Your 2019 Formulary - healthalliance.org · Your 2019 Formulary. Effective January 1, 2019. Updated...

Your 2019 Formulary

Effective January 1, 2019Updated April 1, 2019

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.

Health Alliance IND & SG Formulary

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 brand-name 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. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips

Tier 1 Preventive and preferred generic

Preventive care medications and preferred generic medications are available at no out-of-pocket cost.

Tier 2 Non-preferred generic (most generics)

Use Tier 2 medications for the lowest out-of-pocket costs. Alternatives may be found in Tier 1.

Tier 3 Preferred brand name Use Tier 3 medications, instead of Tier 4, to help reduce your out-of-pocket costs.

Tier 4 Non-preferred brand name

Many Tier 4 medications may have lower-cost options in Tier 1, 2 and 3. Ask your doctor or pharmacist if they could work for you.

Tier 5 Preferred specialty pharmacy and medical

Specialty medications may be limited to a specialty pharmacy.

Tier 6 Non-preferred specialty pharmacy and medical

Specialty medications may be limited to a specialty pharmacy.

General Medical (GM)

Medications covered under the medical benefit

These medications are not covered under your pharmacy benefit. They are provided and managed in a doctor’s office or hospital.

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 are covered at $0 under preventive benefit.

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.

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

Table of Contents

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

Inflammation .................................................6Anesthetics ................................................... 17Anti-Addiction / Substance Abuse

Treatment Agents .......................................22Antibacterials ................................................23Anticoagulants ..............................................35Anticonvulsants - Drugs for Seizures ........ 39Antidementia Agents - Drugs for

Alzheimer's Disease and Dementia .......... 43Antidepressants ........................................... 44Antiemetics - Drugs for Nausea and

Vomiting ......................................................47Antifungals ....................................................49Antigout Agents ............................................52Anti-inflammatory Agents ............................52Antimigraine Agents .................................... 53Antimyasthenic Agents ................................54Antimycobacterials ...................................... 55Antineoplastics - Drugs for Cancer ............ 55Antiparasitics ................................................66Antiparkinson Agents .................................. 68Antiplatelets ..................................................70Antipsychotics - Drugs for Mood

Disorders .....................................................70Antivirals ....................................................... 73Anxiolytics - Drugs for Anxiety ................... 79Bipolar Agents - Drugs for Mood

Disorders .....................................................80Blood Products / Modifiers / Volume

Expanders - Drugs for Bleeding Disorders 81

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ....................... 86

Central Nervous System Agents - Drugs for Attention Deficit Disorder .................104

Central Nervous System Agents - Drugs for Multiple Sclerosis ...............................106

Central Nervous System Agents - Miscellaneous ...........................................107

Dental and Oral Agents - Drugs for Mouth and Throat Conditions .............................109

Dermatological Agents - Drugs for Skin Conditions .................................................110

Diabetes - Antidiabetic Agents ..................116Diabetes - Glucose Monitoring ..................120Diabetes - Glycemic Agents ...................... 120Diabetes - Insulins ......................................120Electrolytes / Minerals / Metals / Vitamins123

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer .......................................139

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

......................................................................140Genetic or Enzyme Disorder: Drugs for

Replacement, Modifiers, Treatment ........144Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions ...............146Genitourinary Agents - Drugs for Prostate

Conditions .................................................148Hormonal Agents - Adrenal ....................... 149Hormonal Agents - Men's Health .............. 154Hormonal Agents - Osteoporosis ............. 155Hormonal Agents - Parathyroid ................ 155Hormonal Agents - Pituitary ...................... 155Hormonal Agents - Prostaglandins .......... 159Hormonal Agents - Sex Hormones and

Birth Control ............................................. 160Hormonal Agents - Thyroid ....................... 168Immunological Agents - Drugs for

Immune System Stimulation or Suppression ..............................................170

Immunological Agents - Drugs for Vaccination ............................................... 177

Inflammatory Bowel Disease Agents ........179Metabolic Bone Disease Agents - Drugs

for Osteoporosis ...................................... 181Miscellaneous Therapeutic Agents .......... 182Ophthalmic Agents - Drugs for Eye

Allergy, Infection and Inflammation ....... 196Ophthalmic Agents - Drugs for Glaucoma......................................................................199Ophthalmic Agents - Drugs for

Miscellaneous Eye Conditions ................201Otic Agents - Drugs for Ear Conditions ... 204Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold ............205Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions .................................................208

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ........................ 213

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ........213

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm .......................... 214

Sleep Disorder Agents ............................... 215Index of Drugs.............................................. 217

5

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ACTIVE-KETOPROFEN EXTERNAL CREAM 5 %

4

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

4Brand

penalty applies

aspirin childrens oral tablet chewable 81 mg

PV

aspirin ec low dose oral tablet delayed release 81 mg

PV

aspirin low dose oral tablet chewable 81 mg

PV

bayer aspirin ec low dose oral tablet delayed release 81 mg

PV

CALDOLOR INTRAVENOUS SOLUTION 800 MG/8ML

GM

CAMBIA ORAL PACKET 50 MG

4

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

4Brand

penalty applies

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

2

choline-mag trisalicylate oral liquid 500 mg/5ml

2

DAYPRO ORAL TABLET 600 MG

4Brand

penalty applies

DICLOFENAC EPOLAMINE TRANSDERMAL PATCH 1.3 %

4 ST

diclofenac potassium oral tablet 50 mg

2

Drug NameDrug Tier

Notes

diclofenac sodium er oral tablet extended release 24 hour 100 mg

2

diclofenac sodium oral tablet delayed release 25 mg

2

diclofenac sodium oral tablet delayed release 50 mg, 75 mg

1

diclofenac sodium transdermal gel 1 %

2

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

2

diflunisal oral tablet 500 mg

2

DITHOL EXTERNAL THERAPY PACK 1.5-10 %

4

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG

4Brand

penalty applies

EC-NAPROXEN ORAL TABLET DELAYED RELEASE 375 MG, 500 MG

4Brand

penalty applies

ENOVARX-IBUPROFEN EXTERNAL CREAM 10 %

4

EQUAPAX/IBUPROFEN/MINREX ORAL THERAPY PACK 800 MG

4

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

2

etodolac oral capsule 200 mg, 300 mg

2

etodolac oral tablet 400 mg, 500 mg

2

FBL KIT EXTERNAL CREAM 15-4-5 %

4

Updated April 1, 2019

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

6

Drug NameDrug Tier

Notes

FELDENE ORAL CAPSULE 10 MG, 20 MG

4Brand

penalty applies

fenoprofen calcium oral capsule 200 mg, 400 mg

2

fenoprofen calcium oral tablet 600 mg

2

fenortho oral capsule 200 mg

2

FLECTOR TRANSDERMAL PATCH 1.3 %

4 ST

flurbiprofen oral tablet 100 mg, 50 mg

2

ibu oral tablet 600 mg, 800 mg

2

ibuprofen lysine intravenous solution 10 mg/ml

GM

ibuprofen oral suspension 100 mg/5ml

2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

2

IC 400 ORAL KIT 400 MG

4

IC 800 ORAL KIT 800 MG

4

INDOCIN ORAL SUSPENSION 25 MG/5ML

4

INDOCIN RECTAL SUPPOSITORY 50 MG

3

indomethacin er oral capsule extended release 75 mg

2

indomethacin oral capsule 25 mg, 50 mg

2

indomethacin sodium intravenous solution reconstituted 1 mg

GM

Drug NameDrug Tier

Notes

ketoprofen er oral capsule extended release 24 hour 200 mg

2

ketoprofen oral capsule 25 mg

2

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

2

ketorolac tromethamine intramuscular solution 60 mg/2ml

2

ketorolac tromethamine oral tablet 10 mg

2QL (20 EA

per 30 days)

LIDOPROFEN EXTERNAL CREAM 5-5-2 %

4

LODINE ORAL TABLET 400 MG

4Brand

penalty applies

meclofenamate sodium oral capsule 100 mg, 50 mg

2

mefenamic acid oral capsule 250 mg

2

meloxicam oral tablet 15 mg, 7.5 mg

1

MOBIC ORAL TABLET 15 MG, 7.5 MG

4Brand

penalty applies

nabumetone oral tablet 500 mg, 750 mg

2

NALFON ORAL CAPSULE 400 MG

4Brand

penalty applies

NALFON ORAL TABLET 600 MG

4Brand

penalty applies

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

4Brand

penalty applies



7

Drug NameDrug Tier

Notes

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

4

NAPROSYN ORAL SUSPENSION 125 MG/5ML

4Brand

penalty applies

naproxen dr oral tablet delayed release 375 mg, 500 mg

2

naproxen oral suspension 125 mg/5ml

2

naproxen oral tablet 250 mg, 375 mg, 500 mg

2

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

2

naproxen sodium oral tablet 275 mg, 550 mg

2

NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML

GM

oxaprozin oral tablet 600 mg

2

piroxicam oral capsule 10 mg, 20 mg

2

QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 MG

4

salsalate oral tablet 500 mg, 750 mg

2

SPRIX NASAL SOLUTION 15.75 MG/SPRAY

4QL (5 EA

per 30 days)

sulindac oral tablet 150 mg, 200 mg

2

tolmetin sodium oral capsule 400 mg

2

tolmetin sodium oral tablet 200 mg, 600 mg

2

Drug NameDrug Tier

Notes

VOLTAREN TRANSDERMAL GEL 1 %

4Brand

penalty applies

VOPAC KT EXTERNAL CREAM 5-5-2 %

4

Analgesics - Drugs for Pain

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

acetaminophen-codeine #2 oral tablet 300-15 mg

2


2


2

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

2

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

2

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

4PA; Brand

penalty applies

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

GM

APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG

4

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

2

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

4 ST



8

Drug NameDrug Tier

Notes

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

2

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

4PA; QL (60 EA per 30

days)

BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG

4

BUPAP ORAL TABLET 50-300 MG

4Brand

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

2

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

4

BUTALBITAL-ACETAMINOPHEN ORAL CAPSULE 50-300 MG

2

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

2

butalbital-apap oral tablet 50-325 mg

2

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

2

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

2

Drug NameDrug Tier

Notes

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

2

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

2

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

2

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

2

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

GM

butorphanol tartrate nasal solution 10 mg/ml

2

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

4Brand

penalty applies

BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

4

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

2

codeine sulfate oral tablet 30 mg, 60 mg

2

DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 25 MG/ML, 50 MG/ML, 75 MG/1.5ML, 75 MG/ML

GM

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

GM

DILAUDID ORAL LIQUID 1 MG/ML

4Brand

penalty applies

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG

4Brand

penalty applies



9

Drug NameDrug Tier

Notes

DOLOPHINE ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG

4

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR

4

Brand penalty

applies; QL (15 EA per 30 days)


4

Brand penalty



4

Brand penalty



4

Brand penalty



4

Brand penalty


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

GM

duraxin oral capsule 300-200-20 mg

2

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


days)

Drug NameDrug Tier

Notes

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

2

esgic oral capsule 50-325-40 mg

2

ESGIC ORAL TABLET 50-325-40 MG

4Brand

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

2 PA

FENTANYL CITRATE INJECTION SOLUTION 1500 MCG/30ML

GM

FENTANYL CITRATE INJECTION SOLUTION PREFILLED SYRINGE 50 MCG/5ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION 2500 MCG/50ML, 5000 MCG/100ML

GM

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

GM



10

Drug NameDrug Tier

Notes

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-%, 0.4-0.15-0.9 MG/200ML-%, 0.4-0.2-0.9 MG/200ML-%, 1.25-0.2-0.9 MG/250ML-%

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

2QL (15 EA

per 30 days)

Drug NameDrug Tier

Notes

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.08-0.9 MG/100ML-%, 0.2-0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.25-0.08-0.9 MG/125ML-%, 0.3-0.125-0.9 MG/100ML-%, 0.4-0.15-0.9 MG/200ML-%, 0.5-0.0625-0.9 MG/100ML-%, 0.5-0.0625-0.9 MG/250ML-%, 0.5-0.1-0.9 MG/100ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%, 0.6-0.125-0.9 MG/200ML-%, 0.75-0.1-0.9 MG/150ML-%, 0.75-0.125-0.9 MG/250ML-%, 1-0.0625-0.9 MG/250ML-%, 1-0.1-0.9 MG/250ML-%, 1-0.125-0.9 MG/250ML-%, 1.25-0.0625-0.9 MG/250ML-%, 1.25-0.075-0.9 MG/250ML-%

GM

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

4 PA

FIORICET ORAL CAPSULE 50-300-40 MG

4Brand

penalty applies

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

4Brand

penalty applies

FIORINAL ORAL CAPSULE 50-325-40 MG

4Brand

penalty applies

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

4Brand

penalty applies



11

Drug NameDrug Tier

Notes

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

2

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

2

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

2

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


days)

hydromorphone hcl injection solution 4 mg/ml

GM

hydromorphone hcl oral liquid 1 mg/ml

2

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

2

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

2

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

GM

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

GM

HYDROMORPHONE HCL SOLUTION 2 MG/ML INJECTION 2 MG/ML

GM

Drug NameDrug Tier

Notes

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

GM

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

GM

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/100ML-%, 100-0.9 MG/50ML-%, 12-0.9 MG/30ML-%, 15-0.9 MG/30ML-%, 150-0.9 MG/150ML-%, 2-0.9 MG/50ML-%, 20-0.9 MG/100ML-%, 200-0.9 MG/100ML-%, 24-0.9 MG/30ML-%, 25-0.9 MG/250ML-%, 250-0.9 MG/250ML-%, 3-0.9 MG/30ML-%, 30-0.9 MG/150ML-%, 30-0.9 MG/30ML-%, 36-0.9 MG/30ML-%, 40-0.9 MG/200ML-%, 5-0.9 MG/50ML-%, 50-0.9 MG/250ML-%, 60-0.9 MG/30ML-%, 9-0.9 MG/30ML-%

GM



12

Drug NameDrug Tier

Notes

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.4-0.9 MG/2ML-%, 0.5-0.9 MG/0.5ML-%, 0.5-0.9 MG/ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 10-0.9 MG/25ML-%, 12-0.9 MG/30ML-%, 12.5-0.9 MG/25ML-%, 2-0.9 MG/10ML-%, 2-0.9 MG/ML-%, 2.5-0.9 MG/25ML-%, 20-0.9 MG/50ML-%, 25-0.9 MG/25ML-%, 25-0.9 MG/50ML-%, 3-0.9 MG/30ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-%

GM

HYDROMORPHONE-BUPIVACAINE-NACL EPIDURAL SOLUTION 2.5-0.1-0.9 MG/250ML-%, 4-0.125-0.9 MG/200ML-%

GM

HYDROMORPHONE-ROPIVACAINE-NACL EPIDURAL SOLUTION 2-0.1-0.9 MG/250ML-%

GM

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

4 PA

IBUDONE ORAL TABLET 10-200 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

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

4

ST; Brand penalty


KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG

4ST; QL (60 EA per 30

days)

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

4 PA

levorphanol tartrate oral tablet 2 mg, 3 mg

2

lorcet hd oral tablet 10-325 mg

2

lorcet oral tablet 5-325 mg

2

lorcet plus oral tablet 7.5-325 mg

2

LORTAB ORAL ELIXIR 10-300 MG/15ML

4

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

4

MEDROX-RX EXTERNAL OINTMENT 0.05-7-20 %

4

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

GM



13

Drug NameDrug Tier

Notes

meperidine hcl oral solution 50 mg/5ml

2

meperidine hcl oral tablet 100 mg, 50 mg

2

MEPERIDINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 300-0.9 MG/30ML-%

GM

methadone hcl injection solution 10 mg/ml

GM

methadone hcl intensol oral concentrate 10 mg/ml

2

methadone hcl oral concentrate 10 mg/ml

2

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

2

methadone hcl oral tablet 10 mg, 5 mg

2

methadone hcl oral tablet soluble 40 mg

2

METHADOSE ORAL CONCENTRATE 10 MG/ML

4Brand

penalty applies

methadose oral tablet soluble 40 mg

2

METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML

4Brand

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

2

Drug NameDrug Tier

Notes

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

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


days)

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


days)

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

2QL (90 EA

per 30 days)

MORPHINE SULFATE IN DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 250-5 MG/250ML-%

GM

MORPHINE SULFATE IN DEXTROSE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-5 MG/25ML-%

GM

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

GM

morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

GM



14

Drug NameDrug Tier

Notes

morphine sulfate intramuscular device 10 mg/0.7ml

GM

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

GM

morphine sulfate intravenous solution 150 mg/30ml

GM

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

2

morphine sulfate oral tablet 15 mg, 30 mg

2

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

2

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

GM

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

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%, 1000-0.9 MG/100ML-%, 150-0.9 MG/150ML-%, 250-0.9 MG/250ML-%, 250-0.9 MG/50ML-%, 500-0.9 MG/100ML-%

GM

Drug NameDrug Tier

Notes

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 150-0.9 MG/30ML-%, 2-0.9 MG/2ML-%, 2-0.9 MG/ML-%, 275-0.9 MG/55ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 5-0.9 MG/5ML-%, 55-0.9 MG/55ML-%, 60-0.9 MG/30ML-%

GM

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

4

Brand penalty


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

GM

NALOCET ORAL TABLET 2.5-300 MG

4

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

4Brand

penalty applies

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


days)

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

4

ST; QL (120 EA per 30 days)

OPANA ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG

4 PA



15

Drug NameDrug Tier

Notes

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


days)

oxycodone hcl oral capsule 5 mg

2

oxycodone hcl oral concentrate 100 mg/5ml

2

oxycodone hcl oral solution 5 mg/5ml

2

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

2

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

2

oxycodone-aspirin oral tablet 4.8355-325 mg

2

oxycodone-ibuprofen oral tablet 5-400 mg

2

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


days)

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

2

oxymorphone hcl er oral tablet extended release 12 hour 15 mg, 7.5 mg

2QL (60 EA

per 30 days)

oxymorphone hcl oral tablet 10 mg, 5 mg

2

pentazocine-naloxone hcl oral tablet 50-0.5 mg

2

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

phrenilin forte oral capsule 50-300-40 mg

2

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

4

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG

3

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

GM

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG

4Brand

penalty applies

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG

4 PA

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

4 PA

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

GM

tencon oral tablet 50-325 mg

2

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


days)



16

Drug NameDrug Tier

Notes

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

2

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

2

tramadol hcl oral tablet 50 mg

2

tramadol-acetaminophen oral tablet 37.5-325 mg

2

TREZIX ORAL CAPSULE 320.5-30-16 MG

4

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG

4Brand

penalty applies

TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 MG

4Brand

penalty applies

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

GM

ULTRACET ORAL TABLET 37.5-325 MG

4Brand

penalty applies

ULTRAM ORAL TABLET 50 MG

4Brand

penalty applies

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

4

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

4

verdrocet oral tablet 2.5-325 mg

2

vicodin es oral tablet 7.5-300 mg

2

vicodin hp oral tablet 10-300 mg

2

Drug NameDrug Tier

Notes

vicodin oral tablet 5-300 mg

2

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


days)

zebutal oral capsule 50-325-40 mg

2

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


days)

Anesthetics

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

4

7T LIDO EXTERNAL GEL 2 %

4

agoneaze external kit 2.5-2.5 %

2

anodyne lpt external kit 2.5-2.5 %

2

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

GM

BUFFERED LIDOCAINE INJECTION SOLUTION PREFILLED SYRINGE 0.9-8.4 %

GM

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

GM

bupivacaine hcl injection solution 0.25 %

GM

BUPIVACAINE HCL INJECTION SOLUTION 312.5 MG/10ML

GM



17

Drug NameDrug Tier

Notes

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML), 0.25 %, 0.5 % (20 ML), 0.5 % (30 ML), 0.5 % (60 ML)

GM

BUPIVACAINE HCL SOLUTION 0.5 % INJECTION 0.5 %

GM

bupivacaine hcl solution 0.5 % injection 0.5 %

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.0625-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.15-0.9 %, 0.2-0.9 %, 0.25-0.9 %

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.1-0.9 %, 0.25-0.9 %, 0.5-0.9 %

GM

BUPIVACAINE HCL-NACL INJECTION SOLUTION 0.03-0.9 %, 0.0625-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.2-0.9 %, 0.25-0.9 %, 0.375-0.9 %, 0.5-0.9 %

GM

BUPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.0625-0.9 % (50 ML), 0.1-0.9 % (50 ML), 0.125-0.9 % (50 ML), 0.25-0.9 %, 0.25-0.9 % (20 ML), 0.25-0.9 % (30 ML), 0.375-0.9 %

GM

bupivacaine in dextrose intrathecal solution 0.75-8.25 %

GM

BUPIVACAINE IN DEXTROSE SOLUTION PREFILLED SYRINGE 0.75-8.25 % (2 ML)

GM

Drug NameDrug Tier

Notes

bupivacaine spinal intrathecal solution 0.75-8.25 %

GM

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

GM

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

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 external solution 4 %

2

COCAINE HCL NASAL SOLUTION 40 MG/ML

GM

dermacinrx empricaine external kit 2.5-2.5 %

2

dermacinrx prizopak external kit 2.5-2.5 %

2

ethyl chloride external aerosol

2

EXPAREL INJECTION SUSPENSION 1.3 %

GM



18

Drug NameDrug Tier

Notes

FLEXIN EXTERNAL PATCH 0.0375-5 %

4

glydo external gel 2 % 2

GOPRELTO NASAL SOLUTION 40 MG/ML

GM

LETS KIT 4

LEVATIO EXTERNAL PATCH 0.03-5 %

4

lido bdk external kit 2.5-2.5 %

2

lidocaine external ointment 5 %

2QL (50 GM

per 30 days)

lidocaine external patch 5 %

2

lidocaine hcl (cardiac) intravenous solution 10 mg/ml, 20 mg/ml

GM

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

GM

LIDOCAINE HCL EPIDURAL SOLUTION PREFILLED SYRINGE 400 MG/20ML

GM

lidocaine hcl external cream 3 %

2

lidocaine hcl external gel 2 %

2

lidocaine hcl external lotion 3 %

2

lidocaine hcl external solution 4 %

2

lidocaine hcl injection solution 0.5 %, 1 %, 2 %

GM

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML, 200 MG/10ML, 400 MG/20ML

GM

Drug NameDrug Tier

Notes

LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG

4

LIDOCAINE HCL-SODIUM CHLORIDE INJECTION SOLUTION 0.25-0.9 %

GM

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 %

2

lidocaine-prilocaine external kit 2.5-2.5 %

2

LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 %

4

LIDODERM EXTERNAL PATCH 5 %

4Brand

penalty applies

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

GM

lido-k external lotion 3 % 2

lidopin external cream 3 %

2

lidopril external kit 2.5-2.5 %

2

lidopril xr external kit 2.5-2.5 %

2

lido-prilo caine pack external kit 2.5-2.5 %

2



19

Drug NameDrug Tier

Notes

LIDOZION EXTERNAL LOTION 3 %

4

livixil pak external kit 2.5-2.5 %

2

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 %

4

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

4

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

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

GM

Drug NameDrug Tier

Notes

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

GM

PLIAGLIS EXTERNAL CREAM 7-7 %

4

polocaine injection solution 1 %, 2 %

GM

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

GM

port-prep external kit 2.5-2.5 %

2

premium lidocaine external ointment 5 %

2QL (50 GM

per 30 days)

prikaan external kit 2.5-2.5 %

2

prikaan lite external kit 2.5-2.5 %

2

prilolid external kit 2.5-2.5 %

2

prilovix external kit 2.5-2.5 %

2

prilovix plus external kit 2.5-2.5 %

2

priloxx lp external kit 2.5-2.5 %

2

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

GM

relador pak external kit 2.5-2.5 %

2

relador pak plus external kit 2.5-2.5 %

2

RENOVO EXTERNAL PATCH 0.0375-5 %

4

ROPIVACAINE HCL EPIDURAL SOLUTION PREFILLED SYRINGE 0.5 %

GM



20

Drug NameDrug Tier

Notes

ropivacaine hcl injection solution 10 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 SOLUTION 5 MG/ML INJECTION 5 MG/ML

GM

ropivacaine hcl solution 5 mg/ml injection 5 mg/ml

GM

ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.07-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.2-0.9 %

GM

ROPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.2-0.9 %

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.15-0.9 %, 0.2-0.9 %, 0.25-0.9 %

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.1-0.9 %, 0.2-0.9 %

GM

sensorcaine injection solution 0.25 %, 0.5 %

GM

Drug NameDrug Tier

Notes

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

soluline external kit 2.5-2.5 %

2

solupicc external kit 2.5-2.5 %

2

SYNERA EXTERNAL PATCH 70-70 MG

GM

SYNVEXIA TC EXTERNAL CREAM 4-1 %

4

vexatrol external kit 2.5-2.5 %

2

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



21

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 %

2

ZINGO INTRADERMAL JET-INJECTOR 0.5 MG

4

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium oral tablet delayed release 333 mg

1

ANTABUSE ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

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

3

buprenorphine hcl sublingual tablet 2 mg, 8 mg

1

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

1

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

1

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

PV

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

PV

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

Drug NameDrug Tier

Notes

disulfiram oral tablet 250 mg, 500 mg

1

LUCEMYRA ORAL TABLET 0.18 MG

3QL (224

EA per 14 days)

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

2

naloxone hcl injection solution cartridge 0.4 mg/ml

2

naloxone hcl injection solution prefilled syringe 2 mg/2ml

2

naltrexone hcl oral tablet 50 mg

1

NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG

3

NARCAN NASAL LIQUID 4 MG/0.1ML

3

NICORETTE MOUTH/THROAT GUM 2 MG

PV

nicotine polacrilex mouth/throat gum 2 mg, 4 mg

PV

nicotine polacrilex mouth/throat lozenge 2 mg

PV

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

PV


PV


PV

NICOTROL INHALATION INHALER 10 MG

PV



22

Drug NameDrug Tier

Notes

NICOTROL NS NASAL SOLUTION 10 MG/ML

PV

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

3

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

3Brand

penalty applies

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

3

ZUBSOLV SUBLINGUAL TABLET 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

3

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HOUR 150 MG

PV

Antibacterials

AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG

4QL (12 EA

per 30 days)

ALTABAX EXTERNAL OINTMENT 1 %

3

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

2

amoxicillin oral capsule 250 mg, 500 mg

2

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

1

amoxicillin oral tablet 500 mg

2

Drug NameDrug Tier

Notes

amoxicillin oral tablet 875 mg

1

amoxicillin oral tablet chewable 125 mg, 250 mg

2

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

2

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

2

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

2

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

2

ampicillin oral capsule 500 mg

1

ampicillin sodium injection solution reconstituted 1 gm, 10 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, 15 (10-5) gm, 3 (2-1) gm

GM

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

GM



23

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

4

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

4Brand

penalty applies

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

4Brand

penalty applies

AVELOX INTRAVENOUS SOLUTION 400 MG/250ML

GM

AVELOX ORAL TABLET 400 MG

4Brand

penalty applies

avidoxy oral tablet 100 mg

2

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM

GM

AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

azithromycin intravenous solution reconstituted 500 mg

GM

azithromycin oral packet 1 gm

2

Drug NameDrug Tier

Notes

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

2

azithromycin oral tablet 250 mg, 500 mg, 600 mg

2

aztreonam injection solution reconstituted 1 gm, 2 gm

GM

baciim intramuscular solution reconstituted 50000 unit

GM

bacitracin intramuscular solution reconstituted 50000 unit

GM

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

BACTRIM DS ORAL TABLET 800-160 MG

4Brand

penalty applies

BACTRIM ORAL TABLET 400-80 MG

4Brand

penalty applies

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

5Specialty Medical

BAXDELA ORAL TABLET 450 MG

5

benzalkonium chloride external solution , 50 %

2

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

GM

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

GM



24

Drug NameDrug Tier

Notes

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

GM

BUCALSEP EXTERNAL LIQUID

4

BUCALSEP EXTERNAL SOLUTION

4

cefaclor er oral tablet extended release 12 hour 500 mg

2

cefaclor oral capsule 250 mg, 500 mg

2

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

2

cefadroxil oral capsule 500 mg

2

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

2

cefadroxil oral tablet 1 gm

2

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 GM/100ML-%, 2-0.9 GM/50ML-%, 3-0.9 GM/100ML-%

GM

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 GM/10ML-%

GM

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 mg

GM

Drug NameDrug Tier

Notes

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 GM/10ML, 2 GM/20ML, 3 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 2-5 GM/100ML-%, 2-5 GM/50ML-%, 3-5 GM/100ML-%

GM

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

GM

CEFAZOLIN SODIUM-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 GM/10ML-%

GM

cefdinir oral capsule 300 mg

2

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

2

cefditoren pivoxil oral tablet 200 mg, 400 mg

2

cefepime hcl injection solution reconstituted 1 gm, 2 gm

GM

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

GM



25

Drug NameDrug Tier

Notes

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

GM

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

2

CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

cefotaxime sodium injection solution reconstituted 1 gm, 500 mg

GM

cefotetan disodium injection solution reconstituted 1 gm, 10 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

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

2

cefpodoxime proxetil oral tablet 100 mg, 200 mg

2

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

2

Drug NameDrug Tier

Notes

cefprozil oral tablet 250 mg, 500 mg

2

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

cefuroxime axetil oral tablet 250 mg, 500 mg

2

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 %

3

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral capsule 750 mg

2



26

Drug NameDrug Tier

Notes

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

2

cephalexin oral tablet 250 mg, 500 mg

2

chloramphenicol sod succinate intravenous solution reconstituted 1 gm

GM

CIPRO IN D5W INTRAVENOUS SOLUTION 400 MG/200ML

GM

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

3

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

3Brand

penalty applies

CIPRO ORAL TABLET 250 MG, 500 MG

4Brand

penalty applies

ciprofloxacin hcl oral tablet 100 mg, 750 mg

2

ciprofloxacin hcl oral tablet 250 mg, 500 mg

1

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

GM

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

2

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

2

clarithromycin er oral tablet extended release 24 hour 500 mg

2

Drug NameDrug Tier

Notes

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

2

clarithromycin oral tablet 250 mg, 500 mg

2

CLEOCIN ORAL CAPSULE 150 MG, 300 MG

4Brand

penalty applies

CLEOCIN ORAL CAPSULE 75 MG

3Brand

penalty applies

CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML

4Brand

penalty applies

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

GM

CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2ML, 600 MG/4ML, 900 MG/6ML

GM

CLEOCIN VAGINAL CREAM 2 %

4Brand

penalty applies

CLEOCIN VAGINAL SUPPOSITORY 100 MG

3

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

2

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

2

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

GM



27

Drug NameDrug Tier

Notes

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

GM

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

GM

clindamycin phosphate vaginal cream 2 %

2

CLINDESSE VAGINAL CREAM 2 %

4

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

6Specialty Medical

DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

GM

daptomycin intravenous solution reconstituted 500 mg

GM

Drug NameDrug Tier

Notes

demeclocycline hcl oral tablet 150 mg, 300 mg

2

dicloxacillin sodium oral capsule 250 mg, 500 mg

2

DIFICID ORAL TABLET 200 MG

4 ST

DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

doxy 100 intravenous solution reconstituted 100 mg

GM

doxycycline hyclate intravenous solution reconstituted 100 mg

GM

doxycycline hyclate oral capsule 100 mg, 50 mg

2

doxycycline hyclate oral tablet 100 mg, 20 mg

2

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

2

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

2

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

2

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

2

e.e.s. 400 oral tablet 400 mg

2

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

3Brand

penalty applies

ertapenem sodium injection solution reconstituted 1 gm

2



28

Drug NameDrug Tier

Notes

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

3Brand

penalty applies

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

3

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

4

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ERYTHROCIN STEARATE ORAL TABLET 250 MG

4

erythromycin base oral capsule delayed release particles 250 mg

2

erythromycin base oral tablet 250 mg, 500 mg

2

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml

2

erythromycin ethylsuccinate oral tablet 400 mg

2

FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML

4

FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML

4

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

4

Drug NameDrug Tier

Notes

FLAGYL ORAL CAPSULE 375 MG

4Brand

penalty applies

FLAGYL ORAL TABLET 250 MG, 500 MG

4Brand

penalty applies

FURADANTIN ORAL SUSPENSION 25 MG/5ML

4Brand

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 %

2

gentamicin sulfate external ointment 0.1 %

2

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

GM

HIPREX ORAL TABLET 1 GM

4Brand

penalty applies

hydrogen peroxide solution 30 %

2

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

GM

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

4Brand

penalty applies

iodine tincture external tincture 2 %

2

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG

4Brand

penalty applies

LEVAQUIN ORAL TABLET 500 MG, 750 MG

4Brand

penalty applies



29

Drug NameDrug Tier

Notes

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

2

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

2

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-%

5Specialty Medical

linezolid intravenous solution 600 mg/300ml

5Specialty Medical

linezolid oral suspension reconstituted 100 mg/5ml

5QL (900

ML per 30 days)

linezolid oral tablet 600 mg

5QL (60 EA

per 30 days)

lugols external solution 2

MACROBID ORAL CAPSULE 100 MG

4Brand

penalty applies

MACRODANTIN ORAL CAPSULE 100 MG, 50 MG

4Brand

penalty applies

MACRODANTIN ORAL CAPSULE 25 MG

3Brand

penalty applies

mafenide acetate external packet 5 %

2

MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

Drug NameDrug Tier

Notes

MAXIPIME INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

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

2

methenamine mandelate oral tablet 0.5 gm, 1 gm

2

METROGEL-VAGINAL VAGINAL GEL 0.75 %

4Brand

penalty applies

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

GM

METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/100ML-%

GM

METRONIDAZOLE INTRAVENOUS SOLUTION 5 MG/ML

GM

metronidazole oral capsule 375 mg

2

metronidazole oral tablet 250 mg, 500 mg

2

metronidazole vaginal gel 0.75 %

2



30

Drug NameDrug Tier

Notes

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

GM

MINOCIN ORAL CAPSULE 50 MG

4Brand

penalty applies

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

2

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

2

mondoxyne nl oral capsule 100 mg, 50 mg, 75 mg

2

MONUROL ORAL PACKET 3 GM

4

morgidox oral capsule 100 mg, 50 mg

2

moxifloxacin hcl in nacl intravenous solution 400 mg/250ml

GM

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 MG/250ML

GM

moxifloxacin hcl oral tablet 400 mg

2

mupirocin external ointment 2 %

2

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

GM

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

GM

Drug NameDrug Tier

Notes

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

GM

neomycin sulfate oral tablet 500 mg

2

neomycin-polymyxin b gu irrigation solution 40-200000

2

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

2

nitrofurantoin monohydrate macrocrystals oral capsule 100 mg

2

nitrofurantoin oral suspension 25 mg/5ml

2

NUTRIDOX ORAL KIT 75 MG

4

NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6Specialty Medical

NUZYRA ORAL TABLET 150 MG

6QL (30 EA

per 14 days)

ofloxacin oral tablet 300 mg, 400 mg

2

okebo oral capsule 75 mg

2

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 400 MG

5Specialty Medical

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

GM

paromomycin sulfate oral capsule 250 mg

2



31

Drug NameDrug Tier

Notes

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

2

penicillin v potassium oral tablet 250 mg, 500 mg

1

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

polymyxin b sulfate injection solution reconstituted 500000 unit

GM

Drug NameDrug Tier

Notes

PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 500-500 MG

GM

PRIMSOL ORAL SOLUTION 50 MG/5ML

4

SILVADENE EXTERNAL CREAM 1 %

4Brand

penalty applies

silver nitrate external ointment 10 %

2

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

2

silver sulfadiazine external cream 1 %

2

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

6Specialty Medical

SIVEXTRO ORAL TABLET 200 MG

6QL (6 EA

per 30 days)

soloxide oral tablet delayed release 150 mg

2

SPECTRACEF ORAL TABLET 400 MG

4Brand

penalty applies

ssd external cream 1 % 2

streptomycin sulfate intramuscular solution reconstituted 1 gm

GM

sulfadiazine oral tablet 500 mg

2

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

GM

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

2



32

Drug NameDrug Tier

Notes

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

1

SULFAMYLON EXTERNAL CREAM 85 MG/GM

4

SULFAMYLON EXTERNAL PACKET 5 %

4Brand

penalty applies

sulfatrim pediatric oral suspension 200-40 mg/5ml

2

SUPRAX ORAL CAPSULE 400 MG

4

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

4Brand

penalty applies

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

4

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

4

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

GM

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

GM

TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML

GM

tazicef intravenous solution reconstituted 1 gm, 2 gm

GM

Drug NameDrug Tier

Notes

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

GM

tetracycline hcl oral capsule 250 mg, 500 mg

2

tigecycline intravenous solution reconstituted 50 mg

GM

tinidazole oral tablet 250 mg, 500 mg

2

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

2

TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 15 (10-5) GM, 3 (2-1) GM

GM

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM

GM

VANCOCIN HCL ORAL CAPSULE 125 MG, 250 MG

4Brand

penalty applies



33

Drug NameDrug Tier

Notes

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/100ML-%, 1-5 GM/250ML-%, 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%, 1.5-5 GM/300ML-%, 1.5-5 GM/500ML-%, 1.75-5 GM/500ML-%, 2-5 GM/500ML-%

GM

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

GM

vancomycin hcl in dextrose solution 750-5 mg/150ml-% intravenous 750-5 mg/150ml-%

GM

VANCOMYCIN HCL IN DEXTROSE SOLUTION 750-5 MG/150ML-% INTRAVENOUS 750-5 MG/150ML-%

GM

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/150ML-%, 1-0.9 GM/250ML-%, 1.25-0.9 GM/150ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/150ML-%, 1.5-0.9 GM/250ML-%, 1.5-0.9 GM/300ML-%, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-%, 1.75-0.9 GM/500ML-%, 2-0.9 GM/250ML-%, 2-0.9 GM/500ML-%, 2.5-0.9 GM/500ML-%, 750-0.9 MG/250ML-%

GM

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

GM

Drug NameDrug Tier

Notes

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

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 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

2

VANCOSOL PACK INTRAVENOUS KIT 1-0.9 GM-%

GM

vandazole vaginal gel 0.75 %

2

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

GM

VIBRAMYCIN ORAL CAPSULE 100 MG

4Brand

penalty applies

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

4Brand

penalty applies

VIBRAMYCIN ORAL SYRUP 50 MG/5ML

3



34

Drug NameDrug Tier

Notes

XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5Specialty Medical

XIFAXAN ORAL TABLET 200 MG, 550 MG

5 PA

ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML

6Specialty Medical

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM

GM

ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ZITHROMAX ORAL PACKET 1 GM

4

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

4Brand

penalty applies

ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG

4Brand

penalty applies

ZITHROMAX TRI-PAK ORAL TABLET 500 MG

4Brand

penalty applies

ZITHROMAX Z-PAK ORAL TABLET 250 MG

4Brand

penalty applies

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

GM

Drug NameDrug Tier

Notes

ZOSYN INTRAVENOUS SOLUTION RECONSTITUTED 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

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

5Specialty Medical

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

5QL (900

ML per 30 days)

ZYVOX ORAL TABLET 600 MG

5QL (60 EA

per 30 days)

Anticoagulants

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

4

ACD FORMULA B IN VITRO SOLUTION 440-1.47-1.32

4

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

4

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

2

ANTICOAGULANT COMPOUND IN VITRO SOLUTION

4



35

Drug NameDrug Tier

Notes

anticoagulant sodium citrate in vitro solution 4 gm/100ml

2

argatroban in sodium chloride intravenous solution 50 mg/50ml

GM

argatroban intravenous solution 125 mg/125ml, 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

4Brand

penalty applies

BEVYXXA ORAL CAPSULE 40 MG, 80 MG

4QL (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-%

6Specialty Medical

CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 MG

GM

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

3Brand

penalty applies

DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML

GM

ELIQUIS ORAL TABLET 2.5 MG, 5 MG

3

Drug NameDrug Tier

Notes

ELIQUIS STARTER PACK ORAL TABLET 5 MG

3

enoxaparin sodium injection solution 300 mg/3ml

2

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

2

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

2

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

3

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

2

heparin (porcine) in nacl injection solution 100-0.45 unit/ml-%, 50-0.45 unit/ml-%

2



36

Drug NameDrug Tier

Notes

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 100-0.45 UT/100ML-%, 100-0.9 UT/100ML-%, 1000-0.9 UNIT/L-%, 1000-0.9 UT/100ML-%, 1000-0.9 UT/250ML-%, 10000-0.9 UNIT/L-%, 10000-0.9 UT/100ML-%, 10000-0.9 UT/500ML-%, 1250-0.9 UT/250ML-%, 150-0.45 UT/150ML-%, 1500-0.9 UT/150ML-%, 1500-0.9 UT/250ML-%, 15000-0.9 UT/500ML-%, 20000-0.9 UNIT/L-%, 250-0.45 UT/250ML-%, 250-0.9 UT/250ML-%, 2500-0.9 UT/250ML-%, 2500-0.9 UT/500ML-%, 25000-0.9 UT/250ML-%, 25000-0.9 UT/500ML-%, 3000-0.9 UNIT/L-%, 3000-0.9 UT/500ML-%, 4000-0.9 UT/500ML-%, 40000-0.9 UNIT/L-%, 500-0.45 UT/500ML-%, 500-0.9 UT/500ML-%, 5000-0.45 UNIT/L-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%, 6000-0.9 UNIT/L-%, 8000-0.9 UNIT/L-%

GM

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2000-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 4000-0.9 UNIT/L-%, 500-0.45 UT/250ML-%

4

heparin (porcine) in nacl intravenous solution 25000-0.45 ut/250ml-%

2

Drug NameDrug Tier

Notes

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 100-0.9 UNT/50ML-%, 20-0.45 UNT/20ML-%, 4-0.9 UNIT/2ML-%, 50-0.9 UNT/50ML-%

GM

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20-0.9 UNT/20ML-%, 50-0.45 UNT/50ML-%

4

HEPARIN (PORCINE) IN NACL SOLUTION 2-0.9 UNIT/ML-% INJECTION 2-0.9 UNIT/ML-%

4

heparin (porcine) in nacl solution 2-0.9 unit/ml-% injection 2-0.9 unit/ml-%

2

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

GM

HEPARIN (PORCINE) IN NACL SOLUTION 25000-0.45 UT/500ML-% INTRAVENOUS 25000-0.45 UT/500ML-%

GM

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

2

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 10000-5 UT/100ML-%

GM

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 40-5 UNIT/ML-%

4



37

Drug NameDrug Tier

Notes

HEPARIN SOD (PORCINE)-D10 INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-10 UNT/50ML-%

GM

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

2

HEPARIN SODIUM (PORCINE) INTRAVENOUS SOLUTION PREFILLED SYRINGE 10000 UNIT/10ML, 3000 UNIT/3ML, 5000 UNIT/5ML

4

HEPARIN SODIUM (PORCINE) INTRAVENOUS SOLUTION PREFILLED SYRINGE 15000 UNIT/3ML, 6000 UNIT/6ML, 7000 UNIT/7ML

GM

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

2

HEPARIN SODIUM/D5W INTRAVENOUS SOLUTION 50-5 UNIT/ML-%

4

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

2

LOVENOX INJECTION SOLUTION 300 MG/3ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

3

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

4 ST

SODIUM CITRATE IN VITRO SOLUTION PREFILLED SYRINGE 4 %

4

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

TNKASE INTRAVENOUS KIT 50 MG

GM

TRICITRASOL IN VITRO CONCENTRATE 46.7 %

4

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

2

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

3



38

Drug NameDrug Tier

Notes

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

3

Anticonvulsants - Drugs for Seizures

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

4 ST

BANZEL ORAL SUSPENSION 40 MG/ML

4

BANZEL ORAL TABLET 200 MG, 400 MG

4

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

GM ST

BRIVIACT ORAL SOLUTION 10 MG/ML

4 ST

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

4 ST

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

2

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

2

carbamazepine oral suspension 100 mg/5ml

2

carbamazepine oral tablet 200 mg

2

carbamazepine oral tablet chewable 100 mg

2

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

4Brand

penalty applies

CELONTIN ORAL CAPSULE 300 MG

4

Drug NameDrug Tier

Notes

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

GM

clobazam oral suspension 2.5 mg/ml

2

clobazam oral tablet 10 mg, 20 mg

2

DEPACON INTRAVENOUS SOLUTION 100 MG/ML

GM

DEPAKENE ORAL CAPSULE 250 MG

4Brand

penalty applies

DEPAKENE ORAL SOLUTION 250 MG/5ML

4Brand

penalty applies

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

4Brand

penalty applies

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

4Brand

penalty applies

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 125 MG

4Brand

penalty applies

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

4Brand

penalty applies

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG

4Brand

penalty applies

diazepam rectal gel 10 mg, 2.5 mg, 20 mg

2

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

4Brand

penalty applies

DILANTIN ORAL CAPSULE 100 MG

4Brand

penalty applies



39

Drug NameDrug Tier

Notes

DILANTIN ORAL CAPSULE 30 MG

4

DILANTIN ORAL SUSPENSION 125 MG/5ML

4Brand

penalty applies

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

2

divalproex sodium oral capsule delayed release sprinkle 125 mg

2

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

2

epitol oral tablet 200 mg 2

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

4

ethosuximide oral capsule 250 mg

2

ethosuximide oral solution 250 mg/5ml

2

felbamate oral suspension 600 mg/5ml

2

felbamate oral tablet 400 mg, 600 mg

2

FELBATOL ORAL SUSPENSION 600 MG/5ML

3Brand

penalty applies

FELBATOL ORAL TABLET 400 MG, 600 MG

3Brand

penalty applies

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

GM

FYCOMPA ORAL SUSPENSION 0.5 MG/ML

4

Drug NameDrug Tier

Notes

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

4

gabapentin oral capsule 100 mg, 300 mg, 400 mg

2

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

2

gabapentin oral tablet 600 mg, 800 mg

2

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

4Brand

penalty applies

KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML

GM

KEPPRA ORAL SOLUTION 100 MG/ML

4Brand

penalty applies

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

4Brand

penalty applies

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

4Brand

penalty applies

LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 (42)-100(14) MG

4

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

4Brand

penalty applies

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

4Brand

penalty applies

LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG

4Brand

penalty applies



40

Drug NameDrug Tier

Notes

LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-100 (7) MG, 25 (84)-100(14) MG

4Brand

penalty applies

LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG

4

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

4Brand

penalty applies

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

2

lamotrigine oral tablet 100 mg, 150 mg, 200 mg

1

lamotrigine oral tablet 25 mg

2

lamotrigine oral tablet chewable 25 mg, 5 mg

2

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

2

lamotrigine starter kit-blue oral kit 25 (35) mg

2

lamotrigine starter kit-green oral kit 25 (84)-100(14) mg

2

lamotrigine starter kit-orange oral kit 25 (42)-100 (7) mg

2

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

2

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

GM

Drug NameDrug Tier

Notes

levetiracetam intravenous solution 500 mg/5ml

GM

levetiracetam oral solution 100 mg/ml

2

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

2

MYSOLINE ORAL TABLET 250 MG

3Brand

penalty applies

MYSOLINE ORAL TABLET 50 MG

4Brand

penalty applies

NEMBUTAL INJECTION SOLUTION 50 MG/ML

GM

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

4Brand

penalty applies

NEURONTIN ORAL SOLUTION 250 MG/5ML

4Brand

penalty applies

NEURONTIN ORAL TABLET 600 MG, 800 MG

4Brand

penalty applies

ONFI ORAL SUSPENSION 2.5 MG/ML

4Brand

penalty applies

ONFI ORAL TABLET 10 MG, 20 MG

4Brand

penalty applies

oxcarbazepine oral suspension 300 mg/5ml

2

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

2

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

4

PEGANONE ORAL TABLET 250 MG

4



41

Drug NameDrug Tier

Notes

pentobarbital sodium injection solution 50 mg/ml

GM

phenobarbital oral elixir 20 mg/5ml

2

phenobarbital oral solution 20 mg/5ml

2

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

2

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

GM

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

4Brand

penalty applies

phenytoin infatabs oral tablet chewable 50 mg

2

phenytoin oral suspension 125 mg/5ml

2

phenytoin oral tablet chewable 50 mg

2

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

2

phenytoin sodium injection solution 50 mg/ml

GM

primidone oral tablet 250 mg, 50 mg

2

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

4PA; Brand

penalty applies

roweepra oral tablet 1000 mg, 500 mg, 750 mg

2

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

2

Drug NameDrug Tier

Notes

SABRIL ORAL PACKET 500 MG

6 PA

SABRIL ORAL TABLET 500 MG

6 PA

subvenite oral tablet 100 mg, 150 mg, 200 mg

1

subvenite oral tablet 25 mg

2

subvenite starter kit-blue oral kit 25 (35) mg

2

subvenite starter kit-green oral kit 25 (84)-100(14) mg

2

subvenite starter kit-orange oral kit 25 (42)-100 (7) mg

2

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG

4

TEGRETOL ORAL SUSPENSION 100 MG/5ML

4Brand

penalty applies

TEGRETOL ORAL TABLET 200 MG

4Brand

penalty applies

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

4Brand

penalty applies

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

2

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

4Brand

penalty applies

TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 MG

4Brand

penalty applies

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

2 PA



42

Drug NameDrug Tier

Notes

topiramate oral capsule sprinkle 15 mg, 25 mg

2

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

2

TRILEPTAL ORAL SUSPENSION 300 MG/5ML

4Brand

penalty applies

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

4Brand

penalty applies

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

4 PA

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

GM

valproate sodium oral solution 250 mg/5ml

2

valproic acid oral capsule 250 mg

2

valproic acid oral solution 250 mg/5ml

2

vigabatrin oral packet 500 mg

6 PA

vigabatrin oral tablet 500 mg

6 PA

vigadrone oral packet 500 mg

6 PA

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

GM

VIMPAT ORAL SOLUTION 10 MG/ML

4

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

4

ZARONTIN ORAL CAPSULE 250 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

ZARONTIN ORAL SOLUTION 250 MG/5ML

4Brand

penalty applies

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

4Brand

penalty applies

zonisamide oral capsule 100 mg, 25 mg, 50 mg

2

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

ARICEPT ORAL TABLET 23 MG

3Brand

penalty applies

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

2

donepezil hcl oral tablet dispersible 10 mg, 5 mg

2

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

3Brand

penalty applies

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

2

galantamine hydrobromide oral solution 4 mg/ml

2

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

2

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

2

memantine hcl oral solution 2 mg/ml

2



43

Drug NameDrug Tier

Notes

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

2

NAMENDA ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG

4Brand

penalty applies

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

4Brand

penalty applies

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

4

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

4

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

4

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

4Brand

penalty applies

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG

4Brand

penalty applies

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

2

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

2

Drug NameDrug Tier

Notes

Antidepressants

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

2

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

2

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

4Brand

penalty applies

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


days)

