Partnership 2017 Formulary List of Covered Drugs FOR ... · PDF filePartnership 2017 Formulary...

Medicaid Only_DHS Approved 12/15/2016

Partnership 2017 Formulary

List of Covered Drugs

FOR MEMBERS ENROLLED IN MEDICAID ONLY

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID: 17379, Version Number 19

This formulary was updated on 5/23/2017. For more recent information or other questions, please contact

Family Care Customer Service at 1-800-963-0035 or, for TTY users, Wisconsin Relay 711, 8 a.m. – 8 p.m.,

7 days a week, or visit www.carewisc.org.

i

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

make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Care Wisconsin Health Plan, Inc.

When it refers to “plan” or “our plan,” it means Partnership.

This document includes a list of the drugs (formulary) for our plan which is current as of 5/23/2017. For an

updated formulary, please contact us. Our contact information, along with the date we last updated the

formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time

during the year.

Care Wisconsin Health Plan, Inc., contracts with the Wisconsin Department of Health Services (DHS) to

offer the Partnership Program.

To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin

Customer Service at 1-800-963-0035 (TTY/TDD Wisconsin Relay System 711).

ii

What is the Care Wisconsin Formulary?

A formulary is a list of covered drugs selected by Care Wisconsin in consultation with a team of health care

providers, which represents the prescription therapies believed to be a necessary part of a quality treatment

program. Care Wisconsin will generally cover the drugs listed in our formulary as long as the drug is

medically necessary, the prescription is filled at a Care Wisconsin network pharmacy, and other plan rules

are followed. For more information on how to fill your prescriptions, please review your Member

Handbook.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we

will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less

expensive generic drug becomes available or when new adverse information about the safety or effectiveness

of a drug is released.

Other types of formulary changes, such as removing a drug from our formulary, will not affect members who

are currently taking the drug. It will remain available at the same cost-sharing for those members taking it

for the remainder of the coverage year. We feel it is important that you have continued access for the

remainder of the coverage year to the formulary drugs that were available when you chose our plan, except

for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy

restrictions on a drug, we must notify affected members of the change at least 60 days before the change

becomes effective, or at the time the member requests a refill of the drug, at which time the member will

receive a 60-day supply of the drug.

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer

removes the drug from the market, we will immediately remove the drug from our formulary and provide

notice to members who take the drug. The enclosed formulary is current as of 5/23/2017. To get updated

information about the drugs covered by Care Wisconsin, please contact us. Our contact information appears

on the front and back cover pages.

In the event of a mid-year non-maintenance formulary change, we will mail you updates to the formulary as

needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or

printing them from our Web site.

How do I use the Formulary?

To find your drug within the formulary:

Alphabetical Listing

The formulary begins on page 1. You should look for your drug in the listing that begins on page 2. The

Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs

and generic drugs are listed in the Index. Look in the Index and find your drug.

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What are generic drugs?

Partnership covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as

having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand

name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits

may include:

• Prior Authorization: Partnership requires you [or your physician] to get prior authorization for

certain drugs. This means that you will need to get approval from Partnership before you fill your

prescriptions. If you don’t get approval, Partnership may not cover the drug.

• Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will

cover. For example, Partnership provides 62 tablets per prescription for Xifaxan. This may be in

addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B

both treat your medical condition, Partnership may not cover Drug B unless you try Drug A first. If

Drug A does not work for you, Partnership will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 1. You can also get more information about the restrictions applied to specific covered drugs

by visiting our Web site. We have posted on line documents that explain our prior authorization and step

therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date

we last updated the formulary, appears on the front and back cover pages.

You can ask Partnership to make an exception to these restrictions or limits or for a list of other, similar

drugs that may treat your health condition. See the section, “How do I request an exception to the Partnership

formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member

Services and ask if your drug is covered.

If you learn that Partnership does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Partnership. When you

receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered

by Partnership.

iv

• You can ask Partnership to make an exception and cover your drug. See below for information about

how to request an exception.

How do I request an exception to the Partnership Formulary?

You can ask Partnership to make an exception to our coverage rules. There are several types of exceptions

that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Partnership limits the amount of the drug that we will cover. If your drug has a quantity limit, you

can ask us to waive the limit and cover a greater amount.

Generally, Partnership will only approve your request for an exception if the alternative drugs included on

the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition

and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction

exception. When you request a formulary or utilization restriction exception you should submit a

statement from your prescriber or physician supporting your request. Generally, we must make our

decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited

(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72

hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24

hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an

exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you

may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need

a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide

if you should switch to an appropriate drug that we cover or request a formulary exception so that we will

cover the drug you take. While you talk to your doctor to determine the right course of action for you, we

may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will

cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a

network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a

member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have

provided you with 91 to 98-day transition supply, consistent with dispensing increment, (unless you have a

prescription written for fewer days). We will cover more than one refill of these drugs for the first 90days

you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your

drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day

v

emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary

exception.

Current members with a change in where they receive care

Partnership has a transition process that addresses unplanned transitions as members change treatment

settings due to changes in the type of care they require. Changes in where you live or receive care may

warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of

program enrollment. Examples of situations include:

• You were discharged from the hospital and were provided a discharge list of medications based upon

the formulary of the hospital.

• Beneficiaries who give up Hospice Status to revert back to standard Medicaid benefits.

• Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of

medications that are highly individualized.

Please note that our transition policy applies only to those drugs that are on our formulary and are

supplied by a network pharmacy.

For more information

For more detailed information about your Partnership prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about Partnership, please contact us. Our contact information, along with the date we

last updated the formulary, appears on the front and back cover pages.

For more information about Medicaid, please contact the Wisconsin Department of Health Services by

calling 1-800-362-3002. You can also get information by visiting their website at

www.dhs.wisconsin.gov/Medicaid.

Partnership Formulary

The formulary that begins on the next page provides coverage information about the drugs covered by

Partnership.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EMBEDA) and

generic drugs are listed in lower-case italics (e.g., fentanyl).

The information in the Requirements/Limits column tells you if Partnership has any special requirements for

coverage of your drug.

1

LEGEND

1: Covered Medications

1(CW): CW OTC

1(ND): Non D RX

1(SO): State OTC

HR: High Risk Medication (PA required for ages 65 or over)

LA: This prescription drug is limited to certain pharmacies.

PA: You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug.

QL: There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.

ST: In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the drug table. Last Updated 05/19/2017 Effective Date: 06/01/2017

2

Care Wisconsin Medicaid (List of Covered Drugs)

Drug Tier Notes

abacavir sulfate oral tablet 300 mg 1 QL (62 per 31 days)

abacavir sulfate-lamivudine oral tablet 600-300 mg

1 QL (31 per 31 days)

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg


ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

1

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 400 MG

1 ST; QL (1 per 26 days)

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG

1

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

1

acamprosate calcium oral tablet delayed release 333 mg

1

acarbose oral tablet 100 mg, 25 mg, 50 mg 1 QL (93 per 31 days)

acebutolol hcl oral capsule 200 mg, 400 mg 1

acetaminophen er oral tablet extended release 650 mg

1(SO)

acetaminophen extra strength oral liquid 500 mg/15ml

1(SO)

acetaminophen extra strength oral tablet 500 mg 1(SO)

acetaminophen oral capsule 500 mg 1(SO)

acetaminophen oral elixir 160 mg/5ml 1(SO)

acetaminophen oral liquid 160 mg/5ml 1(SO)

acetaminophen oral solution 160 mg/5ml 1(SO)

acetaminophen oral suspension 160 mg/5ml 1(SO)

acetaminophen oral tablet 325 mg 1(SO)

acetaminophen oral tablet chewable 80 mg 1(SO)

acetaminophen rectal suppository 120 mg, 650 mg 1(SO)

acetaminophen-codeine #2 oral tablet 300-15 mg 1 QL (413 per 31 days)



3

Drug Tier Notes


acetaminophen-codeine oral solution 120-12 mg/5ml

1 QL (5167 per 31 days)

acetazolamide oral tablet 125 mg, 250 mg 1

acetic acid otic solution 2 % 1

acetylcysteine inhalation solution 10 %, 20 % 1

ACID GONE ORAL SUSPENSION 95-358 MG/15ML

1(SO)

ACID GONE ORAL TABLET CHEWABLE 160-105 MG

1(SO)

acidophilus extra strength oral capsule 1(CW)

acidophilus oral tablet chewable 1(CW)

acidophilus probiotic oral capsule 100 mg 1(CW)

acidophilus probiotic oral tablet 1(SO)

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1

acne maximum strength external cream 10 % 1(SO)

acne medication 10 external lotion 10 % 1(SO)

acne medication 5 external lotion 5 % 1(SO)

acne treatment external bar 10 % 1(SO)

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML

1 ST

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

1 ST

ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

1

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

1 PA; LA

acyclovir external ointment 5 % 1

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5ml 1

acyclovir oral tablet 400 mg, 800 mg 1

acyclovir sodium intravenous solution 50 mg/ml 1

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

1


4

Drug Tier Notes

ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML

1 PA; LA

adapalene external cream 0.1 % 1

adapalene external gel 0.1 %, 0.3 % 1

ADCIRCA ORAL TABLET 20 MG 1 PA

adefovir dipivoxil oral tablet 10 mg 1

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


adriamycin intravenous solution 2 mg/ml 1

adrucil intravenous solution 500 mg/10ml 1

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


ADVIL JUNIOR STRENGTH ORAL TABLET 100 MG

1(SO)

ADVIL ORAL CAPSULE 200 MG 1(SO)

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG


AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG

1 PA; QL (31 per 31 days)

AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG


AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG


AFTERA ORAL TABLET 1.5 MG 1(SO)

ALBENZA ORAL TABLET 200 MG 1

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

1

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

1

albuterol sulfate oral syrup 2 mg/5ml 1


5

Drug Tier Notes

albuterol sulfate oral tablet 2 mg, 4 mg 1

alclometasone dipropionate external cream 0.05 %

1

alclometasone dipropionate external ointment 0.05 %

1

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

1 PA; LA

ALECENSA ORAL CAPSULE 150 MG 1 PA

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg


alendronate sodium oral tablet 35 mg, 70 mg 1 QL (4 per 28 days)

alevazol external ointment 1 % 1(SO)

ALEVE ORAL CAPSULE 220 MG 1(SO)

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

1 PA

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML


ALINIA ORAL TABLET 500 MG 1 QL (41 per 31 days)

ALIVIO EXTERNAL PATCH 0.03-5 % 1(CW)

all day allergy oral capsule 10 mg 1(SO)

allergy medication oral tablet 25 mg 1(SO)

allergy relief oral tablet dispersible 10 mg 1(SO)

allergy relief-d oral tablet extended release 12 hour 5-120 mg

1(SO)

allopurinol oral tablet 100 mg, 300 mg 1

ALMACONE ORAL TABLET CHEWABLE 200-200-25 MG

1(SO)

alosetron hcl oral tablet 0.5 mg, 1 mg 1 QL (62 per 31 days)

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 %

1

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg


ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

1

alprazolam oral tablet 0.25 mg, 0.5 mg 1 QL (124 per 31 days)


6

Drug Tier Notes

alprazolam oral tablet 1 mg 1 QL (248 per 31 days)

alprazolam oral tablet 2 mg 1 QL (155 per 31 days)

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg


alprazolam xr oral tablet extended release 24 hour 0.5 mg


aluminum hydroxide gel oral suspension 320 mg/5ml

1(SO)

alyacen 1/35 oral tablet 1-35 mg-mcg 1

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral syrup 50 mg/5ml 1

amantadine hcl oral tablet 100 mg 1

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

1

amcinonide external cream 0.1 % 1

amcinonide external lotion 0.1 % 1

amcinonide external ointment 0.1 % 1

AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG 1

amikacin sulfate injection solution 500 mg/2ml 1

amiloride hcl oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

aminophylline intravenous solution 25 mg/ml 1

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 7 %, 8.5 %

1

AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 %

1

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 %

1

AMINOSYN-HBC INTRAVENOUS SOLUTION 7 %

1

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

1

AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 %

1

amiodarone hcl intravenous solution 150 mg/3ml 1


7

Drug Tier Notes

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

1

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 1

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 PA; HR

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg


amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg


amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg


amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg


ammonium lactate external cream 12 % 1

ammonium lactate external lotion 12 % 1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

1 PA; HR

amoxicill-clarithro-lansopraz oral 1

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet chewable 125 mg, 250 mg 1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

1


8

Drug Tier Notes

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg


amphetamine-dextroamphetamine oral tablet 30 mg


amphotericin b injection solution reconstituted 50 mg

1

ampicillin oral capsule 250 mg, 500 mg 1

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg

1

ampicillin sodium intravenous solution reconstituted 10 gm

1

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm

1

ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm

1

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG

1 PA; ST; QL (62 per 31 days)

ANADROL-50 ORAL TABLET 50 MG 1

anastrozole oral tablet 1 mg 1 QL (31 per 31 days)

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR

1

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

1

antacid & antigas oral suspension 200-200-20 mg/5ml, 400-400-40 mg/5ml

1(SO)

antacid extra strength oral tablet chewable 675-135 mg

1(CW)

antacid oral tablet chewable 1177 mg, 420 mg, 500 mg, 550-110 mg

1(CW)

antacid ultra strength oral tablet chewable 1000 mg, 1000-200 mg

1(CW)

anti-diarrheal oral capsule 2 mg 1(CW)

anti-diarrheal oral tablet 2 mg 1(CW)

antifungal external cream 2 % 1(SO)


9

Drug Tier Notes

anti-itch maximum strength external cream 1 % 1(CW)

anti-oxidant formula oral capsule 1(CW)

antiseptic skin cleanser external solution 4 % 1(CW)

ANUSOL-HC RECTAL SUPPOSITORY 25 MG 1(CW)

APOKYN SUBCUTANEOUS SOLUTION 10 MG/ML


apraclonidine hcl ophthalmic solution 0.5 % 1

aprepitant oral capsule 125 mg, 40 mg, 80 mg 1 QL (31 per 31 days)

aprepitant oral capsule 80 & 125 mg 1 QL (12 per 31 days)

APRI ORAL TABLET 0.15-30 MG-MCG 1

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM


APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG


APTIOM ORAL TABLET 600 MG 1 QL (62 per 31 days)

APTIVUS ORAL CAPSULE 250 MG 1 QL (124 per 31 days)

APTIVUS ORAL SOLUTION 100 MG/ML 1 QL (295 per 28 days)

AQUORAL MOUTH/THROAT AEROSOL SOLUTION

1(CW)

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG

1

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

1

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

1

aripiprazole oral tablet dispersible 10 mg 1

ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 15 MG

1

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

1 ST

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT


arthricream rub external cream 10 % 1(CW)


10

Drug Tier Notes

ARTHRITIS HOT EXTERNAL CREAM 10-15 %

1(CW)

arthritis pain relief oral tablet extended release 650 mg

1(SO)

arthritis relief/aloe external aerosol 10 % 1(CW)

artificial tears ophthalmic ointment 83-15 % 1(SO)

artificial tears ophthalmic solution 0.1-0.3 %, 1-0.3 %, 1.4 %, 5-6 mg/ml

1(SO)

ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 %

1(ND)

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG

1 PA; HR; QL (382 per 31 days)

ASPERCREME EXTERNAL LOTION 10 % 1(CW)

ASPERCREME HEAT EXTERNAL GEL 10 % 1(CW)

ASPERCREME LIDOCAINE EXTERNAL PATCH 4 %

1(CW)

aspirin ec low strength oral tablet delayed release 81 mg

1(SO)

aspirin ec oral tablet delayed release 325 mg 1(SO)

aspirin oral tablet 325 mg 1(SO)

aspirin oral tablet chewable 81 mg 1(SO)

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML

1

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG

1 ST

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

1

athletes foot external cream 1 % 1(CW)

athletes foot external powder 2 % 1(SO)

athletes foot powder spray external aerosol powder 2 %

1(SO)

athletes foot spray external aerosol 1 % 1(SO)


11

Drug Tier Notes

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


atovaquone oral suspension 750 mg/5ml 1

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

1

ATRIPLA ORAL TABLET 600-200-300 MG 1 QL (31 per 31 days)

atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml

1

atropine sulfate ophthalmic solution 1 % 1

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT


AUBAGIO ORAL TABLET 14 MG, 7 MG 1 PA; ST; LA; QL (30 per 30 days)

AUBRA ORAL TABLET 0.1-20 MG-MCG 1

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML

1 PA

AVASTIN INTRAVENOUS SOLUTION 400 MG/16ML

1

AVIANE ORAL TABLET 0.1-20 MG-MCG 1

AVONEX INTRAMUSCULAR KIT 30 MCG 1 PA

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

1 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

1 PA

AYR NASAL MIST ALLERGY/SINUS NASAL SOLUTION 2.65 %

1(CW)

AYR NASAL SOLUTION 0.65 % 1(CW)

AYR SALINE NASAL NASAL GEL 1(CW)

azacitidine injection suspension reconstituted 100 mg

1

AZASAN ORAL TABLET 100 MG, 75 MG 1 ST

AZASITE OPHTHALMIC SOLUTION 1 % 1

azathioprine oral tablet 50 mg 1

azathioprine sodium injection solution reconstituted 100 mg

1

azelastine hcl nasal solution 0.1 %, 0.15 % 1


12

Drug Tier Notes

azelastine hcl ophthalmic solution 0.05 % 1

azithromycin intravenous solution reconstituted 500 mg

1

azithromycin oral packet 1 gm 1

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

AZOLEN TINCTURE EXTERNAL SOLUTION 2 %

1(SO)

AZOPT OPHTHALMIC SUSPENSION 1 % 1

aztreonam injection solution reconstituted 1 gm 1

b-12 compliance injection injection kit 1000 mcg/ml

1(ND)

B-12 DOTS ORAL TABLET DISPERSIBLE 500 MCG

1(CW)

b-12 oral tablet 2000 mcg, 2500 mcg 1(CW)

b-12 sublingual tablet sublingual 100-5000 mcg, 3000 mcg

1(CW)

b-6 oral tablet 100 mg 1(CW)

bacitracin external ointment 500 unit/gm 1(SO)

bacitracin intramuscular solution reconstituted 50000 unit

1

bacitracin ophthalmic ointment 500 unit/gm 1

bacitracin-neomycin-polymyxin external ointment 400-5-5000

1(SO)

bacitracin-polymyxin b external ointment 500-10000 unit/gm

1(SO)

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

1

baclofen oral tablet 10 mg, 20 mg 1

balsalazide disodium oral capsule 750 mg 1

BALZIVA ORAL TABLET 0.4-35 MG-MCG 1

BANZEL ORAL SUSPENSION 40 MG/ML 1 QL (2852 per 31 days)


13

Drug Tier Notes

BANZEL ORAL TABLET 200 MG 1 QL (496 per 31 days)

BANZEL ORAL TABLET 400 MG 1 QL (248 per 31 days)

BARACLUDE ORAL SOLUTION 0.05 MG/ML 1 PA

BAYER ADVANCED ASPIRIN EX ST ORAL TABLET 500 MG

1(SO)

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG

1(SO)

BAYER ASPIRIN ORAL TABLET 325 MG 1(SO)

BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG

1(SO)

bcg vaccine injection injectable 1

bedding spray lice treatment aerosol 0.5 % 1(SO)

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

1 PA

BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML

1(SO)

BENADRYL ALLERGY ORAL CAPSULE 25 MG

1(SO)

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1

BENEFIBER ON THE GO ORAL PACKET 1(CW)

BENEFIBER ORAL POWDER 1(CW)

BENGAY COLD THERAPY EXTERNAL GEL 5 %

1(CW)

BENGAY ULTRA STRENGTH EXTERNAL CREAM 4-10-30 %

1(CW)

BENGAY VANISHING SCENT EXTERNAL GEL 2.5 %

1(CW)

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

1

benzonatate oral capsule 100 mg, 150 mg, 200 mg 1(ND)

benzoyl peroxide external gel 10 %, 2.5 %, 5 % 1(SO)

benzoyl peroxide wash external liquid 10 %, 5 % 1(SO)


14

Drug Tier Notes

benzoyl peroxide-erythromycin external gel 5-3 % 1

benztropine mesylate injection solution 1 mg/ml 1

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

1 PA; HR

BERRI-FREEZ PAIN RELIEVING EXTERNAL GEL 4.5 %

1(CW)

betamethasone dipropionate aug external cream 0.05 %

1

betamethasone dipropionate aug external gel 0.05 %

1

betamethasone dipropionate aug external lotion 0.05 %

1

betamethasone dipropionate aug external ointment 0.05 %

1

betamethasone dipropionate external cream 0.05 %

1

betamethasone dipropionate external lotion 0.05 %

1

betamethasone dipropionate external ointment 0.05 %

1

betamethasone valerate external cream 0.1 % 1

betamethasone valerate external foam 0.12 % 1

betamethasone valerate external lotion 0.1 % 1

betamethasone valerate external ointment 0.1 % 1

BETASERON SUBCUTANEOUS KIT 0.3 MG 1 PA; QL (15 per 31 days)

betaxolol hcl ophthalmic solution 0.5 % 1

betaxolol hcl oral tablet 10 mg, 20 mg 1

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

bexarotene oral capsule 75 mg 1 PA

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

1

bicalutamide oral tablet 50 mg 1 QL (31 per 31 days)

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML

1


15

Drug Tier Notes

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

1

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

1

BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1

BIOFREEZE EXTERNAL GEL 4 % 1(CW)

biospec dmx oral liquid 15-25 mg/5ml 1(SO)

BIOTENE MOISTURIZING MOUTH MOUTH/THROAT SOLUTION

1(CW)

BIOTENE ORALBALANCE DRY MOUTH MOUTH/THROAT GEL

1(CW)

bisacodyl ec oral tablet delayed release 5 mg 1(CW)

bisacodyl laxative rectal suppository 10 mg 1(CW)

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

bleomycin sulfate injection solution reconstituted 30 unit

1

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

1

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

1

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5

1

BOSULIF ORAL TABLET 100 MG 1 PA; QL (124 per 31 days)

BOSULIF ORAL TABLET 500 MG 1 PA; QL (31 per 31 days)

bp wash external liquid 2.5 % 1(SO)

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH

1

briellyn oral tablet 0.4-35 mg-mcg 1

BRILINTA ORAL TABLET 60 MG, 90 MG 1

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %

1


16

Drug Tier Notes

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

1 PA

BRIVIACT ORAL SOLUTION 10 MG/ML 1 PA

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

1 PA

bromfenac sodium ophthalmic solution 0.09 % 1

bromocriptine mesylate oral capsule 5 mg 1

bromocriptine mesylate oral tablet 2.5 mg 1

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

1

budesonide nasal suspension 32 mcg/act 1

bumetanide injection solution 0.25 mg/ml 1

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

1 PA

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg


bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg






bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg


bupropion hcl oral tablet 100 mg 1 QL (186 per 31 days)

bupropion hcl oral tablet 75 mg 1

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML

1

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg


BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG

1

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG

1


17

Drug Tier Notes

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

1

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML

1

cabergoline oral tablet 0.5 mg 1

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

1

CAFERGOT ORAL TABLET 1-100 MG 1

CALCET CREAMY BITES ORAL TABLET CHEWABLE 500-400 MG-UNIT

1(CW)

CALCI-MIX ORAL CAPSULE 1250 (500 CA) MG

1(CW)

calcipotriene external cream 0.005 % 1

calcipotriene external ointment 0.005 % 1

calcipotriene external solution 0.005 % 1

calcipotriene-betameth diprop external ointment 0.005-0.064 %

1

calcitonin (salmon) nasal solution 200 unit/act 1 QL (4 per 28 days)

cal-citrate plus vitamin d oral tablet 250-100 mg-unit

1(CW)

calcitriol intravenous solution 1 mcg/ml 1

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

calcium + d3 oral tablet 600-200 mg-unit 1(CW)

calcium 1000 + d oral tablet 1000-800 mg-unit 1(CW)

calcium 500 + d oral tablet 500-125 mg-unit 1(CW)

calcium 500 + d3 oral tablet 500-600 mg-unit 1(CW)

calcium 500 +d oral tablet 500-400 mg-unit 1(CW)

calcium 500/d oral tablet chewable 500-400 mg-unit

1(CW)

calcium 500+d oral tablet 500-200 mg-unit 1(CW)

calcium 600 oral tablet 1500 (600 ca) mg, 600 mg 1(CW)

calcium 600/vitamin d oral tablet chewable 600-400 mg-unit

1(CW)


18

Drug Tier Notes

calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit, 600-800 mg-unit

1(CW)

calcium 600-d oral tablet 600-400 mg-unit 1(CW)

calcium acetate (phos binder) oral capsule 667 mg 1

calcium acetate (phos binder) oral tablet 667 mg 1

calcium antacid extra strength oral tablet chewable 750 mg

1(CW)

calcium carbonate antacid oral tablet 648 mg, 650 mg

1(CW)

calcium carbonate antacid oral tablet chewable 500 mg

1(CW)

calcium carbonate oral suspension 1250 (500 ca) mg/5ml

1(SO)

calcium carbonate oral tablet 1250 (500 ca) mg 1(CW)

calcium carbonate oral tablet chewable 1250 (500 ca) mg, 260 mg

1(CW)

calcium carbonate-vitamin d oral capsule 600-200 mg-unit

1(CW)

calcium carbonate-vitamin d oral tablet 500-400 mg-unit

1(CW)

calcium citrate + d oral tablet 250-200 mg-unit, 315-200 mg-unit, 315-250 mg-unit

1(CW)

calcium citrate + d3 oral tablet 200-250 mg-unit 1(CW)

calcium citrate oral tablet 200 mg 1(CW)

calcium citrate-vitamin d oral tablet 200-125 mg-unit

1(CW)

calcium oral tablet 500 mg, 600 mg 1(CW)

calcium oral tablet chewable 500-100 mg-unit 1(CW)

calcium plus vitamin d3 oral capsule 600-500 mg-unit

1(CW)

calcium-vitamin d oral tablet 600-200 mg-unit 1(CW)

calcium-vitamin d3 oral capsule 600-400 mg-unit 1(CW)

CALTRATE 600+D3 SOFT ORAL TABLET CHEWABLE 600-800 MG-UNIT

1(CW)

