H5969_ACA108501_1 CMS Accepted 07212012
AlohaCare Advantage (HMO) 2013 COMpreHensive FOrMulAry(list of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
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AlohaCare Advantage (HMO)
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014. AlohaCare Advantage is a health plan with a Medicare contract. Call 1-866-973-6395 to receive material in an alternate format or language. 00013470 Version 13 H5969_ACA108501_1 CMS Accepted 07212012
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What is the AlohaCare Advantage (HMO) Formulary? A formulary is a list of covered drugs selected by AlohaCare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. AlohaCare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AlohaCare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug
from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 15, 2012. To get updated information about the drugs covered by AlohaCare Advantage, please visit our Web site at www.AlohaCare.org or call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990.
If we make any mid-year non-maintenance changes to the AlohaCare Advantage formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary. How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR, HYPERTENSION/ LIPIDS. If you know what your drug is used for, look for the category name in the list that begins page 1. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 78. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? AlohaCare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active
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ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: AlohaCare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AlohaCare Advantage before you fill your prescriptions. If you don’t get approval, AlohaCare Advantage may not cover the drug.
• Quantity Limits: For certain drugs, AlohaCare Advantage limits the amount of the drug that AlohaCare Advantage will cover. For example, AlohaCare Advantage provides 18 tablets/30 days per prescription for sumatriptan 50mg. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, AlohaCare
Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AlohaCare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AlohaCare Advantage will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.AlohaCare.org. You can ask AlohaCare Advantage to make an exception to these restrictions or limits. See the section, “How do I request an exception to the
AlohaCare Advantage’s formulary?” on page iii for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. AlohaCare Advantage pays for certain OTC drugs, Prilosec OTC 20mg, omeprazole OTC 20mg, Prevacid 24 Hour 15mg, Claritin OTC 10mg, loratadine OTC 10mg, Allegra OTC 180mg, Zyrtec OTC 10mg and cetirizine OTC 10mg. AlohaCare Advantage will provide these OTC drugs at no cost to you. The cost to AlohaCare Advantage of these OTC drugs will not count toward your total drug costs. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that AlohaCare Advantage does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by AlohaCare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AlohaCare Advantage.
• You can ask AlohaCare Advantage to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the AlohaCare Advantage’s Formulary? You can ask AlohaCare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage
restrictions or limits on your drug. For example, for certain drugs, AlohaCare Advantage limits the amount of the drug that we will cover. If your drug has a
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quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of
coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated as the high-cost tier.
Generally, AlohaCare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Transition policy for level of care changes Upon notification, AlohaCare Advantage will cover up to a 60-day supply of a prescription drug (unless you have a prescription written for fewer days) for current members who have a level of care change. A level of care change includes the following situations: if you enter a long-term care facility from a hospital or other setting; if you leave a long-term care facility to return to a community/home setting; if you are discharged from a hospital to a community/home setting; if you end your skilled nursing facility stay covered under Medicare Part A and need to revert to coverage under AlohaCare Advantage; if your hospice status reverts to standard Medicare Part
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A and B benefits; or, if you are discharged from a psychiatric hospital with a drug regimen that is highly individualized. For more information For more detailed information about your AlohaCare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have any questions about AlohaCare Advantage, please call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990. Or visit www.AlohaCare.org. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov. AlohaCare Advantage’s Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by AlohaCare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 78. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CIPRO) and generic drugs are listed in lower-case italics (e.g., ciprofloxacin).
The information in the Requirements/Limits column tells you if AlohaCare Advantage has any special requirements for coverage of your drug. The following abbreviations explain any restrictions on coverage, which are described in more detail on page iii. BvsD = Part B versus Part D: This drug may be covered under Medicare Part B or Part D, depending on the circumstances MO = Mail Order service available: This service helps you save money on your prescription drug costs and your drugs will be conveniently mailed to your home. PA = Prior Authorization QL = Quantity Limit ST = Step Therapy LA = Limited Access: This prescription may be available only at certain pharmacies. For more information consult your Provider & Pharmacy Directory or call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990. All drugs on the AlohaCare Advantage formulary are listed with a tier designation. The tier designation of a drug and coverage level determines the amount of copayment or coinsurance that you will pay for that drug. Please refer to the following table for copayment and coinsurance amounts. For more information, please see the Evidence of Coverage.
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Effective January 1, 2013 Initial Coverage Coverage Gap
(Doughnut Hole) Catastrophic
Coverage
When your total drug cost for Part D drugs (paid by you and any Part D plan) for 2013 is less than $2,970, you pay:
Once the total cost of your Part D drugs paid by you and any Part D plan reaches $2,970, you pay:
Once your out-of-pocket expense (TrOOP) for covered Part D drugs reach $4,750 you pay:
Tier 1: Preferred Generic Drugs • 30-day retail • 90-day retail • 90-day mail order
• $4 copay • $12 copay • $8 copay
Member pays 79% of the costs of generic drugs for a 30 or 90-day supply
The greater of: $2.65 or 5% $2.65 or 5% $2.65 or 5%
Tier 2: Non-Preferred Generic Drugs • 30-day retail • 90-day retail • 90-day mail order
• $7 copay • $21 copay • $14 copay
Member pays 79% of the costs of generic drugs for a 30 or 90-day supply
The greater of: $2.65 or 5% $2.65 or 5% $2.65 or 5%
Tier 3: Preferred Brand Drugs • 30-day retail • 90-day retail • 90-day mail order
• $40 copay • $120 copay • $80 copay
Member pays no more than 47.5% of the costs of brand drugs for a 30 or 90-day supply
The greater of: $6.60 or 5% $6.60 or 5% $6.60 or 5%
Tier 4: Non-Preferred Brand Drugs • 30-day retail • 90-day retail • 90-day mail
• $80 copay • $240 copay • $160 copay
Member pays no more than 47.5% of the costs of brand drugs for a 30 or 90-day supply
The greater of: $6.60 or 5% $6.60 or 5% $6.60 or 5%
Tier 5: Specialty Drugs • 30-day retail • 90-day retail • 90-day mail order
• 33% coinsurance • 33% coinsurance • 33% coinsurance
Member pays for a 30 or 90-day supply
The greater of: $6.60 or 5% $6.60 or 5% $6.60 or 5%
Page 1 of 89
Drug Tier Requirements/
Limits
Anti - Infectives
Antifungal Agents
ABELCET IV 5
mg/mL
4 BvsD; MO
AMBISOME IV
SUSP 50 mg
4 BvsD; MO
AMPHOTEC IV
SUSP 50 mg
4 BvsD; MO
amphotericin B
Solution for Injection
50 mg
2 BvsD; MO
ANCOBON
CAPSULE 250 mg,
500 mg
5 MO
CANCIDAS IV
SOLUTION 50 mg,
70 mg
4 BvsD; MO
clotrimazole Troche
10 mg
2 MO
ERAXIS(WATER
DILUENT) IV
SOLUTION 100 mg
3 BvsD; MO
fluconazole Oral Susp
10 mg/mL, 40 mg/mL
1 MO
fluconazole tablet 100
mg, 200 mg, 50 mg
1 MO
fluconazole tablet 150
mg
1 MO; QL (2 EA
per 30 day(s))
fluconazole in
dextrose (iso-osmotic)
IV Piggy Back 400
mg/200 mL
1 BvsD; MO
flucytosine capsule
250 mg, 500 mg
2 MO
griseofulvin microsize
Oral Susp 125 mg/5
mL
1 MO
GRIS-PEG TABLET
125 mg, 250 mg
3 MO
Drug Tier Requirements/
Limits
itraconazole capsule
100 mg
2 MO; QL (120 EA
per 30 day(s))
ketoconazole tablet
200 mg
1 MO
MYCAMINE IV
SOLUTION 100 mg,
50 mg
4 BvsD; MO
nystatin Oral Susp
100,000 unit/mL
1 MO
nystatin tablet 500,000
unit
1 MO
SPORANOX ORAL
SOLN 10 mg/mL
4 MO
terbinafine tablet 250
mg
1 MO
VFEND ORAL SUSP
200 mg/5 mL (40
mg/mL)
5 MO
VFEND TABLET 200
mg, 50 mg
5 MO
VFEND IV SOLN
200 mg
4 BvsD; MO
voriconazole tablet
200 mg, 50 mg
2 MO
Antivirals
acyclovir capsule 200
mg
1 MO
acyclovir Oral Susp
200 mg/5 mL
1 MO
acyclovir tablet 400
mg, 800 mg
1 MO
acyclovir sodium IV
powder for Solution
500 mg
2 MO
amantadine capsule
100 mg
1 MO
amantadine Syrup 50
mg/5 mL
1 MO
Page 2 of 89
Drug Tier Requirements/
Limits
amantadine tablet 100
mg
1 MO
APTIVUS CAPSULE
250 mg
5 MO
APTIVUS ORAL
SOLN 100 mg/mL
5 MO
ATRIPLA TABLET
600-200-300 mg
5 MO
BARACLUDE ORAL
SOLN 0.05 mg/mL
3 MO
BARACLUDE
TABLET 0.5 mg, 1
mg
5 MO
COMBIVIR TABLET
150-300 mg
5 MO
COMPLERA
TABLET 200-25-300
mg
5 MO
CRIXIVAN
CAPSULE 200 mg,
400 mg
4 MO
CYTOVENE IV
SOLUTION 500 mg
4 BvsD; MO
didanosine
capsule,delayed
release 125 mg, 200
mg, 250 mg, 400 mg
2 MO
EDURANT TABLET
25 mg
5 MO
EMTRIVA
CAPSULE 200 mg
4 MO
EMTRIVA ORAL
SOLN 10 mg/mL
4 MO
EPIVIR ORAL SOLN
10 mg/mL
4 MO
EPIVIR TABLET 150
mg, 300 mg
4 MO
Drug Tier Requirements/
Limits
EPIVIR HBV ORAL
SOLN 25 mg/5 mL (5
mg/mL)
4 MO
EPIVIR HBV
TABLET 100 mg
4 MO
EPZICOM TABLET
600-300 mg
5 MO
famciclovir tablet 125
mg, 250 mg, 500 mg
1 MO
foscarnet IV 24 mg/mL 1 MO
FUZEON SUB-Q KIT
90 mg
5 MO
ganciclovir capsule
250 mg, 500 mg
2 MO
ganciclovir IV
Solution 500 mg
2 BvsD; MO
HEPSERA TABLET
10 mg
5 MO; QL (30 EA
per 30 day(s))
INCIVEK TABLET
375 mg
5 MO
INTELENCE
TABLET 100 mg, 200
mg
5 MO
INVIRASE
CAPSULE 200 mg
4 MO
INVIRASE TABLET
500 mg
5 MO
ISENTRESS
TABLET 400 mg
5 MO
KALETRA TABLET
100-25 mg
4 MO
KALETRA ORAL
SOLN 400-100 mg/5
mL
5 MO
KALETRA TABLET
200-50 mg
5 MO
lamivudine tablet 150
mg, 300 mg
2 MO
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Drug Tier Requirements/
Limits
lamivudine-zidovudine
tablet 150-300 mg
2 MO
LEXIVA ORAL
SUSP 50 mg/mL
4 MO
LEXIVA TABLET
700 mg
5 MO
nevirapine tablet 200
mg
2 MO
NORVIR CAPSULE
100 mg
3 MO
NORVIR TABLET
100 mg
3 MO
NORVIR ORAL
SOLN 80 mg/mL
4 MO
PREZISTA TABLET
75 mg
4 MO
PREZISTA TABLET
150 mg, 400 mg, 600
mg
5 MO
REBETOL ORAL
SOLN 40 mg/mL
4 MO
RELENZA
DISKHALER FOR
INHALATION 5
mg/actuation
3 MO
RESCRIPTOR
DISPERSIBLE
TABLET 100 mg
3 MO
RESCRIPTOR
TABLET 200 mg
3 MO
RETROVIR IV 10
mg/mL
4 MO
REYATAZ
CAPSULE 100 mg
4 MO
REYATAZ
CAPSULE 150 mg,
200 mg, 300 mg
5 MO
Drug Tier Requirements/
Limits
RIBAPAK DOSE
PACK TABLETS
400-400 mg (28)-mg
(28), 600-400 mg
(28)-mg (28), 600-600
mg (28)-mg (28)
2 MO
RIBASPHERE
TABLET 400 mg, 600
mg
2 MO
RIBASPHERE
CAPSULE 200 mg
2 MO; QL (180 EA
per 30 day(s))
RIBASPHERE
TABLET 200 mg
2 MO; QL (180 EA
per 30 day(s))
ribavirin capsule 200
mg
2 MO
ribavirin tablet 200
mg
2 MO
rimantadine tablet 100
mg
1 MO
SELZENTRY
TABLET 150 mg, 300
mg
5 MO
stavudine capsule 15
mg, 20 mg, 30 mg, 40
mg
1 MO
SUSTIVA CAPSULE
200 mg, 50 mg
4 MO
SUSTIVA TABLET
600 mg
4 MO
SYNAGIS IM SOLN
50 mg/0.5 mL
4 MO
TAMIFLU CAPSULE
30 mg, 45 mg, 75 mg
3 MO
TAMIFLU ORAL
SUSP 6 mg/mL
3 MO
TRIZIVIR TABLET
300-150-300 mg
5 MO
TRUVADA TABLET
200-300 mg
5 MO
Page 4 of 89
Drug Tier Requirements/
Limits
TYZEKA TABLET
600 mg
5 MO
valacyclovir tablet 1
g, 500 mg
2 MO; QL (60 EA
per 30 day(s))
VALCYTE TABLET
450 mg
4 MO
VALTREX TABLET
1 g, 500 mg
4 MO; QL (60 EA
per 30 day(s))
VICTRELIS
CAPSULE 200 mg
5 MO
VIDEX 2 GRAM
PEDIATRIC ORAL
SOLUTION 10
mg/mL (Final)
4 MO
VIDEX EC
CAPSULE,DELAYE
D RELEASE 125 mg
4 MO
VIRACEPT TABLET
250 mg, 625 mg
3 MO
VIRAMUNE ORAL
SUSP 50 mg/5 mL
4 MO
VIRAMUNE
TABLET 200 mg
4 MO
VIRAMUNE XR
TABLET,EXTENDE
D RELEASE 400 mg
4 MO
VIREAD ORAL
POWDER 40
mg/scoop (40
mg/gram)
4 MO
VIREAD TABLET
150 mg, 200 mg, 250
mg, 300 mg
4 MO
VISTIDE IV 75
mg/mL
3 BvsD; MO
ZERIT CAPSULE 15
mg, 20 mg, 30 mg, 40
mg
4 MO
Drug Tier Requirements/
Limits
ZERIT ORAL
SOLUTION 1 mg/mL
4 MO
ZIAGEN ORAL
SOLN 20 mg/mL
4 MO
ZIAGEN TABLET
300 mg
4 MO
zidovudine capsule
100 mg
2 MO
zidovudine Syrup 10
mg/mL
2 MO
zidovudine tablet 300
mg
2 MO
Cephalosporins
CEDAX CAPSULE
400 mg
4 MO
cefaclor capsule 250
mg, 500 mg
1 MO
cefaclor ER
tablet,extended
release,12 hr 500 mg
1 MO
cefadroxil capsule 500
mg
1 MO
cefadroxil Oral Susp
250 mg/5 mL, 500
mg/5 mL
1 MO
cefadroxil tablet 1
gram
1 MO
cefazolin Solution for
Injection 1 gram, 10
gram, 500 mg
2 MO
cefazolin in dextrose
(iso-osmotic) IV Piggy
Back 1 gram/50 mL
1 MO
cefdinir capsule 300
mg
1 MO
cefdinir Oral Susp 125
mg/5 mL, 250 mg/5
mL
1 MO
Page 5 of 89
Drug Tier Requirements/
Limits
cefepime Solution for
Injection 1 gram, 2
gram
2 MO
cefotaxime Solution
for Injection 1 gram,
10 gram, 2 gram
2 MO
cefotetan IV Solution
10 gram
1 MO
cefotetan Solution for
Injection 1 gram, 2
gram
3 MO
cefoxitin IV Solution 1
gram, 10 gram, 2
gram
1 MO
cefpodoxime Oral
Susp 100 mg/5 mL, 50
mg/5 mL
2 MO
cefpodoxime tablet
100 mg, 200 mg
2 MO
cefprozil Oral Susp
125 mg/5 mL, 250
mg/5 mL
2 MO
cefprozil tablet 250
mg, 500 mg
2 MO
ceftazidime in
dextrose 5 % in water
IV Piggy Back 1
gram/50 mL, 2
gram/50 mL
2 MO
ceftriaxone IV
Solution 1 gram, 2
gram
1 MO
ceftriaxone Solution
for Injection 10 gram,
250 mg, 500 mg
2 MO
cefuroxime axetil
tablet 250 mg, 500 mg
2 MO
cefuroxime sodium
Solution for Injection
1.5 gram, 750 mg
2 BvsD; MO
Drug Tier Requirements/
Limits
cefuroxime sodium IV
Solution 7.5 gram
2 MO
cephalexin capsule
250 mg, 500 mg
1 MO
cephalexin Oral Susp
125 mg/5 mL, 250
mg/5 mL
1 MO
cephalexin tablet 250
mg, 500 mg
1 MO
CLAFORAN IV
SOLUTION 1 gram
3 BvsD; MO
FORTAZ SOLUTION
FOR INJECTION 6
gram
4 MO
FORTAZ IN D5W IV
PIGGY BACK 1
gram/50 mL, 2
gram/50 mL
4 MO
SUPRAX TABLET
400 mg
4 MO; QL (20 per
30 Day(s))
TEFLARO IV
SOLUTION 400 mg,
600 mg
4 BvsD; MO
ZINACEF IN
STERILE WATER IV
PIGGY BACK 1.5
gram/50 mL
4 BvsD; MO
Erythromycins / Other Macrolides
azithromycin IV
Solution 500 mg
2 MO
azithromycin Oral
Susp 100 mg/5 mL,
200 mg/5 mL
2 MO
azithromycin tablet
250 mg, 500 mg, 600
mg
2 MO
clarithromycin ER
tablet,extended
release 24 hr 500 mg
1 MO
Page 6 of 89
Drug Tier Requirements/
Limits
clarithromycin Oral
Susp 125 mg/5 mL,
250 mg/5 mL
1 MO
clarithromycin tablet
250 mg, 500 mg
1 MO
E.E.S. 400 TABLET
400 mg
1 MO
ERYPED 200 ORAL
SUSP 200 mg/5 mL
3 MO
ERY-TAB
TABLET,DELAYED
RELEASE 250 mg,
333 mg
1 MO
ERY-TAB
TABLET,DELAYED
RELEASE 500 mg
3 MO
ERYTHROCIN IV
SOLUTION 500 mg
3 BvsD; MO
ERYTHROCIN
STEARATE TABLET
250 mg
2 MO
erythromycin tablet
250 mg, 500 mg
3 MO
erythromycin
ethylsuccinate tablet
400 mg
1 MO
ZMAX ORAL
SUSPENSION,EXTE
NDED RELEASE 2
gram/60 mL
4 MO
Miscellaneous Antiinfectives
ALBENZA TABLET
200 mg
4 MO
ALINIA ORAL SUSP
100 mg/5 mL
4 MO
ALINIA TABLET
500 mg
4 MO; QL (6 EA
per 30 day(s))
Drug Tier Requirements/
Limits
amikacin Injection
100 mg/2 mL, 500
mg/2 mL
1 MO
atovaquone-proguanil
tablet 250-100 mg
2 MO
AZACTAM
SOLUTION FOR
INJECTION 2 gram
4 MO
AZACTAM IN ISO-
OSMOTIC
DEXTROSE IV
PIGGY BACK 1
gram/50 mL, 2
gram/50 mL
4 MO
aztreonam Solution
for Injection 1 gram
2 MO
BACIIM IM 50,000
unit
2 MO
bacitracin IM 50,000
unit
2 MO
BILTRICIDE
TABLET 600 mg
3 MO
CAPASTAT
SOLUTION FOR
INJECTION 1 gram
3 BvsD; MO
chloramphenicol sod
succinate IV Solution
1 gram
4 BvsD; MO
chloroquine tablet 250
mg, 500 mg
1 MO
CLEOCIN CAPSULE
75 mg
4 MO
CLEOCIN IN D5W
IV PIGGY BACK 300
mg/50 mL, 600 mg/50
mL, 900 mg/50 mL
4 BvsD; MO
clindamycin capsule
150 mg, 300 mg
1 MO
clindamycin IV 600
mg/4 mL
1 MO
Page 7 of 89
Drug Tier Requirements/
Limits
colistin (colistimethate
sodium) Solution for
Injection 150 mg
2 MO
CUBICIN IV
SOLUTION 500 mg
4 BvsD; MO
dapsone tablet 100
mg, 25 mg
3 MO
DARAPRIM
TABLET 25 mg
3 MO
DORIBAX IV SUSP
500 mg
4 BvsD; MO
ethambutol tablet 100
mg, 400 mg
1 MO
FLAGYL ER
TABLET,EXTENDE
D RELEASE 750 mg
4 MO
gentamicin Injection
40 mg/mL
1 MO
gentamicin in sodium
chloride(iso-osmotic)
IV Piggy Back 100
mg/100 mL, 60 mg/50
mL, 80 mg/100 mL
1 BvsD; MO
gentamicin in sodium
chloride(iso-osmotic)
IV Piggy Back 80
mg/50 mL
1 MO
gentamicin in sodium
chloride(iso-osmotic)
IV Piggy Back 70
mg/50 mL, 90 mg/100
mL
3 MO
gentamicin sulfate
(PF) IV 80 mg/8 mL
3 MO
hydroxychloroquine
tablet 200 mg
1 MO
imipenem-cilastatin IV
Solution 250 mg, 500
mg
2 BvsD; MO
Drug Tier Requirements/
Limits
INVANZ SOLUTION
FOR INJECTION 1
gram
3 BvsD; MO
isoniazid Injection 100
mg/mL
1 MO
isoniazid tablet 100
mg, 300 mg
1 MO
isoniazid Syrup 50
mg/5 mL
3 MO
kanamycin Injection 1
gram/3 mL
2 MO
KETEK TABLET 300
mg, 400 mg
4 MO
MALARONE
TABLET 250-100 mg,
62.5-25 mg
4 MO
mefloquine tablet 250
mg
1 MO
MEPRON ORAL
SUSP 750 mg/5 mL
4 MO
meropenem IV
Solution 500 mg
2 BvsD; MO
MERREM IV
SOLUTION 500 mg
4 BvsD; MO
metronidazole capsule
375 mg
1 MO
metronidazole tablet
250 mg, 500 mg
1 MO
metronidazole in
sodium chloride (iso-
osm) IV Piggy Back
500 mg/100 mL
1 MO
MYCOBUTIN
CAPSULE 150 mg
4 MO
NEBUPENT
SOLUTION FOR
INHALATION 300
mg
4 BvsD; MO
Page 8 of 89
Drug Tier Requirements/
Limits
neomycin tablet 500
mg
2 MO
paromomycin capsule
250 mg
2 MO
PASER ORAL
PACKET 4 gram
3 MO
PENTAM
SOLUTION FOR
INJECTION 300 mg
4 BvsD; MO
polymyxin B sulfate
Solution for Injection
500,000 unit
2 MO
PRIFTIN TABLET
150 mg
4 MO
primaquine tablet 26.3
mg
4 MO
PRIMAXIN IV IV
SOLUTION 250 mg,
500 mg
4 MO
QUALAQUIN
CAPSULE 324 mg
4 MO
rifampin capsule 150
mg, 300 mg
1 MO
rifampin IV Solution
600 mg
2 MO
RIFATER TABLET
50-120-300 mg
4 MO
SEROMYCIN
CAPSULE 250 mg
4 MO
streptomycin IM 1
gram
3 MO
STROMECTOL
TABLET 3 mg
3 MO
SYNERCID IV
SOLUTION 500 mg
5 BvsD; MO
TOBI NEB
SOLUTION 300 mg/5
mL
5 BvsD; MO
Drug Tier Requirements/
Limits
tobramycin in NS IV
Piggy Back 80 mg/100
mL
3 BvsD; MO
tobramycin in NS IV
Piggy Back 60 mg/50
mL
3 MO
tobramycin Injection
10 mg/mL, 40 mg/mL
1 MO
TRECATOR
TABLET 250 mg
4 MO
TYGACIL IV
SOLUTION 50 mg
4 BvsD; MO
XIFAXAN TABLET
200 mg, 550 mg
4 MO
ZYVOX IV 600
mg/300 mL
4 MO
ZYVOX ORAL SUSP
100 mg/5 mL
4 MO
ZYVOX TABLET
600 mg
4 MO
Penicillins
amoxicillin capsule
250 mg, 500 mg
1 MO
amoxicillin chewable
tablet 125 mg, 250 mg
1 MO
amoxicillin Oral Susp
125 mg/5 mL, 200
mg/5 mL, 250 mg/5
mL, 400 mg/5 mL
1 MO
amoxicillin tablet 500
mg, 875 mg
1 MO
amoxicillin-potassium
clavulanate chewable
tablet 200-28.5 mg,
400-57 mg
1 MO
Page 9 of 89
Drug Tier Requirements/
Limits
amoxicillin-potassium
clavulanate Oral Susp
200-28.5 mg/5 mL,
250-62.5 mg/5 mL,
400-57 mg/5 mL, 600-
42.9 mg/5 mL
1 MO
amoxicillin-potassium
clavulanate tablet
250-125 mg, 500-125
mg, 875-125 mg
1 MO
ampicillin capsule 250
mg, 500 mg
1 MO
ampicillin Oral Susp
125 mg/5 mL, 250
mg/5 mL
1 MO
ampicillin Solution for
Injection 1 gram, 10
gram
2 MO
ampicillin Solution for
Injection 125 mg
4 MO
ampicillin-sulbactam
Solution for Injection
15 gram, 3 gram
2 MO
BICILLIN C-R IM
SYRINGE 1,200,000
unit/ 2
mL(600k/600k),
1,200,000 unit/ 2
mL(900k/300k)
4 MO
BICILLIN L-A IM
SYRINGE 1,200,000
unit/2 mL, 2,400,000
unit/4 mL, 600,000
unit/mL
4 MO
dicloxacillin capsule
250 mg, 500 mg
1 MO
MOXATAG
TABLET,EXTENDE
D RELEASE 775 mg
4 MO
Drug Tier Requirements/
Limits
nafcillin Solution for
Injection 1 gram, 10
gram
2 MO
nafcillin in D2.4W IV
Piggy Back 1 gram/50
mL
4 MO
oxacillin Solution for
Injection 1 gram, 10
gram
3 MO
oxacillin in dextrose,
iso-osmotic IV Piggy
Back 1 g/50 mL, 2
g/50 mL
4 MO
penicillin G pot in
dextrose IV Piggy
Back 2 million unit/50
mL, 3 million unit/50
mL
3 BvsD; MO
penicillin G potassium
Solution for Injection
5 million unit
2 MO
penicillin G procaine
IM Syringe 1.2 million
unit/2 mL
3 BvsD; MO
penicillin G sodium
Solution for Injection
5 million unit
3 BvsD; MO
penicillin V potassium
tablet 250 mg, 500 mg
1 MO
penicillin V potassium
Oral Solution 125
mg/5 mL, 250 mg/5
mL
2 MO
PFIZERPEN-G
SOLUTION FOR
INJECTION 20
million unit
2 MO
piperacillin-
tazobactam IV
Solution 3.375 gram,
4.5 gram
2 BvsD; MO
Page 10 of 89
Drug Tier Requirements/
Limits
TIMENTIN IV
SOLUTION 3.1 g
4 BvsD; MO
ZOSYN IV
SOLUTION 3.375
gram
4 BvsD; MO
ZOSYN IN
DEXTROSE (ISO-
OSMOTIC) IV
PIGGY BACK 2.25
gram/50 mL, 3.375
gram/50 mL
4 BvsD; MO
Quinolones
AVELOX TABLET
400 mg
4 MO
AVELOX ABC
PACK TABLET 400
mg
4 MO
AVELOX IN
SODIUM
CHLORIDE (ISO-
OSMOTIC) IV
PIGGY BACK 400
mg/250 mL
4 BvsD; MO
CIPRO ORAL SUSP
250 mg/5 mL, 500
mg/5 mL
4 MO
ciprofloxacin tablet
100 mg, 250 mg, 500
mg, 750 mg
1 MO
ciprofloxacin IV 400
mg/40 mL
2 MO
ciprofloxacin ER
tablet,extended
release 24hr mphase
1,000 mg, 500 mg
2 MO
FACTIVE TABLET
320 mg
4 MO
LEVAQUIN ORAL
SOLN 250 mg/10 mL
4 MO
Drug Tier Requirements/
Limits
LEVAQUIN
TABLET 250 mg, 500
mg, 750 mg
4 MO
LEVAQUIN IN D5W
IV PIGGY BACK 750
mg/150 mL
4 BvsD; MO
levofloxacin IV 25
mg/mL
2 BvsD; MO
levofloxacin Oral Soln
250 mg/10 mL
2 MO
levofloxacin tablet 250
mg, 500 mg, 750 mg
2 MO
levofloxacin in D5W
IV Piggy Back 500
mg/100 mL
2 BvsD; MO
NOROXIN TABLET
400 mg
4 MO
ofloxacin tablet 200
mg, 300 mg, 400 mg
2 MO
Sulfa's / Related Agents
sulfadiazine tablet 500
mg
1 MO
sulfamethoxazole-
trimethoprim IV 400-
80 mg/5 mL
1 MO
sulfamethoxazole-
trimethoprim Oral
Susp 200-40 mg/5 mL
1 MO
sulfamethoxazole-
trimethoprim tablet
400-80 mg, 800-160
mg
1 MO
Tetracyclines
demeclocycline tablet
150 mg, 300 mg
2 MO
doxycycline hyclate
capsule 100 mg, 50
mg
1 MO
Page 11 of 89
Drug Tier Requirements/
Limits
doxycycline hyclate
tablet 100 mg, 20 mg
1 MO
doxycycline hyclate IV
Solution 100 mg
2 MO
doxycycline
monohydrate capsule
75 mg
1 MO
doxycycline
monohydrate tablet
150 mg, 50 mg, 75 mg
1 MO
minocycline capsule
100 mg, 50 mg, 75 mg
1 MO
minocycline tablet 100
mg, 50 mg, 75 mg
1 MO
minocycline ER
tablet,extended
release 24 hr 135 mg,
45 mg, 90 mg
2 MO
ORACEA CAPSULE,
EXTENDED
RELEASE 40 mg
4 MO
tetracycline capsule
250 mg, 500 mg
1 MO
VIBRAMYCIN
SYRUP 50 mg/5 mL
4 MO
Urinary Tract Agents
FURADANTIN
ORAL SUSP 25 mg/5
mL
4 MO
MACRODANTIN
CAPSULE 25 mg
3 MO
methenamine
hippurate tablet 1
gram
1 MO
MONUROL ORAL
PACKET 3 gram
4 MO
nitrofurantoin Oral
Susp 25 mg/5 mL
2 MO
Drug Tier Requirements/
Limits
nitrofurantoin
macrocrystal capsule
50 mg
1 MO
nitrofurantoin
monohydrate/macrocr
ystals capsule 100 mg
2 MO
PRIMSOL ORAL
SOLN 50 mg/5 mL
3 MO
trimethoprim tablet
100 mg
1 MO
Vancomycin
VANCOCIN
CAPSULE 125 mg,
250 mg
4 MO
vancomycin capsule
125 mg, 250 mg
2 MO
vancomycin IV
Solution 1,000 mg
2 MO
vancomycin IV
Solution 10 gram, 500
mg
4 BvsD; MO
Antineoplastic / Immunosuppressant Drugs
Adjunctive Agents
amifostine crystalline
IV Solution 500 mg
2 MO
dexrazoxane IV
Solution 500 mg
2 BvsD; MO
ELITEK IV
SOLUTION 1.5 mg
4 BvsD; MO
FUSILEV IV
SOLUTION 50 mg
4 BvsD; MO
KEPIVANCE
SOLUTION 6.25 mg
5 BvsD; MO
leucovorin calcium
tablet 25 mg, 5 mg
1 MO
leucovorin calcium
Solution for Injection
100 mg, 350 mg
2 BvsD; MO
Page 12 of 89
Drug Tier Requirements/
Limits
leucovorin calcium
tablet 10 mg, 15 mg
3 MO
mesna IV 100 mg/mL 1 BvsD; MO
MESNEX TABLET
400 mg
4 MO
XGEVA SUB-Q 120
mg/1.7 mL (70
mg/mL)
5 BvsD; MO
ZINECARD IV
SOLUTION 250 mg
4 BvsD; MO
