Regence BlueShield Essential Formulary

Regence BlueShield

Essential Formulary

Regence BlueShield 1800 9th Avenue

Seattle, WA 98101

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Regence BlueShield serves select counties in Washington and is an independent licensee of the Blue Cross and Blue Shield Association.

Prescription drug benefits from Regence BlueShield Regence BlueShield wants you to get the most from your benefits and to have the information you need to make smart decisions about prescription drugs. Our prescription drug benefit provides resources to help you and your doctor understand the latest and best information about effective, quality drugs that also provide value. Regence BlueShield prescription drug program Your prescription drug coverage provides benefits for drugs listed on the Regence BlueShield Essential Formulary. Medications not listed on this formulary (non-formulary medications) are not covered. The formulary is a list of Food and Drug Administration (FDA)-approved prescription generic, brand-name and specialty drugs. Regence consults with a team of physicians and pharmacists to develop the formulary, which offers drug treatment choices for covered medical conditions. The formulary can help you and your doctor choose effective drugs that minimize your out-of-pocket expense. You can buy formulary drugs at participating retail, mail-order and specialty pharmacies. The Regence formulary is available on regence.com. Changes to the formulary Our Pharmacy & Therapeutics Committee (made up of doctors and pharmacists who practice in the communities we serve) continues to review the latest evidence to identify opportunities for promoting safe, effective and affordable drug therapy. Generally, if you are currently taking a formulary drug, its formulary status will not change during the year unless:

• The same drug becomes available in generic form, or • Safety or effectiveness concerns are raised, or • The Pharmacy & Therapeutics Committee determines that changes to the formulary would “overall” be

in the best interest of health plan members. In such cases, impacted individuals are always notified in writing if the formulary change results in a reduction of benefits or an increase in copay.

What is the Essential Formulary prescription drug benefit? With an Essential Formulary benefit, prescription drugs fall into one of four categories or “tiers.” Each tier has a different cost share.* Tier 1— Generic and select brand-name insulin Lowest cost share.

Generic drugs are as effective, safe and high-quality as their brand-name counterparts, yet less expensive.

Tier 2—Category 1 brand-name Because of their value and effectiveness, these are considered to be preferred when there is no generic.

Tier 3—Category 2 brand-name These drugs may be more expensive and are less preferred than their alternatives in Tier 1 or Tier 2.

Tier 4—Specialty medications These are used to treat complex medical conditions and are available through our designated specialty pharmacy. They may require more involvement with your doctor and require special storage and handling.

*“Cost share” means that your benefit may feature a deductible, fixed-dollar copay tiers, percentage/coinsurance tiers, or a combination of both.

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What are your cost shares for Tier 1, 2, 3 or 4 drugs? You can find your cost shares in your benefit booklet or when you log in to regence.com. Of course, you can always call Customer Service at the number listed on the back of your member card. About prescription drugs Preventive drugs Preventive care benefits are an integral part of a comprehensive health care plan that includes preventive drug therapies. Under some plans, you may not be required to pay a copay or coinsurance, or meet your deductible for preventive medications. Preventive drugs are prescribed to prevent the occurrence of a disease or condition for those individuals with risk factors, or to prevent the recurrence of a disease or condition for those who have recovered. They do not include drugs that treat an existing illness, injury or condition. Refer to your plan benefit booklet or online benefit summary to determine if your plan covers preventive drugs. To view the covered PPACA Preventive Care Medication List, go to RegenceRx.com and click on Learn About Medications > What’s Covered. Advantages of generic drugs Consumer Reports says, “Generics are every bit as pure, potent, and safe as brands.”1 That’s because the FDA regulates generic drugs just as it does brand-name drugs, ensuring that generics offer the same level of quality, strength, effectiveness and purity as their brand-name equivalents. All generics, by law, must have the same active ingredients as their brand-named equivalent.

• Generic equivalent: The same active ingredient, strength and dosage form as the brand-name • Generic alternative: A different chemical that has a similar effect as the brand-name

Generic drugs generally cost less than brand-name drugs because they are created without the expenses incurred by brand-name drugs (such as research, development and marketing). Talk with your doctor to see whether a generic drug is right for you. About specialty drugs Many people with complex conditions, such as, but not limited to, multiple sclerosis, rheumatoid arthritis and cancer, require special medications. These drugs are available through our designated specialty pharmacy and may require special handling. We have created the Specialty Pharmacy Program to focus solely on the delivery of specialty drugs and the specific needs of members who require them. The program includes:

• Educational materials, counseling and product information • 24-hour access to clinical assistance from pharmacists and nurses • Refill reminders • Free delivery and supplies • Convenient delivery in unmarked packaging to assure privacy

You are allowed to fill your first specialty prescription at a retail pharmacy if the medication is available. After this fill, you will get a letter advising you that all future fills must be done at one of our contracted specialty pharmacies in order for your drug to be covered. For more information on the Specialty Pharmacy Program, refer to the Benefit from Special Programs section of RegenceRx.com.

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Tips for getting your prescription filled Filling your prescription at a retail pharmacy We have contracted with RegenceRx for our participating pharmacy network. This network provides with you access to a nationwide network of over 55,000 pharmacies. To receive coverage under your plan’s prescription drug benefit, you need to use a pharmacy in this network and present your member card before purchasing your prescription. This will not only ensure that you pay the correct cost share, it will also provide the pharmacist with your prescription history to help inform him or her of any drug sensitivities you may have. If you go to a pharmacy not in the network, your medication will not be covered. Most pharmacies in your area are part of the network. If you need a prescription filled while you’re traveling, you’ll find network pharmacies throughout the United States. Simply go to Find a Provider on regence.com. Your prescription drug benefit usually provides you with a 30-day supply of medication at a retail pharmacy. Check your benefit booklet or benefit summary online to determine your pharmacy benefit limit. If your prescription is filled for less than the typical 30-day supply, you will still have to pay the full copay amount. Save time and money with prescriptions by mail If you take a maintenance medication, you can receive your medicine by mail from Walgreens Mail Service Pharmacy™, an independent company that provides our members with mail-order pharmacy service. You save time with fewer trips to the local pharmacy, and you save money with discounted prices and lower cost shares. This service lets you receive prescriptions up to the maximum supply allowed by your health plan—typically 90 days, but it may vary by plan—at a lower cost than what you would pay for the same amount at a retail pharmacy. Refer to your benefit booklet for details. How to receive your prescription by mail from the Walgreens Mail Service Pharmacy Getting started is easy!

1. Since it takes about two weeks to receive your prescription, ask your doctor to write two separate prescriptions (be sure that your doctor indicates if refills are allowed on your prescription):

a. One for a 30-day supply that you can fill right away at a local retail pharmacy

b. One for a 90-day supply, or supply maximum allowed by your plan, that you can mail or fax to Walgreens Mail Service within two weeks of your medicine running out

2. Complete a Mail Service Registration Form, which you can download from the Get Prescriptions section on RegenceRx.com.

3. Send your prescription(s), order form and payment for each prescription to the address or fax number located on the order form. You can pay with a personal check or credit card.

You will receive your prescriptions by mail in about two weeks, delivered in sealed, insulated (when necessary) and tamper-evident packaging. Make it even easier Ordering new prescriptions and refills is easier once you establish an account with the Walgreens Mail Service Pharmacy. Simply log in to Walgreens.com/MailService and follow the instructions for convenient online refilling of your prescription. Or order your refills by calling Walgreens Customer Care at 1 (888) 832-5462.

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http://www.regencerx.com/

Quality drug therapy with the Prior Authorization Program Using your medications correctly for maintaining good health is important. Our Prior Authorization Program supports you and your doctor as you make decisions about your care and the use of prescription medications. The program aims to improve the quality of your drug therapy by:

• Promoting the appropriate use of your medications • Checking the appropriate length of your drug therapy

How the program works When you go to the pharmacy to fill your prescription, your prescription drug therapy is checked to see if it meets recommended guidelines:

• If the drug meets these guidelines, your prescription is filled instantly without interruption. • If the drug does not meet the guidelines, your prescription will not be filled until it has been reviewed.

Review process The prior authorization process is simple. Your doctor or pharmacist can request prior authorization by going to RegenceRx.com/pa, calling 1 (800) 643-5918, or faxing 1 (888) 437-1510.

Once we receive your doctor’s information, our review process will take one to two business days. We’ll send you a letter confirming the decision made about the drug therapy. We’ll also fax the notification to your doctor. If your drug therapy is approved, then your prescription is covered by your prescription drug benefit, and it can be filled at your pharmacy the same day the decision is made. Medications subject to the Prior Authorization Program Drugs tagged with PA in the formulary must go through the prior authorization review process. For an updated list of medications that require prior authorization, refer to the Get Prescriptions section of RegenceRx.com.

Frequently asked questions Q. What are my cost-share amounts? A. Check your benefit booklet to see what your cost share is for each tier. Q. What if I want to take a brand-name drug, even if there is a generic available? A. The drug you take is your choice. In some cases, if you choose to stay on a brand-name drug when a generic is available, you may have to pay more or up to the full price for your medication. Q. Are the drugs just the ones that are the cheapest? A. No. All the drugs on our formulary must be FDA-approved and determined by the Pharmacy & Therapeutics Committee to be safe and effective. When several drugs are similar in safety and effectiveness, one or more of the lower-cost choices are selected for our formulary. Q. I’ve heard that some people can’t take generic drugs. Why not? A. A brand-name drug and its generic equivalent have the same active ingredients. However, different manufacturers sometimes use different inactive ingredients to hold the active ingredients together in a pill or capsule. In rare instances, people may have an allergic reaction to the inactive ingredients. This type of allergic reaction can happen just as often with a brand-name drug as with a generic drug. Q. What if there is no generic drug available to substitute for my brand-name drug? A. Even if your brand-name drug does not have a generic equivalent yet, there may be another generic available within the same class of drugs that will work just as well for you. Consult with your doctor to evaluate your options. Q. What if my doctor says I have to take a drug not included on the formulary?

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A. Non-formulary medications are not covered under your prescription drug benefit. If you choose to use a non-formulary medication, you will be responsible for the full price. Although not typically covered, if a medication not on the formulary is determined to be medically necessary, it may be substituted for coverage. You or your doctor will need to request prior authorization so that we can determine that a medication not on the formulary is medically necessary. Review your benefit booklet or employer’s contract for more information on this substitution process. Q. Are there any excluded categories of drugs? A. Yes. Common exclusions include drugs for obesity, infertility and sexual dysfunction on the Regence BlueShield Essential Formulary. Certain drugs that have an available generic or an over-the-counter alternative are not covered. Review your benefit booklet or employer’s contract for your plan’s exclusions. Q. What does it mean when my drug is covered under the medical benefit? A. Drugs covered under the medical benefit are often injected or infused and typically require administration by a health care professional. These drugs and their related services are covered under your medical benefit and are excluded from coverage under the prescription drug benefit. Please refer to your benefit contract, log in to see your benefits on regence.com or contact Customer Service for coverage details specific to your plan. Q. Can I use any pharmacy I want? A. No. To receive benefit coverage under this program, you need to use a participating network pharmacy. If you go to a pharmacy not in the network, you will receive no benefits at all. When it comes to specialty drugs, they are covered only when purchased through our specialty pharmacy. Refer to your benefit booklet for details about the Specialty Pharmacy Program and coverage at a non-network pharmacy. Q. How do I find a network pharmacy near my home or when I am away? A. Most pharmacies in your area are likely to be part of the network. There are also network pharmacies throughout the United States. Use Find a Provider on regence.com or call the toll-free 24-hour Pharmacy Locator line at 1 (800) 391-9701 to find a network pharmacy near you. Q. How do I enroll in the Specialty Pharmacy Program? A. You are allowed to fill your first specialty prescription at the retail pharmacy. After a fill, we will send a letter advising you that future fills must be done at one of our contracted specialty pharmacies for your drug to be covered by your health plan. Call Customer Service using the number on the back of your member card for more information about our contracted specialty pharmacies. Q. Is there more drug information available to members? A. Members may log in to regence.com for more information on their medications and benefits.

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*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*.....................................................................................................................................................................................................3*Amebicides*.............................................................................................................................................................................................................................................................................................................................4*Aminoglycosides*............................................................................................................................................................................................................................................................................................................4*Analgesics - Anti-Inflammatory*.............................................................................................................................................................................................................................................................5*Analgesics - Nonnarcotic*..................................................................................................................................................................................................................................................................................7*Analgesics - Opioid*....................................................................................................................................................................................................................................................................................................8*Androgens-Anabolic*............................................................................................................................................................................................................................................................................................11*Anorectal Agents*.......................................................................................................................................................................................................................................................................................................12*Anthelmintics*..................................................................................................................................................................................................................................................................................................................13*Antianginal Agents*.................................................................................................................................................................................................................................................................................................13*Antianxiety Agents*.................................................................................................................................................................................................................................................................................................14*Antiarrhythmics*...........................................................................................................................................................................................................................................................................................................14*Antiasthmatic And Bronchodilator Agents*........................................................................................................................................................................................................................15*Anticoagulants*...............................................................................................................................................................................................................................................................................................................18*Anticonvulsants*............................................................................................................................................................................................................................................................................................................19*Antidepressants*............................................................................................................................................................................................................................................................................................................21*Antidiabetics*.....................................................................................................................................................................................................................................................................................................................24*Antidiarrheals*..................................................................................................................................................................................................................................................................................................................27*Antidotes*................................................................................................................................................................................................................................................................................................................................27*Antiemetics*.........................................................................................................................................................................................................................................................................................................................28*Antifungals*..........................................................................................................................................................................................................................................................................................................................29*Antihistamines*...............................................................................................................................................................................................................................................................................................................29*Antihyperlipidemics*..............................................................................................................................................................................................................................................................................................31*Antihypertensives*.....................................................................................................................................................................................................................................................................................................32*Anti-Infective Agents - Misc.*.................................................................................................................................................................................................................................................................35*Antimalarials*....................................................................................................................................................................................................................................................................................................................36*Antimyasthenic/Cholinergic Agents*............................................................................................................................................................................................................................................37*Antimycobacterial Agents*...........................................................................................................................................................................................................................................................................37*Antineoplastics And Adjunctive Therapies*.......................................................................................................................................................................................................................38*Antiparkinson Agents*.........................................................................................................................................................................................................................................................................................41*Antipsychotics/Antimanic Agents*...................................................................................................................................................................................................................................................42*Antiseptics & Disinfectants*.......................................................................................................................................................................................................................................................................44*Antivirals*................................................................................................................................................................................................................................................................................................................................45*Assorted Classes*.........................................................................................................................................................................................................................................................................................................48*Beta Blockers*..................................................................................................................................................................................................................................................................................................................50*Calcium Channel Blockers*.........................................................................................................................................................................................................................................................................51*Cardiotonics*.......................................................................................................................................................................................................................................................................................................................52*Cardiovascular Agents - Misc.*..............................................................................................................................................................................................................................................................52*Cephalosporins*..............................................................................................................................................................................................................................................................................................................53*Contraceptives*................................................................................................................................................................................................................................................................................................................54*Corticosteroids*...............................................................................................................................................................................................................................................................................................................59*Cough/Cold/Allergy*..............................................................................................................................................................................................................................................................................................60*Dermatologicals*...........................................................................................................................................................................................................................................................................................................61*Diagnostic Products*...............................................................................................................................................................................................................................................................................................76*Digestive Aids*................................................................................................................................................................................................................................................................................................................76*Diuretics*..................................................................................................................................................................................................................................................................................................................................77*Endocrine And Metabolic Agents - Misc.*...........................................................................................................................................................................................................................78*Estrogens*................................................................................................................................................................................................................................................................................................................................81

Essential WA

Table of Contents

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*Fluoroquinolones*.......................................................................................................................................................................................................................................................................................................82*Gastrointestinal Agents - Misc.*............................................................................................................................................................................................................................................................82*Genitourinary Agents - Miscellaneous*.....................................................................................................................................................................................................................................84*Gout Agents*.......................................................................................................................................................................................................................................................................................................................85*Hematological Agents - Misc.*...............................................................................................................................................................................................................................................................86*Hematopoietic Agents*........................................................................................................................................................................................................................................................................................87*Hemostatics*........................................................................................................................................................................................................................................................................................................................89*Hypnotics*...............................................................................................................................................................................................................................................................................................................................89*Laxatives*................................................................................................................................................................................................................................................................................................................................90*Macrolides*............................................................................................................................................................................................................................................................................................................................91*Medical Devices*..........................................................................................................................................................................................................................................................................................................92*Migraine Products*....................................................................................................................................................................................................................................................................................................93*Minerals & Electrolytes*...................................................................................................................................................................................................................................................................................93*Mouth/Throat/Dental Agents*..................................................................................................................................................................................................................................................................95*Multivitamins*..................................................................................................................................................................................................................................................................................................................96*Musculoskeletal Therapy Agents*......................................................................................................................................................................................................................................................97*Nasal Agents - Systemic And Topical*......................................................................................................................................................................................................................................97*Neuromuscular Agents*......................................................................................................................................................................................................................................................................................98*Nutrients*..................................................................................................................................................................................................................................................................................................................................98*Ophthalmic Agents*.................................................................................................................................................................................................................................................................................................99*Otic Agents*.....................................................................................................................................................................................................................................................................................................................104*Oxytocics*...........................................................................................................................................................................................................................................................................................................................105*Penicillins*..........................................................................................................................................................................................................................................................................................................................105*Progestins*..........................................................................................................................................................................................................................................................................................................................106*Psychotherapeutic And Neurological Agents - Misc.*....................................................................................................................................................................................106*Respiratory Agents - Misc.*.....................................................................................................................................................................................................................................................................109*Sulfonamides*................................................................................................................................................................................................................................................................................................................109*Tetracyclines*................................................................................................................................................................................................................................................................................................................109*Thyroid Agents*.........................................................................................................................................................................................................................................................................................................110*Toxoids*.................................................................................................................................................................................................................................................................................................................................110*Ulcer Drugs*....................................................................................................................................................................................................................................................................................................................110*Urinary Anti-Infectives*................................................................................................................................................................................................................................................................................113*Urinary Antispasmodics*..............................................................................................................................................................................................................................................................................114*Vaccines*..............................................................................................................................................................................................................................................................................................................................114*Vaginal Products*....................................................................................................................................................................................................................................................................................................116*Vasopressors*.................................................................................................................................................................................................................................................................................................................116*Vitamins*..............................................................................................................................................................................................................................................................................................................................117

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Essential WA

CURRENT AS OF 1/1/2014

Drug Tier Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Amphetamines**

*Amphetamine Mixtures***

amphetamine-dextroamphet er oral capsule extended release 24 hour

Tier 1

amphetamine-dextroamphetamine oral tablet Tier 1

*Amphetamines***

dextroamphetamine sulfate oral tablet Tier 1

dextroamphetamine sulfate er oral capsule extended release 24 hour

Tier 1

methamphetamine hcl oral tablet Tier 1

VYVANSE ORAL CAPSULE Tier 3

*Analeptics**

*Analeptics***

caffeine citrate oral solution 20 mg/ml Tier 1

*Anorexiants Non-Amphetamine**

*Anorexiants Non-Amphetamine***

benzphetamine hcl oral tablet Tier 1

diethylpropion hcl oral tablet Tier 1

diethylpropion hcl er oral tablet extended release 24 hr*

Tier 1

phendimetrazine tartrate oral tablet Tier 1

phendimetrazine tartrate er oral capsule extended release 24 hour

Tier 1

*Attention-Deficit/Hyperactivity Disorder (Adhd) Agents**

*Adhd Agent - Selective Alpha Adrenergic Agonists***

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Drug Tier Notes

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

KAPVAY ORAL MISC Tier 3

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***

STRATTERA ORAL CAPSULE Tier 3

*Stimulants - Misc.**

*Stimulants - Misc.***

DAYTRANA TRANSDERMAL PATCH Tier 3

dexmethylphenidate hcl oral tablet Tier 1

FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

metadate er oral tablet extendedrelease* Tier 1

methylphenidate hcl oral solution Tier 1

methylphenidate hcl oral tablet Tier 1

methylphenidate hcl er oral tablet extendedrelease*

Tier 1

methylphenidate hcl er (cd) oral capsule extended release*

Tier 1

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg

Tier 1

modafinil oral tablet Tier 1 PA; QL (30 EA per 30 Day(s))

NUVIGIL ORAL TABLET 150 MG Tier 3 PA; QL (30 EA per 30 Day(s))

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED

Tier 3

*Amebicides*

*Amebicides**

*Amebicides***

YODOXIN ORAL TABLET Tier 3

*Aminoglycosides*

*Aminoglycosides**

*Aminoglycosides***

neomycin sulfate oral tablet Tier 1

paromomycin sulfate oral capsule Tier 1

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Drug Tier Notes

TOBI INHALATION NEBULIZATION SOLUTION

Tier 4 SP

*Analgesics - Anti-Inflammatory*

*Antirheumatic - Enzyme Inhibitors**

*Antirheumatic - Janus Kinase (Jak) Inhibitors***

XELJANZ ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Antirheumatic Antimetabolites**

*Antirheumatic Antimetabolites***

RHEUMATREX ORAL TABLET Tier 3

*Anti-Tnf-Alpha - Monoclonoal Antibodies**

*Anti-Tnf-Alpha - Monoclonoal Antibodies***

HUMIRA SUBCUTANEOUS* KIT Tier 4 PA; SP

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT

Tier 4 PA; SP

SIMPONI SUBCUTANEOUS* SOLUTION 50 MG/0.5ML

Tier 4 PA; SP; QL (5 ML per 30 Day(s))

*Gold Compounds**

*Gold Compounds***

RIDAURA ORAL CAPSULE Tier 2

*Interleukin-1 Blockers**

*Interleukin-1 Blockers***

ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP; QL (4 EA per 30 Day(s))

*Interleukin-1 Receptor Antagonist (Il-1Ra)**

*Interleukin-1 Receptor Antagonist (Il-1Ra)***

KINERET SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**

*Cyclooxygenase 2 (Cox-2) Inhibitors***

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 50 MG

Tier 3 PA; QL (60 EA per 30 Day(s))

CELEBREX ORAL CAPSULE 400 MG Tier 3 PA; QL (30 EA per 30 Day(s))

*Nonsteroidal Anti-Inflammatory Agent Combinations***

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Drug Tier Notes

diclofenac-misoprostol oral tablet delayed release Tier 1

VIMOVO ORAL TABLET DELAYED RELEASE

Tier 3 PA

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral tablet delayed release Tier 1

diclofenac sodium er oral tablet extended release 24 hr*

Tier 1

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac er oral tablet extended release 24 hr* Tier 1

fenoprofen calcium oral tablet Tier 1

flurbiprofen oral tablet Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

indomethacin oral capsule Tier 1

indomethacin er oral capsule extended release* Tier 1

ketoprofen oral capsule Tier 1

ketoprofen er oral capsule extended release 24 hour

Tier 1

ketorolac tromethamine oral tablet Tier 1

meclofenamate sodium oral capsule Tier 1

mefenamic acid oral capsule Tier 1

meloxicam oral suspension Tier 1

meloxicam oral tablet Tier 1

nabumetone oral tablet Tier 1

NALFON ORAL CAPSULE 400 MG Tier 3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HR* 750 MG

Tier 3

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen dr oral tablet delayed release Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

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Drug Tier Notes

SPRIX NASAL SOLUTION Tier 3 PA; QL (5 EA per 30 Day(s))

sulindac oral tablet Tier 1

tolmetin sodium oral capsule Tier 1

tolmetin sodium oral tablet Tier 1

*Pyrimidine Synthesis Inhibitors**

*Pyrimidine Synthesis Inhibitors***

leflunomide oral tablet Tier 1

*Selective Costimulation Modulators**

*Selective Costimulation Modulators***

ORENCIA SUBCUTANEOUS* SOLUTION Tier 4 PA; SP; QL (4 ML per 30 Day(s))

*Soluble Tumor Necrosis Factor Receptor Agents**

*Soluble Tumor Necrosis Factor Receptor Agents***

ENBREL SUBCUTANEOUS* KIT Tier 4 PA; SP; QL (8 EA per 30 Day(s))

ENBREL SUBCUTANEOUS* SOLUTION Tier 4 PA; SP; QL (4 ML per 30 Day(s))

ENBREL SURECLICK SUBCUTANEOUS* SOLUTION


*Analgesics - Nonnarcotic*

*Analgesic Combinations**

*Analgesic Combinations***

duraxin oral capsule Tier 1

ed-flex oral capsule Tier 1

*Analgesics-Sedatives***

ali-flex oral tablet Tier 1

alpain oral tablet Tier 1

butalbital-acetaminophen oral tablet Tier 1

butalbital-apap-caffeine oral capsule Tier 1

butalbital-apap-caffeine oral tablet Tier 1

butalbital-asa-caffeine oral capsule Tier 1

butalbital-aspirin-caffeine oral capsule Tier 1

butalbital-aspirin-caffeine oral tablet Tier 1

capacet oral capsule Tier 1

margesic oral capsule Tier 1

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Drug Tier Notes

marten-tab oral tablet Tier 1

repan oral tablet Tier 1

rhinoflex-650 oral tablet Tier 1

tencon oral tablet Tier 1

zebutal oral capsule Tier 1

zflex oral tablet Tier 1

zgesic oral tablet extendedrelease* Tier 1

*Salicylates**

*Salicylate Combinations***

choline & mag trisalicylate oral tablet 1000 mg Tier 1

choline-mag trisalicylate oral liquid† Tier 1

*Salicylates***

aspirin low dose oral tablet Tier 1 1 (Preventative Medication); OTC

diflunisal oral tablet Tier 1

mst 600 oral tablet Tier 1

salsalate oral tablet Tier 1

*Analgesics - Opioid*

*Opioid Agonists**

*Opioid Agonists***

AVINZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

codeine sulfate oral solution Tier 1

codeine sulfate oral tablet Tier 1

CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

EXALGO ORAL T24A Tier 3

fentanyl transdermal patch 72 hr Tier 1

fentanyl citrate buccal lollipop Tier 1 PA; QL (90 EA per 30 Day(s))

hydromorphone hcl oral tablet Tier 1

hydromorphone hcl re suppository Tier 1

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 130 MG, 150 MG, 200 MG, 40 MG, 70 MG

Tier 3

LAZANDA NASAL SOLUTION 100 MCG/ACT


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Drug Tier Notes

levorphanol tartrate oral tablet Tier 1

meperidine hcl oral solution Tier 1

meperidine hcl oral tablet Tier 1

methadone hcl oral concentrate Tier 1

methadone hcl oral solution Tier 1

methadone hcl oral tablet Tier 1

methadone hcl oral tablet soluble Tier 1

methadose oral concentrate Tier 1

methadose oral tablet soluble Tier 1

morphine sulfate oral solution Tier 1

morphine sulfate oral tablet Tier 1

morphine sulfate re suppository Tier 1

morphine sulfate (concentrate) oral solution 20 mg/ml

Tier 1

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

Tier 1

morphine sulfate er oral tablet extendedrelease* Tier 1

morphine sulfate er beads oral capsule extended release 24 hour

Tier 1

NUCYNTA ORAL TABLET Tier 3

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

ONSOLIS BUCCAL FILM 1200 MCG Tier 3 PA; QL (90 EA per 30 Day(s))

OPANA ER ORAL T12A Tier 3 QL (60 EA per 30 Day(s))

oxycodone hcl oral capsule Tier 1

oxycodone hcl oral concentrate Tier 1

oxycodone hcl oral solution Tier 1

oxycodone hcl oral tablet Tier 1

OXYCONTIN ORAL T12A Tier 3 PA

oxymorphone hcl oral tablet Tier 1

oxymorphone hcl er oral tablet extended release 12 hr*

Tier 1 QL (60 EA per 30 Day(s))

SUBSYS SUBLINGUAL LIQUID† 100 MCG Tier 3 PA; QL (90 EA per 30 Day(s))

tramadol hcl oral tablet Tier 1

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Drug Tier Notes

tramadol hcl er oral capsule extended release 24 hour

Tier 1

tramadol hcl er oral tablet extended release 24 hr*

Tier 1

tramadol hcl er (biphasic) oral tablet extended release 24 hr* 100 mg

Tier 1

*Opioid Combinations**

*Codeine Combinations***

acetaminophen-codeine oral solution Tier 1

acetaminophen-codeine oral tablet Tier 1

acetaminophen-codeine #2 oral tablet Tier 1



ascomp-codeine oral capsule Tier 1

butalbital-apap-caff-cod oral capsule Tier 1

butalbital-asa-caff-codeine oral capsule Tier 1

*Dihydrocodeine Combinations***

apap-caff-dihydrocodeine oral tablet Tier 1

trezix oral capsule Tier 1

*Hydrocodone Combinations***

co-gesic oral tablet Tier 1

hydrocodone-acetaminophen oral solution7.5-325 mg/15ml, 7.5-500 mg/15ml

Tier 1

hydrocodone-acetaminophen oral tablet Tier 1

hydrocodone-ibuprofen oral tablet Tier 1

ibudone oral tablet 5-200 mg Tier 1

reprexain oral tablet 10-200 mg Tier 1

stagesic oral capsule Tier 1

VICODIN ORAL TABLET 5-300 MG Tier 3

VICODIN ES ORAL TABLET 7.5-300 MG Tier 3

VICODIN HP ORAL TABLET 10-300 MG Tier 3

*Opioid Combinations***

endocet oral tablet Tier 1

endodan oral tablet Tier 1

11

Drug Tier Notes

oxycodone-acetaminophen oral capsule Tier 1

oxycodone-acetaminophen oral tablet Tier 1

oxycodone-aspirin oral tablet Tier 1

oxycodone-ibuprofen oral tablet Tier 1

roxicet oral tablet 5-325 mg Tier 1

*Pentazocine Combinations***

pentazocine-acetaminophen oral tablet Tier 1

*Tramadol Combinations***

tramadol-acetaminophen oral tablet Tier 1

*Opioid Partial Agonists**

*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual Tier 1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

Tier 1

butorphanol tartrate nasal solution Tier 1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 20 MCG/HR, 5 MCG/HR

Tier 3

pentazocine-naloxone oral tablet Tier 1

pentazocine-naloxone hcl oral tablet Tier 1

SUBOXONE SUBLINGUAL FILM Tier 2

*Androgens-Anabolic*

*Anabolic Steroids**

*Anabolic Steroids***

ANADROL-50 ORAL TABLET Tier 3

oxandrolone oral tablet Tier 1

*Androgens**

*Androgens***

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


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

Tier 2 QL (150 GM per 30 Day(s))

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM, 50 MG/5GM


12

Drug Tier Notes

ANDROGEL PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%)


ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)


ANDROXY ORAL TABLET Tier 3

AXIRON TRANSDERMAL SOLUTION Tier 3 PA; QL (180 ML per 30 Day(s))

danazol oral capsule Tier 1

FORTESTA TRANSDERMAL GEL Tier 3 PA; QL (120 GM per 30 Day(s))

METHITEST ORAL TABLET Tier 2

testosterone cypionate intramuscular* oil Tier 1SI; 1 (Self Injectable); 2 (Limited to a 30 day supply)

testosterone enanthate intramuscular* oil Tier 1SI; 1 (Self Injectable); 2 (Limited to a 30 day supply)

