Hometown Health | Nevada Health Insurance...tramadol hcl er 100 mg tablet 1 ST tramadol hcl er 150...

STANDARD FORMULARY

January 2018 INTRODUCTION

Foreword

The HometownRx Standard Formulary is a useful reference for drug product selection. The goal of the

Drug Formulary is to enhance the physician and pharmacist’s abilities to provide optimal cost effective

drug therapy for patients. Ultimately, specific drug selection for an individual member is dependent on

your prescriber.

The Formulary is a continually reviewed and revised list of drugs, which mirror the prevailing clinical opinion of the Pharmaceutical & Therapeutics and Formulary Committees. Due to this continual review process, the HometownRx Standard Formulary may not be a complete list of all covered drug products and is not meant to be comprehensive in nature. Formulary change notices will be provided as necessary.

Benefit Coverage and Limitations The Drug Formulary is a list of covered and preferred drug products for members. The Standard Formulary is a closed formulary and any drug not found in this Formulary listing shall be considered a Non-Formulary drug. If you choose to use a Non–Formulary medication HometownRx may not reimburse for these drug products and may require you to pay 100% of the cost. Furthermore, if you choose to use a drug that is not on formulary or excluded, the cost, does not accumulate towards meeting your annual deductible or out-of-pocket maximum. In addition, certain classes of medication are not covered under your pharmacy benefit. These medication classes include: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hemantinics, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications. An ancillary charge/member paid difference may apply to brand medications when an equivalent generic is available. If a member or provider chooses a brand product over the generic the member may be responsible for their copay plus the cost difference between the brand medication and the generic medication. Ancillary charges do not apply toward your deductible or out-of-pocket maximum. The Drug Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact HometownRx at 1-844-373-0970.

How to Use the Formulary The Formulary is organized by sections either by drug class or disease state and then by the name of the drug product in alphabetical order. All drug names and strengths listed are included in the formulary. The formulary denotes all medications by product name, strength and dosage form. Generics are denoted in lower case letters by the ingredient name and the formulary will only denote the proprietary – brand names in capital letters that are covered on the formulary.

LAST REVISED 11/01/2017

STANDARD FORMULARY


For all products within the Drug Formulary, the tier level is denoted throughout the document using the following symbols in the legend below. See your schedule of benefits for the cost sharing you will pay for a given tier.

For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These prescribing types include Quantity Limit, Prior Authorization, Step Therapy, Age Limits, Max Fill Limits, and Max Days’ Supply which are denoted throughout the document as described below.

STANDARD FORMULARY


S

Formulary Product descriptions* To assist in understanding which specific drug products are covered, examples are noted below. All covered strengths and dosages forms are specified within the Formulary. Preferred Generic Products:

Preferred Brand Products and Non-Preferred Generics:

Non - Preferred Brand Products and High Cost Generics:

Specialty Products:

Preventive Products:

* The examples described in this section are for demonstration purposes only and may not reflect what is actually on formulary.

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICSNONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital-asa-caffeine cap 1

CELEBREX 100 MG CAPSULEcelecoxib

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

celecoxib 100 mg capsule 3QL 30 / 30 DAYS

ST


ST


ST


ST

diclofenac pot 50 mg tablet 1

diclofenac sod dr 25 mg tab 1



diclofenac sod ec 25 mg tab 1



diclofenac sod er 100 mg tab 1

diclofenac-misoprost 50-0.2 tb 1

diclofenac-misoprost 50-200 tb 1

diclofenac-misoprost 75-0.2 tb 1

diclofenac-misoprost 75-200 tb 1

diflunisal 500 mg tablet 1

PAGE 4 LAST UPDATED 01/2018

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

etodolac 200 mg capsule 1

etodolac 300 mg capsule 1

etodolac 400 mg tablet 1

etodolac 500 mg tablet 1

etodolac er 400 mg tablet 1



fenoprofen 600 mg tablet 1

FLECTOR 1.3% PATCHdiclofenac epolamine

2QL 30 / 30 DAYS

AL1 At least 6 yrs old

flurbiprofen 100 mg tablet 1

flurbiprofen 50 mg tablet 1

ibuprofen 100 mg/5 ml susp 1

ibuprofen 400 mg tablet 1



indomethacin 25 mg capsule 1

indomethacin 50 mg capsule 1

indomethacin er 75 mg capsule 1

ketoprofen 50 mg capsule 1

ketoprofen 75 mg capsule 1

ketoprofen er 200 mg capsule 1

ketorolac 10 mg tablet 1 QL 20 / 30 day(s)

ketorolac 15 mg/ml carpuject 1

ketorolac 15 mg/ml isecure syr 1

ketorolac 30 mg/ml carpuject 1

ketorolac 60 mg/2 ml carpuject 1

meclofenamate 100 mg capsule 1

meclofenamate 50 mg capsule 1

mefenamic acid 250 mg capsule 1

meloxicam 15 mg tablet 1

meloxicam 7.5 mg tablet 1

meloxicam 7.5 mg/5 ml susp 1

nabumetone 500 mg tablet 1



nabumetone 750 mg tablet 1NALFON 400 MG CAPSULEfenoprofen calcium

3

NAPRELAN CR 750 MG TABLETnaproxen sodium

3

naproxen 125 mg/5 ml suspen 1

naproxen 250 mg tablet 1


naproxen 500 mg kit 1


naproxen dr 375 mg tablet 1

naproxen dr 500 mg tablet 1

naproxen ec 375 mg tablet 1

naproxen ec 500 mg tablet 1

naproxen sod cr 500 mg tablet 1

naproxen sod er 500 mg tablet 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

naproxen sodium ds 550 mg tab 1

oxaprozin 600 mg caplet 1

oxaprozin 600 mg tablet 1

piroxicam 10 mg capsule 1

piroxicam 20 mg capsule 1

salsalate 500 mg tablet 1

salsalate 750 mg tablet 1SPRIX 15.75 MG NASAL SPRAYketorolac tromethamine

3

sulindac 150 mg tablet 1

sulindac 200 mg tablet 1

tolmetin sodium 200 mg tab 1

tolmetin sodium 400 mg cap 1

tolmetin sodium 600 mg tab 1VIMOVO DR 375-20 MG TABLETnaproxen/esomeprazole magnesium

2

VIMOVO DR 500-20 MG TABLETnaproxen/esomeprazole magnesium

2



ZORVOLEX 18 MG CAPSULEdiclofenac submicronized

3QL 3 / 1 DAYS

ST

ZORVOLEX 35 MG CAPSULEdiclofenac submicronized

3QL 3 / 1 DAYS

ST

OPIOID ANALGESICS, LONG-ACTINGBUTRANS 10 MCG/HR PATCHbuprenorphine

3

BUTRANS 20 MCG/HR PATCHbuprenorphine

3

BUTRANS 5 MCG/HR PATCHbuprenorphine

3

fentanyl 100 mcg/hr patch 1





hydromorphone hcl er 12 mg tab 3 PA




KADIAN ER 200 MG CAPSULEmorphine sulfate

3 ST

KADIAN ER 40 MG CAPSULEmorphine sulfate

3 ST

levorphanol 2 mg tablet 1

methadone 10 mg/5 ml solution 1

methadone 10 mg/ml oral conc 1

methadone 40 mg tablet dispr 1

methadone 5 mg/5 ml solution 1

methadone hcl 10 mg tablet 1

methadone hcl 5 mg tablet 1

methadone intensol 10 mg/ml 1

methadose 40 mg tablet dispr 1

morphine sulf er 100 mg tablet 1







morphine sulfate er 10 mg cap 1 ST


morphine sulfate er 120 mg cap 2 QL 30 / 30 DAYS



morphine sulfate er 30 mg cap 2 QL 30 / FILL








MS CONTIN 30 MG TABLETmorphine sulfate

3

NUCYNTA ER 100 MG TABLETtapentadol hcl

2

QL 180 / 30 DAYS

ST



2

QL 180 / 30 DAYS

ST



2

QL 180 / 30 DAYS

ST



2

QL 180 / 30 DAYS

ST



2

QL 180 / 30 DAYS

ST




OPANA ER 20 MG TABLEToxymorphone hcl

2QL 60 / 30 DAYS

ST

OXYCONTIN 10 MG TABLEToxycodone hcl

3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST

oxymorphone hcl er 10 mg tab 1 QL 60 / 30 DAYS





oxymorphone hcl er 5 mg tablet 1 QL 60 / 30 DAYS

oxymorphone hcl er 7.5 mg tab 1 QL 60 / 30 DAYS

tramadol hcl er 100 mg capsule 1

tramadol hcl er 100 mg tablet 1 ST








OPIOID ANALGESICS, SHORT-ACTINGABSTRAL 100 MCG TAB SUBLINGUALfentanyl citrate

2 PA

ABSTRAL 200 MCG TAB SUBLINGUALfentanyl citrate

2 PA


2 PA


2 PA


2 PA


2 PA

acetaminop-codeine 120-12 mg/5 1

acetaminophen-cod #2 tablet 1



asa-butalb-caff-cod #3 capsule 1

ascomp with codeine capsule 1

butalb-caff-acetaminoph-codein 1

butalbital comp-codeine #3 cap 1

butorphanol 10 mg/ml spray 1

carisoprodol cpd-codeine tab 1

carisoprodol-aspirin-codein tb 1

codeine sulfate 15 mg tablet 1



endocet 10-325 mg tablet 1

endocet 2.5-325 mg tablet 1

endocet 5-325 tablet 1

endocet 7.5-325 mg tablet 1

fentanyl cit otfc 1,200 mcg 1 PA

fentanyl cit otfc 1,600 mcg 1 PA

fentanyl citrate otfc 200 mcg 1 PA






FENTORA 100 MCG BUCCAL TABLETfentanyl citrate

2 PA


2 PA


2 PA


2 PA


2 PA

hydrocodone-acetamin 10-300 mg 1


hydrocodone-acetamin 10-325/15 1

hydrocodone-acetamin 2.5-108/5 1

hydrocodone-acetamin 2.5-325 1

hydrocodone-acetamin 5-163/7.5 1

hydrocodone-acetamin 5-217/10 1





hydrocodone-acetamn 7.5-325/15 1

hydrocodone-ibuprofen 10-200 1

hydrocodone-ibuprofen 2.5-200 1

hydrocodone-ibuprofen 5-200 mg 1

hydrocodone-ibuprofen 7.5-200 1

hydromorphone 1 mg/ml carpujct 1

hydromorphone 1 mg/ml solution 1

hydromorphone 1 mg/ml syringe 1

hydromorphone 2 mg tablet 1


hydromorphone 2 mg/ml isecure 1

hydromorphone 3 mg suppos 1





hydromorphone 5 mg/5 ml soln 1


LAZANDA 100 MCG NASAL SPRAYfentanyl citrate

3PA

ST

lorcet 5-325 mg tablet 1

lorcet hd 10-325 mg tablet 1

meperidine 100 mg tablet 1

meperidine 50 mg tablet 1

meperidine 50 mg/5 ml solution 1

morphine sulf 10 mg suppos 1

morphine sulf 10 mg/5 ml soln 1





morphine sulfate ir 15 mg tab 2

morphine sulfate ir 30 mg tab 2

nalbuphine 10 mg/ml ampul 1

nalbuphine 100 mg/10 ml vial 1

nalbuphine 20 mg/ml ampul 1

nalbuphine 200 mg/10 ml vial 1NUCYNTA 100 MG TABLETtapentadol hcl

2 QL 180 / 30 DAYS

NUCYNTA 50 MG TABLETtapentadol hcl

2 QL 180 / 30 DAYS

NUCYNTA 75 MG TABLETtapentadol hcl

2 QL 180 / 30 DAYS

OXAYDO 5 MG TABLEToxycodone hcl

3 ST

oxycodon-acetaminophen 2.5-325 1

oxycodon-acetaminophen 7.5-325 1

oxycodone hcl 10 mg tablet 1

oxycodone hcl 100 mg/5 ml soln 1






oxycodone hcl 5 mg capsule 1


oxycodone hcl 5 mg/5 ml soln 1

oxycodone-acetaminophen 10-325 1

oxycodone-acetaminophen 5-325 1

oxycodone-aspirin 4.8355-325 1

oxycodone-ibuprofen 5-400 tab 1

oxymorphone hcl 10 mg tablet 1 QL 60 / 30 DAYS

oxymorphone hcl 5 mg tablet 1 QL 60 / 30 DAYS

pentazocine-naloxone tablet 1SUBSYS 100 MCG SPRAYfentanyl

3 PA

TALWIN 30 MG/ML AMPULpentazocine lactate

3

TALWIN 30 MG/ML VIALpentazocine lactate

3

tramadol hcl 50 mg tablet 1

tramadol-acetaminophn 37.5-325 1

vicodin hp 10-300 mg tablet 1XARTEMIS XR 7.5-325 MG TABLEToxycodone hcl/acetaminophen

3 PA

xylon 10-200 mg tablet 1

ANESTHETICSLOCAL ANESTHETICS

ethyl chloride spray 1

lidocaine 2% viscous soln 1

lidocaine 3% cream 1

lidocaine 5% ointment 1

lidocaine 5% patch 2

lidocaine hcl 2% jelly 1

lidocaine hcl 2% jelly 1

lidocaine hcl 3% lotion 1

lidocaine hcl 4% solution 1

lidocaine hcl 4% solution 1

lidocaine-prilocaine cream 1



lidocaine-prilocaine cream 1LIDODERM 5% PATCHlidocaine

2

SYNERA PATCHlidocaine/tetracaine

3

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTSALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calc dr 333 mg tab 1

disulfiram 250 mg tablet 1

disulfiram 500 mg tablet 1

naltrexone 50 mg tablet 1

OPIOID DEPENDENCE TREATMENTS

buprenorphin-naloxon 8-2 mg sl 3 PA

buprenorphine 2 mg tablet sl 3

buprenorphine 8 mg tablet sl 3

buprenorphn-naloxn 2-0.5 mg sl 3 PA

SUBOXONE 12 MG-3 MG SL FILMbuprenorphine hcl/naloxone hcl

4 PA

SUBOXONE 2 MG-0.5 MG SL FILMbuprenorphine hcl/naloxone hcl

4 PA


4 PA


4 PA

OPIOID REVERSAL AGENTSnaloxone 2 mg/2 ml syringe 3

SMOKING CESSATION AGENTS

buproban 150 mg tablet 5 PA

bupropion hcl sr 150 mg tablet 5

QL 60 / 30 DAYS

PA


bupropion hcl sr 150 mg tablet 5

QL 60 / 30 DAYS

PA




ANTIBACTERIALSAMINOGLYCOSIDES

garamycin 0.3% eye drops 2GARAMYCIN 3 MG/ML EYE DROPSgentamicin sulfate

2

gentak 0.3 % eye ointment 1

gentamicin 0.1% cream 1

gentamicin 0.1% ointment 1

gentamicin 0.3% eye drops 1

gentamicin 0.3% eye ointment 1

gentamicin 3 mg/gm eye oint 1

gentamicin 3 mg/ml eye drops 1

neomycin 500 mg tablet 1

paromomycin 250 mg capsule 1

tobramycin 0.3% eye drops 1TOBREX 0.3% EYE OINTMENTtobramycin

2

ANTIBACTERIALS, OTHERALTABAX 1% OINTMENTretapamulin

3

azuphen mb capsule 1

bacitracin 500 unit/gm ophth 1BACTROBAN NASAL 2% OINTMENTmupirocin calcium

3

CLEOCIN 100 MG VAGINAL OVULEclindamycin phosphate

3

clindamycin 2% vaginal cream 1

clindamycin 75 mg/5 ml soln 1

clindamycin hcl 150 mg capsule 1



clindamycin pediatr 75 mg/5 ml 1

clindamycin ph 1% gel 1

clindamycin ph 1% solution 1

clindamycin phos 1% pledget 1

clindamycin phosp 1% lotion 1



clindamycin phosphate 1% foam 1

erythromycin-benzoyl gel 1FLAGYL ER 750 MG TABLETmetronidazole

3

hyophen tablet 1

linezolid 100 mg/5 ml susp 3 PA

linezolid 600 mg tablet 2 PA

methenamine hipp 1 gm tablet 1

methenamine md 500 mg tablet 1

metronidazole 250 mg tablet 1

metronidazole 375 mg capsule 1

metronidazole 500 mg tablet 1

metronidazole vaginal 0.75% gl 1MONUROL 3 GM SACHETfosfomycin tromethamine

3

mupirocin 2% cream 1 QL 1 / 7 DAYS

mupirocin 2% ointment 1 QL 1 / 7 DAYS

neomy-polymyxin b 40 mg/ml amp 1

neomy-polymyxin b 40 mg/ml vl 1

nitrofurantoin 25 mg/5 ml susp 1

nitrofurantoin mcr 100 mg cap 1

nitrofurantoin mcr 50 mg cap 1

nitrofurantoin mono-mcr 100 mg 1PRIMSOL 50 MG/5 ML ORAL SOLNtrimethoprim

3

SIVEXTRO 200 MG TABLETtedizolid phosphate

2 PA

SULFAMYLON 8.5% CREAMmafenide acetate

3

tinidazole 250 mg tablet 1

tinidazole 500 mg tablet 1

trimethoprim 100 mg tablet 1

ur n-c tablet 1

urophen mb tablet 1

ustell capsule 1



vancomycin hcl 125 mg capsule 1

vancomycin hcl 250 mg capsule 1XIFAXAN 200 MG TABLETrifaximin

3 PA

XIFAXAN 550 MG TABLETrifaximin

3 PA

BETA-LACTAM, CEPHALOSPORINSCEDAX 400 MG CAPSULEceftibuten

3

CEDAX 400 MG CAPSULEceftibuten dihydrate

3

cefaclor 125 mg/5 ml susp 1

cefaclor 250 mg capsule 1

cefaclor 250 mg/5 ml susp 1

cefaclor 375 mg/5 ml suspen 1

cefaclor 500 mg capsule 1

cefaclor er 500 mg tablet 1

cefadroxil 1 gm tablet 1

cefadroxil 250 mg/5 ml susp 1

cefadroxil 500 mg capsule 1

cefadroxil 500 mg/5 ml susp 1

cefdinir 125 mg/5 ml susp 1

cefdinir 250 mg/5 ml susp 1

cefdinir 300 mg capsule 1

cefditoren pivoxil 200 mg tab 1

cefditoren pivoxil 400 mg tab 1

cefixime 100 mg/5 ml susp 3

cefixime 200 mg/5 ml susp 3

cefpodoxime 100 mg tablet 1

cefpodoxime 100 mg/5 ml susp 1

cefpodoxime 200 mg tablet 1

cefpodoxime 50 mg/5 ml susp 1

cefprozil 125 mg/5 ml susp 1

cefprozil 250 mg tablet 1

cefprozil 250 mg/5 ml susp 1

cefprozil 500 mg tablet 1



ceftibuten 180 mg/5 ml susp 3

ceftibuten 400 mg capsule 3CEFTIN 250 MG/5 ML ORAL SUSPcefuroxime axetil

2

cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

cephalexin 125 mg/5 ml susp 1

cephalexin 250 mg capsule 1

cephalexin 250 mg tablet 1

cephalexin 250 mg/5 ml susp 1


cephalexin 500 mg tablet 1


BETA-LACTAM, PENICILLINSamox-clav 200-28.5 mg tab chew 1

amox-clav 200-28.5 mg/5 ml sus 1

amox-clav 250-125 mg tablet 1


amox-clav 400-57 mg tab chew 1

amox-clav 400-57 mg/5 ml susp 1




amox-clav er 1,000-62.5 mg tab 1

amoxicillin 125 mg tab chew 1

amoxicillin 125 mg/5 ml susp 1


amoxicillin 250 mg capsule 1

amoxicillin 250 mg tab chew 1



amoxicillin 500 mg capsule 1

amoxicillin 500 mg tablet 1

amoxicillin 875 mg tablet 1

ampicillin 125 mg/5 ml susp 1



ampicillin 250 mg capsule 1

ampicillin 250 mg/5 ml susp 1

ampicillin 500 mg capsule 1AUGMENTIN 125-31.25 MG/5 MLamoxicillin/potassium clavulanate

2

dicloxacillin 250 mg capsule 1

dicloxacillin 500 mg capsule 1MOXATAG ER 775 MG TABLETamoxicillin

3

penicillin vk 125 mg/5 ml soln 1

penicillin vk 250 mg tablet 1

penicillin vk 250 mg/5 ml soln 1

penicillin vk 500 mg tablet 1

MACROLIDESAZASITE 1% EYE DROPSazithromycin

3

azithromycin 1 gm pwd packet 1

azithromycin 100 mg/5 ml susp 1 QL 30 / FILL

azithromycin 200 mg/5 ml susp 1 QL 3 / 10 DAYS

azithromycin 250 mg tablet 1 QL 8 / FILL

azithromycin 500 mg tablet 1 QL 10 / FILL

azithromycin 600 mg tablet 1

clarithromycin 125 mg/5 ml sus 1

clarithromycin 250 mg tablet 1

clarithromycin 250 mg/5 ml sus 1

clarithromycin 500 mg tablet 1

clarithromycin er 500 mg tab 1DIFICID 200 MG TABLETfidaxomicin

2 PA

E.E.S. 400 FILMTABerythromycin ethylsuccinate

1

ery 2% pads 1ERY-TAB EC 333 MG TABLETerythromycin base

3

ERYTHROCIN 250 MG FILMTABerythromycin stearate

1



erythromycin 0.5% eye ointment 1

erythromycin 0.5% eye ointment 1

erythromycin 2% gel 1

erythromycin 2% pledgets 1

erythromycin 2% solution 1

erythromycin 250 mg filmtab 1

erythromycin 500 mg filmtab 1

erythromycin dr 250 mg cap 1

erythromycin ec 250 mg cap 1

erythromycin es 400 mg tab 1KETEK 300 MG TABLETtelithromycin

3

KETEK 400 MG TABLETtelithromycin

3

PCE 500 MG TABLETerythromycin base

3

ZITHROMAX 1 GM POWDER PACKETazithromycin

3

QUINOLONESBESIVANCE 0.6% SUSPbesifloxacin hcl

2

CILOXAN 0.3% OINTMENTciprofloxacin hcl

2

CIPRO 10% SUSPENSIONciprofloxacin

2

CIPRO 5% SUSPENSIONciprofloxacin

2

ciprofloxacin 0.2% otic soln 1

ciprofloxacin 0.3% eye drop 1

ciprofloxacin 250 mg/5 ml susp 2

ciprofloxacin 500 mg/5 ml susp 2

ciprofloxacin er 1,000 mg tab 1

ciprofloxacin er 500 mg tablet 1

ciprofloxacin hcl 100 mg tab 1

ciprofloxacin hcl 250 mg tab 1 QL 30 / FILL




PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFACTIVE 320 MG TABLETgemifloxacin mesylate

3

gatifloxacin 0.5% eye drops 2LEVAQUIN 750 MG TABLETlevofloxacin

3

levofloxacin 0.5% eye drops 1

levofloxacin 25 mg/ml solution 1

levofloxacin 250 mg tablet 1

levofloxacin 250 mg/10 ml soln 1


levofloxacin 500 mg/20 ml soln 1


MOXEZA 0.5% EYE DROPSmoxifloxacin hcl

3QL 3 / FILL

ST

ofloxacin 0.3% ear drops 1

ofloxacin 0.3% eye drops 1

ofloxacin 200 mg tablet 1

ofloxacin 300 mg tablet 1

ofloxacin 400 mg tablet 1VIGAMOX 0.5% EYE DROPSmoxifloxacin hcl

2 QL 3 / FILL

ZYMAXID 0.5% EYE DROPSgatifloxacin

2

SULFONAMIDESAVC 15% CREAMsulfanilamide

2

BLEPH-10 10% EYE DROPSsulfacetamide sodium

1

silver sulfadiazine 1% cream 1

sodium sulfacetamide 10% lot 1

sodium sulfacetamide 10% lotn 1SSD 1% CREAMsilver sulfadiazine

1

sulfacetamide 10% eye drops 1

sulfacetamide 10% eye ointment 1

sulfacetamide sod 10% top susp 1

sulfadiazine 500 mg tablet 1



sulfamethoxazole-tmp ds tablet 1

sulfamethoxazole-tmp ss tablet 1

sulfamethoxazole-tmp susp 1

sulfamethoxazole-tmp susp 1SULFATRIM PEDIATRIC SUSPENSIONsulfamethoxazole/trimethoprim

1

TETRACYCLINESdemeclocycline 150 mg tablet 1

demeclocycline 300 mg tablet 1

doxycycline 25 mg/5 ml susp 1

doxycycline hyc dr 100 mg tab 1



doxycycline hyclate 100 mg cap 1

doxycycline hyclate 100 mg tab 1

doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1

doxycycline mono 100 mg tablet 1

doxycycline mono 150 mg cap 1



doxycycline mono 75 mg capsule 1


minocycline 100 mg capsule 1



minocycline er 135 mg tablet 1



minocycline hcl 100 mg tablet 1

minocycline hcl 50 mg tablet 1

minocycline hcl 75 mg tablet 1SOLODYN ER 55 MG TABLETminocycline hcl

3

tetracycline 250 mg capsule 1



tetracycline 500 mg capsule 1VIBRAMYCIN 25 MG/5 ML SUSPdoxycycline monohydrate

2

ANTICONVULSANTSANTICONVULSANTS, OTHER

levetiracetam 1,000 mg tablet 1

levetiracetam 100 mg/ml soln 1

levetiracetam 250 mg tablet 1


levetiracetam 500 mg/5 ml soln 1


levetiracetam er 500 mg tablet 1

levetiracetam er 750 mg tablet 1POTIGA 200 MG TABLETezogabine

2

POTIGA 300 MG TABLETezogabine

2


2


2

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG KAPSEALmethsuximide

3

ethosuximide 250 mg capsule 1

ethosuximide 250 mg/5 ml soln 1

zonisamide 100 mg capsule 1



GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDIASTAT 2.5 MG PEDI SYSTEMdiazepam

2

diazepam 10 mg rectal gel syst 1

diazepam 2.5 mg rectal gel sys 1

divalproex dr 125 mg cap sprnk 1

divalproex sod dr 125 mg tab 1





divalproex sod er 250 mg tab 1

divalproex sod er 500 mg tab 1

gabapentin 100 mg capsule 1

gabapentin 250 mg/5 ml soln 1



gabapentin 600 mg tablet 1

gabapentin 800 mg tablet 1GABITRIL 12 MG TABLETtiagabine hcl

3

GABITRIL 16 MG TABLETtiagabine hcl

3

GRALISE 30-DAY STARTER PACKgabapentin

3 ST

GRALISE ER 300 MG TABLETgabapentin

3 ST

GRALISE ER 600 MG TABLETgabapentin

3 ST

phenobarbital 100 mg tablet 1


phenobarbital 16.2 mg tablet 1

phenobarbital 20 mg/5 ml elix 1

phenobarbital 20 mg/5 ml soln 1






primidone 250 mg tablet 1

primidone 50 mg tablet 1SABRIL 500 MG POWDER PACKETvigabatrin

4

tiagabine hcl 2 mg tablet 1

tiagabine hcl 4 mg tablet 1

valproic acid 250 mg capsule 1

valproic acid 250 mg/5 ml soln 1



GLUTAMATE REDUCING AGENTSfelbamate 400 mg tablet 1

felbamate 600 mg tablet 1

felbamate 600 mg/5 ml susp 1

FYCOMPA 10 MG TABLETperampanel

3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 4 / 1 DAYS

ST


3QL 2 / 1 DAYS

ST


3QL 2 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST

LAMICTAL ODT 100 MG TABLETlamotrigine

2 AL1 At least 2 yrs old







LAMICTAL ODT START KT (ORANGE)lamotrigine


lamotrigine 100 mg tablet 1QL 60 / 30 DAYS






lamotrigine 25 mg disper tab 1 AL1 At least 2 yrs old





lamotrigine 25 mg tb start kit 1 AL1 At least 2 yrs old

lamotrigine 5 mg disper tablet 1 AL1 At least 2 yrs old

lamotrigine er 100 mg tablet 1 AL1 At least 2 yrs old






lamotrigine odt 100 mg tablet 2 AL1 At least 2 yrs old




lamotrigine odt kit (orange) 3 AL1 At least 2 yrs old

lamotrigine tab start kit-blue 1 AL1 At least 2 yrs old

topiramate 100 mg tablet 1

topiramate 15 mg sprinkle cap 1


topiramate 25 mg sprinkle cap 1



SODIUM CHANNEL AGENTS

APTIOM 200 MG TABLETeslicarbazepine acetate

3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 2 / 1 DAYS

ST


3QL 2 / 1 DAYS

ST

BANZEL 200 MG TABLETrufinamide

3

QL 240 / 30 DAYS

ST




BANZEL 40 MG/ML SUSPENSIONrufinamide

3ST


BANZEL 400 MG TABLETrufinamide

3ST


carbamazepine 100 mg tab chew 1

carbamazepine 100 mg/5 ml susp 1

carbamazepine 200 mg tablet 1

carbamazepine er 100 mg cap 1


carbamazepine er 200 mg tablet 1


carbamazepine er 400 mg tablet 1DILANTIN 30 MG CAPSULEphenytoin sodium extended

2

epitol 200 mg tablet 1

oxcarbazepine 150 mg tablet 1

oxcarbazepine 300 mg tablet 1

oxcarbazepine 300 mg/5 ml susp 1

oxcarbazepine 600 mg tablet 1PEGANONE 250 MG TABLETethotoin

3

phenytoin 100 mg/4 ml susp 1

phenytoin 125 mg/5 ml susp 1

phenytoin 50 mg infatab 1

phenytoin 50 mg tablet chew 1

phenytoin sod ext 100 mg cap 1

phenytoin sod ext 200 mg cap 1

phenytoin sod ext 300 mg cap 1TEGRETOL XR 100 MG TABLETcarbamazepine

2

VIMPAT 10 MG/ML SOLUTIONlacosamide


VIMPAT 100 MG TABLETlacosamide





PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSVIMPAT 200 MG TABLETlacosamide




ANTIDEMENTIA AGENTSANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 1 mg tab 1

CHOLINESTERASE INHIBITORSARICEPT 23 MG TABLETdonepezil hcl

2

ARICEPT 5 MG TABLETdonepezil hcl

3

donepezil hcl 10 mg tablet 1



donepezil hcl odt 10 mg tablet 1

donepezil hcl odt 5 mg tablet 1EXELON 2 MG/ML ORAL SOLUTIONrivastigmine tartrate

2

EXELON 4.6 MG/24HR PATCHrivastigmine

2

EXELON 9.5 MG/24HR PATCHrivastigmine

2

galantamine 4 mg/ml oral soln 1

galantamine er 16 mg capsule 1



galantamine hbr 12 mg tablet 1



rivastigmine 1.5 mg capsule 1

rivastigmine 13.3 mg/24hr ptch 2

rivastigmine 3 mg capsule 1

rivastigmine 4.5 mg capsule 1

rivastigmine 4.6 mg/24hr patch 2

rivastigmine 6 mg capsule 1

rivastigmine 9.5 mg/24hr patch 2



N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine 5-10 mg titration pk 3

memantine hcl 10 mg tablet 3

memantine hcl 2 mg/ml solution 3

memantine hcl 5 mg tablet 3NAMENDA 2 MG/ML SOLUTIONmemantine hcl

3

NAMENDA 5 MG TABLETmemantine hcl

3

ANTIDEPRESSANTSANTIDEPRESSANTS, OTHER

APLENZIN ER 174 MG TABLETbupropion hbr

3 ST

budeprion sr 150 mg tablet 1 QL 60 / 30 DAYS

bupropion hcl 100 mg tablet 1QL 60 / 30 DAYS


bupropion hcl 75 mg tablet 1QL 60 / 30 DAYS


bupropion hcl sr 100 mg tablet 1 AL1 At least 18 yrs old

bupropion hcl sr 100 mg tablet 1 AL1 At least 18 yrs old

bupropion hcl sr 200 mg tab 1 QL 60 / 30 DAYS

bupropion hcl sr 200 mg tablet 1 QL 60 / 30 DAYS

bupropion hcl sr 200 mg tablet 1 QL 60 / 30 DAYS

bupropion hcl xl 150 mg tablet 1

QL 30 / 30 DAYS

ST


bupropion hcl xl 300 mg tablet 1

QL 30 / 30 DAYS

ST


chlordiazepo-amitriptyl 5-12.5 1

chlordiazepox-amitriptyl 10-25 1

FORFIVO XL 450 MG TABLETbupropion hcl

3ST




mirtazapine 15 mg odt 1QL 30 / 30 DAYS


mirtazapine 15 mg tablet 1QL 30 / 30 DAYS










mirtazapine 7.5 mg tablet 1QL 30 / 30 DAYS


olanzapine-fluoxetine 12-25 mg 1 ST





perphen-amitrip 2 mg-10 mg tab 1 AL1 At least 18 yrs old





MONOAMINE OXIDASE INHIBITORSEMSAM 12 MG/24 HOURS PATCHselegiline

3

EMSAM 6 MG/24 HOURS PATCHselegiline

3

EMSAM 9 MG/24 HOURS PATCHselegiline

3

MARPLAN 10 MG TABLETisocarboxazid

3



phenelzine sulfate 15 mg tab 1

tranylcypromine sulf 10 mg tab 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR)