Antineoplastic / Immunosuppressant Drugs
ADRIAMYCIN PFS
IV 2 mg/mL
1 BvsD; MO
AFINITOR TABLET
10 mg, 2.5 mg, 5 mg,
7.5 mg
5 MO
ALIMTA IV
SOLUTION 500 mg
4 BvsD; MO
ALKERAN IV
SOLUTION 50 mg
4 BvsD; MO
anastrozole tablet 1
mg
2 MO
ARIMIDEX TABLET
1 mg
4 MO
AROMASIN
TABLET 25 mg
4 MO
ARRANON IV 250
mg/50 mL
4 BvsD; MO
ARZERRA IV 100
mg/5 mL
5 MO
AVASTIN IV 25
mg/mL
5 BvsD; MO
AZASAN TABLET
100 mg, 75 mg
4 BvsD; MO
azathioprine tablet 50
mg
1 BvsD; MO
azathioprine Solution
for Injection 100 mg
2 BvsD; MO
Drug Tier Requirements/
Limits
bicalutamide tablet 50
mg
1 MO
BICNU IV
SOLUTION 100 mg
4 BvsD; MO
bleomycin Solution for
Injection 30 unit
2 BvsD; MO
BUSULFEX IV 60
mg/10 mL
4 BvsD; MO
CAMPATH IV 30
mg/mL
5 BvsD; MO
CAPRELSA TABLET
100 mg, 300 mg
5 MO
carboplatin IV 10
mg/mL
2 BvsD; MO
CASODEX TABLET
50 mg
4 MO
CEENU CAPSULE
10 mg, 100 mg, 40 mg
4 MO
CELLCEPT
CAPSULE 250 mg
4 BvsD; MO
CELLCEPT ORAL
SUSP 200 mg/mL
4 BvsD; MO
CELLCEPT TABLET
500 mg
4 BvsD; MO
CELLCEPT
INTRAVENOUS IV
SOLUTION 500 mg
4 BvsD; MO
cisplatin IV 1 mg/mL 2 BvsD; MO
cladribine IV 10
mg/10 mL
2 BvsD; MO
CLOLAR IV 20
mg/20 mL
5 BvsD; MO
COSMEGEN IV
SOLUTION 0.5 mg
3 BvsD; MO
cyclophosphamide
tablet 25 mg, 50 mg
2 BvsD; MO
cyclosporine capsule
100 mg, 25 mg
2 BvsD; MO
Page 13 of 89
Drug Tier Requirements/
Limits
cyclosporine IV 250
mg/5 mL
2 BvsD; MO
cyclosporine modified
capsule 100 mg
2 BvsD; MO
cyclosporine modified
Oral Soln 100 mg/mL
2 BvsD; MO
cyclosporine modified
capsule 50 mg
4 BvsD; MO
cytarabine Injection
20 mg/mL
2 BvsD; MO
cytarabine (PF)
Injection 2 gram/20
mL (100 mg/mL)
1 BvsD; MO
cytarabine (PF)
Solution for Injection
500 mg
2 BvsD; MO
dacarbazine IV
Solution 200 mg
2 BvsD; MO
DACOGEN IV
SOLUTION 50 mg
4 BvsD; MO
daunorubicin IV Inj 5
mg/mL
4 BvsD; MO
DOCEFREZ IV
SOLUTION 20 mg,
80 mg
4 BvsD; MO
docetaxel IV 80 mg/4
mL (20 mg/mL)
2 BvsD; MO
docetaxel IV 80 mg/8
mL (10 mg/mL)
4 BvsD; MO
DOXIL IV 2 mg/mL 4 BvsD; MO
doxorubicin IV 50
mg/25 mL
2 BvsD; MO
DROXIA CAPSULE
200 mg, 300 mg, 400
mg
3 MO
ELIGARD SUB-Q
SYRINGE 22.5 mg,
30 mg, 45 mg, 7.5 mg
4 BvsD; MO
Drug Tier Requirements/
Limits
ELLENCE IV 200
mg/100 mL
5 BvsD; MO
ELOXATIN SOLN
100 mg/20 mL
4 BvsD; MO
ELSPAR SOLUTION
FOR INJECTION
10,000 unit
4 BvsD; MO
EMCYT CAPSULE
140 mg
4 MO
epirubicin IV 50
mg/25 mL
2 BvsD; MO
ERBITUX IV 100
mg/50 mL
4 BvsD; MO
ERIVEDGE
CAPSULE 150 mg
5 MO
ETOPOPHOS IV
SOLUTION 100 mg
4 BvsD; MO
etoposide IV 20
mg/mL
2 BvsD; MO
exemestane tablet 25
mg
2 MO
FARESTON
TABLET 60 mg
4 MO
FASLODEX IM
SYRINGE 250 mg/5
mL
5 BvsD; MO
FEMARA TABLET
2.5 mg
4 MO
fludarabine IV powder
for Solution 50 mg
2 BvsD; MO
fluorouracil IV 500
mg/10 mL
2 BvsD; MO
flutamide capsule 125
mg
2 MO
gemcitabine IV
Solution 1 gram
4 BvsD; MO
GEMZAR IV
SOLUTION 1 gram
4 BvsD; MO
Page 14 of 89
Drug Tier Requirements/
Limits
GENGRAF
CAPSULE 100 mg,
25 mg
2 BvsD; MO
GENGRAF ORAL
SOLN 100 mg/mL
2 BvsD; MO
GLEEVEC TABLET
100 mg, 400 mg
5 MO
HALAVEN IV 1 mg/2
mL (0.5 mg/mL)
4 BvsD; MO
HERCEPTIN IV
SOLUTION 440 mg
5 BvsD; MO
HEXALEN
CAPSULE 50 mg
5 MO
HYCAMTIN IV
SOLUTION 4 mg
4 BvsD; MO
hydroxyurea capsule
500 mg
2 MO
idarubicin IV 1 mg/mL 2 BvsD; MO
IFEX IV SOLUTION
3 gram
4 BvsD; MO
ifosfamide IV Solution
1 gram
4 BvsD; MO
INLYTA TABLET 1
mg, 5 mg
4 MO
irinotecan IV 100
mg/5 mL
2 MO
IXEMPRA IV
SOLUTION 45 mg
4 BvsD; MO
JAKAFI TABLET 10
mg, 15 mg, 20 mg, 25
mg, 5 mg
5 MO
JEVTANA IV 10
mg/mL (Final)
5 MO
letrozole tablet 2.5 mg 2 MO
LEUKERAN
TABLET 2 mg
4 MO
leuprolide Sub-Q Kit 1
mg/0.2 mL
2 MO
Drug Tier Requirements/
Limits
LUPRON DEPOT IM
SYRINGE KIT 3.75
mg, 7.5 mg
4 BvsD; MO
LUPRON DEPOT (3
MONTH) IM
SYRINGE KIT 22.5
mg
4 BvsD; MO
LUPRON DEPOT (4
MONTH) IM
SYRINGE KIT 30 mg
4 BvsD; MO
LUPRON DEPOT (6
MONTH) IM
SYRINGE KIT 45 mg
4 MO
LUPRON DEPOT-
PED IM KIT 11.25
mg, 15 mg
4 BvsD; MO
LUPRON DEPOT-
PED (3 MONTH) IM
SYRINGE KIT 11.25
mg
4 BvsD; MO
LYSODREN
TABLET 500 mg
3 MO
MATULANE
CAPSULE 50 mg
3 MO
megestrol Oral Susp
400 mg/10 mL (40
mg/mL)
1 MO
megestrol tablet 20
mg, 40 mg
1 MO
melphalan IV Solution
50 mg
2 BvsD; MO
mercaptopurine tablet
50 mg
2 MO
methotrexate sodium
tablet 2.5 mg
1 BvsD; MO
methotrexate sodium
(PF) Injection 25
mg/mL
1 BvsD; MO
Page 15 of 89
Drug Tier Requirements/
Limits
methotrexate sodium
(PF) Solution for
Injection 1 gram
3 BvsD; MO
mitomycin IV Solution
20 mg
2 BvsD; MO
mitoxantrone
Concentrate, IV 2
mg/mL
2 BvsD; MO
MUSTARGEN
SOLUTION FOR
INJECTION 10 mg
3 BvsD; MO
mycophenolate mofetil
capsule 250 mg
2 BvsD; MO
mycophenolate mofetil
tablet 500 mg
2 BvsD; MO
MYFORTIC
TABLET,DELAYED
RELEASE 180 mg,
360 mg
4 BvsD; MO
NEORAL CAPSULE
100 mg, 25 mg
4 BvsD; MO
NEORAL ORAL
SOLN 100 mg/mL
4 BvsD; MO
NEXAVAR TABLET
200 mg
4 MO
NILANDRON
TABLET 150 mg
4 MO
NULOJIX IV
SOLUTION 250 mg
5 MO
octreotide acetate
Injection 1,000
mcg/mL, 100 mcg/mL,
200 mcg/mL, 50
mcg/mL, 500 mcg/mL
2 BvsD; MO
ONTAK IV 150
mcg/mL
5 BvsD; MO
oxaliplatin IV Soln
100 mg/20 mL
2 BvsD; MO
Drug Tier Requirements/
Limits
paclitaxel
Concentrate, IV 6
mg/mL
2 BvsD; MO
pentostatin IV
Solution 10 mg
2 BvsD; MO
PROGRAF
CAPSULE 0.5 mg, 1
mg, 5 mg
4 BvsD; MO
PROGRAF IV 5
mg/mL
4 BvsD; MO
RAPAMUNE ORAL
SOLN 1 mg/mL
4 BvsD; MO
RAPAMUNE
TABLET 0.5 mg, 1
mg, 2 mg
4 BvsD; MO
REVLIMID
CAPSULE 10 mg, 15
mg, 25 mg, 5 mg
5 MO; LA
RHEUMATREX
TABLETS IN A
DOSE PACK 2.5 mg
4 BvsD; MO
RITUXAN
CONCENTRATE, IV
10 mg/mL
3 BvsD; MO
SANDIMMUNE
CAPSULE 100 mg,
25 mg
4 BvsD; MO
SANDIMMUNE IV
250 mg/5 mL
4 BvsD; MO
SANDIMMUNE
ORAL SOLN 100
mg/mL
4 BvsD; MO
SIMULECT IV
SOLUTION 20 mg
4 BvsD; MO
SOMATULINE
DEPOT SUB-Q
SYRINGE 120 mg/0.5
mL, 90 mg/0.3 mL
4 BvsD; MO
Page 16 of 89
Drug Tier Requirements/
Limits
SPRYCEL TABLET
100 mg, 140 mg, 20
mg, 50 mg, 70 mg, 80
mg
5 MO
SUTENT CAPSULE
12.5 mg, 25 mg, 50
mg
5 MO
TABLOID TABLET
40 mg
4 MO
tacrolimus capsule 0.5
mg, 1 mg, 5 mg
2 BvsD; MO
tamoxifen tablet 10
mg, 20 mg
1 MO
TARCEVA TABLET
100 mg, 150 mg, 25
mg
5 MO
TARGRETIN
CAPSULE 75 mg
4 MO
TARGRETIN
TOPICAL GEL 1 %
4 MO
TASIGNA CAPSULE
150 mg
3 MO
TASIGNA CAPSULE
200 mg
4 MO
THALOMID
CAPSULE 100 mg,
150 mg, 200 mg, 50
mg
5 MO
thiotepa Solution for
Injection 15 mg
2 BvsD; MO
topotecan IV Solution
4 mg
2 BvsD; MO
TORISEL IV
SOLUTION 30 mg/3
mL (10 mg/mL)
(Final)
4 BvsD; MO
TREANDA IV
SOLUTION 100 mg
4 BvsD; MO
Drug Tier Requirements/
Limits
TRELSTAR IM
SYRINGE 11.25 mg/2
mL, 3.75 mg/2 mL
4 BvsD; MO
tretinoin
(chemotherapy)
capsule 10 mg
2 MO
TREXALL TABLET
10 mg, 15 mg, 5 mg,
7.5 mg
4 BvsD; MO
TRISENOX IV 10
mg/10 mL
4 BvsD; MO
TYKERB TABLET
250 mg
4 MO
VECTIBIX IV 100
mg/5 mL (20 mg/mL)
4 BvsD; MO
VELCADE
SOLUTION FOR
INJECTION 3.5 mg
4 BvsD; MO
VIDAZA SUB-Q
SOLN 100 mg
5 BvsD; MO
vinblastine IV powder
for Solution 10 mg
2 BvsD; MO
vincristine IV 1 mg/mL 2 BvsD; MO
vinorelbine IV 50
mg/5 mL
2 BvsD; MO
VOTRIENT TABLET
200 mg
5 MO
XALKORI CAPSULE
200 mg, 250 mg
5 MO
YERVOY IV 50
mg/10 mL (5 mg/mL)
5 BvsD; MO
ZANOSAR IV
SOLUTION 1 gram
4 BvsD; MO
ZELBORAF
TABLET 240 mg
5 MO
ZOLINZA CAPSULE
100 mg
5 MO
Page 17 of 89
Drug Tier Requirements/
Limits
ZORTRESS TABLET
0.25 mg
4 BvsD; MO
ZORTRESS TABLET
0.5 mg, 0.75 mg
5 BvsD; MO
ZYTIGA TABLET
250 mg
5 MO
Autonomic / Cns Drugs, Neurology / Psych
Anticonvulsants
BANZEL ORAL
SUSP 40 mg/mL
4 MO
BANZEL TABLET
200 mg, 400 mg
4 MO
carbamazepine
chewable tablet 100
mg
1 MO
carbamazepine ER
capsule,extended
release mphase12hr
100 mg, 200 mg, 300
mg
1 MO
carbamazepine Oral
Susp 100 mg/5 mL
1 MO
carbamazepine tablet
200 mg
1 MO
CARBATROL
CAPSULE,
EXTENDED
RELEASE 100 mg,
200 mg, 300 mg
4 MO
CELONTIN
CAPSULE 300 mg
4 MO
DEPAKOTE
TABLET,DELAYED
RELEASE 125 mg,
250 mg, 500 mg
4 MO
DEPAKOTE ER
TABLET,EXTENDE
D RELEASE 250 mg,
500 mg
4 MO
Drug Tier Requirements/
Limits
DEPAKOTE
SPRINKLES
CAPSULE 125 mg
4 MO
DILANTIN
CAPSULE 30 mg
4 MO
DILANTIN
INFATABS
CHEWABLE
TABLET 50 mg
4 MO
divalproex ER
tablet,extended
release 24 hr 250 mg,
500 mg
1 MO
divalproex sprinkle
capsule 125 mg
1 MO
divalproex
tablet,delayed release
125 mg, 250 mg, 500
mg
1 MO
EPITOL TABLET
200 mg
2 MO
EQUETRO
CAPSULE,
EXTENDED
RELEASE 100 mg,
200 mg, 300 mg
4 MO
ethosuximide capsule
250 mg
1 MO
ethosuximide Syrup
250 mg/5 mL
1 MO
felbamate Oral Susp
600 mg/5 mL
2 MO
felbamate tablet 400
mg, 600 mg
2 MO
FELBATOL ORAL
SUSP 600 mg/5 mL
4 MO
FELBATOL TABLET
400 mg, 600 mg
4 MO
fosphenytoin Injection
100 mg PE/2 mL
1 MO
Page 18 of 89
Drug Tier Requirements/
Limits
gabapentin capsule
100 mg, 300 mg, 400
mg
1 MO
gabapentin tablet 600
mg, 800 mg
1 MO
GABITRIL TABLET
12 mg, 16 mg, 2 mg, 4
mg
4 MO
GRALISE
TABLET,EXTENDE
D RELEASE 300 mg,
600 mg
3 MO
GRALISE 30-DAY
STARTER PACK
TABLET,EXT.
RELEASE 300 mg
(9)- 600 mg (69)
3 MO
KEPPRA ORAL
SOLN 100 mg/mL
4 MO
KEPPRA TABLET
1,000 mg, 250 mg,
500 mg, 750 mg
4 MO
KEPPRA XR
TABLET,EXTENDE
D RELEASE 500 mg,
750 mg
4 MO
LAMICTAL
TABLET 100 mg, 150
mg, 200 mg, 25 mg
4 MO
LAMICTAL
STARTER (BLUE)
KIT TABLETS IN A
DOSE PACK 25 mg
(35)
4 MO
LAMICTAL
STARTER (GREEN)
KIT TABLETS,
DOSE PACK 25 mg
(84) -100 mg (14)
4 MO
Drug Tier Requirements/
Limits
LAMICTAL
STARTER
(ORANGE) KIT
TABLETS, DOSE
PACK 25 mg (42) -
100 mg (7)
4 MO
LAMICTAL XR
TABLET,EXTENDE
D RELEASE 100 mg,
200 mg, 25 mg, 250
mg, 50 mg
4 MO
LAMICTAL XR
STARTER (BLUE)
TABLET,EXTEND
RELEASE 25 mg (21)
-50 mg (7)
4 MO
LAMICTAL XR
STARTER (GREEN)
TAB,EXT.REL 50
mg(14)-100mg (14)-
200 mg (7)
4 MO
LAMICTAL XR
STARTER
(ORANGE)
TAB,EXT.REL 25mg
(14)-50 mg (14)-
100mg (7)
4 MO
lamotrigine chewable
dispersible tablet 25
mg, 5 mg
2 MO
lamotrigine tablet 100
mg, 150 mg, 200 mg,
25 mg
2 MO
levetiracetam IV 500
mg/5 mL
2 BvsD; MO
levetiracetam ER
tablet,extended
release 24 hr 500 mg,
750 mg
2 MO
levetiracetam Oral
Soln 100 mg/mL
2 MO
Page 19 of 89
Drug Tier Requirements/
Limits
levetiracetam tablet
1,000 mg, 250 mg, 500
mg, 750 mg
2 MO
LYRICA CAPSULE
100 mg, 150 mg, 200
mg, 225 mg, 25 mg,
300 mg, 50 mg, 75 mg
3
NEURONTIN ORAL
SOLN 250 mg/5 mL
4 MO
ONFI TABLET 10
mg, 20 mg, 5 mg
4 MO
oxcarbazepine tablet
150 mg, 300 mg, 600
mg
2 MO
PEGANONE
TABLET 250 mg
3 MO
phenobarbital Elixir
20 mg/5 mL
1 MO
phenobarbital tablet
16.2 mg, 30 mg, 32.4
mg, 64.8 mg, 97.2 mg
1 MO
PHENYTEK
CAPSULE 200 mg,
300 mg
4 MO
phenytoin Oral Susp
125 mg/5 mL
1 MO
phenytoin sodium IV
50 mg/mL
3 MO
phenytoin sodium
extended capsule 100
mg
1 MO
POTIGA TABLET
200 mg, 300 mg, 400
mg, 50 mg
5 MO
primidone tablet 250
mg, 50 mg
1 MO
SABRIL ORAL
POWDER IN
PACKET 500 mg
5 MO; LA
Drug Tier Requirements/
Limits
SABRIL TABLET
500 mg
5 MO; LA
STAVZOR
CAPSULE,DELAYE
D RELEASE 125 mg,
250 mg, 500 mg
3 MO
TEGRETOL XR
TABLET,EXTENDE
D RELEASE 100 mg,
200 mg, 400 mg
3 MO
TOPAMAX
SPRINKLE
CAPSULE 15 mg, 25
mg
4 MO
TOPAMAX TABLET
100 mg, 200 mg, 25
mg, 50 mg
4 MO
topiramate sprinkle
capsule 15 mg, 25 mg
2 MO
topiramate tablet 100
mg, 200 mg, 25 mg, 50
mg
2 MO
TRILEPTAL ORAL
SUSP 300 mg/5 mL
4 MO
TRILEPTAL
TABLET 150 mg, 300
mg, 600 mg
4 MO
valproate sodium IV
500 mg/5 mL (100
mg/mL)
1 MO
valproic acid capsule
250 mg
1 MO
valproic acid (as
sodium salt) Oral Soln
250 mg/5 mL
1 MO
VIMPAT IV 200
mg/20 mL
4 MO
VIMPAT ORAL
SOLN 10 mg/mL
4 MO
Page 20 of 89
Drug Tier Requirements/
Limits
VIMPAT TABLET
100 mg, 150 mg, 200
mg, 50 mg
4 MO
zonisamide capsule
100 mg, 25 mg, 50 mg
2 MO
Antiparkinsonism Agents
APOKYN SUBQ
CARTRIDGE 10
mg/mL
4 BvsD; MO
AZILECT TABLET
0.5 mg, 1 mg
4 MO
benztropine tablet 0.5
mg, 1 mg, 2 mg
1 MO
benztropine Injection
2 mg/2 mL
3 MO
bromocriptine capsule
5 mg
2 MO
bromocriptine tablet
2.5 mg
2 MO
carbidopa-levodopa
disintegrating tablet
10-100 mg, 25-100
mg, 25-250 mg
1 MO
carbidopa-levodopa
ER tablet,extended
release 25-100 mg,
50-200 mg
1 MO
carbidopa-levodopa
tablet 10-100 mg, 25-
100 mg, 25-250 mg
1 MO
COMTAN TABLET
200 mg
4 MO
LODOSYN TABLET
25 mg
4 MO
MIRAPEX TABLET
0.125 mg, 0.25 mg,
0.5 mg, 0.75 mg, 1
mg, 1.5 mg
4 MO
Drug Tier Requirements/
Limits
MIRAPEX ER
TABLET,EXTENDE
D RELEASE 0.375
mg, 0.75 mg, 1.5 mg,
2.25 mg, 3 mg, 3.75
mg, 4.5 mg
4 MO
pramipexole tablet
0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5
mg
1 MO
ropinirole ER
tablet,extended
release 24 hr 12 mg, 2
mg, 4 mg, 6 mg, 8 mg
2 MO
ropinirole tablet 0.25
mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg, 5 mg
2 MO
selegiline capsule 5
mg
1 MO
selegiline tablet 5 mg 1 MO
STALEVO 100
TABLET 25-100-200
mg
4 MO
STALEVO 125
TABLET 31.25-125-
200 mg
4 MO
STALEVO 150
TABLET 37.5-150-
200 mg
4 MO
STALEVO 200
TABLET 50-200-200
mg
4 MO
STALEVO 50
TABLET 12.5-50-200
mg
4 MO
STALEVO 75
TABLET 18.75-75-
200 mg
4 MO
TASMAR TABLET
100 mg
4 MO
Page 21 of 89
Drug Tier Requirements/
Limits
trihexyphenidyl Elixir
0.4 mg/mL
1 MO
trihexyphenidyl tablet
2 mg, 5 mg
1 MO
ZELAPAR
DISINTEGRATING
TABLET 1.25 mg
4 MO
Migraine / Cluster Headache Therapy
dihydroergotamine
Injection 1 mg/mL
1 MO
ergotamine-caffeine
tablet 1-100 mg
1 MO
MAXALT TABLET
10 mg, 5 mg
4 MO; QL (12 EA
per 30 day(s))
MAXALT-MLT
DISINTEGRATING
TABLET 10 mg, 5 mg
4 MO; QL (12 EA
per 30 day(s))
MIGERGOT
RECTAL
SUPPOSITORY 2-
100 mg
1 MO
MIGRANAL NASAL
SPRAY 0.5 mg/pump
act. (4 mg/mL)
4 MO
sumatriptan Sub-Q 6
mg/0.5 mL
2 MO
sumatriptan Sub-Q
Pen Injector 6 mg/0.5
mL
2 MO
sumatriptan tablet 25
mg
2 MO
sumatriptan tablet 50
mg
2 MO; QL (18 EA
per 30 day(s))
sumatriptan tablet 100
mg
2 MO; QL (9 EA
per 30 day(s))
Miscellaneous Neurological Therapy
ARICEPT TABLET
10 mg, 23 mg, 5 mg
4 MO; QL (30 EA
per 30 day(s))
Drug Tier Requirements/
Limits
ARICEPT ODT
DISINTEGRATING
TABLET 10 mg, 5 mg
4 MO; QL (30 EA
per 30 day(s))
COPAXONE SUB-Q
KIT 20 mg
4 MO
donepezil
disintegrating tablet
10 mg, 5 mg
2 MO; QL (30 EA
per 30 day(s))
donepezil tablet 10
mg, 5 mg
2 MO; QL (30 EA
per 30 day(s))
EXELON ORAL
SOLN 2 mg/mL
4 MO
EXELON
TRANSDERM 24 HR
PATCH 4.6 mg/24
hour, 9.5 mg/24 hour
4 MO
EXELON CAPSULE
1.5 mg, 3 mg, 4.5 mg,
6 mg
4 MO; QL (60 EA
per 30 day(s))
galantamine Oral Soln
4 mg/mL
2 MO
galantamine tablet 12
mg, 4 mg, 8 mg
2 MO
galantamine ER 24 hr
capsule,extended
release 16 mg, 24 mg,
8 mg
2 MO; QL (30 EA
per 30 day(s))
MYTELASE
TABLET 10 mg
4 MO
NAMENDA ORAL
SOLN 10 mg/5 mL
3 MO
NAMENDA TABLET
10 mg
3 MO; QL (60 EA
per 30 day(s))
NAMENDA TABLET
5 mg
3 MO; QL (90 EA
per 30 day(s))
NAMENDA
TITRATION PAK
TABLETS IN A
DOSE PACK 5-10 mg
3 MO
Page 22 of 89
Drug Tier Requirements/
Limits
rivastigmine capsule
1.5 mg, 3 mg, 4.5 mg,
6 mg
2 MO; QL (60 EA
per 30 day(s))
TYSABRI IV 300
mg/15 mL
4 BvsD; MO; LA
XENAZINE TABLET
12.5 mg, 25 mg
5 MO; LA
Muscle Relaxants / Antispasmodic Therapy
AMRIX
CAPSULE,EXTEND
ED RELEASE 15 mg,
30 mg
4 MO
baclofen tablet 10 mg,
20 mg
1 MO
carisoprodol tablet
350 mg
1 MO
carisoprodol-ASA-
codeine tablet 200-
325-16 mg
1 MO
carisoprodol-aspirin
tablet 200-325 mg
1 MO
chlorzoxazone tablet
500 mg
1 MO
cyclobenzaprine ER
capsule,extended
release 24 hr 15 mg,
30 mg
1 MO
cyclobenzaprine tablet
10 mg, 5 mg, 7.5 mg
1 MO
dantrolene capsule
100 mg, 25 mg, 50 mg
2 MO
meprobamate tablet
200 mg, 400 mg
2 MO
MESTINON SYRUP
60 mg/5 mL
4 MO
MESTINON
TIMESPAN
TABLET,EXTENDE
D RELEASE 180 mg
4 MO
Drug Tier Requirements/
Limits
methocarbamol tablet
500 mg, 750 mg
2 MO
orphenadrine citrate
ER tablet,extended
release 100 mg
2 MO
ORPHENADRINE
COMPOUND
TABLET 25-385-30
mg
2 MO
ORPHENADRINE
COMPOUND-DS
TABLET 50-770-60
mg
2 MO
pyridostigmine
bromide tablet 60 mg
1 MO
REGONOL
INJECTION 5 mg/mL
1 MO
SKELAXIN TABLET
800 mg
4 MO
SOMA TABLET 250
mg
4 MO
tizanidine capsule 2
mg, 4 mg, 6 mg
2 MO
tizanidine tablet 2 mg,
4 mg
2 MO
ZANAFLEX
CAPSULE 2 mg, 4
mg, 6 mg
4 MO
Narcotic Analgesics
acetaminophen-
codeine Elixir 120-12
mg/5 mL
1
acetaminophen-
codeine tablet 300-15
mg, 300-30 mg, 300-
60 mg
1
ASCOMP
W/CODEINE
CAPSULE 30-50-325-
40 mg
2
Page 23 of 89
Drug Tier Requirements/
Limits
buprenorphine
sublingual tablet 8 mg
2
buprenorphine
Syringe 0.3 mg/mL
2 BvsD
buprenorphine
sublingual tablet 2 mg
2 MO
codeine-butalbital-
acetaminophen-
caffeine cap 30-50-
325-40 mg
1
codeine tablet 15 mg,
30 mg, 60 mg
1
DILAUDID-5 ORAL
LIQUID 1 mg/mL
4
DURAMORPH (PF)
INJECTION 0.5
mg/mL, 1 mg/mL
2
ENDOCET TABLET
10-325 mg, 10-650
mg, 5-325 mg, 7.5-
325 mg, 7.5-500 mg
1
fentanyl Transderm
Patch 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50
mcg/hr, 75 mcg/hr
2
fentanyl Lozenge on a
Handle 1,200 mcg,
1,600 mcg, 200 mcg,
400 mcg, 600 mcg,
800 mcg
2
hydrocodone-
acetaminophen Oral
Soln 7.5-500 mg/15
mL
1
Drug Tier Requirements/
Limits
hydrocodone-
acetaminophen tablet
10-325 mg, 10-500
mg, 10-650 mg, 10-
660 mg, 2.5-500 mg,
5-325 mg, 5-500 mg,
7.5-325 mg, 7.5-500
mg, 7.5-650 mg, 7.5-
750 mg
1
hydrocodone-
acetaminophen tablet
10-300 mg, 10-750
mg, 5-300 mg, 7.5-300
mg
2
hydrocodone-
acetaminophen Oral
Soln 7.5-325 mg/15
mL
2 MO
hydrocodone-
ibuprofen tablet 7.5-
200 mg
1
hydromorphone tablet
2 mg, 4 mg, 8 mg
1
hydromorphone (PF)
Injection 10 mg/mL
1
ibuprofen-oxycodone
tablet 400-5 mg
1
levorphanol tartrate
tablet 2 mg
2
MAGNACET
TABLET 10-400 mg,
5-400 mg, 7.5-400 mg
4
meperidine Oral Soln
50 mg/5 mL
1
meperidine tablet 100
mg, 50 mg
1
meperidine (PF)
Injection 25 mg/mL,
50 mg/mL
2
methadone Injection
10 mg/mL
1
Page 24 of 89
Drug Tier Requirements/
Limits
methadone Oral
Concentrate 10
mg/mL
1
methadone tablet 10
mg, 5 mg
1
methadone Oral Soln
10 mg/5 mL, 5 mg/5
mL
4
METHADOSE
TABLET 10 mg
1
morphine ER
tablet,extended
release 100 mg, 15
mg, 200 mg, 30 mg, 60
mg
1
morphine Oral Soln
10 mg/5 mL, 20 mg/5
mL
1
morphine tablet 15
mg, 30 mg
1
morphine ER
capsule,extended
release pellets 100
mg, 20 mg, 30 mg, 50
mg, 60 mg, 80 mg
2 MO
morphine concentrate
Oral 100 mg/5 mL (20
mg/mL)
1
OPANA TABLET 10
mg, 5 mg
4
OPANA ER
TABLET,EXTENDE
D RELEASE 10 mg,
20 mg, 30 mg, 40 mg,
5 mg
4
oxycodone capsule 5
mg
1
oxycodone Oral
Concentrate 20
mg/mL
1
Drug Tier Requirements/
Limits
oxycodone tablet 15
mg, 30 mg, 5 mg
1
oxycodone-
acetaminophen
capsule 5-500 mg
1
oxycodone-
acetaminophen tablet
10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325
mg, 7.5-500 mg
1
oxycodone-aspirin
tablet 4.8355-325 mg
2
oxymorphone tablet
10 mg, 5 mg
2
oxymorphone ER
tablet,extended
release,12 hr 15 mg,
7.5 mg
2 MO
REPREXAIN
TABLET 10-200 mg
2
REPREXAIN
TABLET 5-200 mg
3
REPREXAIN
TABLET 2.5-200 mg
3 MO
ROXICET ORAL
SOLN 5-325 mg/5 mL
3
ROXICET TABLET
5-500 mg
3
STAGESIC
CAPSULE 5-500 mg
2
Non-Narcotic Analgesics
ARTHROTEC 50
TABLET,DELAYED
RELEASE 50-200
mg-mcg
4 MO
ARTHROTEC 75
TABLET,DELAYED
RELEASE 75-200
mg-mcg
4 MO
Page 25 of 89
Drug Tier Requirements/
Limits
butorphanol tartrate
Injection 1 mg/mL, 2
mg/mL
2
butorphanol tartrate
Nasal Spray 10 mg/mL
2
CELEBREX
CAPSULE 100 mg,
200 mg, 400 mg, 50
mg
3 MO; QL (60 EA
per 30 day(s))
diclofenac potassium
tablet 50 mg
1 MO
diclofenac sodium
tablet,delayed release
75 mg
1 MO
diclofenac ER
tablet,extended
release 24 hr 100 mg
2 MO
diclofenac sodium
tablet,delayed release
25 mg, 50 mg
2 MO
diflunisal tablet 500
mg
2 MO
etodolac capsule 200
mg
2 MO
etodolac ER
tablet,extended
release 24 hr 400 mg,
500 mg, 600 mg
2 MO
etodolac tablet 400
mg, 500 mg
2 MO
fenoprofen tablet 600
mg
2 MO
flurbiprofen tablet 100
mg, 50 mg
1 MO
ibuprofen Oral Susp
100 mg/5 mL
1 MO
ibuprofen tablet 400
mg, 600 mg, 800 mg
1 MO
Drug Tier Requirements/
Limits
INDOCIN ORAL
SUSP 25 mg/5 mL
4 MO
indomethacin capsule
25 mg, 50 mg
1 MO
indomethacin ER
capsule,extended
release 75 mg
2 MO
ketoprofen capsule 50
mg, 75 mg
1 MO
ketoprofen ER 24 hr
capsule,extended
release 200 mg
2 MO
ketorolac Injection 15
mg/mL, 30 mg/mL (1
mL)
1 MO
ketorolac tablet 10 mg 1 MO; QL (20 EA
per 30 day(s))
meclofenamate
capsule 100 mg, 50
mg
2 MO
mefenamic acid
capsule 250 mg
2 MO
meloxicam Oral Susp
7.5 mg/5 mL
1 MO
meloxicam tablet 15
mg, 7.5 mg
1 MO
nabumetone tablet 500
mg, 750 mg
1 MO
nalbuphine Injection
10 mg/mL, 20 mg/mL
2
NALFON CAPSULE
200 mg, 400 mg
4 MO
naloxone Syringe 1
mg/mL
2 MO
naltrexone tablet 50
mg
2 MO
naproxen Oral Susp
125 mg/5 mL
1 MO
Page 26 of 89
Drug Tier Requirements/
Limits
naproxen tablet 250
mg, 375 mg, 500 mg
1 MO
naproxen
tablet,delayed release
375 mg, 500 mg
2 MO
naproxen sodium
tablet 275 mg, 550 mg
1 MO
oxaprozin tablet 600
mg
1 MO
pentazocine-
acetaminophen tablet
25-650 mg
2
pentazocine-naloxone
tablet 50-0.5 mg
2
piroxicam capsule 10
mg, 20 mg
1 MO
SUBOXONE
SUBLINGUAL FILM
2-0.5 mg, 8-2 mg
4
SUBOXONE
SUBLINGUAL
TABLET 2-0.5 mg, 8-
2 mg
4
sulindac tablet 150
mg, 200 mg
1 MO
TALWIN
INJECTION 30
mg/mL
4 BvsD
tolmetin capsule 400
mg
2 MO
tolmetin tablet 200
mg, 600 mg
2 MO
tramadol tablet 50 mg 1 MO
tramadol ER
tablet,extended
release 24 hr 100 mg,
200 mg
2 MO
Drug Tier Requirements/
Limits
tramadol ER
tablet,extended
release 24hr mphase
300 mg
2 MO
tramadol-
acetaminophen tablet
37.5-325 mg
2 MO
VIVITROL IM
SUSPENSION,EXTE
NDED RELEASE 380
mg
4 BvsD; MO
VOLTAREN
TOPICAL GEL 1 %
4 MO
Psychotherapeutic Drugs
ABILIFY IM 9.75
mg/1.3 mL
4 MO
ABILIFY ORAL
SOLN 1 mg/mL
4 MO
ABILIFY TABLET
10 mg, 15 mg, 2 mg,
20 mg, 30 mg, 5 mg
4 MO
ABILIFY DISCMELT
DISINTEGRATING
TABLET 10 mg, 15
mg
4 MO
ADDERALL XR
CAPSULE,EXTEND
ED RELEASE 10 mg,
15 mg, 20 mg, 25 mg,
30 mg, 5 mg
4
amitriptyline tablet 10
mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
1 MO
amitriptyline-
chlordiazepoxide
tablet 12.5-5 mg, 25-
10 mg
2 MO
amoxapine tablet 100
mg, 150 mg, 25 mg, 50
mg
2 MO
Page 27 of 89
Drug Tier Requirements/
Limits
AMPHETAMINE
SALT COMBO
TABLET 10 mg, 12.5
mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
1
APLENZIN
TABLET,EXTENDE
D RELEASE 174 mg,
348 mg, 522 mg
4 MO
BUDEPRION SR
TABLET,EXTENDE
D RELEASE 100 mg,
150 mg
2 MO
BUDEPRION XL 24
HR TABLET,
EXTENDED
RELEASE 150 mg,
300 mg
2 MO
bupropion HCl SR
tablet,extended
release 100 mg, 200
mg
1 MO
bupropion HCl tablet
100 mg, 75 mg
1 MO
bupropion HCl SR
tablet,extended
release 150 mg
2 MO
buspirone tablet 10
mg, 15 mg, 30 mg, 5
mg, 7.5 mg
1 MO
chlorpromazine
Injection 25 mg/mL
1 MO
chlorpromazine tablet
10 mg, 100 mg, 200
mg, 25 mg, 50 mg
1 MO
citalopram Oral Soln
10 mg/5 mL
2 MO
citalopram tablet 10
mg, 20 mg, 40 mg
2 MO
clomipramine capsule
25 mg, 50 mg, 75 mg
1 MO
Drug Tier Requirements/
Limits
clonazepam
disintegrating tablet
0.125 mg, 0.25 mg, 0.5
mg, 1 mg, 2 mg
1 MO
clonazepam tablet 0.5
mg, 1 mg, 2 mg
1 MO
clorazepate
dipotassium tablet 15
mg, 3.75 mg, 7.5 mg
1 MO
clozapine tablet 100
mg, 25 mg, 50 mg
1 MO
clozapine tablet 200
mg
4 MO
CLOZARIL TABLET
100 mg, 25 mg
4 MO
CONCERTA
TABLET,EXTENDE
D RELEASE 18 mg,
27 mg, 36 mg, 54 mg
4
CYMBALTA
CAPSULE,DELAYE
D RELEASE 20 mg,
30 mg, 60 mg
4 MO
desipramine tablet 10
mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
1 MO
DESOXYN TABLET
5 mg
4
dexmethylphenidate
tablet 10 mg, 2.5 mg,
5 mg
1
dextroamphetamine
tablet 10 mg, 5 mg
1
dextroamphetamine
ER capsule,extended
release 10 mg, 15 mg,
5 mg
2
diazepam Oral Soln 5
mg/5 mL
1 MO
Page 28 of 89
Drug Tier Requirements/
Limits
diazepam Rectal Kit
12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
1 MO
diazepam tablet 10
mg, 2 mg, 5 mg
1 MO
DIAZEPAM
INTENSOL ORAL
CONCENTRATE 5
mg/mL
1 MO
doxepin capsule 10
mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
1 MO
doxepin Oral
Concentrate 10
mg/mL
1 MO
EFFEXOR XR
CAPSULE,EXTEND
ED RELEASE 150
mg, 37.5 mg, 75 mg
4 MO
EMSAM
TRANSDERM 24 HR
PATCH 12 mg/24 hr,
6 mg/24 hr, 9 mg/24
hr
4 MO
ergoloid tablet 1 mg 2 MO
escitalopram Oral
Soln 5 mg/5 mL
2 MO
escitalopram tablet 10
mg, 20 mg, 5 mg
2 MO
FANAPT TABLET 1
mg, 10 mg, 12 mg, 2
mg, 4 mg, 6 mg, 8 mg
4 MO
FANAPT TABLETS
IN A DOSE PACK
1mg(2)-2mg(2)-
4mg(2)-6mg(2)
4 MO
FAZACLO
DISINTEGRATING
TABLET 100 mg,
12.5 mg, 150 mg, 200
mg, 25 mg
4 MO
Drug Tier Requirements/
Limits
fluoxetine capsule 10
mg, 20 mg, 40 mg
2 MO
fluoxetine
capsule,delayed
release 90 mg
2 MO
fluoxetine Oral Soln
20 mg/5 mL
2 MO
fluoxetine tablet 10
mg, 20 mg
2 MO
fluphenazine
decanoate Injection 25
mg/mL
2 MO
fluphenazine Elixir 2.5
mg/5 mL
1 MO
fluphenazine Injection
2.5 mg/mL
1 MO
fluphenazine Oral
Concentrate 5 mg/mL
1 MO
fluphenazine tablet 1
mg, 10 mg, 2.5 mg, 5
mg
1 MO
fluvoxamine tablet 100
mg, 25 mg, 50 mg
2 MO
FOCALIN TABLET
10 mg, 2.5 mg, 5 mg
3
FOCALIN XR
CAPSULE,EXTEND
ED RELEASE 10 mg,
15 mg, 20 mg, 30 mg,
40 mg, 5 mg
4
FOCALIN XR
