2017 LIST OF COVERED DRUGS - Bright Health...tramadol hcl TB24 100mg 2 QL (90 tabs / 25 days)...

2017 LIST OF COVERED DRUGS Please read: this document has information about the drugs we cover in the following plans:

Gold EPO Silver EPO Bronze EPO Catastrophic EPO Silver HSA EPO Bronze HSA EPO

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

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What is the drug list? The drug list is a list of drugs covered under Bright Health plans. Bright Health works with a team of health care providers to choose drugs that provide quality treatment. Bright Health plans cover the drugs on our drug list, as long as:

• The drug is medically necessary• The prescription is filled at an in-network pharmacy• Other plan rules are followed

Can the drug list change? The drug list may change from time to time as described in plan documents or other plan materials. The enclosed drug list is the most current drug list covered by Bright Health plans.

How do I use the drug list? There are two ways to find a drug on the drug list:

1. Medical ConditionThe drug list starts on page 4. The drugs on this drug list are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under cardiovascular.

• If you know what your drug is used for, look for the category name in the list that starts on page 4.

• Then look under the category name for your drug

2. Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that starts on page 48. The Index is an alphabetical list of all the drugs in this document. Both brand name drugs and generic drugs are in the Index.

• Look in the Index and find your drug• Next to your drug, see the page number where you can find coverage

information• Turn to the page listed in the Index and find the name of your drug in

the first column of the list

Bright Health drug list The drug list gives information about the drugs covered by Bright Health. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs, but provide the same quality of treatment.

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The first column of the chart lists the drug name. Brand-name drugs are capitalized. Generic drugs are listed in lower-case italics.

The second column of the chart, Drug Tier, tells you which tier the drug falls under. Drug tiers are how we divide prescription drugs into different levels of cost. How much you will pay will depend on the individual plan, however, here’s what the drug tier tells you:

• Tier 1: Preventive drugs with no member cost share under the ACA• Tier 2: Generic drugs• Tier 3: Preferred Brand drugs• Tier 4: Non-preferred Brand drugs• Tier 5: Specialty drugs

The information in the Requirements/Limits column tells you if there are any special requirements for coverage of that drug. These requirements and limits may include:

Prior Authorization (PA): Bright Health asks you and your doctor to give more information for prior authorization of certain drugs. This means that you need to get approval from Bright Health before you fill your prescriptions. If you don’t get approval, Bright Health may not cover the drug.

Quantity Limits (QL): For certain drugs, Bright Health limits the amount of the drug that it will cover. Bright Health also limits the amount of drugs you may receive within a class of drugs. These classes have an “§” next to them on the drug list. These are drugs with safety and addiction risks; therefore, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.

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

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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

EXCH_Bright Health eff 10/01/2017

Drug Name Drug Tier Requirements/Limits ANALGESICS

COX-2 INHIBITORS celecoxib 2

GOUT allopurinol 2 allopurinol sodium 2 colchicine 2 colchicine w/ probenecid 2 probenecid 2

NON-OPIOID ANALGESICS butalbital-acetaminophen 2 QL (48 tabs per 25

days) butalbital-acetaminophen-caffeine CAPS 2 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine SOLN 2 QL (720 mL / 25 days) butalbital-acetaminophen-caffeine TABS 2 QL (48 tabs / 25 days) butalbital-aspirin-caffeine CAPS 2 QL (48 caps / 25 days) butalbital-aspirin-caffeine TABS 2 QL (48 tabs / 25 days)

NSAIDS diclofenac potassium 2 diclofenac sodium 2 etodolac 2 fenoprofen calcium 2 flurbiprofen 2 ibuprofen 2 indomethacin 2 ketoprofen 2 ketorolac tromethamine SOLN 2 ketorolac tromethamine TABS 2 QL (20 tabs / 25 days) meclofenamate sodium 2 mefenamic acid 2 meloxicam 2 nabumetone 2 naproxen 2 naproxen sodium 2 oxaprozin 2 piroxicam 2 sulindac 2 tolmetin sodium 2

NSAIDS, COMBINATIONS diclofenac w/ misoprostol 2

OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl dihydrate 2 QL (90 tabs / 25 days),

PA

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Drug Name Drug Tier Requirements/Limits SUBOXONE 2-0.5MG 3 QL (90 units / 25 days),

PA SUBOXONE 4-1MG 3 QL (90 units / 25 days),

PA SUBOXONE 8-2MG 3 QL (90 units / 25 days),

PA SUBOXONE 12-3MG 3 QL (60 films per 25

days), PA OPIOID ANALGESICS acetaminophen w/ codeine SOLN 2 QL (5000 mL / 25 days) acetaminophen w/ codeine TABS 2 QL (400 tabs / 25 days) butalbital-acetaminophen-caffeine w/

codeine 2 QL (48 caps per 25

days) CAPITAL/CODEINE 4 QL (5000 mL / 25 days) CODEINE SULFATE SOLN 3 QL (210 mL / 25 days) codeine sulfate TABS 2 QL (42 tabs / 25 days) fentanyl 2 QL (10 patches / 25

days) hydrocodone-acetaminophen SOLN 2 QL (5540 mL / 25 days) hydrocodone-acetaminophen TABS 2 QL (375 tabs / 25 days) hydrocodone-acetaminophen TABS 2 QL (400 tabs / 25 days) hydrocodone-ibuprofen 2 QL (50 tabs per 25

days) hydromorphone hcl LIQD 2 QL (600 mL / 25 days) HYDROMORPHONE HCL SUPP 4 QL (120 units / 25 days) hydromorphone hcl TABS 2 QL (180 tabs / 25 days) meperidine hcl SOLN 10mg/ml, 25mg/ml,

50mg/ml, 100mg/ml 2

meperidine hcl SOLN 50mg/5ml 2 QL (90 mL / 25 days) meperidine hcl TABS 2 QL (18 tabs / 25 days) methadone hcl CONC 2 QL (30mL / 25 days) methadone hcl SOLN 5mg/5ml 2 QL (600 mL / 25 days) methadone hcl SOLN 10mg/5ml 2 QL (300 mL / 25 days) METHADONE HCL SOLN 10mg/ml 4 QL (1 vial / 25 days) methadone hcl TABS 5mg 2 QL (120 tabs / 25 days) methadone hcl TABS 10mg 2 QL (60 tabs / 25 days) methadone hcl TBSO 2 QL (9 tabs / 25 days) morphine sulfate CP24 10mg, 20mg,

30mg, 50mg, 60mg, 80mg 2 QL (60 caps / 25 days)

morphine sulfate CP24 100mg 2 QL (30 caps / 25 days) morphine sulfate SOLN 1mg/ml, 4mg/ml,

8mg/ml, 10mg/ml, 15mg/ml, 25mg/ml 2

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 150mg/30ml

4

morphine sulfate SOLN 10mg/5ml, 20mg/5ml

2 QL (900 mL / 25 days)

morphine sulfate SOLN 100mg/5ml 2 QL (180 mL / 25 days) morphine sulfate SUPP 5mg, 10mg, 20mg 2 QL (180 supp / 25 days)

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Drug Name Drug Tier Requirements/Limits MORPHINE SULFATE SUPP 30mg 3 QL (180 supp / 25 days) morphine sulfate TABS 2 QL (180 tabs / 25 days) morphine sulfate TBCR 15mg, 30mg,

60mg 2 QL (120 tabs / 25 days)

morphine sulfate TBCR 100mg, 200mg 2 QL (60 tabs / 25 days) morphine sulfate beads 30mg, 45mg,

60mg 2 QL (60 caps / 25 days)

morphine sulfate beads 75mg, 90mg, 120mg

2 QL (30 caps / 25 days)

oxycodone hcl CAPS 2 QL (180 caps / 25 days) oxycodone hcl CONC 2 QL (180 mL / 25 days) oxycodone hcl SOLN 2 QL (900 mL / 25 days) oxycodone hcl T12A 10mg, 15mg, 30mg,


oxycodone hcl T12A 20mg 2 QL (120 / 25 days) oxycodone hcl T12A 60mg, 80mg 2 QL (60 tabs / 25 days) oxycodone hcl TABS 2 QL (180 tabs / 25 days) oxycodone w/ acetaminophen SOLN 2 QL (1850 mL / 25 days) oxycodone w/ acetaminophen TABS 2 QL (375 tabs / 25 days) oxycodone-aspirin 2 QL (375 tabs / 25 days) oxycodone-ibuprofen 2 QL (28 tabs / 25 days) tramadol hcl TABS 2 QL (240 tabs / 25 days) tramadol hcl TB24 100mg 2 QL (90 tabs / 25 days) tramadol hcl TB24 200mg, 300mg 2 QL (30 tabs / 25 days) SALICYLATES aspirin 1 QL (100 tabs / 30 days);

OTC; $0 copay-age and gender restrictions apply

diflunisal 2 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 LIDOCAINE HCL/DEXTROSE 4 ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate 2 chloramphenicol sodium succinate 2 erythromycin-sulfisoxazole 2 gentamicin in saline 2 gentamicin sulfate 2 GENTAMICIN SULFATE/0.9% S 4 kanamycin sulfate 2 neomycin sulfate 2 paromomycin sulfate 2 streptomycin sulfate 2 SULFADIAZINE 4

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Drug Name Drug Tier Requirements/Limits tinidazole 2 tobramycin 2 PA tobramycin sulfate 2 TOBRAMYCIN SULFATE/SODIUM 4 ANTI-INFECTIVES - MISCELLANEOUS atovaquone 2 AZACTAM IN ISO-OSMOTIC DE 4 aztreonam 2 BILTRICIDE 4 CAYSTON 5 PA clindamycin hcl 2 clindamycin palmitate hydrochloride 2 clindamycin phosphate 2 CUBICIN 4 dapsone 2 DAPTOMYCIN 2 DARAPRIM 4 DORIBAX 4 DORIPENEM 2 EMVERM 4 FLAGYL ER 4 imipenem-cilastatin 2 INVANZ 4 ivermectin 2 linezolid 2 linezolid in sodium chloride 2 meropenem 2 methenamine hippurate 2 metronidazole 2 metronidazole in nacl 2 NEBUPENT 4 nitrofurantoin 2 PA; High Risk

Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year

nitrofurantoin macrocrystal 2 PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year

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Drug Name Drug Tier Requirements/Limits nitrofurantoin monohyd macro 2 PA; High Risk

Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year

PENTAM 300 4 polymyxin b sulfate 2 PRIMSOL 3 sulfamethoxazole-trimethoprim 2 trimethoprim 2 TYGACIL 4 vancomycin hcl CAPS 2 ST; PA** vancomycin hcl SOLR 2 ANTIFUNGALS ABELCET 4 AMBISOME 4 AMPHOTEC 4 amphotericin b 2 BIO-STATIN 3 CANCIDAS 4 ERAXIS 4 fluconazole 2 fluconazole in dextrose 2 fluconazole in nacl 2 FLUCONAZOLE IN NACL 4 griseofulvin microsize 2 griseofulvin ultramicrosize 2 itraconazole 2 PA MYCAMINE 4 NOXAFIL 3 nystatin 2 terbinafine hcl 2 PA voriconazole 2 PA ANTIMALARIALS atovaquone-proguanil hcl 2 chloroquine phosphate 2 mefloquine hcl 2 PRIMAQUINE PHOSPHATE 4 quinine sulfate 2 ANTIRETROVIRAL AGENTS abacavir sulfate 2 APTIVUS 3 CRIXIVAN 3 didanosine 2 EDURANT 3

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Drug Name Drug Tier Requirements/Limits EMTRIVA 3 FUZEON 5 PA INTELENCE 3 INVIRASE 3 ISENTRESS 3 lamivudine 2 LEXIVA 3 nevirapine 2 NORVIR 3 PREZISTA 3 RESCRIPTOR 4 RETROVIR IV INFUSION 3 REYATAZ 3 SELZENTRY 3 stavudine 2 SUSTIVA 3 TIVICAY 3 VIDEX PEDIATRIC 3 VIRACEPT 3 VIREAD 3 VITEKTA 3 zidovudine 2 ANTIRETROVIRAL COMBINATION AGENTS ABACAVIR SULFATE-LAMIVUDINE 2 abacavir sulfate-lamivudine-zidovudine 2 ATRIPLA 3 COMPLERA 3 EPZICOM 3 EVOTAZ 3 GENVOYA 3 KALETRA 3 lamivudine-zidovudine 2 LOPINAVIR-RITONAVIR 2 PREZCOBIX 3 STRIBILD 3 TRIUMEQ 3 TRUVADA 3 ANTITUBERCULAR AGENTS cycloserine 2 ethambutol hcl 2 isoniazid 2 PRIFTIN 3 pyrazinamide 2 rifabutin 2 RIFAMATE 3 rifampin 2

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Drug Name Drug Tier Requirements/Limits RIFATER 3 ANTIVIRALS acyclovir 2 acyclovir sodium 2 adefovir dipivoxil 2 BARACLUDE 3 cidofovir 2 entecavir 2 EPCLUSA 5 PA EPIVIR HBV 3 famciclovir 2 foscarnet sodium 2 HARVONI 5 PA lamivudine (hbv) 2 OSELTAMIVIR PHOSPHATE 30mg 2 QL (28 caps / 90 days) OSELTAMIVIR PHOSPHATE 45mg, 75mg 2 QL (14 caps / 90 days) PEGASYS 5 PA REBETOL 5 PA RIBAVIRIN 2 ribavirin (hepatitis c) 2 PA rimantadine hydrochloride 2 SOVALDI 5 PA TAMIFLU CAPS 30mg 3 QL (28 caps / 90 days) TAMIFLU CAPS 45mg, 75mg 3 QL (14 caps / 90 days) TAMIFLU SUSR 3 QL (180 mL / 90 days) TYZEKA 5 PA valacyclovir hcl 2 valganciclovir hcl 2 VIRAZOLE 4 CEPHALOSPORINS CEDAX 4 cefaclor 2 CEFACLOR ER 3 cefadroxil 2 CEFAZOLIN 4 CEFAZOLIN SODIUM SOLN 4 cefazolin sodium SOLR 2 CEFAZOLIN SODIUM/DEXTROSE 4 cefdinir 2 cefditoren pivoxil 2 CEFEPIME 4 cefepime hcl 2 CEFEPIME/DEXTROSE 4 cefixime 2 cefotaxime sodium 2 cefotetan disodium 2

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Drug Name Drug Tier Requirements/Limits CEFOTETAN/DEXTROSE 4 CEFOXITIN SODIUM 4 cefoxitin sodium 1gm, 2gm, 10gm 2 cefpodoxime proxetil 2 cefprozil 2 ceftazidime 1gm, 2gm, 6gm 2 CEFTAZIDIME 100gm 4 CEFTAZIDIME/DEXTROSE 4 ceftibuten 2 CEFTIN 3 ceftriaxone sodium 2 cefuroxime axetil 2 cefuroxime sodium 1.5gm, 7.5gm, 750mg 2 CEFUROXIME SODIUM 7.5gm, 75gm,

225gm 4

CEFUROXIME/DEXTROSE 4 cephalexin 2 CLAFORAN 4 FORTAZ 4 MAXIPIME 4 MEFOXIN 4 SUPRAX 3 ZINACEF 4 ERYTHROMYCINS/MACROLIDES azithromycin 2 clarithromycin 2 DIFICID 3 PA ERYPED 400 3 ERYTHROCIN LACTOBIONATE 4 erythromycin base 2 erythromycin ethylsuccinate 2 erythromycin stearate 2 PCE 4 ZMAX 4 FLUOROQUINOLONES AVELOX 4 ciprofloxacin 2 ciprofloxacin hcl 2 ciprofloxacin in d5w 2 ciprofloxacin-ciprofloxacin hcl 2 FACTIVE 4 levofloxacin 2 levofloxacin in d5w 2 moxifloxacin hcl 2 ofloxacin 2 PENICILLINS