BRINTELLIX 10 MG TABLETvortioxetine hydrobromide

3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST

citalopram hbr 10 mg tablet 1QL 30 / 30 DAYS


citalopram hbr 10 mg/5 ml soln 1 AL1 At least 18 yrs old





desvenlafaxine er 100 mg tab 3QL 1 / 1 DAYS

ST


ST


ST

desvenlafaxine er 50 mg tablet 3QL 1 / 1 DAYS

ST

desvenlafaxine fum er 100 mg 3QL 1 / 1 DAYS

ST

desvenlafaxine fum er 50 mg 3QL 1 / 1 DAYS

ST

desvenlafaxine suc er 100 mg 3QL 1 / 1 DAYS

ST



desvenlafaxine suc er 50 mg tb 3QL 1 / 1 DAYS

ST

escitalopram 10 mg tablet 3 QL 1 / 1 DAYS



escitalopram oxalate 5 mg/5 ml 3

FETZIMA 20-40 MG TITRATION PAKlevomilnacipran hcl

3QL 1 / 1 DAYS

ST

FETZIMA ER 120 MG CAPSULElevomilnacipran hcl

3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST

fluoxetine 20 mg/5 ml solution 1 AL1 At least 18 yrs old

fluoxetine dr 90 mg capsule 1

QL 4 / 28 DAYS

ST


fluoxetine hcl 10 mg capsule 1 AL1 At least 18 yrs old

fluoxetine hcl 10 mg tablet 1QL 30 / 30 DAYS



fluoxetine hcl 20 mg tablet 1QL 30 / 30 DAYS



fluvoxamine maleate 100 mg tab 1



KHEDEZLA ER 100 MG TABLETdesvenlafaxine

3QL 1 / 1 DAYS

ST



KHEDEZLA ER 50 MG TABLETdesvenlafaxine

3QL 1 / 1 DAYS

ST

maprotiline 25 mg tablet 1



nefazodone hcl 100 mg tablet 1 AL1 At least 18 yrs old





paroxetine cr 12.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine cr 25 mg tablet 1 AL1 At least 18 yrs old

paroxetine cr 37.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 12.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 25 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 37.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine hcl 10 mg tablet 1QL 30 / 30 DAYS








PAXIL 10 MG/5 ML SUSPENSIONparoxetine hcl


PRISTIQ ER 100 MG TABLETdesvenlafaxine succinate

2QL 1 / 1 DAYS


PRISTIQ ER 50 MG TABLETdesvenlafaxine succinate

2QL 1 / 1 DAYS


sertraline 20 mg/ml oral conc 1 AL1 At least 18 yrs old



sertraline hcl 100 mg tablet 1 AL1 At least 18 yrs old

sertraline hcl 25 mg tablet 1QL 30 / 30 DAYS


sertraline hcl 50 mg tablet 1QL 60 / 30 DAYS


trazodone 100 mg tablet 1 AL1 At least 18 yrs old




TRINTELLIX 10 MG TABLETvortioxetine hydrobromide

3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST


3QL 1 / 1 DAYS

ST

venlafaxine hcl 100 mg tablet 1 AL1 At least 18 yrs old


venlafaxine hcl 37.5 mg tablet 1 AL1 At least 18 yrs old



venlafaxine hcl er 150 mg cap 1

QL 30 / 30 DAYS

ST


venlafaxine hcl er 150 mg tab 1QL 30 / 30 DAYS


VENLAFAXINE HCL ER 150 MG TABvenlafaxine hcl

1QL 30 / 30 DAYS


venlafaxine hcl er 225 mg tab 1


1QL 30 / 30 DAYS




venlafaxine hcl er 37.5 mg cap 1

QL 30 / 30 DAYS

ST


venlafaxine hcl er 37.5 mg tab 1QL 30 / 30 DAYS


VENLAFAXINE HCL ER 37.5 MG TABvenlafaxine hcl

1QL 30 / 30 DAYS


venlafaxine hcl er 75 mg cap 1

QL 30 / 30 DAYS

ST


venlafaxine hcl er 75 mg tab 1QL 30 / 30 DAYS



1QL 30 / 30 DAYS


VIIBRYD 10 MG TABLETvilazodone hcl

3 ST


3 ST


3 ST

TRICYCLICSamitriptyline hcl 10 mg tab 1

amitriptyline hcl 100 mg tab 1





amoxapine 100 mg tablet 1




clomipramine 25 mg capsule 1





desipramine 10 mg tablet 1






doxepin 10 mg capsule 1

doxepin 10 mg/ml oral conc 1






imipramine hcl 10 mg tablet 1



imipramine pamoate 100 mg cap 1




nortriptyline 10 mg/5 ml sol 1

nortriptyline hcl 10 mg cap 1




protriptyline hcl 10 mg tablet 1

protriptyline hcl 5 mg tablet 1

trimipramine maleate 100 mg cp 1

trimipramine maleate 25 mg cap 1

trimipramine maleate 50 mg cap 1

ANTIEMETICSANTIEMETICS, OTHER

compro 25 mg suppository 1

meclizine 25 mg tablet 1



metoclopramide 10 mg tablet 1

metoclopramide 10 mg/10 ml sol 1

metoclopramide 5 mg tablet 1

metoclopramide 5 mg/5 ml soln 1

metoclopramide 5 mg/5 ml syrup 1

perphenazine 16 mg tablet 1




phenadoz 12.5 mg suppository 1 AL1 At least 2 yrs old

phenadoz 25 mg suppository 1 AL1 At least 2 yrs old

prochlorperazine 10 mg tab 1

prochlorperazine 25 mg supp 1

prochlorperazine 5 mg tablet 1

promethazine 12.5 mg suppos 1 AL1 At least 2 yrs old

promethazine 25 mg suppository 1 AL1 At least 2 yrs old

promethazine 50 mg suppository 1 AL1 At least 2 yrs old

promethazine 50 mg tablet 1 AL1 At least 2 yrs old

promethegan 12.5 mg suppos 1 AL1 At least 2 yrs old

promethegan 25 mg suppository 1 AL1 At least 2 yrs old

promethegan 50 mg suppository 1 AL1 At least 2 yrs old

TRANSDERM-SCOP 1.5 MG/3 DAYscopolamine

3

trimethobenzamide 300 mg cap 1

EMETOGENIC THERAPY ADJUNCTSANZEMET 100 MG TABLETdolasetron mesylate

2 QL 1 / FILL

ANZEMET 50 MG TABLETdolasetron mesylate

2 QL 1 / FILL

aprepitant 125 mg capsule 2 QL 2 / 30 DAYS



CESAMET 1 MG CAPSULEnabilone

3 ST



dronabinol 10 mg capsule 3 PA

dronabinol 2.5 mg capsule 3 PA

dronabinol 5 mg capsule 3 PA

EMEND 125 MG CAPSULEaprepitant

2 QL 2 / 30 DAYS


2 QL 4 / 30 DAYS


2 QL 4 / 30 DAYS

granisetron hcl 1 mg tablet 1 QL 2 / FILL

ondansetron 4 mg/5 ml solution 1 QL 50 / 15 DAYS

ondansetron hcl 24 mg tablet 1



ondansetron odt 4 mg tablet 1

ondansetron odt 8 mg tablet 1SANCUSO 3.1 MG/24 HR PATCHgranisetron

2

VARUBI 90 MG TABLETrolapitant hcl

3 ST

ZUPLENZ 4 MG SOLUBLE FILMondansetron

3

ZUPLENZ 8 MG SOLUBLE FILMondansetron

3

ANTIFUNGALSciclodan 8% solution 1

ciclopirox 0.77% cream 1

ciclopirox 0.77% gel 1

ciclopirox 0.77% topical susp 1

ciclopirox 1% shampoo 1

ciclopirox 8% solution 1

clotrimazole 1% cream 1

clotrimazole 10 mg troche 1

econazole nitrate 1% cream 1ERTACZO 2% CREAMsertaconazole nitrate

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSEXELDERM 1% CREAMsulconazole nitrate

3

EXELDERM 1% SOLUTIONsulconazole nitrate

3

exoderm lotion 1

fluconazole 10 mg/ml susp 1

fluconazole 100 mg tablet 1

fluconazole 150 mg tablet 1 QL 4 / FILL


fluconazole 40 mg/ml susp 1


flucytosine 250 mg capsule 1

flucytosine 500 mg capsule 1

griseofulvin 125 mg/5 ml susp 1

griseofulvin micro 500 mg tab 1

griseofulvin ultra 125 mg tab 1

griseofulvin ultra 250 mg tab 1

gynazole 1 2% cream 2

itraconazole 100 mg capsule 1QL 30 / FILL

PA

ketoconazole 2% cream 1

ketoconazole 2% foam 1

ketoconazole 2% shampoo 1

ketoconazole 200 mg tablet 1

ketodan 2% foam 2KETODAN 2% FOAM KITketoconazole/skin cleanser combination no.28

2

naftifine hcl 2% cream 3NAFTIN 2% CREAMnaftifine hcl

3

NATACYN EYE DROPSnatamycin

2

NOXAFIL 40 MG/ML SUSPENSIONposaconazole


nyamyc 100,000 units/gm powder 1

nystatin 100,000 unit/gm cream 1



nystatin 100,000 unit/gm powd 1

nystatin 100,000 unit/ml susp 1

nystatin 100,000 units/gm oint 1

nystatin 500,000 unit oral tab 1

nystatin 500,000 unit/5 ml sus 1

nystatin-triamcinolone cream 1

nystatin-triamcinolone ointm 1

nystop 100,000 units/gm powder 1ORAVIG 50 MG BUCCAL TABLETmiconazole

3 ST

oxiconazole nitrate 1% cream 3

pedi-dri topical powder 1PENLAC 8% SOLUTIONciclopirox

3

SPORANOX 10 MG/ML SOLUTIONitraconazole

2

terbinafine hcl 250 mg tablet 1

terconazole 0.4% cream 1

terconazole 0.8% cream 1

terconazole 80 mg suppository 1VFEND 40 MG/ML SUSPENSIONvoriconazole

3 PA

voriconazole 200 mg tablet 1 PA

voriconazole 40 mg/ml susp 3 PA

voriconazole 50 mg tablet 1 PA

XOLEGEL 2% GELketoconazole


ANTIGOUT AGENTSallopurinol 100 mg tablet 1

allopurinol 300 mg tablet 1

colchicine 0.6 mg tablet 1 QL 4 / 1 DAYS

COLCRYS 0.6 MG TABLETcolchicine

3 QL 4 / 1 DAYS

probenecid 500 mg tablet 1

probenecid-colchicine tabs 1

ULORIC 40 MG TABLETfebuxostat

3QL 30 / 30 DAYS




ULORIC 80 MG TABLETfebuxostat

3QL 30 / 30 DAYS


ANTIMIGRAINE AGENTSERGOT ALKALOIDS

CAFERGOT TABLETergotamine tartrate/caffeine

2

dihydroergotamine 1 mg/ml am 1

dihydroergotamine 1 mg/ml vl 1

dihydroergotamine 4 mg/ml spry 1 QL 8 / 30 DAYS

ERGOMAR 2 MG TABLET SLergotamine tartrate

2

ergotamine-caffeine 1-100mg tb 2

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate 12.5 mg tab 3 ST

almotriptan malate 6.25 mg tab 3QL 6 / FILL

ST

ALSUMA 6 MG/0.5 ML AUTO-INJECTsumatriptan succinate

3 QL 1 / FILL

AXERT 12.5 MG TABLETalmotriptan malate

3QL 6 / FILL

ST

AXERT 6.25 MG TABLETalmotriptan malate

3QL 6 / FILL

ST

FROVA 2.5 MG TABLETfrovatriptan succinate

3QL 9 / FILL

ST

IMITREX 6 MG/0.5 ML CARTRIDGESsumatriptan succinate

3 QL 1 / FILL

IMITREX 6 MG/0.5 ML PEN INJECTsumatriptan succinate

3 QL 1 / FILL

naratriptan 1 mg tablet 1QL 9 / FILL

ST

naratriptan 2.5 mg tablet 1QL 9 / FILL

ST

naratriptan hcl 1 mg tablet 1QL 9 / FILL

ST



naratriptan hcl 2.5 mg tablet 1QL 9 / FILL

ST

RELPAX 20 MG TABLETeletriptan hbr

2 QL 6 / FILL

RELPAX 40 MG TABLETeletriptan hbr

2 QL 6 / FILL

rizatriptan 10 mg odt 1 QL 9 / FILL

rizatriptan 10 mg tablet 1 QL 9 / FILL

rizatriptan 5 mg odt 1 QL 9 / FILL

rizatriptan 5 mg tablet 1 QL 9 / FILL

sumatriptan 20 mg nasal spray 1 QL 6 / FILL

sumatriptan 4 mg/0.5 ml inject 1 QL 1 / FILL

sumatriptan 5 mg nasal spray 1 QL 6 / FILL

sumatriptan 6 mg/0.5 ml inject 1 QL 1 / FILL

sumatriptan 6 mg/0.5 ml refill 1 QL 1 / FILL

sumatriptan 6 mg/0.5 ml syrng 1

sumatriptan 6 mg/0.5 ml vial 1 QL 2.5 / FILL

sumatriptan succ 100 mg tablet 1 QL 9 / FILL



SUMAVEL DOSEPRO 6 MG/0.5 MLsumatriptan succinate

3 QL 1 / 30 day(s)

zolmitriptan 2.5 mg odt 3QL 6 / FILL

ST

zolmitriptan 2.5 mg tablet 3QL 6 / FILL

ST

zolmitriptan 5 mg odt 3QL 3 / FILL

ST

zolmitriptan 5 mg tablet 3QL 3 / FILL

ST

ZOMIG 5 MG NASAL SPRAYzolmitriptan

3QL 6 / FILL

ST



ANTIMYASTHENIC AGENTSPARASYMPATHOMIMETICS

guanidine hcl 125 mg tablet 1MESTINON 180 MG TIMESPANpyridostigmine bromide

2

MESTINON 60 MG/5 ML SYRUPpyridostigmine bromide

2

pyridostigmine br 60 mg tablet 1

pyridostigmine er 180 mg tab 2

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, OTHER

dapsone 100 mg tablet 1

dapsone 25 mg tablet 1MYCOBUTIN 150 MG CAPSULErifabutin

2

rifabutin 150 mg capsule 2

ANTITUBERCULARScycloserine 250 mg capsule 1

ethambutol hcl 100 mg tablet 1

ethambutol hcl 400 mg tablet 1

isoniazid 100 mg tablet 1

isoniazid 300 mg tablet 1

isoniazid 50 mg/5 ml solution 1PASER GRANULES 4 GM PACKETaminosalicylic acid

3

PRIFTIN 150 MG TABLETrifapentine

3

pyrazinamide 500 mg tablet 1RIFAMATE CAPSULErifampin/isoniazid

3

rifampin 150 mg capsule 1

rifampin 300 mg capsule 1RIFATER TABLETrifampin/isoniazid/pyrazinamide

3

SEROMYCIN 250 MG CAPSULEcycloserine

2

TRECATOR 250 MG TABLETethionamide

3



ANTINEOPLASTICSALKYLATING AGENTS

ALKERAN 2 MG TABLETmelphalan

2

cyclophosphamide 25 mg tab 1

cyclophosphamide 50 mg tablet 1GLEOSTINE 10 MG CAPSULElomustine

2

GLEOSTINE 100 MG CAPSULElomustine

2

GLEOSTINE 40 MG CAPSULElomustine

2

HEXALEN 50 MG CAPSULEaltretamine

2

LEUKERAN 2 MG TABLETchlorambucil

2

LOMUSTINE 10 MG CAPSULElomustine

2


2


2

MATULANE 50 MG CAPSULEprocarbazine hcl

4

MYLERAN 2 MG TABLETbusulfan

2 PA

TEMODAR 20 MG CAPSULEtemozolomide

4 PA

temozolomide 100 mg capsule 4






ANTIANDROGENSbicalutamide 50 mg tablet 1

flutamide 125 mg capsule 1NILANDRON 150 MG TABLETnilutamide

2



XTANDI 40 MG CAPSULEenzalutamide

2QL 4 / 1 DAYS

ST

ZYTIGA 250 MG TABLETabiraterone acetate

2 PA

ANTIANGIOGENIC AGENTS

POMALYST 1 MG CAPSULEpomalidomide

2QL 21 / 28 DAYS

PA


2QL 21 / 28 DAYS

PA


2QL 21 / 28 DAYS

PA


2QL 21 / 28 DAYS

PA

REVLIMID 10 MG CAPSULElenalidomide

4


4

REVLIMID 2.5 MG CAPSULElenalidomide

4


4


4

THALOMID 100 MG CAPSULEthalidomide

4


4


4


4

ANTIESTROGENS/MODIFIERSEMCYT 140 MG CAPSULEestramustine phosphate sodium

2

FARESTON 60 MG TABLETtoremifene citrate

2

tamoxifen 10 mg tablet 5

tamoxifen 20 mg tablet 5



ANTIMETABOLITES

capecitabine 150 mg tablet 4 PA

capecitabine 500 mg tablet 4 PA

DROXIA 200 MG CAPSULEhydroxyurea

2


2


2

fluorouracil 2% topical soln 1

fluorouracil 5% cream 1

fluorouracil 5% topical soln 1

hydroxyurea 500 mg capsule 1

mercaptopurine 50 mg tablet 1

PURIXAN 20 MG/ML ORAL SUSPmercaptopurine

2ST

AL1 Up to 5 yrs old

TABLOID 40 MG TABLETthioguanine

2

XELODA 150 MG TABLETcapecitabine

4 PA

XELODA 500 MG TABLETcapecitabine

4 PA

ANTINEOPLASTICS, OTHER

HEMANGEOL 4.28 MG/ML ORAL SOLNpropranolol hcl

3PA

ST

leucovorin calcium 10 mg tab 1



leucovorin calcium 5 mg tab 1LYSODREN 500 MG TABLETmitotane

2

SYLATRON 200 MCG KITpeginterferon alfa-2b

4 PA


4 PA


4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSYNRIBO 3.5 MG/ML VIALomacetaxine mepesuccinate

2 PA

ZOLINZA 100 MG CAPSULEvorinostat

4

AROMATASE INHIBITORS, 3RD GENERATIONanastrozole 1 mg tablet 1

exemestane 25 mg tablet 1

letrozole 2.5 mg tablet 1

ENZYME INHIBITORSetoposide 50 mg capsule 1HYCAMTIN 0.25 MG CAPSULEtopotecan hcl

2 PA

HYCAMTIN 1 MG CAPSULEtopotecan hcl

2 PA

MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TABLETeverolimus

3QL 30 / 30 DAYS

PA

AFINITOR 2.5 MG TABLETeverolimus

3QL 30 / 30 DAYS

PA

AFINITOR 5 MG TABLETeverolimus

3QL 30 / 30 DAYS

PA

AFINITOR 7.5 MG TABLETeverolimus

3QL 30 / 30 DAYS

PA

BOSULIF 100 MG TABLETbosutinib

2 PA

BOSULIF 500 MG TABLETbosutinib

2 PA

CAPRELSA 100 MG TABLETvandetanib

2PA

ST

CAPRELSA 300 MG TABLETvandetanib

2PA

ST

COMETRIQ 100 MG DAILY-DOSE PKcabozantinib s-malate

4 PA

COMETRIQ 140 MG DAILY-DOSE PKcabozantinib s-malate

4 PA

COMETRIQ 60 MG DAILY-DOSE PACKcabozantinib s-malate

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSERIVEDGE 150 MG CAPSULEvismodegib

4 PA

ICLUSIG 15 MG TABLETponatinib hcl

2 PA

ICLUSIG 45 MG TABLETponatinib hcl

2 PA

imatinib mesylate 100 mg tab 3 PA

imatinib mesylate 400 mg tab 3 PA

IMBRUVICA 140 MG CAPSULEibrutinib

2 PA

INLYTA 1 MG TABLETaxitinib

2 PA

INLYTA 5 MG TABLETaxitinib

2 PA

IRESSA 250 MG TABLETgefitinib

2QL 2 / 1 DAYS

PA

JAKAFI 10 MG TABLETruxolitinib phosphate

4 PA


4 PA


4 PA


4 PA


4 PA

MEKINIST 0.5 MG TABLETtrametinib dimethyl sulfoxide

2 PA

MEKINIST 2 MG TABLETtrametinib dimethyl sulfoxide

2 PA

NEXAVAR 200 MG TABLETsorafenib tosylate

2 PA

SPRYCEL 100 MG TABLETdasatinib

2 PA


2 PA


2 PA


2 PA


2 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSPRYCEL 80 MG TABLETdasatinib

2 PA

STIVARGA 40 MG TABLETregorafenib

2 PA

SUTENT 12.5 MG CAPSULEsunitinib malate

2 PA

SUTENT 25 MG CAPSULEsunitinib malate

2

SUTENT 50 MG CAPSULEsunitinib malate

2 PA

TAFINLAR 50 MG CAPSULEdabrafenib mesylate

2 PA

TAFINLAR 75 MG CAPSULEdabrafenib mesylate

2 PA

TARCEVA 100 MG TABLETerlotinib hcl

4 PA


4 PA


4 PA

TASIGNA 150 MG CAPSULEnilotinib hcl

2 PA

TASIGNA 200 MG CAPSULEnilotinib hcl

2 PA

TYKERB 250 MG TABLETlapatinib ditosylate

3 PA

VOTRIENT 200 MG TABLETpazopanib hcl

3

XALKORI 200 MG CAPSULEcrizotinib

4 PA

XALKORI 250 MG CAPSULEcrizotinib

4 PA

ZELBORAF 240 MG TABLETvemurafenib

2 PA

ZYKADIA 150 MG CAPSULEceritinib

2 PA

RETINOIDSbexarotene 75 mg capsule 4TARGRETIN 1% GELbexarotene

3

TARGRETIN 75 MG CAPSULEbexarotene

4


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTARGRETIN 75 MG SOFTGELbexarotene

4

tretinoin 10 mg capsule 1 AL1 Up to 30 yrs old

TREATMENT ADJUNCTSMESNEX 400 MG TABLETmesna

2

ANTIPARASITICSANTIHELMINTHICS

ALBENZA 200 MG TABLETalbendazole

2

BILTRICIDE 600 MG TABLETpraziquantel

2

ivermectin 3 mg tablet 2 ST

SKLICE 0.5% LOTIONivermectin

3 ST

STROMECTOL 3 MG TABLETivermectin

2 ST

ANTIPROTOZOALSALINIA 100 MG/5 ML SUSPENSIONnitazoxanide

2

ALINIA 500 MG TABLETnitazoxanide

2

atovaquone 750 mg/5 ml susp 2

atovaquone-proguanil 250-100 1

atovaquone-proguanil 62.5-25 1

chloroquine ph 250 mg tablet 1

chloroquine ph 500 mg tablet 1COARTEM TABLETSartemether/lumefantrine

3

DARAPRIM 25 MG TABLETpyrimethamine

2

hydroxychloroquine 200 mg tab 1

mefloquine hcl 250 mg tablet 1NEBUPENT 300 MG INHAL POWDERpentamidine isethionate

2

primaquine 26.3 mg tablet 3

quinine sulfate 324 mg capsule 1 PA



PEDICULICIDES/SCABICIDESEURAX 10% CREAMcrotamiton

2

EURAX 10% LOTIONcrotamiton

2

lindane 1% lotion 1

lindane 1% shampoo 1

malathion 0.5% lotion 1

permethrin 5% cream 1

ANTIPARKINSON AGENTSANTICHOLINERGICS

benztropine mes 0.5 mg tab 1

benztropine mes 1 mg tablet 1

benztropine mes 2 mg tablet 1

trihexyphenidyl 2 mg tablet 1

trihexyphenidyl 2 mg/5 ml elx 1

trihexyphenidyl 5 mg tablet 1

ANTIPARKINSON AGENTS, OTHERamantadine 100 mg capsule 1

amantadine 100 mg tablet 1

amantadine 100 mg/10 ml soln 1

amantadine 50 mg/5 ml solution 1

carbidopa-levodopa-enta 100 mg 1 ST






entacapone 200 mg tablet 1TASMAR 100 MG TABLETtolcapone

3

tolcapone 100 mg tablet 3



DOPAMINE AGONISTS

APOKYN 30 MG/3 ML CARTRIDGEapomorphine hcl

4QL 10 / FILL

PA

bromocriptine 2.5 mg tablet 1

bromocriptine 5 mg capsule 1NEUPRO 1 MG/24 HR PATCHrotigotine

3 ST

NEUPRO 2 MG/24 HR PATCHrotigotine

3 ST


3 ST


3 ST


3 ST


3 ST

pramipexole 0.125 mg tablet 1




pramipexole 1 mg tablet 1


pramipexole er 0.375 mg tablet 2 ST



pramipexole er 2.25 mg tablet 2

pramipexole er 3 mg tablet 2 ST


ropinirole hcl 0.25 mg tablet 1

ropinirole hcl 0.5 mg tablet 1

ropinirole hcl 1 mg tablet 1







ropinirole hcl er 12 mg tablet 1





DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa 25 mg tablet 2

carbidopa-levo 10-100 mg odt 1



carbidopa-levo er 25-100 tab 1

carbidopa-levo er 50-200 tab 1

carbidopa-levodopa 10-100 tab 1



MONOAMINE OXIDASE B (MAO-B) INHIBITORSAZILECT 0.5 MG TABLETrasagiline mesylate

3 ST

AZILECT 1 MG TABLETrasagiline mesylate

3 ST

rasagiline mesylate 0.5 mg tab 3 ST

rasagiline mesylate 1 mg tab 3 ST

selegiline hcl 5 mg capsule 1

selegiline hcl 5 mg tablet 1

ANTIPSYCHOTICS1ST GENERATION/TYPICAL

chlorpromazine 10 mg tablet 1





fluphenazine 1 mg tablet 1




fluphenazine 2.5 mg tablet 1

fluphenazine 2.5 mg/5 ml elix 1


fluphenazine 5 mg/ml conc 1

haloperidol 0.5 mg tablet 1

haloperidol 1 mg tablet 1





haloperidol lac 2 mg/ml conc 1

loxapine 10 mg capsule 1



loxapine 50 mg capsule 1ORAP 1 MG TABLETpimozide

2

ORAP 2 MG TABLETpimozide

2

pimozide 1 mg tablet 2

pimozide 2 mg tablet 2

thioridazine 10 mg tablet 1



thiothixene 1 mg capsule 1




trifluoperazine 1 mg tablet 1




2ND GENERATION/ATYPICAL

aripiprazole 10 mg tablet 2 QL 30 / 30 DAYS








aripiprazole odt 10 mg tablet 2 QL 30 / 30 DAYS

aripiprazole odt 15 mg tablet 2 QL 30 / 30 DAYS

FANAPT 1 MG TABLETiloperidone

3 ST


3 ST


3 ST


3 ST


3 ST


3 ST


3 ST

GEODON 20 MG CAPSULEziprasidone hcl

3 QL 60 / FILL


3 QL 60 / FILL


3 QL 60 / FILL


3 QL 60 / FILL

INVEGA ER 1.5 MG TABLETpaliperidone

3 ST

INVEGA ER 3 MG TABLETpaliperidone

3 ST


3 ST


3 ST

LATUDA 120 MG TABLETlurasidone hcl

2 ST


2 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLATUDA 40 MG TABLETlurasidone hcl

2 ST


2 ST


2 ST

olanzapine 10 mg tablet 3


olanzapine 2.5 mg tablet 3



olanzapine 7.5 mg tablet 3

olanzapine odt 10 mg tablet 3




paliperidone er 1.5 mg tablet 3 ST

paliperidone er 3 mg tablet 3 ST



quetiapine er 150 mg tablet 2 ST





quetiapine fumarate 100 mg tab 1






risperidone 0.25 mg odt 1

risperidone 0.25 mg tablet 1



risperidone 0.5 mg odt 1

risperidone 0.5 mg tablet 1

risperidone 1 mg odt 1

risperidone 1 mg tablet 1

risperidone 1 mg/ml solution 1







SAPHRIS 10 MG TAB SL BLK CHERYasenapine maleate

3

QL 2 / 1 DAYS

ST


SAPHRIS 5 MG TAB SL BLK CHERRYasenapine maleate

3

QL 2 / 1 DAYS

ST


SEROQUEL XR 150 MG TABLETquetiapine fumarate

2 ST


2 ST


2 ST


2 ST


2 ST

ziprasidone hcl 20 mg capsule 1 QL 60 / FILL




ZYPREXA 10 MG TABLETolanzapine

3


3

ZYPREXA 2.5 MG TABLETolanzapine

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSZYPREXA 20 MG TABLETolanzapine

3


3

ZYPREXA 7.5 MG TABLETolanzapine

3

ZYPREXA ZYDIS 10 MG TABLETolanzapine

3


3


3


3

TREATMENT-RESISTANTclozapine 100 mg tablet 1

clozapine 200 mg tablet 1



clozapine odt 100 mg tablet 1

clozapine odt 12.5 mg tablet 1

clozapine odt 150 mg tablet 3

clozapine odt 25 mg tablet 1FAZACLO 150 MG ODTclozapine

3 ST

VERSACLOZ 50 MG/ML SUSPENSIONclozapine

3QL 18 / 1 DAYS

ST

ANTISPASTICITY AGENTSbaclofen 10 mg tablet 1

baclofen 20 mg tablet 1

dantrolene sodium 100 mg cap 1



tizanidine hcl 2 mg capsule 1

tizanidine hcl 2 mg tablet 1


tizanidine hcl 4 mg tablet 1




ANTIVIRALSANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir 375 mg/5 ml vial 1

foscarnet 24 mg/ml infus bttl 1VALCYTE 450 MG TABLETvalganciclovir hcl

3 ST

VALCYTE 50 MG/ML SOLUTIONvalganciclovir hcl

3 ST

valganciclovir 450 mg tablet 3 ST

ZIRGAN 0.15% OPHTHALMIC GELganciclovir

3

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil 10 mg tab 3BARACLUDE 0.05 MG/ML SOLUTIONentecavir

4

BARACLUDE 0.5 MG TABLETentecavir

4

BARACLUDE 1 MG TABLETentecavir

4

entecavir 0.5 mg tablet 4

entecavir 1 mg tablet 4EPIVIR HBV 25 MG/5 ML SOLNlamivudine

2

HEPSERA 10 MG TABLETadefovir dipivoxil

3

lamivudine 100 mg tablet 2

lamivudine hbv 100 mg tablet 2TYZEKA 600 MG TABLETtelbivudine

3

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTSEPCLUSA 400 MG-100 MG TABLETsofosbuvir/velpatasvir

4 PA

INCIVEK 375 MG TABLETtelaprevir

4 PA

OLYSIO 150 MG CAPSULEsimeprevir sodium

4 PA

SOVALDI 400 MG TABLETsofosbuvir

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSVICTRELIS 200 MG CAPSULEboceprevir

4 PA

ZEPATIER 50-100 MG TABLETelbasvir/grazoprevir

4 PA

ANTI-HEPATITIS C (HCV) AGENTS, OTHERINTRON A 10 MILLION UNITS VIALinterferon alfa-2b,recomb.

4 PA

INTRON A 18 MILLION UNIT/3 MLinterferon alfa-2b,recomb.

4 PA

INTRON A 18 MILLION UNITS VIALinterferon alfa-2b,recomb.

4 PA

INTRON A 50 MILLION UNITS VIALinterferon alfa-2b,recomb.