CAPSULE,EXTEND
ED RELEASE 25 mg,
35 mg
4 MO
GEODON IM 20 mg 4 BvsD; MO
GEODON CAPSULE
20 mg, 40 mg, 60 mg,
80 mg
4 MO
Page 29 of 89
Drug Tier Requirements/
Limits
HALDOL
INJECTION 5 mg/mL
4 MO
HALDOL
DECANOATE IM
100 mg/mL, 50
mg/mL
4 MO
haloperidol tablet 0.5
mg, 1 mg, 10 mg, 2
mg, 20 mg, 5 mg
1 MO
haloperidol decanoate
IM 100 mg/mL, 50
mg/mL
2 MO
haloperidol Injection
5 mg/mL
1 MO
haloperidol Oral
Concentrate 2 mg/mL
1 MO
imipramine tablet 10
mg, 25 mg, 50 mg
1 MO
imipramine pamoate
capsule 100 mg, 125
mg, 150 mg, 75 mg
2 MO
INTUNIV ER
TABLET,EXTENDE
D RELEASE 1 mg, 2
mg, 3 mg, 4 mg
4 MO
INVEGA
TABLET,EXTENDE
D RELEASE 1.5 mg,
3 mg, 6 mg, 9 mg
4 MO
INVEGA
SUSTENNA IM
SYRINGE 39 mg/0.25
mL, 78 mg/0.5 mL
4 BvsD; MO
INVEGA
SUSTENNA IM
SYRINGE 117
mg/0.75 mL, 156
mg/mL (1 mL), 234
mg/1.5 mL
5 BvsD; MO
LATUDA TABLET
20 mg, 40 mg, 80 mg
4 MO
Drug Tier Requirements/
Limits
LEXAPRO ORAL
SOLN 5 mg/5 mL
4 MO
LEXAPRO TABLET
10 mg, 20 mg, 5 mg
4 MO
lithium carbonate
capsule 150 mg, 300
mg
1 MO
lithium carbonate ER
tablet,extended
release 300 mg, 450
mg
1 MO
lithium carbonate
tablet 300 mg
1 MO
lithium carbonate
capsule 600 mg
3 MO
lithium citrate Oral
Soln 8 mEq/5 mL
1 MO
loxapine capsule 10
mg, 25 mg, 5 mg, 50
mg
1 MO
LUNESTA TABLET
1 mg, 2 mg, 3 mg
4 PA
LUVOX CR
CAPSULE,EXTEND
ED RELEASE 100
mg, 150 mg
4 MO
maprotiline tablet 25
mg, 50 mg, 75 mg
1 MO
MARPLAN TABLET
10 mg
4 MO
METADATE CD
CAPSULE,EXTEND
ED RELEASE 10 mg,
20 mg, 30 mg, 40 mg,
50 mg, 60 mg
4
METADATE ER
TABLET,EXTENDE
D RELEASE 20 mg
2
methamphetamine
tablet 5 mg
2
Page 30 of 89
Drug Tier Requirements/
Limits
METHYLIN
CHEWABLE
TABLET 10 mg, 2.5
mg, 5 mg
3
METHYLIN ORAL
SOLN 10 mg/5 mL, 5
mg/5 mL
3
methylphenidate ER
tablet,extended
release 20 mg
1
methylphenidate Oral
Soln 5 mg/5 mL
1
methylphenidate tablet
10 mg, 20 mg, 5 mg
1
methylphenidate ER
capsule,extended
release multiphase 50-
50 20 mg, 30 mg, 40
mg
1 MO
mirtazapine
disintegrating tablet
15 mg, 30 mg, 45 mg
2 MO
mirtazapine tablet 15
mg, 30 mg, 45 mg, 7.5
mg
2 MO
NARDIL TABLET 15
mg
4 MO
nefazodone tablet 100
mg, 150 mg, 200 mg,
250 mg, 50 mg
1 MO
nortriptyline capsule
10 mg, 25 mg, 50 mg,
75 mg
1 MO
olanzapine
disintegrating tablet
10 mg, 15 mg, 20 mg,
5 mg
2 MO
olanzapine IM 10 mg 2 MO
Drug Tier Requirements/
Limits
olanzapine tablet 10
mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg
2 MO
ORAP TABLET 1
mg, 2 mg
4 MO
paroxetine ER
tablet,extended
release 24 hr 12.5 mg
1 MO
paroxetine ER
tablet,extended
release 24 hr 25 mg,
37.5 mg
2 MO
paroxetine tablet 10
mg, 20 mg, 30 mg, 40
mg
2 MO
PAXIL ORAL SUSP
10 mg/5 mL
3 MO
perphenazine tablet 16
mg, 2 mg, 4 mg, 8 mg
1 MO
perphenazine-
amitriptyline tablet 2-
10 mg, 2-25 mg, 4-10
mg, 4-25 mg, 4-50 mg
1 MO
PEXEVA TABLET
10 mg, 20 mg, 30 mg,
40 mg
4 MO
phenelzine tablet 15
mg
2 MO
PRISTIQ
TABLET,EXTENDE
D RELEASE 100 mg,
50 mg
4 MO
protriptyline tablet 10
mg, 5 mg
2 MO
PROVIGIL TABLET
100 mg, 200 mg
3
PROZAC WEEKLY
CAPSULE,DELAYE
D RELEASE 90 mg
4 MO
Page 31 of 89
Drug Tier Requirements/
Limits
quetiapine tablet 100
mg, 200 mg, 25 mg,
300 mg, 400 mg, 50
mg
2 MO
RISPERDAL
CONSTA IM
SYRINGE 12.5 mg/2
mL, 25 mg/2 mL, 37.5
mg/2 mL, 50 mg/2 mL
4 BvsD; MO
RISPERDAL M-TAB
DISINTEGRATING
TABLET 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
4 MO
risperidone
disintegrating tablet
0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg
2 MO
risperidone Oral Soln
1 mg/mL
2 MO
risperidone tablet 0.25
mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
2 MO
risperidone
disintegrating tablet
0.25 mg
3 MO
ROZEREM TABLET
8 mg
4 PA; MO
SAPHRIS
SUBLINGUAL
TABLET 10 mg, 5 mg
4 MO
SARAFEM TABLET
10 mg, 20 mg
4 MO
SEROQUEL
TABLET 100 mg, 200
mg, 25 mg, 300 mg,
400 mg, 50 mg
4 MO
SEROQUEL XR
TABLET,EXTENDE
D RELEASE 150 mg,
200 mg, 300 mg, 400
mg, 50 mg
4 MO
Drug Tier Requirements/
Limits
sertraline Oral
Concentrate 20
mg/mL
2 MO
sertraline tablet 100
mg, 25 mg, 50 mg
2 MO
STRATTERA
CAPSULE 10 mg,
100 mg, 18 mg, 25
mg, 40 mg, 60 mg, 80
mg
4 MO
SURMONTIL
CAPSULE 100 mg
4 MO
SYMBYAX
CAPSULE 12-25 mg,
12-50 mg, 3-25 mg, 6-
25 mg, 6-50 mg
4 MO
thioridazine tablet 10
mg, 100 mg, 25 mg, 50
mg
1 MO
thiothixene capsule 1
mg, 10 mg, 2 mg, 5 mg
1 MO
TOFRANIL-PM
CAPSULE 100 mg,
125 mg, 150 mg, 75
mg
4 MO
tranylcypromine tablet
10 mg
1 MO
trazodone tablet 100
mg, 150 mg, 300 mg,
50 mg
1 MO
trifluoperazine tablet
1 mg, 10 mg, 2 mg, 5
mg
1 MO
trimipramine capsule
100 mg, 25 mg, 50 mg
2 MO
venlafaxine tablet 100
mg, 25 mg, 37.5 mg,
50 mg, 75 mg
1 MO
Page 32 of 89
Drug Tier Requirements/
Limits
venlafaxine ER
capsule,extended
release 24 hr 150 mg,
37.5 mg, 75 mg
2 MO
venlafaxine ER
tablet,24 hr extended
release 150 mg, 225
mg, 37.5 mg, 75 mg
4 MO
VIIBRYD TABLET
10 mg, 20 mg, 40 mg
4 MO
VIIBRYD TABLETS
IN A DOSE PACK 10
mg (7)-20 mg (7)-40
mg (16)
4 MO
VYVANSE
CAPSULE 20 mg, 30
mg, 40 mg, 50 mg, 60
mg, 70 mg
4
XYREM ORAL
SOLN 500 mg/mL
4 LA
zaleplon capsule 10
mg, 5 mg
2
ziprasidone capsule
20 mg, 40 mg, 60 mg,
80 mg
2 MO
zolpidem ER
tablet,extended
release,multiphase
12.5 mg, 6.25 mg
2
zolpidem tablet 10 mg,
5 mg
2
ZYPREXA IM 10 mg 4 MO
ZYPREXA TABLET
10 mg, 15 mg, 2.5 mg,
20 mg, 5 mg, 7.5 mg
4 MO
ZYPREXA ZYDIS
DISINTEGRATING
TABLET 10 mg, 15
mg, 20 mg, 5 mg
4 MO
Cardiovascular, Hypertension / Lipids
Drug Tier Requirements/
Limits
Antiarrhythmic Agents
amiodarone IV 50
mg/mL
1 MO
amiodarone tablet 200
mg, 400 mg
1 MO
disopyramide capsule
100 mg, 150 mg
1 MO
flecainide tablet 100
mg, 150 mg, 50 mg
2 MO
mexiletine capsule 150
mg, 200 mg, 250 mg
1 MO
MULTAQ TABLET
400 mg
4 MO; QL (60 EA
per 30 day(s))
PACERONE
TABLET 200 mg
2 MO
PACERONE
TABLET 100 mg
4 MO
procainamide
Injection 100 mg/mL,
500 mg/mL
1 MO
propafenone ER
capsule,extended
release 12 hr 225 mg,
325 mg, 425 mg
2 MO
propafenone tablet
150 mg, 225 mg, 300
mg
2 MO
quinidine ER
tablet,extended
release 324 mg
1 MO
quinidine Injection 80
mg/mL
3 MO
quinidine sulfate ER
tablet,extended
release 300 mg
1 MO
quinidine tablet 200
mg, 300 mg
1 MO
Page 33 of 89
Drug Tier Requirements/
Limits
SORINE TABLET
120 mg, 160 mg, 240
mg, 80 mg
2 MO
sotalol tablet 120 mg,
160 mg, 240 mg, 80
mg
1 MO
TIKOSYN CAPSULE
125 mcg, 250 mcg,
500 mcg
4 MO
Antihypertensive Therapy
acebutolol capsule
200 mg, 400 mg
1 MO
ADCIRCA TABLET
20 mg
3 MO
AFEDITAB CR
TABLET,EXTENDE
D RELEASE 30 mg,
60 mg
1 MO
ALDACTAZIDE
TABLET 50-50 mg
4 MO
amiloride tablet 5 mg 1 MO
amiloride-
hydrochlorothiazide
tablet 5-50 mg
1 MO
amlodipine tablet 10
mg, 2.5 mg, 5 mg
1 MO
amlodipine-benazepril
capsule 10-20 mg, 10-
40 mg, 2.5-10 mg, 5-
10 mg, 5-20 mg, 5-40
mg
2 MO
atenolol tablet 100
mg, 25 mg, 50 mg
1 MO
atenolol-
chlorthalidone tablet
100-25 mg, 50-25 mg
1 MO
AZOR TABLET 10-
20 mg, 10-40 mg, 5-
20 mg, 5-40 mg
4 MO
Drug Tier Requirements/
Limits
benazepril tablet 10
mg, 20 mg, 40 mg, 5
mg
1 MO
benazepril-
hydrochlorothiazide
tablet 10-12.5 mg, 20-
12.5 mg, 20-25 mg, 5-
6.25 mg
1 MO
betaxolol tablet 20 mg 1 MO
bisoprolol fumarate
tablet 10 mg, 5 mg
1 MO
bisoprolol-
hydrochlorothiazide
tablet 10-6.25 mg, 2.5-
6.25 mg, 5-6.25 mg
1 MO
bumetanide Injection
0.25 mg/mL
1 MO
bumetanide tablet 0.5
mg, 1 mg, 2 mg
1 MO
BYSTOLIC TABLET
10 mg, 2.5 mg, 20 mg,
5 mg
4 MO
captopril tablet 100
mg, 12.5 mg, 25 mg,
50 mg
1 MO
captopril-
hydrochlorothiazide
tablet 25-15 mg, 25-25
mg, 50-15 mg, 50-25
mg
1 MO
CARDURA XL
TABLET,EXTENDE
D RELEASE 4 mg, 8
mg
4 MO; QL (60 EA
per 30 day(s))
CARTIA XT
CAPSULE,EXTEND
ED RELEASE 120
mg, 180 mg, 240 mg,
300 mg
1 MO
Page 34 of 89
Drug Tier Requirements/
Limits
carvedilol tablet 12.5
mg, 25 mg, 3.125 mg,
6.25 mg
1 MO
chlorothiazide tablet
250 mg, 500 mg
1 MO
chlorothiazide sodium
IV Solution 500 mg
1 BvsD; MO
chlorthalidone tablet
25 mg, 50 mg
1 MO
clonidine tablet 0.1
mg, 0.2 mg, 0.3 mg
1 MO
clonidine Weekly
Transderm Patch 0.1
mg/24 hr, 0.2 mg/24
hr, 0.3 mg/24 hr
1 MO
CLORPRES TABLET
0.1-15 mg, 0.2-15 mg,
0.3-15 mg
4 MO
COREG CR
CAPSULE,
EXTENDED
RELEASE 10 mg, 20
mg, 40 mg, 80 mg
4 MO
COZAAR TABLET
100 mg
4 ST; MO; QL (30
EA per 30 day(s))
COZAAR TABLET
25 mg, 50 mg
4 ST; MO; QL (60
EA per 30 day(s))
DEMSER CAPSULE
250 mg
4 MO
DIBENZYLINE
CAPSULE 10 mg
4 MO
DILT-CD
CAPSULE,EXTEND
ED RELEASE 120
mg, 300 mg
1 MO
diltiazem CD
capsule,extended
release 24 hr 120 mg,
240 mg, 300 mg
1 MO
Drug Tier Requirements/
Limits
diltiazem ER
capsule,extended
release 180 mg, 360
mg
1 MO
diltiazem ER
capsule,extended
release 12 hr 120 mg,
60 mg, 90 mg
1 MO
diltiazem IV 5 mg/mL 1 MO
diltiazem tablet 120
mg, 30 mg, 60 mg, 90
mg
1 MO
diltiazem IV powder
for Solution 100 mg
3 MO
DILT-XR CAPSULE,
EXTENDED
RELEASE 180 mg,
240 mg
1 MO
DIOVAN TABLET
320 mg
4 ST; MO; QL (30
EA per 30 day(s))
DIOVAN TABLET
160 mg, 40 mg, 80 mg
4 ST; MO; QL (60
EA per 30 day(s))
DIOVAN HCT
TABLET 160-12.5
mg, 160-25 mg, 320-
12.5 mg, 320-25 mg,
80-12.5 mg
4 ST; MO; QL (30
EA per 30 day(s))
DIURIL ORAL SUSP
250 mg/5 mL
4 MO
DIURIL IV
SOLUTION 500 mg
4 BvsD; MO
doxazosin tablet 1 mg,
2 mg, 4 mg, 8 mg
1 MO; QL (60 EA
per 30 day(s))
DYNACIRC CR
TABLET,EXTENDE
D RELEASE 10 mg, 5
mg
4 MO
DYRENIUM
CAPSULE 100 mg,
50 mg
4 MO
Page 35 of 89
Drug Tier Requirements/
Limits
EDARBI TABLET 40
mg, 80 mg
3 ST; MO
EDARBYCLOR
TABLET 40-12.5 mg,
40-25 mg
3 MO
EDECRIN TABLET
25 mg
4 MO
enalapril maleate
tablet 10 mg, 2.5 mg,
20 mg, 5 mg
1 MO
enalapril-
hydrochlorothiazide
tablet 10-25 mg, 5-
12.5 mg
1 MO
eplerenone tablet 25
mg, 50 mg
2 MO
eprosartan tablet 600
mg
2 MO
EXFORGE TABLET
10-160 mg, 10-320
mg, 5-160 mg, 5-320
mg
4 MO
EXFORGE HCT
TABLET 10-160-12.5
mg, 10-160-25 mg,
10-320-25 mg, 5-160-
12.5 mg, 5-160-25 mg
4 MO
felodipine ER
tablet,extended
release 24 hr 10 mg,
2.5 mg, 5 mg
1 MO
fosinopril tablet 10
mg, 20 mg, 40 mg
1 MO
fosinopril-
hydrochlorothiazide
tablet 10-12.5 mg, 20-
12.5 mg
1 MO
furosemide Injection
10 mg/mL
1 MO
Drug Tier Requirements/
Limits
furosemide Oral Soln
10 mg/mL
1 MO
furosemide tablet 20
mg, 40 mg, 80 mg
1 MO
furosemide Oral Soln
40 mg/5 mL
3 MO
guanfacine tablet 1
mg, 2 mg
1 MO
hydralazine Injection
20 mg/mL
1 MO
hydralazine tablet 10
mg, 100 mg, 25 mg, 50
mg
1 MO
hydrochlorothiazide
capsule 12.5 mg
1 MO
hydrochlorothiazide
tablet 12.5 mg, 25 mg,
50 mg
1 MO
HYZAAR TABLET
100-12.5 mg, 100-25
mg, 50-12.5 mg
4 ST; MO; QL (30
EA per 30 day(s))
indapamide tablet
1.25 mg, 2.5 mg
1 MO
irbesartan tablet 150
mg, 300 mg, 75 mg
2 MO
irbesartan-
hydrochlorothiazide
tablet 150-12.5 mg,
300-12.5 mg
2 MO
isradipine capsule 2.5
mg, 5 mg
2 MO
labetalol IV 5 mg/mL 1 MO
labetalol tablet 100
mg, 200 mg, 300 mg
1 MO
LEVATOL TABLET
20 mg
4 MO
lisinopril tablet 10 mg,
2.5 mg, 20 mg, 30 mg,
40 mg, 5 mg
1 MO
Page 36 of 89
Drug Tier Requirements/
Limits
lisinopril-
hydrochlorothiazide
tablet 10-12.5 mg, 20-
12.5 mg, 20-25 mg
1 MO
losartan tablet 100
mg, 25 mg, 50 mg
1 MO
losartan-
hydrochlorothiazide
tablet 100-12.5 mg,
100-25 mg, 50-12.5
mg
1 MO
methyclothiazide
tablet 5 mg
1 MO
methyldopa tablet 250
mg, 500 mg
1 MO
methyldopa-
hydrochlorothiazide
tablet 250-15 mg, 250-
25 mg
1 MO
methyldopate IV 250
mg/5 mL
1 MO
metolazone tablet 10
mg, 2.5 mg, 5 mg
1 MO
metoprolol succinate
ER tablet,extended
release 24 hr 100 mg,
200 mg, 25 mg, 50 mg
2 MO
metoprolol tartrate-
hydrochlorothiazide
tablet 100-25 mg, 100-
50 mg, 50-25 mg
1 MO
metoprolol IV 5 mg/5
mL
1 BvsD; MO
metoprolol tartrate
tablet 100 mg, 25 mg,
50 mg
1 MO
MICARDIS TABLET
20 mg, 40 mg, 80 mg
3 ST; MO
Drug Tier Requirements/
Limits
MICARDIS HCT
TABLET 40-12.5 mg,
80-12.5 mg, 80-25 mg
3 ST; MO
minoxidil tablet 10
mg, 2.5 mg
2 MO
moexipril tablet 15
mg, 7.5 mg
2 MO
moexipril-
hydrochlorothiazide
tablet 15-12.5 mg, 15-
25 mg, 7.5-12.5 mg
2 MO
nadolol tablet 20 mg,
40 mg, 80 mg
2 MO
nadolol-
bendroflumethiazide
tablet 40-5 mg, 80-5
mg
2 MO
nicardipine capsule 20
mg, 30 mg
1 MO
NIFEDIAC CC
TABLET,EXTENDE
D RELEASE 90 mg
1 MO
NIFEDICAL XL
TABLET,EXTENDE
D RELEASE 30 mg,
60 mg
1 MO
nifedipine capsule 10
mg, 20 mg
1 MO
nifedipine ER
tablet,24 hr extended
release 30 mg, 60 mg,
90 mg
1 MO
nimodipine capsule 30
mg
2 MO
nisoldipine ER
tablet,extended
release 24 hr 20 mg,
30 mg, 40 mg
2 MO
pindolol tablet 10 mg,
5 mg
2 MO
Page 37 of 89
Drug Tier Requirements/
Limits
prazosin capsule 2
mg, 5 mg
1 MO; QL (120 EA
per 30 day(s))
prazosin capsule 1 mg 1 MO; QL (90 EA
per 30 day(s))
propranolol ER
capsule,24
hr,extended release
120 mg, 160 mg, 60
mg, 80 mg
1 MO
propranolol IV 1
mg/mL
1 MO
propranolol Oral Soln
20 mg/5 mL, 40 mg/5
mL
1 MO
propranolol tablet 10
mg, 20 mg, 40 mg, 60
mg, 80 mg
1 MO
propranolol-
hydrochlorothiazide
tablet 40-25 mg, 80-25
mg
1 MO
quinapril tablet 10
mg, 20 mg, 40 mg, 5
mg
1 MO
quinapril-
hydrochlorothiazide
tablet 10-12.5 mg, 20-
12.5 mg, 20-25 mg
1 MO
ramipril capsule 1.25
mg
1 MO
ramipril capsule 10
mg, 2.5 mg, 5 mg
2 MO
REMODULIN
INJECTION 1
mg/mL, 10 mg/mL,
2.5 mg/mL, 5 mg/mL
4 BvsD; MO
reserpine tablet 0.1
mg, 0.25 mg
1 MO
spironolactone tablet
100 mg, 25 mg, 50 mg
1 MO
Drug Tier Requirements/
Limits
spironolactone-
hydrochlorothiazide
tablet 25-25 mg
1 MO
SULAR
TABLET,EXTENDE
D RELEASE 34 mg,
8.5 mg
4 MO
TAZTIA XT
CAPSULE,EXTEND
ED RELEASE 120
mg, 180 mg, 240 mg,
300 mg, 360 mg
1 MO
TEKTURNA
TABLET 150 mg, 300
mg
4 MO
TEKTURNA HCT
TABLET 150-12.5
mg, 150-25 mg, 300-
12.5 mg, 300-25 mg
4 MO
terazosin capsule 1
mg, 10 mg, 2 mg, 5 mg
1 MO
THALITONE
TABLET 15 mg
4 MO
timolol tablet 10 mg,
20 mg, 5 mg
1 MO
torsemide tablet 10
mg, 100 mg, 20 mg, 5
mg
1 MO
torsemide IV 20 mg/2
mL (10 mg/mL)
4 MO
trandolapril tablet 1
mg, 2 mg, 4 mg
1 MO
triamterene-
hydrochlorothiazide
capsule 37.5-25 mg,
50-25 mg
1 MO
triamterene-
hydrochlorothiazide
tablet 37.5-25 mg, 75-
50 mg
1 MO
Page 38 of 89
Drug Tier Requirements/
Limits
verapamil ER (PM)
capsule 24hr pellet
CT,ext.release 100
mg, 200 mg, 300 mg
1 MO
verapamil ER (SR)
tablet,extended
release 120 mg, 180
mg, 240 mg
1 MO
verapamil ER 24 hr
capsule,extended
release 120 mg, 180
mg, 240 mg
1 MO
verapamil IV 2.5
mg/mL
1 MO
verapamil tablet 120
mg, 40 mg, 80 mg
1 MO
Cardiac Glycosides
digoxin Injection 250
mcg/mL
1 MO
digoxin Oral Soln 50
mcg/mL
1 MO
digoxin tablet 125
mcg, 250 mcg
1 MO
LANOXIN
PEDIATRIC
INJECTION 100
mcg/mL
4 BvsD; MO
Coagulation Therapy
AGGRENOX
CAPSULE,
EXTENDED
RELEASE 200-25 mg
4 MO; QL (60 EA
per 30 day(s))
ARIXTRA SUB-Q
SYRINGE 10 mg/0.8
mL, 2.5 mg/0.5 mL, 5
mg/0.4 mL, 7.5
mg/0.6 mL
4 BvsD; MO
cilostazol tablet 100
mg, 50 mg
2 MO
Drug Tier Requirements/
Limits
clopidogrel tablet 300
mg
2 MO
clopidogrel tablet 75
mg
2 MO; QL (30 per
30 Day(s))
CYKLOKAPRON IV
100 mg/mL
3 MO
dipyridamole tablet 25
mg, 50 mg, 75 mg
2 MO
enoxaparin Sub-Q
Syringe 100 mg/mL,
120 mg/0.8 mL, 150
mg/mL, 30 mg/0.3 mL,
40 mg/0.4 mL, 60
mg/0.6 mL, 80 mg/0.8
mL
2 BvsD; MO
fondaparinux Sub-Q
Syringe 10 mg/0.8 mL,
2.5 mg/0.5 mL, 5
mg/0.4 mL, 7.5 mg/0.6
mL
1 BvsD; MO
FRAGMIN SUB-Q
25,000 unit/mL
4 BvsD; MO
FRAGMIN SUB-Q
SYRINGE 10,000
unit/mL, 12,500
unit/0.5 mL, 15,000
unit/0.6 mL, 18,000
unit/0.72 mL, 2,500
unit/0.2 mL, 5,000
unit/0.2 mL, 7,500
unit/0.3 mL
4 BvsD; MO
heparin (porcine)
Injection 1,000
unit/mL, 10,000
unit/mL, 20,000
unit/mL, 5,000
unit/mL
2 MO
heparin (porcine) in
D5W IV 20,000
unit/500 mL
2 BvsD; MO
Page 39 of 89
Drug Tier Requirements/
Limits
heparin (porcine) in
0.9 % NaCl (PF) IV
2,000 unit/1,000 mL
2 MO
heparin (porcine) in
0.45 % NaCl IV
25,000 unit/250 mL,
25,000 unit/500 mL
3 MO
JANTOVEN
TABLET 1 mg, 10
mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg,
7.5 mg
2 MO
LOVENOX SUB-Q
300 mg/3 mL
4 BvsD; MO
LOVENOX SUB-Q
SYRINGE 100
mg/mL, 120 mg/0.8
mL, 150 mg/mL, 30
mg/0.3 mL, 40 mg/0.4
mL, 60 mg/0.6 mL, 80
mg/0.8 mL
4 BvsD; MO
pentoxifylline ER
tablet,extended
release 400 mg
1 MO
PLAVIX TABLET
300 mg
3 MO
PLAVIX TABLET 75
mg
3 MO; QL (30 EA
per 30 day(s))
PRADAXA
CAPSULE 150 mg,
75 mg
4 MO
PROMACTA
TABLET 12.5 mg, 25
mg, 50 mg, 75 mg
5 MO
ticlopidine tablet 250
mg
1 MO
warfarin tablet 1 mg,
10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg,
7.5 mg
1 MO
Direct Renin Inhibitors
Drug Tier Requirements/
Limits
AMTURNIDE
TABLET 150-5-12.5
mg, 300-10-12.5 mg,
300-10-25 mg, 300-5-
12.5 mg, 300-5-25 mg
4 MO; QL (30 EA
per 30 day(s))
Lipid/Cholesterol Lowering Agents
ADVICOR
TABLET,EXTENDE
D RELEASE 1,000-20
mg, 1,000-40 mg,
500-20 mg, 750-20
mg
4 MO
atorvastatin tablet 10
mg, 20 mg, 40 mg, 80
mg
2 ST; MO
CADUET 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
4 MO; QL (30 EA
per 30 day(s))
CHOLESTYRAMINE
LIGHT PACKET 4
gram
2 MO
colestipol Oral
Granules 5 gram
2 MO
colestipol tablet 1
gram
2 MO
CRESTOR TABLET
10 mg, 20 mg, 40 mg,
5 mg
4 ST; MO
fenofibrate tablet 160
mg, 54 mg
1 MO
fenofibrate micronized
capsule 134 mg, 200
mg, 67 mg
2 MO
FIBRICOR TABLET
105 mg, 35 mg
3 MO
fluvastatin capsule 20
mg, 40 mg
2 MO
Page 40 of 89
Drug Tier Requirements/
Limits
gemfibrozil tablet 600
mg
1 MO
lovastatin tablet 10
mg, 20 mg, 40 mg
1 MO
LOVAZA CAPSULE
1 gram
4 MO
NIACOR TABLET
500 mg
4 MO
NIASPAN
EXTENDED-
RELEASE
TABLET,EXTENDE
D RELEASE 1,000
mg, 500 mg, 750 mg
4 MO
pravastatin tablet 10
mg, 20 mg, 40 mg, 80
mg
1 MO
PREVALITE ORAL
POWDER 4 gram
2 MO
simvastatin tablet 10
mg, 20 mg, 40 mg, 5
mg, 80 mg
1 MO
VYTORIN 10-10
TABLET 10-10 mg
4 MO; QL (30 EA
per 30 day(s))
VYTORIN 10-20
TABLET 10-20 mg
4 MO; QL (30 EA
per 30 day(s))
VYTORIN 10-40
TABLET 10-40 mg
4 MO; QL (30 EA
per 30 day(s))
VYTORIN 10-80
TABLET 10-80 mg
4 MO; QL (30 EA
per 30 day(s))
WELCHOL ORAL
POWDER PACK 3.75
gram
4 MO
WELCHOL TABLET
625 mg
4 MO
ZETIA TABLET 10
mg
4 MO; QL (30 EA
per 30 day(s))
Miscellaneous Cardiovascular Agents
Drug Tier Requirements/
Limits
RANEXA
TABLET,EXTENDE
D RELEASE 1,000
mg, 500 mg
4 PA; MO
Nitrates
isosorbide dinitrate
ER tablet,extended
release 40 mg
1 MO
isosorbide dinitrate
sublingual tablet 2.5
mg, 5 mg
1 MO
isosorbide dinitrate
tablet 10 mg, 20 mg,
30 mg, 5 mg
1 MO
isosorbide
mononitrate ER
tablet,extended
release 24 hr 120 mg,
30 mg, 60 mg
1 MO
isosorbide
mononitrate tablet 20
mg
1 MO
MINITRAN
TRANSDERM 24 HR
PATCH 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6
mg/hr
3 MO
NITRO-BID
TRANSDERMAL
OINTMENT 2 %
2 MO
nitroglycerin IV 50
mg/10 mL (5 mg/mL)
1 MO
nitroglycerin
Transderm 24 hr
Patch 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6
mg/hr
1 MO
NITROLINGUAL
SPRAY 0.4 mg/dose
4 MO
Page 41 of 89
Drug Tier Requirements/
Limits
NITROSTAT
SUBLINGUAL
TABLET 0.3 mg, 0.4
mg, 0.6 mg
3 MO
Dermatologicals/Topical Therapy
Antipsoriatic / Antiseborrheic
AMEVIVE IM 15 mg
(0.5 mL)
4 BvsD; MO
calcipotriene
Ointment 0.005 %
2 MO
calcipotriene Topical
Soln 0.005 %
2 MO
DOVONEX
TOPICAL CREAM
0.005 %
4 MO
selenium sulfide
Topical Susp 2.5 %
1 MO
SORIATANE
CAPSULE 10 mg,
17.5 mg, 25 mg
4 MO
TACLONEX SCALP
TOPICAL SUSP
0.005-0.064 %
4 MO
Burn Therapy
silver sulfadiazine
Topical Cream 1 %
1 MO
SSD TOPICAL
CREAM 1 %
1 MO
Miscellaneous Dermatologicals
8-MOP CAPSULE 10
mg
4 MO
ALDARA TOPICAL
CREAM PACKET 5
%
4 MO
ammonium lactate
Lotion 12 %
1 MO
ammonium lactate
Topical Cream 12 %
1 MO
Drug Tier Requirements/
Limits
CARAC TOPICAL
CREAM 0.5 %
4 MO
ELIDEL TOPICAL
CREAM 1 %
4 MO
FLUOROPLEX
TOPICAL CREAM 1
%
4 MO
fluorouracil Topical
Cream 5 %
2 MO
imiquimod Topical
Cream Packet 5 %
2 MO
LACLOTION 12 % 2 MO
OXSORALEN
LOTION 1 %
4 MO
OXSORALEN
ULTRA CAPSULE
10 mg
4 MO
PANRETIN
TOPICAL GEL 0.1 %
4 MO
podofilox Topical Soln
0.5 %
2 MO
PROTOPIC
OINTMENT 0.03 %,
0.1 %
4 MO
SOLARAZE
TOPICAL GEL 3 %
4 MO
U-CORT TOPICAL
CREAM 1-10 %
4 MO
UVADEX
INJECTION 20
mcg/mL
4 BvsD; MO
VEREGEN
OINTMENT 15 %
4 MO
Therapy For Acne
ACANYA TOPICAL
GEL 1.2-2.5 %
4 MO
adapalene Topical
Cream 0.1 %
2 MO
Page 42 of 89
Drug Tier Requirements/
Limits
adapalene Topical Gel
0.1 %
2 MO
AMNESTEEM
CAPSULE 10 mg, 20
mg, 40 mg
2 MO
AVITA TOPICAL
CREAM 0.025 %
2 MO
AZELEX TOPICAL
CREAM 20 %
4 MO
CLARAVIS
CAPSULE 10 mg, 20
mg, 30 mg, 40 mg
2 MO
clindamycin Lotion 1
%
2 MO
clindamycin
phosphate Topical
Swab 1 %
2 MO
clindamycin Topical
Gel 1 %
2 MO
clindamycin Topical
Soln 1 %
2 MO
clindamycin-benzoyl
peroxide Topical Gel
1-5 %
2 MO
ERY PADS
TOPICAL SWAB 2 %
2 MO
erythromycin with
ethanol Topical Gel 2
%
2 MO
erythromycin with
ethanol Topical Soln 2
%
2 MO
erythromycin-benzoyl
peroxide Topical Gel
3-5 %
2 MO
FINACEA TOPICAL
GEL 15 %
4 MO
METROGEL
TOPICAL 1 %
4 MO
Drug Tier Requirements/
Limits
metronidazole Lotion
0.75 %
2 MO
metronidazole Topical
Cream 0.75 %
2 MO
metronidazole Topical
Gel 0.75 %
2 MO
TAZORAC TOPICAL
CREAM 0.05 %, 0.1
%
4 MO
TAZORAC TOPICAL
GEL 0.05 %, 0.1 %
4 MO
tretinoin Topical
Cream 0.025 %, 0.05
%, 0.1 %
2 MO
tretinoin Topical Gel
0.01 %, 0.025 %
2 MO
Topical Anesthetics
lidocaine Ointment 5
%
1 MO
lidocaine (PF)
Injection 10 mg/mL (1
%)
1 MO
lidocaine Injection 5
mg/mL (0.5 %)
1 MO
lidocaine Mucosal Gel
2 %
1 MO
lidocaine Mucosal
Soln 4 %
1 MO
lidocaine Mucous
Membrane Jelly in
Applicator 2 %
1 MO
lidocaine-prilocaine
Topical Cream 2.5-2.5
%
1 MO
LIDODERM
ADHESIVE PATCH
5 %(700 mg/patch)
4 MO
SYNERA PATCH 70-
70 mg
4 MO
Page 43 of 89
Drug Tier Requirements/
Limits
Topical Antibacterials
ALTABAX
OINTMENT 1 %
4 MO
BACTROBAN
TOPICAL CREAM 2
%
3 MO
CORTISPORIN
TOPICAL CREAM
3.5-10,000-0.5 mg/g-
unit/g-%
3 MO
gentamicin Ointment
0.1 %
1 MO
gentamicin Topical
Cream 0.1 %
1 MO
mupirocin Ointment 2
%
1 MO
PHISOHEX
TOPICAL LIQUID 3
%
3 MO
sulfacetamide sodium
(acne) Topical Susp
10 %
2 MO
SULFAMYLON
TOPICAL CREAM
85 mg/g
3 MO
SULFAMYLON
TOPICAL PACKET
50 gram
3 MO
Topical Antifungals
ciclopirox Topical
Cream 0.77 %
2 MO
ciclopirox Topical Gel
0.77 %
2 MO
ciclopirox Topical
Soln 8 %
2 MO
ciclopirox Topical
Susp 0.77 %
2 MO
clotrimazole Topical
Cream 1 %
1 MO
Drug Tier Requirements/
Limits
clotrimazole Topical
Soln 1 %
1 MO
clotrimazole-
betamethasone Lotion
1-0.05 %
2 MO
clotrimazole-
betamethasone
Topical Cream 1-0.05
%
2 MO
econazole Topical
Cream 1 %
1 MO
EXELDERM
TOPICAL CREAM 1
%
3 MO
EXELDERM
TOPICAL SOLN 1 %
3 MO
EXTINA TOPICAL
FOAM 2 %
3 MO
ketoconazole Shampoo
2 %
1 MO
ketoconazole Topical
Cream 2 %
1 MO
ketoconazole Topical
Foam 2 %
1 MO
NYAMYC TOPICAL
POWDER 100,000
unit/g
2 MO
nystatin Ointment
100,000 unit/g
1 MO
nystatin Topical
Cream 100,000 unit/g
1 MO
nystatin Topical
Powder 100,000 unit/g
2 MO
nystatin-triamcinolone
Ointment 100,000-0.1
unit/gram-%
1 MO
nystatin-triamcinolone
Topical Cream
100,000-0.1 unit/g-%
1 MO
Page 44 of 89
Drug Tier Requirements/
Limits
NYSTOP TOPICAL
POWDER 100,000
unit/g
2 MO
PEDI-DRI TOPICAL
POWDER 100,000
unit/g
2 MO
Topical Antivirals
DENAVIR TOPICAL
CREAM 1 %
3 MO
ZOVIRAX
OINTMENT 5 %
4 MO
ZOVIRAX TOPICAL
CREAM 5 %
4 MO
Topical Corticosteroids
ALA-CORT
TOPICAL CREAM 1
%
2 MO
ALA-SCALP
LOTION 2 %
4 MO
alclometasone
Ointment 0.05 %
1 MO
alclometasone Topical
Cream 0.05 %
1 MO
amcinonide Lotion 0.1
%
1 MO
amcinonide Ointment
0.1 %
1 MO
amcinonide Topical
Cream 0.1 %
1 MO
betamethasone
dipropionate Lotion
0.05 %
1 MO
betamethasone
dipropionate Ointment
0.05 %
1 MO
betamethasone
dipropionate Topical
Cream 0.05 %
1 MO
Drug Tier Requirements/
Limits
betamethasone
valerate Lotion 0.1 %
1 MO
betamethasone
valerate Ointment 0.1
%
1 MO
betamethasone
valerate Topical
Cream 0.1 %
1 MO
betamethasone,
augmented Lotion
0.05 %
1 MO
betamethasone,
augmented Ointment
0.05 %
1 MO
betamethasone,
augmented Topical
Cream 0.05 %
1 MO
CAPEX SHAMPOO
0.01 %
4 MO
clobetasol Lotion 0.05
%
1 MO
clobetasol Ointment
0.05 %
1 MO
clobetasol Shampoo
0.05 %
1 MO
clobetasol Topical
Foam 0.05 %
1 MO
clobetasol Topical Gel
0.05 %
1 MO
clobetasol Topical
Soln 0.05 %
1 MO
clobetasol-emollient
Topical Cream 0.05 %
1 MO
CORDRAN LOTION
0.05 %
4 MO
CORDRAN TAPE 4
mcg/cm2
4 MO
Page 45 of 89
Drug Tier Requirements/
Limits
DERMA-
SMOOTHE/FS
BODY OIL
TOPICAL 0.01 %
4 MO
DESONATE
TOPICAL GEL 0.05
%
3 MO
desonide Lotion 0.05
%
1 MO
desonide Ointment
0.05 %
1 MO
desonide Topical
Cream 0.05 %
1 MO
desoximetasone
Ointment 0.25 %
2 MO
desoximetasone
Topical Cream 0.05
%, 0.25 %
2 MO
desoximetasone
Topical Gel 0.05 %
2 MO
diflorasone Ointment
0.05 %
2 MO
diflorasone Topical
Cream 0.05 %
2 MO
fluocinolone Ointment
0.025 %
1 MO
fluocinolone Topical
Body Oil 0.01 %
1 MO
fluocinolone Topical
