2020 632 3T Platinum eff 09/01/2020 · 2020 632 3T Platinum eff 09/01/2020 PA - Prior Authorization...

2020 632 3T Platinum eff 09/01/2020

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol (generic of ZYLOPRIM) TABS

1

colchicine w/ probenecid 1

COLCRYS QL (120 tabs / 30 days)

2 QL

febuxostat (generic of ULORIC)

1 PA

KRYSTEXXA 3 NDS NM LA PA

MITIGARE QL (60 caps / 30 days)

3 QL

probenecid 1

NSAIDS celecoxib (generic of CELEBREX) CAPS 50mg

QL (240 caps / 30 days)

1 QL

celecoxib (generic of CELEBREX) CAPS 100mg


1 QL



1 QL



1 QL

diclofenac potassium QL (120 tabs / 30 days)

1 QL

diclofenac sodium TB24; TBEC

1

diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

diflunisal TABS 1

ec-naproxen (generic of EC-NAPROSYN) 375mg

1

ec-naproxen 500mg 1

etodolac CAPS 1

etodolac (generic of LODINE) TABS 400mg

1

etodolac TABS 500mg 1

etodolac TB24 1

flurbiprofen TABS 100mg 1

ibu tab 600mg 1

Drug Name Drug Tier

Requirements/Limits

ibu tab 800mg 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

meclofenamate sodium CAPS

1

meloxicam (generic of MOBIC) TABS

1

nabumetone TABS 1

naproxen (generic of NAPROSYN) TABS 250mg

1

naproxen TABS 375mg, 500mg

1

naproxen dr (generic of EC-NAPROSYN) 375mg

1

naproxen dr 500mg 1

naproxen sodium TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

QMIIZ ODT 3

sulindac TABS 1

tolmetin sodium 1

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

1 QL

acetaminophen w/ codeine 300-30mg


1 QL

acetaminophen w/ codeine 300-60mg


1 QL

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

1 QL

acetaminophen-caff-dihydrocod CAPS


1 QL

2020 632 3T Platinum eff 09/01/2020


2

Drug Name Drug Tier

Requirements/Limits

acetaminophen-caff-dihydrocod TABS


1 QL

BELBUCA 75mcg, 150mcg, 300mcg, 450mcg, 600mcg

QL (60 buccal films / 30 days)

2 QL PA

BELBUCA 750mcg, 900mcg QL (60 buccal films / 30 days)

3 NDS QL PA

buprenorphine patch (generic of BUTRANS)

QL (4 patches / 28 days)

1 QL PA

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

dvorah QL (300 tabs / 30 days)

1 QL

nalbuphine hcl SOLN 1

tramadol hcl CP24 QL (30 caps / 30 days)

1 QL PA

tramadol hcl TB24 QL (30 tabs / 30 days)

1 QL PA

tramadol hcl er (biphasic) 100mg


1 QL PA



1 QL PA



1 QL PA

tramadol hcl tab 50 mg (generic of ULTRAM)


1 QL

tramadol hcl tab 100 mg QL (120 tabs / 30 days)

1 QL

tramadol-acetaminophen (generic of ULTRACET)


1 QL

trezix QL (300 caps / 30 days)

1 QL

OPIOID ANALGESICS, CII ARYMO ER 15mg, 30mg

QL (90 tabs / 30 days) 3 QL PA

ARYMO ER 60mg QL (90 tabs / 30 days)

3 NDS QL PA

Drug Name Drug Tier

Requirements/Limits

CODEINE SULFATE 15mg, 60mg


3 QL

codeine sulfate 30mg QL (180 tabs / 30 days)

1 QL

endocet 2.5-325mg (generic of PERCOCET)


1 QL

endocet 5-325mg (generic of PERCOCET)


1 QL

endocet 7.5-325mg (generic of PERCOCET)


1 QL

endocet 10-325mg (generic of PERCOCET)


1 QL

fentanyl 37.5mcg/hr QL (10 patches / 30 days)

1 QL PA

fentanyl 62.5mcg/hr, 87.5mcg/hr


3 NDS QL PA

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

3 NDS QL PA

fentanyl citrate TABS QL (120 tabs / 30 days)

3 NDS QL PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)


1 QL PA



1 QL PA



1 QL PA



1 QL PA

2020 632 3T Platinum eff 09/01/2020


3

Drug Name Drug Tier

Requirements/Limits



1 QL PA

hydrocodone bitartrate (generic of ZOHYDRO ER) C12A


1 QL PA

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 7.5-300mg


1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 10-300mg


1 QL

hydrocodone-acetaminophen 10-325mg (generic of NORCO)


1 QL

hydrocodone-ibuprofen QL (150 tabs / 30 days)

1 QL

hydromorphone hcl (generic of DILAUDID) LIQD

QL (600 mL / 30 days)

1 QL

hydromorphone hcl (generic of DILAUDID) SOLN 1mg/ml, 2mg/ml

1 B/D

hydromorphone hcl SOLN 4mg/ml, 10mg/ml, 50mg/5ml, 500mg/50ml

1 B/D

hydromorphone hcl T24A 12mg, 16mg


1 QL PA

hydromorphone hcl T24A 32mg


3 NDS QL PA

Drug Name Drug Tier

Requirements/Limits

hydromorphone hcl (generic of DILAUDID) TABS


1 QL

hydromorphone hcl t24a 8mg QL (30 tabs / 30 days)

1 QL PA

HYDROMORPHONE HYDROCHLORI SOLN 1mg/ml, 2mg/ml, 4mg/ml

3 B/D

HYSINGLA ER QL (30 tabs / 30 days)

2 QL PA

KADIAN 200mg QL (60 caps / 30 days)

3 NDS QL PA

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


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

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

QL (450 mL / 30 days)

1 QL PA

methadone hcl (generic of METHADONE HCL) SOLN 10mg/ml

1

methadone hcl intensol (generic of METHADOSE)

QL (90 mL / 30 days)

1 QL PA

methadone tab 5mg (generic of DOLOPHINE)


1 QL PA

methadone tab 10mg (generic of DOLOPHINE)


1 QL PA

MORPHABOND ER 15mg QL (90 tabs / 30 days)

3 QL PA

MORPHABOND ER 30mg, 60mg, 100mg


3 NDS QL PA

morphine sul inj 1mg/ml 1 B/D

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


1 QL PA

2020 632 3T Platinum eff 09/01/2020


4

Drug Name Drug Tier

Requirements/Limits

morphine sulfate (generic of KADIAN) CP24 100mg


3 NDS QL PA

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

3 B/D

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

1 B/D

morphine sulfate TABS QL (180 tabs / 30 days)

1 QL

morphine sulfate beads QL (30 caps / 30 days)

1 QL PA

morphine sulfate ext-rel tab (generic of MS CONTIN)


1 QL PA

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

1 QL


QL (900 mL / 30 days)

1 QL


QL (180 mL / 30 days)

1 QL

NUCYNTA 50mg, 75mg QL (180 tabs / 30 days)

2 QL

NUCYNTA 100mg QL (180 tabs / 30 days)

3 NDS QL

NUCYNTA ER QL (60 tabs / 30 days)

2 QL PA

OXAYDO 5mg QL (540 tabs / 30 days)

3 QL

OXAYDO 7.5mg QL (360 tabs / 30 days)

3 NDS QL

oxycodone hcl CAPS QL (180 caps / 30 days)

1 QL

oxycodone hcl CONC QL (180 mL / 30 days)

1 QL

oxycodone hcl SOLN QL (900 mL / 30 days)

1 QL

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


1 QL

Drug Name Drug Tier

Requirements/Limits

oxycodone hcl TABS 10mg, 20mg


1 QL

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


1 QL

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


1 QL

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


1 QL

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


1 QL

oxycodone-aspirin QL (360 tabs / 30 days)

1 QL

oxycodone-ibuprofen QL (120 tabs / 30 days)

1 QL

OXYCONTIN QL (60 tabs / 30 days)

2 QL PA

oxymorphone tabs 5mg QL (180 tabs / 30 days)

1 QL

oxymorphone tabs (generic of OPANA) 10mg


1 QL

SUBSYS SPRAY 100MCG QL (120 spray units / 30 days)

3 NDS QL PA


3 NDS QL PA


3 NDS QL PA

SUBSYS SPRAY 600MCG QL (120 sprays / 30 days)

3 NDS QL PA


3 NDS QL PA


3 NDS QL PA

2020 632 3T Platinum eff 09/01/2020


5

Drug Name Drug Tier

Requirements/Limits


3 NDS QL PA

XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg


3 QL PA

XTAMPZA ER 36mg QL (240 caps / 30 days)

3 NDS QL PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%

1 B/D

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

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE)

1 B/D

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

1 B/D

lidocaine inj 2% preservative free (pf) (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 4% preservative free (pf)

1

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

ARIKAYCE 3 NDS NM LA PA

BETHKIS 3 NDS NM PA

gentamicin in saline 1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 3 NDS

SULFADIAZINE TABS 3

TOBI PODHALER 3 NDS NM LA PA

tobramycin (generic of KITABIS PAK) NEBU

3 NDS NM PA

tobramycin inj 1.2 gm/30ml 1

tobramycin inj 1.2gm 3 NDS

tobramycin inj 10mg/ml 1

Drug Name Drug Tier

Requirements/Limits

tobramycin inj 80mg/2ml 1

tobramycin sulfate SOLN 1

ZEMDRI 3 NDS

ANTI-INFECTIVES - MISCELLANEOUS AEMCOLO

QL (12 tabs / 30 days) 3 QL

albendazole (generic of ALBENZA) TABS

3 NDS

ALINIA 3 NDS

atovaquone (generic of MEPRON) SUSP

3 NDS

aztreonam (generic of AZACTAM)

1

CAYSTON 3 NDS NM LA PA

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin phosphate in d5w 1

CLINDAMYCIN PHOSPHATE IN NACL

3

clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)

1

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

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

DALVANCE 3 NDS

dapsone TABS 1

daptomycin (generic of DAPTOMYCIN) 350mg

3 NDS

daptomycin (generic of CUBICIN) 500mg

3 NDS

EMVERM QL (12 tabs / 365 days)

3 NDS QL

ertapenem sodium (generic of INVANZ)

1

FIRVANQ 3

imipenem-cilastatin 1

imipenem-cilastatin (generic of PRIMAXIN IV)

1

ivermectin (generic of STROMECTOL) TABS

1

linezolid in sodium chloride 1

2020 632 3T Platinum eff 09/01/2020


6

Drug Name Drug Tier

Requirements/Limits

linezolid inj (generic of ZYVOX)

1

linezolid susp (generic of ZYVOX)

3 NDS

linezolid tab 600mg (generic of ZYVOX)

1

meropenem (generic of MERREM)

1

MEROPENEM/SODIUM CHLORIDE

3

methenamine hippurate (generic of HIPREX)

1

metronidazole (generic of FLAGYL) CAPS; TABS

1

METRONIDAZOLE SOLN 3

metronidazole in nacl 1

metronidazole in nacl (generic of METRONIDAZOLE)

1

nitrofurantoin SUSP 3

nitrofurantoin macrocrystal (generic of MACRODANTIN)

2

nitrofurantoin monohyd macro (generic of MACROBID)

2

ORBACTIV 3 NDS

pentamidine isethionate inh (generic of NEBUPENT)

1 B/D

pentamidine isethionate inj (generic of PENTAM 300)

1

polymyxin b sulfate SOLR 1

praziquantel (generic of BILTRICIDE) TABS

1

pyrimethamine TABS 3 NDS PA

RECARBRIO 3 NDS

SIVEXTRO 3 NDS

SOLOSEC 3

sulfamethoxazole-trimethop ds (generic of BACTRIM DS)

1

sulfamethoxazole-trimethoprim inj

1

sulfamethoxazole-trimethoprim susp

1

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

1

SYNERCID 3 NDS

TIGECYCLINE 50mg 3 NDS

Drug Name Drug Tier

Requirements/Limits

tigecycline (generic of TYGACIL) 50mg

3 NDS

tinidazole TABS 1

trimethoprim TABS 1

VABOMERE 3 NDS

vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg


1 QL

vancomycin hcl (generic of VANCOCIN) CAPS 250mg


3 NDS QL

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

1

VANCOMYCIN HYDROCHLORIDE SOLN 500mg/100ml, 1000mg/200ml, 1500mg/300ml, 2000mg/400ml

3

VANCOMYCIN HYDROCHLORIDE SOLR

3

VANCOMYCIN IN NACL 3

VANCOMYCIN INJ 250MG 3

VIBATIV 3 NDS

XENLETA 3 NDS NM

XIFAXAN TAB 200MG QL (9 tabs / 30 days)

3 NDS QL

ZYVOX SOLN 200mg/100ml 3 NDS

ANTIFUNGALS ABELCET 3 NDS B/D

AMBISOME 3 NDS B/D

amphotericin b SOLR 1 B/D

CASPOFUNGIN ACETATE 50mg, 70mg

3 NDS

caspofungin acetate (generic of CANCIDAS) 50mg, 70mg

3 NDS

CRESEMBA 3 NDS

ERAXIS 50mg 3

ERAXIS 100mg 3 NDS

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole inj nacl 200 1

fluconazole inj nacl 400 1

flucytosine (generic of ANCOBON) CAPS

3 NDS

griseofulvin microsize 1

2020 632 3T Platinum eff 09/01/2020


7

Drug Name Drug Tier

Requirements/Limits

griseofulvin ultramicrosize 1

itraconazole (generic of SPORANOX) CAPS

1 PA

itraconazole (generic of SPORANOX) SOLN

3 NDS

ketoconazole TABS 1 PA

micafungin sodium (generic of MYCAMINE)

3 NDS

MYCAMINE 3 NDS

NOXAFIL SOLN 3 NDS

NOXAFIL SUSP QL (630 mL / 30 days)

3 NDS QL

nystatin TABS 1

posaconazole (generic of NOXAFIL)


3 NDS QL

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

1 QL

TOLSURA 3 NDS PA

voriconazole (generic of VFEND) SUSR

3 NDS PA

voriconazole (generic of VFEND) TABS 50mg

1

voriconazole (generic of VFEND) TABS 200mg

3 NDS

voriconazole inj 200mg (generic of VFEND IV)

3 NDS PA

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)

1

atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)

1

chloroquine phosphate TABS

1

COARTEM 3

KRINTAFEL 3

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 26.3mg

3

primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg

1

Drug Name Drug Tier

Requirements/Limits

quinine sulfate (generic of QUALAQUIN) CAPS

1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1 NM

APTIVUS 3 NDS NM

atazanavir sulfate (generic of REYATAZ)

1 NM

CRIXIVAN 3 NM

didanosine 1 NM

EDURANT 3 NDS NM

efavirenz (generic of SUSTIVA) CAPS 50mg

1 NM

efavirenz (generic of SUSTIVA) CAPS 200mg

3 NDS NM

efavirenz (generic of SUSTIVA) TABS

3 NDS NM

EMTRIVA 2 NM

fosamprenavir tab 700 mg (generic of LEXIVA)

3 NDS NM

FUZEON 3 NDS NM

INTELENCE 25mg 2 NM

INTELENCE 100mg, 200mg 3 NDS NM

INVIRASE 3 NDS NM

ISENTRESS CHEW 25mg 2 NM

ISENTRESS CHEW 100mg 3 NDS NM

ISENTRESS PACK 2 NM

ISENTRESS TABS 3 NDS NM

ISENTRESS HD 3 NDS NM

lamivudine (generic of EPIVIR)

1 NM

LEXIVA SUSP 3 NM

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

1 NM

nevirapine tab 100mg er 1 NM

nevirapine tab 200mg (generic of VIRAMUNE)

1 NM

nevirapine tab 400mg er (generic of VIRAMUNE XR)

1 NM

NORVIR PACK 2 NM

NORVIR SOLN 2 NM

PIFELTRO 3 NDS NM

PREZISTA SUSP QL (400 mL / 30 days)

3 NDS QL NM

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

2 QL NM

2020 632 3T Platinum eff 09/01/2020


8

Drug Name Drug Tier

Requirements/Limits


3 NDS QL NM


3 NDS QL NM


3 NDS QL NM

REYATAZ PACK 3 NDS NM

ritonavir (generic of NORVIR) 1 NM

SELZENTRY SOLN 3 NDS NM

SELZENTRY TABS 25mg 3 NM

SELZENTRY TABS 75mg, 150mg, 300mg

3 NDS NM

stavudine 15mg, 20mg 1 NM

stavudine (generic of ZERIT) 30mg, 40mg

1 NM

tenofovir disoproxil fumarate (generic of VIREAD)

1 NM

TIVICAY 10mg 2 NM

TIVICAY 25mg, 50mg 3 NDS NM

TIVICAY PD 2 NM

TROGARZO 3 NDS NM LA

TYBOST 3 NM

VIRACEPT 3 NDS NM

VIREAD POWD 3 NDS NM

VIREAD TABS 150mg, 200mg, 250mg

3 NDS NM

zidovudine cap 100mg (generic of RETROVIR)

1 NM

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

1 NM

zidovudine tab 300mg 1 NM

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of EPZICOM)

1 NM

abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

3 NDS NM

ATRIPLA 3 NDS NM

BIKTARVY 3 NDS NM

CIMDUO 3 NDS NM

COMPLERA 3 NDS NM

DELSTRIGO 3 NDS NM

DESCOVY 3 NDS NM

DOVATO 3 NDS NM

EVOTAZ 3 NDS NM

Drug Name Drug Tier

Requirements/Limits

GENVOYA 3 NDS NM

JULUCA 3 NDS NM

KALETRA TAB 100-25MG 2 NM

KALETRA TAB 200-50MG 3 NDS NM

lamivudine-zidovudine (generic of COMBIVIR)

1 NM

lopinavir-ritonavir (generic of KALETRA)

1 NM

ODEFSEY 3 NDS NM

PREZCOBIX 3 NDS NM

STRIBILD 3 NDS NM

SYMFI 3 NDS NM

SYMFI LO 3 NDS NM

SYMTUZA 3 NDS NM

TEMIXYS 3 NDS NM

TRIUMEQ 3 NDS NM

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

3 NDS QL NM


3 NDS QL NM


3 NDS QL NM


3 NDS QL NM

ANTITUBERCULAR AGENTS cycloserine CAPS 3 NDS

ethambutol hcl TABS 100mg 1

ethambutol hcl (generic of MYAMBUTOL) TABS 400mg

1

isoniazid SYRP 1

isoniazid tabs 1

PASER D/R 3

PRETOMANID 3

PRIFTIN 3

pyrazinamide TABS 1

rifabutin (generic of MYCOBUTIN)

1

rifampin (generic of RIFADIN) CAPS; SOLR

1

SIRTURO 100mg 3 NDS LA PA

TRECATOR 3

ANTIVIRALS acyclovir CAPS 1

acyclovir (generic of ZOVIRAX) SUSP; TABS

1

2020 632 3T Platinum eff 09/01/2020


9

Drug Name Drug Tier

Requirements/Limits

acyclovir sodium 1 B/D

adefovir dipivoxil (generic of HEPSERA)

3 NDS NM

BARACLUDE SOLN 3 NDS NM

cidofovir 3 NDS

entecavir (generic of BARACLUDE)

1 NM

EPCLUSA 3 NDS NM PA

EPIVIR HBV SOLN 3 NM

famciclovir TABS 1

GANCICLOVIR INJ 500MG/10ML

3 B/D

ganciclovir sodium (generic of CYTOVENE)

1 B/D

HARVONI 3 NDS NM PA

lamivudine (hbv) (generic of EPIVIR HBV)

1 NM

MAVYRET 3 NDS NM PA

oseltamivir phosphate (generic of TAMIFLU) CAPS; SUSR

1

PEGASYS 3 NDS NM PA

PEGASYS PROCLICK 3 NDS NM PA

PREVYMIS INJ 3 NDS

PREVYMIS TABS QL (28 tabs / 28 days)

3 NDS QL

RELENZA DISKHALER 2

ribavirin 200mg 1 NM

rimantadine hydrochloride 1

SITAVIG QL (2 tabs / 30 days)

3 NDS QL PA

valacyclovir hcl (generic of VALTREX) TABS

1

valganciclovir hcl (generic of VALCYTE)

3 NDS

VEMLIDY 3 NDS NM

VOSEVI 3 NDS NM PA

XOFLUZA 3

CEPHALOSPORINS AVYCAZ 3 NDS

cefaclor 1

CEFACLOR ER TAB 500MG 3

cefadroxil 1

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 1

Drug Name Drug Tier

Requirements/Limits

cefazolin sodium SOLR 1gm 1

CEFAZOLIN SODIUM 1 GM/50ML

3

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm 1

cefepime inj 2gm 1

CEFEPIME/DEXTROSE 3

cefixime (generic of SUPRAX) 1

cefotetan disodium (generic of CEFOTAN)

1

CEFOXITIN SODIUM 3

cefoxitin sodium 1gm, 2gm, 10gm

1

cefpodoxime proxetil 1

cefprozil 1

ceftazidime SOLR 1

CEFTAZIDIME/DEXTROSE 3

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

1

cefuroxime axetil 1

cefuroxime sodium 1

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

FETROJA 3 NDS

SUPRAX CHEW 2

SUPRAX SUSR 500mg/5ml 2

tazicef SOLR 1

TEFLARO 3 NDS

ZERBAXA 3 NDS

ERYTHROMYCINS/MACROLIDES azithromycin PACK 1

azithromycin (generic of ZITHROMAX) SOLR

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS 250mg, 500mg

1

azithromycin TABS 600mg 1

clarithromycin SUSR; TABS 1

2020 632 3T Platinum eff 09/01/2020


10

Drug Name Drug Tier

Requirements/Limits

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 3 NDS

ery-tab 1

ERYTHROCIN LACTOBIONATE

3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate (generic of E.E.S. GRANULES) SUSR 200mg/5ml

1

erythromycin ethylsuccinate (generic of ERYPED 400) SUSR 400mg/5ml

3 NDS

erythromycin ethylsuccinate TABS

1

erythromycin tab ec 1

FLUOROQUINOLONES BAXDELA 3 NDS

CIPRO SUSR 3

CIPRO SUSP 3

ciprofloxacin hcl TABS 100mg, 750mg

1

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

1

ciprofloxacin in d5w 1

levofloxacin SOLN 1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 1

moxifloxacin hcl TABS 1

moxifloxacin hcl in sodium chloride

1

MOXIFLOXACIN HYDROCHLORID SOLN 400mg/250ml

3

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate 200-28.5 chw tabs

1

amoxicillin & pot clavulanate 200/5ml susr

1

Drug Name Drug Tier

Requirements/Limits

amoxicillin & pot clavulanate 250-125 tabs

1

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

1

amoxicillin & pot clavulanate 400-57 chw tabs

1


1

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

1


1

amoxicillin & pot clavulanate 875-125 tabs

1

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin cap 500mg 1

ampicillin inj 1

ampicillin sodium 1

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

NAFCILLIN IN DEXTROSE 3

nafcillin sodium 1gm, 2gm 1

nafcillin sodium 10gm 3 NDS

NAFCILLIN SODIUM FOR INJ 10GM

3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 3 NDS

PENICILLIN G POT IN DEXTROSE 1MU

3


3


3

PENICILLIN G PROCAINE 3

penicillin g sodium 1

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11

Drug Name Drug Tier

Requirements/Limits

penicillin v potassium 1

penicilln gk inj 5mu 1

penicilln gk inj 20mu 1

pfizerpen-g inj 5mu 1

pfizerpen-g inj 20mu 1

piper/tazoba inj 2-0.25gm 1





ZOSYN 3

TETRACYCLINES demeclocycline hcl 1

doxy 100 1

doxycycline (monohydrate) CAPS; TABS

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 20mg, 50mg, 100mg

1

doxycycline hyclate (generic of ACTICLATE) TABS 75mg, 150mg

1

doxycycline hyclate (generic of DORYX) TBEC

1

doxycycline hyclate tab 75 mg dr

1


1


1

minocycline hcl CAPS 50mg, 75mg

1

minocycline hcl (generic of MINOCIN) CAPS 100mg

1

minocycline hcl TABS 1

minocycline tab 45mg er 1 PA

Drug Name Drug Tier

Requirements/Limits

minocycline tab 55mg er (generic of SOLODYN)

3 NDS PA


3 NDS PA


3 NDS PA



3 NDS PA


3 NDS PA


MINOLIRA 3 PA

mondoxyne nl cap 75mg 1

mondoxyne nl cap 100mg 1

tetracycline hcl CAPS 1

VIBRAMYCIN SYRP 2

XIMINO 3 NDS PA

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 3 NDS B/D NM

cyclophosphamide CAPS 1 B/D

cyclophosphamide SOLR 3 NDS B/D

dacarbazine 100mg 1 B/D

EMCYT 2

GLEOSTINE 10mg 3

GLEOSTINE 40mg, 100mg 3 NDS

IFEX INJ 3GM 3 B/D

ifosfamide SOLN 1 B/D

IFOSFAMIDE INJ 3GM 3 B/D

LEUKERAN 3 NDS

TREANDA 3 NDS B/D NM

ANTHRACYCLINES adriamycin SOLN 1 B/D

doxorubicin hcl 1 B/D

doxorubicin hcl liposomal (generic of DOXIL)

3 NDS B/D

epirubicin hcl 50mg/25ml 1 B/D

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

1 B/D

ANTIBIOTICS bleomycin sulfate 1 B/D

mitomycin SOLR 5mg 1 B/D

mitomycin SOLR 20mg, 40mg

3 NDS B/D

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12

Drug Name Drug Tier

Requirements/Limits

valrubicin (generic of VALSTAR)

3 NDS NM

ANTIMETABOLITES adrucil inj 1 B/D

ALIMTA 3 NDS B/D

azacitidine (generic of VIDAZA)

3 NDS B/D NM

cytarabine 1 B/D

decitabine (generic of DACOGEN)

3 NDS B/D NM

fludarabine phosphate SOLN 3 NDS B/D

fludarabine phosphate SOLR 1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 3 NDS NM PA

gemcitabine inj soln 1gm/10ml, 2gm/20ml, 200mg/2ml

1 B/D

gemcitabine inj soln (generic of GEMCITABINE) 1gm/26.3ml, 2gm/52.6ml, 200mg/5.26ml

1 B/D

gemcitabine inj solr 1 B/D

INFUGEM 3 NDS B/D

mercaptopurine TABS 1

methotrexate sodium inj soln 1 B/D

methotrexate sodium inj solr 1 B/D

NIPENT 3 NDS B/D

PURIXAN 3 NDS NM

TABLOID 3 NDS

ANTIMITOTIC, TAXOIDS ABRAXANE 3 NDS B/D

docetaxel CONC 20mg/ml 3 NDS B/D

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

3 NDS B/D

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

3 NDS B/D

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

3 NDS B/D

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

3 NDS B/D

Drug Name Drug Tier

Requirements/Limits

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

3 NDS B/D

JEVTANA 3 NDS NM PA

paclitaxel 1 B/D

TAXOTERE 3 NDS B/D

ANTIMITOTIC, VINCA ALKALOIDS MARQIBO 3 NDS B/D NM

vinblastine sulfate 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERS ADAKVEO 3 NDS NM PA

ARZERRA 3 NDS B/D NM

AVASTIN 3 NDS NM LA PA

BAVENCIO 3 NDS NM LA PA

BELEODAQ 3 NDS NM PA

BESPONSA 3 NDS NM LA PA

BORTEZOMIB 3 NDS NM PA

CYRAMZA 3 NDS NM LA PA

DARZALEX 3 NDS NM LA PA

DARZALEX FASPRO 3 NDS NM PA

DAURISMO 3 NDS NM LA PA

EMPLICITI 3 NDS NM LA PA

ENHERTU 3 NDS NM LA PA

ERBITUX 3 NDS B/D NM

ERIVEDGE 3 NDS NM LA PA

FARYDAK 3 NDS NM LA PA

GAZYVA 3 NDS NM LA PA

HERCEPTIN 3 NDS NM PA

HERCEPTIN HYLECTA 3 NDS NM PA

HERZUMA 3 NDS NM PA

IBRANCE CAPS QL (21 caps / 28 days)

3 NDS QL NM LA PA

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Drug Name Drug Tier

Requirements/Limits

IBRANCE TABS QL (21 tabs / 28 days)

3 NDS QL NM LA PA

IDHIFA QL (30 tabs / 30 days)

3 NDS QL NM LA PA

IMFINZI 3 NDS NM LA PA

KADCYLA 3 NDS B/D NM

KANJINTI 3 NDS NM PA

KEYTRUDA 3 NDS NM PA

KISQALI 3 NDS NM PA

KISQALI FEMARA 200 DOSE 3 NDS NM PA



KYPROLIS 3 NDS NM LA PA

LARTRUVO 3 NDS NM LA PA

LIBTAYO 3 NDS NM LA PA

LUMOXITI 3 NDS NM LA PA

LYNPARZA 3 NDS NM LA PA

MVASI 3 NDS NM LA PA

MYLOTARG 3 NDS NM LA PA

NINLARO 3 NDS NM PA

ODOMZO 3 NDS NM LA PA

OGIVRI 3 NDS NM PA

ONTRUZANT 3 NDS NM PA

OPDIVO 3 NDS NM LA PA

PADCEV 3 NDS NM LA PA

PERJETA 3 NDS NM PA

POLIVY 3 NDS NM PA

PORTRAZZA 3 NDS NM LA PA

POTELIGEO 3 NDS NM LA PA

RITUXAN 3 NDS NM LA PA

RITUXAN HYCELA 3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

RUBRACA 3 NDS NM LA PA

RUXIENCE 3 NDS NM PA

SARCLISA 3 NDS NM LA PA

TALZENNA 3 NDS NM LA PA

TECENTRIQ 3 NDS NM LA PA

temsirolimus (generic of TORISEL)

3 NDS B/D NM

TIBSOVO 3 NDS NM LA PA

TRAZIMERA 3 NDS NM PA

TRODELVY 3 NDS NM LA PA

TRUXIMA 3 NDS NM PA

VECTIBIX 3 NDS B/D NM

VELCADE 3 NDS NM PA

VENCLEXTA 10mg 3 NM LA PA

VENCLEXTA 50mg, 100mg 3 NDS NM LA PA

VENCLEXTA STARTING PACK

3 NDS NM LA PA

VERZENIO 3 NDS NM LA PA

YERVOY 3 NDS NM PA

ZALTRAP 3 NDS NM LA PA

ZEJULA 3 NDS NM LA PA

ZIRABEV 3 NDS NM PA

ZOLINZA 3 NDS NM PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)

3 NDS NM PA

anastrozole (generic of ARIMIDEX) TABS

1

bicalutamide (generic of CASODEX)

1

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 2 B/D NM

ELIGARD INJ 22.5MG 2 B/D NM

ELIGARD INJ 30MG 2 B/D NM

ELIGARD INJ 45MG 2 B/D NM

ERLEADA 3 NDS NM LA PA

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14

Drug Name Drug Tier

Requirements/Limits

exemestane (generic of AROMASIN)

1

FIRMAGON 80mg 3 B/D NM

FIRMAGON 120mg/vial 3 NDS B/D NM

flutamide 1

fulvestrant (generic of FASLODEX)

3 NDS B/D

hydroxyprogesterone caproate (antineoplastic)

3 NDS B/D

letrozole (generic of FEMARA) TABS

1

leuprolide inj 1mg/0.2 1 NM PA

LUPRON DEPOT (1-MONTH) 3 NDS NM PA

LUPRON DEPOT (6-MONTH) 3 NDS NM PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

3 NDS NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

3 NDS NM PA

LUPRON DEPOT INJ 30MG (4-MONTH)

3 NDS NM PA

LYSODREN 2

megestrol ac sus 40mg/ml 2

megestrol ac tab 20mg 2

megestrol ac tab 40mg 2

megestrol sus 625mg/5ml 3 PA

nilutamide (generic of NILANDRON)

3 NDS

NUBEQA 3 NDS NM LA PA

SOLTAMOX 3 NDS

tamoxifen citrate TABS 1

toremifene citrate (generic of FARESTON)

3 NDS

TRELSTAR MIXJECT 3 NDS NM PA

VANTAS 3 NM PA

XTANDI 3 NDS NM LA PA

ZOLADEX 3 NM PA

ZYTIGA 500mg 3 NDS NM LA PA

IMMUNOMODULATORS POMALYST 1mg, 2mg

QL (21 caps / 21 days) 3 NDS QL NM

LA PA

POMALYST 3mg, 4mg QL (21 caps / 28 days)

3 NDS QL NM LA PA

Drug Name Drug Tier

Requirements/Limits

REVLIMID 3 NDS NM LA PA

THALOMID 3 NDS NM PA

KINASE INHIBITORS AFINITOR 10mg

QL (30 tabs / 30 days) 3 NDS QL NM

PA

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

3 NDS QL NM PA


3 NDS QL NM PA


3 NDS QL NM PA

ALECENSA 3 NDS NM LA PA

ALIQOPA 3 NDS NM LA PA

ALUNBRIG 3 NDS NM LA PA

AYVAKIT QL (30 tabs / 30 days)

3 NDS QL NM LA PA

BALVERSA 3 NDS NM LA PA

BOSULIF 3 NDS NM PA

BRAFTOVI 3 NDS NM LA PA

BRUKINSA 3 NDS NM LA PA

CABOMETYX QL (30 tabs / 30 days)

3 NDS QL NM LA PA

CALQUENCE 3 NDS NM LA PA

CAPRELSA 3 NDS NM LA PA

COMETRIQ 3 NDS NM LA PA

COPIKTRA 3 NDS NM LA PA

COTELLIC 3 NDS NM LA PA

erlotinib hcl (generic of TARCEVA) 25mg


3 NDS QL NM PA

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


3 NDS QL NM PA

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15

Drug Name Drug Tier

Requirements/Limits

everolimus (generic of AFINITOR)


3 NDS QL NM PA

GILOTRIF TAB 20MG 3 NDS NM LA PA



ICLUSIG 3 NDS NM LA PA

imatinib mesylate (generic of GLEEVEC) 100mg


3 NDS QL NM PA

imatinib mesylate (generic of GLEEVEC) 400mg


3 NDS QL NM PA

IMBRUVICA 3 NDS NM LA PA

INLYTA 1mg QL (180 tabs / 30 days)

3 NDS QL NM LA PA

INLYTA 5mg QL (120 tabs / 30 days)

3 NDS QL NM LA PA

INREBIC 3 NDS NM LA PA

IRESSA 3 NDS NM LA PA

JAKAFI QL (60 tabs / 30 days)