4 PA

moderiba 200-400 mg dosepack 4 PA

moderiba 600-400 mg dosepack 4 PA

PEGASYS 180 MCG/0.5 ML SYRINGEpeginterferon alfa-2a

4

PEGASYS 180 MCG/ML VIALpeginterferon alfa-2a

4QL 5 / FILL

PA

PEGASYS PROCLICK 135 MCG/0.5peginterferon alfa-2a

4QL 5 / FILL

PA

PEGINTRON 120 MCG KITpeginterferon alfa-2b

3QL 5 / FILL

PA


3QL 5 / FILL

PA


3QL 5 / FILL

PA


3QL 5 / FILL

PA

PEGINTRON REDIPEN 120 MCGpeginterferon alfa-2b

3QL 5 / FILL

PA

PEGINTRON REDIPEN 120 MCG 4PKpeginterferon alfa-2b

3QL 5 / FILL

PA


3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPEGINTRON REDIPEN 150 MCG 4PKpeginterferon alfa-2b

3 PA


3 PA


3 PA


3 PA


3 PA

REBETOL 40 MG/ML SOLUTIONribavirin

4 PA

ribasphere 200 mg capsule 4 PA

ribasphere 200 mg tablet 4 PA



RIBASPHERE RIBAPAK 200-400 MGribavirin

4 PA


4 PA


4 PA


1 PA

RIBATAB 400-400 MG DOSEPACKribavirin

4 PA

RIBATAB 400-600 MG DOSEPACKribavirin

4 PA

ribavirin 200 mg capsule 4 PA

ribavirin 200 mg tablet 4 PA

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

ISENTRESS 100 MG TABLET CHEWraltegravir potassium

2

QL 60 / 30 DAYS

ST


ISENTRESS 25 MG TABLET CHEWraltegravir potassium

2

QL 60 / 30 DAYS

ST




ISENTRESS 400 MG TABLETraltegravir potassium

2

QL 60 / 30 DAYS

ST


STRIBILD TABLETelvitegravir/cobicistat/emtricitabine/tenofovir disoproxil

2

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)ATRIPLA TABLETefavirenz/emtricitabine/tenofovir disoproxil fumarate


COMPLERA TABLETemtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate

2 PA

EDURANT 25 MG TABLETrilpivirine hcl

2

INTELENCE 100 MG TABLETetravirine

3 ST


3 ST


3 ST

nevirapine 200 mg tablet 1

nevirapine 50 mg/5 ml susp 1

nevirapine er 400 mg tablet 2RESCRIPTOR 100 MG TABLETdelavirdine mesylate

3

RESCRIPTOR 200 MG TABLETdelavirdine mesylate

3

SUSTIVA 200 MG CAPSULEefavirenz

3

SUSTIVA 50 MG CAPSULEefavirenz

3

SUSTIVA 600 MG TABLETefavirenz

3

VIRAMUNE 50 MG/5 ML SUSPnevirapine

2

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)

abacavir 300 mg tablet 1

abacavir-lamivudine-zidov tab 3

didanosine dr 125 mg capsule 1





didanosine dr 400 mg capsule 1EMTRIVA 10 MG/ML SOLUTIONemtricitabine

2 ST

EMTRIVA 200 MG CAPSULEemtricitabine

2QL 30 / 30 DAYS

ST

EPZICOM TABLETabacavir sulfate/lamivudine

2

lamivudine 10 mg/ml oral soln 2



lamivudine-zidovudine tablet 1

stavudine 1 mg/ml solution 1

stavudine 15 mg capsule 1



stavudine 40 mg capsule 1TRUVADA 200 MG-300 MG TABLETemtricitabine/tenofovir disoproxil fumarate

3

VIDEX 2 GM PEDIATRIC SOLNdidanosine

2

VIDEX 4 GM PEDIATRIC SOLNdidanosine

2

VIREAD 150 MG TABLETtenofovir disoproxil fumarate

2


2


2


2

VIREAD POWDERtenofovir disoproxil fumarate

2

ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate

2

zidovudine 100 mg capsule 1

zidovudine 300 mg tablet 1

zidovudine 50 mg/5 ml syrup 1



ANTI-HIV AGENTS, OTHERFUZEON 90 MG VIALenfuvirtide

2

SELZENTRY 150 MG TABLETmaraviroc

2 ST

SELZENTRY 300 MG TABLETmaraviroc

2 ST

ANTI-HIV AGENTS, PROTEASE INHIBITORSAPTIVUS 100 MG/ML SOLUTIONtipranavir/vitamin e tpgs

3

APTIVUS 250 MG CAPSULEtipranavir

3

CRIXIVAN 200 MG CAPSULEindinavir sulfate

2

CRIXIVAN 400 MG CAPSULEindinavir sulfate

2

INVIRASE 200 MG CAPSULEsaquinavir mesylate

3

INVIRASE 500 MG TABLETsaquinavir mesylate

3

KALETRA 100-25 MG TABLETlopinavir/ritonavir

2

KALETRA 200-50 MG TABLETlopinavir/ritonavir

2

KALETRA 80 MG-20 MG/ML SOLNlopinavir/ritonavir

2

LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium

3 ST

LEXIVA 700 MG TABLETfosamprenavir calcium

3QL 30 / 30 DAYS

ST

NORVIR 100 MG SOFTGEL CAPritonavir

3

NORVIR 100 MG TABLETritonavir

3

NORVIR 80 MG/ML SOLUTIONritonavir

3

PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate

3 ST

PREZISTA 150 MG TABLETdarunavir ethanolate

3 ST


3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPREZISTA 600 MG TABLETdarunavir ethanolate

3 ST


3 ST


3 ST

REYATAZ 150 MG CAPSULEatazanavir sulfate

3QL 2 / 1 DAYS

ST


3QL 2 / 1 DAYS

ST


3 ST

VIRACEPT 250 MG TABLETnelfinavir mesylate

3

VIRACEPT 625 MG TABLETnelfinavir mesylate

3

ANTI-INFLUENZA AGENTSRELENZA 5 MG DISKHALERzanamivir

3

rimantadine hcl 100 mg tablet 1TAMIFLU 30 MG CAPSULEoseltamivir phosphate

3 QL 10 / FILL

TAMIFLU 45 MG CAPSULEoseltamivir phosphate

3 QL 10 / FILL

TAMIFLU 6 MG/ML SUSPENSIONoseltamivir phosphate

3 QL 60 / FILL

TAMIFLU 75 MG CAPSULEoseltamivir phosphate

3 QL 10 / FILL

ANTIHERPETIC AGENTSacyclovir 200 mg capsule 1

acyclovir 200 mg/5 ml susp 1

acyclovir 400 mg tablet 1

acyclovir 5% ointment 1

acyclovir 800 mg tablet 1DENAVIR 1% CREAMpenciclovir

3

famciclovir 125 mg tablet 1 QL 21 / FILL





trifluridine 1% eye drops 1

valacyclovir hcl 1 gram tablet 3 QL 30 / 30 DAYS

valacyclovir hcl 500 mg tablet 3 QL 30 / 30 DAYS

VALTREX 1 GM CAPLETvalacyclovir hcl

3 QL 30 / 30 DAYS

VALTREX 500 MG CAPLETvalacyclovir hcl

3 QL 30 / 30 DAYS

ZOVIRAX 5% CREAMacyclovir

2

ANXIOLYTICSANXIOLYTICS, OTHER

buspirone hcl 10 mg tablet 1




buspirone hcl 7.5 mg tablet 1

meprobamate 200 mg tablet 1

meprobamate 400 mg tablet 1

BENZODIAZEPINESalprazolam 0.25 mg tablet 1

alprazolam 0.5 mg tablet 1

alprazolam 1 mg tablet 1

alprazolam 2 mg tablet 1

alprazolam er 0.5 mg tablet 1

alprazolam er 1 mg tablet 1



alprazolam odt 0.25 mg tab 1

alprazolam odt 0.5 mg tab 1

alprazolam odt 1 mg tab 1

alprazolam odt 2 mg tab 1

alprazolam xr 0.5 mg tablet 1

alprazolam xr 1 mg tablet 1





chlordiazepoxide 10 mg capsule 1



clonazepam 0.125 mg dis tab 1

clonazepam 0.125 mg odt 1


clonazepam 0.5 mg dis tablet 1


clonazepam 0.5 mg tablet 1

clonazepam 1 mg dis tablet 1

clonazepam 1 mg odt 1

clonazepam 1 mg tablet 1

clonazepam 2 mg odt 1

clonazepam 2 mg tablet 1

clorazepate 15 mg tablet 1

clorazepate 3.75 mg tablet 1

clorazepate 7.5 mg tablet 1

diazepam 10 mg tablet 1



diazepam 5 mg/5 ml solution 1

lorazepam 0.5 mg tablet 1

lorazepam 1 mg tablet 1

lorazepam 2 mg tablet 1

lorazepam 2 mg/ml oral concent 1

lorazepam intensol 2 mg/ml 1

oxazepam 10 mg capsule 1



BIPOLAR AGENTSMOOD STABILIZERS

lithium 8 meq/5 ml solution 1

lithium carbonate 150 mg cap 1




lithium carbonate 300 mg tab 1


lithium carbonate er 300 mg tb 1

lithium carbonate er 450 mg tb 1

BLOOD GLUCOSE REGULATORSANTIDIABETIC AGENTS

acarbose 100 mg tablet 1



ACTOPLUS MET XR 15-1,000 MG TBpioglitazone hcl/metformin hcl

2QL 30 / 30 DAYS

ST

AVANDIA 2 MG TABLETrosiglitazone maleate

3QL 30 / 30 DAYS

ST

BYDUREON 2 MG PEN INJECTexenatide microspheres

2 ST

BYDUREON 2 MG VIALexenatide microspheres

2 ST

BYETTA 10 MCG DOSE PEN INJexenatide

2 ST

BYETTA 5 MCG DOSE PEN INJexenatide

2 ST

chlorpropamide 100 mg tablet 1

chlorpropamide 250 mg tablet 1CYCLOSET 0.8 MG TABLETbromocriptine mesylate

3 PA

glimepiride 1 mg tablet 1



glipizide 10 mg tablet 1

glipizide 5 mg tablet 1

glipizide er 10 mg tablet 1

glipizide er 2.5 mg tablet 1

glipizide er 5 mg tablet 1

glipizide xl 10 mg tablet 1

glipizide xl 2.5 mg tablet 1



glipizide xl 5 mg tablet 1

glipizide-metformin 2.5-250 mg 1

glipizide-metformin 2.5-500 mg 1

glipizide-metformin 5-500 mg 1

glyburid-metformin 1.25-250 mg 1

glyburide 1.25 mg tablet 1

glyburide 2.5 mg tablet 1

glyburide 5 mg tablet 1

glyburide micro 1.5 mg tab 1

glyburide micro 3 mg tablet 1

glyburide micro 6 mg tablet 1

glyburide-metformin 2.5-500 mg 1

glyburide-metformin 5-500 mg 1GLYSET 25 MG TABLETmiglitol

3

INVOKAMET 150-1,000 MG TABLETcanagliflozin/metformin hcl

2 ST

INVOKAMET 150-500 MG TABLETcanagliflozin/metformin hcl

2 ST

INVOKAMET 50-1,000 MG TABLETcanagliflozin/metformin hcl

2 ST

INVOKAMET 50-500 MG TABLETcanagliflozin/metformin hcl

2 ST

INVOKAMET XR 150-1,000 MG TABcanagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST

INVOKAMET XR 150-500 MG TABLETcanagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST

INVOKAMET XR 50-1,000 MG TABcanagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST

INVOKAMET XR 50-500 MG TABLETcanagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST

INVOKANA 100 MG TABLETcanagliflozin

2 ST

INVOKANA 300 MG TABLETcanagliflozin

2 ST

JANUMET 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl

2 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSJANUMET 50-500 MG TABLETsitagliptin phosphate/metformin hcl

2 ST

JANUMET XR 100-1,000 MG TABLETsitagliptin phosphate/metformin hcl

2 ST

JANUMET XR 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl

2 ST

JANUMET XR 50-500 MG TABLETsitagliptin phosphate/metformin hcl

2 ST

JANUVIA 100 MG TABLETsitagliptin phosphate

2 ST


2 ST


2 ST

JARDIANCE 10 MG TABLETempagliflozin

2 ST

JARDIANCE 25 MG TABLETempagliflozin

2 ST

JENTADUETO 2.5 MG-1000 MG TABlinagliptin/metformin hcl

2QL 2 / 1 DAYS

ST


2QL 2 / 1 DAYS

ST


2QL 2 / 1 DAYS

ST

JENTADUETO XR 2.5 MG-1,000 MGlinagliptin/metformin hcl

2QL 30 / 30 DAYS

ST

JENTADUETO XR 5 MG-1,000 MG TBlinagliptin/metformin hcl

2QL 30 / 30 DAYS

ST

KOMBIGLYZE XR 2.5-1,000 MG TABsaxagliptin hcl/metformin hcl

2 ST

KOMBIGLYZE XR 5-1,000 MG TABsaxagliptin hcl/metformin hcl

2 ST

KOMBIGLYZE XR 5-500 MG TABLETsaxagliptin hcl/metformin hcl

2 ST

metformin er 1,000 mg osm-tab 3 ST

metformin er 500 (generic for glucophage xr) 1

metformin hcl 1,000 mg tablet 1

metformin hcl 500 mg tablet 1



metformin hcl 850 mg tablet 1

metformin hcl er 500 mg osm-tb 3 ST

metformin hcl er 750 mg tablet 1

miglitol 100 mg tablet 2



nateglinide 120 mg tablet 1 ST

nateglinide 60 mg tablet 1 ST

ONGLYZA 2.5 MG TABLETsaxagliptin hcl

2 ST

ONGLYZA 5 MG TABLETsaxagliptin hcl

2 ST

pioglitazone hcl 15 mg tablet 1 QL 30 / 30 DAYS



pioglitazone-glimepiride 30-2 1 ST

pioglitazone-glimepiride 30-4 1 ST

pioglitazone-metformin 15-500 1QL 30 / 30 DAYS

ST

pioglitazone-metformin 15-850 1QL 30 / 30 DAYS

ST

repaglinide 0.5 mg tablet 2

repaglinide 1 mg tablet 2

repaglinide 2 mg tablet 2

repaglinide-metformin 1-500 mg 2

repaglinide-metformin 2-500 mg 2RIOMET 500 MG/5 ML SOLUTIONmetformin hcl

2

SYMLINPEN 120 PEN INJECTORpramlintide acetate

2 ST

SYMLINPEN 60 PEN INJECTORpramlintide acetate

2 ST

SYNJARDY 12.5-1,000 MG TABLETempagliflozin/metformin hcl

2 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSYNJARDY 12.5-500 MG TABLETempagliflozin/metformin hcl

2 ST

SYNJARDY 5-1,000 MG TABLETempagliflozin/metformin hcl

2 ST

SYNJARDY 5-500 MG TABLETempagliflozin/metformin hcl

2 ST

SYNJARDY XR 10-1,000 MG TABLETempagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST

SYNJARDY XR 12.5-1,000 MG TABempagliflozin/metformin hcl

2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST

tolazamide 250 mg tablet 1

tolazamide 500 mg tablet 1

tolbutamide 500 mg tablet 1TRADJENTA 5 MG TABLETlinagliptin

2 ST

VICTOZA 2-PAK 18 MG/3 ML PENliraglutide

2 ST

VICTOZA 3-PAK 18 MG/3 ML PENliraglutide

2 ST

GLYCEMIC AGENTSGLUCAGEN 1 MG HYPOKITglucagon,human recombinant

3

GLUCAGON 1 MG EMERGENCY KITglucagon,human recombinant

2

PROGLYCEM 50 MG/ML ORAL SUSPdiazoxide

3

INSULINSAPIDRA 100 UNITS/ML VIALinsulin glulisine

2 QL 40 / 28 DAYS

APIDRA SOLOSTAR 100 UNITS/MLinsulin glulisine

2 QL 30 / 28 DAYS

BASAGLAR 100 UNIT/ML KWIKPENinsulin glargine,human recombinant analog

2 QL 30 / 28 day(s)

HUMALOG 100 UNITS/ML CARTRIDGEinsulin lispro

3 QL 30 / 28 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHUMALOG 100 UNITS/ML KWIKPENinsulin lispro

3 QL 40 / 30 day(s)

HUMALOG 100 UNITS/ML VIALinsulin lispro

3 QL 40 / 28 DAYS

HUMALOG 200 UNITS/ML KWIKPENinsulin lispro

3 QL 20 / 30 day(s)

HUMALOG MIX 50-50 KWIKPENinsulin lispro protamine and insulin lispro

3 QL 30 / 28 DAYS

HUMALOG MIX 50-50 VIALinsulin lispro protamine and insulin lispro

3 QL 40 / 28 DAYS

HUMALOG MIX 75-25 KWIKPENinsulin lispro protamine and insulin lispro

3 QL 30 / 28 DAYS

HUMALOG MIX 75-25 VIALinsulin lispro protamine and insulin lispro

3 QL 40 / 28 DAYS

HUMULIN R 500 UNITS/ML VIALinsulin regular, human

3 QL 40 / 28 DAYS

LANTUS 100 UNIT/ML VIALinsulin glargine,human recombinant analog

2 QL 40 / 28 DAYS

LANTUS SOLOSTAR 100 UNIT/MLinsulin glargine,human recombinant analog

2 QL 30 / 28 DAYS

LEVEMIR 100 UNITS/ML VIALinsulin detemir

3 QL 40 / 28 DAYS

LEVEMIR FLEXPEN 100 UNITS/MLinsulin detemir

3 QL 30 / 28 day(s)

LEVEMIR FLEXTOUCH 100 UNITS/MLinsulin detemir

3 QL 30 / 28 DAYS

NOVOLOG 100 UNIT/ML CARTRIDGEinsulin aspart

2 QL 40 / 28 DAYS

NOVOLOG 100 UNIT/ML VIALinsulin aspart

2 QL 40 / 28 DAYS

NOVOLOG 100 UNITS/ML FLEXPENinsulin aspart

2 QL 30 / 28 DAYS

NOVOLOG MIX 70-30 FLEXPEN SYRNinsulin aspart protamine human/insulin aspart

2

NOVOLOG MIX 70-30 VIALinsulin aspart protamine human/insulin aspart

2

TOUJEO SOLOSTAR 300 UNITS/MLinsulin glargine,human recombinant analog

2 QL 7.5 / 28 day(s)

TRESIBA FLEXTOUCH 100 UNITS/MLinsulin degludec

3 ST

TRESIBA FLEXTOUCH 200 UNITS/MLinsulin degludec

3 ST



BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERSANTICOAGULANTS

ARIXTRA 10 MG/0.8 ML SYRINGEfondaparinux sodium

3 PA

ARIXTRA 2.5 MG SYRINGEfondaparinux sodium

3 PA

ARIXTRA 2.5 MG/0.5 ML SYRINGEfondaparinux sodium

3 PA

ARIXTRA 5 MG/0.4 ML SYRINGEfondaparinux sodium

3 PA

ARIXTRA 7.5 MG/0.6 ML SYRINGEfondaparinux sodium

3 PA

ELIQUIS 2.5 MG TABLETapixaban

2 QL 2 / 1 DAYS

ELIQUIS 5 MG TABLETapixaban

2 QL 2 / 1 DAYS

enoxaparin 100 mg/ml syringe 4 MD 28 / 14 day(s)

enoxaparin 120 mg/0.8 ml syr 4 MD 1 / 14 Days

enoxaparin 150 mg/ml syringe 4 MD 28 / 14 day(s)

enoxaparin 30 mg/0.3 ml syr 4 MD 28 / 14 day(s)

enoxaparin 300 mg/3 ml vial 4 MD 28 / 14 day(s)




fondaparinux 10 mg/0.8 ml syr 3 PA

fondaparinux 2.5 mg/0.5 ml syr 3 PA

fondaparinux 5 mg/0.4 ml syr 3 PA

fondaparinux 7.5 mg/0.6 ml syr 3 PA

FRAGMIN 10,000 UNITS/ML SYRINGdalteparin sodium,porcine

3 PA

FRAGMIN 12,500 UNITS/0.5 MLdalteparin sodium,porcine

3 PA


3 PA


3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFRAGMIN 2,500 UNITS/0.2 ML SYRdalteparin sodium,porcine

3 PA

FRAGMIN 25,000 UNITS/ML VIALdalteparin sodium,porcine

3 PA

FRAGMIN 5,000 UNITS/0.2 ML SYRdalteparin sodium,porcine

3 PA

FRAGMIN 7,500 UNITS/0.3 ML SYRdalteparin sodium,porcine

3 PA

FRAGMIN 95,000 UNITS/3.8 ML VLdalteparin sodium,porcine

3 PA

heparin 1,000 unit/10 (100/ml) 1

heparin 10 unit/10 ml (1/ml) 1

heparin 10,000 unit/10 ml vial 1



heparin 2 unit/2 ml (1/ml) syr 1


heparin 20 units/2 ml (10/ml) 1



heparin 25,000 unit/250 ml-d5w 1






heparin 40,000 units/4 ml vial 1




heparin 50,000 units/10 ml vl 1

heparin 50,000 units/5 ml vial 1




heparin flush 10 units/ml syr 1



heparin iv flush 1 unit/ml syr 1

heparin iv flush 100 units/ml 1

heparin lock flush 10 units/ml 1

heparin lock flush 100 unit/ml 1

heparin sod 1,000 unit/ml vial 1

heparin sod 10,000 unit/ml vl 1

heparin sod 20,000 unit/ml vl 1

heparin sod 5,000 unit/0.5 ml 1

heparin sod 5,000 unit/ml vial 1

heparin-d5w 25,000 unit/250 ml 1

jantoven 1 mg tablet 1



jantoven 2.5 mg tablet 1





jantoven 7.5 mg tablet 1PRADAXA 110 MG CAPSULEdabigatran etexilate mesylate

3 QL 60 / 30 DAYS

PRADAXA 150 MG CAPSULEdabigatran etexilate mesylate

3 QL 60 / 30 DAYS

PRADAXA 75 MG CAPSULEdabigatran etexilate mesylate

3 QL 600 / 30 day(s)

warfarin sodium 1 mg tablet 1



warfarin sodium 2.5 mg tablet 1





warfarin sodium 7.5 mg tablet 1XARELTO 10 MG TABLETrivaroxaban

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSXARELTO 15 MG TABLETrivaroxaban

2

XARELTO 20 MG TABLETrivaroxaban

2

XARELTO STARTER PACKrivaroxaban

2

ZONTIVITY 2.08 MG TABLETvorapaxar sulfate

3 PA

BLOOD FORMATION MODIFIERSanagrelide hcl 0.5 mg capsule 1

anagrelide hcl 1 mg capsule 1ARANESP 100 MCG/0.5 ML SYRINGEdarbepoetin alfa in polysorbate 80

4 PA

ARANESP 100 MCG/ML VIALdarbepoetin alfa in polysorbate 80

4 PA

ARANESP 150 MCG/0.3 ML SYRINGEdarbepoetin alfa in polysorbate 80

4 PA


4 PA


4 PA

ARANESP 25 MCG/0.42 ML SYRINGdarbepoetin alfa in polysorbate 80

4 PA


4 PA


4 PA


4 PA


4 PA


4 PA

ARANESP 500 MCG/1 ML SYRINGEdarbepoetin alfa in polysorbate 80

4 PA


4 PA


4 PA

EPOGEN 10,000 UNITS/ML VIALepoetin alfa

3 PA


4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSEPOGEN 20,000 UNITS/2 ML VIALepoetin alfa

3 PA


3 PA


3 PA


3 PA

NEULASTA 6 MG/0.6 ML SYRINGEpegfilgrastim

4 PA

NEUPOGEN 300 MCG/0.5 ML SYRfilgrastim

4 PA

NEUPOGEN 300 MCG/ML VIALfilgrastim

4 PA

NEUPOGEN 480 MCG/0.8 ML SYRfilgrastim

4 PA

PROCRIT 10,000 UNITS/ML VIALepoetin alfa

3 PA


4 PA


3 PA


3 PA


3 PA


3 PA

PROMACTA 12.5 MG TABLETeltrombopag olamine

4 PA

PROMACTA 25 MG TABLETeltrombopag olamine

4 PA


4 PA


4 PA

HEMOSTASIS AGENTSaminocaproic acid 1,000 mg tab 1

aminocaproic acid 25% solution 1

aminocaproic acid 500 mg tab 1CORIFACT KITfactor xiii

4



tranexamic acid 650 mg tablet 1 PA

PLATELET MODIFYING AGENTSAGGRENOX 25 MG-200 MG CAPSULEaspirin/dipyridamole

2 ST

aspirin-dipyridam er 25-200 mg 2 ST

BRILINTA 60 MG TABLETticagrelor

2

BRILINTA 90 MG TABLETticagrelor

2

cilostazol 100 mg tablet 1

cilostazol 50 mg tablet 1

clopidogrel 300 mg tablet 1

clopidogrel 75 mg tablet 1

dipyridamole 25 mg tablet 1



EFFIENT 10 MG TABLETprasugrel hcl

3QL 30 / 30 DAYS

PA

EFFIENT 5 MG TABLETprasugrel hcl

3QL 30 / 30 DAYS

PA

ticlopidine 250 mg tablet 1

CARDIOVASCULAR AGENTSALPHA-ADRENERGIC AGONISTS

clonidine 0.1 mg/day patch 1 QL 4 / 28 DAYS



clonidine hcl 0.1 mg tablet 1



guanfacine 1 mg tablet 1

guanfacine 2 mg tablet 1

methyldopa 250 mg tablet 1

methyldopa 500 mg tablet 1

midodrine hcl 10 mg tablet 1



midodrine hcl 2.5 mg tablet 1

midodrine hcl 5 mg tablet 1

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 1 mg tab 1 QL 30 / 30 DAYS




phenoxybenzamine hcl 10 mg cap 2

prazosin 1 mg capsule 1



terazosin 1 mg capsule 1




ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil 16 mg tb 3

candesartan cilexetil 32 mg tb 3

candesartan cilexetil 4 mg tab 3

candesartan cilexetil 8 mg tab 3

EDARBI 40 MG TABLETazilsartan medoxomil

3QL 30 / 30 DAYS

ST

EDARBI 80 MG TABLETazilsartan medoxomil

3QL 30 / 30 DAYS

ST

eprosartan mesylate 600 mg tab 1 QL 30 / 30 DAYS

irbesartan 150 mg tablet 1



losartan potassium 100 mg tab 1



olmesartan medoxomil 20 mg tab 3





telmisartan 20 mg tablet 2



valsartan 160 mg tablet 1




ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 10 mg tablet 1

benazepril hcl 20 mg tablet 1



captopril 100 mg tablet 1

captopril 12.5 mg tablet 1



enalapril maleate 10 mg tab 1

enalapril maleate 2.5 mg tab 1

enalapril maleate 20 mg tab 1

enalapril maleate 5 mg tablet 1

fosinopril sodium 10 mg tab 1



lisinopril 10 mg tablet 1

lisinopril 2.5 mg tablet 1





moexipril hcl 15 mg tablet 1

moexipril hcl 7.5 mg tablet 1

perindopril erbumine 2 mg tab 1





quinapril 10 mg tablet 1




ramipril 1.25 mg capsule 1

ramipril 10 mg capsule 1

ramipril 2.5 mg capsule 1

ramipril 5 mg capsule 1

trandolapril 1 mg tablet 1



ANTIARRHYTHMICSamiodarone hcl 200 mg tablet 1

amiodarone hcl 400 mg tablet 1

disopyramide 100 mg capsule 1

disopyramide 150 mg capsule 1

flecainide acetate 100 mg tab 1



mexiletine 150 mg capsule 1

mexiletine 200 mg capsule 1

mexiletine 250 mg capsule 1MULTAQ 400 MG TABLETdronedarone hcl

3 QL 60 / 30 DAYS

NORPACE CR 100 MG CAPSULEdisopyramide phosphate

3

propafenone hcl 150 mg tablet 1

propafenone hcl 225 mg tab 1

propafenone hcl 300 mg tab 1

propafenone hcl er 225 mg cap 1



quinidine gluc er 324 mg tab 1

quinidine sulf er 300 mg tab 1



quinidine sulfate 200 mg tab 1

quinidine sulfate 300 mg tab 1

sotalol 120 mg tablet 1




sotalol af 120 mg tablet 1

sotalol af 160 mg tablet 1

sotalol af 80 mg tablet 1TIKOSYN 125 MCG CAPSULEdofetilide

2

TIKOSYN 250 MCG CAPSULEdofetilide

2

TIKOSYN 500 MCG CAPSULEdofetilide

2

BETA-ADRENERGIC BLOCKING AGENTSacebutolol 200 mg capsule 1

acebutolol 400 mg capsule 1

atenolol 100 mg tablet 1



betaxolol 10 mg tablet 1

betaxolol 20 mg tablet 1

bisoprolol fumarate 10 mg tab 1

bisoprolol fumarate 5 mg tab 1BYSTOLIC 10 MG TABLETnebivolol hcl

2

BYSTOLIC 2.5 MG TABLETnebivolol hcl

2

BYSTOLIC 20 MG TABLETnebivolol hcl

2

BYSTOLIC 5 MG TABLETnebivolol hcl

2

carvedilol 12.5 mg tablet 1

carvedilol 25 mg tablet 1




PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCOREG CR 10 MG CAPSULEcarvedilol phosphate

2 ST

COREG CR 20 MG CAPSULEcarvedilol phosphate

2 ST


2 ST


2 ST

labetalol hcl 100 mg tablet 1

labetalol hcl 200 mg tablet 1

labetalol hcl 300 mg tablet 1LEVATOL 20 MG TABLETpenbutolol sulfate

3

metoprolol succ er 100 mg tab 1




metoprolol tartrate 100 mg tab 1



nadolol 20 mg tablet 1



pindolol 10 mg tablet 1

pindolol 5 mg tablet 1

propranolol 10 mg tablet 1


propranolol 20 mg/5 ml soln 1


propranolol 40 mg/5 ml soln 1



propranolol er 120 mg capsule 1






timolol maleate 10 mg tablet 1



CALCIUM CHANNEL BLOCKING AGENTSafeditab cr 30 mg tablet 1

afeditab cr 60 mg tablet 1

amlodipine besylate 10 mg tab 1

amlodipine besylate 2.5 mg tab 1

amlodipine besylate 5 mg tab 1CARDIZEM LA 120 MG TABLETdiltiazem hcl

2

cartia xt 120 mg capsule 1




dilt xr 120 mg capsule 1

dilt-cd 120 mg capsule 1



dilt-cd er 300 mg capsule 1

diltia xt 120 mg capsule 1

diltiazem 120 mg tablet 1

diltiazem 12hr er 120 mg cap 1



diltiazem 24hr cd 120 mg cap 1








diltiazem 24hr er 180 mg tab 1
















diltiazem er 120 mg capsule 1

diltiazem er 180 mg capsule 1

diltzac er 120 mg capsule 1





felodipine er 10 mg tablet 1

felodipine er 2.5 mg tablet 1

felodipine er 5 mg tablet 1

isradipine 2.5 mg capsule 1

isradipine 5 mg capsule 1

matzim la 180 mg tablet 1





nicardipine 20 mg capsule 1

nicardipine 30 mg capsule 1

nifedical xl 30 mg tablet 1

nifedical xl 60 mg tablet 1

nifedipine 10 mg capsule 1



nifedipine 20 mg capsule 1

nifedipine er 30 mg tablet 1






nimodipine 30 mg capsule 1

nisoldipine er 17 mg tablet 1


nisoldipine er 25.5 mg tablet 1




nisoldipine er 8.5 mg tablet 1

taztia xt 120 mg capsule 1





verapamil 120 mg tablet 1

verapamil 360 mg cap pellet 1



verapamil er 120 mg capsule 1

verapamil er 120 mg tablet 1





verapamil er pm 100 mg capsule 1



verapamil sr 120 mg capsule 1





CARDIOVASCULAR AGENTS, OTHERamiloride hcl-hctz 5-50 mg tab 1

amlod-valsa-hctz 10-160-12.5mg 2 QL 30 / 30 DAYS

amlod-valsa-hctz 10-160-25 mg 2 QL 30 / 30 DAYS

amlod-valsa-hctz 10-320-25 mg 2

amlod-valsa-hctz 5-160-12.5 mg 2 QL 30 / 30 DAYS

amlod-valsa-hctz 5-160-25 mg 2 QL 30 / 30 DAYS

amlodipine-atorvast 10-10 mg 1 QL 30 / 30 DAYS




amlodipine-atorvast 2.5-10 mg 1 QL 30 / 30 DAYS







amlodipine-benazepril 10-20 mg 1


amlodipine-benazepril 2.5-10 1




amlodipine-olmesartan 10-20 mg 2




amlodipine-valsartan 10-160 mg 2 QL 30 / 30 DAYS






atenolol-chlorthalidone 100-25 1

atenolol-chlorthalidone 50-25 1

benazepril-hctz 10-12.5 mg tab 1

benazepril-hctz 20-12.5 mg tab 1

benazepril-hctz 20-25 mg tab 1

benazepril-hctz 5-6.25 mg tab 1BIDIL TABLETisosorbide dinitrate/hydralazine hcl

2

bisoprolol-hctz 10-6.25 mg tab 1

bisoprolol-hctz 2.5-6.25 mg tb 1

bisoprolol-hctz 5-6.25 mg tab 1

candesartan-hctz 16-12.5 mg tb 1 QL 30 / 30 DAYS

candesartan-hctz 32-12.5 mg tb 1 QL 30 / 30 DAYS

candesartan-hctz 32-25 mg tab 1 QL 30 / 30 DAYS

captopril-hctz 25-15 mg tablet 1



captopril-hctz 50-25 mg tablet 1DEMSER 250 MG CAPSULEmetyrosine

2

digitek 125 mcg tablet 1

digitek 250 mcg tablet 1

digox 125 mcg tablet 1

digox 250 mcg tablet 1

digoxin 0.125 mg tablet 1

digoxin 0.25 mg tablet 1

digoxin 125 mcg tablet 1

digoxin 250 mcg tablet 1

enalapril-hctz 10-25 mg tablet 1

enalapril-hctz 5-12.5 mg tab 1

fosinopril-hctz 10-12.5 mg tab 1



fosinopril-hctz 20-12.5 mg tab 1

irbesartan-hctz 150-12.5 mg tb 1 QL 30 / 30 DAYS

irbesartan-hctz 300-12.5 mg tb 1 QL 30 / 30 DAYS

isoxsuprine 10 mg tablet 1

lisinopril-hctz 10-12.5 mg tab 1

lisinopril-hctz 20-12.5 mg tab 1

lisinopril-hctz 20-25 mg tab 1

losartan-hctz 100-12.5 mg tab 1

losartan-hctz 100-25 mg tab 1

losartan-hctz 50-12.5 mg tab 1

methyldopa-hctz 250-15 mg tab 1

methyldopa-hctz 250-25 mg tab 1

metoprolol-hctz 100-25 mg tab 1



moexipril-hctz 15-12.5 mg tab 1

moexipril-hctz 15-25 mg tablet 1

moexipril-hctz 7.5-12.5 mg tab 1

nadolol-bendroflu 40-5 mg tab 1

nadolol-bendroflu 80-5 mg tab 1

olmesartan-hctz 20-12.5 mg tab 3 QL 30 / 30 DAYS

olmesartan-hctz 40-12.5 mg tab 3 QL 30 / 30 DAYS

olmesartan-hctz 40-25 mg tab 3 QL 30 / 30 DAYS

olmsrtn-amldpn-hctz 20-5-12.5 2 ST


olmsrtn-amldpn-hctz 40-10-25mg 2 ST


olmsrtn-amldpn-hctz 40-5-25 mg 2 ST

pentoxifylline er 400 mg tab 1

propranolol-hctz 40-25 mg tab 1

propranolol-hctz 80-25 mg tab 1

quinapril-hctz 10-12.5 mg tab 1



quinapril-hctz 20-12.5 mg tab 1

quinapril-hctz 20-25 mg tab 1RANEXA ER 1,000 MG TABLETranolazine

2

RANEXA ER 500 MG TABLETranolazine

2

reserpine 0.1 mg tablet 1

reserpine 0.25 mg tablet 1

spironolactone-hctz 25-25 tab 1

TEKTURNA 150 MG TABLETaliskiren hemifumarate

3QL 30 / 30 DAYS

ST

TEKTURNA 300 MG TABLETaliskiren hemifumarate

3QL 30 / 30 DAYS

ST

TEKTURNA HCT 150-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide

2 ST

TEKTURNA HCT 150-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide

2 ST

TEKTURNA HCT 300-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide

2 ST

TEKTURNA HCT 300-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide

2 ST

telmisartan-amlodipine 40-10 2 ST

telmisartan-amlodipine 40-5 mg 2 ST

telmisartan-amlodipine 80-10 2 ST

telmisartan-amlodipine 80-5 mg 2 ST

telmisartan-hctz 40-12.5 mg tb 2

telmisartan-hctz 80-12.5 mg tb 2

telmisartan-hctz 80-25 mg tab 2

trandolapr-verapam er 1-240 mg 2QL 30 / 30 DAYS

ST


ST


ST


ST



triamterene-hctz 37.5-25 mg cp 1

triamterene-hctz 37.5-25 mg tb 1

triamterene-hctz 75-50 mg tab 1

valsartan-hctz 160-12.5 mg tab 1 QL 30 / 30 DAYS

valsartan-hctz 160-25 mg tab 1 QL 30 / 30 DAYS


valsartan-hctz 320-25 mg tab 1 QL 30 / 30 DAYS


DIURETICS, CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 2

acetazolamide 250 mg tablet 2

acetazolamide er 500 mg cap 2

DIURETICS, LOOPbumetanide 0.5 mg tablet 1

bumetanide 1 mg tablet 1

bumetanide 2 mg tablet 1EDECRIN 25 MG TABLETethacrynic acid

3

furosemide 10 mg/ml solution 1

furosemide 20 mg tablet 1



torsemide 10 mg tablet 1




DIURETICS, POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1DYRENIUM 100 MG CAPSULEtriamterene