*Anorectal Agents*

*Intrarectal Steroids**

*Intrarectal Steroids***

colocort re enema Tier 1

CORTIFOAM RE FOAM Tier 3

hydrocortisone re enema Tier 1

*Rectal Combinations**

*Rectal Anesthetic/Steroids***

analpram-hc re lotion Tier 1

hydrocortisone ace-pramoxine re cream Tier 1

hydrocortisone ace-pramoxine re kit Tier 1

lidocaine-hydrocortisone ace re cream Tier 1

lidocaine-hydrocortisone ace re gel Tier 1

lidocaine-hydrocortisone ace re kit 2-2 %, 3-1 %, 3-2.5 %

Tier 1

PROCTOFOAM HC RE FOAM Tier 3

*Rectal Steroids**

*Rectal Steroids***

anucort-hc re suppository Tier 1

hemril-30 re suppository Tier 1

hydrocortisone re cream Tier 1

hydrocortisone acetate re suppository Tier 1

13

Drug Tier Notes

proctosol hc re cream Tier 1

proctozone-hc re cream Tier 1

*Vasodilating Agents**

*Nitrate Vasodilating Agents***

RECTIV RE OINTMENT Tier 3

*Anthelmintics*

*Anthelmintics**

*Anthelmintics***

ALBENZA ORAL TABLET Tier 2

BILTRICIDE ORAL TABLET Tier 2

STROMECTOL ORAL TABLET Tier 2

*Antianginal Agents*

*Antianginals-Other**

*Antianginals-Other***

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

*Nitrates**

*Nitrates***

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE*

Tier 3

isoditrate er oral tablet extendedrelease* Tier 1

isosorbide dinitrate oral tablet Tier 1

isosorbide dinitrate sublingual tablet sublingual2.5 mg

Tier 1

isosorbide dinitrate er oral tablet extendedrelease*

Tier 1

isosorbide mononitrate oral tablet Tier 1

isosorbide mononitrate er oral tablet extended release 24 hr*

Tier 1

minitran transdermal patch 24 hr Tier 1

NITRO-BID TRANSDERMAL OINTMENT Tier 3

NITRO-DUR TRANSDERMAL PATCH 24 HR 0.3 MG/HR, 0.8 MG/HR

Tier 3

nitroglycerin transdermal patch 24 hr Tier 1

nitroglycerin translingual aerosol, solution Tier 1

14

Drug Tier Notes

nitroglycerin er oral capsule extended release* Tier 1

NITROLINGUAL TRANSLINGUAL SOLUTION

Tier 2

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL

Tier 3

*Antianxiety Agents*

*Antianxiety Agents - Misc.**

*Antianxiety Agents - Misc.***

buspirone hcl oral tablet Tier 1

hydroxyzine hcl oral syrup Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule Tier 1

meprobamate oral tablet Tier 1

*Benzodiazepines**

*Benzodiazepines***

alprazolam oral tablet Tier 1

alprazolam oral tablet dispersible Tier 1

alprazolam er oral tablet extended release 24 hr* Tier 1

chlordiazepoxide hcl oral capsule Tier 1

clorazepate dipotassium oral tablet Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

lorazepam oral concentrate Tier 1

lorazepam oral tablet Tier 1

oxazepam oral capsule Tier 1

*Antiarrhythmics*

*Antiarrhythmics Type I-A**

*Antiarrhythmics Type I-A***

disopyramide phosphate oral capsule Tier 1

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG

Tier 3

quinidine gluconate er oral tablet extendedrelease*

Tier 1

quinidine sulfate oral tablet Tier 1

15

Drug Tier Notes

quinidine sulfate er oral tablet extendedrelease* Tier 1

*Antiarrhythmics Type I-B**

*Antiarrhythmics Type I-B***

mexiletine hcl oral capsule Tier 1

*Antiarrhythmics Type I-C**

*Antiarrhythmics Type I-C***

flecainide acetate oral tablet Tier 1

propafenone hcl oral tablet Tier 1

propafenone hcl er oral capsule extended release 12 hour

Tier 1

*Antiarrhythmics Type Iii**

*Antiarrhythmics Type Iii***

amiodarone hcl oral tablet Tier 1

MULTAQ ORAL TABLET Tier 3

pacerone oral tablet Tier 1

TIKOSYN ORAL CAPSULE Tier 3

*Antiasthmatic And Bronchodilator Agents*

*Anti-Inflammatory Agents**

*Anti-Inflammatory Agents***

cromolyn sodium inhalation nebulization solution Tier 1

*Asthma And Bronchodilator Agent Combinations**

*Xanthine-Expectorants***

difil-g forte oral liquid† Tier 1

*Bronchodilators - Anticholinergics**

*Bronchodilators - Anticholinergics***

ATROVENT HFA INHALATION AEROSOL, SOLUTION

Tier 2

ipratropium bromide inhalation solution Tier 1

SPIRIVA HANDIHALER INHALATION CAPSULE

Tier 2

TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 3

*Leukotriene Modulators**

*5-Lipoxygenase Inhibitors***

16

Drug Tier Notes

ZYFLO ORAL TABLET Tier 3

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

*Leukotriene Receptor Antagonists***

montelukast sodium oral packet Tier 1

montelukast sodium oral tablet Tier 1

montelukast sodium oral tablet chewable Tier 1

zafirlukast oral tablet Tier 1

*Selective Phosphodiesterase 4 (Pde4) Inhibitors**

*Selective Phosphodiesterase 4 (Pde4) Inhibitors***

DALIRESP ORAL TABLET Tier 3

*Steroid Inhalants**

*Steroid Inhalants***

ALVESCO INHALATION AEROSOL, SOLUTION

Tier 3

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

budesonide inhalation suspension Tier 1

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

Tier 2

PULMICORT INHALATION SUSPENSION 1 MG/2ML

Tier 2

17

Drug Tier Notes

PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2

QVAR INHALATION AEROSOL, SOLUTION Tier 2

*Sympathomimetics**

*Adrenergic Combinations***

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2

ADVAIR HFA INHALATION AEROSOL† Tier 2

COMBIVENT INHALATION AEROSOL† Tier 3

COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION

Tier 3

DULERA INHALATION AEROSOL† Tier 2

ipratropium-albuterol inhalation solution Tier 1

SYMBICORT INHALATION AEROSOL† Tier 3

*Beta Adrenergics***

albuterol sulfate inhalation nebulization solution Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

albuterol sulfate er oral tablet extended release 12 hr*

Tier 1

ARCAPTA NEOHALER INHALATION CAPSULE

Tier 3

BROVANA INHALATION NEBULIZATION SOLUTION

Tier 3

FORADIL AEROLIZER INHALATION CAPSULE

Tier 3

levalbuterol hcl inhalation nebulization solution Tier 1

MAXAIR AUTOHALER INHALATION AEROSOL, BREATH ACTIVATED

Tier 3

metaproterenol sulfate oral syrup Tier 1

metaproterenol sulfate oral tablet Tier 1

PERFOROMIST INHALATION NEBULIZATION SOLUTION

Tier 3

PROAIR HFA INHALATION AEROSOL, SOLUTION

Tier 2

PROVENTIL HFA INHALATION AEROSOL, SOLUTION

Tier 3

18

Drug Tier Notes

SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2

terbutaline sulfate oral tablet Tier 1

VENTOLIN HFA INHALATION AEROSOL, SOLUTION

Tier 2

XOPENEX HFA INHALATION AEROSOL† Tier 3

*Mixed Adrenergics***

epinephrine hcl injection solution Tier 1

*Xanthines**

*Xanthines***

elixophyllin oral elixir Tier 1

LUFYLLIN ORAL TABLET 200 MG Tier 3

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG

Tier 3

theochron oral tablet extended release 12 hr* Tier 1

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline er oral tablet extended release 12 hr*

Tier 1

theophylline er oral tablet extended release 24 hr*

Tier 1

*Anticoagulants*

*Coumarin Anticoagulants**

*Coumarin Anticoagulants***

jantoven oral tablet Tier 1

warfarin sodium oral tablet Tier 1

*Direct Factor Xa Inhibitors**

*Direct Factor Xa Inhibitors***

ELIQUIS ORAL TABLET Tier 3 PA; QL (60 EA per 30 Day(s))

XARELTO ORAL TABLET Tier 2

*Heparins And Heparinoid-Like Agents**

*Heparins And Heparinoid-Like Agents***

heparin (porcine) lock flush intravenous* solution Tier 1

heparin lock flush intravenous* solution Tier 1

19

Drug Tier Notes

monoject flush syr/hep lock intravenous* solution100 unit/ml

Tier 1

*Low Molecular Weight Heparins***

enoxaparin sodium injection solution Tier 4 SP

enoxaparin sodium subcutaneous* solution Tier 4 SP

FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 25000 UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

Tier 3

*Synthetic Heparinoid-Like Agents***

fondaparinux sodium subcutaneous* solution Tier 4 SP

*Thrombin Inhibitors**

*Thrombin Inhibitors - Selective Direct & Reversible***

PRADAXA ORAL CAPSULE Tier 2

*Anticonvulsants*

*Anticonvulsants - Benzodiazepines**

*Anticonvulsants - Benzodiazepines***

clonazepam oral tablet Tier 1

clonazepam oral tablet dispersible Tier 1

DIASTAT PEDIATRIC RE GEL Tier 2

diazepam re gel Tier 1

*Anticonvulsants - Misc.**

*Anticonvulsants - Misc.***

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet chewable Tier 1

carbamazepine er oral capsule extended release 12 hour

Tier 1

carbamazepine er oral tablet extended release 12 hr*

Tier 1

epitol oral tablet Tier 1

gabapentin oral capsule Tier 1

20

Drug Tier Notes

gabapentin oral solution Tier 1

gabapentin oral tablet Tier 1

LAMICTAL ORAL TABLET CHEWABLE 2 MG

Tier 3

LAMICTAL ODT ORAL TABLET DISPERSIBLE

Tier 3

lamotrigine oral tablet Tier 1

lamotrigine oral tablet chewable Tier 1

lamotrigine er oral tablet extended release 24 hr* Tier 1

levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1

levetiracetam er oral tablet extended release 24 hr*

Tier 1

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


LYRICA ORAL CAPSULE 300 MG Tier 3 PA; QL (60 EA per 30 Day(s))

LYRICA ORAL SOLUTION Tier 3 PA; QL (900 ML per 30 Day(s))

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

POTIGA ORAL TABLET Tier 3

primidone oral tablet Tier 1

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

Tier 3

topiragen oral tablet Tier 1

topiramate oral capsule sprinkle Tier 1

topiramate oral tablet Tier 1

VIMPAT ORAL SOLUTION Tier 3

VIMPAT ORAL TABLET Tier 3

zonisamide oral capsule Tier 1

*Carbamates**

*Carbamates***

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

*Gaba Modulators**

*Gaba Modulators***

21

Drug Tier Notes

SABRIL ORAL PACKET Tier 4 SP

SABRIL ORAL TABLET Tier 4 SP

tiagabine hcl oral tablet Tier 1

*Hydantoins**

*Hydantoins***

DILANTIN ORAL CAPSULE 30 MG Tier 2

PEGANONE ORAL TABLET Tier 3

phenytoin oral suspension Tier 1

phenytoin oral tablet chewable Tier 1

phenytoin infatabs oral tablet chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

*Succinimides**

*Succinimides***

CELONTIN ORAL CAPSULE Tier 2

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

*Valproic Acid**

*Valproic Acid***

divalproex sodium oral capsule sprinkle Tier 1

divalproex sodium oral tablet delayed release Tier 1

divalproex sodium er oral tablet extended release 24 hr*

Tier 1

STAVZOR ORAL CAPSULE DELAYED RELEASE 125 MG

Tier 3

valproate sodium oral syrup Tier 1

valproic acid oral capsule Tier 1

valproic acid oral syrup Tier 1

*Antidepressants*

*Alpha-2 Receptor Antagonists (Tetracyclics)**

*Alpha-2 Receptor Antagonists (Tetracyclics)***

mirtazapine oral tablet Tier 1

mirtazapine oral tablet dispersible Tier 1

22

Drug Tier Notes

*Antidepressants - Misc.**

*Antidepressants - Misc.***

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 174 MG

Tier 3

budeprion sr oral tablet extended release 12 hr* Tier 1

bupropion hcl oral tablet Tier 1

bupropion hcl er (sr) oral tablet extended release 12 hr*

Tier 1

bupropion hcl er (xl) oral tablet extended release 24 hr*

Tier 1

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

maprotiline hcl oral tablet Tier 1

*Modified Cyclics**

*Modified Cyclics***

nefazodone hcl oral tablet Tier 1

trazodone hcl oral tablet Tier 1

VIIBRYD ORAL TABLET Tier 3 PA

*Monoamine Oxidase Inhibitors (Maois)**

*Monoamine Oxidase Inhibitors (Maois)***

EMSAM TRANSDERMAL PATCH 24 HR Tier 3

MARPLAN ORAL TABLET Tier 3

phenelzine sulfate oral tablet Tier 1

tranylcypromine sulfate oral tablet Tier 1

*Selective Serotonin Reuptake Inhibitors (Ssris)**

*Selective Serotonin Reuptake Inhibitors (Ssris)***

citalopram hydrobromide oral solution Tier 1

citalopram hydrobromide oral tablet Tier 1

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

fluoxetine hcl oral capsule Tier 1

fluoxetine hcl oral capsule delayed release Tier 1

fluoxetine hcl oral solution Tier 1

23

Drug Tier Notes

fluoxetine hcl oral tablet Tier 1

fluvoxamine maleate oral tablet Tier 1

paroxetine hcl oral tablet Tier 1

paroxetine hcl er oral tablet extended release 24 hr*

Tier 1

paroxetine mesylate oral tablet Tier 1

PAXIL ORAL SUSPENSION Tier 3

sertraline hcl oral concentrate Tier 1

sertraline hcl oral tablet Tier 1

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***

CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES

Tier 3 PA

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3 PA

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3 PA

venlafaxine hcl oral tablet Tier 1

venlafaxine hcl er oral capsule extended release 24 hour

Tier 1

venlafaxine hcl er oral tablet extended release 24 hr*

Tier 1

*Tricyclic Agents**

*Tricyclic Agents***

amitriptyline hcl oral tablet Tier 1

amoxapine oral tablet Tier 1

clomipramine hcl oral capsule Tier 1

desipramine hcl oral tablet Tier 1

doxepin hcl oral capsule Tier 1

doxepin hcl oral concentrate Tier 1

imipramine hcl oral tablet Tier 1

imipramine pamoate oral capsule Tier 1

nortriptyline hcl oral capsule Tier 1

protriptyline hcl oral tablet Tier 1

24

Drug Tier Notes

trimipramine maleate oral capsule Tier 1

*Antidiabetics*

*Alpha-Glucosidase Inhibitors**

*Alpha-Glucosidase Inhibitors***

acarbose oral tablet Tier 1

GLYSET ORAL TABLET 25 MG Tier 3

*Antidiabetic - Amylin Analogs**

*Antidiabetic - Amylin Analogs***

SYMLINPEN 120 SUBCUTANEOUS* SOLUTION

Tier 3

SYMLINPEN 60 SUBCUTANEOUS* SOLUTION

Tier 3

*Antidiabetic Combinations**

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***

JANUMET ORAL TABLET Tier 2 PA; QL (30 EA per 30 Day(s))

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR*


JENTADUETO ORAL TABLET Tier 3 PA; QL (60 EA per 30 Day(s))

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR*


*Dpp-4 Inhibitor-Hmg Coa Reducctase Inhibitor Comb***

JUVISYNC ORAL TABLET Tier 2 PA; QL (30 EA per 30 Day(s))

*Meglitinide-Biguanide Combinations***

PRANDIMET ORAL TABLET Tier 3

*Sulfonylurea-Biguanide Combinations***

glipizide-metformin hcl oral tablet Tier 1

glyburide-metformin oral tablet Tier 1

*Sulfonylurea-Thiazolidinedione Combinations***

pioglitazone hcl-glimepiride oral tablet Tier 1

*Thiazolidinedione-Biguanide Combinations***

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HR* 15-1000 MG

Tier 3

25

Drug Tier Notes

pioglitazone hcl-metformin hcl oral tablet Tier 1

*Biguanides**

*Biguanides***

GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG

Tier 3

metformin hcl oral tablet Tier 1

metformin hcl er oral tablet extended release 24 hr*

Tier 1

metformin hcl er (osm) oral tablet extended release 24 hr*

Tier 1

RIOMET ORAL SOLUTION Tier 3

*Diabetic Other**

*Diabetic Other***

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED

Tier 2

GLUCAGON EMERGENCY INJECTION KIT Tier 2

PROGLYCEM ORAL SUSPENSION Tier 3

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

JANUVIA ORAL TABLET Tier 2 PA; QL (30 EA per 30 Day(s))

ONGLYZA ORAL TABLET Tier 3 PA; QL (30 EA per 30 Day(s))

TRADJENTA ORAL TABLET Tier 3 PA; QL (30 EA per 30 Day(s))

*Dopamine Receptor Agonists - Antidiabetic**

*Dopamine Receptor Agonists - Ergot Derivatives***

CYCLOSET ORAL TABLET Tier 3

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)**

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***

BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED

Tier 2 PA

BYETTA 10 MCG PEN SUBCUTANEOUS* SOLUTION

Tier 2 PA

BYETTA 5 MCG PEN SUBCUTANEOUS* SOLUTION

Tier 2 PA

26

Drug Tier Notes

VICTOZA SUBCUTANEOUS* SOLUTION Tier 3 PA; QL (9 ML per 30 Day(s))

*Insulin Sensitizing Agents**

*Thiazolidinediones***

AVANDIA ORAL TABLET 2 MG Tier 3

pioglitazone hcl oral tablet Tier 1

*Insulin**

*Human Insulin***

APIDRA INJECTION SOLUTION Tier 3

APIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION

Tier 3

HUMALOG SUBCUTANEOUS* SOLUTION Tier 2

HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION

Tier 2

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* SUSPENSION

Tier 2

HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION

Tier 2

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* SUSPENSION

Tier 2

humulin n subcutaneous* suspension Tier 1 OTC

humulin r injection solution Tier 1 OTC

humulin r u-500 (concentrated) subcutaneous* solution

Tier 1

LANTUS SUBCUTANEOUS* SOLUTION Tier 2

LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION

Tier 2

LEVEMIR SUBCUTANEOUS* SOLUTION Tier 2

LEVEMIR FLEXPEN SUBCUTANEOUS* SOLUTION

Tier 2

novolin 70/30 subcutaneous* suspension Tier 1 OTC

novolin 70/30 relion subcutaneous* suspension Tier 1 OTC

novolin n subcutaneous* suspension Tier 1 OTC

novolin n relion subcutaneous* suspension Tier 1 OTC

novolin r relion injection solution Tier 1 OTC

NOVOLOG SUBCUTANEOUS* SOLUTION Tier 2

27

Drug Tier Notes

NOVOLOG FLEXPEN SUBCUTANEOUS* SOLUTION

Tier 2

NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION

Tier 2

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* SUSPENSION

Tier 2

NOVOLOG PENFILL SUBCUTANEOUS* SOLUTION

Tier 2

*Meglitinide Analogues**

*Meglitinide Analogues***

nateglinide oral tablet Tier 1

PRANDIN ORAL TABLET Tier 2

*Sulfonylureas**

*Sulfonylureas***

chlorpropamide oral tablet Tier 1

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide er oral tablet extended release 24 hr* Tier 1

glipizide xl oral tablet extended release 24 hr* 2.5 mg

Tier 1

glyburide oral tablet Tier 1

glyburide micronized oral tablet Tier 1

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

*Antidiarrheals*

*Antiperistaltic Agents**

*Antiperistaltic Agents***

diphenoxylate-atropine oral liquid† Tier 1

diphenoxylate-atropine oral tablet Tier 1

lomotil oral tablet Tier 1

loperamide hcl oral capsule Tier 1

MOTOFEN ORAL TABLET Tier 3

OPIUM ORAL TINCTURE Tier 3

PAREGORIC ORAL TINCTURE Tier 3

*Antidotes*

28

Drug Tier Notes

*Antidote Combinations And Kits**

*Antidote Combinations And Kits***

cyanide antidote combination kit Tier 1

*Antidotes - Chelating Agents**

*Antidotes - Chelating Agents***

CHEMET ORAL CAPSULE Tier 2

EXJADE ORAL TABLET SOLUBLE Tier 4 SP

FERRIPROX ORAL TABLET Tier 4 SP

pentetate calcium trisodium combination solution Tier 1

pentetate zinc trisodium combination solution Tier 1

*Antidotes**

*Antidotes***

acetylcysteine intravenous* solution Tier 1

*Opioid Antagonists**

*Opioid Antagonists***

naltrexone hcl oral tablet Tier 1

*Antiemetics*

*5-Ht3 Receptor Antagonists**

*5-Ht3 Receptor Antagonists***

ANZEMET ORAL TABLET Tier 3

granisetron hcl oral tablet Tier 1

GRANISOL ORAL SOLUTION Tier 3

ondansetron oral tablet dispersible Tier 1

ondansetron hcl oral solution Tier 1

ondansetron hcl oral tablet Tier 1

SANCUSO TRANSDERMAL PATCH Tier 3

ZUPLENZ ORAL FILM Tier 3

*Antiemetics - Anticholinergic**

*Antiemetics - Anticholinergic***

dimenhydrinate injection solution Tier 1

TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR

Tier 3

trimethobenzamide hcl oral capsule Tier 1

29

Drug Tier Notes

*Antiemetics - Miscellaneous**

*Antiemetics - Miscellaneous***

CESAMET ORAL CAPSULE Tier 3

dronabinol oral capsule Tier 1

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists**

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists***

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

Tier 2

*Antifungals*

*Antifungals**

*Antifungals***

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension Tier 1

griseofulvin microsize oral tablet Tier 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 1

LAMISIL ORAL PACKET Tier 3

nystatin oral tablet Tier 1

terbinafine hcl oral tablet Tier 1

TERBINEX COMBINATION KIT Tier 3

*Imidazole-Related Antifungals**

*Imidazoles***

ketoconazole oral tablet Tier 1

*Triazoles***

fluconazole oral suspension reconstituted Tier 1

fluconazole oral tablet Tier 1

itraconazole oral capsule Tier 1

NOXAFIL ORAL SUSPENSION Tier 3

SPORANOX ORAL SOLUTION Tier 3

VFEND ORAL SUSPENSION RECONSTITUTED

Tier 3

voriconazole oral tablet Tier 1

*Antihistamines*

30

Drug Tier Notes

*Antihistamines - Alkylamines**

*Antihistamines - Alkylamines***

dexchlorpheniramine maleate oral syrup Tier 1

respa-br oral tablet extended release 12 hr* Tier 1

*Antihistamines - Ethanolamines**

*Antihistamines - Ethanolamines***

arbinoxa oral tablet Tier 1

carbinoxamine maleate oral tablet Tier 1

clemastine fumarate oral syrup Tier 1

clemastine fumarate oral tablet 2.68 mg Tier 1

diphenhydramine hcl injection solution Tier 1

diphenhydramine hcl oral capsule 50 mg Tier 1 OTC

diphenhydramine hcl oral elixir Tier 1 OTC

diphenhydramine hcl oral liquid† Tier 1 OTC

*Antihistamines - Non-Sedating**

*Antihistamines - Non-Sedating***

cetirizine hcl oral syrup Tier 1 OTC

CLARINEX ORAL SYRUP Tier 3

desloratadine oral tablet Tier 1

desloratadine oral tablet dispersible Tier 1

fexofenadine hcl oral tablet 60 mg Tier 1 OTC

levocetirizine dihydrochloride oral solution Tier 1

levocetirizine dihydrochloride oral tablet Tier 1

*Antihistamines - Phenothiazines**

*Antihistamines - Phenothiazines***

phenadoz re suppository 12.5 mg Tier 1

promethazine hcl injection solution Tier 1

promethazine hcl oral syrup Tier 1

promethazine hcl oral tablet Tier 1

promethazine hcl re suppository Tier 1

promethegan re suppository Tier 1

*Antihistamines - Piperidines**

*Antihistamines - Piperidines***

31

Drug Tier Notes

cyproheptadine hcl oral syrup Tier 1

cyproheptadine hcl oral tablet Tier 1

*Antihyperlipidemics*

*Antihyperlipidemics - Combinations**

*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb***

VYTORIN ORAL TABLET Tier 3 PA

*Antihyperlipidemics - Misc.**

*Antihyperlipidemics - Misc.***

LOVAZA ORAL CAPSULE Tier 3

VASCEPA ORAL CAPSULE Tier 3

*Bile Acid Sequestrants**

*Bile Acid Sequestrants***

cholestyramine light oral powder Tier 1

colestipol hcl oral packet Tier 1

colestipol hcl oral tablet Tier 1

prevalite oral powder Tier 1

WELCHOL ORAL PACKET Tier 3

WELCHOL ORAL TABLET Tier 3

*Fibric Acid Derivatives**

*Fibric Acid Derivatives***

fenofibrate oral tablet Tier 1

fenofibrate micronized oral capsule Tier 1

fenofibric acid oral tablet Tier 1

FENOGLIDE ORAL TABLET Tier 3

gemfibrozil oral tablet Tier 1

LIPOFEN ORAL CAPSULE Tier 3

TRILIPIX ORAL CAPSULE DELAYED RELEASE

Tier 3

*Hmg Coa Reductase Inhibitors**

*Hmg Coa Reductase Inhibitor Combinations***

SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

32

Drug Tier Notes

*Hmg Coa Reductase Inhibitors***

atorvastatin calcium oral tablet Tier 1

CRESTOR ORAL TABLET Tier 3 PA

fluvastatin sodium oral capsule Tier 1

LIVALO ORAL TABLET Tier 3 PA

lovastatin oral tablet Tier 1

pravastatin sodium oral tablet Tier 1

simvastatin oral tablet Tier 1

*Intestinal Cholesterol Absorption Inhibitors**

*Intestinal Cholesterol Absorption Inhibitors***

ZETIA ORAL TABLET Tier 3

*Microsomal Triglyceride Transfer Protein (Mtp) Inhibitors**

*Microsomal Triglyceride Transfer Protein Inhibitors***

JUXTAPID ORAL CAPSULE Tier 4 PA; SP; 1 (Limited to 60mg a day)

*Nicotinic Acid Derivatives**

*Nicotinic Acid Derivatives***

niacor oral tablet Tier 1

NIASPAN ORAL TABLET EXTENDEDRELEASE*

Tier 2

*Antihypertensives*

*Ace Inhibitors**

*Ace Inhibitors***

benazepril hcl oral tablet Tier 1

captopril oral tablet Tier 1

enalapril maleate oral tablet Tier 1

fosinopril sodium oral tablet Tier 1

lisinopril oral tablet Tier 1

moexipril hcl oral tablet Tier 1

perindopril erbumine oral tablet Tier 1

quinapril hcl oral tablet Tier 1

ramipril oral capsule Tier 1

33

Drug Tier Notes

trandolapril oral tablet Tier 1

*Agents For Pheochromocytoma**

*Agents For Pheochromocytoma***

DEMSER ORAL CAPSULE Tier 3

DIBENZYLINE ORAL CAPSULE Tier 3

*Angiotensin Ii Receptor Antagonists**

*Angiotensin Ii Receptor Antagonists***

ATACAND ORAL TABLET Tier 3 PA

BENICAR ORAL TABLET Tier 2 PA

DIOVAN ORAL TABLET Tier 3 PA

EDARBI ORAL TABLET Tier 3 PA

eprosartan mesylate oral tablet Tier 1

irbesartan oral tablet Tier 1

losartan potassium oral tablet Tier 1

MICARDIS ORAL TABLET Tier 2 PA

*Antiadrenergic Antihypertensives**

*Antiadrenergics - Centrally Acting***

clonidine hcl oral tablet Tier 1

clonidine hcl transdermal patch weekly Tier 1

guanfacine hcl oral tablet Tier 1

methyldopa oral tablet Tier 1

*Antiadrenergics - Peripherally Acting***

doxazosin mesylate oral tablet Tier 1

prazosin hcl oral capsule Tier 1

terazosin hcl oral capsule Tier 1

*Reserpine***

reserpine oral tablet Tier 1

*Antihypertensive Combinations**

*Ace Inhibitor & Calcium Channel Blocker Combinations***

amlodipine besy-benazepril hcl oral capsule Tier 1

TARKA ORAL TABLET EXTENDEDRELEASE*

Tier 3

*Ace Inhibitors & Thiazide/Thiazide-Like***

34

Drug Tier Notes

benazepril-hydrochlorothiazide oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

enalapril-hydrochlorothiazide oral tablet Tier 1

fosinopril sodium-hctz oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb***

methyldopa-hydrochlorothiazide oral tablet Tier 1

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb***

AZOR ORAL TABLET Tier 3 PA

EXFORGE ORAL TABLET Tier 3 PA

TWYNSTA ORAL TABLET Tier 3 PA

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***

BENICAR HCT ORAL TABLET Tier 2 PA

candesartan cilexetil-hctz oral tablet Tier 1 PA

irbesartan-hydrochlorothiazide oral tablet Tier 1

losartan potassium-hctz oral tablet Tier 1

MICARDIS HCT ORAL TABLET Tier 2 PA

valsartan-hydrochlorothiazide oral tablet Tier 1 PA

*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides***

EXFORGE HCT ORAL TABLET Tier 3 PA

TRIBENZOR ORAL TABLET Tier 3 PA

*Beta Blocker & Diuretic Combinations***

atenolol-chlorthalidone oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

metoprolol-hydrochlorothiazide oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

propranolol-hctz oral tablet Tier 1

*Direct Renin Inhibitors & Calcium Channel Blocker Comb***

35

Drug Tier Notes

TEKAMLO ORAL TABLET Tier 3 PA

*Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb***

TEKTURNA HCT ORAL TABLET Tier 3 PA

*Direct Renin Inhibitors-Ca Channel Blocker-Thiazide Comb***

AMTURNIDE ORAL TABLET Tier 3 PA

*Direct Renin Inhibitors**

*Direct Renin Inhibitors***

TEKTURNA ORAL TABLET Tier 3 PA

*Selective Aldosterone Receptor Antagonists (Saras)**

*Selective Aldosterone Receptor Antagonists (Saras)***

eplerenone oral tablet Tier 1

*Vasodilators**

*Vasodilators***

hydralazine hcl oral tablet Tier 1

minoxidil oral tablet Tier 1

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.**

*Anti-Infective Agents - Misc.***

CAYSTON INHALATION SOLUTION RECONSTITUTED

Tier 4 SP

FLAGYL ER ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

metronidazole oral tablet Tier 1

NEBUPENT INHALATION SOLUTION RECONSTITUTED

Tier 3

pentamidine isethionate injection solution reconstituted

Tier 1

PRIMSOL ORAL SOLUTION Tier 3

tinidazole oral tablet Tier 1

trimethoprim oral tablet Tier 1

vancomycin hcl oral capsule Tier 1

XIFAXAN ORAL TABLET Tier 3

36

Drug Tier Notes

*Anti-Infective Misc. - Combinations**

*Anti-Infective Misc. - Combinations***

e.s.p. oral suspension reconstituted Tier 1

erythromycin-sulfisoxazole oral suspension reconstituted

Tier 1

sulfamethoxazole-tmp ds oral tablet Tier 1

sulfamethoxazole-trimethoprim oral tablet Tier 1

*Antiprotozoal Agents**

*Antiprotozoal Agents***

ALINIA ORAL SUSPENSION RECONSTITUTED

Tier 2

ALINIA ORAL TABLET Tier 2

MEPRON ORAL SUSPENSION Tier 2

*Ketolides**

*Ketolides***

KETEK ORAL TABLET Tier 3

*Leprostatics**

*Leprostatics***

dapsone oral tablet Tier 1

*Lincosamides**

*Lincosamides***

clindamycin hcl oral capsule Tier 1

clindamycin palmitate hcl oral solution reconstituted

Tier 1

*Oxazolidinones**

*Oxazolidinones***

ZYVOX ORAL SUSPENSION RECONSTITUTED

Tier 3

ZYVOX ORAL TABLET Tier 3

*Antimalarials*

*Antimalarial Combinations**

*Antimalarial Combinations***

atovaquone-proguanil hcl oral tablet Tier 1

COARTEM ORAL TABLET Tier 2

37

Drug Tier Notes

*Antimalarials**

*Antimalarials***

chloroquine phosphate oral tablet Tier 1

DARAPRIM ORAL TABLET Tier 2

hydroxychloroquine sulfate oral tablet Tier 1

mefloquine hcl oral tablet Tier 1

PRIMAQUINE PHOSPHATE ORAL TABLET Tier 2

quinine sulfate oral capsule Tier 1 PA

*Antimyasthenic/Cholinergic Agents*

*Antimyasthenic/Cholinergic Agents**

*Antimyasthenic/Cholinergic Agents***

guanidine hcl oral tablet Tier 1

MESTINON ORAL SYRUP Tier 3

MESTINON ORAL TABLET EXTENDEDRELEASE*

Tier 3

PROSTIGMIN ORAL TABLET Tier 3

pyridostigmine bromide oral tablet Tier 1

*Antimycobacterial Agents*

*Anti Tb Combinations**

*Anti Tb Combinations***

RIFAMATE ORAL CAPSULE Tier 3

RIFATER ORAL TABLET Tier 3

*Antimycobacterial Agents**

*Antimycobacterial Agents***

cycloserine oral capsule Tier 1

ethambutol hcl oral tablet Tier 1

isoniazid oral syrup Tier 1

isoniazid oral tablet Tier 1

MYCOBUTIN ORAL CAPSULE Tier 3

PASER ORAL PACKET Tier 3

PRIFTIN ORAL TABLET Tier 3

pyrazinamide oral tablet Tier 1

rifampin oral capsule Tier 1

38

Drug Tier Notes

SEROMYCIN ORAL CAPSULE Tier 2

TRECATOR ORAL TABLET Tier 3

*Antineoplastics And Adjunctive Therapies*

*Alkylating Agents**

*Alkylating Agents***

HEXALEN ORAL CAPSULE Tier 2

MYLERAN ORAL TABLET Tier 4 SP

*Imidazotetrazines***

TEMODAR ORAL CAPSULE Tier 4 SP

*Nitrogen Mustards***

ALKERAN ORAL TABLET Tier 2

cyclophosphamide oral tablet Tier 1

LEUKERAN ORAL TABLET Tier 2

*Antimetabolites**

*Antimetabolites***

mercaptopurine oral tablet Tier 1

methotrexate oral tablet Tier 1

TABLOID ORAL TABLET Tier 2

TREXALL ORAL TABLET Tier 3

XELODA ORAL TABLET Tier 4 SP

*Antineoplastic - Hedgehog Pathway Inhibitors**

*Antineoplastic - Hedgehog Pathway Inhibitors***

ERIVEDGE ORAL CAPSULE Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Antineoplastic - Hormonal And Related Agents**

