (186 EA per 31 days)

NESINA ORAL TABLET 12.5 MG, 25 MG,

6.25 MG 1 QL (31 EA per 31 days)

NEUAC EXTERNAL GEL 1.2-5 % 1

NEUPOGEN INJECTION SOLUTION 300

MCG/ML, 480 MCG/1.6ML 1 PA; QL (14 ML per 31 days)

NEUPOGEN INJECTION SOLUTION

PREFILLED SYRINGE 300 MCG/0.5ML, 480

MCG/0.8ML

1 PA; QL (14 ML per 31 days)

NEUPRO TRANSDERMAL PATCH 24 HOUR

1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4

MG/24HR, 6 MG/24HR, 8 MG/24HR


nevirapine er oral tablet extended release 24 hour

100 mg 1

nevirapine er oral tablet extended release 24 hour


nevirapine oral suspension 50 mg/5ml 1 QL (1240 ML per 31 days)

nevirapine oral tablet 200 mg 1 QL (62 EA per 31 days)

NEXAFED ORAL TABLET ABUSE-

DETERRENT 30 MG 1(SO)

NEXAVAR ORAL TABLET 200 MG 1 PA; LA; QL (124 EA per 31 days)

NEXT CHOICE ONE DOSE ORAL TABLET

1.5 MG 1(SO)



69

Drug Tier Notes

niacin er (antihyperlipidemic) oral tablet

extended release 1000 mg, 500 mg, 750 mg 1

niacin er oral capsule extended release 250 mg,

500 mg 1(CW)

niacin er oral tablet extended release 1000 mg,

250 mg, 500 mg, 750 mg 1(CW)

niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg 1(CW)

niacinamide oral tablet 500 mg 1(CW)

NIACOR ORAL TABLET 500 MG 1

nicardipine hcl intravenous solution 2.5 mg/ml 1

nicardipine hcl oral capsule 20 mg, 30 mg 1

NICODERM CQ TRANSDERMAL PATCH 24

HOUR 14 MG/24HR, 21 MG/24HR, 7

MG/24HR

1(SO) PA; QL (30 EA per 30 days)

NICORETTE MOUTH/THROAT GUM 2 MG, 4

MG 1(SO) PA; QL (270 EA per 30 days)

nicotine mini mouth/throat lozenge 2 mg 1(SO) PA; QL (270 EA per 30 days)

nicotine polacrilex mouth/throat gum 2 mg, 4 mg 1(SO) PA; QL (270 EA per 30 days)

nicotine transdermal patch 24 hour 14 mg/24hr,

21 mg/24hr, 7 mg/24hr 1(SO) PA; QL (30 EA per 30 days)

NICOTROL INHALATION INHALER 10 MG 1

nifedipine er osmotic release oral tablet extended

release 24 hour 30 mg, 60 mg, 90 mg 1 QL (62 EA per 31 days)

nifedipine oral capsule 10 mg, 20 mg 1

NIKKI ORAL TABLET 3-0.02 MG 1

nilutamide oral tablet 150 mg 1 QL (62 EA per 31 days)

nimodipine oral capsule 30 mg 1

NINJACOF-XG ORAL LIQUID 200-8 MG/5ML 1(ND)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4

MG 1 PA

nisoldipine er oral tablet extended release 24

hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40

mg, 8.5 mg

1

nitrofurantoin macrocrystal oral capsule 100 mg,

50 mg 1 PA; HR

nitrofurantoin monohyd macro oral capsule 100

mg 1 PA; HR



70

Drug Tier Notes

nitrofurantoin oral suspension 25 mg/5ml 1 PA; HR; QL (7850 ML per 120

days)

nitroglycerin intravenous solution 5 mg/ml 1

nitroglycerin sublingual tablet sublingual 0.3 mg,

0.4 mg, 0.6 mg 1

nitroglycerin transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.6 mg/hr 1 QL (31 EA per 31 days)

nitroglycerin transdermal patch 24 hour 0.4

mg/hr 1 QL (62 EA per 31 days)

NIX CREME RINSE EXTERNAL LIQUID 1 % 1(SO)

nizatidine oral capsule 150 mg, 300 mg 1

nizatidine oral solution 15 mg/ml 1

non-aspirin extra strength oral tablet 500 mg 1(SO)

non-aspirin jr strength oral tablet chewable 160

mg 1(SO)

non-aspirin pain relief oral tablet 325 mg 1(SO)

NORA-BE ORAL TABLET 0.35 MG 1

NORDITROPIN FLEXPRO SUBCUTANEOUS

SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30

MG/3ML, 5 MG/1.5ML

1 PA

norethin ace-eth estrad-fe oral tablet 1-20 mg-

mcg(24) 1

norethindrone acetate oral tablet 5 mg 1

norethindrone acet-ethinyl est oral tablet 1-20

mg-mcg 1

norethindrone oral tablet 0.35 mg 1

norgestimate-eth estradiol oral tablet 0.25-35 mg-

mcg 1

norgestim-eth estrad triphasic oral tablet

0.18/0.215/0.25 mg-35 mcg 1

NORLYROC ORAL TABLET 0.35 MG 1

NORMOSOL-M IN D5W INTRAVENOUS

SOLUTION 1

NORMOSOL-R PH 7.4 INTRAVENOUS

SOLUTION 1

NORTHERA ORAL CAPSULE 100 MG, 200

MG, 300 MG 1 PA

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

MG-MCG 1



71

Drug Tier Notes

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

MCG 1

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

MCG 1

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35

MG-MCG 1

nortriptyline hcl oral capsule 10 mg, 25 mg, 50

mg, 75 mg 1 PA; HR

nortriptyline hcl oral solution 10 mg/5ml 1 PA; HR

NORVIR ORAL CAPSULE 100 MG 1 QL (372 EA per 31 days)

NORVIR ORAL SOLUTION 80 MG/ML 1 QL (496 ML per 31 days)

NORVIR ORAL TABLET 100 MG 1 QL (372 EA per 31 days)

NOVOLIN 70/30 SUBCUTANEOUS

SUSPENSION (70-30) 100 UNIT/ML 1

NOVOLIN N SUBCUTANEOUS SUSPENSION

100 UNIT/ML 1

NOVOLIN R INJECTION SOLUTION 100

UNIT/ML 1

NOVOLOG FLEXPEN SUBCUTANEOUS


NOVOLOG MIX 70/30 FLEXPEN

SUBCUTANEOUS SUSPENSION PEN-

INJECTOR (70-30) 100 UNIT/ML

1

NOVOLOG MIX 70/30 SUBCUTANEOUS

SUSPENSION (70-30) 100 UNIT/ML 1

NOVOLOG PENFILL SUBCUTANEOUS

SOLUTION CARTRIDGE 100 UNIT/ML 1

NOVOLOG SUBCUTANEOUS SOLUTION

100 UNIT/ML 1

NOXAFIL ORAL SUSPENSION 40 MG/ML 1 PA; QL (870 ML per 28 days)

NOXAFIL ORAL TABLET DELAYED

RELEASE 100 MG 1 PA; QL (93 EA per 31 days)

NUEDEXTA ORAL CAPSULE 20-10 MG 1

NULOJIX INTRAVENOUS SOLUTION

RECONSTITUTED 250 MG 1 ST; QL (200 EA per 31 days)

NUMOISYN MOUTH/THROAT LOZENGE 1(CW)

NUPLAZID ORAL TABLET 17 MG 1 PA

nutrilipid intravenous emulsion 20 % 1

nystatin external cream 100000 unit/gm 1



72

Drug Tier Notes

nystatin external ointment 100000 unit/gm 1

nystatin external powder 100000 unit/gm 1

nystatin mouth/throat suspension 100000 unit/ml 1

nystatin oral tablet 500000 unit 1

nystatin-triamcinolone external cream 100000-

0.1 unit/gm-% 1

nystatin-triamcinolone external ointment 100000-

0.1 unit/gm-% 1

nystop external powder 100000 unit/gm 1

OCELLA ORAL TABLET 3-0.03 MG 1

octreotide acetate injection solution 100 mcg/ml,

1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500

mcg/ml

1

ODEFSEY ORAL TABLET 200-25-25 MG 1

ODOMZO ORAL CAPSULE 200 MG 1 PA; LA

OFEV ORAL CAPSULE 100 MG, 150 MG 1

ofloxacin ophthalmic solution 0.3 % 1

OFLOXACIN ORAL TABLET 300 MG 1

ofloxacin oral tablet 400 mg 1

ofloxacin otic solution 0.3 % 1

OGESTREL ORAL TABLET 0.5-50 MG-MCG 1

olanzapine intramuscular solution reconstituted


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

mg, 7.5 mg 1 QL (31 EA per 31 days)

olanzapine oral tablet 20 mg 1 QL (62 EA per 31 days)

olanzapine oral tablet dispersible 10 mg, 15 mg,

20 mg, 5 mg 1

olmesartan medoxomil oral tablet 20 mg, 40 mg,


olmesartan medoxomil-hctz oral tablet 20-12.5

mg, 40-12.5 mg, 40-25 mg 1 QL (31 EA per 31 days)

olmesartan-amlodipine-hctz oral tablet 20-5-12.5

mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg,

40-5-25 mg


olopatadine hcl nasal solution 0.6 % 1

olopatadine hcl ophthalmic solution 0.1 % 1

OMEGA-3 2100 ORAL CAPSULE 1050 MG 1(CW)



