Drug Requirements/ Drug Requirements/ Tier Limits …...2018/10/01 · Drug Name Drug Tier...

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL TABS(Amphetamine-Dextroamphetamine)

FQL(2 ea daily);AL(At least 6yrs old)

ADDERALL XR CP242.5MG-2.5MG-2.5MG-2.5MG, 7.5MG-7.5MG-7.5MG-7.5MG, 1.25MG-1.25MG-1.25MG-1.25MG,3.75MG-3.75MG-3.75MG-3.75MG, 6.25MG-6.25MG-6.25MG-6.25MG(Amphetamine-Dextroamphetamine)

F

QL(1 ea daily);AL(At least 6yrs old)

ADDERALL XR CP245MG-5MG-5MG-5MG(Amphetamine-Dextroamphetamine)

F


amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 1.875mg-1.875mg-1.875mg-1.875mg, 3.125mg-3.125mg-3.125mg-3.125mg

F


DEXEDRINE CP24(DextroamphetamineSulfate)

NFQL(2 ea daily);AL(At least 6yrs old)

dextroamphetamine sulfatecp24 5 mg, 10 mg, 15 mg F


dextroamphetamine sulfatetabs 5 mg, 10 mg F


VYVANSE CAPS FQL(1 ea daily);AL(At least 6yrs old)

VYVANSE CHEW FQL(1 ea daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg F


atomoxetine hcl caps 18mg, 25 mg, 40 mg, 60 mg,80 mg, 100 mg


guanfacine hcl (adhd) tb24 FQL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24(Guanfacine HCl (ADHD)) NF


KAPVAY TB12 0.1 MG(Clonidine HCl (ADHD)) F


STRATTERA CAPS 10 MG(Atomoxetine HCl) NF


STRATTERA CAPS 18MG, 25 MG, 40 MG, 60MG, 80 MG, 100 MG(Atomoxetine HCl)

NF


Stimulants - Misc.

APTENSIO XR CP24 FQL(1 ea daily);AL(At least 6yrs old)

CONCERTA TBCR(Methylphenidate HCl) NF


DAYTRANA PTCH FQL(1 ea daily);AL(At least 6yrs old)

FOCALIN TABS(Dexmethylphenidate HCl) F


FOCALIN XR CP24(Dexmethylphenidate HCl) F


METADATE CD CPCR(Methylphenidate HCl) NF


METHYLIN CHEW 5 MG,10 MG, 2.5 MG(Methylphenidate HCl)

NFAL(At least 6yrs old)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

1

Drug Name DrugTier

Requirements/Limits

METHYLIN SOLN 5MG/5ML, 10 MG/5ML(Methylphenidate HCl)

FQL(10 mldaily); AL(Atleast 6 yrs old)

methylphenidate hcl chewor 5 mg, 10 mg, 2.5 mg F AL(At least 6

yrs old)methylphenidate hcl cp24or 10 mg, 20 mg, 30 mg,40 mg


methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg


METHYLPHENIDATE HCLER TBCR F


methylphenidate hcl tabs or5 mg, 10 mg, 20 mg F


methylphenidate hcl tbcr or18 mg, 27 mg, 36 mg, 54mg


METHYLPHENIDATEHYDROCHLORIDE ERTB24


QUILLICHEW ER CHER FQL(1 ea daily);AL(At least 6yrs old)

QUILLIVANT XR SUSR FQL(5 ml daily);AL(At least 6yrs old)

RITALIN LA CP24 10 MG(Methylphenidate HCl) F


RITALIN LA CP24 20 MG,30 MG, 40 MG(Methylphenidate HCl)


RITALIN TABS(Methylphenidate HCl) NF


AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesBETHKIS NEBU F PA; SP

KITABIS PAK NEBU F PA

neomycin sulfate tabs or F

Drug Name DrugTier

Requirements/Limits

TOBI NEBU (Tobramycin) NF

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

FPA; SP

HUMIRA PEN PNKT F PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT 40MG/0.8ML

FPA; SP

HUMIRA PEN-PS/UVSTARTER PNKT F PA; SP

HUMIRA PSKT F PA; SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ADVIL CAPS (Ibuprofen) NF

ADVIL MIGRAINE CAPS(Ibuprofen) NF

ALEVE CAPS (NaproxenSodium) NF

ANAPROX DS TABS(Naproxen Sodium) NF

ARTHROTEC 50 TBEC(Diclofenac w/ Misoprostol) NF

ARTHROTEC 75 TBEC(Diclofenac w/ Misoprostol) NF

CELEBREX CAPS(Celecoxib) NF PA; QL(2 ea

daily)celecoxib caps or 50 mg,100 mg, 200 mg, 400 mg F PA; QL(2 ea

daily)CHILDRENS ADVIL SUSP(Ibuprofen) NF RX/OTC

CHILDRENS MOTRINSUSP (Ibuprofen) NF RX/OTC

DAYPRO TABS(Oxaprozin) NF

diclofenac potassium tabs50 mg F

diclofenac sodium tb24 or100 mg F


2

Drug Name DrugTier

Requirements/Limits

diclofenac sodium tbec or25 mg, 50 mg, 75 mg F

diclofenac w/ misoprostoltbec F

EC-NAPROSYN TBEC(Naproxen) NF

etodolac caps F

etodolac tabs F

etodolac tb24 F

FELDENE CAPS(Piroxicam) NF

FENOPROFEN CALCIUMCAPS OR 400 MG F

fenoprofen calcium tabs or600 mg F

FENORTHO CAPS 400MG F

flurbiprofen tabs or 50 mg,100 mg F

ibuprofen caps or 200 mg F

ibuprofen chew or 100 mg F

ibuprofen susp or 100mg/5ml F RX/OTC

ibuprofen tabs or 400 mg,600 mg, 800 mg F

INDOCIN SUPP F

INDOCIN SUSP F

indomethacin caps or 25mg, 50 mg F

indomethacin cpcr or 75mg F

ketoprofen caps or 50 mg,75 mg F

KETOPROFEN CAPS OR50 MG, 75 MG F

KETOPROFEN ER CP24 F

ketorolac tromethaminetabs or 10 mg F QL(20 ea per

30 days retail)

Drug Name DrugTier

Requirements/Limits

LODINE TABS (Etodolac) NF

MECLOFENAMATESODIUM CAPS OR 50MG, 100 MG

F

mefenamic acid caps or250 mg F

meloxicam tabs or 15 mg,7.5 mg F

MOBIC TABS (Meloxicam) NF

nabumetone tabs or 500mg, 750 mg F

NALFON CAPS F

NAPROSYN SUSP(Naproxen) NF

NAPROSYN TABS(Naproxen) NF

naproxen sodium caps or220 mg F

naproxen sodium tabs or275 mg, 550 mg F

naproxen susp or 125mg/5ml F

naproxen tabs or 250 mg,375 mg, 500 mg F

naproxen tbec or 375 mg,500 mg F

oxaprozin tabs 600 mg F

piroxicam caps or 10 mg,20 mg F

PONSTEL CAPS(Mefenamic Acid) NF

sulindac tabs or 150 mg,200 mg F

TOLMETIN SODIUMCAPS 400 MG F

tolmetin sodium caps 400mg F

TOLMETIN SODIUM TABS200 MG, 600 MG F

Pyrimidine Synthesis InhibitorsARAVA TABS(Leflunomide) NF


3

Drug Name DrugTier

Requirements/Limits

leflunomide tabs or 10 mg,20 mg F

Soluble Tumor Necrosis Factor Receptor AgentsENBREL SOSY 50 MG/ML,25 MG/0.5ML F PA; SP

ENBREL SURECLICKSOAJ F PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinationsbutalbital-acetaminophen-caffeine caps F QL(6 ea daily)

butalbital-acetaminophen-caffeine tabs F QL(6 ea daily)

butalbital-aspirin-caffeinecaps 50mg-40mg-325mg F QL(6 ea daily)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 50MG-40MG-325MG

FQL(6 ea daily)

ESGIC TABS (Butalbital-Acetaminophen-Caffeine) NF QL(6 ea daily)

FIORICET CAPS(Butalbital-Acetaminophen-Caffeine)

NFQL(6 ea daily)

FIORINAL CAPS(Butalbital-Aspirin-Caffeine) NF QL(6 ea daily)

Analgesics Otheracetaminophen caps or500 mg F

acetaminophen chew or 80mg F

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml F

acetaminophen liqd or 160mg/5ml F

acetaminophen supp re120 mg, 325 mg, 650 mg F

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml F

acetaminophen tabs or 325mg, 500 mg F

TYLENOL CHILDRENSSUSP (Acetaminophen) NF

Drug Name DrugTier

Requirements/Limits

TYLENOL EXTRASTRENGTH TABS(Acetaminophen)

NF

TYLENOL INFANTSPAIN+FEVER SUSP(Acetaminophen)

NF

TYLENOL INFANTS SUSP(Acetaminophen) NF

TYLENOL TABS(Acetaminophen) NF

Salicylatesaspirin buffered (cal carb-mag carb-mag oxide) tabs F

aspirin chew or 81 mg F

ASPIRIN SUPP RE 120MG, 200 MG, 300 MG, 600MG

F

aspirin supp re 300 mg,600 mg F

aspirin tabs or 325 mg F

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F

BUFFERIN TABS (AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))

NF

choline & mag salicylateliqd F

diflunisal tabs F

DISALCID TABS(Salsalate) NF

ECOTRIN MAXIMUMSTRENGTH TBEC(Aspirin)

NF

ECOTRIN REGULARSTRENGTH TBEC(Aspirin)

NF

salsalate tabs or 500 mg,750 mg F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsDEMEROL TABS OR 100MG (Meperidine HCl) NF


4

Drug Name DrugTier

Requirements/Limits

DILAUDID LIQD OR 1MG/ML (HydromorphoneHCl)

NFQL(16 ml daily)

DILAUDID TABS OR 2MG, 4 MG, 8 MG(Hydromorphone HCl)

NFQL(6 ea daily)

DURAGESIC PT72(Fentanyl) NF PA

EMBEDA CPCR F PA

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

FPA

hydromorphone hcl liqd or1 mg/ml F QL(16 ml daily)

HYDROMORPHONE HCLSUPP RE 3 MG F

12 permonth;QL(0.4ea daily,12 eaper fill retail)

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F QL(6 ea daily)

meperidine hcl tabs or 50mg, 100 mg F

morphine sulfate soln or 10mg/5ml, 20 mg/5ml F

500 permonth;QL(16.67 ml daily)

MORPHINE SULFATESUPP RE 5 MG, 10 MG,20 MG, 30 MG

FQL(6 ea daily)

MORPHINE SULFATETABS OR 15 MG, 30 MG F QL(6 ea daily)

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

FPA

MS CONTIN TBCR(Morphine Sulfate) NF PA

oxycodone hcl caps or 5mg F QL(6 ea daily)

oxycodone hcl conc or 100mg/5ml F QL(6 ml daily)

oxycodone hcl soln or 5mg/5ml F QL(6 ml daily)

oxycodone hcl tabs or 5mg, 10 mg, 15 mg, 20 mg,30 mg

FQL(6 ea daily)

ROXICODONE TABS(Oxycodone HCl) NF QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

tramadol hcl tabs or 50 mg F QL(6 ea daily)

tramadol hcl tb24 or 100mg, 200 mg, 300 mg F PA

ULTRAM TABS (TramadolHCl) NF QL(6 ea daily)

XTAMPZA ER C12A F PA

Opioid Combinationsacetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F QL(16 ml daily)

acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg

FQL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps F QL(6 ea daily)

butalbital-aspirin-caffeinew/cod caps 50mg-40mg-30mg-325mg

FQL(6 ea daily)

FIORICET/CODEINECAPS (Butalbital-Acetaminophen-Caffeine w/Codeine)

NF

QL(6 ea daily)

FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)

NFQL(6 ea daily)

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

F

QL(16 ml daily)

hydrocodone-acetaminophen tabs 5mg-300mg, 5mg-325mg,10mg-300mg, 10mg-325mg, 2.5mg-325mg,7.5mg-300mg, 7.5mg-325mg

F

QL(6 ea daily)

hydrocodone-ibuprofentabs F QL(6 ea daily)

IBUDONE TABS(Hydrocodone-Ibuprofen) NF QL(6 ea daily)

NORCO TABS(Hydrocodone-Acetaminophen)

NFQL(6 ea daily)

oxycodone w/acetaminophen tabs F QL(6 ea daily)


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Drug Name DrugTier

Requirements/Limits

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN F

200 permonth;QL(6.67ml daily)

PERCOCET TABS(Oxycodone w/Acetaminophen)

NFQL(6 ea daily)

PRIMLEV TABS 5MG-300MG, 10MG-300MG F QL(6 ea daily)

REPREXAIN TABS(Hydrocodone-Ibuprofen) NF QL(6 ea daily)

tramadol-acetaminophentabs 37.5mg-325mg F QL(3 ea daily)

TYLENOL/CODEINE #3TABS (Acetaminophen w/Codeine)

NFQL(6 ea daily)

TYLENOL/CODEINE #4TABS (Acetaminophen w/Codeine)

NFQL(6 ea daily)

ULTRACET TABS(Tramadol-Acetaminophen) NF QL(3 ea daily)

XODOL TABS(Hydrocodone-Acetaminophen)

NFQL(6 ea daily)

Opioid Partial Agonistsbuprenorphine hcl subl sl 2mg, 8 mg F Smart PA

Required

BUPRENORPHINE PTWK F

BUTRANS PTWK F

SUBOXONE FILM F AL(At least 6yrs old)

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAndrogensANDRODERM PT24 F PA

ANDROGEL GEL 25MG/2.5GM (Testosterone) NF PA

ANDROGEL GEL 40.5MG/2.5GM, 20.25MG/1.25GM

FPA

ANDROGEL PUMP GEL F PA

Drug Name DrugTier

Requirements/Limits

ANDROXY TABS F

AXIRON SOLN(Testosterone) NF PA

danazol caps or 50 mg,100 mg, 200 mg F

DEPO-TESTOSTERONESOLN (TestosteroneCypionate)

NFPA

testosterone cypionate solnim 100 mg/ml, 200 mg/ml F PA

testosterone enanthatesoln im F PA

testosterone gel td 25mg/2.5gm F PA

TESTOSTERONE GEL TD25 MG/2.5GM F PA

testosterone soln td 30mg/act F PA

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM(Hydrocortisone(Intrarectal))

NF

CORTIFOAM FOAM F

hydrocortisone (intrarectal)enem 100 mg/60ml F

Rectal CombinationsANALPRAM HC CREA(Hydrocortisone Acetate w/Pramoxine)

NF

ANALPRAM HC SINGLESCREA (HydrocortisoneAcetate w/ Pramoxine)

NF

ANALPRAM-HC CREA1%-1% (HydrocortisoneAcetate w/ Pramoxine)

NF

hydrocortisone acetate w/pramoxine crea F

PROCORT CREA F

Rectal SteroidsANUSOL-HC CREA(Hydrocortisone (Rectal)) NF


6

Drug Name DrugTier

Requirements/Limits

hydrocortisone (rectal) crea F

PROCTOCORT CREA 1 %(Hydrocortisone (Rectal)) NF

ANTACIDS

Antacid Combinationsalum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml

F

alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml

F

Antacids - Calcium SaltsANTACID CHEW F

ANTACID SOFT CHEWSCHEW F

calcium carbonate(antacid) chew 400 mg,420 mg, 500 mg, 750 mg,1000 mg

F

calcium carbonate(antacid) tabs 648 mg F

CALCIUM CARBONATETABS OR 648 MG F

CHILDRENSMYLANTAUPSETSTOMACH RELIEF CHEW(Calcium Carbonate(Antacid))

NF

MAALOX CHEW F

TUMS CHEW (CalciumCarbonate (Antacid)) NF

TUMS CHEWY BITESCHEW (Calcium Carbonate(Antacid))

NF

TUMS CHEWY DELIGHTSCHEW F

Drug Name DrugTier

Requirements/Limits

TUMS E-X 750 CHEW(Calcium Carbonate(Antacid))

NF

TUMS EXTRA STRENGTH750 CHEW (CalciumCarbonate (Antacid))

NF

TUMS KIDS CHEW(Calcium Carbonate(Antacid))

NF

TUMS LASTING EFFECTSCHEW (Calcium Carbonate(Antacid))

NF

TUMS SMOOTHIESCHEW (Calcium Carbonate(Antacid))

NF

TUMS ULTRA 1000 CHEW(Calcium Carbonate(Antacid))

NF

Antacids - Magnesium Saltsmagnesium oxide tabs 400mg F

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsALBENZA TABS F PA

BILTRICIDE TABS(Praziquantel) NF

ivermectin tabs or 3 mg F PA

praziquantel tabs or 600mg F

pyrantel pamoate susp or F

REESES PINWORMMEDICINE TABS F

STROMECTOL TABS(Ivermectin) NF PA

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.FIRST-VANCOMYCIN 25SOLN F PA

FIRST-VANCOMYCIN 50SOLN F PA


7

Drug Name DrugTier

Requirements/Limits

FLAGYL CAPS(Metronidazole) NF

FLAGYL TABS(Metronidazole) NF

metronidazole caps or 375mg F

metronidazole tabs or 250mg, 500 mg F

trimethoprim tabs or 100mg F

VANCOCIN HCL CAPS(Vancomycin HCl) NF PA

VANCOMYCIN HCL +SYRSPENDSF PH4 SUSP F PA

vancomycin hcl caps or125 mg, 250 mg F PA

vancomycin hcl solr iv 1000mg F

Anti-infective Misc. - CombinationsBACTRIM DS TABS(Sulfamethoxazole-Trimethoprim)

NF

BACTRIM TABS(Sulfamethoxazole-Trimethoprim)

NF

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

F

sulfamethoxazole-trimethoprim tabs or 80mg-400mg, 160mg-800mg

F

Leprostaticsdapsone tabs or 25 mg,100 mg F

LincosamidesCLEOCIN CAPS OR 75MG, 150 MG, 300 MG(Clindamycin HCl)

NF

clindamycin hcl caps or 75mg, 150 mg, 300 mg F

Oxazolidinoneslinezolid susr or 100mg/5ml F PA

linezolid tabs or 600 mg F PA

Drug Name DrugTier

Requirements/Limits

ZYVOX SUSR OR 100MG/5ML (Linezolid) NF PA

ZYVOX TABS OR 600 MG(Linezolid) NF PA

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-OtherRANEXA TB12 F PA

NitratesDILATRATE SR CPCR F

ISORDIL TITRADOSETABS 5 MG (IsosorbideDinitrate)

NFMP

ISOSORBIDE DINITRATEER TBCR F MP

isosorbide dinitrate tabs F MP

isosorbide mononitrate tabs F MP

isosorbide mononitratetb24 F MP

NITRO-BID OINT F

NITRO-DUR PT24 0.1MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR(Nitroglycerin)

NF

MP

NITRO-DUR PT24 0.3MG/HR, 0.8 MG/HR F

nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F MP

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

FMP

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F MP

NITROSTAT SUBL(Nitroglycerin) NF MP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 30mg F



8

Drug Name DrugTier

Requirements/Limits

buspirone hcl tabs or 5 mg,10 mg, 15 mg, 7.5 mg F


hydroxyzine hcl syrp or 10mg/5ml F QL(10 ml daily)

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F QL(8 ea daily)

HYDROXYZINEPAMOATE CAPS OR 100MG

FQL(4 ea daily)

hydroxyzine pamoate capsor 25 mg, 50 mg F QL(4 ea daily)

VISTARIL CAPS(Hydroxyzine Pamoate) NF QL(4 ea daily)

Benzodiazepines

ALPRAZOLAM INTENSOLCONC F

Limitalprazolam to4mgdaily;QL(60 mlper 15 daysretail); AL(Atleast 6 yrs old)

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg F

Limitalprazolam to4mg daily;QL(4ea daily); AL(Atleast 6 yrs old)

alprazolam tabs or 2 mg F


alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg F


alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg F


alprazolam tbdp or 2 mg F


Drug Name DrugTier

Requirements/Limits

ATIVAN TABS OR 0.5 MG,1 MG (Lorazepam) NF


ATIVAN TABS OR 2 MG(Lorazepam) NF


chlordiazepoxide hcl caps FQL(2 ea daily);AL(At least 6yrs old)

clorazepate dipotassiumtabs 15 mg F


clorazepate dipotassiumtabs 7.5 mg, 3.75 mg F


diazepam conc or 5 mg/ml F QL(2 ml daily)

DIAZEPAM SOLN OR 5MG/5ML F QL(10 ml daily)

diazepam tabs or 2 mg, 5mg, 10 mg F


lorazepam conc or 2 mg/ml FQL(2 ml daily);AL(At least 6yrs old)

lorazepam tabs or 0.5 mg,1 mg F


lorazepam tabs or 2 mg FQL(3 ea daily);AL(At least 6yrs old)

oxazepam caps 10 mg, 15mg, 30 mg F


OXAZEPAM CAPS 30 MG FQL(2 ea daily);AL(At least 6yrs old)

TRANXENE T TABS(Clorazepate Dipotassium) NF


VALIUM TABS (Diazepam) NFQL(4 ea daily);AL(At least 6yrs old)

XANAX TABS 0.25 MG,0.5 MG, 1 MG (Alprazolam) NF



9

Drug Name DrugTier

Requirements/Limits

XANAX TABS 2 MG(Alprazolam) NF


XANAX XR TB24(Alprazolam) NF


ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphatecaps F

NORPACE CAPS(Disopyramide Phosphate) NF

NORPACE CR CP12 F

quinidine gluconate tbcr or324 mg F

QUINIDINE SULFATETABS OR 200 MG, 300MG

F

Antiarrhythmics Type I-Bmexiletine hcl caps F

Antiarrhythmics Type I-Cflecainide acetate tabs F

propafenone hcl cp12 F

propafenone hcl tabs F

RYTHMOL SR CP12(Propafenone HCl) NF

RYTHMOL TABS(Propafenone HCl) NF

Antiarrhythmics Type IIIamiodarone hcl tabs or 100mg, 200 mg F

dofetilide caps F PA

MULTAQ TABS F PA

Drug Name DrugTier

Requirements/Limits

TIKOSYN CAPS(Dofetilide) NF PA

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu in20 mg/2ml F

Bronchodilators - AnticholinergicsATROVENT HFA AERS F

ipratropium bromide soln in0.02 % F

SPIRIVA HANDIHALERCAPS 18 MCG F

Leukotriene ModulatorsACCOLATE TABS(Zafirlukast) NF

montelukast sodium chewor 4 mg, 5 mg F QL(1 ea daily)

montelukast sodium packor 4 mg F

QL(1 ea daily);AL(Up to 3 yrsold )

montelukast sodium tabs or10 mg F QL(1 ea daily)

SINGULAIR CHEW 4 MG,5 MG (MontelukastSodium)

NFQL(1 ea daily)

SINGULAIR PACK 4 MG(Montelukast Sodium) NF

QL(1 ea daily);AL(Up to 3 yrsold )

SINGULAIR TABS 10 MG(Montelukast Sodium) NF QL(1 ea daily)

zafirlukast tabs F

Steroid InhalantsASMANEX TWISTHALER120 METERED DOSESAEPB

F

ASMANEX TWISTHALER14 METERED DOSESAEPB

F


F


10

Drug Name DrugTier

Requirements/Limits


F


F

FLOVENT HFA AERO F

PULMICORT FLEXHALERAEPB F

PULMICORT SUSP(Budesonide (Inhalation)) F AL(Up to 4 yrs

old )Sympathomimetics

ADVAIR DISKUS AEPB F

ST; TryBudesonide,Fluticasone, orMometasoneinhalerfirst;AL(At least6 yrs old - Upto 12 yrs old)

ADVAIR HFA AERO F

ST; TryBudesonide,Fluticasone, orMometasoneinhalerfirst;AL(At least4 yrs old - Upto 12 yrs old)

albuterol sulfate nebu in0.63 mg/3ml, 0.083 %, 0.5%, 1.25 mg/3ml

F

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tabs or 2mg, 4 mg F

BEVESPI AEROSPHEREAERO F PA

COMBIVENT RESPIMATAERS F

DULERA AERO F

ST; TryBudesonide,Fluticasone, orMometasoneinhaler first

ipratropium-albuterol soln F

Drug Name DrugTier

Requirements/Limits

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/3ml, 1.25mg/0.5ml

F

AL(Up to 3 yrsold )

SEREVENT DISKUSAEPB F PA

STIOLTO RESPIMATAERS F PA

SYMBICORT AERO F

ST; TryBudesonide,Fluticasone, orMometasoneinhaler first

VENTOLIN HFA AERS F

XOPENEXCONCENTRATE NEBU(Levalbuterol HCl)

NFAL(Up to 3 yrsold )

XOPENEX NEBU(Levalbuterol HCl) NF AL(Up to 3 yrs

old )Xanthinestheophylline soln F

theophylline tb12 F

theophylline tb24 F

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS(Warfarin Sodium) NF

warfarin sodium tabs F

Direct Factor Xa InhibitorsELIQUIS STARTER PACKTABS F QL(74 ea per

30 days retail)

ELIQUIS TABS 2.5 MG F QL(2 ea daily)

ELIQUIS TABS 5 MG F QL(74 ea per30 days retail)

XARELTO STARTERPACK TBPK F

PA; 51 permonth;QL(1.7ea daily)

XARELTO TABS F QL(2 ea daily)

Heparins And Heparinoid-Like Agents


11

Drug Name DrugTier

Requirements/Limits

enoxaparin sodium soln ij300 mg/3ml F

QL(180 ml per30 days retail)3rtl MAX fill,365rtl day(s)supply,

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F


enoxaparin sodium soln sc30 mg/0.3ml F






enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml F


heparin (porcine) in sodiumchloride soln F

HEPARIN LOCK FLUSHSOLN F

heparin sod (porcine) ind5w soln F

heparin sodium (porcine)lock flush & nacl lock flushkit

F

heparin sodium (porcine)lock flush soln F

heparin sodium (porcine)soln F

HEPARIN SODIUM/D5WSOLN F

HEPARINSODIUM/DEXTROSESOLN

F

Drug Name DrugTier

Requirements/Limits

HEPARIN SODIUM/NACL0.45% SOLN F

HEPARINSODIUM/SODIUMCHLORIDE 0.9% SOLN(Heparin (Porcine) inSodium Chloride)

NF

HEPARINSODIUM/SODIUMCHLORIDE SOLN IJ2UNIT/ML-0.9%

F

LOVENOX SOLN IJ 300MG/3ML (EnoxaparinSodium)

NF


LOVENOX SOLN SC 100MG/ML (EnoxaparinSodium)

NF


LOVENOX SOLN SC 150MG/ML (EnoxaparinSodium)

NFQL(60 ml per30 days retail)

LOVENOX SOLN SC 30MG/0.3ML (EnoxaparinSodium)






LOVENOX SOLN SC 80MG/0.8ML, 120 MG/0.8ML(Enoxaparin Sodium)


SASH KIT FOR FLUSHINGVASCULAR ACCESSDEVICES KIT

F

Thrombin InhibitorsPRADAXA CAPS F QL(2 ea daily)

ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5mg, 1 mg F



12

Drug Name DrugTier

Requirements/Limits

clonazepam tabs or 2 mg FQL(2 ea daily);AL(At least 6yrs old)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg F


clonazepam tbdp or 2 mg FQL(2 ea daily);AL(At least 6yrs old)

DIASTAT ACUDIAL GEL F QL(2 ea per 30days retail)

DIASTAT PEDIATRIC GEL F QL(2 ea per 30days retail)

DIAZEPAM GEL RE 10MG, 20 MG, 2.5 MG F QL(2 ea per 30

days retail)DIAZEPAM RECTAL GELGEL F QL(2 ea per 30

days retail)

KLONOPIN TABS 0.5 MG,1 MG (Clonazepam) NF


KLONOPIN TABS 2 MG(Clonazepam) NF


ONFI SUSP F PA

ONFI TABS F PA

Anticonvulsants - Misc.BANZEL SUSP F PA

BANZEL TABS F PA

carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

carbamazepine susp or100 mg/5ml F

carbamazepine tabs or 200mg F

carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12(Carbamazepine) NF

gabapentin caps or 100mg, 300 mg, 400 mg F

Drug Name DrugTier

Requirements/Limits

gabapentin soln or 250mg/5ml, 300 mg/6ml F

gabapentin tabs or 600 mg,800 mg F

KEPPRA SOLN OR 100MG/ML (Levetiracetam) NF

KEPPRA TABS OR 250MG, 500 MG, 750 MG,1000 MG (Levetiracetam)

NF

KEPPRA XR TB24(Levetiracetam) NF

LAMICTAL CHEWABLEDISPERSIBLE CHEW(Lamotrigine)

NF

LAMICTAL ODT TBDP 25MG, 50 MG, 100 MG, 200MG (Lamotrigine)

NF

LAMICTAL TABS(Lamotrigine) NF

LAMICTAL XR TB24 25MG, 50 MG, 100 MG, 200MG, 250 MG, 300 MG(Lamotrigine)

NF

lamotrigine chew or 5 mg,25 mg F

lamotrigine tabs or 25 mg,100 mg, 150 mg, 200 mg F

lamotrigine tb24 or 25 mg,50 mg, 100 mg, 200 mg,250 mg, 300 mg

F

lamotrigine tbdp or 25 mg,50 mg, 100 mg, 200 mg F

levetiracetam soln or 100mg/ml, 500 mg/5ml F

levetiracetam tabs or 250mg, 500 mg, 750 mg, 1000mg

F

levetiracetam tb24 or 500mg, 750 mg F

LYRICA CAPS F PA

LYRICA SOLN F PA

MYSOLINE TABS(Primidone) NF

NEURONTIN CAPS(Gabapentin) NF


13

Drug Name DrugTier

Requirements/Limits

NEURONTIN SOLN(Gabapentin) NF

NEURONTIN TABS(Gabapentin) NF

oxcarbazepine susp F

oxcarbazepine tabs F

OXTELLAR XR TB24 F ST

primidone tabs or 50 mg,250 mg F

TEGRETOL SUSP(Carbamazepine) NF

TEGRETOL TABS(Carbamazepine) NF

TEGRETOL-XR TB12(Carbamazepine) NF

TOPAMAX SPRINKLECPSP (Topiramate) NF

TOPAMAX TABS(Topiramate) NF

topiramate cpsp or 15 mg,25 mg F

topiramate tabs or 25 mg,50 mg, 100 mg, 200 mg F

TRILEPTAL SUSP(Oxcarbazepine) NF

TRILEPTAL TABS(Oxcarbazepine) NF

VIMPAT SOLN OR 10MG/ML F PA

VIMPAT TABS OR 50 MG,100 MG, 150 MG, 200 MG F PA

ZONEGRAN CAPS(Zonisamide) NF

zonisamide caps or 25 mg,50 mg, 100 mg F

Carbamatesfelbamate susp 600mg/5ml F

felbamate tabs 400 mg F QL(9 ea daily)

felbamate tabs 600 mg F QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

FELBATOL SUSP 600MG/5ML (Felbamate) NF

FELBATOL TABS 400 MG(Felbamate) NF QL(9 ea daily)

