2018 TMP PDP EG Full Formulary for...

PLEASE READ: This document contains information about the drugs we cover in this plan

This formulary was updated on September, 2017. For more recent information

or other questions, please contact us at 1-800-701-9000 or, for TTY users, 711,

Monday - Friday 8:00 a.m. - 8:00 p.m. (from Oct. 1 - Feb. 14 representatives are

available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays,

please leave a message and a representative will return your call on the next

business day. Or visit tuftsmedicarepreferred.org.

Note to existing members: This formulary has changed since last year. Please

review this document to make sure that it still contains the drugs you take.

3-EGPDPFORM-18

Tufts Medicare Preferred PDP Group Retiree2018 Formulary (List of Covered Drugs)

TuFTS MEDiCARE PREFERRED PDP PLANS | 2018

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TufTs Medicare Preferred PdP GrouP reTiree_

2018 formulary (List of covered drugs)

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Tufts Health Plan Medicare Preferred. When it refers to “plan” or “our plan,” it means Tufts Medicare Preferred PDP.

This document includes a list of the drugs (formulary) for our plan which is current as of September, 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

What is the Tufts Medicare Preferred PdP formulary?A formulary is a list of covered drugs selected by Tufts Medicare Preferred PDP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Tufts Medicare Preferred PDP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Tufts Medicare Preferred PDP network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

can the formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of September, 2017. To get updated information about the drugs covered by Tufts Medicare Preferred PDP, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, you will be notified via an errata sheet.

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How do i use the formulary? There are two ways to find your drug within the formulary:

Medical conditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 69. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Tufts Medicare Preferred PDP covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Tufts Medicare Preferred PDP requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from Tufts Medicare Preferred PDP beforeyou fill your prescriptions. If you don’t get approval, Tufts Medicare Preferred PDP may not cover the drug.

• Quantity Limits: For certain drugs, Tufts Medicare Preferred PDP limits the amount of the drug thatTufts Medicare Preferred PDP will cover. For example, Tufts Medicare Preferred PDP provides 30 tablets perprescription for ROZEREM. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Tufts Medicare Preferred PDP requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example, if Drug A andDrug B both treat your medical condition, Tufts Medicare Preferred PDP may not cover Drug B unless youtry Drug A first. If Drug A does not work for you, Tufts Medicare Preferred PDP will then cover Drug B.

• Non-extended day supply drug: For certain drugs, Tufts Medicare Preferred PDP limits quantities up to a30-day supply per fill.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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You can ask Tufts Medicare Preferred PDP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Tufts Medicare Preferred PDP formulary?” below for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Relations and ask if your drug is covered.

If you learn that Tufts Medicare Preferred PDP does not cover your drug, you have two options:

• You can ask Customer Relations for a list of similar drugs that are covered by Tufts Medicare Preferred PDP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Tufts Medicare Preferred PDP.

• You can ask Tufts Medicare Preferred PDP to make an exception and cover your drug. See below for information about how to request an exception.

How do i request an exception to the Tufts Medicare Preferred PdP formulary?You can ask Tufts Medicare Preferred PDP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Tufts Medicare Preferred PDP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Tufts Medicare Preferred PDP will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do i do before i can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

As a current member, if you are admitted to or discharged from a long term facility and experience an unplanned drug change, you can request that we approve a one-time, temporary fill of the non-covered medication to allow you time to discuss a transition plan with your physician. Your physician can also request an exception to coverage for the non-covered drug based on review for medical necessity following the standard exception process outlined previously. The temporary “first fill” will generally be up to a 31-day supply, but may be extended to allow you and your physician time to manage the complexities of multiple medications or when special circumstances warrant. You can request a temporary prescription fill by calling the Tufts Medicare Preferred PDP Customer Relations department.

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for more informationFor more detailed information about your Tufts Medicare Preferred PDP prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Tufts Medicare Preferred PDP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Tufts Medicare Preferred PdP formularyThe formulary that begins on page 3 provides coverage information about the drugs covered by Tufts Medicare Preferred PDP. If you have trouble finding your drug in the list, turn to the Index that begins on page 69.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PROAIR HFA) and generic drugs are listed in lower-case italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Tufts Medicare Preferred PDP has any special requirements for coverage of your drug.

B vs d: Medicare Part B or dThese drugs require prior authorization to determine appropriate coverage under Medicare Part B or Part D.

QL: Quantity Limit applies.Because of potential safety and utilization concerns, Tufts Medicare Preferred PDP has placed dispensing limitations on a small number of prescription drugs. This means that the pharmacy will only dispense a certain quantity of a drug within a given time period. These quantities are based on recognized standards of care, such as U.S. Food and Drug Administration recommendations for use. If your doctor believes you need a quantity greater than the program limitation, your doctor can submit a request for coverage under the Medical Review Process. The Medical Review Process allows you or your doctor to ask Tufts Medicare Preferred PDP to make an exception to our coverage rules. See the section, “How do I request an exception to the Tufts Medicare Preferred PDP formulary?” on page III for information about how to request an exception.

ec: enhanced coverage drug.This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

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La: Limited access drug.This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Relations at 1-800-701-9000, Monday-Friday 8:00 a.m. – 8:00 p.m. (From Oct. 1 –Feb. 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call the on next business day. TTY users should call 711.

Pa: Prior authorization required.The Prior Authorization process encourages rational prescribing of drug products with significant safety and/or financial concerns. A provider can submit a request for coverage based on a member’s medical need for a particular drug. If approved, the member pays the designated tier co-payment. An appeal process exists for denied requests.

sTPa: step Therapy Prior authorization applies.Step Therapy is an automated form of Prior Authorization, which uses claims history for approval of a drug at the point of sale. Step Therapy Programs help encourage the clinically proven use of first-line therapies and are designed to ensure the utilization of the most therapeutically appropriate and cost-effective agents first, before other treatments may be covered.

Members who are currently on drugs that meet the initial Step Therapy criteria will automatically be able to fill their prescriptions for a stepped medication. If the member does not meet the initial Step Therapy criteria, the prescription will deny at the point of sale with a message indicating that Prior Authorization (PA) is required. Physicians may submit Prior Authorization requests to Tufts Medicare Preferred PDP for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process. The Medical Review Process allows you or your doctor to ask Tufts Medicare Preferred PDP to make an exception to our coverage rules. See the section, “How do I request an exception to the Tufts Medicare Preferred PDP formulary?” on page III for information about how to request an exception.

Part B drug:This drug is considered to be Part B and not covered under the Tufts Medicare Preferred PDP. Please contact your medical carrier for coverage details.

Neds: Non-extended day supply drugIn an effort to contain drug costs, certain high-cost drugs will be limited up to a 30-day supply per fill.

sP: available through a designated special Pharmacy provider You have the option to obtain this drug through a designated Specialty Pharmacy provider. These pharmacies specialize in supplying a select number of medications directly to our members. They also provide free delivery to your home, educational support 24/7 by phone, support of nurses and pharmacists, and will work closely with your doctor. Medications include, but are not limited to, drugs used in the treatment of multiple sclerosis, hepatitis C, rheumatoid arthritis, and cancers treated with oral medications. SP-CVS specialty: 1-800-237-2767

Tufts Medicare Preferred PDP

Group Retiree 2018 Formulary (List of Covered Drugs)

Table of Contents

ANTI-INFECTIVES AND INFECTIOUS DISEASE...............................................................................................3BLOOD MODIFYING AGENTS............................................................................................................................. 9CANCER DRUGS................................................................................................................................................... 10CARDIOVASCULAR AGENTS............................................................................................................................ 16DIABETES MELLITUS..........................................................................................................................................21EAR, NOSE AND THROAT...................................................................................................................................23ENHANCED COVERAGE DRUGS.......................................................................................................................24EYE.......................................................................................................................................................................... 25GASTROINTESTINAL DRUGS............................................................................................................................27HOME INFUSION THERAPY...............................................................................................................................30HORMONES........................................................................................................................................................... 34IMMUNOLOGIC AGENTS....................................................................................................................................36MISCELLANEOUS DRUGS..................................................................................................................................38NEUROLOGICAL DRUGS....................................................................................................................................44PAIN AND INFLAMMATORY DISEASES..........................................................................................................48PSYCHIATRIC........................................................................................................................................................52RESPIRATORY DRUGS........................................................................................................................................56SKIN.........................................................................................................................................................................59WOMEN'S HEALTH.............................................................................................................................................. 63

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Tufts Medicare Preferred PDP

Group Retiree 2018 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits

ANTI-INFECTIVES AND INFECTIOUS DISEASE

ANTIFUNGALS, SYSTEMIC AND ORAL TOPICALclotrimazole Tier-1

CRESEMBA Tier-3 NEDS

fluconazole Tier-1

flucytosine Tier-2 NEDS

griseofulvin microsize Tier-1

griseofulvin ultramicrosize Tier-1

itraconazole Tier-1 PA

ketoconazole Tier-2

NOXAFIL Tier-3 NEDS

nystatin Tier-1

terbinafine hcl Tier-1 QL (42 EA per 42 days)

voriconazole oral suspension reconstituted Tier-2 NEDS

voriconazole oral tablet 200 mg Tier-2 QL (28 EA per 14 days); NEDS

voriconazole oral tablet 50 mg Tier-2 QL (56 EA per 14 days); NEDS

ANTI-INFECTIVES, MISCELLANEOUSALBENZA Tier-3 NEDS

ALINIA Tier-3

BILTRICIDE Tier-2

ivermectin Tier-1

linezolid Tier-2 NEDS

methenamine hippurate Tier-1

metronidazole Tier-1

MONUROL Tier-3

neomycin sulfate Tier-1

nitrofurantoin macrocrystal Tier-1 PA; QL (90 EA per 365 days)

nitrofurantoin monohyd macro Tier-1 PA; QL (90 EA per 365 days)

SIVEXTRO Tier-3 NEDS

STROMECTOL Tier-2

trimethoprim Tier-1

vancomycin hcl Tier-2 NEDS

You can find information on what the symbols and abbreviations on this table mean by going to page V.3

Drug Name Drug Tier Requirements/LimitsXIFAXAN ORAL TABLET 200 MG Tier-3 NEDS

XIFAXAN ORAL TABLET 550 MG Tier-3 PA; NEDS

ANTIMALARIALS AND ANTIPROTOZOALSatovaquone Tier-2 NEDS

atovaquone-proguanil hcl Tier-1

chloroquine phosphate Tier-1

COARTEM Tier-2 QL (24 EA per 3 days)

dapsone Tier-1

DARAPRIM Tier-2

hydroxychloroquine sulfate Tier-1

mefloquine hcl Tier-1

NEBUPENT Tier-3 B vs D

paromomycin sulfate Tier-1

PENTAM Tier-2 B vs D

primaquine phosphate Tier-1

quinine sulfate Tier-1

tinidazole Tier-1

ANTIVIRALSabacavir sulfate Tier-1

abacavir sulfate-lamivudine Tier-2 NEDS

abacavir-lamivudine-zidovudine Tier-2 NEDS

acyclovir oral capsule Tier-1

acyclovir oral suspension Tier-2

acyclovir oral tablet Tier-1

adefovir dipivoxil Tier-2 NEDS

amantadine hcl Tier-1

APTIVUS Tier-3 NEDS

ATRIPLA Tier-3 NEDS

COMPLERA Tier-3 NEDS

COPEGUS Tier-3 SP-CVS specialty

CRIXIVAN Tier-2

DESCOVY Tier-3 NEDS

didanosine Tier-1

EDURANT Tier-3 NEDS

EMTRIVA Tier-2

entecavir Tier-2 NEDS


Drug Name Drug Tier Requirements/LimitsEPIVIR Tier-2

EVOTAZ Tier-3 NEDS

famciclovir Tier-1

FUZEON Tier-3 SP-CVS specialty; NEDS

GENVOYA Tier-3 NEDS

INTELENCE ORAL TABLET 100 MG, 25 MG Tier-2

INTELENCE ORAL TABLET 200 MG Tier-3 NEDS

INTRON A Tier-2 SP-CVS specialty

INVIRASE Tier-3 NEDS

ISENTRESS ORAL PACKET Tier-2

ISENTRESS ORAL TABLET Tier-3 QL (120 EA per 30 days); NEDS

ISENTRESS ORAL TABLET CHEWABLE 100 MG

Tier-3 QL (180 EA per 30 days); NEDS

ISENTRESS ORAL TABLET CHEWABLE 25 MG

Tier-2 QL (720 EA per 30 days)

KALETRA ORAL SOLUTION Tier-3 NEDS

KALETRA ORAL TABLET 100-25 MG Tier-2

KALETRA ORAL TABLET 200-50 MG Tier-3 NEDS

lamivudine Tier-1

lamivudine-zidovudine Tier-1

LEXIVA ORAL SUSPENSION Tier-2

LEXIVA ORAL TABLET Tier-3 NEDS

lopinavir-ritonavir Tier-2

nevirapine Tier-1

nevirapine er Tier-1

NORVIR Tier-2

ODEFSEY Tier-3 NEDS

oseltamivir phosphate oral capsule 30 mg Tier-2 QL (56 EA per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg Tier-2 QL (28 EA per 180 days)

PEGASYS Tier-3SP-CVS specialty; QL (4 ML per 28 days); NEDS

PEGASYS PROCLICK Tier-3SP-CVS specialty; QL (4 ML per 28 days); NEDS

PREZCOBIX Tier-3 NEDS

PREZISTA Tier-3 NEDS

REBETOL Tier-2 SP-CVS specialty

RELENZA DISKHALER Tier-2 QL (60 EA per 180 days)

RESCRIPTOR Tier-2


Drug Name Drug Tier Requirements/LimitsREYATAZ Tier-3 NEDS

ribasphere Tier-1 SP-CVS specialty

RIBASPHERE RIBAPAK Tier-3 SP-CVS specialty; NEDS

ribavirin Tier-1 SP-CVS specialty

rimantadine hcl Tier-1

SELZENTRY ORAL TABLET 150 MG Tier-3 QL (60 EA per 30 days); NEDS

SELZENTRY ORAL TABLET 25 MG Tier-3 QL (120 EA per 30 days)

SELZENTRY ORAL TABLET 300 MG Tier-3 QL (120 EA per 30 days); NEDS

SELZENTRY ORAL TABLET 75 MG Tier-3 QL (60 EA per 30 days)

SOVALDI Tier-3 PA; SP-CVS specialty; NEDS

stavudine Tier-1

STRIBILD Tier-3 NEDS

SUSTIVA ORAL CAPSULE 200 MG Tier-3 NEDS

SUSTIVA ORAL CAPSULE 50 MG Tier-2

SUSTIVA ORAL TABLET Tier-3 NEDS

TAMIFLU ORAL SOLUTION Tier-2 QL (360 ML per 180 days)

TIVICAY ORAL TABLET 10 MG Tier-3

TIVICAY ORAL TABLET 25 MG, 50 MG Tier-3 NEDS

TRIUMEQ Tier-3 NEDS

TRUVADA Tier-3 NEDS

TYBOST Tier-2

valacyclovir hcl Tier-2

valganciclovir hcl Tier-2 NEDS

VEMLIDY Tier-3 NEDS

VIDEX Tier-2

VIRACEPT ORAL TABLET 250 MG Tier-2

VIRACEPT ORAL TABLET 625 MG Tier-3 NEDS

VIREAD Tier-3 NEDS

ZERIT Tier-2

ZIAGEN Tier-2

zidovudine Tier-1

BETA-LACTAM ANTIBIOTICSamoxicillin Tier-1

amoxicillin-pot clavulanate Tier-1

amoxicillin-pot clavulanate er Tier-1

ampicillin Tier-1

BICILLIN C-R Tier-2


Drug Name Drug Tier Requirements/LimitsBICILLIN C-R 900/300 Tier-2

BICILLIN L-A Tier-2

cefaclor Tier-1

cefaclor er Tier-1

cefadroxil Tier-1

cefdinir Tier-1

cefixime Tier-1

cefpodoxime proxetil Tier-1

cefprozil Tier-1

cefuroxime axetil Tier-1

cephalexin Tier-1

dicloxacillin sodium Tier-2

penicillin v potassium Tier-1

SUPRAX Tier-3

MACROLIDES AND CLINDAMYCINazithromycin Tier-1

clarithromycin Tier-1

clarithromycin er Tier-1

clindamycin capsules Tier-1

clindamycin oral solution Tier-2

DIFICID Tier-3 PA; NEDS

e.e.s. 400 Tier-1

E.E.S. GRANULES Tier-3

eryped 200 Tier-1

eryped 400 Tier-1

ERY-TAB Tier-3

erythrocin stearate Tier-2

erythromycin base oral capsule delayed release particles

Tier-1

erythromycin base oral tablet Tier-2

erythromycin ethylsuccinate oral suspension reconstituted

Tier-2

erythromycin ethylsuccinate oral tablet Tier-1

PCE Tier-3

ZMAX Tier-3

MYCOBACTERIAL INFECTIONSethambutol hcl Tier-1

isoniazid Tier-1


Drug Name Drug Tier Requirements/LimitsPASER Tier-3

PRIFTIN Tier-2

pyrazinamide Tier-1

rifabutin Tier-1

RIFAMATE Tier-3

rifampin Tier-1

RIFATER Tier-3

SIRTURO Tier-3 PA; NEDS

TRECATOR Tier-3

QUINOLONESciprofloxacin Tier-1

ciprofloxacin hcl Tier-1

ciprofloxacin-ciproflox hcl er Tier-1

levofloxacin oral solution Tier-2

levofloxacin oral tablet Tier-1

moxifloxacin hcl Tier-2

ofloxacin Tier-1

SULFONAMIDESsulfadiazine Tier-1

sulfamethoxazole-trimethoprim Tier-1

TETRACYCLINESdemeclocycline hcl Tier-1

doxycycline hyclate oral capsule 100 mg Tier-2

doxycycline hyclate oral capsule 50 mg Tier-1

doxycycline hyclate oral tablet 100 mg Tier-2

doxycycline hyclate oral tablet 20 mg Tier-1

doxycycline hyclate oral tablet delayed release100 mg

Tier-2

doxycycline hyclate oral tablet delayed release150 mg, 200 mg, 50 mg, 75 mg

Tier-1

doxycycline monohydrate oral capsule Tier-1

doxycycline monohydrate oral suspension reconstituted

Tier-1

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg

Tier-1

doxycycline monohydrate oral tablet 150 mg Tier-2

minocycline hcl Tier-2

minocycline hcl er Tier-2


Drug Name Drug Tier Requirements/Limitstetracycline hcl Tier-2

VIBRAMYCIN Tier-3

BLOOD MODIFYING AGENTS

ANTIPLATELET THERAPYanagrelide hcl Tier-1

aspirin-dipyridamole er Tier-2

BRILINTA Tier-3

cilostazol Tier-1

clopidogrel bisulfate Tier-1

dipyridamole Tier-1 PA

EFFIENT Tier-3

ZONTIVITY Tier-3

BLOOD CELL STIMULATORSGRANIX Tier-3 SP-CVS specialty; NEDS

LEUKINE Tier-3 SP-CVS specialty; NEDS

MOZOBIL Tier-3 NEDS

NEULASTA Tier-3SP-CVS specialty; QL (1 ML per 14 days); NEDS

NEUPOGEN Tier-3SP-CVS specialty; QL (10 ML per 14 days); NEDS

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier-2SP-CVS specialty; QL (10 ML per 14 days)

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

Tier-3SP-CVS specialty; QL (10 ML per 14 days); NEDS

PROMACTA Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

ZARXIO Tier-3SP-CVS specialty; QL (10 ML per 14 days); NEDS

BLOOD THINNERSCOUMADIN Tier-3

ELIQUIS Tier-2

enoxaparin sodium Tier-2

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Tier-2 NEDS

fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml

Tier-1


Drug Name Drug Tier Requirements/LimitsFRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