73

Drug Tier Notes

omega-3 fish oil concentrate oral capsule delayed

release 1000 mg 1(CW)

omega-3 fish oil ex st oral capsule 880 mg 1(CW)

omega-3 fish oil oral capsule 300 mg, 500 mg 1(CW)

omega-3 oral capsule 1400 mg 1(CW)

omega-3 oral capsule delayed release 350 mg 1(CW)

omega-3-acid ethyl esters oral capsule 1 gm 1

omeprazole oral capsule delayed release 10 mg,

20 mg, 40 mg 1

omeprazole oral tablet delayed release 20 mg 1(CW)

omeprazole-sodium bicarbonate oral capsule 20-

1100 mg, 40-1100 mg 1

ondansetron hcl injection solution 4 mg/2ml 1

ondansetron hcl oral solution 4 mg/5ml 1 QL (465 ML per 31 days)

ondansetron hcl oral tablet 24 mg 1 QL (31 EA per 31 days)

ondansetron hcl oral tablet 4 mg, 8 mg 1 QL (62 EA per 31 days)

ondansetron oral tablet dispersible 4 mg, 8 mg 1 QL (62 EA per 31 days)

ONFI ORAL SUSPENSION 2.5 MG/ML 1 QL (496 ML per 31 days)

ONFI ORAL TABLET 10 MG, 20 MG 1 QL (62 EA per 31 days)

OPCICON ONE-STEP ORAL TABLET 1.5 MG 1(SO)

OPSUMIT ORAL TABLET 10 MG 1 ST; QL (93 EA per 31 days)

ORAVIG BUCCAL TABLET 50 MG 1

ORENCIA CLICKJECT SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 125 MG/ML 1 ST

ORENCIA INTRAVENOUS SOLUTION

RECONSTITUTED 250 MG 1 ST

ORENCIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 125 MG/ML, 50

MG/0.4ML, 87.5 MG/0.7ML

1 ST

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20

MG, 5 MG 1 PA

ORFADIN ORAL SUSPENSION 4 MG/ML 1 PA; LA

ORKAMBI ORAL TABLET 100-125 MG, 200-

125 MG 1 PA

orphenadrine citrate er oral tablet extended

release 12 hour 100 mg 1 PA; HR; QL (62 EA per 31 days)

orphenadrine citrate injection solution 30 mg/ml 1 PA; HR



74

Drug Tier Notes

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 1

oseltamivir phosphate oral capsule 30 mg 1 QL (112 EA per 365 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg 1 QL (56 EA per 365 days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30

MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45

MG


OSTEO-PORETICAL ORAL TABLET 600-

1000 MG-UNIT 1(CW)

OTEZLA ORAL TABLET 30 MG 1

oxacillin sodium injection solution reconstituted

10 gm 1

oxaliplatin intravenous solution 100 mg/20ml 1

oxandrolone oral tablet 10 mg 1 QL (62 EA per 31 days)

oxandrolone oral tablet 2.5 mg 1

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 QL (124 EA per 31 days)

oxcarbazepine oral suspension 300 mg/5ml 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600

mg 1

OXTELLAR XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 150 MG, 300 MG, 600 MG 1

oxybutynin chloride er oral tablet extended

release 24 hour 10 mg, 15 mg, 5 mg 1 PA; HR; QL (62 EA per 31 days)

oxybutynin chloride oral syrup 5 mg/5ml 1 PA; HR

oxybutynin chloride oral tablet 5 mg 1 PA; HR

oxycodone hcl er oral tablet er 12 hour abuse-

deterrent 10 mg, 20 mg, 40 mg, 80 mg 1 ST; QL (124 EA per 31 days)

oxycodone hcl er oral tablet er 12 hour abuse-

deterrent 15 mg, 30 mg, 60 mg 1 ST; QL (93 EA per 31 days)

oxycodone hcl oral capsule 5 mg 1 QL (186 EA per 31 days)

oxycodone hcl oral concentrate 100 mg/5ml 1

oxycodone hcl oral solution 5 mg/5ml 1 QL (5580 ML per 31 days)

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg,

30 mg, 5 mg 1 QL (186 EA per 31 days)

oxycodone-acetaminophen oral solution 5-325


oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg 1 QL (381 EA per 31 days)

oxycodone-aspirin oral tablet 4.8355-325 mg 1 QL (372 EA per 31 days)



75

Drug Tier Notes

oxycodone-ibuprofen oral tablet 5-400 mg 1 QL (372 EA per 31 days)

oyster shell calcium plus d oral tablet 500-125

mg-unit 1(CW)

oyster shell calcium/vitamin d oral tablet 250-125

mg-unit 1(CW)

PACERONE ORAL TABLET 100 MG, 200 MG,

400 MG 1

paclitaxel intravenous concentrate 300 mg/50ml 1

pain & fever childrens oral solution 160 mg/5ml 1(SO)

pain & fever junior oral tablet dispersible 160 mg 1(SO)

pain relief extra strength oral capsule 500 mg 1(SO)

pain relieving external gel 3.5 % 1(CW)

paliperidone er oral tablet extended release 24

hour 1.5 mg, 3 mg, 9 mg 1 ST; QL (31 EA per 31 days)

paliperidone er oral tablet extended release 24

hour 6 mg 1 ST; QL (62 EA per 31 days)

pamidronate disodium intravenous solution 30

mg/10ml, 6 mg/ml, 90 mg/10ml 1

PANCREAZE ORAL CAPSULE DELAYED

RELEASE PARTICLES 2600 UNIT 1

PANRETIN EXTERNAL GEL 0.1 % 1 PA

pantoprazole sodium oral tablet delayed release

20 mg, 40 mg 1

paricalcitol intravenous solution 5 mcg/ml 1

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1

paromomycin sulfate oral capsule 250 mg 1

paroxetine hcl er oral tablet extended release 24

hour 12.5 mg, 37.5 mg 1 QL (62 EA per 31 days)

paroxetine hcl er oral tablet extended release 24


paroxetine hcl oral tablet 10 mg, 20 mg 1 QL (31 EA per 31 days)

paroxetine hcl oral tablet 30 mg, 40 mg 1 QL (62 EA per 31 days)

PASER ORAL PACKET 4 GM 1

PATADAY OPHTHALMIC SOLUTION 0.2 % 1

PAXIL ORAL SUSPENSION 10 MG/5ML 1 ST; QL (930 ML per 31 days)

PAZEO OPHTHALMIC SOLUTION 0.7 % 1

PECGEN DMX ORAL LIQUID 15-125

MG/5ML 1(SO)



76

Drug Tier Notes

PEDIA-LAX ORAL LIQUID 50 MG/15ML 1(CW)

PEDIARIX INTRAMUSCULAR SUSPENSION 1

pediatric formula cough/congst oral liquid 10-

100 mg/5ml 1(SO)

PEDVAX HIB INTRAMUSCULAR

SUSPENSION 7.5 MCG/0.5ML 1

peg 3350 oral powder 1(CW)

peg 3350/electrolytes oral solution reconstituted

240 gm 1

peg-3350/electrolytes oral solution reconstituted

236 gm 1

PEGANONE ORAL TABLET 250 MG 1

PEGASYS PROCLICK SUBCUTANEOUS

SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML 1 PA; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION 180

MCG/0.5ML, 180 MCG/ML 1 PA; QL (4 ML per 28 days)

PEG-INTRON REDIPEN SUBCUTANEOUS

KIT 120 MCG/0.5ML 1

PEGINTRON SUBCUTANEOUS KIT 50

MCG/0.5ML 1

penicillin g potassium injection solution

reconstituted 5000000 unit 1

penicillin v potassium oral solution reconstituted

125 mg/5ml, 250 mg/5ml 1

penicillin v potassium oral tablet 250 mg, 500 mg 1

PENTAM INJECTION SOLUTION


pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 PA; HR; QL (372 EA per 31 days)

pentoxifylline er oral tablet extended release 400

mg 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8

mg 1

permethrin external cream 5 % 1

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1

PEXEVA ORAL TABLET 10 MG, 20 MG, 30

MG, 40 MG 1 ST

phenelzine sulfate oral tablet 15 mg 1

phenobarbital oral elixir 20 mg/5ml 1 PA; HR; QL (1550 ML per 31

days)



77

Drug Tier Notes

phenobarbital oral tablet 100 mg, 16.2 mg, 32.4

mg, 64.8 mg, 97.2 mg 1 PA; HR; QL (93 EA per 31 days)

phenobarbital oral tablet 15 mg, 60 mg 1 PA; HR; QL (124 EA per 31 days)

phenobarbital oral tablet 30 mg 1 PA; HR; QL (310 EA per 31 days)

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg,

200 mg, 300 mg 1

phenytoin sodium injection solution 50 mg/ml 1

PHILLIPS ORAL TABLET 500 MG 1(CW)