Cream 0.01 %, 0.025
%
1 MO
fluocinolone Topical
Soln 0.01 %
1 MO
fluocinonide Ointment
0.05 %
1 MO
fluocinonide Topical
Gel 0.05 %
1 MO
fluocinonide Topical
Soln 0.05 %
1 MO
Drug Tier Requirements/
Limits
FLUOCINONIDE-E
TOPICAL CREAM
0.05 %
1 MO
fluticasone Lotion
0.05 %
1 MO
fluticasone Ointment
0.005 %
1 MO
fluticasone Topical
Cream 0.05 %
1 MO
halobetasol
propionate Ointment
0.05 %
2 MO
halobetasol
propionate Topical
Cream 0.05 %
2 MO
HALOG OINTMENT
0.1 %
4 MO
HALOG TOPICAL
CREAM 0.1 %
4 MO
hydrocortisone Lotion
2.5 %
1 MO
hydrocortisone
Ointment 1 %, 2.5 %
1 MO
hydrocortisone
Topical Cream 1 %,
2.5 %
1 MO
hydrocortisone
valerate Ointment 0.2
%
2 MO
hydrocortisone
valerate Topical
Cream 0.2 %
2 MO
KENALOG
TOPICAL AEROSOL
0.147 mg/gram
3 MO
LOCOID LOTION
0.1 %
4 MO
mometasone Lotion
0.1 %
2 MO
Page 46 of 89
Drug Tier Requirements/
Limits
mometasone Ointment
0.1 %
2 MO
mometasone Topical
Cream 0.1 %
2 MO
prednicarbate
Ointment 0.1 %
2 MO
prednicarbate Topical
Cream 0.1 %
2 MO
triamcinolone
acetonide Lotion
0.025 %, 0.1 %
1 MO
triamcinolone
acetonide Ointment
0.025 %, 0.1 %, 0.5 %
1 MO
triamcinolone
acetonide Topical
Cream 0.025 %, 0.1
%, 0.5 %
1 MO
TRIDERM TOPICAL
CREAM 0.1 %
2 MO
Topical Enzymes
SANTYL
OINTMENT 250
unit/g
3 MO
Topical Scabicides / Pediculicides
EURAX LOTION 10
%
3 MO
EURAX TOPICAL
CREAM 10 %
3 MO
lindane Lotion 1 % 3 MO
lindane Shampoo 1 % 3 MO
malathion Lotion 0.5
%
2 MO
permethrin Topical
Cream 5 %
1 MO
Diagnostics / Miscellaneous Agents
Irrigating Solutions
Drug Tier Requirements/
Limits
lactated ringers
Irrigation Soln
2 MO
neomycin-polymyxin B
GU Irrigation Soln
40-200,000 mg-
unit/mL
2 MO
ringers Irrigation Soln 2 MO
Miscellaneous Agents
ACTONEL TABLET
30 mg
4 ST; MO; QL (30
EA per 30 day(s))
ADAGEN IM 250
unit/mL
5 BvsD; MO
alendronate tablet 40
mg
2 MO
anagrelide capsule 0.5
mg, 1 mg
2 MO
ANTABUSE
TABLET 250 mg, 500
mg
4 MO
ARALAST NP IV
SUSP 500 mg
4 BvsD; MO
BUPHENYL ORAL
POWDER
4 MO
BUPHENYL
TABLET 500 mg
4 MO
CAMPRAL
TABLET,DELAYED
RELEASE 333 mg
4 MO; QL (180 EA
per 30 day(s))
CARNITOR IV 200
mg/mL
4 BvsD; MO
CHEMET CAPSULE
100 mg
4 MO
CLINIMIX 4.25%/D5
SULFITE FREE IV
4.25 %
4 BvsD; MO
CLINIMIX E
2.75%/D10 SULFITE
FREE IV 2.75 %
4 BvsD; MO
Page 47 of 89
Drug Tier Requirements/
Limits
CLINIMIX E
2.75%/D5 SULFITE
FREE IV 2.75 %
4 BvsD; MO
dextrose 10 % and
0.45 % sodium
chloride IV
3 BvsD; MO
dextrose 2.5 % and
0.45 % sodium
chloride IV
2 BvsD; MO
dextrose 5 % and 0.9
% sodium chloride IV
2 BvsD; MO
dextrose 5 % and 0.45
% sodium chloride IV
2 BvsD; MO
dextrose 10 % and
0.225 % sodium
chloride IV
3 BvsD; MO
dextrose 10% in water
(D10W) IV Soln
2 BvsD; MO
dextrose 5% in water
(D5W) IV
2 BvsD; MO
dextrose 5% and
0.225 % sodium
chloride IV
2 BvsD; MO
dextrose 5% and 0.33
% sodium chloride IV
3 BvsD; MO
disulfiram tablet 250
mg, 500 mg
1 MO
etidronate disodium
tablet 200 mg, 400 mg
2 MO
EVOXAC CAPSULE
30 mg
4 MO
EXJADE
DISPERSIBLE
TABLET 125 mg
4 MO
EXJADE
DISPERSIBLE
TABLET 250 mg, 500
mg
5 MO
Drug Tier Requirements/
Limits
FOSRENOL
CHEWABLE
TABLET 1,000 mg,
500 mg, 750 mg
4 MO
INCRELEX SUB-Q
10 mg/mL
5 BvsD; MO
KIONEX ORAL
POWDER
2 MO
levocarnitine tablet
330 mg
2 MO
levocarnitine IV 200
mg/mL
4 BvsD; MO
levocarnitine (with
sugar) Oral Soln 100
mg/mL
2 MO
midodrine tablet 10
mg
1 MO
midodrine tablet 2.5
mg, 5 mg
2 MO
ORFADIN CAPSULE
10 mg, 2 mg, 5 mg
5 MO
pilocarpine tablet 5
mg, 7.5 mg
2 MO
PROLASTIN C IV
SUSP 1,000 mg
5 BvsD; MO
RENAGEL TABLET
400 mg, 800 mg
4 MO
RENVELA ORAL
POWDER PACKET
0.8 gram, 2.4 gram
4 MO
RENVELA TABLET
800 mg
4 MO
RILUTEK TABLET
50 mg
5 MO
SKELID TABLET
240 mg
4 MO; QL (60 EA
per 30 day(s))
sodium chloride
Irrigation Soln 0.9 %
2 MO
Page 48 of 89
Drug Tier Requirements/
Limits
sodium chloride 0.9 %
IV 0.9 %
2 BvsD; MO
SYPRINE CAPSULE
250 mg
4 MO
water for irrigation,
sterile Solution
2 MO
ZEMAIRA IV SUSP
1,000 mg
5 BvsD; MO
Smoking Deterrents
BUPROBAN
TABLET,EXTENDE
D RELEASE 150 mg
2 MO
CHANTIX TABLET
0.5 mg, 1 mg
4 PA; MO
CHANTIX
STARTING MONTH
BOX TABLETS IN
DOSE PACK 0.5
(11)-1 (42) mg
4 PA; MO
NICOTROL
INHALATION
CARTRIDGE 10 mg
3 MO
NICOTROL NS
NASAL SPRAY 10
mg/mL
3 MO
ZYBAN
TABLET,EXTENDE
D RELEASE 150 mg
4 MO
Ear, Nose / Throat Medications
Miscellaneous Agents
ASTELIN NASAL
SPRAY AEROSOL
137 mcg
3 MO
azelastine Nasal Spray
Aerosol 137 mcg
2 MO
BACTROBAN
NASAL OINTMENT
2 %
3 MO
Drug Tier Requirements/
Limits
chlorhexidine
gluconate Mouthwash
0.12 %
1 MO
ipratropium bromide
Nasal Spray 0.03 %,
0.06 %
1 MO
PATANASE NASAL
SPRAY 0.6 %
4 MO
PERIOGARD
MOUTHWASH 0.12
%
1 MO
triamcinolone
acetonide Dental
Paste 0.1 %
1 MO
TYZINE NASAL
DROPS 0.05 %, 0.1 %
3 MO
Miscellaneous Otic Preparations
ACETASOL HC EAR
DROPS 1-2 %
2 MO
acetic acid Ear Soln 2
%
1 MO
DERMOTIC OIL
EAR DROPS 0.01 %
3 MO
fluocinolone acetonide
oil Ear Drops 0.01 %
2 MO
hydrocortisone-acetic
acid Ear Drops 1-2 %
1 MO
ofloxacin Ear Drops
0.3 %
2 MO
Otic Steroid / Antibiotic
CIPRO HC EAR
DROPS, SUSP 0.2-1
%
4 MO
CIPRODEX EAR
DROPS, SUSP 0.3-0.1
%
4 MO
COLY-MYCIN S
EAR DROPS, SUSP
3.3-3-10-0.5 mg/mL
3 MO
Page 49 of 89
Drug Tier Requirements/
Limits
CORTISPORIN-TC
EAR DROPS, SUSP
3.3-3-10-0.5 mg/mL
3 MO
neomycin-polymyxin-
HC Ear Drops, Susp
3.5-10,000-1 mg-
unit/mL-%
1 MO
neomycin-polymyxin-
HC Ear Soln 3.5-
10,000-1 mg-unit/mL-
%
1 MO
Endocrine/Diabetes
Adrenal Hormones
A-HYDROCORT
SOLUTION FOR
INJECTION 100 mg
2 BvsD; MO
CELESTONE ORAL
SOLN 0.6 mg/5 mL
3 MO
cortisone tablet 25 mg 1 MO
dexamethasone Elixir
0.5 mg/5 mL
1 MO
dexamethasone tablet
0.5 mg, 0.75 mg, 1.5
mg, 4 mg, 6 mg
1 MO
dexamethasone tablet
1 mg, 2 mg
3 MO
DEXAMETHASONE
INTENSOL DROPS
(CONCENTRATE) 1
mg/mL
4 MO
dexamethasone
Injection 4 mg/mL
1 MO
DEXPAK TABLETS
IN A DOSE PACK
1.5 mg (51 tabs)
3 MO
fludrocortisone tablet
0.1 mg
1 MO
hydrocortisone tablet
10 mg, 20 mg, 5 mg
1 MO
Drug Tier Requirements/
Limits
methylprednisolone
tablet 16 mg, 32 mg, 8
mg
1 MO
methylprednisolone
tablets in a dose pack
4 mg
1 MO
methylprednisolone
acetate Susp for
Injection 40 mg/mL,
80 mg/mL
1 BvsD; MO
methylprednisolone
sodium succ IV
Solution 1,000 mg
3 BvsD; MO
MILLIPRED ORAL
SOLN 10 mg/5 mL
3 MO
ORAPRED ODT
DISINTEGRATING
TABLET 15 mg, 30
mg
4 MO
prednisolone sodium
phosphate Oral Soln
15 mg/5 mL, 5 mg
base/5 mL (6.7 mg/5
mL)
2 MO
prednisone Oral Soln
5 mg/5 mL
1 MO
prednisone tablet 1
mg, 10 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
1 MO
PREDNISONE
INTENSOL ORAL
CONCENTRATE 5
mg/mL
3 BvsD; MO
SOLU-CORTEF (PF)
SOLUTION FOR
INJECTION 100 mg/2
mL, 250 mg/2 mL
3 BvsD; MO
SOLU-MEDROL IV
SOLUTION 2 gram
3 BvsD; MO
Page 50 of 89
Drug Tier Requirements/
Limits
SOLU-MEDROL (PF)
IV SOLUTION 500
mg/4 mL
2 BvsD; MO
SOLU-MEDROL (PF)
SOLUTION FOR
INJECTION 40
mg/mL
3 BvsD; MO
VERIPRED 20 ORAL
SOLN 20 mg/5 mL
3 MO
Antithyroid Agents
methimazole tablet 10
mg, 5 mg
1 MO
propylthiouracil tablet
50 mg
1 MO
Diabetes Therapy
acarbose tablet 100
mg, 25 mg, 50 mg
2 MO
ACTOPLUS MET
TABLET 15-500 mg,
15-850 mg
3 ST; MO
ACTOPLUS MET XR
TABLET,EXTENDE
D RELEASE 15-1,000
mg, 30-1,000 mg
3 ST; MO
ACTOS TABLET 15
mg, 30 mg, 45 mg
3 ST; MO; QL (30
EA per 30 day(s))
alcohol swabs 3 MO
BYETTA SUB-Q
PEN INJECTOR 10
mcg/0.04 mL, 5
mcg/0.02 mL
4 MO
chlorpropamide tablet
100 mg, 250 mg
1 MO
CURITY GAUZE
BANDAGE 2 X 2 "
3 MO
DUETACT TABLET
30-2 mg, 30-4 mg
3 ST; MO
glimepiride tablet 1
mg, 2 mg, 4 mg
1 MO
Drug Tier Requirements/
Limits
glipizide ER tablet,24
hr extended release 10
mg, 2.5 mg, 5 mg
1 MO
glipizide tablet 10 mg,
5 mg
1 MO
glipizide-metformin
tablet 2.5-250 mg, 2.5-
500 mg, 5-500 mg
1 MO
GLUCAGEN
HYPOKIT
INJECTION 1 mg
3 MO
GLUCAGON
EMERGENCY
INJECTION KIT 1
mg
3 MO
glyburide tablet 1.25
mg, 2.5 mg, 5 mg
1 MO
glyburide micronized
tablet 1.5 mg, 3 mg, 6
mg
1 MO
glyburide-metformin
tablet 1.25-250 mg,
2.5-500 mg, 5-500 mg
1 MO
huber safety needles
(disposable) 22 x 3/4 "
3 MO
HUMALOG SUB-Q
100 unit/mL
3 MO
HUMALOG
KWIKPEN SUB-Q
PEN 100 unit/mL
4 MO
HUMALOG MIX 50-
50 SUSP, SUB-Q INJ
100 unit/mL (50-50)
3 MO
HUMALOG MIX 50-
50 KWIKPEN SUB-Q
PEN 100 unit/mL (50-
50)
4 MO
HUMALOG MIX 75-
25 SUSP, SUB-Q INJ
100 unit/mL (75-25)
3 MO
Page 51 of 89
Drug Tier Requirements/
Limits
HUMALOG MIX 75-
25 KWIKPEN SUB-Q
PEN 100 unit/mL (75-
25)
4 MO
INSULIN PEN
NEEDLE 31
3 MO
insulin syringe-needle
U-100 0.3 mL 30, 1
mL 28, 1/2 mL
3 MO
JANUMET TABLET
50-1,000 mg, 50-500
mg
4 ST; MO
JANUMET XR
TABLET,EXTENDE
D RELEASE 100-
1000 mg, 50-1,000
mg, 50-500 mg
4 ST; MO
JANUVIA TABLET
100 mg, 25 mg, 50 mg
4 ST; MO
JENTADUETO
TABLET 2.5-1,000
mg, 2.5-500 mg, 2.5-
850 mg
4 ST; MO
KOMBIGLYZE XR
TABLET,EXTENDE
D RELEASE 2.5-
1,000 mg, 5-1,000 mg,
5-500 mg
4 ST; MO
LANTUS SUB-Q 100
unit/mL
3 MO
LANTUS
SOLOSTAR SUB-Q
INSULIN PEN 100
unit/mL (3 mL)
4 MO
LEVEMIR SUB-Q
100 unit/mL
3 MO
LEVEMIR FLEXPEN
SUB-Q INSULIN
PEN 100 unit/mL (3
mL)
4 MO
Drug Tier Requirements/
Limits
metformin ER
tablet,extended
release 24 hr 500 mg,
750 mg
1 MO
metformin tablet 1,000
mg, 500 mg, 850 mg
1 MO
nateglinide tablet 120
mg, 60 mg
2 MO
NOVOLIN 70/30
SUSP, SUB-Q INJ
100 unit/mL (70-30)
3 MO
NOVOLIN N SUSP,
SUB-Q INJ 100
unit/mL
3 MO
NOVOLIN R
INJECTION 100
unit/mL
3 MO
NOVOLOG SUB-Q
100 unit/mL
3 MO
NOVOLOG
FLEXPEN SUB-Q
100 unit/mL
4 MO
NOVOLOG MIX 70-
30 SUB-Q 100
unit/mL (70-30)
3 MO
NOVOLOG MIX 70-
30 FLEXPEN SUB-Q
100 unit/mL (70-30)
4 MO
ONGLYZA TABLET
2.5 mg, 5 mg
4 ST; MO
PRANDIMET
TABLET 1-500 mg,
2-500 mg
4 MO
PRANDIN TABLET
0.5 mg, 1 mg
4 MO; QL (120 EA
per 30 day(s))
PRANDIN TABLET
2 mg
4 MO; QL (240 EA
per 30 day(s))
PROGLYCEM ORAL
SUSP 50 mg/mL
4 MO
Page 52 of 89
Drug Tier Requirements/
Limits
RIOMET ORAL
SOLN 500 mg/5 mL
3 MO
SYMLINPEN 120
SUB-Q PEN
INJECTOR 2,700
mcg/2.7 mL
4 PA; MO
SYMLINPEN 60
SUB-Q PEN
INJECTOR 1,500
mcg/1.5 mL
4 PA; MO
tolazamide tablet 250
mg, 500 mg
1 MO
tolbutamide tablet 500
mg
1 MO
TRADJENTA
TABLET 5 mg
4 ST; MO
VICTOZA SUB-Q
PEN INJECTOR 0.6
mg/0.1 mL (18 mg/3
mL)
4 MO
Miscellaneous Hormones
ALDURAZYME IV
2.9 mg/5 mL
5 BvsD; MO
ANDROGEL
TRANSDERMAL
GEL PUMP 20.25
mg/1.25 gram (1.62
%)
4
ANDROGEL
TRANSDERMAL
PACKET 1 %(50
mg/5 gram)
4
ANDROXY TABLET
10 mg
2
cabergoline tablet 0.5
mg
2 MO
calcitonin (salmon)
Nasal Spray 200
unit/actuation
2 MO
Drug Tier Requirements/
Limits
calcitriol capsule 0.25
mcg, 0.5 mcg
1 MO
calcitriol IV 1 mcg/mL 1 MO
calcitriol Oral Soln 1
mcg/mL
1 MO
CEREZYME IV
SOLUTION 200 unit
5 BvsD; MO
danazol capsule 100
mg, 200 mg, 50 mg
2 MO
desmopressin
Injection 4 mcg/mL
2 BvsD; MO
desmopressin tablet
0.1 mg, 0.2 mg
2 MO
ELAPRASE IV 6
mg/3 mL
5 BvsD; MO
FABRAZYME IV
SOLUTION 35 mg
5 BvsD; MO
FORTICAL NASAL
SPRAY 200
unit/actuation
2 MO
HECTOROL IV 4
mcg/2 mL
4 BvsD; MO
HECTOROL
CAPSULE 0.5 mcg, 1
mcg, 2.5 mcg
4 MO
KUVAN SOLUBLE
TABLET 100 mg
4 MO
METHITEST
TABLET 10 mg
4
MIACALCIN
INJECTION 200
unit/mL
3 MO
MYOZYME IV
SOLUTION 50 mg
5 BvsD; MO
NAGLAZYME IV 5
mg/5 mL
5 BvsD; MO
oxandrolone tablet 10
mg, 2.5 mg
2
Page 53 of 89
Drug Tier Requirements/
Limits
pamidronate IV 30
mg/10 mL (3 mg/mL),
90 mg/10 mL (9
mg/mL)
2 MO
pamidronate IV 60
mg/10 mL (6 mg/mL)
4 MO
SENSIPAR TABLET
30 mg
3 MO; QL (60 EA
per 30 day(s))
SENSIPAR TABLET
90 mg
5 MO; QL (120 EA
per 30 day(s))
SENSIPAR TABLET
60 mg
5 MO; QL (60 EA
per 30 day(s))
SOMAVERT SUB-Q
SOLN 10 mg, 15 mg,
20 mg
4 BvsD; MO
STIMATE NASAL
SPRAY 150
mcg/spray
4 MO
STRIANT BUCCAL
SYSTEM,SUSTAINE
D RELEASE 30 mg
4 QL (60 EA per 30
day(s))
SYNAREL NASAL
SPRAY 2 mg/mL
5 MO
TESTIM
TRANSDERMAL
GEL 50 mg/5 gram (1
%)
3
testosterone cypionate
IM Oil 100 mg/mL
2
testosterone cypionate
IM Oil 200 mg/mL
2 BvsD; MO
testosterone enanthate
IM Oil 200 mg/mL
2
TESTRED CAPSULE
10 mg
4
ZAVESCA
CAPSULE 100 mg
4 MO
Drug Tier Requirements/
Limits
ZEMPLAR IV
SOLUTION 2
mcg/mL, 5 mcg/mL
4 BvsD; MO
ZEMPLAR
CAPSULE 1 mcg, 2
mcg, 4 mcg
4 MO
ZOMETA IV 4
mg/100 mL, 4 mg/5
mL
5 BvsD; MO
Thyroid Hormones
levothyroxine tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 300
mcg, 50 mcg, 75 mcg,
88 mcg
1 MO
LEVOXYL TABLET
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
1 MO
liothyronine IV 10
mcg/mL
1 MO
liothyronine tablet 25
mcg, 5 mcg, 50 mcg
1 MO
SYNTHROID
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
3 MO
Gastroenterology
Antidiarrheals / Antispasmodics
atropine Syringe 0.1
mg/mL
1 MO
atropine Syringe 0.05
mg/mL
3 MO
Page 54 of 89
Drug Tier Requirements/
Limits
BENTYL IM 10
mg/mL
3 BvsD; MO
CANTIL TABLET 25
mg
3 MO
dicyclomine capsule
10 mg
1 MO
dicyclomine Syrup 10
mg/5 mL
1 MO
dicyclomine tablet 20
mg
1 MO
diphenoxylate-
atropine Oral Liquid
2.5-0.025 mg/5 mL
1
diphenoxylate-
atropine tablet 2.5-
0.025 mg
1
glycopyrrolate
Injection 0.2 mg/mL
2 MO
glycopyrrolate tablet 1
mg, 2 mg
2 MO
loperamide capsule 2
mg
1 MO
methscopolamine
tablet 2.5 mg, 5 mg
2 MO
MOTOFEN TABLET
1-0.025 mg
3 MO
propantheline tablet
15 mg
2 MO
Miscellaneous Gastrointestinal Agents
ALOXI IV 0.25 mg/5
mL
4 BvsD; MO
AMITIZA CAPSULE
24 mcg, 8 mcg
4 PA; MO
ANTIVERT TABLET
50 mg
3 MO
ANZEMET IV 100
mg/5 mL
4 BvsD; MO
Drug Tier Requirements/
Limits
ANZEMET TABLET
100 mg, 50 mg
4 BvsD; MO; QL
(7 EA per 30
day(s))
APRISO
CAPSULE,EXTEND
ED RELEASE 0.375
gram
4 MO
ASACOL
TABLET,DELAYED
RELEASE 400 mg
4 MO
ASACOL HD
TABLET,DELAYED
RELEASE 800 mg
4 MO
balsalazide capsule
750 mg
2 MO
budesonide DR & ER
capsule,delayed &
extended release 3 mg
2 MO
CANASA RECTAL
SUPPOSITORY
1,000 mg
4 MO
CESAMET
CAPSULE 1 mg
4 BvsD; MO
COMPRO RECTAL
SUPPOSITORY 25
mg
2 MO
CREON
CAPSULE,DELAYE
D RELEASE 12,000-
38,000 -60,000 unit,
24,000-76,000 -
120,000 unit, 3,000-
9,500- 15,000 unit,
6,000-19,000 -30,000
unit
3 MO
cromolyn Oral Soln
100 mg/5 mL
2 MO
CYSTADANE ORAL
POWDER
4 MO
DIPENTUM
CAPSULE 250 mg
4 MO
Page 55 of 89
Drug Tier Requirements/
Limits
dronabinol capsule 10
mg, 2.5 mg, 5 mg
2 BvsD
EMEND CAPSULE
40 mg
4 BvsD; MO
EMEND CAPSULE
125 mg
4 BvsD; MO; QL
(2 EA per 30
day(s))
EMEND CAPSULE
80 mg
4 BvsD; MO; QL
(4 EA per 30
day(s))
EMEND CAPSULES
IN A DOSE PACK
125-80-80 mg
4 BvsD; MO; QL
(6 EA per 30
day(s))
ENTOCORT EC
CAPSULE,DELAYE
D & EXTENDED
RELEASE 3 mg
4 MO
ENULOSE ORAL
SOLN 10 gram/15 mL
1 MO
GASTROCROM
ORAL SOLN 100
mg/5 mL
4 MO
GAVILYTE-C ORAL
SOLUTION 240-
22.72-6.72 gram
2 MO
GAVILYTE-N ORAL
SOLUTION 420 g
2 MO
GOLYTELY ORAL
SOLUTION 236-
22.74-6.74 gram
3 MO
GOLYTELY
PACKET 227.1-21.5-
6.36 gram
3 MO
granisetron IV 1
mg/mL (1 mL)
2 BvsD; MO
granisetron tablet 1
mg
2 BvsD; MO
granisetron (PF) IV
100 mcg/mL
2 BvsD; MO
Drug Tier Requirements/
Limits
GRANISOL ORAL
SOLN 1 mg/5 mL
4 BvsD; MO
hydrocortisone Enema
100 mg/60 mL
1 MO
lactulose Oral Soln 10
gram/15 mL
1 MO
LIALDA
TABLET,DELAYED
RELEASE 1.2 g
4 MO
LOTRONEX
TABLET 0.5 mg, 1
mg
3 MO; QL (60 EA
per 30 day(s))
meclizine tablet 12.5
mg, 25 mg
1 MO
mesalamine with
cleansing wipes Rectal
Kit 4 gram/60 mL
1 MO
metoclopramide
Injection 5 mg/mL
1 BvsD; MO
metoclopramide Oral
Soln 5 mg/5 mL
1 MO
metoclopramide tablet
10 mg, 5 mg
1 MO
MOVIPREP ORAL
POWDER PACKET
100-7.5-2.691 gram
3 MO
NULYTELY WITH
FLAVOR PACKS
ORAL SOLUTION
420 g
3 MO
ondansetron
disintegrating tablet 4
mg, 8 mg
2 BvsD; MO
ondansetron HCl Oral
Soln 4 mg/5 mL
2 BvsD; MO
ondansetron HCl
tablet 24 mg, 4 mg, 8
mg
2 BvsD; MO
Page 56 of 89
Drug Tier Requirements/
Limits
ondansetron HCl (PF)
Injection 4 mg/2 mL
2 BvsD; MO
OSMOPREP
TABLET 1.5 gram
4 MO
PANCREAZE
CAPSULE,DELAYE
D RELEASE 10,500-
25,000 -43,750 unit,
16,800-40,000 -70,000
unit, 21,000-37,000 -
61,000 unit, 4,200-
10,000 -17,500 unit
3 MO
PENTASA
CAPSULE,EXTEND
ED RELEASE 250
mg, 500 mg
4 MO
polyethylene glycol
3350 Oral Powder 17
gram/dose
1 MO
prochlorperazine
Rectal Suppository 25
mg
1 MO
prochlorperazine
Edisylate Injection 10
mg/2 mL (5 mg/mL)
1 MO
prochlorperazine
maleate tablet 10 mg,
5 mg
1 MO
RECTIV OINTMENT
0.4 % (w/w)
4 MO
RELISTOR SUB-Q
KIT 12 mg/0.6 mL
4 MO
REMICADE IV
SOLUTION 100 mg
5 BvsD; MO
SUCRAID ORAL
SOLN 8,500 unit/mL
5 MO
sulfasalazine tablet
500 mg
1 MO
Drug Tier Requirements/
Limits
SULFAZINE EC
TABLET,DELAYED
RELEASE 500 mg
1 MO
TRILYTE WITH
FLAVOR PACKETS
ORAL SOLUTION
420 g
2 MO
trimethobenzamide
capsule 300 mg
2 MO
URSO 250 TABLET
250 mg
4 MO
URSO FORTE
TABLET 500 mg
4 MO
ursodiol capsule 300
mg
2 MO
ursodiol tablet 250
mg, 500 mg
2 MO
ZENPEP
CAPSULE,DELAYE
D RELEASE 10,000-
34,000 -55,000 unit,
15,000-51,000 -82,000
unit, 20,000-68,000 -
109,000 unit, 25,000-
85,000- 136,000 unit,
3,000-10,000- 16,000
unit, 5,000-17,000 -
27,000 unit
3 MO
Ulcer Therapy
CARAFATE ORAL
SUSP 100 mg/mL
3 MO
cimetidine Oral Soln
300 mg/5 mL
2 MO
cimetidine tablet 200
mg, 300 mg, 400 mg,
800 mg
2 MO
cimetidine Injection
150 mg/mL
2 MO
Page 57 of 89
Drug Tier Requirements/
Limits
DEXILANT
CAPSULE,
DELAYED
RELEASE 30 mg, 60
mg
3 ST; MO
famotidine Oral Susp
40 mg/5 mL
1 MO
famotidine tablet 20
mg, 40 mg
1 MO
famotidine (PF) IV 20
mg/2 mL
1 MO
famotidine (PF) in
NaCl (iso-osmotic) IV
Piggy Back 20 mg/50
mL
2 MO
HELIDAC ORAL
PACK 250-500-262.4
mg
4 MO
lansoprazole
capsule,delayed
release 15 mg, 30 mg
2 ST; MO
misoprostol tablet 200
mcg
2 MO
nizatidine Oral Soln
150 mg/10 mL
1 MO
nizatidine capsule 150
mg, 300 mg
2 MO
omeprazole
capsule,delayed
release 10 mg, 20 mg,
40 mg
2 MO
pantoprazole
tablet,delayed release
20 mg, 40 mg
2 ST; MO
PEPCID ORAL SUSP
40 mg/5 mL
3 MO
Drug Tier Requirements/
Limits
PREVACID
SOLUTAB
DELAYED
RELEASE,DISINTE
GRATING TABLET
15 mg, 30 mg
4 MO
PREVPAC ORAL
PACK 500-500-30 mg
4 MO
PROTONIX IV
SOLUTION 40 mg
4 MO
PYLERA CAPSULE
140-125-125 mg
3 MO
ranitidine capsule 150
mg, 300 mg
1 MO
ranitidine Syrup 15
mg/mL
1 MO
ranitidine tablet 150
mg, 300 mg
1 MO
ranitidine Injection 25
mg/mL
2 MO
sucralfate tablet 1
gram
1 MO
Immunology, Vaccines / Biotechnology
Biotechnology Drugs
ACTIMMUNE SUB-
Q 2 million unit/0.5
mL
5 MO
ARANESP
(POLYSORBATE)
INJECTION 25
mcg/mL, 40 mcg/mL
3 BvsD; MO
ARANESP
(POLYSORBATE)
SYRINGE 25
mcg/0.42 mL
3 BvsD; MO
ARANESP
(POLYSORBATE)
INJECTION 100
mcg/mL, 60 mcg/mL
4 BvsD; MO
Page 58 of 89
Drug Tier Requirements/
Limits
ARANESP
(POLYSORBATE)
SYRINGE 100
mcg/0.5 mL, 40
mcg/0.4 mL, 60
mcg/0.3 mL
4 BvsD; MO
ARANESP
(POLYSORBATE)
INJECTION 200
mcg/mL, 300 mcg/mL
5 BvsD; MO
ARANESP
(POLYSORBATE)
SYRINGE 150
mcg/0.3 mL, 200
mcg/0.4 mL, 300
mcg/0.6 mL, 500
mcg/mL
5 BvsD; MO
ARCALYST SUB-Q
SOLN 220 mg
5 BvsD; MO; LA
AVONEX IM KIT 30
mcg
5 BvsD; MO
AVONEX
ADMINISTRATION
PACK IM KIT 30
mcg/0.5 mL
5 BvsD; MO
BETASERON SUB-Q
KIT 0.3 mg
5 BvsD; MO
EPOGEN
INJECTION 2,000
unit/mL, 20,000 unit/2
mL, 20,000 unit/mL,
3,000 unit/mL, 4,000
unit/mL
3 BvsD; MO
GENOTROPIN
SUBQ CARTRIDGE
12 mg/mL (36
unit/mL), 5 mg/mL
(15 unit/mL)
4 MO
Drug Tier Requirements/
Limits
GENOTROPIN
MINIQUICK SUB-Q
SYRINGE 0.2
mg/0.25 mL, 0.4
mg/0.25 mL, 0.6
mg/0.25 mL, 0.8
mg/0.25 mL, 1
mg/0.25 mL, 1.2
mg/0.25 mL, 1.4
mg/0.25 mL, 1.6
mg/0.25 mL, 1.8
mg/0.25 mL, 2
mg/0.25 mL
4 MO
HUMATROPE
INJECTION,
CARTRIDGE 12 (36
unit) mg, 24 (72 unit)
mg, 6 (18 unit) mg
4 MO
HUMATROPE
SOLUTION FOR
INJECTION 5 (15
unit) mg
4 MO
INFERGEN SUB-Q
15 mcg/0.5 mL
4 BvsD; MO
INTRON A
INJECTION 6 million
unit/mL
4 BvsD; MO
INTRON A
SOLUTION FOR
INJECTION 10
million unit (1 mL)
4 BvsD; MO
INTRON A SUBQ
PEN KIT 10 million
unit/0.2 mL, 3 million
unit /0.2 mL-6 doses
4 BvsD; MO
INTRON A SUBQ
PEN KIT 5 million
unit/0.2 mL
5 BvsD; MO
LEUKINE
INJECTION 500
mcg/mL
5 BvsD; MO
Page 59 of 89
Drug Tier Requirements/
Limits
LEUKINE
SOLUTION FOR
INJECTION 250 mcg
5 BvsD; MO
NEULASTA SUB-Q
SYRINGE 6
mg/0.6mL
5 BvsD; MO
NEUMEGA SUB-Q
SOLN 5 mg
5 BvsD; MO
NEUPOGEN
INJECTION 480
mcg/1.6 mL
5 BvsD; MO
NEUPOGEN
SYRINGE 300
mcg/0.5 mL, 480
mcg/0.8 mL
5 BvsD; MO
NORDITROPIN
FLEXPRO SUB-Q
PEN INJECTOR 10
mg/1.5 mL (6.7
mg/mL), 15 mg/1.5
mL (10 mg/mL), 5
mg/1.5 mL (3.3
mg/mL)
5 MO
NORDITROPIN
NORDIFLEX SUB-Q
PEN INJECTOR 30
mg/3 mL (10 mg/mL)
5 MO
NUTROPIN SUB-Q
SOLN 10 mg
4 MO
NUTROPIN AQ
SUBQ CARTRIDGE
10 mg/2 mL (5
mg/mL), 20 mg/2 mL
(10 mg/mL)
4 MO
NUTROPIN AQ
NUSPIN SUBQ
CARTRIDGE 5 mg/2
mL (2.5 mg/mL)
4 MO
OMNITROPE SUBQ
CARTRIDGE 5
mg/1.5 mL (3.3
mg/mL)
2 MO
Drug Tier Requirements/
Limits
OMNITROPE SUB-Q
SOLN 5.8 mg
4 MO
OMNITROPE SUBQ
CARTRIDGE 10
mg/1.5 mL
4 MO
PEGASYS SUB-Q
180 mcg/mL
5 MO
PEGASYS
CONVENIENCE
PACK SUB-Q KIT
180 mcg/0.5 mL
5 MO
PEGASYS
PROCLICK SUB-Q
PEN INJECTOR 135
mcg/0.5 mL
5 MO
PEGINTRON SUB-Q
KIT 50 mcg/0.5 mL
4 MO
PEGINTRON
REDIPEN SUBQ KIT
120 mcg/0.5 mL, 150
mcg/0.5 mL, 50
mcg/0.5 mL, 80
mcg/0.5 mL
4 MO
PROCRIT
INJECTION 10,000
unit/mL, 2,000
unit/mL, 3,000
unit/mL, 4,000
unit/mL
3 BvsD; MO
PROCRIT
INJECTION 20,000
unit/mL, 40,000
unit/mL
5 BvsD; MO
PROLEUKIN IV
SOLUTION 22
million unit
5 BvsD; MO
REBIF SUB-Q
SYRINGE 22 mcg/0.5
mL, 44 mcg/0.5 mL
5 MO
Page 60 of 89
Drug Tier Requirements/
Limits
REBIF TITRATION
PACK SUB-Q
SYRINGE
8.8mcg/0.2mL-22
mcg/0.5mL (6)
5 MO
SAIZEN SUB-Q
SOLN 5 mg
4 MO
SAIZEN
CLICK.EASY SUBQ
CARTRIDGE 8.8
mg/1.5 mL (Fnl)
4 MO
SEROSTIM SUB-Q
SOLN 4 mg, 5 mg, 6
mg
5 MO
SYLATRON SUB-Q
KIT 296 mcg, 444
mcg, 888 mcg
5 MO
TEV-TROPIN SUB-Q
SOLN 5 mg
4 MO
ZORBTIVE SUB-Q
SOLN 8.8 mg
5 MO
Vaccines / Miscellaneous Immunologicals
ACTHIB (PF) IM 10
mcg/0.5 mL
4 MO
ADACEL
(ADOLESCENT &
ADULT) (PF) IM
SUSP 2-5-3-5-5 Lf-
mcg-Lf/0.5mL
4 MO
ATGAM IV 50
mg/mL
5 BvsD; MO
BOOSTRIX (PF) IM
SUSP 2.5-8-5 Lf-mcg-
Lf/0.5mL
4 MO
BOOSTRIX (PF) IM
SYRINGE 2.5-8-5 Lf-
mcg-Lf/0.5mL
4 MO
CARIMUNE NF
NANOFILTERED IV
SOLUTION 3 gram
4 BvsD; MO
Drug Tier Requirements/
Limits
CERVARIX
VACCINE (PF) IM
SYRINGE 20-20
mcg/0.5 mL
4 MO
COMVAX (PF) IM 5-
7.5-125 mcg/0.5 mL
4 MO
DAPTACEL
(PEDIATRIC) (PF)
IM SUSP 15-10-5 Lf-
mcg-Lf/0.5mL
4 MO
DECAVAC (PF) IM
SYRINGE 5-2 Lf
unit/0.5 mL
4 BvsD; MO
ENGERIX-B (PF) IM
SUSP 10 mcg/0.5 mL
4 BvsD; MO
ENGERIX-B (PF) IM
SYRINGE 10 mcg/0.5
mL, 20 mcg/mL
4 BvsD; MO
fomepizole IV 1
gram/mL
2 MO
GAMMAGARD
LIQUID IV 10 %
2 BvsD; MO
GAMUNEX-C
INJECTION 1
gram/10 mL (10 %)
4 BvsD; MO
GARDASIL (PF) IM
SUSP 20-40-40-20
mcg/0.5 mL
4 MO
HAVRIX (PF) IM
SUSP 1,440 EL
unit/mL
4 BvsD; MO
HAVRIX (PF) IM
SYRINGE 720 EL
unit/0.5 mL
4 BvsD; MO
INFANRIX (PF) IM
SUSP 25-58-10 Lf-
mcg-Lf/0.5mL
4 MO
IPOL SUSP FOR
INJECTION 40-8-32
unit/0.5 mL
4 MO
Page 61 of 89
Drug Tier Requirements/
Limits
IXIARO (PF) IM
SYRINGE 6 mcg/0.5
mL
4 MO
MENOMUNE -
A/C/Y/W-135 (PF)
SUB-Q SOLN 50 mcg
4 MO
MENVEO A-C-Y-W-
135-DIP (PF) IM KIT
10-5 mcg/0.5 mL
4 MO
M-M-R II (PF) SUB-
Q SUSP 1,000-12,500
TCID50/0.5 mL
4 MO
PEDVAX HIB (PF)
IM 7.5 mcg/0.5 mL
4 MO
PROQUAD (PF)
SUB-Q 10exp3-4.3-3-
3.99 TCID50/0.5
4 MO
RABAVERT (PF) IM
KIT 2.5 unit
4 BvsD; MO
RECOMBIVAX HB
(PF) IM SUSP 10
mcg/mL, 40 mcg/mL
4 BvsD; MO
ROTATEQ
VACCINE ORAL
SUSP 2 mL
4 MO
tetanus-diphtheria
toxoids-Td IM Susp 2-
2 Lf unit/0.5 mL
4 BvsD; MO
THYMOGLOBULIN
IV SOLUTION 25 mg
4 BvsD; MO
TWINRIX (PF) IM
SUSP 720-20 EL unit-
mcg/mL
4 BvsD; MO
TYPHIM VI IM 25
mcg/0.5 mL
4 MO
VAQTA (PF) IM
SUSP 25 unit/0.5 mL
4 BvsD; MO
VARIVAX (PF) SUB-
Q SOLN 1,350
unit/0.5 mL
4 MO
Drug Tier Requirements/
Limits
YF-VAX (PF) SUB-Q
SUSP 10 exp4.74
unit/0.5 mL
4 MO
ZOSTAVAX (PF)
SUB-Q SOLN 19,400
unit
4 MO
Musculoskeletal / Rheumatology
Gout Therapy
allopurinol tablet 100
mg, 300 mg
1 MO
allopurinol IV
Solution 500 mg
3 BvsD; MO
ALOPRIM IV
SOLUTION 500 mg
4 BvsD; MO
colchicine-probenecid
tablet 0.5-500 mg
1 MO
COLCRYS TABLET
0.6 mg
4 MO
probenecid tablet 500
mg
1 MO
Osteoporosis Therapy
ACTONEL TABLET
150 mg
4 ST; MO; QL (1
EA per 30 day(s))
ACTONEL TABLET
35 mg
4 ST; MO; QL (4
EA per 30 day(s))
ACTONEL TABLET
5 mg
4 ST; MO; QL (90
EA per 30 day(s))
alendronate tablet 35
mg
2 MO; QL (17 EA
per 30 day(s))
alendronate tablet 5
mg
2 MO; QL (30 EA
per 30 day(s))
alendronate tablet 70
mg
2 MO; QL (4 EA
per 30 day(s))
alendronate tablet 10
mg
2 MO; QL (60 EA
per 30 day(s))
ATELVIA
TABLET,DELAYED
RELEASE 35 mg
4 ST; MO; QL (4
EA per 30 day(s))
Page 62 of 89
Drug Tier Requirements/
Limits
BONIVA TABLET
150 mg
3 MO; QL (1 EA
per 30 day(s))
BONIVA IV
SYRINGE 3 mg/3 mL
4 BvsD; MO
EVISTA TABLET 60
mg
3 MO; QL (30 EA
per 30 day(s))
FORTEO SUB-Q
PEN INJECTOR 20
mcg/dose - 600
mcg/2.4 mL
4 PA; MO; BvsD
FOSAMAX PLUS D
TABLET 70-2,800
mg-unit, 70-5,600 mg-
unit
4 ST; MO
ibandronate tablet 150
mg
2 MO; QL (1 per
30 Day(s))
Other Rheumatologicals
BENLYSTA IV
