formulario y lista de medicamentos cubiertos · cobertura 2020, excepto como se describe a...

2020

FORMULARIO Y LISTA de MEDICAMENTOS CUBIERTOS

Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO)

POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

ID de envío del archivo de formulario aprobado por HPMS 0002033, Versión 9

Este formulario fue actualizado el 1/Abr/2020. Para ver información más reciente o si tiene otras preguntas, comuníquese con el Servicio de Atención al Cliente de Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO) al 1-877-293-5325 o, para usuarios de TTY, 711, las 24 horas del día, los 7 días de la semana, o visitewww.hopkinsmedicare.com.

Y0124_PPOFormulary0919_C

www.hopkinsmedicare.com

Y0124_PPOFormulary0919_C 2

Nota dirigida a los miembros existentes: Este formulario ha cambiado desde el año pasado. Por favor, revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma.

Cuando en esta lista de medicamentos (formulario) dice “nosotros” o “nuestro”, hace referencia a Johns Hopkins Advantage MD. Cuando menciona “plan” o “nuestro plan”, se refiere a los planes Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO).

Este documento contiene el listado de medicamentos (formulario) de nuestro plan que está actualizado al 1 de abril del 2020. Para obtener un formulario actualizado, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y en la contraportada.

Por lo general, debe acudir a las farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o los copagos/coaseguro pueden cambiar el 1 de enero del 2021 y algunas veces durante el año.

¿Qué es el formulario de los planes Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO)? Un formulario es una lista seleccionada de medicamentos cubiertos por nuestro plan en consulta con un equipo de proveedores de salud, que representa los tratamientos recetados que se cree que deben formar parte de un programa de tratamientos de calidad. Nuestro plan por lo general cubre los medicamentos listados en nuestro formulario, siempre y cuando el medicamento sea necesario en términos médicos, los medicamentos de venta con receta se despachen en una farmacia de la red del plan y se siguen otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de cobertura.

¿Puede cambiar el formulario (listado de medicamentos)? La mayoría de los cambios en la cobertura de medicamentos ocurre el 1.° de enero, pero podríamos agregar o quitar medicamentos de la lista en el transcurso del año, cambiarlos a diferentes niveles de costoscompartidos o agregar nuevas restricciones. Debemos seguir las reglas de Medicare al hacer estos cambios.

A continuación los cambios que pueden afectarlo este año: En los siguientes casos, usted se verá afectado por el cambio de la cobertura durante el año:

• Nuevos medicamentos genéricos. Podemos eliminar de inmediato un medicamento de marca denuestra lista de medicamentos si lo reemplazamos con un nuevo medicamento genérico queaparecerá en el mismo nivel de costo compartido o en un nivel inferior, y con las mismas o menosrestricciones. Además, al añadir el nuevo medicamento genérico, podemos decidir conservar elmedicamento de marca en nuestra lista de medicamentos, pero moverlo de inmediato a un nivel decosto compartido diferente o añadir nuevas restricciones. Si actualmente toma ese medicamento demarca, podríamos no informarle con anticipación antes de hacer el cambio, pero más adelante ledaremos información sobre los cambios específicos que hemos hecho.

o Si hacemos el cambio, usted o la persona que expide su receta pueden solicitarnos quehagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El avisoque le proporcionemos también incluirá información sobre cómo solicitar una excepción, ytambién puede encontrar información en la sección siguiente titulada "¿Cómo solicito unaexcepción al formulario de los planes Johns Hopkins Advantage MD (PPO), Johns HopkinsAdvantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO)?".


• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentosconsidera que un medicamento de nuestro formulario es inseguro o que el fabricante lo quita delmercado, inmediatamente sacaremos el medicamento de nuestro formulario y le notificaremos anuestros miembros que tomen dicho medicamento.

• Otros cambios. Podemos hacer otros cambios que afecten a los miembros que actualmente tomanun medicamento. Por ejemplo, podemos añadir un medicamento genérico que no es nuevo en elmercado para reemplazar un medicamento de marca que actualmente está en el formulario, o añadirnuevas restricciones al medicamento de marca, o moverlo a un nivel diferente de costo compartido.O bien, podemos hacer cambios con base en nuevos lineamientos clínicos. Si nosotros retiramosmedicamentos de nuestro formulario, o agregamos, previa autorización, límites de cantidades y/orestricciones a las terapias escalonadas de un medicamento, estamos obligados a notificarle a losmiembros afectados sobre el cambio, al menos 30 días antes de que el cambio se haga efectivo o enel momento en que el miembro solicite un resurtido del medicamento de venta con receta, cuando elmiembro recibirá un suministro de 30 días del medicamento.

o Si hacemos estos otros cambios, usted o la persona que expide su receta pueden solicitarnosque hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. Elaviso que le proporcionemos también incluirá información sobre cómo solicitar unaexcepción, y también puede encontrar información en la sección siguiente titulada "¿Cómosolicito una excepción al formulario de los planes Johns Hopkins Advantage MD (PPO),Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier(PPO)?".

Cambios que no le afectarán si está tomando el medicamento en la actualidad: Por lo general, si usted está tomando un medicamento incluido en nuestro formulario del 2020 y que estaba bajo cobertura al comienzo del año, no suspenderemos ni reduciremos la cobertura de ese medicamento durante el año de cobertura 2020, excepto como se describe a continuación. Esto significa que estos medicamentos seguirán estando disponibles al mismo costo compartido y sin restricciones para aquellos miembros que lo estén tomando por el resto del año de la cobertura.

El formulario adjunto está vigente al 1 de abril de 2020. Para obtener información actualizada sobre los medicamentos cubiertos por nuestro plan, póngase en contacto con nosotros. Nuestra información de contacto aparece en la portada y la contraportada. En caso de que tengamos un cambio de formulario que no sea de mantenimiento, a mitad de año (es decir, retirar medicamentos de nuestro formulario, agregar requisitos de autorización previa, límites de cantidades y/o de terapias escalonadas a un medicamento, o de que pasemos un medicamento a un nivel de costo compartido más elevado), le notificaremos por correo. También actualizaremos el formulario con la información nueva. La información actualizada del formulario puede obtenerse de nuestro sitio web o llamándonos al número que se encuentra en la página frontal y posterior.

¿Cómo utilizo el formulario? Hay dos maneras de encontrar su medicamento dentro del formulario:

Enfermedad El formulario comienza en la página 11. Los medicamentos en este formulario están agrupados en categorías según el tipo de enfermedad para la que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca están listados bajo la categoría “CARDIOVASCULAR - MEDICAMENTOS PARA TRATAR ENFERMEDADES CARDÍACAS Y CIRCULATORIAS”.


Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 11. Luego busque su medicamento bajo el nombre de la categoría.

Orden alfabético Si no sabe en qué categoría buscar, debe buscar su medicamento en el índice que comienza en la página 58. El índice contiene una lista en orden alfabético de todos los medicamentos incluidos en estedocumento. Tanto los medicamentos de marca como los genéricos están listados en este índice. Busqueen el índice y encuentre su medicamento. Al lado de su medicamento, verá el número de la páginadonde puede encontrar la información sobre la cobertura. Vaya a la página listada en el Índice yencuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Nuestro plan cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico es aquel que contiene los mismos ingredientes activos que el medicamento de marca y tiene la aprobación de la FDA. Por lo general, los medicamentos genéricos son más baratos que los de marca.

¿Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos podrían tener requisitos adicionales o límites de cobertura. Estos requisitos o límites podrían incluir:

• Autorización previa: Nuestro plan le exige a usted o a su médico obtener autorización previa paraciertos medicamentos. Esto significa que deberá recibir la aprobación por parte de nuestro plan antesde surtir sus medicamentos de venta con receta. Si no recibe aprobación, tal vez no cubramos elmedicamento.

• Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad delmedicamento que cubriremos. Por ejemplo, nuestro plan ofrece 30 tabletas cada 30 días porreceta de Januvia. Esto podría ser adicional a un suministro estándar para uno o tres meses.

• Terapia escalonada: En algunos casos, nuestro plan exige que usted primero pruebe algunosmedicamentos para tratar su enfermedad antes de que cubramos otro medicamento para esacondición. Por ejemplo, si el medicamento A y el medicamento B sirven para el tratamiento de sucondición médica, nuestro plan podría no cubrir el medicamento B a menos que pruebe elmedicamento A primero. Si el medicamento A no le sirve, entonces le cubriremos el medicamento B.

Puede averiguar si su medicamento tiene límites o requisitos adicionales al buscar en el formulario que comienza en la página 11. También puede obtener más información sobre las restricciones que aplican a ciertos medicamentos cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones en cuanto a las autorizaciones previas y la terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y en la contraportada.

Puede pedirle a nuestro plan que haga una excepción en cuanto a estas restricciones o límites o pedirle una lista de otros medicamentos similares que puedan servir para tratar su enfermedad. Consulte la sección “¿Cómo solicito una excepción al formulario de Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO)?” en la página 5 para obtener información sobre cómo solicitar una excepción.


¿Qué ocurre si mi medicamento no está en el formulario? Si su medicamento no está incluido en este formulario (listado de medicamentos cubiertos), primero debe ponerse en contacto con Servicio de Atención al Cliente y preguntar si cubrimos su medicamento.

Si se entera de que nuestro plan no cubre su medicamento, tiene dos opciones:

• Puede pedirle a Servicio de Atención al Cliente una lista de medicamentos similares que esténcubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le receteun medicamento similar que esté cubierto por nuestro plan.

• Puede pedirle a nuestro plan que haga una excepción y cubra su medicamento. Más adelanteencontrará información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al formulario para los planes Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO)? Puede pedirle a nuestro plan que haga una excepción en las reglas de cobertura. Existen varios tipos de excepciones que nos puede solicitar.

• Puede pedirnos que cubramos un medicamento aún cuando este no se encuentre en nuestroformulario. De aprobarse, este medicamento será cubierto a un nivel predeterminado de costocompartido y no podrá pedirnos que proporcionemos el medicamento a un nivel de costocompartido más bajo.

• Puede pedirnos que cubramos un medicamento del formulario a un costo compartido más bajosi este medicamento no se encuentra en el nivel de especialidades. Si se aprueba, esto reduciríael monto que debe pagar por su medicamento.

• Puede solicitarnos que no apliquemos las restricciones de cobertura o límites sobre su medicamento.Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad del medicamento quecubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos ellímite y cubramos una cantidad mayor.

Generalmente, solo aprobaremos su solicitud de una excepción si los medicamentos alternativos incluidos en el formulario del plan (el medicamento de costo compartido más bajo) o sus restricciones de uso adicionales no serán igual de efectivos para tratar su enfermedad y/o le causarán efectos médicos adversos.

Debe comunicarse con nosotros para solicitar una decisión inicial de cobertura para una excepción a las restricciones de uso, de los niveles o del formulario. Cuando solicita una excepción al formulario, a los niveles o a las restricciones de uso, debe enviar una declaración por parte de su médico que apoye su solicitud. Por lo general, debemos tomar nuestra decisión dentro de un plazo de 72 horas de haber recibido la declaración de apoyo de su médico. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud puede verse gravemente afectada si tiene esperar hasta 72 horas por una decisión. Si se le concede esta solicitud acelerada, debemos notificarle sobre la decisión no más de 24 horas después de haber recibido la declaración de apoyo de su médico u otra persona que haya emitido la receta.


¿Qué debo hacer antes de poder hablar con mi médico para cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o regular de nuestro plan, podría estar tomando medicamentos que no estén dentro de nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte antes de que pueda surtir sus recetas. Es recomendable que hable con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que usted toma. Mientras habla con su médico para determinar qué debe hacer, podríamos cubrir su medicamento en casos determinados durante los primeros 90 días en los que usted es miembro de nuestro plan.

Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta es por menos días, permitiremos varios surtidos para proporcionarle hasta un máximo de 30 días de suministro del medicamento. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días.

Si es residente de una institución de cuidado a largo plazo y necesita un medicamento que no esté en nuestro formulario o su capacidad para obtener los medicamentos es limitada, pero tiene más de 90 días como miembro del plan, cubriremos un suministro de emergencia para 31 días para ese medicamento mientras tramita una excepción al formulario.

Si experimenta un cambio en su nivel de cuidado, como un cambio de un hospital a un hogar, y necesita un medicamento que no está en nuestro formulario, o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal único por hasta 30 días (o 31 días si es residente de cuidado a largo plazo) de una farmacia de la red. Durante este período, debe usar el proceso de excepción del plan si desea tener una cobertura continua del medicamento después de que finalice el suministro temporal.

Para más información Para más información sobre la cobertura de medicamentos recetados en los planes Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO), consulte su Evidencia de cobertura y otros materiales de los planes.

Si tiene preguntas sobre nuestro plan, contáctenos. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y en la contraportada.

Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, por favor llame a Medicare al 1-800- MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

http://www.medicare.gov/


Formulario de los planes Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO) El formulario que comienza en la próxima página proporciona información sobre la cobertura de medicamentos de nuestro plan. Si tiene algún problema para encontrar su medicamento en el listado, pase al índice que comienza en la página 58

La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca se escriben en mayúsculas (p. ej., SYNTHROID) y los genéricos en minúsculas en cursiva (p. ej., levotiroxina).

La información en la columna de Requerimientos/Límites le dice si nuestro plan tiene algún requerimiento especial para la cobertura de su medicamento.

• PA – Autorización previa

• QL – El medicamento tiene un límite de cantidad

• ST – Requiere terapia escalonada

• NM – No está disponible en farmacias de pedido por correo

• LA – Acceso limitado Este medicamento de venta con receta puede estar disponible solamente enciertas farmacias. Para obtener más información consulte su directorio de farmacias o llame alServicio de Atención al Cliente al 1-877-293-4998 las 24 horas del día, los 7 días de la semana. Losusuarios de TTY deben llamar al 711.

• B/D – Este medicamento puede estar cubierto por las partes B o D de Medicare, dependiendo delas circunstancias. Podría ser necesario enviar información que describa el uso y el entorno delmedicamento para hacer una determinación.

• * No está disponible con suministro para días adicionales.


Johns Hopkins Advantage MD (PPO)

Nivel de costo compartido

Costo compartido estándar en farmacias minoristas (en la red)

Costo compartido estándar de pedido por correo (en la red)

Nivel 1 de costo compartido (genérico preferido)

Copago de $7 por 30 días de suministro

Copago de $10.50 por 60 días de suministro Copago de $14 por 90 días de suministro



Nivel 2 de costo compartido (genérico)

Copago de $15 por 30 días de suministro Copago de $22.50 por 60 días de suministro Copago de $30 por 90 días de suministro


Nivel 3 de costo compartido (marcas preferidas)


Copago de $94 por 60 días de suministro Copago de $141 por 90 días de suministro



Nivel 4 de costo compartido (medicamento no preferido)

Copago de $100 por 30 días de suministro Copago de $200 por 60 días de suministro Copago de $300 por 90 días de suministro


Nivel 5 de costo compartido (nivel de especialidad)

Coaseguro de 26% por 30 días de suministro (solamente)

RECUERDE: -Hay un deducible para medicamentos recetados en los medicamentos de los niveles 3, 4 y 5. No haydeducible para los medicamentos en los niveles 1 y 2.-Los medicamentos se proveen en un centro de cuidados a largo plazo para un suministro de hasta 31 días.

-Los medicamentos del nivel 5 solo están disponibles por 30 días de suministro.-Se puede solicitar por correo para pedir de forma conveniente un suministro de hasta 90 días de unmedicamento de nivel 1 al 4 por dos veces el copago de 30 días, lo que le ahorra dinero y tiempo. Puedecomunicarse con nosotros llamando por teléfono al número que se encuentra en la portada y contraportada.-Puede encontrar la información completa sobre costos compartidos en la Evidencia de cobertura.


Johns Hopkins Advantage MD Plus (PPO)


















RECUERDE: - Hay un deducible para medicamentos recetados en los medicamentos de los niveles 3, 4 y 5. No hay deducible para los medicamentos en los niveles 1 y 2. -Los medicamentos se proveen en un centro de cuidados a largo plazo para un suministro de hasta 31 días. -Los medicamentos del nivel 5 solo están disponibles por 30 días de suministro. -Se puede solicitar por correo para pedir de forma conveniente un suministro de hasta 90 días de un medicamento de nivel 1 al 4 por dos veces el copago de 30 días, lo que le ahorra dinero y tiempo. Puede comunicarse con nosotros llamando por teléfono al número que se encuentra en la portada y contraportada. -Puede encontrar la información completa sobre costos compartidos en la Evidencia de cobertura.


Johns Hopkins Advantage MD Premier (PPO)


















RECUERDE: - Los medicamentos se proveen en un centro de cuidados a largo plazo para un suministro de hasta 31 días.- Los medicamentos del nivel 5 solo están disponibles por 30 días de suministro.- Se puede solicitar por correo para pedir de forma conveniente un suministro de hasta 90 días de unmedicamento de nivel 1 al 4 por dos veces el copago de 30 días, lo que le ahorra dinero y tiempo. Puedecomunicarse con nosotros llamando por teléfono al número que se encuentra en la portada y contraportada.- Puede encontrar la información completa sobre costos compartidos en la Evidencia de cobertura.

PA - Previa autorización QL - Límites de cantidad ST - Terapia escalonada NM - Sin encargos por correo B/D - Cubierto por Medicare Parte A o B LA - Medicamentos con acceso limitado * - Suministro de días no extendidos

11

Johns Hopkins Advantage MD (PPO)

NOMBRE DE MEDICAMENTO NIVEL REQUISITOS / LIMITES

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab (generic of ZYLOPRIM)

Tier 1

colchicine w/ probenecid Tier 2

COLCRYS QL (120 tabs / 30 days)

Tier 3 QL

MITIGARE QL (60 caps / 30 days)

Tier 3 QL

probenecid Tier 2

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib (generic of CELEBREX) CAPS 50mg

QL (240 caps / 30 days)

Tier 2 QL

celecoxib (generic of CELEBREX) CAPS 100mg


Tier 2 QL



Tier 2 QL



Tier 2 QL

diclofenac potassium QL (120 tabs / 30 days)

Tier 2 QL

diclofenac sodium TB24; TBEC

Tier 2

diflunisal TABS Tier 2

etodolac CAPS Tier 2

etodolac (generic of LODINE) TABS 400mg

Tier 2

etodolac TABS 500mg Tier 2

etodolac er Tier 2

flurbiprofen TABS Tier 2

ibu tab 600mg Tier 1

ibu tab 800mg Tier 1

ibuprofen SUSP Tier 2

ibuprofen TABS 400mg, 600mg, 800mg

Tier 1


meloxicam (generic of MOBIC) TABS

Tier 1

nabumetone TABS Tier 1

naproxen (generic of NAPROSYN) TABS 250mg

Tier 1

naproxen TABS 375mg, 500mg

Tier 1

naproxen dr (generic of EC-NAPROSYN) 375mg

Tier 2

naproxen dr (generic of EC-NAPROXEN) 500mg

Tier 2

naproxen sodium TABS 275mg

Tier 2

naproxen sodium (generic of ANAPROX DS) TABS 550mg

Tier 2

piroxicam (generic of FELDENE) CAPS

Tier 2

sulindac TABS Tier 2

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

Tier 2 QL

acetaminophen w/ codeine 300-30mg (generic of TYLENOL/CODEINE #3)


Tier 2 QL

acetaminophen w/ codeine 300-60mg


Tier 2 QL

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

Tier 2 QL

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

Tier 4

nalbuphine hcl SOLN Tier 4

tramadol hcl tab 50 mg (generic of ULTRAM)


Tier 2 QL


12


tramadol-acetaminophen (generic of ULTRACET)


Tier 2 QL

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet 2.5-325mg (generic of PERCOCET)


Tier 2 QL

endocet 5-325mg (generic of PERCOCET)


Tier 2 QL

endocet 7.5-325mg (generic of PERCOCET)


Tier 2 QL

endocet 10-325mg (generic of PERCOCET)


Tier 2 QL

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

Tier 5 * QL PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)

QL (10 patches / 30 days)

Tier 2 QL PA



Tier 2 QL PA



Tier 2 QL PA



Tier 2 QL PA



Tier 2 QL PA

hydroco/apap tab 5-325mg (generic of NORCO)


Tier 2 QL


hydroco/apap tab 7.5-325 (generic of NORCO)


Tier 2 QL

hydroco/apap tab 10-325mg (generic of NORCO)


Tier 2 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

Tier 2 QL

hydrocodone-ibuprofen tab 7.5-200 mg


Tier 2 QL

hydromorphone hcl (generic of DILAUDID) LIQD

QL (600 mL / 30 days)

Tier 2 QL

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

Tier 4 B/D

hydromorphone hcl (generic of DILAUDID) TABS


Tier 2 QL

HYSINGLA ER QL (30 tabs / 30 days)

Tier 3 QL PA

lorcet hd tab 10-325mg (generic of NORCO)


Tier 2 QL

lorcet plus tab 7.5-325 (generic of NORCO)


Tier 2 QL

lorcet tab 5-325mg (generic of NORCO)


Tier 2 QL

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

Tier 2 QL PA

methadone hcl 5mg (generic of DOLOPHINE)


Tier 2 QL PA

methadone hcl 10mg (generic of DOLOPHINE)


Tier 2 QL PA


13


methadone hcl intensol (generic of METHADOSE)

QL (90 mL / 30 days)

Tier 2 QL PA

morphine ext-rel tab (generic of MS CONTIN)


Tier 2 QL PA

morphine sul inj 1mg/ml Tier 4 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

Tier 4 B/D

morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml, 10mg/ml

Tier 4 B/D

morphine sulfate TABS QL (180 tabs / 30 days)

Tier 2 QL

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

Tier 2 QL


QL (900 mL / 30 days)

Tier 2 QL


QL (180 mL / 30 days)

Tier 2 QL

NUCYNTA ER QL (60 tabs / 30 days)

Tier 3 QL PA

oxycodone hcl CAPS QL (180 caps / 30 days)

Tier 2 QL

oxycodone hcl CONC QL (180 mL / 30 days)

Tier 2 QL

oxycodone hcl SOLN QL (900 mL / 30 days)

Tier 2 QL

oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg


Tier 2 QL

oxycodone hcl TABS 10mg, 20mg


Tier 2 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


Tier 2 QL


oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


Tier 2 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)


Tier 2 QL

oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)


Tier 2 QL

ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%

Tier 2 B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) .5%, 1%

Tier 2 B/D

lidocaine inj 0.5% (generic of XYLOCAINE)

Tier 2 B/D

lidocaine inj 1% (generic of XYLOCAINE)

Tier 2 B/D

lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF)

Tier 2 B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN Tier 2

gentamicin in saline Tier 2

gentamicin sulfate SOLN Tier 2

neomycin sulfate TABS Tier 2

paromomycin sulfate CAPS

Tier 2

streptomycin sulfate SOLR Tier 5 *

SULFADIAZINE TABS Tier 4

tobramycin (generic of KITABIS PAK) NEBU

Tier 5 * NM PA

tobramycin inj 1.2 gm/30ml Tier 2

tobramycin inj 1.2gm Tier 5 *

tobramycin inj 10mg/ml Tier 2

tobramycin inj 80mg/2ml Tier 2


14


tobramycin sulfate SOLN Tier 2

ANTI-INFECTIVES - MISCELLANEOUS albendazole (generic of ALBENZA) TABS

Tier 5 *

ALINIA Tier 5 *

atovaquone (generic of MEPRON) SUSP

Tier 5 *

aztreonam (generic of AZACTAM)

Tier 2

CAYSTON Tier 5 * NM LA PA

clindamycin cap 75mg (generic of CLEOCIN)

Tier 1

clindamycin cap 300mg (generic of CLEOCIN)

Tier 1

clindamycin hcl cap 150 mg (generic of CLEOCIN)

Tier 1

clindamycin phosphate in d5w

Tier 2

CLINDAMYCIN PHOSPHATE IN NACL

Tier 4

clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)

Tier 2

clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)

Tier 2

colistimethate sodium (generic of COLY-MYCIN M) SOLR

Tier 2

dapsone TABS Tier 2

daptomycin (generic of DAPTOMYCIN) 350mg

Tier 5 *

daptomycin (generic of CUBICIN) 500mg

Tier 5 *

EMVERM QL (12 tabs / 365 days)

Tier 5 * QL

ertapenem sodium (generic of INVANZ)

Tier 2

imipenem-cilastatin Tier 2

imipenem-cilastatin (generic of PRIMAXIN IV)

Tier 2

ivermectin (generic of STROMECTOL) TABS

Tier 2

linezolid in sodium chloride Tier 4

linezolid inj (generic of ZYVOX)

Tier 2

linezolid susp (generic of ZYVOX)

Tier 5 *


linezolid tab 600mg (generic of ZYVOX)

Tier 2

meropenem (generic of MERREM)

Tier 2

methenamine hippurate (generic of HIPREX)

Tier 2

metronidazole (generic of FLAGYL) TABS

Tier 1

metronidazole in nacl Tier 2

NEBUPENT Tier 4 B/D

nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg

Tier 3

nitrofurantoin monohyd macro (generic of MACROBID)

Tier 3

PENTAM 300 Tier 4

pentamidine isethionate inh (generic of NEBUPENT)

Tier 2 B/D

pentamidine isethionate inj (generic of PENTAM 300)

Tier 2

praziquantel (generic of BILTRICIDE) TABS

Tier 2

SIVEXTRO Tier 5 *

sulfamethoxazole-trimethop ds (generic of BACTRIM DS)

Tier 1

sulfamethoxazole-trimethoprim inj

Tier 2

sulfamethoxazole-trimethoprim susp

Tier 2

sulfamethoxazole-trimethoprim tab 400-80mg (generic of BACTRIM)

Tier 1

SYNERCID Tier 5 *

tigecycline (generic of TYGACIL)

Tier 5 *

trimethoprim TABS Tier 1

vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg


Tier 2 QL

vancomycin hcl (generic of VANCOCIN) CAPS 250mg


Tier 5 * QL


15


vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

Tier 2

VANCOMYCIN IN NACL Tier 4

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET Tier 5 * B/D

AMBISOME Tier 5 * B/D

amphotericin b SOLR Tier 2 B/D

caspofungin acetate (generic of CANCIDAS)

Tier 5 *

fluconazole (generic of DIFLUCAN) SUSR

Tier 2

fluconazole (generic of DIFLUCAN) TABS 50mg, 100mg, 200mg

Tier 2

fluconazole (generic of DIFLUCAN) TABS 150mg

Tier 1

fluconazole inj nacl 200 Tier 2

fluconazole inj nacl 400 Tier 2

flucytosine (generic of ANCOBON) CAPS

Tier 5 *

griseofulvin microsize Tier 2

griseofulvin ultramicrosize Tier 2

itraconazole (generic of SPORANOX) CAPS

Tier 2 PA

ketoconazole TABS Tier 2 PA

MYCAMINE Tier 5 *

NOXAFIL SUSP QL (630 mL / 30 days)

Tier 5 * QL

NOXAFIL TBEC QL (93 tabs / 30 days)

Tier 5 * QL

nystatin TABS Tier 2

posaconazole (generic of NOXAFIL)


Tier 5 * QL

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

Tier 1 QL

voriconazole (generic of VFEND IV) SOLR

Tier 5 * PA

voriconazole (generic of VFEND) SUSR

Tier 5 * PA

voriconazole (generic of VFEND) TABS 50mg

Tier 2

voriconazole (generic of VFEND) TABS 200mg

Tier 5 *


ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl (generic of MALARONE)

Tier 2

chloroquine phosphate TABS

Tier 2

COARTEM Tier 4

mefloquine hcl Tier 2

PRIMAQUINE PHOSPHATE 26.3mg

Tier 3

primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg

Tier 2

quinine sulfate (generic of QUALAQUIN) CAPS

Tier 2 PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate (generic of ZIAGEN)

Tier 2 NM

APTIVUS Tier 5 * NM

atazanavir sulfate (generic of REYATAZ)

Tier 2 NM

CRIXIVAN Tier 4 NM

didanosine 200mg, 400mg Tier 2 NM

didanosine (generic of VIDEX EC) 250mg

Tier 2 NM

EDURANT Tier 5 * NM

efavirenz (generic of SUSTIVA) CAPS 50mg

Tier 2 NM

efavirenz (generic of SUSTIVA) CAPS 200mg

Tier 5 * NM

efavirenz (generic of SUSTIVA) TABS

Tier 5 * NM

EMTRIVA Tier 3 NM

fosamprenavir tab 700 mg (generic of LEXIVA)

Tier 5 * NM

FUZEON Tier 5 * NM

INTELENCE 25mg Tier 4 NM

INTELENCE 100mg, 200mg

Tier 5 * NM

INVIRASE Tier 5 * NM

ISENTRESS CHEW 25mg Tier 3 NM

ISENTRESS CHEW 100mg

Tier 5 * NM

ISENTRESS PACK Tier 3 NM

ISENTRESS TABS Tier 5 * NM

ISENTRESS HD Tier 5 * NM


16


lamivudine (generic of EPIVIR)

Tier 2 NM

LEXIVA SUSP Tier 4 NM

nevirapine susp 50 mg/5ml (generic of VIRAMUNE)

Tier 2 NM

nevirapine tab 100mg er Tier 2 NM

nevirapine tab 200mg (generic of VIRAMUNE)

Tier 2 NM

nevirapine tab 400mg er (generic of VIRAMUNE XR)

Tier 2 NM

NORVIR PACK Tier 4 NM

NORVIR SOLN Tier 4 NM

PIFELTRO Tier 5 * NM

PREZISTA SUSP QL (400 mL / 30 days)

Tier 5 * QL NM

PREZISTA TABS 75mg QL (480 tabs / 30 days)

Tier 4 QL NM


Tier 5 * QL NM


Tier 5 * QL NM


Tier 5 * QL NM

RESCRIPTOR Tier 4 NM

REYATAZ PACK Tier 5 * NM

ritonavir (generic of NORVIR)

Tier 2 NM

SELZENTRY SOLN Tier 5 * NM

SELZENTRY TABS 25mg Tier 4 NM

SELZENTRY TABS 75mg, 150mg, 300mg

Tier 5 * NM

stavudine 15mg, 20mg Tier 2 NM

stavudine (generic of ZERIT) 30mg, 40mg

Tier 2 NM

tenofovir disoproxil fumarate (generic of VIREAD)