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

2

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

2

bupropion hcl oral tablet 100 mg, 75 mg

2

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

4Brand

penalty applies

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

2

citalopram hydrobromide oral solution 10 mg/5ml

2

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

1

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

2

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

4Brand

penalty applies



44

Drug NameDrug Tier

Notes

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

2

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

4 PA

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

2 PA

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

2

doxepin hcl oral concentrate 10 mg/ml

2

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

2

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

4Brand

penalty applies

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

3

escitalopram oxalate oral solution 5 mg/5ml

2

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

2

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

4 PA

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

4

Drug NameDrug Tier

Notes

fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

2

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

1

fluoxetine hcl oral capsule delayed release 90 mg

2

fluoxetine hcl oral solution 20 mg/5ml

2

fluoxetine hcl oral tablet 10 mg, 20 mg

2

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

2

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

2

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

2

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

2

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

4 PA

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG

4Brand

penalty applies

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

2

MARPLAN ORAL TABLET 10 MG

4

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

2

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

2



45

Drug NameDrug Tier

Notes

NARDIL ORAL TABLET 15 MG

4Brand

penalty applies

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

2

NORPRAMIN ORAL TABLET 10 MG, 25 MG

4Brand

penalty applies

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

2

nortriptyline hcl oral solution 10 mg/5ml

2

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

2 PA

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

4Brand

penalty applies

PARNATE ORAL TABLET 10 MG

4Brand

penalty applies

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

2

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

2

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

4Brand

penalty applies

PAXIL ORAL SUSPENSION 10 MG/5ML

3

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

4Brand

penalty applies

Drug NameDrug Tier

Notes

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

2

phenelzine sulfate oral tablet 15 mg

2

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

4PA; Brand

penalty applies

protriptyline hcl oral tablet 10 mg, 5 mg

2

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG

4Brand

penalty applies

REMERON ORAL TABLET 15 MG, 30 MG

4Brand

penalty applies

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

4Brand

penalty applies

sertraline hcl oral concentrate 20 mg/ml

2

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

2

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

4

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

4

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

4Brand

penalty applies

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

4PA; Brand

penalty applies



46

Drug NameDrug Tier

Notes

TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG

4Brand

penalty applies

tranylcypromine sulfate oral tablet 10 mg

2

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

2

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

2

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

4 PA

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

2

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

2

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

4 PA

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

4 PA

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

4Brand

penalty applies

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

4Brand

penalty applies

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG

GM

AKYNZEO ORAL CAPSULE 300-0.5 MG

4QL (3 EA

per 21 days)

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

GM

ANZEMET ORAL TABLET 100 MG, 50 MG

3

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

2QL (6 EA

per 30 days)

BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG

4

CESAMET ORAL CAPSULE 1 MG

4

CINVANTI INTRAVENOUS EMULSION 130 MG/18ML

GMQL (6 ML

per 30 days)

compro rectal suppository 25 mg

2

dimenhydrinate injection solution 50 mg/ml

GM

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

2

droperidol injection solution 2.5 mg/ml

GM

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

GM PA



47

Drug NameDrug Tier

Notes

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

4

Brand penalty


EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

3QL (6 EA

per 30 days)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG

4

Brand penalty


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

GM

granisetron hcl oral tablet 1 mg

2

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

4Brand

penalty applies

meclizine hcl oral tablet 12.5 mg, 25 mg

2

metoclopramide hcl injection solution 5 mg/ml

GM

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

2

metoclopramide hcl oral tablet 10 mg, 5 mg

2

metoclopramide hcl oral tablet dispersible 10 mg, 5 mg

2

ondansetron hcl injection solution 40 mg/20ml

GM

ondansetron hcl oral solution 4 mg/5ml

2

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

2

ONDANSETRON HCL SOLUTION 4 MG/2ML INJECTION 4 MG/2ML

GM

Drug NameDrug Tier

Notes

ondansetron hcl solution 4 mg/2ml injection 4 mg/2ml

GM

ONDANSETRON HCL-DEXTROSE INTRAVENOUS SOLUTION 8-5 MG/50ML-%

GM

ONDANSETRON HCL-NACL INTRAVENOUS SOLUTION 4-0.9 MG/50ML-%

GM

ondansetron odt oral tablet dispersible 4 mg, 8 mg

2

palonosetron hcl intravenous solution 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

2

prochlorperazine edisylate injection solution 5 mg/ml

GM

prochlorperazine maleate oral tablet 10 mg, 5 mg

2

prochlorperazine rectal suppository 25 mg

2

REGLAN ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR

3QL (1 EA

per 30 days)

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 MG/0.4ML

6QL (2 ML

per 30 days)

SYNDROS ORAL SOLUTION 5 MG/ML

4



48

Drug NameDrug Tier

Notes

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML

GM

TIGAN ORAL CAPSULE 300 MG

4Brand

penalty applies

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

4

trimethobenzamide hcl oral capsule 300 mg

2

VARUBI INTRAVENOUS EMULSION 166.5 MG/92.5ML

GM

VARUBI ORAL TABLET 90 MG

4QL (2 EA

per 30 days)

ZOFRAN ORAL TABLET 4 MG, 8 MG

4Brand

penalty applies

ZUPLENZ ORAL FILM 4 MG, 8 MG

4

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

GM

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

GM

amphotericin b injection solution reconstituted 50 mg

GM

ANCOBON ORAL CAPSULE 250 MG, 500 MG

4Brand

penalty applies

AVC VAGINAL VAGINAL CREAM 15 %

4

BIO-STATIN ORAL CAPSULE 1000000 UNIT, 500000 UNIT

4

Drug NameDrug Tier

Notes

bio-statin oral powder 2

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG

GM

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

GM

ciclodan external solution 8 %

2QL (13.2

ML per 30 days)

CICLODAN SOLUTION EXTERNAL KIT 8 %

4Brand

penalty applies

ciclopirox external gel 0.77 %

2

ciclopirox external shampoo 1 %

2

ciclopirox external solution 8 %

2QL (13.2

ML per 30 days)

ciclopirox olamine external cream 0.77 %

2

ciclopirox olamine external suspension 0.77 %

2

ciclopirox treatment external kit 8 %

2

clotrimazole external cream 1 %

2

clotrimazole external solution 1 %

2

clotrimazole mouth/throat lozenge 10 mg

2

clotrimazole mouth/throat troche 10 mg

2



49

Drug NameDrug Tier

Notes

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG

GM

CRESEMBA ORAL CAPSULE 186 MG

6 PA

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

4Brand

penalty applies

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

4Brand

penalty applies

econazole nitrate external cream 1 %

2

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ERTACZO EXTERNAL CREAM 2 %

4 ST

EXELDERM EXTERNAL CREAM 1 %

4 ST

EXELDERM EXTERNAL SOLUTION 1 %

4

EXODERM EXTERNAL LOTION 25-1 %

4

EXTINA EXTERNAL FOAM 2 %

4Brand

penalty applies

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

GM

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

2

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

2

Drug NameDrug Tier

Notes

flucytosine oral capsule 250 mg, 500 mg

2

FUNGIMEZ EXTERNAL SOLUTION

4

griseofulvin microsize oral suspension 125 mg/5ml

2

griseofulvin microsize oral tablet 500 mg

2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

2

GYNAZOLE-1 VAGINAL CREAM 2 %

4

itraconazole oral capsule 100 mg

2

itraconazole oral solution 10 mg/ml

2

JUBLIA EXTERNAL SOLUTION 10 %

4 PA

KERYDIN EXTERNAL SOLUTION 5 %

4 PA

ketoconazole external cream 2 %

2

ketoconazole external foam 2 %

2

ketoconazole external shampoo 2 %

2

ketoconazole oral tablet 200 mg

2

LOPROX EXTERNAL CREAM 0.77 %

4Brand

penalty applies

LOPROX EXTERNAL KIT 0.77 %

4 PA

LOPROX EXTERNAL SHAMPOO 1 %

4Brand

penalty applies

LOPROX EXTERNAL SUSPENSION 0.77 %

4Brand

penalty applies



50

Drug NameDrug Tier

Notes

LULICONAZOLE EXTERNAL CREAM 1 %

4 ST

LUZU EXTERNAL CREAM 1 %

4 ST

MENTAX EXTERNAL CREAM 1 %

4 PA

miconazole 3 vaginal suppository 200 mg

2

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

4

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

naftifine hcl external cream 1 %, 2 %

2 ST

NAFTIN EXTERNAL CREAM 2 %

4ST; Brand

penalty applies

NAFTIN EXTERNAL GEL 1 %, 2 %

4

NIZORAL EXTERNAL SHAMPOO 2 %

4Brand

penalty applies

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML

6PA;

Specialty Medical

NOXAFIL ORAL SUSPENSION 40 MG/ML

6 PA

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

6 PA

nystatin external cream 100000 unit/gm

2

nystatin external ointment 100000 unit/gm

2

Drug NameDrug Tier

Notes

nystatin external powder 100000 unit/gm

2

nystatin mouth/throat suspension 100000 unit/ml

2

nystatin oral tablet 500000 unit

2

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

2

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

2

nystop external powder 100000 unit/gm

2

ORAVIG BUCCAL TABLET 50 MG

4

oxiconazole nitrate external cream 1 %

2 ST

OXISTAT EXTERNAL CREAM 1 %

4ST; Brand

penalty applies

OXISTAT EXTERNAL LOTION 1 %

4 ST

PENLAC EXTERNAL SOLUTION 8 %

4

Brand penalty

applies; QL (13.2 ML per 30 days)

RECURA EXTERNAL CREAM

4

SPORANOX ORAL CAPSULE 100 MG

4Brand

penalty applies

SPORANOX ORAL SOLUTION 10 MG/ML

4Brand

penalty applies

SPORANOX PULSEPAK ORAL CAPSULE 100 MG

4Brand

penalty applies



51

Drug NameDrug Tier

Notes

terbinafine hcl oral tablet 250 mg

2

terconazole vaginal cream 0.4 %, 0.8 %

2

terconazole vaginal suppository 80 mg

2

VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

5PA;

Specialty Medical

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML

6 PA

VFEND ORAL TABLET 200 MG, 50 MG

6 PA

voriconazole intravenous solution reconstituted 200 mg

5PA;

Specialty Medical

voriconazole oral suspension reconstituted 40 mg/ml

5 PA

voriconazole oral tablet 200 mg, 50 mg

5 PA

VUSION EXTERNAL OINTMENT 0.25-15-81.35 %

4

XOLEGEL COREPAK EXTERNAL KIT 2 & 1 %

4

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

4

XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 %

4

XOLEGEL EXTERNAL GEL 2 %

4

Antigout Agents

allopurinol oral tablet 100 mg, 300 mg

1

Drug NameDrug Tier

Notes

allopurinol sodium intravenous solution reconstituted 500 mg

GM

ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

COLCHICINE ORAL CAPSULE 0.6 MG

4

COLCHICINE ORAL TABLET 0.6 MG

3

colchicine-probenecid oral tablet 0.5-500 mg

2

COLCRYS ORAL TABLET 0.6 MG

3

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG

4 PA

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML

6PA;

Specialty Medical

MITIGARE ORAL CAPSULE 0.6 MG

4

probenecid oral tablet 500 mg

2

ULORIC ORAL TABLET 40 MG, 80 MG

4

ZURAMPIC ORAL TABLET 200 MG

4 PA

ZYLOPRIM ORAL TABLET 100 MG, 300 MG

4Brand

penalty applies

Anti-inflammatory Agents

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

6 PA

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

6 PA



52

Drug NameDrug Tier

Notes

Antimigraine Agents

AIMOVIG4

PA; QL (1 ML per 28

days)

AIMOVIG4

PA; QL (2 ML per 28

days)

almotriptan malate oral tablet 12.5 mg, 6.25 mg

2QL (9 EA

per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG

4

Brand penalty


CAFERGOT ORAL TABLET 1-100 MG

4Brand

penalty applies

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

2PA; QL (8 ML per 30

days)

eletriptan hydrobromide oral tablet 20 mg, 40 mg

2QL (9 EA

per 30 days)

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

4

ergotamine-caffeine oral tablet 1-100 mg

2

FROVA ORAL TABLET 2.5 MG

4

Brand penalty


frovatriptan succinate oral tablet 2.5 mg

2QL (9 EA

per 30 days)

Drug NameDrug Tier

Notes

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

3

Brand penalty


IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG

4

Brand penalty


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

4

Brand penalty

applies; QL (2 ML per 30 days)

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

4

Brand penalty


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML

4

Brand penalty


MAXALT ORAL TABLET 10 MG

4

Brand penalty


MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG, 5 MG

4

Brand penalty


MIGERGOT RECTAL SUPPOSITORY 2-100 MG

4

MIGRANAL NASAL SOLUTION 4 MG/ML

4

PA; Brand penalty




53

Drug NameDrug Tier

Notes

naratriptan hcl oral tablet 1 mg, 2.5 mg

2QL (9 EA

per 30 days)

RELPAX ORAL TABLET 20 MG, 40 MG

4

Brand penalty


rizatriptan benzoate oral tablet 10 mg, 5 mg

2QL (12 EA

per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

2QL (12 EA

per 30 days)

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

2QL (6 EA

per 30 days)

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

2QL (9 EA

per 30 days)

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

2QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

2QL (2 ML

per 30 days)

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

2QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

2QL (2 ML

per 30 days)

zolmitriptan oral tablet 2.5 mg, 5 mg

2QL (9 EA

per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg

2QL (9 EA

per 30 days)

Drug NameDrug Tier

Notes

ZOMIG NASAL SOLUTION 2.5 MG, 5 MG

4QL (6 EA

per 30 days)

ZOMIG ORAL TABLET 2.5 MG, 5 MG

4

Brand penalty


ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG

4

Brand penalty


Antimyasthenic Agents

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

GM

GUANIDINE HCL ORAL TABLET 125 MG

4

MESTINON ORAL SYRUP 60 MG/5ML

3Brand

penalty applies

MESTINON ORAL TABLET 60 MG

4Brand

penalty applies

MESTINON ORAL TABLET EXTENDED RELEASE 180 MG

3Brand

penalty applies

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

GM

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

GM

pyridostigmine bromide er oral tablet extended release 180 mg

2



54

Drug NameDrug Tier

Notes

pyridostigmine bromide oral solution 60 mg/5ml

2

pyridostigmine bromide oral tablet 60 mg

2

REGONOL INTRAVENOUS SOLUTION 10 MG/2ML

GM

Antimycobacterials

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

GM

cycloserine oral capsule 250 mg

2

dapsone oral tablet 100 mg, 25 mg

2

ethambutol hcl oral tablet 100 mg, 400 mg

2

isoniazid injection solution 100 mg/ml

GM

isoniazid oral syrup 50 mg/5ml

2

isoniazid oral tablet 100 mg, 300 mg

2

MYAMBUTOL ORAL TABLET 100 MG, 400 MG

4Brand

penalty applies

MYCOBUTIN ORAL CAPSULE 150 MG

3Brand

penalty applies

PASER ORAL PACKET 4 GM

4

PRIFTIN ORAL TABLET 150 MG

4

pyrazinamide oral tablet 500 mg

2

rifabutin oral capsule 150 mg

2

RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

GM

Drug NameDrug Tier

Notes

RIFADIN ORAL CAPSULE 150 MG, 300 MG

4Brand

penalty applies

RIFAMATE ORAL CAPSULE 150-300 MG

4

rifampin intravenous solution reconstituted 600 mg

GM

rifampin oral capsule 150 mg, 300 mg

2

RIFATER ORAL TABLET 50-120-300 MG

4

SIRTURO ORAL TABLET 100 MG

6 PA

TRECATOR ORAL TABLET 250 MG

4

Antineoplastics - Drugs for Cancer

abiraterone acetate oral tablet 250 mg

5 PA

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG

6PA;

Specialty Medical

ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

adriamycin intravenous solution 2 mg/ml

GM PA

adriamycin intravenous solution reconstituted 10 mg, 50 mg

GM PA

adrucil intravenous solution 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

GM PA

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

6 PA



55

Drug NameDrug Tier

Notes

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

6 PA

ALECENSA ORAL CAPSULE 150 MG

6 PA

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG

6PA;

Specialty Medical

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG

6PA;

Specialty Medical

ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

ALKERAN ORAL TABLET 2 MG

3PA; Brand

penalty applies

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

6 PA

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG

6 PA

anastrozole oral tablet 1 mg

2

ARIMIDEX ORAL TABLET 1 MG

4Brand

penalty applies

AROMASIN ORAL TABLET 25 MG

4Brand

penalty applies

ARRANON INTRAVENOUS SOLUTION 5 MG/ML

6PA;

Specialty Medical

arsenic trioxide intravenous solution 10 mg/10ml

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

azacitidine injection suspension reconstituted 100 mg

6PA;

Specialty Medical

AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML

GM

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

6PA;

Specialty Medical

BENDAMUSTINE HCL INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG

6PA;

Specialty Medical

bexarotene oral capsule 75 mg

6 PA

bicalutamide oral tablet 50 mg

2



56

Drug NameDrug Tier

Notes

BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

bleomycin sulfate injection solution reconstituted 15 unit, 30 unit

6PA;

Specialty Medical

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG

6PA;

Specialty Medical

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3.5 MG

6PA;

Specialty Medical

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG


days)

BRAFTOVI ORAL CAPSULE 50 MG, 75 MG

6 PA

busulfan intravenous solution 6 mg/ml

6PA;

Specialty Medical

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML

6PA;

Specialty Medical

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

6 PA

CALQUENCE ORAL CAPSULE 100 MG

6 PA

CAMPATH INTRAVENOUS SOLUTION 30 MG/ML

6PA;

Specialty Medical

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

GM PA

Drug NameDrug Tier

Notes

capecitabine oral tablet 150 mg, 500 mg

4 PA

CAPRELSA ORAL TABLET 100 MG, 300 MG

6 PA

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

GM PA

carmustine intravenous solution reconstituted 100 mg

6PA;

Specialty Medical

CASODEX ORAL TABLET 50 MG

4Brand

penalty applies

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

GM PA

cladribine intravenous solution 10 mg/10ml

6PA;

Specialty Medical

clofarabine intravenous solution 1 mg/ml

6PA;

Specialty Medical

CLOLAR INTRAVENOUS SOLUTION 1 MG/ML

6PA;

Specialty Medical

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

6 PA

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

6 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

6 PA

COPIKTRA ORAL CAPSULE 15 MG, 25 MG

6 PA



57

Drug NameDrug Tier

Notes

COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG

6PA;

Specialty Medical

COTELLIC ORAL TABLET 20 MG

6 PA

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

6PA;

Specialty Medical

cyclophosphamide oral capsule 25 mg, 50 mg

2 PA

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

cytarabine injection solution 20 mg/ml

6PA;

Specialty Medical

dacarbazine intravenous solution reconstituted 100 mg, 200 mg

6PA;

Specialty Medical

DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

dactinomycin intravenous solution reconstituted 0.5 mg

6PA;

Specialty Medical

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

6PA;

Specialty Medical

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

GM PA

DAURISMO ORAL TABLET 100 MG, 25 MG

6 PA

Drug NameDrug Tier

Notes

decitabine intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

dexrazoxane intravenous solution reconstituted 250 mg, 500 mg

GM

docetaxel (non-alcohol) intravenous solution 160 mg/8ml, 20 mg/ml, 80 mg/4ml

6PA;

Specialty Medical

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

6PA;

Specialty Medical

docetaxel intravenous concentrate 200 mg/10ml

GM PA

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

6PA;

Specialty Medical

DOXIL INTRAVENOUS INJECTABLE 2 MG/ML

6PA;

Specialty Medical

doxorubicin hcl intravenous solution 2 mg/ml

GM PA

doxorubicin hcl liposomal intravenous injectable 2 mg/ml

6PA;

Specialty Medical

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

4

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG

6Specialty Medical

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

6PA;

Specialty Medical

ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML

6PA;

Specialty Medical



58

Drug NameDrug Tier

Notes

EMCYT ORAL CAPSULE 140 MG

3 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG

6PA;

Specialty Medical

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

ERIVEDGE ORAL CAPSULE 150 MG

6 PA

ERLEADA ORAL TABLET 60 MG

6 PA

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT

6PA;

Specialty Medical

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

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

GM PA

etoposide oral capsule 50 mg

2 PA

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

exemestane oral tablet 25 mg

2

FARESTON ORAL TABLET 60 MG

3PA; Brand

penalty applies

Drug NameDrug Tier

Notes

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

6 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

6PA;

Specialty Medical

FEMARA ORAL TABLET 2.5 MG

4Brand

penalty applies

floxuridine injection solution reconstituted 0.5 gm

6PA;

Specialty Medical

fludarabine phosphate intravenous solution 50 mg/2ml

6PA;

Specialty Medical

fludarabine phosphate intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

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

GM PA

flutamide oral capsule 125 mg

2 PA

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

6PA;

Specialty Medical

FUSILEV INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML

6PA;

Specialty Medical

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

GM



59

Drug NameDrug Tier

Notes

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

6 PA

GLEEVEC ORAL TABLET 100 MG


days)

GLEEVEC ORAL TABLET 400 MG


days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

6 PA

GLIADEL WAFER IMPLANT WAFER 7.7 MG

GM

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML

6PA;

Specialty Medical

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG

6PA;

Specialty Medical

HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 MG

GM PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

4 PA

HYDREA ORAL CAPSULE 500 MG

4Brand

penalty applies

hydroxyurea oral capsule 500 mg

2

Drug NameDrug Tier

Notes

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

6 PA

ICLUSIG ORAL TABLET 15 MG, 45 MG


days)

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

IDHIFA ORAL TABLET 100 MG, 50 MG

6 PA

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 GM

6PA;

Specialty Medical

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

6PA;

Specialty Medical

ifosfamide intravenous solution reconstituted 1 gm, 3 gm

6PA;

Specialty Medical

imatinib mesylate oral tablet 100 mg


days)

imatinib mesylate oral tablet 400 mg


days)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

6 PA

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

6 PA

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

6PA;

Specialty Medical



60

Drug NameDrug Tier

Notes

INLYTA ORAL TABLET 1 MG, 5 MG

6 PA

IRESSA ORAL TABLET 250 MG

6 PA

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

GM PA

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 MG, 45 MG

6PA;

Specialty Medical

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

6 PA

JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML

6PA;

Specialty Medical

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG

6PA;

Specialty Medical

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 175 MG, 300 MG

6PA;

Specialty Medical

KISQALI 200 DOSE ORAL TABLET 200 MG

6 PA


6 PA


6 PA

Drug NameDrug Tier

Notes

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG

6 PA

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

6 PA

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

6 PA

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

6 PA


6 PA

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

6 PA

LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 MG

6 PA


6 PA

letrozole oral tablet 2.5 mg

2

leucovorin calcium injection solution 500 mg/50ml

6PA;

Specialty Medical



61

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

2

LEUKERAN ORAL TABLET 2 MG

3 PA

levoleucovorin calcium intravenous solution 175 mg/17.5ml

6PA;

Specialty Medical

LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION RECONSTITUTED 175 MG

6PA;

Specialty Medical

levoleucovorin calcium intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

levoleucovorin calcium pf intravenous solution 250 mg/25ml

6PA;

Specialty Medical

LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML

6PA;

Specialty Medical

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

6 PA

LORBRENA ORAL TABLET 100 MG, 25 MG

6 PA

LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

6PA;

Specialty Medical

LYNPARZA ORAL TABLET 100 MG, 150 MG

6 PA

LYSODREN ORAL TABLET 500 MG

3 PA

Drug NameDrug Tier

Notes

MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML

6PA;

Specialty Medical

MATULANE ORAL CAPSULE 50 MG

6 PA

MEKINIST ORAL TABLET 0.5 MG, 2 MG

6 PA

MEKTOVI ORAL TABLET 15 MG

6 PA

melphalan hcl intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

melphalan oral tablet 2 mg

2 PA

mercaptopurine oral tablet 50 mg

2

mesna intravenous solution 100 mg/ml

6Specialty Medical

MESNEX INTRAVENOUS SOLUTION 100 MG/ML

6Specialty Medical

MESNEX ORAL TABLET 400 MG

3

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

6Specialty Medical

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

GM PA

MYLERAN ORAL TABLET 2 MG

3



62

Drug NameDrug Tier

Notes

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

6PA;

Specialty Medical

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

6PA;

Specialty Medical

NERLYNX ORAL TABLET 40 MG

6 PA

NEXAVAR ORAL TABLET 200 MG

6 PA

NILANDRON ORAL TABLET 150 MG

3Brand

penalty applies

nilutamide oral tablet 150 mg

2

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

6 PA

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

ODOMZO ORAL CAPSULE 200 MG

6 PA

ONCASPAR INJECTION SOLUTION 750 UNIT/ML

6PA;

Specialty Medical

ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML

6PA;

Specialty Medical

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

6PA;

Specialty Medical

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

GM PA

Drug NameDrug Tier

Notes

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

6PA;

Specialty Medical

PANRETIN EXTERNAL GEL 0.1 %

4

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML

6PA;

Specialty Medical

PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 75 MG

6PA;

Specialty Medical

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

6 PA

PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML

6PA;

Specialty Medical

POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML

6PA;

Specialty Medical

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT

6PA;

Specialty Medical

PURIXAN ORAL SUSPENSION 2000 MG/100ML

4

QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML

6Specialty Medical

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

6 PA



63

Drug NameDrug Tier

Notes

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

ROMIDEPSIN INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

6 PA

RYDAPT ORAL CAPSULE 25 MG

6 PA

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

6 PA

STIVARGA ORAL TABLET 40 MG

6 PA

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

6 PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

6PA;

Specialty Medical

SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 400 MG

6PA;

Specialty Medical

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

6 PA

TABLOID ORAL TABLET 40 MG

3

Drug NameDrug Tier

Notes

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

6 PA

TAGRISSO ORAL TABLET 40 MG, 80 MG

6 PA

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG

6 PA

tamoxifen citrate oral tablet 10 mg, 20 mg

PV

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

6 PA

TARGRETIN EXTERNAL GEL 1 %

6 PA

TARGRETIN ORAL CAPSULE 75 MG

6 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG


days)

TASIGNA ORAL CAPSULE 50 MG

4

TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ML, 80 MG/4ML

6PA;

Specialty Medical

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML

6PA;

Specialty Medical

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

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

6 PA

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

5 PA



64

Drug NameDrug Tier

Notes

teniposide intravenous solution 10 mg/ml

6PA;

Specialty Medical

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG

6PA;

Specialty Medical

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

6 PA

thiotepa injection solution reconstituted 15 mg

6PA;

Specialty Medical

TIBSOVO ORAL TABLET 250 MG

6 PA

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

2 PA

TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 25 MG

6PA;

Specialty Medical

tretinoin oral capsule 10 mg

2 PA

TYKERB ORAL TABLET 250 MG

6 PA

Drug NameDrug Tier

Notes

UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML

6PA;

Specialty Medical

VALCHLOR EXTERNAL GEL 0.016 %

6 PA

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML

6PA;

Specialty Medical

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

6PA;

Specialty Medical

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

6PA;

Specialty Medical

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

6 PA

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

6 PA

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

6 PA

VIDAZA INJECTION SUSPENSION RECONSTITUTED 100 MG

6PA;

Specialty Medical

vinblastine sulfate intravenous solution 1 mg/ml

6PA;

Specialty Medical

vincasar pfs intravenous solution 1 mg/ml

GM PA

vincristine sulfate intravenous solution 1 mg/ml

GM PA

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

6PA;

Specialty Medical



65

Drug NameDrug Tier

Notes

VITRAKVI ORAL CAPSULE 100 MG, 25 MG

6 PA

VITRAKVI ORAL SOLUTION 20 MG/ML

6 PA

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG

6 PA

VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

GM

VOTRIENT ORAL TABLET 200 MG

6 PA

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

6PA;

Specialty Medical

XALKORI ORAL CAPSULE 200 MG, 250 MG

6 PA

XELODA ORAL TABLET 150 MG, 500 MG

6 PA

XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML

6PA;

Specialty Medical

XOSPATA ORAL TABLET 40 MG

6 PA

XTANDI ORAL CAPSULE 40 MG

6 PA

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

6PA;

Specialty Medical

YESCARTA INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

YONSA ORAL TABLET 125 MG

6 PA

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

6PA;

Specialty Medical

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

6PA;

Specialty Medical

ZEJULA ORAL CAPSULE 100 MG

6 PA

ZELBORAF ORAL TABLET 240 MG

6 PA

ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML

6Specialty Medical

ZINECARD INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

ZOLINZA ORAL CAPSULE 100 MG

6 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG

6 PA

ZYKADIA ORAL CAPSULE 150 MG

6 PA

ZYTIGA ORAL TABLET 250 MG, 500 MG

6 PA

Antiparasitics

albendazole oral tablet 200 mg

2

ALBENZA ORAL TABLET 200 MG

4Brand

penalty applies

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

4

ALINIA ORAL TABLET 500 MG

4



66

Drug NameDrug Tier

Notes

ARAKODA ORAL TABLET 100 MG

3

atovaquone oral suspension 750 mg/5ml

2

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

2

BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG

4

BILTRICIDE ORAL TABLET 600 MG

4Brand

penalty applies

chloroquine phosphate oral tablet 250 mg, 500 mg

2

COARTEM ORAL TABLET 20-120 MG

3

crotan external lotion 10 %

2 ST

DARAPRIM ORAL TABLET 25 MG

6

ELIMITE EXTERNAL CREAM 5 %

4Brand

penalty applies

EMVERM ORAL TABLET CHEWABLE 100 MG

4

EURAX EXTERNAL CREAM 10 %

3 ST

EURAX EXTERNAL LOTION 10 %

4ST; Brand

penalty applies

hydroxychloroquine sulfate oral tablet 200 mg

2

IMPAVIDO ORAL CAPSULE 50 MG

4

ivermectin oral tablet 3 mg

2

KRINTAFEL ORAL TABLET 150 MG

3QL (2 EA

per 30 days)

Drug NameDrug Tier

Notes

lindane external shampoo 1 %

2

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

4Brand

penalty applies

malathion external lotion 0.5 %

2

mefloquine hcl oral tablet 250 mg

2

MEPRON ORAL SUSPENSION 750 MG/5ML

3Brand

penalty applies

NATROBA EXTERNAL SUSPENSION 0.9 %

4Brand

penalty applies

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

4

OVIDE EXTERNAL LOTION 0.5 %

4Brand

penalty applies

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

GM

permethrin external cream 5 %

2

PLAQUENIL ORAL TABLET 200 MG

4Brand

penalty applies

praziquantel oral tablet 600 mg

2

primaquine phosphate tablet 26.3 mg oral 26.3 mg

2

primaquine phosphate tablet 26.3 mg oral 26.3 mg

2Brand

penalty applies

QUALAQUIN ORAL CAPSULE 324 MG

4Brand

penalty applies



67

Drug NameDrug Tier

Notes

quinine sulfate oral capsule 324 mg

2

SKLICE EXTERNAL LOTION 0.5 %

4

SOLOSEC ORAL PACKET 2 GM

4

spinosad external suspension 0.9 %

2

STROMECTOL ORAL TABLET 3 MG

4Brand

penalty applies

sulfurated lime external solution

2

ULESFIA EXTERNAL LOTION 5 %

4

Antiparkinson Agents

amantadine hcl oral capsule 100 mg

2

amantadine hcl oral syrup 50 mg/5ml

2

amantadine hcl oral tablet 100 mg

2

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

6 PA

AZILECT ORAL TABLET 0.5 MG, 1 MG

4Brand

penalty applies

benztropine mesylate injection solution 1 mg/ml

GM

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

1

bromocriptine mesylate oral capsule 5 mg

2

bromocriptine mesylate oral tablet 2.5 mg

2

carbidopa oral tablet 25 mg

2

Drug NameDrug Tier

Notes

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

2

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

2

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

2

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

2

COGENTIN INJECTION SOLUTION 1 MG/ML

GM

COMTAN ORAL TABLET 200 MG

4Brand

penalty applies

entacapone oral tablet 200 mg

2

INBRIJA INHALATION CAPSULE 42 MG

4

LODOSYN ORAL TABLET 25 MG

4Brand

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

4Brand

penalty applies

MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

4Brand

penalty applies



68

Drug NameDrug Tier

Notes

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

4

PARLODEL ORAL CAPSULE 5 MG

4Brand

penalty applies

PARLODEL ORAL TABLET 2.5 MG

4Brand

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

2

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

2

rasagiline mesylate oral tablet 0.5 mg, 1 mg

2

REQUIP ORAL TABLET 5 MG

4Brand

penalty applies

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 2 MG, 4 MG, 8 MG

4Brand

penalty applies

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

2

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

2

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

4

Drug NameDrug Tier

Notes

selegiline hcl oral capsule 5 mg

2

selegiline hcl oral tablet 5 mg

2

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG

4Brand

penalty applies

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

4Brand

penalty applies

STALEVO 100 ORAL TABLET 25-100-200 MG

4Brand

penalty applies

STALEVO 125 ORAL TABLET 31.25-125-200 MG

4Brand

penalty applies


4Brand

penalty applies

STALEVO 200 ORAL TABLET 50-200-200 MG

4Brand

penalty applies


4Brand

penalty applies


4Brand

penalty applies

TASMAR ORAL TABLET 100 MG

4Brand

penalty applies

tolcapone oral tablet 100 mg

2

trihexyphenidyl hcl oral elixir 0.4 mg/ml

2

trihexyphenidyl hcl oral tablet 2 mg, 5 mg

2

XADAGO ORAL TABLET 100 MG, 50 MG

4



69

Drug NameDrug Tier

Notes

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG

4

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

4Brand

penalty applies

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

2

BRILINTA ORAL TABLET 60 MG, 90 MG

3

cilostazol oral tablet 100 mg, 50 mg

2

clopidogrel bisulfate oral tablet 300 mg

2

clopidogrel bisulfate oral tablet 75 mg

1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

2

EFFIENT ORAL TABLET 10 MG, 5 MG

4PA; Brand

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

Drug NameDrug Tier

Notes

KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

PLAVIX ORAL TABLET 75 MG

4Brand

penalty applies

prasugrel hcl oral tablet 10 mg, 5 mg

2 PA

REOPRO INTRAVENOUS SOLUTION 2 MG/ML

GM

ZONTIVITY ORAL TABLET 2.08 MG

4 ST

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

5

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

5

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

4

Brand penalty


ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG

GM

aripiprazole oral solution 1 mg/ml

2

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

2QL (30 EA

per 30 days)

aripiprazole oral tablet dispersible 10 mg, 15 mg

2QL (30 EA

per 30 days)



70

Drug NameDrug Tier

Notes

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML

5

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

5

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

2

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

2

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

2

CLOZARIL ORAL TABLET 100 MG, 25 MG

4Brand

penalty applies

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

4 PA

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

4 PA

FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG

4Brand

penalty applies

fluphenazine decanoate injection solution 25 mg/ml

GM

fluphenazine hcl injection solution 2.5 mg/ml

GM

Drug NameDrug Tier

Notes

fluphenazine hcl oral concentrate 5 mg/ml

2

fluphenazine hcl oral elixir 2.5 mg/5ml

2

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

2

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

GM

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

4Brand

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

2

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

1

haloperidol oral tablet 10 mg, 20 mg

2

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

4

Brand penalty




71

Drug NameDrug Tier

Notes

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

5

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

5

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

4 PA

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

2

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

2

NUPLAZID ORAL CAPSULE 34 MG

4 PA

NUPLAZID ORAL TABLET 10 MG

4 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

2

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

2

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

2QL (30 EA

per 30 days)

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 90 MG

5

Drug NameDrug Tier

Notes

pimozide oral tablet 1 mg, 2 mg

2

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

2QL (30 EA

per 30 days)

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

2

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

4 PA

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

5

RISPERDAL ORAL SOLUTION 1 MG/ML

4Brand

penalty applies

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

4Brand

penalty applies

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg

2

risperidone oral solution 1 mg/ml

2

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

2

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

2

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

4 PA



72

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

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

4

Brand penalty


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

2

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

2

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

2

VERSACLOZ ORAL SUSPENSION 50 MG/ML

4

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

4 PA

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

4

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

2

ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG

GM

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

4Brand

penalty applies

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

5

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

Antivirals

abacavir sulfate oral solution 20 mg/ml

2

abacavir sulfate oral tablet 300 mg

2

abacavir sulfate-lamivudine oral tablet 600-300 mg

2

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

2

acyclovir external cream 5 %

2

acyclovir external ointment 5 %

2QL (15 GM

per 30 days)

acyclovir oral capsule 200 mg

2

acyclovir oral suspension 200 mg/5ml

2

acyclovir oral tablet 400 mg, 800 mg

2

acyclovir sodium intravenous solution 50 mg/ml

GM

adefovir dipivoxil oral tablet 10 mg

2 PA

APTIVUS ORAL CAPSULE 250 MG

3

APTIVUS ORAL SOLUTION 100 MG/ML

3

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

2

ATRIPLA ORAL TABLET 600-200-300 MG

6

BARACLUDE ORAL SOLUTION 0.05 MG/ML

4 PA



73

Drug NameDrug Tier

Notes

BARACLUDE ORAL TABLET 0.5 MG, 1 MG

4PA; Brand

penalty applies

BIKTARVY ORAL TABLET 50-200-25 MG

4

cidofovir intravenous solution 75 mg/ml

GM

CIMDUO ORAL TABLET 300-300 MG

6

COMBIVIR ORAL TABLET 150-300 MG

4Brand

penalty applies

COMPLERA ORAL TABLET 200-25-300 MG

6

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

CYTOVENE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DAKLINZA ORAL TABLET 30 MG, 60 MG

6 PA

DELSTRIGO ORAL TABLET 100-300-300 MG

6 PA

DENAVIR EXTERNAL CREAM 1 %

4 ST

DESCOVY ORAL TABLET 200-25 MG

6

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

2

EDURANT ORAL TABLET 25 MG

4

efavirenz oral capsule 200 mg, 50 mg

2

efavirenz oral tablet 600 mg

2

EMTRIVA ORAL CAPSULE 200 MG

3

Drug NameDrug Tier

Notes

EMTRIVA ORAL SOLUTION 10 MG/ML

3

entecavir oral tablet 0.5 mg, 1 mg

2 PA

EPCLUSA ORAL TABLET 400-100 MG

5 PA

EPIVIR HBV ORAL SOLUTION 5 MG/ML

4

EPIVIR HBV ORAL TABLET 100 MG

4Brand

penalty applies

EPIVIR ORAL SOLUTION 10 MG/ML

4Brand

penalty applies

EPIVIR ORAL TABLET 150 MG, 300 MG

4Brand

penalty applies

EPZICOM ORAL TABLET 600-300 MG

4Brand

penalty applies

EVOTAZ ORAL TABLET 300-150 MG

6

famciclovir oral tablet 125 mg, 250 mg, 500 mg

2

FLUMADINE ORAL TABLET 100 MG

4Brand

penalty applies

fosamprenavir calcium oral tablet 700 mg

2

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML

GM

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

6

GANCICLOVIR INTRAVENOUS SOLUTION 500 MG/250ML

GM



74

Drug NameDrug Tier

Notes

ganciclovir sodium intravenous solution 500 mg/10ml

GM

ganciclovir sodium intravenous solution reconstituted 500 mg

GM

GENVOYA ORAL TABLET 150-150-200-10 MG

6

HARVONI ORAL TABLET 90-400 MG

5 PA

HEPSERA ORAL TABLET 10 MG

4PA; Brand

penalty applies

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

4

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

6PA;

Specialty Medical

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

6PA;

Specialty Medical

INVIRASE ORAL TABLET 500 MG

3

ISENTRESS HD ORAL TABLET 600 MG

3

ISENTRESS ORAL PACKET 100 MG

3

ISENTRESS ORAL TABLET 400 MG

3

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

3

JULUCA ORAL TABLET 50-25 MG

6

KALETRA ORAL SOLUTION 400-100 MG/5ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

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

3

lamivudine oral solution 10 mg/ml

2

lamivudine oral tablet 100 mg, 150 mg, 300 mg

2

lamivudine-zidovudine oral tablet 150-300 mg

2

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG

5 PA

LEXIVA ORAL SUSPENSION 50 MG/ML

4

LEXIVA ORAL TABLET 700 MG

4Brand

penalty applies

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

2

MAVYRET ORAL TABLET 100-40 MG

5 PA

MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG

6

moderiba oral tablet 200 mg

5

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

2

nevirapine oral suspension 50 mg/5ml

2

nevirapine oral tablet 200 mg

2

NORVIR ORAL PACKET 100 MG

4

NORVIR ORAL SOLUTION 80 MG/ML

3

NORVIR ORAL TABLET 100 MG

3Brand

penalty applies



75

Drug NameDrug Tier

Notes

ODEFSEY ORAL TABLET 200-25-25 MG

6

oseltamivir phosphate oral capsule 30 mg

2QL (20 EA

per 30 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg

2QL (10 EA

per 180 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

2QL (120

ML per 180 days)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

5 PA

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

5 PA

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML

5 PA

PIFELTRO ORAL TABLET 100 MG

4

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

6PA;

Specialty Medical

PREVYMIS ORAL TABLET 240 MG, 480 MG

6 PA

PREZCOBIX ORAL TABLET 800-150 MG

6

PREZISTA ORAL SUSPENSION 100 MG/ML

4

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

4

Drug NameDrug Tier

Notes

RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML

GM

REBETOL ORAL SOLUTION 40 MG/ML

6

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

4QL (20 EA

per 180 days)

RESCRIPTOR ORAL TABLET 200 MG

3

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RETROVIR ORAL CAPSULE 100 MG

4Brand

penalty applies

RETROVIR ORAL SYRUP 50 MG/5ML

4Brand

penalty applies

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

3Brand

penalty applies

REYATAZ ORAL PACKET 50 MG

4

ribasphere oral capsule 200 mg

5

ribasphere oral tablet 200 mg

5

ribasphere oral tablet 400 mg, 600 mg

6

ribasphere ribapak oral tablet 400 mg, 600 mg

6

RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG

6

ribasphere ribapak oral tablet therapy pack 400 & 600 mg

6



76

Drug NameDrug Tier

Notes

ribavirin inhalation solution reconstituted 6 gm

6PA;

Specialty Medical

ribavirin oral capsule 200 mg

5

ribavirin oral tablet 200 mg

5

rimantadine hcl oral tablet 100 mg

2

ritonavir oral tablet 100 mg

2

SELZENTRY ORAL SOLUTION 20 MG/ML

4

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

4

SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG

5 PA

SOVALDI ORAL TABLET 400 MG

6 PA

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

2

STRIBILD ORAL TABLET 150-150-200-300 MG

6

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

3Brand

penalty applies

SUSTIVA ORAL TABLET 600 MG

3Brand

penalty applies

SYMFI LO ORAL TABLET 400-300-300 MG

6

SYMFI ORAL TABLET 600-300-300 MG

6

SYMTUZA ORAL TABLET 800-150-200-10 MG

6

Drug NameDrug Tier

Notes

TAMIFLU ORAL CAPSULE 30 MG

4

Brand penalty


TAMIFLU ORAL CAPSULE 45 MG, 75 MG

4

Brand penalty


TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

4

Brand penalty


TECHNIVIE ORAL TABLET 12.5-75-50 MG

6 PA

tenofovir disoproxil fumarate oral tablet 300 mg

2

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

6

TRIUMEQ ORAL TABLET 600-50-300 MG

6

TRIZIVIR ORAL TABLET 300-150-300 MG

4Brand

penalty applies

TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML

6Specialty Medical

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

6

TYBOST ORAL TABLET 150 MG

4 ST

valacyclovir hcl oral tablet 1 gm, 500 mg

2



77

Drug NameDrug Tier

Notes

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

6

VALCYTE ORAL TABLET 450 MG

6

valganciclovir hcl oral solution reconstituted 50 mg/ml

5

valganciclovir hcl oral tablet 450 mg

5

VALTREX ORAL TABLET 1 GM, 500 MG

4Brand

penalty applies

VEMLIDY ORAL TABLET 25 MG

5 PA

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG

4

VIDEX EC ORAL CAPSULE DELAYED RELEASE 200 MG, 250 MG, 400 MG

4Brand

penalty applies

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

3

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50

6 PA

VIRACEPT ORAL TABLET 250 MG, 625 MG

4

VIRAMUNE ORAL SUSPENSION 50 MG/5ML

4Brand

penalty applies

VIRAMUNE ORAL TABLET 200 MG

4Brand

penalty applies

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

6PA;

Specialty Medical

VIREAD ORAL POWDER 40 MG/GM

3

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

3

VIREAD ORAL TABLET 300 MG

3Brand

penalty applies

VOSEVI ORAL TABLET 400-100-100 MG

6 PA

XOFLUZA ORAL TABLET THERAPY PACK 20 (2) MG, 40 (2) MG

4QL (2 EA per 180 days)

ZEPATIER ORAL TABLET 50-100 MG

6 PA

ZIAGEN ORAL SOLUTION 20 MG/ML

4Brand

penalty applies

ZIAGEN ORAL TABLET 300 MG

4Brand

penalty applies

zidovudine oral capsule 100 mg

2

zidovudine oral syrup 50 mg/5ml

2

zidovudine oral tablet 300 mg

2

ZOVIRAX EXTERNAL CREAM 5 %

3Brand

penalty applies

ZOVIRAX EXTERNAL OINTMENT 5 %

3

Brand penalty

applies; QL (15 GM per

30 days)

ZOVIRAX ORAL CAPSULE 200 MG

4Brand

penalty applies



78

Drug NameDrug Tier

Notes

ZOVIRAX ORAL SUSPENSION 200 MG/5ML

4Brand

penalty applies

ZOVIRAX ORAL TABLET 400 MG, 800 MG

4Brand

penalty applies

Anxiolytics - Drugs for Anxiety

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

2

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

4

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

2

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

2 ST

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

2

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

GM

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG

4Brand

penalty applies

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

1

buspirone hcl oral tablet 30 mg, 7.5 mg

2

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

2

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

2

Drug NameDrug Tier

Notes

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

2

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

2

diazepam intensol oral concentrate 5 mg/ml

2

diazepam oral concentrate 5 mg/ml

2

diazepam oral solution 5 mg/5ml

2

diazepam oral tablet 10 mg, 2 mg, 5 mg

2

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

4

estazolam oral tablet 1 mg, 2 mg

2

HALCION ORAL TABLET 0.25 MG

4Brand

penalty applies

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

GM

hydroxyzine hcl oral syrup 10 mg/5ml

2

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

2

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

2

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

4Brand

penalty applies



79

Drug NameDrug Tier

Notes

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

GM

lorazepam intensol oral concentrate 2 mg/ml

2

lorazepam oral concentrate 2 mg/ml

2

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

2

LORAZEPAM-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%

GM

meprobamate oral tablet 200 mg, 400 mg

2

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 30 MG/30ML

GM

MIDAZOLAM HCL-DEXTROSE INTRAVENOUS SOLUTION 50-5 MG/50ML-%

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 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

Drug NameDrug Tier

Notes

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

GM

oxazepam oral capsule 10 mg, 15 mg, 30 mg

2

quazepam oral tablet 15 mg

2

TRANXENE-T ORAL TABLET 7.5 MG

4Brand

penalty applies

triazolam oral tablet 0.125 mg, 0.25 mg

2

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG

4Brand

penalty applies

VISTARIL ORAL CAPSULE 25 MG, 50 MG

4Brand

penalty applies

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

4Brand

penalty applies

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

4Brand

penalty applies

Bipolar Agents - Drugs for Mood Disorders

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

2

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

1

lithium carbonate oral tablet 300 mg

2

lithium oral solution 8 meq/5ml

2

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

4Brand

penalty applies



80

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

6Specialty Medical

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

6Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 3000 UNIT

6PA;

Specialty Medical

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

6Specialty Medical

AGRYLIN ORAL CAPSULE 0.5 MG

4Brand

penalty applies

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

6Specialty Medical

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

6Specialty Medical

Drug NameDrug Tier

Notes

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

6Specialty Medical

AMICAR ORAL SOLUTION 0.25 GM/ML

4

AMICAR ORAL TABLET 1000 MG, 500 MG

4Brand

penalty applies

aminocaproic acid intravenous solution 250 mg/ml

GM

aminocaproic acid oral tablet 1000 mg, 500 mg

2

anagrelide hcl oral capsule 0.5 mg, 1 mg

2

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

6

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

6

ASTRINGYN EXTERNAL SOLUTION 259 MG/GM

4



81

Drug NameDrug Tier

Notes

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

6Specialty Medical

CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM

COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT

6Specialty Medical

CORIFACT INTRAVENOUS KIT 1000-1600 UNIT

6Specialty Medical

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML

GM

DOPTELET ORAL TABLET 20 MG

6 PA

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

6Specialty Medical

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

6

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED

6Specialty Medical

Drug NameDrug Tier

Notes

FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED

GM

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

5

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

5

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

5

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

6Specialty Medical

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, 250 unit, 500 unit

6Specialty Medical

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1700 UNIT

6Specialty Medical

HESPAN INTRAVENOUS SOLUTION 6-0.9 %

GM

hetastarch-nacl intravenous solution 6-0.9 %

GM



82

Drug NameDrug Tier

Notes

HEXTEND INTRAVENOUS SOLUTION 6 %

GM

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

6Specialty Medical

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

6Specialty Medical

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

6Specialty Medical

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

6Specialty Medical

KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT

GM

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

6Specialty Medical

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

6Specialty Medical

Drug NameDrug Tier

Notes

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

6Specialty Medical

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

6Specialty Medical

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

6Specialty Medical

LMD IN D5W INTRAVENOUS SOLUTION 10-5 %

GM

LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 %

GM

LYSTEDA ORAL TABLET 650 MG

3Brand

penalty applies

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

4

MONOCLATE-P INTRAVENOUS KIT 1000 UNIT

6Specialty Medical

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

6Specialty Medical



83

Drug NameDrug Tier

Notes

MONSELS FERRIC SUBSULFATE EXTERNAL SOLUTION

4

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML

6PA;

