2019 LISTA DE MEDICAMENTOS CUBIERTOS (FORMULARIO) … · 2019-01-31 · de 8:30 am a 8 pm, de lunes a viernes de 10 am a 6 pm, los sábados o visite Llame gratis a CHOICE al 1-866-783-1444

¿Tiene preguntas acerca del plan médico VNSNY CHOICE FIDA Complete deMedicare-Medicaid? Llame gratis a CHOICE al:

1-866-783-1444 TTY: 711de 8 am a 8 pm, los 7 días de la semana

220 East 42nd Street, 3rd Floor, New York, NY 10017www.vnsnychoice.org

2019 LISTA DE MEDICAMENTOS

CUBIERTOS (FORMULARIO)

VNSNY CHOICE FIDA Complete (Plan Medicare-Medicaid)

H8490_CY2019_LOCD_16702_sb2_Approved_10122018

Para inscribirse en VNSNY CHOICE FIDA Complete y conocer mássobre otras opciones para su atención médica, llame al Agente de

Inscripciones (New York Medicaid Choice) al número gratuito:1-855-600-FIDA TTY: 1-888-329-1541de 8:30 am a 8 pm, de lunes a viernes

de 10 am a 6 pm, los sábadoso visite www.nymedicaidchoice.com

Llame gratis a CHOICE al 1-866-783-1444

TTY: 711de 8 am a 8 pm, los 7 días de la semana

220 East 42nd Street, 3rd Floor, New York, NY 10017 www.vnsnychoice.org

2019 List a de Medicam

entos Cubiertos (Formulario) V

NSN

Y CHO

ICE FIDA

Complete

ID del formulario: 19099, Version: 05

©2019 VNSNY CHOICE

Actualizado: 08/2018

Vigencia: 01 de enero de 2019

ID del Formulario : 19099, Version: 09 Vigencia: 01 de febrero de 2019

Actualizado: 01/23/2019

AVISO DE NO DISCRIMINACIÓN

Los planes de salud de VNSNY CHOICE cumplen con las leyes federales de derechos civiles. VNSNY CHOICE no excluye a ninguna persona ni las trata diferentemente en base de raza, religión, color, país de origen, edad, discapacidad, sexo, orientación sexual, identidad sexual o expresión sexual.

VNSNY CHOICE le ofrece lo siguiente:

Recursos y servicios gratuitos para personas con discapacidades para ayudarles a comunicarsecon nosotros, tales como:

o Intérpretes calificados en lenguaje a señas

o Información por escrito en otros formatos (en letras grandes, audio, formatos electrónicosaccesibles, otros formatos)

Servicios gratuitos de idiomas para personas que hablan otros idiomas, tales como:

o Intérpretes calificados

o Información escrita en otros idiomas

Si necesita estos servicios, llámenos al 1-866-783-1444. Para servicios de TTY, llame al 711.

Si usted cree que VNSNY CHOICE no le ha dado estos servicios o le ha tratado de manera diferente debido a raza, religión, color, país de origen, edad, discapacidad, sexo, orientación sexual, identidad sexual o expresión sexual, puede presentar una queja ante VNSNY CHOICE:

Correo: VNSNY CHOICE Health Plans 220 East 42nd Street, 3rd Floor, New York, NY 10017

Teléfono: 1-888-634-1558 (TTY: 711)

En persona: 220 East 42nd Street, 3rd Floor, New York, NY 10017

Fax: 646-459-7729

Correo electrónico: [email protected]

Web: www.vnsny.ethicspoint.com

También puede presentar una queja de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE.UU., por:

Web: Portal de Quejas de la Oficina de Derechos Civiles, en ocrportal.hhs.gov/ocr/portal/lobby.jsf

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201 Encontrará formularios de quejas en www.hhs.gov/ocr/office/file/index.html

Teléfono: 1-800-368-1019 (TTY/TDD 800-537-7697)

mailto:[email protected]

http://www.vnsny.ethicspoint.com/

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

Si tiene alguna pregunta, por favor llame a VNSNY CHOICE FIDA Complete al 1-866-783-1444 (TTY 711), 7 días a la semana de 8 am a 8 pm. La llamada es gratuita. Para obtener más información, visite www.vnsnychoice.org.

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VNSNY CHOICE FIDA Complete | Lista de medicamentos cubiertos para 2019 (Formulario)

Introducción

Este documento se llama la Lista de Medicamentos Cubiertos (también llamado la Lista de Medicamentos). Le informa sobre cuáles de sus medicamentos de receta, medicamentos sin receta y artículos están cubiertos por VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan). La Lista de Medicamentos también le notifica si hay reglas especiales o restricciones en algunos de los medicamentos cubiertos por VNSNY CHOICE FIDA Complete. Términos clave y sus definiciones se encuentran en el último capítulo del Manual del Miembro.

Tabla de Contenido

A. Renuncias de garantías ........................................................................... III

B. Preguntas frecuentes .............................................................................. III

B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos? (Llamamos "Lista de medicamentos" a la Lista de medicamentos cubiertos, para abreviar.) ...................... IV

B2. ¿La Lista de medicamentos cambia alguna vez? ............................... IV

B3. ¿Qué sucede cuando hay un cambio en la Lista de medicamentos? ................................................................................. V

B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo en particular para obtener ciertos medicamentos? ............................................................................... VII

B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer algo para obtenerlo? ................... VIII

B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por ejemplo, requisitos de autorización (aprobación) previa, límites de cantidad o restricciones de tratamiento)? .................................................................................. VIII

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos? .............................................................................. VIII


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B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de medicamentos? ........................................................ VIII

B9. ¿Qué pasará si usted es un miembro nuevo de VNSNY CHOICE FIDA Complete y no puede encontrar su medicamento en la Lista o tiene problemas para obtener su medicamento? .................................................................................. IX

B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento? ................................................................................... X

B11. ¿Cómo puede pedir una excepción? ............................................... XI

B12. ¿Qué son los medicamentos genéricos? ......................................... XI

B13. ¿Qué son los medicamentos de venta libre (OTC)? ........................ XI

B14. ¿VNSNY CHOICE FIDA Complete cubre algún producto de venta libre que no sea un medicamento? ......................................... XI

B15. ¿Cuál es su copago? ...................................................................... XII

B16. ¿Qué son los niveles de medicamentos? ........................................ XII

C. Lista de medicamentos cubiertos ........................................................... XII

D. Lista de medicamentos por enfermedad................................................ XV


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A. Renuncias de garantías Esta es una lista de medicamentos que los miembros pueden obtener en VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan). VNSNY CHOICE FIDA Complete es un plan de salud administrado

que tiene contrato con Medicare y el Departamento de salud del estado de New York (Medicaid) para proporcionar los beneficios de los dos programas a los participantes a través del programa FIDA (Fully Integrated Duals Advantage Demonstration).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-783-1444 (TTY es 711) de 8 a. m. a 8 p. m., 7 días a la semana. La llamada es gratuita.

Usted puede obtener este documento información gratis en otros formatos, como en letra grande, braille o audio. Llame al 1-866-783-1444 (TTY es 711) de 8 a. m. a 8 p. m., 7 días a la semana. La llamada es gratuita.

Durante su llamada de bienvenida, su administrador de cuidados de VNSNY CHOICE FIDA Complete confirmará su idioma o preferencia de formato para correos y comunicaciones futuras. Si en algún momento necesita solicitar un cambio, comuníquese con el Departamento de Servicios para participantes al 1-866-783-1444 (TTY es 711), de 8 a. m. a 8 p. m., 7 días a la semana.

El Estado de New York ha creado un programa de ombudsman del participante, llamado Independent Consumer Advocacy Network (ICAN), para proporcionar a los participantes ayuda gratuita y confidencial en todos los servicios que ofrece VNSNY CHOICE FIDA Complete. Puede comunicarse con el programa ICAN gratis al 1-844-614-8800 o por Internet en icannys.org. (Los usuarios de TTY deben llamar al 711 y seguir los pasos para marcar 844-614-8800).

B. Preguntas frecuentes Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos cubiertos. Usted puede consultar todas las Preguntas frecuentes o buscar alguna pregunta y su respuesta.


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B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos? (Llamamos "Lista de medicamentos" a la Lista de medicamentos cubiertos, para abreviar.)

Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 3 son los medicamentos cubiertos por VNSNY CHOICE FIDA Complete. Los medicamentos están disponibles en las farmacias de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ellos, para trabajar con nosotros y proporcionarle servicios a usted. Llamamos a estas farmacias “farmacias de la red”.

VNSNY CHOICE FIDA Complete cubrirá cualquiera de los medicamentos necesarios de la Lista de medicamentos, si:

su médico u otro proveedor médico dice que usted los necesita para mejorar o para seguir sano,

el medicamento es necesario para tratar su enfermedad, y

usted surte la receta en una farmacia de la red de VNSNY CHOICE FIDA Complete.

VNSNY CHOICE FIDA Complete puede requerir algunos pasos adicionales para acceder a ciertos medicamentos (lea la pregunta B4 de abajo). En algunos casos, usted tendrá que hacer algo antes de poder obtener el medicamento, como intentar en primer lugar otros medicamentos.

Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en vnsnychoice.org o llame a Servicios para participantes al 1-866-783-1444.

B2. ¿La Lista de medicamentos cambia alguna vez?

Sí. VNSNY CHOICE FIDA Complete podría agregar o quitar medicamentos de la Lista de medicamentos durante el año.

También podemos cambiar nuestras reglas sobre sobre algunos medicamentos. Por ejemplo, podríamos:

Decidir si exigir o no una aprobación previa para algún medicamento. (Aprobación previa es un permiso que da VNSNY CHOICE FIDA Complete o su equipo interdisciplinario (IDT) antes que usted pueda obtener un medicamento.)


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Aumentar o reducir la cantidad de un medicamento que usted puede obtener (llamado límites de cantidad).

Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia progresiva significa que usted podría tener que probar un medicamento antes que cubramos otro medicamento.)

Para obtener más información acerca de estas reglas de medicamentos, lea la pregunta B4.

Si usted está tomando algún medicamento que estuvo cubierto al principio del año, por general no le quitamos ni cambiamos la cobertura de ese medicamento durante el resto del año, a menos que:

un medicamento nuevo y más económico que es igual de eficiente que un medicamento que se encuentra actualmente en la Lista de medicamentos llega a estar disponible, o

nos damos cuenta de que un medicamento no es seguro, o

un medicamento es eliminado del mercado.

Las preguntas B3 y B6 de abajo tienen más información sobre lo que sucederá cuando cambie la Lista de medicamentos.

Usted siempre puede leer la Lista de medicamentos actualizada de VNSNY CHOICE FIDA Complete en internet, en vnsnychoice.org.

También puede llamar a Servicios para participantes para revisar la Lista de medicamentos actual, llamando al 1-866-783-1444.

B3. ¿Qué sucede cuando hay un cambio en la Lista de medicamentos?

Algunos cambios a la Lista de Medicamentos ocurren inmediatamente. Por ejemplo:

Un medicamento genérico nuevo llega a estar disponible. A veces, un medicamento nuevo y más económico que es igual de eficiente que un medicamento que se encuentra actualmente en la Lista de Medicamentos llega a estar disponible. Cuando eso ocurre, podemos eliminar el medicamento actual, pero su costo para el medicamento nuevo será el mismo. Cuando agregamos el medicamento genérico nuevo, también podemos decidir


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mantener el medicamento actual en la lista, pero cambiar sus reglas o límites de cobertura.

o Es posible que no le notifiquemos cuando se haga este cambio, pero le enviaremos información sobre el cambio específico o los cambios que hemos hecho.

o Usted o su proveedor pueden solicitar una excepción a estos cambios. Le enviaremos una notificación con los pasos que puede realizar para solicitar una excepción. Por favor lea la pregunta B10 para más información sobre excepciones.

Un medicamento es eliminado del mercado. Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es seguro o el fabricante del medicamento retira un medicamento del mercado, lo quitaremos de la Lista de medicamentos. Si está tomando el medicamento, se lo haremos saber. Usted debería contactar a su farmacéutico y si es necesario contactar a su médico o proveedor de servicios a fin de discutir otras opciones.

Podemos hacer otros cambios que pueden afectar las medicinas que usted toma. Podemos notificarle por adelantado sobre esos otros cambios a la Lista de Medicamentos. Estos cambios pueden ocurrir si:

La FDA publica nuevas directrices o hay nuevas guías clínicas sobre un medicamento.

Agregamos un medicamento genérico y

o Reemplazamos un medicamento de marca actualmente en la Lista de Medicamentos o

o Cambiamos las reglas de cobertura o los límites del medicamento de marca.

Cuando ocurren estos cambios, le notificaremos por lo menos 30 días antes de que hagamos el cambio a la Lista de Medicamentos o cuando vaya a rellenar su medicamento. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de Medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Después usted puede:

Recibir un suministro de 30 días antes de que se haga el cambio a la Lista de Medicamentos, o


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Solicitar una excepción de estos cambios. Para más información sobre las excepciones, por favor lea la pregunta B10.

B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo en particular para obtener ciertos medicamentos?

Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede obtener. En algunos casos, usted, su médico u otro proveedor tendrán que hacer algo antes de poder obtener el medicamento. Por ejemplo:

Aprobación previa (o autorización previa): para algunos medicamentos, usted o su médico u otro profesional médico deben obtener una aprobación de VNSNY CHOICE FIDA Complete o su equipo interdisciplinario (IDT) antes de surtir su receta. VNSNY CHOICE FIDA Complete podría no cubrir el medicamento si usted no consigue la aprobación.

Límites de cantidad: a veces VNSNY CHOICE FIDA Complete limita la cantidad de un medicamento que usted puede obtener.

Tratamiento progresivo: a veces VNSNY CHOICE FIDA Complete exige que usted siga un tratamiento progresivo. Esto significa que usted tendrá que probar los medicamentos para su enfermedad en un cierto orden. Usted podría tener que probar un medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el primer medicamento no funciona para usted, entonces cubriremos el segundo.

Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo las tablas que comienzan en la página 3. Usted también puede obtener más información visitando nuestro sitio web en vnsnychoice.org. Tenemos en Internet documentos que explican nuestras restricciones de aprobación previa y de tratamiento progresivo. También puede pedirnos que le enviemos una copia.

Usted puede pedir una excepción a esos límites. Lea la pregunta 11 para obtener más información sobre las excepciones.

Esto le dará tiempo para hablar con su médico u otro proveedor. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos, que usted pueda tomar en su lugar o si tiene que pedir una excepción. Por favor lea más información sobre las excepciones en las preguntas B10-B12.


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B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer algo para obtenerlo?

La Lista de medicamentos cubiertos de la página 3 tiene una columna llamada "Medidas necesarias, restricciones o límites de uso".

B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por ejemplo, requisitos de autorización (aprobación) previa, límites de cantidad o restricciones de tratamiento)?

En algunos casos, le avisaremos por adelantado si agregamos requisitos de aprobación previa, límites de cantidad o restricciones de tratamiento progresivo a un medicamento. Lea la pregunta B3 para más información sobre esta notificación por adelantado y situaciones en las que no le notificaremos por adelantado cuando nuestras reglas sobre los medicamentos en la Lista de medicamentos cambien.

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?

Hay dos maneras de encontrar un medicamento:

Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del medicamento), o

Puede buscar por enfermedad.

Para buscar por orden alfabético, vaya a la sección del Índice de medicamentos cubiertos en la página I-1. Luego, busque por el nombre del medicamento en la lista.

Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por enfermedad” de la página 3. Los medicamentos de esta sección están agrupados en categorías, de acuerdo con el tipo de enfermedades para las que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe buscar en la categoría Agentes cardiovasculares. Ahí encontrará los medicamentos que traten enfermedades del corazón.

B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de medicamentos?

Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios para participantes al 1-866-783-1444 y pregunte por él. Si se


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entera que VNSNY CHOICE FIDA Complete no cubrirá el medicamento, usted puede hacer algo de lo siguiente:

Pida a Servicios para participantes una lista de medicamentos similar al que usted quiera tomar. Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un medicamento similar al de la Lista de medicamentos que usted quiere tomar, O

Usted también puede pedir al plan o a su equipo interdisciplinario (IDT) que haga una excepción para cubrir su medicamento. Por favor lea más información sobre las excepciones en las preguntas B10-B12.

B9. ¿Qué pasará si usted es un miembro nuevo de VNSNY CHOICE FIDA Complete y no puede encontrar su medicamento en la Lista o tiene problemas para obtener su medicamento?

Podemos ayudarle. Podríamos cubrir su suministro de medicamento temporariamente de 31 días durante los primeros 90 días en que usted sea miembro de VNSNY CHOICE FIDA Complete. Esto le dará tiempo para hablar con su médico u otro proveedor. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su lugar o tiene que pedir una excepción.

Si su receta es escrita por menos de los días indicados, le permitiremos múltiples suministros hasta un máximo de 31 días de su medicamento.

Cubriremos un suministro de 31 días de su medicamento si: usted está tomando algún medicamento que no esté en nuestra

Lista de medicamentos, o

las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor médico, o

el medicamento requiere aprobación previa de VNSNY CHOICE FIDA Complete o de su equipo interdisciplinario (IDT), o

usted toma algún medicamento que forme parte de una restricción de tratamiento progresivo.

Si usted está en un hogar para personas de la tercera edad u otra institución de cuidados a largo plazo y necesita un medicamento que no está en la Lista de Medicamentos o si no puede obtener el medicamento que necesita,


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podemos ayudarle. Si usted ha estado en el plan por más de 90 días, vive en una institución de cuidados a largo plazo, y necesita su suministro de inmediato:

Le cubriremos un suministro de 31 días del medicamento que (a menos que tenga una receta para menos días), aunque sea o no sea un nuevo miembro de VNSNY CHOICE FIDA Complete.

Esto es adicional al suministro temporero durante los primeros 90 días de ser miembro de VNSNY CHOICE FIDA Complete.

Si experimenta un cambio en el nivel de atención, por ejemplo, se traslada del hospital a su hogar y requiere un medicamento que no está en nuestro formulario, o si su capacidad de obtener sus medicamentos es limitada, pero ya transcurrieron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro temporario por única vez de hasta 30 días (o 31 días si usted reside en un hogar de cuidados a largo plazo) cuando acuda a una farmacia de la red. Durante este período, usted debe utilizar el proceso de excepciones del plan si desea obtener una cobertura continua del medicamento luego de que el suministro temporario se haya acabado. Para solicitar un suministro temporario de un medicamento, comuníquese con Servicios para participantes.

B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento?

Sí. Usted puede pedirle a VNSNY CHOICE FIDA Complete o a su equipo interdisciplinario (IDT) que haga una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos. Usted también puede pedirle a VNSNY CHOICE FIDA Complete o a su equipo interdisciplinario (IDT) un cambio a las reglas de su medicamento.

Por ejemplo, VNSNY CHOICE FIDA Complete podría limitar la cantidad que cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede pedirnos a nosotros o a su equipo interdisciplinario (IDT) que quitemos el límite y que cubramos más.

Otros ejemplos: usted puede pedirnos a nosotros o a su equipo interdisciplinario (IDT) que quitemos las restricciones de tratamiento progresivo o los requisitos de aprobación previa.


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B11. ¿Cómo puede pedir una excepción?

Primero, VNSNY CHOICE FIDA Complete o su equipo interdisciplinario (IDT) debe recibir una declaración de su proveedor médico apoyando su pedido de una excepción. Después de recibir la declaración, le daremos una decisión sobre su pedido de excepción a más tardar en 72 horas. Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72 horas para obtener una decisión, entonces usted puede pedir una excepción rápida. Ésta es una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión a más tardar 24 horas después de recibir la declaración de apoyo de su proveedor médico.