3

eplerenone 25 mg tablet 1

eplerenone 50 mg tablet 1

spironolactone 100 mg tablet 1





DIURETICS, THIAZIDEchlorothiazide 250 mg tablet 1

chlorothiazide 500 mg tablet 1

chlorthalidone 25 mg tablet 1

chlorthalidone 50 mg tablet 1

hydrochlorothiazide 12.5 mg cp 1

hydrochlorothiazide 12.5 mg tb 1

hydrochlorothiazide 25 mg tab 1

hydrochlorothiazide 50 mg tab 1

indapamide 1.25 mg tablet 1

indapamide 2.5 mg tablet 1

methyclothiazide 5 mg tablet 1

metolazone 10 mg tablet 1

metolazone 2.5 mg tablet 1

metolazone 5 mg tablet 1

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVESANTARA 30 MG CAPSULEfenofibrate,micronized

3 ST

ANTARA 90 MG CAPSULEfenofibrate,micronized

3 ST

fenofibrate 120 mg tablet 3

fenofibrate 130 mg capsule 1


fenofibrate 145 mg tablet 1 QL 30 / 30 DAYS






fenofibrate 48 mg tablet 1 QL 30 / 30 DAYS




fenofibric acid 105 mg tablet 1 ST



fenofibric acid 35 mg tablet 1 ST

FENOGLIDE 120 MG TABLETfenofibrate

3

FENOGLIDE 40 MG TABLETfenofibrate

3

FIBRICOR 35 MG TABLETfenofibric acid

3 ST

gemfibrozil 600 mg tablet 1

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV 20 MG TABLETlovastatin

2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST

atorvastatin 10 mg tablet 1 QL 30 / 30 DAYS




fluvastatin er 80 mg tablet 1QL 30 / 30 DAYS

ST

fluvastatin sodium 20 mg cap 1QL 30 / 30 DAYS

ST

fluvastatin sodium 40 mg cap 1QL 30 / 30 DAYS

ST

LIVALO 1 MG TABLETpitavastatin calcium

3 ST


3 ST


3 ST

lovastatin 10 mg tablet 1





pravastatin sodium 10 mg tab 1

pravastatin sodium 20 mg tab 1 QL 30 / 30 DAYS

pravastatin sodium 40 mg tab 1 QL 30 / 30 DAYS

pravastatin sodium 80 mg tab 1

rosuvastatin calcium 10 mg tab 1




simvastatin 10 mg tablet 1 QL 30 / 30 DAYS





DYSLIPIDEMICS, OTHERcholestyramine light powder 1

cholestyramine powder 1

colestipol hcl 1 gm tablet 1

colestipol hcl granules packet 1

colestipol micronized 1 gm tab 1

ezetimibe 10 mg tablet 2 QL 30 / 30 DAYS

ezetimibe-simvastatin 10-20 mg 2 QL 30 / 30 DAYS



JUXTAPID 10 MG CAPSULElomitapide mesylate

4 PA


4 PA


4 PA

KYNAMRO 200 MG/ML SYRINGEmipomersen sodium

4 PA

LOVAZA 1 GM CAPSULEomega-3 acid ethyl esters

2QL 120 / 30 DAYS

ST



niacin er 1,000 mg tablet 1 ST

niacin er 500 mg tablet 1 ST

niacin er 750 mg tablet 1 ST

niacor 500 mg tablet 1NIASPAN ER 1,000 MG TABLETniacin

2 ST

NIASPAN ER 500 MG TABLETniacin

2 ST

NIASPAN ER 750 MG TABLETniacin

2 ST

omega-3 ethyl esters 1 gm cap 2QL 120 / 30 DAYS

ST

prevalite powder 1QUESTRAN POWDERcholestyramine (with sugar)

1

REPATHA 140 MG/ML SURECLICKevolocumab

4 PA

REPATHA 140 MG/ML SYRINGEevolocumab

4 PA

REPATHA 420 MG/3.5ML PUSHTRONXevolocumab

4 PA

SIMCOR 1,000-20 MG TABLETniacin/simvastatin

2

SIMCOR 1,000-40 MG TABLETniacin/simvastatin

2

SIMCOR 500-20 MG TABLETniacin/simvastatin

2


2


2

VASCEPA 1 GM CAPSULEicosapent ethyl

2 PA

VYTORIN 10-10 MG TABLETezetimibe/simvastatin

2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST


2QL 30 / 30 DAYS

ST




2QL 30 / 30 DAYS

ST

WELCHOL 3.75G PACKETcolesevelam hcl

2 ST

WELCHOL 625 MG TABLETcolesevelam hcl

2 ST

ZETIA 10 MG TABLETezetimibe

2QL 30 / 30 DAYS

ST

VASODILATORS, DIRECT-ACTING ARTERIALhydralazine 10 mg tablet 1

hydralazine 100 mg tablet 1



minoxidil 10 mg tablet 1

minoxidil 2.5 mg tablet 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUSamyl nitrite ampul 1DILATRATE-SR 40 MG CAPSULEisosorbide dinitrate

2

isosorbide dn 10 mg tablet 1

isosorbide dn 2.5 mg tab sl 1




isosorbide dn 5 mg tablet sl 1

isosorbide dn er 40 mg tablet 1

isosorbide mn 10 mg tablet 1

isosorbide mn 20 mg tablet 1

isosorbide mn er 120 mg tab 1

isosorbide mn er 30 mg tablet 1

isosorbide mn er 60 mg tablet 1NITRO-BID 2% OINTMENTnitroglycerin

2

NITRO-DUR 0.3 MG/HR PATCHnitroglycerin

2

NITRO-DUR 0.8 MG/HR PATCHnitroglycerin

2



nitroglycerin 0.1 mg/hr patch 1


nitroglycerin 0.3 mg tablet sl 2





nitroglycerin 400 mcg spray 1

nitroglycerin er 2.5 mg cap 1

nitroglycerin er 6.5 mg cap 1

nitroglycerin er 9 mg capsule 1NITROLINGUAL 0.4 MG SPRAYnitroglycerin

2

NITROMIST 400 MCG SPRAYnitroglycerin

3

CENTRAL NERVOUS SYSTEM AGENTSATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

d-amphetamine er 10 mg capsule 1

QL 2 / 1 DAYS

PA

AL1 Up to 18 yrs old


QL 4 / 1 DAYS

PA



QL 2 / 1 DAYS

PA


dextroamp-amphet er 10 mg cap 1

QL 30 / 30 DAYS

PA



QL 30 / 30 DAYS

PA



QL 2 / 1 DAYS

PA





QL 2 / 1 DAYS

PA



QL 2 / 1 DAYS

PA



QL 30 / 30 DAYS

PA


dextroamp-amphetam 12.5 mg tab 1PA


dextroamp-amphetam 7.5 mg tab 1PA


dextroamp-amphetamin 10 mg tab 1PA








dextroamp-amphetamine 5 mg tab 1PA


dextroamphetamine 10 mg tab 1

QL 4 / 1 DAYS

PA


dextroamphetamine 5 mg tab 1

QL 2 / 1 DAYS

PA


methamphetamine 5 mg tablet 3QL 4 / 1 DAYS




VYVANSE 20 MG CAPSULElisdexamfetamine dimesylate

2

PA

ST



2

PA

ST



2

PA

ST



2

PA

ST



2

PA

ST



2

PA

ST


zenzedi 10 mg tablet 3QL 4 / 1 DAYS


zenzedi 5 mg tablet 3QL 4 / 1 DAYS


ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

clonidine hcl er 0.1 mg tablet 3 AL1 Up to 18 yrs old

DAYTRANA 10 MG/9 HR PATCHmethylphenidate

2 AL1 Up to 17 yrs old

DAYTRANA 15 MG/9 HR PATCHmethylphenidate


DAYTRANA 20 MG/9 HOUR PATCHmethylphenidate


DAYTRANA 30 MG/9 HOUR PATCHmethylphenidate


dexmethylphenidate 10 mg tab 1

QL 2 / 1 DAYS

ST




dexmethylphenidate 2.5 mg tab 1

QL 2 / 1 DAYS

PA

ST


dexmethylphenidate 5 mg tab 1

QL 2 / 1 DAYS

PA

ST


dexmethylphenidate er 10 mg cp 3

QL 1 / 1 DAYS

PA

ST



QL 1 / 1 DAYS

PA

ST



QL 1 / 1 DAYS

PA

ST


dexmethylphenidate er 25 mg cp 3 QL 1 / 1 DAYS


QL 1 / 1 DAYS

ST

AL1 Up to 18.0 yrs old

dexmethylphenidate er 35 mg cp 3 QL 1 / 1 DAYS


QL 1 / 1 DAYS

ST


dexmethylphenidate er 5 mg cap 3

QL 1 / 1 DAYS

PA

ST




FOCALIN XR 10 MG CAPSULEdexmethylphenidate hcl

3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST



3

QL 1 / 1 DAYS

ST


guanfacine hcl er 1 mg tablet 2 AL1 Up to 18 yrs old




INTUNIV ER 1 MG TABLETguanfacine hcl





PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSINTUNIV ER 3 MG TABLETguanfacine hcl




METADATE CD 20 MG CAPSULEmethylphenidate hcl

3

QL 2 / 1 DAYS

PA


METADATE CD 30 MG CAPSULEmethylphenidate hcl

3

QL 2 / 1 DAYS

PA


methylphenidate 10 mg tablet 3

QL 3 / 1 DAYS

PA


methylphenidate 10 mg/5 ml sol 3PA



QL 3 / 1 DAYS

PA



QL 3 / 1 DAYS

PA


methylphenidate 5 mg/5 ml soln 3PA


methylphenidate cd 10 mg cap 3QL 2 / 1 DAYS

PA

methylphenidate cd 20 mg cap 3

QL 2 / 1 DAYS

PA



QL 2 / 1 DAYS

PA



QL 2 / 1 DAYS

PA





PA


PA

methylphenidate er 10 mg cap 3QL 2 / 1 DAYS

PA

methylphenidate er 18 mg tab 3

QL 30 / 30 DAYS

PA


methylphenidate er 20 mg cap 3

QL 2 / 1 DAYS

PA


methylphenidate er 20 mg tab 3QL 3 / 1 DAYS

PA


QL 30 / 30 DAYS

PA



QL 2 / 1 DAYS

PA



QL 2 / 1 DAYS

PA



QL 2 / 1 DAYS

PA



PA


QL 30 / 30 DAYS

PA



PA



methylphenidate sr 20 mg tab 3QL 3 / 1 DAYS

PA

QUILLIVANT XR 25 MG/5 ML SUSPmethylphenidate hcl

3

QL 360 / 30 DAYS

ST


RITALIN 10 MG TABLETmethylphenidate hcl

3QL 3 / 1 DAYS



3QL 3 / 1 DAYS



3QL 3 / 1 DAYS


STRATTERA 10 MG CAPSULEatomoxetine hcl

2QL 30 / 30 DAYS



2QL 30 / 30 DAYS



2QL 30 / 30 DAYS



2QL 30 / 30 DAYS



2QL 30 / 30 DAYS



2QL 30 / 30 DAYS



2QL 30 / 30 DAYS


CENTRAL NERVOUS SYSTEM, OTHERbutalb-acetamin-caff 50-325-40 1

butalbit-acetaminophen-caff cp 1

butalbital-acetaminophn 50-325 1

capacet capsule 1HORIZANT ER 300 MG TABLETgabapentin enacarbil

3 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHORIZANT ER 600 MG TABLETgabapentin enacarbil

3 ST

MARGESIC CAPSULEbutalbital/acetaminophen/caffeine

1

MARTEN-TAB 325-50 TABLETbutalbital/acetaminophen

1

NUEDEXTA 20-10 MG CAPSULEdextromethorphan hbr/quinidine sulfate

3 PA

phendimetrazine 35 mg tablet 1

phendimetrazine er 105 mg cap 1RILUTEK 50 MG TABLETriluzole

2

riluzole 50 mg tablet 2

tencon 50-325 mg tablet 1

tetrabenazine 12.5 mg tablet 3 PA

tetrabenazine 25 mg tablet 3 PA

XENAZINE 12.5 MG TABLETtetrabenazine

3 PA

XENAZINE 25 MG TABLETtetrabenazine

3 PA

ZEBUTAL 50-325-40 MG CAPSULEbutalbital/acetaminophen/caffeine

1

FIBROMYALGIA AGENTS

CYMBALTA 20 MG CAPSULEduloxetine hcl

3

QL 30 / 30 DAYS

ST



3

QL 30 / 30 DAYS

ST



3

QL 30 / 30 DAYS

ST


duloxetine hcl dr 20 mg cap 1

QL 30 / 30 DAYS

ST



QL 30 / 30 DAYS

ST





QL 30 / 30 DAYS

ST


LYRICA 100 MG CAPSULEpregabalin

2 ST


2 ST

LYRICA 20 MG/ML ORAL SOLUTIONpregabalin

2 ST


2 ST


2 ST


2 ST


2 ST


2 ST


2 ST

SAVELLA 100 MG TABLETmilnacipran hcl


SAVELLA 12.5 MG TABLETmilnacipran hcl






MULTIPLE SCLEROSIS AGENTSAMPYRA ER 10 MG TABLETdalfampridine

4 PA

AUBAGIO 14 MG TABLETteriflunomide

4 PA

AUBAGIO 7 MG TABLETteriflunomide

4 PA

AVONEX 30 MCG VIAL KITinterferon beta-1a/albumin human

4 PA

AVONEX PREFILLED SYR 30 MCG KTinterferon beta-1a

4 PA

BETASERON 0.3 MG KITinterferon beta-1b

4QL 15 / FILL

PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCOPAXONE 20 MG/ML SYRINGEglatiramer acetate

4 PA

EXTAVIA 0.3 MG KITinterferon beta-1b

4QL 15 / FILL

PA

EXTAVIA 0.3 MG VIALinterferon beta-1b

4QL 15 / FILL

PA

GILENYA 0.5 MG CAPSULEfingolimod hcl

4 PA

glatopa 20 mg/ml syringe 4 PA

REBIF 22 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human

4QL 15 / 30 DAYS

PA

REBIF 44 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human

4QL 15 / 30 DAYS

PA

REBIF REBIDOSE TITRATION PACKinterferon beta-1a/albumin human

4QL 15 / 30 DAYS

PA

TECFIDERA DR 120 MG CAPSULEdimethyl fumarate

4 PA

TECFIDERA DR 240 MG CAPSULEdimethyl fumarate

4 PA

TECFIDERA STARTER PACKdimethyl fumarate

4 PA

DENTAL AND ORAL AGENTScevimeline hcl 30 mg capsule 1

chlorhexidine 0.12% rinse 1DEBACTEROL SOLUTIONsulfuric acid/sulfonated phenol

3

denta 5000 plus cream 1

dentagel 1.1% gel 1

fluoridex defense 1.1% gel 1FLUORIDEX SENSITIVITY RLF GELsodium fluoride/potassium nitrate

1

neutral sodium fluoride 1

oralone 0.1% paste 1

paroex 0.12% oral rinse 1

periogard 0.12% oral rinse 1

pilocarpine hcl 5 mg tablet 1



pilocarpine hcl 7.5 mg tablet 1

sf 1.1% gel 1

sf 5000 plus cream 1

triamcinolone 0.1% paste 1

DERMATOLOGICAL AGENTS8-MOP 10 MG CAPSULEmethoxsalen

3

ABSORICA 10 MG CAPSULEisotretinoin

3 PA


3 PA


3 PA


3 PA

acitretin 10 mg capsule 2

acitretin 17.5 mg capsule 2

acitretin 25 mg capsule 2

adapalene 0.1% cream 3QL 1 / 25 DAYS


adapalene 0.1% gel 3QL 1 / 25 DAYS


adapalene 0.1% lotion 2QL 1 / 25 DAYS


adapalene 0.3% gel 2QL 1 / 25 DAYS


adapalene 0.3% gel pump 2QL 1 / 25 DAYS


ALDARA 5% CREAMimiquimod

3

ALPHAQUIN HP 4% CREAMhydroquinone/sunscreens (oxybenzone/octinoxate)

1

ammonium lactate 12% cream 1

amnesteem 10 mg capsule 3 PA





ANALPRAM HC 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl

2

ATRALIN 0.05% GELtretinoin


AZELEX 20% CREAMazelaic acid

3

bp 10-1 wash 1

bp cleansing wash 1

bp-50% urea emulsion 1

calcipotriene 0.005% cream 1

calcipotriene 0.005% ointment 1

calcipotriene 0.005% solution 1

calcipotriene-betameth dp oint 1

calcitrene 0.005% ointment 1

calcitriol 3 mcg/g ointment 1 PA

claravis 10 mg capsule 3 PA




clind ph-benzoyl perox 1.2-5% 2

clinda-benzoyl perox 1-5% pump 2

clindamycin-benzoyl perox 1-5% 2

clotrimazole-betamethasone crm 1

clotrimazole-betamethasone lot 1CONDYLOX 0.5% GELpodofilox

2

CORTISPORIN CREAMneomycin sulfate/polymyxin b sulfate/hydrocortisone

1

CORTISPORIN OINTMENTneomycin/bacitracin/polymyxin b/hydrocortisone

1

dermazene cream 1

diclofenac sodium 1% gel 2

DIFFERIN 0.1% CREAMadapalene

3QL 1 / 25 DAYS




DIFFERIN 0.1% GELadapalene

3QL 1 / 25 DAYS


DIFFERIN 0.1% LOTIONadapalene

2QL 1 / 25 DAYS


DIFFERIN 0.3% GELadapalene

2QL 1 / 25 DAYS


DIFFERIN 0.3% GEL PUMPadapalene

2QL 1 / 25 DAYS


doxepin 5% cream 1

ELIDEL 1% CREAMpimecrolimus

3QL 1 / 10 DAYS

ST

EPIDUO 0.1-2.5% GELadapalene/benzoyl peroxide

2QL 45 / 30 DAYS


EPIDUO 0.1-2.5% GEL PUMPadapalene/benzoyl peroxide

2QL 45 / 30 DAYS


FINACEA 15% GELazelaic acid

2

finasteride 1 mg tablet 1FLUOROPLEX 1% CREAMfluorouracil

3

grafco silver nit applicator 1

hydrocort-pram 2.5%-1% crm kit 1

hydrocort-pram 2.5%-1% crm kit 1

hydrocortisone-iodoquinol crm 1

hydrocortisone-pramoxine cream 1

hydroquinone 4% cream 1

hydroquinone tr 4% cream 1

imiquimod 5% cream packet 1

lactic acid 10% e cream 1

lactic acid 10% lotion 1

latrix 50% topical suspension 1

lidocaine-hc 2.8-0.55% gel 1

melpaque hp 4% cream 1

methoxsalen 10 mg capsule 2



methoxsalen 10 mg softgel 2METROGEL TOPICAL 1% GELmetronidazole

2

METROGEL TOPICAL 1% PUMPmetronidazole

2

metronidazole 0.75% cream 1

metronidazole 0.75% lotion 1

metronidazole top 1% gel pump 1

metronidazole topical 0.75% gl 1

metronidazole topical 1% gel 1

myorisan 10 mg capsule 3 PA




NATROBA 0.9% TOPICAL SUSPspinosad

3

obagi elastiderm skin 4% cream 1

obagi nu-derm blender 4% cream 1

obagi nu-derm clear 4% cream 1OVACE 10% WASHsulfacetamide sodium

3 ST

OVACE PLUS 10% CREAMsulfacetamide sodium

3 ST

OVACE PLUS 10% SHAMPOOsulfacetamide sodium

3 ST

OVACE PLUS 10% WASHsulfacetamide sodium

3 ST

OVACE PLUS 9.8% LOTIONsulfacetamide sodium

3 ST

OVACE PLUS WASH 10% CLNSNG GELsulfacetamide sodium

3 ST

OXSORALEN 1% LOTIONmethoxsalen

2

OXSORALEN-ULTRA 10 MG CAPmethoxsalen

2

PICATO 0.015% GELingenol mebutate

3 ST

PICATO 0.05% GELingenol mebutate

3 ST



podocon-25 liquid 1

podofilox 0.5% topical soln 1PRAMOSONE 1% LOTIONhydrocortisone acetate/pramoxine hcl

2

PRAMOSONE 1%-1% OINTMENThydrocortisone acetate/pramoxine hcl

2

PRAMOSONE 2.5%-1% CREAMhydrocortisone acetate/pramoxine hcl

2

PRAMOSONE 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl

2

PRAMOSONE 2.5%-1% OINTMENThydrocortisone acetate/pramoxine hcl

2

PROCTOFOAM-HC 1%-1% FOAMhydrocortisone acetate/pramoxine hcl

2

PROTOPIC 0.03% OINTMENTtacrolimus

2QL 1 / 10 DAYS

ST

PROTOPIC 0.1% OINTMENTtacrolimus

2QL 1 / 10 DAYS

ST

PRUDOXIN 5% CREAMdoxepin hcl

3

RECTIV 0.4% OINTMENTnitroglycerin

3

REGRANEX 0.01% GELbecaplermin

3

rosadan 0.75% cream 1

rosadan 0.75% gel 1

salacyn 6% lotion 1

salicylic acid 26% liquid 1

salicylic acid 27.5% liquid 1

salicylic acid 6% cream 1

salicylic acid 6% cream 1

salicylic acid 6% foam 1

salicylic acid 6% gel 1

salicylic acid 6% lotion 1

salicylic acid 6% lotion 1

salicylic acid 6% shampoo 1SALKERA 6% FOAMsalicylic acid/ammonium lactate/aloe vera

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSALVAX 6% FOAMsalicylic acid

1

SANTYL OINTMENTcollagenase clostridium histolyticum

2

seb-prev 10% wash 3 ST

selenium sulfide 2.25% shampoo 1

selenium sulfide 2.5% lotion 1

silver nitrate applicator 1

sod sulface-sulfur 9-4.5% wash 1

sod sulface-sulfur 9-4.5% wash 1

sod sulfacet-sulfur 10-4% pad 1

sod sulfacet-sulfur 10-5% clsr 1

sod sulfacet-sulfur 10-5% lotn 1

sod sulfacetam 10% clnsng gel 3 ST

sod sulfacetamide 10% shampoo 3 ST

sod sulfacetamide-sulfur foam 1

sod sulfacetamide-sulfur lotn 1

sod sulfacetamide-sulfur lotn 1

sodium sulf-sulfur cleanser 1

sodium sulfacet-sulfur wash 1

sodium sulfacetamide 10% wash 3 ST

SORIATANE 10 MG CAPSULEacitretin

2

SORIATANE 17.5 MG CAPSULEacitretin

2

SORIATANE 25 MG CAPSULEacitretin

2

spinosad 0.9% topical susp 1

sss 10-5 cream 1

sss 10-5 foam 1STELARA 45 MG/0.5 ML SYRINGEustekinumab

4 PA

STELARA 90 MG/ML SYRINGEustekinumab

4 PA

sulfacet sod-sulfur 10-4% pad 1

sulfacetamide-sulfur 10-5% crm 1



sulfacetamide-sulfur 8-4% susp 1

sulfacleanse 8-4 suspension 1TACLONEX 0.005%-0.064% SUSPENScalcipotriene/betamethasone dipropionate

2

TACLONEX OINTMENTcalcipotriene/betamethasone dipropionate

2

tacrolimus 0.03% ointment 2QL 1 / 10 DAYS

ST

tacrolimus 0.1% ointment 2QL 1 / 10 DAYS

ST

TAZORAC 0.05% CREAMtazarotene

2

TAZORAC 0.05% GELtazarotene

2

TAZORAC 0.1% CREAMtazarotene

2

TAZORAC 0.1% GELtazarotene

2

tl hydroquinone 4% cream 1TRETIN-X 0.0375% CREAMtretinoin

3 PA

tretinoin 0.01% gel 1

tretinoin 0.025% cream 1

tretinoin 0.025% gel 1

tretinoin 0.05% cream 1 PA

tretinoin 0.05% emollient crm 1 PA

tretinoin 0.1% cream 1

tretinoin gel micro 0.04% tube 1ULESFIA 5% LOTIONbenzyl alcohol

2

VELTIN 1.2 %-0.025 % GELclindamycin phosphate/tretinoin

3 ST

VELTIN 1.2%-0.025% GELclindamycin phosphate/tretinoin

3 ST

VEREGEN 15% OINTMENTsinecatechins

3 PA

VOLTAREN 1% GELdiclofenac sodium

2



zenatane 10 mg capsule 3 PA




ZIANA GELclindamycin phosphate/tretinoin

3ST


ZONALON 5% CREAMdoxepin hcl

3

ZYCLARA 3.75% CREAMimiquimod

3

ZYCLARA 3.75% CREAM PUMPimiquimod

3

ELECTROLYTES/MINERALS/METALS/VITAMINSbp vit 3 capsule 1CHEMET 100 MG CAPSULEsuccimer

2

cyanocobalamin 1,000 mcg/ml 1

cyanocobalamin 10,000 mcg/10 1

cyanocobalamin 30,000 mcg/30 1EFFER-K 10 MEQ TABLET EFFpotassium bicarbonate/citric acid

2

EFFER-K 20 MEQ TABLET EFFpotassium bicarbonate/citric acid

2

effer-k 25 meq tablet eff 1EXJADE 125 MG TABLETdeferasirox

4 PA

EXJADE 250 MG TABLETdeferasirox

4 PA

EXJADE 500 MG TABLETdeferasirox

4 PA

ferocon capsule 1

ferrex 150 forte capsule 1FERRIPROX 500 MG TABLETdeferiprone

4

FLUOR-A-DAY 0.5 MG TAB CHEWsodium fluoride/xylitol

5

FLUORABON 0.25 MG/0.6 ML DROPSfluoride (sodium)




fluoride 0.25 mg tablet chew 5 AL1 Up to 6 yrs old

fluoride 0.5 mg tablet chew 5 AL1 Up to 6 yrs old

fluoride 1 mg tablet chewable 5 AL1 Up to 6 yrs old

focalgin dss tablet 1

folic acid 1 mg tablet 1

folic acid-vit b6-vit b12 tab 1

folplex 2.2 tablet 1

hydroxocobalamin 1,000 mcg/ml 1

iferex 150 forte capsule 1

k effervescent 25 meq tablet 1

kionex 15 gm/60 ml suspension 1

klor-con m10 tablet 1

klor-con m20 tablet 1

klor-con sprinkle er 10 meq cp 1

klor-con sprinkle er 8 meq cap 1

levocarnitine 1 g/10 ml soln 1

levocarnitine 330 mg tablet 1MEPHYTON 5 MG TABLETphytonadione (vit k1)

2

multi-vit w-fluor 0.25 mg/ml 1

multivit-fluor 0.25 mg tab chw 1


multivit-fluor 0.25 mg/ml drop 1



multivit-fluor 0.5 mg tab chew 1

multivit-fluor 0.5 mg tab chew 1


multivit-fluoride 1 mg tab chw 1

multivit-fluoride 1 mg tab chw 1MVC-FLUORIDE 0.25 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride

1

MVC-FLUORIDE 0.5 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride

1

MVC-FLUORIDE 1 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride

1



myferon-150 forte capsule 1NICAZEL TABLETniacinamide/azelaic acid/zinc oxide/vit b6/copper/fa

3

PHYSIOLYTE IRRIGATION SOLNphysiological irrigating solution no.1

3

PHYSIOSOL IRRIGATION SOLNphysiological irrigating solution no.1

3

poly-iron 150 forte capsule 1POTABA 500 MG CAPSULEpotassium aminobenzoate

3

potassium 25 meq tablet eff 1

potassium cl 10% (20 meq/15 ml 1


potassium cl 20 meq packet 1


potassium cl 25 meq tab eff 1

potassium cl er 10 meq capsule 1

potassium cl er 10 meq tablet 1




potassium cl er 8 meq capsule 1

potassium cl er 8 meq tablet 1SAMSCA 15 MG TABLETtolvaptan

4

SAMSCA 30 MG TABLETtolvaptan

4

se-natal 19 tablet 1

sod polystyren sulf 15 g/60 ml 1

sodium chloride 0.9% irrig. 1

sodium fluoride 0.5 mg(1.1 mg) 5 AL1 Up to 6 yrs old

sodium fluoride 0.5 mg/ml drop 5 AL1 Up to 6 yrs old

sodium fluoride 1 mg (2.2 mg) 5 AL1 Up to 6 yrs old

sps 15 gm/60 ml suspension 1SPS 15 GM/60 ML SUSPENSIONsodium polystyrene sulfonate/sorbitol solution

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSYPRINE 250 MG CAPSULEtrientine hcl

3

thrivite 19 tablet 1

tl icon capsule 1

tri-vit-fluor 0.25 mg/ml drop 1

tri-vit-fluor 0.5 mg/ml drop 1

triple-vit w-fluor 0.25 mg/ml 1

GASTROINTESTINAL AGENTSANTISPASMODICS, GASTROINTESTINAL

b-donna tablet 3

chlordiazepoxide-clidinium cap 1CUVPOSA 1 MG/5 ML SOLUTIONglycopyrrolate

3

dicyclomine 10 mg capsule 1

dicyclomine 10 mg/5 ml soln 1

dicyclomine 20 mg tablet 1DONNATAL ELIXIRphenobarbital/hyoscyamine sulf/atropinesulf/scopolamine hb

3

DONNATAL TABLETphenobarbital/hyoscyamine sulf/atropinesulf/scopolamine hb

3

glycopyrrolate 1 mg tablet 1

glycopyrrolate 2 mg tablet 1

hyoscyamine 0.125 mg odt 1

hyoscyamine 0.125 mg tab sl 1

hyoscyamine 0.125 mg/5 ml elix 1

hyoscyamine 0.125 mg/ml drop 1

hyoscyamine er 0.375 mg tab 1

hyoscyamine sr 0.375 mg tab 1

hyoscyamine sulf 0.125 mg tab 1

hyosyne 0.125 mg/ml drop 1

hyosyne 125 mcg/5 ml elixir 1

methscopolamine brom 2.5 mg tb 1

methscopolamine brom 5 mg tab 1

oscimin 0.125 mg odt 1



oscimin 0.125 mg tablet 1

phenohytro tablet 3

propantheline 15 mg tablet 1

GASTROINTESTINAL AGENTS, OTHERcromolyn 100 mg/5 ml oral conc 1

diphenoxylat-atrop 2.5-0.025/5 1

diphenoxylate-atrop 2.5-0.025 1GATTEX 5 MG 30-VIAL KITteduglutide

3 PA

GATTEX 5 MG ONE-VIAL KITteduglutide

3 PA

lansoprazol-amoxicil-clarithro 3

loperamide 2 mg capsule 1MYALEPT 11.3 MG (5 MG/ML) VIALmetreleptin

3 QL 1 / 1 DAYS

OMECLAMOX-PAK COMBO PACKomeprazole/clarithromycin/amoxicillin trihydrate

3

paregoric liquid 1PYLERA CAPSULEcolloidal bismuth subcitrate/metronidazole/tetracyclinehcl


RELISTOR 12 MG/0.6 ML KITmethylnaltrexone bromide

3 PA

RELISTOR 12 MG/0.6 ML VIALmethylnaltrexone bromide

3 PA

ursodiol 250 mg tablet 1

ursodiol 300 mg capsule 1

ursodiol 500 mg tablet 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine 200 mg tablet 1

cimetidine 300 mg tablet 1

cimetidine 300 mg/5 ml soln 1



nizatidine 15 mg/ml solution 1

nizatidine 150 mg capsule 1

nizatidine 300 mg capsule 1



ranitidine 15 mg/ml syrup 1

ranitidine 150 mg capsule 1

ranitidine 150 mg tablet 1

ranitidine 150 mg/10 ml syrup 1

ranitidine 300 mg capsule 1

ranitidine 300 mg tablet 1

IRRITABLE BOWEL SYNDROME AGENTSalosetron hcl 0.5 mg tablet 2

alosetron hcl 1 mg tablet 2

AMITIZA 24 MCG CAPSULESlubiprostone

2ST


AMITIZA 8 MCG CAPSULElubiprostone

2ST


LINZESS 145 MCG CAPSULElinaclotide

2QL 30 / 30 DAYS

PA

LINZESS 290 MCG CAPSULElinaclotide

2QL 30 / 30 DAYS

PA

LOTRONEX 0.5 MG TABLETalosetron hcl

2

LOTRONEX 1 MG TABLETalosetron hcl

2

LAXATIVESconstulose 10 gm/15 ml soln 1

enulose 10 gm/15 ml solution 1

gavilyte-c solution 1 AL1 50.0 to 75.0 yrs old

gavilyte-g solution 1 AL1 50.0 to 75.0 yrs old

gavilyte-h and bisacodyl kit 1 AL1 50.0 to 75.0 yrs old

gavilyte-n solution 1 AL1 50.0 to 75.0 yrs old

generlac 10 gm/15 ml solution 1GOLYTELY PACKETpeg 3350/sod sulf/sod bicarb/sod chloride/potassiumchloride