PHOSPHOLINE IODIDE OPHTHALMIC

SOLUTION RECONSTITUTED 0.125 % 1

PHYSIOLYTE IRRIGATION SOLUTION 1

PHYSIOSOL IRRIGATION IRRIGATION

SOLUTION 1

PICATO EXTERNAL GEL 0.015 % 1 QL (3 EA per 31 days)

PICATO EXTERNAL GEL 0.05 % 1 QL (2 EA per 31 days)

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4

% 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

pimozide oral tablet 1 mg, 2 mg 1

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG

(21/5) 1

pindolol oral tablet 10 mg, 5 mg 1

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 QL (31 EA per 31 days)

pioglitazone hcl-glimepiride oral tablet 30-2 mg,

30-4 mg 1

pioglitazone hcl-metformin hcl oral tablet 15-500

mg, 15-850 mg 1

piperacillin sod-tazobactam so intravenous

solution reconstituted 3.375 (3-0.375) gm, 4.5 (4-

0.5) gm

1

PIRMELLA 1/35 ORAL TABLET 1-35 MG-

MCG 1

PLAN B ONE-STEP ORAL TABLET 1.5 MG 1(SO)

PLEGRIDY SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 125 MCG/0.5ML 1 PA

podofilox external solution 0.5 % 1



78

Drug Tier Notes

POLAR FROST EXTERNAL GEL 4 % 1(CW)

polyethylene glycol 3350 oral packet 1(CW)

polyethylene glycol 3350 oral powder 1

polyethylene glycol 3350 powder 1(CW)

polymyxin b-trimethoprim ophthalmic solution

10000-0.1 unit/ml-% 1

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3

MG, 4 MG 1 PA; QL (21 EA per 28 days)

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG 1

potassium chloride crys er oral tablet extended

release 10 meq, 20 meq 1

potassium chloride er oral capsule extended

release 10 meq, 8 meq 1

potassium chloride er oral tablet extended release

10 meq, 8 meq 1

potassium chloride in dextrose intravenous

solution 20-5 meq/l-%, 40-5 meq/l-% 1

potassium chloride in nacl intravenous solution

20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% 1

potassium chloride intravenous solution 2

meq/ml, 20 meq/100ml 1

potassium chloride oral solution 20 meq/15ml

(10%), 40 meq/15ml (20%) 1

potassium citrate er oral tablet extended release

10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540

mg)

1

PRADAXA ORAL CAPSULE 110 MG, 150

MG, 75 MG 1

PRALUENT SUBCUTANEOUS SOLUTION

PEN-INJECTOR 150 MG/ML, 75 MG/ML 1 PA

pramipexole dihydrochloride er oral tablet

extended release 24 hour 3.75 mg 1 QL (93 EA per 31 days)

pramipexole dihydrochloride oral tablet 0.125

mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg 1 QL (93 EA per 31 days)

pramipexole dihydrochloride oral tablet 0.75 mg 1 QL (186 EA per 31 days)

pravastatin sodium oral tablet 10 mg, 20 mg, 40


prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1

prednicarbate external cream 0.1 % 1



79

Drug Tier Notes

prednicarbate external ointment 0.1 % 1

prednisolone sodium phosphate ophthalmic

solution 1 % 1

prednisolone sodium phosphate oral solution 15

mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml 1

prednisolone sodium phosphate oral tablet

dispersible 10 mg, 15 mg, 30 mg 1

PREDNISONE INTENSOL ORAL


prednisone oral solution 5 mg/5ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20

mg, 5 mg, 50 mg 1

PREDNISONE ORAL TABLET THERAPY

PACK 10 MG (21), 10 MG (48), 5 MG (21), 5

MG (48)

1

preferred plus insulin syringe 28g x 1/2" 0.5 ml 1

PREMARIN INJECTION SOLUTION

RECONSTITUTED 25 MG 1 PA; HR

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,

0.625 MG, 0.9 MG, 1.25 MG 1 PA; HR

PREMASOL INTRAVENOUS SOLUTION 10

%, 6 % 1

PREMPHASE ORAL TABLET 0.625-5 MG 1 PA; HR

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-

1.5 MG, 0.625-2.5 MG, 0.625-5 MG 1 PA; HR

PREPARATION H RECTAL CREAM 1-0.25-

14.4-15 % 1(CW)

PREVIFEM ORAL TABLET 0.25-35 MG-MCG 1

PREZCOBIX ORAL TABLET 800-150 MG 1

PREZISTA ORAL SUSPENSION 100 MG/ML 1 QL (372 ML per 31 days)

PREZISTA ORAL TABLET 150 MG 1 QL (248 EA per 31 days)




PRIFTIN ORAL TABLET 150 MG 1

primaquine phosphate oral tablet 26.3 mg 1

primidone oral tablet 250 mg, 50 mg 1



80

Drug Tier Notes

PROAIR HFA INHALATION AEROSOL

SOLUTION 108 (90 BASE) MCG/ACT 1 QL (27 GM per 31 days)

PROAIR RESPICLICK INHALATION

AEROSOL POWDER BREATH ACTIVATED

108 (90 BASE) MCG/ACT


probenecid oral tablet 500 mg 1

procainamide hcl injection solution 100 mg/ml,

500 mg/ml 1

PROCALAMINE INTRAVENOUS SOLUTION

3 % 1

prochlorperazine edisylate injection solution 5

mg/ml 1

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 1

PROCRIT INJECTION SOLUTION 10000

UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML 1 PA; QL (12 ML per 28 days)


UNIT/ML 1 PA; QL (23 ML per 31 days)





PROCTOCORT RECTAL SUPPOSITORY 30

MG 1(CW)

PROCTO-MED HC RECTAL CREAM 2.5 % 1

PROCTO-PAK RECTAL CREAM 1 % 1

PROCTOSOL HC RECTAL CREAM 2.5 % 1

PROCTOZONE-HC RECTAL CREAM 2.5 % 1

progesterone micronized oral capsule 100 mg,

200 mg 1

PROGLYCEM ORAL SUSPENSION 50

MG/ML 1

PROGRAF INTRAVENOUS SOLUTION 5

MG/ML 1

PROLASTIN-C INTRAVENOUS SOLUTION


PROLEUKIN INTRAVENOUS SOLUTION

RECONSTITUTED 22000000 UNIT 1 PA



81

Drug Tier Notes

PROLIA SUBCUTANEOUS SOLUTION 60

MG/ML 1 ST; QL (1 ML per 180 days)

PROMACTA ORAL TABLET 12.5 MG 1 PA; QL (62 EA per 31 days)

PROMACTA ORAL TABLET 25 MG, 50 MG,

75 MG 1 PA; QL (31 EA per 31 days)

promethazine hcl oral syrup 6.25 mg/5ml 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50

mg 1 PA; HR

promethazine hcl rectal suppository 50 mg 1

promethazine vc plain oral syrup 6.25-5 mg/5ml 1

propafenone hcl er oral capsule extended release

12 hour 225 mg, 325 mg, 425 mg 1

propafenone hcl oral tablet 150 mg, 225 mg, 300

mg 1

propantheline bromide oral tablet 15 mg 1

proparacaine hcl ophthalmic solution 0.5 % 1

propranolol hcl er oral capsule extended release

24 hour 120 mg, 160 mg, 60 mg, 80 mg 1

propranolol hcl intravenous solution 1 mg/ml 1

propranolol hcl oral solution 20 mg/5ml, 40

mg/5ml 1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg,

60 mg, 80 mg 1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1

propylthiouracil oral tablet 50 mg 1

PROQUAD SUBCUTANEOUS INJECTABLE 1

PROSOL INTRAVENOUS SOLUTION 20 % 1

protriptyline hcl oral tablet 10 mg, 5 mg 1 PA; HR

PROVENTIL HFA INHALATION AEROSOL


pseudoephedrine hcl oral syrup 30 mg/5ml 1(SO)

pseudoephedrine hcl oral tablet 30 mg, 60 mg 1(SO)

PULMICORT FLEXHALER INHALATION


180 MCG/ACT


PULMICORT FLEXHALER INHALATION


90 MCG/ACT




82

Drug Tier Notes

PULMICORT INHALATION SUSPENSION

0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML 1

PULMOZYME INHALATION SOLUTION 1

MG/ML 1 QL (155 ML per 31 days)

PURE & GENTLE LUBRICANT

OPHTHALMIC SOLUTION 3 MG/ML 1(SO)

PURIXAN ORAL SUSPENSION 2000

MG/100ML 1

px ultra strength rub external ointment 4-10-30 % 1(CW)

pyrazinamide oral tablet 500 mg 1

pyridostigmine bromide oral tablet 60 mg 1

pyridoxine hcl oral tablet 100 mg 1(CW)

pyridoxine hcl oral tablet 50 mg 1(CW) QL (31 EA per 31 days)

QUADRACEL INTRAMUSCULAR

SUSPENSION 1

QUASENSE ORAL TABLET 0.15-0.03 MG 1

QUETIAPINE FUMARATE ER ORAL

TABLET EXTENDED RELEASE 24 HOUR 150

MG




MG




MG


quetiapine fumarate er oral tablet extended

release 24 hour 400 mg 1 QL (62 EA per 31 days)