FELBATOL TABS 600 MG(Felbamate) NF QL(6 ea daily)

GABA ModulatorsGABITRIL TABS 12 MG,16 MG (Tiagabine HCl) NF PA

GABITRIL TABS 2 MG, 4MG (Tiagabine HCl) NF PA;

tiagabine hcl tabs 12 mg,16 mg F PA

tiagabine hcl tabs 2 mg, 4mg F PA;

HydantoinsDILANTIN CAPS 100 MG(Phenytoin SodiumExtended)

NF

DILANTIN INFATABSCHEW (Phenytoin) NF

DILANTIN-125 SUSP(Phenytoin) NF

PHENYTEK CAPS(Phenytoin SodiumExtended)

NF

phenytoin chew or 50 mg F

phenytoin sodium extendedcaps F

phenytoin susp or 125mg/5ml F

Succinimidesethosuximide caps or 250mg F

ethosuximide soln or 250mg/5ml F

ZARONTIN CAPS(Ethosuximide) NF

ZARONTIN SOLN(Ethosuximide) NF

Valproic AcidDEPAKENE CAPS(Valproic Acid) NF


14

Drug Name DrugTier

Requirements/Limits

DEPAKENE SOLN(Valproate Sodium) NF

DEPAKOTE ER TB24(Divalproex Sodium) NF

DEPAKOTE SPRINKLESCSDR (Divalproex Sodium) NF

DEPAKOTE TBEC 125MG, 250 MG (DivalproexSodium)

NFQL(16 ea daily)

DEPAKOTE TBEC 500 MG(Divalproex Sodium) NF QL(8 ea daily)

divalproex sodium csdr or125 mg F

divalproex sodium tb24 or250 mg, 500 mg F

divalproex sodium tbec or125 mg, 250 mg F QL(16 ea daily)

divalproex sodium tbec or500 mg F QL(8 ea daily)

valproate sodium soln or250 mg/5ml F

valproic acid caps 250 mg F

ANTIDEPRESSANTS - Drugs to TreatDepressionAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs or 15 mg,30 mg, 45 mg F


mirtazapine tabs or 7.5 mg F QL(1 ea daily)

mirtazapine tbdp or 15 mg,30 mg, 45 mg F


REMERON SOLTAB TBDP(Mirtazapine) NF


REMERON TABS(Mirtazapine) NF


Antidepressants - Misc.

bupropion hcl tabs or 75mg, 100 mg F


Drug Name DrugTier

Requirements/Limits

bupropion hcl tb12 or 100mg, 150 mg, 200 mg F


bupropion hcl tb24 or 150mg, 300 mg F


MAPROTILINE HCL TABS F AL(At least 6yrs old)

WELLBUTRIN SR TB12(Bupropion HCl) NF


WELLBUTRIN XL TB24(Bupropion HCl) NF


Monoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24 F PA; AL(At least6 yrs old)

MARPLAN TABS F AL(At least 6yrs old)

NARDIL TABS (PhenelzineSulfate) NF AL(At least 6

yrs old)PARNATE TABS(Tranylcypromine Sulfate) NF AL(At least 6

yrs old)phenelzine sulfate tabs or15 mg F AL(At least 6

yrs old)tranylcypromine sulfatetabs 10 mg F AL(At least 6

yrs old)Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG(Citalopram Hydrobromide) NF


CELEXA TABS 20 MG, 40MG (CitalopramHydrobromide)


citalopram hydrobromidesoln 10 mg/5ml F

QL(20 mldaily); AL(Atleast 6 yrs old)

citalopram hydrobromidetabs 10 mg F


citalopram hydrobromidetabs 20 mg, 40 mg F


escitalopram oxalate soln 5mg/5ml F



15

Drug Name DrugTier

Requirements/Limits

escitalopram oxalate tabs10 mg F

45 permonth;QL(1.5ea daily); AL(Atleast 6 yrs old)

escitalopram oxalate tabs20 mg F


escitalopram oxalate tabs 5mg F


FLUOXETINE DR CPDR F PA; AL(At least6 yrs old)

fluoxetine hcl caps or 10mg, 40 mg F


fluoxetine hcl caps or 20mg F


fluoxetine hcl soln or 20mg/5ml F


fluvoxamine maleate cp24100 mg F


fluvoxamine maleate cp24150 mg F


fluvoxamine maleate tabs100 mg F






LEXAPRO SOLN 5MG/5ML (EscitalopramOxalate)

NFQL(20 mldaily); AL(Atleast 6 yrs old)

LEXAPRO TABS 10 MG(Escitalopram Oxalate) NF




Drug Name DrugTier

Requirements/Limits



paroxetine hcl tabs 10 mg,20 mg, 30 mg F


paroxetine hcl tabs 40 mg F


paroxetine hcl tb24 25 mg,12.5 mg, 37.5 mg F


PAXIL CR TB24(Paroxetine HCl) NF


PAXIL SUSP 10 MG/5ML FQL(30 mldaily); AL(Atleast 6 yrs old)

PAXIL TABS 10 MG, 20MG, 30 MG (ParoxetineHCl)


PAXIL TABS 40 MG(Paroxetine HCl) NF


PEXEVA TABS F PA; AL(At least6 yrs old)

PROZAC CAPS 10 MG, 40MG (Fluoxetine HCl) NF


PROZAC CAPS 20 MG(Fluoxetine HCl) NF


sertraline hcl conc or 20mg/ml F


sertraline hcl tabs or 100mg F


sertraline hcl tabs or 25 mg FQL(3 ea daily);AL(At least 6yrs old)

sertraline hcl tabs or 50 mg FQL(4 ea daily);AL(At least 6yrs old)


16

Drug Name DrugTier

Requirements/Limits

ZOLOFT CONC 20 MG/ML(Sertraline HCl) NF


ZOLOFT TABS 100 MG(Sertraline HCl) NF






Serotonin Modulators

NEFAZODONE HCL TABS100 MG F


NEFAZODONE HCL TABS150 MG F


nefazodone hcl tabs 50mg, 250 mg F


NEFAZODONEHYDROCHLORIDE TABS F


trazodone hcl tabs or 100mg F








VIIBRYD TABS F PA; AL(At least6 yrs old)

Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG,30 MG (Duloxetine HCl) NF


CYMBALTA CPEP 60 MG(Duloxetine HCl) NF


Drug Name DrugTier

Requirements/Limits

desvenlafaxine succinatetb24 F


duloxetine hcl cpep or 20mg, 30 mg F


duloxetine hcl cpep or 60mg F


EFFEXOR XR CP24 150MG (Venlafaxine HCl) NF


EFFEXOR XR CP24 75MG, 37.5 MG (VenlafaxineHCl)


PRISTIQ TB24(Desvenlafaxine Succinate) NF


venlafaxine hcl cp24 150mg F


venlafaxine hcl cp24 75mg, 37.5 mg F


venlafaxine hcl tabs 25 mg FQL(4 ea daily);AL(At least 6yrs old)

venlafaxine hcl tabs 50 mg,100 mg, 37.5 mg F


venlafaxine hcl tabs 75 mg FQL(5 ea daily);AL(At least 6yrs old)

Tricyclic Agentsamitriptyline hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg

FAL(At least 6yrs old)

AMOXAPINE TABS F AL(At least 6yrs old)

ANAFRANIL CAPS(Clomipramine HCl) NF AL(At least 6

yrs old)clomipramine hcl caps or25 mg, 50 mg, 75 mg F AL(At least 6

yrs old)desipramine hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg



17

Drug Name DrugTier

Requirements/Limits

doxepin hcl caps or 10 mg,25 mg, 50 mg, 75 mg, 100mg, 150 mg


doxepin hcl conc or 10mg/ml F

QL(6 ml daily);AL(At least 6yrs old)

ELAVIL TABS(Amitriptyline HCl) NF AL(At least 6

yrs old)imipramine hcl tabs or 10mg, 25 mg, 50 mg F AL(At least 6

yrs old)

imipramine pamoate caps F AL(At least 6yrs old)

NORPRAMIN TABS(Desipramine HCl) NF AL(At least 6

yrs old)nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg F AL(At least 6

yrs old)nortriptyline hcl soln or 10mg/5ml F AL(At least 6

yrs old)PAMELOR CAPS(Nortriptyline HCl) NF AL(At least 6

yrs old)

protriptyline hcl tabs F AL(At least 6yrs old)

SURMONTIL CAPS(Trimipramine Maleate) NF AL(At least 6

yrs old)TOFRANIL TABS(Imipramine HCl) NF AL(At least 6

yrs old)trimipramine maleate capsor 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old)ANTIDIABETICS - Drugs to Regulate BloodSugarAlpha-Glucosidase Inhibitorsacarbose tabs F

PRECOSE TABS(Acarbose) NF

Antidiabetic - Amylin AnalogsSYMLINPEN 120 SOPN F PA

SYMLINPEN 60 SOPN F PA

Antidiabetic CombinationsACTOPLUS MET TABS(Pioglitazone HCl-Metformin HCl)

NFMP

ACTOPLUS MET XR TB24 F

Drug Name DrugTier

Requirements/Limits

glipizide-metformin hcl tabs F MP

GLUCOVANCE TABS(Glyburide-Metformin) NF MP

glyburide-metformin tabs F MP

GLYXAMBI TABS F PA

JANUMET TABS F PA

JANUMET XR TB24 F PA

JENTADUETO TABS F PA;

JENTADUETO XR TB24 F PA

KOMBIGLYZE XR TB24 F PA

pioglitazone hcl-metforminhcl tabs F MP

BiguanidesGLUCOPHAGE TABS(Metformin HCl) NF MP

GLUCOPHAGE XR TB24(Metformin HCl) NF MP

metformin hcl tabs or 500mg, 850 mg, 1000 mg F MP

metformin hcl tb24 or 500mg, 750 mg F MP

METFORMINHYDROCHLORIDE SOLN F

RIOMET SOLN F

Diabetic OtherCVS GLUCOSE BITSCHEW F

CVS GLUCOSE CHEW 4GM F

DEX4 FAST ACTINGGLUCOSEGO-POUCHGEL

F

DEX4 QUICK DISSOLVEGLUCOSE CHEW F

dextrose (diabetic use) gel40 %, 15 gm/38gm F


18

Drug Name DrugTier

Requirements/Limits

GLUCAGONEMERGENCY KIT KIT F

1 permonth;QL(0.034 ea daily)

GLUCOSE CHEW 4 GM F

GLUCOSE GEL 15GM/33GM F

GNP GLUCOSE CHEW 4GM F

GNP QUICK DISSOLVEGLUCOSE CHEW F

INSTA-GLUCOSE GEL F

LEADER QUICKDISSOLVE GLUCOSECHEW

F

SM GLUCOSE CHEW 4GM F

WALGREENS GLUCOSECHEW 4 GM F

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA TABS F PA

ONGLYZA TABS F PA

TRADJENTA TABS F PA;

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON PEN PEN F PA

BYDUREON SRER F PA

BYETTA SOPN F PA

VICTOZA SOPN F PA

Insulin Sensitizing AgentsACTOS TABS(Pioglitazone HCl) NF MP

pioglitazone hcl tabs F MP

InsulinHUMALOG JUNIORKWIKPEN SOPN F

HUMALOG KWIKPENSOPN F

Drug Name DrugTier

Requirements/Limits

HUMALOG MIX 50/50KWIKPEN SUPN F

HUMALOG MIX 50/50SUSP F

HUMALOG MIX 75/25KWIKPEN SUPN F

HUMALOG MIX 75/25SUSP F

HUMALOG SOCT F

HUMALOG SOLN F

HUMULIN 70/30 KWIKPENSUPN 70UNIT/ML-30UNIT/ML

F

HUMULIN 70/30 SUSP70UNIT/ML-30UNIT/ML F

HUMULIN N KWIKPENSUPN 100 UNIT/ML F

HUMULIN N SUSP 100UNIT/ML F

HUMULIN R SOLN F

HUMULIN R U-500(CONCENTRATED) SOLN F PA

HUMULIN R U-500KWIKPEN SOPN F PA

LANTUS SOLN 100UNIT/ML F

LANTUS SOLOSTARSOPN 100 UNIT/ML F

LEVEMIR FLEXTOUCHSOPN F

LEVEMIR SOLN F

NOVOLOG FLEXPENSOPN 100 UNIT/ML F

NOVOLOG MIX 70/30PREFILLED FLEXPENSUPN

F

NOVOLOG MIX 70/30SUSP F

NOVOLOG PENFILLSOCT 100 UNIT/ML F

Meglitinide Analogues


19

Drug Name DrugTier

Requirements/Limits

nateglinide tabs F MP

PRANDIN TABS(Repaglinide) NF

repaglinide tabs F

STARLIX TABS(Nateglinide) NF MP

SulfonylureasAMARYL TABS(Glimepiride) NF MP

glimepiride tabs F MP

glipizide tabs or 5 mg, 10mg F MP

glipizide tb24 or 5 mg, 10mg, 2.5 mg F MP

GLUCOTROL TABS(Glipizide) NF MP

GLUCOTROL XL TB24(Glipizide) NF MP

glyburide micronized tabs F MP

glyburide tabs or 5 mg, 2.5mg, 1.25 mg F MP

GLYNASE TABS(Glyburide Micronized) NF MP

TOLAZAMIDE TABS F

TOLBUTAMIDE TABS F

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat DiarrheaAntidiarrheal/Probiotic Agents - Misc.bismuth subsalicylate chewor 262 mg F

bismuth subsalicylate suspor 262 mg/15ml, 525mg/30ml, 527 mg/30ml

F

bismuth subsalicylate tabsor 262 mg F

PEPTO BISMOL TABS(Bismuth Subsalicylate) NF

PEPTO-BISMOL CHEW262 MG (BismuthSubsalicylate)

NF

Drug Name DrugTier

Requirements/Limits

PEPTO-BISMOLINSTACOOL CHEW(Bismuth Subsalicylate)

NF

PEPTO-BISMOL SUSP262 MG/15ML (BismuthSubsalicylate)

NF

PEPTO-BISMOL TO-GOCHEW (BismuthSubsalicylate)

NF

Antiperistaltic Agentsdiphenoxylate w/ atropinetabs F

DIPHENOXYLATE/ATROPINE LIQD F

IMODIUM A-D CAPS 2 MG(Loperamide HCl) NF RX/OTC

IMODIUM A-D LIQD 1MG/7.5ML (LoperamideHCl)

NF

IMODIUM A-D TABS 2 MG(Loperamide HCl) NF

LOMOTIL TABS(Diphenoxylate w/ Atropine) NF

loperamide hcl caps or 2mg F RX/OTC

loperamide hcl liqd or 1mg/5ml, 1 mg/7.5ml F

loperamide hcl susp or 1mg/7.5ml F

loperamide hcl tabs or 2mg F

ANTIDOTES AND SPECIFIC ANTAGONISTS

Opioid AntagonistsNALOXONE HCL SOCT IJ0.4 MG/ML F

naloxone hcl soln ij 0.4mg/ml, 4 mg/10ml F

NALOXONE HCL SOSY IJ2 MG/2ML F

naltrexone hcl tabs or F

NARCAN LIQD F

VIVITROL SUSR F SP


20

Drug Name DrugTier

Requirements/Limits

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor AntagonistsANZEMET TABS F PA

granisetron hcl tabs or 1mg F PA

ondansetron hcl tabs or 4mg, 8 mg F QL(1 ea daily)

ondansetron tbdp F QL(1 ea daily)

ZOFRAN ODT TBDP(Ondansetron) NF QL(1 ea daily)

ZOFRAN TABS 4 MG, 8MG (Ondansetron HCl) NF QL(1 ea daily)

Antiemetics - Anticholinergicdimenhydrinate tabs or 50mg F

DRAMAMINE CHEW 50MG F

DRAMAMINE TABS(Dimenhydrinate) NF

meclizine hcl chew or 25mg F

meclizine hcl tabs or 25mg, 12.5 mg F RX/OTC

TIGAN CAPS OR 300 MG(Trimethobenzamide HCl) NF

trimethobenzamide hclcaps or 300 mg F

Substance P/Neurokinin 1 (NK1) Receptoraprepitant caps 40 mg, 80mg, F QL(6 ea per 21

days retail)EMEND CAPS OR 40 MG,80 MG (Aprepitant) NF QL(6 ea per 21

days retail)EMEND TRIPACK CAPS(Aprepitant) NF QL(6 ea per 21

days retail)

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungalsgriseofulvin microsize susp F

griseofulvin microsize tabs F

Drug Name DrugTier

Requirements/Limits

LAMISIL TABS(Terbinafine HCl) NF QL(90 ea per

365 days retail)

nystatin tabs or 500000 unit F

terbinafine hcl tabs or 250mg F QL(90 ea per

365 days retail)Imidazole-Related AntifungalsDIFLUCAN SUSR 10MG/ML (Fluconazole) NF QL(20 ml daily)

DIFLUCAN SUSR 40MG/ML (Fluconazole) NF

DIFLUCAN TABS 50 MG,100 MG, 150 MG, 200 MG(Fluconazole)

NFQL(2 ea daily)

fluconazole susr or 10mg/ml F QL(20 ml daily)

fluconazole susr or 40mg/ml F

fluconazole tabs or 50 mg,100 mg, 150 mg, 200 mg F QL(2 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesCHLOR-TRIMETON SYRP(ChlorpheniramineMaleate)

NF

CHLOR-TRIMETON TABS(ChlorpheniramineMaleate)

NF

chlorpheniramine maleatesyrp or 2 mg/5ml F

chlorpheniramine maleatetabs or 4 mg F

Antihistamines - EthanolaminesALER-DRYL TABS F

BENADRYL ALLERGYCAPS (DiphenhydramineHCl)

NF

BENADRYL ALLERGYCHILDRENS CHEW(Diphenhydramine HCl)

NF

BENADRYL ALLERGYCHILDRENS LIQD(Diphenhydramine HCl)

NF


21

Drug Name DrugTier

Requirements/Limits

BENADRYL ALLERGYTABS (DiphenhydramineHCl)

NF

clemastine fumarate tabsor 1.34 mg F

diphenhydramine hcl capsor 25 mg F

diphenhydramine hcl capsor 50 mg F RX/OTC

diphenhydramine hcl chewor 12.5 mg F

diphenhydramine hcl elix or12.5 mg/5ml F RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

F

diphenhydramine hcl tabsor 25 mg F

SILPHEN COUGH SYRP F

TAVIST ALLERGY TABS(Clemastine Fumarate) NF

Antihistamines - Non-SedatingALLEGRA ALLERGYCHILDRENS SUSP 30MG/5ML (FexofenadineHCl)

NF

QL(5 ml daily)

ALLEGRA ALLERGYCHILDRENS TBDP 30 MG F QL(1 ea daily)

ALLEGRA ALLERGYTABS (Fexofenadine HCl) NF QL(1 ea daily)

cetirizine hcl caps 10 mg F QL(1 ea daily)

cetirizine hcl chew 5 mg,10 mg F QL(1 ea daily)

cetirizine hcl soln 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTCcetirizine hcl syrp 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTCcetirizine hcl tabs 5 mg, 10mg F QL(1 ea daily)

CLARITIN ALLERGYCHILDRENS SYRP(Loratadine)

NFQL(5 ml daily)

CLARITIN CAPS 10 MG(Loratadine) NF QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

CLARITIN CHEW 5 MG F QL(1 ea daily)

CLARITIN CHEW 5 MG(Loratadine) NF QL(1 ea daily)

CLARITIN CHILDRENSCHEW (Loratadine) NF QL(1 ea daily)

CLARITIN REDITABSTBDP 10 MG (Loratadine) NF QL(1 ea daily)

CLARITIN REDITABSTBDP 5 MG F QL(1 ea daily)

CLARITIN SYRP 5MG/5ML (Loratadine) NF QL(5 ml daily)

CLARITIN TABS 10 MG(Loratadine) NF QL(1 ea daily)

fexofenadine hcl susp or 30mg/5ml F QL(5 ml daily)

fexofenadine hcl tabs or 60mg, 180 mg F QL(1 ea daily)

loratadine caps or 10 mg F QL(1 ea daily)

loratadine chew or 5 mg F QL(1 ea daily)

loratadine soln or 5 mg/5ml F QL(5 ml daily)

loratadine syrp or 5 mg/5ml F QL(5 ml daily)

loratadine tabs or 10 mg F QL(1 ea daily)

loratadine tbdp or 10 mg F QL(1 ea daily)

ZYRTEC ALLERGY CAPS(Cetirizine HCl) NF QL(1 ea daily)

ZYRTEC ALLERGYCHILDRENS TBDP F QL(1 ea daily)

ZYRTEC ALLERGY TABS(Cetirizine HCl) NF QL(1 ea daily)

ZYRTEC ALLERGY TBDP F QL(1 ea daily)

ZYRTEC CHILDRENSALLERGY SOLN(Cetirizine HCl)

NFQL(5 ml daily);RX/OTC

Antihistamines - Phenothiazinespromethazine hcl soln or6.25 mg/5ml F

promethazine hcl supp re25 mg, 50 mg, 12.5 mg F


22

Drug Name DrugTier

Requirements/Limits

promethazine hcl syrp or6.25 mg/5ml F

promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F

Antihistamines - Piperidinescyproheptadine hcl syrp or2 mg/5ml F

cyproheptadine hcl tabs or4 mg F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolBile Acid Sequestrantscholestyramine light pack F MP

cholestyramine light powd F MP

cholestyramine pack or 4gm F MP

cholestyramine powd or 4gm/dose F MP

COLESTID FLAVOREDGRAN 5 GM (ColestipolHCl)

NFMP

COLESTID GRAN(Colestipol HCl) NF MP

COLESTID PACK(Colestipol HCl) NF MP

COLESTID TABS(Colestipol HCl) NF MP

colestipol hcl gran F MP

colestipol hcl pack F MP

colestipol hcl tabs F MP

QUESTRAN LIGHT POWD(Cholestyramine Light) NF MP

QUESTRAN PACK(Cholestyramine) NF MP

QUESTRAN POWD(Cholestyramine) NF MP

Fibric Acid Derivativesfenofibrate micronized caps134 mg, 200 mg F MP

Drug Name DrugTier

Requirements/Limits

fenofibrate micronized caps67 mg F

fenofibrate tabs or 48 mg,145 mg, 160 mg F MP

fenofibrate tabs or 54 mg F

FENOFIBRIC ACID TABS F

FIBRICOR TABS F

gemfibrozil tabs or 600 mg F MP

LOFIBRA CAPS 134 MG,200 MG (FenofibrateMicronized)

NFMP

LOFIBRA CAPS 67 MG(Fenofibrate Micronized) NF

LOFIBRA TABS 160 MG(Fenofibrate) NF MP

LOFIBRA TABS 54 MG(Fenofibrate) NF

LOPID TABS (Gemfibrozil) NF MP

TRICOR TABS(Fenofibrate) NF MP

TRIGLIDE TABS F MP

HMG CoA Reductase Inhibitorsatorvastatin calcium tabs or10 mg, 20 mg, 40 mg, 80mg

FQL(1 ea daily);MP

LIPITOR TABS(Atorvastatin Calcium) NF QL(1 ea daily);

MP

lovastatin tabs F MP

MEVACOR TABS(Lovastatin) NF MP

PRAVACHOL TABS(Pravastatin Sodium) NF MP

pravastatin sodium tabs F MP

simvastatin tabs or 5 mg,10 mg, 20 mg, 40 mg, 80mg

FMP

ZOCOR TABS(Simvastatin) NF MP

Intestinal Cholesterol Absorption Inhibitors


23

Drug Name DrugTier

Requirements/Limits

ezetimibe tabs 10 mg F PA

ZETIA TABS (Ezetimibe) NF PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL TABS(Quinapril HCl) NF MP

ACEON TABS (PerindoprilErbumine) NF

ALTACE CAPS (Ramipril) NF MP

benazepril hcl tabs or 5mg, 10 mg, 20 mg, 40 mg F MP

captopril tabs or 25 mg, 50mg, 100 mg, 12.5 mg F MP

enalapril maleate tabs or 5mg, 10 mg, 20 mg, 2.5 mg F MP

EPANED SOLN F

EPANED SOLR F

fosinopril sodium tabs F MP

lisinopril tabs or 5 mg, 10mg, 20 mg, 30 mg, 40 mg,2.5 mg

FMP

LOTENSIN TABS(Benazepril HCl) NF MP

MAVIK TABS (Trandolapril) NF MP

moexipril hcl tabs F

perindopril erbumine tabs F

PRINIVIL TABS (Lisinopril) NF MP

quinapril hcl tabs F MP

ramipril caps F MP

trandolapril tabs F MP

VASOTEC TABS (EnalaprilMaleate) NF MP

ZESTRIL TABS (Lisinopril) NF MP

Drug Name DrugTier

Requirements/Limits

Angiotensin II Receptor AntagonistsAVAPRO TABS(Irbesartan) NF MP

BENICAR TABS(Olmesartan Medoxomil) NF

ST; Trylosartan andirbesartan first

COZAAR TABS (LosartanPotassium) NF MP

DIOVAN TABS (Valsartan) NF MP

irbesartan tabs F MP

losartan potassium tabs F MP

olmesartan medoxomil tabsor 5 mg, 20 mg, 40 mg F

ST; Trylosartan andirbesartan first

valsartan tabs F MP

Antiadrenergic AntihypertensivesCARDURA TABS(Doxazosin Mesylate) NF MP

CATAPRES TABS(Clonidine HCl) NF MP

CATAPRES-TTS-1 PTWK(Clonidine HCl) NF AL(At least 6

yrs old); MPCATAPRES-TTS-2 PTWK(Clonidine HCl) NF AL(At least 6

yrs old); MPCATAPRES-TTS-3 PTWK(Clonidine HCl) NF AL(At least 6

yrs old); MPclonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

FAL(At least 6yrs old); MP

clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg F MP

doxazosin mesylate tabs or1 mg, 2 mg, 4 mg, 8 mg F MP

guanfacine hcl tabs F MP

methyldopa tabs F MP

MINIPRESS CAPS(Prazosin HCl) NF MP

prazosin hcl caps F MP

TENEX TABS (GuanfacineHCl) NF MP


24

Drug Name DrugTier

Requirements/Limits

terazosin hcl caps F MP

Antihypertensive CombinationsACCURETIC TABS(Quinapril-Hydrochlorothiazide)

NF

amlodipine besylate-benazepril hcl caps F MP

atenolol & chlorthalidonetabs F MP

AVALIDE TABS(Irbesartan-Hydrochlorothiazide)

NFMP

benazepril &hydrochlorothiazide tabs F MP

BENICAR HCT TABS(Olmesartan Medoxomil-Hydrochlorothiazide)

NF

ST; Trylosartan hctzand irbesartanhctz first

bisoprolol &hydrochlorothiazide tabs F MP

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F MP

CORZIDE TABS (Nadolol& Bendroflumethiazide) NF

DIOVAN HCT TABS(Valsartan-Hydrochlorothiazide)

NFMP

enalapril maleate &hydrochlorothiazide tabs F MP

fosinopril sodium &hydrochlorothiazide tabs F MP

HYZAAR TABS (LosartanPotassium &Hydrochlorothiazide)

NFMP

irbesartan-hydrochlorothiazide tabs F MP

lisinopril &hydrochlorothiazide tabs F MP

LOPRESSOR HCT TABS(Metoprolol &Hydrochlorothiazide)

NFMP

losartan potassium &hydrochlorothiazide tabs F MP

LOTENSIN HCT TABS(Benazepril &Hydrochlorothiazide)

NFMP

Drug Name DrugTier

Requirements/Limits

LOTREL CAPS(Amlodipine Besylate-Benazepril HCl)

NFMP

metoprolol &hydrochlorothiazide tabs F MP

METOPROLOL/HYDROCHLOROTHIAZIDE TABS F MP

moexipril-hydrochlorothiazide tabs F

nadolol &bendroflumethiazide tabs F

olmesartan medoxomil-hydrochlorothiazide tabs F

ST; Trylosartan hctzand irbesartanhctz first

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F

quinapril-hydrochlorothiazide tabs F

TENORETIC 100 TABS(Atenolol & Chlorthalidone) NF MP

TENORETIC 50 TABS(Atenolol & Chlorthalidone) NF MP

valsartan-hydrochlorothiazide tabs F MP

VASERETIC TABS(Enalapril Maleate &Hydrochlorothiazide)

NFMP

ZESTORETIC TABS(Lisinopril &Hydrochlorothiazide)

NFMP

ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NF MP

Selective Aldosterone Receptor Antagonistseplerenone tabs F PA

INSPRA TABS(Eplerenone) NF PA

Vasodilatorshydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F MP

minoxidil tabs or 10 mg, 2.5mg F MP

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)


25

Drug Name DrugTier

Requirements/Limits

Antimalarial Combinationsatovaquone-proguanil hcltabs F

COARTEM TABS F

MALARONE TABS(Atovaquone-ProguanilHCl)

NF

AntimalarialsCHLOROQUINEPHOSPHATE TABS OR250 MG

F

chloroquine phosphatetabs or 500 mg F

hydroxychloroquine sulfatetabs or 200 mg F

PLAQUENIL TABS(HydroxychloroquineSulfate)

NF

PRIMAQUINEPHOSPHATE TABS F

QUALAQUIN CAPS(Quinine Sulfate) NF

quinine sulfate caps or 324mg F

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic AgentsMESTINON SYRP 60MG/5ML F

MESTINON TABS 60 MG(Pyridostigmine Bromide) NF

MESTINON TIMESPANTBCR (PyridostigmineBromide)

NF

pyridostigmine bromidetabs or 60 mg F

pyridostigmine bromidetbcr or 180 mg F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Antimycobacterial Agentsethambutol hcl tabs or 100mg, 400 mg F