2 AL1 50.0 to 75.0 yrs old

KRISTALOSE 10 GM PACKETlactulose

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSKRISTALOSE 20 GM PACKETlactulose

2

lactulose 10 gm/15 ml solution 1MOVIPREP POWDER PACKETpeg 3350/sodium sulfate/sod chloride/kcl/ascorbatesod/vit c

2 AL1 50.0 to 75.0 yrs old

OSMOPREP TABLETsodium phosphate,monobasic/sodium phosphate,dibasic

3 AL1 50.0 to 75.0 yrs old

peg 3350 electrolyte soln 1 AL1 50.0 to 75.0 yrs old

peg 3350-electrolyte solution 1 AL1 50.0 to 75.0 yrs old

peg-3350 and electrolytes soln 1 AL1 50.0 to 75.0 yrs old

peg-prep kit 1

polyethylene glycol 3350 powd 1

polyethylene glycol 3350 powd 1PREPOPIK POWDER PACKETsodium picosulfate/magnesium oxide/citric acid

3 AL1 50.0 to 75.0 yrs old

SUPREP BOWEL PREP KITsodium sulfate/potassium sulfate/magnesium sulfate

2 AL1 50.0 to 75.0 yrs old

trilyte with flavor packets 1 AL1 50.0 to 75.0 yrs old

PROTECTANTSCARAFATE 1 GM/10 ML SUSPsucralfate

2

misoprostol 100 mcg tablet 1

misoprostol 200 mcg tablet 1

sucralfate 1 gm tablet 1

PROTON PUMP INHIBITORSACIPHEX DR 20 MG TABLETrabeprazole sodium

3 QL 1 / 1 DAYS

DEXILANT DR 30 MG CAPSULEdexlansoprazole

3 PA

DEXILANT DR 60 MG CAPSULEdexlansoprazole

3 PA

esomeprazole mag dr 20 mg cap 3 ST

esomeprazole mag dr 40 mg cap 3 ST

lansoprazole dr 15 mg capsule 3

lansoprazole dr 30 mg capsule 3QL 30 / 30 DAYS

ST



omeprazole dr 10 mg capsule 1 QL 30 / 30 DAYS



omeprazole-bicarb 20-1,100 cap 1

omeprazole-bicarb 40-1,100 cap 1

pantoprazole sod dr 20 mg tab 1 QL 30 / 30 DAYS

pantoprazole sod dr 40 mg tab 1 QL 30 / 30 DAYS

PREVACID 15 MG SOLUTABlansoprazole

3 QL 30 / 30 DAYS

PREVACID 30 MG SOLUTABlansoprazole

3 QL 30 / 30 DAYS

rabeprazole sod dr 20 mg tab 3 QL 1 / 1 DAYS

ZEGERID 20 MG PACKETomeprazole/sodium bicarbonate

3

ZEGERID 40 MG PACKETomeprazole/sodium bicarbonate

3

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENTBUPHENYL 500 MG TABLETsodium phenylbutyrate

2

CARBAGLU 200 MG DISPER TABLETcarglumic acid

4

CREON DR 12,000 UNITS CAPSULElipase/protease/amylase

2


2


2


2

CYSTADANE 1 GRAM/1.7 ML POWDERbetaine

4

KUVAN 100 MG TABLETsapropterin dihydrochloride

3 PA

ORFADIN 10 MG CAPSULEnitisinone

4 PA


4 PA


4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSORFADIN 5 MG CAPSULEnitisinone

4 PA

pancrelipase dr 5,000 unit cap 2PERTZYE DR 16,000 UNIT CAPSULElipase/protease/amylase

3

PERTZYE DR 8,000 UNIT CAPSULElipase/protease/amylase

3

ULTRESA DR 13,800 UNIT CAPSULElipase/protease/amylase

3


3


3

VIOKACE 10,440-39,150 UNITS TBlipase/protease/amylase

3 ST

VIOKACE 20,880-78,300 UNITS TBlipase/protease/amylase

3 ST

ZAVESCA 100 MG CAPSULEmiglustat

4 PA

ZENPEP DR 10,000 UNITS CAPSULElipase/protease/amylase

2


2


2


2


2


2

GENITOURINARY AGENTSANTISPASMODICS, URINARY

darifenacin er 15 mg tablet 2 ST

darifenacin er 7.5 mg tablet 2 ST

DETROL LA 2 MG CAPSULEtolterodine tartrate

2 QL 30 / 30 DAYS

DETROL LA 4 MG CAPSULEtolterodine tartrate

2 QL 30 / 30 DAYS

ENABLEX 15 MG TABLETdarifenacin hydrobromide

2 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSENABLEX 7.5 MG TABLETdarifenacin hydrobromide

2 ST

flavoxate hcl 100 mg tablet 1GELNIQUE 10% GEL SACHETSoxybutynin chloride

2 QL 30 / 30 DAYS

MYRBETRIQ ER 25 MG TABLETmirabegron

3 ST

oxybutynin 5 mg tablet 1

oxybutynin 5 mg/5 ml syrup 1

oxybutynin cl er 10 mg tablet 1

oxybutynin cl er 15 mg tablet 1

oxybutynin cl er 5 mg tablet 1OXYTROL 3.9 MG/24HR PATCHoxybutynin

2

tolterodine tart er 2 mg cap 2 QL 30 / 30 DAYS

tolterodine tart er 4 mg cap 2 QL 30 / 30 DAYS

tolterodine tartrate 1 mg tab 1 QL 30 / 30 DAYS

tolterodine tartrate 2 mg tab 1 QL 30 / 30 DAYS

TOVIAZ ER 4 MG TABLETfesoterodine fumarate

2QL 30 / 30 DAYS

ST

TOVIAZ ER 8 MG TABLETfesoterodine fumarate

2QL 30 / 30 DAYS

ST

trospium chloride 20 mg tablet 1

trospium chloride er 60 mg cap 1VESICARE 10 MG TABLETsolifenacin succinate

2

VESICARE 5 MG TABLETsolifenacin succinate

2

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tablet 3 ST

CARDURA XL 4 MG TABLETdoxazosin mesylate

3

CARDURA XL 8 MG TABLETdoxazosin mesylate

3

CIALIS 2.5 MG TABLETtadalafil

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCIALIS 5 MG TABLETtadalafil

3 PA

dutasteride 0.5 mg capsule 3 ST

finasteride 5 mg tablet 1

RAPAFLO 4 MG CAPSULEsilodosin

2QL 30 / 30 DAYS

ST

RAPAFLO 8 MG CAPSULEsilodosin

2QL 30 / 30 DAYS

ST

tamsulosin hcl 0.4 mg capsule 1 QL 30 / 30 DAYS

UROXATRAL 10 MG TABLETalfuzosin hcl

3 ST

GENITOURINARY AGENTS, OTHERbethanechol 10 mg tablet 1

bethanechol 25 mg tablet 1

bethanechol 5 mg tablet 1

bethanechol 50 mg tablet 1CUPRIMINE 250 MG CAPSULEpenicillamine

2 PA

CYSTAGON 150 MG CAPSULEcysteamine bitartrate

4 PA

CYSTAGON 50 MG CAPSULEcysteamine bitartrate

4 PA

cytra-3 syrup 1DEPEN 250 MG TITRATABpenicillamine

3 PA

ELMIRON 100 MG CAPSULEpentosan polysulfate sodium

2

phenazopyridine 100 mg tab 1

phenazopyridine 200 mg tab 1

phospha 250 neutral tablet 1

potass cit-sod cit-citric soln 1

potassium cit-citric acid soln 1

potassium citrate er 10 meq tb 1

potassium citrate er 15 meq tb 1

potassium citrate er 5 meq tab 1

sod citrate-citric acid soln 1



tricitrates oral solution 1UROCIT-K ER 15 MEQ TABLETpotassium citrate

2

virt-phos 250 neutral tablet 1

virtrate-2 solution 1

virtrate-3 solution 1

virtrate-k solution 1

PHOSPHATE BINDERScalcium acetate 667 mg capsule 1

calcium acetate 667 mg gelcap 1

calcium acetate 667 mg tablet 1

eliphos 667 mg tablet 1FOSRENOL 1,000 MG TABLET CHEWlanthanum carbonate

2

FOSRENOL 500 MG TABLET CHEWlanthanum carbonate

2

FOSRENOL 750 MG TABLET CHEWlanthanum carbonate

2

PHOSLYRA 667 MG/5 ML SOLUTIONcalcium acetate

3

RENAGEL 400 MG TABLETsevelamer hcl

3

RENAGEL 800 MG TABLETsevelamer hcl

3

RENVELA 0.8 GM POWDER PACKETsevelamer carbonate


RENVELA 2.4 GM POWDER PACKETsevelamer carbonate


RENVELA 800 MG TABLETsevelamer carbonate


VELPHORO 500 MG CHEWABLE TABsucroferric oxyhydroxide

3 QL 6 / 1 DAYS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)ALA-CORT 1% CREAMhydrocortisone

1

alclometasone dipr 0.05% oint 1

alclometasone dipro 0.05% crm 1

amcinonide 0.1% cream 1

amcinonide 0.1% lotion 1



amcinonide 0.1% ointment 1

anucort-hc 25 mg suppository 1

betamethasone dp 0.05% crm 1

betamethasone dp 0.05% lot 1

betamethasone dp 0.05% oint 1

betamethasone dp aug 0.05% crm 1

betamethasone dp aug 0.05% gel 1

betamethasone dp aug 0.05% lot 1

betamethasone dp aug 0.05% oin 1

betamethasone va 0.1% cream 1

betamethasone va 0.1% lotion 1

betamethasone valer 0.1% ointm 1

betamethasone valer 0.12% foam 1CAPEX SHAMPOOfluocinolone acetonide

2

clobetasol 0.05% cream 1

clobetasol 0.05% gel 1

clobetasol 0.05% ointment 1

clobetasol 0.05% shampoo 1

clobetasol 0.05% solution 1

clobetasol 0.05% topical lotn 1

clobetasol prop 0.05% foam 1

clocortolone 0.1% cream pump 3

clocortolone pivalate 0.1% crm 3CORDRAN 0.05% CREAMflurandrenolide

3 QL 2 / 10 DAYS

CORDRAN 0.05% LOTIONflurandrenolide

3 QL 2 / 10 DAYS

CORDRAN 4 MCG/SQ CM TAPE LARGEflurandrenolide

2 QL 2 / 10 DAYS

CORDRAN 4 MCG/SQ CM TAPE SMALLflurandrenolide

2 QL 2 / 10 DAYS

cormax 0.05% solution 1

cortisone 25 mg tablet 1DELTASONE 20 MG TABLETprednisone

1

DESONATE 0.05% GELdesonide

3



desonide 0.05% cream 1

desonide 0.05% lotion 1

desonide 0.05% ointment 1

desoximetasone 0.05% cream 1

desoximetasone 0.05% gel 1

desoximetasone 0.05% ointment 1

desoximetasone 0.25% cream 1

desoximetasone 0.25% ointment 1

dexamethasone 0.5 mg tablet 1

dexamethasone 0.5 mg/5 ml elx 1

dexamethasone 0.5 mg/5 ml liq 1


dexamethasone 1 mg tablet 1





dexamethasone intensol 1mg/1ml 3DEXPAK 13 DAY 1.5 MG TABLETdexamethasone

3

diflorasone 0.05% cream 3

diflorasone 0.05% ointment 3

fludrocortisone 0.1 mg tablet 1

fluocinolone 0.01% body oil 1

fluocinolone 0.01% cream 1

fluocinolone 0.01% scalp oil 1

fluocinolone 0.01% solution 1

fluocinolone 0.025% cream 1

fluocinolone 0.025% ointment 1

fluocinonide 0.05% cream 1

fluocinonide 0.05% gel 1

fluocinonide 0.05% ointment 1

fluocinonide 0.05% solution 1

fluocinonide 0.1% cream 3

fluticasone prop 0.005% oint 1



fluticasone prop 0.05% cream 1

fluticasone prop 0.05% lotion 1

halobetasol prop 0.05% cream 1

halobetasol prop 0.05% ointmnt 1HALOG 0.1% CREAMhalcinonide

2

HALOG 0.1% OINTMENThalcinonide

2

hemmorex-hc 30 mg suppository 1

hydrocortisone 1% cream 1

hydrocortisone 1% cream 1

hydrocortisone 1% ointment 1

hydrocortisone 10 mg tablet 1

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% lotion 1

hydrocortisone 2.5% ointment 1



hydrocortisone ac 25 mg supp 1

hydrocortisone ac 30 mg supp 1

hydrocortisone buty 0.1% cream 1

hydrocortisone butyr 0.1% oint 1

hydrocortisone butyr 0.1% soln 1

hydrocortisone val 0.2% cream 1

hydrocortisone val 0.2% ointmt 1KENALOG 0.147 MG/GRAM SPRAYtriamcinolone acetonide

2

LOCOID 0.1% CREAMhydrocortisone butyrate

2

LOCOID 0.1% LOTIONhydrocortisone butyrate

2

methylprednisolone 16 mg tab 1


methylprednisolone 4 mg dosepk 1

methylprednisolone 4 mg tablet 1




millipred 5 mg tablet 3

millipred dp 5 mg 12-day pack 3

millipred dp 5 mg 6-day pack 3

mometasone furoate 0.1% cream 1

mometasone furoate 0.1% oint 1

mometasone furoate 0.1% soln 1ORAPRED ODT 10 MG TABLETprednisolone sod phosphate

3

prednicarbate 0.1% cream 1

prednicarbate 0.1% ointment 1

prednisolone 15 mg/5 ml soln 1


prednisolone 15 mg/5 ml syrup 1


prednisolone odt 10 mg tablet 3

prednisolone sod ph 25 mg/5 ml 1

prednisone 1 mg tablet 1

prednisone 10 mg tab dose pack 1



prednisone 2.5 mg tablet 1


prednisone 5 mg tab dose pack 1



prednisone 5 mg/5 ml solution 1

prednisone 5 mg/ml solution 3

prednisone 50 mg tablet 1PRELONE 15 MG/5 ML SYRUPprednisolone

1

proctosol-hc 2.5% cream 1

proctozone-hc 2.5% cream 1RAYOS DR 1 MG TABLETprednisone

3 ST



scalacort 2% lotion 1TEXACORT 2.5% SOLUTIONhydrocortisone

3

triamcinolone 0.025% cream 1

triamcinolone 0.025% lotion 1

triamcinolone 0.025% oint 1


triamcinolone 0.1% lotion 1

triamcinolone 0.1% ointment 1

triamcinolone 0.147 mg/g spray 2


triamcinolone 0.5% ointment 1

trianex 0.05% ointment 1

triderm 0.1% cream 1

u-cort 1% cream 1VANOS 0.1% CREAMfluocinonide

3

VERDESO 0.05% FOAMdesonide

3 ST

VERIPRED 20 20 MG/5 ML SOLNprednisolone sod phosphate

3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin 0.01% solution 1 PA

desmopressin 0.01% spray 1 PA

desmopressin 0.1 mg/ml sol 1 PA

desmopressin 0.1 mg/ml spray 1

desmopressin 10 mcg/0.1 ml spr 1

desmopressin acetate 0.1 mg tb 1

desmopressin acetate 0.2 mg tb 1GENOTROPIN 12 MG CARTRIDGEsomatropin

4 PA

GENOTROPIN 5 MG CARTRIDGEsomatropin

4 PA

GENOTROPIN MINIQUICK 0.2 MGsomatropin

4 PA


4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSGENOTROPIN MINIQUICK 0.6 MGsomatropin

4 PA


4 PA

GENOTROPIN MINIQUICK 1 MGsomatropin

4 PA


4 PA


4 PA


4 PA


4 PA

GENOTROPIN MINIQUICK 2 MGsomatropin

4 PA

GONAL-F RFF REDI-JECT 300 UNITfollitropin alfa, recombinant

4 PA


4 PA


4 PA

HUMATROPE 12 MG CARTRIDGEsomatropin

4 PA


4 PA

HUMATROPE 5 MG VIALsomatropin

4 PA


4 PA

INCRELEX 40 MG/4 ML VIALmecasermin

4 PA

NORDITROPIN FLEXPRO 10 MG/1.5somatropin

4 PA


4 PA

NORDITROPIN FLEXPRO 30 MG/3 MLsomatropin

4 PA


4 PA

NORDITROPIN NORDIFLEX 30 MG/3somatropin

4 PA

NUTROPIN 10 MG VIALsomatropin

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNUTROPIN AQ 20 MG/2ML PEN CARTsomatropin

4 PA

NUTROPIN AQ NUSPIN 10 INJECTORsomatropin

4 PA


4 PA


4 PA

NUTROPIN AQ PEN CARTRIDGEsomatropin

4 PA

OMNITROPE 10 MG/1.5 ML CRTGsomatropin

4 PA

OMNITROPE 5 MG/1.5 ML CRTGsomatropin

4 PA

OMNITROPE 5.8 MG VIALsomatropin

4 PA

SAIZEN 5 MG VIALsomatropin

4 PA

SAIZEN 8.8 MG CLICK.EASY CARTGsomatropin

4 PA

SAIZEN 8.8 MG VIALsomatropin

4 PA

SEROSTIM 4 MG VIALsomatropin

4 PA


4 PA


4 PA

STIMATE 1.5 MG/ML NASAL SPRAYdesmopressin acetate

4 PA

TEV-TROPIN 5 MG VIALsomatropin

4 PA

ZORBTIVE 8.8 MG VIALsomatropin

4 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)ANABOLIC STEROIDS

ANADROL-50 TABLEToxymetholone

3

oxandrolone 10 mg tablet 1

oxandrolone 2.5 mg tablet 1



ANDROGENS

androxy 10 mg tablet 3 QL 4 / 1 DAYS

danazol 100 mg capsule 1

danazol 200 mg capsule 1

danazol 50 mg capsule 1METHITEST 10 MG TABLETmethyltestosterone

3 PA

methyltestosterone 10 mg cap 3 PA

testosteron cyp 1,000 mg/10 ml 1 PA

testosteron cyp 2,000 mg/10 ml 1 PA

testosteron enan 1,000 mg/5 ml 1 PA

testosterone 10 mg gel pump 3 PA

testosterone 12.5 mg/1.25 gram 3 PA

testosterone 25 mg/2.5 gm pkt 3 PA

testosterone 50 mg/5 gram gel 3 PA

testosterone 50 mg/5 gram pkt 3 PA

testosterone cyp 100 mg/ml 1 PA

testosterone cyp 200 mg/ml 1 PA

testosterone enan 200 mg/ml 1 PA

ESTROGENSALORA 0.025 MG PATCHestradiol

2 QL 8 / 28 DAYS

ALORA 0.05 MG PATCHestradiol

2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS

altavera-28 tablet 5

alyacen 1-35-28 tablet 5

alyacen 7-7-7-28 tablet 5

amabelz 0.5 mg-0.1 mg tablet 1

amabelz 1 mg-0.5 mg tablet 1



amethia 0.15-0.03-0.01 mg tab 5 MD 1 / 91 Days

amethia lo tablet 5 MD 1 / 91 Days

apri 28 day tablet 5

aranelle 28 tablet 5

ashlyna 0.15-0.03-0.01 mg tab 5 MD 1 / 91 Days

aubra-28 tablet 5

aviane-28 tablet 5

azurette 28 day tablet 5

balziva 28 tablet 5

bekyree 28 day tablet 5BEYAZ 28 TABLETdrospirenone/ethinyl estradiol/levomefolate calcium

2

blisovi 24 fe tablet 5

blisovi fe 1-20 tablet 5

blisovi fe 1.5-30 tablet 5BREVICON 28 TABLETnorethindrone-ethinyl estradiol

5

briellyn tablet 5

camrese 0.15-0.03-0.01 mg tab 5 MD 1 / 91 Days

camrese lo tablet 5 MD 1 / 91 Days

caziant 28 day tablet 5

chateal-28 tablet 5COMBIPATCH 0.05-0.14 MG PTCHestradiol/norethindrone acetate

2

COMBIPATCH 0.05-0.25 MG PTCHestradiol/norethindrone acetate

2

covaryx h.s. tablet 1

covaryx tablet 1

cryselle-28 tablet 5

cyclafem 1-35-28 tablet 5

cyclafem 7-7-7-28 tablet 5

cyred 28 day tablet 5

dasetta 1-35-28 tablet 5

dasetta 7/7/7-28 tablet 5

daysee 0.15-0.03-0.01 mg tab 5 MD 1 / 91 Days



delyla-28 tablet 5

desogest-eth estra 0.15-0.03mg 5

desogestr-eth estrad eth estra 5

desogestrel-ethinyl estrad tab 5

drosp-ee-levomef 3-0.02-0.451 5

drospirenone-ee 3-0.02 mg tab 5

drospirenone-ee 3-0.03 mg tab 5DUAVEE 0.45-20 MG TABLETestrogens, conjugated/bazedoxifene acetate

3 QL 1 / 1 DAYS

eemt ds 1.25-2.5 mg tablet 1

eemt hs 0.625-1.25 mg tablet 1

elinest-28 tablet 5

emoquette 28 day tablet 5

enpresse-28 tablet 5

enskyce 28 tablet 5

estarylla 0.25-0.035 mg tablet 5ESTRACE 0.01% CREAMestradiol

2

estradiol 0.025 mg patch 2 QL 8 / 28 DAYS


estradiol 0.0375 mg/day patch 1 QL 4 / 28 DAYS





estradiol 0.5 mg tablet 1

estradiol 1 mg tablet 1

estradiol 2 mg tablet 1

estradiol tds 0.025 mg/day 1 QL 4 / 28 DAYS








estradiol-noreth 0.5-0.1 mg tb 1

estradiol-noreth 1-0.5 mg tab 1ESTRING 2 MG VAGINAL RINGestradiol

2

ESTROGEL 0.06% GELestradiol

3

estrogen-methyltestos f.s. tab 1

estrogen-methyltestos h.s. tab 1

estropipate 0.625(0.75 mg) tab 1

estropipate 1.25(1.5 mg) tab 1

estropipate 2.5(3 mg) tab 1

ethynodiol-eth estra 1mg-50mcg 5EVAMIST 1.53 MG/SPRAYestradiol

2

falmina-28 tablet 5

fyavolv 1 mg-5 mcg tablet 1

gianvi 3 mg-0.02 mg tablet 5

gildagia 0.4 mg-0.035 mg tab 5

gildess 1 mg-20 mcg tablet 5

gildess 1.5 mg-30 mcg tablet 5

gildess 24 fe 1-0.02 mg tablet 5

gildess fe 1-20 tablet 5

gildess fe 1.5-30 tablet 5

introvale 0.15-0.03 mg tablet 5 MD 1 / 91 Days

jinteli 1 mg-5 mcg tablet 1

jolessa 0.15 mg-0.03 mg tablet 5 MD 1 / 91 Days

juleber 28 day tablet 5

junel 1 mg-20 mcg tablet 5

junel 1.5 mg-30 mcg tablet 5

junel fe 1 mg-20 mcg tablet 5

junel fe 1.5 mg-30 mcg tablet 5

junel fe 24 tablet 5

kaitlib fe chewable tablet 5

kariva 28 day tablet 5



kelnor 1-35 28 tablet 5

kimidess 28 day tablet 5

kurvelo tablet 5

larin 1.5 mg-30 mcg tablet 5

larin 21 1-20 tablet 5

larin 24 fe 1 mg-20 mcg tablet 5

larin fe 1-20 tablet 5

larin fe 1.5-30 tablet 5

larissia-28 tablet 5LAYOLIS FE CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate

5

leena 28 tablet 5

lessina-28 tablet 5

levonest-28 tablet 5

levono-e estrad 0.10-0.02-0.01 5 MD 1 / 91 Days

levono-e estrad 0.15-0.03-0.01 5 MD 1 / 91 Days

levonor-eth estra 0.09-0.02 mg 5

levonor-eth estrad 0.1-0.02 mg 5

levonor-eth estrad 0.15-0.03 5

levonor-eth estrad 0.15-0.03 5 MD 1 / 91 Days

levonor-eth estrad triphasic 5

levora-28 tablet 5LO LOESTRIN FE 1-10 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate

2

lomedia 24 fe 1 mg-20 mcg tab 5

lopreeza 0.5 mg-0.1 mg tablet 1

lopreeza 1 mg-0.5 mg tablet 1

loryna 3 mg-0.02 mg tablet 5

low-ogestrel-28 tablet 5

lutera-28 tablet 5

marlissa-28 tablet 5MENEST 0.3 MG TABLETestrogens,esterified

3

MENEST 0.625 MG TABLETestrogens,esterified

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMENEST 1.25 MG TABLETestrogens,esterified

3

MENEST 2.5 MG TABLETestrogens,esterified

3

microgestin 21 1-20 tablet 5

microgestin 21 1.5-30 tab 5MICROGESTIN 24 FE 1 MG-20 MCGnorethindrone acetate-ethinyl estradiol/ferrous fumarate

5

microgestin fe 1-20 tablet 5

microgestin fe 1.5-30 tab 5

mimvey 1-0.5 mg tablet 1

mimvey lo 0.5-0.1 mg tablet 1MINIVELLE 0.025 MG PATCHestradiol

2 QL 8 / 28 DAYS

MINIVELLE 0.0375 MG PATCHestradiol

2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS

mono-linyah 28 tablet 5

mononessa 28 tablet 5

myzilra-28 tablet 5

necon 0.5-35-28 tablet 5

necon 1-35-28 tablet 5



necon 7-7-7-28 tablet 5

nikki 3 mg-0.02 mg tablet 5

noret-estr-fe 0.4-0.035(21)-75 5

noreth-estrad-fe 1-0.02(21)-75 5

noreth-estrad-fe 1-0.02(24)-75 5

norethin-estra-fe 0.8-0.025 mg 5

norethin-eth estrad 1 mg-5 mcg 1

norethind-eth estrad 1-0.02 mg 5



norg-ee 0.18-0.215-0.25/0.025 5

norg-ee 0.18-0.215-0.25/0.035 5

norg-ethin estra 0.25-0.035 mg 5NORINYL 1-35 28 TABLETnorethindrone-ethinyl estradiol

5

nortrel 0.5-35-28 tablet 5

nortrel 1-35 21 tablet 5

nortrel 1-35 28 tablet 5

nortrel 7-7-7-28 tablet 5NUVARING VAGINAL RINGetonogestrel/ethinyl estradiol

5

ocella 3 mg-0.03 mg tablet 5

ogestrel tablet 5

orsythia-28 tablet 5

philith 0.4-0.035 mg tablet 5

pimtrea 28 day tablet 5

pirmella 1-35-28 tablet 5

pirmella 7-7-7-28 tablet 5

portia-28 tablet 5PREMARIN 0.3 MG TABLETestrogens, conjugated

2

PREMARIN 0.45 MG TABLETestrogens, conjugated

2


2


2


2

PREMPHASE 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate

2

PREMPRO 0.3 MG-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate

2

PREMPRO 0.45-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate

2

PREMPRO 0.625-2.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate

2

PREMPRO 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate

2



previfem tablet 5

quasense 0.15-0.03 mg tablet 5 MD 1 / 91 Days

rajani 28 tablet 5

reclipsen 28 day tablet 5SAFYRAL TABLETdrospirenone/ethinyl estradiol/levomefolate calcium

2

setlakin 0.15 mg-0.03 mg tab 5 MD 1 / 91 Days

sprintec 28 day tablet 5

sronyx 0.10-0.02 mg tablet 5

syeda 28 tablet 5

tarina fe 1-20 tablet 5

tilia fe 28 tablet 5

tri-estarylla tablet 5

tri-legest fe-28 day tablet 5

tri-linyah tablet 5

tri-lo-estarylla tablet 5

tri-lo-marzia tablet 5

tri-lo-sprintec tablet 5

tri-previfem tablet 5

tri-sprintec tablet 5

trinessa lo tablet 5

trinessa tablet 5

trivora-28 tablet 5VAGIFEM 10 MCG VAGINAL TABestradiol

2

velivet 28 day tablet 5

vestura 3 mg-0.02 mg tablet 5

vienva-28 tablet 5

viorele 28 day tablet 5VIVELLE-DOT 0.025 MG PATCHestradiol

2 QL 8 / 28 DAYS

VIVELLE-DOT 0.0375 MG PATCHestradiol

2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS


2 QL 8 / 28 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSVIVELLE-DOT 0.1 MG PATCHestradiol

2 QL 8 / 28 DAYS

vyfemla 28 tablet 5

wera 0.5/0.035 mg 28 tablet 5

wymzya fe chewable tablet 5

xulane patch 5

yuvafem 10 mcg vaginal insert 2

zarah tablet 5

zenchent 0.4 mg-35 mcg tablet 5

zenchent fe tablet chewable 5

zeosa chewable tablet 5

zovia 1-35e tablet 5

zovia 1-50e tablet 5

PROGESTINScamila 0.35 mg tablet 5CRINONE 4% GELprogesterone, micronized

4

deblitane 0.35 mg tablet 5

DEPO-SUBQ PROVERA 104 SYRINGEmedroxyprogesterone acetate

3QL 0.65 / 84 DAYSMD 1 / 90 Days

ENDOMETRIN 100 MG SUPPOSITORYprogesterone, micronized

2

errin 0.35 mg tablet 5

heather tablet 5

jencycla 0.35 mg tablet 5

jolivette tablet 5

levonorgestrel 1.5 mg tablet 5

lyza 0.35 mg tablet 5

medroxyprogesterone 10 mg tab 5

medroxyprogesterone 150 mg/ml 5 QL 1 / 84 DAYS

medroxyprogesterone 150 mg/ml 5 QL 1 / 84 DAYS

medroxyprogesterone 2.5 mg tab 5

medroxyprogesterone 5 mg tab 5

megestrol 20 mg tablet 1

megestrol 40 mg tablet 1



megestrol acet 40 mg/ml susp 1

megestrol acet 400 mg/10 ml 1

nora-be tablet 5

norethindrone 0.35 mg tablet 5

norethindrone 5 mg tablet 1

norlyroc 0.35 mg tablet 5

progesterone 100 mg capsule 3

progesterone 200 mg capsule 3

sharobel 0.35 mg tablet 5

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSclomiphene citrate 50 mg tab 1

raloxifene hcl 60 mg tablet 5 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)ARMOUR THYROID 120 MG TABLETthyroid,pork

2

ARMOUR THYROID 15 MG TABLETthyroid,pork

2


2


2


2


2


2


2

levothyroxine 100 mcg tablet 1














liothyronine sod 25 mcg tab 1

liothyronine sod 5 mcg tab 1

liothyronine sod 50 mcg tab 1NATURE-THROID 113.75 MG TABLETthyroid,pork

2

NATURE-THROID 130 MG TABLETthyroid,pork

2

NATURE-THROID 146.25 MG TABLETthyroid,pork

1


2


2


2


1


2


2


2


2


2


1

np thyroid 15 mg tablet 1



np thyroid 90 mg tablet 1SYNTHROID 100 MCG TABLETlevothyroxine sodium

3

SYNTHROID 112 MCG TABLETlevothyroxine sodium

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSYNTHROID 125 MCG TABLETlevothyroxine sodium

3


3


3


3


3


3


3


3


3


3

THYROLAR-1 STRENGTH TABLETliotrix

3

THYROLAR-1/2 STRENGTH TABliotrix

3

THYROLAR-1/4 STRENGTH TABliotrix

3


3


3

WESTHROID 130 MG TABLETthyroid,pork

2


2

WESTHROID 32.5 MG TABLETthyroid,pork

2


2

WESTHROID 97.5 MG TABLETthyroid,pork

1

WP THYROID 113.75 MG TABLETthyroid,pork

2

WP THYROID 130 MG TABLETthyroid,pork

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSWP THYROID 16.25 MG TABLETthyroid,pork

2


2


2

WP THYROID 65 MG TABLETthyroid,pork

2


2


1

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)cabergoline 0.5 mg tablet 1EGRIFTA 1 MG VIALtesamorelin acetate

4 PA

EGRIFTA 2 MG VIALtesamorelin acetate

4 PA

ELIGARD 22.5 MG SYRINGE KITleuprolide acetate

4

ELIGARD 30 MG SYRINGE KITleuprolide acetate

4

ELIGARD 45 MG SYRINGE KITleuprolide acetate

4

ELIGARD 7.5 MG SYRINGE KITleuprolide acetate

4

leuprolide 2wk 1 mg/0.2 ml kit 1

leuprolide 2wk 14 mg/2.8 ml kt 1

octreotide 1,000 mcg/5 ml vial 1

octreotide 1,000 mcg/ml vial 1

octreotide 5,000 mcg/5 ml vial 1

octreotide acet 0.05 mg/ml vl 1

octreotide acet 100 mcg/ml amp 1

octreotide acet 100 mcg/ml vl 1



octreotide acet 50 mcg/ml vial 1




PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSIGNIFOR 0.3 MG/ML AMPULEpasireotide diaspartate

2

SIGNIFOR 0.6 MG/ML AMPULEpasireotide diaspartate

2

SIGNIFOR 0.9 MG/ML AMPULEpasireotide diaspartate

2

SOMAVERT 10 MG VIALpegvisomant

4 PA


4 PA


4 PA

SYNAREL 2 MG/ML NASAL SPRAYnafarelin acetate

4

HORMONAL AGENTS, SUPPRESSANT (THYROID)ANTITHYROID AGENTS

methimazole 10 mg tablet 1

methimazole 5 mg tablet 1

propylthiouracil 50 mg tablet 1

sski 1 gm/ml solution 3

IMMUNOLOGICAL AGENTSANGIOEDEMA AGENTS

BERINERT 500 UNIT KITc1 esterase inhibitor

4 PA

CINRYZE 500 UNIT VIALc1 esterase inhibitor

4 PA

FIRAZYR 30 MG/3 ML SYRINGEicatibant acetate

4 PA

RUCONEST 2,100 UNIT VIALc1 esterase inhibitor, recombinant

4 PA

IMMUNE SUPPRESSANTSAZASAN 100 MG TABLETazathioprine

2

AZASAN 75 MG TABLETazathioprine

2

azathioprine 50 mg tablet 1CIMZIA 200 MG VIAL KITcertolizumab pegol

4 PA

CIMZIA 200 MG/ML STARTER KITcertolizumab pegol

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCIMZIA 200 MG/ML SYRINGE KITcertolizumab pegol

4 PA

cyclosporine 100 mg capsule 1

cyclosporine 100 mg/ml soln 1

cyclosporine 25 mg capsule 1

cyclosporine modified 100 mg 1

cyclosporine modified 25 mg 1

cyclosporine modified 50 mg 1ENBREL 25 MG KITetanercept

4 PA

ENBREL 25 MG/0.5 ML SYRINGEetanercept

4 PA

ENBREL 50 MG/ML SURECLICK SYRetanercept

4 PA

ENBREL 50 MG/ML SYRINGEetanercept

4 PA

gengraf 100 mg capsule 1

gengraf 100 mg/ml solution 1

gengraf 25 mg capsule 1

gengraf 50 mg capsule 1HUMIRA 20 MG/0.4 ML SYRINGEadalimumab

4 PA

HUMIRA 40 MG/0.8 ML PENadalimumab

4 PA

HUMIRA 40 MG/0.8 ML SYRINGEadalimumab

4 PA

HUMIRA PEDIATRIC CROHN'S STARTadalimumab

4 PA

HUMIRA PEN CROHN-UC-HS STARTERadalimumab

3 PA

HUMIRA PEN PSORIASIS-UVEITISadalimumab

4 PA

KINERET 100 MG/0.67 ML SYRINGEanakinra

3 PA

methotrexate 1 gm vial 1

methotrexate 1 gram/40 ml vial 1

methotrexate 100 mg/4 ml vial 1

methotrexate 2.5 mg tablet 1




methotrexate 25 mg/ml vial 1



mycophenolate 200 mg/ml susp 3

mycophenolate 250 mg capsule 3

mycophenolate 500 mg tablet 3

mycophenolic acid dr 180 mg tb 3

mycophenolic acid dr 360 mg tb 3ORENCIA 125 MG/ML SYRINGEabatacept

3 PA

OTREXUP 10 MG/0.4 ML AUTO-INJmethotrexate/pf

4

QL 1.6 / 28 DAYS

PA

ST


3

QL 1.6 / 28 DAYS

PA

ST


3

QL 1.6 / 28 DAYS

PA

ST


3

QL 1.6 / 28 DAYS

PA

ST

RAPAMUNE 0.5 MG TABLETsirolimus

2 PA

RAPAMUNE 1 MG TABLETsirolimus

2 PA

RAPAMUNE 1 MG/ML ORAL SOLNsirolimus

2 PA

RAPAMUNE 2 MG TABLETsirolimus

2 PA

RASUVO 20 MG/0.4 ML AUTOINJmethotrexate/pf

3QL 1.6 / 28 DAYS

ST

RHEUMATREX 2.5 MG TABLETmethotrexate sodium

3

SANDIMMUNE 100 MG/ML SOLNcyclosporine

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSIMPONI 50 MG/0.5 ML SYRINGEgolimumab

4 PA

sirolimus 0.5 mg tablet 2 PA

sirolimus 1 mg tablet 2 PA

sirolimus 2 mg tablet 2 PA

tacrolimus 0.5 mg capsule 1

tacrolimus 1 mg capsule 1

tacrolimus 5 mg capsule 1TREXALL 10 MG TABLETmethotrexate sodium

2

TREXALL 15 MG TABLETmethotrexate sodium

2

TREXALL 5 MG TABLETmethotrexate sodium

2

TREXALL 7.5 MG TABLETmethotrexate sodium

2

XELJANZ 5 MG TABLETtofacitinib citrate

4 PA

ZORTRESS 0.25 MG TABLETeverolimus

3 PA


3 PA


3 PA

IMMUNIZING AGENTS, PASSIVEgammagard liquid 10% vial 4GAMMAGARD LIQUID 10% VIALimmune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml

4

IMMUNOMODULATORSACTEMRA 162 MG/0.9 ML SYRINGEtocilizumab

4 PA

ACTIMMUNE 100 MCG/0.5 ML VIALinterferon gamma-1b,recomb.