MG


quetiapine fumarate oral tablet 100 mg, 200 mg,

25 mg, 300 mg, 400 mg, 50 mg 1

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

mg 1

quinapril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg 1

quinidine gluconate er oral tablet extended

release 324 mg 1

quinidine sulfate oral tablet 200 mg, 300 mg 1



83

Drug Tier Notes

quinine sulfate oral capsule 324 mg 1 PA; QL (44 EA per 7 days)

QVAR INHALATION AEROSOL SOLUTION

40 MCG/ACT, 80 MCG/ACT 1

ra anti-itch maximum strength external ointment

1 % 1(SO)

ra budesonide nasal suspension 32 mcg/act 1(CW)

ra fish oil oral capsule 900 mg 1(CW)

ra fish oil oral capsule delayed release 1400 mg,

600 mg 1(CW)

ra hemorrhoid relief rectal suppository 0.25-85.5

% 1(CW)

ra melatonin sublingual tablet sublingual 1 mg 1(CW)

ra tussin chest congestion oral syrup 100 mg/5ml 1(SO)

RABAVERT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 1

RADICAVA INTRAVENOUS SOLUTION 30

MG/100ML 1 PA

raloxifene hcl oral tablet 60 mg 1

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

mg 1

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HOUR 1000 MG, 500 MG 1

ranitidine acid reducer oral tablet 75 mg 1(CW)

ranitidine hcl injection solution 50 mg/2ml 1

ranitidine hcl oral capsule 150 mg, 300 mg 1

ranitidine hcl oral syrup 15 mg/ml 1

ranitidine hcl oral tablet 150 mg, 300 mg 1

RAPAFLO ORAL CAPSULE 4 MG, 8 MG 1 QL (31 EA per 31 days)

RAPAMUNE ORAL SOLUTION 1 MG/ML 1

rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 QL (31 EA per 31 days)

RAVICTI ORAL LIQUID 1.1 GM/ML 1

RECLIPSEN ORAL TABLET 0.15-30 MG-

MCG 1

RECOMBIVAX HB INJECTION SUSPENSION

10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML 1

REFRESH OPHTHALMIC SOLUTION 1.4-0.6

% 1(SO)

REGRANEX EXTERNAL GEL 0.01 % 1 PA



84

Drug Tier Notes

RELENZA DISKHALER INHALATION

AEROSOL POWDER BREATH ACTIVATED 5

MG/BLISTER


reliever external patch 0.05-5 % 1(CW)

RELI-ON INSULIN SYRINGE 29G 0.3 ML 1

RELISTOR ORAL TABLET 150 MG 1 ST

RELISTOR SUBCUTANEOUS SOLUTION 12

MG/0.6ML, 8 MG/0.4ML 1 ST; QL (36 ML per 28 days)

REMODULIN INJECTION SOLUTION 1

MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML 1

RENVELA ORAL PACKET 0.8 GM 1 QL (540 EA per 31 days)

RENVELA ORAL PACKET 2.4 GM 1 QL (186 EA per 31 days)

RENVELA ORAL TABLET 800 MG 1 QL (540 EA per 31 days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1

REPATHA PUSHTRONEX SYSTEM

SUBCUTANEOUS SOLUTION CARTRIDGE

420 MG/3.5ML

1 PA

REPATHA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 140 MG/ML 1 PA

REPATHA SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 140 MG/ML 1 PA

RESCRIPTOR ORAL TABLET 100 MG 1 QL (372 EA per 31 days)

RESCRIPTOR ORAL TABLET 200 MG 1 QL (186 EA per 31 days)

RESTASIS OPHTHALMIC EMULSION 0.05 % 1 QL (62 EA per 31 days)

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG,

7.5 MG 1

RETROVIR INTRAVENOUS SOLUTION 10

MG/ML 1

REVLIMID ORAL CAPSULE 10 MG, 15 MG,

2.5 MG, 25 MG, 5 MG 1 PA; LA; QL (28 EA per 28 days)

REVLIMID ORAL CAPSULE 20 MG 1 PA; QL (28 EA per 28 days)

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1

MG, 2 MG, 3 MG, 4 MG 1 PA

REYATAZ ORAL CAPSULE 150 MG, 200 MG 1 QL (62 EA per 31 days)

REYATAZ ORAL CAPSULE 300 MG 1 QL (31 EA per 31 days)

REYATAZ ORAL PACKET 50 MG 1

RHINARIS NASAL SOLUTION 0.2 % 1(CW)

RIBASPHERE ORAL CAPSULE 200 MG 1 QL (186 EA per 31 days)



85

Drug Tier Notes

RIBASPHERE ORAL TABLET 200 MG 1 QL (186 EA per 31 days)

RIBASPHERE ORAL TABLET 400 MG 1

ribavirin oral capsule 200 mg 1 QL (186 EA per 31 days)

ribavirin oral tablet 200 mg 1 QL (186 EA per 31 days)

RID AEROSOL 0.5 % 1(SO)

rifabutin oral capsule 150 mg 1

rifampin intravenous solution reconstituted 600

mg 1

rifampin oral capsule 150 mg, 300 mg 1

RIFATER ORAL TABLET 50-120-300 MG 1

riluzole oral tablet 50 mg 1

rimantadine hcl oral tablet 100 mg 1

ringers intravenous solution 1

ringers irrigation irrigation solution 1

RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED 12.5 MG, 25

MG


RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED 37.5 MG, 50

MG


risperidone oral solution 1 mg/ml 1

risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3


risperidone oral tablet 0.5 mg 1 QL (124 EA per 31 days)

risperidone oral tablet dispersible 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg 1

RITUXAN INTRAVENOUS SOLUTION 500

MG/50ML 1 PA

rivastigmine tartrate oral capsule 1.5 mg, 3 mg,

4.5 mg, 6 mg 1

RIVASTIGMINE TRANSDERMAL PATCH 24

HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5

MG/24HR


ROBINUL INJECTION SOLUTION 0.4

MG/2ML 1

ROBINUL-FORTE ORAL TABLET 2 MG 1

ROBITUSSIN CHILDRENS COUGH LA ORAL

SYRUP 7.5 MG/5ML 1(SO)



86

Drug Tier Notes

ROBITUSSIN COUGH/CHEST DM MAX


ROBITUSSIN LINGERING LA COUGH ORAL

LIQUID 15 MG/5ML 1(SO)

ROBITUSSIN MUCUS+CHEST CONGEST

ORAL LIQUID 100 MG/5ML 1(SO)

ROBITUSSIN PEAK COLD DM ORAL SYRUP

100-10 MG/5ML 1(SO)

ROLAIDS ORAL TABLET CHEWABLE 550-

110 MG 1(CW)

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg, 5 mg 1

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40


ROTARIX ORAL SUSPENSION

RECONSTITUTED 1

ROTATEQ ORAL SOLUTION 1

roweepra oral tablet 1000 mg, 750 mg 1

ROWEEPRA ORAL TABLET 500 MG 1

ROZEREM ORAL TABLET 8 MG 1 QL (31 EA per 31 days)

RUBRACA ORAL TABLET 200 MG, 300 MG 1 PA

RYDAPT ORAL CAPSULE 25 MG 1 PA; QL (248 EA per 31 days)

SABRIL ORAL PACKET 500 MG 1 QL (186 EA per 31 days)

SABRIL ORAL TABLET 500 MG 1 QL (186 EA per 31 days)

SALESE MOUTH/THROAT LOZENGE 1(CW)

saline bacteriostatic injection solution 0.9 % 1(CW)

saline nasal gel 1(CW)

saline nasal spray nasal solution 0.65 % 1(SO)

salsalate oral tablet 500 mg, 750 mg 1(ND)

SAMSCA ORAL TABLET 15 MG, 30 MG 1 PA; QL (62 EA per 31 days)

SANDIMMUNE ORAL CAPSULE 100 MG, 25

MG 1

SANDIMMUNE ORAL SOLUTION 100

MG/ML 1

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR KIT 10 MG, 20 MG, 30

MG

1



87

Drug Tier Notes

SANTYL EXTERNAL OINTMENT 250

UNIT/GM 1 QL (31 GM per 31 days)

SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MG, 2.5 MG, 5 MG 1 ST; QL (62 EA per 31 days)

SAVELLA ORAL TABLET 100 MG, 12.5 MG,

25 MG, 50 MG 1

SAVELLA TITRATION PACK ORAL 12.5 &

25 & 50 MG 1

sb non-aspirin oral tablet chewable 80 mg 1(SO)

scalp relief maximum strength external solution 1

% 1(SO)

SCOT-TUSSIN DIABETES CF ORAL LIQUID

10 MG/5ML 1(SO)

SCOT-TUSSIN SENIOR ORAL LIQUID 15-200

MG/5ML 1(SO)

selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

selenium sulfide external lotion 2.5 % 1

SELZENTRY ORAL TABLET 150 MG 1 QL (248 EA per 31 days)

SELZENTRY ORAL TABLET 25 MG, 300 MG 1 QL (124 EA per 31 days)

SELZENTRY ORAL TABLET 75 MG 1 QL (62 EA per 31 days)

senna laxative oral tablet 8.6 mg 1(CW)

senna leaves oral leaves 1(CW)

senna oral capsule 8.6 mg 1(CW)

senna oral syrup 176 mg/5ml 1(CW)

senna-docusate sodium oral tablet 8.6-50 mg 1(CW)