*Androgen Biosynthesis Inhibitors***

ZYTIGA ORAL TABLET Tier 4PA; SP; QL (120 EA per 30 Day(s))

*Antiadrenals***

LYSODREN ORAL TABLET Tier 2

*Antiandrogens***

bicalutamide oral tablet Tier 1

39

Drug Tier Notes

flutamide oral capsule Tier 1

NILANDRON ORAL TABLET Tier 3

XTANDI ORAL CAPSULE Tier 4PA; SP; QL (120 EA per 30 Day(s))

*Antiestrogens***

FARESTON ORAL TABLET Tier 2

SOLTAMOX ORAL SOLUTION Tier 3

tamoxifen citrate oral tablet Tier 1

*Aromatase Inhibitors***

anastrozole oral tablet Tier 1

exemestane oral tablet Tier 1

letrozole oral tablet Tier 1

*Estrogens-Antineoplastic***

EMCYT ORAL CAPSULE Tier 2

*Progestins-Antineoplastic***

DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML

Tier 3 1 (Preventative Medication)

megestrol acetate oral suspension 40 mg/ml Tier 1

megestrol acetate oral tablet Tier 1

*Antineoplastic - Immunomodulators**

*Antineoplastic - Immunomodulators***

POMALYST ORAL CAPSULE Tier 4 PA; SP; QL (21 EA per 30 Day(s))

*Antineoplastic Enzyme Inhibitors**

*Antineoplastic - Braf Kinase Inhibitors***

ZELBORAF ORAL TABLET Tier 4PA; SP; QL (240 EA per 30 Day(s))

*Antineoplastic - Histone Deacetylase Inhibitors***

ZOLINZA ORAL CAPSULE Tier 4PA; SP; QL (120 EA per 30 Day(s))

*Antineoplastic - Mtor Kinase Inhibitors***

AFINITOR ORAL TABLET Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Antineoplastic - Multikinase Inhibitors***

NEXAVAR ORAL TABLET Tier 4PA; SP; QL (120 EA per 30 Day(s))

40

Drug Tier Notes

STIVARGA ORAL TABLET Tier 4 PA; SP; QL (84 EA per 28 Day(s))

SUTENT ORAL CAPSULE Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Antineoplastic - Tyrosine Kinase Inhibitors***

BOSULIF ORAL TABLET 100 MG Tier 4PA; SP; QL (180 EA per 30 Day(s))

BOSULIF ORAL TABLET 500 MG Tier 4 PA; SP; QL (36 EA per 30 Day(s))

CAPRELSA ORAL TABLET 100 MG Tier 4 PA; SP; QL (90 EA per 30 Day(s))

CAPRELSA ORAL TABLET 300 MG Tier 4 PA; SP; QL (30 EA per 30 Day(s))

COMETRIQ (100 MG DAILY DOSE) ORAL KIT

Tier 4PA; SP; 1 (Limited to 140mg a day)

COMETRIQ (140 MG DAILY DOSE) ORAL KIT

Tier 4PA; SP; 1 (Limited to 140mg a day)

COMETRIQ (60 MG DAILY DOSE) ORAL KIT Tier 4PA; SP; 1 (Limited to 140mg a day)

GLEEVEC ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

ICLUSIG ORAL TABLET 15 MG Tier 4 PA; SP; QL (90 EA per 30 Day(s))

ICLUSIG ORAL TABLET 45 MG Tier 4 PA; SP; QL (30 EA per 30 Day(s))

INLYTA ORAL TABLET Tier 4PA; SP; QL (120 EA per 30 Day(s))

SPRYCEL ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

TARCEVA ORAL TABLET Tier 4 PA; SP; QL (30 EA per 30 Day(s))

TASIGNA ORAL CAPSULE Tier 4PA; SP; QL (120 EA per 30 Day(s))

TYKERB ORAL TABLET Tier 4PA; SP; QL (180 EA per 30 Day(s))

VOTRIENT ORAL TABLET Tier 4PA; SP; QL (120 EA per 30 Day(s))

XALKORI ORAL CAPSULE Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Janus Associated Kinase (Jak) Inhibitors***

JAKAFI ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Antineoplastics Misc.**

*Antineoplastics Misc.***

hydroxyurea oral capsule Tier 1

MATULANE ORAL CAPSULE Tier 4 SP

41

Drug Tier Notes

SYLATRON SUBCUTANEOUS* KIT 296 MCG, 444 MCG, 888 MCG

Tier 4 PA; SP

*Retinoids***

tretinoin oral capsule Tier 1

*Selective Retinoid X Receptor Agonists***

TARGRETIN ORAL CAPSULE Tier 4 SP

*Chemotherapy Rescue/Antidote Agents**

*Folic Acid Antagonists Rescue Agents***

leucovorin calcium oral tablet Tier 1

*Urinary Tract Protective Agents***

MESNEX ORAL TABLET Tier 4 SP

*Mitotic Inhibitors**

*Mitotic Inhibitors***

etoposide oral capsule Tier 1

*Topoisomerase I Inhibitors**

*Topoisomerase I Inhibitors***

HYCAMTIN ORAL CAPSULE Tier 4 SP

*Antiparkinson Agents*

*Antiparkinson Adjuvants**

*Decarboxylase Inhibitors***

LODOSYN ORAL TABLET Tier 3

*Antiparkinson Anticholinergics**

*Antiparkinson Anticholinergics***

benztropine mesylate oral tablet Tier 1

trihexyphenidyl hcl oral elixir Tier 1

trihexyphenidyl hcl oral tablet Tier 1

*Antiparkinson Comt Inhibitors**

*Central/Peripheral Comt Inhibitors***

TASMAR ORAL TABLET 100 MG Tier 3

*Peripheral Comt Inhibitors***

entacapone oral tablet Tier 1

*Antiparkinson Dopaminergics**

*Antiparkinson Dopaminergics***

42

Drug Tier Notes

amantadine hcl oral capsule Tier 1

amantadine hcl oral syrup Tier 1

amantadine hcl oral tablet Tier 1

bromocriptine mesylate oral capsule Tier 1

bromocriptine mesylate oral tablet Tier 1

*Levodopa Combinations***

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet dispersible Tier 1

carbidopa-levodopa er oral tablet extendedrelease*

Tier 1

carbidopa-levodopa-entacapone oral tablet Tier 1

STALEVO 100 ORAL TABLET Tier 3






*Nonergoline Dopamine Receptor Agonists***

APOKYN SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

NEUPRO TRANSDERMAL PATCH 24 HR Tier 3

pramipexole dihydrochloride oral tablet Tier 1

ropinirole hcl oral tablet Tier 1

ropinirole hcl er oral tablet extended release 24 hr*

Tier 1

*Antiparkinson Monoamine Oxidase Inhibitors**

*Antiparkinson Monoamine Oxidase Inhibitors***

AZILECT ORAL TABLET Tier 2

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

*Antipsychotics/Antimanic Agents*

*Antimanic Agents**

43

Drug Tier Notes

*Antimanic Agents***

lithium carbonate oral capsule Tier 1

lithium carbonate oral tablet Tier 1

lithium carbonate er oral tablet extendedrelease* Tier 1

lithium citrate oral solution Tier 1

*Antipsychotics - Misc.**

*Antipsychotics - Misc.***

LATUDA ORAL TABLET Tier 3 PA

ziprasidone hcl oral capsule Tier 1 PA

*Benzisoxazoles**

*Benzisoxazoles***

FANAPT ORAL TABLET Tier 3 PA

INVEGA ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3 PA

risperidone oral tablet Tier 1

risperidone oral tablet dispersible Tier 1

risperidone m-tab oral tablet dispersible 2 mg, 4 mg

Tier 1

*Butyrophenones**

*Butyrophenones***

haloperidol oral tablet Tier 1

haloperidol lactate oral concentrate Tier 1

*Dibenzapines**

*Dibenzodiazepines***

clozapine oral tablet Tier 1

clozapine oral tablet dispersible Tier 1

FAZACLO ORAL TABLET DISPERSIBLE 150 MG

Tier 3

*Dibenzo-Oxepino Pyrroles***

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL

Tier 3 PA

*Dibenzothiazepines***

quetiapine fumarate oral tablet Tier 1

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

44

Drug Tier Notes

*Dibenzoxazepines***

loxapine succinate oral capsule Tier 1

*Thienbenzodiazepines***

olanzapine oral tablet Tier 1

olanzapine oral tablet dispersible Tier 1

*Phenothiazines**

*Phenothiazines***

chlorpromazine hcl oral tablet Tier 1

compro re suppository Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

perphenazine oral tablet Tier 1

prochlorperazine re suppository Tier 1

prochlorperazine maleate oral tablet Tier 1

thioridazine hcl oral tablet Tier 1

trifluoperazine hcl oral tablet Tier 1

*Quinolinone Derivatives**

*Quinolinone Derivatives***

ABILIFY ORAL SOLUTION Tier 2 PA

ABILIFY ORAL TABLET Tier 2 PA; QL (30 EA per 30 Day(s))

ABILIFY DISCMELT ORAL TABLET DISPERSIBLE


*Thioxanthenes**

*Thioxanthenes***

thiothixene oral capsule Tier 1

*Antiseptics & Disinfectants*

*Antiseptics & Disinfectants**

*Antiseptics & Disinfectants***

forma-ray external solution Tier 1

formadon external solution Tier 1

formaldehyde external solution 10 % Tier 1

*Chlorine Antiseptics**

45

Drug Tier Notes

*Chlorine Antiseptics***

chlorhexidine gluconate xx solution 20 % Tier 1

*Iodine Antiseptics**

*Iodine Antiseptics***

iodine external solution Tier 1 OTC

iodine tincture external tincture Tier 1 OTC

lugols external solution Tier 1

*Antivirals*

*Antiretrovirals**

*Antiretroviral Combinations***

ATRIPLA ORAL TABLET Tier 3

COMPLERA ORAL TABLET Tier 3

EPZICOM ORAL TABLET Tier 3

KALETRA ORAL SOLUTION Tier 2

KALETRA ORAL TABLET Tier 2

lamivudine-zidovudine oral tablet Tier 1

STRIBILD ORAL TABLET Tier 4 SP

TRIZIVIR ORAL TABLET Tier 4 SP

TRUVADA ORAL TABLET Tier 3

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***

SELZENTRY ORAL TABLET Tier 4 SP

*Antiretrovirals - Integrase Inhibitors***

ISENTRESS ORAL TABLET Tier 2

ISENTRESS ORAL TABLET CHEWABLE Tier 2

*Antiretrovirals - Protease Inhibitors***

APTIVUS ORAL CAPSULE Tier 4 SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 2

INVIRASE ORAL CAPSULE Tier 2

INVIRASE ORAL TABLET Tier 2

LEXIVA ORAL SUSPENSION Tier 2

LEXIVA ORAL TABLET Tier 4 SP

NORVIR ORAL CAPSULE Tier 2

46

Drug Tier Notes

NORVIR ORAL TABLET Tier 2

PREZISTA ORAL SUSPENSION Tier 2

PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 800 MG

Tier 4 SP

PREZISTA ORAL TABLET 75 MG Tier 2

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 2

VIRACEPT ORAL TABLET Tier 4 SP

*Antiretrovirals - Rti-Non-Nucleoside Analogues***

EDURANT ORAL TABLET Tier 4 SP

INTELENCE ORAL TABLET Tier 4 SP

nevirapine oral tablet Tier 1

RESCRIPTOR ORAL TABLET Tier 4 SP

SUSTIVA ORAL CAPSULE Tier 4 SP

SUSTIVA ORAL TABLET Tier 4 SP

VIRAMUNE ORAL SUSPENSION Tier 2

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

*Antiretrovirals - Rti-Nucleoside Analogues-Purines***

abacavir sulfate oral tablet Tier 1

didanosine oral capsule delayed release Tier 1

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM

Tier 3

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***

EMTRIVA ORAL CAPSULE Tier 3

EMTRIVA ORAL SOLUTION Tier 3

EPIVIR HBV ORAL SOLUTION Tier 2

EPIVIR HBV ORAL TABLET Tier 2

lamivudine oral tablet Tier 1

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***

stavudine oral capsule Tier 1

stavudine oral solution reconstituted Tier 1

47

Drug Tier Notes

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

*Antiretrovirals - Rti-Nucleotide Analogues***

VIREAD ORAL POWDER Tier 2

VIREAD ORAL TABLET Tier 2

*Cmv Agents**

*Cmv Agents***

VALCYTE ORAL SOLUTION RECONSTITUTED

Tier 4 SP

VALCYTE ORAL TABLET Tier 4 SP

*Hepatitis Agents**

*Hepatitis B Agents***

BARACLUDE ORAL TABLET Tier 4 SP

HEPSERA ORAL TABLET Tier 4 SP

TYZEKA ORAL TABLET Tier 4 SP

*Hepatitis C Agents***

INCIVEK ORAL TABLET Tier 4PA; SP; QL (180 EA per 30 Day(s))

PEG-INTRON SUBCUTANEOUS* KIT Tier 4 PA; SP; QL (2 EA per 30 Day(s))

PEG-INTRON REDIPEN SUBCUTANEOUS* KIT


PEGASYS SUBCUTANEOUS* KIT Tier 4 PA; SP; QL (2 EA per 30 Day(s))

PEGASYS SUBCUTANEOUS* SOLUTION Tier 4 PA; SP; QL (4 ML per 30 Day(s))

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML


REBETOL ORAL SOLUTION Tier 4 SP

RIBAPAK ORAL MISC Tier 4 SP

RIBAPAK ORAL TABLET Tier 4 SP

RIBASPHERE ORAL CAPSULE Tier 4 SP

RIBASPHERE ORAL TABLET Tier 4 SP

RIBATAB ORAL MISC Tier 4 SP

RIBATAB ORAL TABLET Tier 4 SP

ribavirin oral capsule Tier 4 SP

48

Drug Tier Notes

ribavirin oral misc Tier 4 SP

ribavirin oral tablet Tier 4 SP

VICTRELIS ORAL CAPSULE Tier 4PA; SP; QL (360 EA per 30 Day(s))

*Herpes Agents**

*Herpes Agents - Purine Analogues***

acyclovir oral capsule Tier 1

acyclovir oral suspension Tier 1

acyclovir oral tablet Tier 1

valacyclovir hcl oral tablet Tier 1

*Herpes Agents - Thymidine Analogues***

famciclovir oral tablet Tier 1

*Influenza Agents**

*Influenza Agents***

rimantadine hcl oral tablet Tier 1

*Neuraminidase Inhibitors***

RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED


TAMIFLU ORAL CAPSULE 30 MG Tier 2 QL (168 EA per 365 Day(s))

TAMIFLU ORAL CAPSULE 45 MG, 75 MG Tier 2 QL (84 EA per 365 Day(s))

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

Tier 2 QL (1080 ML per 365 Day(s))

*Respiratory Syncytial Virus (Rsv) Agents**

*Rsv Agents - Nucleoside Analogues***

VIRAZOLE INHALATION SOLUTION RECONSTITUTED

Tier 4 SP

*Assorted Classes*

*Chelating Agents**

*Chelating Agents***

CUPRIMINE ORAL CAPSULE Tier 3

DEPEN TITRATABS ORAL TABLET Tier 3

SYPRINE ORAL CAPSULE Tier 2

*Immunomodulators**

*Antileprotics***

49

Drug Tier Notes

THALOMID ORAL CAPSULE Tier 4 SP

*Immunomodulators For Myelodysplastic Syndromes***

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG


REVLIMID ORAL CAPSULE 20 MG Tier 4 PA; QL (30 EA per 30 Day(s))

*Immunosuppressive Agents**

*Cyclosporine Analogs***

cyclosporine oral capsule Tier 1

cyclosporine modified oral capsule Tier 1

cyclosporine modified oral solution Tier 1

gengraf oral capsule Tier 1

gengraf oral solution Tier 1

SANDIMMUNE ORAL SOLUTION Tier 3

*Inosine Monophosphate Dehydrogenase Inhibitors***

CELLCEPT ORAL SUSPENSION RECONSTITUTED

Tier 3

mycophenolate mofetil oral capsule Tier 1

mycophenolate mofetil oral tablet Tier 1

MYFORTIC ORAL TABLET DELAYED RELEASE

Tier 2

*Macrolide Immunosuppressants***

hecoria oral capsule Tier 1

RAPAMUNE ORAL SOLUTION Tier 2

RAPAMUNE ORAL TABLET Tier 2

tacrolimus oral capsule Tier 1

ZORTRESS ORAL TABLET Tier 4 SP

*Purine Analogs***

AZASAN ORAL TABLET Tier 3

azathioprine oral tablet Tier 1

*Irrigation Solutions**

*Irrigation Solutions***

physiolyte irrigation solution Tier 1

physiosol irrigation irrigation solution Tier 1

50

Drug Tier Notes

sterile water for irrigation irrigation solution Tier 1

water for irrigation, sterile irrigation solution Tier 1

*Potassium Removing Resins**

*Potassium Removing Resins***

kionex oral suspension Tier 1

sodium polystyrene sulfonate oral suspension Tier 1

*Beta Blockers*

*Alpha-Beta Blockers**

*Alpha-Beta Blockers***

carvedilol oral tablet Tier 1

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

labetalol hcl oral tablet Tier 1

*Beta Blockers Cardio-Selective**

*Beta Blockers Cardio-Selective***

acebutolol hcl oral capsule Tier 1

atenolol oral tablet Tier 1

betaxolol hcl oral tablet Tier 1

bisoprolol fumarate oral tablet Tier 1

BYSTOLIC ORAL TABLET Tier 3

metoprolol succinate er oral tablet extended release 24 hr*

Tier 1

metoprolol tartrate oral tablet Tier 1

*Beta Blockers Non-Selective**

*Beta Blockers Non-Selective***

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 80 MG

Tier 3

LEVATOL ORAL TABLET Tier 3

nadolol oral tablet Tier 1

pindolol oral tablet Tier 1

propranolol hcl oral solution Tier 1

propranolol hcl oral tablet Tier 1

propranolol hcl er oral capsule extended release 24 hour

Tier 1

51

Drug Tier Notes

sorine oral tablet Tier 1

sotalol hcl oral tablet Tier 1

timolol maleate oral tablet Tier 1

*Calcium Channel Blockers*

*Calcium Channel Blockers**

*Calcium Channel Blockers***

afeditab cr oral tablet extended release 24 hr* Tier 1

amlodipine besylate oral tablet Tier 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR* 120 MG

Tier 3

cartia xt oral capsule extended release 24 hour Tier 1

dilt-cd oral capsule extended release 24 hour Tier 1

dilt-xr oral capsule extended release 24 hour 180 mg

Tier 1

diltiazem hcl oral tablet Tier 1

diltiazem hcl er oral capsule extended release 12 hour

Tier 1

diltiazem hcl er oral capsule extended release 24 hour

Tier 1

diltiazem hcl er beads oral capsule extended release 24 hour 300 mg, 360 mg, 420 mg

Tier 1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

Tier 1

diltzac oral capsule extended release 24 hour Tier 1

felodipine er oral tablet extended release 24 hr* Tier 1

isradipine oral capsule 2.5 mg, 5 mg Tier 1

matzim la oral tablet extended release 24 hr* Tier 1

nicardipine hcl oral capsule Tier 1

nifediac cc oral tablet extended release 24 hr* Tier 1

nifedical xl oral tablet extended release 24 hr* Tier 1

nifedipine oral capsule Tier 1

nifedipine er oral tablet extended release 24 hr* Tier 1

nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 90 mg

Tier 1

nimodipine oral capsule Tier 1

52

Drug Tier Notes

nisoldipine er oral tablet extended release 24 hr*17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

Tier 1

taztia xt oral capsule extended release 24 hour Tier 1

verapamil hcl oral tablet Tier 1

verapamil hcl er oral capsule extended release 24 hour

Tier 1

verapamil hcl er oral tablet extendedrelease* Tier 1

verapamil hcl er (co) oral tablet extended release 24 hr*

Tier 1

*Cardiotonics*

*Cardiac Glycosides**

*Cardiac Glycosides***

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

*Cardiovascular Agents - Misc.*

*Cardiovascular Agents Misc. - Combinations**

*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb***

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG

Tier 3

*Nitrate & Vasodilator Combinations***

BIDIL ORAL TABLET Tier 3

*Impotence Agents**

*Prostaglandin - Impotence Agents***

CAVERJECT INTRACAVERNOSAL * SOLUTION RECONSTITUTED

Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

CAVERJECT IMPULSE INTRACAVERNOSAL * KIT

Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

EDEX INTRACAVERNOSAL * KIT 10 MCG, 20 MCG

Tier 31 (May not be a covered benefit. Consult your benefit booklet)

MUSE URETHRAL PELLET Tier 31 (May not be a covered benefit. Consult your benefit booklet)

*Selective Cgmp Phosphodiesterase Type 5 Inhibitors***

CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 3 PA; QL (30 EA per 30 Day(s))

53

Drug Tier Notes

*Peripheral Vasodilators**

*Peripheral Vasodilators***

isoxsuprine hcl oral tablet 10 mg Tier 1

*Prostaglandin Vasodilators**

*Prostaglandin Vasodilators***

TYVASO INHALATION SOLUTION Tier 4 PA; SP

VENTAVIS INHALATION SOLUTION Tier 4PA; SP; QL (540 ML per 30 Day(s))

*Pulmonary Hypertension - Endothelin Receptor Antagonists**

*Pulmonary Hypertension - Endothelin Receptor Antagonists***

LETAIRIS ORAL TABLET Tier 4 PA; SP; QL (30 EA per 30 Day(s))

TRACLEER ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Pulmonary Hypertension - Phosphodiesterase Inhibitors**

*Pulmonary Hypertension - Phosphodiesterase Inhibitors***

ADCIRCA ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

sildenafil citrate oral tablet Tier 1 PA; QL (90 EA per 30 Day(s))

*Cephalosporins*

*Cephalosporins - 1St Generation**

*Cephalosporins - 1St Generation***

cefadroxil oral capsule Tier 1

cefadroxil oral suspension reconstituted Tier 1

cefadroxil oral tablet Tier 1

cephalexin oral capsule 250 mg, 500 mg Tier 1

cephalexin oral suspension reconstituted Tier 1

cephalexin oral tablet Tier 1

KEFLEX ORAL CAPSULE 750 MG Tier 3

*Cephalosporins - 2Nd Generation**

*Cephalosporins - 2Nd Generation***

cefaclor oral capsule Tier 1

cefaclor oral suspension reconstituted Tier 1

cefaclor er oral tablet extended release 12 hr* Tier 1

54

Drug Tier Notes

cefprozil oral suspension reconstituted Tier 1

cefprozil oral tablet Tier 1

CEFTIN ORAL SUSPENSION RECONSTITUTED 250 MG/5ML

Tier 3

cefuroxime axetil oral suspension reconstituted125 mg/5ml

Tier 1

cefuroxime axetil oral tablet Tier 1

*Cephalosporins - 3Rd Generation**

*Cephalosporins - 3Rd Generation***

CEDAX ORAL CAPSULE Tier 3

CEDAX ORAL SUSPENSION RECONSTITUTED

Tier 3

cefdinir oral capsule Tier 1

cefdinir oral suspension reconstituted Tier 1

cefditoren pivoxil oral tablet Tier 1

cefpodoxime proxetil oral suspension reconstituted

Tier 1

cefpodoxime proxetil oral tablet Tier 1

SUPRAX ORAL SUSPENSION RECONSTITUTED

Tier 3

SUPRAX ORAL TABLET Tier 3

SUPRAX ORAL TABLET CHEWABLE Tier 3

*Contraceptives*

*Combination Contraceptives - Oral**

*Biphasic Contraceptives - Oral***

azurette oral tablet Tier 1 1 (Preventative Medication)

kariva oral tablet Tier 1 1 (Preventative Medication)

LO LOESTRIN FE ORAL TABLET Tier 3

necon 10/11 (28) oral tablet Tier 1 1 (Preventative Medication)

viorele oral tablet Tier 1 1 (Preventative Medication)

*Combination Contraceptives - Oral***

altavera oral tablet Tier 1 1 (Preventative Medication)

alyacen 1/35 oral tablet Tier 1 1 (Preventative Medication)

apri oral tablet Tier 1 1 (Preventative Medication)

aviane oral tablet Tier 1 1 (Preventative Medication)

55

Drug Tier Notes

balziva oral tablet Tier 1 1 (Preventative Medication)

BEYAZ ORAL TABLET Tier 3

briellyn oral tablet Tier 1 1 (Preventative Medication)

chateal oral tablet Tier 1 1 (Preventative Medication)

cryselle-28 oral tablet Tier 1 1 (Preventative Medication)

cyclafem 1/35 oral tablet Tier 1 1 (Preventative Medication)

dasetta 1/35 oral tablet Tier 1 1 (Preventative Medication)

drospirenone-ethinyl estradiol oral tablet Tier 1 1 (Preventative Medication)

elinest oral tablet Tier 1 1 (Preventative Medication)

emoquette oral tablet Tier 1 1 (Preventative Medication)

enskyce oral tablet Tier 1 1 (Preventative Medication)

estarylla oral tablet Tier 1 1 (Preventative Medication)

falmina oral tablet Tier 1 1 (Preventative Medication)

generess fe oral tablet chewable Tier 1 1 (Preventative Medication)

gianvi oral tablet Tier 1 1 (Preventative Medication)

gildagia oral tablet Tier 1 1 (Preventative Medication)

gildess 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

gildess 1/20 oral tablet Tier 1 1 (Preventative Medication)

gildess fe 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

gildess fe 1/20 oral tablet Tier 1 1 (Preventative Medication)

junel 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

junel 1/20 oral tablet Tier 1 1 (Preventative Medication)

junel fe 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

junel fe 1/20 oral tablet Tier 1 1 (Preventative Medication)

kelnor 1/35 oral tablet Tier 1 1 (Preventative Medication)

kurvelo oral tablet Tier 1 1 (Preventative Medication)

lessina oral tablet Tier 1 1 (Preventative Medication)

levonorgestrel-ethinyl estrad oral tablet Tier 1 1 (Preventative Medication)

levora 0.15/30 (28) oral tablet Tier 1 1 (Preventative Medication)

loryna oral tablet Tier 1 1 (Preventative Medication)

low-ogestrel oral tablet Tier 1 1 (Preventative Medication)

lutera oral tablet Tier 1 1 (Preventative Medication)

marlissa oral tablet Tier 1 1 (Preventative Medication)

56

Drug Tier Notes

microgestin 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

microgestin 1/20 oral tablet Tier 1 1 (Preventative Medication)

microgestin fe 1.5/30 oral tablet Tier 1 1 (Preventative Medication)

microgestin fe 1/20 oral tablet Tier 1 1 (Preventative Medication)

mono-linyah oral tablet Tier 1 1 (Preventative Medication)

mononessa oral tablet Tier 1 1 (Preventative Medication)

necon 0.5/35 (28) oral tablet Tier 1 1 (Preventative Medication)



norethin-eth estradiol-fe oral tablet chewable Tier 1 1 (Preventative Medication)

norgestimate-eth estradiol oral tablet Tier 1 1 (Preventative Medication)

nortrel 0.5/35 (28) oral tablet Tier 1 1 (Preventative Medication)

nortrel 1/35 (21) oral tablet Tier 1 1 (Preventative Medication)

nortrel 1/35 (28) oral tablet Tier 1 1 (Preventative Medication)

ocella oral tablet Tier 1 1 (Preventative Medication)

ogestrel oral tablet Tier 1 1 (Preventative Medication)

orsythia oral tablet Tier 1 1 (Preventative Medication)

philith oral tablet Tier 1 1 (Preventative Medication)

pirmella 1/35 oral tablet Tier 1 1 (Preventative Medication)

portia-28 oral tablet Tier 1 1 (Preventative Medication)

previfem oral tablet Tier 1 1 (Preventative Medication)

reclipsen oral tablet Tier 1 1 (Preventative Medication)

SAFYRAL ORAL TABLET Tier 3

solia oral tablet Tier 1 1 (Preventative Medication)

sprintec 28 oral tablet Tier 1 1 (Preventative Medication)

sronyx oral tablet Tier 1 1 (Preventative Medication)

syeda oral tablet Tier 1 1 (Preventative Medication)

vestura oral tablet Tier 1 1 (Preventative Medication)

wera oral tablet Tier 1 1 (Preventative Medication)

wymzya fe oral tablet chewable Tier 1 1 (Preventative Medication)

zarah oral tablet Tier 1 1 (Preventative Medication)

zenchent oral tablet Tier 1 1 (Preventative Medication)

zenchent fe oral tablet chewable Tier 1 1 (Preventative Medication)

57

Drug Tier Notes

zovia 1/35e (28) oral tablet Tier 1 1 (Preventative Medication)

zovia 1/50e (28) oral tablet Tier 1 1 (Preventative Medication)

*Continuous Contraceptives - Oral***

amethyst oral tablet Tier 1 1 (Preventative Medication)

*Extended-Cycle Contraceptives - Oral***

amethia oral tablet Tier 1 1 (Preventative Medication)

amethia lo oral tablet Tier 1 1 (Preventative Medication)

camrese oral tablet Tier 1 1 (Preventative Medication)

camrese lo oral tablet Tier 1 1 (Preventative Medication)

daysee oral tablet Tier 1 1 (Preventative Medication)

introvale oral tablet Tier 1 1 (Preventative Medication)

jolessa oral tablet Tier 1 1 (Preventative Medication)

levonorgest-eth estrad 91-day oral tablet Tier 1 1 (Preventative Medication)

quasense oral tablet Tier 1 1 (Preventative Medication)

*Four Phase Contraceptives - Oral***

NATAZIA ORAL TABLET Tier 3

*Triphasic Contraceptives - Oral***

alyacen 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

aranelle oral tablet Tier 1 1 (Preventative medication.)

caziant oral tablet Tier 1 1 (Preventative Medication)

cesia oral tablet Tier 1 1 (Preventative Medication)

cyclafem 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

dasetta 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

enpresse-28 oral tablet Tier 1 1 (Preventative Medication)

leena oral tablet Tier 1 1 (Preventative Medication)

levonest oral tablet Tier 1 1 (Preventative Medication)

myzilra oral tablet Tier 1 1 (Preventative Medication)

necon 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

norgestim-eth estrad triphasic oral tablet Tier 1 1 (Preventative Medication)

nortrel 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

pirmella 7/7/7 oral tablet Tier 1 1 (Preventative Medication)

tilia fe oral tablet Tier 1 1 (Preventative Medication)

tri-estarylla oral tablet Tier 1 1 (Preventative Medication)

58

Drug Tier Notes

tri-legest fe oral tablet Tier 1 1 (Preventative Medication)

tri-linyah oral tablet Tier 1 1 (Preventative Medication)

tri-previfem oral tablet Tier 1 1 (Preventative Medication)

tri-sprintec oral tablet Tier 1 1 (Preventative Medication)

trinessa (28) oral tablet Tier 1 1 (Preventative Medication)

trivora (28) oral tablet Tier 1 1 (Preventative Medication)

velivet oral tablet Tier 1 1 (Preventative Medication)

*Combination Contraceptives - Transdermal**

*Combination Contraceptives - Transdermal***

ORTHO EVRA TRANSDERMAL PATCH WEEKLY

Tier 2

*Combination Contraceptives - Vaginal**

*Combination Contraceptives - Vaginal***

NUVARING VAGINAL RING Tier 3 1 (Preventative Medication)