3 NDS QL NM LA PA

KOSELUGO 3 NDS NM LA PA

LENVIMA 4 MG DAILY DOSE 3 NDS NM LA PA

LENVIMA 8 MG DAILY DOSE 3 NDS NM LA PA

LENVIMA 10 MG DAILY DOSE

3 NDS NM LA PA

LENVIMA 12MG DAILY DOSE

3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

LORBRENA 3 NDS NM LA PA

MEKINIST 3 NDS NM LA PA

MEKTOVI 3 NDS NM LA PA

NERLYNX 3 NDS NM LA PA

NEXAVAR 3 NDS NM LA PA

PEMAZYRE 3 NDS NM LA PA

PIQRAY 200MG DAILY DOSE

3 NDS NM PA


3 NDS NM PA


3 NDS NM PA

QINLOCK 3 NDS NM LA PA

RETEVMO 3 NDS NM LA PA

ROZLYTREK 3 NDS NM LA PA

RYDAPT 3 NDS NM PA

SPRYCEL 3 NDS NM PA

STIVARGA 3 NDS NM LA PA

SUTENT QL (30 caps / 30 days)

3 NDS QL NM PA

TABRECTA 3 NDS NM PA

TAFINLAR 3 NDS NM LA PA

TAGRISSO QL (30 tabs / 30 days)

3 NDS QL NM LA PA

TASIGNA 3 NDS NM PA

TUKYSA 3 NDS NM LA PA

TURALIO 3 NDS NM LA PA

TYKERB 3 NDS NM LA PA

VITRAKVI 3 NDS NM LA PA

VIZIMPRO 3 NDS NM LA PA

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16

Drug Name Drug Tier

Requirements/Limits

VOTRIENT 3 NDS NM LA PA

XALKORI 3 NDS NM LA PA

XOSPATA 3 NDS NM LA PA

ZELBORAF 3 NDS NM LA PA

ZYDELIG 3 NDS NM LA PA

ZYKADIA 3 NDS NM LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

3 NDS NM PA

ERWINAZE 3 NDS NM LA PA

HALAVEN 3 NDS B/D NM

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 3 NDS B/D NM

LONSURF 3 NDS NM PA

MATULANE 3 NDS LA

mitoxantrone hcl 1 B/D NM

SIKLOS 100mg 3

SIKLOS 1000mg 3 NDS

SYLATRON 3 NDS NM PA

SYLVANT 3 NDS NM LA PA

SYNRIBO 3 NDS NM PA

TAZVERIK 3 NDS NM LA PA

tretinoin CAPS 3 NDS

XPOVIO 40 MG ONCE WEEKLY

3 NDS NM LA PA

XPOVIO 40 MG TWICE WEEKLY

3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA


3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin SOLN 1 B/D

oxaliplatin inj 50mg 3 NDS B/D

oxaliplatin inj 50mg/10ml 1 B/D

oxaliplatin inj 100mg 3 NDS B/D

oxaliplatin inj 100mg/20ml 1 B/D

PROTECTIVE AGENTS dexrazoxane hcl 3 NDS B/D

ELITEK 3 NDS B/D

KHAPZORY 3 NDS B/D NM

leucovorin calcium SOLN 500mg/50ml

1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

levoleucovorin calcium 175mg/17.5ml

3 NDS B/D NM

levoleucovorin calcium 250mg/25ml

1 B/D NM

levoleucovorin calcium 50mg 3 NDS B/D NM

MESNEX TABS 3 NDS

TOTECT 3 NDS B/D

ZINECARD 3 NDS B/D

TOPOISOMERASE INHIBITORS ETOPOPHOS 3 B/D

etoposide SOLN 1 B/D

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

1 B/D

irinotecan hcl 300mg/15ml, 500mg/25ml

1 B/D

ONIVYDE 3 NDS B/D NM

toposar 1 B/D

topotecan hcl (generic of TOPOTECAN HCL) SOLN

3 NDS B/D

topotecan hcl (generic of HYCAMTIN) SOLR

3 NDS B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

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17

Drug Name Drug Tier

Requirements/Limits

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril-hydrochlorothiazide tab 10/12.5mg

1

fosinopril-hydrochlorothiazide tab 20/12.5mg

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

trandolapril-verapamil hcl 1

trandolapril-verapamil hcl (generic of TARKA)

1

ACE INHIBITORS benazepril hcl TABS 5mg 1

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

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

EPANED 3 NDS

fosinopril sodium 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 5mg, 30mg, 40mg

1

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

1

moexipril hcl 1

perindopril erbumine 1

QBRELIS 3 NDS

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril 1mg, 2mg 1

trandolapril (generic of MAVIK) 4mg

1

Drug Name Drug Tier

Requirements/Limits

ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR 3

eplerenone (generic of INSPRA)

1

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) TABS

1

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR)

1

amlodipine besylate-valsartan (generic of EXFORGE)

1

amlodipine-valsartan-hydrochlorothiazide (generic of EXFORGE HCT)

1

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

ENTRESTO 2

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide tab 100-12.5mg (generic of HYZAAR)

1

losartan-hydrochlorothiazide tab 100-25mg (generic of HYZAAR)

1

losartan-hydrochlorothiazidetab 50-12.5mg (generic of HYZAAR)

1

olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)

1

olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)

1

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18

Drug Name Drug Tier

Requirements/Limits

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil (generic of ATACAND)

1

EDARBI 3

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR) TABS

1

olmesartan medoxomil (generic of BENICAR) TABS

1

telmisartan (generic of MICARDIS)

1

valsartan (generic of DIOVAN) 1

ANTIARRHYTHMICS amiodarone hcl soln 1

amiodarone tab 100mg 1



disopyramide phosphate (generic of NORPACE)

3

dofetilide (generic of TIKOSYN)

1 NM

flecainide acetate 1

MULTAQ 2

NORPACE CR 3

pacerone 1

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl TABS 1

quinidine sulfate 1

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

1

sorine 240mg 1

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

1

sotalol hcl 240mg 1

Drug Name Drug Tier

Requirements/Limits

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

1

SOTYLIZE 3

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3 NDS

atorvastatin calcium (generic of LIPITOR) TABS

1

EZALLOR SPRINKLE 3

FLOLIPID 3

fluvastatin sodium CAPS 1

fluvastatin sodium (generic of LESCOL XL) TB24

1

LIVALO 3

lovastatin 1

pravastatin sodium 10mg, 80mg

1

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

1

rosuvastatin calcium (generic of CRESTOR)

1

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

1

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ZYPITAMAG 3

ANTILIPEMICS, MISCELLANEOUS ANTARA 3

cholestyramine (generic of QUESTRAN)

1

cholestyramine light pack 1

cholestyramine light powd (generic of QUESTRAN LIGHT)

1

choline fenofibrate (generic of TRILIPIX)

1

colesevelam hcl (generic of WELCHOL)

1

colestipol hcl gran (generic of COLESTID)

1

colestipol hcl pack (generic of COLESTID)

1

colestipol hcl tabs (generic of COLESTID)

1

2020 632 3T Platinum eff 09/01/2020


19

Drug Name Drug Tier

Requirements/Limits

ezetimibe (generic of ZETIA) 1

ezetimibe-simvastatin (generic of VYTORIN)

1

fenofibrate CAPS 1

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

1

fenofibrate TABS 54mg, 160mg

1

fenofibrate micronized 1

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 3 NDS NM LA PA

NEXLETOL QL (30 tabs / 30 days)

3 QL PA

NEXLIZET QL (30 tabs / 30 days)

3 QL PA

niacin (antihyperlipidemic) 1

niacin er (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

omega-3-acid ethyl esters (generic of LOVAZA)

1 PA

PRALUENT 2 NM PA

prevalite PACK 1

prevalite (generic of QUESTRAN LIGHT) POWD

1

TRIGLIDE 3

VASCEPA 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

metoprolol & hydrochlorothiazide

1

metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT)

1

propranolol & hydrochlorothiazide

1

Drug Name Drug Tier

Requirements/Limits

BETA-BLOCKERS acebutolol hcl CAPS 1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl 1

bisoprolol fumarate 1

BYSTOLIC 2

carvedilol (generic of COREG) 1

carvedilol er (generic of COREG CR)

1

KAPSPARGO SPRINKLE 3

labetalol hcl SOLN; TABS 1

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate SOCT 1

metoprolol tartrate SOLN 1

metoprolol tartrate TABS 25mg, 37.5mg, 75mg

1

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

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol cap er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

propranolol oral sol 1

propranolol tab 1

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

1

amlodipine besylate-atorvastatin calcium (generic of CADUET)

1

CALCIUM CHANNEL BLOCKERS amlodipine besylate (generic of NORVASC) TABS

1

CARDIZEM LA 120mg 3

cartia xt (generic of CARDIZEM CD)

1

dilt-xr 1

2020 632 3T Platinum eff 09/01/2020


20

Drug Name Drug Tier

Requirements/Limits

diltiazem cd (generic of CARDIZEM CD)

1

diltiazem er tab 180mg (generic of CARDIZEM LA)

1


1


1


1


1

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

1

diltiazem hcl TABS 90mg 1

diltiazem hcl cap er/12hr 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD) 120mg

1

diltiazem hcl coated beads cap sr 24hr (generic of TIAZAC) 120mg

1

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

1

diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg, 300mg

1

diltiazem inj 1

felodipine 1

isradipine 1

KATERZIA 3

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

NICARDIPINE HYDROCHLORIDE SOLN

3

nifedipine TB24 30mg, 60mg, 90mg

1

Drug Name Drug Tier

Requirements/Limits

nifedipine (generic of PROCARDIA XL) TB24 30mg, 60mg, 90mg

1

nimodipine CAPS 3 NDS

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NYMALIZE 3 NDS

taztia xt (generic of TIAZAC) 1

tiadylt er (generic of TIAZAC) 1

verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

verapamil hcl CP24 300mg, 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 1

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

1

verapamil hcl TBCR 180mg 1

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) .25mg

PA if 70 years and older

1 PA

digitek (generic of LANOXIN) .125mg


1 QL

digox (generic of LANOXIN) 125mcg


1 QL

digox (generic of LANOXIN) 250mcg


1 PA

digoxin (generic of LANOXIN) TABS 125mcg


1 QL

digoxin (generic of LANOXIN) TABS 250mcg


1 PA

digoxin inj (generic of LANOXIN)

1

2020 632 3T Platinum eff 09/01/2020


21

Drug Name Drug Tier

Requirements/Limits

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

1 PA

LANOXIN PEDIATRIC INJ 3

LANOXIN TABS 62.5MCG QL (60 tabs / 30 days)

2 QL

DIURETICS acetazolamide CP12; TABS 1

ALDACTAZIDE 3

amiloride & hydrochlorothiazide

1

amiloride hcl TABS 1

bumetanide SOLN 1

bumetanide (generic of BUMEX) TABS

1

chlorothiazide TABS 1

chlorthalidone 1

DIURIL 3

ethacrynic acid (generic of EDECRIN)

3 NDS

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide oral soln 8 mg/ml 1

furosemide oral soln 10 mg/ml 1

hydrochlorothiazide CAPS; TABS

1

indapamide 1

KEVEYIS 3 NDS NM PA

methazolamide TABS 1

metolazone 1

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide 1

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

1

triamterene & hydrochlorothiazide tab 37.5-25mg (generic of MAXZIDE-25)

1

Drug Name Drug Tier

Requirements/Limits

triamterene & hydrochlorothiazide tab 75-50mg (generic of MAXZIDE)

1

MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)

1

BIDIL 2

clonidine hcl (generic of CATAPRES) TABS

1

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

1


1


1

CORLANOR SOL 5MG/5ML 3

CORLANOR TAB 5MG 2

CORLANOR TAB 7.5MG 2

DEMSER 3 NDS PA

hydralazine hcl SOLN; TABS 1

midodrine hcl 1

minoxidil TABS 1

NORTHERA 100mg QL (90 caps / 30 days)

3 NDS QL NM LA PA

NORTHERA 200mg, 300mg QL (180 caps / 30 days)

3 NDS QL NM LA PA

phenoxybenzamine hcl (generic of DIBENZYLINE) CAPS

3 NDS PA

ranolazine (generic of RANEXA)

1

TEKTURNA HCT 2

VYNDAMAX QL (30 caps / 30 days)

3 NDS QL NM LA PA

VYNDAQEL 3 NDS NM LA PA

NITRATES DILATRATE SR 3

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

1

isosorbide dinitrate 10mg, 20mg, 30mg

1

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22

Drug Name Drug Tier

Requirements/Limits

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 40mg

3 NDS

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran (generic of NITRO-DUR)

1

NITRO-BID 2

NITRO-DUR .3mg/hr, .8mg/hr

2

nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) SOLN .4mg/spray

1

nitroglycerin (generic of NITROSTAT) SUBL

1

nitroglycerin td patch 1

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 3 NDS NM LA

PA

alyq (generic of ADCIRCA) 3 NDS NM PA

ambrisentan (generic of LETAIRIS)

3 NDS NM LA PA

bosentan (generic of TRACLEER)

3 NDS NM LA PA

epoprostenol sodium (generic of FLOLAN)

3 NDS B/D NM LA

FLOLAN 3 NDS B/D NM LA

OPSUMIT 3 NDS NM LA PA

ORENITRAM .25mg, 1mg, 2.5mg, 5mg

3 NDS NM LA PA

ORENITRAM .125mg 2 NM LA PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO)

3 NDS NM PA

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

1 NM PA

tadalafil (pulmonary hypertension) (generic of ADCIRCA)

3 NDS NM PA

TRACLEER TBSO 3 NDS NM LA PA

treprostinil 3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

TYVASO 3 NDS NM PA

UPTRAVI 3 NDS NM LA PA

VELETRI 3 NDS B/D NM LA

VENTAVIS 3 NDS NM PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM INTENSOL

QL (300 mL / 30 days) 3 QL

alprazolam tab 0.5mg (generic of XANAX)


1 QL

alprazolam tab 0.25mg (generic of XANAX)


1 QL

alprazolam tab 1mg (generic of XANAX)


1 QL

alprazolam tab 2mg (generic of XANAX)


1 QL

buspirone hcl TABS 1

fluvoxamine cap er 100mg QL (90 caps / 30 days)

1 QL

fluvoxamine cap er 150mg QL (60 caps / 30 days)

1 QL

fluvoxamine tab 25mg 1



lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

lorazepam intensol QL (150 mL / 30 days)

1 QL

ANTICONVULSANTS APTIOM 3 NDS

BANZEL 3 NDS PA

BRIVIACT INJ 50MG/5ML 3 PA

BRIVIACT SOL 10MG/ML 3 NDS PA

BRIVIACT TAB 10MG 3 NDS PA




2020 632 3T Platinum eff 09/01/2020


23

Drug Name Drug Tier

Requirements/Limits


carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CELONTIN 3

clobazam (generic of ONFI) 1 PA

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

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


1 QL

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

1 QL

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


1 QL

clorazepate dipotassium QL (180 tabs / 30 days)


1 QL PA

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

diazepam (generic of VALIUM) TABS

QL (120 tabs / 30 days) PA if 65 years and older

1 QL PA

diazepam gel 1

diazepam inj 1

diazepam intensol 5mg/ml QL (240 mL / 30 days)


1 QL PA

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


1 QL PA

DILANTIN CAP 30MG 3

DILANTIN CAP 100MG 3

DILANTIN CHEW TAB 50MG 3

DILANTIN-125 SUSP 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

1

Drug Name Drug Tier

Requirements/Limits

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

EPIDIOLEX QL (600 mL / 30 days)

3 NDS QL NM LA PA

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

3 NDS

felbamate (generic of FELBATOL) TABS

1

FYCOMPA SUSP 3 NDS PA

FYCOMPA TABS 2mg 2 PA

FYCOMPA TABS 4mg, 6mg, 8mg, 10mg, 12mg

3 NDS PA

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

1 QL

gabapentin (generic of NEURONTIN) TABS 600mg


1 QL

gabapentin (generic of NEURONTIN) TABS 800mg


1 QL

LAMICTAL ODT KIT 3

LAMICTAL XR KIT 3

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL STARTER/NOT TAKI) KIT

1

lamotrigine (generic of LAMICTAL STARTER/TAKING C) KIT

1

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24

Drug Name Drug Tier

Requirements/Limits

lamotrigine (generic of LAMICTAL STARTER/TAKING V) KIT 25mg

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

lamotrigine (generic of LAMICTAL ODT) TBDP

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

levetiracetam in sodium chloride (generic of LEVETIRACETAM)

1

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

1

NAYZILAM 3

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 150mg, 300mg

2

OXTELLAR XR 600mg 3 NDS

PEGANONE 3

phenobarbital ELIX PA if 70 years and older

3 PA

phenobarbital TABS PA if 70 years and older

2 PA

phenobarbital sodium SOLN PA if 70 years and older

3 PA

PHENYTEK 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN-125) SUSP

1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

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

1

phenytoin sodium inj 50mg/ml 1

Drug Name Drug Tier

Requirements/Limits

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


1 QL PA

pregabalin (generic of LYRICA) CAPS 200mg


1 QL PA

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


1 QL PA

pregabalin (generic of LYRICA) SOLN

QL (900 mL / 30 days)

1 QL PA

primidone (generic of MYSOLINE) TABS

1

roweepra (generic of KEPPRA)

1

roweepra xr (generic of KEPPRA XR)

1

SPRITAM 3

subvenite starter kit (generic of LAMICTAL STARTER/NOT TAKI)

1

subvenite starter kit (generic of LAMICTAL STARTER/TAKING C)

1

subvenite starter kit (generic of LAMICTAL STARTER/TAKING V) 25mg

1

subvenite tab (generic of LAMICTAL)

1

SYMPAZAN 5mg 3 PA

SYMPAZAN 10mg, 20mg 3 NDS PA

tiagabine hcl (generic of GABITRIL)

1

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

topiramate CS24 25mg, 50mg, 100mg, 150mg

1

topiramate CS24 200mg 3 NDS

topiramate (generic of TOPAMAX) TABS

1

TROKENDI XR 25mg, 50mg 2

TROKENDI XR 100mg, 200mg

3 NDS

2020 632 3T Platinum eff 09/01/2020


25

Drug Name Drug Tier

Requirements/Limits

valproate sodium SOLN 1

valproic acid CAPS 1

VALTOCO 3

vigabatrin powd pack 500mg (generic of SABRIL)

QL (180 packets / 30 days)

3 NDS QL NM LA PA

vigabatrin tab 500mg (generic of SABRIL)


3 NDS QL NM LA PA

vigadrone (generic of SABRIL)


3 NDS QL NM LA PA

VIMPAT 50mg 2

VIMPAT 100mg, 150mg, 200mg

3 NDS

VIMPAT INJ 200MG/20ML 3 NDS

VIMPAT SOL 10MG/ML 3 NDS

XCOPRI MAINTENANCE PAK 150-200MG

3 NDS

XCOPRI PAK 12.5-25MG 3

XCOPRI PAK 50-100MG 3 NDS

XCOPRI PAK 50-200MG 3 NDS

XCOPRI TABS 3 NDS

XCOPRI TITRATION PAK 150-200MG

3 NDS

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

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA donepezil 5mg odt 1

donepezil 10mg odt 1

donepezil hydrochloride (generic of ARICEPT)

1

galantamine hydrobromide SOLN

1

galantamine hydrobromide (generic of RAZADYNE) TABS 4mg

1

galantamine hydrobromide TABS 8mg, 12mg

1

galantamine hydrobromide er (generic of RAZADYNE ER)

1

Drug Name Drug Tier

Requirements/Limits

memantine hcl cp24 (generic of NAMENDA XR)

PA if < 30 yrs

1 PA

memantine soln PA if < 30 yrs

1 PA

memantine tabs (generic of NAMENDA)

PA if < 30 yrs

1 PA

memantine titration pak (generic of NAMENDA TITRATION PAK)

PA if < 30 yrs

1 PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

3 PA

NAMZARIC 2

rivastigmine tartrate 1

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

1


1


1

ANTIDEPRESSANTS amitriptyline hcl TABS 2

amoxapine 2

bupropion hcl TABS 1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

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

1

bupropion hcl TB24 450mg QL (30 tabs / 30 days)

1 QL

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

3 PA

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

3

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26

Drug Name Drug Tier

Requirements/Limits

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

3

DESVENLAFAXINE ER 3

desvenlafaxine succinate (generic of PRISTIQ)

1 PA

doxepin hcl CAPS; CONC 2

DRIZALMA SPRINKLE 20mg, 30mg, 60mg


3 QL PA

DRIZALMA SPRINKLE 40mg


3 QL PA

duloxetine cap 20mg (generic of CYMBALTA)


1 QL



1 QL

duloxetine cap 40mg QL (90 caps / 30 days)

1 QL



1 QL

EMSAM 3 NDS PA

escitalopram oxalate SOLN 1

escitalopram oxalate (generic of LEXAPRO) TABS

1

FETZIMA 2 PA

FETZIMA TITRATION PACK 2 PA

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl CPDR 1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

fluoxetine hcl (generic of FLUOXETINE HYDROCHLORIDE) TABS 60mg

1

imipramine hcl TABS 1

imipramine pamoate 3

maprotiline hcl 1

MARPLAN TAB 10MG 3

mirtazapine tab 15mg odt (generic of REMERON SOLTAB)

1

Drug Name Drug Tier

Requirements/Limits


1


1

mirtazapine tabs 7.5mg, 45mg

1

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

1

nefazodone hcl 1

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 3

paroxetine er tab (generic of PAXIL CR)


3 QL

paroxetine hcl tabs (generic of PAXIL)

1

PAXIL SUSP 3

PEXEVA 10mg, 30mg QL (60 tabs / 30 days)

3 QL

PEXEVA 20mg, 40mg QL (30 tabs / 30 days)

3 QL

phenelzine sulfate (generic of NARDIL) TABS

1

protriptyline hcl 3

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

trimipramine maleate CAPS 3

TRINTELLIX 2

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine tab 1

venlafaxine tab 225mg er 1

VIIBRYD STARTER PACK 2

VIIBRYD TAB 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS

QL (120 caps / 30 days) 1 QL

amantadine hcl SYRP; TABS

1

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Drug Name Drug Tier

Requirements/Limits

APOKYN QL (20 cartridges / 30 days)

3 NDS QL NM LA PA

benztropine mesylate inj (generic of COGENTIN)

1

benztropine mesylate tab 0.5mg


2 PA

benztropine mesylate tab 1mg PA if 70 years and older

2 PA

benztropine mesylate tab 2mg PA if 70 years and older

2 PA

bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

1

carbidopa (generic of LODOSYN) TABS

3 NDS

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa TBCR; TBDP

1

carbidopa-levodopa-entacapone

1

carbidopa-levodopa-entacapone (generic of STALEVO 100)

1

carbidopa-levodopa-entacapone (generic of STALEVO 150)

1

DUOPA 3 NDS B/D NM

entacapone (generic of COMTAN)

1

GOCOVRI QL (60 caps / 30 days)

3 NDS QL NM LA PA

INBRIJA 3 NDS NM LA PA

NEUPRO 2

NOURIANZ QL (30 tabs / 30 days)

3 NDS QL NM

OSMOLEX ER T4PK QL (60 tabs / 30 days)

3 QL NM PA

OSMOLEX ER TB24 QL (30 tabs / 30 days)

3 QL NM PA

pramipexole er (generic of MIRAPEX ER)

1

pramipexole tab 0.5mg (generic of MIRAPEX)

1

pramipexole tab 0.25mg 1

Drug Name Drug Tier

Requirements/Limits


1


1

pramipexole tab 1.5mg 1

pramipexole tab 1mg (generic of MIRAPEX)

1

rasagiline mesylate (generic of AZILECT) TABS

1

ropinirole er 2mg, 4mg, 8mg 1

ropinirole er (generic of REQUIP XL) 6mg, 12mg

1

ropinirole tab 0.5mg 1

ropinirole tab 0.25mg 1

ropinirole tab 1mg 1





RYTARY 3

selegiline hcl CAPS; TABS 1

trihexyphenidyl hcl PA if 70 years and older

2 PA

XADAGO 3 NDS

ZELAPAR 3 NDS

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

3 NDS QL

ABILIFY MYCITE QL (30 tabs / 30 days)

3 NDS QL PA

aripiprazole odt QL (60 tabs / 30 days)

3 NDS QL

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

3 NDS QL

aripiprazole tabs (generic of ABILIFY)


1 QL

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


3 NDS QL

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

3 NDS QL

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Drug Name Drug Tier

Requirements/Limits

ARISTADA INITIO 3 NDS

CAPLYTA QL (30 caps / 30 days)

2 QL

chlorpromazine hcl TABS 1

CHLORPROMAZINE INJ 3

clozapine odt 12.5mg, 25mg 1 PA

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

1 QL PA


1 QL PA


1 QL PA

clozapine tab 25mg (generic of CLOZARIL)

1


1



1 QL



1 QL

FANAPT QL (60 tabs / 30 days)

3 QL PA

FANAPT TITRATION PACK 3 PA

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON INJ QL (6 mL / 3 days)

3 QL

haloperidol TABS 1

haloperidol conc 2mg/ml 1

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

1

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

1

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

1

INVEGA SUSTENNA 39mg/0.25ml


3 QL

Drug Name Drug Tier

Requirements/Limits

INVEGA SUSTENNA 78mg/0.5ml, 117mg/0.75ml, 156mg/ml, 234mg/1.5ml


3 NDS QL

INVEGA TRINZA QL (1 injection / 90 days)

3 NDS QL

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


2 QL

LATUDA 80mg QL (60 tabs / 30 days)

2 QL

loxapine succinate 1

molindone hcl 1

NUPLAZID CAPS QL (30 caps / 30 days)

3 NDS QL NM LA PA

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

3 NDS QL NM LA PA

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

1 QL

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


1 QL

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


1 QL

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


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 10mg


1 QL

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


1 QL

paliperidone (generic of INVEGA) 6mg


1 QL

perphenazine TABS 1

PERSERIS QL (1 injection / 30 days)

3 NDS QL

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Drug Name Drug Tier

Requirements/Limits

pimozide 1

quetiapine fumarate (generic of SEROQUEL) TABS

1

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


1 QL PA

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


1 QL PA

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

3 NDS QL

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


3 NDS QL

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

2 QL

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

2 QL

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

3 NDS QL

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

3 NDS QL

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

1 QL

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

1

risperidone TABS .25mg 1

risperidone odt 1mg, 2mg, 3mg, 4mg


1 QL

risperidone odt .25mg, .5mg QL (90 tabs / 30 days)

1 QL

SAPHRIS QL (60 tabs / 30 days)

3 QL

SECUADO QL (30 patches / 30 days)

2 QL

thioridazine hcl TABS 1

thiothixene 1

Drug Name Drug Tier

Requirements/Limits

trifluoperazine hcl 1

VERSACLOZ QL (600 mL / 30 days)

3 NDS QL PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

3 NDS QL PA

VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)

3 NDS QL PA

VRAYLAR THERAPY PACK 2 PA

ziprasidone hcl (generic of GEODON)


1 QL

ziprasidone mesylate (generic of GEODON)

QL (6 injections / 3 days)

1 QL

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

3 NDS QL PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

3 NDS QL PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

3 QL PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADZENYS ER SUS 1.25MG

QL (450 ml / 30 days) 3 QL

ADZENYS XR-ODT 3.1mg, 6.3mg, 9.4mg


3 QL

ADZENYS XR-ODT 12.5mg, 15.7mg, 18.8mg


3 QL

amphetamine er sus 1.25mg/ml

QL (450 mL / 30 days)

1 QL

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


1 QL



1 QL

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Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL



1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


1 QL



1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL



1 QL



1 QL



1 QL

APTENSIO XR 10mg, 15mg, 20mg, 30mg


3 QL

Drug Name Drug Tier

Requirements/Limits

APTENSIO XR 40mg, 50mg, 60mg


3 QL

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


1 QL

atomoxetine hcl (generic of STRATTERA) 40mg


1 QL

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


1 QL

COTEMPLA XR-ODT QL (60 tabs / 30 days)

3 QL

DAYTRANA QL (30 patches / 30 days)

3 QL

dexmethylphenidate hcl (generic of FOCALIN XR) CP24 5mg, 10mg, 15mg, 20mg


1 QL

dexmethylphenidate hcl (generic of FOCALIN XR) CP24 25mg, 30mg, 35mg, 40mg


1 QL

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


1 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg


1 QL

dextroamphetamine sulfate (generic of DEXEDRINE) CP24 5mg, 10mg


1 QL

dextroamphetamine sulfate (generic of DEXEDRINE) CP24 15mg


1 QL

dextroamphetamine sulfate TABS


1 QL

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Drug Name Drug Tier

Requirements/Limits

DYANAVEL XR QL (240 ml / 30 days)

3 QL

guanfacine er (adhd) (generic of INTUNIV)


2 PA

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

3 QL

JORNAY PM 60mg, 80mg, 100mg


3 QL

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

1 QL

methylphenidate hcl CHEW QL (180 tabs / 30 days)

1 QL

methylphenidate hcl CP24 10mg, 15mg, 20mg, 30mg


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 10mg, 20mg, 30mg


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 40mg


1 QL

methylphenidate hcl CP24 40mg, 50mg, 60mg


1 QL

methylphenidate hcl CPCR 10mg, 20mg, 30mg


1 QL

methylphenidate hcl CPCR 40mg, 50mg, 60mg


1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml

QL (1800 mL / 30 days)

1 QL

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

QL (900 mL / 30 days)

1 QL

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


1 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


1 QL

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl TB24 18mg, 27mg, 36mg


1 QL

methylphenidate hcl TB24 54mg


1 QL

methylphenidate hcl (generic of CONCERTA) TBCR 18mg, 27mg, 36mg


1 QL

methylphenidate hcl (generic of CONCERTA) TBCR 54mg


1 QL

methylphenidate hcl tbcr 10 mg


1 QL

methylphenidate hcl tbcr 20mg


1 QL

METHYLPHENIDATE HCL TBCR 72MG


1 QL

MYDAYIS CAP 12.5MG QL (60 caps / 30 days)

2 QL

MYDAYIS CAP 25MG QL (60 caps / 30 days)

2 QL

MYDAYIS CAP 37.5MG QL (30 caps / 30 days)

2 QL

MYDAYIS CAP 50MG QL (30 caps / 30 days)

2 QL

QUILLICHEW ER 20mg, 30mg


3 QL

QUILLICHEW ER 40mg QL (30 tabs / 30 days)

3 QL

QUILLIVANT XR QL (360 mL / 30 days)

3 QL

RELEXXII QL (30 tabs / 30 days)

1 QL

VYVANSE CAPS 10mg, 20mg, 30mg


2 QL

VYVANSE CAPS 40mg, 50mg, 60mg, 70mg


2 QL

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Drug Name Drug Tier

Requirements/Limits

VYVANSE CHEW 10mg, 20mg, 30mg


2 QL

VYVANSE CHEW 40mg, 50mg, 60mg


2 QL

zenzedi 2.5mg, 5mg, 7.5mg, 10mg


1 QL

zenzedi 15mg QL (120 tabs / 30 days)

1 QL


1 QL


1 QL

HYPNOTICS BELSOMRA

QL (30 tabs / 30 days) 2 QL

DAYVIGO QL (30 tabs / 30 days)

3 QL

doxepin hcl (sleep) (generic of SILENOR)


1 QL

HETLIOZ 3 NDS NM LA PA

ramelteon (generic of ROZEREM)


1 QL

temazepam (generic of RESTORIL) 7.5mg

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

1 QL PA

temazepam (generic of RESTORIL) 15mg

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

1 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

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

1 QL PA

MIGRAINE

Drug Name Drug Tier

Requirements/Limits

AIMOVIG QL (1 pen / 30 days)

2 QL NM PA

almotriptan malate QL (12 tabs / 30 days)

1 QL

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

3 NDS

dihydroergotamine mesylate nasal spr 4 mg/ml (generic of MIGRANAL)

QL (8 mL / 30 days)

3 NDS QL PA

eletriptan hydrobromide (generic of RELPAX)


1 QL

EMGALITY SOAJ QL (2 pens / 30 days)

2 QL NM PA

EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)

2 QL NM PA

ergotamine w/ caffeine (generic of CAFERGOT)

1

frovatriptan succinate (generic of FROVA)


1 QL

migergot 3 NDS

naratriptan hcl (generic of AMERGE)


1 QL

ONZETRA XSAIL QL (16 nosepieces / 30 days)

3 NDS QL

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

1 QL

rizatriptan benzoate (generic of MAXALT) 10mg


1 QL

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

1 QL

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


1 QL

sumatriptan (generic of IMITREX) SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

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Drug Name Drug Tier

Requirements/Limits

sumatriptan (generic of IMITREX) SOLN 20mg/act


1 QL

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


1 QL

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


1 QL

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


1 QL

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


1 QL

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


1 QL

sumatriptan inj 6mg/0.5ml SOSY


1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

sumatriptan-naproxen sodium (generic of TREXIMET)


1 QL

TOSYMRA QL (18 nasal units / 30 days)

3 QL

ZEMBRACE SYMTOUCH QL (24 pens / 30 days)

3 NDS QL

zolmitriptan (generic of ZOMIG) TABS


1 QL

Drug Name Drug Tier

Requirements/Limits

zolmitriptan (generic of ZOMIG ZMT) TBDP


1 QL

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

2 QL

MISCELLANEOUS AUSTEDO 6mg


PA

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

3 NDS QL NM PA

EQUETRO 3

FIRDAPSE 3 NDS NM LA PA

GRALISE 300mg QL (180 tabs / 30 days)

2 QL PA

GRALISE 600mg QL (90 tabs / 30 days)

2 QL PA

GRALISE STARTER 2 PA

HORIZANT 3 PA

INGREZZA CAPS QL (30 caps / 30 days)

3 NDS QL NM PA

INGREZZA CPPK QL (28 caps / 28 days)

3 NDS QL NM PA

lithium carb tab 300mg 1

lithium carbonate CAPS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM SOLN 8MEQ/5ML 3

LYRICA CR QL (60 tabs / 30 days)

2 QL PA

NUEDEXTA QL (60 caps / 30 days)

2 QL PA

paroxetine mesylate (vasomotor) (generic of BRISDELLE)


3 QL

pyridostigmine bromide (generic of MESTINON) SOLN

3 NDS

pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR

1

pyridostigmine bromide tab 30 mg

1

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Drug Name Drug Tier

Requirements/Limits

pyridostigmine tab 60mg (generic of MESTINON)