SENOKOT S ORAL TABLET 8.6-50 MG 1(CW)

SENSIPAR ORAL TABLET 30 MG 1

SENSIPAR ORAL TABLET 60 MG 1 QL (62 EA per 31 days)

SENSIPAR ORAL TABLET 90 MG 1 QL (124 EA per 31 days)

SEREVENT DISKUS INHALATION


50 MCG/DOSE


sertraline hcl oral concentrate 20 mg/ml 1 QL (310 ML per 31 days)

sertraline hcl oral tablet 100 mg 1 QL (62 EA per 31 days)

sertraline hcl oral tablet 25 mg, 50 mg 1 QL (93 EA per 31 days)



88

Drug Tier Notes

SEVELAMER CARBONATE ORAL PACKET

0.8 GM, 2.4 GM 1

SHAROBEL ORAL TABLET 0.35 MG 1

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3

MG/ML, 0.6 MG/ML, 0.9 MG/ML 1 PA; LA; QL (62 ML per 31 days)

sildenafil citrate oral tablet 20 mg 1 PA; QL (93 EA per 31 days)

SILENOR ORAL TABLET 3 MG, 6 MG 1 QL (31 EA per 31 days)

silver sulfadiazine external cream 1 % 1

SIMBRINZA OPHTHALMIC SUSPENSION 1-

0.2 % 1

SIMPONI ARIA INTRAVENOUS SOLUTION

50 MG/4ML 1 ST

SIMPONI SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML 1 ST; QL (3 ML per 31 days)

SIMPONI SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/ML, 50

MG/0.5ML

1 ST; QL (3 ML per 31 days)

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


sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1

SIRTURO ORAL TABLET 100 MG 1

SIVEXTRO INTRAVENOUS SOLUTION

RECONSTITUTED 200 MG 1 PA; QL (6 EA per 28 days)

SIVEXTRO ORAL TABLET 200 MG 1 PA; QL (6 EA per 28 days)

sleep-aid maximum strength oral capsule 50 mg 1(SO)

slow iron oral tablet extended release 160 (50 fe)

mg 1(CW)

slow release iron oral tablet extended release 45

mg, 47.5 mg, 50 mg 1(CW)

sm fish oil oral capsule 554 mg 1(CW)

sm hydrocortisone max st external ointment 1 % 1(CW)

sm ibuprofen jr oral tablet 100 mg 1(SO)

sm pain relief/menthol external gel 1(CW)

sm slow release iron oral tablet extended release

142 (45 fe) mg, 143 (45 fe) mg 1(CW)

sm vitamin d3 oral capsule 4000 unit 1(CW)

sodium bicarbonate oral tablet 325 mg, 650 mg 1(SO)



89

Drug Tier Notes

sodium chloride (hypertonic) ointment 5 %

ophthalmic 5 % 1(SO)

sodium chloride (hypertonic) ophthalmic ointment

5 % 1(CW)

sodium chloride (hypertonic) ophthalmic solution

5 % 1(SO)

sodium chloride injection solution 2.5 meq/ml 1

sodium chloride intravenous solution 0.45 %, 0.9

%, 3 %, 5 % 1

sodium chloride irrigation solution 0.9 % 1

sodium phenylbutyrate oral powder 3 gm/tsp 1

sodium polystyrene sulfonate oral suspension 15

gm/60ml 1

SOLTAMOX ORAL SOLUTION 10 MG/5ML 1 PA

SOMATULINE DEPOT SUBCUTANEOUS

SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90

MG/0.3ML

1 PA; QL (1 ML per 28 days)

SOMAVERT SUBCUTANEOUS SOLUTION

RECONSTITUTED 10 MG, 15 MG, 20 MG 1 PA; QL (62 EA per 31 days)

SOMBRA COOL THERAPY EXTERNAL GEL

6 % 1(CW)

sorbitol oral solution 70 % 1(CW)

sorbitol rectal solution 70 % 1(CW)

sorbitol solution 70 % 1(CW)

SORINE ORAL TABLET 120 MG, 160 MG, 240

MG, 80 MG 1

sotalol hcl (af) oral tablet 120 mg 1

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 1

SOVALDI ORAL TABLET 400 MG 1 PA; QL (28 EA per 28 days)

SPIRIVA HANDIHALER INHALATION

CAPSULE 18 MCG 1 QL (31 EA per 31 days)

SPIRIVA RESPIMAT INHALATION

AEROSOL SOLUTION 1.25 MCG/ACT 1

SPIRIVA RESPIMAT INHALATION

AEROSOL SOLUTION 2.5 MCG/ACT 1 QL (4 GM per 30 days)

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolactone-hctz oral tablet 25-25 mg 1



90

Drug Tier Notes

SPRINTEC 28 ORAL TABLET 0.25-35 MG-

MCG 1

SPRITAM ORAL TABLET DISINTEGRATING

SOLUBLE 1000 MG 1 QL (93 EA per 31 days)

SPRITAM ORAL TABLET DISINTEGRATING

SOLUBLE 250 MG, 500 MG, 750 MG 1 QL (124 EA per 31 days)

SPRYCEL ORAL TABLET 100 MG, 50 MG, 70


SPRYCEL ORAL TABLET 140 MG 1 PA; QL (31 EA per 31 days)

SPRYCEL ORAL TABLET 20 MG 1 PA; QL (93 EA per 31 days)

sps oral suspension 15 gm/60ml 1

SRONYX ORAL TABLET 0.1-20 MG-MCG 1

ST JOSEPH LOW DOSE ORAL TABLET

CHEWABLE 81 MG 1(SO)

stavudine oral capsule 15 mg, 20 mg 1 QL (124 EA per 31 days)

stavudine oral capsule 30 mg, 40 mg 1 QL (62 EA per 31 days)

STELARA SUBCUTANEOUS SOLUTION


STELARA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 90 MG/ML 1 PA; ST

sterile water for irrigation irrigation solution 1

STIOLTO RESPIMAT INHALATION

AEROSOL SOLUTION 2.5-2.5 MCG/ACT 1 QL (4 GM per 30 days)

STIVARGA ORAL TABLET 40 MG 1 PA; QL (84 EA per 28 days)

stool softener oral capsule 100 mg, 250 mg 1(CW)

stool softener oral tablet 100 mg 1(CW)

STRATTERA ORAL CAPSULE 10 MG, 18

MG, 25 MG 1 QL (93 EA per 31 days)

STRATTERA ORAL CAPSULE 100 MG, 40

MG, 60 MG, 80 MG 1 QL (31 EA per 31 days)

streptomycin sulfate intramuscular solution


STRIBILD ORAL TABLET 150-150-200-300


SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-

0.5 MG, 4-1 MG, 8-2 MG 1

SUBSYS SUBLINGUAL LIQUID 100 MCG,

200 MCG, 400 MCG, 600 MCG, 800 MCG 1 PA; QL (186 EA per 31 days)



91

Drug Tier Notes

sucralfate oral tablet 1 gm 1

SUDAFED 24 HOUR ORAL TABLET

EXTENDED RELEASE 24 HOUR 240 MG 1(SO)

SUDAFED CHILDRENS ORAL LIQUID 15

MG/5ML 1(SO)

SUDOGEST ORAL TABLET 30 MG, 60 MG 1(SO)

sulfacetamide sodium external suspension 10 % 1

sulfacetamide sodium ophthalmic ointment 10 % 1

sulfacetamide sodium ophthalmic solution 10 % 1

sulfacetamide-prednisolone ophthalmic solution

10-0.23 % 1

sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim intravenous

solution 400-80 mg/5ml 1

sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5ml 1

sulfamethoxazole-trimethoprim oral tablet 400-80

mg, 800-160 mg 1

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet delayed release 500 mg 1

sulindac oral tablet 150 mg, 200 mg 1 QL (62 EA per 31 days)

sumatriptan nasal solution 20 mg/act 1 QL (8 EA per 31 days)

sumatriptan nasal solution 5 mg/act 1 QL (32 EA per 31 days)

sumatriptan succinate oral tablet 100 mg, 25 mg,


sumatriptan succinate refill subcutaneous

solution cartridge 4 mg/0.5ml, 6 mg/0.5ml 1 QL (5 ML per 31 days)

sumatriptan succinate subcutaneous solution 6


sumatriptan succinate subcutaneous solution

auto-injector 4 mg/0.5ml, 6 mg/0.5ml 1 QL (5 ML per 31 days)

sumatriptan succinate subcutaneous solution

prefilled syringe 6 mg/0.5ml 1 QL (5 ML per 31 days)

super antioxidants protector oral capsule 1(CW)

SUPER OMEGA-3 ORAL CAPSULE 1(CW)

SUPER TWIN EPA/DHA ORAL CAPSULE

1250 MG 1(CW)

SUPRAX ORAL CAPSULE 400 MG 1



92

Drug Tier Notes

supress dm pediatric oral liquid 5-50 mg/ml 1(SO)

SUSTIVA ORAL CAPSULE 200 MG 1 QL (124 EA per 31 days)

SUSTIVA ORAL CAPSULE 50 MG 1 QL (496 EA per 31 days)