Tier-3 NEDS

FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML

Tier-2

jantoven Tier-1

PRADAXA Tier-3

warfarin sodium Tier-1

XARELTO Tier-2

XARELTO STARTER PACK Tier-2

BLOOD, MISCELLANEOUSpentoxifylline er Tier-1

STIMATE Tier-3

tranexamic acid Tier-1

CANCER DRUGS

INJECTABLE AGENTSABRAXANE Tier-3 NEDS

ALIMTA Tier-3 NEDS

ALKERAN Tier-3 NEDS

ARRANON Tier-3 NEDS

AVASTIN Tier-3 NEDS

azacitidine Tier-2 NEDS

BAVENCIO Tier-3 NEDS

BELEODAQ Tier-3 NEDS

BICNU Tier-3 NEDS

bleomycin sulfate Tier-1 PA

busulfan Tier-1

CAMPTOSAR Tier-2

carboplatin Tier-1

cisplatin Tier-1

cladribine Tier-1 PA

clofarabine Tier-1

CLOLAR Tier-3 NEDS

COSMEGEN Tier-3 NEDS

CYRAMZA Tier-2 PA

cytarabine Tier-1 PA

cytarabine (pf) Tier-1 PA


Drug Name Drug Tier Requirements/Limitsdacarbazine Tier-1

DACOGEN Tier-3 NEDS

DARZALEX Tier-3 NEDS

daunorubicin hcl Tier-1

decitabine Tier-2 NEDS

dexrazoxane Tier-1

docetaxel Tier-2 NEDS

doxorubicin hcl Tier-1

doxorubicin hcl liposomal Tier-1

ELITEK Tier-3 NEDS

ELLENCE Tier-3 NEDS

EMPLICITI Tier-3 NEDS

epirubicin hcl Tier-1

ERBITUX Tier-3 NEDS

ERWINAZE Tier-3 NEDS

ETOPOPHOS Tier-3 NEDS

etoposide Tier-1

FASLODEX Tier-3 NEDS

fludarabine phosphate Tier-1

fluorouracil Tier-1 PA

ganciclovir sodium Tier-1 PA

gemcitabine hcl Tier-2 NEDS

HALAVEN Tier-3 NEDS

HERCEPTIN Tier-3 NEDS

idarubicin hcl Tier-1

ifosfamide Tier-1

IMFINZI Tier-3 NEDS

irinotecan hcl Tier-1

ISTODAX (OVERFILL) Tier-3 NEDS

JEVTANA Tier-3 NEDS

KADCYLA Tier-3 PA; NEDS

KEYTRUDA Tier-3 NEDS

LARTRUVO Tier-3 NEDS

melphalan hcl Tier-1

mitomycin Tier-1

mitoxantrone hcl Tier-1

MUSTARGEN Tier-3 NEDS


Drug Name Drug Tier Requirements/LimitsOPDIVO Tier-3 NEDS

oxaliplatin Tier-1

paclitaxel Tier-1

PERJETA Tier-3 PA; NEDS

PROLEUKIN Tier-3 NEDS

RITUXAN Tier-3 PA; NEDS

SYLATRON Tier-3SP-CVS specialty; QL (4 EA per 28 days); NEDS

SYNRIBO Tier-3 NEDS

TECENTRIQ Tier-3 NEDS

thiotepa Tier-2 NEDS

topotecan hcl Tier-2 NEDS

TORISEL Tier-3 NEDS

TREANDA Tier-3 NEDS

TRISENOX Tier-3 NEDS

VECTIBIX Tier-3 NEDS

VELCADE Tier-3 NEDS

vinblastine sulfate Tier-1 PA

vincasar pfs Tier-1 PA

vincristine sulfate Tier-1 PA

vinorelbine tartrate Tier-1

YERVOY Tier-3 NEDS

YONDELIS Tier-3 NEDS

ZALTRAP Tier-3 NEDS

ZANOSAR Tier-3 NEDS

ORAL AGENTS

AFINITOR Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

AFINITOR DISPERZ Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

ALECENSA Tier-3 PA; SP-CVS specialty; NEDS

ALKERAN Tier-2 Part B

ALUNBRIG Tier-3 PA; SP-CVS specialty; NEDS

anastrozole Tier-1

bexarotene Tier-1 SP-CVS specialty

bicalutamide Tier-1

BOSULIF ORAL TABLET 100 MG Tier-3PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS



BOSULIF ORAL TABLET 500 MG Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

CABOMETYX Tier-3 PA; SP-CVS specialty; NEDS

capecitabine Tier-1 Part B; SP-CVS specialty

CAPRELSA ORAL TABLET 100 MG Tier-3PA; QL (60 EA per 30 days); NEDS

CAPRELSA ORAL TABLET 300 MG Tier-3PA; QL (30 EA per 30 days); NEDS

COMETRIQ (100 MG DAILY DOSE) Tier-3 PA; NEDS



COTELLIC Tier-3 PA; SP-CVS specialty; NEDS

CYCLOPHOSPHAMIDE Tier-2 B vs D; SP-CVS specialty

DROXIA Tier-2

EMCYT Tier-2 SP-CVS specialty

ERIVEDGE Tier-3 PA; SP-CVS specialty; NEDS

etoposide Tier-1 Part B; SP-CVS specialty

exemestane Tier-1

FARESTON Tier-2

FARYDAK Tier-3 PA; SP-CVS specialty; NEDS

flutamide Tier-1

GILOTRIF Tier-3 PA; NEDS

GLEOSTINE Tier-3 SP-CVS specialty

HEXALEN Tier-3 NEDS

HYCAMTIN Tier-2 Part B; SP-CVS specialty

hydroxyurea Tier-1

IBRANCE Tier-3 PA; SP-CVS specialty; NEDS

ICLUSIG Tier-3 PA; NEDS

imatinib mesylate Tier-2 SP-CVS specialty; NEDS

IMBRUVICA Tier-3 PA; NEDS

INLYTA Tier-3 PA; SP-CVS specialty; NEDS

IRESSA Tier-3 PA; NEDS

JAKAFI Tier-3 PA; SP-CVS specialty; NEDS

KISQALI 200 DOSE Tier-3 PA; SP-CVS specialty; NEDS



KISQALI FEMARA 200 DOSE Tier-3 PA; SP-CVS specialty; NEDS

KISQALI FEMARA 400 DOSE Tier-3 PA; SP-CVS specialty; NEDS


Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 600 DOSE Tier-3 PA; SP-CVS specialty; NEDS

KYPROLIS Tier-3 NEDS

LENVIMA 10 MG DAILY DOSE Tier-3 PA; NEDS






letrozole Tier-1

LEUKERAN Tier-2

LONSURF Tier-3 PA; SP-CVS specialty; NEDS

LYNPARZA Tier-3 PA; NEDS

LYSODREN Tier-2

MATULANE Tier-3 NEDS

megestrol acetate Tier-1 PA

MEKINIST Tier-3 PA; SP-CVS specialty; NEDS

mercaptopurine Tier-1

MYLERAN Tier-2 Part B

NEXAVAR Tier-3PA; SP-CVS specialty; QL (220 EA per 30 days); NEDS

nilutamide Tier-2 NEDS

NINLARO Tier-3 PA; SP-CVS specialty; NEDS

ODOMZO Tier-3 PA; SP-CVS specialty; NEDS

POMALYST Tier-3 PA; SP-CVS specialty; NEDS

PURIXAN Tier-3 NEDS

REVLIMID Tier-3 PA; SP-CVS specialty; NEDS

RUBRACA Tier-3PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

RYDAPT Tier-3 PA; SP-CVS specialty; NEDS

SOLTAMOX Tier-2

SPRYCEL ORAL TABLET 100 MG, 140 MG Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG

Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

STIVARGA Tier-3PA; SP-CVS specialty; QL (90 EA per 30 days); NEDS

SUTENT Tier-3 PA; SP-CVS specialty; NEDS

TABLOID Tier-2 SP-CVS specialty

TAFINLAR Tier-3 PA; SP-CVS specialty; NEDS


Drug Name Drug Tier Requirements/LimitsTAGRISSO Tier-3 PA; NEDS

tamoxifen citrate Tier-1

TARCEVA ORAL TABLET 100 MG Tier-3SP-CVS specialty; QL (90 EA per 30 days); NEDS

TARCEVA ORAL TABLET 150 MG, 25 MG Tier-3SP-CVS specialty; QL (30 EA per 30 days); NEDS

TARGRETIN Tier-3 SP-CVS specialty; NEDS

TASIGNA Tier-3 PA; SP-CVS specialty; NEDS

temozolomide Tier-2 Part B; SP-CVS specialty

THALOMID Tier-3 SP-CVS specialty; NEDS

tretinoin Tier-1 SP-CVS specialty

TYKERB Tier-3PA; SP-CVS specialty; QL (180 EA per 30 days); NEDS

VENCLEXTA ORAL TABLET 10 MG, 50 MG Tier-3 PA

VENCLEXTA ORAL TABLET 100 MG Tier-3 PA; NEDS

VENCLEXTA STARTING PACK Tier-3 PA; NEDS

VOTRIENT Tier-3PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

XALKORI Tier-3 PA; SP-CVS specialty; NEDS

XTANDI Tier-3PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

ZEJULA Tier-3 PA; NEDS

ZELBORAF Tier-3 PA; SP-CVS specialty; NEDS

ZOLINZA Tier-3 PA; SP-CVS specialty; NEDS

ZURAMPIC Tier-3 PA

ZYDELIG Tier-3 PA; NEDS

ZYKADIA Tier-3 PA; SP-CVS specialty; NEDS

ZYTIGA Tier-3PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

PROTECTIVE AGENTSFUSILEV Tier-3 NEDS

leucovorin calcium Tier-1

levoleucovorin calcium Tier-2 NEDS

mesna Tier-1

MESNEX Tier-3 NEDS

ZINECARD Tier-2



CARDIOVASCULAR AGENTS

ACE INHIBITORSbenazepril hcl Tier-1

captopril Tier-1

enalapril maleate Tier-1

fosinopril sodium Tier-1

lisinopril Tier-1

moexipril hcl Tier-1

perindopril erbumine Tier-1

quinapril hcl Tier-1

ramipril Tier-1

trandolapril Tier-1

ALPHA1 BLOCKERSCARDURA XL Tier-3

doxazosin mesylate Tier-1

prazosin hcl Tier-1

terazosin hcl Tier-1

ANGINACORLANOR Tier-3 PA

isosorbide dinitrate Tier-1

isosorbide dinitrate er Tier-1

isosorbide mononitrate Tier-1

isosorbide mononitrate er Tier-1

NITRO-BID Tier-3

nitroglycerin intravenous Tier-1

nitroglycerin sublingual Tier-1

nitroglycerin transdermal Tier-1

nitroglycerin translingual Tier-2

NITROMIST Tier-3

NITROSTAT Tier-2

RANEXA Tier-2

ANGIOTENSIN II RECEPTOR BLOCKERScandesartan cilexetil Tier-1

eprosartan mesylate Tier-1

irbesartan Tier-1

losartan potassium Tier-1


Drug Name Drug Tier Requirements/Limitsolmesartan medoxomil Tier-2

telmisartan Tier-2

valsartan Tier-1

ANTI-ARRHYTHMICS AND CARDIAC GLYCOSIDESamiodarone hcl Tier-1

digitek oral tablet 125 mcg Tier-1

digitek oral tablet 250 mcg Tier-1 PA

digoxin injection Tier-1

digoxin oral solution Tier-1 PA

digoxin oral tablet 125 mcg Tier-1

digoxin oral tablet 250 mcg Tier-1 PA

disopyramide phosphate Tier-1 PA

dofetilide Tier-2

flecainide acetate Tier-1

LANOXIN ORAL TABLET 125 MCG, 62.5 MCG

Tier-3

LANOXIN TABLET 187.5 MCG, 250 MCG Tier-3 PA

mexiletine hcl Tier-1

MULTAQ Tier-3

NORPACE CR Tier-3 PA

propafenone hcl Tier-1

propafenone hcl er Tier-2

quinidine gluconate er Tier-1

quinidine sulfate Tier-1

sorine Tier-1

sotalol hcl Tier-1

sotalol hcl (af) Tier-1

SOTYLIZE Tier-3

ANTIHYPERTENSIVE FIXED-DOSE COMBINATION PRODUCTSamlodipine besy-benazepril hcl Tier-1

amlodipine besylate-valsartan Tier-2

amlodipine-atorvastatin Tier-2

amlodipine-olmesartan Tier-2

amlodipine-valsartan-hctz Tier-2

atenolol-chlorthalidone Tier-1

benazepril-hydrochlorothiazide Tier-1


Drug Name Drug Tier Requirements/Limitsbisoprolol-hydrochlorothiazide Tier-1

candesartan cilexetil-hctz Tier-1

captopril-hydrochlorothiazide Tier-1

DUTOPROL Tier-3

enalapril-hydrochlorothiazide Tier-1

ENTRESTO Tier-3 PA

fosinopril sodium-hctz Tier-1

irbesartan-hydrochlorothiazide Tier-1

lisinopril-hydrochlorothiazide Tier-1

losartan potassium-hctz Tier-1

metoprolol-hydrochlorothiazide Tier-1

moexipril-hydrochlorothiazide Tier-1

nadolol-bendroflumethiazide Tier-1

olmesartan medoxomil-hctz Tier-2

olmesartan-amlodipine-hctz Tier-2

propranolol-hctz Tier-1

quinapril-hydrochlorothiazide Tier-1

TEKTURNA HCT Tier-2

telmisartan-amlodipine Tier-1

telmisartan-hctz Tier-2

trandolapril-verapamil hcl er Tier-1

valsartan-hydrochlorothiazide Tier-1

BETA AND ALPHA BLOCKERScarvedilol Tier-1

COREG CR Tier-3

labetalol hcl Tier-1

BETA BLOCKERSacebutolol hcl Tier-1

atenolol Tier-1

betaxolol hcl Tier-1

bisoprolol fumarate Tier-1

metoprolol succinate er Tier-1

metoprolol tartrate Tier-1

nadolol Tier-2

pindolol Tier-1

propranolol hcl Tier-1

propranolol hcl er Tier-1


Drug Name Drug Tier Requirements/Limitstimolol maleate Tier-1

CALCIUM CHANNEL BLOCKERSafeditab cr Tier-1

amlodipine besylate Tier-1

cartia xt Tier-1

diltiazem hcl Tier-1

diltiazem hcl er Tier-1

diltiazem hcl er beads Tier-1

diltiazem hcl er coated beads Tier-1

dilt-xr Tier-1

felodipine er Tier-1

isradipine Tier-1

matzim la Tier-1

nicardipine hcl Tier-1

nifedipine Tier-1 PA

nifedipine er Tier-1

nifedipine er osmotic release Tier-1

nimodipine Tier-1

nisoldipine er Tier-1

taztia xt Tier-1

verapamil hcl Tier-1

verapamil hcl er Tier-1

CENTRALLY ACTING AGENTSclonidine hcl Tier-1

midodrine hcl Tier-1

NORTHERA Tier-3 PA; NEDS

DIRECT RENIN INHIBITORSTEKTURNA Tier-2

DIURETICSamiloride hcl Tier-1

amiloride-hydrochlorothiazide Tier-1

bumetanide Tier-1

chlorothiazide Tier-1

chlorthalidone Tier-1

EDECRIN Tier-2

eplerenone Tier-1

ethacrynic acid Tier-2


Drug Name Drug Tier Requirements/Limitsfurosemide Tier-1

hydrochlorothiazide Tier-1

indapamide Tier-1

methyclothiazide Tier-1

metolazone Tier-1

spironolactone Tier-1

spironolactone-hctz Tier-1

torsemide Tier-1

triamterene-hctz Tier-1

LIPID LOWERING AGENTSatorvastatin calcium Tier-1

cholestyramine light Tier-1

colestipol hcl Tier-1

ezetimibe Tier-2

ezetimibe-simvastatin Tier-2

fenofibrate Tier-1

fenofibrate micronized Tier-2

fenofibric acid Tier-2

fluvastatin sodium Tier-2

fluvastatin sodium er Tier-2

gemfibrozil Tier-1

JUXTAPID Tier-3 PA; NEDS

KYNAMRO Tier-3 PA; SP-CVS specialty; NEDS

lovastatin Tier-1

niacin er Tier-2

niacor Tier-1

omega-3-acid ethyl esters Tier-2

pravastatin sodium Tier-1

PREVALITE Tier-3

REPATHA Tier-3 PA; SP-CVS specialty; NEDS

REPATHA PUSHTRONEX SYSTEM Tier-3 PA; SP-CVS specialty; NEDS

REPATHA SURECLICK Tier-3 PA; SP-CVS specialty; NEDS

rosuvastatin calcium Tier-2

simvastatin Tier-1

VASCEPA Tier-2

WELCHOL Tier-3



POTASSIUM REPLACEMENTklor-con Tier-1

klor-con 10 Tier-1

klor-con m10 Tier-1

KLOR-CON M15 Tier-3

klor-con m20 Tier-1

klor-con sprinkle Tier-1

K-TAB Tier-3

potassium chloride Tier-1

potassium chloride crys er Tier-1

potassium chloride er Tier-1

VASODILATORSBIDIL Tier-2

hydralazine hcl Tier-1

minoxidil Tier-1

DIABETES MELLITUS

DIABETIC SUPPLIESassure insulin safety syringe Tier-1

comfort assist insulin syringe Tier-1

cvs gauze sterile Tier-1

exel comfort point pen needle Tier-1

gauze pads Tier-1

global alcohol prep ease Tier-1

insulin syringe Tier-1

INSULIN SYRINGE Tier-2

lancets Tier-1 Part B

ONETOUCH TEST STRIPS Tier-2 Part B

preferred plus insulin syringe Tier-1

RELI-ON INSULIN SYRINGE Tier-2

GLUCOSE ELEVATINGGLUCAGEN HYPOKIT Tier-2

GLUCAGON EMERGENCY Tier-2

PROGLYCEM Tier-3

INSULINSHUMALOG Tier-2

HUMALOG KWIKPEN Tier-2

HUMALOG MIX 50/50 Tier-2


Drug Name Drug Tier Requirements/LimitsHUMALOG MIX 50/50 KWIKPEN Tier-2

HUMALOG MIX 75/25 Tier-2

HUMALOG MIX 75/25 KWIKPEN Tier-2

HUMULIN 70/30 Tier-2

HUMULIN 70/30 KWIKPEN Tier-2

HUMULIN N Tier-2

HUMULIN N KWIKPEN Tier-2

HUMULIN R Tier-2

HUMULIN R U-500 (CONCENTRATED) Tier-2

HUMULIN R U-500 KWIKPEN Tier-2

LANTUS Tier-2

LANTUS SOLOSTAR Tier-2

TOUJEO SOLOSTAR Tier-3

NON-INSULIN INJECTABLESBYDUREON Tier-2

BYETTA 10 MCG PEN Tier-3

BYETTA 5 MCG PEN Tier-3

SYMLINPEN 120 Tier-2

SYMLINPEN 60 Tier-2

TRULICITY Tier-2

ORAL AGENTSacarbose Tier-1

ACTOPLUS MET XR Tier-3

chlorpropamide Tier-1 PA

glimepiride Tier-1

glipizide Tier-1

glipizide er Tier-1

glipizide-metformin hcl Tier-1

glyburide Tier-1 PA

glyburide micronized Tier-1 PA

glyburide-metformin Tier-1 PA

INVOKAMET Tier-2

INVOKAMET XR Tier-2

INVOKANA Tier-2

JANUMET Tier-2

JANUMET XR Tier-2

JANUVIA Tier-2


Drug Name Drug Tier Requirements/LimitsJARDIANCE Tier-2

JENTADUETO Tier-2

JENTADUETO XR Tier-2

metformin hcl Tier-1

metformin hcl er Tier-1

metformin hcl er (osm) 1,000 mg Tier-1

miglitol Tier-2

nateglinide Tier-1

pioglitazone hcl Tier-1

pioglitazone hcl-glimepiride Tier-1

pioglitazone hcl-metformin hcl Tier-2

repaglinide Tier-1

repaglinide-metformin hcl Tier-2

RIOMET Tier-2

SYNJARDY Tier-2

tolazamide Tier-1

tolbutamide Tier-1

TRADJENTA Tier-2

EAR, NOSE AND THROAT

EARacetasol hc Tier-1

acetic acid Tier-1

CIPRO HC Tier-2

CIPRODEX Tier-2

fluocinolone acetonide Tier-1

hydrocortisone-acetic acid Tier-1

ofloxacin Tier-2

MOUTH AND THROATcevimeline hcl Tier-1

chlorhexidine gluconate Tier-1

periogard Tier-1

pilocarpine hcl Tier-1

triamcinolone acetonide Tier-1

NOSEazelastine hcl Tier-1 QL (120 ML per 90 days)

BACTROBAN NASAL Tier-3

budesonide Tier-1


Drug Name Drug Tier Requirements/Limitscyproheptadine hcl Tier-1 PA

desloratadine Tier-1

flunisolide Tier-2 QL (150 ML per 90 days)

fluticasone propionate Tier-1 QL (48 GM per 90 days)

hydroxyzine hcl Tier-1 PA

hydroxyzine pamoate Tier-1 PA

ipratropium bromide nasal solution 0.03 % Tier-1 QL (180 ML per 90 days)

ipratropium bromide nasal solution 0.06 % Tier-1 QL (90 ML per 90 days)

levocetirizine dihydrochloride Tier-1

mometasone furoate Tier-2 QL (102 GM per 90 days)

olopatadine hcl Tier-1 QL (91.5 GM per 90 days)