CAMILA ORAL TABLET 0.35 MG 1


19

Drug Tier Notes

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG

1

candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg 1 QL (62 per 31 days)

candesartan cilexetil oral tablet 32 mg 1 QL (31 per 31 days)

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg


CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

1

CAPRELSA ORAL TABLET 100 MG 1 PA; QL (62 per 31 days)

CAPRELSA ORAL TABLET 300 MG 1 PA; QL (31 per 31 days)

capsaicin arthritis relief external liquid 0.15 % 1(SO)

capsaicin external cream 0.025 %, 0.075 % 1(SO)

capsaicin hot patch external pad 0.025 % 1(CW)

capsaicin hp external cream 0.1 % 1(SO)

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

CAPZASIN-P EXTERNAL CREAM 0.035 % 1(CW)

CARBAGLU ORAL TABLET 200 MG 1

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

1

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

1

carbamazepine oral suspension 100 mg/5ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet chewable 100 mg 1

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

1


20

Drug Tier Notes

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

1

carbinoxamine maleate oral solution 4 mg/5ml 1

carbinoxamine maleate oral tablet 4 mg 1

carboplatin intravenous solution 150 mg/15ml 1

carisoprodol-aspirin oral tablet 200-325 mg 1 PA; HR; QL (248 per 31 days)

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg


carteolol hcl ophthalmic solution 1 % 1

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG


CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG


carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1

CASTIVA COOLING EXTERNAL LOTION 5-14 %

1(CW)

CASTIVA WARMING EXTERNAL LOTION 0.035 %

1(CW)

castor oil oil 1(CW)

castor oil oral oil 100 % 1(CW)

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG


caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1

cefaclor er oral tablet extended release 12 hour 500 mg

1

cefaclor oral capsule 250 mg, 500 mg 1

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

1

cefadroxil oral tablet 1 gm 1

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg

1

cefdinir oral capsule 300 mg 1


21

Drug Tier Notes

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefepime hcl injection solution reconstituted 1 gm, 2 gm

1

cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg

1

cefotetan disodium injection solution reconstituted 1 gm, 2 gm

1

cefoxitin sodium injection solution reconstituted 10 gm

1

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

1

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

1

cefpodoxime proxetil oral tablet 100 mg, 200 mg 1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefprozil oral tablet 250 mg, 500 mg 1

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

1

ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg

1

ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

1

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg

1

celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 QL (62 per 31 days)

celecoxib oral capsule 400 mg 1 QL (31 per 31 days)

CELONTIN ORAL CAPSULE 300 MG 1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cephalexin oral tablet 250 mg, 500 mg 1

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

1 PA


22

Drug Tier Notes

cetirizine hcl allergy child oral solution 5 mg/5ml 1(SO)

cetirizine hcl oral syrup 1 mg/ml 1(SO) QL (310 per 31 days)

cetirizine hcl oral tablet 10 mg, 5 mg 1(SO)

cetirizine hcl oral tablet chewable 10 mg, 5 mg 1(SO)

cetirizine-pseudoephedrine er oral tablet extended release 12 hour 5-120 mg

1(SO)

cevimeline hcl oral capsule 30 mg 1

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

1 PA

CHANTIX ORAL TABLET 0.5 MG 1 PA; QL (11 per 31 days)

CHANTIX ORAL TABLET 1 MG 1 PA; QL (174 per 84 days)

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42


cheratussin ac oral solution 100-10 mg/5ml 1(ND)

chest rub external ointment 4.8-1.2-2.6 % 1(CW)

childrens acetaminophen oral suspension 160 mg/5ml

1(SO)

childrens acetaminophen oral tablet dispersible 80 mg

1(SO)

childrens ibuprofen 100 oral suspension 100 mg/5ml

1(SO)

childrens loratadine oral syrup 5 mg/5ml 1(SO)

childrens mucus relief cough oral liquid 5-100 mg/5ml

1(SO)

childrens pepto oral tablet chewable 400 mg 1(CW)

childrens silfedrine oral liquid 15 mg/5ml 1(SO)

CHILDRENS SOOTHE ORAL TABLET CHEWABLE 400 MG

1(CW)

childs ibuprofen oral suspension 100 mg/5ml 1(SO)

chloramphenicol sod succinate intravenous solution reconstituted 1 gm

1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg


chlorhexidine gluconate external liquid 4 % 1(CW)


23

Drug Tier Notes

chlorhexidine gluconate mouth/throat solution 0.12 %

1

chloroquine phosphate oral tablet 250 mg, 500 mg 1

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorothiazide sodium intravenous solution reconstituted 500 mg

1

chlorpromazine hcl injection solution 50 mg/2ml 1

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

1

chlorpropamide oral tablet 100 mg, 250 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

chlorzoxazone oral tablet 500 mg 1 PA; HR; QL (186 per 31 days)

cholestyramine light oral packet 4 gm 1

cholestyramine light oral powder 4 gm/dose 1

chorionic gonadotropin intramuscular solution reconstituted 10000 unit

1 PA

CIALIS ORAL TABLET 2.5 MG, 5 MG 1 PA; QL (31 per 31 days)

ciclopirox external shampoo 1 % 1

ciclopirox external solution 8 % 1

ciclopirox olamine external cream 0.77 % 1

ciclopirox olamine external suspension 0.77 % 1

cilostazol oral tablet 100 mg, 50 mg 1

CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML

1 ST

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG 1 ST

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT


ciprofloxacin hcl ophthalmic solution 0.3 % 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

ciprofloxacin in d5w intravenous solution 200 mg/100ml

1

ciprofloxacin intravenous solution 400 mg/40ml 1

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

1


24

Drug Tier Notes

cisplatin intravenous solution 100 mg/100ml 1

citalopram hydrobromide oral solution 10 mg/5ml 1 QL (620 per 31 days)

citalopram hydrobromide oral tablet 10 mg, 40 mg 1 QL (31 per 31 days)

citalopram hydrobromide oral tablet 20 mg 1 QL (186 per 31 days)

CITRUCEL ORAL TABLET 500 MG 1(CW)

cladribine intravenous solution 10 mg/10ml 1

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

clarithromycin er oral tablet extended release 24 hour 500 mg

1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

clarithromycin oral tablet 250 mg, 500 mg 1

CLARITIN ALLERGY CHILDRENS ORAL SYRUP 5 MG/5ML

1(SO)

CLARITIN CHILDRENS ORAL TABLET CHEWABLE 5 MG

1(SO)

CLARITIN ORAL CAPSULE 10 MG 1(SO)

CLARITIN ORAL TABLET 10 MG 1(SO)

CLARITIN-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG

1(SO)

CLARITIN-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-240 MG

1(SO)

clemastine fumarate oral tablet 2.68 mg 1

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

1

clindamycin phos-benzoyl perox external gel 1-5 %

1

clindamycin phosphate external gel 1 % 1

clindamycin phosphate external lotion 1 % 1

clindamycin phosphate external solution 1 % 1

clindamycin phosphate external swab 1 % 1


25

Drug Tier Notes

clindamycin phosphate in d5w intravenous solution 600 mg/50ml

1

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml

1

clindamycin phosphate vaginal cream 2 % 1

CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %

1


1


1

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

1

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %

1


1


1


1


1

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

1


1


1

clobetasol propionate e external cream 0.05 % 1

clobetasol propionate external foam 0.05 % 1

clobetasol propionate external gel 0.05 % 1

clobetasol propionate external lotion 0.05 % 1

clobetasol propionate external ointment 0.05 % 1

clobetasol propionate external shampoo 0.05 % 1

clobetasol propionate external solution 0.05 % 1


26

Drug Tier Notes

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

1 PA; HR

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr


clopidogrel bisulfate oral tablet 75 mg 1 QL (31 per 31 days)

clorazepate dipotassium oral tablet 15 mg 1 QL (186 per 31 days)

clorazepate dipotassium oral tablet 3.75 mg 1 QL (744 per 31 days)

clorazepate dipotassium oral tablet 7.5 mg 1 QL (372 per 31 days)

clotrimazole 3 vaginal cream 2 % 1(SO)

clotrimazole af external cream 1 % 1(SO)

clotrimazole external cream 1 % 1

clotrimazole external solution 1 % 1

clotrimazole mouth/throat troche 10 mg 1

clotrimazole-7 vaginal cream 1 % 1(SO)

clotrimazole-betamethasone external cream 1-0.05 %

1

clotrimazole-betamethasone external lotion 1-0.05 %

1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

clozapine oral tablet dispersible 100 mg, 150 mg, 200 mg, 25 mg

1 ST

clozapine oral tablet dispersible 12.5 mg 1

COARTEM ORAL TABLET 20-120 MG 1 QL (24 per 31 days)

COLACE CLEAR ORAL CAPSULE 50 MG 1(CW)

COLACE ORAL CAPSULE 100 MG 1(CW)

colchicine oral tablet 0.6 mg 1

colchicine-probenecid oral tablet 0.5-500 mg 1

colestipol hcl oral granules 5 gm 1

colestipol hcl oral tablet 1 gm 1


27

Drug Tier Notes

colistimethate sodium injection solution reconstituted 150 mg

1 PA

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

1

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

1

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG


COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG


COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG


COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML

1

COMPLERA ORAL TABLET 200-25-300 MG 1 QL (31 per 31 days)

compro rectal suppository 25 mg 1

cool n heat external stick 10-30 % 1(CW)

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML


COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML


cortisone acetate oral tablet 25 mg 1

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

1 ST

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

1 ST

COTELLIC ORAL TABLET 20 MG 1 PA; LA

cough relief oral liquid 15 mg/5ml 1(SO)

cough syrup oral syrup 100 mg/5ml 1(SO)

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

1

CREO-TERPIN ORAL SYRUP 10 MG/15ML 1(SO)

CRIXIVAN ORAL CAPSULE 200 MG 1 QL (465 per 31 days)


28

Drug Tier Notes

CRIXIVAN ORAL CAPSULE 400 MG 1 QL (279 per 31 days)

cromolyn sodium inhalation nebulization solution 20 mg/2ml

1

cromolyn sodium ophthalmic solution 4 % 1

cromolyn sodium oral concentrate 100 mg/5ml 1

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

1

cvs antacid supreme oral suspension 400-135 mg/5ml

1(SO)

cvs b-12 oral tablet dispersible 1500 mcg 1(CW)

cvs fluticasone propionate nasal suspension 50 mcg/act

1(CW)

cvs gauze sterile pad 2"x2" 1

cvs glucose bits oral tablet chewable 1 gm 1(CW)

cvs hot steam inhalation liquid 6.2 % 1(CW)

cvs hydrocortisone acetate external cream 0.5 % 1(CW)

cvs laxative dietary supplemnt oral tablet 500 mg 1(CW)

cvs nasal mist nasal aerosol solution 0.9 % 1(CW)

cvs natural fiber supplement oral packet 58.6 % 1(CW)

cvs senna-extra oral tablet 17.2 mg 1(CW)

cvs slow release iron oral tablet extended release 143 (45 fe) mg

1(CW)

cvs sore muscle rub external gel 2.5 % 1(CW)

cvs stool softener oral capsule 50 mg 1(CW)

cvs targeted acne spot external cream 2.5 % 1(SO)

cyanocobalamin injection solution 1000 mcg/ml 1(ND)

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

1

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg 1 PA; HR; QL (93 per 31 days)

cyclobenzaprine hcl oral tablet 7.5 mg 1 PA; HR; QL (186 per 31 days)

cyclophosphamide oral capsule 25 mg, 50 mg 1

cyclosporine intravenous solution 50 mg/ml 1


29

Drug Tier Notes

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

1

cyclosporine modified oral solution 100 mg/ml 1

cyclosporine oral capsule 100 mg, 25 mg 1

cyproheptadine hcl oral syrup 2 mg/5ml 1 PA; HR

cyproheptadine hcl oral tablet 4 mg 1 PA; HR

CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

1

CYSTADANE ORAL POWDER 1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 1

CYSTARAN OPHTHALMIC SOLUTION 0.44 %


cytarabine (pf) injection solution 100 mg/ml 1

cytarabine injection solution 20 mg/ml 1

D3 DOTS ORAL TABLET DISPERSIBLE 2000 UNIT

1(CW)

dacarbazine intravenous solution reconstituted 200 mg

1

DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG

1 PA

DALIRESP ORAL TABLET 500 MCG 1 QL (31 per 31 days)

danazol oral capsule 100 mg, 200 mg, 50 mg 1

dapsone oral tablet 100 mg, 25 mg 1

DAPTACEL INTRAMUSCULAR SUSPENSION 10-15-5

1

daptomycin intravenous solution reconstituted 500 mg

1

DARAPRIM ORAL TABLET 25 MG 1

daunorubicin hcl intravenous injectable 5 mg/ml 1

daytime cough oral liquid 15 mg/15ml 1(SO)

DEBLITANE ORAL TABLET 0.35 MG 1

DEBROX OTIC SOLUTION 6.5 % 1(CW)

DECARA ORAL CAPSULE 25000 UNIT 1(CW)

decitabine intravenous solution reconstituted 50 mg

1


30

Drug Tier Notes

DELSYM COUGH/CHEST CONGEST DM ORAL LIQUID 5-100 MG/5ML

1(SO)

DELYLA ORAL TABLET 0.1-20 MG-MCG 1

DEMSER ORAL CAPSULE 250 MG 1

DEPEN TITRATABS ORAL TABLET 250 MG 1

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

1

DERMAFUNGAL EXTERNAL OINTMENT 2 % 1(SO)

DESCOVY ORAL TABLET 200-25 MG 1

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 PA; HR

desloratadine oral tablet 5 mg 1

desloratadine oral tablet dispersible 2.5 mg, 5 mg 1

desmopressin ace spray refrig nasal solution 0.01 %

1

desmopressin acetate injection solution 4 mcg/ml 1

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

1

desonide external cream 0.05 % 1

desonide external lotion 0.05 % 1

desonide external ointment 0.05 % 1

desoximetasone external cream 0.05 %, 0.25 % 1

desoximetasone external gel 0.05 % 1

desoximetasone external ointment 0.25 % 1

desvenlafaxine er oral tablet extended release 24 hour 100 mg, 50 mg

1

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

1

DEX4 GLUCOSE GO-POUCH ORAL GEL 15 GM/33GM

1(CW)

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

1

dexamethasone oral elixir 0.5 mg/5ml 1


31

Drug Tier Notes

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

1

dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

1

DEXEDRINE ORAL TABLET 10 MG 1 QL (186 per 31 days)

DEXEDRINE ORAL TABLET 5 MG 1 QL (155 per 31 days)

dexmethylphenidate hcl oral tablet 2.5 mg 1 QL (248 per 31 days)

dexmethylphenidate hcl oral tablet 5 mg 1 QL (124 per 31 days)

dexrazoxane intravenous solution reconstituted 250 mg

1

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg






dextroamphetamine sulfate oral tablet 10 mg 1 QL (186 per 31 days)

dextroamphetamine sulfate oral tablet 5 mg 1 QL (155 per 31 days)

dextrose in lactated ringers intravenous solution 5 %

1

dextrose intravenous solution 10 %, 5 % 1

dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

1

DIABETIC TUSSIN DM ORAL LIQUID 100-10 MG/5ML

1(SO)

DIABETIC TUSSIN ORAL LIQUID 100 MG/5ML

1(SO)

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML


diazepam oral solution 1 mg/ml 1 QL (1240 per 31 days)

diazepam oral tablet 10 mg 1 QL (124 per 31 days)




32

Drug Tier Notes

diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

1

diclofenac sodium ophthalmic solution 0.1 % 1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

diclofenac sodium transdermal gel 1 % 1 PA

diclofenac sodium transdermal gel 3 % 1 PA; QL (100 per 31 days)

diclofenac sodium transdermal solution 1.5 % 1

dicloxacillin sodium oral capsule 250 mg, 500 mg 1

dicyclomine hcl intramuscular solution 10 mg/ml 1

dicyclomine hcl oral capsule 10 mg 1

dicyclomine hcl oral solution 10 mg/5ml 1

dicyclomine hcl oral tablet 20 mg 1

didanosine oral capsule delayed release 125 mg 1 QL (93 per 31 days)

didanosine oral capsule delayed release 200 mg 1 QL (62 per 31 days)

didanosine oral capsule delayed release 250 mg, 400 mg


diflorasone diacetate external cream 0.05 % 1

diflorasone diacetate external ointment 0.05 % 1

diflunisal oral tablet 500 mg 1

DIGITEK ORAL TABLET 125 MCG 1 QL (31 per 31 days)

DIGITEK ORAL TABLET 250 MCG 1 PA; HR; QL (31 per 31 days)

digoxin injection solution 0.25 mg/ml 1 PA; HR

digoxin oral solution 0.05 mg/ml 1 PA; HR

digoxin oral tablet 125 mcg 1 QL (31 per 31 days)

digoxin oral tablet 250 mcg 1 PA; HR; QL (31 per 31 days)

dihydroergotamine mesylate injection solution 1 mg/ml

1

DILANTIN ORAL CAPSULE 30 MG 1

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 360 mg, 420 mg



33

Drug Tier Notes

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg


diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

1

diltiazem hcl intravenous solution 50 mg/10ml 1

diltiazem hcl intravenous solution reconstituted 100 mg

1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

1

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg


DIPENTUM ORAL CAPSULE 250 MG 1

diphenhydramine hcl (sleep) oral tablet 50 mg 1(SO)

diphenhydramine hcl injection solution 50 mg/ml 1

diphenhydramine hcl oral capsule 25 mg, 50 mg 1(SO)

diphenhydramine hcl oral elixir 12.5 mg/5ml 1

diphenhydramine hcl oral liquid 12.5 mg/5ml 1(SO)

diphenhydramine hcl oral tablet 25 mg 1(SO)

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml

1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

disopyramide phosphate oral capsule 100 mg, 150 mg

1 PA; HR

disulfiram oral tablet 250 mg, 500 mg 1

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

1

divalproex sodium oral capsule delayed release sprinkle 125 mg

1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1

docetaxel intravenous concentrate 80 mg/4ml 1

docetaxel intravenous solution 80 mg/8ml 1


34

Drug Tier Notes

docusate sodium oral capsule 100 mg, 250 mg 1(CW)

docusate sodium oral liquid 50 mg/5ml 1(CW)

docusate sodium oral syrup 60 mg/15ml 1(CW)

docusate sodium oral tablet 100 mg 1(CW)

DOCUSOL KIDS RECTAL ENEMA 100 MG/5ML

1(CW)

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1

donepezil hcl oral tablet 10 mg 1 QL (62 per 31 days)

donepezil hcl oral tablet 5 mg 1 QL (31 per 31 days)

donepezil hcl oral tablet dispersible 10 mg 1 QL (62 per 31 days)

donepezil hcl oral tablet dispersible 5 mg 1 QL (31 per 31 days)

dorzolamide hcl ophthalmic solution 2 % 1 QL (10 per 31 days)

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml


doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 PA; HR

doxepin hcl oral concentrate 10 mg/ml 1 PA; HR

doxercalciferol intravenous solution 4 mcg/2ml 1

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

1

doxorubicin hcl intravenous solution 2 mg/ml 1

doxorubicin hcl liposomal intravenous injectable 2 mg/ml

1

DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1

doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline hyclate oral tablet delayed release 50 mg

1

doxycycline monohydrate oral capsule 100 mg, 50 mg

1

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1


35

Drug Tier Notes

DRAMAMINE LESS DROWSY ORAL TABLET 25 MG

1(SO)

DRAMAMINE ORAL TABLET 50 MG 1(SO)

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 PA; QL (62 per 31 days)

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

1

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg


DURAFLEX COMFORT EXTERNAL GEL 1(CW)

duramorph injection solution 0.5 mg/ml, 1 mg/ml 1

DUREZOL OPHTHALMIC EMULSION 0.05 % 1

dutasteride oral capsule 0.5 mg 1 QL (31 per 31 days)

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1 QL (31 per 31 days)

ear wax drops otic solution 6.5 % 1(CW)

econazole nitrate external cream 1 % 1

ECONTRA EZ ORAL TABLET 1.5 MG 1(SO)

EDURANT ORAL TABLET 25 MG 1 QL (31 per 31 days)

ELIDEL EXTERNAL CREAM 1 % 1 ST

ELIPHOS ORAL TABLET 667 MG 1

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 1

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG

1 PA

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 7.5 MG

1

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG


EMCYT ORAL CAPSULE 140 MG 1 PA

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

1

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

1


36

Drug Tier Notes

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR


EMTRIVA ORAL CAPSULE 200 MG 1 QL (31 per 31 days)

EMTRIVA ORAL SOLUTION 10 MG/ML 1 QL (705 per 28 days)

EMVERM ORAL TABLET CHEWABLE 100 MG

1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

1

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

1

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

1

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


ENEMEEZ MINI RECTAL ENEMA 283 MG 1(CW)

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

1

enoxaparin sodium injection solution 300 mg/3ml 1 QL (35 per 31 days)

enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml


enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml


enoxaparin sodium subcutaneous solution 30 mg/0.3ml






ENPRESSE-28 ORAL TABLET 1

entacapone oral tablet 200 mg 1 QL (310 per 31 days)

entecavir oral tablet 0.5 mg, 1 mg 1 PA


37

Drug Tier Notes

enulose oral solution 10 gm/15ml 1

EPCLUSA ORAL TABLET 400-100 MG 1 PA

epinastine hcl ophthalmic solution 0.05 % 1

EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML

1

EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML


EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML

1

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML

1

epirubicin hcl intravenous solution 200 mg/100ml 1

epitol oral tablet 200 mg 1

EPIVIR HBV ORAL SOLUTION 5 MG/ML 1

eplerenone oral tablet 25 mg, 50 mg 1

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

1 PA

eprosartan mesylate oral tablet 600 mg 1 QL (31 per 31 days)

eq allergy relief (cetirizine) oral solution 1 mg/ml 1(SO)

eq allergy relief childrens oral elixir 12.5 mg/5ml 1(SO)

eq aspirin oral tablet delayed release 500 mg 1(SO)

eq therapeutic moisturizing external cream 1(CW)

eql calcium/vitamin d oral capsule 600-100 mg-unit

1(CW)

EQUALACTIN ORAL TABLET CHEWABLE 625 MG

1(CW)

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

1 PA

ergoloid mesylates oral tablet 1 mg 1

ERIVEDGE ORAL CAPSULE 150 MG 1 PA; QL (28 per 28 days)

ERRIN ORAL TABLET 0.35 MG 1

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT



38

Drug Tier Notes

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

1

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

1

ERYTHROCIN STEARATE ORAL TABLET 250 MG

1

erythromycin base oral tablet 250 mg, 500 mg 1

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml

1

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin external gel 2 % 1

erythromycin external solution 2 % 1

erythromycin ophthalmic ointment 5 mg/gm 1

ESBRIET ORAL CAPSULE 267 MG 1 PA

escitalopram oxalate oral solution 5 mg/5ml 1 QL (620 per 31 days)

escitalopram oxalate oral tablet 10 mg 1 QL (47 per 31 days)

escitalopram oxalate oral tablet 20 mg, 5 mg 1 QL (31 per 31 days)

esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg

1

esomeprazole sodium intravenous solution reconstituted 20 mg, 40 mg

1

ESTRACE VAGINAL CREAM 0.1 MG/GM 1

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA; HR

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

1

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

1

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1

ethambutol hcl oral tablet 100 mg, 400 mg 1

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5ml 1


39

Drug Tier Notes

ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg

1

etodolac oral capsule 200 mg 1 QL (62 per 31 days)

etodolac oral capsule 300 mg 1 QL (93 per 31 days)

etodolac oral tablet 400 mg, 500 mg 1 QL (62 per 31 days)

etoposide intravenous solution 500 mg/25ml 1

EURAX EXTERNAL CREAM 10 % 1

EURAX EXTERNAL LOTION 10 % 1

EVOTAZ ORAL TABLET 300-150 MG 1

EXEL COMFORT POINT PEN NEEDLE 29G X 12MM

1

exel pen needles 1/2" 29g x 12mm 1

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR


exemestane oral tablet 25 mg 1 QL (62 per 31 days)

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

1 PA

extra strength acetaminophen oral capsule 500 mg 1(SO)

eye itch relief ophthalmic solution 0.025 % 1(SO)

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG

1 PA

FALLBACK SOLO ORAL TABLET 1.5 MG 1(SO)

FALMINA ORAL TABLET 0.1-20 MG-MCG 1

famciclovir oral tablet 125 mg, 250 mg, 500 mg 1

famotidine intravenous solution 20 mg/2ml 1

famotidine oral suspension reconstituted 40 mg/5ml

1

famotidine oral tablet 20 mg, 40 mg 1

famotidine premixed intravenous solution 20-0.9 mg/50ml-%

1

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG


FARESTON ORAL TABLET 60 MG 1 PA; QL (31 per 31 days)


40

Drug Tier Notes

FARXIGA ORAL TABLET 10 MG, 5 MG 1 QL (31 per 31 days)

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

1 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML


felbamate oral suspension 600 mg/5ml 1

felbamate oral tablet 400 mg, 600 mg 1

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg


femynor oral tablet 0.25-35 mg-mcg 1

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg


fenofibrate oral capsule 150 mg, 50 mg 1

fenofibrate oral tablet 145 mg, 160 mg 1 QL (31 per 31 days)

fenofibrate oral tablet 48 mg, 54 mg 1 QL (62 per 31 days)

fenofibric acid oral capsule delayed release 135 mg, 45 mg

1

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; ST; QL (11 per 33 days)

FERRIPROX ORAL TABLET 500 MG 1

ferrous gluconate oral tablet 240 (27 fe) mg, 324 (37.5 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg

1(CW)

ferrous sulfate er oral tablet extended release 140 (45 fe) mg

1(CW)

ferrous sulfate oral syrup 300 (60 fe) mg/5ml 1(CW)

ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg 1(SO) PA

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

1(CW)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

1 ST

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG

1 ST


41

Drug Tier Notes

FEVERALL ADULTS RECTAL SUPPOSITORY 650 MG

1(SO)

FEVERALL CHILDRENS RECTAL SUPPOSITORY 120 MG

1(SO)