1

RADICAVA 3 NDS NM LA PA

riluzole (generic of RILUTEK) 1

RUZURGI 3 NDS NM LA PA

SAVELLA QL (60 tabs / 30 days)

2 QL

SAVELLA TITRATION PACK 2

TEGSEDI QL (4 syringes / 28 days)

3 NDS QL NM LA PA

tetrabenazine (generic of XENAZINE) 12.5mg


3 NDS QL NM PA

tetrabenazine (generic of XENAZINE) 25mg


3 NDS QL NM PA

TIGLUTIK QL (600 mL / 30 days)

3 NDS QL PA

MULTIPLE SCLEROSIS AGENTS AUBAGIO


LA PA

AVONEX QL (4 injections / 28 days)

3 NDS QL NM PA

AVONEX PEN QL (4 injections / 28 days)

3 NDS QL NM PA

BETASERON QL (14 syringes / 28 days)

3 NDS QL NM PA

dalfampridine (generic of AMPYRA) TB12

3 NDS NM PA

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

3 NDS QL NM PA

glatiramer acetate 20mg/ml (generic of COPAXONE)

QL (30 syringes / 30 days)

3 NDS QL NM PA

glatiramer acetate 40mg/ml (generic of COPAXONE)


3 NDS QL NM PA

Drug Name Drug Tier

Requirements/Limits

glatopa (generic of COPAXONE) 20mg/ml


3 NDS QL NM PA

glatopa (generic of COPAXONE) 40mg/ml


3 NDS QL NM PA

LEMTRADA 3 NDS NM LA PA

MAVENCLAD PAK 10MG(4) QL (16 tabs in lifetime)

3 NDS QL NM LA PA


3 NDS QL NM LA PA


3 NDS QL NM LA PA


3 NDS QL NM LA PA


3 NDS QL NM LA PA


3 NDS QL NM LA PA


3 NDS QL NM LA PA

MAYZENT 2mg QL (30 tabs / 30 days)

3 NDS QL NM LA PA

MAYZENT .25mg QL (112 tabs / 28 days)

3 NDS QL NM LA PA

OCREVUS 3 NDS NM LA PA

PLEGRIDY SOPN QL (2 pens / 28 days)

3 NDS QL NM PA

PLEGRIDY SOSY QL (2 syringes / 28 days)

3 NDS QL NM PA

PLEGRIDY STARTER PACK SOPN

QL (2 pens / 28 days)

3 NDS QL NM PA

PLEGRIDY STARTER PACK SOSY


3 NDS QL NM PA

REBIF QL (12 injections / 28 days)

3 NDS QL NM PA

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Drug Name Drug Tier

Requirements/Limits

REBIF REBIDOSE QL (12 injections / 28 days)

3 NDS QL NM PA

REBIF REBIDOSE TITRATION


3 NDS QL NM PA

REBIF TITRATION PACK QL (12 injections / 28 days)

3 NDS QL NM PA

TECFIDERA 120mg QL (14 caps / 7 days)

3 NDS QL NM LA PA

TECFIDERA 240mg QL (60 caps / 30 days)

3 NDS QL NM LA PA

TECFIDERA STARTER PACK

3 NDS NM LA PA

TYSABRI 3 NDS NM LA PA

VUMERITY QL (120 caps / 30 days)

3 NDS QL NM LA PA

VUMERITY STARTER 3 NDS NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX 3 NDS NM PA

cyclobenzaprine hcl TABS 5mg, 10mg


2 PA

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

1

dantrolene sodium CAPS 100mg

1

DYSPORT 3 NM PA

MYOBLOC 3 NM PA

tizanidine hcl (generic of ZANAFLEX) CAPS

1

tizanidine tabs 2mg 1

tizanidine tabs (generic of ZANAFLEX) 4mg

1

XEOMIN INJ 50 UNITS 3 NM PA

XEOMIN INJ 100 UNITS 3 NDS NM PA

XEOMIN INJ 200 UNITS 3 NDS NM PA

NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg


1 QL PA

Drug Name Drug Tier

Requirements/Limits

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


1 QL PA

modafinil (generic of PROVIGIL) 100mg


1 QL PA

modafinil (generic of PROVIGIL) 200mg


1 QL PA

SUNOSI QL (30 tabs / 30 days)

2 QL PA

WAKIX 4.45mg QL (14 tabs / 7 days)

3 NDS QL NM LA PA

WAKIX 17.8mg QL (60 tabs / 30 days)

3 NDS QL NM LA PA

XYREM QL (540 mL / 30 days)

3 NDS QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

BUNAVAIL MIS 2.1-0.3MG QL (90 films / 30 days)

2 QL

BUNAVAIL MIS 4.2-0.7MG QL (90 films / 30 days)

2 QL

BUNAVAIL MIS 6.3-1MG QL (60 films / 30 days)

2 QL

buprenorphine hcl SUBL QL (90 tabs / 30 days)

1 QL PA

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

QL (90 films / 30 days)

1 QL

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


1 QL



1 QL



1 QL

buprenorphine hcl-naloxone hcl sl


1 QL

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Drug Name Drug Tier

Requirements/Limits

bupropion hcl (smoking deterrent)

1

CHANTIX CONTINUING MONTH

2 PA

CHANTIX STARTER PACK 2 PA

CHANTIX TABS 2 PA

disulfiram (generic of ANTABUSE) TABS

1

fluoxetine hcl (pmdd) (generic of SARAFEM)

(generic of SARAFEM)

1

LUCEMYRA QL (228 tabs / 14 days)

3 NDS QL PA

naloxone inj 0.4mg/ml 1

naloxone inj 1mg/ml 1

naltrexone hcl TABS 1

NARCAN 2

NICOTROL INHALER 3

NICOTROL NS 3

SUBLOCADE 3 NDS NM

VIVITROL 3 NDS NM

ZUBSOLV SUB 0.7-0.18MG QL (90 tabs / 30 days)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 3 NDS PA

ANDRODERM QL (30 patches / 30 days)

2 QL PA

AVEED 3 NM LA PA

oxandrolone TABS 1 PA

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

1 QL PA

Drug Name Drug Tier

Requirements/Limits

testosterone (generic of ANDROGEL PUMP) GEL 1.62%

QL (150 grams / 30 days)

1 QL PA

testosterone (generic of FORTESTA) GEL 10mg/act


1 QL PA

testosterone (generic of ANDROGEL) GEL 20.25mg/1.25gm, 40.5mg/2.5gm


1 QL PA

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


1 QL PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

1 PA

testosterone enanthate SOLN

1 PA

testosterone td soln 30 mg/act QL (180 mL / 30 days)

1 QL PA

XYOSTED 3 PA

ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN 2

BD ALCOHOL SWABS 2

BD ULTRAFINE INSULIN SYRINGE

2

BD ULTRAFINE/NANO PEN NEEDLES

2

BYDUREON BCISE QL (4 pens / 28 days)

2 QL

BYDUREON PEN QL (4 pens / 28 days)

2 QL

BYETTA QL (1 pen / 30 days)

3 QL

FIASP 2

FIASP FLEXTOUCH 2

FIASP PENFILL 2

GAUZE PADS 2X2 2

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Drug Name Drug Tier

Requirements/Limits

HUMULIN R U-500 (CONCENTRATE)

3 NDS B/D

HUMULIN R U-500 KWIKPEN 3 NDS

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 (brand RELION not covered)

2

NOVOLIN 70/30 FLEXPEN (brand RELION not covered)

2

NOVOLIN N (brand RELION not covered)

2

NOVOLIN N FLEXPEN (brand RELION not covered)

2

NOVOLIN R (brand RELION not covered)

2

NOVOLIN R FLEXPEN (brand RELION not covered)

2

NOVOLOG 2

NOVOLOG 70/30 FLEXPEN 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG PENFILL 2

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

2 QL

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

2 QL

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

2 QL

SYMLINPEN 60 3 NDS PA

SYMLINPEN 120 3 NDS PA

TRESIBA FLEXTOUCH 2

TRESIBA INJ 2

TRULICITY QL (4 pens / 28 days)

2 QL

VICTOZA QL (3 pens / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

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

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) TABS

1

FARXIGA QL (30 tabs / 30 days)

2 QL

glimepiride (generic of AMARYL) 1mg, 2mg


1 QL

glimepiride (generic of AMARYL) 4mg


1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

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


1 QL

glipizide er (generic of GLUCOTROL XL) 10mg


1 QL

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


1 QL

glipizide xl (generic of GLUCOTROL XL) 10mg


1 QL

glipizide-metformin 2.5-250 mg


1 QL

glipizide-metformin 2.5-500 mg


1 QL

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL

GLYXAMBI QL (30 tabs / 30 days)

2 QL

JANUMET QL (60 tabs / 30 days)

2 QL

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Drug Name Drug Tier

Requirements/Limits

JANUMET XR TAB 50-500MG


2 QL

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

2 QL

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

2 QL

JANUVIA QL (30 tabs / 30 days)

2 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

2 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

2 QL

JENTADUETO QL (60 tabs / 30 days)

2 QL

JENTADUETO TAB XR 2.5-1000 MG


2 QL

JENTADUETO TAB XR 5-1000 MG


2 QL

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

(generic of GLUCOPHAGE XR)

1 QL

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

(generic of GLUCOPHAGE XR)

1 QL

metformin hcl (generic of RIOMET) SOLN

QL (780 mL / 30 days)

1 QL

metformin hcl TABS 500mg QL (150 tabs / 30 days)

1 QL


1 QL


1 QL

miglitol (generic of GLYSET) 1

nateglinide QL (90 tabs / 30 days)

1 QL

pioglitazone hcl (generic of ACTOS)


1 QL

pioglitazone hcl-glimepiride (generic of DUETACT)


1 QL

Drug Name Drug Tier

Requirements/Limits

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)


1 QL

repaglinide 2mg QL (240 tabs / 30 days)

1 QL

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

1 QL

RIOMET QL (780 mL / 30 days)

3 QL

RIOMET ER QL (600 mL / 30 days)

3 QL

RYBELSUS QL (30 tabs / 30 days)

2 QL

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

2 QL

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

2 QL

SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days)

2 QL

SYNJARDY TAB 12.5-1000MG


2 QL

SYNJARDY XR TAB 5-1000MG


2 QL



2 QL

SYNJARDY XR TAB 12.5-1000MG


2 QL



2 QL

TRADJENTA QL (30 tabs / 30 days)

2 QL

TRIJARDY XR TAB ER 24HR 5-2.5-1000MG


2 QL

TRIJARDY XR TAB ER 24HR 10-5-1000 MG


2 QL

TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG


2 QL

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Drug Name Drug Tier

Requirements/Limits

TRIJARDY XR TAB ER 24HR 25-5-1000 MG


2 QL

XIGDUO XR TAB 2.5-1000MG


2 QL

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

2 QL


2 QL


2 QL


2 QL

BISPHOSPHONATES alendronate sodium SOLN 1

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

BINOSTO 3

FOSAMAX PLUS D 3

ibandronate sodium inj (generic of BONIVA)


1 B/D QL

ibandronate sodium tabs (generic of BONIVA)

1 B/D

PAMIDRONATE DISODIUM 6mg/ml

3 B/D

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

1 B/D

pamidronate inj 30mg 1 B/D

pamidronate inj 90mg 1 B/D

risedronate sodium (generic of ACTONEL) TABS

1

risedronate sodium (generic of ATELVIA) TBEC

1

zoledronic acid inj 4mg/100ml 1 B/D NM

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

1 B/D NM

zoledronic inj 4mg/5ml 1 B/D NM

ZOLEDRONIC INJ 4MG/100ML

3 B/D NM

CHELATING AGENTS CHEMET 3

Drug Name Drug Tier

Requirements/Limits

clovique (generic of SYPRINE)

3 NDS PA

deferasirox tab (generic of JADENU)

3 NDS NM PA

deferasirox tab for oral susp (generic of EXJADE)

3 NDS NM PA

deferoxamine mesylate 2gm 1 NM PA

deferoxamine mesylate (generic of DESFERAL) 500mg

1 NM PA

FERRIPROX 3 NDS NM LA PA

JADENU 180mg 3 NDS NM LA PA

JADENU SPRINKLE 3 NDS NM LA PA

kionex sus 15gm/60ml 1

LOKELMA 2

penicillamine (generic of DEPEN TITRATABS) TABS

3 NDS

sodium polystyrene sulfonate powder

1

sodium polystyrene sulfonate susp

1

sps 1

trientine hcl (generic of SYPRINE)

3 NDS PA

VELTASSA 3 NDS LA

CONTRACEPTIVES altavera tab 1

alyacen 1/35 1

amethia (generic of SEASONIQUE)

1

amethia lo (generic of LOSEASONIQUE)

1

ANNOVERA 3

apri 1

aranelle 1

ashlyna (generic of SEASONIQUE)

1

aubra 1

aviane 1

BALCOLTRA 3

balziva 1

bekyree (generic of MIRCETTE)

1

2020 632 3T Platinum eff 09/01/2020


40

Drug Name Drug Tier

Requirements/Limits

blisovi 24 fe 1

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

1

briellyn 1

camila 1

camrese lo tab (generic of LOSEASONIQUE)

1

caziant pak 1

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

cyred tab 1

dasetta 1/35 1

dasetta 7/7/7 1

deblitane 1

DEPO-SUBQ PROVERA 104 2

desogestrel & ethinyl estradiol 1

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

1

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

drospirenone-ethinyl estradiol (generic of YAZ)

1

drospirenone-ethinyl estradiol-levomefolate calcium (generic of BEYAZ)

1

drospirenone-ethinyl estradiol-levomefolate calcium (generic of SAFYRAL)

1

ELLA 3

eluryng (generic of NUVARING)

1

emoquette 1

enpresse-28 1

enskyce 1

errin 1

estarylla tab 0.25-35 1

ethynodiol diacet & eth estrad 1

ethynodiol tab 1-50 1

etonogestrel-ethinyl estradiol (generic of NUVARING)

1

falmina 1

fayosim (generic of QUARTETTE)

1

Drug Name Drug Tier

Requirements/Limits

femynor 1

gianvi tab 3-0.02mg (generic of YAZ)

1

hailey 24 fe 1

heather 1

incassia 1

introvale 1

isibloom 1

jasmiel (generic of YAZ) 1

jolessa tab 0.15-0.03 mg 1

jolivette 1

juleber 1

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

1

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

1

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

1

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

1

junel fe 24 1

kaitlib fe (generic of GENERESS FE)

1

kariva (generic of MIRCETTE) 1

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

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

1

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

1

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

1

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

1

larissia tab 1

layolis fe chw (generic of GENERESS FE)

1

leena tab 1

lessina 1

levonest 1

levonor/ethi tab 1

levonorgestrel & eth estradiol 1

levonorgestrel-ethinyl estradiol (91-day)

1

2020 632 3T Platinum eff 09/01/2020


41

Drug Name Drug Tier

Requirements/Limits

levonorgestrel-ethinyl estradiol (91-day) (generic of LOSEASONIQUE)

1

levonorgestrel-ethinyl estradiol (91-day) (generic of QUARTETTE)

1

levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONIQUE)

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30-28 1

LO LOESTRIN FE 2

loryna (generic of YAZ) 1

low-ogestrel 1

lutera 1

lyza 1

marlissa 1

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

1

melodetta 24 fe (generic of MINASTRIN 24 FE)

1

mibelas 24 fe (generic of MINASTRIN 24 FE)

1

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

1

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

1

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

1

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

1

mili 1

mono-linyah tab 0.25-35 1

NATAZIA 2

necon 0.5/35-28 1

nikki (generic of YAZ) 1

nora-be tab 1

nore/eth/fer chw 0.4mg-35 1

noreth/ethin chw fe (generic of GENERESS FE)

1

norethin acet & estrad-fe (generic of MINASTRIN 24 FE)

1

Drug Name Drug Tier

Requirements/Limits

norethindrone (contraceptive) 1

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

1

norgest/ethi tab 0.25/35 1

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

1

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

1

nortrel 0.5/35 (28) 1

nortrel 1/35 1

nortrel 7/7/7 1

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

1

orsythia 1

philith 1

pimtrea (generic of MIRCETTE)

1

pirmella 1/35 1

portia-28 1

previfem 1

reclipsen 1

rivelsa (generic of QUARTETTE)

1

setlakin tab 1

sharobel 1

SLYND 3

sprintec 28 1

sronyx 1

syeda (generic of YASMIN 28) 1

tarina 24 fe 1

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

1

TAYTULLA 2

tilia fe (generic of ESTROSTEP FE)

1

tri-estarylla 1

tri-legest fe (generic of ESTROSTEP FE)

1

tri-linyah 1

2020 632 3T Platinum eff 09/01/2020


42

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

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

1

tri-mili 1

tri-previfem 1

tri-sprintec 1

tri-vylibra 1

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

1

trivora-28 1

tulana 1

tydemy (generic of SAFYRAL) 1

velivet 1

vienva 1

viorele (generic of MIRCETTE)

1

vyfemla 1

vylibra 1

wymzya fe 1

xulane dis 150-35 1

zarah (generic of YASMIN 28) 1

zovia 1/35e 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 NDS NM PA

ORILISSA 3 NDS PA

SYNAREL 3 NDS

ENZYME REPLACEMENTS ALDURAZYME 3 NDS NM LA

PA

CARBAGLU 3 NDS NM LA PA

CARNITOR SOLN 200mg/ml 3 B/D

CERDELGA 3 NDS NM PA

CEREZYME 3 NDS NM LA PA

CYSTADANE 3 NDS NM LA

CYSTAGON 3 NM LA PA

ELAPRASE 3 NDS NM LA PA

ELELYSO 3 NDS NM PA

Drug Name Drug Tier

Requirements/Limits

FABRAZYME 3 NDS NM LA PA

GALAFOLD 3 NDS NM LA PA

KANUMA 3 NDS NM LA PA

KUVAN 3 NDS NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 3 NDS NM LA PA

miglustat (generic of ZAVESCA)

3 NDS NM PA

NAGLAZYME 3 NDS NM LA PA

nitisinone (generic of ORFADIN)

3 NDS NM PA

NITYR 3 NDS NM LA PA

ORFADIN 3 NDS NM LA PA

PALYNZIQ 3 NDS NM LA PA

PROCYSBI 3 NDS NM LA PA

RAVICTI 3 NDS NM LA PA

REVCOVI 3 NDS NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

3 NDS NM PA

STRENSIQ 3 NDS NM LA PA

VIMIZIM 3 NDS NM PA

VPRIV 3 NDS NM PA

ESTROGENS ALORA 3

DELESTROGEN 10mg/ml 3

DEPO-ESTRADIOL 3

dotti (generic of VIVELLE-DOT)

2

estradiol (generic of VIVELLE-DOT) PTTW

2

estradiol (generic of CLIMARA) PTWK

2

2020 632 3T Platinum eff 09/01/2020


43

Drug Name Drug Tier

Requirements/Limits

estradiol (generic of ESTRACE) TABS

1

estradiol vaginal cream (generic of ESTRACE)

1

estradiol vaginal tab (generic of VAGIFEM)

1

estradiol valerate (generic of DELESTROGEN) OIL

1

ESTRING 2

FEMRING 3

fyavolv 2

fyavolv (generic of FEMHRT LOW DOSE)

2

IMVEXXY MAINTENANCE PACK

3 PA

IMVEXXY STARTER PACK 3 PA

jinteli 2

MENEST 3

MENOSTAR 3

norethindrone acetate-ethinyl estradiol

2

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

2

PREMARIN CREAM 2

PREMARIN INJ 3

PREMARIN TABS 2

PREMPHASE 2

PREMPRO 2

yuvafem vaginal tablet 10 mcg (generic of VAGIFEM)

1

GLUCOCORTICOIDS cortisone acetate TABS 1

DEPO-MEDROL 20mg/ml 3 B/D

DEXAMETHASONE CONC 3

dexamethasone ELIX; SOLN; TABS

1

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

1

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

1

Drug Name Drug Tier

Requirements/Limits

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

KENALOG-10 3 B/D

KENALOG-80 3 B/D

MEDROL TAB 2MG 3 B/D

methylpr ss inj (generic of SOLU-MEDROL)

1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

methylprednisolone acetate (generic of DEPO-MEDROL)

1 B/D

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

1 B/D

prednisolone sodium phosphate SOLN

1 B/D

prednisolone sodium phosphate (generic of ORAPRED ODT) TBDP

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

PREDNISONE CON 5MG/ML 3 B/D

prednisone pak 5mg 1

prednisone pak 10mg 1

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL 2gm 3 B/D

2020 632 3T Platinum eff 09/01/2020


44

Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (generic of KENALOG-40) SUSP 40mg/ml

1 B/D

GLUCOSE ELEVATING AGENTS diazoxide (generic of PROGLYCEM) SUSP

1

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

GVOKE HYPOPEN 2-PACK 2

GVOKE PFS 2

PROGLYCEM SUS 50MG/ML 3

MISCELLANEOUS BYNFEZIA PEN 3 NDS NM PA

cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1 B/D

CHORIONIC GONADOTROPIN SOLR

3 NM PA

cinacalcet hcl (generic of SENSIPAR)

3 NDS B/D NM

CRYSVITA 3 NDS NM LA PA

EGRIFTA 3 NDS NM LA PA

EVENITY 3 NDS NM PA

FORTEO 3 NDS NM PA

GENOTROPIN 3 NDS NM PA

GENOTROPIN MINIQUICK .2mg

3 NM PA

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

3 NDS NM PA

HUMATROPE 3 NDS NM PA

HUMATROPE COMBO PACK 3 NDS NM PA

INCRELEX 3 NDS NM LA PA

ISTURISA 3 NDS NM LA PA

JYNARQUE PAK 30-15MG 3 NDS NM LA PA



Drug Name Drug Tier

Requirements/Limits


JYNARQUE TABS 3 NDS NM LA PA

KORLYM 3 NDS NM LA PA

LUPRON DEP-PED INJ 7.5MG

3 NDS NM PA

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

3 NDS NM PA

LUPRON DEPOT-PED (1-MONTH

3 NDS NM PA

LUPRON DEPOT-PED (3-MONTH

3 NDS NM PA

MYALEPT 3 NDS NM LA PA

NATPARA 3 NDS NM PA

NORDITROPIN FLEXPRO 3 NDS NM PA

NOVAREL 5000unit 3 NM PA

NUTROPIN AQ NUSPIN 5 3 NDS NM LA PA



octreotide acetate (generic of SANDOSTATIN) 50mcg/ml

1 NM PA

octreotide acetate 200mcg/ml

1 NM PA

octreotide acetate (generic of SANDOSTATIN) 500mcg/ml

3 NDS NM PA

octreotide acetate 1000mcg/ml

3 NDS NM PA

octreotide inj 100mcg/ml (generic of SANDOSTATIN)

1 NM PA

OMNITROPE 5.8MG 3 NDS NM LA PA

OMNITROPE 5MG 3 NDS NM LA PA

OMNITROPE 10MG 3 NDS NM LA PA

OSPHENA 2 PA

PREGNYL W/DILUENT BENZYL

3 NM PA

PROLIA QL (1 injection / 180 days)

2 QL NM

2020 632 3T Platinum eff 09/01/2020


45

Drug Name Drug Tier

Requirements/Limits

raloxifene hcl (generic of EVISTA)

1

SAIZEN 3 NDS NM LA PA

SAIZENPREP RECONSTITUTION

3 NDS NM LA PA

SAMSCA 3 NDS NM LA PA

SANDOSTATIN LAR DEPOT 3 NDS NM PA

SEROSTIM 3 NDS NM LA PA

SIGNIFOR 3 NDS NM LA PA

SIGNIFOR LAR 3 NDS NM LA PA

SOMATULINE DEPOT 3 NDS NM PA

SOMAVERT 3 NDS NM LA PA

TEPEZZA 3 NDS NM LA PA

tolvaptan (generic of SAMSCA)

3 NDS NM PA

TYMLOS 3 NDS NM PA

XGEVA 3 NDS NM PA

ZOMACTON 5mg 3 NM PA

ZOMACTON 10mg 3 NDS NM PA

ZORBTIVE 3 NDS NM PA

PHOSPHATE BINDER AGENTS AURYXIA 3 NDS PA

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

1

calcium acetate (phosphate binder) TABS

1

FOSRENOL PACK 3 NDS

lanthanum chew tab (generic of FOSRENOL)

3 NDS

PHOSLYRA 2

sevelamer carbonate (generic of RENVELA) PACK

3 NDS

sevelamer carbonate (generic of RENVELA) TABS

1

sevelamer tab 400mg 1

sevelamer tab 800mg (generic of RENAGEL)

1

VELPHORO 3 NDS

Drug Name Drug Tier

Requirements/Limits

PROGESTINS CRINONE 2 PA

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

THYROID AGENTS euthyrox (generic of SYNTHROID)

1

levo-t (generic of SYNTHROID)

1

levothyroxine sodium (generic of SYNTHROID) TABS

1

levoxyl (generic of SYNTHROID)

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

TIROSINT-SOL 3

unithroid (generic of SYNTHROID)

1

VASOPRESSINS DDAVP SPRAY (REFRIGERATED)

2

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

desmopressin inj 4mcg/ml (generic of DDAVP)

1

STIMATE 3 NDS NM

GASTROINTESTINAL ANTIEMETICS AKYNZEO CAPS 3 B/D

AKYNZEO SOLN; SOLR 3

2020 632 3T Platinum eff 09/01/2020


46

Drug Name Drug Tier

Requirements/Limits

aprepitant (generic of EMEND) 40mg, 80mg

1 B/D

aprepitant 125mg 1 B/D

aprepitant pak 80mg & 125mg 1 B/D

BONJESTA 3

CINVANTI 3

compro 1

doxylamine-pyridoxine (generic of DICLEGIS)

1

dronabinol (generic of MARINOL)


1 B/D QL

EMEND SUSR 3 B/D

fosaprepitant dimeglumine (generic of EMEND)

1

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 1

metoclopramide odt 5mg 1

METOCLOPRAMIDE ODT 10MG

3

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

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 1

ondansetron hcl oral soln 1 B/D

ondansetron odt 1 B/D

palonosetron hcl (generic of ALOXI) SOLN

1

palonosetron hcl SOSY 1

PALONOSETRON HYDROCHLORID 0.25MG/2ML

3

phenadoz PA if 70 years and older

3 PA

prochlorperazine inj 1

prochlorperazine maleate TABS

1

prochlorperazine supp 1

promethazine hcl SUPP PA if 70 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

promethazine hcl SYRP; TABS


1 PA

promethazine hcl inj (generic of PHENERGAN)


3 PA

promethegan PA if 70 years and older

3 PA

SANCUSO QL (4 patches / 28 days)

3 NDS QL

scopolamine (generic of TRANSDERM SCOP)



3 QL PA

SUSTOL 3

SYNDROS QL (120 mL / 30 days)

3 NDS B/D QL

VARUBI TAB 90MG 2 B/D

ZUPLENZ 3 NDS B/D

ANTISPASMODICS atropine sulfate SOSY .25mg/5ml, 1mg/10ml

3

CUVPOSA 3

dicyclomine hcl cap 10mg 2

dicyclomine hcl inj (generic of BENTYL)

3

dicyclomine hcl soln 10mg/5ml

3

dicyclomine hcl tab 20mg 2

GLYCATE 3

glycopyrrolate SOLN 1

GLYCOPYRROLATE SOSY .2mg/ml, .4mg/2ml

3

glycopyrrolate tab 1mg 1

glycopyrrolate tab 2mg 1

methscopolamine bromide TABS


1 PA

propantheline bromide TABS 1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine oral soln 1

famotidine SUSR 1

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

1

2020 632 3T Platinum eff 09/01/2020


47

Drug Name Drug Tier

Requirements/Limits

famotidine in nacl 1

famotidine inj 1

nizatidine 1

INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CPEP

1

budesonide (generic of UCERIS) TB24

3 NDS

colocort (generic of CORTENEMA)

1

DIPENTUM 3 NDS

ENTYVIO 3 NDS NM PA

hydrocortisone (enema) (generic of CORTENEMA)

1

mesalamine (generic of APRISO) CP24

1

mesalamine (generic of DELZICOL) CPDR

1

mesalamine (generic of CANASA) SUPP

3 NDS

mesalamine (generic of LIALDA) TBEC 1.2gm

1

mesalamine (generic of ASACOL HD) TBEC 800mg

1

mesalamine enema 1

mesalamine w/ cleanser (generic of ROWASA)

1

PENTASA 3 NDS

SFROWASA 3 NDS

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS FOAM 3

LAXATIVES CLENPIQ 3

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g (generic of GOLYTELY)

1

gavilyte-n/flavor pack (generic of NULYTELY)

1

generlac 1

Drug Name Drug Tier

Requirements/Limits

GOLYTELY 3

KRISTALOSE 3

lactulose SOLN 1

lactulose (encephalopathy) 1

MOVIPREP 3

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

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

1

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

1

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

1

PLENVU 3

SUPREP BOWEL PREP KIT 2

trilyte (generic of NULYTELY) 1

MISCELLANEOUS alosetron hcl (generic of LOTRONEX)

3 NDS PA

AMITIZA CAP 8MCG 2

AMITIZA CAP 24MCG 2

amoxicillin-clarithromycin w/ lansoprazole

1

CHOLBAM 3 NDS NM LA PA

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

3 NDS

diphenoxylate w/ atropine LIQD

3

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

2

GATTEX 3 NDS NM LA PA

LINZESS 3

loperamide hcl CAPS 1

LOPERAMIDE HYDROCHLORIDE SOLN

3

misoprostol (generic of CYTOTEC) TABS

1

MOTEGRITY 3

MOVANTIK 2

2020 632 3T Platinum eff 09/01/2020


48

Drug Name Drug Tier

Requirements/Limits

OCALIVA 3 NDS NM LA PA

OMECLAMOX-PAK 3

RELISTOR 3 NDS PA

SUCRAID 3 NDS LA

sucralfate (generic of CARAFATE) SUSP; TABS

1

SYMPROIC 3

TALICIA 3

TRULANCE 3

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

VIBERZI 3 NDS PA

XERMELO 3 NDS NM LA PA

XIFAXAN TAB 550MG 3 NDS PA

ZELNORM QL (60 tabs / 30 days)

3 QL PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

VIOKACE 10 2

VIOKACE 20 3 NDS

ZENPEP 2

PROTON PUMP INHIBITORS DEXILANT

QL (30 caps / 30 days) 2 QL

esomeprazole magnesium (generic of NEXIUM) CPDR


1 QL ST

esomeprazole magnesium (generic of NEXIUM) PACK


1 QL

esomeprazole sodium inj (generic of NEXIUM I.V.)