*Emergency Contraceptives**

*Emergency Contraceptives***

ELLA ORAL TABLET Tier 3 1 (Preventative Medication)

levonorgestrel oral tablet Tier 1 1 (Preventative Medication)

my way oral tablet Tier 1 1 (Preventative Medication)

next choice one dose oral tablet Tier 1 1 (Preventative Medication)

*Progestin Contraceptives - Injectable**

*Progestin Contraceptives - Injectable***

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION

Tier 3

medroxyprogesterone acetate intramuscular* suspension


*Progestin Contraceptives - Oral**

*Progestin Contraceptives - Oral***

camila oral tablet Tier 1 1 (Preventative Medication)

errin oral tablet Tier 1 1 (Preventative Medication)

heather oral tablet Tier 1 1 (Preventative Medication)

jencycla oral tablet Tier 1 1 (Preventative Medication)

jolivette oral tablet Tier 1 1 (Preventative Medication)

59

Drug Tier Notes

lyza oral tablet Tier 1 1 (Preventative Medication)

nora-be oral tablet Tier 1 1 (Preventative Medication)

norethindrone oral tablet Tier 1 1 (Preventative Medication)

*Corticosteroids*

*Glucocorticosteroids**

*Glucocorticosteroids***

asmalpred plus oral solution Tier 1

baycadron oral elixir Tier 1

budesonide er oral capsule extended release 24 hour

Tier 1

CELESTONE ORAL SOLUTION Tier 3

cortisone acetate oral tablet Tier 1

DEXAMETHASONE ORAL CONCENTRATE Tier 3

dexamethasone oral elixir Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

DEXAMETHASONE INTENSOL ORAL CONCENTRATE

Tier 3

DEXPAK 10 DAY ORAL TABLET Tier 3



hydrocortisone oral tablet Tier 1

methylprednisolone oral tablet Tier 1

methylprednisolone (pak) oral tablet Tier 1

MILLIPRED ORAL TABLET Tier 3

MILLIPRED DP ORAL TABLET Tier 3

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG

Tier 3

prednisolone oral solution Tier 1

prednisolone sodium phosphate oral solution Tier 1

PREDNISONE ORAL CONCENTRATE Tier 2

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone (pak) oral tablet Tier 1

60

Drug Tier Notes

PREDNISONE INTENSOL ORAL CONCENTRATE

Tier 2

RAYOS ORAL TABLET DELAYED RELEASE 1 MG

Tier 3

*Mineralocorticoids**

*Mineralocorticoids***

fludrocortisone acetate oral tablet Tier 1

*Cough/Cold/Allergy*

*Antitussives**

*Antitussive - Nonnarcotic***

benzonatate oral capsule Tier 1

*Antitussive - Opioid***

hydrocodone-homatropine oral syrup Tier 1

hydrocodone-homatropine oral tablet Tier 1

hydromet oral syrup Tier 1

tussigon oral tablet Tier 1

*Cough/Cold/Allergy Combinations**

*Antitussive-Expectorants-Decongestant***

pseudoephedrine-dm-gg oral syrup 30-15-150 mg/5ml

Tier 1

tgq 30pse/150gfn/15dm oral syrup Tier 1

*Decongestant & Antihistamine***

brompheniramine-phenylephrine oral suspension Tier 1 OTC

CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

entre-b oral suspension Tier 1 OTC

promethazine vc oral syrup Tier 1

promethazine-phenylephrine oral syrup Tier 1

rescon-jr oral tablet extended release 12 hr* 4-20 mg

Tier 1

*Decongestant W/ Expectorant***

phenylephrine-guaifenesin oral liquid† Tier 1

phenylephrine-guaifenesin oral syrup Tier 1 OTC

*Non-Narc Antitussive-Antihistamine***

promethazine-dm oral syrup Tier 1

61

Drug Tier Notes

*Non-Narc Antitussive-Decongestant-Antihistamine***

bromfed dm oral syrup Tier 1

phenylephrine-chlorphen-dm oral liquid†1.75-0.75-2.75 mg/ml

Tier 1

phenylephrine-chlorphen-dm oral syrup Tier 1 OTC

tgq 15dm/5peh/2cpm oral syrup Tier 1

*Opioid Antitussive-Antihistamine***

hydrocod polst-cpm polst er oral liquid extendedrelease*

Tier 1

promethazine-codeine oral syrup Tier 1

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR

Tier 3

*Opioid Antitussive-Decongestant***

REZIRA ORAL SOLUTION Tier 3

*Opioid Antitussive-Decongestant-Antihistamine***

phenyleph-promethazine-cod oral syrup Tier 1

promethazine vc/codeine oral syrup Tier 1

ZUTRIPRO ORAL SOLUTION Tier 3

*Misc. Respiratory Inhalants**

*Misc. Respiratory Inhalants***

sodium chloride inhalation aerosol, solution Tier 1 OTC

sodium chloride inhalation nebulization solution0.9 %

Tier 1 OTC

sodium chloride inhalation nebulization solution10 %, 3 %, 7 %

Tier 1

*Mucolytics**

*Mucolytics***

acetylcysteine inhalation solution Tier 1

*Dermatologicals*

*Acne Products**

*Acne Antibiotics***

clindacin-p external swab Tier 1

clindamax external gel Tier 1

62

Drug Tier Notes

clindamax external lotion Tier 1

clindamycin phosphate external foam Tier 1

clindamycin phosphate external gel Tier 1

clindamycin phosphate external kit Tier 1

clindamycin phosphate external lotion Tier 1

clindamycin phosphate external solution Tier 1

clindamycin phosphate external swab Tier 1

ery external pad Tier 1

erythromycin external gel Tier 1

erythromycin external pad Tier 1

erythromycin external solution Tier 1

sulfacetamide sodium external suspension Tier 1

*Acne Combinations***

ACANYA EXTERNAL GEL Tier 3

avar cleanser external emulsion Tier 1

avar-e emollient external cream Tier 1

avar-e green external cream Tier 1

BENZACLIN EXTERNAL GEL Tier 3

benzoyl peroxide-erythromycin external gel Tier 1

benzoyl peroxide-erythromycin external packet Tier 1

bp 10-1 external emulsion Tier 1

bp cleansing wash external emulsion Tier 1

cerisa wash external emulsion Tier 1

claris clarifying wash external emulsion Tier 1

clindamycin phos-benzoyl perox external gel Tier 1

EPIDUO EXTERNAL GEL Tier 3

prascion external emulsion Tier 1

prascion fc external pad Tier 1

prascion ra external cream Tier 1

rosanil cleanser external emulsion Tier 1

sulfacet-sulfur wash &cleanser external kit Tier 1

sulfacetamide sodium-sulfur external cream 10-5 %

Tier 1

63

Drug Tier Notes

sulfacetamide sodium-sulfur external foam Tier 1

sulfacetamide sodium-sulfur external liquid† Tier 1

sulfacetamide sodium-sulfur external lotion Tier 1

sulfacetamide sodium-sulfur external pad Tier 1

sulfacetamide sodium-sulfur external suspension Tier 1

sulfacetamide-sulfur in urea external emulsion Tier 1

sulfacetamide-sulfur in urea external gel Tier 1

sulfacetamide-sulfur-cleanser external kit Tier 1

sulfacetamide-sulfur-sunscreen external cream Tier 1

VELTIN EXTERNAL GEL Tier 3

zencia external liquid† Tier 1

ZIANA EXTERNAL GEL Tier 3

*Acne Products***

ABSORICA ORAL CAPSULE Tier 3

adapalene external cream Tier 1

adapalene external gel Tier 1

amnesteem oral capsule Tier 1

ATRALIN EXTERNAL GEL Tier 3 PA

avita external cream Tier 1 PA

avita external gel Tier 1 PA

AZELEX EXTERNAL CREAM Tier 3

benzepro external foam Tier 1

benzepro short contact external foam Tier 1

benziq wash external liquid† Tier 1

benzoyl peroxide external foam 5.3 % Tier 1

benzoyl peroxide external gel 10 %, 5 % Tier 1 OTC

benzoyl peroxide external kit Tier 1

benzoyl peroxide external liquid† 4 % Tier 1 OTC

benzoyl peroxide external lotion 3 % Tier 1

benzoyl peroxide external misc Tier 1

benzoyl peroxide cleanser external lotion 6 % Tier 1 OTC

benzoyl peroxide wash external kit 8 & 5 % Tier 1

bp wash external liquid† 7 % Tier 1

64

Drug Tier Notes

claravis oral capsule Tier 1

clearplex x external gel Tier 1

DIFFERIN EXTERNAL GEL 0.3 % Tier 3

DIFFERIN EXTERNAL LOTION Tier 3

lavoclen-4 creamy wash external liquid† Tier 1

lavoclen-8 creamy wash external liquid† Tier 1

myorisan oral capsule Tier 1

oscion cleanser external lotion 6 % Tier 1

TRETIN-X EXTERNAL CREAM 0.0375 % Tier 3 PA

tretinoin external cream Tier 1 PA

tretinoin external gel Tier 1 PA

tretinoin microsphere external gel 0.04 % Tier 1 PA

zaclir cleansing external lotion 8 % Tier 1

*Agents For External Genital And Perianal Warts**

*Agents For External Genital And Perianal Warts***

VEREGEN EXTERNAL OINTMENT Tier 3

*Agents For Facial Wrinkles**

*Agents For Facial Wrinkles - Retinoids***

AVAGE EXTERNAL CREAM Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

REFISSA EXTERNAL CREAM Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

RENOVA EXTERNAL CREAM Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

RENOVA PUMP EXTERNAL CREAM Tier 31 (May not be a covered benefit. Consult your benefit booklet.)

*Antibiotics - Topical**

*Antibiotic Steroid Combinations - Topical***

CORTISPORIN EXTERNAL CREAM Tier 3

CORTISPORIN EXTERNAL OINTMENT Tier 3

*Antibiotics - Topical***

ALTABAX EXTERNAL OINTMENT Tier 3

centany external ointment Tier 1

65

Drug Tier Notes

gentamicin sulfate external cream Tier 1

gentamicin sulfate external ointment Tier 1

mupirocin external ointment Tier 1

mupirocin calcium external cream Tier 1

*Antifungals - Topical**

*Antifungals - Topical Combinations***

clotrimazole-betamethasone external cream Tier 1

clotrimazole-betamethasone external lotion Tier 1

dermazene external cream Tier 1

exoderm external lotion Tier 1

hydrocortisone-iodoquinol external cream Tier 1

nystatin-triamcinolone external cream Tier 1

nystatin-triamcinolone external ointment Tier 1

versiclear external lotion Tier 1

*Antifungals - Topical***

ciclodan external cream Tier 1

ciclodan external solution Tier 1

ciclopirox external gel Tier 1

ciclopirox external kit Tier 1

ciclopirox external shampoo Tier 1

ciclopirox external solution Tier 1

ciclopirox olamine external cream Tier 1

ciclopirox olamine external suspension Tier 1

CNL8 NAIL EXTERNAL KIT Tier 3

MENTAX EXTERNAL CREAM Tier 3

NAFTIN EXTERNAL CREAM 2 % Tier 3

nyamyc external powder Tier 1

nystatin external cream Tier 1

nystatin external ointment Tier 1

nystatin external powder Tier 1

nystop external powder Tier 1

pedi-dri external powder Tier 1

PEDIPIROX-4 NAIL EXTERNAL KIT Tier 3

66

Drug Tier Notes

PENLAC EXTERNAL SOLUTION Tier 3

*Imidazole-Related Antifungals - Topical***

clotrimazole external cream Tier 1 OTC

clotrimazole external solution Tier 1 OTC

clotrimazole anti-fungal external cream Tier 1 OTC

econazole nitrate external cream Tier 1

ERTACZO EXTERNAL CREAM Tier 3

EXELDERM EXTERNAL CREAM Tier 3

EXELDERM EXTERNAL SOLUTION Tier 3

ketoconazole external cream Tier 1

ketoconazole external foam Tier 1

ketoconazole external shampoo Tier 1

ketodan external foam Tier 1

ketodan external kit Tier 1

OXISTAT EXTERNAL CREAM Tier 3

XOLEGEL EXTERNAL GEL Tier 3

*Anti-Inflammatory Agents - Topical**

*Anti-Inflammatory Agents - Topical***

FLECTOR TRANSDERMAL PATCH Tier 3 PA; QL (60 EA per 30 Day(s))

VOLTAREN TRANSDERMAL GEL Tier 2

*Antineoplastic Or Premalignant Lesion Agents - Topical**

*Antineoplastic Antimetabolites - Topical***

CARAC EXTERNAL CREAM Tier 3

FLUOROPLEX EXTERNAL CREAM Tier 3

fluorouracil external cream Tier 1

fluorouracil external solution Tier 1

*Antineoplastic Or Premalignant Lesions - Topical Misc.***

PICATO EXTERNAL GEL Tier 3

*Antineoplastic Or Premalignant Lesions - Topical Nsaid's***

SOLARAZE TRANSDERMAL GEL Tier 3

*Antineoplastic Retinoids - Topical***

67

Drug Tier Notes

PANRETIN EXTERNAL GEL Tier 3

*Topical Selective Retinoid X Receptor Agonists***

TARGRETIN EXTERNAL GEL Tier 3

*Antipruritics - Topical**

*Antipruritics - Topical***

PRUDOXIN EXTERNAL CREAM Tier 3

ZONALON EXTERNAL CREAM Tier 3

*Antipsoriatics**

*Antipsoriatics - Systemic***

8-MOP ORAL CAPSULE Tier 3

OXSORALEN ULTRA ORAL CAPSULE Tier 3

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

Tier 3

STELARA SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

*Antipsoriatics***

calcipotriene external cream Tier 1

calcipotriene external ointment Tier 1

calcipotriene external solution Tier 1

DOVONEX EXTERNAL CREAM Tier 3

dritho-creme hp external cream Tier 1

TAZORAC EXTERNAL CREAM Tier 2

TAZORAC EXTERNAL GEL Tier 2

VECTICAL EXTERNAL OINTMENT Tier 3

*Antiseborrheic Products**

*Antiseborrheic Combinations***

selenium sulf-pyrithione-urea external shampoo Tier 1

sulfacetamide sodium-urea external pad 10 % Tier 1

*Antiseborrheic Products***

glycolic acid xx solution Tier 1 OTC

mexar wash external liquid† Tier 1

OVACE PLUS EXTERNAL CREAM Tier 3

OVACE PLUS EXTERNAL SHAMPOO Tier 3

selenium sulfide external lotion Tier 1

68

Drug Tier Notes

sulfacetamide sodium external liquid† Tier 1

sulfacetamide sodium external lotion 10 % Tier 1

*Antivirals - Topical**

*Antivirals - Topical***

acyclovir external ointment Tier 1

DENAVIR EXTERNAL CREAM Tier 3

ZOVIRAX EXTERNAL CREAM Tier 3

*Burn Products**

*Burn Products***

mafenide acetate external packet Tier 1

silver sulfadiazine external cream Tier 1

ssd external cream Tier 1

SULFAMYLON EXTERNAL CREAM Tier 3

thermazene external cream Tier 1

*Cauterizing Agents**

*Cauterizing Agent Combinations***

arzol silver nit applicators external misc Tier 1

silver nitrate-pot nitrate external misc Tier 1

*Cauterizing Agents***

silver nitrate external ointment Tier 1

silver nitrate external solution Tier 1

*Corticosteroids - Topical**

*Corticosteroids - Topical***

ala cort external cream Tier 1

alclometasone dipropionate external cream Tier 1

alclometasone dipropionate external ointment Tier 1

alphatrex external gel Tier 1

amcinonide external cream Tier 1

amcinonide external lotion Tier 1

amcinonide external ointment Tier 1

apexicon external ointment Tier 1

apexicon e external cream Tier 1

betamethasone dipropionate external cream Tier 1

69

Drug Tier Notes

betamethasone dipropionate external lotion Tier 1

betamethasone dipropionate external ointment Tier 1

betamethasone dipropionate aug external cream Tier 1

betamethasone dipropionate aug external gel Tier 1

betamethasone dipropionate aug external lotion Tier 1

betamethasone dipropionate aug external ointment

Tier 1

betamethasone valerate external cream Tier 1

betamethasone valerate external foam Tier 1

betamethasone valerate external lotion Tier 1

betamethasone valerate external ointment Tier 1

CAPEX EXTERNAL SHAMPOO Tier 3

clobetasol prop emollient base external cream Tier 1

clobetasol propionate external cream Tier 1

clobetasol propionate external foam Tier 1

clobetasol propionate external gel Tier 1

clobetasol propionate external lotion Tier 1

clobetasol propionate external ointment Tier 1

clobetasol propionate external shampoo Tier 1

clobetasol propionate external solution Tier 1

CLOBEX SPRAY EXTERNAL LIQUID† Tier 3

CLODERM EXTERNAL CREAM Tier 3

CLODERM PUMP EXTERNAL CREAM Tier 3

CORDRAN EXTERNAL LOTION Tier 3

CORDRAN EXTERNAL TAPE Tier 3

CORDRAN SP EXTERNAL CREAM Tier 3

DESONATE EXTERNAL GEL Tier 3

desonide external cream Tier 1

desonide external lotion Tier 1

desonide external ointment Tier 1

desonide crea-moisturizing lot external kit Tier 1

DESOWEN EXTERNAL CREAM Tier 3

DESOWEN EXTERNAL LOTION Tier 3

70

Drug Tier Notes

DESOWEN CREAM W/CETAPHIL LOT EXTERNAL KIT

Tier 3

DESOWEN LOT W/CETAPHIL CREAM EXTERNAL KIT

Tier 3

DESOWEN OINT W/CETAPHIL LOT EXTERNAL KIT

Tier 3

desoximetasone external cream Tier 1

desoximetasone external gel Tier 1

desoximetasone external ointment Tier 1

diflorasone diacetate external cream Tier 1

diflorasone diacetate external ointment Tier 1

fluocinolone acetonide external cream Tier 1

fluocinolone acetonide external oil Tier 1

fluocinolone acetonide external ointment Tier 1

fluocinolone acetonide external solution Tier 1

fluocinolone acetonide scalp external oil Tier 1

fluocinonide external cream Tier 1

fluocinonide external gel Tier 1

fluocinonide external ointment Tier 1

fluocinonide external solution Tier 1

fluocinonide emulsified base external cream Tier 1

fluticasone propionate external cream Tier 1

fluticasone propionate external lotion Tier 1

fluticasone propionate external ointment Tier 1

halobetasol propionate external cream Tier 1

halobetasol propionate external ointment Tier 1

HALOG EXTERNAL CREAM Tier 3

HALOG EXTERNAL OINTMENT Tier 3

hydrocortisone external cream 1 % Tier 1 OTC

hydrocortisone external cream 2.5 % Tier 1

hydrocortisone external lotion 1 % Tier 1 OTC

hydrocortisone external lotion 2.5 % Tier 1

hydrocortisone external ointment 1 % Tier 1 OTC

hydrocortisone external ointment 2.5 % Tier 1

71

Drug Tier Notes

hydrocortisone acetate external ointment 1 % Tier 1 OTC

hydrocortisone butyrate external cream Tier 1

hydrocortisone butyrate external ointment Tier 1

hydrocortisone butyrate external solution Tier 1

hydrocortisone valerate external cream Tier 1

hydrocortisone valerate external ointment Tier 1

KENALOG EXTERNAL AEROSOL, SOLUTION

Tier 3

LOCOID EXTERNAL LOTION Tier 3

LOCOID LIPOCREAM EXTERNAL CREAM Tier 3

lokara external lotion Tier 1

mometasone furoate external cream Tier 1

mometasone furoate external ointment Tier 1

mometasone furoate external solution Tier 1

OLUX-E EXTERNAL FOAM Tier 3

PEDIADERM HC EXTERNAL KIT Tier 3

PEDIADERM TA EXTERNAL KIT Tier 3

prednicarbate external cream Tier 1

prednicarbate external ointment Tier 1

scalacort external lotion Tier 1

synalar external cream Tier 1

synalar external ointment Tier 1

TEXACORT EXTERNAL SOLUTION Tier 3

triamcinolone & emollient external kit Tier 1

triamcinolone acetonide external cream Tier 1

triamcinolone acetonide external lotion Tier 1

triamcinolone acetonide external ointment Tier 1

trianex external ointment Tier 1

triderm external cream Tier 1

VANOS EXTERNAL CREAM Tier 3

VERDESO EXTERNAL FOAM Tier 3

*Steroid-Local Anesthetic Combinations***

hydrocortisone ace-pramoxine external cream Tier 1

72

Drug Tier Notes

pramcort external cream Tier 1

PRAMOSONE EXTERNAL LOTION Tier 3

PRAMOSONE EXTERNAL OINTMENT Tier 3

PRAMOSONE E EXTERNAL CREAM Tier 3

pramoxine-hc external cream Tier 1

*Topical Steroid Combinations***

cortalo external gel Tier 1

fluocinolone & cleanser external kit Tier 1

halac external kit Tier 1

halonate pac external kit Tier 1

hydrocortisone ace-aloe vera external gel Tier 1

hydrocortisone acetate-aloe external gel Tier 1

hydrocortisone-aloe vera external cream Tier 1 OTC

TACLONEX EXTERNAL OINTMENT Tier 3

TACLONEX EXTERNAL SUSPENSION Tier 3

u-cort external cream Tier 1

ULTRAVATE PAC EXTERNAL KIT 0.05 & 12 % (CREAM)

Tier 3

*Emollient/Keratolytic Agents**

*Emollient/Keratolytic Agents***

cem-urea external solution Tier 1

cerovel external gel Tier 1

cerovel external lotion Tier 1

remeven external cream Tier 1

u-kera e external cream Tier 1

umecta mousse external foam Tier 1

urea external cream 39 %, 40 %, 45 %, 50 % Tier 1

urea external gel Tier 1

urea external lotion 40 %, 45 % Tier 1

urea nail external gel 45 % Tier 1

urea nail film external suspension Tier 1

x-viate external cream Tier 1

x-viate external gel Tier 1

73

Drug Tier Notes

*Emollient/Keratolytic Combinations***

latrix external suspension Tier 1

uramaxin external foam Tier 1

urea external emulsion Tier 1

urea in lactic ac-salicylic ac external suspension Tier 1

urea in zn undecyl-lactic acid external emulsion45 %

Tier 1

urea nail external kit Tier 1

*Emollients**

*Emollient Combinations***

lactic acid e external cream Tier 1 OTC

lactic acid-vitamin e external cream Tier 1 OTC

*Emollients***

ammonium lactate external cream Tier 1 OTC

ammonium lactate external lotion 10 % Tier 1

ammonium lactate external lotion 12 % Tier 1 OTC

hyaluronate sodium (emollient) external gel Tier 1

hygel external gel Tier 1

laclotion external lotion Tier 1

lactic acid external lotion Tier 1

*Enzymes - Topical**

*Enzymes - Topical***

revina external ointment Tier 1

SANTYL EXTERNAL OINTMENT Tier 3

vasolex external ointment Tier 1

*Immunomodulating Agents - Topical**

*Immunomodulators Imidazoquinolinamines - Topical***

ALDARA EXTERNAL CREAM Tier 3

imiquimod external cream Tier 1

ZYCLARA EXTERNAL CREAM Tier 3

*Immunosuppressive Agents - Topical**

*Macrolide Immunosuppressants - Topical***

ELIDEL EXTERNAL CREAM Tier 3

74

Drug Tier Notes

PROTOPIC EXTERNAL OINTMENT Tier 2

*Keratolytic/Antimitotic Agents**

*Keratolytic And/Or Antimitotic Combinations***

pyrogallic acid external ointment Tier 1

salicylic acid in ammon lact external foam Tier 1

*Keratolytic/Antimitotic Agents***

aliclen external shampoo Tier 1

CONDYLOX EXTERNAL GEL Tier 3

podocon external solution Tier 1

podofilox external solution Tier 1

salacyn external cream Tier 1

salacyn external lotion Tier 1

salicylic acid external cream Tier 1

salicylic acid external foam Tier 1

salicylic acid external gel Tier 1

salicylic acid external liquid† Tier 1

salicylic acid external lotion Tier 1

salicylic acid external shampoo Tier 1

salicylic acid wart remover external liquid† Tier 1

salvax external foam Tier 1

*Local Anesthetics - Topical**

*Local Anesthetics - Topical***

lidocaine external ointment Tier 1

lidocaine hcl external cream Tier 1

lidocaine hcl external gel Tier 1

lidocaine hcl external lotion Tier 1

LIDODERM EXTERNAL PATCH Tier 3

pramox external gel Tier 1

*Topical Anesthetic Combinations***

lidocaine-prilocaine external cream Tier 1

SYNERA EXTERNAL PATCH Tier 3

*Topical Anesthetic Gasses***

75

Drug Tier Notes

ethyl chloride external aerosol† Tier 1

*Misc. Topical**

*Misc. Topical***

hypercare external solution Tier 1

sodium chloride external solution Tier 1 OTC

*Skin Protectants***

benzoin compound external tincture Tier 1 OTC

*Pigmenting-Depigmenting Agents**

*Depigmenting Agents***

alphaquin hp external cream Tier 1

hydroquinone time release external cream Tier 1

melpaque hp external cream Tier 1

melquin 3 external solution Tier 1

melquin hp external cream Tier 1

nuquin hp external cream Tier 1

nuquin hp external gel Tier 1

remergent hq external cream Tier 1

*Pigmenting Agents***

OXSORALEN EXTERNAL LOTION Tier 2

*Rosacea Agents**

*Rosacea Agents***

FINACEA EXTERNAL GEL Tier 3

METROGEL EXTERNAL GEL Tier 3

metronidazole external cream Tier 1

metronidazole external gel 0.75 % Tier 1

metronidazole external lotion Tier 1

ORACEA ORAL CAPSULE DELAYED RELEASE

Tier 3

rosadan external cream Tier 1

rosadan external gel Tier 1

*Scabicides & Pediculicides**

*Scabicides & Pediculicides***

acticin external cream Tier 1

76

Drug Tier Notes

EURAX EXTERNAL CREAM Tier 2

EURAX EXTERNAL LOTION Tier 2

lindane external lotion Tier 1

lindane external shampoo Tier 1

malathion external lotion Tier 1

NATROBA EXTERNAL SUSPENSION Tier 3

permethrin external cream Tier 1

SKLICE EXTERNAL LOTION Tier 3

spinosad external suspension Tier 1

ULESFIA EXTERNAL LOTION Tier 3

*Tar Products**

*Tar Products***

coal tar external solution Tier 1

*Wound Care Products**

*Wound Care - Growth Factor Agents***

REGRANEX EXTERNAL GEL Tier 3

*Wound Care Combinations***

lidocaine-collagen-aloe vera external gel Tier 1

*Diagnostic Products*

*Diagnostic Tests**

*Diagnostic Tests***

BAYER BREEZE 2 TEST IN VITRO DISK Tier 2 OTC

BAYER CONTOUR NEXT TEST IN VITRO STRIP

Tier 2 OTC

BAYER CONTOUR TEST IN VITRO STRIP Tier 2 OTC

*Digestive Aids*

*Digestive Enzymes**

*Digestive Enzymes***

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES

Tier 2

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES

Tier 3

ULTRESA ORAL CAPSULE DELAYED RELEASE PARTICLES

Tier 3

77

Drug Tier Notes

VIOKACE ORAL TABLET Tier 3

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES

Tier 2

*Diuretics*

*Carbonic Anhydrase Inhibitors**

*Carbonic Anhydrase Inhibitors***

acetazolamide oral tablet Tier 1

acetazolamide er oral capsule extended release 12 hour

Tier 1

acetazolamide sodium injection solution reconstituted

Tier 1

methazolamide oral tablet Tier 1

*Diuretic Combinations**

*Diuretic Combinations***

amiloride-hydrochlorothiazide oral tablet Tier 1

spironolactone-hctz oral tablet Tier 1

triamterene-hctz oral capsule 37.5-25 mg Tier 1

triamterene-hctz oral tablet Tier 1

*Loop Diuretics**

*Loop Diuretics***

bumetanide oral tablet Tier 1

EDECRIN ORAL TABLET Tier 3

furosemide oral solution Tier 1

furosemide oral tablet Tier 1

torsemide oral tablet Tier 1

*Potassium Sparing Diuretics**

*Potassium Sparing Diuretics***

amiloride hcl oral tablet Tier 1

DYRENIUM ORAL CAPSULE 100 MG Tier 3

spironolactone oral tablet Tier 1

*Thiazides And Thiazide-Like Diuretics**

*Thiazides And Thiazide-Like Diuretics***

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet Tier 1

78

Drug Tier Notes

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

indapamide oral tablet Tier 1

methyclothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

*Endocrine And Metabolic Agents - Misc.*

*Bone Density Regulators**

*Bisphosphonates***

ACTONEL ORAL TABLET Tier 2 PA

alendronate sodium oral tablet Tier 1

ATELVIA ORAL TABLET DELAYED RELEASE

Tier 2 PA

BINOSTO ORAL TABLET EFFERVESCENT Tier 3

etidronate disodium oral tablet Tier 1

FOSAMAX PLUS D ORAL TABLET Tier 3

ibandronate sodium oral tablet Tier 1

SKELID ORAL TABLET Tier 3

*Calcitonins***

calcitonin (salmon) nasal solution Tier 1

*Parathyroid Hormone And Derivatives***

FORTEO SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

*Fertility Regulators**

*Ovulation Stimulants-Gonadotropins***

NOVAREL INTRAMUSCULAR* SOLUTION RECONSTITUTED

Tier 4SP; 1 (May not be a covered benefit. Consult your benefit booklet.)

PREGNYL INTRAMUSCULAR* SOLUTION RECONSTITUTED

Tier 4SP; 1 (May not be a covered benefit. Consult your benefit booklet.)

*Ovulation Stimulants-Synthetic***

clomiphene citrate oral tablet Tier 11 (May not be a covered benefit. Consult your benefit booklet.)

serophene oral tablet Tier 11 (May not be a covered benefit. Consult your benefit booklet.)