B12. ¿Qué son los medicamentos genéricos?

Los medicamentos genéricos están compuestos por los mismos ingredientes que los medicamentos de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidas. Los medicamentos genéricos son aprobados por la Administración de alimentos y medicamentos (FDA). VNSNY CHOICE FIDA Complete cubre tanto medicamentos de marca como medicamentos genéricos.

B13. ¿Qué son los medicamentos de venta libre (OTC)?

OTC quiere decir "medicamentos que se venden sin receta". VNSNY CHOICE FIDA Complete cubre algunos medicamentos de venta libre cuando su proveedor escribe una receta para ellos. Usted puede leer la Lista de medicamentos de VNSNY CHOICE FIDA Complete para ver qué medicamentos de venta libre están cubiertos.

B14. ¿VNSNY CHOICE FIDA Complete cubre algún producto de venta libre que no sea un medicamento?

VNSNY CHOICE FIDA Complete cubre algunos productos de venta libre que no son medicamentos cuando su proveedor escribe una receta para ellos. Ejemplos de productos sin receta, que no son medicamentos, incluyen gasas con alcohol.


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Usted puede leer la Lista de medicamentos de VNSNY CHOICE FIDA Complete para ver qué productos de venta libre, que no son medicamentos, están cubiertos.

B15. ¿Cuál es su copago?

Usted no tiene copagos por medicamentos incluidos en la Lista de medicamentos.

B16. ¿Qué son los niveles de medicamentos?

Los niveles son grupos de medicamentos de nuestra Lista de medicamentos.

Los medicamentos de Nivel 1 son medicamentos genéricos.

Los medicamentos de Nivel 2 son medicamentos de marca.

Los medicamentos del Nivel 3 son medicamentos con receta no cubiertos por Medicare.

Los medicamentos del Nivel 4 son medicamentos de venta libre no cubiertos por Medicare.

C. Lista de medicamentos cubiertos La siguiente Lista de medicamentos cubiertos le da información sobre los medicamentos cubiertos por VNSNY CHOICE FIDA Complete. Si usted tiene problemas para encontrar su medicamento en la lista, pase al Índice de medicamentos cubiertos que comienza en la página I-1. El índice alfabético nombra todos los medicamentos cubiertos por VNSNY CHOICE FIDA Complete.

La primera columna de la tabla tiene el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (p.ej.: ROZEREM) y los medicamentos genéricos están escritos en cursivas minúsculas (p.ej.: zaleplon).

La información de la columna titulada "Medidas necesarias, restricciones o límites de uso", le indica si VNSNY CHOICE FIDA Complete tiene alguna regla para cubrir su medicamento.

Nota: el símbolo “*” junto a un medicamento significa que el medicamento no es un “medicamento de Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones.

Una apelación es una manera formal de pedirnos que revisemos alguna decisión que hayamos tomado sobre su cobertura y que la cambiemos si le parece que hemos cometido un error. Por


XIII

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ejemplo, VNSNY CHOICE FIDA Complete o su equipo interdisciplinario (IDT) podría decidir que un medicamento que usted quiere no está cubierto o que ya no está cubierto por Medicare o Medicaid.

Si usted o su médico u otro proveedor no están de acuerdo con nuestra decisión, usted puede apelar. Para solicitar las instrucciones sobre cómo apelar, haga lo siguiente:

o Llame a Servicios para participantes al 1-866-783-1444 o a la Red independiente de defensa al consumidor (ICAN) al 1-844-614-8800. (Los usuarios de TTY deben llamar al 711 y luego seguir las indicaciones para marcar 844-614-8800.). Usted también puede leer el Capítulo 9, del Manual del miembro para enterarse sobre cómo apelar una decisión.

Las siguientes abreviaturas de Utilization Management se pueden

encontrar en el cuerpo de este documento

ABREVIATURAS DE LAS NOTAS DE COBERTURA

ABREVIATURA DESCRIPCIÓN EXPLICACIÓN

Restricciones de Utilization Management

PA Restricción de

autorización previa

Usted (o su médico) deben obtener una autorización previa de VNSNY CHOICE FIDA Complete antes de llenar su receta para este medicamento. Sin la autorización previa, es posible que VNSNY CHOICE FIDA Complete no cubra este medicamento.

PA BvD

Restricción de autorización previa

para la determinación de la Parte B vs. la

Parte D

Este medicamento puede ser elegible para su pago según la Parte B o Parte D de Medicare. Usted (o su médico) deben obtener una autorización previa de VNSNY CHOICE FIDA Complete para determinar que este medicamento está cubierto por la Parte D de Medicare antes de llenar su receta para este medicamento. Sin la autorización previa, es posible que VNSNY CHOICE FIDA Complete no cubra este medicamento.


XIV

?


PA-HRM

Restricción de autorización previa

para medicamentos de alto riesgo

Este medicamento ha sido considerado por la CMS como potencialmente perjudicial y, por lo tanto, una medicación de alto riesgo para los beneficiarios de Medicare a partir de los 65 años. Los participantes a partir de los 65 años deben obtener una autorización previa de VNSNY CHOICE FIDA Complete antes de llenar su receta para este medicamento. Sin la autorización previa, es posible que VNSNY CHOICE FIDA Complete no cubra este medicamento.

PA NSO

Restricción de autorización previa solo para nuevos

participantes

Si usted es un participante nuevo o si no ha tomado este medicamento con anterioridad, usted (o su médico) deben obtener una autorización previa de VNSNY CHOICE FIDA Complete antes de llenar su receta para este medicamento. Sin la autorización previa, es posible que VNSNY CHOICE FIDA Complete no cubra este medicamento.

QL Restricción de límite

de cantidad

VNSNY CHOICE FIDA Complete limita el número cubierto de este medicamento por receta, o dentro de un período específico.

ST Restricción de

tratamiento escalonado

Antes de que VNSNY CHOICE FIDA Complete proporcione cobertura para este medicamento, usted debe probar otro(s) medicamento(s) para tratar su enfermedad. Este medicamento solo puede ser cubierto si el(los) otro(s) medicamentos no son adecuados para usted.

Las siguientes abreviaturas adicionales de las notas de cobertura se pueden encontrar en el cuerpo de este documento


XV

?

OTROS REQUISITOS ESPECIALES PARA LA COBERTURA


LA Medicamento de acceso limitado

Esta receta puede estar disponible solo en ciertas farmacias. Para obtener más información, consulte con su proveedor o en el Directorio de proveedores o llame a Servicios al participante al 1-866-783-1444, 7 días de la semana, de 8 a. m. a 8 p. m. Los usuarios de TTY deben llamar al 711.

NM Medicamento no

disponible para envíos por correo postal

Usted puede recibir más de un suministro de 1 mes de la mayoría de los medicamentos en el listado por correo postal por un costo reducido. Los medicamentos que no están disponibles para envíos por correo postal se marcan como “NM” en la columna Requisitos/Limitaciones en su formulario.

* No es un medicamento

de la Parte D Este medicamento no pertenece a la Parte D, o es un medicamento o producto de venta libre.

D. Lista de medicamentos por enfermedad

Los medicamentos de esta sección están agrupados en categorías de acuerdo con el tipo de enfermedad para la que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe buscar en la categoría Agentes cardiovasculares. Ahí encontrará los medicamentos que traten enfermedades del corazón.

1

Analgesics.................................................................................................................................................................. 3

Anesthetics .............................................................................................................................................................. 13

Anti-Addiction/Substance Abuse Treatment Agents .......................................................................................... 14

Antianxiety Agents ................................................................................................................................................. 16

Antibacterials ......................................................................................................................................................... 18

Anticancer Agents .................................................................................................................................................. 29

Anticholinergic Agents .......................................................................................................................................... 42

Anticonvulsants ...................................................................................................................................................... 42

Antidementia Agents ............................................................................................................................................. 47

Antidepressants ...................................................................................................................................................... 48

Antidiabetic Agents ................................................................................................................................................ 51

Antifungals.............................................................................................................................................................. 56

Antigout Agents ...................................................................................................................................................... 59

Antihistamines ........................................................................................................................................................ 60

Anti-Infectives (Skin And Mucous Membrane) .................................................................................................. 64

Antimigraine Agents .............................................................................................................................................. 65

Antimycobacterials ................................................................................................................................................ 66

Antinausea Agents ................................................................................................................................................. 67

Antiparasite Agents ............................................................................................................................................... 69

Antiparkinsonian Agents....................................................................................................................................... 71

Antipsychotic Agents ............................................................................................................................................. 72

Antivirals (Systemic) .............................................................................................................................................. 78

Blood Products/Modifiers/Volume Expanders ................................................................................................... 86

Table of Contents

2

Caloric Agents ........................................................................................................................................................ 90

Cardiovascular Agents .......................................................................................................................................... 96

Central Nervous System Agents ......................................................................................................................... 110

Contraceptives ...................................................................................................................................................... 114

Cough And Cold Products .................................................................................................................................. 123

Dental And Oral Agents ...................................................................................................................................... 126

Dermatological Agents......................................................................................................................................... 127

Devices ................................................................................................................................................................... 135

Enzyme Replacement/Modifiers ......................................................................................................................... 144

Eye, Ear, Nose, Throat Agents ............................................................................................................................ 146

Gastrointestinal Agents ....................................................................................................................................... 154

Genitourinary Agents .......................................................................................................................................... 168

Heavy Metal Antagonists .................................................................................................................................... 169

Hormonal Agents, Stimulant/Replacement/Modifying .................................................................................... 169

Immunological Agents ......................................................................................................................................... 177

Inflammatory Bowel Disease Agents .................................................................................................................. 189

Irrigating Solutions .............................................................................................................................................. 190

Metabolic Bone Disease Agents .......................................................................................................................... 191

Miscellaneous Therapeutic Agents ..................................................................................................................... 193

Ophthalmic Agents .............................................................................................................................................. 195

Replacement Preparations .................................................................................................................................. 196

Respiratory Tract Agents .................................................................................................................................... 203

Skeletal Muscle Relaxants ................................................................................................................................... 209

Sleep Disorder Agents.......................................................................................................................................... 209

Vasodilating Agents ............................................................................................................................................. 211

Vitamins And Minerals ....................................................................................................................................... 212

Puede encontrar información acerca del significado de los símbolos y abreviaturas de esta tabla en las páginas XIII-XV de este documento.