Tier 2 NM

TIVICAY 10mg Tier 3 NM

TIVICAY 25mg, 50mg Tier 5 * NM

TROGARZO Tier 5 * NM LA

TYBOST Tier 4 NM

VIDEX EC 125mg Tier 4 NM

VIDEX PEDIATRIC Tier 4 NM

VIRACEPT Tier 5 * NM

VIREAD POWD Tier 5 * NM

VIREAD TABS 150mg, 200mg, 250mg

Tier 5 * NM


zidovudine cap 100mg (generic of RETROVIR)

Tier 2 NM

zidovudine syp 50mg/5ml (generic of RETROVIR)

Tier 2 NM

zidovudine tab 300mg Tier 2 NM

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine (generic of EPZICOM)

Tier 2 NM

abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

Tier 5 * NM

ATRIPLA Tier 5 * NM

BIKTARVY Tier 5 * NM

CIMDUO Tier 5 * NM

COMPLERA Tier 5 * NM

DELSTRIGO Tier 5 * NM

DESCOVY Tier 5 * NM

DOVATO Tier 5 * NM

EVOTAZ Tier 5 * NM

GENVOYA Tier 5 * NM

JULUCA Tier 5 * NM

KALETRA TAB 100-25MG Tier 4 NM

KALETRA TAB 200-50MG Tier 5 * NM

lamivudine-zidovudine (generic of COMBIVIR)

Tier 2 NM

lopinavir-ritonavir (generic of KALETRA)

Tier 2 NM

ODEFSEY Tier 5 * NM

PREZCOBIX Tier 5 * NM

STRIBILD Tier 5 * NM

SYMFI Tier 5 * NM

SYMFI LO Tier 5 * NM

SYMTUZA Tier 5 * NM

TEMIXYS Tier 5 * NM

TRIUMEQ Tier 5 * NM

TRUVADA TAB 100-150 QL (30 tabs / 30 days)

Tier 5 * QL NM


Tier 5 * QL NM


Tier 5 * QL NM


Tier 5 * QL NM

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS Tier 5 *


17


ethambutol hcl TABS 100mg

Tier 2

ethambutol hcl (generic of MYAMBUTOL) TABS 400mg

Tier 2

isoniazid TABS Tier 1

isoniazid syp 50mg/5ml Tier 2

PASER D/R Tier 4

PRIFTIN Tier 4

pyrazinamide TABS Tier 2

rifabutin (generic of MYCOBUTIN)

Tier 2

rifampin (generic of RIFADIN) CAPS; SOLR

Tier 2

RIFATER Tier 4

SIRTURO Tier 5 * LA PA

TRECATOR Tier 4

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS Tier 1

acyclovir (generic of ZOVIRAX) SUSP

Tier 2

acyclovir (generic of ZOVIRAX) TABS

Tier 1

acyclovir sodium Tier 2 B/D

adefovir dipivoxil (generic of HEPSERA)

Tier 5 * NM

BARACLUDE SOLN Tier 5 * NM

entecavir (generic of BARACLUDE)

Tier 2 NM

EPCLUSA Tier 5 * NM PA

EPIVIR HBV SOLN Tier 4 NM

famciclovir Tier 2

ganciclovir sodium (generic of CYTOVENE)

Tier 2 B/D

HARVONI Tier 5 * NM PA

lamivudine (hbv) (generic of EPIVIR HBV)

Tier 2 NM

MAVYRET Tier 5 * NM PA

oseltamivir phosphate (generic of TAMIFLU) CAPS 30mg

QL (168 caps / year)

Tier 2 QL

oseltamivir phosphate (generic of TAMIFLU) CAPS 45mg, 75mg

QL (84 caps / year)

Tier 2 QL


oseltamivir phosphate (generic of TAMIFLU) SUSR

QL (1080 mL / year)

Tier 2 QL

PEGASYS Tier 5 * NM PA

PEGASYS PROCLICK Tier 5 * NM PA

RELENZA DISKHALER QL (6 inhalers / year)

Tier 3 QL

ribavirin 200mg Tier 2 NM

rimantadine hydrochloride Tier 2

valacyclovir hcl (generic of VALTREX) TABS

Tier 2

valganciclovir hcl (generic of VALCYTE)

Tier 5 *

VEMLIDY Tier 5 * NM

VOSEVI Tier 5 * NM PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor Tier 2

CEFACLOR MONOHYDRATE ER

Tier 4

cefadroxil CAPS Tier 1

cefadroxil SUSR; TABS Tier 2

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

Tier 3

cefazolin inj Tier 2

cefazolin sodium SOLR 1gm

Tier 2

CEFAZOLIN SODIUM 1 GM/50ML

Tier 3

cefdinir Tier 2

cefepime hcl Tier 2

cefixime (generic of SUPRAX) SUSR

Tier 2

cefoxitin sodium Tier 2

cefpodoxime proxetil Tier 2

cefprozil Tier 2

ceftazidime SOLR Tier 2

CEFTAZIDIME/DEXTROSE Tier 4

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

Tier 2

cefuroxime axetil Tier 2

cefuroxime sodium Tier 2

cephalexin (generic of KEFLEX) CAPS 250mg, 500mg

Tier 1


18


cephalexin SUSR Tier 2

tazicef SOLR Tier 2

TEFLARO Tier 5 *

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK Tier 2

azithromycin (generic of ZITHROMAX) SOLR; SUSR

Tier 2

azithromycin (generic of ZITHROMAX) TABS

Tier 1

clarithromycin TABS Tier 2

clarithromycin er (generic of BIAXIN XL)

Tier 2

clarithromycin for susp Tier 2

DIFICID Tier 5 *

e.e.s 400 Tier 2

ery-tab Tier 2

ERYTHROCIN LACTOBIONATE

Tier 4

erythrocin stearate Tier 2

erythromycin base Tier 2

erythromycin cap 250mg ec Tier 2

erythromycin ethylsuccinate TABS

Tier 2

erythromycin tab ec Tier 2

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin hcl tab 100mg

Tier 2

ciprofloxacin hcl tab (generic of CIPRO) 250mg, 500mg

Tier 1

ciprofloxacin hcl tab 750mg

Tier 1

ciprofloxacin in d5w Tier 2

levofloxacin (generic of LEVAQUIN) TABS

Tier 1

levofloxacin in d5w Tier 2

levofloxacin inj 25mg/ml Tier 2

levofloxacin oral soln 25 mg/ml

Tier 2

PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin CAPS; SUSR; TABS

Tier 1

amoxicillin CHEW Tier 2


amoxicillin & pot clavulanate 200-28.5 chw tabs

Tier 2

amoxicillin & pot clavulanate 200/5ml susr

Tier 2

amoxicillin & pot clavulanate 250-125 tabs

Tier 2

amoxicillin & pot clavulanate 250/5ml susr (generic of AUGMENTIN)

Tier 2

amoxicillin & pot clavulanate 400-57 chw tabs

Tier 2


Tier 2

amoxicillin & pot clavulanate 500-125 tabs (generic of AUGMENTIN)

Tier 2


Tier 2

amoxicillin & pot clavulanate 875-125 tabs

Tier 2

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

Tier 2

ampicillin & sulbactam sodium (generic of UNASYN)

Tier 2

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

Tier 2

ampicillin cap 500mg Tier 1

ampicillin inj Tier 2

ampicillin sodium Tier 2

BICILLIN L-A Tier 4

dicloxacillin sodium Tier 2

nafcillin sodium 1gm, 2gm Tier 2

nafcillin sodium 10gm Tier 5 *

NAFCILLIN SODIUM FOR INJ 10GM

Tier 4

oxacillin sodium SOLR 1gm, 2gm

Tier 2

oxacillin sodium SOLR 10gm

Tier 5 *

PENICILLIN G POT IN DEXTROSE 2MU

Tier 4

PENICILLIN G POT IN DEXTROSE 3MU

Tier 4

PENICILLIN G PROCAINE Tier 4

penicillin g sodium Tier 2


19


penicillin v potassium SOLR

Tier 2

penicillin v potassium TABS

Tier 1

penicilln gk inj 5mu Tier 2

penicilln gk inj 20mu Tier 2

pfizerpen-g inj 5mu Tier 2

pfizerpen-g inj 20mu Tier 2

piper/tazoba inj 2-0.25gm (generic of ZOSYN)

Tier 2


Tier 2


Tier 2

piper/tazoba inj 12-1.5gm Tier 2


Tier 2

TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 Tier 2

doxycycline (monohydrate) CAPS 50mg, 100mg

Tier 1

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

Tier 2

doxycycline hyclate CAPS 50mg

Tier 2

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

Tier 2

doxycycline hyclate SOLR Tier 2

doxycycline hyclate TABS 20mg, 100mg

Tier 2

minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg

Tier 2

minocycline hcl CAPS 75mg

Tier 2

mondoxyne nl cap 100mg Tier 1

tetracycline hcl CAPS Tier 2

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA Tier 5 * B/D NM

cyclophosphamide CAPS Tier 2 B/D

cyclophosphamide SOLR Tier 5 * B/D

EMCYT Tier 4

GLEOSTINE 10mg Tier 4


GLEOSTINE 40mg, 100mg

Tier 5 *

LEUKERAN Tier 5 *

ANTHRACYCLINES adriamycin SOLN Tier 2 B/D

doxorubicin hcl Tier 2 B/D

doxorubicin hcl liposomal (generic of DOXIL)

Tier 5 * B/D

epirubicin hcl 50mg/25ml Tier 2 B/D

epirubicin hcl (generic of ELLENCE) 200mg/100ml

Tier 2 B/D

ANTIMETABOLITES adrucil inj Tier 2 B/D

ALIMTA Tier 5 * B/D

azacitidine (generic of VIDAZA)

Tier 5 * B/D NM

cytarabine 20mg/ml Tier 2 B/D

fluorouracil SOLN Tier 2 B/D

gemcitabine inj soln (generic of GEMCITABINE)

Tier 2 B/D

gemcitabine inj solr Tier 2 B/D

mercaptopurine TABS Tier 2

methotrexate sodium inj soln

Tier 2 B/D

methotrexate sodium inj solr Tier 2 B/D

PURIXAN Tier 5 * NM

TABLOID Tier 5 *

ANTIMITOTIC, TAXOIDS ABRAXANE Tier 5 * B/D

docetaxel (generic of TAXOTERE) CONC 20mg/ml, 80mg/4ml

Tier 5 * B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

Tier 5 * B/D

docetaxel (generic of DOCETAXEL) CONC 160mg/8ml

Tier 5 * B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

Tier 5 * B/D

docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

Tier 5 * B/D

paclitaxel Tier 2 B/D

TAXOTERE 80mg/4ml Tier 5 * B/D


20


ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate Tier 2 B/D

vinorelbine tartrate (generic of NAVELBINE)

Tier 2 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN Tier 5 * NM LA PA

BORTEZOMIB Tier 5 * NM PA

DAURISMO Tier 5 * NM LA PA

ERIVEDGE Tier 5 * NM LA PA

FARYDAK Tier 5 * NM LA PA

HERCEPTIN Tier 5 * NM PA

HERCEPTIN HYLECTA Tier 5 * NM PA

IBRANCE CAPS QL (21 caps / 28 days)

Tier 5 * QL NM LA PA

IDHIFA QL (30 tabs / 30 days)


KADCYLA Tier 5 * B/D NM

KANJINTI Tier 5 * NM PA

KEYTRUDA Tier 5 * NM PA

KISQALI Tier 5 * NM PA

KISQALI FEMARA 200 DOSE

Tier 5 * NM PA


Tier 5 * NM PA


Tier 5 * NM PA

LYNPARZA Tier 5 * NM LA PA

MVASI Tier 5 * NM LA PA

NINLARO Tier 5 * NM PA

ODOMZO Tier 5 * NM LA PA

OGIVRI Tier 5 * NM PA

RITUXAN Tier 5 * NM LA PA

RITUXAN HYCELA Tier 5 * NM LA PA

RUBRACA Tier 5 * NM LA PA

RUXIENCE Tier 5 * NM PA

TALZENNA Tier 5 * NM LA PA

TECENTRIQ Tier 5 * NM LA PA

TIBSOVO Tier 5 * NM LA PA

VELCADE Tier 5 * NM PA

VENCLEXTA 10mg Tier 4 NM LA PA

VENCLEXTA 50mg, 100mg

Tier 5 * NM LA PA

VENCLEXTA STARTING PACK

Tier 5 * NM LA PA

VERZENIO Tier 5 * NM LA PA

ZEJULA Tier 5 * NM LA PA

ZIRABEV Tier 5 * NM PA

ZOLINZA Tier 5 * NM PA


HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)

Tier 5 * NM PA

anastrozole (generic of ARIMIDEX) TABS

Tier 1

bicalutamide (generic of CASODEX)

Tier 2

DEPO-PROVERA INJ 400/ML

Tier 4 B/D

ERLEADA Tier 5 * NM LA PA

exemestane (generic of AROMASIN)

Tier 2

flutamide Tier 2

fulvestrant (generic of FASLODEX)

Tier 5 * B/D

letrozole (generic of FEMARA) TABS

Tier 1

leuprolide inj 1mg/0.2 Tier 2 NM PA

LUPRON DEPOT (1-MONTH) 3.75mg

Tier 5 * NM PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

Tier 5 * NM PA

LYSODREN Tier 3

megestrol ac sus 40mg/ml Tier 3

megestrol ac tab 20mg Tier 3

megestrol ac tab 40mg Tier 3

megestrol sus 625mg/5ml (generic of MEGACE ES)

Tier 4 PA

nilutamide (generic of NILANDRON)

Tier 5 *

NUBEQA Tier 5 * NM LA PA

SOLTAMOX Tier 5 *

tamoxifen citrate TABS Tier 1

toremifene citrate (generic of FARESTON)

Tier 5 *

TRELSTAR DEP INJ 3.75MG

Tier 5 * NM PA

TRELSTAR LA INJ 11.25MG

Tier 5 * NM PA

XTANDI Tier 5 * NM LA PA

ZYTIGA 500mg Tier 5 * NM LA PA

IMMUNOMODULATORS POMALYST CAP 1MG

QL (21 caps / 21 days) Tier 5 * QL NM LA

PA

POMALYST CAP 2MG QL (21 caps / 21 days)





21




REVLIMID QL (28 caps / 28 days)


THALOMID 50mg, 100mg QL (28 caps / 28 days)

Tier 5 * QL NM PA

THALOMID 150mg, 200mg


Tier 5 * QL NM PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) Tier 5 * QL NM PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

Tier 5 * QL NM PA


Tier 5 * QL NM PA


Tier 5 * QL NM PA

ALECENSA Tier 5 * NM LA PA

ALUNBRIG Tier 5 * NM LA PA

AYVAKIT QL (30 tabs / 30 days)


BALVERSA Tier 5 * NM LA PA

BOSULIF Tier 5 * NM PA

BRAFTOVI Tier 5 * NM LA PA

BRUKINSA Tier 5 * NM LA PA

CABOMETYX QL (30 tabs / 30 days)


CALQUENCE Tier 5 * NM LA PA

CAPRELSA Tier 5 * NM LA PA

COMETRIQ Tier 5 * NM LA PA

COPIKTRA Tier 5 * NM LA PA

COTELLIC Tier 5 * NM LA PA

erlotinib hcl (generic of TARCEVA) 25mg


Tier 5 * QL NM PA

erlotinib hcl (generic of TARCEVA) 100mg, 150mg


Tier 5 * QL NM PA

everolimus (generic of AFINITOR) 2.5mg, 5mg, 7.5mg


Tier 5 * QL NM PA

GILOTRIF TAB 20MG Tier 5 * NM LA PA



ICLUSIG Tier 5 * NM LA PA


imatinib mesylate (generic of GLEEVEC) 100mg


Tier 5 * QL NM PA

imatinib mesylate (generic of GLEEVEC) 400mg


Tier 5 * QL NM PA

IMBRUVICA Tier 5 * NM LA PA

INLYTA 1mg QL (180 tabs / 30 days)


INLYTA 5mg QL (120 tabs / 30 days)


INREBIC Tier 5 * NM LA PA

IRESSA Tier 5 * NM LA PA

JAKAFI QL (60 tabs / 30 days)


LENVIMA 4 MG DAILY DOSE

Tier 5 * NM LA PA


Tier 5 * NM LA PA


Tier 5 * NM LA PA

LENVIMA 12MG DAILY DOSE

Tier 5 * NM LA PA


Tier 5 * NM LA PA


Tier 5 * NM LA PA


Tier 5 * NM LA PA


Tier 5 * NM LA PA

LORBRENA Tier 5 * NM LA PA

MEKINIST Tier 5 * NM LA PA

MEKTOVI Tier 5 * NM LA PA

NERLYNX Tier 5 * NM LA PA

NEXAVAR Tier 5 * NM LA PA

PIQRAY 200MG DAILY DOSE

Tier 5 * NM PA


Tier 5 * NM PA


Tier 5 * NM PA

ROZLYTREK Tier 5 * NM LA PA

RYDAPT Tier 5 * NM PA

SPRYCEL Tier 5 * NM PA

STIVARGA Tier 5 * NM LA PA


22


SUTENT QL (30 caps / 30 days)

Tier 5 * QL NM PA

TAFINLAR Tier 5 * NM LA PA

TAGRISSO QL (30 tabs / 30 days)


TASIGNA Tier 5 * NM PA

TURALIO Tier 5 * NM LA PA

TYKERB Tier 5 * NM LA PA

VITRAKVI Tier 5 * NM LA PA

VIZIMPRO Tier 5 * NM LA PA

VOTRIENT Tier 5 * NM LA PA

XALKORI Tier 5 * NM LA PA

XOSPATA Tier 5 * NM LA PA

ZELBORAF Tier 5 * NM LA PA

ZYDELIG Tier 5 * NM LA PA

ZYKADIA Tier 5 * NM LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

Tier 5 * NM PA

hydroxyurea (generic of HYDREA) CAPS

Tier 2

LONSURF Tier 5 * NM PA

MATULANE Tier 5 * LA

SYLATRON 200mcg, 300mcg

Tier 5 * NM PA

SYNRIBO Tier 5 * NM PA

tretinoin (chemotherapy) Tier 5 *

XPOVIO 60 MG ONCE WEEKLY

Tier 5 * NM LA PA


Tier 5 * NM LA PA

XPOVIO 80 MG TWICE WEEKLY

Tier 5 * NM LA PA


Tier 5 * NM LA PA

PLATINUM-BASED AGENTS carboplatin Tier 2 B/D

cisplatin SOLN Tier 2 B/D

oxaliplatin inj 50mg Tier 5 * B/D

oxaliplatin inj 50mg/10ml Tier 2 B/D

oxaliplatin inj 100mg Tier 5 * B/D

oxaliplatin inj 100mg/20ml Tier 2 B/D

PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml

Tier 2 B/D

leucovorin calcium SOLR Tier 2 B/D

leucovorin calcium TABS Tier 2

MESNEX TABS Tier 5 *


TOPOISOMERASE INHIBITORS etoposide SOLN Tier 2 B/D

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml

Tier 2 B/D

irinotecan hcl 500mg/25ml Tier 2 B/D

toposar Tier 2 B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl cap 10-20 mg (generic of LOTREL)

Tier 1

amlodipine-benazepril hcl cap 2.5-10 mg

Tier 1

amlodipine-benazepril hcl cap 5-10 mg (generic of LOTREL)

Tier 1

amlodipine-benazepril hcl cap 5-20 mg (generic of LOTREL)

Tier 1

amlodipine-benazepril hcl cap 5-40 mg

Tier 1

amlodipine-benazepril hcl cap 10-40mg (generic of LOTREL)

Tier 1

benazepril & hydrochlorothiazide

Tier 1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

Tier 1

captopril & hydrochlorothiazide

Tier 1

enalapril maleate & hydrochlorothiazide

Tier 1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

Tier 1

fosinopril sodium & hydrochlorothiazide

Tier 1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

Tier 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

Tier 1


23


ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 5mg Tier 1

benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

Tier 1

captopril TABS Tier 1

enalapril maleate (generic of VASOTEC) TABS

Tier 1

fosinopril sodium Tier 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

Tier 1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

Tier 1

moexipril hcl Tier 1

perindopril erbumine Tier 1

quinapril hcl (generic of ACCUPRIL)

Tier 1

ramipril (generic of ALTACE)

Tier 1

trandolapril 1mg, 2mg Tier 1

trandolapril (generic of MAVIK) 4mg

Tier 1

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone (generic of INSPRA)

Tier 2

spironolactone (generic of ALDACTONE) TABS

Tier 1

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate (generic of CARDURA) TABS

Tier 1

prazosin hcl (generic of MINIPRESS)

Tier 2

terazosin hcl 1mg, 2mg, 5mg

Tier 1

terazosin hcl 10mg Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil (generic of AZOR)

Tier 1


amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)

Tier 1


Tier 1


Tier 1


Tier 1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)

Tier 1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)

Tier 1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)

Tier 1


Tier 1


Tier 1

ENTRESTO Tier 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

Tier 1

losartan-hydrochlorothiazide (generic of HYZAAR)

Tier 1

olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)

Tier 1

olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)

Tier 1

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

Tier 1


24


ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE irbesartan (generic of AVAPRO)

Tier 1

losartan potassium (generic of COZAAR)

Tier 1

olmesartan medoxomil (generic of BENICAR) TABS

Tier 1

telmisartan (generic of MICARDIS)

Tier 1

valsartan (generic of DIOVAN)

Tier 1

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln Tier 2

amiodarone tab 100mg Tier 2



disopyramide phosphate (generic of NORPACE)

Tier 4

dofetilide (generic of TIKOSYN)

Tier 2 NM

flecainide acetate Tier 2

MULTAQ Tier 4

NORPACE CR Tier 4

pacerone 100mg, 400mg Tier 2

pacerone 200mg Tier 1

propafenone hcl Tier 2

propafenone hcl 12hr (generic of RYTHMOL SR)

Tier 2

quinidine sulfate Tier 2

sorine (generic of BETAPACE) 80mg, 120mg, 160mg

Tier 1

sorine 240mg Tier 1

sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg

Tier 1

sotalol hcl 240mg Tier 1

sotalol hcl (afib/afl) (generic of BETAPACE AF)

Tier 2


ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium (generic of LIPITOR) TABS

Tier 1

lovastatin Tier 1

pravastatin sodium 10mg, 80mg

Tier 1

pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg

Tier 1

rosuvastatin calcium (generic of CRESTOR)


Tier 1 QL

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

Tier 1

simvastatin (generic of ZOCOR) TABS 80mg


Tier 1 QL

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine (generic of QUESTRAN)

Tier 2

cholestyramine light pack Tier 2

cholestyramine light powd (generic of QUESTRAN LIGHT)

Tier 2

colesevelam hcl (generic of WELCHOL)

Tier 2

colestipol hcl gran (generic of COLESTID)

Tier 2

colestipol hcl pack (generic of COLESTID)

Tier 2

colestipol hcl tabs (generic of COLESTID)

Tier 2

ezetimibe (generic of ZETIA)

Tier 2

fenofibrate (generic of TRICOR) TABS 48mg, 145mg

Tier 2

fenofibrate TABS 54mg, 160mg

Tier 2

fenofibrate micronized 67mg, 134mg, 200mg

Tier 2

gemfibrozil (generic of LOPID) TABS

Tier 1

JUXTAPID Tier 5 * NM LA PA


25


niacin (antihyperlipidemic) Tier 2

niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg


Tier 2 QL

niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg

Tier 2

niacor Tier 2

PRALUENT Tier 3 NM PA

prevalite PACK Tier 2

prevalite (generic of QUESTRAN LIGHT) POWD

Tier 2

VASCEPA Tier 4

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone (generic of TENORETIC 50)

Tier 1

atenolol & chlorthalidone (generic of TENORETIC 100)

Tier 1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

Tier 1

metoprolol & hctz tab 50-25mg (generic of LOPRESSOR HCT)

Tier 2

metoprolol & hctz tab 100-25mg

Tier 2

metoprolol & hctz tab 100-50mg

Tier 2

propranolol & hydrochlorothiazide

Tier 2

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS Tier 1

atenolol (generic of TENORMIN) TABS

Tier 1

bisoprolol fumarate Tier 1

BYSTOLIC 2.5mg, 5mg, 10mg


Tier 4 QL


BYSTOLIC 20mg QL (60 tabs / 30 days)

Tier 4 QL

carvedilol (generic of COREG)

Tier 1

labetalol hcl TABS Tier 2

metoprolol succinate (generic of TOPROL XL)

Tier 1

metoprolol tartrate SOCT Tier 2

metoprolol tartrate SOLN Tier 2

metoprolol tartrate TABS 25mg

Tier 1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

Tier 1

nadolol (generic of CORGARD) TABS

Tier 2

pindolol Tier 2

propranolol cap er (generic of INDERAL LA)

Tier 2

propranolol hcl TABS Tier 2

propranolol oral sol Tier 2

timolol maleate TABS Tier 2

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate (generic of NORVASC) TABS

Tier 1

cartia xt cap 120/24hr (generic of CARDIZEM CD)

Tier 2


Tier 2


Tier 2


Tier 2

dilt-xr cap Tier 2

diltiazem cap 240mg cd (generic of CARDIZEM CD)

Tier 2

diltiazem cap 360mg cd (generic of CARDIZEM CD)

Tier 2

diltiazem cap er/12hr Tier 2

diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg

Tier 1

diltiazem hcl TABS 90mg Tier 1


26


diltiazem hcl coated beads (generic of CARDIZEM CD) CP24

Tier 2

diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD)

Tier 2

diltiazem hcl extended release beads cap sr (generic of TIAZAC) 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

Tier 2

diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg

Tier 2

diltiazem inj Tier 2

felodipine Tier 2

isradipine Tier 2

nicardipine hcl CAPS Tier 2

nifedipine (generic of PROCARDIA XL) TB24

Tier 2

nifedipine er (generic of ADALAT CC)

Tier 2

nimodipine CAPS Tier 5 *

NYMALIZE Tier 5 *

taztia xt (generic of TIAZAC) Tier 2

tiadylt er (generic of TIAZAC)

Tier 2

verapamil cap er (generic of VERELAN PM) 100mg, 200mg

Tier 2

verapamil cap er (generic of VERELAN) 120mg, 180mg, 240mg

Tier 2

verapamil cap er 300mg, 360mg

Tier 2

verapamil hcl SOLN Tier 2

verapamil hcl TABS Tier 1

verapamil hcl tab er (generic of CALAN SR) 120mg, 240mg

Tier 1

verapamil hcl tab er 180mg Tier 1

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek (generic of LANOXIN) .25mg

PA if 70 years and older

Tier 2 PA


digitek (generic of LANOXIN) .125mg


Tier 2 QL

digox (generic of LANOXIN) 125mcg


Tier 2 QL

digox (generic of LANOXIN) 250mcg


Tier 2 PA

digoxin (generic of LANOXIN) TABS 125mcg


Tier 2 QL

digoxin (generic of LANOXIN) TABS 250mcg


Tier 2 PA

digoxin inj (generic of LANOXIN)

Tier 2

digoxin sol 50mcg/ml PA if 70 years and older

Tier 2 PA

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS

Tier 2

amiloride & hydrochlorothiazide

Tier 1

amiloride hcl TABS Tier 1

bumetanide SOLN Tier 2

bumetanide (generic of BUMEX) TABS

Tier 2

chlorothiazide tabs Tier 2

chlorthalidone Tier 2

furosemide SOLN Tier 1

furosemide (generic of LASIX) TABS

Tier 1

furosemide inj Tier 2

hydrochlorothiazide CAPS; TABS

Tier 1

indapamide Tier 1

methazolamide TABS Tier 2

metolazone Tier 2

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

Tier 2

torsemide tabs Tier 1

triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)

Tier 1


27


triamterene & hydrochlorothiazide tabs (generic of MAXZIDE)

Tier 1

triamterene & hydrochlorothiazide tabs (generic of MAXZIDE-25)

Tier 1

MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)

Tier 2

clonidine hcl (generic of CATAPRES) TABS

Tier 1

clonidine hcl ptwk (generic of CATAPRES-TTS-1) .1mg/24hr

Tier 2


Tier 2


Tier 2

CORLANOR Tier 4

DEMSER Tier 5 * PA

hydralazine hcl SOLN; TABS

Tier 2

midodrine hcl Tier 2

minoxidil TABS Tier 1

NORTHERA 100mg QL (90 caps / 30 days)


NORTHERA 200mg, 300mg



ranolazine (generic of RANEXA)

Tier 2

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab Tier 1

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

Tier 2

isosorbide dinitrate 10mg, 20mg, 30mg

Tier 2

isosorbide mononitrate er Tier 1

minitran (generic of NITRO-DUR)

Tier 2

NITRO-BID Tier 3

NITRO-DUR DIS 0.3MG/HR Tier 4

NITRO-DUR DIS 0.8MG/HR Tier 4


nitroglycerin (generic of NITROSTAT) SUBL

Tier 2

nitroglycerin td patch .1mg/hr

Tier 2

nitroglycerin td patch (generic of NITRO-DUR) .2mg/hr, .4mg/hr, .6mg/hr

Tier 2

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS

QL (90 tabs / 30 days) Tier 5 * QL NM LA

PA

ambrisentan (generic of LETAIRIS)



bosentan (generic of TRACLEER) 62.5mg



bosentan (generic of TRACLEER) 125mg



OPSUMIT QL (30 tabs / 30 days)


sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO)


Tier 2 QL NM PA

treprostinil Tier 5 * NM LA PA

VENTAVIS Tier 5 * NM PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg (generic of XANAX)


Tier 2 QL

alprazolam tab 0.25mg (generic of XANAX)


Tier 2 QL

alprazolam tab 1mg (generic of XANAX)


Tier 2 QL


28


alprazolam tab 2mg (generic of XANAX)


Tier 2 QL

buspirone hcl TABS 5mg, 10mg, 15mg

Tier 1

buspirone hcl TABS 7.5mg, 30mg

Tier 2

fluvoxamine maleate TABS Tier 2

lorazepam (generic of ATIVAN) SOLN

Tier 2

lorazepam (generic of ATIVAN) TABS


Tier 2 QL

lorazepam intensol QL (150 mL / 30 days)