Specialty Medical

MULPLETA ORAL TABLET 3 MG

6 PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

6

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

6

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

6

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

6

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

6 PA

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

6Specialty Medical

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

6Specialty Medical

Drug NameDrug Tier

Notes

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 500 MCG

6PA;

Specialty Medical

NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 2500 UNIT, 3000 UNIT, 4000 UNIT

6Specialty Medical

OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

GM

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

6

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

6Specialty Medical

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

6Specialty Medical

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

5 PA

protamine sulfate intravenous solution 10 mg/ml

GM



84

Drug NameDrug Tier

Notes

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

GM

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

6Specialty Medical

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

4

RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT

4

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

5 PA

RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED

GM

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

6Specialty Medical

SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

TAVALISSE ORAL TABLET 100 MG, 150 MG

6 PA

THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT

4

THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT

4

THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

4

THROMBOGEN EXTERNAL KIT 10000 UNIT

4

THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT

4

tranexamic acid intravenous solution 1000 mg/10ml

GM

tranexamic acid oral tablet 650 mg

2

TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT

6Specialty Medical

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

6 PA

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML

6PA;

Specialty Medical

VOLUVEN INTRAVENOUS SOLUTION 6-0.9 %

GM



85

Drug NameDrug Tier

Notes

VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT

6Specialty Medical

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

6Specialty Medical

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

6Specialty Medical

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

6Specialty Medical

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

5

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

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

4Brand

penalty applies

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

4Brand

penalty applies

acebutolol hcl oral capsule 200 mg, 400 mg

2

acetazolamide er oral capsule extended release 12 hour 500 mg

2

acetazolamide oral tablet 125 mg, 250 mg

2

acetazolamide sodium injection solution reconstituted 500 mg

GM

Drug NameDrug Tier

Notes

ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

4Brand

penalty applies

ADENOCARD INTRAVENOUS SOLUTION 12 MG/4ML, 6 MG/2ML

GM

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

GM

ADENOSINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 60 MG/20ML, 90 MG/30ML

GM

AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML

GM

ALDACTAZIDE ORAL TABLET 25-25 MG

4Brand

penalty applies

ALDACTAZIDE ORAL TABLET 50-50 MG

3

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG

4Brand

penalty applies

ALISKIREN FUMARATE ORAL TABLET 150 MG, 300 MG

3

alprostadil injection solution 500 mcg/ml

GM

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

4Brand

penalty applies

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

4 PA

amiloride hcl oral tablet 5 mg

2



86

Drug NameDrug Tier

Notes

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2

AMIODARONE HCL IN DEXTROSE INTRAVENOUS SOLUTION 1000-5 MG/500ML-%, 450-5 MG/250ML-%, 750-5 MG/500ML-%

GM

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

GM

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

2

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

1

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

2

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

2

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

2

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

2

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

2

Drug NameDrug Tier

Notes

ANTARA ORAL CAPSULE 30 MG, 90 MG

4

ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 %

GM

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

4Brand

penalty applies

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

4Brand

penalty applies

atenolol oral tablet 100 mg, 25 mg, 50 mg

2

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

2

atorvastatin calcium oral tablet 10 mg, 20 mg

2 PV*

atorvastatin calcium oral tablet 40 mg, 80 mg

2

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

4Brand

penalty applies

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG

4Brand

penalty applies

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

1

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

2

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

3Brand

penalty applies



87

Drug NameDrug Tier

Notes

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

3Brand

penalty applies

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

4Brand

penalty applies

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG

4Brand

penalty applies

betaxolol hcl oral tablet 10 mg, 20 mg

2

BIDIL ORAL TABLET 20-37.5 MG

4

bisoprolol fumarate oral tablet 10 mg, 5 mg

2

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

1

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

GM

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

2

BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

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

3

BYVALSON ORAL TABLET 5-80 MG

4

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

4Brand

penalty applies

CALAN ORAL TABLET 120 MG

4Brand

penalty applies

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

4Brand

penalty applies

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

2

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

2

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

2

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

2

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

4Brand

penalty applies



88

Drug NameDrug Tier

Notes

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG

3Brand

penalty applies

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

4

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

4Brand

penalty applies

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

4Brand

penalty applies

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

4Brand

penalty applies

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

2

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

1

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

2

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG

4Brand

penalty applies

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

4Brand

penalty applies


4Brand

penalty applies


4Brand

penalty applies

Drug NameDrug Tier

Notes

chlorothiazide oral tablet 250 mg, 500 mg

2

chlorothiazide sodium intravenous solution reconstituted 500 mg

GM

chlorthalidone oral tablet 25 mg, 50 mg

2

cholestyramine light oral packet 4 gm

2

cholestyramine light oral powder 4 gm/dose

2

cholestyramine oral packet 4 gm

2

cholestyramine oral powder 4 gm/dose

2

choline fenofibrate oral capsule delayed release 135 mg

2

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

GM

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

6Specialty Medical

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

2

colesevelam hcl oral packet 3.75 gm

2

colesevelam hcl oral tablet 625 mg

2

COLESTID FLAVORED ORAL GRANULES 5 GM

4Brand

penalty applies

COLESTID FLAVORED ORAL PACKET 5 GM

4Brand

penalty applies



89

Drug NameDrug Tier

Notes

COLESTID ORAL GRANULES 5 GM

4Brand

penalty applies

COLESTID ORAL PACKET 5 GM

4Brand

penalty applies

COLESTID ORAL TABLET 1 GM

4Brand

penalty applies

colestipol hcl oral granules 5 gm

2

colestipol hcl oral packet 5 gm

2

colestipol hcl oral tablet 1 gm

2

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

4Brand

penalty applies

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

4Brand

penalty applies

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG

4Brand

penalty applies

CORLANOR ORAL TABLET 5 MG, 7.5 MG

4 ST

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

4Brand

penalty applies

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

4Brand

penalty applies

Drug NameDrug Tier

Notes

DEMADEX ORAL TABLET 10 MG

4Brand

penalty applies

DEMSER ORAL CAPSULE 250 MG

4

DIBENZYLINE ORAL CAPSULE 10 MG

4

PA; Brand penalty


digitek oral tablet 125 mcg, 250 mcg

2

digox oral tablet 125 mcg, 250 mcg

2

digoxin injection solution 0.25 mg/ml

GM

digoxin oral solution 0.05 mg/ml

2

digoxin oral tablet 125 mcg, 250 mcg

2

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG

3

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

2

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

2

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

2

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

2



90

Drug NameDrug Tier

Notes

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

2

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

GM

DILTIAZEM HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML

GM

diltiazem hcl intravenous solution reconstituted 100 mg

GM

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

2

DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 250-5 MG/250ML-%

GM

DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125-0.9 MG/125ML-%, 250-0.9 MG/250ML-%

GM

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

2

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

4Brand

penalty applies

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

4Brand

penalty applies

disopyramide phosphate oral capsule 100 mg, 150 mg

2

Drug NameDrug Tier

Notes

DIURIL ORAL SUSPENSION 250 MG/5ML

4

dobutamine hcl intravenous solution 250 mg/20ml, 500 mg/40ml

GM

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

2

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

2

DURACLON EPIDURAL SOLUTION 100 MCG/ML

6Specialty Medical

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

4

DYAZIDE ORAL CAPSULE 37.5-25 MG

4Brand

penalty applies

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

4

EDARBI ORAL TABLET 40 MG, 80 MG

4

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

4



91

Drug NameDrug Tier

Notes

EDECRIN ORAL TABLET 25 MG

4Brand

penalty applies

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

2

enalaprilat intravenous injectable 1.25 mg/ml

GM

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

2

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

4 PA

EPANED ORAL SOLUTION 1 MG/ML

4

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

EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/5ML-%

GM

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 1-5 MG/250ML-%, 16-5 MG/250ML-%, 2-5 MG/100ML-%, 2-5 MG/250ML-%, 4-5 MG/250ML-%, 5-5 MG/250ML-%, 6.25-5 MG/250ML-%, 8-5 MG/250ML-%

GM

Drug NameDrug Tier

Notes

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION PREFILLED SYRINGE 5000-5 MCG/50ML-%, 750-5 MCG/25ML-%

GM

EPINEPHRINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 80-0.9 MCG/10ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 1-0.9 MG/250ML-%, 10-0.9 MG/250ML-%, 16-0.9 MG/250ML-%, 2-0.9 MG/250ML-%, 2.5-0.9 MG/250ML-%, 4-0.9 MG/250ML-%, 5-0.9 MG/250ML-%, 8-0.9 MG/250ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/10ML-%, 100-0.9 MCG/10ML-%, 1200-0.9 MCG/50ML-%, 200-0.9 MCG/10ML-%, 3000-0.9 MCG/15ML-%, 40-0.9 MCG/10ML-%, 50-0.9 MCG/5ML-%, 500-0.9 MCG/10ML-%, 500-0.9 MCG/50ML-%, 5000-0.9 MCG/50ML-%, 6000-0.9 MCG/50ML-%

GM

epinephrine injection solution 30 mg/30ml

GM

EPINEPHRINE INJECTION SOLUTION PREFILLED SYRINGE 1 MG/10ML

GM



92

Drug NameDrug Tier

Notes

epinephrine pf injection solution 1 mg/ml

GM

epinephrine pf injection solution prefilled syringe 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

2

eprosartan mesylate oral tablet 600 mg

2

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

4

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

2

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

4Brand

penalty applies

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

4Brand

penalty applies

ezetimibe oral tablet 10 mg

2

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

2

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

2

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

2

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

2

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

2

fenofibric acid oral capsule delayed release 135 mg, 45 mg

2

fenofibric acid oral tablet 105 mg, 35 mg

2

FIBRICOR ORAL TABLET 105 MG, 35 MG

4Brand

penalty applies

FIRST-ATENOLOL ORAL SOLUTION 10 MG/ML, 2 MG/ML

4

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

2



93

Drug NameDrug Tier

Notes

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

2 PA

fluvastatin sodium oral capsule 20 mg, 40 mg

2

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

2

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

2

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

2

furosemide oral tablet 20 mg, 40 mg, 80 mg

1

gemfibrozil oral tablet 600 mg

2

guanfacine hcl oral tablet 1 mg, 2 mg

1

hydralazine hcl injection solution 20 mg/ml

GM

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

2

hydrochlorothiazide oral capsule 12.5 mg

1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

4Brand

penalty applies

ibutilide fumarate intravenous solution 1 mg/10ml

GM

Drug NameDrug Tier

Notes

indapamide oral tablet 1.25 mg, 2.5 mg

2

INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG

4Brand

penalty applies

INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

4

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

4

INSPRA ORAL TABLET 25 MG, 50 MG

4Brand

penalty applies

irbesartan oral tablet 150 mg, 300 mg, 75 mg

2

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

2

isoproterenol hcl injection solution 0.2 mg/ml

GM

ISORDIL TITRADOSE ORAL TABLET 40 MG

3

ISORDIL TITRADOSE ORAL TABLET 5 MG

4Brand

penalty applies

isosorbide dinitrate er oral tablet extended release 40 mg

2

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

2

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

2

isosorbide mononitrate oral tablet 10 mg, 20 mg

2



94

Drug NameDrug Tier

Notes

isradipine oral capsule 2.5 mg, 5 mg

2

ISUPREL INJECTION SOLUTION 0.2 MG/ML

GM

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

6 PA

KEVEYIS ORAL TABLET 50 MG

6 PA

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

6 PA

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20 MG/4ML, 25 MG/5ML, 50 MG/10ML

GM

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

2

labetalol hcl solution 5 mg/ml intravenous 5 mg/ml

GM

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 MG/ML

GM

LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 200-5 MG/200ML-%, 250-5 MG/250ML-%, 500-5 MG/250ML-%

GM

LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 200-0.9 MG/200ML-%, 500-0.9 MG/500ML-%

GM

Drug NameDrug Tier

Notes

LANOXIN INJECTION SOLUTION 0.25 MG/ML

GM

LANOXIN ORAL TABLET 125 MCG, 250 MCG

4Brand

penalty applies

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG

4

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

GM

LASIX ORAL TABLET 20 MG, 40 MG, 80 MG

4Brand

penalty applies

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG

4PA; Brand

penalty applies

LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML

GM

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

4Brand

penalty applies

LIPOFEN ORAL CAPSULE 150 MG, 50 MG

4

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

1

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

1

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

4 PA

LOPID ORAL TABLET 600 MG

4Brand

penalty applies

LOPRESSOR HCT ORAL TABLET 50-25 MG

4Brand

penalty applies



95

Drug NameDrug Tier

Notes

LOPRESSOR ORAL TABLET 100 MG, 50 MG

4Brand

penalty applies

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

1

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

1

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

4Brand

penalty applies

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG

4Brand

penalty applies

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

4Brand

penalty applies

lovastatin oral tablet 10 mg, 20 mg

2 PV*

lovastatin oral tablet 40 mg

2 PA; PV*

LOVAZA ORAL CAPSULE 1 GM

4PA; 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

2

MAXZIDE ORAL TABLET 75-50 MG

4Brand

penalty applies

MAXZIDE-25 ORAL TABLET 37.5-25 MG

4Brand

penalty applies

methyclothiazide oral tablet 5 mg

2

methyldopa oral tablet 250 mg, 500 mg

2

Drug NameDrug Tier

Notes

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

2

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

2

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

2

metoprolol tartrate intravenous solution 5 mg/5ml

GM

METOPROLOL TARTRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 5 MG/5ML

GM

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

1

metoprolol tartrate oral tablet 37.5 mg, 75 mg

2

METOPROLOL-HCTZ ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

4

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

2

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

2

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

4Brand

penalty applies

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG

4Brand

penalty applies

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

2



96

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2

minoxidil oral tablet 10 mg, 2.5 mg

2

moexipril hcl oral tablet 15 mg, 7.5 mg

2

MULTAQ ORAL TABLET 400 MG

3

nadolol oral tablet 20 mg, 40 mg, 80 mg

2

nadolol-bendroflumethiazide oral tablet 40-5 mg

2

NATRECOR INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG

GM

NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-%

GM

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

2

NIACOR ORAL TABLET 500 MG

4

Drug NameDrug Tier

Notes

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG

4Brand

penalty applies

NICARDIPINE HCL IN DEXTROSE INTRAVENOUS SOLUTION 25-5 MG/250ML-%

GM

NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 125-0.9 MG/250ML-%, 25-0.9 MG/250ML-%, 50-0.9 MG/250ML-%

GM

NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-%, 4-0.9 MG/10ML-%

GM

nicardipine hcl intravenous solution 2.5 mg/ml

GM

nicardipine hcl oral capsule 20 mg, 30 mg

2

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2

nifedipine oral capsule 10 mg, 20 mg

2

nimodipine oral capsule 30 mg

2

NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-%

GM



97

Drug NameDrug Tier

Notes

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

2

NITRO-BID TRANSDERMAL OINTMENT 2 %

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3Brand

penalty applies

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

3

nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

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

2

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2

nitroglycerin translingual solution 0.4 mg/spray

2

NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY

4Brand

penalty applies

Drug NameDrug Tier

Notes

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY

3

NITROPRESS INTRAVENOUS SOLUTION 25 MG/ML

GM

nitroprusside sodium intravenous solution 25 mg/ml

GM

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

3Brand

penalty applies

nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

2

norepinephrine bitartrate intravenous solution 1 mg/ml

GM

NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 12.5-5 MG/250ML-%, 16-5 MG/250ML-%, 16-5 MG/500ML-%, 8-5 MG/500ML-%

GM

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 12.5-0.9 MG/250ML-%, 15-0.9 MG/250ML-%, 16-0.9 MG/100ML-%, 16-0.9 MG/250ML-%, 16-0.9 MG/500ML-%, 32-0.9 MG/250ML-%, 32-0.9 MG/500ML-%, 4-0.9 MG/500ML-%, 6-0.9 MG/50ML-%, 8-0.9 MG/500ML-%

GM



98

Drug NameDrug Tier

Notes

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/50ML-%, 2-0.9 MG/50ML-%

GM

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

3

NORPACE ORAL CAPSULE 100 MG, 150 MG

4Brand

penalty applies

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

6 PA

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

4Brand

penalty applies

NYMALIZE ORAL SOLUTION 30 MG/10ML, 60 MG/20ML

4

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

2

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

2

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

2

omega-3-acid ethyl esters oral capsule 1 gm

2 PA

OSMITROL INTRAVENOUS SOLUTION 10 %, 5 %

GM

osmitrol intravenous solution 15 %, 20 %

GM

Drug NameDrug Tier

Notes

pacerone oral tablet 100 mg, 200 mg, 400 mg

2

pentoxifylline er oral tablet extended release 400 mg

2

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

2

phenoxybenzamine hcl oral capsule 10 mg


days)

phentolamine mesylate injection solution reconstituted 5 mg

GM

phenylephrine hcl injection solution 10 mg/ml

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

PHENYLEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 10-5 MG/250ML-%, 100-5 MG/250ML-%, 20-5 MG/250ML-%, 20-5 MG/500ML-%, 200-5 MG/250ML-%, 25-5 MG/250ML-%, 30-5 MG/250ML-%, 40-5 MG/250ML-%, 40-5 MG/500ML-%, 50-5 MG/250ML-%, 8-5 MG/100ML-%

GM



99

Drug NameDrug Tier

Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/100ML-%, 10-0.9 MG/250ML-%, 100-0.9 MG/100ML-%, 100-0.9 MG/250ML-%, 100-0.9 MG/500ML-%, 160-0.9 MG/500ML-%, 20-0.9 MG/250ML-%, 20-0.9 MG/500ML-%, 200-0.9 MG/250ML-%, 25-0.9 MG/250ML-%, 250-0.9 MG/250ML-%, 30-0.9 MG/100ML-%, 30-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 40-0.9 MG/500ML-%, 50-0.9 MG/250ML-%, 50-0.9 MG/500ML-%, 60-0.9 MG/250ML-%, 80-0.9 MG/250ML-%, 80-0.9 MG/500ML-%

GM

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5-0.9 MG/5ML-%, 1.6-0.9 MG/20ML-%

GM

pindolol oral tablet 10 mg, 5 mg

2

POLIDOCANOL INTRAVENOUS SOLUTION 5 %

GM

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML

6 PA

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG

4Brand

penalty applies

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

2 PV*

Drug NameDrug Tier

Notes

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

2

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG

4

prevalite oral packet 4 gm

2

prevalite oral powder 4 gm/dose

2

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG

4Brand

penalty applies

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

GM

PROCARDIA ORAL CAPSULE 10 MG

4Brand

penalty applies

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

4Brand

penalty applies

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

2

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

2

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

2

propranolol hcl intravenous solution 1 mg/ml

GM

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

2

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

2



100

Drug NameDrug Tier

Notes

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

2

PROSTIN VR INJECTION SOLUTION 500 MCG/ML

GM

QBRELIS ORAL SOLUTION 1 MG/ML

4

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE

4Brand

penalty applies

QUESTRAN ORAL PACKET 4 GM

4Brand

penalty applies

QUESTRAN ORAL POWDER 4 GM/DOSE

4Brand

penalty applies

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

2

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

2

quinidine gluconate er oral tablet extended release 324 mg

2

quinidine sulfate oral tablet 200 mg, 300 mg

2

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

2

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

4Brand

penalty applies

ranolazine er oral tablet extended release 12 hour 1000 mg, 500 mg

2

RECTIV RECTAL OINTMENT 0.4 %

4

Drug NameDrug Tier

Notes

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

6 PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

6 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

6 PA

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

2

RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG, 425 MG

4Brand

penalty applies

simvastatin oral tablet 10 mg, 20 mg, 40 mg

2 PV*

simvastatin oral tablet 5 mg, 80 mg

2

SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

2

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

2

SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML

GM



101

Drug NameDrug Tier

Notes

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

2

SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 %

GM

SOTYLIZE ORAL SOLUTION 5 MG/ML

4

spironolactone oral tablet 100 mg, 25 mg, 50 mg

2

spironolactone-hctz oral tablet 25-25 mg

2

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG

4Brand

penalty applies

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG

4Brand

penalty applies

taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

2

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

3

TEKTURNA ORAL TABLET 150 MG, 300 MG

3

telmisartan oral tablet 20 mg, 40 mg, 80 mg

2

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

2

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

2

TENORETIC 100 ORAL TABLET 100-25 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

TENORETIC 50 ORAL TABLET 50-25 MG

4Brand

penalty applies

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG

4Brand

penalty applies

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

4Brand

penalty applies

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

4Brand

penalty applies

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

2

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

4Brand

penalty applies

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

2

trandolapril oral tablet 1 mg, 2 mg, 4 mg

2

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

2

triamterene-hctz oral capsule 37.5-25 mg

2

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg

2

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



102

Drug NameDrug Tier

Notes

TRICOR ORAL TABLET 145 MG, 48 MG

4Brand

penalty applies

TRIGLIDE ORAL TABLET 160 MG

4Brand

penalty applies

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG

4Brand

penalty applies

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG

4Brand

penalty applies

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

2

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

2

VARITHENA INTRAVENOUS FOAM 180 MG/18ML

GM

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM

4 PA

VASERETIC ORAL TABLET 10-25 MG

4Brand

penalty applies

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

4Brand

penalty applies

VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML

GM

VECAMYL ORAL TABLET 2.5 MG

4

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

2

Drug NameDrug Tier

Notes

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

2

verapamil hcl intravenous solution 2.5 mg/ml

GM

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg

2

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

4Brand

penalty applies

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

4Brand

penalty applies

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

4Brand

penalty applies

WELCHOL ORAL PACKET 3.75 GM

4Brand

penalty applies

WELCHOL ORAL TABLET 625 MG

4Brand

penalty applies

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

4Brand

penalty applies

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

4Brand

penalty applies

ZETIA ORAL TABLET 10 MG

4Brand

penalty applies

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG

4Brand

penalty applies

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG

4Brand

penalty applies



103

Drug NameDrug Tier

Notes

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG

4 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

4

Brand penalty


ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

4

Brand penalty


ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 30 MG

4

Brand penalty


amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

2QL (30 EA

per 30 days)

amphetamine-dextroamphetamine er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg

2QL (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

2QL (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

4

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg

2QL (60 EA

per 30 days)

Drug NameDrug Tier

Notes

atomoxetine hcl oral capsule 100 mg, 40 mg, 60 mg, 80 mg

2QL (30 EA

per 30 days)

clonidine hcl er oral tablet extended release 12 hour 0.1 mg

2

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG

4

Brand penalty


CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG

4

Brand penalty


DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

4QL (30 EA

per 30 days)

DESOXYN ORAL TABLET 5 MG

4Brand

penalty applies

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

4

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

2QL (30 EA

per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

2QL (90 EA

per 30 days)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

2QL (150

EA per 30 days)



104

Drug NameDrug Tier

Notes

dextroamphetamine sulfate oral solution 5 mg/5ml

2

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

2QL (180

EA per 30 days)

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 2.5 MG/ML

4PA; AL (Max 13 Years)

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG

4

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

4

Brand penalty


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

2

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

4Brand

penalty applies

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG

4Brand

penalty applies

metadate er oral tablet extended release 20 mg

2QL (90 EA

per 30 days)

methamphetamine hcl oral tablet 5 mg

2

METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML

4

Brand penalty


Drug NameDrug Tier

Notes

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

2QL (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

2QL (30 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 10 mg

2

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg

2QL (30 EA

per 30 days)


2QL (90 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

2


2QL (60 EA

per 30 days)


1QL (1 EA per 1 day)

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

2QL (900

ML per 30 days)

methylphenidate hcl oral tablet 10 mg

2QL (180

EA per 30 days)


2


2QL (90 EA

per 30 days)

methylphenidate hcl oral tablet chewable 10 mg

2



105

Drug NameDrug Tier

Notes

methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg

2QL (90 EA

per 30 days)

PROCENTRA ORAL SOLUTION 5 MG/5ML

4Brand

penalty applies

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG

4PA; AL (Max 13 Years)

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

4

PA; QL (180 ML per 30

days); AL (Max 12 Years)

relexxii oral tablet extended release 72 mg


RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG

4

Brand penalty


RITALIN ORAL TABLET 10 MG

4

Brand penalty



4Brand

penalty applies


4

Brand penalty


STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG

4

Brand penalty


Drug NameDrug Tier

Notes

STRATTERA ORAL CAPSULE 100 MG, 40 MG, 60 MG, 80 MG

4

Brand penalty


VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

4QL (30 EA

per 30 days)

VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


days)

zenzedi oral tablet 10 mg, 5 mg


ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

4QL (60 EA

per 30 days)

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG

6 PA

AUBAGIO ORAL TABLET 14 MG, 7 MG

5

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

6 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

6 PA

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

5

BETASERON SUBCUTANEOUS KIT 0.3 MG

5



106

Drug NameDrug Tier

Notes

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML

5

dalfampridine er oral tablet extended release 12 hour 10 mg

6 PA

EXTAVIA SUBCUTANEOUS KIT 0.3 MG

6

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG

6

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

5

glatopa subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

5

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML

6PA;

Specialty Medical

OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML

6PA;

Specialty Medical

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

5

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

5

Drug NameDrug Tier

Notes

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

5

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

5

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

5

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

5

TECFIDERA ORAL 120 & 240 MG

5

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

5

TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

6PA;

Specialty Medical

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

6 PA



107

Drug NameDrug Tier

Notes

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

2

cisatracurium besylate (pf) intravenous solution 10 mg/5ml, 200 mg/20ml

GM

cisatracurium besylate intravenous solution 20 mg/10ml

GM

CISATRACURIUM BESYLATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MG/5ML

GM

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML

GM

GRALISE ORAL TABLET 300 MG, 600 MG

4 ST

GRALISE STARTER ORAL 300 & 600 MG

4 ST

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG

4 ST

INGREZZA ORAL CAPSULE 40 MG, 80 MG

6 PA

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG

4

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

4

Drug NameDrug Tier

Notes

LYRICA ORAL SOLUTION 20 MG/ML

4

NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 MG/10ML, 200 MG/20ML

GM

ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

pancuronium bromide intravenous solution 1 mg/ml

GM

QUELICIN INJECTION SOLUTION 20 MG/ML

GM

RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML

6Specialty Medical

RILUTEK ORAL TABLET 50 MG

6

riluzole oral tablet 50 mg 6

rocuronium bromide intravenous solution 100 mg/10ml, 50 mg/5ml

GM

ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/10ML, 20 MG/2ML

GM

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

4 PA

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

4 PA

succinylcholine chloride injection solution 20 mg/ml

GM



108

Drug NameDrug Tier

Notes

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML

6 PA

tetrabenazine oral tablet 12.5 mg, 25 mg

5 PA

TIGLUTIK ORAL SUSPENSION 50 MG/10ML

6

vecuronium bromide intravenous solution reconstituted 10 mg, 20 mg

GM

XENAZINE ORAL TABLET 12.5 MG, 25 MG

6 PA

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN DENTAL 1 MG GM

BOCASAL MOUTH/THROAT PACKET

4

cavarest dental gel 1.1 % 2

cevimeline hcl oral capsule 30 mg

2

chlorhexidine gluconate mouth/throat solution 0.12 %

2

clinpro 5000 dental paste 1.1 %

2

DEBACTEROL MOUTH/THROAT SOLUTION 30-50 %

4

denta 5000 plus dental cream 1.1 %

2

dentagel dental gel 1.1 % 2

EVOXAC ORAL CAPSULE 30 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION

4

fluoridex daily renewal mouth/throat concentrate 0.63 %

2

fluoridex dental paste 1.1 %

2

fluoridex enhanced whitening dental paste 1.1 %

2

fluoridex sensitivity relief dental paste 1.1-5 %

2

KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG

6PA;

Specialty Medical

lidocaine viscous mouth/throat solution 2 %

2

MI PASTE DENTAL PASTE

4

MI PASTE PLUS DENTAL PASTE

4

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML

4

NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 %

4

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 0.2 %

4

neutral sodium fluoride mouth/throat solution 0.2 %

2



109

Drug NameDrug Tier

Notes

NEUTRASAL MOUTH/THROAT PACKET

4

NUMOISYN MOUTH/THROAT LOZENGE

4

oralone mouth/throat paste 0.1 %

2

paroex mouth/throat solution 0.12 %

2

PERIDEX MOUTH/THROAT SOLUTION 0.12 %

4Brand

penalty applies

periogard mouth/throat solution 0.12 %

2

pilocarpine hcl oral tablet 5 mg, 7.5 mg

2

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

4

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 %

4

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 %

4

PREVIDENT 5000 PLUS DENTAL CREAM 1.1 %

4

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

4

PREVIDENT DENTAL GEL 1.1 %

4

prevident mouth/throat solution 0.2 %

2

REMESENSE DENTAL 3 %

4

SALAGEN ORAL TABLET 5 MG, 7.5 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

SALIVAMAX MOUTH/THROAT PACKET

4

sf 5000 plus dental cream 1.1 %

2

sf dental gel 1.1 % 2

topex topical anesthetic mouth/throat aerosol 20 %

2

triamcinolone acetonide mouth/throat paste 0.1 %

2

XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION

4

Dermatological Agents - Drugs for Skin Conditions

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

4 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

2

ACZONE EXTERNAL GEL 5 %

4PA; Brand

penalty applies

ACZONE EXTERNAL GEL 7.5 %

4 PA

adapalene external cream 0.1 %

2

adapalene external gel 0.1 %, 0.3 %

2

ALCOHOL PREP PADS EXTERNAL 70 %

4

ALLEVYN AG NON-ADHESIVE EXTERNAL PAD

4

ammonium lactate external cream 12 %

2

ammonium lactate external lotion 12 %

2



110

Drug NameDrug Tier

Notes

amnesteem oral capsule 10 mg, 20 mg, 40 mg

2

ANACAINE EXTERNAL OINTMENT 10 %

4

AQUACEL AG BURN EXTERNAL PAD 4"X5"

4

ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 %

4

ATRAPRO DERMAL SPRAY EXTERNAL LIQUID

4

avar cleanser external emulsion 10-5 %

2

avar-e emollient external cream 10-5 %

2

avar-e green external cream 10-5 %

2

avita external cream 0.025 %

2

avita external gel 0.025 %

2

azelaic acid external gel 15 %

2 PA

AZELEX EXTERNAL CREAM 20 %

4 PA

balsam peru-castor oil external ointment

2

BEAU RX EXTERNAL GEL

4

BENSAL HP EXTERNAL OINTMENT 3-6 %

4

benzoin compound external tincture

2

benzoin external tincture 2

bp 10-1 external emulsion 10-1 %

2

BP CLEANSING WASH EXTERNAL EMULSION 10-4 %

4

Drug NameDrug Tier

Notes

BPCO EXTERNAL OINTMENT

4

calcipotriene external cream 0.005 %

2

calcipotriene external ointment 0.005 %

2

calcipotriene external solution 0.005 %

2

calcipotriene-betameth diprop external ointment 0.005-0.064 %

2 ST

calcitrene external ointment 0.005 %

2

calcitriol external ointment 3 mcg/gm

2 ST

celacyn gel external 2

CELACYN GEL EXTERNAL

4

cem-urea external solution 45 %

2

ceramax external cream 2

CERAMAX EXTERNAL LOTION

4

cerovel external lotion 40 %

2

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2

CLINDACIN ETZ EXTERNAL KIT 1 %

4

clindacin etz external swab 1 %

2

CLINDACIN PAC EXTERNAL KIT 1 %

4

clindacin-p external swab 1 %

2

clindamycin phosphate external foam 1 %

2

clindamycin phosphate external gel 1 %

2



111

Drug NameDrug Tier

Notes

clindamycin phosphate external lotion 1 %

2

clindamycin phosphate external solution 1 %

2

clindamycin phosphate external swab 1 %

2

CLINOIN EXTERNAL CREAM 1.25-0.025-1 %

4

clotrimazole-betamethasone external cream 1-0.05 %

2

clotrimazole-betamethasone external lotion 1-0.05 %

2

coal tar external solution 20 %

2

CONDYLOX EXTERNAL GEL 0.5 %

3

COPASIL EXTERNAL GEL

4

CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5

4

CORTISPORIN EXTERNAL OINTMENT 1 %

4

dapsone external gel 5 % 2 PA

DERMULCERA EXTERNAL OINTMENT

4

diclofenac sodium transdermal gel 3 %

2 PA

doxepin hcl external cream 5 %

2

DRITHO-CREME HP EXTERNAL CREAM 1 %

3

DRYSOL EXTERNAL SOLUTION 20 %

3

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML

6 PA

Drug NameDrug Tier

Notes

ELIDEL EXTERNAL CREAM 1 %

4Brand

penalty applies

EPIFOAM EXTERNAL FOAM 1-1 %

4

ery external pad 2 % 2

erythromycin external gel 2 %

2

erythromycin external pad 2 %

2

erythromycin external solution 2 %

2

EUCRISA EXTERNAL OINTMENT 2 %

4 PA

FINACEA EXTERNAL FOAM 15 %

4 PA

FINACEA EXTERNAL GEL 15 %

4PA; Brand

penalty applies

fluorouracil external cream 5 %

2

fluorouracil external solution 2 %, 5 %

2

glycolic acid solution 70 %

2

GORDOFILM EXTERNAL SOLUTION 16.7-16.7 %

4

HYDRO 35 EXTERNAL FOAM 35 %

4

HYLIRA EXTERNAL LOTION 0.1 %

4

imiquimod external cream 5 %

2

INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 & 5 %

4

INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 & 5 %

4



112

Drug NameDrug Tier

Notes

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2

KELARX EXTERNAL GEL

4

KERALYT EXTERNAL GEL 6 %

4

KERALYT SCALP EXTERNAL KIT 6 %

4

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

4

LAC-HYDRIN EXTERNAL CREAM 12 %

4Brand

penalty applies

lactic acid e external cream 10-3500 %-unt/30gm

2

lactic acid external lotion 10 %

2

LATRIX XM EXTERNAL EMULSION 45 %

4

LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 20 %

4

LOTRISONE EXTERNAL CREAM 1-0.05 %

4Brand

penalty applies

LOYON EXTERNAL SOLUTION

4

methoxsalen oral capsule 10 mg

2

methoxsalen rapid oral capsule 10 mg

2

methyl salicylate external liquid

2

metopic external cream 41 %

2

metronidazole external cream 0.75 %

2

metronidazole external gel 0.75 %, 1 %

2

Drug NameDrug Tier

Notes

metronidazole external lotion 0.75 %

2

MICROCYN EXTERNAL LIQUID 0.023 %

4

MIRVASO EXTERNAL GEL 0.33 %

4 PA

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2

NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 %

4

NUVAIL EXTERNAL SOLUTION

4

OVACE PLUS EXTERNAL CREAM 10 %

4

OVACE PLUS EXTERNAL SHAMPOO 10 %

4

OVACE PLUS WASH EXTERNAL LIQUID 10 %

4

OVACE WASH EXTERNAL LIQUID 10 %

4

OXSORALEN ULTRA ORAL CAPSULE 10 MG

3Brand

penalty applies

PICATO EXTERNAL GEL 0.015 %, 0.05 %

4 PA

pimecrolimus external cream 1 %

2

podocon external solution 25 %

2

podofilox external solution 0.5 %

2

pramox external gel 1 % 2

PRUDOXIN EXTERNAL CREAM 5 %

4Brand

penalty applies



113

Drug NameDrug Tier

Notes

PURAPLY EXTERNAL SHEET 6X9CM

GM

pyrogallic acid external ointment 25-2 %

2

QUTENZA (2 PATCH) EXTERNAL KIT 8 %

6Specialty Medical

QUTENZA EXTERNAL KIT 8 %

6Specialty Medical

RECEDO EXTERNAL GEL

4

REGRANEX EXTERNAL GEL 0.01 %

4 PA

RESORCINOL-SULFUR EXTERNAL LOTION 2-5 %

4

restizan external gel 2

RETIN-A MICRO EXTERNAL GEL 0.1 %

4Brand

penalty applies

RETIN-A MICRO PUMP EXTERNAL GEL 0.1 %

4Brand

penalty applies

RHOFADE EXTERNAL CREAM 1 %

4 PA

rosadan external cream 0.75 %

2

rosadan external gel 0.75 %

2

ROSADAN EXTERNAL KIT 0.75 % (CREAM)

4

ROSADAN EXTERNAL KIT 0.75 % (GEL)

4 PA

SALEX EXTERNAL SHAMPOO 6 %

4

salicylic acid external cream 6 %

2

salicylic acid external foam 6 %

2

salicylic acid external gel 6 %

2

Drug NameDrug Tier

Notes

salicylic acid external liquid 26 %, 27.5 %

2

salicylic acid external lotion 6 %

2

salicylic acid external shampoo 6 %

2

salicylic acid external solution 26 %

2

salicylic acid wart remover external liquid 27.5 %

2

salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)

2

salimez external cream 6 %

2

SALIMEZ FORTE EXTERNAL CREAM 10 %

4

salisol forte external solution 26 %

2

salitech forte external lotion 6 %

2

SALVAX DUO PLUS EXTERNAL KIT 6 & 35 %

4

SALVAX EXTERNAL FOAM 6 %

4

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

6

SCALACORT DK EXTERNAL KIT 2 & 2-2 %

4

SCARCIN EXTERNAL GEL

4

SCARSILK EXTERNAL GEL

4

selenium sulfide external lotion 2.5 %

2

selenium sulfide external shampoo 2.25 %, 2.3 %

2



114

Drug NameDrug Tier

Notes

selenium sulf-pyrithione-urea external shampoo 2.25 %

2

SELRX EXTERNAL SHAMPOO 2.3 %

4

sodium sulfacetamide external shampoo 10 %

2

sodium sulfacetamide wash liquid 10 % external 10 %

2

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL 10 %

4

SOOLANTRA EXTERNAL CREAM 1 %

4 PA

SORIATANE ORAL CAPSULE 10 MG, 25 MG

3Brand

penalty applies

SP SCAR MANAGEMENT EXTERNAL GEL

4

sss 10-5 external cream 10-5 %

2

sulfacetamide sodium (acne) external lotion 10 %

2

sulfacetamide sodium external liquid 10 %

2

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %

2

sulfacetamide sodium-sulfur external emulsion 10-5 %

2

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %

2

sulfacetamide sodium-sulfur external pad 10-4 %

2

Drug NameDrug Tier

Notes

sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 %

2

sulfacetamide sod-sulfur wash external kit 9-4.5 %

2

sulfacetamide-sulfur in urea external emulsion 10-5 %

2

sulfacleanse 8/4 external suspension 8-4 %

2

sulfamez wash external emulsion 10-1 %

2

SUMADAN EXTERNAL KIT 9-4.5 %

4

SUMAXIN CP EXTERNAL KIT 10-4 %

4

tacrolimus external ointment 0.03 %, 0.1 %

2

tazarotene external cream 0.1 %

2 PA

TAZORAC EXTERNAL CREAM 0.05 %

4 PA

TAZORAC EXTERNAL CREAM 0.1 %

4PA; Brand

penalty applies

TAZORAC EXTERNAL GEL 0.05 %, 0.1 %

4 PA

THERAHONEY EXTERNAL SHEET

4

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

2

tretinoin external gel 0.01 %, 0.025 %

2

tretinoin microsphere external gel 0.04 %, 0.1 %

2

tretinoin microsphere pump external gel 0.04 %, 0.1 %

2

TRI-CHLOR EXTERNAL LIQUID 80 %

4



115

Drug NameDrug Tier

Notes

turpentine external spirit 2

umecta mousse external foam 40 %

2

urea external cream 39 %, 40 %, 41 %, 45 %

2

urea external lotion 40 % 2

urea external suspension 40 %

2

urea hydrating external foam 35 %

2

urea in zn undecyl-lactic acid external emulsion 50 %

2

urea nail external gel 45 %

2

urea-c40 external lotion 40 %

2

uredeb external cream 39 %

2

ure-k external cream 50 %

2

uremez-40 external cream 40 %

2

VECTICAL EXTERNAL OINTMENT 3 MCG/GM

4ST; Brand

penalty applies

VENELEX EXTERNAL OINTMENT

4

VEREGEN EXTERNAL OINTMENT 15 %

4

VIRASAL EXTERNAL LIQUID 27.5 %

4

XERAC AC EXTERNAL SOLUTION 6.25 %

4

XERFORM OIL EMULSION ROLL EXTERNAL

4

XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD

4

Drug NameDrug Tier

Notes

XEROFORM OIL EMULSION GAUZE EXTERNAL PAD

4

XEROFORM OIL EMULSION STRIP EXTERNAL

4

XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL

4

XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL

4

XEROFORM PETROLAT PATCH 2"X2" EXTERNAL PAD

4

XEROFORM PETROLAT PATCH 4"X4" EXTERNAL PAD

4

XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL

4

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg

2

ZITHRANOL EXTERNAL SHAMPOO 1 %

4

ZONALON EXTERNAL CREAM 5 %

4Brand

penalty applies

Diabetes - Antidiabetic Agents

acarbose oral tablet 100 mg, 25 mg, 50 mg

2

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG

4Brand

penalty applies

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

4Brand

penalty applies

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML

4 PA



116

Drug NameDrug Tier

Notes

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML

4 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

4Brand

penalty applies

AVANDIA ORAL TABLET 2 MG, 4 MG

4 ST

BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML

3PA; QL

(3.4 ML per 28 days)

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

3PA; QL


Drug NameDrug Tier

Notes

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

3PA; QL


chlorpropamide oral tablet 100 mg, 250 mg

2

CYCLOSET ORAL TABLET 0.8 MG

4

DUETACT ORAL TABLET 30-2 MG, 30-4 MG

3Brand

penalty applies

FARXIGA ORAL TABLET 10 MG, 5 MG


days)

glimepiride oral tablet 1 mg, 2 mg, 4 mg

1

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

2

glipizide oral tablet 10 mg, 5 mg

1

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

2

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

2

GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 MG

4Brand

penalty applies

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

4Brand

penalty applies

GLUCOTROL ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

4Brand

penalty applies



117

Drug NameDrug Tier

Notes

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

2

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

2

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

2

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG

4Brand

penalty applies

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

4Brand

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)

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


days)

Drug NameDrug Tier

Notes

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

1

METFORMIN HCL ORAL SOLUTION 500 MG/5ML

4

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

1

miglitol oral tablet 100 mg, 25 mg, 50 mg

2

nateglinide oral tablet 120 mg, 60 mg

2

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)



118

Drug NameDrug Tier

Notes

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 0.25 OR 0.5 MG/DOSE

4PA; QL


OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 1 MG/DOSE


days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg

2

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

2

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

2

PRANDIN ORAL TABLET 1 MG, 2 MG

4Brand

penalty applies

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG

4Brand

penalty applies

QTERN ORAL TABLET 10-5 MG


days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg

2

repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

2

RIOMET ORAL SOLUTION 500 MG/5ML

4

Drug NameDrug Tier

Notes

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

4Brand

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

4 ST

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

4 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)

tolazamide oral tablet 250 mg, 500 mg

2

tolbutamide oral tablet 500 mg

2

TRADJENTA ORAL TABLET 5 MG


days)



119

Drug NameDrug Tier

Notes

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

4 PA

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


days)

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML


days)

Diabetes - Glucose Monitoring

FREESTYLE INSULINX TEST IN VITRO STRIP

3QL (150

EA per 30 days)

FREESTYLE LITE TEST IN VITRO STRIP

3QL (150

EA per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP


Drug NameDrug Tier

Notes

FREESTYLE TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION PCX PLUS TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION QID TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION SOF-TACT TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP

3

Diabetes - Glycemic Agents

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

3

GLUCAGON EMERGENCY INJECTION KIT 1 MG

3

PROGLYCEM ORAL SUSPENSION 50 MG/ML

4

Diabetes - Insulins

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4ST; QL (1 ML per 1

day)

ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

4QL (60 ML

per 30 days)

ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

4ST; QL

(0.67 ML per 1 day)



120

Drug NameDrug Tier

Notes

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 (90) & 8 (90) UNIT, 8 UNIT

4QL (60 EA

per 30 days)

AFREZZA INHALATION POWDER 4 UNIT

4QL (180

EA per 30 days)

AFREZZA INHALATION POWDER 8 (90)& 12 (90) UNIT

4

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4QL (60 ML

per 30 days)

APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML

4QL (60 ML

per 30 days)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4QL (1 ML per 1 day)

COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM

3

COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM

3

EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , 29G X 8MM

3

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4ST; QL (60 ML per 30

days)

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

GOODSENSE CLICKFINE PEN NEEDLE 31G X 5 MM

3

Drug NameDrug Tier

Notes

GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

3

HEALTHWISE INSULIN SYR/NEEDLE 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

3

HEALTHWISE MICRON PEN NEEDLES 32G X 4 MM

3

HUMALOG U-100 AND U-200 KWIKPEN

3QL (60 ML

per 30 days)

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)



121

Drug NameDrug Tier

Notes

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R U-500 VIAL (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

3

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 1 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 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

3

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (2 ML per 1 day)

LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

MAXI-COMFORT SAFETY PEN NEEDLE 29G X 5MM , 29G X 8MM

3

NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM

3

NOVOFINE PEN NEEDLE 32G X 6 MM

3



122

Drug NameDrug Tier

Notes

NOVOFINE PLUS PEN NEEDLE 32G X 4 MM

3

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)

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)

Drug NameDrug Tier

Notes

NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

NOVOTWIST PEN NEEDLE 32G X 5 MM

3

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

3QL (60 ML

per 30 days)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

3QL (60 ML

per 30 days)

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

4QL (60 ML

per 30 days)

TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML

4QL (60 ML

per 30 days)

TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM

3

ULTRACARE PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 33G X 4 MM

3

Electrolytes / Minerals / Metals / Vitamins

ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

4

ACTIVE FE ORAL TABLET 75-1.25 MG

4

ACTIVITE ORAL TABLET 1 MG

4

adc/f (0.5mg/ml) oral solution 0.5 mg/ml

2



123

Drug NameDrug Tier

Notes

ADRENAL C FORMULA ORAL TABLET

4

ADVANCED AM/PM ORAL

4

AMINO ACID INTRAVENOUS SOLUTION 10 %

GM

aminoam rms oral capsule

2

aminorelief rms oral capsule

2

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %, 8.5 %

GM

aminosyn ii/electrolytes intravenous solution 8.5 %

GM

AMINOSYN INTRAVENOUS SOLUTION 10 %, 8.5 %

GM

AMINOSYN M INTRAVENOUS SOLUTION 3.5 %

GM

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %

GM

aminosyn/electrolytes intravenous solution 8.5 %

GM

AMINOSYN-HBC INTRAVENOUS SOLUTION 7 %

GM

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

GM

AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 %

GM

ANIMI-3 ORAL CAPSULE 1 MG

4

Drug NameDrug Tier

Notes

ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG

4

AP-ZEL ORAL TABLET 4

AQUASOL A INTRAMUSCULAR SOLUTION 50000 UNIT/ML

GM

argyle sterile saline irrigation solution 0.9 %

2

ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML

GM

b-6 folic acid oral capsule 400-1000-50 mcg-mcg-mg

2

BACMIN ORAL TABLET 4

bd posiflush intravenous solution 0.9 %

2

biocel oral tablet 2

bp vit 3 oral capsule 1 mg

2

b-plex oral tablet 2

b-plex plus oral tablet 2

CALCIFOL ORAL WAFER 1342-1.6 MG

4

CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS 10 %

GM

calcium chloride solution 10 % intravenous 10 %

GM

CALCIUM GLUCONATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1000 MG/10ML

GM



124

Drug NameDrug Tier

Notes

CALCIUM GLUCONATE-DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/100ML-%, 1-5 GM/50ML-%, 2-5 GM/100ML-%, 2-5 GM/50ML-%, 4-5 GM/250ML-%

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%, 1-0.9 GM/50ML-%, 3-0.9 GM/100ML-%, 4-0.9 GM/250ML-%

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 GM/50ML-%

GM

CALCIUM-FOLIC ACID PLUS D ORAL WAFER 1342-1 MG

4

CARBAGLU ORAL TABLET 200 MG

6 PA

CARDIOPLEGIC SOLUTION PERFUSION

GM

cardioplegic solution perfusion

GM

CARNITOR INTRAVENOUS SOLUTION 200 MG/ML

GM

CARNITOR ORAL SOLUTION 1 GM/10ML

4Brand

penalty applies

CARNITOR ORAL TABLET 330 MG

4Brand

penalty applies

CARNITOR SF ORAL SOLUTION 1 GM/10ML

4Brand

penalty applies

CENTRATEX ORAL CAPSULE 106-1 MG

4

Drug NameDrug Tier

Notes

CHEMET ORAL CAPSULE 100 MG

4

chromagen oral capsule 2

chromic chloride intravenous solution 40 mcg/10ml

GM

CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG

4

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 %

GM


GM


GM


GM


GM

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

GM

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %

GM

CLINIMIX N9G20E INTRAVENOUS SOLUTION 2.75 %

GM

CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 %

GM



125

Drug NameDrug Tier

Notes


GM


GM

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

GM


GM


GM

clinisol sf intravenous solution 15 %

GM

cod liver oil oral oil 2

COPPER CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML

GM

corvita 150 oral tablet 150-1.25 mg

2

corvita oral tablet 1.25 mg

2

CORVITE 150 ORAL TABLET , 150-1.25 MG

4

CORVITE FE ORAL TABLET

4

corvite free oral tablet 2

CORVITE ORAL TABLET 1.25 MG

4

cyanocobalamin injection solution 1000 mcg/ml

2

cytra k crystals oral packet 3300-1002 mg

2

d3 vitamin oral liquid 400 unit/ml

PVAL (Min 65

Years)