Si tiene alguna pregunta, por favor llame a VNSNY CHOICE FIDA Complete al 1-866-783-1444 (TTY 711), 7 días a la semana de 8 am a 8 pm. La llamada es gratuita. Para obtener más información, visite www.vnsnychoice.org

VNSNY CHOICE FIDA Complete ID del formulario: 19099, Versión: 09 Vigente: 1 de febrero de 2019

3

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Analgesics

Analgesics, Miscellaneous

8 hour er 650 mg caplet muscle

aches & pain 650 mg * 4 $0

QL (180 per 30 days)

acephen 120 mg suppository outer

120 mg * 4 $0

QL (30 per 30 days)


325 mg * 4 $0

QL (30 per 30 days)


650 mg * 4 $0

QL (30 per 30 days)

acetaminophen 120 mg suppos outer

120 mg * (Acephen) 4 $0

QL (30 per 30 days)

acetaminophen 650 mg suppos outer

650 mg * (Acephen) 4 $0

QL (30 per 30 days)

acetaminophen 80 mg rapid tab

children's 80 mg *

(Children's

Acetaminophen) 4 $0

QL (30 per 30 days)

acetaminophen-codeine oral

solution 120-12 mg/5 ml 1 $0


acetaminophen-codeine oral tablet

300-15 mg 1 $0



300-30 mg

(Tylenol-Codeine

#3) 1 $0



300-60 mg

(Tylenol-Codeine

#4) 1 $0


buprenorphine hcl injection solution

0.3 mg/ml (Buprenex) 1 $0

buprenorphine hcl injection syringe

0.3 mg/ml 1 $0

butalbital-acetaminophen-caff oral

tablet 50-325-40 mg (Esgic) 1 $0

PA-HRM; QL (180 per

30 days); AGE (Max

64 Years)

http://www.vnsnychoice.org/


.



4

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

butalbital-aspirin-caffeine oral

capsule 50-325-40 mg (Fiorinal) 1 $0

PA-HRM; QL (180 per

30 days); AGE (Max

64 Years)

butalbital-aspirin-caffeine oral

tablet 50-325-40 mg 1 $0

PA-HRM; QL (180 per

30 days); AGE (Max

64 Years)

child pain-fever 160 mg/5 ml 160

mg/5 ml * 4 $0


child pain-fever 160 mg/5 ml 160

mg/5 ml * 4 $0


child tactinal 80 mg tab chw 80 mg

* 4 $0

QL (30 per 30 days)

child tylenol 160 mg tab chew 160

mg * 4 $0

QL (30 per 30 days)

children's fever reducing supp for

ages 3-6 years 120 mg * 4 $0

QL (30 per 30 days)

children's mapap 80 mg rapid 80

mg * 4 $0

QL (30 per 30 days)

child's mapap 160 mg tab chew 160

mg * 4 $0

QL (30 per 30 days)

codeine sulfate oral tablet 15 mg, 30

mg, 60 mg 1 $0


cvs acetaminophen 325 mg tab 325

mg * (Athenol) 4 $0


cvs child non-asa 80 mg tb chw 80

mg * 4 $0

QL (30 per 30 days)

cvs child pain relief 160 mg 160 mg

* 4 $0

QL (30 per 30 days)

cvs child pain rlf 160 mg/5 ml

children's, a/f 160 mg/5 ml * 4 $0


cvs non-asa 80 mg tablet chw

children's 80 mg * 4 $0

QL (30 per 30 days)





5

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs non-aspirin 500 mg caplet

caplet, ex-strength 500 mg * 4 $0


cvs non-aspirin jr tab chew 160 mg

* 4 $0

QL (30 per 30 days)

cvs pain relief 325 mg liq gel 325

mg * 4 $0


cvs pain relief adult liquid 500

mg/15 ml * 4 $0


endocet oral tablet 10-325 mg 1 $0 QL (180 per 30 days)

endocet oral tablet 2.5-325 mg, 5-

325 mg 1 $0


endocet oral tablet 7.5-325 mg 1 $0 QL (240 per 30 days)

eql jr acetaminophen 160 mg tab

160 mg * 4 $0

QL (30 per 30 days)

fentanyl citrate buccal lozenge on a

handle 1,200 mcg, 1,600 mcg, 200

mcg, 400 mcg, 600 mcg, 800 mcg

(Actiq) 1 $0

PA; QL (120 per 30

days)

fentanyl transdermal patch 72 hour

100 mcg/hr, 12 mcg/hr, 25 mcg/hr,

50 mcg/hr, 75 mcg/hr

(Duragesic) 1 $0

QL (10 per 30 days)

feverall 120 mg suppository

children's, outer 120 mg * 4 $0

QL (30 per 30 days)

feverall 325 mg suppository junior

str, inner 325 mg * 4 $0

QL (30 per 30 days)

feverall 650 mg suppository adult,

inner 650 mg * 4 $0

QL (30 per 30 days)

gnp pain reliever 500 mg caplt

caplet,x-strength 500 mg * 4 $0


hydrocodone-acetaminophen oral

solution 7.5-325 mg/15 ml (Hycet) 1 $0



tablet 10-325 mg (Lorcet HD) 1 $0




.



6

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


tablet 2.5-325 mg (Verdrocet) 1 $0



tablet 5-325 mg

(Lorcet

(hydrocodone)) 1 $0



tablet 7.5-325 mg (Lorcet Plus) 1 $0


hydrocodone-ibuprofen oral tablet

7.5-200 mg 1 $0


hydromorphone (pf) injection

solution 10 (mg/ml) (5 ml), 10

mg/ml

1 $0

hydromorphone oral liquid 1 mg/ml (Dilaudid) 1 $0 QL (1200 per 30 days)

hydromorphone oral tablet 2 mg, 4

mg, 8 mg (Dilaudid) 1 $0


HYSINGLA ER ORAL

TABLET,ORAL

ONLY,EXT.REL.24 HR 100 MG,

120 MG, 20 MG, 30 MG, 40 MG,

60 MG, 80 MG

2 $0

QL (30 per 30 days)

infant pain rlf 80 mg/0.8 ml a/f 80

mg/0.8 ml * 4 $0

QL (30 per 30 days)

kro acetaminophen 325 mg cap 325

mg * (Pain Relief) 4 $0


LAZANDA NASAL SPRAY,NON-

AEROSOL 100 MCG/SPRAY, 300

MCG/SPRAY, 400 MCG/SPRAY

2 $0

PA; QL (30 per 30

days)

little remedies fever 160 mg/5

a/f,d/f,gluten-free 160 mg/5 ml * 4 $0


lorcet (hydrocodone) oral tablet 5-

325 mg 1 $0


lorcet hd oral tablet 10-325 mg 1 $0 QL (180 per 30 days)

lorcet plus oral tablet 7.5-325 mg 1 $0 QL (180 per 30 days)





7

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

mapap 160 mg/5 ml liquid 160 mg/5

ml * 4 $0


mapap 160 mg/5 ml suspension 160

mg/5 ml * 4 $0


mapap 325 mg tablet 325 mg * 4 $0 QL (360 per 30 days)

mapap 500 mg caplet caplet,boxed

500 mg * 4 $0


mapap 500 mg capsule 500 mg * 4 $0 QL (240 per 30 days)

mapap 500 mg/15 ml liquid 500

mg/15 ml * 4 $0


mapap 80 mg tablet chew 80 mg * 4 $0 QL (30 per 30 days)

mapap arthritis er 650 mg cplt 650

mg * 4 $0


masophen 325 mg tablet 325 mg * 4 $0 QL (360 per 30 days)

masophen 500 mg tablet 500 mg * 4 $0 QL (240 per 30 days)

methadone injection solution 10

mg/ml 1 $0

methadone oral solution 10 mg/5 ml 1 $0 QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 1 $0 QL (1200 per 30 days)

methadone oral tablet 10 mg (Dolophine) 1 $0 QL (120 per 30 days)

methadone oral tablet 5 mg (Dolophine) 1 $0 QL (180 per 30 days)

methadose oral tablet,soluble 40 mg 1 $0 QL (30 per 30 days)

morphine 10 mg/ml isecure syrg l/f,

p/f, suv, inner 10 mg/ml 1 $0

morphine concentrate oral solution

100 mg/5 ml (20 mg/ml) 1 $0


morphine injection syringe 10

mg/ml 1 $0

morphine intravenous solution 10

mg/ml 1 $0

morphine oral solution 10 mg/5 ml 1 $0 QL (700 per 30 days)

morphine oral solution 20 mg/5 ml

(4 mg/ml) 1 $0




.