SOLUTION 120 mg
4 BvsD; MO
DEPEN TITRATABS
TABLET 250 mg
4 MO
ENBREL SUB-Q KIT
25 mg (1 mL)
5 BvsD; MO
ENBREL SUB-Q
SYRINGE 25
mg/0.5mL (0.51), 50
mg/mL (0.98 mL)
5 BvsD; MO
HUMIRA SUB-Q
KIT 20 mg/0.4 mL, 40
mg/0.8 mL
5 BvsD; MO
HUMIRA CROHN'S
DISEASE STARTER
PACK SUBQ PEN
KIT 40 mg/0.8 mL
5 MO
KINERET SUB-Q
SYRINGE 100
mg/0.67 mL
5 MO
leflunomide tablet 10
mg, 20 mg
2 MO
Drug Tier Requirements/
Limits
RIDAURA
CAPSULE 3 mg
4 MO
Obstetrics / Gynecology
Estrogens / Progestins
CAMILA TABLET
0.35 mg
1 MO
CENESTIN TABLET
0.3 mg, 0.45 mg,
0.625 mg, 0.9 mg,
1.25 mg
3 MO
CRINONE
VAGINAL GEL 8 %
4 MO
DEPO-ESTRADIOL
IM OIL 5 mg/mL
4 MO
DEPO-PROVERA IM
400 mg/mL
4 BvsD; MO
DEPO-SUBQ
PROVERA 104
SYRINGE 104
mg/0.65 mL
4 MO
DIVIGEL
TRANSDERMAL
GEL PACKET 1 (0.1)
mg (%)
3 MO
ENDOMETRIN
VAGINAL INSERTS
100 mg
4 MO
ENJUVIA TABLET
0.3 mg, 0.45 mg,
0.625 mg, 0.9 mg,
1.25 mg
4 MO
ERRIN TABLET 0.35
mg
1 MO
ESTRACE
VAGINAL CREAM
0.01 % (0.1 mg/g)
4 MO
estradiol tablet 0.5
mg, 1 mg, 2 mg
1 MO
Page 63 of 89
Drug Tier Requirements/
Limits
estradiol Weekly
Transderm Patch
0.025 mg/24 hr,
0.0375 mg/24 hr, 0.05
mg/24 hr, 0.06 mg/24
hr, 0.075 mg/24 hr,
0.1 mg/24 hr
1 MO
estradiol valerate IM
Oil 10 mg/mL, 20
mg/mL, 40 mg/mL
2 MO
estradiol-
norethindrone acet
tablet 1-0.5 mg
1 MO
ESTRING VAGINAL
2 mg
4 MO; QL (1 EA
per 90 day(s))
estropipate tablet 0.75
mg, 1.5 mg, 3 mg
1 MO
EVAMIST
TRANSDERMAL
SPRAY 1.53 mg/spray
(1.7%)
3 MO
FEMHRT 1/5
TABLET 1-5 mg-mcg
4 MO
FEMHRT LOW
DOSE TABLET 0.5-
2.5 mg-mcg
4 MO
FEMRING
VAGINAL 0.05
mg/24 hr, 0.1 mg/24
hr
4 MO; QL (1 EA
per 90 day(s))
JINTELI TABLET 1-
5 mg-mcg
2 MO
JOLIVETTE
TABLET 0.35 mg
1 MO
medroxyprogesterone
IM Susp 150 mg/mL
1 MO
medroxyprogesterone
tablet 10 mg, 2.5 mg,
5 mg
1 MO
Drug Tier Requirements/
Limits
MENEST TABLET
0.3 mg, 0.625 mg,
1.25 mg, 2.5 mg
3 MO
MENOSTAR
TRANSDERM
PATCH 14 mcg/24 hr
3 MO
NORA-BE TABLET
0.35 mg
1 MO
norethindrone acetate
tablet 5 mg
1 MO
PREMARIN
SOLUTION FOR
INJECTION 25 mg
4 BvsD; MO
PREMARIN
TABLET 0.3 mg, 0.45
mg, 0.625 mg, 0.9 mg,
1.25 mg
4 MO
PREMARIN
VAGINAL CREAM
0.625 mg/gram
4 MO
PREMPHASE
TABLET 0.625 mg
(14)/ 0.625mg-
5mg(14)
3 MO; QL (30 EA
per 30 day(s))
PREMPRO TABLET
0.3-1.5 mg, 0.45-1.5
mg, 0.625-2.5 mg,
0.625-5 mg
4 MO; QL (30 EA
per 30 day(s))
progesterone
micronized capsule
100 mg, 200 mg
2 MO
VIVELLE-DOT
TRANSDERM
PATCH 0.025 mg/24
hr, 0.0375 mg/24 hr,
0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24
hr
4 MO
Miscellaneous Ob/Gyn
clindamycin Vaginal
Cream 2 %
1 MO
Page 64 of 89
Drug Tier Requirements/
Limits
metronidazole Vaginal
Gel 0.75 %
1 MO
MICONAZOLE-3
VAGINAL
SUPPOSITORY 200
mg
2 MO
terconazole Vaginal
Cream 0.4 %
1 MO
terconazole Vaginal
Suppository 80 mg
1 MO
VANDAZOLE
VAGINAL GEL 0.75
%
2 MO
ZAZOLE VAGINAL
CREAM 0.4 %
2 MO
Oral Contraceptives / Related Agents
AMETHIA
TABLETS,3 MONTH
DOSE PACK 0.15
mg-30 mcg (84)/10
mcg (7)
2 MO
AMETHYST
TABLET 90-20 mcg
2 MO
APRI TABLET 0.15-
30 mg-mcg
1 MO
ARANELLE (28)
TABLET 0.5/1/0.5-35
mg-mcg
1 MO
AVIANE TABLET
0.1-20 mg-mcg
1 MO
BALZIVA (28)
TABLET 0.4-35 mg-
mcg
1 MO
BRIELLYN TABLET
0.4-35 mg-mcg
2 MO
CRYSELLE (28)
TABLET 0.3-30 mg-
mcg
1 MO
Drug Tier Requirements/
Limits
CYCLAFEM 1/35
(28) TABLET 1-35
mg-mcg
2 MO
CYCLAFEM 7/7/7
(28) TABLET
0.5/0.75/1 mg- 35 mcg
2 MO
EMOQUETTE
TABLET 0.15-30 mg-
mcg
1 MO
ENPRESSE TABLET
50-30 (6)/75-40
(5)/125-30(10)
1 MO
FEMCON FE
CHEWABLE
TABLET 0.4mg-
35mcg(21) & 75 mg
(7)
4 MO
GIANVI TABLET 3-
20 mg-mcg
2 MO
INTROVALE
TABLETS,3 MONTH
DOSE PACK 0.15-30
mg-mcg
2 MO
JUNEL 1.5/30 (21)
TABLET 1.5-30 mg-
mcg
1 MO
JUNEL 1/20 (21)
TABLET 1-20 mg-
mcg
1 MO
JUNEL FE 1.5/30 (28)
TABLET 1.5-30 mg-
mcg
1 MO
JUNEL FE 1/20 (28)
TABLET 1-20 mg-
mcg
1 MO
KARIVA TABLET
0.15-0.02mg x21 /0.01
mg x 5
2 MO
KELNOR 1/35 (28)
TABLET 1-35 mg-
mcg
2 MO
Page 65 of 89
Drug Tier Requirements/
Limits
LEENA 28 TABLET
0.5/1/0.5-35 mg-mcg
1 MO
LESSINA TABLET
0.1-20 mg-mcg
1 MO
LEVORA-28
TABLET 0.15-30 mg-
mcg
1 MO
LOESTRIN 24 FE
TABLET 1-20 (24)-
75(4) mg-mcg-mg
4 MO
LOW-OGESTREL
(28) TABLET 0.3-30
mg-mcg
1 MO
LUTERA (28)
TABLET 0.1-20 mg-
mcg
1 MO
LYBREL TABLET
90-20 mcg
4 MO
MARLISSA TABLET
0.15-30 mg-mcg
2 MO
MICROGESTIN
1.5/30 (21) TABLET
1.5-30 mg-mcg
1 MO
MICROGESTIN 1/20
(21) TABLET 1-20
mg-mcg
1 MO
MICROGESTIN FE
1.5/30 (28) TABLET
1.5-30 mg-mcg
1 MO
MICROGESTIN FE
1/20 (28) TABLET 1-
20 mg-mcg
1 MO
MONONESSA (28)
TABLET 0.25-35 mg-
mcg
1 MO
NECON 0.5/35 (28)
TABLET 0.5-35 mg-
mcg
1 MO
Drug Tier Requirements/
Limits
NECON 1/35 (28)
TABLET 1-35 mg-
mcg
1 MO
NECON 10/11 (28)
TABLET 0.5-35/1-35
mg-mcg/mg-mcg
1 MO
NECON 7/7/7 (28)
TABLET 0.5/0.75/1
mg- 35 mcg
1 MO
NORTREL 0.5/35
(28) TABLET 0.5-35
mg-mcg
1 MO
NORTREL 1/35 (21)
TABLET 1-35 mg-
mcg
1 MO
NORTREL 1/35 (28)
TABLET 1-35 mg-
mcg
1 MO
NORTREL 7/7/7 (28)
TABLET 0.5/0.75/1
mg- 35 mcg
1 MO
OCELLA TABLET 3-
0.03 mg
2 MO
OGESTREL (28)
TABLET 0.5-50 mg-
mcg
1 MO
ORSYTHIA TABLET
0.1-20 mg-mcg
1 MO
ORTHO TRI-
CYCLEN LO
TABLET
0.18/0.215/0.25 mg-25
mcg
4 MO
OVCON-50 (28)
TABLET 1-50 mg-
mcg
4 MO
PORTIA TABLET
0.15-30 mg-mcg
1 MO
PREVIFEM TABLET
0.25-35 mg-mcg
1 MO
Page 66 of 89
Drug Tier Requirements/
Limits
QUASENSE
TABLETS,3 MONTH
DOSE PACK 0.15-30
mg-mcg
2 MO
RECLIPSEN (28)
TABLET 0.15-30 mg-
mcg
2 MO
SEASONIQUE
TABLETS,3 MONTH
DOSE PACK 0.15
mg-30 mcg (84)/10
mcg (7)
4 MO
SPRINTEC (28)
TABLET 0.25-35 mg-
mcg
1 MO
SRONYX TABLET
0.1-20 mg-mcg
1 MO
TRI-LEGEST FE
TABLET 1-20(5)/1-
30(7) /1mg-35mcg (9)
2 MO
TRINESSA (28)
TABLET
0.18/0.215/0.25 mg-35
mcg (28)
2 MO
TRI-PREVIFEM (28)
TABLET
0.18/0.215/0.25 mg-35
mcg (28)
2 MO
TRI-SPRINTEC (28)
TABLET
0.18/0.215/0.25 mg-35
mcg (28)
2 MO
TRIVORA (28)
TABLET 50-30
(6)/75-40 (5)/125-
30(10)
1 MO
VELIVET TABLET
0.1/.125/.15-25 mg-
mcg
1 MO
VESTURA TABLET
3-20 mg-mcg
2 MO
Drug Tier Requirements/
Limits
ZEOSA CHEWABLE
TABLET 0.4mg-
35mcg(21) & 75 mg
(7)
2 MO
ZOVIA 1/35E (28)
TABLET 1-35 mg-
mcg
1 MO
ZOVIA 1/50E (28)
TABLET 1-50 mg-
mcg
1 MO
Oxytocics
METHERGINE
TABLET 0.2 mg
4 MO
methylergonovine
tablet 0.2 mg
1 MO
Ophthalmology
Antibiotics
AZASITE EYE
DROPS 1 %
3 MO
bacitracin Eye
Ointment 500 unit/g
1 MO
bacitracin-polymyxin
B Eye Ointment 500-
10,000 unit/g
1 MO
CILOXAN EYE
OINTMENT 0.3 %
4 MO
ciprofloxacin Eye
Drops 0.3 %
1 MO
erythromycin Eye
Ointment 5 mg/gram
(0.5 %)
1 MO
GENTAK EYE
OINTMENT 0.3 % (3
mg/g)
1 MO
gentamicin Eye Drops
0.3 %
1 MO
levofloxacin Eye
Drops 0.5 %
2 MO
Page 67 of 89
Drug Tier Requirements/
Limits
MOXEZA EYE
DROPS 0.5 %
3 MO
NATACYN EYE
DROPS 5 %
4 MO
neomycin-bacitracin-
polymyxin Eye Oint
3.5-400-10,000 mg-
unit-unit/g
1 MO
neomycin-polymyxin-
gramicidin Eye Drops
1.75-10K-0.025 mg-
unit-mg/mL
1 MO
ofloxacin Eye Drops
0.3 %
2 MO
tobramycin Eye Drops
0.3 %
1 MO
TOBREX EYE
OINTMENT 0.3 %
3 MO
trimethoprim-
polymyxin B Eye
Drops 0.1-10,000 %-
unit/mL
1 MO
VIGAMOX EYE
DROPS 0.5 %
4 MO
Antivirals
trifluridine Eye Drops
1 %
2 MO
VIROPTIC EYE
DROPS 1 %
3 MO
ZIRGAN EYE GEL
0.15 %
4 MO
Beta-Blockers
betaxolol Eye Drops
0.5 %
1 MO
BETOPTIC S EYE
DROPS 0.25 %
4 MO
carteolol Eye Drops 1
%
1 MO
Drug Tier Requirements/
Limits
levobunolol Eye
Drops 0.5 %
1 MO
metipranolol Eye
Drops 0.3 %
1 MO
timolol Eye Gel
Forming Soln 0.25 %,
0.5 %
1 MO
timolol maleate Eye
Drops 0.25 %, 0.5 %
1 MO
Cholinesterase Inhibitor Miotics
PHOSPHOLINE
IODIDE EYE DROPS
0.125 %
4 MO
Cycloplegic Mydriatics
tropicamide Eye
Drops 0.5 %, 1 %
1 MO
Direct Acting Miotics
ISOPTO CARPINE
EYE DROPS 1 %, 2
%, 4 %
3 MO
PILOPINE HS EYE
GEL 4 %
3 MO
Miscellaneous Ophthalmologics
ALOCRIL EYE
DROPS 2 %
3 MO
ALOMIDE EYE
DROPS 0.1 %
3 MO
azelastine Eye Drops
0.05 %
2 MO
cromolyn Eye Drops 4
%
1 MO
ELESTAT EYE
DROPS 0.05 %
4 MO
EMADINE EYE
DROPS 0.05 %
3 MO
epinastine Eye Drops
0.05 %
2 MO
Page 68 of 89
Drug Tier Requirements/
Limits
PATADAY EYE
DROPS 0.2 %
3 MO
PATANOL EYE
DROPS 0.1 %
3 MO
proparacaine Eye
Drops 0.5 %
1 MO
RESTASIS EYE
DROPPERETTE 0.05
%
4 MO; QL (60 EA
per 30 day(s))
Non-Steroidal Anti-Inflammatory Agents
ACUVAIL (PF) EYE
DROPPERETTE 0.45
%
4 MO
bromfenac Eye Drops
0.09 %
2 MO
diclofenac Eye Drops
0.1 %
1 MO
flurbiprofen Eye
Drops 0.03 %
1 MO
ketorolac Eye Drops
0.4 %, 0.5 %
2 MO
NEVANAC EYE
DROPS 0.1 %
3 MO
Oral Drugs For Glaucoma
acetazolamide tablet
125 mg, 250 mg
1 MO
acetazolamide ER
capsule,extended
release 500 mg
2 MO
acetazolamide
Solution for Injection
500 mg
2 MO
methazolamide tablet
25 mg, 50 mg
1 MO
Other Glaucoma Drugs
AZOPT EYE DROPS
1 %
3 MO
Drug Tier Requirements/
Limits
COMBIGAN EYE
DROPS 0.2-0.5 %
3 MO
dorzolamide Eye
Drops 2 %
1 MO
dorzolamide-timolol
Eye Drops 2-0.5 %
2 MO
latanoprost Eye Drops
0.005 %
2 MO
LUMIGAN EYE
DROPS 0.01 %, 0.03
%
3 MO
TRAVATAN Z EYE
DROPS 0.004 %
4 MO
XALATAN EYE
DROPS 0.005 %
4 MO
Steroid-Antibiotic Combinations
neomycin-bacitracin-
poly-HC Eye Ointment
3.5-400-10,000 mg-
unit/g-1%
1 MO
neomycin-polymyxin-
dexameth Eye Drops
3.5-10,000-0.1
mg/mL-unit/mL-%
1 MO
neomycin-polymyxin-
dexameth Eye
Ointment 3.5-10,000-
0.1 mg-unit/g-%
1 MO
neomycin-polymyxin-
HC Eye Drops, Susp
3.5-10,000-10 mg-
unit-mg/mL
1 MO
PRED-G EYE
DROPS 0.3-1 %
3 MO
PRED-G S.O.P. EYE
OINTMENT 0.3-0.6
%
3 MO
TOBRADEX EYE
OINTMENT 0.3-0.1
%
3 MO
Page 69 of 89
Drug Tier Requirements/
Limits
tobramycin-
dexamethasone Eye
Drops, Susp 0.3-0.1 %
2 MO
ZYLET EYE DROPS
0.3-0.5 %
4 MO
Steroids
ALREX EYE DROPS
0.2 %
3 MO
dexamethasone Eye
Drops 0.1 %
1 MO
FLAREX EYE
DROPS 0.1 %
3 MO
FML FORTE EYE
DROPS 0.25 %
3 MO
FML S.O.P. EYE
OINTMENT 0.1 %
3 MO
LOTEMAX EYE
DROPS 0.5 %
4 MO
LOTEMAX EYE
OINTMENT 0.5 %
4 MO
MAXIDEX EYE
DROPS 0.1 %
3 MO
prednisolone acetate
Eye Drops, Susp 1 %
1 MO
prednisolone sodium
phosphate Eye Drops
1 %
1 MO
VEXOL EYE DROPS
1 %
3 MO
Steroid-Sulfonamide Combinations
BLEPHAMIDE EYE
DROPS 10-0.2 %
3 MO
BLEPHAMIDE
S.O.P. EYE
OINTMENT 10-0.2 %
3 MO
Drug Tier Requirements/
Limits
sulfacetamide-
prednisolone Eye
Drops 10 %-0.23 %
(0.25 %)
1 MO
Sulfonamides
BLEPH-10 EYE
DROPS 10 %
3 MO
sulfacetamide sodium
Eye Drops 10 %
1 MO
sulfacetamide sodium
Eye Ointment 10 %
1 MO
Sympathomimetics
ALPHAGAN P EYE
DROPS 0.1 %, 0.15 %
3 MO
apraclonidine Eye
Drops 0.5 %
2 MO
brimonidine Eye
Drops 0.15 %, 0.2 %
1 MO
IOPIDINE EYE
DROPPERETTE 1 %
4 MO
IOPIDINE EYE
DROPS 0.5 %
4 MO
Vasoconstrictor Decongestants
AK-CON EYE
DROPS 0.1 %
1 MO
Otc-Product
Otc-Product
OTC-PRODUCT 1 MO
Respiratory And Allergy
Antihistamine / Antiallergenic Agents
carbinoxamine Oral
Liquid 4 mg/5 mL
2 MO
carbinoxamine tablet
4 mg
2 MO
cetirizine Oral Soln 1
mg/mL
1 MO
Page 70 of 89
Drug Tier Requirements/
Limits
CLARINEX
DISINTEGRATING
TABLET 2.5 mg, 5
mg
4 ST; MO
CLARINEX SYRUP
2.5 mg/5 mL (0.5
mg/mL)
4 ST; MO
CLARINEX TABLET
5 mg
4 ST; MO
CLARINEX-D 12
HOUR
TABLET,EXTENDE
D RELEASE 2.5-120
mg
4 MO
CLARINEX-D 24
HOUR
TABLET,EXTENDE
D RELEASE 5-240
mg
4 MO
clemastine Syrup 0.67
mg/5 mL
1 MO
clemastine tablet 2.68
mg
1 MO
cyproheptadine Syrup
2 mg/5 mL
2 MO
cyproheptadine tablet
4 mg
2 MO
diphenhydramine
capsule 50 mg
1 MO
epinephrine HCl
Syringe 0.1 mg/mL
1 MO
EPIPEN IM
INJECTOR 0.3
mg/0.3 mL
4 MO
EPIPEN JR IM
INJECTOR 0.15
mg/0.3 mL
4 MO
hydroxyzine IM 25
mg/mL, 50 mg/mL
1 MO
Drug Tier Requirements/
Limits
hydroxyzine Syrup 10
mg/5 mL
1 MO
hydroxyzine tablet 10
mg, 25 mg, 50 mg
1 MO
hydroxyzine pamoate
capsule 100 mg, 25
mg, 50 mg
1 MO
levocetirizine Oral
Soln 2.5 mg/5 mL
2 MO
levocetirizine tablet 5
mg
2 MO
PALGIC ORAL
LIQUID 4 mg/5 mL
2 MO
PALGIC TABLET 4
mg
4 MO
PHENADOZ
RECTAL
SUPPOSITORY 12.5
mg, 25 mg
2 MO
promethazine
Injection 50 mg/mL
1 MO
promethazine Rectal
Suppository 12.5 mg,
25 mg
1 MO
promethazine Syringe
25 mg/mL
1 MO
promethazine Syrup
6.25 mg/5 mL
1 MO
promethazine tablet
12.5 mg, 25 mg, 50 mg
1 MO
PROMETHEGAN
RECTAL
SUPPOSITORY 25
mg, 50 mg
2 MO
TWINJECT
AUTOINJECTOR IM
PEN 0.15 mg/0.15
mL, 0.3 mg/0.3 mL
3 MO
Page 71 of 89
Drug Tier Requirements/
Limits
XYZAL ORAL
SOLN 2.5 mg/5 mL
4 ST; MO
XYZAL TABLET 5
mg
4 ST; MO
Pulmonary Agents
ACCOLATE
TABLET 10 mg, 20
mg
3 MO
acetylcysteine Soln
100 mg/mL (10 %),
200 mg/mL (20 %)
1 MO
ADVAIR DISKUS
FOR INHALATION
100-50 mcg/dose,
250-50 mcg/dose,
500-50 mcg/dose
4 MO
ADVAIR HFA
AEROSOL
INHALER 115-21
mcg/actuation, 230-21
mcg/actuation, 45-21
mcg/actuation
4 MO
albuterol sulfate Neb
Solution 0.63 mg/3
mL, 1.25 mg/3 mL, 2.5
mg /3 mL (0.083 %), 5
mg/mL
1 BvsD; MO
albuterol sulfate ER
tablet,extended
release,12 hr 4 mg, 8
mg
1 MO
albuterol sulfate Syrup
2 mg/5 mL
1 MO
albuterol sulfate tablet
2 mg, 4 mg
1 MO
aminophylline IV 250
mg/10 mL
1 MO
Drug Tier Requirements/
Limits
ASMANEX
TWISTHALER
BREATH
ACTIVATED 110
mcg (30 doses), 220
mcg (14 doses)
4 MO
ATROVENT HFA
AEROSOL
INHALER 17
mcg/actuation
3 MO
BECONASE AQ
NASAL SPRAY 42
mcg (0.042 %)
4 MO
BROVANA NEB
SOLUTION 15 mcg/2
mL
4 BvsD; MO
budesonide Neb
Suspension 0.25 mg/2
mL, 0.5 mg/2 mL
2 BvsD; MO
COMBIVENT
AEROSOL
INHALER 18-103
mcg/actuation
3 MO
cromolyn Neb
Solution 20 mg/2 mL
1 BvsD; MO
ELIXOPHYLLIN 80
mg/15 mL
3 MO
FLOVENT HFA
AEROSOL
INHALER 110
mcg/actuation, 220
mcg/actuation, 44
mcg/actuation
3 MO
flunisolide Nasal
Spray 25 mcg (0.025
%)
1 MO
fluticasone Nasal
Spray, Susp 50
mcg/actuation
2 MO
Page 72 of 89
Drug Tier Requirements/
Limits
ipratropium bromide
Soln for Inhalation
0.02 %
1 MO
ipratropium-albuterol
Neb Solution 0.5 mg-3
mg(2.5 mg base)/3 mL
1 MO
levalbuterol Neb
Solution 1.25 mg/0.5
mL
1 PA; MO; BvsD
LUFYLLIN TABLET
200 mg
3 MO
MAXAIR
AUTOHALER
BREATH
ACTIVATED 200
mcg/Inhalation
4 MO
metaproterenol Syrup
10 mg/5 mL
1 MO
metaproterenol tablet
10 mg, 20 mg
1 MO
NASACORT AQ
NASAL SPRAY
AEROSOL 55 mcg
3 MO
NASONEX SPRAY
50 mcg/actuation
3 MO
OMNARIS NASAL
SPRAY 50 mcg
3 MO
PERFOROMIST NEB
SOLUTION 20 mcg/2
mL
4 BvsD; MO
PROAIR HFA
AEROSOL
INHALER 90
mcg/actuation
1 MO
PROVENTIL HFA
AEROSOL
INHALER 90
mcg/actuation
3 MO
Drug Tier Requirements/
Limits
PULMICORT NEB
SUSPENSION 1 mg/2
mL
4 BvsD; MO
PULMICORT
FLEXHALER
BREATH
ACTIVATED 180
mcg/actuation, 90
mcg/actuation
4 MO
PULMOZYME SOLN
FOR INHALATION 1
mg/mL
4 BvsD; MO
QVAR AEROSOL
INHALER 40
mcg/actuation, 80
mcg/actuation
4 MO
REVATIO TABLET
20 mg
5 MO
SEREVENT DISKUS
FOR INHALATION
50 mcg/dose
4 MO
SINGULAIR
CHEWABLE
TABLET 4 mg, 5 mg
3 MO
SINGULAIR ORAL
GRANULES IN
PACKET 4 mg
3 MO
SINGULAIR
TABLET 10 mg
3 MO
SPIRIVA WITH
HANDIHALER &
INHALATION
CAPSULES 18 mcg
3 MO
SYMBICORT HFA
AEROSOL
INHALER 160-4.5
mcg/actuation, 80-4.5
mcg/actuation
3 MO; QL (10.2
GM per 30
day(s))
terbutaline tablet 2.5
mg, 5 mg
1 MO
Page 73 of 89
Drug Tier Requirements/
Limits
terbutaline Sub-Q 1
mg/mL
2 BvsD; MO
theophylline ER
tablet,extended
release 400 mg, 600
mg
1 MO
theophylline ER
tablet,extended
release,12 hr 100 mg,
200 mg, 300 mg, 450
mg
1 MO
TRACLEER
TABLET 125 mg,
62.5 mg
5 PA; MO; LA
triamcinolone
acetonide Nasal Spray
Aerosol 55 mcg
2 MO
VENTAVIS NEB
SOLUTION 10
mcg/mL
5 BvsD; MO
VENTOLIN HFA
AEROSOL
INHALER 90
mcg/actuation
3 MO
XOLAIR SUB-Q
SOLN 150 mg
4 BvsD; MO
XOPENEX NEB
SOLUTION 0.31
mg/3 mL, 0.63 mg/3
mL, 1.25 mg/3 mL
4 PA; MO; BvsD
XOPENEX HFA
AEROSOL
INHALER 45
mcg/actuation
4 MO
zafirlukast tablet 10
mg, 20 mg
2 MO
ZYFLO TABLET 600
mg
4 MO
ZYFLO CR
TABLET,EXTENDE
D RELEASE 600 mg
4 MO
Drug Tier Requirements/
Limits
Urologicals
Anticholinergics / Antispasmodics
DETROL TABLET 1
mg, 2 mg
3 MO
DETROL LA
CAPSULE,EXTEND
ED RELEASE 2 mg,
4 mg
3 MO
ENABLEX
TABLET,EXTENDE
D RELEASE 15 mg,
7.5 mg
4 MO; QL (30 EA
per 30 day(s))
flavoxate tablet 100
mg
2 MO
oxybutynin chloride
ER tablet,24 hr
extended release 10
mg, 15 mg, 5 mg
1 MO
oxybutynin chloride
Syrup 5 mg/5 mL
1 MO
oxybutynin chloride
tablet 5 mg
1 MO
SANCTURA
TABLET 20 mg
3 MO; QL (60 EA
per 30 day(s))
SANCTURA XR
CAPSULE,EXTEND
ED RELEASE 60 mg
3 MO; QL (30 EA
per 30 day(s))
trospium tablet 20 mg 2 MO; QL (60 EA
per 30 day(s))
VESICARE TABLET
10 mg, 5 mg
4 MO; QL (30 EA
per 30 day(s))
Benign Prostatic Hyperplasia(Bph) Therapy
alfuzosin ER
tablet,extended
release 24 hr 10 mg
1 MO
AVODART
CAPSULE 0.5 mg
4 MO; QL (30 EA
per 30 day(s))
finasteride tablet 5 mg 1 MO; QL (30 EA
per 30 day(s))
Page 74 of 89
Drug Tier Requirements/
Limits
JALYN CAPSULE,
EXTENDED
RELEASE 0.5-0.4 mg
3 MO
tamsulosin ER
capsule,extended
release 24 hr 0.4 mg
1 MO; QL (60 EA
per 30 day(s))
UROXATRAL
TABLET,EXTENDE
D RELEASE 10 mg
4 MO; QL (30 EA
per 30 day(s))
Cholinergic Stimulants
bethanechol chloride
tablet 10 mg, 25 mg, 5
mg, 50 mg
2 MO
Miscellaneous Urologicals
ammonium chloride
IV 5 mEq/mL
3 BvsD; MO
CYSTAGON
CAPSULE 150 mg,
50 mg
3 MO
ELMIRON
CAPSULE 100 mg
3 MO
Vitamins, Hematinics / Electrolytes
Electrolytes
0.45 % sodium
chloride with
potassium chloride IV
20 mEq/L
3 BvsD; MO
0.9 % sodium chloride
& potassium chloride
IV 20 mEq/L
1 BvsD; MO
0.9 % sodium chloride
& potassium chloride
IV 40 mEq/L
3 BvsD; MO
calcium acetate
capsule 667 mg
2 MO
D5-0.45 % sodium
chloride & potassium
chloride IV 10 mEq/L,
20 mEq/L, 40 mEq/L
1 BvsD; MO
Drug Tier Requirements/
Limits
D5-0.45 % sodium
chloride & potassium
chloride IV 30 mEq/L
3 BvsD; MO
D5-0.225 % sodium
chloride & potassium
chloride IV 20 mEq/L
3 BvsD; MO
D5-0.33 % in sodium
chloride & potassium
chloride IV 20 mEq/L
1 BvsD; MO
D5 & 0.9 % sodium
chloride with
potassium chloride IV
20 mEq/L, 40 mEq/L
1 BvsD; MO
D5-LR with potassium
chloride IV 20 mEq/L
1 MO
D5W with potassium
chloride IV 30 mEq/L,
40 mEq/L
2 BvsD; MO
D5W with potassium
chloride IV 20 mEq/L
3 BvsD; MO
dextrose 5% and
lactated ringers IV
1 MO
ELIPHOS TABLET
667 mg
1 MO
KLOR-CON
TABLET,EXTENDE
D RELEASE 8 mEq
1 MO
KLOR-CON 10
TABLET,EXTENDE
D RELEASE 10 mEq
1 MO
KLOR-CON M15
TABLET,EXTENDE
D RELEASE 15 mEq
3 MO
KLOR-CON M20
TABLET,EXTENDE
D RELEASE 20 mEq
1 MO
lactated ringers IV 3 BvsD; MO
magnesium sulfate
Syringe 4 mEq/mL
3 BvsD; MO
Page 75 of 89
Drug Tier Requirements/
Limits
NORMOSOL-R IN
D5W IV 5 %
3 BvsD; MO
potassium chloride IV
Piggy Back 10
mEq/100 mL, 10
mEq/50 mL
1 BvsD; MO
potassium chloride IV
Soln 2 mEq/mL
1 BvsD; MO
potassium chloride ER
capsule,extended
release 10 mEq, 8
mEq
1 MO
potassium chloride ER
tablet,extended
release(part/cryst) 10
mEq, 20 mEq
1 MO
potassium chloride IV
Piggy Back 20 mEq/50
mL, 30 mEq/100 mL
3 BvsD; MO
ringers IV 1 MO
sodium chloride IV 2.5
mEq/mL
1 BvsD; MO
sodium chloride 0.45
% IV 0.45 %
1 BvsD; MO
sodium chloride 3 %
IV 3 %
1 BvsD; MO
sodium chloride 5 %
IV 5 %
1 BvsD; MO
sodium lactate IV 5
mEq/mL
1 BvsD; MO
sodium lactate IV Soln
167 mEq/L
1 BvsD; MO
Miscellaneous Nutrition Products
AMINOSYN II 10 %
IV
3 BvsD; MO
AMINOSYN II 15%
IV 15 %
2 MO
AMINOSYN II 7 %
IV 7 %
3 BvsD; MO
Drug Tier Requirements/
Limits
AMINOSYN II 8.5 %
IV 8.5 %
3 BvsD; MO
AMINOSYN M 3.5 %
IV 3.5 %
3 BvsD; MO
AMINOSYN-HBC
7% IV 7 %
3 BvsD; MO
AMINOSYN-PF 10 %
IV 10 %
3 BvsD; MO
AMINOSYN-PF 7 %
(SULFITE-FREE) IV
7 %
3 BvsD; MO
CLINIMIX 2.75%/D5
SULFITE FREE IV
2.75 %
3 BvsD; MO
CLINIMIX
4.25%/D10 SULFITE
FREE IV 4.25 %
3 BvsD; MO
CLINIMIX
4.25%/D20 SULFITE
FREE IV 4.25 %
3 BvsD; MO
CLINIMIX 5%/D15
SULFITE FREE IV 5
%
3 BvsD; MO
CLINIMIX 5%/D20
SULFITE FREE IV 5
%
3 BvsD; MO
CLINIMIX 5%/D25
SULFITE FREE IV 5
%
3 BvsD; MO
CLINIMIX E
4.25%/D25 SULFITE
FREE IV 4.25 %
3 BvsD; MO
CLINIMIX E
4.25%/D5 SULFITE
FREE IV 4.25 %
3 BvsD; MO
CLINIMIX E 5%/D15
SULFITE FREE IV 5
%
3 BvsD; MO
Page 76 of 89
Drug Tier Requirements/
Limits
CLINIMIX E 5%/D20
SULFITE FREE IV 5
%
3 BvsD; MO
CLINIMIX E 5%/D25
SULFITE FREE IV 5
%
3 BvsD; MO
FREAMINE III 3 %
WITH
ELECTROLYTES IV
3 %
3 BvsD; MO
FREAMINE III 8.5 %
IV 8.5 %
3 BvsD; MO
HEPATAMINE 8%
IV 8 %
3 BvsD; MO
HEPATASOL 8 % IV
8 %
3 BvsD; MO
INTRALIPID IV 20
%
2 BvsD; MO
INTRALIPID IV 30
%
3 BvsD; MO
IONOSOL-B IN D5W
IV 5 %
3 BvsD; MO
IONOSOL-MB IN
D5W IV 5 %
3 BvsD; MO
ISOLYTE-H IN D5W
IV 5 %
3 BvsD; MO
ISOLYTE-P IN D5W
IV 5 %
3 BvsD; MO
ISOLYTE-S IV 3 BvsD; MO
ISOLYTE-S IN D5W
IV
3 BvsD; MO
NEPHRAMINE 5.4 %
IV 5.4 %
3 BvsD; MO
NORMOSOL-R PH
7.4 IV
3 BvsD; MO
PLASMA-LYTE 148
IV
3 BvsD; MO
Drug Tier Requirements/
Limits
PLASMA-LYTE A
IV
3 BvsD; MO
PLASMA-LYTE-56
IN D5W IV 5 %
3 BvsD; MO
PREMASOL 10 % IV 2 BvsD; MO
PREMASOL 6 % IV 3 BvsD; MO
PROCALAMINE 3%
IV 3 %
3 BvsD; MO
PROSOL 20% IV 3 BvsD; MO
TRAVASOL 10 % IV
10 %
2 MO
TROPHAMINE 10 %
IV 10 %
3 BvsD; MO
TROPHAMINE 6%
IV 6 %
3 BvsD; MO
Vitamins / Hematinics
PRENATAL PLUS
WITH IRON
(CALCIUM
CARBONATE)
TABLET 27-1 mg
1 MO
sodium fluoride tablet
1 mg fluoride (2.2 mg)
1 MO
Page 77 of 89
OTC Drugs
Drug Tier Requirements/
Limits
ALAVERT
DISINTEGRATING
TABLET 10 mg
1 MO
ALAVERT TABLET
10 mg
1 MO
ALL DAY
ALLERGY
(CETIRIZINE)
CHEWABLE
TABLET 10 mg, 5 mg
1 MO
ALL DAY
ALLERGY
(CETIRIZINE)
TABLET 10 mg
1 MO
ALLEGRA
ALLERGY TABLET
180 mg, 60 mg
1 MO
ALLER-EASE
TABLET 180 mg
1 MO
ALLERGY RELIEF
(FEXOFENADINE)
TABLET 180 mg
1 MO
ALLERGY RELIEF
(LORATADINE)
ORAL SOLN 5 mg/5
mL
1 MO
ALLERGY RELIEF
(LORATADINE)
TABLET 10 mg
1 MO
cetirizine tablet 5 mg 1 MO
CHILDREN'S
ALLERGY RELIEF
(CETIRIZINE)
CHEWABLE
TABLET 10 mg, 5 mg
1 MO
CHILDREN'S
ALLEGRA
ALLERGY
DISINTEGRATING
TABLET 30 mg
1 MO
CHILDREN'S
ALLEGRA
ALLERGY ORAL
SUSP 30 mg/5 mL
1 MO
Drug Tier Requirements/
Limits
CHILDREN'S
ALLEGRA
ALLERGY TABLET
30 mg
1 MO
CHILDREN'S
ALLERGY RELIEF
ORAL SOLN 5 mg/5
mL
1 MO
CHILDREN'S
CLEAR-ATADINE
DISINTEGRATING
TABLET 10 mg
1 MO
CHILDREN'S WAL-
ZYR CHEWABLE
TABLET 10 mg
1 MO
CLEAR-ATADINE
TABLET 10 mg
1 MO
loratadine Oral Soln 5
mg/5 mL
1 MO
loratadine tablet 10
mg
1 MO
NON-DROWSY
ALLERGY TABLET
10 mg
1 MO
omeprazole
tablet,delayed release
20 mg
1 MO
omeprazole
magnesium
capsule,delayed
release 20 mg
1 MO
PREVACID 24HR
CAPSULE,DELAYE
D RELEASE 15 mg
1 MO
PRILOSEC OTC
TABLET,DELAYED
RELEASE 20 mg
1 MO
WAL-ITIN TABLET
10 mg
1 MO
WAL-ZYR TABLET
10 mg
1 MO
Page 78 of 89
Index
0.45 % NaCl-potassium
chloride.............................. 74
0.9% NaCl & potassium
chloride.............................. 74
8-Mop .................................... 41
Abelcet .................................... 1
Abilify ................................... 26
Abilify Discmelt .................... 26
Acanya .................................. 41
acarbose ................................. 50
Accolate ................................ 71
acebutolol .............................. 33
acetaminophen-codeine ......... 22
Acetasol HC .......................... 48
acetazolamide ........................ 68
acetazolamide sodium ........... 68
acetic acid .............................. 48
acetylcysteine ........................ 71
ActHIB (PF) .......................... 60
Actimmune ............................ 57
Actonel ............................ 46, 61
Actoplus MET ....................... 50
Actoplus Met XR .................. 50
Actos ..................................... 50
Acuvail (PF) .......................... 68
acyclovir .................................. 1
acyclovir sodium ..................... 1
Adacel (Adolescent
&Adult)(PF) ...................... 60
Adagen .................................. 46
adapalene ......................... 41, 42
Adcirca .................................. 33
Adderall XR .......................... 26
Adriamycin PFS .................... 12
Advair Diskus ....................... 71
Advair HFA........................... 71
Advicor.................................. 39
Afeditab CR .......................... 33
Afinitor .................................. 12
Aggrenox ............................... 38
A-Hydrocort .......................... 49
AK-Con ................................. 69
Ala-Cort ................................ 44
Ala-Scalp ............................... 44
Alavert ................................... 77
Albenza ................................... 6
albuterol sulfate ..................... 71
alclometasone ........................ 44
alcohol swabs ........................ 50
Aldactazide ........................... 33
Aldara ................................... 41
Aldurazyme .......................... 52
alendronate ..................... 46, 61
alfuzosin ............................... 73
Alimta ................................... 12
Alinia ...................................... 6
Alkeran ................................. 12
All Day Allergy (cetirizine) .. 77
Allegra Allergy ..................... 77
