State of Illinois Employees Group Formulary€¦ · A formulary is a list of prescribed medications...

State of Illinois Employees Group Formulary

Updated August 1, 2020

For the most current list of covered medications or if you have questions, call the Customer Service number on the back of your ID card or visit YourHealthAllliance.org.

On YourHealthAlliance.org, you can also:

• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

State of Illinois Employees

2

Understanding your formulary

What is a formulary?A formulary is a list of prescribed medications chosen by your plan for their safety, cost and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. The formulary includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

About this formulary Where differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details.

How do I use my formulary?You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand name, and if special rules apply. Bring this list with you when you see your doctor. If you have questions on how your medication is covered, call the Customer Service number on the back of your ID card or visit YourHealthAlliance.org.

What are tiers?Tiers are the different cost levels you pay for a medication. Generally, the higher your medication’s tier, the more you’ll pay out of pocket for it.

When does the formulary change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equivalent becomes available.

• Medications may move to a higher tier or be excluded from coverage during the year as other formulary alternatives become available.

When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?You (or your authorized representative) and your doctor can ask for a coverage request by calling the Customer Service number on the back of your ID card.

3

Medication tips

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. If you choose a brand-name medication after a generic version is available, you may pay the generic copayment plus the cost difference between the brand-name and generic medication. These medications will have a comment saying “Brand penalty applies” in the notes section.

Over-the-counter (OTC) medicationsAn OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option.

4

Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier InformationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost.

Drug Tier Drug Tier Description Helpful Tips

Preventive Brands and generics used for preventive care No out-of-pocket cost. Deductible does not apply

Tier 1Reduced GenericsGenerics

Select low cost genericsMost generic drugs

Tier 2Preferred brandsPreferred specialty**

Many brands have lower-cost generic options

Tier 3Non-preferred brandsNon-preferred specialty**

Specialty products may be limited to a specialty pharmacy

General Medical Medical benefit Provided and administered in a doctor’s office or

hospital and not covered by the pharmacy benefit

Drug list InformationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AL Age Limit – Based on government or manufacturer guidelines, these medications are only covered for certain age groups.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

PV* Preventive* – These medications may be covered as preventive care if you meet the guidelines based on your plan.

QL Quantity Limit – Medication may be limited to a certain quantity.

RG Reduced Generic

ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

** LGHP and CIP plans have a separate copay tier for specialty medications (Tier 4).

Table of Contents

Analgesics - Drugs for Pain ...........................8Analgesics - Drugs for Pain and

Inflammation .................................................6Anesthetics ................................................... 15Anti-Addiction / Substance Abuse

Treatment Agents .......................................20Antibacterials ................................................21Anticoagulants ..............................................32Anticonvulsants - Drugs for Seizures ........ 34Antidementia Agents - Drugs for

Alzheimer's Disease and Dementia .......... 39Antidepressants ........................................... 40Antiemetics - Drugs for Nausea and

Vomiting ......................................................43Antifungals ....................................................44Antigout Agents ............................................48Anti-inflammatory Agents ............................48Antimigraine Agents .................................... 48Antimyasthenic Agents ................................50Antimycobacterials ...................................... 51Antineoplastics - Drugs for Cancer ............ 52Antiparasitics ................................................66Antiparkinson Agents .................................. 67Antiplatelets ..................................................69Antipsychotics - Drugs for Mood

Disorders .....................................................69Antivirals ....................................................... 72Anxiolytics - Drugs for Anxiety ................... 78Bipolar Agents - Drugs for Mood

Disorders .....................................................79Blood Products / Modifiers / Volume

Expanders - Drugs for Bleeding Disorders 80

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ....................... 85

Central Nervous System Agents - Drugs for Attention Deficit Disorder .................101

Central Nervous System Agents - Drugs for Multiple Sclerosis ...............................104

Central Nervous System Agents - Miscellaneous ...........................................106

Dental and Oral Agents - Drugs for Mouth and Throat Conditions .............................107

Dermatological Agents - Drugs for Skin Conditions .................................................109

Diabetes - Antidiabetic Agents ..................118Diabetes - Glucose Monitoring ..................122Diabetes - Glycemic Agents ...................... 122Diabetes - Insulins ......................................122Electrolytes / Minerals / Metals / Vitamins126

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer .......................................140

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

......................................................................142Genetic or Enzyme Disorder - Drugs for

Replacement, Modification, Treatment .. 146Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions ...............149Genitourinary Agents - Drugs for Prostate

Conditions .................................................152Hormonal Agents - Adrenal ....................... 153Hormonal Agents - Men's Health .............. 155Hormonal Agents - Osteoporosis ............. 156Hormonal Agents - Pituitary ...................... 156Hormonal Agents - Prostaglandins .......... 160Hormonal Agents - Sex Hormones and

Birth Control ............................................. 160Hormonal Agents - Thyroid ....................... 170Immunological Agents - Drugs for

Immune System Stimulation or Suppression ..............................................171

Immunological Agents - Drugs for Vaccination ............................................... 178

Inflammatory Bowel Disease Agents ........181Metabolic Bone Disease Agents - Drugs

for Osteoporosis ...................................... 183Metabolic Bone Disease Agents - Other .. 184Miscellaneous Therapeutic Agents .......... 184Ophthalmic Agents - Drugs for Eye

Allergy, Infection and Inflammation ....... 198Ophthalmic Agents - Drugs for Glaucoma......................................................................200Ophthalmic Agents - Drugs for

Miscellaneous Eye Conditions ................202Otic Agents - Drugs for Ear Conditions ... 206Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold ............207Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions .................................................209

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ........................ 214

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ........215

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm .......................... 216

Sleep Disorder Agents ............................... 217Index of Drugs.............................................. 219

5

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ACTIVE-KETOPROFEN EXTERNAL CREAM 5 %

3

adult aspirin regimen oral tablet delayed release 81 mg

PV

ANJESO INTRAVENOUS INJECTABLE 30 MG/ML

GM

ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 75-0.2 MG

3Brand

penalty applies

aspirin adult low strength oral tablet delayed release 81 mg

PV

aspirin childrens oral tablet chewable 81 mg

PV

aspirin ec low dose oral tablet delayed release 81 mg

PV

aspirin ec low strength oral tablet delayed release 81 mg

PV

aspirin ec oral tablet delayed release 81 mg

PV

aspirin low dose oral tablet chewable 81 mg

PV

aspirin low dose oral tablet delayed release 81 mg

PV

aspirin oral tablet delayed release 81 mg

PV

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG

3

CALDOLOR INTRAVENOUS SOLUTION 800 MG/8ML

GM

Drug NameDrug Tier

Notes

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG

3Brand

penalty applies

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

1

DAYPRO ORAL TABLET 600 MG

3Brand

penalty applies

DICLOFENAC EPOLAMINE TRANSDERMAL PATCH 1.3 %

3 ST

diclofenac potassium oral tablet 50 mg

1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

1

diclofenac sodium oral tablet delayed release 25 mg

1

diclofenac sodium oral tablet delayed release 50 mg, 75 mg

RG

diclofenac sodium transdermal gel 1 %

1

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg

1

DICLOSTREAM EXTERNAL THERAPY PACK 1.5-10 %

3

diflunisal oral tablet 500 mg

1

DIMENTHO EXTERNAL THERAPY PACK 1.5 & 10 %

3

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG

3Brand

penalty applies


PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria, RG = Reduced Generic

6

Drug NameDrug Tier

Notes

ec-naproxen oral tablet delayed release 375 mg, 500 mg

1

ENOVARX-IBUPROFEN EXTERNAL CREAM 10 %

3

EQUAPAX/IBUPROFEN/MINREX ORAL THERAPY PACK 800 MG

3

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

1

etodolac oral capsule 200 mg, 300 mg

1

etodolac oral tablet 400 mg, 500 mg

1

FBL KIT EXTERNAL CREAM 15-4-5 %

3

FELDENE ORAL CAPSULE 10 MG, 20 MG

3Brand

penalty applies

fenoprofen calcium oral capsule 200 mg, 400 mg

1

fenoprofen calcium oral tablet 600 mg

1

fenortho oral capsule 200 mg

1

FLECTOR TRANSDERMAL PATCH 1.3 %

3 ST

flurbiprofen oral tablet 100 mg, 50 mg

1

goodsense aspirin low dose oral tablet delayed release 81 mg

PV

ibu oral tablet 400 mg, 600 mg, 800 mg

1

ibuprofen lysine intravenous solution 10 mg/ml

GM

Drug NameDrug Tier

Notes

ibuprofen oral suspension 100 mg/5ml

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN ORAL SUSPENSION 25 MG/5ML

3

INDOCIN RECTAL SUPPOSITORY 50 MG

2

indomethacin er oral capsule extended release 75 mg

1

indomethacin oral capsule 25 mg, 50 mg

1

indomethacin sodium intravenous solution reconstituted 1 mg

GM

ketoprofen er oral capsule extended release 24 hour 200 mg

1

ketoprofen oral capsule 25 mg, 50 mg, 75 mg

1

ketorolac tromethamine oral tablet 10 mg

1QL (20 EA

per 30 days)

KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 60-150-60 MG/50ML

GM

KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 15-100-30 MG/50ML

GM

LIDOPROFEN EXTERNAL CREAM 5-5-2 %

3

LODINE ORAL TABLET 400 MG

3Brand

penalty applies



7

Drug NameDrug Tier

Notes

meclofenamate sodium oral capsule 100 mg, 50 mg

1

mefenamic acid oral capsule 250 mg

1

meloxicam oral tablet 15 mg, 7.5 mg

RG

MOBIC ORAL TABLET 15 MG, 7.5 MG

3Brand

penalty applies

nabumetone oral tablet 500 mg, 750 mg

1

NALFON ORAL CAPSULE 400 MG

3Brand

penalty applies

NALFON ORAL TABLET 600 MG

3Brand

penalty applies

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

3Brand

penalty applies

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

3

NAPRO EXTERNAL CREAM 15 %

3

NAPROSYN ORAL SUSPENSION 125 MG/5ML

3Brand

penalty applies

naproxen dr oral tablet delayed release 375 mg, 500 mg

1

naproxen oral suspension 125 mg/5ml

1

naproxen oral tablet 250 mg, 375 mg, 500 mg

1

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

1

Drug NameDrug Tier

Notes

naproxen sodium oral tablet 275 mg, 550 mg

1

NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML

GM

oxaprozin oral tablet 600 mg

1

piroxicam oral capsule 10 mg, 20 mg

1

qc aspirin low dose oral tablet delayed release 81 mg

PV

salsalate oral tablet 500 mg, 750 mg

1

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG

3

sulindac oral tablet 150 mg, 200 mg

1

tolmetin sodium oral capsule 400 mg

1

tolmetin sodium oral tablet 600 mg

1

VOLTAREN TRANSDERMAL GEL 1 %

3Brand

penalty applies

VOPAC KT EXTERNAL CREAM 5-5-2 %

3

Analgesics - Drugs for Pain

7T GUMMY ES ORAL TABLET CHEWABLE 500 MG

3

acetaminophen-codeine #2 oral tablet 300-15 mg

1


1


1



8

Drug NameDrug Tier

Notes

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

1

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

1

ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3PA; Brand

penalty applies

alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml

GM

apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

1

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG

3 PA

ascomp-codeine oral capsule 50-325-40-30 mg

1

BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

3QL (60 EA

per 30 days)

BUPAP ORAL TABLET 50-300 MG

3Brand

penalty applies

BUPRENEX INJECTION SOLUTION 0.3 MG/ML

GM

buprenorphine hcl injection solution 0.3 mg/ml

GM

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr

1

Drug NameDrug Tier

Notes

butalbital-acetaminophen capsule 50-300 mg oral 50-300 mg

1

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 50-300 MG

1

butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg

1

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

1

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

1

butalbital-apap-caffeine oral tablet 50-325-40 mg

1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

1

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

1

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

1

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

GM

butorphanol tartrate nasal solution 10 mg/ml

1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR

3Brand

penalty applies

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

1

clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 mcg/ml

3Specialty Medical



9

Drug NameDrug Tier

Notes

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

1

DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/ML, 50 MG/ML, 75 MG/ML

GM

DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML

GM

DILAUDID ORAL LIQUID 1 MG/ML

3Brand

penalty applies

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG

3Brand

penalty applies

DOLOPHINE ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG

3

DURACLON EPIDURAL SOLUTION 100 MCG/ML

3Specialty Medical

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR

3PA; Brand

penalty applies


3PA; Brand

penalty applies


3PA; Brand

penalty applies


3PA; Brand

penalty applies


3PA; Brand

penalty applies

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

GM

Drug NameDrug Tier

Notes

duraxin oral capsule 300-200-20 mg

1

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

3 PA

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

ESGIC ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

ESGIC ORAL TABLET 50-325-40 MG

3Brand

penalty applies

fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

GM

fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml

GM

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

1 PA

FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

FENTANYL CITRATE INJECTION SOLUTION 1500 MCG/30ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION 5000 MCG/100ML

GM



10

Drug NameDrug Tier

Notes

FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1500 MCG/30ML, 250 MCG/5ML, 2750 MCG/55ML

GM

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2-0.9 MG/100ML-%, 2.5-0.9 MG/250ML-%

GM

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 5-0.9 MCG/ML-%, 550-0.9 MCG/55ML-%

GM

FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.3-0.2-0.9 MG/150ML-%

GM

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr

1 PA

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625-0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%

GM

Drug NameDrug Tier

Notes

FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2-0.125-0.9 MCG/ML-%-%

GM

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

FIORICET ORAL CAPSULE 50-300-40 MG

3Brand

penalty applies

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG

3Brand

penalty applies

FIORINAL ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 MG

3Brand

penalty applies

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

1 PA

hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1

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

1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

1

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

1 PA



11

Drug NameDrug Tier

Notes

hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml

GM

hydromorphone hcl oral liquid 1 mg/ml

1

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg

1

hydromorphone hcl pf injection solution 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 50 mg/5ml, 500 mg/50ml

GM

hydromorphone hcl rectal suppository 3 mg

1

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION 1 MG/ML

GM

hydromorphone hcl solution 1 mg/ml injection 1 mg/ml

GM

HYDROMORPHONE HCL-NACL INJECTION SOLUTION 20-0.9 MG/100ML-%

GM

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 30-0.9 MG/30ML-%

GM

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 2-0.9 MG/ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-%

GM

Drug NameDrug Tier

Notes

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

3 PA

INFUMORPH 200 INJECTION SOLUTION 200 MG/20ML (10 MG/ML)

GM

INFUMORPH 500 INJECTION SOLUTION 500 MG/20ML (25 MG/ML)

GM

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

3PA; Brand

penalty applies

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG

3 PA

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

3 PA

levorphanol tartrate oral tablet 2 mg, 3 mg

1

lorcet hd oral tablet 10-325 mg

1

lorcet oral tablet 5-325 mg

1

LORTAB ORAL ELIXIR 10-300 MG/15ML

3

MEDI-DERM-RX EXTERNAL CREAM 0.035-5-20 %

3

MEDROX-RX EXTERNAL OINTMENT 0.05-7-20 %

3



12

Drug NameDrug Tier

Notes

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

GM

meperidine hcl oral solution 50 mg/5ml

1

meperidine hcl oral tablet 100 mg, 50 mg

1

methadone hcl injection solution 10 mg/ml

GM

methadone hcl intensol oral concentrate 10 mg/ml

1

methadone hcl oral concentrate 10 mg/ml

1

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

1

methadone hcl oral tablet 10 mg, 5 mg

1

methadone hcl oral tablet soluble 40 mg

1

METHADOSE ORAL CONCENTRATE 10 MG/ML

3Brand

penalty applies

methadose oral tablet soluble 40 mg

1

METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML

3Brand

penalty applies

mitigo injection solution 200 mg/20ml (10 mg/ml), 500 mg/20ml (25 mg/ml)

GM

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

GM

Drug NameDrug Tier

Notes

morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

GM

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

1 PA

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

1 PA

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

1 PA

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

GM

morphine sulfate injection solution 2 mg/ml, 4 mg/ml

GM

morphine sulfate intramuscular device 10 mg/0.7ml

GM

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

GM

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

1

morphine sulfate oral tablet 15 mg, 30 mg

1

morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

1

MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS 1 MG/ML

GM



13

Drug NameDrug Tier

Notes

morphine sulfate solution 1 mg/ml intravenous 1 mg/ml

GM

MORPHINE SULFATE-NACL INJECTION SOLUTION PREFILLED SYRINGE 5-0.9 MG/5ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%, 500-0.9 MG/100ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 150-0.9 MG/30ML-%, 2-0.9 MG/ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 55-0.9 MG/55ML-%

GM

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

3PA; Brand

penalty applies

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

GM

NALOCET ORAL TABLET 2.5-300 MG

3

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

3Brand

penalty applies

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG

3 PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

3 ST

Drug NameDrug Tier

Notes

OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG

3 PA

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 PA

oxycodone hcl oral capsule 5 mg

1

oxycodone hcl oral concentrate 100 mg/5ml

1

oxycodone hcl oral solution 5 mg/5ml

1

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

1

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

1

oxycodone-aspirin oral tablet 4.8355-325 mg

1

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 PA

oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

1 PA

oxymorphone hcl oral tablet 10 mg, 5 mg

1

pentazocine-naloxone hcl oral tablet 50-0.5 mg

1



14

Drug NameDrug Tier

Notes

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

3Brand

penalty applies

PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 MCG/20ML, 500 MCG/5ML

GM

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

3

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG

2

PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

3

remifentanil hcl intravenous solution reconstituted 1 mg, 2 mg, 5 mg

GM

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG

3Brand

penalty applies

SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml

GM

tencon oral tablet 50-325 mg

1

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

1 ST

tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

1 ST

Drug NameDrug Tier

Notes

tramadol hcl oral tablet 100 mg, 50 mg

1

tramadol-acetaminophen oral tablet 37.5-325 mg

1

TREZIX ORAL CAPSULE 320.5-30-16 MG

3Brand

penalty applies

ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG

GM

ULTRACET ORAL TABLET 37.5-325 MG

3Brand

penalty applies

ULTRAM ORAL TABLET 50 MG

3Brand

penalty applies

VANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML

3

VANATOL S ORAL SOLUTION 50-325-40 MG/15ML

3

VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML

3

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG

3 PA

ZEBUTAL ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

3PA; Brand

penalty applies

Anesthetics

1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %

3



15

Drug NameDrug Tier

Notes

7T LIDO EXTERNAL GEL 2 %

3

AGONEAZE EXTERNAL KIT 2.5-2.5 %

3

ANODYNE LPT EXTERNAL KIT 2.5-2.5 %

3

ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 mg/ml

GM

bupivacaine hcl (pf) injection solution 0.25 %, 0.5 %, 0.75 %

GM

bupivacaine hcl injection solution 0.25 %, 0.5 %

GM

BUPIVACAINE HCL INJECTION SOLUTION 312.5 MG/10ML

GM

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML), 125 MG/4ML, 250 MG/8ML, 312.5 MG/10ML, 625 MG/20ML

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.25-0.9 %

GM

bupivacaine in dextrose intrathecal solution 0.75-8.25 %

GM

bupivacaine spinal intrathecal solution 0.75-8.25 %

GM

bupivacaine-epinephrine (pf) injection solution 0.25% -1:200000, 0.5% -1:200000

GM

Drug NameDrug Tier

Notes

bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

CARBOCAINE INJECTION SOLUTION 1 %, 2 %

GM

CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 1 %, 1.5 %, 2 %

GM

CETACAINE EXTERNAL AEROSOL 2-2-14 %

GM

chloroprocaine hcl (pf) injection solution 2 %, 3 %

GM

CITANEST FORTE DENTAL INJECTION SOLUTION 4% -1:200000

GM

CITANEST PLAIN DENTAL INJECTION SOLUTION 4 %

GM

CLOROTEKAL INTRATHECAL SOLUTION 50 MG/5ML

GM

COCAINE HCL NASAL SOLUTION 40 MG/ML

GM

c-topical external solution 4 %

1

DERMACINRX EMPRICAINE EXTERNAL KIT 2.5-2.5 %

3

DERMACINRX PRIZOPAK EXTERNAL KIT 2.5-2.5 %

3

ethyl chloride external aerosol

1

EXPAREL INJECTION SUSPENSION 1.3 %

GM

FLEXIN EXTERNAL PATCH 0.0375-5 %

3



16

Drug NameDrug Tier

Notes

glydo external prefilled syringe 2 %

1

GOPRELTO NASAL SOLUTION 40 MG/ML

GM

LETS KIT 3

LEVATIO EXTERNAL PATCH 0.03-5 %

3

LIDO BDK EXTERNAL KIT 2.5-2.5 %

3

lidocaine external ointment 5 %

1QL (50 GM

per 30 days)

lidocaine external patch 5 %

1

lidocaine hcl (cardiac) intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (cardiac) pf intravenous solution 100 mg/5ml

GM

lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 %

GM

lidocaine hcl external cream 3 %

1

lidocaine hcl external lotion 3 %

1

lidocaine hcl external solution 4 %

1

lidocaine hcl injection solution 0.5 %

GM

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML

GM

Drug NameDrug Tier

Notes

LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG

3

LIDOCAINE HCL SOLUTION 1 % INJECTION 1 %

GM

lidocaine hcl solution 1 % injection 1 %

GM

LIDOCAINE HCL SOLUTION 2 % INJECTION 2 %

GM

lidocaine hcl solution 2 % injection 2 %

GM

lidocaine hcl urethral/mucosal external gel 2 %

1

lidocaine hcl urethral/mucosal external prefilled syringe 2 %

1

lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%

GM

LIDOCAINE IN DEXTROSE SOLUTION 5-7.5 %

GM

lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1:100000, 1.5 %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 %-1:50000

GM

lidocaine-prilocaine external cream 2.5-2.5 %

1

lidocaine-prilocaine external kit 2.5-2.5 %

1

LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 %

3

LIDODERM EXTERNAL PATCH 5 %

3Brand

penalty applies



17

Drug NameDrug Tier

Notes

LIDO-EPINEPHRINE-TETRACAINE EXTERNAL SOLUTION 4-0.05-0.5 %

GM

lidopin external cream 3 %

1

LIDOPRIL EXTERNAL KIT 2.5-2.5 %

3

LIDOPRIL XR EXTERNAL KIT 2.5-2.5 %

3

LIDO-PRILO CAINE PACK EXTERNAL KIT 2.5-2.5 %

3

LIDO-SORB EXTERNAL LOTION 3 %

3

LIVIXIL PAK EXTERNAL KIT 2.5-2.5 %

3

MARCAINE INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 %

GM

MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 0.25 %, 0.5 %

GM

MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 %

GM

MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MEDI-DERM/L-RX EXTERNAL CREAM 2-0.035-5-20 %

3

Drug NameDrug Tier

Notes

MEDI-PATCH RX EXTERNAL PATCH 0.5-0.035-5-20 %

3

NAROPIN INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 5 MG/ML, 7.5 MG/ML

GM

NESACAINE INJECTION SOLUTION 1 %, 2 %

GM

NESACAINE-MPF INJECTION SOLUTION 2 %, 3 %

GM

NUMBRINO NASAL SOLUTION 40 MG/ML

GM

NUVAKAAN EXTERNAL KIT 2.5-2.5 %

3

ORABLOC INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

PAINGO KFT EXTERNAL KIT 2.5-2.5-10-30 %

GM

PLIAGLIS EXTERNAL CREAM 7-7 %

3

polocaine injection solution 1 %, 2 %

GM

polocaine-mpf injection solution 1 %, 1.5 %, 2 %

GM

premium lidocaine external ointment 5 %

1QL (50 GM

per 30 days)

PRILOLID EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX LITE EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX LITE PLUS EXTERNAL KIT 2.5-2.5 %

3



18

Drug NameDrug Tier

Notes

PRILOVIX PLUS EXTERNAL KIT 2.5-2.5 %

3

prilovix ultralite external kit 2.5-2.5 %

1

prilovix ultralite plus external kit 2.5-2.5 %

1

RECK SOLUTION PREFILLED SYRINGE 123-0.25-0.04- 15 MG/50ML

GM

RELADOR PAK EXTERNAL KIT 2.5-2.5 %

3

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 %

3

RENOVO EXTERNAL PATCH 0.0375-5 %

3

ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml

GM

ROPIVACAINE HCL INJECTION SOLUTION 33.4 MG/ML

GM

ROPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.2 %, 0.5 %

GM

ROPIVACAINE HCL SOLUTION 2 MG/ML INJECTION 2 MG/ML

GM

ropivacaine hcl solution 2 mg/ml injection 2 mg/ml

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 %

GM

ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED SYRINGE 123-0.04-15 MG/50ML

GM

Drug NameDrug Tier

Notes

sensorcaine injection solution 0.25 %, 0.5 %

GM

sensorcaine/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

sensorcaine-mpf injection solution 0.25 %, 0.5 %, 0.75 %

GM

sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %

GM

SYNERA EXTERNAL PATCH 70-70 MG

GM

SYNVEXIA TC EXTERNAL CREAM 4-1 %

3

VEXATROL EXTERNAL KIT 2.5-2.5 %

3

xylocaine dental injection solution 2 %-1:100000, 2 %-1:50000

GM

XYLOCAINE INJECTION SOLUTION 0.5 %, 1 %, 2 %

GM

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %-1:200000, 1 %-1:100000, 2 %-1:100000

GM

XYLOCAINE-MPF INJECTION SOLUTION 0.5 %, 1 %, 1.5 %, 2 %

GM



19

Drug NameDrug Tier

Notes

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000

GM

ZERUVIA EXTERNAL PATCH 4-1 %

3

ZINGO INTRADERMAL JET-INJECTOR 0.5 MG

3

ZIONODIL 100 EXTERNAL LOTION 3 %

3

ZIONODIL EXTERNAL LOTION 3 %

3

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium oral tablet delayed release 333 mg

RG

ANTABUSE ORAL TABLET 250 MG, 500 MG

2Brand

penalty applies

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG

2

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

RG

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

RG

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

RG

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

PV

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

PV

Drug NameDrug Tier

Notes

CHANTIX ORAL TABLET 0.5 MG, 1 MG

PV

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

PV

disulfiram oral tablet 250 mg, 500 mg

RG

goodsense nicotine mouth/throat gum 2 mg, 4 mg

PV

LUCEMYRA ORAL TABLET 0.18 MG

2QL (224

EA per 14 days)

naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml

RG

naloxone hcl injection solution cartridge 0.4 mg/ml

RG

naloxone hcl injection solution prefilled syringe 2 mg/2ml

RG

naltrexone hcl oral tablet 50 mg

RG

NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG

2

NARCAN NASAL LIQUID 4 MG/0.1ML

2

NICORETTE MOUTH/THROAT GUM 2 MG

PV

nicotine polacrilex mouth/throat gum 2 mg, 4 mg

PV

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

PV

nicotine step 1 transdermal patch 24 hour 21 mg/24hr

PV



20

Drug NameDrug Tier

Notes


PV


PV

NICOTROL INHALATION INHALER 10 MG

PV

NICOTROL NS NASAL SOLUTION 10 MG/ML

PV

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML

2

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

2

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

2

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

2

Antibacterials

AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG

3QL (12 EA

per 30 days)

ALTABAX EXTERNAL OINTMENT 1 %

3 ST

amoxicillin oral capsule 250 mg, 500 mg

1

Drug NameDrug Tier

Notes

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

RG

amoxicillin oral tablet 500 mg

1

amoxicillin oral tablet 875 mg

RG

amoxicillin oral tablet chewable 125 mg, 250 mg

1

amoxicillin-potassium clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

1

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

1

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

1

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

1

ampicillin oral capsule 500 mg

RG

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg

GM

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

GM

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

GM



21

Drug NameDrug Tier

Notes

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

GM

ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML

3PA;

Specialty Pharmacy

AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 600-42.9 MG/5ML

3Brand

penalty applies

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

3

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

3Brand

penalty applies

AUGMENTIN ORAL TABLET 500-125 MG

3Brand

penalty applies

avidoxy oral tablet 100 mg

1

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM

GM

AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

azithromycin intravenous solution reconstituted 500 mg

GM

azithromycin oral packet 1 gm

1

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

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

1

Drug NameDrug Tier

Notes

aztreonam injection solution reconstituted 1 gm, 2 gm

GM

baciim intramuscular solution reconstituted 50000 unit

GM

bacitracin intramuscular solution reconstituted 50000 unit

GM

BACTRIM DS ORAL TABLET 800-160 MG

3Brand

penalty applies

BACTRIM ORAL TABLET 400-80 MG

3Brand

penalty applies

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

2Specialty Medical

BAXDELA ORAL TABLET 450 MG

2Specialty Pharmacy

benzalkonium chloride external solution , 50 %

1

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

GM

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

GM

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

GM

cefaclor er oral tablet extended release 12 hour 500 mg

1

cefaclor oral capsule 250 mg, 500 mg

1



22

Drug NameDrug Tier

Notes

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

1

cefadroxil oral capsule 500 mg

1

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

1

cefadroxil oral tablet 1 gm

1

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 GM/100ML-%, 3-0.9 GM/100ML-%

GM

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 300 gm, 500 mg

GM

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 GM/10ML, 2 GM/20ML

GM

cefazolin sodium intravenous solution reconstituted 1 gm

GM

cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-%

GM

cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml)

GM

cefdinir oral capsule 300 mg

1

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

1

Drug NameDrug Tier

Notes

cefditoren pivoxil oral tablet 200 mg, 400 mg

1

cefepime hcl injection solution reconstituted 1 gm, 2 gm

GM

cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml

GM

cefepime-dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

cefixime oral capsule 400 mg

1

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

1

CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

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

GM

cefotetan disodium injection solution reconstituted 1 gm, 2 gm

GM

cefotetan disodium-dextrose intravenous solution reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml)

GM

cefoxitin sodium injection solution reconstituted 10 gm

GM

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

GM



23

Drug NameDrug Tier

Notes

CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML)

GM

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

1

cefpodoxime proxetil oral tablet 100 mg, 200 mg

1

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

1

cefprozil oral tablet 250 mg, 500 mg

1

ceftazidime and dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

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

GM

ceftriaxone sodium in dextrose intravenous solution 20 mg/ml, 40 mg/ml

GM

ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, 2 gm, 250 mg, 500 mg

GM

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

GM

ceftriaxone sodium-dextrose intravenous solution reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml)

GM

Drug NameDrug Tier

Notes

cefuroxime axetil oral tablet 250 mg, 500 mg

1

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

GM

cefuroxime sodium intravenous solution reconstituted 1.5 gm

GM

CENTANY AT EXTERNAL KIT 2 %

2

cephalexin oral capsule 250 mg, 500 mg

RG

cephalexin oral capsule 750 mg

1

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

1

cephalexin oral tablet 250 mg, 500 mg

1

chloramphenicol sod succinate intravenous solution reconstituted 1 gm

GM

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)

2

CIPRO ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

ciprofloxacin hcl oral tablet 100 mg, 750 mg

1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

RG

ciprofloxacin in d5w intravenous solution 200 mg/100ml, 400 mg/200ml

GM

clarithromycin er oral tablet extended release 24 hour 500 mg

1



24

Drug NameDrug Tier

Notes

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

1

clarithromycin oral tablet 250 mg, 500 mg

1

CLEOCIN ORAL CAPSULE 150 MG, 300 MG

3Brand

penalty applies

CLEOCIN ORAL CAPSULE 75 MG

2Brand

penalty applies

CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML

3Brand

penalty applies

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML

GM

CLEOCIN VAGINAL CREAM 2 %

3Brand

penalty applies

CLEOCIN VAGINAL SUPPOSITORY 100 MG

2

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

1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

1

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

GM

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

GM

clindamycin phosphate vaginal cream 2 %

1

Drug NameDrug Tier

Notes

CLINDESSE VAGINAL CREAM 2 %

3

colistimethate sodium (cba) injection solution reconstituted 150 mg

GM

COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 MG

GM

CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

3Specialty Medical

daptomycin intravenous solution reconstituted 350 mg, 500 mg

GM

demeclocycline hcl oral tablet 150 mg, 300 mg

1

dicloxacillin sodium oral capsule 250 mg, 500 mg

1

DIFICID ORAL TABLET 200 MG

3 ST

doxy 100 intravenous solution reconstituted 100 mg

GM

doxycycline hyclate intravenous solution reconstituted 100 mg

GM

doxycycline hyclate oral capsule 100 mg, 50 mg

1

doxycycline hyclate oral tablet 100 mg, 20 mg

1



25

Drug NameDrug Tier

Notes

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg

1

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

1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

1

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

1

E.E.S. 400 ORAL TABLET 400 MG

3

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

2Brand

penalty applies

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

2Brand

penalty applies

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

2Brand

penalty applies

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

3Brand

penalty applies

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ERYTHROCIN STEARATE ORAL TABLET 250 MG

3

erythromycin base oral capsule delayed release particles 250 mg

1

Drug NameDrug Tier

Notes

erythromycin base oral tablet 250 mg, 500 mg

1

erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg

1

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

1

erythromycin ethylsuccinate oral tablet 400 mg

1

erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg

1

FETROJA INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

3Specialty Medical

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML

3

FLAGYL ORAL CAPSULE 375 MG

3Brand

penalty applies

FLAGYL ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%

GM

gentamicin sulfate external cream 0.1 %

1

gentamicin sulfate external ointment 0.1 %

1

gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml

GM



26

Drug NameDrug Tier

Notes

HIPREX ORAL TABLET 1 GM

3Brand

penalty applies

hydrogen peroxide solution 30 %

1

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

GM

iodine tincture external tincture 2 %

1

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG

3Brand

penalty applies

levofloxacin in d5w intravenous solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml

GM

levofloxacin intravenous solution 25 mg/ml

GM

levofloxacin oral solution 25 mg/ml

1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

1

LINCOCIN INJECTION SOLUTION 300 MG/ML

GM

lincomycin hcl injection solution 300 mg/ml

GM

linezolid in sodium chloride intravenous solution 600-0.9 mg/300ml-%

2Specialty Medical

linezolid intravenous solution 600 mg/300ml

2Specialty Medical

linezolid oral suspension reconstituted 100 mg/5ml

2

Specialty Pharmacy;

QL (900 ML per 30

days)

Drug NameDrug Tier

Notes

linezolid oral tablet 600 mg

2

Specialty Pharmacy; QL (60 EA

per 30 days)

MACROBID ORAL CAPSULE 100 MG

3Brand

penalty applies

MACRODANTIN ORAL CAPSULE 100 MG, 50 MG

3Brand

penalty applies

MACRODANTIN ORAL CAPSULE 25 MG

2Brand

penalty applies

mafenide acetate external packet 5 %

1

meropenem intravenous solution reconstituted 1 gm, 500 mg

GM

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, 500 MG/50ML

GM

MERREM INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 500 MG

GM

methenamine hippurate oral tablet 1 gm

1

methenamine mandelate oral tablet 0.5 gm, 1 gm

1

metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-%

GM

metronidazole oral capsule 375 mg

1

metronidazole oral tablet 250 mg, 500 mg

1



27

Drug NameDrug Tier

Notes

metronidazole vaginal gel 0.75 %

1

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

GM

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

1

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

1

mondoxyne nl oral capsule 100 mg, 75 mg

1

MONUROL ORAL PACKET 3 GM

3

morgidox oral capsule 100 mg

1

moxifloxacin hcl in nacl intravenous solution 400 mg/250ml

GM

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 MG/250ML

GM

moxifloxacin hcl oral tablet 400 mg

1

mupirocin external ointment 2 %

1

NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/100ML

GM

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

GM

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

GM

Drug NameDrug Tier

Notes

neomycin sulfate oral tablet 500 mg

1

neomycin-polymyxin b gu irrigation solution 40-200000

1

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

1

nitrofurantoin monohydrate macrocrystals oral capsule 100 mg

1

nitrofurantoin oral suspension 25 mg/5ml

1

NUTRIDOX ORAL KIT 75 MG

3

NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3Specialty Medical

NUZYRA ORAL TABLET 150 MG

3


per 14 days)

ofloxacin oral tablet 300 mg, 400 mg

1

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 400 MG

2Specialty Medical

OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

oxacillin sodium injection solution reconstituted 1 gm, 2 gm

GM



28

Drug NameDrug Tier

Notes

oxacillin sodium intravenous solution reconstituted 10 gm

GM

paromomycin sulfate oral capsule 250 mg

1

PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 20000 UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML

GM

penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit

GM

penicillin g procaine intramuscular suspension 600000 unit/ml

GM

penicillin g sodium injection solution reconstituted 5000000 unit

GM

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral tablet 250 mg, 500 mg

RG

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT

GM

piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

GM

Drug NameDrug Tier

Notes

polymyxin b sulfate injection solution reconstituted 500000 unit

GM

PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 500-500 MG

GM

PRIMSOL ORAL SOLUTION 50 MG/5ML

3

RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM

3Specialty Medical

SILVADENE EXTERNAL CREAM 1 %

3Brand

penalty applies

silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %

1

silver sulfadiazine external cream 1 %

1

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

3Specialty Medical

SIVEXTRO ORAL TABLET 200 MG

3


per 30 days)

SOLOSEC ORAL PACKET 2 GM

3

ssd external cream 1 % 1

streptomycin sulfate intramuscular solution reconstituted 1 gm

GM

sulfadiazine oral tablet 500 mg

1



29

Drug NameDrug Tier

Notes

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml

GM

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

RG

SULFAMYLON EXTERNAL CREAM 85 MG/GM

3

SULFAMYLON EXTERNAL PACKET 5 %

3Brand

penalty applies

sulfatrim pediatric oral suspension 200-40 mg/5ml

1

SUPRAX ORAL CAPSULE 400 MG

3Brand

penalty applies

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3Brand

penalty applies

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

3

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

3

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

GM

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

GM

Drug NameDrug Tier

Notes

TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML

GM

tazicef intravenous solution reconstituted 1 gm, 2 gm

GM

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

GM

tetracycline hcl oral capsule 250 mg, 500 mg

1

tigecycline intravenous solution reconstituted 50 mg

GM

tinidazole oral tablet 250 mg, 500 mg

1

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml

GM

tobramycin sulfate injection solution reconstituted 1.2 gm

GM

trimethoprim oral tablet 100 mg

1

TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 3 (2-1) GM

GM

UNASYN INTRAVENOUS SOLUTION RECONSTITUTED 15 (10-5) GM

GM



30

Drug NameDrug Tier

Notes

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM

GM

VANCOCIN HCL ORAL CAPSULE 125 MG

3Brand

penalty applies

VANCOCIN ORAL CAPSULE 250 MG

3Brand

penalty applies

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%

GM

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%

GM

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%

GM

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-%

GM

VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS 750-0.9 MG/150ML-%

GM

vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous 750-0.9 mg/150ml-%

GM

Drug NameDrug Tier

Notes

VANCOMYCIN HCL INTRAVENOUS SOLUTION 1000 MG/10ML, 1250 MG/12.5ML, 1500 MG/15ML, 1750 MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML

GM

vancomycin hcl intravenous solution 1000 mg/200ml, 1500 mg/300ml, 2000 mg/400ml, 500 mg/100ml

GM

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 5 gm, 500 mg, 750 mg

GM

vancomycin hcl oral capsule 125 mg, 250 mg

1

vancomycin hcl oral solution reconstituted 250 mg/5ml

1

vandazole vaginal gel 0.75 %

1

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

GM

VIBRAMYCIN ORAL CAPSULE 100 MG

3Brand

penalty applies

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

3Brand

penalty applies

VIBRAMYCIN ORAL SYRUP 50 MG/5ML

2

XENLETA INTRAVENOUS SOLUTION 150 MG/15ML

3Specialty Medical



31

Drug NameDrug Tier

Notes

XENLETA ORAL TABLET 600 MG

3Specialty Pharmacy

XEPI EXTERNAL CREAM 1 %

3 ST

XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

2Specialty Medical

XIFAXAN ORAL TABLET 200 MG, 550 MG

2PA;

Specialty Pharmacy

ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML

3Specialty Medical

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM

GM

ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ZITHROMAX ORAL PACKET 1 GM

3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3Brand

penalty applies

ZITHROMAX ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

ZITHROMAX TRI-PAK ORAL TABLET 500 MG

3Brand

penalty applies

ZITHROMAX Z-PAK ORAL TABLET 250 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 GM/50ML, 4-0.5 GM/100ML

GM

ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 MG/300ML

2Specialty Medical

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

2

Specialty Pharmacy;

QL (900 ML per 30

days)

ZYVOX ORAL TABLET 600 MG

2


per 30 days)

Anticoagulants

ACD FORMULA A IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

3

ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

3

ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

anticoagulant cit dext soln a in vitro solution 0.8-2.45-2.2 gm/100ml

1

anticoagulant sodium citrate in vitro solution 4 gm/100ml

1



32

Drug NameDrug Tier

Notes

argatroban in sodium chloride intravenous solution 50-0.9 mg/50ml-%

GM

argatroban intravenous solution 250 mg/2.5ml, 50 mg/50ml

GM

ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML

3Brand

penalty applies

BEVYXXA ORAL CAPSULE 40 MG, 80 MG

3QL (30 EA

per 30 days)

bivalirudin trifluoroacetate intravenous solution reconstituted 250 mg

GM

BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 250-0.9 MG/50ML-%, 500-0.9 MG/100ML-%

3Specialty Medical

CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 MG

GM

DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML

GM

ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG

2

ELIQUIS ORAL TABLET 2.5 MG, 5 MG

2

enoxaparin sodium injection solution 300 mg/3ml

1

Drug NameDrug Tier

Notes

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

1

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

1

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

2

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%

GM

heparin (porcine) in nacl intravenous solution 25000-0.45 ut/500ml-%

GM

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

1

heparin sodium (porcine) injection solution prefilled syringe 5000 unit/0.5ml

GM

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

1



33

Drug NameDrug Tier

Notes

heparin sodium (porcine) pf injection solution 5000 unit/ml

GM

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

RG

LOVENOX INJECTION SOLUTION 300 MG/3ML

2Brand

penalty applies

LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML

3Brand

penalty applies

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

3

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

3 ST

SODIUM CITRATE IN VITRO SOLUTION PREFILLED SYRINGE 4 %

GM

SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION PREFILLED SYRINGE 120 MG/3ML

GM

SODIUM CITRATE-GENTAMICIN SULF INTRAVENOUS SOLUTION 4-320 %-MCG/ML

GM

THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM PA

Drug NameDrug Tier

Notes

TNKASE INTRAVENOUS KIT 50 MG

GM

TRICITRASOL IN VITRO CONCENTRATE 46.7 %

3

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

RG

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG

2

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

2

Anticonvulsants - Drugs for Seizures

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

3 ST

BANZEL ORAL SUSPENSION 40 MG/ML

3

BANZEL ORAL TABLET 200 MG, 400 MG

3

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

GM ST

BRIVIACT ORAL SOLUTION 10 MG/ML

3 ST

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

3 ST

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

1

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

1



34

Drug NameDrug Tier

Notes

carbamazepine oral suspension 100 mg/5ml

1

carbamazepine oral tablet 200 mg

1

carbamazepine oral tablet chewable 100 mg

1

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

3

CELONTIN ORAL CAPSULE 300 MG

3

CEREBYX INJECTION SOLUTION 100 MG PE/2ML, 500 MG PE/10ML

GM

clobazam oral suspension 2.5 mg/ml

1

clobazam oral tablet 10 mg, 20 mg

1

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 MG, 500 MG

3

DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 MG, 500 MG

3

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 125 MG

3

DIACOMIT ORAL CAPSULE 250 MG, 500 MG

3

DIACOMIT ORAL PACKET 250 MG, 500 MG

3

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

3

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG

3

Drug NameDrug Tier

Notes

diazepam rectal gel 10 mg, 2.5 mg, 20 mg

1

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

2

DILANTIN ORAL CAPSULE 100 MG, 30 MG

2

DILANTIN ORAL SUSPENSION 125 MG/5ML

3

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

1

divalproex sodium oral capsule delayed release sprinkle 125 mg

1

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

1

EPIDIOLEX ORAL SOLUTION 100 MG/ML

3PA;

Specialty Pharmacy

epitol oral tablet 200 mg 1

ethosuximide oral capsule 250 mg

1

ethosuximide oral solution 250 mg/5ml

1

felbamate oral suspension 600 mg/5ml

1

felbamate oral tablet 400 mg, 600 mg

1

FELBATOL ORAL SUSPENSION 600 MG/5ML

2

FELBATOL ORAL TABLET 400 MG, 600 MG

2

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml

GM



35

Drug NameDrug Tier

Notes

FYCOMPA ORAL SUSPENSION 0.5 MG/ML

3

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

3

gabapentin oral capsule 100 mg, 300 mg, 400 mg

1

gabapentin oral solution 250 mg/5ml, 300 mg/6ml

1

gabapentin oral tablet 600 mg, 800 mg

1

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG

3

KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML

GM

KEPPRA ORAL SOLUTION 100 MG/ML

3

KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG

3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

3

LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG

3

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG

3

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

3

LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG

3

Drug NameDrug Tier

Notes

LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG

3

LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG

3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

3

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

1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg

RG

lamotrigine oral tablet 25 mg

1

lamotrigine oral tablet chewable 25 mg, 5 mg

1

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

1

lamotrigine starter kit-blue oral kit 35 x 25 mg

1

lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg

1

lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

1

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

1

levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

GM



36

Drug NameDrug Tier

Notes

levetiracetam intravenous solution 500 mg/5ml

GM

levetiracetam oral solution 100 mg/ml

1

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

1

MYSOLINE ORAL TABLET 250 MG, 50 MG

3

NAYZILAM NASAL SOLUTION 5 MG/0.1ML

3

NEMBUTAL INJECTION SOLUTION 50 MG/ML

GM

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

2

NEURONTIN ORAL SOLUTION 250 MG/5ML

2

NEURONTIN ORAL TABLET 600 MG, 800 MG

2

ONFI ORAL SUSPENSION 2.5 MG/ML

3

ONFI ORAL TABLET 10 MG, 20 MG

3

oxcarbazepine oral suspension 300 mg/5ml

1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

3

PEGANONE ORAL TABLET 250 MG

3

pentobarbital sodium injection solution 50 mg/ml

GM

phenobarbital oral elixir 20 mg/5ml

1

Drug NameDrug Tier

Notes

phenobarbital oral solution 20 mg/5ml

1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

GM

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

3

phenytoin infatabs oral tablet chewable 50 mg

1

phenytoin oral suspension 125 mg/5ml

1

phenytoin oral tablet chewable 50 mg

1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium injection solution 50 mg/ml

GM

primidone oral tablet 250 mg, 50 mg

1

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

3 PA

roweepra oral tablet 1000 mg, 500 mg, 750 mg

1

roweepra xr oral tablet extended release 24 hour 500 mg, 750 mg

1

SABRIL ORAL PACKET 500 MG

3PA;

Specialty Pharmacy

SABRIL ORAL TABLET 500 MG

3PA;

Specialty Pharmacy



37

Drug NameDrug Tier

Notes

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG

3 ST

subvenite oral tablet 100 mg, 150 mg, 200 mg

RG

subvenite oral tablet 25 mg

1

subvenite starter kit-blue oral kit 35 x 25 mg

1

subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg

1

subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

1

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG

3

TEGRETOL ORAL SUSPENSION 100 MG/5ML

3

TEGRETOL ORAL TABLET 200 MG

3

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

3

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg

1

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

2

TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 MG

2

topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

1 PA

Drug NameDrug Tier

Notes

topiramate oral capsule sprinkle 15 mg, 25 mg

1

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

1

TRILEPTAL ORAL SUSPENSION 300 MG/5ML

3

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

3

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

3 PA

valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml

GM

valproic acid oral capsule 250 mg

1

valproic acid oral solution 250 mg/5ml

1

VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML

3

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK 7.5 MG/0.1ML

3

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK 10 MG/0.1ML

3

VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML

3

vigabatrin oral packet 500 mg

2PA;

Specialty Pharmacy

vigabatrin oral tablet 500 mg

2PA;

Specialty Pharmacy



38

Drug NameDrug Tier

Notes

vigadrone oral packet 500 mg

2PA;

Specialty Pharmacy

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

GM

VIMPAT ORAL SOLUTION 10 MG/ML

3

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3

ZARONTIN ORAL CAPSULE 250 MG

3

ZARONTIN ORAL SOLUTION 250 MG/5ML

3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

3

zonisamide oral capsule 100 mg, 25 mg, 50 mg

1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

ARICEPT ORAL TABLET 23 MG

2Brand

penalty applies

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg

1

donepezil hcl oral tablet dispersible 10 mg, 5 mg

1

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

2Brand

penalty applies

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

1

Drug NameDrug Tier

Notes

galantamine hydrobromide oral solution 4 mg/ml

1

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

1

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

1

memantine hcl oral solution 10 mg/5ml, 2 mg/ml

1

memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg

1

NAMENDA ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 10 MG

3Brand

penalty applies

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

3Brand

penalty applies

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

3

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG

3

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

3



39

Drug NameDrug Tier

Notes

RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG

3Brand

penalty applies

RAZADYNE ORAL TABLET 4 MG

3Brand

penalty applies

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

1

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

1

Antidepressants

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

1

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

1

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

3Brand

penalty applies

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG

3ST; QL (30 EA per 30

days)

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

1

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

1

bupropion hcl oral tablet 100 mg, 75 mg

1

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

1

citalopram hydrobromide oral solution 10 mg/5ml

1

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

RG

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

1

CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG

3Brand

penalty applies

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

1

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

3 PA

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

1 PA

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

1

doxepin hcl oral concentrate 10 mg/ml

1

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

1

EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG

3Brand

penalty applies



40

Drug NameDrug Tier

Notes

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

2

escitalopram oxalate oral solution 5 mg/5ml

1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

1

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

3 PA

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

3

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg

RG

fluoxetine hcl oral capsule delayed release 90 mg

1

fluoxetine hcl oral solution 20 mg/5ml

1

fluoxetine hcl oral tablet 10 mg, 20 mg

1

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

1

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

1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

1

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

1

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

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

1

MARPLAN ORAL TABLET 10 MG

3

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

1

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

1

NARDIL ORAL TABLET 15 MG

3Brand

penalty applies

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

NORPRAMIN ORAL TABLET 10 MG, 25 MG

3Brand

penalty applies

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1

nortriptyline hcl oral solution 10 mg/5ml

1

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

1 ST

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

3Brand

penalty applies

PARNATE ORAL TABLET 10 MG

3Brand

penalty applies

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

1

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

1



41

Drug NameDrug Tier

Notes

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG

3Brand

penalty applies

PAXIL ORAL SUSPENSION 10 MG/5ML

2

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

3Brand

penalty applies

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1

phenelzine sulfate oral tablet 15 mg

1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

3PA; Brand

penalty applies

protriptyline hcl oral tablet 10 mg, 5 mg

1

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG

3Brand

penalty applies

REMERON ORAL TABLET 15 MG, 30 MG

3Brand

penalty applies

REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG

3Brand

penalty applies

sertraline hcl oral concentrate 20 mg/ml

1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg

RG

SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

3PA;

Specialty Medical

SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG

3ST; Brand

penalty applies

tranylcypromine sulfate oral tablet 10 mg

1

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

3 PA

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

1

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

3 PA

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

3 PA

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG

3Brand

penalty applies

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

3Brand

penalty applies

ZOLOFT ORAL CONCENTRATE 20 MG/ML

3Brand

penalty applies



42

Drug NameDrug Tier

Notes

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS SOLUTION 235-0.25 MG/20ML

GM

AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG

GM

AKYNZEO ORAL CAPSULE 300-0.5 MG

3QL (3 EA

per 21 days)

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

GM

ANZEMET ORAL TABLET 100 MG, 50 MG

2

aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg

1QL (6 EA

per 30 days)

BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG

3

CINVANTI INTRAVENOUS EMULSION 130 MG/18ML

GMQL (6 ML

per 30 days)

compro rectal suppository 25 mg

1

dimenhydrinate injection solution 50 mg/ml

GM

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

1

droperidol injection solution 2.5 mg/ml

GM

Drug NameDrug Tier

Notes

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

GM PA

EMEND ORAL CAPSULE 40 MG, 80 MG

3

Brand penalty

applies; QL (6 EA per 30 days)

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

2QL (6 EA

per 30 days)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG

3

Brand penalty


fosaprepitant dimeglumine intravenous solution reconstituted 150 mg

GM PA

granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml

GM

granisetron hcl oral tablet 1 mg

1

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

meclizine hcl oral tablet 12.5 mg, 25 mg

1

metoclopramide hcl injection solution 5 mg/ml

GM

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

1

metoclopramide hcl oral tablet 10 mg, 5 mg

1

metoclopramide hcl oral tablet dispersible 10 mg, 5 mg

1



43

Drug NameDrug Tier

Notes

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

GM

ondansetron hcl oral solution 4 mg/5ml

1

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

1

ondansetron odt oral tablet dispersible 4 mg, 8 mg

1

palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 mg/5ml

GM

palonosetron hcl intravenous solution prefilled syringe 0.25 mg/5ml

GM

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

1

prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml

GM

prochlorperazine maleate oral tablet 10 mg, 5 mg

1

prochlorperazine rectal suppository 25 mg

1

REGLAN ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR

2QL (1 EA

per 30 days)

scopolamine transdermal patch 72 hour 1 mg/3days

1

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 MG/0.4ML

3

Specialty Pharmacy; QL (2 ML

per 30 days)