8

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

MORPHINE ORAL TABLET 15

MG 2 $0


MORPHINE ORAL TABLET 30

MG 2 $0


morphine oral tablet extended

release 100 mg, 200 mg, 60 mg (MS Contin) 1 $0

QL (60 per 30 days)

morphine oral tablet extended

release 15 mg, 30 mg (MS Contin) 1 $0

QL (90 per 30 days)

non-aspirin 80 mg tab chew

children's 80 mg * 4 $0

QL (30 per 30 days)

non-aspirin child's drops 100 mg/ml

* 4 $0

QL (30 per 30 days)

nortemp 80 mg/0.8 ml drop 80

mg/0.8 ml * 4 $0

QL (30 per 30 days)

NUCYNTA ER ORAL TABLET

EXTENDED RELEASE 12 HR 100

MG, 150 MG, 200 MG, 250 MG, 50

MG

2 $0

QL (60 per 30 days)

NUCYNTA ORAL TABLET 100

MG, 50 MG, 75 MG 2 $0


oxycodone oral solution 5 mg/5 ml 1 $0 QL (1300 per 30 days)

oxycodone oral tablet 10 mg 1 $0 QL (180 per 30 days)

oxycodone oral tablet 15 mg, 30 mg (Roxicodone) 1 $0 QL (120 per 30 days)

oxycodone oral tablet 20 mg 1 $0 QL (120 per 30 days)

oxycodone oral tablet 5 mg (Roxicodone) 1 $0 QL (180 per 30 days)

oxycodone oral tablet,oral

only,ext.rel.12 hr 10 mg, 15 mg, 20

mg, 30 mg, 40 mg, 60 mg, 80 mg

(OxyContin) 2 $0

QL (60 per 30 days)

oxycodone-acetaminophen oral

solution 5-325 mg/5 ml 1 $0



tablet 10-325 mg (Endocet) 1 $0






9

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


tablet 2.5-325 mg, 5-325 mg (Endocet) 1 $0



tablet 7.5-325 mg (Endocet) 1 $0


oxycodone-aspirin oral tablet

4.8355-325 mg 1 $0


OXYCONTIN ORAL

TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15

MG, 20 MG, 30 MG, 40 MG, 60

MG, 80 MG

2 $0

QL (60 per 30 days)

pain & fever 325 mg tablet 325 mg

* 4 $0


pediacare fever reducer susp 160

mg/5 ml * 4 $0


pharbetol 325 mg tablet regular

strength 325 mg * 4 $0


pharbetol 500 mg caplet extra-str,

caplet 500 mg * 4 $0


qc non-aspirin 500 mg caplet

caplet,ex-strength 500 mg * 4 $0


ra acetaminophen er 650 mg tab

650 mg *

(8 Hour Pain

Reliever) 4 $0


ra athenol 325 mg tablet 325 mg * 4 $0 QL (360 per 30 days)

ra non-aspirin 160 mg/5 ml

children's,cherry 160 mg/5 ml * 4 $0


sm pain rel jr str tab chew 160 mg * 4 $0 QL (30 per 30 days)

SUBLOCADE SUBCUTANEOUS

SOLUTION, EXTENDED REL

SYRINGE 100 MG/0.5 ML, 300

MG/1.5 ML

2 $0

tactinal 325 mg tablet 325 mg * 4 $0 QL (360 per 30 days)



.



10

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

tactinal 500 mg tablet extra-strength

500 mg * 4 $0


tramadol oral tablet 50 mg (Ultram) 1 $0 QL (240 per 30 days)

tramadol-acetaminophen oral tablet

37.5-325 mg (Ultracet) 1 $0


tylophen 500 mg capsule 500 mg * 4 $0 QL (240 per 30 days)

XTAMPZA ER ORAL

CAPSULE,SPRINKLE,ER 12HR

TMPRR 13.5 MG, 18 MG, 9 MG

2 $0

QL (60 per 30 days)

XTAMPZA ER ORAL


TMPRR 27 MG

2 $0


XTAMPZA ER ORAL


TMPRR 36 MG

2 $0


Nonsteroidal Anti-Inflammatory

Agents

aspirin 300 mg suppository 300 mg

* 4 $0

aspirin 325 mg tablet 325 mg * (Bayer Aspirin) 4 $0

aspirin 325 mg tablet coated 325 mg

* (Bayer Aspirin) 4 $0

aspirin 600 mg suppository 600 mg

* 4 $0

aspirin 81 mg chewable tablet 81

mg * (Aspirin Childrens) 4 $0

aspirin ec 325 mg tablet 325 mg * (Aspir-Trin) 4 $0

aspirin ec 81 mg tablet 81 mg * (Adult Aspirin

Regimen) 4 $0

aspir-low ec 81 mg tablet 81 mg * 4 $0

aspir-trin ec 325 mg tablet 325 mg * 4 $0

bufferin 325 mg tablet coated 325

mg * 4 $0





11

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

CALDOLOR INTRAVENOUS

RECON SOLN 800 MG/8 ML (100

MG/ML)

2 $0

celecoxib oral capsule 100 mg, 200

mg, 50 mg (Celebrex) 1 $0

QL (60 per 30 days)

diclofenac potassium oral tablet 50

mg 1 $0

diclofenac sodium oral tablet

extended release 24 hr 100 mg (Voltaren-XR) 1 $0

diclofenac sodium oral

tablet,delayed release (dr/ec) 25 mg,

50 mg, 75 mg

1 $0

diclofenac sodium topical drops 1.5

% 1 $0


diclofenac sodium topical gel 3 % (Solaraze) 1 $0 PA; QL (100 per 28

days)

ecotrin ec 325 mg tablet saftey

coated 325 mg * 4 $0

ecpirin ec 325 mg tablet 325 mg * 4 $0

etodolac oral capsule 200 mg, 300

mg 1 $0

etodolac oral tablet 400 mg (Lodine) 1 $0

etodolac oral tablet 500 mg 1 $0

FLECTOR TRANSDERMAL

PATCH 12 HOUR 1.3 % 2 $0

PA

flurbiprofen oral tablet 100 mg, 50

mg 1 $0

gnp chld ibuprofen 100 mg/5 ml a/f

100 mg/5 ml * 4 $0

gnp ibuprofen jr str 100 mg tb 100

mg * 4 $0

ibu oral tablet 400 mg, 600 mg, 800

mg 1 $0



.



12

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ibuprofen 200 mg tablet 200 mg * (Advil) 4 $0

ibuprofen oral suspension 100 mg/5

ml (Child Ibuprofen) 1 $0

ibuprofen oral tablet 400 mg, 600

mg, 800 mg (IBU) 1 $0

indomethacin oral capsule 25 mg 1 $0

PA-HRM; QL (240 per

30 days); AGE (Max

64 Years)

indomethacin oral capsule 50 mg 1 $0

PA-HRM; QL (120 per

30 days); AGE (Max

64 Years)

indomethacin sodium intravenous

recon soln 1 mg 1 $0

infant ibuprofen 50 mg/1.25 ml

d/f,a/f,non-staining 50 mg/1.25 ml * 4 $0

infants' advil 50 mg/1.25 ml 50

mg/1.25 ml * 4 $0

ketorolac oral tablet 10 mg 1 $0

PA-HRM; QL (20 per

30 days); AGE (Max

64 Years)

low dose aspirin ec 81 mg tab 81 mg

* 4 $0

mefenamic acid oral capsule 250 mg 1 $0

meloxicam oral suspension 7.5 mg/5

ml 2 $0

meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 1 $0

nabumetone oral tablet 500 mg, 750

mg 1 $0

naproxen oral tablet 250 mg, 375

mg 1 $0

naproxen oral tablet 500 mg (Naprosyn) 1 $0

naproxen oral tablet,delayed release

(dr/ec) 375 mg, 500 mg (EC-Naprosyn) 1 $0





13

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

PENNSAID TOPICAL SOLUTION

IN METERED-DOSE PUMP 20

MG/GRAM /ACTUATION(2 %)

2 $0

PA; QL (224 per 28

days)

qc lo-dose aspirin ec 81 mg tb 81

mg * 4 $0

ra aspirin 325 mg tablet 325 mg * (Bayer Aspirin) 4 $0

ra aspirin ec 325 mg tablet regular

strength 325 mg * (Aspir-Trin) 4 $0

sm ibuprofen 200 mg softgel softgel

200 mg * (Advil Liqui-Gel) 4 $0

sm ibuprofen ib 100 mg tablet junior

strength 100 mg * (Advil) 4 $0

st. joseph aspirin 81 mg chew

orange 81 mg * 4 $0

st. joseph aspirin ec 81 mg tb 81 mg

* 4 $0

sulindac oral tablet 150 mg, 200 mg 1 $0

tri-buffered aspirin 325 mg tb

coated tablet 325 mg * 4 $0

VOLTAREN TOPICAL GEL 1 % 1 $0

wal-profen 200 mg caplet f/c,caplet

200 mg * 4 $0

wal-profen 200 mg softgel softgel

200 mg * 4 $0

Anesthetics

Local Anesthetics

glydo mucous membrane jelly in

applicator 2 % 1 $0

QL (30 per 30 days)

lidocaine (pf) injection solution 10

mg/ml (1 %), 15 mg/ml (1.5 %), 20

mg/ml (2 %), 5 mg/ml (0.5 %)

(Xylocaine-MPF) 1 $0

lidocaine (pf) injection solution 40

mg/ml (4 %) 1 $0



.