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Drug Name Drug Tier Requirements/Limits amoxicillin 2 amoxicillin & pot clavulanate 2 ampicillin 2 ampicillin & sulbactam sodium 2 ampicillin sodium 2 AUGMENTIN 3 BACTOCILL IN DEXTROSE 4 BICILLIN C-R 4 BICILLIN L-A 4 dicloxacillin sodium 2 NAFCILLIN 4 nafcillin sodium 2 oxacillin sodium 2 penicillin g potassium 2 PENICILLIN G POTASSIUM IN 4 PENICILLIN G PROCAINE 4 penicillin g sodium 2 penicillin v potassium 2 piperacillin sodium-tazobactam sodium 2 ZOSYN 4 TETRACYCLINES demeclocycline hcl 2 doxycycline (monohydrate) 2 doxycycline hyclate 2 minocycline hcl 2 tetracycline hcl 2 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN 3 BICNU 3 busulfan 2 BUSULFEX 3 CYCLOPHOSPHAMIDE CAPS 3 cyclophosphamide SOLR; TABS 2 dacarbazine 2 EMCYT 3 GLEOSTINE 3 GLIADEL WAFER 3 HEXALEN 3 ifosfamide 2 LEUKERAN 3 melphalan 2 melphalan hcl 2 MYLERAN 3 TEMODAR 5 PA temozolomide 5 PA

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Drug Name Drug Tier Requirements/Limits ZANOSAR 3 ANTHRACYCLINES ADRIAMYCIN 3 daunorubicin hcl 2 DAUNOXOME 3 doxorubicin hcl 2 doxorubicin hcl liposomal 2 epirubicin hcl SOLN 2 EPIRUBICIN HCL SOLR 3 idarubicin hcl 2 ANTIBIOTICS bleomycin sulfate 2 dactinomycin 2 mitomycin 2 ANTIMETABOLITES ALIMTA 3 ARRANON 3 azacitidine 5 PA capecitabine 5 PA cladribine 2 CLOLAR 3 cytarabine 2 decitabine 5 PA DEPOCYT 3 floxuridine 2 fludarabine phosphate 2 fluorouracil 2 gemcitabine hcl 2 mercaptopurine 2 methotrexate sodium SOLN; SOLR 2 NIPENT 3 TABLOID 3 ANTIMITOTIC, TAXOIDS ABRAXANE 3 DOCETAXEL CONC 20mg/0.5ml,

80mg/2ml, 140mg/7ml, 160mg/8ml 3

docetaxel CONC 20mg/ml, 80mg/4ml 2 DOCETAXEL SOLN 3 DOCETAXEL (NON-ALCOHOL FO 3 paclitaxel 2 ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 2 VINBLASTINE SULFATE SOLR 3 vincristine sulfate 2 vinorelbine tartrate 2 BIOLOGIC RESPONSE MODIFIERS

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Drug Name Drug Tier Requirements/Limits ARZERRA 5 PA ERBITUX 5 PA ERIVEDGE 5 PA GAZYVA 5 PA IBRANCE 5 PA LYNPARZA 5 PA RITUXAN 5 PA YERVOY 5 PA ZALTRAP 5 PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole 2 bicalutamide 2 DEPO-PROVERA 4 ELIGARD 5 PA exemestane 2 FARESTON 3 FASLODEX 3 FIRMAGON 5 PA flutamide 2 letrozole 2 leuprolide acetate 5 PA LUPRON DEPOT (1-MONTH) 5 PA LUPRON DEPOT (3-MONTH) 5 PA LUPRON DEPOT (4-MONTH) 5 PA LUPRON DEPOT (6-MONTH) 5 PA LUPRON DEPOT-PED (1-MONTH 5 PA LUPRON DEPOT-PED (3-MONTH 5 PA LYSODREN 3 megestrol acetate 2 megestrol acetate (appetite) 2 nilutamide 2 tamoxifen citrate 2 $0 copay for women >

35 years for the primary prevention of breast cancer

ZYTIGA 5 PA KINASE INHIBITORS AFINITOR 5 PA BOSULIF 5 PA CAPRELSA 5 PA COMETRIQ 5 PA ICLUSIG 5 PA imatinib mesylate 5 PA IMBRUVICA 5 PA INLYTA 5 PA JAKAFI 5 PA

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Drug Name Drug Tier Requirements/Limits LENVIMA 8 MG DAILY DOSE 5 PA LENVIMA 10 MG DAILY DOSE 5 PA LENVIMA 14 MG DAILY DOSE 5 PA LENVIMA 18 MG DAILY DOSE 5 PA LENVIMA 20 MG DAILY DOSE 5 PA LENVIMA 24 MG DAILY DOSE 5 PA MEKINIST 5 PA SPRYCEL 5 PA SUTENT 5 PA TAFINLAR 5 PA TARCEVA 5 PA TYKERB 5 PA XALKORI 5 PA ZELBORAF 5 PA ZYKADIA 5 PA MISCELLANEOUS bexarotene 5 PA hydroxyurea 2 ifosfamide & mesna 2 MATULANE 3 mitoxantrone hcl 5 PA ONCASPAR 5 PA PHOTOFRIN 3 QUADRAMET 3 THERACYS 3 TICE BCG 3 tretinoin (chemotherapy) 2 TRISENOX 3 UVADEX 3 PLATINUM-BASED AGENTS carboplatin 2 cisplatin 2 ELOXATIN 3 oxaliplatin 2 PROTECTIVE AGENTS amifostine 2 dexrazoxane 2 KEPIVANCE 3 leucovorin calcium 2 mesna 2 MESNEX 3 TOPOISOMERASE INHIBITORS CAMPTOSAR 3 ETOPOPHOS 3 etoposide 2 HYCAMTIN 5 PA

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Drug Name Drug Tier Requirements/Limits irinotecan hcl 2 TENIPOSIDE 3 TOPOTECAN HCL SOLN 3 topotecan hcl SOLR 2 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl 2 benazepril & hydrochlorothiazide 2 captopril & hydrochlorothiazide 2 enalapril maleate & hydrochlorothiazide 2 fosinopril sodium & hydrochlorothiazide 2 lisinopril & hydrochlorothiazide 2 quinapril-hydrochlorothiazide 2 trandolapril-verapamil hcl 2 ACE INHIBITORS benazepril hcl 2 captopril 2 enalapril maleate 2 fosinopril sodium 2 lisinopril 2 perindopril erbumine 2 quinapril hcl 2 ramipril 2 trandolapril 2 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 2 ALPHA BLOCKERS doxazosin mesylate 2 prazosin hcl 2 terazosin hcl 2 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan 2 amlodipine-valsartan-hydrochlorothiazide 2 candesartan cilexetil-hydrochlorothiazide 2 irbesartan-hydrochlorothiazide 2 losartan potassium & hydrochlorothiazide 2 telmisartan-amlodipine 2 telmisartan-hydrochlorothiazide 2 valsartan-hydrochlorothiazide 2 ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 4 ST candesartan cilexetil 2 irbesartan 2 losartan potassium 2 OLMESARTAN MEDOXOMIL 2

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Drug Name Drug Tier Requirements/Limits telmisartan 2 valsartan 2 ANTIARRHYTHMICS amiodarone hcl 2 disopyramide phosphate 2 dofetilide 5 PA flecainide acetate 2 lidocaine hcl (cardiac) 2 lidocaine in d5w 2 mexiletine hcl 2 procainamide hcl 100mg/ml 2 PROCAINAMIDE HCL 500mg/ml 4 propafenone hcl 2 quinidine sulfate 2 sotalol hcl 2 sotalol hcl (afib/afl) 2 SOTALOL HYDROCHLORIDE 4 ANTILIPEMICS, BILE ACID RESINS cholestyramine 2 cholestyramine light 2 colestipol hcl 2 WELCHOL 3 ANTILIPEMICS, FIBRATES choline fenofibrate 2 fenofibrate 2 fenofibrate micronized 2 fenofibric acid 2 gemfibrozil 2 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium 2 lovastatin 2 pravastatin sodium 2 rosuvastatin calcium 2 simvastatin 5mg, 10mg, 20mg, 40mg 2 simvastatin 80mg 2 ST ANTILIPEMICS, MISCELLANEOUS niacin (antihyperlipidemic) 2 ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters 2 PA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 2 bisoprolol & hydrochlorothiazide 2 metoprolol & hydrochlorothiazide 2 nadolol & bendroflumethiazide 2 propranolol & hydrochlorothiazide 2

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Drug Name Drug Tier Requirements/Limits BETA-BLOCKERS acebutolol hcl 2 atenolol 2 betaxolol hcl 2 bisoprolol fumarate 2 carvedilol 2 labetalol hcl 2 metoprolol succinate 2 metoprolol tartrate 2 nadolol 2 pindolol 2 propranolol hcl 2 timolol maleate 2 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium 2 CALCIUM CHANNEL BLOCKERS amlodipine besylate 2 CARDENE IV 4 diltiazem hcl CP12; CP24; SOLN; TABS 2 DILTIAZEM HCL SOLR 4 diltiazem hcl coated beads 2 diltiazem hcl extended release beads 2 felodipine 2 isradipine 2 nicardipine hcl 2 nifedipine 2 nimodipine 2 nisoldipine 2 verapamil hcl 2 DIGITALIS GLYCOSIDES digoxin 2 LANOXIN 3 LANOXIN PEDIATRIC 4 DIURETICS acetazolamide 2 acetazolamide sodium 2 ALDACTAZIDE 3 amiloride & hydrochlorothiazide 2 amiloride hcl 2 bumetanide 2 chlorothiazide 2 chlorothiazide sodium 2 chlorthalidone 2 ethacrynate sodium 2 ethacrynic acid 2 FUROSEMIDE SOLN 8mg/ml 2

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Drug Name Drug Tier Requirements/Limits furosemide SOLN 10mg/ml 2 furosemide TABS 2 hydrochlorothiazide 2 indapamide 2 methazolamide 2 metolazone 2 spironolactone 2 spironolactone & hydrochlorothiazide 2 TORSEMIDE SOLN 4 torsemide TABS 2 triamterene & hydrochlorothiazide 2 MISCELLANEOUS clonidine hcl 2 guanfacine hcl 2 hydralazine hcl 2 methyldopa 2 methyldopate hcl 2 midodrine hcl 2 phenoxybenzamine hcl 2 reserpine 2 NITRATES isosorbide dinitrate 2 isosorbide mononitrate 2 NITRO-BID 4 nitroglycerin AERS 2 nitroglycerin CPCR 2 nitroglycerin PT24 2 NITROGLYCERIN SOLN 5mg/ml 4 nitroglycerin SOLN .4mg/spray 2 nitroglycerin in d5w 2 NITROSTAT 3 PULMONARY ARTERIAL HYPERTENSION epoprostenol sodium 5 PA LETAIRIS 5 PA ORENITRAM 5 PA REMODULIN 5 PA sildenafil citrate (pulmonary hypertension) 2 PA TRACLEER 5 PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam 2mg 2 QL (60 tabs / 25 days) alprazolam .25mg, .5mg, 1mg 2 QL (90 tabs / 25 days) buspirone hcl 2

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Drug Name Drug Tier Requirements/Limits hydroxyzine hcl SYRP; TABS 2 PA; High Risk

Medications require PA for members age 65 and older

lorazepam CONC 2 QL (150 mL / 25 days) lorazepam TABS 2 QL (150 tabs / 25 days) ANTICONVULSANTS carbamazepine 2 CELONTIN 4 clonazepam 2 clorazepate dipotassium 2 QL (120 tabs / 25 days) diazepam CONC 2 QL (240 mL / 25 days) diazepam SOLN 1mg/ml 2 QL (1200 mL / 25 days) diazepam SOLN 5mg/ml 2 diazepam TABS 2 QL (120 tabs / 25 days) DILANTIN 4 divalproex sodium 2 ethosuximide 2 fosphenytoin sodium 2 gabapentin 2 lamotrigine 2 LEVETIRACETAM SOLN 4 levetiracetam SOLN 100mg/ml,

500mg/5ml 2

levetiracetam TABS 2 levetiracetam TB24 2 LEVETIRACETAM IN SODIUM CHLORIDE 2 LYRICA 4 ST; PA** PEGANONE 4 phenobarbital 2 phenytoin 2 phenytoin sodium 2 phenytoin sodium extended 2 primidone 2 topiramate 2 valproate sodium 2 valproic acid 2 zonisamide 2 ANTIDEMENTIA donepezil hydrochloride 2 EXELON 3 PA galantamine hydrobromide 2 memantine hcl 2 PA; PA applies for

members less than 30 years of age

rivastigmine tartrate 2 PA ANTIDEPRESSANTS

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Drug Name Drug Tier Requirements/Limits amitriptyline hcl 10mg 2 QL (150 tabs / 25 days);

QL applies to members age 65 and older

amitriptyline hcl 25mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and older

amitriptyline hcl 50mg 2 QL (30 tabs / 25 days); QL applies to members age 65 and older

amitriptyline hcl 75mg, 100mg, 150mg 2 Members 65 and older subject to PA

amoxapine 25mg, 50mg, 100mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and older

amoxapine 150mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and older

bupropion hcl 2 citalopram hydrobromide 2 clomipramine hcl 25mg, 50mg 2 QL (150 caps / 25

days); QL applies to members age 65 and older

clomipramine hcl 75mg 2 QL (90 caps / 25 days); QL applies to members age 65 and older

desipramine hcl 10mg, 25mg, 50mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and older

desipramine hcl 75mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and older

desipramine hcl 100mg, 150mg 2 QL (30 tabs / 25 days); QL applies to members age 65 and older

desvenlafaxine 2 doxepin hcl CAPS 10mg, 25mg, 50mg 2 QL (90 caps / 25 days);


doxepin hcl CAPS 75mg 2 QL (60 caps / 25 days); QL applies to members age 65 and older

doxepin hcl CAPS 100mg, 150mg 2 QL (30 caps / 25 days); QL applies to members age 65 and older

doxepin hcl CONC 2 QL (450 mL / 25 days); QL applies to members age 65 and older

duloxetine hcl 2

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Drug Name Drug Tier Requirements/Limits escitalopram oxalate 2 fluoxetine hcl CAPS 2 fluoxetine hcl CPDR 2 fluoxetine hcl SOLN 2 fluoxetine hcl TABS 10mg, 20mg 2 FLUOXETINE HCL TABS 60mg 4 imipramine hcl 10mg, 25mg 2 QL (120 tabs / 25 days);


imipramine hcl 50mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and older

imipramine pamoate 75mg, 100mg 2 QL (30 caps / 25 days); QL applies to members age 65 and older

imipramine pamoate 125mg, 150mg 2 Members 65 and older subject to PA

mirtazapine 2 nefazodone hcl 2 nortriptyline hcl CAPS 10mg 2 QL (150 caps / 25

days); QL applies to members age 65 and older

nortriptyline hcl CAPS 25mg 2 QL (60 caps / 25 days); QL applies to members age 65 and older

nortriptyline hcl CAPS 50mg 2 QL (30 caps / 25 days); QL applies to members age 65 and older

nortriptyline hcl CAPS 75mg 2 Members 65 and older subject to PA

nortriptyline hcl SOLN 2 QL (750 mL / 25 days); QL applies to members age 65 and older

paroxetine hcl 2 phenelzine sulfate 2 protriptyline hcl 5mg 2 QL (90 tabs / 25 days);


protriptyline hcl 10mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and older

sertraline hcl 2 tranylcypromine sulfate 2 trazodone hcl 2 trimipramine maleate 25mg, 50mg 2 QL (60 caps / 25 days);