SYNDROS ORAL SOLUTION 5 MG/ML

3

Drug NameDrug Tier

Notes

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML

GM

TIGAN ORAL CAPSULE 300 MG

3Brand

penalty applies

TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

3Brand

penalty applies

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

3Brand

penalty applies

trimethobenzamide hcl oral capsule 300 mg

1

VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X 90 MG

3QL (2 EA

per 30 days)

ZOFRAN ORAL TABLET 4 MG, 8 MG

3Brand

penalty applies

ZUPLENZ ORAL FILM 4 MG, 8 MG

3

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

GM

ALA-QUIN EXTERNAL CREAM 3-0.5 %

3

ALCORTIN A EXTERNAL GEL 1-2-1 %

3

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

GM

amphotericin b intravenous solution reconstituted 50 mg

GM



44

Drug NameDrug Tier

Notes

ANCOBON ORAL CAPSULE 250 MG, 500 MG

3Brand

penalty applies

BIO-STATIN ORAL CAPSULE 1000000 UNIT, 500000 UNIT

3

bio-statin oral powder 1

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG

GM

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

GM

ciclodan external solution 8 %

1QL (13.2

ML per 30 days)

ciclopirox external gel 0.77 %

1

ciclopirox external shampoo 1 %

1

ciclopirox external solution 8 %

1QL (13.2

ML per 30 days)

ciclopirox olamine external cream 0.77 %

1

ciclopirox olamine external suspension 0.77 %

1

clotrimazole external cream 1 %

1

clotrimazole external solution 1 %

1

clotrimazole mouth/throat lozenge 10 mg

1

clotrimazole mouth/throat troche 10 mg

1

clotrimazole-betamethasone external cream 1-0.05 %

1

Drug NameDrug Tier

Notes

clotrimazole-betamethasone external lotion 1-0.05 %

1

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG

3PA;

Specialty Medical

CRESEMBA ORAL CAPSULE 186 MG

3PA;

Specialty Pharmacy

dermazene external cream 1-1 %

1

DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML

3Brand

penalty applies

DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3Brand

penalty applies

econazole nitrate external cream 1 %

1

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ERTACZO EXTERNAL CREAM 2 %

3 ST

EXELDERM EXTERNAL CREAM 1 %

3 ST

EXELDERM EXTERNAL SOLUTION 1 %

3 ST

EXODERM EXTERNAL LOTION 25-1 %

3

EXTINA EXTERNAL FOAM 2 %

3Brand

penalty applies

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

GM



45

Drug NameDrug Tier

Notes

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

1

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

1

flucytosine oral capsule 250 mg, 500 mg

1

FUNGIMEZ EXTERNAL SOLUTION

3

griseofulvin microsize oral suspension 125 mg/5ml

1

griseofulvin microsize oral tablet 500 mg

1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

1

GYNAZOLE-1 VAGINAL CREAM 2 %

3

hydrocortisone-iodoquinol external cream 1-1 %

1

IODOQUIMEZ-HC EXTERNAL CREAM 1-1.9 %

3

iodoquinol-hc-aloe polysacch external gel 1-2-1 %

1

iodoquinol-hydrocortisone-aloe external cream 1-1.9 %

1

itraconazole oral capsule 100 mg

1

itraconazole oral solution 10 mg/ml

1

JUBLIA EXTERNAL SOLUTION 10 %

3 PA

KERYDIN EXTERNAL SOLUTION 5 %

3 PA

ketoconazole external cream 2 %

1

Drug NameDrug Tier

Notes

ketoconazole external foam 2 %

1

ketoconazole external shampoo 2 %

1

ketoconazole oral tablet 200 mg

1

ketodan external foam 2 %

1

LOPROX EXTERNAL CREAM 0.77 %

3Brand

penalty applies

LOPROX EXTERNAL SHAMPOO 1 %

3Brand

penalty applies

LOPROX EXTERNAL SUSPENSION 0.77 %

3Brand

penalty applies

LULICONAZOLE EXTERNAL CREAM 1 %

3 ST

LUZU EXTERNAL CREAM 1 %

3 ST

MENTAX EXTERNAL CREAM 1 %

3 ST

micafungin sodium intravenous solution reconstituted 100 mg, 50 mg

GM

miconazole 3 vaginal suppository 200 mg

1

MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL OINTMENT 0.25-15-81.35 %

3

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

naftifine hcl external cream 1 %, 2 %

1 ST

naftifine hcl external gel 1 %

1 ST



46

Drug NameDrug Tier

Notes

NAFTIN EXTERNAL CREAM 2 %

3ST; Brand

penalty applies

NAFTIN EXTERNAL GEL 1 %

3ST; Brand

penalty applies

NAFTIN EXTERNAL GEL 2 %

3 ST

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML

3Specialty Medical

NOXAFIL ORAL SUSPENSION 40 MG/ML

3Specialty Pharmacy

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

3Specialty Pharmacy

nystatin external cream 100000 unit/gm

1

nystatin external ointment 100000 unit/gm

1

nystatin external powder 100000 unit/gm

1

nystatin mouth/throat suspension 100000 unit/ml

1

nystatin oral tablet 500000 unit

1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

1

nystop external powder 100000 unit/gm

1

ORAVIG BUCCAL TABLET 50 MG

3

oxiconazole nitrate external cream 1 %

1 ST

Drug NameDrug Tier

Notes

OXISTAT EXTERNAL CREAM 1 %

3ST; Brand

penalty applies

OXISTAT EXTERNAL LOTION 1 %

3 ST

posaconazole oral tablet delayed release 100 mg

3Specialty Pharmacy

QUINJA EXTERNAL GEL 1.25-1 %

3

RECURA EXTERNAL CREAM

3

SPORANOX ORAL CAPSULE 100 MG

3Brand

penalty applies

SPORANOX ORAL SOLUTION 10 MG/ML

3Brand

penalty applies

SPORANOX PULSEPAK ORAL CAPSULE 100 MG

3Brand

penalty applies

SULCONAZOLE NITRATE EXTERNAL CREAM 1 %

3 ST

SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 %

3 ST

terbinafine hcl oral tablet 250 mg

1

terconazole vaginal cream 0.4 %, 0.8 %

1

terconazole vaginal suppository 80 mg

1

VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

2Specialty Medical

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML

3Specialty Pharmacy



47

Drug NameDrug Tier

Notes

VFEND ORAL TABLET 200 MG, 50 MG

3Specialty Pharmacy

voriconazole intravenous solution reconstituted 200 mg

2Specialty Medical

voriconazole oral suspension reconstituted 40 mg/ml

2Specialty Pharmacy

voriconazole oral tablet 200 mg, 50 mg

2Specialty Pharmacy

VUSION EXTERNAL OINTMENT 0.25-15-81.35 %

3

VYTONE EXTERNAL CREAM 1-1.9 %

3

XOLEGEL COREPAK EXTERNAL KIT 2 & 1 %

3

XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 %

3

XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 %

3

XOLEGEL EXTERNAL GEL 2 %

3

ZOLPAK EXTERNAL KIT 1 %

3

Antigout Agents

allopurinol oral tablet 100 mg, 300 mg

RG

allopurinol sodium intravenous solution reconstituted 500 mg

GM

ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

COLCHICINE ORAL CAPSULE 0.6 MG

2

colchicine tablet 0.6 mg oral 0.6 mg

1

Drug NameDrug Tier

Notes

COLCHICINE TABLET 0.6 MG ORAL 0.6 MG

2

colchicine-probenecid oral tablet 0.5-500 mg

1

COLCRYS ORAL TABLET 0.6 MG

2

febuxostat oral tablet 40 mg, 80 mg

1

GLOPERBA ORAL SOLUTION 0.6 MG/5ML

3

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML

3PA;

Specialty Medical

MITIGARE ORAL CAPSULE 0.6 MG

2

probenecid oral tablet 500 mg

1

ULORIC ORAL TABLET 40 MG, 80 MG

3Brand

penalty applies

ZYLOPRIM ORAL TABLET 100 MG, 300 MG

3Brand

penalty applies

Anti-inflammatory Agents

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

3PA;

Specialty Pharmacy

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG

3PA;

Specialty Pharmacy

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

3PA; QL (1 ML per 28

days)

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 MG/1.5ML

3PA; QL

(1.5 ML per 28 days)



48

Drug NameDrug Tier

Notes

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML

3PA; QL


almotriptan malate oral tablet 12.5 mg, 6.25 mg

1QL (9 EA

per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG

3

Brand penalty


CAFERGOT ORAL TABLET 1-100 MG

2Brand

penalty applies

CAMBIA ORAL PACKET 50 MG

3

D.H.E. 45 INJECTION SOLUTION 1 MG/ML

GM

dihydroergotamine mesylate injection solution 1 mg/ml

GM

dihydroergotamine mesylate nasal solution 4 mg/ml


days)

eletriptan hydrobromide oral tablet 20 mg, 40 mg

1QL (9 EA

per 30 days)

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML


days)

Drug NameDrug Tier

Notes

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

3

ergotamine-caffeine oral tablet 1-100 mg

1

FROVA ORAL TABLET 2.5 MG

3

Brand penalty


frovatriptan succinate oral tablet 2.5 mg

1QL (9 EA

per 30 days)

IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT

2

Brand penalty


IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG

3

Brand penalty


IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML, 6 MG/0.5ML

3

Brand penalty

applies; QL (2 ML per 30 days)

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML

3

Brand penalty


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML

3

Brand penalty




49

Drug NameDrug Tier

Notes

MAXALT ORAL TABLET 10 MG

3

Brand penalty


MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

3

Brand penalty


MIGERGOT RECTAL SUPPOSITORY 2-100 MG

3

MIGRANAL NASAL SOLUTION 4 MG/ML

3

PA; Brand penalty


naratriptan hcl oral tablet 1 mg, 2.5 mg

1QL (9 EA

per 30 days)

RELPAX ORAL TABLET 20 MG, 40 MG

3

Brand penalty


rizatriptan benzoate oral tablet 10 mg, 5 mg

1QL (12 EA

per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

1QL (12 EA

per 30 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act

1QL (6 EA

per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

1QL (9 EA

per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

1QL (2 ML

per 30 days)

Drug NameDrug Tier

Notes

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

1QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

1QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

1QL (2 ML

per 30 days)

VYEPTI INTRAVENOUS SOLUTION 100 MG/ML

3PA;

Specialty Medical

zolmitriptan oral tablet 2.5 mg, 5 mg

1QL (9 EA

per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg

1QL (9 EA

per 30 days)

ZOMIG NASAL SOLUTION 2.5 MG, 5 MG

3QL (6 EA

per 30 days)

ZOMIG ORAL TABLET 2.5 MG, 5 MG

3

Brand penalty


ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG

3

Brand penalty


Antimyasthenic Agents

BLOXIVERZ INTRAVENOUS SOLUTION 10 MG/10ML, 5 MG/10ML

GM

GUANIDINE HCL ORAL TABLET 125 MG

3

MESTINON ORAL SOLUTION 60 MG/5ML

2Brand

penalty applies



50

Drug NameDrug Tier

Notes

MESTINON ORAL TABLET 60 MG

3Brand

penalty applies

MESTINON ORAL TABLET EXTENDED RELEASE 180 MG

2Brand

penalty applies

neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 MG/5ML

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 MG/3ML, 4 MG/4ML

GM

pyridostigmine bromide er oral tablet extended release 180 mg

1

pyridostigmine bromide oral solution 60 mg/5ml

1

pyridostigmine bromide oral tablet 30 mg, 60 mg

1

REGONOL INTRAVENOUS SOLUTION 10 MG/2ML

GM

Antimycobacterials

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

GM

cycloserine oral capsule 250 mg

1

dapsone oral tablet 100 mg, 25 mg

1

ethambutol hcl oral tablet 100 mg, 400 mg

1

isoniazid injection solution 100 mg/ml

GM

Drug NameDrug Tier

Notes

isoniazid oral syrup 50 mg/5ml

1

isoniazid oral tablet 100 mg, 300 mg

1

MYAMBUTOL ORAL TABLET 400 MG

3Brand

penalty applies

MYCOBUTIN ORAL CAPSULE 150 MG

2Brand

penalty applies

PASER ORAL PACKET 4 GM

3

PRETOMANID ORAL TABLET 200 MG

3PA; QL (30 EA per 30

days)

PRIFTIN ORAL TABLET 150 MG

3

pyrazinamide oral tablet 500 mg

1

rifabutin oral capsule 150 mg

1

RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

GM

RIFADIN ORAL CAPSULE 150 MG, 300 MG

3Brand

penalty applies

rifampin intravenous solution reconstituted 600 mg

GM

rifampin oral capsule 150 mg, 300 mg

1

SIRTURO ORAL TABLET 100 MG

3PA;

Specialty Pharmacy

SIRTURO ORAL TABLET 20 MG

3

TRECATOR ORAL TABLET 250 MG

3



51

Drug NameDrug Tier

Notes

Antineoplastics - Drugs for Cancer

abiraterone acetate oral tablet 250 mg

2PA;

Specialty Pharmacy

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG

3PA;

Specialty Medical

ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

3PA;

Specialty Medical

adriamycin intravenous solution 2 mg/ml

GM PA

adriamycin intravenous solution reconstituted 10 mg, 50 mg

GM PA

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

ALECENSA ORAL CAPSULE 150 MG

3PA;

Specialty Pharmacy

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG

3PA;

Specialty Medical

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG

3PA;

Specialty Medical

ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

ALKERAN ORAL TABLET 2 MG

2PA; Brand

penalty applies

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

3PA;

Specialty Pharmacy

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG

3PA;

Specialty Pharmacy

anastrozole oral tablet 1 mg

1

ARIMIDEX ORAL TABLET 1 MG

3Brand

penalty applies

AROMASIN ORAL TABLET 25 MG

3Brand

penalty applies

ARRANON INTRAVENOUS SOLUTION 5 MG/ML

3PA;

Specialty Medical

arsenic trioxide intravenous solution 10 mg/10ml

3PA;

Specialty Medical

ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 1000 MG/50ML

3PA;

Specialty Medical

ASPARLAS INTRAVENOUS SOLUTION 3750 UNIT/5ML

3PA;

Specialty Medical

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

3PA;

Specialty Medical

AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG

3PA;

Specialty Pharmacy

azacitidine injection suspension reconstituted 100 mg

3PA;

Specialty Medical



52

Drug NameDrug Tier

Notes

AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG

3PA;

Specialty Pharmacy

BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML

GM

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

3PA;

Specialty Medical

BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML

3PA;

Specialty Medical

BENDAMUSTINE HCL INTRAVENOUS SOLUTION 100 MG/4ML

3PA;

Specialty Medical

BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML

3PA;

Specialty Medical

BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG

3PA;

Specialty Medical

bexarotene oral capsule 75 mg

3PA;

Specialty Pharmacy

bicalutamide oral tablet 50 mg

1

BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

bleomycin sulfate injection solution reconstituted 15 unit, 30 unit

3PA;

Specialty Medical

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG

3PA;

Specialty Medical

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3.5 MG

3PA;

Specialty Medical

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG

3

PA; Specialty

Pharmacy; QL (30 EA

per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG

3PA;

Specialty Pharmacy

BRUKINSA ORAL CAPSULE 80 MG

3PA;

Specialty Pharmacy

busulfan intravenous solution 6 mg/ml

3PA;

Specialty Medical

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML

3PA;

Specialty Medical

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

3PA;

Specialty Pharmacy

CALQUENCE ORAL CAPSULE 100 MG

3PA;

Specialty Pharmacy

CAMPATH INTRAVENOUS SOLUTION 30 MG/ML

3PA;

Specialty Medical



53

Drug NameDrug Tier

Notes

CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5ML, 300 MG/15ML, 40 MG/2ML

GM PA

capecitabine oral tablet 150 mg, 500 mg

3 PA

CAPRELSA ORAL TABLET 100 MG, 300 MG

3PA;

Specialty Pharmacy

carboplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml

GM PA

carmustine intravenous solution reconstituted 100 mg

3PA;

Specialty Medical

CASODEX ORAL TABLET 50 MG

3Brand

penalty applies

cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml

GM PA

cladribine intravenous solution 10 mg/10ml

3PA;

Specialty Medical

clofarabine intravenous solution 1 mg/ml

3PA;

Specialty Medical

CLOLAR INTRAVENOUS SOLUTION 1 MG/ML

3PA;

Specialty Medical

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

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

COPIKTRA ORAL CAPSULE 15 MG, 25 MG

3PA;

Specialty Pharmacy

COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG

3PA;

Specialty Medical

COTELLIC ORAL TABLET 20 MG

3PA;

Specialty Pharmacy

cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 mg

3PA;

Specialty Medical

cyclophosphamide oral capsule 25 mg, 50 mg

1 PA

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

3PA;

Specialty Medical

cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml

3PA;

Specialty Medical

cytarabine injection solution 20 mg/ml

3PA;

Specialty Medical

dacarbazine intravenous solution reconstituted 100 mg, 200 mg

3PA;

Specialty Medical

DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

3PA;

Specialty Medical

dactinomycin intravenous solution reconstituted 0.5 mg

3PA;

Specialty Medical

DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800-30000 MG-UT/15ML

3PA;

Specialty Pharmacy



54

Drug NameDrug Tier

Notes

DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

3PA;

Specialty Medical

daunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml

GM PA

DAURISMO ORAL TABLET 100 MG, 25 MG

3PA;

Specialty Pharmacy

decitabine intravenous solution reconstituted 50 mg

3PA;

Specialty Medical

dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 mg

GM

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, 200 mg/10ml, 80 mg/4ml

3PA;

Specialty Medical

docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 mg/8ml

3PA;

Specialty Medical

DOXIL INTRAVENOUS INJECTABLE 2 MG/ML

3PA;

Specialty Medical

doxorubicin hcl intravenous solution 2 mg/ml

GM PA

doxorubicin hcl liposomal intravenous injectable 2 mg/ml

3PA;

Specialty Medical

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

3

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG

3Specialty Medical

Drug NameDrug Tier

Notes

ELLENCE INTRAVENOUS SOLUTION 200 MG/100ML, 50 MG/25ML

3PA;

Specialty Medical

ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML

3PA;

Specialty Medical

EMCYT ORAL CAPSULE 140 MG

2 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG

3PA;

Specialty Medical

ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml

3PA;

Specialty Medical

ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 MG/100ML

3PA;

Specialty Medical

ERIVEDGE ORAL CAPSULE 150 MG

3PA;

Specialty Pharmacy

ERLEADA ORAL TABLET 60 MG

3PA;

Specialty Pharmacy

erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg

2PA;

Specialty Pharmacy

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT

3PA;

Specialty Medical



55

Drug NameDrug Tier

Notes

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

GM PA

etoposide oral capsule 50 mg

1 PA

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

3Specialty Pharmacy

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

exemestane oral tablet 25 mg

1

FARESTON ORAL TABLET 60 MG

2PA; Brand

penalty applies

FARYDAK ORAL CAPSULE 10 MG, 20 MG

3PA;

Specialty Pharmacy

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

3PA;

Specialty Medical

FEMARA ORAL TABLET 2.5 MG

3Brand

penalty applies

floxuridine injection solution reconstituted 0.5 gm

3PA;

Specialty Medical

fludarabine phosphate intravenous solution 50 mg/2ml

3PA;

Specialty Medical

fludarabine phosphate intravenous solution reconstituted 50 mg

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

GM PA

flutamide oral capsule 125 mg

1 PA

FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML

3PA;

Specialty Medical

fulvestrant intramuscular solution 250 mg/5ml

3PA;

Specialty Medical

GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML

3PA;

Specialty Medical

gemcitabine hcl intravenous solution 1 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, 200 mg/2ml

GM

gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml

GM PA

gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mg

GM PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

3PA;

Specialty Pharmacy

GLEEVEC ORAL TABLET 100 MG

3

PA; Specialty

Pharmacy; QL (90 EA

per 30 days)

GLEEVEC ORAL TABLET 400 MG

3

PA; Specialty

Pharmacy; QL (30 EA

per 30 days)



56

Drug NameDrug Tier

Notes

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

3PA;

Specialty Pharmacy

GLIADEL WAFER IMPLANT WAFER 7.7 MG

GM

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML

3PA;

Specialty Medical

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600-10000 MG-UNT/5ML

3PA;

Specialty Pharmacy

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

3PA;

Specialty Medical

HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

2PA;

Specialty Medical

HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 MG

GM PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

3 PA

HYDREA ORAL CAPSULE 500 MG

3Brand

penalty applies

hydroxyurea oral capsule 500 mg

1

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

3PA;

Specialty Pharmacy

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

ICLUSIG ORAL TABLET 15 MG, 45 MG

3

PA; Specialty

Pharmacy; QL (30 EA

per 30 days)

IDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 MG/20ML, 5 MG/5ML

3PA;

Specialty Medical

idarubicin hcl intravenous solution 10 mg/10ml, 20 mg/20ml, 5 mg/5ml

3PA;

Specialty Medical

IDHIFA ORAL TABLET 100 MG, 50 MG

3PA;

Specialty Pharmacy

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 GM

3PA;

Specialty Medical

ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml

3PA;

Specialty Medical

ifosfamide intravenous solution reconstituted 1 gm, 3 gm

3PA;

Specialty Medical

imatinib mesylate oral tablet 100 mg

2

PA; Specialty

Pharmacy; QL (90 EA

per 30 days)

imatinib mesylate oral tablet 400 mg

2

PA; Specialty

Pharmacy; QL (30 EA

per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

3PA;

Specialty Pharmacy



57

Drug NameDrug Tier

Notes

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

3PA;

Specialty Pharmacy

IMLYGIC INTRALESIONAL SUSPENSION 1000000 UNIT/ML, 100000000 UNIT/ML

3PA;

Specialty Medical

INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-%

3PA;

Specialty Medical

INLYTA ORAL TABLET 1 MG, 5 MG

3PA;

Specialty Pharmacy

INREBIC ORAL CAPSULE 100 MG

3PA;

Specialty Pharmacy

IRESSA ORAL TABLET 250 MG

3PA;

Specialty Pharmacy

irinotecan hcl intravenous solution 100 mg/5ml, 300 mg/15ml, 40 mg/2ml, 500 mg/25ml

GM PA

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

3PA;

Specialty Medical

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 MG, 45 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

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

3PA;

Specialty Pharmacy

JELMYTO SOLUTION RECONSTITUTED 40 MG

3PA;

Specialty Medical

JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML

3PA;

Specialty Medical

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG

3PA;

Specialty Medical

KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

2PA;

Specialty Medical

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

3PA;

Specialty Medical

KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 175 MG, 300 MG

3PA;

Specialty Medical

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 200 MG

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

KOSELUGO ORAL CAPSULE 10 MG, 25 MG

3PA;

Specialty Pharmacy



58

Drug NameDrug Tier

Notes

KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 30 MG, 60 MG

3PA;

Specialty Medical

LARTRUVO INTRAVENOUS SOLUTION 190 MG/19ML, 500 MG/50ML

3PA;

Specialty Medical

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

3PA;

Specialty Pharmacy

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3 X 4 MG

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

letrozole oral tablet 2.5 mg

1

leucovorin calcium injection solution 100 mg/10ml, 500 mg/50ml

GM PA

Drug NameDrug Tier

Notes

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg

GM PA

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

1

LEUKERAN ORAL TABLET 2 MG

2 PA

levoleucovorin calcium intravenous solution reconstituted 50 mg

3PA;

Specialty Medical

levoleucovorin calcium pf intravenous solution 175 mg/17.5ml, 250 mg/25ml

3PA;

Specialty Medical

LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML

3PA;

Specialty Medical

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

3PA;

Specialty Pharmacy

LORBRENA ORAL TABLET 100 MG, 25 MG

3PA;

Specialty Pharmacy

LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

3PA;

Specialty Medical

LYNPARZA ORAL TABLET 100 MG, 150 MG

3PA;

Specialty Pharmacy

LYSODREN ORAL TABLET 500 MG

2 PA

MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML

3PA;

Specialty Medical

MATULANE ORAL CAPSULE 50 MG

3PA;

Specialty Pharmacy



59

Drug NameDrug Tier

Notes

MEKINIST ORAL TABLET 0.5 MG, 2 MG

3PA;

Specialty Pharmacy

MEKTOVI ORAL TABLET 15 MG

3PA;

Specialty Pharmacy

melphalan hcl intravenous solution reconstituted 50 mg

3PA;

Specialty Medical

melphalan oral tablet 2 mg

1 PA

mercaptopurine oral tablet 50 mg

1

mesna intravenous solution 100 mg/ml

3Specialty Medical

MESNEX INTRAVENOUS SOLUTION 100 MG/ML

3Specialty Medical

MESNEX ORAL TABLET 400 MG

2

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

GM PA

MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 20 MG/40ML

GM

mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 mg/12.5ml, 30 mg/15ml

3Specialty Medical

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

GM PA

MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

2PA;

Specialty Medical

MYLERAN ORAL TABLET 2 MG

2

Drug NameDrug Tier

Notes

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

3PA;

Specialty Medical

NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/5ML

3PA;

Specialty Medical

NERLYNX ORAL TABLET 40 MG

3PA;

Specialty Pharmacy

NEXAVAR ORAL TABLET 200 MG

3PA;

Specialty Pharmacy

NILANDRON ORAL TABLET 150 MG

2Brand

penalty applies

nilutamide oral tablet 150 mg

1

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

3PA;

Specialty Pharmacy

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

3PA;

Specialty Medical

NUBEQA ORAL TABLET 300 MG

3PA;

Specialty Pharmacy

ODOMZO ORAL CAPSULE 200 MG

3PA;

Specialty Pharmacy

OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

2PA;

Specialty Medical

ONCASPAR INJECTION SOLUTION 750 UNIT/ML

3PA;

Specialty Medical



60

Drug NameDrug Tier

Notes

ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML

3PA;

Specialty Medical

ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

2PA;

Specialty Medical

OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 240 MG/24ML, 40 MG/4ML

3PA;

Specialty Medical

oxaliplatin intravenous solution 100 mg/20ml, 50 mg/10ml

GM PA

oxaliplatin intravenous solution reconstituted 100 mg, 50 mg

GM PA

paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml

3PA;

Specialty Medical

PADCEV INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 30 MG

3PA;

Specialty Medical

PANRETIN EXTERNAL GEL 0.1 %

3

paraplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml

GM PA

PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG

3PA;

Specialty Pharmacy

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG-MG-U/ML, 80-40-2000 MG-MG-U/ML

3PA;

Specialty Medical

PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 75 MG

3PA;

Specialty Medical

PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 MG

3PA;

Specialty Pharmacy

PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 & 50 MG

3PA;

Specialty Pharmacy

PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 2 X 150 MG

3PA;

Specialty Pharmacy

POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG

3PA;

Specialty Medical

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

3PA;

Specialty Pharmacy

PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML

3PA;

Specialty Medical

POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML

3PA;

Specialty Medical

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT

3PA;

Specialty Medical

PURIXAN ORAL SUSPENSION 2000 MG/100ML

3



61

Drug NameDrug Tier

Notes

QINLOCK ORAL TABLET 50 MG

3PA;

Specialty Pharmacy

QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML

3Specialty Medical

RETEVMO ORAL CAPSULE 40 MG, 80 MG

3PA;

Specialty Pharmacy

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

3PA;

Specialty Pharmacy

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML

3PA;

Specialty Medical

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

3PA;

Specialty Medical

ROMIDEPSIN INTRAVENOUS SOLUTION 27.5 MG/5.5ML

3PA;

Specialty Medical

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG

3PA;

Specialty Pharmacy

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

3PA;

Specialty Pharmacy

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

2PA;

Specialty Medical

RYDAPT ORAL CAPSULE 25 MG

3PA;

Specialty Pharmacy

SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, 500 MG/25ML

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

3PA;

Specialty Pharmacy

STIVARGA ORAL TABLET 40 MG

3PA;

Specialty Pharmacy

STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 1 MCI/ML

GM

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

3PA;

Specialty Pharmacy

SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 400 MG

3PA;

Specialty Medical

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

3PA;

Specialty Pharmacy

TABLOID ORAL TABLET 40 MG

2

TABRECTA ORAL TABLET 150 MG, 200 MG

3PA;

Specialty Pharmacy

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

3PA;

Specialty Pharmacy

TAGRISSO ORAL TABLET 40 MG, 80 MG

3PA;

Specialty Pharmacy

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG

3PA;

Specialty Pharmacy

tamoxifen citrate oral tablet 10 mg, 20 mg

PV

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

3PA;

Specialty Pharmacy



62

Drug NameDrug Tier

Notes

TARGRETIN EXTERNAL GEL 1 %

3PA;

Specialty Pharmacy

TARGRETIN ORAL CAPSULE 75 MG

3PA;

Specialty Pharmacy

TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG

2

PA; Specialty

Pharmacy; QL (30 EA

per 30 days)

TAXOTERE INTRAVENOUS CONCENTRATE 80 MG/4ML

3PA;

Specialty Medical

TAZVERIK ORAL TABLET 200 MG

3PA;

Specialty Pharmacy

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML, 840 MG/14ML

3PA;

Specialty Medical

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG

3PA;

Specialty Pharmacy

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

2PA;

Specialty Pharmacy

teniposide intravenous solution 10 mg/ml

3PA;

Specialty Medical

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

3PA;

Specialty Pharmacy

thiotepa injection solution reconstituted 100 mg, 15 mg

3PA;

Specialty Medical

TIBSOVO ORAL TABLET 250 MG

3PA;

Specialty Pharmacy

toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

GM PA

topotecan hcl intravenous solution 4 mg/4ml

GM PA

topotecan hcl intravenous solution reconstituted 4 mg

GM PA

toremifene citrate oral tablet 60 mg

1 PA

TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 420 MG

2PA;

Specialty Medical

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 25 MG

3PA;

Specialty Medical

tretinoin oral capsule 10 mg

1 PA

TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 180 MG

3PA;

Specialty Medical



63

Drug NameDrug Tier

Notes

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

3PA;

Specialty Medical

TUKYSA ORAL TABLET 150 MG, 50 MG

3PA;

Specialty Pharmacy

TURALIO ORAL CAPSULE 200 MG

3PA;

Specialty Pharmacy

TYKERB ORAL TABLET 250 MG

3PA;

Specialty Pharmacy

UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML

3PA;

Specialty Medical

VALCHLOR EXTERNAL GEL 0.016 %

3PA;

Specialty Pharmacy

valrubicin intravesical solution 40 mg/ml

3PA;

Specialty Medical

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML

3PA;

Specialty Medical

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

3PA;

Specialty Medical

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

3PA;

Specialty Medical

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

3PA;

Specialty Pharmacy

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3PA;

Specialty Pharmacy

VIDAZA INJECTION SUSPENSION RECONSTITUTED 100 MG

3PA;

Specialty Medical

vinblastine sulfate intravenous solution 1 mg/ml

3PA;

Specialty Medical

vincristine sulfate intravenous solution 1 mg/ml

GM PA

vinorelbine tartrate intravenous solution 10 mg/ml, 50 mg/5ml

3PA;

Specialty Medical

VITRAKVI ORAL CAPSULE 100 MG, 25 MG

3PA;

Specialty Pharmacy

VITRAKVI ORAL SOLUTION 20 MG/ML

3PA;

Specialty Pharmacy

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG

3PA;

Specialty Pharmacy

VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

GM

VOTRIENT ORAL TABLET 200 MG

3PA;

Specialty Pharmacy

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

3PA;

Specialty Medical

XALKORI ORAL CAPSULE 200 MG, 250 MG

3PA;

Specialty Pharmacy



64

Drug NameDrug Tier

Notes

XELODA ORAL TABLET 150 MG, 500 MG

3PA;

Specialty Pharmacy

XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML

3PA;

Specialty Medical

XOSPATA ORAL TABLET 40 MG

3PA;

Specialty Pharmacy

XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

XTANDI ORAL CAPSULE 40 MG

3PA;

Specialty Pharmacy

YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 MG/10ML

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

YESCARTA INTRAVENOUS SUSPENSION

3PA;

Specialty Medical

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

3PA;

Specialty Medical

YONSA ORAL TABLET 125 MG

3PA;

Specialty Pharmacy

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 MG/8ML

3PA;

Specialty Medical

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

3PA;

Specialty Medical

ZEJULA ORAL CAPSULE 100 MG

3PA;

Specialty Pharmacy

ZELBORAF ORAL TABLET 240 MG

3PA;

Specialty Pharmacy

ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 4 MG

3PA;

Specialty Medical

ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML

3Specialty Medical

ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

2PA;

Specialty Medical

ZOLINZA ORAL CAPSULE 100 MG

3PA;

Specialty Pharmacy

ZYDELIG ORAL TABLET 100 MG, 150 MG

3PA;

Specialty Pharmacy



65

Drug NameDrug Tier

Notes

ZYKADIA ORAL TABLET 150 MG

3PA;

Specialty Pharmacy

ZYTIGA ORAL TABLET 250 MG, 500 MG

3PA;

Specialty Pharmacy

Antiparasitics

albendazole oral tablet 200 mg

1

ALBENZA ORAL TABLET 200 MG

3Brand

penalty applies

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

3

ALINIA ORAL TABLET 500 MG

3

ARAKODA ORAL TABLET 100 MG

2

atovaquone oral suspension 750 mg/5ml

1

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

1

BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG

3

BILTRICIDE ORAL TABLET 600 MG

3Brand

penalty applies

chloroquine phosphate oral tablet 250 mg, 500 mg

1

COARTEM ORAL TABLET 20-120 MG

2

crotan external lotion 10 %

1 PA

DARAPRIM ORAL TABLET 25 MG

3Specialty Pharmacy

Drug NameDrug Tier

Notes

ELIMITE EXTERNAL CREAM 5 %

3Brand

penalty applies

EMVERM ORAL TABLET CHEWABLE 100 MG

3

hydroxychloroquine sulfate oral tablet 200 mg

1

IMPAVIDO ORAL CAPSULE 50 MG

3PA;

Specialty Pharmacy

ivermectin oral tablet 3 mg

1

KRINTAFEL ORAL TABLET 150 MG

2QL (2 EA

per 30 days)

lindane external shampoo 1 %

1

MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG

3Brand

penalty applies

malathion external lotion 0.5 %

1

mefloquine hcl oral tablet 250 mg

1

MEPRON ORAL SUSPENSION 750 MG/5ML

2Brand

penalty applies

NATROBA EXTERNAL SUSPENSION 0.9 %

3Brand

penalty applies

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

3Brand

penalty applies

OVIDE EXTERNAL LOTION 0.5 %

3Brand

penalty applies

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

GM



66

Drug NameDrug Tier

Notes

pentamidine isethionate inhalation solution reconstituted 300 mg

1

pentamidine isethionate injection solution reconstituted 300 mg

GM

permethrin external cream 5 %

1

PLAQUENIL ORAL TABLET 200 MG

3Brand

penalty applies

praziquantel oral tablet 600 mg

1

primaquine phosphate oral tablet 26.3 mg

1

pyrimethamine oral tablet 25 mg

3Specialty Pharmacy

PYRIMETHAMINE-LEUCOVORIN ORAL CAPSULE 12.5-2.5 MG, 25-10 MG, 25-5 MG, 50-10 MG, 50-20 MG, 50-25 MG, 75-25 MG

3

QUALAQUIN ORAL CAPSULE 324 MG

3Brand

penalty applies

quinine sulfate oral capsule 324 mg

1

SKLICE EXTERNAL LOTION 0.5 %

3

spinosad external suspension 0.9 %

1

STROMECTOL ORAL TABLET 3 MG

3Brand

penalty applies

sulfurated lime external solution

1

Antiparkinson Agents

amantadine hcl oral capsule 100 mg

1

amantadine hcl oral syrup 50 mg/5ml

1

Drug NameDrug Tier

Notes

amantadine hcl oral tablet 100 mg

1

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

3PA;

Specialty Pharmacy

AZILECT ORAL TABLET 0.5 MG, 1 MG

3Brand

penalty applies

benztropine mesylate injection solution 1 mg/ml

GM

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

RG

bromocriptine mesylate oral capsule 5 mg

1

bromocriptine mesylate oral tablet 2.5 mg

1

carbidopa oral tablet 25 mg

1

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

1

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

1

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

1

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

1

COGENTIN INJECTION SOLUTION 1 MG/ML

GM

COMTAN ORAL TABLET 200 MG

3Brand

penalty applies



67

Drug NameDrug Tier

Notes

entacapone oral tablet 200 mg

1

INBRIJA INHALATION CAPSULE 42 MG

3PA;

Specialty Pharmacy

KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

3PA;

Specialty Pharmacy

LODOSYN ORAL TABLET 25 MG

3Brand

penalty applies

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

3Brand

penalty applies

MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG

3Brand

penalty applies

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

3

NOURIANZ ORAL TABLET 20 MG, 40 MG

3PA;

Specialty Pharmacy

PARLODEL ORAL CAPSULE 5 MG

3Brand

penalty applies

PARLODEL ORAL TABLET 2.5 MG

3Brand

penalty applies

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

1

Drug NameDrug Tier

Notes

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

1

rasagiline mesylate oral tablet 0.5 mg, 1 mg

1

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 6 MG

3Brand

penalty applies

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

3

selegiline hcl oral capsule 5 mg

1

selegiline hcl oral tablet 5 mg

1

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG

3Brand

penalty applies

STALEVO 100 ORAL TABLET 25-100-200 MG

3Brand

penalty applies

STALEVO 125 ORAL TABLET 31.25-125-200 MG

3Brand

penalty applies


3Brand

penalty applies

STALEVO 200 ORAL TABLET 50-200-200 MG

3Brand

penalty applies



68

Drug NameDrug Tier

Notes


3Brand

penalty applies


3Brand

penalty applies

TASMAR ORAL TABLET 100 MG

3Brand

penalty applies

tolcapone oral tablet 100 mg

1

trihexyphenidyl hcl oral solution 0.4 mg/ml

1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg

1

XADAGO ORAL TABLET 100 MG, 50 MG

3

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG

3

Antiplatelets

AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 MG/15ML

GM

AGGRASTAT INTRAVENOUS SOLUTION 12.5-0.9 MG/250ML-%, 5-0.9 MG/100ML-%

GM

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

3Brand

penalty applies

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

1

BRILINTA ORAL TABLET 60 MG, 90 MG

2

CABLIVI INJECTION KIT 11 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

cilostazol oral tablet 100 mg, 50 mg

1

clopidogrel bisulfate oral tablet 300 mg

1

clopidogrel bisulfate oral tablet 75 mg

RG

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

1

EFFIENT ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

eptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml

GM

INTEGRILIN INTRAVENOUS SOLUTION 20 MG/10ML, 200 MG/100ML, 75 MG/100ML

GM

KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

PLAVIX ORAL TABLET 75 MG

3Brand

penalty applies

prasugrel hcl oral tablet 10 mg, 5 mg

1

ZONTIVITY ORAL TABLET 2.08 MG

3

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

2Specialty Pharmacy

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

2Specialty Pharmacy



69

Drug NameDrug Tier

Notes

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

3

Brand penalty


ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG

GM

aripiprazole oral solution 1 mg/ml

1

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

1QL (30 EA

per 30 days)

aripiprazole oral tablet dispersible 10 mg, 15 mg

1QL (30 EA

per 30 days)

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML

2Specialty Pharmacy

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

2Specialty Pharmacy

CAPLYTA ORAL CAPSULE 42 MG

3 PA

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

GM

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

1

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

1

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

1

Drug NameDrug Tier

Notes

CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

3Brand

penalty applies

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

3 PA

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

3 PA

fluphenazine decanoate injection solution 25 mg/ml

GM

fluphenazine hcl injection solution 2.5 mg/ml

GM

fluphenazine hcl oral concentrate 5 mg/ml

1

fluphenazine hcl oral elixir 2.5 mg/5ml

1

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

1

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

GM

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

3Brand

penalty applies

HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

GM

HALDOL INJECTION SOLUTION 5 MG/ML

GM

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

GM

haloperidol lactate injection solution 5 mg/ml

GM

haloperidol lactate oral concentrate 2 mg/ml

1



70

Drug NameDrug Tier

Notes

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

RG

haloperidol oral tablet 10 mg, 20 mg

1

INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, 6 MG, 9 MG

3

Brand penalty


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML

2Specialty Pharmacy

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

2Specialty Pharmacy

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

3 PA

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

1

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

1

NUPLAZID ORAL CAPSULE 34 MG

3 PA

NUPLAZID ORAL TABLET 10 MG

3 PA

olanzapine intramuscular solution reconstituted 10 mg

GM

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

1

Drug NameDrug Tier

Notes

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

1

paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

1QL (30 EA

per 30 days)

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 90 MG

2Specialty Pharmacy

pimozide oral tablet 1 mg, 2 mg

1

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

1QL (30 EA

per 30 days)

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

1

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3 PA

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG

2Specialty Pharmacy

RISPERDAL ORAL SOLUTION 1 MG/ML

3Brand

penalty applies

RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3Brand

penalty applies

risperidone oral solution 1 mg/ml

1

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

RG



71

Drug NameDrug Tier

Notes

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

3 PA

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR

3 PA

SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG

3Brand

penalty applies

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

3

Brand penalty


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

1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

1

VERSACLOZ ORAL SUSPENSION 50 MG/ML

3

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

3 PA

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

3 PA

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

1

Drug NameDrug Tier

Notes

ziprasidone mesylate intramuscular solution reconstituted 20 mg

GM

ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG

GM

ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG

3Brand

penalty applies

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG

2Specialty Pharmacy

ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG

3Brand

penalty applies

Antivirals

abacavir sulfate oral solution 20 mg/ml

1

abacavir sulfate oral tablet 300 mg

1

abacavir sulfate-lamivudine oral tablet 600-300 mg

1

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

3Specialty Pharmacy

acyclovir external cream 5 %

1

acyclovir external ointment 5 %

1QL (15 GM

per 30 days)

acyclovir oral capsule 200 mg

1

acyclovir oral suspension 200 mg/5ml

1

acyclovir oral tablet 400 mg, 800 mg

1



72

Drug NameDrug Tier

Notes

acyclovir sodium intravenous solution 50 mg/ml

GM

adefovir dipivoxil oral tablet 10 mg

1 PA

APTIVUS ORAL CAPSULE 250 MG

2

APTIVUS ORAL SOLUTION 100 MG/ML

2

atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg

1

ATRIPLA ORAL TABLET 600-200-300 MG

3Specialty Pharmacy

BARACLUDE ORAL SOLUTION 0.05 MG/ML

3 PA

BARACLUDE ORAL TABLET 0.5 MG, 1 MG

3PA; Brand

penalty applies

BIKTARVY ORAL TABLET 50-200-25 MG

3Specialty Pharmacy

cidofovir intravenous solution 75 mg/ml

GM

CIMDUO ORAL TABLET 300-300 MG

3Specialty Pharmacy

COMBIVIR ORAL TABLET 150-300 MG

2Brand

penalty applies

COMPLERA ORAL TABLET 200-25-300 MG

3Specialty Pharmacy

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2

CYTOVENE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DELSTRIGO ORAL TABLET 100-300-300 MG

3Specialty Pharmacy

Drug NameDrug Tier

Notes

DENAVIR EXTERNAL CREAM 1 %

3 ST

DESCOVY ORAL TABLET 200-25 MG

3Specialty

Pharmacy; PV*

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

1

DOVATO ORAL TABLET 50-300 MG

3Specialty Pharmacy

EDURANT ORAL TABLET 25 MG

3

efavirenz oral capsule 200 mg, 50 mg

1

efavirenz oral tablet 600 mg

1

EMTRIVA ORAL CAPSULE 200 MG

2

EMTRIVA ORAL SOLUTION 10 MG/ML

2

entecavir oral tablet 0.5 mg, 1 mg

1 PA

EPCLUSA ORAL TABLET 400-100 MG

2PA;

Specialty Pharmacy

EPIVIR HBV ORAL SOLUTION 5 MG/ML

3

EPIVIR HBV ORAL TABLET 100 MG

2Brand

penalty applies

EPIVIR ORAL SOLUTION 10 MG/ML

3Brand

penalty applies

EPIVIR ORAL TABLET 150 MG, 300 MG

2Brand

penalty applies

EPZICOM ORAL TABLET 600-300 MG

3Brand

penalty applies

EVOTAZ ORAL TABLET 300-150 MG

3Specialty Pharmacy



73

Drug NameDrug Tier

Notes

famciclovir oral tablet 125 mg, 250 mg, 500 mg

1

fosamprenavir calcium oral tablet 700 mg

1

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML

GM

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

3Specialty Pharmacy

GANCICLOVIR INTRAVENOUS SOLUTION 500 MG/250ML

GM

ganciclovir sodium intravenous solution 500 mg/10ml

GM

ganciclovir sodium intravenous solution reconstituted 500 mg

GM

GENVOYA ORAL TABLET 150-150-200-10 MG

3Specialty Pharmacy

HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG

2PA;

Specialty Pharmacy

HARVONI ORAL TABLET 45-200 MG, 90-400 MG

2PA;

Specialty Pharmacy

HEPSERA ORAL TABLET 10 MG

3PA; Brand

penalty applies

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

3

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

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

3PA;

Specialty Medical

INVIRASE ORAL TABLET 500 MG

2

ISENTRESS HD ORAL TABLET 600 MG

2

ISENTRESS ORAL PACKET 100 MG

3

ISENTRESS ORAL TABLET 400 MG

2

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

3

JULUCA ORAL TABLET 50-25 MG

3Specialty Pharmacy

KALETRA ORAL SOLUTION 400-100 MG/5ML

2Brand

penalty applies

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

2

lamivudine oral solution 10 mg/ml

1

lamivudine oral tablet 100 mg, 150 mg, 300 mg

1

lamivudine-zidovudine oral tablet 150-300 mg

1

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG

2PA;

Specialty Pharmacy

LEXIVA ORAL SUSPENSION 50 MG/ML

3

LEXIVA ORAL TABLET 700 MG

3Brand

penalty applies

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

1



74

Drug NameDrug Tier

Notes

MAVYRET ORAL TABLET 100-40 MG

2PA;

Specialty Pharmacy

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

1

nevirapine oral suspension 50 mg/5ml

1

nevirapine oral tablet 200 mg

1

NORVIR ORAL PACKET 100 MG

3

NORVIR ORAL SOLUTION 80 MG/ML

2

NORVIR ORAL TABLET 100 MG

3Brand

penalty applies

ODEFSEY ORAL TABLET 200-25-25 MG

3Specialty Pharmacy

oseltamivir phosphate oral capsule 30 mg

1QL (20 EA

per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg

1QL (10 EA

per 180 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

1QL (120

ML per 180 days)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

3PA;

Specialty Pharmacy

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

3PA;

Specialty Pharmacy

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML

3PA;

Specialty Pharmacy

PIFELTRO ORAL TABLET 100 MG

3

Drug NameDrug Tier

Notes

PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 MG/24ML

3PA;

Specialty Medical

PREVYMIS ORAL TABLET 240 MG, 480 MG

3PA;

Specialty Pharmacy

PREZCOBIX ORAL TABLET 800-150 MG

3Specialty Pharmacy

PREZISTA ORAL SUSPENSION 100 MG/ML

3

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

3

RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML

GM

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

3QL (20 EA

per 180 days)

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RETROVIR ORAL CAPSULE 100 MG

3Brand

penalty applies

RETROVIR ORAL SYRUP 50 MG/5ML

3Brand

penalty applies

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

2Brand

penalty applies

REYATAZ ORAL PACKET 50 MG

2

ribavirin inhalation solution reconstituted 6 gm

3PA;

Specialty Medical



75

Drug NameDrug Tier

Notes

ribavirin oral capsule 200 mg

2PA;

Specialty Pharmacy

ribavirin oral tablet 200 mg

2PA;

Specialty Pharmacy

rimantadine hcl oral tablet 100 mg

1

ritonavir oral tablet 100 mg

1

RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG

3

SELZENTRY ORAL SOLUTION 20 MG/ML

3Specialty Pharmacy

SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

3Specialty Pharmacy

SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG

2PA;

Specialty Pharmacy

SOVALDI ORAL PACKET 150 MG, 200 MG

3PA;

Specialty Pharmacy

SOVALDI ORAL TABLET 200 MG, 400 MG

3PA;

Specialty Pharmacy

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

1

STRIBILD ORAL TABLET 150-150-200-300 MG

3Specialty Pharmacy

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

2Brand

penalty applies

SUSTIVA ORAL TABLET 600 MG

2Brand

penalty applies

SYMFI LO ORAL TABLET 400-300-300 MG

3Specialty Pharmacy

Drug NameDrug Tier

Notes

SYMFI ORAL TABLET 600-300-300 MG

3Specialty Pharmacy

SYMTUZA ORAL TABLET 800-150-200-10 MG

3Specialty Pharmacy

TAMIFLU ORAL CAPSULE 30 MG

3

Brand penalty


TAMIFLU ORAL CAPSULE 45 MG, 75 MG

3

Brand penalty


TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

3

Brand penalty


TEMIXYS ORAL TABLET 300-300 MG

3Specialty Pharmacy

tenofovir disoproxil fumarate oral tablet 300 mg

1

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

3Specialty Pharmacy

TIVICAY PD ORAL TABLET SOLUBLE 5 MG

3Specialty Pharmacy

TRIUMEQ ORAL TABLET 600-50-300 MG

3Specialty Pharmacy

TRIZIVIR ORAL TABLET 300-150-300 MG

3Specialty Pharmacy

TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML

3Specialty Medical

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

3Specialty

Pharmacy; PV*



76

Drug NameDrug Tier

Notes

TYBOST ORAL TABLET 150 MG

3 ST

valacyclovir hcl oral tablet 1 gm, 500 mg

1

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

3Specialty Pharmacy

VALCYTE ORAL TABLET 450 MG

3Specialty Pharmacy

valganciclovir hcl oral solution reconstituted 50 mg/ml

2Specialty Pharmacy

valganciclovir hcl oral tablet 450 mg

2Specialty Pharmacy

VALTREX ORAL TABLET 1 GM, 500 MG

3Brand

penalty applies

VEMLIDY ORAL TABLET 25 MG

2PA;

Specialty Pharmacy

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50

3PA;

Specialty Pharmacy

VIRACEPT ORAL TABLET 250 MG, 625 MG

3

VIRAMUNE ORAL SUSPENSION 50 MG/5ML

3Brand

penalty applies

VIRAMUNE ORAL TABLET 200 MG

3Brand

penalty applies

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

3Brand

penalty applies

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

3PA;

Specialty Medical

VIREAD ORAL POWDER 40 MG/GM

2

Drug NameDrug Tier

Notes

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VIREAD ORAL TABLET 300 MG

2Brand

penalty applies

VOSEVI ORAL TABLET 400-100-100 MG

3PA;

Specialty Pharmacy

XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 X 20 MG

3QL (2 EA per 180 days)

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 X 40 MG


ZEPATIER ORAL TABLET 50-100 MG

3PA;

Specialty Pharmacy

ZIAGEN ORAL SOLUTION 20 MG/ML

3Brand

penalty applies

ZIAGEN ORAL TABLET 300 MG

3Brand

penalty applies

zidovudine oral capsule 100 mg

1

zidovudine oral syrup 50 mg/5ml

1

zidovudine oral tablet 300 mg

1

ZOVIRAX EXTERNAL CREAM 5 %

2Brand

penalty applies

ZOVIRAX EXTERNAL OINTMENT 5 %

2

Brand penalty

applies; QL (15 GM per

30 days)

ZOVIRAX ORAL SUSPENSION 200 MG/5ML

3Brand

penalty applies



77

Drug NameDrug Tier

Notes

Anxiolytics - Drugs for Anxiety

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

1

alprazolam intensol oral concentrate 1 mg/ml

1

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

1

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

1 ST

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

1

ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML

GM

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

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

RG

buspirone hcl oral tablet 30 mg, 7.5 mg

1

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

1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

1

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

1

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

1

diazepam intensol oral concentrate 5 mg/ml

1

Drug NameDrug Tier

Notes

diazepam oral concentrate 5 mg/ml

1

diazepam oral solution 5 mg/5ml

1

diazepam oral tablet 10 mg, 2 mg, 5 mg

1

diazepam solution 5 mg/ml injection 5 mg/ml

GM

DIAZEPAM SOLUTION 5 MG/ML INJECTION 5 MG/ML

GM

DORAL ORAL TABLET 15 MG

3Brand

penalty applies

estazolam oral tablet 1 mg, 2 mg

1

HALCION ORAL TABLET 0.25 MG

3Brand

penalty applies

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

GM

hydroxyzine hcl oral syrup 10 mg/5ml

1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

1

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

1

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

lorazepam injection solution 2 mg/ml, 4 mg/ml

GM

lorazepam intensol oral concentrate 2 mg/ml

1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

1



78

Drug NameDrug Tier

Notes

meprobamate oral tablet 200 mg, 400 mg

1

midazolam hcl (pf) injection solution 10 mg/2ml, 2 mg/2ml, 5 mg/5ml, 5 mg/ml

GM

midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml

GM

MIDAZOLAM HCL INTRAVENOUS SOLUTION 150 MG/30ML

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.8 MG/100ML-%, 50-0.8 MG/50ML-%, 50-0.9 MG/50ML-%

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 MG/2ML-%, 5-0.9 MG/5ML-%, 55-0.9 MG/55ML-%