SUSTIVA ORAL TABLET 600 MG 1 QL (31 EA per 31 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG,

37.5 MG, 50 MG 1 PA; QL (28 EA per 28 days)

SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG, 600 MCG 1 PA; QL (4 EA per 28 days)

SYMBICORT INHALATION AEROSOL 160-

4.5 MCG/ACT, 80-4.5 MCG/ACT 1 QL (11 GM per 30 days)

SYMLINPEN 120 SUBCUTANEOUS


SYMLINPEN 60 SUBCUTANEOUS


SYNAGIS INTRAMUSCULAR SOLUTION 50

MG/0.5ML 1 PA

SYNAREL NASAL SOLUTION 2 MG/ML 1 PA

SYNERCID INTRAVENOUS SOLUTION

RECONSTITUTED 150-350 MG 1

SYNRIBO SUBCUTANEOUS SOLUTION


SYNTHROID ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175


75 MCG, 88 MCG

1

SYPRINE ORAL CAPSULE 250 MG 1 PA

SYSTANE OPHTHALMIC GEL 0.4-0.3 % 1(SO)

TABLOID ORAL TABLET 40 MG 1 PA

tacrolimus external ointment 0.03 %, 0.1 % 1 ST

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1

TAFINLAR ORAL CAPSULE 50 MG 1 PA; LA; QL (186 EA per 31 days)

TAFINLAR ORAL CAPSULE 75 MG 1 PA; LA; QL (124 EA per 31 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG 1 PA; LA

TAKE ACTION ORAL TABLET 1.5 MG 1(SO)

TAMIFLU ORAL SUSPENSION

RECONSTITUTED 6 MG/ML 1 QL (540 ML per 31 days)

tamoxifen citrate oral tablet 10 mg, 20 mg 1

tamsulosin hcl oral capsule 0.4 mg 1 QL (62 EA per 31 days)



93

Drug Tier Notes

TARCEVA ORAL TABLET 100 MG, 150 MG 1 PA; QL (31 EA per 31 days)

TARCEVA ORAL TABLET 25 MG 1 PA; QL (93 EA per 31 days)

TARGRETIN EXTERNAL GEL 1 % 1 PA

TARINA FE 1/20 ORAL TABLET 1-20 MG-

MCG 1

TASIGNA ORAL CAPSULE 150 MG, 200 MG 1 PA; QL (124 EA per 31 days)

tazarotene external cream 0.1 % 1 PA

TAZORAC EXTERNAL CREAM 0.05 % 1 PA

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % 1 PA

TAZTIA XT ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 180 MG, 240 MG 1 QL (62 EA per 31 days)

TAZTIA XT ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 300 MG, 360 MG 1 QL (31 EA per 31 days)

TECENTRIQ INTRAVENOUS SOLUTION

1200 MG/20ML 1

TECFIDERA ORAL 120 & 240 MG 1 PA

TECFIDERA ORAL CAPSULE DELAYED

RELEASE 120 MG, 240 MG 1 PA

TEFLARO INTRAVENOUS SOLUTION


TEGRETOL-XR ORAL TABLET EXTENDED

RELEASE 12 HOUR 100 MG 1

telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 QL (31 EA per 31 days)

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

5 mg, 80-10 mg, 80-5 mg 1 QL (31 EA per 31 days)

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5

mg, 80-25 mg 1 QL (31 EA per 31 days)

temazepam oral capsule 15 mg, 22.5 mg, 30 mg 1 QL (31 EA per 31 days)

temazepam oral capsule 7.5 mg 1 QL (124 EA per 31 days)

TENIVAC INTRAMUSCULAR INJECTABLE

5-2 LFU 1

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

mg 1

terbinafine hcl external cream 1 % 1(CW)

terbinafine hcl oral tablet 250 mg 1 QL (93 EA per 365 days)

terbutaline sulfate injection solution 1 mg/ml 1

terbutaline sulfate oral tablet 2.5 mg, 5 mg 1

terconazole vaginal cream 0.4 %, 0.8 % 1



94

Drug Tier Notes

terconazole vaginal suppository 80 mg 1

testosterone cypionate intramuscular solution 100

mg/ml, 200 mg/ml 1

testosterone enanthate intramuscular solution 200

mg/ml 1

testosterone transdermal gel 12.5 mg/act (1%) 1

tetanus-diphtheria toxoids td intramuscular

suspension 2-2 lf/0.5ml 1

tetrabenazine oral tablet 12.5 mg, 25 mg 1

tetracycline hcl oral capsule 250 mg, 500 mg 1

THALOMID ORAL CAPSULE 100 MG, 200


THALOMID ORAL CAPSULE 150 MG 1 PA; QL (62 EA per 31 days)

theophylline er oral tablet extended release 12

hour 100 mg, 200 mg, 300 mg, 450 mg 1

theophylline er oral tablet extended release 24

hour 400 mg, 600 mg 1

theophylline oral solution 80 mg/15ml 1

THERA-D 4000 ORAL TABLET 4000 UNIT 1(CW)

thiamine hcl oral tablet 100 mg 1(CW)

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

50 mg 1 PA; HR

thiotepa injection solution reconstituted 15 mg 1

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

THYMOGLOBULIN INTRAVENOUS

SOLUTION RECONSTITUTED 25 MG 1

tiagabine hcl oral tablet 2 mg, 4 mg 1

TIGECYCLINE INTRAVENOUS SOLUTION


TIGER BALM LINIMENT EXTERNAL

LIQUID 16-28 % 1(CW)

TIGER BALM MUSCLE RUB EXTERNAL

CREAM 3-5-15 % 1(CW)

timolol maleate ophthalmic gel forming solution

0.25 %, 0.5 % 1

timolol maleate ophthalmic solution 0.25 %, 0.5

% 1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1



95

Drug Tier Notes

TINACTIN EXTERNAL AEROSOL 1 % 1(SO)

TINACTIN EXTERNAL CREAM 1 % 1(SO)

TIVICAY ORAL TABLET 10 MG, 25 MG, 50


tizanidine hcl oral tablet 2 mg, 4 mg 1

TOBI PODHALER INHALATION CAPSULE

28 MG 1 PA

TOBRADEX OPHTHALMIC OINTMENT 0.3-

0.1 % 1

TOBRADEX OPHTHALMIC SUSPENSION

0.3-0.1 % 1

TOBRADEX ST OPHTHALMIC SUSPENSION

0.3-0.05 % 1

tobramycin inhalation nebulization solution 300

mg/5ml 1

tobramycin ophthalmic solution 0.3 % 1

tobramycin sulfate injection solution 10 mg/ml,

80 mg/2ml 1

tobramycin-dexamethasone ophthalmic

suspension 0.3-0.1 % 1

tolazamide oral tablet 250 mg, 500 mg 1

tolbutamide oral tablet 500 mg 1

tolnaftate antifungal external cream 1 % 1(SO)

tolnaftate external aerosol powder 1 % 1(SO)

tolnaftate external powder 1 % 1(SO)

tolnaftate external solution 1 % 1(SO)

tolnaftate powder 1(SO)

topiramate er oral capsule er 24 hour sprinkle

100 mg, 150 mg, 200 mg, 25 mg, 50 mg 1

topiramate oral capsule sprinkle 15 mg, 25 mg 1

topiramate oral tablet 100 mg, 200 mg, 50 mg 1 QL (124 EA per 31 days)

topiramate oral tablet 25 mg 1 QL (93 EA per 31 days)

topotecan hcl intravenous solution reconstituted 4

mg 1

TORISEL INTRAVENOUS SOLUTION 25

MG/ML 1 QL (100 ML per 28 days)

torsemide oral tablet 100 mg, 20 mg 1

total fiber oral powder 1(CW)



96

Drug Tier Notes

TOUJEO SOLOSTAR SUBCUTANEOUS


TPN ELECTROLYTES INTRAVENOUS

SOLUTION 1

TRACLEER ORAL TABLET 125 MG, 62.5 MG 1 QL (62 EA per 31 days)

TRADJENTA ORAL TABLET 5 MG 1 QL (31 EA per 31 days)

tramadol hcl er oral capsule extended release 24

hour 100 mg, 200 mg, 300 mg 1 QL (31 EA per 31 days)

tramadol hcl oral tablet 50 mg 1 QL (248 EA per 31 days)

tramadol-acetaminophen oral tablet 37.5-325 mg 1 QL (381 EA per 31 days)

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

tranexamic acid intravenous solution 1000

mg/10ml 1

tranexamic acid oral tablet 650 mg 1 QL (30 EA per 5 days)

TRANSDERM-SCOP (1.5 MG)