Version 10 10/01/17 22


Drug Name Drug Tier Requirements/Limits trimipramine maleate 100mg 2 QL (30 caps / 25 days);


venlafaxine hcl 2 ANTIPARKINSONIAN AGENTS amantadine hcl 2 AZILECT 3 benztropine mesylate 2 bromocriptine mesylate 2 carbidopa 2 carbidopa-levodopa 2 carbidopa-levodopa-entacapone 2 entacapone 2 pramipexole dihydrochloride 2 RASAGILINE MESYLATE 2 ropinirole hydrochloride 2 selegiline hcl 2 trihexyphenidyl hcl 2 ANTIPSYCHOTICS aripiprazole 2 CHLORPROMAZINE HCL SOLN 4 chlorpromazine hcl TABS 2 clozapine 2 ergoloid mesylates 2 fluphenazine decanoate 2 fluphenazine hcl 2 haloperidol 2 haloperidol decanoate 2 haloperidol lactate 2 loxapine succinate 2 olanzapine 2 paliperidone 2 perphenazine 2 pimozide 2 quetiapine fumarate 2 risperidone 2 thioridazine hcl 2 thiothixene 2 trifluoperazine hcl 2 ziprasidone hcl 2 ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine 5mg

CP24 2 QL (90 caps / 25 days)

amphetamine-dextroamphetamine 5mg TABS

2 QL (90 tabs / 25 days)

amphetamine-dextroamphetamine 7.5mg 2 QL (90 tabs / 25 days)

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Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine 10mg




amphetamine-dextroamphetamine 12.5mg 2 QL (90 tabs / 25 days) amphetamine-dextroamphetamine 15mg




amphetamine-dextroamphetamine 20mg CP24




amphetamine-dextroamphetamine 25mg 2 QL (30 caps / 25 days) amphetamine-dextroamphetamine 30mg




atomoxetine hcl 2 dextroamphetamine sulfate CP24 5mg,


dextroamphetamine sulfate CP24 15mg 2 QL (60 caps / 25 days) dextroamphetamine sulfate SOLN 2 QL (1,200 mL / 25 days) dextroamphetamine sulfate TABS 2.5mg,

5mg, 7.5mg, 10mg 2 QL (120 tabs / 25 days)

dextroamphetamine sulfate TABS 15mg, 20mg


dextroamphetamine sulfate TABS 30mg 2 QL (30 tabs / 25 days) guanfacine hcl (adhd) 2 ST; PA** methamphetamine hcl 2 QL (150 tabs / 25 days) methylphenidate hcl CHEW 2 QL (180 chew tabs / 25

days) methylphenidate hcl CP24 20mg, 30mg 2 QL (60 caps / 25 days) methylphenidate hcl CP24 40mg 2 QL (30 caps / 25 days) methylphenidate hcl CPCR 10mg, 20mg,


methylphenidate hcl CPCR 40mg, 50mg, 60mg


methylphenidate hcl SOLN 5mg/5ml 2 QL (1800 mL / 25 days) methylphenidate hcl SOLN 10mg/5ml 2 QL (900 mL / 25 days) methylphenidate hcl TABS 5mg, 10mg 2 QL (180 tabs / 25 days) methylphenidate hcl TABS 20mg 2 QL (90 tabs / 25 days) methylphenidate hcl TB24 18mg, 27mg,


methylphenidate hcl TB24 54mg 2 QL (30 tabs / 25 days) methylphenidate hcl TBCR 10mg, 20mg 2 QL (90 tabs / 25 days) methylphenidate hcl TBCR 18mg, 27mg,


Version 10 10/01/17 24


Drug Name Drug Tier Requirements/Limits methylphenidate hcl TBCR 54mg 2 QL (30 tabs / 25 days) STRATTERA 3 HYPNOTICS temazepam 2 QL (15 caps / 25 days) zaleplon 2 QL (15 caps / 25 days) zolpidem tartrate 2 QL (15 tabs / 25 days) MIGRAINE almotriptan malate 2 QL (12 tabs / 25 days) CAFERGOT 3 dihydroergotamine mesylate 1mg/ml 2 dihydroergotamine mesylate 4mg/ml 2 QL (8 kits / 25 days) ERGOMAR 4 ST ERGOTAMINE W/ CAFFEINE 2 naratriptan hcl 2 QL (12 tabs / 25 days) rizatriptan benzoate 2 QL (18 tabs / 25 days) sumatriptan 5mg/act 2 QL (24 sprays / 25

days) sumatriptan 20mg/act 2 QL (12 sprays / 25

days) sumatriptan succinate SOAJ 4mg/0.5ml 2 QL (18 syringes / 25

days) sumatriptan succinate SOAJ 6mg/0.5ml 2 QL (12 units / 25 days) sumatriptan succinate SOCT 4mg/0.5ml 2 QL (18 syringes / 25

days) sumatriptan succinate SOCT 6mg/0.5ml 2 QL (12 units / 25 days) sumatriptan succinate SOLN 4mg/0.5ml 2 QL (18 syringes / 25

days) sumatriptan succinate SOLN 6mg/0.5ml 2 QL (12 vials per 25

days) sumatriptan succinate SOSY 2 QL (12 units / 25 days) sumatriptan succinate TABS 2 QL (12 tabs / 25 days) zolmitriptan 2 QL (12 tabs / 25 days) MISCELLANEOUS LITHIUM 4 lithium carbonate 2 MESTINON 3 pyridostigmine bromide 2 REGONOL 4 riluzole 2 tetrabenazine 5 PA MULTIPLE SCLEROSIS AGENTS BETASERON 3 PA COPAXONE 4 PA glatiramer acetate 3 PA REBIF 3 PA REBIF REBIDOSE 3 PA REBIF REBIDOSE TITRATION 3 PA

Version 10 10/01/17 25


Drug Name Drug Tier Requirements/Limits MUSCULOSKELETAL THERAPY AGENTS baclofen 2 carisoprodol 2 PA; High Risk


chlorzoxazone 2 cyclobenzaprine hcl 2 PA; High Risk


dantrolene sodium 2 metaxalone 2 PA; High Risk


methocarbamol 2 PA; High Risk Medications require PA for members age 65 and older

orphenadrine citrate SOLN 2 orphenadrine citrate TB12 2 PA; High Risk


orphenadrine w/ aspirin & caff 2 PA; High Risk Medications require PA for members age 65 and older

tizanidine hcl 2 NARCOLEPSY/CATAPLEXY modafinil 2 PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 PA bupropion hcl (smoking deterrent) 1 $0 limited to 2

treatment cycles/year CHANTIX 1 $0 limited to 2

treatment cycles/year disulfiram 2 naloxone hcl 2 naltrexone hcl 2 nicotine 1 OTC; $0 limited to 2

treatment cycles/year nicotine polacrilex 1 OTC; $0 limited to 2

treatment cycles/year CYSTIC FIBROSIS AGENTS HYDROLYTIC ENZYMES PULMOZYME 5 PA

Version 10 10/01/17 26


Drug Name Drug Tier Requirements/Limits ENDOCRINE AND METABOLIC ANDROGENS methyltestosterone 2 PA oxandrolone 2 PA testosterone 2 PA testosterone cypionate 2 PA testosterone enanthate 2 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose 2 ANTIDIABETICS, BIGUANIDE metformin hcl 2 ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl 2 glyburide-metformin 2 PA; High Risk


ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate 2 PA JANUVIA 3 ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET 3 JANUMET XR 3 ANTIDIABETICS, INSULIN HUMULIN 70/30 4 OTC HUMULIN 70/30 KWIKPEN 4 OTC HUMULIN N 4 OTC HUMULIN N KWIKPEN 4 OTC HUMULIN R 4 OTC LANTUS 3 NOVOLIN 70/30 3 OTC;RELION not

covered NOVOLIN N 3 OTC;RELION not

covered NOVOLIN R 3 OTC;RELION not

covered NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG MIX 70/30 FLEXPEN 3 NOVOLOG PENFILL 3 ANTIDIABETICS, INSULIN SENSITIZER pioglitazone hcl 2 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl 2

Version 10 10/01/17 27


Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA

COMBINATION pioglitazone hcl-glimepiride 2 ANTIDIABETICS, INSULIN^ LANTUS SOLOSTAR 3 ANTIDIABETICS, MEGLITINIDE nateglinide 2 repaglinide 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION repaglinide-metformin hcl 2 ANTIDIABETICS, SULFONYLUREA glimepiride 2 glipizide 2 glyburide 2 PA; High Risk


glyburide micronized 2 PA; High Risk Medications require PA for members age 65 and older

BISPHOSPHONATES alendronate sodium 2 FOSAMAX PLUS D 4 ST; PA** ibandronate sodium 2 PAMIDRONATE DISODIUM SOLN 6mg/ml 4 pamidronate disodium SOLN 30mg/10ml,

90mg/10ml 2

pamidronate disodium SOLR 2 risedronate sodium 2 zoledronic acid CONC 5 PA ZOLEDRONIC ACID SOLN 4mg/100ml 5 PA zoledronic acid SOLN 5mg/100ml 5 PA ZOMETA 5 PA CALCIUM RECEPTOR AGONISTS SENSIPAR 5 PA CHELATING AGENTS CHEMET 4 DEPEN TITRATABS 4 EXJADE 5 PA FERRIPROX 5 PA sodium polystyrene sulfonate 2 CONTRACEPTIVES desogestrel & ethinyl estradiol 1 desogestrel-ethinyl estradiol (biphasic) 1 desogestrel-ethinyl estradiol (triphasic) 2

Version 10 10/01/17 28


Drug Name Drug Tier Requirements/Limits drospirenone-ethinyl estradiol 2 ELLA 1 ethynodiol diacet & eth estrad 1 IMPLANON 4 QL (1 / 300 days) levonorgestrel & eth estradiol 1 levonorgestrel (emergency oc) 1 levonorgestrel-eth estradiol (triphasic) 1 levonorgestrel-ethinyl estradiol (91-day) 1 levonorgestrel-ethinyl estradiol (91-day) 2 levonorgestrel-ethinyl estradiol

(continuous) 2

LILETTA 4 QL (1 / 300 days) medroxyprogesterone acetate

(contraceptive) 1 QL (4 inj / 300 days)

MIRENA 4 QL (1 / 300 days) NECON 10/11-28 1 NEXPLANON 4 QL (1 / 300 days) norelgestromin-ethinyl estradiol 2 norethin acet & estrad-fe 2 norethindrone & eth estradiol 1 norethindrone & ethinyl estradiol-fe 2 norethindrone & mestranol 1 norethindrone (contraceptive) 2 norethindrone acet & eth estra 1 norethindrone acetate-ethinyl estradiol-fe 1 norethindrone-eth estradiol (triphasic) 1 norgestimate-ethinyl estradiol 1 norgestimate-ethinyl estradiol (triphasic) 1 norgestrel & ethinyl estradiol 1 NUVARING 1 QL (13 / 300 days) PARAGARD INTRAUTERINE COP 1 QL (1 unit / 300 days) SKYLA 4 QL (1 / 300 days) ENDOMETRIOSIS danazol 2 ENZYME REPLACEMENTS ADAGEN 5 PA BUPHENYL 5 PA MYOZYME 5 PA sodium phenylbutyrate 2 PA ZAVESCA 5 PA ESTROGENS DEPO-ESTRADIOL 4 ENJUVIA 4 PA; High Risk


Version 10 10/01/17 29


Drug Name Drug Tier Requirements/Limits ESTRACE 3 estradiol 2 PA; High Risk


estradiol valerate 2 ESTRING 4 ESTROGEL 4 PA; High Risk


estropipate 2 PA; High Risk Medications require PA for members age 65 and older

MENEST 4 PA; High Risk Medications require PA for members age 65 and older

norethindrone acetate-ethinyl estradiol 2 yuvafem 2 FERTILITY REGULATORS chorionic gonadotropin 5 PA clomiphene citrate 2 FOLLISTIM AQ 5 PA GONAL-F 5 PA, ST GONAL-F RFF 5 PA, ST GONAL-F RFF REDIJECT 5 PA, ST OVIDREL 5 PA GLUCOCORTICOIDS cortisone acetate 2 DEPO-MEDROL 4 dexamethasone 2 DEXAMETHASONE INTENSOL 3 dexamethasone sodium phosphate 2 DEXPAK 6 DAY 4 DEXPAK 10 DAY 4 DEXPAK 13 DAY 4 fludrocortisone acetate 2 hydrocortisone 2 hydrocortisone sod succinate 2 MEDROL 3 methylprednisolone 2 methylprednisolone acetate 2 methylprednisolone sod succ 2 prednisolone 2

Version 10 10/01/17 30


Drug Name Drug Tier Requirements/Limits prednisolone sodium phosphate SOLN

5mg/5ml, 15mg/5ml, 25mg/5ml 2

PREDNISOLONE SODIUM PHOSPHATE SOLN 20mg/5ml

2

prednisolone sodium phosphate TBDP 2 prednisone 2 PREDNISONE INTENSOL 3 SOLU-CORTEF 4 SOLU-MEDROL 4 VERIPRED 20 4 GLUCOSE ELEVATING AGENTS GLUCAGON EMERGENCY KIT 3 HUMAN GROWTH HORMONES GENOTROPIN 5 PA, ST GENOTROPIN MINIQUICK 5 PA, ST NORDITROPIN FLEXPRO 5 PA NUTROPIN 5 PA, ST NUTROPIN AQ NUSPIN 5 5 PA, ST NUTROPIN AQ NUSPIN 10 5 PA, ST NUTROPIN AQ PEN 5 PA, ST ZORBTIVE 5 PA MISCELLANEOUS cabergoline 2 calcitonin (salmon) 2 FORTEO 5 PA octreotide acetate 5 PA raloxifene hcl 2 $0 copay for women >

35 years for the primary prevention of breast cancer

SAMSCA 5 PA SOMATULINE DEPOT 5 PA XGEVA 5 PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) 2 PHOSLYRA 3 PROGESTINS medroxyprogesterone acetate 2 norethindrone acetate 2 progesterone micronized 2 THYROID AGENTS levothyroxine sodium 2 liothyronine sodium 2 methimazole 2 propylthiouracil 2 SYNTHROID 3

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Drug Name Drug Tier Requirements/Limits THYROLAR-1 4 THYROLAR-1/2 4 THYROLAR-1/4 4 THYROLAR-2 4 THYROLAR-3 4 VASOPRESSINS desmopressin acetate 2 desmopressin acetate refrigerated 2 desmopressin acetate spray 2 desmopressin acetate spray refrigerated 2 GASTROINTESTINAL ANTICHOLINERGICS atropine sulfate 2 dicyclomine hcl 2 glycopyrrolate 2 hyoscyamine sulfate 2 methscopolamine bromide 2 ANTIEMETICS AKYNZEO 4 QL (2 capsules per 21

days) ANTIVERT 3 CESAMET 4 QL (18 caps / 25 days) dimenhydrinate 2 dronabinol 2 QL (60 caps / 25 days) EMEND 4 QL (6 kits / 25 days) granisetron hcl SOLN 2 QL (2 mL / 21 days) granisetron hcl TABS 2 QL (12 tablets / 21

days) meclizine hcl 2 metoclopramide hcl 2 ondansetron 2 QL (18 tablets / 21

days) ondansetron hcl SOLN 4mg/2ml,

40mg/20ml 2 QL (20 mL / 21 days)

ondansetron hcl SOLN 4mg/5ml 2 QL (200 mL / 21 days) ondansetron hcl TABS 4mg, 8mg 2 QL (18 tablets / 21

days) ondansetron hcl TABS 24mg 2 QL (2 tablets / 21 days) prochlorperazine 2 prochlorperazine edisylate 2 prochlorperazine maleate 2 promethazine hcl SOLN; SUPP 2 promethazine hcl SYRP; TABS 2 PA; High Risk


scopolamine 2

Version 10 10/01/17 32


Drug Name Drug Tier Requirements/Limits TRANSDERM-SCOP 4 trimethobenzamide hcl 2 PA; High Risk