GM

MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%

GM

oxazepam oral capsule 10 mg, 15 mg, 30 mg

1

quazepam oral tablet 15 mg

1

TRANXENE-T ORAL TABLET 7.5 MG

3Brand

penalty applies

triazolam oral tablet 0.125 mg, 0.25 mg

1

Drug NameDrug Tier

Notes

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG

3Brand

penalty applies

VISTARIL ORAL CAPSULE 25 MG, 50 MG

3Brand

penalty applies

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG

3Brand

penalty applies

Bipolar Agents - Drugs for Mood Disorders

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

3

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

1

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

RG

lithium carbonate oral tablet 300 mg

1

lithium oral solution 8 meq/5ml

1

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

2



79

Drug NameDrug Tier

Notes

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

3Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT, 750 UNIT

3Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 3000 UNIT

3PA;

Specialty Medical

AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

AGRYLIN ORAL CAPSULE 0.5 MG

3Brand

penalty applies

ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

3Specialty Medical

Drug NameDrug Tier

Notes

ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

3Specialty Medical

ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

3Specialty Medical

AMICAR ORAL SOLUTION 0.25 GM/ML

3Brand

penalty applies

AMICAR ORAL TABLET 1000 MG, 500 MG

3Brand

penalty applies

aminocaproic acid intravenous solution 250 mg/ml

GM

aminocaproic acid oral solution 0.25 gm/ml

1

aminocaproic acid oral tablet 1000 mg, 500 mg

1

anagrelide hcl oral capsule 0.5 mg, 1 mg

1

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

3Specialty Pharmacy



80

Drug NameDrug Tier

Notes

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

3Specialty Pharmacy

BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM

COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT

3Specialty Medical

CORIFACT INTRAVENOUS KIT 1000-1600 UNIT

3Specialty Medical

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML

GM

DOPTELET ORAL TABLET 20 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT

3Specialty Medical

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

3Specialty Pharmacy

ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT

3Specialty Medical

FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED

GM

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

2Specialty Pharmacy

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6ML

2Specialty Pharmacy

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

2Specialty Pharmacy



81

Drug NameDrug Tier

Notes

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML

GM

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

3Specialty Medical

HESPAN INTRAVENOUS SOLUTION 6-0.9 %

GM

hetastarch-nacl intravenous solution 6-0.9 %

GM

HEXTEND INTRAVENOUS SOLUTION 6 %

GM

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

3Specialty Medical

IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT

3Specialty Medical

IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

Drug NameDrug Tier

Notes

KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT

GM

KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

3Specialty Medical

KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

3Specialty Medical

KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

LEUKINE INJECTION SOLUTION RECONSTITUTED 250 MCG

3Specialty Medical

LMD IN D5W INTRAVENOUS SOLUTION 10-5 %

GM

LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 %

GM

LYSTEDA ORAL TABLET 650 MG

2Brand

penalty applies



82

Drug NameDrug Tier

Notes

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

3

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

3Specialty Medical

MONSELS FERRIC SUBSULFATE EXTERNAL SOLUTION

3

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML

3PA;

Specialty Medical

MULPLETA ORAL TABLET 3 MG

3PA;

Specialty Pharmacy

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

3Specialty Pharmacy

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

3Specialty Pharmacy

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

3Specialty Pharmacy

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

3Specialty Pharmacy

Drug NameDrug Tier

Notes

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

2Specialty Pharmacy

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

2Specialty Pharmacy

NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG

3Specialty Medical

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG, 250 MCG, 500 MCG

3PA;

Specialty Medical

NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

3Specialty Medical

NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

3Specialty Medical

OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

3Specialty Medical



83

Drug NameDrug Tier

Notes

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

GM

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

3Specialty Pharmacy

PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

3Specialty Medical

PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT

3Specialty Medical

PROMACTA ORAL PACKET 25 MG

3PA;

Specialty Pharmacy

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

3PA;

Specialty Pharmacy

protamine sulfate intravenous solution 10 mg/ml

GM

REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT

GM

REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG, 75 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT

3Specialty Medical

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

3

RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT

3

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

2Specialty Pharmacy

RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED

GM

RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML

3PA;

Specialty Medical

TAVALISSE ORAL TABLET 100 MG, 150 MG

3PA;

Specialty Pharmacy

THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT

3



84

Drug NameDrug Tier

Notes

THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT

3

THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

3

THROMBOGEN EXTERNAL KIT 10000 UNIT

3

THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT

3

tranexamic acid intravenous solution 1000 mg/10ml

GM

tranexamic acid oral tablet 650 mg

1

TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 1000-0.7 MG/100ML-%

GM

TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT

3Specialty Medical

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

2Specialty Pharmacy

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML

3PA;

Specialty Medical

VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT

3Specialty Medical

WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT

3Specialty Medical

Drug NameDrug Tier

Notes

XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

3Specialty Medical

XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

3Specialty Medical

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

2Specialty Pharmacy

ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

2Specialty Pharmacy

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3Brand

penalty applies

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3Brand

penalty applies

acebutolol hcl oral capsule 200 mg, 400 mg

1

acetazolamide sodium injection solution reconstituted 500 mg

GM

ADENOCARD INTRAVENOUS SOLUTION 6 MG/2ML

GM

adenosine intravenous solution 12 mg/4ml, 6 mg/2ml

GM

AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML

GM



85

Drug NameDrug Tier

Notes

ALDACTAZIDE ORAL TABLET 25-25 MG

3Brand

penalty applies

ALDACTAZIDE ORAL TABLET 50-50 MG

2

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

aliskiren fumarate oral tablet 150 mg, 300 mg

1

alprostadil injection solution 500 mcg/ml

GM

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 40 MG, 60 MG

3 PA

amiloride hcl oral tablet 5 mg

1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

1

amiodarone hcl intravenous solution 150 mg/3ml, 450 mg/9ml, 900 mg/18ml

GM

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

1

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

RG

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

1

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

1

Drug NameDrug Tier

Notes

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

1

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

1

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

1

ANTARA ORAL CAPSULE 30 MG, 90 MG

3

ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 %

GM

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG

3Brand

penalty applies

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3Brand

penalty applies

atenolol oral tablet 100 mg, 25 mg, 50 mg

1

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

1

atorvastatin calcium oral tablet 10 mg, 20 mg

1 PV*

atorvastatin calcium oral tablet 40 mg, 80 mg

1

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG

3Brand

penalty applies

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG

3Brand

penalty applies



86

Drug NameDrug Tier

Notes

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG

3Brand

penalty applies

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

RG

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

1

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG

2Brand

penalty applies

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

2Brand

penalty applies

BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG

3Brand

penalty applies

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG

3Brand

penalty applies

betaxolol hcl oral tablet 10 mg, 20 mg

1

BIDIL ORAL TABLET 20-37.5 MG

3

BIORPHEN INTRAVENOUS SOLUTION 0.5 MG/5ML

GM

bisoprolol fumarate oral tablet 10 mg, 5 mg

1

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

RG

BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

Drug NameDrug Tier

Notes

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML

GM

BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 MG/100ML

GM

BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 MG/250ML

GM

bumetanide injection solution 0.25 mg/ml

GM

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg

1

BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

2

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

3Brand

penalty applies

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG

3Brand

penalty applies

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

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

1

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

1



87

Drug NameDrug Tier

Notes

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

1

CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML-%, 20-4.8 MG/200ML-%, 40-0.83 MG/200ML-%

GM

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

3Brand

penalty applies

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG

2Brand

penalty applies

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

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

3Brand

penalty applies

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

3Brand

penalty applies

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG

3Brand

penalty applies

cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1

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

RG

Drug NameDrug Tier

Notes

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

1

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG

3Brand

penalty applies

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR

3Brand

penalty applies


3Brand

penalty applies


3Brand

penalty applies

chlorothiazide oral tablet 250 mg, 500 mg

1

chlorothiazide sodium intravenous solution reconstituted 500 mg

GM

chlorthalidone oral tablet 25 mg, 50 mg

1

cholestyramine light oral packet 4 gm

1

cholestyramine light oral powder 4 gm/dose

1

cholestyramine oral packet 4 gm

1

cholestyramine oral powder 4 gm/dose

1

CLEVIPREX INTRAVENOUS EMULSION 25 MG/50ML, 50 MG/100ML

GM

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

1

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

1



88

Drug NameDrug Tier

Notes

colesevelam hcl oral packet 3.75 gm

1

colesevelam hcl oral tablet 625 mg

1

COLESTID FLAVORED ORAL GRANULES 5 GM

3Brand

penalty applies

COLESTID FLAVORED ORAL PACKET 5 GM

3Brand

penalty applies

COLESTID ORAL GRANULES 5 GM

3Brand

penalty applies

COLESTID ORAL PACKET 5 GM

3Brand

penalty applies

COLESTID ORAL TABLET 1 GM

3Brand

penalty applies

colestipol hcl oral granules 5 gm

1

colestipol hcl oral packet 5 gm

1

colestipol hcl oral tablet 1 gm

1

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG

3Brand

penalty applies

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG

3Brand

penalty applies

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

CORLANOR ORAL SOLUTION 5 MG/5ML

3 PA

CORLANOR ORAL TABLET 5 MG, 7.5 MG

3 PA

Drug NameDrug Tier

Notes

CORLOPAM INTRAVENOUS SOLUTION 10 MG/ML, 20 MG/2ML

GM

CORVERT INTRAVENOUS SOLUTION 1 MG/10ML

GM

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3Brand

penalty applies

DEMSER ORAL CAPSULE 250 MG

3

DIBENZYLINE ORAL CAPSULE 10 MG

3

PA; Brand penalty


digitek oral tablet 125 mcg, 250 mcg

1

digox oral tablet 125 mcg, 250 mcg

1

digoxin injection solution 0.25 mg/ml

GM

digoxin oral solution 0.05 mg/ml

1

digoxin oral tablet 125 mcg, 250 mcg

1

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG

2

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1



89

Drug NameDrug Tier

Notes

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

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

1

diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml

GM

diltiazem hcl intravenous solution reconstituted 100 mg

GM

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

1

DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-%

GM

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

1

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

3Brand

penalty applies

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

3Brand

penalty applies

disopyramide phosphate oral capsule 100 mg, 150 mg

1

DIURIL ORAL SUSPENSION 250 MG/5ML

3

dobutamine hcl intravenous solution 250 mg/20ml

GM

Drug NameDrug Tier

Notes

dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 mg/ml, 4-5 mg/ml-%

GM

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

1

dopamine hcl intravenous solution 40 mg/ml

GM

dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 mg/ml-%, 3.2-5 mg/ml-%

GM

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

1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

3

DYAZIDE ORAL CAPSULE 37.5-25 MG

3Brand

penalty applies

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

3Brand

penalty applies

EDARBI ORAL TABLET 40 MG, 80 MG

3 ST

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

3 ST

EDECRIN ORAL TABLET 25 MG

3Brand

penalty applies

EMERPHED INTRAVENOUS SOLUTION 5 MG/ML

GM

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

1



90

Drug NameDrug Tier

Notes

enalaprilat intravenous injectable 1.25 mg/ml

GM

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

1

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

3

EPANED ORAL SOLUTION 1 MG/ML

3

EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 25 MG/5ML, 50 MG/5ML

GM

ephedrine sulfate injection solution 50 mg/ml

GM

ephedrine sulfate intravenous solution 50 mg/ml

GM

EPHEDRINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML

GM

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 4-5 MG/250ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 8-0.9 MG/250ML-%

GM

epinephrine pf injection solution 1 mg/ml

GM

epinephrine solution prefilled syringe 1 mg/10ml injection 1 mg/10ml

GM

Drug NameDrug Tier

Notes

EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION 1 MG/10ML

GM

EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/10ML-%

GM

eplerenone oral tablet 25 mg, 50 mg

1

EQUAPAX/ATORVASTATIN/COQ10 ORAL THERAPY PACK 20 & 100 MG

3

esmolol hcl intravenous solution 100 mg/10ml

GM

ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

esmolol hcl-sodium chloride intravenous solution 2000 mg/100ml, 2500 mg/250ml

GM

ethacrynate sodium intravenous solution reconstituted 50 mg

GM

ethacrynic acid oral tablet 25 mg

1



91

Drug NameDrug Tier

Notes

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

3Brand

penalty applies

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG

3Brand

penalty applies

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG

3 PA

ezetimibe oral tablet 10 mg

1

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

1

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

1

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

1

fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg

1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

1

fenofibric acid oral capsule delayed release 135 mg, 45 mg

1

fenofibric acid oral tablet 105 mg

1

FIBRICOR ORAL TABLET 105 MG, 35 MG

3

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

1

Drug NameDrug Tier

Notes

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

1 PA

fluvastatin sodium oral capsule 20 mg, 40 mg

1

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

1

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

1

FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%

GM

furosemide injection solution 10 mg/ml

GM

furosemide oral solution 10 mg/ml, 8 mg/ml

1

furosemide oral tablet 20 mg, 40 mg, 80 mg

RG

gemfibrozil oral tablet 600 mg

1

guanfacine hcl oral tablet 1 mg, 2 mg

RG

hydralazine hcl injection solution 20 mg/ml

GM

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

1

hydrochlorothiazide oral capsule 12.5 mg

RG

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

RG

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

3Brand

penalty applies

ibutilide fumarate intravenous solution 1 mg/10ml

GM



92

Drug NameDrug Tier

Notes

indapamide oral tablet 1.25 mg, 2.5 mg

1

INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG

3Brand

penalty applies

INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

3

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

3

INSPRA ORAL TABLET 25 MG, 50 MG

3Brand

penalty applies

irbesartan oral tablet 150 mg, 300 mg, 75 mg

1

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

1

isoproterenol hcl injection solution 0.2 mg/ml

GM

ISORDIL TITRADOSE ORAL TABLET 40 MG

2Brand

penalty applies

ISORDIL TITRADOSE ORAL TABLET 5 MG

3Brand

penalty applies

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

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

1

isosorbide mononitrate oral tablet 10 mg, 20 mg

1

isoxsuprine hcl oral tablet 10 mg, 20 mg

1

Drug NameDrug Tier

Notes

isradipine oral capsule 2.5 mg, 5 mg

1

ISUPREL INJECTION SOLUTION 0.2 MG/ML

GM

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

3PA;

Specialty Pharmacy

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20 MG/4ML

GM

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

1

labetalol hcl solution 5 mg/ml intravenous 5 mg/ml

GM

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 MG/ML

GM

LANOXIN INJECTION SOLUTION 0.25 MG/ML

GM

LANOXIN ORAL TABLET 125 MCG, 250 MCG

2

LANOXIN ORAL TABLET 62.5 MCG

3

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

GM

LASIX ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG

3PA; Brand

penalty applies

LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML

GM



93

Drug NameDrug Tier

Notes

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3Brand

penalty applies

LIPOFEN ORAL CAPSULE 150 MG, 50 MG

3

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

RG

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

RG

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

3 PA

LOPID ORAL TABLET 600 MG

3Brand

penalty applies

LOPRESSOR HCT ORAL TABLET 50-25 MG

3Brand

penalty applies

LOPRESSOR ORAL TABLET 100 MG, 50 MG

3Brand

penalty applies

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

RG

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

RG

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3Brand

penalty applies

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG

3Brand

penalty applies

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

3Brand

penalty applies

lovastatin oral tablet 10 mg, 20 mg, 40 mg

1 PV*

Drug NameDrug Tier

Notes

LOVAZA ORAL CAPSULE 1 GM

3PA; Brand

penalty applies

mannitol intravenous solution 20 %, 25 %

GM

matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

MAXZIDE ORAL TABLET 75-50 MG

3Brand

penalty applies

MAXZIDE-25 ORAL TABLET 37.5-25 MG

3Brand

penalty applies

methyldopa oral tablet 250 mg, 500 mg

1

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

1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

1

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

1

metoprolol tartrate intravenous solution 5 mg/5ml

GM

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

RG

metoprolol tartrate oral tablet 37.5 mg, 75 mg

1

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

1

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

1



94

Drug NameDrug Tier

Notes

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

3Brand

penalty applies

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

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

1

milrinone lactate in dextrose intravenous solution 20-5 mg/100ml-%, 40-5 mg/200ml-%

GM

milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml

GM

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG

3Brand

penalty applies

minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

minoxidil oral tablet 10 mg, 2.5 mg

1

moexipril hcl oral tablet 15 mg, 7.5 mg

1

MULTAQ ORAL TABLET 400 MG

2

nadolol oral tablet 20 mg, 40 mg, 80 mg

1

NEXLETOL ORAL TABLET 180 MG

3 PA

NEXLIZET ORAL TABLET 180-10 MG

3 PA

NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-%

GM

niacin (antihyperlipidemic) oral tablet 500 mg

1

Drug NameDrug Tier

Notes

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

1

niacor oral tablet 500 mg 1

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG

3Brand

penalty applies

NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 20-0.9 MG/200ML-%, 40-0.9 MG/200ML-%

GM

nicardipine hcl intravenous solution 2.5 mg/ml

GM

nicardipine hcl oral capsule 20 mg, 30 mg

1

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine oral capsule 10 mg, 20 mg

1

nimodipine oral capsule 30 mg

1

NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-%

GM

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

1



95

Drug NameDrug Tier

Notes

NITRO-BID TRANSDERMAL OINTMENT 2 %

2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

2Brand

penalty applies

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

2

nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 mcg/ml-%

GM

nitroglycerin intravenous solution 5 mg/ml

GM

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

nitroglycerin translingual solution 0.4 mg/spray

1

NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY

3Brand

penalty applies

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY

2

NITROPRESS INTRAVENOUS SOLUTION 25 MG/ML

GM

nitroprusside sodium intravenous solution 25 mg/ml

GM

Drug NameDrug Tier

Notes

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

2Brand

penalty applies

nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

1

norepinephrine bitartrate intravenous solution 1 mg/ml

GM

NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 8-5 MG/500ML-%

GM

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 16-0.9 MG/250ML-%

GM

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

2

NORPACE ORAL CAPSULE 100 MG, 150 MG

3Brand

penalty applies

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

3PA;

Specialty Pharmacy

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

1

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

1



96

Drug NameDrug Tier

Notes

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

1

omega-3-acid ethyl esters oral capsule 1 gm

1 PA

OSMITROL INTRAVENOUS SOLUTION 10 %

GM

osmitrol intravenous solution 15 %, 20 %

GM

PACERONE ORAL TABLET 100 MG, 400 MG

3Brand

penalty applies

pacerone oral tablet 200 mg

1

pentoxifylline er oral tablet extended release 400 mg

1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

1

phenoxybenzamine hcl oral capsule 10 mg


days)

phentolamine mesylate injection solution reconstituted 5 mg

GM

PHENYLEPHRINE HCL (PRESSORS) INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5 MG/5ML, 1 MG/10ML

GM

phenylephrine hcl intravenous solution 10 mg/ml

GM

PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/10ML, 0.8 MG/10ML, 1 MG/10ML

GM

Drug NameDrug Tier

Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/250ML-%, 20-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML-%, 80-0.9 MG/250ML-%

GM

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5-0.9 MG/5ML-%

GM

pindolol oral tablet 10 mg, 5 mg

1

POLIDOCANOL INTRAVENOUS SOLUTION 5 %

GM

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML

3 PA

PRAVACHOL ORAL TABLET 20 MG, 40 MG

3Brand

penalty applies

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 PV*

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

1

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG

3

prevalite oral packet 4 gm

1

prevalite oral powder 4 gm/dose

1

PRINIVIL ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies



97

Drug NameDrug Tier

Notes

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

GM

PROCARDIA ORAL CAPSULE 10 MG

3Brand

penalty applies

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

3Brand

penalty applies

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol hcl intravenous solution 1 mg/ml

GM

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

1

PROSTIN VR INJECTION SOLUTION 500 MCG/ML

GM

QBRELIS ORAL SOLUTION 1 MG/ML

3

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE

3Brand

penalty applies

Drug NameDrug Tier

Notes

QUESTRAN ORAL PACKET 4 GM

3Brand

penalty applies

QUESTRAN ORAL POWDER 4 GM/DOSE

3Brand

penalty applies

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

1

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

1

quinidine gluconate er oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg

1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

3Brand

penalty applies

ranolazine er oral tablet extended release 12 hour 1000 mg, 500 mg

1

RECTIV RECTAL OINTMENT 0.4 %

3

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

3 PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

3 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

3 PA



98

Drug NameDrug Tier

Notes

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG, 425 MG

3Brand

penalty applies

simvastatin oral tablet 10 mg, 20 mg, 40 mg

RG PV*

simvastatin oral tablet 5 mg, 80 mg

RG

SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

sodium tetradecyl sulfate intravenous solution 3 %

GM

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

1

SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML

GM

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 %

GM

SOTYLIZE ORAL SOLUTION 5 MG/ML

3

spironolactone oral tablet 100 mg, 25 mg, 50 mg

1

spironolactone-hctz oral tablet 25-25 mg

1

Drug NameDrug Tier

Notes

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG

3Brand

penalty applies

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG

3Brand

penalty applies

taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

2

TEKTURNA ORAL TABLET 150 MG, 300 MG

2Brand

penalty applies

telmisartan oral tablet 20 mg, 40 mg, 80 mg

1

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

1

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

1

TENORETIC 100 ORAL TABLET 100-25 MG

3Brand

penalty applies

TENORETIC 50 ORAL TABLET 50-25 MG

3Brand

penalty applies

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1



99

Drug NameDrug Tier

Notes

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3Brand

penalty applies

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3Brand

penalty applies

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

3Brand

penalty applies

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

1

trandolapril oral tablet 1 mg, 2 mg, 4 mg

1

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

1

triamterene oral capsule 100 mg, 50 mg

1

triamterene-hctz oral capsule 37.5-25 mg

1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg

1

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

3Brand

penalty applies

TRICOR ORAL TABLET 145 MG, 48 MG

3Brand

penalty applies

TRIGLIDE ORAL TABLET 160 MG

3

Drug NameDrug Tier

Notes

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG

3Brand

penalty applies

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG

3Brand

penalty applies

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VARITHENA INTRAVENOUS FOAM 180 MG/18ML

GM

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM

3 PA

VASERETIC ORAL TABLET 10-25 MG

3Brand

penalty applies

VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

3Brand

penalty applies

VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML

GM

VECAMYL ORAL TABLET 2.5 MG

3

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

1

verapamil hcl intravenous solution 2.5 mg/ml

GM



100

Drug NameDrug Tier

Notes

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg

1

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

3Brand

penalty applies

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3Brand

penalty applies

VYNDAMAX ORAL CAPSULE 61 MG

3PA;

Specialty Pharmacy

VYNDAQEL ORAL CAPSULE 20 MG

3PA;

Specialty Pharmacy

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

3Brand

penalty applies

WELCHOL ORAL PACKET 3.75 GM

3Brand

penalty applies

WELCHOL ORAL TABLET 625 MG

3Brand

penalty applies

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3Brand

penalty applies

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

3Brand

penalty applies

ZETIA ORAL TABLET 10 MG

3Brand

penalty applies

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG

3Brand

penalty applies

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG

3 PA

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

3

Brand penalty


ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

3

Brand penalty


ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 30 MG

3

Brand penalty


amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1QL (30 EA

per 30 days)

amphetamine-dextroamphetamine er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg

1QL (60 EA

per 30 days)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1QL (90 EA

per 30 days)

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3



101

Drug NameDrug Tier

Notes

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg

1QL (60 EA

per 30 days)

atomoxetine hcl oral capsule 100 mg, 40 mg, 60 mg, 80 mg

1QL (30 EA

per 30 days)

clonidine hcl er oral tablet extended release 12 hour 0.1 mg

1

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG

3

Brand penalty


CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG

3

Brand penalty


DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

3QL (30 EA

per 30 days)

DESOXYN ORAL TABLET 5 MG

3Brand

penalty applies

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

3

Brand penalty


dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

1QL (30 EA

per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

1QL (90 EA

per 30 days)

Drug NameDrug Tier

Notes

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1QL (150

EA per 30 days)

dextroamphetamine sulfate oral solution 5 mg/5ml

1

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

1QL (180

EA per 30 days)

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 2.5 MG/ML

3

PA; AL (Min 6

Years and Max 12 Years)

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG

3

Brand penalty


FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

3

Brand penalty


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

1

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

3Brand

penalty applies

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG

3Brand

penalty applies

metadate er oral tablet extended release 20 mg

1QL (90 EA

per 30 days)

methamphetamine hcl oral tablet 5 mg

1



102

Drug NameDrug Tier

Notes

METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML

3

Brand penalty


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1QL (30 EA

per 30 days)

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

1QL (30 EA

per 30 days)

METHYLPHENIDATE HCL ER (XR) ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3

methylphenidate hcl er oral tablet extended release 10 mg

1

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg

1QL (30 EA

per 30 days)


1QL (90 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

1


1QL (60 EA

per 30 days)


1QL (1 EA per 1 day)

Drug NameDrug Tier

Notes

methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml

1QL (900

ML per 30 days)

methylphenidate hcl oral tablet 10 mg

1QL (180

EA per 30 days)


1


1QL (90 EA

per 30 days)

methylphenidate hcl oral tablet chewable 10 mg

1

methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg

1QL (90 EA

per 30 days)

PROCENTRA ORAL SOLUTION 5 MG/5ML

3Brand

penalty applies

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG

3

PA; AL (Min 6


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 25 MG/5ML

3

PA; QL (180 ML per 30 days)

relexxii oral tablet extended release 72 mg


RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG

3

Brand penalty


RITALIN ORAL TABLET 10 MG

3

Brand penalty




103

Drug NameDrug Tier

Notes


3Brand

penalty applies


3

Brand penalty


STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG

3

Brand penalty


STRATTERA ORAL CAPSULE 100 MG, 40 MG, 60 MG, 80 MG

3

Brand penalty


VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

3QL (30 EA

per 30 days)

VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3

PA; QL (30 EA per 30 days); AL

(Min 6 Years and

Max 12 Years)

ZENZEDI ORAL TABLET 10 MG, 5 MG

3

Brand penalty

applies; QL (2 EA per 1

day)

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3QL (60 EA

per 30 days)

Central Nervous System Agents - Drugs for Multiple Sclerosis

AUBAGIO ORAL TABLET 14 MG, 7 MG

2Specialty Pharmacy

Drug NameDrug Tier

Notes

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

2Specialty Pharmacy

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

2Specialty Pharmacy

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

2Specialty Pharmacy

BETASERON SUBCUTANEOUS KIT 0.3 MG

2Specialty Pharmacy

dalfampridine er oral tablet extended release 12 hour 10 mg

3PA;

Specialty Pharmacy

EXTAVIA SUBCUTANEOUS KIT 0.3 MG

2Specialty Pharmacy

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG

3Specialty Pharmacy

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

2Specialty Pharmacy

glatopa subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

2Specialty Pharmacy

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML

3PA;

Specialty Medical

MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 10 MG

3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy



104

Drug NameDrug Tier

Notes


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

MAYZENT ORAL TABLET 0.25 MG, 2 MG

3Specialty Pharmacy

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG

3Specialty Pharmacy

OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML

3PA;

Specialty Medical

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

2Specialty Pharmacy

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

2Specialty Pharmacy

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

2Specialty Pharmacy

Drug NameDrug Tier

Notes

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

2Specialty Pharmacy

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

2Specialty Pharmacy

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

2Specialty Pharmacy

TECFIDERA ORAL 120 & 240 MG

2Specialty Pharmacy

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

2Specialty Pharmacy

TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

3PA;

Specialty Medical

VUMERITY (STARTER) ORAL CAPSULE DELAYED RELEASE 231 MG

3PA;

Specialty Pharmacy

VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG

3PA;

Specialty Pharmacy

ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG

3PA;

Specialty Pharmacy

ZEPOSIA ORAL CAPSULE 0.92 MG

3PA;

Specialty Pharmacy



105

Drug NameDrug Tier

Notes

ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 0.23MG & 0.46MG & 0.92MG

3PA;

Specialty Pharmacy

Central Nervous System Agents - Miscellaneous

ANECTINE INJECTION SOLUTION 20 MG/ML

GM

atracurium besylate intravenous solution 100 mg/10ml, 50 mg/5ml

GM

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG

3PA;

Specialty Pharmacy

CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML

GM

caffeine citrate intravenous solution 60 mg/3ml

GM

caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

1

cisatracurium besylate (pf) intravenous solution 10 mg/5ml, 200 mg/20ml

GM

cisatracurium besylate intravenous solution 20 mg/10ml

GM

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML

GM

GRALISE ORAL TABLET 300 MG, 600 MG

3 ST

GRALISE STARTER ORAL 300 & 600 MG

3 ST

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG

3 ST

Drug NameDrug Tier

Notes

INGREZZA ORAL CAPSULE 40 MG, 80 MG

3PA;

Specialty Pharmacy

INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG

3PA;

Specialty Pharmacy

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG

3

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

3

LYRICA ORAL SOLUTION 20 MG/ML

3

NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 MG/10ML, 200 MG/20ML

GM

ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML

3PA;

Specialty Medical

pancuronium bromide intravenous solution 1 mg/ml

GM

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

1

pregabalin oral solution 20 mg/ml

1

QUELICIN INJECTION SOLUTION 20 MG/ML

GM

RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML

3PA;

Specialty Medical

RILUTEK ORAL TABLET 50 MG

3Specialty Pharmacy

riluzole oral tablet 50 mg3

Specialty Pharmacy



106

Drug NameDrug Tier

Notes

rocuronium bromide intravenous solution 100 mg/10ml, 50 mg/5ml

GM

ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/10ML, 75 MG/7.5ML

GM

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

3 PA

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

3 PA

succinylcholine chloride injection solution 20 mg/ml

GM

SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE 100 MG/5ML, 140 MG/7ML, 200 MG/10ML

GM

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML

3PA;

Specialty Pharmacy

tetrabenazine oral tablet 12.5 mg, 25 mg

2PA;

Specialty Pharmacy

TIGLUTIK ORAL SUSPENSION 50 MG/10ML

3Specialty Pharmacy

vecuronium bromide intravenous solution reconstituted 10 mg, 20 mg

GM

XENAZINE ORAL TABLET 12.5 MG, 25 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN DENTAL 1 MG GM

BOCASAL MOUTH/THROAT PACKET

3

cavarest dental gel 1.1 % 1

cevimeline hcl oral capsule 30 mg

1

chlorhexidine gluconate mouth/throat solution 0.12 %

1

clinpro 5000 dental paste 1.1 %

1

DEBACTEROL MOUTH/THROAT SOLUTION 30-50 %

3

denta 5000 plus dental cream 1.1 %

1

dentagel dental gel 1.1 % 1

easygel dental gel 0.4 % 1

EVOXAC ORAL CAPSULE 30 MG

3Brand

penalty applies

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION

3

fluoridex daily renewal mouth/throat concentrate 0.63 %

1

fluoridex dental paste 1.1 %

1

fluoridex enhanced whitening dental paste 1.1 %

1

fluoridex sensitivity relief dental paste 1.1-5 %

1



107

Drug NameDrug Tier

Notes

KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG

3PA;

Specialty Medical

lidocaine viscous hcl mouth/throat solution 2 %

1

MI PASTE DENTAL PASTE

3

MI PASTE PLUS DENTAL PASTE

3

MUCOSITISRX MOUTH/THROAT PACKET

3

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML

3

NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 %

3

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 0.2 %

3

neutral sodium fluoride mouth/throat solution 0.2 %

1

NEUTRASAL MOUTH/THROAT PACKET

3

NUMOISYN MOUTH/THROAT LOZENGE

3

oralone mouth/throat paste 0.1 %

1

paroex mouth/throat solution 0.12 %

1

Drug NameDrug Tier

Notes

PERIDEX MOUTH/THROAT SOLUTION 0.12 %

3Brand

penalty applies

periogard mouth/throat solution 0.12 %

1

pilocarpine hcl oral tablet 5 mg, 7.5 mg

1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

3

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 %

3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 %

3

PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 %

3

PREVIDENT 5000 PLUS DENTAL CREAM 1.1 %

3

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

3

PREVIDENT DENTAL GEL 1.1 %

3

prevident mouth/throat solution 0.2 %

1

REMESENSE DENTAL 3 %

3

SALAGEN ORAL TABLET 5 MG, 7.5 MG

3Brand

penalty applies

SALIVAMAX MOUTH/THROAT PACKET

3

sf 5000 plus dental cream 1.1 %

1

sf dental gel 1.1 % 1

sodium fluoride 5000 plus dental cream 1.1 %

1



108

Drug NameDrug Tier

Notes

sodium fluoride 5000 ppm dental cream 1.1 %

1

sodium fluoride 5000 ppm dental paste 1.1 %

1

sodium fluoride 5000 sensitive dental paste 1.1-5 %

1

sodium fluoride dental cream 1.1 %

1

sodium fluoride dental gel 1.1 %

1

TOPEX TOPICAL ANESTHETIC MOUTH/THROAT AEROSOL 20 %

3

triamcinolone acetonide mouth/throat paste 0.1 %

1

XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION

3

Dermatological Agents - Drugs for Skin Conditions

ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, 8 MG

3 PA

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

3 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

1

ACZONE EXTERNAL GEL 5 %

3Brand

penalty applies

adapalene external cream 0.1 %

1

adapalene external gel 0.1 %, 0.3 %

1

ALA SCALP EXTERNAL LOTION 2 %

3

Drug NameDrug Tier

Notes

ala-cort external cream 1 %, 2.5 %

1

alclometasone dipropionate external cream 0.05 %

1

alclometasone dipropionate external ointment 0.05 %

1

ALCOHOL PREP PADS EXTERNAL 70 %

3

amcinonide external cream 0.1 %

1

amcinonide external lotion 0.1 %

1

amcinonide external ointment 0.1 %

1

ammonium lactate external cream 12 %

1

ammonium lactate external lotion 12 %

1

amnesteem oral capsule 10 mg, 20 mg, 40 mg


ANACAINE EXTERNAL OINTMENT 10 %

3

APEXICON E EXTERNAL CREAM 0.05 %

3

AQUACEL AG BURN EXTERNAL PAD 4"X5"

3

arzol silver nit applicators external 75-25 %

1

ATRAPRO DERMAL SPRAY EXTERNAL LIQUID

3

avar cleanser external emulsion 10-5 %

1

AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 %

3

AVAR-E GREEN EXTERNAL CREAM 10-5 %

3



109

Drug NameDrug Tier

Notes

avita external cream 0.025 %

1

avita external gel 0.025 %

1

azelaic acid external gel 15 %

1 PA

AZELEX EXTERNAL CREAM 20 %

3 PA

balsam peru-castor oil external ointment

1

BENSAL HP EXTERNAL OINTMENT 3-6 %

3

benzoin compound external tincture

1

benzoin external tincture 1

beser external lotion 0.05 %

1

betamethasone dipropionate aug external cream 0.05 %

1

betamethasone dipropionate aug external gel 0.05 %

1

betamethasone dipropionate aug external lotion 0.05 %

1

betamethasone dipropionate aug external ointment 0.05 %

1

betamethasone dipropionate external cream 0.05 %

1

betamethasone dipropionate external lotion 0.05 %

1

betamethasone dipropionate external ointment 0.05 %

1

betamethasone valerate external cream 0.1 %

1

betamethasone valerate external lotion 0.1 %

1

Drug NameDrug Tier

Notes

betamethasone valerate external ointment 0.1 %

1

bp 10-1 external emulsion 10-1 %

1

BP CLEANSING WASH EXTERNAL EMULSION 10-4 %

3 PA

BPCO EXTERNAL OINTMENT

3

calcipotriene external cream 0.005 %

1

calcipotriene external ointment 0.005 %

1

calcipotriene external solution 0.005 %

1

calcipotriene-betameth diprop external ointment 0.005-0.064 %

1 ST

CALCITRENE EXTERNAL OINTMENT 0.005 %

3Brand

penalty applies

calcitriol external ointment 3 mcg/gm

1 ST

CAPEX EXTERNAL SHAMPOO 0.01 %

3

cem-urea external solution 45 %

1

cerovel external lotion 40 %

1

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg


clindacin etz external swab 1 %

1

clindacin-p external swab 1 %

1

clindamycin phosphate external foam 1 %

1

clindamycin phosphate external gel 1 %

1



110

Drug NameDrug Tier

Notes

clindamycin phosphate external lotion 1 %

1

clindamycin phosphate external solution 1 %

1

clindamycin phosphate external swab 1 %

1

clobetasol prop emollient base external cream 0.05 %

1

clobetasol propionate e external cream 0.05 %

1

clobetasol propionate emulsion external foam 0.05 %

1

clobetasol propionate external cream 0.05 %

1

clobetasol propionate external foam 0.05 %

1

clobetasol propionate external gel 0.05 %

1

clobetasol propionate external lotion 0.05 %

1

clobetasol propionate external ointment 0.05 %

1

clobetasol propionate external shampoo 0.05 %

1

clobetasol propionate external solution 0.05 %

1

CLOBEX EXTERNAL LOTION 0.05 %

3Brand

penalty applies

CLOBEX EXTERNAL SHAMPOO 0.05 %

3Brand

penalty applies

clocortolone pivalate external cream 0.1 %

1

clodan external shampoo 0.05 %

1

CLODERM EXTERNAL CREAM 0.1 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

coal tar external solution 20 %

1

CONDYLOX EXTERNAL GEL 0.5 %

2

CORDRAN EXTERNAL CREAM 0.025 %

3

CORDRAN EXTERNAL CREAM 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL LOTION 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL TAPE 4 MCG/SQCM

3

CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML

3

CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5

3

CORTISPORIN EXTERNAL OINTMENT 1 %

3

CUTIVATE EXTERNAL LOTION 0.05 %

3Brand

penalty applies

dapsone external gel 5 % 1

DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 %

3Brand

penalty applies

DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 %

3Brand

penalty applies

DERMULCERA EXTERNAL OINTMENT

3

DESONATE EXTERNAL GEL 0.05 %

3

desonide external cream 0.05 %

1



111

Drug NameDrug Tier

Notes

desonide external gel 0.05 %

1

desonide external lotion 0.05 %

1

desonide external ointment 0.05 %

1

DESOWEN EXTERNAL CREAM 0.05 %

3Brand

penalty applies

desoximetasone external cream 0.05 %, 0.25 %

1

desoximetasone external gel 0.05 %

1

desoximetasone external liquid 0.25 %

1

desoximetasone external ointment 0.05 %, 0.25 %

1

diclofenac sodium transdermal gel 3 %

1

diflorasone diacetate external cream 0.05 %

1

diflorasone diacetate external ointment 0.05 %

1

DIPROLENE AF EXTERNAL CREAM 0.05 %

3Brand

penalty applies

DIPROLENE EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

doxepin hcl external cream 5 %

1

DRITHO-CREME HP EXTERNAL CREAM 1 %

2

DRYSOL EXTERNAL SOLUTION 20 %

2

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML

2PA;

Specialty Pharmacy

ELIDEL EXTERNAL CREAM 1 %

3Brand

penalty applies

EPIFOAM EXTERNAL FOAM 1-1 %

3

ery external pad 2 % 1

erythromycin external gel 2 %

1

erythromycin external solution 2 %

1

EUCRISA EXTERNAL OINTMENT 2 %

3 PA

FINACEA EXTERNAL FOAM 15 %

3 PA

FINACEA EXTERNAL GEL 15 %

3PA; Brand

penalty applies

fluocinolone acetonide body external oil 0.01 %

1

fluocinolone acetonide external cream 0.01 %, 0.025 %

1

fluocinolone acetonide external ointment 0.025 %

1

fluocinolone acetonide external solution 0.01 %

1

fluocinolone acetonide scalp external oil 0.01 %

1

fluocinonide emulsified base external cream 0.05 %

1

fluocinonide external cream 0.05 %

1

fluocinonide external gel 0.05 %

1



112

Drug NameDrug Tier

Notes

fluocinonide external ointment 0.05 %

1

fluocinonide external solution 0.05 %

1

fluorouracil external cream 5 %

1

fluorouracil external solution 2 %, 5 %

1

flurandrenolide external cream 0.05 %

1

flurandrenolide external lotion 0.05 %

1

flurandrenolide external ointment 0.05 %

1

fluticasone propionate external cream 0.05 %

1

fluticasone propionate external lotion 0.05 %

1

fluticasone propionate external ointment 0.005 %

1

glycolic acid solution 70 %

1

GORDOFILM EXTERNAL SOLUTION 16.7-16.7 %

3

grafco silver nit applicator external 75-25 %

1

halcinonide external cream 0.1 %

1

halobetasol propionate external cream 0.05 %

1

halobetasol propionate external ointment 0.05 %

1

HALOG EXTERNAL CREAM 0.1 %

3Brand

penalty applies

HALOG EXTERNAL OINTMENT 0.1 %

3

Drug NameDrug Tier

Notes

hydrocortisone ace-pramoxine external cream 2.5-1 %

1

hydrocortisone butyr lipo base external cream 0.1 %

1

hydrocortisone butyrate external cream 0.1 %

1

hydrocortisone butyrate external lotion 0.1 %

1

hydrocortisone butyrate external ointment 0.1 %

1

hydrocortisone butyrate external solution 0.1 %

1

hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone valerate external cream 0.2 %

1

hydrocortisone valerate external ointment 0.2 %

1

imiquimod external cream 5 %

1

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg


KENALOG EXTERNAL AEROSOL SOLUTION 0.147 MG/GM

3Brand

penalty applies

KERALYT EXTERNAL GEL 6 %

3

KERALYT SCALP EXTERNAL KIT 6 %

3

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

3

lactic acid e external cream 10-3500 %-unt/30gm

1



113

Drug NameDrug Tier

Notes

lactic acid external lotion 10 %

1

LATRIX XM EXTERNAL EMULSION 45 %

3

LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 20 %

GM

LOCOID EXTERNAL LOTION 0.1 %

3Brand

penalty applies

LOCOID LIPOCREAM EXTERNAL CREAM 0.1 %

3Brand

penalty applies

LOYON EXTERNAL SOLUTION

3

methoxsalen rapid oral capsule 10 mg

1

methyl salicylate external liquid

1

metronidazole external cream 0.75 %

1

metronidazole external gel 0.75 %, 1 %

1

metronidazole external lotion 0.75 %

1

MICROCYN EXTERNAL LIQUID 0.023 %

3

MIRVASO EXTERNAL GEL 0.33 %

3 PA

mometasone furoate external cream 0.1 %

1

mometasone furoate external ointment 0.1 %

1

mometasone furoate external solution 0.1 %

1

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg


NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 %

3

Drug NameDrug Tier

Notes

nolix external cream 0.05 %

1

nolix external lotion 0.05 %

1

NUCORT EXTERNAL LOTION 2 %

3

NUVAIL EXTERNAL SOLUTION

3

OLUX EXTERNAL FOAM 0.05 %

3Brand

penalty applies

OLUX-E EXTERNAL FOAM 0.05 %

3Brand

penalty applies

OVACE PLUS EXTERNAL CREAM 10 %

3

OVACE PLUS EXTERNAL SHAMPOO 10 %

3

OVACE PLUS WASH EXTERNAL LIQUID 10 %

3

OVACE WASH EXTERNAL LIQUID 10 %

3

OXSORALEN ULTRA ORAL CAPSULE 10 MG

2Brand

penalty applies

PANDEL EXTERNAL CREAM 0.1 %

3

PICATO EXTERNAL GEL 0.015 %, 0.05 %

3 PA

pimecrolimus external cream 1 %

1

podocon external solution 25 %

1

podofilox external solution 0.5 %

1

PRAMOSONE EXTERNAL CREAM 1-1 %, 1-2.5 %

3



114

Drug NameDrug Tier

Notes

PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 %

2

PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 %

2

pramox external gel 1 % 1

PRE & POST SX POUCH EXTERNAL THERAPY PACK 4 & 2 & 5 %

3

prednicarbate external cream 0.1 %

1

prednicarbate external ointment 0.1 %

1

PRUDOXIN EXTERNAL CREAM 5 %

3Brand

penalty applies

PSORCON EXTERNAL CREAM 0.05 %

3

PURAPLY EXTERNAL SHEET 6X9CM

GM

PYROGALLIC ACID EXTERNAL OINTMENT 25-2 %

3

QBREXZA EXTERNAL PAD 2.4 %

3 PA

QUTENZA (2 PATCH) EXTERNAL KIT 8 %

3Specialty Medical

QUTENZA EXTERNAL KIT 8 %

3Specialty Medical

REGRANEX EXTERNAL GEL 0.01 %

3 PA

RESORCINOL-SULFUR EXTERNAL LOTION 2-5 %

3

RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 %

3Brand

penalty applies

RETIN-A EXTERNAL GEL 0.01 %, 0.025 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

RETIN-A MICRO EXTERNAL GEL 0.1 %

3Brand

penalty applies

RETIN-A MICRO PUMP EXTERNAL GEL 0.1 %

3Brand

penalty applies

RHOFADE EXTERNAL CREAM 1 %

3 PA

rosadan external cream 0.75 %

1

rosadan external gel 0.75 %

1

SALEX EXTERNAL KIT 6 % (CREAM), 6 % (LOTION)

3

SALEX EXTERNAL SHAMPOO 6 %

3

salicylic acid external cream 6 %

1

salicylic acid external foam 6 %

1

salicylic acid external gel 6 %

1

salicylic acid external liquid 27.5 %

1

salicylic acid external lotion 6 %

1

salicylic acid external shampoo 6 %

1

salicylic acid external solution 26 %

1

salicylic acid wart remover external liquid 27.5 %

1

salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)

1

salimez external cream 6 %

1

SALIMEZ FORTE EXTERNAL CREAM 10 %

3



115

Drug NameDrug Tier

Notes

SALVAX DUO PLUS EXTERNAL KIT 6 & 35 %

3

SALVAX EXTERNAL FOAM 6 %

3

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

3

SCALACORT DK EXTERNAL KIT 2 & 2-2 %

3

SCENESSE SUBCUTANEOUS IMPLANT 16 MG

3PA;

Specialty Medical

selenium sulfide external lotion 2.5 %

1

selenium sulfide external shampoo 2.25 %, 2.3 %

1

SELRX EXTERNAL SHAMPOO 2.3 %

3

sodium sulfacetamide external shampoo 10 %

1

sodium sulfacetamide wash liquid 10 % external 10 %

1

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL 10 %

3

SOOLANTRA EXTERNAL CREAM 1 %

3 PA

SORIATANE ORAL CAPSULE 10 MG, 25 MG

2Brand

penalty applies

sss 10-5 external cream 10-5 %

1

sulfacetamide sodium (acne) external lotion 10 %

1

sulfacetamide sodium external liquid 10 %

1

Drug NameDrug Tier

Notes

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %

1

sulfacetamide sodium-sulfur external emulsion 10-5 %

1

sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur external pad 10-4 %

1

sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 %

1

sulfacetamide-sulfur in urea external emulsion 10-5 %

1

sulfacleanse 8/4 external suspension 8-4 %

1

sulfamez wash external emulsion 10-1 %

1

SYNALAR EXTERNAL CREAM 0.025 %

3Brand

penalty applies

SYNALAR EXTERNAL OINTMENT 0.025 %

3Brand

penalty applies

SYNALAR EXTERNAL SOLUTION 0.01 %

3Brand

penalty applies

tacrolimus external ointment 0.03 %, 0.1 %

1

TASOPROL EXTERNAL KIT 0.05 %

3

tazarotene external cream 0.1 %

1 PA

TAZORAC EXTERNAL CREAM 0.05 %

3 PA



116

Drug NameDrug Tier

Notes

TAZORAC EXTERNAL CREAM 0.1 %

3PA; Brand

penalty applies

TAZORAC EXTERNAL GEL 0.05 %, 0.1 %

3 PA

TEMOVATE EXTERNAL CREAM 0.05 %

3Brand

penalty applies

TEMOVATE EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

TEXACORT EXTERNAL SOLUTION 2.5 %

3

THERAHONEY EXTERNAL SHEET

3

TOPICORT EXTERNAL CREAM 0.05 %, 0.25 %

3Brand

penalty applies

TOPICORT EXTERNAL GEL 0.05 %

3Brand

penalty applies

TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 %

2Brand

penalty applies

TOPICORT SPRAY EXTERNAL LIQUID 0.25 %

3Brand

penalty applies

tovet external foam 0.05 %

1

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin microsphere external gel 0.04 %, 0.1 %

1

tretinoin microsphere pump external gel 0.04 %, 0.1 %

1

triamcinolone acetonide external aerosol solution 0.147 mg/gm

1

Drug NameDrug Tier

Notes

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide external lotion 0.025 %, 0.1 %

1

triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 %, 0.5 %

1

trianex external ointment 0.05 %

1

TRI-CHLOR EXTERNAL LIQUID 80 %

3

triderm external cream 0.1 %, 0.5 %

1

TRIDESILON EXTERNAL CREAM 0.05 %

3Brand

penalty applies

turpentine external spirit 1

urea external cream 39 %, 40 %, 41 %, 45 %

1

urea external lotion 40 % 1

urea external suspension 40 %

1

urea hydrating external foam 35 %

1

urea nail external gel 45 %

1

urea-c40 external lotion 40 %

1

uredeb external cream 39 %

1

uremez-40 external cream 40 %

1

VECTICAL EXTERNAL OINTMENT 3 MCG/GM

3ST; Brand

penalty applies

VENELEX EXTERNAL OINTMENT

3

VERDESO EXTERNAL FOAM 0.05 %

3



117

Drug NameDrug Tier

Notes

VEREGEN EXTERNAL OINTMENT 15 %

3

VIRASAL EXTERNAL LIQUID 27.5 %

3

XERAC AC EXTERNAL SOLUTION 6.25 %

3

XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD

3

XEROFORM OIL EMULSION GAUZE EXTERNAL PAD

3

XEROFORM OIL EMULSION STRIP EXTERNAL

3

XEROFORM OIL ROLL 4"X9' EXTERNAL 3 %

3

XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL

3

XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL

3

XEROFORM PETROLAT PATCH 2"X2" EXTERNAL PAD

3

XEROFORM PETROLAT PATCH 4"X4" EXTERNAL PAD

3

XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL

3

xurea external cream 39 %

1

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg


ZITHRANOL EXTERNAL SHAMPOO 1 %

3

ZONALON EXTERNAL CREAM 5 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

Diabetes - Antidiabetic Agents

acarbose oral tablet 100 mg, 25 mg, 50 mg

1

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG

3Brand

penalty applies

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

3Brand

penalty applies

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML

3 PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML

3 PA

ALOGLIPTIN BENZOATE ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 MG, 12.5-500 MG


days)

ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG

3Brand

penalty applies

AVANDIA ORAL TABLET 2 MG, 4 MG

3 ST

BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML

2PA; QL




118

Drug NameDrug Tier

Notes

BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG


days)

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG


days)

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

2PA; QL


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

2PA; QL


CYCLOSET ORAL TABLET 0.8 MG

3

DUETACT ORAL TABLET 30-2 MG, 30-4 MG

2Brand

penalty applies

FARXIGA ORAL TABLET 10 MG, 5 MG


days)

glimepiride oral tablet 1 mg, 2 mg, 4 mg

RG

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

1

glipizide oral tablet 10 mg, 5 mg

RG

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

1

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

1

GLUCOTROL ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

1

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG

3Brand

penalty applies

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG


days)

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


days)

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


days)

INVOKANA ORAL TABLET 100 MG, 300 MG


days)

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


days)

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


days)



119

Drug NameDrug Tier

Notes

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


days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


days)

JARDIANCE ORAL TABLET 10 MG, 25 MG


days)

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


days)

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


days)

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


days)

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


days)

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


days)

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG


days)

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

RG

metformin hcl oral solution 500 mg/5ml

1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

RG

miglitol oral tablet 100 mg, 25 mg, 50 mg

1

Drug NameDrug Tier

Notes

nateglinide oral tablet 120 mg, 60 mg

1

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG


days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

2PA; QL


OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML


days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg

1

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

1

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

1

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

QTERN ORAL TABLET 10-5 MG


days)

QTERN ORAL TABLET 5-5 MG

3PA; QL (1 EA per 1

day)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg

1



120

Drug NameDrug Tier

Notes

RIOMET ORAL SOLUTION 500 MG/5ML

3Brand

penalty applies

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG


days)

SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG


days)

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML


days)

STARLIX ORAL TABLET 120 MG, 60 MG

3Brand

penalty applies

STEGLATRO ORAL TABLET 15 MG, 5 MG


days)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG


days)

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

3 ST

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

3 ST

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG


days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG


days)

Drug NameDrug Tier

Notes

tolbutamide oral tablet 500 mg

1

TRADJENTA ORAL TABLET 5 MG


days)

TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG


days)

TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG


days)

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG


days)

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

3 PA

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


days)



121

Drug NameDrug Tier

Notes

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML


days)

Diabetes - Glucose Monitoring

FREESTYLE INSULINX TEST IN VITRO STRIP

2QL (150

EA per 30 days)

FREESTYLE LITE TEST IN VITRO STRIP

2QL (150

EA per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP

2QL (150

EA per 30 days)

FREESTYLE TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION PCX PLUS TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION QID TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION SOF-TACT TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP

2

Diabetes - Glycemic Agents

BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE

3

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE

3

Drug NameDrug Tier

Notes

diazoxide oral suspension 50 mg/ml

1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

2

GLUCAGON EMERGENCY KIT INJECTION KIT 1 MG

2

GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED 1 MG/ML

GM

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML

3

PROGLYCEM ORAL SUSPENSION 50 MG/ML

3Brand

penalty applies

Diabetes - Insulins

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3ST; QL (60 ML per 30

days)

ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT

3QL (60 EA

per 30 days)

AFREZZA INHALATION POWDER 4 UNIT

3QL (180

EA per 30 days)

AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT

3

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)



122

Drug NameDrug Tier

Notes

APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

BD AUTOSHIELD DUO PEN NEEDLES 30G X 5 MM

2

BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 31G X 6MM 0.5 ML

2

BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

2

BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML

2

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

2QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG VIAL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

2QL (60 ML

per 30 days)



123

Drug NameDrug Tier

Notes

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

INSULIN ASPART FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

INSULIN ASPART PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

INSULIN ASPART PROT & ASPART SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

Drug NameDrug Tier

Notes

INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 12MM , 29G X 5MM , 29G X 8MM , 30G X 5 MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

2

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

2

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML

2



124

Drug NameDrug Tier

Notes

MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML-%

GM

NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM

2

NOVOFINE PEN NEEDLE 32G X 6 MM

2

NOVOFINE PLUS PEN NEEDLE 32G X 4 MM

2

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML


days)

Drug NameDrug Tier

Notes

NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML


days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

NOVOTWIST PEN NEEDLE 32G X 5 MM

2

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

2QL (60 ML

per 30 days)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

2QL (60 ML

per 30 days)

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

2QL (60 ML

per 30 days)

TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)



125

Drug NameDrug Tier

Notes

Electrolytes / Minerals / Metals / Vitamins

ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

3

ACTIVE FE ORAL TABLET 75-1.25 MG

3

ACTIVITE ORAL TABLET 1 MG

3

adc/f (0.5mg/ml) oral solution 0.5 mg/ml

1

ADRENAL C FORMULA ORAL TABLET

3

aminoamrms oral capsule

1

aminobenzoate potassium oral packet 2 gm

1

aminoreliefrms oral capsule

1

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %

GM

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

GM

ANIMI-3 ORAL CAPSULE 1 MG

3

ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG

3

AQUASOL A INTRAMUSCULAR SOLUTION 15 MG/ML

GM

ARGININE HCL INJECTION SOLUTION 6 GM/30ML

GM

argyle sterile saline irrigation solution 0.9 %

1

argyle sterile water irrigation solution

1

Drug NameDrug Tier

Notes

ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML

GM

ASCORBIC ACID INTRAVENOUS SOLUTION 15000 MG/30ML

GM

ATABEX OB ORAL TABLET 29-1 MG

3

b-6 folic acid oral capsule 8.333-100-1 mg

1

BACMIN ORAL TABLET 3

biocel oral tablet 1

bp vit 3 oral capsule 1 mg

1

b-plex oral tablet 1

b-plex plus oral tablet 1

CALCIFOL ORAL WAFER 1342-1.6 MG

3

CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS 10 %

GM

calcium chloride solution 10 % intravenous 10 %

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%, 2-0.675 GM/100ML-%

GM

CALCIUM-FOLIC ACID PLUS D ORAL WAFER 1342-1 MG

3

CARBAGLU ORAL TABLET 200 MG

3PA;

Specialty Pharmacy

CARDIOPLEGIA DEL NIDO FORMULA PERFUSION SOLUTION

GM

CARDIOPLEGIA IND PLASMA HIGH K PERFUSION SOLUTION

GM



126

Drug NameDrug Tier

Notes

CARDIOPLEGIA IND PLASMA-TROMET PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION HIGH K PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION LOW DEX PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION NON-ENR PERFUSION SOLUTION

GM

CARDIOPLEGIA MAIN LOW DEXTROSE PERFUSION SOLUTION

GM

CARDIOPLEGIA MAIN LOW TROMETHA PERFUSION SOLUTION

GM

CARDIOPLEGIA MAIN PLASMA-TROME PERFUSION SOLUTION

GM

CARDIOPLEGIA MAINTENANCE PERFUSION SOLUTION

GM

CARDIOPLEGIA REPERFUSATE 4:1 PERFUSION SOLUTION

GM

CARDIOPLEGIC SOLUTION PERFUSION

GM

cardioplegic solution perfusion

GM

CARNITOR INTRAVENOUS SOLUTION 200 MG/ML

GM

CARNITOR ORAL SOLUTION 1 GM/10ML

3Brand

penalty applies

CARNITOR ORAL TABLET 330 MG

3Brand

penalty applies

CARNITOR SF ORAL SOLUTION 1 GM/10ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

CENTRATEX ORAL CAPSULE 106-1 MG

3

CHEMET ORAL CAPSULE 100 MG

3

chromagen oral capsule 1

chromic chloride intravenous solution 40 mcg/10ml

GM

CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 MG

3

CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG

3

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

GM


GM


GM

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

GM

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %

GM

CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 %

GM

CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 %

GM

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

GM

CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %

GM



127

Drug NameDrug Tier

Notes

CLINISOL SF INTRAVENOUS SOLUTION 15 %

GM

CLINOLIPID INTRAVENOUS EMULSION 20 %

GM

clovique oral capsule 250 mg

3PA;

Specialty Pharmacy

cod liver oil oral oil 1

corvita 150 oral tablet 150-1.25 mg

1

corvita oral tablet 1.25 mg

1

CORVITE 150 ORAL TABLET , 150-1.25 MG

3

CORVITE FE ORAL TABLET

3

CUPRIC CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML

GM

curity sterile saline irrigation solution 0.9 %

1

cyanocobalamin injection solution 1000 mcg/ml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

GM

cytra k crystals oral packet 3300-1002 mg

1

DAVITE ORAL TABLET 1 MG

3

DECARA ORAL CAPSULE 1.25 MG (50000 UT)

3

deferasirox oral tablet 180 mg, 360 mg, 90 mg

2PA;

Specialty Pharmacy

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

3


3


3

delflex-sm/1.5% dextrose intraperitoneal solution 347 mosm/l

1

delflex-sm/2.5% dextrose intraperitoneal solution 398 mosm/l

1

dexifol oral tablet 5 mg 1

DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION

GM

dextrose in lactated ringers intravenous solution 5 %

GM

dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, 70 %

GM

DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS 250 MG/ML

GM

dextrose solution 250 mg/ml intravenous 250 mg/ml

GM

DEXTROSE SOLUTION 50 % INTRAVENOUS 50 %

GM

dextrose solution 50 % intravenous 50 %

GM



128

Drug NameDrug Tier

Notes

dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.3 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

GM

dextrose-sodium chloride intravenous solution 5-0.225 %, 5-0.3 %, 5-0.45 %, 5-0.9 %

GM

DIALYVITE 3000 ORAL TABLET 3 MG

3

DIALYVITE 5000 ORAL TABLET 5 MG

3

dialyvite oral tablet 1

DIALYVITE SUPREME D ORAL TABLET 3 MG

3

DIALYVITE/ZINC ORAL TABLET

3

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 344 MOSM/L

3


3


3

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 346 MOSM/L

3


3


3

Drug NameDrug Tier

Notes

DILUENT FOR LEFAMULIN INTRAVENOUS SOLUTION 0.9 %

GM

DRISDOL ORAL CAPSULE 1.25 MG (50000 UT)

3Brand

penalty applies

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

1

ELITE-OB ORAL TABLET 50-1.25 MG

3

ELLIOTTS B INTRATHECAL SOLUTION

GM

ENBRACE HR ORAL CAPSULE

3

ergocalciferol oral capsule 1.25 mg (50000 ut)

1

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

3PA;

Specialty Pharmacy

EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 %

3

fabb oral tablet 2.2-25-1 mg

1

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg

1

FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML

GM

FERIVAFA ORAL CAPSULE 110-1 MG

3

ferocon oral capsule 1

ferotrinsic oral capsule 1



129

Drug NameDrug Tier

Notes

FERRALET 90 ORAL TABLET 90-1 MG

3

FERRAPLUS 90 ORAL TABLET 90-1 MG

3

FERRIPROX ORAL SOLUTION 100 MG/ML

3PA;

Specialty Pharmacy

FERRIPROX ORAL TABLET 1000 MG, 500 MG

3PA;

Specialty Pharmacy

FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG

3

FERRLECIT INTRAVENOUS SOLUTION 12.5 MG/ML

GM

FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG

3

FERROTRIN ORAL CAPSULE

3

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

3

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

3

fluoritab oral solution 0.275 (0.125 f) mg/drop

PV

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

3

folbee plus oral tablet 1

FOLGARD OS ORAL TABLET 500-1.1 MG

3

FOLGARD RX ORAL TABLET 2.2-25-1 MG

3

folic acid injection solution 5 mg/ml

GM

Drug NameDrug Tier

Notes

folic acid oral tablet 1 mg 1

folic acid oral tablet 400 mcg, 800 mcg

PV

FOLIVANE-F ORAL CAPSULE 125-1 MG

3

FOLIVANE-PLUS ORAL CAPSULE

3

folplex 2.2 oral tablet 2.2-25-0.5 mg

1

FOLTRATE ORAL TABLET 500-1 MCG-MG

3

foltrin oral capsule 1

FORTAVIT ORAL CAPSULE

3

FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

GM

FREAMINE III INTRAVENOUS SOLUTION 10 %

GM

FUSION PLUS ORAL CAPSULE

3

GALZIN ORAL CAPSULE 25 MG, 50 MG

2

GENICIN VITA-S ORAL TABLET 1 MG

3

GLUTATHIONE INJECTION SOLUTION 200 MG/ML, 6 GM/30ML

GM

GLUTATHIONE INTRAVENOUS SOLUTION 6 GM/30ML

GM

GLYCINE INJECTION SOLUTION 50 MG/ML

GM

gnp folic acid oral tablet 400 mcg

PV

hematinic/folic acid oral tablet 324-1 mg

1



130

Drug NameDrug Tier

Notes

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG

3

hematogen forte oral capsule 460-60-0.01-1 mg

1

hematogen oral capsule 1

HEMATRON-AF ORAL TABLET 150-1 MG

3

HEMOCYTE PLUS ORAL CAPSULE 106-1 MG

3

hemocyte-f oral tablet 324-1 mg

1

HEPATAMINE INTRAVENOUS SOLUTION 8 %

GM

hydroxocobalamin acetate intramuscular solution 1000 mcg/ml

GM

HYLAVITE ORAL TABLET

3

HYPERLYTE-CR INTRAVENOUS CONCENTRATE

GM

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG

3

iferex 150 forte oral capsule 150-25-1 mg-mcg-mg

1

INFUVITE ADULT INTRAVENOUS INJECTABLE

GM

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

GM

INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML

GM

Drug NameDrug Tier

Notes

INTEGRA F ORAL CAPSULE 125-1 MG

3

INTEGRA PLUS ORAL CAPSULE

3

intralipid intravenous emulsion 20 %

GM

INTRALIPID INTRAVENOUS EMULSION 30 %

GM

iodine strong oral solution 5 %

1

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION

GM

IROSPAN 24/6 ORAL 3

IS 24/6 ORAL 3

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION

GM

ISOLYTE-S INTRAVENOUS SOLUTION

GM

ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION

GM

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

3PA;

Specialty Pharmacy

JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG

3PA;

Specialty Pharmacy

JYNARQUE ORAL TABLET 15 MG, 30 MG

3PA;

Specialty Pharmacy

JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

3PA;

Specialty Pharmacy



131

Drug NameDrug Tier

Notes

KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 %

GM

kcl in dextrose-nacl intravenous solution 0.15-5-0.45 %, 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

GM

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

GM

KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 MEQ-MG /100ML

GM

kionex oral suspension 15 gm/60ml

1

klor-con 10 oral tablet extended release 10 meq

1

klor-con m10 oral tablet extended release 10 meq

1

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

3

klor-con m20 oral tablet extended release 20 meq

1

klor-con oral packet 20 meq

1

klor-con oral tablet extended release 8 meq

1

klor-con sprinkle oral capsule extended release 10 meq, 8 meq

1

klor-con/ef oral tablet effervescent 25 meq

1

Drug NameDrug Tier

Notes

K-PHOS NO 2 ORAL TABLET 305-700 MG

3

K-PHOS ORAL TABLET 500 MG

3

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG

3

k-prime oral tablet effervescent 25 meq

1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

3Brand

penalty applies

k-tan plus oral capsule 162-115.2-1 mg

1

lactated ringers intravenous solution

GM

lactated ringers irrigation solution

1

LEVOCARNITINE INJECTION SOLUTION 500 MG/ML

GM

levocarnitine oral solution 1 gm/10ml

1

levocarnitine oral tablet 330 mg

1

levocarnitine sf oral solution 1 gm/10ml

1

LIPO INTRAMUSCULAR SOLUTION 50-50-25 MG/ML

GM

LIPO-C INTRAMUSCULAR SOLUTION

GM

LIQUIVIDA HYDRATION INTRAVENOUS KIT 0.9 %

GM

LORID ORAL TABLET 1 MG

3



132

Drug NameDrug Tier

Notes

ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

LYSINE HCL INJECTION SOLUTION 100 MG/ML

GM

lysiplex plus oral tablet 1

M.V.I. ADULT INTRAVENOUS INJECTABLE

GM

M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

GM

MAGNEBIND 400 ORAL TABLET 400-200-1 MG

3

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%

GM

MAGNESIUM SULFATE INTRAVENOUS SOLUTION 1000 MG/1.6ML, 2000 MG/3.2ML, 3000 MG/4.8ML, 4000 MG/6.4ML

GM

magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml

GM

MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 2-0.9 GM/50ML-%

GM

MANGANESE CHLORIDE INTRAVENOUS SOLUTION 0.1 MG/ML

GM

MEPHYTON ORAL TABLET 5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

METHYLCOBALAMIN INJECTION SOLUTION 150 MG/30ML, 30 MG/30ML, 300 MG/30ML

GM

METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 10000 MCG, 50000 MCG

GM

MIC-L-CARNITINE INJECTION SOLUTION 25-50-50-50 MG/ML

GM

MICROPLEGIA MSA-MSG PERFUSION SOLUTION

GM

MIFEPREX ORAL TABLET 200 MG

3Brand

penalty applies

mifepristone oral tablet 200 mg

1

M-NATAL PLUS ORAL TABLET 27-1 MG


MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG

3

MULTIGEN ORAL TABLET 70 MG

3

MULTIGEN PLUS ORAL TABLET 50-101-1 MG

3

MULTIPRO ORAL CAPSULE

3

multi-vit/iron/fluoride oral solution 0.25-10 mg/ml

1

multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg

1



133

Drug NameDrug Tier

Notes

multivitamin/fluoride/iron oral solution 0.25-10 mg/ml

1

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

1

mvc-fluoride oral tablet chewable 0.25 mg, 1 mg

1

myferon 150 forte oral capsule 150-25-1 mg-mcg-mg

1

mynephrocaps oral capsule 1 mg

1

mynephron oral capsule 1 mg

1

na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml

GM

n-acetyl-l-cysteine oral capsule 600 mg

1

nafrinse drops oral solution 0.275 (0.125 f) mg/drop

PV

nafrinse oral tablet chewable 2.2 (1 f) mg

PV

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

2

NEONATAL COMPLETE ORAL TABLET 27-1 MG


NEONATAL PLUS ORAL TABLET 27-1 MG


NEOVITE ORAL TABLET

3

NEPHPLEX RX ORAL TABLET

3

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

GM

NEPHRON FA ORAL TABLET

3

nephronex oral tablet 1

Drug NameDrug Tier

Notes

NEPHRO-VITE RX ORAL TABLET 1 MG

3

NESTABS ORAL TABLET 32-1 MG

3

NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

3

NICADAN ORAL TABLET

3

NICAZEL FORTE ORAL TABLET

3

NICAZEL ORAL TABLET 3

NICOMIDE ORAL TABLET 750-27-2-0.5 MG

3

NIFEREX ORAL TABLET

3

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R INTRAVENOUS SOLUTION

GM

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION

GM

NUFERA ORAL TABLET 3

NUTRICAP ORAL TABLET

3

nutrifac zx oral tablet 1

nutrilipid intravenous emulsion 20 %

GM

NUTRIVIT ORAL LIQUID 3

OMEGAVEN INTRAVENOUS EMULSION 10 GM/100ML, 5 GM/50ML

3PA;

Specialty Medical



134

Drug NameDrug Tier

Notes

ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG


ONEVITE ORAL TABLET 1 MG

3

ORACIT ORAL SOLUTION 490-640 MG/5ML

2

PERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 %

GM

phospha 250 neutral oral tablet 155-852-130 mg

1

phosphorous oral tablet 155-852-130 mg

1

phospho-trin 250 neutral oral tablet 155-852-130 mg

1

PHYSIOLYTE IRRIGATION SOLUTION

3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

3

phytonadione injection solution 1 mg/0.5ml, 10 mg/ml

GM

phytonadione oral tablet 5 mg

1

PLASMA-LYTE 148 INTRAVENOUS SOLUTION

GM

PLASMA-LYTE A INTRAVENOUS SOLUTION

GM

PLEGISOL PERFUSION SOLUTION

GM

PLENAMINE INTRAVENOUS SOLUTION 15 %

GM

Drug NameDrug Tier

Notes

pnv prenatal plus multivit+dha oral 27-1 & 312 mg

1

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

1

polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg

1

POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG, 1 MG

3

POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML

3

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

3

POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML

3

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG

3

pot bicarb-pot chloride oral tablet effervescent 25 meq

1

POTABA ORAL CAPSULE 500 MG

3

potassium acetate intravenous solution 2 meq/ml

GM

potassium bicarbonate oral tablet effervescent 25 meq

1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1

potassium chloride er oral capsule extended release 10 meq, 8 meq

1



135

Drug NameDrug Tier

Notes

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

1

potassium chloride in dextrose intravenous solution 20-5 meq/l-%

GM

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

GM

potassium chloride intravenous solution 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml

GM

potassium chloride oral packet 20 meq

1

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

1

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

1

potassium citrate-citric acid oral solution 1100-334 mg/5ml

1

potassium phosphates(71 meq k) intravenous solution 45 mmole/15ml

GM

PREMASOL INTRAVENOUS SOLUTION 10 %

GM

PREMESISRX ORAL TABLET 1 MG

3

PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG

3

Drug NameDrug Tier

Notes

PRENATA ORAL TABLET CHEWABLE 29-1 MG

3

prenatal oral tablet 27-1 mg


prenatal plus iron oral tablet 29-1 mg

1

PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG

3

PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG

3

PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG

3

PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG

3

PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG

3

PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG

3

PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG

3

PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG

3

PRENATVITE COMPLETE ORAL TABLET 1 MG

3

PRENATVITE PLUS ORAL TABLET 1 MG

3

PRENATVITE RX ORAL TABLET 0.8 MG

3

PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION 22-4 MEQ/L

GM



136

Drug NameDrug Tier

Notes

PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION 32-2.5 MEQ/L

GM

PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION 32-2 MEQ/L

GM

PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION 32-2-3.5 MEQ/L

GM

PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION 32-4-2.5 MEQ/L

GM

PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION 32-1.2 MEQ/L

GM

PROCALAMINE INTRAVENOUS SOLUTION 3 %

GM

PROSOL INTRAVENOUS SOLUTION 20 %

GM

purevit dualfe plus oral capsule 162-115.2-1 mg

1

PYRIDOXAL-5 PHOSPHATE INJECTION SOLUTION 100 MG/ML

GM

PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION 100 MG/ML

GM

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml

GM

QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML

3

Drug NameDrug Tier

Notes

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 1 MG

3

RELNATE DHA ORAL CAPSULE 28-1-200 MG

3

REMEDIENT ORAL CAPSULE 1 MG

3

renal oral capsule 1 mg 1

RENATABS ORAL TABLET 1 MG

3

RENATABS WITH IRON ORAL 1 & 100 MG

3

REQ 49+ ORAL TABLET 3

ringers intravenous solution

GM

ringers irrigation irrigation solution

1

saline bacteriostatic injection solution 0.9 %

GM

SALINE-PHENOL INJECTION SOLUTION 0.4-0.9 %

GM

SAMSCA ORAL TABLET 15 MG, 30 MG

3PA;

Specialty Pharmacy

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

3

SELENIOUS ACID INTRAVENOUS SOLUTION 60 MCG/ML

GM

se-tan plus oral capsule 162-115.2-1 mg

1

SIDEROL ORAL TABLET

3

SMOFLIPID INTRAVENOUS EMULSION 20 %

GM

sod citrate-citric acid oral solution 500-334 mg/5ml

1



137

Drug NameDrug Tier

Notes

sodium acetate intravenous solution 2 meq/ml

GM

SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS 8.4 %

GM

sodium bicarbonate solution 8.4 % intravenous 8.4 %

GM

SODIUM BICARBONATE-DEXTROSE INTRAVENOUS SOLUTION 150-5 MEQ/L-%

GM

sodium chloride (pf) injection solution 0.9 %

GM

sodium chloride bacteriostatic injection solution 0.9 %

GM

sodium chloride injection solution 2.5 meq/ml

GM

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

GM

sodium chloride irrigation solution 0.9 %

1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml

PV

sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

sodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

1

Drug NameDrug Tier

Notes

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

1

sps oral suspension 15 gm/60ml

1

sterile water for irrigation irrigation solution

1

STROVITE FORTE ORAL SYRUP

3

STROVITE FORTE ORAL TABLET

3

STROVITE ONE ORAL TABLET

3

SUPERVITE ORAL LIQUID

3

SUPPORT ORAL LIQUID

3

SUPPORT-500 ORAL CAPSULE

3

SYNAGEX ORAL CAPSULE 1.25 MG

3

SYNATEK ORAL CAPSULE 1.25 MG

3

SYPRINE ORAL CAPSULE 250 MG

3PA;

Specialty Pharmacy

TALIVA ORAL CAPSULE 1 MG

3

TARON FORTE ORAL CAPSULE

3

taron-crystals oral packet 3300-1002 mg

1

TAURINE INJECTION SOLUTION 50 MG/ML

GM

thiamine hcl injection solution 100 mg/ml

GM

tis-u-sol irrigation solution 1

tl-hem 150 oral tablet 150-1 mg

1



138

Drug NameDrug Tier

Notes

tolvaptan oral tablet 30 mg

3PA;

Specialty Pharmacy

tpn electrolytes intravenous concentrate

GM

TRAVASOL INTRAVENOUS SOLUTION 10 %

GM

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

3

tricitrates oral solution 550-500-334 mg/5ml

1

tricon oral capsule 1

trientine hcl oral capsule 250 mg

3PA;

Specialty Pharmacy

trigels-f forte oral capsule 460-60-0.01-1 mg

1

trinate oral tablet 1

triphrocaps oral capsule 1 mg

1

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

3

TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

3

tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

TRONVITE ORAL TABLET 1 MG

3

TROPHAMINE INTRAVENOUS SOLUTION 10 %

GM

tryptophan oral capsule 500 mg

1

Drug NameDrug Tier

Notes

UDAMIN SP ORAL TABLET 1 MG

3

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 346 MOSM/L

3

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 396 MOSM/L

3

ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION 485 MOSM/L

3

ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

3

ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 395 MOSM/L

3

ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 483 MOSM/L

3

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1080 MG)

2Brand

penalty applies


2Brand

penalty applies


2Brand

penalty applies

urosex oral tablet 1

v-c forte oral capsule 1

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM

3 PA



139

Drug NameDrug Tier

Notes

VENOFER INTRAVENOUS SOLUTION 20 MG/ML

GM

vic-forte oral capsule 1

virt-caps oral capsule 1 mg

1

VIRT-FEFA PLUS ORAL CAPSULE

3

virt-gard oral tablet 2.2-25-1 mg

1

virt-phos 250 neutral oral tablet 155-852-130 mg

1

visiv intravenous solution 5 %

GM

vita s forte oral tablet 1

vitacel oral tablet 1

VITAFOL ORAL TABLET 3

VITAFOL-OB+DHA ORAL 65-1 & 250 MG

3

VITAL-D RX ORAL TABLET 1 MG

3

VITAMAX PEDIATRIC ORAL SOLUTION

3

VITAMEZ ORAL CAPSULE 1 MG

3

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml

GM

vita-min oral capsule 1

vitamins acd-fluoride oral solution 0.25 mg/ml

1

VITAROCA PLUS ORAL TABLET

3

VITA-RX DIABETIC VITAMIN ORAL CAPSULE

3

VITASURE ORAL TABLET 1 MG

3

Drug NameDrug Tier

Notes

VITATHELY WITH GINGER ORAL TABLET 27-1 MG


vp-pnv-dha oral capsule 28-1-215.8 mg

1

vp-vite rx oral tablet 1 mg 1

water for irrigation, sterile irrigation solution

1

weekly-d oral capsule 1.25 mg (50000 ut)

1

wheat germ oil oral oil 1

XVITE ORAL TABLET 1 MG

3

ZINC CHLORIDE INTRAVENOUS SOLUTION 1 MG/ML

GM

ZINC SULFATE INTRAVENOUS SOLUTION 3 MG/ML

GM

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG

3Brand

penalty applies

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG

3

CARAFATE ORAL SUSPENSION 1 GM/10ML

2Brand

penalty applies

CARAFATE ORAL TABLET 1 GM

3Brand

penalty applies

cimetidine hcl oral solution 300 mg/5ml

1

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

1

CYTOTEC ORAL TABLET 100 MCG, 200 MCG

3Brand

penalty applies



140

Drug NameDrug Tier

Notes

DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG

3 PA

esomeprazole sodium intravenous solution reconstituted 40 mg

GM

famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

GM

famotidine oral suspension reconstituted 40 mg/5ml

1

famotidine oral tablet 20 mg, 40 mg

1

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

GM

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML

3

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML

3

lansoprazole oral capsule delayed release 15 mg, 30 mg

1

lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg

1

misoprostol oral tablet 100 mcg, 200 mcg

1

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG

1QL (120

EA per 30 days)

NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20 MG

1QL (120

EA per 30 days)

NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

Drug NameDrug Tier

Notes

nizatidine oral capsule 150 mg, 300 mg

1

nizatidine oral solution 15 mg/ml

1

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

1

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML

3

pantoprazole sodium intravenous solution reconstituted 40 mg

GM

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

1

PEPCID ORAL TABLET 20 MG, 40 MG

3Brand

penalty applies

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG

3Brand

penalty applies

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE 15 MG, 30 MG

3Brand

penalty applies

PRILOSEC ORAL PACKET 10 MG, 2.5 MG

3

PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

PROTONIX ORAL PACKET 40 MG

3

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG

3Brand

penalty applies



141

Drug NameDrug Tier

Notes

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG

3

rabeprazole sodium oral tablet delayed release 20 mg

1

sucralfate oral suspension 1 gm/10ml

1

sucralfate oral tablet 1 gm

1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL ORAL CAPSULE 300 MG

3Brand

penalty applies

alosetron hcl oral tablet 0.5 mg, 1 mg

1

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

2QL (60 EA

per 30 days)

amoxicill-clarithro-lansopraz oral

1

ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG

3

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1.2 MG/3ML

GM

belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg

1

BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML

GM

CHENODAL ORAL TABLET 250 MG

3Specialty Pharmacy

chlordiazepoxide-clidinium oral capsule 5-2.5 mg

1

Drug NameDrug Tier

Notes

clearlax oral powder 17 gm/scoop

1

PV*; QL (1 GM per

365 days); AL (Min 50 Years and

Max 75 Years)

CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML

3

constulose oral solution 10 gm/15ml

1

cromolyn sodium oral concentrate 100 mg/5ml

1

CUVPOSA ORAL SOLUTION 1 MG/5ML

3

dicyclomine hcl intramuscular solution 10 mg/ml

GM

dicyclomine hcl oral capsule 10 mg

RG

dicyclomine hcl oral solution 10 mg/5ml

1

dicyclomine hcl oral tablet 20 mg

RG

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

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

1

DONNATAL ORAL ELIXIR 16.2 MG/5ML

3

DONNATAL ORAL TABLET 16.2 MG

3

ed-spaz oral tablet dispersible 0.125 mg

1

ENTEREG ORAL CAPSULE 12 MG

3

enulose oral solution 10 gm/15ml

1



142

Drug NameDrug Tier

Notes

GASTROCROM ORAL CONCENTRATE 100 MG/5ML

3Brand

penalty applies

GATTEX SUBCUTANEOUS KIT 5 MG

3PA;

Specialty Pharmacy

gavilax oral powder 17 gm/scoop

1

PV*; QL (1 GM per


Max 75 Years)

gavilyte-c oral solution reconstituted 240 gm

1

PV*; QL (1 ML per 365 days); AL (Min 50


gavilyte-g oral solution reconstituted 236 gm

1



gavilyte-h oral kit 5-210 mg-gm

1

gavilyte-n with flavor pack oral solution reconstituted 420 gm

1



generlac oral solution 10 gm/15ml

1

glycolax oral powder 17 gm/scoop

1

PV*; QL (1 GM per


Max 75 Years)

Drug NameDrug Tier

Notes

glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml

GM

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 0.6 MG/3ML, 1 MG/5ML

GM

glycopyrrolate oral tablet 1 mg, 2 mg

1

glycopyrrolate pf injection solution prefilled syringe 0.2 mg/ml, 0.4 mg/2ml

GM

GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML

GM

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

3

QL (1 EA per 365

days); AL (Min 50


GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

Brand penalty

applies; QL (1 ML per 365 days); AL (Min 50 Years and

Max 75 Years)

healthylax oral packet 17 gm

1

PV*; QL (1 EA per 365 days); AL (Min 50


HELIDAC THERAPY ORAL

3



143

Drug NameDrug Tier

Notes

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

1

hyoscyamine sulfate oral elixir 0.125 mg/5ml

1

hyoscyamine sulfate oral solution 0.125 mg/ml

1

hyoscyamine sulfate oral tablet 0.125 mg

1

hyoscyamine sulfate oral tablet dispersible 0.125 mg

1

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

1

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

1

hyosyne oral elixir 0.125 mg/5ml

1

hyosyne oral solution 0.125 mg/ml

1

KRISTALOSE ORAL PACKET 10 GM, 20 GM

3

LACTOJEN ORAL CAPSULE

3

lactulose encephalopathy oral solution 10 gm/15ml

1

lactulose oral packet 10 gm

1

lactulose oral solution 10 gm/15ml, 20 gm/30ml

1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG

3

LEVSIN ORAL TABLET 0.125 MG

3

LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG

3

Drug NameDrug Tier

Notes

LIBRAX ORAL CAPSULE 5-2.5 MG

3Brand

penalty applies

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

2QL (30 EA

per 30 days)

LOMOTIL ORAL TABLET 2.5-0.025 MG

3Brand

penalty applies

loperamide hcl oral capsule 2 mg

1

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

3Brand

penalty applies

methscopolamine bromide oral tablet 2.5 mg, 5 mg

1

mineral oil heavy oral oil 1

MOTEGRITY ORAL TABLET 1 MG, 2 MG

3QL (30 EA

per 30 days)

MOTOFEN ORAL TABLET 1-0.025 MG

3

MOVANTIK ORAL TABLET 12.5 MG, 25 MG

3QL (30 EA

per 30 days)

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

3

MYTESI ORAL TABLET DELAYED RELEASE 125 MG

3 PA

nulev oral tablet dispersible 0.125 mg

1



144

Drug NameDrug Tier

Notes

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM

3

Brand penalty

applies; QL (1 ML per 365 days); AL (Min 50 Years and

Max 75 Years)

OMECLAMOX-PAK ORAL 500-500-20 MG

3

opium oral tincture 10 mg/ml (1%)

1

oscimin oral tablet 0.125 mg

1

oscimin sr oral tablet extended release 12 hour 0.375 mg

1

oscimin sublingual tablet sublingual 0.125 mg

1

OSMOPREP ORAL TABLET 1.102-0.398 GM

3

pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml

1

pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg

1

peg 3350 oral packet 17 gm

1



peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

1



Drug NameDrug Tier

Notes

peg-3350/electrolytes oral solution reconstituted 236 gm

1



peg-prep oral kit 5-210 mg-gm

1

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

1

phenohytro oral elixir 16.2 mg/5ml

1

phenohytro oral tablet 16.2 mg

1

polyethylene glycol 3350 oral packet 17 gm

1



PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

3

propantheline bromide oral tablet 15 mg

1

PYLERA ORAL CAPSULE 140-125-125 MG

3

RELISTOR ORAL TABLET 150 MG

2 PA

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

2 PA

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

3PA;

Specialty Pharmacy

sodium bicarbonate oral powder

1



145

Drug NameDrug Tier

Notes

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/177ML

3

SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 MG

3

symax-sl sublingual tablet sublingual 0.125 mg

1

symax-sr oral tablet extended release 12 hour 0.375 mg

1

SYMPROIC ORAL TABLET 0.2 MG

3QL (30 EA

per 30 days)

trilyte oral solution reconstituted 420 gm

1



TRULANCE ORAL TABLET 3 MG

3QL (30 EA

per 30 days)

URSO 250 ORAL TABLET 250 MG

3Brand

penalty applies

URSO FORTE ORAL TABLET 500 MG

3Brand

penalty applies

ursodiol oral capsule 300 mg

1

ursodiol oral tablet 250 mg, 500 mg

1

VIBERZI ORAL TABLET 100 MG, 75 MG

2PA;

Specialty Pharmacy

XERMELO ORAL TABLET 250 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG

3PA;

Specialty Pharmacy

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

3PA;

Specialty Medical

AMMONUL INTRAVENOUS SOLUTION 10-10 %

GM

BRINEURA KIT 2 X 150 MG/5ML

3PA;

Specialty Medical

BUPHENYL ORAL POWDER 3 GM/TSP

3Brand

penalty applies

BUPHENYL ORAL TABLET 500 MG

3Brand

penalty applies

CERDELGA ORAL CAPSULE 84 MG

3PA;

Specialty Pharmacy

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

3PA;

Specialty Medical

CHOLBAM ORAL CAPSULE 250 MG, 50 MG

3PA;

Specialty Pharmacy

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

2



146

Drug NameDrug Tier

Notes

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML

3PA;

Specialty Medical

CYSTADANE ORAL POWDER

3

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

3

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML

3PA;

Specialty Medical

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT

3PA;

Specialty Medical

ENZADYNE ORAL CAPSULE

3

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG

3PA;

Specialty Medical

GALAFOLD ORAL CAPSULE 123 MG

3PA;

Specialty Pharmacy

KANUMA INTRAVENOUS SOLUTION 20 MG/10ML

3PA;

Specialty Medical

KUVAN ORAL PACKET 100 MG, 500 MG

3PA;

Specialty Pharmacy

KUVAN ORAL TABLET SOLUBLE 100 MG

3PA;

Specialty Pharmacy

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML

3PA;

Specialty Medical

miglustat oral capsule 100 mg

3PA;

Specialty Pharmacy

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG

3PA;

Specialty Pharmacy

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

3PA;

Specialty Medical

nitisinone oral capsule 10 mg, 2 mg, 5 mg

3Specialty Pharmacy

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG

3PA;

Specialty Pharmacy

OCALIVA ORAL TABLET 10 MG, 5 MG

3PA;

Specialty Pharmacy

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

3PA;

Specialty Pharmacy

ORFADIN ORAL SUSPENSION 4 MG/ML

3PA;

Specialty Pharmacy

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML

3PA;

Specialty Pharmacy

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

3



147

Drug NameDrug Tier

Notes

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

3

RAVICTI ORAL LIQUID 1.1 GM/ML

3PA;

Specialty Pharmacy

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML

3PA;

Specialty Medical

sod benz-sod phenylacet intravenous solution 10-10 %

GM

sodium phenylbutyrate oral powder 3 gm/tsp

1

sodium phenylbutyrate oral tablet 500 mg

1

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

3PA;

Specialty Medical

SUCRAID ORAL SOLUTION 8500 UNIT/ML

3PA;

Specialty Pharmacy

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML

3PA;

Specialty Medical

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT

3

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

3PA;

Specialty Medical

XURIDEN ORAL PACKET 2 GM

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

ZAVESCA ORAL CAPSULE 100 MG

3PA;

Specialty Pharmacy

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

2

ZOLGENSMA 10.1-10.5 KG INTRAVENOUS KIT 7X8.3 ML

3PA;

Specialty Medical

ZOLGENSMA 10.6-11.0 KG INTRAVENOUS KIT 2X5.5ML & 6X8.3ML

3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical



148

Drug NameDrug Tier

Notes


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical


3PA;

Specialty Medical

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation solution 0.25 %

1

Drug NameDrug Tier

Notes

aminoacetic acid irrigation solution 1.5 %

1

AURYXIA ORAL TABLET 1 GM 210 MG(FE)

3

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

1

BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-5 MG

GM

calcium acetate (phos binder) oral capsule 667 mg

1

calcium acetate (phos binder) oral tablet 667 mg

1

calcium acetate oral tablet 667 mg

1

CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 MCG

3

QL (4 EA per 30

days); AL (Min 18 Years)

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 40 MCG

3

QL (4 EA per 30


CERVIDIL VAGINAL INSERT 10 MG

3

CIALIS ORAL TABLET 10 MG, 20 MG

3

Brand penalty

applies; QL (4 EA per 30 days);

AL (Min 18 Years)



149

Drug NameDrug Tier

Notes

CIALIS ORAL TABLET 2.5 MG, 5 MG

3

ST; Brand penalty


AL (Min 18 Years)

darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

1

DEPEN TITRATABS ORAL TABLET 250 MG

2Specialty Pharmacy

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG

3Brand

penalty applies

DETROL ORAL TABLET 1 MG, 2 MG

3Brand

penalty applies

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 5 MG

3Brand

penalty applies

EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG

3

QL (4 EA per 30


ELMIRON ORAL CAPSULE 100 MG

3

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

3Brand

penalty applies

FEM PH VAGINAL GEL 0.9-0.025 %

3

flavoxate hcl oral tablet 100 mg

1

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

GELNIQUE TRANSDERMAL GEL 10 %

3

glycine irrigation solution 1.5 %

1

glycine urologic irrigation solution 1.5 %

1

hyophen oral tablet 81.6 mg

1

INTRAROSA VAGINAL INSERT 6.5 MG

3

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

1

LEVITRA ORAL TABLET 10 MG, 20 MG

3

Brand penalty


AL (Min 18 Years)

LITHOSTAT ORAL TABLET 250 MG

3

me/naphos/mb/hyo1 oral tablet 81.6 mg

1

MUSE URETHRAL PELLET 1000 MCG, 125 MCG, 250 MCG, 500 MCG

3

QL (4 EA per 30


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

2

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

1

oxybutynin chloride oral syrup 5 mg/5ml

1

oxybutynin chloride oral tablet 5 mg

1



150

Drug NameDrug Tier

Notes

penicillamine oral tablet 250 mg

2Specialty Pharmacy

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PHENYLEPHRINE HCL INTRACAVERNOSAL SOLUTION 2 MG/2ML

GM

PHOSLYRA ORAL SOLUTION 667 MG/5ML

3

phosphasal oral tablet 81.6 mg

1

PREPIDIL VAGINAL GEL 0.5 MG/3GM

3

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG

3

PYRIDIUM ORAL TABLET 100 MG, 200 MG

3

QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-0.1-1 MG

GM

RENACIDIN IRRIGATION SOLUTION

3

RENAGEL ORAL TABLET 800 MG

3Brand

penalty applies

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

3Brand

penalty applies

RENVELA ORAL TABLET 800 MG

3Brand

penalty applies

RIMSO-50 INTRAVESICAL SOLUTION 50 %

GM

sevelamer carbonate oral packet 0.8 gm, 2.4 gm

1

Drug NameDrug Tier

Notes

sevelamer carbonate oral tablet 800 mg

1

sevelamer hcl oral tablet 400 mg, 800 mg

1

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1

QL (4 EA per 30


solifenacin succinate oral tablet 10 mg, 5 mg

1

STAXYN ORAL TABLET DISPERSIBLE 10 MG

3

Brand penalty


AL (Min 18 Years)

STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG

3

QL (4 EA per 30


SUPER BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10 MG

GM

SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-20-0.2-2 MG

GM

SUPER TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-100 MG-MG-MCG

GM

tadalafil oral tablet 10 mg, 20 mg

1

QL (4 EA per 30




151

Drug NameDrug Tier

Notes

tadalafil oral tablet 2.5 mg, 5 mg

1

ST; QL (30 EA per 30 days); AL (Min 18 Years)

THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 MG

3 PA

THIOLA ORAL TABLET 100 MG

3 PA

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

1

tolterodine tartrate oral tablet 1 mg, 2 mg

1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

3

trospium chloride er oral capsule extended release 24 hour 60 mg

1

trospium chloride oral tablet 20 mg

1

URELLE ORAL TABLET 81 MG

3

uretron d/s oral tablet 1

uribel oral capsule 118 mg

1

URIMAR-T ORAL TABLET 120 MG

3

urin ds oral tablet 1

URO-458 ORAL TABLET 81 MG

3

UROGESIC-BLUE ORAL TABLET 81.6 MG

3

uro-mp oral capsule 118 mg

1

URYL ORAL TABLET 81.6 MG

3

Drug NameDrug Tier

Notes

ustell oral capsule 120 mg

1

uticap oral capsule 120 mg

1

utira-c oral tablet 81.6 mg 1

utrona-c oral tablet 81.6 mg

1

vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

QL (4 EA per 30


vardenafil hcl oral tablet dispersible 10 mg

1

QL (4 EA per 30


VELPHORO ORAL TABLET CHEWABLE 500 MG

3Specialty Pharmacy

VESICARE ORAL TABLET 10 MG, 5 MG

2Brand

penalty applies

VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG

3

Brand penalty


AL (Min 18 Years)

vilamit mb oral capsule 118 mg

1

VILEVEV MB ORAL TABLET 81 MG

3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er oral tablet extended release 24 hour 10 mg

1

AVODART ORAL CAPSULE 0.5 MG

3Brand

penalty applies



152

Drug NameDrug Tier

Notes

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

2

dutasteride oral capsule 0.5 mg

1

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

1

finasteride oral tablet 5 mg

1

FLOMAX ORAL CAPSULE 0.4 MG

3Brand

penalty applies

JALYN ORAL CAPSULE 0.5-0.4 MG

3Brand

penalty applies

PROSCAR ORAL TABLET 5 MG

3Brand

penalty applies

RAPAFLO ORAL CAPSULE 4 MG, 8 MG

3Brand

penalty applies

silodosin oral capsule 4 mg, 8 mg

1

tamsulosin hcl oral capsule 0.4 mg

1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

RG

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

3Brand

penalty applies

Hormonal Agents - Adrenal

BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3-3) MG/ML

GM

Drug NameDrug Tier

Notes

BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3-3) MG/ML INJECTION 6 (3-3) MG/ML

GM

betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml

GM

BETAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 12 MG/2ML, 6 MG/ML

GM

CELESTONE SOLUSPAN INJECTION SUSPENSION 6 (3-3) MG/ML

GM

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG

3Brand

penalty applies

cortisone acetate oral tablet 25 mg

1

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML

GM

dexamethasone intensol oral concentrate 1 mg/ml

1

dexamethasone oral elixir 0.5 mg/5ml

1

dexamethasone oral solution 0.5 mg/5ml

1

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

RG



153

Drug NameDrug Tier

Notes

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

1

DEXAMETHASONE SOD PHOS-BUPIV INJECTION SOLUTION PREFILLED SYRINGE 0.01-0.375 %

GM

dexamethasone sod phosphate pf injection solution 10 mg/ml

GM

dexamethasone sod phosphate pf injection solution prefilled syringe 10 mg/ml

GM

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

GM

DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML

GM

fludrocortisone acetate oral tablet 0.1 mg

1

HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

3

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

1

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML

GM

KENALOG-80 INJECTION SUSPENSION 80 MG/ML

GM

LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML

GM

Drug NameDrug Tier

Notes

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

2Brand

penalty applies

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK 4 MG

3Brand

penalty applies

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

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

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION 80 MG/ML

GM

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

GM

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

1

methylprednisolone oral tablet therapy pack 4 mg

1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg

GM

METHYLPREDNISOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML, 80-5 MG/ML

GM



154

Drug NameDrug Tier

Notes

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 MG (48)

3

MILLIPRED ORAL TABLET 5 MG

2

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 30 MG

3Brand

penalty applies

PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML

3Brand

penalty applies

prednisolone oral solution 15 mg/5ml

1

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

1

prednisone intensol oral concentrate 5 mg/ml

1

prednisone oral solution 5 mg/5ml

1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

RG

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

1

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

GM

Drug NameDrug Tier

Notes

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG, 500 MG

GM

TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 1.5 MG (21)

3

triamcinolone acetonide suspension 40 mg/ml injection 40 mg/ml

GM

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

TRIAMCINOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML

GM

ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 32 MG

GM

Hormonal Agents - Men's Health

ANADROL-50 ORAL TABLET 50 MG

3

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

3 PA

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

2PA; Brand

penalty applies

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

2PA; Brand

penalty applies



155

Drug NameDrug Tier

Notes

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%)

3PA; Brand

penalty applies

danazol oral capsule 100 mg, 200 mg, 50 mg

1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML

3Brand

penalty applies

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)

3PA; Brand

penalty applies

JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG

3 PA

METHITEST ORAL TABLET 10 MG

3

methyltestosterone oral capsule 10 mg

1

NATESTO NASAL GEL 5.5 MG/ACT

3 PA

oxandrolone oral tablet 10 mg, 2.5 mg

1

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%)

3PA; Brand

penalty applies

TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML

3

TESTOPEL IMPLANT PELLET 75 MG

GM PA

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MG/ML

3

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1

testosterone enanthate intramuscular solution 200 mg/ml

1

Drug NameDrug Tier

Notes

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1 PA

testosterone transdermal solution 30 mg/act

1 PA

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

3PA; Brand

penalty applies

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)

3PA; Brand

penalty applies

Hormonal Agents - Osteoporosis

EVISTA ORAL TABLET 60 MG

3Brand

penalty applies

OSPHENA ORAL TABLET 60 MG

3

raloxifene hcl oral tablet 60 mg

PV

Hormonal Agents - Pituitary

ACTHAR INJECTION GEL 80 UNIT/ML

3PA;

Specialty Pharmacy

BYNFEZIA PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2500 MCG/ML (2.8 ML)

3PA;

Specialty Pharmacy

cabergoline oral tablet 0.5 mg

1

carboprost tromethamine intramuscular solution 250 mcg/ml

GM



156

Drug NameDrug Tier

Notes

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

3PA;

Specialty Pharmacy

chorionic gonadotropin intramuscular solution reconstituted 10000 unit

3PA;

Specialty Pharmacy

clomiphene citrate oral tablet 50 mg

1 PA

DDAVP INJECTION SOLUTION 4 MCG/ML

GM

DDAVP NASAL SOLUTION 0.01 %

3Brand

penalty applies

DDAVP ORAL TABLET 0.1 MG, 0.2 MG

3Brand

penalty applies

DDAVP RHINAL TUBE NASAL SOLUTION 0.01 %

3

desmopressin ace spray refrig nasal solution 0.01 %

1

desmopressin acetate injection solution 4 mcg/ml

GM

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

1

desmopressin acetate spray nasal solution 0.01 %

1

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

3PA;

Specialty Medical

FENSOLVI SUBCUTANEOUS KIT 45 MG

3PA;

Specialty Medical

FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

3PA;

Specialty Medical

FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML

2PA;

Specialty Pharmacy

ganirelix acetate subcutaneous solution prefilled syringe 250 mcg/0.5ml

3PA;

Specialty Pharmacy

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

3PA;

Specialty Pharmacy

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

3PA;

Specialty Pharmacy

GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 UNIT, 450 UNIT

3PA;

Specialty Pharmacy

GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML

3PA;

Specialty Pharmacy

GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

3PA;

Specialty Pharmacy



157

Drug NameDrug Tier

Notes

HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML

GM

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

3PA;

Specialty Pharmacy

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

3PA;

Specialty Pharmacy

ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG

3PA;

Specialty Pharmacy

leuprolide acetate injection kit 1 mg/0.2ml

3PA;

Specialty Pharmacy

LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR SOLUTION 25-5 MG/ML

GM

LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 MG

3PA;

Specialty Medical

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

3PA;

Specialty Medical

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

3PA;

Specialty Medical

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG INTRAMUSCULAR KIT 30 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG INTRAMUSCULAR KIT 45 MG

3PA;

Specialty Medical

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

3PA;

Specialty Medical

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED)

3PA;

Specialty Medical

MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

3PA;

Specialty Pharmacy

MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 MG

3

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

3PA;

Specialty Pharmacy

novarel intramuscular solution reconstituted 10000 unit

3PA;

Specialty Pharmacy

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

3PA;

Specialty Pharmacy

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML

3PA;

Specialty Pharmacy



158

Drug NameDrug Tier

Notes


3PA;

Specialty Pharmacy


3PA;

Specialty Pharmacy

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

2PA;

Specialty Pharmacy

OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML

3PA;

Specialty Pharmacy

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG

3PA;

Specialty Pharmacy

ORILISSA ORAL TABLET 150 MG, 200 MG

3 PA

OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML

3PA;

Specialty Pharmacy

oxytocin injection solution 10 unit/ml

GM

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 20 UNIT/L

GM

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 15-0.9 UT/250ML-%, 30-0.9 UT/500ML-%

GM

PITOCIN INJECTION SOLUTION 10 UNIT/ML

GM

pregnyl intramuscular solution reconstituted 10000 unit

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG

3PA;

Specialty Pharmacy

SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG

3PA;

Specialty Pharmacy

SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

3PA;

Specialty Pharmacy

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

3PA;

Specialty Medical

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

3PA;

Specialty Medical

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

3PA;

Specialty Pharmacy

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

3PA;

Specialty Medical

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

3PA;

Specialty Pharmacy

STIMATE NASAL SOLUTION 1.5 MG/ML

2

SUPPRELIN LA SUBCUTANEOUS KIT 50 MG

3PA;

Specialty Medical

SYNAREL NASAL SOLUTION 2 MG/ML

2



159

Drug NameDrug Tier

Notes

TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

3PA;

Specialty Medical

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

3PA;

Specialty Medical

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 22.5 MG

3PA;

Specialty Medical

VANTAS SUBCUTANEOUS KIT 50 MG

3PA;

Specialty Medical

VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-%

GM

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

GM

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG

3PA;

Specialty Medical

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 5 MG

3PA;

Specialty Pharmacy

Hormonal Agents - Prostaglandins

KORLYM ORAL TABLET 300 MG

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 1-0.5 MG

3Brand

penalty applies

afirmelle oral tablet 0.1-20 mg-mcg

PV

ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3

altavera oral tablet 0.15-30 mg-mcg

PV

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

PV

alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg

1

amethia lo oral tablet 0.1-0.02 & 0.01 mg

PV

amethia oral tablet 0.15-0.03 &0.01 mg

PV

amethyst oral tablet 90-20 mcg

PV

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

3

ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR

3

apri oral tablet 0.15-30 mg-mcg

PV

aranelle oral tablet 0.5/1/0.5-35 mg-mcg

PV

ashlyna oral tablet 0.15-0.03 &0.01 mg

PV

aubra eq oral tablet 0.1-20 mg-mcg

PV



160

Drug NameDrug Tier

Notes

aubra oral tablet 0.1-20 mg-mcg

PV

aurovela 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela 1/20 oral tablet 1-20 mg-mcg

PV

aurovela 24 fe oral tablet 1-20 mg-mcg(24)

PV

aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela fe 1/20 oral tablet 1-20 mg-mcg

PV

aviane oral tablet 0.1-20 mg-mcg

PV

AYGESTIN ORAL TABLET 5 MG

3Brand

penalty applies

ayuna oral tablet 0.15-30 mg-mcg

PV

azurette oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21)

3

balziva oral tablet 0.4-35 mg-mcg

PV

bekyree oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BEYAZ ORAL TABLET 3-0.02-0.451 MG

3Brand

penalty applies

blisovi 24 fe oral tablet 1-20 mg-mcg(24)

PV

blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

blisovi fe 1/20 oral tablet 1-20 mg-mcg

PV

briellyn oral tablet 0.4-35 mg-mcg

PV

camila oral tablet 0.35 mg

PV

Drug NameDrug Tier

Notes

camrese lo oral tablet 0.1-0.02 & 0.01 mg

PV

camrese oral tablet 0.15-0.03 &0.01 mg

PV

caziant oral tablet 0.1/0.125/0.15 -0.025 mg

PV

charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

chateal eq oral tablet 0.15-30 mg-mcg

PV

chateal oral tablet 0.15-30 mg-mcg

PV

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY

3

CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3Brand

penalty applies

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

3

covaryx hs oral tablet 0.625-1.25 mg

1

covaryx oral tablet 1.25-2.5 mg

1

CRINONE VAGINAL GEL 4 %, 8 %

3

cryselle-28 oral tablet 0.3-30 mg-mcg

PV

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

PV

cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV



161

Drug NameDrug Tier

Notes

cyred eq oral tablet 0.15-30 mg-mcg

PV

cyred oral tablet 0.15-30 mg-mcg

PV

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

PV

dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

daysee oral tablet 0.15-0.03 &0.01 mg

PV

deblitane oral tablet 0.35 mg

PV

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

3

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

3Brand

penalty applies

delyla oral tablet 0.1-20 mg-mcg

PV

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

3Brand

penalty applies

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML

3Brand

penalty applies

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML

3

Drug NameDrug Tier

Notes

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg

PV

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM

3

dotti transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg

PV

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

PV

DUAVEE ORAL TABLET 0.45-20 MG

3

EC-RX PROGESTERONE TRANSDERMAL CREAM 10 %

3

eemt hs oral tablet 0.625-1.25 mg

1

eemt oral tablet 1.25-2.5 mg

1

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%)