TRANSDERMAL PATCH 72 HOUR 1

MG/3DAYS


tranylcypromine sulfate oral tablet 10 mg 1

TRAVASOL INTRAVENOUS SOLUTION 10

% 1

TRAVATAN Z OPHTHALMIC SOLUTION

0.004 % 1

trazodone hcl oral tablet 100 mg, 150 mg, 300

mg, 50 mg 1

TREANDA INTRAVENOUS SOLUTION


TRECATOR ORAL TABLET 250 MG 1

TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 11.25 MG,

22.5 MG, 3.75 MG

1 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1

tretinoin external gel 0.01 %, 0.025 % 1

tretinoin microsphere external gel 0.04 %, 0.1 % 1

tretinoin oral capsule 10 mg 1

TREXALL ORAL TABLET 10 MG, 15 MG, 5

MG, 7.5 MG 1

triamcinolone acetonide external cream 0.025 %,

0.1 %, 0.5 % 1



97

Drug Tier Notes

triamcinolone acetonide external lotion 0.025 %,

0.1 % 1

triamcinolone acetonide external ointment 0.025

%, 0.1 %, 0.5 % 1

triamcinolone acetonide mouth/throat paste 0.1 % 1

TRIAMINIC COUGH & CONGESTION ORAL

SYRUP 5-100 MG/5ML 1(SO)

triamterene-hctz oral capsule 37.5-25 mg, 50-25

mg 1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

triazolam oral tablet 0.125 mg 1 QL (31 EA per 31 days)

triazolam oral tablet 0.25 mg 1 QL (62 EA per 31 days)

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

5 mg 1

trifluridine ophthalmic solution 1 % 1

trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA; HR

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA; HR

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-

35 MG-MCG 1

TRILYTE ORAL SOLUTION


trimethoprim oral tablet 100 mg 1

trimipramine maleate oral capsule 100 mg, 25

mg, 50 mg 1 PA; HR

TRINESSA (28) ORAL TABLET

0.18/0.215/0.25 MG-35 MCG 1

TRINTELLIX ORAL TABLET 10 MG, 20 MG,

5 MG 1 ST; QL (31 EA per 31 days)

triple antibiotic external ointment 3.5-400-5000 1(SO)

TRI-PREVIFEM ORAL TABLET

0.18/0.215/0.25 MG-35 MCG 1

TRISENOX INTRAVENOUS SOLUTION 10

MG/10ML 1

TRISPEC DMX PEDIATRIC ORAL LIQUID

10-187 MG/5ML 1(SO)

TRI-SPRINTEC ORAL TABLET

0.18/0.215/0.25 MG-35 MCG 1

TRIUMEQ ORAL TABLET 600-50-300 MG 1



98

Drug Tier Notes

TRIVORA (28) ORAL TABLET 1

TROKENDI XR ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 100 MG, 200 MG, 25 MG,

50 MG

1

TROPHAMINE INTRAVENOUS SOLUTION

10 % 1

TRUMENBA INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 1

TRUVADA ORAL TABLET 100-150 MG, 133-

200 MG, 167-250 MG, 200-300 MG 1 QL (31 EA per 31 days)

trymine cg oral liquid 225-7.5 mg/5ml 1(ND)

TUMS CHEWY DELIGHTS ORAL TABLET


TUMS E-X 750 ORAL TABLET CHEWABLE

750 MG 1(CW)

TUMS KIDS ORAL TABLET CHEWABLE 750

MG 1(CW)

TUMS ORAL TABLET CHEWABLE 500 MG 1(CW)

TUMS SMOOTHIES ORAL TABLET


TUMS ULTRA 1000 ORAL TABLET


tussin cough oral syrup 15 mg/5ml 1(SO)

tussin dm max adult oral liquid 10-200 mg/5ml 1(SO)

TWINRIX INTRAMUSCULAR SUSPENSION

720-20 1

TYBOST ORAL TABLET 150 MG 1

TYGACIL INTRAVENOUS SOLUTION


TYKERB ORAL TABLET 250 MG 1 PA; QL (186 EA per 31 days)

TYLENOL EXTRA STRENGTH ORAL

TABLET 500 MG 1(SO)

TYLENOL INFANTS PAIN+FEVER ORAL

SUSPENSION 160 MG/5ML 1(SO)

TYMLOS SUBCUTANEOUS SOLUTION PEN-

INJECTOR 3120 MCG/1.56ML 1 PA

TYPHIM VI INTRAMUSCULAR SOLUTION

25 MCG/0.5ML 1



99

Drug Tier Notes

TYSABRI INTRAVENOUS CONCENTRATE

300 MG/15ML 1 PA

UCERIS ORAL TABLET EXTENDED

RELEASE 24 HOUR 9 MG 1 ST

UCERIS RECTAL FOAM 2 MG/ACT 1 ST

ULTRA MIDE 25 EXTERNAL LOTION 25 % 1(CW)

ULTRACIN T EXTERNAL LOTION 10 % 1(CW)

ULTRACIN-M EXTERNAL GEL 10 % 1(CW)

UNITHROID ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 150 MCG, 175 MCG, 200


88 MCG

1

UPTRAVI ORAL TABLET 1000 MCG, 1200

MCG, 1400 MCG, 1600 MCG, 200 MCG, 400

MCG, 600 MCG, 800 MCG

1 PA; LA

UPTRAVI ORAL TABLET THERAPY PACK

200 & 800 MCG 1 PA; LA

urea external cream 10 %, 20 %, 39 %, 40 %, 45

%, 47 %, 50 % 1(CW)

urea external gel 40 % 1(CW)

urea external lotion 10 %, 40 %, 45 % 1(CW)

urea external suspension 40 % 1(CW)

urevaz external cream 44 % 1(CW)

ursodiol oral capsule 300 mg 1

ursodiol oral tablet 250 mg, 500 mg 1

UTOPIC EXTERNAL CREAM 41 % 1(CW)

valacyclovir hcl oral tablet 1 gm 1 QL (93 EA per 31 days)

valacyclovir hcl oral tablet 500 mg 1 QL (62 EA per 31 days)

VALCHLOR EXTERNAL GEL 0.016 % 1

valganciclovir hcl oral solution reconstituted 50

mg/ml 1

valganciclovir hcl oral tablet 450 mg 1

valproate sodium intravenous solution 500

mg/5ml 1

valproic acid oral capsule 250 mg 1

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

mg 1



100

Drug Tier Notes

valsartan-hydrochlorothiazide oral tablet 160-

12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg,

80-12.5 mg


vancomycin hcl intravenous solution reconstituted

10 gm, 1000 mg, 500 mg 1

vancomycin hcl oral capsule 125 mg, 250 mg 1

vaporizing steam inhalation liquid 6.2 % 1(CW)

VAQTA INTRAMUSCULAR SUSPENSION 25

UNIT/0.5ML, 50 UNIT/ML 1

VARIVAX SUBCUTANEOUS INJECTABLE

1350 PFU/0.5ML 1

VARIZIG INTRAMUSCULAR SOLUTION 125

UNIT/1.2ML 1 PA

VASCEPA ORAL CAPSULE 1 GM 1

VELCADE INJECTION SOLUTION

RECONSTITUTED 3.5 MG 1 PA; QL (14 EA per 21 days)

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025

MG 1

VENCLEXTA ORAL TABLET 10 MG, 100

MG, 50 MG 1 PA

VENCLEXTA STARTING PACK ORAL

TABLET THERAPY PACK 10 & 50 & 100 MG 1 PA

venlafaxine hcl er oral capsule extended release

24 hour 150 mg, 37.5 mg, 75 mg 1 QL (62 EA per 31 days)

venlafaxine hcl er oral tablet extended release 24

hour 150 mg, 225 mg, 37.5 mg, 75 mg 1 QL (31 EA per 31 days)

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5

mg, 50 mg, 75 mg 1

VENTAVIS INHALATION SOLUTION 10

MCG/ML, 20 MCG/ML 1 QL (270 ML per 30 days)

VENTOLIN HFA INHALATION AEROSOL


verapamil hcl er oral capsule extended release 24

hour 100 mg, 300 mg 1 QL (31 EA per 31 days)

verapamil hcl er oral capsule extended release 24

hour 120 mg, 180 mg, 200 mg, 240 mg, 360 mg 1 QL (62 EA per 31 days)

verapamil hcl er oral tablet extended release 180

mg, 240 mg 1

verapamil hcl intravenous solution 2.5 mg/ml 1



101

Drug Tier Notes

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

VERSACLOZ ORAL SUSPENSION 50 MG/ML 1 ST; QL (558 ML per 31 days)

VESICARE ORAL TABLET 10 MG, 5 MG 1 PA; HR

VESTURA ORAL TABLET 3-0.02 MG 1

VICKS DAYQUIL COUGH ORAL LIQUID 15

MG/15ML 1(SO)

VICKS DAYQUIL MUCUS CONTROL DM


VICKS NATURE FUSION CONGEST ORAL

LIQUID 20-200 MG/30ML 1(SO)

VICODIN ES ORAL TABLET 7.5-300 MG 1 QL (382 EA per 31 days)

VICODIN HP ORAL TABLET 10-300 MG 1 QL (382 EA per 31 days)

VICODIN ORAL TABLET 5-300 MG 1 QL (382 EA per 31 days)

VICTOZA SUBCUTANEOUS SOLUTION

PEN-INJECTOR 18 MG/3ML 1

VIDEX ORAL SOLUTION RECONSTITUTED

2 GM 1 QL (1240 ML per 31 days)

vigabatrin oral packet 500 mg 1 LA; QL (186 EA per 31 days)

VIGAMOX OPHTHALMIC SOLUTION 0.5 % 1

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40

MG 1

VIIBRYD STARTER PACK ORAL KIT 10 &


VIMPAT INTRAVENOUS SOLUTION 200

MG/20ML 1

VIMPAT ORAL SOLUTION 10 MG/ML 1 QL (1442 ML per 31 days)