FEVERALL INFANTS RECTAL SUPPOSITORY 80 MG

1(SO)

FEVERALL JUNIOR STRENGTH RECTAL SUPPOSITORY 325 MG

1(SO)

fexofenadine hcl oral tablet 180 mg, 60 mg 1(CW)

fiber laxative oral capsule 0.52 gm 1(CW)

fiber oral powder 1(CW)

fiber oral tablet 625 mg 1(CW)

fiber therapy oral tablet 500 mg 1(CW)

finasteride oral tablet 5 mg 1 QL (31 per 31 days)

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML

1 PA

fish oil maximum strength oral capsule delayed release 1200 mg

1(CW)

fish oil oral capsule 1000 mg, 1200 mg, 435 mg 1(CW)

fish oil oral tablet chewable 875 mg 1(CW)

FISH OIL PEARLS ORAL CAPSULE 150 MG, 180 MG, 183.33 MG

1(CW)

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

1

FLEET ENEMA RECTAL ENEMA 7-19 GM/118ML

1(CW)

FLEXALL EXTERNAL GEL 16 %, 7 % 1(CW)

FLEXALL ULTRA PLUS EXTERNAL GEL 3.1-16-10 %

1(CW)

FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 MCG/ACT

1(CW)

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT



42

Drug Tier Notes

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT


fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

1

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

1

fluconazole oral tablet 100 mg, 150 mg, 50 mg 1

flucytosine oral capsule 250 mg, 500 mg 1

fludarabine phosphate intravenous solution reconstituted 50 mg

1

fludrocortisone acetate oral tablet 0.1 mg 1

flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (50 per 31 days)

fluocinolone acetonide body external oil 0.01 % 1

fluocinolone acetonide external cream 0.01 %, 0.025 %

1

fluocinolone acetonide external ointment 0.025 % 1

fluocinolone acetonide external solution 0.01 % 1

fluocinolone acetonide otic oil 0.01 % 1

fluocinonide external cream 0.1 % 1

fluocinonide external gel 0.05 % 1

fluocinonide external ointment 0.05 % 1

fluocinonide external solution 0.05 % 1

fluorometholone ophthalmic suspension 0.1 % 1

fluorouracil external cream 5 % 1

fluorouracil external solution 2 %, 5 % 1

fluorouracil intravenous solution 2.5 gm/50ml 1

fluoxetine hcl oral capsule 10 mg 1 QL (186 per 31 days)



fluoxetine hcl oral capsule delayed release 90 mg 1 QL (4 per 28 days)

fluoxetine hcl oral solution 20 mg/5ml 1 QL (620 per 31 days)

fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg 1 QL (31 per 31 days)


43

Drug Tier Notes

fluphenazine decanoate injection solution 25 mg/ml

1

fluphenazine hcl injection solution 2.5 mg/ml 1

fluphenazine hcl oral concentrate 5 mg/ml 1

fluphenazine hcl oral elixir 2.5 mg/5ml 1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

1

flurazepam hcl oral capsule 15 mg, 30 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1 QL (93 per 31 days)

flurbiprofen sodium ophthalmic solution 0.03 % 1

flutamide oral capsule 125 mg 1

fluticasone propionate external cream 0.05 % 1

fluticasone propionate external lotion 0.05 % 1

fluticasone propionate external ointment 0.005 % 1

fluticasone propionate nasal suspension 50 mcg/act


fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg


fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg


folic acid oral tablet 1 mg 1(ND)

folic acid oral tablet 400 mcg, 800 mcg 1(CW)

fomepizole intravenous solution 1 gm/ml 1

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml


FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

1 PA; QL (2.4 per 28 days)

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

1

fosphenytoin sodium injection solution 100 mg pe/2ml

1


44

Drug Tier Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

1

FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

1

FUNGICURE INTENSIVE/NAILGUARD EXTERNAL SOLUTION 1 %

1(SO)

FUNGOID TINCTURE EXTERNAL KIT 2 % 1(SO)

FUNGOID TINCTURE EXTERNAL SOLUTION 2 %

1(SO)

furosemide injection solution 10 mg/ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG


FYCOMPA ORAL SUSPENSION 0.5 MG/ML 1 QL (744 per 31 days)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 QL (279 per 31 days)

gabapentin oral solution 250 mg/5ml 1

gabapentin oral tablet 600 mg, 800 mg 1 QL (186 per 31 days)

GABITRIL ORAL TABLET 12 MG, 16 MG 1

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

1

galantamine hydrobromide oral solution 4 mg/ml 1

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

1

GAMASTAN S/D INTRAMUSCULAR INJECTABLE

1

GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML

1

ganciclovir sodium intravenous solution reconstituted 500 mg

1

GARDASIL 9 INTRAMUSCULAR SUSPENSION

1


45

Drug Tier Notes

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

1

GARDASIL INTRAMUSCULAR SUSPENSION 1 QL (3 per 365 days)

gatifloxacin ophthalmic solution 0.5 % 1

GATTEX SUBCUTANEOUS KIT 5 MG 1

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM

1

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM

1

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

1

GAVISCON EXTRA STRENGTH ORAL SUSPENSION 254-237.5 MG/5ML

1(SO)

GAVISCON ORAL SUSPENSION 95-358 MG/15ML

1(SO)

GELUSIL ORAL TABLET CHEWABLE 200-200-25 MG

1(SO)

gemcitabine hcl intravenous solution reconstituted 1 gm

1

gemfibrozil oral tablet 600 mg 1 QL (62 per 31 days)

generlac oral solution 10 gm/15ml 1

GENGRAF ORAL CAPSULE 100 MG, 25 MG 1

gengraf oral capsule 50 mg 1

GENGRAF ORAL SOLUTION 100 MG/ML 1

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%

1

gentamicin sulfate external cream 0.1 % 1

gentamicin sulfate external ointment 0.1 % 1

gentamicin sulfate injection solution 40 mg/ml 1

gentamicin sulfate intravenous solution 10 mg/ml 1

gentamicin sulfate ophthalmic ointment 0.3 % 1

gentamicin sulfate ophthalmic solution 0.3 % 1

GENTEAL SEVERE OPHTHALMIC GEL 0.3 % 1(SO)


46

Drug Tier Notes

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

1 ST

GERI-HYDROLAC 5 EXTERNAL LOTION 5 % 1(CW)

geri-mucil oral powder 68 % 1(CW)

GIANVI ORAL TABLET 3-0.02 MG 1

GILDAGIA ORAL TABLET 0.4-35 MG-MCG 1

GILENYA ORAL CAPSULE 0.5 MG 1 PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG


GLEEVEC ORAL TABLET 100 MG 1 PA; QL (186 per 31 days)

GLEEVEC ORAL TABLET 400 MG 1 PA; QL (62 per 31 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG

1

glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

glipizide oral tablet 10 mg, 5 mg 1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

1

global alcohol prep ease pad 70 % 1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

1

GLUCAGON EMERGENCY INJECTION KIT 1 MG

1

glucose oral gel 40 % 1(CW)

glucose oral liquid , 15 gm/59ml 1(CW)

glucose oral tablet chewable 4 gm, 4-6 gm-mg 1(CW)

glycopyrrolate injection solution 4 mg/20ml 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

gnp cold & hot extra strength external ointment 7.6-29 %

1(CW)

gnp fish oil oral capsule delayed release 840 mg 1(CW)

gnp iron oral tablet 200 (65 fe) mg 1(CW)

gnp melatonin maximum strength oral tablet 5 mg 1(CW)


47

Drug Tier Notes

gnp motion sickness relief oral tablet 25 mg 1(SO)

gnp vitamin d-400 oral tablet 90-400 mg-unit 1(CW)

GOLD BOND PAIN RELIEVING FOOT EXTERNAL CREAM 16 %

1(CW)

GORDONS UREA EXTERNAL OINTMENT 22 %, 40 %

1(CW)

granisetron hcl intravenous solution 0.1 mg/ml, 1 mg/ml


granisetron hcl oral tablet 1 mg 1 QL (62 per 31 days)

griseofulvin microsize oral suspension 125 mg/5ml 1

griseofulvin microsize oral tablet 500 mg 1

guaifenesin oral syrup 100 mg/5ml 1(SO)

guaifenesin oral tablet 200 mg, 400 mg 1(CW)

guaifenesin-codeine oral syrup 100-10 mg/5ml 1(ND)

guaifenesin-dm oral syrup 100-10 mg/5ml 1(SO)

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

1 PA

guanfacine hcl oral tablet 1 mg, 2 mg 1

guanidine hcl oral tablet 125 mg 1

GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % 1(SO)

GYNE-LOTRIMIN VAGINAL CREAM 1 % 1(SO)

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML

1 PA

halobetasol propionate external cream 0.05 % 1

halobetasol propionate external ointment 0.05 % 1

haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

1

haloperidol lactate injection solution 5 mg/ml 1

haloperidol lactate oral concentrate 2 mg/ml 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1

HARVONI ORAL TABLET 90-400 MG 1 PA

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

1


48

Drug Tier Notes

hemorrhoidal cooling rectal gel 0.25-50 % 1(CW)

hemorrhoidal external pad 50 % 1(CW)

hemorrhoidal rectal cream 1-0.25-14.4-15 % 1(CW)

hemorrhoidal rectal ointment 0.25-14-74.9 %, 0.25-3-14-71.9 %

1(CW)

hemorrhoidal rectal suppository 0.25-3-85.5 %, 0.25-88.44 %

1(CW)

heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-%

1

heparin sod (porcine) in d5w intravenous solution 100 unit/ml

1

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

1

HEPATAMINE INTRAVENOUS SOLUTION 8 %

1

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 440 MG

1

HETLIOZ ORAL CAPSULE 20 MG 1 QL (31 per 31 days)

HEXALEN ORAL CAPSULE 50 MG 1 PA

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

1

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

1

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

1

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

1

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

1

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

1

hydralazine hcl injection solution 20 mg/ml 1


49

Drug Tier Notes

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

HYDROCIL ORAL PACKET 95 % 1(CW)

HYDROCIL ORAL POWDER 95 % 1(CW)

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

1 QL (5683 per 31 days)

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 QL (186 per 31 days)

hydrocortisone acetate external cream 1 % 1(CW)

hydrocortisone acetate rectal suppository 25 mg, 30 mg

1(CW)

hydrocortisone butyr lipo base external cream 0.1 %

1

hydrocortisone butyrate external ointment 0.1 % 1

hydrocortisone butyrate external solution 0.1 % 1

hydrocortisone external cream 0.5 % 1(CW)

hydrocortisone external cream 1 %, 2.5 % 1

hydrocortisone external lotion 1 % 1(SO)

hydrocortisone external lotion 2.5 % 1

hydrocortisone external ointment 0.5 % 1(SO)

hydrocortisone external ointment 1 %, 2.5 % 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

hydrocortisone rectal cream 1 % 1(SO)

hydrocortisone rectal enema 100 mg/60ml 1

hydrocortisone valerate external cream 0.2 % 1

hydrocortisone valerate external ointment 0.2 % 1

hydrocortisone-acetic acid otic solution 1-2 % 1

hydrocortisone-aloe external cream 1 % 1(SO)


50

Drug Tier Notes

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg


hydromorphone hcl injection solution 2 mg/ml 1

hydromorphone hcl oral liquid 1 mg/ml 1 QL (1984 per 31 days)

hydromorphone hcl oral tablet 2 mg, 4 mg 1 QL (372 per 31 days)

hydromorphone hcl oral tablet 8 mg 1 QL (248 per 31 days)

hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml

1

hydroxychloroquine sulfate oral tablet 200 mg 1

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

1 PA

hydroxyurea oral capsule 500 mg 1

hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml

1 PA; HR

hydroxyzine hcl oral syrup 10 mg/5ml 1 PA; HR

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; HR

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

1 PA; HR

HYPERRAB S/D INTRAMUSCULAR INJECTABLE 150 UNIT/ML

1

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


ibandronate sodium intravenous solution 3 mg/3ml 1

ibandronate sodium oral tablet 150 mg 1 QL (1 per 28 days)

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

1 PA

ibuprofen junior strength oral tablet chewable 100 mg

1(SO)

ibuprofen oral capsule 200 mg 1(SO)

ibuprofen oral suspension 100 mg/5ml 1 QL (5000 per 31 days)

ibuprofen oral tablet 200 mg 1(SO)

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 QL (124 per 31 days)

ICAPS LUTEIN & OMEGA-3 ORAL CAPSULE 1(CW)


51

Drug Tier Notes

ICAPS LUTEIN & ZEAXANTHIN ORAL TABLET DELAYED RELEASE

1(CW)

ice blue external gel 2 % 1(CW)

ICLUSIG ORAL TABLET 15 MG, 45 MG 1 PA

ICY HOT EXTERNAL STICK 10-30 % 1(CW)

ICY HOT NATURALS EXTERNAL CREAM 7.5 %

1(CW)

ICY HOT PAIN RELIEVING EXTERNAL GEL 2.5 %

1(CW)

ICY HOT PM EXTERNAL PATCH 0.025-5 % 1(CW)

ICY HOT POWER EXTERNAL GEL 16 % 1(CW)

idarubicin hcl intravenous solution 10 mg/10ml 1

ifosfamide intravenous solution reconstituted 1 gm 1

ILARIS SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG

1 PA

ILEVRO OPHTHALMIC SUSPENSION 0.3 % 1

IMBRUVICA ORAL CAPSULE 140 MG 1 PA; QL (124 per 31 days)

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; HR

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

1 PA; HR

imiquimod external cream 5 % 1

IMODIUM A-D ORAL CAPSULE 2 MG 1(CW)

IMODIUM A-D ORAL TABLET 2 MG 1(CW)

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

1

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

1 PA

indapamide oral tablet 1.25 mg, 2.5 mg 1

indomethacin er oral capsule extended release 75 mg


indomethacin oral capsule 25 mg, 50 mg 1 PA; HR

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

1


52

Drug Tier Notes

INLYTA ORAL TABLET 1 MG 1 PA; QL (186 per 31 days)

INLYTA ORAL TABLET 5 MG 1 PA; QL (62 per 31 days)

INTELENCE ORAL TABLET 100 MG, 25 MG 1 QL (124 per 31 days)

INTELENCE ORAL TABLET 200 MG 1 QL (62 per 31 days)

intense cough reliever oral liquid 20-300 mg/5ml, 30-200 mg/5ml

1(SO)

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

1 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

1 PA

INTROVALE ORAL TABLET 0.15-0.03 MG 1

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

1

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 39 MG/0.25ML, 78 MG/0.5ML


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 234 MG/1.5ML


INVIRASE ORAL CAPSULE 200 MG 1 QL (310 per 31 days)

INVIRASE ORAL TABLET 500 MG 1 QL (124 per 31 days)

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG 1 QL (31 per 31 days)

IPOL INJECTION INJECTABLE 1

ipratropium bromide inhalation solution 0.02 % 1

ipratropium bromide nasal solution 0.03 % 1 QL (62 per 31 days)

ipratropium bromide nasal solution 0.06 % 1 QL (31 per 31 days)

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

1

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 QL (31 per 31 days)

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg



53

Drug Tier Notes

IRESSA ORAL TABLET 250 MG 1 PA

irinotecan hcl intravenous solution 100 mg/5ml 1

iron (ferrous gluconate) oral tablet 256 (28 fe) mg 1(CW)

iron oral tablet 90 (18 fe) mg 1(SO) PA

ISENTRESS ORAL PACKET 100 MG 1

ISENTRESS ORAL TABLET 400 MG 1 QL (124 per 31 days)

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG


isoniazid injection solution 100 mg/ml 1

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1

isosorbide dinitrate er oral tablet extended release 40 mg

1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

isradipine oral capsule 2.5 mg, 5 mg 1

ISTODAX INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

1 PA

itraconazole oral capsule 100 mg 1 PA

ivermectin oral tablet 3 mg 1

IXIARO INTRAMUSCULAR SUSPENSION 1

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG



54

Drug Tier Notes

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


JINTELI ORAL TABLET 1-5 MG-MCG 1

jock itch spray external aerosol powder 1 % 1(SO)

JOLIVETTE ORAL TABLET 0.35 MG 1

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG 1

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG 1

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

1 PA

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1 PA

KALETRA ORAL TABLET 100-25 MG 1 QL (310 per 31 days)

KALETRA ORAL TABLET 200-50 MG 1 QL (155 per 31 days)

KALYDECO ORAL PACKET 50 MG, 75 MG 1 PA

KALYDECO ORAL TABLET 150 MG 1 PA

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

1

KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG


kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

1

kcl-lactated ringers-d5w intravenous solution 20 meq/l

1

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG 1

KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG

1


55

Drug Tier Notes

ketoconazole external cream 2 % 1

ketoconazole external shampoo 2 % 1

ketoconazole oral tablet 200 mg 1

ketoprofen oral capsule 50 mg 1 QL (186 per 31 days)

ketoprofen oral capsule 75 mg 1 QL (124 per 31 days)

ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml

1 PA; HR

ketorolac tromethamine intramuscular solution 60 mg/2ml

1 PA; HR

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

1

ketorolac tromethamine oral tablet 10 mg 1 PA; HR; QL (20 per 5 days)

ketotifen fumarate ophthalmic solution 0.025 % 1(SO)

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

1 PA

KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

1 PA

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5)

1

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

1 ST

KINRIX INTRAMUSCULAR SUSPENSION 1

KIONEX ORAL POWDER 1

KISQALI 200 DOSE ORAL TABLET 200 MG 1 PA



KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

1

klor-con m10 oral tablet extended release 10 meq 1

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

1

klor-con m20 oral tablet extended release 20 meq 1

KONSYL ORAL PACKET 100 %, 28.3 %, 60.3 %, 71.67 %

1(CW)

KONSYL ORAL POWDER 60.3 %, 71.67 % 1(CW)


56

Drug Tier Notes

KONSYL-D ORAL POWDER 52.3 % 1(CW)

KORLYM ORAL TABLET 300 MG 1 PA

KUVAN ORAL PACKET 100 MG, 500 MG 1 PA

KUVAN ORAL TABLET SOLUBLE 100 MG 1 PA

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML


KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG

1

labetalol hcl intravenous solution 5 mg/ml 1

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1

LAC-HYDRIN FIVE EXTERNAL LOTION 5 % 1(CW)

lactated ringers intravenous solution 1

lactated ringers irrigation solution 1

lactulose oral solution 10 gm/15ml 1

LAMISIL AF DEFENSE EXTERNAL AEROSOL POWDER 1 %

1(SO)

lamivudine oral solution 10 mg/ml 1 QL (992 per 31 days)

lamivudine oral tablet 100 mg 1

lamivudine oral tablet 150 mg 1 QL (62 per 31 days)

lamivudine oral tablet 300 mg 1 QL (31 per 31 days)

lamivudine-zidovudine oral tablet 150-300 mg 1 QL (62 per 31 days)

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

1

lansoprazole capsule delayed release 15 mg oral (rx) 15 mg

1(CW)

lansoprazole oral capsule delayed release 15 mg, 30 mg

1

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

1


57

Drug Tier Notes

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

1

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG 1

LARIN 1/20 ORAL TABLET 1-20 MG-MCG 1

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG 1

larissia oral tablet 0.1-20 mg-mcg 1

LARTRUVO INTRAVENOUS SOLUTION 500 MG/50ML

1 PA

latanoprost ophthalmic solution 0.005 % 1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

1

laxative pills oral tablet 15 mg, 25 mg 1(CW)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT


LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG 1

leflunomide oral tablet 10 mg, 20 mg 1 QL (31 per 31 days)

LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG

1 PA

LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG

1 PA

LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG

1 PA

LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG

1 PA

LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG

1 PA

LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG

1 PA

LESSINA ORAL TABLET 0.1-20 MG-MCG 1

LETAIRIS ORAL TABLET 10 MG, 5 MG 1 QL (31 per 31 days)

letrozole oral tablet 2.5 mg 1 QL (31 per 31 days)

leucovorin calcium injection solution reconstituted 100 mg, 350 mg

1


58

Drug Tier Notes

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

1

LEUKERAN ORAL TABLET 2 MG 1

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

1

leuprolide acetate injection kit 1 mg/0.2ml 1

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

1

LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML

1

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

1

levetiracetam intravenous solution 500 mg/5ml 1

levetiracetam oral solution 100 mg/ml 1

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

1

levobunolol hcl ophthalmic solution 0.5 % 1

levocarnitine oral solution 1 gm/10ml 1

levocarnitine oral tablet 330 mg 1

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

1

levocetirizine dihydrochloride oral tablet 5 mg 1

levofloxacin in d5w intravenous solution 500 mg/100ml

1

levofloxacin intravenous solution 25 mg/ml 1

levofloxacin ophthalmic solution 0.5 % 1

levofloxacin oral solution 25 mg/ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

levoleucovorin calcium intravenous solution 175 mg/17.5ml

1

LEVONEST ORAL TABLET 1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

1

levonorgestrel oral tablet 1.5 mg 1(SO)


59

Drug Tier Notes

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

1

levorphanol tartrate oral tablet 2 mg 1 QL (186 per 31 days)

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

1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

LEXIVA ORAL SUSPENSION 50 MG/ML 1 QL (1628 per 28 days)

LEXIVA ORAL TABLET 700 MG 1 QL (124 per 31 days)

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

1

lice treatment external liquid 0.33-4 %, 1 % 1(SO)

lice treatment external lotion 1 % 1(SO)

LICIDE AEROSOL 0.5 % 1(CW)

lidocaine external patch 5 % 1 PA; QL (93 per 31 days)

lidocaine hcl (pf) injection solution 0.5 % 1

lidocaine hcl external gel 2 % 1

lidocaine hcl external solution 4 % 1

lidocaine hcl injection solution 2 % 1

lidocaine viscous mouth/throat solution 2 % 1

lidocaine-prilocaine external cream 2.5-2.5 % 1

LIDOCARE ARM/NECK/LEG EXTERNAL PATCH 4 %

1(CW)

LIDOCREAM EXTERNAL CREAM 4 % 1(CW)

lindane external shampoo 1 % 1

linezolid intravenous solution 600 mg/300ml 1 PA

linezolid oral suspension reconstituted 100 mg/5ml 1 PA

linezolid oral tablet 600 mg 1 PA

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

1

liothyronine sodium intravenous solution 10 mcg/ml

1


60

Drug Tier Notes

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

1

liquid calcium with d3 oral capsule 600-1000 mg-unit

1(CW)

liquituss gg oral liquid 200 mg/5ml 1(SO)

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

lithium carbonate er oral tablet extended release 300 mg, 450 mg

1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1

lithium carbonate oral tablet 300 mg 1

lithium oral solution 8 meq/5ml 1

LOMEDIA 24 FE ORAL TABLET 1-20 MG-MCG(24)

1

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

1 PA

loperamide hcl oral capsule 2 mg 1

lopinavir-ritonavir oral solution 400-100 mg/5ml 1

loratadine allergy relief oral tablet dispersible 10 mg

1(SO)

loratadine oral tablet 10 mg 1(SO)

loratadine-d 24hr oral tablet extended release 24 hour 10-240 mg

1(SO)

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML


lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

lorcet hd oral tablet 10-325 mg 1 QL (381 per 31 days)

LORCET ORAL TABLET 5-325 MG 1 QL (382 per 31 days)

LORCET PLUS ORAL TABLET 7.5-325 MG 1 QL (382 per 31 days)

LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


LORYNA ORAL TABLET 3-0.02 MG 1


61

Drug Tier Notes

losartan potassium oral tablet 100 mg, 25 mg, 50 mg


losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg


LOTEMAX OPHTHALMIC GEL 0.5 % 1

LOTEMAX OPHTHALMIC OINTMENT 0.5 % 1

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

1

LOTRIMIN AF EXTERNAL AEROSOL 2 % 1(SO)

LOTRIMIN AF EXTERNAL POWDER 2 % 1(SO)

LOTRIMIN AF JOCK ITCH POWDER EXTERNAL AEROSOL POWDER 2 %

1(SO)

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1

low-ogestrel oral tablet 0.3-30 mg-mcg 1

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1

lubricant eye drops ophthalmic solution 0.4-0.3 %, 0.5 %

1(SO)

lubricant eye ophthalmic ointment 1(SO)

LUMIGAN OPHTHALMIC SOLUTION 0.01 % 1

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

1 PA

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG


LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG


LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG


LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG


LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG


LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG


LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG



62

Drug Tier Notes

LUTERA ORAL TABLET 0.1-20 MG-MCG 1

LUZU EXTERNAL CREAM 1 % 1

LYNPARZA ORAL CAPSULE 50 MG 1 PA

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

1

LYRICA ORAL SOLUTION 20 MG/ML 1

LYSODREN ORAL TABLET 500 MG 1

LYZA ORAL TABLET 0.35 MG 1

MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML

1(SO)

mag-al oral liquid 200-200 mg/5ml 1(SO)

magnesium citrate oral solution 1.745 gm/30ml 1(CW)

magnesium oral capsule 500 mg 1(CW)

magnesium oral tablet 250 mg, 400 mg 1(CW)

magnesium oxide (antacid) oral capsule 500 mg 1(SO)

magnesium oxide -mg supplement oral tablet 250 mg

1(CW)

magnesium oxide oral capsule 400 mg 1(CW)

magnesium oxide oral tablet 250 mg, 400 (240 mg) mg, 400 (241.3 mg) mg, 400 mg, 500 mg

1(CW)

magnesium sulfate injection solution 50 % 1

MAKENA INTRAMUSCULAR OIL 250 MG/ML

1 PA

malathion external lotion 0.5 % 1

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 1

MAR-COF CG EXPECTORANT ORAL LIQUID 225-7.5 MG/5ML

1(ND)

marlissa oral tablet 0.15-30 mg-mcg 1

MARPLAN ORAL TABLET 10 MG 1 ST

MATULANE ORAL CAPSULE 50 MG 1 PA

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

1

meclizine hcl oral tablet 12.5 mg, 25 mg 1


63

Drug Tier Notes

medicated pain relieving external patch 1.2-5.7-6.3 %

1(CW)