H2-RECEPTOR ANTAGONISTS cimetidine 2 cimetidine hcl 2 famotidine 2 ranitidine hcl 2 INFLAMMATORY BOWEL DISEASE balsalazide disodium 2 budesonide 2 DIPENTUM 4 hydrocortisone (intrarectal) 2 mesalamine enema 4 gm 2 mesalamine rectal enema 4 gm & cleanser

wipe kit 2

sulfasalazine 2 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl 2 PA LAXATIVES bisacodyl-peg 3350-pot chloride-sod

bicarb-sod chloride 1 $0 copay for members

age 50 through 74 COLYTE-FLAVOR PACKS 3 GOLYTELY 3 lactulose 2 lactulose (encephalopathy) 2 MOVIPREP 3 $0 copay for members

age 50 through 74 OSMOPREP 4 peg 3350-kcl-sod bicarb-sod chloride-sod

sulfate 1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350 2 SUPREP BOWEL PREP KIT 4 $0 copay for members

age 50 through 74 MISCELLANEOUS CARAFATE 4 cromolyn sodium (mastocytosis) 2 diphenoxylate w/ atropine 2 loperamide hcl 2 misoprostol 2 sucralfate 2 ursodiol 2 PANCREATIC ENZYMES

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Drug Name Drug Tier Requirements/Limits CREON 3 ZENPEP 3 PROTON PUMP INHIBITORS omeprazole 2 QL (90 caps / 365 days) pantoprazole sodium 2 QL (90 tabs / 365 days) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 2 CARDURA XL 3 ST; PA** dutasteride 2 dutasteride-tamsulosin hcl 2 finasteride 2 tamsulosin hcl 2 CONTRACEPTIVES ENCARE 1 OTC OPTIONS CONCEPTROL VAGINA 1 OTC OPTIONS GYNOL II VAGINAL 1 OTC SHUR-SEAL 1 OTC TODAY SPONGE 1 OTC VCF VAGINAL CONTRACEPTIVE 1 OTC MISCELLANEOUS bethanechol chloride 2 ELMIRON 4 flavoxate hcl 2 phenazopyridine hcl 2 potassium citrate (alkalinizer) 2 URINARY ANTISPASMODICS darifenacin hydrobromide 2 oxybutynin chloride 2 tolterodine tartrate 2 trospium chloride 2 VAGINAL ANTI-INFECTIVES CLEOCIN 3 clindamycin phosphate vaginal 2 metronidazole vaginal 2 miconazole nitrate vaginal 2 terconazole vaginal 2 HEMATOLOGIC ANTICOAGULANTS ARGATROBAN 4 argatroban 250mg/2.5ml 2 COUMADIN 4 enoxaparin sodium 2 fondaparinux sodium 2 FRAGMIN 4

Version 10 10/01/17 34


Drug Name Drug Tier Requirements/Limits heparin sodium (porcine) 2 PRADAXA 4 warfarin sodium 2 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 5 PA LEUKINE 5 PA NEULASTA 5 PA NEULASTA ONPRO KIT 5 PA NEUPOGEN 5 PA NEUPOGEN INJ 480/1.6 5 PA PROCRIT 5 PA PROMACTA 5 PA ZARXIO 5 PA MISCELLANEOUS anagrelide hcl 2 cilostazol 2 FIRAZYR 5 PA pentoxifylline 2 tranexamic acid 2 PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 2 BRILINTA 3 clopidogrel bisulfate 2 dipyridamole 2 PA; High Risk


EFFIENT 3 prasugrel hcl 2 IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS CIMZIA 5 PA, ST ENBREL 5 PA ENBREL SURECLICK 5 PA HUMIRA 5 PA HUMIRA PEN-CROHNS DISEASE 5 PA KINERET 5 PA, ST ORENCIA 5 PA, ST ORENCIA CLICKJECT 5 PA, ST REMICADE 5 PA, ST DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) hydroxychloroquine sulfate 2 leflunomide 2 methotrexate sodium TABS 2 OTEZLA 5 PA, ST RHEUMATREX 4

Version 10 10/01/17 35


Drug Name Drug Tier Requirements/Limits IMMUNOGLOBULIN CARIMUNE NANOFILTERED 5 PA HYQVIA 5 PA IMMUNOGLOBULINS GAMASTAN S/D 5 PA IMMUNOMODULATORS ACTIMMUNE 5 PA ALFERON N 5 PA ARCALYST 5 PA INTRON A 5 PA INTRON A W/DILUENT 5 PA REVLIMID 5 PA THALOMID 5 PA IMMUNOSUPPRESSANTS ATGAM 4 azathioprine 2 BENLYSTA 5 PA CELLCEPT INTRAVENOUS 4 cyclosporine 2 cyclosporine modified (for microemulsion) 2 mycophenolate mofetil 2 MYCOPHENOLATE MOFETIL HCL 2 mycophenolate sodium 2 PROGRAF 4 RAPAMUNE 3 SANDIMMUNE 4 SIMULECT 4 sirolimus 2 tacrolimus 2 THYMOGLOBULIN 4 VACCINES ACTHIB 1 $0 copay for members

age 18 and younger ADACEL 1 AFLURIA 2016-2017 1 BEXSERO 1 BOOSTRIX 1 CERVARIX 1 COMVAX 1 $0 copay for members

age 18 and younger DAPTACEL 1 $0 copay for members

age 18 and younger DIPHTHERIA/TETANUS TOXOID 1 $0 copay for members

age 18 and younger ENGERIX-B 1 FLUAD 2016-2017 1

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Drug Name Drug Tier Requirements/Limits FLUBLOK 2016-2017 1 FLUCELVAX QUADRIVALENT 20 1 FLULAVAL QUADRIVALENT 201 1 FLUVIRIN 2016-2017 1 FLUZONE HIGH-DOSE PF 2016 1 FLUZONE INTRADERMAL QUADR 1 FLUZONE QUADRIVALENT 2016 1 GARDASIL 1 GARDASIL 9 1 HAVRIX 1 HIBERIX 1 $0 copay for members

age 18 and younger INFANRIX 1 $0 copay for members

age 18 and younger IPOL INACTIVATED IPV 1 $0 copay for members

age 18 and younger KINRIX 1 $0 copay for members

age 18 and younger M-M-R II 1 MEDICAL PROVIDER SINGLE U 1 MENACTRA 1 MENHIBRIX 1 $0 copay for members

age 18 and younger MENOMUNE-A/C/Y/W-135 1 MENVEO 1 PEDIARIX 1 $0 copay for members

age 18 and younger PEDVAX HIB 1 $0 copay for members

age 18 and younger PENTACEL 1 $0 copay for members

age 18 and younger PNEUMOVAX 23/5 DOSE 1 PREVNAR 13 1 PROQUAD 1 $0 copay for members

age 18 and younger RECOMBIVAX HB 1 ROTARIX 1 $0 copay for members

age 18 and younger ROTATEQ 1 $0 copay for members

age 18 and younger TENIVAC 1 $0 copay for members

age 19 and older TETANUS/DIPHTHERIA TOXOID 1 $0 copay for members

age 19 and older TRIPEDIA 1 $0 copay for members

age 18 and younger TRUMENBA 1

Version 10 10/01/17 37


Drug Name Drug Tier Requirements/Limits TWINRIX 1 $0 copay for members

age 19 and older VAQTA 1 VARIVAX 1 ZOSTAVAX 1 $0 copay for members

age 19 and older MEDICAL DEVICES CONTRACEPTIVES FC2 FEMALE CONDOM 1 OTC OMNIFLEX DIAPHRAGM 1 QL (1 / 300 days) ORTHO DIAPHRAGM ALL-FLEX/ 1 QL (1 / 300 days) ORTHO DIAPHRAGM COIL SPRI 1 QL (1 / 300 days) ORTHO DIAPHRAGM FLAT SPRI 1 QL (1 / 300 days) PRENTIF CAVITY-RIM CERVIC 1 QL (1 / 300 days) PRENTIF FITTING SET 1 QL (1 / 300 days) WIDE-SEAL SILICONE DIAPHR 1 QL (1 / 300 days) DIABETIC SUPPLIES BD INSULIN SYRINGE ULTRAF 3 OTC BD SWABS SINGLE USE 3 OTC CHEMSTRIP 9 STRIPS 3 OTC ONETOUCH DELICA LANCING D 3 OTC ONETOUCH PING METER REMOT 3 OTC ONETOUCH ULTRA 2 3 OTC ONETOUCH ULTRA BLUE 3 OTC ONETOUCH ULTRASOFT LANCET 3 OTC ONETOUCH VERIO 3 OTC ONETOUCH VERIO MID CONTRO 3 OTC TAMPER-TUF CONTAINER CLOS 3 OTC MISCELLANEOUS AEROCHAMBER PLUS FLOW-VU 3 FLEXICHAMBER CHILD MASK/S 3 OTC HUMATROPEN 3 OPTICHAMBER FACE MASK/SMA 3 OTC PEDIATRIC PANDA MASK 3 OTC NUTRITIONAL/ SUPPLEMENTS ELECTROLYTES potassium bicarbonate 2 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES AMMONIUM CHLORIDE 4 FLUORABON 1 $0 applies for ages 5

and under KLOR-CON M15 3 magnesium sulfate 2 MAGNESIUM SULFATE IN D5W 4 magnesium sulfate in dextrose 2

Version 10 10/01/17 38


Drug Name Drug Tier Requirements/Limits potassium chloride CPCR 2 potassium chloride SOLN 10%, 20% 2 potassium chloride TBCR 2 potassium chloride microencapsulated

crystals cr 2

sodium chloride 2.5meq/ml 2 sodium chloride flush 2 sodium fluoride CHEW 2 sodium fluoride SOLN 1 $0 applies for ages 5

and under sodium fluoride TABS 1mg 2 sodium fluoride TABS .5mg 1 $0 applies for ages 5

and under IV REPLACEMENT SOLUTIONS ISOLYTE-S 4 NORMOSOL -R 4 PLASMA-LYTE A 4 PLASMA-LYTE-148 4 potassium chloride SOLN .4meq/ml,

2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

2

potassium chloride in nacl 2 sodium chloride .45%, .9%, 3%, 5% 2 VITAMINS BABY SUPER DAILY D3 1 OTC;$0 applies for ages

65 and older calcitriol 2 cholecalciferol CAPS 400unit 1 OTC; $0 applies for ages

65 and older cholecalciferol CAPS 50000unit 2 OTC cholecalciferol CHEW 1 OTC; $0 applies for ages

65 and older cholecalciferol LIQD 1 OTC; $0 applies for ages

65 and older cholecalciferol TABS 1 OTC; $0 applies for ages

65 and older CITRANATAL 90 DHA 3 CITRANATAL ASSURE 3 CITRANATAL B-CALM 3 CITRANATAL DHA 3 CITRANATAL HARMONY 3 CITRANATAL RX 3 cyanocobalamin 2 D-VI-SOL 1 OTC; $0 applies for ages

65 and older DDROPS BOOSTER 1 OTC; $0 applies for ages

65 and older

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Drug Name Drug Tier Requirements/Limits doxercalciferol 2 ergocalciferol 2 folic acid 1mg 2 folic acid 400mcg, 800mcg 1 QL (100 tabs / 30 days);

OTC; $0 copay for women ages 55 and under

folic acid-pyridoxine-cyanocobalamin 2 MEPHYTON 3 paricalcitol 2 ped multivitamins w/fl & iron 2 pediatric multivitamins w/fl 2 pediatric vitamins acd fluoride & iron 2 pediatric vitamins acd w/ fluoride 2 prenatal vit w/ iron carbonyl-folic acid 2 QUFLORA PEDIATRIC CHEW 4 quflora pediatric SOLN 2 VITAMIN D2 1 OTC; $0 applies for ages

65 and older VITAMIN D3 1 OTC; $0 applies for ages

65 and older WELLESSE VITAMIN D3 1 OTC; $0 applies for ages

65 and older OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 BLEPHAMIDE 3 BLEPHAMIDE S.O.P. 3 neomycin-polymy-dexameth 2 neomycin-polymyxin-hc (ophth) 2 sulfacetamide sod-prednisolone 2 TOBRADEX 3 tobramycin-dexamethasone 2 ANTI-INFECTIVES AZASITE 4 bacitracin (ophthalmic) 2 bacitracin-polymyxin b (ophth) 2 BESIVANCE 4 CILOXAN 3 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 2 gatifloxacin (ophth) 2 gentamicin sulfate (ophth) 2 levofloxacin (ophth) 2 NATACYN 3 neomycin-polymyxin-gramicidin 2 ofloxacin (ophth) 2

Version 10 10/01/17 40


Drug Name Drug Tier Requirements/Limits polymyxin b-trimethoprim 2 sulfacetamide sodium (ophth) 2 tobramycin (ophth) 2 TOBREX 3 trifluridine 2 VIGAMOX 3 ZIRGAN 4 ANTI-INFLAMMATORIES ALREX 4 bromfenac sodium (ophth) 2 dexamethasone sodium phosphate (ophth) 2 diclofenac sodium (ophth) 2 DUREZOL 4 FLAREX 4 fluorometholone (ophth) 2 flurbiprofen sodium 2 FML 4 FML FORTE 4 ketorolac tromethamine (ophth) 2 LOTEMAX 4 MAXIDEX 4 PRED MILD 3 prednisolone acetate (ophth) 2 PREDNISOLONE SODIUM PHOSP 3 VEXOL 4 ANTIALLERGICS ALOMIDE 4 azelastine hcl (ophth) 2 BEPREVE 4 cromolyn sodium (ophth) 2 epinastine hcl (ophth) 2 olopatadine hcl 2 PATADAY 4 ANTIGLAUCOMA ALPHAGAN P 4 apraclonidine hcl 2 AZOPT 4 betaxolol hcl (ophth) 2 BETIMOL 4 BETOPTIC-S 3 bimatoprost 2 brimonidine tartrate 2 carteolol hcl (ophth) 2 COMBIGAN 3 dorzolamide hcl 2 dorzolamide hcl-timolol maleate 2

Version 10 10/01/17 41


Drug Name Drug Tier Requirements/Limits IOPIDINE 4 ISTALOL 4 latanoprost 2 levobunolol hcl 2 metipranolol 2 PHOSPHOLINE IODIDE 4 PILOPINE HS 4 SIMBRINZA 3 timolol maleate (ophth) 2 TIMOPTIC OCUDOSE 3 TRAVATAN Z 4 ST; PA** ZIOPTAN 4 ST; PA** MISCELLANEOUS atropine sulfate (ophthalmic) 2 naphazoline hcl 2 phenylephrine hcl (ophth) 2 proparacaine hcl 2 tropicamide 2 OTHER IRRIGATION SOLUTIONS irrigation solutions, physiological 2 ringer's irrigation 2 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine (anaphylaxis) 2 Generic Adrenaclick epinephrine hcl SOSY 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS COMBIVENT RESPIMAT 3 QL (2 inhalers / 25

days) ipratropium-albuterol 2 QL (6 boxes / 25 days) ANTICHOLINERGICS ipratropium bromide 2 QL (5 boxes / 25 days) ipratropium bromide (nasal) 2 ANTIHISTAMINES azelastine hcl 2 QL (2 bottles / 25 days) brompheniramine tannate 2 carbinoxamine maleate 2 cyproheptadine hcl 2 dexchlorpheniramine maleate 2 diphenhydramine hcl 2 fexofenadine hcl 2 hydroxyzine hcl SOLN 2 PA; High Risk


Version 10 10/01/17 42


Drug Name Drug Tier Requirements/Limits hydroxyzine pamoate 2 PA; High Risk


olopatadine hcl (nasal) 2 QL (1 container / 25 days)

BETA AGONISTS albuterol sulfate NEBU .5% 2 QL (3 boxes / 25 days) albuterol sulfate NEBU .5% 2 QL (4 boxes / 25 days) albuterol sulfate NEBU .083%,

.63mg/3ml, 1.25mg/3ml 2 QL (5 boxes / 25 days)

albuterol sulfate SYRP 2 albuterol sulfate TABS 2 albuterol sulfate TB12 2 levalbuterol hcl 1.25mg/0.5ml 2 QL (90 mL / 25 days) levalbuterol hcl .31mg/3ml, .63mg/3ml,