1

lansoprazole (generic of PREVACID) CPDR


1 QL

Drug Name Drug Tier

Requirements/Limits

lansoprazole (generic of PREVACID SOLUTAB) TBDD


1 QL

NEXIUM GRA 2.5MG DR 3

NEXIUM GRA 5MG DR 3

NEXIUM GRA 10MG DR QL (30 packets / 30 days)

3 QL


3 QL


3 QL

omeprazole cap 10mg 1



pantoprazole sodium (generic of PROTONIX) SOLR; TBEC

1

PRILOSEC 3

PROTONIX PACK QL (30 packets / 30 days)

3 QL

rabeprazole sodium (generic of ACIPHEX)


1 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

CARDURA XL 3

dutasteride (generic of AVODART) CAPS

1

dutasteride-tamsulosin hcl (generic of JALYN)

1

finasteride (generic of PROSCAR) TABS 5mg

1

silodosin (generic of RAPAFLO)

1

tamsulosin hcl (generic of FLOMAX)

1

MISCELLANEOUS bethanechol chloride TABS 1

ELMIRON 3 NDS

INTRAROSA 3 PA

2020 632 3T Platinum eff 09/01/2020


49

Drug Name Drug Tier

Requirements/Limits

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

1

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

1

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

1

THIOLA 3 NDS

THIOLA EC 3 NDS

URINARY ANTISPASMODICS darifenacin hydrobromide (generic of ENABLEX)

1

GELNIQUE 3

MYRBETRIQ 2

oxybutynin chloride SYRP 1

oxybutynin chloride TABS 1

oxybutynin chloride (generic of DITROPAN XL) TB24 5mg, 10mg

1

oxybutynin chloride TB24 15mg

1

OXYTROL 3

solifenacin succinate (generic of VESICARE)

1

tolterodine er (generic of DETROL LA)

1

tolterodine tartrate (generic of DETROL)

1

TOVIAZ 2

trospium chloride 1

VAGINAL ANTI-INFECTIVES CLEOCIN SUPP 3

clindamycin cre 2% vag (generic of CLEOCIN)

1

CLINDESSE 3

GYNAZOLE-1 3

metronidazole vaginal 1

miconazole 3 SUPP 1

terconazole vaginal 1

vandazole 1

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

Drug Name Drug Tier

Requirements/Limits

ELIQUIS 2.5mg QL (60 tabs / 30 days)

2 QL

ELIQUIS 5mg QL (74 tabs / 30 days)

2 QL

ELIQUIS STARTER PACK QL (74 tabs / 30 days)

2 QL

enoxaparin sodium (generic of LOVENOX)

1

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

1

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

3 NDS

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

3 NDS

heparin sod (porcine) in d5w 1

heparin sod inj 5000u/0.5ml 1 B/D

heparin sodium (porcine) 1000 u/ml

1 B/D


1 B/D


1 B/D


1 B/D

HEPARIN SODIUM INJ 5000U/0.5ML

3 B/D

HEPARIN SODIUM INJ 5000U/ML

3 B/D

HEPARIN SODIUM/NACL 0.45%

3

jantoven 1

PRADAXA QL (60 caps / 30 days)

3 QL

warfarin sodium 1

XARELTO 2.5mg QL (60 tabs / 30 days)

2 QL

XARELTO 10mg, 15mg, 20mg


2 QL

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Drug Name Drug Tier

Requirements/Limits

XARELTO STARTER PACK QL (51 tabs / 30 days)

2 QL

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, 40mcg/ml

2 NM PA

ARANESP ALBUMIN FREE SOLN 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml

3 NDS NM PA

ARANESP ALBUMIN FREE SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml

2 NM PA

ARANESP ALBUMIN FREE SOSY 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

3 NDS NM PA

LEUKINE 3 NDS NM PA

MOZOBIL 3 NDS NM PA

NPLATE 3 NDS NM PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

2 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

3 NDS NM PA

ZARXIO 3 NDS NM PA

MISCELLANEOUS anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT QL (24 boxes / 30 days)

3 NDS QL NM LA PA

CABLIVI 3 NDS NM LA PA

cilostazol 1

CINRYZE QL (20 vials / 30 days)

3 NDS QL NM LA PA

DOPTELET 3 NDS NM LA PA

DROXIA CAP 200MG 3

DROXIA CAP 300MG 3

DROXIA CAP 400MG 3

ENDARI 3 NDS NM LA PA

GIVLAARI 3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

HAEGARDA 2000unit QL (30 vials / 30 days)

3 NDS QL NM LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

3 NDS QL NM LA PA

icatibant acetate (generic of FIRAZYR)


3 NDS QL NM PA

KALBITOR QL (18 mL / 30 days)

3 NDS QL NM LA PA

MULPLETA 3 NDS NM PA

OXBRYTA 3 NDS NM LA PA

pentoxifylline TBCR 1

PROMACTA PACK 12.5mg QL (360 packets / 30 days)

3 NDS QL NM LA PA

PROMACTA PACK 25mg QL (180 packets / 30 days)

3 NDS QL NM LA PA

PROMACTA TABS 12.5mg, 25mg


3 NDS QL NM LA PA

PROMACTA TABS 50mg, 75mg


3 NDS QL NM LA PA

REBLOZYL 3 NDS NM LA PA

RUCONEST QL (12 vials / 30 days)

3 NDS QL NM PA

SOLIRIS 3 NDS NM LA PA

TAKHZYRO QL (2 vials / 28 days)

3 NDS QL NM LA PA

TAVALISSE QL (60 tabs / 30 days)

3 NDS QL NM LA PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

ULTOMIRIS 3 NDS NM LA PA

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)

1

BRILINTA 2

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Drug Name Drug Tier

Requirements/Limits

clopidogrel bisulfate (generic of PLAVIX) TABS 75mg

1

clopidogrel bisulfate TABS 300mg

1

prasugrel hcl (generic of EFFIENT)

1

ZONTIVITY 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) AVSOLA 3 NDS NM PA

ENBREL SOLR QL (16 vials / 28 days)

3 NDS QL NM PA

ENBREL SOSY 25mg/0.5ml QL (16 syringes / 28 days)

3 NDS QL NM PA

ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)

3 NDS QL NM PA

ENBREL MINI QL (8 injections / 28 days)

3 NDS QL NM PA

ENBREL SURECLICK QL (8 injections / 28 days)

3 NDS QL NM PA

HUMIRA 10mg/0.1ml, 20mg/0.2ml


3 NDS QL NM PA

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

3 NDS QL NM PA

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

3 NDS QL NM PA

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

3 NDS QL NM PA

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

3 NDS QL NM PA

HUMIRA PEDIATRIC CROHNS DISEASE

3 NDS NM PA

HUMIRA PEN QL (6 pens / 28 days)

3 NDS QL NM PA

HUMIRA PEN CD/UC/HS STARTER

3 NDS NM PA

Drug Name Drug Tier

Requirements/Limits

HUMIRA PEN INJ CD/UC/HS STARTER

3 NDS NM PA

HUMIRA PEN INJ PS/UV STARTER

3 NDS NM PA

HUMIRA PEN-PS/UV STARTER

3 NDS NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

leflunomide (generic of ARAVA) TABS


1 QL

methotrexate sodium tabs 1

RENFLEXIS 3 NDS NM LA PA

RINVOQ QL (30 tabs / 30 days)

3 NDS QL NM PA

SKYRIZI QL (7 kits / year)

3 NDS QL NM PA

STELARA SOLN 45mg/0.5ml

QL (1 vial / 28 days)

3 NDS QL NM LA PA

STELARA SOSY QL (1 syringe / 28 days)

3 NDS QL NM PA

TREXALL 2 B/D

XATMEP 3 B/D

XELJANZ QL (60 tabs / 30 days)

3 NDS QL NM PA

XELJANZ XR QL (30 tabs / 30 days)

3 NDS QL NM PA

IMMUNOGLOBULINS BIVIGAM 3 NDS NM PA

CUTAQUIG 3 NDS NM LA PA

CUVITRU 3 NDS NM LA PA

CYTOGAM 3 NDS NM

GAMASTAN 2 B/D NM

GAMMAGARD LIQUID 3 NDS NM PA

GAMMAGARD S/D 3 NDS NM PA

GAMMAKED 3 NDS NM PA

GAMMAPLEX 3 NDS NM PA

GAMMAPLEX 10GM/100ML 3 NDS NM PA

GAMUNEX-C 3 NDS NM PA

HIZENTRA 3 NDS NM LA PA

HYQVIA 3 NDS NM PA

OCTAGAM 3 NDS NM PA

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Drug Name Drug Tier

Requirements/Limits

PANZYGA 3 NDS NM PA

PRIVIGEN 3 NDS NM PA

XEMBIFY 3 NDS NM LA PA

IMMUNOMODULATORS ACTIMMUNE 3 NDS NM LA

PA

ARCALYST 3 NDS NM PA

GRASTEK 3 PA

ILARIS 3 NDS NM LA PA

INTRON-A INJ 10MU 3 NDS B/D NM




ODACTRA 3 PA

ORALAIR 2 NM PA

RAGWITEK 3 PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 3 NDS B/D NM

ASTAGRAF XL .5mg, 1mg 3 B/D NM

ATGAM 3 NDS B/D

AZASAN 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

BENLYSTA 3 NDS NM PA

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D NM

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

1 B/D NM

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D NM

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

1 B/D NM

ENVARSUS XR 3 B/D NM

everolimus (immunosuppressant) (generic of ZORTRESS) .5mg, .75mg

3 NDS B/D NM

everolimus (immunosuppressant) (generic of ZORTRESS) .25mg

1 B/D NM

Drug Name Drug Tier

Requirements/Limits

gengraf (generic of NEORAL) 1 B/D NM

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D NM

mycophenolate mofetil (generic of CELLCEPT) SUSR

3 NDS B/D NM

mycophenolate sodium tbec (generic of MYFORTIC)

1 B/D NM

NULOJIX 3 NDS B/D NM

PROGRAF PACK 3 B/D NM

SANDIMMUNE SOLN 100MG/ML

3 B/D NM

sirolimus (generic of RAPAMUNE) SOLN

3 NDS B/D NM

sirolimus (generic of RAPAMUNE) TABS 2mg

3 NDS B/D NM

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

1 B/D NM

tacrolimus (generic of PROGRAF) CAPS

1 B/D NM

ZORTRESS TAB 0.5MG 3 NDS B/D NM



ZORTRESS TAB 1MG 3 NDS B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3 B/D

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

KINRIX 3

M-M-R II 3

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Drug Name Drug Tier

Requirements/Limits

MENACTRA 3

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3 B/D

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SHINGRIX QL (2 vials per lifetime)

3 QL

TDVAX 3 B/D

TENIVAC 3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX QL (1 vial per lifetime)

3 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 1

klor-con 10 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con pak 20meq 1

klor-con spr cap 8meq 1

klor-con spr cap 10meq 1

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

3

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

1

magnesium sulfate SOLN 50%

1

Drug Name Drug Tier

Requirements/Limits

MAGNESIUM SULFATE IN D5W

3

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

1

magnesium sulfate inj 50% 1

potassium chloride CPCR 1

potassium chloride PACK 1

potassium chloride SOLN 10%, 20%

1

potassium chloride TBCR 8meq, 10meq

1

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

1

potassium chloride microencapsulated crystals er

1

sodium chloride SOLN 2.5meq/ml

1

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

1

TPN ELECTROLYTES 3 B/D

IV NUTRITION AMINOSYN II INJ 10% 3 B/D

AMINOSYN-PF 7% 3 B/D

CLINIMIX 4.25%/DEXTROSE 5

3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D

CLINIMIX 5%/DEXTROSE 20%

3 B/D

CLINIMIX E 2.75%/DEXTROSE

3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D

CLINIMIX E 5%/DEXTROSE 15

3 B/D

CLINIMIX E 5%/DEXTROSE 20

3 B/D

CLINIMIX INJ 4.25/D10 3 B/D

clinisol sf 15% 1 B/D

CLINOLIPID 3 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

hepatamine 1 B/D

INTRALIPID 30% 3 B/D

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Drug Name Drug Tier

Requirements/Limits

INTRALIPID INJ 20% 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID INJ 20% 3 B/D

plenamine 1 B/D

PREMASOL 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

SMOFLIPID 3 B/D

TRAVASOL 3 B/D

TROPHAMINE INJ 6% 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS dextrose SOLN 50%, 70% 1

dextrose 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/NACL 0.3% 3

dextrose 10% 1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

dextrose in lactated ringers 1

dextrose w/ sodium chloride 1

ISOLYTE-P/DEXTROSE 5% 3

ISOLYTE-S 3

kcl0.15%/d5w/nacl0.2% 1

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.15%/D5W/NACL 0.225%

3

kcl/d5w/nacl inj 0.22%/0.45% 1

kcl/nacl inj 0.15%-0.9% 1

lactated ringer's 1

NORMOSOL-M IN D5W 3

NORMOSOL-R 3

NORMOSOL-R IN D5W 3

PLASMA-LYTE A 3

PLASMA-LYTE-148 3

potassium chloride SOLN 2meq/ml

1

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

1

potassium chloride 0.15% in nacl 0.45%

1

Drug Name Drug Tier

Requirements/Limits

potassium chloride in dextrose 1

potassium chloride in dextrose & sodium chloride

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE/DEXTRO

3

sodium chloride SOLN .9%, 3%, 5%

1

sodium chloride 0.45% 1

VITAMINS calcitriol (generic of ROCALTROL) CAPS; SOLN

1 B/D

calcitriol inj 1 B/D

doxercalciferol CAPS 1 B/D

M-NATAL PLUS 2

ONE VITE WOMENS PRENATAL

2

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

1 B/D

paricalcitol CAPS 4mcg 1 B/D

PNV FOLIC ACID + IRON MUL

2

PRENATAL 2

PRENATAL PLUS 2

PRENATAL PLUS LOW IRON 2

RAYALDEE 3 NDS

TRICARE 2

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

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Drug Name Drug Tier

Requirements/Limits

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OINT 2

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate soln (ophth)

1

levofloxacin (ophth) 1

MOXEZA 2

moxifloxacin hcl (ophth) (generic of MOXEZA) .5%

1

moxifloxacin hcl (ophth) (generic of VIGAMOX) .5%

1

NATACYN 3

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin

1

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

sulfacetamide sodium (ophth) OINT

1

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

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 3

trifluridine 1

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 2

ALREX 3

bromfenac sodium (ophth) 1

BROMSITE 3

Drug Name Drug Tier

Requirements/Limits

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 2

fluorometholone (ophth) 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

ILEVRO 2

INVELTYS 3

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

1

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

1

LOTEMAX GEL; OINT 3

LOTEMAX SM 3

loteprednol etabonate (generic of LOTEMAX)

1

MAXIDEX 2

NEVANAC 2

PRED MILD 2

prednisolone acetate (ophth) (generic of PRED FORTE)

1

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3

PROLENSA 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) 1

BEPREVE 3

cromolyn sodium (ophth) 1

epinastine hcl (ophth) 1

LASTACAFT 2

olopatadine hcl 0.1% 1

olopatadine hcl 0.2% 1

PAZEO 2

ZERVIATE 3

ANTIGLAUCOMA ALPHAGAN P .1% 2

AZOPT 2

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Drug Name Drug Tier

Requirements/Limits

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

brimonidine sol 0.15% (generic of ALPHAGAN P)

1

carteolol hcl (ophth) 1

COMBIGAN 2

dorzol/timol sol 22.3-6.8 pf (generic of COSOPT PF)

1

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl 1

LUMIGAN 2

PHOSPHOLINE IODIDE 3

pilocarpine hcl (generic of ISOPTO CARPINE) SOLN

1

RHOPRESSA 3

SIMBRINZA 2

timolol maleate (ophth) soln (generic of TIMOPTIC)

1

timolol maleate gel (generic of TIMOPTIC-XE)

1

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

1

TIMOPTIC OCUDOSE 3

travoprost (generic of TRAVATAN Z)

1

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

2

BEOVU 3 NDS NM LA PA

CYSTARAN 3 NDS NM LA PA

EYLEA 3 NDS NM LA PA

LACRISERT 3

LUCENTIS SOLN 3 NDS NM LA PA

Drug Name Drug Tier

Requirements/Limits

LUCENTIS SOSY .3mg/0.05ml

3 NDS NM LA PA

OXERVATE 3 NDS NM LA PA

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

RESTASIS MULTIDOSE 2

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

QL (60 blisters / 30 days)

2 QL

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

2 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

2 QL

ipratropium-albuterol 1 B/D

TRELEGY ELLIPTA QL (60 blisters / 30 days)

2 QL

ANTICHOLINERGICS ATROVENT HFA

QL (2 inhalers / 30 days) 3 QL

INCRUSE ELLIPTA QL (30 blisters / 30 days)

2 QL

ipratropium bromide (nasal) 1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

SPIRIVA RESPIMAT 1.25MCG/ACT

QL (1 inhaler / 30 days)

2 QL

SPIRIVA RESPIMAT 2.5MCG/ACT

QL (1 inhaler / 30 days)

2 QL

SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK)


2 QL

ANTIHISTAMINE COMBINATIONS

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Drug Name Drug Tier

Requirements/Limits

azelastine hcl-fluticasone propionate (generic of DYMISTA)

QL (1 bottle / 30 days)

1 QL

CLARINEX-D 12 HOUR 3

DYMISTA QL (1 bottle / 30 days)

2 QL

SEMPREX-D 3

ANTIHISTAMINES azelastine hcl SOLN 1

cetirizine hcl SOLN 1

cyproheptadine hcl SYRP; TABS


2 PA

desloratadine (generic of CLARINEX) TABS

1

desloratadine TBDP 1

diphenhydramine hcl inj 50mg/ml

1

hydroxyzine hcl SYRP PA if 70 years and older

2 PA

hydroxyzine hcl TABS PA if 70 years and older

1 PA

hydroxyzine hcl inj PA if 70 years and older

3 PA

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


1 PA

hydroxyzine pamoate CAPS 100mg


1 PA

levocetirizine oral soln 1

levocetirizine tab 5 mg 1

olopatadine hcl (nasal) (generic of PATANASE)

1

QUZYTTIR 3

BETA AGONISTS albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Ventolin HFA)

1 QL

Drug Name Drug Tier

Requirements/Limits

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

QL (2 inhalers / 30 days) (generic of Proair HFA)

1 QL

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

QL (2 inhalers / 30 days) (generic of Proventil HFA)

1 QL

albuterol sulfate NEBU .083%, .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

1 B/D

albuterol sulfate SYRP 1

albuterol sulfate TABS 1

albuterol sulfate TB12 1

ARCAPTA NEOHALER QL (30 caps / 30 days)

3 QL

BROVANA 3 NDS B/D

levalbuterol hcl (generic of XOPENEX) NEBU

1 B/D

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

1 B/D

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

1 QL

PERFOROMIST 3 NDS B/D

PROAIR DIGIHALER QL (2 inhalers / 30 days)

3 QL

PROAIR RESPICLICK QL (2 inhalers / 30 days)

2 QL

SEREVENT DISKUS QL (60 inhalations / 30 days)

2 QL

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

2 QL

terbutaline sulfate SOLN 3 NDS

terbutaline sulfate TABS 1

VENTOLIN HFA QL (2 inhalers / 30 days)

2 QL

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

1

zafirlukast (generic of ACCOLATE)

1

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Drug Name Drug Tier

Requirements/Limits

MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ARALAST NP 3 NDS NM LA PA

CINQAIR 3 NDS NM LA PA

DALIRESP 2

ELIXOPHYLLIN 3

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

(generic of EpiPen)

1

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

(generic of EpiPen)

1

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

(generic of Adrenaclick)

1

ESBRIET 3 NDS NM PA

FASENRA 3 NDS NM LA PA

FASENRA PEN 3 NDS NM LA PA

GLASSIA 3 NDS NM LA PA

KALYDECO 3 NDS NM PA

NUCALA 3 NDS NM LA PA

OFEV 3 NDS NM PA

ORKAMBI 3 NDS NM PA

PROLASTIN-C 3 NDS NM LA PA

PULMOZYME 3 NDS NM PA

SYMDEKO 3 NDS NM LA PA

SYMJEPI 2

THEO-24 3

theophylline 1

theophylline tab er 12hr 300 mg

1

theophylline tab er 12hr 450 mg

1

Drug Name Drug Tier

Requirements/Limits

theophylline tab sr 24hr 1

TRIKAFTA 3 NDS NM LA PA

XOLAIR 3 NDS NM LA PA

ZEMAIRA 3 NDS NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 inhalers / 30 days) 3 QL

flunisolide (nasal) QL (3 bottles / 30 days)

1 QL

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL

mometasone furoate (nasal) (generic of NASONEX)


1 QL

OMNARIS QL (1 inhaler / 30 days)

3 QL

QNASL QL (1 inhaler / 30 days)

3 QL

QNASL CHILDRENS QL (1 inhaler / 30 days)

3 QL

XHANCE QL (2 bottles / 30 days)

3 QL

ZETONNA QL (1 inhaler / 30 days)

3 QL

STEROID INHALANTS ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

STEROID/BETA-AGONIST COMBINATIONS

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Drug Name Drug Tier

Requirements/Limits

ADVAIR DISKUS QL (60 inhalations / 30 days)

2 QL

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

BREO ELLIPTA QL (60 blisters / 30 days)

2 QL

SYMBICORT QL (1 inhaler / 30 days)

2 QL

TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NDS PA

ABSORICA LD 3 NDS PA

adapalene (generic of DIFFERIN) CREA

1

adapalene GEL .1% 1

adapalene (generic of DIFFERIN) GEL .3%

1

ADAPALENE SOLN 3

adapalene-benzoyl peroxide gel 0.1-2.5% (generic of EPIDUO)

1

AKLIEF QL (45 grams / 30 days)

3 QL PA

ALTRENO QL (45 grams / 30 days)

3 QL PA

amnesteem 1 PA

AMZEEQ QL (30 grams / 30 days)

3 QL

ARAZLO QL (45 grams / 30 days)

3 QL PA

avita (generic of RETIN-A) CREA


1 QL PA

avita GEL QL (45 grams / 30 days)

1 QL PA

AZELEX 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1 PA

clindacin-p 1

clindam/benz gel 1.2-2.5% (generic of ACANYA)


1 QL

Drug Name Drug Tier

Requirements/Limits

clindamy/ben gel 1-5% (generic of BENZACLIN)

1

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

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


1 QL

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

1

clindamycin phosphate (topical) SOLN


1 QL

clindamycin phosphate (topical) SWAB

1

clindamycin phosphate-benzoyl peroxide (refrigerate)

1

clindamycin phosphate-tretinoin (generic of ZIANA)

1

dapsone gel 5% (generic of ACZONE)


1 QL

dapsone gel 7.5% (generic of ACZONE)


1 QL

DIFFERIN LOTN 3

EPIDUO FORTE 2

ery pad 2% 1

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

FABIOR QL (100 grams / 30 days)

3 QL PA

isotretinoin CAPS 1 PA

myorisan 1 PA

neuac gel 1.2-5% 1

ONEXTON 2

RETIN-A MICRO .06% QL (50 grams / 30 days)

3 NDS QL PA

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Drug Name Drug Tier

Requirements/Limits

RETIN-A MICRO PUMP .08%


3 NDS QL PA

sulfacetamide sodium (acne) (generic of KLARON)

1

tretinoin (generic of RETIN-A) CREA


1 QL PA

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


1 QL PA

tretinoin (generic of ATRALIN) GEL .05%


1 QL PA

tretinoin microsphere (generic of RETIN-A MICRO)


1 QL PA

VELTIN 2

zenatane 1 PA

DERMATOLOGY, ANTIBIOTICS ALTABAX

QL (30 grams / 30 days) 3 QL

CENTANY QL (220 grams / 30 days)

3 QL

CORTISPORIN 3

gentamicin sulfate (topical) 1

mafenide acetate (generic of SULFAMYLON) PACK

1

mupirocin OINT QL (220 grams / 30 days)

1 QL

silver sulfadiazine (generic of SILVADENE) CREA

1

ssd (generic of SILVADENE) 1

SULFAMYLON CREA 3

XEPI 3

DERMATOLOGY, ANTIFUNGALS ciclopirox olamine (generic of LOPROX) CREA


1 QL

ciclopirox olamine (generic of LOPROX) SUSP


1 QL

clotrimazole (topical) CREA 1

Drug Name Drug Tier

Requirements/Limits

clotrimazole (topical) SOLN QL (30 mL / 30 days)

1 QL

clotrimazole w/ betamethasone CREA

1

clotrimazole w/ betamethasone LOTN


1 QL

econazole nitrate CREA QL (85 grams / 30 days)

1 QL

ERTACZO QL (60 grams / 30 days)

3 NDS QL

JUBLIA QL (8 mL / 30 days)

3 NDS QL

ketoconazole cream QL (60 grams / 30 days)

1 QL

ketoconazole foam (generic of EXTINA)


1 QL

ketodan (generic of EXTINA) QL (100 grams / 30 days)

1 QL

luliconazole QL (60 grams / 30 days)

1 QL

MENTAX 3

miconazole-zinc oxide-white petrolatum

1 PA

naftifine hcl CREA 1% QL (90 grams / 30 days)

1 QL

naftifine hcl (generic of NAFTIN) CREA 2%


1 QL

naftifine hcl (generic of NAFTIN) GEL


1 QL

NAFTIN GEL 1% QL (90 grams / 30 days)

2 QL

NAFTIN GEL 2% QL (60 grams / 30 days)

2 QL

nyamyc QL (60 grams / 30 days)

1 QL

nystatin (topical) 1

nystatin pow 100000 QL (60 grams / 30 days)

1 QL

nystop QL (60 grams / 30 days)

1 QL

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Drug Name Drug Tier

Requirements/Limits

OXISTAT LOTN QL (60 mL / 30 days)

3 QL PA

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

1 PA

acitretin 17.5mg 1 PA

calcipotriene OINT QL (120 grams / 30 days)

1 QL PA

calcipotriene SOLN QL (120 mL / 30 days)

1 QL PA

calcitrene QL (120 grams / 30 days)

1 QL PA

methoxsalen rapid (generic of OXSORALEN ULTRA)

3 NDS

SORILUX QL (120 grams / 30 days)

3 NDS QL PA

tazarotene (generic of TAZORAC) CREA


1 QL PA

TAZORAC CREAM 0.05% QL (60 grams / 30 days)

2 QL PA

TAZORAC GEL 0.1% QL (100 grams / 30 days)

2 QL PA

TAZORAC GEL 0.05% QL (100 grams / 30 days)

2 QL PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1

selenium sulfide LOTN 1

XOLEGEL QL (45 grams / 30 days)

3 NDS QL

DERMATOLOGY, CORTICOSTEROIDS ALA SCALP 3

ala-cort 1

alclometasone dipropionate 1

amcinonide CREA; LOTN 1

AMCINONIDE OINT 3

APEXICON E QL (60 grams / 30 days)

3 NDS QL

beser (generic of CUTIVATE) LOTN

QL (120 mL / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL; LOTN

1

betamethasone dipropionate augmented (generic of DIPROLENE) OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

BRYHALI QL (100 grams / 30 days)

2 QL

calcipotriene-betamethasone dipropionate (generic of TACLONEX) OINT


1 QL PA

calcipotriene-betamethasone dipropionate (generic of TACLONEX) SUSP


3 NDS QL PA

CAPEX 2

clobetasol propionate (generic of TEMOVATE) CREA; OINT


1 QL

clobetasol propionate (generic of OLUX) FOAM


1 QL

clobetasol propionate GEL QL (60 grams / 30 days)

1 QL

clobetasol propionate (generic of CLOBEX) LIQD

QL (125 mL / 30 days)

1 QL

clobetasol propionate (generic of CLOBEX) LOTN; SHAM

QL (118 mL / 30 days)

1 QL

clobetasol propionate SOLN QL (50 mL / 30 days)

1 QL

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Drug Name Drug Tier

Requirements/Limits

clobetasol propionate emo QL (60 grams / 30 days)

1 QL

clobetasol propionate emulsion (generic of OLUX-E)


1 QL

clocortolone pivalate (generic of CLODERM)

1

clodan (generic of CLOBEX) QL (118 mL / 30 days)

1 QL

CORDRAN TAPE 3

DESONATE QL (60 grams / 30 days)

3 QL

desonide (generic of DESOWEN) CREA


1 QL

desonide (generic of DESONATE) GEL


1 QL

desonide LOTN QL (118 mL / 30 days)

1 QL

desonide OINT QL (60 grams / 30 days)

1 QL

desoximetasone (generic of TOPICORT) LIQD

QL (100 mL / 30 days)

1 QL

DUOBRII QL (100 grams / 30 days)

3 NDS QL PA

ENSTILAR QL (120 grams / 30 days)

2 QL PA

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

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

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN


1 QL

Drug Name Drug Tier

Requirements/Limits

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

1

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

1 QL

fluocinonide GEL QL (60 grams / 30 days)

1 QL

fluocinonide OINT QL (60 grams / 30 days)

1 QL

fluocinonide SOLN QL (60 mL / 30 days)

1 QL

fluocinonide emulsified base QL (120 grams / 30 days)

1 QL

flurandrenolide (generic of CORDRAN) CREA


1 QL

flurandrenolide (generic of CORDRAN) LOTN

1

fluticasone propionate CREA; OINT

1

fluticasone propionate (generic of CUTIVATE) LOTN

QL (120 mL / 30 days)

1 QL

halcinonide (generic of HALOG)


1 QL

halobetasol propionate CREA; OINT


1 QL

HALOBETASOL PROPIONATE FOAM

3 NDS

HALOG OINT QL (240 grams / 30 days)

3 NDS QL

hydrocortisone (topical) cream 1%

1

hydrocortisone (topical) cream 2.5%

1

hydrocortisone (topical) lotion 2.5%

1

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Drug Name Drug Tier

Requirements/Limits

hydrocortisone (topical) oint 1%


1 QL

hydrocortisone (topical) oint 2.5%

1

hydrocortisone butyrate cream 0.1%


1 QL

hydrocortisone butyrate cream 0.1% lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone butyrate lotion 0.1% (generic of LOCOID)

1

hydrocortisone butyrate oint 0.1%


1 QL

hydrocortisone butyrate soln 0.1%


1 QL

IMPOYZ QL (60 grams / 30 days)

3 QL

LEXETTE 3 NDS

mometasone furoate CREA; OINT; SOLN

1

nolix (generic of CORDRAN) CREA


1 QL

nolix (generic of CORDRAN) LOTN

1

PANDEL QL (80 grams / 30 days)

3 NDS QL

prednicarbate 1

SERNIVO 3 NDS

TEXACORT 2

tovet (generic of OLUX-E) QL (100 grams / 30 days)

1 QL

triamcinolone acetonide (topical) (generic of KENALOG) AERS

1

triamcinolone acetonide (topical) CREA .1%


1 QL

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

1

Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (topical) LOTN

1

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

1

triderm QL (454 grams / 30 days)

1 QL

ULTRAVATE LOTN QL (120 mL / 30 days)

3 NDS QL

VERDESO QL (100 grams / 30 days)

3 NDS QL

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 1 QL PA

lidocaine OINT QL (50 grams / 30 days)

1 QL PA

lidocaine (generic of LIDODERM) PTCH 5%

QL (3 patches / 1 day)

1 QL PA

lidocaine hcl GEL QL (30 mL / 30 days)

1 QL PA

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

1 QL PA

lidocaine-prilocaine QL (30 grams / 30 days)

1 QL PA

ZTLIDO QL (3 patches / 1 day)

3 QL PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of ZOVIRAX) CREA


3 NDS QL

acyclovir topical (generic of ZOVIRAX) OINT


1 QL

azelaic acid (generic of FINACEA) GEL


1 QL

CONDYLOX 2

CORTIFOAM 2

DENAVIR QL (5 grams / 30 days)

3 NDS QL

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Drug Name Drug Tier

Requirements/Limits

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


1 QL PA

diclofenac sodium (topical) 1.5% soln

QL (450 mL / 30 days)

1 QL PA

diclofenac sodium (topical) 3% gel


3 NDS QL PA

doxycycline (rosacea) 1

FINACEA AER 15% 2

FLUOROPLEX QL (30 grams / 30 days)

3 NDS QL

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


1 QL

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

1 QL

imiquimod (generic of ALDARA) CREA 5%


1 QL

IVERMECTIN CREA QL (45 grams / 30 days)

1 QL

lactic acid (ammonium lactate) 1

metronidazole (topical) (generic of METROCREAM) CREA

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

metronidazole gel 0.75% 1

MIRVASO QL (30 grams / 30 days)

3 QL

NORITATE QL (60 grams / 30 days)

3 NDS QL

PANRETIN QL (60 grams / 30 days)

3 NDS QL

PENNSAID QL (224 grams / 28 days)

3 NDS QL PA

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

3 QL

Drug Name Drug Tier

Requirements/Limits

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

3 QL

pimecrolimus (generic of ELIDEL)


1 QL PA

podofilox SOLN 1

procto-med hc (generic of ANUSOL-HC)

1

procto-pak (generic of PROCTOCORT)

1

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

1

proctozone-hc (generic of ANUSOL-HC)

1

QBREXZA 3 PA

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

tacrolimus (topical) (generic of PROTOPIC)


1 QL

TARGRETIN GEL QL (60 grams / 30 days)

3 NDS QL NM PA

VALCHLOR QL (60 grams / 30 days)

3 NDS QL NM LA PA

XERESE QL (5 grams / 30 days)

3 NDS QL

DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan


1 QL

malathion 1

NATROBA 3

permethrin cre 5% (generic of ELIMITE)

1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu 1

REGRANEX QL (30 grams / 30 days)

3 NDS QL PA

SANTYL 3

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Drug Name Drug Tier

Requirements/Limits

sodium chloride 0.9% irrigation

1

water for irrigation, sterile 1

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

1

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

1

clotrimazole TROC 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

ORAVIG 3 NDS

paroex sol 0.12% (generic of PERIDEX)

1

periogard (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

1

triamcinolone acetonide (mouth)

1

OTIC acetic acid (otic) 1

CIPRO HC 3

CIPRODEX 2

ciprofloxacin hcl (otic) 1

ciprofloxacin-fluocinolone acetonide

1

CORTISPORIN-TC 3

flac (generic of DERMOTIC) 1

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

hydrocortisone w/acetic acid 1

neomycin-polymyxin-hc (otic) 1

ofloxacin (otic) 1

OTOVEL 3

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Index A abacavir sulfate ...................7 abacavir sulfate-lamivudine.8 abacavir sulfate-lamivudine-zidovudine ..........................................8 ABELCET............................6 ABILIFY

see aripiprazole tabs ..... 27 ABILIFY MAINTENA ......... 27 ABILIFY MYCITE .............. 27 abiraterone acetate ........... 13 ABRAXANE ...................... 12 ABSORICA ....................... 59 ABSORICA LD .................. 59 acamprosate calcium ........ 35 ACANYA

see clindam/benz gel 1.2-2.5% ........................ 59

acarbose ........................... 37 ACCOLATE

see zafirlukast ............... 57 ACCUPRIL

see quinapril hcl ............ 17 ACCURETIC

see quinapril-hydrochlorothiazide .................................. 17

acebutolol hcl .................... 19 acetaminophen w/ codeine 300-15mg ............................1 acetaminophen w/ codeine 300-30mg ............................1 acetaminophen w/ codeine 300-60mg ............................1 acetaminophen w/ codeine soln .....................................1 acetaminophen-caff-dihydrocod .................................... 1, 2 acetazolamide ................... 21 acetic acid ......................... 64 acetic acid (otic) ................ 65 acetylcysteine ................... 58 ACIPHEX

see rabeprazole sodium 48 acitretin ............................. 61 ACTHIB ............................. 52

ACTICLATE see doxycycline hyclate . 11

ACTIGALL see ursodiol ................... 48

ACTIMMUNE .................... 52 ACTIQ

see fentanyl citrate .......... 2 ACTONEL

see risedronate sodium . 39 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 38

ACTOS see pioglitazone hcl ....... 38

ACULAR see ketorolac tromethamine (ophth) .... 55

ACULAR LS see ketorolac tromethamine (ophth) .... 55

ACUVAIL .......................... 55 acyclovir .............................. 8 acyclovir sodium ................. 9 acyclovir topical ................ 63 ACZONE

see dapsone gel 5% ...... 59 see dapsone gel 7.5% ... 59

ADACEL ........................... 52 ADAKVEO ........................ 12 adapalene ......................... 59 ADAPALENE .................... 59 adapalene-benzoyl peroxide gel 0.1-2.5% ...................... 59 ADCIRCA

see alyq ......................... 22 see tadalafil (pulmonary hypertension) ................ 22

ADDERALL see amphetamine-dextroamphetamine tab 10 mg......... 30 see amphetamine-dextroamphetamine tab 12.5 mg...... 30 see amphetamine-dextroamphetamine tab 15 mg......... 30

see amphetamine-dextroamphetamine tab 20 mg ........ 30 see amphetamine-dextroamphetamine tab 30 mg ........ 30 see amphetamine-dextroamphetamine tab 5 mg .......... 30 see amphetamine-dextroamphetamine tab 7.5 mg ....... 30

ADDERALL XR see amphetamine-dextroamphetamine cap sr 24hr 10 mg ...................................... 29 see amphetamine-dextroamphetamine cap sr 24hr 15 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 20 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 25 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 30 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 29

adefovir dipivoxil ................. 9 ADEMPAS ........................ 22 adriamycin ........................ 11 adrucil inj .......................... 12 ADVAIR DISKUS .............. 59 ADVAIR HFA .................... 59 ADZENYS ER SUS 1.25MG.......................................... 29 ADZENYS XR-ODT .......... 29 AEMCOLO .......................... 5

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AFINITOR ......................... 14 see everolimus .............. 15