3

elinest oral tablet 0.3-30 mg-mcg

PV

ELLA ORAL TABLET 30 MG

PV

eluryng vaginal ring 0.12-0.015 mg/24hr

PV



162

Drug NameDrug Tier

Notes

emoquette oral tablet 0.15-30 mg-mcg

PV

ENDOMETRIN VAGINAL INSERT 100 MG

2

enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg

PV

enskyce oral tablet 0.15-30 mg-mcg

PV

errin oral tablet 0.35 mg PV

est estrogens-methyltest ds oral tablet 1.25-2.5 mg

1

est estrogens-methyltest hs oral tablet 0.625-1.25 mg

1

est estrogens-methyltest oral tablet 1.25-2.5 mg

1

estarylla oral tablet 0.25-35 mg-mcg

PV

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

ESTRACE VAGINAL CREAM 0.1 MG/GM

2Brand

penalty applies

estradiol oral tablet 0.5 mg, 1 mg, 2 mg

RG

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

1

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

1

estradiol vaginal cream 0.1 mg/gm

1

estradiol vaginal tablet 10 mcg

1

Drug NameDrug Tier

Notes

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

1

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

1

ESTRING VAGINAL RING 2 MG

2

ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%)

3

ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

3Brand

penalty applies

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

PV

etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr

PV

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

3

FALESSA ORAL KIT 20-1-0.1 MCG-MG

3

falmina oral tablet 0.1-20 mg-mcg

PV

fayosim oral tablet 42-21-21-7 days

PV

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG

2Brand

penalty applies

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

3

femynor oral tablet 0.25-35 mg-mcg

PV



163

Drug NameDrug Tier

Notes

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG, 200 MG

3

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG

3Brand

penalty applies

gianvi oral tablet 3-0.02 mg

PV

hailey 1.5/30 oral tablet 1.5-30 mg-mcg

PV

hailey 24 fe oral tablet 1-20 mg-mcg(24)

PV

hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

hailey fe 1/20 oral tablet 1-20 mg-mcg

PV

heather oral tablet 0.35 mg

PV

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

3PA;

Specialty Medical

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

2PA;

Specialty Pharmacy

incassia oral tablet 0.35 mg

PV

introvale oral tablet 0.15-0.03 mg

PV

isibloom oral tablet 0.15-30 mg-mcg

PV

jaimiess oral tablet 0.15-0.03 &0.01 mg

PV

jasmiel oral tablet 3-0.02 mg

PV

jencycla oral tablet 0.35 mg

PV

jinteli oral tablet 1-5 mg-mcg

1

Drug NameDrug Tier

Notes

jolessa oral tablet 0.15-0.03 mg

PV

juleber oral tablet 0.15-30 mg-mcg

PV

junel 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel 1/20 oral tablet 1-20 mg-mcg

PV

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel fe 1/20 oral tablet 1-20 mg-mcg

PV

junel fe 24 oral tablet 1-20 mg-mcg(24)

PV

kaitlib fe oral tablet chewable 0.8-25 mg-mcg

PV

kalliga oral tablet 0.15-30 mg-mcg

PV

kariva oral tablet 0.15-0.02/0.01 mg (21/5)

PV

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

PV

kelnor 1/50 oral tablet 1-50 mg-mcg

PV

kurvelo oral tablet 0.15-30 mg-mcg

PV

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG

GM PV

larin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin 1/20 oral tablet 1-20 mg-mcg

PV

larin 24 fe oral tablet 1-20 mg-mcg(24)

PV

larin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin fe 1/20 oral tablet 1-20 mg-mcg

PV



164

Drug NameDrug Tier

Notes

larissia oral tablet 0.1-20 mg-mcg

PV

layolis fe oral tablet chewable 0.8-25 mg-mcg

PV

leena oral tablet 0.5/1/0.5-35 mg-mcg

PV

lessina oral tablet 0.1-20 mg-mcg

PV

levonest oral tablet 50-30/75-40/ 125-30 mcg

PV

levonorgest-eth est & eth est oral tablet 42-21-21-7 days

PV

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg

PV

levonorgestrel oral tablet 1.5 mg

PV

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg

PV

levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg

PV

levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg

PV

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 19.5 MCG/DAY

GM PV

lillow oral tablet 0.15-30 mg-mcg

PV

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG

3

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

3Brand

penalty applies

Drug NameDrug Tier

Notes

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

3Brand

penalty applies

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

3Brand

penalty applies

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

3Brand

penalty applies

lojaimiess oral tablet 0.1-0.02 & 0.01 mg

PV

lopreeza oral tablet 1-0.5 mg

1

loryna oral tablet 3-0.02 mg

PV

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG

3Brand

penalty applies

low-ogestrel oral tablet 0.3-30 mg-mcg

PV

lo-zumandimine oral tablet 3-0.02 mg

PV

lutera oral tablet 0.1-20 mg-mcg

PV

lyza oral tablet 0.35 mg PV

MAKENA INTRAMUSCULAR OIL 250 MG/ML

3PA;

Specialty Medical

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML

3PA;

Specialty Pharmacy

marlissa oral tablet 0.15-30 mg-mcg

PV

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

PV

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

PV



165

Drug NameDrug Tier

Notes

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

RG

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

1

megestrol acetate oral tablet 20 mg, 40 mg

1

melodetta 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

2

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR

2

mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

microgestin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin 1/20 oral tablet 1-20 mg-mcg

PV

microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin fe 1/20 oral tablet 1-20 mg-mcg

PV

mili oral tablet 0.25-35 mg-mcg

PV

mimvey oral tablet 1-0.5 mg

1

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24)

3Brand

penalty applies

MINIVELLE PATCH TWICE WEEKLY 0.025 MG/24HR TRANSDERMAL 0.025 MG/24HR

2

Drug NameDrug Tier

Notes


3


2


3


2


3


2


3


2


3



166

Drug NameDrug Tier

Notes

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

3Brand

penalty applies

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR

GM PV

mono-linyah oral tablet 0.25-35 mg-mcg

PV

NATAZIA ORAL TABLET 3/2-2/2-3/1 MG

PV

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

NEXPLANON SUBCUTANEOUS IMPLANT 68 MG

GM PV

nikki oral tablet 3-0.02 mg

PV

nora-be oral tablet 0.35 mg

PV

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

PV

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone acetate oral tablet 5 mg

1

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

PV

norethindrone oral tablet 0.35 mg

PV

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg

PV

Drug NameDrug Tier

Notes

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

PV

norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg

PV

norlyda oral tablet 0.35 mg

PV

norlyroc oral tablet 0.35 mg

PV

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

nortrel 1/35 (21) oral tablet 1-35 mg-mcg

PV

nortrel 1/35 (28) oral tablet 1-35 mg-mcg

PV

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

3Brand

penalty applies

ocella oral tablet 3-0.03 mg

PV

orsythia oral tablet 0.1-20 mg-mcg

PV

ORTHO MICRONOR ORAL TABLET 0.35 MG

3Brand

penalty applies

PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

GM PV

philith oral tablet 0.4-35 mg-mcg

PV

pimtrea oral tablet 0.15-0.02/0.01 mg (21/5)

PV



167

Drug NameDrug Tier

Notes

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

PV

pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

PLAN B ONE-STEP ORAL TABLET 1.5 MG

3

portia-28 oral tablet 0.15-30 mg-mcg

PV

PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

3

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

GM

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

3

PREMARIN VAGINAL CREAM 0.625 MG/GM

3

PREMPHASE ORAL TABLET 0.625-5 MG

3

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

3

preventeza oral tablet 1.5 mg

PV

previfem oral tablet 0.25-35 mg-mcg

PV

progesterone intramuscular oil 50 mg/ml

1

progesterone micronized oral capsule 100 mg, 200 mg

1

progesterone micronized transdermal cream 10 %

1

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

QUARTETTE ORAL TABLET 42-21-21-7 DAYS

3Brand

penalty applies

reclipsen oral tablet 0.15-30 mg-mcg

PV

rivelsa oral tablet 42-21-21-7 days

PV

SAFYRAL ORAL TABLET 3-0.03-0.451 MG

3Brand

penalty applies

SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG

3Brand

penalty applies

setlakin oral tablet 0.15-0.03 mg

PV

sharobel oral tablet 0.35 mg

PV

simliya oral tablet 0.15-0.02/0.01 mg (21/5)

PV

simpesse oral tablet 0.15-0.03 &0.01 mg

PV

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG

GM PV

SLYND ORAL TABLET 4 MG

PV

sprintec 28 oral tablet 0.25-35 mg-mcg

PV

sronyx oral tablet 0.1-20 mg-mcg

PV

syeda oral tablet 3-0.03 mg

PV

tarina 24 fe oral tablet 1-20 mg-mcg(24)

PV

tarina fe 1/20 eq oral tablet 1-20 mg-mcg

PV

tarina fe 1/20 oral tablet 1-20 mg-mcg

PV



168

Drug NameDrug Tier

Notes

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24)

3

tilia fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

trivora (28) oral tablet 50-30/75-40/ 125-30 mcg

PV

tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

Drug NameDrug Tier

Notes

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tulana oral tablet 0.35 mg PV

TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24HR

3

tydemy oral tablet 3-0.03-0.451 mg

PV

VAGIFEM VAGINAL TABLET 10 MCG

3Brand

penalty applies

velivet oral tablet 0.1/0.125/0.15 -0.025 mg

PV

vienva oral tablet 0.1-20 mg-mcg

PV

viorele oral tablet 0.15-0.02/0.01 mg (21/5)

PV

VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3Brand

penalty applies

volnea oral tablet 0.15-0.02/0.01 mg (21/5)

PV

vyfemla oral tablet 0.4-35 mg-mcg

PV

vylibra oral tablet 0.25-35 mg-mcg

PV

wera oral tablet 0.5-35 mg-mcg

PV

wymzya fe oral tablet chewable 0.4-35 mg-mcg

PV

xulane transdermal patch weekly 150-35 mcg/24hr

PV

YASMIN 28 ORAL TABLET 3-0.03 MG

3Brand

penalty applies



169

Drug NameDrug Tier

Notes

YAZ ORAL TABLET 3-0.02 MG

3Brand

penalty applies

yuvafem vaginal tablet 10 mcg

1

zarah oral tablet 3-0.03 mg

PV

zovia 1/35e (28) oral tablet 1-35 mg-mcg

PV

zumandimine oral tablet 3-0.03 mg

PV

Hormonal Agents - Thyroid

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

2

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

3Brand

penalty applies

euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

levothyroxine sodium intravenous solution 100 mcg/5ml, 200 mcg/5ml, 500 mcg/5ml

GM

levothyroxine sodium intravenous solution reconstituted 100 mcg, 200 mcg, 500 mcg

GM

Drug NameDrug Tier

Notes

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

1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine sodium intravenous solution 10 mcg/ml

GM

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

1

methimazole oral tablet 10 mg, 5 mg

1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

3

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

1

propylthiouracil oral tablet 50 mg

1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

2

TAPAZOLE ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies



170

Drug NameDrug Tier

Notes

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML

GM

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

1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

3

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

3PA;

Specialty Pharmacy

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

3PA;

Specialty Medical

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

3PA;

Specialty Pharmacy

ALFERON N INJECTION SOLUTION 5000000 UNIT/ML

3PA;

Specialty Medical

ARAVA ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

3PA;

Specialty Pharmacy

ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML

3PA;

Specialty Medical

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

3

ATGAM INTRAVENOUS INJECTABLE 50 MG/ML

3PA;

Specialty Medical

AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

AZASAN ORAL TABLET 100 MG, 75 MG

3

azathioprine oral tablet 50 mg

1

azathioprine sodium injection solution reconstituted 100 mg

GM

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

3PA;

Specialty Medical



171

Drug NameDrug Tier

Notes

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML

3PA;

Specialty Pharmacy

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

3PA;

Specialty Pharmacy

BERINERT INTRAVENOUS KIT 500 UNIT

3PA;

Specialty Medical

BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML

3PA;

Specialty Medical

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM

3PA;

Specialty Medical

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CELLCEPT ORAL CAPSULE 250 MG

2

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

2

CELLCEPT ORAL TABLET 500 MG

2

CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 MG/ML

2PA;

Specialty Pharmacy

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML

2PA;

Specialty Pharmacy

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG

2PA;

Specialty Medical

Drug NameDrug Tier

Notes

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

3PA;

Specialty Medical

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

3PA;

Specialty Pharmacy

COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

3PA;

Specialty Pharmacy

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML

3PA;

Specialty Pharmacy

CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML

3PA;

Specialty Pharmacy

cyclosporine intravenous solution 50 mg/ml

GM

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

1

cyclosporine modified oral solution 100 mg/ml

1



172

Drug NameDrug Tier

Notes

cyclosporine oral capsule 100 mg, 25 mg

1

CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML

3Specialty Medical

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

3PA;

Specialty Pharmacy

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

3PA;

Specialty Pharmacy

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

3PA;

Specialty Medical

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

3

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

3Specialty Pharmacy

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML

3

PA; Specialty

Pharmacy; QL (18 ML

per 30 days)

Drug NameDrug Tier

Notes

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

3PA;

Specialty Medical

GAMASTAN INTRAMUSCULAR INJECTABLE

3PA;

Specialty Medical

GAMASTAN S/D INTRAMUSCULAR INJECTABLE

3PA;

Specialty Medical

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 MG/10ML

3PA;

Specialty Medical

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

3PA;

Specialty Medical

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM

3PA;

Specialty Medical

GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

3PA;

Specialty Medical



173

Drug NameDrug Tier

Notes

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

3PA;

Specialty Medical

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

3PA;

Specialty Medical

gengraf oral capsule 100 mg, 25 mg

1

gengraf oral solution 100 mg/ml

1

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT

3PA;

Specialty Pharmacy

HEPAGAM B INJECTION SOLUTION

GM

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

3PA;

Specialty Pharmacy

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML

3PA;

Specialty Pharmacy

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

2PA;

Specialty Pharmacy

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML

2PA;

Specialty Pharmacy

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2PA;

Specialty Pharmacy

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

2PA;

Specialty Pharmacy

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

GM

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML, 900 UNIT/3ML

GM

HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT

3Specialty Medical

HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 UNIT/ML

GM



174

Drug NameDrug Tier

Notes

icatibant acetate subcutaneous solution 30 mg/3ml

3

PA; Specialty

Pharmacy; QL (18 ML

per 30 days)

ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML

3PA;

Specialty Pharmacy

ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

3PA;

Specialty Pharmacy

IMOGAM RABIES-HT INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

IMURAN ORAL TABLET 50 MG

3Brand

penalty applies

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

2PA;

Specialty Medical

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML

3PA;

Specialty Medical

KEDRAB INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 MG/1.14ML

3PA;

Specialty Pharmacy

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

3PA;

Specialty Pharmacy

KYMRIAH INTRAVENOUS SUSPENSION

3PA;

Specialty Medical

leflunomide oral tablet 10 mg, 20 mg

1

methotrexate oral tablet 2.5 mg

1

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml

1

methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml

1

methotrexate sodium injection solution reconstituted 1 gm

3Specialty Medical

methotrexate sodium oral tablet 2.5 mg

1

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT

3Specialty Medical

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

GM

mycophenolate mofetil oral capsule 250 mg

1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

1

mycophenolate mofetil oral tablet 500 mg

1

mycophenolate sodium oral tablet delayed release 180 mg, 360 mg

1



175

Drug NameDrug Tier

Notes

MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG

3Brand

penalty applies

NABI-HB INTRAMUSCULAR SOLUTION

GM

NEORAL ORAL CAPSULE 100 MG, 25 MG

2

NEORAL ORAL SOLUTION 100 MG/ML

2

NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML

3PA;

Specialty Medical

OLUMIANT ORAL TABLET 1 MG, 2 MG

3PA;

Specialty Pharmacy

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

3PA;

Specialty Pharmacy

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

3PA;

Specialty Medical

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

OTEZLA ORAL TABLET 30 MG

2PA;

Specialty Pharmacy

OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG

2PA;

Specialty Pharmacy

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

3PA;

Specialty Medical

PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

3PA;

Specialty Medical

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

GM

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

2

PROVENGE INTRAVENOUS SUSPENSION

3PA;

Specialty Medical

RAPAMUNE ORAL SOLUTION 1 MG/ML

2

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

2

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

2PA;

Specialty Medical



176

Drug NameDrug Tier

Notes

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

3Specialty Medical

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

3Specialty Medical

RIDAURA ORAL CAPSULE 3 MG

2

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG

2PA;

Specialty Pharmacy

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT

3PA;

Specialty Medical

SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML

GM

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

2

SANDIMMUNE ORAL SOLUTION 100 MG/ML

2

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML

3PA;

Specialty Pharmacy

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML

2PA;

Specialty Medical

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

2PA;

Specialty Pharmacy

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 20 MG

GM

sirolimus oral solution 1 mg/ml

1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg

1

SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML

2PA;

Specialty Pharmacy

STELARA INTRAVENOUS SOLUTION 130 MG/26ML

2PA;

Specialty Medical

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML

2PA;

Specialty Pharmacy

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

2PA;

Specialty Pharmacy

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML

3PA;

Specialty Medical

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

1

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML

3

PA; Specialty

Pharmacy; QL (4 ML

per 28 days)

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML

3PA;

Specialty Pharmacy



177

Drug NameDrug Tier

Notes

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 80 MG/ML

3PA;

Specialty Pharmacy

temsirolimus intravenous solution 25 mg/ml

3PA;

Specialty Medical

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG

GM PA

TORISEL INTRAVENOUS SOLUTION 25 MG/ML

3PA;

Specialty Medical

TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 MG/ML

2PA;

Specialty Pharmacy

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

2PA;

Specialty Pharmacy

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

2

UPLIZNA INTRAVENOUS SOLUTION 100 MG/10ML

3PA;

Specialty Medical

WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML

3Specialty Medical

XELJANZ ORAL TABLET 10 MG, 5 MG

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG, 22 MG

2PA;

Specialty Pharmacy

XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

3PA;

Specialty Pharmacy

ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML

GM

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG

3Specialty Pharmacy

Immunological Agents - Drugs for Vaccination

ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

PVAL (Max 6

Years)

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

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

BCG VACCINE INJECTION INJECTABLE

GM

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV



178

Drug NameDrug Tier

Notes

BIOTHRAX INTRAMUSCULAR SUSPENSION

GM

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF-MCG/0.5

PV

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

PV

DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR SUSPENSION 25-5 LFU/0.5ML

PV

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

PV

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML

PV

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PVAL (Min 65

Years)

FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 0.5 ML

PVAL (Min 65

Years)

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML

PV

Drug NameDrug Tier

Notes

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML

PVAL (Min 65

Years)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

GARDASIL 9 INTRAMUSCULAR SUSPENSION

PV

AL (Min 9 Years and

Max 27 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

AL (Min 9 Years and

Max 27 Years)

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

PV



179

Drug NameDrug Tier

Notes

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML

PVAL (Min 18

Years)

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

PVAL (Max 6

Years)

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

GM

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

PV

IPOL INJECTION INJECTABLE

PVAL (Max 17

Years)

IXIARO INTRAMUSCULAR SUSPENSION

GM

KINRIX INTRAMUSCULAR SUSPENSION

PV

MENACTRA INTRAMUSCULAR INJECTABLE

PV

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

PV

M-M-R II INJECTION SOLUTION RECONSTITUTED

PV

PEDIARIX INTRAMUSCULAR SUSPENSION

PV

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

PVAL (Max 6

Years)

Drug NameDrug Tier

Notes

PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED

PV

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML

PV

PREVNAR 13 INTRAMUSCULAR SUSPENSION

PV

PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED

PV

QUADRACEL INTRAMUSCULAR SUSPENSION

PV

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

GM

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

PV

ROTARIX ORAL SUSPENSION RECONSTITUTED

PVAL (Max 8 Months)

ROTATEQ ORAL SOLUTION

PVAL (Max 8 Months)

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

PV

QL (2 EA per 1

lifetime); AL (Min 50

Years)

STAMARIL INJECTION SUSPENSION RECONSTITUTED

GM

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML

PV



180

Drug NameDrug Tier

Notes

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

PV

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML

PV

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML

GM

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

PV

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

PV

VIVOTIF ORAL CAPSULE DELAYED RELEASE


YF-VAX SUBCUTANEOUS INJECTABLE

GM

Inflammatory Bowel Disease Agents

ana-lex rectal kit 2-2 % 1

ANALPRAM HC EXTERNAL CREAM 2.5-1 %

2

ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 %

2

ANALPRAM-HC EXTERNAL CREAM 1-1 %

2

Drug NameDrug Tier

Notes

ANALPRAM-HC EXTERNAL LOTION 2.5-1 %

3

anucort-hc rectal suppository 25 mg

1

ANUSOL-HC EXTERNAL CREAM 2.5 %

3Brand

penalty applies

anusol-hc rectal suppository 25 mg

1

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

2Brand

penalty applies

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

3Brand

penalty applies

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG

3Brand

penalty applies

AZULFIDINE ORAL TABLET 500 MG

3Brand

penalty applies

balsalazide disodium oral capsule 750 mg

1

budesonide er oral tablet extended release 24 hour 9 mg

2PA;

Specialty Pharmacy

budesonide oral capsule delayed release particles 3 mg

2Specialty Pharmacy

CANASA RECTAL SUPPOSITORY 1000 MG

2Brand

penalty applies

COLAZAL ORAL CAPSULE 750 MG

3Brand

penalty applies

colocort rectal enema 100 mg/60ml

1

CORTENEMA RECTAL ENEMA 100 MG/60ML

3Brand

penalty applies



181

Drug NameDrug Tier

Notes

CORTIFOAM EXTERNAL FOAM 10 %

2

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

2Brand

penalty applies

DIPENTUM ORAL CAPSULE 250 MG

2

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 MG

3Specialty Pharmacy

hemmorex-hc rectal suppository 25 mg

1

hydrocortisone (perianal) external cream 1 %, 2.5 %

1

hydrocortisone ace-pramoxine external cream 1-1 %

1

hydrocortisone acetate rectal suppository 25 mg, 30 mg

1

hydrocortisone rectal enema 100 mg/60ml

1

hydrocort-pramoxine (perianal) external cream 2.5-1 %

1

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

3Brand

penalty applies

lidocaine-hydrocort (perianal) external cream 3-0.5 %

1

lidocaine-hydrocortisone ace rectal cream 3-0.5 %

1

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 %

3

lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3-2.5 %

1

Drug NameDrug Tier

Notes

mesalamine er oral capsule extended release 24 hour 0.375 gm

1

mesalamine oral capsule delayed release 400 mg

1

mesalamine oral tablet delayed release 1.2 gm, 800 mg

1

mesalamine rectal enema 4 gm

1

mesalamine rectal suppository 1000 mg

1

mesalamine-cleanser rectal kit 4 gm

1

ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 6 MG

3

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

3

PROCORT EXTERNAL CREAM 1.85-1.15 %

3

PROCTOCORT EXTERNAL CREAM 1 %

3Brand

penalty applies

PROCTOCORT RECTAL SUPPOSITORY 30 MG

3

PROCTOFOAM HC EXTERNAL FOAM 1-1 %

3

procto-med hc external cream 2.5 %

1

procto-pak external cream 1 %

1

proctosol hc external cream 2.5 %

1

proctozone-hc external cream 2.5 %

1



182

Drug NameDrug Tier

Notes

ROWASA RECTAL KIT 4 GM

3Brand

penalty applies

SFROWASA RECTAL ENEMA 4 GM/60ML

2

sulfasalazine oral tablet 500 mg

1

sulfasalazine oral tablet delayed release 500 mg

1

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG

3PA;

Specialty Pharmacy

UCERIS RECTAL FOAM 2 MG/ACT

3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG

3ST; Brand

penalty applies

alendronate sodium oral solution 70 mg/75ml

1

alendronate sodium oral tablet 10 mg

RG

alendronate sodium oral tablet 35 mg, 70 mg

RGQL (4 EA

per 28 days)

alendronate sodium oral tablet 5 mg

1

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG

3ST; Brand

penalty applies

BINOSTO ORAL TABLET EFFERVESCENT 70 MG

3 ST

BONIVA INTRAVENOUS SOLUTION 3 MG/3ML

GM

BONIVA ORAL TABLET 150 MG

3Brand

penalty applies

calcitonin (salmon) nasal solution 200 unit/act

1

Drug NameDrug Tier

Notes

EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 105 MG/1.17ML

3PA;

Specialty Medical

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 600 MCG/2.4ML

3PA;

Specialty Pharmacy

FOSAMAX ORAL TABLET 70 MG

3

Brand penalty


FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT

3

ibandronate sodium intravenous solution 3 mg/3ml

GM

ibandronate sodium oral tablet 150 mg

1

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

2

pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

2Specialty Medical

pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

2Specialty Medical

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60 MG/ML

3Specialty Medical

RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG

3PA;

Specialty Pharmacy

RECLAST INTRAVENOUS SOLUTION 5 MG/100ML

3Specialty Medical



183

Drug NameDrug Tier

Notes

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

1 ST

risedronate sodium oral tablet delayed release 35 mg

1 ST

TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG/2.48ML

3PA;

Specialty Pharmacy

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

3PA;

Specialty Pharmacy

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML

3Specialty Medical

zoledronic acid intravenous concentrate 4 mg/5ml

2Specialty Medical

zoledronic acid intravenous solution 4 mg/100ml, 5 mg/100ml

2Specialty Medical

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcg/ml

GM

calcitriol oral capsule 0.25 mcg, 0.5 mcg

1

calcitriol oral solution 1 mcg/ml

1

cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg

2PA;

Specialty Pharmacy

doxercalciferol intravenous solution 4 mcg/2ml

GM

Drug NameDrug Tier

Notes

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

1 PA

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML, 4 MCG/2ML

GM

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

3PA;

Specialty Medical

paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml

GM

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg

1 ST

PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 MG/0.5ML, 5 MG/ML

3Specialty Medical

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG

3Brand

penalty applies

ROCALTROL ORAL SOLUTION 1 MCG/ML

3Brand

penalty applies

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

3PA;

Specialty Pharmacy

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

GM

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG

3ST; Brand

penalty applies

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS SOLUTION 1:20

GM



184

Drug NameDrug Tier

Notes

ACETADOTE INTRAVENOUS SOLUTION 200 MG/ML

GM

acetylcysteine intravenous solution 200 mg/ml

GM

ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ACTHREL INTRAVENOUS SOLUTION RECONSTITUTED 100 MCG

GM

ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML

3PA;

Specialty Medical

adenosine (diagnostic) intravenous solution 3 mg/ml

GM

adenosine intravenous solution 3 mg/ml

GM

ALBUKED 25 INTRAVENOUS SOLUTION 25 %

GM

ALBUKED 5 INTRAVENOUS SOLUTION 5 %

GM

albumin human intravenous solution 25 %, 5 %

GM

ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 %

GM

albumin-zlb intravenous solution 25 %, 5 %

GM

alburx intravenous solution 5 %

GM

ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

Drug NameDrug Tier

Notes

ALDER SUBCUTANEOUS SOLUTION 1:20

GM

ALPHA-LIPOIC ACID INJECTION SOLUTION 25 MG/ML

GM

ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6"

3

AMD FOAM DRESSING TOPSHEET PAD 4"X4"

3

AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN SYCAMORE SUBCUTANEOUS SOLUTION 1:20

GM

AMIDATE INTRAVENOUS SOLUTION 2 MG/ML

GM

AMPHADASE INJECTION SOLUTION 150 UNIT/ML

GM

ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED

GM

ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED

3Specialty Medical



185

Drug NameDrug Tier

Notes

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 200 MG

3Specialty Medical

ANESTHESIA S/I-40 INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40A INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40H INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40S INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-60 INTRAVENOUS KIT 200 MG/20ML

GM

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION RECONSTITUTED

GM

APP SLIM RMS ORAL CAPSULE

3

ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

arnica flower tincture 1

ARTISS EXTERNAL SOLUTION

3

ASPERGILLUS FUMIGATUS INJECTION SOLUTION 1:10 , 1:20

GM

AUREOBASIDIUM PULLULANS INJECTION SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20

GM

AZALGIA ORAL CAPSULE

3

BACTERIOSTATIC WATER(BENZ ALC) INJECTION SOLUTION

GM

BAHIA SUBCUTANEOUS SOLUTION 1:20

GM

bal in oil intramuscular solution 100 mg/ml

GM

BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 1:20

GM

BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

BIOFREQUENCY INSOLES

3

BIOGUARD GAUZE SPONGES PAD 4"X4"

3

BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , 4"X5"

3

BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , 3"X8"

3

BLACK WALNUT POLLEN SUBCUTANEOUS SOLUTION 1:20

GM



186

Drug NameDrug Tier

Notes

BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20

GM

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

GM PA

BOTRYTIS INJECTION SOLUTION 1:20 , 43000 PNU/ML

GM

BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

BOX ELDER SUBCUTANEOUS SOLUTION 1:20

GM

BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 2.5 GM, 500 MG

GM

BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 MG/5ML

GM

BROME SUBCUTANEOUS SOLUTION 1:20

GM

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 1 GM/5ML

GM

CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 1:20

GM

CANDIDA ALBICANS EXTRACT INJECTION SOLUTION 100 MG/ML

GM

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

Drug NameDrug Tier

Notes

CARDIOVID PLUS ORAL CAPSULE

3

CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM

CAYA VAGINAL DIAPHRAGM

PV

CEDAR ELM SUBCUTANEOUS SOLUTION 1:20

GM

CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG

GM

CHLORHEXIDINE GLUCONATE SOLUTION 20 %

3

CLADOSPORIUM CLADOSPORIOIDES INJECTION SOLUTION 1:20 , 64000 PNU/ML

GM

CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL SOLUTION 1:20

GM

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

COCKLEBUR SUBCUTANEOUS SOLUTION 1:20

GM



187

Drug NameDrug Tier

Notes

CORN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 MG

GM

cosyntropin injection solution reconstituted 0.25 mg

GM

CROFAB INTRAVENOUS SOLUTION RECONSTITUTED

GM

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

3

CURITY AMD ANTIMICROBIAL STRIP

3

CURITY IODOFORM PACKING STRIP

3

CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 GM

GM

CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 MG

GM

DANDELION SUBCUTANEOUS SOLUTION 1:20

GM

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

GM

Drug NameDrug Tier

Notes

DEFLUX INJECTION PREFILLED SYRINGE 50-15 MG/ML

GM

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

GM

dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml

GM

DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 MCG/10ML, 400 MCG/4ML

GM

dexmedetomidine hcl intravenous solution 200 mcg/2ml

GM

DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 200MCG/50ML -5%, 400MCG/100ML -5%

GM

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

diluent for treprostinil intravenous solution

GM

DIMERCAPTOPROPANE-SULFONATE INJECTION SOLUTION 250 MG/5ML

GM

DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML

GM

dipyridamole intravenous solution 5 mg/ml

GM



188

Drug NameDrug Tier

Notes

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

DOG FENNEL SUBCUTANEOUS SOLUTION 1:20

GM

DOJOLVI ORAL LIQUID 100 %

3

DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 2.1-600 MG

GM

DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 MG/3ML

GM

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT

GM PA

EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 1:20

GM

ENCARE VAGINAL SUPPOSITORY 100 MG

PV

ENDARI ORAL PACKET 5 GM

3

ENGLISH PLANTAIN SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

EPICOCCUM NIGRUM INJECTION SOLUTION 1:10

GM

EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

ergoloid mesylates oral tablet 1 mg

1

EROS-CTD DEVICE 3

etomidate intravenous solution 2 mg/ml

GM

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

EXCILON AMD DRAIN SPONGES PAD 4"X4"

3

FC FEMALE CONDOMPV

QL (36 EA per 365 days)

FC2 FEMALE CONDOMPV

QL (36 EA per 365 days)

FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

PV

FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml

GM

fomepizole intravenous solution 1.5 gm/1.5ml

GM

formaldehyde external solution 10 %, 37 %

1



189

Drug NameDrug Tier

Notes

fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

FRESENIUS PROPOVEN INTRAVENOUS EMULSION 2000 MG/100ML

GM

FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

GELFOAM-JMI SPONGE EXTERNAL KIT

3

GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML

GM

GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML

GM

GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

GIVLAARI SUBCUTANEOUS SOLUTION 189 MG/ML

3PA;

Specialty Pharmacy

GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM

GM

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG

GM

Drug NameDrug Tier

Notes

GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION RECONSTITUTED 1 MG

GM

glutaraldehyde external solution 25 %

1

GOLDENROD SUBCUTANEOUS SOLUTION 1:20

GM

GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU

2

HACKBERRY SUBCUTANEOUS SOLUTION 1:20

GM

HISTATROL INJECTION SOLUTION 2.75 MG/ML

GM

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION 25 %

GM

HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML

GM

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

HYLENEX INJECTION SOLUTION 150 UNIT/ML

GM



190

Drug NameDrug Tier

Notes

HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 24 MG/3ML

GM

IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

indocyanine green intravenous solution reconstituted 25 mg

GM

INFED INJECTION SOLUTION 50 MG/ML

GM

isosulfan blue subcutaneous solution 1 %

GM

IV STABILIZER FOR LUMOXITI INTRAVENOUS SOLUTION 0.7-6.5-6.4 MG/ML

GM

JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20

GM

JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

KAPOK SUBCUTANEOUS SOLUTION 1:20

GM

kedbumin intravenous solution 25 %

GM

KERLIX AMD ANTIMICROBIAL

3

KERLIX AMD SUPER SPONGES PAD 6"X6-3/4"

3

KETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 MG/ML

GM

Drug NameDrug Tier

Notes

KETAMINE HCL INJECTION SOLUTION 0.6 MG/ML, 1 MG/ML

GM

ketamine hcl injection solution 10 mg/ml, 100 mg/ml, 50 mg/ml

GM

KETAMINE HCL INJECTION SOLUTION PREFILLED SYRINGE 30 MG/3ML, 50 MG/5ML, 50 MG/ML

GM

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%

GM

KINEVAC INJECTION SOLUTION RECONSTITUTED 5 MCG

GM

KOCHIA SUBCUTANEOUS SOLUTION 1:20

GM

LAMBS QUARTERS SUBCUTANEOUS SOLUTION 1:20

GM

LENSCALE SUBCUTANEOUS SOLUTION 1:20

GM

LEXISCAN INTRAVENOUS SOLUTION 0.4 MG/5ML

GM

MACI INTRA-ARTICULAR SHEET

GM

MACRILEN ORAL PACKET 60 MG

3Specialty Pharmacy

MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM



191

Drug NameDrug Tier

Notes

MELALEUCA SUBCUTANEOUS SOLUTION 1:20

GM

MESQUITE SUBCUTANEOUS SOLUTION 1:20

GM

methergine oral tablet 0.2 mg

1

methylergonovine maleate injection solution 0.2 mg/ml

GM

methylergonovine maleate oral tablet 0.2 mg

1

MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20

GM

MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

MIXED VESPID VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

mixed vespid venom protein subcutaneous solution reconstituted 1100-1100-1100 mcg

GM

Drug NameDrug Tier

Notes

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120-120-120 MCG

GM

MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 88 MG/4ML

GM

MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM

MUCOR INJECTION SOLUTION 1:20

GM

MUCOR INTRADERMAL SOLUTION 1:20

GM

MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

MUGWORT SUBCUTANEOUS SOLUTION 1:20

GM

MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML

GM PA

NITHIODOTE INTRAVENOUS KIT 300MG/10ML&12.5 GM/50ML

GM

OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION

GM



192

Drug NameDrug Tier

Notes

OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION

GM

ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM

3

OLIVE TREE SUBCUTANEOUS SOLUTION 1:20

GM

OPTIONS CONCEPTROL VAGINAL GEL 4 %

PV

ORAFATE MOUTH/THROAT PASTE 10 %

3

ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK 3 X 100 IR & 6 X 300 IR

3

ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 100 IR

3

Drug NameDrug Tier

Notes

ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 30 MG/2ML

GM

OXBRYTA ORAL TABLET 500 MG

3PA;

Specialty Pharmacy

PECAN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

PENICILLIUM NOTATUM INJECTION SOLUTION 1:10 , 1:20

GM

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

PERENNIAL RYE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

PHENOL INJECTION SOLUTION 6 %

GM

PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 %

3PA;

Specialty Pharmacy

PLASBUMIN-25 INTRAVENOUS SOLUTION 25 %

GM



193

Drug NameDrug Tier

Notes

PLASBUMIN-5 INTRAVENOUS SOLUTION 5 %

GM

PLASMANATE INTRAVENOUS SOLUTION 5 %

GM

pralidoxime chloride intramuscular solution auto-injector 600 mg/2ml

GM

PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML

GM

PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML

GM

PRIVET SUBCUTANEOUS SOLUTION 1:20

GM

propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

PROTHELIAL MOUTH/THROAT PASTE 10 %

3

PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

GM

PROVAYBLUE INTRAVENOUS SOLUTION 50 MG/10ML

GM

QUEEN PALM SUBCUTANEOUS SOLUTION 1:20

GM

RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

Drug NameDrug Tier

Notes

RADIOGARDASE ORAL CAPSULE 0.5 GM

3PA;

Specialty Pharmacy

RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 1-U

2

RAPPORT RLS KIT 3

RAPPORT VTD KIT 3

RED BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

RED CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

RED MAPLE SUBCUTANEOUS SOLUTION 1:20

GM

RED MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

R-GENE 10 INTRAVENOUS SOLUTION 10 %

GM

RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20

GM

ROUGH PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20

GM



194

Drug NameDrug Tier

Notes

RUZURGI ORAL TABLET 10 MG

3PA;

Specialty Pharmacy

SACCHAROMYCES CEREVISIAE INJECTION SOLUTION 1:20

GM

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

SAGEBRUSH SUBCUTANEOUS SOLUTION 1:20

GM

SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20

GM

SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20

GM

SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 1:20

GM

SODIUM HYALURONATE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

sodium nitrite intravenous solution 30 mg/ml

GM

sodium saccharin powder 1

sodium thiosulfate intravenous solution 25 %

GM

SOLESTA INJECTION GEL 50-15 MG/ML

GM

SORBITOL IRRIGATION SOLUTION 3 %

3

sorbitol irrigation solution 3.3 %

1

Drug NameDrug Tier

Notes

sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml

1

SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20

GM

SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML

3PA;

Specialty Medical

SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

STEMPHYLIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

STERILE DILUENT FLOLAN PH 12 INTRAVENOUS SOLUTION

GM

sterile diluent/epoprostenol intravenous solution

GM

sterile water for injection injection solution

GM

sterile water for injection intravenous solution

GM

SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

SWEET GUM SUBCUTANEOUS SOLUTION 1:20

GM

SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML

GM



195

Drug NameDrug Tier

Notes

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML

GM

TACHOSIL EXTERNAL PATCH 4.8 X 4.8 CM, 9.5 X 4.8 CM

3

TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8"

3

TELFA AMD NON-ADHERENT PAD 3"X8"

3

THYROGEN INTRAMUSCULAR SOLUTION RECONSTITUTED 1.1 MG

GM

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS SOLUTION 10000 BAU/ML, 100000 BAU/ML

GM

TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML

3

TISSEEL EXTERNAL SOLUTION

3

TODAY SPONGE VAGINAL 1000 MG

PV

TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

Drug NameDrug Tier

Notes

TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 %

PV

vcf vaginal contraceptive vaginal gel 4 %

PV

VENOMIL MIXED VESPID VENOM INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

VIRGINIA LIVE OAK SUBCUTANEOUS SOLUTION 1:20

GM

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

VISTOGARD ORAL PACKET 10 GM

3Specialty Pharmacy

VITRASE INJECTION SOLUTION 200 UNIT/ML

GM

WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20

GM

WHITE ASH SUBCUTANEOUS SOLUTION 1:20

GM



196

Drug NameDrug Tier

Notes

WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

WHITE OAK SUBCUTANEOUS SOLUTION 1:20

GM

WHITE PINE SUBCUTANEOUS SOLUTION 1:20

GM

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 %

PV


PV


PV


PV


PV

Drug NameDrug Tier

Notes


PV


PV


PV

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT

GM PA

XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG

3PA;

Specialty Medical

XYZMUNE ORAL CAPSULE

3

YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20

GM

YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM



197

Drug NameDrug Tier

Notes

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MCG

GM

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR LS OPHTHALMIC SOLUTION 0.4 %

3Brand

penalty applies

ACULAR OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

ACUVAIL OPHTHALMIC SOLUTION 0.45 %

3

ALOCRIL OPHTHALMIC SOLUTION 2 %

3

ALOMIDE OPHTHALMIC SOLUTION 0.1 %

2

ALREX OPHTHALMIC SUSPENSION 0.2 %

3

AZASITE OPHTHALMIC SOLUTION 1 %

3

azelastine hcl ophthalmic solution 0.05 %

1

bacitracin ophthalmic ointment 500 unit/gm

1

BEPREVE OPHTHALMIC SOLUTION 1.5 %

3

BESIVANCE OPHTHALMIC SUSPENSION 0.6 %

3

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 %

3

BLEPH-10 OPHTHALMIC SOLUTION 10 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

1

BROMSITE OPHTHALMIC SOLUTION 0.075 %

3

CILOXAN OPHTHALMIC OINTMENT 0.3 %

3

CILOXAN OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

ciprofloxacin hcl ophthalmic solution 0.3 %

1

cromolyn sodium ophthalmic solution 4 %

RG

dexamethasone sodium phosphate ophthalmic solution 0.1 %

1

DEXYCU INTRAOCULAR SUSPENSION 9 %

2Specialty Pharmacy

diclofenac sodium ophthalmic solution 0.1 %

1

DUREZOL OPHTHALMIC EMULSION 0.05 %

3

epinastine hcl ophthalmic solution 0.05 %

1

erythromycin ophthalmic ointment 5 mg/gm

1

FLAREX OPHTHALMIC SUSPENSION 0.1 %

2

fluorometholone ophthalmic suspension 0.1 %

1

flurbiprofen sodium ophthalmic solution 0.03 %

1



198

Drug NameDrug Tier

Notes

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

2

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %

3Brand

penalty applies

FML OPHTHALMIC OINTMENT 0.1 %

2

gatifloxacin ophthalmic solution 0.5 %

1

gentak ophthalmic ointment 0.3 %

1

gentamicin sulfate ophthalmic solution 0.3 %

1

ILEVRO OPHTHALMIC SUSPENSION 0.3 %

3

ILUVIEN INTRAVITREAL IMPLANT 0.19 MG

3

INVELTYS OPHTHALMIC SUSPENSION 1 %

3

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

1

KLARITY-A OPHTHALMIC SOLUTION 1 %

3

levofloxacin ophthalmic solution 0.5 %

1

LOTEMAX OPHTHALMIC GEL 0.5 %

3

LOTEMAX OPHTHALMIC OINTMENT 0.5 %

3

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

3Brand

penalty applies

LOTEMAX SM OPHTHALMIC GEL 0.38 %

3

Drug NameDrug Tier

Notes

loteprednol etabonate ophthalmic suspension 0.5 %

1

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

3

MITOSOL OPHTHALMIC KIT 0.2 MG

GM

MOXEZA OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

moxifloxacin hcl (2x day) ophthalmic solution 0.5 %

1

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 1 MG/ML, 5 MG/ML

GM

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML

GM

moxifloxacin hcl ophthalmic solution 0.5 %

1

NATACYN OPHTHALMIC SUSPENSION 5 %

3

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

3

OCUFLOX OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

ofloxacin ophthalmic solution 0.3 %

1

olopatadine hcl ophthalmic solution 0.1 %, 0.2 %

1

OZURDEX INTRAVITREAL IMPLANT 0.7 MG

3Specialty Medical

PAZEO OPHTHALMIC SOLUTION 0.7 %

3



199

Drug NameDrug Tier

Notes

POVIDONE-IODINE OPHTHALMIC SOLUTION 5 %

3

PRED FORTE OPHTHALMIC SUSPENSION 1 %

3Brand

penalty applies

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

2

PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC SUSPENSION 1-0.5-0.075 %

3

prednisolone acetate ophthalmic suspension 1 %

1

prednisolone acetate p-f ophthalmic suspension 1 %

1

prednisolone sodium phosphate ophthalmic solution 1 %

1

PROLENSA OPHTHALMIC SOLUTION 0.07 %

3

sulfacetamide sodium ophthalmic ointment 10 %

1

sulfacetamide sodium ophthalmic solution 10 %

1

tobramycin ophthalmic solution 0.3 %

RG

TOBREX OPHTHALMIC OINTMENT 0.3 %

2

TOBREX OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

TRIESENCE INTRAOCULAR SUSPENSION 40 MG/ML

3

Drug NameDrug Tier

Notes

trifluridine ophthalmic solution 1 %

1

TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.09 %

3

TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.5 %

3

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

ZERVIATE OPHTHALMIC SOLUTION 0.24 %

3

ZIRGAN OPHTHALMIC GEL 0.15 %

3

ZYMAXID OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er oral capsule extended release 12 hour 500 mg

1

acetazolamide oral tablet 125 mg, 250 mg

1

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

2Brand

penalty applies

apraclonidine hcl ophthalmic solution 0.5 %

1

AZOPT OPHTHALMIC SUSPENSION 1 %

3

betaxolol hcl ophthalmic solution 0.5 %

1



200

Drug NameDrug Tier

Notes

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %

3

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

2

bimatoprost ophthalmic solution 0.03 %

1

brimonidine tartrate ophthalmic solution 0.15 %

1

brimonidine tartrate ophthalmic solution 0.2 %

RG

BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 0.15-2 %

3

carteolol hcl ophthalmic solution 1 %

1

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

3

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

3Brand

penalty applies

COSOPT PF OPHTHALMIC SOLUTION 2-0.5 %

3Brand

penalty applies

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 %

3

dorzolamide hcl solution 2 % ophthalmic 2 %

1

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

1

dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 %

1

DURYSTA INTRAOCULAR IMPLANT 10 MCG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

IOPIDINE OPHTHALMIC SOLUTION 1 %

3

ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 %

3Brand

penalty applies

ISTALOL OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

KEVEYIS ORAL TABLET 50 MG

3PA;

Specialty Pharmacy

latanoprost ophthalmic solution 0.005 %

1

LATANOPROST-TIMOLOL MALEATE OPHTHALMIC SOLUTION 0.005-0.5 %

3

levobunolol hcl ophthalmic solution 0.5 %

1

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

2

methazolamide oral tablet 25 mg, 50 mg

1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

2

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

1

RHOPRESSA OPHTHALMIC SOLUTION 0.02 %

3

ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 %

3

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

3



201

Drug NameDrug Tier

Notes

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

RG

timolol maleate ophthalmic solution 0.5 % (daily)

1

TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC SOLUTION 0.5-0.15-2 -0.005%

3

TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC SOLUTION 0.5-0.15-2 %

3

TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC SOLUTION 0.5-0.15-0.005 %

3

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 %

2

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 %

2Brand

penalty applies

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 %

3Brand

penalty applies

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

2Brand

penalty applies

travoprost (bak free) ophthalmic solution 0.004 %

1

Drug NameDrug Tier

Notes

TRUSOPT OPHTHALMIC SOLUTION 2 %

3Brand

penalty applies

VYZULTA OPHTHALMIC SOLUTION 0.024 %

3

XALATAN OPHTHALMIC SOLUTION 0.005 %

3Brand

penalty applies

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %

3

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-fluor intravenous solution 10 %, 25 %

GM

ak-poly-bac ophthalmic ointment 500-10000 unit/gm

1

AKTEN OPHTHALMIC GEL 3.5 %

3

ALCAINE OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

altacaine ophthalmic solution 0.5 %

1

altafrin ophthalmic solution 10 %, 2.5 %

1

AMVISC INTRAOCULAR SOLUTION 12 MG/ML

3

AMVISC PLUS INTRAOCULAR SOLUTION 16 MG/ML

3

atropine sulfate ophthalmic ointment 1 %

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 %

3

atropine sulfate ophthalmic solution 1 %

1



202

Drug NameDrug Tier

Notes

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

1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

1

balanced salt intraocular solution

1

BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML

3Specialty Medical

BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML

3PA;

Specialty Medical

BEVACIZUMAB INTRAVITREAL SOLUTION PREFILLED SYRINGE 2.5 MG/0.1ML, 3.25 MG/0.13ML, 3.75 MG/0.15ML

3PA;

Specialty Medical

BIOLON INTRAOCULAR SOLUTION 10 MG/ML

3

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

2

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

2

bss intraocular solution 1

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 %

2Brand

penalty applies

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 %

2

cyclopentolate hcl ophthalmic solution 0.5 %

1

Drug NameDrug Tier

Notes

cyclopentolate hcl ophthalmic solution 1 %, 2 %

RG

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 %

3

DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 1-5 MG/ML

GM

DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 1-0.5-0.4 MG/ML

GM

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML

3Specialty Medical

EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 MG/0.05ML

3Specialty Medical

FLUORESCITE INTRAVENOUS SOLUTION 10 %

GM

GELFILM OPHTHALMIC FILM

3

HEALON GV INTRAOCULAR SOLUTION 14 MG/ML

3

HEALON INTRAOCULAR SOLUTION 10 MG/ML

3

HEALON PRO INTRAOCULAR SOLUTION 10 MG/ML

3

HEALON5 INTRAOCULAR SOLUTION 23 MG/ML

3

HEALON5 PRO INTRAOCULAR SOLUTION 23 MG/ML

3



203

Drug NameDrug Tier

Notes

homatropaire ophthalmic solution 5 %

1

HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 175 UNIT/ML

GM

ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 %

3

LACRISERT OPHTHALMIC INSERT 5 MG

3

LASTACAFT OPHTHALMIC SOLUTION 0.25 %

3

LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5-0.25 MG/ML

GM

LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 1-1.5 %

GM

LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML)

GM

LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML, 0.5 MG/0.05ML

3Specialty Medical

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.3 MG/0.05ML

3

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.5 MG/0.05ML

3Specialty Medical

Drug NameDrug Tier

Notes

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VG/ML

3PA;

Specialty Medical

MACUGEN INTRAOCULAR SOLUTION 0.3 MG

3Specialty Medical

MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1

3Brand

penalty applies

MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1

3Brand

penalty applies

MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 %

GM

MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 20 MG

3

MIOSTAT INTRAOCULAR SOLUTION 0.01 %

3

MOXIFLOXACIN HCL-BSS INTRAVITREAL SOLUTION 1 MG/ML

GM

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000 , 5-400-10000

1

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

1



204

Drug NameDrug Tier

Notes

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

1

neo-polycin hc ophthalmic ointment 1 %

1

neo-polycin ophthalmic ointment 3.5-400-10000

1

OMIDRIA INTRAOCULAR SOLUTION 1-0.3 %

GM

OXERVATE OPHTHALMIC SOLUTION 0.002 %

3PA;

Specialty Pharmacy

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

1

polycin ophthalmic ointment 500-10000 unit/gm

1

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

1

POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-%

3Brand

penalty applies

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

2

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

2

PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1-0.075 %

3

PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 1-0.075 %

GM

Drug NameDrug Tier

Notes

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION 1-0.5 %

3

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

3

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SUSPENSION 1-0.5-0.075 %

3

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

3

proparacaine hcl ophthalmic solution 0.5 %

1

PROVISC INTRAOCULAR SOLUTION 10 MG/ML

3

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

2

RESTASIS OPHTHALMIC EMULSION 0.05 %

2

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

tetracaine hcl ophthalmic solution 0.5 %

1

TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.025 %

GM



205

Drug NameDrug Tier

Notes

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

2

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

2Brand

penalty applies

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

2

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

1

TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 15-1 MG/ML

GM

TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC SOLUTION 1-1-2.5 %

3

TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 1-2.5 %

3

TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC SOLUTION 1-0.5-2.5-0.5 %

3

VISIONBLUE OPHTHALMIC SOLUTION 0.06 %

GM

VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 MG

3Specialty Medical

XIIDRA OPHTHALMIC SOLUTION 5 %

3

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %

3

Drug NameDrug Tier

Notes

Otic Agents - Drugs for Ear Conditions

acetic acid otic solution 2 %

1

CETRAXAL OTIC SOLUTION 0.2 %

3Brand

penalty applies

CIPRO HC OTIC SUSPENSION 0.2-1 %

3

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

3

ciprofloxacin hcl otic solution 0.2 %

1

CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3-0.025 %

3

cortic-nd otic solution 10-10-1 mg/ml

1

DERMOTIC OTIC OIL 0.01 %

3Brand

penalty applies

exotic-hc otic solution 10-10-1 mg/ml

1

flac otic oil 0.01 % 1

fluocinolone acetonide otic oil 0.01 %

1

hydrocortisone-acetic acid otic solution 1-2 %

1

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1

1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

1

ofloxacin otic solution 0.3 %

1

OTICIN HC NR OTIC SOLUTION 10-10-1 MG/ML

3



206

Drug NameDrug Tier

Notes

OTIPRIO INTRATYMPANIC SUSPENSION 6 %

3

OTOVEL OTIC SOLUTION 0.3-0.025 %

3

PRAMOTIC OTIC LIQUID 1-0.1 %

3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL SOLUTION 0.1 %

3

azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

1

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY

3

benzonatate oral capsule 100 mg, 150 mg, 200 mg

1

bromfed dm oral syrup 30-2-10 mg/5ml

1

brompheniramine tannate oral tablet chewable 12 mg

1

budesonide nasal suspension 32 mcg/act

1

carbinoxamine maleate oral solution 4 mg/5ml

1

carbinoxamine maleate oral tablet 4 mg

1

CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML

3PA;