4 PA

ARCALYST 220 MG INJECTIONrilonacept

4

leflunomide 10 mg tablet 1

leflunomide 20 mg tablet 1OTEZLA 30 MG TABLETapremilast

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSOTEZLA STARTER PACKapremilast

4 PA

RIDAURA 3 MG CAPSULEauranofin

2

VACCINESFLUARIX QUAD 2017-2018 SYRINGEinfluenza virus vaccine quadrivalent 2017-18 (36 mosup)/pf

5

FLUBLOK 2017-2018 VIALinfluenza virus vaccine tv 2017-18(18 yrs andolder)rcmb/pf

5

FLUBLOK QUAD 2017-2018 SYRINGEinfluenza virus vaccine qv 2017-18(18 yrs andolder)rcmb/pf

5

FLUVIRIN 2017-2018 SYRINGEinfluenza virus vaccine trival 2017-2018 (4yr and older)/pf

5

FLUVIRIN 2017-2018 VIALinfluenza virus vaccine trivalent 2017-2018 (4 yr andolder)

5

FLUZONE HIGH-DOSE 2017-18 SYRinfluenza virus vaccine trival split 2017-2018(65 yr up)/pf

5

GARDASIL VIALhuman papillomavirus vaccine, quadrivalent/pf

5

HAVRIX 1,440 UNITS/ML SYRINGEhepatitis a virus vaccine/pf

3

HAVRIX 1,440 UNITS/ML VIALhepatitis a virus vaccine/pf

3

M-M-R II VACCINE WITH DILUENTmeasles, mumps, and rubella vaccine live/pf

5

MENACTRA VIALmeningococcalvaccine a,c,y,w-135,diphtheria toxoidconj/pf

5

PNEUMOVAX 23 VIALpneumococcal 23-valent polysaccharide vaccine

5

RECOMBIVAX HB 10 MCG/ML VIALhepatitis b virus vaccine recombinant/pf

5

RECOMBIVAX HB 40 MCG/ML VIALhepatitis b virus vaccine recombinant/pf

5

TENIVAC SYRINGEtetanus and diphtheria toxoids, adsorbed, adult/pf

5

TENIVAC VIALtetanus and diphtheria toxoids, adsorbed, adult/pf

5



tetanus diphtheria toxoids 5TWINRIX VACCINE SYRINGEhepatitis a virus and hepatitis b virus vaccine/pf

3

TWINRIX VACCINE VIALhepatitis a virus and hepatitis b virus vaccine/pf

3

INFLAMMATORY BOWEL DISEASE AGENTSAMINOSALICYLATES

APRISO ER 0.375 GRAM CAPSULEmesalamine

2 QL 120 / 30 DAYS

ASACOL HD DR 800 MG TABLETmesalamine

2

balsalazide disodium 750 mg cp 1CANASA 1,000 MG SUPPOSITORYmesalamine

2

DIPENTUM 250 MG CAPSULEolsalazine sodium

3

GIAZO 1.1 GM TABLETbalsalazide disodium

3

mesalamine 4 gm/60 ml enema 1PENTASA 250 MG CAPSULEmesalamine

2

PENTASA 500 MG CAPSULEmesalamine

2

GLUCOCORTICOIDSbudesonide ec 3 mg capsule 1

colocort 100 mg enema 1CORTIFOAM 10% AEROSOLhydrocortisone acetate

2

hydrocortisone 100 mg/60 ml 1

SULFONAMIDESsulfasalazine 500 mg tablet 1

sulfasalazine dr 500 mg tab 1

METABOLIC BONE DISEASE AGENTS

alendronate sodium 10 mg tab 1 QL 30 / 30 DAYS



alendronate sodium 5 mg tablet 1 QL 30 / 30 DAYS




BINOSTO 70 MG TABLET EFFalendronate sodium

3 ST

BONIVA 150 MG TABLETibandronate sodium

3

calcitonin-salmon 200 units sp 1

calcitriol 0.25 mcg capsule 1

calcitriol 0.5 mcg capsule 1

calcitriol 1 mcg/ml solution 1

doxercalciferol 0.5 mcg cap 2

doxercalciferol 1 mcg capsule 2

doxercalciferol 2.5 mcg cap 2

etidronate disodium 200 mg tab 1

etidronate disodium 400 mg tab 1FORTEO 600 MCG/2.4 ML PEN INJteriparatide

4 PA

FOSAMAX PLUS D 70 MG-2,800 IUalendronate sodium/cholecalciferol (vitamin d3)

2 QL 4 / 28 DAYS

FOSAMAX PLUS D 70 MG-5,600 IUalendronate sodium/cholecalciferol (vitamin d3)

2 QL 4 / 28 DAYS

HECTOROL 0.5 MCG CAPSULEdoxercalciferol

2

HECTOROL 1 MCG CAPSULEdoxercalciferol

2

HECTOROL 2.5 MCG CAPSULEdoxercalciferol

2

ibandronate sodium 150 mg tab 3MIACALCIN 200 UNIT/ML VIALcalcitonin,salmon,synthetic

3

MIACALCIN 400 UNIT/2 ML VIALcalcitonin,salmon,synthetic

3

paricalcitol 1 mcg capsule 2



risedronate sod dr 35 mg tab 3 ST

risedronate sodium 150 mg tab 3

risedronate sodium 30 mg tab 3 QL 30 / 30 DAYS

risedronate sodium 35 mg tab 3 QL 4 / 28 DAYS



risedronate sodium 5 mg tablet 3 QL 30 / 30 DAYS

SENSIPAR 30 MG TABLETcinacalcet hcl

3 PA


3 PA


3 PA

vit d2 1.25 mg (50,000 unit) 1ZEMPLAR 1 MCG CAPSULEparicalcitol

2

ZEMPLAR 2 MCG CAPSULEparicalcitol

2

MISCELLANEOUS THERAPEUTIC AGENTScompound 347 inhalation 1

enlite serter 3

femcap 22 mm cervical cap 5



formadon 10% solution 1FORMADON 10% SOLUTIONformaldehyde

1

formaldehyde 10% solution 1

glucocom autolink system 3

guardian real time starter kit 3

guardian rt replace charger 3

guardian rt replace monitor 3

guardian rt replace test plug 3

guardian test plug 3

insulin syrin 0.5 ml 30gx1/2" 2

insulin syrin 0.5 ml 30gx5/16" 2

insulin syringe 1 ml 30gx1/2" 2

insulin syringe 1 ml 30gx5/16" 2

isomethept-dichloralp-acetamin 1

magellan insul syringe 0.3 ml 2

magellan insul syringe 0.5 ml 2

magellan insulin syr 0.3 ml 2



magellan insulin syr 0.5 ml 2

magellan insulin syringe 1 ml 2

magellan insulin syringe 1 ml 2

methylergonovine 0.2 mg tablet 1

monoject 0.5 ml syrn 28gx1/2" 2

monoject 1 ml syrn 28gx1/2" 2

monoject insulin syr 0.3 ml 2

monoject insulin syr 0.5 ml 2

monoject insulin syr 1 ml 2

monoject insulin syr u-100 2

monoject syringe 1 ml 2


nodolor capsule 1

pen needle 30g x 5/16" 2



replacement pediatric monitor 3

sen-serter 3

terrell liquid 1

ulticare ins safety 1ml 29x1/2 2

ulticare safety 0.5 ml 29gx1/2 2

wide seal diaphragm 60mm 5








OPHTHALMIC AGENTSOPHTHALMIC AGENTS, OTHER

ak-poly-bac eye ointment 1ALCAINE 0.5% EYE DROPSproparacaine hcl

1

altacaine 0.5% eye drops 1



atropine 1% eye drops 1

atropine 1% eye ointment 1

bacitracin-polymyxin eye oint 1BLEPHAMIDE EYE OINTMENTsulfacetamide sodium/prednisolone acetate

2

cyclopentolate 1% eye drops 1

cyclopentolate hcl 2% drops 1CYSTARAN 0.44% EYE DROPScysteamine hcl

3

FLUCAINE EYE DROPSproparacaine hcl/fluorescein sodium

1

fluorescein-proparacaine drops 1

homatropaire 5% eye drops 1

homatropine 5% eye drops 1

naphazoline 0.1% eye drops 1

neo-bacit-poly-hc eye ointment 1

neo-polycin eye ointment 1

neo-polycin hc eye ointment 1

neomyc-bacit-polymix eye oint 1

neomyc-polym-dexamet eye ointm 1

neomyc-polym-dexameth eye drop 1

neomyc-polym-gramicid eye drop 1

neomycin-poly-hc eye drops 1

phenylephrine 10% eye drops 1

phenylephrine 2.5% eye drop 1

polycin eye ointment 1

polymyxin b-tmp eye drops 1

proparacaine 0.5% eye drops 1RESTASIS 0.05% EYE EMULSIONcyclosporine

2

sulf-pred 10-0.23% eye drops 1

tetracaine 0.5% eye drops 1

tetracaine 0.5% steri-unit sol 1TOBRADEX EYE OINTMENTtobramycin/dexamethasone

2

TOBRADEX ST EYE DROPStobramycin/dexamethasone

2 ST



tobramycin-dexameth ophth susp 1

tropicamide 0.5% eye drops 1

tropicamide 1% eye drops 1XIIDRA 5% EYE DROPSlifitegrast

3 PA

ZYLET EYE DROPStobramycin/loteprednol etabonate

2

OPHTHALMIC ANTI-ALLERGY AGENTSALOCRIL 2% EYE DROPSnedocromil sodium

3

ALOMIDE 0.1% EYE DROPSlodoxamide tromethamine

3

azelastine hcl 0.05% drops 1BEPREVE 1.5% EYE DROPSbepotastine besilate

3

cromolyn 4% eye drops 1

epinastine hcl 0.05% eye drops 1LASTACAFT 0.25% EYE DROPSalcaftadine

3 ST

olopatadine hcl 0.1% eye drops 2

olopatadine hcl 0.2% eye drop 2PATADAY 0.2% EYE DROPSolopatadine hcl

2

PATANOL 0.1% EYE DROPSolopatadine hcl

2

OPHTHALMIC ANTI-INFLAMMATORIESACUVAIL 0.45% OPHTH SOLUTIONketorolac tromethamine/pf

2

ALREX 0.2% EYE DROPSloteprednol etabonate

2

bromfenac sodium 0.09% eye drp 3

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1DUREZOL 0.05% EYE DROPSdifluprednate

2 QL 10 / FILL

FLAREX 0.1% EYE DROPSfluorometholone acetate

3

fluorometholone 0.1% drops 1

flurbiprofen 0.03% eye drop 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFML S.O.P. 0.1% OINTMENTfluorometholone

2

ILEVRO 0.3% OPHTH DROPSnepafenac

3

ketorolac 0.4% ophth solution 1

ketorolac 0.5% ophth solution 1LOTEMAX 0.5% EYE DROPSloteprednol etabonate

2

LOTEMAX 0.5% EYE OINTMENTloteprednol etabonate

3

NEVANAC 0.1% DROPTAINERnepafenac

2

PRED MILD 0.12% EYE DROPSprednisolone acetate

2

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1VEXOL 1% EYE DROPSrimexolone

3

OPHTHALMIC ANTIGLAUCOMA AGENTSALPHAGAN P 0.1% DROPSbrimonidine tartrate

2

apraclonidine hcl 0.5% drops 3AZOPT 1% EYE DROPSbrinzolamide

3

BETIMOL 0.5% EYE DROPStimolol

3

BETOPTIC S 0.25% EYE DROPSbetaxolol hcl

2

brimonidine 0.2% eye drop 1

brimonidine tartrate 0.15% drp 1

carteolol hcl 1% eye drops 1COMBIGAN 0.2%-0.5% EYE DROPSbrimonidine tartrate/timolol maleate

2

dorzolamide hcl 2% eye drops 1

dorzolamide-timolol eye drops 1IOPIDINE 0.5% EYE DROPSapraclonidine hcl

3

IOPIDINE 1% EYE DROPSapraclonidine hcl

3

levobunolol 0.25% eye drops 1



levobunolol 0.5% eye drops 1

methazolamide 25 mg tablet 1

methazolamide 50 mg tablet 1

metipranolol 0.3% eye drops 1PHOSPHOLINE IODIDE 0.125%echothiophate iodide

3

pilocarpine 1% eye drops 1

pilocarpine 2% eye drops 1

pilocarpine 4% eye drops 1SIMBRINZA 1%-0.2% EYE DROPSbrinzolamide/brimonidine tartrate

2

timolol 0.25% eye drops 1

timolol 0.25% gel-solution 1

timolol 0.25% gfs gel-solution 1

timolol 0.5% eye drops 1

timolol 0.5% gel-solution 1

timolol 0.5% gfs gel-solution 1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost 0.03% eye drops 3

latanoprost 0.005% eye drops 3LUMIGAN 0.01% EYE DROPSbimatoprost

3

TRAVATAN Z 0.004% EYE DROPtravoprost

2

ZIOPTAN 0.0015% EYE DROPStafluprost/pf

3

OTIC AGENTSacetasol hc ear drops 1CIPRO HC OTIC SUSPENSIONciprofloxacin hcl/hydrocortisone

3 ST

CIPRODEX OTIC SUSPENSIONciprofloxacin hcl/dexamethasone

2ST


COLY-MYCIN S EAR DROPSneomycin sulf/colistin sul/hydrocortisone ac/thonzoniumbrom

3

COLY-MYCIN S OTIC SUSP DROPneomycin sulf/colistin sul/hydrocortisone ac/thonzoniumbrom

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCORTISPORIN-TC EAR SUSPENSIONneomycin sulf/colistin sul/hydrocortisone ac/thonzoniumbrom

3

fluocinolone oil 0.01% ear drp 1

hydrocortison-acetic acid soln 1

neomycin-polymyxin-hc ear soln 1

neomycin-polymyxin-hc ear susp 1OTOVEL 0.3%-0.025% EAR DROPSciprofloxacin hcl/fluocinolone acetonide

2

RESPIRATORY TRACT/PULMONARY AGENTSANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

AEROSPAN 80 MCG INHALERflunisolide

3QL 17.9 / 30 DAYS

ST

ALVESCO 160 MCG INHALERciclesonide

2

QL 12.2 / 30 DAYS

ST


ALVESCO 80 MCG INHALERciclesonide

2

QL 12.2 / 30 DAYS

ST


ASMANEX TWISTHALER 110 MCG #30mometasone furoate

2 QL 2 / 30 DAYS


2 QL 2 / 30 DAYS


2 QL 2 / 30 DAYS


2 QL 2 / 30 DAYS

ASMANEX TWISTHALR 220 MCG #120mometasone furoate

2 QL 2 / 30 DAYS

BECONASE AQ 0.042% SPRAYbeclomethasone dipropionate

3 QL 50 / 30 DAYS

budesonide 0.25 mg/2 ml susp 1 AL1 Up to 8 yrs old

budesonide 0.5 mg/2 ml susp 1 AL1 Up to 8 yrs old

budesonide 1 mg/2 ml inh susp 2 AL1 Up to 8 yrs old

budesonide 32 mcg nasal spray 3 QL 25.8 / 30 DAYS

FLOVENT 100 MCG DISKUSfluticasone propionate

3 QL 120 / 30 DAYS



flunisolide 0.025% spray 1

fluticasone prop 50 mcg spray 1 QL 32 / 30 DAYS

mometasone furoate 50 mcg spry 2 QL 34 / 30 day(s)

NASONEX 50 MCG NASAL SPRAYmometasone furoate

2 QL 34 / 30 DAYS

PULMICORT 1 MG/2 ML RESPULEbudesonide


PULMICORT 180 MCG FLEXHALERbudesonide

2 QL 2 / 30 DAYS

PULMICORT 90 MCG FLEXHALERbudesonide

2 QL 2 / 30 DAYS

QNASL 80 MCG NASAL SPRAYbeclomethasone dipropionate

3 ST

QVAR 40 MCG ORAL INHALERbeclomethasone dipropionate

2 QL 17.4 / 30 DAYS

QVAR 80 MCG ORAL INHALERbeclomethasone dipropionate

2 QL 17.4 / 30 DAYS

RHINOCORT AQUA NASAL SPRAYbudesonide

3 QL 25.8 / 30 DAYS

triamcinolone 55 mcg nasal spr 1VERAMYST 27.5 MCG NASAL SPRAYfluticasone furoate

3 QL 20 / 30 DAYS

ZETONNA 37 MCG NASAL SPRAYciclesonide

3 ST

ANTIHISTAMINESarbinoxa 4 mg tablet 1

arbinoxa 4 mg/5 ml liquid 1ASTEPRO 0.15% NASAL SPRAYazelastine hcl

2 QL 60 / 30 DAYS

azelastine 0.1% (137 mcg) spry 1 QL 60 / 30 DAYS

azelastine 0.15% nasal spray 1 QL 60 / 30 DAYS

carbinoxamine 4 mg/5 ml liquid 1

carbinoxamine maleate 4 mg tab 1CLARINEX 0.5 MG/ML (2.5 MG/5)desloratadine

2

clemastine 0.5 mg/5 ml syrup 1

clemastine fum 2.68 mg tab 1

cyproheptadine 2 mg/5 ml syrup 1



cyproheptadine 4 mg tablet 1

cyproheptadine 4 mg/10 ml syrp 1

desloratadine 2.5 mg odt 1

desloratadine 5 mg odt 1

desloratadine 5 mg tablet 1

diphenhydramine 50 mg/ml vial 1

hydroxyzine 10 mg/5 ml soln 1

hydroxyzine 10 mg/5 ml syrup 1

hydroxyzine 50 mg/25 ml syrup 1

hydroxyzine hcl 10 mg tablet 1



hydroxyzine pam 100 mg cap 1



levocetirizine 2.5 mg/5 ml sol 1

levocetirizine 5 mg tablet 1

olopatadine 665 mcg nasal spry 3 QL 30.5 / 30 DAYS

PATANASE 665 MCG NASAL SPRAYolopatadine hcl

3QL 30.5 / 30 DAYS

ST

promethazine 12.5 mg tablet 1 AL1 At least 2 yrs old

promethazine 25 mg tablet 1 AL1 At least 2 yrs old

promethazine 6.25 mg/5 ml syrp 1 AL1 At least 2 yrs old

ANTILEUKOTRIENESmontelukast sod 10 mg tablet 1

montelukast sod 4 mg granules 1

montelukast sod 4 mg tab chew 1

montelukast sod 5 mg tab chew 1

zafirlukast 10 mg tablet 1

zafirlukast 20 mg tablet 1ZYFLO 600 MG FILMTABzileuton

3 ST

ZYFLO CR 600 MG TABLETzileuton

3 ST



BRONCHODILATORS, ANTICHOLINERGICATROVENT HFA INHALERipratropium bromide

2 QL 38.7 / 30 DAYS

ipratropium 0.03% spray 1

ipratropium 0.06% spray 1

ipratropium br 0.02% soln 1

SPIRIVA 18 MCG CP-HANDIHALERtiotropium bromide

2QL 1 / 1 DAYS

ST

TUDORZA PRESSAIR 400 MCG INHaclidinium bromide

2QL 1 / 30 DAYS

ST

BRONCHODILATORS, SYMPATHOMIMETICADRENACLICK 0.15 MG AUTO-INJCTepinephrine

3

ADRENACLICK 0.3 MG AUTO-INJECTepinephrine

2 QL 3 / FILL

albuterol 2.5 mg/0.5 ml sol 1

albuterol 5 mg/ml solution 1

albuterol sul 0.63 mg/3 ml sol 1

albuterol sul 1.25 mg/3 ml sol 1

albuterol sul 2.5 mg/3 ml soln 1

albuterol sulf 2 mg/5 ml syrup 1

albuterol sulfate 2 mg tab 1

albuterol sulfate 4 mg tab 1

albuterol sulfate er 4 mg tab 1

albuterol sulfate er 8 mg tab 1ARCAPTA NEOHALER 75 MCG CAPindacaterol maleate

3 ST

BROVANA 15 MCG/2 ML SOLUTIONarformoterol tartrate

3QL 60 / FILL

PA

epinephrine 0.1 mg/ml syringe 1

epinephrine 0.15 mg auto-injct 1

epinephrine 0.3 mg auto-inject 1 QL 3 / FILL

EPIPEN 2-PAK 0.3 MG AUTO-INJCTepinephrine

2 QL 3 / FILL

EPIPEN JR 2-PAK 0.15 MG INJCTRepinephrine

2 QL 3 / FILL


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFORADIL AEROLIZER 12 MCG CAPformoterol fumarate

2 QL 120 / 30 DAYS

levalbuterol 0.31 mg/3 ml sol 1 ST



levalbuterol conc 1.25 mg/0.5 1 ST

levalbuterol tar hfa 45mcg inh 2 ST

metaproterenol 10 mg tablet 1

metaproterenol 10 mg/5 ml syr 1

metaproterenol 20 mg tablet 1

PERFOROMIST 20 MCG/2 ML SOLNformoterol fumarate

2QL 60 / 30 DAYS

PA

PROAIR HFA 90 MCG INHALERalbuterol sulfate

2 QL 8.5 / 15 DAYS

PROAIR RESPICLICK INHAL POWDERalbuterol sulfate

2 QL 2 / 30 DAYS

PROVENTIL HFA 90 MCG INHALERalbuterol sulfate

3 QL 13.4 / 30 DAYS

SEREVENT DISKUS 50 MCGsalmeterol xinafoate

3 QL 120 / 30 DAYS

terbutaline sulfate 2.5 mg tab 1

terbutaline sulfate 5 mg tab 1VENTOLIN HFA 90 MCG INHALERalbuterol sulfate

2 QL 36 / 30 DAYS

XOPENEX HFA 45 MCG INHALERlevalbuterol tartrate

3 ST

CYSTIC FIBROSIS AGENTSCAYSTON 75 MG INHAL SOLUTIONaztreonam lysine

4 PA

KALYDECO 150 MG TABLETivacaftor

4 PA

MAST CELL STABILIZERScromolyn 20 mg/2 ml neb soln 1

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASEDALIRESP 500 MCG TABLETroflumilast

2 PA

LUFYLLIN 200 MG TABLETdyphylline

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTHEO-24 ER 100 MG CAPSULEtheophylline anhydrous

3

theochron er 100 mg tablet 1



theophylline 80 mg/15 ml soln 1

theophylline 80 mg/15 ml soln 1

theophylline er 100 mg tablet 1


theophylline er 300 mg tab 1

theophylline er 450 mg tab 1


PULMONARY ANTIHYPERTENSIVESADCIRCA 20 MG TABLETtadalafil

4 PA

ADEMPAS 0.5 MG TABLETriociguat

4 PA

ADEMPAS 1 MG TABLETriociguat

4 PA


4 PA

ADEMPAS 2 MG TABLETriociguat

4 PA


4 PA

LETAIRIS 10 MG TABLETambrisentan

3 PA

LETAIRIS 5 MG TABLETambrisentan

3 PA

OPSUMIT 10 MG TABLETmacitentan

4 PA

REMODULIN 1 MG/ML VIALtreprostinil sodium

4 PA


4 PA

REMODULIN 2.5 MG/ML VIALtreprostinil sodium

4 PA


4 PA

REVATIO 20 MG TABLETsildenafil citrate

4 PA



sildenafil 20 mg tablet 1 PA

TRACLEER 125 MG TABLETbosentan

4 PA

TRACLEER 62.5 MG TABLETbosentan

4 PA

TYVASO 1.74 MG/2.9 ML SOLUTIONtreprostinil

4 PA

TYVASO INHALATION REFILL KITtreprostinil/nebulizer accessories

4 PA

TYVASO INHALATION STARTER KITtreprostinil/nebulizer and accessories

4 PA

TYVASO INSTITUTIONAL START KITtreprostinil/nebulizer and accessories

4 PA

VENTAVIS 10 MCG/1 ML SOLUTIONiloprost tromethamine

3 PA

VENTAVIS 20 MCG/1 ML SOLUTIONiloprost tromethamine

3 PA

RESPIRATORY TRACT AGENTS, OTHERacetylcysteine 10% vial 1

acetylcysteine 20% vial 1

ADVAIR 100-50 DISKUSfluticasone propionate/salmeterol xinafoate

2QL 60 / 30 DAYS

ST


2QL 60 / 30 DAYS

ST


2

QL 60 / 30 DAYS

PA

ST

ADVAIR HFA 115-21 MCG INHALERfluticasone propionate/salmeterol xinafoate

2QL 12 / 30 DAYS

ST


2QL 12 / 30 DAYS

ST


2QL 12 / 30 DAYS

ST

ANORO ELLIPTA 62.5-25 MCG INHumeclidinium bromide/vilanterol trifenatate

3QL 60 / 30 DAYS

ST

benzonatate 100 mg capsule 1



benzonatate 200 mg capsule 1

BREO ELLIPTA 100-25 MCG INHfluticasone furoate/vilanterol trifenatate

2QL 60 / 30 DAYS

ST

BREO ELLIPTA 200-25 MCG INHfluticasone furoate/vilanterol trifenatate

2QL 60 / 30 DAYS

ST

bromfed dm cough syrup 1

bromphenir-pseudoephed-dm syr 1COMBIVENT RESPIMAT INHAL SPRAYipratropium bromide/albuterol sulfate

2

DULERA 100 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate

2

QL 26 / 30 DAYS

ST


DULERA 200 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate

2

QL 26 / 30 DAYS

ST


fluticasone-salmeterol 113-14 1

fluticasone-salmeterol 232-14 1 ST

fluticasone-salmeterol 55-14 1 ST

GRASTEK 2,800 BAU SL TABLETallergenic extract,grass pollen-timothy,standard

3 PA

hydrocod-cpm-pseudoep 5-4-60/5 2

hydrocodone-chlorphen er susp 1

hydrocodone-homatropine 5-1.5 1

hydrocodone-homatropine soln 1

hydrocodone-homatropine syrup 1

hydromet syrup 1

iprat-albut 0.5-3(2.5) mg/3 ml 1

promethazine vc syrup 1

promethazine vc-codeine syrup 1

promethazine-codeine syrup 1

promethazine-dm solution 1

promethazine-dm syrup 1

promethazine-pe-codeine syrup 1

promethazine-phenylephrine syr 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPULMOZYME 1 MG/ML AMPULdornase alfa

4 PA

SYMBICORT 160-4.5 MCG INHALERbudesonide/formoterol fumarate

2

QL 20.4 / 30 DAYS

ST


SYMBICORT 80-4.5 MCG INHALERbudesonide/formoterol fumarate

2

QL 20.4 / 30 DAYS

ST


TOBI 300 MG/5 ML SOLUTIONtobramycin in 0.225 % sodium chloride

4 PA

tobramycin 300 mg/5 ml ampule 4 PA

TUSSICAPS 5 MG-4 MG CAPSULEhydrocodone polistirex/chlorpheniramine polistirex

2

TYZINE 0.1% NOSE DROPStetrahydrozoline hcl

3

TYZINE PEDIATRIC 0.05% DROPtetrahydrozoline hcl

3

VIRAZOLE 6 GM VIALribavirin

4 PA

VITUZ SOLUTIONhydrocodone bitartrate/chlorpheniramine maleate

2

SKELETAL MUSCLE RELAXANTScarisoprodol 250 mg tablet 1

carisoprodol 350 mg tablet 1

chlorzoxazone 500 mg tablet 1

cyclobenzaprine 10 mg tablet 1

cyclobenzaprine 5 mg tablet 1

cyclobenzaprine 7.5 mg tablet 1LORZONE 375 MG TABLETchlorzoxazone

3 ST

metaxalone 800 mg tablet 3

methocarbamol 500 mg tablet 1

methocarbamol 750 mg tablet 1

orphenadrine er 100 mg tablet 1SKELAXIN 800 MG TABLETmetaxalone

3



SLEEP DISORDER AGENTSGABA RECEPTOR MODULATORS

estazolam 1 mg tablet 1

estazolam 2 mg tablet 1

eszopiclone 1 mg tablet 2QL 1 / 1 DAYS

ST


ST


ST

flurazepam 15 mg capsule 1

flurazepam 30 mg capsule 1

temazepam 15 mg capsule 1 QL 1 / 1 DAYS

temazepam 22.5 mg capsule 1 QL 15 / 30 DAYS

temazepam 30 mg capsule 1 QL 1 / 1 DAYS

temazepam 7.5 mg capsule 1 QL 15 / 30 DAYS

triazolam 0.125 mg tablet 1 QL 15 / 30 DAYS

triazolam 0.25 mg tablet 1 QL 15 / 30 DAYS

zaleplon 10 mg capsule 1 QL 1 / 1 DAYS

zaleplon 5 mg capsule 1 QL 1 / 1 DAYS

zolpidem tart 1.75 mg tab sl 3 ST

zolpidem tart 3.5 mg tablet sl 3 ST

zolpidem tart er 12.5 mg tab 1 QL 15 / 30 DAYS

zolpidem tart er 6.25 mg tab 1 QL 15 / 30 DAYS

zolpidem tartrate 10 mg tablet 1 QL 30 / 30 DAYS

zolpidem tartrate 5 mg tablet 1 QL 30 / 30 DAYS

SLEEP DISORDERS, OTHER

armodafinil 150 mg tablet 3

QL 30 / fill(s)