MEDROX EXTERNAL PATCH 0.0375-5 %, 0.0375-5-20 %

1(CW)

medroxyprogesterone acetate intramuscular suspension 150 mg/ml


medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

1

mefloquine hcl oral tablet 250 mg 1

megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml

1 PA; HR

megestrol acetate oral tablet 20 mg, 40 mg 1 PA; HR

MEKINIST ORAL TABLET 0.5 MG 1 PA; LA; QL (124 per 31 days)

MEKINIST ORAL TABLET 2 MG 1 PA; LA; QL (31 per 31 days)

melatonin er oral tablet extended release 10 mg, 3 mg

1(CW)

melatonin fast meltz oral tablet dispersible 500 mcg

1(CW)

melatonin gummies oral tablet chewable 2.5 mg 1(CW)

melatonin oral capsule 10 mg, 5 mg 1(CW)

melatonin oral tablet 1 mg, 10 mg, 3 mg, 3-10 mg, 3-2 mg, 300 mcg

1(CW)

melatonin oral tablet dispersible 3 mg, 5 mg 1(CW)

melatonin sublingual tablet sublingual 5 mg 1(CW)

melatonin tr with vitamin b6 oral tablet extended release 3-10 mg

1(CW)

meloxicam oral tablet 15 mg 1 QL (31 per 31 days)

meloxicam oral tablet 7.5 mg 1 QL (62 per 31 days)

melphalan hcl intravenous solution reconstituted 50 mg

1

memantine hcl oral solution 2 mg/ml 1 QL (372 per 31 days)

memantine hcl oral tablet 10 mg, 5 mg 1 QL (62 per 31 days)

memantine hcl oral tablet 5 (28)-10 (21) mg 1

MENACTRA INTRAMUSCULAR INJECTABLE

1


64

Drug Tier Notes

mencaps external patch 0.0225-4.5 % 1(CW)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

1 PA; HR

MENHIBRIX INTRAMUSCULAR SOLUTION RECONSTITUTED 5-5-2.5 MCG

1

MENOMUNE SUBCUTANEOUS INJECTABLE 1

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

1

meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

1 PA; HR

meperidine hcl oral solution 50 mg/5ml 1

meperidine hcl oral tablet 100 mg, 50 mg 1 PA; HR; QL (372 per 31 days)

MEPHYTON ORAL TABLET 5 MG 1(CW)

mercaptopurine oral tablet 50 mg 1

meropenem intravenous solution reconstituted 500 mg

1

MESALAMINE ORAL TABLET DELAYED RELEASE 800 MG

1

mesalamine-cleanser rectal kit 4 gm 1

mesna intravenous solution 100 mg/ml 1

MESNEX ORAL TABLET 400 MG 1

METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG


METAMUCIL MULTIHEALTH FIBER ORAL PACKET 58.12 %

1(CW)

METAMUCIL MULTIHEALTH FIBER ORAL POWDER 55.46 %, 63 %

1(CW)

METAMUCIL ORAL POWDER 28.3 %, 48.57 % 1(CW)

METAMUCIL ORAL WAFER 1(CW)

METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 %

1(CW)

METAMUCIL SMOOTH TEXTURE ORAL POWDER 58.6 %

1(CW)

metaproterenol sulfate oral syrup 10 mg/5ml 1

metaproterenol sulfate oral tablet 10 mg, 20 mg 1


65

Drug Tier Notes

metaxalone oral tablet 800 mg 1 PA; HR; QL (124 per 31 days)

metformin hcl er oral tablet extended release 24 hour 500 mg


metformin hcl er oral tablet extended release 24 hour 750 mg


metformin hcl oral tablet 1000 mg, 850 mg 1 QL (62 per 31 days)

metformin hcl oral tablet 500 mg 1 QL (124 per 31 days)

methadone hcl injection solution 10 mg/ml 1

methadone hcl oral solution 10 mg/5ml 1 QL (500 per 31 days)

methadone hcl oral solution 5 mg/5ml 1 QL (992 per 31 days)

methadone hcl oral tablet 10 mg, 5 mg 1 QL (248 per 31 days)

methenamine hippurate oral tablet 1 gm 1

methimazole oral tablet 10 mg, 5 mg 1

methocarbamol injection solution 1000 mg/10ml 1 PA; HR

methocarbamol oral tablet 500 mg, 750 mg 1 PA; HR

methotrexate oral tablet 2.5 mg 1

methotrexate sodium (pf) injection solution 1 gm/40ml

1

methotrexate sodium injection solution 50 mg/2ml 1

methotrexate sodium injection solution reconstituted 1 gm

1

methoxsalen rapid oral capsule 10 mg 1

methscopolamine bromide oral tablet 2.5 mg, 5 mg 1

methyclothiazide oral tablet 5 mg 1

methyldopa oral tablet 250 mg, 500 mg 1 PA; HR

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

1 PA; HR

methyldopate hcl intravenous solution 250 mg/5ml 1 PA; HR

methylphenidate hcl er (cd) oral capsule extended release 10 mg

1

methylphenidate hcl er oral tablet extended release 10 mg, 20 mg


methylphenidate hcl oral solution 10 mg/5ml 1 QL (930 per 31 days)

methylphenidate hcl oral solution 5 mg/5ml 1 QL (1860 per 31 days)


66

Drug Tier Notes

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg


methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

methylprednisolone oral tablet therapy pack 4 mg 1

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

1

metipranolol ophthalmic solution 0.3 % 1

metoclopramide hcl injection solution 5 mg/ml 1

metoclopramide hcl oral solution 5 mg/5ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg


metoprolol tartrate intravenous solution 1 mg/ml, 5 mg/5ml

1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1

metronidazole external cream 0.75 % 1

metronidazole external gel 0.75 %, 1 % 1

metronidazole external lotion 0.75 % 1

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

1

metronidazole oral tablet 250 mg, 500 mg 1

metronidazole vaginal gel 0.75 % 1

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

1

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

1

MI-ACID ORAL TABLET CHEWABLE 700-300 MG

1(CW)


67

Drug Tier Notes

miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm)

1(SO)

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

1(SO)

miconazole 3 vaginal cream 4 % 1(SO)

miconazole 3 vaginal suppository 200 mg 1(SO)

miconazole 7 vaginal suppository 100 mg 1(SO)

miconazole nitrate external cream 2 % 1(SO)

miconazole nitrate powder 2 % 1(SO)

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

1

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

1

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

1

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1

milk of magnesia concentrate oral suspension 2400 mg/10ml

1(CW)

milk of magnesia oral suspension 400 mg/5ml 1(CW)

MIMVEY LO ORAL TABLET 0.5-0.1 MG 1

MIMVEY ORAL TABLET 1-0.5 MG 1

mineral freez external gel 2 % 1(CW)

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.6 MG/HR


MINITRAN TRANSDERMAL PATCH 24 HOUR 0.4 MG/HR


minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1

minoxidil oral tablet 10 mg, 2.5 mg 1

mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1 QL (31 per 31 days)

mirtazapine oral tablet 7.5 mg 1


68

Drug Tier Notes

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg


misoprostol oral tablet 100 mcg, 200 mcg 1

mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

1

mitoxantrone hcl intravenous concentrate 25 mg/12.5ml

1

M-M-R II SUBCUTANEOUS INJECTABLE 1

modafinil oral tablet 100 mg, 200 mg 1 PA; QL (62 per 31 days)

moexipril hcl oral tablet 15 mg, 7.5 mg 1

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1

MOI-STIR MOUTH/THROAT SOLUTION 1(CW)

molindone hcl oral tablet 10 mg, 25 mg, 5 mg 1

mometasone furoate external cream 0.1 % 1

mometasone furoate external ointment 0.1 % 1

MONISTAT 1 COMBO PACK VAGINAL KIT 1200 & 2 MG & %

1(SO)

MONISTAT 1 DAY OR NIGHT VAGINAL KIT 1200 & 2 MG & %

1(SO)

MONISTAT 3 COMBINATION PACK VAGINAL KIT 200 & 2 MG-% (9GM), 200-2 MG-%

1(SO)

MONISTAT 3 COMBO PACK APP VAGINAL KIT 200 & 2 MG-% (9GM)

1(SO)

MONISTAT 3 VAGINAL CREAM 4 % 1(SO)

MONISTAT 7 COMBO PACK APP VAGINAL KIT 100 & 2 MG-% (9GM)

1(SO)

MONISTAT 7 COMPLETE THERAPY VAGINAL KIT 100-2 MG-%

1(SO)

MONONESSA ORAL TABLET 0.25-35 MG-MCG

1

montelukast sodium oral packet 4 mg 1 QL (31 per 31 days)

montelukast sodium oral tablet 10 mg 1 QL (31 per 31 days)

montelukast sodium oral tablet chewable 4 mg, 5 mg



69

Drug Tier Notes

morphine sulfate (concentrate) oral solution 100 mg/5ml


morphine sulfate (pf) intravenous solution 2 mg/ml 1

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg


morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg


morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

1 QL (1550 per 31 days)

morphine sulfate oral tablet 15 mg, 30 mg 1 QL (186 per 31 days)

motion sickness relief oral tablet 50 mg 1(SO)

motion sickness relief oral tablet chewable 25 mg 1(SO)

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

1

MOXEZA OPHTHALMIC SOLUTION 0.5 % 1

moxifloxacin hcl intravenous solution 400 mg/250ml

1

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML


mucus relief dm max oral liquid 5-100 mg/5ml 1(SO)

MULTAQ ORAL TABLET 400 MG 1

mupirocin external ointment 2 % 1

MURO 128 OPHTHALMIC OINTMENT 5 % 1(CW)

muscle rub external cream 10-15 % 1(CW)

muscle rub ultra strength external cream 4-10-30 %

1(CW)

MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG

1

MY WAY ORAL TABLET 1.5 MG 1(SO)

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

1

mycophenolate mofetil oral capsule 250 mg 1


70

Drug Tier Notes

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

1

mycophenolate mofetil oral tablet 500 mg 1

mycophenolic acid oral tablet delayed release 180 mg, 360 mg

1

MYLANTA ORAL SUSPENSION 200-200-20 MG/5ML

1(SO)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG

1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG

1

MYTESI ORAL TABLET DELAYED RELEASE 125 MG

1

nabumetone oral tablet 500 mg 1 QL (124 per 31 days)

nabumetone oral tablet 750 mg 1 QL (62 per 31 days)

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

1

nafcillin sodium injection solution reconstituted 1 gm, 10 gm

1

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

1 PA

naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml 1

naltrexone hcl oral tablet 50 mg 1

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 28-10 MG

1

naproxen dr oral tablet delayed release 375 mg, 500 mg

1

naproxen oral suspension 125 mg/5ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium oral capsule 220 mg 1(SO)

naproxen sodium oral tablet 220 mg 1(SO)

naproxen sodium oral tablet 275 mg, 550 mg 1

naratriptan hcl oral tablet 1 mg, 2.5 mg 1 QL (9 per 31 days)


71

Drug Tier Notes

NASADROPS SALINE ON THE GO NASAL SOLUTION 0.9 %

1(CW)

nasal decongestant oral liquid 30 mg/5ml 1(SO)

nasal decongestant oral tablet 30 mg 1(SO)

NASAL MOIST NASAL SOLUTION 0.65 % 1(CW)

NASOGEL NASAL GEL 1(CW)

nateglinide oral tablet 120 mg, 60 mg 1

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

1 PA; HR

natural fiber laxative oral powder 28.3 %, 30.9 %, 48.57 %, 58.6 %

1(CW)

natural fiber therapy oral powder 30 % 1(CW)

natural psyllium seed oral powder 100 % 1(CW)

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

1

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

1

NECON 10/11 (28) ORAL TABLET 35 MCG 1

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

neomycin sulfate oral tablet 500 mg 1

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

1

neomycin-polymyxin b gu irrigation solution 40-200000

1

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

1

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

1

neomycin-polymyxin-hc otic solution 1 % 1


72

Drug Tier Notes

neomycin-polymyxin-hc otic suspension 3.5-10000-1

1

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

1

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


NEUAC EXTERNAL GEL 1.2-5 % 1

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML


NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR


nevirapine er oral tablet extended release 24 hour 100 mg

1

nevirapine er oral tablet extended release 24 hour 400 mg


nevirapine oral suspension 50 mg/5ml 1 QL (1240 per 31 days)

nevirapine oral tablet 200 mg 1 QL (62 per 31 days)

NEXAFED ORAL TABLET ABUSE-DETERRENT 30 MG

1(SO)

NEXAVAR ORAL TABLET 200 MG 1 PA; LA; QL (124 per 31 days)

NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG

1(SO)

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

1

niacin er oral capsule extended release 250 mg, 500 mg

1(CW)

niacin er oral tablet extended release 1000 mg, 250 mg, 500 mg, 750 mg

1(CW)

niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg 1(CW)

niacinamide oral tablet 500 mg 1(CW)

NIACOR ORAL TABLET 500 MG 1

nicardipine hcl intravenous solution 2.5 mg/ml 1


73

Drug Tier Notes

nicardipine hcl oral capsule 20 mg, 30 mg 1

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR

1(SO) PA; QL (30 per 30 days)

NICORETTE MOUTH/THROAT GUM 2 MG, 4 MG


nicotine mini mouth/throat lozenge 2 mg 1(SO) PA; QL (270 per 30 days)

nicotine polacrilex mouth/throat gum 2 mg, 4 mg 1(SO) PA; QL (270 per 30 days)

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr


NICOTROL INHALATION INHALER 10 MG 1

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg


nifedipine oral capsule 10 mg, 20 mg 1

NIKKI ORAL TABLET 3-0.02 MG 1

nilutamide oral tablet 150 mg 1 QL (62 per 31 days)

nimodipine oral capsule 30 mg 1

NINJACOF-XG ORAL LIQUID 200-8 MG/5ML 1(ND)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

1 PA

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

1 PA; HR

nitrofurantoin monohyd macro oral capsule 100 mg

1 PA; HR

nitrofurantoin oral suspension 25 mg/5ml 1 PA; HR; QL (7850 per 120 days)

nitroglycerin intravenous solution 5 mg/ml 1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr


nitroglycerin transdermal patch 24 hour 0.4 mg/hr 1 QL (62 per 31 days)

NIX CREME RINSE EXTERNAL LIQUID 1 % 1(SO)

nizatidine oral capsule 150 mg, 300 mg 1


74

Drug Tier Notes

nizatidine oral solution 15 mg/ml 1

non-aspirin extra strength oral tablet 500 mg 1(SO)

non-aspirin jr strength oral tablet chewable 160 mg

1(SO)

non-aspirin pain relief oral tablet 325 mg 1(SO)

NORA-BE ORAL TABLET 0.35 MG 1

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

1 PA

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg(24)

1

norethindrone acetate oral tablet 5 mg 1

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

1

norethindrone oral tablet 0.35 mg 1

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

1

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg

1

NORLYROC ORAL TABLET 0.35 MG 1

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION

1

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION

1

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

1 PA

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

1

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

1

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

1

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

1

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1 PA; HR


75

Drug Tier Notes

nortriptyline hcl oral solution 10 mg/5ml 1 PA; HR

NORVIR ORAL CAPSULE 100 MG 1 QL (372 per 31 days)

NORVIR ORAL SOLUTION 80 MG/ML 1 QL (496 per 31 days)

NORVIR ORAL TABLET 100 MG 1 QL (372 per 31 days)

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

1

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML

1

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML

1

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

1

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

1

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

1

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

1

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

1

NOXAFIL ORAL SUSPENSION 40 MG/ML 1 PA; QL (870 per 28 days)

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG


NUEDEXTA ORAL CAPSULE 20-10 MG 1

NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG


NUMOISYN MOUTH/THROAT LOZENGE 1(CW)

NUPLAZID ORAL TABLET 17 MG 1 PA

nutrilipid intravenous emulsion 20 % 1

nystatin external cream 100000 unit/gm 1

nystatin external ointment 100000 unit/gm 1

nystatin external powder 100000 unit/gm 1

nystatin mouth/throat suspension 100000 unit/ml 1

nystatin oral tablet 500000 unit 1


76

Drug Tier Notes

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

1

OCELLA ORAL TABLET 3-0.03 MG 1

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1

ODEFSEY ORAL TABLET 200-25-25 MG 1

ODOMZO ORAL CAPSULE 200 MG 1 PA; LA

OFEV ORAL CAPSULE 100 MG, 150 MG 1

ofloxacin ophthalmic solution 0.3 % 1

OFLOXACIN ORAL TABLET 300 MG 1

ofloxacin oral tablet 400 mg 1

ofloxacin otic solution 0.3 % 1

OGESTREL ORAL TABLET 0.5-50 MG-MCG 1

olanzapine intramuscular solution reconstituted 10 mg


olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg


olanzapine oral tablet 20 mg 1 QL (62 per 31 days)

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

1

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg


olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg


olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg


olopatadine hcl nasal solution 0.6 % 1

olopatadine hcl ophthalmic solution 0.1 % 1

OMEGA-3 2100 ORAL CAPSULE 1050 MG 1(CW)

omega-3 fish oil concentrate oral capsule delayed release 1000 mg

1(CW)

omega-3 fish oil ex st oral capsule 880 mg 1(CW)


77

Drug Tier Notes

omega-3 fish oil oral capsule 300 mg, 500 mg 1(CW)

omega-3 oral capsule 1400 mg 1(CW)

omega-3 oral capsule delayed release 350 mg 1(CW)

omega-3-acid ethyl esters oral capsule 1 gm 1

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

1

omeprazole oral tablet delayed release 20 mg 1(CW)

omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40-1100 mg

1

ondansetron hcl injection solution 4 mg/2ml 1

ondansetron hcl oral solution 4 mg/5ml 1 QL (465 per 31 days)

ondansetron hcl oral tablet 24 mg 1 QL (31 per 31 days)

ondansetron hcl oral tablet 4 mg, 8 mg 1 QL (62 per 31 days)

ondansetron oral tablet dispersible 4 mg, 8 mg 1 QL (62 per 31 days)

ONFI ORAL SUSPENSION 2.5 MG/ML 1 QL (496 per 31 days)

ONFI ORAL TABLET 10 MG, 20 MG 1 QL (62 per 31 days)

OPCICON ONE-STEP ORAL TABLET 1.5 MG 1(SO)

OPSUMIT ORAL TABLET 10 MG 1 ST; QL (93 per 31 days)

ORAVIG BUCCAL TABLET 50 MG 1

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

1 ST

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

1 ST

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML

1 ST

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

1 PA

ORFADIN ORAL SUSPENSION 4 MG/ML 1 PA; LA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

1 PA

orphenadrine citrate er oral tablet extended release 12 hour 100 mg


orphenadrine citrate injection solution 30 mg/ml 1 PA; HR

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 1


78

Drug Tier Notes

oseltamivir phosphate oral capsule 30 mg 1 QL (112 per 365 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg 1 QL (56 per 365 days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


OSTEO-PORETICAL ORAL TABLET 600-1000 MG-UNIT

1(CW)

OTEZLA ORAL TABLET 30 MG 1

oxacillin sodium injection solution reconstituted 10 gm

1

oxaliplatin intravenous solution 100 mg/20ml 1

oxandrolone oral tablet 10 mg 1 QL (62 per 31 days)

oxandrolone oral tablet 2.5 mg 1

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 QL (124 per 31 days)

oxcarbazepine oral suspension 300 mg/5ml 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

1

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg


oxybutynin chloride oral syrup 5 mg/5ml 1 PA; HR

oxybutynin chloride oral tablet 5 mg 1 PA; HR

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 40 mg, 80 mg


oxycodone hcl er oral tablet er 12 hour abuse-deterrent 15 mg, 30 mg, 60 mg


oxycodone hcl oral capsule 5 mg 1 QL (186 per 31 days)

oxycodone hcl oral concentrate 100 mg/5ml 1

oxycodone hcl oral solution 5 mg/5ml 1 QL (5580 per 31 days)

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg


oxycodone-acetaminophen oral solution 5-325 mg/5ml

1 QL (1860 per 31 days)

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg



79

Drug Tier Notes

oxycodone-aspirin oral tablet 4.8355-325 mg 1 QL (372 per 31 days)

oxycodone-ibuprofen oral tablet 5-400 mg 1 QL (372 per 31 days)

oyster shell calcium plus d oral tablet 500-125 mg-unit

1(CW)

oyster shell calcium/vitamin d oral tablet 250-125 mg-unit

1(CW)

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

1

paclitaxel intravenous concentrate 300 mg/50ml 1

pain & fever childrens oral solution 160 mg/5ml 1(SO)

pain & fever junior oral tablet dispersible 160 mg 1(SO)

pain relief extra strength oral capsule 500 mg 1(SO)

pain relieving external gel 3.5 % 1(CW)

paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg


paliperidone er oral tablet extended release 24 hour 6 mg


pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

1

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600 UNIT

1

PANRETIN EXTERNAL GEL 0.1 % 1 PA

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

1

paricalcitol intravenous solution 5 mcg/ml 1

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1

paromomycin sulfate oral capsule 250 mg 1

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 37.5 mg


paroxetine hcl er oral tablet extended release 24 hour 25 mg


paroxetine hcl oral tablet 10 mg, 20 mg 1 QL (31 per 31 days)

paroxetine hcl oral tablet 30 mg, 40 mg 1 QL (62 per 31 days)

PASER ORAL PACKET 4 GM 1

PATADAY OPHTHALMIC SOLUTION 0.2 % 1


80

Drug Tier Notes

PAXIL ORAL SUSPENSION 10 MG/5ML 1 ST; QL (930 per 31 days)

PAZEO OPHTHALMIC SOLUTION 0.7 % 1

PECGEN DMX ORAL LIQUID 15-125 MG/5ML 1(SO)

PEDIA-LAX ORAL LIQUID 50 MG/15ML 1(CW)

PEDIARIX INTRAMUSCULAR SUSPENSION 1

pediatric formula cough/congst oral liquid 10-100 mg/5ml

1(SO)

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

1

peg 3350 oral powder 1(CW)

peg-3350/electrolytes oral solution reconstituted 236 gm

1

PEGANONE ORAL TABLET 250 MG 1

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML


PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML


PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

1

PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

1

penicillin g potassium injection solution reconstituted 5000000 unit

1

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral tablet 250 mg, 500 mg 1

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

1

pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 PA; HR; QL (372 per 31 days)

pentoxifylline er oral tablet extended release 400 mg

1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

permethrin external cream 5 % 1

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1


81

Drug Tier Notes

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 4000 UNIT

1

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

1 ST

phenelzine sulfate oral tablet 15 mg 1

phenobarbital oral elixir 20 mg/5ml 1 PA; HR; QL (1550 per 31 days)

phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg


phenobarbital oral tablet 15 mg, 60 mg 1 PA; HR; QL (124 per 31 days)

phenobarbital oral tablet 30 mg 1 PA; HR; QL (310 per 31 days)

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium injection solution 50 mg/ml 1

PHILLIPS ORAL TABLET 500 MG 1(CW)

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

1

PHYSIOLYTE IRRIGATION SOLUTION 1

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

1

PICATO EXTERNAL GEL 0.015 % 1 QL (3 per 31 days)

PICATO EXTERNAL GEL 0.05 % 1 QL (2 per 31 days)

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

pimozide oral tablet 1 mg, 2 mg 1

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

1

pindolol oral tablet 10 mg, 5 mg 1

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 QL (31 per 31 days)

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

1

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

1


82

Drug Tier Notes

piperacillin sod-tazobactam so intravenous solution reconstituted 3.375 (3-0.375) gm, 4.5 (4-0.5) gm

1

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG

1

PLAN B ONE-STEP ORAL TABLET 1.5 MG 1(SO)

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML

1 PA

podofilox external solution 0.5 % 1

POLAR FROST EXTERNAL GEL 4 % 1(CW)

polyethylene glycol 3350 oral packet 1(CW)

polyethylene glycol 3350 oral powder 1

polyethylene glycol 3350 powder 1(CW)

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

1

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG


PORTIA-28 ORAL TABLET 0.15-30 MG-MCG 1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1

potassium chloride er oral capsule extended release 10 meq, 8 meq

1

potassium chloride er oral tablet extended release 10 meq, 8 meq

1

potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

1

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

1

potassium chloride intravenous solution 2 meq/ml, 20 meq/100ml

1

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

1

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

1

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG

1


83

Drug Tier Notes

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

1

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML

1 PA

pramipexole dihydrochloride er oral tablet extended release 24 hour 3.75 mg


pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg


pramipexole dihydrochloride oral tablet 0.75 mg 1 QL (186 per 31 days)

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1

prednicarbate external cream 0.1 % 1

prednicarbate external ointment 0.1 % 1

prednisolone sodium phosphate ophthalmic solution 1 %

1

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

1

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

1

prednisone oral solution 5 mg/5ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

PREDNISONE ORAL TABLET THERAPY PACK 10 MG (21), 10 MG (48), 5 MG (21), 5 MG (48)

1

preferred plus insulin syringe 28g x 1/2" 0.5 ml 1

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

1 PA; HR

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

1 PA; HR

PREMASOL INTRAVENOUS SOLUTION 10 %, 6 %

1

PREMPHASE ORAL TABLET 0.625-5 MG 1 PA; HR


84

Drug Tier Notes

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

1 PA; HR

PREPARATION H RECTAL CREAM 1-0.25-14.4-15 %

1(CW)

PREVIFEM ORAL TABLET 0.25-35 MG-MCG 1

PREZCOBIX ORAL TABLET 800-150 MG 1

PREZISTA ORAL SUSPENSION 100 MG/ML 1 QL (372 per 31 days)

PREZISTA ORAL TABLET 150 MG 1 QL (248 per 31 days)




PRIFTIN ORAL TABLET 150 MG 1

primaquine phosphate oral tablet 26.3 mg 1

primidone oral tablet 250 mg, 50 mg 1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

1

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT


probenecid oral tablet 500 mg 1

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

1

PROCALAMINE INTRAVENOUS SOLUTION 3 %

1

prochlorperazine edisylate injection solution 5 mg/ml

1

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 1

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML


PROCRIT INJECTION SOLUTION 2000 UNIT/ML



85

Drug Tier Notes





PROCTOCORT RECTAL SUPPOSITORY 30 MG

1(CW)