Drug NameDrug Tier

Notes

DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

4


4


4

delflex-sm/1.5% dextrose intraperitoneal solution 347 mosm/l

2

delflex-sm/2.5% dextrose intraperitoneal solution 398 mosm/l

2

dexifol oral tablet 5 mg 2

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



126

Drug NameDrug Tier

Notes

dextrose-nacl intravenous solution 10-0.2 %, 10-0.225 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.3 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

GM

DIALYVITE 3000 ORAL TABLET 3 MG

4

DIALYVITE 5000 ORAL TABLET 5 MG

4

dialyvite oral tablet 2

DIALYVITE SUPREME D ORAL TABLET 3 MG

4

DIALYVITE/ZINC ORAL TABLET

4

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 344 MOSM/L

4


4


4

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 346 MOSM/L

4


4


4

DRISDOL ORAL CAPSULE 50000 UNIT

4Brand

penalty applies

Drug NameDrug Tier

Notes

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

4

effer-k oral tablet effervescent 25 meq

2

ELLIOTTS B INTRATHECAL SOLUTION

GM

ergocalciferol oral capsule 50000 unit

2

ESCAVITE D ORAL TABLET CHEWABLE 0.25-6 MG

4

escavite lq oral liquid 0.25-6 mg/ml

2

ESCAVITE ORAL TABLET CHEWABLE 0.25-7.5 MG

4

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

6 PA

EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 %

4

fabb oral tablet 2.2-25-1 mg

2

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg

2

FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML

GM

FERIVAFA ORAL CAPSULE 110-1 MG

4

ferocon oral capsule 2

ferotrinsic oral capsule 2

FERRALET 90 ORAL TABLET 90-1 MG

4

FERRAPLUS 90 ORAL TABLET 90-1 MG

4



127

Drug NameDrug Tier

Notes

FERRIPROX ORAL SOLUTION 100 MG/ML

6 PA

FERRIPROX ORAL TABLET 500 MG

6 PA

FERRLECIT INTRAVENOUS SOLUTION 12.5 MG/ML

GM

FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG

4

FERROTRIN ORAL CAPSULE

4

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

4

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

4

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

4

folbee plus oral tablet 2

FOLGARD OS ORAL TABLET 500-1.1 MG

4

FOLGARD RX ORAL TABLET 2.2-25-1 MG

4

folic acid injection solution 5 mg/ml

GM

folic acid oral tablet 1 mg 2

folic acid oral tablet 400 mcg, 800 mcg

PV

FOLIKA-T ORAL TABLET 1 MG

4

FOLIVANE-F ORAL CAPSULE 125-1 MG

4

FOLIVANE-PLUS ORAL CAPSULE

4

folplex 2.2 oral tablet 2.2-25-0.5 mg

2

FOLTRATE ORAL TABLET 500-1 MCG-MG

4

foltrin oral capsule 2

Drug NameDrug Tier

Notes

FORTAVIT ORAL CAPSULE

4

FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

GM

FREAMINE III INTRAVENOUS SOLUTION 10 %

GM

FUSION PLUS ORAL CAPSULE

4

GALZIN ORAL CAPSULE 25 MG, 50 MG

3

GENICIN VITA-S ORAL TABLET 1 MG

4

glucose intravenous solution 5 %

GM

gnp folic acid oral tablet 400 mcg

PV

hematinic/folic acid oral tablet 324-1 mg

2

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG

4

hematogen forte oral capsule 460-60-0.01-1 mg

2

hematogen oral capsule 2

HEMATRON-AF ORAL TABLET 150-1 MG

4

HEMETAB ORAL TABLET 22-6-1-0.025 MG

4

HEMOCYTE PLUS ORAL CAPSULE 106-1 MG

4

hemocyte-f oral tablet 324-1 mg

2

HEPATAMINE INTRAVENOUS SOLUTION 8 %

GM



128

Drug NameDrug Tier

Notes

hydroxocobalamin acetate intramuscular solution 1000 mcg/ml

GM

HYLAVITE ORAL TABLET

4

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG

4

iferex 150 forte oral capsule 150-25-1 mg-mcg-mg

2

INFUVITE ADULT INTRAVENOUS INJECTABLE

GM

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

GM

INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML

GM

INTEGRA F ORAL CAPSULE 125-1 MG

4

INTEGRA PLUS ORAL CAPSULE

4

intralipid intravenous emulsion 20 %

GM

INTRALIPID INTRAVENOUS EMULSION 30 %

GM

iodine strong oral solution 5 %

2

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION

GM

IROSPAN 24/6 ORAL 4

IS 24/6 ORAL 4

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION

GM

Drug NameDrug Tier

Notes

ISOLYTE-S INTRAVENOUS SOLUTION

GM

ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION

GM

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

6 PA

JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG

6 PA

JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

6 PA

KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 %

GM

kcl in d5w lactated ringers intravenous solution 40 meq/l

GM

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

GM

KCL IN LACTATED RINGERS INTRAVENOUS SOLUTION 20 MEQ/L

GM

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

GM

KCL-LIDOCAINE IN NACL INTRAVENOUS SOLUTION 20-10 MEQ-MG /100ML

GM



129

Drug NameDrug Tier

Notes

KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 MEQ-MG /100ML

GM

kionex oral suspension 15 gm/60ml

2

klor-con 10 oral tablet extended release 10 meq

2

klor-con m10 oral tablet extended release 10 meq

2

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

4

klor-con m20 oral tablet extended release 20 meq

2

klor-con oral packet 20 meq

2

klor-con oral tablet extended release 8 meq

2

klor-con sprinkle oral capsule extended release 10 meq, 8 meq

2

klor-con/ef oral tablet effervescent 25 meq

2

K-PHOS NO 2 ORAL TABLET 305-700 MG

4

K-PHOS ORAL TABLET 500 MG

4

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG

4

k-prime oral tablet effervescent 25 meq

2

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

4Brand

penalty applies

k-tan plus oral capsule 162-115.2-1 mg

2

lactated ringers intravenous solution

GM

Drug NameDrug Tier

Notes

lactated ringers irrigation solution

2

lecithin oral granules 2

levocarnitine oral solution 1 gm/10ml

2

levocarnitine oral tablet 330 mg

2

LIQUIVIDA HYDRATION INTRAVENOUS KIT 0.9 %

GM

LORID ORAL TABLET 1 MG

4

lysiplex plus oral tablet 2

M.V.I. ADULT INTRAVENOUS INJECTABLE

GM

M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

GM

M.V.I.-12 (WITHOUT VITAMIN K) INTRAVENOUS INJECTABLE

GM

MAGNEBIND 400 ORAL TABLET 400-200-1 MG

4

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%

GM



130

Drug NameDrug Tier

Notes

MAGNESIUM SULFATE IN D5W INTRAVENOUS SOLUTION 1-5 GM/50ML-%, 10-5 GM/100ML-%, 10-5 GM/250ML-%, 2-5 GM/100ML-%, 2-5 GM/50ML-%, 20-5 GM/250ML-%, 20-5 GM/500ML-%, 20-5 GM/L-%, 25-5 GM/250ML-%, 3-5 GM/50ML-%, 4-5 GM/100ML-%, 4-5 GM/50ML-%, 40-5 GM/500ML-%, 40-5 GM/L-%, 5-5 GM/100ML-%, 50-5 GM/500ML-%, 6-5 GM/100ML-%, 6-5 GM/50ML-%

GM

magnesium sulfate injection solution 50 %

2

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-LACT RINGERS INTRAVENOUS SOLUTION 10 GM/250ML, 20 GM/250ML, 20 GM/500ML, 25 GM/250ML, 40 GM/1000ML, 40 GM/500ML, 50 GM/500ML

GM

Drug NameDrug Tier

Notes

MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 1-0.9 GM/50ML-%, 10-0.9 GM/100ML-%, 2-0.9 GM/100ML-%, 2-0.9 GM/50ML-%, 20-0.9 GM/250ML-%, 3-0.9 GM/150ML-%, 3-0.9 GM/50ML-%, 4-0.9 GM/100ML-%, 4-0.9 GM/50ML-%, 40-0.9 GM/500ML-%, 40-0.9 GM/L-%, 6-0.9 GM/100ML-%, 6-0.9 GM/150ML-%, 6-0.9 GM/50ML-%

GM

MANGANESE CHLORIDE INTRAVENOUS SOLUTION 0.1 MG/ML

GM

MAXFE ORAL TABLET 160-1 MG

4

MEPHYTON ORAL TABLET 5 MG

4Brand

penalty applies

MIFEPREX ORAL TABLET 200 MG

4

M-NATAL PLUS ORAL TABLET 27-1 MG

4

monoject flush syringe intravenous solution 0.9 %

2

monoject sodium chloride flush intravenous solution 0.9 %

2

MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG

4

MULTIGEN ORAL TABLET 70 MG

4

MULTIGEN PLUS ORAL TABLET 50-101-1 MG

4



131

Drug NameDrug Tier

Notes

multi-vit/iron/fluoride oral solution 0.25-10 mg/ml

2

multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg

2

multivitamin/fluoride/iron oral solution 0.25-10 mg/ml

2

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

2

mvc-fluoride oral tablet chewable 0.25 mg, 1 mg

2

myferon 150 forte oral capsule 150-25-1 mg-mcg-mg

2

mynephrocaps oral capsule 1 mg

2

mynephron oral capsule 1 mg

2

na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml

GM

n-acetyl-l-cysteine oral capsule 600 mg

2

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

3

NEPHPLEX RX ORAL TABLET

4

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

GM

NEPHRON FA ORAL TABLET

4

nephronex oral tablet 2

Drug NameDrug Tier

Notes

NEPHRO-VITE RX ORAL TABLET 1 MG

4

NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

4

NICADAN ORAL TABLET

4

NICAZEL FORTE ORAL TABLET

4

NICAZEL ORAL TABLET 4

NICOMIDE ORAL TABLET 750-27-2-0.5 MG

4

NIFEREX ORAL TABLET

4

normal saline flush intravenous solution 0.9 %

2

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 4

NUTRICAP ORAL TABLET

4

nutrifac zx oral tablet 2

nutrilipid intravenous emulsion 20 %

GM

NUTRIVIT ORAL LIQUID 4

OMEGAVEN INTRAVENOUS EMULSION 10 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical



132

Drug NameDrug Tier

Notes

ONEVITE ORAL TABLET 1 MG

4

ORACIT ORAL SOLUTION 490-640 MG/5ML

3

PERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 %

GM

phospha 250 neutral oral tablet 155-852-130 mg

2

phosphorous oral tablet 155-852-130 mg

2

phospho-trin 250 neutral oral tablet 155-852-130 mg

2

physiolyte irrigation solution

2

physiosol irrigation irrigation solution

2

phytonadione injection solution 1 mg/0.5ml

GM

phytonadione oral tablet 5 mg

2

PLASMA-LYTE 148 INTRAVENOUS SOLUTION

GM

PLASMA-LYTE A INTRAVENOUS SOLUTION

GM

PLEGISOL PERFUSION SOLUTION

GM

plenamine intravenous solution 15 %

GM

pnv prenatal plus multivit+dha oral 27-1 & 312 mg

2

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

2

Drug NameDrug Tier

Notes

polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg

2

POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG, 1 MG

4

POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML

4

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

4

POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML

4

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG

4

pot bicarb-pot chloride oral tablet effervescent 25 meq

2

potassium acetate intravenous solution 2 meq/ml

GM

POTASSIUM ACETATE-NACL INTRAVENOUS SOLUTION 10 MEQ/100ML

GM

potassium bicarbonate oral tablet effervescent 25 meq

2

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

2

potassium chloride er oral capsule extended release 10 meq, 8 meq

2

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

2



133

Drug NameDrug Tier

Notes

POTASSIUM CHLORIDE IN D5W INTRAVENOUS SOLUTION 10 MEQ/500ML, 20 MEQ/250ML, 40 MEQ/250ML, 40 MEQ/500ML

GM

potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

GM

POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 10 MEQ/100ML, 10 MEQ/500ML, 10-0.9 MEQ/L-%, 20 MEQ/250ML, 30 MEQ/100ML, 40 MEQ/250ML, 40 MEQ/500ML

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 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/50ml, 40 meq/100ml

GM

POTASSIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MEQ/5ML

GM

potassium chloride oral packet 20 meq

2

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

2

potassium chloride proamp intravenous solution 2 meq/ml

GM

Drug NameDrug Tier

Notes

POTASSIUM CHLORIDE SOLUTION 20 MEQ/100ML INTRAVENOUS 20 MEQ/100ML

GM

potassium chloride solution 20 meq/100ml intravenous 20 meq/100ml

GM

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

2

potassium citrate-citric acid oral solution 1100-334 mg/5ml

2

POTASSIUM PHOSPHATE-NACL INTRAVENOUS SOLUTION 15 MMOL/100ML

GM

POTASSIUM PHOSPHATES-DEXTROSE INTRAVENOUS SOLUTION 15 MMOL/250ML, 30 MMOL/500ML, 7.5 MMOL/100ML, 9 MMOL/50ML

GM



134

Drug NameDrug Tier

Notes

POTASSIUM PHOSPHATES-NACL INTRAVENOUS SOLUTION 10 MMOL/100ML, 10 MMOL/250ML, 15 MMOL/150ML, 15 MMOL/250ML, 20 MMOL/100ML, 22 MMOL/500ML, 30 MMOL/250ML, 30 MMOL/500ML, 40 MMOL/250ML, 5 MMOL/250ML, 7 MMOL/100ML, 7.5 MMOL/100ML, 9 MMOL/100ML

GM

PREMASOL INTRAVENOUS SOLUTION 10 %

GM

premasol intravenous solution 6 %

GM

PREMESISRX ORAL TABLET 1 MG

4

prenatal oral tablet 27-1 mg

2

prenatal plus iron oral tablet 29-1 mg

2

PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION 22-4 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

PROCALAMINE INTRAVENOUS SOLUTION 3 %

GM

PROSOL INTRAVENOUS SOLUTION 20 %

GM

Drug NameDrug Tier

Notes

PROTECT PLUS ORAL CAPSULE

4

PROTECTIRON ORAL TABLET 60-1 MG

4

PUREFE PLUS ORAL CAPSULE 106-1 MG

4

purevit dualfe plus oral capsule 162-115.2-1 mg

2

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

2

quflora pediatric oral tablet chewable 0.25 mg, 1 mg

2

RELNATE DHA ORAL CAPSULE 28-1-200 MG

4

renal oral capsule 1 mg 2

RENATABS ORAL TABLET 1 MG

4

RENATABS WITH IRON ORAL 1 & 100 MG

4

REQ 49+ ORAL TABLET 4

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML

6PA;

Specialty Medical

ringers intravenous solution

GM

ringers irrigation irrigation solution

2

saline bacteriostatic injection solution 0.9 %

GM

saline flush intravenous solution 0.9 %

2



135

Drug NameDrug Tier

Notes

saline flush zr intravenous solution 0.9 %

2

saline-benzyl alcohol solution 0.9 % injection 0.9 %

GM

SALINE-BENZYL ALCOHOL SOLUTION 0.9 % INJECTION 0.9 %

GM

SALINE-PHENOL INJECTION SOLUTION 0.4-0.9 %

GM

SAMSCA ORAL TABLET 15 MG, 30 MG

6 PA

se-tan plus oral capsule 162-115.2-1 mg

2

SIDEROL ORAL TABLET

4

SMOFLIPID INTRAVENOUS EMULSION 20 %

GM

sod citrate-citric acid oral solution 500-334 mg/5ml

2

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 MEQ/L

GM

sodium chloride bacteriostatic injection solution 0.9 %

GM

Drug NameDrug Tier

Notes

sodium chloride flush intravenous solution 0.9 %

2

sodium chloride injection solution 0.9 %, 2.5 meq/ml

GM

sodium chloride intravenous solution 0.45 %, 3 %, 5 %

GM

sodium chloride irrigation solution 0.9 %

2

SODIUM CHLORIDE SOLUTION 0.9 % INTRAVENOUS 0.9 %

GM

sodium chloride solution 0.9 % intravenous 0.9 %

GM

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 lactate intravenous solution 5 meq/ml

GM

SODIUM PHOSPHATE-NACL INTRAVENOUS SOLUTION 10 MMOL/100ML, 15 MMOL/100ML, 15 MMOL/250ML, 30 MMOL/250ML, 40 MMOL/250ML, 7.5 MMOL/100ML, 9 MMOL/50ML

GM



136

Drug NameDrug Tier

Notes

SODIUM PHOSPHATES-DEXTROSE INTRAVENOUS SOLUTION 15 MMOL/100ML, 15 MMOL/250ML

GM

sodium polystyrene sulfonate oral powder

2

sodium polystyrene sulfonate oral suspension 15 gm/60ml

2

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

2

sps oral suspension 15 gm/60ml

2

STROVITE FORTE ORAL SYRUP

4

STROVITE FORTE ORAL TABLET

4

STROVITE ONE ORAL TABLET

4

SUPERVITE ORAL LIQUID

4

SUPPORT ORAL LIQUID

4

SUPPORT-500 ORAL CAPSULE

4

swabflush saline flush intravenous solution 0.9 %

2

SYNAGEX ORAL CAPSULE 1.25 MG

4

SYNATEK ORAL CAPSULE 1.25 MG

4

SYNTHAMIN 17 INTRAVENOUS SOLUTION 10 %

GM

SYPRINE ORAL CAPSULE 250 MG

6 PA

Drug NameDrug Tier

Notes

TALIVA ORAL CAPSULE 1 MG

4

TARON FORTE ORAL CAPSULE

4

taron-crystals oral packet 3300-1002 mg

2

thiamine hcl injection solution 100 mg/ml

GM

tis-u-sol irrigation solution 2

tl gard rx oral tablet 2.2-25-1 mg

2

TL G-FOL OS ORAL TABLET 500-1.1 MG

4

tl icon oral capsule 2

TL-FLUORIVITE ORAL TABLET CHEWABLE 0.25-7.5 MG

4

tl-hem 150 oral tablet 150-1 mg

2

tpn electrolytes intravenous solution

GM

TRAVASOL INTRAVENOUS SOLUTION 10 %

GM

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

4

tricitrates oral solution 550-500-334 mg/5ml

2

tricon oral capsule 2

trientine hcl oral capsule 250 mg

6 PA

trigels-f forte oral capsule 460-60-0.01-1 mg

2

triphrocaps oral capsule 1 mg

2

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

4



137

Drug NameDrug Tier

Notes

TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

4

tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

TRONVITE ORAL TABLET 1 MG

4

TROPHAMINE INTRAVENOUS SOLUTION 10 %, 6 %

GM

tryptophan oral capsule 500 mg

2

UDAMIN SP ORAL TABLET 1 MG

4

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 346 MOSM/L

4

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 396 MOSM/L

4

ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION 485 MOSM/L

4

ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

4

ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 395 MOSM/L

4

ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 483 MOSM/L

4

Drug NameDrug Tier

Notes

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1080 MG)

3Brand

penalty applies


3Brand

penalty applies


3Brand

penalty applies

urosex oral tablet 2

v-c forte oral capsule 2

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM

4 PA

VENOFER INTRAVENOUS SOLUTION 20 MG/ML

GM

vic-forte oral capsule 2

virt-caps oral capsule 1 mg

2

VIRT-FEFA PLUS ORAL CAPSULE

4

virt-gard oral tablet 2.2-25-1 mg

2

virt-phos 250 neutral oral tablet 155-852-130 mg

2

vita s forte oral tablet 2

vitacel oral tablet 2

VITAFOL ORAL TABLET 4

VITAL-D RX ORAL TABLET 1 MG

4

vitamax pediatric oral solution

2

VITAMEZ ORAL CAPSULE 1 MG

4

vitamin d (cholecalciferol) oral capsule 400 unit

PVAL (Min 65

Years)



138

Drug NameDrug Tier

Notes

vitamin d (ergocalciferol) oral capsule 50000 unit

2

vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml

GM

vita-min oral capsule 2

vitamins acd-fluoride oral solution 0.25 mg/ml

2

VITAROCA PLUS ORAL TABLET

4

VITA-RX DIABETIC VITAMIN ORAL CAPSULE

4

vol-care rx oral tablet 1 mg

2

vp-vite rx oral tablet 1 mg 2

wheat germ oil oral oil 2

xvite oral tablet 1 mg 2

ZINC TRACE METAL INTRAVENOUS SOLUTION 1 MG/ML

GM

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG

4Brand

penalty applies

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG

4

CARAFATE ORAL SUSPENSION 1 GM/10ML

3

CARAFATE ORAL TABLET 1 GM

4Brand

penalty applies

cimetidine hcl oral solution 300 mg/5ml

2

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

2

Drug NameDrug Tier

Notes

CYTOTEC ORAL TABLET 100 MCG, 200 MCG

4Brand

penalty applies

DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG

4 PA

esomeprazole sodium intravenous solution reconstituted 20 mg, 40 mg

GM

famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

GM

famotidine oral suspension reconstituted 40 mg/5ml

2

famotidine oral tablet 20 mg, 40 mg

2

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

GM

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML

2 PA

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML

2

lansoprazole oral capsule delayed release 15 mg, 30 mg

2

lansoprazole oral tablet dispersible 15 mg, 30 mg

2

misoprostol oral tablet 100 mcg, 200 mcg

2

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG

2

Brand penalty


NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20 MG

2QL (120

EA per 30 days)



139

Drug NameDrug Tier

Notes

NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

nizatidine oral capsule 150 mg, 300 mg

2

nizatidine oral solution 15 mg/ml

2

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

2

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML

2

pantoprazole sodium intravenous solution reconstituted 40 mg

GM

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

2

PEPCID ORAL TABLET 20 MG, 40 MG

4Brand

penalty applies

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG

4Brand

penalty applies

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG

4Brand

penalty applies

PRILOSEC ORAL PACKET 10 MG, 2.5 MG

4

PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

PROTONIX ORAL PACKET 40 MG

4

Drug NameDrug Tier

Notes

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG

4Brand

penalty applies

rabeprazole sodium oral tablet delayed release 20 mg

2

ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml

GM

ranitidine hcl oral capsule 150 mg, 300 mg

2

ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml

1

ranitidine hcl oral tablet 150 mg, 300 mg

2

sucralfate oral tablet 1 gm

2

ZANTAC INJECTION SOLUTION 1000 MG/40ML, 150 MG/6ML, 50 MG/2ML

GM

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL ORAL CAPSULE 300 MG

4Brand

penalty applies

alosetron hcl oral tablet 0.5 mg, 1 mg

2

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

3QL (60 EA

per 30 days)

amoxicill-clarithro-lansopraz oral

2

ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG

4

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1.2 MG/3ML, 2 MG/5ML

GM



140

Drug NameDrug Tier

Notes

belladonna alkaloids-opium rectal suppository 16.2-60 mg

2

belladonna-opium rectal suppository 16.2-30 mg

2

BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML

GM

CHENODAL ORAL TABLET 250 MG

6

chlordiazepoxide-clidinium oral capsule 5-2.5 mg

2

CHOLBAM ORAL CAPSULE 250 MG, 50 MG

6 PA

CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML

4

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM

4

Brand penalty

applies; QL (1 ML per 365 days); AL (Min 50 Years and

Max 75 Years)

constulose oral solution 10 gm/15ml

2

cromolyn sodium oral concentrate 100 mg/5ml

2

CUVPOSA ORAL SOLUTION 1 MG/5ML

4

dicyclomine hcl intramuscular solution 10 mg/ml

GM

dicyclomine hcl oral capsule 10 mg

1

dicyclomine hcl oral solution 10 mg/5ml

2

dicyclomine hcl oral tablet 20 mg

1

Drug NameDrug Tier

Notes

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

2

diphenoxylate-atropine oral tablet 2.5-0.025 mg

2

ed-spaz oral tablet dispersible 0.125 mg

2

ENTEREG ORAL CAPSULE 12 MG

4

enulose oral solution 10 gm/15ml

2

GASTROCROM ORAL CONCENTRATE 100 MG/5ML

4Brand

penalty applies

GATTEX SUBCUTANEOUS KIT 5 MG

6 PA

gavilyte-c oral solution reconstituted 240 gm

2

PV*; QL (1 ML per 365 days); AL (Min 50

Years and Max 75 Years)

gavilyte-g oral solution reconstituted 236 gm

2



gavilyte-h oral kit 5-210 mg-gm

2

gavilyte-n with flavor pack oral solution reconstituted 420 gm

2



generlac oral solution 10 gm/15ml

2



141

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 INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/2ML

GM

glycopyrrolate oral tablet 1 mg, 2 mg

2

GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML

GM

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

4

QL (1 EA per 365

days); AL (Min 50


GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

4

Brand penalty


Max 75 Years)

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

2

hyoscyamine sulfate oral elixir 0.125 mg/5ml

2

hyoscyamine sulfate oral solution 0.125 mg/ml

2

hyoscyamine sulfate oral tablet 0.125 mg

2

Drug NameDrug Tier

Notes

hyoscyamine sulfate oral tablet dispersible 0.125 mg

2

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

2

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

2

KRISTALOSE ORAL PACKET 10 GM

4Brand

penalty applies

KRISTALOSE ORAL PACKET 20 GM

4

lactulose encephalopathy oral solution 10 gm/15ml

2

lactulose oral packet 10 gm

2

lactulose oral solution 10 gm/15ml, 20 gm/30ml

2

LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG

4

LEVSIN ORAL TABLET 0.125 MG

4

LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG

4

LIBRAX ORAL CAPSULE 5-2.5 MG

4Brand

penalty applies

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

3QL (30 EA

per 30 days)

LOMOTIL ORAL TABLET 2.5-0.025 MG

4Brand

penalty applies

loperamide hcl oral capsule 2 mg

2

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

4Brand

penalty applies



142

Drug NameDrug Tier

Notes

methscopolamine bromide oral tablet 2.5 mg, 5 mg

2

mineral oil heavy oral oil 2

MOTOFEN ORAL TABLET 1-0.025 MG

4

MOVANTIK ORAL TABLET 12.5 MG, 25 MG

4QL (30 EA

per 30 days)

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

4

nulev oral tablet dispersible 0.125 mg

2

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM

4

Brand penalty


Max 75 Years)

OMECLAMOX-PAK ORAL 500-500-20 MG

4

opium oral tincture 10 mg/ml (1%)

2

oscimin oral tablet 0.125 mg

2

oscimin oral tablet dispersible 0.125 mg

2

oscimin sr oral tablet extended release 12 hour 0.375 mg

2

oscimin sublingual tablet sublingual 0.125 mg

2

OSMOPREP ORAL TABLET 1.102-0.398 GM

4

paregoric oral tincture 2 mg/5ml

2

Drug NameDrug Tier

Notes

peg 3350/electrolytes oral solution reconstituted 240 gm

2



peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

2



peg-3350/electrolytes oral solution reconstituted 236 gm

2



peg-prep oral kit 5-210 mg-gm

2

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

2

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

4

propantheline bromide oral tablet 15 mg

2

PYLERA ORAL CAPSULE 140-125-125 MG

4

RELISTOR ORAL TABLET 150 MG

3 PA

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

3 PA

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

6 PA



143

Drug NameDrug Tier

Notes

sodium bicarbonate oral powder

2

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/177ML

4

SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 MG

4

symax-sr oral tablet extended release 12 hour 0.375 mg

2

SYMPROIC ORAL TABLET 0.2 MG

4QL (30 EA

per 30 days)

trilyte oral solution reconstituted 420 gm

2



TRULANCE ORAL TABLET 3 MG

4QL (30 EA

per 30 days)

URSO 250 ORAL TABLET 250 MG

4Brand

penalty applies

URSO FORTE ORAL TABLET 500 MG

4Brand

penalty applies

ursodiol oral capsule 300 mg

2

ursodiol oral tablet 250 mg, 500 mg

2

VIBERZI ORAL TABLET 100 MG, 75 MG

5 PA

XERMELO ORAL TABLET 250 MG

6 PA

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG

6 PA

Drug NameDrug Tier

Notes

Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment

ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML

6PA;

Specialty Medical

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

6PA;

Specialty Medical

AMMONUL INTRAVENOUS SOLUTION 10-10 %

GM

BRINEURA KIT 2 X 150 MG/5ML

6PA;

Specialty Medical

BUPHENYL ORAL POWDER 3 GM/TSP

4Brand

penalty applies

BUPHENYL ORAL TABLET 500 MG

4Brand

penalty applies

CERDELGA ORAL CAPSULE 84 MG

6 PA

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

3

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML

6 PA

CYSTADANE ORAL POWDER

4

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

4



144

Drug NameDrug Tier

Notes

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML

6PA;

Specialty Medical

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT

6PA;

Specialty Medical

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG

6PA;

Specialty Medical

GALAFOLD ORAL CAPSULE 123 MG

6 PA

KANUMA INTRAVENOUS SOLUTION 20 MG/10ML

6PA;

Specialty Medical

KUVAN ORAL PACKET 100 MG, 500 MG

6

KUVAN ORAL TABLET SOLUBLE 100 MG

6 PA

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

miglustat oral capsule 100 mg

6 PA

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

6PA;

Specialty Medical

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG

6 PA

OCALIVA ORAL TABLET 10 MG, 5 MG

6 PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

6 PA

Drug NameDrug Tier

Notes

ORFADIN ORAL SUSPENSION 4 MG/ML

6 PA

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML

6 PA

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

4

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

4

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 MG

6 PA

RAVICTI ORAL LIQUID 1.1 GM/ML

6 PA

sod benz-sod phenylacet intravenous solution 10-10 %

GM

sodium phenylbutyrate oral powder 3 gm/tsp

2

sodium phenylbutyrate oral tablet 500 mg

2

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

6PA;

Specialty Medical

SUCRAID ORAL SOLUTION 8500 UNIT/ML

6 PA



145

Drug NameDrug Tier

Notes

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML

6PA;

Specialty Medical

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT

4

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

ZAVESCA ORAL CAPSULE 100 MG

6 PA

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 10000-32000 UNIT, 15000-47000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT, 5000-24000 UNIT

3

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation solution 0.25 %

2

aminoacetic acid irrigation solution 1.5 %

2

AURYXIA ORAL TABLET 1 GM 210 MG(FE)

4

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

2

calcium acetate (phos binder) oral capsule 667 mg

2

Drug NameDrug Tier

Notes

calcium acetate (phos binder) oral tablet 667 mg

2

CIALIS ORAL TABLET 10 MG, 20 MG

4

PA; Brand penalty

applies; QL (4 EA per 30 days);

AL (Min 18 Years)

CIALIS ORAL TABLET 2.5 MG, 5 MG

4

PA; Brand penalty

applies; QL (30 EA per 30 days);

AL (Min 18 Years)

darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

2

DEPEN TITRATABS ORAL TABLET 250 MG

5

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG

4Brand

penalty applies

DETROL ORAL TABLET 1 MG, 2 MG

4Brand

penalty applies

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 5 MG

4Brand

penalty applies

ELMIRON ORAL CAPSULE 100 MG

4

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG, 7.5 MG

4Brand

penalty applies

FEM PH VAGINAL GEL 0.9-0.025 %

4

flavoxate hcl oral tablet 100 mg

2



146

Drug NameDrug Tier

Notes

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG

4Brand

penalty applies

GELNIQUE PUMP TRANSDERMAL GEL 10 %

4

GELNIQUE TRANSDERMAL GEL 10 %

4

glycine irrigation solution 1.5 %

2

glycine urologic irrigation solution 1.5 %

2

hyophen oral tablet 81.6 mg

2

INTRAROSA VAGINAL INSERT 6.5 MG

4

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

2

LITHOSTAT ORAL TABLET 250 MG

4

me/naphos/mb/hyo1 oral tablet 81.6 mg

2

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

3

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

2

oxybutynin chloride oral syrup 5 mg/5ml

2

oxybutynin chloride oral tablet 5 mg

2

phenazo oral tablet 200 mg

2

phenazopyridine hcl oral tablet 100 mg, 200 mg

2

Drug NameDrug Tier

Notes

PHOSLYRA ORAL SOLUTION 667 MG/5ML

4

phosphasal oral tablet 81.6 mg

2

PYRIDIUM ORAL TABLET 100 MG, 200 MG

4

RELAGARD VAGINAL GEL 0.9-0.025 %

4

RENACIDIN IRRIGATION SOLUTION

4

RENAGEL ORAL TABLET 800 MG

4Brand

penalty applies

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

4Brand

penalty applies

RENVELA ORAL TABLET 800 MG

4Brand

penalty applies

RIMSO-50 INTRAVESICAL SOLUTION 50 %

GM

sevelamer carbonate oral packet 0.8 gm, 2.4 gm

2

sevelamer carbonate oral tablet 800 mg

2

sevelamer hcl oral tablet 400 mg, 800 mg

2

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg


days)

tadalafil oral tablet 10 mg, 20 mg

2

PA; QL (4 EA per 30 days); AL (Min 18 Years)

tadalafil oral tablet 2.5 mg, 5 mg

2

PA; QL (30 EA per 30 days); AL (Min 18 Years)



147

Drug NameDrug Tier

Notes

THIOLA ORAL TABLET 100 MG

4 PA

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

2

tolterodine tartrate oral tablet 1 mg, 2 mg

2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

4

trospium chloride er oral capsule extended release 24 hour 60 mg

2

trospium chloride oral tablet 20 mg

2

URECHOLINE ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG

4Brand

penalty applies

uretron d/s oral tablet 2

uribel oral capsule 118 mg

2

URIMAR-T ORAL TABLET 120 MG

4

urin ds oral tablet 2

uro-458 oral tablet 81 mg 2

UROGESIC-BLUE ORAL TABLET 81.6 MG

4

uro-mp oral capsule 118 mg

2

uryl oral tablet 81.6 mg 2

ustell oral capsule 120 mg

2

uticap oral capsule 120 mg

2

utira-c oral tablet 81.6 mg 2

utrona-c oral tablet 81.6 mg

2

VELPHORO ORAL TABLET CHEWABLE 500 MG

6

Drug NameDrug Tier

Notes

VESICARE ORAL TABLET 10 MG, 5 MG

3

VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG

4

PA; Brand penalty


vilamit mb oral capsule 118 mg

2

vilevev mb oral tablet 81 mg

2

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er oral tablet extended release 24 hour 10 mg

2

AVODART ORAL CAPSULE 0.5 MG

4Brand

penalty applies

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

3

dutasteride oral capsule 0.5 mg

2

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

2

finasteride oral tablet 5 mg

2

FLOMAX ORAL CAPSULE 0.4 MG

4Brand

penalty applies

JALYN ORAL CAPSULE 0.5-0.4 MG

4Brand

penalty applies

PROSCAR ORAL TABLET 5 MG

4Brand

penalty applies

RAPAFLO CAPSULE 4 MG ORAL 4 MG

4Brand

penalty applies



148

Drug NameDrug Tier

Notes

RAPAFLO CAPSULE 4 MG ORAL 4 MG

4

RAPAFLO ORAL CAPSULE 8 MG

4Brand

penalty applies

silodosin oral capsule 4 mg, 8 mg

2

tamsulosin hcl oral capsule 0.4 mg

2

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

4Brand

penalty applies

Hormonal Agents - Adrenal

ala-cort external cream 1 %, 2.5 %

2

alclometasone dipropionate external cream 0.05 %

2

alclometasone dipropionate external ointment 0.05 %

2

amcinonide external cream 0.1 %

2

amcinonide external lotion 0.1 %

2

amcinonide external ointment 0.1 %

2

BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3-3) MG/ML

GM

betamethasone dipropionate aug external cream 0.05 %

2

betamethasone dipropionate aug external gel 0.05 %

2

Drug NameDrug Tier

Notes

betamethasone dipropionate aug external lotion 0.05 %

2

betamethasone dipropionate aug external ointment 0.05 %

2

betamethasone dipropionate external cream 0.05 %

2

betamethasone dipropionate external lotion 0.05 %

2

betamethasone dipropionate external ointment 0.05 %

2

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

betamethasone valerate external cream 0.1 %

2

betamethasone valerate external lotion 0.1 %

2

betamethasone valerate external ointment 0.1 %

2

CELESTONE SOLUSPAN INJECTION SUSPENSION 6 (3-3) MG/ML

GM

clobetasol prop emollient base external cream 0.05 %

2

clobetasol propionate e external cream 0.05 %

2



149

Drug NameDrug Tier

Notes

clobetasol propionate emulsion external foam 0.05 %

2

clobetasol propionate external cream 0.05 %

2

clobetasol propionate external foam 0.05 %

2

clobetasol propionate external gel 0.05 %

2

clobetasol propionate external lotion 0.05 %

2

clobetasol propionate external ointment 0.05 %

2

clobetasol propionate external shampoo 0.05 %

2

clobetasol propionate external solution 0.05 %

2

clocortolone pivalate external cream 0.1 %

2

clocortolone pivalate pump external cream 0.1 %

2

clodan external shampoo 0.05 %

2

CLODERM EXTERNAL CREAM 0.1 %

4Brand

penalty applies

CLODERM PUMP EXTERNAL CREAM 0.1 %

4Brand

penalty applies

CORDRAN EXTERNAL CREAM 0.025 %

4

CORDRAN EXTERNAL CREAM 0.05 %

4Brand

penalty applies

CORDRAN EXTERNAL LOTION 0.05 %

4Brand

penalty applies

CORDRAN EXTERNAL TAPE 4 MCG/SQCM

4

Drug NameDrug Tier

Notes

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG

4Brand

penalty applies

cortisone acetate oral tablet 25 mg

2

DECADRON ORAL ELIXIR 0.5 MG/5ML

4Brand

penalty applies

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

4

deltasone oral tablet 20 mg

1

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML

GM

desonide external cream 0.05 %

2

desonide external lotion 0.05 %

2

desonide external ointment 0.05 %

2

desoximetasone external cream 0.05 %, 0.25 %

2

desoximetasone external gel 0.05 %

2

desoximetasone external liquid 0.25 %

2 ST

desoximetasone external ointment 0.05 %, 0.25 %

2

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

3

dexamethasone oral elixir 0.5 mg/5ml

2

dexamethasone oral solution 0.5 mg/5ml

2



150

Drug NameDrug Tier

Notes

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

1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

2

DEXAMETHASONE SOD PHOS IN D5W INTRAVENOUS SOLUTION 10-5 MG/50ML-%, 12-5 MG/50ML-%, 20-5 MG/50ML-%, 8-5 MG/50ML-%

GM

DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS SOLUTION 10-0.9 MG/50ML-%, 12-0.9 MG/50ML-%, 20-0.9 MG/50ML-%, 8-0.9 MG/50ML-%

GM

dexamethasone sod phosphate pf injection solution 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

DEXAMETHASONE SODIUM PHOSPHATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MG/2.5ML, 4 MG/ML, 8 MG/2ML

GM

DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML

GM

dexpak 10 day oral tablet therapy pack 1.5 mg (35)

2

Drug NameDrug Tier

Notes

dexpak 13 day oral tablet therapy pack 1.5 mg (51)

2

DEXPAK 6 DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4Brand

penalty applies

diflorasone diacetate external cream 0.05 %

2

diflorasone diacetate external ointment 0.05 %

2

fludrocortisone acetate oral tablet 0.1 mg

2

fluocinolone acetonide body external oil 0.01 %

2

fluocinolone acetonide external cream 0.01 %, 0.025 %

2

fluocinolone acetonide external ointment 0.025 %

2

fluocinolone acetonide external solution 0.01 %

2

fluocinolone acetonide scalp external oil 0.01 %

2

fluocinonide emulsified base external cream 0.05 %

2

fluocinonide external cream 0.05 %

2

fluocinonide external gel 0.05 %

2

fluocinonide external ointment 0.05 %

2

fluocinonide external solution 0.05 %

2

flurandrenolide external cream 0.05 %

2

flurandrenolide external lotion 0.05 %

2

flurandrenolide external ointment 0.05 %

2



151

Drug NameDrug Tier

Notes

fluticasone propionate external cream 0.05 %

2

fluticasone propionate external lotion 0.05 %

2

fluticasone propionate external ointment 0.005 %

2

halobetasol propionate external cream 0.05 %

2

halobetasol propionate external ointment 0.05 %

2

HALOG EXTERNAL CREAM 0.1 %

4

HALOG EXTERNAL OINTMENT 0.1 %

4

HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4

hydrocortisone butyr lipo base external cream 0.1 %

2

hydrocortisone butyrate external cream 0.1 %

2

hydrocortisone butyrate external lotion 0.1 %

2

hydrocortisone butyrate external ointment 0.1 %

2

hydrocortisone butyrate external solution 0.1 %

2

hydrocortisone external cream 1 %, 2.5 %

2

hydrocortisone external lotion 2.5 %

2

hydrocortisone external ointment 1 %, 2.5 %

2

hydrocortisone in absorbase external ointment 1 %

2

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

2

Drug NameDrug Tier

Notes

hydrocortisone valerate external cream 0.2 %

2

hydrocortisone valerate external ointment 0.2 %

2

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML

GM

LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML

GM

LIDOCILONE I INJECTION SUSPENSION 20-20 MG/4ML

GM

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

3Brand

penalty applies

MEDROL ORAL TABLET 2 MG

3

MEDROL ORAL TABLET THERAPY PACK 4 MG

4Brand

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



152

Drug NameDrug Tier

Notes

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

2

methylprednisolone oral tablet therapy pack 4 mg

2

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

GM

METHYLPREDNISOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML, 80-5 MG/ML

GM

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 MG (48)

4

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48)

4

MILLIPRED ORAL SOLUTION 10 MG/5ML

4Brand

penalty applies

MILLIPRED ORAL TABLET 5 MG

3

mometasone furoate external cream 0.1 %

2

mometasone furoate external ointment 0.1 %

2

mometasone furoate external solution 0.1 %

2

nolix external cream 0.05 %

2

nolix external lotion 0.05 %

2

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 30 MG

4Brand

penalty applies

prednicarbate external cream 0.1 %

2

Drug NameDrug Tier

Notes

prednicarbate external ointment 0.1 %

2

prednisolone oral solution 15 mg/5ml

2

prednisolone oral syrup 15 mg/5ml

2

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

2

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

3

prednisone oral solution 5 mg/5ml

2

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

2

PSORCON EXTERNAL CREAM 0.05 %

4

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

GM

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG, 500 MG

GM



153

Drug NameDrug Tier

Notes

TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4

triamcinolone acetonide external aerosol solution 0.147 mg/gm

2

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

2

triamcinolone acetonide external lotion 0.025 %, 0.1 %

2

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

2

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

triderm external cream 0.1 %, 0.5 %

2

VERIPRED 20 ORAL SOLUTION 20 MG/5ML

4Brand

penalty applies

ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 32 MG

GM

Hormonal Agents - Men's Health

ANADROL-50 ORAL TABLET 50 MG

4

Drug NameDrug Tier

Notes

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

4 PA

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

3PA; Brand

penalty applies

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

3PA; Brand

penalty applies

danazol oral capsule 100 mg, 200 mg, 50 mg

2

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML

4Brand

penalty applies

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)

4PA; Brand

penalty applies

METHITEST ORAL TABLET 10 MG

4

methyltestosterone oral capsule 10 mg

2

oxandrolone oral tablet 10 mg, 2.5 mg

2

STRIANT BUCCAL 30 MG

4 PA

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%)

4PA; Brand

penalty applies

TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML

4

TESTOPEL IMPLANT PELLET 75 MG

GM PA



154

Drug NameDrug Tier

Notes

TESTOSTERONE CYPIONATE INJECTION SOLUTION 100 MG/ML, 150 MG/ML, 200 MG/ML, 50 MG/ML

4

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

2

TESTOSTERONE ENANTHATE INJECTION SOLUTION 200 MG/ML

4

testosterone enanthate intramuscular solution 200 mg/ml

2

TESTOSTERONE PROPIONATE INJECTION SOLUTION 100 MG/ML

4

testosterone transdermal gel 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%)

2 PA

testosterone transdermal solution 30 mg/act

2 PA

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

4PA; Brand

penalty applies

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)

4PA; Brand

penalty applies

Hormonal Agents - Osteoporosis

clomiphene citrate oral tablet 50 mg

2 PA

EVISTA ORAL TABLET 60 MG

4Brand

penalty applies

OSPHENA ORAL TABLET 60 MG

4

Drug NameDrug Tier

Notes

raloxifene hcl oral tablet 60 mg

PV

Hormonal Agents - Parathyroid

cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg

6 PA

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

6 PA

Hormonal Agents - Pituitary

BRAVELLE INJECTION SOLUTION RECONSTITUTED 75 UNIT

6 PA

cabergoline oral tablet 0.5 mg

2

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

6 PA

chorionic gonadotropin intramuscular solution reconstituted 10000 unit

6 PA

DDAVP INJECTION SOLUTION 4 MCG/ML

GM

DDAVP NASAL SOLUTION 0.01 %

4Brand

penalty applies

DDAVP ORAL TABLET 0.1 MG, 0.2 MG

4Brand

penalty applies

DDAVP RHINAL TUBE NASAL SOLUTION 0.01 %

4

desmopressin ace spray refrig nasal solution 0.01 %

2

desmopressin acetate injection solution 4 mcg/ml

GM

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

2



155

Drug NameDrug Tier

Notes

desmopressin acetate spray nasal solution 0.01 %

2

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED 1 MG

6 PA

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

6PA;

Specialty Medical

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG

6PA;

Specialty Medical

FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML

5 PA

ganirelix acetate solution 250 mcg/0.5ml subcutaneous 250 mcg/0.5ml

6 PA

GANIRELIX ACETATE SOLUTION 250 MCG/0.5ML SUBCUTANEOUS 250 MCG/0.5ML

6 PA

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

6 PA

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

6 PA

Drug NameDrug Tier

Notes

GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 UNIT, 450 UNIT

6 PA

GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML

6 PA

GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

6 PA

HCG INJECTION SOLUTION RECONSTITUTED 12000 UNIT, 50000 UNIT, 6000 UNIT

6 PA

HP ACTHAR INJECTION GEL 80 UNIT/ML

6 PA

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

6 PA

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

6 PA

leuprolide acetate injection kit 1 mg/0.2ml

6 PA

LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR SOLUTION 25-5 MG/ML

GM

LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 MG

6PA;

Specialty Medical



156

Drug NameDrug Tier

Notes

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

6PA;

Specialty Medical

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

6PA;

Specialty Medical

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG INTRAMUSCULAR KIT 30 MG

6PA;

Specialty Medical

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG INTRAMUSCULAR KIT 45 MG

6PA;

Specialty Medical

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

6PA;

Specialty Medical

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED)

6PA;

Specialty Medical

MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

6 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

6 PA

novarel intramuscular solution reconstituted 10000 unit

6 PA

Drug NameDrug Tier

Notes

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

6 PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML

6 PA


6 PA


6 PA

octreotide acetate solution 100 mcg/ml injection 100 mcg/ml

6 PA


5 PA


6 PA


5 PA


6 PA


5 PA


6 PA


5 PA


6 PA



157

Drug NameDrug Tier

Notes


5 PA

OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML

5 PA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG

5 PA

OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML

6 PA

oxytocin injection solution 10 unit/ml

GM

OXYTOCIN-DEXTROSE INTRAVENOUS SOLUTION 10-5 UT/500ML-%, 15-5 UT/250ML-%, 20-5 UT/500ML-%, 30-5 UNIT/L-%, 30-5 UT/500ML-%

GM

OXYTOCIN-DEXTROSE-LACT RINGERS INTRAVENOUS SOLUTION 10-5 UNIT/L-%, 10-5 UT/500ML-%, 20-5 UNIT/L-%, 20-5 UT/500ML-%, 30-5 UNIT/L-%, 30-5 UT/500ML-%, 40-5 UNIT/L-%

GM

Drug NameDrug Tier

Notes

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 10 UNIT/500ML, 10 UNIT/L, 15 UNIT/250ML, 20 UNIT/500ML, 20 UNIT/L, 30 UNIT/L, 40 UNIT/500ML, 40 UNIT/L

GM

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 10-0.9 UNIT/L-%, 10-0.9 UT/500ML-%, 15-0.9 UT/250ML-%, 20-0.45 UNIT/L-%, 20-0.9 UT/500ML-%, 30-0.9 UNIT/L-%, 30-0.9 UT/500ML-%, 40-0.9 UNIT/L-%, 40-0.9 UT/500ML-%, 60-0.9 UNIT/L-%, 80-0.9 UNIT/L-%

GM

PITOCIN INJECTION SOLUTION 10 UNIT/ML

GM

pregnyl intramuscular solution reconstituted 10000 unit

6 PA

SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG

6 PA

SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG

6 PA

SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

6 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

6PA;

Specialty Medical



158

Drug NameDrug Tier

Notes

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

6PA;

Specialty Medical

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

6 PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

6PA;

Specialty Medical

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

6 PA

STIMATE NASAL SOLUTION 1.5 MG/ML

3

SUPPRELIN LA SUBCUTANEOUS KIT 50 MG

6PA;

Specialty Medical

SYNAREL NASAL SOLUTION 2 MG/ML

3

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

6PA;

Specialty Medical

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 22.5 MG

6PA;

Specialty Medical

VANTAS SUBCUTANEOUS KIT 50 MG

6PA;