*Gnrh/Lhrh Antagonists**

79

Drug Tier Notes

*Gnrh/Lhrh Antagonists***

CETROTIDE SUBCUTANEOUS* KIT Tier 4 SP

*Growth Hormone Releasing Hormones (Ghrh)**

*Growth Hormone Releasing Hormones (Ghrh)***

EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG


*Growth Hormones**

*Growth Hormones***

GENOTROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

HUMATROPE INJECTION SOLUTION RECONSTITUTED

Tier 4 PA; SP

NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION

Tier 4 PA; SP

NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS* SOLUTION 30 MG/3ML

Tier 4 PA; SP

NUTROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG

Tier 4 PA; SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS* SOLUTION

Tier 4 PA; SP


Tier 4 PA; SP


Tier 4 PA; SP

NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION

Tier 4 PA; SP

OMNITROPE SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

OMNITROPE SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

SAIZEN INJECTION SOLUTION RECONSTITUTED

Tier 4 PA; SP

SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED

Tier 4 PA; SP

80

Drug Tier Notes

TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

ZORBTIVE SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

*Hormone Receptor Modulators**

*Selective Estrogen Receptor Modulators (Serms)***

EVISTA ORAL TABLET Tier 2

*Metabolic Modifiers**

*Calcimimetic Agents***

SENSIPAR ORAL TABLET Tier 2

*Carnitine Replenisher - Agents***

levocarnitine oral tablet Tier 1

*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents***

ORFADIN ORAL CAPSULE Tier 4 SP

*Hyperammonemia Treatment - Agents***

CARBAGLU ORAL TABLET Tier 4 SP

*Hyperparathyroid Treatment - Vitamin D Analogs***

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

HECTOROL ORAL CAPSULE Tier 3

ZEMPLAR ORAL CAPSULE Tier 3

*Phenylketonuria Treatment - Agents***

KUVAN ORAL TABLET SOLUBLE Tier 4 SP

*Urea Cycle Disorder - Agents***

BUPHENYL ORAL TABLET Tier 2

*Posterior Pituitary Hormones**

*Vasopressin***

desmopressin ace refrigerated nasal solution Tier 1

desmopressin ace rhinal tube nasal solution Tier 1

desmopressin ace spray refrig nasal solution Tier 1

desmopressin acetate oral tablet Tier 1

*Prolactin Inhibitors**

81

Drug Tier Notes

*Dopamine Receptor Agonists***

cabergoline oral tablet Tier 1

*Somatostatic Agents**

*Somatostatic Agents***

SIGNIFOR SUBCUTANEOUS* SOLUTION Tier 3 PA

*Vasopressin Receptor Antagonists**

*Selective Vasopressin V2-Receptor Antagonists***

SAMSCA ORAL TABLET Tier 4 SP

*Estrogens*

*Estrogen Combinations**

*Estrogen & Androgen***

covaryx oral tablet Tier 1

covaryx hs oral tablet Tier 1

est estrogens-methyltest oral tablet Tier 1

methyltest-est estrogens oral tablet Tier 1

methyltest-est estrogens hs oral tablet Tier 1

*Estrogen & Progestin***

COMBIPATCH TRANSDERMAL PATCH BIWEEKLY

Tier 3

estradiol-norethindrone acet oral tablet Tier 1

jinteli oral tablet Tier 1

mimvey oral tablet Tier 1

PREMPHASE ORAL TABLET Tier 2

PREMPRO ORAL TABLET Tier 2

*Estrogens**

*Estrogens***

ALORA TRANSDERMAL PATCH BIWEEKLY 0.075 MG/24HR

Tier 3

CENESTIN ORAL TABLET Tier 3

ENJUVIA ORAL TABLET Tier 3

estradiol oral tablet Tier 1

estradiol transdermal patch weekly Tier 1

82

Drug Tier Notes

estradiol valerate intramuscular* oil Tier 1SI; 1 (Self Injectable); 2 (Limited to a 30 day supply)

ESTROGEL TRANSDERMAL GEL Tier 3

estropipate oral tablet Tier 1

EVAMIST TRANSDERMAL SOLUTION Tier 3

MENEST ORAL TABLET Tier 3

MINIVELLE TRANSDERMAL PATCH BIWEEKLY 0.1 MG/24HR

Tier 3

PREMARIN ORAL TABLET Tier 2

VIVELLE-DOT TRANSDERMAL PATCH BIWEEKLY

Tier 3

*Fluoroquinolones*

*Fluoroquinolones**

*Fluoroquinolones***

AVELOX ORAL TABLET Tier 2

AVELOX ABC PACK ORAL TABLET Tier 2

CIPRO ORAL SUSPENSION RECONSTITUTED

Tier 3

ciprofloxacin hcl oral tablet Tier 1

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr*

Tier 1

FACTIVE ORAL TABLET Tier 3

levofloxacin oral solution Tier 1

levofloxacin oral tablet Tier 1

NOROXIN ORAL TABLET Tier 3

ofloxacin oral tablet Tier 1

*Gastrointestinal Agents - Misc.*

*Gallstone Solubilizing Agents**

*Gallstone Solubilizing Agents***

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 1

*Gastrointestinal Antiallergy Agents**

*Gastrointestinal Antiallergy Agents***

cromolyn sodium oral concentrate Tier 1

83

Drug Tier Notes

*Gastrointestinal Chloride Channel Activators**

*Gastrointestinal Chloride Channel Activators***

AMITIZA ORAL CAPSULE Tier 3

*Gastrointestinal Stimulants**

*Gastrointestinal Stimulants***

metoclopramide hcl oral solution Tier 1

metoclopramide hcl oral tablet Tier 1

*Inflammatory Bowel Agents**

*Inflammatory Bowel Agents***

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

ASACOL HD ORAL TABLET DELAYED RELEASE

Tier 3

balsalazide disodium oral capsule Tier 1

CANASA RE SUPPOSITORY Tier 3

DIPENTUM ORAL CAPSULE Tier 3

GIAZO ORAL TABLET Tier 3

mesalamine re enema Tier 1

PENTASA ORAL CAPSULE EXTENDED RELEASE*

Tier 2

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet delayed release Tier 1

sulfazine oral tablet Tier 1

sulfazine ec oral tablet delayed release Tier 1

*Tumor Necrosis Factor Alpha Blockers***

CIMZIA SUBCUTANEOUS* KIT Tier 4 PA; SP; QL (1 EA per 30 Day(s))

CIMZIA PREFILLED SUBCUTANEOUS* KIT Tier 4 PA; SP; QL (1 EA per 30 Day(s))

CIMZIA STARTER KIT SUBCUTANEOUS* KIT


*Intestinal Acidifiers**

*Intestinal Acidifiers***

enulose oral solution Tier 1

generlac oral solution Tier 1

84

Drug Tier Notes

*Irritable Bowel Syndrome (Ibs) Agents**

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists***

LINZESS ORAL CAPSULE Tier 3

*Ibs Agent - Selective 5-Ht3 Receptor Antagonists***

LOTRONEX ORAL TABLET Tier 3

*Peripheral Opioid Receptor Antagonists**

*Peripheral Opioid Receptor Antagonists***

RELISTOR SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

*Phosphate Binder Agents**

*Phosphate Binder Agents***

calcium acetate oral capsule Tier 1

calcium acetate (phos binder) oral tablet Tier 1

FOSRENOL ORAL TABLET CHEWABLE Tier 3

PHOSLYRA ORAL SOLUTION Tier 3

RENAGEL ORAL TABLET Tier 3

RENVELA ORAL PACKET Tier 3

RENVELA ORAL TABLET Tier 3

*Short Bowel Syndrome (Sbs) Agents**

*Glucagon-Like Peptide-2 (Glp-2) Analogs***

GATTEX SUBCUTANEOUS* KIT Tier 4 PA; SP

*Genitourinary Agents - Miscellaneous*

*Alkalinizers**

*Citrates***

citric acid-sodium citrate oral solution Tier 1

cytra-2 oral solution Tier 1

cytra-3 oral syrup Tier 1

cytra-k oral solution Tier 1

ORACIT ORAL SOLUTION Tier 3

pot & sod cit-cit ac oral solution Tier 1

potassium citrate er oral tablet extendedrelease* Tier 1

potassium citrate-citric acid oral solution Tier 1

sod citrate-citric acid oral solution Tier 1

85

Drug Tier Notes

tricitrates oral solution Tier 1

UROCIT-K 15 ORAL TABLET EXTENDEDRELEASE*

Tier 3

*Cystinosis Agents**

*Cystinosis Agents***

CYSTAGON ORAL CAPSULE Tier 4 SP

*Genitourinary Irrigants**

*Anti-Infective Genitourinary Irrigants***

neomycin-polymyxin b gu irrigation solution Tier 1

*Genitourinary Irrigants***

acetic acid irrigation solution Tier 1

sodium chloride irrigation solution 0.9 % Tier 1

sorbitol irrigation solution Tier 1

*Interstitial Cystitis Agents**

*Interstitial Cystitis Agents***

ELMIRON ORAL CAPSULE Tier 2

*Prostatic Hypertrophy Agents**

*5-Alpha Reductase Inhibitors***

AVODART ORAL CAPSULE Tier 2

finasteride oral tablet 5 mg Tier 1

*Alpha 1-Adrenoceptor Antagonists***

alfuzosin hcl er oral tablet extended release 24 hr*

Tier 1

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HR* 4 MG

Tier 3

RAPAFLO ORAL CAPSULE Tier 3

tamsulosin hcl oral capsule Tier 1

*Urinary Analgesics**

*Urinary Analgesics***

phenazo oral tablet Tier 1

phenazopyridine hcl oral tablet Tier 1

*Gout Agents*

*Gout Agent Combinations**

*Gout Agent Combinations***

86

Drug Tier Notes

colchicine-probenecid oral tablet Tier 1

*Gout Agents**

*Gout Agents***

allopurinol oral tablet Tier 1

COLCRYS ORAL TABLET Tier 2

ULORIC ORAL TABLET Tier 3

*Uricosurics**

*Uricosurics***

probenecid oral tablet Tier 1

*Hematological Agents - Misc.*

*Bradykinin B2 Receptor Antagonists**

*Bradykinin B2 Receptor Antagonists***

FIRAZYR SUBCUTANEOUS* SOLUTION Tier 4 PA; SP; QL (9 ML per 30 Day(s))

*Hematorheologic Agents**

*Hematorheologic Agents***

pentoxifylline er oral tablet extendedrelease* Tier 1

*Platelet Aggregation Inhibitors**

*Cyclopentyltriazolopyrimidine (Cptp) Derivatives***

BRILINTA ORAL TABLET Tier 3 PA; QL (60 EA per 30 Day(s))

*Phosphodiesterase Iii Inhibitors***

cilostazol oral tablet Tier 1

*Platelet Aggregation Inhibitor Combinations***

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR

Tier 3

*Platelet Aggregation Inhibitors***

dipyridamole oral tablet Tier 1

*Quinazoline Agents***

anagrelide hcl oral capsule Tier 1

*Thienopyridine Derivatives***

clopidogrel bisulfate oral tablet Tier 1

EFFIENT ORAL TABLET Tier 3 PA

ticlopidine hcl oral tablet Tier 1

87

Drug Tier Notes

*Hematopoietic Agents*

*Agents For Gaucher Disease**

*Agents For Gaucher Disease***

ZAVESCA ORAL CAPSULE Tier 4 PA; SP

*Agents For Sickle Cell Anemia**

*Cytotoxic Agents***

DROXIA ORAL CAPSULE Tier 3

*Cobalamins**

*Cobalamins***

cyanocobalamin injection solution Tier 1

*Folic Acid/Folates**

*Folic Acid/Folates***

fa-8 oral capsule Tier 1 OTC

fa-8 oral tablet Tier 1 OTC

folic acid oral capsule 0.8 mg Tier 1 OTC

folic acid oral tablet 1 mg, 400 mcg, 800 mcg Tier 1 OTC

kp folic acid oral tablet Tier 1 OTC

*Hematopoietic Growth Factors**

*Erythropoiesis-Stimulating Agents (Esas)***

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/0.5ML, 100 MCG/ML, 150 MCG/0.3ML, 150 MCG/0.75ML, 200 MCG/0.4ML, 200 MCG/ML, 25 MCG/0.42ML, 25 MCG/ML, 300 MCG/0.6ML, 300 MCG/ML, 40 MCG/0.4ML, 40 MCG/ML, 500 MCG/ML, 60 MCG/0.3ML, 60 MCG/ML

Tier 4 SP

EPOGEN INJECTION SOLUTION Tier 4 SP

PROCRIT INJECTION SOLUTION Tier 4 SP

*Granulocyte Colony-Stimulating Factors (G-Csf)***

NEULASTA SUBCUTANEOUS* SOLUTION Tier 4 PA; SP

NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML

Tier 4 PA; SP

*Interleukins***

NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA; SP

88

Drug Tier Notes

*Thrombopoietin (Tpo) Receptor Agonists***

PROMACTA ORAL TABLET Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Hematopoietic Mixtures**

*Cobalamin Combinations***

FOLTRATE ORAL TABLET Tier 3

*Folic Acid/Folate Combinations***

folcaps oral tablet Tier 1

nufol oral tablet Tier 1

tl gard rx oral tablet Tier 1

*Iron Combinations***

ferotrinsic oral capsule Tier 1

ferrogels forte oral capsule Tier 1

hematogen fa oral capsule Tier 1

hematogen forte oral capsule Tier 1

iferex 150 forte oral capsule Tier 1

poly-iron 150 forte oral capsule Tier 1

*Iron W/ Folic Acid***

hemocyte-f oral tablet Tier 1

tandem f oral capsule Tier 1

*Iron-B12-Folate***

ferraplus 90 oral tablet Tier 1

*Iron**

*Iron***

carbonyl iron oral suspension Tier 1 OTC

carbonyl iron oral tablet chewable Tier 1 OTC

ezfe 200 oral capsule Tier 1 OTC

fer-iron oral solution Tier 1 OTC

ferretts oral tablet Tier 1 OTC

ferrex 150 oral capsule Tier 1 OTC

ferrimin 150 oral tablet Tier 1 OTC

ferrocite oral tablet Tier 1 OTC

ferrous fumarate oral tablet 324 mg, 325 (106 fe) mg, 90 mg

Tier 1 OTC

89

Drug Tier Notes

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

Tier 1 OTC

ferrous gluconate iron oral tablet Tier 1 OTC

ferrous sulfate oral elixir Tier 1 OTC

ferrous sulfate oral liquid† Tier 1 OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml Tier 1 OTC

ferrous sulfate oral syrup Tier 1 OTC

ferrous sulfate oral tablet 325 (65 fe) mg Tier 1 OTC

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

Tier 1 OTC

ferrous sulfate dried er oral tablet extendedrelease*

Tier 1 OTC

ferrous sulfate er oral tablet extendedrelease* Tier 1 OTC

iferex 150 oral capsule Tier 1 OTC

kp ferrous gluconate oral tablet Tier 1 OTC

kp ferrous sulfate oral tablet Tier 1 OTC

myferon 150 oral capsule Tier 1 OTC

mykidz iron 10 oral suspension Tier 1 OTC

novaferrum pediatric drops oral liquid† Tier 1 OTC

nu-iron oral capsule Tier 1 OTC

polysaccharide iron complex oral capsule Tier 1 OTC

profe oral capsule Tier 1 OTC

proferrin es oral tablet Tier 1 OTC

slow release iron oral tablet extendedrelease* 50 mg

Tier 1 OTC

*Hemostatics*

*Hemostatics - Systemic**

*Hemostatics - Systemic***

aminocaproic acid oral syrup Tier 1

aminocaproic acid oral tablet Tier 1

tranexamic acid oral tablet Tier 1

*Hypnotics*

*Antihistamine Hypnotics**

*Antihistamine Hypnotics***

90

Drug Tier Notes

diphenhydramine hcl (sleep) oral capsule Tier 1 OTC

*Barbiturate Hypnotics**

*Barbiturate Hypnotics***

phenobarbital oral elixir Tier 1

phenobarbital oral solution Tier 1

phenobarbital oral tablet Tier 1

*Hypnotics - Tricyclic Agents**

*Hypnotics - Tricyclic Agents***

SILENOR ORAL TABLET Tier 3

*Non-Barbiturate Hypnotics**

*Benzodiazepine Hypnotics***

estazolam oral tablet Tier 1

flurazepam hcl oral capsule Tier 1

midazolam hcl oral syrup Tier 1

temazepam oral capsule Tier 1

triazolam oral tablet Tier 1

*Non-Benzodiazepine - Gaba-Receptor Modulators***

INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL 3.5 MG


LUNESTA ORAL TABLET Tier 3 QL (14 EA per 30 Day(s))

zaleplon oral capsule Tier 1

zolpidem tartrate oral tablet Tier 1

zolpidem tartrate er oral tablet extendedrelease* Tier 1 QL (14 EA per 30 Day(s))

*Selective Melatonin Receptor Agonists**

*Selective Melatonin Receptor Agonists***

ROZEREM ORAL TABLET Tier 3 QL (14 EA per 30 Day(s))

*Laxatives*

*Laxative Combinations**

*Bowel Evacuant Combinations***

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM

Tier 3

gavilyte-c oral solution reconstituted Tier 1

gavilyte-g oral solution reconstituted Tier 1

91

Drug Tier Notes

gavilyte-n with flavor pack oral solution reconstituted

Tier 1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

Tier 3

HALFLYTELY WITH FLAVOR PACKS ORAL KIT

Tier 3

MOVIPREP ORAL SOLUTION RECONSTITUTED

Tier 3

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Tier 1

peg 3350-kcl-nabcb-nacl-nasulf oral solution reconstituted

Tier 1

peg 3350/electrolytes oral solution reconstituted Tier 1

peg-3350/electrolytes oral solution reconstituted Tier 1

PREPOPIK ORAL PACKET Tier 3

SUPREP BOWEL PREP ORAL SOLUTION Tier 3

trilyte oral solution reconstituted Tier 1

*Laxatives - Miscellaneous**

*Laxatives - Miscellaneous***

constulose oral solution Tier 1

KRISTALOSE ORAL PACKET Tier 3

lactulose oral solution Tier 1

polyethylene glycol 3350 oral packet Tier 1 OTC

polyethylene glycol 3350 oral powder Tier 1 OTC

*Saline Laxatives**

*Saline Laxative Mixtures***

OSMOPREP ORAL TABLET Tier 3

VISICOL ORAL TABLET Tier 3

*Macrolides*

*Azithromycin**

*Azithromycin***

azithromycin oral packet Tier 1

azithromycin oral suspension reconstituted Tier 1

azithromycin oral tablet Tier 1

ZITHROMAX ORAL PACKET Tier 3

92

Drug Tier Notes

*Clarithromycin**

*Clarithromycin***

clarithromycin oral suspension reconstituted Tier 1

clarithromycin oral tablet Tier 1

clarithromycin er oral tablet extended release 24 hr*

Tier 1

*Erythromycins**

*Erythromycins***

e.e.s. 400 oral tablet Tier 1

ERY-TAB ORAL TABLET DELAYED RELEASE 333 MG

Tier 3

erythrocin stearate oral tablet 250 mg Tier 1

erythromycin base oral capsule delayed release particles

Tier 1

erythromycin base oral tablet Tier 1

ERYTHROMYCIN BASE COATED ORAL TABLET DELAYED RELEASE

Tier 3

erythromycin ethylsuccinate oral suspension reconstituted

Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

erythromycin stearate oral tablet Tier 1

PCE ORAL TABLET DELAYED RELEASE 500 MG

Tier 3

*Fidaxomicin**

*Fidaxomicin***

DIFICID ORAL TABLET Tier 3

*Medical Devices*

*Diabetic Supplies**

*Glucose Monitoring Test Supplies***

LANCET DEVICE XX MISC Tier 2 OTC

SURE COMFORT LANCING PEN XX MISC Tier 2 OTC

*Parenteral Therapy Supplies**

*Needles & Syringes***

INSULIN SYRINGE XX MISC 28G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML

Tier 2 OTC

93

Drug Tier Notes

PEN NEEDLES 3/16" XX MISC Tier 2 OTC

*Migraine Products*

*Migraine Combinations**

*Ergot Combinations***

CAFERGOT ORAL TABLET Tier 2

*Migraine Combinations***

apap-isometheptene-caffeine oral tablet Tier 1

*Selective Serotonin Agonist-Nsaid Combinations***

TREXIMET ORAL TABLET Tier 3 PA; QL (12 EA per 30 Day(s))

*Migraine Products**

*Migraine Products***

dihydroergotamine mesylate injection solution Tier 1

dihydroergotamine mesylate nasal solution Tier 1

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

Tier 3

*Serotonin Agonists**

*Selective Serotonin Agonists 5-Ht(1)***

ALSUMA SUBCUTANEOUS* SOLUTION Tier 3 PA; QL (3 ML per 30 Day(s))

AXERT ORAL TABLET Tier 3 PA; QL (12 EA per 30 Day(s))

FROVA ORAL TABLET Tier 3 PA; QL (12 EA per 30 Day(s))

naratriptan hcl oral tablet Tier 1 QL (12 EA per 30 Day(s))

RELPAX ORAL TABLET Tier 2 PA; QL (12 EA per 30 Day(s))

rizatriptan benzoate oral tablet Tier 1 PA; QL (12 EA per 30 Day(s))

rizatriptan benzoate oral tablet dispersible Tier 1 PA; QL (12 EA per 30 Day(s))

sumatriptan nasal solution Tier 1 QL (6 EA per 30 Day(s))

sumatriptan succinate oral tablet Tier 1 QL (12 EA per 30 Day(s))

sumatriptan succinate subcutaneous* solution Tier 1 QL (3 ML per 30 Day(s))

SUMAVEL DOSEPRO SUBCUTANEOUS* DEVICE

Tier 3 PA; QL (3 ML per 30 Day(s))

ZOMIG NASAL SOLUTION Tier 3 PA; QL (6 EA per 30 Day(s))

ZOMIG ORAL TABLET Tier 3 PA; QL (12 EA per 30 Day(s))

ZOMIG ZMT ORAL TABLET DISPERSIBLE Tier 3 PA; QL (12 EA per 30 Day(s))

*Minerals & Electrolytes*

94

Drug Tier Notes

*Fluoride**

*Fluoride***

sodium fluoride oral solution Tier 1 1 (Preventative Medication)

sodium fluoride oral tablet Tier 1 1 (Preventative Medication)

sodium fluoride oral tablet chewable Tier 1 1 (Preventative Medication)

*Magnesium**

*Magnesium Combinations***

MAGNEBIND 400 ORAL TABLET Tier 3

*Phosphate**

*Phosphate***

phospha 250 neutral oral tablet Tier 1

*Potassium**

*Potassium Combinations***

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

pot bicarb-pot chloride oral tablet effervescent Tier 1

*Potassium***

effer-k oral tablet effervescent 25 meq Tier 1

k-effervescent oral tablet effervescent Tier 1

k-tabs oral tablet extendedrelease* Tier 1

k-vescent oral tablet effervescent Tier 1

klor-con oral packet 20 meq Tier 1

klor-con oral tablet extendedrelease* Tier 1

klor-con 10 oral tablet extendedrelease* Tier 1

klor-con m15 oral tablet extendedrelease* Tier 1

klor-con m20 oral tablet extendedrelease* Tier 1

klor-con/ef oral tablet effervescent Tier 1

potassium bicarbonate oral tablet effervescent Tier 1

potassium chloride oral liquid† 40 meq/15ml (20%)

Tier 1

potassium chloride oral solution Tier 1

potassium chloride crys er oral tablet extendedrelease*

Tier 1

95

Drug Tier Notes

potassium chloride er oral capsule extended release*

Tier 1

potassium chloride er oral tablet extendedrelease*

Tier 1

*Sodium**

*Sodium***

monoject flush syringe injection solution Tier 1

normal saline flush intravenous* solution Tier 1

*Zinc**

*Zinc***

GALZIN ORAL CAPSULE Tier 3

zinc sulfate oral capsule Tier 1 OTC

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral**

*Anesthetics Topical Oral***

lidocaine hcl mouth/throat solution Tier 1

lidocaine viscous mouth/throat solution Tier 1

LTA 360 KIT MOUTH/THROAT SOLUTION Tier 3

*Antiallergy Agents - Mouth/Throat**

*Antiallergy Agents - Mouth/Throat***

APHTHASOL MOUTH/THROAT PASTE Tier 3

*Anti-Infectives - Throat**

*Anti-Infectives - Throat***

clotrimazole mouth/throat troche Tier 1

nystatin mouth/throat suspension Tier 1

*Antiseptics - Mouth/Throat**

*Antiseptics - Mouth/Throat***

chlorhexidine gluconate mouth/throat solution Tier 1

periogard mouth/throat solution Tier 1

*Dental Products**

*Dental Products - Combinations***

fluoridex sensitivity relief dental paste Tier 1

*Fluoride Dental Products***

cavirinse mouth/throat solution Tier 1

96

Drug Tier Notes

clinpro 5000 dental paste Tier 1

controlrx dental paste Tier 1

denta 5000 plus dental cream Tier 1

dentagel dental gel Tier 1

karigel-n dental gel Tier 1

perio med mouth/throat concentrate Tier 1

phos-flur dental gel Tier 1

sf dental gel Tier 1

stannous fluoride mouth/throat concentrate Tier 1

*Steroids - Mouth/Throat**

*Steroids - Mouth/Throat***

oralone mouth/throat paste Tier 1

triamcinolone acetonide mouth/throat paste Tier 1

*Throat Products - Misc.**

*Saliva Stimulants***

cevimeline hcl oral capsule Tier 1

pilocarpine hcl oral tablet Tier 1

*Multivitamins*

*Multiple Vitamins W/ Minerals**

*Multiple Vitamins W/ Minerals***

NICAZEL ORAL TABLET Tier 3

TRI-ZEL ORAL TABLET Tier 3

*Ped Mv W/ Fluoride**

*Ped Mv W/ Fluoride***

multi-vitamin/fluoride oral solution Tier 1

multi-vitamin/fluoride oral tablet chewable Tier 1

*Ped Vitamins Acd W/ Fluoride***

tri-vitamin/fluoride oral solution Tier 1

*Prenatal Vitamins**

*Prenatal Mv & Min W/Fe-Fa***

right step prenatal oral tablet Tier 1 OTC

se-natal 19 oral tablet Tier 1

*Prenatal Mv & Min W/Fe-Fa-Dha***

97

Drug Tier Notes

taron-prex oral capsule Tier 1

*Prenatal Vitamins***

bp folinatal plus b oral tablet Tier 1

*Vitamin Mixtures**

*Niacinamide W/ Zinc-Copper & Folic Acid***

niacinamide-zn-cu-methylfolate oral tablet Tier 1

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants**

*Central Muscle Relaxants***

baclofen oral tablet Tier 1

carisoprodol oral tablet Tier 1

chlorzoxazone oral tablet Tier 1

cyclobenzaprine hcl oral tablet Tier 1

cyclobenzaprine hcl transdermal cream Tier 1

enovarx-cyclobenzaprine hcl transdermal cream Tier 1

LORZONE ORAL TABLET 375 MG Tier 3

metaxalone oral tablet Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate er oral tablet extended release 12 hr*

Tier 1

tizanidine hcl oral capsule Tier 1

tizanidine hcl oral tablet Tier 1

*Direct Muscle Relaxants**

*Direct Muscle Relaxants***

dantrolene sodium oral capsule Tier 1

*Muscle Relaxant Combinations**

*Muscle Relaxant Combinations***

carisoprodol-aspirin oral tablet Tier 1

carisoprodol-aspirin-codeine oral tablet Tier 1

orphenadrine-aspirin-caffeine oral tablet Tier 1

*Nasal Agents - Systemic And Topical*

*Nasal Antiallergy**

*Nasal Antihistamines***

98

Drug Tier Notes

ASTEPRO NASAL SOLUTION 0.15 % Tier 3

azelastine hcl nasal solution Tier 1

PATANASE NASAL SOLUTION Tier 3

*Nasal Anticholinergics**

*Nasal Anticholinergics***

ipratropium bromide nasal solution Tier 1

*Nasal Anti-Infectives**

*Nasal Antibiotics***

BACTROBAN NASAL NASAL OINTMENT Tier 3

*Nasal Steroids**

*Nasal Steroids***

BECONASE AQ NASAL SUSPENSION Tier 3 PA

flunisolide nasal solution 25 mcg/act (0.025%) Tier 1

fluticasone propionate nasal suspension Tier 1

NASONEX NASAL SUSPENSION Tier 3 PA

QNASL NASAL AEROSOL, SOLUTION Tier 3 PA

RHINOCORT AQUA NASAL SUSPENSION Tier 3 PA

triamcinolone acetonide nasal inhaler Tier 1

VERAMYST NASAL SUSPENSION Tier 3 PA

ZETONNA NASAL AEROSOL, SOLUTION Tier 3 PA

*Sympathomimetic Decongestants**

*Topical Decongestants***

ADRENALIN NASAL SOLUTION Tier 3

epinephrine hcl (nasal) nasal solution Tier 1

TYZINE NASAL SOLUTION Tier 3

*Neuromuscular Agents*

*Als Agents**

*Benzathiazoles***

RILUTEK ORAL TABLET Tier 2

*Nutrients*

*Proteins**

*Amino Acids-Single***

acetylcysteine oral capsule Tier 1 OTC

99

Drug Tier Notes

n-acetyl-l-cysteine oral capsule Tier 1

*Ophthalmic Agents*

*Beta-Blockers - Ophthalmic**

*Beta-Blockers - Ophthalmic Combinations***

COMBIGAN OPHTHALMIC SOLUTION Tier 3

dorzolamide hcl-timolol mal ophthalmic solution Tier 1

*Beta-Blockers - Ophthalmic***

betaxolol hcl ophthalmic solution Tier 1

BETIMOL OPHTHALMIC SOLUTION 0.5 % Tier 3

BETOPTIC-S OPHTHALMIC SUSPENSION Tier 3

carteolol hcl ophthalmic solution Tier 1

istalol ophthalmic solution Tier 1

levobunolol hcl ophthalmic solution Tier 1

metipranolol ophthalmic solution Tier 1

timolol hemihydrate ophthalmic solution Tier 1

timolol maleate ophthalmic gel forming solution Tier 1

timolol maleate ophthalmic solution Tier 1

*Cycloplegic Mydriatics**

*Cycloplegic Mydriatics***

atropine sulfate ophthalmic ointment Tier 1

atropine sulfate ophthalmic solution Tier 1

cyclopentolate hcl ophthalmic solution Tier 1

homatropaire ophthalmic solution Tier 1

homatropine hbr ophthalmic solution Tier 1

ISOPTO HYOSCINE OPHTHALMIC SOLUTION

Tier 3

mydral ophthalmic solution Tier 1

tropicamide ophthalmic solution Tier 1

*Miotics**

*Miotics - Cholinesterase Inhibitors***

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED

Tier 2

*Miotics - Direct Acting***

100

Drug Tier Notes

ISOPTO CARBACHOL OPHTHALMIC SOLUTION

Tier 2

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Tier 1

PILOPINE HS OPHTHALMIC GEL Tier 3

*Ophthalmic Adrenergic Agents**

*Ophthalmic Selective Alpha Adrenergic Agonists***

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

Tier 3

apraclonidine hcl ophthalmic solution Tier 1

BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.15 %

Tier 3

brimonidine tartrate ophthalmic solution 0.2 % Tier 1

IOPIDINE OPHTHALMIC SOLUTION 1 % Tier 3

*Ophthalmic Anti-Infectives**

*Ophthalmic Antibiotics***

AZASITE OPHTHALMIC SOLUTION Tier 3

bacitracin ophthalmic ointment Tier 1

BESIVANCE OPHTHALMIC SUSPENSION Tier 3

CILOXAN OPHTHALMIC OINTMENT Tier 3

ciprofloxacin hcl ophthalmic solution Tier 1

erythromycin ophthalmic ointment Tier 1

garamycin ophthalmic ointment Tier 1

gentak ophthalmic ointment Tier 1

gentak ophthalmic solution Tier 1

gentamicin sulfate ophthalmic ointment Tier 1

gentamicin sulfate ophthalmic solution Tier 1

ilotycin ophthalmic ointment Tier 1

levofloxacin ophthalmic solution Tier 1

MOXEZA OPHTHALMIC SOLUTION Tier 3

ofloxacin ophthalmic solution Tier 1

romycin ophthalmic ointment Tier 1

tobramycin sulfate ophthalmic solution Tier 1

TOBREX OPHTHALMIC OINTMENT Tier 3

101

Drug Tier Notes

VIGAMOX OPHTHALMIC SOLUTION Tier 2

ZYMAXID OPHTHALMIC SOLUTION Tier 3

*Ophthalmic Antifungal***

NATACYN OPHTHALMIC SUSPENSION Tier 3

*Ophthalmic Anti-Infective Combinations***

ak-poly-bac ophthalmic ointment Tier 1

bacitracin-polymyxin b ophthalmic ointment Tier 1

neo-polycin ophthalmic ointment Tier 1

neomycin-bacitracin zn-polymyx ophthalmic ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic solution