ENHANCED COVERAGE DRUGS

COUGH & COLD PREPARATIONSbenzonatate Tier-2 EC

hydrocodone-homatropine Tier-2 EC

promethazine vc/codeine Tier-2 EC

promethazine-codeine Tier-2 EC

promethazine-dm Tier-2 EC

pseudoeph-chlorphen-hydrocod Tier-2 EC

ERECTILE DYSFUNCTIONCAVERJECT Tier-3 EC

CAVERJECT IMPULSE Tier-3 EC

CIALIS Tier-3 EC; QL (4 EA per 30 days)

EDEX Tier-3 EC

LEVITRA Tier-3 EC; QL (4 EA per 30 days)

MUSE Tier-3 EC

sildenafil 25, 50 & 100 mg tablets Tier-2 EC; QL (4 EA per 30 days)

OBESITY MANAGEMENTADIPEX-P Tier-3 PA; EC

BELVIQ Tier-3 PA; EC

diethylpropion hcl Tier-2 PA; EC

diethylpropion hcl er Tier-2 PA; EC

phendimetrazine tartrate Tier-2 PA; EC

phendimetrazine tartrate er Tier-2 PA; EC

phentermine hcl Tier-2 PA; EC

QSYMIA Tier-3 PA; EC


Drug Name Drug Tier Requirements/LimitsSAXENDA Tier-3 PA; EC

XENICAL Tier-3 PA; EC

VITAMINS/MINERALScyanocobalamin (vitamin b12) Tier-2 EC

ergocalciferol (rx and otc) Tier-2 EC

folic acid (rx and otc) Tier-2 EC

MEPHYTON Tier-3 EC

NASCOBAL Tier-3 EC

vitamin d (ergocalciferol) Tier-2 EC

EYE

ALLERGYALOCRIL Tier-3

ALOMIDE Tier-3

azelastine hcl Tier-1

cromolyn sodium Tier-1

EMADINE Tier-3

epinastine hcl Tier-1

LASTACAFT Tier-3

olopatadine hcl Tier-2

ANTI-INFECTIVESAZASITE Tier-3

bacitracin Tier-1

bacitracin-polymyxin b Tier-1

bacitra-neomycin-polymyxin-hc Tier-1

BESIVANCE Tier-2

BLEPHAMIDE Tier-3

BLEPHAMIDE S.O.P. Tier-3

ciprofloxacin hcl Tier-1

erythromycin Tier-1

gatifloxacin Tier-1

gentak Tier-1

gentamicin sulfate Tier-2

levofloxacin Tier-1

MOXEZA Tier-3

neomycin-bacitracin zn-polymyx Tier-1

neomycin-polymyxin-hc Tier-1

ofloxacin Tier-1


Drug Name Drug Tier Requirements/Limitspolymyxin b-trimethoprim Tier-1

sulfacetamide sodium Tier-1

sulfacetamide-prednisolone Tier-1

TOBRADEX Tier-3

TOBRADEX ST Tier-3

tobramycin Tier-1

tobramycin-dexamethasone Tier-1

VIGAMOX Tier-2

ANTI-INFLAMMATORIESALREX Tier-2

bromfenac sodium Tier-1

dexamethasone sodium phosphate Tier-1

diclofenac sodium Tier-1

DUREZOL Tier-2

FLAREX Tier-3

fluorometholone Tier-1

flurbiprofen sodium Tier-1

FML Tier-2

FML FORTE Tier-3

ILEVRO Tier-3

ketorolac tromethamine Tier-1

LOTEMAX Tier-2

MAXIDEX Tier-3

neomycin-polymyxin-dexameth Tier-1

neomycin-polymyxin-gramicidin Tier-1

neomycin-polymyxin-hc Tier-1

NEVANAC Tier-3

PRED MILD Tier-2

PRED-G Tier-2

PRED-G S.O.P. Tier-2

prednisolone acetate Tier-2

prednisolone sodium phosphate Tier-1

PROLENSA Tier-3

ZYLET Tier-3

ANTIVIRALStrifluridine Tier-1

ZIRGAN Tier-3



GLAUCOMAacetazolamide Tier-1

acetazolamide er Tier-1

ALPHAGAN P 0.1% Tier-2

apraclonidine hcl Tier-1

AZOPT Tier-2

betaxolol hcl Tier-1

BETIMOL Tier-2

BETOPTIC-S Tier-3

bimatoprost Tier-1

brimonidine tartrate Tier-1

carteolol hcl Tier-1

COMBIGAN Tier-2

dorzolamide hcl Tier-1

dorzolamide hcl-timolol mal Tier-1

IOPIDINE Tier-3

latanoprost Tier-1

levobunolol hcl Tier-1

LUMIGAN Tier-2

methazolamide Tier-1

metipranolol Tier-1

PHOSPHOLINE IODIDE Tier-2

pilocarpine hcl Tier-1

SIMBRINZA Tier-3

timolol maleate ophthalmic gel forming solution Tier-2

timolol maleate ophthalmic solution Tier-1

TRAVATAN Z Tier-2

OPHTHALMIC DRUGS, MISCELLANEOUSatropine sulfate Tier-1

CYSTARAN Tier-2

NATACYN Tier-3

proparacaine hcl Tier-1

RESTASIS Tier-2

GASTROINTESTINAL DRUGS

EMESISALOXI Tier-3 B vs D; NEDS


Drug Name Drug Tier Requirements/LimitsANZEMET Tier-2 B vs D

aprepitant Tier-2 B vs D

CESAMET Tier-2 B vs D

compro Tier-1

dronabinol Tier-2 B vs D

EMEND Tier-2 B vs D

granisetron hcl Tier-1 B vs D

meclizine hcl Tier-1

metoclopramide hcl Tier-1

ondansetron Tier-1 B vs D

ondansetron hcl Tier-1 B vs D

prochlorperazine Tier-1

prochlorperazine maleate Tier-1

promethazine hcl Tier-1 PA

SANCUSO Tier-3 B vs D

TRANSDERM-SCOP PATCH Tier-3

VARUBI Tier-3 B vs D

ENZYMESCARBAGLU Tier-3 PA; NEDS

CREON Tier-2

CYSTAGON Tier-3

ZENPEP Tier-3

GASTROINTESTINAL DRUGS, MISCELLANEOUSalosetron hcl Tier-2 NEDS

CHOLBAM Tier-3 PA; NEDS

constulose Tier-1

cromolyn sodium Tier-1

dicyclomine hcl Tier-1

enulose Tier-1

GATTEX Tier-3 PA; SP-CVS specialty; NEDS

generlac Tier-1

glycopyrrolate Tier-1

KRISTALOSE Tier-2

lactulose Tier-1

levocarnitine Tier-1

loperamide hcl Tier-2


Drug Name Drug Tier Requirements/Limitsmegestrol acetate Tier-1 PA

MOVANTIK Tier-2

MOVIPREP Tier-3

MYTESI Tier-2 PA

OCALIVA Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

OSMOPREP Tier-3

peg 3350-kcl-na bicarb-nacl Tier-1

peg-3350/electrolytes Tier-1

polyethylene glycol 3350 Tier-1

propantheline bromide Tier-1

RELISTOR Tier-3 NEDS

SUPREP BOWEL PREP KIT Tier-3

trilyte Tier-1

UCERIS Tier-3

ursodiol Tier-1

GASTROINTESTINAL DRUGS, PEPTIC ULCER TREATMENT, REFLUX (GERD)amoxicill-clarithro-lansopraz Tier-2

CARAFATE SUSPENSION Tier-3

cimetidine Tier-2

cimetidine solution Tier-1

esomeprazole magnesium Tier-2

famotidine Tier-1

lansoprazole Tier-2

methscopolamine bromide Tier-1

misoprostol Tier-1

nizatidine Tier-1

omeprazole Tier-1

omeprazole-sodium bicarbonate Tier-3

pantoprazole sodium Tier-1

PYLERA Tier-2

rabeprazole sodium Tier-2

ranitidine hcl Tier-1

sucralfate Tier-1

INFLAMMATORY BOWEL DISEASEAMITIZA Tier-2


Drug Name Drug Tier Requirements/LimitsAPRISO Tier-2

balsalazide disodium Tier-1

budesonide Tier-1

CANASA Tier-2

colocort Tier-1

DELZICOL Tier-3

hydrocortisone Tier-1

LINZESS Tier-2

mesalamine Tier-2

mesalamine-cleanser Tier-1

SFROWASA Tier-3

sulfasalazine Tier-1

UCERIS Tier-3 NEDS

HOME INFUSION THERAPY

ACUTE CARE DRUGSABELCET Tier-3 PA; NEDS

acetazolamide sodium Tier-1

acyclovir sodium Tier-1 PA

AMBISOME Tier-3 PA; NEDS

amikacin sulfate Tier-1

aminophylline Tier-1

amphotericin b Tier-1 PA

ampicillin sodium Tier-1

ampicillin-sulbactam sodium Tier-1

ARGATROBAN Tier-3

atropine sulfate Tier-1

AVELOX Tier-2

AVYCAZ Tier-2

azithromycin Tier-1

aztreonam Tier-1

bactocill in dextrose Tier-1

benztropine mesylate Tier-1

bumetanide Tier-1

butorphanol tartrate Tier-1

calcitriol Tier-1

CANCIDAS Tier-3 NEDS

CAPASTAT SULFATE Tier-2


Drug Name Drug Tier Requirements/LimitsCARDENE IV Tier-3

cefazolin sodium Tier-1

cefepime hcl Tier-1

cefotaxime sodium Tier-1

cefotetan disodium Tier-1

cefoxitin sodium Tier-1

ceftazidime Tier-1

ceftriaxone sodium Tier-1

cefuroxime sodium Tier-1

chloramphenicol sod succinate Tier-1

cidofovir Tier-2 NEDS

ciprofloxacin Tier-1

ciprofloxacin in d5w Tier-1

clindamycin phosphate Tier-1

clindamycin phosphate in d5w Tier-1

colistimethate sodium Tier-1

CRESEMBA Tier-3 NEDS

cyclosporine Tier-1 B vs D

DALVANCE Tier-2

daptomycin Tier-1

dexamethasone sodium phosphate Tier-1

diltiazem hcl Tier-1

diphenhydramine hcl Tier-1

DORIBAX Tier-2

DOXY 100 Tier-3

EMEND Tier-2 B vs D

ERAXIS Tier-2

ERYTHROCIN LACTOBIONATE Tier-2

esomeprazole sodium Tier-1

fluconazole in sodium chloride Tier-1

furosemide Tier-1

gentamicin in saline Tier-1


granisetron hcl Tier-1 B vs D

heparin sodium (porcine) Tier-1

hydroxyzine hcl Tier-1

imipenem-cilastatin Tier-1


Drug Name Drug Tier Requirements/LimitsINVANZ Tier-2

isoniazid Tier-1

labetalol hcl Tier-1

levetiracetam in nacl Tier-1

levofloxacin Tier-1

levofloxacin in d5w Tier-1

levothyroxine sodium Tier-1

lidocaine hcl Tier-1

lidocaine hcl (pf) Tier-1

LINCOCIN Tier-2

lincomycin hcl Tier-1

linezolid Tier-1

meropenem Tier-1

methotrexate sodium Tier-1 B vs D

methotrexate sodium (pf) Tier-1 B vs D

metoclopramide hcl Tier-1

metoprolol tartrate Tier-1

metronidazole in nacl Tier-1

moxifloxacin hcl Tier-1

MYCAMINE Tier-2

nafcillin sodium Tier-1

ondansetron hcl Tier-1 B vs D

ORBACTIV Tier-2

oxacillin sodium Tier-1

penicillin g pot in dextrose Tier-1

penicillin g potassium Tier-1

penicillin g sodium Tier-1

piperacillin sod-tazobactam so Tier-1

polymyxin b sulfate Tier-1

prochlorperazine edisylate Tier-1

PROGRAF INJECTION Tier-2 B vs D

promethazine hcl Tier-1

RETROVIR Tier-2

rifampin Tier-1

SIVEXTRO Tier-2

streptomycin sulfate Tier-1

sulfamethoxazole-trimethoprim Tier-1


Drug Name Drug Tier Requirements/LimitsSYNERCID Tier-3 NEDS

TEFLARO Tier-2

tigecycline Tier-1

tobramycin sulfate Tier-1

TYGACIL Tier-2

valproate sodium Tier-1

vancomycin hcl Tier-1

voriconazole Tier-1

ZERBAXA Tier-3 NEDS

ELECTROLYTESdextrose Tier-1

dextrose in lactated ringers Tier-1

dextrose-nacl Tier-1

IONOSOL-MB IN D5W Tier-2

ISOLYTE-P IN D5W Tier-2

ISOLYTE-S Tier-2

kcl in dextrose-nacl Tier-1

kcl-lactated ringers-d5w Tier-1

lactated ringers Tier-1

magnesium sulfate Tier-1

NORMOSOL-M IN D5W Tier-2

NORMOSOL-R IN D5W Tier-2

NORMOSOL-R PH 7.4 Tier-2

PLASMA-LYTE 148 Tier-2

PLASMA-LYTE A Tier-2

potassium chloride Tier-1

potassium chloride in dextrose Tier-1

potassium chloride in nacl Tier-1

ringers Tier-1

sodium chloride Tier-1

sodium lactate Tier-1

IV NUTRITIONAMINOSYN II Tier-2 B vs D

AMINOSYN II/ELECTROLYTES Tier-2 B vs D

AMINOSYN/ELECTROLYTES Tier-2 B vs D

AMINOSYN-HBC Tier-2 B vs D

AMINOSYN-PF Tier-2 B vs D


Drug Name Drug Tier Requirements/LimitsAMINOSYN-RF Tier-2 B vs D

CLINIMIX E/DEXTROSE (2.75/10) Tier-2 B vs D





CLINIMIX E/DEXTROSE (5/15) Tier-2 B vs D



CLINIMIX/DEXTROSE (2.75/5) Tier-2 B vs D





CLINIMIX/DEXTROSE (5/15) Tier-2 B vs D



CLINISOL SF Tier-2 B vs D

FREAMINE HBC Tier-2 B vs D

HEPATAMINE Tier-2 B vs D

INTRALIPID Tier-2 B vs D

NEPHRAMINE Tier-2 B vs D

NUTRILIPID Tier-2 B vs D

PLENAMINE Tier-2 B vs D

PREMASOL Tier-2 B vs D

PROCALAMINE Tier-2 B vs D

PROSOL Tier-2 B vs D

tpn electrolytes Tier-1 B vs D

TRAVASOL Tier-2 B vs D

TROPHAMINE Tier-2 B vs D

HORMONES

ADRENAL CORTICOSTEROIDScortisone acetate Tier-1

DEPO-MEDROL Tier-2

dexamethasone Tier-1

dexamethasone intensol Tier-1

dexpak 13 day Tier-1


Drug Name Drug Tier Requirements/Limitsfludrocortisone acetate Tier-1

HP ACTHAR Tier-3 PA; NEDS


MEDROL Tier-3

methylprednisolone Tier-1 Transplant

methylprednisolone acetate Tier-1 Transplant

methylprednisolone sodium succ Tier-1 Transplant

MILLIPRED Tier-3 Transplant

ORAPRED ODT Tier-3 Transplant

prednisolone sodium phosphate Tier-1 Transplant

prednisone Tier-1 Transplant

PREDNISONE INTENSOL Tier-3 Transplant

SOLU-CORTEF Tier-3

SOLU-MEDROL Tier-3

VERIPRED 20 Tier-3 Transplant

ANDROGENSANADROL-50 Tier-3

AVEED Tier-3

danazol Tier-1

DEPO-TESTOSTERONE Tier-3

METHITEST Tier-3

methyltestosterone Tier-2 NEDS

oxandrolone Tier-1

testosterone Tier-2

testosterone cypionate Tier-1

testosterone enanthate Tier-1

GONADOTROPIN RELEASING AGONISTSELIGARD Tier-2

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG

Tier-3 NEDS

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

Tier-2

leuprolide acetate Tier-1

LUPRON DEPOT (1-MONTH) Tier-3 NEDS





Drug Name Drug Tier Requirements/LimitsLUPRON DEPOT-PED (1-MONTH) Tier-3 NEDS

SYNAREL Tier-3 NEDS

TRELSTAR MIXJECT Tier-3 NEDS

THYROID REPLACEMENT AND ANTITHYROID AGENTSlevothyroxine sodium Tier-1

levoxyl Tier-1

liothyronine sodium Tier-1

methimazole Tier-1

propylthiouracil Tier-1

SYNTHROID Tier-3

THYROLAR-1 Tier-3

THYROLAR-1/2 Tier-3

THYROLAR-1/4 Tier-3

THYROLAR-2 Tier-3

THYROLAR-3 Tier-3

TIROSINT Tier-3

TRIOSTAT Tier-2

unithroid Tier-1

IMMUNOLOGIC AGENTS

IMMUNE STIMULANTSACTHIB Tier-2 Part B

ACTIMMUNE Tier-3 NEDS

ADACEL Tier-2

ADAGEN Tier-3 NEDS

bcg vaccine Tier-1

BEXSERO Tier-2

BIVIGAM Tier-3 PA; NEDS

BOOSTRIX Tier-2

CARIMUNE NF Tier-3 PA; NEDS

DAPTACEL Tier-2

diphtheria-tetanus toxoids dt Tier-1

ENGERIX-B Tier-2 B vs D

FLEBOGAMMA DIF Tier-3 PA; NEDS

GAMASTAN S/D Tier-2 PA

GAMMAGARD Tier-3 PA; NEDS

GAMMAGARD S/D LESS IGA Tier-3 PA; NEDS


Drug Name Drug Tier Requirements/LimitsGAMMAKED Tier-3 PA; NEDS

GAMMAPLEX Tier-3 PA; NEDS

GAMUNEX-C Tier-3 PA; NEDS

GARDASIL 9 Tier-2

HAVRIX Tier-2

HIBERIX Tier-2

HYPERRAB S/D Tier-2

IMOGAM RABIES-HT Tier-2

IMOVAX RABIES Tier-2

INFANRIX Tier-2

IPOL Tier-2

IXIARO Tier-2

KINRIX Tier-2

MENACTRA Tier-2

MENOMUNE Tier-2

MENVEO Tier-2

M-M-R II Tier-2

OCTAGAM Tier-2 PA

PEDIARIX Tier-2

PEDVAX HIB Tier-2

PNEUMOVAX 23 Tier-2 Part B

PREVNAR 13 Tier-2 Part B

PRIVIGEN Tier-3 PA; NEDS

PROQUAD Tier-2

QUADRACEL Tier-2

RABAVERT Tier-2

RECOMBIVAX HB Tier-2 B vs D

ROTARIX Tier-2

ROTATEQ Tier-2

TENIVAC Tier-2

tetanus-diphtheria toxoids td Tier-1

TRUMENBA Tier-2

TWINRIX Tier-2

TYPHIM VI Tier-2

VAQTA Tier-2

VARIVAX Tier-2

VARIZIG Tier-2


Drug Name Drug Tier Requirements/LimitsYF-VAX Tier-2

ZINPLAVA Tier-3 PA; NEDS

ZOSTAVAX Tier-2

IMMUNOSUPPRESSIVESASTAGRAF XL Tier-3 B vs D

ATGAM Tier-2 B vs D

BENLYSTA Tier-3 PA; NEDS

CELLCEPT Tier-3 B vs D; NEDS

cyclosporine Tier-1 B vs D

cyclosporine modified Tier-1 B vs D

ENVARSUS XR Tier-3 B vs D; SP-CVS specialty

gengraf Tier-1 B vs D

mycophenolate mofetil Tier-1 B vs D

mycophenolate mofetil hcl Tier-1 B vs D

mycophenolate sodium Tier-1 B vs D

NULOJIX Tier-3 B vs D; NEDS

RAPAMUNE ORAL SOLUTION Tier-2 B vs D

SIMULECT Tier-3 B vs D; NEDS

sirolimus Tier-1 B vs D

tacrolimus Tier-1 B vs D

THYMOGLOBULIN Tier-2 B vs D

ZORTRESS Tier-3B vs D; QL (60 EA per 30 days); NEDS

MISCELLANEOUS DRUGS

ACROMEGALYoctreotide acetate Tier-1

SANDOSTATIN LAR DEPOT Tier-3 NEDS

SIGNIFOR LAR Tier-3 PA; QL (2 EA per 28 days); NEDS

SOMATULINE DEPOT Tier-3 NEDS

SOMAVERT Tier-3 PA; SP-CVS specialty; NEDS

AMYOTROPHIC LATERAL SCLEROSISriluzole Tier-2

ANAPHYLAXIS EMERGENCYepinephrine Tier-1 QL (2 EA per 1 day)

BOTULINUM TOXINSBOTOX Tier-2 PA


Drug Name Drug Tier Requirements/LimitsDYSPORT Tier-2 PA

XEOMIN Tier-2 PA

CASTLEMAN'S DISEASESYLVANT Tier-3 PA; NEDS

CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMESARCALYST Tier-3 PA; SP-CVS specialty; NEDS