14

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

lidocaine hcl injection solution 10

mg/ml (1 %), 20 mg/ml (2 %), 5

mg/ml (0.5 %)

(Xylocaine) 1 $0

lidocaine hcl mucous membrane

jelly 2 % 1 $0

QL (30 per 30 days)

lidocaine hcl mucous membrane

solution 4 % (40 mg/ml) 1 $0

lidocaine topical adhesive

patch,medicated 5 % (Lidoderm) 1 $0

PA; QL (90 per 30

days)

lidocaine topical ointment 5 % 1 $0 PA; QL (90 per 30

days)

lidocaine viscous mucous membrane

solution 2 % 1 $0

lidocaine-prilocaine topical cream

2.5-2.5 % 1 $0

PA; QL (30 per 30

days)

Anti-Addiction/Substance

Abuse Treatment Agents

Anti-Addiction/Substance Abuse

Treatment Agents

acamprosate oral tablet,delayed

release (dr/ec) 333 mg 1 $0

buprenorphine hcl sublingual tablet

2 mg, 8 mg 1 $0

QL (90 per 30 days)

buprenorphine-naloxone sublingual

tablet 2-0.5 mg, 8-2 mg 1 $0

QL (90 per 30 days)

bupropion hcl (smoking deter) oral

tablet extended release 12 hr 150

mg

(Zyban) 1 $0

CHANTIX CONTINUING

MONTH BOX ORAL TABLET 1

MG

2 $0






15

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

CHANTIX ORAL TABLET 0.5

MG, 1 MG 2 $0


CHANTIX STARTING MONTH

BOX ORAL TABLETS,DOSE

PACK 0.5 MG (11)- 1 MG (42)

2 $0


disulfiram oral tablet 250 mg, 500

mg (Antabuse) 1 $0

gnp nicotine 2 mg lozenge mint, 3

quittube 2 mg * (Nicorette) 4 $0

LUCEMYRA ORAL TABLET 0.18

MG 2 $0


naloxone injection solution 0.4

mg/ml 1 $0

naloxone injection syringe 0.4

mg/ml, 1 mg/ml 1 $0

naltrexone oral tablet 50 mg 1 $0

NARCAN NASAL SPRAY,NON-

AEROSOL 4 MG/ACTUATION 2 $0

QL (4 per 30 days)

nicorelief 2 mg gum 2 mg * 4 $0

nicorelief 4 mg gum 4 mg * 4 $0

nicotine 14 mg/24hr patch step 2

(otc) 14 mg/24 hr * (Nicoderm CQ) 4 $0


nicotine 2 mg chewing gum sugar

free 2 mg * (Nicorelief) 4 $0

nicotine 21 mg/24hr patch outer



nicotine 4 mg chewing gum 4 mg * (Nicorelief) 4 $0

nicotine 4 mg lozenge mint, 3


nicotine 7 mg/24hr patch step 3



NICOTROL INHALATION

CARTRIDGE 10 MG 2 $0




.



16

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

pub stop smoking aid 2 mg lozg 2

mg * 4 $0

pub stop smoking aid 4 mg lozg 4

mg * 4 $0

ra nicotine 2 mg lozenge s/f,mint,4


ra nicotine 21 mg/24hr patch step 1



SUBOXONE SUBLINGUAL FILM

12-3 MG, 8-2 MG 2 $0

QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM

2-0.5 MG, 4-1 MG 2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 0.7-0.18 MG, 1.4-0.36

MG, 11.4-2.9 MG, 2.9-0.71 MG,

5.7-1.4 MG

2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 8.6-2.1 MG 2 $0

QL (60 per 30 days)

Antianxiety Agents

Benzodiazepines

alprazolam oral tablet 0.25 mg, 0.5

mg, 1 mg (Xanax) 1 $0


alprazolam oral tablet 2 mg (Xanax) 1 $0 QL (150 per 30 days)

buspirone oral tablet 10 mg, 15 mg,

30 mg, 5 mg, 7.5 mg 1 $0

chlordiazepoxide hcl oral capsule

10 mg, 25 mg, 5 mg 1 $0


clobazam oral suspension 2.5 mg/ml (Onfi) 1 $0 PA NSO; QL (480 per

30 days)

clobazam oral tablet 10 mg, 20 mg (Onfi) 1 $0 PA NSO; QL (60 per

30 days)

clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 1 $0 QL (90 per 30 days)





17

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

clonazepam oral tablet 2 mg (Klonopin) 1 $0 QL (300 per 30 days)

clonazepam oral

tablet,disintegrating 0.125 mg, 0.25

mg, 0.5 mg, 1 mg

1 $0

QL (90 per 30 days)

clonazepam oral

tablet,disintegrating 2 mg 1 $0


clorazepate dipotassium oral tablet

15 mg, 3.75 mg 1 $0


clorazepate dipotassium oral tablet

7.5 mg (Tranxene T-Tab) 1 $0


DIASTAT ACUDIAL RECTAL

KIT 12.5-15-17.5-20 MG, 5-7.5-10

MG

2 $0

DIASTAT RECTAL KIT 2.5 MG 2 $0

diazepam injection solution 5 mg/ml 1 $0 QL (10 per 28 days)

diazepam injection syringe 5 mg/ml 1 $0 QL (10 per 28 days)

diazepam intensol oral concentrate

5 mg/ml 1 $0


diazepam oral solution 5 mg/5 ml (1

mg/ml) 1 $0


diazepam oral tablet 10 mg, 2 mg, 5

mg (Valium) 1 $0


diazepam rectal kit 12.5-15-17.5-20

mg, 5-7.5-10 mg (Diastat AcuDial) 2 $0

diazepam rectal kit 2.5 mg (Diastat) 2 $0

lorazepam injection solution 2

mg/ml, 4 mg/ml (Ativan) 1 $0

QL (2 per 30 days)

lorazepam injection syringe 2

mg/ml, 4 mg/ml 1 $0

QL (2 per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg (Ativan) 1 $0 QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) 1 $0 QL (150 per 30 days)

ONFI ORAL SUSPENSION 2.5

MG/ML 2 $0

PA NSO; QL (480 per

30 days)



.



18

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ONFI ORAL TABLET 10 MG, 20

MG 2 $0

PA NSO; QL (60 per

30 days)

temazepam oral capsule 15 mg, 30

mg (Restoril) 1 $0

PA-HRM; (High Risk

Med. QL applies to all

members; PA required

for 65 years and older

with over 90 days

cumulative use with

any benzodiazepine

hypnotic drug); QL (30

per 30 days); AGE

(Max 64 Years)

Antibacterials

Aminoglycosides

BETHKIS INHALATION

SOLUTION FOR

NEBULIZATION 300 MG/4 ML

2 $0

PA BvD

gentamicin in nacl (iso-osm)

intravenous piggyback 100 mg/100

ml, 100 mg/50 ml, 120 mg/100 ml,

60 mg/50 ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50 ml, 90 mg/100

ml

1 $0

gentamicin injection solution 20

mg/2 ml, 40 mg/ml 1 $0

gentamicin sulfate (ped) (pf)

injection solution 20 mg/2 ml 1 $0

gentamicin sulfate (pf) intravenous

solution 100 mg/10 ml, 60 mg/6 ml,

80 mg/8 ml

1 $0

neomycin oral tablet 500 mg 1 $0

streptomycin intramuscular recon

soln 1 gram 1 $0





19

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TOBI PODHALER INHALATION

CAPSULE, W/INHALATION

DEVICE 28 MG

2 $0


tobramycin in 0.225 % nacl

inhalation solution for nebulization

300 mg/5 ml

(Tobi) 1 $0

PA BvD

tobramycin in 0.9 % nacl

intravenous piggyback 60 mg/50 ml 1 $0

tobramycin sulfate injection solution

10 mg/ml, 40 mg/ml 1 $0

Antibacterials, Miscellaneous

bacitracin intramuscular recon soln

50,000 unit (BACiiM) 1 $0

chloramphenicol sod succinate

intravenous recon soln 1 gram 1 $0

clindamycin hcl oral capsule 150

mg, 300 mg, 75 mg (Cleocin HCl) 1 $0

clindamycin in 5 % dextrose


ml, 600 mg/50 ml, 900 mg/50 ml

1 $0

clindamycin phosphate injection

solution 150 (mg/ml) (6 ml) 1 $0

clindamycin phosphate injection

solution 150 mg/ml (Cleocin) 1 $0

clindamycin phosphate intravenous

solution 600 mg/4 ml (Cleocin) 1 $0

colistin (colistimethate na) injection

recon soln 150 mg

(Coly-Mycin M

Parenteral) 1 $0

PA BvD

daptomycin intravenous recon soln

350 mg 2 $0

daptomycin intravenous recon soln

500 mg (Cubicin) 1 $0



.



20

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

FIRVANQ ORAL RECON SOLN

25 MG/ML, 50 MG/ML 2 $0

linezolid 600 mg/300 ml-0.9% nacl

600 mg/300 ml 1 $0

linezolid in dextrose 5% intravenous

piggyback 600 mg/300 ml (Zyvox) 1 $0

linezolid oral suspension for

reconstitution 100 mg/5 ml (Zyvox) 1 $0

linezolid oral tablet 600 mg (Zyvox) 1 $0

methenamine hippurate oral tablet 1

gram (Hiprex) 1 $0

metronidazole in nacl (iso-os)


ml

(Metro I.V.) 1 $0

metronidazole oral tablet 250 mg,

500 mg (Flagyl) 1 $0

nitrofurantoin macrocrystal oral

capsule 100 mg, 25 mg, 50 mg (Macrodantin) 1 $0

PA-HRM; (High Risk




with over 90 days

cumulative use of

nitrofurantoin drugs);

QL (120 per 30 days);

AGE (Max 64 Years)





21

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nitrofurantoin monohyd/m-cryst

oral capsule 100 mg (Macrobid) 1 $0

PA-HRM; (High Risk




with over 90 days

cumulative use of

nitrofurantoin drugs);

QL (60 per 30 days);

AGE (Max 64 Years)

polymyxin b sulfate injection recon

soln 500,000 unit 1 $0

SYNERCID INTRAVENOUS

RECON SOLN 500 MG 2 $0

trimethoprim oral tablet 100 mg 1 $0

vancomycin intravenous recon soln

1,000 mg, 10 gram, 250 mg, 5 gram,

500 mg, 750 mg

1 $0

PA BvD

vancomycin oral capsule 125 mg,

250 mg (Vancocin) 1 $0

XIFAXAN ORAL TABLET 200

MG 2 $0

PA; QL (9 per 30 days)

XIFAXAN ORAL TABLET 550

MG 2 $0

PA

Cephalosporins

cefaclor oral capsule 250 mg, 500

mg 1 $0

cefaclor oral suspension for

reconstitution 125 mg/5 ml, 250

mg/5 ml, 375 mg/5 ml

1 $0

cefadroxil oral capsule 500 mg 1 $0

cefadroxil oral suspension for


mg/5 ml

1 $0



.