Tier 1

polycin b ophthalmic ointment Tier 1

polymyxin b-trimethoprim ophthalmic solution Tier 1

*Ophthalmic Antivirals***

trifluridine ophthalmic solution Tier 1

ZIRGAN OPHTHALMIC GEL Tier 3

*Ophthalmic Sulfonamides***

sulfacetamide sodium ophthalmic ointment Tier 1

sulfacetamide sodium ophthalmic solution Tier 1

*Ophthalmic Decongestants**

*Ophthalmic Decongestants***

phenylephrine hcl ophthalmic solution Tier 1

*Ophthalmic Immunomodulators**

*Ophthalmic Immunomodulators***

RESTASIS OPHTHALMIC EMULSION Tier 3

*Ophthalmic Local Anesthetics**

*Ophthalmic Local Anesthetics***

altacaine ophthalmic solution Tier 1

parcaine ophthalmic solution Tier 1

proparacaine hcl ophthalmic solution Tier 1

tetracaine hcl ophthalmic solution Tier 1

tetravisc ophthalmic solution Tier 1

tetravisc forte ophthalmic solution Tier 1

102

Drug Tier Notes

*Ophthalmic Steroids**

*Ophthalmic Steroid Combinations***

bacitra-neomycin-polymyxin-hc ophthalmic ointment

Tier 1

bacitracin-polymyx-neo-hc ophthalmic ointment Tier 1

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT

Tier 3

neo-polycin hc ophthalmic ointment Tier 1

neomycin-polymyxin-dexameth ophthalmic ointment

Tier 1

neomycin-polymyxin-dexameth ophthalmic suspension

Tier 1

neomycin-polymyxin-hc ophthalmic suspension Tier 1

poly-dex ophthalmic ointment Tier 1

PRED-G OPHTHALMIC SUSPENSION Tier 3

PRED-G S.O.P. OPHTHALMIC OINTMENT Tier 3

sulfacetamide-prednisolone ophthalmic solution Tier 1

TOBRADEX OPHTHALMIC OINTMENT Tier 2

TOBRADEX ST OPHTHALMIC SUSPENSION Tier 2

tobramycin-dexamethasone ophthalmic suspension

Tier 1

ZYLET OPHTHALMIC SUSPENSION Tier 3

*Ophthalmic Steroids***

ALREX OPHTHALMIC SUSPENSION Tier 2

dexamethasone sodium phosphate ophthalmic solution

Tier 1

DUREZOL OPHTHALMIC EMULSION Tier 3

FLAREX OPHTHALMIC SUSPENSION Tier 3

fluorometholone ophthalmic suspension Tier 1

FML OPHTHALMIC OINTMENT Tier 2

LOTEMAX OPHTHALMIC OINTMENT Tier 2

LOTEMAX OPHTHALMIC SUSPENSION Tier 2

PRED MILD OPHTHALMIC SUSPENSION Tier 3

prednisolone acetate ophthalmic suspension Tier 1

103

Drug Tier Notes

prednisolone sodium phosphate ophthalmic solution

Tier 1

VEXOL OPHTHALMIC SUSPENSION Tier 3

*Ophthalmics - Misc.**

*Ophthalmic Antiallergic***

ALOCRIL OPHTHALMIC SOLUTION Tier 3

ALOMIDE OPHTHALMIC SOLUTION Tier 3

azelastine hcl ophthalmic solution Tier 1

BEPREVE OPHTHALMIC SOLUTION Tier 3

cromolyn sodium ophthalmic solution Tier 1

EMADINE OPHTHALMIC SOLUTION Tier 3

epinastine hcl ophthalmic solution Tier 1

LASTACAFT OPHTHALMIC SOLUTION Tier 3

PATADAY OPHTHALMIC SOLUTION Tier 2

PATANOL OPHTHALMIC SOLUTION Tier 2

*Ophthalmic Carbonic Anhydrase Inhibitors***

AZOPT OPHTHALMIC SUSPENSION Tier 3

dorzolamide hcl ophthalmic solution Tier 1

*Ophthalmic Diagnostic Products***

fluorescein-proparacaine ophthalmic solution Tier 1

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents***

ACUVAIL OPHTHALMIC SOLUTION Tier 3

bromfenac sodium ophthalmic solution Tier 1

diclofenac sodium ophthalmic solution Tier 1

flurbiprofen sodium ophthalmic solution Tier 1

NEVANAC OPHTHALMIC SUSPENSION Tier 2

*Ophthalmics - Cystinosis Agents**

CYSTARAN OPHTHALMIC SOLUTION Tier 3

*Prostaglandins - Ophthalmic**

*Prostaglandins - Ophthalmic***

latanoprost ophthalmic solution Tier 1

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Tier 3

104

Drug Tier Notes

TRAVATAN Z OPHTHALMIC SOLUTION Tier 2

travoprost ophthalmic solution Tier 1

ZIOPTAN OPHTHALMIC SOLUTION Tier 3

*Otic Agents*

*Otic Agents - Miscellaneous**

*Otic Agents - Miscellaneous***

acetic acid otic solution Tier 1

*Otic Anti-Infectives**

*Otic Anti-Infectives***

ciprofloxacin hcl otic solution Tier 1

ofloxacin otic solution Tier 1

*Otic Combinations**

*Otic Analgesic Combinations***

antipyrine-benzocaine otic solution 5.4-1.4 %, 54-14 mg/ml

Tier 1

aurodex otic solution Tier 1

auroguard otic solution Tier 1

cortic-nd otic solution Tier 1

exotic-hc otic solution Tier 1

myoxin otic suspension Tier 1

oticin otic liquid† Tier 1

otomar otic solution Tier 1

otomax-hc otic solution Tier 1

otozin otic liquid† Tier 1

pramoxine-hc-chloroxylenol aq otic solution Tier 1

*Otic Steroid-Anti-Infective Combinations***

CIPRO HC OTIC SUSPENSION Tier 3

CIPRODEX OTIC SUSPENSION Tier 2

COLY-MYCIN S OTIC SUSPENSION Tier 3

CORTISPORIN-TC OTIC SUSPENSION Tier 3

neomycin-polymyxin-hc otic solution Tier 1

neomycin-polymyxin-hc otic suspension Tier 1

*Otic Steroids**

105

Drug Tier Notes

*Otic Steroids***

acetasol hc otic solution Tier 1

fluocinolone acetonide otic oil Tier 1

hydrocortisone-acetic acid otic solution Tier 1

*Oxytocics*

*Oxytocics**

*Oxytocics***

methylergonovine maleate oral tablet Tier 1

*Penicillins*

*Aminopenicillins**

*Aminopenicillins***

amoxicillin oral capsule Tier 1

amoxicillin oral suspension reconstituted Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet chewable Tier 1

ampicillin oral capsule Tier 1

ampicillin oral suspension reconstituted Tier 1

MOXATAG ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

*Natural Penicillins**

*Natural Penicillins***

penicillin v potassium oral solution reconstituted Tier 1

penicillin v potassium oral tablet Tier 1

*Penicillin Combinations**

*Penicillin Combinations***

amoxicillin-pot clavulanate oral suspension reconstituted

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

amoxicillin-pot clavulanate oral tablet chewable Tier 1

amoxicillin-pot clavulanate er oral tablet extended release 12 hr*

Tier 1

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

Tier 3

*Penicillinase-Resistant Penicillins**

106

Drug Tier Notes

*Penicillinase-Resistant Penicillins***

dicloxacillin sodium oral capsule Tier 1

*Progestins*

*Progestins**

*Progestins***

medroxyprogesterone acetate oral tablet Tier 1

norethindrone acetate oral tablet Tier 1

progesterone micronized oral capsule Tier 1

*Psychotherapeutic And Neurological Agents - Misc.*

*Agents For Chemical Dependency**

*Alcohol Deterrents***

CAMPRAL ORAL TABLET DELAYED RELEASE

Tier 3

disulfiram oral tablet Tier 1

*Anti-Cataplectic Agents**

*Anti-Cataplectic Agents***

XYREM ORAL SOLUTION Tier 4PA; SP; QL (540 ML per 30 Day(s))

*Antidementia Agents**

*Cholinomimetics - Ache Inhibitors***

ARICEPT ORAL TABLET 23 MG Tier 3

donepezil hcl oral tablet 10 mg, 5 mg Tier 1

donepezil hcl oral tablet dispersible Tier 1

EXELON ORAL SOLUTION Tier 3

EXELON TRANSDERMAL PATCH 24 HR Tier 3

galantamine hydrobromide oral solution Tier 1

galantamine hydrobromide oral tablet Tier 1

galantamine hydrobromide er oral capsule extended release 24 hour

Tier 1

rivastigmine tartrate oral capsule Tier 1

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***

NAMENDA ORAL SOLUTION Tier 3

NAMENDA ORAL TABLET Tier 3

107

Drug Tier Notes

NAMENDA TITRATION PAK ORAL TABLET Tier 3

*Combination Psychotherapeutics**

*Benzodiazepines & Tricyclic Agents***

chlordiazepoxide-amitriptyline oral tablet Tier 1

*Phenothiazines & Tricyclic Agents***

perphenazine-amitriptyline oral tablet Tier 1

*Thienbenzodiazepines & Ssris***

olanzapine-fluoxetine hcl oral capsule Tier 1

*Fibromyalgia Agents**

*Fibromyalgia Agent - Snris***

SAVELLA ORAL TABLET Tier 3 PA

*Movement Disorder Drug Therapy**

*Movement Disorder Drug Therapy***

XENAZINE ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Multiple Sclerosis Agents**

*Ms Agents - Pyrimidine Synthesis Inhibitors***

AUBAGIO ORAL TABLET Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Multiple Sclerosis Agents - Interferons***

AVONEX INTRAMUSCULAR* KIT Tier 4 SP

AVONEX PEN INTRAMUSCULAR* KIT Tier 4 SP

AVONEX PREFILLED INTRAMUSCULAR* KIT

Tier 4 SP

BETASERON SUBCUTANEOUS* SOLUTION RECONSTITUTED


EXTAVIA SUBCUTANEOUS* SOLUTION RECONSTITUTED


REBIF SUBCUTANEOUS* SOLUTION Tier 4 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION

Tier 4 SP

REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION

Tier 4 SP

*Multiple Sclerosis Agents - Potassium Channel Blockers***

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR*


108

Drug Tier Notes

*Multiple Sclerosis Agents***

COPAXONE SUBCUTANEOUS* KIT Tier 4 SP

*Sphingosine 1-Phosphate (S1p) Receptor Modulators***

GILENYA ORAL CAPSULE Tier 4 PA; SP; QL (30 EA per 30 Day(s))

*Postherpetic Neuralgia (Phn) Agents**

*Postherpetic Neuralgia (Phn) Agents***

gabapentin (phn) oral tablet Tier 1

GRALISE ORAL TABLET Tier 3

*Premenstrual Dysphoric Disorder (Pmdd) Agents**

*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris***

fluoxetine hcl (pmdd) oral capsule 20 mg Tier 1

*Pseudobulbar Affect (Pba) Agents**

*Pseudobulbar Affect Agent Combinations***

NUEDEXTA ORAL CAPSULE Tier 3

*Psychotherapeutic And Neurological Agents - Misc.**

*Psychotherapeutic And Neurological Agents - Misc.***

ergoloid mesylates oral tablet Tier 1

ORAP ORAL TABLET Tier 2

*Restless Leg Syndrome (Rls) Agents**

*Restless Leg Syndrome (Rls) Agents***

HORIZANT ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

*Smoking Deterrents**

*Smoking Deterrents***

buproban oral tablet extended release 12 hr* Tier 1 1 (Preventative Medication)

bupropion hcl er (smoking det) oral tablet extended release 12 hr*


CHANTIX ORAL TABLET Tier 3 1 (Preventative Medication)

CHANTIX STARTING MONTH PAK ORAL TABLET


NICOTROL INHALATION INHALER Tier 3 PA; 1 (Preventative Medication)

109

Drug Tier Notes

NICOTROL NS NASAL SOLUTION Tier 3 PA; 1 (Preventative Medication)

*Respiratory Agents - Misc.*

*Cystic Fibrosis Agents**

*Cftr Potentiators***

KALYDECO ORAL TABLET Tier 4 PA; SP; QL (60 EA per 30 Day(s))

*Sulfonamides*

*Sulfonamides**

*Sulfonamides***

sulfadiazine oral tablet Tier 1

*Tetracyclines*

*Tetracyclines**

*Tetracyclines***

ALODOX CONVENIENCE COMBINATION KIT

Tier 3

avidoxy oral tablet Tier 1

demeclocycline hcl oral tablet Tier 1

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral capsule delayed release particles

Tier 1

doxycycline hyclate oral tablet Tier 1

doxycycline hyclate oral tablet delayed release Tier 1

doxycycline monohydrate oral capsule Tier 1

doxycycline monohydrate oral suspension reconstituted

Tier 1

doxycycline monohydrate oral tablet Tier 1

doxycycline-eyelid cleans-spr combination kit Tier 1

minocycline hcl oral capsule Tier 1

minocycline hcl oral tablet Tier 1

minocycline hcl er oral tablet extended release 24 hr*

Tier 1

minocycline-acne care products combination kit Tier 1

morgidox combination kit 2 x 100 mg Tier 1

morgidox oral capsule Tier 1

OCUDOX COMBINATION KIT Tier 3

110

Drug Tier Notes

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR* 55 MG


tetracycline hcl oral capsule Tier 1

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED

Tier 3

*Thyroid Agents*

*Antithyroid Agents**

*Antithyroid Agents***

methimazole oral tablet Tier 1

propylthiouracil oral tablet Tier 1

*Thyroid Hormones**

*Thyroid Hormones***

levothyroxine sodium oral tablet Tier 1

liothyronine sodium oral tablet Tier 1

nature-throid oral tablet 130 mg, 16.25 mg, 195 mg, 32.5 mg, 65 mg

Tier 1

THYROLAR-1 ORAL TABLET Tier 3

THYROLAR-1/2 ORAL TABLET Tier 3

THYROLAR-1/4 ORAL TABLET Tier 3



unithroid oral tablet Tier 1

unithroid direct oral tablet Tier 1

westhroid oral tablet 130 mg, 32.5 mg, 65 mg Tier 1

*Toxoids*

*Toxoid Combinations**

*Toxoid Combinations***

DECAVAC INTRAMUSCULAR* INJECTABLE


TENIVAC INTRAMUSCULAR* INJECTABLE Tier 2 1 (Preventative Medication)

*Toxoids**

*Toxoids***

tetanus toxoid adsorbed intramuscular* solution Tier 1 1 (Preventative Medication)

*Ulcer Drugs*

111

Drug Tier Notes

*Antispasmodics**

*Anticholinergic Combinations***

belladonna alkaloids-opium re suppository Tier 1

belladonna-opium re suppository Tier 1

clidinium-chlordiazepoxide oral capsule Tier 1

DONNATAL ORAL ELIXIR Tier 3

DONNATAL ORAL TABLET Tier 3

DONNATAL EXTENTABS ORAL TABLET EXTENDEDRELEASE*

Tier 3

*Antispasmodics***

dicyclomine hcl oral capsule Tier 1

dicyclomine hcl oral solution Tier 1

dicyclomine hcl oral tablet Tier 1

*Belladonna Alkaloids***

ATROPEN INTRAMUSCULAR* DEVICE 0.5 MG/0.7ML

Tier 3

atropine sulfate injection solution Tier 1

ed-spaz oral tablet dispersible Tier 1

hyomax-sl sublingual tablet sublingual Tier 1

hyoscyamine sulfate oral elixir Tier 1

hyoscyamine sulfate oral solution Tier 1

hyoscyamine sulfate oral tablet Tier 1

hyoscyamine sulfate oral tablet dispersible Tier 1

hyoscyamine sulfate sublingual tablet sublingual Tier 1

hyoscyamine sulfate er oral tablet extended release 12 hr*

Tier 1

nulev oral tablet dispersible Tier 1

oscimin oral tablet Tier 1

oscimin oral tablet dispersible Tier 1

oscimin sr oral tablet extended release 12 hr* Tier 1

symax duotab oral tablet extendedrelease* Tier 1

symax fastabs oral tablet dispersible Tier 1

symax-sl sublingual tablet sublingual Tier 1

symax-sr oral tablet extended release 12 hr* Tier 1

112

Drug Tier Notes

*Quaternary Anticholinergics***

CANTIL ORAL TABLET Tier 3

glycopyrrolate oral tablet Tier 1

methscopolamine bromide oral tablet Tier 1

propantheline bromide oral tablet Tier 1

*H-2 Antagonists**

*H-2 Antagonists***

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1

cimetidine hcl oral solution Tier 1

famotidine oral suspension reconstituted Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup 150 mg/10ml, 75 mg/5ml Tier 1

ranitidine hcl oral tablet 300 mg Tier 1

*Misc. Anti-Ulcer**

*Misc. Anti-Ulcer***

sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1

*Proton Pump Inhibitors**

*Proton Pump Inhibitors***

ACIPHEX ORAL TABLET DELAYED RELEASE

Tier 3 PA

DEXILANT ORAL CAPSULE DELAYED RELEASE

Tier 2 PA

lansoprazole oral capsule delayed release 15 mg Tier 1 PA; OTC

lansoprazole oral capsule delayed release 30 mg Tier 1 PA

NEXIUM ORAL CAPSULE DELAYED RELEASE

Tier 3 PA

NEXIUM ORAL PACKET Tier 3 PA

omeprazole oral capsule delayed release Tier 1

pantoprazole sodium oral tablet delayed release Tier 1

*Ulcer Drugs - Prostaglandins**

113

Drug Tier Notes

*Ulcer Drugs - Prostaglandins***

misoprostol oral tablet Tier 1

*Ulcer Therapy Combinations**

*Proton Pump Inhibitor-Antacid Combinations***

omeprazole-sodium bicarbonate oral capsule20-1100 mg

Tier 1 OTC

omeprazole-sodium bicarbonate oral capsule40-1100 mg

Tier 1

ZEGERID ORAL PACKET Tier 3

*Ulcer Anti-Infective W/ Bismuth Combinations***

HELIDAC ORAL MISC Tier 3

PYLERA ORAL CAPSULE Tier 3

*Ulcer Anti-Infective W/ Proton Pump Inhibitors***

PREVPAC ORAL MISC Tier 3

*Urinary Anti-Infectives*

*Urinary Anti-Infective Combinations**

*Urinary Antiseptic-Antispasmodic &/Or Analgesics***

hyophen oral tablet Tier 1

phosphasal oral tablet Tier 1

uretron d/s oral tablet Tier 1

ustell oral capsule Tier 1

uta oral capsule Tier 1

uticap oral capsule Tier 1

utira-c oral tablet Tier 1

utrona-c oral tablet Tier 1

*Urinary Anti-Infectives**

*Urinary Anti-Infectives***

methenamine hippurate oral tablet Tier 1

methenamine mandelate oral tablet 0.5 gm Tier 1

MONUROL ORAL PACKET Tier 3

nitrofurantoin oral suspension Tier 1

114

Drug Tier Notes

nitrofurantoin macrocrystal oral capsule Tier 1

nitrofurantoin monohyd macro oral capsule Tier 1

*Urinary Antispasmodics*

*Urinary Antispasmodic Combinations**

*Urinary Antispasmodic Combinations***

phenazopyridine-butabarb-hyosc oral tablet Tier 1

urelief plus oral tablet Tier 1

*Urinary Antispasmodics - Beta-3 Adrenergic Agonists**

*Urinary Antispasmodics - Beta-3 Adrenergic Agonists***

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 4 PA; SP

*Urinary Antispasmodics**

*Urinary Antispasmodics***

bethanechol chloride oral tablet Tier 1

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 2

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

flavoxate hcl oral tablet Tier 1

GELNIQUE TRANSDERMAL GEL Tier 3

oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet Tier 1

oxybutynin chloride er oral tablet extended release 24 hr*

Tier 1

OXYTROL TRANSDERMAL PATCH BIWEEKLY

Tier 3

tolterodine tartrate oral tablet Tier 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

trospium chloride oral tablet Tier 1

trospium chloride er oral capsule extended release 24 hour

Tier 1

VESICARE ORAL TABLET Tier 3

*Vaccines*

115

Drug Tier Notes

*Bacterial Vaccines**

*Bacterial Vaccines***

ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED


HIBERIX INTRAMUSCULAR* SOLUTION RECONSTITUTED


PEDVAX HIB INTRAMUSCULAR* SOLUTION


PNEUMOVAX 23 INJECTION INJECTABLE Tier 2 1 (Preventative Medication)

VIVOTIF BERNA VACCINE ORAL CAPSULE DELAYED RELEASE


*Viral Vaccines**

*Viral Vaccine Combinations***

M-M-R II SUBCUTANEOUS* INJECTABLE Tier 2 1 (Preventative Medication)

PROQUAD SUBCUTANEOUS* INJECTABLE Tier 2 1 (Preventative Medication)

TWINRIX INTRAMUSCULAR* SUSPENSION Tier 2 1 (Preventative Medication)

*Viral Vaccines***

AFLURIA INTRAMUSCULAR* SUSPENSION Tier 2 1 (Preventative medication.)

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR* SUSPENSION


ENGERIX-B INJECTION SUSPENSION Tier 2 1 (Preventative Medication)

FLUARIX INTRAMUSCULAR* SUSPENSION Tier 2 1 (Preventative Medication)

FLUMIST NASAL LIQUID† Tier 3 1 (Preventative Medication)

FLUZONE PEDIATRIC PF INTRAMUSCULAR* SUSPENSION


FLUZONE PRESERVATIVE FREE INTRAMUSCULAR* SUSPENSION


GARDASIL INTRAMUSCULAR* SUSPENSION


HAVRIX INTRAMUSCULAR* SUSPENSION Tier 2 1 (Preventative Medication)

INFLUENZA A (H1N1) MONOVAL VAC NASAL LIQUID†


ROTARIX ORAL SUSPENSION RECONSTITUTED


ROTATEQ ORAL SOLUTION Tier 2 1 (Preventative Medication)

VAQTA INTRAMUSCULAR* SUSPENSION Tier 2 1 (Preventative Medication)

116

Drug Tier Notes

VARIVAX SUBCUTANEOUS* INJECTABLE Tier 2 1 (Preventative Medication)

ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED


*Vaginal Products*

*Vaginal Anti-Infectives**

*Imidazole-Related Antifungals***

GYNAZOLE-1 VAGINAL CREAM Tier 3

miconazole 3 combo pack vaginal kit Tier 1 OTC

miconazole nitrate vaginal kit Tier 1 OTC

terconazole vaginal cream Tier 1

terconazole vaginal suppository Tier 1

zazole vaginal cream Tier 1

zazole vaginal suppository Tier 1

*Vaginal Anti-Infectives***

AVC VAGINAL VAGINAL CREAM Tier 3

CLEOCIN VAGINAL SUPPOSITORY Tier 3

clindamycin phosphate vaginal cream Tier 1

metronidazole vaginal gel Tier 1

vandazole vaginal gel Tier 1

*Vaginal Estrogens**

*Vaginal Estrogens***

ESTRACE VAGINAL CREAM Tier 3

ESTRING VAGINAL RING Tier 3

VAGIFEM VAGINAL TABLET 10 MCG Tier 3

*Vaginal Progestins**

*Vaginal Progestins***

CRINONE VAGINAL GEL Tier 4 SP

ENDOMETRIN VAGINAL INSERT Tier 3

*Vasopressors*

*Anaphylaxis Therapy Agents**

*Anaphylaxis Therapy Agents***

ADRENACLICK INJECTION DEVICE 0.15 MG/0.15ML

Tier 3

117

Drug Tier Notes

AUVI-Q INJECTION DEVICE 0.15 MG/0.15ML

Tier 3

EPIPEN INJECTION DEVICE Tier 3

EPIPEN 2-PAK INJECTION DEVICE Tier 3

EPIPEN JR 2-PAK INJECTION DEVICE Tier 3

*Vasopressors**

*Vasopressors***

ephedrine sulfate injection solution Tier 1

midodrine hcl oral tablet Tier 1

*Vitamins*

*Oil Soluble Vitamins**

*Vitamin D***

cholecalciferol oral capsule Tier 1 OTC

cholecalciferol oral liquid† Tier 1 OTC

cholecalciferol oral tablet Tier 1 OTC

cholecalciferol oral tablet chewable Tier 1 OTC

vitamin d (ergocalciferol) oral capsule Tier 1

vitamin d3 oral capsule 1000 unit, 400 unit Tier 1 1 (Preventative Medication); OTC

vitamin d3 oral tablet 1000 unit, 400 unit Tier 1 1 (Preventative Medication); OTC

*Vitamin K***

MEPHYTON ORAL TABLET Tier 2

*Water Soluble Vitamins**

*Paba***

aminobenzoate potassium oral packet Tier 1

POTABA ORAL CAPSULE Tier 3

POTABA ORAL TABLET Tier 3

*Vitamin B-3***

niacin oral tablet 500 mg Tier 1 OTC

niacin er oral tablet extendedrelease* 1000 mg Tier 1 OTC

118

Index

8-MOP ........................................................................67abacavir sulfate ............................................46ABILIFY .................................................................44ABILIFY DISCMELT .......................44ABSORICA ........................................................63ACANYA ..............................................................62acarbose ...................................................................24acebutolol hcl ...................................................50acetaminophen-codeine ....................10acetaminophen-codeine #2 ..........10acetaminophen-codeine #3 ..........10acetaminophen-codeine #4 ..........10acetasol hc ........................................................104acetazolamide ..................................................77acetazolamide er .........................................77acetazolamide sodium .........................77acetic acid .............................................................85acetic acid .........................................................104acetylcysteine ...................................................28acetylcysteine ...................................................61acetylcysteine ...................................................98ACIPHEX ..........................................................112ACTHIB ..............................................................114acticin ..........................................................................75ACTONEL ...........................................................78ACTOPLUS MET XR 15-1000 MG.....................................................................................24ACUVAIL ........................................................103acyclovir ..................................................................48acyclovir ..................................................................68adapalene ...............................................................63ADCIRCA ............................................................53ADRENACLICK 0.15 MG/0.15ML.....................................................116ADRENALIN ..................................................98ADVAIR DISKUS ..................................17ADVAIR HFA ...............................................17afeditab cr .............................................................51AFINITOR ...........................................................39AFLURIA ..........................................................115AFLURIA PRESERVATIVE FREE .........................................................................115AGGRENOX ...................................................86ak-poly-bac ......................................................101ala cort .......................................................................68ALBENZA ...........................................................13albuterol sulfate ............................................17albuterol sulfate er ...................................17alclometasone dipropionate .......68ALDARA ...............................................................73alendronate sodium ................................78

alfuzosin hcl er ...............................................85aliclen ..........................................................................74ali-flex ..............................................................................7ALINIA .....................................................................36ALKERAN ..........................................................38allopurinol ............................................................86ALOCRIL ..........................................................103ALODOX CONVENIENCE ..............................................................................................109ALOMIDE .......................................................103ALORA 0.075 MG/24HR..............81alpain ................................................................................7ALPHAGAN P 0.1 %.......................100alphaquin hp ......................................................75alphatrex ..................................................................68alprazolam ............................................................14alprazolam er ...................................................14ALREX ..................................................................102ALSUMA ..............................................................93ALTABAX ..........................................................64altacaine ..............................................................101altavera ......................................................................54ALVESCO ...........................................................16alyacen 1/35 .......................................................54alyacen 7/7/7 .....................................................57amantadine hcl ...............................................41amantadine hcl ...............................................42amcinonide ...........................................................68amethia ......................................................................57amethia lo ..............................................................57amethyst ....................................................................57amiloride hcl .....................................................77amiloride-hydrochlorothiazide ..................................................................................................77aminobenzoate potassium .........117aminocaproic acid ....................................89amiodarone hcl ..............................................15AMITIZA ..............................................................83amitriptyline hcl ...........................................23amlodipine besy-benazepril hcl ..................................................................................................33amlodipine besylate ................................51ammonium lactate .....................................73ammonium lactate 10 %....................73ammonium lactate 12 %....................73amnesteem .............................................................63amoxapine .............................................................23amoxicillin ........................................................105amoxicillin-pot clavulanate ..............................................................................................105

amoxicillin-pot clavulanate er ..............................................................................................105amphetamine-dextroamphet er ..........................................................................................................3amphetamine-dextroamphetamine .................................................................................................3ampicillin ............................................................105AMPYRA ..........................................................107AMTURNIDE ................................................35ANADROL-50 ..............................................11anagrelide hcl ..................................................86analpram-hc .......................................................12anastrozole ...........................................................39ANDRODERM 2 MG/24HR, 4 MG/24HR................................................................11ANDROGEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)................................11ANDROGEL 25 MG/2.5GM, 50 MG/5GM..................................................................11ANDROGEL PUMP 12.5 MG/ACT (1%).................................................12ANDROGEL PUMP 20.25 MG/ACT (1.62%).......................................12ANDROXY ........................................................12antipyrine-benzocaine 5.4-1.4 %, 54-14 mg/ml...........................................104anucort-hc .............................................................12ANZEMET ..........................................................28apap-caff-dihydrocodeine .............10apap-isometheptene-caffeine ..................................................................................................93apexicon ...................................................................68apexicon e ..............................................................68APHTHASOL .................................................95APIDRA ..................................................................26APIDRA SOLOSTAR .......................26APLENZIN 174 MG..............................22APOKYN ...............................................................42apraclonidine hcl ....................................100apri ...................................................................................54APRISO ....................................................................83APTIVUS ..............................................................45aranelle ......................................................................57

119

ARANESP (ALBUMIN FREE) 100 MCG/0.5ML, 100 MCG/ML, 150 MCG/0.3ML, 150 MCG/0.75ML, 200 MCG/0.4ML, 200 MCG/ML, 25 MCG/0.42ML, 25 MCG/ML, 300 MCG/0.6ML, 300 MCG/ML, 40 MCG/0.4ML, 40 MCG/ML, 500 MCG/ML, 60 MCG/0.3ML, 60 MCG/ML.........87arbinoxa ...................................................................30ARCALYST ..........................................................5ARCAPTA NEOHALER ..............17ARICEPT 23 MG....................................106arzol silver nit applicators ...........68ASACOL HD ...................................................83ascomp-codeine ............................................10asmalpred plus ...............................................59ASMANEX 120 METERED DOSES .......................................................................16ASMANEX 14 METERED DOSES .......................................................................16ASMANEX 30 METERED DOSES .......................................................................16ASMANEX 60 METERED DOSES .......................................................................16ASMANEX 7 METERED DOSES .......................................................................16aspirin low dose ...............................................8ASTEPRO 0.15 %......................................97ATACAND .........................................................33ATELVIA ..............................................................78atenolol ......................................................................50atenolol-chlorthalidone ....................34atorvastatin calcium ..............................32atovaquone-proguanil hcl .............36ATRALIN .............................................................63ATRIPLA ..............................................................45ATROPEN 0.5 MG/0.7ML......111atropine sulfate ..............................................99atropine sulfate ..........................................111ATROVENT HFA ...................................15AUBAGIO .......................................................107AUGMENTIN 125-31.25 MG/5ML...............................................................105aurodex ..................................................................104auroguard ..........................................................104AUVI-Q 0.15 MG/0.15ML.......117AVAGE ....................................................................64AVANDIA 2 MG........................................26avar cleanser ....................................................62avar-e emollient ............................................62avar-e green .......................................................62

AVC VAGINAL .....................................116AVELOX ...............................................................82AVELOX ABC PACK ......................82aviane ...........................................................................54avidoxy ...................................................................109AVINZA ......................................................................8avita ................................................................................63AVODART .........................................................85AVONEX ..........................................................107AVONEX PEN .........................................107AVONEX PREFILLED ..............107AXERT ......................................................................93AXIRON .................................................................12AZASAN ................................................................49AZASITE ...........................................................100azathioprine ........................................................49azelastine hcl ....................................................98azelastine hcl ................................................103AZELEX .................................................................63AZILECT ...............................................................42azithromycin ......................................................91AZOPT ..................................................................103AZOR ..........................................................................34azurette ......................................................................54bacitracin ...........................................................100bacitracin-polymyxin b ................101bacitracin-polymyx-neo-hc ......102bacitra-neomycin-polymyxin-hc ..............................................................................................102baclofen .....................................................................97BACTROBAN NASAL ..................98balsalazide disodium ............................83balziva .........................................................................55BANZEL .................................................................19BARACLUDE ...............................................47baycadron ..............................................................59BAYER BREEZE 2 TEST ..........76BAYER CONTOUR NEXT TEST .............................................................................76BAYER CONTOUR TEST .......76BECONASE AQ ........................................98belladonna alkaloids-opium ..............................................................................................110belladonna-opium ..................................111benazepril hcl ...................................................32benazepril-hydrochlorothiazide ..................................................................................................33BENICAR .............................................................33BENICAR HCT ...........................................34BENZACLIN ...................................................62benzepro ...................................................................63benzepro short contact .......................63benziq wash .........................................................63

benzoin compound ....................................75benzonatate ..........................................................60benzoyl peroxide ..........................................63benzoyl peroxide 10 %, 5 %........63benzoyl peroxide 3 %.............................63benzoyl peroxide 4 %.............................63benzoyl peroxide 5.3 %.......................63benzoyl peroxide cleanser 6 %............................................................................................63benzoyl peroxide wash 8 & 5 %............................................................................................63benzoyl peroxide-erythromycin ..................................................................................................62benzphetamine hcl ........................................3benztropine mesylate ............................41BEPREVE .........................................................103BESIVANCE ...............................................100betamethasone dipropionate .....68betamethasone dipropionate .....69betamethasone dipropionate aug ..................................................................................................69betamethasone valerate ....................69BETASERON .............................................107betaxolol hcl .......................................................50betaxolol hcl .......................................................99bethanechol chloride ........................114BETIMOL 0.5 %..........................................99BETOPTIC-S ...................................................99BEYAZ ......................................................................55bicalutamide ......................................................38BIDIL ...........................................................................52BILTRICIDE ....................................................13BINOSTO ..............................................................78bisoprolol fumarate ................................50bisoprolol-hydrochlorothiazide ..................................................................................................34BLEPHAMIDE S.O.P. ..................102BOSULIF 100 MG....................................40BOSULIF 500 MG....................................40bp 10-1 ........................................................................62bp cleansing wash .....................................62bp folinatal plus b ......................................97bp wash 7 %.........................................................63briellyn .......................................................................55BRILINTA ...........................................................86BRIMONIDINE TARTRATE 0.15 %........................................................................100brimonidine tartrate 0.2 %........100bromfed dm ..........................................................61bromfenac sodium .................................103bromocriptine mesylate ....................42brompheniramine-phenylephrine ..................................................................................................60