1.25mg/3ml 2 QL (300 mL / 25 days)

metaproterenol sulfate 2 PROAIR HFA 3 QL (2 inhalers / 25

days) PROAIR RESPICLICK 3 QL (2 packages / 25

days) PROVENTIL HFA 4 terbutaline sulfate 2 VENTOLIN HFA 4 COLD/COUGH benzonatate 2 guaifenesin-codeine 2 OTC hydrocodone w/ homatropine 2 NORTUSS-EX 3 promethazine & phenylephrine 2 promethazine w/codeine 2 promethazine-dm 2 promethazine-phenylephrine-codeine 2 pseudoephed-bromphen-dm 2 LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium 2 zafirlukast 2 MAST CELL STABILIZERS cromolyn sodium 2 QL (2 boxes / 25 days) MISCELLANEOUS acetylcysteine 2 ARALAST NP 5 PA epinephrine hcl SOLN 2 ORKAMBI 5 PA sodium chloride (inhalant) 2 TYZINE 4

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Drug Name Drug Tier Requirements/Limits TYZINE PEDIATRIC NASAL DR 4 NASAL STEROIDS budesonide (nasal) 2 QL (2 containers / 25

days) flunisolide (nasal) 2 QL (3 containers / 25

days) fluticasone propionate (nasal) 2 QL (1 container / 25

days) triamcinolone acetonide (nasal) 2 QL (1 container / 25

days) STEROID INHALANTS ASMANEX HFA 3 QL (1 inhaler per 25

days) ASMANEX TWISTHALER 30 MET 3 QL (2 inhalers / 25

days) ASMANEX TWISTHALER 60 MET 3 QL (2 inhalers per 25

days) ASMANEX TWISTHALER 120 ME 3 QL (1 inhaler per 25

days) budesonide (inhalation) 1mg/2ml 2 QL (1 box / 25 days) budesonide (inhalation) .5mg/2ml 2 QL (2 boxes / 25 days) budesonide (inhalation) .25mg/2ml 2 QL (3 boxes / 25 days) QVAR 3 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 3 ADVAIR HFA 3 XANTHINES aminophylline 2 theophylline 2 TOPICAL DERMATOLOGY, ACNE adapalene 2 PA; PA applies for

members age 35 and older

AZELEX 4 ST; PA** BENZAMYCINPAK 3 benzoyl peroxide 2 benzoyl peroxide-erythromycin 2 clindamycin phosphate (topical) 2 clindamycin phosphate-benzoyl peroxide 2 clindamycin phosphate-benzoyl peroxide

(refrigerate) 2

erythromycin (acne aid) 2 isotretinoin 2 PA sulfacetamide sodium (acne) 2

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Drug Name Drug Tier Requirements/Limits tretinoin 2 PA; PA applies for

members age 35 and older

tretinoin microsphere 2 PA; PA applies for members age 35 and older

DERMATOLOGY, ACTINIC KERATOSIS fluorouracil (topical) 2 imiquimod 2 PICATO 4 DERMATOLOGY, ANTIBIOTICS ALTABAX 4 BACTROBAN NASAL 4 CORTISPORIN 4 gentamicin sulfate (topical) 2 IV PREP WIPES 3 mupirocin 2 PHISOHEX 4 silver sulfadiazine 2 SULFAMYLON 4 DERMATOLOGY, ANTIFUNGALS CLOTRIMAZOLE CRYS 4 clotrimazole (topical) 2 clotrimazole w/ betamethasone 2 econazole nitrate 2 ERTACZO 4 EXELDERM 4 ST ketoconazole (topical) CREA; FOAM 2 naftifine hcl 2 nystatin (topical) 2 nystatin-triamcinolone 2 oxiconazole nitrate 2 OXISTAT 4 DERMATOLOGY, ANTIPRURITIC doxepin hcl (antipruritic) 2 hydrocortisone (rectal) 2 DERMATOLOGY, ANTIPSORIATICS acitretin 2 calcipotriene 2 calcitriol (topical) 2 methoxsalen rapid 2 8-MOP 4 TAZORAC 3 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole (topical) SHAM 2 selenium sulfide 2

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Drug Name Drug Tier Requirements/Limits DERMATOLOGY, CORTICOSTEROIDS alclometasone dipropionate 2 amcinonide CREA; LOTN 2 AMCINONIDE OINT 3 betamethasone dipropionate (topical) 2 betamethasone dipropionate augmented 2 betamethasone valerate 2 calcipotriene-betamethasone dipropionate 2 CAPEX 4 clobetasol propionate 2 clocortolone pivalate 2 CORDRAN 4 DESONATE 4 desonide 2 DESOWEN OINTMENT/CETAPHIL 4 desoximetasone 2 diflorasone diacetate 2 fluocinolone acetonide 2 fluocinonide 2 flurandrenolide 2 fluticasone propionate 2 halobetasol propionate 2 HALOG 4 hydrocortisone (topical) 2 hydrocortisone butyrate 2 hydrocortisone butyrate hydrophilic lipo

base 2

hydrocortisone valerate 2 mometasone furoate 2 PEDIADERM HC 4 PEDIADERM TA 4 prednicarbate 2 TACLONEX 4 TEXACORT 4 triamcinolone acetonide (topical) 2 TRIANEX 4 VERDESO 4 DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 2 QL (50gm / 25 days) lidocaine PTCH 2 PA lidocaine hcl GEL 2 QL (30gm / 25 days) lidocaine hcl SOLN 2 QL (50mL / 25 days) lidocaine-prilocaine 2 pramoxine hcl 2 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical 2

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Drug Name Drug Tier Requirements/Limits diclofenac sodium (topical) 2 ELIDEL 3 ST; PA** lactic acid (ammonium lactate) 2 podofilox 2 tacrolimus (topical) 2 ST; PA** TARGRETIN 5 PA DERMATOLOGY, ROSACEA metronidazole (topical) 2 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 4 lindane 2 malathion 2 permethrin 2 SKLICE 4 spinosad 2 DERMATOLOGY, WOUND CARE AGENTS sodium chloride (gu irrigant) 2 MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate (mouth-throat) 2 clotrimazole TROC 2 lidocaine hcl (mouth-throat) 2 nystatin (mouth-throat) 2 ORAVIG 4 pilocarpine hcl (oral) 2 triamcinolone acetonide (mouth) 2 OTIC acetic acid (otic) 2 acetic acid-aluminum acetate 2 CIPRO HC 4 CIPRODEX 3 CORTISPORIN-TC 4 fluocinolone acetonide (otic) 2 hydrocortisone w/acetic acid 2 neomycin-polymyxin-hc (otic) 2 ofloxacin (otic) 2

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Index 8-MOP ............................................ 45 abacavir sulfate ................................. 8 ABACAVIR SULFATE-LAMIVUDINE ........ 9 abacavir sulfate-lamivudine-zidovudine 9 ABELCET .......................................... 8 ABRAXANE ...................................... 13 acamprosate calcium ........................ 26 acarbose ......................................... 27 acebutolol hcl ................................... 18 acetaminophen w/ codeine ................. 5 acetazolamide .................................. 18 acetazolamide sodium ....................... 18 acetic acid (otic) ............................... 47 acetic acid-aluminum acetate ............. 47 acetylcysteine .................................. 43 acitretin .......................................... 45 ACTHIB ........................................... 36 ACTIMMUNE .................................... 36 acyclovir ......................................... 10 acyclovir sodium .............................. 10 acyclovir topical ............................... 46 ADACEL .......................................... 36 ADAGEN .......................................... 29 adapalene ....................................... 44 adefovir dipivoxil .............................. 10 ADRIAMYCIN ................................... 13 ADVAIR DISKUS ............................... 44 ADVAIR HFA .................................... 44 AEROCHAMBER PLUS FLOW-VU .......... 38 AFINITOR ........................................ 14 AFLURIA 2016-2017 ......................... 36 AKYNZEO ........................................ 32 albuterol sulfate ............................... 43 alclometasone dipropionate ............... 46 ALDACTAZIDE .................................. 18 alendronate sodium .......................... 28 ALFERON N ...................................... 36 alfuzosin hcl .................................... 34 ALIMTA ........................................... 13 ALKERAN ......................................... 12 allopurinol ........................................ 4 allopurinol sodium ............................. 4 almotriptan malate ........................... 25 alogliptin benzoate ........................... 27 ALOMIDE ......................................... 41 alosetron hcl .................................... 33 ALPHAGAN P .................................... 41

alprazolam ...................................... 19 ALREX ............................................. 41 ALTABAX ......................................... 45 amantadine hcl ................................ 23 AMBISOME ....................................... 8 amcinonide ...................................... 46 AMCINONIDE ................................... 46 amifostine ....................................... 15 amikacin sulfate ................................ 6 amiloride & hydrochlorothiazide .......... 18 amiloride hcl .................................... 18 aminophylline .................................. 44 amiodarone hcl ................................ 17 amitriptyline hcl ............................... 21 amlodipine besylate .......................... 18 amlodipine besylate-atorvastatin calcium...................................................... 18 amlodipine besylate-benazepril hcl ...... 16 amlodipine besylate-valsartan ............ 16 amlodipine-valsartan-hydrochlorothiazide...................................................... 16 AMMONIUM CHLORIDE ...................... 38 amoxapine ...................................... 21 amoxicillin ....................................... 12 amoxicillin & pot clavulanate .............. 12 amphetamine-dextroamphetamine 10mg...................................................... 24 amphetamine-dextroamphetamine 12.5mg ........................................... 24 amphetamine-dextroamphetamine 15mg...................................................... 24 amphetamine-dextroamphetamine 20mg...................................................... 24 amphetamine-dextroamphetamine 25mg...................................................... 24 amphetamine-dextroamphetamine 30mg...................................................... 24 amphetamine-dextroamphetamine 5mg...................................................... 23 amphetamine-dextroamphetamine 7.5mg ............................................. 23 AMPHOTEC ....................................... 8 amphotericin b .................................. 8 ampicillin ......................................... 12 ampicillin & sulbactam sodium ............ 12 ampicillin sodium .............................. 12 anagrelide hcl .................................. 35

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anastrozole ...................................... 14 ANTIVERT ....................................... 32 apraclonidine hcl .............................. 41 APTIVUS .......................................... 8 ARALAST NP .................................... 43 ARANESP ALBUMIN FREE ................... 35 ARCALYST ....................................... 36 argatroban ...................................... 34 ARGATROBAN .................................. 34 aripiprazole ..................................... 23 ARRANON ........................................ 13 ARZERRA ........................................ 14 ASMANEX HFA ................................. 44 ASMANEX TWISTHALER 120 ME ......... 44 ASMANEX TWISTHALER 30 MET ......... 44 ASMANEX TWISTHALER 60 MET ......... 44 aspirin ............................................. 6 aspirin-dipyridamole ......................... 35 atenolol ........................................... 18 atenolol & chlorthalidone ................... 17 ATGAM ............................................ 36 atomoxetine hcl ............................... 24 atorvastatin calcium.......................... 17 atovaquone ...................................... 7 atovaquone-proguanil hcl ................... 8 ATRIPLA ........................................... 9 atropine sulfate ................................ 32 atropine sulfate (ophthalmic) ............. 42 AUGMENTIN .................................... 12 AVELOX .......................................... 11 azacitidine ....................................... 13 AZACTAM IN ISO-OSMOTIC DE ........... 7 AZASITE ......................................... 40 azathioprine .................................... 36 azelastine hcl ................................... 42 azelastine hcl (ophth) ....................... 41 AZELEX ........................................... 44 AZILECT .......................................... 23 azithromycin .................................... 11 AZOPT ............................................ 41 aztreonam ........................................ 7 BABY SUPER DAILY D3 ...................... 39 bacitracin (ophthalmic) ..................... 40 bacitracin-polymyxin b (ophth) ........... 40 bacitracin-poly-neomycin-hc .............. 40 baclofen .......................................... 26 BACTOCILL IN DEXTROSE .................. 12 BACTROBAN NASAL .......................... 45

balsalazide disodium ......................... 33 BARACLUDE ..................................... 10 BD INSULIN SYRINGE ULTRAF ............ 38 BD SWABS SINGLE USE .................... 38 benazepril & hydrochlorothiazide ........ 16 benazepril hcl .................................. 16 BENICAR ......................................... 16 BENLYSTA ....................................... 36 BENZAMYCINPAK ............................. 44 benzonatate .................................... 43 benzoyl peroxide .............................. 44 benzoyl peroxide-erythromycin .......... 44 benztropine mesylate ........................ 23 BEPREVE ......................................... 41 BESIVANCE ..................................... 40 betamethasone dipropionate (topical) . 46 betamethasone dipropionate augmented...................................................... 46 betamethasone valerate .................... 46 BETASERON ..................................... 25 betaxolol hcl .................................... 18 betaxolol hcl (ophth) ......................... 41 bethanechol chloride ......................... 34 BETIMOL ......................................... 41 BETOPTIC-S .................................... 41 bexarotene ...................................... 15 BEXSERO ........................................ 36 bicalutamide .................................... 14 BICILLIN C-R ................................... 12 BICILLIN L-A ................................... 12 BICNU ............................................ 12 BILTRICIDE ...................................... 7 bimatoprost ..................................... 41 BIO-STATIN ...................................... 8 bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride ........................... 33 bisoprolol & hydrochlorothiazide ......... 17 bisoprolol fumarate ........................... 18 bleomycin sulfate ............................. 13 BLEPHAMIDE ................................... 40 BLEPHAMIDE S.O.P. .......................... 40 BOOSTRIX ....................................... 36 BOSULIF ......................................... 14 BRILINTA ........................................ 35 brimonidine tartrate .......................... 41 bromfenac sodium (ophth) ................ 41 bromocriptine mesylate ..................... 23 brompheniramine tannate .................. 42

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budesonide ...................................... 33 budesonide (inhalation) ..................... 44 budesonide (nasal) ........................... 44 bumetanide ..................................... 18 BUPHENYL ....................................... 29 buprenorphine hcl-naloxone hcl dihydrate....................................................... 4 bupropion hcl ................................... 21 bupropion hcl (smoking deterrent) ...... 26 buspirone hcl ................................... 19 busulfan .......................................... 12 BUSULFEX ....................................... 12 butalbital-acetaminophen ................... 4 butalbital-acetaminophen-caffeine ....... 4 butalbital-acetaminophen-caffeine w/ codeine ............................................ 5 butalbital-aspirin-caffeine ................... 4 cabergoline ...................................... 31 CAFERGOT ...................................... 25 calcipotriene .................................... 45 calcipotriene-betamethasone dipropionate .................................... 46 calcitonin (salmon) ........................... 31 calcitriol .......................................... 39 calcitriol (topical) .............................. 45 calcium acetate (phosphate binder) .... 31 CAMPTOSAR .................................... 15 CANCIDAS ........................................ 8 candesartan cilexetil ......................... 16 candesartan cilexetil-hydrochlorothiazide...................................................... 16 capecitabine .................................... 13 CAPEX ............................................ 46 CAPITAL/CODEINE ............................. 5 CAPRELSA ....................................... 14 captopril .......................................... 16 captopril & hydrochlorothiazide .......... 16 CARAFATE ....................................... 33 carbamazepine ................................. 20 carbidopa ........................................ 23 carbidopa-levodopa .......................... 23 carbidopa-levodopa-entacapone ......... 23 carbinoxamine maleate ..................... 42 carboplatin ...................................... 15 CARDENE IV .................................... 18 CARDURA XL ................................... 34 CARIMUNE NANOFILTERED ................ 36 carisoprodol ..................................... 26

carteolol hcl (ophth) ......................... 41 carvedilol ........................................ 18 CAYSTON ......................................... 7 CEDAX ............................................ 10 cefaclor ........................................... 10 CEFACLOR ER .................................. 10 cefadroxil ........................................ 10 CEFAZOLIN ...................................... 10 cefazolin sodium ............................... 10 CEFAZOLIN SODIUM ......................... 10 CEFAZOLIN SODIUM/DEXTROSE ......... 10 cefdinir ........................................... 10 cefditoren pivoxil .............................. 10 CEFEPIME ........................................ 10 cefepime hcl .................................... 10 CEFEPIME/DEXTROSE ....................... 10 cefixime .......................................... 10 cefotaxime sodium ........................... 10 cefotetan disodium ........................... 10 CEFOTETAN/DEXTROSE ..................... 11 cefoxitin sodium ............................... 11 CEFOXITIN SODIUM .......................... 11 cefpodoxime proxetil ......................... 11 cefprozil .......................................... 11 ceftazidime ...................................... 11 CEFTAZIDIME .................................. 11 CEFTAZIDIME/DEXTROSE .................. 11 ceftibuten ........................................ 11 CEFTIN ........................................... 11 ceftriaxone sodium ........................... 11 cefuroxime axetil .............................. 11 cefuroxime sodium ........................... 11 CEFUROXIME SODIUM ...................... 11 CEFUROXIME/DEXTROSE ................... 11 celecoxib .......................................... 4 CELLCEPT INTRAVENOUS .................. 36 CELONTIN ....................................... 20 cephalexin ....................................... 11 CERVARIX ....................................... 36 CESAMET ........................................ 32 CHANTIX ......................................... 26 CHEMET .......................................... 28 CHEMSTRIP 9 STRIPS ....................... 38 chloramphenicol sodium succinate ....... 6 chlorhexidine gluconate (mouth-throat)...................................................... 47 chloroquine phosphate ....................... 8 chlorothiazide .................................. 18