ILARIS (150MG DELIVERED) Tier-3 PA; NEDS

CUSHING'S SYNDROME

KORLYM Tier-3PA; QL (120 EA per 30 days); NEDS

SIGNIFOR Tier-3PA; QL (60 ML per 30 days); NEDS

CYSTIC FIBROSISBETHKIS Tier-3 B vs D; NEDS

CAYSTON Tier-3 NEDS

KALYDECO Tier-3PA; QL (60 EA per 30 days); NEDS

ORKAMBI Tier-3PA; QL (120 EA per 30 days); NEDS

PULMOZYME Tier-3 B vs D; NEDS

TOBI PODHALER Tier-3 NEDS

tobramycin Tier-2 B vs D; NEDS

CYSTINURIACYSTADANE Tier-3 NEDS

DETOXIFICATION AGENTSCHEMET Tier-3

EXJADE Tier-3 NEDS

FERRIPROX Tier-3 NEDS

JADENU Tier-3 NEDS

JADENU SPRINKLE Tier-3 NEDS

DUCHENNE MUSCULAR DYSTROPHYEXONDYS 51 Tier-3 PA; NEDS

FABRY DISEASEFABRAZYME Tier-3 PA; NEDS



GAUCHER'S DISEASECERDELGA Tier-3 PA; NEDS

CEREZYME Tier-3 PA; NEDS

ELELYSO Tier-3 PA; NEDS

VPRIV Tier-3 PA; NEDS

ZAVESCA Tier-3 PA; NEDS

GROWTH HORMONE DEFICIENCYEGRIFTA Tier-3 PA; SP-CVS specialty; NEDS

GENOTROPIN Tier-2 PA; SP-CVS specialty

GENOTROPIN MINIQUICK Tier-2 PA; SP-CVS specialty

HUMATROPE Tier-3 PA; SP-CVS specialty; NEDS

INCRELEX Tier-3 PA; SP-CVS specialty; NEDS

NORDITROPIN FLEXPRO Tier-3 PA; SP-CVS specialty; NEDS

NUTROPIN AQ NUSPIN 10 Tier-3 PA; SP-CVS specialty; NEDS



OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML

Tier-3 PA; SP-CVS specialty; NEDS

OMNITROPE SUBCUTANEOUS SOLUTION 5 MG/1.5ML

Tier-2 PA; SP-CVS specialty

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED


SAIZEN Tier-3 PA; SP-CVS specialty; NEDS

SAIZEN CLICK.EASY Tier-3 PA; SP-CVS specialty; NEDS

SEROSTIM Tier-3 PA; SP-CVS specialty; NEDS

ZOMACTON Tier-2 PA; SP-CVS specialty

ZORBTIVE Tier-3 PA; SP-CVS specialty; NEDS

HEREDITARY ANGIOEDEMABERINERT Tier-3 NEDS

CINRYZE Tier-3 PA; NEDS

FIRAZYR Tier-3PA; SP-CVS specialty; QL (18 ML per 30 days); NEDS

RUCONEST Tier-3 NEDS

HEREDITARY TYROSINEMIA TYPE 1ORFADIN ORAL CAPSULE Tier-3 PA; SP-CVS specialty; NEDS

ORFADIN ORAL SUSPENSION Tier-3 PA; NEDS



HUNTINGTON'S CHOREAAUSTEDO Tier-3 PA; SP-CVS specialty; NEDS

tetrabenazine Tier-2 PA; SP-CVS specialty; NEDS

HYPERCALCEMIASENSIPAR Tier-3 NEDS

HYPERPARATHYROIDISMcalcitriol Tier-1

doxercalciferol Tier-1

paricalcitol Tier-1

HYPOPARATHYROIDISM

NATPARA Tier-3PA; SP-CVS specialty; QL (2 EA per 28 days); NEDS

HYPOPHOSPHATASIASTRENSIQ Tier-3 PA; NEDS

LYSOSOMAL ACID LIPASE DEFICIENCYKANUMA Tier-3 PA; NEDS

MUCOPOLYSACCHARIDOSISALDURAZYME Tier-3 NEDS

ELAPRASE Tier-3 NEDS

LUMIZYME Tier-3 NEDS

NAGLAZYME Tier-3 NEDS

MULTIPLE SCLEROSIS

AMPYRA Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

AUBAGIO Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

AVONEX Tier-3SP-CVS specialty; QL (4 EA per 28 days); NEDS

AVONEX PEN Tier-3SP-CVS specialty; QL (4 EA per 28 days); NEDS

AVONEX PREFILLED Tier-3SP-CVS specialty; QL (4 EA per 28 days); NEDS

BETASERON Tier-3SP-CVS specialty; QL (15 EA per 30 days); NEDS

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML


COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML




EXTAVIA Tier-3SP-CVS specialty; QL (15 EA per 30 days); NEDS

GILENYA Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

PLEGRIDY Tier-3SP-CVS specialty; QL (1 ML per 28 days); NEDS

PLEGRIDY STARTER PACK Tier-3 SP-CVS specialty; NEDS

REBIF Tier-3SP-CVS specialty; QL (12 ML per 28 days); NEDS

REBIF REBIDOSE Tier-3SP-CVS specialty; QL (12 ML per 28 days); NEDS

REBIF REBIDOSE TITRATION PACK Tier-3SP-CVS specialty; QL (12 ML per 28 days); NEDS

REBIF TITRATION PACK Tier-3SP-CVS specialty; QL (12 ML per 28 days); NEDS

TECFIDERA ORAL STARTER PACK Tier-3 PA; SP-CVS specialty; NEDS

TECFIDERA ORAL CAPSULE DELAYED RELEASE


TYSABRI Tier-3 PA; NEDS

ZINBRYTA Tier-3PA; SP-CVS specialty; QL (1 ML per 28 days); NEDS

MYASTHENIA GRAVISguanidine hcl Tier-1

MESTINON SYRUP Tier-3

pyridostigmine bromide Tier-1

pyridostigmine bromide er Tier-1

OPIOID ANTAGONISTSbuprenorphine hcl Tier-2 PA; QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl Tier-2 PA; QL (90 EA per 30 days)

EVZIO Tier-3 PA; NEDS

naloxone hcl Tier-1

NARCAN Tier-3 QL (4 EA per 30 days)

SUBOXONE FILM Tier-3 PA; QL (90 EA per 30 days)

PAGET'S DISEASEetidronate disodium Tier-1

PHENYLKETONURIAKUVAN Tier-3 PA; SP-CVS specialty; NEDS

PHEOCHROMOCYTOMADEMSER Tier-3 NEDS


Drug Name Drug Tier Requirements/LimitsDIBENZYLINE Tier-3

phenoxybenzamine hcl Tier-2

PHOSPHATE BINDERSAURYXIA Tier-3 NEDS

calcium acetate (phos binder) Tier-1

RENVELA Tier-2

sevelamer carbonate oral packets Tier-2

POTASSIUM BINDERkionex Tier-1

sodium polystyrene sulfonate Tier-1

sps Tier-1

VELTASSA Tier-3

PRIMARY PERIODIC PARALYSISKEVEYIS Tier-3 PA; NEDS

RESPIRATORY SYNCYTIAL VIRUSSYNAGIS Tier-3 SP-CVS specialty; NEDS

SMOKING CESSATIONbupropion hcl er (smoking det) Tier-1

CHANTIX Tier-3 QL (60 EA per 30 days)

CHANTIX CONTINUING MONTH PAK Tier-3 QL (56 EA per 28 days)

CHANTIX STARTING MONTH PAK Tier-3 QL (53 EA per 28 days)

NICOTROL Tier-2

NICOTROL NS Tier-3

SUCRASE DEFICIENCYSUCRAID Tier-3 NEDS

SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIAalfuzosin hcl er Tier-1

CIALIS Tier-3 PA; QL (30 EA per 30 days)

dutasteride Tier-2

dutasteride-tamsulosin hcl Tier-2

finasteride Tier-1

tamsulosin hcl Tier-1

TARDIVE DYSKINESIAINGREZZA Tier-3 PA; NEDS



UREA CYCLE DISORDERSBUPHENYL Tier-3 NEDS

RAVICTI Tier-3 PA; NEDS

sodium phenylbutyrate Tier-2 NEDS

UROLOGIC DISORDERSbethanechol chloride Tier-1

darifenacin hydrobromide er Tier-2

desmopressin ace rhinal tube Tier-1

desmopressin ace spray refrig Tier-1

desmopressin acetate Tier-1

ELMIRON Tier-3

flavoxate hcl Tier-1

MYRBETRIQ Tier-3

oxybutynin chloride Tier-1

oxybutynin chloride er Tier-1

potassium citrate er Tier-1

SAMSCA Tier-3 NEDS

tolterodine tartrate Tier-2

tolterodine tartrate er Tier-2

TOVIAZ Tier-2

trospium chloride Tier-2

trospium chloride er Tier-2

UROCIT-K 10 Tier-3

UROCIT-K 15 Tier-3

UROCIT-K 5 Tier-3

VESICARE Tier-3

WILSON'S DISEASECUPRIMINE Tier-3 NEDS

DEPEN TITRATABS Tier-2

SYPRINE Tier-3 NEDS

NEUROLOGICAL DRUGS

ALZHEIMER'S DISEASEdonepezil hcl Tier-1

ergoloid mesylates Tier-1

galantamine hydrobromide Tier-1

galantamine hydrobromide er Tier-1

memantine hcl oral solution Tier-2


Drug Name Drug Tier Requirements/Limitsmemantine hcl oral tablet Tier-1

NAMENDA XR Tier-2

NAMENDA XR TITRATION PACK Tier-2

rivastigmine Tier-1

rivastigmine tartrate Tier-1

MIGRAINE THERAPYalmotriptan malate Tier-1

dihydroergotamine mesylate injection Tier-1 PA

dihydroergotamine mesylate nasal Tier-1

frovatriptan succinate Tier-2

MIGERGOT Tier-2

MIGRANAL Tier-3

naratriptan hcl Tier-1

rizatriptan benzoate Tier-1

sumatriptan nasal solution 20 mg/act Tier-2

sumatriptan nasal solution 5 mg/act Tier-1

sumatriptan succinate oral Tier-1

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml

Tier-1

sumatriptan succinate refill subcutaneous solution cartridge 6 mg/0.5ml

Tier-2

sumatriptan succinate subcutaneous solution Tier-2

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml

Tier-1

sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml

Tier-2

sumatriptan succinate subcutaneous solution prefilled syringe

Tier-2

zolmitriptan Tier-1

PARKINSON'S DISEASEAPOKYN Tier-3 NEDS

AZILECT Tier-2

benztropine mesylate Tier-1 PA

bromocriptine mesylate Tier-1

cabergoline Tier-1

carbidopa Tier-1

carbidopa-levodopa Tier-1

carbidopa-levodopa er Tier-1


Drug Name Drug Tier Requirements/Limitscarbidopa-levodopa-entacapone Tier-1

CYCLOSET Tier-2

DUOPA Tier-3

entacapone Tier-1

NEUPRO Tier-3 QL (30 EA per 30 days)

pramipexole dihydrochloride Tier-1

pramipexole dihydrochloride er Tier-1

rasagiline mesylate Tier-2

ropinirole hcl Tier-1

ropinirole hcl er Tier-1

RYTARY Tier-3

selegiline hcl Tier-1

tolcapone Tier-2 NEDS

trihexyphenidyl hcl Tier-1 PA

PSEUDOBULBAR AFFECTNUEDEXTA Tier-2 PA

SEIZURESAPTIOM Tier-3 PA

BANZEL Tier-2

BRIVIACT Tier-3 PA; NEDS

carbamazepine Tier-1

carbamazepine er Tier-1

CELONTIN Tier-3

clonazepam Tier-1

DIASTAT ACUDIAL Tier-2

DIASTAT PEDIATRIC Tier-2

diazepam Tier-1

diazepam intensol Tier-1

DILANTIN Tier-2

DILANTIN INFATABS Tier-2

divalproex sodium Tier-1

divalproex sodium er Tier-1

epitol Tier-1

ethosuximide Tier-1

felbamate Tier-1

fosphenytoin sodium Tier-1

FYCOMPA Tier-3 PA


Drug Name Drug Tier Requirements/Limitsgabapentin Tier-1

GABITRIL Tier-2

HORIZANT Tier-3 QL (60 EA per 30 days)

lamotrigine Tier-1

lamotrigine er Tier-2

levetiracetam Tier-1

levetiracetam er Tier-1

LYRICA Tier-3 STPA

ONFI ORAL SUSPENSION Tier-3

ONFI ORAL TABLET Tier-3 QL (60 EA per 30 days)

oxcarbazepine Tier-1

OXTELLAR XR Tier-3

PEGANONE Tier-3

phenobarbital Tier-1 PA

phenytoin Tier-1

phenytoin sodium Tier-1

phenytoin sodium extended Tier-1

primidone Tier-1

QUDEXY XR Tier-3

roweepra Tier-1

SABRIL Tier-3 NEDS

SAVELLA Tier-2 STPA; QL (180 EA per 90 days)

SPRITAM Tier-3

TEGRETOL-XR Tier-2

tiagabine hcl Tier-1

topiramate Tier-1

topiramate er Tier-1

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

Tier-3

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG

Tier-3 NEDS

valproate sodium Tier-1

valproic acid Tier-1

VIMPAT INTRAVENOUS Tier-3

VIMPAT ORAL SOLUTION Tier-3 PA

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

Tier-3PA; QL (60 EA per 30 days); NEDS

VIMPAT ORAL TABLET 50 MG Tier-3 PA; QL (60 EA per 30 days)


Drug Name Drug Tier Requirements/Limitszonisamide Tier-1

SPASTICITYbaclofen Tier-1

cyclobenzaprine hcl Tier-2 PA

dantrolene sodium Tier-1

tizanidine hcl oral capsule Tier-2

tizanidine hcl oral tablet Tier-1

PAIN AND INFLAMMATORY DISEASES

ARTHRITISACTEMRA Tier-3 PA; SP-CVS specialty; NEDS

AZASAN Tier-3 B vs D

azathioprine Tier-1 B vs D

azathioprine sodium Tier-1 B vs D

CIMZIA Tier-3PA; SP-CVS specialty; QL (2 EA per 28 days); NEDS

CIMZIA PREFILLED Tier-3PA; SP-CVS specialty; QL (2 EA per 30 days); NEDS

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML

Tier-3PA; SP-CVS specialty; QL (8.16 ML per 28 days); NEDS

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED


ENBREL SURECLICK Tier-3PA; SP-CVS specialty; QL (7.84 ML per 28 days); NEDS

HUMIRA Tier-3PA; SP-CVS specialty; QL (6 EA per 28 days); NEDS

HUMIRA PEDIATRIC CROHNS START Tier-3 PA; SP-CVS specialty; NEDS

HUMIRA PEN Tier-3PA; SP-CVS specialty; QL (6 EA per 28 days); NEDS

HUMIRA PEN-CROHNS STARTER Tier-3 PA; SP-CVS specialty; NEDS

HUMIRA PEN-PSORIASIS STARTER Tier-3 PA; SP-CVS specialty; NEDS

INFLECTRA Tier-3 PA; NEDS

KINERET Tier-3PA; QL (20.1 ML per 28 days); NEDS

leflunomide Tier-1

methotrexate Tier-1 B vs D

ORENCIA CLICKJECT Tier-3PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS


Drug Name Drug Tier Requirements/LimitsORENCIA INTRAVENOUS Tier-3 PA; SP-CVS specialty; NEDS

ORENCIA SUBCUTANEOUS Tier-3PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

RASUVO Tier-3

REMICADE Tier-3 PA; NEDS

RIDAURA Tier-3 NEDS

SIMPONI ARIA Tier-3 PA; SP-CVS specialty; NEDS

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML

Tier-3PA; SP-CVS specialty; QL (1 ML per 28 days); NEDS

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/0.5ML


SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

Tier-3PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML


TREXALL Tier-3 B vs D

XELJANZ Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

XELJANZ XR Tier-3PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

GOUTallopurinol Tier-1

colchicine Tier-1

colchicine-probenecid Tier-1

probenecid Tier-1

ULORIC Tier-2 STPA

PAIN, NSAID ANALGESICScelecoxib Tier-2 PA

diclofenac potassium Tier-2

diclofenac sodium Tier-1

diclofenac sodium er Tier-1

diclofenac-misoprostol Tier-1

diflunisal Tier-2

etodolac Tier-1

etodolac er Tier-1

fenoprofen calcium Tier-1

flurbiprofen Tier-1

ibuprofen Tier-1

INDOCIN ORAL SUSPENSION Tier-3


Drug Name Drug Tier Requirements/Limitsindomethacin Tier-1 PA

indomethacin er Tier-2 PA

ketoprofen Tier-1

ketoprofen er Tier-1

meclofenamate sodium Tier-1

mefenamic acid Tier-1

meloxicam Tier-1

nabumetone Tier-1

naproxen Tier-1

naproxen dr Tier-1

naproxen sodium Tier-1

naproxen sodium er Tier-1

oxaprozin Tier-1

piroxicam Tier-2

sulindac Tier-1

tolmetin sodium Tier-1

PAIN, OPIOID AND OTHER ANALGESICS

ABSTRAL Tier-3PA; QL (120 EA per 30 days); NEDS

acetaminophen-codeine Tier-1 QL (3600 ML per 30 days)

acetaminophen-codeine #2 Tier-1 QL (240 EA per 30 days)



ACTIQ Tier-3PA; QL (120 EA per 30 days); NEDS

BELBUCA Tier-3 QL (60 EA per 30 days)

buprenorphine Tier-2 QL (4 EA per 28 days)

butorphanol tartrate Tier-1 QL (7.5 ML per 30 days)

BUTRANS Tier-3 QL (4 EA per 28 days)

codeine sulfate Tier-2 QL (180 EA per 30 days)

EMBEDA Tier-3 QL (60 EA per 30 days)

endocet Tier-2 QL (240 EA per 30 days)

fentanyl Tier-1 QL (10 EA per 30 days)

fentanyl citrate Tier-2PA; QL (120 EA per 30 days); NEDS

FENTORA Tier-3PA; QL (120 EA per 30 days); NEDS


Drug Name Drug Tier Requirements/Limitshydrocodone-acetaminophen oral solution Tier-1 QL (3600 ML per 30 days)

hydrocodone-acetaminophen oral tablet Tier-1 QL (240 EA per 30 days)

hydrocodone-ibuprofen Tier-1 QL (240 EA per 30 days)

hydromorphone hcl er Tier-2 QL (30 EA per 30 days)

hydromorphone hcl oral liquid Tier-1 QL (1350 ML per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg Tier-1 QL (240 EA per 30 days)

hydromorphone hcl oral tablet 8 mg Tier-1 QL (120 EA per 30 days)

HYSINGLA ER Tier-3 QL (60 EA per 30 days)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT


LAZANDA NASAL SOLUTION 400 MCG/ACT


levorphanol tartrate Tier-1 QL (240 EA per 30 days)

methadone hcl oral solution 10 mg/5ml Tier-1 QL (600 ML per 30 days)

methadone hcl oral solution 5 mg/5ml Tier-1 QL (1200 ML per 30 days)

methadone hcl oral tablet Tier-1 QL (120 EA per 30 days)

morphine sulfate (concentrate) Tier-1 QL (180 ML per 30 days)

morphine sulfate er Tier-2 QL (60 EA per 30 days)

morphine sulfate er beads Tier-2 QL (60 EA per 30 days)

morphine sulfate oral solution Tier-1 QL (900 ML per 30 days)

morphine sulfate oral tablet Tier-1 QL (180 EA per 30 days)

oxycodone hcl er Tier-2 QL (60 EA per 30 days)

oxycodone hcl oral capsule Tier-1 QL (240 EA per 30 days)

oxycodone hcl oral concentrate Tier-1 QL (120 ML per 30 days)

oxycodone hcl oral solution Tier-1 QL (2400 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 15 mg Tier-1 QL (180 EA per 30 days)

oxycodone hcl oral tablet 20 mg, 30 mg Tier-1 QL (120 EA per 30 days)

oxycodone hcl oral tablet 5 mg Tier-1 QL (240 EA per 30 days)

oxycodone-acetaminophen oral solution Tier-2 QL (1800 ML per 30 days)

oxycodone-acetaminophen oral tablet Tier-1 QL (240 EA per 30 days)

oxycodone-aspirin Tier-1 QL (240 EA per 30 days)

oxycodone-ibuprofen Tier-1 QL (120 EA per 30 days)

OXYCONTIN Tier-2 QL (60 EA per 30 days)

oxymorphone hcl Tier-1 QL (180 EA per 30 days)

oxymorphone hcl er Tier-1 QL (60 EA per 30 days)