PA




armodafinil 200 mg tablet 3PA



QL 30 / FILL

PA



QL 30 / FILL

PA


modafinil 100 mg tablet 3

QL 30 / 30 DAYS

PA


modafinil 200 mg tablet 3

QL 30 / 30 DAYS

PA


PROVIGIL 100 MG TABLETmodafinil

3

QL 30 / 30 DAYS

PA


PROVIGIL 200 MG TABLETmodafinil

3

QL 30 / 30 DAYS

PA


ROZEREM 8 MG TABLETramelteon

3QL 1 / 1 DAYS

ST

XYREM 500 MG/ML ORAL SOLUTIONsodium oxybate

4 PA


Index of Covered Drugs

88-MOP 109

AABACAVIR SULFATE 62,63ABACAVIR SULFATE/LAMIVUDINE 63ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 62ABATACEPT 150ABIRATERONE ACETATE 45ABSORICA 109ABSTRAL 10ACAMPROSATE CALCIUM 14ACARBOSE 68ACEBUTOLOL HCL 83ACETAMINOPHEN WITH CODEINE PHOSPHATE 10ACETAZOLAMIDE 92ACETYLCYSTEINE 167ACIPHEX 122ACITRETIN 109,114ACLIDINIUM BROMIDE 164ACTEMRA 151ACTIMMUNE 151ACTOPLUS MET XR 68ACUVAIL 158ACYCLOVIR 65,66ADALIMUMAB 149ADAPALENE 109,110,111ADAPALENE/BENZOYL PEROXIDE 111ADCIRCA 166ADEFOVIR DIPIVOXIL 59ADEMPAS 166ADRENACLICK 164ADVAIR DISKUS 167ADVAIR HFA 167AEROSPAN 161AFINITOR 47AGGRENOX 79ALA-CORT 127ALBENDAZOLE 50ALBENZA 50

ALBUTEROL SULFATE 164,165ALCAFTADINE 158ALCAINE 156ALCLOMETASONE DIPROPIONATE 127ALDARA 109ALENDRONATE SODIUM 153,154ALENDRONATE SODIUM/CHOLECALCIFEROL(VITAMIN D3) 154ALFUZOSIN HCL 125,126ALINIA 50ALISKIREN HEMIFUMARATE 91ALISKIRENHEMIFUMARATE/HYDROCHLOROTHIAZIDE 91ALKERAN 44ALLERGENIC EXTRACT,GRASS POLLEN-TIMOTHY,STANDARD 168ALLOPURINOL 40ALMOTRIPTAN MALATE 41ALOCRIL 158ALOMIDE 158ALORA 135ALOSETRON HCL 121ALPHAGAN P 159ALPHAQUIN HP 109ALPRAZOLAM 66,67ALREX 158ALSUMA 41ALTABAX 15ALTOPREV 94ALTRETAMINE 44ALVESCO 161AMANTADINE HCL 51AMBRISENTAN 166AMCINONIDE 127,128AMILORIDE HCL 92AMILORIDE HCL/HYDROCHLOROTHIAZIDE 88AMINOCAPROIC ACID 78AMINOSALICYLIC ACID 43AMIODARONE HCL 82AMITIZA 121AMITRIPTYLINE HCL 35

AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 29AMLODIPINE BESYLATE 85AMLODIPINE BESYLATE/ATORVASTATINCALCIUM 88AMLODIPINE BESYLATE/BENAZEPRIL HCL 88AMLODIPINE BESYLATE/OLMESARTANMEDOXOMIL 88AMLODIPINE BESYLATE/VALSARTAN 88,89AMLODIPINEBESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE 88AMMONIUM LACTATE 109AMOXAPINE 35AMOXICILLIN 18,19AMOXICILLIN/POTASSIUM CLAVULANATE 18,19AMPICILLIN TRIHYDRATE 18,19AMPYRA 107AMYL NITRITE 97ANADROL-50 134ANAGRELIDE HCL 77ANAKINRA 149ANALPRAM HC 110ANASTROZOLE 47ANORO ELLIPTA 167ANTARA 93ANZEMET 37APIDRA 72APIDRA SOLOSTAR 72APIXABAN 74APLENZIN 29APOKYN 52APOMORPHINE HCL 52APRACLONIDINE HCL 159APREMILAST 151,152APREPITANT 37,38APRISO 153APTIOM 26APTIVUS 64ARANESP 77ARCALYST 151ARCAPTA NEOHALER 164

ARFORMOTEROL TARTRATE 164ARICEPT 28ARIPIPRAZOLE 54,55ARIXTRA 74ARMODAFINIL 170,171ARMOUR THYROID 144ARTEMETHER/LUMEFANTRINE 50ASACOL HD 153ASENAPINE MALEATE 57ASMANEX 161ASPIRIN/DIPYRIDAMOLE 79ASTEPRO 162ATAZANAVIR SULFATE 65ATENOLOL 83ATENOLOL/CHLORTHALIDONE 89ATOMOXETINE HCL 105ATORVASTATIN CALCIUM 94ATOVAQUONE 50ATOVAQUONE/PROGUANIL HCL 50ATRALIN 110ATRIPLA 62ATROPINE SULFATE 157ATROVENT HFA 164AUBAGIO 107AUGMENTIN 19AURANOFIN 152AVANDIA 68AVC 21AVONEX 107AXERT 41AXITINIB 48AZASAN 148AZASITE 19AZATHIOPRINE 148AZELAIC ACID 110,111AZELASTINE HCL 158,162AZELEX 110AZILECT 53AZILSARTAN MEDOXOMIL 80AZITHROMYCIN 19,20AZOPT 159

AZTREONAM LYSINE 165

BBACITRACIN 15BACITRACIN/POLYMYXIN B SULFATE 156,157BACLOFEN 58BACTROBAN NASAL 15BALSALAZIDE DISODIUM 153BANZEL 26,27BARACLUDE 59BASAGLAR KWIKPEN U-100 72BECAPLERMIN 113BECLOMETHASONE DIPROPIONATE 161,162BECONASE AQ 161BENAZEPRIL HCL 81BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 89BENZONATATE 167,168BENZTROPINE MESYLATE 51BENZYL ALCOHOL 115BEPOTASTINE BESILATE 158BEPREVE 158BERINERT 148BESIFLOXACIN HCL 20BESIVANCE 20BETAINE 123BETAMETHASONE DIPROPIONATE 128BETAMETHASONE DIPROPIONATE/PROPYLENEGLYCOL 128BETAMETHASONE VALERATE 128BETASERON 107BETAXOLOL HCL 83,159BETHANECHOL CHLORIDE 126BETIMOL 159BETOPTIC S 159BEXAROTENE 49,50BEYAZ 136BICALUTAMIDE 44BIDIL 89BILTRICIDE 50BIMATOPROST 160BINOSTO 154

BISACODYL/SODIUM CHLOR/SODIUMBICARB/POTASSIUM CHL/PEG 3350 121,122BISOPROLOL FUMARATE 83BISOPROLOLFUMARATE/HYDROCHLOROTHIAZIDE 89BLEPH-10 21BLEPHAMIDE S.O.P. 157BOCEPREVIR 60BONIVA 154BOSENTAN 167BOSULIF 47BOSUTINIB 47BREO ELLIPTA 168BREVICON 136BRILINTA 79BRIMONIDINE TARTRATE 159BRIMONIDINE TARTRATE/TIMOLOL MALEATE 159BRINTELLIX 31BRINZOLAMIDE 159BRINZOLAMIDE/BRIMONIDINE TARTRATE 160BROMFENAC SODIUM 158BROMOCRIPTINE MESYLATE 52,68BROMPHENIRAMINEMALEATE/PSEUDOEPHEDRINEHCL/DEXTROMETHORPHAN 168BROVANA 164BUDESONIDE 153,161,162BUDESONIDE/FORMOTEROL FUMARATE 169BUMETANIDE 92BUPHENYL 123BUPRENORPHINE 7BUPRENORPHINE HCL 14BUPRENORPHINE HCL/NALOXONE HCL 14BUPROPION HBR 29BUPROPION HCL 14,29BUSPIRONE HCL 66BUSULFAN 44BUTALBITAL/ACETAMINOPHEN 105,106BUTALBITAL/ACETAMINOPHEN/CAFFEINE 105,106BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE 10

BUTALBITAL/ASPIRIN/CAFFEINE 4BUTOCONAZOLE NITRATE 39BUTORPHANOL TARTRATE 10BUTRANS 7BYDUREON 68BYDUREON PEN 68BYETTA 68BYSTOLIC 83

CC1 ESTERASE INHIBITOR 148C1 ESTERASE INHIBITOR, RECOMBINANT 148CABERGOLINE 147CABOZANTINIB S-MALATE 47CAFERGOT 41CALCIPOTRIENE 110CALCIPOTRIENE/BETAMETHASONEDIPROPIONATE 110,115CALCITONIN,SALMON,SYNTHETIC 154CALCITRIOL 110,154CALCIUM ACETATE 127CANAGLIFLOZIN 69CANAGLIFLOZIN/METFORMIN HCL 69CANASA 153CANDESARTAN CILEXETIL 80CANDESARTANCILEXETIL/HYDROCHLOROTHIAZIDE 89CAPECITABINE 46CAPEX SHAMPOO 128CAPRELSA 47CAPTOPRIL 81CAPTOPRIL/HYDROCHLOROTHIAZIDE 89CARAFATE 122CARBAGLU 123CARBAMAZEPINE 27CARBIDOPA 53CARBIDOPA/LEVODOPA 53CARBIDOPA/LEVODOPA/ENTACAPONE 51CARBINOXAMINE MALEATE 162CARDIZEM LA 85CARDURA XL 125

CARGLUMIC ACID 123CARISOPRODOL 169CARISOPRODOL/ASPIRIN/CODEINE PHOSPHATE10CARTEOLOL HCL 159CARVEDILOL 83CARVEDILOL PHOSPHATE 84CAYSTON 165CEDAX 17CEFACLOR 17CEFADROXIL 17CEFDINIR 17CEFDITOREN PIVOXIL 17CEFIXIME 17CEFPODOXIME PROXETIL 17CEFPROZIL 17CEFTIBUTEN 17,18CEFTIBUTEN DIHYDRATE 17CEFTIN 18CEFUROXIME AXETIL 18CELEBREX 4CELECOXIB 4CELONTIN 23CEPHALEXIN 18CERITINIB 49CERTOLIZUMAB PEGOL 148,149CERVICAL CAP 155CESAMET 37CEVIMELINE HCL 108CHEMET 116CHLORAMBUCIL 44CHLORDIAZEPOXIDE HCL 67CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 119CHLORHEXIDINE GLUCONATE 108CHLOROQUINE PHOSPHATE 50CHLOROTHIAZIDE 93CHLORPROMAZINE HCL 53CHLORPROPAMIDE 68CHLORTHALIDONE 93CHLORZOXAZONE 169CHOLESTYRAMINE (WITH SUGAR) 95,96CHOLESTYRAMINE/ASPARTAME 95,96

CIALIS 125,126CICLESONIDE 161,162CICLOPIROX 38,40CICLOPIROX OLAMINE 38CIDOFOVIR 59CILOSTAZOL 79CILOXAN 20CIMETIDINE 120CIMETIDINE HCL 120CIMZIA 148,149CINACALCET HCL 155CINRYZE 148CIPRO 20CIPRO HC 160CIPRODEX 160CIPROFLOXACIN 20CIPROFLOXACIN HCL 20CIPROFLOXACIN HCL/DEXAMETHASONE 160CIPROFLOXACIN HCL/FLUOCINOLONEACETONIDE 161CIPROFLOXACIN HCL/HYDROCORTISONE 160CIPROFLOXACIN/CIPROFLOXACIN HCL 20CITALOPRAM HYDROBROMIDE 31CITRIC ACID/SODIUM CITRATE 126,127CLARINEX 162CLARITHROMYCIN 19CLEMASTINE FUMARATE 162CLEOCIN 15CLINDAMYCIN HCL 15CLINDAMYCIN PALMITATE HCL 15CLINDAMYCIN PHOSPHATE 15,16CLINDAMYCIN PHOSPHATE/BENZOYLPEROXIDE 110CLINDAMYCIN PHOSPHATE/TRETINOIN 115,116CLOBETASOL PROPIONATE 128CLOCORTOLONE PIVALATE 128CLOMIPHENE CITRATE 144CLOMIPRAMINE HCL 35CLONAZEPAM 67CLONIDINE 79CLONIDINE HCL 79,100

CLOPIDOGREL BISULFATE 79CLORAZEPATE DIPOTASSIUM 67CLOTRIMAZOLE 38CLOTRIMAZOLE/BETAMETHASONEDIPROPIONATE 110CLOZAPINE 58COARTEM 50CODEINEPHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE 10CODEINE SULFATE 10COLCHICINE 40COLCRYS 40COLESEVELAM HCL 97COLESTIPOL HCL 95COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 114COLLOIDAL BISMUTHSUBCITRATE/METRONIDAZOLE/TETRACYCLINEHCL 120COLY-MYCIN S 160COMBIGAN 159COMBIPATCH 136COMBIVENT RESPIMAT 168COMETRIQ 47COMPLERA 62CONDYLOX 110COPAXONE 108CORDRAN 128COREG CR 84CORIFACT 78CORTIFOAM 153CORTISONE ACETATE 128CORTISPORIN 110CORTISPORIN-TC 161CREON 123CRINONE 143CRIXIVAN 64CRIZOTINIB 49CROMOLYN SODIUM 120,158,165CROTAMITON 51CUPRIMINE 126CUVPOSA 119

CYANOCOBALAMIN (VITAMIN B-12) 116CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE 117CYCLOBENZAPRINE HCL 169CYCLOPENTOLATE HCL 157CYCLOPHOSPHAMIDE 44CYCLOSERINE 43CYCLOSET 68CYCLOSPORINE 149,150,157CYCLOSPORINE, MODIFIED 149CYMBALTA 106CYPROHEPTADINE HCL 162,163CYSTADANE 123CYSTAGON 126CYSTARAN 157CYSTEAMINE BITARTRATE 126CYSTEAMINE HCL 157

DDABIGATRAN ETEXILATE MESYLATE 76DABRAFENIB MESYLATE 49DALFAMPRIDINE 107DALIRESP 165DALTEPARIN SODIUM,PORCINE 74,75DANAZOL 135DANTROLENE SODIUM 58DAPSONE 43DARAPRIM 50DARBEPOETIN ALFA IN POLYSORBATE 80 77DARIFENACIN HYDROBROMIDE 124,125DARUNAVIR ETHANOLATE 64,65DASATINIB 48,49DAYTRANA 100DEBACTEROL 108DEFERASIROX 116DEFERIPRONE 116DELAVIRDINE MESYLATE 62DELTASONE 128DEMECLOCYCLINE HCL 22DEMSER 89DENAVIR 65DEPEN 126

DEPO-SUBQ PROVERA 104 143DESIPRAMINE HCL 36DESLORATADINE 162,163DESMOPRESSIN ACETATE 132,134DESMOPRESSIN ACETATE (NON-REFRIGERATED) 132DESOGESTREL-ETHINYLESTRADIOL 136,137,138,142DESOGESTREL-ETHINYL ESTRADIOL/ETHINYLESTRADIOL 136,137,138,139,141,142DESONATE 128DESONIDE 128,129,132DESOXIMETASONE 129DESVENLAFAXINE 31,32,33DESVENLAFAXINE FUMARATE 31DESVENLAFAXINE SUCCINATE 31,32,33DETROL LA 124DEXAMETHASONE 129DEXAMETHASONE SOD PHOSPHATE 158DEXILANT 122DEXLANSOPRAZOLE 122DEXMETHYLPHENIDATE HCL 100,101,102DEXPAK 129DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE 98,99DEXTROAMPHETAMINE SULFATE 98,99,100DEXTROMETHORPHAN HBR/QUINIDINESULFATE 106DIABETIC SUPPLIES,MISCELL 155,156DIAPHRAGMS, WIDE SEAL 156DIASTAT 23DIAZEPAM 23,67DIAZOXIDE 72DICLOFENAC EPOLAMINE 5DICLOFENAC POTASSIUM 4DICLOFENAC SODIUM 4,110,115,158DICLOFENAC SODIUM/MISOPROSTOL 4DICLOFENAC SUBMICRONIZED 7DICLOXACILLIN SODIUM 19DICYCLOMINE HCL 119

DIDANOSINE 62,63DIFFERIN 110,111DIFICID 19DIFLORASONE DIACETATE 129DIFLUNISAL 4DIFLUPREDNATE 158DIGOXIN 89DIHYDROERGOTAMINE MESYLATE 41DILANTIN 27DILATRATE-SR 97DILTIAZEM HCL 85,86,87DIMETHYL FUMARATE 108DIPENTUM 153DIPHENHYDRAMINE HCL 163DIPHENOXYLATE HCL/ATROPINE SULFATE 120DIPYRIDAMOLE 79DISOPYRAMIDE PHOSPHATE 82DISULFIRAM 14DIVALPROEX SODIUM 23,24DOFETILIDE 83DOLASETRON MESYLATE 37DONEPEZIL HCL 28DONNATAL 119DORNASE ALFA 169DORZOLAMIDE HCL 159DORZOLAMIDE HCL/TIMOLOL MALEATE 159DOXAZOSIN MESYLATE 80,125DOXEPIN HCL 36,111,113,116DOXERCALCIFEROL 154DOXYCYCLINE HYCLATE 22DOXYCYCLINE MONOHYDRATE 22,23DRONABINOL 38DRONEDARONE HCL 82DROSPIRENONE/ETHINYLESTRADIOL/LEVOMEFOLATECALCIUM 136,137,142DROXIA 46DUAVEE 137DULERA 168DULOXETINE HCL 106,107DUREZOL 158

DUTASTERIDE 126DYPHYLLINE 165DYRENIUM 92

EE.E.S. 400 19ECHOTHIOPHATE IODIDE 160ECONAZOLE NITRATE 38EDARBI 80EDECRIN 92EDURANT 62EFAVIRENZ 62EFAVIRENZ/EMTRICITABINE/TENOFOVIRDISOPROXIL FUMARATE 62EFFER-K 116EFFIENT 79EGRIFTA 147ELBASVIR/GRAZOPREVIR 60ELETRIPTAN HBR 42ELIDEL 111ELIGARD 147ELIQUIS 74ELMIRON 126ELTROMBOPAG OLAMINE 78ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR DISOPROXIL 62EMCYT 45EMEND 38EMPAGLIFLOZIN 70EMPAGLIFLOZIN/METFORMIN HCL 71,72EMSAM 30EMTRICITABINE 63EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIRDISOPROXIL FUMARATE 62EMTRICITABINE/TENOFOVIR DISOPROXILFUMARATE 63EMTRIVA 63ENABLEX 124,125ENALAPRIL MALEATE 81ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 89ENBREL 149

ENDOMETRIN 143ENFLURANE 155ENFUVIRTIDE 64ENOXAPARIN SODIUM 74ENTACAPONE 51ENTECAVIR 59ENZALUTAMIDE 45EPCLUSA 59EPIDUO 111EPINASTINE HCL 158EPINEPHRINE 164EPIPEN 2-PAK 164EPIPEN JR 2-PAK 164EPIVIR HBV 59EPLERENONE 92EPOETIN ALFA 77,78EPOGEN 77,78EPROSARTAN MESYLATE 80EPZICOM 63ERGOCALCIFEROL (VITAMIN D2) 155ERGOLOID MESYLATES 28ERGOMAR 41ERGOTAMINE TARTRATE 41ERGOTAMINE TARTRATE/CAFFEINE 41ERIVEDGE 48ERLOTINIB HCL 49ERTACZO 38ERY-TAB 19ERYTHROCIN STEARATE 19ERYTHROMYCIN BASE 19,20ERYTHROMYCIN BASE/BENZOYL PEROXIDE 16ERYTHROMYCIN BASE/ETHYL ALCOHOL 19,20ERYTHROMYCIN ETHYLSUCCINATE 19,20ERYTHROMYCIN STEARATE 19ESCITALOPRAM OXALATE 32ESLICARBAZEPINE ACETATE 26ESOMEPRAZOLE MAGNESIUM 122ESTAZOLAM 170ESTRACE 137ESTRADIOL 135,137,138,140,142,143

ESTRADIOL/NORETHINDRONEACETATE 135,136,138,139,140ESTRAMUSTINE PHOSPHATE SODIUM 45ESTRING 138ESTROGEL 138ESTROGENS, CONJUGATED 141ESTROGENS, CONJUGATED/BAZEDOXIFENEACETATE 137ESTROGENS,CONJUGATED/MEDROXYPROGESTERONEACETATE 141ESTROGENS,ESTERIFIED 139,140ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE 136,137,138ESTROPIPATE 138ESZOPICLONE 170ETANERCEPT 149ETHACRYNIC ACID 92ETHAMBUTOL HCL 43ETHINYLESTRADIOL/DROSPIRENONE 137,138,139,140,141,142,143ETHIONAMIDE 43ETHOSUXIMIDE 23ETHOTOIN 27ETHYL CHLORIDE 13ETHYNODIOL DIACETATE-ETHINYLESTRADIOL 138,139,143ETIDRONATE DISODIUM 154ETODOLAC 5ETONOGESTREL/ETHINYL ESTRADIOL 141ETOPOSIDE 47ETRAVIRINE 62EURAX 51EVAMIST 138EVEROLIMUS 47,151EVOLOCUMAB 96EXELDERM 39EXELON 28EXEMESTANE 47EXENATIDE 68

EXENATIDE MICROSPHERES 68EXJADE 116EXTAVIA 108EZETIMIBE 95,97EZETIMIBE/SIMVASTATIN 95,96,97EZOGABINE 23

FFACTIVE 21FACTOR XIII 78FAMCICLOVIR 65,66FANAPT 55FARESTON 45FAZACLO 58FEBUXOSTAT 40,41FELBAMATE 25FELODIPINE 86FENOFIBRATE 93,94FENOFIBRATE NANOCRYSTALLIZED 93FENOFIBRATE,MICRONIZED 93FENOFIBRIC ACID 93,94FENOGLIDE 94FENOPROFEN CALCIUM 5,6FENTANYL 7,13FENTANYL CITRATE 10,11,12FENTORA 11FERRIPROX 116FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FOLIC ACID 116,119FESOTERODINE FUMARATE 125FETZIMA 32FIBRICOR 94FIDAXOMICIN 19FILGRASTIM 78FINACEA 111FINASTERIDE 111,126FINGOLIMOD HCL 108FIRAZYR 148FLAGYL ER 16FLAREX 158FLAVOXATE HCL 125

FLECAINIDE ACETATE 82FLECTOR 5FLOVENT DISKUS 161FLUARIX QUAD 2017-2018 152FLUBLOK 2017-2018 152FLUBLOK QUAD 2017-2018 152FLUCAINE 157FLUCONAZOLE 39FLUCYTOSINE 39FLUDROCORTISONE ACETATE 129FLUNISOLIDE 161,162FLUOCINOLONE ACETONIDE 128,129FLUOCINOLONE ACETONIDE OIL 161FLUOCINOLONE ACETONIDE/SHOWER CAP 129FLUOCINONIDE 129,132FLUOR-A-DAY 116FLUORABON 116FLUORIDE (SODIUM) 108,109,116,117,118FLUORIDEX SENSITIVITY RELIEF 108FLUOROMETHOLONE 158,159FLUOROMETHOLONE ACETATE 158FLUOROPLEX 111FLUOROURACIL 46,111FLUOXETINE HCL 32FLUOXYMESTERONE 135FLUPHENAZINE HCL 53,54FLURANDRENOLIDE 128FLURAZEPAM HCL 170FLURBIPROFEN 5FLURBIPROFEN SODIUM 158FLUTAMIDE 44FLUTICASONE FUROATE 162FLUTICASONE FUROATE/VILANTEROLTRIFENATATE 168FLUTICASONE PROPIONATE 129,130,161,162FLUTICASONE PROPIONATE/SALMETEROLXINAFOATE 167,168FLUVASTATIN SODIUM 94FLUVIRIN 2017-2018 152FLUVOXAMINE MALEATE 32FLUZONE HIGH-DOSE 2017-2018 152

FML S.O.P. 159FOCALIN XR 102FOLIC ACID 117FOLLITROPIN ALFA, RECOMBINANT 133FONDAPARINUX SODIUM 74FORADIL 165FORFIVO XL 29FORMADON 155FORMALDEHYDE 155FORMOTEROL FUMARATE 165FORTEO 154FOSAMAX PLUS D 154FOSAMPRENAVIR CALCIUM 64FOSCARNET SODIUM 59FOSFOMYCIN TROMETHAMINE 16FOSINOPRIL SODIUM 81FOSINOPRILSODIUM/HYDROCHLOROTHIAZIDE 89,90FOSRENOL 127FRAGMIN 74,75FROVA 41FROVATRIPTAN SUCCINATE 41FUROSEMIDE 92FUZEON 64FYCOMPA 25

GGABAPENTIN 24GABAPENTIN ENACARBIL 105,106GABITRIL 24GALANTAMINE HBR 28GAMMAGARD LIQUID 151GANCICLOVIR 59GARAMYCIN 15GARDASIL 152GATIFLOXACIN 21GATTEX 120GEFITINIB 48GELNIQUE 125GEMFIBROZIL 94GEMIFLOXACIN MESYLATE 21

GENOTROPIN 132,133GENTAMICIN SULFATE 15GEODON 55GIAZO 153GILENYA 108GLATIRAMER ACETATE 108GLEOSTINE 44GLIMEPIRIDE 68GLIPIZIDE 68,69GLIPIZIDE/METFORMIN HCL 69GLUCAGEN 72GLUCAGON EMERGENCY KIT 72GLUCAGON,HUMAN RECOMBINANT 72GLYBURIDE 69GLYBURIDE,MICRONIZED 69GLYBURIDE/METFORMIN HCL 69GLYCOPYRROLATE 119GLYSET 69GOLIMUMAB 151GOLYTELY 121GONAL-F RFF REDI-JECT 133GRALISE 24GRANISETRON 38GRANISETRON HCL 38GRASTEK 168GRISEOFULVIN ULTRAMICROSIZE 39GRISEOFULVIN, MICROSIZE 39GUANFACINE HCL 79,102,103GUANIDINE HCL 43

HHALCINONIDE 130HALOBETASOL PROPIONATE 130HALOG 130HALOPERIDOL 54HALOPERIDOL LACTATE 54HAVRIX 152HECTOROL 154HEMANGEOL 46HEPARIN SODIUM,PORCINE 75,76

HEPARIN SODIUM,PORCINE/DEXTROSE 5 % INWATER 75,76HEPARIN SODIUM,PORCINE/PF 75,76HEPATITIS A VIRUS AND HEPATITIS B VIRUSVACCINE/PF 153HEPATITIS A VIRUS VACCINE/PF 152HEPATITIS B VIRUS VACCINERECOMBINANT/PF 152HEPSERA 59HEXALEN 44HOMATROPINE HBR 157HORIZANT 105,106HUMALOG 72,73HUMALOG KWIKPEN U-100 73HUMALOG KWIKPEN U-200 73HUMALOG MIX 50-50 73HUMALOG MIX 50-50 KWIKPEN 73HUMALOG MIX 75-25 73HUMALOG MIX 75-25 KWIKPEN 73HUMAN PAPILLOMAVIRUS VACCINE,QUADRIVALENT/PF 152HUMATROPE 133HUMIRA 149HUMIRA PEDIATRIC CROHN'S 149HUMIRA PEN 149HUMIRA PEN CROHN-UC-HS STARTER 149HUMIRA PEN PSORIASIS-UVEITIS 149HUMULIN R U-500 73HYCAMTIN 47HYDRALAZINE HCL 97HYDROCHLOROTHIAZIDE 93HYDROCODONE BITART/CHLORPHENIRAMINEMALEATE/PSEUDOEPHEDRINE 168HYDROCODONEBITARTRATE/ACETAMINOPHEN 11,12,13HYDROCODONEBITARTRATE/CHLORPHENIRAMINE MALEATE 169HYDROCODONE BITARTRATE/HOMATROPINEMETHYLBROMIDE 168HYDROCODONE POLISTIREX/CHLORPHENIRAMINEPOLISTIREX 168,169

HYDROCODONE/IBUPROFEN 11,13HYDROCORTISONE 127,130,131,132,153HYDROCORTISONE ACETATE 128,130,153HYDROCORTISONE ACETATE/LIDOCAINEHCL/ALOE VERA 111HYDROCORTISONE ACETATE/PRAMOXINEHCL 110,111,113HYDROCORTISONEACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINECMB NO1 111HYDROCORTISONE ACETATE/UREA 132HYDROCORTISONE BUTYRATE 130HYDROCORTISONE VALERATE 130HYDROCORTISONE/ACETIC ACID 160,161HYDROCORTISONE/IODOQUINOL 110,111HYDROMORPHONE HCL 7,11,12HYDROQUINONE 111,112,115HYDROQUINONE MICROSPHERES 111HYDROQUINONE/SUNSCREEN (FERRIC OXIDE) 111HYDROQUINONE/SUNSCREENS(OXYBENZONE/OCTINOXATE) 109HYDROXOCOBALAMIN 117HYDROXYCHLOROQUINE SULFATE 50HYDROXYUREA 46HYDROXYZINE HCL 163HYDROXYZINE PAMOATE 163HYOSCYAMINE SULFATE 119,120

IIBANDRONATE SODIUM 154IBRUTINIB 48IBUPROFEN 5IBUPROFEN/OXYCODONE HCL 13ICATIBANT ACETATE 148ICLUSIG 48ICOSAPENT ETHYL 96ILEVRO 159ILOPERIDONE 55ILOPROST TROMETHAMINE 167IMATINIB MESYLATE 48IMBRUVICA 48

IMIPRAMINE HCL 36IMIPRAMINE PAMOATE 36IMIQUIMOD 109,111,116IMITREX 41IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGAGREATER THAN 50 MCG/ML 151INCIVEK 59INCRELEX 133INDACATEROL MALEATE 164INDAPAMIDE 93INDINAVIR SULFATE 64INDOMETHACIN 5INFLUENZA VIRUS VACCINE QUADRIVALENT 2017-18 (36 MOS UP)/PF 152INFLUENZA VIRUS VACCINE QV 2017-18(18 YRSAND OLDER)RCMB/PF 152INFLUENZA VIRUS VACCINE TRIVAL 2017-2018(4YR AND OLDER)/PF 152INFLUENZA VIRUS VACCINE TRIVAL SPLIT 2017-2018(65 YR UP)/PF 152INFLUENZA VIRUS VACCINE TRIVALENT 2017-2018(4 YR AND OLDER) 152INFLUENZA VIRUS VACCINE TV 2017-18(18 YRSAND OLDER)RCMB/PF 152INGENOL MEBUTATE 112INLYTA 48INSULIN ASPART 73INSULIN ASPART PROTAMINE HUMAN/INSULINASPART 73INSULIN DEGLUDEC 73INSULIN DETEMIR 73INSULIN GLARGINE,HUMAN RECOMBINANTANALOG 72,73INSULIN GLULISINE 72INSULIN LISPRO 72,73INSULIN LISPRO PROTAMINE AND INSULINLISPRO 73INSULIN REGULAR, HUMAN 73INTELENCE 62INTERFERON ALFA-2B,RECOMB. 60INTERFERON BETA-1A 107

INTERFERON BETA-1A/ALBUMIN HUMAN 107,108INTERFERON BETA-1B 107,108INTERFERON GAMMA-1B,RECOMB. 151INTRON A 60INTUNIV 102,103INVEGA 55INVIRASE 64INVOKAMET 69INVOKAMET XR 69INVOKANA 69IOPIDINE 159IPRATROPIUM BROMIDE 164IPRATROPIUM BROMIDE/ALBUTEROLSULFATE 168IRBESARTAN 80IRBESARTAN/HYDROCHLOROTHIAZIDE 90IRESSA 48IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VITC/DOCUSATE SODIUM 117IRON POLYSACCHARIDECOMPLEX/CYANOCOBALAMIN/FOLICACID 116,117,118ISENTRESS 61,62ISOCARBOXAZID 30ISOFLURANE 156ISOMETHEPTENEMUCATE/DICHLORALPHENAZONE/ACETAMINOPHEN 155,156ISONIAZID 43ISOSORBIDE DINITRATE 97ISOSORBIDE DINITRATE/HYDRALAZINE HCL 89ISOSORBIDE MONONITRATE 97ISOTRETINOIN 109,110,112,116ISOXSUPRINE HCL 90ISRADIPINE 86ITRACONAZOLE 39,40IVACAFTOR 165IVERMECTIN 50

JJAKAFI 48

JANUMET 69,70JANUMET XR 70JANUVIA 70JARDIANCE 70JENTADUETO 70JENTADUETO XR 70JUXTAPID 95

KKADIAN 7KALETRA 64KALYDECO 165KENALOG 130KETEK 20KETOCONAZOLE 39,40KETOCONAZOLE/SKIN CLEANSER COMBINATIONNO.28 39KETODAN 39KETOPROFEN 5KETOROLAC TROMETHAMINE 5,6,159KETOROLAC TROMETHAMINE/PF 158KHEDEZLA 32,33KINERET 149KOMBIGLYZE XR 70KRISTALOSE 121,122KUVAN 123KYNAMRO 95

LLABETALOL HCL 84LACOSAMIDE 27,28LACTIC ACID 111LACTULOSE 121,122LAMICTAL ODT 25LAMICTAL ODT (ORANGE) 25LAMIVUDINE 59,63LAMIVUDINE/ZIDOVUDINE 63LAMOTRIGINE 25,26LANSOPRAZOLE 122,123LANSOPRAZOLE/AMOXICILLINTRIHYDRATE/CLARITHROMYCIN 120