Drug Name DrugTier

Requirements/Limits

ISONIAZID SYRP OR 50MG/5ML F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS(Ethambutol HCl) NF

pyrazinamide tabs or F

RIFADIN CAPS OR 150MG, 300 MG (Rifampin) NF

rifampin caps or 150 mg,300 mg F

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAntimetabolitesmercaptopurine tabs or F

methotrexate sodium tabsor 2.5 mg F

PURIXAN SUSP F

Antineoplastic - Hormonal and Related Agentsanastrozole tabs or 1 mg F PA

ARIMIDEX TABS(Anastrozole) NF PA

AROMASIN TABS(Exemestane) NF PA

ELIGARD KIT F PA; SP

exemestane tabs 25 mg F PA

FARESTON TABS F PA

FEMARA TABS (Letrozole) NF

flutamide caps F

letrozole tabs or 2.5 mg F

leuprolide acetate kit ij F PA; SP

LUPRON DEPOT (1-MONTH) KIT F PA; SP



26

Drug Name DrugTier

Requirements/Limits



MEGACE ORAL SUSP(Megestrol Acetate) NF

megestrol acetate susp or40 mg/ml, 400 mg/10ml F

megestrol acetate tabs or20 mg, 40 mg F

tamoxifen citrate tabs or 10mg, 20 mg F

XTANDI CAPS F PA; SP

Antineoplastic Enzyme InhibitorsAFINITOR DISPERZ TBSO F PA; SP

AFINITOR TABS F PA; SP

ALECENSA CAPS F PA; SP

BELEODAQ SOLR F PA; SP

CAPRELSA TABS F PA; SP

COTELLIC TABS F PA; SP

GLEEVEC TABS (ImatinibMesylate) NF PA

ICLUSIG TABS F PA; SP

imatinib mesylate tabs F PA

IMBRUVICA CAPS 140MG F PA; SP

INLYTA TABS F PA; SP

IRESSA TABS F PA; SP

JAKAFI TABS F PA; SP

NEXAVAR TABS F PA; SP

NINLARO CAPS F PA; SP

SPRYCEL TABS F PA; SP

Drug Name DrugTier

Requirements/Limits

SUTENT CAPS F PA; SP

TARCEVA TABS F PA; SP

TASIGNA CAPS 150 MG,200 MG F PA; SP

TYKERB TABS F PA; SP

VOTRIENT TABS F PA; SP

XALKORI CAPS F PA; SP

ZOLINZA CAPS F PA; SP

Antineoplastics Misc.ACTIMMUNE SOLN F PA; SP

ALFERON N SOLN F PA; SP

bexarotene caps 75 mg F PA; SP

HYDREA CAPS(Hydroxyurea) NF

hydroxyurea caps or 500mg F

INTRON A SOLN F PA; SP

INTRON A SOLR F PA; SP

INTRON A W/DILUENTSOLR F PA; SP

MATULANE CAPS F

SYLATRON KIT F PA; SP

TARGRETIN CAPS OR 75MG (Bexarotene) NF PA; SP

tretinoin (chemotherapy)caps F AL(Up to 26 yrs

old )Chemotherapy Rescue/Antidote AgentsLEUCOVORIN CALCIUMTABS OR 10 MG, 15 MG F PA

leucovorin calcium tabs or5 mg, 25 mg F PA

Mitotic InhibitorsETOPOSIDE CAPS OR 50MG F PA; SP


27

Drug Name DrugTier

Requirements/Limits

ANTIPARKINSON AND RELATED THERAPYAGENTS - Drugs to Treat Parkinson's DiseaseAntiparkinson Anticholinergicsbenztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F

trihexyphenidyl hcl elix F

trihexyphenidyl hcl tabs F

Antiparkinson COMT InhibitorsCOMTAN TABS(Entacapone) NF

entacapone tabs 200 mg F

Antiparkinson Dopaminergicsamantadine hcl caps or100 mg F

amantadine hcl syrp or 50mg/5ml F

amantadine hcl tabs or 100mg F

bromocriptine mesylatecaps or 5 mg F

bromocriptine mesylatetabs or 2.5 mg F

carbidopa-levodopa tabs F

carbidopa-levodopa tbcr F

carbidopa-levodopa tbdp F

MIRAPEX ER TB24 0.375MG, 0.75 MG, 3 MG, 1.5MG, 4.5 MG, 3.75 MG(PramipexoleDihydrochloride)

NF

MIRAPEX TABS(PramipexoleDihydrochloride)

NF

PARLODEL CAPS(Bromocriptine Mesylate) NF

PARLODEL TABS(Bromocriptine Mesylate) NF

Drug Name DrugTier

Requirements/Limits

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

F

pramipexoledihydrochloride tb24 0.375mg, 0.75 mg, 3 mg, 1.5 mg,4.5 mg, 3.75 mg

F

REQUIP TABS (RopiniroleHydrochloride) NF

REQUIP XL TB24(Ropinirole Hydrochloride) NF

ropinirole hydrochloridetabs F

ropinirole hydrochloridetb24 F

SINEMET CR TBCR(Carbidopa-Levodopa) NF

SINEMET TABS(Carbidopa-Levodopa) NF

Antiparkinson Monoamine Oxidase InhibitorsELDEPRYL CAPS(Selegiline HCl) NF

selegiline hcl caps or 5 mg F

selegiline hcl tabs or 5 mg F

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate caps or150 mg, 300 mg, 600 mg F AL(At least 6

yrs old)lithium carbonate tabs or300 mg F AL(At least 6

yrs old)lithium carbonate tbcr or300 mg, 450 mg F AL(At least 6

yrs old)

LITHIUM SOLN F AL(At least 6yrs old)

LITHOBID TBCR (LithiumCarbonate) NF AL(At least 6

yrs old)Antipsychotics - Misc.EQUETRO CP12 F

GEODON CAPS OR 20MG, 40 MG (ZiprasidoneHCl)



28

Drug Name DrugTier

Requirements/Limits

LATUDA TABS FQL(1 ea daily);AL(At least 6yrs old)

ziprasidone hcl caps 20mg, 40 mg, 60 mg F


ziprasidone hcl caps 80 mg FQL(2 ea daily);AL(At least 6yrs old)

Benzisoxazoles

INVEGA SUSTENNASUSP 156 MG/ML, 39MG/0.25ML, 117MG/0.75ML

F

1 permonth;QL(1 mlper 30 daysretail); AL(Atleast 18 yrsold); SP

INVEGA SUSTENNASUSP 234 MG/1.5ML F

1 permonth;QL(1.5ml per 30 daysretail); AL(Atleast 18 yrsold); SP

INVEGA SUSTENNASUSP 78 MG/0.5ML F

QL(1 ml per 23days retail);AL(At least 18yrs old); SP

INVEGA TRINZA SUSP F

ST; Try InvegaSustenna first;AL(At least 18yrs old); SP

RISPERDAL CONSTASUSR F

2 permonth;QL(2 eaper 28 daysretail); AL(Atleast 18 yrsold); SP

RISPERDAL M-TAB TBDP0.5 MG (Risperidone) NF


RISPERDAL M-TAB TBDP1 MG (Risperidone) NF


RISPERDAL SOLN 1MG/ML (Risperidone) NF

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

Drug Name DrugTier

Requirements/Limits

RISPERDAL TABS 0.25MG, 0.5 MG (Risperidone) NF


RISPERDAL TABS 1 MG(Risperidone) NF


RISPERDAL TABS 3 MG(Risperidone) NF


RISPERIDONE ODT TBDP FQL(4 ea daily);AL(At least 6yrs old)

risperidone soln 1 mg/ml F

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

risperidone tabs 0.25 mg,0.5 mg F


risperidone tabs 1 mg, 2mg F


risperidone tabs 3 mg, 4mg F


risperidone tbdp 0.25 mg,0.5 mg F


risperidone tbdp 1 mg, 2mg F


risperidone tbdp 3 mg, 4mg F


ButyrophenonesHALDOL DECANOATE100 SOLN (HaloperidolDecanoate)

NFAL(At least 18yrs old); SP

HALDOL DECANOATE 50SOLN (HaloperidolDecanoate)

NFAL(At least 18yrs old); SP

HALDOL SOLN(Haloperidol Lactate) NF AL(At least 6

yrs old); SPhaloperidol decanoate solnim 50 mg/ml, 100 mg/ml F AL(At least 18

yrs old); SP


29

Drug Name DrugTier

Requirements/Limits

haloperidol lactate conc or2 mg/ml F AL(At least 6

yrs old)haloperidol lactate soln ij 5mg/ml F AL(At least 6

yrs old); SPhaloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg


Dibenzapines

CLOZAPINE ODT TBDP FQL(5 ea daily);AL(At least 18yrs old)

clozapine tabs 25 mg, 50mg, 100 mg, 200 mg F


clozapine tbdp 12.5 mg F QL(5 ea daily)

clozapine tbdp 25 mg, 100mg F


CLOZARIL TABS(Clozapine) NF


FAZACLO TBDP 12.5 MG(Clozapine) NF QL(5 ea daily)

FAZACLO TBDP 25 MG,100 MG (Clozapine) NF


loxapine succinate caps F AL(At least 6yrs old)

olanzapine tabs or 15 mg,20 mg, 2.5 mg, 7.5 mg F


olanzapine tabs or 5 mg,10 mg F


olanzapine tbdp or 15 mg,20 mg F


olanzapine tbdp or 5 mg,10 mg F


quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200mg


quetiapine fumarate tabs300 mg, 400 mg F


Drug Name DrugTier

Requirements/Limits

SAPHRIS SUBL FQL(2 ea daily);AL(At least 6yrs old)

SEROQUEL TABS 100MG, 200 MG, 400 MG(Quetiapine Fumarate)

NF

SEROQUEL TABS 25 MG(Quetiapine Fumarate) NF


SEROQUEL TABS 300 MG(Quetiapine Fumarate) NF


ZYPREXA TABS OR 10MG (Olanzapine) NF

ZYPREXA TABS OR 15MG, 20 MG, 2.5 MG, 7.5MG (Olanzapine)


ZYPREXA TABS OR 5 MG(Olanzapine) NF


ZYPREXA ZYDIS TBDP 15MG, 20 MG (Olanzapine) NF


ZYPREXA ZYDIS TBDP 5MG, 10 MG (Olanzapine) NF


Phenothiazineschlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg


fluphenazine decanoatesoln ij F AL(At least 18

yrs old); SPFLUPHENAZINE HCLCONC OR 5 MG/ML F AL(At least 6

yrs old)FLUPHENAZINE HCLELIX OR 2.5 MG/5ML F AL(At least 6

yrs old)fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F AL(At least 6

yrs old)perphenazine tabs or 2 mg,4 mg, 8 mg, 16 mg F AL(At least 6

yrs old)prochlorperazine maleatetabs or 5 mg, 10 mg F AL(At least 6

yrs old)

prochlorperazine supp F AL(At least 6yrs old)

thioridazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old)


30

Drug Name DrugTier

Requirements/Limits

trifluoperazine hcl tabs F AL(At least 6yrs old)

Quinolinone Derivatives

ABILIFY MAINTENA PRSY F

1 permonth;QL(1 eaper 30 daysretail)1 rtl packlmt amt,30 rtlpack lmtday(s),; AL(Atleast 18 yrsold); SP

ABILIFY MAINTENA SRER F

1 permonth;QL(1 eaper 30 daysretail)1 rtl packlmt amt,30 rtlpack lmtday(s),; AL(Atleast 18 yrsold); SP

ABILIFY TABS 2 MG(Aripiprazole) NF

ABILIFY TABS 5 MG, 10MG, 15 MG, 20 MG, 30 MG(Aripiprazole)


aripiprazole tabs 2 mg, 5mg, 10 mg, 15 mg, 20 mg,30 mg


ARISTADA INITIO PRSY F

2 rtl MAXfill,365 rtlday(s) supply,;AL(At least 18yrs old); SP

ARISTADA PRSY F

1 rtl pack lmtamt,30 rtl packlmt day(s),;AL(At least 18yrs old); SP

Thioxanthenes

thiothixene caps F AL(At least 6yrs old)

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectantshydrogen peroxide soln ex3 % F

Drug Name DrugTier

Requirements/Limits

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate soln F

abacavir sulfate tabs F

abacavir sulfate-lamivudinetabs 600mg-300mg F

abacavir sulfate-lamivudine-zidovudine tabs300mg-150mg-300mg

F

APTIVUS CAPS F

APTIVUS SOLN F

atazanavir sulfate caps F

ATRIPLA TABS F

BIKTARVY TABS F QL(1 ea daily)

COMBIVIR TABS(Lamivudine-Zidovudine) NF

COMPLERA TABS F

CRIXIVAN CAPS F

DESCOVY TABS F

didanosine cpdr 200 mg,400 mg F

EDURANT TABS F

efavirenz caps F

efavirenz tabs F

EMTRIVA CAPS F

EMTRIVA SOLN F

EPIVIR SOLN(Lamivudine) NF

EPIVIR TABS (Lamivudine) NF

EPZICOM TABS (AbacavirSulfate-Lamivudine) NF


31

Drug Name DrugTier

Requirements/Limits

EVOTAZ TABS F

fosamprenavir calcium tabs F

FUZEON SOLR F

PA; 1 rtl packlmt amt,30 rtlpack lmtday(s),; SP

GENVOYA TABS F

INTELENCE TABS F

INVIRASE CAPS F

INVIRASE TABS F

ISENTRESS CHEW F

ISENTRESS PACK F

ISENTRESS TABS F

KALETRA SOLN400MG/5ML-100MG/5ML(Lopinavir-Ritonavir)

NF

KALETRA TABS 100MG-25MG, 200MG-50MG F

lamivudine soln F

lamivudine tabs F

lamivudine-zidovudine tabs150mg-300mg F

LEXIVA SUSP 50 MG/ML F

LEXIVA TABS 700 MG(Fosamprenavir Calcium) NF

lopinavir-ritonavir soln F

nevirapine susp 50 mg/5ml F

nevirapine tabs 200 mg F

nevirapine tb24 400 mg F

NORVIR CAPS 100 MG F

NORVIR SOLN 80 MG/ML F

Drug Name DrugTier

Requirements/Limits

NORVIR TABS 100 MG(Ritonavir) NF

ODEFSEY TABS F

PREZCOBIX TABS F

PREZISTA SUSP 100MG/ML F

PREZISTA TABS 75 MG,600 MG, 800 MG F

RESCRIPTOR TABS F

RETROVIR CAPS(Zidovudine) NF

RETROVIR SYRP(Zidovudine) NF

REYATAZ CAPS 150 MG,200 MG, 300 MG(Atazanavir Sulfate)

NF

REYATAZ PACK 50 MG F

ritonavir tabs F

SELZENTRY SOLN F PA

SELZENTRY TABS F PA

stavudine caps F

STRIBILD TABS F

SUSTIVA CAPS(Efavirenz) NF

SUSTIVA TABS (Efavirenz) NF

tenofovir disoproxilfumarate tabs F

TIVICAY TABS 50 MG F

TRIUMEQ TABS F

TRIZIVIR TABS (AbacavirSulfate-Lamivudine-Zidovudine)

NF

TRUVADA TABS F PA

TYBOST TABS F QL(1 ea daily)


32

Drug Name DrugTier

Requirements/Limits

VIDEX EC CPDR 125 MG F

VIDEX EC CPDR 200 MG,400 MG (Didanosine) NF

VIDEXPEDIATRIC SOLR 4GM F

VIRACEPT TABS F

VIRAMUNE SUSP(Nevirapine) NF

VIRAMUNE TABS(Nevirapine) NF

VIRAMUNE XR TB24 400MG (Nevirapine) NF

VIREAD POWD 40 MG/GM F

VIREAD TABS 300 MG(Tenofovir DisoproxilFumarate)

NF

VITEKTA TABS F

ZERIT CAPS 15 MG, 20MG, 30 MG, 40 MG(Stavudine)

NF

ZERIT SOLR 1 MG/ML F

ZIAGEN SOLN (AbacavirSulfate) NF

ZIAGEN TABS (AbacavirSulfate) NF

zidovudine caps F

zidovudine syrp F

zidovudine tabs F

CMV Agentscidofovir soln F PA

CYTOVENE SOLR(Ganciclovir Sodium) NF PA

FOSCAVIR SOLN F PA

ganciclovir sodium solr 500mg F PA

VALCYTE SOLR(Valganciclovir HCl) NF PA

Drug Name DrugTier

Requirements/Limits

VALCYTE TABS(Valganciclovir HCl) NF PA

valganciclovir hcl solr F PA

valganciclovir hcl tabs F PA

Hepatitis Agentsadefovir dipivoxil tabs 10mg F PA

BARACLUDE SOLN 0.05MG/ML F PA

BARACLUDE TABS 0.5MG, 1 MG (Entecavir) NF PA

COPEGUS TABS(Ribavirin (Hepatitis C)) NF PA

entecavir tabs F PA

EPIVIR HBV SOLN 5MG/ML F

EPIVIR HBV TABS 100MG (Lamivudine (HBV)) NF

HEPSERA TABS (AdefovirDipivoxil) NF PA

lamivudine (hbv) tabs F

MAVYRET TABS F PA; SP

MODERIBA 1200 DOSEPACK TABS F PA

MODERIBA 800 DOSEPACK TABS F PA

PEG-INTRON REDIPENKIT 50 MCG/0.5ML F PA; SP

PEGASYS PROCLICKSOLN F PA; SP

PEGASYS SOLN F PA; SP

REBETOL SOLN F PA

RIBASPHERE RIBAPAKTABS 400 MG, 600 MG F PA

RIBASPHERE TABS F PA

ribavirin (hepatitis c) caps F PA

ribavirin (hepatitis c) tabs F PA


33

Drug Name DrugTier

Requirements/Limits

TYZEKA TABS F PA

VEMLIDY TABS F PA

Herpes Agentsacyclovir caps or 200 mg F

acyclovir susp or 200mg/5ml F

acyclovir tabs or 400 mg,800 mg F

famciclovir tabs or 125 mg,250 mg, 500 mg F PA

FAMVIR TABS(Famciclovir) NF PA

valacyclovir hcl tabs or 1gm, 500 mg, 1000 mg F

VALTREX TABS(Valacyclovir HCl) NF

ZOVIRAX CAPS OR 200MG (Acyclovir) NF

ZOVIRAX SUSP OR 200MG/5ML (Acyclovir) NF

ZOVIRAX TABS OR 400MG, 800 MG (Acyclovir) NF

Influenza AgentsFLUMADINE TABS(RimantadineHydrochloride)

NF

oseltamivir phosphate capsor 30 mg, 45 mg, 75 mg F QL(20 ea per

270 days retail)oseltamivir phosphate susror 6 mg/ml F

RELENZA DISKHALERAEPB F

rimantadine hydrochloridetabs 100 mg F

TAMIFLU CAPS 30 MG, 45MG, 75 MG (OseltamivirPhosphate)

NFQL(20 ea per270 days retail)

TAMIFLU SUSR 6 MG/ML(Oseltamivir Phosphate) NF

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

Drug Name DrugTier

Requirements/Limits

carvedilol tabs F MP

COREG TABS (Carvedilol) NF MP

labetalol hcl tabs or 100mg, 200 mg, 300 mg F MP

Beta Blockers Cardio-Selectiveatenolol tabs or 25 mg, 50mg, 100 mg F MP

bisoprolol fumarate tabs F MP

LOPRESSOR TABS(Metoprolol Tartrate) NF MP

metoprolol succinate tb24 F MP

metoprolol tartrate tabs or25 mg, 50 mg, 100 mg F MP

METOPROLOLTARTRATE TABS OR 37.5MG

F

TENORMIN TABS(Atenolol) NF MP

TOPROL XL TB24(Metoprolol Succinate) NF MP

ZEBETA TABS (BisoprololFumarate) NF MP

Beta Blockers Non-SelectiveBETAPACE AF TABS(Sotalol HCl (AFIB/AFL)) NF MP

BETAPACE TABS (SotalolHCl) NF MP

CORGARD TABS(Nadolol) NF MP

INDERAL LA CP24(Propranolol HCl) NF MP

nadolol tabs or 20 mg, 40mg, 80 mg F MP

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160mg

FMP

PROPRANOLOL HCLSOLN OR 20 MG/5ML F

PROPRANOLOL HCLSOLN OR 40 MG/5ML F MP

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 80 mg F MP


34

Drug Name DrugTier

Requirements/Limits

propranolol hcl tabs or 60mg F

sotalol hcl (afib/afl) tabs F MP

sotalol hcl tabs F MP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC TB24(Nifedipine) NF QL(2 ea daily);

MPamlodipine besylate tabs or5 mg, 10 mg, 2.5 mg F QL(1 ea daily);

MPCALAN SR TBCR(Verapamil HCl) NF MP

CALAN TABS (VerapamilHCl) NF MP

CARDIZEM CD CP24(Diltiazem HCl CoatedBeads)

NFQL(1 ea daily);MP

CARDIZEM TABS(Diltiazem HCl) NF MP

diltiazem hcl coated beadscp24 120 mg, 180 mg, 240mg, 300 mg, 360 mg

FQL(1 ea daily);MP

diltiazem hcl cp12 or 120mg F

diltiazem hcl cp12 or 60mg, 90 mg F QL(2 ea daily);

MPdiltiazem hcl cp24 or 120mg F QL(2 ea daily);

MPdiltiazem hcl cp24 or 180mg, 240 mg F QL(1 ea daily);

MPdiltiazem hcl extendedrelease beads cp24 F QL(1 ea daily);

MPdiltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg F MP

felodipine tb24 F MP

nifedipine caps or 10 mg,20 mg F MP

nifedipine tb24 or 30 mg,60 mg, 90 mg F MP

nifedipine tb24 or 30 mg,60 mg, 90 mg F QL(2 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

NORVASC TABS(Amlodipine Besylate) NF QL(1 ea daily);

MPPROCARDIA CAPS(Nifedipine) NF MP

PROCARDIA XL TB24(Nifedipine) NF MP

TIAZAC CP24 (DiltiazemHCl Extended ReleaseBeads)

NFQL(1 ea daily);MP

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 300 mg

FMP

verapamil hcl cp24 or 240mg F

VERAPAMIL HCL SRCP24 F MP

verapamil hcl tabs or 40mg, 80 mg, 120 mg F MP

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F MP

VERELAN CP24 120 MG,180 MG (Verapamil HCl) NF MP

VERELAN CP24 240 MG(Verapamil HCl) NF

VERELAN CP24 360 MG F MP

VERELAN PM CP24(Verapamil HCl) NF MP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN OR 0.05MG/ML F MP

digoxin tabs or 0.125 mg,125 mcg F MP

digoxin tabs or 0.25 mg,250 mcg F

LANOXIN TABS OR 125MCG (Digoxin) NF MP

LANOXIN TABS OR 250MCG (Digoxin) NF

LANOXIN TABS OR 62.5MCG F

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions


35

Drug Name DrugTier

Requirements/Limits

Prostaglandin Vasodilatorsepoprostenol sodium solr F PA; SP

FLOLAN SOLR(Epoprostenol Sodium) NF PA; SP

TYVASO REFILL SOLN F PA; SP

TYVASO SOLN F PA; SP

TYVASO STARTER SOLN F PA; SP

VELETRI SOLR F PA; SP

VENTAVIS SOLN F PA; SP

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS TABS F PA; SP

TRACLEER TABS F PA; SP

Pulmonary Hypertension - PhosphodiesteraseADCIRCA TABS (Tadalafil(Pulmonary Hypertension)) NF PA; SP

REVATIO SUSR OR 10MG/ML F PA

REVATIO TABS OR 20MG (Sildenafil Citrate(Pulmonary Hypertension))

NFPA

sildenafil citrate (pulmonaryhypertension) tabs or 20mg

FPA

tadalafil (pulmonaryhypertension) tabs 20 mg F PA; SP

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

cephalexin caps 250 mg,500 mg, 750 mg F

cephalexin susr 125mg/5ml, 250 mg/5ml F

Drug Name DrugTier

Requirements/Limits

CEPHALEXIN TABS 250MG, 500 MG F

KEFLEX CAPS(Cephalexin) NF

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg F

CEFACLOR ER TB12 F

CEFACLOR SUSR 125MG/5ML, 250 MG/5ML,375 MG/5ML

F

cefprozil susr F

cefprozil tabs F

CEFTIN SUSR 125MG/5ML, 250 MG/5ML F

CEFTIN TABS 500 MG(Cefuroxime Axetil) NF

cefuroxime axetil tabs F

Cephalosporins - 3rd Generationcefdinir caps F

cefdinir susr F

cefixime susr 100 mg/5ml F50ml permonth;QL(1.67ml daily)

cefpodoxime proxetil susr F

cefpodoxime proxetil tabs F

SUPRAX CAPS 400 MG F

SUPRAX CHEW 100 MG,200 MG F

SUPRAX SUSR 100MG/5ML (Cefixime) NF

50ml permonth;QL(1.67ml daily)

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - Oral


36

Drug Name DrugTier

Requirements/Limits

BREVICON-28 TABS(Norethindrone & EthEstradiol)

NF

CYCLESSA TABS(Desogestrel-EthinylEstradiol (Triphasic))

NF

DESOGEN TABS(Desogestrel & EthinylEstradiol)

NF

desogestrel & ethinylestradiol tabs F

desogestrel-ethinylestradiol (biphasic) tabs F

desogestrel-ethinylestradiol (triphasic) tabs F

drospirenone-ethinylestradiol tabs F

ESTROSTEP FE TABS(Norethindrone Acetate-Ethinyl Estradiol-Fe)

NF

ethynodiol diacet & ethestrad tabs F

levonorgestrel & ethestradiol tabs F

levonorgestrel-eth estradiol(triphasic) tabs F

levonorgestrel-ethinylestradiol (91-day) tabs F

levonorgestrel-ethinylestradiol (continuous) tabs F

LOESTRIN 1.5/30-21TABS (Norethindrone Acet& Eth Estra)

NF

LOESTRIN 1/20-21 TABS(Norethindrone Acet & EthEstra)

NF

LOESTRIN FE 1/20 TABS(Norethin Acet & Estrad-Fe)

NFQL(1 ea daily)

LOSEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NF

MIRCETTE TABS(Desogestrel-EthinylEstradiol (Biphasic))

NF

Drug Name DrugTier

Requirements/Limits

MODICON TABS(Norethindrone & EthEstradiol)

NF

NECON 1/50-28 TABS F

NECON 10/11-28 TABS F

norethin acet & estrad-fetabs 75mg-20mcg-1mg F QL(1 ea daily)

norethindrone & ethestradiol tabs F

norethindrone acet & ethestra tabs F

norethindrone acetate-ethinyl estradiol-fe tabs75mg-1mg

F

norethindrone-eth estradiol(triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs 0.25mg-35mcg

F

norgestrel & ethinylestradiol tabs F

NORINYL 1+35 TABS(Norethindrone & EthEstradiol)

NF

OGESTREL TABS F

ORTHO TRI-CYCLEN LOTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

ORTHO TRI-CYCLENTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

ORTHO-CYCLEN TABS(Norgestimate-EthinylEstradiol)

NF

ORTHO-NOVUM 1/35TABS (Norethindrone & EthEstradiol)

NF

ORTHO-NOVUM 7/7/7TABS (Norethindrone-EthEstradiol (Triphasic))

NF


37

Drug Name DrugTier

Requirements/Limits

OVCON-35 TABS(Norethindrone & EthEstradiol)

NF

SEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NF

TRI-NORINYL 28 TABS(Norethindrone-EthEstradiol (Triphasic))

NF

YASMIN 28 TABS(Drospirenone-EthinylEstradiol)

NF

YAZ TABS (Drospirenone-Ethinyl Estradiol) NF

Combination Contraceptives - VaginalNUVARING RING F

Emergency Contraceptiveslevonorgestrel (emergencyoc) tabs 1.5 mg F

PLAN B ONE-STEP TABS(Levonorgestrel(Emergency OC))

NF

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE SUSP(MedroxyprogesteroneAcetate (Contraceptive))

NF

DEPO-PROVERACONTRACEPTIVE SUSY(MedroxyprogesteroneAcetate (Contraceptive))

NF

DEPO-SUBQ PROVERA104 SUSY F

medroxyprogesteroneacetate (contraceptive)susp

F

medroxyprogesteroneacetate (contraceptive)susy

F

Progestin Contraceptives - OralNOR-QD TABS(Norethindrone(Contraceptive))

NF

Drug Name DrugTier

Requirements/Limits

norethindrone(contraceptive) tabs 0.35mg

F

ORTHO MICRONORTABS (Norethindrone(Contraceptive))

NF

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbudesonide cpep or 3 mg F

CORTEF TABS(Hydrocortisone) NF

dexamethasone elix or 0.5mg/5ml F

DEXAMETHASONEINTENSOL CONC F

DEXAMETHASONE SOLNOR 0.5 MG/5ML F

dexamethasone tabs or0.75 mg, 0.5 mg, 4 mg, 6mg, 1.5 mg

F

DEXAMETHASONE TABSOR 1 MG, 2 MG F

dexamethasone tbpk or 1.5mg F

DEXPAK 13 DAY TBPK(Dexamethasone) NF

ENTOCORT EC CPEP(Budesonide) NF

hydrocortisone tabs or 5mg, 10 mg, 20 mg F

KENALOG-10 SUSP F PA

MEDROL DOSEPAK TBPK(Methylprednisolone) NF

MEDROL TABS 2 MG F

MEDROL TABS 4 MG, 8MG, 16 MG(Methylprednisolone)

NF

methylprednisolone sodsucc solr F PA

methylprednisolone tabs or4 mg, 8 mg, 16 mg F


38

Drug Name DrugTier

Requirements/Limits

methylprednisolone tbpk or4 mg F

MILLIPRED TABS 5 MG F

ORAPRED ODT TBDP(Prednisolone SodiumPhosphate)

NF

prednisolone sodiumphosphate soln or 5mg/5ml

F

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

F

prednisolone soln or F

PREDNISOLONE SOLNOR F

prednisolone syrp or F

PREDNISONE INTENSOLCONC F

PREDNISONE SOLN OR 5MG/5ML F

prednisone tabs or 1 mg, 5mg, 10 mg, 20 mg, 2.5 mg F

PREDNISONE TABS OR50 MG F

PREDNISONE TBPK OR 5MG, 10 MG F

SOLU-CORTEF SOLR F PA

SOLU-MEDROL SOLR 2GM, 500 MG F PA

SOLU-MEDROL SOLR 40MG, 125 MG, 1000 MG(Methylprednisolone SodSucc)

NF

PA

TRIAMCINOLONEACETONIDE PF SUSP F PA

TRIAMCINOLONEACETONIDE SUSP IJ 50MG/ML

FPA

Mineralocorticoidsfludrocortisone acetatetabs or 0.1 mg F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms

Drug Name DrugTier

Requirements/Limits

Antitussivesbenzonatate caps F

DELSYM COUGHCHILDRENS SUER(DextromethorphanPolistirex)