Specialty Medical

clemastine fumarate oral tablet 2.68 mg

1

CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 240 MG/3ML

3

Drug NameDrug Tier

Notes

cyproheptadine hcl oral syrup 2 mg/5ml

1

cyproheptadine hcl oral tablet 4 mg

1

desloratadine oral tablet 5 mg

1

desloratadine oral tablet dispersible 2.5 mg, 5 mg

1

dexchlorpheniramine maleate oral solution 2 mg/5ml

1

diphen oral elixir 12.5 mg/5ml

1

diphenhydramine hcl oral elixir 12.5 mg/5ml

1

FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 MG/ML

3PA;

Specialty Pharmacy

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML

3PA;

Specialty Medical

flunisolide nasal solution 25 mcg/act (0.025%)

1

fluticasone propionate nasal suspension 50 mcg/act

1

GILPHEX TR ORAL TABLET 10-388 MG

3

GILTUSS TR ORAL TABLET 10-28-388 MG

3

guaiatussin ac oral syrup 100-10 mg/5ml

1

guaifenesin ac oral syrup 100-10 mg/5ml

1

hydrocodone polst-cpm polst er oral suspension extended release 10-8 mg/5ml

1



207

Drug NameDrug Tier

Notes

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

1

hydrocodone-homatropine oral tablet 5-1.5 mg

1

hydromet oral syrup 5-1.5 mg/5ml

1

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 7 %

3

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-%

3

ipratropium bromide nasal solution 0.03 %, 0.06 %

1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 MG/5ML

3

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

1

levocetirizine dihydrochloride oral tablet 5 mg

1

maxi-tuss ac oral solution 100-10 mg/5ml

1

mometasone furoate nasal suspension 50 mcg/act

1

NASONEX NASAL SUSPENSION 50 MCG/ACT

3Brand

penalty applies

nebusal inhalation nebulization solution 3 %

1

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

3

Drug NameDrug Tier

Notes

NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML

3

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML

3PA;

Specialty Pharmacy

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

3PA;

Specialty Pharmacy

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG

3PA;

Specialty Medical

olopatadine hcl nasal solution 0.6 %

1

OMNARIS NASAL SUSPENSION 50 MCG/ACT

3

PATANASE NASAL SOLUTION 0.6 %

3Brand

penalty applies

promethazine hcl oral solution 6.25 mg/5ml

1

promethazine hcl oral syrup 6.25 mg/5ml

1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

1

promethazine hcl rectal suppository 12.5 mg, 25 mg

1

promethazine-codeine oral solution 6.25-10 mg/5ml

1

promethazine-codeine oral syrup 6.25-10 mg/5ml

1

promethazine-dm oral syrup 6.25-15 mg/5ml

1



208

Drug NameDrug Tier

Notes

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml

1

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

1

promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

1

pseudoephedrine-bromphen-dm oral liquid 30-2-10 mg/5ml

1

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml

1

pulmosal inhalation nebulization solution 7 %

1

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT

3

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT

3

QUZYTTIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RYCLORA ORAL SOLUTION 2 MG/5ML

3Brand

penalty applies

SINUVA NASAL IMPLANT 1350 MCG

2Specialty Medical

sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

1

SSKI ORAL SOLUTION 1 GM/ML

3

SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML-%

3

Drug NameDrug Tier

Notes

TESSALON PERLES ORAL CAPSULE 100 MG

3Brand

penalty applies

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

3

TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 54.3-8 MG

3

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 14.7-2.8 MG/5ML

3

virtussin ac w/alc oral liquid 100-10 mg/5ml

1

XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT

3

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

3PA;

Specialty Medical

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG

3PA;

Specialty Medical

ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT

3

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies

acetylcysteine inhalation solution 10 %, 20 %

1



209

Drug NameDrug Tier

Notes

ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML

GMQL (4 ML

per 30 days)

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

3PA; Brand

penalty applies

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

3 PA

ADYPHREN AMP II INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN AMP INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN II INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

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

1

albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act

1QL (3 GM

per 30 days)

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

1

Drug NameDrug Tier

Notes

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION (5 MG/ML) 0.5%

3

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5%

1

albuterol sulfate oral syrup 2 mg/5ml

1

albuterol sulfate oral tablet 2 mg

1

albuterol sulfate oral tablet 4 mg

RG

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT

3

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

2

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG

3PA;

Specialty Medical

ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG

3QL (30 EA

per 30 days)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

3 PA

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

2QL (1 EA

per 30 days)



210

Drug NameDrug Tier

Notes


2QL (1 EA

per 30 days)

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

2QL (1 EA

per 30 days)


2QL (1 EA

per 30 days)


2QL (1 EA

per 30 days)

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

2

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

2

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT

3

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

3 PA

BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML

3

Drug NameDrug Tier

Notes

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

1

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

2

cromolyn sodium inhalation nebulization solution 20 mg/2ml

1

DALIRESP ORAL TABLET 250 MCG, 500 MCG

3 PA

difil-g forte oral liquid 100-100 mg/5ml

1

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT

2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

2

epinephrine injection solution 30 mg/30ml

GMQL (4 ML

per 30 days)

epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml

1QL (4 EA

per 30 days)

EPINEPHRINE PROFESSIONAL INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)



211

Drug NameDrug Tier

Notes

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

3

Brand penalty


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

3

Brand penalty


EPISNAP INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ESBRIET ORAL CAPSULE 267 MG

3PA;

Specialty Pharmacy

ESBRIET ORAL TABLET 267 MG, 801 MG

3PA;

Specialty Pharmacy

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

3

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

3QL (24 GM

per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

1

Drug NameDrug Tier

Notes

GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML

3PA;

Specialty Medical

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

2

ipratropium bromide inhalation solution 0.02 %

1

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

1

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

1

metaproterenol sulfate oral syrup 10 mg/5ml

1

montelukast sodium oral packet 4 mg

1

montelukast sodium oral tablet 10 mg

1

montelukast sodium oral tablet chewable 4 mg, 5 mg

1

OFEV ORAL CAPSULE 100 MG, 150 MG

3PA;

Specialty Pharmacy

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML

3

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

1QL (3 GM

per 30 days)



212

Drug NameDrug Tier

Notes

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

3QL (3 EA

per 30 days)

PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML

3PA;

Specialty Medical

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

3PA;

Specialty Medical

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

2

PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

3Brand

penalty applies

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

2

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 4 GM

3

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

2

SINGULAIR ORAL PACKET 4 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

SINGULAIR ORAL TABLET 10 MG

3Brand

penalty applies

SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG

3Brand

penalty applies

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

2

STERILE TALC POWDER INTRAPLEURAL SUSPENSION RECONSTITUTED 5 GM

3

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

2

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

2

terbutaline sulfate injection solution 1 mg/ml

GM

terbutaline sulfate oral tablet 2.5 mg, 5 mg

1

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

2

theophylline er oral tablet extended release 12 hour 300 mg, 450 mg

1



213

Drug NameDrug Tier

Notes

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

1

theophylline in d5w intravenous solution 0.8-5 mg/ml-%

GM

theophylline oral solution 80 mg/15ml

1

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

2

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

2

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG

3

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

1QL (3 GM

per 30 days)

wixela inhub inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML

3Brand

penalty applies

XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

YUPELRI INHALATION SOLUTION 175 MCG/3ML

3PA;

Specialty Pharmacy

zafirlukast oral tablet 10 mg, 20 mg

1

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

3PA;

Specialty Medical

zileuton er oral tablet extended release 12 hour 600 mg

2Specialty Pharmacy

ZYFLO ORAL TABLET 600 MG

2Specialty Pharmacy

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

3PA;

Specialty Pharmacy

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

3PA;

Specialty Pharmacy

KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG

3PA;

Specialty Pharmacy

KALYDECO ORAL TABLET 150 MG

3PA;

Specialty Pharmacy

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

3PA;

Specialty Pharmacy

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG

3PA;

Specialty Pharmacy

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

3PA;

Specialty Pharmacy



214

Drug NameDrug Tier

Notes

PULMOZYME INHALATION SOLUTION 1 MG/ML

3PA;

Specialty Pharmacy

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 MG

3PA;

Specialty Pharmacy

TOBI NEBULIZER INHALATION NEBULIZATION SOLUTION 300 MG/5ML

3PA;

Specialty Pharmacy

TOBI PODHALER INHALATION CAPSULE 28 MG

3PA;

Specialty Pharmacy

tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml

2PA;

Specialty Pharmacy

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION 300 MG/5ML

3PA;

Specialty Pharmacy

TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG

3PA;

Specialty Pharmacy

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA ORAL TABLET 20 MG

3PA;

Specialty Pharmacy

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

3PA;

Specialty Pharmacy

alyq oral tablet 20 mg2

PA; Specialty Pharmacy

ambrisentan oral tablet 10 mg, 5 mg

2PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

bosentan oral tablet 125 mg, 62.5 mg

2PA;

Specialty Pharmacy

epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg

2PA;

Specialty Medical

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

3PA;

Specialty Medical

LETAIRIS ORAL TABLET 10 MG, 5 MG

3PA;

Specialty Pharmacy

OPSUMIT ORAL TABLET 10 MG

3PA;

Specialty Pharmacy

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

3PA;

Specialty Pharmacy

REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 MG/20ML, 200 MG/20ML, 50 MG/20ML

3PA;

Specialty Medical

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML

3PA;

Specialty Medical

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML

3PA;

Specialty Pharmacy

REVATIO ORAL TABLET 20 MG

3PA;

Specialty Pharmacy

sildenafil citrate intravenous solution 10 mg/12.5ml

2PA;

Specialty Medical



215

Drug NameDrug Tier

Notes

sildenafil citrate oral suspension reconstituted 10 mg/ml

3PA;

Specialty Pharmacy

sildenafil citrate oral tablet 20 mg

2PA;

Specialty Pharmacy

tadalafil (pah) oral tablet 20 mg

2PA;

Specialty Pharmacy

TRACLEER ORAL TABLET 125 MG, 62.5 MG

3PA;

Specialty Pharmacy

TRACLEER ORAL TABLET SOLUBLE 32 MG

3PA;

Specialty Pharmacy

treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 mg/20ml, 50 mg/20ml

3PA;

Specialty Medical

TYVASO INHALATION SOLUTION 0.6 MG/ML

3PA;

Specialty Pharmacy

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML

3PA;

Specialty Pharmacy

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML

3PA;

Specialty Pharmacy

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3PA;

Specialty Pharmacy

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

3

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

3PA;

Specialty Medical

Drug NameDrug Tier

Notes

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

3PA;

Specialty Pharmacy

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen intrathecal solution 10 mg/20ml, 40 mg/20ml

GM

baclofen oral tablet 10 mg, 20 mg, 5 mg

1

carisoprodol oral tablet 250 mg, 350 mg

1

carisoprodol-aspirin oral tablet 200-325 mg

1

chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg

1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg

1

DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

GM

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

3Brand

penalty applies

dantrolene sodium intravenous solution reconstituted 20 mg

GM

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

1

FEXMID ORAL TABLET 7.5 MG

3Brand

penalty applies



216

Drug NameDrug Tier

Notes

GABLOFEN INTRATHECAL SOLUTION 10000 MCG/20ML, 40000 MCG/20ML

GM

LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/20ML, 10 MG/5ML, 40 MG/20ML

GM

LORZONE ORAL TABLET 375 MG, 750 MG

3Brand

penalty applies

metaxalone oral tablet 400 mg, 800 mg

1

methocarbamol injection solution 1000 mg/10ml

GM

methocarbamol oral tablet 500 mg, 750 mg

1

NORGESIC FORTE ORAL TABLET 50-770-60 MG

3

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

1

orphenadrine citrate injection solution 30 mg/ml

GM

orphenadrine-asa-caffeine oral tablet 50-770-60 mg

1

ORPHENGESIC FORTE ORAL TABLET 770-60-50 MG

3

revonto intravenous solution reconstituted 20 mg

GM

ROBAXIN INJECTION SOLUTION 1000 MG/10ML

GM

ROBAXIN-750 ORAL TABLET 750 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 250 MG

GM

SKELAXIN ORAL TABLET 800 MG

3Brand

penalty applies

SOMA ORAL TABLET 250 MG, 350 MG

3Brand

penalty applies

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

1

tizanidine hcl oral tablet 2 mg, 4 mg

1

VANADOM ORAL TABLET 350 MG

3Brand

penalty applies

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG

3Brand

penalty applies

ZANAFLEX ORAL TABLET 4 MG

3Brand

penalty applies

Sleep Disorder Agents

AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 6.25 MG

3Brand

penalty applies

AMBIEN ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

1

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

3

doxepin hcl oral tablet 3 mg, 6 mg

1

eszopiclone oral tablet 1 mg, 2 mg, 3 mg

1



217

Drug NameDrug Tier

Notes

flurazepam hcl oral capsule 15 mg, 30 mg

1

HETLIOZ ORAL CAPSULE 20 MG

3PA;

Specialty Pharmacy

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG

3Brand

penalty applies

modafinil oral tablet 100 mg, 200 mg

1

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG

3Brand

penalty applies

PROVIGIL ORAL TABLET 100 MG, 200 MG

3Brand

penalty applies

ramelteon oral tablet 8 mg

1

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG

3Brand

penalty applies

ROZEREM ORAL TABLET 8 MG

3Brand

penalty applies

SECONAL ORAL CAPSULE 100 MG

3

SILENOR ORAL TABLET 3 MG, 6 MG

3Brand

penalty applies

SUNOSI ORAL TABLET 150 MG, 75 MG


days)

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

1

WAKIX ORAL TABLET 17.8 MG, 4.45 MG

3PA;

Specialty Pharmacy

XYREM ORAL SOLUTION 500 MG/ML

3PA;

Specialty Pharmacy

Drug NameDrug Tier

Notes

zaleplon oral capsule 10 mg, 5 mg

1

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg

1

zolpidem tartrate oral tablet 10 mg, 5 mg

1



218

Index of Drugs

1ST MEDX-PATCH/ LIDOCAINE........................ 157T GUMMY ES..................... 87T LIDO.............................. 16abacavir sulfate...................72abacavir sulfate-lamivudine 72abacavir-lamivudine-zidovudine...........................72ABANEU-SL..................... 126ABELCET........................... 44ABILIFY.............................. 70ABILIFY MAINTENA...........69abiraterone acetate.............52ABRAXANE........................ 52ABSORICA....................... 109ABSORICA LD..................109ACACIA............................ 184acamprosate calcium..........20acarbose........................... 118ACCOLATE...................... 209ACCUPRIL..........................85ACCURETIC.......................85ACD FORMULA A.............. 32ACD-A NOCLOT-50........... 32acebutolol hcl......................85ACETADOTE....................185acetaminophen-codeine....... 9acetaminophen-codeine #2.. 8acetaminophen-codeine #3.. 8acetaminophen-codeine #4.. 8acetazolamide...................200acetazolamide er.............. 200acetazolamide sodium........ 85acetic acid.................149, 206acetylcysteine........... 185, 209ACIPHEX.......................... 140ACIPHEX SPRINKLE....... 140acitretin............................. 109ACREMONIUM.................185ACTEMRA........................ 171ACTEMRA ACTPEN.........171ACTHAR........................... 156ACTHIB.............................178ACTHREL......................... 185ACTIGALL........................ 142ACTIMMUNE.................... 171ACTIQ...................................9ACTIVASE.......................... 32ACTIVE FE....................... 126ACTIVE-KETOPROFEN.......6ACTIVELLA...................... 160ACTIVITE..........................126ACTONEL.........................183

ACTOPLUS MET..............118ACTOS............................. 118ACULAR........................... 198ACULAR LS......................198ACUVAIL.......................... 198acyclovir..............................72acyclovir sodium................. 73ACZONE...........................109ADACEL........................... 178ADAKVEO........................ 185adapalene......................... 109ADASUVE...........................70adc/f (0.5mg/ml)................126ADCETRIS..........................52ADCIRCA..........................215ADDERALL.......................101ADDERALL XR.................101adefovir dipivoxil ................. 73ADEMPAS........................ 215ADENOCARD.....................85adenosine................... 85, 185adenosine (diagnostic)......185ADLYXIN.......................... 118ADLYXIN STARTER PACK................................ 118ADMELOG........................122ADMELOG SOLOSTAR... 122ADRENAL C FORMULA...126ADRENALIN............. 207, 210adriamycin.......................... 52adult aspirin regimen............ 6ADVAIR DISKUS.............. 210ADVAIR HFA.................... 210ADVATE............................. 80ADYNOVATE......................80ADYPHREN......................210ADYPHREN AMP............. 210ADYPHREN AMP II.......... 210ADYPHREN II...................210AEMCOLO..........................21AFINITOR........................... 52AFINITOR DISPERZ.......... 52afirmelle............................ 160AFLURIA QUADRIVALENT..............178AFREZZA......................... 122AFSTYLA............................80AGGRASTAT......................69AGGRENOX....................... 69AGONEAZE........................16AGRYLIN............................ 80AIMOVIG............................ 48AJOVY.......................... 48, 49

ak-fluor..............................202AKOVAZ............................. 85ak-poly-bac....................... 202AKTEN..............................202AKYNZEO...........................43ALA SCALP...................... 109ala-cort..............................109ALA-QUIN...........................44albendazole........................ 66ALBENZA........................... 66ALBUKED 25.................... 185ALBUKED 5...................... 185albumin human................. 185ALBUMINEX..................... 185albumin-zlb....................... 185alburx................................ 185ALBUTEIN........................ 185albuterol sulfate................ 210ALBUTEROL SULFATE... 210albuterol sulfate er............ 210albuterol sulfate hfa.......... 210ALCAINE.......................... 202alclometasone dipropionate...................... 109ALCOHOL PREP PADS... 109ALCORTIN A...................... 44ALDACTAZIDE................... 86ALDACTONE......................86ALDER..............................185ALDURAZYME................. 146ALECENSA.........................52alendronate sodium.......... 183alfentanil hcl..........................9ALFERON N..................... 171alfuzosin hcl er..................152ALIMTA...............................52ALINIA................................ 66ALIQOPA............................ 52aliskiren fumarate............... 86ALKERAN........................... 52allopurinol........................... 48allopurinol sodium...............48almotriptan malate.............. 49ALOCRIL.......................... 198ALOGLIPTIN BENZOATE 118ALOGLIPTIN-METFORMIN HCL............118ALOGLIPTIN-PIOGLITAZONE............... 118ALOMIDE..........................198ALOPRIM............................48ALORA..............................160alosetron hcl..................... 142

219

ALOXI................................. 43ALPHAGAN P...................200ALPHA-LIPOIC ACID....... 185ALPHANATE/VWF COMPLEX/HUMAN............ 80ALPHANINE SD................. 80alprazolam.......................... 78alprazolam er...................... 78alprazolam intensol.............78alprazolam xr...................... 78ALPROLIX.......................... 80alprostadil ........................... 86ALREX.............................. 198ALTABAX............................21altacaine........................... 202ALTACE..............................86altafrin............................... 202altavera............................. 160ALTERNARIA................... 185ALTOPREV.........................86ALUNBRIG......................... 52ALVESCO.........................210alyacen 1/35..................... 160alyacen 7/7/7.................... 160alyq................................... 215amabelz............................ 160amantadine hcl................... 67AMARYL........................... 118AMBIEN............................ 217AMBIEN CR......................217AMBISOME........................ 44ambrisentan...................... 215amcinonide....................... 109AMD FOAM DRESSING...185AMD FOAM DRESSING TOPSHEET...................... 185AMERGE............................ 49AMERICAN BEECH......... 185AMERICAN COCKROACH.......................................... 185AMERICAN ELM.............. 185AMERICAN SYCAMORE. 185amethia............................. 160amethia lo......................... 160amethyst........................... 160AMICAR..............................80AMIDATE..........................185amiloride hcl........................86amiloride-hydrochlorothiazide.............86aminoacetic acid............... 149aminoamrms..................... 126aminobenzoate potassium 126

aminocaproic acid...............80aminoreliefrms.................. 126AMINOSYN II....................126AMINOSYN-PF.................126amiodarone hcl................... 86AMITIZA............................142amitriptyline hcl................... 40amlodipine besylate............ 86amlodipine besylate-benazepril hcl......................86amlodipine besylate-valsartan............................. 86amlodipine-atorvastatin.......86amlodipine-olmesartan....... 86amlodipine-valsartan-hctz...86ammonium lactate............ 109AMMONUL....................... 146amnesteem....................... 109amoxapine.......................... 40amoxicill-clarithro-lansopraz.......................... 142amoxicillin........................... 21amoxicillin-potassium clavulanate..........................21amoxicillin-potassium clavulanate er..................... 21AMPHADASE................... 185amphetamine-dextroamphetamine.......... 101amphetamine-dextroamphetamine er......101amphotericin b.................... 44ampicillin............................. 21ampicillin sodium................ 21ampicillin-sulbactam sodium.......................... 21, 22AMVISC............................ 202AMVISC PLUS..................202ANACAINE....................... 109ANADROL-50................... 155ANAFRANIL........................40anagrelide hcl..................... 80ana-lex.............................. 181ANALPRAM HC................181ANALPRAM HC SINGLES181ANALPRAM-HC................181ANASCORP......................185ANASPAZ......................... 142anastrozole......................... 52ANAVIP.............................185ANCOBON..........................45ANDEXXA.........................186ANDRODERM.................. 155

ANDROGEL..............155, 156ANDROGEL PUMP.......... 155ANECTINE........................106ANESTHESIA S/I-40........ 186ANESTHESIA S/I-40A...... 186ANESTHESIA S/I-40H......186ANESTHESIA S/I-40S...... 186ANESTHESIA S/I-60........ 186ANGELIQ..........................160ANGIOMAX........................ 32ANIMI-3.............................126ANIMI-3/VITAMIN D......... 126ANJESO............................... 6ANNOVERA......................160ANODYNE LPT.................. 16ANORO ELLIPTA............. 210ANTABUSE........................ 20ANTARA............................. 86anticoagulant cit dext soln a..........................................32anticoagulant sodium citrate.................................. 32ANTIVENIN MICRURUS FULVIUS...........................186anucort-hc.........................181ANUSOL-HC.....................181anusol-hc.......................... 181ANZEMET...........................43apap-caff-dihydrocodeine..... 9APEXICON E....................109APIDRA SOLOSTAR........122APIDRA VIAL....................123APLENZIN.......................... 40APOKYN.............................67APP SLIM RMS................ 186apraclonidine hcl...............200aprepitant............................43apri....................................160APRISO............................ 181APTENSIO XR..................101APTIOM.............................. 34APTIVUS............................ 73AQUACEL AG BURN....... 109AQUASOL A..................... 126ARAKODA.......................... 66ARALAST NP................... 210aranelle............................. 160ARANESP (ALBUMIN FREE)........................... 80, 81ARAVA..............................171ARCALYST.......................171ARCAPTA NEOHALER.... 210ARESTIN.......................... 107

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argatroban.......................... 33argatroban in sodium chloride............................... 33ARGININE HCL................ 126argyle sterile saline........... 126argyle sterile water............126ARICEPT............................ 39ARIKAYCE..........................22ARIMIDEX.......................... 52aripiprazole......................... 70ARISTADA..........................70ARISTADA INITIO.............. 70ARIXTRA............................ 33ARIZONA CYPRESS........186armodafinil ........................ 217ARMOUR THYROID.........170arnica flower..................... 186ARNUITY ELLIPTA...........210AROMASIN.........................52ARRANON..........................52arsenic trioxide....................52ARTHROTEC....................... 6ARTICADENT DENTAL......16ARTISS.............................186ARYMO ER...........................9ARZERRA...........................52arzol silver nit applicators. 109ASACOL HD..................... 181ASCENIV.......................... 171ASCLERA........................... 86ascomp-codeine................... 9ASCOR............................. 126ASCORBIC ACID............. 126ashlyna............................. 160ASMANEX (120 METERED DOSES)......... 210ASMANEX (14 METERED DOSES)............................ 211ASMANEX (30 METERED DOSES)............................ 211ASMANEX (60 METERED DOSES)............................ 211ASMANEX (7 METERED DOSES)............................ 211ASMANEX HFA................ 211ASPARLAS.........................52ASPERGILLUS FUMIGATUS.....................186aspirin................................... 6aspirin adult low strength...... 6aspirin childrens....................6aspirin ec.............................. 6aspirin ec low dose............... 6

aspirin ec low strength.......... 6aspirin low dose.................... 6aspirin-dipyridamole er....... 69ASTAGRAF XL................. 171ATABEX OB..................... 126ATACAND...........................86ATACAND HCT.................. 86atazanavir sulfate................73ATELVIA........................... 183atenolol............................... 86atenolol-chlorthalidone........86ATGAM............................. 171ATIVAN...............................78atomoxetine hcl.................102atorvastatin calcium............ 86atovaquone......................... 66atovaquone-proguanil hcl... 66atracurium besylate.......... 106ATRAPRO DERMAL SPRAY..............................109ATRIPLA.............................73ATROPINE SULFATE.................................. 142, 202atropine sulfate................. 202ATROVENT HFA.............. 211AUBAGIO......................... 104aubra.................................161aubra eq............................160AUGMENTIN...................... 22AUGMENTIN ES-600......... 22AUREOBASIDIUM............186AUREOBASIDIUM PULLULANS.....................186aurovela 1.5/30................. 161aurovela 1/20.................... 161aurovela 24 fe................... 161aurovela fe 1.5/30............. 161aurovela fe 1/20................ 161AURYXIA.......................... 149AUSTEDO........................ 106AUSTRALIAN PINE..........186AVALIDE.............................86AVANDIA.......................... 118AVAPRO.............................86avar cleanser.................... 109AVAR-E EMOLLIENT....... 109AVAR-E GREEN...............109AVASTIN............................ 52aviane............................... 161avidoxy................................22avita.................................. 110AVODART........................ 152AVONEX PEN.................. 104

AVONEX PREFILLED...... 104AVONEX VIAL INTRAMUSCULAR KIT... 104AVSOLA........................... 171AVYCAZ............................. 22AYGESTIN........................161ayuna................................ 161AYVAKIT.............................52azacitidine...........................52AZACTAM...........................22AZALGIA...........................186AZASAN........................... 171AZASITE...........................198azathioprine...................... 171azathioprine sodium..........171AZEDRA DOSIMETRIC......53AZEDRA THERAPEUTIC...53azelaic acid....................... 110azelastine hcl............ 198, 207AZELEX............................ 110AZILECT............................. 67azithromycin........................22AZOPT..............................200AZOR..................................87aztreonam...........................22AZULFIDINE.....................181AZULFIDINE EN-TABS.... 181azurette.............................161b-6 folic acid......................126baciim................................. 22bacitracin.................... 22, 198bacitracin-polymyxin b...... 203bacitra-neomycin-polymyxin-hc.....................203baclofen............................ 216BACMIN............................126BACTERIOSTATIC WATER(BENZ ALC).........186BACTRIM............................22BACTRIM DS......................22BAHIA............................... 186bal in oil .............................186balanced salt.....................203BALCOLTRA.................... 161BALD CYPRESS.............. 186balsalazide disodium........ 181balsam peru-castor oil ...... 110BALVERSA.........................53balziva...............................161BANZEL..............................34BAQSIMI ONE PACK....... 122BAQSIMI TWO PACK.......122BARACLUDE......................73

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BAVENCIO......................... 53BAXDELA........................... 22BAYBERRY (WAX MYRTLE).......................... 186BAYER ASPIRIN EC LOW DOSE....................................6BCG VACCINE................. 178BD AUTOSHIELD DUO PEN NEEDLES.................123BD ULTRA-FINE INSULIN SYRINGES....................... 123BD ULTRA-FINE PEN NEEDLES......................... 123BD VEO INSULIN SYR U/F 1/2UNIT......................123BECONASE AQ................207bekyree............................. 161BELBUCA............................. 9BELEODAQ........................ 53belladonna alkaloids-opium.......................................... 142BELRAPZO.........................53BELSOMRA......................217benazepril hcl......................87benazepril-hydrochlorothiazide.............87BENDAMUSTINE HCL....... 53BENDEKA...........................53BENEFIX............................ 81BENICAR............................87BENICAR HCT................... 87BENLYSTA............... 171, 172BENSAL HP......................110BENTYL............................142benzalkonium chloride........ 22BENZNIDAZOLE................ 66benzoin............................. 110benzoin compound........... 110benzonatate...................... 207benztropine mesylate..........67BEOVU............................. 203BEPREVE.........................198BERINERT........................172BERMUDA GRASS.......... 186beser.................................110BESIVANCE..................... 198BESPONSA........................ 53BETADINE OPHTHALMIC PREP................................ 198BETAMETHASONE COMBO............................ 153betamethasone dipropionate...................... 110

betamethasone dipropionate aug............... 110BETAMETHASONE SOD PHOS & ACET..................153betamethasone sod phos & acet................................153BETAMETHASONE SODIUM PHOSPHATE.... 153betamethasone valerate... 110BETAPACE.........................87BETAPACE AF................... 87BETASERON....................104betaxolol hcl................87, 200bethanechol chloride.........149BETHKIS.......................... 214BETIMOL.......................... 201BETOPTIC-S.................... 201BEVACIZUMAB................ 203BEVESPI AEROSPHERE 211BEVYXXA........................... 33bexarotene..........................53BEXSERO........................ 178BEYAZ.............................. 161bicalutamide........................53BICILLIN C-R......................22BICILLIN C-R 900/300........22BICILLIN L-A.......................22BICNU.................................53BIDIL...................................87BIKTARVY.......................... 73BILTRICIDE........................ 66bimatoprost....................... 201BI-MIX...............................149BINOSTO..........................183biocel................................ 126BIOFREQUENCY INSOLES.......................... 186BIOGUARD GAUZE SPONGES........................ 186BIOGUARD ISLAND DRESSINGS.....................186BIOGUARD NON-ADHERENT DRESSING.. 186BIOLON............................ 203BIORPHEN......................... 87BIO-STATIN........................45bio-statin............................. 45BIOTHRAX....................... 179bisoprolol fumarate............. 87bisoprolol-hydrochlorothiazide.............87bivalirudin trifluoroacetate...33

BIVALIRUDIN-SODIUM CHLORIDE......................... 33BIVIGAM...........................172BLACK WALNUT POLLEN.......................................... 186BLACK WILLOW.............. 187bleomycin sulfate................ 53BLEPH-10.........................198BLEPHAMIDE...................203BLEPHAMIDE S.O.P........ 203BLINCYTO..........................53blisovi 24 fe.......................161blisovi fe 1.5/30.................161blisovi fe 1/20....................161BLOXIVERZ........................50BOCASAL.........................107BONIVA............................ 183BONJESTA.........................43BOOSTRIX....................... 179BORTEZOMIB.................... 53bosentan........................... 215BOSULIF............................ 53BOTOX............................. 187BOTRYTIS........................187BOX ELDER..................... 187bp 10-1..............................110BP CLEANSING WASH... 110bp vit 3.............................. 126BPCO................................110b-plex................................ 126b-plex plus........................ 126BRAFTOVI..........................53BREO ELLIPTA................ 211BREVIBLOC....................... 87BREVIBLOC IN NACL........ 87BREVIBLOC PREMIXED... 87BREVIBLOC PREMIXED DS.......................................87BREVITAL SODIUM......... 187BRIDION...........................187briellyn.............................. 161BRILINTA............................69brimonidine tartrate...........201BRIMONIDINE-DORZOLAMIDE............... 201BRINEURA....................... 146BRIVIACT........................... 34BROME.............................187bromfed dm.......................207bromfenac sodium (once-daily)................................. 198bromocriptine mesylate.......67brompheniramine tannate.207

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BROMSITE....................... 198BROVANA........................ 211BRUKINSA......................... 53bss.................................... 203budesonide....... 181, 207, 211budesonide er................... 181bumetanide......................... 87BUMEX............................... 87BUNAVAIL.......................... 20BUPAP..................................9BUPHENYL...................... 146bupivacaine fisiopharma..... 16bupivacaine hcl................... 16BUPIVACAINE HCL........... 16bupivacaine hcl (pf).............16BUPIVACAINE HCL-NACL.16bupivacaine in dextrose...... 16bupivacaine spinal.............. 16bupivacaine-epinephrine.....16bupivacaine-epinephrine (pf)...................................... 16BUPRENEX.......................... 9buprenorphine.......................9buprenorphine hcl........... 9, 20buprenorphine hcl-naloxone hcl........................20bupropion hcl...................... 40bupropion hcl er (smoking det)......................................20bupropion hcl er (sr)............40bupropion hcl er (xl)............ 40buspirone hcl...................... 78busulfan.............................. 53BUSULFEX.........................53butalbital-acetaminophen......9BUTALBITAL-ACETAMINOPHEN.............. 9butalbital-apap-caff-cod........ 9butalbital-apap-caffeine........ 9butalbital-asa-caff-codeine....9butalbital-aspirin-caffeine......9butorphanol tartrate.............. 9BUTRANS.............................9BYDUREON..................... 119BYDUREON BCISE AUTOINJECTOR..............118BYETTA 10 MCG PEN..... 119BYETTA 5 MCG PEN....... 119BYNFEZIA PEN................156BYSTOLIC.......................... 87cabergoline....................... 156CABLIVI.............................. 69CABOMETYX..................... 53

CADUET............................. 87CAFCIT.............................106CAFERGOT........................49caffeine citrate.................. 106CALAN SR..........................87CALCIFOL........................ 126calcipotriene......................110calcipotriene-betameth diprop................................110calcitonin (salmon)............183CALCITRENE................... 110calcitriol.....................110, 184calcium acetate.................149calcium acetate (phos binder)...............................149CALCIUM CHLORIDE...... 126calcium chloride................ 126CALCIUM DISODIUM VERSENATE.................... 187CALCIUM GLUCONATE-NACL................................ 126CALCIUM-FOLIC ACID PLUS D.............................126CALDOLOR.......................... 6CALIFORNIA PEPPER TREE................................ 187CALQUENCE..................... 53CAMBIA.............................. 49camila............................... 161CAMPATH.......................... 53CAMPTOSAR..................... 54camrese............................ 161camrese lo........................ 161CANASA........................... 181CANCIDAS......................... 45candesartan cilexetil ........... 87candesartan cilexetil-hctz... 87CANDIDA ALBICANS EXTRACT......................... 187CAPASTAT SULFATE........51capecitabine........................54CAPEX..............................110CAPLYTA........................... 70CAPRELSA.........................54captopril .............................. 87captopril-hydrochlorothiazide.............88CARAFATE.......................140CARBAGLU...................... 126carbamazepine................... 35carbamazepine er............... 34CARBATROL......................35carbidopa............................ 67

carbidopa-levodopa............ 67carbidopa-levodopa er........ 67carbidopa-levodopa-entacapone......................... 67carbinoxamine maleate.....207CARBOCAINE.................... 16CARBOCAINE PRESERVATIVE-FREE..... 16carboplatin.......................... 54carboprost tromethamine..156CARDENE IV......................88CARDIOPLEGIA DEL NIDO FORMULA.............. 126CARDIOPLEGIA IND PLASMA HIGH K..............126CARDIOPLEGIA IND PLASMA-TROMET...........127CARDIOPLEGIA INDUCTION HIGH K........ 127CARDIOPLEGIA INDUCTION LOW DEX.... 127CARDIOPLEGIA INDUCTION NON-ENR.... 127CARDIOPLEGIA MAIN LOW DEXTROSE.............127CARDIOPLEGIA MAIN LOW TROMETHA............ 127CARDIOPLEGIA MAIN PLASMA-TROME............. 127CARDIOPLEGIA MAINTENANCE................127CARDIOPLEGIA REPERFUSATE 4:1......... 127CARDIOPLEGIC...............127cardioplegic.......................127CARDIOVID PLUS........... 187CARDIZEM......................... 88CARDIZEM CD...................88CARDIZEM LA....................88CARDURA.......................... 88CARDURA XL...................153CARIMUNE NF.................172carisoprodol...................... 216carisoprodol-aspirin.......... 216carisoprodol-aspirin-codeine................................. 9carmustine.......................... 54CARNITOR....................... 127CARNITOR SF................. 127carteolol hcl.......................201cartia xt............................... 88carvedilol.............................88carvedilol phosphate er.......88

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CASODEX.......................... 54caspofungin acetate............45CAT HAIR EXTRACT....... 187CATAPRES........................ 88CATAPRES-TTS-1............. 88CATAPRES-TTS-2............. 88CATAPRES-TTS-3............. 88CATHFLO ACTIVASE........ 33CATTLE EPITHELIUM..... 187cavarest............................ 107CAVERJECT.................... 149CAVERJECT IMPULSE....149CAYA................................ 187CAYSTON........................ 214caziant.............................. 161CEDAR ELM.....................187cefaclor......................... 22, 23cefaclor er........................... 22cefadroxil ............................ 23CEFAZOLIN IN SODIUM CHLORIDE......................... 23cefazolin sodium................. 23CEFAZOLIN SODIUM........ 23cefazolin sodium-dextrose.. 23cefdinir................................ 23cefditoren pivoxil ................. 23cefepime hcl........................23cefepime-dextrose.............. 23cefixime...............................23CEFOTAN...........................23cefotaxime sodium..............23cefotetan disodium..............23cefotetan disodium-dextrose.............................. 23cefoxitin sodium.................. 23CEFOXITIN SODIUM-DEXTROSE........................ 24cefpodoxime proxetil ...........24cefprozil .............................. 24ceftazidime..........................24ceftazidime and dextrose....24ceftriaxone sodium..............24ceftriaxone sodium in dextrose.............................. 24ceftriaxone sodium-dextrose.............................. 24cefuroxime axetil .................24cefuroxime sodium..............24CELEBREX...........................6celecoxib...............................6CELESTONE SOLUSPAN153CELEXA..............................40CELLCEPT....................... 172

CELLCEPT INTRAVENOUS................172CELONTIN..........................35cem-urea...........................110CENTANY AT..................... 24CENTRATEX.................... 127cephalexin...........................24CEPROTIN......................... 81CERDELGA...................... 146CEREBYX...........................35CEREZYME......................146cerovel.............................. 110CERVIDIL......................... 149CETACAINE....................... 16CETRAXAL.......................206CETROTIDE..................... 157cevimeline hcl................... 107CHANTIX............................ 20CHANTIX CONTINUING MONTH PAK...................... 20CHANTIX STARTING MONTH PAK...................... 20charlotte 24 fe................... 161chateal.............................. 161chateal eq......................... 161CHEMET...........................127CHENODAL......................142CHIRHOSTIM................... 187chloramphenicol sod succinate.............................24chlordiazepoxide hcl........... 78chlordiazepoxide-amitriptyline.........................40chlordiazepoxide-clidinium142chlorhexidine gluconate.... 107CHLORHEXIDINE GLUCONATE................... 187chloroprocaine hcl (pf)........ 16chloroquine phosphate....... 66chlorothiazide......................88chlorothiazide sodium......... 88chlorpromazine hcl..............70chlorthalidone..................... 88chlorzoxazone...................216CHOLBAM........................ 146cholestyramine....................88cholestyramine light............ 88chorionic gonadotropin..... 157chromagen........................127chromic chloride................127CIALIS...................... 149, 150ciclodan...............................45ciclopirox.............................45

ciclopirox olamine............... 45cidofovir.............................. 73cilostazol............................. 69CILOXAN.......................... 198CIMDUO............................. 73cimetidine..........................140cimetidine hcl.................... 140CIMZIA..............................172CIMZIA PREFILLED KIT.. 172CIMZIA STARTER KIT..... 172cinacalcet hcl.................... 184CINQAIR...........................207CINRYZE.......................... 172CINVANTI........................... 43CIPRO................................ 24CIPRO HC........................ 206CIPRODEX....................... 206ciprofloxacin hcl.. 24, 198, 206ciprofloxacin in d5w............ 24CIPROFLOXACIN-FLUOCINOLONE PF........206cisatracurium besylate...... 106cisatracurium besylate (pf)106cisplatin...............................54citalopram hydrobromide.... 40CITANEST FORTE DENTAL..............................16CITANEST PLAIN DENTAL..............................16CITRANATAL ESSENCE. 127CITRANATAL MEDLEY....127CLADOSPORIUM CLADOSPORIOIDES....... 187CLADOSPORIUM SPHAEROSPERMUM......187cladribine............................ 54claravis..............................110clarithromycin......................25clarithromycin er................. 24clearlax............................. 142clemastine fumarate......... 207CLENPIQ.......................... 142CLEOCIN............................25CLEOCIN PHOSPHATE.....25CLEVIPREX........................88CLIMARA..........................161CLIMARA PRO................. 161clindacin etz...................... 110clindacin-p.........................110clindamycin hcl................... 25clindamycin palmitate hcl....25

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clindamycin phosphate............................ 25, 110, 111clindamycin phosphate in d5w..................................... 25CLINDESSE....................... 25CLINIMIX E/DEXTROSE (2.75/5)............................. 127CLINIMIX E/DEXTROSE (4.25/10)........................... 127CLINIMIX E/DEXTROSE (4.25/5)............................. 127CLINIMIX E/DEXTROSE (5/15)................................ 127CLINIMIX E/DEXTROSE (5/20)................................ 127CLINIMIX/DEXTROSE (4.25/10)........................... 127CLINIMIX/DEXTROSE (4.25/5)............................. 127CLINIMIX/DEXTROSE (5/15)................................ 127CLINIMIX/DEXTROSE (5/20)................................ 127CLINISOL SF....................128CLINOLIPID......................128clinpro 5000...................... 107clobazam............................ 35clobetasol prop emollient base.................................. 111clobetasol propionate........111clobetasol propionate e.....111clobetasol propionate emulsion........................... 111CLOBEX........................... 111clocortolone pivalate......... 111clodan............................... 111CLODERM........................111clofarabine.......................... 54CLOLAR............................. 54clomiphene citrate.............157clomipramine hcl.................40clonazepam........................ 78clonidine..............................88clonidine hcl........................ 88clonidine hcl (analgesia)....... 9clonidine hcl er..................102clopidogrel bisulfate............ 69clorazepate dipotassium..... 78CLOROTEKAL....................16clotrimazole.........................45clotrimazole-betamethasone................... 45clovique.............................128

clozapine.............................70CLOZARIL.......................... 70COAGADEX....................... 81coal tar.............................. 111COARTEM..........................66COCAINE HCL................... 16COCKLEBUR................... 187cod liver oil ........................128codeine sulfate....................10COGENTIN.........................67COLAZAL......................... 181COLCHICINE......................48colchicine............................ 48colchicine-probenecid......... 48COLCRYS.......................... 48colesevelam hcl.................. 89COLESTID..........................89COLESTID FLAVORED..... 89colestipol hcl....................... 89colistimethate sodium (cba)....................................25colocort............................. 181COLY-MYCIN M................. 25COMBIGAN...................... 201COMBIPATCH..................161COMBIVENT RESPIMAT. 211COMBIVIR.......................... 73COMETRIQ (100 MG DAILY DOSE)..................... 54COMETRIQ (140 MG DAILY DOSE)..................... 54COMETRIQ (60 MG DAILY DOSE)..................... 54COMPLERA........................73compro................................43COMTAN............................ 67CONCERTA......................102CONDYLOX......................111constulose.........................142COPIKTRA......................... 54CORDRAN........................111COREG...............................89COREG CR........................ 89CORGARD......................... 89CORIFACT......................... 81CORLANOR....................... 89CORLOPAM....................... 89CORN POLLEN................ 188CORTANE-B.....................111CORTEF........................... 153CORTENEMA...................181cortic-nd............................ 206CORTIFOAM.................... 182

cortisone acetate.............. 153CORTISPORIN.................111CORTROSYN...................188CORVERT.......................... 89corvita............................... 128corvita 150........................ 128CORVITE 150...................128CORVITE FE.................... 128COSENTYX (300 MG DOSE).............................. 172COSENTYX 150 MG/ML.. 172COSENTYX SENSOREADY (300 MG).172COSENTYX SENSOREADY PEN........ 172COSMEGEN.......................54COSOPT...........................201COSOPT PF..................... 201cosyntropin....................... 188COTELLIC.......................... 54covaryx............................. 161covaryx hs.........................161COZAAR.............................89CREON.............................146CRESEMBA........................45CRESTOR.......................... 89CRINONE......................... 161CRIXIVAN...........................73CROFAB...........................188cromolyn sodium.......................... 142, 198, 211crotan..................................66cryselle-28........................ 161CRYSVITA........................147c-topical.............................. 16CUBICIN............................. 25CUBICIN RF....................... 25CUPRIC CHLORIDE........ 128CURITY AMD ANTIMICROBIAL SPNGE 188CURITY AMD ANTIMICROBIAL STRIP.. 188CURITY IODOFORM PACKING STRIP.............. 188curity sterile saline............ 128CUROSURF..................... 207CURVULARIA...................188CUTAQUIG.......................172CUTIVATE........................ 111CUVITRU..........................172CUVPOSA........................ 142cyanocobalamin................128CYANOCOBALAMIN........128

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CYANOKIT....................... 188cyclafem 1/35....................161cyclafem 7/7/7...................161cyclobenzaprine hcl.......... 216CYCLOGYL...................... 203CYCLOMYDRIL................203cyclopentolate hcl............. 203cyclophosphamide.............. 54cycloserine..........................51CYCLOSET...................... 119cyclosporine..............172, 173CYCLOSPORINE IN KLARITY...........................203cyclosporine modified....... 172CYKLOKAPRON................ 81CYMBALTA........................ 40cyproheptadine hcl............207CYRAMZA.......................... 54cyred................................. 162cyred eq............................ 162CYSTADANE....................147CYSTAGON......................147CYSVIEW......................... 188cytarabine........................... 54cytarabine (pf).....................54CYTOGAM........................173CYTOMEL........................ 170CYTOTEC.........................140CYTOVENE........................ 73cytra k crystals.................. 128D.H.E. 45............................ 49dacarbazine........................ 54DACOGEN..........................54dactinomycin.......................54dalfampridine er................ 104DALIRESP........................ 211DALVANCE........................ 25danazol............................. 156DANDELION.....................188DANTRIUM.......................216dantrolene sodium............ 216dapsone...................... 51, 111DAPTACEL.......................179daptomycin......................... 25DARAPRIM.........................66darifenacin hydrobromide er.......................................150DARZALEX.........................55DARZALEX FASPRO......... 54dasetta 1/35...................... 162dasetta 7/7/7..................... 162daunorubicin hcl..................55DAURISMO........................ 55

DAVITE.............................128DAYPRO...............................6daysee.............................. 162DAYTRANA...................... 102DDAVP............................. 157DDAVP RHINAL TUBE.....157DEBACTEROL................. 107deblitane........................... 162DECADRON..................... 153DECARA...........................128decitabine........................... 55deferasirox........................ 128deferoxamine mesylate.....188DEFITELIO......................... 33DEFLUX............................188DELESTROGEN...............162DELFLEX-LC/1.5% DEXTROSE...................... 128DELFLEX-LC/2.5% DEXTROSE...................... 128DELFLEX-LC/4.25% DEXTROSE...................... 128delflex-sm/1.5% dextrose. 128delflex-sm/2.5% dextrose. 128DELSTRIGO....................... 73delyla................................ 162DELZICOL........................ 182demeclocycline hcl..............25DEMEROL.......................... 10DEMSER............................ 89DENAVIR............................73denta 5000 plus................ 107dentagel............................ 107DEPAKOTE........................ 35DEPAKOTE ER.................. 35DEPAKOTE SPRINKLES... 35DEPEN TITRATABS.........150DEPO-ESTRADIOL.......... 162DEPO-MEDROL............... 153DEPO-PROVERA.............162DEPO-SUBQ PROVERA 104....................................162DEPO-TESTOSTERONE. 156DERMACINRX EMPRICAINE..................... 16DERMACINRX PRIZOPAK 16DERMA-SMOOTHE/FS BODY................................111DERMA-SMOOTHE/FS SCALP.............................. 111dermazene..........................45DERMOTIC.......................206DERMULCERA.................111

DESCOVY.......................... 73DESFERAL.......................188desipramine hcl...................40desloratadine.................... 207desmopressin ace spray refrig..................................157desmopressin acetate.......157desmopressin acetate spray................................. 157desogestrel-ethinyl estradiol............................ 162DESONATE...................... 111desonide................... 111, 112DESOWEN....................... 112desoximetasone................112DESOXYN........................ 102DESVENLAFAXINE ER......40desvenlafaxine succinate er.........................................40DETROL........................... 150DETROL LA......................150dexamethasone........ 153, 154dexamethasone intensol...153DEXAMETHASONE SOD PHOS-BUPIV....................154dexamethasone sod phosphate pf..................... 154dexamethasone sodium phosphate................. 154, 198DEXAMETHASONE-MOXIFLOXACIN...............203DEXAMETH-MOXIFLOX-KETOROLAC....................203dexchlorpheniramine maleate............................. 207DEXEDRINE.....................102dexifol............................... 128DEXILANT........................ 141DEXMEDETOMIDINE HCL.......................................... 188dexmedetomidine hcl........188dexmedetomidine hcl in nacl................................... 188DEXMEDETOMIDINE HCL-DEXTROSE..............188dexmethylphenidate hcl.... 102dexmethylphenidate hcl er 102DEXONTO 0.4%...............154dexrazoxane hcl..................55dextroamphetamine sulfate.......................................... 102dextroamphetamine sulfate er.......................................102

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dextrose............................ 128DEXTROSE...................... 128DEXTROSE 5%/ELECTROLYTE #48...128dextrose in lactated ringers.......................................... 128dextrose-nacl.................... 129dextrose-sodium chloride..129DEXYCU...........................198DIACOMIT.......................... 35dialyvite.............................129DIALYVITE 3000.............. 129DIALYVITE 5000.............. 129DIALYVITE SUPREME D. 129DIALYVITE/ZINC.............. 129DIANEAL LOW CALCIUM/1.5% DEX........ 129DIANEAL LOW CALCIUM/2.5% DEX........ 129DIANEAL LOW CALCIUM/4.25% DEX...... 129DIANEAL PD-2/1.5% DEXTROSE...................... 129DIANEAL PD-2/2.5% DEXTROSE...................... 129DIANEAL PD-2/4.25% DEXTROSE...................... 129DIASTAT ACUDIAL............ 35DIASTAT PEDIATRIC........ 35diazepam...................... 35, 78DIAZEPAM......................... 78diazepam intensol...............78diazoxide...........................122DIBENZYLINE.................... 89DICLOFENAC EPOLAMINE.........................6diclofenac potassium............ 6diclofenac sodium. 6, 112, 198diclofenac sodium er.............6diclofenac-misoprostol.......... 6DICLOSTREAM....................6dicloxacillin sodium............. 25dicyclomine hcl................. 142didanosine.......................... 73DIFICID...............................25difil-g forte......................... 211diflorasone diacetate.........112DIFLUCAN..........................45diflunisal................................6DIGIFAB........................... 188digitek................................. 89digox................................... 89digoxin................................ 89

dihydroergotamine mesylate............................. 49DILANTIN........................... 35DILANTIN INFATABS.........35DILATRATE-SR..................89DILAUDID........................... 10diltiazem hcl........................ 90diltiazem hcl er....................90diltiazem hcl er beads......... 89diltiazem hcl er coated beads............................ 89, 90DILTIAZEM HCL-SODIUM CHLORIDE......................... 90dilt-xr................................... 90DILUENT FOR LEFAMULIN......................129diluent for treprostinil ........ 188dimenhydrinate................... 43DIMENTHO...........................6DIMERCAPTOPROPANE-SULFONATE.................... 188DIOVAN.............................. 90DIOVAN HCT......................90DIPENTUM....................... 182diphen............................... 207diphenhydramine hcl.........207diphenoxylate-atropine..... 142DIPHTHERIA-TETANUS TOXOIDS DT....................179DIPRIVAN.........................188DIPROLENE..................... 112DIPROLENE AF............... 112dipyridamole............... 69, 188disopyramide phosphate.....90disulfiram............................ 20DITROPAN XL..................150DIURIL................................ 90divalproex sodium...............35divalproex sodium er...........35DIVIGEL............................162dobutamine hcl................... 90dobutamine in d5w..............90docetaxel............................ 55dofetilide............................. 90DOG EPITHELIUM........... 189DOG FENNEL.................. 189DOJOLVI.......................... 189DOLOPHINE.......................10donepezil hcl.......................39DONNATAL...................... 142dopamine hcl...................... 90dopamine in d5w.................90DOPRAM.......................... 106