AFINITOR DISPERZ ......... 14 AGGRENOX

see aspirin-dipyridamole 50 AGRYLIN

see anagrelide hcl ......... 50 AIMOVIG........................... 32 AKLIEF ............................. 59 AKYNZEO ......................... 45 ALA SCALP ...................... 61 ala-cort .............................. 61 albendazole .........................5 ALBENZA

see albendazole ..............5 albuterol sulfate ................. 57 ALCAINE

see proparacaine hcl ..... 56 alclometasone dipropionate .......................................... 61 ALDACTAZIDE ................. 21

see spironolactone & hydrochlorothiazide ....... 21

ALDACTONE see spironolactone ........ 17

ALDARA see imiquimod ............... 64

ALDURAZYME ................. 42 ALECENSA ....................... 14 alendronate sodium .......... 39 alfuzosin hcl ...................... 48 ALIMTA ............................. 12 ALINIA ................................5 ALIQOPA .......................... 14 aliskiren fumarate .............. 21 allopurinol............................1 almotriptan malate ............ 32 ALOCRIL........................... 55 ALOMIDE .......................... 55 ALORA .............................. 42 alosetron hcl ...................... 47 ALOXI

see palonosetron hcl ..... 46 ALPHAGAN P ................... 55

see brimonidine sol 0.15% ...................................... 56

ALPRAZOLAM INTENSOL .......................................... 22

alprazolam tab 0.25mg ..... 22 alprazolam tab 0.5mg ....... 22 alprazolam tab 1mg .......... 22 alprazolam tab 2mg .......... 22 ALREX .............................. 55 ALTABAX .......................... 60 ALTACE

see ramipril .................... 17 altavera tab ....................... 39 ALTOPREV ....................... 18 ALTRENO ......................... 59 ALUNBRIG ....................... 14 alyacen 1/35 ..................... 39 alyq ................................... 22 amantadine hcl ................. 26 AMARYL

see glimepiride .............. 37 AMBIEN

see zolpidem tartrate ..... 32 AMBISOME ........................ 6 ambrisentan ...................... 22 amcinonide ....................... 61 AMCINONIDE ................... 61 AMERGE

see naratriptan hcl ......... 32 amethia ............................. 39 amethia lo ......................... 39 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 21 amiloride hcl ...................... 21 AMINOSYN II INJ 10% ..... 53 AMINOSYN-PF 7% ........... 53 amiodarone hcl soln .......... 18 amiodarone tab 100mg ..... 18 amiodarone tab 200mg ..... 18 amiodarone tab 400mg ..... 18 AMITIZA CAP 24MCG ...... 47 AMITIZA CAP 8MCG ........ 47 amitriptyline hcl ................. 25 amlodipine besylate .......... 19 amlodipine besylate-atorvastatin calcium .......................................... 19 amlodipine besylate-benazepril hcl ..... 16 amlodipine besylate-olmesartan

medoxomil ........................ 17 amlodipine besylate-valsartan............. 17 amlodipine-valsartan-hydrochlorothiazide ..................... 17 amnesteem ....................... 59 amoxapine ........................ 25 amoxicillin ......................... 10 amoxicillin & pot clavulanate 200/5ml susr ..................... 10 amoxicillin & pot clavulanate 200-28.5 chw tabs ............ 10 amoxicillin & pot clavulanate 250/5ml susr ..................... 10 amoxicillin & pot clavulanate 250-125 tabs ..................... 10 amoxicillin & pot clavulanate 400/5ml susr ..................... 10 amoxicillin & pot clavulanate 400-57 chw tabs ............... 10 amoxicillin & pot clavulanate 500-125 tabs ..................... 10 amoxicillin & pot clavulanate 600/5ml susr ..................... 10 amoxicillin & pot clavulanate 875-125 tabs ..................... 10 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs ..... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 47 amphetamine er sus 1.25mg/ml ......................... 29 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 29 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 29 amphetamine-dextroamphetamine tab 10 mg ............... 30 amphetamine-dextroamphetamine tab 12.5 mg ............ 30

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amphetamine-dextroamphetamine tab 15 mg ............... 30 amphetamine-dextroamphetamine tab 20 mg ............... 30 amphetamine-dextroamphetamine tab 30 mg ............... 30 amphetamine-dextroamphetamine tab 5 mg ................. 30 amphetamine-dextroamphetamine tab 7.5 mg .............. 30 amphotericin b ....................6 ampicillin & sulbactam sodium .............................. 10 ampicillin cap 500mg ........ 10 ampicillin inj ....................... 10 ampicillin sodium ............... 10 AMPYRA

see dalfampridine .......... 34 AMZEEQ ........................... 59 ANADROL-50 ................... 36 ANAFRANIL

see clomipramine hcl ..... 25 anagrelide hcl .................... 50 ANAPROX DS

see naproxen sodium ......1 anastrozole ....................... 13 ANCOBON

see flucytosine .................6 ANDRODERM .................. 36 ANDROGEL

see testosterone ............ 36 ANDROGEL PUMP

see testosterone ............ 36 ANNOVERA ...................... 39 ANORO ELLIPTA ............. 56 ANTABUSE

see disulfiram ................ 36 ANTARA ........................... 18 ANUSOL-HC

see procto-med hc ......... 64 see proctosol hc cre 2.5% ...................................... 64 see proctozone-hc ......... 64

APEXICON E .................... 61 APOKYN ........................... 27 aprepitant .......................... 46 aprepitant pak 80mg & 125mg ............................... 46

apri .................................... 39 APRISO

see mesalamine ............ 47 APTENSIO XR .................. 30 APTIOM ............................ 22 APTIVUS ............................ 7 ARALAST NP ................... 58 aranelle ............................. 39 ARANESP ALBUMIN FREE .......................................... 50 ARAVA

see leflunomide ............. 51 ARAZLO ........................... 59 ARCALYST ....................... 52 ARCAPTA NEOHALER .... 57 ARICEPT

see donepezil hydrochloride ................. 25

ARIKAYCE .......................... 5 ARIMIDEX

see anastrozole ............. 13 aripiprazole odt ................. 27 aripiprazole oral solution 1 mg/ml ................................ 27 aripiprazole tabs ............... 27 ARISTADA ........................ 27 ARISTADA INITIO ............ 28 ARIXTRA

see fondaparinux sodium ...................................... 49

armodafinil ........................ 35 ARNUITY ELLIPTA ........... 58 AROMASIN

see exemestane ............ 14 ARTHROTEC 50

see diclofenac w/ misoprostol ...................... 1

ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1

ARYMO ER ......................... 2 ARZERRA ......................... 12 ASACOL HD

see mesalamine ............ 47 ashlyna ............................. 39 aspirin-dipyridamole .......... 50 ASTAGRAF XL ................. 52 ATACAND

see candesartan cilexetil ...................................... 18

ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 17

atazanavir sulfate................ 7 ATELVIA

see risedronate sodium . 39 atenolol ............................. 19 atenolol & chlorthalidone .. 19 ATGAM ............................. 52 ATIVAN

see lorazepam............... 22 atomoxetine hcl................. 30 atorvastatin calcium .......... 18 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ........................ 7 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 7 ATRALIN

see tretinoin .................. 60 ATRIPLA ............................. 8 atropine sulfate ................. 46 ATROPINE SULFATE ...... 56 ATROVENT HFA .............. 56 AUBAGIO ......................... 34 aubra ................................ 39 AUGMENTIN

see amoxicillin & pot clavulanate 250/5ml susr ...................................... 10 see amoxicillin & pot clavulanate 500-125 tabs ...................................... 10

AURYXIA .......................... 45 AUSTEDO ........................ 33 AVALIDE

see irbesartan-hydrochlorothiazide ............................... 17

AVAPRO see irbesartan ............... 18

AVASTIN .......................... 12 AVEED ............................. 36 aviane ............................... 39 avita .................................. 59

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AVODART see dutasteride .............. 48

AVONEX ........................... 34 AVONEX PEN ................... 34 AVSOLA............................ 51 AVYCAZ..............................9 AYGESTIN

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

AYVAKIT ........................... 14 azacitidine ......................... 12 AZACTAM

see aztreonam .................5 AZASAN............................ 52 AZASITE ........................... 55 azathioprine ...................... 52 azelaic acid ....................... 63 azelastine hcl .................... 57 azelastine hcl (ophth) ........ 55 azelastine hcl-fluticasone propionate ......................... 57 AZELEX ............................ 59 AZILECT

see rasagiline mesylate . 27 azithromycin ........................9 AZOPT .............................. 55 AZOR

see amlodipine besylate-olmesartan medoxomil ..................... 17

aztreonam ...........................5 AZULFIDINE

see sulfasalazine ir ........ 47 AZULFIDINE EN-TABS

see sulfasalazine dr ....... 47 B bacitracin (ophthalmic) ...... 55 bacitracin-polymyxin b (ophth) .............................. 55 bacitracin-poly-neomycin-hc .......................................... 54 baclofen ............................ 35 BACTOCILL INJ DEX 1GM .......................................... 10 BACTOCILL INJ DEX 2GM .......................................... 10 BACTRIM

see

sulfamethoxazole-trimethoprim tab 400-80mg .......... 6

BACTRIM DS see sulfamethoxazole-trimethop ds ................................. 6

BALCOLTRA .................... 39 balsalazide disodium......... 47 BALVERSA ....................... 14 balziva ............................... 39 BANZEL ............................ 22 BARACLUDE ...................... 9

see entecavir ................... 9 BASAGLAR KWIKPEN ..... 36 BAVENCIO ....................... 12 BAXDELA ......................... 10 BCG VACCINE ................. 52 BD ALCOHOL SWABS ..... 36 BD ULTRAFINE INSULIN SYRINGE .......................... 36 BD ULTRAFINE/NANO PEN NEEDLES ......................... 36 BECONASE AQ ................ 58 bekyree ............................. 39 BELBUCA ........................... 2 BELEODAQ ...................... 12 BELSOMRA ...................... 32 benazepril & hydrochlorothiazide ..... 16, 17 benazepril hcl .................... 17 BENDEKA ......................... 11 BENICAR

see olmesartan medoxomil ...................................... 18

BENICAR HCT see olmesartan medoxomil-hydrochlorothiazide .............................. 17

BENLYSTA ....................... 52 BENTYL

see dicyclomine hcl inj ... 46 BENZACLIN

see clindamy/ben gel 1-5% .............................. 59

BENZAMYCIN see benzoyl peroxide-erythromycin ... 59

benzoyl

peroxide-erythromycin ...... 59 benztropine mesylate inj ... 27 benztropine mesylate tab 0.5mg ................................ 27 benztropine mesylate tab 1mg ................................... 27 benztropine mesylate tab 2mg ................................... 27 BEOVU ............................. 56 BEPREVE ......................... 55 BERINERT ....................... 50 beser ................................. 61 BESIVANCE ..................... 55 BESPONSA ...................... 12 betamethasone dipropionate (topical) ............................. 61 betamethasone dipropionate augmented ........................ 61 betamethasone valerate ... 61 BETAPACE

see sorine ..................... 18 see sotalol hcl ............... 18

BETAPACE AF see sotalol hcl (afib/afl) . 18

BETASERON ................... 34 betaxolol hcl ...................... 19 betaxolol hcl (ophth) ......... 56 bethanechol chloride ......... 48 BETHKIS ............................ 5 BETIMOL .......................... 56 BETOPTIC-S .................... 56 BEVESPI AEROSPHERE 56 bexarotene ........................ 16 BEXSERO ........................ 52 BEYAZ

see drospirenone-ethinyl estradiol-levomefolate calcium .......................... 40

BIAXIN XL see clarithromycin ......... 10

bicalutamide ..................... 13 BICILLIN C-R .................... 10 BICILLIN L-A .................... 10 BIDIL ................................. 21 BIKTARVY .......................... 8 BILTRICIDE

see praziquantel .............. 6 BINOSTO ......................... 39

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bisoprolol & hydrochlorothiazide ........... 19 bisoprolol fumarate ........... 19 BIVIGAM ........................... 51 bleomycin sulfate .............. 11 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 55

BLEPHAMIDE ................... 54 BLEPHAMIDE S.O.P. ....... 54 blisovi 24 fe ....................... 40 blisovi fe 1.5/30 ................. 40 BONIVA

see ibandronate sodium inj ...................................... 39 see ibandronate sodium tabs ............................... 39

BONJESTA ....................... 46 BOOSTRIX ....................... 52 BORTEZOMIB .................. 12 bosentan ........................... 22 BOSULIF........................... 14 BOTOX ............................. 35 BRAFTOVI ........................ 14 BREO ELLIPTA ................ 59 briellyn .............................. 40 BRILINTA .......................... 50 brimonidine sol 0.15% ....... 56 brimonidine sol 0.2% ......... 56 BRISDELLE

see paroxetine mesylate (vasomotor) ................... 33

BRIVIACT INJ 50MG/5ML 22 BRIVIACT SOL 10MG/ML. 22 BRIVIACT TAB 100MG ..... 23 BRIVIACT TAB 10MG ....... 22 BRIVIACT TAB 25MG ....... 22 BRIVIACT TAB 50MG ....... 22 BRIVIACT TAB 75MG ....... 22 bromfenac sodium (ophth) 55 bromocriptine mesylate ..... 27 BROMSITE ....................... 55 BROVANA ........................ 57 BRUKINSA ........................ 14 BRYHALI........................... 61 budesonide ....................... 47 budesonide (inhalation) ..... 58 bumetanide ....................... 21

BUMEX see bumetanide ............. 21

BUNAVAIL MIS 2.1-0.3MG .......................................... 35 BUNAVAIL MIS 4.2-0.7MG .......................................... 35 BUNAVAIL MIS 6.3-1MG .. 35 BUPHENYL

see sodium phenylbutyrate ...................................... 42

buprenorphine hcl ............. 35 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 35 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 35 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 35 buprenorphine hcl-naloxone hcl dihydrate 8-2mg .......... 35 buprenorphine hcl-naloxone hcl sl.................................. 35 buprenorphine patch ........... 2 bupropion hcl .................... 25 bupropion hcl (smoking deterrent) .......................... 36 buspirone hcl .................... 22 butorphanol nasal spray ...... 2 butorphanol tartrate ............ 2 BUTRANS

see buprenorphine patch . 2 BYDUREON BCISE .......... 36 BYDUREON PEN ............. 36 BYETTA ............................ 36 BYNFEZIA PEN ................ 44 BYSTOLIC ........................ 19 C cabergoline ....................... 44 CABLIVI ............................ 50 CABOMETYX ................... 14 CADUET

see amlodipine besylate-atorvastatin calcium .......................... 19

CAFERGOT see ergotamine w/ caffeine ...................................... 32

CALAN SR see verapamil hcl .......... 20

calcipotriene ..................... 61 calcipotriene-betamethasone dipropionate ...................... 61 calcitonin (salmon) nasal spray ................................. 44 calcitrene .......................... 61 calcitriol ............................. 54 calcitriol inj ........................ 54 calcium acetate (phosphate binder) .............................. 45 CALQUENCE ................... 14 camila ............................... 40 CAMPTOSAR

see irinotecan hcl .......... 16 camrese lo tab .................. 40 CANASA

see mesalamine ............ 47 CANCIDAS

see caspofungin acetate . 6 candesartan cilexetil ......... 18 candesartan cilexetil-hydrochlorothiazide.......................................... 17 CAPEX ............................. 61 CAPLYTA ......................... 28 CAPRELSA ...................... 14 captopril ............................ 17 captopril & hydrochlorothiazide ........... 17 CARAFATE

see sucralfate ................ 48 CARBAGLU ...................... 42 carbamazepine ................. 23 CARBATROL

see carbamazepine ....... 23 carbidopa .......................... 27 carbidopa-levodopa .......... 27 carbidopa-levodopa-entacapone .................................... 27 carboplatin ........................ 16 CARDIZEM

see diltiazem hcl ............ 20 CARDIZEM CD

see cartia xt ................... 19 see diltiazem cd ............ 20 see diltiazem hcl coated beads ............................ 20 see diltiazem hcl coated

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beads cap sr 24hr .......... 20 see diltiazem hcl extended release beads cap sr ..... 20

CARDIZEM LA .................. 19 see diltiazem er tab 180mg ........................... 20 see diltiazem er tab 240mg ........................... 20 see diltiazem er tab 300mg ........................... 20 see diltiazem er tab 360mg ........................... 20 see diltiazem er tab 420mg ........................... 20 see matzim la ................ 20

CARDURA see doxazosin mesylate 17

CARDURA XL ................... 48 CARNITOR ....................... 42

see levocarnitine (metabolic modifiers) ..... 42

CAROSPIR ....................... 17 carteolol hcl (ophth) .......... 56 cartia xt ............................. 19 carvedilol ........................... 19 carvedilol er ....................... 19 CASODEX

see bicalutamide ........... 13 caspofungin acetate ............6 CASPOFUNGIN ACETATE 6 CATAPRES

see clonidine hcl ............ 21 CATAPRES-TTS-1

see clonidine hcl ptwk ... 21 CATAPRES-TTS-2

see clonidine hcl ptwk ... 21 CATAPRES-TTS-3

see clonidine hcl ptwk ... 21 CAYSTON ...........................5 caziant pak ........................ 40 cefaclor ...............................9 CEFACLOR ER TAB 500MG ............................................9 cefadroxil.............................9 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................9 cefazolin inj .........................9 cefazolin sodium .................9

CEFAZOLIN SODIUM 1 GM/50ML ............................ 9 cefdinir ................................ 9 CEFEPIME 1GM SOLN ...... 9 CEFEPIME 2GM SOLN ...... 9 cefepime inj 1gm ................. 9 cefepime inj 2gm ................. 9 CEFEPIME/DEXTROSE ..... 9 cefixime ............................... 9 CEFOTAN

see cefotetan disodium ... 9 cefotetan disodium .............. 9 cefoxitin sodium .................. 9 CEFOXITIN SODIUM ......... 9 cefpodoxime proxetil ........... 9 cefprozil .............................. 9 ceftazidime .......................... 9 CEFTAZIDIME/DEXTROSE ............................................ 9 ceftriaxone sodium .............. 9 cefuroxime axetil ................. 9 cefuroxime sodium .............. 9 CELEBREX

see celecoxib .................. 1 celecoxib ............................. 1 CELEXA

see citalopram hydrobromide ................ 25

CELLCEPT see mycophenolate mofetil ...................................... 52

CELONTIN ........................ 23 CENTANY ......................... 60 cephalexin ........................... 9 CERDELGA ...................... 42 CEREZYME ...................... 42 cetirizine hcl ...................... 57 cevimeline hcl ................... 65 CHANTIX CONTINUING MONTH ............................. 36 CHANTIX STARTER PACK .......................................... 36 CHANTIX TABS ................ 36 CHEMET ........................... 39 chlorhexidine gluconate (mouth-throat) ................... 65 chloroquine phosphate........ 7 chlorothiazide .................... 21

chlorpromazine hcl ............ 28 CHLORPROMAZINE INJ . 28 chlorthalidone ................... 21 CHOLBAM ........................ 47 cholestyramine ................. 18 cholestyramine light pack . 18 cholestyramine light powd 18 choline fenofibrate ............ 18 CHORIONIC GONADOTROPIN ............ 44 ciclopirox olamine ............. 60 cidofovir .............................. 9 cilostazol ........................... 50 CILOXAN .......................... 55

see ciprofloxacin hcl (ophth) ........................... 55

CIMDUO ............................. 8 cimetidine ......................... 46 cimetidine oral soln ........... 46 cinacalcet hcl .................... 44 CINQAIR ........................... 58 CINRYZE .......................... 50 CINVANTI ......................... 46 CIPRO .............................. 10

see ciprofloxacin hcl ...... 10 CIPRO HC ........................ 65 CIPRO SUSP ................... 10 CIPRODEX ....................... 65 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 55 ciprofloxacin hcl (otic) ....... 65 ciprofloxacin in d5w .......... 10 ciprofloxacin-fluocinolone acetonide .......................... 65 cisplatin ............................. 16 citalopram hydrobromide .. 25 claravis ............................. 59 CLARINEX

see desloratadine .......... 57 CLARINEX-D 12 HOUR ... 57 clarithromycin ............... 9, 10 CLENPIQ .......................... 47 CLEOCIN .......................... 49

see clindamycin cre 2% vag ................................ 49 see clindamycin hcl ......... 5

CLEOCIN PEDIATRIC GRANULE

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

CLEOCIN PHOSPHATE see clindamycin phosphate inj ...................5

CLEOCIN-T see clindamycin phosphate (topical) ........ 59

CLIMARA see estradiol .................. 42

clindacin-p ......................... 59 clindam/benz gel 1.2-2.5% 59 clindamy/ben gel 1-5% ...... 59 clindamycin cre 2% vag .... 49 clindamycin hcl ....................5 clindamycin phosphate (topical) ............................. 59 clindamycin phosphate in d5w .....................................5 CLINDAMYCIN PHOSPHATE IN NACL .......5 clindamycin phosphate inj ...5 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 59 clindamycin phosphate-tretinoin ........... 59 clindamycin soln 75mg/5ml .5 CLINDESSE ...................... 49 CLINIMIX 4.25%/DEXTROSE 5 ........ 53 CLINIMIX 5%/DEXTROSE 15% ................................... 53 CLINIMIX 5%/DEXTROSE 20% ................................... 53 CLINIMIX E 2.75%/DEXTROSE ........... 53 CLINIMIX E 4.25%/DEXTROSE ........... 53 CLINIMIX E 5%/DEXTROSE 15 ...................................... 53 CLINIMIX E 5%/DEXTROSE 20 ...................................... 53 CLINIMIX INJ 4.25/D10 .... 53 clinisol sf 15% ................... 53 CLINOLIPID ...................... 53 clobazam........................... 23 clobetasol propionate ........ 61

clobetasol propionate emo 62 clobetasol propionate emulsion ........................... 62 CLOBEX

see clobetasol propionate ...................................... 61 see clodan ..................... 62

clocortolone pivalate ......... 62 clodan ............................... 62 CLODERM

see clocortolone pivalate ...................................... 62

clomipramine hcl ............... 25 clonazepam ...................... 23 clonidine hcl ...................... 21 clonidine hcl ptwk .............. 21 clopidogrel bisulfate .......... 51 clorazepate dipotassium ... 23 clotrimazole ....................... 65 clotrimazole (topical) ......... 60 clotrimazole w/ betamethasone ................. 60 clovique ............................. 39 clozapine odt ..................... 28 clozapine tab 100mg ......... 28 clozapine tab 200mg ......... 28 clozapine tab 25mg ........... 28 clozapine tab 50mg ........... 28 CLOZARIL

see clozapine tab 100mg ...................................... 28 see clozapine tab 200mg ...................................... 28 see clozapine tab 25mg 28 see clozapine tab 50mg 28

COARTEM .......................... 7 codeine sulfate .................... 2 CODEINE SULFATE .......... 2 COGENTIN

see benztropine mesylate inj................................... 27

COLAZAL see balsalazide disodium ...................................... 47

colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 colesevelam hcl ................ 18 COLESTID

see colestipol hcl gran ... 18 see colestipol hcl pack .. 18 see colestipol hcl tabs ... 18

colestipol hcl gran ............. 18 colestipol hcl pack............. 18 colestipol hcl tabs ............. 18 colistimethate sodium ......... 5 colocort ............................. 47 COLY-MYCIN M

see colistimethate sodium ........................................ 5

COMBIGAN ...................... 56 COMBIVENT RESPIMAT . 56 COMBIVIR

see lamivudine-zidovudine ........................................ 8

COMETRIQ ...................... 14 COMPLERA ....................... 8 compro .............................. 46 COMTAN

see entacapone............. 27 CONCERTA

see methylphenidate hcl 31 CONDYLOX ..................... 63 constulose ........................ 47 COPAXONE

see glatiramer acetate 20mg/ml ........................ 34 see glatiramer acetate 40mg/ml ........................ 34 see glatopa ................... 34

COPIKTRA ....................... 14 CORDRAN ....................... 62

see flurandrenolide ........ 62 see nolix ........................ 63

COREG see carvedilol ................ 19

COREG CR see carvedilol er ............ 19

CORGARD see nadolol .................... 19

CORLANOR SOL 5MG/5ML.......................................... 21 CORLANOR TAB 5MG ..... 21 CORLANOR TAB 7.5MG .. 21 CORTEF

see hydrocortisone ........ 43 CORTENEMA

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see colocort ................... 47 see hydrocortisone (enema) ......................... 47

CORTIFOAM .................... 63 cortisone acetate ............... 43 CORTISPORIN ................. 60 CORTISPORIN-TC ........... 65 COSOPT

see dorzolamide hcl-timolol maleate ........ 56

COSOPT PF see dorzol/timol sol 22.3-6.8 pf ..................... 56

COTELLIC ........................ 14 COTEMPLA XR-ODT ....... 30 COUMADIN ...................... 49 COZAAR

see losartan potassium.. 18 CREON ............................. 48 CRESEMBA ........................6 CRESTOR

see rosuvastatin calcium ...................................... 18

CRINONE ......................... 45 CRIXIVAN ...........................7 cromolyn sod neb 20mg/2ml .......................................... 58 cromolyn sodium (mastocytosis) ................... 47 cromolyn sodium (ophth) .. 55 crotan ................................ 64 cryselle-28......................... 40 CRYSVITA ........................ 44 CUBICIN

see daptomycin ...............5 CUTAQUIG ....................... 51 CUTIVATE

see beser ....................... 61 see fluticasone propionate ...................................... 62

CUVITRU .......................... 51 CUVPOSA ........................ 46 cyclafem 1/35 .................... 40 cyclafem 7/7/7 ................... 40 cyclobenzaprine hcl .......... 35 cyclophosphamide ............ 11 cycloserine ..........................8 cyclosporine ...................... 52

cyclosporine modified (for microemulsion) ................. 52 CYKLOKAPRON

see tranexamic acid ...... 50 CYMBALTA

see duloxetine cap 20mg ...................................... 26 see duloxetine cap 30mg ...................................... 26 see duloxetine cap 60mg ...................................... 26

cyproheptadine hcl ............ 57 CYRAMZA ........................ 12 cyred tab ........................... 40 CYSTADANE .................... 42 CYSTAGON ...................... 42 CYSTARAN ...................... 56 cytarabine ......................... 12 CYTOGAM ........................ 51 CYTOMEL

see liothyronine sodium . 45 CYTOTEC

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

see ganciclovir sodium .... 9 D D.H.E. 45

see dihydroergotamine mesylate inj 1 mg/ml ...... 32

dacarbazine ...................... 11 DACOGEN

see decitabine ............... 12 dalfampridine .................... 34 DALIRESP ........................ 58 DALVANCE ........................ 5 danazol ............................. 42 DANTRIUM

see dantrolene sodium .. 35 dantrolene sodium ............ 35 dapsone .............................. 5 dapsone gel 5% ................ 59 dapsone gel 7.5% ............. 59 DAPTACEL ....................... 52 daptomycin ......................... 5 DAPTOMYCIN

see daptomycin ............... 5 darifenacin hydrobromide . 49 DARZALEX ....................... 12

DARZALEX FASPRO ....... 12 dasetta 1/35 ...................... 40 dasetta 7/7/7 ..................... 40 DAURISMO ...................... 12 DAYPRO

see oxaprozin .................. 1 DAYTRANA ...................... 30 DAYVIGO ......................... 32 DDAVP

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

DDAVP SPRAY (REFRIGERATED) ........... 45 deblitane ........................... 40 decitabine ......................... 12 deferasirox tab .................. 39 deferasirox tab for oral susp.......................................... 39 deferoxamine mesylate ..... 39 DELESTROGEN............... 42

see estradiol valerate .... 43 DELSTRIGO ....................... 8 DELZICOL

see mesalamine ............ 47 demeclocycline hcl ............ 11 DEMSER .......................... 21 DENAVIR .......................... 63 DEPAKOTE

see divalproex sodium .. 23 DEPAKOTE ER

see divalproex sodium .. 23 DEPAKOTE SPRINKLES

see divalproex sodium .. 23 DEPEN TITRATABS

see penicillamine ........... 39 DEPO-ESTRADIOL .......... 42 DEPO-MEDROL ............... 43

see methylprednisolone acetate .......................... 43

DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 41

DEPO-PROVERA INJ

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400/ML .............................. 13 DEPO-SUBQ PROVERA 104 .................................... 40 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 36

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 62

DERMA-SMOOTHE/FS SCALP

see fluocinolone acetonide oil body .......................... 62

DERMOTIC see flac .......................... 65 see fluocinolone acetonide (otic) .............................. 65

DESCOVY ..........................8 DESFERAL

see deferoxamine mesylate ........................ 39

desipramine hcl ........... 25, 26 desloratadine .................... 57 desmopressin acetate ....... 45 desmopressin acetate spray .......................................... 45 desmopressin acetate spray refrigerated ........................ 45 desmopressin inj 4mcg/ml. 45 desogestrel & ethinyl estradiol ............................ 40 desogestrel-ethinyl estradiol (biphasic) .......................... 40 DESONATE ...................... 62

see desonide ................. 62 desonide ........................... 62 DESOWEN

see desonide ................. 62 desoximetasone ................ 62 DESVENLAFAXINE ER .... 26 desvenlafaxine succinate .. 26 DETROL

see tolterodine tartrate .. 49 DETROL LA

see tolterodine er ........... 49 dexamethasone ................ 43 DEXAMETHASONE ......... 43

DEXAMETHASONE SODIUM PHOS

see dexamethasone sodium phosphate ......... 43

dexamethasone sodium phosphate ......................... 43 dexamethasone sodium phosphate (ophth) ............. 55 DEXEDRINE

see dextroamphetamine sulfate ............................ 30

DEXILANT ........................ 48 dexmethylphenidate hcl .... 30 dexrazoxane hcl ................ 16 dextroamphetamine sulfate .......................................... 30 dextrose ............................ 54 dextrose 10% .................... 54 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 54 dextrose 5% ...................... 54 DEXTROSE 5% /ELECTROLYTE ............... 54 DEXTROSE 5%/NACL 0.3% .......................................... 54 dextrose in lactated ringers .......................................... 54 dextrose w/ sodium chloride .......................................... 54 DIASTAT ACUDIAL .......... 23 DIASTAT PEDIATRIC....... 23 diazepam .......................... 23 diazepam gel .................... 23 diazepam inj ...................... 23 diazepam intensol 5mg/ml 23 diazepam oral soln 1 mg/ml .......................................... 23 diazoxide ........................... 44 DIBENZYLINE

see phenoxybenzamine hcl.................................. 21

DICLEGIS see doxylamine-pyridoxine ...................................... 46

diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 55

diclofenac sodium (topical) 1% gel ............................... 64 diclofenac sodium (topical) 1.5% soln .......................... 64 diclofenac sodium (topical) 3% gel ............................... 64 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 10 dicyclomine hcl cap 10mg . 46 dicyclomine hcl inj ............. 46 dicyclomine hcl soln 10mg/5ml .......................... 46 dicyclomine hcl tab 20mg . 46 didanosine .......................... 7 DIFFERIN ......................... 59

see adapalene............... 59 DIFICID ............................. 10 DIFLUCAN

see fluconazole ............... 6 diflunisal .............................. 1 digitek ............................... 20 digox ................................. 20 digoxin .............................. 20 digoxin inj .......................... 20 digoxin sol 50mcg/ml ........ 21 dihydroergotamine mesylate inj 1 mg/ml ........................ 32 dihydroergotamine mesylate nasal spr 4 mg/ml ............. 32 DILANTIN

see phenytoin sodium extended ....................... 24

DILANTIN CAP 100MG .... 23 DILANTIN CAP 30MG ...... 23 DILANTIN CHEW TAB 50MG ................................ 23 DILANTIN INFATABS

see phenytoin ................ 24 DILANTIN-125

see phenytoin ................ 24 DILANTIN-125 SUSP ....... 23 DILATRATE SR ................ 21 DILAUDID

see hydromorphone hcl ... 3 diltiazem cd ....................... 20 diltiazem er tab 180mg ..... 20 diltiazem er tab 240mg ..... 20 diltiazem er tab 300mg ..... 20

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diltiazem er tab 360mg ...... 20 diltiazem er tab 420mg ...... 20 diltiazem hcl ...................... 20 diltiazem hcl cap er/12hr ... 20 diltiazem hcl coated beads 20 diltiazem hcl coated beads cap sr 24hr ........................ 20 diltiazem hcl extended release beads cap sr ......... 20 diltiazem inj ....................... 20 dilt-xr ................................. 19 DIOVAN

see valsartan ................. 18 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 18

DIPENTUM ....................... 47 diphenhydramine hcl inj 50mg/ml ............................ 57 diphenoxylate w/ atropine . 47 DIPHTHERIA/TETANUS TOXOID ............................ 52 DIPROLENE

see betamethasone dipropionate augmented 61

DIPROLENE AF see betamethasone dipropionate augmented 61

disopyramide phosphate ... 18 disulfiram........................... 36 DITROPAN XL

see oxybutynin chloride . 49 DIURIL .............................. 21 divalproex sodium ............. 23 docetaxel........................... 12 DOCETAXEL .................... 12

see docetaxel ................ 12 dofetilide............................ 18 DOLOPHINE

see methadone tab 10mg 3 see methadone tab 5mg ..3

donepezil 10mg odt ........... 25 donepezil 5mg odt ............. 25 donepezil hydrochloride .... 25 DOPTELET ....................... 50 DORYX

see doxycycline hyclate . 11

dorzol/timol sol 22.3-6.8 pf 56 dorzolamide hcl ................. 56 dorzolamide hcl-timolol maleate ............................. 56 dotti ................................... 42 DOVATO ............................. 8 doxazosin mesylate .......... 17 doxepin hcl ........................ 26 doxepin hcl (sleep) ............ 32 doxercalciferol ................... 54 DOXIL

see doxorubicin hcl liposomal ....................... 11

doxorubicin hcl .................. 11 doxorubicin hcl liposomal .. 11 doxy 100 ........................... 11 doxycycline (monohydrate) .......................................... 11 doxycycline (rosacea) ....... 64 doxycycline hyclate ........... 11 doxycycline hyclate tab 100 mg dr................................. 11 doxycycline hyclate tab 150 mg dr................................. 11 doxycycline hyclate tab 75 mg dr................................. 11 doxylamine-pyridoxine ...... 46 DRIZALMA SPRINKLE ..... 26 dronabinol ......................... 46 drospirenone-ethinyl estradiol ............................ 40 drospirenone-ethinyl estradiol-levomefolate calcium .............................. 40 DROXIA CAP 200MG ....... 50 DROXIA CAP 300MG ....... 50 DROXIA CAP 400MG ....... 50 DUETACT

see pioglitazone hcl-glimepiride ............... 38

duloxetine cap 20mg ......... 26 duloxetine cap 30mg ......... 26 duloxetine cap 40mg ......... 26 duloxetine cap 60mg ......... 26 DUOBRII ........................... 62 DUOPA ............................. 27 DURAGESIC

see fentanyl patch 100

mcg/hr ............................. 3 see fentanyl patch 12 mcg/hr ............................. 2 see fentanyl patch 25 mcg/hr ............................. 2 see fentanyl patch 50 mcg/hr ............................. 2 see fentanyl patch 75 mcg/hr ............................. 2