SUBSYS Tier-3PA; QL (120 EA per 30 days); NEDS

tramadol hcl Tier-1 QL (240 EA per 30 days)


Drug Name Drug Tier Requirements/Limitstramadol hcl er Tier-1 QL (30 EA per 30 days)

tramadol hcl er (biphasic) Tier-1 QL (30 EA per 30 days)

tramadol-acetaminophen Tier-1 QL (240 EA per 30 days)

PSYCHIATRIC

ALCOHOL DETERRENTSacamprosate calcium Tier-1

disulfiram Tier-1

naltrexone hcl Tier-1

VIVITROL Tier-3 NEDS

ANXIETYalprazolam Tier-1

alprazolam er Tier-1

alprazolam intensol Tier-1

buspirone hcl Tier-1

chlordiazepoxide-amitriptyline Tier-1

clorazepate dipotassium Tier-1

lorazepam Tier-1

lorazepam intensol Tier-1

oxazepam Tier-2

ATTENTION DEFICIT DISORDERADDERALL XR Tier-3 STPA

amphetamine-dextroamphet er Tier-1

amphetamine-dextroamphetamine Tier-1

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg


atomoxetine hcl oral capsule 100 mg, 80 mg Tier-2 QL (30 EA per 30 days)

clonidine hcl er Tier-1

DESOXYN Tier-3 PA

DEXEDRINE Tier-3

dexmethylphenidate hcl Tier-1

dexmethylphenidate hcl er Tier-1

dextroamphetamine sulfate Tier-1

dextroamphetamine sulfate er Tier-1

FOCALIN XR Tier-2 STPA

guanfacine hcl er Tier-1 PA; QL (90 EA per 90 days)

KAPVAY Tier-3

METADATE CD Tier-3


Drug Name Drug Tier Requirements/LimitsMETADATE ER Tier-3

methamphetamine hcl Tier-1 PA

METHYLIN Tier-2

methylphenidate hcl Tier-1

methylphenidate hcl er Tier-1

methylphenidate hcl er (cd) Tier-1

methylphenidate hcl er (la) Tier-1

QUILLIVANT XR Tier-3 STPA

VYVANSE Tier-3 STPA

BIPOLAR DISORDEREQUETRO Tier-3

lithium Tier-1

lithium carbonate Tier-1

lithium carbonate er Tier-1

olanzapine-fluoxetine hcl Tier-1 STPA

RISPERDAL CONSTA Tier-2

risperidone Tier-1

DEPRESSIONamitriptyline hcl Tier-1 PA

amoxapine Tier-1

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG

Tier-3 STPA

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 522 MG

Tier-3 STPA; NEDS

bupropion hcl Tier-1

bupropion hcl er (sr) Tier-1

bupropion hcl er (xl) Tier-1

citalopram hydrobromide Tier-1

clomipramine hcl Tier-1 PA

desipramine hcl Tier-1

desvenlafaxine er Tier-1

desvenlafaxine succinate er Tier-1

doxepin hcl oral capsule Tier-2 PA

doxepin hcl oral concentrate Tier-1 PA

duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg


duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg



Drug Name Drug Tier Requirements/LimitsEMSAM Tier-3 STPA; NEDS

escitalopram oxalate Tier-1

FETZIMA Tier-3 STPA

FETZIMA TITRATION Tier-3 STPA

fluoxetine hcl oral capsule Tier-1

fluoxetine hcl oral capsule delayed release Tier-1

fluoxetine hcl oral solution Tier-1

fluoxetine hcl oral tablet 10 mg, 20 mg Tier-2

fluoxetine hcl oral tablet 60 mg Tier-1

fluvoxamine maleate Tier-1

fluvoxamine maleate er Tier-1

imipramine hcl Tier-1 PA

imipramine pamoate Tier-1 PA

maprotiline hcl Tier-1

MARPLAN Tier-3

mirtazapine Tier-1

nefazodone hcl Tier-1

nortriptyline hcl Tier-1

paroxetine hcl Tier-1

paroxetine hcl er Tier-1

PAXIL ORAL SUSPENSION Tier-3

PEXEVA Tier-3 STPA

phenelzine sulfate Tier-1

protriptyline hcl Tier-1

sertraline hcl Tier-1

SURMONTIL Tier-2 PA

tranylcypromine sulfate Tier-1

trazodone hcl Tier-1

trimipramine maleate Tier-1 PA

TRINTELLIX Tier-3 STPA

venlafaxine hcl Tier-1

venlafaxine hcl er Tier-1

VIIBRYD Tier-3 STPA

VIIBRYD STARTER PACK Tier-3 STPA

INSOMNIAestazolam Tier-1

eszopiclone Tier-2 PA; QL (90 EA per 365 days)


Drug Name Drug Tier Requirements/Limitsflurazepam hcl Tier-1

HETLIOZ Tier-3 PA; NEDS

ROZEREM Tier-3 QL (30 EA per 30 days)

SILENOR Tier-3 QL (30 EA per 30 days)

temazepam Tier-1

triazolam Tier-1

zaleplon Tier-1 PA; QL (90 EA per 365 days)

zolpidem tartrate er Tier-1 PA; QL (90 EA per 365 days)

zolpidem tartrate oral Tier-1 PA; QL (90 EA per 365 days)

zolpidem tartrate sublingual Tier-2 PA; QL (90 EA per 365 days)

NARCOLEPSYarmodafinil Tier-2 PA

modafinil Tier-2 PA

XYREM Tier-3 NEDS

PSYCHOSESABILIFY MAINTENA Tier-3 NEDS

aripiprazole Tier-2 STPA

ARISTADA Tier-3 NEDS

chlorpromazine hcl Tier-1

clozapine Tier-1

FANAPT Tier-3 STPA

FANAPT TITRATION PACK Tier-3 STPA

FAZACLO Tier-2

fluphenazine decanoate Tier-1

fluphenazine hcl Tier-1

GEODON INTRAMUSCULAR INJECTION Tier-3

haloperidol Tier-1

haloperidol decanoate Tier-1

haloperidol lactate Tier-1

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78 MG/0.5ML

Tier-3 NEDS

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML

Tier-2

INVEGA TRINZA Tier-2

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

Tier-3STPA; QL (30 EA per 30 days); NEDS



LATUDA ORAL TABLET 80 MG Tier-3STPA; QL (60 EA per 30 days); NEDS

loxapine succinate Tier-1

NUPLAZID Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

olanzapine intramuscular Tier-1

olanzapine oral Tier-1 STPA

ORAP Tier-2

paliperidone er Tier-2

perphenazine Tier-1

perphenazine-amitriptyline Tier-1

pimozide Tier-1

quetiapine fumarate er Tier-2 STPA

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

Tier-1 STPA

quetiapine fumarate oral tablet 25 mg, 50 mg Tier-1 STPA; QL (60 EA per 30 days)

REXULTI ORAL TABLET 0.25 MG Tier-3

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

Tier-3 NEDS

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG

Tier-3 STPA; NEDS

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG, 5 MG

Tier-3 STPA

thioridazine hcl Tier-1 PA

thiothixene Tier-1

trifluoperazine hcl Tier-1

VERSACLOZ Tier-3 NEDS

VRAYLAR ORAL CAPSULE Tier-3 NEDS

VRAYLAR ORAL CAPSULE THERAPY PACK

Tier-3

ziprasidone hcl Tier-1 STPA

ZYPREXA Tier-2

ZYPREXA RELPREVV Tier-2

RESPIRATORY DRUGS

ASTHMAalbuterol sulfate er Tier-2

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

Tier-1 B vs D; QL (1080 ML per 90 days)


Drug Name Drug Tier Requirements/Limitsalbuterol sulfate inhalation nebulization solution(5 mg/ml) 0.5%

Tier-1 B vs D; QL (180 EA per 90 days)

albuterol sulfate oral syrup Tier-1

albuterol sulfate oral tablet Tier-2

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT

Tier-3 QL (36.6 GM per 90 days)

ALVESCO INHALATION AEROSOL SOLUTION 80 MCG/ACT

Tier-3 QL (18.3 GM per 90 days)

ANORO ELLIPTA Tier-2 QL (180 EA per 90 days)

ARCAPTA NEOHALER Tier-3 QL (90 EA per 90 days)

ARNUITY ELLIPTA Tier-2 QL (90 EA per 90 days)

ASMANEX 120 METERED DOSES Tier-2 QL (360 EA per 90 days)



ASMANEX HFA Tier-2 QL (39 GM per 90 days)

ATROVENT HFA Tier-2 QL (77.4 GM per 90 days)

BREO ELLIPTA Tier-2 QL (180 EA per 90 days)

BROVANA Tier-3 B vs D; QL (360 ML per 90 days)

budesonide Tier-1 B vs D; QL (720 ML per 90 days)

COMBIVENT RESPIMAT Tier-2 QL (24 GM per 90 days)

cromolyn sodium Tier-1 B vs D; QL (720 ML per 90 days)

FLOVENT DISKUS Tier-2 QL (360 EA per 90 days)

FLOVENT HFA Tier-2 QL (72 GM per 90 days)

INCRUSE ELLIPTA Tier-2 QL (90 EA per 90 days)

ipratropium bromide Tier-1 B vs D; QL (900 ML per 90 days)

ipratropium-albuterol Tier-1 B vs D; QL (1620 ML per 90 days)

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml




levalbuterol hcl inhalation nebulization solution1.25 mg/0.5ml

Tier-1 B vs D; QL (270 EA per 90 days)



levalbuterol tartrate Tier-2 QL (90 GM per 90 days)

metaproterenol sulfate Tier-1

montelukast sodium Tier-1

PERFOROMIST Tier-2 B vs D; QL (360 ML per 90 days)

PROAIR HFA Tier-2 QL (51 GM per 90 days)


Drug Name Drug Tier Requirements/LimitsPROAIR RESPICLICK Tier-2 QL (6 EA per 90 days)

PROVENTIL HFA Tier-3 QL (40.2 GM per 90 days)

PULMICORT FLEXHALER Tier-3 QL (6 EA per 90 days)

QVAR Tier-2 QL (52.2 GM per 90 days)

SEREVENT DISKUS Tier-2 QL (180 EA per 90 days)

SPIRIVA HANDIHALER Tier-2 QL (90 EA per 90 days)

SPIRIVA RESPIMAT Tier-2 QL (12 GM per 90 days)

STRIVERDI RESPIMAT Tier-3 QL (180 GM per 90 days)

SYMBICORT Tier-2 QL (30.6 GM per 90 days)

terbutaline sulfate Tier-1

theophylline Tier-1

theophylline er Tier-1

VENTOLIN HFA Tier-3 QL (108 GM per 90 days)

zafirlukast Tier-1

zileuton er Tier-2

IDIOPATHIC PULMONARY FIBROSIS

ESBRIET ORAL CAPSULE Tier-3PA; SP-CVS specialty; QL (270 EA per 30 days); NEDS

ESBRIET ORAL TABLET Tier-3PA; SP-CVS specialty; QL (90 EA per 30 days); NEDS

OFEV Tier-3PA; QL (60 EA per 30 days); NEDS

PULMONARY HYPERTENSIONADCIRCA Tier-3 PA; SP-CVS specialty; NEDS

ADEMPAS Tier-3 PA; SP-CVS specialty; NEDS

LETAIRIS Tier-3 PA; SP-CVS specialty; NEDS

OPSUMIT Tier-3 PA; SP-CVS specialty; NEDS

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG


ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier-3 PA; SP-CVS specialty; NEDS

REMODULIN Tier-3 PA; NEDS

REVATIO ORAL SOLUTION Tier-3 PA; SP-CVS specialty; NEDS

sildenafil citrate intravenous Tier-2 PA; NEDS

sildenafil citrate oral Tier-2 PA; SP-CVS specialty

TRACLEER Tier-3 PA; SP-CVS specialty; NEDS

UPTRAVI ORAL TABLET Tier-3PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS


Drug Name Drug Tier Requirements/LimitsUPTRAVI ORAL TABLET THERAPY PACK Tier-3 PA; SP-CVS specialty; NEDS

VENTAVIS Tier-3 PA; NEDS

RESPIRATORY DRUGS, MISCELLANEOUSacetylcysteine Tier-1 B vs D

ARALAST NP Tier-3 NEDS

DALIRESP Tier-3

GLASSIA Tier-3 NEDS

GRASTEK Tier-3 PA

NUCALA Tier-3 PA; NEDS

ORALAIR Tier-3 PA

PROLASTIN-C Tier-3 NEDS

RAGWITEK Tier-3 PA

XOLAIR Tier-3 PA; NEDS

ZEMAIRA Tier-2

SKIN

ACNE ROSACEAFINACEA Tier-2


NORITATE Tier-3 NEDS

SOOLANTRA Tier-3

ACNE VULGARISABSORICA Tier-3

adapalene Tier-1 PA

ATRALIN Tier-3 PA

avita Tier-1 PA

AZELEX Tier-3

benzoyl peroxide-erythromycin Tier-1

claravis Tier-1

CLINDAGEL Tier-3

clindamax Tier-1

clindamycin phos-benzoyl perox Tier-1


ery Tier-1

erythromycin Tier-1

EVOCLIN Tier-3

FABIOR Tier-3 PA


Drug Name Drug Tier Requirements/LimitsRETIN-A Tier-3 PA

RETIN-A MICRO Tier-3 PA

RETIN-A MICRO PUMP Tier-3 PA

tretinoin Tier-1 PA

tretinoin microsphere Tier-1 PA

BACTERIAL INFECTIONS, TOPICALCORTISPORIN Tier-3


mupirocin Tier-1

mupirocin calcium Tier-1

silver sulfadiazine Tier-1

ssd Tier-1

CORTICOSTEROIDS, TOPICALALA SCALP Tier-3

ala-cort Tier-1

alclometasone dipropionate Tier-1

amcinonide Tier-1

apexicon e Tier-1

betamethasone dipropionate Tier-1

betamethasone dipropionate aug Tier-1

betamethasone valerate Tier-1

CAPEX Tier-3

clobetasol propionate Tier-2

clobetasol propionate e Tier-2

clodan Tier-2

CLODERM PUMP Tier-3

CORDRAN Tier-3

CORMAX SCALP APPLICATION Tier-2

desonide Tier-2

desoximetasone Tier-1

diflorasone diacetate Tier-2

fluocinolone acetonide Tier-1

fluocinolone acetonide body Tier-1

fluocinonide external cream Tier-2 QL (120 GM per 30 days)

fluocinonide external gel Tier-2

fluocinonide external ointment Tier-2


Drug Name Drug Tier Requirements/Limitsfluocinonide external solution Tier-2

fluocinonide-e Tier-2

flurandrenolide external cream Tier-2

flurandrenolide external lotion Tier-2

flurandrenolide external ointment Tier-2 QL (120 GM per 30 days)

fluticasone propionate Tier-1

halobetasol propionate Tier-1

HALOG Tier-3


hydrocortisone butyr lipo base Tier-1

hydrocortisone butyrate Tier-1

hydrocortisone valerate Tier-2

KENALOG Tier-3

mometasone furoate Tier-1

nolix Tier-2

PANDEL Tier-3

prednicarbate Tier-1


TRIANEX Tier-3

triderm Tier-1

FUNGAL INFECTIONS, TOPICALciclopirox external gel Tier-1

ciclopirox external shampoo Tier-1

ciclopirox external solution Tier-2

ciclopirox olamine Tier-1

clotrimazole external cream Tier-2

clotrimazole external solution Tier-1

clotrimazole-betamethasone Tier-2

econazole nitrate Tier-2

ERTACZO Tier-3

EXELDERM Tier-3

ketoconazole Tier-2

MENTAX Tier-3

naftifine hcl external cream 1 % Tier-1

naftifine hcl external cream 2 % Tier-2

NAFTIN GEL Tier-2

nyamyc Tier-1


Drug Name Drug Tier Requirements/Limitsnyata Tier-1

nystatin Tier-1

nystatin-triamcinolone Tier-2

nystop Tier-1

oxiconazole nitrate Tier-2

OXISTAT Tier-2

PSORIASIS AND SEBORRHEAacitretin Tier-2 NEDS

calcipotriene Tier-2 QL (120 GM per 30 days)

calcipotriene-betameth diprop Tier-2

calcitriol Tier-1

COSENTYX 300 DOSE Tier-3PA; SP-CVS specialty; QL (2 ML per 28 days); NEDS

COSENTYX SENSOREADY 300 DOSE Tier-3PA; SP-CVS specialty; QL (2 ML per 28 days); NEDS

methoxsalen rapid Tier-2 NEDS

OTEZLA Tier-3 PA; SP-CVS specialty; NEDS

STELARA Tier-3 PA; SP-CVS specialty; NEDS

TALTZ Tier-3PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

tazarotene Tier-2 PA

TAZORAC Tier-3 PA

SCABIES AND PEDICULOSISEURAX Tier-2

lindane Tier-1

malathion Tier-1

permethrin Tier-2

SKLICE Tier-3

TOPICAL, MISCELLANEOUSammonium lactate Tier-2

ANUSOL-HC Tier-3

diclofenac sodium transdermal gel Tier-2 QL (200 GM per 30 days)

diclofenac sodium transdermal solution Tier-1

doxepin hcl Tier-1 QL (90 GM per 30 days)

ELIDEL Tier-3 STPA

EUCRISA Tier-3 PA

fluorouracil Tier-1

lidocaine external ointment Tier-2 QL (100 GM per 30 days)


Drug Name Drug Tier Requirements/Limitslidocaine external patch Tier-2 PA; QL (90 EA per 30 days)

lidocaine hcl external gel Tier-1 QL (100 ML per 30 days)