Tier 2 QL

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM

QL (60 tabs / 30 days) Tier 5 * QL

BANZEL SUS 40MG/ML Tier 5 * PA

BANZEL TAB 200MG Tier 5 * PA

BANZEL TAB 400MG Tier 5 * PA

BRIVIACT INJ 50MG/5ML Tier 4 PA

BRIVIACT SOL 10MG/ML Tier 5 * PA

BRIVIACT TAB 10MG Tier 5 * PA





carbamazepine CHEW Tier 2

carbamazepine (generic of CARBATROL) CP12

Tier 2

carbamazepine (generic of TEGRETOL) SUSP; TABS

Tier 2

carbamazepine (generic of TEGRETOL-XR) TB12

Tier 2

CELONTIN Tier 4

clobazam (generic of ONFI) Tier 2 PA

clonazepam (generic of KLONOPIN) TABS 2mg


Tier 2 QL

clonazepam (generic of KLONOPIN) TABS .5mg, 1mg


Tier 2 QL


clonazepam TBDP 2mg QL (300 tabs / 30 days)

Tier 2 QL

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


Tier 2 QL

clorazepate dipotassium QL (180 tabs / 30 days)


Tier 2 QL PA

DIASTAT ACUDIAL Tier 4

DIASTAT PEDIATRIC Tier 4

diazepam (generic of VALIUM) TABS



Tier 2 QL PA

diazepam gel Tier 2

diazepam inj Tier 2

diazepam intensol QL (240 mL / 30 days)


Tier 2 QL PA

diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)


Tier 2 QL PA

DILANTIN CAP 30MG Tier 3

DILANTIN CAP 100MG Tier 3

DILANTIN CHEW TAB 50MG

Tier 3

DILANTIN-125 SUSP Tier 4

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

Tier 2

divalproex sodium (generic of DEPAKOTE ER) TB24

Tier 2

divalproex sodium (generic of DEPAKOTE) TBEC

Tier 2

EPIDIOLEX QL (600 mL / 30 days)


epitol (generic of TEGRETOL)

Tier 2

ethosuximide (generic of ZARONTIN) CAPS; SOLN

Tier 2

felbamate (generic of FELBATOL) SUSP

Tier 5 *

felbamate (generic of FELBATOL) TABS

Tier 2


29


FYCOMPA SUSP QL (720 mL / 30 days)

Tier 5 * QL PA

FYCOMPA TABS 2mg QL (60 tabs / 30 days)

Tier 4 QL PA

FYCOMPA TABS 4mg, 6mg


Tier 5 * QL PA

FYCOMPA TABS 8mg, 10mg, 12mg


Tier 5 * QL PA

gabapentin (generic of NEURONTIN) CAPS 100mg


Tier 1 QL



Tier 1 QL



Tier 1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

Tier 2 QL

gabapentin (generic of NEURONTIN) TABS 600mg


Tier 2 QL

gabapentin (generic of NEURONTIN) TABS 800mg


Tier 2 QL

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

Tier 2

lamotrigine (generic of LAMICTAL) TABS

Tier 1

lamotrigine (generic of LAMICTAL XR) TB24

Tier 2

levetiracetam (generic of KEPPRA) SOLN; TABS

Tier 2

levetiracetam (generic of KEPPRA XR) TB24

Tier 2


levetiracetam in sodium chloride (generic of LEVETIRACETAM)

Tier 2

levetiracetam oral soln 100 mg/ml (generic of KEPPRA)

Tier 2

NAYZILAM Tier 4

oxcarbazepine (generic of TRILEPTAL)

Tier 2

PEGANONE Tier 4

phenobarbital ELIX PA if 70 years and older

Tier 4 PA

phenobarbital TABS PA if 70 years and older

Tier 3 PA

PHENOBARBITAL SODIUM SOLN 65mg/ml


Tier 4 PA

phenobarbital sodium SOLN 130mg/ml


Tier 4 PA

PHENYTEK Tier 3

phenytoin (generic of DILANTIN INFATABS) CHEW

Tier 2

phenytoin (generic of DILANTIN-125) SUSP

Tier 2

phenytoin sodium extended (generic of DILANTIN) 100mg

Tier 2

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

Tier 2

phenytoin sodium inj 50mg/ml

Tier 2

pregabalin (generic of LYRICA) CAPS 25mg, 50mg, 75mg, 100mg, 150mg


Tier 2 QL PA

pregabalin (generic of LYRICA) CAPS 200mg


Tier 2 QL PA

pregabalin (generic of LYRICA) CAPS 225mg, 300mg


Tier 2 QL PA

pregabalin (generic of LYRICA) SOLN

QL (900 mL / 30 days)

Tier 2 QL PA


30


primidone (generic of MYSOLINE) TABS

Tier 1

roweepra (generic of KEPPRA)

Tier 2

roweepra xr (generic of KEPPRA XR)

Tier 2

SPRITAM Tier 4

subvenite tab (generic of LAMICTAL)

Tier 1

SYMPAZAN 5mg Tier 4 PA

SYMPAZAN 10mg, 20mg Tier 5 * PA

tiagabine hcl (generic of GABITRIL)

Tier 2

topiramate (generic of TOPAMAX SPRINKLE) CPSP

Tier 2

topiramate (generic of TOPAMAX) TABS

Tier 1

valproate sodium SOLN Tier 2

valproic acid CAPS Tier 2

VALTOCO Tier 4

vigabatrin powd pack 500mg (generic of SABRIL)

QL (180 packets / 30 days)


vigabatrin tab 500mg (generic of SABRIL)



vigadrone (generic of SABRIL)



VIMPAT 50mg QL (120 tabs / 30 days)

Tier 4 QL

VIMPAT 100mg, 150mg, 200mg


Tier 5 * QL

VIMPAT INJ 200MG/20ML Tier 5 *

VIMPAT SOL 10MG/ML QL (1200 mL / 30 days)

Tier 5 * QL

zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg

Tier 2

zonisamide CAPS 50mg Tier 2


ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride (generic of ARICEPT) TABS 5mg


Tier 1 QL

donepezil hydrochloride (generic of ARICEPT) TABS 10mg

Tier 1

donepezil hydrochloride TBDP 5mg


Tier 1 QL

donepezil hydrochloride TBDP 10mg

Tier 1

galantamine hydrobromide SOLN

Tier 2

galantamine hydrobromide (generic of RAZADYNE) TABS


Tier 2 QL

galantamine hydrobromide er (generic of RAZADYNE ER)


Tier 2 QL

memantine hcl cp24 (generic of NAMENDA XR)

PA if < 30 yrs

Tier 2 PA

memantine soln PA if < 30 yrs

Tier 2 PA

memantine tabs (generic of NAMENDA)

PA if < 30 yrs

Tier 2 PA

NAMZARIC Tier 4

rivastigmine tartrate 1.5mg, 3mg


Tier 2 QL

rivastigmine tartrate 4.5mg, 6mg


Tier 2 QL

rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)


Tier 2 QL



Tier 2 QL


31




Tier 2 QL

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS Tier 3

amoxapine tab 25mg Tier 3




bupropion hcl TABS Tier 2

bupropion hcl (generic of WELLBUTRIN SR) TB12

Tier 1

bupropion hcl (generic of WELLBUTRIN XL) TB24 150mg, 300mg

Tier 2

citalopram hydrobromide SOLN

Tier 2

citalopram hydrobromide (generic of CELEXA) TABS

Tier 1

clomipramine hcl (generic of ANAFRANIL) CAPS

Tier 4 PA

desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg

Tier 4

desipramine hcl TABS 50mg, 75mg, 100mg, 150mg

Tier 4

desvenlafaxine succinate (generic of PRISTIQ)


Tier 2 QL PA

doxepin hcl CAPS; CONC Tier 3

DRIZALMA SPRINKLE 20mg, 30mg, 60mg


Tier 4 QL PA

DRIZALMA SPRINKLE 40mg


Tier 4 QL PA

duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg


Tier 2 QL

EMSAM QL (30 patches / 30 days)

Tier 5 * QL PA


escitalopram oxalate SOLN

Tier 2

escitalopram oxalate (generic of LEXAPRO) TABS

Tier 1

FETZIMA 20mg, 40mg QL (60 caps / 30 days)

Tier 4 QL PA

FETZIMA 80mg, 120mg QL (30 caps / 30 days)

Tier 4 QL PA

FETZIMA TITRATION PACK

Tier 4 PA

fluoxetine cap 10mg (generic of PROZAC)

Tier 1


Tier 1


Tier 1

fluoxetine hcl SOLN Tier 1

imipramine hcl TABS Tier 2

maprotiline hcl Tier 2

MARPLAN TAB 10MG QL (180 tabs / 30 days)

Tier 4 QL

mirtazapine TABS 7.5mg Tier 2

mirtazapine (generic of REMERON) TABS 15mg, 30mg

Tier 1

mirtazapine TABS 45mg Tier 1

mirtazapine (generic of REMERON SOLTAB) TBDP

Tier 2

nefazodone hcl Tier 2

nortriptyline hcl (generic of PAMELOR) CAPS

Tier 2

nortriptyline hcl SOLN Tier 4

paroxetine hcl tabs (generic of PAXIL)

Tier 2

PAXIL SUSP QL (900 mL / 30 days)

Tier 4 QL

phenelzine sulfate (generic of NARDIL) TABS

Tier 2

protriptyline hcl Tier 4

sertraline hcl (generic of ZOLOFT) CONC

Tier 2

sertraline hcl (generic of ZOLOFT) TABS

Tier 1

tranylcypromine sulfate (generic of PARNATE)

Tier 2


32


trazodone hcl TABS 50mg, 100mg, 150mg

Tier 1

trimipramine maleate CAPS 25mg


Tier 4 QL



Tier 4 QL



Tier 4 QL

TRINTELLIX 5mg QL (120 tabs / 30 days)

Tier 4 QL


Tier 4 QL


Tier 4 QL

venlafaxine hcl (generic of EFFEXOR XR) CP24

Tier 1

venlafaxine hcl TABS Tier 2

VIIBRYD STARTER PACK Tier 4

VIIBRYD TAB QL (30 tabs / 30 days)

Tier 4 QL

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS


Tier 2 QL

amantadine hcl SYRP Tier 1

amantadine hcl TABS Tier 2

APOKYN QL (20 cartridges / 30 days)


benztropine mesylate inj (generic of COGENTIN)

Tier 2

benztropine mesylate tab 0.5mg


Tier 3 PA

benztropine mesylate tab 1mg


Tier 3 PA

benztropine mesylate tab 2mg


Tier 3 PA


bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

Tier 2

carbidopa-levodopa (generic of SINEMET) TABS

Tier 2

carbidopa-levodopa (generic of SINEMET CR) TBCR

Tier 2

carbidopa-levodopa TBDP Tier 2

carbidopa/levodopa/entacapone

Tier 2

carbidopa/levodopa/entacapone (generic of STALEVO 100)

Tier 2

carbidopa/levodopa/entacapone (generic of STALEVO 150)

Tier 2

entacapone (generic of COMTAN)

Tier 2

NEUPRO Tier 4

pramipexole tab 0.5mg (generic of MIRAPEX)

Tier 1


Tier 1


Tier 1


Tier 1


Tier 1

pramipexole tab 1mg (generic of MIRAPEX)

Tier 1

rasagiline mesylate (generic of AZILECT) TABS

Tier 2

ropinirole tab 0.5mg Tier 1

ropinirole tab 0.25mg Tier 1

ropinirole tab 1mg Tier 1





selegiline hcl CAPS; TABS Tier 2

trihexyphenidyl hcl PA if 70 years and older

Tier 3 PA

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA

QL (1 injection / 28 days)

Tier 5 * QL


33


aripiprazole odt QL (60 tabs / 30 days)

Tier 5 * QL

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

Tier 5 * QL

aripiprazole tab (generic of ABILIFY)


Tier 2 QL

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


Tier 5 * QL

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

Tier 5 * QL

ARISTADA INITIO Tier 5 *

CAPLYTA QL (30 caps / 30 days)

Tier 4 QL

chlorpromazine hcl TABS Tier 2

CHLORPROMAZINE INJ Tier 4

clozapine odt 12.5mg, 25mg

Tier 2 PA

clozapine odt 100mg QL (270 tabs / 30 days)

Tier 2 QL PA


Tier 2 QL PA


Tier 2 QL PA

clozapine tab 25mg (generic of CLOZARIL)

Tier 2


Tier 2



Tier 2 QL



Tier 2 QL

FANAPT QL (60 tabs / 30 days)

Tier 4 QL PA

FANAPT TITRATION PACK Tier 4 PA

fluphenazine decanoate SOLN

Tier 2

fluphenazine hcl Tier 2


GEODON SOLR QL (6 mL / 3 days)

Tier 4 QL

haloperidol TABS Tier 2

haloperidol conc 2mg/ml Tier 1

haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml

Tier 2

haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml

Tier 2

haloperidol lactate inj 5mg/ml (generic of HALDOL)

Tier 2

INVEGA SUST INJ 39 MG/0.25 ML


Tier 4 QL



Tier 5 * QL



Tier 5 * QL

INVEGA SUST INJ 156MG/ML


Tier 5 * QL



Tier 5 * QL

INVEGA TRINZA QL (1 injection / 90 days)

Tier 5 * QL

LATUDA 20mg, 40mg, 60mg, 120mg


Tier 4 QL

LATUDA 80mg QL (60 tabs / 30 days)

Tier 4 QL

loxapine succinate Tier 2

molindone hcl Tier 2

NUPLAZID CAPS QL (30 caps / 30 days)


NUPLAZID TABS 10MG QL (30 tabs / 30 days)



34


olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

Tier 2 QL

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 10mg


Tier 2 QL

olanzapine (generic of ZYPREXA) TABS 7.5mg, 15mg, 20mg


Tier 2 QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 5mg, 15mg, 20mg


Tier 2 QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg


Tier 2 QL

paliperidone (generic of INVEGA) 1.5mg, 3mg, 9mg


Tier 2 QL

paliperidone (generic of INVEGA) 6mg


Tier 2 QL

perphenazine TABS Tier 2

PERSERIS QL (1 injection / 30 days)

Tier 5 * QL

pimozide Tier 2

quetiapine fumarate (generic of SEROQUEL) TABS

Tier 2

quetiapine fumarate (generic of SEROQUEL XR) TB24 50mg, 300mg, 400mg


Tier 2 QL PA

quetiapine fumarate (generic of SEROQUEL XR) TB24 150mg, 200mg


Tier 2 QL PA

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

Tier 5 * QL

REXULTI .25mg, .5mg, 1mg, 2mg


Tier 5 * QL

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

Tier 4 QL


RISPERDAL INJ 25MG QL (2 injections / 28 days)

Tier 4 QL

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

Tier 5 * QL

RISPERDAL INJ 50MG QL (2 injections / 28 days)

Tier 5 * QL

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

Tier 2 QL

risperidone (generic of RISPERDAL) TABS .5mg, 1mg, 2mg, 3mg, 4mg

Tier 1

risperidone TABS .25mg Tier 1

risperidone TBDP 1mg, 2mg, 3mg, 4mg


Tier 2 QL

risperidone TBDP .25mg, .5mg


Tier 2 QL

SAPHRIS QL (60 tabs / 30 days)

Tier 4 QL

SECUADO QL (30 patches / 30 days)

Tier 4 QL

thioridazine hcl TABS Tier 2

thiothixene Tier 2

trifluoperazine hcl Tier 2

VERSACLOZ QL (600 mL / 30 days)

Tier 5 * QL PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

Tier 5 * QL PA

VRAYLAR 3mg, 4.5mg, 6mg


Tier 5 * QL PA

VRAYLAR THERAPY PACK Tier 4 PA

ziprasidone hcl (generic of GEODON)


Tier 2 QL

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

Tier 5 * QL PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

Tier 5 * QL PA


35


ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

Tier 4 QL PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


Tier 2 QL

amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)


Tier 2 QL



Tier 2 QL



Tier 2 QL



Tier 2 QL



Tier 2 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


Tier 2 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


Tier 2 QL



Tier 2 QL


amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


Tier 2 QL



Tier 2 QL



Tier 2 QL



Tier 2 QL

atomoxetine hcl (generic of STRATTERA) 10mg, 18mg, 25mg


Tier 2 QL

atomoxetine hcl (generic of STRATTERA) 40mg


Tier 2 QL

atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg


Tier 2 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 2.5mg, 5mg


Tier 2 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg


Tier 2 QL

guanfacine er (adhd) (generic of INTUNIV)


Tier 3 PA

metadate er tab 20mg QL (90 tabs / 30 days)

Tier 2 QL

methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg


Tier 2 QL


36


methylphenidate hcl (generic of RITALIN) TABS 20mg


Tier 2 QL

methylphenidate hcl oral soln (generic of METHYLIN) 5mg/5ml

QL (1800 mL / 30 days)

Tier 2 QL

methylphenidate hcl oral soln (generic of METHYLIN) 10mg/5ml

QL (900 mL / 30 days)

Tier 2 QL

methylphenidate hcl tbcr 10 mg


Tier 2 QL

methylphenidate hcl tbcr 20mg


Tier 2 QL

HYPNOTICS - DRUGS TO TREAT INSOMNIA doxepin hcl (sleep) (generic of SILENOR)


Tier 2 QL

HETLIOZ Tier 5 * NM LA PA

SILENOR QL (30 tabs / 30 days)

Tier 3 QL

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

Tier 2 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

Tier 2 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year

Tier 2 QL PA

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG

QL (1 pen / 30 days) Tier 3 QL PA


dihydroergotamine mesylate inj 1 mg/ml (generic of D.H.E. 45)

Tier 5 *

dihydroergotamine mesylate nasal spr 4 mg/ml

QL (8 mL / 30 days)

Tier 5 * QL PA

eletriptan hydrobromide (generic of RELPAX)


Tier 2 QL

EMGALITY SOAJ QL (2 pens / 30 days)

Tier 3 QL PA

EMGALITY SOSY 120mg/ml

QL (2 syringes / 30 days)

Tier 3 QL PA

ergotamine w/ caffeine (generic of CAFERGOT) TABS

Tier 2

naratriptan hcl (generic of AMERGE)


Tier 2 QL

rizatriptan benzoate 5mg QL (18 tabs / 30 days)

Tier 2 QL

rizatriptan benzoate (generic of MAXALT) 10mg


Tier 2 QL

rizatriptan benzoate odt 5mg


Tier 2 QL

rizatriptan benzoate odt (generic of MAXALT-MLT) 10mg


Tier 2 QL

sumatriptan (generic of IMITREX) SOLN 5mg/act

QL (24 inhalers / 30 days)

Tier 2 QL

sumatriptan (generic of IMITREX) SOLN 20mg/act


Tier 2 QL

sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ

QL (18 injections / 30 days)

Tier 2 QL


37


sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


Tier 2 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


Tier 2 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


Tier 2 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN


Tier 2 QL

sumatriptan inj 6mg/0.5ml SOSY


Tier 2 QL

sumatriptan succinate (generic of IMITREX) TABS


Tier 2 QL

zolmitriptan (generic of ZOMIG) TABS


Tier 2 QL

zolmitriptan odt (generic of ZOMIG ZMT)


Tier 2 QL

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) Tier 5 * QL NM PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

Tier 5 * QL NM PA

lithium carbonate CAPS; TABS

Tier 1

lithium carbonate er (generic of LITHOBID) 300mg

Tier 2

lithium carbonate er 450mg

Tier 2

LITHIUM SOLN 8MEQ/5ML Tier 4


LYRICA CR QL (60 tabs / 30 days)

Tier 3 QL PA

NUEDEXTA QL (60 caps / 30 days)

Tier 4 QL PA

pyridostigmine tab 60mg (generic of MESTINON)

Tier 2

riluzole (generic of RILUTEK)

Tier 2

tetrabenazine (generic of XENAZINE) 12.5mg


Tier 5 * QL NM PA

tetrabenazine (generic of XENAZINE) 25mg


Tier 5 * QL NM PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON


Tier 5 * QL NM PA

dalfampridine (generic of AMPYRA) TB12

Tier 5 * NM PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

Tier 5 * QL NM PA

glatiramer acetate 20mg/ml (generic of COPAXONE)


Tier 5 * QL NM PA

glatiramer acetate 40mg/ml (generic of COPAXONE)


Tier 5 * QL NM PA

glatopa (generic of COPAXONE) 20mg/ml


Tier 5 * QL NM PA

glatopa (generic of COPAXONE) 40mg/ml


Tier 5 * QL NM PA

MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 10mg, 20mg

Tier 2

cyclobenzaprine hcl TABS 5mg, 10mg


Tier 3 PA


38


dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg

Tier 2

dantrolene sodium CAPS 100mg

Tier 2

tizanidine hcl TABS 2mg Tier 2

tizanidine hcl (generic of ZANAFLEX) TABS 4mg

Tier 2

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil (generic of NUVIGIL) 50mg


Tier 2 QL PA

armodafinil (generic of NUVIGIL) 150mg, 200mg, 250mg


Tier 2 QL PA

XYREM QL (540 mL / 30 days)


PSYCHOTHERAPEUTIC-MISC acamprosate calcium Tier 2

buprenorphine hcl SUBL QL (90 tabs / 30 days)

Tier 2 QL PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg (generic of SUBOXONE)

QL (90 films / 30 days)

Tier 2 QL

buprenorphine hcl-naloxone hcl dihydrate 4-1mg (generic of SUBOXONE)


Tier 2 QL



Tier 2 QL



Tier 2 QL

buprenorphine hcl-naloxone hcl sl


Tier 2 QL

bupropion hcl (smoking deterrent)

Tier 2

CHANTIX Tier 4 PA

CHANTIX CONTINUING MONTH

Tier 4 PA

CHANTIX STARTER PACK Tier 4 PA


disulfiram (generic of ANTABUSE) TABS

Tier 2

naloxone inj 0.4mg/ml Tier 2

naloxone inj 1mg/ml Tier 2

naltrexone hcl TABS Tier 2

NARCAN Tier 3

NICOTROL INHALER Tier 4

NICOTROL NS Tier 4

VIVITROL Tier 5 *

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 Tier 5 * PA

ANDRODERM QL (30 patches / 30 days)

Tier 4 QL PA

oxandrolone TABS Tier 2 PA

testosterone GEL 1% QL (300 grams / 30 days)

Tier 2 QL PA

testosterone (generic of ANDROGEL) GEL 25mg/2.5gm, 50mg/5gm

QL (300 grams / 30 days)

Tier 2 QL PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

Tier 2 PA

testosterone enanthate SOLN

Tier 2 PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES BASAGLAR KWIKPEN Tier 3

BD ALCOHOL SWABS Tier 3

BD ULTRAFINE INSULIN SYRINGE

Tier 3

BD ULTRAFINE/NANO PEN NEEDLES

Tier 3

BYDUREON BCISE QL (4 pens / 28 days)

Tier 3 QL

BYDUREON PEN QL (4 pens / 28 days)

Tier 3 QL

BYETTA QL (1 pen / 30 days)

Tier 4 QL

FIASP Tier 3

FIASP FLEXTOUCH Tier 3


39


FIASP PENFILL Tier 3

GAUZE PADS 2" X 2" Tier 3

HUMULIN R INJ U-500 Tier 5 * B/D

HUMULIN R U-500 KWIKPEN

Tier 5 *

INSULIN PEN NEEDLE Tier 3

INSULIN SAFETY NEEDLES

Tier 3

INSULIN SYRINGE Tier 3

LEVEMIR Tier 3

LEVEMIR FLEXTOUCH Tier 3

NOVOLIN 70/30 (brand RELION not covered)

Tier 3

NOVOLIN 70/30 FLEXPEN (brand RELION not covered)

Tier 3

NOVOLIN N (brand RELION not covered)

Tier 3

NOVOLIN N FLEXPEN (brand RELION not covered)

Tier 3

NOVOLIN R (brand RELION not covered)

Tier 3

NOVOLIN R FLEXPEN (brand RELION not covered)

Tier 3

NOVOLOG Tier 3

NOVOLOG 70/30 FLEXPEN Tier 3

NOVOLOG FLEXPEN Tier 3

NOVOLOG MIX 70/30 Tier 3

NOVOLOG PENFILL Tier 3

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

Tier 3 QL

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

Tier 3 QL

SOLIQUA 100/33 QL (10 pens / 30 days)

Tier 3 QL

TRESIBA FLEXTOUCH Tier 3

TRESIBA INJ Tier 3

TRULICITY QL (4 pens / 28 days)

Tier 3 QL

VICTOZA QL (3 pens / 30 days)

Tier 3 QL


XULTOPHY 100/3.6 QL (5 pens / 30 days)

Tier 3 QL

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose (generic of PRECOSE) TABS

Tier 2

FARXIGA QL (30 tabs / 30 days)

Tier 3 QL

glimepiride (generic of AMARYL) 1mg, 2mg


Tier 2 QL

glimepiride (generic of AMARYL) 4mg


Tier 2 QL

glip/metform tab 2.5-250mg QL (240 tabs / 30 days)

Tier 1 QL

glip/metform tab 2.5-500mg QL (120 tabs / 30 days)

Tier 1 QL

glip/metform tab 5-500mg QL (120 tabs / 30 days)

Tier 1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


Tier 1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


Tier 1 QL

glipizide (generic of GLUCOTROL XL) TB24 2.5mg, 5mg


Tier 1 QL

glipizide (generic of GLUCOTROL XL) TB24 10mg


Tier 1 QL

glipizide xl (generic of GLUCOTROL XL) 2.5mg, 5mg


Tier 1 QL

glipizide xl (generic of GLUCOTROL XL) 10mg


Tier 1 QL

JANUMET QL (60 tabs / 30 days)

Tier 3 QL


40


JANUMET XR TAB 50-500MG


Tier 3 QL

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

Tier 3 QL

JANUMET XR TAB 100-1000


Tier 3 QL

JANUVIA QL (30 tabs / 30 days)

Tier 3 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

Tier 3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

Tier 3 QL

JENTADUETO QL (60 tabs / 30 days)

Tier 3 QL

JENTADUETO TAB XR 2.5-1000 MG


Tier 3 QL

JENTADUETO TAB XR 5-1000 MG


Tier 3 QL

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

Tier 1 QL

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

Tier 1 QL

metformin hcl TABS 500mg


Tier 1 QL



Tier 1 QL



Tier 1 QL

nateglinide (generic of STARLIX)


Tier 1 QL

pioglitazone hcl (generic of ACTOS)


Tier 1 QL

repaglinide 2mg QL (240 tabs / 30 days)

Tier 1 QL


repaglinide .5mg, 1mg QL (120 tabs / 30 days)

Tier 1 QL

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

Tier 3 QL

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

Tier 3 QL

SYNJARDY TAB 12.5-500MG


Tier 3 QL

SYNJARDY TAB 12.5-1000MG


Tier 3 QL

SYNJARDY XR TAB 5-1000MG


Tier 3 QL



Tier 3 QL

SYNJARDY XR TAB 12.5-1000MG


Tier 3 QL



Tier 3 QL

TRADJENTA QL (30 tabs / 30 days)

Tier 3 QL

XIGDUO XR TAB 2.5-1000MG


Tier 3 QL

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

Tier 3 QL

XIGDUO XR TAB 5-1000MG


Tier 3 QL



Tier 3 QL



Tier 3 QL

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium TABS 5mg, 10mg, 35mg

Tier 1

alendronate sodium TABS 40mg

Tier 2


41


alendronate sodium (generic of FOSAMAX) TABS 70mg

Tier 1

ibandronate sodium tabs (generic of BONIVA)

Tier 2 B/D

PAMIDRONATE DISODIUM 6mg/ml

Tier 3 B/D

pamidronate disodium 30mg/10ml, 90mg/10ml

Tier 2 B/D

pamidronate inj 30mg Tier 2 B/D

pamidronate inj 90mg Tier 2 B/D

zoledronic acid inj 4mg/100ml

Tier 2 B/D NM

zoledronic acid inj 5mg/100ml (generic of RECLAST)

Tier 2 B/D NM

zoledronic inj 4mg/5ml Tier 2 B/D NM

CHELATING AGENTS CHEMET Tier 4

deferasirox (generic of JADENU) TABS

Tier 5 * NM PA

DEPEN TITRATABS Tier 5 *

JADENU Tier 5 * NM LA PA

JADENU SPRINKLE Tier 5 * NM LA PA

kionex sus 15gm/60ml Tier 2

LOKELMA Tier 3

penicillamine (generic of DEPEN TITRATABS) TABS

Tier 5 *

sodium polystyrene sulfonate powder

Tier 2

sodium polystyrene sulfonate susp

Tier 2

sps susp 15gm/60ml Tier 2

trientine hcl (generic of SYPRINE)

Tier 5 * PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab Tier 2

alyacen 1/35 (generic of ORTHO-NOVUM 1/35)

Tier 2

apri Tier 2

aranelle Tier 2

aubra Tier 2

aviane Tier 2

balziva Tier 2

bekyree (generic of MIRCETTE)

Tier 2


blisovi fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

Tier 2

briellyn Tier 2

camila Tier 2

caziant pak Tier 2

cryselle-28 Tier 2

cyclafem 1/35 (generic of ORTHO-NOVUM 1/35)

Tier 2

cyclafem 7/7/7 (generic of ORTHO-NOVUM 7/7/7)

Tier 2

cyred tab Tier 2

dasetta 1/35 (generic of ORTHO-NOVUM 1/35)

Tier 2

dasetta 7/7/7 (generic of ORTHO-NOVUM 7/7/7)

Tier 2

deblitane Tier 2

desogestrel & ethinyl estradiol

Tier 2

desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)

Tier 2

drospirenone-ethinyl estradiol (generic of YASMIN 28)

Tier 2

drospirenone-ethinyl estradiol (generic of YAZ)

Tier 2

ELLA Tier 3

eluryng (generic of NUVARING)

Tier 2

emoquette Tier 2

enpresse-28 Tier 2

enskyce Tier 2

errin (generic of ORTHO MICRONOR)

Tier 2

estarylla tab 0.25-35 Tier 2

ethynodiol diacet & eth estrad

Tier 2

ethynodiol tab 1-50 Tier 2

etonogestrel-ethinyl estradiol (generic of NUVARING)

Tier 2

falmina Tier 2

femynor Tier 2

gianvi (generic of YAZ) Tier 2

heather Tier 2

incassia Tier 2

introvale Tier 2


42


isibloom Tier 2

jasmiel (generic of YAZ) Tier 2

jolessa tab 0.15-0.03 mg Tier 2

jolivette (generic of ORTHO MICRONOR)

Tier 2

juleber Tier 2

junel 1.5/30 (generic of LOESTRIN 1.5/30-21)