PROCTO-MED HC RECTAL CREAM 2.5 % 1

PROCTO-PAK RECTAL CREAM 1 % 1

PROCTOSOL HC RECTAL CREAM 2.5 % 1

PROCTOZONE-HC RECTAL CREAM 2.5 % 1

progesterone micronized oral capsule 100 mg, 200 mg

1

PROGLYCEM ORAL SUSPENSION 50 MG/ML 1

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

1

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

1

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT

1 PA

PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML


PROMACTA ORAL TABLET 12.5 MG 1 PA; QL (62 per 31 days)

PROMACTA ORAL TABLET 25 MG, 50 MG, 75 MG


promethazine hcl oral syrup 6.25 mg/5ml 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

1 PA; HR

promethazine hcl rectal suppository 50 mg 1

promethazine vc plain oral syrup 6.25-5 mg/5ml 1

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

1

propantheline bromide oral tablet 15 mg 1

proparacaine hcl ophthalmic solution 0.5 % 1


86

Drug Tier Notes

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol hcl intravenous solution 1 mg/ml 1

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1

propylthiouracil oral tablet 50 mg 1

PROQUAD SUBCUTANEOUS INJECTABLE 1

PROSOL INTRAVENOUS SOLUTION 20 % 1

protriptyline hcl oral tablet 10 mg, 5 mg 1 PA; HR

PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


pseudoephedrine hcl oral syrup 30 mg/5ml 1(SO)

pseudoephedrine hcl oral tablet 30 mg, 60 mg 1(SO)

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT


PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT


PULMICORT INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

1

PULMOZYME INHALATION SOLUTION 1 MG/ML


PURE & GENTLE LUBRICANT OPHTHALMIC SOLUTION 3 MG/ML

1(SO)

PURIXAN ORAL SUSPENSION 2000 MG/100ML

1

px ultra strength rub external ointment 4-10-30 % 1(CW)

pyrazinamide oral tablet 500 mg 1

pyridostigmine bromide oral tablet 60 mg 1

pyridoxine hcl oral tablet 100 mg, 50 mg 1(CW)

QUADRACEL INTRAMUSCULAR SUSPENSION

1


87

Drug Tier Notes

QUASENSE ORAL TABLET 0.15-0.03 MG 1

QUETIAPINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG






quetiapine fumarate er oral tablet extended release 24 hour 400 mg




quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

1

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

quinidine gluconate er oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg 1

quinine sulfate oral capsule 324 mg 1 PA; QL (44 per 7 days)

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

1

ra anti-itch maximum strength external ointment 1 %

1(SO)

ra fish oil oral capsule 900 mg 1(CW)

ra fish oil oral capsule delayed release 1400 mg, 600 mg

1(CW)

ra hemorrhoid relief rectal suppository 0.25-85.5 %

1(CW)

ra melatonin sublingual tablet sublingual 1 mg 1(CW)

ra tussin chest congestion oral syrup 100 mg/5ml 1(SO)

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

1

raloxifene hcl oral tablet 60 mg 1


88

Drug Tier Notes

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

1

ranitidine acid reducer oral tablet 75 mg 1(CW)

ranitidine hcl injection solution 50 mg/2ml 1

ranitidine hcl oral capsule 150 mg, 300 mg 1

ranitidine hcl oral syrup 15 mg/ml 1

ranitidine hcl oral tablet 150 mg, 300 mg 1

RAPAFLO ORAL CAPSULE 4 MG, 8 MG 1 QL (31 per 31 days)

RAPAMUNE ORAL SOLUTION 1 MG/ML 1

rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 QL (31 per 31 days)

RAVICTI ORAL LIQUID 1.1 GM/ML 1

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG 1

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

1

REFRESH OPHTHALMIC SOLUTION 1.4-0.6 %

1(SO)

REGRANEX EXTERNAL GEL 0.01 % 1 PA

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

1 QL (112 per 365 days)

reliever external patch 0.05-5 % 1(CW)

RELI-ON INSULIN SYRINGE 29G 0.3 ML 1

RELISTOR ORAL TABLET 150 MG 1 ST

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML


REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

1

RENVELA ORAL PACKET 0.8 GM 1 QL (540 per 31 days)

RENVELA ORAL PACKET 2.4 GM 1 QL (186 per 31 days)

RENVELA ORAL TABLET 800 MG 1 QL (540 per 31 days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1


89

Drug Tier Notes

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

1 PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

1 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

1 PA

REPREXAIN ORAL TABLET 10-200 MG 1 QL (382 per 31 days)

RESCRIPTOR ORAL TABLET 100 MG 1 QL (372 per 31 days)

RESCRIPTOR ORAL TABLET 200 MG 1 QL (186 per 31 days)

RESTASIS OPHTHALMIC EMULSION 0.05 % 1 QL (62 per 31 days)

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 7.5 MG

1

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

1

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG

1 PA; LA; QL (28 per 28 days)

REVLIMID ORAL CAPSULE 20 MG 1 PA; QL (28 per 28 days)

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

1 PA

REYATAZ ORAL CAPSULE 150 MG, 200 MG 1 QL (62 per 31 days)

REYATAZ ORAL CAPSULE 300 MG 1 QL (31 per 31 days)

REYATAZ ORAL PACKET 50 MG 1

RHINARIS NASAL SOLUTION 0.2 % 1(CW)

RIBASPHERE ORAL CAPSULE 200 MG 1 QL (186 per 31 days)

RIBASPHERE ORAL TABLET 200 MG 1 QL (186 per 31 days)

RIBASPHERE ORAL TABLET 400 MG 1

ribavirin oral capsule 200 mg 1 QL (186 per 31 days)

ribavirin oral tablet 200 mg 1 QL (186 per 31 days)

RID AEROSOL 0.5 % 1(SO)

rifabutin oral capsule 150 mg 1

rifampin intravenous solution reconstituted 600 mg

1

rifampin oral capsule 150 mg, 300 mg 1

RIFATER ORAL TABLET 50-120-300 MG 1


90

Drug Tier Notes

riluzole oral tablet 50 mg 1

rimantadine hcl oral tablet 100 mg 1

ringers intravenous solution 1

ringers irrigation irrigation solution 1

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG


risperidone oral solution 1 mg/ml 1

risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg


risperidone oral tablet 0.5 mg 1 QL (124 per 31 days)

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1

RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML

1 PA

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

1

RIVASTIGMINE TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR


ROBINUL INJECTION SOLUTION 0.4 MG/2ML

1

ROBINUL-FORTE ORAL TABLET 2 MG 1

ROBITUSSIN CHILDRENS COUGH LA ORAL SYRUP 7.5 MG/5ML

1(SO)

ROBITUSSIN COUGH/CHEST DM MAX ORAL LIQUID 10-200 MG/5ML

1(SO)

ROBITUSSIN LINGERING LA COUGH ORAL LIQUID 15 MG/5ML

1(SO)

ROBITUSSIN MUCUS+CHEST CONGEST ORAL LIQUID 100 MG/5ML

1(SO)

ROBITUSSIN PEAK COLD DM ORAL SYRUP 100-10 MG/5ML

1(SO)


91

Drug Tier Notes

ROLAIDS ORAL TABLET CHEWABLE 550-110 MG

1(CW)

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg


ROTARIX ORAL SUSPENSION RECONSTITUTED

1

ROTATEQ ORAL SOLUTION 1

ROWEEPRA ORAL TABLET 500 MG 1

ROZEREM ORAL TABLET 8 MG 1 QL (31 per 31 days)

RUBRACA ORAL TABLET 200 MG, 300 MG 1 PA

SABRIL ORAL PACKET 500 MG 1 QL (186 per 31 days)

SABRIL ORAL TABLET 500 MG 1 QL (186 per 31 days)

SALESE MOUTH/THROAT LOZENGE 1(CW)

saline bacteriostatic injection solution 0.9 % 1(CW)

saline nasal gel 1(CW)

saline nasal spray nasal solution 0.65 % 1(SO)

salsalate oral tablet 500 mg, 750 mg 1(ND)

SAMSCA ORAL TABLET 15 MG, 30 MG 1 PA; QL (62 per 31 days)

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

1

SANDIMMUNE ORAL SOLUTION 100 MG/ML 1

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

1

SANTYL EXTERNAL OINTMENT 250 UNIT/GM


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG


SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

1

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

1

sb non-aspirin oral tablet chewable 80 mg 1(SO)


92

Drug Tier Notes

scalp relief maximum strength external solution 1 %

1(SO)

SCOT-TUSSIN DIABETES CF ORAL LIQUID 10 MG/5ML

1(SO)

SCOT-TUSSIN SENIOR ORAL LIQUID 15-200 MG/5ML

1(SO)

selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

selenium sulfide external lotion 2.5 % 1

SELZENTRY ORAL TABLET 150 MG 1 QL (248 per 31 days)

SELZENTRY ORAL TABLET 25 MG, 300 MG 1 QL (124 per 31 days)

SELZENTRY ORAL TABLET 75 MG 1 QL (62 per 31 days)

senna laxative oral tablet 8.6 mg 1(CW)

senna leaves oral leaves 1(CW)

senna oral capsule 8.6 mg 1(CW)

senna oral syrup 176 mg/5ml 1(CW)

senna-docusate sodium oral tablet 8.6-50 mg 1(CW)

SENOKOT S ORAL TABLET 8.6-50 MG 1(CW)

SENSIPAR ORAL TABLET 30 MG 1

SENSIPAR ORAL TABLET 60 MG 1 QL (62 per 31 days)

SENSIPAR ORAL TABLET 90 MG 1 QL (124 per 31 days)

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


sertraline hcl oral concentrate 20 mg/ml 1 QL (310 per 31 days)

sertraline hcl oral tablet 100 mg 1 QL (62 per 31 days)

sertraline hcl oral tablet 25 mg, 50 mg 1 QL (93 per 31 days)

SHAROBEL ORAL TABLET 0.35 MG 1

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

1 PA; LA; QL (62 per 31 days)

sildenafil citrate oral tablet 20 mg 1 PA; QL (93 per 31 days)

SILENOR ORAL TABLET 3 MG, 6 MG 1 QL (31 per 31 days)

silver sulfadiazine external cream 1 % 1


93

Drug Tier Notes

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

1

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML

1 ST

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML


SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg


sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1

SIRTURO ORAL TABLET 100 MG 1

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG


SIVEXTRO ORAL TABLET 200 MG 1 PA; QL (6 per 28 days)

sleep-aid maximum strength oral capsule 50 mg 1(SO)

slow iron oral tablet extended release 160 (50 fe) mg

1(CW)

slow release iron oral tablet extended release 45 mg, 47.5 mg, 50 mg

1(CW)

sm fish oil oral capsule 554 mg 1(CW)

sm hydrocortisone max st external ointment 1 % 1(CW)

sm ibuprofen jr oral tablet 100 mg 1(SO)

sm pain relief/menthol external gel 1(CW)

sm slow release iron oral tablet extended release 142 (45 fe) mg, 143 (45 fe) mg

1(CW)

sm vitamin d3 oral capsule 4000 unit 1(CW)

sodium bicarbonate oral tablet 325 mg, 650 mg 1(SO)

sodium chloride (hypertonic) ointment 5 % ophthalmic 5 %

1(SO)

sodium chloride (hypertonic) ophthalmic ointment 5 %

1(CW)

sodium chloride (hypertonic) ophthalmic solution 5 %

1(SO)

sodium chloride injection solution 2.5 meq/ml 1


94

Drug Tier Notes

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

1

sodium chloride irrigation solution 0.9 % 1

sodium phenylbutyrate oral powder 3 gm/tsp 1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

1

SOLTAMOX ORAL SOLUTION 10 MG/5ML 1 PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML


SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG


SOMBRA COOL THERAPY EXTERNAL GEL 6 %

1(CW)

sorbitol oral solution 70 % 1(CW)

sorbitol rectal solution 70 % 1(CW)

sorbitol solution 70 % 1(CW)

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

1

sotalol hcl (af) oral tablet 120 mg 1

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 1

SOVALDI ORAL TABLET 400 MG 1 PA; QL (28 per 28 days)

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG


SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

1

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT


spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolactone-hctz oral tablet 25-25 mg 1

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

1

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG


SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG



95

Drug Tier Notes

SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG


SPRYCEL ORAL TABLET 140 MG 1 PA; QL (31 per 31 days)

SPRYCEL ORAL TABLET 20 MG 1 PA; QL (93 per 31 days)

sps oral suspension 15 gm/60ml 1

SRONYX ORAL TABLET 0.1-20 MG-MCG 1

ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 MG

1(SO)

stavudine oral capsule 15 mg, 20 mg 1 QL (124 per 31 days)

stavudine oral capsule 30 mg, 40 mg 1 QL (62 per 31 days)

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML

1 ST

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 90 MG/ML

1 PA; ST

sterile water for irrigation irrigation solution 1

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT


STIVARGA ORAL TABLET 40 MG 1 PA; QL (84 per 28 days)

stool softener oral capsule 100 mg, 250 mg 1(CW)

stool softener oral tablet 100 mg 1(CW)

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG


STRATTERA ORAL CAPSULE 100 MG, 40 MG, 60 MG, 80 MG


streptomycin sulfate intramuscular solution reconstituted 1 gm

1

STRIBILD ORAL TABLET 150-150-200-300 MG


SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

1

SUBSYS SUBLINGUAL LIQUID 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


sucralfate oral tablet 1 gm 1

SUDAFED 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HOUR 240 MG

1(SO)


96

Drug Tier Notes

SUDAFED CHILDRENS ORAL LIQUID 15 MG/5ML

1(SO)

SUDOGEST ORAL TABLET 30 MG, 60 MG 1(SO)

sulfacetamide sodium external suspension 10 % 1

sulfacetamide sodium ophthalmic ointment 10 % 1

sulfacetamide sodium ophthalmic solution 10 % 1

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml

1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet delayed release 500 mg 1

sulindac oral tablet 150 mg, 200 mg 1 QL (62 per 31 days)

sumatriptan nasal solution 20 mg/act 1 QL (8 per 31 days)

sumatriptan nasal solution 5 mg/act 1 QL (32 per 31 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


super antioxidants protector oral capsule 1(CW)

SUPER OMEGA-3 ORAL CAPSULE 1(CW)

SUPER TWIN EPA/DHA ORAL CAPSULE 1250 MG

1(CW)

SUPRAX ORAL CAPSULE 400 MG 1

supress dm pediatric oral liquid 5-50 mg/ml 1(SO)

SUSTIVA ORAL CAPSULE 200 MG 1 QL (124 per 31 days)


97

Drug Tier Notes

SUSTIVA ORAL CAPSULE 50 MG 1 QL (496 per 31 days)

SUSTIVA ORAL TABLET 600 MG 1 QL (31 per 31 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT


SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

1

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

1

SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML

1 PA

SYNAREL NASAL SOLUTION 2 MG/ML 1 PA

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

1

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

SYPRINE ORAL CAPSULE 250 MG 1 PA

SYSTANE OPHTHALMIC GEL 0.4-0.3 % 1(SO)

TABLOID ORAL TABLET 40 MG 1 PA

tacrolimus external ointment 0.03 %, 0.1 % 1 ST

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1

TAFINLAR ORAL CAPSULE 50 MG 1 PA; LA; QL (186 per 31 days)

TAFINLAR ORAL CAPSULE 75 MG 1 PA; LA; QL (124 per 31 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG 1 PA; LA

TAKE ACTION ORAL TABLET 1.5 MG 1(SO)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML


tamoxifen citrate oral tablet 10 mg, 20 mg 1


98

Drug Tier Notes

tamsulosin hcl oral capsule 0.4 mg 1 QL (62 per 31 days)

TARCEVA ORAL TABLET 100 MG, 150 MG 1 PA; QL (31 per 31 days)

TARCEVA ORAL TABLET 25 MG 1 PA; QL (93 per 31 days)

TARGRETIN EXTERNAL GEL 1 % 1 PA

TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG

1

TASIGNA ORAL CAPSULE 150 MG, 200 MG 1 PA; QL (124 per 31 days)

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % 1 PA

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % 1 PA

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG


TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 360 MG


TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML

1

TECFIDERA ORAL 120 & 240 MG 1 PA

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

1 PA

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

1

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG

1

telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 QL (31 per 31 days)

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg


telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg


temazepam oral capsule 15 mg, 22.5 mg, 30 mg 1 QL (31 per 31 days)

temazepam oral capsule 7.5 mg 1 QL (124 per 31 days)

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

terbinafine hcl external cream 1 % 1(CW)

terbinafine hcl oral tablet 250 mg 1 QL (93 per 365 days)

terbutaline sulfate injection solution 1 mg/ml 1


99

Drug Tier Notes

terbutaline sulfate oral tablet 2.5 mg, 5 mg 1

terconazole vaginal cream 0.4 %, 0.8 % 1

terconazole vaginal suppository 80 mg 1

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1

testosterone enanthate intramuscular solution 200 mg/ml

1

testosterone transdermal gel 12.5 mg/act (1%) 1

tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml

1

tetrabenazine oral tablet 12.5 mg, 25 mg 1

tetracycline hcl oral capsule 250 mg, 500 mg 1

THALOMID ORAL CAPSULE 100 MG, 200 MG, 50 MG


THALOMID ORAL CAPSULE 150 MG 1 PA; QL (62 per 31 days)

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg

1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

1

theophylline oral solution 80 mg/15ml 1

THERA-D 4000 ORAL TABLET 4000 UNIT 1(CW)

thiamine hcl oral tablet 100 mg 1(CW)

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1 PA; HR

thiotepa injection solution reconstituted 15 mg 1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

1

tiagabine hcl oral tablet 2 mg, 4 mg 1

TIGER BALM LINIMENT EXTERNAL LIQUID 16-28 %

1(CW)

TIGER BALM MUSCLE RUB EXTERNAL CREAM 3-5-15 %

1(CW)

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

1


100

Drug Tier Notes

timolol maleate ophthalmic solution 0.25 %, 0.5 % 1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

TINACTIN EXTERNAL AEROSOL 1 % 1(SO)

TINACTIN EXTERNAL CREAM 1 % 1(SO)

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


tizanidine hcl oral tablet 2 mg, 4 mg 1

TOBI PODHALER INHALATION CAPSULE 28 MG

1 PA

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

1

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

1

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

1

tobramycin inhalation nebulization solution 300 mg/5ml

1

tobramycin ophthalmic solution 0.3 % 1

tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml

1

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

1

tolazamide oral tablet 250 mg, 500 mg 1

tolbutamide oral tablet 500 mg 1

tolnaftate antifungal external cream 1 % 1(SO)

tolnaftate external aerosol powder 1 % 1(SO)

tolnaftate external powder 1 % 1(SO)

tolnaftate external solution 1 % 1(SO)

tolnaftate powder 1(SO)

topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

1

topiramate oral capsule sprinkle 15 mg, 25 mg 1

topiramate oral tablet 100 mg, 200 mg, 50 mg 1 QL (124 per 31 days)

topiramate oral tablet 25 mg 1 QL (93 per 31 days)


101

Drug Tier Notes

topotecan hcl intravenous solution reconstituted 4 mg

1

TORISEL INTRAVENOUS SOLUTION 25 MG/ML


torsemide oral tablet 100 mg, 20 mg 1

total fiber oral powder 1(CW)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

1

TPN ELECTROLYTES INTRAVENOUS SOLUTION

1

TRACLEER ORAL TABLET 125 MG, 62.5 MG 1 QL (62 per 31 days)

TRADJENTA ORAL TABLET 5 MG 1 QL (31 per 31 days)

tramadol hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg


tramadol hcl oral tablet 50 mg 1 QL (248 per 31 days)

tramadol-acetaminophen oral tablet 37.5-325 mg 1 QL (381 per 31 days)

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

tranexamic acid intravenous solution 1000 mg/10ml

1

tranexamic acid oral tablet 650 mg 1 QL (30 per 5 days)

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS


tranylcypromine sulfate oral tablet 10 mg 1

TRAVASOL INTRAVENOUS SOLUTION 10 % 1

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

1

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

1

TRECATOR ORAL TABLET 250 MG 1

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

1 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1


102

Drug Tier Notes

tretinoin external gel 0.01 %, 0.025 % 1

tretinoin microsphere external gel 0.04 %, 0.1 % 1

tretinoin oral capsule 10 mg 1

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

1

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide external lotion 0.025 %, 0.1 %

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide mouth/throat paste 0.1 % 1

TRIAMINIC COUGH & CONGESTION ORAL SYRUP 5-100 MG/5ML

1(SO)

triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg

1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

triazolam oral tablet 0.125 mg 1 QL (31 per 31 days)

triazolam oral tablet 0.25 mg 1 QL (62 per 31 days)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

1

trifluridine ophthalmic solution 1 % 1

trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA; HR

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA; HR

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

1

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

1

trimethoprim oral tablet 100 mg 1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

1 PA; HR

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG



103

Drug Tier Notes

triple antibiotic external ointment 3.5-400-5000 1(SO)

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRISENOX INTRAVENOUS SOLUTION 10 MG/10ML

1

TRISPEC DMX PEDIATRIC ORAL LIQUID 10-187 MG/5ML

1(SO)

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

1

TRIUMEQ ORAL TABLET 600-50-300 MG 1

TRIVORA (28) ORAL TABLET 1

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

1

TROPHAMINE INTRAVENOUS SOLUTION 10 %

1

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

1

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG


trymine cg oral liquid 225-7.5 mg/5ml 1(ND)

TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE 1177 MG

1(CW)

TUMS E-X 750 ORAL TABLET CHEWABLE 750 MG

1(CW)

TUMS KIDS ORAL TABLET CHEWABLE 750 MG

1(CW)

TUMS ORAL TABLET CHEWABLE 500 MG 1(CW)

TUMS SMOOTHIES ORAL TABLET CHEWABLE 750 MG

1(CW)

TUMS ULTRA 1000 ORAL TABLET CHEWABLE 1000 MG

1(CW)

tussin cough oral syrup 15 mg/5ml 1(SO)

tussin dm max adult oral liquid 10-200 mg/5ml 1(SO)

TWINRIX INTRAMUSCULAR SUSPENSION 720-20

1


104

Drug Tier Notes

TYBOST ORAL TABLET 150 MG 1

TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

1

TYKERB ORAL TABLET 250 MG 1 PA; QL (186 per 31 days)

TYLENOL EXTRA STRENGTH ORAL TABLET 500 MG

1(SO)

TYLENOL INFANTS PAIN+FEVER ORAL SUSPENSION 160 MG/5ML

1(SO)

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML

1

TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

1 PA

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG

1 ST

UCERIS RECTAL FOAM 2 MG/ACT 1 ST

ULTRA MIDE 25 EXTERNAL LOTION 25 % 1(CW)

ULTRACIN T EXTERNAL LOTION 10 % 1(CW)

ULTRACIN-M EXTERNAL GEL 10 % 1(CW)

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

1 PA; LA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

1 PA; LA

urea external cream 10 %, 20 %, 39 %, 40 %, 45 %, 47 %, 50 %

1(CW)

urea external gel 40 % 1(CW)

urea external lotion 10 %, 40 %, 45 % 1(CW)

urea external suspension 40 % 1(CW)

urevaz external cream 44 % 1(CW)

ursodiol oral capsule 300 mg 1

ursodiol oral tablet 250 mg, 500 mg 1

UTOPIC EXTERNAL CREAM 41 % 1(CW)


105

Drug Tier Notes

valacyclovir hcl oral tablet 1 gm 1 QL (93 per 31 days)

valacyclovir hcl oral tablet 500 mg 1 QL (62 per 31 days)

VALCHLOR EXTERNAL GEL 0.016 % 1

valganciclovir hcl oral solution reconstituted 50 mg/ml

1

valganciclovir hcl oral tablet 450 mg 1

valproate sodium intravenous solution 500 mg/5ml 1

valproic acid oral capsule 250 mg 1

valproic acid oral syrup 250 mg/5ml 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg


vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg

1

vancomycin hcl oral capsule 125 mg, 250 mg 1

vaporizing steam inhalation liquid 6.2 % 1(CW)

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

1

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

1

VASCEPA ORAL CAPSULE 1 GM 1

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG


VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

1

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

1 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

1 PA

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg


venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg, 37.5 mg, 75 mg



106

Drug Tier Notes

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML


VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


verapamil hcl er oral capsule extended release 24 hour 100 mg, 300 mg


verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 200 mg, 240 mg, 360 mg


verapamil hcl er oral tablet extended release 180 mg, 240 mg

1

verapamil hcl intravenous solution 2.5 mg/ml 1

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

VERSACLOZ ORAL SUSPENSION 50 MG/ML 1 ST; QL (558 per 31 days)

VESICARE ORAL TABLET 10 MG, 5 MG 1 PA; HR

VESTURA ORAL TABLET 3-0.02 MG 1

VICKS DAYQUIL COUGH ORAL LIQUID 15 MG/15ML

1(SO)

VICKS DAYQUIL MUCUS CONTROL DM ORAL LIQUID 10-200 MG/15ML

1(SO)

VICKS NATURE FUSION CONGEST ORAL LIQUID 20-200 MG/30ML

1(SO)

VICODIN ES ORAL TABLET 7.5-300 MG 1 QL (382 per 31 days)

VICODIN HP ORAL TABLET 10-300 MG 1 QL (382 per 31 days)

VICODIN ORAL TABLET 5-300 MG 1 QL (382 per 31 days)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML

1

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM

1 QL (1240 per 31 days)

VIGAMOX OPHTHALMIC SOLUTION 0.5 % 1

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

1

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG



107

Drug Tier Notes

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

1

VIMPAT ORAL SOLUTION 10 MG/ML 1 QL (1442 per 31 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

1

vinblastine sulfate intravenous solution 1 mg/ml 1

vincasar pfs intravenous solution 1 mg/ml 1

vincristine sulfate intravenous solution 1 mg/ml 1

vinorelbine tartrate intravenous solution 50 mg/5ml

1

VIRACEPT ORAL TABLET 250 MG 1 QL (310 per 31 days)

VIRACEPT ORAL TABLET 625 MG 1 QL (124 per 31 days)

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

1

VIREAD ORAL POWDER 40 MG/GM 1 QL (248 per 31 days)