Aller-ease .............................. 77
Allergy Relief (fexofenadine)
.......................................... 77
Allergy Relief (loratadine) ... 77
allopurinol ............................. 61
allopurinol sodium ................ 61
Alocril ................................... 67
Alomide ................................ 67
Aloprim ................................. 61
Aloxi ..................................... 54
Alphagan P ........................... 69
Alrex ..................................... 69
Altabax ................................. 43
amantadine .......................... 1, 2
AmBisome .............................. 1
amcinonide ........................... 44
Amethia ................................ 64
Amethyst ............................... 64
Amevive ............................... 41
amifostine crystalline ............ 11
amikacin ................................. 6
amiloride ............................... 33
amiloride-hydrochlorothiazide
.......................................... 33
aminophylline ....................... 71
Aminosyn II 10 % ................ 75
Aminosyn II 15% ................. 75
Aminosyn II 7 % .................. 75
Aminosyn II 8.5 % ............... 75
Aminosyn M 3.5 % ............... 75
Aminosyn-HBC 7% .............. 75
Aminosyn-PF 10 % .............. 75
Aminosyn-PF 7 % (Sulfite-
Free) .................................. 75
amiodarone ........................... 32
Amitiza ................................. 54
amitriptyline ......................... 26
amitriptyline-chlordiazepoxide
........................................... 26
amlodipine ............................. 33
amlodipine-benazepril ........... 33
ammonium chloride .............. 74
ammonium lactate ................. 41
Amnesteem ........................... 42
amoxapine ............................. 26
amoxicillin .............................. 8
amoxicillin-pot clavulanate . 8, 9
Amphetamine Salt Combo .... 27
Amphotec ................................ 1
amphotericin B ........................ 1
ampicillin ................................ 9
ampicillin sodium .................... 9
ampicillin-sulbactam ............... 9
Amrix .................................... 22
Amturnide ............................. 39
anagrelide .............................. 46
anastrozole ............................ 12
Ancobon .................................. 1
AndroGel ............................... 52
Androxy ................................ 52
Antabuse ............................... 46
Antivert ................................. 54
Anzemet ................................ 54
Aplenzin ................................ 27
APOKYN .............................. 20
apraclonidine ......................... 69
Apri ....................................... 64
Apriso .................................... 54
Aptivus .................................... 2
Aralast NP ............................. 46
Aranelle (28) ......................... 64
Aranesp (polysorbate) ..... 57, 58
Arcalyst ................................. 58
Aricept ................................... 21
Aricept ODT ......................... 21
Arimidex ............................... 12
Arixtra ................................... 38
Aromasin ............................... 12
Arranon ................................. 12
Arthrotec 50 .......................... 24
Arthrotec 75 .......................... 24
Arzerra .................................. 12
Asacol ................................... 54
Asacol HD ............................. 54
Ascomp w/Codeine ............... 22
Page 79 of 89
Asmanex Twisthaler ............. 71
Astelin ................................... 48
Atelvia ................................... 61
atenolol .................................. 33
atenolol-chlorthalidone ......... 33
Atgam .................................... 60
atorvastatin ............................ 39
atovaquone-proguanil.............. 6
ATRIPLA ................................ 2
atropine.................................. 53
Atrovent HFA ....................... 71
AVASTIN ............................. 12
Avelox ................................... 10
Avelox ABC Pack ................. 10
Avelox in NaCl (iso-osmotic)
........................................... 10
Aviane ................................... 64
Avita ...................................... 42
Avodart.................................. 73
Avonex .................................. 58
Avonex Administration Pack 58
Azactam .................................. 6
Azactam-iso-osmotic dextrose 6
Azasan ................................... 12
Azasite ................................... 66
azathioprine ........................... 12
azathioprine sodium .............. 12
azelastine ......................... 48, 67
Azelex ................................... 42
AZILECT .............................. 20
azithromycin............................ 5
Azopt ..................................... 68
Azor ....................................... 33
aztreonam ................................ 6
BACiiM ................................... 6
bacitracin ........................... 6, 66
bacitracin-polymyxin B......... 66
baclofen ................................. 22
Bactroban .............................. 43
Bactroban Nasal .................... 48
balsalazide ............................. 54
Balziva (28) ........................... 64
Banzel.................................... 17
Baraclude ................................ 2
Beconase AQ......................... 71
benazepril .............................. 33
benazepril-hydrochlorothiazide
........................................... 33
Benlysta ................................. 62
Bentyl .................................... 54
benztropine ........................... 20
betamethasone dipropionate . 44
betamethasone valerate ......... 44
betamethasone, augmented ... 44
Betaseron .............................. 58
betaxolol ......................... 33, 67
bethanechol chloride ............. 74
Betoptic S ............................. 67
bicalutamide ......................... 12
Bicillin C-R ............................ 9
Bicillin L-A ............................ 9
BiCNU .................................. 12
Biltricide ................................. 6
bisoprolol fumarate ............... 33
bisoprolol-hydrochlorothiazide
.......................................... 33
bleomycin ............................. 12
Bleph-10 ............................... 69
Blephamide ........................... 69
Blephamide S.O.P. ............... 69
Boniva ................................... 62
Boostrix (PF) ........................ 60
Briellyn ................................. 64
brimonidine ........................... 69
bromfenac ............................. 68
bromocriptine ....................... 20
Brovana ................................. 71
Budeprion SR ....................... 27
Budeprion XL ....................... 27
budesonide ...................... 54, 71
bumetanide ........................... 33
Buphenyl ............................... 46
buprenorphine ....................... 23
Buproban .............................. 48
bupropion HCl ...................... 27
buspirone .............................. 27
Busulfex ................................ 12
butorphanol tartrate .............. 25
Byetta .................................... 50
Bystolic ................................. 33
cabergoline ........................... 52
Caduet ................................... 39
calcipotriene ......................... 41
calcitonin (salmon) ............... 52
calcitriol ................................ 52
calcium acetate ..................... 74
Camila ................................... 62
Campath ................................ 12
Campral ................................ 46
Canasa ................................... 54
Cancidas .................................. 1
Cantil ..................................... 54
Capastat ................................... 6
Capex .................................... 44
Caprelsa ................................. 12
captopril ................................ 33
captopril-hydrochlorothiazide
........................................... 33
Carac ..................................... 41
Carafate ................................. 56
carbamazepine ....................... 17
Carbatrol ............................... 17
carbidopa-levodopa ............... 20
carbinoxamine maleate ......... 69
carboplatin ............................. 12
Cardura XL ........................... 33
Carimune NF Nanofiltered.... 60
carisoprodol ........................... 22
carisoprodol-ASA-codeine.... 22
carisoprodol-aspirin .............. 22
Carnitor ................................. 46
carteolol ................................. 67
Cartia XT .............................. 33
carvedilol ............................... 34
Casodex ................................. 12
Cedax ...................................... 4
CeeNU ................................... 12
cefaclor .................................... 4
cefadroxil ................................ 4
cefazolin .................................. 4
cefazolin in dextrose (iso-os) .. 4
cefdinir .................................... 4
cefepime .................................. 5
cefotaxime ............................... 5
cefotetan .................................. 5
cefoxitin .................................. 5
cefpodoxime ............................ 5
cefprozil .................................. 5
ceftazidime in D5W ................ 5
ceftriaxone ............................... 5
cefuroxime axetil..................... 5
cefuroxime sodium .................. 5
Celebrex ................................ 25
Celestone ............................... 49
CellCept ................................ 12
CellCept Intravenous ............ 12
Celontin ................................. 17
Cenestin ................................. 62
cephalexin ............................... 5
Cerezyme .............................. 52
Page 80 of 89
Cervarix Vaccine (PF) .......... 60
Cesamet ................................. 54
cetirizine .......................... 69, 77
Chantix .................................. 48
Chantix Starting Month Box . 48
Chemet .................................. 46
Child Allergy Relf(cetirizine)
........................................... 77
Children's Allegra Allergy .... 77
Children's Allergy Relief ...... 77
Children's Clear-Atadine ....... 77
Children's Wal-Zyr ................ 77
chloramphenicol sod succinate 6
chlorhexidine gluconate ........ 48
chloroquine phosphate ............ 6
chlorothiazide ........................ 34
chlorothiazide sodium ........... 34
chlorpromazine...................... 27
chlorpropamide ..................... 50
chlorthalidone........................ 34
chlorzoxazone ....................... 22
Cholestyramine Light ............ 39
ciclopirox .............................. 43
cilostazol ............................... 38
Ciloxan .................................. 66
cimetidine .............................. 56
cimetidine HCl ...................... 56
Cipro...................................... 10
Cipro HC ............................... 48
CIPRODEX ........................... 48
ciprofloxacin ................... 10, 66
ciprofloxacin (mixture) ......... 10
cisplatin ................................. 12
citalopram.............................. 27
cladribine ............................... 12
Claforan ................................... 5
Claravis ................................. 42
Clarinex ................................. 70
Clarinex-D 12 HOUR ........... 70
Clarinex-D 24 HOUR ........... 70
clarithromycin ..................... 5, 6
Clear-Atadine ........................ 77
clemastine.............................. 70
Cleocin .................................... 6
Cleocin in D5W ...................... 6
clindamycin HCl ..................... 6
clindamycin phosphate 6, 42, 63
clindamycin-benzoyl peroxide
........................................... 42
Clinimix 2.75%/D5 Sulfite Free
.......................................... 75
Clinimix 4.25%/D5 Sulfite Free
.......................................... 46
Clinimix 4.25/D10 Sulfite Free
.......................................... 75
Clinimix 4.25/D20 Sulfite Free
.......................................... 75
Clinimix 5%/D15 Sulfite Free
.......................................... 75
Clinimix 5%/D20 Sulfite Free
.......................................... 75
Clinimix 5%/D25 Sulfite Free
.......................................... 75
Clinimix E 2.75/D10 SulfitFree
.......................................... 46
Clinimix E 2.75/D5 SulfiteFree
.......................................... 47
Clinimix E 4.25/D25 SulfitFree
.......................................... 75
Clinimix E 4.25/D5 SulfiteFree
.......................................... 75
Clinimix E 5%/D15 Sulfite
Free ................................... 75
Clinimix E 5%/D20 Sulfite
Free ................................... 76
Clinimix E 5%/D25 Sulfite
Free ................................... 76
clobetasol .............................. 44
clobetasol-emollient ............. 44
CLOLAR .............................. 12
clomipramine ........................ 27
clonazepam ........................... 27
clonidine ............................... 34
clopidogrel ............................ 38
clorazepate dipotassium ........ 27
Clorpres ................................ 34
clotrimazole ...................... 1, 43
clotrimazole-betamethasone . 43
clozapine ............................... 27
Clozaril ................................. 27
cod-butalbital-acetaminop-caf
.......................................... 23
codeine sulfate ...................... 23
colchicine-probenecid ........... 61
Colcrys .................................. 61
colestipol ............................... 39
colistin (colistimethate Na) ..... 7
Coly-Mycin S ....................... 48
Combigan ............................. 68
Combivent ............................. 71
Combivir ................................. 2
Complera ................................. 2
Compro ................................. 54
Comtan .................................. 20
Comvax (PF) ......................... 60
Concerta ................................ 27
Copaxone .............................. 21
Cordran ................................. 44
Coreg CR .............................. 34
cortisone ................................ 49
Cortisporin ............................ 43
Cortisporin-TC ...................... 49
Cosmegen .............................. 12
Cozaar ................................... 34
Creon ..................................... 54
Crestor ................................... 39
Crinone .................................. 62
Crixivan ................................... 2
cromolyn ................... 54, 67, 71
Cryselle (28) .......................... 64
CUBICIN ................................ 7
Curity Gauze ......................... 50
Cyclafem 1/35 (28) ............... 64
Cyclafem 7/7/7 (28) .............. 64
cyclobenzaprine .................... 22
cyclophosphamide ................. 12
cyclosporine .................... 12, 13
cyclosporine modified ........... 13
Cyklokapron .......................... 38
Cymbalta ............................... 27
cyproheptadine ...................... 70
Cystadane .............................. 54
Cystagon ............................... 74
cytarabine .............................. 13
cytarabine (PF) ...................... 13
Cytovene ................................. 2
D10 % & 0.45 % sodium
chloride ............................. 47
D2.5 %-0.45 % sodium
chloride ............................. 47
D5 % and 0.9 % sodium
chloride ............................. 47
D5 %-0.45 % sodium chloride
........................................... 47
D5 in 0.45%NaCl & potassium
Cl ....................................... 74
D5-0.225 % NaCl and KCl ... 74
D5-0.33 % NaCl & potassium
chl ...................................... 74
Page 81 of 89
D5-0.9%NaCl-potassium
chloride.............................. 74
D5-LR with potassium chloride
........................................... 74
D5W with potassium chloride
........................................... 74
dacarbazine ............................ 13
Dacogen ................................ 13
danazol .................................. 52
dantrolene .............................. 22
dapsone.................................... 7
Daptacel (Pediatric) (PF) ...... 60
Daraprim ................................. 7
daunorubicin.......................... 13
DECAVAC (PF) ................... 60
demeclocycline ...................... 10
Demser .................................. 34
Denavir .................................. 44
Depakote ............................... 17
Depakote ER ......................... 17
Depakote Sprinkles ............... 17
Depen Titratabs ..................... 62
Depo-Estradiol ...................... 62
Depo-Provera ........................ 62
Depo-SubQ provera 104 ....... 62
Derma-Smoothe/FS Body Oil
........................................... 45
DermOtic Oil......................... 48
desipramine ........................... 27
desmopressin ......................... 52
Desonate ................................ 45
desonide ................................ 45
desoximetasone ..................... 45
Desoxyn ................................ 27
Detrol .................................... 73
Detrol LA .............................. 73
dexamethasone ...................... 49
Dexamethasone Intensol ....... 49
dexamethasone sodium
phosphate .................... 49, 69
Dexilant ................................. 57
dexmethylphenidate .............. 27
DexPak .................................. 49
dexrazoxane .......................... 11
dextroamphetamine ............... 27
dextrose 10 % & 0.225 % NaCl
........................................... 47
dextrose 10% in water (D10W)
........................................... 47
dextrose 5% in water (D5W) 47
dextrose 5%-0.225 % NaCl .. 47
dextrose 5%-0.33%
sod.chloride ...................... 47
dextrose 5%-lactated ringers 74
diazepam ......................... 27, 28
Diazepam Intensol ................ 28
Dibenzyline ........................... 34
diclofenac potassium ............ 25
diclofenac sodium ........... 25, 68
dicloxacillin ............................ 9
dicyclomine .......................... 54
didanosine ............................... 2
diflorasone ............................ 45
diflunisal ............................... 25
digoxin .................................. 38
dihydroergotamine ................ 21
Dilantin ................................. 17
Dilantin Infatabs ................... 17
Dilaudid-5 ............................. 23
DILT-CD .............................. 34
diltiazem HCl ........................ 34
DILT-XR .............................. 34
Diovan .................................. 34
Diovan HCT ......................... 34
Dipentum .............................. 54
diphenhydramine HCl .......... 70
diphenoxylate-atropine ......... 54
dipyridamole ......................... 38
disopyramide ........................ 32
disulfiram .............................. 47
Diuril ..................................... 34
Diuril IV ............................... 34
divalproex ............................. 17
Divigel .................................. 62
Docefrez ............................... 13
docetaxel ............................... 13
donepezil ............................... 21
Doribax ................................... 7
dorzolamide .......................... 68
dorzolamide-timolol ............. 68
Dovonex ............................... 41
doxazosin .............................. 34
doxepin ................................. 28
Doxil ..................................... 13
doxorubicin ........................... 13
doxycycline hyclate ........ 10, 11
doxycycline monohydrate .... 11
dronabinol ............................. 55
Droxia ................................... 13
DUETACT ........................... 50
Duramorph (PF) .................... 23
DynaCirc CR ......................... 34
Dyrenium .............................. 34
E.E.S. 400 ............................... 6
econazole ............................... 43
Edarbi .................................... 35
Edarbyclor ............................. 35
Edecrin .................................. 35
Edurant .................................... 2
Effexor XR ............................ 28
ELAPRASE .......................... 52
ELESTAT ............................. 67
Elidel ..................................... 41
Eligard ................................... 13
Eliphos .................................. 74
Elitek ..................................... 11
Elixophyllin ........................... 71
Ellence ................................... 13
Elmiron ................................. 74
Eloxatin ................................. 13
Elspar .................................... 13
Emadine ................................ 67
Emcyt .................................... 13
Emend ................................... 55
Emoquette ............................. 64
Emsam ................................... 28
Emtriva .................................... 2
Enablex ................................. 73
enalapril maleate ................... 35
enalapril-hydrochlorothiazide
........................................... 35
Enbrel .................................... 62
Endocet ................................. 23
Endometrin ............................ 62
Engerix-B (PF) ...................... 60
Enjuvia .................................. 62
enoxaparin ............................. 38
Enpresse ................................ 64
Entocort EC ........................... 55
Enulose .................................. 55
epinastine .............................. 67
epinephrine HCl .................... 70
EpiPen ................................... 70
EpiPen Jr ............................... 70
epirubicin .............................. 13
Epitol ..................................... 17
Epivir ....................................... 2
Epivir HBV ............................. 2
eplerenone ............................. 35
Epogen .................................. 58
Page 82 of 89
eprosartan .............................. 35
Epzicom .................................. 2
Equetro .................................. 17
Eraxis(Water Diluent) ............. 1
Erbitux ................................... 13
ergoloid ................................. 28
ergotamine-caffeine .............. 21
Erivedge ................................ 13
Errin ...................................... 62
Ery Pads ................................ 42
EryPed 200 .............................. 6
Ery-Tab ................................... 6
Erythrocin................................ 6
Erythrocin Stearate .................. 6
erythromycin ..................... 6, 66
erythromycin ethylsuccinate ... 6
erythromycin with ethanol .... 42
erythromycin-benzoyl peroxide
........................................... 42
escitalopram .......................... 28
Estrace ................................... 62
estradiol ........................... 62, 63
estradiol valerate ................... 63
estradiol-norethindrone acet .. 63
Estring ................................... 63
estropipate ............................. 63
ethambutol ............................... 7
ethosuximide ......................... 17
etidronate disodium ............... 47
etodolac ................................. 25
Etopophos.............................. 13
etoposide ............................... 13
Eurax ..................................... 46
Evamist.................................. 63