LANTHANUM CARBONATE 127LANTUS 73LANTUS SOLOSTAR 73LAPATINIB DITOSYLATE 49LASTACAFT 158LATANOPROST 160LATUDA 55,56LAYOLIS FE 139LAZANDA 12LEFLUNOMIDE 151LENALIDOMIDE 45LETAIRIS 166LETROZOLE 47LEUCOVORIN CALCIUM 46LEUKERAN 44LEUPROLIDE ACETATE 147LEVALBUTEROL HCL 165LEVALBUTEROL TARTRATE 165LEVAQUIN 21LEVATOL 84LEVEMIR 73LEVEMIR FLEXPEN 73LEVEMIR FLEXTOUCH 73LEVETIRACETAM 23LEVOBUNOLOL HCL 159,160LEVOCARNITINE 117LEVOCARNITINE (WITH SUGAR) 117LEVOCETIRIZINE DIHYDROCHLORIDE 163LEVOFLOXACIN 21LEVOMILNACIPRAN HCL 32LEVONORGESTREL 143LEVONORGESTREL-ETHINYLESTRADIOL 135,136,137,138,139,140,141,142LEVONORGESTREL/ETHINYL ESTRADIOL ANDETHINYL ESTRADIOL 136,139LEVORPHANOL TARTRATE 7LEVOTHYROXINE SODIUM 144,145,146LEXIVA 64LIDOCAINE 13,14LIDOCAINE HCL 13LIDOCAINE/PRILOCAINE 13,14

LIDOCAINE/TETRACAINE 14LIDODERM 14LIFITEGRAST 158LINACLOTIDE 121LINAGLIPTIN 72LINAGLIPTIN/METFORMIN HCL 70LINDANE 51LINEZOLID 16LINZESS 121LIOTHYRONINE SODIUM 145LIOTRIX 146LIPASE/PROTEASE/AMYLASE 123,124LIRAGLUTIDE 72LISDEXAMFETAMINE DIMESYLATE 100LISINOPRIL 81LISINOPRIL/HYDROCHLOROTHIAZIDE 90LITHIUM CARBONATE 67,68LITHIUM CITRATE 67LIVALO 94LO LOESTRIN FE 139LOCOID 130LODOXAMIDE TROMETHAMINE 158LOMITAPIDE MESYLATE 95LOMUSTINE 44LOPERAMIDE HCL 120LOPINAVIR/RITONAVIR 64LORAZEPAM 67LORZONE 169LOSARTAN POTASSIUM 80LOSARTANPOTASSIUM/HYDROCHLOROTHIAZIDE 90LOTEMAX 159LOTEPREDNOL ETABONATE 158,159LOTRONEX 121LOVASTATIN 94LOVAZA 95LOXAPINE SUCCINATE 54LUBIPROSTONE 121LUFYLLIN 165LUMIGAN 160LURASIDONE HCL 55,56

LYRICA 107LYSODREN 46

MM-M-R II VACCINE 152MACITENTAN 166MAFENIDE ACETATE 16MALATHION 51MAPROTILINE HCL 33MARAVIROC 64MARGESIC 106MARPLAN 30MARTEN-TAB 106MATULANE 44MEASLES, MUMPS, AND RUBELLA VACCINELIVE/PF 152MECASERMIN 133MECLIZINE HCL 36MECLOFENAMATE SODIUM 5MEDROXYPROGESTERONE ACETATE 143MEFENAMIC ACID 5MEFLOQUINE HCL 50MEGESTROL ACETATE 143,144MEKINIST 48MELOXICAM 5MELPHALAN 44MEMANTINE HCL 29MENACTRA 152MENEST 139,140MENINGOCOCCALVACCINE A,C,Y,W-135,DIPHTHERIA TOXOID CONJ/PF 152MEPERIDINE HCL 12MEPHYTON 117MEPROBAMATE 66MERCAPTOPURINE 46MESALAMINE 153MESNA 50MESNEX 50MESTINON 43METADATE CD 103METAPROTERENOL SULFATE 165

METAXALONE 169METFORMIN HCL 70,71METHADONE HCL 7METHAMPHETAMINE HCL 99METHAZOLAMIDE 160METHENAMINE HIPPURATE 16METHENAMINE MANDELATE 16METHENAMINE/METHYLENE BLUE/BENZOICACID/SALICYLAT/HYOSCYAMIN 16METHENAMINE/METHYLENEBLUE/SALICYLATE/SODIUMPHOS/HYOSCYAMIN 15,16METHENAMINE/METHYLENE BLUE/SODPHOS/P.SALICYLATE/HYOSCYAMINE 16METHIMAZOLE 148METHITEST 135METHOCARBAMOL 169METHOTREXATE SODIUM 149,150,151METHOTREXATE SODIUM/PF 149,150METHOTREXATE/PF 150METHOXSALEN 109,111,112METHSCOPOLAMINE BROMIDE 119METHSUXIMIDE 23METHYCLOTHIAZIDE 93METHYLDOPA 79METHYLDOPA/HYDROCHLOROTHIAZIDE 90METHYLERGONOVINE MALEATE 156METHYLNALTREXONE BROMIDE 120METHYLPHENIDATE 100METHYLPHENIDATE HCL 103,104,105METHYLPREDNISOLONE 130,131METHYLTESTOSTERONE 135METIPRANOLOL 160METOCLOPRAMIDE HCL 37METOLAZONE 93METOPROLOL SUCCINATE 84METOPROLOL TARTRATE 84METOPROLOLTARTRATE/HYDROCHLOROTHIAZIDE 90METRELEPTIN 120METROGEL 112

METRONIDAZOLE 16,112,113METYROSINE 89MEXILETINE HCL 82MIACALCIN 154MICONAZOLE 40MICROGESTIN 24 FE 140MIDODRINE HCL 79,80MIGLITOL 69,71MIGLUSTAT 124MILNACIPRAN HCL 107MINIVELLE 140MINOCYCLINE HCL 22MINOXIDIL 97MIPOMERSEN SODIUM 95MIRABEGRON 125MIRTAZAPINE 30MISOPROSTOL 122MITOTANE 46MODAFINIL 171MOEXIPRIL HCL 81MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 90MOMETASONE FUROATE 131,161,162MOMETASONE FUROATE/FORMOTEROLFUMARATE 168MONTELUKAST SODIUM 163MONUROL 16MORPHINE SULFATE 7,8,12MOVIPREP 122MOXATAG 19MOXEZA 21MOXIFLOXACIN HCL 21MS CONTIN 8MULTAQ 82MUPIROCIN 16MUPIROCIN CALCIUM 15,16MVC-FLUORIDE 117MYALEPT 120MYCOBUTIN 43MYCOPHENOLATE MOFETIL 150MYCOPHENOLATE SODIUM 150MYLERAN 44

MYRBETRIQ 125

NNABILONE 37NABUMETONE 5,6NADOLOL 84NADOLOL/BENDROFLUMETHIAZIDE 90NAFARELIN ACETATE 148NAFTIFINE HCL 39NAFTIN 39NALBUPHINE HCL 12NALFON 6NALOXONE HCL 14NALTREXONE HCL 14NAMENDA 29NAPHAZOLINE HCL 157NAPRELAN 6NAPROXEN 6NAPROXEN SODIUM 6NAPROXEN/ESOMEPRAZOLE MAGNESIUM 6NARATRIPTAN HCL 41,42NASONEX 162NATACYN 39NATAMYCIN 39NATEGLINIDE 71NATROBA 112NATURE-THROID 145NEBIVOLOL HCL 83NEBUPENT 50NEDOCROMIL SODIUM 158NEFAZODONE HCL 33NELFINAVIR MESYLATE 65NEOMYCIN SULF/COLISTINSUL/HYDROCORTISONE AC/THONZONIUMBROM 160,161NEOMYCIN SULFATE 15NEOMYCIN SULFATE/BACITRACINZINC/POLYMYXIN B/HYDROCORTISONE 157NEOMYCIN SULFATE/BACITRACIN/POLYMYXINB 157NEOMYCIN SULFATE/POLYMYXIN B SULFATE 16

NEOMYCIN SULFATE/POLYMYXIN BSULFATE/GRAMICIDIN D 157NEOMYCIN SULFATE/POLYMYXIN BSULFATE/HYDROCORTISONE 110,157,161NEOMYCIN/BACITRACIN/POLYMYXINB/HYDROCORTISONE 110NEOMYCIN/POLYMYXIN BSULFATE/DEXAMETHASONE 157NEPAFENAC 159NEULASTA 78NEUPOGEN 78NEUPRO 52NEVANAC 159NEVIRAPINE 62NEXAVAR 48NIACIN 96NIACIN/SIMVASTATIN 96NIACINAMIDE/AZELAIC ACID/ZINC OXIDE/VITB6/COPPER/FA 118NIASPAN 96NICARDIPINE HCL 86NICAZEL 118NIFEDIPINE 85,86,87NILANDRON 44NILOTINIB HCL 49NILUTAMIDE 44NIMODIPINE 87NISOLDIPINE 87NITAZOXANIDE 50NITISINONE 123,124NITRO-BID 97NITRO-DUR 97NITROFURANTOIN 16NITROFURANTOIN MACROCRYSTAL 16NITROFURANTOINMONOHYDRATE/MACROCRYSTALS 16NITROGLYCERIN 97,98,113NITROLINGUAL 98NITROMIST 98NIZATIDINE 120NORDITROPIN FLEXPRO 133

NORDITROPIN NORDIFLEX 133NORELGESTROMIN/ETHINYL ESTRADIOL 143NORETHINDRONE 143,144NORETHINDRONE ACETATE 144NORETHINDRONE ACETATE-ETHINYLESTRADIOL 138,139,140NORETHINDRONE ACETATE-ETHINYLESTRADIOL/FERROUSFUMARATE 136,138,139,140,142NORETHINDRONE-ETHINYLESTRADIOL 135,136,138,139,140,141,143NORETHINDRONE-ETHINYL ESTRADIOL/FERROUSFUMARATE 138,139,140,143NORETHINDRONE-MESTRANOL 140NORGESTIMATE-ETHINYLESTRADIOL 137,140,141,142NORGESTREL-ETHINYLESTRADIOL 136,137,139,141NORINYL 1-35 141NORPACE CR 82NORTRIPTYLINE HCL 36NORVIR 64NOVOLOG 73NOVOLOG FLEXPEN 73NOVOLOG MIX 70-30 73NOVOLOG MIX 70-30 FLEXPEN 73NOXAFIL 39NUCYNTA 12NUCYNTA ER 8NUEDEXTA 106NUTROPIN 133NUTROPIN AQ 134NUTROPIN AQ NUSPIN 134NUVARING 141NYSTATIN 39,40NYSTATIN/TRIAMCINOLONE ACETONIDE 40

OOCTREOTIDE ACETATE 147OFLOXACIN 21OLANZAPINE 56,57,58

OLANZAPINE/FLUOXETINE HCL 30OLMESARTAN MEDOXOMIL 80,81OLMESARTAN MEDOXOMIL/AMLODIPINEBESYLATE/HYDROCHLOROTHIAZIDE 90OLMESARTANMEDOXOMIL/HYDROCHLOROTHIAZIDE 90OLOPATADINE HCL 158,163OLSALAZINE SODIUM 153OLYSIO 59OMACETAXINE MEPESUCCINATE 47OMECLAMOX-PAK 120OMEGA-3 ACID ETHYL ESTERS 95,96OMEGA-3/DHA/EPA/B12/FOLIC ACID/PYRIDOXINEHCL/PHYTOSTEROLS 116OMEPRAZOLE 123OMEPRAZOLE/CLARITHROMYCIN/AMOXICILLINTRIHYDRATE 120OMEPRAZOLE/SODIUM BICARBONATE 123OMNITROPE 134ONDANSETRON 38ONDANSETRON HCL 38ONGLYZA 71OPANA ER 9OPSUMIT 166ORAP 54ORAPRED ODT 131ORAVIG 40ORENCIA 150ORFADIN 123,124ORPHENADRINE CITRATE 169OSELTAMIVIR PHOSPHATE 65OSMOPREP 122OTEZLA 151,152OTOVEL 161OTREXUP 150OVACE 112OVACE PLUS 112OVACE PLUS WASH 112OXANDROLONE 134OXAPROZIN 6OXAYDO 12

OXAZEPAM 67OXCARBAZEPINE 27OXICONAZOLE NITRATE 40OXSORALEN 112OXSORALEN-ULTRA 112OXYBUTYNIN 125OXYBUTYNIN CHLORIDE 125OXYCODONE HCL 9,12,13OXYCODONE HCL/ACETAMINOPHEN 10,12,13OXYCODONE HCL/ASPIRIN 13OXYCONTIN 9OXYMETHOLONE 134OXYMORPHONE HCL 9,13OXYTROL 125

PPALIPERIDONE 55,56PANTOPRAZOLE SODIUM 123PAREGORIC 120PARICALCITOL 154,155PAROMOMYCIN SULFATE 15PAROXETINE HCL 33PASER 43PASIREOTIDE DIASPARTATE 148PATADAY 158PATANASE 163PATANOL 158PAXIL 33PAZOPANIB HCL 49PCE 20PEDIATRIC MULTIVIT WITH A,C,D3NO.21/SODIUM FLUORIDE 119PEDIATRIC MULTIVITAMIN NO.12 WITH SODIUMFLUORIDE 117PEDIATRIC MULTIVITAMIN NO.150 WITH SODIUMFLUORIDE 117,156PEDIATRIC MULTIVITAMIN NO.16/SODIUMFLUORIDE 117PEDIATRIC MULTIVITAMIN NO.2/SODIUMFLUORIDE 117

PEDIATRIC MULTIVITAMIN NO.82 WITH SODIUMFLUORIDE 117PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUMFLUORIDE 117PEG 3350/SOD SULF/SOD BICARB/SODCHLORIDE/POTASSIUM CHLORIDE 121,122PEG 3350/SODIUM SULFATE/SODCHLORIDE/KCL/ASCORBATE SOD/VIT C 122PEGANONE 27PEGASYS 60PEGASYS PROCLICK 60PEGFILGRASTIM 78PEGINTERFERON ALFA-2A 60PEGINTERFERON ALFA-2B 46,60,61PEGINTRON 60PEGINTRON REDIPEN 60,61PEGVISOMANT 148PEN NEEDLE, DIABETIC 156PENBUTOLOL SULFATE 84PENCICLOVIR 65PENICILLAMINE 126PENICILLIN V POTASSIUM 19PENLAC 40PENTAMIDINE ISETHIONATE 50PENTASA 153PENTAZOCINE HCL/NALOXONE HCL 13PENTAZOCINE LACTATE 13PENTOSAN POLYSULFATE SODIUM 126PENTOXIFYLLINE 90PERAMPANEL 25PERFOROMIST 165PERINDOPRIL ERBUMINE 81,82PERMETHRIN 51PERPHENAZINE 37PERPHENAZINE/AMITRIPTYLINE HCL 30PERTZYE 124PHENAZOPYRIDINE HCL 126PHENDIMETRAZINE TARTRATE 106PHENELZINE SULFATE 31PHENOBARBITAL 24

PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINESULF/SCOPOLAMINE HB 119,120PHENOXYBENZAMINE HCL 80PHENYLEPHRINE HCL 157PHENYLEPHRINE HCL/PROMETHAZINE HCL 168PHENYTOIN 27PHENYTOIN SODIUM EXTENDED 27PHOSLYRA 127PHOSPHOLINE IODIDE 160PHYSIOLOGICAL IRRIGATING SOLUTION NO.1 118PHYSIOLYTE 118PHYSIOSOL 118PHYTONADIONE (VIT K1) 117PICATO 112PILOCARPINE HCL 108,109,160PIMECROLIMUS 111PIMOZIDE 54PINDOLOL 84PIOGLITAZONE HCL 71PIOGLITAZONE HCL/GLIMEPIRIDE 71PIOGLITAZONE HCL/METFORMIN HCL 68,71PIROXICAM 6PITAVASTATIN CALCIUM 94PNEUMOCOCCAL 23-VALENT POLYSACCHARIDEVACCINE 152PNEUMOVAX 23 152PODOFILOX 110,113PODOPHYLLUM RESIN 113POLYETHYLENE GLYCOL 3350 122POLYMYXIN B SULFATE/TRIMETHOPRIM 157POMALIDOMIDE 45POMALYST 45PONATINIB HCL 48POSACONAZOLE 39POTABA 118POTASSIUM AMINOBENZOATE 118POTASSIUM BICARBONATE/CITRICACID 116,117,118POTASSIUM CHLORIDE 117,118POTASSIUM CHLORIDE/POTASSIUMBICARBONATE/CITRIC ACID 118

POTASSIUM CITRATE 126,127POTASSIUM CITRATE/CITRIC ACID 126,127POTASSIUM IODIDE 148POTIGA 23PRADAXA 76PRAMIPEXOLE DI-HCL 52PRAMLINTIDE ACETATE 71PRAMOSONE 113PRASUGREL HCL 79PRAVASTATIN SODIUM 95PRAZIQUANTEL 50PRAZOSIN HCL 80PRED MILD 159PREDNICARBATE 131PREDNISOLONE 131PREDNISOLONE ACETATE 159PREDNISOLONE SOD PHOSPHATE 131,132,159PREDNISONE 128,131PREGABALIN 107PRELONE 131PREMARIN 141PREMPHASE 141PREMPRO 141PRENATAL VITS NO.119/IRON FUMARATE/FOLICACID/DOCUSATE SOD. 118,119PREPOPIK 122PREVACID 123PREZISTA 64,65PRIFTIN 43PRIMAQUINE PHOSPHATE 50PRIMIDONE 24PRIMSOL 16PRISTIQ 33PROAIR HFA 165PROAIR RESPICLICK 165PROBENECID 40PROBENECID/COLCHICINE 40PROCARBAZINE HCL 44PROCHLORPERAZINE 36,37PROCHLORPERAZINE MALEATE 37PROCRIT 78

PROCTOFOAM-HC 113PROGESTERONE, MICRONIZED 143,144PROGLYCEM 72PROMACTA 78PROMETHAZINE HCL 37,163PROMETHAZINE HCL/CODEINE 168PROMETHAZINE HCL/DEXTROMETHORPHANHBR 168PROMETHAZINE/PHENYLEPHRINEHCL/CODEINE 168PROPAFENONE HCL 82PROPANTHELINE BROMIDE 120PROPARACAINE HCL 156,157PROPARACAINE HCL/FLUORESCEIN SODIUM 157PROPRANOLOL HCL 46,84PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 90PROPYLTHIOURACIL 148PROTOPIC 113PROTRIPTYLINE HCL 36PROVENTIL HFA 165PROVIGIL 171PRUDOXIN 113PULMICORT 162PULMICORT FLEXHALER 162PULMOZYME 169PURIXAN 46PYLERA 120PYRAZINAMIDE 43PYRIDOSTIGMINE BROMIDE 43PYRIMETHAMINE 50

QQNASL 162QUESTRAN 96QUETIAPINE FUMARATE 56,57QUILLIVANT XR 105QUINAPRIL HCL 82QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 90,91QUINIDINE GLUCONATE 82QUINIDINE SULFATE 82,83QUININE SULFATE 50

QVAR 162

RRABEPRAZOLE SODIUM 122,123RALOXIFENE HCL 144RALTEGRAVIR POTASSIUM 61,62RAMELTEON 171RAMIPRIL 82RANEXA 91RANITIDINE HCL 121RANOLAZINE 91RAPAFLO 126RAPAMUNE 150RASAGILINE MESYLATE 53RASUVO 150RAYOS 131REBETOL 61REBIF 108REBIF REBIDOSE 108RECOMBIVAX HB 152RECTIV 113REGORAFENIB 49REGRANEX 113RELENZA 65RELISTOR 120RELPAX 42REMODULIN 166RENAGEL 127RENVELA 127REPAGLINIDE 71REPAGLINIDE/METFORMIN HCL 71REPATHA PUSHTRONEX 96REPATHA SURECLICK 96REPATHA SYRINGE 96RESCRIPTOR 62RESERPINE 91RESTASIS 157RETAPAMULIN 15REVATIO 166REVLIMID 45REYATAZ 65

RHEUMATREX 150RHINOCORT AQUA 162RIBASPHERE RIBAPAK 61RIBATAB 61RIBAVIRIN 60,61,169RIDAURA 152RIFABUTIN 43RIFAMATE 43RIFAMPIN 43RIFAMPIN/ISONIAZID 43RIFAMPIN/ISONIAZID/PYRAZINAMIDE 43RIFAPENTINE 43RIFATER 43RIFAXIMIN 17RILONACEPT 151RILPIVIRINE HCL 62RILUTEK 106RILUZOLE 106RIMANTADINE HCL 65RIMEXOLONE 159RIOCIGUAT 166RIOMET 71RISEDRONATE SODIUM 154,155RISPERIDONE 56,57RITALIN 105RITONAVIR 64RIVAROXABAN 76,77RIVASTIGMINE 28RIVASTIGMINE TARTRATE 28RIZATRIPTAN BENZOATE 42ROFLUMILAST 165ROLAPITANT HCL 38ROPINIROLE HCL 52,53ROSIGLITAZONE MALEATE 68ROSUVASTATIN CALCIUM 95ROTIGOTINE 52ROZEREM 171RUCONEST 148RUFINAMIDE 26,27RUXOLITINIB PHOSPHATE 48

SSABRIL 24SAFYRAL 142SAIZEN 134SALICYLIC ACID 113,114SALICYLIC ACID/AMMONIUM LACTATE/ALOEVERA 113SALKERA 113SALMETEROL XINAFOATE 165SALSALATE 6SALVAX 114SAMSCA 118SANCUSO 38SANDIMMUNE 150SANTYL 114SAPHRIS 57SAPROPTERIN DIHYDROCHLORIDE 123SAQUINAVIR MESYLATE 64SAVELLA 107SAXAGLIPTIN HCL 71SAXAGLIPTIN HCL/METFORMIN HCL 70SCOPOLAMINE 37SELEGILINE 30SELEGILINE HCL 53SELENIUM SULFIDE 114SELZENTRY 64SENSIPAR 155SEREVENT DISKUS 165SEROMYCIN 43SEROQUEL XR 57SEROSTIM 134SERTACONAZOLE NITRATE 38SERTRALINE HCL 33,34SEVELAMER CARBONATE 127SEVELAMER HCL 127SIGNIFOR 148SILDENAFIL CITRATE 166,167SILODOSIN 126SILVER NITRATE/POTASSIUM NITRATE 111,114SILVER SULFADIAZINE 21

SIMBRINZA 160SIMCOR 96SIMEPREVIR SODIUM 59SIMPONI 151SIMVASTATIN 95SINECATECHINS 115SIROLIMUS 150,151SITAGLIPTIN PHOSPHATE 70SITAGLIPTIN PHOSPHATE/METFORMIN HCL 69,70SIVEXTRO 16SKELAXIN 169SKLICE 50SODIUM CHLORIDE IRRIGATING SOLUTION 118SODIUM CHLORIDE/SODIUMBICARBONATE/POTASSIUMCHLORIDE/PEG 121,122SODIUM FLUORIDE/POTASSIUM NITRATE 108SODIUM FLUORIDE/XYLITOL 116SODIUM OXYBATE 171SODIUM PHENYLBUTYRATE 123SODIUM PHOSPHATE,DIBASIC/POTPHOS,MONOB/SOD PHOSPHATE MONO 126,127SODIUM PHOSPHATE,MONOBASIC/SODIUMPHOSPHATE,DIBASIC 122SODIUM PICOSULFATE/MAGNESIUMOXIDE/CITRIC ACID 122SODIUM POLYSTYRENE SULFONATE 118SODIUM POLYSTYRENE SULFONATE/SORBITOLSOLUTION 117,118SODIUM SULFATE/POTASSIUMSULFATE/MAGNESIUM SULFATE 122SODIUM THIOSULFATE/SALICYLIC ACID 39SODIUM/POTASSIUM/POTASSIUMCITRATE/SODIUM CITRATE/CIT AC 126,127SOFOSBUVIR 59SOFOSBUVIR/VELPATASVIR 59SOLIFENACIN SUCCINATE 125SOLODYN 22SOMATROPIN 132,133,134SOMAVERT 148SORAFENIB TOSYLATE 48

SORIATANE 114SOTALOL HCL 83SOVALDI 59SPINOSAD 112,114SPIRIVA 164SPIRONOLACTONE 92,93SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 91SPORANOX 40SPRIX 6SPRYCEL 48,49SPS 118SSD 21STAVUDINE 63STELARA 114STIMATE 134STIVARGA 49STRATTERA 105STRIBILD 62STROMECTOL 50SUBOXONE 14SUBSYS 13SUCCIMER 116SUCRALFATE 122SUCROFERRIC OXYHYDROXIDE 127SULCONAZOLE NITRATE 39SULFACETAMIDE SODIUM 21,112,114SULFACETAMIDE SODIUM/PREDNISOLONEACETATE 157SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE 157SULFACETAMIDE SODIUM/SULFUR 110,114,115SULFACETAMIDE SODIUM/SULFUR/SKINCLEANSER COMB NO.23 114SULFACETAMIDE SODIUM/SULFUR/UREA 110,114SULFADIAZINE 21SULFAMETHOXAZOLE/TRIMETHOPRIM 22SULFAMYLON 16SULFANILAMIDE 21SULFASALAZINE 153SULFATRIM 22SULFURIC ACID/SULFONATED PHENOL 108

SULINDAC 6SUMATRIPTAN 42SUMATRIPTAN SUCCINATE 41,42SUMAVEL DOSEPRO 42SUNITINIB MALATE 49SUPREP 122SUSTIVA 62SUTENT 49SYLATRON 46SYMBICORT 169SYMLINPEN 120 71SYMLINPEN 60 71SYNAREL 148SYNERA 14SYNJARDY 71,72SYNJARDY XR 72SYNRIBO 47SYNTHROID 145,146SYPRINE 119SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3ML 155SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5ML 155,156SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1ML 156SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1ML 155,156SYRINGE WITH NEEDLE,INSULIN,0.3 ML 156SYRINGE WITH NEEDLE,INSULIN,0.5 ML 155,156

TTABLOID 46TACLONEX 115TACROLIMUS 113,115,151TADALAFIL 125,126,166TAFINLAR 49TAFLUPROST/PF 160TALWIN 13TAMIFLU 65TAMOXIFEN CITRATE 45TAMSULOSIN HCL 126

TAPENTADOL HCL 8,12TARCEVA 49TARGRETIN 49,50TASIGNA 49TASMAR 51TAZAROTENE 115TAZORAC 115TECFIDERA 108TEDIZOLID PHOSPHATE 16TEDUGLUTIDE 120TEGRETOL XR 27TEKTURNA 91TEKTURNA HCT 91TELAPREVIR 59TELBIVUDINE 59TELITHROMYCIN 20TELMISARTAN 81TELMISARTAN/AMLODIPINE BESYLATE 91TELMISARTAN/HYDROCHLOROTHIAZIDE 91TEMAZEPAM 170TEMODAR 44TEMOZOLOMIDE 44TENIVAC 152TENOFOVIR DISOPROXIL FUMARATE 63TERAZOSIN HCL 80TERBINAFINE HCL 40TERBUTALINE SULFATE 165TERCONAZOLE 40TERIFLUNOMIDE 107TERIPARATIDE 154TESAMORELIN ACETATE 147TESTOSTERONE 135TESTOSTERONE CYPIONATE 135TESTOSTERONE ENANTHATE 135TETANUS AND DIPHTHERIA TOXOIDS, ADSORBED,ADULT/PF 152TETANUS AND DIPHTHERIA TOXOIDS, ADULT 153TETRABENAZINE 106TETRACAINE HCL 156,157TETRACAINE HCL/PF 157TETRACYCLINE HCL 22,23

TETRAHYDROZOLINE HCL 169TEV-TROPIN 134TEXACORT 132THALIDOMIDE 45THALOMID 45THEO-24 166THEOPHYLLINE ANHYDROUS 166THIOGUANINE 46THIORIDAZINE HCL 54THIOTHIXENE 54THYROID,PORK 144,145,146,147THYROLAR-1 146THYROLAR-1/2 146THYROLAR-1/4 146THYROLAR-2 146THYROLAR-3 146TIAGABINE HCL 24TICAGRELOR 79TICLOPIDINE HCL 79TIKOSYN 83TIMOLOL 159TIMOLOL MALEATE 85,160TINIDAZOLE 16TIOTROPIUM BROMIDE 164TIPRANAVIR 64TIPRANAVIR/VITAMIN E TPGS 64TIZANIDINE HCL 58,59TOBI 169TOBRADEX 157TOBRADEX ST 157TOBRAMYCIN 15TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 169TOBRAMYCIN/DEXAMETHASONE 157,158TOBRAMYCIN/LOTEPREDNOL ETABONATE 158TOBREX 15TOCILIZUMAB 151TOFACITINIB CITRATE 151TOLAZAMIDE 72TOLBUTAMIDE 72TOLCAPONE 51TOLMETIN SODIUM 6

TOLTERODINE TARTRATE 124,125TOLVAPTAN 118TOPIRAMATE 26TOPOTECAN HCL 47TOREMIFENE CITRATE 45TORSEMIDE 92TOUJEO SOLOSTAR 73TOVIAZ 125TRACLEER 167TRADJENTA 72TRAMADOL HCL 9,13TRAMADOL HCL/ACETAMINOPHEN 13TRAMETINIB DIMETHYL SULFOXIDE 48TRANDOLAPRIL 82TRANDOLAPRIL/VERAPAMIL HCL 91TRANEXAMIC ACID 79TRANSDERM-SCOP 37TRANYLCYPROMINE SULFATE 31TRAVATAN Z 160TRAVOPROST 160TRAZODONE HCL 34TRECATOR 43TREPROSTINIL 167TREPROSTINIL SODIUM 166TREPROSTINIL/NEBULIZER ACCESSORIES 167TREPROSTINIL/NEBULIZER AND ACCESSORIES 167TRESIBA FLEXTOUCH U-100 73TRESIBA FLEXTOUCH U-200 73TRETIN-X 115TRETINOIN 50,110,115TRETINOIN MICROSPHERES 115TRETINOIN/EMOLLIENT BASE 115TREXALL 151TRIAMCINOLONEACETONIDE 108,109,130,132,162TRIAMTERENE 92TRIAMTERENE/HYDROCHLOROTHIAZIDE 92TRIAZOLAM 170TRIENTINE HCL 119TRIFLUOPERAZINE HCL 54TRIFLURIDINE 66

TRIHEXYPHENIDYL HCL 51TRIMETHOBENZAMIDE HCL 37TRIMETHOPRIM 16TRIMIPRAMINE MALEATE 36TRINTELLIX 34TROPICAMIDE 158TROSPIUM CHLORIDE 125TRUVADA 63TUDORZA PRESSAIR 164TUSSICAPS 169TWINRIX 153TYKERB 49TYVASO 167TYVASO INSTITUTIONAL START KIT 167TYVASO REFILL KIT 167TYVASO STARTER KIT 167TYZEKA 59TYZINE 169

UULESFIA 115ULORIC 40,41ULTRESA 124UMECLIDINIUM BROMIDE/VILANTEROLTRIFENATATE 167UREA/LACTIC ACID/SALICYLIC ACID 111UREA/LACTIC ACID/ZINC UNDECYLENATE 110UROCIT-K 127UROXATRAL 126URSODIOL 120USTEKINUMAB 114

VVAGIFEM 142VALACYCLOVIR HCL 66VALCYTE 59VALGANCICLOVIR HCL 59VALPROIC ACID 24VALPROIC ACID (AS SODIUM SALT) (VALPROATESODIUM) 24VALSARTAN 81

VALSARTAN/HYDROCHLOROTHIAZIDE 92VALTREX 66VANCOMYCIN HCL 17VANDETANIB 47VANOS 132VARUBI 38VASCEPA 96VELPHORO 127VELTIN 115VEMURAFENIB 49VENLAFAXINE HCL 34,35VENLAFAXINE HCL ER 34,35VENTAVIS 167VENTOLIN HFA 165VERAMYST 162VERAPAMIL HCL 87,88VERDESO 132VEREGEN 115VERIPRED 20 132VERSACLOZ 58VESICARE 125VEXOL 159VFEND 40VIBRAMYCIN 23VICTOZA 2-PAK 72VICTOZA 3-PAK 72VICTRELIS 60VIDEX 63VIGABATRIN 24VIGAMOX 21VIIBRYD 35VILAZODONE HCL 35VIMOVO 6VIMPAT 27,28VIOKACE 124VIRACEPT 65VIRAMUNE 62VIRAZOLE 169VIREAD 63VISMODEGIB 48VITUZ 169

VIVELLE-DOT 142,143VOLTAREN 115VORAPAXAR SULFATE 77VORICONAZOLE 40VORINOSTAT 47VORTIOXETINE HYDROBROMIDE 31,34VOTRIENT 49VYTORIN 96,97VYVANSE 100

WWARFARIN SODIUM 76WELCHOL 97WESTHROID 146WP THYROID 146,147

XXALKORI 49XARELTO 76,77XARTEMIS XR 13XELJANZ 151XELODA 46XENAZINE 106XIFAXAN 17XIIDRA 158XOLEGEL 40XOPENEX HFA 165XTANDI 45XYREM 171

ZZAFIRLUKAST 163ZALEPLON 170ZANAMIVIR 65ZAVESCA 124ZEBUTAL 106ZEGERID 123ZELBORAF 49ZEMPLAR 155ZENPEP 124ZEPATIER 60

ZETIA 97ZETONNA 162ZIAGEN 63ZIANA 116ZIDOVUDINE 63ZILEUTON 163ZIOPTAN 160ZIPRASIDONE HCL 55,57ZIRGAN 59ZITHROMAX 20ZOLINZA 47ZOLMITRIPTAN 42ZOLPIDEM TARTRATE 170ZOMIG 42ZONALON 116ZONISAMIDE 23ZONTIVITY 77ZORBTIVE 134ZORTRESS 151ZORVOLEX 7ZOVIRAX 66ZUPLENZ 38ZYCLARA 116ZYFLO 163ZYFLO CR 163ZYKADIA 49ZYLET 158ZYMAXID 21ZYPREXA 57,58ZYPREXA ZYDIS 58ZYTIGA 45

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