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG


vision plus oral capsule 1(CW)

vision vitamins oral tablet 1(CW)

VITAMELTS ENERGY VITAMIN B-12 ORAL TABLET DISPERSIBLE 1500 MCG

1(CW)

vitamin b1 oral tablet 100 mg 1(CW)

vitamin b-12 er oral tablet extended release 2000 mcg

1(CW)

vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 50 mcg, 500 mcg

1(CW)

vitamin b12 oral tablet extended release 1000 mcg 1(CW)

vitamin b-12 sublingual tablet sublingual 1000 mcg, 2500 mcg, 500 mcg, 5000 mcg

1(CW)

vitamin b-6 oral tablet 25 mg, 50 mg 1(CW)

vitamin b6 oral tablet 250 mg 1(CW)

vitamin d (cholecalciferol) oral capsule 1000 unit, 400 unit

1(CW)

vitamin d (cholecalciferol) oral tablet 1000 unit 1(CW)

vitamin d (ergocalciferol) oral capsule 50000 unit 1(ND)


108

Drug Tier Notes

vitamin d2 oral tablet 2000 unit, 400 unit 1(CW)

vitamin d3 maximum strength oral capsule 5000 unit

1(CW)

vitamin d3 oral capsule 10000 unit, 2000 unit, 50000 unit

1(CW)

vitamin d3 oral liquid 1200 unit/15ml, 5000 unit/ml

1(CW)

vitamin d3 oral tablet 2000 unit, 3000 unit, 400 unit, 5000 unit, 50000 unit

1(CW)

vitamin d3 oral tablet chewable 1000 unit, 400 unit, 5000 unit

1(CW)

vitamin k (phytonadione) oral tablet 100 mcg 1(CW)

vitamin k1 injection solution 1 mg/0.5ml 1(CW)

voriconazole intravenous solution reconstituted 200 mg

1 PA

voriconazole oral suspension reconstituted 40 mg/ml

1 PA

voriconazole oral tablet 200 mg, 50 mg 1 PA; QL (124 per 31 days)

VOTRIENT ORAL TABLET 200 MG 1 PA; QL (124 per 31 days)

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

1

VRAYLAR ORAL CAPSULE 1.5 MG 1 PA; QL (120 per 30 days)

VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG


VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

1 ST

VYFEMLA ORAL TABLET 0.4-35 MG-MCG 1

WAL-TUSSIN COUGH/COLD ORAL SYRUP 30-15 MG/5ML

1(SO)

WAL-ZYR CHILDRENS ORAL SOLUTION 1 MG/ML

1(SO)

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

WYMZYA FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG

1

XALKORI ORAL CAPSULE 200 MG, 250 MG 1 PA; QL (62 per 31 days)


109

Drug Tier Notes

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

1

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

1

XELJANZ ORAL TABLET 5 MG 1 ST

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML


XIFAXAN ORAL TABLET 550 MG 1 PA; QL (62 per 31 days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG


xoten external lotion 12.5-6.25 % 1(CW)

XTANDI ORAL CAPSULE 40 MG 1 ST; QL (124 per 31 days)

XYREM ORAL SOLUTION 500 MG/ML 1 LA; QL (558 per 31 days)

YERVOY INTRAVENOUS SOLUTION 50 MG/10ML

1 PA

YF-VAX SUBCUTANEOUS INJECTABLE 1

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

1 PA

yuvafem vaginal tablet 10 mcg 1

zafirlukast oral tablet 10 mg, 20 mg 1 QL (62 per 31 days)

zaleplon oral capsule 10 mg, 5 mg 1 PA; HR; QL (93 per 365 days)

ZANTAC 75 ORAL TABLET 75 MG 1(CW)

ZAVESCA ORAL CAPSULE 100 MG 1 PA; QL (93 per 31 days)

ZELBORAF ORAL TABLET 240 MG 1 PA; QL (248 per 31 days)

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

1

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG

1

ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG

1


110

Drug Tier Notes

ZENCHENT ORAL TABLET 0.4-35 MG-MCG 1

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT

1

ZENZEDI ORAL TABLET 10 MG 1 QL (186 per 31 days)

ZENZEDI ORAL TABLET 5 MG 1 QL (155 per 31 days)

ZEPATIER ORAL TABLET 50-100 MG 1 PA

ZETIA ORAL TABLET 10 MG 1 QL (31 per 31 days)

ZIAGEN ORAL SOLUTION 20 MG/ML 1 QL (995 per 31 days)

zidovudine oral capsule 100 mg 1 QL (186 per 31 days)

zidovudine oral syrup 50 mg/5ml 1 QL (1736 per 28 days)

zidovudine oral tablet 300 mg 1 QL (62 per 31 days)

ZIMS MAX-FREEZE EXTERNAL GEL 3.7 % 1(CW)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg


ZIRGAN OPHTHALMIC GEL 0.15 % 1

zoledronic acid intravenous concentrate 4 mg/5ml 1

zoledronic acid intravenous solution 5 mg/100ml 1

ZOLINZA ORAL CAPSULE 100 MG 1 PA; QL (124 per 31 days)

zolpidem tartrate oral tablet 10 mg, 5 mg 1 PA; HR; QL (93 per 365 days)

ZOMETA INTRAVENOUS SOLUTION 4 MG/100ML

1

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1

ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG 1 ST; QL (62 per 31 days)

ZORTRESS ORAL TABLET 0.5 MG 1 ST; QL (124 per 31 days)

ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML


ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

1

ZYDELIG ORAL TABLET 100 MG, 150 MG 1

ZYKADIA ORAL CAPSULE 150 MG 1 QL (155 per 31 days)

ZYNCOF ORAL SYRUP 20-400 MG/5ML 1(SO)


111

Drug Tier Notes

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG

1

ZYRTEC ALLERGY ORAL CAPSULE 10 MG 1(SO)

ZYRTEC ALLERGY ORAL TABLET 10 MG 1(SO)

ZYRTEC CHILDRENS ALLERGY ORAL TABLET CHEWABLE 10 MG

1(SO)

ZYRTEC-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG

1(SO)

ZYTIGA ORAL TABLET 250 MG 1 QL (124 per 31 days)

112

Alphabetical Listing A abacavir sulfate ....................... 2 abacavir sulfate-lamivudine ... 2 abacavir-lamivudine-

zidovudine .......................... 2 ABELCET .............................. 2 ABILIFY MAINTENA .......... 2 ABRAXANE .......................... 2 ABSORICA ............................ 2 acamprosate calcium .............. 2 acarbose .................................. 2 acebutolol hcl ......................... 2 acetaminophen ........................ 2 acetaminophen er.................... 2 acetaminophen extra strength . 2 acetaminophen-codeine .......... 3 acetaminophen-codeine #2 ..... 2 acetaminophen-codeine #3 ..... 2 acetaminophen-codeine #4 ..... 3 acetazolamide ......................... 3 acetic acid ............................... 3 acetylcysteine ......................... 3 ACID GONE .......................... 3 acidophilus ............................. 3 acidophilus extra strength....... 3 acidophilus probiotic .............. 3 acitretin ................................... 3 acne maximum strength ......... 3 acne medication 10 ................. 3 acne medication 5 ................... 3 acne treatment ........................ 3 ACTEMRA ............................ 3 ACTHIB ................................. 3 ACTIMMUNE ....................... 3 acyclovir ................................. 3 acyclovir sodium .................... 3 ADACEL ................................ 3 ADAGEN ............................... 4 adapalene ................................ 4 ADCIRCA .............................. 4 adefovir dipivoxil ................... 4 ADEMPAS ............................. 4 adriamycin .............................. 4 adrucil ..................................... 4 ADVAIR DISKUS ................. 4 ADVAIR HFA ....................... 4 ADVIL ................................... 4

ADVIL JUNIOR STRENGTH ............................................ 4

AFEDITAB CR ...................... 4 AFINITOR ............................. 4 AFINITOR DISPERZ ............ 4 AFTERA ................................ 4 ALBENZA ............................. 4 albuterol sulfate .................. 4, 5 albuterol sulfate er .................. 4 alclometasone dipropionate .... 5 ALDURAZYME .................... 5 ALECENSA ........................... 5 alendronate sodium................. 5 alevazol ................................... 5 ALEVE ................................... 5 ALIMTA ................................ 5 ALINIA .................................. 5 ALIVIO .................................. 5 all day allergy ......................... 5 allergy medication .................. 5 allergy relief ........................... 5 allergy relief-d ........................ 5 allopurinol .............................. 5 ALMACONE ......................... 5 alosetron hcl ........................... 5 ALPHAGAN P ....................... 5 alprazolam .......................... 5, 6 alprazolam er .......................... 5 ALPRAZOLAM INTENSOL 5 alprazolam xr .......................... 6 aluminum hydroxide gel ......... 6 alyacen 1/35 ............................ 6 amantadine hcl ........................ 6 AMBISOME .......................... 6 amcinonide ............................. 6 AMETHIA.............................. 6 amikacin sulfate ...................... 6 amiloride hcl ........................... 6 amiloride-hydrochlorothiazide

............................................ 6 aminophylline ......................... 6 AMINOSYN II ....................... 6 AMINOSYN

II/ELECTROLYTES .......... 6 AMINOSYN/ELECTROLYT

ES ....................................... 6 AMINOSYN-HBC ................. 6 AMINOSYN-PF ..................... 6

AMINOSYN-RF .................... 6 amiodarone hcl ................... 6, 7 AMITIZA ............................... 7 amitriptyline hcl ...................... 7 amlodipine besy-benazepril hcl

............................................ 7 amlodipine besylate ................ 7 amlodipine besylate-valsartan 7 amlodipine-atorvastatin .......... 7 amlodipine-olmesartan ........... 7 amlodipine-valsartan-hctz ...... 7 ammonium lactate .................. 7 amoxapine ............................... 7 amoxicill-clarithro-lansopraz . 7 amoxicillin .............................. 7 amoxicillin-pot clavulanate .... 7 amphetamine-

dextroamphetamine ............ 8 amphotericin b ........................ 8 ampicillin ................................ 8 ampicillin sodium ................... 8 ampicillin-sulbactam sodium .. 8 AMPYRA ............................... 8 ANADROL-50 ....................... 8 anastrozole .............................. 8 ANDRODERM ...................... 8 ANDROGEL .......................... 8 antacid ..................................... 8 antacid & antigas .................... 8 antacid extra strength .............. 8 antacid ultra strength .............. 8 anti-diarrheal ........................... 8 antifungal ................................ 8 anti-itch maximum strength .... 9 anti-oxidant formula ............... 9 antiseptic skin cleanser ........... 9 ANUSOL-HC ......................... 9 APOKYN ............................... 9 apraclonidine hcl .................... 9 aprepitant ................................ 9 APRI ....................................... 9 APRISO .................................. 9 APTIOM ................................. 9 APTIVUS ............................... 9 AQUORAL ............................. 9 ARANELLE ........................... 9 ARCALYST ........................... 9 aripiprazole ............................. 9

113

ARIPIPRAZOLE ................... 9 ARISTADA ............................ 9 ARNUITY ELLIPTA ............. 9 arthricream rub ....................... 9 ARTHRITIS HOT ................ 10 arthritis pain relief ................ 10 arthritis relief/aloe ................ 10 artificial tears ........................ 10 ARZOL SILVER NIT

APPLICATORS ............... 10 ASCOMP-CODEINE .......... 10 ASPERCREME .................... 10 ASPERCREME HEAT ........ 10 ASPERCREME LIDOCAINE

.......................................... 10 aspirin ................................... 10 aspirin ec .............................. 10 aspirin ec low strength.......... 10 aspirin-dipyridamole er ........ 10 ASSURE ID INSULIN

SAFETY SYR .................. 10 ASTAGRAF XL .................. 10 atenolol ................................. 10 atenolol-chlorthalidone......... 10 athletes foot .......................... 10 athletes foot powder spray.... 10 athletes foot spray................. 10 atorvastatin calcium.............. 11 atovaquone ........................... 11 atovaquone-proguanil hcl ..... 11 ATRIPLA ............................. 11 atropine sulfate ..................... 11 ATROVENT HFA ............... 11 AUBAGIO ........................... 11 AUBRA ................................ 11 AVASTIN ............................ 11 AVIANE............................... 11 AVONEX ............................. 11 AVONEX PEN .................... 11 AVONEX PREFILLED ....... 11 AYR ..................................... 11 AYR NASAL MIST

ALLERGY/SINUS .......... 11 AYR SALINE NASAL ........ 11 azacitidine............................. 11 AZASAN .............................. 11 AZASITE ............................. 11 azathioprine .......................... 11 azathioprine sodium ............. 11 azelastine hcl .................. 11, 12

azithromycin ......................... 12 AZOLEN TINCTURE ......... 12 AZOPT ................................. 12 aztreonam ............................. 12 B b-12 ....................................... 12 b-12 compliance injection .... 12 B-12 DOTS........................... 12 b-6 ......................................... 12 bacitracin .............................. 12 bacitracin-neomycin-

polymyxin ......................... 12 bacitracin-polymyxin b......... 12 bacitra-neomycin-polymyxin-

hc ...................................... 12 baclofen ................................ 12 balsalazide disodium ............ 12 BALZIVA ............................ 12 BANZEL ........................ 12, 13 BARACLUDE ..................... 13 BAYER ADVANCED

ASPIRIN EX ST .............. 13 BAYER ASPIRIN ................ 13 BAYER ASPIRIN EC LOW

DOSE................................ 13 bcg vaccine ........................... 13 bedding spray lice treatment. 13 BELEODAQ ........................ 13 BENADRYL ALLERGY..... 13 BENADRYL ALLERGY

CHILDRENS.................... 13 benazepril hcl ....................... 13 benazepril-hydrochlorothiazide

.......................................... 13 BENEFIBER ........................ 13 BENEFIBER ON THE GO .. 13 BENGAY COLD THERAPY

.......................................... 13 BENGAY ULTRA

STRENGTH ..................... 13 BENGAY VANISHING

SCENT ............................. 13 BENLYSTA ......................... 13 benzonatate ........................... 13 benzoyl peroxide .................. 13 benzoyl peroxide wash ......... 13 benzoyl peroxide-erythromycin

.......................................... 14 benztropine mesylate ............ 14

BERRI-FREEZ PAIN RELIEVING ..................... 14

betamethasone dipropionate . 14 betamethasone dipropionate

aug .................................... 14 betamethasone valerate ......... 14 BETASERON ....................... 14 betaxolol hcl ......................... 14 bethanechol chloride ............. 14 bexarotene ............................. 14 BEXSERO ............................ 14 bicalutamide ......................... 14 BICILLIN C-R ..................... 15 BICILLIN C-R 900/300 ....... 14 BICILLIN L-A ..................... 15 BICNU .................................. 15 BIOFREEZE ......................... 15 biospec dmx .......................... 15 BIOTENE MOISTURIZING

MOUTH ........................... 15 BIOTENE ORALBALANCE

DRY MOUTH .................. 15 bisacodyl ec .......................... 15 bisacodyl laxative ................. 15 bisoprolol fumarate ............... 15 bisoprolol-hydrochlorothiazide

.......................................... 15 bleomycin sulfate .................. 15 BLEPHAMIDE .................... 15 BLEPHAMIDE S.O.P. ......... 15 BOOSTRIX .......................... 15 BOSULIF ............................. 15 bp wash ................................. 15 BREO ELLIPTA .................. 15 briellyn .................................. 15 BRILINTA ........................... 15 brimonidine tartrate .............. 15 BRIVIACT ........................... 16 bromfenac sodium ................ 16 bromocriptine mesylate ........ 16 budesonide ............................ 16 bumetanide ........................... 16 buprenorphine hcl ................. 16 bupropion hcl ........................ 16 bupropion hcl er (smoking det)

.......................................... 16 bupropion hcl er (sr) ............. 16 bupropion hcl er (xl) ............. 16 buspirone hcl ........................ 16 BUSULFEX ......................... 16

114

butalbital-apap-caff-cod ....... 16 BYDUREON ........................ 16 BYETTA 10 MCG PEN ...... 17 BYETTA 5 MCG PEN ........ 17 C cabergoline ........................... 17 CABOMETYX .................... 17 CAFERGOT ......................... 17 CALCET CREAMY BITES 17 CALCI-MIX ......................... 17 calcipotriene ......................... 17 calcipotriene-betameth diprop

.......................................... 17 calcitonin (salmon) ............... 17 cal-citrate plus vitamin d ...... 17 calcitriol ................................ 17 calcium ................................. 18 calcium + d3 ......................... 17 calcium 1000 + d .................. 17 calcium 500 + d .................... 17 calcium 500 + d3 .................. 17 calcium 500 +d ..................... 17 calcium 500/d ....................... 17 calcium 500+d ...................... 17 calcium 600 .......................... 17 calcium 600/vitamin d .......... 17 calcium 600+d ...................... 18 calcium 600-d ....................... 18 calcium acetate (phos binder)

.......................................... 18 calcium antacid extra strength

.......................................... 18 calcium carbonate ................. 18 calcium carbonate antacid .... 18 calcium carbonate-vitamin d 18 calcium citrate ...................... 18 calcium citrate + d ................ 18 calcium citrate + d3 .............. 18 calcium citrate-vitamin d ...... 18 calcium plus vitamin d3 ....... 18 calcium-vitamin d ................. 18 calcium-vitamin d3 ............... 18 CALTRATE 600+D3 SOFT 18 CAMILA .............................. 18 CANCIDAS ......................... 19 candesartan cilexetil ............. 19 candesartan cilexetil-hctz ..... 19 CAPASTAT SULFATE ....... 19 CAPRELSA ......................... 19 capsaicin ............................... 19

capsaicin arthritis relief ........ 19 capsaicin hot patch ............... 19 capsaicin hp .......................... 19 captopril ................................ 19 captopril-hydrochlorothiazide

.......................................... 19 CAPZASIN-P ....................... 19 CARBAGLU ........................ 19 carbamazepine ...................... 19 carbamazepine er .................. 19 carbidopa-levodopa .............. 19 carbidopa-levodopa er .......... 19 carbidopa-levodopa-

entacapone ........................ 20 carbinoxamine maleate ......... 20 carboplatin ............................ 20 carisoprodol-aspirin .............. 20 carisoprodol-aspirin-codeine 20 carteolol hcl .......................... 20 CARTIA XT ......................... 20 carvedilol .............................. 20 CASTIVA COOLING .......... 20 CASTIVA WARMING ........ 20 castor oil ............................... 20 CAYSTON ........................... 20 caziant ................................... 20 cefaclor ................................. 20 cefaclor er ............................. 20 cefadroxil .............................. 20 cefazolin sodium................... 20 cefdinir............................ 20, 21 cefepime hcl ......................... 21 cefotaxime sodium ............... 21 cefotetan disodium ............... 21 cefoxitin sodium ................... 21 cefpodoxime proxetil ............ 21 cefprozil ................................ 21 ceftazidime ........................... 21 ceftriaxone sodium ............... 21 cefuroxime axetil .................. 21 cefuroxime sodium ............... 21 celecoxib ............................... 21 CELONTIN .......................... 21 cephalexin ............................. 21 CEREZYME ........................ 21 cetirizine hcl ......................... 22 cetirizine hcl allergy child .... 22 cetirizine-pseudoephedrine er

.......................................... 22 cevimeline hcl ....................... 22

CHANTIX ............................ 22 CHANTIX CONTINUING

MONTH PAK .................. 22 CHANTIX STARTING

MONTH PAK .................. 22 cheratussin ac ........................ 22 chest rub ................................ 22 childrens acetaminophen ...... 22 childrens ibuprofen 100 ........ 22 childrens loratadine .............. 22 childrens mucus relief cough 22 childrens pepto ...................... 22 childrens silfedrine ............... 22 CHILDRENS SOOTHE ....... 22 childs ibuprofen .................... 22 chloramphenicol sod succinate

.......................................... 22 chlordiazepoxide hcl ............. 22 chlorhexidine gluconate .. 22, 23 chloroquine phosphate .......... 23 chlorothiazide ....................... 23 chlorothiazide sodium .......... 23 chlorpromazine hcl ............... 23 chlorpropamide ..................... 23 chlorthalidone ....................... 23 chlorzoxazone ....................... 23 cholestyramine light ............. 23 chorionic gonadotropin ......... 23 CIALIS ................................. 23 ciclopirox .............................. 23 ciclopirox olamine ................ 23 cilostazol ............................... 23 CIMZIA ................................ 23 CIMZIA PREFILLED .......... 23 CINRYZE ............................. 23 ciprofloxacin ......................... 23 ciprofloxacin hcl ................... 23 ciprofloxacin in d5w ............. 23 cisplatin ................................. 24 citalopram hydrobromide ..... 24 CITRUCEL ........................... 24 cladribine .............................. 24 CLARAVIS .......................... 24 clarithromycin ....................... 24 clarithromycin er .................. 24 CLARITIN ........................... 24 CLARITIN ALLERGY

CHILDRENS .................... 24 CLARITIN CHILDRENS .... 24 CLARITIN-D 12 HOUR ...... 24

115

CLARITIN-D 24 HOUR ...... 24 clemastine fumarate.............. 24 clindamycin hcl .................... 24 clindamycin palmitate hcl .... 24 clindamycin phos-benzoyl

perox ................................. 24 clindamycin phosphate ... 24, 25 clindamycin phosphate in d5w

.......................................... 25 CLINIMIX E/DEXTROSE

(2.75/5) ............................. 25 CLINIMIX E/DEXTROSE

(4.25/10) ........................... 25 CLINIMIX E/DEXTROSE

(4.25/25) ........................... 25 CLINIMIX E/DEXTROSE

(5/15) ................................ 25 CLINIMIX/DEXTROSE

(2.75/5) ............................. 25 CLINIMIX/DEXTROSE

(4.25/10) ........................... 25 CLINIMIX/DEXTROSE



(4.25/5) ............................. 25 CLINIMIX/DEXTROSE



(5/25) ................................ 25 clobetasol propionate............ 25 clobetasol propionate e ......... 25 clomipramine hcl .................. 26 clonazepam ........................... 26 clonidine hcl ......................... 26 clopidogrel bisulfate ............. 26 clorazepate dipotassium ....... 26 clotrimazole .......................... 26 clotrimazole 3 ....................... 26 clotrimazole af ...................... 26 clotrimazole-7....................... 26 clotrimazole-betamethasone . 26 clozapine............................... 26 COARTEM .......................... 26 COLACE .............................. 26 COLACE CLEAR ................ 26 colchicine ............................. 26

colchicine-probenecid .......... 26 colestipol hcl......................... 26 colistimethate sodium ........... 27 COMBIGAN ........................ 27 COMBIVENT RESPIMAT . 27 COMETRIQ (100 MG DAILY

DOSE) .............................. 27 COMETRIQ (140 MG DAILY

DOSE) .............................. 27 COMETRIQ (60 MG DAILY

DOSE) .............................. 27 COMFORT ASSIST INSULIN

SYRINGE ......................... 27 COMPLERA ........................ 27 compro .................................. 27 cool n heat ............................ 27 COPAXONE ........................ 27 cortisone acetate ................... 27 COSENTYX ......................... 27 COSENTYX SENSOREADY

PEN .................................. 27 COTELLIC ........................... 27 cough relief ........................... 27 cough syrup .......................... 27 CREON ................................ 27 CREO-TERPIN .................... 27 CRIXIVAN .................... 27, 28 cromolyn sodium .................. 28 CRYSELLE-28 .................... 28 cvs antacid supreme.............. 28 cvs b-12 ................................ 28 cvs fluticasone propionate .... 28 cvs gauze sterile .................... 28 cvs glucose bits ..................... 28 cvs hot steam ........................ 28 cvs hydrocortisone acetate .... 28 cvs laxative dietary supplemnt

.......................................... 28 cvs nasal mist........................ 28 cvs natural fiber supplement . 28 cvs senna-extra ..................... 28 cvs slow release iron ............. 28 cvs sore muscle rub .............. 28 cvs stool softener .................. 28 cvs targeted acne spot ........... 28 cyanocobalamin .................... 28 CYCLAFEM 1/35 ................ 28 CYCLAFEM 7/7/7 ............... 28 cyclobenzaprine hcl .............. 28 cyclophosphamide ................ 28

cyclosporine .................... 28, 29 cyclosporine modified .......... 29 cyproheptadine hcl ................ 29 CYRAMZA .......................... 29 CYSTADANE ...................... 29 CYSTAGON ........................ 29 CYSTARAN ......................... 29 cytarabine ............................. 29 cytarabine (pf) ...................... 29 D D3 DOTS .............................. 29 dacarbazine ........................... 29 DAKLINZA ......................... 29 DALIRESP ........................... 29 danazol .................................. 29 dapsone ................................. 29 DAPTACEL ......................... 29 daptomycin ........................... 29 DARAPRIM ......................... 29 daunorubicin hcl ................... 29 daytime cough ...................... 29 DEBLITANE ........................ 29 DEBROX .............................. 29 DECARA .............................. 29 decitabine .............................. 29 DELSYM COUGH/CHEST

CONGEST DM ................ 30 DELYLA .............................. 30 DEMSER .............................. 30 DEPEN TITRATABS .......... 30 DEPO-PROVERA ................ 30 DERMAFUNGAL ............... 30 DESCOVY ........................... 30 desipramine hcl ..................... 30 desloratadine ......................... 30 desmopressin ace spray refrig

.......................................... 30 desmopressin acetate ............ 30 desogestrel-ethinyl estradiol . 30 desonide ................................ 30 desoximetasone ..................... 30 desvenlafaxine er .................. 30 desvenlafaxine succinate er .. 30 DEX4 GLUCOSE GO-

POUCH ............................. 30 dexamethasone ............... 30, 31 DEXAMETHASONE

INTENSOL ....................... 30 dexamethasone sodium

phosphate .......................... 31

116

DEXEDRINE ....................... 31 dexmethylphenidate hcl........ 31 dexrazoxane .......................... 31 dextroamphetamine sulfate .. 31 dextroamphetamine sulfate er