Evista ..................................... 62
Evoxac ................................... 47
Exelderm ............................... 43
Exelon ................................... 21
exemestane ............................ 13
Exforge .................................. 35
Exforge HCT ......................... 35
Exjade.................................... 47
Extina .................................... 43
Fabrazyme ............................. 52
Factive ................................... 10
famciclovir .............................. 2
famotidine ............................. 57
famotidine (PF) ..................... 57
famotidine (PF)-NaCl (iso-os)
........................................... 57
Fanapt ................................... 28
Fareston ................................ 13
Faslodex ................................ 13
FazaClo ................................. 28
felbamate .............................. 17
Felbatol ................................. 17
felodipine .............................. 35
Femara .................................. 13
Femcon Fe ............................ 64
Femhrt 1/5 ............................ 63
Femhrt Low Dose ................. 63
Femring ................................. 63
fenofibrate ............................. 39
fenofibrate micronized .......... 39
fenoprofen ............................. 25
fentanyl ................................. 23
fentanyl citrate ...................... 23
Fibricor ................................. 39
Finacea .................................. 42
finasteride ............................. 73
Flagyl ER ................................ 7
Flarex .................................... 69
flavoxate ............................... 73
flecainide .............................. 32
Flovent HFA ......................... 71
fluconazole ............................. 1
fluconazole in dextrose(iso-o) 1
flucytosine .............................. 1
fludarabine ............................ 13
fludrocortisone ...................... 49
flunisolide ............................. 71
fluocinolone .......................... 45
fluocinolone acetonide oil .... 48
fluocinonide .......................... 45
Fluocinonide-E ..................... 45
Fluoroplex ............................. 41
fluorouracil ..................... 13, 41
fluoxetine .............................. 28
fluphenazine decanoate ........ 28
fluphenazine HCl .................. 28
flurbiprofen ........................... 25
flurbiprofen sodium .............. 68
flutamide ............................... 13
fluticasone ....................... 45, 71
fluvastatin ............................. 39
fluvoxamine .......................... 28
FML Forte ............................ 69
FML S.O.P. ........................... 69
Focalin .................................. 28
Focalin XR ............................ 28
fomepizole ............................. 60
fondaparinux ......................... 38
Fortaz ...................................... 5
Fortaz in D5W ......................... 5
Forteo .................................... 62
FORTICAL ........................... 52
Fosamax Plus D .................... 62
foscarnet .................................. 2
fosinopril ............................... 35
fosinopril-hydrochlorothiazide
........................................... 35
fosphenytoin .......................... 17
FOSRENOL .......................... 47
Fragmin ................................. 38
Freamine III 3 %-Electrolytes
........................................... 76
Freamine III 8.5 % ................ 76
Furadantin ............................. 11
furosemide ............................. 35
Fusilev ................................... 11
Fuzeon ..................................... 2
gabapentin ............................. 18
Gabitril .................................. 18
galantamine ........................... 21
Gammagard Liquid ............... 60
Gamunex-C ........................... 60
ganciclovir ............................... 2
ganciclovir sodium .................. 2
Gardasil (PF) ......................... 60
Gastrocrom ............................ 55
Gavilyte-C ............................. 55
GaviLyte-N ........................... 55
gemcitabine ........................... 13
gemfibrozil ............................ 40
Gemzar .................................. 13
Gengraf ................................. 14
Genotropin ............................ 58
Genotropin Miniquick ........... 58
Gentak ................................... 66
gentamicin ................... 7, 43, 66
gentamicin in NaCl (iso-osm) . 7
gentamicin sulfate (PF) ........... 7
Geodon .................................. 28
Gianvi .................................... 64
Gleevec ................................. 14
glimepiride ............................ 50
glipizide ................................. 50
glipizide-metformin .............. 50
GlucaGen HypoKit ............... 50
Glucagon Emergency ............ 50
Page 83 of 89
glyburide ............................... 50
glyburide micronized ............ 50
glyburide-metformin ............. 50
glycopyrrolate ....................... 54
Golytely ................................. 55
Gralise ................................... 18
Gralise 30-Day Starter Pack .. 18
granisetron ............................. 55
granisetron (PF)..................... 55
Granisol ................................. 55
griseofulvin microsize ............. 1
Gris-PEG ................................. 1
guanfacine ............................. 35
Halaven ................................. 14
Haldol .................................... 29
Haldol Decanoate .................. 29
halobetasol propionate .......... 45
Halog ..................................... 45
haloperidol ............................ 29
haloperidol decanoate ........... 29
haloperidol lactate ................. 29
Havrix (PF) ........................... 60
Hectorol ................................. 52
Helidac .................................. 57
heparin (porcine) ................... 38
heparin (porcine) in D5W ..... 38
heparin (porcine) in NaCl (PF)
........................................... 39
heparin(porcine) in 0.45%
NaCl .................................. 39
Hepatamine 8% ..................... 76
Hepatasol 8 % ....................... 76
Hepsera.................................... 2
Herceptin ............................... 14
Hexalen ................................. 14
huber safety needles (disp.) ... 50
Humalog ................................ 50
Humalog KwikPen ................ 50
Humalog Mix 50-50 .............. 50
Humalog Mix 50-50 KwikPen
........................................... 50
Humalog Mix 75-25 .............. 50
Humalog Mix 75-25 KwikPen
........................................... 51
Humatrope ............................. 58
Humira .................................. 62
Humira Crohn's Dis Start Pck
........................................... 62
Hycamtin ............................... 14
hydralazine ............................ 35
hydrochlorothiazide .............. 35
hydrocodone-acetaminophen 23
hydrocodone-ibuprofen ........ 23
hydrocortisone .......... 45, 49, 55
hydrocortisone valerate ........ 45
hydrocortisone-acetic acid .... 48
hydromorphone ..................... 23
hydromorphone (PF) ............ 23
hydroxychloroquine ................ 7
hydroxyurea .......................... 14
hydroxyzine HCl .................. 70
hydroxyzine pamoate ............ 70
Hyzaar ................................... 35
ibandronate ........................... 62
ibuprofen ............................... 25
ibuprofen-oxycodone ............ 23
idarubicin .............................. 14
Ifex ........................................ 14
ifosfamide ............................. 14
imipenem-cilastatin ................ 7
imipramine HCl .................... 29
imipramine pamoate ............. 29
imiquimod ............................. 41
Incivek .................................... 2
Increlex ................................. 47
indapamide ........................... 35
Indocin .................................. 25
indomethacin ........................ 25
Infanrix (PF) ......................... 60
Infergen ................................. 58
Inlyta ..................................... 14
Insulin Pen Needle ................ 51
insulin syringe-needle U-100 51
Intelence ................................. 2
Intralipid ............................... 76
Intron A ................................ 58
Introvale ................................ 64
Intuniv ER ............................ 29
Invanz ..................................... 7
Invega ................................... 29
Invega Sustenna .................... 29
Invirase ................................... 2
Ionosol-B in D5W ................ 76
Ionosol-MB in D5W ............. 76
Iopidine ................................. 69
IPOL ..................................... 60
ipratropium bromide ....... 48, 72
ipratropium-albuterol ............ 72
irbesartan .............................. 35
irbesartan-hydrochlorothiazide
........................................... 35
irinotecan ............................... 14
Isentress ................................... 2
Isolyte-H in D5W .................. 76
Isolyte-P in D5W .................. 76
Isolyte-S ................................ 76
Isolyte-S in D5W .................. 76
isoniazid .................................. 7
Isopto Carpine ....................... 67
isosorbide dinitrate ................ 40
isosorbide mononitrate .......... 40
isradipine ............................... 35
itraconazole ............................. 1
Ixempra ................................. 14
Ixiaro (PF) ............................. 61
Jakafi ..................................... 14
Jalyn ...................................... 74
Jantoven ................................ 39
Janumet ................................. 51
Janumet XR ........................... 51
Januvia .................................. 51
Jentadueto ............................. 51
Jevtana ................................... 14
Jinteli ..................................... 63
Jolivette ................................. 63
Junel 1.5/30 (21) ................... 64
Junel 1/20 (21) ...................... 64
Junel FE 1.5/30 (28) .............. 64
Junel FE 1/20 (28) ................. 64
Kaletra ..................................... 2
kanamycin ............................... 7
Kariva .................................... 64
Kelnor 1/35 (28) .................... 64
Kenalog ................................. 45
Kepivance ............................. 11
Keppra ................................... 18
Keppra XR ............................ 18
KETEK ................................... 7
ketoconazole ..................... 1, 43
ketoprofen ............................. 25
ketorolac .......................... 25, 68
Kineret ................................... 62
Kionex ................................... 47
Klor-Con ............................... 74
Klor-Con 10 .......................... 74
Klor-Con M15 ....................... 74
Klor-Con M20 ....................... 74
Kombiglyze XR .................... 51
Kuvan .................................... 52
Page 84 of 89
labetalol ................................. 35
LAClotion ............................. 41
lactated ringers ................ 46, 74
lactulose ................................ 55
Lamictal ................................ 18
Lamictal Starter (Blue) Kit ... 18
Lamictal Starter (Green) Kit . 18
Lamictal Starter (Orange) Kit18
Lamictal XR .......................... 18
Lamictal XR Starter (Blue) ... 18
Lamictal XR Starter (Green) . 18
Lamictal XR Starter (Orange)
........................................... 18
lamivudine ............................... 2
lamivudine-zidovudine............ 3
lamotrigine ............................ 18
Lanoxin Pediatric .................. 38
lansoprazole .......................... 57
Lantus .................................... 51
Lantus Solostar ...................... 51
latanoprost ............................. 68
Latuda.................................... 29
Leena 28 ................................ 65
leflunomide ........................... 62
Lessina .................................. 65
letrozole ................................. 14
leucovorin calcium .......... 11, 12
Leukeran................................ 14
Leukine............................ 58, 59
leuprolide .............................. 14
levalbuterol HCl .................... 72
Levaquin................................ 10
Levaquin in D5W .................. 10
Levatol .................................. 35
Levemir ................................. 51
Levemir Flexpen ................... 51
levetiracetam ................... 18, 19
levobunolol............................ 67
levocarnitine .......................... 47
levocarnitine (with sugar) ..... 47
levocetirizine ......................... 70
levofloxacin ..................... 10, 66
levofloxacin in D5W ............. 10
Levora-28 .............................. 65
levorphanol tartrate ............... 23
levothyroxine ........................ 53
Levoxyl ................................. 53
Lexapro ................................. 29
Lexiva...................................... 3
Lialda .................................... 55
lidocaine ............................... 42
lidocaine (PF) ....................... 42
lidocaine HCl ........................ 42
lidocaine-prilocaine .............. 42
Lidoderm .............................. 42
lindane .................................. 46
liothyronine ........................... 53
lisinopril ................................ 35
lisinopril-hydrochlorothiazide
.......................................... 36
lithium carbonate .................. 29
lithium citrate ........................ 29
Locoid ................................... 45
Lodosyn ................................ 20
Loestrin 24 Fe ....................... 65
loperamide ............................ 54
loratadine .............................. 77
losartan ................................. 36
losartan-hydrochlorothiazide 36
Lotemax ................................ 69
Lotronex ............................... 55
lovastatin ............................... 40
Lovaza .................................. 40
Lovenox ................................ 39
Low-Ogestrel (28) ................ 65
loxapine succinate ................ 29
Lufyllin ................................. 72
Lumigan ................................ 68
Lunesta ................................. 29
Lupron Depot ........................ 14
Lupron Depot (3 Month) ...... 14
Lupron Depot (4 Month) ...... 14
Lupron Depot (6 Month) ...... 14
Lupron Depot-Ped ................ 14
Lupron Depot-Ped (3 Month) 14
Lutera (28) ............................ 65
Luvox CR ............................. 29
Lybrel ................................... 65
Lyrica .................................... 19
Lysodren ............................... 14
Macrodantin .......................... 11
Magnacet .............................. 23
magnesium sulfate ................ 74
Malarone ................................. 7
malathion .............................. 46
maprotiline ............................ 29
Marlissa ................................ 65
Marplan ................................. 29
Matulane ............................... 14
Maxair Autohaler .................. 72
Maxalt ................................... 21
Maxalt-MLT ......................... 21
Maxidex ................................ 69
meclizine ............................... 55
meclofenamate ...................... 25
medroxyprogesterone ............ 63
mefenamic acid ..................... 25
mefloquine .............................. 7
megestrol ............................... 14
meloxicam ............................. 25
melphalan .............................. 14
Menest ................................... 63
Menomune - A/C/Y/W-135
(PF) ................................... 61
Menostar ............................... 63
Menveo A-C-Y-W-135-Dip
(PF) ................................... 61
meperidine ............................. 23
meperidine (PF) .................... 23
meprobamate ......................... 22
Mepron .................................... 7
mercaptopurine ..................... 14
meropenem .............................. 7
Merrem .................................... 7
mesalamine-cleansing wipes . 55
mesna .................................... 12
Mesnex .................................. 12
Mestinon ............................... 22
Mestinon Timespan ............... 22
Metadate CD ......................... 29
Metadate ER .......................... 29
metaproterenol ...................... 72
metformin .............................. 51
methadone ....................... 23, 24
Methadose ............................. 24
methamphetamine ................. 29
methazolamide ...................... 68
methenamine hippurate ......... 11
Methergine ............................ 66
methimazole .......................... 50
Methitest ............................... 52
methocarbamol ...................... 22
methotrexate sodium ............. 14
methotrexate sodium (PF) .... 14,
15
methscopolamine .................. 54
methyclothiazide ................... 36
methyldopa ............................ 36
methyldopa-
hydrochlorothiazide .......... 36
Page 85 of 89
methyldopate ......................... 36
methylergonovine.................. 66
Methylin ................................ 30
methylphenidate .................... 30
methylprednisolone ............... 49
methylprednisolone acetate ... 49
methylprednisolone sodium
succ.................................... 49
metipranolol .......................... 67
metoclopramide HCl ............. 55
metolazone ............................ 36
metoprolol succinate ............. 36
metoprolol ta-hydrochlorothiaz
........................................... 36
metoprolol tartrate ................. 36
Metrogel ................................ 42
metronidazole .............. 7, 42, 64
metronidazole in NaCl (iso-os)
............................................. 7
mexiletine .............................. 32
Miacalcin ............................... 52
Micardis ................................ 36
Micardis HCT ....................... 36
Miconazole-3 ........................ 64
Microgestin 1.5/30 (21)......... 65
Microgestin 1/20 (21)............ 65
Microgestin Fe 1.5/30 (28) .... 65
Microgestin FE 1/20 (28) ...... 65
midodrine .............................. 47
Migergot ................................ 21
Migranal ................................ 21
Millipred................................ 49
Minitran ................................. 40
minocycline ........................... 11
minoxidil ............................... 36
Mirapex ................................. 20
Mirapex ER ........................... 20
mirtazapine ............................ 30
misoprostol ............................ 57
mitomycin ............................. 15
mitoxantrone ......................... 15
M-M-R II (PF) ...................... 61
moexipril ............................... 36
moexipril-hydrochlorothiazide
........................................... 36
mometasone .................... 45, 46
Mononessa (28) ..................... 65
Monurol ................................. 11
morphine ............................... 24
morphine concentrate ............ 24
Motofen ................................ 54
MoviPrep .............................. 55
Moxatag .................................. 9
Moxeza ................................. 67
Multaq ................................... 32
mupirocin .............................. 43
Mustargen ............................. 15
Mycamine ............................... 1
Mycobutin ............................... 7
mycophenolate mofetil ......... 15
Myfortic ................................ 15
Myozyme .............................. 52
Mytelase ............................... 21
nabumetone ........................... 25
nadolol .................................. 36
nadolol-bendroflumethiazide 36
nafcillin ................................... 9
nafcillin in D2.4W .................. 9
Naglazyme ............................ 52
nalbuphine ............................ 25
Nalfon ................................... 25
naloxone ............................... 25
naltrexone ............................. 25
Namenda ............................... 21
Namenda Titration Pak ......... 21
naproxen ......................... 25, 26
naproxen sodium .................. 26
Nardil .................................... 30
Nasacort AQ ......................... 72
Nasonex ................................ 72
Natacyn ................................. 67
nateglinide ............................ 51
Nebupent ................................. 7
Necon 0.5/35 (28) ................. 65
Necon 1/35 (28) .................... 65
Necon 10/11 (28) .................. 65
Necon 7/7/7 (28) ................... 65
nefazodone ............................ 30
neomycin ................................ 8
neomycin-bacitracin-poly-HC
.......................................... 68
neomycin-bacitracin-
polymyxin ......................... 67
neomycin-polymyxin B GU . 46
neomycin-polymyxin-dexameth
.......................................... 68
neomycin-polymyxin-
gramicidin ......................... 67
neomycin-polymyxin-HC49, 68
Neoral ................................... 15
Nephramine 5.4 % ................ 76
Neulasta ................................. 59
Neumega ............................... 59
Neupogen .............................. 59
Neurontin .............................. 19
Nevanac ................................. 68
nevirapine ................................ 3
Nexavar ................................. 15
Niacor .................................... 40
Niaspan Extended-Release .... 40
nicardipine ............................. 36
Nicotrol ................................. 48
Nicotrol NS ........................... 48
Nifediac CC .......................... 36
Nifedical XL ......................... 36
nifedipine .............................. 36
Nilandron .............................. 15
nimodipine ............................ 36
nisoldipine ............................. 36
Nitro-Bid ............................... 40
nitrofurantoin ........................ 11
nitrofurantoin macrocrystal ... 11
nitrofurantoin monohyd/m-
cryst ................................... 11
nitroglycerin .......................... 40
Nitrolingual ........................... 40
Nitrostat ................................. 41
nizatidine ............................... 57
Non-Drowsy Allergy ............ 77
Nora-BE ................................ 63
Norditropin FlexPro .............. 59
Norditropin Nordiflex ........... 59
norethindrone acetate ............ 63
Normosol-R in D5W ............. 75
Normosol-R pH 7.4 ............... 76
Noroxin ................................. 10
Nortrel 0.5/35 (28) ................ 65
Nortrel 1/35 (21) ................... 65
Nortrel 1/35 (28) ................... 65
Nortrel 7/7/7 (28) .................. 65
nortriptyline ........................... 30
Norvir ...................................... 3
Novolin 70/30 ....................... 51
Novolin N .............................. 51
Novolin R .............................. 51
Novolog ................................. 51
Novolog Flexpen ................... 51
Novolog Mix 70-30 ............... 51
Novolog Mix 70-30 FlexPen 51
Nulojix .................................. 15
Page 86 of 89
NuLYTELY with Flavor Packs
........................................... 55
Nutropin ................................ 59
Nutropin AQ ......................... 59
Nutropin AQ Nuspin ............. 59
Nyamyc ................................. 43