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chlorothiazide sodium ....................... 18 chlorpromazine hcl ........................... 23 CHLORPROMAZINE HCL ..................... 23 chlorthalidone .................................. 18 chlorzoxazone .................................. 26 cholecalciferol .................................. 39 cholestyramine ................................ 17 cholestyramine light ......................... 17 choline fenofibrate ............................ 17 chorionic gonadotropin ...................... 30 cidofovir .......................................... 10 cilostazol ......................................... 35 CILOXAN ......................................... 40 cimetidine ....................................... 33 cimetidine hcl .................................. 33 CIMZIA ........................................... 35 CIPRO HC ........................................ 47 CIPRODEX ....................................... 47 ciprofloxacin .................................... 11 ciprofloxacin hcl ............................... 11 ciprofloxacin hcl (ophth) .................... 40 ciprofloxacin in d5w .......................... 11 ciprofloxacin-ciprofloxacin hcl ............. 11 cisplatin .......................................... 15 citalopram hydrobromide ................... 21 CITRANATAL 90 DHA ........................ 39 CITRANATAL ASSURE ........................ 39 CITRANATAL B-CALM ........................ 39 CITRANATAL DHA ............................. 39 CITRANATAL HARMONY ..................... 39 CITRANATAL RX ............................... 39 cladribine ........................................ 13 CLAFORAN ....................................... 11 clarithromycin .................................. 11 CLEOCIN ......................................... 34 clindamycin hcl ................................. 7 clindamycin palmitate hydrochloride ..... 7 clindamycin phosphate ....................... 7 clindamycin phosphate (topical) ......... 44 clindamycin phosphate vaginal ........... 34 clindamycin phosphate-benzoyl peroxide...................................................... 44 clindamycin phosphate-benzoyl peroxide (refrigerate) .................................... 44 clobetasol propionate ........................ 46 clocortolone pivalate ......................... 46 CLOLAR ........................................... 13 clomiphene citrate ............................ 30

clomipramine hcl .............................. 21 clonazepam ..................................... 20 clonidine hcl .................................... 19 clopidogrel bisulfate .......................... 35 clorazepate dipotassium .................... 20 clotrimazole ..................................... 47 CLOTRIMAZOLE ................................ 45 clotrimazole (topical) ........................ 45 clotrimazole w/ betamethasone .......... 45 clozapine ......................................... 23 codeine sulfate .................................. 5 CODEINE SULFATE ............................ 5 colchicine ......................................... 4 colchicine w/ probenecid ..................... 4 colestipol hcl .................................... 17 COLYTE-FLAVOR PACKS .................... 33 COMBIGAN ...................................... 41 COMBIVENT RESPIMAT ..................... 42 COMETRIQ ...................................... 14 COMPLERA ....................................... 9 COMVAX ......................................... 36 COPAXONE ...................................... 25 CORDRAN ........................................ 46 cortisone acetate .............................. 30 CORTISPORIN .................................. 45 CORTISPORIN-TC ............................. 47 COUMADIN ...................................... 34 CREON ............................................ 34 CRIXIVAN ......................................... 8 cromolyn sodium .............................. 43 cromolyn sodium (mastocytosis) ........ 33 cromolyn sodium (ophth) .................. 41 CUBICIN .......................................... 7 cyanocobalamin ............................... 39 cyclobenzaprine hcl .......................... 26 cyclophosphamide ............................ 12 CYCLOPHOSPHAMIDE ........................ 12 cycloserine ....................................... 9 cyclosporine .................................... 36 cyclosporine modified (for microemulsion) ................................ 36 cyproheptadine hcl ........................... 42 cytarabine ....................................... 13 dacarbazine ..................................... 12 dactinomycin ................................... 13 danazol ........................................... 29 dantrolene sodium ............................ 26 dapsone ........................................... 7

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DAPTACEL ....................................... 36 DAPTOMYCIN .................................... 7 DARAPRIM ........................................ 7 darifenacin hydrobromide .................. 34 daunorubicin hcl ............................... 13 DAUNOXOME ................................... 13 DDROPS BOOSTER ........................... 39 decitabine ....................................... 13 demeclocycline hcl ............................ 12 DEPEN TITRATABS ............................ 28 DEPOCYT ......................................... 13 DEPO-ESTRADIOL ............................. 29 DEPO-MEDROL ................................. 30 DEPO-PROVERA ............................... 14 desipramine hcl ................................ 21 desmopressin acetate ....................... 32 desmopressin acetate refrigerated ...... 32 desmopressin acetate spray ............... 32 desmopressin acetate spray refrigerated...................................................... 32 desogestrel & ethinyl estradiol ............ 28 desogestrel-ethinyl estradiol (biphasic) 28 desogestrel-ethinyl estradiol (triphasic)...................................................... 28 DESONATE ...................................... 46 desonide ......................................... 46 DESOWEN OINTMENT/CETAPHIL ........ 46 desoximetasone ............................... 46 desvenlafaxine ................................. 21 dexamethasone ................................ 30 DEXAMETHASONE INTENSOL ............. 30 dexamethasone sodium phosphate ..... 30 dexamethasone sodium phosphate (ophth) ........................................... 41 dexchlorpheniramine maleate ............ 42 DEXPAK 10 DAY ............................... 30 DEXPAK 13 DAY ............................... 30 DEXPAK 6 DAY ................................. 30 dexrazoxane .................................... 15 dextroamphetamine sulfate ............... 24 diazepam ........................................ 20 diclofenac potassium .......................... 4 diclofenac sodium .............................. 4 diclofenac sodium (ophth) ................. 41 diclofenac sodium (topical) ................ 47 diclofenac w/ misoprostol ................... 4 dicloxacillin sodium ........................... 12 dicyclomine hcl ................................ 32

didanosine ........................................ 8 DIFICID .......................................... 11 diflorasone diacetate ......................... 46 diflunisal .......................................... 6 digoxin ............................................ 18 dihydroergotamine mesylate .............. 25 DILANTIN ........................................ 20 diltiazem hcl .................................... 18 DILTIAZEM HCL ................................ 18 diltiazem hcl coated beads ................. 18 diltiazem hcl extended release beads .. 18 dimenhydrinate ................................ 32 DIPENTUM ....................................... 33 diphenhydramine hcl ......................... 42 diphenoxylate w/ atropine ................. 33 DIPHTHERIA/TETANUS TOXOID .......... 36 dipyridamole .................................... 35 disopyramide phosphate .................... 17 disulfiram ........................................ 26 divalproex sodium ............................ 20 docetaxel ........................................ 13 DOCETAXEL ..................................... 13 DOCETAXEL (NON-ALCOHOL FO ......... 13 dofetilide ......................................... 17 donepezil hydrochloride ..................... 20 DORIBAX .......................................... 7 DORIPENEM ...................................... 7 dorzolamide hcl ................................ 41 dorzolamide hcl-timolol maleate ......... 41 doxazosin mesylate .......................... 16 doxepin hcl ...................................... 21 doxepin hcl (antipruritic) ................... 45 doxercalciferol ................................. 40 doxorubicin hcl ................................. 13 doxorubicin hcl liposomal ................... 13 doxycycline (monohydrate) ................ 12 doxycycline hyclate ........................... 12 dronabinol ....................................... 32 drospirenone-ethinyl estradiol ............ 29 duloxetine hcl .................................. 21 DUREZOL ........................................ 41 dutasteride ...................................... 34 dutasteride-tamsulosin hcl ................. 34 D-VI-SOL ........................................ 39 econazole nitrate .............................. 45 EDURANT ......................................... 8 EFFIENT .......................................... 35 ELIDEL ............................................ 47

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ELIGARD ......................................... 14 ELLA ............................................... 29 ELMIRON ......................................... 34 ELOXATIN ....................................... 15 EMCYT ............................................ 12 EMEND ............................................ 32 EMTRIVA .......................................... 9 EMVERM ........................................... 7 enalapril maleate .............................. 16 enalapril maleate & hydrochlorothiazide...................................................... 16 ENBREL ........................................... 35 ENBREL SURECLICK .......................... 35 ENCARE .......................................... 34 ENGERIX-B ...................................... 36 ENJUVIA .......................................... 29 enoxaparin sodium ........................... 34 entacapone ...................................... 23 entecavir ......................................... 10 EPCLUSA ......................................... 10 epinastine hcl (ophth) ....................... 41 epinephrine (anaphylaxis) ................. 42 epinephrine hcl .......................... 42, 43 epirubicin hcl ................................... 13 EPIRUBICIN HCL .............................. 13 EPIVIR HBV ..................................... 10 eplerenone ...................................... 16 epoprostenol sodium ......................... 19 EPZICOM .......................................... 9 ERAXIS ............................................ 8 ERBITUX ......................................... 14 ergocalciferol ................................... 40 ergoloid mesylates ............................ 23 ERGOMAR ....................................... 25 ERGOTAMINE W/ CAFFEINE ............... 25 ERIVEDGE ....................................... 14 ERTACZO ........................................ 45 ERYPED 400 .................................... 11 ERYTHROCIN LACTOBIONATE ............ 11 erythromycin (acne aid) .................... 44 erythromycin (ophth) ........................ 40 erythromycin base ............................ 11 erythromycin ethylsuccinate .............. 11 erythromycin stearate ....................... 11 erythromycin-sulfisoxazole ................. 6 escitalopram oxalate ......................... 22 ESTRACE ......................................... 30 estradiol .......................................... 30

estradiol valerate ............................. 30 ESTRING ......................................... 30 ESTROGEL ....................................... 30 estropipate ...................................... 30 ethacrynate sodium .......................... 18 ethacrynic acid ................................. 18 ethambutol hcl .................................. 9 ethosuximide ................................... 20 ethynodiol diacet & eth estrad ............ 29 etodolac ........................................... 4 ETOPOPHOS .................................... 15 etoposide ........................................ 15 EURAX ............................................ 47 EVOTAZ ........................................... 9 EXELDERM ....................................... 45 EXELON .......................................... 20 exemestane ..................................... 14 EXJADE ........................................... 28 FACTIVE .......................................... 11 famciclovir ....................................... 10 famotidine ....................................... 33 FARESTON ....................................... 14 FASLODEX ....................................... 14 FC2 FEMALE CONDOM ....................... 38 felodipine ........................................ 18 fenofibrate ....................................... 17 fenofibrate micronized ....................... 17 fenofibric acid .................................. 17 fenoprofen calcium ............................ 4 fentanyl ........................................... 5 FERRIPROX ...................................... 28 fexofenadine hcl ............................... 42 finasteride ....................................... 34 FIRAZYR ......................................... 35 FIRMAGON ...................................... 14 FLAGYL ER ........................................ 7 FLAREX ........................................... 41 flavoxate hcl .................................... 34 flecainide acetate ............................. 17 FLEXICHAMBER CHILD MASK/S .......... 38 floxuridine ....................................... 13 FLUAD 2016-2017 ............................ 36 FLUBLOK 2016-2017 ......................... 37 FLUCELVAX QUADRIVALENT 20 .......... 37 fluconazole ....................................... 8 fluconazole in dextrose ....................... 8 fluconazole in nacl ............................. 8 FLUCONAZOLE IN NACL ...................... 8

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fludarabine phosphate ....................... 13 fludrocortisone acetate ...................... 30 FLULAVAL QUADRIVALENT 201 .......... 37 flunisolide (nasal) ............................. 44 fluocinolone acetonide ....................... 46 fluocinolone acetonide (otic) .............. 47 fluocinonide ..................................... 46 FLUORABON .................................... 38 fluorometholone (ophth) .................... 41 fluorouracil ...................................... 13 fluorouracil (topical) .......................... 45 fluoxetine hcl ................................... 22 FLUOXETINE HCL ............................. 22 fluphenazine decanoate ..................... 23 fluphenazine hcl ............................... 23 flurandrenolide ................................. 46 flurbiprofen ....................................... 4 flurbiprofen sodium ........................... 41 flutamide ......................................... 14 fluticasone propionate ....................... 46 fluticasone propionate (nasal) ............ 44 FLUVIRIN 2016-2017 ........................ 37 FLUZONE HIGH-DOSE PF 2016 ........... 37 FLUZONE INTRADERMAL QUADR ........ 37 FLUZONE QUADRIVALENT 2016 .......... 37 FML ................................................ 41 FML FORTE ...................................... 41 folic acid ......................................... 40 folic acid-pyridoxine-cyanocobalamin .. 40 FOLLISTIM AQ ................................. 30 fondaparinux sodium ........................ 34 FORTAZ .......................................... 11 FORTEO .......................................... 31 FOSAMAX PLUS D ............................. 28 foscarnet sodium .............................. 10 fosinopril sodium .............................. 16 fosinopril sodium & hydrochlorothiazide...................................................... 16 fosphenytoin sodium ......................... 20 FRAGMIN ........................................ 34 furosemide ...................................... 19 FUROSEMIDE ................................... 18 FUZEON ........................................... 9 gabapentin ...................................... 20 galantamine hydrobromide ................ 20 GAMASTAN S/D ................................ 36 GARDASIL ....................................... 37 GARDASIL 9 .................................... 37

gatifloxacin (ophth) .......................... 40 GAZYVA .......................................... 14 gemcitabine hcl ................................ 13 gemfibrozil ...................................... 17 GENOTROPIN ................................... 31 GENOTROPIN MINIQUICK .................. 31 gentamicin in saline ........................... 6 gentamicin sulfate ............................. 6 gentamicin sulfate (ophth) ................. 40 gentamicin sulfate (topical) ................ 45 GENTAMICIN SULFATE/0.9% S ............ 6 GENVOYA ......................................... 9 glatiramer acetate ............................ 25 GLEOSTINE ..................................... 12 GLIADEL WAFER ............................... 12 glimepiride ...................................... 28 glipizide .......................................... 28 glipizide-metformin hcl ...................... 27 GLUCAGON EMERGENCY KIT .............. 31 glyburide ......................................... 28 glyburide micronized ......................... 28 glyburide-metformin ......................... 27 glycopyrrolate .................................. 32 GOLYTELY ....................................... 33 GONAL-F ......................................... 30 GONAL-F RFF ................................... 30 GONAL-F RFF REDIJECT .................... 30 granisetron hcl ................................. 32 griseofulvin microsize ......................... 8 griseofulvin ultramicrosize .................. 8 guaifenesin-codeine .......................... 43 guanfacine hcl .................................. 19 guanfacine hcl (adhd) ....................... 24 halobetasol propionate ...................... 46 HALOG ............................................ 46 haloperidol ...................................... 23 haloperidol decanoate ....................... 23 haloperidol lactate ............................ 23 HARVONI ........................................ 10 HAVRIX ........................................... 37 heparin sodium (porcine) ................... 35 HEXALEN ......................................... 12 HIBERIX .......................................... 37 HUMATROPEN .................................. 38 HUMIRA .......................................... 35 HUMIRA PEN-CROHNS DISEASE ......... 35 HUMULIN 70/30 ............................... 27 HUMULIN 70/30 KWIKPEN ................. 27