DOPTELET.........................81DORAL............................... 78DORZOLAMIDE HCL....... 201dorzolamide hcl.................201dorzolamide hcl-timolol mal.......................................... 201dorzolamide hcl-timolol mal pf.......................................201dotti ................................... 162DOVATO.............................73doxazosin mesylate............ 90doxepin hcl..........40, 112, 217doxercalciferol...................184DOXIL................................. 55doxorubicin hcl....................55doxorubicin hcl liposomal....55doxy 100............................. 25doxycycline hyclate.......25, 26doxycycline monohydrate... 26DRECHSLERA................. 189DRISDOL..........................129DRITHO-CREME HP........112dronabinol........................... 43droperidol............................43drospiren-eth estrad-levomefol.......................... 162drospirenone-ethinyl estradiol............................ 162DROXIA.............................. 55DRYSOL........................... 112DSUVIA.............................. 10DUAVEE........................... 162DUETACT.........................119DULERA........................... 211duloxetine hcl......................40DUODOTE........................189DUPIXENT........................112DURACLON........................10DURAGESIC-100............... 10DURAGESIC-12................. 10DURAGESIC-25................. 10DURAGESIC-50................. 10DURAGESIC-75................. 10duramorph.......................... 10duraxin................................ 10DUREZOL.........................198DUROLANE......................189DURYSTA.........................201DUST MITE MIXED ALLERGEN EXT...............189dutasteride........................ 153dutasteride-tamsulosin hcl 153DUTOPROL........................90

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DYANAVEL XR.................102DYAZIDE............................ 90DYRENIUM.........................90DYSPORT........................ 189E.E.S. 400...........................26E.E.S. GRANULES.............26EASTERN COTTONWOOD............... 189easygel............................. 107EC-NAPROSYN................... 6ec-naproxen..........................7econazole nitrate................ 45EC-RX PROGESTERONE162EDARBI.............................. 90EDARBYCLOR................... 90EDECRIN............................90EDEX................................ 150ed-spaz............................. 142EDURANT.......................... 73eemt..................................162eemt hs............................. 162efavirenz............................. 73EFFER-K.......................... 129effer-k................................129EFFEXOR XR.....................40EFFIENT.............................69ELAPRASE.......................147ELELYSO......................... 147ELESTRIN........................ 162eletriptan hydrobromide...... 49ELIDEL............................. 112ELIGARD.......................... 157ELIMITE..............................66elinest............................... 162ELIQUIS..............................33ELIQUIS DVT/PE STARTER PACK................ 33ELITEK............................... 55ELITE-OB......................... 129ELIXOPHYLLIN................ 211ELLA................................. 162ELLENCE........................... 55ELLIOTTS B..................... 129ELMIRON......................... 150ELOCTATE.........................81eluryng.............................. 162ELZONRIS..........................55EMBEDA.............................10EMCYT............................... 55EMEND...............................43EMEND TRI-PACK............. 43EMERPHED....................... 90EMFLAZA........................... 48

EMGALITY..........................49EMGALITY (300 MG DOSE)................................ 49emoquette.........................163EMPLICITI.......................... 55EMSAM...............................41EMTRIVA............................73EMVERM............................ 66ENABLEX......................... 150enalapril maleate................ 90enalaprilat........................... 91enalapril-hydrochlorothiazide.............91ENBRACE HR.................. 129ENBREL........................... 173ENBREL MINI...................173ENBREL SURECLICK......173ENCARE...........................189ENDARI............................ 189endocet............................... 10ENDOMETRIN..................163ENGERIX-B...................... 179ENGLISH PLANTAIN....... 189ENHERTU.......................... 55ENOVARX-IBUPROFEN...... 7enoxaparin sodium............. 33enpresse-28......................163enskyce.............................163entacapone......................... 68entecavir............................. 73ENTEREG........................ 142ENTOCORT EC................182ENTRESTO........................ 91ENTYVIO.......................... 173enulose............................. 142ENVARSUS XR................ 173ENZADYNE...................... 147EPANED............................. 91EPCLUSA........................... 73ephedrine sulfate................ 91EPHEDRINE SULFATE......91EPHEDRINE SULFATE (PRESSORS)..................... 91EPICOCCUM....................189EPICOCCUM NIGRUM.... 189EPIDIOLEX.........................35EPIFOAM..........................112epinastine hcl....................198epinephrine................. 91, 211EPINEPHRINE................... 91EPINEPHRINE HCL-DEXTROSE........................ 91EPINEPHRINE HCL-NACL 91

epinephrine pf..................... 91EPINEPHRINE PROFESSIONAL..............211EPINEPHRINE-DEXTROSE........................ 91EPINEPHRINE-NACL.........91EPINEPHRINESNAP-EMS.......................................... 211EPINEPHRINESNAP-V.... 211EPIPEN 2-PAK................. 212EPIPEN JR 2-PAK............212epirubicin hcl.......................55EPISNAP.......................... 212epitol................................... 35EPIVIR................................ 73EPIVIR HBV........................73eplerenone..........................91EPOGEN............................ 81epoprostenol sodium........ 215eptifibatide.......................... 69EPZICOM........................... 73EQUAPAX/ATORVASTATIN/COQ10............................ 91EQUAPAX/IBUPROFEN/MINREX...................................7EQUETRO.......................... 79ERAXIS...............................45ERBITUX............................ 55ergocalciferol.................... 129ergoloid mesylates............189ERGOMAR......................... 49ergotamine-caffeine............ 49ERIVEDGE......................... 55ERLEADA........................... 55erlotinib hcl..........................55EROS-CTD....................... 189errin...................................163ERTACZO...........................45ERWINAZE.........................55ery.....................................112ERYPED 200...................... 26ERYPED 400...................... 26ERY-TAB............................ 26ERYTHROCIN LACTOBIONATE................ 26ERYTHROCIN STEARATE.........................26erythromycin....... 26, 112, 198erythromycin base.............. 26erythromycin ethylsuccinate..................... 26ESBRIET.......................... 212escitalopram oxalate...........41

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ESGIC.................................10esmolol hcl..........................91ESMOLOL HCL.................. 91esmolol hcl-sodium chloride............................... 91esomeprazole sodium.......141ESPEROCT........................ 81est estrogens-methyltest...163est estrogens-methyltest ds...................................... 163est estrogens-methyltest hs...................................... 163estarylla............................ 163estazolam........................... 78ESTRACE.........................163estradiol............................ 163estradiol valerate.............. 163estradiol-norethindrone acet................................... 163ESTRING..........................163ESTROGEL...................... 163ESTROSTEP FE.............. 163eszopiclone.......................217ethacrynate sodium............ 91ethacrynic acid....................91ethambutol hcl.................... 51ethosuximide.......................35ethyl chloride.......................16ethynodiol diac-eth estradiol............................ 163etodolac................................ 7etodolac er............................ 7etomidate.......................... 189etonogestrel-ethinyl estradiol............................ 163ETOPOPHOS..................... 56etoposide............................ 56EUCRISA..........................112EUFLEXXA....................... 189euthyrox............................ 170EVAMIST.......................... 163EVENITY.......................... 183everolimus.................. 56, 173EVISTA............................. 156EVOMELA.......................... 56EVOTAZ............................. 73EVOXAC...........................107EXCILON AMD DRAIN SPONGES........................ 189EXELDERM........................ 45EXELON............................. 39exemestane........................ 56EXFORGE.......................... 92

EXFORGE HCT..................92EXJADE............................129EXODERM..........................45exotic-hc........................... 206EXPAREL........................... 16EXTAVIA...........................104EXTINA...............................45EXTRANEAL.................... 129EYLEA.............................. 203EZALLOR SPRINKLE.........92ezetimibe............................ 92ezetimibe-simvastatin......... 92fabb...................................129FABRAZYME....................147FALESSA..........................163falmina.............................. 163famciclovir...........................74famotidine......................... 141famotidine premixed......... 141FANAPT..............................70FANAPT TITRATION PACK.................................. 70FARESTON........................ 56FARXIGA.......................... 119FARYDAK...........................56FASENRA.........................207FASENRA PEN................ 207FASLODEX.........................56fa-vitamin b-6-vitamin b-12129fayosim............................. 163FBL KIT.................................7FC FEMALE CONDOM.... 189FC2 FEMALE CONDOM.. 189febuxostat........................... 48FEIBA................................. 81felbamate............................ 35FELBATOL......................... 35FELDENE............................. 7felodipine er........................ 92FEM PH............................ 150FEMARA.............................56FEMCAP...........................189FEMHRT LOW DOSE...... 163FEMRING......................... 163femynor.............................163fenofibrate...........................92fenofibrate micronized........ 92fenofibric acid......................92fenoprofen calcium............... 7fenortho.................................7FENSOLVI........................ 157fentanyl............................... 11fentanyl citrate.................... 10

FENTANYL CITRATE...10, 11fentanyl citrate (pf).............. 10FENTANYL CITRATE-NACL.................................. 11FENTANYL CIT-ROPIVACAINE-NACL........ 11FENTANYL-BUPIVACAINE-NACL.........11FENTORA...........................11FERAHEME......................129FERIVAFA........................ 129ferocon..............................129ferotrinsic.......................... 129FERRALET 90.................. 130FERRAPLUS 90............... 130FERRIPROX.....................130FERRIPROX TWICE-A-DAY.................................. 130FERRLECIT......................130FERRO-PLEX HEMATINIC...................... 130FERROTRIN.....................130FETROJA........................... 26FETZIMA............................ 41FETZIMA TITRATION........ 41FEXMID............................ 216FIASP............................... 123FIASP FLEXTOUCH.........123FIASP PENFILL................123FIBRICOR...........................92FIBRYGA............................ 81FINACEA.......................... 112finasteride......................... 153FIORICET........................... 11FIORICET/CODEINE..........11FIORINAL........................... 11FIORINAL/CODEINE #3.....11FIRAZYR.......................... 173FIRE ANT......................... 189FIRMAGON...................... 157FIRMAGON (240 MG DOSE).............................. 157FIRST-LANSOPRAZOLE. 141FIRST-MOUTHWASH BLM.................................. 107FIRST-OMEPRAZOLE..... 141FIRST-PROGESTERONE VGS.................................. 164FIRVANQ............................26flac.................................... 206FLAGYL.............................. 26FLAREX............................198flavoxate hcl......................150

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FLEBOGAMMA DIF..........173flecainide acetate................92FLECTOR............................. 7FLEXBUMIN..................... 189FLEXIN............................... 16FLOLAN............................215FLOMAX........................... 153FLORIVA PLUS................ 130FLOVENT DISKUS...........212FLOVENT HFA................. 212floxuridine........................... 56FLUAD.............................. 179FLUAD QUADRIVALENT. 179FLUARIX QUADRIVALENT..............179FLUBLOK QUADRIVALENT..............179FLUCELVAX QUADRIVALENT..............179fluconazole..........................46fluconazole in sodium chloride............................... 45flucytosine...........................46fludarabine phosphate........ 56fludrocortisone acetate..... 154FLULAVAL QUADRIVALENT..............179flumazenil ..........................189flunisolide..........................207fluocinolone acetonide.................................. 112, 206fluocinolone acetonide body.................................. 112fluocinolone acetonide scalp................................. 112fluocinonide...............112, 113fluocinonide emulsified base.................................. 112FLUORABON................... 130FLUORESCITE.................203fluoridex............................ 107fluoridex daily renewal...... 107fluoridex enhanced whitening...........................107fluoridex sensitivity relief...107fluoritab............................. 130fluorometholone................ 198fluorouracil .................. 56, 113fluoxetine hcl.......................41fluphenazine decanoate......70fluphenazine hcl..................70FLURA-DROPS................ 130flurandrenolide.................. 113

flurazepam hcl.................. 218flurbiprofen............................7flurbiprofen sodium........... 198flutamide............................. 56fluticasone propionate.................................. 113, 207fluticasone-salmeterol.......212FLUTICASONE-SALMETEROL..................212fluvastatin sodium............... 92fluvastatin sodium er...........92fluvoxamine maleate...........41fluvoxamine maleate er.......41FLUZONE HIGH-DOSE QUADRIVALENT..............179FLUZONE QUADRIVALENT..............179FML...................................199FML FORTE..................... 199FML LIQUIFILM................ 199FOCALIN.......................... 102FOCALIN XR.................... 102folbee plus........................ 130FOLGARD OS.................. 130FOLGARD RX.................. 130folic acid............................130FOLIVANE-F.....................130FOLIVANE-PLUS............. 130FOLLISTIM AQ................. 157FOLOTYN...........................56folplex 2.2......................... 130FOLTRATE....................... 130foltrin................................. 130fomepizole........................ 189fondaparinux sodium.......... 33formaldehyde.................... 189FORTAVIT........................ 130FORTEO...........................183FORTESTA.......................156FOSAMAX........................ 183FOSAMAX PLUS D.......... 183fosamprenavir calcium........74fosaprepitant dimeglumine..43FOSCAVIR......................... 74fosinopril sodium.................92fosinopril sodium-hctz......... 92fosphenytoin sodium...........35FOSRENOL...................... 150FRAGMIN........................... 33FREAMINE HBC...............130FREAMINE III ................... 130FREESTYLE INSULINX TEST.................................122

FREESTYLE LITE TEST.. 122FREESTYLE PRECISION NEO TEST........................122FREESTYLE TEST...........122fresenius propoven........... 190FRESENIUS PROPOVEN 190FROVA............................... 49frovatriptan succinate..........49FULPHILA...........................81fulvestrant........................... 56FUNGIMEZ......................... 46furosemide.......................... 92FUROSEMIDE IN SODIUM CHLORIDE..........92FUSARIUM....................... 190FUSION PLUS..................130FUZEON............................. 74fyavolv...............................164FYCOMPA.......................... 36gabapentin.......................... 36GABITRIL........................... 36GABLOFEN...................... 217GALAFOLD.......................147galantamine hydrobromide. 39galantamine hydrobromide er.........................................39GALZIN.............................130GAMASTAN......................173GAMASTAN S/D...............173GAMIFANT....................... 173GAMMAGARD..................173GAMMAGARD S/D LESS IGA....................................173GAMMAKED.....................173GAMMAPLEX................... 174GAMUNEX-C....................174GANCICLOVIR................... 74ganciclovir sodium.............. 74ganirelix acetate................157GARDASIL 9.....................179GASTROCROM................143gatifloxacin........................199GATTEX........................... 143gavilax...............................143gavilyte-c...........................143gavilyte-g.......................... 143gavilyte-h.......................... 143gavilyte-n with flavor pack.143GAZYVA............................. 56GELFILM.......................... 203GELFOAM-JMI SPONGE.190GELNIQUE....................... 150GEL-ONE..........................190

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GELSYN-3........................ 190gemcitabine hcl...................56gemfibrozil .......................... 92GENERESS FE................ 164generlac............................ 143gengraf..............................174GENICIN VITA-S.............. 130GENOTROPIN..................157GENOTROPIN MINIQUICK.......................157gentak............................... 199gentamicin in saline............ 26gentamicin sulfate.......26, 199GENVISC 850...................190GENVOYA.......................... 74GEODON............................70GERMAN COCKROACH..190gianvi................................ 164GILENYA.......................... 104GILOTRIF........................... 56GILPHEX TR.................... 207GILTUSS TR.....................207GIVLAARI......................... 190GLASSIA.......................... 212glatiramer acetate............. 104glatopa.............................. 104GLEEVEC...........................56GLEOLAN.........................190GLEOSTINE....................... 57GLIADEL WAFER...............57glimepiride........................ 119glipizide.............................119glipizide er.........................119glipizide xl......................... 119glipizide-metformin hcl...... 119GLOPERBA........................ 48GLUCAGEN DIAGNOSTIC.......................................... 190GLUCAGEN HYPOKIT.....122GLUCAGON EMERGENCY KIT............ 122GLUCAGON HCL (DIAGNOSTIC)................. 190GLUCOTROL................... 119GLUCOTROL XL.............. 119glutaraldehyde.................. 190GLUTATHIONE................ 130glyburide........................... 119glyburide micronized.........119glyburide-metformin.......... 119GLYCINE.......................... 130glycine...............................150glycine urologic................. 150

glycolax.............................143glycolic acid...................... 113glycopyrrolate................... 143GLYCOPYRROLATE....... 143glycopyrrolate pf............... 143glydo................................... 17GLYNASE.........................119GLYRX-PF........................143GLYSET............................119GLYXAMBI....................... 119gnp folic acid.....................130GOLDENROD...................190GOLYTELY.......................143GONAL-F..........................157GONAL-F RFF..................157GONAL-F RFF REDIJECT157goodsense aspirin low dose...................................... 7goodsense nicotine.............20GOPRELTO........................17GORDOFILM.................... 113grafco silver nit applicator. 113GRALISE.......................... 106GRALISE STARTER........ 106granisetron hcl.................... 43GRANIX.............................. 81GRASTEK.........................190griseofulvin microsize......... 46griseofulvin ultramicrosize.. 46guaiatussin ac...................207guaifenesin ac...................207guanfacine hcl.....................92guanfacine hcl er.............. 102GUANIDINE HCL................50GVOKE PFS..................... 122GYNAZOLE-1..................... 46HACKBERRY................... 190HAEGARDA......................174hailey 1.5/30..................... 164hailey 24 fe....................... 164hailey fe 1.5/30................. 164hailey fe 1/20.................... 164HALAVEN........................... 57halcinonide........................113HALCION............................78HALDOL............................. 70HALDOL DECANOATE...... 70halobetasol propionate..... 113HALOG............................. 113haloperidol.......................... 71haloperidol decanoate........ 70haloperidol lactate...............70HARVONI........................... 74

HAVRIX............................ 179HEALON........................... 203HEALON GV.....................203HEALON PRO.................. 203HEALON5......................... 203HEALON5 PRO................ 203healthylax..........................143heather..............................164HECTOROL......................184HELIDAC THERAPY........ 143HEMABATE...................... 158hematinic/folic acid........... 130hematogen........................131HEMATOGEN FA............. 131hematogen forte................131HEMATRON-AF............... 131HEMLIBRA......................... 82hemmorex-hc....................182HEMOCYTE PLUS........... 131hemocyte-f........................ 131HEMOFIL M........................82HEPAGAM B.................... 174HEPARIN (PORCINE) IN NACL.................................. 33heparin (porcine) in nacl..... 33heparin sodium (porcine).... 33heparin sodium (porcine) pf...................................33, 34HEPATAMINE.................. 131HEPLISAV-B.....................180HEPSERA...........................74HERCEPTIN....................... 57HERCEPTIN HYLECTA..... 57HERZUMA.......................... 57HESPAN............................. 82hetastarch-nacl................... 82HETLIOZ...........................218HEXTEND...........................82HIBERIX........................... 180HIDEX 6-DAY................... 154HIPREX.............................. 27HISTATROL......................190HIZENTRA........................174homatropaire.....................204HONEY BEE VENOM.......190HONEY BEE VENOM PROTEIN..........................190HORIZANT....................... 106HORSE EPITHELIUM...... 190HUMALOG KWIKPEN...... 123HUMALOG MIX 50/50 KWIKPEN......................... 123

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HUMALOG MIX 50/50 VIAL.................................. 123HUMALOG MIX 75/25 KWIKPEN......................... 123HUMALOG MIX 75/25 VIAL.................................. 123HUMALOG U-100 JUNIOR KWIKPEN......................... 123HUMALOG VIAL...............123HUMAN ALBUMIN GRIFOLS.......................... 190HUMATE-P......................... 82HUMATROPE...................158HUMIRA............................174HUMIRA PEDIATRIC CROHNS START............. 174HUMIRA PEN................... 174HUMIRA PEN-CD/UC/HS STARTER......................... 174HUMIRA PEN-PS/UV/ADOL HS START. 174HUMULIN 70/30 KWIKPEN......................... 123HUMULIN 70/30 VIAL.......123HUMULIN N KWIKPEN.... 124HUMULIN N VIAL............. 124HUMULIN R U-500 KWIKPEN......................... 124HUMULIN R U-500 VIAL.. 124HUMULIN R VIAL............. 124HYALGAN.........................190HYALURONIDASE (INTRAOCULAR)..............204HYCAMTIN......................... 57hydralazine hcl....................92HYDREA.............................57hydrochlorothiazide.............92hydrocodone bitartrate er....11hydrocodone polst-cpm polst er.............................. 207hydrocodone-acetaminophen................... 11hydrocodone-homatropine 208hydrocodone-ibuprofen.......11hydrocortisone.. 113, 154, 182hydrocortisone (perianal).. 182hydrocortisone ace-pramoxine................. 113, 182hydrocortisone acetate..... 182hydrocortisone butyr lipo base.................................. 113hydrocortisone butyrate.... 113hydrocortisone valerate.... 113

hydrocortisone-acetic acid 206hydrocortisone-iodoquinol...46hydrocort-pramoxine (perianal)...........................182hydrogen peroxide.............. 27hydromet...........................208hydromorphone hcl............. 12HYDROMORPHONE HCL. 12hydromorphone hcl er.........11hydromorphone hcl pf......... 12HYDROMORPHONE HCL-NACL.................................. 12hydroxocobalamin acetate 131hydroxychloroquine sulfate. 66hydroxyprogesterone caproate............................164hydroxyurea........................ 57hydroxyzine hcl................... 78hydroxyzine pamoate..........78HYLAVITE........................ 131HYLENEX......................... 190HYMOVIS......................... 191hyophen............................ 150hyoscyamine sulfate......... 144hyoscyamine sulfate er..... 144hyoscyamine sulfate sl......144hyosyne............................ 144HYPERHEP B S/D............174HYPERLYTE-CR.............. 131HYPERRAB...................... 174HYPERRAB S/D............... 174HYPERRHO S/D.............. 174HYPERSAL.......................208HYPERTET S/D................174HYSINGLA ER....................12HYZAAR............................. 92ibandronate sodium.......... 183IBRANCE............................57ibu......................................... 7ibuprofen...............................7ibuprofen lysine.....................7ibutilide fumarate................ 92IC GREEN........................ 191ICAR-C PLUS................... 131icatibant acetate................175ICLUSIG............................. 57IDAMYCIN PFS.................. 57idarubicin hcl.......................57IDELVION........................... 82IDHIFA................................ 57iferex 150 forte..................131IFEX....................................57ifosfamide........................... 57

ILARIS.............................. 175ILEVRO.............................199ILUMYA............................ 175ILUVIEN............................199imatinib mesylate................ 57IMBRUVICA..................57, 58imipenem-cilastatin............. 27imipramine hcl.....................41imipramine pamoate........... 41imiquimod......................... 113IMITREX............................. 49IMITREX STATDOSE REFILL................................49IMITREX STATDOSE SYSTEM............................. 49IMLYGIC............................. 58IMOGAM RABIES-HT.......175IMOVAX RABIES..............180IMPAVIDO.......................... 66IMURAN............................175INBRIJA.............................. 68incassia.............................164INCRELEX........................158INCRUSE ELLIPTA.......... 212indapamide......................... 93INDERAL LA.......................93INDERAL XL.......................93INDOCIN...............................7indocyanine green............ 191indomethacin........................ 7indomethacin er.................... 7indomethacin sodium............7INFANRIX......................... 180INFASURF........................208INFED............................... 191INFLECTRA......................175INFUGEM........................... 58INFUMORPH 200............... 12INFUMORPH 500............... 12INFUVITE ADULT.............131INFUVITE PEDIATRIC..... 131INGREZZA........................106INJECTAFER....................131INLYTA............................... 58INNOPRAN XL................... 93INREBIC............................. 58INSPRA.............................. 93INSULIN ASP PROT & ASP FLEXPEN................. 124INSULIN ASPART............ 124INSULIN ASPART FLEXPEN......................... 124

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INSULIN ASPART PENFILL........................... 124INSULIN ASPART PROT & ASPART........................ 124INSULIN PEN NEEDLES. 124INSULIN SYRINGES........ 124INTEGRA F.......................131INTEGRA PLUS............... 131INTEGRILIN........................69INTELENCE........................74intralipid............................ 131INTRALIPID...................... 131INTRAROSA.....................150INTRON A...........................74introvale............................ 164INTUNIV........................... 102INVEGA.............................. 71INVEGA SUSTENNA..........71INVEGA TRINZA................ 71INVELTYS........................ 199INVIRASE........................... 74INVOKAMET.....................119INVOKAMET XR...............119INVOKANA....................... 119iodine strong..................... 131iodine tincture..................... 27IODOQUIMEZ-HC.............. 46iodoquinol-hc-aloe polysacch............................46iodoquinol-hydrocortisone-aloe..................................... 46IONOSOL-MB IN D5W..... 131IOPIDINE.......................... 201IPOL..................................180ipratropium bromide..208, 212ipratropium-albuterol.........212irbesartan............................93irbesartan-hydrochlorothiazide.............93IRESSA...............................58irinotecan hcl.......................58IROSPAN 24/6..................131IS 24/6.............................. 131ISENTRESS....................... 74ISENTRESS HD................. 74isibloom.............................164ISOLYTE-P IN D5W......... 131ISOLYTE-S....................... 131ISOLYTE-S PH 7.4........... 131isoniazid..............................51isoproterenol hcl................. 93ISOPTO ATROPINE.........204ISOPTO CARPINE........... 201

ISORDIL TITRADOSE........93isosorbide dinitrate..............93isosorbide mononitrate....... 93isosorbide mononitrate er... 93isosulfan blue....................191isotretinoin........................ 113isoxsuprine hcl.................... 93isradipine............................ 93ISTALOL........................... 201ISTODAX (OVERFILL)....... 58ISTURISA......................... 158ISUPREL............................ 93itraconazole........................ 46IV STABILIZER FOR LUMOXITI.........................191ivermectin........................... 66IXEMPRA KIT..................... 58IXIARO..............................180IXINITY............................... 82JADENU........................... 131JADENU SPRINKLE.........131jaimiess.............................164JAKAFI................................58JALYN...............................153jantoven.............................. 34JANUMET.........................119JANUMET XR...........119, 120JANUVIA...........................120JARDIANCE..................... 120jasmiel...............................164JATENZO......................... 156JELMYTO........................... 58jencycla.............................164JENTADUETO..................120JENTADUETO XR............120JEVTANA............................58jinteli ..................................164JIVI......................................82JOHNSON GRASS...........191jolessa...............................164JUBLIA................................46juleber............................... 164JULUCA..............................74JUNE GRASS POLLEN STANDARDIZED..............191junel 1.5/30....................... 164junel 1/20.......................... 164junel fe 1.5/30................... 164junel fe 1/20...................... 164junel fe 24......................... 164JUXTAPID.......................... 93JYNARQUE...................... 131KABIVEN.......................... 132

KADCYLA........................... 58KADIAN.............................. 12kaitlib fe.............................164KALBITOR........................ 175KALETRA........................... 74kalliga................................164KALYDECO...................... 214KANJINTI............................58KANUMA.......................... 147KAPOK............................. 191KAPVAY........................... 102KARBINAL ER.................. 208kariva................................ 164KAZANO........................... 120KCENTRA...........................82kcl in dextrose-nacl........... 132kcl-lactated ringers-d5w....132KCL-LIDOCAINE-NACL... 132kedbumin.......................... 191KEDRAB........................... 175KEFLEX.............................. 27kelnor 1/35........................ 164kelnor 1/50........................ 164KENALOG................ 113, 154KENALOG-80................... 154KENGREAL........................ 69KEPIVANCE..................... 108KEPPRA............................. 36KEPPRA XR....................... 36KERALYT......................... 113KERALYT SCALP.............113KERAMATRIX REPLICINE 5CMX5CM........................ 113KERLIX AMD ANTIMICROBIAL..............191KERLIX AMD SUPER SPONGES........................ 191KERYDIN............................46KETALAR......................... 191KETAMINE HCL............... 191ketamine hcl......................191KETAMINE HCL-SODIUM CHLORIDE....................... 191ketoconazole.......................46ketodan............................... 46ketoprofen.............................7ketoprofen er.........................7ketorolac tromethamine 7, 199KETOROLAC-BUPIV-KETAMINE........................... 7KETOROLAC-ROPIV-KETAMINE........................... 7KEVEYIS.......................... 201

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KEVZARA......................... 175KEYTRUDA........................ 58KHAPZORY........................ 58KINERET.......................... 175KINEVAC.......................... 191KINRIX..............................180kionex............................... 132KISQALI (200 MG DOSE).. 58KISQALI (400 MG DOSE).. 58KISQALI (600 MG DOSE).. 58KITABIS PAK....................214KLARITY-A....................... 199KLONOPIN......................... 78klor-con............................. 132klor-con 10........................ 132klor-con m10..................... 132KLOR-CON M15...............132klor-con m20..................... 132klor-con sprinkle................132klor-con/ef......................... 132KOATE................................82KOATE-DVI........................ 82KOCHIA............................ 191KOGENATE FS.................. 82KOMBIGLYZE XR............ 120KORLYM...........................160KOSELUGO........................58KOVALTRY.........................82K-PHOS............................ 132K-PHOS NO 2...................132K-PHOS-NEUTRAL.......... 132k-prime..............................132KRINTAFEL........................ 66KRISTALOSE................... 144KRYSTEXXA...................... 48K-TAB............................... 132k-tan plus.......................... 132kurvelo.............................. 164KUVAN............................. 147KYLEENA......................... 164KYMRIAH......................... 175KYNMOBI........................... 68KYPROLIS..........................59LABETALOL HCL............... 93labetalol hcl.........................93LACRISERT......................204lactated ringers................. 132lactic acid.......................... 114lactic acid e....................... 113LACTOJEN....................... 144lactulose............................144lactulose encephalopathy. 144LAMBS QUARTERS.........191

LAMICTAL.......................... 36LAMICTAL ODT..................36LAMICTAL STARTER........ 36LAMICTAL XR.................... 36lamivudine...........................74lamivudine-zidovudine........ 74lamotrigine.......................... 36lamotrigine er...................... 36lamotrigine starter kit-blue.. 36lamotrigine starter kit-green...................................36lamotrigine starter kit-orange.................................36LANOXIN............................ 93LANOXIN PEDIATRIC........93lansoprazole..................... 141lanthanum carbonate........ 150LANTUS SOLOSTAR....... 124LANTUS U-100 VIAL........ 124larin 1.5/30........................ 164larin 1/20........................... 164larin 24 fe.......................... 164larin fe 1.5/30.................... 164larin fe 1/20....................... 164larissia...............................165LARTRUVO........................ 59LASIX..................................93LASTACAFT..................... 204latanoprost........................ 201LATANOPROST-TIMOLOL MALEATE........ 201LATRIX XM.......................114LATUDA..............................71layolis fe............................165LAZANDA........................... 12LEDIPASVIR-SOFOSBUVIR.................... 74leena................................. 165leflunomide....................... 175LEMTRADA...................... 104LENSCALE....................... 191LENVIMA (10 MG DAILY DOSE)................................ 59LENVIMA (12 MG DAILY DOSE)................................ 59LENVIMA (14 MG DAILY DOSE)................................ 59LENVIMA (18 MG DAILY DOSE)................................ 59LENVIMA (20 MG DAILY DOSE)................................ 59LENVIMA (24 MG DAILY DOSE)................................ 59

LENVIMA (4 MG DAILY DOSE)................................ 59LENVIMA (8 MG DAILY DOSE)................................ 59LESCOL XL........................ 93lessina...............................165LETAIRIS..........................215letrozole.............................. 59LETS...................................17leucovorin calcium.............. 59LEUKERAN........................ 59LEUKINE............................ 82leuprolide acetate............. 158LEUPROLIDE ACETATE-BUPIVACAINE..................158levalbuterol hcl..................212LEVATIO.............................17LEVBID............................. 144LEVEMIR U-100 FLEXTOUCH.................... 124LEVEMIR U-100 VIAL...... 124levetiracetam...................... 37levetiracetam er.................. 36levetiracetam in nacl........... 36LEVITRA...........................150levobunolol hcl.................. 201LEVOCARNITINE.............132levocarnitine......................132levocarnitine sf..................132levocetirizine dihydrochloride................. 208levofloxacin................. 27, 199levofloxacin in d5w..............27levoleucovorin calcium........59levoleucovorin calcium pf....59levonest............................ 165levonorgest-eth est & eth est..................................... 165levonorgest-eth estrad 91-day.................................... 165levonorgestrel................... 165levonorgestrel-ethinyl estrad................................165levonorg-eth estrad triphasic............................ 165LEVOPHED........................ 93levora 0.15/30 (28)............165levorphanol tartrate.............12levo-t................................. 170levothyroxine sodium........ 170levoxyl...............................170LEVSIN............................. 144LEVSIN/SL........................144

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LEVULAN KERASTICK.... 114LEXAPRO...........................41LEXISCAN........................ 191LEXIVA............................... 74LIALDA............................. 182LIBRAX............................. 144LIBTAYO.............................59LIDO BDK........................... 17lidocaine..............................17lidocaine hcl........................ 17LIDOCAINE HCL................ 17lidocaine hcl (cardiac)......... 17lidocaine hcl (cardiac) pf..... 17lidocaine hcl (pf)..................17lidocaine hcl urethral/mucosal................. 17lidocaine in d5w.................. 17LIDOCAINE IN DEXTROSE........................ 17lidocaine viscous hcl......... 108lidocaine-epinephrine..........17LIDOCAINE-EPINEPHRINE................. 204lidocaine-hydrocort (perianal)...........................182lidocaine-hydrocortisone ace.................................... 182LIDOCAINE-HYDROCORTISONE ACE.......................................... 182LIDOCAINE-PHENYLEPHRINE........... 204LIDOCAINE-PHENYLEPHRINE-BSS... 204lidocaine-prilocaine............. 17LIDOCAINE-TETRACAINE 17LIDOCIDEX I.................... 154LIDODERM.........................17LIDO-EPINEPHRINE-TETRACAINE..................... 18lidopin................................. 18LIDOPRIL........................... 18LIDOPRIL XR..................... 18LIDO-PRILO CAINE PACK.18LIDOPROFEN...................... 7LIDO-SORB........................ 18LILETTA (52 MG)............. 165lillow.................................. 165LINCOCIN...........................27lincomycin hcl..................... 27lindane................................ 66linezolid...............................27linezolid in sodium chloride.27

LINZESS...........................144LIORESAL........................ 217liothyronine sodium...........170LIPITOR..............................94LIPO..................................132LIPO-C..............................132LIPOFEN............................ 94LIQUIVIDA HYDRATION..132lisinopril ...............................94lisinopril-hydrochlorothiazide.............94lithium................................. 79lithium carbonate................ 79lithium carbonate er............ 79LITHOBID........................... 79LITHOSTAT...................... 150LIVALO............................... 94LIVIXIL PAK........................18LMD IN D5W.......................82LMD IN NACL..................... 82LO LOESTRIN FE............ 165LOCOID............................ 114LOCOID LIPOCREAM......114LODINE................................ 7LODOSYN.......................... 68LOESTRIN 1.5/30 (21)..... 165LOESTRIN 1/20 (21)........ 165LOESTRIN FE 1.5/30....... 165LOESTRIN FE 1/20.......... 165lojaimiess.......................... 165LOMOTIL.......................... 144LONSURF...........................59loperamide hcl.................. 144LOPID................................. 94lopinavir-ritonavir................ 74lopreeza............................ 165LOPRESSOR..................... 94LOPRESSOR HCT............. 94LOPROX.............................46lorazepam........................... 78lorazepam intensol..............78LORBRENA........................ 59lorcet................................... 12lorcet hd.............................. 12LORID...............................132LORTAB............................. 12loryna................................ 165LORZONE........................ 217losartan potassium..............94losartan potassium-hctz......94LOSEASONIQUE............. 165LOTEMAX.........................199LOTEMAX SM.................. 199

LOTENSIN..........................94LOTENSIN HCT................. 94loteprednol etabonate....... 199LOTREL..............................94LOTRONEX...................... 144lovastatin.............................94LOVAZA..............................94LOVENOX.......................... 34low-ogestrel...................... 165loxapine succinate.............. 71LOYON............................. 114lo-zumandimine................ 165LUCEMYRA........................20LUCENTIS........................ 204ludent................................ 133LULICONAZOLE................ 46LUMIGAN......................... 201LUMIZYME....................... 147LUMOXITI...........................59LUNESTA......................... 218LUPANETA PACK............ 158LUPRON DEPOT (1-MONTH)........................... 158LUPRON DEPOT (3-MONTH)........................... 158LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG................................ 158LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG................................ 158LUPRON DEPOT-PED (1-MONTH)........................... 158LUPRON DEPOT-PED (3-MONTH)........................... 158lutera.................................165LUXTURNA...................... 204LUZU.................................. 46LYNPARZA.........................59LYRICA.............................106LYRICA CR.......................106LYSINE HCL.....................133lysiplex plus...................... 133LYSODREN........................ 59LYSTEDA........................... 82lyza................................... 165M.V.I. ADULT....................133M.V.I. PEDIATRIC............ 133MACI.................................191MACRILEN....................... 191MACROBID........................ 27

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MACRODANTIN................. 27MACUGEN....................... 204mafenide acetate................ 27MAGNEBIND 400............. 133MAGNESIUM SULFATE.. 133magnesium sulfate............133magnesium sulfate in d5w 133MAGNESIUM SULFATE-NACL................................ 133MAKENA...........................165MALARONE........................66malathion............................ 66MANGANESE CHLORIDE133mannitol.............................. 94maprotiline hcl.....................41MARCAINE.........................18MARCAINE PRESERVATIVE FREE......18MARCAINE SPINAL........... 18MARCAINE/EPINEPHRINE......................................... 18MARCAINE/EPINEPHRINE PF....................................18MARINOL........................... 43marlissa............................ 165MARPLAN.......................... 41MARQIBO...........................59MATULANE........................ 59matzim la............................ 94MAVENCLAD (10 TABS)..104MAVENCLAD (4 TABS)....104MAVENCLAD (5 TABS)....105MAVENCLAD (6 TABS)....105MAVENCLAD (7 TABS)....105MAVENCLAD (8 TABS)....105MAVENCLAD (9 TABS)....105MAVYRET.......................... 75MAXALT............................. 50MAXALT-MLT..................... 50MAXICOMFORT SYR 27G X 1/2"................................ 124MAXIDEX..........................199MAXITROL....................... 204maxi-tuss ac......................208MAXZIDE............................94MAXZIDE-25.......................94MAYZENT.........................105MAYZENT STARTER PACK................................ 105me/naphos/mb/hyo1......... 150MEADOW FESCUE GRASS POLLEN.............. 191meclizine hcl....................... 43

meclofenamate sodium.........8MEDI-DERM/L-RX..............18MEDI-DERM-RX.................12MEDI-PATCH RX............... 18MEDROL.......................... 154MEDROX-RX......................12medroxyprogesterone acetate...................... 165, 166mefenamic acid.....................8mefloquine hcl.....................66megestrol acetate............. 166MEKINIST...........................60MEKTOVI............................60MELALEUCA.................... 192melodetta 24 fe................. 166meloxicam.............................8melphalan........................... 60melphalan hcl......................60memantine hcl.................... 39memantine hcl er................ 39MEMBRANEBLUE............204MENACTRA......................180MENEST...........................166MENOPUR....................... 158MENOSTAR..................... 166MENTAX.............................46MENVEO.......................... 180meperidine hcl.................... 13MEPHYTON..................... 133meprobamate......................79MEPRON............................ 66MEPSEVII.........................147mercaptopurine...................60meropenem.........................27MEROPENEM-SODIUM CHLORIDE......................... 27MERREM............................27mesalamine...................... 182mesalamine er.................. 182mesalamine-cleanser........182mesna................................. 60MESNEX.............................60MESQUITE....................... 192MESTINON...................50, 51metadate er.......................102metaproterenol sulfate...... 212metaxalone....................... 217metformin hcl.................... 120metformin hcl er................ 120methadone hcl.................... 13methadone hcl intensol.......13METHADOSE..................... 13methadose.......................... 13

METHADOSE SUGAR-FREE.................................. 13methamphetamine hcl...... 102methazolamide................. 201methenamine hippurate...... 27methenamine mandelate.... 27methergine........................192methimazole..................... 170METHITEST..................... 156methocarbamol................. 217methotrexate.....................175methotrexate sodium........ 175methotrexate sodium (pf)..175methoxsalen rapid............ 114methscopolamine bromide144methyl salicylate............... 114METHYLCOBALAMIN...... 133methyldopa......................... 94methyldopa-hydrochlorothiazide.............94methylergonovine maleate192METHYLIN........................103methylphenidate hcl..........103methylphenidate hcl er......103methylphenidate hcl er (cd).......................................... 103methylphenidate hcl er (la)103METHYLPHENIDATE HCL ER (XR)............................ 103methylprednisolone...........154METHYLPREDNISOLONE ACETATE......................... 154methylprednisolone acetate.............................. 154methylprednisolone sodium succ......................154METHYLPREDNISOLONE-BUPIVACAINE................ 154methyltestosterone........... 156metoclopramide hcl.............43metolazone......................... 94metoprolol succinate er.......94metoprolol tartrate...............94metoprolol-hydrochlorothiazide.............94metronidazole....... 27, 28, 114metronidazole in nacl..........27mexiletine hcl...................... 94MI PASTE......................... 108MI PASTE PLUS...............108MIACALCIN...................... 183mibelas 24 fe.................... 166micafungin sodium..............46

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MICARDIS.......................... 95MICARDIS HCT..................95MIC-L-CARNITINE........... 133miconazole 3.......................46MICONAZOLE-ZINC OXIDE-PETROLAT............ 46MICRHOGAM ULTRA-FILTERED PLUS.............. 175MICROCYN...................... 114microgestin 1.5/30............ 166microgestin 1/20............... 166microgestin fe 1.5/30........ 166microgestin fe 1/20........... 166MICROPLEGIA MSA-MSG.......................................... 133midazolam hcl.....................79MIDAZOLAM HCL.............. 79midazolam hcl (pf).............. 79MIDAZOLAM HCL-SODIUM CHLORIDE..........79MIDAZOLAM-SODIUM CHLORIDE......................... 79midodrine hcl...................... 95MIFEPREX....................... 133mifepristone...................... 133MIGERGOT........................ 50miglitol...............................120miglustat........................... 147MIGRANAL......................... 50mili .................................... 166MILLIPRED.......................155MILLIPRED DP 12-DAY... 155milrinone lactate..................95milrinone lactate in dextrose.............................. 95mimvey............................. 166MINASTRIN 24 FE........... 166mineral oil heavy...............144MINIPRESS........................ 95minitran............................... 95MINIVELLE....................... 166MINOCIN............................ 28minocycline hcl................... 28minoxidil ..............................95MIOCHOL-E..................... 204MIOSTAT..........................204MIRAPEX............................68MIRAPEX ER......................68MIRCERA........................... 83MIRCETTE....................... 167MIRENA (52 MG)..............167mirtazapine......................... 41MIRVASO......................... 114

misoprostol....................... 141MITE (D. FARINAE)..........192MITE (D. PTERONYSSINUS)..........192MITIGARE.......................... 48mitigo.................................. 13mitomycin............................60MITOMYCIN....................... 60MITOSOL..........................199mitoxantrone hcl................. 60MIXED ASPERGILLUS.... 192MIXED FEATHERS.......... 192MIXED RAGWEED...........192MIXED VESPID VENOM PROTEIN..........................192mixed vespid venom protein...............................192M-M-R II............................180M-NATAL PLUS................133MOBIC.................................. 8modafinil ........................... 218moexipril hcl........................95molindone hcl......................71mometasone furoate.114, 208mondoxyne nl..................... 28mono-linyah...................... 167MONONINE........................ 83MONOVISC...................... 192MONSELS FERRIC SUBSULFATE.................... 83montelukast sodium..........212MONUROL......................... 28morgidox............................. 28MORPHINE SULFATE....... 13morphine sulfate........... 13, 14morphine sulfate (concentrate).......................13morphine sulfate (pf)...........13morphine sulfate er............. 13morphine sulfate er beads.. 13MORPHINE SULFATE-NACL.................................. 14MOTEGRITY.................... 144MOTOFEN........................144MOUNTAIN CEDAR......... 192MOUSE EPITHELIUM...... 192MOVANTIK....................... 144MOVIPREP.......................144MOXEZA...........................199MOXIFLOXACIN HCL 28, 199moxifloxacin hcl.......... 28, 199moxifloxacin hcl (2x day).. 199moxifloxacin hcl in nacl....... 28

MOXIFLOXACIN HCL-BSS...................................204MOZOBIL............................83MS CONTIN........................14MUCOR............................ 192MUCOSITISRX.................108MUGWORT...................... 192MULPLETA.........................83MULTAQ.............................95MULTIGEN....................... 133MULTIGEN FOLIC............133MULTIGEN PLUS.............133MULTIPRO....................... 133multi-vit/iron/fluoride..........133multivitamin/fluoride.......... 133multi-vitamin/fluoride.........133multivitamin/fluoride/iron... 134multi-vitamin/fluoride/iron..134mupirocin............................ 28MUSE............................... 150mutamycin.......................... 60MVASI.................................60mvc-fluoride...................... 134MYALEPT......................... 147MYAMBUTOL..................... 51MYCAMINE........................ 46MYCAPSSA......................158MYCOBUTIN...................... 51mycophenolate mofetil ......175mycophenolate mofetil hcl 175mycophenolate sodium.....175myferon 150 forte..............134MYFORTIC....................... 176MYLERAN.......................... 60MYLOTARG........................60mynephrocaps.................. 134mynephron........................134MYOBLOC........................192myorisan........................... 114MYRBETRIQ.................... 150MYSOLINE......................... 37MYTESI............................ 144MYXREDLIN.....................125na ferric gluc cplx in sucrose............................. 134NABI-HB........................... 176nabumetone..........................8n-acetyl-l-cysteine.............134nadolol................................ 95nafcillin sodium................... 28NAFCILLIN SODIUM IN DEXTROSE........................ 28nafrinse............................. 134

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NAFRINSE DAILY ACIDULATED................... 108NAFRINSE DAILY/NEUTRAL..............108nafrinse drops................... 134NAFRINSE WEEKLY........108naftifine hcl..........................46NAFTIN...............................47NAGLAZYME....................147nalbuphine hcl.....................14NALFON............................... 8NALOCET...........................14naloxone hcl........................20NALTREXONE................... 20naltrexone hcl..................... 20NAMENDA..........................39NAMENDA TITRATION PAK.....................................39NAMENDA XR....................39NAMENDA XR TITRATION PACK.............. 39NAMZARIC......................... 39NAPRELAN.......................... 8NAPRO................................. 8NAPROSYN..........................8naproxen...............................8naproxen dr...........................8naproxen sodium.................. 8naproxen sodium er.............. 8naratriptan hcl..................... 50NARCAN.............................20NARDIL...............................41NAROPIN........................... 18NASCOBAL...................... 134NASONEX........................ 208NATACYN.........................199NATAZIA...........................167nateglinide........................ 120NATESTO.........................156NATPARA.........................184NATROBA.......................... 66NATURE-THROID............ 170NAVELBINE........................60NAYZILAM..........................37NEBUPENT........................ 66nebusal............................. 208NEBUSAL......................... 208necon 0.5/35 (28)..............167nefazodone hcl................... 41NEMBUTAL........................ 37neomycin sulfate.................28neomycin-bacitracin zn-polymyx.............................204

neomycin-polymyxin b gu... 28neomycin-polymyxin-dexameth.......................... 204neomycin-polymyxin-gramicidin......................... 204neomycin-polymyxin-hc.................................. 205, 206NEONATAL COMPLETE..134NEONATAL PLUS............ 134neo-polycin....................... 205neo-polycin hc...................205NEOPROFEN....................... 8NEORAL........................... 176neostigmine methylsulfate.. 51NEOSTIGMINE METHYLSULFATE............. 51NEO-SYNALAR................ 114NEOTUSS PLUS.............. 208NEOVITE.......................... 134NEPHPLEX RX.................134NEPHRAMINE..................134NEPHRON FA.................. 134nephronex.........................134NEPHRO-VITE RX........... 134NERLYNX...........................60NESACAINE....................... 18NESACAINE-MPF.............. 18NESINA............................ 120NESTABS......................... 134NEULASTA.........................83NEULASTA ONPRO...........83NEUPOGEN....................... 83NEUPRO............................ 68NEURIN-SL...................... 134NEURONTIN...................... 37neutral sodium fluoride..... 108NEUTRASAL.................... 108NEVANAC........................ 199nevirapine........................... 75nevirapine er....................... 75NEXAVAR...........................60NEXIUM 24HR..................141NEXIUM I.V...................... 141NEXLETOL......................... 95NEXLIZET...........................95NEXPLANON....................167NEXTERONE..................... 95niacin (antihyperlipidemic).. 95niacin er (antihyperlipidemic).............95niacor.................................. 95NIASPAN............................ 95NICADAN..........................134

nicardipine hcl.....................95NICARDIPINE HCL IN NACL.................................. 95NICAZEL...........................134NICAZEL FORTE............. 134NICOMIDE........................134NICORETTE....................... 20nicotine polacrilex............... 20nicotine step 1.....................20nicotine step 2.....................21nicotine step 3.....................21NICOTROL......................... 21NICOTROL NS................... 21nifedipine............................ 95nifedipine er........................ 95nifedipine er osmotic release................................ 95NIFEREX.......................... 134nikki...................................167NILANDRON.......................60nilutamide........................... 60NIMBEX............................ 106nimodipine.......................... 95NINLARO............................60NIPENT...............................60NIPRIDE RTU.....................95nisoldipine er.......................95NITHIODOTE....................192nitisinone...........................147NITRO-BID......................... 96NITRO-DUR........................96nitrofurantoin.......................28nitrofurantoin macrocrystal. 28nitrofurantoin monohydrate macrocrystals......................28nitroglycerin........................ 96nitroglycerin in d5w............. 96NITROLINGUAL................. 96NITROMIST........................ 96NITROPRESS.................... 96nitroprusside sodium...........96NITROSTAT....................... 96nitro-time.............................96NITYR............................... 147NIVESTYM......................... 83nizatidine...........................141nolix.................................. 114nora-be............................. 167NORCO.............................. 14NORDITROPIN FLEXPRO.......................................... 158norepinephrine bitartrate.....96

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NOREPINEPHRINE-DEXTROSE........................ 96NOREPINEPHRINE-SODIUM CHLORIDE..........96norethin ace-eth estrad-fe.167norethindrone....................167norethindrone acetate.......167norethindrone acet-ethinyl est..................................... 167norethindrone-eth estradiol.......................................... 167norethin-eth estradiol-fe....167NORGESIC FORTE......... 217norgestimate-eth estradiol 167norgestimate-ethinyl estradiol triphasic..............167norlyda.............................. 167norlyroc............................. 167NORMOSOL-M IN D5W... 134NORMOSOL-R................. 134NORMOSOL-R IN D5W... 134NORMOSOL-R PH 7.4..... 134NORPACE.......................... 96NORPACE CR....................96NORPRAMIN......................41NORTHERA........................96nortrel 0.5/35 (28)............. 167nortrel 1/35 (21)................ 167nortrel 1/35 (28)................ 167nortrel 7/7/7.......................167nortriptyline hcl....................41NORVASC.......................... 96NORVIR..............................75NOURIANZ......................... 68novarel.............................. 158NOVAREL.........................158NOVOEIGHT...................... 83NOVOFINE AUTOCOVER PEN NEEDLE................... 125NOVOFINE PEN NEEDLE125NOVOFINE PLUS PEN NEEDLE........................... 125NOVOLIN 70/30 FLEXPEN.......................................... 125NOVOLIN 70/30 FLEXPEN RELION............................ 125NOVOLIN 70/30 RELION. 125NOVOLIN 70/30 VIAL.......125NOVOLIN N RELION........125NOVOLIN N VIAL............. 125NOVOLIN R RELION........125NOVOLIN R VIAL............. 125NOVOLOG FLEXPEN...... 125

NOVOLOG MIX 70/30 FLEXPEN......................... 125NOVOLOG MIX 70/30 VIAL.................................. 125NOVOLOG PENFILL........ 125NOVOLOG U-100 VIAL.... 125NOVOSEVEN RT............... 83NOVOTWIST PEN NEEDLE........................... 125NOXAFIL............................ 47np thyroid.......................... 170NPLATE..............................83NUBEQA.............................60NUCALA........................... 208NUCORT.......................... 114NUCYNTA.......................... 14NUCYNTA ER.................... 14NUFERA........................... 134nulev................................. 144NULOJIX...........................176NULYTELY WITH FLAVOR PACKS.............. 145NUMBRINO........................ 18NUMOISYN...................... 108NUPLAZID.......................... 71NUTRICAP....................... 134NUTRIDOX......................... 28nutrifac zx......................... 134nutrilipid............................ 134NUTRIVIT......................... 134NUTROPIN AQ NUSPIN 10......................................158NUTROPIN AQ NUSPIN 20......................................159NUTROPIN AQ NUSPIN 5159NUVAIL.............................114NUVAKAAN........................ 18NUVARING.......................167NUVIGIL........................... 218NUWIQ............................... 83NUZYRA............................. 28nystatin............................... 47nystatin-triamcinolone.........47nystop................................. 47OBIZUR.............................. 83OCALIVA.......................... 147ocella................................ 167OCREVUS........................ 105OCTAGAM........................176OCTAPLAS BLOOD GROUP A......................... 192OCTAPLAS BLOOD GROUP AB.......................193