120

BROVANA .........................................................17budeprion sr .......................................................22budesonide ............................................................16budesonide er ...................................................59bumetanide ...........................................................77BUPHENYL ......................................................80buprenorphine hcl .....................................11buprenorphine hcl-naloxone hcl ..................................................................................................11buproban .............................................................108bupropion hcl ...................................................22bupropion hcl er (smoking det) ..............................................................................................108bupropion hcl er (sr) .............................22bupropion hcl er (xl) .............................22buspirone hcl ....................................................14butalbital-acetaminophen ..................7butalbital-apap-caff-cod ..................10butalbital-apap-caffeine ......................7butalbital-asa-caff-codeine .........10butalbital-asa-caffeine ...........................7butalbital-aspirin-caffeine ................7butorphanol tartrate ..............................11BUTRANS 10 MCG/HR, 20 MCG/HR, 5 MCG/HR.........................11BYDUREON ....................................................25BYETTA 10 MCG PEN .................25BYETTA 5 MCG PEN .....................25BYSTOLIC .........................................................50cabergoline ..........................................................80CADUET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG..........52CAFERGOT ......................................................93caffeine citrate 20 mg/ml......................3calcipotriene ......................................................67calcitonin (salmon) ..................................78calcitriol ...................................................................80calcium acetate ..............................................84calcium acetate (phos binder) ..................................................................................................84camila ..........................................................................58CAMPRAL ......................................................106camrese ......................................................................57camrese lo .............................................................57CANASA ...............................................................83candesartan cilexetil-hctz ..............34CANTIL ...............................................................112capacet ...........................................................................7CAPEX ......................................................................69CAPRELSA 100 MG............................40CAPRELSA 300 MG............................40captopril ...................................................................32

captopril-hydrochlorothiazide ..................................................................................................34CARAC .....................................................................66CARBAGLU ....................................................80carbamazepine ...............................................19carbamazepine er .......................................19carbidopa-levodopa ...............................42carbidopa-levodopa er .......................42carbidopa-levodopa-entacapone ..................................................................................................42carbinoxamine maleate .....................30carbonyl iron ....................................................88CARDIZEM LA 120 MG...............51CARDURA XL 4 MG..........................85carisoprodol .......................................................97carisoprodol-aspirin ..............................97carisoprodol-aspirin-codeine ..................................................................................................97carteolol hcl ........................................................99cartia xt .....................................................................51carvedilol ................................................................50CAVERJECT ...................................................52CAVERJECT IMPULSE ...............52cavirinse ...................................................................95CAYSTON ..........................................................35caziant .........................................................................57CEDAX .....................................................................54cefaclor ......................................................................53cefaclor er .............................................................53cefadroxil ................................................................53cefdinir .......................................................................54cefditoren pivoxil ........................................54cefpodoxime proxetil .............................54cefprozil ....................................................................54CEFTIN 250 MG/5ML.......................54cefuroxime axetil .........................................54cefuroxime axetil 125 mg/5ml..........................................................................54CELEBREX 100 MG, 200 MG, 50 MG...............................................................................5CELEBREX 400 MG................................5CELESTONE ..................................................59CELLCEPT .........................................................49CELONTIN ........................................................21cem-urea ..................................................................72CENESTIN ..........................................................81centany .......................................................................64cephalexin ..............................................................53cephalexin 250 mg, 500 mg..........53cerisa wash ..........................................................62cerovel .........................................................................72CESAMET ...........................................................29cesia ................................................................................57

cetirizine hcl .......................................................30CETROTIDE ....................................................78cevimeline hcl ..................................................96CHANTIX ........................................................108CHANTIX STARTING MONTH PAK .............................................108chateal .........................................................................55CHEMET ...............................................................28chlordiazepoxide hcl .............................14chlordiazepoxide-amitriptyline ..............................................................................................107chlorhexidine gluconate ...................95chlorhexidine gluconate 20 %............................................................................................44chloroquine phosphate .......................37chlorothiazide ..................................................77chlorpromazine hcl ..................................44chlorpropamide .............................................27chlorthalidone .................................................77chlorzoxazone ..................................................97cholecalciferol ............................................117cholestyramine light ...............................31choline & mag trisalicylate 1000 mg................................................................................................8choline-mag trisalicylate ....................8CIALIS 2.5 MG, 5 MG.......................52ciclodan .....................................................................65ciclopirox ................................................................65ciclopirox olamine ....................................65cilostazol ..................................................................86CILOXAN ........................................................100cimetidine 300 mg, 400 mg, 800 mg....................................................................................112cimetidine hcl ...............................................112CIMZIA ....................................................................83CIMZIA PREFILLED ........................83CIMZIA STARTER KIT ...............83CIPRO .........................................................................82CIPRO HC ........................................................104CIPRODEX ....................................................104ciprofloxacin hcl ..........................................82ciprofloxacin hcl ......................................100ciprofloxacin hcl ......................................104ciprofloxacin-ciproflox hcl er ..................................................................................................82citalopram hydrobromide ..............22citric acid-sodium citrate ...............84claravis ......................................................................64CLARINEX ........................................................30CLARINEX-D 12 HOUR .............60claris clarifying wash ..........................62clarithromycin .................................................92clarithromycin er ........................................92

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clearplex x .............................................................64clemastine fumarate ...............................30clemastine fumarate 2.68 mg.....30CLEOCIN ..........................................................116clidinium-chlordiazepoxide ..............................................................................................111clindacin-p ............................................................61clindamax ...............................................................61clindamax ...............................................................62clindamycin hcl .............................................36clindamycin palmitate hcl .............36clindamycin phos-benzoyl perox ..................................................................................................62clindamycin phosphate ......................62clindamycin phosphate ..................116clinpro 5000 .......................................................96clobetasol prop emollient base ..................................................................................................69clobetasol propionate ..........................69CLOBEX SPRAY ....................................69CLODERM .........................................................69CLODERM PUMP .................................69clomiphene citrate ....................................78clomipramine hcl ........................................23clonazepam ..........................................................19clonidine hcl .......................................................33clopidogrel bisulfate ..............................86clorazepate dipotassium ..................14clotrimazole ........................................................66clotrimazole ........................................................95clotrimazole anti-fungal ...................66clotrimazole-betamethasone ......65clozapine ..................................................................43CNL8 NAIL .......................................................65coal tar .......................................................................76COARTEM .........................................................36codeine sulfate ....................................................8co-gesic ......................................................................10colchicine-probenecid .........................85COLCRYS ...........................................................86colestipol hcl .....................................................31colocort ......................................................................12COLY-MYCIN S ...................................104COLYTE WITH FLAVOR PACKS 227.1 GM......................................90COMBIGAN .....................................................99COMBIPATCH ............................................81COMBIVENT .................................................17COMBIVENT RESPIMAT .......17COMETRIQ (100 MG DAILY DOSE) .........................................................................40COMETRIQ (140 MG DAILY DOSE) .........................................................................40

COMETRIQ (60 MG DAILY DOSE) .........................................................................40COMPLERA .....................................................45compro ........................................................................44CONDYLOX ...................................................74constulose ..............................................................91controlrx ..................................................................96CONZIP .......................................................................8COPAXONE .................................................108CORDRAN .........................................................69CORDRAN SP ..............................................69COREG CR ........................................................50cortalo .........................................................................72cortic-nd ...............................................................104CORTIFOAM .................................................12cortisone acetate .........................................59CORTISPORIN ............................................64CORTISPORIN-TC ...........................104covaryx .......................................................................81covaryx hs ..............................................................81CREON .....................................................................76CRESTOR ............................................................32CRINONE .........................................................116CRIXIVAN 200 MG, 400 MG.....................................................................................45cromolyn sodium .........................................15cromolyn sodium .........................................82cromolyn sodium .....................................103cryselle-28 .............................................................55CUPRIMINE ....................................................48cyanide antidote .........................................27cyanocobalamin ...........................................87cyclafem 1/35 ....................................................55cyclafem 7/7/7 .................................................57cyclobenzaprine hcl ................................97cyclopentolate hcl ......................................99cyclophosphamide .....................................38cycloserine ............................................................37CYCLOSET .......................................................25cyclosporine .......................................................49cyclosporine modified .........................49CYMBALTA ...................................................23cyproheptadine hcl ...................................30cyproheptadine hcl ...................................31CYSTAGON .....................................................85CYSTARAN .................................................103cytra-2 .........................................................................84cytra-3 .........................................................................84cytra-k ..........................................................................84DALIRESP ..........................................................16danazol .......................................................................12dantrolene sodium ....................................97dapsone ......................................................................36

DARAPRIM ......................................................37dasetta 1/35 .........................................................55dasetta 7/7/7 .......................................................57daysee ..........................................................................57DAYTRANA .......................................................4DECAVAC ......................................................110demeclocycline hcl ...............................109DEMSER ................................................................33DENAVIR ............................................................68denta 5000 plus .............................................96dentagel .....................................................................96DEPEN TITRATABS ........................48DEPO-PROVERA 400 MG/ML.......................................................................39DEPO-SUBQ PROVERA 104 ..................................................................................................58dermazene ..............................................................65desipramine hcl .............................................23desloratadine ....................................................30desmopressin ace refrigerated ..................................................................................................80desmopressin ace rhinal tube ..................................................................................................80desmopressin ace spray refrig ..................................................................................................80desmopressin acetate ............................80DESONATE ......................................................69desonide ....................................................................69desonide crea-moisturizing lot ..................................................................................................69DESOWEN .........................................................69DESOWEN CREAM W/CETAPHIL LOT ..............................70DESOWEN LOT W/CETAPHIL CREAM .................70DESOWEN OINT W/CETAPHIL LOT ..............................70desoximetasone ..............................................70DESVENLAFAXINE ER ............23DETROL LA ................................................114DEXAMETHASONE .........................59DEXAMETHASONE INTENSOL .........................................................59dexamethasone sodium phosphate ...........................................................102dexchlorpheniramine maleate ..................................................................................................29DEXILANT ....................................................112dexmethylphenidate hcl ........................4DEXPAK 10 DAY ..................................59DEXPAK 13 DAY ..................................59DEXPAK 6 DAY ......................................59dextroamphetamine sulfate .............3

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dextroamphetamine sulfate er .....3DIASTAT PEDIATRIC ..................19diazepam ..................................................................14diazepam ..................................................................19DIBENZYLINE ...........................................33diclofenac potassium ................................6diclofenac sodium ..........................................6diclofenac sodium ..................................103diclofenac sodium er .................................6diclofenac-misoprostol ..........................5dicloxacillin sodium ...........................105dicyclomine hcl ..........................................111didanosine .............................................................46diethylpropion hcl .........................................3diethylpropion hcl er .................................3DIFFERIN ............................................................64DIFFERIN 0.3 %..........................................64DIFICID ...................................................................92difil-g forte ............................................................15diflorasone diacetate ............................70diflunisal ......................................................................8digoxin ........................................................................52dihydroergotamine mesylate .....93DILANTIN 30 MG...................................21DILATRATE-SR .......................................13dilt-cd ...........................................................................51diltiazem hcl .......................................................51diltiazem hcl er ..............................................51diltiazem hcl er beads 300 mg, 360 mg, 420 mg...............................................51diltiazem hcl er coated beads 120 mg, 180 mg, 240 mg, 300 mg........................................................................................51dilt-xr 180 mg....................................................51diltzac ...........................................................................51dimenhydrinate ..............................................28DIOVAN .................................................................33DIPENTUM .......................................................83diphenhydramine hcl ............................30diphenhydramine hcl (sleep) .....89diphenhydramine hcl 50 mg.........30diphenoxylate-atropine ......................27dipyridamole ......................................................86disopyramide phosphate ..................14disulfiram ...........................................................106divalproex sodium .....................................21divalproex sodium er ............................21donepezil hcl ..................................................106donepezil hcl 10 mg, 5 mg..........106DONNATAL ................................................111DONNATAL EXTENTABS ..............................................................................................111dorzolamide hcl ........................................103

dorzolamide hcl-timolol mal .....99DOVONEX .........................................................67doxazosin mesylate ..................................33doxepin hcl ...........................................................23doxycycline hyclate .............................109doxycycline monohydrate ..........109doxycycline-eyelid cleans-spr ..............................................................................................109dritho-creme hp ............................................67dronabinol .............................................................29drospirenone-ethinyl estradiol ..................................................................................................55DROXIA .................................................................87DULERA ................................................................17duraxin ...........................................................................7DUREZOL .......................................................102DYRENIUM 100 MG..........................77e.e.s. 400 ..................................................................92e.s.p. ................................................................................36econazole nitrate .........................................66EDARBI ..................................................................33EDECRIN ..............................................................77EDEX 10 MCG, 20 MCG..............52ed-flex ..............................................................................7ed-spaz ....................................................................111EDURANT ..........................................................46EFFER-K 10 MEQ, 20 MEQ................................................................................94effer-k 25 meq....................................................94EFFIENT ................................................................86EGRIFTA 2 MG............................................79ELIDEL ....................................................................73elinest ...........................................................................55ELIQUIS .................................................................18elixophyllin ..........................................................18ELLA ............................................................................58ELMIRON ............................................................85EMADINE .......................................................103EMCYT ....................................................................39EMEND 125 MG, 40 MG, 80 MG.....................................................................................29emoquette ...............................................................55EMSAM ...................................................................22EMTRIVA ............................................................46ENABLEX .......................................................114enalapril maleate ........................................32enalapril-hydrochlorothiazide ..................................................................................................34ENBREL .....................................................................7ENBREL SURECLICK .......................7endocet .......................................................................10endodan .....................................................................10ENDOMETRIN .......................................116

ENGERIX-B .................................................115ENJUVIA ..............................................................81enovarx-cyclobenzaprine hcl ..................................................................................................97enoxaparin sodium ...................................19enpresse-28 ..........................................................57enskyce .......................................................................55entacapone ...........................................................41entre-b .........................................................................60enulose ........................................................................83ephedrine sulfate .....................................117EPIDUO ...................................................................62epinastine hcl ................................................103epinephrine hcl ..............................................18epinephrine hcl (nasal) ......................98EPIPEN .................................................................117EPIPEN 2-PAK ........................................117EPIPEN JR 2-PAK ..............................117epitol ..............................................................................19EPIVIR HBV ....................................................46eplerenone .............................................................35EPOGEN .................................................................87eprosartan mesylate ...............................33EPZICOM .............................................................45ergoloid mesylates ................................108ERGOMAR ........................................................93ERIVEDGE ........................................................38errin ................................................................................58ERTACZO ...........................................................66ery ......................................................................................62ERY-TAB 333 MG...................................92erythrocin stearate 250 mg...........92erythromycin ......................................................62erythromycin ..................................................100erythromycin base .....................................92ERYTHROMYCIN BASE COATED ................................................................92erythromycin ethylsuccinate ......92erythromycin stearate ..........................92erythromycin-sulfisoxazole ..........36escitalopram oxalate .............................22est estrogens-methyltest ....................81estarylla ....................................................................55estazolam ................................................................90ESTRACE .........................................................116estradiol ....................................................................81estradiol valerate ........................................82estradiol-norethindrone acet ..................................................................................................81ESTRING ..........................................................116ESTROGEL .......................................................82estropipate ............................................................82ethambutol hcl ................................................37

123

ethosuximide ......................................................21ethyl chloride ....................................................74etidronate disodium ................................78etodolac .........................................................................6etodolac er ................................................................6etoposide ..................................................................41EURAX .....................................................................76EVAMIST .............................................................82EVISTA ....................................................................80EXALGO ...................................................................8EXELDERM .....................................................66EXELON ............................................................106exemestane ...........................................................39EXFORGE ...........................................................34EXFORGE HCT .........................................34EXJADE ..................................................................28exoderm .....................................................................65exotic-hc ...............................................................104EXTAVIA .........................................................107ezfe 200 ......................................................................88fa-8 ...................................................................................87FACTIVE ..............................................................82falmina ........................................................................55famciclovir ............................................................48famotidine ..........................................................112famotidine 20 mg, 40 mg..............112FANAPT .................................................................43FARESTON .......................................................39FAZACLO 150 MG................................43felbamate .................................................................20felodipine er ........................................................51fenofibrate .............................................................31fenofibrate micronized ........................31fenofibric acid .................................................31FENOGLIDE ...................................................31fenoprofen calcium ......................................6fentanyl ..........................................................................8fentanyl citrate ....................................................8fer-iron .......................................................................88ferotrinsic ...............................................................88ferraplus 90 .........................................................88ferretts .........................................................................88ferrex 150 ...............................................................88ferrimin 150 ........................................................88FERRIPROX ....................................................28ferrocite .....................................................................88ferrogels forte ..................................................88ferrous fumarate 324 mg, 325 (106 fe) mg, 90 mg......................................88ferrous gluconate 240 (27 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg........................................................................................89ferrous gluconate iron ........................89

ferrous sulfate ..................................................89ferrous sulfate 325 (65 fe) mg........................................................................................89ferrous sulfate 75 (15 fe) mg/ml..............................................................................89ferrous sulfate dried er ......................89ferrous sulfate er .........................................89fexofenadine hcl 60 mg........................30FINACEA ..............................................................75finasteride 5 mg..............................................85FIRAZYR ..............................................................86FLAGYL ER ....................................................35FLAREX .............................................................102flavoxate hcl ...................................................114flecainide acetate ........................................15FLECTOR .............................................................66FLOVENT DISKUS 100 MCG/BLIST........................................................16FLUARIX ..........................................................115fluconazole ...........................................................29flucytosine ..............................................................29fludrocortisone acetate ......................60FLUMIST ..........................................................115flunisolide 25 mcg/act (0.025%)....................................................................98fluocinolone & cleanser ...................72fluocinolone acetonide .......................70fluocinolone acetonide ...................105fluocinolone acetonide scalp ..................................................................................................70fluocinonide ........................................................70fluocinonide emulsified base .....70fluorescein-proparacaine ..........103fluoridex sensitivity relief ..............95fluorometholone .......................................102FLUOROPLEX ............................................66fluorouracil ..........................................................66fluoxetine hcl .....................................................22fluoxetine hcl .....................................................23fluoxetine hcl (pmdd) 20 mg....................................................................................108fluphenazine hcl ............................................44flurazepam hcl ................................................90flurbiprofen ..............................................................6flurbiprofen sodium ............................103flutamide ..................................................................39fluticasone propionate ........................70fluticasone propionate ........................98fluvastatin sodium .....................................32fluvoxamine maleate ..............................23FLUZONE PEDIATRIC PF ..............................................................................................115

FLUZONE PRESERVATIVE FREE .........................................................................115FML ............................................................................102FOCALIN XR ....................................................4folcaps .........................................................................88folic acid 0.8 mg............................................87folic acid 1 mg, 400 mcg, 800 mcg.....................................................................................87FOLTRATE .......................................................88fondaparinux sodium ............................19FORADIL AEROLIZER ...............17FORFIVO XL .................................................22formadon .................................................................44formaldehyde 10 %....................................44forma-ray ................................................................44FORTEO .................................................................78FORTESTA ........................................................12FOSAMAX PLUS D ............................78fosinopril sodium ........................................32fosinopril sodium-hctz ........................34FOSRENOL .......................................................84FRAGMIN 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 25000 UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML.......................................................19FROVA .....................................................................93furosemide .............................................................77gabapentin ............................................................19gabapentin ............................................................20gabapentin (phn) .....................................108galantamine hydrobromide .....106galantamine hydrobromide er ..............................................................................................106GALZIN ..................................................................95garamycin ..........................................................100GARDASIL ....................................................115GATTEX ................................................................84gavilyte-c .................................................................90gavilyte-g ................................................................90gavilyte-n with flavor pack ..........91GELNIQUE ....................................................114gemfibrozil ............................................................31generess fe ............................................................55generlac ....................................................................83gengraf .......................................................................49GENOTROPIN .............................................79GENOTROPIN MINIQUICK ..................................................................................................79gentak .......................................................................100gentamicin sulfate .....................................65

124

gentamicin sulfate .................................100gianvi ............................................................................55GIAZO .......................................................................83gildagia ......................................................................55gildess 1.5/30 ....................................................55gildess 1/20 ..........................................................55gildess fe 1.5/30 ............................................55gildess fe 1/20 ..................................................55GILENYA .........................................................108GLEEVEC ............................................................40glimepiride ...........................................................27glipizide .....................................................................27glipizide er ............................................................27glipizide xl 2.5 mg.......................................27glipizide-metformin hcl .....................24GLUCAGEN HYPOKIT ...............25GLUCAGON EMERGENCY ..................................................................................................25GLUMETZA 500 MG.........................25glyburide ..................................................................27glyburide micronized ............................27glyburide-metformin ..............................24glycolic acid .......................................................67glycopyrrolate .............................................112GLYSET 25 MG...........................................24GOLYTELY 227.1 GM.....................91GRALISE ..........................................................108granisetron hcl ...............................................28GRANISOL ........................................................28griseofulvin microsize .........................29griseofulvin ultramicrosize 125 mg, 250 mg.............................................................29guanfacine hcl .................................................33guanidine hcl ....................................................37GYNAZOLE-1 ..........................................116halac ..............................................................................72HALFLYTELY WITH FLAVOR PACKS ....................................91halobetasol propionate ......................70HALOG ....................................................................70halonate pac .......................................................72haloperidol ...........................................................43haloperidol lactate ...................................43HAVRIX .............................................................115heather ........................................................................58hecoria ........................................................................49HECTOROL ......................................................80HELIDAC .........................................................113hematogen fa .....................................................88hematogen forte ............................................88hemocyte-f .............................................................88hemril-30 .................................................................12heparin (porcine) lock flush .......18

heparin lock flush ......................................18HEPSERA .............................................................47HEXALEN ..........................................................38HIBERIX ............................................................115homatropaire ....................................................99homatropine hbr ..........................................99HORIZANT ...................................................108HUMALOG .......................................................26HUMALOG MIX 50/50 ..................26HUMALOG MIX 50/50 KWIKPEN ...........................................................26HUMALOG MIX 75/25 ..................26HUMALOG MIX 75/25 KWIKPEN ...........................................................26HUMATROPE ..............................................79HUMIRA ....................................................................5HUMIRA PEN-CROHNS STARTER .................................................................5humulin n ................................................................26humulin r .................................................................26humulin r u-500 (concentrated) ..................................................................................................26hyaluronate sodium (emollient) ..................................................................................................73HYCAMTIN .....................................................41hydralazine hcl ...............................................35hydrochlorothiazide ...............................78hydrocod polst-cpm polst er ......61hydrocodone-acetaminophen ..................................................................................................10hydrocodone-acetaminophen 7.5-325 mg/15ml, 7.5-500 mg/15ml......................................................................10hydrocodone-homatropine ...........60hydrocodone-ibuprofen .....................10hydrocortisone ................................................12hydrocortisone ................................................59hydrocortisone 1 %...................................70hydrocortisone 2.5 %.............................70hydrocortisone ace-aloe vera ..................................................................................................72hydrocortisone ace-pramoxine ..................................................................................................12hydrocortisone ace-pramoxine ..................................................................................................71hydrocortisone acetate .......................12hydrocortisone acetate 1 %..........71hydrocortisone acetate-aloe ......72hydrocortisone butyrate ...................71hydrocortisone valerate ....................71hydrocortisone-acetic acid ......105hydrocortisone-aloe vera ...............72hydrocortisone-iodoquinol ..........65

hydromet ..................................................................60hydromorphone hcl .....................................8hydroquinone time release ...........75hydroxychloroquine sulfate ........37hydroxyurea ........................................................40hydroxyzine hcl ..............................................14hydroxyzine pamoate ............................14hygel ...............................................................................73hyomax-sl ...........................................................111hyophen .................................................................113hyoscyamine sulfate ............................111hyoscyamine sulfate er ...................111hypercare ................................................................75ibandronate sodium ................................78ibudone 5-200 mg........................................10ibuprofen 400 mg, 600 mg, 800 mg................................................................................................6ICLUSIG 15 MG..........................................40ICLUSIG 45 MG..........................................40iferex 150 ................................................................89iferex 150 forte ...............................................88ilotycin ....................................................................100imipramine hcl ................................................23imipramine pamoate ..............................23imiquimod ..............................................................73INCIVEK ...............................................................47indapamide ..........................................................78indomethacin .........................................................6indomethacin er ................................................6INFLUENZA A (H1N1) MONOVAL VAC ................................115INLYTA ..................................................................40INNOPRAN XL 80 MG...................50INSULIN SYRINGE 28G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML...............................92INTELENCE ....................................................46INTERMEZZO 3.5 MG....................90introvale ...................................................................57INTUNIV ...................................................................3INVEGA ..................................................................43INVIRASE ...........................................................45iodine ..........................................................................45iodine tincture ...............................................45IOPIDINE 1 %.............................................100ipratropium bromide .............................15ipratropium bromide .............................98ipratropium-albuterol ..........................17irbesartan ...............................................................33irbesartan-hydrochlorothiazide ..................................................................................................34ISENTRESS ......................................................45isoditrate er .........................................................13

125

isoniazid ...................................................................37ISOPTO CARBACHOL .................99ISOPTO HYOSCINE ..........................99isosorbide dinitrate .................................13isosorbide dinitrate 2.5 mg............13isosorbide dinitrate er .........................13isosorbide mononitrate ......................13isosorbide mononitrate er .............13isoxsuprine hcl 10 mg............................53isradipine 2.5 mg, 5 mg......................51istalol ............................................................................99itraconazole ........................................................29JAKAFI .....................................................................40jantoven .....................................................................18JANUMET ...........................................................24JANUMET XR ..............................................24JANUVIA ..............................................................25jencycla ......................................................................58JENTADUETO .............................................24jinteli ..............................................................................81jolessa ..........................................................................57jolivette ......................................................................58junel 1.5/30 ..........................................................55junel 1/20 ................................................................55junel fe 1.5/30 ..................................................55junel fe 1/20 ........................................................55JUVISYNC ..........................................................24JUXTAPID ..........................................................32KADIAN 10 MG, 130 MG, 150 MG, 200 MG, 40 MG, 70 MG.....8KALETRA ...........................................................45KALYDECO ................................................109KAPVAY ...................................................................4karigel-n ...................................................................96kariva ............................................................................54k-effervescent ....................................................94KEFLEX 750 MG.......................................53kelnor 1/35 ............................................................55KENALOG ..........................................................71KETEK ......................................................................36ketoconazole ......................................................29ketoconazole ......................................................66ketodan .......................................................................66ketoprofen ..................................................................6ketoprofen er .........................................................6ketorolac tromethamine ........................6KINERET ..................................................................5kionex ...........................................................................50klor-con .....................................................................94klor-con 10 ...........................................................94klor-con 20 meq..............................................94klor-con m15 .....................................................94klor-con m20 .....................................................94

klor-con/ef .............................................................94KOMBIGLYZE XR ..............................24kp ferrous gluconate ..............................89kp ferrous sulfate ........................................89kp folic acid .........................................................87KRISTALOSE ...............................................91k-tabs .............................................................................94kurvelo ........................................................................55KUVAN ...................................................................80k-vescent ..................................................................94labetalol hcl ........................................................50laclotion ....................................................................73lactic acid ...............................................................73lactic acid e .........................................................73lactic acid-vitamin e ..............................73lactulose ...................................................................91LAMICTAL 2 MG....................................20LAMICTAL ODT ....................................20LAMISIL ................................................................29lamivudine .............................................................46lamivudine-zidovudine .......................45lamotrigine ...........................................................20lamotrigine er ..................................................20LANCET DEVICE .................................92lansoprazole 15 mg...............................112lansoprazole 30 mg...............................112LANTUS .................................................................26LANTUS SOLOSTAR .....................26LASTACAFT ..............................................103latanoprost .......................................................103latrix ...............................................................................73LATUDA ...............................................................43lavoclen-4 creamy wash ..................64lavoclen-8 creamy wash ..................64LAZANDA 100 MCG/ACT...........8leena ...............................................................................57leflunomide ..............................................................7lessina ..........................................................................55LETAIRIS .............................................................53letrozole ....................................................................39leucovorin calcium ...................................41LEUKERAN .....................................................38levalbuterol hcl ..............................................17LEVATOL ...........................................................50LEVEMIR .............................................................26LEVEMIR FLEXPEN ........................26levetiracetam .....................................................20levetiracetam er ............................................20levobunolol hcl ...............................................99levocarnitine ......................................................80levocetirizine dihydrochloride ..................................................................................................30levofloxacin .........................................................82

levofloxacin .....................................................100levonest ......................................................................57levonorgest-eth estrad 91-day ..................................................................................................57levonorgestrel ..................................................58levonorgestrel-ethinyl estrad ..................................................................................................55levora 0.15/30 (28) ..................................55levorphanol tartrate ...................................9levothyroxine sodium ........................110LEXIVA ..................................................................45lidocaine ..................................................................74lidocaine hcl .......................................................74lidocaine hcl .......................................................95lidocaine viscous .........................................95lidocaine-collagen-aloe vera ..................................................................................................76lidocaine-hydrocortisone ace ..................................................................................................12lidocaine-hydrocortisone ace 2-2 %, 3-1 %, 3-2.5 %.......................................12lidocaine-prilocaine ...............................74LIDODERM ......................................................74lindane ........................................................................76LINZESS ................................................................84liothyronine sodium ............................110LIPOFEN ...............................................................31lisinopril ...................................................................32lisinopril-hydrochlorothiazide ..................................................................................................34lithium carbonate .......................................42lithium carbonate .......................................43lithium carbonate er ..............................43lithium citrate ...................................................43LIVALO ..................................................................32LO LOESTRIN FE ..................................54LOCOID ..................................................................71LOCOID LIPOCREAM ..................71LODOSYN ..........................................................41lokara ...........................................................................71lomotil ..........................................................................27loperamide hcl ................................................27lorazepam ..............................................................14loryna ...........................................................................55LORZONE 375 MG................................97losartan potassium ...................................33losartan potassium-hctz ....................34LOTEMAX .....................................................102LOTRONEX .....................................................84lovastatin .................................................................32LOVAZA ...............................................................31low-ogestrel ........................................................55loxapine succinate ....................................44