Tier 2

junel 1/20 (generic of LOESTRIN 1/20-21)

Tier 2

junel fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

Tier 2

junel fe 1/20 (generic of LOESTRIN FE 1/20)

Tier 2

kariva (generic of MIRCETTE)

Tier 2

kelnor 1/35 Tier 2

kelnor 1/50 Tier 2

kurvelo Tier 2

larin 1.5/30 (generic of LOESTRIN 1.5/30-21)

Tier 2

larin 1/20 (generic of LOESTRIN 1/20-21)

Tier 2

larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

Tier 2

larin fe 1/20 (generic of LOESTRIN FE 1/20)

Tier 2

larissia tab Tier 2

leena Tier 2

lessina Tier 2

levonest Tier 2

levonor/ethi tab Tier 2

levonorgestrel & eth estradiol

Tier 2

levonorgestrel-ethinyl estradiol (91-day)

Tier 2

levora 0.15/30-28 Tier 2

loryna (generic of YAZ) Tier 2

low-ogestrel Tier 2

lutera Tier 2

lyza (generic of ORTHO MICRONOR)

Tier 2

marlissa Tier 2


medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

Tier 2

microgestin 1.5/30 (generic of LOESTRIN 1.5/30-21)

Tier 2

microgestin 1/20 (generic of LOESTRIN 1/20-21)

Tier 2

microgestin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

Tier 2

microgestin fe 1/20 (generic of LOESTRIN FE 1/20)

Tier 2

mili Tier 2

mono-linyah tab 0.25-35 Tier 2

necon 0.5/35-28 Tier 2

nikki (generic of YAZ) Tier 2

nora-be tab Tier 2

norethindrone (contraceptive) (generic of ORTHO MICRONOR)

Tier 2

norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)

Tier 2

norgest/ethi tab 0.25/35 Tier 2

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO)

Tier 2

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

Tier 2

nortrel 0.5/35 (28) Tier 2

nortrel 1/35 (generic of ORTHO-NOVUM 1/35)

Tier 2

nortrel 7/7/7 (generic of ORTHO-NOVUM 7/7/7)

Tier 2

NUVARING Tier 4

ocella tab 3-0.03mg (generic of YASMIN 28)

Tier 2

orsythia Tier 2

philith Tier 2

pimtrea (generic of MIRCETTE)

Tier 2


43


pirmella 1/35 (generic of ORTHO-NOVUM 1/35)

Tier 2

portia-28 Tier 2

previfem Tier 2

reclipsen Tier 2

setlakin tab Tier 2

sharobel (generic of ORTHO MICRONOR)

Tier 2

sprintec 28 Tier 2

sronyx Tier 2

syeda (generic of YASMIN 28)

Tier 2

tarina fe 1/20 (generic of LOESTRIN FE 1/20)

Tier 2

tilia fe (generic of ESTROSTEP FE)

Tier 2

tri-estarylla Tier 2

tri-legest fe (generic of ESTROSTEP FE)

Tier 2

tri-linyah Tier 2

tri-lo marzia (generic of ORTHO TRI-CYCLEN LO)

Tier 2

tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)

Tier 2

tri-lo-sprintec (generic of ORTHO TRI-CYCLEN LO)

Tier 2

tri-mili Tier 2

tri-previfem Tier 2

tri-sprintec Tier 2

tri-vylibra Tier 2

tri-vylibra lo (generic of ORTHO TRI-CYCLEN LO)

Tier 2

trivora-28 Tier 2

tulana Tier 2

velivet Tier 2

vienva Tier 2

viorele (generic of MIRCETTE)

Tier 2

vyfemla Tier 2

vylibra Tier 2

xulane Tier 2

zarah (generic of YASMIN 28)

Tier 2

zovia 1/35e Tier 2

ENDOMETRIOSIS danazol CAPS Tier 2

SYNAREL Tier 5 *


ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME Tier 5 * NM LA PA

CARBAGLU Tier 5 * NM LA PA

CERDELGA Tier 5 * NM PA

CEREZYME Tier 5 * NM LA PA

CYSTADANE Tier 5 * NM LA

CYSTAGON Tier 4 NM LA PA

FABRAZYME Tier 5 * NM LA PA

KUVAN Tier 5 * NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

Tier 2 B/D

LUMIZYME Tier 5 * NM LA PA

miglustat (generic of ZAVESCA)

Tier 5 * NM PA

NAGLAZYME Tier 5 * NM LA PA

nitisinone (generic of ORFADIN)

Tier 5 * NM PA

NITYR Tier 5 * NM LA PA

ORFADIN Tier 5 * NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

Tier 5 * NM PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml Tier 4

estradiol (generic of CLIMARA) PTWK

Tier 3

estradiol (generic of ESTRACE) TABS

Tier 2

estradiol vaginal cream (generic of ESTRACE)

Tier 2

estradiol vaginal tab (generic of VAGIFEM)

Tier 2

estradiol valerate (generic of DELESTROGEN) OIL

Tier 2

fyavolv Tier 3

fyavolv (generic of FEMHRT LOW DOSE)

Tier 3

jinteli Tier 3

norethindrone acetate-ethinyl estradiol

Tier 3

norethindrone acetate-ethinyl estradiol (generic of FEMHRT LOW DOSE)

Tier 3

yuvafem vaginal tablet 10 mcg (generic of VAGIFEM)

Tier 2


44


GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS Tier 2

DEXAMETHASONE CONC

Tier 4

dexamethasone ELIX; SOLN

Tier 2

dexamethasone TABS Tier 1

dexamethasone sodium phosphate 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml

Tier 2

dexamethasone sodium phosphate (generic of DEXAMETHASONE SODIUM PHOS) 10mg/ml

Tier 2

fludrocortisone acetate TABS

Tier 2

hydrocortisone (generic of CORTEF) TABS

Tier 2

methylpr ss inj (generic of SOLU-MEDROL)

Tier 2 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

Tier 2

methylpred tab 4mg (generic of MEDROL)

Tier 2 B/D


Tier 2 B/D


Tier 2 B/D


Tier 2 B/D

methylprednisolone acetate (generic of DEPO-MEDROL)

Tier 2 B/D

pred sod pho sol 5mg/5ml (generic of PEDIAPRED)

Tier 2 B/D

prednisolone sodium phosphate SOLN 15mg/5ml

Tier 2 B/D

prednisolone sol 15mg/5ml Tier 2 B/D

prednisolone sol 25mg/5ml Tier 2 B/D

PREDNISONE CON 5MG/ML

Tier 4 B/D

prednisone pak 5mg Tier 2

prednisone pak 10mg Tier 2

prednisone sol 5mg/5ml Tier 2 B/D

prednisone tab 1mg Tier 1 B/D


prednisone tab 2.5mg Tier 1 B/D





SOLU-CORTEF Tier 4

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN HYPOKIT Tier 3

GLUCAGON EMERGENCY KIT

Tier 3

PROGLYCEM SUS 50MG/ML

Tier 4

MISCELLANEOUS cabergoline Tier 2

calcitonin (salmon) (generic of MIACALCIN)

Tier 2 B/D

cinacalcet hcl (generic of SENSIPAR) 30mg, 90mg


Tier 5 * B/D QL NM

cinacalcet hcl (generic of SENSIPAR) 60mg


Tier 5 * B/D QL NM

FORTEO Tier 5 * NM PA

GENOTROPIN Tier 5 * NM PA

GENOTROPIN MINIQUICK .2mg

Tier 3 NM PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

Tier 5 * NM PA

INCRELEX Tier 5 * NM LA PA

KORLYM Tier 5 * NM LA PA

LUPRON DEP-PED INJ 7.5MG

Tier 5 * NM PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

Tier 5 * NM PA

LUPRON DEPOT-PED (1-MONTH

Tier 5 * NM PA

LUPRON DEPOT-PED (3-MONTH

Tier 5 * NM PA

NATPARA Tier 5 * NM PA

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml

Tier 2 NM PA

octreotide acetate 200mcg/ml

Tier 2 NM PA


45


octreotide acetate (generic of SANDOSTATIN) 500mcg/ml

Tier 5 * NM PA

octreotide acetate 1000mcg/ml

Tier 5 * NM PA

OSPHENA Tier 3 PA

PROLIA QL (1 injection / 180 days)

Tier 4 QL NM

raloxifene hcl (generic of EVISTA)

Tier 2

SIGNIFOR Tier 5 * NM LA PA

SOMATULINE DEPOT Tier 5 * NM PA

SOMAVERT Tier 5 * NM LA PA

TYMLOS Tier 5 * NM PA

XGEVA Tier 5 * NM PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA


Tier 5 * QL PA

calcium acetate (phosphate binder) (generic of PHOSLO) CAPS


Tier 2 QL

calcium acetate (phosphate binder) TABS


Tier 2 QL

sevelamer carbonate (generic of RENVELA) PACK 2.4gm


Tier 5 * QL

sevelamer carbonate (generic of RENVELA) PACK .8gm


Tier 5 * QL

sevelamer carbonate (generic of RENVELA) TABS


Tier 2 QL


PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab (generic of PROVERA)

Tier 1

norethindrone acetate (generic of AYGESTIN) TABS

Tier 2

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS euthyrox (generic of SYNTHROID)

Tier 2

levo-t (generic of SYNTHROID)

Tier 2

levothyroxine sodium (generic of SYNTHROID) TABS

Tier 2

levoxyl (generic of SYNTHROID)

Tier 2

liothyronine sodium (generic of CYTOMEL) TABS

Tier 2

methimazole (generic of TAPAZOLE) TABS

Tier 1

propylthiouracil TABS Tier 2

SYNTHROID Tier 4

unithroid (generic of SYNTHROID)

Tier 2

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray (generic of DDAVP)

Tier 2

desmopressin acetate spray refrigerated

Tier 2

desmopressin acetate tabs (generic of DDAVP)

Tier 2

desmopressin inj 4mcg/ml (generic of DDAVP)

Tier 2

STIMATE Tier 5 * NM

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant (generic of EMEND) 40mg, 80mg

Tier 2 B/D

aprepitant 125mg Tier 2 B/D

aprepitant pak 80mg & 125mg

Tier 2 B/D

compro Tier 2


46


dronabinol QL (60 caps / 30 days)

Tier 2 B/D QL

EMEND SUSR Tier 4 B/D

granisetron hcl SOLN Tier 2

granisetron hcl TABS Tier 2 B/D

meclizine hcl TABS Tier 2

metoclopramide hcl SOLN Tier 2

metoclopramide hcl (generic of REGLAN) TABS

Tier 1

metoclopramide hcl inj Tier 2

ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg

Tier 2 B/D

ondansetron hcl TABS 24mg

Tier 2 B/D

ondansetron hcl inj Tier 2

ondansetron hcl oral soln Tier 2 B/D

ondansetron odt Tier 2 B/D

prochlorperazine inj Tier 2

prochlorperazine maleate TABS

Tier 2

prochlorperazine supp Tier 2

promethazine hcl SYRP; TABS


Tier 2 PA

promethazine hcl inj (generic of PHENERGAN)


Tier 4 PA

scopolamine (generic of TRANSDERM SCOP)



Tier 4 QL PA

ANTISPASMODICS - DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10mg Tier 3

dicyclomine hcl soln 10mg/5ml

Tier 4

dicyclomine hcl tab 20mg Tier 3

glycopyrrolate tab 1mg Tier 2

glycopyrrolate tab 2mg Tier 2

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID famotidine SUSR Tier 2

famotidine (generic of PEPCID) TABS 20mg, 40mg

Tier 1

famotidine in nacl Tier 2


famotidine inj Tier 2

ranitidine hcl (generic of ZANTAC) TABS 150mg

Tier 1

ranitidine hcl TABS 300mg Tier 1

ranitidine hcl inj (generic of ZANTAC) 50mg/2ml

Tier 2

ranitidine hcl inj 150mg/6ml

Tier 2

ranitidine syrup Tier 2

INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)

Tier 2

budesonide ec (generic of ENTOCORT EC)

Tier 2

colocort (generic of CORTENEMA)

Tier 2

hydrocortisone (enema) (generic of CORTENEMA)

Tier 2

mesalamine (generic of DELZICOL) CPDR

Tier 2

mesalamine ENEM Tier 2

mesalamine (generic of CANASA) SUPP

Tier 5 *

mesalamine (generic of LIALDA) TBEC 1.2gm

Tier 2

mesalamine w/ cleanser (generic of ROWASA)

Tier 2

sulfasalazine (generic of AZULFIDINE) TABS

Tier 2

sulfasalazine ec (generic of AZULFIDINE EN-TABS)

Tier 2

LAXATIVES constulose Tier 2

enulose Tier 2

gavilyte-c Tier 1

gavilyte-g (generic of GOLYTELY)

Tier 1

gavilyte-n/flavor pack (generic of NULYTELY/FLAVOR PACKS)

Tier 1

generlac Tier 2

GOLYTELY Tier 3

lactulose SOLN Tier 2

lactulose (encephalopathy) Tier 2

NULYTELY/FLAVOR PACKS

Tier 3


47


peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

Tier 1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)

Tier 1

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

Tier 1

PLENVU Tier 4

SUPREP BOWEL PREP KIT

Tier 4

trilyte (generic of NULYTELY/FLAVOR PACKS)

Tier 1

MISCELLANEOUS alosetron hcl (generic of LOTRONEX)

Tier 5 * PA

AMITIZA CAP 8MCG QL (180 caps / 30 days)

Tier 3 QL

AMITIZA CAP 24MCG QL (60 caps / 30 days)

Tier 3 QL

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

Tier 5 *

diphenoxylate w/ atropine LIQD

Tier 4

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

Tier 3

GATTEX Tier 5 * NM LA PA

LINZESS QL (30 caps / 30 days)

Tier 4 QL

loperamide hcl CAPS Tier 2

misoprostol (generic of CYTOTEC) TABS

Tier 2

MOVANTIK 12.5mg QL (60 tabs / 30 days)

Tier 3 QL

MOVANTIK 25mg QL (30 tabs / 30 days)

Tier 3 QL

RELISTOR SOLN Tier 5 * PA

sucralfate (generic of CARAFATE) TABS

Tier 2

ursodiol (generic of ACTIGALL) CAPS

Tier 2

ursodiol (generic of URSO 250) TABS 250mg

Tier 2


ursodiol (generic of URSO FORTE) TABS 500mg

Tier 2

XIFAXAN 550mg Tier 5 * PA

PANCREATIC ENZYMES CREON Tier 3

ZENPEP Tier 4

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT

QL (30 caps / 30 days) Tier 4 QL

esomeprazole magnesium (generic of NEXIUM)


Tier 2 QL ST

lansoprazole (generic of PREVACID) CPDR


Tier 2 QL

omeprazole cap 10mg Tier 1



pantoprazole sodium (generic of PROTONIX) SOLR

Tier 2

pantoprazole sodium tbec (generic of PROTONIX)

Tier 1

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl (generic of UROXATRAL)


Tier 1 QL

dutasteride (generic of AVODART) CAPS


Tier 2 QL

dutasteride-tamsulosin hcl (generic of JALYN)


Tier 2 QL

finasteride (generic of PROSCAR) TABS 5mg

Tier 1

tamsulosin hcl (generic of FLOMAX)

Tier 1

MISCELLANEOUS bethanechol chloride TABS 5mg, 10mg

Tier 2


48


bethanechol chloride (generic of URECHOLINE) TABS 25mg, 50mg

Tier 2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 15) 15meq

Tier 2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 540mg

Tier 2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg

Tier 2

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ

QL (30 tabs / 30 days) Tier 4 QL

oxybutynin chloride SYRP Tier 2

oxybutynin chloride TABS Tier 2

oxybutynin chloride (generic of DITROPAN XL) TB24 5mg


Tier 2 QL

oxybutynin chloride (generic of DITROPAN XL) TB24 10mg


Tier 2 QL

oxybutynin chloride TB24 15mg


Tier 2 QL

tolterodine tartrate cap er (generic of DETROL LA)


Tier 2 QL ST

tolterodine tartrate tabs (generic of DETROL)

Tier 2 ST

TOVIAZ QL (30 tabs / 30 days)

Tier 3 QL

trospium chloride TABS QL (60 tabs / 30 days)

Tier 2 QL

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal (generic of CLEOCIN)

Tier 2

metronidazole vaginal Tier 2

terconazole vaginal Tier 2

vandazole Tier 2


HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN Tier 3

ELIQUIS 2.5mg QL (60 tabs / 30 days)

Tier 3 QL

ELIQUIS 5mg QL (74 tabs / 30 days)

Tier 3 QL

ELIQUIS STARTER PACK QL (74 tabs / 30 days)

Tier 3 QL

enoxaparin sodium (generic of LOVENOX)

Tier 2

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

Tier 2

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

Tier 5 *

heparin sod (porcine) in d5w Tier 3

heparin sod inj 1000/ml Tier 2 B/D




HEPARIN SODIUM/NACL 0.45%

Tier 3

jantoven (generic of COUMADIN)

Tier 1

PRADAXA QL (60 caps / 30 days)

Tier 4 QL

warfarin sodium (generic of COUMADIN)

Tier 1

XARELTO 2.5mg QL (60 tabs / 30 days)

Tier 3 QL

XARELTO 10mg, 15mg, 20mg


Tier 3 QL

XARELTO STARTER PACK QL (51 tabs / 30 days)

Tier 3 QL

HEMATOPOIETIC GROWTH FACTORS PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

Tier 3 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

Tier 5 * NM PA

ZARXIO Tier 5 * NM PA

MISCELLANEOUS anagrelide hcl 1mg Tier 2


49


anagrelide hcl (generic of AGRYLIN) .5mg

Tier 2

BERINERT QL (24 boxes / 30 days)


cilostazol Tier 1

DROXIA Tier 3

ENDARI Tier 5 * NM LA PA

HAEGARDA 2000unit QL (30 vials / 30 days)


HAEGARDA 3000unit QL (20 vials / 30 days)


icatibant acetate (generic of FIRAZYR)


Tier 5 * QL NM PA

pentoxifylline TBCR Tier 1

PROMACTA PACK QL (360 packets / 30 days)


PROMACTA TABS 12.5mg, 25mg



PROMACTA TABS 50mg, 75mg



tranexamic acid (generic of CYKLOKAPRON) SOLN

Tier 2

tranexamic acid (generic of LYSTEDA) TABS

Tier 2

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)

Tier 2

BRILINTA Tier 3

clopidogrel tab 75mg (generic of PLAVIX)

Tier 1

prasugrel hcl (generic of EFFIENT)

Tier 2

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS HUMIRA 10mg/0.1ml, 20mg/0.2ml


Tier 5 * QL NM PA


HUMIRA 40mg/0.4ml QL (6 injections / 28 days)

Tier 5 * QL NM PA

HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)

Tier 5 * QL NM PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

Tier 5 * QL NM PA

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

Tier 5 * QL NM PA

HUMIRA PEDIATRIC CROHNS DISEASE

Tier 5 * NM PA

HUMIRA PEN QL (6 pens / 28 days)

Tier 5 * QL NM PA

HUMIRA PEN CD/UC/HS STARTER

Tier 5 * NM PA

HUMIRA PEN INJ CD/UC/HS STARTER

Tier 5 * NM PA

HUMIRA PEN INJ PS/UV STARTER

Tier 5 * NM PA

HUMIRA PEN-PS/UV STARTER

Tier 5 * NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

Tier 2

leflunomide (generic of ARAVA) TABS


Tier 2 QL

methotrexate sodium tabs Tier 2

REMICADE Tier 5 * NM PA

RENFLEXIS Tier 5 * NM LA PA

STELARA SOLN 45mg/0.5ml

QL (1 vial / 28 days)


STELARA SOSY QL (1 syringe / 28 days)

Tier 5 * QL NM PA

XATMEP Tier 4 B/D

XELJANZ QL (60 tabs / 30 days)

Tier 5 * QL NM PA

XELJANZ XR QL (30 tabs / 30 days)

Tier 5 * QL NM PA

IMMUNOGLOBULINS BIVIGAM Tier 5 * NM PA

GAMASTAN S/D Tier 3 B/D NM

GAMMAGARD LIQUID Tier 5 * NM PA

GAMMAGARD S/D Tier 5 * NM PA

GAMMAKED Tier 5 * NM PA


50


GAMMAPLEX Tier 5 * NM PA

GAMMAPLEX 10GM/100ML Tier 5 * NM PA

GAMUNEX-C Tier 5 * NM PA

OCTAGAM Tier 5 * NM PA

PANZYGA Tier 5 * NM PA

PRIVIGEN Tier 5 * NM PA

IMMUNOMODULATORS ACTIMMUNE Tier 5 * NM LA PA

ARCALYST Tier 5 * NM PA

INTRON-A INJ 10MU Tier 5 * B/D NM




IMMUNOSUPPRESSANTS azathioprine (generic of IMURAN) TABS

Tier 2 B/D

BENLYSTA Tier 5 * NM PA

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

Tier 2 B/D NM

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

Tier 2 B/D NM

cyclosporine modified (for microemulsion) CAPS 50mg

Tier 2 B/D NM

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

Tier 2 B/D NM

gengraf (generic of NEORAL)

Tier 2 B/D NM

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

Tier 2 B/D NM

mycophenolate mofetil (generic of CELLCEPT) SUSR

Tier 5 * B/D NM

mycophenolate sodium tbec (generic of MYFORTIC)

Tier 2 B/D NM

NULOJIX Tier 5 * B/D NM

PROGRAF PACK Tier 4 B/D NM

SANDIMMUNE SOLN 100mg/ml

Tier 3 B/D NM

sirolimus (generic of RAPAMUNE) SOLN

Tier 5 * B/D NM

sirolimus (generic of RAPAMUNE) TABS 2mg

Tier 5 * B/D NM


sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg

Tier 2 B/D NM

tacrolimus (generic of PROGRAF) CAPS

Tier 2 B/D NM

ZORTRESS TAB 0.5MG Tier 5 * B/D NM



ZORTRESS TAB 1MG Tier 5 * B/D NM

VACCINES ACTHIB Tier 3

ADACEL Tier 3

BCG VACCINE Tier 3

BEXSERO Tier 3

BOOSTRIX Tier 3

DAPTACEL Tier 3

DIPHTHERIA/TETANUS TOXOID

Tier 3 B/D

ENGERIX-B SUSP Tier 3 B/D

GARDASIL 9 Tier 3

HAVRIX Tier 3

HIBERIX Tier 3

IMOVAX RABIES (H.D.C.V.)

Tier 3 B/D

INFANRIX Tier 3

IPOL INACTIVATED IPV Tier 3

IXIARO Tier 3

KINRIX Tier 3

M-M-R II Tier 3

MENACTRA Tier 3

MENVEO Tier 3

PEDIARIX Tier 3

PEDVAX HIB Tier 3

PENTACEL Tier 3

PROQUAD Tier 3

QUADRACEL Tier 3

RABAVERT Tier 3 B/D

RECOMBIVAX HB Tier 3 B/D

ROTARIX Tier 3

ROTATEQ Tier 3

SHINGRIX QL (2 vials per lifetime)

Tier 3 QL

TDVAX Tier 3 B/D

TENIVAC Tier 3 B/D

TRUMENBA Tier 3


51


TWINRIX INJ Tier 3

TYPHIM VI Tier 3

VAQTA Tier 3

VARIVAX Tier 3

YF-VAX Tier 3

ZOSTAVAX QL (1 vial per lifetime)

Tier 3 QL

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES klor-con 8 Tier 1

klor-con 10 Tier 1

klor-con m10 Tier 1

klor-con m15 Tier 1

klor-con m20 Tier 1

klor-con pak 20meq Tier 2

klor-con spr cap 8meq Tier 2

klor-con spr cap 10meq Tier 2

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

Tier 3

magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

Tier 3

magnesium sulfate SOLN 50%

Tier 3

MAGNESIUM SULFATE IN D5W

Tier 3

magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W)

Tier 3

magnesium sulfate inj 50% Tier 3

potassium chloride CPCR Tier 2

potassium chloride PACK Tier 2

potassium chloride SOLN 10%, 20%

Tier 2

potassium chloride TBCR 8meq, 10meq

Tier 1

potassium chloride (generic of K-TAB) TBCR 20meq

Tier 1

potassium chloride microencapsulated crystals er

Tier 1


sodium chloride SOLN 2.5meq/ml

Tier 2

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

Tier 2

TPN ELECTROLYTES Tier 4 B/D

IV NUTRITION AMINOSYN II INJ 10% Tier 4 B/D

AMINOSYN-PF 7% Tier 4 B/D

AMINOSYN-PF INJ 10% Tier 4 B/D

CLINIMIX 4.25%/DEXTROSE 5%

Tier 4 B/D

CLINIMIX 5%/DEXTROSE 15%

Tier 4 B/D

CLINIMIX 5%/DEXTROSE 20%

Tier 4 B/D

CLINIMIX INJ 4.25/D10 Tier 4 B/D

clinisol sf 15% Tier 2 B/D

CLINOLIPID Tier 4 B/D

FREAMINE HBC 6.9% Tier 4 B/D

FREAMINE III Tier 4 B/D

hepatamine Tier 4 B/D

INTRALIPID 30% Tier 4 B/D

INTRALIPID INJ 20% Tier 4 B/D

NEPHRAMINE Tier 4 B/D

NUTRILIPID INJ 20% Tier 4 B/D

plenamine Tier 2 B/D

PREMASOL SOL 10% Tier 4 B/D

PROCALAMINE Tier 4 B/D

PROSOL Tier 4 B/D

TRAVASOL Tier 4 B/D

TROPHAMINE INJ 10% Tier 4 B/D

IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% Tier 2

dextrose 5% Tier 2

DEXTROSE 5% /ELECTROLYTE

Tier 3

dextrose 5%/nacl 0.2% Tier 2

DEXTROSE 5%/NACL 0.3%

Tier 4




dextrose 5%/potassium chl Tier 2

dextrose 10% flex contain Tier 2

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

Tier 3



52


dextrose 50% Tier 2

dextrose in lactated ringers Tier 2

dextrose inj 70% Tier 2

IONOSOL-MB/DEXTROSE 5%

Tier 4

ISOLYTE P Tier 4

ISOLYTE S Tier 4

kcl0.15%/d5w/nacl0.2% Tier 2

KCL 0.3%/D5W/NACL 0.9% Tier 4

kcl 0.3%/d5w/nacl 0.45% Tier 2


KCL 0.15%/D5W/NACL 0.225%

Tier 4


kcl/d5w inj 0.3% Tier 2

kcl/d5w/nacl inj 0.22%/0.45%

Tier 2

kcl/d5w/nacl inj .15/.45% Tier 2

kcl/nacl inj 0.3-0.9 Tier 2

kcl/nacl inj 0.15%-0.9% Tier 2

lactated ringer's Tier 2

NORMOSOL-M IN D5W Tier 4

NORMOSOL-R Tier 4

NORMOSOL-R IN D5W Tier 4

PLASMA-LYTE A Tier 4

PLASMA-LYTE-148 Tier 4

pot chloride inj 2meq/ml Tier 2

potassium chloride SOLN 2meq/ml

Tier 2

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

Tier 2

potassium chloride in nacl Tier 2

sodium chloride SOLN 3%, 5%

Tier 2

sodium chloride 0.45% Tier 2

sodium chloride inj 0.9% Tier 2

VITAMINS calcitriol (generic of ROCALTROL) CAPS

Tier 2 B/D

calcitriol inj Tier 2 B/D

calcitriol oral soln 1 mcg/ml (generic of ROCALTROL)

Tier 2 B/D

M-NATAL PLUS Tier 3


paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg

Tier 2 B/D

paricalcitol CAPS 4mcg Tier 2 B/D

PNV FOLIC ACID + IRON MUL

Tier 3

PRENATAL Tier 3

PRENATAL PLUS Tier 3

PRENATAL PLUS LOW IRON

Tier 3

RAYALDEE Tier 5 *

TRICARE Tier 3

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-poly-neomycin-hc Tier 2

BLEPHAMIDE OINT Tier 4

neomycin-polymy-dexameth (generic of MAXITROL) OINT

Tier 1

neomycin-polymy-dexameth (generic of MAXITROL) SUSP

Tier 2

neomycin-polymyxin-hc (ophth)

Tier 2

sulfacetamide sod-prednisolone

Tier 2

TOBRADEX OINT Tier 3

TOBRADEX ST Tier 3

tobramycin-dexamethasone (generic of TOBRADEX)

Tier 2

ZYLET Tier 3

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE Tier 4

bacitracin (ophthalmic) Tier 2

bacitracin-polymyxin b (ophth)

Tier 1

BESIVANCE Tier 3

CILOXAN OINT Tier 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

Tier 1

erythromycin (ophth) Tier 1

gatifloxacin (ophth) (generic of ZYMAXID)

Tier 2


53


gentak Tier 2

gentamicin sulfate soln (ophth)

Tier 1

MOXEZA Tier 3

moxifloxacin hcl (ophth) (generic of VIGAMOX)

Tier 2

NATACYN Tier 4

neomycin-bacitracin zn-polymyxin

Tier 2

neomycin-polymyxin-gramicidin

Tier 2

ofloxacin (ophth) (generic of OCUFLOX)

Tier 2

polymyxin b-trimethoprim (generic of POLYTRIM)

Tier 1

sulfacetamide sodium (ophth) OINT

Tier 2

sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN

Tier 2

tobramycin (ophth) (generic of TOBREX)

Tier 1

trifluridine Tier 2

ZIRGAN Tier 4

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX Tier 3

bromfenac sodium (ophth) Tier 2

BROMSITE Tier 4

dexamethasone sodium phosphate (ophth)

Tier 2

diclofenac sodium (ophth) Tier 2

DUREZOL Tier 3

fluorometholone Tier 2

flurbiprofen sodium Tier 2

ILEVRO Tier 3

ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

Tier 2

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

Tier 2

LOTEMAX GEL; OINT Tier 3

loteprednol etabonate (generic of LOTEMAX)

Tier 2

prednisolone acetate (ophth) (generic of PRED FORTE)

Tier 2


PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

Tier 3

PROLENSA Tier 3

ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine drop 0.05% Tier 2

BEPREVE Tier 3

cromolyn sodium (ophth) Tier 1

LASTACAFT Tier 4

olopatadine hcl 0.2% Tier 2

PAZEO Tier 3

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% Tier 3

AZOPT Tier 3

betaxolol hcl (ophth) Tier 2

BETOPTIC-S Tier 3

brimonidine sol 0.2% Tier 1

brimonidine sol 0.15% (generic of ALPHAGAN P)