.......................................... 31 dextrose ................................ 31 dextrose in lactated ringers ... 31 dextrose-nacl ........................ 31 DIABETIC TUSSIN ............ 31 DIABETIC TUSSIN DM ..... 31 diazepam......................... 31, 32 DIAZEPAM INTENSOL ..... 31 diclofenac potassium ............ 32 diclofenac sodium ................ 32 diclofenac sodium er ............ 32 dicloxacillin sodium ............. 32 dicyclomine hcl .................... 32 didanosine............................. 32 diflorasone diacetate ............. 32 diflunisal ............................... 32 DIGITEK .............................. 32 digoxin .................................. 32 dihydroergotamine mesylate 32 DILANTIN ........................... 32 diltiazem hcl ......................... 33 diltiazem hcl er ..................... 33 diltiazem hcl er beads ........... 32 diltiazem hcl er coated beads 33 dilt-xr .................................... 33 DIPENTUM ......................... 33 diphenhydramine hcl ............ 33 diphenhydramine hcl (sleep) 33 diphenoxylate-atropine ......... 33 diphtheria-tetanus toxoids dt 33 dipyridamole ........................ 33 disopyramide phosphate ....... 33 disulfiram ............................. 33 divalproex sodium ................ 33 divalproex sodium er ............ 33 docetaxel............................... 33 docusate sodium ................... 34 DOCUSOL KIDS ................. 34 dofetilide............................... 34 donepezil hcl ........................ 34 dorzolamide hcl .................... 34 dorzolamide hcl-timolol mal 34 doxazosin mesylate .............. 34 doxepin hcl ........................... 34 doxercalciferol ...................... 34

doxorubicin hcl ..................... 34 doxorubicin hcl liposomal .... 34 DOXY 100 ........................... 34 doxycycline hyclate .............. 34 doxycycline monohydrate .... 34 DRAMAMINE ..................... 35 DRAMAMINE LESS

DROWSY ......................... 35 dronabinol ............................. 35 drospirenone-ethinyl estradiol

.......................................... 35 DROXIA .............................. 35 duloxetine hcl ....................... 35 DURAFLEX COMFORT .... 35 duramorph ............................ 35 DUREZOL ........................... 35 dutasteride ............................ 35 dutasteride-tamsulosin hcl .... 35 E ear wax drops........................ 35 econazole nitrate ................... 35 ECONTRA EZ ..................... 35 EDURANT ........................... 35 ELIDEL ................................ 35 ELIPHOS.............................. 35 ELIQUIS .............................. 35 ELITEK ................................ 35 EMBEDA ............................. 35 EMCYT ................................ 35 EMEND ................................ 35 EMOQUETTE...................... 35 EMSAM ............................... 36 EMTRIVA ............................ 36 EMVERM ............................ 36 enalapril maleate ................... 36 enalapril-hydrochlorothiazide

.......................................... 36 ENBREL .............................. 36 ENBREL SURECLICK ....... 36 ENDOCET ........................... 36 ENEMEEZ MINI ................. 36 ENGERIX-B ........................ 36 enoxaparin sodium ............... 36 ENPRESSE-28 ..................... 36 entacapone ............................ 36 entecavir ............................... 36 enulose .................................. 37 EPCLUSA ............................ 37 epinastine hcl ........................ 37 EPINEPHRINE .................... 37

EPIPEN 2-PAK .................... 37 EPIPEN JR 2-PAK ............... 37 epirubicin hcl ........................ 37 epitol ..................................... 37 EPIVIR HBV ........................ 37 eplerenone ............................. 37 EPOGEN .............................. 37 eprosartan mesylate .............. 37 eq allergy relief (cetirizine) .. 37 eq allergy relief childrens ..... 37 eq aspirin .............................. 37 eq therapeutic moisturizing .. 37 eql calcium/vitamin d ........... 37 EQUALACTIN .................... 37 ERAXIS ................................ 37 ergoloid mesylates ................ 37 ERIVEDGE .......................... 37 ERRIN .................................. 37 ERWINAZE ......................... 37 ERY-TAB ............................. 38 ERYTHROCIN

LACTOBIONATE ........... 38 ERYTHROCIN STEARATE

.......................................... 38 erythromycin ......................... 38 erythromycin base ................ 38 erythromycin ethylsuccinate . 38 ESBRIET .............................. 38 escitalopram oxalate ............. 38 esomeprazole magnesium ..... 38 esomeprazole sodium ........... 38 ESTRACE ............................ 38 estradiol ................................ 38 estradiol valerate ................... 38 estradiol-norethindrone acet . 38 estropipate ............................. 38 ethambutol hcl ...................... 38 ethosuximide ......................... 38 ethynodiol diac-eth estradiol 39 etodolac ................................. 39 etoposide ............................... 39 EURAX ................................ 39 EVOTAZ .............................. 39 EXEL COMFORT POINT

PEN NEEDLE .................. 39 exel pen needles 1/2 .............. 39 EXELON .............................. 39 exemestane ........................... 39 EXJADE ............................... 39

117

extra strength acetaminophen .......................................... 39

eye itch relief ........................ 39 F FABRAZYME ..................... 39 FALLBACK SOLO ............. 39 FALMINA ............................ 39 famciclovir ........................... 39 famotidine............................. 39 famotidine premixed ............ 39 FANAPT .............................. 39 FANAPT TITRATION PACK

.......................................... 39 FARESTON ......................... 39 FARXIGA ............................ 40 FARYDAK .......................... 40 FASLODEX ......................... 40 felbamate .............................. 40 felodipine er.......................... 40 femynor ................................ 40 fenofibrate ............................ 40 fenofibrate micronized ......... 40 fenofibric acid ...................... 40 fentanyl ................................. 40 fentanyl citrate ...................... 40 FERRIPROX ........................ 40 ferrous gluconate .................. 40 ferrous sulfate ....................... 40 ferrous sulfate er ................... 40 FETZIMA ............................ 40 FETZIMA TITRATION ...... 40 FEVERALL ADULTS ......... 41 FEVERALL CHILDRENS .. 41 FEVERALL INFANTS........ 41 FEVERALL JUNIOR

STRENGTH ..................... 41 fexofenadine hcl ................... 41 fiber ...................................... 41 fiber laxative ......................... 41 fiber therapy ......................... 41 finasteride ............................. 41 FIRAZYR ............................. 41 fish oil ................................... 41 fish oil maximum strength.... 41 FISH OIL PEARLS .............. 41 flecainide acetate .................. 41 FLEET ENEMA ................... 41 FLEXALL ............................ 41 FLEXALL ULTRA PLUS ... 41

FLONASE ALLERGY RELIEF ............................ 41

FLOVENT DISKUS ............ 41 FLOVENT HFA ............. 41, 42 fluconazole ........................... 42 fluconazole in sodium chloride

.......................................... 42 flucytosine ............................ 42 fludarabine phosphate........... 42 fludrocortisone acetate ......... 42 flunisolide ............................. 42 fluocinolone acetonide ......... 42 fluocinolone acetonide body 42 fluocinonide .......................... 42 fluorometholone ................... 42 fluorouracil ........................... 42 fluoxetine hcl ........................ 42 fluphenazine decanoate ........ 43 fluphenazine hcl ................... 43 flurazepam hcl ...................... 43 flurbiprofen ........................... 43 flurbiprofen sodium .............. 43 flutamide ............................... 43 fluticasone propionate .......... 43 fluvoxamine maleate ............ 43 fluvoxamine maleate er ........ 43 folic acid ............................... 43 fomepizole ............................ 43 fondaparinux sodium ............ 43 FORTEO .............................. 43 fosinopril sodium .................. 43 fosinopril sodium-hctz .......... 43 fosphenytoin sodium ............ 43 FRAGMIN............................ 44 FREAMINE HBC ................ 44 FUNGICURE

INTENSIVE/NAILGUARD .......................................... 44

FUNGOID TINCTURE ....... 44 furosemide ............................ 44 FUZEON .............................. 44 FYCOMPA ........................... 44 G gabapentin ............................ 44 GABITRIL ........................... 44 galantamine hydrobromide ... 44 galantamine hydrobromide er

.......................................... 44 GAMASTAN S/D ................ 44 GAMMAGARD ................... 44

ganciclovir sodium ............... 44 GARDASIL .......................... 45 GARDASIL 9 ................. 44, 45 gatifloxacin ........................... 45 GATTEX .............................. 45 GAVILYTE-C ...................... 45 GAVILYTE-G ...................... 45 GAVILYTE-N WITH

FLAVOR PACK .............. 45 GAVISCON ......................... 45 GAVISCON EXTRA

STRENGTH ..................... 45 GELUSIL ............................. 45 gemcitabine hcl ..................... 45 gemfibrozil ........................... 45 generlac ................................. 45 gengraf .................................. 45 GENGRAF ........................... 45 gentamicin in saline .............. 45 gentamicin sulfate ................. 45 GENTEAL SEVERE ............ 45 GEODON ............................. 46 GERI-HYDROLAC 5 .......... 46 geri-mucil ............................. 46 GIANVI ................................ 46 GILDAGIA ........................... 46 GILENYA ............................ 46 GILOTRIF ............................ 46 GLEEVEC ............................ 46 GLEOSTINE ........................ 46 glimepiride ............................ 46 glipizide ................................ 46 glipizide er ............................ 46 glipizide-metformin hcl ........ 46 global alcohol prep ease ....... 46 GLUCAGEN HYPOKIT ...... 46 GLUCAGON EMERGENCY

.......................................... 46 glucose .................................. 46 glycopyrrolate ....................... 46 gnp cold & hot extra strength

.......................................... 46 gnp fish oil ............................ 46 gnp iron ................................. 46 gnp melatonin maximum

strength ............................. 46 gnp motion sickness relief .... 47 gnp vitamin d-400 ................. 47 GOLD BOND PAIN

RELIEVING FOOT ......... 47

118

GORDONS UREA ............... 47 granisetron hcl ...................... 47 griseofulvin microsize .......... 47 guaifenesin ........................... 47 guaifenesin-codeine .............. 47 guaifenesin-dm ..................... 47 guanfacine hcl ...................... 47 guanfacine hcl er .................. 47 guanidine hcl ........................ 47 GYNE-LOTRIMIN .............. 47 GYNE-LOTRIMIN 3 ........... 47 H HALAVEN........................... 47 halobetasol propionate.......... 47 haloperidol ............................ 47 haloperidol decanoate ........... 47 haloperidol lactate ................ 47 HARVONI ........................... 47 HAVRIX .............................. 47 hemorrhoidal ........................ 48 hemorrhoidal cooling ........... 48 heparin (porcine) in d5w ...... 48 heparin sod (porcine) in d5w 48 heparin sodium (porcine) ..... 48 HEPATAMINE .................... 48 HERCEPTIN ........................ 48 HETLIOZ ............................. 48 HEXALEN ........................... 48 HIBERIX .............................. 48 HUMIRA .............................. 48 HUMIRA PEDIATRIC

CROHNS START ............ 48 HUMIRA PEN ..................... 48 HUMIRA PEN-CROHNS

STARTER ........................ 48 HUMIRA PEN-PSORIASIS

STARTER ........................ 48 hydralazine hcl ............... 48, 49 hydrochlorothiazide .............. 49 HYDROCIL ......................... 49 hydrocodone-acetaminophen 49 hydrocodone-ibuprofen ........ 49 hydrocortisone ...................... 49 hydrocortisone acetate .......... 49 hydrocortisone butyr lipo base

.......................................... 49 hydrocortisone butyrate ........ 49 hydrocortisone valerate ........ 49 hydrocortisone-acetic acid.... 49 hydrocortisone-aloe .............. 49

hydromorphone hcl............... 50 hydromorphone hcl er .......... 50 hydromorphone hcl pf .......... 50 hydroxychloroquine sulfate .. 50 hydroxyprogesterone caproate

.......................................... 50 hydroxyurea .......................... 50 hydroxyzine hcl .................... 50 hydroxyzine pamoate ........... 50 HYPERRAB S/D ................. 50 HYSINGLA ER ................... 50 I ibandronate sodium .............. 50 IBRANCE ............................ 50 ibuprofen .............................. 50 ibuprofen junior strength ...... 50 ICAPS LUTEIN & OMEGA-3

.......................................... 50 ICAPS LUTEIN &

ZEAXANTHIN ................ 51 ice blue ................................. 51 ICLUSIG .............................. 51 ICY HOT .............................. 51 ICY HOT NATURALS........ 51 ICY HOT PAIN RELIEVING

.......................................... 51 ICY HOT PM ....................... 51 ICY HOT POWER ............... 51 idarubicin hcl ........................ 51 ifosfamide ............................. 51 ILARIS ................................. 51 ILEVRO ............................... 51 IMBRUVICA ....................... 51 imipenem-cilastatin .............. 51 imipramine hcl ...................... 51 imipramine pamoate ............. 51 imiquimod ............................ 51 IMODIUM A-D ................... 51 IMOVAX RABIES .............. 51 INCRELEX .......................... 51 indapamide ........................... 51 indomethacin ........................ 51 indomethacin er .................... 51 INFANRIX ........................... 51 INLYTA ............................... 52 INTELENCE ........................ 52 intense cough reliever ........... 52 INTRON A ........................... 52 INTROVALE ....................... 52 INVANZ ............................... 52

INVEGA SUSTENNA ......... 52 INVIRASE ........................... 52 INVOKAMET ...................... 52 INVOKAMET XR ............... 52 INVOKANA ......................... 52 IPOL ..................................... 52 ipratropium bromide ............. 52 ipratropium-albuterol ............ 52 irbesartan .............................. 52 irbesartan-hydrochlorothiazide

.......................................... 52 IRESSA ................................ 53 irinotecan hcl ........................ 53 iron ........................................ 53 iron (ferrous gluconate) ........ 53 ISENTRESS ......................... 53 isoniazid ................................ 53 isosorbide dinitrate ............... 53 isosorbide dinitrate er ........... 53 isosorbide mononitrate ......... 53 isosorbide mononitrate er ..... 53 isradipine .............................. 53 ISTODAX ............................. 53 itraconazole ........................... 53 ivermectin ............................. 53 IXIARO ................................ 53 J JAKAFI ................................ 53 JANTOVEN ......................... 53 JANUMET ........................... 53 JANUMET XR ..................... 53 JANUVIA ............................. 53 JENTADUETO .................... 54 JENTADUETO XR .............. 54 JINTELI ................................ 54 jock itch spray ....................... 54 JOLIVETTE ......................... 54 JUNEL 1.5/30 ....................... 54 JUNEL 1/20 .......................... 54 JUNEL FE 1.5/30 ................. 54 JUNEL FE 1/20 .................... 54 JUXTAPID ........................... 54 K KADCYLA ........................... 54 KALETRA ........................... 54 KALYDECO ........................ 54 KARIVA ............................... 54 KAZANO ............................. 54 kcl in dextrose-nacl ............... 54 kcl-lactated ringers-d5w ....... 54

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KELNOR 1/35 ..................... 54 KEPIVANCE ....................... 54 ketoconazole ......................... 55 ketoprofen............................. 55 ketorolac tromethamine ........ 55 ketotifen fumarate ................ 55 KEYTRUDA ........................ 55 KIMIDESS ........................... 55 KINERET ............................. 55 KINRIX ................................ 55 KIONEX............................... 55 KISQALI 200 DOSE ........... 55 KISQALI 400 DOSE ........... 55 KISQALI 600 DOSE ........... 55 KLOR-CON 10 .................... 55 klor-con m10 ........................ 55 KLOR-CON M15 ................. 55 klor-con m20 ........................ 55 KONSYL .............................. 55 KONSYL-D ......................... 56 KORLYM ............................ 56 KUVAN ............................... 56 KYNAMRO ......................... 56 KYPROLIS .......................... 56 L labetalol hcl .......................... 56 LAC-HYDRIN FIVE ........... 56 lactated ringers ..................... 56 lactulose ................................ 56 LAMISIL AF DEFENSE ..... 56 lamivudine ............................ 56 lamivudine-zidovudine ......... 56 lamotrigine ........................... 56 lamotrigine er ....................... 56 lansoprazole .......................... 56 LANTUS .............................. 57 LANTUS SOLOSTAR ........ 56 LARIN 1.5/30 ...................... 57 LARIN 1/20 ......................... 57 LARIN FE 1.5/30 ................. 57 LARIN FE 1/20 .................... 57 larissia................................... 57 LARTRUVO ........................ 57 latanoprost ............................ 57 LATUDA ............................. 57 laxative pills ......................... 57 LAZANDA........................... 57 LEENA ................................. 57 leflunomide........................... 57

LENVIMA 10 MG DAILY DOSE................................ 57






LESSINA.............................. 57 LETAIRIS ............................ 57 letrozole ................................ 57 leucovorin calcium ......... 57, 58 LEUKERAN ........................ 58 LEUKINE ............................. 58 leuprolide acetate .................. 58 LEVEMIR ............................ 58 LEVEMIR FLEXTOUCH ... 58 levetiracetam ........................ 58 levetiracetam er .................... 58 levobunolol hcl ..................... 58 levocarnitine ......................... 58 levocetirizine dihydrochloride

.......................................... 58 levofloxacin .......................... 58 levofloxacin in d5w .............. 58 levoleucovorin calcium ........ 58 LEVONEST ......................... 58 levonorgest-eth estrad 91-day

.......................................... 58 levonorgestrel ....................... 58 LEVORA 0.15/30 (28) ......... 59 levorphanol tartrate ............... 59 levothyroxine sodium ........... 59 LEVOXYL ........................... 59 LEXIVA ............................... 59 LIALDA ............................... 59 lice treatment ........................ 59 LICIDE ................................. 59 lidocaine ............................... 59 lidocaine hcl ......................... 59 lidocaine hcl (pf) .................. 59 lidocaine viscous .................. 59 lidocaine-prilocaine .............. 59 LIDOCARE

ARM/NECK/LEG ............ 59 LIDOCREAM ...................... 59

lindane .................................. 59 linezolid ................................ 59 LINZESS .............................. 59 liothyronine sodium ........ 59, 60 liquid calcium with d3 .......... 60 liquituss gg ............................ 60 lisinopril ................................ 60 lisinopril-hydrochlorothiazide

.......................................... 60 lithium ................................... 60 lithium carbonate .................. 60 lithium carbonate er .............. 60 LOMEDIA 24 FE ................. 60 LONSURF ............................ 60 loperamide hcl ...................... 60 lopinavir-ritonavir ................. 60 loratadine .............................. 60 loratadine allergy relief ......... 60 loratadine-d 24hr .................. 60 lorazepam ............................. 60 LORAZEPAM INTENSOL . 60 LORCET ............................... 60 lorcet hd ................................ 60 LORCET PLUS .................... 60 LORTAB .............................. 60 LORYNA ............................. 60 losartan potassium ................ 61 losartan potassium-hctz ........ 61 LOTEMAX ........................... 61 LOTRIMIN AF .................... 61 LOTRIMIN AF JOCK ITCH

POWDER ......................... 61 lovastatin ............................... 61 low-ogestrel .......................... 61 loxapine succinate ................ 61 lubricant eye ......................... 61 lubricant eye drops ............... 61 LUMIGAN ........................... 61 LUMIZYME ......................... 61 LUPRON DEPOT (1-

MONTH) .......................... 61 LUPRON DEPOT (3-



MONTH) .......................... 61 LUPRON DEPOT-PED (1-

MONTH) .......................... 61 LUTERA .............................. 62

120

LUZU ................................... 62 LYNPARZA......................... 62 LYRICA ............................... 62 LYSODREN......................... 62 LYZA ................................... 62 M MAALOX ADVANCED

MAX ST ........................... 62 mag-al ................................... 62 magnesium ........................... 62 magnesium citrate ................ 62 magnesium oxide.................. 62 magnesium oxide (antacid) .. 62 magnesium oxide -mg

supplement ....................... 62 magnesium sulfate ................ 62 MAKENA ............................ 62 malathion .............................. 62 maprotiline hcl...................... 62 MAR-COF CG

EXPECTORANT ............. 62 marlissa................................. 62 MARPLAN .......................... 62 MATULANE ....................... 62 MATZIM LA ....................... 62 meclizine hcl ........................ 62 medicated pain relieving ...... 63 MEDROX ............................ 63 medroxyprogesterone acetate

.......................................... 63 mefloquine hcl ...................... 63 megestrol acetate .................. 63 MEKINIST ........................... 63 melatonin .............................. 63 melatonin er .......................... 63 melatonin fast meltz ............. 63 melatonin gummies .............. 63 melatonin tr with vitamin b6 63 meloxicam ............................ 63 melphalan hcl ....................... 63 memantine hcl ...................... 63 MENACTRA ....................... 63 mencaps ................................ 64 MENEST .............................. 64 MENHIBRIX ....................... 64 MENOMUNE ...................... 64 MENVEO ............................. 64 meperidine hcl ...................... 64 MEPHYTON ........................ 64 mercaptopurine ..................... 64

meropenem ........................... 64 MESALAMINE ................... 64 mesalamine-cleanser ............ 64 mesna .................................... 64 MESNEX.............................. 64 METADATE ER .................. 64 METAMUCIL ...................... 64 METAMUCIL

MULTIHEALTH FIBER . 64 METAMUCIL SMOOTH

TEXTURE ........................ 64 metaproterenol sulfate .......... 64 metaxalone............................ 65 metformin hcl ....................... 65 metformin hcl er ................... 65 methadone hcl ....................... 65 methenamine hippurate ........ 65 methimazole ......................... 65 methocarbamol ..................... 65 methotrexate ......................... 65 methotrexate sodium ............ 65 methotrexate sodium (pf) ..... 65 methoxsalen rapid................. 65 methscopolamine bromide ... 65 methyclothiazide .................. 65 methyldopa ........................... 65 methyldopa-

hydrochlorothiazide .......... 65 methyldopate hcl .................. 65 methylphenidate hcl ....... 65, 66 methylphenidate hcl er ......... 65 methylphenidate hcl er (cd) .. 65 methylprednisolone .............. 66 methylprednisolone acetate .. 66 methylprednisolone sodium

succ ................................... 66 metipranolol.......................... 66 metoclopramide hcl .............. 66 metolazone............................ 66 metoprolol succinate er ........ 66 metoprolol tartrate ................ 66 metoprolol-

hydrochlorothiazide .......... 66 metronidazole ....................... 66 metronidazole in nacl ........... 66 mexiletine hcl ....................... 66 MIACALCIN ....................... 66 MI-ACID .............................. 66 miconazole 3......................... 67 miconazole 3 combo pack .... 67

miconazole 3 combo pack app .......................................... 67

miconazole 7 ......................... 67 miconazole nitrate ................ 67 MICROGESTIN 1.5/30 ........ 67 MICROGESTIN 1/20 ........... 67 MICROGESTIN FE 1.5/30 .. 67 MICROGESTIN FE 1/20 ..... 67 midodrine hcl ........................ 67 milk of magnesia .................. 67 milk of magnesia concentrate

.......................................... 67 MIMVEY ............................. 67 MIMVEY LO ....................... 67 mineral freez ......................... 67 MINITRAN .......................... 67 minocycline hcl .................... 67 minoxidil ............................... 67 mirtazapine ..................... 67, 68 misoprostol ........................... 68 mitomycin ............................. 68 mitoxantrone hcl ................... 68 M-M-R II .............................. 68 modafinil ............................... 68 moexipril hcl ......................... 68 moexipril-hydrochlorothiazide

.......................................... 68 MOI-STIR ............................ 68 molindone hcl ....................... 68 mometasone furoate .............. 68 MONISTAT 1 COMBO

PACK ............................... 68 MONISTAT 1 DAY OR

NIGHT .............................. 68 MONISTAT 3 ...................... 68 MONISTAT 3

COMBINATION PACK .. 68 MONISTAT 3 COMBO

PACK APP ....................... 68 MONISTAT 7 COMBO

PACK APP ....................... 68 MONISTAT 7 COMPLETE

THERAPY ........................ 68 MONONESSA ..................... 68 montelukast sodium .............. 68 morphine sulfate ................... 69 morphine sulfate (concentrate)

.......................................... 69 morphine sulfate (pf) ............ 69 morphine sulfate er ............... 69

121

morphine sulfate er beads ..... 69 motion sickness relief ........... 69 MOVIPREP .......................... 69 MOXEZA ............................. 69 moxifloxacin hcl ................... 69 MOZOBIL ............................ 69 mucus relief dm max ............ 69 MULTAQ ............................. 69 mupirocin ............................. 69 MURO 128 ........................... 69 muscle rub ............................ 69 muscle rub ultra strength ...... 69 MUSTARGEN ..................... 69 MY WAY ............................. 69 mycophenolate mofetil ... 69, 70 mycophenolate mofetil hcl ... 69 mycophenolic acid................ 70 MYLANTA .......................... 70 MYORISAN......................... 70 MYRBETRIQ ...................... 70 MYTESI ............................... 70 N nabumetone .......................... 70 nadolol .................................. 70 nadolol-bendroflumethiazide 70 nafcillin sodium .................... 70 NAGLAZYME..................... 70 naloxone hcl ......................... 70 naltrexone hcl ....................... 70 NAMZARIC......................... 70 naproxen ............................... 70 naproxen dr ........................... 70 naproxen sodium .................. 70 naratriptan hcl ....................... 70 NASADROPS SALINE ON

THE GO ........................... 71 nasal decongestant ................ 71 NASAL MOIST ................... 71 NASOGEL ........................... 71 nateglinide ............................ 71 NATPARA ........................... 71 natural fiber laxative............. 71 natural fiber therapy ............. 71 natural psyllium seed ............ 71 NEBUPENT ......................... 71 NECON 0.5/35 (28) ............. 71 NECON 10/11 (28) .............. 71 NECON 7/7/7 ....................... 71 nefazodone hcl...................... 71 neomycin sulfate .................. 71

neomycin-bacitracin zn-polymyx ............................ 71

neomycin-polymyxin b gu.... 71 neomycin-polymyxin-

dexameth .......................... 71 neomycin-polymyxin-

gramicidin ......................... 71 neomycin-polymyxin-hc 71, 72 NEPHRAMINE .................... 72 NESINA ............................... 72 NEUAC ................................ 72 NEUPOGEN ........................ 72 NEUPRO .............................. 72 nevirapine ............................. 72 nevirapine er ......................... 72 NEXAFED ........................... 72 NEXAVAR .......................... 72 NEXT CHOICE ONE DOSE