22

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cefazolin in dextrose (iso-os)

intravenous piggyback 2 gram/50 ml 2 $0

cefazolin injection recon soln 1

gram, 10 gram, 500 mg 1 $0

cefdinir oral capsule 300 mg 1 $0

cefdinir oral suspension for


mg/5 ml

1 $0

cefditoren pivoxil oral tablet 200 mg 1 $0

cefditoren pivoxil oral tablet 400 mg (Spectracef) 1 $0

cefepime injection recon soln 1

gram, 2 gram (Maxipime) 2 $0

cefotaxime injection recon soln 1

gram, 500 mg 1 $0

cefotaxime injection recon soln 10

gram, 2 gram (Claforan) 1 $0

cefoxitin intravenous recon soln 1

gram, 10 gram, 2 gram 1 $0

cefpodoxime oral suspension for

reconstitution 100 mg/5 ml, 50 mg/5

ml

1 $0

cefpodoxime oral tablet 100 mg, 200

mg 1 $0

cefprozil oral suspension for


mg/5 ml

1 $0

cefprozil oral tablet 250 mg, 500 mg 1 $0

ceftazidime injection recon soln 1

gram (Fortaz) 1 $0

ceftazidime injection recon soln 2

gram, 6 gram (TAZICEF) 1 $0

ceftibuten oral capsule 400 mg 2 $0





23

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ceftibuten oral suspension for

reconstitution 180 mg/5 ml 2 $0

ceftriaxone injection recon soln 1

gram, 10 gram, 2 gram, 250 mg,

500 mg

1 $0

cefuroxime axetil oral tablet 250

mg, 500 mg 1 $0

cefuroxime sodium injection recon

soln 750 mg 1 $0

cefuroxime sodium intravenous

recon soln 1.5 gram, 7.5 gram 1 $0

cephalexin oral capsule 250 mg,

500 mg (Keflex) 1 $0

cephalexin oral suspension for


mg/5 ml

1 $0

SUPRAX ORAL CAPSULE 400

MG 2 $0

tazicef injection recon soln 1 gram,

2 gram, 6 gram 1 $0

TEFLARO INTRAVENOUS

RECON SOLN 400 MG, 600 MG 2 $0

Macrolides

azithromycin intravenous recon soln

500 mg (Zithromax) 1 $0

azithromycin oral packet 1 gram (Zithromax) 2 $0

azithromycin oral suspension for


mg/5 ml

(Zithromax) 1 $0

azithromycin oral tablet 250 mg (6

pack), 500 mg (3 pack), 600 mg 1 $0

azithromycin oral tablet 250 mg,

500 mg (Zithromax) 1 $0



.



24

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

clarithromycin oral suspension for


mg/5 ml

1 $0

clarithromycin oral tablet 250 mg,

500 mg 1 $0

DIFICID ORAL TABLET 200 MG 2 $0 ST; QL (20 per 10

days)

erythromycin ethylsuccinate oral

suspension for reconstitution 200

mg/5 ml

(E.E.S. Granules) 1 $0

erythromycin oral tablet 250 mg,

500 mg 1 $0

Miscellaneous B-Lactam

Antibiotics

aztreonam injection recon soln 1

gram, 2 gram (Azactam) 1 $0

CAYSTON INHALATION

SOLUTION FOR

NEBULIZATION 75 MG/ML

2 $0

LA

ertapenem injection recon soln 1

gram (Invanz) 1 $0

imipenem-cilastatin intravenous


imipenem-cilastatin intravenous

recon soln 500 mg (Primaxin IV) 1 $0

INVANZ INJECTION RECON

SOLN 1 GRAM 2 $0

meropenem intravenous recon soln

1 gram, 500 mg (Merrem) 1 $0

Penicillins

amoxicillin oral capsule 250 mg,

500 mg 1 $0





25

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

amoxicillin oral suspension for


mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1 $0

amoxicillin oral tablet 500 mg, 875

mg 1 $0

amoxicillin oral tablet,chewable 125

mg, 250 mg 1 $0

amoxicillin-pot clavulanate oral

suspension for reconstitution 200-

28.5 mg/5 ml, 400-57 mg/5 ml

1 $0


suspension for reconstitution 600-

42.9 mg/5 ml

(Augmentin ES-

600) 1 $0


tablet 500-125 mg, 875-125 mg (Augmentin) 1 $0


tablet,chewable 200-28.5 mg, 400-

57 mg

1 $0

ampicillin oral capsule 250 mg, 500

mg 1 $0

ampicillin sodium injection recon

soln 1 gram, 10 gram, 125 mg, 2

gram, 250 mg, 500 mg

1 $0

ampicillin sodium intravenous recon

soln 2 gram 1 $0

ampicillin-sulbactam injection

recon soln 1.5 gram, 15 gram, 3

gram

(Unasyn) 1 $0

BICILLIN L-A

INTRAMUSCULAR SYRINGE

1,200,000 UNIT/2 ML, 2,400,000

UNIT/4 ML, 600,000 UNIT/ML

2 $0

dicloxacillin oral capsule 250 mg,

500 mg 1 $0



.



26

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nafcillin 1 gm/ 50 ml inj 1 gram/50

ml 1 $0

nafcillin injection recon soln 1 gram 1 $0

nafcillin injection recon soln 10

gram, 2 gram 1 $0

nafcillin intravenous recon soln 2

gram 1 $0

oxacillin 1 gm add-vantage vl add-

vantage, inner 1 gram 1 $0

oxacillin injection recon soln 1

gram, 10 gram, 2 gram 1 $0

penicillin g potassium injection

recon soln 20 million unit (Pfizerpen-G) 1 $0

penicillin g procaine intramuscular

syringe 1.2 million unit/2 ml,

600,000 unit/ml

1 $0

penicillin v potassium oral recon

soln 125 mg/5 ml, 250 mg/5 ml 1 $0

penicillin v potassium oral tablet

250 mg, 500 mg 1 $0

pfizerpen-g injection recon soln 20

million unit 1 $0

piperacillin-tazobactam intravenous

recon soln 2.25 gram, 3.375 gram,

4.5 gram, 40.5 gram

(Zosyn) 1 $0

PA BvD

Quinolones

BAXDELA ORAL TABLET 450

MG 2 $0

PA; QL (28 per 14

days)

ciprofloxacin hcl oral tablet 250 mg,

500 mg (Cipro) 1 $0

ciprofloxacin hcl oral tablet 750 mg 1 $0





27

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ciprofloxacin in 5 % dextrose


ml

1 $0

ciprofloxacin in 5 % dextrose


ml

(Cipro in D5W) 1 $0

ciprofloxacin lactate intravenous

solution 200 mg/20 ml, 400 mg/40

ml

1 $0

ciprofloxacin oral

suspension,microcapsule recon 250

mg/5 ml, 500 mg/5 ml

(Cipro) 1 $0

levofloxacin in d5w intravenous

piggyback 250 mg/50 ml, 500

mg/100 ml, 750 mg/150 ml

1 $0

levofloxacin intravenous solution 25

mg/ml 1 $0

levofloxacin oral solution 250

mg/10 ml 1 $0

levofloxacin oral tablet 250 mg 1 $0

levofloxacin oral tablet 500 mg, 750

mg (Levaquin) 1 $0

moxifloxacin oral tablet 400 mg (Avelox) 1 $0

ofloxacin oral tablet 300 mg, 400

mg 1 $0

Sulfonamides

sulfadiazine oral tablet 500 mg 1 $0

sulfamethoxazole-trimethoprim

intravenous solution 400-80 mg/5

ml

1 $0

sulfamethoxazole-trimethoprim oral

suspension 200-40 mg/5 ml (Sulfatrim) 1 $0



.



28

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


tablet 400-80 mg (Bactrim) 1 $0


tablet 800-160 mg (Bactrim DS) 1 $0

sulfatrim oral suspension 200-40

mg/5 ml 2 $0

Tetracyclines

doxy-100 intravenous recon soln

100 mg 1 $0

doxycycline hyclate intravenous

recon soln 100 mg (Doxy-100) 1 $0

doxycycline hyclate oral capsule

100 mg, 50 mg (Morgidox) 1 $0

doxycycline hyclate oral tablet 100

mg, 20 mg 1 $0

doxycycline monohydrate oral

capsule 100 mg, 50 mg (Mondoxyne NL) 1 $0

doxycycline monohydrate oral


mg/5 ml

(Vibramycin) 1 $0

doxycycline monohydrate oral tablet

100 mg (Avidoxy) 1 $0

doxycycline monohydrate oral tablet

50 mg 1 $0

minocycline oral capsule 100 mg,

75 mg 1 $0

minocycline oral capsule 50 mg (Minocin) 1 $0

mondoxyne nl oral capsule 100 mg,

50 mg 1 $0

okebo oral capsule 100 mg 1 $0

tetracycline oral capsule 250 mg,

500 mg 1 $0





29

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

tigecycline intravenous recon soln

50 mg (Tygacil) 1 $0

Anticancer Agents

Anticancer Agents

ABRAXANE INTRAVENOUS

SUSPENSION FOR

RECONSTITUTION 100 MG

2 $0

adriamycin intravenous solution 10

mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50

mg/25 ml

1 $0

PA BvD

adrucil intravenous solution 2.5

gram/50 ml, 500 mg/10 ml 1 $0

PA BvD

AFINITOR DISPERZ ORAL

TABLET FOR SUSPENSION 2

MG, 3 MG, 5 MG

2 $0

PA NSO; QL (112 per

28 days)

AFINITOR ORAL TABLET 10

MG 2 $0

PA NSO; QL (56 per

28 days)

AFINITOR ORAL TABLET 2.5

MG, 5 MG, 7.5 MG 2 $0

PA NSO; QL (28 per

28 days)

ALECENSA ORAL CAPSULE 150

MG 2 $0

PA NSO; QL (240 per

30 days)

ALIMTA INTRAVENOUS


ALIQOPA INTRAVENOUS


PA NSO; QL (3 per 28

days)

ALUNBRIG ORAL TABLET 180

MG, 90 MG 2 $0

PA NSO; QL (30 per

30 days)

ALUNBRIG ORAL TABLET 30

MG 2 $0

PA NSO; QL (120 per

30 days)

ALUNBRIG ORAL

TABLETS,DOSE PACK 90 MG

(7)- 180 MG (23)

2 $0

PA NSO; QL (30 per

30 days)

anastrozole oral tablet 1 mg (Arimidex) 1 $0



.