Tier 2

carteolol hcl (ophth) Tier 2

COMBIGAN Tier 3

dorzolamide hcl (generic of TRUSOPT)

Tier 1

dorzolamide hcl-timolol maleate (generic of COSOPT)

Tier 1

latanoprost (generic of XALATAN) SOLN

Tier 1

levobunolol hcl Tier 1

LUMIGAN Tier 3

PHOSPHOLINE IODIDE Tier 4

pilocarpine hcl (generic of ISOPTO CARPINE) SOLN

Tier 2

RHOPRESSA Tier 3

SIMBRINZA Tier 3

timolol maleate (ophth) soln (generic of TIMOPTIC)

Tier 1

timolol maleate gel (generic of TIMOPTIC-XE)

Tier 2

timolol maleate ophth soln 0.5% (once-daily) (generic of ISTALOL)

Tier 2

TRAVATAN Z Tier 4

travoprost (generic of TRAVATAN Z)

Tier 2


54


MISCELLANEOUS ATROPINE SULFATE SOLN 1%

Tier 3

CYSTARAN Tier 5 * NM LA PA

proparacaine hcl (generic of ALCAINE) SOLN

Tier 2

RESTASIS QL (60 single use vials / 30 days)

Tier 3 QL

RESTASIS MULTIDOSE QL (1 bottle / 30 days)

Tier 3 QL

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPTA

QL (60 blisters / 30 days)

Tier 3 QL

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

Tier 3 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

Tier 4 QL

ipratropium-albuterol nebu Tier 2 B/D

TRELEGY ELLIPTA QL (60 blisters / 30 days)

Tier 3 QL

ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA


Tier 4 QL

INCRUSE ELLIPTA QL (30 blisters / 30 days)

Tier 3 QL

ipratropium bromide SOLN Tier 2 B/D

ipratropium bromide (nasal) Tier 2

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine spr 0.1% Tier 2

azelastine spr 0.15% (generic of ASTEPRO)

Tier 2

cetirizine syrup Tier 1

cyproheptadine hcl SYRP; TABS


Tier 3 PA


diphenhydramine hcl inj 50mg/ml

Tier 2

hydroxyzine hcl SYRP PA if 70 years and older

Tier 3 PA

hydroxyzine hcl TABS PA if 70 years and older

Tier 2 PA

hydroxyzine hcl inj PA if 70 years and older

Tier 4 PA

hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg


Tier 2 PA

levocetirizine dihydrochloride SOLN

Tier 2

levocetirizine dihydrochloride TABS

Tier 1

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act


(generic of Ventolin HFA)

Tier 2 QL

albuterol sulfate (generic of PROAIR HFA) AERS 108mcg/act


(generic of Proair HFA)

Tier 2 QL

albuterol sulfate NEBU Tier 2 B/D

albuterol sulfate SYRP Tier 2

albuterol sulfate TABS Tier 2

albuterol sulfate TB12 Tier 2

levalbuterol hcl (generic of XOPENEX) NEBU 1.25mg/3ml

Tier 2 B/D

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (generic of XOPENEX CONCENTRATE)

Tier 2 B/D

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

Tier 2 QL

SEREVENT DISKUS QL (60 inhalations / 30 days)

Tier 3 QL

terbutaline sulfate TABS Tier 2


55


VENTOLIN HFA QL (2 inhalers / 30 days)

Tier 3 QL

LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW; PACK

Tier 2

montelukast sodium (generic of SINGULAIR) TABS

Tier 1

zafirlukast (generic of ACCOLATE)

Tier 2

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu Tier 2 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

Tier 2 B/D

ARALAST NP Tier 5 * NM LA PA

DALIRESP Tier 4

epinephrine (anaphylaxis) (generic of EPIPEN 2-PAK) .3mg/0.3ml

(generic of EpiPen)

Tier 2

epinephrine (anaphylaxis) (generic of EPIPEN-JR 2-PAK) .15mg/0.3ml

(generic of EpiPen)

Tier 2

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

Tier 2

ESBRIET Tier 5 * NM PA

KALYDECO Tier 5 * NM PA

NUCALA Tier 5 * NM LA PA

OFEV Tier 5 * NM PA

ORKAMBI Tier 5 * NM PA

PROLASTIN-C Tier 5 * NM LA PA

PULMOZYME Tier 5 * NM PA

SYMDEKO Tier 5 * NM LA PA

SYMJEPI Tier 4

THEO-24 Tier 4

theophylline Tier 2

theophylline tab er 12hr 300 mg

Tier 2

theophylline tab er 12hr 450 mg

Tier 2

theophylline tab sr 24hr Tier 2

TRIKAFTA Tier 5 * NM LA PA


XOLAIR Tier 5 * NM LA PA

ZEMAIRA Tier 5 * NM LA PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide (nasal)

QL (3 bottles / 30 days)

Tier 2 QL

fluticasone propionate (nasal)

QL (1 bottle / 30 days)

Tier 1 QL

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

Tier 3 QL

budesonide (inhalation) (generic of PULMICORT) .25mg/2ml, .5mg/2ml

Tier 2 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


Tier 3 QL

FLOVENT DISKUS 250mcg/blist


Tier 3 QL

FLOVENT HFA QL (2 inhalers / 30 days)

Tier 3 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

Tier 4 QL

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS


Tier 3 QL

ADVAIR HFA QL (1 inhaler / 30 days)

Tier 3 QL

BREO ELLIPTA QL (60 blisters / 30 days)

Tier 3 QL

SYMBICORT QL (1 inhaler / 30 days)

Tier 3 QL


56


TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE amnesteem Tier 2 PA

avita (generic of RETIN-A) CREA


Tier 2 QL PA

avita GEL QL (45 grams / 30 days)

Tier 2 QL PA

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

Tier 2

claravis Tier 2 PA

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL


Tier 2 QL

clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN

Tier 2

clindamycin phosphate (topical) SOLN


Tier 2 QL

ery pad 2% Tier 2

erythromycin (acne aid) (generic of ERYGEL) GEL

Tier 2

erythromycin (acne aid) SOLN

Tier 2

isotretinoin CAPS Tier 2 PA

myorisan Tier 2 PA

sulfacetamide sodium (acne) (generic of KLARON)

Tier 2

tretinoin (generic of RETIN-A) CREA


Tier 2 QL PA

tretinoin (generic of RETIN-A) GEL .01%, .025%


Tier 2 QL PA

zenatane Tier 2 PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) Tier 2

mupirocin OINT QL (220 grams / 30 days)

Tier 1 QL


silver sulfadiazine (generic of SILVADENE) CREA

Tier 2

ssd (generic of SILVADENE)

Tier 2

SULFAMYLON CREA Tier 4

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) CREA


Tier 2 QL

ciclopirox (generic of LOPROX) SUSP


Tier 2 QL

clotrimazole (topical) CREA

Tier 2

clotrimazole (topical) SOLN


Tier 2 QL

clotrimazole w/ betamethasone (generic of LOTRISONE) CREA

Tier 2

ketoconazole cream QL (60 grams / 30 days)

Tier 2 QL

nyamyc QL (60 grams / 30 days)

Tier 2 QL

nystatin (topical) Tier 2

nystatin pow 100000 QL (60 grams / 30 days)

Tier 2 QL

nystop QL (60 grams / 30 days)

Tier 2 QL

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 10mg, 25mg

Tier 2 PA

acitretin 17.5mg Tier 2 PA

calcipotriene (generic of DOVONEX) CREA


Tier 2 QL PA

calcipotriene OINT QL (120 grams / 30 days)

Tier 2 QL PA

calcipotriene SOLN QL (120 mL / 30 days)

Tier 2 QL PA


57


calcitrene QL (120 grams / 30 days)

Tier 2 QL PA

tazarotene (generic of TAZORAC) CREA


Tier 2 QL PA

TAZORAC CREA .05% QL (60 grams / 30 days)

Tier 4 QL PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

Tier 1

selenium sulfide LOTN Tier 1

DERMATOLOGY, CORTICOSTEROIDS ala-cort Tier 1

alclometasone dipropionate Tier 2

betamethasone dipropionate (topical)

Tier 2

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

Tier 2

betamethasone dipropionate augmented GEL; LOTN

Tier 2

betamethasone dipropionate augmented (generic of DIPROLENE) OINT

Tier 2

betamethasone valerate CREA; LOTN; OINT

Tier 2

ENSTILAR QL (120 grams / 30 days)

Tier 4 QL PA

fluocinolone acetonide CREA .01%

Tier 2

fluocinolone acetonide (generic of SYNALAR) CREA .025%

Tier 2

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL

Tier 2

fluocinolone acetonide (generic of SYNALAR) OINT

Tier 2

fluocinolone acetonide (generic of SYNALAR) SOLN


Tier 2 QL


fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP)

Tier 2

fluocinonide CREA .05% QL (120 grams / 30 days)

Tier 2 QL

fluocinonide GEL QL (60 grams / 30 days)

Tier 2 QL

fluocinonide OINT QL (60 grams / 30 days)

Tier 2 QL

fluocinonide SOLN QL (60 mL / 30 days)

Tier 2 QL

fluocinonide emulsified base QL (120 grams / 30 days)

Tier 2 QL

fluticasone propionate CREA; OINT

Tier 2

halobetasol propionate CREA; OINT


Tier 2 QL

hydrocortisone (topical) cream 1%

Tier 1

hydrocortisone (topical) cream 2.5%

Tier 1

hydrocortisone (topical) lotion 2.5%

Tier 2

hydrocortisone (topical) oint 2.5%

Tier 1

hydrocortisone butyrate cream 0.1% (generic of LOCOID)


Tier 2 QL

hydrocortisone butyrate oint 0.1%


Tier 2 QL

mometasone furoate (generic of ELOCON) CREA

Tier 2

mometasone furoate OINT; SOLN

Tier 2

TEXACORT SOLN 2.5% Tier 4

triamcinolone acetonide (topical) CREA .1%


Tier 1 QL


58


triamcinolone acetonide (topical) CREA .025%, .5%

Tier 1

triamcinolone acetonide (topical) LOTN

Tier 2

triamcinolone acetonide (topical) OINT .025%, .1%, .5%

Tier 1

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) Tier 2 QL PA

lidocaine (generic of LIDODERM) PTCH 5%

QL (3 patches / 1 day)

Tier 2 QL PA

lidocaine hcl GEL QL (30 mL / 30 days)

Tier 2 QL PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

Tier 2 QL PA

lidocaine oint 5% QL (50 grams / 30 days)

Tier 2 QL PA

lidocaine-prilocaine QL (30 grams / 30 days)

Tier 2 QL PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

Tier 2

diclofenac sodium (topical) 1% gel (generic of VOLTAREN)


Tier 2 QL PA

fluorouracil (topical) (generic of EFUDEX) CREA 5%


Tier 2 QL

fluorouracil (topical) SOLN QL (10 mL / 30 days)

Tier 2 QL

imiquimod (generic of ALDARA) CREA 5%


Tier 2 QL

metronidazole (topical) (generic of METROCREAM) CREA

Tier 2

metronidazole (topical) (generic of METROLOTION) LOTN

Tier 2

metronidazole gel 0.75% Tier 2


PANRETIN QL (60 grams / 30 days)

Tier 5 * QL

PICATO .05% QL (2 tubes / 30 days)

Tier 4 QL

PICATO .015% QL (3 tubes / 30 days)

Tier 4 QL

podofilox SOLN Tier 2

procto-med hc (generic of ANUSOL-HC)

Tier 2

procto-pak (generic of PROCTOCORT)

Tier 2

proctosol hc cre 2.5% (generic of ANUSOL-HC)

Tier 2

proctozone-hc (generic of ANUSOL-HC)

Tier 2

RECTIV QL (30 grams / 30 days)

Tier 4 QL

rosadan (generic of METROCREAM)

Tier 2

tacrolimus (topical) (generic of PROTOPIC)


Tier 2 QL

TARGRETIN GEL QL (60 grams / 30 days)

Tier 5 * QL NM PA

VALCHLOR QL (60 grams / 30 days)


DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion Tier 2

permethrin cre 5% (generic of ELIMITE)

Tier 2

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% Tier 2

REGRANEX QL (30 grams / 30 days)

Tier 5 * QL PA

SANTYL Tier 4

sodium chlor sol 0.9% irr Tier 2

water for irrigation, sterile Tier 2

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

Tier 2


59


chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

Tier 1

clotrimazole LOZG Tier 2

lidocaine hcl (mouth-throat) Tier 2

nystatin (mouth-throat) Tier 2

paroex sol 0.12% (generic of PERIDEX)

Tier 1

periogard (generic of PERIDEX)

Tier 1

pilocarpine hcl (oral) (generic of SALAGEN)

Tier 2

triamcinolone acetonide (mouth)

Tier 2

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) Tier 2

CIPRODEX Tier 3

flac (generic of DERMOTIC) Tier 2

fluocinolone acetonide (otic) (generic of DERMOTIC)

Tier 2

neomycin-polymyxin-hc (otic)

Tier 2

ofloxacin (otic) Tier 2

60

Index

A abacavir sulfate ................. 15 abacavir sulfate-lamivudine .......................................... 16 abacavir sulfate-lamivudine-zidovudine ......................... 16 ABELCET.......................... 15 ABILIFY

see aripiprazole tab ....... 33 ABILIFY MAINTENA ......... 32 abiraterone acetate ........... 20 ABRAXANE ...................... 19 acamprosate calcium ........ 38 acarbose ........................... 39 ACCOLATE

see zafirlukast ............... 55 ACCUPRIL

see quinapril hcl ............ 23 ACCURETIC

see quinapril-hydrochlorothiazide ....... 22

acebutolol hcl .................... 25 acetaminophen w/ codeine 300-15mg .......................... 11 acetaminophen w/ codeine 300-30mg .......................... 11 acetaminophen w/ codeine 300-60mg .......................... 11 acetaminophen w/ codeine soln ................................... 11 acetazolamide ................... 26 acetic acid ......................... 58 acetic acid (otic) ................ 59 acetylcysteine ................... 55 acitretin ............................. 56 ACTHIB ............................. 50 ACTIGALL

see ursodiol ................... 47 ACTIMMUNE .................... 50 ACTIQ

see fentanyl citrate ........ 12 ACTOS

see pioglitazone hcl ....... 40 ACULAR

see ketorolac tromethamine (ophth) .... 53

ACULAR LS see ketorolac

tromethamine (ophth) .... 53 acyclovir ............................ 17 acyclovir sodium ............... 17 ADACEL ........................... 50 ADALAT CC

see nifedipine er ............ 26 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg ................................. 35 see amphetamine-dextroamphetamine tab 12.5 mg ......................... 35 see amphetamine-dextroamphetamine tab 15 mg ................................. 35 see amphetamine-dextroamphetamine tab 20 mg ................................. 35 see amphetamine-dextroamphetamine tab 30 mg ................................. 35 see amphetamine-dextroamphetamine tab 5 mg ................................. 35 see amphetamine-dextroamphetamine tab 7.5 mg ........................... 35

ADDERALL XR see amphetamine-dextroamphetamine cap sr 24hr 10 mg .................... 35 see amphetamine-dextroamphetamine cap sr 24hr 15 mg .................... 35 see amphetamine-dextroamphetamine cap sr 24hr 20 mg .................... 35 see amphetamine-dextroamphetamine cap sr 24hr 25 mg .................... 35 see amphetamine-dextroamphetamine cap sr 24hr 30 mg .................... 35 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................... 35

adefovir dipivoxil ............... 17

ADEMPAS ........................ 27 adriamycin ........................ 19 adrucil inj .......................... 19 ADVAIR DISKUS .............. 55 ADVAIR HFA .................... 55 AFINITOR ......................... 21

see everolimus .............. 21 AFINITOR DISPERZ ........ 21 AGGRENOX

see aspirin-dipyridamole 49 AGRYLIN

see anagrelide hcl ......... 49 AIMOVIG .......................... 36 ala-cort .............................. 57 albendazole ...................... 14 ALBENZA

see albendazole ............ 14 albuterol sulfate ................ 54 ALCAINE

see proparacaine hcl ..... 54 alclometasone dipropionate.......................................... 57 ALDACTAZIDE

see spironolactone & hydrochlorothiazide ....... 26

ALDACTONE see spironolactone ........ 23

ALDARA see imiquimod ............... 58

ALDURAZYME ................. 43 ALECENSA ...................... 21 alendronate sodium .... 40, 41 alfuzosin hcl ...................... 47 ALIMTA ............................. 19 ALINIA .............................. 14 aliskiren fumarate ............. 27 allopurinol tab ................... 11 alosetron hcl ..................... 47 ALPHAGAN P

see brimonidine sol 0.15% ...................................... 53

ALPHAGAN P SOL 0.1% . 53 alprazolam tab 0.25mg ..... 27 alprazolam tab 0.5mg ....... 27 alprazolam tab 1mg .......... 27 alprazolam tab 2mg .......... 28 ALREX .............................. 53 ALTACE

61

see ramipril .................... 23 altavera tab ....................... 41 ALUNBRIG ........................ 21 alyacen 1/35 ...................... 41 amantadine hcl .................. 32 AMARYL

see glimepiride .............. 39 AMBIEN

see zolpidem tartrate ..... 36 AMBISOME ....................... 15 ambrisentan ...................... 27 AMERGE

see naratriptan hcl ......... 36 amikacin sulfate ................ 13 amiloride & hydrochlorothiazide ........... 26 amiloride hcl ...................... 26 AMINOSYN II INJ 10% ..... 51 AMINOSYN-PF 7% ........... 51 AMINOSYN-PF INJ 10%... 51 amiodarone hcl soln .......... 24 amiodarone tab 100mg ..... 24 amiodarone tab 200mg ..... 24 amiodarone tab 400mg ..... 24 AMITIZA CAP 24MCG ...... 47 AMITIZA CAP 8MCG ........ 47 amitriptyline hcl ................. 31 amlodipine besylate .......... 25 amlodipine besylate-olmesartan medoxomil ...... 23 amlodipine besylate-valsartan tab 10-160 mg ... 23 amlodipine besylate-valsartan tab 10-320 mg ... 23 amlodipine besylate-valsartan tab 5-160 mg ..... 23 amlodipine besylate-valsartan tab 5-320 mg ..... 23 amlodipine--benazepril hcl cap 10-20 mg .................... 22 amlodipine-benazepril hcl cap 10-40mg ..................... 22 amlodipine-benazepril hcl cap 2.5-10 mg ................... 22 amlodipine-benazepril hcl cap 5-10 mg ...................... 22 amlodipine-benazepril hcl cap 5-20 mg ...................... 22 amlodipine-benazepril hcl cap 5-40 mg ...................... 22

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............................. 23 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................................. 23 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................................. 23 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg .............................. 23 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................................. 23 ammonium lactate ............ 58 amnesteem ....................... 56 amoxapine tab 100mg ...... 31 amoxapine tab 150mg ...... 31 amoxapine tab 25mg ........ 31 amoxapine tab 50mg ........ 31 amoxicillin ......................... 18 amoxicillin & pot clavulanate 200/5ml susr ..................... 18 amoxicillin & pot clavulanate 200-28.5 chw tabs ............ 18 amoxicillin & pot clavulanate 250/5ml susr ..................... 18 amoxicillin & pot clavulanate 250-125 tabs ..................... 18 amoxicillin & pot clavulanate 400/5ml susr ..................... 18 amoxicillin & pot clavulanate 400-57 chw tabs ............... 18 amoxicillin & pot clavulanate 500-125 tabs ..................... 18 amoxicillin & pot clavulanate 600/5ml susr ..................... 18 amoxicillin & pot clavulanate 875-125 tabs ..................... 18 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs...... 18 amphetamine-dextroamphetamine cap sr 24hr 10 mg ........................ 35 amphetamine-dextroamphetamine cap sr 24hr 15 mg ........................ 35 amphetamine-dextroamphetamine cap sr

24hr 20 mg ....................... 35 amphetamine-dextroamphetamine cap sr 24hr 25 mg ....................... 35 amphetamine-dextroamphetamine cap sr 24hr 30 mg ....................... 35 amphetamine-dextroamphetamine cap sr 24hr 5 mg ......................... 35 amphetamine-dextroamphetamine tab 10 mg ..................................... 35 amphetamine-dextroamphetamine tab 12.5 mg ..................................... 35 amphetamine-dextroamphetamine tab 15 mg ..................................... 35 amphetamine-dextroamphetamine tab 20 mg ..................................... 35 amphetamine-dextroamphetamine tab 30 mg ..................................... 35 amphetamine-dextroamphetamine tab 5 mg ..................................... 35 amphetamine-dextroamphetamine tab 7.5 mg ..................................... 35 amphotericin b .................. 15 ampicillin & sulbactam sodium .............................. 18 ampicillin cap 500mg ........ 18 ampicillin inj ...................... 18 ampicillin sodium .............. 18 AMPYRA

see dalfampridine .......... 37 ANADROL-50 ................... 38 ANAFRANIL

see clomipramine hcl .... 31 anagrelide hcl ............. 48, 49 ANAPROX DS

see naproxen sodium .... 11 anastrozole ....................... 20 ANCOBON

see flucytosine .............. 15 ANDRODERM .................. 38 ANDROGEL

62

see testosterone ............ 38 ANORO ELLIPTA ............. 54 ANTABUSE

see disulfiram ................ 38 ANUSOL-HC

see procto-med hc ......... 58 see proctosol hc cre 2.5% ...................................... 58 see proctozone-hc ......... 58

APOKYN ........................... 32 aprepitant .......................... 45 aprepitant pak 80mg & 125mg ............................... 45 apri .................................... 41 APTIOM ............................ 28 APTIVUS........................... 15 ARALAST NP .................... 55 aranelle ............................. 41 ARAVA

see leflunomide ............. 49 ARCALYST ....................... 50 ARICEPT

see donepezil hydrochloride ................. 30

ARIMIDEX see anastrozole ............. 20

aripiprazole odt ................. 33 aripiprazole oral solution 1 mg/ml ................................ 33 aripiprazole tab ................. 33 ARISTADA ........................ 33 ARISTADA INITIO ............ 33 ARIXTRA

see fondaparinux sodium ...................................... 48

armodafinil ........................ 38 ARNUITY ELLIPTA ........... 55 AROMASIN

see exemestane ............ 20 aspirin-dipyridamole .......... 49 ASTEPRO

see azelastine spr 0.15% ...................................... 54

atazanavir sulfate .............. 15 atenolol ............................. 25 atenolol & chlorthalidone ... 25 ATIVAN

see lorazepam ............... 28 atomoxetine hcl ................. 35 atorvastatin calcium .......... 24

atovaquone ....................... 14 atovaquone-proguanil hcl .. 15 ATRIPLA ........................... 16 ATROPINE SULFATE ...... 54 ATROVENT HFA .............. 54 aubra................................. 41 AUGMENTIN

see amoxicillin & pot clavulanate 250/5ml susr ...................................... 18 see amoxicillin & pot clavulanate 500-125 tabs ...................................... 18

AURYXIA .......................... 45 AUSTEDO ........................ 37 AVALIDE

see irbesartan-hydrochlorothiazide ....... 23

AVAPRO see irbesartan ............... 24

AVASTIN .......................... 20 aviane ............................... 41 avita .................................. 56 AVODART

see dutasteride .............. 47 AYGESTIN

see norethindrone acetate ...................................... 45

AYVAKIT ........................... 21 azacitidine ......................... 19 AZACTAM

see aztreonam .............. 14 AZASITE ........................... 52 azathioprine ...................... 50 azelastine drop 0.05% ...... 53 azelastine spr 0.1% .......... 54 azelastine spr 0.15%......... 54 AZILECT

see rasagiline mesylate . 32 azithromycin ...................... 18 AZOPT .............................. 53 AZOR

see amlodipine besylate-olmesartan medoxomil .. 23

aztreonam ......................... 14 AZULFIDINE

see sulfasalazine ........... 46 AZULFIDINE EN-TABS

see sulfasalazine ec ...... 46

B bacitracin (ophthalmic) ...... 52 bacitracin-polymyxin b (ophth) .............................. 52 bacitracin-poly-neomycin-hc.......................................... 52 baclofen ............................ 37 BACTRIM

see sulfamethoxazole-trimethoprim tab 400-80mg ............................. 14

BACTRIM DS see sulfamethoxazole-trimethop ds .................. 14

balsalazide disodium ........ 46 BALVERSA ....................... 21 balziva .............................. 41 BANZEL SUS 40MG/ML ... 28 BANZEL TAB 200MG ....... 28 BANZEL TAB 400MG ....... 28 BARACLUDE .................... 17

see entecavir ................. 17 BASAGLAR KWIKPEN ..... 38 BCG VACCINE ................. 50 BD ALCOHOL SWABS ..... 38 BD ULTRAFINE INSULIN SYRINGE ......................... 38 BD ULTRAFINE/NANO PEN NEEDLES ......................... 38 bekyree ............................. 41 benazepril & hydrochlorothiazide ........... 22 benazepril hcl ................... 23 BENDEKA ........................ 19 BENICAR

see olmesartan medoxomil ...................................... 24

BENICAR HCT see olmesartan medoxomil-hydrochlorothiazide ....... 23

BENLYSTA ....................... 50 BENZAMYCIN

see benzoyl peroxide-erythromycin.................. 56

benzoyl peroxide-erythromycin ..................... 56 benztropine mesylate inj ... 32 benztropine mesylate tab 0.5mg ................................ 32

63

benztropine mesylate tab 1mg ................................... 32 benztropine mesylate tab 2mg ................................... 32 BEPREVE ......................... 53 BERINERT ........................ 49 BESIVANCE ..................... 52 betamethasone dipropionate (topical) ............................. 57 betamethasone dipropionate augmented ........................ 57 betamethasone valerate ... 57 BETAPACE

see sorine ...................... 24 see sotalol hcl ................ 24

BETAPACE AF see sotalol hcl (afib/afl) .. 24

BETASERON .................... 37 betaxolol hcl (ophth) .......... 53 bethanechol chloride ... 47, 48 BETOPTIC-S .................... 53 BEVESPI AEROSPHERE . 54 bexarotene ........................ 22 BEXSERO......................... 50 BIAXIN XL

see clarithromycin er ..... 18 bicalutamide ...................... 20 BICILLIN L-A ..................... 18 BIKTARVY ........................ 16 BILTRICIDE

see praziquantel ............ 14 bisoprolol & hydrochlorothiazide ........... 25 bisoprolol fumarate ........... 25 BIVIGAM ........................... 49 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 53

BLEPHAMIDE ................... 52 blisovi fe 1.5/30 ................. 41 BONIVA

see ibandronate sodium tabs ............................... 41

BOOSTRIX ....................... 50 BORTEZOMIB .................. 20 bosentan ........................... 27 BOSULIF........................... 21 BRAFTOVI ........................ 21 BREO ELLIPTA ................ 55 briellyn .............................. 41

BRILINTA .......................... 49 brimonidine sol 0.15%....... 53 brimonidine sol 0.2%......... 53 BRIVIACT INJ 50MG/5ML 28 BRIVIACT SOL 10MG/ML 28 BRIVIACT TAB 100MG ..... 28 BRIVIACT TAB 10MG....... 28 BRIVIACT TAB 25MG....... 28 BRIVIACT TAB 50MG....... 28 BRIVIACT TAB 75MG....... 28 bromfenac sodium (ophth) 53 bromocriptine mesylate ..... 32 BROMSITE ....................... 53 BRUKINSA ....................... 21 budesonide (inhalation) ..... 55 budesonide ec .................. 46 bumetanide ....................... 26 BUMEX

see bumetanide ............. 26 BUPHENYL

see sodium phenylbutyrate ...................................... 43

buprenorphine hcl ............. 38 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 38 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 38 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 38 buprenorphine hcl-naloxone hcl dihydrate 8-2mg .......... 38 buprenorphine hcl-naloxone hcl sl.................................. 38 bupropion hcl .................... 31 bupropion hcl (smoking deterrent) .......................... 38 buspirone hcl .................... 28 butorphanol tartrate .......... 11 BYDUREON BCISE .......... 38 BYDUREON PEN ............. 38 BYETTA ............................ 38 BYSTOLIC ........................ 25 C cabergoline ....................... 44 CABOMETYX ................... 21 CAFERGOT

see ergotamine w/ caffeine ...................................... 36

CALAN SR see verapamil hcl tab er 26

calcipotriene ..................... 56 calcitonin (salmon) ............ 44 calcitrene .......................... 57 calcitriol ............................. 52 calcitriol inj ........................ 52 calcitriol oral soln 1 mcg/ml.......................................... 52 calcium acetate (phosphate binder) .............................. 45 CALQUENCE ................... 21 camila ............................... 41 CAMPTOSAR

see irinotecan hcl .......... 22 CANASA

see mesalamine ............ 46 CANCIDAS

see caspofungin acetate 15 CAPLYTA ......................... 33 CAPRELSA ...................... 21 captopril ............................ 23 captopril & hydrochlorothiazide ........... 22 CARAFATE

see sucralfate ................ 47 CARBAGLU ...................... 43 carbamazepine ................. 28 CARBATROL

see carbamazepine ....... 28 carbidopa/levodopa/entacapone .................................... 32 carbidopa-levodopa .......... 32 carboplatin ........................ 22 CARDIZEM

see diltiazem hcl ............ 25 CARDIZEM CD

see cartia xt cap 120/24hr ...................................... 25 see cartia xt cap 180/24hr ...................................... 25 see cartia xt cap 240/24hr ...................................... 25 see cartia xt cap 300/24hr ...................................... 25 see diltiazem cap 240mg cd .................................. 25 see diltiazem cap 360mg cd .................................. 25 see diltiazem hcl coated beads ............................ 26 see diltiazem hcl coated

64

beads cap sr 24hr .......... 26 see diltiazem hcl extended release beads cap sr ..... 26