lidocaine hcl external solution Tier-1

lidocaine viscous Tier-1

lidocaine-prilocaine Tier-2

neomycin-polymyxin b Tier-1

PANRETIN Tier-3 NEDS

procto-med hc Tier-1

procto-pak Tier-1

proctosol hc Tier-1

proctozone-hc Tier-1

prudoxin Tier-1

REGRANEX Tier-2

SANTYL Tier-2

selenium sulfide Tier-1

sodium chloride Tier-1

sterile water for irrigation Tier-1

sulfacetamide sodium (acne) Tier-1

SULFAMYLON Tier-3

tacrolimus Tier-2

TARGRETIN Tier-3 SP-CVS specialty; NEDS

VALCHLOR Tier-3 NEDS

VIRAL INFECTIONS, TOPICALCONDYLOX Tier-3

DENAVIR Tier-3 NEDS

imiquimod Tier-1

podofilox Tier-1

ZOVIRAX Tier-2

WOMEN'S HEALTH

CONTRACEPTIVESamethia Tier-1

apri Tier-1

aranelle Tier-1

ashlyna Tier-1

aubra Tier-1

aviane Tier-1

balziva Tier-1


Drug Name Drug Tier Requirements/LimitsBEYAZ Tier-3

briellyn Tier-1

camila Tier-1

deblitane Tier-1

delyla Tier-1

desogestrel-ethinyl estradiol Tier-1

drospirenone-ethinyl estradiol Tier-1

emoquette Tier-1

errin Tier-1

estradiol-norethindrone acet Tier-1

falmina Tier-1

GENERESS FE Tier-3

gildagia Tier-1

introvale Tier-1

jinteli Tier-1

junel 1.5/30 Tier-1

junel 1/20 Tier-1

junel fe 1.5/30 Tier-1

junel fe 1/20 Tier-1

junel fe 24 Tier-1

kariva Tier-1

kelnor 1/35 Tier-1

larin 1.5/30 Tier-1

larin 1/20 Tier-1

larin fe 1.5/30 Tier-1

larin fe 1/20 Tier-1

lessina Tier-1

levonest Tier-1

levonorgest-eth estrad 91-day Tier-1

levonorgestrel-ethinyl estradiol Tier-1

levora 0.15/30 (28) Tier-1

LO LOESTRIN FE Tier-3

marlissa Tier-1

microgestin 1.5/30 Tier-1

microgestin 1/20 Tier-1

microgestin fe 1.5/30 Tier-1

microgestin fe 1/20 Tier-1


Drug Name Drug Tier Requirements/Limitsnecon 0.5/35 (28) Tier-1

necon 1/50 (28) Tier-1

NECON 10/11 (28) Tier-2

necon 7/7/7 Tier-1

nikki Tier-1

norethin ace-eth estrad-fe Tier-1

norethindrone-eth estradiol Tier-1

norethin-eth estradiol-fe Tier-1

norlyroc Tier-1

nortrel 0.5/35 (28) Tier-1

nortrel 1/35 (21) Tier-1

nortrel 1/35 (28) Tier-1

nortrel 7/7/7 Tier-1

NUVARING Tier-2

orsythia Tier-1

ORTHO TRI-CYCLEN (28) Tier-3

portia-28 Tier-1

quasense Tier-1

SAFYRAL Tier-3

sharobel Tier-1

tarina fe 1/20 Tier-1

trinessa (28) Tier-1

tri-previfem Tier-1

tri-sprintec Tier-1

trivora (28) Tier-1

velivet Tier-1

vyfemla Tier-1

ZENCHENT Tier-3

ZENCHENT FE Tier-3

zovia 1/35e (28) Tier-1

zovia 1/50e (28) Tier-1

MENOPAUSAL SYMPTOMS/OSTEOPOROSISalendronate sodium Tier-1

ALORA Tier-3 PA

ANGELIQ Tier-3

calcitonin (salmon) Tier-1


Drug Name Drug Tier Requirements/LimitsCOMBIPATCH Tier-3 PA

CRINONE Tier-2 PA

DELESTROGEN Tier-3

DEPO-ESTRADIOL Tier-2

DEPO-PROVERA Tier-2

DEPO-SUBQ PROVERA 104 Tier-2

DIVIGEL Tier-3

DUAVEE Tier-3 PA

ELESTRIN Tier-3

ESTRACE Tier-2

estradiol Tier-1 PA

estradiol valerate Tier-1

ESTRING Tier-2

estropipate Tier-1 PA

EVAMIST Tier-3

FEMHRT LOW DOSE Tier-3 PA

FEMRING Tier-2

FORTEO Tier-3 PA; SP-CVS specialty; NEDS

fyavolv Tier-1 PA

ibandronate sodium intravenous Tier-1

ibandronate sodium oral Tier-2

medroxyprogesterone acetate Tier-1

MENEST Tier-3 PA

MENOSTAR Tier-3 PA

MIACALCIN Tier-2

norethindrone acetate Tier-1

pamidronate disodium Tier-1

PREMARIN INJECTION Tier-3

PREMARIN ORAL Tier-3 PA

PREMARIN VAGINAL Tier-3

PREMPHASE Tier-3 PA

PREMPRO Tier-3 PA

progesterone micronized Tier-1

PROLIA Tier-2 PA

raloxifene hcl Tier-1

RECLAST Tier-2

risedronate sodium Tier-2


Drug Name Drug Tier Requirements/LimitsXGEVA Tier-3 PA; NEDS

yuvafem Tier-2

zoledronic acid Tier-1

PRENATAL VITAMINSprenatal Tier-1

PRETERM BIRTHhydroxyprogesterone caproate Tier-2 PA; SP-CVS specialty

MAKENA Tier-3 PA; SP-CVS specialty; NEDS

VAGINAL INFECTIONSAVC VAGINAL Tier-3

CLEOCIN Tier-3


GYNAZOLE-1 Tier-3


miconazole 3 Tier-1

NUVESSA Tier-3

terconazole Tier-1

vandazole Tier-2


IndexIndex

abacavir sulfate ............................ 4abacavir sulfate-lamivudine ......... 4abacavir-lamivudine-zidovudine .. 4ABELCET.................................. 30ABILIFY MAINTENA..............55ABRAXANE..............................10ABSORICA................................59ABSTRAL..................................50acamprosate calcium ..................52acarbose ..................................... 22acebutolol hcl ............................. 18acetaminophen-codeine ..............50acetaminophen-codeine #2 .........50acetaminophen-codeine #3 .........50acetaminophen-codeine #4 .........50acetasol hc ..................................23acetazolamide .............................27acetazolamide er .........................27acetazolamide sodium ................ 30acetic acid ...................................23acetylcysteine ..............................59acitretin ...................................... 62ACTEMRA................................ 48ACTHIB..................................... 36ACTIMMUNE........................... 36ACTIQ........................................50ACTOPLUS MET XR............... 22acyclovir ....................................... 4acyclovir sodium .........................30ADACEL....................................36ADAGEN................................... 36adapalene ................................... 59ADCIRCA.................................. 58ADDERALL XR........................52adefovir dipivoxil ..........................4ADEMPAS.................................58ADIPEX-P..................................24afeditab cr ...................................19AFINITOR................................. 12AFINITOR DISPERZ................ 12ALA SCALP.............................. 60ala-cort ....................................... 60ALBENZA................................... 3albuterol sulfate ....................56, 57albuterol sulfate er ..................... 56alclometasone dipropionate ....... 60ALDURAZYME........................ 41ALECENSA............................... 12alendronate sodium .................... 65alfuzosin hcl er ........................... 43ALIMTA.....................................10

Index

ALINIA........................................ 3ALKERAN...........................10, 12allopurinol .................................. 49almotriptan malate ..................... 45ALOCRIL...................................25ALOMIDE..................................25ALORA...................................... 65alosetron hcl ............................... 28ALOXI........................................27ALPHAGAN P 0.1%..................27alprazolam ..................................52alprazolam er ............................. 52alprazolam intensol .................... 52ALREX.......................................26ALUNBRIG............................... 12ALVESCO..................................57amantadine hcl ............................. 4AMBISOME.............................. 30amcinonide ................................. 60amethia ....................................... 63amikacin sulfate ..........................30amiloride hcl ...............................19amiloride-hydrochlorothiazide ...19aminophylline ............................. 30AMINOSYN II...........................33AMINOSYN II/ELECTROLYTES..................33AMINOSYN/ELECTROLYTES..................................................33AMINOSYN-HBC.....................33AMINOSYN-PF.........................33AMINOSYN-RF........................ 34amiodarone hcl ...........................17AMITIZA................................... 29amitriptyline hcl ......................... 53amlodipine besy-benazepril hcl ..17amlodipine besylate ....................19amlodipine besylate-valsartan ....17amlodipine-atorvastatin ............. 17amlodipine-olmesartan ...............17amlodipine-valsartan-hctz ..........17ammonium lactate ...................... 62amoxapine ...................................53amoxicill-clarithro-lansopraz .... 29amoxicillin .................................... 6amoxicillin-pot clavulanate ..........6amoxicillin-pot clavulanate er ......6amphetamine-dextroamphet er ...52amphetamine-dextroamphetamine .................... 52amphotericin b ............................30

Index

ampicillin ......................................6ampicillin sodium ....................... 30ampicillin-sulbactam sodium ..... 30AMPYRA...................................41ANADROL-50........................... 35anagrelide hcl ...............................9anastrozole ................................. 12ANGELIQ.................................. 65ANORO ELLIPTA.....................57ANUSOL-HC.............................62ANZEMET.................................28apexicon e ...................................60APLENZIN.................................53APOKYN................................... 45apraclonidine hcl ........................27aprepitant ................................... 28apri ............................................. 63APRISO......................................30APTIOM.....................................46APTIVUS..................................... 4ARALAST NP........................... 59aranelle .......................................63ARCALYST...............................39ARCAPTA NEOHALER...........57ARGATROBAN........................ 30aripiprazole ................................ 55ARISTADA................................55armodafinil ................................. 55ARNUITY ELLIPTA.................57ARRANON................................ 10ashlyna ........................................63ASMANEX 120 METERED DOSES....................................... 57ASMANEX 30 METERED DOSES....................................... 57ASMANEX 60 METERED DOSES....................................... 57ASMANEX HFA....................... 57aspirin-dipyridamole er ................9assure insulin safety syringe .......21ASTAGRAF XL.........................38atenolol .......................................18atenolol-chlorthalidone .............. 17ATGAM..................................... 38atomoxetine hcl ...........................52atorvastatin calcium ................... 20atovaquone ................................... 4atovaquone-proguanil hcl ............ 4ATRALIN...................................59ATRIPLA..................................... 4atropine sulfate .....................27, 30

69

Index

ATROVENT HFA......................57AUBAGIO..................................41aubra .......................................... 63AURYXIA..................................43AUSTEDO................................. 41AVASTIN...................................10AVC VAGINAL........................ 67AVEED.......................................35AVELOX....................................30aviane ......................................... 63avita ............................................ 59AVONEX................................... 41AVONEX PEN...........................41AVONEX PREFILLED............. 41AVYCAZ................................... 30azacitidine .................................. 10AZASAN....................................48AZASITE................................... 25azathioprine ................................48azathioprine sodium ................... 48azelastine hcl ........................ 23, 25AZELEX.....................................59AZILECT................................... 45azithromycin ........................... 7, 30AZOPT....................................... 27aztreonam ................................... 30bacitracin ....................................25bacitracin-polymyxin b ...............25bacitra-neomycin-polymyxin-hc . 25baclofen ...................................... 48bactocill in dextrose ................... 30BACTROBAN NASAL............. 23balsalazide disodium .................. 30balziva ........................................ 63BANZEL.................................... 46BAVENCIO............................... 10bcg vaccine ................................. 36BELBUCA................................. 50BELEODAQ...............................10BELVIQ..................................... 24benazepril hcl ............................. 16benazepril-hydrochlorothiazide . 17BENLYSTA............................... 38benzonatate .................................24benzoyl peroxide-erythromycin .. 59benztropine mesylate ............ 30, 45BERINERT................................ 40BESIVANCE..............................25betamethasone dipropionate ...... 60betamethasone dipropionate aug60betamethasone valerate ..............60BETASERON............................ 41

Index

betaxolol hcl ......................... 18, 27bethanechol chloride .................. 44BETHKIS................................... 39BETIMOL.................................. 27BETOPTIC-S............................. 27bexarotene .................................. 12BEXSERO..................................36BEYAZ.......................................64bicalutamide ............................... 12BICILLIN C-R............................. 6BICILLIN C-R 900/300............... 7BICILLIN L-A............................. 7BICNU........................................10BIDIL......................................... 21BILTRICIDE................................3bimatoprost .................................27bisoprolol fumarate .................... 18bisoprolol-hydrochlorothiazide ..18BIVIGAM...................................36bleomycin sulfate ........................10BLEPHAMIDE.......................... 25BLEPHAMIDE S.O.P................25BOOSTRIX................................ 36BOSULIF............................. 12, 13BOTOX...................................... 38BREO ELLIPTA........................ 57briellyn ........................................64BRILINTA................................... 9brimonidine tartrate ................... 27BRIVIACT................................. 46bromfenac sodium ...................... 26bromocriptine mesylate .............. 45BROVANA................................ 57budesonide ......................23, 30, 57bumetanide ........................... 19, 30BUPHENYL...............................44buprenorphine ............................ 50buprenorphine hcl ...................... 42buprenorphine hcl-naloxone hcl .42bupropion hcl ............................. 53bupropion hcl er (smoking det) .. 43bupropion hcl er (sr) .................. 53bupropion hcl er (xl) ...................53buspirone hcl .............................. 52busulfan ...................................... 10butorphanol tartrate ............. 30, 50BUTRANS................................. 50BYDUREON..............................22BYETTA 10 MCG PEN.............22BYETTA 5 MCG PEN...............22cabergoline .................................45CABOMETYX...........................13

Index

calcipotriene ...............................62calcipotriene-betameth diprop ... 62calcitonin (salmon) .....................65calcitriol ......................... 30, 41, 62calcium acetate (phos binder) .... 43camila ......................................... 64CAMPTOSAR............................10CANASA....................................30CANCIDAS................................30candesartan cilexetil ...................16candesartan cilexetil-hctz ...........18CAPASTAT SULFATE.............30capecitabine ................................13CAPEX.......................................60CAPRELSA................................13captopril ..................................... 16captopril-hydrochlorothiazide ....18CARAFATE SUSPENSION......29CARBAGLU.............................. 28carbamazepine ............................46carbamazepine er ....................... 46carbidopa ....................................45carbidopa-levodopa ....................45carbidopa-levodopa er ............... 45carbidopa-levodopa-entacapone 46carboplatin ................................. 10CARDENE IV............................31CARDURA XL.......................... 16CARIMUNE NF.........................36carteolol hcl ................................27cartia xt .......................................19carvedilol ....................................18CAVERJECT............................. 24CAVERJECT IMPULSE........... 24CAYSTON................................. 39cefaclor .........................................7cefaclor er .....................................7cefadroxil ......................................7cefazolin sodium ......................... 31cefdinir ..........................................7cefepime hcl ................................31cefixime .........................................7cefotaxime sodium ...................... 31cefotetan disodium ......................31cefoxitin sodium ..........................31cefpodoxime proxetil .................... 7cefprozil ........................................ 7ceftazidime ..................................31ceftriaxone sodium ......................31cefuroxime axetil .......................... 7cefuroxime sodium ......................31celecoxib .....................................49

70

Index

CELLCEPT................................ 38CELONTIN................................ 46cephalexin .....................................7CERDELGA...............................40CEREZYME.............................. 40CESAMET................................. 28cevimeline hcl ............................. 23CHANTIX.................................. 43CHANTIX CONTINUING MONTH PAK............................ 43CHANTIX STARTING MONTH PAK............................ 43CHEMET....................................39chloramphenicol sod succinate .. 31chlordiazepoxide-amitriptyline ...52chlorhexidine gluconate ............. 23chloroquine phosphate ................. 4chlorothiazide .............................19chlorpromazine hcl .....................55chlorpropamide .......................... 22chlorthalidone ............................ 19CHOLBAM................................ 28cholestyramine light ................... 20CIALIS................................. 24, 43ciclopirox ....................................61ciclopirox olamine ......................61cidofovir ......................................31cilostazol .......................................9cimetidine ................................... 29cimetidine solution ..................... 29CIMZIA......................................48CIMZIA PREFILLED................48CINRYZE...................................40CIPRO HC..................................23CIPRODEX................................ 23ciprofloxacin ...........................8, 31ciprofloxacin hcl .....................8, 25ciprofloxacin in d5w ...................31ciprofloxacin-ciproflox hcl er .......8cisplatin ...................................... 10citalopram hydrobromide ...........53cladribine ....................................10claravis ....................................... 59clarithromycin .............................. 7clarithromycin er ..........................7CLEOCIN...................................67CLINDAGEL............................. 59clindamax ................................... 59clindamycin capsules ....................7clindamycin oral solution .............7clindamycin phos-benzoyl perox 59clindamycin phosphate ... 31, 59, 67

Index

clindamycin phosphate in d5w ... 31CLINIMIX E/DEXTROSE (2.75/10)..................................... 34CLINIMIX E/DEXTROSE (2.75/5)....................................... 34CLINIMIX E/DEXTROSE (4.25/10)..................................... 34CLINIMIX E/DEXTROSE (4.25/25)..................................... 34CLINIMIX E/DEXTROSE (4.25/5)....................................... 34CLINIMIX E/DEXTROSE (5/15).......................................... 34CLINIMIX E/DEXTROSE (5/20).......................................... 34CLINIMIX E/DEXTROSE (5/25).......................................... 34CLINIMIX/DEXTROSE (2.75/5)....................................... 34CLINIMIX/DEXTROSE (4.25/10)..................................... 34CLINIMIX/DEXTROSE (4.25/20)..................................... 34CLINIMIX/DEXTROSE (4.25/25)..................................... 34CLINIMIX/DEXTROSE (4.25/5)....................................... 34CLINIMIX/DEXTROSE (5/15).34CLINIMIX/DEXTROSE (5/20).34CLINIMIX/DEXTROSE (5/25).34CLINISOL SF............................ 34clobetasol propionate ................. 60clobetasol propionate e .............. 60clodan ......................................... 60CLODERM PUMP.....................60clofarabine ..................................10CLOLAR.................................... 10clomipramine hcl ........................53clonazepam .................................46clonidine hcl ............................... 19clonidine hcl er ...........................52clopidogrel bisulfate .....................9clorazepate dipotassium ............. 52clotrimazole ............................ 3, 61clotrimazole-betamethasone .......61clozapine .....................................55COARTEM.................................. 4codeine sulfate ............................50colchicine ....................................49colchicine-probenecid ................ 49colestipol hcl ...............................20colistimethate sodium ................. 31

Index

colocort .......................................30COMBIGAN.............................. 27COMBIPATCH..........................66COMBIVENT RESPIMAT....... 57COMETRIQ (100 MG DAILY DOSE)........................................ 13COMETRIQ (140 MG DAILY DOSE)........................................ 13COMETRIQ (60 MG DAILY DOSE)........................................ 13comfort assist insulin syringe ..... 21COMPLERA................................ 4compro ........................................28CONDYLOX..............................63constulose ................................... 28COPAXONE.............................. 41COPEGUS....................................4CORDRAN................................ 60COREG CR................................ 18CORLANOR.............................. 16CORMAX SCALP APPLICATION..........................60cortisone acetate .........................34CORTISPORIN..........................60COSENTYX 300 DOSE............ 62COSENTYX SENSOREADY 300 DOSE...................................62COSMEGEN.............................. 10COTELLIC.................................13COUMADIN................................ 9CREON...................................... 28CRESEMBA.......................... 3, 31CRINONE.................................. 66CRIXIVAN...................................4cromolyn sodium ............ 25, 28, 57CUPRIMINE.............................. 44cvs gauze sterile ..........................21cyanocobalamin (vitamin b12) ...25cyclobenzaprine hcl ....................48CYCLOPHOSPHAMIDE.......... 13CYCLOSET............................... 46cyclosporine ..........................31, 38cyclosporine modified .................38cyproheptadine hcl ..................... 24CYRAMZA................................ 10CYSTADANE............................39CYSTAGON.............................. 28CYSTARAN.............................. 27cytarabine ...................................10cytarabine (pf) ............................ 10dacarbazine ................................ 11DACOGEN.................................11

71

Index

DALIRESP.................................59DALVANCE.............................. 31danazol ....................................... 35dantrolene sodium ...................... 48dapsone .........................................4DAPTACEL............................... 36daptomycin ................................. 31DARAPRIM.................................4darifenacin hydrobromide er ......44DARZALEX...............................11daunorubicin hcl .........................11deblitane ..................................... 64decitabine ................................... 11DELESTROGEN....................... 66delyla .......................................... 64DELZICOL.................................30demeclocycline hcl ........................8DEMSER....................................42DENAVIR.................................. 63DEPEN TITRATABS................ 44DEPO-ESTRADIOL.................. 66DEPO-MEDROL....................... 34DEPO-PROVERA......................66DEPO-SUBQ PROVERA 104...66DEPO-TESTOSTERONE..........35DESCOVY................................... 4desipramine hcl .......................... 53desloratadine .............................. 24desmopressin ace rhinal tube ..... 44desmopressin ace spray refrig ....44desmopressin acetate ..................44desogestrel-ethinyl estradiol ...... 64desonide ......................................60desoximetasone ...........................60DESOXYN.................................52desvenlafaxine er ........................53desvenlafaxine succinate er ........53dexamethasone ........................... 34dexamethasone intensol ..............34dexamethasone sodium phosphate ..............................26, 31DEXEDRINE............................. 52dexmethylphenidate hcl .............. 52dexmethylphenidate hcl er ..........52dexpak 13 day .............................34dexrazoxane ................................11dextroamphetamine sulfate .........52dextroamphetamine sulfate er .... 52dextrose .......................................33dextrose in lactated ringers ........33dextrose-nacl .............................. 33DIASTAT ACUDIAL................46

Index

DIASTAT PEDIATRIC............. 46diazepam .....................................46diazepam intensol ....................... 46DIBENZYLINE......................... 43diclofenac potassium .................. 49diclofenac sodium ...........26, 49, 62diclofenac sodium er ...................49diclofenac-misoprostol ............... 49dicloxacillin sodium ..................... 7dicyclomine hcl ...........................28didanosine .................................... 4diethylpropion hcl .......................24diethylpropion hcl er .................. 24DIFICID....................................... 7diflorasone diacetate .................. 60diflunisal .....................................49digitek ......................................... 17digoxin ........................................ 17dihydroergotamine mesylate ...... 45DILANTIN................................. 46DILANTIN INFATABS............ 46diltiazem hcl ......................... 19, 31diltiazem hcl er ........................... 19diltiazem hcl er beads .................19diltiazem hcl er coated beads ..... 19dilt-xr .......................................... 19diphenhydramine hcl .................. 31diphtheria-tetanus toxoids dt ......36dipyridamole .................................9disopyramide phosphate .............17disulfiram ....................................52divalproex sodium ...................... 46divalproex sodium er .................. 46DIVIGEL....................................66docetaxel .....................................11dofetilide .....................................17donepezil hcl ...............................44DORIBAX..................................31dorzolamide hcl .......................... 27dorzolamide hcl-timolol mal ...... 27doxazosin mesylate ..................... 16doxepin hcl ............................53, 62doxercalciferol ............................41doxorubicin hcl ...........................11doxorubicin hcl liposomal .......... 11DOXY 100..................................31doxycycline hyclate .......................8doxycycline monohydrate ............. 8dronabinol .................................. 28drospirenone-ethinyl estradiol ... 64DROXIA.....................................13DUAVEE....................................66