NF

DELSYM SUER(DextromethorphanPolistirex)

NF

dextromethorphan hbr capsor 15 mg F

dextromethorphan hbr syrpor 15 mg/5ml F

dextromethorphanpolistirex suer 30 mg/5ml F

hydrocodone w/homatropine syrp 5mg/5ml-1.5mg/5ml

F

QL(240 ml per12 days retail);AL(At least 18yrs old)

hydrocodone w/homatropine tabs 5mg-1.5mg


ROBITUSSIN LINGERINGCOLDLONG-ACTINGCOUGHGELS CAPS(Dextromethorphan HBr)

NF

TESSALON PERLESCAPS (Benzonatate) NF

Cough/Cold/Allergy CombinationsACTIDOM DMX LIQD F QL(16 ml daily)

ALLEGRA-D 12 HOURALLERGY &CONGESTION TB12(Fexofenadine-Pseudoephedrine)

NF

QL(2 ea daily)

ALLEGRA-D 24 HOURALLERGY &CONGESTION TB24(Fexofenadine-Pseudoephedrine)

NF

QL(1 ea daily)

BALAMINE DM SYRP F

BIOBRON SF SYRP F QL(16 ml daily)

BIODESP DM SYRP F QL(16 ml daily)


39

Drug Name DrugTier

Requirements/Limits

brompheniramine &pseudoeph elix 1mg/5ml-15mg/5ml

FQL(8 ml daily)

brompheniramine &pseudoeph liqd 1mg/5ml-15mg/5ml

FQL(8 ml daily)

BRONKIDS LIQD F

BRONTUSS DX LIQD F QL(16 ml daily)

BROTAPP DM LIQD F

cetirizine-pseudoephedrinetb12 F QL(2 ea daily)

CHERACOL PLUS LIQD(Dextromethorphan-Guaifenesin)

NFQL(16 ml daily)

CHERACOL-D COUGHLIQD (Dextromethorphan-Guaifenesin)

NFQL(16 ml daily)

chlorpheniramine &pseudoeph tabs F

CLARITIN-D 12 HOURTB12 (Loratadine &Pseudoephedrine)

NFQL(2 ea daily)

CLARITIN-D 24 HOURTB24 (Loratadine &Pseudoephedrine)

NFQL(1 ea daily)

DECONEX DMX TABS15MG-380MG-10MG(Phenylephrine w/ DM-GG)

NF

DESGEN DM SYRP15MG/5ML-100MG/5ML-5MG/5ML

FQL(16 ml daily)

dextromethorphan-guaifenesin liqd 10mg/5ml-100mg/5ml, 10mg/5ml-200mg/5ml, 20mg/10ml-200mg/10ml, 20mg/10ml-400mg/10ml, 15mg/7.5ml-150mg/7.5ml, 10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml

F

QL(16 ml daily)

dextromethorphan-guaifenesin soln 10mg/5ml-100mg/5ml, 20mg/10ml-200mg/10ml

F

QL(16 ml daily)

Drug Name DrugTier

Requirements/Limits

dextromethorphan-guaifenesin syrp 10mg/5ml-100mg/5ml, 10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml

F

dextromethorphan-guaifenesin tabs 20mg-400mg, 20mg-20mg-400mg-400mg

F

QL(2 ea daily)

dextromethorphan-guaifenesin tb12 30mg-600mg

FQL(2 ea daily)

DOMETUSS-DMX LIQD F QL(16 ml daily)

ED BRON GP LIQD F

EXACTUSS LIQD(Phenylephrine w/ DM-GG) NF QL(16 ml

daily); RX/OTC

EXACTUSS TR TABS F RX/OTC

FATHER JOHNSMEDICINE PLUS SOLN F

fexofenadine-pseudoephedrine tb1260mg-120mg

FQL(2 ea daily)

fexofenadine-pseudoephedrine tb24180mg-240mg

FQL(1 ea daily)

G-TUSICOF LIQD F QL(16 ml daily)

G-ZYNCOF SYRP F

GILTUSS COUGH & COLDLIQD 29MG/5ML-390MG/5ML-10MG/5ML

FQL(16 ml daily)

GILTUSS COUGH & COLDTABS 28MG-388MG-10MG F RX/OTC

GILTUSS LIQD(Phenylephrine w/ DM-GG) NF QL(16 ml

daily); RX/OTC

GILTUSS TR TABS F RX/OTC

guaifenesin-codeine liqd100mg/5ml-10mg/5ml F



40

Drug Name DrugTier

Requirements/Limits

guaifenesin-codeine soln100mg/5ml-10mg/5ml F


guaifenesin-codeine syrp100mg/5ml-10mg/5ml F


LOHIST-D LIQD F QL(16 ml daily)

LOHIST-DM SYRP F QL(16 ml daily)

loratadine &pseudoephedrine tb125mg-120mg

FQL(2 ea daily)

loratadine &pseudoephedrine tb2410mg-240mg, 10mg-10mg-240mg-240mg

F

QL(1 ea daily)

MUCINEX CHILDRENSMULTI-SYMPTOM COLDLIQD (Phenylephrine w/DM-GG)

NF

QL(16 ml daily)

MUCINEX CONGESTION& COUGH CHILDRENSLIQD (Phenylephrine w/DM-GG)

NF

QL(16 ml daily)

MUCINEX D TB12(Pseudoephedrine-Guaifenesin)

NF

MUCINEX DM TB12(Dextromethorphan-Guaifenesin)

NFQL(2 ea daily)

MUCINEX FAST-MAXSEVERE CONGESTION &COUGH CLEAR & COOLLIQD (Phenylephrine w/DM-GG)

NF

QL(16 ml daily)

MUCINEX FAST-MAXSEVERE CONGESTION &COUGH LIQD20MG/20ML-400MG/20ML-10MG/20ML(Phenylephrine w/ DM-GG)

NF

QL(16 ml daily)

MUCINEX STUFFY NOSE& COLD CHILDRENSLIQD (Phenylephrine-Guaifenesin)

NF

Drug Name DrugTier

Requirements/Limits

NEOTUSS PLUS LIQD F

NEOTUSS-D LIQD F QL(16 ml daily)

NIVANEX DMX TABS F

phenylephrine w/ dm-ggliqd 5mg/ml-100mg/ml-2.5mg/ml, 10mg/5ml-100mg/5ml-5mg/5ml,10mg/5ml-200mg/5ml-5mg/5ml, 5mg/5ml-75mg/5ml-2.5mg/5ml,15mg/5ml-350mg/5ml-10mg/5ml, 5mg/5ml-100mg/5ml-2.5mg/5ml,20mg/20ml-400mg/20ml-10mg/20ml, 10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml-5mg/5ml-5mg/5ml

F

QL(16 ml daily)

phenylephrine w/ dm-ggliqd 5mg/ml-50mg/ml-2.5mg/ml, 7.5mg/ml-88mg/ml-2.5mg/ml,15mg/5ml-300mg/5ml-10mg/5ml, 28mg/5ml-388mg/5ml-10mg/5ml,7.5mg/2.5ml-150mg/2.5ml-5mg/2.5ml

F

QL(16 mldaily); RX/OTC

phenylephrine w/ dm-ggsyrp 10mg/5ml-100mg/5ml-5mg/5ml

FQL(16 ml daily)

phenylephrine w/ dm-ggtabs 15mg-380mg-10mg,20mg-400mg-10mg

F

phenylephrine-brompheniramine-dm elix1mg/5ml-5mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-5mg/5ml-5mg/5ml-2.5mg/5ml-2.5mg/5ml

F

QL(16 ml daily)

phenylephrine-chlorphen-dm liqd F

phenylephrine-guaifenesinliqd 100mg/5ml-2.5mg/5ml F

phenylephrine-guaifenesintabs 400mg-10mg, 400mg-400mg-10mg-10mg

F


41

Drug Name DrugTier

Requirements/Limits

promethazine &phenylephrine soln F QL(16 ml daily)

promethazine &phenylephrine syrp F QL(16 ml daily)

promethazine w/codeinesoln F


promethazine w/codeinesyrp F


promethazine-dm syrp F QL(16 ml daily)

PROMETHAZINE/PHENYLEPHRINE SYRP F QL(16 ml daily)

pseudoephed-bromphen-dm elix F

pseudoephed-bromphen-dm syrp F

pseudoephedrine w/codeine-gg soln F


pseudoephedrine w/ dm-ggliqd 10mg/5ml-30mg/5ml-100mg/5ml

F

pseudoephedrine-guaifenesin tb12 60mg-600mg

F

QC MEDIFIN PE TABS(Phenylephrine-Guaifenesin)

NF

ROBITUSSIN CHILDRENSCOUGH & COLD CF LIQD F QL(16 ml daily)

ROBITUSSIN PEAK COLDCOUGH+ CHESTCONGESTION DM MAXSTRENGTH LIQD(Dextromethorphan-Guaifenesin)

NF

QL(16 ml daily)

ROBITUSSIN PEAK COLDDM SYRP(Dextromethorphan-Guaifenesin)

NF

Drug Name DrugTier

Requirements/Limits

ROBITUSSIN PEAK COLDMULTI-SYMPTOM COLDLIQD (Phenylephrine w/DM-GG)

NF

QL(16 ml daily)

ROBITUSSIN TO GOCOUGH &COLD CF LIQD(Phenylephrine w/ DM-GG)

NFQL(16 ml daily)

RYCONTUSS LIQD(Phenylephrine-Chlorphen-DM)

NF

SUPRESS-PE PEDIATRICLIQD F

TRICODE GF LIQD F


TUSICOF LIQD F QL(16 ml daily)

TUSNEL C SYRP F


TUSSI-PRES PEDIATRICLIQD (Phenylephrine w/DM-GG)

NFQL(16 ml daily)

ZYNCOF SYRP F

ZYRTEC-DALLERGY/CONGESTIONTB12 (Cetirizine-Pseudoephedrine)

NF

QL(2 ea daily)

Expectorantsguaifenesin liqd or 100mg/5ml, 200 mg/10ml, 400mg/20ml

FQL(16 ml daily)

guaifenesin soln or 100mg/5ml, 200 mg/10ml, 300mg/15ml

FQL(16 ml daily)

guaifenesin syrp or 100mg/5ml, 200 mg/10ml F QL(16 ml daily)

guaifenesin tabs or 200mg, 400 mg F

guaifenesin tb12 or 600mg, 1200 mg F

HERBAL EXPEC LIQD F QL(16 ml daily)


42

Drug Name DrugTier

Requirements/Limits

MUCINEX MAXIMUMSTRENGTH TB12(Guaifenesin)

NF

MUCINEX TB12(Guaifenesin) NF

YODEFAN-NF CHESTCONGESTION LIQD F QL(16 ml daily)

Misc. Respiratory InhalantsHYPER-SAL NEBU(Sodium Chloride(Inhalant))

NF

HYPERSAL NEBU 7 %(Sodium Chloride(Inhalant))

NF

sodium chloride (inhalant)nebu 3 %, 7 % F

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA CAPS F PA

ACNE MEDICATION 10LOTN F

ACNE MEDICATION 5LOTN F

BENZAC AC WASH LIQD(Benzoyl Peroxide) NF RX/OTC

BENZEFOAM FOAM(Benzoyl Peroxide) NF RX/OTC

BENZEFOAM ULTRAFOAM (Benzoyl Peroxide) NF

BENZIQ GEL F

BENZIQ LS GEL F

BENZIQ WASH LIQD F

benzoyl peroxide bar ex 10% F

BENZOYL PEROXIDECLEANSER LOTN F

benzoyl peroxide crea ex10 %, 2.5 % F

benzoyl peroxide foam ex5.3 % F RX/OTC

Drug Name DrugTier

Requirements/Limits

benzoyl peroxide foam ex9.8 % F

benzoyl peroxide gel ex 10% F RX/OTC

BENZOYL PEROXIDEGEL EX 2.5 % F

benzoyl peroxide gel ex 5% F

benzoyl peroxide liqd ex 4%, 7 % F

benzoyl peroxide liqd ex 5%, 10 %, 2.5 % F RX/OTC

benzoyl peroxide lotn ex 6% F

BP GEL GEL F

CLEAN & CLEARADVANTAGE 3-IN-1EXFOLIATING CLEANSERLOTN

F

CLEOCIN-T LOTN(Clindamycin Phosphate(Topical))

NF

CLEOCIN-T SOLN(Clindamycin Phosphate(Topical))

NF

clindamycin phosphate(topical) lotn 1 % F

clindamycin phosphate(topical) soln 1 % F

DESQUAM-X WASH LIQD(Benzoyl Peroxide) NF RX/OTC

ERYGEL GEL(Erythromycin (Acne Aid)) NF

erythromycin (acne aid) gel2 % F

erythromycin (acne aid)pads 2 % F

erythromycin (acne aid)soln 2 % F

isotretinoin caps or 10 mg,20 mg, 30 mg, 40 mg F PA

KLARON LOTN(Sulfacetamide Sodium(Acne))

NF


43

Drug Name DrugTier

Requirements/Limits

NEUTROGENA ON-THE-SPOT ACNE TREATMENTCREA (Benzoyl Peroxide)

NF

OC8 GEL F

PANOXYL LIQD (BenzoylPeroxide) NF RX/OTC

PANOXYL-4 CREAMYWASH LIQD (BenzoylPeroxide)

NF

RETIN-A CREA 0.025 %,0.05 %, 0.1 % (Tretinoin) NF AL(Up to 26 yrs

old )RETIN-A MICRO GEL(Tretinoin Microsphere) NF AL(Up to 26 yrs

old )RETIN-A MICRO PUMPGEL 0.04 %, 0.1 %(Tretinoin Microsphere)

NFAL(Up to 26 yrsold )

RETIN-A MICRO PUMPGEL 0.08 % F AL(Up to 26 yrs

old )

RIAX FOAM F

sulfacetamide sodium(acne) lotn 10 % F

TRETIN-X CREA 0.075 % F AL(Up to 26 yrsold )

tretinoin crea ex 0.025 %,0.05 %, 0.1 % F AL(Up to 26 yrs

old )

tretinoin microsphere gel F AL(Up to 26 yrsold )

ZACLIR CLEANSINGLOTN F

Anti-inflammatory Agents - Topicaldiclofenac sodium (topical)gel 1 % F QL(200 gm per

30 days retail)VOLTAREN GEL(Diclofenac Sodium(Topical))

NFQL(200 gm per30 days retail)

Antibiotics - TopicalBACIGUENT OINT(Bacitracin (Topical)) NF

bacitracin (topical) oint 500unit/gm F

bacitracin zinc oint ex 500unit/gm F

bacitracin-polymyxin b oint F

Drug Name DrugTier

Requirements/Limits

BACTROBAN CREA(Mupirocin Calcium(Topical))

NF

CENTANY OINT 2 % F

gentamicin sulfate (topical)crea 0.1 % F

gentamicin sulfate (topical)oint 0.1 % F

mupirocin calcium (topical)crea 2 % F

mupirocin oint ex 2 % F

neomycin-bacitracin-polymyxin oint F

neomycin-bacitracin-polymyxin-pramoxine oint F

NEOSPORIN ORIGINALOINT (Neomycin-Bacitracin-Polymyxin)

NF

POLYSPORIN OINT(Bacitracin-Polymyxin B) NF

Antifungals - TopicalALOE VESTAANTIFUNGAL OINT(Miconazole Nitrate(Topical))

NF

ALOE VESTA CLEARANTIFUNGAL OINT(Miconazole Nitrate(Topical))

NF

butenafine hcl crea 1 % F RX/OTC

ciclopirox olamine susp ex0.77 % F

clotrimazole (topical) crea 1% F RX/OTC

clotrimazole (topical) soln 1% F RX/OTC

clotrimazole w/betamethasone crea 1%-0.05%

F

ketoconazole (topical) crea2 % F

ketoconazole (topical)sham 2 % F


44

Drug Name DrugTier

Requirements/Limits

LAMISIL AT CREA(Terbinafine HCl (Topical)) NF

LAMISIL AT JOCK ITCHCREA (Terbinafine HCl(Topical))

NF

LOPROX SUSP 0.77 %(Ciclopirox Olamine) NF

LOTRIMIN AF AERO 2 % F

LOTRIMIN AF CREA 1 %(Clotrimazole (Topical)) NF RX/OTC

LOTRIMIN AF FOR HERCREA (Clotrimazole(Topical))

NFRX/OTC

LOTRIMIN AF JOCK ITCHCREA (Clotrimazole(Topical))

NFRX/OTC

LOTRIMIN ULTRA CREA(Butenafine HCl) NF RX/OTC

LOTRIMIN ULTRA CREA 1% F RX/OTC

LOTRISONE CREA(Clotrimazole w/Betamethasone)

NF

MENTAX CREA 1 % F RX/OTC

MICATIN CREA(Miconazole Nitrate(Topical))

NF

miconazole nitrate (topical)aerp F

miconazole nitrate (topical)crea F

miconazole nitrate (topical)oint F

miconazole nitrate (topical)powd F

MICONAZOLE NITRATEPOWD F

NIZORAL SHAM(Ketoconazole (Topical)) NF

nystatin (topical) crea F

nystatin (topical) oint F

nystatin (topical) powd F

Drug Name DrugTier

Requirements/Limits

terbinafine hcl (topical) crea1 % F

TINACTIN AERO(Tolnaftate) NF

TINACTIN AERP(Tolnaftate) NF

TINACTIN CREA(Tolnaftate) NF

TINACTIN DEODORANTAERP (Tolnaftate) NF

TINACTIN JOCK ITCHAERP (Tolnaftate) NF

TINACTIN JOCK ITCHCREA (Tolnaftate) NF

tolnaftate aero ex 1 % F

tolnaftate aerp ex 1 % F

tolnaftate crea ex 1 % F

tolnaftate liqd ex 1 % F

tolnaftate soln ex 1 % F

XOLEGEL GEL 2 % F

Antihistamines-Topicaldiphenhydramine hcl(topical) crea F

diphenhydramine hcl(topical) gel F

diphenhydramine hcl(topical) soln F

Antiseborrheic ProductsOVACE PLUS WASH LIQD(Sulfacetamide Sodium) NF

OVACE WASH LIQD(Sulfacetamide Sodium) NF

selenium sulfide lotn ex 2.5% F

sulfacetamide sodium liqdex 10 % F

Antivirals - Topical

ABREVA CREA FLimit 2 permonth;QL(0.067 gm daily)


45

Drug Name DrugTier

Requirements/Limits

acyclovir topical oint 5 % F

ZOVIRAX OINT EX 5 %(Acyclovir Topical) NF

Burn ProductsSILVADENE CREA (SilverSulfadiazine) NF

silver sulfadiazine crea ex1 % F

Corticosteroids - Topicalbetamethasonedipropionate (topical) lotn0.05 %

F

betamethasonedipropionate augmentedcrea 0.05 %

F

betamethasone valeratecrea ex 0.1 % F

betamethasone valeratelotn ex 0.1 % F

betamethasone valerateoint ex 0.1 % F

CAPEX SHAM 0.01 % F

clobetasol propionate creaex 0.05 % F QL(60 gm per

fill retail)clobetasol propionateemollient base crea 0.05 % F

clobetasol propionate gelex 0.05 % F QL(118 gm per

fill retail)clobetasol propionate ointex 0.05 % F QL(60 gm per

fill retail)clobetasol propionate solnex 0.05 % F

CVS HDYROCORTISONEACETATE CREA F

DERMA-SMOOTHE/FSBODY OIL (FluocinoloneAcetonide)

NF

DERMA-SMOOTHE/FSSCALP OIL (FluocinoloneAcetonide)

NF

DIPROLENE AF CREA(BetamethasoneDipropionate Augmented)

NF

Drug Name DrugTier

Requirements/Limits

ELOCON CREA(Mometasone Furoate) NF

ELOCON OINT(Mometasone Furoate) NF

fluocinolone acetonide oilex 0.01 % F

fluocinonide crea ex 0.05 % F

fluocinonide oint ex 0.05 % F QL(60 gm perfill retail)

fluocinonide soln ex 0.05 % F

fluticasone propionate creaex 0.05 % F

fluticasone propionate ointex 0.005 % F

halobetasol propionatecrea 0.05 % F QL(2 gm daily)

halobetasol propionate oint0.05 % F QL(2 gm daily)

hydrocortisone (topical)crea 0.5 %, 2.5 % F

hydrocortisone (topical)crea 1%, 1 % F RX/OTC

hydrocortisone (topical) gel1 % F

hydrocortisone (topical) lotn1 %, 2.5 % F

hydrocortisone (topical) oint0.5 %, 2.5 % F

hydrocortisone (topical) oint1 % F RX/OTC

hydrocortisone acetate(topical) crea F

mometasone furoate creaex 0.1 % F

mometasone furoate ointex 0.1 % F

mometasone furoate solnex 0.1 % F

MONISTAT SOOTHINGCARE ITCH RELIEF CREA(Hydrocortisone (Topical))

NFRX/OTC

TEMOVATE CREA(Clobetasol Propionate) NF QL(60 gm per

fill retail)


46

Drug Name DrugTier

Requirements/Limits

TEMOVATE E CREA(Clobetasol PropionateEmollient Base)

NF

TEMOVATE OINT(Clobetasol Propionate) NF QL(60 gm per

fill retail)triamcinolone acetonide(topical) crea 0.025 %, 0.1%, 0.5 %

F

triamcinolone acetonide(topical) lotn 0.025 %, 0.1%

F

triamcinolone acetonide(topical) oint 0.025 %, 0.1%, 0.5 %

F

ULTRAVATE CREA(Halobetasol Propionate) NF QL(2 gm daily)

ULTRAVATE OINT(Halobetasol Propionate) NF QL(2 gm daily)

Emollient/Keratolytic AgentsATRAC-TAIN CREA 10 %(Urea) NF

CARMOL 20 CREA (Urea) NF

REA-LO CREA 30 % F

urea crea ex 10 %, 20 %,50 % F

urea crea ex 40 % F RX/OTC

EmollientsLAC-HYDRIN CREA(Lactic Acid (AmmoniumLactate))

NFRX/OTC

LAC-HYDRIN LOTN(Lactic Acid (AmmoniumLactate))

NFRX/OTC

LAC-HYDRIN TWELVELOTN (Lactic Acid(Ammonium Lactate))

NFRX/OTC

lactic acid (ammoniumlactate) crea 12 % F RX/OTC

lactic acid (ammoniumlactate) lotn 10 % F

lactic acid (ammoniumlactate) lotn 12 % F RX/OTC

Drug Name DrugTier

Requirements/Limits

NOBLE MYSTIQUE EMU-LAC CREA F

Immunomodulating Agents - TopicalALDARA CREA(Imiquimod) NF

imiquimod crea ex 5 % F

Keratolytic/Antimitotic AgentsAMBI EVEN & CLEAREXFOLIATING WASHLIQD

F

AMBI EVEN & CLEARFOAMINGCLEANSERLIQD

F

BETASAL SHAM F

CLEAN & CLEAR ACNETRIPLECLEAR BUBBLEFOAM CLEANSER FOAM

F

CLEAN & CLEARADVANTAGE OILABSORBING CLEANSERCREA

F

CLEAN & CLEARBLACKHEAD ERASERSCRUB CREA (SalicylicAcid)

NF

CLEAN & CLEAR DEEPCLEANING ASTRINGENTSENSITIVE SKIN LIQD

F

CLN ACNE CLEANSERLIQD F

COMPOUND W LIQD(Salicylic Acid) NF

COMPOUND W MAXIMUMSTRENGTH GEL (SalicylicAcid)

NF

CONDYLOX SOLN(Podofilox) NF

CORN & CALLUSREMOVER SOLN F

CVS PSORIASISMEDICATED SHAMPOOPLUS CONDITIONERSHAM

F


47

Drug Name DrugTier

Requirements/Limits

CVS THERAPEUTICDANDRUFFMAXIMUMSTRENGTH SHAM

F

CVS THERAPEUTICMAXIMUM STRENGTHSHAM

F

DENOREX EXTRASTRENGTH 2-IN-1 SHAM F

DERMAREST PSORIASISGEL 3 % F

DERMAREST PSORIASISMEDICATED SHAMPOOPLUS CONDITIONERSHAM

F

FREEZONE LIQD F

GOLD BOND PSORIASISRELIEF MULTI-SYMPTOMCREA

F

KERALYT GEL 3 % F

KERALYT GEL 6 %(Salicylic Acid) NF

MG217 PSORIASISMULTI-SYMPTOM CREA 3%

F

MOSCO CALLUS/CORNREMOVER SOLN F

NEUTROGENA T/SALSHAM F

P & S SHAM F

podofilox soln ex 0.5 % F

SALAC FOAM F

SALEX SHAM (SalicylicAcid) NF

salicylic acid crea ex 2 %, 6% F

salicylic acid foam ex 6 % F PA

salicylic acid gel ex 2 %, 6%, 17 % F

salicylic acid liqd ex 2 %, 3%, 17 %, 26 % F

Drug Name DrugTier

Requirements/Limits

salicylic acid lotn ex 0.5 %,6 % F

salicylic acid sham ex 6 % F

salicylic acid soln ex 17 %,26 % F

SALVAX FOAM (SalicylicAcid) NF PA

SELSUN BLUE DEEPCLEANSING SHAM F

SELSUN BLUENATURALS DRYSCALPSHAM

F

SELSUN BLUENATURALS SHAM F

THERAPEUTIC T+PLUSMAXIMUM STRENGTHSHAM

F

Local Anesthetics - Topicallidocaine crea ex 4 % F

lidocaine hcl crea ex 4 % F

lidocaine hcl gel ex 2 % F RX/OTC

lidocaine hcl soln ex 4 % F

lidocaine oint ex 5 % F PA; QL(50 gmper fill retail)

lidocaine ptch ex 5 % F PA; QL(3 eadaily)

lidocaine-prilocaine crea2.5%-2.5% F

LIDODERM PTCH(Lidocaine) NF PA; QL(3 ea

daily)

LMX 4 CREA (Lidocaine) NF

PREDATOR CREA(Lidocaine HCl) NF

XOLIDO CREA F

Misc. TopicalCALAMINE LOTN EX F

DRYSOL SOLN 20 % F


48

Drug Name DrugTier

Requirements/Limits

MEIJER CALAMINE LOTN F

QC CALAMINE LOTN F

SM CALAMINE LOTN F

zinc oxide (topical) crea 13% F

zinc oxide (topical) oint 20%, 40 % F

Rosacea AgentsMETROCREAM CREA(Metronidazole (Topical)) NF

METROLOTION LOTN(Metronidazole (Topical)) NF

metronidazole (topical)crea 0.75 % F

metronidazole (topical) gel0.75 % F

metronidazole (topical) lotn0.75 % F

Scabicides & PediculicidesA-200 GEL EX 0.33%-4% F

crotamiton lotn ex 10 % F PA

ELIMITE CREA(Permethrin) NF

EURAX CREA 10 % F PA

EURAX LOTN (Crotamiton) NF PA

KLOUT SHAM F

LICEMD GEL 0.33%-4% F

lindane sham F

LINDANE SHAM F

LYCELLE GEL F

NATROBA SUSP F PA

nit remover gel F

Drug Name DrugTier

Requirements/Limits

NIX CREME RINSE LIQD(Permethrin) NF

permethrin crea ex 5 % F

permethrin liqd ex 1 % F

pyrethrins-piperonylbutoxide-permethrin-nitremover kit 0.5%-0.33%-4%

F

RA LICE SOLUTION KITKIT 0.5%-0.33%-4% F

RID COMPLETE LICEELIMINATION KIT(Pyrethrins-PiperonylButoxide-Permethrin-NitRemover)

NF

SCHOOLTIME SHAMPOOSHAM F

SKLICE LOTN F PA

SPINOSAD SUSP F PA

DIAGNOSTIC PRODUCTS

Diagnostic TestsALBUSTIX STRP F

CHEMSTRIP-MICRALSTRP F

TRUE METRIX BLOODGLUCOSETEST STRIPSSTRP

F

INSULINUSERSLIMITED TO150 PER 30DAYS, NON-INSULINUSERSLIMITED TO100 PER 90DAYS;RX/OTC


49

Drug Name DrugTier

Requirements/Limits

TRUE METRIX SELFMONITORING BLOODGLUCOSE STRIPS STRP

F


TRUETEST BLOODGLUCOSE TEST STRIPSSTRP

F


TRUETEST BLOODGLUCOSE TEST STRP F


TRUETEST STRIPS STRP F


TRUETRACK BLOODGLUCOSE TEST STRP F


Drug Name DrugTier

Requirements/Limits

TRUETRACK TEST STRP F


DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes

CREON CPEP F500 permonth;QL(16.67 ea daily)

SUCRAID SOLN F PA

ZENPEP CPEP10000UNIT-3000UNIT-14000UNIT, 32000UNIT-10000UNIT-42000UNIT,63000UNIT-20000UNIT-84000UNIT, 126000UNIT-40000UNIT-168000UNIT

F

500 permonth;;QL(16.67 ea daily)

ZENPEP CPEP17000UNIT-5000UNIT-24000UNIT, 47000UNIT-15000UNIT-63000UNIT,79000UNIT-25000UNIT-105000UNIT

F

500 permonth;QL(16.67 ea daily)

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide cp12 or 500mg F

acetazolamide tabs or 125mg, 250 mg F

DIAMOX CP12(Acetazolamide) NF

methazolamide tabs or 25mg, 50 mg F

NEPTAZANE TABS(Methazolamide) NF

Diuretic Combinations


50

Drug Name DrugTier

Requirements/Limits

ALDACTAZIDE TABS25MG-25MG(Spironolactone &Hydrochlorothiazide)

NF

MP

ALDACTAZIDE TABS50MG-50MG F

amiloride &hydrochlorothiazide tabs F

DYAZIDE CAPS(Triamterene &Hydrochlorothiazide)

NFMP

MAXZIDE TABS(Triamterene &Hydrochlorothiazide)

NFMP

MAXZIDE-25 TABS(Triamterene &Hydrochlorothiazide)