Specialty Medical

VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-%

GM

Drug NameDrug Tier

Notes

VASOPRESSIN-DEXTROSE INTRAVENOUS SOLUTION 100-5 UT/100ML-%, 20-5 UT/100ML-%, 25-5 UT/250ML-%, 50-5 UT/250ML-%, 60-5 UT/100ML-%

GM

VASOPRESSIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.9 UT/100ML-%, 100-0.9 UT/250ML-%, 25-0.9 UT/250ML-%, 40-0.9 UT/100ML-%, 50-0.9 UT/250ML-%, 50-0.9 UT/50ML-%, 60-0.9 UT/100ML-%, 80-0.9 UT/100ML-%

GM

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

GM

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG

6PA;

Specialty Medical

Hormonal Agents - Prostaglandins

CERVIDIL VAGINAL INSERT 10 MG

4

HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML

GM

KORLYM ORAL TABLET 300 MG

6 PA

PREPIDIL VAGINAL GEL 0.5 MG/3GM

4

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG

4



159

Drug NameDrug Tier

Notes

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

4Brand

penalty applies

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

2

amethia lo oral tablet 0.1-0.02 & 0.01 mg

PV

amethia oral tablet 0.15-0.03 &0.01 mg

PV

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

4

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

aubra oral tablet 0.1-20 mg-mcg

PV

aviane oral tablet 0.1-20 mg-mcg

PV

AYGESTIN ORAL TABLET 5 MG

4Brand

penalty applies

azurette oral tablet 0.15-0.02/0.01 mg (21/5)

PV

Drug NameDrug Tier

Notes

BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21)

4

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

4Brand

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

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

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

4

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

4Brand

penalty applies



160

Drug NameDrug Tier

Notes

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

4

covaryx hs oral tablet 0.625-1.25 mg

2

covaryx oral tablet 1.25-2.5 mg

2

CRINONE VAGINAL GEL 4 %, 8 %

4

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

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

4

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

4Brand

penalty applies

delyla oral tablet 0.1-20 mg-mcg

PV

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

GM

Drug NameDrug Tier

Notes

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

4Brand

penalty applies

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML

4Brand

penalty applies

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML

4

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

4

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

4

EC-RX PROGESTERONE TRANSDERMAL CREAM 10 %

4

eemt hs oral tablet 0.625-1.25 mg

2

eemt oral tablet 1.25-2.5 mg

2



161

Drug NameDrug Tier

Notes

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%)

4

elinest oral tablet 0.3-30 mg-mcg

PV

ELLA ORAL TABLET 30 MG

PV

emoquette oral tablet 0.15-30 mg-mcg

PV

ENDOMETRIN VAGINAL INSERT 100 MG

3

enpresse-28 oral tablet 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

2

est estrogens-methyltest hs oral tablet 0.625-1.25 mg

2

est estrogens-methyltest oral tablet 1.25-2.5 mg

2

estarylla oral tablet 0.25-35 mg-mcg

PV

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG

4Brand

penalty applies

ESTRACE VAGINAL CREAM 0.1 MG/GM

3Brand

penalty applies

estradiol oral tablet 0.5 mg, 1 mg, 2 mg

1

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

2

Drug NameDrug Tier

Notes

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

2

estradiol vaginal cream 0.1 mg/gm

2

estradiol vaginal tablet 10 mcg

2

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

2

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

2

ESTRING VAGINAL RING 2 MG

3

ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%)

4

ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

4Brand

penalty applies

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

PV

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

4

FALESSA ORAL KIT 20-1-0.1 MCG-MG

4

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

3Brand

penalty applies



162

Drug NameDrug Tier

Notes

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

4

femynor oral tablet 0.25-35 mg-mcg

PV

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG

4

FIRST-PROGESTERONE VGS 200 VAGINAL SUPPOSITORY 200 MG

4

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG

4Brand

penalty applies

gianvi oral tablet 3-0.02 mg

PV

hailey 24 fe oral tablet 1-20 mg-mcg(24)

PV

heather oral tablet 0.35 mg

PV

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

6PA;

Specialty Medical

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

5 PA

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

jasmiel oral tablet 3-0.02 mg

PV

jencycla oral tablet 0.35 mg

PV

jinteli oral tablet 1-5 mg-mcg

2

Drug NameDrug Tier

Notes

jolessa oral tablet 0.15-0.03 mg

PV

jolivette oral tablet 0.35 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

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

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



163

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 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

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

lillow oral tablet 0.15-30 mg-mcg

PV

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG

4

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

4Brand

penalty applies

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

4Brand

penalty applies

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

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

4Brand

penalty applies

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg

2

loryna oral tablet 3-0.02 mg

PV

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG

4Brand

penalty applies

low-ogestrel oral tablet 0.3-30 mg-mcg

PV

lutera oral tablet 0.1-20 mg-mcg

PV

lyza oral tablet 0.35 mg PV

MAKENA INTRAMUSCULAR OIL 250 MG/ML

6PA;

Specialty Medical

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML

6 PA

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

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

1

MEGACE ES ORAL SUSPENSION 625 MG/5ML

4Brand

penalty applies



164

Drug NameDrug Tier

Notes

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

2

megestrol acetate oral tablet 20 mg, 40 mg

2

melodetta 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR

3

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 lo oral tablet 0.5-0.1 mg

2

mimvey oral tablet 1-0.5 mg

2

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24)

4Brand

penalty applies

MINIVELLE 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

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR

GM

mono-linyah oral tablet 0.25-35 mg-mcg

PV

mononessa oral tablet 0.25-35 mg-mcg

PV

myzilra oral tablet 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

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, 1-20 mg-mcg(24)

PV

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone acetate oral tablet 5 mg

2

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

PV

norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone oral tablet 0.35 mg

PV



165

Drug NameDrug Tier

Notes

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg

PV

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

PV

ocella oral tablet 3-0.03 mg

PV

ogestrel oral tablet 0.5-50 mg-mcg

PV

orsythia oral tablet 0.1-20 mg-mcg

PV

ORTHO MICRONOR ORAL TABLET 0.35 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

4Brand

penalty applies

ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

4Brand

penalty applies

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG

4Brand

penalty applies

ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG

4Brand

penalty applies

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1-35 MG-MCG

4Brand

penalty applies

PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

GM

philith oral tablet 0.4-35 mg-mcg

PV

pimtrea oral tablet 0.15-0.02/0.01 mg (21/5)

PV

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

4Brand

penalty applies

portia-28 oral tablet 0.15-30 mg-mcg

PV

PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

4

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

GM



166

Drug NameDrug Tier

Notes

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

4

PREMARIN VAGINAL CREAM 0.625 MG/GM

4

PREMPHASE ORAL TABLET 0.625-5 MG

4

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

4

preventeza oral tablet 1.5 mg

PV

previfem oral tablet 0.25-35 mg-mcg

PV

progesterone intramuscular oil 50 mg/ml

2

progesterone micronized oral capsule 100 mg, 200 mg

2

progesterone micronized transdermal cream 10 %

2

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG

4Brand

penalty applies

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG

4Brand

penalty applies

QUARTETTE ORAL TABLET 42-21-21-7 DAYS

4Brand

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

4Brand

penalty applies

Drug NameDrug Tier

Notes

SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG

4Brand

penalty applies

setlakin oral tablet 0.15-0.03 mg

PV

sharobel oral tablet 0.35 mg

PV

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG

GM

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

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24)

4

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



167

Drug NameDrug Tier

Notes

tri-lo-marzia 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

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

4Brand

penalty applies

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 PV

tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tulana oral tablet 0.35 mg PV

tydemy oral tablet 3-0.03-0.451 mg

PV

VAGIFEM VAGINAL TABLET 10 MCG

4Brand

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

Drug NameDrug Tier

Notes

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

4Brand

penalty applies

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

4Brand

penalty applies

YAZ ORAL TABLET 3-0.02 MG

4Brand

penalty applies

yuvafem vaginal tablet 10 mcg

2

zarah oral tablet 3-0.03 mg

PV

zovia 1/35e (28) oral tablet 1-35 mg-mcg

PV

Hormonal Agents - Thyroid

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

3

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

4Brand

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

2



168

Drug NameDrug Tier

Notes

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

2

levothyroxine sodium intravenous solution reconstituted 100 mcg, 200 mcg, 500 mcg

GM

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

2

levothyroxine-liothyronine oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

2

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

2

liothyronine sodium intravenous solution 10 mcg/ml

GM

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

2

methimazole oral tablet 10 mg, 5 mg

2

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

4

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

2

Drug NameDrug Tier

Notes

PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 MG/0.5ML, 5 MG/ML

6Specialty Medical

propylthiouracil oral tablet 50 mg

2

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

3Brand

penalty applies

TAPAZOLE ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)

3

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)

3

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)

3

THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)

3

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)

3

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

4

TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML

GM



169

Drug NameDrug Tier

Notes

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

2

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

4

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

4

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

6 PA

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

6PA;

Specialty Medical

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

6 PA

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

6 PA

ALFERON N INJECTION SOLUTION 5000000 UNIT/ML

6PA;

Specialty Medical

ARAVA ORAL TABLET 10 MG, 20 MG

4Brand

penalty applies

Drug NameDrug Tier

Notes

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

6 PA

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

4

ATGAM INTRAVENOUS INJECTABLE 50 MG/ML

6PA;

Specialty Medical

AZASAN ORAL TABLET 100 MG, 75 MG

4

azathioprine oral tablet 50 mg

2

azathioprine sodium injection solution reconstituted 100 mg

GM

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

6PA;

Specialty Medical

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML

6 PA

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

6 PA

BERINERT INTRAVENOUS KIT 500 UNIT

6PA;

Specialty Medical

BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical

CARIMUNE NF SOLUTION RECONSTITUTED 12 GM INTRAVENOUS 12 GM

6PA;

Specialty Medical



170

Drug NameDrug Tier

Notes

carimune nf solution reconstituted 12 gm intravenous 12 gm

6PA;

Specialty Medical

CARIMUNE NF SOLUTION RECONSTITUTED 6 GM INTRAVENOUS 6 GM

6PA;

Specialty Medical

carimune nf solution reconstituted 6 gm intravenous 6 gm

6PA;

Specialty Medical

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CELLCEPT ORAL CAPSULE 250 MG

4Brand

penalty applies

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

4Brand

penalty applies

CELLCEPT ORAL TABLET 500 MG

4Brand

penalty applies

CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 MG/ML

6 PA

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML

6 PA

CIMZIA VIAL KIT 6 PA

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

6PA;

Specialty Medical

COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

6 PA

Drug NameDrug Tier

Notes

COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

6 PA

COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

6 PA

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

6 PA

CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML

6 PA

cyclosporine intravenous solution 50 mg/ml

GM

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

2

cyclosporine modified oral solution 100 mg/ml

2

cyclosporine oral capsule 100 mg, 25 mg

2

CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML

6Specialty Medical

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML

5 PA

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

5 PA



171

Drug NameDrug Tier

Notes

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

5 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

5 PA

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

6PA;

Specialty Medical

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

4

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML


days)

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

6PA;

Specialty Medical

GAMASTAN INTRAMUSCULAR INJECTABLE

6PA;

Specialty Medical

GAMASTAN S/D INTRAMUSCULAR INJECTABLE

6PA;

Specialty Medical

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 MG/10ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6PA;

Specialty Medical

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM

6PA;

Specialty Medical

GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML

6PA;

Specialty Medical

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

6PA;

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

6PA;

Specialty Medical

gengraf oral capsule 100 mg, 25 mg

2

gengraf oral solution 100 mg/ml

2

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT

6 PA

HEPAGAM B INJECTION SOLUTION

GM



172

Drug NameDrug Tier

Notes

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

6 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

5 PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML

5 PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

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

5 PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

GM

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

GM

HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

Drug NameDrug Tier

Notes

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT

6Specialty Medical

HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 UNIT/ML

GM

HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6 PA

ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML

6 PA

ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

6 PA

IMOGAM RABIES-HT INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

IMURAN ORAL TABLET 50 MG

4Brand

penalty applies

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

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

6 PA



173

Drug NameDrug Tier

Notes

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML

6 PA

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

6 PA

KYMRIAH INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

leflunomide oral tablet 10 mg, 20 mg

2

methotrexate (anti-rheumatic) oral tablet 2.5 mg

2

methotrexate oral tablet 2.5 mg

2

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml

2

methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml

2

methotrexate sodium injection solution reconstituted 1 gm

6Specialty Medical

methotrexate sodium oral tablet 2.5 mg

2

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT

6Specialty Medical

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

GM

mycophenolate mofetil oral capsule 250 mg

2

Drug NameDrug Tier

Notes

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

2

mycophenolate mofetil oral tablet 500 mg

2

mycophenolate sodium oral tablet delayed release 180 mg, 360 mg

2

MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG

4Brand

penalty applies

NABI-HB INTRAMUSCULAR SOLUTION

GM

NEORAL ORAL CAPSULE 100 MG, 25 MG

3Brand

penalty applies

NEORAL ORAL SOLUTION 100 MG/ML

3Brand

penalty applies

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

6PA;

Specialty Medical

OLUMIANT ORAL TABLET 2 MG

6 PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

6 PA



174

Drug NameDrug Tier

Notes

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

6PA;

Specialty Medical

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

6 PA

OTEZLA ORAL TABLET 30 MG

6 PA

OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG

6 PA

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6PA;

Specialty Medical

PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

6PA;

Specialty Medical

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

GM

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

3Brand

penalty applies

PROGRAF ORAL PACKET 0.2 MG, 1 MG

4

PROVENGE INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

RAPAMUNE ORAL SOLUTION 1 MG/ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6ST;

Specialty Medical

RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

6Specialty Medical

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

6Specialty Medical

RIDAURA ORAL CAPSULE 3 MG

3

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT

6PA;

Specialty Medical

SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML

GM

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

3Brand

penalty applies

SANDIMMUNE ORAL SOLUTION 100 MG/ML

3

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML

6 PA

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML

6PA;

Specialty Medical



175

Drug NameDrug Tier

Notes

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

6 PA

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

6 PA

SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 20 MG

GM

sirolimus oral solution 1 mg/ml

2

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg

2

STELARA INTRAVENOUS SOLUTION 130 MG/26ML

6PA;

Specialty Medical

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

6 PA

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML

6PA;

Specialty Medical

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

2

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML

6 PA

temsirolimus intravenous solution 25 mg/ml

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG

GM PA

TORISEL INTRAVENOUS SOLUTION 25 MG/ML

6PA;

Specialty Medical

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

6 PA

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

3

WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML

6Specialty Medical

XELJANZ ORAL TABLET 10 MG, 5 MG

6 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG

6 PA

ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML

GM

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG

6



176

Drug NameDrug Tier

Notes

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 INTRAMUSCULAR SUSPENSION

PV

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

BCG VACCINE INJECTION INJECTABLE

GM

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

BIOTHRAX INTRAMUSCULAR SUSPENSION

GM

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF-MCG/0.5

PV

Drug NameDrug Tier

Notes

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

EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

PV

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML

PV

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV



177

Drug NameDrug Tier

Notes

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUMIST QUADRIVALENT NASAL SUSPENSION

PV

AL (Min 2 Years and

Max 49 Years)

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

GARDASIL 9 INTRAMUSCULAR SUSPENSION

4

AL (Min 9 Years and

Max 27 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

4

AL (Min 9 Years and

Max 27 Years)

Drug NameDrug Tier

Notes

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

PV

HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML

PVAL (Min 18

Years)

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 SUBCUTANEOUS INJECTABLE

PV



178

Drug NameDrug Tier

Notes

PEDIARIX INTRAMUSCULAR SUSPENSION

PV

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

PVAL (Max 6

Years)

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 30

days); AL (Min 50 Years)

Drug NameDrug Tier

Notes

STAMARIL INJECTION SUSPENSION RECONSTITUTED

GM

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML

PV

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

PV

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

TWINRIX INTRAMUSCULAR SUSPENSION 720-20

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

4QL (4 EA per 365 days)

YF-VAX SUBCUTANEOUS INJECTABLE

GM

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

PVAL (Min 60

Years)

Inflammatory Bowel Disease Agents

ana-lex rectal kit 2-2 % 2



179

Drug NameDrug Tier

Notes

ANUSOL-HC RECTAL CREAM 2.5 %

4Brand

penalty applies

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

3

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

4Brand

penalty applies

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG

4Brand

penalty applies

AZULFIDINE ORAL TABLET 500 MG

4Brand

penalty applies

balsalazide disodium oral capsule 750 mg

2

budesonide er oral tablet extended release 24 hour 9 mg

5 PA

budesonide oral capsule delayed release particles 3 mg

5

CANASA RECTAL SUPPOSITORY 1000 MG

3Brand

penalty applies

COLAZAL ORAL CAPSULE 750 MG

4Brand

penalty applies

colocort rectal enema 100 mg/60ml

2

CORTENEMA RECTAL ENEMA 100 MG/60ML

4Brand

penalty applies

CORTIFOAM RECTAL FOAM 10 %

3

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

3

DIPENTUM ORAL CAPSULE 250 MG

3

Drug NameDrug Tier

Notes

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 MG

6

hydrocortisone ace-pramoxine rectal cream 1-1 %

2

hydrocortisone rectal cream 1 %, 2.5 %

2

hydrocortisone rectal enema 100 mg/60ml

2

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

4Brand

penalty applies

lidocaine-hydrocortisone ace rectal cream 3-0.5 %

2

lidocaine-hydrocortisone ace rectal gel 2.8-0.55 %

2

lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3-2.5 %

2

mesalamine oral tablet delayed release 1.2 gm, 800 mg

2

mesalamine rectal enema 4 gm

2

mesalamine rectal suppository 1000 mg

2

mesalamine-cleanser rectal kit 4 gm

2

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

4

PROCORT RECTAL CREAM 1.85-1.15 %

4

PROCTOCORT RECTAL CREAM 1 %

4Brand

penalty applies

PROCTOFOAM HC RECTAL FOAM 1-1 %

4



180

Drug NameDrug Tier

Notes

procto-med hc rectal cream 2.5 %

2

procto-pak rectal cream 1 %

2

proctosol hc rectal cream 2.5 %

2

proctozone-hc rectal cream 2.5 %

2

ROWASA RECTAL KIT 4 GM

4Brand

penalty applies

SFROWASA RECTAL ENEMA 4 GM/60ML

4

sulfasalazine oral tablet 500 mg

2

sulfasalazine oral tablet delayed release 500 mg

2

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG

6 PA

UCERIS RECTAL FOAM 2 MG/ACT

4

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG

4ST; Brand

penalty applies

alendronate sodium oral solution 70 mg/75ml

2

alendronate sodium oral tablet 10 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1QL (4 EA

per 28 days)

alendronate sodium oral tablet 40 mg, 5 mg

2

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG

4ST; Brand

penalty applies

BINOSTO ORAL TABLET EFFERVESCENT 70 MG

4 ST

Drug NameDrug Tier

Notes

BONIVA INTRAVENOUS SOLUTION 3 MG/3ML

GM

BONIVA ORAL TABLET 150 MG

4ST; Brand

penalty applies

calcitonin (salmon) nasal solution 200 unit/act

2

calcitriol intravenous solution 1 mcg/ml

GM

calcitriol oral capsule 0.25 mcg, 0.5 mcg

2

calcitriol oral solution 1 mcg/ml

2

doxercalciferol intravenous solution 4 mcg/2ml

GM

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

2 PA

etidronate disodium oral tablet 200 mg, 400 mg

2

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

6 PA

FOSAMAX ORAL TABLET 70 MG

4

Brand penalty


FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT

4

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML, 4 MCG/2ML

GM

ibandronate sodium intravenous solution 3 mg/3ml

GM

ibandronate sodium oral tablet 150 mg

2



181

Drug NameDrug Tier

Notes

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

3

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

6PA;

Specialty Medical

pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

5Specialty Medical

pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

5Specialty Medical

paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml

GM

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg

2 ST

PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML

6Specialty Medical

RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG

6 PA

RECLAST INTRAVENOUS SOLUTION 5 MG/100ML

6Specialty Medical

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

2 ST

risedronate sodium oral tablet delayed release 35 mg

2 ST

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG

4Brand

penalty applies

ROCALTROL ORAL SOLUTION 1 MCG/ML

4Brand

penalty applies

Drug NameDrug Tier

Notes

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

6 PA

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML

6Specialty Medical

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

GM

ZEMPLAR ORAL CAPSULE 2 MCG

4ST; Brand

penalty applies

zoledronic acid intravenous concentrate 4 mg/5ml

5Specialty Medical

zoledronic acid intravenous solution 4 mg/100ml

5Specialty Medical

zoledronic acid intravenous solution 5 mg/100ml

6Specialty Medical

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS SOLUTION 1:20

GM

ACETADOTE INTRAVENOUS SOLUTION 200 MG/ML

GM

acetylcysteine intravenous solution 200 mg/ml

GM

ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM



182

Drug NameDrug Tier

Notes

ACTHREL INTRAVENOUS SOLUTION RECONSTITUTED 100 MCG

GM

adenosine (diagnostic) intravenous solution 3 mg/ml

GM

adenosine intravenous solution 3 mg/ml

GM

ADREVIEW INTRAVENOUS SOLUTION 10 MCI/5ML

GM

ALBUKED 25 INTRAVENOUS SOLUTION 25 %

GM

ALBUKED 5 INTRAVENOUS SOLUTION 5 %

GM

albumin human intravenous solution 25 %, 5 %

GM

ALBUMINAR-25 INTRAVENOUS SOLUTION 25 %

GM

ALBUMINAR-5 INTRAVENOUS SOLUTION 5 %

GM

ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 %

GM

albumin-zlb intravenous solution 25 %, 5 %

GM

alburx intravenous solution 5 %

GM

ALBUTEIN INTRAVENOUS SOLUTION 5 %

GM

albutein solution 25 % intravenous 25 %

GM

ALBUTEIN SOLUTION 25 % INTRAVENOUS 25 %

GM

Drug NameDrug Tier

Notes

ALDER SUBCUTANEOUS SOLUTION 1:20

GM

ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6"

4

AMD FOAM DRESSING TOPSHEET PAD 4"X4"

4

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

AMYVID INTRAVENOUS SOLUTION 500-1900 MBQ/ML

GM

ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED

GM

ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED

6Specialty Medical



183

Drug NameDrug Tier

Notes

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

6Specialty 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

ANTIZOL INTRAVENOUS SOLUTION 1 GM/ML

GM

APP SLIM RMS ORAL CAPSULE

4

argyle sterile water irrigation solution

2

ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

arnica flower tincture 2

ARTISS EXTERNAL SOLUTION

4

AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

Drug NameDrug Tier

Notes

AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20

GM

AXUMIN INTRAVENOUS SOLUTION 9-221 MCI/ML

GM

bacteriostatic water(benz alc) solution injection

GM

BACTERIOSTATIC WATER(BENZ ALC) SOLUTION INJECTION

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

4

BIOGUARD GAUZE SPONGES PAD 4"X4"

4

BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , 4"X5"

4

BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , 3"X8"

4

BLACK WALNUT POLLEN SUBCUTANEOUS SOLUTION 1:20

GM



184

Drug NameDrug Tier

Notes

BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20

GM

boric acid external granules

2

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

GM PA

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 SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CARDIOVID PLUS ORAL CAPSULE

4

Drug NameDrug Tier

Notes

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

CERETEC INTRAVENOUS KIT

GM

CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG

GM

chlorhexidine gluconate solution 20 %

2

CHOLETEC INTRAVENOUS KIT

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

CORN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 MG

GM



185

Drug NameDrug Tier

Notes

cosyntropin injection solution reconstituted 0.25 mg

GM

CROFAB INTRAVENOUS SOLUTION RECONSTITUTED

GM

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

4

CURITY AMD ANTIMICROBIAL STRIP

4

CURITY IODOFORM PACKING STRIP

4

CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 GM

GM

CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 MG

GM

DATSCAN INTRAVENOUS SOLUTION 185 MBQ/2.5ML

GM

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

GM

DEFINITY INTRAVENOUS SUSPENSION 6.52 MG/ML

GM

DEFLUX INJECTION PREFILLED SYRINGE 50-15 MG/ML

GM

Drug NameDrug Tier

Notes

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

GM

dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml

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

DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML

GM

dipyridamole intravenous solution 5 mg/ml

GM

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

DOG FENNEL SUBCUTANEOUS SOLUTION 1:20

GM



186

Drug NameDrug Tier

Notes

DOTAREM INTRAVENOUS SOLUTION 2.5 MMOL/5ML, 5 MMOL/10ML, 50 MMOL/100ML

GM

DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 2.1-600 MG

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

ENDARI ORAL PACKET 5 GM

6

ENGLISH PLANTAIN SUBCUTANEOUS SOLUTION 1:20

GM

EOVIST INTRAVENOUS SOLUTION 0.25 MOL/L

GM

EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

ergoloid mesylates oral tablet 1 mg

2

etomidate intravenous solution 2 mg/ml

GM

Drug NameDrug Tier

Notes

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

EXCILON AMD DRAIN SPONGES PAD 4"X4"

4

FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

PV

FIRDAPSE ORAL TABLET 10 MG

6 PA

FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

FLUDEOXYGLUCOSE F 18 INTRAVENOUS SOLUTION 20-300 MCI/ML

GM

flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml

GM

fomepizole intravenous solution 1.5 gm/1.5ml

GM

formadon external solution 10 %

2

formaldehyde external solution 10 %, 37 %

2

FORMA-RAY EXTERNAL SOLUTION 20 %

4

fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM



187

Drug NameDrug Tier

Notes

GADAVIST INTRAVENOUS SOLUTION 1 MMOL/ML

GM

GELFOAM-JMI SPONGE EXTERNAL KIT

4

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

GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM

GM

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG

GM

GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION RECONSTITUTED 1 MG

GM

glutaraldehyde external solution 25 %

2

GOLDENROD SUBCUTANEOUS SOLUTION 1:20

GM

GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU

3

Drug NameDrug Tier

Notes

HACKBERRY SUBCUTANEOUS SOLUTION 1:20

GM

heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml

2

heparin sodium flush intravenous kit 100-0.9 unit/ml-%

2

heparin sodium lock flush intravenous solution 100 unit/ml

2

HEPATOLITE INTRAVENOUS KIT

GM

HEPMED COMBINATION KIT 100&0.9&2.5-2.5 UT/ML

4

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



188

Drug NameDrug Tier

Notes

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

HYLENEX INJECTION SOLUTION 150 UNIT/ML

GM

HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 24 MG/3ML

GM

IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

INDICLOR INTRAVENOUS SOLUTION

GM

indium in 111 oxyquinoline intravenous solution 1 mci/ml

GM

indocyanine green intravenous solution reconstituted 25 mg

GM

INFED INJECTION SOLUTION 50 MG/ML

GM

isosulfan blue subcutaneous solution 1 %

GM

JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20

GM

JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML

6PA;

Specialty Medical

KAPOK SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

kedbumin intravenous solution 25 %

GM

KERLIX AMD ANTIMICROBIAL

4

KERLIX AMD SUPER SPONGES PAD 6"X6-3/4"

4

KETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 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

GM

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 20-0.9 MG/2ML-%

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



189

Drug NameDrug Tier

Notes

LUMASON INTRAVENOUS SUSPENSION RECONSTITUTED 60.7-25 MG

GM

MACI INTRA-ARTICULAR SHEET

GM

MACRILEN ORAL PACKET 60 MG

6

MAGNEVIST INTRAVENOUS SOLUTION 469.01 MG/ML

GM

MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

MELALEUCA SUBCUTANEOUS SOLUTION 1:20

GM

MESQUITE SUBCUTANEOUS SOLUTION 1:20

GM

methergine oral tablet 0.2 mg

2

methylergonovine maleate injection solution 0.2 mg/ml

GM

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

Drug NameDrug Tier

Notes

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, 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 SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

MUGWORT SUBCUTANEOUS SOLUTION 1:20

GM

MULTIHANCE INTRAVENOUS SOLUTION 529 MG/ML

GM

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG

6 PA



190

Drug NameDrug Tier

Notes

MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML

GM PA

MYOVIEW 30ML INTRAVENOUS KIT

GM

NETSPOT INTRAVENOUS KIT

GM

NITHIODOTE INTRAVENOUS KIT 300MG/10ML&12.5 GM/50ML

GM

OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION

GM

OCTREOSCAN INTRAVENOUS KIT

GM

ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM

4

OLIVE TREE SUBCUTANEOUS SOLUTION 1:20

GM

OMNIPAQUE INTRAVENOUS SOLUTION 350 MG/ML

GM

Drug NameDrug Tier

Notes

OMNISCAN INJECTION INJECTABLE 287 MG/ML

GM

OMNISCAN INTRAVENOUS SOLUTION 287 MG/ML

GM

OMNISCAN/SODIUM CHLORIDE INTRAVENOUS SOLUTION 287-0.9 MG/ML-%

GM

OPTIONS CONCEPTROL VAGINAL GEL 4 %

PV

OPTIRAY 350 INJECTION SOLUTION 74 %

GM

OPTISON INTRAVENOUS SUSPENSION

GM

ORAFATE MOUTH/THROAT PASTE 10 %

4

ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL 300 IR

4

ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 300 IR

4

ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK 100(3) & 300(6) IR

4

ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 100 IR

4

ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR

4



191

Drug NameDrug Tier

Notes

ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 30 MG/2ML

GM

PECAN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

PERENNIAL RYE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 %

6 PA

PLASBUMIN-25 INTRAVENOUS SOLUTION 25 %

GM

PLASBUMIN-5 INTRAVENOUS SOLUTION 5 %

GM

PLASMANATE INTRAVENOUS SOLUTION 5 %

GM

pralidoxime chloride intramuscular solution auto-injector 600 mg/2ml

GM

Drug NameDrug Tier

Notes

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

PROHANCE INTRAVENOUS SOLUTION 279.3 MG/ML

GM

propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

PROPOFOL INTRAVENOUS PREFILLED SYRINGE 100 MG/10ML, 150 MG/15ML, 200 MG/20ML, 50 MG/5ML

GM

PROTHELIAL MOUTH/THROAT PASTE 10 %

4

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



192

Drug NameDrug Tier

Notes

RADIOGARDASE ORAL CAPSULE 0.5 GM

6

RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 1-U

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

Drug NameDrug Tier

Notes

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

SAGEBRUSH SUBCUTANEOUS SOLUTION 1:20

GM

sash kit intravenous kit 100-0.9 unit/ml-%

2

SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20

GM

SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20

GM

SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 1:20

GM

sodium nitrite intravenous solution 30 mg/ml

GM

sodium saccharin powder 2

SODIUM THIOSULFATE SOLUTION 25 % INTRAVENOUS 25 %

GM

sodium thiosulfate solution 25 % intravenous 25 %

GM

SOLESTA INJECTION GEL 50-15 MG/ML

GM

SOLU-PREF COMBINATION KIT 100&0.9&2.5-2.5 UT/ML

4

SORBITOL IRRIGATION SOLUTION 3 %

4

sorbitol irrigation solution 3.3 %

2

sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml

2



193

Drug NameDrug Tier

Notes

SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20

GM

SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML

6PA;

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 intravenous solution

GM

STERILE WATER FOR INJECTION SOLUTION INJECTION

GM

sterile water for injection solution injection

GM

sterile water for irrigation irrigation solution

2

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

Drug NameDrug Tier

Notes

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML

GM

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML

GM

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML

6 PA

TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

TECHNET TC 99M SULFUR COLLOID INJECTION KIT

GM

technetium tc 99m mebrofenin intravenous kit

GM

TECHNETIUM TC 99M MEDRONATE INTRAVENOUS KIT

GM

TECHNETIUM TC 99M PYROPHOS INTRAVENOUS KIT

GM

technetium tc 99m sestamibi intravenous kit

GM

TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8"

4

TELFA AMD NON-ADHERENT PAD 3"X8"

4

thallous chloride tl 201 intravenous solution 1 mci/ml

GM

THALLOUS CHLORIDE TL 201 INTRAVENOUS SOLUTION 2 MCI/ML

GM



194

Drug NameDrug Tier

Notes

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

4

TISSEEL EXTERNAL SOLUTION

4

TISSEEL VHSD EXTERNAL SOLUTION

4

TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

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

VISIPAQUE INTRAVENOUS SOLUTION 320 MG/ML

GM

Drug NameDrug Tier

Notes

VISTOGARD ORAL PACKET 10 GM

6

VITRASE INJECTION SOLUTION 200 UNIT/ML

GM

VIZAMYL INTRAVENOUS SOLUTION 4.05 MCI/ML

GM

volumex intravenous solution prefilled syringe 25 mcci/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

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



195

Drug NameDrug Tier

Notes

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

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT

GM PA

XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG

6PA;

Specialty Medical

XURIDEN ORAL PACKET 2 GM

6 PA

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

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 %

4Brand

penalty applies

ACULAR OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies

ACUVAIL OPHTHALMIC SOLUTION 0.45 %

4

ALOCRIL OPHTHALMIC SOLUTION 2 %

4

ALOMIDE OPHTHALMIC SOLUTION 0.1 %

3

ALREX OPHTHALMIC SUSPENSION 0.2 %

4

AZASITE OPHTHALMIC SOLUTION 1 %

4

azelastine hcl ophthalmic solution 0.05 %

2

bacitracin ophthalmic ointment 500 unit/gm

2

BEPREVE OPHTHALMIC SOLUTION 1.5 %

4

BESIVANCE OPHTHALMIC SUSPENSION 0.6 %

4

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 %

4

BLEPH-10 OPHTHALMIC SOLUTION 10 %

4Brand

penalty applies



196

Drug NameDrug Tier

Notes

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

2

BROMSITE OPHTHALMIC SOLUTION 0.075 %

4

CEFUROXIME SODIUM-NACL INTRAOCULAR SOLUTION PREFILLED SYRINGE 3-0.9 MG/0.3ML-%

GM

CILOXAN OPHTHALMIC OINTMENT 0.3 %

4

CILOXAN OPHTHALMIC SOLUTION 0.3 %

4Brand

penalty applies

ciprofloxacin hcl ophthalmic solution 0.3 %

2

cromolyn sodium ophthalmic solution 4 %

1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

2

DEXYCU INTRAOCULAR SUSPENSION 9 %

5

diclofenac sodium ophthalmic solution 0.1 %

2

DUREZOL OPHTHALMIC EMULSION 0.05 %

4

ELESTAT OPHTHALMIC SOLUTION 0.05 %

4Brand

penalty applies

EMADINE OPHTHALMIC SOLUTION 0.05 %

4

epinastine hcl ophthalmic solution 0.05 %

2

erythromycin ophthalmic ointment 5 mg/gm

2

Drug NameDrug Tier

Notes

FLAREX OPHTHALMIC SUSPENSION 0.1 %

3

fluorometholone ophthalmic suspension 0.1 %

2

flurbiprofen sodium ophthalmic solution 0.03 %

2

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

3

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %

4Brand

penalty applies

FML OPHTHALMIC OINTMENT 0.1 %

3

gatifloxacin ophthalmic solution 0.5 %

2

gentak ophthalmic ointment 0.3 %

2

gentamicin sulfate ophthalmic solution 0.3 %

2

ILEVRO OPHTHALMIC SUSPENSION 0.3 %

4

ILUVIEN INTRAVITREAL IMPLANT 0.19 MG

4

INVELTYS OPHTHALMIC SUSPENSION 1 %

4

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

2

levofloxacin ophthalmic solution 0.5 %

2

LOTEMAX OPHTHALMIC GEL 0.5 %

4

LOTEMAX OPHTHALMIC OINTMENT 0.5 %

4



197

Drug NameDrug Tier

Notes

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

4

LOTEMAX SM OPHTHALMIC GEL 0.38 %

4

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

4

MITOSOL OPHTHALMIC KIT 0.2 MG

GM

MOXEZA OPHTHALMIC SOLUTION 0.5 %

4

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 5 MG/ML

GM

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML

GM

moxifloxacin hcl ophthalmic solution 0.5 %

2

NATACYN OPHTHALMIC SUSPENSION 5 %

4

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

4

OCUFLOX OPHTHALMIC SOLUTION 0.3 %

4Brand

penalty applies

ofloxacin ophthalmic solution 0.3 %

2

olopatadine hcl ophthalmic solution 0.1 %, 0.2 %

2

OMNIPRED OPHTHALMIC SUSPENSION 1 %

4Brand

penalty applies

PATADAY OPHTHALMIC SOLUTION 0.2 %

4Brand

penalty applies

Drug NameDrug Tier

Notes

PATANOL OPHTHALMIC SOLUTION 0.1 %

4Brand

penalty applies

PAZEO OPHTHALMIC SOLUTION 0.7 %

4

PRED FORTE OPHTHALMIC SUSPENSION 1 %

4Brand

penalty applies

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

3

prednisolone acetate ophthalmic suspension 1 %

2

prednisolone acetate p-f ophthalmic suspension 1 %

2

prednisolone sodium phosphate ophthalmic solution 1 %

2

PROLENSA OPHTHALMIC SOLUTION 0.07 %

4

sulfacetamide sodium ophthalmic ointment 10 %

2

sulfacetamide sodium ophthalmic solution 10 %

2

tobramycin ophthalmic solution 0.3 %

1

TOBREX OPHTHALMIC OINTMENT 0.3 %

3

TOBREX OPHTHALMIC SOLUTION 0.3 %

4Brand

penalty applies

TRIESENCE INTRAOCULAR SUSPENSION 40 MG/ML

4

trifluridine ophthalmic solution 1 %

2



198

Drug NameDrug Tier

Notes

TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.09 %

4

TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.5 %

4

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies

VIROPTIC OPHTHALMIC SOLUTION 1 %

4Brand

penalty applies

ZIRGAN OPHTHALMIC GEL 0.15 %

4

ZYMAXID OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies

Ophthalmic Agents - Drugs for Glaucoma

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

3

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

3Brand

penalty applies

apraclonidine hcl ophthalmic solution 0.5 %

2

AZOPT OPHTHALMIC SUSPENSION 1 %

4

betaxolol hcl ophthalmic solution 0.5 %

2

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %

4

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

3

bimatoprost ophthalmic solution 0.03 %

2

Drug NameDrug Tier

Notes

brimonidine tartrate ophthalmic solution 0.15 %

2

brimonidine tartrate ophthalmic solution 0.2 %

1

BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 0.15-2 %

4

carteolol hcl ophthalmic solution 1 %

2

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

4

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

4Brand

penalty applies

COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

4Brand

penalty applies

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 %

4

dorzolamide hcl solution 2 % ophthalmic 2 %

2

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

2

DORZOLAMIDE HCL-TIMOLOL MAL SOLUTION 22.3-6.8 MG/ML OPHTHALMIC 22.3-6.8 MG/ML

4

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

2

IOPIDINE OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies



199

Drug NameDrug Tier

Notes

IOPIDINE OPHTHALMIC SOLUTION 1 %

4

ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 %

4Brand

penalty applies

ISTALOL OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies

LATANOPROST SOLUTION 0.005 % OPHTHALMIC 0.005 %

4

latanoprost solution 0.005 % ophthalmic 0.005 %

2

LATANOPROST-TIMOLOL MALEATE OPHTHALMIC SOLUTION 0.005-0.5 %

4

levobunolol hcl ophthalmic solution 0.5 %

2

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

3

methazolamide oral tablet 25 mg, 50 mg

2

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

3

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

2

RHOPRESSA OPHTHALMIC SOLUTION 0.02 %

4

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

4

Drug NameDrug Tier

Notes

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

2

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.5 % (daily)

2

TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC SOLUTION 0.5-0.15-2 -0.005%

4

TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC SOLUTION 0.5-0.15-2 %

4

TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC SOLUTION 0.5-0.15-0.005 %

4

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 %

4

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 %

3Brand

penalty applies

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 %

4Brand

penalty applies

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

3

TRUSOPT OPHTHALMIC SOLUTION 2 %

4Brand

penalty applies



200

Drug NameDrug Tier

Notes

VYZULTA OPHTHALMIC SOLUTION 0.024 %

4

XALATAN OPHTHALMIC SOLUTION 0.005 %

4Brand

penalty applies

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %

4

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-fluor intravenous solution 10 %, 25 %

GM

AKTEN OPHTHALMIC GEL 3.5 %

4

ALCAINE OPHTHALMIC SOLUTION 0.5 %

4Brand

penalty applies

altacaine ophthalmic solution 0.5 %

2

altafrin ophthalmic solution 10 %, 2.5 %

2

AMVISC INTRAOCULAR SOLUTION 12 MG/ML

4

AMVISC PLUS INTRAOCULAR SOLUTION 16 MG/ML

4

atropine sulfate ophthalmic ointment 1 %

2

atropine sulfate ophthalmic solution 1 %

2

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

2

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

2

balanced salt intraocular solution

2

Drug NameDrug Tier

Notes

BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML

6PA;

Specialty Medical

BIOLON INTRAOCULAR SOLUTION 10 MG/ML

4

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

3

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

3

bss intraocular solution 2

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 %

3Brand

penalty applies

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 %

3

cyclopentolate hcl ophthalmic solution 0.5 %

2

cyclopentolate hcl ophthalmic solution 1 %, 2 %

1

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 %

4

DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 1-5 MG/ML

GM

DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 1-0.5-0.4 MG/ML

GM



201

Drug NameDrug Tier

Notes

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML

6Specialty Medical

FLUORESCITE INTRAVENOUS SOLUTION 10 %

GM

GATIFLOXACIN-DEXAMETHASONE OPHTHALMIC SOLUTION 0.5-0.1 %

4

GELFILM OPHTHALMIC FILM

4

HEALON GV INTRAOCULAR SOLUTION 14 MG/ML

4

HEALON INTRAOCULAR SOLUTION 10 MG/ML

4

HEALON5 INTRAOCULAR SOLUTION 23 MG/ML

4

homatropaire ophthalmic solution 5 %

2

homatropine hbr ophthalmic solution 5 %

2

ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 %

4

JETREA INTRAVITREAL SOLUTION 0.375 MG/0.3ML

6PA;

Specialty Medical

LACRISERT OPHTHALMIC INSERT 5 MG

4

LASTACAFT OPHTHALMIC SOLUTION 0.25 %

4

LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5-0.25 MG/ML

GM

Drug NameDrug Tier

Notes

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

6Specialty Medical

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.3 MG/0.05ML

4

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.5 MG/0.05ML

6Specialty Medical

LUXTURNA INTRAOCULAR SUSPENSION

6PA;

Specialty Medical

MACUGEN INTRAOCULAR SOLUTION 0.3 MG

6Specialty Medical

MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1

4Brand

penalty applies

MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1

4Brand

penalty applies

MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 %

GM



202

Drug NameDrug Tier

Notes

MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 20 MG

4

MIOSTAT INTRAOCULAR SOLUTION 0.01 %

4

MOXIFLOXACIN HCL-BSS INTRAVITREAL SOLUTION 1 MG/ML

GM

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000 , 5-400-10000

2

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

2

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

2

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

2

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

2

neo-polycin hc ophthalmic ointment 1 %

2

neo-polycin ophthalmic ointment 3.5-400-10000

2

OXERVATE OPHTHALMIC SOLUTION 0.002 %

6 PA

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

2

polycin ophthalmic ointment 500-10000 unit/gm

2

Drug NameDrug Tier

Notes

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

2

POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-%

4Brand

penalty applies

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

3

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

3

PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1-0.075 %

4

PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 1-0.075 %

GM

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SOLUTION 1-0.5 %

4

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION 1-0.5 %

4

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

4

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SUSPENSION 1-0.5-0.075 %

4

proparacaine hcl ophthalmic solution 0.5 %

2



203

Drug NameDrug Tier

Notes

PROVISC INTRAOCULAR SOLUTION 10 MG/ML

4

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

3

RESTASIS OPHTHALMIC EMULSION 0.05 %

3

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

2

tetcaine ophthalmic solution 0.5 %

2

tetracaine hcl ophthalmic solution 0.5 %

2

tetravisc forte ophthalmic solution 0.5 %

2

tetravisc ophthalmic solution 0.5 %

2

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

3

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

3Brand

penalty applies

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

3

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

2

TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 15-1 MG/ML

GM

TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC SOLUTION 1-1-2.5 %

4

Drug NameDrug Tier

Notes

TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC SOLUTION 1-0.5-2.5-0.5 %

4

VISIONBLUE OPHTHALMIC SOLUTION 0.06 %

GM

VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 MG

6Specialty Medical

XIIDRA OPHTHALMIC SOLUTION 5 %

4

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %

4

Otic Agents - Drugs for Ear Conditions

acetic acid otic solution 2 %

2

CETRAXAL OTIC SOLUTION 0.2 %

4Brand

penalty applies

CIPRO HC OTIC SUSPENSION 0.2-1 %

4

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

4

ciprofloxacin hcl otic solution 0.2 %

2

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML

4

DERMOTIC OTIC OIL 0.01 %

4Brand

penalty applies

flac otic oil 0.01 % 2

FLOXIN OTIC OTIC SOLUTION 0.3 %

4Brand

penalty applies

fluocinolone acetonide otic oil 0.01 %

2



204

Drug NameDrug Tier

Notes

hydrocortisone-acetic acid otic solution 1-2 %

2

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1

2

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2

ofloxacin otic solution 0.3 %

2

OTIPRIO INTRATYMPANIC SUSPENSION 6 %

4

OTOVEL OTIC SOLUTION 0.3-0.025 %

4

PRAMOTIC OTIC LIQUID 1-0.1 %

4

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

ADRENALIN NASAL SOLUTION 0.1 %

4

ASTEPRO NASAL SOLUTION 0.15 %

4Brand

penalty applies

azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

2

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY

4

benzonatate oral capsule 100 mg, 150 mg, 200 mg

2

biotuss oral liquid 10-15-300 mg/5ml

2

biotuss pediatric oral liquid 2.5-5-50 mg/ml

2

bromfed dm oral syrup 30-2-10 mg/5ml

2

brompheniramine tannate oral tablet chewable 12 mg

2

Drug NameDrug Tier

Notes

budesonide nasal suspension 32 mcg/act

2

CARBAPHEN 12 ORAL LIQUID 10-4-27.5 MG/5ML

4

CARBAPHEN 12 PED ORAL SUSPENSION 2.5-1.25-7.5 MG/ML

4

carbinoxamine maleate oral solution 4 mg/5ml

2

carbinoxamine maleate oral tablet 4 mg

2

CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML

6PA;

Specialty Medical

clemastine fumarate oral tablet 2.68 mg

2

CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 240 MG/3ML

4

cyproheptadine hcl oral syrup 2 mg/5ml

2

cyproheptadine hcl oral tablet 4 mg

2

desloratadine oral tablet 5 mg

2

desloratadine oral tablet dispersible 2.5 mg, 5 mg

2

dexchlorpheniramine maleate oral syrup 2 mg/5ml

2

diphenhydramine hcl injection solution 50 mg/ml

2

diphenhydramine hcl oral elixir 12.5 mg/5ml

2



205

Drug NameDrug Tier

Notes

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML

6 PA

EXACTUSS ORAL LIQUID 10-28-388 MG/5ML

4

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML

6PA;

Specialty Medical

flunisolide nasal solution 25 mcg/act (0.025%)

2

fluticasone propionate nasal suspension 50 mcg/act

2

GILPHEX TR ORAL TABLET 10-388 MG

4

GILTUSS ORAL LIQUID 10-28-388 MG/5ML

4

giltuss pediatric oral liquid 2.5-7.5-88 mg/ml

2

GILTUSS TR ORAL TABLET 10-28-388 MG

4

hydrocodone polst-cpm polst er oral suspension extended release 10-8 mg/5ml

2

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

2

hydrocodone-homatropine oral tablet 5-1.5 mg

2

hydromet oral syrup 5-1.5 mg/5ml

2

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 7 %

4

Drug NameDrug Tier

Notes

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-%

4

ipratropium bromide nasal solution 0.03 %, 0.06 %

2

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 MG/5ML

4

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

2

levocetirizine dihydrochloride oral tablet 5 mg

2

mometasone furoate nasal suspension 50 mcg/act

2

NASONEX NASAL SUSPENSION 50 MCG/ACT

4Brand

penalty applies

nebusal inhalation nebulization solution 3 %

2

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

4

NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML

4

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

olopatadine hcl nasal solution 0.6 %

2

OMNARIS NASAL SUSPENSION 50 MCG/ACT

4



206

Drug NameDrug Tier

Notes

PATANASE NASAL SOLUTION 0.6 %

4Brand

penalty applies

phenadoz rectal suppository 12.5 mg, 25 mg

2

PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML

4Brand

penalty applies

phenylephrine-guaifenesin oral liquid 1.5-20 mg/ml

2

promethazine hcl injection solution 25 mg/ml, 50 mg/ml

2

promethazine hcl oral solution 6.25 mg/5ml

2

promethazine hcl oral syrup 6.25 mg/5ml

2

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

2

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg

2

promethazine-codeine oral solution 6.25-10 mg/5ml

2

promethazine-codeine oral syrup 6.25-10 mg/5ml

2

promethazine-dm oral syrup 6.25-15 mg/5ml

2

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml

2

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

2

promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

2

Drug NameDrug Tier

Notes

pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml

2

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml

2

pulmosal inhalation nebulization solution 7 %

2

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT

4

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT

4

rhinocort allergy nasal suspension 32 mcg/act

2

RYCLORA ORAL SYRUP 2 MG/5ML

4Brand

penalty applies

SINUVA NASAL IMPLANT 1350 MCG

4

sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

2

SSKI ORAL SOLUTION 1 GM/ML

4

SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML-%

4

TESSALON PERLES ORAL CAPSULE 100 MG

4Brand

penalty applies

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

4



207

Drug NameDrug Tier

Notes

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML

4Brand

penalty applies

TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 54.3-8 MG

4

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 14.7-2.8 MG/5ML

4

XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT

4

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

6PA;

Specialty Medical

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG

6PA;

Specialty Medical

ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT

4

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE ORAL TABLET 10 MG, 20 MG

4Brand

penalty applies

acetylcysteine inhalation solution 10 %, 20 %

2

ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML

GMQL (4 ML

per 30 days)