126

LTA 360 KIT ...................................................95LUFYLLIN 200 MG..............................18lugols .............................................................................45LUMIGAN 0.01 %................................103LUNESTA ............................................................90lutera .............................................................................55LYRICA ..................................................................20LYRICA 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG...........................................................................20LYRICA 300 MG........................................20LYSODREN ......................................................38lyza ...................................................................................59mafenide acetate ..........................................68MAGNEBIND 400 .................................94malathion ................................................................76maprotiline hcl ...............................................22margesic .......................................................................7marlissa .....................................................................55MARPLAN .........................................................22marten-tab .................................................................8MATULANE ...................................................40matzim la .................................................................51MAXAIR AUTOHALER .............17meclofenamate sodium ...........................6medroxyprogesterone acetate ..................................................................................................58medroxyprogesterone acetate ..............................................................................................106mefenamic acid ..................................................6mefloquine hcl .................................................37megestrol acetate ........................................39megestrol acetate 40 mg/ml..........39meloxicam ..................................................................6melpaque hp .......................................................75melquin 3 ................................................................75melquin hp ............................................................75MENEST ................................................................82MENTAX ..............................................................65meperidine hcl ....................................................9MEPHYTON ................................................117meprobamate ....................................................14MEPRON ...............................................................36mercaptopurine .............................................38mesalamine ..........................................................83MESNEX ...............................................................41MESTINON .......................................................37metadate er ..............................................................4metaproterenol sulfate ........................17metaxalone ...........................................................97metformin hcl ....................................................25metformin hcl er ...........................................25metformin hcl er (osm) .......................25

methadone hcl .....................................................9methadose ..................................................................9methamphetamine hcl ..............................3methazolamide ................................................77methenamine hippurate ................113methenamine mandelate 0.5 gm....................................................................................113methimazole ....................................................110METHITEST ....................................................12methocarbamol ..............................................97methotrexate ......................................................38methscopolamine bromide ........112methyclothiazide ..........................................78methyldopa ...........................................................33methyldopa-hydrochlorothiazide ..................................................................................................34methylergonovine maleate ........105methylphenidate hcl ....................................4methylphenidate hcl er ...........................4methylphenidate hcl er (cd) ............4methylphenidate hcl er (la) 20 mg, 30 mg, 40 mg.............................................4methylprednisolone .................................59methylprednisolone (pak) ..............59methyltest-est estrogens ....................81methyltest-est estrogens hs ..........81metipranolol .......................................................99metoclopramide hcl ................................83metolazone ............................................................78metoprolol succinate er ....................50metoprolol tartrate ...................................50metoprolol-hydrochlorothiazide ..................................................................................................34METROGEL .....................................................75metronidazole ..................................................35metronidazole ..................................................75metronidazole ..............................................116metronidazole 0.75 %............................75mexar wash ..........................................................67mexiletine hcl ....................................................15MICARDIS .........................................................33MICARDIS HCT .......................................34miconazole 3 combo pack .........116miconazole nitrate ................................116microgestin 1.5/30 ....................................56microgestin 1/20 ..........................................56microgestin fe 1.5/30 ............................56microgestin fe 1/20 ..................................56midazolam hcl .................................................90midodrine hcl ................................................117MILLIPRED ......................................................59MILLIPRED DP .........................................59mimvey ........................................................................81

minitran .....................................................................13MINIVELLE 0.1 MG/24HR......82minocycline hcl ..........................................109minocycline hcl er .................................109minocycline-acne care products ..............................................................................................109minoxidil ..................................................................35MIRAPEX ER ................................................42mirtazapine ..........................................................21misoprostol ......................................................112M-M-R II ............................................................115modafinil ......................................................................4moexipril hcl ......................................................32moexipril-hydrochlorothiazide ..................................................................................................34mometasone furoate ...............................71monoject flush syr/hep lock 100 unit/ml............................................................................19monoject flush syringe ........................95mono-linyah ........................................................56mononessa .............................................................56montelukast sodium ................................16MONUROL ....................................................113morgidox ..............................................................109morgidox 2 x 100 mg..........................109morphine sulfate ..............................................9morphine sulfate (concentrate) 20 mg/ml........................................................................9morphine sulfate er ......................................9morphine sulfate er 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg................................................................................................9morphine sulfate er beads .................9MOTOFEN ..........................................................27MOVIPREP ........................................................91MOXATAG ...................................................105MOXEZA ..........................................................100mst 600 ...........................................................................8MULTAQ ..............................................................15multi-vitamin/fluoride ..........................96mupirocin ...............................................................65mupirocin calcium ....................................65MUSE ..........................................................................52my way ........................................................................58MYCOBUTIN ................................................37mycophenolate mofetil ........................49mydral ..........................................................................99myferon 150 ........................................................89MYFORTIC .......................................................49mykidz iron 10 .................................................89MYLERAN .........................................................38myorisan ..................................................................64myoxin .....................................................................104

127

MYRBETRIQ .............................................114myzilra ........................................................................57nabumetone .............................................................6n-acetyl-l-cysteine .....................................99nadolol ........................................................................50nadolol-bendroflumethiazide ..................................................................................................34NAFTIN 2 %......................................................65NALFON 400 MG.........................................6naltrexone hcl ..................................................28NAMENDA ...................................................106NAMENDA TITRATION PAK ..............................................................................................107NAPRELAN 750 MG...............................6naproxen ......................................................................6naproxen dr .............................................................6naproxen sodium 275 mg, 550 mg................................................................................................6naratriptan hcl ................................................93NASONEX ..........................................................98NATACYN .....................................................101NATAZIA .............................................................57nateglinide ............................................................27NATROBA ..........................................................76nature-throid 130 mg, 16.25 mg, 195 mg, 32.5 mg, 65 mg.................110NEBUPENT ......................................................35necon 0.5/35 (28) ........................................56necon 1/35 (28) ..............................................56necon 1/50 (28) ..............................................56necon 10/11 (28) ..........................................54necon 7/7/7 ...........................................................57nefazodone hcl ................................................22neomycin sulfate ..............................................4neomycin-bacitracin zn-polymyx ..............................................................................................101neomycin-polymyxin b gu ..............85neomycin-polymyxin-dexameth ..............................................................................................102neomycin-polymyxin-gramicidin ..............................................................................................101neomycin-polymyxin-hc ................102neomycin-polymyxin-hc ................104neo-polycin ......................................................101neo-polycin hc .............................................102NEULASTA ......................................................87NEUMEGA ........................................................87NEUPOGEN 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML........................................................87NEUPRO ................................................................42NEVANAC .....................................................103nevirapine ..............................................................46

NEXAVAR .........................................................39NEXIUM ............................................................112next choice one dose ..............................58niacin 500 mg................................................117niacin er 1000 mg....................................117niacinamide-zn-cu-methylfolate ..................................................................................................97niacor ...........................................................................32NIASPAN ..............................................................32nicardipine hcl ................................................51NICAZEL ..............................................................96NICOTROL ....................................................108NICOTROL NS ........................................109nifediac cc .............................................................51nifedical xl ............................................................51nifedipine ................................................................51nifedipine er ........................................................51nifedipine er osmotic 30 mg, 90 mg........................................................................................51NILANDRON .................................................39nimodipine ............................................................51nisoldipine er 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg............................................................................52NITRO-BID .......................................................13NITRO-DUR 0.3 MG/HR, 0.8 MG/HR........................................................................13nitrofurantoin ...............................................113nitrofurantoin macrocrystal ..............................................................................................114nitrofurantoin monohyd macro ..............................................................................................114nitroglycerin ......................................................13nitroglycerin er ..............................................14NITROLINGUAL ....................................14NITROSTAT ....................................................14nizatidine .............................................................112nora-be .......................................................................59NORDITROPIN FLEXPRO ..................................................................................................79NORDITROPIN NORDIFLEX PEN 30 MG/3ML........................................79norethindrone ..................................................59norethindrone acetate .....................106norethin-eth estradiol-fe ..................56norgestimate-eth estradiol ............56norgestim-eth estrad triphasic ..................................................................................................57normal saline flush ..................................95NOROXIN ...........................................................82NORPACE CR 100 MG...................14nortrel 0.5/35 (28) ....................................56nortrel 1/35 (21) ..........................................56

nortrel 1/35 (28) ..........................................56nortrel 7/7/7 ........................................................57nortriptyline hcl ............................................23NORVIR ..................................................................45NORVIR ..................................................................46novaferrum pediatric drops ........89NOVAREL ..........................................................78novolin 70/30 ....................................................26novolin 70/30 relion ...............................26novolin n ..................................................................26novolin n relion .............................................26novolin r relion ..............................................26NOVOLOG .........................................................26NOVOLOG FLEXPEN ....................27NOVOLOG MIX 70/30 ...................27NOVOLOG MIX 70/30 FLEXPEN .............................................................27NOVOLOG PENFILL .......................27NOXAFIL .............................................................29NUCYNTA .............................................................9NUCYNTA ER .................................................9NUEDEXTA .................................................108nufol ................................................................................88nu-iron ........................................................................89nulev ...........................................................................111nuquin hp ................................................................75NUTROPIN 10 MG.................................79NUTROPIN AQ NUSPIN 10 ..................................................................................................79NUTROPIN AQ NUSPIN 20 ..................................................................................................79NUTROPIN AQ NUSPIN 5 .....79NUTROPIN AQ PEN .........................79NUVARING ......................................................58NUVIGIL 150 MG........................................4nyamyc ........................................................................65nystatin .......................................................................29nystatin .......................................................................65nystatin .......................................................................95nystatin-triamcinolone .......................65nystop ...........................................................................65ocella .............................................................................56OCUDOX ..........................................................109ofloxacin ..................................................................82ofloxacin ..............................................................100ofloxacin ..............................................................104ogestrel ......................................................................56olanzapine .............................................................44olanzapine-fluoxetine hcl ...........107OLUX-E ..................................................................71omeprazole .......................................................112omeprazole-sodium bicarbonate 20-1100 mg........................................................113

128

omeprazole-sodium bicarbonate 40-1100 mg........................................................113OMNITROPE ..................................................79ondansetron ........................................................28ondansetron hcl ............................................28ONGLYZA ..........................................................25ONSOLIS 1200 MCG..............................9OPANA ER ............................................................9OPIUM ......................................................................27ORACEA ...............................................................75ORACIT ..................................................................84oralone .......................................................................96ORAP .......................................................................108ORAPRED ODT 10 MG..................59ORENCIA .................................................................7ORFADIN .............................................................80orphenadrine citrate er .....................97orphenadrine-aspirin-caffeine ..................................................................................................97orsythia ......................................................................56ORTHO EVRA .............................................58oscimin ...................................................................111oscimin sr ...........................................................111oscion cleanser 6 %..................................64OSMOPREP ......................................................91oticin ..........................................................................104otomar .....................................................................104otomax-hc ..........................................................104otozin .........................................................................104OVACE PLUS ...............................................67oxandrolone ........................................................11oxaprozin ....................................................................6oxazepam ................................................................14oxcarbazepine ..................................................20OXISTAT ..............................................................66OXSORALEN ................................................75OXSORALEN ULTRA ...................67oxybutynin chloride ............................114oxybutynin chloride er ....................114oxycodone hcl ......................................................9oxycodone-acetaminophen ..........11oxycodone-aspirin .....................................11oxycodone-ibuprofen ............................11OXYCONTIN .....................................................9oxymorphone hcl .............................................9oxymorphone hcl er ....................................9OXYTROL ......................................................114pacerone ..................................................................15PANRETIN .........................................................66pantoprazole sodium .........................112parcaine ................................................................101PAREGORIC ...................................................27paromomycin sulfate .................................4

paroxetine hcl ..................................................23paroxetine hcl er ..........................................23paroxetine mesylate ................................23PASER .......................................................................37PATADAY ......................................................103PATANASE ......................................................98PATANOL .......................................................103PAXIL .........................................................................23PCE 500 MG.......................................................92PEDIADERM HC ....................................71PEDIADERM TA .....................................71pedi-dri ......................................................................65PEDIPIROX-4 NAIL ...........................65PEDVAX HIB ............................................115peg 3350/electrolytes ............................91peg 3350-kcl-na bicarb-nacl .....91peg 3350-kcl-nabcb-nacl-nasulf ..................................................................................................91peg-3350/electrolytes ...........................91PEGANONE .....................................................21PEGASYS .............................................................47PEGASYS PROCLICK 135 MCG/0.5ML........................................................47PEG-INTRON ................................................47PEG-INTRON REDIPEN ............47PEN NEEDLES 3/16" ........................93penicillin v potassium ......................105PENLAC .................................................................66pentamidine isethionate ....................35PENTASA ............................................................83pentazocine-acetaminophen ......11pentazocine-naloxone ..........................11pentazocine-naloxone hcl ..............11pentetate calcium trisodium .......28pentetate zinc trisodium ...................28pentoxifylline er ............................................86PERFOROMIST .........................................17perindopril erbumine ............................32perio med ................................................................96periogard ................................................................95permethrin .............................................................76perphenazine .....................................................44perphenazine-amitriptyline .....107PERTZYE .............................................................76phenadoz 12.5 mg........................................30phenazo ......................................................................85phenazopyridine hcl ...............................85phenazopyridine-butabarb-hyosc ..............................................................................................114phendimetrazine tartrate ....................3phendimetrazine tartrate er ............3phenelzine sulfate .......................................22phenobarbital ...................................................90

phenyleph-promethazine-cod ..................................................................................................61phenylephrine hcl ...................................101phenylephrine-chlorphen-dm ..................................................................................................61phenylephrine-chlorphen-dm 1.75-0.75-2.75 mg/ml.............................61phenylephrine-guaifenesin ...........60phenytoin .................................................................21phenytoin infatabs .....................................21phenytoin sodium extended .........21philith ...........................................................................56phos-flur ...................................................................96PHOSLYRA ......................................................84phospha 250 neutral ..............................94phosphasal ........................................................113PHOSPHOLINE IODIDE ............99physiolyte ................................................................49physiosol irrigation .................................49PICATO ...................................................................66pilocarpine hcl ................................................96pilocarpine hcl 1 %, 2 %, 4 %........................................................................................100PILOPINE HS ............................................100pindolol ......................................................................50pioglitazone hcl .............................................26pioglitazone hcl-glimepiride .....24pioglitazone hcl-metformin hcl ..................................................................................................25pirmella 1/35 .....................................................56pirmella 7/7/7 ...................................................57piroxicam ....................................................................6PNEUMOVAX 23 ...............................115podocon .....................................................................74podofilox ..................................................................74polycin b ...............................................................101poly-dex .................................................................102polyethylene glycol 3350 ................91poly-iron 150 forte ...................................88polymyxin b-trimethoprim ........101polysaccharide iron complex ..................................................................................................89POMALYST .....................................................39portia-28 ..................................................................56pot & sod cit-cit ac ..................................84pot bicarb-pot chloride ......................94POTABA ............................................................117potassium bicarbonate .......................94potassium chloride ...................................94potassium chloride 40 meq/15ml (20%)..............................................................................94potassium chloride crys er ...........94potassium chloride er ..........................95

129

potassium citrate er ................................84potassium citrate-citric acid ......84POTIGA ...................................................................20PRADAXA ..........................................................19pramcort ..................................................................72pramipexole dihydrochloride ..................................................................................................42PRAMOSONE ...............................................72PRAMOSONE E ........................................72pramox ........................................................................74pramoxine-hc ....................................................72pramoxine-hc-chloroxylenol aq ..............................................................................................104PRANDIMET ..................................................24PRANDIN .............................................................27prascion ....................................................................62prascion fc ............................................................62prascion ra ...........................................................62pravastatin sodium ...................................32prazosin hcl .........................................................33PRED MILD .................................................102PRED-G ...............................................................102PRED-G S.O.P. .........................................102prednicarbate ...................................................71prednisolone ......................................................59prednisolone acetate .........................102prednisolone sodium phosphate ..................................................................................................59prednisolone sodium phosphate ..............................................................................................103PREDNISONE ..............................................59prednisone (pak) ..........................................59PREDNISONE INTENSOL .....60PREGNYL ...........................................................78PREMARIN .......................................................82PREMPHASE .................................................81PREMPRO ...........................................................81PREPOPIK ..........................................................91prevalite ....................................................................31previfem ....................................................................56PREVPAC ........................................................113PREZISTA ...........................................................46PREZISTA 150 MG, 400 MG, 600 MG, 800 MG........................................46PREZISTA 75 MG....................................46PRIFTIN ..................................................................37PRIMAQUINE PHOSPHATE ..................................................................................................37primidone ...............................................................20PRIMSOL ..............................................................35PRISTIQ ..................................................................23PROAIR HFA .................................................17probenecid ............................................................86

prochlorperazine .........................................44prochlorperazine maleate .............44PROCRIT ..............................................................87PROCTOFOAM HC ............................12proctosol hc ........................................................13proctozone-hc ..................................................13profe ...............................................................................89proferrin es ..........................................................89progesterone micronized ............106PROGLYCEM ...............................................25PROMACTA ....................................................88promethazine hcl .........................................30promethazine vc ............................................60promethazine vc/codeine ................61promethazine-codeine .........................61promethazine-dm ........................................60promethazine-phenylephrine ..................................................................................................60promethegan ......................................................30propafenone hcl ............................................15propafenone hcl er ...................................15propantheline bromide ...................112proparacaine hcl .....................................101propranolol hcl ..............................................50propranolol hcl er .....................................50propranolol-hctz ..........................................34propylthiouracil ........................................110PROQUAD ......................................................115PROSTIGMIN ...............................................37PROTOPIC ..........................................................74protriptyline hcl ............................................23PROVENTIL HFA ..................................17PRUDOXIN .......................................................67pseudoephedrine-dm-gg 30-15-150 mg/5ml.......................................60PULMICORT 1 MG/2ML.............16PULMICORT FLEXHALER ..................................................................................................17PYLERA .............................................................113pyrazinamide .....................................................37pyridostigmine bromide ....................37pyrogallic acid ................................................74QNASL ......................................................................98quasense ...................................................................57quetiapine fumarate ................................43QUILLIVANT XR ......................................4quinapril hcl .......................................................32quinapril-hydrochlorothiazide ..................................................................................................34quinidine gluconate er ........................14quinidine sulfate ...........................................14quinidine sulfate er ..................................15quinine sulfate .................................................37

QVAR ..........................................................................17ramipril ......................................................................32RANEXA ...............................................................13ranitidine hcl .................................................112ranitidine hcl 150 mg/10ml, 75 mg/5ml......................................................................112ranitidine hcl 300 mg.........................112RAPAFLO ............................................................85RAPAMUNE ...................................................49RAYOS 1 MG..................................................60REBETOL ............................................................47REBIF ......................................................................107REBIF REBIDOSE TITRATION PACK ..........................107REBIF TITRATION PACK ..............................................................................................107reclipsen ...................................................................56RECTIV ...................................................................13REFISSA ................................................................64REGRANEX .....................................................76RELENZA DISKHALER ............48RELISTOR ..........................................................84RELPAX .................................................................93remergent hq .....................................................75remeven .....................................................................72RENAGEL ...........................................................84RENOVA ...............................................................64RENOVA PUMP .......................................64RENVELA ...........................................................84repan ..................................................................................8reprexain 10-200 mg...............................10rescon-jr 4-20 mg........................................60RESCRIPTOR ................................................46reserpine ..................................................................33respa-br .....................................................................30RESTASIS .......................................................101revina ............................................................................73REVLIMID 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG....................................49REVLIMID 20 MG..................................49REYATAZ 150 MG, 200 MG, 300 MG.......................................................................46REZIRA ...................................................................61RHEUMATREX .............................................5RHINOCORT AQUA ........................98rhinoflex-650 .........................................................8RIBAPAK .............................................................47RIBASPHERE ...............................................47RIBATAB .............................................................47ribavirin ....................................................................47ribavirin ....................................................................48RIDAURA ................................................................5RIFAMATE .......................................................37

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rifampin .....................................................................37RIFATER ...............................................................37right step prenatal .....................................96RILUTEK ..............................................................98rimantadine hcl .............................................48RIOMET ..................................................................25risperidone ...........................................................43risperidone m-tab 2 mg, 4 mg........................................................................................43rivastigmine tartrate ..........................106rizatriptan benzoate ................................93romycin ..................................................................100ropinirole hcl ....................................................42ropinirole hcl er ...........................................42rosadan ......................................................................75rosanil cleanser ............................................62ROTARIX .........................................................115ROTATEQ .......................................................115roxicet 5-325 mg............................................11ROZEREM ..........................................................90SABRIL ....................................................................20SABRIL ....................................................................21SAFYRAL ............................................................56SAIZEN ....................................................................79SAIZEN CLICK.EASY ...................79salacyn ........................................................................74salicylic acid ......................................................74salicylic acid in ammon lact ......74salicylic acid wart remover ........74salsalate ........................................................................8salvax ............................................................................74SAMSCA ...............................................................81SANCUSO ...........................................................28SANDIMMUNE .........................................49SANTYL .................................................................73SAPHRIS ...............................................................43SAVELLA ........................................................107scalacort ..................................................................71selegiline hcl ......................................................42selenium sulfide ............................................67selenium sulf-pyrithione-urea ..................................................................................................67SELZENTRY ..................................................45se-natal 19 ............................................................96SENSIPAR ..........................................................80SEREVENT DISKUS ........................18SEROMYCIN .................................................38serophene ...............................................................78SEROQUEL XR .........................................43sertraline hcl .....................................................23sf ...........................................................................................96SIGNIFOR ...........................................................81sildenafil citrate ............................................53

SILENOR ..............................................................90silver nitrate .......................................................68silver nitrate-pot nitrate ...................68silver sulfadiazine ......................................68SIMCOR ..................................................................31SIMPONI 50 MG/0.5ML....................5simvastatin ............................................................32SKELID ....................................................................78SKLICE ....................................................................76slow release iron 50 mg.....................89sod citrate-citric acid ...........................84sodium chloride ............................................61sodium chloride ............................................75sodium chloride 0.9 %..........................61sodium chloride 0.9 %..........................85sodium chloride 10 %, 3 %, 7 %............................................................................................61sodium fluoride ..............................................93sodium fluoride ..............................................94sodium polystyrene sulfonate ..................................................................................................50SOLARAZE ......................................................66solia .................................................................................56SOLODYN 55 MG...............................110SOLTAMOX ....................................................39sorbitol .......................................................................85SORIATANE 10 MG, 17.5 MG, 25 MG...........................................................................67sorine ............................................................................51sotalol hcl ...............................................................51spinosad ....................................................................76SPIRIVA HANDIHALER ...........15spironolactone ................................................77spironolactone-hctz .................................77SPORANOX .....................................................29sprintec 28 ............................................................56SPRIX ..............................................................................7SPRYCEL .............................................................40sronyx ...........................................................................56ssd ......................................................................................68stagesic ......................................................................10STALEVO 100 ..............................................42STALEVO 125 ..............................................42STALEVO 150 ..............................................42STALEVO 200 ..............................................42STALEVO 50 ..................................................42STALEVO 75 ..................................................42stannous fluoride ........................................96stavudine ..................................................................46STAVZOR 125 MG................................21STELARA ............................................................67sterile water for irrigation ............50STIVARGA ........................................................40

STRATTERA ......................................................4STRIBILD ............................................................45STROMECTOL ...........................................13SUBOXONE .....................................................11SUBSYS 100 MCG......................................9sucralfate ............................................................112sulfacetamide sodium ...........................62sulfacetamide sodium ...........................68sulfacetamide sodium .......................101sulfacetamide sodium 10 %..........68sulfacetamide sodium-sulfur .....63sulfacetamide sodium-sulfur 10-5 %...........................................................................62sulfacetamide sodium-urea 10 %............................................................................................67sulfacetamide-prednisolone ..............................................................................................102sulfacetamide-sulfur in urea ......63sulfacetamide-sulfur-cleanser ..................................................................................................63sulfacetamide-sulfur-sunscreen ..................................................................................................63sulfacet-sulfur wash &cleanser ..................................................................................................62sulfadiazine ......................................................109sulfamethoxazole-tmp ds .................36sulfamethoxazole-trimethoprim ..................................................................................................36SULFAMYLON ..........................................68sulfasalazine ......................................................83sulfazine ....................................................................83sulfazine ec ...........................................................83sulindac .........................................................................7sumatriptan ..........................................................93sumatriptan succinate .........................93SUMAVEL DOSEPRO ...................93SUPRAX .................................................................54SUPREP BOWEL PREP ...............91SURE COMFORT LANCING PEN .................................................................................92SUSTIVA ..............................................................46SUTENT ..................................................................40syeda ..............................................................................56SYLATRON 296 MCG, 444 MCG, 888 MCG............................................41symax duotab ................................................111symax fastabs ................................................111symax-sl ................................................................111symax-sr ...............................................................111SYMBICORT ..................................................17SYMLINPEN 120 ....................................24SYMLINPEN 60 ........................................24synalar ........................................................................71

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SYNERA ................................................................74SYPRINE ...............................................................48TABLOID .............................................................38TACLONEX .....................................................72tacrolimus ..............................................................49TAMIFLU 30 MG......................................48TAMIFLU 45 MG, 75 MG...........48TAMIFLU 6 MG/ML............................48tamoxifen citrate ..........................................39tamsulosin hcl ..................................................85tandem f ....................................................................88TARCEVA ..........................................................40TARGRETIN ...................................................41TARGRETIN ...................................................67TARKA .....................................................................33taron-prex ..............................................................96TASIGNA .............................................................40TASMAR 100 MG....................................41TAZORAC ..........................................................67taztia xt .......................................................................52TEGRETOL-XR 100 MG..............20TEKAMLO .........................................................34TEKTURNA .....................................................35TEKTURNA HCT ...................................35temazepam ............................................................90TEMODAR .........................................................38tencon ...............................................................................8TENIVAC .........................................................110terazosin hcl .......................................................33terbinafine hcl .................................................29TERBINEX .........................................................29terbutaline sulfate ......................................18terconazole .......................................................116testosterone cypionate ........................12testosterone enanthate ........................12tetanus toxoid adsorbed ...............110tetracaine hcl ................................................101tetracycline hcl ...........................................110tetravisc .................................................................101tetravisc forte ................................................101TEV-TROPIN .................................................80TEXACORT ......................................................71tgq 15dm/5peh/2cpm .............................61tgq 30pse/150gfn/15dm .....................60THALOMID ......................................................48THEO-24 100 MG.....................................18theochron ................................................................18theophylline .........................................................18theophylline er ................................................18thermazene ...........................................................68thioridazine hcl ..............................................44thiothixene .............................................................44THYROLAR-1 ..........................................110

THYROLAR-1/2 ....................................110THYROLAR-1/4 ....................................110THYROLAR-2 ..........................................110THYROLAR-3 ..........................................110tiagabine hcl ......................................................21ticlopidine hcl ..................................................86TIKOSYN .............................................................15tilia fe ............................................................................57timolol hemihydrate ................................99timolol maleate ..............................................51timolol maleate ..............................................99tinidazole .................................................................35tizanidine hcl .....................................................97tl gard rx ..................................................................88TOBI ..................................................................................5TOBRADEX .................................................102TOBRADEX ST .....................................102tobramycin sulfate ................................100tobramycin-dexamethasone ..............................................................................................102TOBREX ............................................................100tolazamide .............................................................27tolbutamide ..........................................................27tolmetin sodium .................................................7tolterodine tartrate ...............................114topiragen .................................................................20topiramate .............................................................20torsemide .................................................................77TOVIAZ ..............................................................114TRACLEER .......................................................53TRADJENTA ..................................................25tramadol hcl ...........................................................9tramadol hcl er ..............................................10tramadol hcl er (biphasic) 100 mg........................................................................................10tramadol-acetaminophen ...............11trandolapril .........................................................33tranexamic acid ............................................89TRANSDERM-SCOP ........................28tranylcypromine sulfate ....................22TRAVATAN Z .........................................104travoprost ...........................................................104trazodone hcl ....................................................22TRECATOR ......................................................38tretinoin .....................................................................41tretinoin .....................................................................64tretinoin microsphere 0.04 %............................................................................................64TRETIN-X 0.0375 %.............................64TREXALL ............................................................38TREXIMET ........................................................93trezix ..............................................................................10triamcinolone & emollient ...........71

triamcinolone acetonide ..................71triamcinolone acetonide ..................96triamcinolone acetonide ..................98triamterene-hctz ...........................................77triamterene-hctz 37.5-25 mg.......77trianex ..........................................................................71triazolam ..................................................................90TRIBENZOR ...................................................34tricitrates .................................................................85triderm ........................................................................71tri-estarylla ..........................................................57trifluoperazine hcl .....................................44trifluridine .........................................................101trihexyphenidyl hcl ...................................41tri-legest fe ............................................................58tri-linyah ..................................................................58TRILIPIX ...............................................................31trilyte .............................................................................91trimethobenzamide hcl .......................28trimethoprim ......................................................35trimipramine maleate ...........................24trinessa (28) ........................................................58tri-previfem ..........................................................58tri-sprintec ............................................................58tri-vitamin/fluoride ..................................96trivora (28) ...........................................................58TRI-ZEL ..................................................................96TRIZIVIR ..............................................................45tropicamide ..........................................................99trospium chloride ...................................114trospium chloride er ..........................114TRUVADA .........................................................45TUDORZA PRESSAIR ...................15TUSSICAPS ......................................................61tussigon ......................................................................60TWINRIX ..........................................................115TWYNSTA .........................................................34TYKERB ................................................................40TYVASO ................................................................53TYZEKA ................................................................47TYZINE ...................................................................98u-cort .............................................................................72u-kera e ......................................................................72ULESFIA ...............................................................76ULORIC ..................................................................86ULTRAVATE PAC 0.05 & 12 % (CREAM)........................................................72ULTRESA ............................................................76umecta mousse ................................................72unithroid ..............................................................110unithroid direct ..........................................110uramaxin ..................................................................73urea ..................................................................................72

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urea ..................................................................................73urea 39 %, 40 %, 45 %, 50 %............................................................................................72urea 40 %, 45 %............................................72urea in lactic ac-salicylic ac .....73urea in zn undecyl-lactic acid 45 %............................................................................................73urea nail ...................................................................73urea nail 45 %..................................................72urea nail film .....................................................72urelief plus ........................................................114uretron d/s .........................................................113UROCIT-K 15 ................................................85ursodiol ......................................................................82ustell ...........................................................................113uta ..................................................................................113uticap ........................................................................113utira-c ......................................................................113utrona-c .................................................................113VAGIFEM 10 MCG............................116valacyclovir hcl .............................................48VALCYTE ...........................................................47valproate sodium ........................................21valproic acid ......................................................21valsartan-hydrochlorothiazide ..................................................................................................34vancomycin hcl ..............................................35vandazole ............................................................116VANOS .....................................................................71VAQTA ................................................................115VARIVAX .......................................................116VASCEPA ............................................................31vasolex ........................................................................73VECTICAL .........................................................67velivet ...........................................................................58VELTIN ...................................................................63venlafaxine hcl ................................................23venlafaxine hcl er .......................................23VENTAVIS ........................................................53VENTOLIN HFA ......................................18VERAMYST ....................................................98verapamil hcl ....................................................52verapamil hcl er ...........................................52verapamil hcl er (co) ............................52VERDESO ...........................................................71VEREGEN ...........................................................64versiclear ................................................................65VESICARE .....................................................114vestura .........................................................................56VEXOL .................................................................103VFEND ......................................................................29VIBRAMYCIN .........................................110VICODIN 5-300 MG.............................10

VICODIN ES 7.5-300 MG............10VICODIN HP 10-300 MG.............10VICTOZA .............................................................26VICTRELIS .......................................................48VIDEX 2 GM....................................................46VIGAMOX ......................................................101VIIBRYD ...............................................................22VIMOVO ...................................................................6VIMPAT ..................................................................20VIOKACE ............................................................77viorele ..........................................................................54VIRACEPT .........................................................46VIRAMUNE .....................................................46VIRAMUNE XR ........................................46VIRAZOLE ........................................................48VIREAD ..................................................................47VISICOL .................................................................91vitamin d (ergocalciferol) ..........117vitamin d3 1000 unit, 400 unit..................................................................................117VIVELLE-DOT ...........................................82VIVOTIF BERNA VACCINE ..............................................................................................115VOLTAREN .....................................................66voriconazole .......................................................29VOTRIENT ........................................................40VYTORIN ............................................................31VYVANSE ..............................................................3warfarin sodium ...........................................18water for irrigation, sterile ..........50WELCHOL .........................................................31wera ................................................................................56westhroid 130 mg, 32.5 mg, 65 mg....................................................................................110wymzya fe ...............................................................56XALKORI ............................................................40XARELTO ...........................................................18XELJANZ .................................................................5XELODA ...............................................................38XENAZINE ....................................................107XIFAXAN ............................................................35XOLEGEL ...........................................................66XOPENEX HFA .........................................18XTANDI ..................................................................39x-viate ..........................................................................72XYREM ...............................................................106YODOXIN ...............................................................4zaclir cleansing 8 %.................................64zafirlukast ..............................................................16zaleplon .....................................................................90zarah ..............................................................................56ZAVESCA ...........................................................87zazole ........................................................................116

zebutal .............................................................................8ZEGERID ..........................................................113ZELBORAF .......................................................39ZEMPLAR ...........................................................80zenchent ....................................................................56zenchent fe ............................................................56zencia ............................................................................63ZENPEP ...................................................................77ZETIA .........................................................................32ZETONNA ..........................................................98zflex ......................................................................................8zgesic .................................................................................8ZIANA .......................................................................63zidovudine ..............................................................47zinc sulfate ............................................................95ZIOPTAN ..........................................................104ziprasidone hcl ...............................................43ZIRGAN ..............................................................101ZITHROMAX ................................................91ZOLINZA ..............................................................39zolpidem tartrate .........................................90zolpidem tartrate er ................................90ZOMIG ......................................................................93ZOMIG ZMT ...................................................93ZONALON ..........................................................67zonisamide ............................................................20ZORBTIVE .........................................................80ZORTRESS ........................................................49ZOSTAVAX .................................................116zovia 1/35e (28) ............................................57zovia 1/50e (28) ............................................57ZOVIRAX ............................................................68ZUPLENZ .............................................................28ZUTRIPRO .........................................................61ZYCLARA ..........................................................73ZYFLO ......................................................................15ZYFLO CR ..........................................................16ZYLET ...................................................................102ZYMAXID ......................................................101ZYTIGA ..................................................................38ZYVOX ....................................................................36

Regence BlueShield Essential Formulary

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