NFMP

spironolactone &hydrochlorothiazide tabs F MP

triamterene &hydrochlorothiazide caps F MP

triamterene &hydrochlorothiazide tabs F MP

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F MP

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg F MP

BUMEX TABS(Bumetanide) NF MP

DEMADEX TABS(Torsemide) NF MP

furosemide soln or 10mg/ml F MP

FUROSEMIDE SOLN OR 8MG/ML F MP

furosemide tabs or 20 mg,40 mg, 80 mg F MP

LASIX TABS (Furosemide) NF MP

torsemide tabs F MP

Potassium Sparing DiureticsALDACTONE TABS(Spironolactone) NF MP

Drug Name DrugTier

Requirements/Limits

amiloride hcl tabs or 5 mg F

DYRENIUM CAPS F

spironolactone tabs or 25mg, 50 mg, 100 mg F MP

Thiazides and Thiazide-Like DiureticsCHLOROTHIAZIDE TABS250 MG F MP

chlorothiazide tabs 500 mg F MP

chlorthalidone tabs F MP

DIURIL SUSP F

hydrochlorothiazide caps or12.5 mg F MP

hydrochlorothiazide tabs or25 mg, 50 mg F MP

indapamide tabs F MP

METHYCLOTHIAZIDETABS F

metolazone tabs F MP

MICROZIDE CAPS(Hydrochlorothiazide) NF MP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density RegulatorsALENDRONATE SODIUMTABS 40 MG F

alendronate sodium tabs 5mg, 10 mg, 35 mg, 70 mg F

FOSAMAX TABS(Alendronate Sodium) NF

Growth HormonesGENOTROPIN MINIQUICKSOLR F PA; SP

GENOTROPIN SOLR 12MG F PA; SP

NORDITROPIN FLEXPROSOLN 30 MG/3ML, 15MG/1.5ML

FPA; SP

Hormone Receptor Modulators


51

Drug Name DrugTier

Requirements/Limits

EVISTA TABS (RaloxifeneHCl) NF

raloxifene hcl tabs 60 mg F

Insulin-Like Growth Factors (Somatomedins)INCRELEX SOLN F PA; SP

Metabolic Modifierscalcitriol caps or 0.25 mcg,0.5 mcg F

ELAPRASE SOLN F PA; SP

ROCALTROL CAPS 0.25MCG, 0.5 MCG (Calcitriol) NF

SENSIPAR TABS F PA

Posterior Pituitary HormonesDDAVP SOLN NA 0.01 % F

DDAVP SOLN NA 0.01 %(Desmopressin AcetateSpray)

NF

DDAVP TABS OR 0.1 MG,0.2 MG (DesmopressinAcetate)

NFPA

desmopressin acetatespray refrigerated soln F

desmopressin acetatespray soln 0.01 % F

desmopressin acetate tabsor 0.1 mg, 0.2 mg F PA

STIMATE SOLN F SP

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsCLIMARA PRO PTWK F

PREMPRO TABS F QL(1 ea daily)

EstrogensALORA PTTW F

CLIMARA PTWK(Estradiol) NF

Drug Name DrugTier

Requirements/Limits

ESTRACE TABS(Estradiol) NF

estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr

F

estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

F

estradiol tabs or 0.5 mg, 1mg, 2 mg F

ESTROPIPATE TABS F

MENEST TABS F

MENOSTAR PTWK F

MINIVELLE PTTW F

PREMARIN TABS OR0.625 MG, 0.45 MG, 0.3MG, 0.9 MG, 1.25 MG

F

VIVELLE-DOT PTTW(Estradiol) NF

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO TABS 250 MG, 500MG (Ciprofloxacin HCl) NF

CIPROFLOXACIN HCLTABS OR 100 MG F

ciprofloxacin hcl tabs or250 mg, 500 mg, 750 mg F

LEVAQUIN TABS(Levofloxacin) NF

levofloxacin soln or 25mg/ml F

levofloxacin tabs or 250mg, 500 mg, 750 mg F

ofloxacin tabs 400 mg F

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulents


52

Drug Name DrugTier

Requirements/Limits

GAS-X CHEW(Simethicone) NF

GAS-X EXTRASTRENGTH CHEW 125MG (Simethicone)

NF

MYLICON INFANTS GASRELIEF SUSP(Simethicone)

NF

MYLICON SUSP(Simethicone) NF

PHAZYME CAPS(Simethicone) NF

PHAZYME ULTRASTRENGTH CAPS(Simethicone)

NF

simethicone caps or125mg, 125 mg, 180 mg F

simethicone chew or 80mg, 125 mg F

simethicone susp or 20mg/0.3ml, 40 mg/0.6ml F

Gallstone Solubilizing AgentsACTIGALL CAPS(Ursodiol) NF

URSO 250 TABS(Ursodiol) NF

URSO FORTE TABS(Ursodiol) NF

ursodiol caps or 300 mg F

ursodiol tabs or 250 mg,500 mg F

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAPS F PA

Gastrointestinal Stimulantsmetoclopramide hcl soln or5 mg/5ml, 10 mg/10ml F

metoclopramide hcl tabs or5 mg, 10 mg F

METOCLOPRAMIDE ODTTBDP F

REGLAN TABS(Metoclopramide HCl) NF

Inflammatory Bowel Agents

Drug Name DrugTier

Requirements/Limits

ASACOL HD TBEC F QL(9 ea daily)

ASACOL HD TBEC(Mesalamine) NF QL(9 ea daily)

AZULFIDINE EN-TABSTBEC (Sulfasalazine) NF QL(8 ea daily)

AZULFIDINE TABS(Sulfasalazine) NF QL(8 ea daily)

balsalazide disodium caps F QL(9 ea daily)

COLAZAL CAPS(Balsalazide Disodium) NF QL(9 ea daily)

DIPENTUM CAPS F QL(4 ea daily)

GIAZO TABS F QL(9 ea daily)

mesalamine enem re 4 gm F QL(60 ml daily)

mesalamine tbec or 800mg F QL(9 ea daily)

PENTASA CPCR F QL(9 ea daily)

SFROWASA ENEM F QL(60 ml daily)

sulfasalazine tabs or 500mg F QL(8 ea daily)

sulfasalazine tbec or 500mg F QL(8 ea daily)

Intestinal Acidifierslactulose (encephalopathy)soln F

Irritable Bowel Syndrome (IBS) AgentsLINZESS CAPS F PA

Phosphate Binder Agentscalcium acetate (phosphatebinder) caps 667 mg F

calcium acetate (phosphatebinder) tabs 667 mg F RX/OTC

ELIPHOS TABS (CalciumAcetate (PhosphateBinder))

NFRX/OTC

FOSRENOL CHEW 500MG, 750 MG, 1000 MG(Lanthanum Carbonate)

NFPA


53

Drug Name DrugTier

Requirements/Limits

FOSRENOL PACK 750MG, 1000 MG F PA

lanthanum carbonate chew F PA

RENAGEL TABS F

RENVELA PACK 0.8 GM,2.4 GM (SevelamerCarbonate)

F

RENVELA TABS 800 MG(Sevelamer Carbonate) NF

sevelamer carbonate tabs800 mg F

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) tbcr F

potassium citrate-citric acidsoln 1100mg/5ml-334mg/5ml, 1100mg/5ml-1100mg/5ml-334mg/5ml-334mg/5ml

F

RX/OTC

UROCIT-K 10 TBCR(Potassium Citrate(Alkalinizer))

NF


NF


NF

Interstitial Cystitis AgentsELMIRON CAPS F PA

Prostatic Hypertrophy AgentsAVODART CAPS(Dutasteride) NF

dutasteride caps or 0.5 mg F

finasteride tabs or 5 mg F

FLOMAX CAPS(Tamsulosin HCl) NF

Drug Name DrugTier

Requirements/Limits

PROSCAR TABS(Finasteride) NF

tamsulosin hcl caps 0.4 mg F

Urinary Analgesicsphenazopyridine hcl tabs or100 mg, 200 mg F

PYRIDIUM TABS(Phenazopyridine HCl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agentsallopurinol tabs or 100 mg,300 mg F

COLCHICINE TABS OR0.6 MG F PA

COLCRYS TABS 0.6 MG F PA

ULORIC TABS F PA

ZYLOPRIM TABS(Allopurinol) NF

Uricosuricsprobenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersHematorheologic Agentspentoxifylline tbcr or F

Platelet Aggregation InhibitorsBRILINTA TABS 90 MG F PA

cilostazol tabs F

clopidogrel bisulfate tabs or75 mg, 300 mg F

dipyridamole tabs or 25mg, 50 mg, 75 mg F

PLAVIX TABS (ClopidogrelBisulfate) NF

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher Disease


54

Drug Name DrugTier

Requirements/Limits

CEREZYME SOLR F PA; SP

CobalaminsB-12 TABS OR 2500 MCG F

cyanocobalamin tabs F

Folic Acid/Folatesfolic acid tabs 1 mg F RX/OTC

folic acid tabs 400 mcg,800 mcg F

Hematopoietic Growth FactorsEPOGEN SOLN F PA; SP

NEULASTA ONPRO KITPSKT F PA; SP

NEULASTA SOSY F PA; SP

NEUPOGEN SOLN F PA; SP

NEUPOGEN SOSY F PA; SP

PROCRIT SOLN 2000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 20000 UNIT/ML,40000 UNIT/ML

F

PA; SP

PROMACTA TABS F PA; SP

IronFEMIRON TABS F

FERRETTS TABS F

FERRIMIN 150 TABS F

FERROUS FUMARATETABS OR 29 MG F

ferrous fumarate tabs or324 mg F

ferrous gluconate tabs or27 mg, 240 mg F

FERROUS GLUCONATETABS OR 324 MG F

ferrous sulfate tabs F

Drug Name DrugTier

Requirements/Limits

ferrous sulfate tbec F

HEMOCYTE TABS(Ferrous Fumarate) NF

SM IRON TABS F

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - SystemicAMICAR SOLN F

AMICAR TABS F

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSAntihistamine Hypnoticsdiphenhydramine hcl(sleep) caps 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) caps 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) liqd 50 mg/30ml F QL(30 ml daily)

diphenhydramine hcl(sleep) tabs 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tbdp 25 mg F QL(2 ea daily)

doxylamine succinate(sleep) tabs 25 mg F

NYTOL MAXIMUMSTRENGTH TABS(Diphenhydramine HCl(Sleep))

NF

QL(1 ea daily)

UNISOM SLEEPGELSCAPS (DiphenhydramineHCl (Sleep))

NFQL(1 ea daily)

UNISOM SLEEPMELTSTBDP (DiphenhydramineHCl (Sleep))

NFQL(2 ea daily)

UNISOM TABS(Doxylamine Succinate(Sleep))

NF

WAL-SLEEP Z LIQUIDSHOTS LIQD F QL(50 ml daily)


55

Drug Name DrugTier

Requirements/Limits

ZZZQUIL CAPS 25 MG(Diphenhydramine HCl(Sleep))

NFQL(2 ea daily)

ZZZQUIL LIQD 50MG/30ML(Diphenhydramine HCl(Sleep))

NF

QL(30 ml daily)

Barbiturate Hypnoticsphenobarbital elix or 20mg/5ml F

phenobarbital soln or 20mg/5ml F

PHENOBARBITAL TABSOR 15 MG, 30 MG, 60 MG,100 MG

F

phenobarbital tabs or 16.2mg, 32.4 mg, 64.8 mg, 97.2mg

F

Non-Barbiturate HypnoticsAMBIEN TABS (ZolpidemTartrate) NF QL(1 ea daily)

RESTORIL CAPS 15 MG,30 MG (Temazepam) NF QL(1 ea daily)

temazepam caps 15 mg,30 mg F QL(1 ea daily)

zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)

Selective Melatonin Receptor Agonists

ROZEREM TABS FST; QL(1 eadaily); AL(Atleast 6 yrs old)

LAXATIVES - Bowel Treatment Drugs

Bulk LaxativesEVAC POWD (Psyllium) NF

KONSYL DAILY FIBERPOWD 100 % (Psyllium) NF

KONSYL ORIGINALFORMULADAILY FIBERPOWD (Psyllium)

NF

METAMUCIL CAPS 0.52GM (Psyllium) NF

METAMUCIL ORIGINALTEXTURE POWD(Psyllium)

NF

Drug Name DrugTier

Requirements/Limits

METAMUCIL POWD 48.57% (Psyllium) NF

psyllium caps 0.52 gm, 520mg F

psyllium powd 30 %, 33 %,68 %, 100 %, 28.3 %, 30.9%, 58.6 %, 48.57 %,

F

Laxative CombinationsCOLYTE-FLAVOR PACKSSOLR (PEG 3350-KCl-SodBicarb-Sod Chloride-SodSulfate)

NF

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

F

sennosides-docusatesodium tabs F

SENOKOT S TABS(Sennosides-DocusateSodium)

NF

Laxatives - Miscellaneouslactulose soln F

MIRALAX PACK(Polyethylene Glycol 3350) NF RX/OTC

MIRALAX POWD(Polyethylene Glycol 3350) NF RX/OTC

polyethylene glycol 3350pack or F RX/OTC

polyethylene glycol 3350powd or F RX/OTC

Saline LaxativesFLEET ENEMA ENEM(Sodium Phosphates) NF

FLEET ENEMA SIX PACKENEM (SodiumPhosphates)

NF

FLEET PEDIATRIC ENEM(Sodium Phosphates) NF


56

Drug Name DrugTier

Requirements/Limits

magnesium citrate soln or1.745gm/30ml, 1.745gm/30ml,

F

magnesium hydroxide suspor 7.75 %, 400 mg/5ml,1200 mg/15ml, 2400mg/30ml,

F

MILK OF MAGNESIACONCENTRATE SUSP F

sodium phosphates enem F

sodium phosphates soln F

Stimulant Laxativesbisacodyl supp re 10 mg F

bisacodyl tbec or 5 mg F

DULCOLAX SUPP(Bisacodyl) NF

DULCOLAX TBEC(Bisacodyl) NF

EX-LAX MAXIMUMSTRENGTH TABS(Sennosides)

NF

EX-LAX TABS(Sennosides) NF

sennosides tabs 15 mg, 25mg, 8.6 mg, 17.2 mg F

SENOKOT TABS(Sennosides) NF

SENOKOT XTRA TABS(Sennosides) NF

Surfactant LaxativesCOLACE CAPS (DocusateSodium) NF

COLACE CLEAR CAPS(Docusate Sodium) NF

docusate calcium caps F

docusate sodium caps or50 mg, 100 mg, 250 mg F

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amides

Drug Name DrugTier

Requirements/Limits

lidocaine hcl (local anesth.)soln 0.5 %, 1 %, 2 % F PA

LIDOCAINE HCL SOLN IJ4 % F PA

XYLOCAINE SOLN IJ 0.5%, 1 %, 2 % (Lidocaine HCl(Local Anesth.))

NFPA

XYLOCAINE-MPF SOLN0.5 %, 1 %, 2 % (LidocaineHCl (Local Anesth.))

NFPA

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinAZITHROMYCIN PACKOR 1 GM F

azithromycin susr or 100mg/5ml, 200 mg/5ml F

azithromycin tabs or 250mg, 500 mg, 600 mg F

ZITHROMAX PACK OR 1GM F

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Azithromycin)

NF

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Azithromycin)

NF

ZITHROMAX TRI-PAKTABS (Azithromycin) NF

ZITHROMAX Z-PAK TABS(Azithromycin) NF

ZMAX SUSR F

ClarithromycinBIAXIN SUSR(Clarithromycin) NF

BIAXIN TABS(Clarithromycin) NF

CLARITHROMYCIN SUSROR 125 MG/5ML, 250MG/5ML

F

clarithromycin susr or 125mg/5ml, 250 mg/5ml F

clarithromycin tabs or 250mg, 500 mg F


57

Drug Name DrugTier

Requirements/Limits

clarithromycin tb24 or 500mg F

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-TapeGAUZE PADS 2X2, 3X3,4X4 F

ContraceptivesCONDOMS F

DIAPHRAGMS F

OMNIFLEX DIAPHRAGMDPRH F

Diabetic SuppliesINSULIN PUMP INFUSIONSUPPLIES F

LANCETS AND LANCETDEVICES F

LIBERTY GLUCOSECONTROL LEVEL 1 SOLN F

1/ 90days;QL(0.012ea daily)

LIBERTY GLUCOSECONTROL LEVEL 2 SOLN F


TRUE METRIX CONTROLSOLUTION LEVEL 1SOLN

F1/ 90days;QL(0.012ea daily)





TRUECONTROLGLUCOSE CONTROLLEVEL 0 LIQD


TRUECONTROLGLUCOSE CONTROLLEVEL 1 LIQD


TRUETEST GLUCOSECONTROLLEVEL 1 LIQD F




Drug Name DrugTier

Requirements/Limits



URIN-TEK KIT F

Misc. DevicesALCOHOL SWABS F

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES F

Respiratory Therapy SuppliesSPACER/AEROCHAMBER F Limit 2 per year

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine Combinations

CAFERGOT TABS(Ergotamine w/ Caffeine) NF

10 permonth;QL(0.34ea daily)

ergotamine w/ caffeine tabs F10 permonth;QL(0.34ea daily)

MIGERGOT SUPP F 12 per month;

Serotonin Agonists

AMERGE TABS(Naratriptan HCl) NF

9 permonth;;QL(0.3ea daily)

IMITREX SOLN NA 5MG/ACT, 20 MG/ACT(Sumatriptan)

NF6 permonth;QL(0.2ea daily)

IMITREX SOLN SC 6MG/0.5ML (SumatriptanSuccinate)

NF

4 doses (2ml)permonth;QL(0.067 ml daily)

IMITREX STATDOSEREFILL SOCT(Sumatriptan Succinate)

NF


IMITREX STATDOSESYSTEM SOAJ 6MG/0.5ML (SumatriptanSuccinate)

NF



58

Drug Name DrugTier

Requirements/Limits

IMITREX TABS OR 25 MG,50 MG, 100 MG(Sumatriptan Succinate)

NF9 permonth;QL(0.3ea daily)

MAXALT TABS (RizatriptanBenzoate) NF


MAXALT-MLT TBDP(Rizatriptan Benzoate) NF


naratriptan hcl tabs F9 permonth;;QL(0.3ea daily)

rizatriptan benzoate tabs F18 permonth;QL(0.6ea daily)

rizatriptan benzoate tbdp F18 permonth;QL(0.6ea daily)

sumatriptan soln na 5mg/act, 20 mg/act F


sumatriptan succinate soajsc 6 mg/0.5ml F


sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml F


sumatriptan succinate solnsc 6 mg/0.5ml F


SUMATRIPTANSUCCINATE SOSY SC 6MG/0.5ML

F


sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F


zolmitriptan tabs or 5 mg,2.5 mg F


zolmitriptan tbdp or 2.5 mg F9 permonth;;QL(0.3ea daily)

Drug Name DrugTier

Requirements/Limits

zolmitriptan tbdp or 5 mg F

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

ZOMIG TABS OR 5 MG,2.5 MG (Zolmitriptan) NF


ZOMIG ZMT TBDP 2.5 MG(Zolmitriptan) NF


ZOMIG ZMT TBDP 5 MG(Zolmitriptan) NF

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

MINERALS & ELECTROLYTES

CalciumCAL-CITRATE CAPS F

CAL-LAC CAPS F

CAL-MINT CHEW F

CALCI-CHEW CHEW F

CALCIUM ACETATE TABSOR F

CALCIUM ASPARTATETABS F

CALCIUM CAPS 250 MG F

CALCIUM CARBONATECHEW OR 260 MG F

calcium carbonate tabs or600mg, 500 mg, 600 mg,1250 mg, 1500 mg

F

calcium carbonate-vitamind caps F

calcium carbonate-vitamind chew F

calcium carbonate-vitamind tabs F

CALCIUM CHEW 500 MG F


59

Drug Name DrugTier

Requirements/Limits

CALCIUM CITRATE TABSOR 200 MG, 250 MG, 1040MG

F

calcium citrate tabs or 200mg, 950 mg F

CALCIUM GLUCONATETABS OR 50 MG, 500 MG F

CALCIUM LACTATE TABS100 MG, 750 MG F

CALCIUM PLUS VITAMIND CAPS F

calcium tabs 500 mg, 600mg F

CALCIUM TABS 600MG-200UNIT F

calcium w/ vitamin d tabs F

CHELATED CALCIUMTABS F

ELITE CALCIUM TABS F

oyster shell tabs F

RA CALCIUM HI-CAL/VITAMIND TABS500MG-125UNIT

F

FluorideLOZI-FLUR LOZG F

LURIDE SOLN (SodiumFluoride) NF

sodium fluoride chew or0.25 mg, 0.5 mg, 1 mg, 1.1mg, 2.2 mg

F

sodium fluoride soln or 0.5mg/ml F

SODIUM FLUORIDE TABSOR 0.5 MG, 1 MG F

MagnesiumMAG-200 TABS(Magnesium Oxide (MgSupplement))

NF

MAGNESIUM CAPS 400MG F

magnesium oxide (mgsupplement) caps F

Drug Name DrugTier

Requirements/Limits

magnesium oxide (mgsupplement) tabs F

MAGNESIUM OXIDECAPS 400 MG F

MAGOX 400 TABS(Magnesium Oxide (MgSupplement))

NF

Mineral CombinationsBONE ESSENTIALS CAPS F

CAL-MAG-K CHELA MAXCAPS F

CALCIUM & VITAMIN D3BONEHEALTH LIQD F

COLAMINE TABS F

CVS CALCIUMCHEWABLES 600PLUSCHEW

F

MULTI-MINERALS TABS F

multiple minerals tabs F

NF FORMULAS CALCIUMMAGNESIUM LIQD F

NUTRA-SUPPORT BONECAPS F

PotassiumCHELATED POTASSIUMTABS F

K-TAB TBCR 10 MEQ(Potassium Chloride) NF

K-TAB TBCR 8 MEQ, 20MEQ F

KLOR-CON M15 TBCR F

KLOR-CON/25 PACK F

MICRO-K CPCR(Potassium Chloride) NF

potassium chloride cpcr or8 meq, 10 meq F

POTASSIUM CHLORIDEER TBCR F

POTASSIUM CHLORIDEGRAN XX F RX/OTC


60

Drug Name DrugTier

Requirements/Limits

potassium chloridemicroencapsulated crystalser tbcr

F

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F

potassium chloride tbcr or8 meq, 10 meq F

POTASSIUM TABS 75 MG(Potassium) NF

potassium tabs 75 mg, 99mg F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating AgentsCUPRIMINE CAPS 250MG F

ImmunomodulatorsREVLIMID CAPS F PA; SP

THALOMID CAPS F PA; SP

Immunosuppressive AgentsASTAGRAF XL CP24 F SP

azathioprine tabs or 50 mg F

CELLCEPT CAPS(Mycophenolate Mofetil) NF SP

CELLCEPT SUSR(Mycophenolate Mofetil) NF SP

CELLCEPT TABS(Mycophenolate Mofetil) NF SP

cyclosporine caps or 100mg F SP

cyclosporine modified (formicroemulsion) caps 25mg, 100 mg

FSP

cyclosporine modified (formicroemulsion) soln 100mg/ml

FSP

IMURAN TABS(Azathioprine) NF

mycophenolate mofetilcaps F SP

Drug Name DrugTier

Requirements/Limits

mycophenolate mofetil susr F SP

mycophenolate mofetil tabs F SP

mycophenolate sodiumtbec F SP

MYFORTIC TBEC(Mycophenolate Sodium) NF SP

NEORAL CAPS(Cyclosporine Modified (ForMicroemulsion))

NFSP

NEORAL SOLN(Cyclosporine Modified (ForMicroemulsion))

NFSP

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG(Tacrolimus)

NFSP

RAPAMUNE SOLN 1MG/ML F SP

RAPAMUNE TABS 1 MG,2 MG (Sirolimus) NF SP

SANDIMMUNE CAPS OR100 MG (Cyclosporine) NF SP

SANDIMMUNE SOLN OR100 MG/ML F SP

sirolimus tabs or 1 mg, 2mg F SP

tacrolimus caps or 0.5 mg,1 mg, 5 mg F SP

ZORTRESS TABS F PA; SP

Potassium Removing AgentsKAYEXALATE POWD(Sodium PolystyreneSulfonate)

NF

sodium polystyrenesulfonate powd or F

sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Orallidocaine hcl (mouth-throat)soln 2 % F

Anti-infectives - Throat


61

Drug Name DrugTier

Requirements/Limits

clotrimazole lozg mt 10 mg F

clotrimazole troc mt 10 mg F

nystatin (mouth-throat)susp F

Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) soln 0.12 % F

PERIDEX SOLN(Chlorhexidine Gluconate(Mouth-Throat))

NF

Steroids - Mouth/Throattriamcinolone acetonide(mouth) pste F

Throat Products - Misc.AQUORAL SOLN F RX/OTC

BIOTENE DRY MOUTHMOISTURIZING SPRAYSOLN

FRX/OTC

CAPHOSOL SOLN F RX/OTC

CVS DRY MOUTH SPRAYSOLN F RX/OTC

EQL DRY MOUTH ORALRINSE SOLN F RX/OTC

MOI-STIR SOLN F RX/OTC

MOUTHKOTE SOLN F RX/OTC

NUMOISYN LIQD F RX/OTC

ORAL RELIEF SPRAYFOR DRYMOUTH &DISCOMFORT SOLN

FRX/OTC

RA DRY MOUTH SOLN F RX/OTC

MULTIVITAMINS

MultivitaminsMULTIVITAMINS /WMINERALS F

Prenatal VitaminsCLASSIC PRENATALTABS F

Drug Name DrugTier

Requirements/Limits

CO-NATAL FA TABS F

COMPLETENATE CHEW F

CVS PRENATAL TABS F

EQL PRENATALFORMULA TABS F

GNP DAILY PRENATALMISC F

GNP PRENATAL TABS F

GOODSENSE PRENATALVITAMINS TABS F

HM ONE DAILYPRENATAL COMBO MISC F

HM PRENATAL TABS F

INATAL GT TABS F

KP PRENATALMULTIVITAMINS TABS F

KPN PRENATAL TABS F

M-VIT TABS F RX/OTC

MYNATAL ADVANCETABS F

MYNATAL CAPS F

MYNATAL PLUS TABS F

MYNATAL ULTRACAPLETTABS F

MYNATAL-Z TABS F

MYNATE 90 PLUS TBCR F

NAT-RUL PRENATALVITAMINS TABS F

NATALVIT TABS F

NEONATAL PLUS TABS F RX/OTC

NIVA-PLUS TABS F RX/OTC

NUTRICION PORVIDATABS F


62

Drug Name DrugTier

Requirements/Limits

O-CAL FA TABS F RX/OTC

O-CAL PRENATAL TABS F

ONE-A-DAY WOMENSPRENATAL MISC F

PERRY PRENATAL CAPS F

PNV FERROUSFUMARATE/DOCUSATE/FOLIC ACID TABS

F

PNV FOLIC ACID + IRONMULTIVITAMIN TABS F RX/OTC

PNV PRENATAL PLUSMULTIVITAMIN TABS F RX/OTC

PNV TABS 29-1 TABS F

PNV-VP-U CAPS F

PRE-NATAL FORMULATABS F

PRENATABS FA TABS F

PRENATABS RX TABS F

PRENATAL 19 CHEW F

PRENATAL 19 TABS F

PRENATAL AND IRONTABS F

PRENATAL FORTE TABS F

PRENATALMULTIVITAMIN TABS F

PRENATAL PLUS IRONTABS F

PRENATAL PLUS TABS F RX/OTC

PRENATAL TABS 22MG-2MG-25MG-1.84MG-200MG-27MG-4000UNIT-20MG-3MG-12MCG-400UNIT-1MG-10MG-120MG

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG,30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

F

PRENATAL TABS4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG

F

PRENATAL VITAMIN &MINERAL TABS F

PRENATALVITAMIN/IRON TABS F

PRENATAL VITAMINSPLUS LOW IRON TABS F RX/OTC

PRENATAL VITAMINSTABS F

PRENATAL-U CAPS F

PREPLUS TABS F RX/OTC

PRETAB TABS F

PX PRENATALMULTIVITAMINS TABS F

QC PRENATAL TABS F

RA ONE DAILY MISC F


63

Drug Name DrugTier

Requirements/Limits

RA PRENATALFORMULA/FOLICACIDTABS

F

RA PRENATAL TABS F

SE-NATAL 19 CHEW F

SE-NATAL 19 TABS F

SM ONE DAILYPRENATAL MISC F

SM PRENATAL VITAMINSTABS F

THERANATAL CORENUTRITION TABS F RX/OTC

THRIVITE 19 TABS F

THRIVITE RX TABS F

TRIADVANCE TABS F

TRICARE TABS F RX/OTC

TRINATAL GT TABS F

TRINATAL RX 1 TABS F

VIL-RX TABS F

VINATE M TABS F

VINATE ONE TABS F

VIRT-ADVANCE TABS F

VIRT-VITE GT TABS F

VITAFOL-OB TABS F

VOL-PLUS TABS F RX/OTC

VOL-TAB RX TABS F

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxantsbaclofen tabs or 10 mg, 20mg F

Drug Name DrugTier

Requirements/Limits

cyclobenzaprine hcl tabs or5 mg, 10 mg F

methocarbamol tabs or 500mg, 750 mg F

ROBAXIN TABS OR 500MG (Methocarbamol) NF

ROBAXIN-750 TABS(Methocarbamol) NF

tizanidine hcl tabs or 2 mg,4 mg F

ZANAFLEX TABS 4 MG(Tizanidine HCl) NF

Direct Muscle RelaxantsDANTRIUM CAPS 25 MG(Dantrolene Sodium) NF

dantrolene sodium caps or25 mg, 100 mg F

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Antiallergyazelastine hcl soln na 0.1%, 137 mcg/spray F

cromolyn sodium (nasal)aers 5.2 mg/act F

NASALCROM AERS(Cromolyn Sodium (Nasal)) NF

Nasal Anticholinergicsipratropium bromide (nasal)soln F

Nasal SteroidsFLONASE ALLERGYRELIEF CHILDRENSSUSP (FluticasonePropionate (Nasal))

NF

RX/OTC

FLONASE ALLERGYRELIEF SUSP (FluticasonePropionate (Nasal))

NFRX/OTC

FLUNISOLIDE SOLN F

fluticasone propionate(nasal) susp 50 mcg/act F RX/OTC

NASACORT ALLERGY24HR AERO(Triamcinolone Acetonide(Nasal))

NF

RX/OTC


64

Drug Name DrugTier

Requirements/Limits

NASACORT ALLERGY24HR AERO 55 MCG/ACT F RX/OTC

NASACORT ALLERGY24HR CHILDRENS AERO(Triamcinolone Acetonide(Nasal))

NF

RX/OTC

triamcinolone acetonide(nasal) aero 55 mcg/act F RX/OTC

Sympathomimetic DecongestantsNASAL DECONGESTANTLIQD F

NASAL DECONGESTANTSYRP F

pseudoephedrine hcl tabsor 30 mg, 60 mg F

pseudoephedrine hcl tb12or 120 mg F

SUDAFED 24 HOUR TB24 F

SUDAFED CONGESTIONTABS (PseudoephedrineHCl)