Index

duloxetine hcl ..............................53DUOPA...................................... 46DUREZOL................................. 26dutasteride .................................. 43dutasteride-tamsulosin hcl ......... 43DUTOPROL...............................18DYSPORT..................................39e.e.s. 400 .......................................7E.E.S. GRANULES......................7econazole nitrate ........................ 61EDECRIN...................................19EDEX......................................... 24EDURANT...................................4EFFIENT...................................... 9EGRIFTA................................... 40ELAPRASE................................41ELELYSO.................................. 40ELESTRIN................................. 66ELIDEL...................................... 62ELIGARD...................................35ELIQUIS.......................................9ELITEK...................................... 11ELLENCE.................................. 11ELMIRON..................................44EMADINE..................................25EMBEDA................................... 50EMCYT...................................... 13EMEND................................28, 31emoquette ....................................64EMPLICITI................................ 11EMSAM..................................... 54EMTRIVA....................................4enalapril maleate ........................16enalapril-hydrochlorothiazide ....18ENBREL.................................... 48ENBREL SURECLICK............. 48endocet ........................................50ENGERIX-B...............................36enoxaparin sodium ....................... 9entacapone ..................................46entecavir ....................................... 4ENTRESTO................................18enulose ........................................28ENVARSUS XR........................ 38epinastine hcl ..............................25epinephrine .................................38epirubicin hcl ..............................11epitol ...........................................46EPIVIR......................................... 5eplerenone .................................. 19eprosartan mesylate ....................16EQUETRO................................. 53

72

Index

ERAXIS......................................31ERBITUX...................................11ergocalciferol (rx and otc) ..........25ergoloid mesylates ......................44ERIVEDGE................................ 13errin ............................................ 64ERTACZO..................................61ERWINAZE............................... 11ery ...............................................59eryped 200 .................................... 7eryped 400 .................................... 7ERY-TAB.....................................7ERYTHROCIN LACTOBIONATE..................... 31erythrocin stearate ........................7erythromycin .........................25, 59erythromycin base ........................ 7erythromycin ethylsuccinate .........7ESBRIET....................................58escitalopram oxalate .................. 54esomeprazole magnesium ...........29esomeprazole sodium ..................31estazolam .................................... 54ESTRACE.................................. 66estradiol ......................................66estradiol valerate ........................66estradiol-norethindrone acet ......64ESTRING................................... 66estropipate .................................. 66eszopiclone ................................. 54ethacrynic acid ........................... 19ethambutol hcl .............................. 7ethosuximide ...............................46etidronate disodium ....................42etodolac ...................................... 49etodolac er ..................................49ETOPOPHOS.............................11etoposide ...............................11, 13EUCRISA...................................62EURAX...................................... 62EVAMIST.................................. 66EVOCLIN...................................59EVOTAZ...................................... 5EVZIO........................................ 42exel comfort point pen needle .....21EXELDERM.............................. 61exemestane ..................................13EXJADE.....................................39EXONDYS 51............................39EXTAVIA.................................. 42ezetimibe .....................................20ezetimibe-simvastatin ................. 20

Index

FABIOR..................................... 59FABRAZYME........................... 39falmina ........................................64famciclovir ....................................5famotidine ...................................29FANAPT.................................... 55FANAPT TITRATION PACK...55FARESTON............................... 13FARYDAK.................................13FASLODEX............................... 11FAZACLO..................................55felbamate .................................... 46felodipine er ................................19FEMHRT LOW DOSE.............. 66FEMRING.................................. 66fenofibrate .................................. 20fenofibrate micronized ................20fenofibric acid .............................20fenoprofen calcium ..................... 49fentanyl ....................................... 50fentanyl citrate ............................50FENTORA..................................50FERRIPROX.............................. 39FETZIMA...................................54FETZIMA TITRATION............ 54FINACEA...................................59finasteride ...................................43FIRAZYR...................................40FIRMAGON...............................35FLAREX.................................... 26flavoxate hcl ................................44FLEBOGAMMA DIF................ 36flecainide acetate ........................17FLOVENT DISKUS.................. 57FLOVENT HFA.........................57fluconazole ....................................3fluconazole in sodium chloride ...31flucytosine .....................................3fludarabine phosphate ................11fludrocortisone acetate ...............35flunisolide ................................... 24fluocinolone acetonide ..........23, 60fluocinolone acetonide body .......60fluocinonide .......................... 60, 61fluocinonide-e .............................61fluorometholone ..........................26fluorouracil ...........................11, 62fluoxetine hcl .............................. 54fluphenazine decanoate .............. 55fluphenazine hcl ..........................55flurandrenolide ...........................61flurazepam hcl ............................ 55

Index

flurbiprofen .................................49flurbiprofen sodium .................... 26flutamide .....................................13fluticasone propionate ..........24, 61fluvastatin sodium .......................20fluvastatin sodium er .................. 20fluvoxamine maleate ...................54fluvoxamine maleate er ...............54FML............................................26FML FORTE.............................. 26FOCALIN XR............................ 52folic acid (rx and otc) ................. 25fondaparinux sodium ....................9FORTEO.................................... 66fosinopril sodium ........................16fosinopril sodium-hctz ................ 18fosphenytoin sodium ................... 46FRAGMIN..................................10FREAMINE HBC...................... 34frovatriptan succinate .................45furosemide ............................ 20, 31FUSILEV....................................15FUZEON...................................... 5fyavolv .........................................66FYCOMPA.................................46gabapentin .................................. 47GABITRIL................................. 47galantamine hydrobromide ........ 44galantamine hydrobromide er .... 44GAMASTAN S/D...................... 36GAMMAGARD.........................36GAMMAGARD S/D LESS IGA36GAMMAKED............................ 37GAMMAPLEX.......................... 37GAMUNEX-C............................37ganciclovir sodium ..................... 11GARDASIL 9.............................37gatifloxacin .................................25GATTEX.................................... 28gauze pads .................................. 21gemcitabine hcl ...........................11gemfibrozil ..................................20GENERESS FE.......................... 64generlac ...................................... 28gengraf ........................................38GENOTROPIN...........................40GENOTROPIN MINIQUICK....40gentak ......................................... 25gentamicin in saline ....................31gentamicin sulfate ...........25, 31, 60GENVOYA.................................. 5

73

Index

GEODON INTRAMUSCULAR INJECTION................................55gildagia .......................................64GILENYA.................................. 42GILOTRIF..................................13GLASSIA................................... 59GLEOSTINE.............................. 13glimepiride ..................................22glipizide ...................................... 22glipizide er ..................................22glipizide-metformin hcl ...............22global alcohol prep ease ............ 21GLUCAGEN HYPOKIT............21GLUCAGON EMERGENCY....21glyburide .....................................22glyburide micronized ..................22glyburide-metformin ...................22glycopyrrolate .............................28gnp ultra com insulin syringe .....21GNP ULTRA COM INSULIN SYRINGE...................................21granisetron hcl ..................... 28, 31GRANIX.......................................9GRASTEK..................................59griseofulvin microsize ...................3griseofulvin ultramicrosize ...........3guanfacine hcl er ........................ 52guanidine hcl .............................. 42GYNAZOLE-1...........................67HALAVEN.................................11halobetasol propionate ...............61HALOG...................................... 61haloperidol ................................. 55haloperidol decanoate ................55haloperidol lactate ..................... 55HAVRIX.....................................37heparin sodium (porcine) ........... 31HEPATAMINE.......................... 34HERCEPTIN.............................. 11HETLIOZ................................... 55HEXALEN................................. 13HIBERIX....................................37HORIZANT................................47HP ACTHAR............................. 35HUMALOG................................21HUMALOG KWIKPEN............ 21HUMALOG MIX 50/50.............21HUMALOG MIX 50/50 KWIKPEN..................................22HUMALOG MIX 75/25.............22HUMALOG MIX 75/25 KWIKPEN..................................22

Index

HUMATROPE........................... 40HUMIRA....................................48HUMIRA PEDIATRIC CROHNS START...................... 48HUMIRA PEN........................... 48HUMIRA PEN-CROHNS STARTER.................................. 48HUMIRA PEN-PSORIASIS STARTER.................................. 48HUMULIN 70/30....................... 22HUMULIN 70/30 KWIKPEN....22HUMULIN N............................. 22HUMULIN N KWIKPEN..........22HUMULIN R..............................22HUMULIN R U-500 (CONCENTRATED)................. 22HUMULIN R U-500 KWIKPEN..................................22HYCAMTIN...............................13hydralazine hcl ........................... 21hydrochlorothiazide ....................20hydrocodone-acetaminophen ..... 51hydrocodone-homatropine ......... 24hydrocodone-ibuprofen .............. 51hydrocortisone ................30, 35, 61hydrocortisone butyr lipo base ...61hydrocortisone butyrate ..............61hydrocortisone valerate ..............61hydrocortisone-acetic acid ......... 23hydromorphone hcl .....................51hydromorphone hcl er ................ 51hydroxychloroquine sulfate .......... 4hydroxyprogesterone caproate ...67hydroxyurea ................................13hydroxyzine hcl .....................24, 31hydroxyzine pamoate .................. 24HYPERRAB S/D....................... 37HYSINGLA ER..........................51ibandronate sodium ....................66IBRANCE.................................. 13ibuprofen .................................... 49ICLUSIG.................................... 13idarubicin hcl ............................. 11ifosfamide ................................... 11ILARIS (150MG DELIVERED)39ILEVRO..................................... 26imatinib mesylate ........................13IMBRUVICA............................. 13IMFINZI.....................................11imipenem-cilastatin .................... 31imipramine hcl ............................54imipramine pamoate ...................54

Index

imiquimod ...................................63IMOGAM RABIES-HT............. 37IMOVAX RABIES.................... 37INCRELEX................................ 40INCRUSE ELLIPTA..................57indapamide ................................. 20INDOCIN ORAL SUSPENSION............................49indomethacin .............................. 50indomethacin er ..........................50INFANRIX.................................37INFLECTRA.............................. 48INGREZZA................................ 43INLYTA..................................... 13INTELENCE................................ 5INTRALIPID..............................34INTRON A................................... 5introvale ......................................64INVANZ.....................................32INVEGA SUSTENNA...............55INVEGA TRINZA..................... 55INVIRASE................................... 5INVOKAMET............................22INVOKAMET XR..................... 22INVOKANA...............................22IONOSOL-MB IN D5W............ 33IOPIDINE...................................27IPOL........................................... 37ipratropium bromide ............ 24, 57ipratropium-albuterol .................57irbesartan ................................... 16irbesartan-hydrochlorothiazide ..18IRESSA...................................... 13irinotecan hcl ..............................11ISENTRESS................................. 5ISOLYTE-P IN D5W.................33ISOLYTE-S................................33isoniazid ..................................7, 32isosorbide dinitrate .....................16isosorbide dinitrate er ................ 16isosorbide mononitrate ...............16isosorbide mononitrate er .......... 16isradipine ....................................19ISTODAX (OVERFILL)............11itraconazole .................................. 3ivermectin ..................................... 3IXIARO...................................... 37JADENU.....................................39JADENU SPRINKLE................ 39JAKAFI...................................... 13jantoven ...................................... 10JANUMET................................. 22

74

Index

JANUMET XR...........................22JANUVIA...................................22JARDIANCE..............................23JENTADUETO.......................... 23JENTADUETO XR....................23JEVTANA.................................. 11jinteli ...........................................64junel 1.5/30 .................................64junel 1/20 ....................................64junel fe 1.5/30 ............................. 64junel fe 1/20 ................................ 64junel fe 24 ................................... 64JUXTAPID.................................20KADCYLA.................................11KALETRA................................... 5KALYDECO.............................. 39KANUMA.................................. 41KAPVAY................................... 52kariva ..........................................64kcl in dextrose-nacl .....................33kcl-lactated ringers-d5w .............33kelnor 1/35 ..................................64KENALOG.................................61ketoconazole ........................... 3, 61ketoprofen ...................................50ketoprofen er ...............................50ketorolac tromethamine ..............26KEVEYIS...................................43KEYTRUDA.............................. 11KINERET...................................48KINRIX...................................... 37kionex ..........................................43KISQALI 200 DOSE..................13KISQALI 400 DOSE..................13KISQALI 600 DOSE..................13KISQALI FEMARA 200 DOSE 13KISQALI FEMARA 400 DOSE 13KISQALI FEMARA 600 DOSE 14klor-con .......................................21klor-con 10 ..................................21klor-con m10 ...............................21KLOR-CON M15.......................21klor-con m20 ...............................21klor-con sprinkle .........................21KORLYM...................................39KRISTALOSE............................28K-TAB........................................21KUVAN......................................42KYNAMRO............................... 20KYPROLIS................................ 14labetalol hcl ..........................18, 32lactated ringers ...........................33

Index

lactulose ......................................28lamivudine .................................... 5lamivudine-zidovudine ..................5lamotrigine ................................. 47lamotrigine er ............................. 47lancets .........................................21LANOXIN..................................17lansoprazole ............................... 29LANTUS.................................... 22LANTUS SOLOSTAR...............22larin 1.5/30 ................................. 64larin 1/20 .................................... 64larin fe 1.5/30 ............................. 64larin fe 1/20 ................................ 64LARTRUVO.............................. 11LASTACAFT.............................25latanoprost ..................................27LATUDA..............................55, 56LAZANDA.................................51leflunomide ................................. 48LENVIMA 10 MG DAILY DOSE..........................................14LENVIMA 14 MG DAILY DOSE..........................................14LENVIMA 18 MG DAILY DOSE..........................................14LENVIMA 20 MG DAILY DOSE..........................................14LENVIMA 24 MG DAILY DOSE..........................................14LENVIMA 8 MG DAILY DOSE..........................................14lessina .........................................64LETAIRIS.................................. 58letrozole ...................................... 14leucovorin calcium ..................... 15LEUKERAN...............................14LEUKINE.....................................9leuprolide acetate ....................... 35levalbuterol hcl ...........................57levalbuterol tartrate ................... 57levetiracetam .............................. 47levetiracetam er .......................... 47levetiracetam in nacl .................. 32LEVITRA...................................24levobunolol hcl ........................... 27levocarnitine ...............................28levocetirizine dihydrochloride ....24levofloxacin .......................8, 25, 32levofloxacin in d5w .....................32levoleucovorin calcium ...............15levonest .......................................64

Index

levonorgest-eth estrad 91-day .... 64levonorgestrel-ethinyl estradiol ..64levora 0.15/30 (28) ..................... 64levorphanol tartrate ................... 51levothyroxine sodium ............32, 36levoxyl .........................................36LEXIVA....................................... 5lidocaine ............................... 62, 63lidocaine hcl ......................... 32, 63lidocaine hcl (pf) .........................32lidocaine viscous ........................ 63lidocaine-prilocaine ................... 63LINCOCIN.................................32lincomycin hcl .............................32lindane ........................................ 62linezolid .................................. 3, 32LINZESS.................................... 30liothyronine sodium ....................36lisinopril ..................................... 16lisinopril-hydrochlorothiazide ....18lithium .........................................53lithium carbonate ....................... 53lithium carbonate er ................... 53LO LOESTRIN FE.....................64LONSURF..................................14loperamide hcl ............................28lopinavir-ritonavir ........................5lorazepam ................................... 52lorazepam intensol ..................... 52losartan potassium ..................... 16losartan potassium-hctz ..............18LOTEMAX.................................26lovastatin .................................... 20loxapine succinate ...................... 56LUMIGAN................................. 27LUMIZYME...............................41LUPRON DEPOT (1-MONTH).35LUPRON DEPOT (3-MONTH).35LUPRON DEPOT (4-MONTH).35LUPRON DEPOT (6-MONTH).35LUPRON DEPOT-PED (1-MONTH).................................... 36LYNPARZA...............................14LYRICA..................................... 47LYSODREN...............................14magnesium sulfate ...................... 33MAKENA...................................67malathion ....................................62maprotiline hcl ........................... 54marlissa ...................................... 64MARPLAN................................ 54MATULANE..............................14

75

Index

matzim la .................................... 19MAXIDEX................................. 26meclizine hcl ............................... 28meclofenamate sodium ............... 50MEDROL................................... 35medroxyprogesterone acetate .....66mefenamic acid ...........................50mefloquine hcl .............................. 4megestrol acetate ..................14, 29MEKINIST.................................14meloxicam ...................................50melphalan hcl ............................. 11memantine hcl .......................44, 45MENACTRA..............................37MENEST.................................... 66MENOMUNE.............................37MENOSTAR.............................. 66MENTAX...................................61MENVEO...................................37MEPHYTON..............................25mercaptopurine ...........................14meropenem ................................. 32mesalamine .................................30mesalamine-cleanser .................. 30mesna ..........................................15MESNEX....................................15MESTINON SYRUP................. 42METADATE CD........................52METADATE ER........................53metaproterenol sulfate ................57metformin hcl ..............................23metformin hcl er ......................... 23metformin hcl er (osm) 1,000 mg23methadone hcl .............................51methamphetamine hcl .................53methazolamide ............................27methenamine hippurate ................ 3methimazole ................................36METHITEST..............................35methotrexate ............................... 48methotrexate sodium ...................32methotrexate sodium (pf) ............32methoxsalen rapid ...................... 62methscopolamine bromide ..........29methyclothiazide .........................20METHYLIN............................... 53methylphenidate hcl ....................53methylphenidate hcl er ............... 53methylphenidate hcl er (cd) ........ 53methylphenidate hcl er (la) .........53methylprednisolone .....................35methylprednisolone acetate ........35

Index

methylprednisolone sodium succ 35methyltestosterone ...................... 35metipranolol ............................... 27metoclopramide hcl .............. 28, 32metolazone ..................................20metoprolol succinate er .............. 18metoprolol tartrate ............... 18, 32metoprolol-hydrochlorothiazide .18metronidazole ................... 3, 59, 67metronidazole in nacl ................. 32mexiletine hcl ..............................17MIACALCIN............................. 66miconazole 3 ...............................67microgestin 1.5/30 ...................... 64microgestin 1/20 ......................... 64microgestin fe 1.5/30 .................. 64microgestin fe 1/20 ..................... 64midodrine hcl ..............................19MIGERGOT...............................45miglitol ........................................23MIGRANAL...............................45MILLIPRED...............................35minocycline hcl .............................8minocycline hcl er .........................8minoxidil .....................................21mirtazapine .................................54misoprostol ................................. 29mitomycin ................................... 11mitoxantrone hcl .........................11M-M-R II....................................37modafinil .....................................55moexipril hcl ...............................16moexipril-hydrochlorothiazide ...18mometasone furoate ..............24, 61montelukast sodium .................... 57MONUROL..................................3morphine sulfate ......................... 51morphine sulfate (concentrate) ...51morphine sulfate er .....................51morphine sulfate er beads .......... 51MOVANTIK.............................. 29MOVIPREP................................29MOXEZA...................................25moxifloxacin hcl ......................8, 32MOZOBIL....................................9MULTAQ...................................17mupirocin ....................................60mupirocin calcium ......................60MUSE.........................................24MUSTARGEN........................... 11MYCAMINE..............................32mycophenolate mofetil ................38

Index

mycophenolate mofetil hcl ..........38mycophenolate sodium ............... 38MYLERAN................................ 14MYRBETRIQ............................ 44MYTESI..................................... 29nabumetone .................................50nadolol ........................................18nadolol-bendroflumethiazide ......18nafcillin sodium .......................... 32naftifine hcl .................................61NAFTIN GEL.............................61NAGLAZYME...........................41naloxone hcl ................................42naltrexone hcl ............................. 52NAMENDA XR......................... 45NAMENDA XR TITRATION PACK......................................... 45naproxen .....................................50naproxen dr ................................ 50naproxen sodium ........................ 50naproxen sodium er .................... 50naratriptan hcl ............................45NARCAN................................... 42NASCOBAL.............................. 25NATACYN.................................27nateglinide .................................. 23NATPARA................................. 41NEBUPENT................................. 4necon 0.5/35 (28) ........................65necon 1/50 (28) ...........................65NECON 10/11 (28).....................65necon 7/7/7 ................................. 65nefazodone hcl ............................54neomycin sulfate ........................... 3neomycin-bacitracin zn-polymyx 25neomycin-polymyxin b ................ 63neomycin-polymyxin-dexameth .. 26neomycin-polymyxin-gramicidin 26neomycin-polymyxin-hc ........25, 26NEPHRAMINE..........................34NEULASTA.................................9NEUPOGEN.................................9NEUPRO.................................... 46NEVANAC.................................26nevirapine .....................................5nevirapine er .................................5NEXAVAR.................................14niacin er ......................................20niacor ..........................................20nicardipine hcl ............................19NICOTROL................................43NICOTROL NS..........................43