DUREZOL ........................ 55 dutasteride ........................ 48 dutasteride-tamsulosin hcl 48 dvorah ................................. 2 DYANAVEL XR................. 31 DYAZIDE

see triamterene & hydrochlorothiazide cap 37.5-25mg ..................... 21

DYMISTA .......................... 57 see azelastine hcl-fluticasone propionate ...................................... 57

DYSPORT ........................ 35 E E.E.S. GRANULES

see erythromycin ethylsuccinate ............... 10

EC-NAPROSYN see ec-naproxen ............. 1 see naproxen dr .............. 1

ec-naproxen ........................ 1 econazole nitrate .............. 60 EDARBI ............................ 18 EDARBYCLOR ................. 17 EDECRIN

see ethacrynic acid ....... 21 EDURANT .......................... 7 efavirenz ............................. 7 EFFEXOR XR

see venlafaxine cap er .. 26 EFFIENT

see prasugrel hcl ........... 51 EFUDEX

see fluorouracil (topical) cream 5% ...................... 64

EGRIFTA .......................... 44 ELAPRASE ....................... 42 ELELYSO ......................... 42

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eletriptan hydrobromide .... 32 ELIDEL

see pimecrolimus .......... 64 ELIGARD INJ 22.5MG ...... 13 ELIGARD INJ 30MG ......... 13 ELIGARD INJ 45MG ......... 13 ELIGARD INJ 7.5MG ........ 13 ELIMITE

see permethrin cre 5% .. 64 ELIQUIS ............................ 49 ELIQUIS STARTER PACK .......................................... 49 ELITEK ............................. 16 ELIXOPHYLLIN ................ 58 ELLA ................................. 40 ELLENCE

see epirubicin hcl ........... 11 ELMIRON.......................... 48 eluryng .............................. 40 EMCYT ............................. 11 EMEND ............................. 46

see aprepitant ................ 46 see fosaprepitant dimeglumine .................. 46

EMGALITY ........................ 32 emoquette ......................... 40 EMPLICITI ........................ 12 EMSAM ............................. 26 EMTRIVA ............................7 EMVERM ............................5 ENABLEX

see darifenacin hydrobromide ................ 49

enalapril maleate ............... 17 enalapril maleate & hydrochlorothiazide ........... 17 ENBREL............................ 51 ENBREL MINI ................... 51 ENBREL SURECLICK ...... 51 ENDARI ............................ 50 endocet 10-325mg ..............2 endocet 2.5-325mg .............2 endocet 5-325mg ................2 endocet 7.5-325mg .............2 ENGERIX-B ...................... 52 ENHERTU ......................... 12 enoxaparin sodium ............ 49 enpresse-28 ...................... 40

enskyce ............................. 40 ENSTILAR ........................ 62 entacapone ....................... 27 entecavir ............................. 9 ENTOCORT EC

see budesonide ............. 47 ENTRESTO ...................... 17 ENTYVIO .......................... 47 enulose ............................. 47 ENVARSUS XR ................ 52 EPANED ........................... 17 EPCLUSA ........................... 9 EPIDIOLEX ....................... 23 EPIDUO

see adapalene-benzoyl peroxide gel 0.1-2.5% ... 59

EPIDUO FORTE ............... 59 epinastine hcl (ophth)........ 55 epinephrine (anaphylaxis) . 58 EPIPEN 2-PAK

see epinephrine (anaphylaxis) ................. 58

EPIPEN-JR 2-PAK see epinephrine (anaphylaxis) ................. 58

epirubicin hcl ..................... 11 epitol ................................. 23 EPIVIR

see lamivudine ................ 7 EPIVIR HBV ........................ 9

see lamivudine (hbv) ....... 9 eplerenone ........................ 17 epoprostenol sodium......... 22 EPZICOM

see abacavir sulfate-lamivudine ........... 8

EQUETRO ........................ 33 ERAXIS ............................... 6 ERBITUX .......................... 12 ergotamine w/ caffeine ...... 32 ERIVEDGE ....................... 12 ERLEADA ......................... 13 erlotinib hcl ........................ 14 errin................................... 40 ERTACZO ......................... 60 ertapenem sodium .............. 5 ERWINAZE ....................... 16 ery pad 2% ........................ 59

ERYGEL see erythromycin (acne aid) ................................ 59

ERYPED 400 see erythromycin ethylsuccinate ............... 10

ery-tab .............................. 10 ERYTHROCIN LACTOBIONATE .............. 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 59 erythromycin (ophth) ......... 55 erythromycin base ............ 10 erythromycin cap 250mg ec.......................................... 10 erythromycin ethylsuccinate.......................................... 10 erythromycin tab ec .......... 10 ESBRIET .......................... 58 escitalopram oxalate ......... 26 esomeprazole magnesium 48 esomeprazole sodium inj .. 48 estarylla tab 0.25-35 ......... 40 ESTRACE

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

estradiol ...................... 42, 43 estradiol vaginal cream ..... 43 estradiol vaginal tab .......... 43 estradiol valerate .............. 43 ESTRING .......................... 43 ESTROSTEP FE

see tilia fe ...................... 41 see tri-legest fe.............. 41

ethacrynic acid .................. 21 ethambutol hcl .................... 8 ethosuximide .................... 23 ethynodiol diacet & eth estrad ................................ 40 ethynodiol tab 1-50 ........... 40 etodolac .............................. 1 etonogestrel-ethinyl estradiol.......................................... 40 ETOPOPHOS ................... 16 etoposide .......................... 16 euthyrox ............................ 45 EVENITY .......................... 44

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everolimus......................... 15 everolimus (immunosuppressant) ....... 52 EVISTA

see raloxifene hcl .......... 45 EVOCLIN

see clindamycin phosphate (topical) ........ 59

EVOTAZ..............................8 EVOXAC

see cevimeline hcl ......... 65 EXELON

see rivastigmine td patch 24hr 13.3mg/24hr .......... 25 see rivastigmine td patch 24hr 4.6mg/24hr ............ 25 see rivastigmine td patch 24hr 9.5mg/24hr ............ 25

exemestane ...................... 14 EXFORGE

see amlodipine besylate-valsartan ......... 17

EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide .............. 17

EXJADE see deferasirox tab for oral susp ............................... 39

EXTINA see ketoconazole foam.. 60 see ketodan ................... 60

EYLEA .............................. 56 EZALLOR SPRINKLE ....... 18 ezetimibe........................... 19 ezetimibe-simvastatin ....... 19 F FABIOR............................. 59 FABRAZYME .................... 42 falmina .............................. 40 famciclovir ...........................9 famotidine ......................... 46 famotidine in nacl .............. 47 famotidine inj ..................... 47 FANAPT ............................ 28 FANAPT TITRATION PACK .......................................... 28 FARESTON

see toremifene citrate .... 14 FARXIGA .......................... 37 FARYDAK ......................... 12 FASENRA ......................... 58 FASENRA PEN ................ 58 FASLODEX

see fulvestrant ............... 14 fayosim ............................. 40 febuxostat ........................... 1 felbamate .......................... 23 FELBATOL

see felbamate ................ 23 FELDENE

see piroxicam .................. 1 felodipine .......................... 20 FEMARA

see letrozole .................. 14 FEMHRT LOW DOSE

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

FEMRING ......................... 43 femynor ............................. 40 fenofibrate ......................... 19 fenofibrate micronized....... 19 fentanyl ............................... 2 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr ... 3 fentanyl patch 12 mcg/hr ..... 2 fentanyl patch 25 mcg/hr ..... 2 fentanyl patch 50 mcg/hr ..... 2 fentanyl patch 75 mcg/hr ..... 2 FERRIPROX ..................... 39 FETROJA ........................... 9 FETZIMA .......................... 26 FETZIMA TITRATION PACK .......................................... 26 FIASP ............................... 36 FIASP FLEXTOUCH ......... 36 FIASP PENFILL ................ 36 FINACEA

see azelaic acid ............. 63 FINACEA AER 15% .......... 64 finasteride ......................... 48 FIRAZYR

see icatibant acetate ..... 50 FIRDAPSE ........................ 33 FIRMAGON ...................... 14

FIRVANQ ............................ 5 flac .................................... 65 FLAGYL

see metronidazole ........... 6 FLAREX ............................ 55 flecainide acetate .............. 18 FLOLAN ............................ 22

see epoprostenol sodium ...................................... 22

FLOLIPID .......................... 18 FLOMAX

see tamsulosin hcl ......... 48 FLOVENT DISKUS ........... 58 FLOVENT HFA ................. 58 fluconazole ......................... 6 fluconazole inj nacl 200 ...... 6 fluconazole inj nacl 400 ...... 6 flucytosine ........................... 6 fludarabine phosphate ...... 12 fludrocortisone acetate ..... 43 flunisolide (nasal) .............. 58 fluocinolone acetonide ...... 62 fluocinolone acetonide (otic).......................................... 65 fluocinolone acetonide oil body .................................. 62 fluocinonide ...................... 62 fluocinonide emulsified base.......................................... 62 fluorometholone (ophth) .... 55 FLUOROPLEX.................. 64 fluorouracil ........................ 12 fluorouracil (topical) cream 5% .................................... 64 fluorouracil (topical) soln ... 64 fluoxetine hcl ..................... 26 fluoxetine hcl (pmdd) ........ 36 FLUOXETINE HYDROCHLORIDE

see fluoxetine hcl .......... 26 fluphenazine decanoate .... 28 fluphenazine hcl ................ 28 flurandrenolide .................. 62 flurbiprofen .......................... 1 flurbiprofen sodium ........... 55 flutamide ........................... 14 fluticasone propionate ....... 62 fluticasone propionate

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(nasal) ............................... 58 fluvastatin sodium ............. 18 fluvoxamine cap er ............ 22 fluvoxamine tab 100mg ..... 22 fluvoxamine tab 25mg ....... 22 fluvoxamine tab 50mg ....... 22 FML ................................... 55 FML FORTE ...................... 55 FOCALIN

see dexmethylphenidate hcl .................................. 30

FOCALIN XR see dexmethylphenidate hcl .................................. 30

FOLOTYN ......................... 12 fondaparinux sodium ......... 49 FORTEO ........................... 44 FORTESTA

see testosterone ............ 36 FOSAMAX

see alendronate sodium 39 FOSAMAX PLUS D .......... 39 fosamprenavir tab 700 mg ..7 fosaprepitant dimeglumine 46 fosinopril sodium ............... 17 fosinopril-hydrochlorothiazide tab 10/12.5mg ................ 17 fosinopril-hydrochlorothiazide tab 20/12.5mg ................ 17 FOSRENOL ...................... 45

see lanthanum chew tab 45 FRAGMIN ......................... 49 FREAMINE HBC 6.9% ...... 53 FREAMINE III ................... 53 FROVA

see frovatriptan succinate ...................................... 32

frovatriptan succinate ........ 32 fulvestrant ......................... 14 furosemide ........................ 21 furosemide oral soln 10 mg/ml ................................ 21 furosemide oral soln 8 mg/ml .......................................... 21 FUZEON .............................7 fyavolv ............................... 43 FYCOMPA ........................ 23

G gabapentin ........................ 23 GABITRIL

see tiagabine hcl ........... 24 GALAFOLD ....................... 42 galantamine hydrobromide 25 galantamine hydrobromide er ...................................... 25 GAMASTAN ...................... 51 GAMMAGARD LIQUID ..... 51 GAMMAGARD S/D ........... 51 GAMMAKED ..................... 51 GAMMAPLEX ................... 51 GAMMAPLEX 10GM/100ML .......................................... 51 GAMUNEX-C .................... 51 GANCICLOVIR INJ 500MG/10ML ...................... 9 ganciclovir sodium .............. 9 GARDASIL 9 ..................... 52 GASTROCROM

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

gatifloxacin (ophth) ........... 55 GATTEX ........................... 47 GAUZE PADS 2X2 ........... 36 gavilyte-c ........................... 47 gavilyte-g .......................... 47 gavilyte-n/flavor pack ........ 47 GAZYVA ........................... 12 GELNIQUE ....................... 49 GEMCITABINE

see gemcitabine inj soln 12 gemcitabine inj soln .......... 12 gemcitabine inj solr ........... 12 gemfibrozil ........................ 19 GENERESS FE

see kaitlib fe .................. 40 see layolis fe chw .......... 40 see noreth/ethin chw fe . 41

generlac ............................ 47 gengraf .............................. 52 GENOTROPIN .................. 44 GENOTROPIN MINIQUICK .......................................... 44 gentak ............................... 55 gentamicin in saline ............ 5 gentamicin sulfate ............... 5

gentamicin sulfate (topical).......................................... 60 gentamicin sulfate soln (ophth) .............................. 55 GENVOYA .......................... 8 GEODON

see ziprasidone hcl ....... 29 see ziprasidone mesylate ...................................... 29

GEODON INJ ................... 28 gianvi tab 3-0.02mg .......... 40 GILENYA CAP 0.5MG ...... 34 GILOTRIF TAB 20MG ...... 15 GILOTRIF TAB 30MG ...... 15 GILOTRIF TAB 40MG ...... 15 GIVLAARI ......................... 50 GLASSIA .......................... 58 glatiramer acetate 20mg/ml.......................................... 34 glatiramer acetate 40mg/ml.......................................... 34 glatopa .............................. 34 GLEEVEC

see imatinib mesylate .... 15 GLEOSTINE ..................... 11 glimepiride ........................ 37 glipizide ............................. 37 glipizide er ........................ 37 glipizide xl ......................... 37 glipizide-metformin 2.5-250 mg ..................................... 37 glipizide-metformin 2.5-500 mg ..................................... 37 glipizide-metformin 5-500mg.......................................... 37 GLUCAGEN HYPOKIT ..... 44 GLUCAGON EMERGENCY KIT .................................... 44 GLUCOTROL

see glipizide .................. 37 GLUCOTROL XL

see glipizide er .............. 37 see glipizide xl ............... 37

GLYCATE ......................... 46 glycopyrrolate ................... 46 GLYCOPYRROLATE ....... 46 glycopyrrolate tab 1mg ..... 46 glycopyrrolate tab 2mg ..... 46

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glydo ................................. 63 GLYSET

see miglitol .................... 38 GLYXAMBI ........................ 37 GOCOVRI ......................... 27 GOLYTELY ....................... 47

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

GRALISE .......................... 33 GRALISE STARTER ......... 33 granisetron hcl .................. 46 GRASTEK ......................... 52 griseofulvin microsize ..........6 griseofulvin ultramicrosize ...7 guanfacine er (adhd) ......... 31 GVOKE HYPOPEN 2-PACK .......................................... 44 GVOKE PFS ..................... 44 GYNAZOLE-1 ................... 49 H HAEGARDA ...................... 50 hailey 24 fe........................ 40 HALAVEN ......................... 16 halcinonide ........................ 62 HALDOL

see haloperidol lactate inj 5mg/ml........................... 28

HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 28

HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 28

halobetasol propionate ...... 62 HALOBETASOL PROPIONATE .................. 62 HALOG ............................. 62

see halcinonide ............. 62 haloperidol ........................ 28 haloperidol conc 2mg/ml ... 28 haloperidol decanoate ....... 28 haloperidol lactate inj 5mg/ml .......................................... 28 HARVONI............................9 HAVRIX............................. 52 heather .............................. 40

heparin sod (porcine) in d5w .......................................... 49 heparin sod inj 5000u/0.5ml .......................................... 49 heparin sodium (porcine) 1000 u/ml .......................... 49 heparin sodium (porcine) 10000 u/ml ........................ 49 heparin sodium (porcine) 20000 u/ml ........................ 49 heparin sodium (porcine) 5000 u/ml .......................... 49 HEPARIN SODIUM INJ 5000U/0.5ML .................... 49 HEPARIN SODIUM INJ 5000U/ML ......................... 49 HEPARIN SODIUM/NACL 0.45%................................ 49 hepatamine ....................... 53 HEPSERA

see adefovir dipivoxil ....... 9 HERCEPTIN ..................... 12 HERCEPTIN HYLECTA .... 12 HERZUMA ........................ 12 HETLIOZ ........................... 32 HIBERIX ........................... 52 HIPREX

see methenamine hippurate ......................... 6

HIZENTRA ........................ 51 HORIZANT ....................... 33 HUMATROPE ................... 44 HUMATROPE COMBO PACK ................................ 44 HUMIRA ............................ 51 HUMIRA INJ 10MG/0.2ML 51 HUMIRA KIT 20MG/0.4ML 51 HUMIRA KIT 40MG/0.8ML 51 HUMIRA PEDIATRIC CROHNS DISEASE .......... 51 HUMIRA PEN ................... 51 HUMIRA PEN CD/UC/HS STARTER ......................... 51 HUMIRA PEN INJ CD/UC/HS STARTER ....... 51 HUMIRA PEN INJ PS/UV STARTER ......................... 51 HUMIRA PEN-PS/UV

STARTER ......................... 51 HUMULIN R U-500 (CONCENTRATE) ............ 37 HUMULIN R U-500 KWIKPEN ......................... 37 HYCAMTIN

see topotecan hcl .......... 16 hydralazine hcl .................. 21 HYDREA

see hydroxyurea ............ 16 hydrochlorothiazide ........... 21 hydrocodone bitartrate ........ 3 hydrocodone-acetaminophen 10-300mg ........................... 3 hydrocodone-acetaminophen 10-325mg ........................... 3 hydrocodone-acetaminophen 5-300mg ............................. 3 hydrocodone-acetaminophen 5-325mg ............................. 3 hydrocodone-acetaminophen 7.5-300mg .......................... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 3 hydrocodone-acetaminophen 7.5-325mg .......................... 3 hydrocodone-ibuprofen ....... 3 hydrocortisone .................. 43 hydrocortisone (enema) .... 47 hydrocortisone (topical) cream 1% ......................... 62 hydrocortisone (topical) cream 2.5% ...................... 62 hydrocortisone (topical) lotion 2.5% ........................ 62 hydrocortisone (topical) oint 1% .................................... 63 hydrocortisone (topical) oint 2.5% ................................. 63 hydrocortisone butyrate cream 0.1% ...................... 63 hydrocortisone butyrate cream 0.1% lipo base ....... 63 hydrocortisone butyrate lotion 0.1% ........................ 63 hydrocortisone butyrate oint 0.1% ................................. 63 hydrocortisone butyrate soln

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0.1% .................................. 63 hydrocortisone w/acetic acid .......................................... 65 hydromorphone hcl .............3 hydromorphone hcl t24a 8mg .....................................3 HYDROMORPHONE HYDROCHLORI .................3 hydroxychloroquine sulfate .......................................... 51 hydroxyprogesterone caproate (antineoplastic) ... 14 hydroxyurea ...................... 16 hydroxyzine hcl ................. 57 hydroxyzine hcl inj ............. 57 hydroxyzine pamoate ........ 57 HYQVIA ............................ 51 HYSINGLA ER ....................3 HYZAAR

see losartan-hydrochlorothiazide tab 100-12.5mg ........ 17 see losartan-hydrochlorothiazide tab 100-25mg ........... 17 see losartan-hydrochlorothiazidetab 50-12.5mg ........... 17

I ibandronate sodium inj ...... 39 ibandronate sodium tabs ... 39 IBRANCE .................... 12, 13 ibu tab 600mg .....................1 ibu tab 800mg .....................1 ibuprofen .............................1 icatibant acetate ................ 50 ICLUSIG............................ 15 IDHIFA .............................. 13 IFEX INJ 3GM ................... 11 ifosfamide.......................... 11 IFOSFAMIDE INJ 3GM ..... 11 ILARIS .............................. 52 ILEVRO ............................. 55 imatinib mesylate .............. 15 IMBRUVICA ...................... 15 IMFINZI ............................. 13 imipenem-cilastatin .............5 imipramine hcl ................... 26

imipramine pamoate ......... 26 imiquimod ......................... 64 IMITREX

see sumatriptan ....... 32, 33 see sumatriptan inj 6mg/0.5ml ..................... 33 see sumatriptan succinate ...................................... 33

IMITREX STATDOSE REFILL

see sumatriptan inj 4mg/0.5ml ..................... 33 see sumatriptan inj 6mg/0.5ml ..................... 33

IMITREX STATDOSE SYSTEM

see sumatriptan inj 4mg/0.5ml ..................... 33 see sumatriptan inj 6mg/0.5ml ..................... 33

IMOVAX RABIES (H.D.C.V.) .......................................... 52 IMPOYZ ............................ 63 IMURAN

see azathioprine ............ 52 IMVEXXY MAINTENANCE PACK ................................ 43 IMVEXXY STARTER PACK .......................................... 43 INBRIJA ............................ 27 incassia ............................. 40 INCRELEX ........................ 44 INCRUSE ELLIPTA .......... 56 indapamide ....................... 21 INDERAL LA

see propranolol cap er ... 19 INFANRIX ......................... 52 INFUGEM ......................... 12 INGREZZA ........................ 33 INLYTA ............................. 15 INREBIC ........................... 15 INSPRA

see eplerenone ............. 17 INSULIN PEN NEEDLES .. 37 INSULIN SAFETY NEEDLES ......................... 37 INSULIN SYRINGES ........ 37 INTELENCE ........................ 7

INTRALIPID 30% .............. 53 INTRALIPID INJ 20% ....... 54 INTRAROSA ..................... 48 INTRON-A INJ 10MU ....... 52 INTRON-A INJ 18MU ....... 52 INTRON-A INJ 25MU ....... 52 INTRON-A INJ 50MU ....... 52 introvale ............................ 40 INTUNIV

see guanfacine er (adhd) ...................................... 31

INVANZ see ertapenem sodium .... 5

INVEGA see paliperidone ............ 28

INVEGA SUSTENNA ........ 28 INVEGA TRINZA .............. 28 INVELTYS ........................ 55 INVIRASE ........................... 7 IPOL INACTIVATED IPV .. 52 ipratropium bromide (nasal).......................................... 56 ipratropium sol inhal .......... 56 ipratropium-albuterol ......... 56 irbesartan .......................... 18 irbesartan-hydrochlorothiazide........................................ 17 IRESSA ............................ 15 irinotecan hcl .................... 16 ISENTRESS ....................... 7 ISENTRESS HD ................. 7 isibloom ............................ 40 ISOLYTE-P/DEXTROSE 5%.......................................... 54 ISOLYTE-S ....................... 54 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISOPTO CARPINE

see pilocarpine hcl ........ 56 ISORDIL TITRADOSE

see isosorbide dinitrate 21, 22

isosorbide dinitrate ...... 21, 22 isosorbide mononitrate ..... 22 isosorbide mononitrate er . 22 isotretinoin ........................ 59 isradipine .......................... 20 ISTALOL

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see timolol maleate ophth soln 0.5% (once-daily) ... 56

ISTURISA ......................... 44 itraconazole .........................7 ivermectin............................5 IVERMECTIN .................... 64 IXEMPRA KIT ................... 16 IXIARO .............................. 52 J JADENU............................ 39

see deferasirox tab ........ 39 JADENU SPRINKLE ......... 39 JAKAFI .............................. 15 JALYN

see dutasteride-tamsulosin hcl .................................. 48

jantoven ............................ 49 JANUMET ......................... 37 JANUMET XR TAB 100-1000 ........................... 38 JANUMET XR TAB 50-1000 .......................................... 38 JANUMET XR TAB 50-500MG ......................... 38 JANUVIA ........................... 38 JARDIANCE ...................... 38 jasmiel ............................... 40 JENTADUETO .................. 38 JENTADUETO TAB XR 2.5-1000 MG ..................... 38 JENTADUETO TAB XR 5-1000 MG ........................ 38 JEVTANA .......................... 12 jinteli .................................. 43 jolessa tab 0.15-0.03 mg ... 40 jolivette .............................. 40 JORNAY PM ..................... 31 JUBLIA .............................. 60 juleber ............................... 40 JULUCA ..............................8 junel 1.5/30 ....................... 40 junel 1/20 .......................... 40 junel fe 1.5/30 ................... 40 junel fe 1/20 ...................... 40 junel fe 24 ......................... 40 JUXTAPID ......................... 19 JYNARQUE PAK 30-15MG .......................................... 44

JYNARQUE PAK 45-15MG .......................................... 44 JYNARQUE PAK 60-30MG .......................................... 44 JYNARQUE PAK 90-30MG .......................................... 44 JYNARQUE TABS ............ 44 K KADCYLA ......................... 13 KADIAN .............................. 3

see morphine sulfate ... 3, 4 kaitlib fe ............................. 40 KALBITOR ........................ 50 KALETRA

see lopinavir-ritonavir ...... 8 KALETRA TAB 100-25MG .. 8 KALETRA TAB 200-50MG .. 8 KALYDECO ...................... 58 KANJINTI .......................... 13 KANUMA .......................... 42 KAPSPARGO SPRINKLE . 19 kariva ................................ 40 KATERZIA ........................ 20 KCL 0.15%/D5W/NACL 0.225% .............................. 54 KCL 0.3%/D5W/NACL 0.9% .......................................... 54 kcl/d5w/nacl inj 0.22%/0.45% .......................................... 54 kcl/nacl inj 0.15%-0.9% ..... 54 kcl0.15%/d5w/nacl0.2% .... 54 KEFLEX

see cephalexin ................ 9 kelnor 1/35 ........................ 40 kelnor 1/50 ........................ 40 KENALOG

see triamcinolone acetonide (topical) ......... 63

KENALOG-10 ................... 43 KENALOG-40

see triamcinolone acetonide ....................... 44

KENALOG-80 ................... 43 KEPPRA

see levetiracetam .......... 24 see levetiracetam oral soln 100 mg/ml ..................... 24 see roweepra ................ 24

KEPPRA XR see levetiracetam .......... 24 see roweepra xr ............ 24

ketoconazole ...................... 7 ketoconazole cream .......... 60 ketoconazole foam ............ 60 ketoconazole shampoo ..... 61 ketodan ............................. 60 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 55 KEVEYIS .......................... 21 KEYTRUDA ...................... 13 KHAPZORY ...................... 16 KINRIX .............................. 52 kionex sus 15gm/60ml ...... 39 KISQALI ............................ 13 KISQALI FEMARA 200 DOSE ............................... 13 KISQALI FEMARA 400 DOSE ............................... 13 KISQALI FEMARA 600 DOSE ............................... 13 KITABIS PAK

see tobramycin ................ 5 KLARON

see sulfacetamide sodium (acne) ............................ 60

KLONOPIN see clonazepam ............ 23

klor-con 10 ........................ 53 klor-con 8 .......................... 53 klor-con m10 ..................... 53 klor-con m15 ..................... 53 klor-con m20 ..................... 53 klor-con pak 20meq .......... 53 klor-con spr cap 10meq .... 53 klor-con spr cap 8meq ...... 53 KORLYM .......................... 44 KOSELUGO ..................... 15 KRINTAFEL ........................ 7 KRISTALOSE ................... 47 KRYSTEXXA ...................... 1 K-TAB

see potassium chloride . 53 kurvelo .............................. 40 KUVAN ............................. 42 KYPROLIS ........................ 13

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L labetalol hcl ....................... 19 LACRISERT ...................... 56 lactated ringer's ................. 54 lactic acid (ammonium lactate) .............................. 64 lactulose ............................ 47 lactulose (encephalopathy) .......................................... 47 LAMICTAL

see lamotrigine .............. 24 see subvenite tab .......... 24

LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 23 LAMICTAL ODT ................ 23

see lamotrigine .............. 24 LAMICTAL STARTER/NOT TAKI

see lamotrigine .............. 23 see subvenite starter kit. 24

LAMICTAL STARTER/TAKING C


LAMICTAL STARTER/TAKING V


LAMICTAL XR .................. 23 see lamotrigine .............. 24

LAMISIL see terbinafine hcl ...........7

lamivudine ...........................7 lamivudine (hbv) ..................9 lamivudine-zidovudine ........8 lamotrigine .................. 23, 24 LANOXIN

see digitek ..................... 20 see digox ....................... 20 see digoxin .................... 20 see digoxin inj ................ 20

LANOXIN PEDIATRIC INJ 21 LANOXIN TABS 62.5MCG 21 lansoprazole ...................... 48 lanthanum chew tab .......... 45 larin 1.5/30 ........................ 40 larin 1/20 ........................... 40

larin fe 1.5/30 .................... 40 larin fe 1/20 ....................... 40 larissia tab ......................... 40 LARTRUVO ...................... 13 LASIX

see furosemide .............. 21 LASTACAFT ..................... 55 latanoprost ........................ 56 LATUDA ............................ 28 layolis fe chw .................... 40 leena tab ........................... 40 leflunomide ....................... 51 LEMTRADA ...................... 34 LENVIMA 10 MG DAILY DOSE ................................ 15 LENVIMA 12MG DAILY DOSE ................................ 15 LENVIMA 14 MG DAILY DOSE ................................ 15 LENVIMA 18 MG DAILY DOSE ................................ 15 LENVIMA 20 MG DAILY DOSE ................................ 15 LENVIMA 24 MG DAILY DOSE ................................ 15 LENVIMA 4 MG DAILY DOSE ................................ 15 LENVIMA 8 MG DAILY DOSE ................................ 15 LESCOL XL

see fluvastatin sodium ... 18 lessina ............................... 40 LETAIRIS

see ambrisentan ............ 22 letrozole ............................ 14 leucovorin calcium ............ 16 LEUKERAN ...................... 11 LEUKINE .......................... 50 leuprolide inj 1mg/0.2 ........ 14 levalbuterol hcl .................. 57 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 57 levalbuterol tartrate hfa ..... 57 LEVAQUIN

see levofloxacin ............. 10 LEVEMIR .......................... 37 LEVEMIR FLEXTOUCH ... 37 levetiracetam .................... 24

LEVETIRACETAM see levetiracetam in sodium chloride ............. 24

levetiracetam in sodium chloride ............................. 24 levetiracetam oral soln 100 mg/ml ................................ 24 levobunolol hcl .................. 56 levocarnitine (metabolic modifiers) .......................... 42 levocetirizine oral soln ...... 57 levocetirizine tab 5 mg ...... 57 levofloxacin ....................... 10 levofloxacin (ophth) ........... 55 levofloxacin in d5w ............ 10 levoleucovorin calcium ...... 16 levoleucovorin calcium 50mg.......................................... 16 levonest ............................ 40 levonor/ethi tab ................. 40 levonorgestrel & eth estradiol.......................................... 40 levonorgestrel-ethinyl estradiol (91-day) ........ 40, 41 levonorgestrel-ethinyl estradiol (continuous) ....... 41 levora 0.15/30-28 .............. 41 levo-t ................................. 45 levothyroxine sodium ........ 45 levoxyl ............................... 45 LEXAPRO

see escitalopram oxalate ...................................... 26

LEXETTE .......................... 63 LEXIVA ............................... 7

see fosamprenavir tab 700 mg ................................... 7

LIALDA see mesalamine ............ 47

LIBTAYO .......................... 13 lidocaine ........................... 63 lidocaine hcl ...................... 63 lidocaine hcl (local anesth.) 5 lidocaine hcl (mouth-throat).......................................... 65 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5%

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preservative free (pf) ...........5 lidocaine inj 2% preservative free (pf) ...............................5 lidocaine inj 4% preservative free (pf) ...............................5 lidocaine-prilocaine ........... 63 LIDODERM

see lidocaine ................. 63 linezolid in sodium chloride .5 linezolid inj ..........................6 linezolid susp ......................6 linezolid tab 600mg .............6 LINZESS ........................... 47 liothyronine sodium ........... 45 LIPITOR

see atorvastatin calcium 18 lisinopril ............................. 17 lisinopril & hydrochlorothiazide ........... 17 lithium carb tab 300mg ...... 33 lithium carbonate ............... 33 LITHIUM SOLN 8MEQ/5ML .......................................... 33 LITHOBID

see lithium carbonate .... 33 LIVALO ............................. 18 LO LOESTRIN FE ............. 41 LOCOID

see hydrocortisone butyrate lotion 0.1% ....... 63

LOCOID LIPOCREAM see hydrocortisone butyrate cream 0.1% lipo base .............................. 63

LODINE see etodolac ....................1

LODOSYN see carbidopa ................ 27

LOESTRIN 1.5/30-21 see junel 1.5/30 ............. 40 see larin 1.5/30 .............. 40 see microgestin 1.5/30 .. 41

LOESTRIN 1/20-21 see junel 1/20 ................ 40 see larin 1/20 ................. 40 see microgestin 1/20 ..... 41 see norethindrone acet & eth estra ........................ 41

LOESTRIN FE 1.5/30 see blisovi fe 1.5/30....... 40 see junel fe 1.5/30 ......... 40 see larin fe 1.5/30 .......... 40 see microgestin fe 1.5/30 ...................................... 41

LOESTRIN FE 1/20 see junel fe 1/20 ............ 40 see larin fe 1/20 ............. 40 see microgestin fe 1/20 . 41 see tarina fe 1/20 .......... 41

LOKELMA ......................... 39 LOMOTIL

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

LONSURF ......................... 16 loperamide hcl .................. 47 LOPERAMIDE HYDROCHLORIDE .......... 47 LOPID

see gemfibrozil .............. 19 lopinavir-ritonavir ................ 8 LOPRESSOR

see metoprolol tartrate .. 19 LOPRESSOR HCT

see metoprolol & hydrochlorothiazide ....... 19

LOPROX see ciclopirox olamine ... 60

lorazepam ......................... 22 lorazepam intensol ............ 22 LORBRENA ...................... 15 lorcet hd tab 10-325mg ....... 3 lorcet plus tab 7.5-325 ........ 3 lorcet tab 5-325mg .............. 3 loryna ................................ 41 losartan potassium ............ 18 losartan-hydrochlorothiazide tab 100-12.5mg ................. 17 losartan-hydrochlorothiazide tab 100-25mg .................... 17 losartan-hydrochlorothiazidetab 50-12.5mg .................... 17 LOSEASONIQUE

see amethia lo ............... 39 see camrese lo tab ........ 40 see levonorgestrel-ethinyl estradiol (91-day) .......... 41

LOTEMAX ........................ 55 see loteprednol etabonate ...................................... 55