NF

SUDAFED NASALDECONGESTANTMAXIMUM STRENGTHTABS (PseudoephedrineHCl)

NF

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK TABS (Riluzole) NF

riluzole tabs 50 mg F

NUTRIENTS

Misc. Nutritional SubstancesFISH OIL CAPS F

FISH OIL CHEW F

FISH OIL PEARLS CAPS F

FISH OIL TRIPLESTRENGTH CAPS F

FISH OIL ULTRA CAPS F

Drug Name DrugTier

Requirements/Limits

HM FISH OIL CAPS F

OMEGA POWER CAPS F

OMEGA-3 2100 CAPS F

OMEGA-3 CAPS F

OMEGA-3 EPA FISH OILCAPS F

omega-3 fatty acids caps F

omega-3 fatty acids chew F

OMEGA-3 FISH OILEXTRA STRENGTH CAPS F

RA FISH OIL EXTRASTRENGTH CAPS F

RA TRIPLE STRENGTHFISH OIL CAPS F

SALMON CAPS F

SALMON OIL CAPS F

SALMON OIL-1000 CAPS F

SM FISH OIL CAPS F

SUPER TWIN EPA/DHACAPS F

ULTRA OMEGA 3 CAPS F

ULTRA OMEGA-3 FISHOIL BURP-LESS CAPS F

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricantsartificial tear ointment oint F

artificial tear solution soln F

carboxymethylcellulosesodium (ophth) soln 0.25%, 0.5 %

F

CVS LUBRICANT GELDROPS GEL F

GENTEAL MILD SOLN F


65

Drug Name DrugTier

Requirements/Limits

GENTEAL MILD TOMODERATE SOLN(Hypromellose (Ophth))

NF

GENTEAL SEVERE GEL F

GONIOVISC SOLN F

hypromellose (ophth) soln F

ISOPTO TEARS SOLN F

polyethylene glycol-propylene glycol (ophth)soln 0.4%-0.3%

F

REFRESH LIQUIGELSOLN F

REFRESH TEARS SOLN(CarboxymethylcelluloseSodium (Ophth))

NF

SYSTANE OVERNIGHTTHERAPY LUBRICANTEYE GEL

F

SYSTANE SOLN(Polyethylene Glycol-Propylene Glycol (Ophth))

NF

SYSTANE ULTRA HOME& AWAY PACK SOLN(Polyethylene Glycol-Propylene Glycol (Ophth))

NF

SYSTANE ULTRA SOLN(Polyethylene Glycol-Propylene Glycol (Ophth))

NF

THERATEARS SOLN 0.25% (CarboxymethylcelluloseSodium (Ophth))

NF

Beta-blockers - OphthalmicBETAGAN SOLN(Levobunolol HCl) NF

betaxolol hcl (ophth) soln F

BETIMOL SOLN F

BETOPTIC-S SUSP F

carteolol hcl (ophth) soln F

CARTEOLOL HCL SOLN F

Drug Name DrugTier

Requirements/Limits

COSOPT SOLN(Dorzolamide HCl-TimololMaleate)

NF

dorzolamide hcl-timololmaleate soln 2%-0.5%,22.3mg/ml-6.8mg/ml

F

DORZOLAMIDEHCL/TIMOLOL MALEATESOLN

F

ISTALOL SOLN F

ISTALOL SOLN (TimololMaleate (Ophth)) NF

levobunolol hcl soln 0.5 % F

METIPRANOLOL SOLN F

timolol maleate (ophth) solg F

timolol maleate (ophth) soln F

TIMOLOL MALEATEOPHTHALMIC GELFORMING SOLG

F

TIMOPTIC OCUDOSESOLN F

TIMOPTIC SOLN (TimololMaleate (Ophth)) NF

TIMOPTIC-XE SOLG 0.25% (Timolol Maleate(Ophth))

NF

TIMOPTIC-XE SOLG 0.25%, 0.5 % F

Cycloplegic MydriaticsATROPINE SULFATEOINT OP 1 % F

ATROPINE SULFATESOLN OP 1 % F

CYCLOGYL SOLN 1 %, 2% (Cyclopentolate HCl) NF

cyclopentolate hcl soln op 1%, 2 % F

homatropine hbr soln F

ISOPTO ATROPINE SOLN F


66

Drug Name DrugTier

Requirements/Limits

MYDRIACYL SOLN(Tropicamide) NF

tropicamide soln op 0.5 %,1 % F

MioticsISOPTO CARPINE SOLN(Pilocarpine HCl) NF

pilocarpine hcl soln op 1 %,2 %, 4 % F

Ophthalmic Adrenergic AgentsALPHAGAN P SOLN 0.1 % F

ALPHAGAN P SOLN 0.15% (Brimonidine Tartrate) NF

brimonidine tartrate soln op0.15 %, 0.2 % F

Ophthalmic Anti-infectivesBACITRACIN OINT OP500 UNIT/GM F QL(4 gm per 7

days retail)bacitracin-polymyxin b(ophth) oint F

BLEPH-10 SOLN(Sulfacetamide Sodium(Ophth))

NF

CILOXAN OINT 0.3 % F

CILOXAN SOLN(Ciprofloxacin HCl (Ophth)) NF

ciprofloxacin hcl (ophth)soln 0.3 % F

erythromycin (ophth) oint F

GENTAK OINT F

gentamicin sulfate (ophth)oint F

gentamicin sulfate (ophth)soln F

levofloxacin (ophth) soln F

moxifloxacin hcl (ophth)soln 0.5 % F

NATACYN SUSP F

neomycin-bacitracin zn-polymyxin oint F

Drug Name DrugTier

Requirements/Limits

neomycin-polymyxin-gramicidin soln0.025mg/ml-10000unit/ml-1.75mg/ml

F

NEOSPORIN SOLN(Neomycin-Polymyxin-Gramicidin)

NF

OCUFLOX SOLN(Ofloxacin (Ophth)) NF

ofloxacin (ophth) soln 0.3% F

polymyxin b-trimethoprimsoln 0.1%-10000unit/ml F

POLYTRIM SOLN(Polymyxin B-Trimethoprim)

NF

sulfacetamide sodium(ophth) soln 10 % F

SULFACETAMIDESODIUM OINT OP 10 % F

tobramycin (ophth) soln 0.3% F

TOBREX OINT 0.3 % F

TOBREX SOLN(Tobramycin (Ophth)) NF

trifluridine soln op 1 % F

VIGAMOX SOLN(Moxifloxacin HCl (Ophth)) NF

VIROPTIC SOLN(Trifluridine) NF

Ophthalmic Decongestantsnaphazoline w/pheniramine soln F

NAPHCON-A SOLN(Naphazoline w/Pheniramine)

NF

OPCON-A SOLN(Naphazoline w/Pheniramine)

NF

phenylephrine hcl (ophth)soln 10 % F

phenylephrine hcl (ophth)soln 2.5 % F QL(16 ml daily)

Ophthalmic Immunomodulators


67

Drug Name DrugTier

Requirements/Limits

RESTASIS EMUL 0.05 % F PA

RESTASIS MULTIDOSEEMUL 0.05 % F PA

Ophthalmic Steroidsbacitracin-poly-neomycin-hc oint F

BLEPHAMIDE S.O.P.OINT F

BLEPHAMIDE SUSP F

DEXAMETHASONESODIUM PHOSPHATESOLN OP 0.1 %

F

fluorometholone (ophth)susp F

FML FORTE SUSP F

FML LIQUIFILM SUSP(Fluorometholone (Ophth)) NF

FML OINT F

MAXIDEX SUSP 0.1 % F

MAXITROL OINT(Neomycin-Polymy-Dexameth)

NF

MAXITROL SUSP(Neomycin-Polymy-Dexameth)

NF

neomycin-polymy-dexameth oint F

neomycin-polymy-dexameth susp F

NEOMYCIN/POLYMYXIN/HYDROCORTISONESUSP

F

OMNIPRED SUSP(Prednisolone Acetate(Ophth))

NF

PRED FORTE SUSP(Prednisolone Acetate(Ophth))

NF

PRED MILD SUSP F

PRED-G S.O.P. OINT F

Drug Name DrugTier

Requirements/Limits

PRED-G SUSP F

prednisolone acetate(ophth) susp F

PREDNISOLONEACETATE P-F SUSP F

PREDNISOLONE SODIUMPHOSPHATE SOLN OP 1%

F

sulfacetamide sod-prednisolone soln F

TOBRADEX OINT 0.3%-0.1% F QL(4 gm per 7

days retail)TOBRADEX SUSP(Tobramycin-Dexamethasone)

NF

tobramycin-dexamethasone susp0.3%-0.1%

F

Ophthalmics - Misc.ACULAR LS SOLN(Ketorolac Tromethamine(Ophth))

NF

ACULAR SOLN (KetorolacTromethamine (Ophth)) NF

AZOPT SUSP F PA

cromolyn sodium (ophth)soln F

diclofenac sodium (ophth)soln F

dorzolamide hcl soln 2 % F

DORZOLAMIDE HCLSOLN 2 % F

flurbiprofen sodium soln0.03 % F

ketorolac tromethamine(ophth) soln F

ketotifen fumarate (ophth)soln 0.025 % F

OCUFEN SOLN(Flurbiprofen Sodium) NF

TRUSOPT SOLN(Dorzolamide HCl) NF


68

Drug Name DrugTier

Requirements/Limits

ZADITOR SOLN (KetotifenFumarate (Ophth)) NF

Prostaglandins - Ophthalmiclatanoprost soln op 0.005% F QL(2.5 ml per

fill retail)LATANOPROST SOLN OP0.005 % F QL(2.5 ml per

fill retail)

TRAVATAN Z SOLN F PA

TRAVOPROST SOLN F PA

XALATAN SOLN(Latanoprost) NF QL(2.5 ml per

fill retail)

ZIOPTAN SOLN F PA

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneouscarbamide peroxide (otic)soln 6.5 % F

DEBROX SOLN(Carbamide Peroxide(Otic))

NF

Otic Anti-infectivesFLOXIN OTIC SOLN(Ofloxacin (Otic)) NF

ofloxacin (otic) soln 0.3 % F

Otic CombinationsCIPRODEX SUSP F

neomycin-polymyxin-hc(otic) soln F

neomycin-polymyxin-hc(otic) susp F

Otic Steroidshydrocortisone w/aceticacid soln F

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocicsmethylergonovine maleatetabs or 0.2 mg F

Drug Name DrugTier

Requirements/Limits

PASSIVE IMMUNIZING AND TREATMENTAGENTS - Antibody Drugs to Treat Low ImmuneSystemMonoclonal AntibodiesSYNAGIS SOLN F PA; SP

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg F

AMOXICILLIN CHEW 125MG, 250 MG F

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

F

amoxicillin tabs 500 mg,875 mg F

ampicillin caps 250 mg,500 mg F

AMPICILLIN CAPS 500MG F

AMPICILLIN SUSR 125MG/5ML, 250 MG/5ML F

Natural PenicillinsPENICILLIN VPOTASSIUM SOLR 125MG/5ML, 250 MG/5ML

F

penicillin v potassium solr125 mg/5ml, 250 mg/5ml F

penicillin v potassium tabs250 mg, 500 mg F

Penicillin Combinationsamoxicillin & potclavulanate susr F

amoxicillin & potclavulanate tabs F

amoxicillin & potclavulanate tb12 F

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F

AUGMENTIN ES-600SUSR (Amoxicillin & PotClavulanate)

NF


69

Drug Name DrugTier

Requirements/Limits

AUGMENTIN SUSR125MG/5ML-31.25MG/5ML F

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Amoxicillin & PotClavulanate)

NF

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Amoxicillin & PotClavulanate)

NF

AUGMENTIN XR TB12(Amoxicillin & PotClavulanate)

NF

Penicillinase-Resistant Penicillinsdicloxacillin sodium caps F

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsAYGESTIN TABS(Norethindrone Acetate) NF

hydroxyprogesteronecaproate oil im 250 mg/ml F PA; SP

MAKENA OIL IM 250MG/ML(HydroxyprogesteroneCaproate)

NF

PA; SP

MAKENA SOAJ SC 275MG/1.1ML F PA; SP

medroxyprogesteroneacetate tabs or 5 mg, 10mg, 2.5 mg

F

MEGACE ES SUSP(Megestrol Acetate(Appetite))

NF

megestrol acetate(appetite) susp 625 mg/5ml F

norethindrone acetate tabsor 5 mg F

progesterone micronizedcaps or 100 mg, 200 mg F

PROMETRIUM CAPS(Progesterone Micronized) NF

PROVERA TABS(MedroxyprogesteroneAcetate)

NF

Drug Name DrugTier

Requirements/Limits

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium tbec F

ANTABUSE TABS(Disulfiram) NF

disulfiram tabs or 250 mg,500 mg F

Antidementia AgentsARICEPT TABS (DonepezilHydrochloride) NF PA

donepezil hydrochloridetabs F PA

donepezil hydrochloridetbdp F PA

EXELON CAPS(Rivastigmine Tartrate) NF PA

EXELON PT24(Rivastigmine) NF PA

galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg F PA

GALANTAMINEHYDROBROMIDE SOLN 4MG/ML

FPA

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg F PA

memantine hcl soln 2mg/ml F PA

memantine hcl tabs 10 mg F QL(6 ea daily)

memantine hcl tabs 5 mg F PA; QL(6 eadaily)

NAMENDA TABS 10 MG(Memantine HCl) NF QL(6 ea daily)

NAMENDA TABS 5 MG(Memantine HCl) NF PA; QL(6 ea

daily)RAZADYNE ER CP24(GalantamineHydrobromide)

NFPA

RAZADYNE TABS(GalantamineHydrobromide)

NFPA

rivastigmine pt24 F PA


70

Drug Name DrugTier

Requirements/Limits

rivastigmine tartrate caps F PA

Multiple Sclerosis AgentsAVONEX KIT F PA; SP

AVONEX PEN AJKT F PA; SP

AVONEX PSKT F PA; SP

BETASERON KIT F PA; SP

COPAXONE SOSY 20MG/ML (GlatiramerAcetate)

FPA; SP

COPAXONE SOSY 40MG/ML (GlatiramerAcetate)

NFPA; SP

EXTAVIA KIT F PA; SP

GILENYA CAPS 0.5 MG F PA; SP

glatiramer acetate sosy 40mg/ml F PA; SP

REBIF REBIDOSE SOAJ F PA; SP

REBIF REBIDOSETITRATIONPACK SOAJ F PA; SP

REBIF SOSY F PA; SP

REBIF TITRATION PACKSOSY F PA; SP

Postherpetic Neuralgia (PHN)/Neuropathic PainGRALISE TABS F PA

Psychotherapeutic and Neurological Agents -

ORAP TABS (Pimozide) NF AL(At least 6yrs old)

pimozide tabs F AL(At least 6yrs old)

Restless Leg Syndrome (RLS) AgentsHORIZANT TBCR F PA

Smoking Deterrentsbupropion hcl (smokingdeterrent) tb12 150 mg F QL(180 ea per

180 days retail)

Drug Name DrugTier

Requirements/Limits

CHANTIX CONTINUINGMONTHPAK TABS F QL(180 ea per

180 days retail)CHANTIX STARTINGMONTH PAK TABS F QL(180 ea per

180 days retail)

CHANTIX TABS F QL(180 ea per180 days retail)

NICODERM CQ PT24(Nicotine) NF QL(180 ea per

180 days retail)NICORETTE GUM(Nicotine Polacrilex) NF QL(180 ea per

180 days retail)NICORETTE LOZG(Nicotine Polacrilex) NF QL(180 ea per

180 days retail)NICORETTE MINI LOZG(Nicotine Polacrilex) NF QL(180 ea per

180 days retail)NICORETTE STARTERKIT GUM (NicotinePolacrilex)

NFQL(180 ea per180 days retail)

nicotine polacrilex gum mt2 mg, 4 mg F QL(180 ea per

180 days retail)nicotine polacrilex lozg mt 2mg, 4 mg F QL(180 ea per

180 days retail)

nicotine pt24 F QL(180 ea per180 days retail)

NICOTINETRANSDERMAL SYSTEMKIT

FQL(180 ea per180 days retail)

NICOTROL INHALERINHA F QL(180 ea per

180 days retail)

NICOTROL NS SOLN F QL(180 ml per180 days retail)

ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NF QL(180 ea per

180 days retail)RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)ARALAST NP SOLR F PA

GLASSIA SOLN F PA

PROLASTIN-C SOLR 1000MG F PA

ZEMAIRA SOLR F PA

Cystic Fibrosis AgentsPULMOZYME SOLN F PA; SP


71

Drug Name DrugTier

Requirements/Limits

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidesSULFADIAZINE TABS OR500 MG F

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesACTICLATE TABS(Doxycycline Hyclate) NF

ADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))

NF

ADOXA PAK 2/100 TABS(Doxycycline(Monohydrate))

NF

ADOXA TABS 50 MG, 100MG (Doxycycline(Monohydrate))

NF

demeclocycline hcl tabs F PA

DORYX MPC TBEC F

DORYX TBEC(Doxycycline Hyclate) NF

doxycycline (monohydrate)caps 50 mg, 100 mg F

doxycycline (monohydrate)tabs 50 mg, 100 mg F

doxycycline hyclate caps or50 mg, 100 mg F

doxycycline hyclate tabs or20 mg, 75 mg, 100 mg, 150mg

F

DOXYCYCLINE HYCLATETABS OR 50 MG F

doxycycline hyclate tbec or50 mg, 75 mg, 100 mg, 150mg, 200 mg

F

MINOCIN CAPS OR 50MG, 75 MG, 100 MG(Minocycline HCl)

NF

minocycline hcl caps or 50mg, 75 mg, 100 mg F

minocycline hcl tabs or 50mg, 75 mg, 100 mg F

Drug Name DrugTier

Requirements/Limits

MONODOX CAPS 100 MG(Doxycycline(Monohydrate))

NF

TARGADOX TABS F

tetracycline hcl caps or 250mg, 500 mg F

TETRACYCLINE HCLCAPS OR 250 MG, 500MG (Tetracycline HCl)

NF

VIBRAMYCIN CAPS 100MG (Doxycycline Hyclate) NF

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs or 5 mg,10 mg F

propylthiouracil tabs or F

TAPAZOLE TABS(Methimazole) NF

Thyroid HormonesARMOUR THYROID TABS15 MG, 30 MG, 60 MG, 90MG, 120 MG (Thyroid)

NF

ARMOUR THYROID TABS180 MG, 240 MG F

CYTOMEL TABS(Liothyronine Sodium) NF

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

F

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg F

NATURE-THROID NT-2.5TABS F

NATURE-THROID TABS F

SYNTHROID TABS(Levothyroxine Sodium) NF

thyroid tabs or 15 mg, 30mg, 60 mg, 90 mg, 120 mg F


72

Drug Name DrugTier

Requirements/Limits

WESTHROID TABS F

WP THYROID TABS F

TOXOIDS

Toxoid CombinationsDIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

F

TENIVAC INJ F

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDSUSP

F

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsANASPAZ TBDP(Hyoscyamine Sulfate) NF QL(4 ea daily)

BENTYL CAPS OR 10 MG(Dicyclomine HCl) NF

BENTYL TABS OR 20 MG(Dicyclomine HCl) NF

CUVPOSA SOLN F

dicyclomine hcl caps or 10mg F

dicyclomine hcl soln or 10mg/5ml F

dicyclomine hcl tabs or 20mg F

glycopyrrolate tabs or 1mg, 2 mg F

hyoscyamine sulfate elix or0.125 mg/5ml F

hyoscyamine sulfate solnor 0.125 mg/ml F QL(8 ml daily)

hyoscyamine sulfate subl sl0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tabsor 0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tb12or 0.375 mg F QL(2 ea daily)

hyoscyamine sulfate tbdpor 0.125 mg F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

LEVBID TB12(Hyoscyamine Sulfate) NF QL(2 ea daily)

LEVSIN TABS OR 0.125MG (Hyoscyamine Sulfate) NF QL(4 ea daily)

LEVSIN/SL SUBL(Hyoscyamine Sulfate) NF QL(4 ea daily)

methscopolamine bromidetabs or 5 mg, 2.5 mg F

PROPANTHELINEBROMIDE TABS OR 15MG

F

ROBINUL FORTE TABS(Glycopyrrolate) NF

ROBINUL TABS OR 1 MG(Glycopyrrolate) NF

SYMAX DUOTAB TBCR F

H-2 AntagonistsDEPRIZINE FUSEPAQSUSR F

DEPRIZINE RAPIDPAQSUSR F

famotidine susr or 40mg/5ml F

famotidine tabs or 10 mg,40 mg F

famotidine tabs or 20 mg F RX/OTC

PEPCID AC EZ CHEWSMAXIMUM STRENGTHCHEW

F

PEPCID AC MAXIMUMSTRENGTH TABS(Famotidine)

NFRX/OTC

PEPCID AC TABS(Famotidine) NF

PEPCID SUSR 40 MG/5ML(Famotidine) NF

PEPCID TABS 20 MG(Famotidine) NF RX/OTC

PEPCID TABS 40 MG(Famotidine) NF

ranitidine hcl caps or 150mg, 300 mg F


73

Drug Name DrugTier

Requirements/Limits

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

F

ranitidine hcl tabs or 150mg F RX/OTC

ranitidine hcl tabs or 75mg, 300 mg F

ZANTAC 150 MAXIMUMSTRENGTH TABS(Ranitidine HCl)

NFRX/OTC

ZANTAC 75 TABS(Ranitidine HCl) NF

ZANTAC TABS OR 150MG (Ranitidine HCl) NF RX/OTC

ZANTAC TABS OR 300MG (Ranitidine HCl) NF

Misc. Anti-UlcerCARAFATE TABS 1 GM(Sucralfate) NF

sucralfate tabs or 1 gm F

Proton Pump InhibitorsCVS OMEPRAZOLE TBEC F

EQ OMEPRAZOLE TBEC F

EQL OMEPRAZOLE TBEC F

FIRST-LANSOPRAZOLESUSP F

FIRST-OMEPRAZOLESUSP F

GNP OMEPRAZOLETBEC F

HM OMEPRAZOLE TBEC F

KLS OMEPRAZOLE TBEC F

lansoprazole cpdr or 15 mg F RX/OTC

lansoprazole cpdr or 30 mg F

OMEPRAZOLE +SYRSPEND SFALKASUSP

F

omeprazole cpdr or 10 mg,40 mg F

Drug Name DrugTier

Requirements/Limits

omeprazole cpdr or 20 mg F RX/OTC

OMEPRAZOLE TBEC OR20 MG F

pantoprazole sodium tbecor 20 mg, 40 mg F

PREVACID 24HR CPDR(Lansoprazole) NF RX/OTC

PREVACID CPDR 15 MG(Lansoprazole) NF RX/OTC

PREVACID CPDR 30 MG(Lansoprazole) NF

PRILOSEC CPDR 10 MG,40 MG (Omeprazole) NF

PRILOSEC CPDR 20 MG(Omeprazole) NF RX/OTC

PROTONIX PACK OR 40MG F

PROTONIX TBEC OR 20MG, 40 MG (PantoprazoleSodium)

NF

PX OMEPRAZOLE TBEC F

RA OMEPRAZOLE TBEC F

SB OMEPRAZOLE TBEC F

SM OMEPRAZOLE TBEC F

SW OMEPRAZOLE TBEC F

TGT OMEPRAZOLE TBEC F

Ulcer Drugs - ProstaglandinsCYTOTEC TABS(Misoprostol) NF

misoprostol tabs or 100mcg, 200 mcg F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesFURADANTIN SUSP(Nitrofurantoin) NF

MACROBID CAPS(Nitrofurantoin MonohydMacro)

NF


74

Drug Name DrugTier

Requirements/Limits

MACRODANTIN CAPS(NitrofurantoinMacrocrystal)

NF

nitrofurantoin macrocrystalcaps or 25 mg, 50 mg, 100mg

F

nitrofurantoin monohydmacro caps 100 mg F

nitrofurantoin susp or 25mg/5ml F

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - Antimuscarinics

DETROL LA CP24(Tolterodine Tartrate) NF

ST; Tryoxybutynin ortolterodine IRfirst

DETROL TABS(Tolterodine Tartrate) NF ST

DITROPAN XL TB24(Oxybutynin Chloride) NF QL(1 ea daily)

oxybutynin chloride syrp or5 mg/5ml F

oxybutynin chloride tabs or5 mg F

oxybutynin chloride tb24 or5 mg, 10 mg, 15 mg F QL(1 ea daily)

tolterodine tartrate cp24 2mg, 4 mg F

ST; Tryoxybutynin ortolterodine IRfirst

tolterodine tartrate tabs 1mg, 2 mg F ST

trospium chloride tabs 20mg F

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabsor 5 mg, 10 mg, 25 mg, 50mg

F

URECHOLINE TABS(Bethanechol Chloride) NF

VACCINES

Bacterial VaccinesBEXSERO SUSY F

Drug Name DrugTier

Requirements/Limits

MENACTRA INJ F

MENOMUNE-A/C/Y/W-135INJ F

MENVEO SOLR F

PNEUMONIA VACCINE F AL

Viral VaccinesCERVARIX SUSP F

ENGERIX-B INJ F

ENGERIX-B SUSP F

GARDASIL 9 SUSP F

GARDASIL 9 SUSY F

GARDASIL SUSP F

HAVRIX SUSP F

INFLUENZA VACCINE F AL

M-M-R II INJ F

RECOMBIVAX HB SUSP F

SHINGRIX SUSR F

Limit 2 dosesperlifetime;QL(1ea per fillretail,2 ea per999 daysretail); AL(Atleast 50 yrsold)

TWINRIX SUSP F

VAQTA SUSP F

VARIVAX INJ F

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesMiscellaneous Vaginal Products


75

Drug Name DrugTier

Requirements/Limits

NONOXYNOLSPERMICIDES F

Vaginal Anti-infectivesAVC CREA F

CLEOCIN CREA VA 2 %(Clindamycin PhosphateVaginal)

NF

CLEOCIN SUPP VA 100MG F

clindamycin phosphatevaginal crea F

clotrimazole vaginal crea F

GYNE-LOTRIMIN 3 CREA(Clotrimazole Vaginal) NF

GYNE-LOTRIMIN CREA(Clotrimazole Vaginal) NF

METROGEL-VAGINALGEL (MetronidazoleVaginal)

NF

metronidazole vaginal gel0.75 % F

MICONAZOLE 3 SUPP F

miconazole nitrate vaginalcrea F

miconazole nitrate vaginalkit F

miconazole nitrate vaginalsupp F

MONISTAT 1 COMBOPACK KIT (MiconazoleNitrate Vaginal)

NF

MONISTAT 1 DAY ORNIGHT COMBO PACK KIT(Miconazole NitrateVaginal)

NF

MONISTAT 3COMBINATION PACK KIT(Miconazole NitrateVaginal)

NF

MONISTAT 3 CREA(Miconazole NitrateVaginal)

NF

MONISTAT 7COMBINATION PACK KIT F

Drug Name DrugTier

Requirements/Limits

MONISTAT 7 SIMPLYCURE CREA (MiconazoleNitrate Vaginal)

NF

TERAZOL 3 CREA(Terconazole Vaginal) NF

TERAZOL 7 CREA(Terconazole Vaginal) NF

TERCONAZOLE CREA F

terconazole vaginal crea0.4 %, 0.8 % F

Vaginal EstrogensESTRACE CREA (EstradiolVaginal) NF

estradiol vaginal crea F

estradiol vaginal tabs F

ESTRING RING F

FEMRING RING 0.1MG/24HR F PA

PREMARIN CREA VA0.625 MG/GM F PA

VAGIFEM TABS (EstradiolVaginal) NF

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml F

Limit 2 permonth;QL(0.067 ea daily)

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml

F

Limit 2 permonth;QL(2 eaper 30 daysretail)

Vasopressorsmidodrine hcl tabs F QL(2 ea daily)

VITAMINS

Oil Soluble Vitaminscholecalciferol caps or 400unit, 1000 unit, 2000 unit,5000 unit, 10000 unit,50000 unit

F


76

Drug Name DrugTier

Requirements/Limits

cholecalciferol tabs or 400unit, 1000 unit, 2000 unit,5000 unit, 50000 unit

F

DECARA CAPS F

DRISDOL CAPS(Ergocalciferol) NF

ergocalciferol caps F

HM VITAMIN D3 CAPS F

KEY-E CHEW OR F AL(At least 6yrs old)

MEPHYTON TABS(Phytonadione) NF

NATURAL VITAMIN ETABS F

OPTIMAL D3 M CAPS F

phytonadione tabs or 5 mg F

SM VITAMIN D3MAXIMUM STRENGTHCAPS

F

THERA-D 4000 TABS F

VITAMIN D2 TABS F

VITAMIN D3 TABS OR3000 UNIT, 10000 UNIT F

vitamin e caps or 100 unit,200 unit, 400 unit, 600 unit,1000 unit

F

VITAMIN E CHEW OR 400UNIT F AL(At least 6

yrs old)VITAMIN E TABS OR 100UNIT, 200 UNIT F

vitamin e tabs or 400 unit F

Water Soluble VitaminsB-1 TABS F

niacin cpcr F

niacin tabs F

niacin tbcr F

Drug Name DrugTier

Requirements/Limits

niacinamide tabs F

niacinamide tbcr F

pyridoxine hcl tabs F

SLO-NIACIN TBCR(Niacin) NF

thiamine hcl tabs F


77

IndexA-200 49abacavir sulfate 31abacavir sulfate-lamivudine 31abacavir sulfate-lamivudine-zidovudine 31ABILIFY 31ABILIFY MAINTENA 31ABREVA 45ABSORICA 43acamprosate calcium 70acarbose 18ACCOLATE 10ACCUPRIL 24ACCURETIC 25ACEON 24acetaminophen 4acetaminophen w/ codeine 5acetazolamide 50ACNE MEDICATION 10 43ACNE MEDICATION 5 43ACTICLATE 72ACTIDOM DMX 39ACTIGALL 53ACTIMMUNE 27ACTOPLUS MET 18ACTOPLUS MET XR 18ACTOS 19ACULAR 68ACULAR LS 68acyclovir 34acyclovir topical 46ADALAT CC 35ADCIRCA 36ADDERALL 1ADDERALL XR 1adefovir dipivoxil 33ADOXA 72ADOXA PAK 1/100 72ADOXA PAK 2/100 72ADVAIR DISKUS 11ADVAIR HFA 11ADVIL 2ADVIL MIGRAINE 2AFINITOR 27AFINITOR DISPERZ 27ALBENZA 7