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HUMULIN N ..................................... 27 HUMULIN N KWIKPEN ....................... 27 HUMULIN R ..................................... 27 HYCAMTIN ....................................... 15 hydralazine hcl ................................. 19 hydrochlorothiazide .......................... 19 hydrocodone w/ homatropine ............. 43 hydrocodone-acetaminophen .............. 5 hydrocodone-ibuprofen ...................... 5 hydrocortisone ................................. 30 hydrocortisone (intrarectal) ............... 33 hydrocortisone (rectal) ...................... 45 hydrocortisone (topical) .................... 46 hydrocortisone butyrate .................... 46 hydrocortisone butyrate hydrophilic lipo base ............................................... 46 hydrocortisone sod succinate ............. 30 hydrocortisone valerate ..................... 46 hydrocortisone w/acetic acid .............. 47 hydromorphone hcl ............................ 5 HYDROMORPHONE HCL ...................... 5 hydroxychloroquine sulfate ................ 35 hydroxyurea .................................... 15 hydroxyzine hcl .......................... 20, 42 hydroxyzine pamoate ........................ 43 hyoscyamine sulfate ......................... 32 HYQVIA ........................................... 36 ibandronate sodium .......................... 28 IBRANCE ......................................... 14 ibuprofen ......................................... 4 ICLUSIG .......................................... 14 idarubicin hcl ................................... 13 ifosfamide ....................................... 12 ifosfamide & mesna .......................... 15 imatinib mesylate ............................. 14 IMBRUVICA ..................................... 14 imipenem-cilastatin ........................... 7 imipramine hcl ................................. 22 imipramine pamoate ......................... 22 imiquimod ....................................... 45 IMPLANON ....................................... 29 indapamide ..................................... 19 indomethacin .................................... 4 INFANRIX ........................................ 37 INLYTA ........................................... 14 INTELENCE ....................................... 9 INTRON A ........................................ 36 INTRON A W/DILUENT ...................... 36

INVANZ ............................................ 7 INVIRASE ......................................... 9 IOPIDINE ........................................ 42 IPOL INACTIVATED IPV ..................... 37 ipratropium bromide ......................... 42 ipratropium bromide (nasal) .............. 42 ipratropium-albuterol ........................ 42 irbesartan ....................................... 16 irbesartan-hydrochlorothiazide ........... 16 irinotecan hcl ................................... 16 irrigation solutions, physiological ....... 42 ISENTRESS ....................................... 9 ISOLYTE-S ....................................... 39 isoniazid ........................................... 9 isosorbide dinitrate ........................... 19 isosorbide mononitrate ...................... 19 isotretinoin ...................................... 44 isradipine ........................................ 18 ISTALOL .......................................... 42 itraconazole ...................................... 8 IV PREP WIPES ................................ 45 ivermectin ........................................ 7 JAKAFI ............................................ 14 JANUMET ......................................... 27 JANUMET XR .................................... 27 JANUVIA ......................................... 27 KALETRA .......................................... 9 kanamycin sulfate ............................. 6 KEPIVANCE ...................................... 15 ketoconazole (topical) ....................... 45 ketoprofen ........................................ 4 ketorolac tromethamine ..................... 4 ketorolac tromethamine (ophth) ......... 41 KINERET ......................................... 35 KINRIX ........................................... 37 KLOR-CON M15 ................................ 38 labetalol hcl ..................................... 18 lactic acid (ammonium lactate) ........... 47 lactulose ......................................... 33 lactulose (encephalopathy) ................ 33 lamivudine ....................................... 9 lamivudine (hbv) .............................. 10 lamivudine-zidovudine ....................... 9 lamotrigine ...................................... 20 LANOXIN ......................................... 18 LANOXIN PEDIATRIC ......................... 18 LANTUS .......................................... 27 LANTUS SOLOSTAR .......................... 28

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latanoprost ...................................... 42 leflunomide ..................................... 35 LENVIMA 10 MG DAILY DOSE ............. 15 LENVIMA 14 MG DAILY DOSE ............. 15 LENVIMA 18 MG DAILY DOSE ............. 15 LENVIMA 20 MG DAILY DOSE ............. 15 LENVIMA 24 MG DAILY DOSE ............. 15 LENVIMA 8 MG DAILY DOSE ............... 15 LETAIRIS ......................................... 19 letrozole .......................................... 14 leucovorin calcium ............................ 15 LEUKERAN ....................................... 12 LEUKINE ......................................... 35 leuprolide acetate ............................. 14 levalbuterol hcl ................................ 43 levetiracetam ................................... 20 LEVETIRACETAM .............................. 20 LEVETIRACETAM IN SODIUM CHLORIDE...................................................... 20 levobunolol hcl ................................. 42 levofloxacin ..................................... 11 levofloxacin (ophth) .......................... 40 levofloxacin in d5w ........................... 11 levonorgestrel & eth estradiol ............. 29 levonorgestrel (emergency oc) ........... 29 levonorgestrel-eth estradiol (triphasic) 29 levonorgestrel-ethinyl estradiol (91-day)...................................................... 29 levonorgestrel-ethinyl estradiol (continuous) .................................... 29 levothyroxine sodium ........................ 31 LEXIVA ............................................ 9 lidocaine ......................................... 46 lidocaine hcl ..................................... 46 lidocaine hcl (cardiac) ....................... 17 lidocaine hcl (local anesth.) ................. 6 lidocaine hcl (mouth-throat) .............. 47 LIDOCAINE HCL/DEXTROSE ................ 6 lidocaine in d5w ............................... 17 lidocaine-prilocaine ........................... 46 LILETTA .......................................... 29 lindane ............................................ 47 linezolid ........................................... 7 linezolid in sodium chloride ................. 7 liothyronine sodium .......................... 31 lisinopril .......................................... 16 lisinopril & hydrochlorothiazide ........... 16 LITHIUM .......................................... 25

lithium carbonate ............................. 25 loperamide hcl ................................. 33 LOPINAVIR-RITONAVIR ...................... 9 lorazepam ....................................... 20 losartan potassium ........................... 16 losartan potassium & hydrochlorothiazide...................................................... 16 LOTEMAX ........................................ 41 lovastatin ........................................ 17 loxapine succinate ............................ 23 LUPRON DEPOT (1-MONTH) ............... 14 LUPRON DEPOT (3-MONTH) ............... 14 LUPRON DEPOT (4-MONTH) ............... 14 LUPRON DEPOT (6-MONTH) ............... 14 LUPRON DEPOT-PED (1-MONTH .......... 14 LUPRON DEPOT-PED (3-MONTH .......... 14 LYNPARZA ....................................... 14 LYRICA ........................................... 20 LYSODREN ...................................... 14 magnesium sulfate ........................... 38 MAGNESIUM SULFATE IN D5W ........... 38 magnesium sulfate in dextrose ........... 38 malathion ........................................ 47 MATULANE ...................................... 15 MAXIDEX ......................................... 41 MAXIPIME ....................................... 11 meclizine hcl .................................... 32 meclofenamate sodium ...................... 4 MEDICAL PROVIDER SINGLE U ........... 37 MEDROL .......................................... 30 medroxyprogesterone acetate ............ 31 medroxyprogesterone acetate (contraceptive) ................................ 29 mefenamic acid ................................. 4 mefloquine hcl .................................. 8 MEFOXIN ......................................... 11 megestrol acetate ............................. 14 megestrol acetate (appetite) .............. 14 MEKINIST ........................................ 15 meloxicam ........................................ 4 melphalan ....................................... 12 melphalan hcl .................................. 12 memantine hcl ................................. 20 MENACTRA ...................................... 37 MENEST .......................................... 30 MENHIBRIX ..................................... 37 MENOMUNE-A/C/Y/W-135 ................. 37 MENVEO .......................................... 37

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meperidine hcl .................................. 5 MEPHYTON ...................................... 40 mercaptopurine ................................ 13 meropenem ...................................... 7 mesalamine enema 4 gm ................... 33 mesalamine rectal enema 4 gm & cleanser wipe kit .............................. 33 mesna ............................................ 15 MESNEX .......................................... 15 MESTINON ...................................... 25 metaproterenol sulfate ...................... 43 metaxalone ..................................... 26 metformin hcl .................................. 27 methadone hcl .................................. 5 METHADONE HCL .............................. 5 methamphetamine hcl ....................... 24 methazolamide ................................ 19 methenamine hippurate ..................... 7 methimazole .................................... 31 methocarbamol ................................ 26 methotrexate sodium .................. 13, 35 methoxsalen rapid ............................ 45 methscopolamine bromide ................. 32 methyldopa ..................................... 19 methyldopate hcl .............................. 19 methylphenidate hcl ................... 24, 25 methylprednisolone .......................... 30 methylprednisolone acetate ............... 30 methylprednisolone sod succ .............. 30 methyltestosterone ........................... 27 metipranolol .................................... 42 metoclopramide hcl .......................... 32 metolazone ...................................... 19 metoprolol & hydrochlorothiazide ........ 17 metoprolol succinate ......................... 18 metoprolol tartrate ........................... 18 metronidazole ................................... 7 metronidazole (topical) ..................... 47 metronidazole in nacl ......................... 7 metronidazole vaginal ....................... 34 mexiletine hcl .................................. 17 miconazole nitrate vaginal ................. 34 midodrine hcl ................................... 19 minocycline hcl ................................ 12 MIRENA .......................................... 29 mirtazapine ..................................... 22 misoprostol ..................................... 33 mitomycin ....................................... 13

mitoxantrone hcl .............................. 15 M-M-R II ......................................... 37 modafinil ......................................... 26 mometasone furoate ......................... 46 montelukast sodium ......................... 43 morphine sulfate ............................ 5, 6 MORPHINE SULFATE ....................... 5, 6 morphine sulfate beads ...................... 6 MOVIPREP ....................................... 33 moxifloxacin hcl ............................... 11 mupirocin ........................................ 45 MYCAMINE ....................................... 8 mycophenolate mofetil ...................... 36 MYCOPHENOLATE MOFETIL HCL ......... 36 mycophenolate sodium ...................... 36 MYLERAN ........................................ 12 MYOZYME ........................................ 29 nabumetone ..................................... 4 nadolol ............................................ 18 nadolol & bendroflumethiazide ........... 17 NAFCILLIN ....................................... 12 nafcillin sodium ................................ 12 naftifine hcl ..................................... 45 naloxone hcl .................................... 26 naltrexone hcl .................................. 26 naphazoline hcl ................................ 42 naproxen .......................................... 4 naproxen sodium ............................... 4 naratriptan hcl ................................. 25 NATACYN ........................................ 40 nateglinide ...................................... 28 NEBUPENT ........................................ 7 NECON 10/11-28 .............................. 29 nefazodone hcl ................................. 22 neomycin sulfate ............................... 6 neomycin-polymy-dexameth .............. 40 neomycin-polymyxin-gramicidin ......... 40 neomycin-polymyxin-hc (ophth) ......... 40 neomycin-polymyxin-hc (otic) ............ 47 NEULASTA ....................................... 35 NEULASTA ONPRO KIT ...................... 35 NEUPOGEN ...................................... 35 NEUPOGEN INJ 480/1.6 ..................... 35 nevirapine ........................................ 9 NEXPLANON .................................... 29 niacin (antihyperlipidemic) ................. 17 nicardipine hcl .................................. 18 nicotine ........................................... 26

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nicotine polacrilex ............................. 26 nifedipine ........................................ 18 nilutamide ....................................... 14 nimodipine ...................................... 18 NIPENT ........................................... 13 nisoldipine ....................................... 18 NITRO-BID ...................................... 19 nitrofurantoin .................................... 7 nitrofurantoin macrocrystal ................. 7 nitrofurantoin monohyd macro ............ 8 nitroglycerin .................................... 19 NITROGLYCERIN .............................. 19 nitroglycerin in d5w .......................... 19 NITROSTAT ..................................... 19 NORDITROPIN FLEXPRO .................... 31 norelgestromin-ethinyl estradiol ......... 29 norethin acet & estrad-fe ................... 29 norethindrone & eth estradiol ............. 29 norethindrone & ethinyl estradiol-fe .... 29 norethindrone & mestranol ................ 29 norethindrone (contraceptive) ............ 29 norethindrone acet & eth estra ........... 29 norethindrone acetate ....................... 31 norethindrone acetate-ethinyl estradiol 30 norethindrone acetate-ethinyl estradiol-fe ................................................... 29 norethindrone-eth estradiol (triphasic) 29 norgestimate-ethinyl estradiol ............ 29 norgestimate-ethinyl estradiol (triphasic)...................................................... 29 norgestrel & ethinyl estradiol ............. 29 NORMOSOL -R ................................. 39 nortriptyline hcl ................................ 22 NORTUSS-EX ................................... 43 NORVIR ........................................... 9 NOVOLIN 70/30 ............................... 27 NOVOLIN N ..................................... 27 NOVOLIN R ...................................... 27 NOVOLOG ....................................... 27 NOVOLOG FLEXPEN .......................... 27 NOVOLOG MIX 70/30 ........................ 27 NOVOLOG MIX 70/30 FLEXPEN ........... 27 NOVOLOG PENFILL ........................... 27 NOXAFIL .......................................... 8 NUTROPIN ....................................... 31 NUTROPIN AQ NUSPIN 10 .................. 31 NUTROPIN AQ NUSPIN 5 ................... 31 NUTROPIN AQ PEN ........................... 31

NUVARING ...................................... 29 nystatin ........................................... 8 nystatin (mouth-throat) .................... 47 nystatin (topical) .............................. 45 nystatin-triamcinolone ...................... 45 octreotide acetate ............................. 31 ofloxacin ......................................... 11 ofloxacin (ophth) .............................. 40 ofloxacin (otic) ................................. 47 olanzapine ....................................... 23 OLMESARTAN MEDOXOMIL ................ 16 olopatadine hcl ................................. 41 olopatadine hcl (nasal) ...................... 43 omega-3-acid ethyl esters ................. 17 omeprazole ..................................... 34 OMNIFLEX DIAPHRAGM ..................... 38 ONCASPAR ...................................... 15 ondansetron .................................... 32 ondansetron hcl ............................... 32 ONETOUCH DELICA LANCING D .......... 38 ONETOUCH PING METER REMOT ......... 38 ONETOUCH ULTRA 2 ......................... 38 ONETOUCH ULTRA BLUE .................... 38 ONETOUCH ULTRASOFT LANCET ......... 38 ONETOUCH VERIO ............................ 38 ONETOUCH VERIO MID CONTRO ........ 38 OPTICHAMBER FACE MASK/SMA ......... 38 OPTIONS CONCEPTROL VAGINA ......... 34 OPTIONS GYNOL II VAGINAL ............. 34 ORAVIG .......................................... 47 ORENCIA ......................................... 35 ORENCIA CLICKJECT ......................... 35 ORENITRAM ..................................... 19 ORKAMBI ........................................ 43 orphenadrine citrate ......................... 26 orphenadrine w/ aspirin & caff ............ 26 ORTHO DIAPHRAGM ALL-FLEX/ .......... 38 ORTHO DIAPHRAGM COIL SPRI .......... 38 ORTHO DIAPHRAGM FLAT SPRI .......... 38 OSELTAMIVIR PHOSPHATE ................ 10 OSMOPREP ...................................... 33 OTEZLA ........................................... 35 OVIDREL ......................................... 30 oxacillin sodium ............................... 12 oxaliplatin ....................................... 15 oxandrolone .................................... 27 oxaprozin ......................................... 4 oxiconazole nitrate ........................... 45