OCTAPLAS BLOOD GROUP B......................... 193OCTAPLAS BLOOD GROUP O.........................193octreotide acetate............. 159OCUFLOX........................ 199ODACTRA........................ 193ODEFSEY...........................75ODOMZO............................60OFEV................................ 212ofloxacin..............28, 199, 206OGIVRI............................... 60olanzapine.......................... 71olanzapine-fluoxetine hcl.... 41OLIVE TREE.....................193olmesartan medoxomil........96olmesartan medoxomil-hctz..................................... 96olmesartan-amlodipine-hctz..................................... 97olopatadine hcl..........199, 208OLUMIANT....................... 176OLUX................................ 114OLUX-E............................ 114OMECLAMOX-PAK.......... 145omega-3-acid ethyl esters.. 97OMEGAVEN..................... 134omeprazole....................... 141OMEPRAZOLE+SYRSPEND SF ALKA.....................141OMIDRIA.......................... 205OMNARIS......................... 208OMNITROPE.................... 159ONCASPAR........................60ondansetron hcl.................. 44ondansetron odt..................44ONE VITE WOMENS PLUS................................ 135ONEVITE.......................... 135ONFI................................... 37ONGLYZA.........................120ONIVYDE............................61ONPATTRO......................106ONTRUZANT......................61OPDIVO..............................61opium................................ 145OPSUMIT......................... 215OPTIONS CONCEPTROL193ORABLOC.......................... 18ORACIT............................ 135ORAFATE.........................193ORALAIR.......................... 193

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ORALAIR ADULT SAMPLE KIT.....................193ORALAIR ADULT STARTER PACK.............. 193ORALAIR CHILDRENS SAMPLE KIT.....................193ORALAIR CHILDRENS STARTER PACK.............. 193oralone..............................108ORAPRED ODT............... 155ORAVIG..............................47ORBACTIV......................... 28ORCHARD GRASS POLLEN............................193ORENCIA......................... 176ORENCIA CLICKJECT.....176ORENITRAM.................... 215ORFADIN..........................147ORILISSA......................... 159ORKAMBI......................... 214orphenadrine citrate..........217orphenadrine citrate er......217orphenadrine-asa-caffeine 217ORPHENGESIC FORTE.. 217orsythia............................. 167ORTHO MICRONOR........167ORTHOVISC.................... 193ORTIKOS..........................182oscimin..............................145oscimin sr..........................145oseltamivir phosphate.........75OSENI...............................120OSMITROL......................... 97osmitrol............................... 97OSMOPREP..................... 145OSPHENA........................ 156OTEZLA............................176OTICIN HC NR................. 206OTIPRIO........................... 207OTOVEL........................... 207OVACE PLUS...................114OVACE PLUS WASH....... 114OVACE WASH................. 114OVIDE.................................66OVIDREL.......................... 159oxacillin sodium............ 28, 29OXACILLIN SODIUM IN DEXTROSE........................ 28oxaliplatin............................61oxandrolone...................... 156oxaprozin.............................. 8OXAYDO............................ 14oxazepam........................... 79

OXBRYTA.........................193oxcarbazepine.................... 37OXERVATE...................... 205oxiconazole nitrate..............47OXISTAT............................ 47OXSORALEN ULTRA.......114OXTELLAR XR................... 37oxybutynin chloride........... 150oxybutynin chloride er.......150oxycodone hcl.....................14OXYCODONE HCL ER...... 14oxycodone-acetaminophen.14oxycodone-aspirin...............14OXYCONTIN...................... 14oxymorphone hcl................ 14oxymorphone hcl er............ 14oxytocin.............................159OXYTOCIN-LACTATED RINGERS......................... 159OXYTOCIN-SODIUM CHLORIDE....................... 159OZEMPIC......................... 120OZURDEX........................ 199PACERONE........................97pacerone.............................97paclitaxel.............................61PADCEV............................. 61PAINGO KFT...................... 18paliperidone er.................... 71palonosetron hcl................. 44PALYNZIQ........................ 147PAMELOR.......................... 41pamidronate disodium...... 183PANCREAZE....................147pancuronium bromide....... 106PANDEL........................... 114PANHEMATIN.................... 84PANRETIN..........................61pantoprazole sodium........ 141PANZYGA.........................176PARAGARD INTRAUTERINE COPPER.......................................... 167paraplatin............................ 61paricalcitol.........................184PARLODEL.........................68PARNATE...........................41paroex...............................108paromomycin sulfate...........29paroxetine hcl..................... 41paroxetine hcl er................. 41PARSABIV........................184PASER................................51

PATANASE.......................208PAXIL..................................42PAXIL CR........................... 42PAZEO..............................199pb-hyoscy-atropine-scopolamine......................145PECAN POLLEN.............. 193PEDIAPRED..................... 155PEDIARIX......................... 180PEDVAX HIB.................... 180peg 3350...........................145peg 3350-kcl-na bicarb-nacl................................... 145peg-3350/electrolytes....... 145PEGANONE....................... 37PEGASYS...........................75PEGASYS PROCLICK....... 75PEGINTRON...................... 75peg-prep........................... 145PEMAZYRE........................ 61penicillamine..................... 151PENICILLIN G POT IN DEXTROSE........................ 29penicillin g potassium..........29penicillin g procaine............ 29penicillin g sodium.............. 29penicillin v potassium..........29PENICILLIUM NOTATUM 193PENTACEL.......................180PENTAM.............................66pentamidine isethionate......67PENTASA......................... 182pentazocine-naloxone hcl... 14pentobarbital sodium.......... 37pentoxifylline er...................97PEPCID............................ 141PERCOCET........................15PERENNIAL RYE GRASS POLLEN............................193PERFOROMIST............... 212PERIDEX.......................... 108PERIKABIVEN..................135perindopril erbumine........... 97periogard...........................108PERJETA............................61permethrin...........................67perphenazine...................... 44perphenazine-amitriptyline..42PERSERIS..........................71PERTZYE......................... 148PFIZERPEN........................29phenazo............................ 151phenazopyridine hcl..........151

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phenelzine sulfate...............42phenobarbital...................... 37phenobarbital sodium......... 37phenobarbital-belladonna alk..................................... 145phenohytro........................145PHENOL........................... 193phenoxybenzamine hcl....... 97phentolamine mesylate.......97phenylephrine hcl........97, 205PHENYLEPHRINE HCL.................................... 97, 151PHENYLEPHRINE HCL (PRESSORS)..................... 97PHENYLEPHRINE HCL-NACL.................................. 97PHENYTEK........................ 37phenytoin............................ 37phenytoin infatabs...............37phenytoin sodium................37phenytoin sodium extended............................. 37PHESGO............................ 61philith................................ 167PHOMA EXIGUA.............. 193PHOSLYRA...................... 151phospha 250 neutral......... 135phosphasal....................... 151PHOSPHOLINE IODIDE.. 201phosphorous..................... 135phospho-trin 250 neutral...135PHOTOFRIN.......................61PHOTREXA VISCOUS.....193PHYSIOLYTE................... 135PHYSIOSOL IRRIGATION.......................................... 135phytonadione.................... 135PICATO............................ 114PIFELTRO.......................... 75pilocarpine hcl...........108, 201pimecrolimus.....................114pimozide............................. 71pimtrea..............................167pindolol............................... 97pioglitazone hcl................. 120pioglitazone hcl-glimepiride.......................................... 120pioglitazone hcl-metformin hcl..................................... 120piperacillin sod-tazobactam so........................................ 29PIQRAY (200 MG DAILY DOSE)................................ 61

PIQRAY (250 MG DAILY DOSE)................................ 61PIQRAY (300 MG DAILY DOSE)................................ 61pirmella 1/35..................... 168pirmella 7/7/7.................... 168piroxicam.............................. 8PITOCIN........................... 159PLAN B ONE-STEP..........168PLAQUENIL........................67PLASBUMIN-25................193PLASBUMIN-5..................194PLASMA-LYTE 148.......... 135PLASMA-LYTE A..............135PLASMANATE..................194PLAVIX............................... 69PLEGISOL........................ 135PLEGRIDY........................105PLEGRIDY STARTER PACK................................ 105PLENAMINE..................... 135PLIAGLIS............................18PNEUMOVAX 23..............180pnv prenatal plus multivit+dha.......................135podocon............................ 114podofilox........................... 114POLIDOCANOL..................97POLIVY...............................61polocaine............................ 18polocaine-mpf..................... 18polycin...............................205polyethylene glycol 3350.. 145poly-iron 150 forte.............135polymyxin b sulfate............. 29polymyxin b-trimethoprim..205polysaccharide iron forte...135POLYTRIM....................... 205POLY-VI-FLOR.................135POLY-VI-FLOR FS........... 135POLY-VI-FLOR/IRON.......135POMALYST........................ 61portia-28............................168PORTRAZZA...................... 61posaconazole......................47pot bicarb-pot chloride...... 135POTABA........................... 135potassium acetate.............135potassium bicarbonate......135potassium chloride............136potassium chloride crys er 135potassium chloride er135, 136

potassium chloride in dextrose............................ 136potassium chloride in nacl 136potassium citrate er.......... 136potassium citrate-citric acid.......................................... 136potassium phosphates(71 meq k)...............................136POTELIGEO....................... 61POVIDONE-IODINE......... 200PRADAXA...........................34pralidoxime chloride..........194PRALUENT.........................97pramipexole dihydrochloride................... 68pramipexole dihydrochloride er............... 68PRAMOSONE.......... 114, 115PRAMOTIC.......................207pramox..............................115prasugrel hcl....................... 69PRAVACHOL......................97pravastatin sodium..............97PRAXBIND....................... 194praziquantel........................ 67prazosin hcl.........................97PRE & POST SX POUCH 115PRECEDEX...................... 194PRECISION PCX PLUS TEST.................................122PRECISION QID TEST.... 122PRECISION SOF-TACT TEST.................................122PRECISION XTRA BLOOD GLUCOSE...........122PRECISION XTRA KETONE........................... 122PRECOSE........................ 120PRED FORTE...................200PRED MILD...................... 200PRED-G............................205PRED-G S.O.P................. 205prednicarbate....................115PREDNISOL ACE-MOXIFLOX-BROMFEN.... 200prednisolone..................... 155prednisolone acetate........ 200prednisolone acetate p-f... 200prednisolone sodium phosphate................. 155, 200PREDNISOLONE-BROMFENAC...................205

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PREDNISOLONE-GATIFLOXACIN............... 205PREDNISOLON-GATIFLOX-BROMFENAC 205PREDNISOLON-MOXIFLOX-BROMFENAC.......................................... 205prednisone........................ 155prednisone intensol...........155PREFEST......................... 168pregabalin......................... 106pregnyl.............................. 159PREMARIN.......................168PREMASOL......................136PREMESISRX.................. 136premium lidocaine...............18PREMPHASE................... 168PREMPRO........................168PRENAISSANCE..............136PRENATA.........................136prenatal.............................136prenatal plus iron.............. 136PRENATE.........................136PRENATE DHA................ 136PRENATE ELITE..............136PRENATE ENHANCE...... 136PRENATE ESSENTIAL.... 136PRENATE MINI................ 136PRENATE PIXIE...............136PRENATE RESTORE...... 136PRENATVITE COMPLETE.......................................... 136PRENATVITE PLUS.........136PRENATVITE RX............. 136PREPIDIL......................... 151PREPOPIK....................... 145PRESTALIA........................ 97PRETOMANID....................51PREVACID....................... 141PREVACID SOLUTAB......141prevalite.............................. 97preventeza........................ 168PREVIDENT..................... 108prevident........................... 108PREVIDENT 5000 BOOSTER PLUS..............108PREVIDENT 5000 DRY MOUTH.............................108PREVIDENT 5000 ENAMEL PROTECT.........108PREVIDENT 5000 ORTHO DEFENSE.........................108PREVIDENT 5000 PLUS..108

PREVIDENT 5000 SENSITIVE....................... 108previfem............................ 168PREVNAR 13................... 180PREVYMIS......................... 75PREZCOBIX....................... 75PREZISTA.......................... 75PRIALT............................... 15PRIFTIN..............................51PRILOLID........................... 18PRILOSEC........................141PRILOVIX........................... 18PRILOVIX LITE...................18PRILOVIX LITE PLUS........ 18PRILOVIX PLUS.................19prilovix ultralite.................... 19prilovix ultralite plus............ 19primaquine phosphate........ 67PRIMAXIN IV...................... 29primidone............................ 37PRIMLEV............................ 15PRIMSOL............................29PRINIVIL.............................97PRISMASOL B22GK 4/0.. 136PRISMASOL BGK 0/2.5... 137PRISMASOL BGK 2/0...... 137PRISMASOL BGK 2/3.5... 137PRISMASOL BGK 4/2.5... 137PRISMASOL BK 0/0/1.2... 137PRISTIQ............................. 42PRIVET.............................194PRIVIGEN.........................176PROAIR HFA....................212PROAIR RESPICLICK......213probenecid.......................... 48PROBUPHINE IMPLANT KIT...................................... 15procainamide hcl.................98PROCALAMINE................137PROCARDIA...................... 98PROCARDIA XL................. 98PROCENTRA................... 103prochlorperazine................. 44prochlorperazine edisylate..44prochlorperazine maleate... 44PROCORT........................182PROCRIT............................84PROCTOCORT................ 182PROCTOFOAM HC..........182procto-med hc...................182procto-pak.........................182proctosol hc...................... 182proctozone-hc................... 182

PROFILNINE...................... 84PROFILNINE SD................ 84progesterone.....................168progesterone micronized.. 168PROGLYCEM...................122PROGRAF........................ 176PROLASTIN-C..................213PROLATE........................... 15PROLENSA...................... 200PROLEUKIN....................... 61PROLIA.............................183PROMACTA....................... 84promethazine hcl.............. 208promethazine-codeine...... 208promethazine-dm..............208promethazine-phenyleph-codeine............................. 209promethazine-phenylephrine................... 209promethegan.....................209PROMETRIUM................. 168propafenone hcl.................. 98propafenone hcl er..............98propantheline bromide...... 145proparacaine hcl............... 205propofol.............................194propranolol hcl.................... 98propranolol hcl er................ 98propranolol-hctz.................. 98propylthiouracil ..................170PROQUAD........................180PROSCAR........................ 153PROSOL...........................137PROSTIN E2.................... 151PROSTIN VR......................98protamine sulfate................ 84PROTHELIAL................... 194PROTONIX....................... 141PROTOPAM CHLORIDE..194protriptyline hcl....................42PROVAYBLUE................. 194PROVENGE..................... 176PROVERA........................ 168PROVIGIL.........................218PROVISC..........................205PROZAC.............................42PRUDOXIN.......................115pseudoephedrine-bromphen-dm................... 209PSORCON........................115PULMICORT FLEXHALER.......................................... 213

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PULMICORT SUSPENSION.................. 213pulmosal........................... 209PULMOZYME................... 215PURAPLY......................... 115purevit dualfe plus.............137PURIXAN............................61PYLERA............................145pyrazinamide...................... 51PYRIDIUM........................ 151pyridostigmine bromide.......51pyridostigmine bromide er.. 51PYRIDOXAL-5 PHOSPHATE....................137PYRIDOXINE HCL........... 137pyridoxine hcl....................137pyrimethamine.................... 67PYRIMETHAMINE-LEUCOVORIN.................... 67PYROGALLIC ACID......... 115QBRELIS............................ 98QBREXZA.........................115qc aspirin low dose............... 8QINLOCK............................62QNASL..............................209QNASL CHILDRENS........209QTERN............................. 120QUAD-MIX........................151QUADRACEL................... 180QUADRAMET.....................62QUALAQUIN.......................67QUARTETTE.................... 168quazepam........................... 79QUDEXY XR.......................37QUEEN PALM.................. 194QUELICIN.........................106QUESTRAN........................98QUESTRAN LIGHT............ 98quetiapine fumarate............ 71quetiapine fumarate er........71QUFLORA PEDIATRIC.... 137QUILLICHEW ER............. 103QUILLIVANT XR...............103quinapril hcl.........................98quinapril-hydrochlorothiazide.............98quinidine gluconate er.........98quinidine sulfate..................98quinine sulfate.....................67QUINJA...............................47QUTENZA.........................115QUTENZA (2 PATCH)...... 115QUZYTTIR........................209

QVAR REDIHALER.......... 213RABAVERT...................... 180RABBIT EPITHELIUM...... 194RABEPRAZOLE SODIUM 142rabeprazole sodium.......... 142RADICAVA....................... 106RADIOGARDASE.............194RAGWITEK.......................194raloxifene hcl.....................156ramelteon..........................218ramipril ................................ 98RANEXA............................. 98ranolazine er....................... 98RAPAFLO......................... 153RAPAMUNE..................... 176RAPIVAB............................ 75RAPPORT RLS................ 194RAPPORT VTD................ 194rasagiline mesylate............. 68RAVICTI............................148RAYALDEE.......................183RAZADYNE........................ 40RAZADYNE ER.................. 40REBIF............................... 105REBIF REBIDOSE............105REBIF REBIDOSE TITRATION PACK............ 105REBIF TITRATION PACK 105REBINYN............................84REBLOZYL......................... 84RECARBRIO...................... 29RECK..................................19RECLAST......................... 183reclipsen........................... 168RECOMBINATE................. 84RECOMBIVAX HB............180RECOTHROM.................... 84RECOTHROM SPRAY KIT 84RECTIV...............................98RECURA.............................47RED BIRCH...................... 194RED CEDAR.....................194RED MAPLE..................... 194RED MULBERRY............. 194RED TOP GRASS POLLEN............................194REGLAN............................. 44REGONOL..........................51REGRANEX......................115RELADOR PAK.................. 19RELADOR PAK PLUS........19RELENZA DISKHALER......75relexxii ...............................103

RELISTOR........................145RELNATE DHA.................137RELPAX..............................50REMEDIENT.....................137REMERON......................... 42REMERON SOLTAB.......... 42REMESENSE................... 108REMICADE.......................176remifentanil hcl....................15REMODULIN.................... 215RENACIDIN...................... 151RENAGEL.........................151renal..................................137RENATABS...................... 137RENATABS WITH IRON.. 137RENFLEXIS......................176RENOVO............................ 19RENVELA......................... 151repaglinide........................ 120REPATHA...........................98REPATHA PUSHTRONEX SYSTEM............................. 98REPATHA SURECLICK..... 98REQ 49+...........................137REQUIP XL.........................68RESORCINOL-SULFUR.. 115RESTASIS........................ 205RESTASIS MULTIDOSE.. 205RESTORIL........................218RETACRIT..........................84RETEVMO.......................... 62RETIN-A........................... 115RETIN-A MICRO.............. 115RETIN-A MICRO PUMP... 115RETROVIR......................... 75REVATIO.......................... 215REVCOVI..........................148REVLIMID...........................62revonto..............................217REXULTI.............................71REYATAZ........................... 75R-GENE 10.......................194RHIZOPUS....................... 194RHOFADE........................ 115RHOGAM ULTRA-FILTERED PLUS.............. 177RHOPHYLAC................... 177RHOPRESSA................... 201RIASTAP............................ 84ribavirin......................... 75, 76RIDAURA..........................177rifabutin............................... 51RIFADIN............................. 51

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rifampin............................... 51RILUTEK...........................106riluzole.............................. 106rimantadine hcl................... 76RIMSO-50.........................151ringers...............................137ringers irrigation................ 137RINVOQ............................177RIOMET............................121risedronate sodium........... 184RISPERDAL....................... 71RISPERDAL CONSTA....... 71risperidone.................... 71, 72RITALIN.................... 103, 104RITALIN LA.......................103ritonavir............................... 76RITUXAN............................ 62RITUXAN HYCELA.............62rivastigmine.........................40rivastigmine tartrate............ 40rivelsa............................... 168RIXUBIS............................. 84rizatriptan benzoate............ 50ROBAXIN..........................217ROBAXIN-750.................. 217ROCALTROL....................184ROCKLATAN....................201rocuronium bromide..........107ROCURONIUM BROMIDE.......................................... 107ROMIDEPSIN..................... 62ropinirole hcl....................... 68ropinirole hcl er................... 68ropivacaine hcl....................19ROPIVACAINE HCL........... 19ROPIVACAINE HCL-NACL 19ROPIV-CLONIDINE-KETOROLAC......................19rosadan.............................115rosuvastatin calcium........... 99ROTARIX..........................180ROTATEQ........................ 180ROUGH MARSH ELDER. 194ROUGH PIGWEED.......... 194ROWASA..........................183roweepra.............................37roweepra xr.........................37ROXICODONE................... 15ROZEREM........................218ROZLYTREK...................... 62RUBRACA.......................... 62RUCONEST......................177RUKOBIA............................76

RUSSIAN THISTLE.......... 194RUXIENCE......................... 62RUZURGI......................... 195RYANODEX......................217RYBELSUS.......................121RYCLORA........................ 209RYDAPT............................. 62RYTARY............................. 68RYTHMOL SR.................... 99SABRIL............................... 37SACCHAROMYCES CEREVISIAE.................... 195SAFYRAL......................... 168SAGEBRUSH................... 195SAIZEN.............................159SAIZENPREP................... 159SALAGEN.........................108SALEX.............................. 115salicylic acid......................115salicylic acid wart remover 115salicylic acid-cleanser....... 115salimez..............................115SALIMEZ FORTE............. 115saline bacteriostatic.......... 137SALINE-PHENOL............. 137SALIVAMAX..................... 108salsalate................................8SALVAX............................116SALVAX DUO PLUS........ 116SAMSCA...........................137SANCUSO.......................... 44SANDIMMUNE................. 177SANDOSTATIN................ 159SANDOSTATIN LAR DEPOT............................. 159SANTYL............................116SAPHRIS............................ 72SARCLISA.......................... 62SAVAYSA........................... 34SAVELLA..........................107SAVELLA TITRATION PACK................................ 107SCALACORT DK..............116SCENESSE...................... 116SCLEROSOL INTRAPLEURAL...............213scopolamine........................44SEASONIQUE.................. 168SECONAL.........................218SECUADO.......................... 72SEGLUROMET.................121SELECT-OB..................... 137selegiline hcl....................... 68

SELENIOUS ACID............137selenium sulfide................ 116SELRX.............................. 116SELZENTRY.......................76SENSIPAR........................184sensorcaine........................ 19sensorcaine/epinephrine.....19sensorcaine-mpf................. 19sensorcaine-mpf/epinephrine.................. 19SENSORCAINE-MPF/EPINEPHRINE...........19SEREVENT DISKUS........ 213SEROQUEL........................72SEROQUEL XR..................72SEROSTIM....................... 145sertraline hcl....................... 42se-tan plus........................ 137setlakin..............................168sevelamer carbonate........ 151sevelamer hcl....................151sf....................................... 108sf 5000 plus...................... 108SFROWASA..................... 183SHAGBARK HICKORY.... 195sharobel............................ 168SHEEP SORREL..............195SHINGRIX........................ 180SHORT RAGWEED POLLEN EXT....................195SIDEROL.......................... 137SIGNIFOR........................ 159SIGNIFOR LAR................ 159sildenafil citrate. 151, 215, 216SILENOR.......................... 218SILIQ.................................177silodosin............................153SILVADENE........................29silver nitrate........................ 29silver sulfadiazine............... 29SIMBRINZA...................... 201simliya...............................168simpesse...........................168SIMPONI...........................177SIMPONI ARIA................. 177SIMULECT........................177simvastatin..........................99SINEMET............................68SINGULAIR...................... 213SINUVA............................ 209sirolimus............................177SIRTURO............................51SIVEXTRO..........................29

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SKELAXIN........................ 217SKLICE............................... 67SKYLA.............................. 168SKYRIZI (150 MG DOSE) 177SLYND..............................168SMOFLIPID...................... 137sod benz-sod phenylacet..148sod citrate-citric acid......... 137sodium acetate................. 138SODIUM BICARBONATE.138sodium bicarbonate.. 138, 145SODIUM BICARBONATE-DEXTROSE...................... 138sodium chloride.........138, 209sodium chloride (pf).......... 138sodium chloride bacteriostatic.....................138SODIUM CITRATE............. 34SODIUM CITRATE LOCK FLUSH................................ 34SODIUM CITRATE-GENTAMICIN SULF........... 34SODIUM DIURIL.................99SODIUM EDECRIN............ 99sodium fluoride......... 109, 138sodium fluoride 5000 plus.108sodium fluoride 5000 ppm 109sodium fluoride 5000 sensitive............................109SODIUM HYALURONATE195sodium nitrite.................... 195sodium phenylbutyrate......148sodium polystyrene sulfonate........................... 138sodium saccharin..............195sodium sulfacetamide....... 116sodium sulfacetamide wash................................. 116SODIUM SULFACETAMIDE WASH 116sodium tetradecyl sulfate.... 99sodium thiosulfate.............195SOFOSBUVIR-VELPATASVIR................... 76SOLESTA......................... 195solifenacin succinate.........151SOLIQUA..........................121SOLIRIS..............................84SOLOSEC.......................... 29SOLU-CORTEF................ 155SOLU-MEDROL............... 155SOMA............................... 217SOMATULINE DEPOT..... 159

SOMAVERT......................159SOOLANTRA....................116SORBITOL........................195sorbitol.............................. 195sorbitol-mannitol............... 195SORIATANE..................... 116sorine.................................. 99SORREL/DOCK MIX........ 195SOTALOL HCL................... 99sotalol hcl............................99sotalol hcl (af)..................... 99SOTRADECOL................... 99SOTYLIZE.......................... 99SOVALDI............................ 76spinosad............................. 67SPINRAZA........................195SPINY PIGWEED............. 195SPIRIVA HANDIHALER... 213SPIRIVA RESPIMAT........ 213spironolactone.................... 99spironolactone-hctz.............99SPORANOX....................... 47SPORANOX PULSEPAK... 47SPRAVATO (56 MG DOSE)................................ 42SPRAVATO (84 MG DOSE)................................ 42sprintec 28........................ 168SPRITAM............................38SPRYCEL........................... 62sps.................................... 138sronyx............................... 168ssd...................................... 29SSKI..................................209sss 10-5............................ 116ST JOSEPH LOW DOSE..... 8STALEVO 100.................... 68STALEVO 125.................... 68STALEVO 150.................... 68STALEVO 200.................... 68STALEVO 50...................... 69STALEVO 75...................... 69STAMARIL........................180STARLIX...........................121stavudine............................ 76STAXYN........................... 151STEGLATRO.................... 121STEGLUJAN.....................121STELARA......................... 177STEMPHYLIUM................195STENDRA.........................151STERILE DILUENT FLOLAN PH 12.................195

sterile diluent/epoprostenol.......................................... 195STERILE TALC POWDER213sterile water for injection... 195sterile water for irrigation.. 138STIMATE.......................... 159STIOLTO RESPIMAT....... 213STIVARGA..........................62STRATTERA.................... 104STRENSIQ....................... 148streptomycin sulfate............29STRIBILD............................76STRIVERDI RESPIMAT... 213STROMECTOL...................67STRONTIUM CHLORIDE SR-89..................................62STROVITE FORTE...........138STROVITE ONE............... 138SUBLOCADE......................21SUBOXONE....................... 21SUBSYS............................. 15subvenite............................ 38subvenite starter kit-blue.....38subvenite starter kit-green.. 38subvenite starter kit-orange 38succinylcholine chloride.... 107SUCCINYLCHOLINE CHLORIDE....................... 107SUCRAID..........................148sucralfate.......................... 142sufentanil citrate..................15SULAR................................99SULCONAZOLE NITRATE.47sulfacetamide sodium.................................. 116, 200sulfacetamide sodium (acne)................................116sulfacetamide sodium-sulfur................................. 116sulfacetamide-prednisolone..................... 205sulfacetamide-sulfur in urea...................................116sulfacleanse 8/4................116sulfadiazine.........................29sulfamethoxazole-trimethoprim........................30sulfamez wash.................. 116SULFAMYLON................... 30sulfasalazine..................... 183sulfatrim pediatric................30sulfurated lime.................... 67sulindac.................................8

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sumatriptan......................... 50sumatriptan succinate.........50sumatriptan succinate refill . 50SUNOSI............................ 218SUPARTZ FX................... 195SUPER BI-MIX................. 151SUPER QUAD-MIX.......... 151SUPER TRI-MIX............... 151SUPERVITE..................... 138SUPPORT........................ 138SUPPORT-500................. 138SUPPRELIN LA................ 159SUPRAX............................. 30SUPREP BOWEL PREP KIT.................................... 146SURVANTA...................... 209SUSTIVA............................ 76SUSTOL............................. 44SUTENT............................. 62SWEET GUM....................195SWEET VERNAL GRASS POLLEN............................195syeda................................ 168SYLVANT........................... 62SYMAX DUOTAB............. 146symax-sl............................146symax-sr........................... 146SYMBICORT.................... 213SYMBYAX.......................... 42SYMDEKO........................215SYMFI.................................76SYMFI LO........................... 76SYMLINPEN 120.............. 121SYMLINPEN 60................ 121SYMPAZAN........................ 38SYMPROIC.......................146SYMTUZA...........................76SYNAGEX........................ 138SYNAGIS..........................177SYNALAR......................... 116SYNAREL......................... 159SYNATEK......................... 138SYNDROS.......................... 44SYNERA............................. 19SYNERCID......................... 30SYNJARDY.......................121SYNJARDY XR.................121SYNRIBO............................62SYNTHROID.....................170SYNVEXIA TC.................... 19SYNVISC.......................... 195SYNVISC ONE................. 196SYPRINE.......................... 138

TABLOID............................ 62TABRECTA.........................62TACHOSIL........................196tacrolimus................. 116, 177tadalafil ..................... 151, 152tadalafil (pah).................... 216TAFINLAR.......................... 62TAGRISSO......................... 62TAKHZYRO...................... 177TALIVA............................. 138TALL RAGWEED..............196TALTZ.......................177, 178TALZENNA......................... 62TAMIFLU............................ 76tamoxifen citrate................. 62tamsulosin hcl................... 153TAPAZOLE....................... 170TAPERDEX 6-DAY...........155TARCEVA...........................62TARGRETIN....................... 63tarina 24 fe........................168tarina fe 1/20.....................168tarina fe 1/20 eq................168TARKA................................99TARON FORTE................ 138taron-crystals.................... 138TASIGNA............................ 63TASMAR.............................69TASOPROL...................... 116TAURINE.......................... 138TAVALISSE........................ 84TAXOTERE........................ 63TAYTULLA........................169tazarotene.........................116tazicef................................. 30TAZICEF.............................30TAZORAC.................116, 117taztia xt............................... 99TAZVERIK.......................... 63TDVAX..............................180TECENTRIQ....................... 63TECFIDERA..................... 105TEFLARO........................... 30TEGRETOL........................ 38TEGRETOL-XR.................. 38TEGSEDI.......................... 107TEKTURNA........................ 99TEKTURNA HCT................ 99TELFA AMD ISLAND DRESSING....................... 196TELFA AMD NON-ADHERENT...................... 196telmisartan.......................... 99

telmisartan-amlodipine........99telmisartan-hctz.................. 99temazepam....................... 218TEMIXYS............................ 76TEMODAR..........................63TEMOVATE...................... 117temozolomide..................... 63temsirolimus......................178tencon................................. 15teniposide........................... 63TENIVAC.......................... 181tenofovir disoproxil fumarate..............................76TENORETIC 100................ 99TENORETIC 50.................. 99TENORMIN.........................99TEPADINA..........................63TEPEZZA..........................160terazosin hcl......................153terbinafine hcl..................... 47terbutaline sulfate............. 213terconazole......................... 47TERIPARATIDE (RECOMBINANT).............184TESSALON PERLES....... 209TESTIM.............................156TESTONE CIK..................156TESTOPEL....................... 156testosterone...................... 156TESTOSTERONE CYPIONATE..................... 156testosterone cypionate......156testosterone enanthate..... 156tetrabenazine.................... 107tetracaine hcl.................... 205tetracycline hcl.................... 30TEXACORT...................... 117THALOMID......................... 63THEO-24...........................213theophylline.......................214theophylline er.......... 213, 214theophylline in d5w........... 214THERAHONEY.................117thiamine hcl.......................138THIOLA.............................152THIOLA EC.......................152thioridazine hcl....................72thiotepa............................... 63thiothixene.......................... 72THROMBATE III ................. 34THROMBIN-JMI..................85THROMBIN-JMI EPISTAXIS......................... 84

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THROMBOGEN..................85THYMOGLOBULIN...........178THYROGEN..................... 196tiadylt er.............................. 99tiagabine hcl........................38TIAZAC............................. 100TIBSOVO............................63TICE BCG.........................178TIGAN.................................44tigecycline........................... 30TIGLUTIK..........................107TIKOSYN.......................... 100tilia fe................................ 169timolol maleate..........100, 202TIMOLOL-BRIMON-DORZOL-LATANOPR...... 202TIMOLOL-BRIMONIDINE-DORZOLAMID..................202TIMOLOL-DORZOLAMID-LATANOPROST............... 202TIMOPTIC.........................202TIMOPTIC OCUDOSE..... 202TIMOPTIC-XE...................202TIMOTHY GRASS POLLEN ALLERGEN....... 196tinidazole.............................30TIROSINT......................... 171TISSEEL........................... 196TISSUEBLUE................... 205tis-u-sol............................. 138TIVICAY..............................76TIVICAY PD........................76tizanidine hcl..................... 217tl-hem 150.........................138TNKASE............................. 34TOBI NEBULIZER............ 215TOBI PODHALER.............215TOBRADEX...................... 206TOBRADEX ST................ 206tobramycin................ 200, 215TOBRAMYCIN..................215tobramycin sulfate...............30tobramycin-dexamethasone................ 206TOBREX........................... 200TODAY SPONGE............. 196tolbutamide....................... 121tolcapone............................ 69tolmetin sodium.....................8tolterodine tartrate.............152tolterodine tartrate er........ 152tolvaptan........................... 139TOPAMAX.......................... 38

TOPAMAX SPRINKLE....... 38TOPEX TOPICAL ANESTHETIC................... 109TOPICORT....................... 117TOPICORT SPRAY.......... 117topiramate...........................38topiramate er.......................38toposar................................63topotecan hcl...................... 63TOPROL XL......................100toremifene citrate................ 63TORISEL.......................... 178torsemide.......................... 100TOTECT............................. 63TOUJEO MAX SOLOSTAR...................... 125TOUJEO SOLOSTAR.......125tovet.................................. 117TOVIAZ.............................152tpn electrolytes..................139TRACLEER.......................216TRADJENTA.....................121tramadol hcl........................ 15tramadol hcl er.................... 15tramadol hcl er (biphasic)... 15tramadol-acetaminophen.... 15trandolapril ........................ 100trandolapril-verapamil hcl er.......................................100tranexamic acid...................85TRANEXAMIC ACID-NACL.................................. 85TRANSDERM SCOP (1.5 MG).....................................44TRANSDERM-SCOP (1.5 MG).....................................44TRANXENE-T.....................79tranylcypromine sulfate.......42TRAVASOL.......................139TRAVATAN Z................... 202travoprost (bak free)......... 202TRAZIMERA....................... 63trazodone hcl...................... 42TREANDA...........................63TRECATOR........................ 51TRELEGY ELLIPTA..........214TRELSTAR MIXJECT.......160TREMFYA.........................178treprostinil ......................... 216TRESIBA.......................... 125TRESIBA FLEXTOUCH....125tretinoin....................... 63, 117tretinoin microsphere........ 117

tretinoin microsphere pump.......................................... 117TRETTEN........................... 85TREXALL..........................178TREZIX............................... 15tri femynor.........................169triamcinolone acetonide.......................... 109, 117, 155TRIAMCINOLONE ACETONIDE.....................155TRIAMCINOLONE-BUPIVACAINE..................155TRIAMCINOLONE-MOXIFLOXACIN...............206triamterene........................100triamterene-hctz................100trianex............................... 117triazolam............................. 79TRIBENZOR..................... 100TRICARE PRENATAL DHA ONE......................... 139TRI-CHLOR...................... 117TRICHOPHYTON............. 196TRICITRASOL.................... 34tricitrates........................... 139tricon................................. 139TRICOR............................ 100triderm...............................117TRIDESILON.................... 117trientine hcl....................... 139TRIESENCE..................... 200tri-estarylla........................ 169trifluoperazine hcl................72trifluridine.......................... 200trigels-f forte......................139TRIGLIDE......................... 100trihexyphenidyl hcl.............. 69TRIJARDY XR.................. 121TRIKAFTA........................ 215tri-legest fe........................ 169TRILEPTAL.........................38tri-linyah............................ 169TRILIPIX........................... 100tri-lo-estarylla.................... 169tri-lo-marzia.......................169tri-lo-mili ............................ 169tri-lo-sprintec..................... 169TRILURON....................... 196trilyte................................. 146trimethobenzamide hcl........44trimethoprim........................30tri-mili ................................ 169trimipramine maleate.......... 42

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trinate................................139TRINTELLIX....................... 42TRIOSTAT........................ 171triphrocaps........................ 139TRIPLE PMB.................... 200TRIPLE PMK.................... 200tri-previfem........................169TRIPTODUR.....................160tri-sprintec......................... 169TRIUMEQ........................... 76TRI-VI-FLOR.....................139TRI-VI-FLORO..................139TRIVISC............................196tri-vitamin/fluoride............. 139tri-vite/fluoride................... 139trivora (28)........................ 169tri-vylibra........................... 169tri-vylibra lo....................... 169TRIZIVIR.............................76TRODELVY........................ 63TROGARZO....................... 76TROKENDI XR................... 38TRONVITE........................139TROPHAMINE..................139TROPICAMIDE-CYCLOPENTOLATE-PE.. 206TROPICAMIDE-PHENYLEPHRINE........... 206TROPIC-PROPARACA-PE-KETOROLAC..............206trospium chloride.............. 152trospium chloride er.......... 152TRULANCE...................... 146TRULICITY....................... 121TRUMENBA......................181TRUSOPT.........................202TRUVADA...........................76TRUXIMA............................64tryptophan.........................139TUDORZA PRESSAIR..... 214TUKYSA............................. 64tulana................................ 169TURALIO............................ 64turpentine..........................117TUSSICAPS..................... 209TUXARIN ER.................... 209TUZISTRA XR.................. 209TWINRIX...........................181TWIRLA............................ 169TWYNSTA........................ 100TYBOST............................. 77tydemy.............................. 169TYGACIL............................ 30

TYKERB............................. 64TYMLOS........................... 184TYPHIM VI........................181TYSABRI.......................... 105TYVASO........................... 216TYVASO REFILL.............. 216TYVASO STARTER......... 216UCERIS............................ 183UDAMIN SP......................139UDENYCA.......................... 85ULORIC.............................. 48ULTIVA............................... 15ULTOMIRIS........................ 85ULTRABAG/DIANEAL PD-2/1.5% DEX...................... 139ULTRABAG/DIANEAL PD-2/2.5% DEX...................... 139ULTRABAG/DIANEAL PD-2/4.25%DEX..................... 139ULTRABAG/DIANEAL/1.5% DEXTROSE..................139ULTRABAG/DIANEAL/2.5% DEXTROSE..................139ULTRABAG/DIANEAL/4.25% DEX............................ 139ULTRACET.........................15ULTRAM............................. 15UNASYN.............................30unithroid............................ 171UNITUXIN...........................64UPLIZNA...........................178UPTRAVI.......................... 216urea...................................117urea hydrating...................117urea nail ............................ 117urea-c40............................117uredeb...............................117URELLE............................152uremez-40.........................117uretron d/s.........................152uribel................................. 152URIMAR-T........................ 152urin ds............................... 152URO-458...........................152UROCIT-K 10................... 139UROCIT-K 15................... 139UROCIT-K 5..................... 139UROGESIC-BLUE............ 152uro-mp.............................. 152urosex............................... 139UROXATRAL....................153URSO 250........................ 146URSO FORTE.................. 146

ursodiol............................. 146URYL................................ 152ustell ................................. 152UTIBRON NEOHALER.....214uticap................................ 152utira-c................................152utrona-c.............................152VABOMERE....................... 31VAGIFEM..........................169valacyclovir hcl....................77VALCHLOR........................ 64VALCYTE........................... 77valganciclovir hcl.................77VALIUM.............................. 79valproate sodium................ 38valproic acid........................38valrubicin.............................64valsartan........................... 100valsartan-hydrochlorothiazide...........100VALSTAR........................... 64VALTOCO 10 MG DOSE....38VALTOCO 15 MG DOSE....38VALTOCO 20 MG DOSE....38VALTOCO 5 MG DOSE......38VALTREX........................... 77VANADOM........................217VANATOL LQ..................... 15VANATOL S........................15VANCOCIN.........................31VANCOCIN HCL.................31VANCOMYCIN HCL........... 31vancomycin hcl................... 31VANCOMYCIN HCL IN DEXTROSE........................ 31vancomycin hcl in dextrose.31vancomycin hcl in nacl........31VANCOMYCIN HCL IN NACL.................................. 31vandazole........................... 31VANTAS........................... 160VAPRISOL........................160VAQTA..............................181vardenafil hcl.....................152VARITHENA..................... 100VARIVAX.......................... 181VARUBI (180 MG DOSE)... 44VASCEPA.........................100VASERETIC..................... 100VASOSTRICT...................160VASOTEC.........................100VAZCULEP.......................100v-c forte.............................139

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VCF VAGINAL CONTRACEPTIVE........... 196vcf vaginal contraceptive.. 196VECAMYL.........................100VECTIBIX........................... 64VECTICAL........................ 117vecuronium bromide......... 107VELCADE........................... 64VELETRI...........................216velivet................................169VELPHORO......................152VELTASSA....................... 139VEMLIDY............................ 77VENCLEXTA...................... 64VENCLEXTA STARTING PACK.................................. 64VENELEX......................... 117venlafaxine hcl.................... 42venlafaxine hcl er................42VENOFER........................ 140VENOMIL MIXED VESPID VENOM.............................196VENTAVIS........................ 216VENTOLIN HFA................214verapamil hcl.............100, 101verapamil hcl er................ 100VERDESO........................ 117VEREGEN........................ 118VERELAN......................... 101VERELAN PM...................101VERSACLOZ...................... 72VERZENIO......................... 64VESICARE........................152VEXATROL.........................19VFEND..........................47, 48VFEND IV........................... 47VIAGRA............................ 152VIBATIV.............................. 31VIBERZI............................146VIBRAMYCIN..................... 31vic-forte............................. 140VICTOZA.......................... 121VIDAZA...............................64VIEKIRA PAK..................... 77vienva............................... 169vigabatrin............................ 38vigadrone............................ 39VIGAMOX......................... 200VIIBRYD............................. 42VIIBRYD STARTER PACK.42vilamit mb..........................152VILEVEV MB.................... 152VIMIZIM............................ 148

VIMPAT.............................. 39vinblastine sulfate............... 64vincristine sulfate................ 64vinorelbine tartrate.............. 64VIOKACE..........................148viorele............................... 169VIRACEPT..........................77VIRAMUNE.........................77VIRAMUNE XR...................77VIRASAL...........................118VIRAZOLE.......................... 77VIREAD.............................. 77VIRGINIA LIVE OAK.........196virt-caps............................ 140VIRT-FEFA PLUS.............140virt-gard.............................140virt-phos 250 neutral......... 140virtussin ac w/alc...............209VISCO-3........................... 196VISIONBLUE.................... 206visiv...................................140VISTARIL............................79VISTOGARD.....................196VISUDYNE....................... 206vita s forte......................... 140vitacel................................140VITAFOL...........................140VITAFOL-OB+DHA...........140VITAL-D RX...................... 140VITAMAX PEDIATRIC......140VITAMEZ.......................... 140vita-min............................. 140vitamin d (ergocalciferol)...140vitamin k1..........................140vitamins acd-fluoride.........140VITAROCA PLUS............. 140VITA-RX DIABETIC VITAMIN........................... 140VITASURE........................140VITATHELY WITH GINGER............................140VITRAKVI........................... 64VITRASE.......................... 196VIVELLE-DOT.................. 169VIVITROL........................... 21VIVOTIF............................181VIZIMPRO.......................... 64VOGELXO........................ 156VOGELXO PUMP.............156volnea............................... 169VOLTAREN.......................... 8VONVENDI......................... 85VOPAC KT............................8

VORAXAZE........................ 64voriconazole........................48VOSEVI.............................. 77VOTRIENT..........................64vp-pnv-dha........................140VPRIV............................... 148vp-vite rx........................... 140VRAYLAR........................... 72VTOL LQ.............................15VUMERITY....................... 105VUMERITY (STARTER)... 105VUSION.............................. 48VYEPTI............................... 50vyfemla............................. 169vylibra............................... 169VYNDAMAX......................101VYNDAQEL...................... 101VYTONE............................. 48VYTORIN..........................101VYVANSE.........................104VYXEOS............................. 64VYZULTA..........................202WAKIX.............................. 218warfarin sodium.................. 34WASP VENOM PROTEIN 196water for irrigation, sterile. 140weekly-d............................140WELCHOL........................ 101WELLBUTRIN SR...............42WELLBUTRIN XL............... 42wera.................................. 169WESTERN JUNIPER....... 196WESTHROID....................171wheat germ oil .................. 140WHITE ASH......................196WHITE BIRCH.................. 197WHITE FACED HORNET VENOM.............................197WHITE MULBERRY......... 197WHITE OAK......................197WHITE PINE.....................197WHITE-FACED HORNET VENOM.............................197WIDE-SEAL DIAPHRAGM 60......................................197WIDE-SEAL DIAPHRAGM 65......................................197WIDE-SEAL DIAPHRAGM 70......................................197WIDE-SEAL DIAPHRAGM 75......................................197WIDE-SEAL DIAPHRAGM 80......................................197

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WIDE-SEAL DIAPHRAGM 85......................................197WIDE-SEAL DIAPHRAGM 90......................................197WIDE-SEAL DIAPHRAGM 95......................................197WILATE.............................. 85WINRHO SDF...................178wixela inhub...................... 214WP THYROID...................171wymzya fe.........................169XADAGO............................ 69XALATAN......................... 202XALKORI............................ 64XANAX................................79XANAX XR..........................79XARELTO........................... 34XARELTO STARTER PACK.................................. 34XELJANZ.......................... 178XELJANZ XR.................... 178XELODA............................. 65XEMBIFY.......................... 178XENAZINE........................107XENLETA..................... 31, 32XEOMIN............................197XEPI....................................32XERAC AC....................... 118XERAVA............................. 32XERMELO........................ 146XEROFORM OIL EMULSION 2"X2"............. 118XEROFORM OIL EMULSION GAUZE..........118XEROFORM OIL EMULSION STRIP........... 118XEROFORM OIL ROLL 4"X9'................................. 118XEROFORM PETROLAT GAUZE 1"X8"................... 118XEROFORM PETROLAT GAUZE 5"X9"................... 118XEROFORM PETROLAT PATCH 2"X2"....................118XEROFORM PETROLAT PATCH 4"X4"....................118XEROFORM PETROLATUM ROLL 4"X9'................................. 118XEROSTOMIA RELIEF SPRAY..............................109XGEVA............................. 184XHANCE...........................209

XIAFLEX........................... 197XIFAXAN............................ 32XIGDUO XR......................121XIIDRA..............................206XOFIGO..............................65XOFLUZA (40 MG DOSE)..77XOFLUZA (80 MG DOSE)..77XOLAIR.............................209XOLEGEL........................... 48XOLEGEL COREPAK........ 48XOLEGEL DUO/HEAD & SHOULDERS..................... 48XOLEGEL DUO/XOLEX..... 48XOPENEX........................ 214XOPENEX CONCENTRATE.............. 214XOSPATA...........................65XPOVIO (100 MG ONCE WEEKLY)............................65XPOVIO (40 MG ONCE WEEKLY)............................65XPOVIO (40 MG TWICE WEEKLY)............................65XPOVIO (60 MG ONCE WEEKLY)............................65XPOVIO (60 MG TWICE WEEKLY)............................65XPOVIO (80 MG ONCE WEEKLY)............................65XPOVIO (80 MG TWICE WEEKLY)............................65XTAMPZA ER.....................15XTANDI...............................65xulane............................... 169XULTOPHY...................... 122xurea.................................118XURIDEN..........................148XVITE............................... 140XYLOCAINE....................... 19xylocaine dental.................. 19XYLOCAINE/EPINEPHRINE......................................... 19XYLOCAINE-MPF.............. 19XYLOCAINE-MPF/EPINEPHRINE...........20XYNTHA............................. 85XYNTHA SOLOFUSE.........85XYREM............................. 218XYZMUNE........................ 197YASMIN 28....................... 169YAZ...................................170YELLOW DOCK............... 197

YELLOW HORNET VENOM PROTEIN............197YELLOW JACKET VENOM PROTEIN....197, 198YERVOY.............................65YESCARTA........................ 65YF-VAX.............................181YONDELIS..........................65YONSA............................... 65YUPELRI.......................... 214yuvafem............................ 170zafirlukast..........................214zaleplon............................ 218ZALTRAP............................65ZANAFLEX....................... 217ZANOSAR.......................... 65zarah.................................170ZARONTIN......................... 39ZARXIO.............................. 85ZAVESCA......................... 148ZEBUTAL............................15ZEJULA.............................. 65ZELAPAR........................... 69ZELBORAF.........................65ZEMAIRA..........................214ZEMDRI.............................. 32ZEMPLAR.........................184zenatane........................... 118ZENPEP........................... 148ZENZEDI.......................... 104ZEPATIER.......................... 77ZEPOSIA.......................... 105ZEPOSIA 7-DAY STARTER PACK.............. 105ZEPOSIA STARTER KIT..106ZEPZELCA......................... 65ZERBAXA........................... 32ZERUVIA............................ 20ZERVIATE........................ 200ZESTORETIC................... 101ZESTRIL........................... 101ZETIA................................101ZETONNA.........................209ZEVALIN Y-90.................... 65ZIAC..................................101ZIAGEN.............................. 77zidovudine...........................77ZIEXTENZO........................85zileuton er......................... 214ZILRETTA.........................155ZINC CHLORIDE..............140ZINC SULFATE................ 140ZINGO................................ 20

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ZINPLAVA........................ 178ZIONODIL...........................20ZIONODIL 100....................20ZIOPTAN.......................... 202ziprasidone hcl....................72ziprasidone mesylate.......... 72ZIRABEV............................ 65ZIRGAN............................ 200ZITHRANOL..................... 118ZITHROMAX.......................32ZITHROMAX TRI-PAK....... 32ZITHROMAX Z-PAK........... 32ZOCOR.............................101ZOFRAN............................. 44ZOHYDRO ER....................15ZOLADEX......................... 160zoledronic acid..................184ZOLGENSMA 10.1-10.5 KG.....................................148ZOLGENSMA 10.6-11.0 KG.....................................148ZOLGENSMA 11.1-11.5 KG.....................................148ZOLGENSMA 11.6-12.0 KG.....................................148ZOLGENSMA 12.1-12.5 KG.....................................148ZOLGENSMA 12.6-13.0 KG.....................................148ZOLGENSMA 13.1-13.5 KG.....................................148ZOLGENSMA 2.6-3.0 KG.148ZOLGENSMA 3.1-3.5 KG.148ZOLGENSMA 3.6-4.0 KG.148ZOLGENSMA 4.1-4.5 KG.149ZOLGENSMA 4.6-5.0 KG.149ZOLGENSMA 5.1-5.5 KG.149ZOLGENSMA 5.6-6.0 KG.149ZOLGENSMA 6.1-6.5 KG.149ZOLGENSMA 6.6-7.0 KG.149ZOLGENSMA 7.1-7.5 KG.149ZOLGENSMA 7.6-8.0 KG.149ZOLGENSMA 8.1-8.5 KG.149ZOLGENSMA 8.6-9.0 KG.149ZOLGENSMA 9.1-9.5 KG.149ZOLGENSMA 9.6-10.0 KG.......................................... 149ZOLINZA.............................65zolmitriptan......................... 50ZOLOFT........................42, 43ZOLPAK..............................48zolpidem tartrate............... 218zolpidem tartrate er...........218

ZOMACTON..................... 160ZOMIG................................ 50ZOMIG ZMT........................50ZONALON........................ 118ZONEGRAN....................... 39zonisamide..........................39ZONTIVITY......................... 69ZORBTIVE........................146ZORTRESS...................... 178ZOSYN............................... 32zovia 1/35e (28)................ 170ZOVIRAX............................ 77ZUBSOLV........................... 21zumandimine.................... 170ZUPLENZ........................... 44ZYDELIG............................ 65ZYFLO.............................. 214ZYKADIA............................ 66ZYLET...............................206ZYLOPRIM......................... 48ZYMAXID..........................200ZYPITAMAG..................... 101ZYPREXA........................... 72ZYPREXA RELPREVV.......72ZYPREXA ZYDIS............... 72ZYTIGA...............................66ZYVOX................................32

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DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats,

other formats)

• Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on thebasis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

cmp-nondiscrim15MWCM-0318

DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

formats) • Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-851-3379 (TTY: 711). 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫1-800-851-3379（TTY: 711）。 Polish: UWAGA: Je li mówi Polskie, usługi pomocy j zyka, bezpłatnie, s dost pne dla Ciebie. Zadzwo 1-800-851-3379 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-800-851-3379 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-851-3379 전화 (TTY: 711). ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-800-851-3379 (TTY: 711). Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-800-851-3379 (TTY: 711). .(TTY: 711) 3379-851-800-1 تنبيه: إذا كنت تتحدث اللغة العربية ، خدمات المساعدة اللغوية ، مجانا ، تتوفر لك . ستدعاء Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-800-851-3379 (TTY: 711). ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1-800-851-3379 (TTY: 711).

�યા�: તમે વાત તો �જુરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટ� ��લ�� છે. કૉલ 1-800-851-3379 (TTY: 711).

注意：あなたは、日本語、無料で言語支援サービスを、話す場合は、あなたに利用可能です。 1-800-851-3379コール

（TTY: 711）。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-800-851-3379 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. Виклик 1-800-851-3379 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-800-851-3379 (TTY: 711).

State of Illinois Employees Group Formulary€¦ · A formulary is a list of prescribed medications...

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Transcript of State of Illinois Employees Group Formulary€¦ · A formulary is a list of prescribed medications...