ALBUSTIX 49albuterol sulfate 11ALCOHOL SWABS 58ALDACTAZIDE 51ALDACTONE 51ALDARA 47ALECENSA 27ALENDRONATE SODIUM 51alendronate sodium 51ALER-DRYL 21ALEVE 2ALFERON N 27ALLEGRA ALLERGY 22ALLEGRA ALLERGYCHILDRENS 22ALLEGRA-D 12 HOURALLERGY &CONGESTION 39ALLEGRA-D 24 HOURALLERGY &CONGESTION 39allopurinol 54ALOE VESTAANTIFUNGAL 44ALOE VESTA CLEARANTIFUNGAL 44ALORA 52ALPHAGAN P 67alprazolam 9ALPRAZOLAM INTENSOL 9ALTACE 24alum & mag hydrox-simethicone 7amantadine hcl 28AMARYL 20AMBI EVEN & CLEAREXFOLIATING WASH 47AMBI EVEN & CLEARFOAMINGCLEANSER 47AMBIEN 56AMERGE 58AMICAR 55amiloride &hydrochlorothiazide 51amiloride hcl 51amiodarone hcl 10AMITIZA 53amitriptyline hcl 17amlodipine besylate 35amlodipine besylate-benazeprilhcl 25

AMOXAPINE 17amoxicillin 69AMOXICILLIN 69amoxicillin 69amoxicillin & pot clavulanate 69AMOXICILLIN/CLAVULANATEPOTASSIUM 69amphetamine-dextroamphetamine 1ampicillin 69AMPICILLIN 69ANAFRANIL 17ANALPRAM HC 6ANALPRAM HC SINGLES 6ANALPRAM-HC 6ANAPROX DS 2ANASPAZ 73anastrozole 26ANDRODERM 6ANDROGEL 6ANDROGEL PUMP 6ANDROXY 6ANTABUSE 70ANTACID 7ANTACID SOFT CHEWS 7ANUSOL-HC 6ANZEMET 21aprepitant 21APTENSIO XR 1APTIVUS 31AQUORAL 62ARALAST NP 71ARAVA 3ARICEPT 70ARIMIDEX 26aripiprazole 31ARISTADA 31ARISTADA INITIO 31ARMOUR THYROID 72AROMASIN 26ARTHROTEC 50 2ARTHROTEC 75 2artificial tear ointment 65artificial tear solution 65ASACOL HD 53ASMANEX TWISTHALER 120METERED DOSES 10

Index 1

ASMANEX TWISTHALER 14METERED DOSES 10ASMANEX TWISTHALER 30METERED DOSES 10ASMANEX TWISTHALER 60METERED DOSES 11ASMANEX TWISTHALER 7METERED DOSES 11aspirin 4ASPIRIN 4aspirin 4aspirin buffered (cal carb-magcarb-mag oxide) 4ASTAGRAF XL 61atazanavir sulfate 31atenolol 34atenolol & chlorthalidone 25ATIVAN 9atomoxetine hcl 1atorvastatin calcium 23atovaquone-proguanil hcl 26ATRAC-TAIN 47ATRIPLA 31ATROPINE SULFATE 66ATROVENT HFA 10AUGMENTIN 70AUGMENTIN ES-600 69AUGMENTIN XR 70AVALIDE 25AVAPRO 24AVC 76AVODART 54AVONEX 71AVONEX PEN 71AXIRON 6AYGESTIN 70azathioprine 61azelastine hcl 64AZITHROMYCIN 57azithromycin 57AZOPT 68AZULFIDINE 53AZULFIDINE EN-TABS 53B-1 77B-12 55BACIGUENT 44BACITRACIN 67bacitracin (topical) 44

bacitracin zinc 44bacitracin-poly-neomycin-hc

68bacitracin-polymyxin b 44bacitracin-polymyxin b(ophth) 67baclofen 64BACTRIM 8BACTRIM DS 8BACTROBAN 44BALAMINE DM 39balsalazide disodium 53BANZEL 13BARACLUDE 33BELEODAQ 27BENADRYL ALLERGY 21BENADRYL ALLERGYCHILDRENS 21benazepril &hydrochlorothiazide 25benazepril hcl 24BENICAR 24BENICAR HCT 25BENTYL 73BENZAC AC WASH 43BENZEFOAM 43BENZEFOAM ULTRA 43BENZIQ 43BENZIQ LS 43BENZIQ WASH 43benzonatate 39benzoyl peroxide 43BENZOYL PEROXIDE 43benzoyl peroxide 43BENZOYL PEROXIDECLEANSER 43benztropine mesylate 28BETAGAN 66betamethasone dipropionate(topical) 46betamethasone dipropionateaugmented 46betamethasone valerate 46BETAPACE 34BETAPACE AF 34BETASAL 47BETASERON 71betaxolol hcl (ophth) 66bethanechol chloride 75

BETHKIS 2BETIMOL 66BETOPTIC-S 66BEVESPI AEROSPHERE 11bexarotene 27BEXSERO 75BIAXIN 57BIKTARVY 31BILTRICIDE 7BIOBRON SF 39BIODESP DM 39BIOTENE DRY MOUTHMOISTURIZING SPRAY 62bisacodyl 57bismuth subsalicylate 20bisoprolol &hydrochlorothiazide 25bisoprolol fumarate 34BLEPH-10 67BLEPHAMIDE 68BLEPHAMIDE S.O.P. 68BONE ESSENTIALS 60BP GEL 43BREVICON-28 37BRILINTA 54brimonidine tartrate 67bromocriptine mesylate 28brompheniramine &pseudoeph 40BRONKIDS 40BRONTUSS DX 40BROTAPP DM 40budesonide 38BUFFERIN 4bumetanide 51BUMEX 51BUPRENORPHINE 6buprenorphine hcl 6bupropion hcl 15bupropion hcl (smokingdeterrent) 71buspirone hcl 8,9butalbital-acetaminophen-caffeine 4butalbital-acetaminophen-caffeine w/ codeine 5butalbital-aspirin-caffeine 4butalbital-aspirin-caffeinew/cod 5

Index 2

BUTALBITAL/ASPIRIN/CAFFEINE 4butenafine hcl 44BUTRANS 6BYDUREON 19BYDUREON PEN 19BYETTA 19CAFERGOT 58CAL-CITRATE 59CAL-LAC 59CAL-MAG-K CHELA MAX 60CAL-MINT 59CALAMINE 48CALAN 35CALAN SR 35CALCI-CHEW 59calcitriol 52CALCIUM 59calcium 60CALCIUM 60CALCIUM & VITAMIN D3BONEHEALTH 60CALCIUM ACETATE 59calcium acetate (phosphatebinder) 53CALCIUM ASPARTATE 59CALCIUM CARBONATE 7,59calcium carbonate 59calcium carbonate (antacid) 7calcium carbonate-vitamin d 59CALCIUM CITRATE 60calcium citrate 60CALCIUM GLUCONATE 60CALCIUM LACTATE 60CALCIUM PLUS VITAMIN D 60calcium w/ vitamin d 60CAPEX 46CAPHOSOL 62CAPRELSA 27captopril 24CAPTOPRIL/HYDROCHLOROTHIAZIDE 25CARAFATE 74carbamazepine 13carbamide peroxide (otic) 69CARBATROL 13carbidopa-levodopa 28

carboxymethylcellulose sodium(ophth) 65CARDIZEM 35CARDIZEM CD 35CARDURA 24CARMOL 20 47CARTEOLOL HCL 66carteolol hcl (ophth) 66carvedilol 34CATAPRES 24CATAPRES-TTS-1 24CATAPRES-TTS-2 24CATAPRES-TTS-3 24cefaclor 36CEFACLOR 36CEFACLOR ER 36cefadroxil 36cefdinir 36cefixime 36cefpodoxime proxetil 36cefprozil 36CEFTIN 36cefuroxime axetil 36CELEBREX 2celecoxib 2CELEXA 15CELLCEPT 61CENTANY 44cephalexin 36CEPHALEXIN 36CEREZYME 55CERVARIX 75cetirizine hcl 22cetirizine-pseudoephedrine

40CHANTIX 71CHANTIX CONTINUINGMONTHPAK 71CHANTIX STARTING MONTHPAK 71CHELATED CALCIUM 60CHELATED POTASSIUM 60CHEMSTRIP-MICRAL 49CHERACOL PLUS 40CHERACOL-D COUGH 40CHILDRENS ADVIL 2CHILDRENS MOTRIN 2

CHILDRENS MYLANTAUPSETSTOMACH RELIEF 7CHLOR-TRIMETON 21chlordiazepoxide hcl 9chlorhexidine gluconate (mouth-throat) 62CHLOROQUINEPHOSPHATE 26chloroquine phosphate 26CHLOROTHIAZIDE 51chlorothiazide 51chlorpheniramine &pseudoeph 40chlorpheniramine maleate 21chlorpromazine hcl 30chlorthalidone 51cholecalciferol 76,77cholestyramine 23cholestyramine light 23choline & mag salicylate 4ciclopirox olamine 44cidofovir 33cilostazol 54CILOXAN 67CIPRO 52CIPRODEX 69CIPROFLOXACIN HCL 52ciprofloxacin hcl 52ciprofloxacin hcl (ophth) 67citalopram hydrobromide 15CLARITHROMYCIN 57clarithromycin 57,58CLARITIN 22CLARITIN ALLERGYCHILDRENS 22CLARITIN CHILDRENS 22CLARITIN REDITABS 22CLARITIN-D 12 HOUR 40CLARITIN-D 24 HOUR 40CLASSIC PRENATAL 62CLEAN & CLEAR ACNETRIPLECLEAR BUBBLE FOAMCLEANSER 47CLEAN & CLEAR ADVANTAGE3-IN-1 EXFOLIATINGCLEANSER 43CLEAN & CLEAR ADVANTAGEOIL ABSORBINGCLEANSER 47CLEAN & CLEAR BLACKHEADERASER SCRUB 47

Index 3

CLEAN & CLEAR DEEPCLEANING ASTRINGENTSENSITIVE SKIN 47clemastine fumarate 22CLEOCIN 8,76CLEOCIN-T 43CLIMARA 52CLIMARA PRO 52clindamycin hcl 8clindamycin phosphate(topical) 43clindamycin phosphatevaginal 76CLN ACNE CLEANSER 47clobetasol propionate 46clobetasol propionate emollientbase 46clomipramine hcl 17clonazepam 12,13clonidine hcl 24clopidogrel bisulfate 54clorazepate dipotassium 9clotrimazole 62clotrimazole (topical) 44clotrimazole vaginal 76clotrimazole w/betamethasone 44clozapine 30CLOZAPINE ODT 30CLOZARIL 30CO-NATAL FA 62COARTEM 26COLACE 57COLACE CLEAR 57COLAMINE 60COLAZAL 53COLCHICINE 54COLCRYS 54COLESTID 23COLESTID FLAVORED 23colestipol hcl 23COLYTE-FLAVOR PACKS 56COMBIVENT RESPIMAT 11COMBIVIR 31COMPLERA 31COMPLETENATE 62COMPOUND W 47COMPOUND W MAXIMUMSTRENGTH 47

COMTAN 28CONCERTA 1CONDOMS 58CONDYLOX 47COPAXONE 71COPEGUS 33COREG 34CORGARD 34CORN & CALLUSREMOVER 47CORTEF 38CORTENEMA 6CORTIFOAM 6CORZIDE 25COSOPT 66COTELLIC 27COUMADIN 11COZAAR 24CREON 50CRIXIVAN 31cromolyn sodium 10cromolyn sodium (nasal) 64cromolyn sodium (ophth) 68crotamiton 49CUPRIMINE 61CUVPOSA 73CVS CALCIUM CHEWABLES600PLUS 60CVS DRY MOUTH SPRAY62CVS GLUCOSE 18CVS GLUCOSE BITS 18CVS HDYROCORTISONEACETATE 46CVS LUBRICANT GELDROPS 65CVS OMEPRAZOLE 74CVS PRENATAL 62CVS PSORIASIS MEDICATEDSHAMPOO PLUSCONDITIONER 47CVS THERAPEUTICDANDRUFFMAXIMUMSTRENGTH 48CVS THERAPEUTICMAXIMUM STRENGTH 48cyanocobalamin 55CYCLESSA 37cyclobenzaprine hcl 64CYCLOGYL 66cyclopentolate hcl 66

cyclosporine 61cyclosporine modified (formicroemulsion) 61CYMBALTA 17cyproheptadine hcl 23CYTOMEL 72CYTOTEC 74CYTOVENE 33danazol 6DANTRIUM 64dantrolene sodium 64dapsone 8DAYPRO 2DAYTRANA 1DDAVP 52DEBROX 69DECARA 77DECONEX DMX 40DELSYM 39DELSYM COUGHCHILDRENS 39DEMADEX 51demeclocycline hcl 72DEMEROL 4DENOREX EXTRA STRENGTH2-IN-1 48DEPAKENE 14DEPAKOTE 15DEPAKOTE ER 15DEPAKOTE SPRINKLES 15DEPO-PROVERACONTRACEPTIVE 38DEPO-SUBQ PROVERA104 38DEPO-TESTOSTERONE 6DEPRIZINE FUSEPAQ 73DEPRIZINE RAPIDPAQ 73DERMA-SMOOTHE/FSBODY 46DERMA-SMOOTHE/FSSCALP 46DERMAREST PSORIASIS 48DERMAREST PSORIASISMEDICATED SHAMPOO PLUSCONDITIONER 48DESCOVY 31DESGEN DM 40desipramine hcl 17desmopressin acetate 52desmopressin acetate spray 52

Index 4

desmopressin acetate sprayrefrigerated 52DESOGEN 37desogestrel & ethinylestradiol 37desogestrel-ethinyl estradiol(biphasic) 37desogestrel-ethinyl estradiol(triphasic) 37DESQUAM-X WASH 43desvenlafaxine succinate 17DETROL 75DETROL LA 75DEX4 FAST ACTINGGLUCOSEGO-POUCH 18DEX4 QUICK DISSOLVEGLUCOSE 18dexamethasone 38DEXAMETHASONE 38dexamethasone 38DEXAMETHASONE 38dexamethasone 38DEXAMETHASONEINTENSOL 38DEXAMETHASONE SODIUMPHOSPHATE 68DEXEDRINE 1DEXPAK 13 DAY 38dextroamphetamine sulfate 1dextromethorphan hbr 39dextromethorphan polistirex 39dextromethorphan-guaifenesin

40dextrose (diabetic use) 18DIAMOX 50DIAPHRAGMS 58DIASTAT ACUDIAL 13DIASTAT PEDIATRIC 13diazepam 9DIAZEPAM 9diazepam 9DIAZEPAM 13DIAZEPAM RECTAL GEL 13diclofenac potassium 2diclofenac sodium 2,3diclofenac sodium (ophth) 68diclofenac sodium (topical) 44diclofenac w/ misoprostol 3dicloxacillin sodium 70dicyclomine hcl 73

didanosine 31DIFLUCAN 21diflunisal 4DIGOXIN 35digoxin 35DILANTIN 14DILANTIN INFATABS 14DILANTIN-125 14DILATRATE SR 8DILAUDID 5diltiazem hcl 35diltiazem hcl coated beads 35diltiazem hcl extended releasebeads 35dimenhydrinate 21DIOVAN 24DIOVAN HCT 25DIPENTUM 53diphenhydramine hcl 22diphenhydramine hcl(sleep) 55diphenhydramine hcl(topical) 45diphenoxylate w/ atropine 20DIPHENOXYLATE/ATROPINE

20DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 73DIPROLENE AF 46dipyridamole 54DISALCID 4disopyramide phosphate 10disulfiram 70DITROPAN XL 75DIURIL 51divalproex sodium 15docusate calcium 57docusate sodium 57dofetilide 10DOMETUSS-DMX 40donepezil hydrochloride 70DORYX 72DORYX MPC 72dorzolamide hcl 68DORZOLAMIDE HCL 68dorzolamide hcl-timololmaleate 66

DORZOLAMIDE HCL/TIMOLOLMALEATE 66doxazosin mesylate 24doxepin hcl 18doxycycline (monohydrate) 72doxycycline hyclate 72DOXYCYCLINE HYCLATE 72doxycycline hyclate 72doxylamine succinate(sleep) 55DRAMAMINE 21DRISDOL 77drospirenone-ethinylestradiol 37DRYSOL 48DULCOLAX 57DULERA 11duloxetine hcl 17DURAGESIC 5dutasteride 54DYAZIDE 51DYRENIUM 51EC-NAPROSYN 3ECOTRIN MAXIMUMSTRENGTH 4ECOTRIN REGULARSTRENGTH 4ED BRON GP 40EDURANT 31efavirenz 31EFFEXOR XR 17ELAPRASE 52ELAVIL 18ELDEPRYL 28ELIGARD 26ELIMITE 49ELIPHOS 53ELIQUIS 11ELIQUIS STARTER PACK 11ELITE CALCIUM 60ELMIRON 54ELOCON 46EMBEDA 5EMEND 21EMEND TRIPACK 21EMSAM 15EMTRIVA 31enalapril maleate 24

Index 5

enalapril maleate &hydrochlorothiazide 25ENBREL 4ENBREL SURECLICK 4ENGERIX-B 75enoxaparin sodium 12entacapone 28entecavir 33ENTOCORT EC 38EPANED 24epinephrine (anaphylaxis) 76EPIVIR 31EPIVIR HBV 33eplerenone 25EPOGEN 55epoprostenol sodium 36EPZICOM 31EQ OMEPRAZOLE 74EQL DRY MOUTH ORALRINSE 62EQL OMEPRAZOLE 74EQL PRENATAL FORMULA 62EQUETRO 28ergocalciferol 77ergotamine w/ caffeine 58ERYGEL 43erythromycin (acne aid) 43erythromycin (ophth) 67escitalopram oxalate 15,16ESGIC 4ESTRACE 52estradiol 52estradiol vaginal 76ESTRING 76ESTROPIPATE 52ESTROSTEP FE 37ethambutol hcl 26ethosuximide 14ethynodiol diacet & ethestrad 37etodolac 3ETOPOSIDE 27EURAX 49EVAC 56EVISTA 52EVOTAZ 32EX-LAX 57

EX-LAX MAXIMUMSTRENGTH 57EXACTUSS 40EXACTUSS TR 40EXELON 70exemestane 26EXTAVIA 71ezetimibe 24famciclovir 34famotidine 73FAMVIR 34FARESTON 26FATHER JOHNS MEDICINEPLUS 40FAZACLO 30felbamate 14FELBATOL 14FELDENE 3felodipine 35FEMARA 26FEMIRON 55FEMRING 76fenofibrate 23fenofibrate micronized 23FENOFIBRIC ACID 23FENOPROFEN CALCIUM 3fenoprofen calcium 3FENORTHO 3fentanyl 5FERRETTS 55FERRIMIN 150 55FERROUS FUMARATE 55ferrous fumarate 55ferrous gluconate 55FERROUS GLUCONATE 55ferrous sulfate 55fexofenadine hcl 22fexofenadine-pseudoephedrine

40FIBRICOR 23finasteride 54FIORICET 4FIORICET/CODEINE 5FIORINAL 4FIORINAL/CODEINE #3 5FIRST-LANSOPRAZOLE 74FIRST-OMEPRAZOLE 74

FIRST-VANCOMYCIN 25 7FIRST-VANCOMYCIN 50 7FISH OIL 65FISH OIL PEARLS 65FISH OIL TRIPLESTRENGTH 65FISH OIL ULTRA 65FLAGYL 8flecainide acetate 10FLEET ENEMA 56FLEET ENEMA SIX PACK 56FLEET PEDIATRIC 56FLOLAN 36FLOMAX 54FLONASE ALLERGYRELIEF 64FLONASE ALLERGY RELIEFCHILDRENS 64FLOVENT HFA 11FLOXIN OTIC 69fluconazole 21fludrocortisone acetate 39FLUMADINE 34FLUNISOLIDE 64fluocinolone acetonide 46fluocinonide 46fluorometholone (ophth) 68FLUOXETINE DR 16fluoxetine hcl 16fluphenazine decanoate 30FLUPHENAZINE HCL 30fluphenazine hcl 30flurbiprofen 3flurbiprofen sodium 68flutamide 26fluticasone propionate 46fluticasone propionate(nasal) 64fluvoxamine maleate 16FML 68FML FORTE 68FML LIQUIFILM 68FOCALIN 1FOCALIN XR 1folic acid 55FOSAMAX 51fosamprenavir calcium 32FOSCAVIR 33

Index 6

fosinopril sodium 24fosinopril sodium &hydrochlorothiazide 25FOSRENOL 53,54FREEZONE 48FURADANTIN 74furosemide 51FUROSEMIDE 51furosemide 51FUZEON 32G-TUSICOF 40G-ZYNCOF 40gabapentin 13GABITRIL 14galantamine hydrobromide 70GALANTAMINEHYDROBROMIDE 70galantamine hydrobromide 70ganciclovir sodium 33GARDASIL 75GARDASIL 9 75GAS-X 53GAS-X EXTRA STRENGTH 53GAUZE PADS 2X2, 3X3,4X4 58gemfibrozil 23GENOTROPIN 51GENOTROPIN MINIQUICK 51GENTAK 67gentamicin sulfate (ophth) 67gentamicin sulfate (topical) 44GENTEAL MILD 65GENTEAL MILD TOMODERATE 66GENTEAL SEVERE 66GENVOYA 32GEODON 28GIAZO 53GILENYA 71GILTUSS 40GILTUSS COUGH & COLD 40GILTUSS TR 40GLASSIA 71glatiramer acetate 71GLEEVEC 27glimepiride 20glipizide 20glipizide-metformin hcl 18

GLUCAGON EMERGENCYKIT 19GLUCOPHAGE 18GLUCOPHAGE XR 18GLUCOSE 19GLUCOTROL 20GLUCOTROL XL 20GLUCOVANCE 18glyburide 20glyburide micronized 20glyburide-metformin 18glycopyrrolate 73GLYNASE 20GLYXAMBI 18GNP DAILY PRENATAL 62GNP GLUCOSE 19GNP OMEPRAZOLE 74GNP PRENATAL 62GNP QUICK DISSOLVEGLUCOSE 19GOLD BOND PSORIASISRELIEF MULTI-SYMPTOM 48GOLYTELY 56GONIOVISC 66GOODSENSE PRENATALVITAMINS 62GRALISE 71granisetron hcl 21griseofulvin microsize 21guaifenesin 42guaifenesin-codeine 40guanfacine hcl 24guanfacine hcl (adhd) 1GYNE-LOTRIMIN 76GYNE-LOTRIMIN 3 76HALDOL 29HALDOL DECANOATE100 29HALDOL DECANOATE 50 29halobetasol propionate 46haloperidol 30haloperidol decanoate 29haloperidol lactate 30HAVRIX 75HEMOCYTE 55heparin (porcine) in sodiumchloride 12HEPARIN LOCK FLUSH 12

heparin sod (porcine) in d5w 12heparin sodium (porcine) 12heparin sodium (porcine) lockflush 12heparin sodium (porcine) lockflush & nacl lock flush 12HEPARIN SODIUM/D5W 12HEPARINSODIUM/DEXTROSE 12HEPARIN SODIUM/NACL0.45% 12HEPARIN SODIUM/SODIUMCHLORIDE 12HEPARIN SODIUM/SODIUMCHLORIDE 0.9% 12HEPSERA 33HERBAL EXPEC 42HM FISH OIL 65HM OMEPRAZOLE 74HM ONE DAILY PRENATALCOMBO 62HM PRENATAL 62HM VITAMIN D3 77homatropine hbr 66HORIZANT 71HUMALOG 19HUMALOG JUNIORKWIKPEN 19HUMALOG KWIKPEN 19HUMALOG MIX 50/50 19HUMALOG MIX 50/50KWIKPEN 19HUMALOG MIX 75/25 19HUMALOG MIX 75/25KWIKPEN 19HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CD/UC/HSSTARTER 2HUMIRA PEN-PS/UVSTARTER 2HUMULIN 70/30 19HUMULIN 70/30 KWIKPEN 19HUMULIN N 19HUMULIN N KWIKPEN 19HUMULIN R 19HUMULIN R U-500(CONCENTRATED) 19HUMULIN R U-500KWIKPEN 19hydralazine hcl 25

Index 7

HYDREA 27hydrochlorothiazide 51hydrocodone w/homatropine 39hydrocodone-acetaminophen 5hydrocodone-ibuprofen 5hydrocortisone 38hydrocortisone (intrarectal) 6hydrocortisone (rectal) 7hydrocortisone (topical) 46hydrocortisone acetate(topical) 46hydrocortisone acetate w/pramoxine 6hydrocortisone w/acetic acid 69hydrogen peroxide 31hydromorphone hcl 5HYDROMORPHONE HCL 5hydromorphone hcl 5hydroxychloroquine sulfate 26hydroxyprogesteronecaproate 70hydroxyurea 27hydroxyzine hcl 9HYDROXYZINE PAMOATE 9hydroxyzine pamoate 9hyoscyamine sulfate 73HYPER-SAL 43HYPERSAL 43hypromellose (ophth) 66HYZAAR 25IBUDONE 5ibuprofen 3ICLUSIG 27imatinib mesylate 27IMBRUVICA 27imipramine hcl 18imipramine pamoate 18imiquimod 47IMITREX 58,59IMITREX STATDOSEREFILL 58IMITREX STATDOSESYSTEM 58IMODIUM A-D 20IMURAN 61INATAL GT 62INCRELEX 52indapamide 51

INDERAL LA 34INDOCIN 3indomethacin 3INFLUENZA VACCINE 75INLYTA 27INSPRA 25INSTA-GLUCOSE 19INSULIN PUMP INFUSIONSUPPLIES 58INSULIN SYRINGES AND PENNEEDLES 58INTELENCE 32INTRON A 27INTRON A W/DILUENT 27INTUNIV 1INVEGA SUSTENNA 29INVEGA TRINZA 29INVIRASE 32ipratropium bromide 10ipratropium bromide(nasal) 64ipratropium-albuterol 11irbesartan 24irbesartan-hydrochlorothiazide

25IRESSA 27ISENTRESS 32ISONIAZID 26isoniazid 26ISOPTO ATROPINE 66ISOPTO CARPINE 67ISOPTO TEARS 66ISORDIL TITRADOSE 8isosorbide dinitrate 8ISOSORBIDE DINITRATEER 8isosorbide mononitrate 8isotretinoin 43ISTALOL 66ivermectin 7JAKAFI 27JANUMET 18JANUMET XR 18JANUVIA 19JENTADUETO 18JENTADUETO XR 18K-TAB 60KALETRA 32

KAPVAY 1KAYEXALATE 61KEFLEX 36KENALOG-10 38KEPPRA 13KEPPRA XR 13KERALYT 48ketoconazole (topical) 44ketoprofen 3KETOPROFEN 3KETOPROFEN ER 3ketorolac tromethamine 3ketorolac tromethamine(ophth) 68ketotifen fumarate (ophth) 68KEY-E 77KITABIS PAK 2KLARON 43KLONOPIN 13KLOR-CON M15 60KLOR-CON/25 60KLOUT 49KLS OMEPRAZOLE 74KOMBIGLYZE XR 18KONSYL DAILY FIBER 56KONSYL ORIGINALFORMULADAILY FIBER 56KP PRENATALMULTIVITAMINS 62KPN PRENATAL 62labetalol hcl 34LAC-HYDRIN 47LAC-HYDRIN TWELVE 47lactic acid (ammoniumlactate) 47lactulose 56lactulose (encephalopathy) 53LAMICTAL 13LAMICTAL CHEWABLEDISPERSIBLE 13LAMICTAL ODT 13LAMICTAL XR 13LAMISIL 21LAMISIL AT 45LAMISIL AT JOCK ITCH 45lamivudine 32lamivudine (hbv) 33lamivudine-zidovudine 32

Index 8

lamotrigine 13LANCETS AND LANCETDEVICES 58LANOXIN 35lansoprazole 74lanthanum carbonate 54LANTUS 19LANTUS SOLOSTAR 19LASIX 51latanoprost 69LATANOPROST 69LATUDA 29LEADER QUICK DISSOLVEGLUCOSE 19leflunomide 4LETAIRIS 36letrozole 26LEUCOVORIN CALCIUM 27leucovorin calcium 27leuprolide acetate 26levalbuterol hcl 11LEVAQUIN 52LEVBID 73LEVEMIR 19LEVEMIR FLEXTOUCH 19levetiracetam 13levobunolol hcl 66levofloxacin 52levofloxacin (ophth) 67levonorgestrel & ethestradiol 37levonorgestrel (emergencyoc) 38levonorgestrel-eth estradiol(triphasic) 37levonorgestrel-ethinyl estradiol(91-day) 37levonorgestrel-ethinyl estradiol(continuous) 37levothyroxine sodium 72LEVSIN 73LEVSIN/SL 73LEXAPRO 16LEXIVA 32LIBERTY GLUCOSE CONTROLLEVEL 1 58LIBERTY GLUCOSE CONTROLLEVEL 2 58LICEMD 49lidocaine 48

lidocaine hcl 48LIDOCAINE HCL 57lidocaine hcl (localanesth.) 57lidocaine hcl (mouth-throat) 61lidocaine-prilocaine 48LIDODERM 48lindane 49LINDANE 49linezolid 8LINZESS 53liothyronine sodium 72LIPITOR 23lisinopril 24lisinopril &hydrochlorothiazide 25LITHIUM 28lithium carbonate 28LITHOBID 28LMX 4 48LODINE 3LOESTRIN 1.5/30-21 37LOESTRIN 1/20-21 37LOESTRIN FE 1/20 37LOFIBRA 23LOHIST-D 41LOHIST-DM 41LOMOTIL 20loperamide hcl 20LOPID 23lopinavir-ritonavir 32LOPRESSOR 34LOPRESSOR HCT 25LOPROX 45loratadine 22loratadine &pseudoephedrine 41lorazepam 9losartan potassium 24losartan potassium &hydrochlorothiazide 25LOSEASONIQUE 37LOTENSIN 24LOTENSIN HCT 25LOTREL 25LOTRIMIN AF 45LOTRIMIN AF FOR HER 45