CARDURA see doxazosin mesylate 23

CARNITOR see levocarnitine (metabolic modifiers) ..... 43

carteolol hcl (ophth) .......... 53 cartia xt cap 120/24hr ....... 25 cartia xt cap 180/24hr ....... 25 cartia xt cap 240/24hr ....... 25 cartia xt cap 300/24hr ....... 25 carvedilol ........................... 25 CASODEX

see bicalutamide ........... 20 caspofungin acetate .......... 15 CATAPRES

see clonidine hcl ............ 27 CATAPRES-TTS-1

see clonidine hcl ptwk ... 27 CATAPRES-TTS-2

see clonidine hcl ptwk ... 27 CATAPRES-TTS-3

see clonidine hcl ptwk ... 27 CAYSTON ......................... 14 caziant pak ........................ 41 cefaclor ............................. 17 CEFACLOR MONOHYDRATE ER ........ 17 cefadroxil........................... 17 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ................ 17 cefazolin inj ....................... 17 cefazolin sodium ............... 17 CEFAZOLIN SODIUM 1 GM/50ML .......................... 17 cefdinir .............................. 17 cefepime hcl ...................... 17 cefixime ............................. 17 cefoxitin sodium ................ 17 cefpodoxime proxetil ......... 17 cefprozil............................. 17 ceftazidime ........................ 17 CEFTAZIDIME/DEXTROSE .......................................... 17 ceftriaxone sodium ............ 17 cefuroxime axetil ............... 17 cefuroxime sodium ............ 17 CELEBREX

see celecoxib ................ 11 celecoxib ........................... 11 CELEXA

see citalopram hydrobromide ................ 31

CELLCEPT see mycophenolate mofetil ...................................... 50

CELONTIN ........................ 28 cephalexin ................... 17, 18 CERDELGA ...................... 43 CEREZYME ...................... 43 cetirizine syrup .................. 54 cevimeline hcl ................... 58 CHANTIX .......................... 38 CHANTIX CONTINUING MONTH ............................. 38 CHANTIX STARTER PACK .......................................... 38 CHEMET ........................... 41 chlorhexidine gluconate (mouth-throat) ................... 59 chloroquine phosphate...... 15 chlorothiazide tabs ............ 26 chlorpromazine hcl ............ 33 CHLORPROMAZINE INJ .. 33 chlorthalidone ................... 26 cholestyramine .................. 24 cholestyramine light pack .. 24 cholestyramine light powd . 24 ciclopirox ........................... 56 cilostazol ........................... 49 CILOXAN .......................... 52

see ciprofloxacin hcl (ophth) ........................... 52

CIMDUO ........................... 16 cinacalcet hcl .................... 44 CIPRO

see ciprofloxacin hcl tab 18 CIPRODEX ....................... 59 ciprofloxacin hcl (ophth) .... 52 ciprofloxacin hcl tab .......... 18 ciprofloxacin in d5w .......... 18 cisplatin ............................. 22 citalopram hydrobromide .. 31 claravis .............................. 56 clarithromycin .................... 18 clarithromycin er ............... 18 clarithromycin for susp ...... 18 CLEOCIN

see clindamycin cap 300mg ........................... 14 see clindamycin cap 75mg ...................................... 14 see clindamycin hcl cap 150 mg .......................... 14 see clindamycin phosphate vaginal ......... 48

CLEOCIN PEDIATRIC GRANULE

see clindamycin soln 75mg/5ml ...................... 14

CLEOCIN PHOSPHATE see clindamycin phosphate inj ................. 14

CLEOCIN-T see clindamycin phosphate (topical) ........ 56

CLIMARA see estradiol .................. 43

clindamycin cap 300mg .... 14 clindamycin cap 75mg ...... 14 clindamycin hcl cap 150 mg.......................................... 14 clindamycin phosphate (topical) ............................. 56 clindamycin phosphate in d5w ................................... 14 CLINDAMYCIN PHOSPHATE IN NACL .... 14 clindamycin phosphate inj . 14 clindamycin phosphate vaginal .............................. 48 clindamycin soln 75mg/5ml.......................................... 14 CLINIMIX 4.25%/DEXTROSE 5% ..... 51 CLINIMIX 5%/DEXTROSE 15% .................................. 51 CLINIMIX 5%/DEXTROSE 20% .................................. 51 CLINIMIX INJ 4.25/D10 .... 51 clinisol sf 15% ................... 51 CLINOLIPID ...................... 51 clobazam .......................... 28 clomipramine hcl ............... 31 clonazepam ...................... 28 clonidine hcl ...................... 27 clonidine hcl ptwk.............. 27 clopidogrel tab 75mg ........ 49

65

clorazepate dipotassium ... 28 clotrimazole ....................... 59 clotrimazole (topical) ......... 56 clotrimazole w/ betamethasone ................. 56 clozapine odt ..................... 33 clozapine tab 100mg ......... 33 clozapine tab 200mg ......... 33 clozapine tab 25mg ........... 33 clozapine tab 50mg ........... 33 CLOZARIL

see clozapine tab 100mg ...................................... 33 see clozapine tab 200mg ...................................... 33 see clozapine tab 25mg 33 see clozapine tab 50mg 33

COARTEM ........................ 15 COGENTIN

see benztropine mesylate inj ................................... 32

COLAZAL see balsalazide disodium ...................................... 46

colchicine w/ probenecid ... 11 COLCRYS ......................... 11 colesevelam hcl ................ 24 COLESTID

see colestipol hcl gran ... 24 see colestipol hcl pack .. 24 see colestipol hcl tabs ... 24

colestipol hcl gran ............. 24 colestipol hcl pack ............. 24 colestipol hcl tabs .............. 24 colistimethate sodium ....... 14 colocort ............................. 46 COLY-MYCIN M

see colistimethate sodium ...................................... 14

COMBIGAN ...................... 53 COMBIVENT RESPIMAT . 54 COMBIVIR

see lamivudine-zidovudine ...................................... 16

COMETRIQ ....................... 21 COMPLERA ...................... 16 compro .............................. 45 COMTAN

see entacapone ............. 32 constulose ......................... 46

COPAXONE see glatiramer acetate 20mg/ml ........................ 37 see glatiramer acetate 40mg/ml ........................ 37 see glatopa .................... 37

COPIKTRA ....................... 21 COREG

see carvedilol ................ 25 CORGARD

see nadolol .................... 25 CORLANOR ..................... 27 CORTEF

see hydrocortisone ........ 44 CORTENEMA

see colocort ................... 46 see hydrocortisone (enema) ......................... 46

cortisone acetate .............. 44 COSOPT

see dorzolamide hcl-timolol maleate .............. 53

COTELLIC ........................ 21 COUMADIN ...................... 48

see jantoven .................. 48 see warfarin sodium ...... 48

COZAAR see losartan potassium . 24

CREON ............................. 47 CRESTOR

see rosuvastatin calcium ...................................... 24

CRIXIVAN ......................... 15 cromolyn sodium (mastocytosis) ................... 47 cromolyn sodium (ophth) .. 53 cromolyn sodium nebu ...... 55 cryselle-28 ........................ 41 CUBICIN

see daptomycin ............. 14 cyclafem 1/35 .................... 41 cyclafem 7/7/7 ................... 41 cyclobenzaprine hcl .......... 37 cyclophosphamide ............ 19 cycloserine ........................ 16 cyclosporine ...................... 50 cyclosporine modified (for microemulsion) ................. 50 CYKLOKAPRON

see tranexamic acid ...... 49

CYMBALTA see duloxetine hcl ......... 31

cyproheptadine hcl............ 54 cyred tab ........................... 41 CYSTADANE .................... 43 CYSTAGON ..................... 43 CYSTARAN ...................... 54 cytarabine ......................... 19 CYTOMEL

see liothyronine sodium 45 CYTOTEC

see misoprostol ............. 47 CYTOVENE

see ganciclovir sodium .. 17 D D.H.E. 45

see dihydroergotamine mesylate inj 1 mg/ml ..... 36

dalfampridine .................... 37 DALIRESP ........................ 55 danazol ............................. 43 DANTRIUM

see dantrolene sodium .. 38 dantrolene sodium ............ 38 dapsone ............................ 14 DAPTACEL ....................... 50 daptomycin ....................... 14 DAPTOMYCIN

see daptomycin ............. 14 dasetta 1/35 ...................... 41 dasetta 7/7/7 ..................... 41 DAURISMO ...................... 20 DDAVP

see desmopressin acetate spray ............................. 45 see desmopressin acetate tabs ............................... 45 see desmopressin inj 4mcg/ml ........................ 45

deblitane ........................... 41 deferasirox ........................ 41 DELESTROGEN............... 43

see estradiol valerate .... 43 DELSTRIGO ..................... 16 DELZICOL

see mesalamine ............ 46 DEMSER .......................... 27 DEPAKOTE

see divalproex sodium .. 28 DEPAKOTE ER

66

see divalproex sodium ... 28 DEPAKOTE SPRINKLES

see divalproex sodium ... 28 DEPEN TITRATABS ......... 41

see penicillamine ........... 41 DEPO-MEDROL

see methylprednisolone acetate........................... 44

DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 42

DEPO-PROVERA INJ 400/ML .............................. 20 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 38

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 57

DERMA-SMOOTHE/FS SCALP

see fluocinolone acetonide oil body .......................... 57

DERMOTIC see flac .......................... 59 see fluocinolone acetonide (otic) .............................. 59

DESCOVY ........................ 16 desipramine hcl ................. 31 desmopressin acetate spray .......................................... 45 desmopressin acetate spray refrigerated ........................ 45 desmopressin acetate tabs .......................................... 45 desmopressin inj 4mcg/ml. 45 desogestrel & ethinyl estradiol ............................ 41 desogestrel-ethinyl estradiol (biphasic) .......................... 41 desvenlafaxine succinate .. 31 DETROL

see tolterodine tartrate tabs ............................... 48

DETROL LA see tolterodine tartrate cap er ................................... 48

dexamethasone ................ 44

DEXAMETHASONE ......... 44 DEXAMETHASONE SODIUM PHOS

see dexamethasone sodium phosphate ......... 44

dexamethasone sodium phosphate ......................... 44 dexamethasone sodium phosphate (ophth) ............. 53 DEXILANT ........................ 47 dexmethylphenidate hcl .... 35 dextrose 10% flex contain . 51 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 51 dextrose 10%/nacl 0.45% . 51 dextrose 2.5%/nacl 0.45% 51 dextrose 5% ...................... 51 DEXTROSE 5% /ELECTROLYTE ............... 51 dextrose 5%/nacl 0.2% ..... 51 dextrose 5%/nacl 0.225% . 51 DEXTROSE 5%/NACL 0.3% .......................................... 51 dextrose 5%/nacl 0.45% ... 51 dextrose 5%/nacl 0.9% ..... 51 dextrose 5%/potassium chl .......................................... 51 dextrose 50% .................... 52 dextrose in lactated ringers .......................................... 52 dextrose inj 70% ............... 52 DIASTAT ACUDIAL .......... 28 DIASTAT PEDIATRIC....... 28 diazepam .......................... 28 diazepam gel .................... 28 diazepam inj ...................... 28 diazepam intensol ............. 28 diazepam oral soln 1 mg/ml .......................................... 28 diclofenac potassium ........ 11 diclofenac sodium ............. 11 diclofenac sodium (ophth) . 53 diclofenac sodium (topical) 1% gel ............................... 58 dicloxacillin sodium ........... 18 dicyclomine hcl cap 10mg . 46 dicyclomine hcl soln 10mg/5ml .......................... 46 dicyclomine hcl tab 20mg .. 46

didanosine ........................ 15 DIFICID ............................. 18 DIFLUCAN

see fluconazole ............. 15 diflunisal ............................ 11 digitek ............................... 26 digox ................................. 26 digoxin .............................. 26 digoxin inj .......................... 26 digoxin sol 50mcg/ml ........ 26 dihydroergotamine mesylate inj 1 mg/ml ........................ 36 dihydroergotamine mesylate nasal spr 4 mg/ml ............. 36 DILANTIN

see phenytoin sodium extended ....................... 29

DILANTIN CAP 100MG .... 28 DILANTIN CAP 30MG ...... 28 DILANTIN CHEW TAB 50MG ................................ 28 DILANTIN INFATABS

see phenytoin ................ 29 DILANTIN-125

see phenytoin ................ 29 DILANTIN-125 SUSP ....... 28 DILAUDID

see hydromorphone hcl . 12 diltiazem cap 240mg cd .... 25 diltiazem cap 360mg cd .... 25 diltiazem cap er/12hr ........ 25 diltiazem hcl ...................... 25 diltiazem hcl coated beads 26 diltiazem hcl coated beads cap sr 24hr ........................ 26 diltiazem hcl extended release beads cap sr ........ 26 diltiazem inj ....................... 26 dilt-xr cap .......................... 25 DIOVAN

see valsartan ................. 24 DIOVAN HCT

see valsartan-hydrochlorothiazide ....... 23

diphenhydramine hcl inj 50mg/ml ............................ 54 diphenoxylate w/ atropine . 47 DIPHTHERIA/TETANUS TOXOID ............................ 50 DIPROLENE

67

see betamethasone dipropionate augmented 57

DIPROLENE AF see betamethasone dipropionate augmented 57

disopyramide phosphate ... 24 disulfiram........................... 38 DITROPAN XL

see oxybutynin chloride . 48 divalproex sodium ............. 28 docetaxel........................... 19 DOCETAXEL .................... 19

see docetaxel ................ 19 dofetilide............................ 24 DOLOPHINE

see methadone hcl 10mg ...................................... 12 see methadone hcl 5mg 12

donepezil hydrochloride .... 30 dorzolamide hcl ................. 53 dorzolamide hcl-timolol maleate ............................. 53 DOVATO ........................... 16 DOVONEX

see calcipotriene ........... 56 doxazosin mesylate .......... 23 doxepin hcl ........................ 31 doxepin hcl (sleep) ............ 36 DOXIL

see doxorubicin hcl liposomal ....................... 19

doxorubicin hcl .................. 19 doxorubicin hcl liposomal .. 19 doxy 100 ........................... 19 doxycycline (monohydrate) .......................................... 19 doxycycline hyclate ........... 19 DRIZALMA SPRINKLE ..... 31 dronabinol ......................... 46 drospirenone-ethinyl estradiol ............................ 41 DROXIA ............................ 49 duloxetine hcl .................... 31 DURAGESIC

see fentanyl patch 100 mcg/hr ........................... 12 see fentanyl patch 12 mcg/hr ........................... 12 see fentanyl patch 25 mcg/hr ........................... 12

see fentanyl patch 50 mcg/hr ........................... 12 see fentanyl patch 75 mcg/hr ........................... 12

DUREZOL ......................... 53 dutasteride ........................ 47 dutasteride-tamsulosin hcl 47 DYAZIDE

see triamterene & hydrochlorothiazide cap 37.5-25 mg .................... 26

E e.e.s 400 ........................... 18 EC-NAPROSYN

see naproxen dr ............ 11 EC-NAPROXEN

see naproxen dr ............ 11 EDURANT ........................ 15 efavirenz ........................... 15 EFFEXOR XR

see venlafaxine hcl ........ 32 EFFIENT

see prasugrel hcl ........... 49 EFUDEX

see fluorouracil (topical) 58 eletriptan hydrobromide .... 36 ELIMITE

see permethrin cre 5% .. 58 ELIQUIS ............................ 48 ELIQUIS STARTER PACK .......................................... 48 ELLA ................................. 41 ELLENCE

see epirubicin hcl .......... 19 ELOCON

see mometasone furoate ...................................... 57

eluryng .............................. 41 EMCYT ............................. 19 EMEND ............................. 46

see aprepitant ............... 45 EMGALITY ........................ 36 emoquette ......................... 41 EMSAM ............................. 31 EMTRIVA .......................... 15 EMVERM .......................... 14 enalapril maleate .............. 23 enalapril maleate & hydrochlorothiazide ........... 22 ENDARI ............................ 49

endocet 10-325mg ............ 12 endocet 2.5-325mg ........... 12 endocet 5-325mg .............. 12 endocet 7.5-325mg ........... 12 ENGERIX-B ...................... 50 enoxaparin sodium ........... 48 enpresse-28 ...................... 41 enskyce ............................ 41 ENSTILAR ........................ 57 entacapone ....................... 32 entecavir ........................... 17 ENTOCORT EC

see budesonide ec ........ 46 ENTRESTO ...................... 23 enulose ............................. 46 EPCLUSA ......................... 17 EPIDIOLEX ....................... 28 epinephrine (anaphylaxis) . 55 EPIPEN 2-PAK

see epinephrine (anaphylaxis) ................. 55

EPIPEN-JR 2-PAK see epinephrine (anaphylaxis) ................. 55

epirubicin hcl ..................... 19 epitol ................................. 28 EPIVIR

see lamivudine .............. 16 EPIVIR HBV ..................... 17

see lamivudine (hbv) ..... 17 eplerenone ........................ 23 EPZICOM

see abacavir sulfate-lamivudine ..................... 16

ergotamine w/ caffeine ...... 36 ERIVEDGE ....................... 20 ERLEADA ......................... 20 erlotinib hcl ....................... 21 errin .................................. 41 ertapenem sodium ............ 14 ery pad 2% ....................... 56 ERYGEL

see erythromycin (acne aid) ................................ 56

ery-tab .............................. 18 ERYTHROCIN LACTOBIONATE .............. 18 erythrocin stearate ............ 18 erythromycin (acne aid) .... 56 erythromycin (ophth) ......... 52

68

erythromycin base ............. 18 erythromycin cap 250mg ec .......................................... 18 erythromycin ethylsuccinate .......................................... 18 erythromycin tab ec ........... 18 ESBRIET........................... 55 escitalopram oxalate ......... 31 esomeprazole magnesium 47 estarylla tab 0.25-35 ......... 41 ESTRACE

see estradiol .................. 43 see estradiol vaginal cream ............................ 43

estradiol ............................ 43 estradiol vaginal cream ..... 43 estradiol vaginal tab .......... 43 estradiol valerate ............... 43 ESTROSTEP FE

see tilia fe ...................... 43 see tri-legest fe .............. 43

ethambutol hcl ................... 17 ethosuximide ..................... 28 ethynodiol diacet & eth estrad ................................ 41 ethynodiol tab 1-50 ........... 41 etodolac ............................ 11 etodolac er ........................ 11 etonogestrel-ethinyl estradiol .......................................... 41 etoposide .......................... 22 euthyrox ............................ 45 everolimus......................... 21 EVISTA

see raloxifene hcl .......... 45 EVOTAZ............................ 16 EVOXAC

see cevimeline hcl ......... 58 EXELON

see rivastigmine td patch 24hr 13.3 mg/24hr ......... 31 see rivastigmine td patch 24hr 4.6 mg/24hr ........... 30 see rivastigmine td patch 24hr 9.5 mg/24hr ........... 30

exemestane ...................... 20 EXFORGE

see amlodipine besylate-valsartan tab 10-160 mg 23 see amlodipine besylate-

valsartan tab 10-320 mg 23 see amlodipine besylate-valsartan tab 5-160 mg .. 23 see amlodipine besylate-valsartan tab 5-320 mg .. 23

EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg ................... 23 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ...................... 23 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ...................... 23 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg .......................... 23 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ............................. 23

ezetimibe .......................... 24 F FABRAZYME .................... 43 falmina .............................. 41 famciclovir ......................... 17 famotidine ......................... 46 famotidine in nacl .............. 46 famotidine inj ..................... 46 FANAPT ............................ 33 FANAPT TITRATION PACK .......................................... 33 FARESTON

see toremifene citrate .... 20 FARXIGA .......................... 39 FARYDAK ......................... 20 FASLODEX

see fulvestrant ............... 20 felbamate .......................... 28 FELBATOL

see felbamate ................ 28 FELDENE

see piroxicam ................ 11 felodipine .......................... 26 FEMARA

see letrozole .................. 20 FEMHRT LOW DOSE

see fyavolv .................... 43 see norethindrone acetate-ethinyl estradiol ............. 43

femynor ............................. 41 fenofibrate ......................... 24 fenofibrate micronized ...... 24 fentanyl citrate .................. 12 fentanyl patch 100 mcg/hr 12 fentanyl patch 12 mcg/hr .. 12 fentanyl patch 25 mcg/hr .. 12 fentanyl patch 50 mcg/hr .. 12 fentanyl patch 75 mcg/hr .. 12 FETZIMA .......................... 31 FETZIMA TITRATION PACK.......................................... 31 FIASP ............................... 38 FIASP FLEXTOUCH ......... 38 FIASP PENFILL ................ 39 finasteride ......................... 47 FIRAZYR

see icatibant acetate ..... 49 flac .................................... 59 FLAGYL

see metronidazole ......... 14 flecainide acetate .............. 24 FLOMAX

see tamsulosin hcl ......... 47 FLOVENT DISKUS ........... 55 FLOVENT HFA ................. 55 fluconazole ....................... 15 fluconazole inj nacl 200 .... 15 fluconazole inj nacl 400 .... 15 flucytosine ......................... 15 fludrocortisone acetate ..... 44 flunisolide (nasal) .............. 55 fluocinolone acetonide ...... 57 fluocinolone acetonide (otic).......................................... 59 fluocinolone acetonide oil body .................................. 57 fluocinonide ...................... 57 fluocinonide emulsified base.......................................... 57 fluorometholone ................ 53 fluorouracil ........................ 19 fluorouracil (topical) .......... 58 fluoxetine cap 10mg .......... 31 fluoxetine cap 20mg .......... 31 fluoxetine cap 40mg .......... 31 fluoxetine hcl ..................... 31 fluphenazine decanoate .... 33 fluphenazine hcl ................ 33 flurbiprofen ........................ 11

69

flurbiprofen sodium ........... 53 flutamide ........................... 20 fluticasone propionate ....... 57 fluticasone propionate (nasal) ............................... 55 fluvoxamine maleate ......... 28 FOCALIN

see dexmethylphenidate hcl .................................. 35

fondaparinux sodium ......... 48 FORTEO ........................... 44 FOSAMAX

see alendronate sodium 41 fosamprenavir tab 700 mg 15 fosinopril sodium ............... 23 fosinopril sodium & hydrochlorothiazide ........... 22 FREAMINE HBC 6.9% ...... 51 FREAMINE III ................... 51 fulvestrant ......................... 20 furosemide ........................ 26 furosemide inj .................... 26 FUZEON ........................... 15 fyavolv ............................... 43 FYCOMPA ........................ 29 G gabapentin ........................ 29 GABITRIL

see tiagabine hcl ........... 30 galantamine hydrobromide 30 galantamine hydrobromide er ....................................... 30 GAMASTAN S/D ............... 49 GAMMAGARD LIQUID ..... 49 GAMMAGARD S/D ........... 49 GAMMAKED ..................... 49 GAMMAPLEX ................... 50 GAMMAPLEX 10GM/100ML .......................................... 50 GAMUNEX-C .................... 50 ganciclovir sodium ............ 17 GARDASIL 9 ..................... 50 GASTROCROM

see cromolyn sodium (mastocytosis) ............... 47

gatifloxacin (ophth) ............ 52 GATTEX............................ 47 GAUZE PADS 2 ................ 39 gavilyte-c ........................... 46 gavilyte-g........................... 46

gavilyte-n/flavor pack ........ 46 GEMCITABINE

see gemcitabine inj soln 19 gemcitabine inj soln .......... 19 gemcitabine inj solr ........... 19 gemfibrozil ........................ 24 generlac ............................ 46 gengraf .............................. 50 GENOTROPIN .................. 44 GENOTROPIN MINIQUICK .......................................... 44 gentak ............................... 53 gentamicin in saline .......... 13 gentamicin sulfate ............. 13 gentamicin sulfate (topical) .......................................... 56 gentamicin sulfate soln (ophth) .............................. 53 GENVOYA ........................ 16 GEODON .......................... 33

see ziprasidone hcl........ 34 gianvi ................................ 41 GILENYA CAP 0.5MG ...... 37 GILOTRIF TAB 20MG....... 21 GILOTRIF TAB 30MG....... 21 GILOTRIF TAB 40MG....... 21 glatiramer acetate 20mg/ml .......................................... 37 glatiramer acetate 40mg/ml .......................................... 37 glatopa .............................. 37 GLEEVEC

see imatinib mesylate .... 21 GLEOSTINE ..................... 19 glimepiride ........................ 39 glip/metform tab 2.5-250mg .......................................... 39 glip/metform tab 2.5-500mg .......................................... 39 glip/metform tab 5-500mg . 39 glipizide ............................. 39 glipizide xl ......................... 39 GLUCAGEN HYPOKIT ..... 44 GLUCAGON EMERGENCY KIT .................................... 44 GLUCOTROL

see glipizide .................. 39 GLUCOTROL XL

see glipizide .................. 39 see glipizide xl ............... 39

glycopyrrolate tab 1mg ..... 46 glycopyrrolate tab 2mg ..... 46 glydo ................................. 58 GOLYTELY ....................... 46

see gavilyte-g ................ 46 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........................... 47

granisetron hcl .................. 46 griseofulvin microsize ....... 15 griseofulvin ultramicrosize 15 guanfacine er (adhd) ......... 35 H HAEGARDA ..................... 49 HALDOL

see haloperidol lactate inj 5mg/ml .......................... 33

HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 33

HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 33

halobetasol propionate ..... 57 haloperidol ........................ 33 haloperidol conc 2mg/ml ... 33 haloperidol decanoate ...... 33 haloperidol lactate inj 5mg/ml.......................................... 33 HARVONI ......................... 17 HAVRIX ............................ 50 heather ............................. 41 heparin sod (porcine) in d5w.......................................... 48 heparin sod inj 1000/ml ..... 48 heparin sod inj 10000/ml ... 48 heparin sod inj 20000/ml ... 48 heparin sod inj 5000/ml ..... 48 HEPARIN SODIUM/NACL 0.45% ............................... 48 hepatamine ....................... 51 HEPSERA

see adefovir dipivoxil ..... 17 HERCEPTIN ..................... 20 HERCEPTIN HYLECTA ... 20 HETLIOZ .......................... 36 HIBERIX ........................... 50 HIPREX

see methenamine hippurate ....................... 14

70

HUMIRA ............................ 49 HUMIRA INJ 10MG/0.2ML 49 HUMIRA KIT 20MG/0.4ML 49 HUMIRA KIT 40MG/0.8ML 49 HUMIRA PEDIATRIC CROHNS DISEASE .......... 49 HUMIRA PEN ................... 49 HUMIRA PEN CD/UC/HS STARTER ......................... 49 HUMIRA PEN INJ CD/UC/HS STARTER ....... 49 HUMIRA PEN INJ PS/UV STARTER ......................... 49 HUMIRA PEN-PS/UV STARTER ......................... 49 HUMULIN R INJ U-500 ..... 39 HUMULIN R U-500 KWIKPEN ......................... 39 hydralazine hcl .................. 27 HYDREA

see hydroxyurea ............ 22 hydrochlorothiazide ........... 26 hydroco/apap tab 10-325mg .......................................... 12 hydroco/apap tab 5-325mg .......................................... 12 hydroco/apap tab 7.5-325 . 12 hydrocodone-acetaminophen 7.5-325 mg/15ml ............... 12 hydrocodone-ibuprofen tab 7.5-200 mg ........................ 12 hydrocortisone .................. 44 hydrocortisone (enema) .... 46 hydrocortisone (topical) cream 1% .......................... 57 hydrocortisone (topical) cream 2.5% ....................... 57 hydrocortisone (topical) lotion 2.5% ........................ 57 hydrocortisone (topical) oint 2.5% .................................. 57 hydrocortisone butyrate cream 0.1% ....................... 57 hydrocortisone butyrate oint 0.1% .................................. 57 hydromorphone hcl ........... 12 hydroxychloroquine sulfate .......................................... 49 hydroxyurea ...................... 22 hydroxyzine hcl ................. 54

hydroxyzine hcl inj ............ 54 hydroxyzine pamoate ........ 54 HYSINGLA ER .................. 12 HYZAAR

see losartan-hydrochlorothiazide ....... 23

I ibandronate sodium tabs... 41 IBRANCE .......................... 20 ibu tab 600mg ................... 11 ibu tab 800mg ................... 11 ibuprofen ........................... 11 icatibant acetate ................ 49 ICLUSIG ........................... 21 IDHIFA .............................. 20 ILEVRO ............................. 53 imatinib mesylate .............. 21 IMBRUVICA ...................... 21 imipenem-cilastatin ........... 14 imipramine hcl ................... 31 imiquimod ......................... 58 IMITREX

see sumatriptan ............. 36 see sumatriptan inj 6mg/0.5ml ..................... 37 see sumatriptan succinate ...................................... 37

IMITREX STATDOSE REFILL

see sumatriptan inj 4mg/0.5ml ..................... 37 see sumatriptan inj 6mg/0.5ml ..................... 37

IMITREX STATDOSE SYSTEM

see sumatriptan inj 4mg/0.5ml ..................... 36 see sumatriptan inj 6mg/0.5ml ..................... 37

IMOVAX RABIES (H.D.C.V.) .......................................... 50 IMURAN

see azathioprine ............ 50 incassia ............................. 41 INCRELEX ........................ 44 INCRUSE ELLIPTA .......... 54 indapamide ....................... 26 INDERAL LA

see propranolol cap er ... 25 INFANRIX ......................... 50

INLYTA ............................. 21 INREBIC ........................... 21 INSPRA

see eplerenone ............. 23 INSULIN PEN NEEDLE .... 39 INSULIN SAFETY NEEDLES ......................... 39 INSULIN SYRINGE .......... 39 INTELENCE ..................... 15 INTRALIPID 30% .............. 51 INTRALIPID INJ 20% ....... 51 INTRON-A INJ 10MU ....... 50 INTRON-A INJ 18MU ....... 50 INTRON-A INJ 25MU ....... 50 INTRON-A INJ 50MU ....... 50 introvale ............................ 41 INTUNIV

see guanfacine er (adhd) ...................................... 35

INVANZ see ertapenem sodium .. 14

INVEGA see paliperidone ............ 34

INVEGA SUST INJ 117 MG/0.75 ML ...................... 33 INVEGA SUST INJ 156MG/ML ........................ 33 INVEGA SUST INJ 234 MG/1.5 ML ........................ 33 INVEGA SUST INJ 39 MG/0.25 ML ...................... 33 INVEGA SUST INJ 78 MG/0.5 ML ........................ 33 INVEGA TRINZA .............. 33 INVIRASE ......................... 15 IONOSOL-MB/DEXTROSE 5% .................................... 52 IPOL INACTIVATED IPV .. 50 ipratropium bromide .......... 54 ipratropium bromide (nasal).......................................... 54 ipratropium-albuterol nebu 54 irbesartan .......................... 24 irbesartan-hydrochlorothiazide ........... 23 IRESSA ............................ 21 irinotecan hcl .................... 22 ISENTRESS ..................... 15 ISENTRESS HD ............... 15 isibloom ............................ 42