nystatin .............................. 1, 43
nystatin-triamcinolone .......... 43
Nystop ................................... 44
Ocella .................................... 65
octreotide acetate ................... 15
ofloxacin.................... 10, 48, 67
Ogestrel (28) ......................... 65
olanzapine ............................. 30
omeprazole ...................... 57, 77
omeprazole magnesium......... 77
Omnaris ................................. 72
Omnitrope ............................. 59
ondansetron ........................... 55
ondansetron HCl ................... 55
ondansetron HCl (PF) ........... 56
Onfi ....................................... 19
Onglyza ................................. 51
Ontak ..................................... 15
Opana .................................... 24
Opana ER .............................. 24
Oracea ................................... 11
Orap ....................................... 30
Orapred ODT ........................ 49
Orfadin .................................. 47
orphenadrine citrate ............... 22
Orphenadrine Compound ...... 22
Orphenadrine Compound-DS 22
Orsythia ................................. 65
Ortho Tri-Cyclen Lo ............. 65
OsmoPrep .............................. 56
OTC-PRODUCT ................... 69
Ovcon-50 (28) ....................... 65
oxacillin ................................... 9
oxacillin in dextrose, iso-osm . 9
oxaliplatin.............................. 15
oxandrolone ........................... 52
oxaprozin ............................... 26
oxcarbazepine ........................ 19
Oxsoralen .............................. 41
Oxsoralen Ultra ..................... 41
oxybutynin chloride .............. 73
oxycodone ............................. 24
oxycodone-acetaminophen .... 24
oxycodone-aspirin ................. 24
oxymorphone ........................ 24
Pacerone ............................... 32
paclitaxel ............................... 15
PALGIC ................................ 70
pamidronate .......................... 53
Pancreaze .............................. 56
Panretin ................................. 41
pantoprazole ......................... 57
paromomycin .......................... 8
paroxetine HCl ...................... 30
Paser ....................................... 8
Pataday ................................. 68
Patanase ................................ 48
Patanol .................................. 68
Paxil ...................................... 30
Pedi-Dri ................................ 44
Pedvax HIB (PF) .................. 61
Peganone ............................... 19
Pegasys ................................. 59
Pegasys Convenience Pack ... 59
Pegasys ProClick .................. 59
PegIntron .............................. 59
PegIntron Redipen ................ 59
penicillin G pot in dextrose .... 9
penicillin G potassium ............ 9
penicillin G procaine .............. 9
penicillin G sodium ................ 9
penicillin V potassium ............ 9
Pentam .................................... 8
Pentasa .................................. 56
pentazocine-acetaminophen . 26
pentazocine-naloxone ........... 26
pentostatin ............................. 15
pentoxifylline ........................ 39
Pepcid ................................... 57
Perforomist ........................... 72
Periogard ............................... 48
permethrin ............................. 46
perphenazine ......................... 30
perphenazine-amitriptyline ... 30
PEXEVA .............................. 30
Pfizerpen-G ............................. 9
Phenadoz ............................... 70
phenelzine ............................. 30
phenobarbital ........................ 19
Phenytek ............................... 19
phenytoin .............................. 19
phenytoin sodium ................. 19
phenytoin sodium extended .. 19
Phisohex ............................... 43
Phospholine Iodide ................ 67
pilocarpine HCl ..................... 47
Pilopine HS ........................... 67
pindolol ................................. 36
piperacillin-tazobactam ........... 9
piroxicam .............................. 26
Plasma-Lyte 148 ................... 76
Plasma-Lyte A ...................... 76
Plasma-Lyte-56 in D5W ....... 76
Plavix .................................... 39
podofilox ............................... 41
polyethylene glycol 3350 ...... 56
polymyxin B sulfate ................ 8
Portia ..................................... 65
potassium chloride ................ 75
Potiga .................................... 19
Pradaxa .................................. 39
pramipexole ........................... 20
Prandimet .............................. 51
Prandin .................................. 51
pravastatin ............................. 40
prazosin ................................. 37
Pred-G ................................... 68
Pred-G S.O.P. ........................ 68
prednicarbate ......................... 46
prednisolone acetate .............. 69
prednisolone sodium phosphate
..................................... 49, 69
prednisone ............................. 49
Prednisone Intensol ............... 49
Premarin ................................ 63
Premasol 10 % ...................... 76
Premasol 6 % ........................ 76
Premphase ............................. 63
Prempro ................................. 63
Prenatal Plus with Iron (Ca) .. 76
Prevacid 24Hr ....................... 77
Prevacid SoluTab .................. 57
Prevalite ................................ 40
Previfem ................................ 65
Prevpac .................................. 57
Prezista .................................... 3
Priftin ...................................... 8
Prilosec OTC ......................... 77
primaquine .............................. 8
Primaxin IV ............................. 8
primidone .............................. 19
Primsol .................................. 11
Pristiq .................................... 30
ProAir HFA ........................... 72
Page 87 of 89
probenecid ............................. 61
procainamide ......................... 32
Procalamine 3% .................... 76
prochlorperazine .................... 56
prochlorperazine Edisylate .... 56
prochlorperazine maleate ...... 56
Procrit .................................... 59
progesterone micronized ....... 63
Proglycem ............................. 51
Prograf ................................... 15
Prolastin C ............................. 47
Proleukin ............................... 59
Promacta................................ 39
promethazine ......................... 70
Promethegan.......................... 70
propafenone ........................... 32
propantheline ......................... 54
proparacaine .......................... 68
propranolol ............................ 37
propranolol-hydrochlorothiazid
........................................... 37
propylthiouracil ..................... 50
ProQuad (PF) ........................ 61
Prosol 20% ............................ 76
Protonix ................................. 57
Protopic ................................. 41
protriptyline ........................... 30
Proventil HFA ....................... 72
Provigil .................................. 30
Prozac Weekly ...................... 30
Pulmicort ............................... 72
Pulmicort Flexhaler ............... 72
Pulmozyme............................ 72
Pylera .................................... 57
pyridostigmine bromide ........ 22
Qualaquin ................................ 8
Quasense ............................... 66
quetiapine .............................. 31
quinapril ................................ 37
quinapril-hydrochlorothiazide
........................................... 37
quinidine gluconate ............... 32
quinidine sulfate .................... 32
Qvar ....................................... 72
RabAvert (PF) ....................... 61
ramipril .................................. 37
Ranexa ................................... 40
ranitidine HCl ........................ 57
Rapamune.............................. 15
REBETOL ............................... 3
Rebif ..................................... 59
Rebif Titration Pack ............. 60
Reclipsen (28) ....................... 66
Recombivax HB (PF) ........... 61
Rectiv .................................... 56
Regonol ................................. 22
Relenza Diskhaler ................... 3
Relistor ................................. 56
Remicade .............................. 56
Remodulin ............................ 37
Renagel ................................. 47
Renvela ................................. 47
Reprexain .............................. 24
Rescriptor ............................... 3
reserpine ............................... 37
Restasis ................................. 68
Retrovir ................................... 3
Revatio .................................. 72
REVLIMID ........................... 15
Reyataz ................................... 3
Rheumatrex ........................... 15
RibaPak Dose Pack ................. 3
Ribasphere .............................. 3
ribavirin .................................. 3
Ridaura ................................. 62
rifampin .................................. 8
Rifater ..................................... 8
Rilutek .................................. 47
rimantadine ............................. 3
ringers ............................. 46, 75
RIOMET ............................... 52
Risperdal Consta ................... 31
Risperdal M-TAB ................. 31
risperidone ............................ 31
Rituxan ................................. 15
rivastigmine .......................... 22
ropinirole .............................. 20
RotaTeq Vaccine .................. 61
Roxicet .................................. 24
Rozerem ................................ 31
Sabril ..................................... 19
Saizen ................................... 60
Saizen click.easy ................... 60
Sanctura ................................ 73
Sanctura XR .......................... 73
Sandimmune ......................... 15
Santyl .................................... 46
Saphris .................................. 31
Sarafem ................................. 31
Seasonique ............................ 66
selegiline HCl ........................ 20
selenium sulfide .................... 41
Selzentry ................................. 3
Sensipar ................................. 53
Serevent Diskus .................... 72
Seromycin ............................... 8
Seroquel ................................ 31
Seroquel XR .......................... 31
Serostim ................................ 60
sertraline ................................ 31
silver sulfadiazine ................. 41
Simulect ................................ 15
simvastatin ............................ 40
Singulair ................................ 72
Skelaxin ................................. 22
Skelid .................................... 47
sodium chloride ............... 47, 75
sodium chloride 0.45 % ........ 75
sodium chloride 0.9 % .......... 48
sodium chloride 3 % ............. 75
sodium chloride 5 % ............. 75
sodium fluoride ..................... 76
sodium lactate ....................... 75
Solaraze ................................. 41
Solu-Cortef (PF) .................... 49
Solu-Medrol .......................... 49
Solu-Medrol (PF) .................. 50
Soma ..................................... 22
Somatuline Depot .................. 15
SOMAVERT ......................... 53
Soriatane ............................... 41
Sorine .................................... 33
sotalol .................................... 33
Spiriva with HandiHaler ....... 72
spironolactone ....................... 37
spironolacton-hydrochlorothiaz
........................................... 37
Sporanox ................................. 1
Sprintec (28) .......................... 66
Sprycel .................................. 16
Sronyx ................................... 66
SSD ....................................... 41
Stagesic ................................. 24
Stalevo 100 ............................ 20
Stalevo 125 ............................ 20
Stalevo 150 ............................ 20
Stalevo 200 ............................ 20
Stalevo 50 .............................. 20
Stalevo 75 .............................. 20
stavudine ................................. 3
Page 88 of 89
Stavzor .................................. 19
Stimate .................................. 53
Strattera ................................. 31
streptomycin ............................ 8
Striant .................................... 53
Stromectol ............................... 8
Suboxone ............................... 26
Sucraid .................................. 56
sucralfate ............................... 57
Sular ...................................... 37
sulfacetamide sodium ............ 69
sulfacetamide sodium (acne) . 43
sulfacetamide-prednisolone .. 69
sulfadiazine ........................... 10
sulfamethoxazole-trimethoprim
........................................... 10
Sulfamylon ............................ 43
sulfasalazine .......................... 56
Sulfazine EC ......................... 56
sulindac ................................. 26
sumatriptan succinate ............ 21
Suprax ..................................... 5
Surmontil ............................... 31
Sustiva ..................................... 3
Sutent .................................... 16
Sylatron ................................. 60
Symbicort .............................. 72
Symbyax................................ 31
SymlinPen 120 ...................... 52
SymlinPen 60 ........................ 52
Synagis .................................... 3
Synarel .................................. 53
Synera.................................... 42
Synercid .................................. 8
Synthroid ............................... 53
Syprine .................................. 48
Tabloid .................................. 16
Taclonex Scalp ...................... 41
tacrolimus .............................. 16
Talwin ................................... 26
Tamiflu .................................... 3
tamoxifen .............................. 16
tamsulosin ............................. 74
Tarceva .................................. 16
Targretin ................................ 16
Tasigna .................................. 16
Tasmar ................................... 20
Tazorac .................................. 42
Taztia XT .............................. 37
Teflaro ..................................... 5
Tegretol XR .......................... 19
Tekturna ................................ 37
Tekturna HCT ....................... 37
terazosin ................................ 37
terbinafine ............................... 1
terbutaline ....................... 72, 73
terconazole ............................ 64
Testim ................................... 53
testosterone cypionate .......... 53
testosterone enanthate ........... 53
Testred .................................. 53
tetanus-diphtheria toxoids-Td61
tetracycline ........................... 11
Tev-Tropin ............................ 60
Thalitone ............................... 37
Thalomid ............................... 16
theophylline .......................... 73
thioridazine ........................... 31
thiotepa ................................. 16
thiothixene ............................ 31
Thymoglobulin ..................... 61
ticlopidine ............................. 39
Tikosyn ................................. 33
Timentin ............................... 10
timolol maleate ............... 37, 67
tizanidine .............................. 22
Tobi ......................................... 8
TobraDex .............................. 68
tobramycin in NS .................... 8
tobramycin sulfate ............ 8, 67
tobramycin-dexamethasone .. 69
Tobrex ................................... 67
Tofranil-PM .......................... 31
tolazamide ............................. 52
tolbutamide ........................... 52
tolmetin ................................. 26
Topamax ............................... 19
topiramate ............................. 19
topotecan ............................... 16
Torisel ................................... 16
torsemide .............................. 37
Tracleer ................................. 73
Tradjenta ............................... 52
tramadol ................................ 26
tramadol-acetaminophen ...... 26
trandolapril ........................... 37
tranylcypromine .................... 31
Travasol 10 % ....................... 76
Travatan Z ............................ 68
trazodone .............................. 31
Treanda ................................. 16
Trecator ................................... 8
Trelstar .................................. 16
tretinoin ................................. 42
tretinoin (chemotherapy) ....... 16
Trexall ................................... 16
triamcinolone acetonide . 46, 48,
73
triamterene-hydrochlorothiazid
........................................... 37
Triderm ................................. 46
trifluoperazine ....................... 31
trifluridine ............................. 67
trihexyphenidyl ..................... 21
Tri-Legest Fe ......................... 66
Trileptal ................................. 19
TriLyte With Flavor Packets . 56
trimethobenzamide ................ 56
trimethoprim ......................... 11
trimethoprim-polymyxin B ... 67
trimipramine .......................... 31
TriNessa (28) ........................ 66
Tri-Previfem (28) .................. 66
Trisenox ................................ 16
Tri-Sprintec (28) ................... 66
Trivora (28) ........................... 66
Trizivir .................................... 3
TrophAmine 10 % ................. 76
Trophamine 6% ..................... 76
tropicamide ........................... 67
trospium ................................ 73
Truvada ................................... 3
Twinject Autoinjector ........... 70
Twinrix (PF) .......................... 61
Tygacil .................................... 8
Tykerb ................................... 16
Typhim VI ............................. 61
TYSABRI ............................. 22
Tyzeka ..................................... 4
Tyzine ................................... 48
U-Cort ................................... 41
Uroxatral ............................... 74
URSO 250 ............................. 56
URSO Forte .......................... 56
ursodiol ................................. 56
Uvadex .................................. 41
valacyclovir ............................. 4
Valcyte .................................... 4
valproate sodium ................... 19
valproic acid .......................... 19
Page 89 of 89
valproic acid (as sodium salt) 19
Valtrex ..................................... 4
Vancocin ............................... 11
vancomycin ........................... 11
Vandazole.............................. 64
Vaqta (PF) ............................. 61
Varivax (PF) .......................... 61
Vectibix ................................. 16
Velcade.................................. 16
Velivet ................................... 66
venlafaxine ...................... 31, 32
Ventavis ................................ 73
Ventolin HFA ........................ 73
verapamil ............................... 38
Veregen ................................. 41
Veripred 20 ........................... 50
Vesicare ................................. 73
Vestura .................................. 66
Vexol ..................................... 69
Vfend ....................................... 1
Vfend IV ................................. 1
Vibramycin............................ 11
Victoza .................................. 52
Victrelis ................................... 4
Vidaza ................................... 16
Videx 2 gram Pediatric ........... 4
Videx EC ................................. 4
Vigamox ................................ 67
Viibryd .................................. 32
Vimpat ............................. 19, 20
vinblastine ............................. 16
vincristine .............................. 16
vinorelbine ............................ 16
Viracept ................................... 4
Viramune ................................. 4
Viramune XR .......................... 4
Viread ..................................... 4
Viroptic ................................. 67
Vistide ..................................... 4
Vivelle-Dot ........................... 63
Vivitrol ................................. 26
Voltaren ................................ 26
voriconazole ........................... 1
Votrient ................................. 16
Vytorin 10-10 ....................... 40
Vytorin 10-20 ....................... 40
Vytorin 10-40 ....................... 40
Vytorin 10-80 ....................... 40
Vyvanse ................................ 32
Wal-itin ................................. 77
Wal-Zyr ................................ 77
warfarin ................................. 39
water for irrigation, sterile .... 48
WelChol ................................ 40
Xalatan .................................. 68
Xalkori .................................. 16
Xenazine ............................... 22
Xgeva .................................... 12
Xifaxan ................................... 8
Xolair .................................... 73
Xopenex ................................ 73
Xopenex HFA ....................... 73
Xyrem ................................... 32
Xyzal ..................................... 71
Yervoy .................................. 16
YF-Vax (PF) ......................... 61
zafirlukast ............................. 73
zaleplon ................................. 32
Zanaflex ................................ 22
Zanosar ................................. 16
ZAVESCA ............................ 53
ZAZOLE ............................... 64
Zelapar .................................. 21
Zelboraf ................................. 16
Zemaira ................................. 48
Zemplar ................................. 53
Zenpep ................................... 56
Zeosa ..................................... 66
Zerit ......................................... 4
Zetia ...................................... 40
Ziagen ..................................... 4
zidovudine ............................... 4
Zinacef in Sterile Water .......... 5
Zinecard ................................ 12
ziprasidone HCl .................... 32
Zirgan .................................... 67
Zmax ....................................... 6
Zolinza .................................. 16
zolpidem ................................ 32
Zometa .................................. 53
zonisamide ............................ 20
Zorbtive ................................. 60
Zortress ................................. 17
ZOSTAVAX (PF) ................. 61
Zosyn ..................................... 10
Zosyn in dextrose (iso-osm) .. 10
Zovia 1/35E (28) ................... 66
Zovia 1/50E (28) ................... 66
Zovirax .................................. 44
Zyban .................................... 48
Zyflo ...................................... 73
Zyflo CR ............................... 73
Zylet ...................................... 69
Zyprexa ................................. 32
Zyprexa Zydis ....................... 32
Zytiga .................................... 17
Zyvox ...................................... 8
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