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OXISTAT ......................................... 45 oxybutynin chloride .......................... 34 oxycodone hcl ................................... 6 oxycodone w/ acetaminophen ............. 6 oxycodone-aspirin ............................. 6 oxycodone-ibuprofen ......................... 6 paclitaxel ........................................ 13 paliperidone ..................................... 23 pamidronate disodium ....................... 28 PAMIDRONATE DISODIUM ................. 28 pantoprazole sodium ......................... 34 PARAGARD INTRAUTERINE COP ......... 29 paricalcitol ....................................... 40 paromomycin sulfate ......................... 6 paroxetine hcl .................................. 22 PATADAY ......................................... 41 PCE ................................................ 11 ped multivitamins w/fl & iron ............. 40 PEDIADERM HC ................................ 46 PEDIADERM TA ................................ 46 PEDIARIX ........................................ 37 pediatric multivitamins w/fl ................ 40 PEDIATRIC PANDA MASK ................... 38 pediatric vitamins acd fluoride & iron ... 40 pediatric vitamins acd w/ fluoride ....... 40 PEDVAX HIB .................................... 37 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................................ 33 peg 3350-potassium chloride-sod bicarbonate-sod chloride ................... 33 PEGANONE ...................................... 20 PEGASYS ......................................... 10 penicillin g potassium ........................ 12 PENICILLIN G POTASSIUM IN ............. 12 PENICILLIN G PROCAINE ................... 12 penicillin g sodium ............................ 12 penicillin v potassium ........................ 12 PENTACEL ....................................... 37 PENTAM 300 ..................................... 8 pentoxifylline ................................... 35 perindopril erbumine ......................... 16 permethrin ...................................... 47 perphenazine ................................... 23 phenazopyridine hcl .......................... 34 phenelzine sulfate ............................ 22 phenobarbital ................................... 20 phenoxybenzamine hcl ...................... 19 phenylephrine hcl (ophth) .................. 42

phenytoin ........................................ 20 phenytoin sodium ............................. 20 phenytoin sodium extended ............... 20 PHISOHEX ....................................... 45 PHOSLYRA ....................................... 31 PHOSPHOLINE IODIDE ...................... 42 PHOTOFRIN ..................................... 15 PICATO ........................................... 45 pilocarpine hcl (oral) ......................... 47 PILOPINE HS ................................... 42 pimozide ......................................... 23 pindolol ........................................... 18 pioglitazone hcl ................................ 27 pioglitazone hcl-glimepiride ................ 28 pioglitazone hcl-metformin hcl ............ 27 piperacillin sodium-tazobactam sodium 12 piroxicam ......................................... 4 PLASMA-LYTE A ................................ 39 PLASMA-LYTE-148 ............................ 39 PNEUMOVAX 23/5 DOSE .................... 37 podofilox ......................................... 47 polyethylene glycol 3350 ................... 33 polymyxin b sulfate ........................... 8 polymyxin b-trimethoprim ................. 41 potassium bicarbonate ...................... 38 potassium chloride ............................ 39 potassium chloride in nacl .................. 39 potassium chloride microencapsulated crystals cr ....................................... 39 potassium citrate (alkalinizer) ............ 34 PRADAXA ........................................ 35 pramipexole dihydrochloride .............. 23 pramoxine hcl .................................. 46 prasugrel hcl .................................... 35 pravastatin sodium ........................... 17 prazosin hcl ..................................... 16 PRED MILD ...................................... 41 prednicarbate .................................. 46 prednisolone .................................... 30 prednisolone acetate (ophth) ............. 41 PREDNISOLONE SODIUM PHOSP ........ 41 prednisolone sodium phosphate .......... 31 PREDNISOLONE SODIUM PHOSPHATE . 31 prednisone ...................................... 31 PREDNISONE INTENSOL .................... 31 prenatal vit w/ iron carbonyl-folic acid . 40 PRENTIF CAVITY-RIM CERVIC ............ 38 PRENTIF FITTING SET ....................... 38

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PREVNAR 13 .................................... 37 PREZCOBIX ...................................... 9 PREZISTA ......................................... 9 PRIFTIN ........................................... 9 PRIMAQUINE PHOSPHATE ................... 8 primidone ........................................ 20 PRIMSOL .......................................... 8 PROAIR HFA .................................... 43 PROAIR RESPICLICK ......................... 43 probenecid ....................................... 4 procainamide hcl .............................. 17 PROCAINAMIDE HCL ......................... 17 prochlorperazine .............................. 32 prochlorperazine edisylate ................. 32 prochlorperazine maleate .................. 32 PROCRIT ......................................... 35 progesterone micronized ................... 31 PROGRAF ........................................ 36 PROMACTA ...................................... 35 promethazine & phenylephrine ........... 43 promethazine hcl .............................. 32 promethazine w/codeine .................... 43 promethazine-dm ............................. 43 promethazine-phenylephrine-codeine .. 43 propafenone hcl ............................... 17 proparacaine hcl ............................... 42 propranolol & hydrochlorothiazide ....... 17 propranolol hcl ................................. 18 propylthiouracil ................................ 31 PROQUAD ........................................ 37 protriptyline hcl ................................ 22 PROVENTIL HFA ............................... 43 pseudoephed-bromphen-dm .............. 43 PULMOZYME .................................... 26 pyrazinamide .................................... 9 pyridostigmine bromide ..................... 25 QUADRAMET .................................... 15 quetiapine fumarate .......................... 23 quflora pediatric ............................... 40 QUFLORA PEDIATRIC ........................ 40 quinapril hcl ..................................... 16 quinapril-hydrochlorothiazide ............. 16 quinidine sulfate ............................... 17 quinine sulfate .................................. 8 QVAR .............................................. 44 raloxifene hcl ................................... 31 ramipril ........................................... 16 ranitidine hcl .................................... 33

RAPAMUNE ...................................... 36 RASAGILINE MESYLATE ..................... 23 REBETOL ......................................... 10 REBIF ............................................. 25 REBIF REBIDOSE .............................. 25 REBIF REBIDOSE TITRATION ............. 25 RECOMBIVAX HB .............................. 37 REGONOL ........................................ 25 REMICADE ....................................... 35 REMODULIN .................................... 19 repaglinide ...................................... 28 repaglinide-metformin hcl .................. 28 RESCRIPTOR ..................................... 9 reserpine ......................................... 19 RETROVIR IV INFUSION ..................... 9 REVLIMID ........................................ 36 REYATAZ .......................................... 9 RHEUMATREX .................................. 35 RIBAVIRIN ....................................... 10 ribavirin (hepatitis c) ........................ 10 rifabutin ........................................... 9 RIFAMATE ........................................ 9 rifampin ........................................... 9 RIFATER .......................................... 10 riluzole ............................................ 25 rimantadine hydrochloride ................. 10 ringer's irrigation .............................. 42 risedronate sodium ........................... 28 risperidone ...................................... 23 RITUXAN ......................................... 14 rivastigmine tartrate ......................... 20 rizatriptan benzoate .......................... 25 ropinirole hydrochloride ..................... 23 rosuvastatin calcium ......................... 17 ROTARIX ......................................... 37 ROTATEQ ........................................ 37 SAMSCA .......................................... 31 SANDIMMUNE .................................. 36 scopolamine .................................... 32 selegiline hcl .................................... 23 selenium sulfide ............................... 45 SELZENTRY ...................................... 9 SENSIPAR ....................................... 28 sertraline hcl .................................... 22 SHUR-SEAL ..................................... 34 sildenafil citrate (pulmonary hypertension) .................................. 19 silver sulfadiazine ............................. 45

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SIMBRINZA ..................................... 42 SIMULECT ....................................... 36 simvastatin ...................................... 17 sirolimus ......................................... 36 SKLICE ........................................... 47 SKYLA ............................................. 29 sodium chloride ................................ 39 sodium chloride (gu irrigant) .............. 47 sodium chloride (inhalant) ................. 43 sodium chloride flush ........................ 39 sodium fluoride ................................ 39 sodium phenylbutyrate ...................... 29 sodium polystyrene sulfonate ............. 28 SOLU-CORTEF .................................. 31 SOLU-MEDROL ................................. 31 SOMATULINE DEPOT ......................... 31 sotalol hcl ........................................ 17 sotalol hcl (afib/afl) .......................... 17 SOTALOL HYDROCHLORIDE ............... 17 SOVALDI ......................................... 10 spinosad ......................................... 47 spironolactone ................................. 19 spironolactone & hydrochlorothiazide .. 19 SPRYCEL ......................................... 15 stavudine ......................................... 9 STRATTERA ..................................... 25 streptomycin sulfate .......................... 6 STRIBILD ......................................... 9 SUBOXONE 12-3MG ........................... 5 SUBOXONE 2-0.5MG .......................... 5 SUBOXONE 4-1MG ............................. 5 SUBOXONE 8-2MG ............................. 5 sucralfate ........................................ 33 sulfacetamide sodium (acne).............. 44 sulfacetamide sodium (ophth) ............ 41 sulfacetamide sod-prednisolone .......... 40 SULFADIAZINE .................................. 6 sulfamethoxazole-trimethoprim ........... 8 SULFAMYLON ................................... 45 sulfasalazine .................................... 33 sulindac ........................................... 4 sumatriptan ..................................... 25 sumatriptan succinate ....................... 25 SUPRAX .......................................... 11 SUPREP BOWEL PREP KIT .................. 33 SUSTIVA .......................................... 9 SUTENT .......................................... 15 SYNTHROID ..................................... 31

TABLOID ......................................... 13 TACLONEX ....................................... 46 tacrolimus ....................................... 36 tacrolimus (topical) ........................... 47 TAFINLAR ........................................ 15 TAMIFLU ......................................... 10 tamoxifen citrate .............................. 14 TAMPER-TUF CONTAINER CLOS .......... 38 tamsulosin hcl .................................. 34 TARCEVA ......................................... 15 TARGRETIN ..................................... 47 TAZORAC ........................................ 45 telmisartan ...................................... 17 telmisartan-amlodipine ...................... 16 telmisartan-hydrochlorothiazide ......... 16 temazepam ..................................... 25 TEMODAR ........................................ 12 temozolomide .................................. 12 TENIPOSIDE .................................... 16 TENIVAC ......................................... 37 terazosin hcl .................................... 16 terbinafine hcl ................................... 8 terbutaline sulfate ............................ 43 terconazole vaginal ........................... 34 testosterone .................................... 27 testosterone cypionate ...................... 27 testosterone enanthate ..................... 27 TETANUS/DIPHTHERIA TOXOID .......... 37 tetrabenazine ................................... 25 tetracycline hcl ................................. 12 TEXACORT ....................................... 46 THALOMID ....................................... 36 theophylline ..................................... 44 THERACYS ....................................... 15 thioridazine hcl ................................ 23 thiothixene ...................................... 23 THYMOGLOBULIN ............................. 36 THYROLAR-1 .................................... 32 THYROLAR-1/2 ................................. 32 THYROLAR-1/4 ................................. 32 THYROLAR-2 .................................... 32 THYROLAR-3 .................................... 32 TICE BCG ........................................ 15 timolol maleate ................................ 18 timolol maleate (ophth) ..................... 42 TIMOPTIC OCUDOSE ......................... 42 tinidazole ......................................... 7 TIVICAY ........................................... 9

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tizanidine hcl ................................... 26 TOBRADEX ...................................... 40 tobramycin ....................................... 7 tobramycin (ophth) ........................... 41 tobramycin sulfate ............................. 7 TOBRAMYCIN SULFATE/SODIUM .......... 7 tobramycin-dexamethasone ............... 40 TOBREX .......................................... 41 TODAY SPONGE ............................... 34 tolmetin sodium ................................ 4 tolterodine tartrate ........................... 34 topiramate ...................................... 20 topotecan hcl ................................... 16 TOPOTECAN HCL .............................. 16 torsemide ........................................ 19 TORSEMIDE ..................................... 19 TRACLEER ....................................... 19 tramadol hcl ..................................... 6 trandolapril ...................................... 16 trandolapril-verapamil hcl .................. 16 tranexamic acid ................................ 35 TRANSDERM-SCOP ........................... 33 tranylcypromine sulfate ..................... 22 TRAVATAN Z .................................... 42 trazodone hcl ................................... 22 tretinoin .......................................... 45 tretinoin (chemotherapy) ................... 15 tretinoin microsphere ........................ 45 triamcinolone acetonide (mouth) ........ 47 triamcinolone acetonide (nasal) .......... 44 triamcinolone acetonide (topical) ........ 46 triamterene & hydrochlorothiazide ...... 19 TRIANEX ......................................... 46 trifluoperazine hcl ............................. 23 trifluridine ....................................... 41 trihexyphenidyl hcl ........................... 23 trimethobenzamide hcl ...................... 33 trimethoprim .................................... 8 trimipramine maleate .................. 22, 23 TRIPEDIA ........................................ 37 TRISENOX ....................................... 15 TRIUMEQ .......................................... 9 tropicamide ..................................... 42 trospium chloride ............................. 34 TRUMENBA ...................................... 37 TRUVADA ......................................... 9 TWINRIX ......................................... 38 TYGACIL .......................................... 8

TYKERB ........................................... 15 TYZEKA ........................................... 10 TYZINE ........................................... 43 TYZINE PEDIATRIC NASAL DR ............ 44 ursodiol ........................................... 33 UVADEX .......................................... 15 valacyclovir hcl ................................ 10 valganciclovir hcl .............................. 10 valproate sodium .............................. 20 valproic acid .................................... 20 valsartan ......................................... 17 valsartan-hydrochlorothiazide ............ 16 vancomycin hcl ................................. 8 VAQTA ............................................ 38 VARIVAX ......................................... 38 VCF VAGINAL CONTRACEPTIVE .......... 34 venlafaxine hcl ................................. 23 VENTOLIN HFA ................................. 43 verapamil hcl ................................... 18 VERDESO ........................................ 46 VERIPRED 20 ................................... 31 VEXOL ............................................ 41 VIDEX PEDIATRIC .............................. 9 VIGAMOX ........................................ 41 vinblastine sulfate ............................ 13 VINBLASTINE SULFATE ..................... 13 vincristine sulfate ............................. 13 vinorelbine tartrate ........................... 13 VIRACEPT ......................................... 9 VIRAZOLE ....................................... 10 VIREAD ............................................ 9 VITAMIN D2 ..................................... 40 VITAMIN D3 ..................................... 40 VITEKTA ........................................... 9 voriconazole ..................................... 8 warfarin sodium ............................... 35 WELCHOL ........................................ 17 WELLESSE VITAMIN D3 ..................... 40 WIDE-SEAL SILICONE DIAPHR ........... 38 XALKORI ......................................... 15 XGEVA ............................................ 31 YERVOY .......................................... 14 yuvafem .......................................... 30 zafirlukast ....................................... 43 zaleplon .......................................... 25 ZALTRAP ......................................... 14 ZANOSAR ........................................ 13 ZARXIO ........................................... 35

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ZAVESCA ........................................ 29 ZELBORAF ....................................... 15 ZENPEP ........................................... 34 zidovudine ........................................ 9 ZINACEF ......................................... 11 ZIOPTAN ......................................... 42 ziprasidone hcl ................................. 23 ZIRGAN .......................................... 41 ZMAX .............................................. 11 zoledronic acid ................................. 28

ZOLEDRONIC ACID ........................... 28 zolmitriptan ..................................... 25 zolpidem tartrate .............................. 25 ZOMETA .......................................... 28 zonisamide ...................................... 20 ZORBTIVE ....................................... 31 ZOSTAVAX ...................................... 38 ZOSYN ............................................ 12 ZYKADIA ......................................... 15 ZYTIGA ........................................... 14

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2017 LIST OF COVERED DRUGS - Bright Health...tramadol hcl TB24 100mg 2 QL (90 tabs / 25 days)...

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Transcript of 2017 LIST OF COVERED DRUGS - Bright Health...tramadol hcl TB24 100mg 2 QL (90 tabs / 25 days)...