71

ISOLYTE P ....................... 52 ISOLYTE S ....................... 52 isoniazid ............................ 17 isoniazid syp 50mg/5ml ..... 17 ISOPTO CARPINE

see pilocarpine hcl ......... 53 ISORDIL TITRADOSE

see isosorbide dinitrate . 27 isosorb mononitrate tab .... 27 isosorbide dinitrate ............ 27 isosorbide mononitrate er . 27 isotretinoin......................... 56 isradipine........................... 26 ISTALOL

see timolol maleate ophth soln 0.5% (once-daily) ... 53

itraconazole ....................... 15 ivermectin.......................... 14 IXIARO .............................. 50 J JADENU............................ 41

see deferasirox .............. 41 JADENU SPRINKLE ......... 41 JAKAFI .............................. 21 JALYN

see dutasteride-tamsulosin hcl .................................. 47

jantoven ............................ 48 JANUMET ......................... 39 JANUMET XR TAB 100-1000 .................................. 40 JANUMET XR TAB 50-1000 .......................................... 40 JANUMET XR TAB 50-500MG .............................. 40 JANUVIA ........................... 40 JARDIANCE ...................... 40 jasmiel ............................... 42 JENTADUETO .................. 40 JENTADUETO TAB XR 2.5-1000 MG ........................... 40 JENTADUETO TAB XR 5-1000 MG ........................... 40 jinteli .................................. 43 jolessa tab 0.15-0.03 mg ... 42 jolivette .............................. 42 juleber ............................... 42 JULUCA ............................ 16 junel 1.5/30 ....................... 42 junel 1/20 .......................... 42

junel fe 1.5/30 ................... 42 junel fe 1/20 ...................... 42 JUXTAPID ........................ 24 K KADCYLA ......................... 20 KALETRA

see lopinavir-ritonavir .... 16 KALETRA TAB 100-25MG 16 KALETRA TAB 200-50MG 16 KALYDECO ...................... 55 KANJINTI .......................... 20 kariva ................................ 42 kcl 0.075%/d5w/nacl 0.45% .......................................... 52 KCL 0.15%/D5W/NACL 0.225% .............................. 52 kcl 0.15%/d5w/nacl 0.9% .. 52 kcl 0.3%/d5w/nacl 0.45% .. 52 KCL 0.3%/D5W/NACL 0.9% .......................................... 52 kcl/d5w inj 0.3% ................ 52 kcl/d5w/nacl inj .15/.45% ... 52 kcl/d5w/nacl inj 0.22%/0.45% .......................................... 52 kcl/nacl inj 0.15%-0.9% ..... 52 kcl/nacl inj 0.3-0.9 ............. 52 kcl0.15%/d5w/nacl0.2% .... 52 KEFLEX

see cephalexin .............. 17 kelnor 1/35 ........................ 42 kelnor 1/50 ........................ 42 KEPPRA

see levetiracetam .......... 29 see levetiracetam oral soln 100 mg/ml ..................... 29 see roweepra ................ 30

KEPPRA XR see levetiracetam .......... 29 see roweepra xr ............ 30

ketoconazole ..................... 15 ketoconazole cream .......... 56 ketoconazole shampoo ..... 57 ketorolac tromethamine (ophth) .............................. 53 KEYTRUDA ...................... 20 KINRIX .............................. 50 kionex sus 15gm/60ml ...... 41 KISQALI ............................ 20 KISQALI FEMARA 200 DOSE ................................ 20

KISQALI FEMARA 400 DOSE ............................... 20 KISQALI FEMARA 600 DOSE ............................... 20 KITABIS PAK

see tobramycin .............. 13 KLARON

see sulfacetamide sodium (acne) ............................ 56

KLONOPIN see clonazepam ............ 28

klor-con 10 ........................ 51 klor-con 8 .......................... 51 klor-con m10 ..................... 51 klor-con m15 ..................... 51 klor-con m20 ..................... 51 klor-con pak 20meq .......... 51 klor-con spr cap 10meq .... 51 klor-con spr cap 8meq ...... 51 KORLYM .......................... 44 K-TAB

see potassium chloride . 51 kurvelo .............................. 42 KUVAN ............................. 43 L labetalol hcl ....................... 25 lactated ringer's ................ 52 lactulose ........................... 46 lactulose (encephalopathy).......................................... 46 LAMICTAL

see lamotrigine .............. 29 see subvenite tab .......... 30

LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 29 LAMICTAL XR

see lamotrigine .............. 29 LAMISIL

see terbinafine hcl ......... 15 lamivudine ........................ 16 lamivudine (hbv) ............... 17 lamivudine-zidovudine ...... 16 lamotrigine ........................ 29 LANOXIN

see digitek ..................... 26 see digox ....................... 26 see digoxin .................... 26 see digoxin inj ............... 26

lansoprazole ..................... 47

72

larin 1.5/30 ........................ 42 larin 1/20 ........................... 42 larin fe 1.5/30 .................... 42 larin fe 1/20 ....................... 42 larissia tab ......................... 42 LASIX

see furosemide .............. 26 LASTACAFT ..................... 53 latanoprost ........................ 53 LATUDA ............................ 33 leena ................................. 42 leflunomide ........................ 49 LENVIMA 10 MG DAILY DOSE ................................ 21 LENVIMA 12MG DAILY DOSE ................................ 21 LENVIMA 14 MG DAILY DOSE ................................ 21 LENVIMA 18 MG DAILY DOSE ................................ 21 LENVIMA 20 MG DAILY DOSE ................................ 21 LENVIMA 24 MG DAILY DOSE ................................ 21 LENVIMA 4 MG DAILY DOSE ................................ 21 LENVIMA 8 MG DAILY DOSE ................................ 21 lessina ............................... 42 LETAIRIS

see ambrisentan ............ 27 letrozole ............................ 20 leucovorin calcium ............ 22 LEUKERAN ....................... 19 leuprolide inj 1mg/0.2 ........ 20 levalbuterol hcl .................. 54 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ........... 54 levalbuterol tartrate hfa ..... 54 LEVAQUIN

see levofloxacin ............. 18 LEVEMIR .......................... 39 LEVEMIR FLEXTOUCH.... 39 levetiracetam ..................... 29 LEVETIRACETAM

see levetiracetam in sodium chloride ............. 29

levetiracetam in sodium chloride ............................. 29 levetiracetam oral soln 100

mg/ml ................................ 29 levobunolol hcl .................. 53 levocarnitine (metabolic modifiers) .......................... 43 levocetirizine dihydrochloride .......................................... 54 levofloxacin ....................... 18 levofloxacin in d5w ............ 18 levofloxacin inj 25mg/ml .... 18 levofloxacin oral soln 25 mg/ml ................................ 18 levonest ............................ 42 levonor/ethi tab ................. 42 levonorgestrel & eth estradiol .......................................... 42 levonorgestrel-ethinyl estradiol (91-day) .............. 42 levora 0.15/30-28 .............. 42 levo-t ................................. 45 levothyroxine sodium ........ 45 levoxyl ............................... 45 LEXAPRO

see escitalopram oxalate ...................................... 31

LEXIVA ............................. 16 see fosamprenavir tab 700 mg ................................. 15

LIALDA see mesalamine ............ 46

lidocaine ............................ 58 lidocaine hcl ...................... 58 lidocaine hcl (local anesth.) .......................................... 13 lidocaine hcl (mouth-throat) .......................................... 59 lidocaine inj 0.5% .............. 13 lidocaine inj 1% ................. 13 lidocaine inj 1.5% preservative free (pf) ......... 13 lidocaine oint 5% ............... 58 lidocaine-prilocaine ........... 58 LIDODERM

see lidocaine ................. 58 linezolid in sodium chloride .......................................... 14 linezolid inj ........................ 14 linezolid susp .................... 14 linezolid tab 600mg ........... 14 LINZESS ........................... 47 liothyronine sodium ........... 45

LIPITOR see atorvastatin calcium 24

lisinopril ............................. 23 lisinopril & hydrochlorothiazide ........... 22 lithium carbonate .............. 37 lithium carbonate er .......... 37 LITHIUM SOLN 8MEQ/5ML.......................................... 37 LITHOBID

see lithium carbonate er 37 LOCOID

see hydrocortisone butyrate cream 0.1% ..... 57

LODINE see etodolac .................. 11

LOESTRIN 1.5/30-21 see junel 1.5/30 ............. 42 see larin 1.5/30.............. 42 see microgestin 1.5/30 .. 42

LOESTRIN 1/20-21 see junel 1/20 ................ 42 see larin 1/20................. 42 see microgestin 1/20 ..... 42 see norethindrone acet & eth estra ........................ 42

LOESTRIN FE 1.5/30 see blisovi fe 1.5/30 ...... 41 see junel fe 1.5/30 ......... 42 see larin fe 1.5/30 .......... 42 see microgestin fe 1.5/30 ...................................... 42

LOESTRIN FE 1/20 see junel fe 1/20 ............ 42 see larin fe 1/20............. 42 see microgestin fe 1/20 . 42 see tarina fe 1/20 .......... 43

LOKELMA ......................... 41 LOMOTIL

see diphenoxylate w/ atropine ......................... 47

LONSURF ........................ 22 loperamide hcl .................. 47 LOPID

see gemfibrozil .............. 24 lopinavir-ritonavir .............. 16 LOPRESSOR

see metoprolol tartrate .. 25 LOPRESSOR HCT

see metoprolol & hctz tab

73

50-25mg ........................ 25 LOPROX

see ciclopirox ................. 56 lorazepam ......................... 28 lorazepam intensol ............ 28 LORBRENA ...................... 21 lorcet hd tab 10-325mg ..... 12 lorcet plus tab 7.5-325 ...... 12 lorcet tab 5-325mg ............ 12 loryna ................................ 42 losartan potassium ............ 24 losartan-hydrochlorothiazide .......................................... 23 LOTEMAX ......................... 53

see loteprednol etabonate ...................................... 53

LOTENSIN see benazepril hcl ......... 23

LOTENSIN HCT see benazepril & hydrochlorothiazide ....... 22

loteprednol etabonate ....... 53 LOTREL

see amlodipine--benazepril hcl cap 10-20 mg ................................. 22 see amlodipine-benazepril hcl cap 10-40mg ............ 22 see amlodipine-benazepril hcl cap 5-10 mg ............. 22 see amlodipine-benazepril hcl cap 5-20 mg ............. 22

LOTRISONE see clotrimazole w/ betamethasone .............. 56

LOTRONEX see alosetron hcl ........... 47

lovastatin ........................... 24 LOVENOX

see enoxaparin sodium . 48 low-ogestrel ....................... 42 loxapine succinate ............ 33 LUMIGAN.......................... 53 LUMIZYME ....................... 43 LUPRON DEPOT (1-MONTH)............................ 20 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 20 LUPRON DEPOT-PED (1-MONTH ............................. 44

LUPRON DEPOT-PED (3-MONTH ............................. 44 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 44 LUPRON DEP-PED INJ 7.5MG ............................... 44 lutera ................................. 42 LYNPARZA ....................... 20 LYRICA

see pregabalin ............... 29 LYRICA CR ....................... 37 LYSODREN ...................... 20 LYSTEDA

see tranexamic acid ...... 49 lyza ................................... 42 M MACROBID

see nitrofurantoin monohyd macro ............ 14

MACRODANTIN see nitrofurantoin macrocrystal .................. 14

magnesium sulfate ............ 51 MAGNESIUM SULFATE ... 51

see magnesium sulfate . 51 MAGNESIUM SULFATE IN D5W .................................. 51

see magnesium sulfate in dextrose ........................ 51

magnesium sulfate in dextrose ............................ 51 magnesium sulfate inj 50% .......................................... 51 MALARONE

see atovaquone-proguanil hcl.................................. 15

malathion .......................... 58 maprotiline hcl ................... 31 marlissa ............................ 42 MARPLAN TAB 10MG ...... 31 MATULANE ...................... 22 MAVIK

see trandolapril .............. 23 MAVYRET ........................ 17 MAXALT

see rizatriptan benzoate 36 MAXALT-MLT

see rizatriptan benzoate odt ................................. 36

MAXITROL

see neomycin-polymy-dexameth ...................... 52

MAXZIDE see triamterene & hydrochlorothiazide tabs 27

MAXZIDE-25 see triamterene & hydrochlorothiazide tabs 27

meclizine hcl ..................... 46 MEDROL

see methylpred tab 16mg ...................................... 44 see methylpred tab 32mg ...................................... 44 see methylpred tab 4mg 44 see methylpred tab 8mg 44

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 44

medroxyprogesterone acetate (contraceptive) ..... 42 medroxyprogesterone acetate tab ........................ 45 mefloquine hcl .................. 15 MEGACE ES

see megestrol sus 625mg/5ml .................... 20

megestrol ac sus 40mg/ml 20 megestrol ac tab 20mg ..... 20 megestrol ac tab 40mg ..... 20 megestrol sus 625mg/5ml . 20 MEKINIST ......................... 21 MEKTOVI ......................... 21 meloxicam ........................ 11 memantine hcl cp24 .......... 30 memantine soln ................ 30 memantine tabs ................ 30 MENACTRA ..................... 50 MENVEO .......................... 50 MEPRON

see atovaquone............. 14 mercaptopurine ................. 19 meropenem ...................... 14 MERREM

see meropenem ............ 14 mesalamine ...................... 46 mesalamine w/ cleanser ... 46 MESNEX .......................... 22 MESTINON

see pyridostigmine tab

74

60mg ............................. 37 metadate er tab 20mg ....... 35 metformin er ...................... 40 metformin hcl .................... 40 methadone hcl .................. 12 methadone hcl 10mg ........ 12 methadone hcl 5mg .......... 12 methadone hcl intensol ..... 13 METHADOSE

see methadone hcl intensol .......................... 13

methazolamide .................. 26 methenamine hippurate .... 14 methimazole ...................... 45 methotrexate sodium inj soln .......................................... 19 methotrexate sodium inj solr .......................................... 19 methotrexate sodium tabs . 49 METHYLIN

see methylphenidate hcl oral soln ......................... 36

methylphenidate hcl .... 35, 36 methylphenidate hcl oral soln .......................................... 36 methylphenidate hcl tbcr 10 mg ..................................... 36 methylphenidate hcl tbcr 20mg ................................. 36 methylpr ss inj ................... 44 methylpred pak 4mg ......... 44 methylpred tab 16mg ........ 44 methylpred tab 32mg ........ 44 methylpred tab 4mg .......... 44 methylpred tab 8mg .......... 44 methylprednisolone acetate .......................................... 44 metoclopramide hcl ........... 46 metoclopramide hcl inj ...... 46 metolazone ....................... 26 metoprolol & hctz tab 100-25mg ................................. 25 metoprolol & hctz tab 100-50mg ................................. 25 metoprolol & hctz tab 50-25mg ................................. 25 metoprolol succinate ......... 25 metoprolol tartrate ............. 25 METROCREAM

see metronidazole

(topical) ......................... 58 see rosadan .................. 58

METROLOTION see metronidazole (topical) ......................... 58

metronidazole ................... 14 metronidazole (topical)...... 58 metronidazole gel 0.75% .. 58 metronidazole in nacl ........ 14 metronidazole vaginal ....... 48 MIACALCIN

see calcitonin (salmon) .. 44 MICARDIS

see telmisartan .............. 24 microgestin 1.5/30 ............ 42 microgestin 1/20 ............... 42 microgestin fe 1.5/30......... 42 microgestin fe 1/20 ........... 42 midodrine hcl .................... 27 miglustat ........................... 43 mili .................................... 42 MINIPRESS

see prazosin hcl ............ 23 minitran ............................. 27 MINOCIN

see minocycline hcl ....... 19 minocycline hcl ................. 19 minoxidil ............................ 27 MIRAPEX

see pramipexole tab 0.125mg ........................ 32 see pramipexole tab 0.25mg .......................... 32 see pramipexole tab 0.5mg ............................ 32 see pramipexole tab 0.75mg .......................... 32 see pramipexole tab 1.5mg ............................ 32 see pramipexole tab 1mg ...................................... 32

MIRCETTE see bekyree ................... 41 see desogestrel-ethinyl estradiol (biphasic) ........ 41 see kariva ...................... 42 see pimtrea ................... 42 see viorele ..................... 43

mirtazapine ....................... 31 misoprostol ....................... 47

MITIGARE ........................ 11 M-M-R II ............................ 50 M-NATAL PLUS................ 52 MOBIC

see meloxicam .............. 11 moexipril hcl ...................... 23 molindone hcl ................... 33 mometasone furoate ......... 57 mondoxyne nl cap 100mg . 19 mono-linyah tab 0.25-35 ... 42 montelukast sodium .......... 55 morphine ext-rel tab .......... 13 morphine sul inj 1mg/ml .... 13 morphine sulfate ............... 13 MORPHINE SULFATE ..... 13

see morphine sulfate ..... 13 morphine sulfate oral soln 100mg/5ml ........................ 13 morphine sulfate oral soln 10mg/5ml .......................... 13 morphine sulfate oral soln 20mg/5ml .......................... 13 MOVANTIK ....................... 47 MOXEZA .......................... 53 moxifloxacin hcl (ophth) .... 53 MS CONTIN

see morphine ext-rel tab 13 MULTAQ ........................... 24 mupirocin .......................... 56 MVASI .............................. 20 MYAMBUTOL

see ethambutol hcl ........ 17 MYCAMINE ...................... 15 MYCOBUTIN

see rifabutin .................. 17 mycophenolate mofetil ...... 50 mycophenolate sodium tbec.......................................... 50 MYFORTIC

see mycophenolate sodium tbec ................... 50

myorisan ........................... 56 MYRBETRIQ .................... 48 MYSOLINE

see primidone................ 30 N nabumetone ...................... 11 nadolol .............................. 25 nafcillin sodium ................. 18 NAFCILLIN SODIUM FOR

75

INJ 10GM .......................... 18 NAGLAZYME .................... 43 nalbuphine hcl ................... 11 naloxone inj 0.4mg/ml ....... 38 naloxone inj 1mg/ml .......... 38 naltrexone hcl .................... 38 NAMENDA

see memantine tabs ...... 30 NAMENDA XR

see memantine hcl cp24 30 NAMZARIC ....................... 30 NAPROSYN

see naproxen ................. 11 naproxen ........................... 11 naproxen dr ....................... 11 naproxen sodium .............. 11 naratriptan hcl ................... 36 NARCAN ........................... 38 NARDIL

see phenelzine sulfate ... 31 NATACYN ......................... 53 nateglinide......................... 40 NATPARA ......................... 44 NAVELBINE

see vinorelbine tartrate .. 20 NAYZILAM ........................ 29 NEBUPENT ...................... 14

see pentamidine isethionate inh ............... 14

necon 0.5/35-28 ................ 42 nefazodone hcl .................. 31 neomycin sulfate ............... 13 neomycin-bacitracin zn-polymyxin .......................... 53 neomycin-polymy-dexameth .......................................... 52 neomycin-polymyxin-gramicidin.......................... 53 neomycin-polymyxin-hc (ophth) .............................. 52 neomycin-polymyxin-hc (otic) .......................................... 59 NEORAL

see cyclosporine modified (for microemulsion) ........ 50 see gengraf ................... 50

NEPHRAMINE .................. 51 NERLYNX ......................... 21 NEUPRO........................... 32 NEURONTIN

see gabapentin .............. 29 nevirapine susp 50 mg/5ml .......................................... 16 nevirapine tab 100mg er ... 16 nevirapine tab 200mg ....... 16 nevirapine tab 400mg er ... 16 NEXAVAR ......................... 21 NEXIUM

see esomeprazole magnesium .................... 47

niacin (antihyperlipidemic) 25 niacin er (antihyperlipidemic) .......................................... 25 niacor ................................ 25 NIASPAN

see niacin er (antihyperlipidemic) ....... 25

nicardipine hcl ................... 26 NICOTROL INHALER ....... 38 NICOTROL NS ................. 38 nifedipine .......................... 26 nifedipine er ...................... 26 nikki................................... 42 NILANDRON

see nilutamide ............... 20 nilutamide ......................... 20 nimodipine ........................ 26 NINLARO .......................... 20 nitisinone ........................... 43 NITRO-BID ....................... 27 NITRO-DUR

see minitran ................... 27 see nitroglycerin td patch ...................................... 27

NITRO-DUR DIS 0.3MG/HR .......................................... 27 NITRO-DUR DIS 0.8MG/HR .......................................... 27 nitrofurantoin macrocrystal 14 nitrofurantoin monohyd macro ................................ 14 nitroglycerin ...................... 27 nitroglycerin td patch ......... 27 NITROSTAT

see nitroglycerin ............ 27 NITYR ............................... 43 NIZORAL

see ketoconazole shampoo ....................... 57

nora-be tab ....................... 42

NORCO see hydroco/apap tab 10-325mg ........................... 12 see hydroco/apap tab 5-325mg ........................... 12 see hydroco/apap tab 7.5-325 ................................ 12 see lorcet hd tab 10-325mg ........................... 12 see lorcet plus tab 7.5-325 ...................................... 12 see lorcet tab 5-325mg . 12

norethindrone (contraceptive) .................. 42 norethindrone acet & eth estra .................................. 42 norethindrone acetate ....... 45 norethindrone acetate-ethinyl estradiol ............................ 43 norgest/ethi tab 0.25/35 .... 42 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg.......................................... 42 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg.......................................... 42 NORMOSOL-M IN D5W ... 52 NORMOSOL-R ................. 52 NORMOSOL-R IN D5W ... 52 NORPACE

see disopyramide phosphate ..................... 24

NORPACE CR .................. 24 NORPRAMIN

see desipramine hcl ...... 31 NORTHERA ..................... 27 nortrel 0.5/35 (28) ............. 42 nortrel 1/35 ....................... 42 nortrel 7/7/7 ...................... 42 nortriptyline hcl ................. 31 NORVASC

see amlodipine besylate 25 NORVIR

see ritonavir .................. 16 NORVIR PACK ................. 16 NORVIR SOLN ................. 16 NOVOLIN 70/30................ 39 NOVOLIN 70/30 FLEXPEN

76

.......................................... 39 NOVOLIN N ...................... 39 NOVOLIN N FLEXPEN ..... 39 NOVOLIN R ...................... 39 NOVOLIN R FLEXPEN ..... 39 NOVOLOG ........................ 39 NOVOLOG 70/30 FLEXPEN .......................................... 39 NOVOLOG FLEXPEN ...... 39 NOVOLOG MIX 70/30 ...... 39 NOVOLOG PENFILL ........ 39 NOXAFIL........................... 15

see posaconazole ......... 15 NUBEQA ........................... 20 NUCALA ........................... 55 NUCYNTA ER ................... 13 NUEDEXTA ...................... 37 NULOJIX ........................... 50 NULYTELY/FLAVOR PACKS .............................. 46

see gavilyte-n/flavor pack ...................................... 46 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ................... 47 see trilyte ....................... 47

NUPLAZID CAPS ............. 33 NUPLAZID TABS 10MG ... 33 NUTRILIPID INJ 20% ....... 51 NUVARING ....................... 42

see eluryng .................... 41 see etonogestrel-ethinyl estradiol ......................... 41

NUVIGIL see armodafinil .............. 38

nyamyc ............................. 56 NYMALIZE ........................ 26 nystatin ............................. 15 nystatin (mouth-throat) ...... 59 nystatin (topical) ................ 56 nystatin pow 100000 ......... 56 nystop ............................... 56 O ocella tab 3-0.03mg .......... 42 OCTAGAM ........................ 50 octreotide acetate ....... 44, 45 OCUFLOX

see ofloxacin (ophth) ..... 53 ODEFSEY ......................... 16 ODOMZO .......................... 20

OFEV ................................ 55 ofloxacin (ophth) ............... 53 ofloxacin (otic) ................... 59 OGIVRI ............................. 20 olanzapine ........................ 34 olmesartan medoxomil ...... 24 olmesartan medoxomil-amlodipine-hydrochlorothiazide ........... 23 olmesartan medoxomil-hydrochlorothiazide ........... 23 olopatadine hcl 0.2% ........ 53 omeprazole cap 10mg ...... 47 omeprazole cap 20mg ...... 47 omeprazole cap 40mg ...... 47 ondansetron hcl ................ 46 ondansetron hcl inj ............ 46 ondansetron hcl oral soln .. 46 ondansetron odt ................ 46 ONFI

see clobazam ................ 28 OPSUMIT ......................... 27 ORFADIN .......................... 43

see nitisinone ................ 43 ORKAMBI ......................... 55 orsythia ............................. 42 ORTHO MICRONOR

see errin ........................ 41 see jolivette ................... 42 see lyza ......................... 42 see norethindrone (contraceptive) .............. 42 see sharobel .................. 43

ORTHO TRI-CYCLEN LO see norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................... 42 see tri-lo marzia ............. 43 see tri-lo-estarylla .......... 43 see tri-lo-sprintec ........... 43 see tri-vylibra lo ............. 43

ORTHO-NOVUM 1/35 see alyacen 1/35 ........... 41 see cyclafem 1/35 ......... 41 see dasetta 1/35 ............ 41 see nortrel 1/35 ............. 42 see pirmella 1/35 ........... 43

ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 ........ 41

see dasetta 7/7/7 ........... 41 see nortrel 7/7/7 ............ 42

oseltamivir phosphate ....... 17 OSPHENA ........................ 45 oxacillin sodium ................ 18 oxaliplatin inj 100mg ......... 22 oxaliplatin inj 100mg/20ml 22 oxaliplatin inj 50mg ........... 22 oxaliplatin inj 50mg/10ml .. 22 oxandrolone ...................... 38 oxcarbazepine .................. 29 oxybutynin chloride ........... 48 oxycodone hcl ................... 13 oxycodone w/ acetaminophen 10-325mg 13 oxycodone w/ acetaminophen 2.5-325mg.......................................... 13 oxycodone w/ acetaminophen 5-325mg .. 13 oxycodone w/ acetaminophen 7.5-325mg.......................................... 13 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 39 OZEMPIC INJ 1MG/DOSE.......................................... 39 P pacerone ........................... 24 paclitaxel ........................... 19 paliperidone ...................... 34 PAMELOR

see nortriptyline hcl ....... 31 pamidronate disodium ...... 41 PAMIDRONATE DISODIUM.......................................... 41 pamidronate inj 30mg ....... 41 pamidronate inj 90mg ....... 41 PANRETIN ....................... 58 pantoprazole sodium ........ 47 pantoprazole sodium tbec . 47 PANZYGA ........................ 50 paricalcitol ......................... 52 PARLODEL

see bromocriptine mesylate ........................ 32

PARNATE see tranylcypromine sulfate ........................... 31

paroex sol 0.12% .............. 59

77

paromomycin sulfate ......... 13 paroxetine hcl tabs ............ 31 PASER D/R ....................... 17 PAXIL ................................ 31

see paroxetine hcl tabs.. 31 PAZEO .............................. 53 PEDIAPRED

see pred sod pho sol 5mg/5ml ......................... 44

PEDIARIX ......................... 50 PEDVAX HIB .................... 50 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 47 PEGANONE ...................... 29 PEGASYS ......................... 17 PEGASYS PROCLICK ..... 17 penicillamine ..................... 41 PENICILLIN G POT IN DEXTROSE 2MU .............. 18 PENICILLIN G POT IN DEXTROSE 3MU .............. 18 PENICILLIN G PROCAINE .......................................... 18 penicillin g sodium ............. 18 penicillin v potassium ........ 19 penicilln gk inj 20mu .......... 19 penicilln gk inj 5mu ............ 19 PENTACEL ....................... 50 PENTAM 300 .................... 14

see pentamidine isethionate inj ................ 14

pentamidine isethionate inh .......................................... 14 pentamidine isethionate inj 14 pentoxifylline ..................... 49 PEPCID

see famotidine ............... 46 PERCOCET

see endocet 10-325mg .. 12 see endocet 2.5-325mg . 12 see endocet 5-325mg .... 12 see endocet 7.5-325mg . 12 see oxycodone w/ acetaminophen 10-325mg ...................................... 13 see oxycodone w/ acetaminophen 2.5-325mg

...................................... 13 see oxycodone w/ acetaminophen 5-325mg ...................................... 13 see oxycodone w/ acetaminophen 7.5-325mg ...................................... 13

PERIDEX see chlorhexidine gluconate (mouth-throat) ...................................... 59 see paroex sol 0.12% .... 59 see periogard ................ 59

perindopril erbumine ......... 23 periogard ........................... 59 permethrin cre 5% ............ 58 perphenazine .................... 34 PERSERIS ........................ 34 pfizerpen-g inj 20mu ......... 19 pfizerpen-g inj 5mu ........... 19 phenelzine sulfate ............. 31 PHENERGAN

see promethazine hcl inj 46 phenobarbital .................... 29 phenobarbital sodium........ 29 PHENOBARBITAL SODIUM .......................................... 29 PHENYTEK ...................... 29

see phenytoin sodium extended ....................... 29

phenytoin .......................... 29 phenytoin sodium extended .......................................... 29 phenytoin sodium inj 50mg/ml ............................ 29 philith ................................ 42 PHOSLO

see calcium acetate (phosphate binder) ........ 45

PHOSPHOLINE IODIDE ... 53 PICATO ............................ 58 PIFELTRO ........................ 16 pilocarpine hcl ................... 53 pilocarpine hcl (oral).......... 59 pimozide ........................... 34 pimtrea .............................. 42 pindolol ............................. 25 pioglitazone hcl ................. 40 piper/tazoba inj 12-1.5gm . 19 piper/tazoba inj 2-0.25gm . 19

piper/tazoba inj 3-0.375gm19 piper/tazoba inj 36-4.5gm . 19 piper/tazoba inj 4-0.5gm ... 19 PIQRAY 200MG DAILY DOSE ............................... 21 PIQRAY 250MG DAILY DOSE ............................... 21 PIQRAY 300MG DAILY DOSE ............................... 21 pirmella 1/35 ..................... 43 piroxicam .......................... 11 PLAQUENIL

see hydroxychloroquine sulfate ........................... 49

PLASMA-LYTE A.............. 52 PLASMA-LYTE-148 .......... 52 PLAVIX

see clopidogrel tab 75mg ...................................... 49

plenamine ......................... 51 PLENVU ........................... 47 PNV FOLIC ACID + IRON MUL .................................. 52 podofilox ........................... 58 polymyxin b-trimethoprim .. 53 POLYTRIM

see polymyxin b-trimethoprim .................. 53

POMALYST CAP 1MG ..... 20 POMALYST CAP 2MG ..... 20 POMALYST CAP 3MG ..... 20 POMALYST CAP 4MG ..... 21 portia-28 ........................... 43 posaconazole ................... 15 pot chloride inj 2meq/ml .... 52 potassium chloride ...... 51, 52 POTASSIUM CHLORIDE . 52 potassium chloride in nacl 52 potassium chloride microencapsulated crystals er ...................................... 51 potassium citrate (alkalinizer) er tabs ............................... 48 PRADAXA ........................ 48 PRALUENT ...................... 25 pramipexole tab 0.125mg . 32 pramipexole tab 0.25mg ... 32 pramipexole tab 0.5mg ..... 32 pramipexole tab 0.75mg ... 32 pramipexole tab 1.5mg ..... 32