LOTEMAX SM .................. 55 LOTENSIN

see benazepril hcl ......... 17 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 17

loteprednol etabonate ....... 55 LOTREL

see amlodipine besylate-benazepril hcl . 16

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

lovastatin .......................... 18 LOVAZA

see omega-3-acid ethyl esters ............................ 19

LOVENOX see enoxaparin sodium . 49

low-ogestrel ...................... 41 loxapine succinate ............ 28 LUCEMYRA ...................... 36 LUCENTIS ........................ 56 luliconazole ....................... 60 LUMIGAN ......................... 56 LUMIZYME ....................... 42 LUMOXITI ......................... 13 LUPANETA PACK ............ 42 LUPRON DEPOT (1-MONTH) ....................... 14 LUPRON DEPOT (6-MONTH) ....................... 14 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 14 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 14 LUPRON DEPOT INJ 30MG (4-MONTH) ....................... 14 LUPRON DEPOT-PED (1-MONTH ........................ 44 LUPRON DEPOT-PED (3-MONTH ........................ 44 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 44 LUPRON DEP-PED INJ 7.5MG ............................... 44

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lutera ................................. 41 LUXIQ

see betamethasone valerate.......................... 61

LYNPARZA ....................... 13 LYRICA

see pregabalin ............... 24 LYRICA CR ....................... 33 LYSODREN ...................... 14 LYSTEDA

see tranexamic acid ...... 50 lyza ................................... 41 M MACROBID

see nitrofurantoin monohyd macro ...............6

MACRODANTIN see nitrofurantoin macrocrystal ....................6

mafenide acetate .............. 60 magnesium sulfate ............ 53 MAGNESIUM SULFATE ... 53

see magnesium sulfate . 53 MAGNESIUM SULFATE IN D5W .................................. 53

see magnesium sulfate in dextrose......................... 53

magnesium sulfate in dextrose ............................ 53 magnesium sulfate inj 50% .......................................... 53 MALARONE

see atovaquone-proguanil hcl tab 250-100 mg ..........7 see atovaquone-proguanil hcl tab 62.5-25 mg ...........7

malathion .......................... 64 maprotiline hcl ................... 26 MARINOL

see dronabinol ............... 46 marlissa............................. 41 MARPLAN TAB 10MG ...... 26 MARQIBO ......................... 12 MATULANE ...................... 16 matzim la........................... 20 MAVENCLAD PAK 10MG(10) .......................... 34 MAVENCLAD PAK 10MG(4)

.......................................... 34 MAVENCLAD PAK 10MG(5) .......................................... 34 MAVENCLAD PAK 10MG(6) .......................................... 34 MAVENCLAD PAK 10MG(7) .......................................... 34 MAVENCLAD PAK 10MG(8) .......................................... 34 MAVENCLAD PAK 10MG(9) .......................................... 34 MAVIK

see trandolapril .............. 17 MAVYRET .......................... 9 MAXALT

see rizatriptan benzoate 32 MAXALT-MLT

see rizatriptan benzoate odt ................................. 32

MAXIDEX .......................... 55 MAXITROL

see neomycin-polymy-dexameth .................................... 54

MAXZIDE see triamterene & hydrochlorothiazide tab 75-50mg ........................ 21

MAXZIDE-25 see triamterene & hydrochlorothiazide tab 37.5-25mg ..................... 21

MAYZENT ......................... 34 meclizine hcl ..................... 46 meclofenamate sodium ....... 1 MEDROL

see methylpred tab 16mg ...................................... 43 see methylpred tab 32mg ...................................... 43 see methylpred tab 4mg 43 see methylpred tab 8mg 43

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 43

MEDROL TAB 2MG .......... 43 medroxyprogesterone acetate .............................. 45

medroxyprogesterone acetate (contraceptive) ..... 41 mefloquine hcl .................... 7 megestrol ac sus 40mg/ml 14 megestrol ac tab 20mg ..... 14 megestrol ac tab 40mg ..... 14 megestrol sus 625mg/5ml . 14 MEKINIST ......................... 15 MEKTOVI ......................... 15 melodetta 24 fe ................. 41 meloxicam .......................... 1 memantine hcl cp24 .......... 25 memantine soln ................ 25 memantine tabs ................ 25 memantine titration pak .... 25 MENACTRA ..................... 53 MENEST ........................... 43 MENOSTAR ..................... 43 MENTAX ........................... 60 MENVEO .......................... 53 MEPRON

see atovaquone............... 5 mercaptopurine ................. 12 meropenem ........................ 6 MEROPENEM/SODIUM CHLORIDE ......................... 6 MERREM

see meropenem .............. 6 mesalamine ...................... 47 mesalamine enema .......... 47 mesalamine w/ cleanser ... 47 MESNEX .......................... 16 MESTINON

see pyridostigmine bromide ......................... 33 see pyridostigmine tab 60mg ............................. 34

MESTINON TIMESPAN see pyridostigmine bromide ......................... 33

metadate er tab 20mg ....... 31 metformin er ..................... 38 metformin hcl .................... 38 methadone hcl .................... 3 METHADONE HCL

see methadone hcl .......... 3 methadone hcl intensol ....... 3 methadone tab 10mg .......... 3

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methadone tab 5mg ............3 METHADOSE

see methadone hcl intensol ............................3

methazolamide .................. 21 methenamine hippurate ......6 methimazole ...................... 45 methotrexate sodium inj soln .......................................... 12 methotrexate sodium inj solr .......................................... 12 methotrexate sodium tabs . 51 methoxsalen rapid ............. 61 methscopolamine bromide 46 METHYLIN

see methylphenidate hcl 31 methylphenidate hcl .......... 31 methylphenidate hcl tbcr 10 mg ..................................... 31 methylphenidate hcl tbcr 20mg ................................. 31 METHYLPHENIDATE HCL TBCR 72MG ..................... 31 methylpr ss inj ................... 43 methylpred pak 4mg ......... 43 methylpred tab 16mg ........ 43 methylpred tab 32mg ........ 43 methylpred tab 4mg .......... 43 methylpred tab 8mg .......... 43 methylprednisolone acetate .......................................... 43 metoclopramide hcl ........... 46 metoclopramide hcl inj ...... 46 METOCLOPRAMIDE ODT 10MG ................................ 46 metoclopramide odt 5mg .. 46 metolazone ....................... 21 metoprolol & hydrochlorothiazide ........... 19 metoprolol succinate ......... 19 metoprolol tartrate ............. 19 METROCREAM

see metronidazole (topical).......................... 64 see rosadan cre 0.75% . 64

METROLOTION see metronidazole (topical).......................... 64

metronidazole ..................... 6 METRONIDAZOLE ............. 6

see metronidazole in nacl 6 metronidazole (topical)...... 64 metronidazole gel 0.75% .. 64 metronidazole in nacl .......... 6 metronidazole vaginal ....... 49 MIACALCIN

see calcitonin (salmon) nasal spray .................... 44

mibelas 24 fe .................... 41 micafungin sodium .............. 7 MICARDIS

see telmisartan .............. 18 MICARDIS HCT

see telmisartan-hydrochlorothiazide .............................. 18

miconazole 3 ..................... 49 miconazole-zinc oxide-white petrolatum ......................... 60 microgestin 1.5/30 ............ 41 microgestin 1/20 ............... 41 microgestin fe 1.5/30......... 41 microgestin fe 1/20 ........... 41 midodrine hcl .................... 21 migergot ............................ 32 miglitol ............................... 38 miglustat ........................... 42 MIGRANAL

see dihydroergotamine mesylate nasal spr 4 mg/ml ............................ 32

mili .................................... 41 MINASTRIN 24 FE

see melodetta 24 fe ....... 41 see mibelas 24 fe .......... 41 see norethin acet & estrad-fe ........................ 41

MINIPRESS see prazosin hcl ............ 17

minitran ............................. 22 MINOCIN

see minocycline hcl ....... 11 minocycline hcl ................. 11 minocycline tab 105mg er . 11 minocycline tab 115mg er . 11 minocycline tab 135mg er . 11

minocycline tab 45mg er ... 11 minocycline tab 55mg er ... 11 minocycline tab 65mg er ... 11 minocycline tab 80mg er ... 11 minocycline tab 90mg er ... 11 MINOLIRA ........................ 11 minoxidil ............................ 21 MIRAPEX

see pramipexole tab 0.125mg ........................ 27 see pramipexole tab 0.5mg ............................ 27 see pramipexole tab 0.75mg .......................... 27 see pramipexole tab 1mg ...................................... 27

MIRAPEX ER see pramipexole er ........ 27

MIRCETTE see bekyree .................. 39 see desogestrel-ethinyl estradiol (biphasic) ........ 40 see kariva ...................... 40 see pimtrea ................... 41 see viorele ..................... 42

mirtazapine tab 15mg odt . 26 mirtazapine tab 30mg odt . 26 mirtazapine tab 45mg odt . 26 mirtazapine tabs ............... 26 MIRVASO ......................... 64 misoprostol ....................... 47 MITIGARE .......................... 1 mitomycin ......................... 11 mitoxantrone hcl ............... 16 M-M-R II ............................ 52 M-NATAL PLUS................ 54 MOBIC

see meloxicam ................ 1 modafinil ........................... 35 moexipril hcl ...................... 17 molindone hcl ................... 28 mometasone furoate ......... 63 mometasone furoate (nasal).......................................... 58 mondoxyne nl cap 100mg . 11 mondoxyne nl cap 75mg ... 11 mono-linyah tab 0.25-35 ... 41 montelukast sodium .......... 57

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MORPHABOND ER ............3 morphine sul inj 1mg/ml ......3 morphine sulfate ............. 3, 4 MORPHINE SULFATE .......4

see morphine sulfate .......4 morphine sulfate beads .......4 morphine sulfate ext-rel tab.4 morphine sulfate oral soln 100mg/5ml ..........................4 morphine sulfate oral soln 10mg/5ml ............................4 morphine sulfate oral soln 20mg/5ml ............................4 MOTEGRITY ..................... 47 MOVANTIK ....................... 47 MOVIPREP ....................... 47 MOXEZA ........................... 55

see moxifloxacin hcl (ophth) ........................... 55

moxifloxacin hcl ................. 10 moxifloxacin hcl (ophth) .... 55 moxifloxacin hcl in sodium chloride ............................. 10 MOXIFLOXACIN HYDROCHLORID ............. 10 MOZOBIL .......................... 50 MS CONTIN

see morphine sulfate ext-rel tab ........................4

MULPLETA ....................... 50 MULTAQ ........................... 18 mupirocin .......................... 60 MVASI ............................... 13 MYALEPT ......................... 44 MYAMBUTOL

see ethambutol hcl ..........8 MYCAMINE .........................7

see micafungin sodium ....7 MYCOBUTIN

see rifabutin .....................8 mycophenolate mofetil ...... 52 mycophenolate sodium tbec .......................................... 52 MYDAYIS CAP 12.5MG .... 31 MYDAYIS CAP 25MG ....... 31 MYDAYIS CAP 37.5MG .... 31 MYDAYIS CAP 50MG ....... 31 MYFORTIC

see mycophenolate sodium tbec ................... 52

MYLOTARG ...................... 13 MYOBLOC ........................ 35 myorisan ........................... 59 MYRBETRIQ .................... 49 MYSOLINE

see primidone ................ 24 N nabumetone ........................ 1 nadolol .............................. 19 NAFCILLIN IN DEXTROSE .......................................... 10 nafcillin sodium ................. 10 NAFCILLIN SODIUM FOR INJ 10GM .......................... 10 naftifine hcl ........................ 60 NAFTIN ............................. 60

see naftifine hcl ............. 60 NAGLAZYME .................... 42 nalbuphine hcl ..................... 2 naloxone inj 0.4mg/ml ....... 36 naloxone inj 1mg/ml .......... 36 naltrexone hcl ................... 36 NAMENDA

see memantine tabs ...... 25 NAMENDA TITRATION PAK

see memantine titration pak ................................ 25

NAMENDA XR see memantine hcl cp24 25

NAMENDA XR TITRATION PACK ................................ 25 NAMZARIC ....................... 25 NAPROSYN

see naproxen .................. 1 naproxen ............................. 1 naproxen dr ......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 32 NARCAN ........................... 36 NARDIL

see phenelzine sulfate ... 26 NASONEX

see mometasone furoate (nasal) ........................... 58

NATACYN ......................... 55 NATAZIA ........................... 41

nateglinide ........................ 38 NATPARA ......................... 44 NATROBA ........................ 64 NAYZILAM ........................ 24 NEBUPENT

see pentamidine isethionate inh ................. 6

necon 0.5/35-28 ................ 41 nefazodone hcl ................. 26 neomycin sulfate ................. 5 neomycin/polymyxin b gu . 64 neomycin-bacitracin zn-polymyxin ..................... 55 neomycin-polymy-dexameth.......................................... 54 neomycin-polymyxin-gramicidin ..................................... 55 neomycin-polymyxin-hc (ophth) .............................. 54 neomycin-polymyxin-hc (otic).......................................... 65 NEORAL

see cyclosporine modified (for microemulsion) ....... 52 see gengraf ................... 52

NEPHRAMINE .................. 54 NERLYNX ......................... 15 neuac gel 1.2-5% .............. 59 NEUPRO .......................... 27 NEURONTIN

see gabapentin.............. 23 NEVANAC ........................ 55 nevirapine susp 50 mg/5ml . 7 nevirapine tab 100mg er ..... 7 nevirapine tab 200mg ......... 7 nevirapine tab 400mg er ..... 7 NEXAVAR ........................ 15 NEXIUM

see esomeprazole magnesium ................... 48

NEXIUM GRA 10MG DR .. 48 NEXIUM GRA 2.5MG DR . 48 NEXIUM GRA 20MG DR .. 48 NEXIUM GRA 40MG DR .. 48 NEXIUM GRA 5MG DR .... 48 NEXIUM I.V.

see esomeprazole sodium inj .................................. 48

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NEXLETOL ....................... 19 NEXLIZET ......................... 19 niacin (antihyperlipidemic). 19 niacin er (antihyperlipidemic) .......................................... 19 niacor ................................ 19 NIASPAN

see niacin er (antihyperlipidemic) ....... 19

nicardipine hcl ................... 20 NICARDIPINE HYDROCHLORIDE .......... 20 NICOTROL INHALER ....... 36 NICOTROL NS ................. 36 nifedipine........................... 20 nikki ................................... 41 NILANDRON

see nilutamide ............... 14 nilutamide.......................... 14 nimodipine......................... 20 NINLARO .......................... 13 NIPENT ............................. 12 nisoldipine ......................... 20 nitisinone ........................... 42 NITRO-BID ........................ 22 NITRO-DUR ...................... 22

see minitran ................... 22 nitrofurantoin .......................6 nitrofurantoin macrocrystal ..6 nitrofurantoin monohyd macro ..................................6 nitroglycerin ....................... 22 nitroglycerin td patch ......... 22 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............ 22 NITROSTAT

see nitroglycerin ............ 22 NITYR ............................... 42 nizatidine ........................... 47 nolix .................................. 63 nora-be tab........................ 41 NORCO

see hydrocodone-acetaminophen 10-325mg ...................3 see hydrocodone-acetaminoph

en 5-325mg ..................... 3 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see lorcet hd tab 10-325mg ........................ 3 see lorcet plus tab 7.5-325 ........................................ 3 see lorcet tab 5-325mg .... 3

NORDITROPIN FLEXPRO .......................................... 44 nore/eth/fer chw 0.4mg-35 41 noreth/ethin chw fe ........... 41 norethin acet & estrad-fe ... 41 norethindrone (contraceptive) .................. 41 norethindrone acet & eth estra .................................. 41 norethindrone acetate ....... 45 norethindrone acetate-ethinyl estradiol ............................ 43 norgest/ethi tab 0.25/35 .... 41 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 41 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 41 NORITATE ........................ 64 NORMOSOL-M IN D5W ... 54 NORMOSOL-R ................. 54 NORMOSOL-R IN D5W .... 54 NORPACE

see disopyramide phosphate ..................... 18

NORPACE CR .................. 18 NORPRAMIN

see desipramine hcl ...... 25 NORTHERA ...................... 21 nortrel 0.5/35 (28) ............. 41 nortrel 1/35 ........................ 41 nortrel 7/7/7 ....................... 41 nortriptyline hcl .................. 26 NORVASC

see amlodipine besylate 19 NORVIR

see ritonavir .................... 8 NORVIR PACK ................... 7 NORVIR SOLN ................... 7 NOURIANZ ....................... 27 NOVAREL ........................ 44 NOVOLIN 70/30................ 37 NOVOLIN 70/30 FLEXPEN.......................................... 37 NOVOLIN N ...................... 37 NOVOLIN N FLEXPEN ..... 37 NOVOLIN R ...................... 37 NOVOLIN R FLEXPEN ..... 37 NOVOLOG ....................... 37 NOVOLOG 70/30 FLEXPEN.......................................... 37 NOVOLOG FLEXPEN ...... 37 NOVOLOG MIX 70/30 ...... 37 NOVOLOG PENFILL ........ 37 NOXAFIL ............................ 7

see posaconazole ........... 7 NPLATE ............................ 50 NUBEQA .......................... 14 NUCALA ........................... 58 NUCYNTA .......................... 4 NUCYNTA ER .................... 4 NUEDEXTA ...................... 33 NULOJIX .......................... 52 NULYTELY

see gavilyte-n/flavor pack ...................................... 47 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 47 see trilyte ....................... 47

NULYTELY/FLAVOR PACKS ............................. 47 NUPLAZID CAPS ............. 28 NUPLAZID TABS 10MG ... 28 NUTRILIPID INJ 20% ....... 54 NUTROPIN AQ NUSPIN 10.......................................... 44 NUTROPIN AQ NUSPIN 20.......................................... 44 NUTROPIN AQ NUSPIN 5 44 NUVARING

see eluryng ................... 40 see etonogestrel-ethinyl

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estradiol ......................... 40 NUVIGIL

see armodafinil .............. 35 nyamyc ............................. 60 NYMALIZE ........................ 20 nystatin ...............................7 nystatin (mouth-throat) ...... 65 nystatin (topical) ................ 60 nystatin pow 100000 ......... 60 nystop ............................... 60 O OCALIVA .......................... 48 ocella tab 3-0.03mg .......... 41 OCREVUS ........................ 34 OCTAGAM ........................ 51 octreotide acetate ............. 44 octreotide inj 100mcg/ml ... 44 OCUFLOX

see ofloxacin (ophth) ..... 55 ODACTRA ........................ 52 ODEFSEY ...........................8 ODOMZO .......................... 13 OFEV ................................ 58 ofloxacin (ophth) ............... 55 ofloxacin (otic) ................... 65 OGIVRI ............................. 13 olanzapine......................... 28 olanzapine odt ................... 28 olmesartan medoxomil ...... 18 olmesartan medoxomil-amlodipine-hydrochlorothiazide .................... 17 olmesartan medoxomil-hydrochlorothiazide ...................................... 17 olopatadine hcl (nasal) ...... 57 olopatadine hcl 0.1% ......... 55 olopatadine hcl 0.2% ......... 55 OLUX

see clobetasol propionate ...................................... 61

OLUX-E see clobetasol propionate emulsion ........................ 62 see tovet ........................ 63

OMECLAMOX-PAK .......... 48 omega-3-acid ethyl esters . 19 omeprazole cap 10mg ...... 48

omeprazole cap 20mg ...... 48 omeprazole cap 40mg ...... 48 OMNARIS ......................... 58 OMNITROPE 10MG ......... 44 OMNITROPE 5.8MG ........ 44 OMNITROPE 5MG ........... 44 ondansetron hcl ................ 46 ondansetron hcl inj ............ 46 ondansetron hcl oral soln .. 46 ondansetron odt ................ 46 ONE VITE WOMENS PRENATAL ....................... 54 ONEXTON ........................ 59 ONFI

see clobazam ................ 23 ONIVYDE .......................... 16 ONTRUZANT .................... 13 ONZETRA XSAIL ............. 32 OPANA

see oxymorphone tabs .... 4 OPDIVO ............................ 13 OPSUMIT ......................... 22 ORALAIR .......................... 52 ORAPRED ODT

see prednisolone sodium phosphate ..................... 43

ORAVIG ............................ 65 ORBACTIV ......................... 6 ORENITRAM .................... 22 ORFADIN .......................... 42

see nitisinone ................ 42 ORILISSA ......................... 42 ORKAMBI ......................... 58 orsythia ............................. 41 ORTHO TRI-CYCLEN LO

see norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ......................... 41 see tri-lo- tab marzia ...... 42 see tri-lo-estarylla .......... 42 see tri-lo-sprintec ........... 42 see tri-vylibra lo ............. 42

oseltamivir phosphate ......... 9 OSMOLEX ER .................. 27 OSMOPREP ..................... 47 OSPHENA ........................ 44 OTOVEL ........................... 65

oxacillin sodium ................ 10 oxaliplatin inj 100mg ......... 16 oxaliplatin inj 100mg/20ml 16 oxaliplatin inj 50mg ........... 16 oxaliplatin inj 50mg/10ml .. 16 oxandrolone ...................... 36 oxaprozin ............................ 1 OXAYDO ............................ 4 OXBRYTA ........................ 50 oxcarbazepine .................. 24 OXERVATE ...................... 56 OXISTAT .......................... 61 OXSORALEN ULTRA

see methoxsalen rapid .. 61 OXTELLAR XR ................. 24 oxybutynin chloride ........... 49 oxycodone hcl ..................... 4 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 4 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone-aspirin............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone tabs .............. 4 OXYTROL ........................ 49 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 37 OZEMPIC INJ 1MG/DOSE.......................................... 37 P pacerone ........................... 18 paclitaxel ........................... 12 PADCEV ........................... 13 paliperidone ...................... 28 palonosetron hcl ............... 46 PALONOSETRON HYDROCHLORID 0.25MG/2ML ..................... 46 PALYNZIQ ........................ 42 PAMELOR

see nortriptyline hcl ....... 26 pamidronate disodium ...... 39 PAMIDRONATE DISODIUM

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.......................................... 39 pamidronate inj 30mg ....... 39 pamidronate inj 90mg ....... 39 PANCREAZE .................... 48 PANDEL............................ 63 PANRETIN ........................ 64 pantoprazole sodium ......... 48 PANZYGA ......................... 52 paricalcitol ......................... 54 PARLODEL

see bromocriptine mesylate ........................ 27

PARNATE see tranylcypromine sulfate ............................ 26

paroex sol 0.12% .............. 65 paromomycin sulfate ...........5 paroxetine er tab ............... 26 paroxetine hcl tabs ............ 26 paroxetine mesylate (vasomotor) ....................... 33 PASER D/R .........................8 PATANASE

see olopatadine hcl (nasal) ...................................... 57

PAXIL ................................ 26 see paroxetine hcl tabs.. 26

PAXIL CR see paroxetine er tab ..... 26

PAZEO .............................. 55 PEDIAPRED

see pred sod pho sol 5mg/5ml ......................... 43

PEDIARIX ......................... 53 PEDVAX HIB .................... 53 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 47 PEGANONE ...................... 24 PEGASYS ...........................9 PEGASYS PROCLICK .......9 PEMAZYRE ...................... 15 penicillamine ..................... 39 PENICILLIN G POT IN DEXTROSE 1MU .............. 10 PENICILLIN G POT IN

DEXTROSE 2MU ............. 10 PENICILLIN G POT IN DEXTROSE 3MU ............. 10 PENICILLIN G PROCAINE .......................................... 10 penicillin g sodium ............ 10 penicillin v potassium ........ 11 penicilln gk inj 20mu ......... 11 penicilln gk inj 5mu ........... 11 PENNSAID ....................... 64 PENTACEL ....................... 53 PENTAM 300

see pentamidine isethionate inj .................. 6

pentamidine isethionate inh 6 pentamidine isethionate inj . 6 PENTASA ......................... 47 pentoxifylline ..................... 50 PEPCID

see famotidine ............... 46 PERCOCET

see endocet 10-325mg .... 2 see endocet 2.5-325mg ... 2 see endocet 5-325mg ...... 2 see endocet 7.5-325mg ... 2 see oxycodone w/ acetaminophen 10-325mg ........................................ 4 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 4 see oxycodone w/ acetaminophen 5-325mg . 4 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 4

PERFOROMIST ............... 57 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 65 see paroex sol 0.12% .... 65 see periogard ................ 65

perindopril erbumine ......... 17 periogard ........................... 65 PERJETA .......................... 13 permethrin cre 5% ............ 64 perphenazine .................... 28

PERSERIS ....................... 28 PERTZYE ......................... 48 PEXEVA ........................... 26 pfizerpen-g inj 20mu ......... 11 pfizerpen-g inj 5mu ........... 11 phenadoz .......................... 46 phenelzine sulfate ............. 26 PHENERGAN

see promethazine hcl inj 46 phenobarbital .................... 24 phenobarbital sodium ....... 24 phenoxybenzamine hcl ..... 21 PHENYTEK ...................... 24

see phenytoin sodium extended ....................... 24

phenytoin .......................... 24 phenytoin sodium extended.......................................... 24 phenytoin sodium inj 50mg/ml ............................ 24 philith ................................ 41 PHOSLO

see calcium acetate (phosphate binder) ........ 45

PHOSLYRA ...................... 45 PHOSPHOLINE IODIDE .. 56 PICATO ............................ 64 PIFELTRO .......................... 7 pilocarpine hcl ................... 56 pilocarpine hcl (oral) ......... 65 pimecrolimus .................... 64 pimozide ........................... 29 pimtrea .............................. 41 pindolol ............................. 19 pioglitazone hcl ................. 38 pioglitazone hcl-glimepiride.......................................... 38 pioglitazone hcl-metformin hcl ..................................... 38 piper/tazoba inj 12-1.5gm . 11 piper/tazoba inj 2-0.25gm . 11 piper/tazoba inj 3-0.375gm11 piper/tazoba inj 36-4.5gm . 11 piper/tazoba inj 4-0.5gm ... 11 PIQRAY 200MG DAILY DOSE ............................... 15 PIQRAY 250MG DAILY DOSE ............................... 15

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PIQRAY 300MG DAILY DOSE ................................ 15 pirmella 1/35 ..................... 41 piroxicam.............................1 PLAQUENIL

see hydroxychloroquine sulfate ............................ 51

PLASMA-LYTE A .............. 54 PLASMA-LYTE-148 .......... 54 PLAVIX

see clopidogrel bisulfate 51 PLEGRIDY ........................ 34 PLEGRIDY STARTER PACK ................................ 34 plenamine ......................... 54 PLENVU............................ 47 PNV FOLIC ACID + IRON MUL .................................. 54 podofilox............................ 64 POLIVY ............................. 13 polymyxin b sulfate .............6 polymyxin b-trimethoprim .. 55 POLYTRIM

see polymyxin b-trimethoprim ............... 55

POMALYST ...................... 14 portia-28 ............................ 41 PORTRAZZA .................... 13 posaconazole ......................7 potassium chloride ...... 53, 54 POTASSIUM CHLORIDE . 54 potassium chloride 0.15% in nacl 0.45% ........................ 54 potassium chloride in dextrose ............................ 54 potassium chloride in dextrose & sodium chloride .......................................... 54 potassium chloride in nacl . 54 potassium chloride microencapsulated crystals er ....................................... 53 POTASSIUM CHLORIDE/DEXTRO ....... 54 potassium citrate (alkalinizer) er tabs ............................... 49 POTELIGEO ..................... 13 PRADAXA ......................... 49

PRALUENT ....................... 19 pramipexole er .................. 27 pramipexole tab 0.125mg . 27 pramipexole tab 0.25mg ... 27 pramipexole tab 0.5mg ..... 27 pramipexole tab 0.75mg ... 27 pramipexole tab 1.5mg ..... 27 pramipexole tab 1mg ........ 27 prasugrel hcl ..................... 51 PRAVACHOL

see pravastatin sodium . 18 pravastatin sodium ............ 18 praziquantel ........................ 6 prazosin hcl ....................... 17 PRECOSE

see acarbose ................. 37 PRED FORTE

see prednisolone acetate (ophth) ........................... 55

PRED MILD ...................... 55 pred sod pho sol 5mg/5ml . 43 PRED-G ............................ 54 PRED-G S.O.P. ................ 54 prednicarbate .................... 63 prednisolone acetate (ophth) .......................................... 55 prednisolone sodium phosphate ......................... 43 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 55 prednisolone sol 15mg/5ml .......................................... 43 prednisolone sol 25mg/5ml .......................................... 43 PREDNISONE CON 5MG/ML ............................ 43 prednisone pak 10mg ....... 43 prednisone pak 5mg ......... 43 prednisone sol 5mg/5ml .... 43 prednisone tab 10mg ........ 43 prednisone tab 1mg .......... 43 prednisone tab 2.5mg ....... 43 prednisone tab 20mg ........ 43 prednisone tab 50mg ........ 43 prednisone tab 5mg .......... 43 pregabalin ......................... 24 PREGNYL W/DILUENT BENZYL ............................ 44

PREMARIN CREAM ......... 43 PREMARIN INJ ................ 43 PREMARIN TABS ............ 43 PREMASOL 10%.............. 54 PREMPHASE ................... 43 PREMPRO ....................... 43 PRENATAL ....................... 54 PRENATAL PLUS ............ 54 PRENATAL PLUS LOW IRON ................................. 54 PRETOMANID .................... 8 PREVACID

see lansoprazole ........... 48 PREVACID SOLUTAB

see lansoprazole ........... 48 prevalite ............................ 19 previfem ............................ 41 PREVYMIS INJ ................... 9 PREVYMIS TABS ............... 9 PREZCOBIX ....................... 8 PREZISTA ...................... 7, 8 PRIFTIN .............................. 8 PRILOSEC ....................... 48 primaquine phosphate ........ 7 PRIMAQUINE PHOSPHATE............................................ 7

see primaquine phosphate ........................................ 7

PRIMAXIN IV see imipenem-cilastatin ... 5

primidone .......................... 24 PRINIVIL

see lisinopril .................. 17 PRISTIQ

see desvenlafaxine succinate ....................... 26

PRIVIGEN ........................ 52 PROAIR DIGIHALER ........ 57 PROAIR HFA

see albuterol sulfate ...... 57 PROAIR RESPICLICK ...... 57 probenecid .......................... 1 PROCALAMINE................ 54 PROCARDIA XL

see nifedipine ................ 20 prochlorperazine inj .......... 46 prochlorperazine maleate . 46 prochlorperazine supp ...... 46

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PROCRIT .......................... 50 PROCTOCORT

see procto-pak ............... 64 procto-med hc ................... 64 procto-pak ......................... 64 proctosol hc cre 2.5% ....... 64 proctozone-hc ................... 64 PROCYSBI ....................... 42 progesterone micronized... 45 PROGLYCEM

see diazoxide ................ 44 PROGLYCEM SUS 50MG/ML .......................... 44 PROGRAF ........................ 52

see tacrolimus ............... 52 PROLASTIN-C .................. 58 PROLENSA ...................... 55 PROLIA ............................. 44 PROMACTA ...................... 50 promethazine hcl ............... 46 promethazine hcl inj .......... 46 promethegan ..................... 46 PROMETRIUM

see progesterone micronized ..................... 45

propafenone hcl ................ 18 propantheline bromide ...... 46 proparacaine hcl ............... 56 propranolol & hydrochlorothiazide ........... 19 propranolol cap er ............. 19 propranolol inj 1mg/ml ....... 19 propranolol oral sol ........... 19 propranolol tab .................. 19 propylthiouracil .................. 45 PROQUAD ........................ 53 PROSCAR

see finasteride ............... 48 PROSOL ........................... 54 PROTONIX ....................... 48

see pantoprazole sodium ...................................... 48

PROTOPIC see tacrolimus (topical).. 64

protriptyline hcl .................. 26 PROVENTIL HFA

see albuterol sulfate ...... 57 PROVERA

see medroxyprogesterone acetate .......................... 45

PROVIGIL see modafinil ................. 35

PROZAC see fluoxetine hcl .......... 26

PULMICORT see budesonide (inhalation) .................... 58

PULMICORT FLEXHALER .......................................... 58 PULMOZYME ................... 58 PURIXAN .......................... 12 pyrazinamide ...................... 8 pyridostigmine bromide ..... 33 pyridostigmine bromide tab 30 mg ................................ 33 pyridostigmine tab 60mg ... 34 pyrimethamine .................... 6 Q QBRELIS .......................... 17 QBREXZA ......................... 64 QINLOCK .......................... 15 QMIIZ ODT ......................... 1 QNASL .............................. 58 QNASL CHILDRENS ........ 58 QUADRACEL ................... 53 QUALAQUIN

see quinine sulfate .......... 7 QUARTETTE

see fayosim ................... 40 see levonorgestrel-ethinyl estradiol (91-day) .......... 41 see rivelsa ..................... 41

QUESTRAN see cholestyramine ....... 18

QUESTRAN LIGHT see cholestyramine light powd .............................. 18 see prevalite .................. 19

quetiapine fumarate .......... 29 QUILLICHEW ER ............. 31 QUILLIVANT XR ............... 31 quinapril hcl ....................... 17 quinapril-hydrochlorothiazide .......................................... 17 quinidine sulfate ................ 18 quinine sulfate ..................... 7

QUZYTTIR ........................ 57 R RABAVERT ...................... 53 rabeprazole sodium .......... 48 RADICAVA ....................... 34 RAGWITEK ...................... 52 raloxifene hcl .................... 45 ramelteon .......................... 32 ramipril .............................. 17 RANEXA

see ranolazine ............... 21 ranolazine ......................... 21 RAPAFLO

see silodosin ................. 48 RAPAMUNE

see sirolimus ................. 52 rasagiline mesylate ........... 27 RAVICTI ........................... 42 RAYALDEE ...................... 54 RAZADYNE

see galantamine hydrobromide ................ 25

RAZADYNE ER see galantamine hydrobromide er ............ 25

REBIF ............................... 34 REBIF REBIDOSE ............ 35 REBIF REBIDOSE TITRATION ....................... 35 REBIF TITRATION PACK 35 REBLOZYL ....................... 50 RECARBRIO ...................... 6 RECLAST

see zoledronic acid inj 5mg/100ml .................... 39

reclipsen ........................... 41 RECOMBIVAX HB ............ 53 RECTIV ............................ 64 REGLAN

see metoclopramide hcl 46 REGRANEX ..................... 64 RELENZA DISKHALER ...... 9 RELEXXII ......................... 31 RELISTOR ........................ 48 RELPAX

see eletriptan hydrobromide ................ 32

REMERON

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see mirtazapine tabs ..... 26 REMERON SOLTAB

see mirtazapine tab 15mg odt ................................. 26 see mirtazapine tab 30mg odt ................................. 26 see mirtazapine tab 45mg odt ................................. 26