LOTRIMIN AF JOCK ITCH 45LOTRIMIN ULTRA 45LOTRISONE 45lovastatin 23LOVENOX 12loxapine succinate 30LOZI-FLUR 60LUPRON DEPOT (1-MONTH) 26LUPRON DEPOT (3-MONTH) 26LUPRON DEPOT (4-MONTH) 27LUPRON DEPOT (6-MONTH) 27LURIDE 60LYCELLE 49LYRICA 13M-M-R II 75M-VIT 62MAALOX 7MACROBID 74MACRODANTIN 75MAG-200 60MAGNESIUM 60magnesium citrate 57magnesium hydroxide 57magnesium oxide 7MAGNESIUM OXIDE 60magnesium oxide (mgsupplement) 60MAGOX 400 60MAKENA 70MALARONE 26MAPROTILINE HCL 15MARPLAN 15MATULANE 27MAVIK 24MAVYRET 33MAXALT 59MAXALT-MLT 59MAXIDEX 68MAXITROL 68MAXZIDE 51MAXZIDE-25 51meclizine hcl 21MECLOFENAMATE SODIUM 3MEDROL 38

Index 9

MEDROL DOSEPAK 38medroxyprogesteroneacetate 70medroxyprogesterone acetate(contraceptive) 38mefenamic acid 3MEGACE ES 70MEGACE ORAL 27megestrol acetate 27megestrol acetate (appetite) 70MEIJER CALAMINE 49meloxicam 3memantine hcl 70MENACTRA 75MENEST 52MENOMUNE-A/C/Y/W-135 75MENOSTAR 52MENTAX 45MENVEO 75meperidine hcl 5MEPHYTON 77mercaptopurine 26mesalamine 53MESTINON 26MESTINON TIMESPAN 26METADATE CD 1METAMUCIL 56METAMUCIL ORIGINALTEXTURE 56metformin hcl 18METFORMINHYDROCHLORIDE 18methazolamide 50methimazole 72methocarbamol 64methotrexate sodium 26methscopolamine bromide 73METHYCLOTHIAZIDE 51methyldopa 24methylergonovine maleate 69METHYLIN 1,2methylphenidate hcl 2METHYLPHENIDATE HCLER 2METHYLPHENIDATEHYDROCHLORIDE ER 2methylprednisolone 38,39methylprednisolone sodsucc 38

METIPRANOLOL 66metoclopramide hcl 53METOCLOPRAMIDE ODT 53metolazone 51metoprolol &hydrochlorothiazide 25metoprolol succinate 34metoprolol tartrate 34METOPROLOLTARTRATE 34METOPROLOL/HYDROCHLOROTHIAZIDE 25METROCREAM 49METROGEL-VAGINAL 76METROLOTION 49metronidazole 8metronidazole (topical) 49metronidazole vaginal 76MEVACOR 23mexiletine hcl 10MG217 PSORIASIS MULTI-SYMPTOM 48MICATIN 45MICONAZOLE 3 76MICONAZOLE NITRATE 45miconazole nitrate (topical)45miconazole nitrate vaginal 76MICRO-K 60MICROZIDE 51midodrine hcl 76MIGERGOT 58MILK OF MAGNESIACONCENTRATE 57MILLIPRED 39MINIPRESS 24MINIVELLE 52MINOCIN 72minocycline hcl 72minoxidil 25MIRALAX 56MIRAPEX 28MIRAPEX ER 28MIRCETTE 37mirtazapine 15misoprostol 74MOBIC 3MODERIBA 1200 DOSEPACK 33

MODERIBA 800 DOSEPACK 33MODICON 37moexipril hcl 24moexipril-hydrochlorothiazide

25MOI-STIR 62mometasone furoate 46MONISTAT 1 COMBOPACK 76MONISTAT 1 DAY OR NIGHTCOMBO PACK 76MONISTAT 3 76MONISTAT 3 COMBINATIONPACK 76MONISTAT 7 COMBINATIONPACK 76MONISTAT 7 SIMPLYCURE 76MONISTAT SOOTHING CAREITCH RELIEF 46MONODOX 72montelukast sodium 10morphine sulfate 5MORPHINE SULFATE 5morphine sulfate 5MOSCO CALLUS/CORNREMOVER 48MOUTHKOTE 62moxifloxacin hcl (ophth) 67MS CONTIN 5MUCINEX 43MUCINEX CHILDRENS MULTI-SYMPTOM COLD 41MUCINEX CONGESTION &COUGH CHILDRENS 41MUCINEX D 41MUCINEX DM 41MUCINEX FAST-MAX SEVERECONGESTION & COUGH 41MUCINEX FAST-MAX SEVERECONGESTION & COUGHCLEAR & COOL 41MUCINEX MAXIMUMSTRENGTH 43MUCINEX STUFFY NOSE &COLD CHILDRENS 41MULTAQ 10MULTI-MINERALS 60multiple minerals 60MULTIVITAMINS /WMINERALS 62mupirocin 44

Index 10

mupirocin calcium (topical) 44MYAMBUTOL 26mycophenolate mofetil 61mycophenolate sodium 61MYDRIACYL 67MYFORTIC 61MYLICON 53MYLICON INFANTS GASRELIEF 53MYNATAL 62MYNATAL ADVANCE 62MYNATAL PLUS 62MYNATAL ULTRACAPLET 62MYNATAL-Z 62MYNATE 90 PLUS 62MYSOLINE 13nabumetone 3nadolol 34nadolol &bendroflumethiazide 25NALFON 3NALOXONE HCL 20naloxone hcl 20NALOXONE HCL 20naltrexone hcl 20NAMENDA 70naphazoline w/ pheniramine 67NAPHCON-A 67NAPROSYN 3naproxen 3naproxen sodium 3naratriptan hcl 59NARCAN 20NARDIL 15NASACORT ALLERGY24HR 64,65NASACORT ALLERGY 24HRCHILDRENS 65NASAL DECONGESTANT 65NASALCROM 64NAT-RUL PRENATALVITAMINS 62NATACYN 67NATALVIT 62nateglinide 20NATROBA 49NATURAL VITAMIN E 77NATURE-THROID 72

NATURE-THROID NT-2.5 72NECON 1/50-28 37NECON 10/11-28 37NEFAZODONE HCL 17nefazodone hcl 17NEFAZODONEHYDROCHLORIDE 17neomycin sulfate 2neomycin-bacitracin zn-polymyxin 67neomycin-bacitracin-polymyxin

44neomycin-bacitracin-polymyxin-pramoxine 44neomycin-polymy-dexameth 68neomycin-polymyxin-gramicidin

67neomycin-polymyxin-hc(otic) 69NEOMYCIN/POLYMYXIN/HYDROCORTISONE 68NEONATAL PLUS 62NEORAL 61NEOSPORIN 67NEOSPORIN ORIGINAL 44NEOTUSS PLUS 41NEOTUSS-D 41NEPTAZANE 50NEULASTA 55NEULASTA ONPRO KIT 55NEUPOGEN 55NEURONTIN 13NEUTROGENA ON-THE-SPOT ACNETREATMENT 44NEUTROGENA T/SAL 48nevirapine 32NEXAVAR 27NF FORMULAS CALCIUMMAGNESIUM 60niacin 77niacinamide 77NICODERM CQ 71NICORETTE 71NICORETTE MINI 71NICORETTE STARTERKIT 71nicotine 71nicotine polacrilex 71NICOTINE TRANSDERMALSYSTEM 71

NICOTROL INHALER 71NICOTROL NS 71nifedipine 35NINLARO 27nit remover 49NITRO-BID 8NITRO-DUR 8nitrofurantoin 75nitrofurantoin macrocrystal 75nitrofurantoin monohydmacro 75nitroglycerin 8NITROSTAT 8NIVA-PLUS 62NIVANEX DMX 41NIX CREME RINSE 49NIZORAL 45NOBLE MYSTIQUE EMU-LAC 47NONOXYNOLSPERMICIDES 76NOR-QD 38NORCO 5NORDITROPIN FLEXPRO 51norethin acet & estrad-fe 37norethindrone & eth estradiol37norethindrone(contraceptive) 38norethindrone acet & ethestra 37norethindrone acetate 70norethindrone acetate-ethinylestradiol-fe 37norethindrone-eth estradiol(triphasic) 37norgestimate-ethinylestradiol 37norgestimate-ethinyl estradiol(triphasic) 37norgestrel & ethinyl estradiol 37NORINYL 1+35 37NORPACE 10NORPACE CR 10NORPRAMIN 18nortriptyline hcl 18NORVASC 35NORVIR 32NOVOLOG FLEXPEN 19NOVOLOG MIX 70/30 19

Index 11

NOVOLOG MIX 70/30PREFILLED FLEXPEN 19NOVOLOG PENFILL 19NUMOISYN 62NUTRA-SUPPORT BONE 60NUTRICION PORVIDA 62NUVARING 38nystatin 21nystatin (mouth-throat) 62nystatin (topical) 45NYTOL MAXIMUMSTRENGTH 55O-CAL FA 63O-CAL PRENATAL 63OC8 44OCUFEN 68OCUFLOX 67ODEFSEY 32ofloxacin 52ofloxacin (ophth) 67ofloxacin (otic) 69OGESTREL 37olanzapine 30olmesartan medoxomil 24olmesartan medoxomil-hydrochlorothiazide 25OMEGA POWER 65OMEGA-3 65OMEGA-3 2100 65OMEGA-3 EPA FISH OIL 65omega-3 fatty acids 65OMEGA-3 FISH OIL EXTRASTRENGTH 65omeprazole 74OMEPRAZOLE 74OMEPRAZOLE + SYRSPENDSFALKA 74OMNIFLEX DIAPHRAGM 58OMNIPRED 68ondansetron 21ondansetron hcl 21ONE-A-DAY WOMENSPRENATAL 63ONFI 13ONGLYZA 19OPCON-A 67OPTIMAL D3 M 77

ORAL RELIEF SPRAY FORDRYMOUTH &DISCOMFORT 62ORAP 71ORAPRED ODT 39ORTHO MICRONOR 38ORTHO TRI-CYCLEN 37ORTHO TRI-CYCLEN LO 37ORTHO-CYCLEN 37ORTHO-NOVUM 1/35 37ORTHO-NOVUM 7/7/7 37oseltamivir phosphate 34OVACE PLUS WASH 45OVACE WASH 45OVCON-35 38oxaprozin 3oxazepam 9OXAZEPAM 9oxcarbazepine 14OXTELLAR XR 14oxybutynin chloride 75oxycodone hcl 5oxycodone w/acetaminophen 5oxycodone-aspirin 6OXYCODONE/ACETAMINOPHEN 6oyster shell 60P & S 48PAMELOR 18PANOXYL 44PANOXYL-4 CREAMYWASH 44pantoprazole sodium 74PARLODEL 28PARNATE 15paroxetine hcl 16PAXIL 16PAXIL CR 16peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 56PEG-INTRON REDIPEN 33PEGASYS 33PEGASYS PROCLICK 33PENICILLIN VPOTASSIUM 69penicillin v potassium 69PENTASA 53pentoxifylline 54

PEPCID 73PEPCID AC 73PEPCID AC EZ CHEWSMAXIMUM STRENGTH 73PEPCID AC MAXIMUMSTRENGTH 73PEPTO BISMOL 20PEPTO-BISMOL 20PEPTO-BISMOLINSTACOOL 20PEPTO-BISMOL TO-GO 20PERCOCET 6PERIDEX 62perindopril erbumine 24permethrin 49perphenazine 30PERRY PRENATAL 63PEXEVA 16PHAZYME 53PHAZYME ULTRASTRENGTH 53phenazopyridine hcl 54phenelzine sulfate 15phenobarbital 56PHENOBARBITAL 56phenobarbital 56phenylephrine hcl (ophth) 67phenylephrine w/ dm-gg 41phenylephrine-brompheniramine-dm 41phenylephrine-chlorphen-dm

41phenylephrine-guaifenesin 41PHENYTEK 14phenytoin 14phenytoin sodium extended 14phytonadione 77pilocarpine hcl 67pimozide 71pioglitazone hcl 19pioglitazone hcl-metforminhcl 18piroxicam 3PLAN B ONE-STEP 38PLAQUENIL 26PLAVIX 54PNEUMONIA VACCINE 75PNV FERROUSFUMARATE/DOCUSATE/FOLICACID 63

Index 12

PNV FOLIC ACID + IRONMULTIVITAMIN 63PNV PRENATAL PLUSMULTIVITAMIN 63PNV TABS 29-1 63PNV-VP-U 63podofilox 48polyethylene glycol 3350 56polyethylene glycol-propyleneglycol (ophth) 66polymyxin b-trimethoprim 67POLYSPORIN 44POLYTRIM 67PONSTEL 3POTASSIUM 61potassium 61potassium chloride 60POTASSIUM CHLORIDE 60potassium chloride 61POTASSIUM CHLORIDEER 60potassium chloridemicroencapsulated crystalser 61potassium citrate(alkalinizer) 54potassium citrate-citric acid 54PRADAXA 12pramipexole dihydrochloride 28PRANDIN 20PRAVACHOL 23pravastatin sodium 23praziquantel 7prazosin hcl 24PRE-NATAL FORMULA 63PRECOSE 18PRED FORTE 68PRED MILD 68PRED-G 68PRED-G S.O.P. 68PREDATOR 48prednisolone 39PREDNISOLONE 39prednisolone acetate (ophth) 68PREDNISOLONE ACETATE P-F 68prednisolone sodiumphosphate 39PREDNISOLONE SODIUMPHOSPHATE 68

PREDNISONE 39prednisone 39PREDNISONE 39PREDNISONE INTENSOL 39PREMARIN 52,76PREMPRO 52PRENATABS FA 63PRENATABS RX 63PRENATAL 63PRENATAL 19 63PRENATAL AND IRON 63PRENATAL FORTE 63PRENATALMULTIVITAMIN 63PRENATAL PLUS 63PRENATAL PLUS IRON 63PRENATAL VITAMIN &MINERAL 63PRENATALVITAMIN/IRON 63PRENATAL VITAMINS 63PRENATAL VITAMINS PLUSLOW IRON 63PRENATAL-U 63PREPLUS 63PRETAB 63PREVACID 74PREVACID 24HR 74PREZCOBIX 32PREZISTA 32PRILOSEC 74PRIMAQUINEPHOSPHATE 26primidone 14PRIMLEV 6PRINIVIL 24PRISTIQ 17probenecid 54PROCARDIA 35PROCARDIA XL 35prochlorperazine 30prochlorperazine maleate 30PROCORT 6PROCRIT 55PROCTOCORT 7progesterone micronized 70PROGRAF 61PROLASTIN-C 71

PROMACTA 55promethazine &phenylephrine 42promethazine hcl 22promethazine w/codeine 42promethazine-dm 42PROMETHAZINE/PHENYLEPHRINE 42PROMETRIUM 70propafenone hcl 10PROPANTHELINEBROMIDE 73propranolol hcl 34PROPRANOLOL HCL 34propranolol hcl 34,35PROPRANOLOL/HYDROCHLOROTHIAZIDE 25propylthiouracil 72PROSCAR 54PROTONIX 74protriptyline hcl 18PROVERA 70PROZAC 16pseudoephed-bromphen-dm 42pseudoephedrine hcl 65pseudoephedrine w/ codeine-gg 42pseudoephedrine w/ dm-gg 42pseudoephedrine-guaifenesin

42psyllium 56PULMICORT 11PULMICORT FLEXHALER 11PULMOZYME 71PURIXAN 26PX OMEPRAZOLE 74PX PRENATALMULTIVITAMINS 63pyrantel pamoate 7pyrazinamide 26pyrethrins-piperonyl butoxide-permethrin-nit remover 49PYRIDIUM 54pyridostigmine bromide 26pyridoxine hcl 77QC CALAMINE 49QC MEDIFIN PE 42QC PRENATAL 63QUALAQUIN 26QUESTRAN 23

Index 13

QUESTRAN LIGHT 23quetiapine fumarate 30QUILLICHEW ER 2QUILLIVANT XR 2quinapril hcl 24quinapril-hydrochlorothiazide

25quinidine gluconate 10QUINIDINE SULFATE 10quinine sulfate 26RA CALCIUM HI-CAL/VITAMIND 60RA DRY MOUTH 62RA FISH OIL EXTRASTRENGTH 65RA LICE SOLUTION KIT 49RA OMEPRAZOLE 74RA ONE DAILY 63RA PRENATAL 64RA PRENATALFORMULA/FOLICACID 64RA TRIPLE STRENGTH FISHOIL 65raloxifene hcl 52ramipril 24RANEXA 8ranitidine hcl 73,74RAPAMUNE 61RAZADYNE 70RAZADYNE ER 70REA-LO 47REBETOL 33REBIF 71REBIF REBIDOSE 71REBIF REBIDOSETITRATIONPACK 71REBIF TITRATION PACK 71RECOMBIVAX HB 75REESES PINWORMMEDICINE 7REFRESH LIQUIGEL 66REFRESH TEARS 66REGLAN 53RELENZA DISKHALER 34REMERON 15REMERON SOLTAB 15RENAGEL 54RENVELA 54repaglinide 20

REPREXAIN 6REQUIP 28REQUIP XL 28RESCRIPTOR 32RESTASIS 68RESTASIS MULTIDOSE 68RESTORIL 56RETIN-A 44RETIN-A MICRO 44RETIN-A MICRO PUMP 44RETROVIR 32REVATIO 36REVLIMID 61REYATAZ 32RIAX 44RIBASPHERE 33RIBASPHERE RIBAPAK 33ribavirin (hepatitis c) 33RID COMPLETE LICEELIMINATION 49RIFADIN 26rifampin 26RILUTEK 65riluzole 65rimantadine hydrochloride 34RIOMET 18RISPERDAL 29RISPERDAL CONSTA 29RISPERDAL M-TAB 29risperidone 29RISPERIDONE ODT 29RITALIN 2RITALIN LA 2ritonavir 32rivastigmine 70rivastigmine tartrate 71rizatriptan benzoate 59ROBAXIN 64ROBAXIN-750 64ROBINUL 73ROBINUL FORTE 73ROBITUSSIN CHILDRENSCOUGH & COLD CF 42ROBITUSSIN LINGERINGCOLDLONG-ACTINGCOUGHGELS 39

ROBITUSSIN PEAK COLDCOUGH+ CHEST CONGESTIONDM MAX STRENGTH 42ROBITUSSIN PEAK COLDDM 42ROBITUSSIN PEAK COLDMULTI-SYMPTOM COLD 42ROBITUSSIN TO GO COUGH&COLD CF 42ROCALTROL 52ropinirole hydrochloride 28ROXICODONE 5ROZEREM 56RYCONTUSS 42RYTHMOL 10RYTHMOL SR 10SALAC 48SALEX 48salicylic acid 48SALMON 65SALMON OIL 65SALMON OIL-1000 65salsalate 4SALVAX 48SANDIMMUNE 61SAPHRIS 30SASH KIT FOR FLUSHINGVASCULAR ACCESSDEVICES 12SB OMEPRAZOLE 74SCHOOLTIME SHAMPOO 49SE-NATAL 19 64SEASONIQUE 38selegiline hcl 28selenium sulfide 45SELSUN BLUE DEEPCLEANSING 48SELSUN BLUE NATURALS 48SELSUN BLUE NATURALSDRYSCALP 48SELZENTRY 32sennosides 57sennosides-docusatesodium 56SENOKOT 57SENOKOT S 56SENOKOT XTRA 57SENSIPAR 52SEREVENT DISKUS 11SEROQUEL 30

Index 14

sertraline hcl 16sevelamer carbonate 54SFROWASA 53SHINGRIX 75sildenafil citrate (pulmonaryhypertension) 36SILPHEN COUGH 22SILVADENE 46silver sulfadiazine 46simethicone 53simvastatin 23SINEMET 28SINEMET CR 28SINGULAIR 10sirolimus 61SKLICE 49SLO-NIACIN 77SM CALAMINE 49SM FISH OIL 65SM GLUCOSE 19SM IRON 55SM OMEPRAZOLE 74SM ONE DAILY PRENATAL 64SM PRENATAL VITAMINS 64SM VITAMIN D3 MAXIMUMSTRENGTH 77sodium chloride (inhalant) 43sodium fluoride 60SODIUM FLUORIDE 60sodium phosphates 57sodium polystyrenesulfonate 61SOLU-CORTEF 39SOLU-MEDROL 39sotalol hcl 35sotalol hcl (afib/afl) 35SPACER/AEROCHAMBER 58SPINOSAD 49SPIRIVA HANDIHALER 10spironolactone 51spironolactone &hydrochlorothiazide 51SPRYCEL 27STARLIX 20stavudine 32STIMATE 52STIOLTO RESPIMAT 11STRATTERA 1

STRIBILD 32STROMECTOL 7SUBOXONE 6SUCRAID 50sucralfate 74SUDAFED 24 HOUR 65SUDAFED CONGESTION 65SUDAFED NASALDECONGESTANT MAXIMUMSTRENGTH 65sulfacetamide sod-prednisolone 68sulfacetamide sodium 45SULFACETAMIDESODIUM 67sulfacetamide sodium(acne) 44sulfacetamide sodium(ophth) 67SULFADIAZINE 72sulfamethoxazole-trimethoprim 8sulfasalazine 53sulindac 3sumatriptan 59sumatriptan succinate 59SUMATRIPTANSUCCINATE 59sumatriptan succinate 59SUPER TWIN EPA/DHA 65SUPRAX 36SUPRESS-PE PEDIATRIC42SURMONTIL 18SUSTIVA 32SUTENT 27SW OMEPRAZOLE 74SYLATRON 27SYMAX DUOTAB 73SYMBICORT 11SYMLINPEN 120 18SYMLINPEN 60 18SYNAGIS 69SYNTHROID 72SYSTANE 66SYSTANE OVERNIGHTTHERAPY LUBRICANTEYE 66SYSTANE ULTRA 66SYSTANE ULTRA HOME &AWAY PACK 66

tacrolimus 61tadalafil (pulmonaryhypertension) 36TAMIFLU 34tamoxifen citrate 27tamsulosin hcl 54TAPAZOLE 72TARCEVA 27TARGADOX 72TARGRETIN 27TASIGNA 27TAVIST ALLERGY 22TEGRETOL 14TEGRETOL-XR 14temazepam 56TEMOVATE 46TEMOVATE E 47TENEX 24TENIVAC 73tenofovir disoproxil fumarate 32TENORETIC 100 25TENORETIC 50 25TENORMIN 34TERAZOL 3 76TERAZOL 7 76terazosin hcl 25terbinafine hcl 21terbinafine hcl (topical) 45TERCONAZOLE 76terconazole vaginal 76TESSALON PERLES 39testosterone 6TESTOSTERONE 6testosterone 6testosterone cypionate 6testosterone enanthate 6TETANUS/DIPHTHERIATOXOIDS-ADSORBED 73tetracycline hcl 72TETRACYCLINE HCL 72TGT OMEPRAZOLE 74THALOMID 61theophylline 11THERA-D 4000 77THERANATAL CORENUTRITION 64THERAPEUTIC T+PLUSMAXIMUM STRENGTH 48

Index 15

THERATEARS 66thiamine hcl 77thioridazine hcl 30thiothixene 31THRIVITE 19 64THRIVITE RX 64thyroid 72tiagabine hcl 14TIAZAC 35TIGAN 21TIKOSYN 10timolol maleate (ophth) 66TIMOLOL MALEATEOPHTHALMIC GELFORMING 66TIMOPTIC 66TIMOPTIC OCUDOSE 66TIMOPTIC-XE 66TINACTIN 45TINACTIN DEODORANT 45TINACTIN JOCK ITCH 45TIVICAY 32tizanidine hcl 64TOBI 2TOBRADEX 68tobramycin (ophth) 67tobramycin-dexamethasone 68TOBREX 67TOFRANIL 18TOLAZAMIDE 20TOLBUTAMIDE 20TOLMETIN SODIUM 3tolmetin sodium 3TOLMETIN SODIUM 3tolnaftate 45tolterodine tartrate 75TOPAMAX 14TOPAMAX SPRINKLE 14topiramate 14TOPROL XL 34torsemide 51TRACLEER 36TRADJENTA 19tramadol hcl 5tramadol-acetaminophen 6trandolapril 24TRANXENE T 9

tranylcypromine sulfate 15TRAVATAN Z 69TRAVOPROST 69trazodone hcl 17TRETIN-X 44tretinoin 44tretinoin (chemotherapy) 27tretinoin microsphere 44TRI-NORINYL 28 38TRIADVANCE 64TRIAMCINOLONEACETONIDE 39triamcinolone acetonide(mouth) 62triamcinolone acetonide(nasal) 65triamcinolone acetonide(topical) 47TRIAMCINOLONEACETONIDE PF 39triamterene &hydrochlorothiazide 51TRIAMTERENE/HYDROCHLOROTHIAZIDE 51TRICARE 64TRICODE GF 42TRICOR 23trifluoperazine hcl 31trifluridine 67TRIGLIDE 23trihexyphenidyl hcl 28TRILEPTAL 14trimethobenzamide hcl 21trimethoprim 8trimipramine maleate 18TRINATAL GT 64TRINATAL RX 1 64TRIUMEQ 32TRIZIVIR 32tropicamide 67trospium chloride 75TRUE METRIX BLOODGLUCOSETEST STRIPS 49TRUE METRIX CONTROLSOLUTION LEVEL 1 58TRUE METRIX CONTROLSOLUTION LEVEL 2 58TRUE METRIX CONTROLSOLUTION LEVEL 3 58TRUE METRIX SELFMONITORING BLOODGLUCOSE STRIPS 50

TRUECONTROL GLUCOSECONTROL LEVEL 0 58TRUECONTROL GLUCOSECONTROL LEVEL 1 58TRUETEST BLOOD GLUCOSETEST 50TRUETEST BLOOD GLUCOSETEST STRIPS 50TRUETEST GLUCOSECONTROLLEVEL 1 58TRUETEST GLUCOSECONTROLLEVEL 2 58TRUETEST GLUCOSECONTROLLEVEL 3 58TRUETEST STRIPS 50TRUETRACK BLOODGLUCOSE TEST 50TRUETRACK TEST 50TRUSOPT 68TRUVADA 32TUMS 7TUMS CHEWY BITES 7TUMS CHEWY DELIGHTS 7TUMS E-X 750 7TUMS EXTRA STRENGTH750 7TUMS KIDS 7TUMS LASTING EFFECTS 7TUMS SMOOTHIES 7TUMS ULTRA 1000 7TUSICOF 42TUSNEL C 42TUSSI-PRES PEDIATRIC 42TWINRIX 75TYBOST 32TYKERB 27TYLENOL 4TYLENOL CHILDRENS 4TYLENOL EXTRASTRENGTH 4TYLENOL INFANTS 4TYLENOL INFANTSPAIN+FEVER 4TYLENOL/CODEINE #3 6TYLENOL/CODEINE #4 6TYVASO 36TYVASO REFILL 36TYVASO STARTER 36TYZEKA 34ULORIC 54ULTRA OMEGA 3 65

Index 16

ULTRA OMEGA-3 FISH OILBURP-LESS 65ULTRACET 6ULTRAM 5ULTRAVATE 47UNISOM 55UNISOM SLEEPGELS 55UNISOM SLEEPMELTS 55urea 47URECHOLINE 75URIN-TEK 58UROCIT-K 10 54UROCIT-K 15 54UROCIT-K 5 54URSO 250 53URSO FORTE 53ursodiol 53VAGIFEM 76valacyclovir hcl 34VALCYTE 33valganciclovir hcl 33VALIUM 9valproate sodium 15valproic acid 15valsartan 24valsartan-hydrochlorothiazide

25VALTREX 34VANCOCIN HCL 8vancomycin hcl 8VANCOMYCIN HCL +SYRSPENDSF PH4 8VAQTA 75VARIVAX 75VASERETIC 25VASOTEC 24VELETRI 36VEMLIDY 34venlafaxine hcl 17VENTAVIS 36VENTOLIN HFA 11verapamil hcl 35VERAPAMIL HCL SR 35VERELAN 35VERELAN PM 35VIBRAMYCIN 72VICTOZA 19

VIDEX EC 33VIDEXPEDIATRIC 33VIGAMOX 67VIIBRYD 17VIL-RX 64VIMPAT 14VINATE M 64VINATE ONE 64VIRACEPT 33VIRAMUNE 33VIRAMUNE XR 33VIREAD 33VIROPTIC 67VIRT-ADVANCE 64VIRT-VITE GT 64VISTARIL 9VITAFOL-OB 64VITAMIN D2 77VITAMIN D3 77vitamin e 77VITAMIN E 77vitamin e 77VITEKTA 33VIVELLE-DOT 52VIVITROL 20VOL-PLUS 64VOL-TAB RX 64VOLTAREN 44VOTRIENT 27VYVANSE 1WAL-SLEEP Z LIQUIDSHOTS 55WALGREENS GLUCOSE 19warfarin sodium 11WELLBUTRIN SR 15WELLBUTRIN XL 15WESTHROID 73WP THYROID 73XALATAN 69XALKORI 27XANAX 9,10XANAX XR 10XARELTO 11XARELTO STARTERPACK 11XODOL 6XOLEGEL 45

XOLIDO 48XOPENEX 11XOPENEX CONCENTRATE 11XTAMPZA ER 5XTANDI 27XYLOCAINE 57XYLOCAINE-MPF 57YASMIN 28 38YAZ 38YODEFAN-NF CHESTCONGESTION 43ZACLIR CLEANSING 44ZADITOR 69zafirlukast 10ZANAFLEX 64ZANTAC 74ZANTAC 150 MAXIMUMSTRENGTH 74ZANTAC 75 74ZARONTIN 14ZEBETA 34ZEMAIRA 71ZENPEP 50ZERIT 33ZESTORETIC 25ZESTRIL 24ZETIA 24ZIAC 25ZIAGEN 33zidovudine 33zinc oxide (topical) 49ZIOPTAN 69ziprasidone hcl 29ZITHROMAX 57ZITHROMAX TRI-PAK 57ZITHROMAX Z-PAK 57ZMAX 57ZOCOR 23ZOFRAN 21ZOFRAN ODT 21ZOLINZA 27zolmitriptan 59ZOLOFT 17zolpidem tartrate 56ZOMIG 59ZOMIG ZMT 59ZONEGRAN 14

Index 17

zonisamide 14ZORTRESS 61ZOVIRAX 34,46ZYBAN 71ZYLOPRIM 54ZYNCOF 42ZYPREXA 30ZYPREXA ZYDIS 30ZYRTEC ALLERGY 22ZYRTEC ALLERGYCHILDRENS 22ZYRTEC CHILDRENSALLERGY 22ZYRTEC-DALLERGY/CONGESTION 42ZYVOX 8ZZZQUIL 56

Index 18

Drug Requirements/ Drug Requirements/ Tier Limits …...2018/10/01 · Drug Name Drug Tier...

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Transcript of Drug Requirements/ Drug Requirements/ Tier Limits …...2018/10/01 · Drug Name Drug Tier...