.......................................... 72 niacin .................................... 72 niacin er ................................ 72 niacin er (antihyperlipidemic)

.......................................... 72 niacinamide .......................... 72 NIACOR ............................... 72 nicardipine hcl ................ 72, 73 NICODERM CQ .................. 73 NICORETTE ........................ 73 nicotine ................................. 73 nicotine mini ......................... 73 nicotine polacrilex ................ 73 NICOTROL .......................... 73 nifedipine .............................. 73 nifedipine er osmotic release 73 NIKKI ................................... 73 nilutamide ............................. 73 nimodipine ............................ 73 NINJACOF-XG.................... 73 NINLARO ............................ 73 nisoldipine er ........................ 73 nitrofurantoin ........................ 73 nitrofurantoin macrocrystal .. 73 nitrofurantoin monohyd macro

.......................................... 73 nitroglycerin ......................... 73 NIX CREME RINSE............ 73 nizatidine ........................ 73, 74 non-aspirin extra strength ..... 74 non-aspirin jr strength .......... 74 non-aspirin pain relief .......... 74

NORA-BE ............................ 74 NORDITROPIN FLEXPRO 74 norethin ace-eth estrad-fe ..... 74 norethindrone ........................ 74 norethindrone acetate ............ 74 norethindrone acet-ethinyl est

.......................................... 74 norgestimate-eth estradiol .... 74 norgestim-eth estrad triphasic

.......................................... 74 NORLYROC ........................ 74 NORMOSOL-M IN D5W .... 74 NORMOSOL-R PH 7.4 ........ 74 NORTHERA ........................ 74 NORTREL 0.5/35 (28) ......... 74 NORTREL 1/35 (21) ............ 74 NORTREL 1/35 (28) ............ 74 NORTREL 7/7/7 .................. 74 nortriptyline hcl .............. 74, 75 NORVIR ............................... 75 NOVOLIN 70/30 .................. 75 NOVOLIN N ........................ 75 NOVOLIN R ........................ 75 NOVOLOG .......................... 75 NOVOLOG FLEXPEN ........ 75 NOVOLOG MIX 70/30 ....... 75 NOVOLOG MIX 70/30

FLEXPEN ......................... 75 NOVOLOG PENFILL ......... 75 NOXAFIL ............................. 75 NUEDEXTA ........................ 75 NULOJIX ............................. 75 NUMOISYN ......................... 75 NUPLAZID .......................... 75 nutrilipid ............................... 75 nystatin ................................. 75 nystatin-triamcinolone .......... 76 O OCELLA .............................. 76 octreotide acetate .................. 76 ODEFSEY ............................ 76 ODOMZO ............................. 76 OFEV .................................... 76 ofloxacin ............................... 76 OFLOXACIN ....................... 76 OGESTREL .......................... 76 olanzapine ............................. 76 olmesartan medoxomil ......... 76 olmesartan medoxomil-hctz . 76 olmesartan-amlodipine-hctz . 76

122

olopatadine hcl ..................... 76 omega-3 ................................ 77 OMEGA-3 2100 ................... 76 omega-3 fish oil .................... 77 omega-3 fish oil concentrate 76 omega-3 fish oil ex st ........... 76 omega-3-acid ethyl esters ..... 77 omeprazole ........................... 77 omeprazole-sodium

bicarbonate ....................... 77 ondansetron .......................... 77 ondansetron hcl .................... 77 ONFI .................................... 77 OPCICON ONE-STEP ........ 77 OPSUMIT ............................ 77 ORAVIG .............................. 77 ORENCIA ............................ 77 ORENCIA CLICKJECT ...... 77 ORFADIN ............................ 77 ORKAMBI ........................... 77 orphenadrine citrate .............. 77 orphenadrine citrate er .......... 77 ORSYTHIA .......................... 77 oseltamivir phosphate ........... 78 OSENI .................................. 78 OSTEO-PORETICAL .......... 78 OTEZLA .............................. 78 oxacillin sodium ................... 78 oxaliplatin ............................. 78 oxandrolone .......................... 78 oxazepam .............................. 78 oxcarbazepine ....................... 78 OXTELLAR XR .................. 78 oxybutynin chloride.............. 78 oxybutynin chloride er ......... 78 oxycodone hcl ...................... 78 oxycodone hcl er .................. 78 oxycodone-acetaminophen ... 78 oxycodone-aspirin ................ 79 oxycodone-ibuprofen ........... 79 oyster shell calcium plus d ... 79 oyster shell calcium/vitamin d

.......................................... 79 P PACERONE ......................... 79 paclitaxel .............................. 79 pain & fever childrens .......... 79 pain & fever junior ............... 79 pain relief extra strength ....... 79 pain relieving ........................ 79

paliperidone er ...................... 79 pamidronate disodium .......... 79 PANCREAZE ...................... 79 PANRETIN .......................... 79 pantoprazole sodium............. 79 paricalcitol ............................ 79 paromomycin sulfate ............ 79 paroxetine hcl ....................... 79 paroxetine hcl er ................... 79 PASER.................................. 79 PATADAY ........................... 79 PAXIL .................................. 80 PAZEO ................................. 80 PECGEN DMX .................... 80 PEDIA-LAX ......................... 80 PEDIARIX ........................... 80 pediatric formula cough/congst

.......................................... 80 PEDVAX HIB ...................... 80 peg 3350 ............................... 80 peg-3350/electrolytes ........... 80 PEGANONE ........................ 80 PEGASYS ............................ 80 PEGASYS PROCLICK ....... 80 PEGINTRON ....................... 80 PEG-INTRON REDIPEN .... 80 penicillin g potassium ........... 80 penicillin v potassium ........... 80 PENTAM.............................. 80 pentazocine-naloxone hcl ..... 80 pentoxifylline er ................... 80 perindopril erbumine ............ 80 permethrin ............................ 80 perphenazine ......................... 80 PERTZYE ............................ 81 PEXEVA .............................. 81 phenelzine sulfate ................. 81 phenobarbital ........................ 81 phenytoin .............................. 81 phenytoin sodium ................. 81 phenytoin sodium extended .. 81 PHILLIPS ............................. 81 PHOSPHOLINE IODIDE .... 81 PHYSIOLYTE ..................... 81 PHYSIOSOL IRRIGATION 81 PICATO................................ 81 pilocarpine hcl ...................... 81 pimozide ............................... 81 PIMTREA ............................ 81 pindolol ................................. 81

pioglitazone hcl .................... 81 pioglitazone hcl-glimepiride . 81 pioglitazone hcl-metformin hcl

.......................................... 81 piperacillin sod-tazobactam so

.......................................... 82 PIRMELLA 1/35 .................. 82 PLAN B ONE-STEP ............ 82 PLEGRIDY .......................... 82 podofilox ............................... 82 POLAR FROST .................... 82 polyethylene glycol 3350 ..... 82 polymyxin b-trimethoprim ... 82 POMALYST ......................... 82 PORTIA-28 .......................... 82 potassium chloride ................ 82 potassium chloride crys er .... 82 potassium chloride er ............ 82 potassium chloride in dextrose

.......................................... 82 potassium chloride in nacl .... 82 potassium citrate er ............... 82 POTIGA ............................... 82 PRADAXA ........................... 83 PRALUENT ......................... 83 pramipexole dihydrochloride 83 pramipexole dihydrochloride er

.......................................... 83 pravastatin sodium ................ 83 prazosin hcl ........................... 83 prednicarbate ........................ 83 prednisolone sodium phosphate

.......................................... 83 prednisone ............................. 83 PREDNISONE ..................... 83 PREDNISONE INTENSOL . 83 preferred plus insulin syringe

.......................................... 83 PREMARIN ......................... 83 PREMASOL ......................... 83 PREMPHASE ....................... 83 PREMPRO ........................... 84 PREPARATION H ............... 84 PREVIFEM .......................... 84 PREZCOBIX ........................ 84 PREZISTA ........................... 84 PRIFTIN ............................... 84 primaquine phosphate ........... 84 primidone .............................. 84 PRISTIQ ............................... 84

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PROAIR HFA ...................... 84 PROAIR RESPICLICK ....... 84 probenecid ............................ 84 procainamide hcl .................. 84 PROCALAMINE ................. 84 prochlorperazine ................... 84 prochlorperazine edisylate.... 84 prochlorperazine maleate ..... 84 PROCRIT ....................... 84, 85 PROCTOCORT ................... 85 PROCTO-MED HC ............. 85 PROCTO-PAK ..................... 85 PROCTOSOL HC ................ 85 PROCTOZONE-HC............. 85 progesterone micronized ...... 85 PROGLYCEM ..................... 85 PROGRAF ........................... 85 PROLASTIN-C .................... 85 PROLEUKIN ....................... 85 PROLIA ............................... 85 PROMACTA ........................ 85 promethazine hcl .................. 85 promethazine vc plain .......... 85 propafenone hcl .................... 85 propafenone hcl er ................ 85 propantheline bromide.......... 85 proparacaine hcl ................... 85 propranolol hcl ..................... 86 propranolol hcl er ................. 86 propranolol-hctz ................... 86 propylthiouracil .................... 86 PROQUAD .......................... 86 PROSOL .............................. 86 protriptyline hcl .................... 86 PROVENTIL HFA ............... 86 pseudoephedrine hcl ............. 86 PULMICORT ....................... 86 PULMICORT FLEXHALER

.......................................... 86 PULMOZYME .................... 86 PURE & GENTLE

LUBRICANT ................... 86 PURIXAN ............................ 86 px ultra strength rub ............. 86 pyrazinamide ........................ 86 pyridostigmine bromide ....... 86 pyridoxine hcl ....................... 86 Q QUADRACEL ..................... 86 QUASENSE ......................... 87

quetiapine fumarate .............. 87 quetiapine fumarate er .......... 87 QUETIAPINE FUMARATE

ER ..................................... 87 quinapril hcl .......................... 87 quinapril-hydrochlorothiazide

.......................................... 87 quinidine gluconate er .......... 87 quinidine sulfate ................... 87 quinine sulfate ...................... 87 QVAR ................................... 87 R ra anti-itch maximum strength

.......................................... 87 ra fish oil ............................... 87 ra hemorrhoid relief .............. 87 ra melatonin .......................... 87 ra tussin chest congestion ..... 87 RABAVERT ........................ 87 raloxifene hcl ........................ 87 ramipril ................................. 88 RANEXA ............................. 88 ranitidine acid reducer .......... 88 ranitidine hcl ......................... 88 RAPAFLO ............................ 88 RAPAMUNE........................ 88 rasagiline mesylate ............... 88 RAVICTI .............................. 88 RECLIPSEN ......................... 88 RECOMBIVAX HB............. 88 REFRESH ............................ 88 REGRANEX ........................ 88 RELENZA DISKHALER .... 88 reliever .................................. 88 RELI-ON INSULIN

SYRINGE ......................... 88 RELISTOR ........................... 88 REMODULIN ...................... 88 RENVELA ........................... 88 repaglinide ............................ 88 REPATHA............................ 89 REPATHA PUSHTRONEX

SYSTEM .......................... 89 REPATHA SURECLICK .... 89 REPREXAIN........................ 89 RESCRIPTOR ...................... 89 RESTASIS............................ 89 RESTORIL ........................... 89 RETROVIR .......................... 89 REVLIMID .......................... 89

REXULTI ............................. 89 REYATAZ ........................... 89 RHINARIS ........................... 89 RIBASPHERE ...................... 89 ribavirin ................................ 89 RID ....................................... 89 rifabutin ................................ 89 rifampin ................................ 89 RIFATER ............................. 89 riluzole .................................. 90 rimantadine hcl ..................... 90 ringers ................................... 90 ringers irrigation ................... 90 RISPERDAL CONSTA ....... 90 risperidone ............................ 90 RITUXAN ............................ 90 RIVASTIGMINE ................. 90 rivastigmine tartrate .............. 90 ROBINUL ............................ 90 ROBINUL-FORTE .............. 90 ROBITUSSIN CHILDRENS

COUGH LA ...................... 90 ROBITUSSIN

COUGH/CHEST DM MAX .......................................... 90

ROBITUSSIN LINGERING LA COUGH ...................... 90

ROBITUSSIN MUCUS+CHEST CONGEST ........................ 90

ROBITUSSIN PEAK COLD DM .................................... 90

ROLAIDS ............................. 91 ropinirole hcl ........................ 91 rosuvastatin calcium ............. 91 ROTARIX ............................ 91 ROTATEQ ........................... 91 ROWEEPRA ........................ 91 ROZEREM ........................... 91 RUBRACA ........................... 91 S SABRIL ................................ 91 SALESE ............................... 91 saline ..................................... 91 saline bacteriostatic .............. 91 saline nasal spray .................. 91 salsalate ................................. 91 SAMSCA .............................. 91 SANDIMMUNE ................... 91

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SANDOSTATIN LAR DEPOT ............................. 91

SANTYL .............................. 91 SAPHRIS ............................. 91 SAVELLA ............................ 91 SAVELLA TITRATION

PACK ............................... 91 sb non-aspirin ....................... 91 scalp relief maximum strength

.......................................... 92 SCOT-TUSSIN DIABETES

CF ..................................... 92 SCOT-TUSSIN SENIOR ..... 92 selegiline hcl ......................... 92 selenium sulfide.................... 92 SELZENTRY ....................... 92 senna ..................................... 92 senna laxative ....................... 92 senna leaves .......................... 92 senna-docusate sodium ......... 92 SENOKOT S ........................ 92 SENSIPAR ........................... 92 SEREVENT DISKUS .......... 92 sertraline hcl ......................... 92 SHAROBEL ......................... 92 SIGNIFOR ........................... 92 sildenafil citrate .................... 92 SILENOR ............................. 92 silver sulfadiazine ................. 92 SIMBRINZA ........................ 93 SIMPONI ............................. 93 SIMPONI ARIA ................... 93 simvastatin ............................ 93 sirolimus ............................... 93 SIRTURO ............................. 93 SIVEXTRO .......................... 93 sleep-aid maximum strength 93 slow iron ............................... 93 slow release iron ................... 93 sm fish oil ............................. 93 sm hydrocortisone max st ..... 93 sm ibuprofen jr ..................... 93 sm pain relief/menthol .......... 93 sm slow release iron ............. 93 sm vitamin d3 ....................... 93 sodium bicarbonate .............. 93 sodium chloride .............. 93, 94 sodium chloride (hypertonic) 93 sodium phenylbutyrate ......... 94

sodium polystyrene sulfonate .......................................... 94

SOLTAMOX ........................ 94 SOMATULINE DEPOT ...... 94 SOMAVERT ........................ 94 SOMBRA COOL THERAPY

.......................................... 94 sorbitol .................................. 94 SORINE................................ 94 sotalol hcl ............................. 94 sotalol hcl (af) ....................... 94 SOVALDI ............................ 94 SPIRIVA HANDIHALER ... 94 SPIRIVA RESPIMAT .......... 94 spironolactone ...................... 94 spironolactone-hctz .............. 94 SPRINTEC 28 ...................... 94 SPRITAM ............................. 94 SPRYCEL ............................ 95 sps ......................................... 95 SRONYX.............................. 95 ST JOSEPH LOW DOSE..... 95 stavudine ............................... 95 STELARA ............................ 95 sterile water for irrigation ..... 95 STIOLTO RESPIMAT ........ 95 STIVARGA .......................... 95 stool softener ........................ 95 STRATTERA ....................... 95 streptomycin sulfate ............. 95 STRIBILD ............................ 95 SUBOXONE ........................ 95 SUBSYS ............................... 95 sucralfate .............................. 95 SUDAFED 24 HOUR .......... 95 SUDAFED CHILDRENS .... 96 SUDOGEST ......................... 96 sulfacetamide sodium ........... 96 sulfacetamide-prednisolone .. 96 sulfadiazine ........................... 96 sulfamethoxazole-trimethoprim

.......................................... 96 sulfasalazine ......................... 96 sulindac ................................. 96 sumatriptan ........................... 96 sumatriptan succinate ........... 96 super antioxidants protector . 96 SUPER OMEGA-3 .............. 96 SUPER TWIN EPA/DHA .... 96 SUPRAX .............................. 96

supress dm pediatric ............. 96 SUSTIVA ....................... 96, 97 SUTENT ............................... 97 SYLATRON ......................... 97 SYMBICORT ....................... 97 SYMLINPEN 120 ................ 97 SYMLINPEN 60 .................. 97 SYNAGIS ............................. 97 SYNAREL ............................ 97 SYNERCID .......................... 97 SYNRIBO ............................. 97 SYNTHROID ....................... 97 SYPRINE ............................. 97 SYSTANE ............................ 97 T TABLOID ............................. 97 tacrolimus ............................. 97 TAFINLAR .......................... 97 TAGRISSO ........................... 97 TAKE ACTION ................... 97 TAMIFLU ............................ 97 tamoxifen citrate ................... 97 tamsulosin hcl ....................... 98 TARCEVA ........................... 98 TARGRETIN ....................... 98 TARINA FE 1/20 ................. 98 TASIGNA ............................. 98 TAZORAC ........................... 98 TAZTIA XT ......................... 98 TECENTRIQ ........................ 98 TECFIDERA ........................ 98 TEFLARO ............................ 98 TEGRETOL-XR ................... 98 telmisartan ............................ 98 telmisartan-amlodipine ......... 98 telmisartan-hctz .................... 98 temazepam ............................ 98 TENIVAC ............................. 98 terazosin hcl .......................... 98 terbinafine hcl ....................... 98 terbutaline sulfate ........... 98, 99 terconazole ............................ 99 testosterone ........................... 99 testosterone cypionate .......... 99 testosterone enanthate ........... 99 tetanus-diphtheria toxoids td 99 tetrabenazine ......................... 99 tetracycline hcl ...................... 99 THALOMID ......................... 99 theophylline .......................... 99

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theophylline er ...................... 99 THERA-D 4000 ................... 99 thiamine hcl .......................... 99 thioridazine hcl ..................... 99 thiotepa ................................. 99 thiothixene ............................ 99 THYMOGLOBULIN ........... 99 tiagabine hcl ......................... 99 TIGER BALM LINIMENT . 99 TIGER BALM MUSCLE RUB

.......................................... 99 timolol maleate ............. 99, 100 TINACTIN ......................... 100 TIVICAY ........................... 100 tizanidine hcl ...................... 100 TOBI PODHALER ............ 100 TOBRADEX ...................... 100 TOBRADEX ST ................ 100 tobramycin .......................... 100 tobramycin sulfate .............. 100 tobramycin-dexamethasone 100 tolazamide .......................... 100 tolbutamide ......................... 100 tolnaftate ............................. 100 tolnaftate antifungal............ 100 topiramate ........................... 100 topiramate er ....................... 100 topotecan hcl ...................... 101 TORISEL ........................... 101 torsemide ............................ 101 total fiber ............................ 101 TOUJEO SOLOSTAR ....... 101 TPN ELECTROLYTES ..... 101 TRACLEER ....................... 101 TRADJENTA ..................... 101 tramadol hcl ........................ 101 tramadol hcl er .................... 101 tramadol-acetaminophen .... 101 trandolapril ......................... 101 tranexamic acid .................. 101 TRANSDERM-SCOP (1.5

MG) ................................ 101 tranylcypromine sulfate ...... 101 TRAVASOL....................... 101 TRAVATAN Z .................. 101 trazodone hcl ...................... 101 TREANDA ......................... 101 TRECATOR ....................... 101 TRELSTAR MIXJECT ...... 101 tretinoin ...................... 101, 102

tretinoin microsphere .......... 102 TREXALL .......................... 102 triamcinolone acetonide ..... 102 TRIAMINIC COUGH &

CONGESTION .............. 102 triamterene-hctz .................. 102 triazolam ............................. 102 trifluoperazine hcl ............... 102 trifluridine ........................... 102 trihexyphenidyl hcl ............. 102 TRI-LEGEST FE ................ 102 TRILYTE ........................... 102 trimethoprim ....................... 102 trimipramine maleate .......... 102 TRINESSA (28) ................. 102 TRINTELLIX ..................... 102 triple antibiotic ................... 103 TRI-PREVIFEM ................ 103 TRISENOX ........................ 103 TRISPEC DMX PEDIATRIC

........................................ 103 TRI-SPRINTEC ................. 103 TRIUMEQ .......................... 103 TRIVORA (28)................... 103 TROKENDI XR ................. 103 TROPHAMINE .................. 103 TRUMENBA...................... 103 TRUVADA ........................ 103 trymine cg ........................... 103 TUMS ................................. 103 TUMS CHEWY DELIGHTS

........................................ 103 TUMS E-X 750 .................. 103 TUMS KIDS....................... 103 TUMS SMOOTHIES ......... 103 TUMS ULTRA 1000.......... 103 tussin cough ........................ 103 tussin dm max adult ............ 103 TWINRIX ........................... 103 TYBOST ............................ 104 TYGACIL .......................... 104 TYKERB ............................ 104 TYLENOL EXTRA

STRENGTH ................... 104 TYLENOL INFANTS

PAIN+FEVER ................ 104 TYPHIM VI ....................... 104 TYSABRI ........................... 104 U UCERIS .............................. 104

ULTRA MIDE 25 ............... 104 ULTRACIN T .................... 104 ULTRACIN-M ................... 104 UNITHROID ...................... 104 UPTRAVI ........................... 104 urea ..................................... 104 urevaz ................................. 104 ursodiol ............................... 104 UTOPIC .............................. 104 V valacyclovir hcl .................. 105 VALCHLOR ...................... 105 valganciclovir hcl ............... 105 valproate sodium ................ 105 valproic acid ....................... 105 valsartan .............................. 105 valsartan-hydrochlorothiazide

........................................ 105 vancomycin hcl ................... 105 vaporizing steam ................. 105 VAQTA .............................. 105 VARIVAX .......................... 105 VASCEPA .......................... 105 VELCADE ......................... 105 VELIVET ........................... 105 VENCLEXTA .................... 105 VENCLEXTA STARTING

PACK ............................. 105 venlafaxine hcl .................... 106 venlafaxine hcl er ............... 105 VENTAVIS ........................ 106 VENTOLIN HFA ............... 106 verapamil hcl ...................... 106 verapamil hcl er .................. 106 VERSACLOZ ..................... 106 VESICARE ......................... 106 VESTURA .......................... 106 VICKS DAYQUIL COUGH

........................................ 106 VICKS DAYQUIL MUCUS

CONTROL DM .............. 106 VICKS NATURE FUSION

CONGEST ...................... 106 VICODIN ........................... 106 VICODIN ES ...................... 106 VICODIN HP ..................... 106 VICTOZA ........................... 106 VIDEX ................................ 106 VIGAMOX ......................... 106 VIIBRYD ........................... 106

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VIIBRYD STARTER PACK ........................................ 106

VIMPAT ............................ 107 vinblastine sulfate ............... 107 vincasar pfs ......................... 107 vincristine sulfate ............... 107 vinorelbine tartrate ............. 107 VIRACEPT ........................ 107 VIRAZOLE ........................ 107 VIREAD ............................. 107 vision plus .......................... 107 vision vitamins ................... 107 VITAMELTS ENERGY

VITAMIN B-12.............. 107 vitamin b1 ........................... 107 vitamin b12 ......................... 107 vitamin b-12 ....................... 107 vitamin b-12 ....................... 107 vitamin b-12 er ................... 107 vitamin b6 ........................... 107 vitamin b-6 ......................... 107 vitamin d (cholecalciferol) . 107 vitamin d (ergocalciferol) ... 107 vitamin d2 ........................... 108 vitamin d3 ........................... 108 vitamin d3 maximum strength

........................................ 108 vitamin k (phytonadione) ... 108 vitamin k1 ........................... 108 voriconazole ....................... 108 VOTRIENT ........................ 108 VPRIV ................................ 108

VRAYLAR ......................... 108 VYFEMLA ......................... 108 W WAL-TUSSIN

COUGH/COLD .............. 108 WAL-ZYR CHILDRENS .. 108 warfarin sodium .................. 108 WYMZYA FE .................... 108 X XALKORI .......................... 108 XARELTO ......................... 109 XARELTO STARTER PACK

........................................ 109 XELJANZ .......................... 109 XGEVA .............................. 109 XIFAXAN .......................... 109 XIGDUO XR ...................... 109 XOLAIR ............................. 109 xoten ................................... 109 XTANDI ............................. 109 XYREM.............................. 109 Y YERVOY ........................... 109 YF-VAX ............................. 109 YONDELIS ........................ 109 yuvafem .............................. 109 Z zafirlukast ........................... 109 zaleplon .............................. 109 ZANTAC 75 ....................... 109 ZAVESCA.......................... 109 ZELBORAF ....................... 109

ZEMAIRA .......................... 109 ZENATANE ....................... 109 ZENCHENT ....................... 110 ZENCHENT FE ................. 109 ZENPEP ............................. 110 ZENZEDI ........................... 110 ZEPATIER ......................... 110 ZETIA ................................. 110 ZIAGEN ............................. 110 zidovudine .......................... 110 ZIMS MAX-FREEZE ........ 110 ziprasidone hcl .................... 110 ZIRGAN ............................. 110 zoledronic acid .................... 110 ZOLINZA ........................... 110 zolpidem tartrate ................. 110 ZOMETA ........................... 110 zonisamide .......................... 110 ZORTRESS ........................ 110 ZOSTAVAX ....................... 110 ZOVIA 1/35E (28) ............. 110 ZYDELIG ........................... 110 ZYKADIA .......................... 110 ZYNCOF ............................ 110 ZYPREXA RELPREVV .... 111 ZYRTEC ALLERGY ......... 111 ZYRTEC CHILDRENS

ALLERGY ..................... 111 ZYRTEC-D ALLERGY &

CONGESTION ............... 111 ZYTIGA ............................. 111

This formulary was updated on 5/23/2017. For more recent information or other questions, please contact

Partnership Customer Service at 1-800-963-0035 or, for TTY users, Wisconsin Relay 711, 8 a.m. – 8 p.m., 7

days a week, or visit www.carewisc.org.

Care Wisconsin Health Plan

P.O. Box 14017

Madison, Wisconsin 53708-0017

1-800-963-0035

TTY/TDD Wisconsin Relay System 711

www.carewisc.org

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