Drug NameDrug Tier

Notes

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

4PA; Brand

penalty applies

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

4 PA

AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT

3

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

2

ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

4QL (3 GM

per 30 days)

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

2

albuterol sulfate oral syrup 2 mg/5ml

2

albuterol sulfate oral tablet 2 mg

2

albuterol sulfate oral tablet 4 mg

1

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT

4

aminophylline intravenous solution 25 mg/ml

2



208

Drug NameDrug Tier

Notes

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

4

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG

6PA;

Specialty Medical

ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG

4QL (30 EA

per 30 days)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

4 PA

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

3QL (1 EA

per 30 days)


3QL (1 EA

per 30 days)

ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

3QL (1 EA

per 30 days)


3QL (1 EA

per 30 days)

Drug NameDrug Tier

Notes


3QL (1 EA

per 30 days)

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT

3

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

3

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT

4

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

4 PA

BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML

4

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

2

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

3

cromolyn sodium inhalation nebulization solution 20 mg/2ml

2

DALIRESP ORAL TABLET 250 MCG, 500 MCG

4 PA

difil-g forte oral liquid 100-100 mg/5ml

2



209

Drug NameDrug Tier

Notes

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT

3

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

4

EPINEPHRINE INJECTION SOLUTION 0.3 MG/0.3ML

2QL (4 EA

per 30 days)

EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.15 MG/0.3ML

2QL (4 EA

per 30 days)

EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML INJECTION 0.3 MG/0.3ML

2QL (4 EA

per 30 days)

epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml

2QL (4 EA

per 30 days)

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

4

Brand penalty


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

4QL (4 EA

per 30 days)

ESBRIET ORAL CAPSULE 267 MG

6 PA

ESBRIET ORAL TABLET 267 MG, 801 MG

6 PA

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

4

Drug NameDrug Tier

Notes

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

4QL (24 GM

per 30 days)

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

2

GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML

6PA;

Specialty Medical

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

4

ipratropium bromide inhalation solution 0.02 %

2

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

2

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

2

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

2

metaproterenol sulfate oral syrup 10 mg/5ml

2

metaproterenol sulfate oral tablet 10 mg, 20 mg

2

montelukast sodium oral packet 4 mg

2

montelukast sodium oral tablet 10 mg

2



210

Drug NameDrug Tier

Notes

montelukast sodium oral tablet chewable 4 mg, 5 mg

2

OFEV ORAL CAPSULE 100 MG, 150 MG

6 PA

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML

4

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

2QL (3 GM

per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

2QL (3 EA

per 30 days)

PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML

6PA;

Specialty Medical

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

3

PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

4Brand

penalty applies

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

3QL (17.4

GM per 30 days)

Drug NameDrug Tier

Notes

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

3

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 4 GM

4

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

3

SINGULAIR ORAL PACKET 4 MG

4Brand

penalty applies

SINGULAIR ORAL TABLET 10 MG

4Brand

penalty applies

SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG

4Brand

penalty applies

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

3

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

3

STERILE TALC POWDER INTRAPLEURAL SUSPENSION RECONSTITUTED 5 GM

4

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

4

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

3



211

Drug NameDrug Tier

Notes

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

3

terbutaline sulfate injection solution 1 mg/ml

GM

terbutaline sulfate oral tablet 2.5 mg, 5 mg

2

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

4

theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

2

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg

2

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

2

theophylline in d5w intravenous solution 0.8-5 mg/ml-%

GM

theophylline oral solution 80 mg/15ml

2

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

4

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

3

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG

4

Drug NameDrug Tier

Notes

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

2QL (3 GM

per 30 days)

wixela inhub inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

2 PA

XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML

4Brand

penalty applies

XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT

4

XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML

4Brand

penalty applies

zafirlukast oral tablet 10 mg, 20 mg

2

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

zileuton er oral tablet extended release 12 hour 600 mg

5

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG

5

ZYFLO ORAL TABLET 600 MG

5



212

Drug NameDrug Tier

Notes

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

6 PA

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

6 PA

KALYDECO ORAL PACKET 50 MG, 75 MG

6 PA

KALYDECO ORAL TABLET 150 MG

6 PA

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

6 PA

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG

6 PA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

6 PA

PULMOZYME INHALATION SOLUTION 1 MG/ML

6 PA

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG

6 PA

TOBI NEBULIZER INHALATION NEBULIZATION SOLUTION 300 MG/5ML

6 PA

TOBI PODHALER INHALATION CAPSULE 28 MG

6 PA

tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml

5 PA

Drug NameDrug Tier

Notes

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION 300 MG/5ML

6 PA

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA ORAL TABLET 20 MG

6 PA

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

6 PA

alyq oral tablet 20 mg 5 PA

epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg

5PA;

Specialty Medical

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

6PA;

Specialty Medical

LETAIRIS ORAL TABLET 10 MG, 5 MG

6 PA

OPSUMIT ORAL TABLET 10 MG

6 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

6 PA

REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

6PA;

Specialty Medical

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML

6PA;

Specialty Medical

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML

6 PA



213

Drug NameDrug Tier

Notes

REVATIO ORAL TABLET 20 MG

6 PA

sildenafil citrate intravenous solution 10 mg/12.5ml

5PA;

Specialty Medical

sildenafil citrate oral tablet 20 mg

5 PA

tadalafil (pah) oral tablet 20 mg

5 PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG

6 PA

TRACLEER ORAL TABLET SOLUBLE 32 MG

6 PA

TYVASO INHALATION SOLUTION 0.6 MG/ML

6 PA

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML

6 PA

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML

6 PA

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

6 PA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

4

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

6PA;

Specialty Medical

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

6 PA

Drug NameDrug Tier

Notes

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

2

carisoprodol oral tablet 250 mg, 350 mg

2

carisoprodol-aspirin oral tablet 200-325 mg

2

CHLORZOXAZONE ORAL TABLET 250 MG

4

chlorzoxazone oral tablet 500 mg

2

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

2

cyclobenzaprine hcl oral tablet 7.5 mg

2 ST

DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

GM

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

4Brand

penalty applies

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

2

FEXMID ORAL TABLET 7.5 MG

4ST; Brand

penalty applies

GABLOFEN INTRATHECAL SOLUTION 10000 MCG/20ML, 40000 MCG/20ML

GM



214

Drug NameDrug Tier

Notes

LIORESAL INTRATHECAL INTRATHECAL SOLUTION 2000 MCG/ML, 40 MG/20ML, 500 MCG/ML

GM

LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML

GM

LORZONE ORAL TABLET 375 MG, 750 MG

4

metaxall oral tablet 800 mg

2

metaxalone oral tablet 400 mg, 800 mg

2

methocarbamol injection solution 1000 mg/10ml

GM

methocarbamol oral tablet 500 mg, 750 mg

2

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

2

orphenadrine citrate injection solution 30 mg/ml

GM

revonto intravenous solution reconstituted 20 mg

GM

ROBAXIN INJECTION SOLUTION 1000 MG/10ML

GM

ROBAXIN ORAL TABLET 500 MG

4Brand

penalty applies

ROBAXIN-750 ORAL TABLET 750 MG

4Brand

penalty applies

RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 250 MG

GM

Drug NameDrug Tier

Notes

SKELAXIN ORAL TABLET 800 MG

4Brand

penalty applies

SOMA ORAL TABLET 250 MG, 350 MG

4Brand

penalty applies

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

2

tizanidine hcl oral tablet 2 mg, 4 mg

2

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG

4Brand

penalty applies

ZANAFLEX ORAL TABLET 4 MG

4Brand

penalty applies

Sleep Disorder Agents

AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 6.25 MG

4Brand

penalty applies

AMBIEN ORAL TABLET 10 MG, 5 MG

4Brand

penalty applies

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

2

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

4

BUTISOL SODIUM ORAL TABLET 30 MG

4

eszopiclone oral tablet 1 mg, 2 mg, 3 mg

2

flurazepam hcl oral capsule 15 mg, 30 mg

2

HETLIOZ ORAL CAPSULE 20 MG

6 PA

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG

4Brand

penalty applies



215

Drug NameDrug Tier

Notes

modafinil oral tablet 100 mg, 200 mg

2

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG

4Brand

penalty applies

PROVIGIL ORAL TABLET 100 MG, 200 MG

4Brand

penalty applies

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG

4Brand

penalty applies

ROZEREM ORAL TABLET 8 MG

4

SECONAL ORAL CAPSULE 100 MG

4

SILENOR ORAL TABLET 3 MG, 6 MG

4

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

2

XYREM ORAL SOLUTION 500 MG/ML

6 PA

zaleplon oral capsule 10 mg, 5 mg

2

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg

2

zolpidem tartrate oral tablet 10 mg, 5 mg

2



216

Index of Drugs

1ST MEDX-PATCH/ LIDOCAINE........................ 177T LIDO.............................. 17abacavir sulfate...................73abacavir sulfate-lamivudine 73abacavir-lamivudine-zidovudine...........................73ABANEU-SL..................... 123ABELCET........................... 49ABILIFY.............................. 70ABILIFY MAINTENA...........70abiraterone acetate.............55ABRAXANE........................ 55ABSORICA....................... 110ABSTRAL............................. 8ACACIA............................ 182acamprosate calcium..........22acarbose........................... 116ACCOLATE...................... 208ACCUPRIL..........................86ACCURETIC.......................86ACD FORMULA A.............. 35ACD FORMULA B.............. 35ACD-A NOCLOT-50........... 35acebutolol hcl......................86ACETADOTE....................182acetaminophen-codeine....... 8acetaminophen-codeine #2.. 8acetaminophen-codeine #3.. 8acetaminophen-codeine #4.. 8acetazolamide.....................86acetazolamide er................ 86acetazolamide sodium........ 86acetic acid.................146, 204acetylcysteine........... 182, 208ACIPHEX.......................... 139ACIPHEX SPRINKLE....... 139acitretin............................. 110ACREMONIUM.................182ACTEMRA........................ 170ACTEMRA ACTPEN.........170ACTHIB.............................177ACTHREL......................... 183ACTIGALL........................ 140ACTIMMUNE.................... 170ACTIQ...................................8ACTIVASE.......................... 35ACTIVE FE....................... 123ACTIVE-KETOPROFEN.......6ACTIVELLA...................... 160ACTIVITE..........................123ACTONEL.........................181ACTOPLUS MET..............116

ACTOS............................. 116ACULAR........................... 196ACULAR LS......................196ACUVAIL.......................... 196acyclovir..............................73acyclovir sodium................. 73ACZONE...........................110ADACEL........................... 177ADAGEN...........................144ADALAT CC........................86adapalene......................... 110ADASUVE...........................70adc/f (0.5mg/ml)................123ADCETRIS..........................55ADCIRCA..........................213ADDERALL.......................104ADDERALL XR.................104adefovir dipivoxil ................. 73ADEMPAS........................ 213ADENOCARD.....................86adenosine................... 86, 183ADENOSINE.......................86adenosine (diagnostic)......183ADLYXIN.......................... 117ADLYXIN STARTER PACK................................ 116ADMELOG........................120ADMELOG SOLOSTAR... 120ADRENAL C FORMULA...124ADRENALIN............. 205, 208ADREVIEW.......................183adriamycin.......................... 55adrucil ................................. 55ADVAIR DISKUS.............. 208ADVAIR HFA.................... 208ADVANCED AM/PM......... 124ADVATE............................. 81ADYNOVATE......................81AEMCOLO..........................23AEROSPAN......................208AFINITOR........................... 56AFINITOR DISPERZ.......... 55AFLURIA...........................177AFLURIA PRESERVATIVE FREE....177AFLURIA QUADRIVALENT..............177AFREZZA......................... 121AFSTYLA............................81AGGRASTAT......................70AGGRENOX....................... 70agoneaze............................ 17AGRYLIN............................ 81

AIMOVIG............................ 53ak-fluor..............................201AKOVAZ............................. 86AKTEN..............................201AKYNZEO...........................47ala-cort..............................149albendazole........................ 66ALBENZA........................... 66ALBUKED 25.................... 183ALBUKED 5...................... 183albumin human................. 183ALBUMINAR-25................183ALBUMINAR-5..................183ALBUMINEX..................... 183albumin-zlb....................... 183alburx................................ 183ALBUTEIN........................ 183albutein............................. 183albuterol sulfate................ 208albuterol sulfate er............ 208ALBUTEROL SULFATE HFA...................................208ALCAINE.......................... 201alclometasone dipropionate...................... 149ALCOHOL PREP PADS... 110ALDACTAZIDE................... 86ALDACTONE......................86ALDER..............................183ALDURAZYME................. 144ALECENSA.........................56alendronate sodium.......... 181alfentanil hcl..........................8ALFERON N..................... 170alfuzosin hcl er..................148ALIMTA...............................56ALINIA................................ 66ALIQOPA............................ 56ALISKIREN FUMARATE.... 86ALKERAN........................... 56ALLEVYN AG NON-ADHESIVE........................110allopurinol........................... 52allopurinol sodium...............52almotriptan malate.............. 53ALOCRIL.......................... 196ALOGLIPTIN BENZOATE 117ALOGLIPTIN-METFORMIN HCL............117ALOGLIPTIN-PIOGLITAZONE............... 117ALOMIDE..........................196ALOPRIM............................52

217

ALORA..............................160alosetron hcl..................... 140ALOXI................................. 47ALPHAGAN P...................199ALPHANATE/VWF COMPLEX/HUMAN............ 81ALPHANINE SD................. 81alprazolam.......................... 79alprazolam er...................... 79ALPRAZOLAM INTENSOL.79alprazolam xr...................... 79ALPROLIX.......................... 81alprostadil ........................... 86ALREX.............................. 196ALTABAX............................23altacaine........................... 201ALTACE..............................86altafrin............................... 201altavera............................. 160ALTERNARIA................... 183ALTOPREV.........................86ALUNBRIG......................... 56ALVESCO.........................208alyacen 1/35..................... 160alyacen 7/7/7.................... 160alyq................................... 213amabelz............................ 160amantadine hcl................... 68AMARYL........................... 117AMBIEN............................ 215AMBIEN CR......................215AMBISOME........................ 49amcinonide....................... 149AMD FOAM DRESSING...183AMD FOAM DRESSING TOPSHEET...................... 183AMERGE............................ 53AMERICAN BEECH......... 183AMERICAN COCKROACH.......................................... 183AMERICAN ELM.............. 183AMERICAN SYCAMORE. 183amethia............................. 160amethia lo......................... 160AMICAR..............................81AMIDATE..........................183amikacin sulfate.................. 23amiloride hcl........................86amiloride-hydrochlorothiazide.............87AMINO ACID.................... 124aminoacetic acid............... 146aminoam rms.................... 124

aminocaproic acid...............81aminophylline....................208aminorelief rms................. 124AMINOSYN.......................124AMINOSYN II....................124aminosyn ii/electrolytes.....124AMINOSYN M...................124AMINOSYN/ELECTROLYTES...................................124aminosyn/electrolytes....... 124AMINOSYN-HBC..............124AMINOSYN-PF.................124AMINOSYN-RF.................124amiodarone hcl................... 87AMIODARONE HCL IN DEXTROSE........................ 87AMITIZA............................140amitriptyline hcl................... 44amlodipine besylate............ 87amlodipine besylate-benazepril hcl......................87amlodipine besylate-valsartan............................. 87amlodipine-atorvastatin.......87amlodipine-olmesartan....... 87amlodipine-valsartan-hctz...87ammonium lactate............ 110AMMONUL....................... 144amnesteem....................... 111amoxapine.......................... 44amoxicill-clarithro-lansopraz.......................... 140amoxicillin........................... 23amoxicillin-potassium clavulanate..........................23amoxicillin-potassium clavulanate er..................... 23AMPHADASE................... 183amphetamine-dextroamphetamine.......... 104amphetamine-dextroamphetamine er......104amphotericin b.................... 49ampicillin............................. 23ampicillin sodium................ 23ampicillin-sulbactam sodium................................ 23AMPYRA...........................106AMVISC............................ 201AMVISC PLUS..................201AMYVID............................ 183ANACAINE....................... 111ANADROL-50................... 154

ANAFRANIL........................44anagrelide hcl..................... 81ana-lex.............................. 179ANASCORP......................183ANASPAZ......................... 140anastrozole......................... 56ANAVIP.............................183ANCOBON..........................49ANDEXXA.........................184ANDRODERM.................. 154ANDROGEL......................154ANDROGEL PUMP.......... 154ANECTINE........................107ANESTHESIA S/I-40........ 184ANESTHESIA S/I-40A...... 184ANESTHESIA S/I-40H......184ANESTHESIA S/I-40S...... 184ANESTHESIA S/I-60........ 184ANGELIQ..........................160ANGIOMAX........................ 35ANIMI-3.............................124ANIMI-3/VITAMIN D......... 124anodyne lpt......................... 17ANORO ELLIPTA............. 209ANTABUSE........................ 22ANTARA............................. 87anticoagulant cit dext soln a..........................................35ANTICOAGULANT COMPOUND...................... 35anticoagulant sodium citrate.................................. 36ANTIVENIN MICRURUS FULVIUS...........................184ANTIZOL...........................184ANUSOL-HC.....................180ANZEMET...........................47APADAZ............................... 8apap-caff-dihydrocodeine..... 8APIDRA SOLOSTAR........121APIDRA VIAL....................121APLENZIN.......................... 44APOKYN.............................68APP SLIM RMS................ 184apraclonidine hcl...............199aprepitant............................47apri....................................160APRISO............................ 180APTENSIO XR..................104APTIOM.............................. 39APTIVUS............................ 73AP-ZEL............................. 124AQUACEL AG BURN....... 111

218

AQUASOL A..................... 124ARAKODA.......................... 67ARALAST NP................... 209aranelle............................. 160ARANESP (ALBUMIN FREE)................................. 81ARAVA..............................170ARCALYST.......................170ARCAPTA NEOHALER.... 209ARESTIN.......................... 109argatroban.......................... 36argatroban in sodium chloride............................... 36argyle sterile saline........... 124argyle sterile water............184ARICEPT............................ 43ARIMIDEX.......................... 56aripiprazole......................... 70ARISTADA..........................71ARISTADA INITIO.............. 71ARIXTRA............................ 36ARIZONA CYPRESS........184armodafinil ........................ 215ARMOUR THYROID.........168arnica flower..................... 184ARNUITY ELLIPTA...........209AROMASIN.........................56ARRANON..........................56arsenic trioxide....................56ARTHROTEC....................... 6ARTICADENT DENTAL......17ARTISS.............................184ARYMO ER...........................8ARZERRA...........................56ARZOL SILVER NIT APPLICATORS.................111ASACOL HD..................... 180ASCLERA........................... 87ascomp-codeine................... 9ASCOR............................. 124ashlyna............................. 160ASMANEX 120 METERED DOSES............................. 209ASMANEX 14 METERED DOSES............................. 209ASMANEX 30 METERED DOSES............................. 209ASMANEX 60 METERED DOSES............................. 209ASMANEX 7 METERED DOSES............................. 209ASMANEX HFA................ 209aspirin childrens....................6

aspirin ec low dose............... 6aspirin low dose.................... 6aspirin-dipyridamole er....... 70ASTAGRAF XL................. 170ASTEPRO.........................205ASTRINGYN.......................81ATACAND...........................87ATACAND HCT.................. 87atazanavir sulfate................73ATELVIA........................... 181atenolol............................... 87atenolol-chlorthalidone........87ATGAM............................. 170ATIVAN...............................79atomoxetine hcl.................104atorvastatin calcium............ 87atovaquone......................... 67atovaquone-proguanil hcl... 67atracurium besylate.......... 107ATRAPRO DERMAL SPRAY..............................111ATRIPLA.............................73ATROPINE SULFATE...... 140atropine sulfate................. 201ATROVENT HFA.............. 209AUBAGIO......................... 106aubra.................................160aubra eq............................160AUGMENTIN...................... 24AUGMENTIN ES-600......... 24AUREOBASIDIUM............184AURYXIA.......................... 146AUSTEDO........................ 107AUSTRALIAN PINE..........184AVALIDE.............................87AVANDIA.......................... 117AVAPRO.............................87avar cleanser.................... 111avar-e emollient................ 111avar-e green..................... 111AVASTIN............................ 56AVC VAGINAL....................49AVELOX............................. 24aviane............................... 160avidoxy................................24avita.................................. 111AVODART........................ 148AVONEX PEN.................. 106AVONEX PREFILLED...... 106AVONEX VIAL INTRAMUSCULAR KIT... 106AVYCAZ............................. 24AXUMIN............................184

AYGESTIN........................160azacitidine...........................56AZACTAM...........................24AZACTAM IN DEXTROSE. 24AZASAN........................... 170AZASITE...........................196azathioprine...................... 170azathioprine sodium..........170AZEDRA DOSIMETRIC......56AZEDRA THERAPEUTIC...56azelaic acid....................... 111azelastine hcl............ 196, 205AZELEX............................ 111AZILECT............................. 68azithromycin........................24AZOPT..............................199AZOR..................................87aztreonam...........................24AZULFIDINE.....................180AZULFIDINE EN-TABS.... 180azurette.............................160b-6 folic acid......................124baciim................................. 24bacitracin.................... 24, 196bacitracin-polymyxin b...... 201bacitra-neomycin-polymyxin-hc.....................201baclofen............................ 214BACMIN............................124bacteriostatic water(benz alc).................................... 184BACTERIOSTATIC WATER(BENZ ALC).........184BACTOCILL IN DEXTROSE........................ 24BACTRIM............................24BACTRIM DS......................24BAHIA............................... 184bal in oil .............................184balanced salt.....................201BALCOLTRA.................... 160BALD CYPRESS.............. 184balsalazide disodium........ 180balsam peru-castor oil ...... 111balziva...............................160BANZEL..............................39BARACLUDE................73, 74BASAGLAR KWIKPEN.....121BAVENCIO......................... 56BAXDELA........................... 24BAYBERRY (WAX MYRTLE).......................... 184bayer aspirin ec low dose..... 6

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BCG VACCINE................. 177bd posiflush.......................124BEAU RX.......................... 111BECONASE AQ................205bekyree............................. 160BELBUCA............................. 9BELEODAQ........................ 56belladonna alkaloids-opium.......................................... 141belladonna-opium............. 141BELSOMRA......................215benazepril hcl......................87benazepril-hydrochlorothiazide.............87BENDAMUSTINE HCL....... 56BENDEKA...........................56BENEFIX............................ 82BENICAR............................88BENICAR HCT................... 87BENLYSTA....................... 170BENSAL HP......................111BENTYL............................141benzalkonium chloride........ 24BENZHYDROCODONE-ACETAMINOPHEN.............. 9BENZNIDAZOLE................ 67benzoin............................. 111benzoin compound........... 111benzonatate...................... 205benztropine mesylate..........68BEPREVE.........................196BERINERT........................170BERMUDA GRASS.......... 184BESIVANCE..................... 196BESPONSA........................ 56BETADINE OPHTHALMIC PREP................................ 196BETAMETHASONE COMBO............................ 149betamethasone dipropionate...................... 149betamethasone dipropionate aug............... 149BETAMETHASONE SOD PHOS & ACET..................149betamethasone sod phos & acet................................149BETAMETHASONE SODIUM PHOSPHATE.... 149betamethasone valerate... 149BETAPACE.........................88BETAPACE AF................... 88BETASERON....................106

betaxolol hcl................88, 199bethanechol chloride.........146BETHKIS.......................... 213BETIMOL.......................... 199BETOPTIC-S.................... 199BEVACIZUMAB................ 201BEVESPI AEROSPHERE 209BEVYXXA........................... 36bexarotene..........................56BEXSERO........................ 177BEYAZ.............................. 160bicalutamide........................56BICILLIN C-R......................24BICILLIN C-R 900/300........24BICILLIN L-A.......................25BICNU.................................57BIDIL...................................88BIKTARVY.......................... 74BILTRICIDE........................ 67bimatoprost....................... 199BINOSTO..........................181biocel................................ 124BIOFREQUENCY INSOLES.......................... 184BIOGUARD GAUZE SPONGES........................ 184BIOGUARD ISLAND DRESSINGS.....................184BIOGUARD NON-ADHERENT DRESSING.. 184BIOLON............................ 201BIO-STATIN........................49bio-statin............................. 49BIOTHRAX....................... 177biotuss.............................. 205biotuss pediatric................205bisoprolol fumarate............. 88bisoprolol-hydrochlorothiazide.............88bivalirudin trifluoroacetate...36BIVALIRUDIN-SODIUM CHLORIDE......................... 36BIVIGAM...........................170BLACK WALNUT POLLEN.......................................... 184BLACK WILLOW.............. 185bleomycin sulfate................ 57BLEPH-10.........................196BLEPHAMIDE...................201BLEPHAMIDE S.O.P........ 201BLINCYTO..........................57blisovi 24 fe.......................160blisovi fe 1.5/30.................160

blisovi fe 1/20....................160BLOXIVERZ........................54BOCASAL.........................109BONIVA............................ 181BONJESTA.........................47BOOSTRIX....................... 177boric acid.......................... 185BORTEZOMIB.................... 57BOSULIF............................ 57BOTOX............................. 185BOTRYTIS........................185BOX ELDER..................... 185bp 10-1..............................111BP CLEANSING WASH... 111bp vit 3.............................. 124BPCO................................111b-plex................................ 124b-plex plus........................ 124BRAFTOVI..........................57BRAVELLE....................... 155BREO ELLIPTA................ 209BREVIBLOC....................... 88BREVIBLOC IN NACL........ 88BREVIBLOC PREMIXED... 88BREVIBLOC PREMIXED DS.......................................88BREVITAL SODIUM......... 185BRIDION...........................185briellyn.............................. 160BRILINTA............................70brimonidine tartrate...........199BRIMONIDINE-DORZOLAMIDE............... 199BRINEURA....................... 144BRIVIACT........................... 39BROME.............................185bromfed dm.......................205bromfenac sodium (once-daily)................................. 197bromocriptine mesylate.......68brompheniramine tannate.205BROMSITE....................... 197BROVANA........................ 209bss.................................... 201BUCALSEP.........................25budesonide....... 180, 205, 209budesonide er................... 180BUFFERED LIDOCAINE.... 17bumetanide......................... 88BUMEX............................... 88BUNAVAIL.......................... 22BUPAP..................................9BUPHENYL...................... 144

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bupivacaine hcl............. 17, 18BUPIVACAINE HCL..... 17, 18bupivacaine hcl (pf).............17BUPIVACAINE HCL-NACL.18bupivacaine in dextrose...... 18BUPIVACAINE IN DEXTROSE........................ 18bupivacaine spinal.............. 18bupivacaine-epinephrine.....18bupivacaine-epinephrine (pf)...................................... 18BUPRENEX.......................... 9buprenorphine.......................9BUPRENORPHINE.............. 9buprenorphine hcl........... 9, 22buprenorphine hcl-naloxone hcl........................22bupropion hcl...................... 44bupropion hcl er (smoking det)......................................22bupropion hcl er (sr)............44bupropion hcl er (xl)............ 44buspirone hcl...................... 79busulfan.............................. 57BUSULFEX.........................57BUTALBITAL-ACETAMINOPHEN.............. 9butalbital-acetaminophen......9butalbital-apap...................... 9butalbital-apap-caff-cod........ 9butalbital-apap-caffeine........ 9butalbital-asa-caff-codeine....9butalbital-aspirin-caffeine......9BUTISOL SODIUM........... 215butorphanol tartrate.............. 9BUTRANS.............................9BYDUREON..................... 117BYDUREON BCISE AUTOINJECTOR..............117BYETTA 10 MCG PEN..... 117BYETTA 5 MCG PEN....... 117BYSTOLIC.......................... 88BYVALSON........................ 88cabergoline....................... 155CABOMETYX..................... 57CADUET............................. 88CAFCIT.............................108CAFERGOT........................53caffeine citrate.................. 108CALAN................................88CALAN SR..........................88CALCIFOL........................ 124calcipotriene......................111

calcipotriene-betameth diprop................................111calcitonin (salmon)............181calcitrene.......................... 111calcitriol.....................111, 181calcium acetate (phos binder)...............................146CALCIUM CHLORIDE...... 124calcium chloride................ 124CALCIUM DISODIUM VERSENATE.................... 185CALCIUM GLUCONATE.. 124CALCIUM GLUCONATE-DEXTROSE...................... 125CALCIUM GLUCONATE-NACL................................ 125CALCIUM-FOLIC ACID PLUS D.............................125CALDOLOR.......................... 6CALIFORNIA PEPPER TREE................................ 185CALQUENCE..................... 57CAMBIA................................ 6camila............................... 160CAMPATH.......................... 57CAMPTOSAR..................... 57camrese............................ 160camrese lo........................ 160CANASA........................... 180CANCIDAS......................... 49candesartan cilexetil ........... 88candesartan cilexetil-hctz... 88CANDIDA ALBICANS EXTRACT......................... 185CAPASTAT SULFATE........55capecitabine........................57CAPRELSA.........................57captopril .............................. 88captopril-hydrochlorothiazide.............88CARAFATE.......................139CARBAGLU...................... 125carbamazepine................... 39carbamazepine er............... 39CARBAPHEN 12.............. 205CARBAPHEN 12 PED...... 205CARBATROL......................39carbidopa............................ 68carbidopa-levodopa............ 68carbidopa-levodopa er........ 68carbidopa-levodopa-entacapone......................... 68carbinoxamine maleate.....205

CARBOCAINE.................... 18CARBOCAINE PRESERVATIVE-FREE..... 18carboplatin.......................... 57CARDENE IV......................88CARDIOPLEGIC...............125cardioplegic.......................125CARDIOVID PLUS........... 185CARDIZEM......................... 89CARDIZEM CD.............88, 89CARDIZEM LA....................89CARDURA.......................... 89CARDURA XL...................148CARIMUNE NF.........170, 171carimune nf....................... 171carisoprodol...................... 214carisoprodol-aspirin.......... 214carisoprodol-aspirin-codeine................................. 9carmustine.......................... 57CARNITOR....................... 125CARNITOR SF................. 125carteolol hcl.......................199cartia xt............................... 89carvedilol.............................89carvedilol phosphate er.......89CASODEX.......................... 57caspofungin acetate............49CAT HAIR EXTRACT....... 185CATAPRES........................ 89CATAPRES-TTS-1............. 89CATAPRES-TTS-2............. 89CATAPRES-TTS-3............. 89CATHFLO ACTIVASE........ 36CATTLE EPITHELIUM..... 185cavarest............................ 109CAYA................................ 185CAYSTON........................ 213caziant.............................. 160CEDAR ELM.....................185cefaclor............................... 25cefaclor er........................... 25cefadroxil ............................ 25CEFAZOLIN IN SODIUM CHLORIDE......................... 25cefazolin sodium................. 25CEFAZOLIN SODIUM........ 25cefazolin sodium-dextrose.. 25CEFAZOLIN SODIUM-DEXTROSE........................ 25CEFAZOLIN SODIUM-NACL.................................. 25cefdinir................................ 25

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cefditoren pivoxil ................. 25cefepime hcl........................25cefepime-dextrose.............. 26cefixime...............................26CEFOTAN...........................26cefotaxime sodium..............26cefotetan disodium..............26cefotetan disodium-dextrose.............................. 26cefoxitin sodium.................. 26cefoxitin sodium-dextrose... 26cefpodoxime proxetil ...........26cefprozil .............................. 26ceftazidime..........................26ceftazidime and dextrose....26ceftriaxone sodium..............26ceftriaxone sodium in dextrose.............................. 26ceftriaxone sodium-dextrose.............................. 26cefuroxime axetil .................26cefuroxime sodium..............26CEFUROXIME SODIUM-NACL................................ 197celacyn..............................111CELACYN.........................111CELEBREX...........................6celecoxib...............................6CELESTONE SOLUSPAN149CELEXA..............................44CELLCEPT....................... 171CELLCEPT INTRAVENOUS................171CELONTIN..........................39cem-urea...........................111CENTANY AT..................... 26CENTRATEX.................... 125cephalexin.....................26, 27CEPROTIN......................... 82ceramax............................ 111CERAMAX........................ 111CERDELGA...................... 144CEREBYX...........................39CERETEC.........................185CEREZYME......................144cerovel.............................. 111CERVIDIL......................... 159CESAMET.......................... 47CETRAXAL.......................204CETROTIDE..................... 155cevimeline hcl................... 109CHANTIX............................ 22

CHANTIX CONTINUING MONTH PAK...................... 22CHANTIX STARTING MONTH PAK...................... 22chateal.............................. 160chateal eq......................... 160CHEMET...........................125CHENODAL......................141CHIRHOSTIM................... 185chloramphenicol sod succinate.............................27chlordiazepoxide hcl........... 79chlordiazepoxide-amitriptyline.........................44chlordiazepoxide-clidinium141chlorhexidine gluconate.................................. 109, 185chloroprocaine hcl (pf)........ 18chloroquine phosphate....... 67chlorothiazide......................89chlorothiazide sodium......... 89chlorpromazine hcl..............71chlorpropamide................. 117chlorthalidone..................... 89CHLORZOXAZONE......... 214chlorzoxazone...................214CHOLBAM........................ 141cholestyramine....................89cholestyramine light............ 89CHOLETEC...................... 185choline fenofibrate.............. 89choline-mag trisalicylate....... 6chorionic gonadotropin..... 155chromagen........................125chromic chloride................125CIALIS.............................. 146ciclodan...............................49CICLODAN SOLUTION......49ciclopirox.............................49ciclopirox olamine............... 49ciclopirox treatment.............49cidofovir.............................. 74cilostazol............................. 70CILOXAN.......................... 197CIMDUO............................. 74cimetidine..........................139cimetidine hcl.................... 139CIMZIA..............................171CIMZIA PREFILLED KIT.. 171CIMZIA STARTER KIT..... 171cinacalcet hcl.................... 155CINQAIR...........................205CINRYZE.......................... 171

CINVANTI........................... 47CIPRO................................ 27CIPRO HC........................ 204CIPRO IN D5W...................27CIPRODEX....................... 204ciprofloxacin........................27ciprofloxacin hcl.. 27, 197, 204ciprofloxacin in d5w............ 27ciprofloxacin-ciproflox hcl er.........................................27cisatracurium besylate...... 108CISATRACURIUM BESYLATE....................... 108cisatracurium besylate (pf)108cisplatin...............................57citalopram hydrobromide.... 44CITANEST FORTE DENTAL..............................18CITANEST PLAIN DENTAL..............................18CITRANATAL MEDLEY....125CLADOSPORIUM CLADOSPORIOIDES....... 185CLADOSPORIUM SPHAEROSPERMUM......185cladribine............................ 57claravis..............................111clarithromycin......................27clarithromycin er................. 27clemastine fumarate......... 205CLENPIQ.......................... 141CLEOCIN............................27CLEOCIN PHOSPHATE.....27CLEVIPREX........................89CLIMARA..........................160CLIMARA PRO................. 160CLINDACIN ETZ...............111clindacin etz...................... 111CLINDACIN PAC.............. 111clindacin-p.........................111clindamycin hcl................... 27clindamycin palmitate hcl....27clindamycin phosphate............................ 28, 111, 112clindamycin phosphate in d5w..................................... 27CLINDESSE....................... 28CLINIMIX E/DEXTROSE (2.75/10)........................... 125CLINIMIX E/DEXTROSE (2.75/5)............................. 125CLINIMIX E/DEXTROSE (4.25/10)........................... 125

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CLINIMIX E/DEXTROSE (4.25/25)........................... 125CLINIMIX E/DEXTROSE (4.25/5)............................. 125CLINIMIX E/DEXTROSE (5/15)................................ 125CLINIMIX E/DEXTROSE (5/20)................................ 125CLINIMIX N9G20E........... 125CLINIMIX/DEXTROSE (4.25/10)........................... 125CLINIMIX/DEXTROSE (4.25/25)........................... 126CLINIMIX/DEXTROSE (4.25/5)............................. 126CLINIMIX/DEXTROSE (5/15)................................ 126CLINIMIX/DEXTROSE (5/20)................................ 126CLINIMIX/DEXTROSE (5/25)................................ 126clinisol sf........................... 126CLINOIN........................... 112clinpro 5000...................... 109clobazam............................ 39clobetasol prop emollient base.................................. 149clobetasol propionate........150clobetasol propionate e.....149clobetasol propionate emulsion........................... 150clocortolone pivalate......... 150clocortolone pivalate pump.......................................... 150clodan............................... 150CLODERM........................150CLODERM PUMP............ 150clofarabine.......................... 57CLOLAR............................. 57clomiphene citrate.............155clomipramine hcl.................44clonazepam........................ 79clonidine..............................89clonidine hcl........................ 89clonidine hcl (analgesia)..... 89clonidine hcl er..................104clopidogrel bisulfate............ 70clorazepate dipotassium..... 79CLOROTEKAL....................18clotrimazole.........................49clotrimazole-betamethasone................. 112clozapine.............................71

CLOZARIL.......................... 71COAGADEX....................... 82coal tar.............................. 112COARTEM..........................67cocaine hcl..........................18COCAINE HCL................... 18COCKLEBUR................... 185cod liver oil ........................126codeine sulfate......................9COGENTIN.........................68COLAZAL......................... 180COLCHICINE......................52colchicine-probenecid......... 52COLCRYS.......................... 52colesevelam hcl.................. 89COLESTID..........................90COLESTID FLAVORED..... 89colestipol hcl....................... 90colistimethate sodium (cba)....................................28colocort............................. 180COLY-MYCIN M................. 28COLY-MYCIN S................204COLYTE WITH FLAVOR PACKS..............................141COMBIGAN...................... 199COMBIPATCH..................161COMBIVENT RESPIMAT. 209COMBIVIR.......................... 74COMETRIQ (100 MG DAILY DOSE)..................... 57COMETRIQ (140 MG DAILY DOSE)..................... 57COMETRIQ (60 MG DAILY DOSE)..................... 57COMFORT EZ MICRO PEN NEEDLES.................121COMFORT EZ SHORT PEN NEEDLES.................121COMPLERA........................74compro................................47COMTAN............................ 68CONCERTA......................104CONDYLOX......................112constulose.........................141COPASIL.......................... 112COPAXONE..................... 107COPIKTRA......................... 57COPPER CHLORIDE....... 126CORDRAN........................150COREG...............................90COREG CR........................ 90CORGARD......................... 90

CORIFACT......................... 82CORLANOR....................... 90CORLOPAM....................... 90CORN POLLEN................ 185CORTEF........................... 150CORTENEMA...................180CORTIFOAM.................... 180cortisone acetate.............. 150CORTISPORIN.................112CORTROSYN...................185CORVERT.......................... 90corvita............................... 126corvita 150........................ 126CORVITE..........................126CORVITE 150...................126CORVITE FE.................... 126corvite free........................ 126COSENTYX 150 MG/ML.. 171COSENTYX 300 DOSE....171COSENTYX SENSOREADY 300 DOSE.......................................... 171COSENTYX SENSOREADY PEN........ 171COSMEGEN.......................58COSOPT...........................199COSOPT PF..................... 199cosyntropin....................... 186COTELLIC.......................... 58COUMADIN........................ 36covaryx............................. 161covaryx hs.........................161COZAAR.............................90CREON.............................144CRESEMBA........................50CRESTOR.......................... 90CRINONE......................... 161CRIXIVAN...........................74CROFAB...........................186cromolyn sodium.......................... 141, 197, 209crotan..................................67cryselle-28........................ 161CRYSVITA........................144CUBICIN............................. 28CUBICIN RF....................... 28CURITY AMD ANTIMICROBIAL SPNGE 186CURITY AMD ANTIMICROBIAL STRIP.. 186CURITY IODOFORM PACKING STRIP.............. 186CUROSURF..................... 205

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CURVULARIA...................186CUVITRU..........................171CUVPOSA........................ 141cyanocobalamin................126CYANOKIT....................... 186cyclafem 1/35....................161cyclafem 7/7/7...................161cyclobenzaprine hcl.......... 214CYCLOGYL...................... 201CYCLOMYDRIL................201cyclopentolate hcl............. 201cyclophosphamide.............. 58cycloserine..........................55CYCLOSET...................... 117cyclosporine......................171CYCLOSPORINE IN KLARITY...........................201cyclosporine modified....... 171CYKLOKAPRON................ 82CYMBALTA........................ 44cyproheptadine hcl............205CYRAMZA.......................... 58cyred................................. 161cyred eq............................ 161CYSTADANE....................144CYSTAGON......................144CYSVIEW......................... 186cytarabine........................... 58cytarabine (pf).....................58CYTOGAM........................171CYTOMEL........................ 168CYTOTEC.........................139CYTOVENE........................ 74cytra k crystals.................. 126D.H.E. 45............................ 53d3 vitamin......................... 126dacarbazine........................ 58DACOGEN..........................58dactinomycin.......................58DAKLINZA.......................... 74dalfampridine er................ 107DALIRESP........................ 209DALVANCE........................ 28danazol............................. 154DANTRIUM.......................214dantrolene sodium............ 214dapsone...................... 55, 112DAPTACEL.......................177DAPTOMYCIN....................28daptomycin......................... 28DARAPRIM.........................67darifenacin hydrobromide er.......................................146

DARZALEX.........................58dasetta 1/35...................... 161dasetta 7/7/7..................... 161DATSCAN.........................186daunorubicin hcl..................58DAURISMO........................ 58DAYPRO...............................6daysee.............................. 161DAYTRANA...................... 104DDAVP............................. 155DDAVP RHINAL TUBE.....155DEBACTEROL................. 109deblitane........................... 161DECADRON..................... 150decitabine........................... 58deferoxamine mesylate.....186DEFINITY......................... 186DEFITELIO......................... 36DEFLUX............................186DELESTROGEN...............161DELFLEX-LC/1.5% DEXTROSE...................... 126DELFLEX-LC/2.5% DEXTROSE...................... 126DELFLEX-LC/4.25% DEXTROSE...................... 126delflex-sm/1.5% dextrose. 126delflex-sm/2.5% dextrose. 126DELSTRIGO....................... 74deltasone.......................... 150delyla................................ 161DELZICOL........................ 180DEMADEX.......................... 90demeclocycline hcl..............28DEMEROL............................ 9DEMSER............................ 90DENAVIR............................74denta 5000 plus................ 109dentagel............................ 109DEPACON.......................... 39DEPAKENE........................ 39DEPAKOTE........................ 39DEPAKOTE ER.................. 39DEPAKOTE SPRINKLES... 39DEPEN TITRATABS.........146DEPO-ESTRADIOL.......... 161DEPO-MEDROL............... 150DEPO-PROVERA.............161DEPO-SUBQ PROVERA 104....................................161DEPO-TESTOSTERONE. 154dermacinrx empricaine....... 18dermacinrx prizopak........... 18

DERMOTIC.......................204DERMULCERA.................112DESCOVY.......................... 74DESFERAL.......................186desipramine hcl...................45desloratadine.................... 205desmopressin ace spray refrig..................................155desmopressin acetate.......155desmopressin acetate spray................................. 156desogestrel-ethinyl estradiol............................ 161desonide........................... 150desoximetasone................150DESOXYN........................ 104DESVENLAFAXINE ER......45desvenlafaxine succinate er.........................................45DETROL........................... 146DETROL LA......................146dexamethasone........ 150, 151DEXAMETHASONE INTENSOL........................150DEXAMETHASONE SOD PHOS IN D5W.................. 151DEXAMETHASONE SOD PHOS-NACL.....................151dexamethasone sod phosphate pf..................... 151dexamethasone sodium phosphate................. 151, 197DEXAMETHASONE SODIUM PHOSPHATE.... 151DEXAMETHASONE-MOXIFLOXACIN...............201DEXAMETH-MOXIFLOX-KETOROLAC....................201dexchlorpheniramine maleate............................. 205DEXEDRINE.....................104dexifol............................... 126DEXILANT........................ 139DEXMEDETOMIDINE HCL.......................................... 186dexmedetomidine hcl........186dexmedetomidine hcl in nacl................................... 186DEXMEDETOMIDINE HCL-DEXTROSE..............186dexmethylphenidate hcl.... 104dexmethylphenidate hcl er 104DEXONTO 0.4%...............151

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dexpak 10 day.................. 151dexpak 13 day.................. 151DEXPAK 6 DAY................151dexrazoxane....................... 58dextroamphetamine sulfate.......................................... 105dextroamphetamine sulfate er.......................................104dextrose............................ 126DEXTROSE...................... 126DEXTROSE 5%/ELECTROLYTE #48...126dextrose in lactated ringers.......................................... 126dextrose-nacl.................... 127DEXYCU...........................197dialyvite.............................127DIALYVITE 3000.............. 127DIALYVITE 5000.............. 127DIALYVITE SUPREME D. 127DIALYVITE/ZINC.............. 127DIANEAL LOW CALCIUM/1.5% DEX........ 127DIANEAL LOW CALCIUM/2.5% DEX........ 127DIANEAL LOW CALCIUM/4.25% DEX...... 127DIANEAL PD-2/1.5% DEXTROSE...................... 127DIANEAL PD-2/2.5% DEXTROSE...................... 127DIANEAL PD-2/4.25% DEXTROSE...................... 127DIASTAT ACUDIAL............ 39DIASTAT PEDIATRIC........ 39diazepam...................... 39, 79DIAZEPAM......................... 79diazepam intensol...............79DIBENZYLINE.................... 90DICLOFENAC EPOLAMINE.........................6diclofenac potassium............ 6diclofenac sodium. 6, 112, 197diclofenac sodium er.............6diclofenac-misoprostol.......... 6dicloxacillin sodium............. 28dicyclomine hcl................. 141didanosine.......................... 74DIFICID...............................28difil-g forte......................... 209diflorasone diacetate.........151DIFLUCAN..........................50diflunisal................................6

DIGIFAB........................... 186digitek................................. 90digox................................... 90digoxin................................ 90dihydroergotamine mesylate............................. 53DILANTIN..................... 39, 40DILANTIN INFATABS.........39DILATRATE-SR..................90DILAUDID............................. 9diltiazem hcl........................ 91DILTIAZEM HCL.................91diltiazem hcl er..............90, 91diltiazem hcl er beads......... 90diltiazem hcl er coated beads.................................. 90DILTIAZEM HCL-DEXTROSE........................ 91DILTIAZEM HCL-SODIUM CHLORIDE......................... 91dilt-xr................................... 91dimenhydrinate................... 47DIOVAN.............................. 91DIOVAN HCT......................91DIPENTUM....................... 180diphenhydramine hcl.........205diphenoxylate-atropine..... 141DIPHTHERIA-TETANUS TOXOIDS DT....................177DIPRIVAN.........................186dipyridamole............... 70, 186disopyramide phosphate.....91disulfiram............................ 22DITHOL.................................6DITROPAN XL..................146DIURIL................................ 91divalproex sodium...............40divalproex sodium er...........40DIVIGEL............................161dobutamine hcl................... 91dobutamine in d5w..............91docetaxel............................ 58docetaxel (non-alcohol)...... 58dofetilide............................. 91DOG EPITHELIUM........... 186DOG FENNEL.................. 186DOLOPHINE.......................10donepezil hcl.......................43dopamine hcl...................... 91dopamine in d5w.................91DOPRAM.......................... 108DOPTELET.........................82DORAL............................... 79

DORIPENEM...................... 28DORZOLAMIDE HCL....... 199dorzolamide hcl.................199DORZOLAMIDE HCL-TIMOLOL MAL..................199dorzolamide hcl-timolol mal.......................................... 199dorzolamide hcl-timolol mal pf.......................................199DOTAREM........................187doxazosin mesylate............ 91doxepin hcl..................45, 112doxercalciferol...................181DOXIL................................. 58doxorubicin hcl....................58doxorubicin hcl liposomal....58doxy 100............................. 28doxycycline hyclate.............28doxycycline monohydrate... 28DRECHSLERA................. 187DRISDOL..........................127DRITHO-CREME HP........112dronabinol........................... 47droperidol............................47drospiren-eth estrad-levomefol.......................... 161drospirenone-ethinyl estradiol............................ 161DROXIA.............................. 58DRYSOL........................... 112DSUVIA.............................. 10DUAVEE........................... 161DUETACT.........................117DULERA........................... 210duloxetine hcl......................45DUODOTE........................187DUPIXENT................112, 206DURACLON........................91DURAGESIC-100............... 10DURAGESIC-12................. 10DURAGESIC-25................. 10DURAGESIC-50................. 10DURAGESIC-75................. 10duramorph.......................... 10duraxin................................ 10DUREZOL.........................197DUST MITE MIXED ALLERGEN EXT...............187dutasteride........................ 148dutasteride-tamsulosin hcl 148DUTOPROL........................91DUZALLO........................... 52DYANAVEL XR.................105

225

DYAZIDE............................ 91DYRENIUM.........................91DYSPORT........................ 187e.e.s. 400............................ 28E.E.S. GRANULES.............28EASTERN COTTONWOOD............... 187EASY TOUCH SAFETY PEN NEEDLES.................121EC-NAPROSYN................... 6EC-NAPROXEN................... 6econazole nitrate................ 50EC-RX PROGESTERONE161EDARBI.............................. 91EDARBYCLOR................... 91EDECRIN............................92ed-spaz............................. 141EDURANT.......................... 74eemt..................................161eemt hs............................. 161efavirenz............................. 74EFFER-K.......................... 127effer-k................................127EFFEXOR XR.....................45EFFIENT.............................70EGRIFTA.......................... 156ELAPRASE.......................145ELELYSO......................... 145ELESTAT..........................197ELESTRIN........................ 162eletriptan hydrobromide...... 53ELIDEL............................. 112ELIGARD.......................... 156ELIMITE..............................67elinest............................... 162ELIQUIS..............................36ELIQUIS STARTER PACK. 36ELITEK............................... 58ELIXOPHYLLIN................ 210ELLA................................. 162ELLENCE........................... 58ELLIOTTS B..................... 127ELMIRON......................... 146ELOCTATE.........................82ELZONRIS..........................58EMADINE......................... 197EMBEDA.............................10EMCYT............................... 59EMEND.........................47, 48EMEND TRI-PACK............. 48EMFLAZA........................... 52emoquette.........................162EMPLICITI.......................... 59