76

Index

nifedipine .................................... 19nifedipine er ................................19nifedipine er osmotic release ......19nikki ............................................ 65nilutamide ...................................14nimodipine .................................. 19NINLARO.................................. 14nisoldipine er ..............................19NITRO-BID................................16nitrofurantoin macrocrystal ......... 3nitrofurantoin monohyd macro .... 3nitroglycerin ............................... 16NITROMIST.............................. 16NITROSTAT..............................16nizatidine .................................... 29nolix ............................................ 61NORDITROPIN FLEXPRO...... 40norethin ace-eth estrad-fe ...........65norethindrone acetate .................66norethindrone-eth estradiol ........65norethin-eth estradiol-fe .............65NORITATE................................ 59norlyroc ...................................... 65NORMOSOL-M IN D5W..........33NORMOSOL-R IN D5W...........33NORMOSOL-R PH 7.4............. 33NORPACE CR........................... 17NORTHERA.............................. 19nortrel 0.5/35 (28) ...................... 65nortrel 1/35 (21) ......................... 65nortrel 1/35 (28) ......................... 65nortrel 7/7/7 ................................65nortriptyline hcl ..........................54NORVIR.......................................5NOXAFIL.....................................3NUCALA................................... 59NUEDEXTA.............................. 46NULOJIX................................... 38NUPLAZID................................ 56NUTRILIPID..............................34NUTROPIN AQ NUSPIN 10.....40NUTROPIN AQ NUSPIN 20.....40NUTROPIN AQ NUSPIN 5.......40NUVARING...............................65NUVESSA..................................67nyamyc ........................................61nyata ........................................... 62nystatin ................................... 3, 62nystatin-triamcinolone ................62nystop ..........................................62OCALIVA.................................. 29OCTAGAM................................37

Index

octreotide acetate ....................... 38ODEFSEY.................................... 5ODOMZO...................................14OFEV..........................................58ofloxacin ........................... 8, 23, 25olanzapine .................................. 56olanzapine-fluoxetine hcl ............53olmesartan medoxomil ................17olmesartan medoxomil-hctz ........18olmesartan-amlodipine-hctz .......18olopatadine hcl ..................... 24, 25omega-3-acid ethyl esters ...........20omeprazole ................................. 29omeprazole-sodium bicarbonate 29OMNITROPE.............................40ondansetron ................................ 28ondansetron hcl .................... 28, 32ONETOUCH TEST STRIPS..... 21ONFI...........................................47OPDIVO.....................................12OPSUMIT.................................. 58ORALAIR.................................. 59ORAP......................................... 56ORAPRED ODT........................ 35ORBACTIV................................32ORENCIA.................................. 49ORENCIA CLICKJECT............ 48ORENITRAM............................ 58ORFADIN.................................. 40ORKAMBI................................. 39orsythia .......................................65ORTHO TRI-CYCLEN (28)......65oseltamivir phosphate ...................5OSMOPREP...............................29OTEZLA.....................................62oxacillin sodium ......................... 32oxaliplatin ...................................12oxandrolone ................................35oxaprozin .................................... 50oxazepam .................................... 52oxcarbazepine .............................47oxiconazole nitrate ..................... 62OXISTAT...................................62OXTELLAR XR........................ 47oxybutynin chloride .................... 44oxybutynin chloride er ................44oxycodone hcl ............................. 51oxycodone hcl er .........................51oxycodone-acetaminophen ......... 51oxycodone-aspirin ...................... 51oxycodone-ibuprofen .................. 51OXYCONTIN............................ 51

Index

oxymorphone hcl ........................ 51oxymorphone hcl er .................... 51paclitaxel .................................... 12paliperidone er ........................... 56pamidronate disodium ................66PANDEL.................................... 61PANRETIN................................ 63pantoprazole sodium .................. 29paricalcitol ................................. 41paromomycin sulfate .................... 4paroxetine hcl ............................. 54paroxetine hcl er .........................54PASER..........................................8PAXIL ORAL SUSPENSION... 54PCE...............................................7PEDIARIX................................. 37PEDVAX HIB............................37peg 3350-kcl-na bicarb-nacl ...... 29peg-3350/electrolytes ................. 29PEGANONE...............................47PEGASYS.................................... 5PEGASYS PROCLICK............... 5penicillin g pot in dextrose ......... 32penicillin g potassium .................32penicillin g sodium ..................... 32penicillin v potassium ...................7PENTAM......................................4pentoxifylline er ..........................10PERFOROMIST........................ 57perindopril erbumine ..................16periogard .................................... 23PERJETA................................... 12permethrin .................................. 62perphenazine ...............................56perphenazine-amitriptyline .........56PEXEVA.................................... 54phendimetrazine tartrate ............ 24phendimetrazine tartrate er ........24phenelzine sulfate ....................... 54phenobarbital ............................. 47phenoxybenzamine hcl ................43phentermine hcl .......................... 24phenytoin .................................... 47phenytoin sodium ........................47phenytoin sodium extended .........47PHOSPHOLINE IODIDE..........27pilocarpine hcl ......................23, 27pimozide ......................................56pindolol .......................................18pioglitazone hcl .......................... 23pioglitazone hcl-glimepiride .......23pioglitazone hcl-metformin hcl ...23

77

Index

piperacillin sod-tazobactam so .. 32piroxicam ....................................50PLASMA-LYTE 148................. 33PLASMA-LYTE A.................... 33PLEGRIDY................................ 42PLEGRIDY STARTER PACK..42PLENAMINE.............................34PNEUMOVAX 23......................37podofilox .....................................63polyethylene glycol 3350 ............ 29polymyxin b sulfate .....................32polymyxin b-trimethoprim .......... 26POMALYST.............................. 14portia-28 .....................................65potassium chloride ............... 21, 33potassium chloride crys er ..........21potassium chloride er ................. 21potassium chloride in dextrose ...33potassium chloride in nacl ......... 33potassium citrate er .................... 44PRADAXA.................................10pramipexole dihydrochloride ..... 46pramipexole dihydrochloride er .46pravastatin sodium ..................... 20prazosin hcl ................................ 16PRED MILD...............................26PRED-G......................................26PRED-G S.O.P........................... 26prednicarbate ............................. 61prednisolone acetate ...................26prednisolone sodium phosphate.............................................. 26, 35prednisone .................................. 35PREDNISONE INTENSOL.......35preferred plus insulin syringe .....21PREMARIN............................... 66PREMASOL...............................34PREMPHASE............................ 66PREMPRO................................. 66prenatal ...................................... 67PREVALITE.............................. 20PREVNAR 13............................ 37PREZCOBIX................................5PREZISTA................................... 5PRIFTIN.......................................8primaquine phosphate .................. 4primidone ....................................47PRIVIGEN................................. 37PROAIR HFA............................ 57PROAIR RESPICLICK............. 58probenecid .................................. 49PROCALAMINE....................... 34

Index

prochlorperazine ........................ 28prochlorperazine edisylate ......... 32prochlorperazine maleate ...........28PROCRIT..................................... 9procto-med hc .............................63procto-pak ...................................63proctosol hc ................................ 63proctozone-hc ............................. 63progesterone micronized ............ 66PROGLYCEM........................... 21PROGRAF INJECTION............ 32PROLASTIN-C.......................... 59PROLENSA............................... 26PROLEUKIN............................. 12PROLIA......................................66PROMACTA................................9promethazine hcl .................. 28, 32promethazine vc/codeine ............ 24promethazine-codeine .................24promethazine-dm ........................ 24propafenone hcl ..........................17propafenone hcl er ......................17propantheline bromide ............... 29proparacaine hcl ........................ 27propranolol hcl ...........................18propranolol hcl er ...................... 18propranolol-hctz .........................18propylthiouracil ..........................36PROQUAD.................................37PROSOL.....................................34protriptyline hcl ..........................54PROVENTIL HFA.....................58prudoxin ......................................63pseudoeph-chlorphen-hydrocod . 24PULMICORT FLEXHALER.....58PULMOZYME...........................39PURIXAN.................................. 14PYLERA.................................... 29pyrazinamide ................................ 8pyridostigmine bromide ..............42pyridostigmine bromide er ......... 42QSYMIA.................................... 24QUADRACEL........................... 37quasense ..................................... 65QUDEXY XR.............................47quetiapine fumarate ....................56quetiapine fumarate er ............... 56QUILLIVANT XR..................... 53quinapril hcl ............................... 16quinapril-hydrochlorothiazide ... 18quinidine gluconate er ................17quinidine sulfate ......................... 17

Index

quinine sulfate .............................. 4QVAR.........................................58RABAVERT.............................. 37rabeprazole sodium .................... 29RAGWITEK...............................59raloxifene hcl ..............................66ramipril .......................................16RANEXA................................... 16ranitidine hcl .............................. 29RAPAMUNE ORAL SOLUTION................................ 38rasagiline mesylate .....................46RASUVO....................................49RAVICTI....................................44REBETOL.................................... 5REBIF.........................................42REBIF REBIDOSE.................... 42REBIF REBIDOSE TITRATION PACK................... 42REBIF TITRATION PACK.......42RECLAST.................................. 66RECOMBIVAX HB...................37REGRANEX.............................. 63RELENZA DISKHALER............ 5RELI-ON INSULIN SYRINGE.21RELISTOR.................................29REMICADE............................... 49REMODULIN............................ 58RENVELA................................. 43repaglinide ..................................23repaglinide-metformin hcl ..........23REPATHA..................................20REPATHA PUSHTRONEX SYSTEM.................................... 20REPATHA SURECLICK.......... 20RESCRIPTOR..............................5RESTASIS..................................27RETIN-A.................................... 60RETIN-A MICRO......................60RETIN-A MICRO PUMP.......... 60RETROVIR................................ 32REVATIO ORAL SOLUTION..58REVLIMID.................................14REXULTI...................................56REYATAZ................................... 6ribasphere .....................................6RIBASPHERE RIBAPAK........... 6ribavirin ........................................6RIDAURA..................................49rifabutin ........................................ 8RIFAMATE..................................8rifampin .................................. 8, 32

78

Index

RIFATER..................................... 8riluzole ........................................38rimantadine hcl .............................6ringers ........................................ 33RIOMET.....................................23risedronate sodium ..................... 66RISPERDAL CONSTA............. 53risperidone ..................................53RITUXAN.................................. 12rivastigmine ................................ 45rivastigmine tartrate ...................45rizatriptan benzoate ....................45ropinirole hcl ..............................46ropinirole hcl er ..........................46rosuvastatin calcium ...................20ROTARIX.................................. 37ROTATEQ................................. 37roweepra .....................................47ROZEREM.................................55RUBRACA.................................14RUCONEST...............................40RYDAPT.................................... 14RYTARY....................................46SABRIL......................................47SAFYRAL..................................65SAIZEN......................................40SAIZEN CLICK.EASY............. 40SAMSCA....................................44SANCUSO................................. 28SANDOSTATIN LAR DEPOT. 38SANTYL.................................... 63SAPHRIS....................................56SAVELLA..................................47SAXENDA.................................25selegiline hcl ...............................46selenium sulfide .......................... 63SELZENTRY............................... 6SENSIPAR................................. 41SEREVENT DISKUS................ 58SEROSTIM................................ 40sertraline hcl ...............................54sevelamer carbonate oral packets ........................................ 43SFROWASA.............................. 30sharobel ...................................... 65SIGNIFOR..................................39SIGNIFOR LAR.........................38sildenafil 25, 50 & 100 mg tablets ......................................... 24sildenafil citrate ..........................58SILENOR................................... 55silver sulfadiazine .......................60

Index

SIMBRINZA.............................. 27SIMPONI....................................49SIMPONI ARIA.........................49SIMULECT................................ 38simvastatin ..................................20sirolimus ..................................... 38SIRTURO.....................................8SIVEXTRO............................ 3, 32SKLICE...................................... 62sodium chloride .................... 33, 63sodium lactate .............................33sodium phenylbutyrate ................44sodium polystyrene sulfonate ..... 43SOLTAMOX..............................14SOLU-CORTEF.........................35SOLU-MEDROL....................... 35SOMATULINE DEPOT............ 38SOMAVERT.............................. 38SOOLANTRA............................59sorine .......................................... 17sotalol hcl ................................... 17sotalol hcl (af) ............................ 17SOTYLIZE.................................17SOVALDI.....................................6SPIRIVA HANDIHALER......... 58SPIRIVA RESPIMAT................58spironolactone ............................ 20spironolactone-hctz .................... 20SPRITAM...................................47SPRYCEL.................................. 14sps ...............................................43ssd ...............................................60stavudine .......................................6STELARA.................................. 62sterile water for irrigation ..........63STIMATE...................................10STIVARGA................................14STRENSIQ.................................41streptomycin sulfate ....................32STRIBILD.................................... 6STRIVERDI RESPIMAT.......... 58STROMECTOL........................... 3SUBOXONE FILM....................42SUBSYS.....................................51SUCRAID.................................. 43sucralfate .................................... 29sulfacetamide sodium ................. 26sulfacetamide sodium (acne) ...... 63sulfacetamide-prednisolone ........26sulfadiazine ...................................8sulfamethoxazole-trimethoprim................................................ 8, 32

Index

SULFAMYLON.........................63sulfasalazine ............................... 30sulindac ...................................... 50sumatriptan .................................45sumatriptan succinate .................45sumatriptan succinate refill ........45SUPRAX...................................... 7SUPREP BOWEL PREP KIT....29SURMONTIL.............................54SUSTIVA..................................... 6SUTENT.....................................14SYLATRON...............................12SYLVANT................................. 39SYMBICORT.............................58SYMLINPEN 120...................... 22SYMLINPEN 60........................ 22SYNAGIS...................................43SYNAREL..................................36SYNERCID................................ 33SYNJARDY............................... 23SYNRIBO.................................. 12SYNTHROID.............................36SYPRINE................................... 44TABLOID...................................14tacrolimus .............................38, 63TAFINLAR................................ 14TAGRISSO................................ 15TALTZ....................................... 62TAMIFLU ORAL SOLUTION... 6tamoxifen citrate .........................15tamsulosin hcl .............................43TARCEVA................................. 15TARGRETIN....................... 15, 63tarina fe 1/20 .............................. 65TASIGNA...................................15tazarotene ................................... 62TAZORAC................................. 62taztia xt ....................................... 19TECENTRIQ..............................12TECFIDERA.............................. 42TEFLARO.................................. 33TEGRETOL-XR.........................47TEKTURNA...............................19TEKTURNA HCT......................18telmisartan ..................................17telmisartan-amlodipine .............. 18telmisartan-hctz .......................... 18temazepam .................................. 55temozolomide ..............................15TENIVAC...................................37terazosin hcl ............................... 16terbinafine hcl ...............................3

79

Index

terbutaline sulfate .......................58terconazole ................................. 67testosterone .................................35testosterone cypionate ................ 35testosterone enanthate ................35tetanus-diphtheria toxoids td ......37tetrabenazine .............................. 41tetracycline hcl ............................. 9THALOMID...............................15theophylline ................................ 58theophylline er ............................58thioridazine hcl ...........................56thiotepa .......................................12thiothixene .................................. 56THYMOGLOBULIN.................38THYROLAR-1...........................36THYROLAR-1/2........................36THYROLAR-1/4........................36THYROLAR-2...........................36THYROLAR-3...........................36tiagabine hcl ............................... 47tigecycline ...................................33timolol maleate ..................... 19, 27tinidazole ...................................... 4TIROSINT..................................36TIVICAY......................................6tizanidine hcl .............................. 48TOBI PODHALER.................... 39TOBRADEX.............................. 26TOBRADEX ST.........................26tobramycin ............................26, 39tobramycin sulfate ...................... 33tobramycin-dexamethasone ........26tolazamide .................................. 23tolbutamide .................................23tolcapone .................................... 46tolmetin sodium .......................... 50tolterodine tartrate ..................... 44tolterodine tartrate er .................44topiramate .................................. 47topiramate er .............................. 47topotecan hcl .............................. 12TORISEL....................................12torsemide .................................... 20TOUJEO SOLOSTAR............... 22TOVIAZ..................................... 44tpn electrolytes ............................34TRACLEER............................... 58TRADJENTA.............................23tramadol hcl ............................... 51tramadol hcl er ........................... 52tramadol hcl er (biphasic) ..........52

Index

tramadol-acetaminophen ............52trandolapril ................................ 16trandolapril-verapamil hcl er .....18tranexamic acid .......................... 10TRANSDERM-SCOP PATCH..28tranylcypromine sulfate ..............54TRAVASOL...............................34TRAVATAN Z...........................27trazodone hcl .............................. 54TREANDA.................................12TRECATOR.................................8TRELSTAR MIXJECT..............36tretinoin ................................ 15, 60tretinoin microsphere ................. 60TREXALL..................................49triamcinolone acetonide . 23, 24, 61triamterene-hctz ..........................20TRIANEX...................................61triazolam .....................................55triderm ........................................ 61trifluoperazine hcl ...................... 56trifluridine .................................. 26trihexyphenidyl hcl ..................... 46trilyte .......................................... 29trimethoprim .................................3trimipramine maleate ................. 54trinessa (28) ................................65TRINTELLIX.............................54TRIOSTAT.................................36tri-previfem .................................65TRISENOX................................ 12tri-sprintec .................................. 65TRIUMEQ....................................6trivora (28) ................................. 65TROKENDI XR......................... 47TROPHAMINE..........................34trospium chloride ....................... 44trospium chloride er ................... 44TRULICITY...............................22TRUMENBA..............................37TRUVADA...................................6TWINRIX...................................37TYBOST...................................... 6TYGACIL...................................33TYKERB.................................... 15TYPHIM VI................................37TYSABRI...................................42UCERIS................................29, 30ULORIC..................................... 49unithroid ..................................... 36UPTRAVI.............................58, 59UROCIT-K 10............................44

Index

UROCIT-K 15............................44UROCIT-K 5..............................44ursodiol .......................................29valacyclovir hcl ............................ 6VALCHLOR.............................. 63valganciclovir hcl ......................... 6valproate sodium .................. 33, 47valproic acid ...............................47valsartan .....................................17valsartan-hydrochlorothiazide ... 18vancomycin hcl ....................... 3, 33vandazole ....................................67VAQTA...................................... 37VARIVAX..................................37VARIZIG....................................37VARUBI.....................................28VASCEPA..................................20VECTIBIX................................. 12VELCADE................................. 12velivet ..........................................65VELTASSA................................43VEMLIDY....................................6VENCLEXTA............................ 15VENCLEXTA STARTING PACK......................................... 15venlafaxine hcl ............................54venlafaxine hcl er ....................... 54VENTAVIS................................ 59VENTOLIN HFA.......................58verapamil hcl ..............................19verapamil hcl er ..........................19VERIPRED 20........................... 35VERSACLOZ............................ 56VESICARE................................ 44VIBRAMYCIN............................ 9VIDEX..........................................6VIGAMOX.................................26VIIBRYD................................... 54VIIBRYD STARTER PACK.....54VIMPAT.....................................47vinblastine sulfate .......................12vincasar pfs .................................12vincristine sulfate ....................... 12vinorelbine tartrate .....................12VIRACEPT.................................. 6VIREAD.......................................6vitamin d (ergocalciferol) ...........25VIVITROL................................. 52voriconazole ........................... 3, 33VOTRIENT................................ 15VPRIV........................................ 40VRAYLAR.................................56

80

Index

vyfemla ........................................65VYVANSE.................................53warfarin sodium ......................... 10WELCHOL.................................20XALKORI.................................. 15XARELTO................................. 10XARELTO STARTER PACK...10XELJANZ...................................49XELJANZ XR............................49XENICAL...................................25XEOMIN.................................... 39XGEVA...................................... 67XIFAXAN.................................... 4XOLAIR.....................................59XTANDI.....................................15XYREM......................................55YERVOY................................... 12YF-VAX.....................................38YONDELIS................................ 12yuvafem .......................................67zafirlukast ................................... 58zaleplon ...................................... 55ZALTRAP.................................. 12ZANOSAR................................. 12ZARXIO.......................................9ZAVESCA..................................40ZEJULA..................................... 15ZELBORAF............................... 15ZEMAIRA..................................59ZENCHENT...............................65ZENCHENT FE......................... 65ZENPEP..................................... 28ZERBAXA................................. 33ZERIT...........................................6ZIAGEN....................................... 6zidovudine .....................................6zileuton er ................................... 58ZINBRYTA................................42ZINECARD................................15ZINPLAVA................................ 38ziprasidone hcl ........................... 56ZIRGAN.....................................26ZMAX.......................................... 7zoledronic acid ........................... 67ZOLINZA...................................15zolmitriptan ................................ 45zolpidem tartrate ........................ 55zolpidem tartrate er .................... 55ZOMACTON............................. 40zonisamide .................................. 48ZONTIVITY.................................9ZORBTIVE................................ 40

Index

ZORTRESS................................ 38ZOSTAVAX...............................38zovia 1/35e (28) .......................... 65zovia 1/50e (28) .......................... 65ZOVIRAX.................................. 63ZURAMPIC............................... 15ZYDELIG...................................15ZYKADIA..................................15ZYLET....................................... 26ZYPREXA..................................56ZYPREXA RELPREVV............56ZYTIGA..................................... 15

81

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