VIMPAT ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG 1

vinblastine sulfate intravenous solution 1 mg/ml 1

vincasar pfs intravenous solution 1 mg/ml 1

vincristine sulfate intravenous solution 1 mg/ml 1

vinorelbine tartrate intravenous solution 50

mg/5ml 1

VIRACEPT ORAL TABLET 250 MG 1 QL (310 EA per 31 days)

VIRACEPT ORAL TABLET 625 MG 1 QL (124 EA per 31 days)

VIREAD ORAL POWDER 40 MG/GM 1 QL (248 GM per 31 days)

VIREAD ORAL TABLET 150 MG, 200 MG,

250 MG, 300 MG 1 QL (31 EA per 31 days)



102

Drug Tier Notes

vision plus oral capsule 1(CW)

vision vitamins oral tablet 1(CW)

VITAMELTS ENERGY VITAMIN B-12 ORAL

TABLET DISPERSIBLE 1500 MCG 1(CW)

vitamin b1 oral tablet 100 mg 1(CW)

vitamin b-12 er oral tablet extended release 2000

mcg 1(CW)

vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250

mcg, 50 mcg, 500 mcg 1(CW)

vitamin b12 oral tablet extended release 1000

mcg 1(CW)

vitamin b-12 sublingual tablet sublingual 1000

mcg, 2500 mcg, 500 mcg, 5000 mcg 1(CW)

vitamin b-6 oral tablet 25 mg, 50 mg 1(CW) QL (31 EA per 31 days)

vitamin b6 oral tablet 250 mg 1(CW) QL (31 EA per 31 days)

vitamin d (cholecalciferol) oral capsule 1000

unit, 400 unit 1(CW)

vitamin d (cholecalciferol) oral tablet 1000 unit 1(CW)

vitamin d (ergocalciferol) oral capsule 50000 unit 1(ND)

vitamin d2 oral tablet 2000 unit, 400 unit 1(CW)

vitamin d3 maximum strength oral capsule 5000

unit 1(CW)

vitamin d3 oral capsule 10000 unit, 2000 unit,

50000 unit 1(CW)

vitamin d3 oral liquid 1200 unit/15ml, 5000

unit/ml 1(CW)

vitamin d3 oral tablet 2000 unit, 3000 unit, 400

unit, 5000 unit, 50000 unit 1(CW)

vitamin d3 oral tablet chewable 1000 unit, 400

unit, 5000 unit 1(CW)

vitamin k (phytonadione) oral tablet 100 mcg 1(CW)

vitamin k1 injection solution 1 mg/0.5ml 1(CW)

voriconazole intravenous solution reconstituted

200 mg 1 PA

voriconazole oral suspension reconstituted 40

mg/ml 1 PA

voriconazole oral tablet 200 mg, 50 mg 1 PA; QL (124 EA per 31 days)

VOTRIENT ORAL TABLET 200 MG 1 PA; QL (124 EA per 31 days)



103

Drug Tier Notes

VPRIV INTRAVENOUS SOLUTION

RECONSTITUTED 400 UNIT 1

VRAYLAR ORAL CAPSULE 1.5 MG 1 PA; QL (120 EA per 30 days)

VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6

MG 1 PA; QL (60 EA per 30 days)

VRAYLAR ORAL CAPSULE THERAPY

PACK 1.5 & 3 MG 1 ST

VYFEMLA ORAL TABLET 0.4-35 MG-MCG 1

VYXEOS INTRAVENOUS SUSPENSION

RECONSTITUTED 100-44 MG 1 PA

WAL-TUSSIN COUGH/COLD ORAL SYRUP

30-15 MG/5ML 1(SO)

WAL-ZYR CHILDRENS ORAL SOLUTION 1

MG/ML 1(SO)

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg,

2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1

WYMZYA FE ORAL TABLET CHEWABLE

0.4-35 MG-MCG 1

XALKORI ORAL CAPSULE 200 MG, 250 MG 1 PA; QL (62 EA per 31 days)

XARELTO ORAL TABLET 10 MG, 15 MG, 20

MG 1

XARELTO STARTER PACK ORAL TABLET

THERAPY PACK 15 & 20 MG 1

XATMEP ORAL SOLUTION 2.5 MG/ML 1

XELJANZ ORAL TABLET 5 MG 1 ST

XGEVA SUBCUTANEOUS SOLUTION 120

MG/1.7ML 1 PA; QL (2 ML per 28 days)

XIFAXAN ORAL TABLET 550 MG 1 PA; QL (62 EA per 31 days)

XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG, 10-500 MG,

5-500 MG


XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 5-1000 MG 1 QL (62 EA per 31 days)

XOLAIR SUBCUTANEOUS SOLUTION

RECONSTITUTED 150 MG 1 PA; QL (12 EA per 31 days)

xoten external lotion 12.5-6.25 % 1(CW)

XTANDI ORAL CAPSULE 40 MG 1 ST; QL (124 EA per 31 days)

XYREM ORAL SOLUTION 500 MG/ML 1 LA; QL (558 ML per 31 days)



104

Drug Tier Notes

YERVOY INTRAVENOUS SOLUTION 50

MG/10ML 1 PA

YF-VAX SUBCUTANEOUS INJECTABLE 1

YONDELIS INTRAVENOUS SOLUTION


yuvafem vaginal tablet 10 mcg 1

zafirlukast oral tablet 10 mg, 20 mg 1 QL (62 EA per 31 days)

zaleplon oral capsule 10 mg, 5 mg 1 PA; HR; QL (93 EA per 365 days)

ZANTAC 75 ORAL TABLET 75 MG 1(CW)

ZAVESCA ORAL CAPSULE 100 MG 1 PA; QL (93 EA per 31 days)

ZEJULA ORAL CAPSULE 100 MG 1 PA; QL (93 EA per 31 days)

ZELBORAF ORAL TABLET 240 MG 1 PA; QL (248 EA per 31 days)

ZEMAIRA INTRAVENOUS SOLUTION


ZENATANE ORAL CAPSULE 10 MG, 20 MG,

40 MG 1

ZENCHENT FE ORAL TABLET CHEWABLE

0.4-35 MG-MCG 1

ZENCHENT ORAL TABLET 0.4-35 MG-MCG 1

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000 UNIT, 15000

UNIT, 20000 UNIT, 25000 UNIT, 3000-10000

UNIT, 40000 UNIT, 5000 UNIT

1

ZENZEDI ORAL TABLET 10 MG 1 QL (186 EA per 31 days)

ZENZEDI ORAL TABLET 5 MG 1 QL (155 EA per 31 days)

ZEPATIER ORAL TABLET 50-100 MG 1 PA

ZIAGEN ORAL SOLUTION 20 MG/ML 1 QL (995 ML per 31 days)

zidovudine oral capsule 100 mg 1 QL (186 EA per 31 days)

zidovudine oral syrup 50 mg/5ml 1 QL (1736 ML per 28 days)

zidovudine oral tablet 300 mg 1 QL (62 EA per 31 days)

ZIMS MAX-FREEZE EXTERNAL GEL 3.7 % 1(CW)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60


ZIRGAN OPHTHALMIC GEL 0.15 % 1

zoledronic acid intravenous concentrate 4 mg/5ml 1

zoledronic acid intravenous solution 5 mg/100ml 1

ZOLINZA ORAL CAPSULE 100 MG 1 PA; QL (124 EA per 31 days)



105

Drug Tier Notes

zolpidem tartrate oral tablet 10 mg, 5 mg 1 PA; HR; QL (93 EA per 365 days)

ZOMETA INTRAVENOUS SOLUTION 4

MG/100ML 1

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1

ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG 1 ST; QL (62 EA per 31 days)

ZORTRESS ORAL TABLET 0.5 MG 1 ST; QL (124 EA per 31 days)

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

MCG 1

ZYDELIG ORAL TABLET 100 MG, 150 MG 1

ZYKADIA ORAL CAPSULE 150 MG 1 QL (155 EA per 31 days)

ZYNCOF ORAL SYRUP 20-400 MG/5ML 1(SO)

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 210 MG 1

ZYRTEC ALLERGY ORAL CAPSULE 10 MG 1(SO)

ZYRTEC ALLERGY ORAL TABLET 10 MG 1(SO)

ZYRTEC CHILDRENS ALLERGY ORAL

TABLET CHEWABLE 10 MG 1(SO)

ZYRTEC-D ALLERGY & CONGESTION

ORAL TABLET EXTENDED RELEASE 12

HOUR 5-120 MG

1(SO)

ZYTIGA ORAL TABLET 250 MG, 500 MG 1 QL (124 EA per 31 days)

This formulary was updated on 10/24/2017. For more recent information or other questions, please contact

Partnership Customer Service at 1-800-963-0035 or, for TTY users, Wisconsin Relay 711, 8 a.m. – 8 p.m., 7

days a week, or visit www.carewisc.org.

Care Wisconsin Health Plan

P.O. Box 14017

Madison, Wisconsin 53708-0017

1-800-963-0035

TTY/TDD Wisconsin Relay System 711

www.carewisc.org

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