EMSAM...............................45EMTRIVA............................74EMVERM............................ 67ENABLEX......................... 146enalapril maleate................ 92enalaprilat........................... 92enalapril-hydrochlorothiazide.............92ENBREL................... 171, 172ENBREL MINI...................171ENBREL SURECLICK......172ENDARI............................ 187endocet............................... 10ENDOMETRIN..................162ENGERIX-B...................... 177ENGLISH PLANTAIN....... 187ENOVARX-IBUPROFEN...... 6enoxaparin sodium............. 36enpresse-28......................162enskyce.............................162entacapone......................... 68entecavir............................. 74ENTEREG........................ 141ENTOCORT EC................180ENTRESTO........................ 92ENTYVIO.......................... 172enulose............................. 141ENVARSUS XR................ 172EOVIST.............................187EPANED............................. 92EPCLUSA........................... 74ephedrine sulfate................ 92EPHEDRINE SULFATE......92EPHEDRINE SULFATE-NACL.................................. 92EPICOCCUM....................187EPIFOAM..........................112epinastine hcl....................197epinephrine................. 92, 210EPINEPHRINE........... 92, 210EPINEPHRINE HCL-DEXTROSE........................ 92EPINEPHRINE HCL-NACL 92epinephrine pf..................... 93EPINEPHRINE-DEXTROSE........................ 93EPINEPHRINE-NACL.........93EPIPEN 2-PAK................. 210EPIPEN JR 2-PAK............210epirubicin hcl.......................59epitol................................... 40EPIVIR................................ 74EPIVIR HBV........................74

eplerenone..........................93EPOGEN............................ 82epoprostenol sodium........ 213eprosartan mesylate........... 93eptifibatide.......................... 70EPZICOM........................... 74EQUAPAX/ATORVASTATIN/COQ10............................ 93EQUAPAX/IBUPROFEN/MINREX...................................6EQUETRO.......................... 40ERAXIS...............................50ERBITUX............................ 59ergocalciferol.................... 127ergoloid mesylates............187ERGOMAR......................... 53ergotamine-caffeine............ 53ERIVEDGE......................... 59ERLEADA........................... 59errin...................................162ERTACZO...........................50ertapenem sodium.............. 28ERWINAZE.........................59ery.....................................112ERYPED 200...................... 29ERYPED 400...................... 29ERY-TAB............................ 29ERYTHROCIN LACTOBIONATE................ 29ERYTHROCIN STEARATE.........................29erythromycin............. 112, 197erythromycin base.............. 29erythromycin ethylsuccinate..................... 29ESBRIET.......................... 210ESCAVITE........................ 127ESCAVITE D.................... 127escavite lq.........................127escitalopram oxalate...........45esgic................................... 10ESGIC.................................10esmolol hcl..........................93ESMOLOL HCL.................. 93esmolol hcl-sodium chloride............................... 93esomeprazole sodium.......139est estrogens-methyltest...162est estrogens-methyltest ds...................................... 162est estrogens-methyltest hs...................................... 162estarylla............................ 162

226

estazolam........................... 79ESTRACE.........................162estradiol............................ 162estradiol valerate.............. 162estradiol-norethindrone acet................................... 162ESTRING..........................162ESTROGEL...................... 162ESTROSTEP FE.............. 162eszopiclone.......................215ethacrynate sodium............ 93ethacrynic acid....................93ethambutol hcl.................... 55ethosuximide.......................40ethyl chloride.......................18ethynodiol diac-eth estradiol............................ 162etidronate disodium.......... 181etodolac................................ 6etodolac er............................ 6etomidate.......................... 187ETOPOPHOS..................... 59etoposide............................ 59EUCRISA..........................112EUFLEXXA....................... 187EURAX............................... 67euthyrox............................ 168EVAMIST.......................... 162EVISTA............................. 155EVOMELA.......................... 59EVOTAZ............................. 74EVOXAC...........................109EXACTUSS...................... 206EXCILON AMD DRAIN SPONGES........................ 187EXELDERM........................ 50EXELON............................. 43exemestane........................ 59EXFORGE.......................... 93EXFORGE HCT..................93EXJADE............................127EXODERM..........................50EXPAREL........................... 18EXTAVIA...........................107EXTINA...............................50EXTRANEAL.................... 127EYLEA.............................. 202EZ FLU SHOT-FLUCELVAX QUAD......... 177ezetimibe............................ 93ezetimibe-simvastatin......... 93fabb...................................127FABRAZYME....................145

FALESSA..........................162falmina.............................. 162famciclovir...........................74famotidine......................... 139famotidine premixed......... 139FANAPT..............................71FANAPT TITRATION PACK.................................. 71FARESTON........................ 59FARXIGA.......................... 117FARYDAK...........................59FASENRA.........................206FASLODEX.........................59fa-vitamin b-6-vitamin b-12127fayosim............................. 162FAZACLO........................... 71FBL KIT.................................6FEIBA................................. 82felbamate............................ 40FELBATOL......................... 40FELDENE............................. 7felodipine er........................ 93FEM PH............................ 146FEMARA.............................59FEMCAP...........................187FEMHRT LOW DOSE...... 162FEMRING......................... 163femynor.............................163fenofibrate...........................93fenofibrate micronized........ 93fenofibric acid......................93fenoprofen calcium............... 7fenortho.................................7fentanyl............................... 11fentanyl citrate.................... 10FENTANYL CITRATE.........10fentanyl citrate (pf).............. 10FENTANYL CITRATE-NACL.................................. 11FENTANYL CIT-ROPIVACAINE-NACL........ 11FENTANYL-BUPIVACAINE-NACL.........11FENTORA...........................11FERAHEME......................127FERIVAFA........................ 127ferocon..............................127ferotrinsic.......................... 127FERRALET 90.................. 127FERRAPLUS 90............... 127FERRIPROX.....................128FERRLECIT......................128

FERRO-PLEX HEMATINIC...................... 128FERROTRIN.....................128FETZIMA............................ 45FETZIMA TITRATION........ 45FEXMID............................ 214FIASP............................... 121FIASP FLEXTOUCH.........121FIBRICOR...........................93FIBRYGA............................ 82FINACEA.......................... 112finasteride......................... 148FIORICET........................... 11FIORICET/CODEINE..........11FIORINAL........................... 11FIORINAL/CODEINE #3.....11FIRAZYR.......................... 172FIRDAPSE........................187FIRE ANT......................... 187FIRMAGON...................... 156FIRST-ATENOLOL............. 93FIRST-LANSOPRAZOLE. 139FIRST-MOUTHWASH BLM.................................. 109FIRST-OMEPRAZOLE..... 139FIRST-PROGESTERONE VGS 100........................... 163FIRST-PROGESTERONE VGS 200........................... 163FIRST-VANCOMYCIN 25...29FIRST-VANCOMYCIN 50...29FIRVANQ............................29flac.................................... 204FLAGYL.............................. 29FLAREX............................197flavoxate hcl......................146FLEBOGAMMA DIF..........172flecainide acetate................93FLECTOR............................. 7FLEXBUMIN..................... 187FLEXIN............................... 19FLOLAN............................213FLOMAX........................... 148FLORIVA PLUS................ 128FLOVENT DISKUS...........210FLOVENT HFA................. 210FLOXIN OTIC................... 204floxuridine........................... 59FLUAD.............................. 177FLUARIX QUADRIVALENT..............177FLUBLOK QUADRIVALENT..............177

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FLUCELVAX QUADRIVALENT......177, 178fluconazole..........................50fluconazole in sodium chloride............................... 50flucytosine...........................50fludarabine phosphate........ 59FLUDEOXYGLUCOSE F 18......................................187fludrocortisone acetate..... 151FLULAVAL QUADRIVALENT..............178FLUMADINE....................... 74flumazenil ..........................187FLUMIST QUADRIVALENT..............178flunisolide..........................206fluocinolone acetonide.................................. 151, 204fluocinolone acetonide body.................................. 151fluocinolone acetonide scalp................................. 151fluocinonide.......................151fluocinonide emulsified base.................................. 151FLUORABON................... 128FLUORESCITE.................202fluoridex............................ 109fluoridex daily renewal...... 109fluoridex enhanced whitening...........................109fluoridex sensitivity relief...109fluorometholone................ 197fluorouracil .................. 59, 112fluoxetine hcl.......................45fluoxetine hcl (pmdd).......... 45fluphenazine decanoate......71fluphenazine hcl..................71FLURA-DROPS................ 128flurandrenolide.................. 151flurazepam hcl.................. 215flurbiprofen............................7flurbiprofen sodium........... 197flutamide............................. 59fluticasone propionate.................................. 152, 206FLUTICASONE-SALMETEROL..................210fluvastatin sodium............... 94fluvastatin sodium er...........94fluvoxamine maleate...........45fluvoxamine maleate er.......45

FLUZONE HIGH-DOSE....178FLUZONE QUADRIVALENT..............178FML...................................197FML FORTE..................... 197FML LIQUIFILM................ 197FOCALIN.......................... 105FOCALIN XR.................... 105folbee plus........................ 128FOLGARD OS.................. 128FOLGARD RX.................. 128folic acid............................128FOLIKA-T..........................128FOLIVANE-F.....................128FOLIVANE-PLUS............. 128FOLLISTIM AQ................. 156FOLOTYN...........................59folplex 2.2......................... 128FOLTRATE....................... 128foltrin................................. 128fomepizole........................ 187fondaparinux sodium.......... 36formadon...........................187formaldehyde.................... 187FORMA-RAY.................... 187FORTAVIT........................ 128FORTEO...........................181FORTESTA.......................154FOSAMAX........................ 181FOSAMAX PLUS D.......... 181fosamprenavir calcium........74FOSCAVIR......................... 74fosinopril sodium.................94fosinopril sodium-hctz......... 94fosphenytoin sodium...........40FOSRENOL...................... 147FRAGMIN........................... 36FREAMINE HBC...............128FREAMINE III ................... 128FREESTYLE INSULINX TEST.................................120FREESTYLE LITE TEST.. 120FREESTYLE PRECISION NEO TEST........................120FREESTYLE TEST...........120fresenius propoven........... 187FROVA............................... 53frovatriptan succinate..........53FULPHILA...........................82FUNGIMEZ......................... 50FURADANTIN.....................29furosemide.......................... 94

FUROSEMIDE IN SODIUM CHLORIDE..........94FUSARIUM....................... 187FUSILEV.............................59FUSION PLUS..................128FUZEON............................. 74fyavolv...............................163FYCOMPA.......................... 40gabapentin.......................... 40GABITRIL........................... 40GABLOFEN...................... 214GADAVIST........................188GALAFOLD.......................145galantamine hydrobromide. 43galantamine hydrobromide er.........................................43GALZIN.............................128GAMASTAN......................172GAMASTAN S/D...............172GAMIFANT....................... 172GAMMAGARD..................172GAMMAGARD S/D LESS IGA....................................172GAMMAKED.....................172GAMMAPLEX................... 172GAMUNEX-C....................172GANCICLOVIR................... 74ganciclovir sodium.............. 75ganirelix acetate................156GANIRELIX ACETATE..... 156GARDASIL 9.....................178GASTROCROM................141gatifloxacin........................197GATIFLOXACIN-DEXAMETHASONE......... 202GATTEX........................... 141gavilyte-c...........................141gavilyte-g.......................... 141gavilyte-h.......................... 141gavilyte-n with flavor pack.141GAZYVA............................. 59GELFILM.......................... 202GELFOAM-JMI SPONGE.188GELNIQUE....................... 147GELNIQUE PUMP............147GEL-ONE..........................188GELSYN-3........................ 188gemcitabine hcl.............59, 60gemfibrozil .......................... 94GENERESS FE................ 163generlac............................ 141gengraf..............................172GENICIN VITA-S.............. 128

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GENOTROPIN..................156GENOTROPIN MINIQUICK.......................156gentak............................... 197gentamicin in saline............ 29gentamicin sulfate.......29, 197GENVISC 850...................188GENVOYA.......................... 75GEODON............................71GERMAN COCKROACH..188gianvi................................ 163GILENYA.......................... 107GILOTRIF........................... 60GILPHEX TR.................... 206GILTUSS.......................... 206giltuss pediatric................. 206GILTUSS TR.....................206GLASSIA.......................... 210glatiramer acetate............. 107glatopa.............................. 107GLEEVEC...........................60GLEOLAN.........................188GLEOSTINE....................... 60GLIADEL WAFER...............60glimepiride........................ 117glipizide er.........................117glipizide ir..........................117glipizide xl......................... 117glipizide-metformin hcl...... 117GLUCAGEN DIAGNOSTIC.......................................... 188GLUCAGEN HYPOKIT.....120GLUCAGON EMERGENCY...................120GLUCAGON HCL (DIAGNOSTIC)................. 188GLUCOPHAGE................ 117GLUCOPHAGE XR.......... 117glucose............................. 128GLUCOTROL................... 117GLUCOTROL XL.............. 117glutaraldehyde.................. 188glyburide........................... 118glyburide micronized.........118glyburide-metformin.......... 118glycine...............................147glycine urologic................. 147glycolic acid...................... 112glycopyrrolate................... 142GLYCOPYRROLATE....... 142glydo................................... 19GLYNASE.........................118GLYRX-PF........................142

GLYSET............................118GLYXAMBI....................... 118gnp folic acid.....................128GOLDENROD...................188GOLYTELY.......................142GONAL-F..........................156GONAL-F RFF..................156GONAL-F RFF REDIJECT156GOODSENSE CLICKFINE PEN NEEDLE................... 121GOODSENSE PEN NEEDLE PENFINE...........121GOPRELTO........................19GORDOFILM.................... 112GRALISE.......................... 108GRALISE STARTER........ 108granisetron hcl.................... 48GRANIX.............................. 82GRASTEK.........................188griseofulvin microsize......... 50griseofulvin ultramicrosize.. 50guanfacine hcl.....................94guanfacine hcl er.............. 105GUANIDINE HCL................54GYNAZOLE-1..................... 50HACKBERRY................... 188HAEGARDA......................172hailey 24 fe....................... 163HALAVEN........................... 60HALCION............................79HALDOL............................. 71HALDOL DECANOATE...... 71halobetasol propionate..... 152HALOG............................. 152haloperidol.......................... 71haloperidol decanoate........ 71haloperidol lactate...............71HARVONI........................... 75HAVRIX............................ 178HCG..................................156HEALON........................... 202HEALON GV.....................202HEALON5......................... 202HEALTHWISE INSULIN SYR/NEEDLE................... 121HEALTHWISE MICRON PEN NEEDLES.................121heather..............................163HECTOROL......................181HELIXATE FS.....................82HEMABATE...................... 159hematinic/folic acid........... 128hematogen........................128

HEMATOGEN FA............. 128hematogen forte................128HEMATRON-AF............... 128HEMETAB........................ 128HEMLIBRA......................... 82HEMOCYTE PLUS........... 128hemocyte-f........................ 128hemofil m............................ 82HEMOFIL M........................82HEPAGAM B.................... 172heparin (porcine) in d5w..... 36heparin (porcine) in nacl36, 37HEPARIN (PORCINE) IN NACL.................................. 37heparin lock flush..............188heparin sod (porcine) in d5w..................................... 37HEPARIN SOD (PORCINE) IN D5W........... 37HEPARIN SOD (PORCINE)-D10................. 38heparin sodium (porcine).... 38HEPARIN SODIUM (PORCINE)......................... 38heparin sodium (porcine) pf.........................................38heparin sodium flush.........188heparin sodium lock flush. 188HEPARIN SODIUM/D5W... 38HEPATAMINE.................. 128HEPATOLITE................... 188HEPLISAV-B.....................178HEPMED.......................... 188HEPSERA...........................75HERCEPTIN....................... 60HESPAN............................. 82hetastarch-nacl................... 82HETLIOZ...........................215HEXTEND...........................83HIBERIX........................... 178HIDEX 6-DAY................... 152HIPREX.............................. 29HISTATROL......................188HIZENTRA........................173homatropaire.....................202homatropine hbr................202HONEY BEE VENOM.......188HONEY BEE VENOM PROTEIN..........................188HORIZANT....................... 108HORSE EPITHELIUM...... 188HP ACTHAR..................... 156HUMALOG KWIKPEN...... 121

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HUMALOG MIX 50/50 KWIKPEN......................... 121HUMALOG MIX 50/50 VIAL.................................. 121HUMALOG MIX 75/25 KWIKPEN......................... 121HUMALOG MIX 75/25 VIAL.................................. 121HUMALOG U-100 JUNIOR KWIKPEN......................... 121HUMALOG U-100 VIAL AND CARTRIDGE............ 122HUMAN ALBUMIN GRIFOLS.......................... 188HUMATE-P......................... 83HUMATROPE...................156HUMIRA............................173HUMIRA PEDIATRIC CROHNS START............. 173HUMIRA PEN................... 173HUMIRA PEN-CD/UC/HS STARTER......................... 173HUMIRA PEN-PS/UV/ADOL HS START. 173HUMULIN 70/30 KWIKPEN......................... 122HUMULIN 70/30 VIAL.......122HUMULIN N KWIKPEN.... 122HUMULIN N VIAL............. 122HUMULIN R U-500 KWIKPEN......................... 122HUMULIN R U-500 VIAL (CONCENTRATED)......... 122HUMULIN R VIAL............. 122HYALGAN.................188, 189HYCAMTIN......................... 60hydralazine hcl....................94HYDREA.............................60HYDRO 35........................112hydrochlorothiazide.............94hydrocodone polst-cpm polst er.............................. 206hydrocodone-acetaminophen................... 12hydrocodone-homatropine 206hydrocodone-ibuprofen.......12hydrocortisone.......... 152, 180hydrocortisone ace-pramoxine......................... 180hydrocortisone butyr lipo base.................................. 152hydrocortisone butyrate.... 152

hydrocortisone in absorbase......................... 152hydrocortisone valerate.... 152hydrocortisone-acetic acid 205hydrogen peroxide.............. 29hydromet...........................206hydromorphone hcl............. 12HYDROMORPHONE HCL. 12hydromorphone hcl er.........12hydromorphone hcl pf......... 12HYDROMORPHONE HCL-NACL............................ 12, 13HYDROMORPHONE-BUPIVACAINE-NACL.........13HYDROMORPHONE-ROPIVACAINE-NACL........ 13hydroxocobalamin acetate 129hydroxychloroquine sulfate. 67hydroxyprogesterone caproate............................163hydroxyurea........................ 60hydroxyzine hcl................... 79hydroxyzine pamoate..........79HYLAVITE........................ 129HYLENEX......................... 189HYLIRA.............................112HYMOVIS......................... 189hyophen............................ 147hyoscyamine sulfate......... 142hyoscyamine sulfate er..... 142hyoscyamine sulfate sl......142HYPERHEP B S/D............173HYPERRAB...................... 173HYPERRAB S/D............... 173HYPERRHO S/D.............. 173HYPERSAL.......................206HYPERTET S/D................173HYQVIA............................ 173HYSINGLA ER....................13HYZAAR............................. 94ibandronate sodium.......... 181IBRANCE............................60ibu......................................... 7IBUDONE........................... 13ibuprofen...............................7ibuprofen lysine.....................7ibutilide fumarate................ 94IC 400................................... 7IC 800................................... 7IC GREEN........................ 189ICAR-C PLUS................... 129ICLUSIG............................. 60IDAMYCIN PFS.................. 60

idarubicin hcl.......................60IDELVION........................... 83IDHIFA................................ 60iferex 150 forte..................129IFEX....................................60ifosfamide........................... 60ILARIS.............................. 173ILEVRO.............................197ILUMYA............................ 173ILUVIEN............................197imatinib mesylate................ 60IMBRUVICA........................60imipenem-cilastatin............. 29imipramine hcl.....................45imipramine pamoate........... 45imiquimod......................... 112IMITREX............................. 53IMITREX STATDOSE REFILL................................53IMITREX STATDOSE SYSTEM............................. 53IMLYGIC............................. 60IMOGAM RABIES-HT.......173IMOVAX RABIES..............178IMPAVIDO.......................... 67IMURAN............................173INBRIJA.............................. 68incassia.............................163INCRELEX........................156INCRUSE ELLIPTA.......... 210indapamide......................... 94INDERAL LA.......................94INDERAL XL.......................94INDICLOR.........................189indium in 111 oxyquinoline189INDOCIN...............................7indocyanine green............ 189indomethacin........................ 7indomethacin er.................... 7indomethacin sodium............7INFANRIX......................... 178INFASURF........................206INFED............................... 189INFLECTRA......................173INFUMORPH 200............... 13INFUMORPH 500............... 13INFUVITE ADULT.............129INFUVITE PEDIATRIC..... 129INGREZZA........................108INJECTAFER....................129INLYTA............................... 61INNOPRAN XL................... 94

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INOVA 4/1 ACNE CONTROL THERAPY...... 112INOVA 8/2 ACNE CONTROL THERAPY...... 112INSPRA.............................. 94INSULIN PEN NEEDLES. 122INSULIN SYRINGES........ 122INTEGRA F.......................129INTEGRA PLUS............... 129INTEGRILIN........................70INTELENCE........................75intralipid............................ 129INTRALIPID...................... 129INTRAROSA.....................147INTRON A...........................75introvale............................ 163INTUNIV........................... 105INVANZ...............................29INVEGA.............................. 71INVEGA SUSTENNA..........72INVEGA TRINZA................ 72INVELTYS........................ 197INVIRASE........................... 75INVOKAMET.....................118INVOKAMET XR...............118INVOKANA....................... 118iodine strong..................... 129iodine tincture..................... 29IONOSOL-MB IN D5W..... 129IOPIDINE.................. 199, 200IPOL..................................178ipratropium bromide..206, 210ipratropium-albuterol.........210irbesartan............................94irbesartan-hydrochlorothiazide.............94IRESSA...............................61irinotecan hcl.......................61IROSPAN 24/6..................129IS 24/6.............................. 129ISENTRESS....................... 75ISENTRESS HD................. 75isibloom.............................163ISOLYTE-P IN D5W......... 129ISOLYTE-S....................... 129ISOLYTE-S PH 7.4........... 129isoniazid..............................55isoproterenol hcl................. 94ISOPTO ATROPINE.........202ISOPTO CARPINE........... 200ISORDIL TITRADOSE........94isosorbide dinitrate..............94isosorbide dinitrate er......... 94

isosorbide mononitrate....... 94isosorbide mononitrate er... 94isosulfan blue....................189isotretinoin........................ 113isradipine............................ 95ISTALOL........................... 200ISTODAX (OVERFILL)....... 61ISUPREL............................ 95itraconazole........................ 50ivermectin........................... 67IXEMPRA KIT..................... 61IXIARO..............................178IXINITY............................... 83JADENU........................... 129JADENU SPRINKLE.........129JAKAFI................................61JALYN...............................148jantoven.............................. 38JANUMET.........................118JANUMET XR...................118JANUVIA...........................118JARDIANCE..................... 118jasmiel...............................163jencycla.............................163JENTADUETO..................118JENTADUETO XR............118JETREA............................ 202JEVTANA............................61jinteli ..................................163JIVI......................................83JOHNSON GRASS...........189jolessa...............................163jolivette..............................163JUBLIA................................50juleber............................... 163JULUCA..............................75JUNE GRASS POLLEN STANDARDIZED..............189junel 1.5/30....................... 163junel 1/20.......................... 163junel fe 1.5/30................... 163junel fe 1/20...................... 163junel fe 24......................... 163JUXTAPID.......................... 95JYNARQUE...................... 129KABIVEN.......................... 129KADCYLA........................... 61KADIAN.............................. 13kaitlib fe.............................163KALBITOR........................ 189KALETRA........................... 75KALYDECO...................... 213KANUMA.......................... 145

KAPOK............................. 189KAPVAY........................... 105KARBINAL ER.................. 206kariva................................ 163KAZANO........................... 118KCENTRA...........................83kcl in d5w lactated ringers 129kcl in dextrose-nacl........... 129KCL IN LACTATED RINGERS......................... 129kcl-lactated ringers-d5w....129KCL-LIDOCAINE IN NACL.......................................... 129KCL-LIDOCAINE-NACL... 130kedbumin.......................... 189KEDRAB........................... 173KEFLEX.............................. 29KELARX............................113kelnor 1/35........................ 163kelnor 1/50........................ 163KENALOG........................ 152KENGREAL........................ 70KEPIVANCE..................... 109KEPPRA............................. 40KEPPRA XR....................... 40KERALYT......................... 113KERALYT SCALP.............113KERAMATRIX REPLICINE 5CMX5CM........................ 113KERLIX AMD ANTIMICROBIAL..............189KERLIX AMD SUPER SPONGES........................ 189KERYDIN............................50KETALAR......................... 189ketamine hcl......................189KETAMINE HCL............... 189KETAMINE HCL-SODIUM CHLORIDE....................... 189ketoconazole.......................50ketoprofen.............................7ketoprofen er.........................7ketorolac tromethamine 7, 197KEVEYIS............................ 95KEVZARA................. 173, 174KEYTRUDA........................ 61KHAPZORY........................ 61KHEDEZLA.........................45KINERET.......................... 174KINEVAC.......................... 189KINRIX..............................178kionex............................... 130KISQALI 200 DOSE............61

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KISQALI 400 DOSE............61KISQALI 600 DOSE............61KITABIS PAK....................213KLONOPIN......................... 79klor-con............................. 130klor-con 10........................ 130klor-con m10..................... 130KLOR-CON M15...............130klor-con m20..................... 130klor-con sprinkle................130klor-con/ef......................... 130KOATE................................83KOATE-DVI........................ 83KOCHIA............................ 189KOGENATE FS.................. 83KOMBIGLYZE XR............ 118KORLYM...........................159KOVALTRY.........................83K-PHOS............................ 130K-PHOS NO 2...................130K-PHOS-NEUTRAL.......... 130k-prime..............................130KRINTAFEL........................ 67KRISTALOSE................... 142KRYSTEXXA...................... 52K-TAB............................... 130k-tan plus.......................... 130kurvelo.............................. 163KUVAN............................. 145KYLEENA......................... 163KYMRIAH......................... 174KYNAMRO..........................95KYPROLIS..........................61LABETALOL HCL............... 95labetalol hcl.........................95LABETALOL HCL-DEXTROSE........................ 95LABETALOL HCL-SODIUM CHLORIDE..........95LAC-HYDRIN....................113LACRISERT......................202lactated ringers................. 130lactic acid.......................... 113lactic acid e....................... 113lactulose............................142lactulose encephalopathy. 142LAMBS QUARTERS.........189LAMICTAL.......................... 40LAMICTAL ODT..................40LAMICTAL STARTER........ 41LAMICTAL XR.................... 41lamivudine...........................75lamivudine-zidovudine........ 75

lamotrigine.......................... 41lamotrigine er...................... 41lamotrigine starter kit-blue.. 41lamotrigine starter kit-green...................................41lamotrigine starter kit-orange.................................41LANOXIN............................ 95LANOXIN PEDIATRIC........95lansoprazole..................... 139lanthanum carbonate........ 147LANTUS SOLOSTAR....... 122LANTUS U-100 VIAL........ 122larin 1.5/30........................ 163larin 1/20........................... 163larin 24 fe.......................... 163larin fe 1.5/30.................... 163larin fe 1/20....................... 163larissia...............................164LARTRUVO........................ 61LASIX..................................95LASTACAFT..................... 202LATANOPROST............... 200latanoprost........................ 200LATANOPROST-TIMOLOL MALEATE........ 200LATRIX XM.......................113LATUDA..............................72layolis fe............................164LAZANDA........................... 13lecithin...............................130LEDIPASVIR-SOFOSBUVIR.................... 75leena................................. 164leflunomide....................... 174LEMTRADA...................... 107LENSCALE....................... 189LENVIMA 10 MG DAILY DOSE..................................61LENVIMA 12 MG DAILY DOSE..................................61LENVIMA 14 MG DAILY DOSE..................................61LENVIMA 18 MG DAILY DOSE..................................61LENVIMA 20 MG DAILY DOSE..................................61LENVIMA 24 MG DAILY DOSE..................................61LENVIMA 4 MG DAILY DOSE..................................61LENVIMA 8 MG DAILY DOSE..................................61

LESCOL XL........................ 95lessina...............................164LETAIRIS..........................213letrozole.............................. 61LETS...................................19leucovorin calcium........ 61, 62LEUKERAN........................ 62LEUKINE............................ 83leuprolide acetate............. 156LEUPROLIDE ACETATE-BUPIVACAINE..................156levalbuterol hcl..................210LEVALBUTEROL HFA..... 210LEVAQUIN..........................29LEVATIO.............................19LEVBID............................. 142LEVEMIR U-100 FLEXTOUCH.................... 122LEVEMIR U-100 VIAL...... 122levetiracetam...................... 41levetiracetam er.................. 41levetiracetam in nacl........... 41levobunolol hcl.................. 200levocarnitine......................130levocetirizine dihydrochloride................. 206levofloxacin................. 30, 197levofloxacin in d5w..............30levoleucovorin calcium........62LEVOLEUCOVORIN CALCIUM............................62levoleucovorin calcium pf....62levonest............................ 164levonorgest-eth est & eth est..................................... 164levonorgest-eth estrad 91-day.................................... 164levonorgestrel................... 164levonorgestrel-ethinyl estrad................................164levonorg-eth estrad triphasic............................ 164LEVOPHED........................ 95levora 0.15/30 (28)............164levorphanol tartrate.............13levo-t................................. 169levothyroxine sodium........ 169levothyroxine-liothyronine. 169levoxyl...............................169LEVSIN............................. 142LEVSIN/SL........................142LEVULAN KERASTICK.... 113LEXAPRO...........................45

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LEXISCAN........................ 189LEXIVA............................... 75LIALDA............................. 180LIBRAX............................. 142LIBTAYO.............................62lido bdk............................... 19lidocaine..............................19LIDOCAINE HCL................ 19lidocaine hcl........................ 19lidocaine hcl (cardiac)......... 19lidocaine hcl (pf)..................19LIDOCAINE HCL-SODIUM CHLORIDE......................... 19lidocaine in d5w.................. 19LIDOCAINE IN DEXTROSE........................ 19lidocaine viscous...............109lidocaine-epinephrine..........19LIDOCAINE-EPINEPHRINE................. 202lidocaine-hydrocortisone ace.................................... 180LIDOCAINE-PHENYLEPHRINE........... 202LIDOCAINE-PHENYLEPHRINE-BSS... 202lidocaine-prilocaine............. 19LIDOCAINE-TETRACAINE 19LIDOCIDEX I.................... 152LIDOCILONE I.................. 152LIDODERM.........................19LIDO-EPINEPHRINE-TETRACAINE..................... 19lido-k................................... 19lidopin................................. 19lidopril ................................. 19lidopril xr............................. 19lido-prilo caine pack............ 19LIDOPROFEN...................... 7LIDOZION...........................20LILETTA (52 MG)............. 164lillow.................................. 164LINCOCIN...........................30lincomycin hcl..................... 30lindane................................ 67linezolid...............................30linezolid in sodium chloride.30LINZESS...........................142LIORESAL........................ 215LIORESAL INTRATHECAL.......................................... 215liothyronine sodium...........169LIPITOR..............................95

LIPOFEN............................ 95LIQUIVIDA HYDRATION..130lisinopril ...............................95lisinopril-hydrochlorothiazide.............95lithium................................. 80lithium carbonate................ 80lithium carbonate er............ 80LITHOBID........................... 80LITHOSTAT...................... 147LIVALO............................... 95livixil pak............................. 20LMD IN D5W.......................83LMD IN NACL..................... 83LO LOESTRIN FE............ 164LODINE................................ 7LODOSYN.......................... 68LOESTRIN 1.5/30 (21)..... 164LOESTRIN 1/20 (21)........ 164LOESTRIN FE 1.5/30....... 164LOESTRIN FE 1/20.......... 164LOMOTIL.......................... 142LONSURF...........................62loperamide hcl.................. 142LOPID................................. 95lopinavir-ritonavir................ 75lopreeza............................ 164LOPRESSOR..................... 96LOPRESSOR HCT............. 95LOPROX.............................50lorazepam........................... 80lorazepam intensol..............80LORAZEPAM-DEXTROSE.80LORBRENA........................ 62lorcet................................... 13lorcet hd.............................. 13lorcet plus........................... 13LORID...............................130LORTAB............................. 13loryna................................ 164LORZONE........................ 215losartan potassium..............96losartan potassium-hctz......96LOSEASONIQUE............. 164LOTEMAX.................197, 198LOTEMAX SM.................. 198LOTENSIN..........................96LOTENSIN HCT................. 96LOTREL..............................96LOTRISONE..................... 113LOTRONEX...................... 142lovastatin.............................96LOVAZA..............................96

LOVENOX.......................... 38low-ogestrel...................... 164loxapine succinate.............. 72LOYON............................. 113LUCEMYRA........................22LUCENTIS........................ 202lugols.................................. 30LULICONAZOLE................ 51LUMASON........................ 190LUMIGAN......................... 200LUMIZYME....................... 145LUMOXITI...........................62LUNESTA......................... 215LUPANETA PACK............ 156LUPRON DEPOT (1-MONTH)........................... 157LUPRON DEPOT (3-MONTH)........................... 157LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG................................ 157LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG................................ 157LUPRON DEPOT-PED (1-MONTH)........................... 157LUPRON DEPOT-PED (3-MONTH)........................... 157lutera.................................164LUXTURNA...................... 202LUZU.................................. 51LYNPARZA.........................62LYRICA.............................108LYRICA CR.......................108lysiplex plus...................... 130LYSODREN........................ 62LYSTEDA........................... 83lyza................................... 164M.V.I. ADULT....................130M.V.I. PEDIATRIC............ 130M.V.I.-12 (WITHOUT VITAMIN K).......................130MACI.................................190MACRILEN....................... 190MACROBID........................ 30MACRODANTIN................. 30MACUGEN....................... 202mafenide acetate................ 30MAGNEBIND 400............. 130magnesium sulfate............131MAGNESIUM SULFATE.. 131

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magnesium sulfate in d5w 130MAGNESIUM SULFATE IN D5W............................. 131MAGNESIUM SULFATE-LACT RINGERS............... 131MAGNESIUM SULFATE-NACL................................ 131MAGNEVIST.....................190MAKENA...........................164MALARONE........................67malathion............................ 67MANGANESE CHLORIDE131mannitol.............................. 96maprotiline hcl.....................45MARCAINE.........................20MARCAINE PRESERVATIVE FREE......20MARCAINE SPINAL........... 20MARCAINE/EPINEPHRINE......................................... 20MARCAINE/EPINEPHRINE PF....................................20MARINOL........................... 48marlissa............................ 164MARPLAN.......................... 45MARQIBO...........................62MATULANE........................ 62matzim la............................ 96MAVYRET.......................... 75MAXALT............................. 53MAXALT-MLT..................... 53MAXFE............................. 131MAXI-COMFORT SAFETY PEN NEEDLE................... 122MAXIDEX..........................198MAXIPIME.......................... 30MAXITROL....................... 202MAXZIDE............................96MAXZIDE-25.......................96me/naphos/mb/hyo1......... 147MEADOW FESCUE GRASS POLLEN.............. 190meclizine hcl....................... 48meclofenamate sodium.........7MEDI-DERM/L-RX..............20MEDI-DERM-RX.................13MEDI-PATCH RX............... 20MEDROL.......................... 152MEDROX-RX......................13medroxyprogesterone acetate.............................. 164mefenamic acid.....................7mefloquine hcl.....................67

MEGACE ES.................... 164megestrol acetate............. 165MEKINIST...........................62MEKTOVI............................62MELALEUCA.................... 190melodetta 24 fe................. 165meloxicam.............................7melphalan........................... 62melphalan hcl......................62memantine hcl.............. 43, 44memantine hcl er................ 43MEMBRANEBLUE............202MENACTRA......................178MENEST...........................165MENOPUR....................... 157MENOSTAR..................... 165MENTAX.............................51MENVEO.......................... 178meperidine hcl.............. 13, 14MEPERIDINE HCL-SODIUM CHLORIDE..........14MEPHYTON..................... 131meprobamate......................80MEPRON............................ 67MEPSEVII.........................145mercaptopurine...................62meropenem.........................30MEROPENEM-SODIUM CHLORIDE......................... 30MERREM............................30mesalamine...................... 180mesalamine-cleanser........180mesna................................. 62MESNEX.............................62MESQUITE....................... 190MESTINON.........................54metadate er.......................105metaproterenol sulfate...... 210metaxall ............................ 215metaxalone....................... 215metformin hcl er................ 118METFORMIN HCL IR....... 118metformin hcl ir ................. 118methadone hcl.................... 14methadone hcl intensol.......14METHADOSE..................... 14methadose.......................... 14METHADOSE SUGAR-FREE.................................. 14methamphetamine hcl...... 105methazolamide................. 200methenamine hippurate...... 30methenamine mandelate.... 30

methergine........................190methimazole..................... 169METHITEST..................... 154methocarbamol................. 215methotrexate.....................174methotrexate (anti-rheumatic).........................174methotrexate sodium........ 174methotrexate sodium (pf)..174methoxsalen..................... 113methoxsalen rapid............ 113methscopolamine bromide143methyclothiazide................. 96methyl salicylate............... 113methyldopa......................... 96methyldopa-hydrochlorothiazide.............96methylergonovine maleate190METHYLIN........................105methylphenidate hcl..105, 106methylphenidate hcl er......105methylphenidate hcl er (cd).......................................... 105methylphenidate hcl er (la)105methylprednisolone...........153METHYLPREDNISOLONE ACETATE......................... 152methylprednisolone acetate.............................. 152methylprednisolone sodium succ......................153METHYLPREDNISOLONE-BUPIVACAINE................ 153methyltestosterone........... 154metoclopramide hcl.............48metolazone......................... 96metopic............................. 113metoprolol succinate er.......96metoprolol tartrate...............96METOPROLOL TARTRATE.........................96METOPROLOL-HCTZ ER.. 96metoprolol-hydrochlorothiazide.............96METROGEL-VAGINAL.......30METRONIDAZOLE.............30metronidazole............. 30, 113metronidazole in nacl..........30METRONIDAZOLE IN NACL.................................. 30mexiletine hcl...................... 96MI PASTE......................... 109MI PASTE PLUS...............109

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MIACALCIN...................... 182mibelas 24 fe.................... 165MICARDIS.......................... 96MICARDIS HCT..................96miconazole 3.......................51MICONAZOLE-ZINC OXIDE-PETROLAT............ 51MICRHOGAM ULTRA-FILTERED PLUS.............. 174MICROCYN...................... 113microgestin 1.5/30............ 165microgestin 1/20............... 165microgestin fe 1.5/30........ 165microgestin fe 1/20........... 165midazolam hcl.....................80MIDAZOLAM HCL.............. 80MIDAZOLAM HCL-DEXTROSE........................ 80MIDAZOLAM HCL-SODIUM CHLORIDE..........80MIDAZOLAM-SODIUM CHLORIDE......................... 80midodrine hcl...................... 96MIFEPREX....................... 131MIGERGOT........................ 53miglitol...............................118miglustat........................... 145MIGRANAL......................... 53mili .................................... 165MILLIPRED.......................153MILLIPRED DP.................153MILLIPRED DP 12-DAY... 153milrinone lactate..................97milrinone lactate in dextrose.............................. 97mimvey............................. 165mimvey lo..........................165MINASTRIN 24 FE........... 165mineral oil heavy...............143MINIPRESS........................ 97minitran............................... 97MINIVELLE....................... 165MINOCIN............................ 31minocycline hcl................... 31minoxidil ..............................97MIOCHOL-E..................... 203MIOSTAT..........................203MIRAPEX............................68MIRAPEX ER......................68MIRCERA........................... 83MIRCETTE....................... 165MIRENA (52 MG)..............165mirtazapine......................... 45

MIRVASO......................... 113misoprostol....................... 139MITE (D. FARINAE)..........190MITE (D. PTERONYSSINUS)..........190MITIGARE.......................... 52mitigo.................................. 14mitomycin............................62MITOMYCIN....................... 62MITOSOL..........................198mitoxantrone hcl................. 62MIXED ASPERGILLUS.... 190MIXED FEATHERS.......... 190MIXED RAGWEED...........190MIXED VESPID VENOM PROTEIN..........................190M-M-R II............................178M-NATAL PLUS................131MOBIC.................................. 7modafinil ........................... 216moderiba.............................75MODERIBA 1200 DOSE PACK.................................. 75moexipril hcl........................97molindone hcl......................72mometasone furoate.153, 206mondoxyne nl..................... 31MONOCLATE-P................. 83monoject flush syringe...... 131monoject sodium chloride flush.................................. 131mono-linyah...................... 165mononessa....................... 165MONONINE........................ 83MONOVISC...................... 190MONSELS FERRIC SUBSULFATE.................... 84montelukast sodium..210, 211MONUROL......................... 31morgidox............................. 31MORPHINE SULFATE. 14, 15morphine sulfate........... 14, 15morphine sulfate (concentrate).......................14morphine sulfate (pf)...........14morphine sulfate er............. 14morphine sulfate er beads.. 14MORPHINE SULFATE IN DEXTROSE........................ 14MORPHINE SULFATE-NACL.................................. 15MOTOFEN........................143MOUNTAIN CEDAR......... 190

MOUSE EPITHELIUM...... 190MOVANTIK....................... 143MOVIPREP.......................143MOXEZA...........................198MOXIFLOXACIN HCL 31, 198moxifloxacin hcl.......... 31, 198moxifloxacin hcl in nacl....... 31MOXIFLOXACIN HCL-BSS...................................203MOZOBIL............................84MS CONTIN........................15MUCOR............................ 190MUGWORT...................... 190MULPLETA.........................84MULTAQ.............................97MULTIGEN....................... 131MULTIGEN FOLIC............131MULTIGEN PLUS.............131MULTIHANCE.................. 190multi-vit/iron/fluoride..........132multivitamin/fluoride.......... 132multi-vitamin/fluoride.........132multivitamin/fluoride/iron... 132multi-vitamin/fluoride/iron..132mupirocin............................ 31mutamycin.......................... 62mvc-fluoride...................... 132MYALEPT......................... 190MYAMBUTOL..................... 55MYCAMINE........................ 51MYCOBUTIN...................... 55mycophenolate mofetil ......174mycophenolate mofetil hcl 174mycophenolate sodium.....174myferon 150 forte..............132MYFORTIC....................... 174MYLERAN.......................... 62MYLOTARG........................63mynephrocaps.................. 132mynephron........................132MYOBLOC........................191myorisan........................... 113MYOVIEW 30ML.............. 191MYRBETRIQ.................... 147MYSOLINE......................... 41myzilra.............................. 165na ferric gluc cplx in sucrose............................. 132NABI-HB........................... 174nabumetone..........................7n-acetyl-l-cysteine.............132nadolol................................ 97

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nadolol-bendroflumethiazide........... 97nafcillin sodium................... 31NAFCILLIN SODIUM IN DEXTROSE........................ 31NAFRINSE DAILY ACIDULATED................... 109NAFRINSE DAILY/NEUTRAL..............109NAFRINSE WEEKLY........109naftifine hcl..........................51NAFTIN...............................51NAGLAZYME....................145nalbuphine hcl.....................15NALFON............................... 7NALOCET...........................15naloxone hcl........................22NALTREXONE................... 22naltrexone hcl..................... 22NAMENDA..........................44NAMENDA TITRATION PAK.....................................44NAMENDA XR....................44NAMENDA XR TITRATION PACK.............. 44NAMZARIC......................... 44NAPRELAN...................... 7, 8NAPROSYN..........................8naproxen...............................8naproxen dr...........................8naproxen sodium.................. 8naproxen sodium er.............. 8naratriptan hcl..................... 54NARCAN.............................22NARDIL...............................46NAROPIN........................... 20NASCOBAL...................... 132NASONEX........................ 206NATACYN.........................198NATAZIA...........................165nateglinide........................ 118NATPARA.........................182NATRECOR........................97NATROBA.......................... 67NATURE-THROID............ 169NAVELBINE........................63NEBUPENT........................ 67nebusal............................. 206NEBUSAL......................... 206necon 0.5/35 (28)..............165nefazodone hcl................... 46NEMBUTAL........................ 41neomycin sulfate.................31

neomycin-bacitracin zn-polymyx.............................203neomycin-polymyxin b gu... 31neomycin-polymyxin-dexameth.......................... 203neomycin-polymyxin-gramicidin......................... 203neomycin-polymyxin-hc.................................. 203, 205neo-polycin....................... 203neo-polycin hc...................203NEOPROFEN....................... 8NEORAL........................... 174neostigmine methylsulfate.. 54NEOSTIGMINE METHYLSULFATE............. 54NEO-SYNALAR................ 113NEOTUSS PLUS.............. 206NEPHPLEX RX.................132NEPHRAMINE..................132NEPHRON FA.................. 132nephronex.........................132NEPHRO-VITE RX........... 132NERLYNX...........................63NESACAINE....................... 20NESACAINE-MPF.............. 20NESINA............................ 118NETSPOT.........................191NEULASTA.........................84NEULASTA ONPRO...........84NEUPOGEN....................... 84NEUPRO............................ 69NEURIN-SL...................... 132NEURONTIN...................... 41neutral sodium fluoride..... 109NEUTRASAL.................... 110NEVANAC........................ 198nevirapine........................... 75nevirapine er....................... 75NEXAVAR...........................63NEXIUM 24HR..................139NEXIUM I.V...................... 140NEXPLANON....................165NEXTERONE..................... 97niacin er (antihyperlipidemic).............97NIACOR..............................97NIASPAN............................ 97NICADAN..........................132nicardipine hcl.....................97NICARDIPINE HCL IN DEXTROSE........................ 97

NICARDIPINE HCL IN NACL.................................. 97NICAZEL...........................132NICAZEL FORTE............. 132NICOMIDE........................132NICORETTE....................... 22nicotine polacrilex............... 22nicotine step 1.....................22nicotine step 2.....................22nicotine step 3.....................22NICOTROL......................... 22NICOTROL NS................... 23nifedipine............................ 97nifedipine er........................ 97nifedipine er osmotic release................................ 97NIFEREX.......................... 132nikki...................................165NILANDRON.......................63nilutamide........................... 63NIMBEX............................ 108nimodipine.......................... 97NINLARO............................63NIPENT...............................63NIPRIDE RTU.....................97nisoldipine er.......................98NITHIODOTE....................191NITRO-BID......................... 98NITRO-DUR........................98nitrofurantoin.......................31nitrofurantoin macrocrystal. 31nitrofurantoin monohydrate macrocrystals......................31nitroglycerin........................ 98nitroglycerin er.................... 98nitroglycerin in d5w............. 98NITROLINGUAL................. 98NITROMIST........................ 98NITROPRESS.................... 98nitroprusside sodium...........98NITROSTAT....................... 98nitro-time.............................98NITYR............................... 145NIVESTYM......................... 84nizatidine...........................140NIZORAL............................ 51nolix.................................. 153nora-be............................. 165NORCO.............................. 15NORDITROPIN FLEXPRO.......................................... 157norepinephrine bitartrate.....98

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NOREPINEPHRINE-DEXTROSE........................ 98NOREPINEPHRINE-SODIUM CHLORIDE....98, 99norethin ace-eth estrad-fe.165norethindrone....................165norethindrone acetate.......165norethindrone acet-ethinyl est..................................... 165norethindrone-eth estradiol.......................................... 166norethin-eth estradiol-fe....166norgestimate-eth estradiol 166norgestimate-ethinyl estradiol triphasic..............166norlyda.............................. 166norlyroc............................. 166normal saline flush............132NORMOSOL-M IN D5W... 132NORMOSOL-R................. 132NORMOSOL-R IN D5W... 132NORMOSOL-R PH 7.4..... 132NORPACE.......................... 99NORPACE CR....................99NORPRAMIN......................46NORTHERA........................99nortrel 0.5/35 (28)............. 166nortrel 1/35 (21)................ 166nortrel 1/35 (28)................ 166nortrel 7/7/7.......................166nortriptyline hcl....................46NORVASC.......................... 99NORVIR..............................75novarel.............................. 157NOVAREL.........................157NOVOEIGHT...................... 84NOVOFINE AUTOCOVER PEN NEEDLE................... 122NOVOFINE PEN NEEDLE122NOVOFINE PLUS PEN NEEDLE........................... 123NOVOLIN 70/30 RELION. 123NOVOLIN 70/30 VIAL.......123NOVOLIN N RELION........123NOVOLIN N VIAL............. 123NOVOLIN R RELION........123NOVOLIN R VIAL............. 123NOVOLOG FLEXPEN...... 123NOVOLOG MIX 70/30 FLEXPEN......................... 123NOVOLOG MIX 70/30 VIAL.................................. 123NOVOLOG PENFILL........ 123

NOVOLOG U-100 VIAL.... 123NOVOSEVEN RT............... 84NOVOTWIST PEN NEEDLE........................... 123NOXAFIL............................ 51np thyroid.......................... 169NPLATE..............................84NUCALA........................... 206NUCYNTA.......................... 15NUCYNTA ER.................... 15NUFERA........................... 132nulev................................. 143NULOJIX...........................174NULYTELY WITH FLAVOR PACKS.............. 143NUMOISYN...................... 110NUPLAZID.......................... 72NUTRICAP....................... 132NUTRIDOX......................... 31nutrifac zx......................... 132nutrilipid............................ 132NUTRIVIT......................... 132NUTROPIN AQ NUSPIN 10......................................157NUTROPIN AQ NUSPIN 20......................................157NUTROPIN AQ NUSPIN 5157NUVAIL.............................113NUVARING.......................166NUVIGIL........................... 216NUWIQ............................... 84NUZYRA............................. 31NYMALIZE..........................99nystatin............................... 51nystatin-triamcinolone.........51nystop................................. 51OBIZUR.............................. 84OCALIVA.......................... 145ocella................................ 166OCREVUS........................ 107OCTAGAM........................174OCTAPLAS BLOOD GROUP A......................... 191OCTAPLAS BLOOD GROUP AB.......................191OCTAPLAS BLOOD GROUP B......................... 191OCTAPLAS BLOOD GROUP O.........................191OCTREOSCAN................ 191octreotide acetate..... 157, 158OCUFLOX........................ 198ODACTRA........................ 191