78

pramipexole tab 1mg ........ 32 prasugrel hcl ..................... 49 PRAVACHOL

see pravastatin sodium.. 24 pravastatin sodium ............ 24 praziquantel ...................... 14 prazosin hcl ....................... 23 PRECOSE

see acarbose ................. 39 PRED FORTE

see prednisolone acetate (ophth) ........................... 53

pred sod pho sol 5mg/5ml . 44 prednisolone acetate (ophth) .......................................... 53 prednisolone sodium phosphate ......................... 44 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 53 prednisolone sol 15mg/5ml .......................................... 44 prednisolone sol 25mg/5ml .......................................... 44 PREDNISONE CON 5MG/ML ............................ 44 prednisone pak 10mg ....... 44 prednisone pak 5mg ......... 44 prednisone sol 5mg/5ml .... 44 prednisone tab 10mg ........ 44 prednisone tab 1mg .......... 44 prednisone tab 2.5mg ....... 44 prednisone tab 20mg ........ 44 prednisone tab 50mg ........ 44 prednisone tab 5mg .......... 44 pregabalin ......................... 29 PREMASOL SOL 10% ...... 51 PRENATAL ....................... 52 PRENATAL PLUS ............. 52 PRENATAL PLUS LOW IRON ................................. 52 PREVACID

see lansoprazole ........... 47 prevalite ............................ 25 previfem ............................ 43 PREZCOBIX ..................... 16 PREZISTA ........................ 16 PRIFTIN ............................ 17 primaquine phosphate ...... 15 PRIMAQUINE PHOSPHATE .......................................... 15

see primaquine phosphate ...................................... 15

PRIMAXIN IV see imipenem-cilastatin . 14

primidone .......................... 30 PRINIVIL

see lisinopril .................. 23 PRISTIQ

see desvenlafaxine succinate ....................... 31

PRIVIGEN ......................... 50 PROAIR HFA

see albuterol sulfate ...... 54 probenecid ........................ 11 PROCALAMINE ................ 51 PROCARDIA XL

see nifedipine ................ 26 prochlorperazine inj .......... 46 prochlorperazine maleate . 46 prochlorperazine supp ...... 46 PROCRIT .......................... 48 PROCTOCORT

see procto-pak .............. 58 procto-med hc ................... 58 procto-pak ......................... 58 proctosol hc cre 2.5% ....... 58 proctozone-hc ................... 58 PROGLYCEM SUS 50MG/ML .......................... 44 PROGRAF ........................ 50

see tacrolimus ............... 50 PROLASTIN-C .................. 55 PROLENSA ...................... 53 PROLIA ............................. 45 PROMACTA ..................... 49 promethazine hcl .............. 46 promethazine hcl inj .......... 46 propafenone hcl ................ 24 propafenone hcl 12hr ........ 24 proparacaine hcl ............... 54 propranolol & hydrochlorothiazide ........... 25 propranolol cap er ............. 25 propranolol hcl .................. 25 propranolol oral sol ........... 25 propylthiouracil .................. 45 PROQUAD ........................ 50 PROSCAR

see finasteride ............... 47 PROSOL ........................... 51

PROTONIX see pantoprazole sodium ...................................... 47 see pantoprazole sodium tbec ............................... 47

PROTOPIC see tacrolimus (topical) . 58

protriptyline hcl ................. 31 PROVERA

see medroxyprogesterone acetate tab .................... 45

PROZAC see fluoxetine cap 10mg 31 see fluoxetine cap 20mg 31 see fluoxetine cap 40mg 31

PULMICORT see budesonide (inhalation) .................... 55

PULMICORT FLEXHALER.......................................... 55 PULMOZYME ................... 55 PURIXAN .......................... 19 pyrazinamide .................... 17 pyridostigmine tab 60mg ... 37 Q QUADRACEL ................... 50 QUALAQUIN

see quinine sulfate ........ 15 QUESTRAN

see cholestyramine ....... 24 QUESTRAN LIGHT

see cholestyramine light powd ............................. 24 see prevalite .................. 25

quetiapine fumarate .......... 34 quinapril hcl ...................... 23 quinapril-hydrochlorothiazide.......................................... 22 quinidine sulfate ................ 24 quinine sulfate .................. 15 R RABAVERT ...................... 50 raloxifene hcl .................... 45 ramipril .............................. 23 RANEXA

see ranolazine ............... 27 ranitidine hcl ..................... 46 ranitidine hcl inj ................. 46 ranitidine syrup ................. 46 ranolazine ......................... 27

79

RAPAMUNE see sirolimus ................. 50

rasagiline mesylate ........... 32 RAYALDEE ....................... 52 RAZADYNE

see galantamine hydrobromide ................ 30

RAZADYNE ER see galantamine hydrobromide er ............ 30

RECLAST see zoledronic acid inj 5mg/100ml ..................... 41

reclipsen............................ 43 RECOMBIVAX HB ............ 50 RECTIV ............................. 58 REGLAN

see metoclopramide hcl. 46 REGRANEX ...................... 58 RELENZA DISKHALER .... 17 RELISTOR ........................ 47 RELPAX

see eletriptan hydrobromide ................ 36

REMERON see mirtazapine ............. 31

REMERON SOLTAB see mirtazapine ............. 31

REMICADE ....................... 49 RENFLEXIS ...................... 49 RENVELA

see sevelamer carbonate ...................................... 45

repaglinide ........................ 40 RESCRIPTOR .................. 16 RESTASIS ........................ 54 RESTASIS MULTIDOSE .. 54 RESTORIL

see temazepam ............. 36 RETIN-A

see avita ........................ 56 see tretinoin ................... 56

RETROVIR see zidovudine cap 100mg ...................................... 16 see zidovudine syp 50mg/5ml ....................... 16

REVATIO see sildenafil citrate tab 20 mg (pulmonary

hypertension) ................ 27 REVLIMID ......................... 21 REXULTI ........................... 34 REYATAZ ......................... 16

see atazanavir sulfate ... 15 RHOPRESSA ................... 53 ribavirin 200mg ................. 17 rifabutin ............................. 17 RIFADIN

see rifampin ................... 17 rifampin ............................. 17 RIFATER .......................... 17 RILUTEK

see riluzole .................... 37 riluzole .............................. 37 rimantadine hydrochloride . 17 RISPERDAL

see risperidone .............. 34 RISPERDAL INJ 12.5MG . 34 RISPERDAL INJ 25MG .... 34 RISPERDAL INJ 37.5MG . 34 RISPERDAL INJ 50MG .... 34 risperidone ........................ 34 RITALIN

see methylphenidate hcl ................................ 35, 36

ritonavir ............................. 16 RITUXAN .......................... 20 RITUXAN HYCELA ........... 20 rivastigmine tartrate .......... 30 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 31 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 30 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 30 rizatriptan benzoate .......... 36 rizatriptan benzoate odt .... 36 ROCALTROL

see calcitriol .................. 52 see calcitriol oral soln 1 mcg/ml ........................... 52

ropinirole tab 0.25mg ........ 32 ropinirole tab 0.5mg .......... 32 ropinirole tab 1mg ............. 32 ropinirole tab 2mg ............. 32 ropinirole tab 3mg ............. 32 ropinirole tab 4mg ............. 32 ropinirole tab 5mg ............. 32 rosadan ............................. 58

rosuvastatin calcium ......... 24 ROTARIX .......................... 50 ROTATEQ ........................ 50 ROWASA

see mesalamine w/ cleanser ........................ 46

roweepra ........................... 30 roweepra xr ....................... 30 ROXICODONE

see oxycodone hcl ........ 13 ROZLYTREK .................... 21 RUBRACA ........................ 20 RUXIENCE ....................... 20 RYDAPT ........................... 21 RYTHMOL SR

see propafenone hcl 12hr ...................................... 24

S SABRIL

see vigabatrin powd pack 500mg ........................... 30 see vigabatrin tab 500mg ...................................... 30 see vigadrone................ 30

SALAGEN see pilocarpine hcl (oral) ...................................... 59

SANDIMMUNE ................. 50 see cyclosporine ........... 50

SANDOSTATIN see octreotide acetate .. 44, 45

SANTYL ............................ 58 SAPHRIS .......................... 34 scopolamine ..................... 46 SECUADO ........................ 34 selegiline hcl ..................... 32 selenium sulfide ................ 57 SELZENTRY .................... 16 SENSIPAR

see cinacalcet hcl .......... 44 SEREVENT DISKUS ........ 54 SEROQUEL

see quetiapine fumarate 34 SEROQUEL XR

see quetiapine fumarate 34 sertraline hcl ..................... 31 setlakin tab ....................... 43 sevelamer carbonate ........ 45 sharobel ............................ 43

80

SHINGRIX ......................... 50 SIGNIFOR ......................... 45 sildenafil citrate tab 20 mg (pulmonary hypertension) . 27 SILENOR .......................... 36

see doxepin hcl (sleep).. 36 SILVADENE

see silver sulfadiazine ... 56 see ssd .......................... 56

silver sulfadiazine .............. 56 SIMBRINZA ...................... 53 simvastatin ........................ 24 SINEMET

see carbidopa-levodopa 32 SINEMET CR

see carbidopa-levodopa 32 SINGULAIR

see montelukast sodium 55 sirolimus ............................ 50 SIRTURO .......................... 17 SIVEXTRO ........................ 14 sodium chlor sol 0.9% irr ... 58 sodium chloride ........... 51, 52 sodium chloride 0.45% ...... 52 sodium chloride inj 0.9% ... 52 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 51 sodium phenylbutyrate ...... 43 sodium polystyrene sulfonate powder .............................. 41 sodium polystyrene sulfonate susp .................................. 41 SOLIQUA 100/33 .............. 39 SOLTAMOX ...................... 20 SOLU-CORTEF ................ 44 SOLU-MEDROL

see methylpr ss inj ......... 44 SOMATULINE DEPOT ..... 45 SOMAVERT ...................... 45 SORIATANE

see acitretin ................... 56 sorine ................................ 24 sotalol hcl .......................... 24 sotalol hcl (afib/afl) ............ 24 spironolactone ................... 23 spironolactone & hydrochlorothiazide ........... 26 SPORANOX

see itraconazole ............ 15 sprintec 28 ........................ 43

SPRITAM .......................... 30 SPRYCEL ......................... 21 sps susp 15gm/60ml ......... 41 sronyx ............................... 43 ssd .................................... 56 STALEVO 100

see carbidopa/levodopa/entacapone ............................ 32

STALEVO 150 see carbidopa/levodopa/entacapone ............................ 32

STARLIX see nateglinide .............. 40

stavudine .......................... 16 STELARA ......................... 49 STIMATE .......................... 45 STIVARGA ........................ 21 STRATTERA

see atomoxetine hcl ...... 35 streptomycin sulfate .......... 13 STRIBILD .......................... 16 STROMECTOL

see ivermectin ............... 14 SUBOXONE

see buprenorphine hcl-naloxone hcl dihydrate 12-3mg ............................... 38 see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ............................ 38 see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................... 38 see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................... 38

subvenite tab .................... 30 sucralfate .......................... 47 sulfacetamide sodium (acne) .......................................... 56 sulfacetamide sodium (ophth) .............................. 53 sulfacetamide sod-prednisolone ..................... 52 SULFADIAZINE ................ 13 sulfamethoxazole-trimethop ds ...................................... 14 sulfamethoxazole-

trimethoprim inj ................. 14 sulfamethoxazole-trimethoprim susp ............. 14 sulfamethoxazole-trimethoprim tab 400-80mg.......................................... 14 SULFAMYLON ................. 56 sulfasalazine ..................... 46 sulfasalazine ec ................ 46 sulindac ............................ 11 sumatriptan ....................... 36 sumatriptan inj 4mg/0.5ml 36, 37 sumatriptan inj 6mg/0.5ml . 37 sumatriptan succinate ....... 37 SUPRAX

see cefixime .................. 17 SUPREP BOWEL PREP KIT.......................................... 47 SUSTIVA

see efavirenz ................. 15 SUTENT ........................... 22 syeda ................................ 43 SYLATRON ...................... 22 SYMBICORT .................... 55 SYMDEKO ........................ 55 SYMFI ............................... 16 SYMFI LO ......................... 16 SYMJEPI .......................... 55 SYMPAZAN ...................... 30 SYMTUZA ........................ 16 SYNALAR

see fluocinolone acetonide ...................................... 57

SYNAREL ......................... 43 SYNERCID ....................... 14 SYNJARDY TAB 12.5-1000MG ............................ 40 SYNJARDY TAB 12.5-500MG .............................. 40 SYNJARDY TAB 5-1000MG.......................................... 40 SYNJARDY TAB 5-500MG.......................................... 40 SYNJARDY XR TAB 10-1000MG ............................ 40 SYNJARDY XR TAB 12.5-1000MG ............................ 40 SYNJARDY XR TAB 25-1000MG ............................ 40

81

SYNJARDY XR TAB 5-1000MG ............................ 40 SYNRIBO .......................... 22 SYNTHROID ..................... 45

see euthyrox .................. 45 see levo-t ....................... 45 see levothyroxine sodium ...................................... 45 see levoxyl ..................... 45 see unithroid .................. 45

SYPRINE see trientine hcl ............. 41

T TABLOID........................... 19 tacrolimus.......................... 50 tacrolimus (topical) ............ 58 TAFINLAR ......................... 22 TAGRISSO ....................... 22 TALZENNA ....................... 20 TAMIFLU

see oseltamivir phosphate ...................................... 17

tamoxifen citrate ................ 20 tamsulosin hcl ................... 47 TAPAZOLE

see methimazole ........... 45 TARCEVA

see erlotinib hcl ............. 21 TARGRETIN ..................... 58

see bexarotene .............. 22 tarina fe 1/20 ..................... 43 TASIGNA .......................... 22 TAXOTERE ....................... 19

see docetaxel ................ 19 tazarotene ......................... 57 tazicef ............................... 18 TAZORAC ......................... 57

see tazarotene ............... 57 taztia xt ............................. 26 TDVAX .............................. 50 TECENTRIQ ..................... 20 TEFLARO ......................... 18 TEGRETOL

see carbamazepine ....... 28 see epitol ....................... 28

TEGRETOL-XR see carbamazepine ....... 28

TEKTURNA see aliskiren fumarate ... 27

telmisartan ........................ 24

temazepam ....................... 36 TEMIXYS .......................... 16 TENIVAC .......................... 50 tenofovir disoproxil fumarate .......................................... 16 TENORETIC 100

see atenolol & chlorthalidone ................ 25

TENORETIC 50 see atenolol & chlorthalidone ................ 25

TENORMIN see atenolol ................... 25

terazosin hcl ...................... 23 terbinafine hcl ................... 15 terbutaline sulfate ............. 54 terconazole vaginal ........... 48 testosterone ...................... 38 testosterone cypionate ...... 38 testosterone enanthate ..... 38 tetrabenazine .................... 37 tetracycline hcl .................. 19 TEXACORT SOLN 2.5% .. 57 THALOMID ....................... 21 THEO-24 ........................... 55 theophylline ....................... 55 theophylline tab er 12hr 300 mg ..................................... 55 theophylline tab er 12hr 450 mg ..................................... 55 theophylline tab sr 24hr ..... 55 thioridazine hcl .................. 34 thiothixene ........................ 34 tiadylt er ............................ 26 tiagabine hcl ...................... 30 TIAZAC

see diltiazem hcl extended release beads cap sr ..... 26 see taztia xt ................... 26 see tiadylt er .................. 26

TIBSOVO .......................... 20 tigecycline ......................... 14 TIKOSYN

see dofetilide ................. 24 tilia fe ................................ 43 timolol maleate .................. 25 timolol maleate (ophth) soln .......................................... 53 timolol maleate gel ............ 53 timolol maleate ophth soln

0.5% (once-daily) .............. 53 TIMOPTIC

see timolol maleate (ophth) soln ................... 53

TIMOPTIC-XE see timolol maleate gel . 53

TIVICAY ............................ 16 tizanidine hcl ..................... 38 TOBRADEX ...................... 52

see tobramycin-dexamethasone............. 52

TOBRADEX ST ................ 52 tobramycin ........................ 13 tobramycin (ophth) ............ 53 tobramycin inj 1.2 gm/30ml.......................................... 13 tobramycin inj 1.2gm ......... 13 tobramycin inj 10mg/ml ..... 13 tobramycin inj 80mg/2ml ... 13 tobramycin sulfate............. 14 tobramycin-dexamethasone.......................................... 52 TOBREX

see tobramycin (ophth) . 53 tolterodine tartrate cap er .. 48 tolterodine tartrate tabs ..... 48 TOPAMAX

see topiramate .............. 30 TOPAMAX SPRINKLE

see topiramate .............. 30 topiramate ......................... 30 toposar .............................. 22 TOPROL XL

see metoprolol succinate ...................................... 25

toremifene citrate .............. 20 torsemide tabs .................. 26 TOVIAZ ............................. 48 TPN ELECTROLYTES ..... 51 TRACLEER

see bosentan ................ 27 TRADJENTA .................... 40 tramadol hcl tab 50 mg ..... 11 tramadol-acetaminophen .. 12 trandolapril ........................ 23 tranexamic acid................. 49 TRANSDERM SCOP

see scopolamine ........... 46 tranylcypromine sulfate ..... 31 TRAVASOL ...................... 51

82

TRAVATAN Z .................... 53 see travoprost ................ 53

travoprost .......................... 53 trazodone hcl .................... 32 TRECATOR ...................... 17 TRELEGY ELLIPTA .......... 54 TRELSTAR DEP INJ 3.75MG ............................. 20 TRELSTAR LA INJ 11.25MG .......................................... 20 treprostinil ......................... 27 TRESIBA FLEXTOUCH .... 39 TRESIBA INJ .................... 39 tretinoin ............................. 56 tretinoin (chemotherapy) ... 22 triamcinolone acetonide (mouth) ............................. 59 triamcinolone acetonide (topical) ....................... 57, 58 triamterene & hydrochlorothiazide cap 37.5-25 mg ........................ 26 triamterene & hydrochlorothiazide tabs ... 27 TRIBENZOR

see olmesartan medoxomil-amlodipine-hydrochlorothiazide ....... 23

TRICARE .......................... 52 TRICOR

see fenofibrate ............... 24 trientine hcl ........................ 41 tri-estarylla ........................ 43 trifluoperazine hcl .............. 34 trifluridine .......................... 53 trihexyphenidyl hcl ............ 32 TRIKAFTA ......................... 55 tri-legest fe ........................ 43 TRILEPTAL

see oxcarbazepine ........ 29 tri-linyah ............................ 43 tri-lo marzia ....................... 43 tri-lo-estarylla .................... 43 tri-lo-sprintec ..................... 43 trilyte ................................. 47 trimethoprim ...................... 14 tri-mili ................................ 43 trimipramine maleate ........ 32 TRINTELLIX ...................... 32 tri-previfem ........................ 43

tri-sprintec ......................... 43 TRIUMEQ ......................... 16 trivora-28 ........................... 43 tri-vylibra ........................... 43 tri-vylibra lo ....................... 43 TRIZIVIR

see abacavir sulfate-lamivudine-zidovudine ... 16

TROGARZO ..................... 16 TROPHAMINE INJ 10% ... 51 trospium chloride .............. 48 TRULICITY ....................... 39 TRUMENBA ...................... 50 TRUSOPT

see dorzolamide hcl ...... 53 TRUVADA TAB 100-150 ... 16 TRUVADA TAB 133-200 ... 16 TRUVADA TAB 167-250 ... 16 TRUVADA TAB 200-300 ... 16 tulana ................................ 43 TURALIO .......................... 22 TWINRIX INJ .................... 51 TYBOST ........................... 16 TYGACIL

see tigecycline ............... 14 TYKERB ........................... 22 TYLENOL/CODEINE #3

see acetaminophen w/ codeine 300-30mg......... 11

TYMLOS ........................... 45 TYPHIM VI ........................ 51 U ULTRACET

see tramadol-acetaminophen .............. 12

ULTRAM see tramadol hcl tab 50 mg ................................. 11

UNASYN see ampicillin & sulbactam sodium ........................... 18

UNASYN BULK PACK see ampicillin & sulbactam sodium ........................... 18

unithroid ............................ 45 URECHOLINE

see bethanechol chloride ...................................... 48

UROCIT-K 10 see potassium citrate

(alkalinizer) er tabs ........ 48 UROCIT-K 15

see potassium citrate (alkalinizer) er tabs ........ 48

UROCIT-K 5 see potassium citrate (alkalinizer) er tabs ........ 48

UROXATRAL see alfuzosin hcl ............ 47

URSO 250 see ursodiol ................... 47

URSO FORTE see ursodiol ................... 47

ursodiol ............................. 47 V VAGIFEM

see estradiol vaginal tab 43 see yuvafem vaginal tablet 10 mcg .......................... 43

valacyclovir hcl.................. 17 VALCHLOR ...................... 58 VALCYTE

see valganciclovir hcl .... 17 valganciclovir hcl............... 17 VALIUM

see diazepam ................ 28 valproate sodium .............. 30 valproic acid ...................... 30 valsartan ........................... 24 valsartan-hydrochlorothiazide ........... 23 VALTOCO ........................ 30 VALTREX

see valacyclovir hcl ....... 17 VANCOCIN

see vancomycin hcl ....... 14 VANCOCIN HCL

see vancomycin hcl ....... 14 vancomycin hcl ........... 14, 15 VANCOMYCIN IN NACL .. 15 vandazole ......................... 48 VAQTA ............................. 51 VARIVAX .......................... 51 VASCEPA ......................... 25 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 22

VASOTEC see enalapril maleate .... 23

VELCADE ......................... 20

83

velivet ................................ 43 VEMLIDY .......................... 17 VENCLEXTA ..................... 20 VENCLEXTA STARTING PACK ................................ 20 venlafaxine hcl .................. 32 VENTAVIS ........................ 27 VENTOLIN HFA ................ 55 verapamil cap er ............... 26 verapamil hcl ..................... 26 verapamil hcl tab er ........... 26 VERELAN

see verapamil cap er ..... 26 VERELAN PM

see verapamil cap er ..... 26 VERSACLOZ .................... 34 VERZENIO ........................ 20 VFEND

see voriconazole ........... 15 VFEND IV

see voriconazole ........... 15 VIBRAMYCIN

see doxycycline hyclate . 19 VICTOZA .......................... 39 VIDAZA

see azacitidine ............... 19 VIDEX EC ......................... 16

see didanosine .............. 15 VIDEX PEDIATRIC ........... 16 vienva ............................... 43 vigabatrin powd pack 500mg .......................................... 30 vigabatrin tab 500mg ........ 30 vigadrone .......................... 30 VIGAMOX

see moxifloxacin hcl (ophth) ........................... 53

VIIBRYD STARTER PACK .......................................... 32 VIIBRYD TAB .................... 32 VIMPAT............................. 30 VIMPAT INJ 200MG/20ML 30 VIMPAT SOL 10MG/ML .... 30 vincristine sulfate .............. 20 vinorelbine tartrate ............ 20 viorele ............................... 43 VIRACEPT ........................ 16 VIRAMUNE

see nevirapine susp 50 mg/5ml........................... 16

see nevirapine tab 200mg ...................................... 16

VIRAMUNE XR see nevirapine tab 400mg er ................................... 16

VIREAD ............................ 16 see tenofovir disoproxil fumarate ........................ 16

VISTARIL see hydroxyzine pamoate ...................................... 54

VITRAKVI ......................... 22 VIVITROL ......................... 38 VIZIMPRO ........................ 22 VOLTAREN

see diclofenac sodium (topical) 1% gel ............. 58

voriconazole ...................... 15 VOSEVI ............................ 17 VOTRIENT ........................ 22 VRAYLAR ......................... 34 VRAYLAR THERAPY PACK .......................................... 34 vyfemla ............................. 43 vylibra ............................... 43 W warfarin sodium ................ 48 water for irrigation, sterile 58 WELCHOL

see colesevelam hcl ...... 24 WELLBUTRIN SR

see bupropion hcl .......... 31 WELLBUTRIN XL

see bupropion hcl .......... 31 X XALATAN

see latanoprost .............. 53 XALKORI .......................... 22 XANAX

see alprazolam tab 0.25mg .......................... 27 see alprazolam tab 0.5mg ...................................... 27 see alprazolam tab 1mg 27 see alprazolam tab 2mg 28

XARELTO ......................... 48 XARELTO STARTER PACK .......................................... 48 XATMEP ........................... 49 XELJANZ .......................... 49

XELJANZ XR .................... 49 XENAZINE

see tetrabenazine .......... 37 XGEVA ............................. 45 XIFAXAN .......................... 47 XIGDUO XR TAB 10-1000MG ............................ 40 XIGDUO XR TAB 10-500MG.......................................... 40 XIGDUO XR TAB 2.5-1000MG ............................ 40 XIGDUO XR TAB 5-1000MG.......................................... 40 XIGDUO XR TAB 5-500MG.......................................... 40 XOLAIR ............................ 55 XOPENEX

see levalbuterol hcl ....... 54 XOPENEX CONCENTRATE

see levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...................................... 54

XOSPATA ......................... 22 XPOVIO 100 MG ONCE WEEKLY ........................... 22 XPOVIO 60 MG ONCE WEEKLY ........................... 22 XPOVIO 80 MG ONCE WEEKLY ........................... 22 XPOVIO 80 MG TWICE WEEKLY ........................... 22 XTANDI ............................ 20 xulane ............................... 43 XULTOPHY 100/3.6 ......... 39 XYLOCAINE

see lidocaine hcl (local anesth.) ......................... 13 see lidocaine inj 0.5% ... 13 see lidocaine inj 1% ...... 13

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ......................... 13 see lidocaine inj 1.5% preservative free (pf) ..... 13

XYREM ............................. 38 Y YASMIN 28

see drospirenone-ethinyl estradiol ........................ 41 see ocella tab 3-0.03mg 42

84

see syeda ...................... 43 see zarah ....................... 43

YAZ see drospirenone-ethinyl estradiol ......................... 41 see gianvi ...................... 41 see jasmiel .................... 42 see loryna ...................... 42 see nikki ........................ 42

YF-VAX ............................. 51 yuvafem vaginal tablet 10 mcg ................................... 43 Z zafirlukast .......................... 55 ZANAFLEX

see tizanidine hcl ........... 38 ZANTAC

see ranitidine hcl ........... 46 see ranitidine hcl inj ....... 46

zarah ................................. 43 ZARONTIN

see ethosuximide .......... 28 ZARXIO............................. 48 ZAVESCA

see miglustat ................. 43 ZEJULA............................. 20 ZELBORAF ....................... 22 ZEMAIRA .......................... 55 ZEMPLAR

see paricalcitol ............... 52 zenatane ........................... 56 ZENPEP............................ 47 ZERIT

see stavudine ................ 16 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 22

ZESTRIL

see lisinopril .................. 23 ZETIA

see ezetimibe ................ 24 ZIAC

see bisoprolol & hydrochlorothiazide ....... 25

ZIAGEN see abacavir sulfate ...... 15

zidovudine cap 100mg ...... 16 zidovudine syp 50mg/5ml . 16 zidovudine tab 300mg ....... 16 ziprasidone hcl .................. 34 ZIRABEV .......................... 20 ZIRGAN ............................ 53 ZITHROMAX

see azithromycin ........... 18 ZOCOR

see simvastatin ............. 24 ZOFRAN

see ondansetron hcl ...... 46 zoledronic acid inj 4mg/100ml ........................ 41 zoledronic acid inj 5mg/100ml ........................ 41 zoledronic inj 4mg/5ml ...... 41 ZOLINZA ........................... 20 zolmitriptan ....................... 37 zolmitriptan odt ................. 37 ZOLOFT

see sertraline hcl ........... 31 zolpidem tartrate ............... 36 ZOMIG

see zolmitriptan ............. 37 ZOMIG ZMT

see zolmitriptan odt ....... 37 ZONEGRAN

see zonisamide ............. 30 zonisamide ........................ 30

ZORTRESS TAB 0.25MG 50 ZORTRESS TAB 0.5MG .. 50 ZORTRESS TAB 0.75MG 50 ZORTRESS TAB 1MG ..... 50 ZOSTAVAX ...................... 51 ZOSYN

see piper/tazoba inj 2-0.25gm .......................... 19 see piper/tazoba inj 3-0.375gm ........................ 19 see piper/tazoba inj 36-4.5gm ............................ 19 see piper/tazoba inj 4-0.5gm ............................ 19

zovia 1/35e ....................... 43 ZOVIRAX

see acyclovir ................. 17 ZYDELIG .......................... 22 ZYKADIA .......................... 22 ZYLET .............................. 52 ZYLOPRIM

see allopurinol tab ......... 11 ZYMAXID

see gatifloxacin (ophth) . 52 ZYPREXA

see olanzapine .............. 34 ZYPREXA RELPREVV ..... 34 ZYPREXA RELPREVV INJ 210MG .............................. 35 ZYPREXA ZYDIS

see olanzapine .............. 34 ZYTIGA ............................. 20

see abiraterone acetate 20 ZYVOX

see linezolid inj .............. 14 see linezolid susp .......... 14 see linezolid tab 600mg 14

Este formulario fue actualizado el 1/Abr/2020. Para ver información más reciente o si tiene otras preguntas, comuníquese con el Servicio de Atención al Cliente de Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) y Johns Hopkins Advantage MD Premier (PPO) al 1-877-293-5325 o, para usuarios de TTY, 711, las 24 horas del día, los 7 días de la semana, o visite www.hopkinsmedicare.com.

http://www.hopkinsmedicare.com/

formulario y lista de medicamentos cubiertos · cobertura 2020, excepto como se describe a...

Documents