RENAGEL see sevelamer tab 800mg ...................................... 45

RENFLEXIS ...................... 51 RENVELA

see sevelamer carbonate ...................................... 45

repaglinide ........................ 38 REQUIP XL

see ropinirole er ............. 27 RESTASIS ........................ 56 RESTASIS MULTIDOSE .. 56 RESTORIL

see temazepam ............. 32 RETEVMO ........................ 15 RETIN-A

see avita ........................ 59 see tretinoin ................... 60

RETIN-A MICRO ............... 59 see tretinoin microsphere ...................................... 60

RETIN-A MICRO PUMP ... 60 RETROVIR

see zidovudine cap 100mg ........................................8 see zidovudine syp 50mg/5ml .........................8

REVATIO see sildenafil citrate (pulmonary hypertension) ...................................... 22 see sildenafil citrate tab 20 mg (pulmonary hypertension) ................. 22

REVCOVI .......................... 42 REVLIMID ......................... 14 REXULTI ........................... 29 REYATAZ ...........................8

see atazanavir sulfate .....7 RHOPRESSA ................... 56

ribavirin 200mg ................... 9 rifabutin ............................... 8 RIFADIN

see rifampin ..................... 8 rifampin ............................... 8 RILUTEK

see riluzole .................... 34 riluzole .............................. 34 rimantadine hydrochloride ... 9 RINVOQ ............................ 51 RIOMET ............................ 38

see metformin hcl .......... 38 RIOMET ER ...................... 38 risedronate sodium ........... 39 RISPERDAL

see risperidone .............. 29 RISPERDAL INJ 12.5MG . 29 RISPERDAL INJ 25MG .... 29 RISPERDAL INJ 37.5MG . 29 RISPERDAL INJ 50MG .... 29 risperidone ........................ 29 risperidone odt .................. 29 RITALIN

see methylphenidate hcl 31 RITALIN LA

see methylphenidate hcl 31 ritonavir ............................... 8 RITUXAN .......................... 13 RITUXAN HYCELA ........... 13 rivastigmine tartrate .......... 25 rivastigmine td patch 24hr 13.3mg/24hr ...................... 25 rivastigmine td patch 24hr 4.6mg/24hr ........................ 25 rivastigmine td patch 24hr 9.5mg/24hr ........................ 25 rivelsa ............................... 41 rizatriptan benzoate .......... 32 rizatriptan benzoate odt .... 32 ROCALTROL

see calcitriol .................. 54 ropinirole er ....................... 27 ropinirole tab 0.25mg ........ 27 ropinirole tab 0.5mg .......... 27 ropinirole tab 1mg ............. 27 ropinirole tab 2mg ............. 27 ropinirole tab 3mg ............. 27 ropinirole tab 4mg ............. 27

ropinirole tab 5mg ............. 27 rosadan cre 0.75% ............ 64 rosuvastatin calcium ......... 18 ROTARIX .......................... 53 ROTATEQ ........................ 53 ROWASA

see mesalamine w/ cleanser ........................ 47

roweepra ........................... 24 roweepra xr ....................... 24 ROXICODONE

see oxycodone hcl .......... 4 ROZEREM

see ramelteon ............... 32 ROZLYTREK .................... 15 RUBRACA ........................ 13 RUCONEST ..................... 50 RUXIENCE ....................... 13 RUZURGI ......................... 34 RYBELSUS ...................... 38 RYDAPT ........................... 15 RYTARY ........................... 27 RYTHMOL SR

see propafenone hcl ...... 18 S SABRIL

see vigabatrin powd pack 500mg ........................... 25 see vigabatrin tab 500mg ...................................... 25 see vigadrone................ 25

SAFYRAL see drospirenone-ethinyl estradiol-levomefolate calcium .......................... 40 see tydemy .................... 42

SAIZEN ............................. 45 SAIZENPREP RECONSTITUTION .......... 45 SALAGEN

see pilocarpine hcl (oral) ...................................... 65

SAMSCA .......................... 45 see tolvaptan ................. 45

SANCUSO ........................ 46 SANDIMMUNE

see cyclosporine ........... 52 SANDIMMUNE SOLN

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100MG/ML ........................ 52 SANDOSTATIN

see octreotide acetate ... 44 see octreotide inj 100mcg/ml ..................... 44

SANDOSTATIN LAR DEPOT ............................. 45 SANTYL ............................ 64 SAPHRIS .......................... 29 SARAFEM

see fluoxetine hcl (pmdd) ...................................... 36

SARCLISA ........................ 13 SAVELLA .......................... 34 SAVELLA TITRATION PACK ................................ 34 scopolamine ...................... 46 SEASONIQUE

see amethia ................... 39 see ashlyna ................... 39 see levonorgestrel-ethinyl estradiol (91-day) .......... 41

SECUADO ........................ 29 selegiline hcl ..................... 27 selenium sulfide ................ 61 SELZENTRY .......................8 SEMPREX-D ..................... 57 SENSIPAR

see cinacalcet hcl .......... 44 SEREVENT DISKUS ........ 57 SERNIVO .......................... 63 SEROQUEL

see quetiapine fumarate 29 SEROQUEL XR

see quetiapine fumarate 29 SEROSTIM ....................... 45 sertraline hcl ...................... 26 setlakin tab ........................ 41 sevelamer carbonate ........ 45 sevelamer tab 400mg ....... 45 sevelamer tab 800mg ....... 45 SFROWASA ..................... 47 sharobel ............................ 41 SHINGRIX ......................... 53 SIGNIFOR ......................... 45 SIGNIFOR LAR ................. 45 SIKLOS ............................. 16 sildenafil citrate (pulmonary

hypertension) .................... 22 sildenafil citrate tab 20 mg (pulmonary hypertension) . 22 SILENOR

see doxepin hcl (sleep) . 32 silodosin ............................ 48 SILVADENE

see silver sulfadiazine ... 60 see ssd .......................... 60

silver sulfadiazine ............. 60 SIMBRINZA ...................... 56 simvastatin ........................ 18 SINEMET

see carbidopa-levodopa 27 SINGULAIR

see montelukast sodium 57 sirolimus ............................ 52 SIRTURO ............................ 8 SITAVIG .............................. 9 SIVEXTRO .......................... 6 SKLICE ............................. 64 SKYRIZI ............................ 51 SLYND .............................. 41 SMOFLIPID ...................... 54 sodium chloride ........... 53, 54 sodium chloride 0.45%...... 54 sodium chloride 0.9% irrigation ............................ 65 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 53 sodium phenylbutyrate ...... 42 sodium polystyrene sulfonate powder .............................. 39 sodium polystyrene sulfonate susp .................................. 39 solifenacin succinate ......... 49 SOLIQUA 100/33 .............. 37 SOLIRIS ............................ 50 SOLODYN

see minocycline tab 105mg er ....................... 11 see minocycline tab 115mg er ....................... 11 see minocycline tab 55mg er ................................... 11 see minocycline tab 65mg er ................................... 11 see minocycline tab 80mg

er ................................... 11 SOLOSEC .......................... 6 SOLTAMOX ...................... 14 SOLU-CORTEF 1000MG . 43 SOLU-CORTEF 100MG ... 43 SOLU-CORTEF 250MG ... 43 SOLU-CORTEF 500MG ... 43 SOLU-MEDROL ............... 43

see methylpr ss inj ........ 43 SOMATULINE DEPOT ..... 45 SOMAVERT ..................... 45 SORIATANE

see acitretin ................... 61 SORILUX .......................... 61 sorine ................................ 18 sotalol hcl .......................... 18 sotalol hcl (afib/afl) ............ 18 SOTYLIZE ........................ 18 SPIRIVA HANDIHALER ... 56 SPIRIVA RESPIMAT 1.25MCG/ACT .................. 56 SPIRIVA RESPIMAT 2.5MCG/ACT .................... 56 SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK) .. 56 spironolactone .................. 17 spironolactone & hydrochlorothiazide ........... 21 SPORANOX

see itraconazole .............. 7 sprintec 28 ........................ 41 SPRITAM .......................... 24 SPRYCEL ......................... 15 sps .................................... 39 sronyx ............................... 41 ssd .................................... 60 STALEVO 100

see carbidopa-levodopa-entacapone ............................ 27

STALEVO 150 see carbidopa-levodopa-entacapone ............................ 27

stavudine ............................ 8 STELARA ......................... 51 STIMATE .......................... 45

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STIVARGA ........................ 15 STRATTERA

see atomoxetine hcl ...... 30 STRENSIQ ........................ 42 streptomycin sulfate ............5 STRIBILD ............................8 STRIVERDI RESPIMAT.... 57 STROMECTOL

see ivermectin .................5 SUBLOCADE .................... 36 SUBOXONE

see buprenorphine hcl-naloxone hcl dihydrate 12-3mg .......................... 35 see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ......................... 35 see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................ 35 see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................ 35

SUBSYS SPRAY 100MCG .4 SUBSYS SPRAY 1200MCG ............................................4 SUBSYS SPRAY 1600MCG ............................................5 SUBSYS SPRAY 200MCG .4 SUBSYS SPRAY 400MCG .4 SUBSYS SPRAY 600MCG .4 SUBSYS SPRAY 800MCG .4 subvenite starter kit ........... 24 subvenite tab ..................... 24 SUCRAID .......................... 48 sucralfate .......................... 48 SULAR

see nisoldipine ............... 20 sulfacetamide sodium (acne) .......................................... 60 sulfacetamide sodium (ophth) .............................. 55 sulfacetamide sod-prednisolone .............. 54 SULFADIAZINE ..................5 sulfamethoxazole-trimethop ds ........................................6 sulfamethoxazole-trimethopri

m inj .................................... 6 sulfamethoxazole-trimethoprim susp ................................ 6 sulfamethoxazole-trimethoprim tab 400-80mg .................. 6 SULFAMYLON ................. 60

see mafenide acetate .... 60 sulfasalazine dr ................. 47 sulfasalazine ir .................. 47 sulindac ............................... 1 sumatriptan ................. 32, 33 sumatriptan inj 4mg/0.5ml . 33 sumatriptan inj 6mg/0.5ml . 33 sumatriptan succinate ....... 33 sumatriptan-naproxen sodium .............................. 33 SUNOSI ............................ 35 SUPRAX ............................. 9

see cefixime .................... 9 SUPREP BOWEL PREP KIT .......................................... 47 SUSTIVA

see efavirenz ................... 7 SUSTOL ........................... 46 SUTENT ........................... 15 syeda ................................ 41 SYLATRON ...................... 16 SYLVANT ......................... 16 SYMBICORT .................... 59 SYMDEKO ........................ 58 SYMFI ................................. 8 SYMFI LO ........................... 8 SYMJEPI .......................... 58 SYMLINPEN 120 .............. 37 SYMLINPEN 60 ................ 37 SYMPAZAN ...................... 24 SYMPROIC ....................... 48 SYMTUZA ........................... 8 SYNALAR

see fluocinolone acetonide ...................................... 62

SYNAREL ......................... 42 SYNDROS ........................ 46 SYNERCID ......................... 6 SYNJARDY TAB 12.5-1000MG .................... 38 SYNJARDY TAB 12.5-500MG ...................... 38

SYNJARDY TAB 5-1000MG.......................................... 38 SYNJARDY TAB 5-500MG.......................................... 38 SYNJARDY XR TAB 10-1000MG ....................... 38 SYNJARDY XR TAB 12.5-1000MG .................... 38 SYNJARDY XR TAB 25-1000MG ....................... 38 SYNJARDY XR TAB 5-1000MG ......................... 38 SYNRIBO ......................... 16 SYNTHROID .................... 45

see euthyrox ................. 45 see levo-t ...................... 45 see levothyroxine sodium ...................................... 45 see levoxyl .................... 45 see unithroid ................. 45

SYPRINE see clovique .................. 39 see trientine hcl ............. 39

T TABLOID .......................... 12 TABRECTA ...................... 15 TACLONEX

see calcipotriene-betamethasone dipropionate ............. 61

tacrolimus ......................... 52 tacrolimus (topical) ............ 64 tadalafil (pulmonary hypertension) .................... 22 TAFINLAR ........................ 15 TAGRISSO ....................... 15 TAKHZYRO ...................... 50 TALICIA ............................ 48 TALZENNA ....................... 13 TAMIFLU

see oseltamivir phosphate ........................................ 9

tamoxifen citrate ............... 14 tamsulosin hcl ................... 48 TAPAZOLE

see methimazole ........... 45 TARCEVA

see erlotinib hcl ............. 14

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TARGRETIN ..................... 64 see bexarotene .............. 16

tarina 24 fe ........................ 41 tarina fe 1/20 ..................... 41 TARKA

see trandolapril-verapamil hcl .................................. 17

TASIGNA .......................... 15 TAVALISSE ...................... 50 TAXOTERE ....................... 12

see docetaxel ................ 12 TAYTULLA ........................ 41 tazarotene ......................... 61 tazicef .................................9 TAZORAC

see tazarotene ............... 61 TAZORAC CREAM 0.05% 61 TAZORAC GEL 0.05% ..... 61 TAZORAC GEL 0.1% ....... 61 taztia xt ............................. 20 TAZVERIK ........................ 16 TDVAX .............................. 53 TECENTRIQ ..................... 13 TECFIDERA ...................... 35 TECFIDERA STARTER PACK ................................ 35 TEFLARO ...........................9 TEGRETOL

see carbamazepine ....... 23 see epitol ....................... 23

TEGRETOL-XR see carbamazepine ....... 23

TEGSEDI .......................... 34 TEKTURNA

see aliskiren fumarate ... 21 TEKTURNA HCT .............. 21 telmisartan ........................ 18 telmisartan-amlodipine ...... 18 telmisartan-hydrochlorothiazide ...................................... 18 temazepam ....................... 32 TEMIXYS ............................8 TEMOVATE

see clobetasol propionate ...................................... 61

temsirolimus ...................... 13 TENIVAC .......................... 53 tenofovir disoproxil fumarate

............................................ 8 TENORETIC 100

see atenolol & chlorthalidone ................ 19

TENORETIC 50 see atenolol & chlorthalidone ................ 19

TENORMIN see atenolol ................... 19

TEPEZZA .......................... 45 terazosin hcl ...................... 17 terbinafine hcl ..................... 7 terbutaline sulfate ............. 57 terconazole vaginal ........... 49 testosterone ...................... 36 testosterone cypionate ...... 36 testosterone enanthate ..... 36 testosterone td soln 30 mg/act ............................... 36 tetrabenazine .................... 34 tetracycline hcl .................. 11 TEXACORT ...................... 63 THALOMID ....................... 14 THEO-24 ........................... 58 theophylline ....................... 58 theophylline tab er 12hr 300 mg ..................................... 58 theophylline tab er 12hr 450 mg ..................................... 58 theophylline tab sr 24hr ..... 58 THIOLA ............................. 49 THIOLA EC ....................... 49 thioridazine hcl .................. 29 thiothixene ........................ 29 tiadylt er ............................ 20 tiagabine hcl ...................... 24 TIAZAC

see diltiazem hcl coated beads cap sr 24hr ......... 20 see diltiazem hcl extended release beads cap sr ..... 20 see taztia xt ................... 20 see tiadylt er .................. 20

TIBSOVO .......................... 13 tigecycline ........................... 6 TIGECYCLINE .................... 6 TIGLUTIK .......................... 34 TIKOSYN

see dofetilide ................. 18 tilia fe ................................ 41 timolol maleate ................. 19 timolol maleate (ophth) soln.......................................... 56 timolol maleate gel ............ 56 timolol maleate ophth soln 0.5% (once-daily) .............. 56 TIMOPTIC

see timolol maleate (ophth) soln ................... 56

TIMOPTIC OCUDOSE ..... 56 TIMOPTIC-XE

see timolol maleate gel . 56 tinidazole ............................ 6 TIROSINT ......................... 45 TIROSINT-SOL................. 45 TIVICAY .............................. 8 TIVICAY PD ........................ 8 tizanidine hcl ..................... 35 tizanidine tabs ................... 35 TOBI PODHALER ............... 5 TOBRADEX ...................... 54

see tobramycin-dexamethasone .................................... 54

TOBRADEX ST ................ 54 tobramycin .......................... 5 tobramycin (ophth) ............ 55 tobramycin inj 1.2 gm/30ml . 5 tobramycin inj 1.2gm ........... 5 tobramycin inj 10mg/ml ....... 5 tobramycin inj 80mg/2ml ..... 5 tobramycin sulfate............... 5 tobramycin-dexamethasone.......................................... 54 TOBREX ........................... 55

see tobramycin (ophth) . 55 tolmetin sodium................... 1 TOLSURA ........................... 7 tolterodine er ..................... 49 tolterodine tartrate............. 49 tolvaptan ........................... 45 TOPAMAX

see topiramate .............. 24 TOPAMAX SPRINKLE

see topiramate .............. 24 TOPICORT

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see desoximetasone ..... 62 topiramate ......................... 24 toposar .............................. 16 topotecan hcl ..................... 16 TOPOTECAN HCL

see topotecan hcl .......... 16 TOPROL XL

see metoprolol succinate ...................................... 19

toremifene citrate .............. 14 TORISEL

see temsirolimus ........... 13 torsemide .......................... 21 TOSYMRA ........................ 33 TOTECT............................ 16 tovet .................................. 63 TOVIAZ ............................. 49 TPN ELECTROLYTES ..... 53 TRACLEER ....................... 22

see bosentan ................. 22 TRADJENTA ..................... 38 tramadol hcl ........................2 tramadol hcl er (biphasic) 100mg .................................2 tramadol hcl er (biphasic) 200mg .................................2 tramadol hcl er (biphasic) 300mg .................................2 tramadol hcl tab 100 mg .....2 tramadol hcl tab 50 mg .......2 tramadol-acetaminophen ....2 trandolapril ........................ 17 trandolapril-verapamil hcl .. 17 tranexamic acid ................. 50 TRANSDERM SCOP

see scopolamine ........... 46 tranylcypromine sulfate ..... 26 TRAVASOL ....................... 54 TRAVATAN Z

see travoprost ................ 56 travoprost .......................... 56 TRAZIMERA ..................... 13 trazodone hcl .................... 26 TREANDA ......................... 11 TRECATOR ........................8 TRELEGY ELLIPTA .......... 56 TRELSTAR MIXJECT ....... 14 treprostinil ......................... 22

TRESIBA FLEXTOUCH .... 37 TRESIBA INJ .................... 37 tretinoin ....................... 16, 60 tretinoin microsphere ........ 60 TREXALL .......................... 51 TREXIMET

see sumatriptan-naproxen sodium ........................... 33

trezix ................................... 2 triamcinolone acetonide .... 44 triamcinolone acetonide (mouth) ............................. 65 triamcinolone acetonide (topical) ............................. 63 triamterene & hydrochlorothiazide cap 37.5-25mg ......................... 21 triamterene & hydrochlorothiazide tab 37.5-25mg ......................... 21 triamterene & hydrochlorothiazide tab 75-50mg ............................ 21 TRIBENZOR

see olmesartan medoxomil-amlodipine-hydrochlorothiazide ............. 17

TRICARE .......................... 54 TRICOR

see fenofibrate .............. 19 triderm ............................... 63 trientine hcl ....................... 39 tri-estarylla ........................ 41 trifluoperazine hcl .............. 29 trifluridine .......................... 55 TRIGLIDE ......................... 19 trihexyphenidyl hcl ............ 27 TRIJARDY XR TAB ER 24HR 10-5-1000 MG......... 38 TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG.... 38 TRIJARDY XR TAB ER 24HR 25-5-1000 MG......... 39 TRIJARDY XR TAB ER 24HR 5-2.5-1000MG......... 38 TRIKAFTA ........................ 58 tri-legest fe ........................ 41 TRILEPTAL

see oxcarbazepine ........ 24 tri-linyah ............................ 41 TRILIPIX

see choline fenofibrate .. 18 tri-lo- tab marzia ................ 42 tri-lo-estarylla .................... 42 tri-lo-sprintec ..................... 42 trilyte ................................. 47 trimethoprim ........................ 6 tri-mili ................................ 42 trimipramine maleate ........ 26 TRINTELLIX ..................... 26 tri-previfem ........................ 42 tri-sprintec ......................... 42 TRIUMEQ ........................... 8 trivora-28 .......................... 42 tri-vylibra ........................... 42 tri-vylibra lo ....................... 42 TRIZIVIR

see abacavir sulfate-lamivudine-zidovudine ................................... 8

TRODELVY ...................... 13 TROGARZO ....................... 8 TROKENDI XR ................. 24 TROPHAMINE INJ 10% ... 54 TROPHAMINE INJ 6% ..... 54 trospium chloride .............. 49 TRULANCE ...................... 48 TRULICITY ....................... 37 TRUMENBA ..................... 53 TRUSOPT

see dorzolamide hcl ...... 56 TRUVADA TAB 100-150 .... 8 TRUVADA TAB 133-200 .... 8 TRUVADA TAB 167-250 .... 8 TRUVADA TAB 200-300 .... 8 TRUXIMA ......................... 13 TUKYSA ........................... 15 tulana ................................ 42 TURALIO .......................... 15 TWINRIX INJ .................... 53 TWYNSTA

see telmisartan-amlodipine ...................................... 18

TYBOST ............................. 8 tydemy .............................. 42 TYGACIL

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see tigecycline .................6 TYKERB............................ 15 TYMLOS ........................... 45 TYPHIM VI ........................ 53 TYSABRI........................... 35 TYVASO ........................... 22 U UCERIS

see budesonide ............. 47 UCERIS FOAM ................. 47 ULORIC

see febuxostat .................1 ULTOMIRIS ...................... 50 ULTRACET

see tramadol-acetaminophen .2

ULTRAM see tramadol hcl tab 50 mg ...................................2

ULTRAVATE LOTN .......... 63 UNASYN

see ampicillin & sulbactam sodium ........................... 10

UNASYN BULK PACK see ampicillin & sulbactam sodium ........................... 10

unithroid ............................ 45 UPTRAVI .......................... 22 UROCIT-K 10

see potassium citrate (alkalinizer) er tabs ........ 49

UROCIT-K 15 see potassium citrate (alkalinizer) er tabs ........ 49

UROCIT-K 5 see potassium citrate (alkalinizer) er tabs ........ 49

UROXATRAL see alfuzosin hcl ............ 48

URSO 250 see ursodiol ................... 48

URSO FORTE see ursodiol ................... 48

ursodiol ............................. 48 V VABOMERE ........................6 VAGIFEM

see estradiol vaginal tab 43

see yuvafem vaginal tablet 10 mcg .......................... 43

valacyclovir hcl .................... 9 VALCHLOR ...................... 64 VALCYTE

see valganciclovir hcl ...... 9 valganciclovir hcl ................. 9 VALIUM

see diazepam ................ 23 valproate sodium .............. 25 valproic acid ...................... 25 valrubicin ........................... 12 valsartan ........................... 18 valsartan-hydrochlorothiazide ........................................ 18 VALSTAR

see valrubicin ................ 12 VALTOCO ......................... 25 VALTREX

see valacyclovir hcl ......... 9 VANCOCIN

see vancomycin hcl ......... 6 VANCOCIN HCL

see vancomycin hcl ......... 6 vancomycin hcl ................... 6 VANCOMYCIN HYDROCHLORIDE ............ 6 VANCOMYCIN IN NACL .... 6 VANCOMYCIN INJ 250MG 6 vandazole ......................... 49 VANTAS ........................... 14 VAQTA .............................. 53 VARIVAX .......................... 53 VARUBI TAB 90MG .......... 46 VASCEPA ......................... 19 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 17

VASOTEC see enalapril maleate .... 17

VECTIBIX ......................... 13 VELCADE ......................... 13 VELETRI ........................... 22 velivet ................................ 42 VELPHORO ...................... 45 VELTASSA ....................... 39 VELTIN ............................. 60 VEMLIDY ............................ 9

VENCLEXTA .................... 13 VENCLEXTA STARTING PACK ................................ 13 venlafaxine cap er............. 26 venlafaxine tab ................. 26 venlafaxine tab 225mg er . 26 VENTAVIS ........................ 22 VENTOLIN HFA................ 57 verapamil hcl .................... 20 VERDESO ........................ 63 VERELAN

see verapamil hcl .......... 20 VERELAN PM

see verapamil hcl .......... 20 VERSACLOZ .................... 29 VERZENIO ....................... 13 VESICARE

see solifenacin succinate ...................................... 49

VFEND see voriconazole ............. 7

VFEND IV see voriconazole inj 200mg ............................. 7

VIBATIV .............................. 6 VIBERZI ............................ 48 VIBRAMYCIN ................... 11

see doxycycline (monohydrate) ............... 11 see doxycycline hyclate 11

VICTOZA .......................... 37 VIDAZA

see azacitidine .............. 12 vienva ............................... 42 vigabatrin powd pack 500mg.......................................... 25 vigabatrin tab 500mg ........ 25 vigadrone .......................... 25 VIGAMOX

see moxifloxacin hcl (ophth) ........................... 55

VIIBRYD STARTER PACK.......................................... 26 VIIBRYD TAB ................... 26 VIMIZIM ............................ 42 VIMPAT ............................ 25 VIMPAT INJ 200MG/20ML 25 VIMPAT SOL 10MG/ML ... 25

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vinblastine sulfate ............. 12 vincristine sulfate .............. 12 vinorelbine tartrate ............ 12 VIOKACE 10 ..................... 48 VIOKACE 20 ..................... 48 viorele ............................... 42 VIRACEPT ..........................8 VIRAMUNE

see nevirapine susp 50 mg/5ml.............................7 see nevirapine tab 200mg ........................................7

VIRAMUNE XR see nevirapine tab 400mg er .....................................7

VIREAD...............................8 see tenofovir disoproxil fumarate ..........................8

VISTARIL see hydroxyzine pamoate ...................................... 57

VITRAKVI.......................... 15 VIVELLE-DOT

see dotti ......................... 42 see estradiol .................. 42

VIVITROL.......................... 36 VIZIMPRO ......................... 15 VOLTAREN

see diclofenac sodium (topical) 1% gel .............. 64

voriconazole ........................7 voriconazole inj 200mg .......7 VOSEVI...............................9 VOTRIENT ........................ 16 VPRIV ............................... 42 VRAYLAR ......................... 29 VRAYLAR THERAPY PACK .......................................... 29 VUMERITY ....................... 35 VUMERITY STARTER ...... 35 vyfemla ............................. 42 vylibra ............................... 42 VYNDAMAX ...................... 21 VYNDAQEL ...................... 21 VYTORIN

see ezetimibe-simvastatin ...................................... 19

VYVANSE ................... 31, 32

W WAKIX .............................. 35 warfarin sodium ................ 49 water for irrigation, sterile 65 WELCHOL

see colesevelam hcl ...... 18 WELLBUTRIN SR

see bupropion hcl .......... 25 WELLBUTRIN XL

see bupropion hcl .......... 25 wymzya fe ......................... 42 X XADAGO .......................... 27 XALATAN

see latanoprost .............. 56 XALKORI .......................... 16 XANAX

see alprazolam tab 0.25mg .......................... 22 see alprazolam tab 0.5mg ...................................... 22 see alprazolam tab 1mg 22 see alprazolam tab 2mg 22

XARELTO ......................... 49 XARELTO STARTER PACK .......................................... 50 XATMEP ........................... 51 XCOPRI MAINTENANCE PAK 150-200MG ............... 25 XCOPRI PAK 12.5-25MG . 25 XCOPRI PAK 50-100MG .. 25 XCOPRI PAK 50-200MG .. 25 XCOPRI TABS .................. 25 XCOPRI TITRATION PAK 150-200MG ....................... 25 XELJANZ .......................... 51 XELJANZ XR .................... 51 XEMBIFY .......................... 52 XENAZINE

see tetrabenazine .......... 34 XENLETA ........................... 6 XEOMIN INJ 100 UNITS ... 35 XEOMIN INJ 200 UNITS ... 35 XEOMIN INJ 50 UNITS ..... 35 XEPI.................................. 60 XERESE ........................... 64 XERMELO ........................ 48 XGEVA ............................. 45

XHANCE ........................... 58 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 48 XIGDUO XR TAB 10-1000MG ....................... 39 XIGDUO XR TAB 10-500MG.......................................... 39 XIGDUO XR TAB 2.5-1000MG ...................... 39 XIGDUO XR TAB 5-1000MG.......................................... 39 XIGDUO XR TAB 5-500MG.......................................... 39 XIMINO ............................. 11 XODOL

see hydrocodone-acetaminophen 5-300mg ..................... 3

XOFLUZA ........................... 9 XOLAIR ............................ 58 XOLEGEL ......................... 61 XOPENEX

see levalbuterol hcl ....... 57 XOPENEX CONCENTRATE

see levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...................................... 57

XOSPATA ......................... 16 XPOVIO 100 MG ONCE WEEKLY ........................... 16 XPOVIO 40 MG ONCE WEEKLY ........................... 16 XPOVIO 40 MG TWICE WEEKLY ........................... 16 XPOVIO 60 MG ONCE WEEKLY ........................... 16 XPOVIO 60 MG TWICE WEEKLY ........................... 16 XPOVIO 80 MG ONCE WEEKLY ........................... 16 XPOVIO 80 MG TWICE WEEKLY ........................... 16 XTAMPZA ER ..................... 5 XTANDI ............................ 14 xulane dis 150-35 ............. 42 XULTOPHY 100/3.6 ......... 37 XYLOCAINE

see lidocaine hcl (local

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anesth.) ...........................5 see lidocaine inj 0.5% ......5 see lidocaine inj 1% .........5

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ...........................5 see lidocaine inj 1.5% preservative free (pf) .......5 see lidocaine inj 2% preservative free (pf) .......5

XYOSTED ......................... 36 XYREM ............................. 35 Y YASMIN 28

see drospirenone-ethinyl estradiol ......................... 40 see ocella tab 3-0.03mg 41 see syeda ...................... 41 see zarah ....................... 42

YAZ see drospirenone-ethinyl estradiol ......................... 40 see gianvi tab 3-0.02mg 40 see jasmiel .................... 40 see loryna ...................... 41 see nikki ........................ 41

YERVOY ........................... 13 YF-VAX ............................. 53 yuvafem vaginal tablet 10 mcg ................................... 43 Z zafirlukast .......................... 57 ZALTRAP .......................... 13 ZANAFLEX

see tizanidine hcl ........... 35 see tizanidine tabs ......... 35

zarah ................................. 42 ZARONTIN

see ethosuximide .......... 23 ZARXIO............................. 50 ZAVESCA

see miglustat ................. 42 ZEJULA............................. 13 ZELAPAR.......................... 27 ZELBORAF ....................... 16 ZELNORM ........................ 48 ZEMAIRA .......................... 58 ZEMBRACE SYMTOUCH . 33

ZEMDRI .............................. 5 ZEMPLAR

see paricalcitol .............. 54 zenatane ........................... 60 ZENPEP ........................... 48 zenzedi ............................. 32 ZERBAXA ........................... 9 ZERIT

see stavudine .................. 8 ZERVIATE ........................ 55 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 17

ZESTRIL see lisinopril .................. 17

ZETIA see ezetimibe ................ 19

ZETONNA ......................... 58 ZIAC

see bisoprolol & hydrochlorothiazide ....... 19

ZIAGEN see abacavir sulfate ........ 7

ZIANA see clindamycin phosphate-tretinoin........ 59

zidovudine cap 100mg ........ 8 zidovudine syp 50mg/5ml ... 8 zidovudine tab 300mg ......... 8 ZINECARD ....................... 16 ziprasidone hcl .................. 29 ziprasidone mesylate ........ 29 ZIRABEV .......................... 13 ZIRGAN ............................ 55 ZITHROMAX

see azithromycin ............. 9 ZOCOR

see simvastatin ............. 18 ZOFRAN

see ondansetron hcl ...... 46 ZOHYDRO ER

see hydrocodone bitartrate ........................................ 3

ZOLADEX ......................... 14 zoledronic acid inj 4mg/100ml ........................ 39 zoledronic acid inj 5mg/100ml ........................ 39

ZOLEDRONIC INJ 4MG/100ML ...................... 39 zoledronic inj 4mg/5ml ...... 39 ZOLINZA .......................... 13 zolmitriptan ....................... 33 ZOLOFT

see sertraline hcl ........... 26 zolpidem tartrate ............... 32 ZOMACTON ..................... 45 ZOMIG

see zolmitriptan ............. 33 ZOMIG NASAL SPRAY .... 33 ZOMIG ZMT

see zolmitriptan ............. 33 ZONEGRAN

see zonisamide ............. 25 zonisamide ....................... 25 ZONTIVITY ....................... 51 ZORBTIVE ........................ 45 ZORTRESS

see everolimus (immunosuppressant) ... 52

ZORTRESS TAB 0.25MG 52 ZORTRESS TAB 0.5MG .. 52 ZORTRESS TAB 0.75MG 52 ZORTRESS TAB 1MG ..... 52 ZOSTAVAX ...................... 53 ZOSYN ............................. 11 zovia 1/35e ....................... 42 ZOVIRAX

see acyclovir ................... 8 see acyclovir topical ...... 63

ZTLIDO ............................. 63 ZUBSOLV SUB 0.7-0.18MG.......................................... 36 ZUBSOLV SUB 1.4-0.36MG.......................................... 36 ZUBSOLV SUB 11.4-2.9MG.......................................... 36 ZUBSOLV SUB 2.9-0.71MG.......................................... 36 ZUBSOLV SUB 5.7-1.4MG.......................................... 36 ZUBSOLV SUB 8.6-2.1MG.......................................... 36 ZUPLENZ ......................... 46 ZYDELIG .......................... 16 ZYKADIA .......................... 16

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ZYLET ............................... 55 ZYLOPRIM

see allopurinol .................1 ZYMAXID

see gatifloxacin (ophth) . 55 ZYPITAMAG ..................... 18 ZYPREXA

see olanzapine .............. 28 ZYPREXA RELPREVV ..... 29 ZYPREXA RELPREVV INJ 210MG .............................. 29 ZYPREXA ZYDIS

see olanzapine odt ........ 28 ZYTIGA ............................. 14

see abiraterone acetate 13 ZYVOX ............................... 6

see linezolid inj ................ 6 see linezolid susp ............ 6 see linezolid tab 600mg .. 6

2020 632 3T Platinum eff 09/01/2020 · 2020 632 3T Platinum eff 09/01/2020 PA - Prior Authorization...

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Transcript of 2020 632 3T Platinum eff 09/01/2020 · 2020 632 3T Platinum eff 09/01/2020 PA - Prior Authorization...