ODEFSEY...........................76ODOMZO............................63OFEV................................ 211ofloxacin..............31, 198, 205ogestrel............................. 166okebo.................................. 31olanzapine.......................... 72olanzapine-fluoxetine hcl.... 46OLIVE TREE.....................191olmesartan medoxomil........99olmesartan medoxomil-hctz..................................... 99olmesartan-amlodipine-hctz..................................... 99olopatadine hcl..........198, 206OLUMIANT....................... 174OMECLAMOX-PAK.......... 143omega-3-acid ethyl esters.. 99OMEGAVEN..................... 132omeprazole....................... 140OMEPRAZOLE+SYRSPEND SF ALKA.....................140OMNARIS......................... 206OMNIPAQUE....................191OMNIPRED...................... 198OMNISCAN...................... 191OMNISCAN/SODIUM CHLORIDE....................... 191OMNITROPE.................... 158ONCASPAR........................63ondansetron hcl.................. 48ONDANSETRON HCL........48ONDANSETRON HCL-DEXTROSE........................ 48ONDANSETRON HCL-NACL.................................. 48ondansetron odt..................48ONEVITE.......................... 133ONFI................................... 41ONGLYZA.........................119ONIVYDE............................63ONPATTRO......................108OPANA............................... 15OPDIVO..............................63opium................................ 143OPSUMIT......................... 213OPTIONS CONCEPTROL191OPTIRAY 350................... 191OPTISON..........................191ORABLOC.......................... 20ORACIT............................ 133ORAFATE.........................191ORALAIR.......................... 191

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ORALAIR ADULT SAMPLE KIT.....................191ORALAIR ADULT STARTER PACK.............. 191ORALAIR CHILDRENS SAMPLE KIT.....................191ORALAIR CHILDRENS STARTER PACK.............. 191oralone..............................110ORAPRED ODT............... 153ORAVIG..............................51ORBACTIV......................... 31ORCHARD GRASS POLLEN............................192ORENCIA......................... 175ORENCIA CLICKJECT.....174ORENITRAM.................... 213ORFADIN..........................145ORKAMBI......................... 213orphenadrine citrate..........215orphenadrine citrate er......215orsythia............................. 166ORTHO MICRONOR........166ORTHO TRI-CYCLEN (28).......................................... 166ORTHO TRI-CYCLEN LO 166ORTHO-CYCLEN (28)......166ORTHO-NOVUM 1/35 (28).......................................... 166ORTHO-NOVUM 7/7/7 (28)................................... 166ORTHOVISC.................... 192oscimin..............................143oscimin sr..........................143oseltamivir phosphate.........76OSENI...............................119OSMITROL......................... 99osmitrol............................... 99OSMOPREP..................... 143OSPHENA........................ 155OTEZLA............................175OTIPRIO........................... 205OTOVEL........................... 205OVACE PLUS...................113OVACE PLUS WASH....... 113OVACE WASH................. 113OVIDE.................................67OVIDREL.......................... 158oxacillin sodium.................. 31oxaliplatin............................63oxandrolone...................... 154oxaprozin.............................. 8OXAYDO............................ 15

oxazepam........................... 80oxcarbazepine.................... 41OXERVATE...................... 203oxiconazole nitrate..............51OXISTAT............................ 51OXSORALEN ULTRA.......113OXTELLAR XR................... 41oxybutynin chloride........... 147oxybutynin chloride er.......147oxycodone hcl.....................16OXYCODONE HCL ER...... 16oxycodone-acetaminophen.16oxycodone-aspirin...............16oxycodone-ibuprofen.......... 16OXYCONTIN...................... 16oxymorphone hcl................ 16oxymorphone hcl er............ 16oxytocin.............................158OXYTOCIN-DEXTROSE.. 158OXYTOCIN-DEXTROSE-LACT RINGERS............... 158OXYTOCIN-LACTATED RINGERS......................... 158OXYTOCIN-SODIUM CHLORIDE....................... 158OZEMPIC......................... 119pacerone.............................99paclitaxel.............................63PAINGO KFT...................... 20paliperidone er.................... 72palonosetron hcl................. 48PALYNZIQ........................ 145PAMELOR.......................... 46pamidronate disodium...... 182PANCREAZE....................145pancuronium bromide....... 108PANHEMATIN.................... 84PANRETIN..........................63pantoprazole sodium........ 140PANZYGA.........................175PARAGARD INTRAUTERINE COPPER.......................................... 166paregoric...........................143paricalcitol.........................182PARLODEL.........................69PARNATE...........................46paroex...............................110paromomycin sulfate...........31paroxetine hcl..................... 46paroxetine hcl er................. 46PARSABIV........................169PASER................................55

PATADAY......................... 198PATANASE.......................207PATANOL......................... 198PAXIL..................................46PAXIL CR........................... 46PAZEO..............................198PECAN POLLEN.............. 192PEDIARIX......................... 179PEDVAX HIB.................... 179peg 3350/electrolytes........143peg 3350-kcl-na bicarb-nacl................................... 143peg-3350/electrolytes....... 143PEGANONE....................... 41PEGASYS...........................76PEGASYS PROCLICK....... 76PEGINTRON...................... 76peg-prep........................... 143PENICILLIN G POT IN DEXTROSE........................ 32penicillin g potassium..........32penicillin g procaine............ 32penicillin g sodium.............. 32penicillin v potassium..........32PENICILLIUM NOTATUM 192PENLAC............................. 51PENTACEL.......................179PENTAM.............................67PENTASA......................... 180pentazocine-naloxone hcl... 16pentobarbital sodium.......... 42pentoxifylline er...................99PEPCID............................ 140PERCOCET........................16PERENNIAL RYE GRASS POLLEN............................192PERFOROMIST............... 211PERIDEX.......................... 110PERIKABIVEN..................133perindopril erbumine........... 99periogard...........................110PERJETA............................63permethrin...........................67perphenazine...................... 48perphenazine-amitriptyline..46PERSERIS..........................72PERTZYE......................... 145PFIZERPEN........................32phenadoz.......................... 207phenazo............................ 147phenazopyridine hcl..........147phenelzine sulfate...............46PHENERGAN................... 207

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phenobarbital...................... 42phenobarbital sodium......... 42phenobarbital-belladonna alk..................................... 143phenoxybenzamine hcl....... 99phentolamine mesylate.......99phenylephrine hcl........99, 203PHENYLEPHRINE HCL..... 99PHENYLEPHRINE HCL-DEXTROSE........................ 99PHENYLEPHRINE HCL-NACL................................ 100phenylephrine-guaifenesin207PHENYTEK........................ 42phenytoin............................ 42phenytoin infatabs...............42phenytoin sodium................42phenytoin sodium extended............................. 42philith................................ 166PHOMA EXIGUA.............. 192PHOSLYRA...................... 147phospha 250 neutral......... 133phosphasal....................... 147PHOSPHOLINE IODIDE.. 200phosphorous..................... 133phospho-trin 250 neutral...133PHOTOFRIN.......................63PHOTREXA VISCOUS.....192phrenilin forte...................... 16physiolyte..........................133physiosol irrigation............ 133phytonadione.................... 133PICATO............................ 113PIFELTRO.......................... 76pilocarpine hcl...........110, 200pimecrolimus.....................113pimozide............................. 72pimtrea..............................166pindolol............................. 100pioglitazone hcl................. 119pioglitazone hcl-glimepiride.......................................... 119pioglitazone hcl-metformin hcl..................................... 119piperacillin sod-tazobactam so........................................ 32pirmella 1/35..................... 166pirmella 7/7/7.................... 166piroxicam.............................. 8PITOCIN........................... 158PLAN B ONE-STEP..........166PLAQUENIL........................67

PLASBUMIN-25................192PLASBUMIN-5..................192PLASMA-LYTE 148.......... 133PLASMA-LYTE A..............133PLASMANATE..................192PLAVIX............................... 70PLEGISOL........................ 133PLEGRIDY........................107PLEGRIDY STARTER PACK................................ 107plenamine......................... 133PLIAGLIS............................20PNEUMOVAX 23..............179pnv prenatal plus multivit+dha.......................133podocon............................ 113podofilox........................... 113POLIDOCANOL................100polocaine............................ 20polocaine-mpf..................... 20polycin...............................203poly-iron 150 forte.............133polymyxin b sulfate............. 32polymyxin b-trimethoprim..203polysaccharide iron forte...133POLYTRIM....................... 203POLY-VI-FLOR.................133POLY-VI-FLOR FS........... 133POLY-VI-FLOR/IRON.......133POMALYST........................ 63portia-28............................166port-prep............................. 20PORTRAZZA...................... 63pot bicarb-pot chloride...... 133potassium acetate.............133POTASSIUM ACETATE-NACL................................ 133potassium bicarbonate......133potassium chloride............134POTASSIUM CHLORIDE. 134potassium chloride crys er 133potassium chloride er........133POTASSIUM CHLORIDE IN D5W............................. 134potassium chloride in dextrose............................ 134POTASSIUM CHLORIDE IN NACL............................134potassium chloride in nacl 134potassium chloride proamp.......................................... 134potassium citrate er.......... 134

potassium citrate-citric acid.......................................... 134POTASSIUM PHOSPHATE-NACL.........134POTASSIUM PHOSPHATES-DEXTROSE...................... 134POTASSIUM PHOSPHATES-NACL...... 135POTELIGEO....................... 63PRADAXA...........................38pralidoxime chloride..........192PRALUENT.......................100pramipexole dihydrochloride................... 69pramipexole dihydrochloride er............... 69PRAMOTIC.......................205pramox..............................113PRANDIN..........................119prasugrel hcl....................... 70PRAVACHOL....................100pravastatin sodium............100PRAXBIND....................... 192praziquantel........................ 67prazosin hcl.......................100PRECEDEX...................... 192PRECISION PCX PLUS TEST.................................120PRECISION QID TEST.... 120PRECISION SOF-TACT TEST.................................120PRECISION XTRA BLOOD GLUCOSE...........120PRECISION XTRA KETONE........................... 120PRECOSE........................ 119PRED FORTE...................198PRED MILD...................... 198PRED-G............................203PRED-G S.O.P................. 203prednicarbate....................153prednisolone..................... 153prednisolone acetate........ 198prednisolone acetate p-f... 198prednisolone sodium phosphate................. 153, 198PREDNISOLONE-BROMFENAC...................203PREDNISOLONE-GATIFLOXACIN............... 203PREDNISOLON-GATIFLOX-BROMFENAC 203

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prednisone........................ 153PREDNISONE INTENSOL.......................................... 153PREFEST......................... 166pregnyl.............................. 158PREMARIN...............166, 167PREMASOL......................135premasol........................... 135PREMESISRX.................. 135premium lidocaine...............20PREMPHASE................... 167PREMPRO........................167prenatal.............................135prenatal plus iron.............. 135PREPIDIL......................... 159PREPOPIK....................... 143PRESTALIA...................... 100PREVACID....................... 140PREVACID SOLUTAB......140prevalite............................ 100preventeza........................ 167PREVIDENT..................... 110prevident........................... 110PREVIDENT 5000 BOOSTER PLUS..............110PREVIDENT 5000 DRY MOUTH.............................110PREVIDENT 5000 ENAMEL PROTECT.........110PREVIDENT 5000 PLUS..110PREVIDENT 5000 SENSITIVE....................... 110previfem............................ 167PREVNAR 13................... 179PREVYMIS......................... 76PREZCOBIX....................... 76PREZISTA.......................... 76PRIALT............................... 16PRIFTIN..............................55prikaan................................ 20prikaan lite.......................... 20prilolid................................. 20PRILOSEC........................140prilovix.................................20prilovix plus......................... 20priloxx lp..............................20primaquine phosphate........ 67PRIMAXIN IV...................... 32primidone............................ 42PRIMLEV............................ 16PRIMSOL............................32PRINIVIL...........................100PRISMASOL B22GK 4/0.. 135

PRISMASOL BGK 2/0...... 135PRISMASOL BGK 2/3.5... 135PRISTIQ............................. 46PRIVET.............................192PRIVIGEN.........................175PROAIR HFA....................211PROAIR RESPICLICK......211probenecid.......................... 52PROBUPHINE IMPLANT KIT...................................... 16procainamide hcl...............100PROCALAMINE................135PROCARDIA.................... 100PROCARDIA XL............... 100PROCENTRA................... 106prochlorperazine................. 48prochlorperazine edisylate..48prochlorperazine maleate... 48PROCORT........................180PROCRIT............................84PROCTOCORT................ 180PROCTOFOAM HC..........180procto-med hc...................181procto-pak.........................181proctosol hc...................... 181proctozone-hc................... 181PROCYSBI....................... 145PROFILNINE...................... 84PROFILNINE SD................ 84progesterone.....................167progesterone micronized.. 167PROGLYCEM...................120PROGRAF........................ 175PROHANCE..................... 192PROLASTIN-C..................211PROLENSA...................... 198PROLEUKIN....................... 63PROLIA.............................182PROMACTA....................... 84promethazine hcl.............. 207promethazine-codeine...... 207promethazine-dm..............207promethazine-phenyleph-codeine............................. 207promethazine-phenylephrine................... 207promethegan.....................207PROMETRIUM................. 167propafenone hcl................ 100propafenone hcl er............100propantheline bromide...... 143proparacaine hcl............... 203propofol.............................192

PROPOFOL......................192propranolol hcl.................. 100propranolol hcl er.............. 100propranolol-hctz................ 101propylthiouracil ..................169PROQUAD........................179PROSCAR........................ 148PROSOL...........................135PROSTIN E2.................... 159PROSTIN VR....................101protamine sulfate................ 84PROTECT PLUS.............. 135PROTECTIRON................135PROTHELIAL................... 192PROTONIX....................... 140PROTOPAM CHLORIDE..192protriptyline hcl....................46PROVAYBLUE................. 192PROVENGE..................... 175PROVERA........................ 167PROVIGIL.........................216PROVISC..........................204PROZAC.............................46PRUDOXIN.......................113pseudoeph-chlorphen-hydrocod........................... 207pseudoephedrine-bromphen-dm................... 207PSORCON........................153PULMICORT FLEXHALER.......................................... 211PULMICORT SUSPENSION.................. 211pulmosal........................... 207PULMOZYME................... 213PURAPLY......................... 114PUREFE PLUS.................135purevit dualfe plus.............135PURIXAN............................63PYLERA............................143pyrazinamide...................... 55PYRIDIUM........................ 147pyridostigmine bromide.......55pyridostigmine bromide er.. 54PYRIDOXINE HCL........... 135pyridoxine hcl....................135pyrogallic acid................... 114QBRELIS.......................... 101QMIIZ ODT........................... 8QNASL..............................207QNASL CHILDRENS........207QTERN............................. 119QUADRACEL................... 179

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QUADRAMET.....................63QUALAQUIN.......................67QUARTETTE.................... 167quazepam........................... 80QUDEXY XR.......................42QUEEN PALM.................. 192QUELICIN.........................108QUESTRAN......................101QUESTRAN LIGHT.......... 101quetiapine fumarate............ 72quetiapine fumarate er........72quflora pediatric................ 135QUILLICHEW ER............. 106QUILLIVANT XR...............106quinapril hcl.......................101quinapril-hydrochlorothiazide...........101quinidine gluconate er.......101quinidine sulfate................101quinine sulfate.....................68QUTENZA.........................114QUTENZA (2 PATCH)...... 114QVAR................................211QVAR REDIHALER.......... 211RABAVERT...................... 179RABBIT EPITHELIUM...... 192rabeprazole sodium.......... 140RADICAVA....................... 108RADIOGARDASE.............193RAGWITEK.......................193raloxifene hcl.....................155ramipril .............................. 101RANEXA........................... 101ranitidine hcl......................140ranolazine er..................... 101RAPAFLO................. 148, 149RAPAMUNE..................... 175RAPIVAB............................ 76rasagiline mesylate............. 69RAVICTI............................145RAYALDEE.......................182RAZADYNE........................ 44RAZADYNE ER.................. 44REBETOL........................... 76REBIF............................... 107REBIF REBIDOSE............107REBIF REBIDOSE TITRATION PACK............ 107REBIF TITRATION PACK 107REBINYN............................85RECEDO.......................... 114RECK..................................20RECLAST......................... 182

reclipsen........................... 167RECOMBINATE................. 85RECOMBIVAX HB............179RECOTHROM.................... 85RECOTHROM SPRAY KIT 85RECTIV.............................101RECURA.............................51RED BIRCH...................... 193RED CEDAR.....................193RED MAPLE..................... 193RED MULBERRY............. 193RED TOP GRASS POLLEN............................193REGLAN............................. 48REGONOL..........................55REGRANEX......................114relador pak..........................20relador pak plus.................. 20RELAGARD...................... 147RELENZA DISKHALER......76relexxii ...............................106RELISTOR........................143RELNATE DHA.................135RELPAX..............................54REMERON......................... 46REMERON SOLTAB.......... 46REMESENSE................... 110REMICADE.......................175remifentanil hcl....................16REMODULIN.................... 213RENACIDIN...................... 147RENAGEL.........................147renal..................................135RENATABS...................... 135RENATABS WITH IRON.. 135RENFLEXIS......................175RENOVO............................ 20RENVELA......................... 147REOPRO............................ 70repaglinide........................ 119repaglinide-metformin hcl. 119REPATHA.........................101REPATHA PUSHTRONEX SYSTEM........................... 101REPATHA SURECLICK... 101REQ 49+...........................135REQUIP.............................. 69REQUIP XL.........................69RESCRIPTOR.................... 76RESORCINOL-SULFUR.. 114RESTASIS........................ 204RESTASIS MULTIDOSE.. 204restizan............................. 114

RESTORIL........................216RETACRIT..........................85RETIN-A MICRO GEL 0.04 %, 0.1 %........................... 114RETIN-A MICRO PUMP... 114RETROVIR......................... 76REVATIO.................. 213, 214REVCOVI..........................135REVLIMID...........................63revonto..............................215REXULTI.............................72REYATAZ........................... 76R-GENE 10.......................193rhinocort allergy................ 207RHIZOPUS....................... 193RHOFADE........................ 114RHOGAM ULTRA-FILTERED PLUS.............. 175RHOPHYLAC................... 175RHOPRESSA................... 200RIASTAP............................ 85ribasphere...........................76ribasphere ribapak.............. 76RIBASPHERE RIBAPAK.... 76ribavirin............................... 77RIDAURA..........................175rifabutin............................... 55RIFADIN............................. 55RIFAMATE..........................55rifampin............................... 55RIFATER............................ 55RILUTEK...........................108riluzole.............................. 108rimantadine hcl................... 77RIMSO-50.........................147ringers...............................135ringers irrigation................ 135RIOMET............................119risedronate sodium........... 182RISPERDAL....................... 72RISPERDAL CONSTA....... 72risperidone.......................... 72risperidone m-tab................72RITALIN............................ 106RITALIN LA.......................106ritonavir............................... 77RITUXAN............................ 64RITUXAN HYCELA.............64rivastigmine.........................44rivastigmine tartrate............ 44rivelsa............................... 167RIXUBIS............................. 85rizatriptan benzoate............ 54

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ROBAXIN..........................215ROBAXIN-750.................. 215ROCALTROL....................182rocuronium bromide..........108ROCURONIUM BROMIDE.......................................... 108ROMIDEPSIN..................... 64ropinirole hcl....................... 69ropinirole hcl er................... 69ROPIVACAINE HCL..... 20, 21ropivacaine hcl....................21ROPIVACAINE HCL-NACL 21rosadan.............................114ROSADAN........................ 114rosuvastatin calcium......... 101ROTARIX..........................179ROTATEQ........................ 179ROUGH MARSH ELDER. 193ROUGH PIGWEED.......... 193ROWASA..........................181roweepra.............................42roweepra xr.........................42ROXICODONE................... 16ROXYBOND....................... 16ROZEREM........................216RUBRACA.......................... 64RUCONEST......................175RUSSIAN THISTLE.......... 193RYANODEX......................215RYCLORA........................ 207RYDAPT............................. 64RYTARY............................. 69RYTHMOL SR.................. 101SABRIL............................... 42SACCHAROMYCES CEREVISIAE.................... 193SAFYRAL......................... 167SAGEBRUSH................... 193SAIZEN.............................158SAIZENPREP................... 158SALAGEN.........................110SALEX.............................. 114salicylic acid......................114salicylic acid wart remover 114salicylic acid-cleanser....... 114salimez..............................114SALIMEZ FORTE............. 114saline bacteriostatic.......... 135saline flush........................135saline flush zr....................136saline-benzyl alcohol........ 136SALINE-BENZYL ALCOHOL.........................136

SALINE-PHENOL............. 136salisol forte........................114salitech forte..................... 114SALIVAMAX..................... 110salsalate................................8SALVAX............................114SALVAX DUO PLUS........ 114SAMSCA...........................136SANCUSO.......................... 48SANDIMMUNE................. 175SANDOSTATIN................ 158SANDOSTATIN LAR DEPOT............................. 158SANTYL............................114SAPHRIS............................ 72sash kit ..............................193SAVAYSA........................... 38SAVELLA..........................108SAVELLA TITRATION PACK................................ 108SCALACORT DK..............114SCARCIN..........................114SCARSILK........................ 114SCLEROSOL INTRAPLEURAL...............211SEASONIQUE.................. 167SECONAL.........................216SEGLUROMET.................119selegiline hcl....................... 69selenium sulfide................ 114selenium sulf-pyrithione-urea...................................115SELRX.............................. 115SELZENTRY.......................77SENSIPAR........................155sensorcaine........................ 21sensorcaine/epinephrine.....21sensorcaine-mpf................. 21sensorcaine-mpf/epinephrine.................. 21SENSORCAINE-MPF/EPINEPHRINE...........21SEREVENT DISKUS........ 211SEROQUEL........................73SEROQUEL XR..................73SEROSTIM....................... 143sertraline hcl....................... 46se-tan plus........................ 136setlakin..............................167sevelamer carbonate........ 147sevelamer hcl....................147sf....................................... 110sf 5000 plus...................... 110

SFROWASA..................... 181SHAGBARK HICKORY.... 193sharobel............................ 167SHEEP SORREL..............193SHINGRIX........................ 179SHORT RAGWEED POLLEN EXT....................193SIDEROL.......................... 136SIGNIFOR........................ 159SIGNIFOR LAR................ 159sildenafil citrate......... 147, 214SILENOR.......................... 216SILIQ.................................175silodosin............................149SILVADENE........................32silver nitrate........................ 32silver sulfadiazine............... 32SIMBRINZA...................... 200SIMPONI...........................176SIMPONI ARIA................. 175SIMULECT........................176simvastatin........................101SINEMET............................69SINEMET CR......................69SINGULAIR...................... 211SINUVA............................ 207sirolimus............................176SIRTURO............................55SIVEXTRO..........................32SKELAXIN........................ 215SKLICE............................... 68SKYLA.............................. 167SMOFLIPID...................... 136sod benz-sod phenylacet..145sod citrate-citric acid......... 136sodium acetate................. 136SODIUM BICARBONATE.136sodium bicarbonate.. 136, 144SODIUM BICARBONATE-DEXTROSE...................... 136sodium chloride.........136, 207SODIUM CHLORIDE........136sodium chloride bacteriostatic.....................136sodium chloride flush........ 136SODIUM CITRATE............. 38SODIUM CITRATE LOCK FLUSH................................ 38SODIUM CITRATE-GENTAMICIN SULF........... 38SODIUM DIURIL...............101SODIUM EDECRIN.......... 101sodium fluoride................. 136

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sodium lactate...................136sodium nitrite.................... 193sodium phenylbutyrate......145SODIUM PHOSPHATE-NACL................................ 136SODIUM PHOSPHATES-DEXTROSE...................... 137sodium polystyrene sulfonate........................... 137sodium saccharin..............193sodium sulfacetamide....... 115sodium sulfacetamide wash................................. 115SODIUM SULFACETAMIDE WASH 115SODIUM THIOSULFATE..193sodium thiosulfate.............193SOFOSBUVIR-VELPATASVIR................... 77SOLESTA......................... 193SOLIQUA..........................119SOLIRIS..............................85SOLOSEC.......................... 68soloxide...............................32SOLU-CORTEF................ 153soluline................................21SOLU-MEDROL............... 153solupicc...............................21SOLU-PREF..................... 193SOMA............................... 215SOMATULINE DEPOT..... 159SOMAVERT......................159SOOLANTRA....................115SORBITOL........................193sorbitol.............................. 193sorbitol-mannitol............... 193SORIATANE..................... 115sorine................................ 101SORREL/DOCK MIX........ 194SOTALOL HCL................. 101sotalol hcl..........................102sotalol hcl (af)................... 101SOTRADECOL................. 102SOTYLIZE........................ 102SOVALDI............................ 77SP SCAR MANAGEMENT115SPECTRACEF....................32spinosad............................. 68SPINRAZA........................194SPINY PIGWEED............. 194SPIRIVA HANDIHALER... 211SPIRIVA RESPIMAT........ 211spironolactone.................. 102

spironolactone-hctz...........102SPORANOX....................... 51SPORANOX PULSEPAK... 51SPRAVATO (56 MG DOSE)................................ 46SPRAVATO (84 MG DOSE)................................ 46sprintec 28........................ 167SPRIX................................... 8SPRYCEL........................... 64sps.................................... 137sronyx............................... 167ssd...................................... 32SSKI..................................207sss 10-5............................ 115STALEVO 100.................... 69STALEVO 125.................... 69STALEVO 150.................... 69STALEVO 200.................... 69STALEVO 50...................... 69STALEVO 75...................... 69STAMARIL........................179STARLIX...........................119stavudine............................ 77STEGLATRO.................... 119STEGLUJAN.....................119STELARA......................... 176STEMPHYLIUM................194STERILE DILUENT FLOLAN PH 12.................194sterile diluent/epoprostenol.......................................... 194STERILE TALC POWDER211sterile water for injection... 194STERILE WATER FOR INJECTION.......................194sterile water for irrigation.. 194STIMATE.......................... 159STIOLTO RESPIMAT....... 211STIVARGA..........................64STRATTERA.................... 106STRENSIQ....................... 145streptomycin sulfate............32STRIANT.......................... 154STRIBILD............................77STRIVERDI RESPIMAT... 211STROMECTOL...................68STROVITE FORTE...........137STROVITE ONE............... 137SUBLOCADE......................23SUBOXONE....................... 23SUBSYS............................. 16subvenite............................ 42

subvenite starter kit-blue.....42subvenite starter kit-green.. 42subvenite starter kit-orange 42succinylcholine chloride.... 108SUCRAID..........................145sucralfate.......................... 140sufentanil citrate..................16SULAR..............................102sulfacetamide sodium.................................. 115, 198sulfacetamide sodium (acne)................................115sulfacetamide sodium-sulfur................................. 115sulfacetamide sod-sulfur wash................................. 115sulfacetamide-prednisolone..................... 204sulfacetamide-sulfur in urea...................................115sulfacleanse 8/4................115sulfadiazine.........................32sulfamethoxazole-trimethoprim..................32, 33sulfamez wash.................. 115SULFAMYLON................... 33sulfasalazine..................... 181sulfatrim pediatric................33sulfurated lime.................... 68sulindac.................................8SUMADAN........................115sumatriptan......................... 54sumatriptan succinate.........54sumatriptan succinate refill . 54SUMAXIN CP................... 115SUPARTZ FX................... 194SUPERVITE..................... 137SUPPORT........................ 137SUPPORT-500................. 137SUPPRELIN LA................ 159SUPRAX............................. 33SUPREP BOWEL PREP KIT.................................... 144SURMONTIL.......................46SURVANTA...................... 207SUSTIVA............................ 77SUSTOL............................. 48SUTENT............................. 64swabflush saline flush.......137SWEET GUM....................194SWEET VERNAL GRASS POLLEN............................194syeda................................ 167

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SYLATRON........................ 64SYLVANT........................... 64SYMAX DUOTAB............. 144symax-sr........................... 144SYMBICORT.................... 212SYMBYAX.......................... 46SYMDEKO........................213SYMFI.................................77SYMFI LO........................... 77SYMLINPEN 120.............. 119SYMLINPEN 60................ 119SYMPAZAN........................ 42SYMPROIC.......................144SYMTUZA...........................77SYNAGEX........................ 137SYNAGIS..........................176SYNAREL......................... 159SYNATEK......................... 137SYNDROS.......................... 48SYNERA............................. 21SYNERCID......................... 33SYNJARDY.......................119SYNJARDY XR.................119SYNRIBO............................64SYNTHAMIN 17................137SYNTHROID.....................169SYNVEXIA TC.................... 21SYNVISC.......................... 194SYNVISC ONE................. 194SYPRINE.......................... 137TABLOID............................ 64tacrolimus................. 115, 176tadalafil ............................. 147tadalafil (pah).................... 214TAFINLAR.......................... 64TAGRISSO......................... 64TAKHZYRO...................... 194TALIVA............................. 137TALL RAGWEED..............194TALTZ...............................176TALZENNA......................... 64TAMIFLU............................ 77tamoxifen citrate................. 64tamsulosin hcl................... 149TAPAZOLE....................... 169TAPERDEX 6-DAY...........154TARCEVA...........................64TARGRETIN....................... 64tarina 24 fe........................167tarina fe 1/20.....................167tarina fe 1/20 eq................167TARKA..............................102TARON FORTE................ 137

taron-crystals.................... 137TASIGNA............................ 64TASMAR.............................69TAVALISSE........................ 85TAXOTERE........................ 64TAYTULLA........................167tazarotene.........................115tazicef................................. 33TAZICEF.............................33TAZORAC.........................115taztia xt............................. 102TDVAX..............................179TECENTRIQ....................... 64TECFIDERA..................... 107TECHNET TC 99M SULFUR COLLOID...........194technetium tc 99m mebrofenin........................194TECHNETIUM TC 99M MEDRONATE...................194TECHNETIUM TC 99M PYROPHOS..................... 194technetium tc 99m sestamibi...........................194TECHNIVIE.........................77TEFLARO........................... 33TEGRETOL........................ 42TEGRETOL-XR.................. 42TEGSEDI.......................... 109TEKTURNA...................... 102TEKTURNA HCT.............. 102TELFA AMD ISLAND DRESSING....................... 194TELFA AMD NON-ADHERENT...................... 194telmisartan........................ 102telmisartan-amlodipine......102telmisartan-hctz................ 102temazepam....................... 216TEMODAR..........................64temozolomide..................... 64temsirolimus......................176tencon................................. 16teniposide........................... 65TENIVAC.......................... 179tenofovir disoproxil fumarate..............................77TENORETIC 100.............. 102TENORETIC 50................ 102TENORMIN.......................102TEPADINA..........................65terazosin hcl......................149terbinafine hcl..................... 52

terbutaline sulfate............. 212terconazole......................... 52TESSALON PERLES....... 207TESTIM.............................154TESTONE CIK..................154TESTOPEL....................... 154testosterone...................... 155TESTOSTERONE CYPIONATE..................... 155testosterone cypionate......155TESTOSTERONE ENANTHATE.................... 155testosterone enanthate..... 155TESTOSTERONE PROPIONATE.................. 155tetcaine............................. 204tetrabenazine.................... 109tetracaine hcl.................... 204tetracycline hcl.................... 33tetravisc............................ 204tetravisc forte.................... 204thallous chloride tl 201...... 194THALLOUS CHLORIDE TL 201...............................194THALOMID......................... 65THEO-24...........................212theochron..........................212theophylline.......................212theophylline er.................. 212theophylline in d5w........... 212THERAHONEY.................115thiamine hcl.......................137THIOLA.............................148thioridazine hcl....................73thiotepa............................... 65thiothixene.......................... 73THROMBATE III ................. 38THROMBIN-JMI..................85THROMBIN-JMI EPISTAXIS......................... 85THROMBOGEN..................85THYMOGLOBULIN...........176THYROGEN..................... 195THYROLAR-1................... 169THYROLAR-1/2................ 169THYROLAR-1/4................ 169THYROLAR-2................... 169THYROLAR-3................... 169tiagabine hcl........................42TIAZAC............................. 102TIBSOVO............................65TICE BCG.........................176TIGAN.................................49

244

tigecycline........................... 33TIGLUTIK..........................109TIKOSYN.......................... 102tilia fe................................ 167timolol maleate..........102, 200TIMOLOL-BRIMON-DORZOL-LATANOPR...... 200TIMOLOL-BRIMONIDINE-DORZOLAMID..................200TIMOLOL-DORZOLAMID-LATANOPROST............... 200TIMOPTIC.........................200TIMOPTIC OCUDOSE..... 200TIMOPTIC-XE...................200TIMOTHY GRASS POLLEN ALLERGEN....... 195tinidazole.............................33TIROSINT......................... 169TISSEEL........................... 195TISSEEL VHSD................ 195tis-u-sol............................. 137TIVICAY..............................77tizanidine hcl..................... 215tl gard rx............................137TL G-FOL OS................... 137tl icon................................ 137TL-FLUORIVITE............... 137tl-hem 150.........................137TNKASE............................. 38TOBI NEBULIZER............ 213TOBI PODHALER.............213TOBRADEX...................... 204TOBRADEX ST................ 204tobramycin................ 198, 213TOBRAMYCIN..................213tobramycin sulfate...............33tobramycin-dexamethasone................ 204TOBREX........................... 198TOFRANIL.......................... 47tolazamide........................ 119tolbutamide....................... 119tolcapone............................ 69tolmetin sodium.....................8tolterodine tartrate.............148tolterodine tartrate er........ 148TOPAMAX.......................... 42TOPAMAX SPRINKLE....... 42topex topical anesthetic.... 110topiramate...........................43topiramate er.......................42toposar................................65topotecan hcl...................... 65

TOPROL XL......................102toremifene citrate................ 65TORISEL.......................... 176torsemide.......................... 102TOTECT............................. 65TOUJEO MAX SOLOSTAR...................... 123TOUJEO SOLOSTAR.......123TOVIAZ.............................148tpn electrolytes..................137TRACLEER.......................214TRADJENTA.....................119tramadol hcl er.................... 17tramadol hcl er (biphasic)...................................... 16, 17tramadol hcl ir ..................... 17tramadol-acetaminophen.... 17trandolapril ........................ 102trandolapril-verapamil hcl er.......................................102tranexamic acid...................85TRANSDERM-SCOP (1.5 MG).....................................49TRANXENE-T.....................80tranylcypromine sulfate.......47TRAVASOL.......................137TRAVATAN Z................... 200trazodone hcl...................... 47TREANDA...........................65TRECATOR........................ 55TRELEGY ELLIPTA..........212TRELSTAR MIXJECT.......159TREMFYA.........................176TRESIBA.......................... 123TRESIBA FLEXTOUCH....123tretinoin....................... 65, 115tretinoin microsphere........ 115tretinoin microsphere pump.......................................... 115TRETTEN........................... 85TREXALL..........................176TREZIX............................... 17tri femynor.........................167triamcinolone acetonide.................................. 110, 154TRIAMCINOLONE ACETONIDE.....................154TRIAMCINOLONE-BUPIVACAINE..................154TRIAMCINOLONE-MOXIFLOXACIN...............204triamterene-hctz................102triazolam............................. 80

TRIBENZOR..................... 102TRICARE PRENATAL DHA ONE......................... 137TRI-CHLOR...................... 115TRICHOPHYTON............. 195TRICITRASOL.................... 38tricitrates........................... 137tricon................................. 137TRICOR............................ 103triderm...............................154trientine hcl....................... 137TRIESENCE..................... 198tri-estarylla........................ 167trifluoperazine hcl................73trifluridine.......................... 198trigels-f forte......................137TRIGLIDE......................... 103trihexyphenidyl hcl.............. 69tri-legest fe........................ 167TRILEPTAL.........................43tri-linyah............................ 167TRILIPIX........................... 103tri-lo-estarylla.................... 167tri-lo-marzia.......................168tri-lo-sprintec..................... 168trilyte................................. 144trimethobenzamide hcl........49trimethoprim........................33tri-mili ................................ 168trimipramine maleate.......... 47trinessa (28)......................168TRI-NORINYL (28)........... 168TRINTELLIX....................... 47TRIOSTAT........................ 169triphrocaps........................ 137TRIPLE PMB.................... 199TRIPLE PMK.................... 199tri-previfem........................168TRIPTODUR.....................159tri-sprintec......................... 168TRIUMEQ........................... 77TRI-VI-FLOR.....................137TRI-VI-FLORO..................138TRIVISC............................195tri-vitamin/fluoride............. 138tri-vite/fluoride................... 138trivora (28)........................ 168tri-vylibra........................... 168tri-vylibra lo....................... 168TRIZIVIR.............................77TROGARZO....................... 77TROKENDI XR................... 43TRONVITE........................138

245

TROPHAMINE..................138TROPICAMIDE-CYCLOPENTOLATE-PE.. 204TROPIC-PROPARACA-PE-KETOROLAC..............204trospium chloride.............. 148trospium chloride er.......... 148TRUEPLUS 5-BEVEL PEN NEEDLES......................... 123TRULANCE...................... 144TRULICITY....................... 120TRUMENBA......................179TRUSOPT.........................200TRUVADA...........................77tryptophan.........................138TUDORZA PRESSAIR..... 212tulana................................ 168turpentine..........................116TUSSICAPS..................... 207TUSSIONEX PENNKINETIC ER............208TUXARIN ER.................... 208TUZISTRA XR.................. 208TWINRIX...........................179TWYNSTA........................ 103TYBOST............................. 77tydemy.............................. 168TYGACIL............................ 33TYKERB............................. 65TYLENOL WITH CODEINE #3...................... 17TYLENOL WITH CODEINE #4...................... 17TYMLOS........................... 182TYPHIM VI........................179TYSABRI.......................... 107TYVASO........................... 214TYVASO REFILL.............. 214TYVASO STARTER......... 214UCERIS............................ 181UDAMIN SP......................138UDENYCA.......................... 85ULESFIA.............................68ULORIC.............................. 52ULTIVA............................... 17ULTOMIRIS........................ 85ULTRABAG/DIANEAL PD-2/1.5% DEX...................... 138ULTRABAG/DIANEAL PD-2/2.5% DEX...................... 138ULTRABAG/DIANEAL PD-2/4.25%DEX..................... 138

ULTRABAG/DIANEAL/1.5% DEXTROSE..................138ULTRABAG/DIANEAL/2.5% DEXTROSE..................138ULTRABAG/DIANEAL/4.25% DEX............................ 138ULTRACARE PEN NEEDLES......................... 123ULTRACET.........................17ULTRAM............................. 17umecta mousse................ 116UNASYN.............................33unithroid............................ 170UNITUXIN...........................65UPTRAVI.......................... 214urea...................................116urea hydrating...................116urea in zn undecyl-lactic acid................................... 116urea nail ............................ 116urea-c40............................116URECHOLINE.................. 148uredeb...............................116ure-k..................................116uremez-40.........................116uretron d/s.........................148uribel................................. 148URIMAR-T........................ 148urin ds............................... 148uro-458............................. 148UROCIT-K 10................... 138UROCIT-K 15................... 138UROCIT-K 5..................... 138UROGESIC-BLUE............ 148uro-mp.............................. 148urosex............................... 138UROXATRAL....................149URSO 250........................ 144URSO FORTE.................. 144ursodiol............................. 144uryl.................................... 148ustell ................................. 148UTIBRON NEOHALER.....212uticap................................ 148utira-c................................148utrona-c.............................148VABOMERE....................... 33VAGIFEM..........................168valacyclovir hcl....................77VALCHLOR........................ 65VALCYTE........................... 78valganciclovir hcl.................78VALIUM.............................. 80

valproate sodium................ 43valproic acid........................43valsartan........................... 103valsartan-hydrochlorothiazide...........103VALSTAR........................... 65VALTREX........................... 78VANATOL LQ..................... 17VANATOL S........................17VANCOCIN HCL.................33VANCOMYCIN HCL........... 34vancomycin hcl................... 34VANCOMYCIN HCL IN DEXTROSE........................ 34vancomycin hcl in dextrose.34VANCOMYCIN HCL IN NACL.................................. 34vancomycin hcl in nacl........34VANCOSOL PACK............. 34vandazole........................... 34VANTAS........................... 159VAPRISOL........................159VAQTA..............................179VARITHENA..................... 103VARIVAX.......................... 179VARUBI.............................. 49VASCEPA.........................103VASERETIC..................... 103VASOPRESSIN-DEXTROSE...................... 159VASOPRESSIN-SODIUM CHLORIDE....................... 159VASOSTRICT...................159VASOTEC.........................103VAZCULEP.......................103v-c forte.............................138vcf vaginal contraceptive.. 195VECAMYL.........................103VECTIBIX........................... 65VECTICAL........................ 116vecuronium bromide......... 109VELCADE........................... 65VELETRI...........................214velivet................................168VELPHORO......................148VELTASSA....................... 138VEMLIDY............................ 78VENCLEXTA...................... 65VENCLEXTA STARTING PACK.................................. 65VENELEX......................... 116venlafaxine hcl.................... 47venlafaxine hcl er................47

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VENOFER........................ 138VENOMIL MIXED VESPID VENOM.............................195VENTAVIS........................ 214VENTOLIN HFA................212verapamil hcl.....................103verapamil hcl er................ 103verdrocet.............................17VEREGEN........................ 116VERELAN......................... 103VERELAN PM...................103VERIPRED 20.................. 154VERSACLOZ...................... 73VERZENIO......................... 65VESICARE........................148vexatrol............................... 21VFEND................................52VFEND IV........................... 52VIAGRA............................ 148VIBATIV.............................. 34VIBERZI............................144VIBRAMYCIN..................... 34vic-forte............................. 138vicodin.................................17vicodin es............................17vicodin hp............................17VICTOZA.......................... 120VIDAZA...............................65VIDEX................................. 78VIDEX EC........................... 78VIEKIRA PAK..................... 78vienva............................... 168vigabatrin............................ 43vigadrone............................ 43VIGAMOX......................... 199VIIBRYD............................. 47VIIBRYD STARTER PACK.47vilamit mb..........................148vilevev mb.........................148VIMIZIM............................ 146VIMPAT.............................. 43vinblastine sulfate............... 65vincasar pfs.........................65vincristine sulfate................ 65vinorelbine tartrate.............. 65VIOKACE..........................146viorele............................... 168VIRACEPT..........................78VIRAMUNE.........................78VIRAMUNE XR...................78VIRASAL...........................116VIRAZOLE.......................... 78VIREAD.............................. 78

VIRGINIA LIVE OAK.........195VIROPTIC.........................199virt-caps............................ 138VIRT-FEFA PLUS.............138virt-gard.............................138virt-phos 250 neutral......... 138VISCO-3........................... 195VISIONBLUE.................... 204VISIPAQUE...................... 195VISTARIL............................80VISTOGARD.....................195VISUDYNE....................... 204vita s forte......................... 138vitacel................................138VITAFOL...........................138VITAL-D RX...................... 138vitamax pediatric...............138VITAMEZ.......................... 138vita-min............................. 139vitamin d (cholecalciferol). 138vitamin d (ergocalciferol)...139vitamin k1..........................139vitamins acd-fluoride.........139VITAROCA PLUS............. 139VITA-RX DIABETIC VITAMIN........................... 139VITRAKVI........................... 66VITRASE.......................... 195VIVELLE-DOT.................. 168VIVITROL........................... 23VIVOTIF............................179VIZAMYL.......................... 195VIZIMPRO.......................... 66VOGELXO........................ 155VOGELXO PUMP.............155vol-care rx......................... 139VOLTAREN.......................... 8volumex............................ 195VOLUVEN...........................85VONVENDI......................... 86VOPAC KT............................8VORAXAZE........................ 66voriconazole........................52VOSEVI.............................. 78VOTRIENT..........................66VPRIV............................... 146vp-vite rx........................... 139VRAYLAR........................... 73VUSION.............................. 52vyfemla............................. 168vylibra............................... 168VYTORIN..........................103VYVANSE.........................106

VYXEOS............................. 66VYZULTA..........................201warfarin sodium.................. 38WASP VENOM PROTEIN 195WELCHOL........................ 103WELLBUTRIN SR...............47WELLBUTRIN XL............... 47wera.................................. 168WESTERN JUNIPER....... 195WESTHROID....................170wheat germ oil .................. 139WHITE ASH......................195WHITE BIRCH.................. 195WHITE FACED HORNET VENOM.............................195WHITE MULBERRY......... 195WHITE OAK......................195WHITE PINE.....................196WHITE-FACED HORNET VENOM.............................196WIDE-SEAL DIAPHRAGM 60......................................196WILATE.............................. 86WINRHO SDF...................176wixela inhub...................... 212WP THYROID...................170wymzya fe.........................168XADAGO............................ 69XALATAN......................... 201XALKORI............................ 66XANAX................................80XANAX XR..........................80XARELTO........................... 38XARELTO STARTER PACK.................................. 39XELJANZ.......................... 176XELJANZ XR.................... 176XELODA............................. 66XENAZINE........................109XEOMIN............................196XERAC AC....................... 116XERAVA............................. 35XERFORM OIL EMULSION ROLL.............116XERMELO........................ 144XEROFORM OIL EMULSION 2"X2"............. 116XEROFORM OIL EMULSION GAUZE..........116XEROFORM OIL EMULSION STRIP........... 116XEROFORM PETROLAT GAUZE 1"X8"................... 116

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XEROFORM PETROLAT GAUZE 5"X9"................... 116XEROFORM PETROLAT PATCH 2"X2"....................116XEROFORM PETROLAT PATCH 4"X4"....................116XEROFORM PETROLATUM ROLL 4"X9'................................. 116XEROSTOMIA RELIEF SPRAY..............................110XGEVA............................. 182XHANCE...........................208XIAFLEX........................... 196XIFAXAN............................ 35XIGDUO XR......................120XIIDRA..............................204XOFIGO..............................66XOFLUZA........................... 78XOLAIR.............................208XOLEGEL........................... 52XOLEGEL COREPAK........ 52XOLEGEL DUO/HEAD & SHOULDERS..................... 52XOLEGEL DUO/XOLEX..... 52XOPENEX........................ 212XOPENEX CONCENTRATE.............. 212XOPENEX HFA................ 212XOSPATA...........................66XTAMPZA ER.....................17XTANDI...............................66xulane............................... 168XULTOPHY...................... 120XURIDEN..........................196xvite.................................. 139XYLOCAINE....................... 21xylocaine dental.................. 21XYLOCAINE/EPINEPHRINE......................................... 21XYLOCAINE-MPF.............. 21XYLOCAINE-MPF/EPINEPHRINE...........22XYNTHA............................. 86XYNTHA SOLOFUSE.........86XYREM............................. 216YASMIN 28....................... 168YAZ...................................168YELLOW DOCK............... 196YELLOW HORNET VENOM PROTEIN............196YELLOW JACKET VENOM PROTEIN............196

YERVOY.............................66YESCARTA........................ 66YF-VAX.............................179YONDELIS..........................66YONSA............................... 66yuvafem............................ 168zafirlukast..........................212zaleplon............................ 216ZALTRAP............................66ZANAFLEX....................... 215ZANOSAR.......................... 66ZANTAC........................... 140zarah.................................168ZARONTIN......................... 43ZARXIO.............................. 86ZAVESCA......................... 146zebutal................................ 17ZEJULA.............................. 66ZELAPAR........................... 70ZELBORAF.........................66ZEMAIRA..........................212ZEMDRI.............................. 35ZEMPLAR.........................182zenatane........................... 116ZENPEP........................... 146zenzedi............................. 106ZENZEDI.......................... 106ZEPATIER.......................... 78ZERBAXA........................... 35zeruvia................................ 22ZESTORETIC................... 103ZESTRIL........................... 103ZETIA................................103ZETONNA.........................208ZEVALIN Y-90.................... 66ZIAC..................................103ZIAGEN.............................. 78zidovudine...........................78zileuton er......................... 212ZILRETTA.........................154ZINC TRACE METAL....... 139ZINECARD......................... 66ZINGO................................ 22ZINPLAVA........................ 176ZIOPTAN.......................... 201ziprasidone hcl....................73ZIRGAN............................ 199ZITHRANOL..................... 116ZITHROMAX.......................35ZITHROMAX TRI-PAK....... 35ZITHROMAX Z-PAK........... 35ZOCOR.............................103ZOFRAN............................. 49

ZOHYDRO ER....................17ZOLADEX......................... 159zoledronic acid..................182ZOLINZA.............................66zolmitriptan......................... 54ZOLOFT..............................47zolpidem tartrate............... 216zolpidem tartrate er...........216ZOMIG................................ 54ZOMIG ZMT........................54ZONALON........................ 116ZONEGRAN....................... 43zonisamide..........................43ZONTIVITY......................... 70ZORBTIVE........................144ZORTRESS...................... 176ZOSTAVAX.......................179ZOSYN............................... 35zovia 1/35e (28)................ 168ZOVIRAX...................... 78, 79ZUBSOLV........................... 23ZUPLENZ........................... 49ZURAMPIC......................... 52ZYBAN................................23ZYDELIG............................ 66ZYFLO.............................. 212ZYFLO CR........................ 212ZYKADIA............................ 66ZYLET...............................204ZYLOPRIM......................... 52ZYMAXID..........................199ZYPITAMAG..................... 104ZYPREXA........................... 73ZYPREXA RELPREVV.......73ZYPREXA ZYDIS............... 73ZYTIGA...............................66ZYVOX................................35

248

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 interpreterso 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 interpreterso 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.

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).

Your 2019 Formulary - healthalliance.org · Your 2019 Formulary. Effective January 1, 2019. Updated...

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