30

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

arsenic trioxide intravenous solution

1 mg/ml 1 $0

AVASTIN INTRAVENOUS

SOLUTION 25 MG/ML 2 $0

PA NSO

azacitidine injection recon soln 100

mg (Vidaza) 1 $0

BAVENCIO INTRAVENOUS


PA NSO

BELEODAQ INTRAVENOUS


PA NSO

BENDEKA INTRAVENOUS


PA NSO

BESPONSA INTRAVENOUS

RECON SOLN 0.9 MG (0.25

MG/ML INITIAL)

2 $0

PA NSO

bexarotene oral capsule 75 mg (Targretin) 1 $0 PA NSO; QL (420 per

30 days)

bicalutamide oral tablet 50 mg (Casodex) 1 $0

bleomycin injection recon soln 15

unit, 30 unit 1 $0

PA BvD

BLINCYTO INTRAVENOUS KIT

35 MCG 2 $0

PA NSO

BORTEZOMIB INTRAVENOUS

RECON SOLN 3.5 MG 2 $0

PA NSO

BOSULIF ORAL TABLET 100

MG 2 $0

PA NSO; QL (90 per

30 days)

BOSULIF ORAL TABLET 400

MG, 500 MG 2 $0

PA NSO; QL (30 per

30 days)

BRAFTOVI ORAL CAPSULE 50

MG 2 $0

PA NSO; QL (120 per

30 days)

BRAFTOVI ORAL CAPSULE 75

MG 2 $0

PA NSO; QL (180 per

30 days)





31

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

CABOMETYX ORAL TABLET 20

MG, 60 MG 2 $0

PA NSO; QL (30 per

30 days)

CABOMETYX ORAL TABLET 40

MG 2 $0

PA NSO; QL (60 per

30 days)

CALQUENCE ORAL CAPSULE

100 MG 2 $0

PA NSO; QL (60 per

30 days)

CAPRELSA ORAL TABLET 100

MG 2 $0

PA NSO; QL (60 per

30 days)

CAPRELSA ORAL TABLET 300

MG 2 $0

PA NSO; QL (30 per

30 days)

clofarabine intravenous solution 20

mg/20 ml (Clolar) 1 $0

COMETRIQ ORAL CAPSULE 100

MG/DAY(80 MG X1-20 MG X1),

140 MG/DAY(80 MG X1-20 MG

X3), 60 MG/DAY (20 MG X

3/DAY)

2 $0

PA NSO; QL (112 per

28 days)

COPIKTRA ORAL CAPSULE 15

MG, 25 MG 2 $0

PA NSO; QL (56 per

28 days)

COTELLIC ORAL TABLET 20

MG 2 $0

PA NSO; LA; QL (63

per 28 days)

cyclophosphamide intravenous

recon soln 1 gram, 2 gram, 500 mg 1 $0

PA BvD

CYCLOPHOSPHAMIDE ORAL

CAPSULE 25 MG, 50 MG 1 $0

PA BvD; ST

CYRAMZA INTRAVENOUS


PA NSO

DARZALEX INTRAVENOUS


PA NSO; LA

DAURISMO ORAL TABLET 100

MG 2 $0

PA NSO; QL (30 per

30 days)

DAURISMO ORAL TABLET 25

MG 2 $0

PA NSO; QL (60 per

30 days)



.



32

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

decitabine intravenous recon soln

50 mg (Dacogen) 1 $0

doxorubicin intravenous solution 10

mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50

mg/25 ml

(Adriamycin) 1 $0

PA BvD

doxorubicin, peg-liposomal

intravenous suspension 2 mg/ml (Doxil) 1 $0

PA BvD

DROXIA ORAL CAPSULE 200

MG, 300 MG, 400 MG 2 $0

ELIGARD (3 MONTH)

SUBCUTANEOUS SYRINGE 22.5

MG

2 $0

ELIGARD (4 MONTH)

SUBCUTANEOUS SYRINGE 30

MG

2 $0

ELIGARD (6 MONTH)


MG

2 $0

ELIGARD SUBCUTANEOUS

SYRINGE 7.5 MG (1 MONTH) 2 $0

EMCYT ORAL CAPSULE 140

MG 2 $0

EMPLICITI INTRAVENOUS


PA NSO

ERIVEDGE ORAL CAPSULE 150

MG 2 $0

PA NSO; QL (30 per

30 days)

ERLEADA ORAL TABLET 60

MG 2 $0

PA NSO; QL (120 per

30 days)

ETOPOPHOS INTRAVENOUS


etoposide intravenous solution 20

mg/ml (Toposar) 1 $0

exemestane oral tablet 25 mg (Aromasin) 1 $0





33

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

FARESTON ORAL TABLET 60

MG 2 $0

FARYDAK ORAL CAPSULE 10

MG, 15 MG, 20 MG 2 $0

PA NSO

FASLODEX INTRAMUSCULAR

SYRINGE 250 MG/5 ML 2 $0

floxuridine injection recon soln 0.5

gram 1 $0

PA BvD

fluorouracil intravenous solution 1

gram/20 ml 1 $0

PA BvD

fluorouracil intravenous solution 5

gram/100 ml, 500 mg/10 ml (Adrucil) 1 $0

PA BvD

flutamide oral capsule 125 mg 1 $0

GAZYVA INTRAVENOUS

SOLUTION 1,000 MG/40 ML 2 $0

PA NSO

GILOTRIF ORAL TABLET 20

MG, 30 MG, 40 MG 2 $0

PA NSO; QL (30 per

30 days)

GLEOSTINE ORAL CAPSULE 10

MG, 100 MG, 40 MG, 5 MG 2 $0

HERCEPTIN INTRAVENOUS


PA NSO

HEXALEN ORAL CAPSULE 50

MG 2 $0

hydroxyurea oral capsule 500 mg (Hydrea) 1 $0

IBRANCE ORAL CAPSULE 100

MG, 125 MG, 75 MG 2 $0

PA NSO; QL (21 per

28 days)

ICLUSIG ORAL TABLET 15 MG 2 $0 PA NSO; QL (60 per

30 days)

ICLUSIG ORAL TABLET 45 MG 2 $0 PA NSO; QL (30 per

30 days)

IDHIFA ORAL TABLET 100 MG,

50 MG 2 $0

PA NSO; QL (30 per

30 days)



.



34

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ifosfamide intravenous recon soln 1

gram (Ifex) 1 $0

PA BvD

ifosfamide intravenous solution 1

gram/20 ml, 3 gram/60 ml 1 $0

PA BvD

ifosfamide-mesna intravenous kit 1-

1 gram, 3,000-1,000 mg 1 $0

PA BvD

imatinib oral tablet 100 mg (Gleevec) 1 $0 PA NSO; QL (90 per

30 days)

imatinib oral tablet 400 mg (Gleevec) 1 $0 PA NSO; QL (60 per

30 days)

IMBRUVICA ORAL CAPSULE

140 MG, 70 MG 2 $0

PA NSO; QL (28 per

28 days)

IMBRUVICA ORAL TABLET 140

MG, 280 MG, 420 MG, 560 MG 2 $0

PA NSO; QL (28 per

28 days)

IMFINZI INTRAVENOUS


PA NSO

IMLYGIC INJECTION

SUSPENSION 10EXP6 (1

MILLION) PFU/ML

2 $0

PA NSO; QL (4 per

365 days)

IMLYGIC INJECTION

SUSPENSION 10EXP8 (100

MILLION) PFU/ML

2 $0


days)

INLYTA ORAL TABLET 1 MG 2 $0 PA NSO; QL (180 per

30 days)

INLYTA ORAL TABLET 5 MG 2 $0 PA NSO; QL (60 per

30 days)

IRESSA ORAL TABLET 250 MG 2 $0 PA NSO; QL (60 per

30 days)

IXEMPRA INTRAVENOUS


JAKAFI ORAL TABLET 10 MG,

15 MG, 20 MG, 25 MG, 5 MG 2 $0

PA NSO; QL (60 per

30 days)





35

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

KEYTRUDA INTRAVENOUS



days)

KISQALI FEMARA CO-PACK

ORAL TABLET 200 MG/DAY(200

MG X 1)-2.5 MG

2 $0

PA NSO; QL (49 per

28 days)



MG X 2)-2.5 MG

2 $0

PA NSO; QL (70 per

28 days)



MG X 3)-2.5 MG

2 $0

PA NSO; QL (91 per

28 days)

KISQALI ORAL TABLET 200

MG/DAY (200 MG X 1) 2 $0

PA NSO; QL (21 per

28 days)


MG/DAY (200 MG X 2) 2 $0

PA NSO; QL (42 per

28 days)


MG/DAY (200 MG X 3) 2 $0

PA NSO; QL (63 per

28 days)

KYPROLIS INTRAVENOUS

RECON SOLN 10 MG, 30 MG, 60

MG

2 $0

PA NSO

LARTRUVO INTRAVENOUS


PA NSO; LA

LENVIMA ORAL CAPSULE 10

MG/DAY (10 MG X 1), 12

MG/DAY (4 MG X 3), 14

MG/DAY(10 MG X 1-4 MG X 1),

18 MG/DAY (10 MG X 1-4 MG

X2), 20 MG/DAY (10 MG X 2), 24

MG/DAY(10 MG X 2-4 MG X 1), 4

MG, 8 MG/DAY (4 MG X 2)

2 $0

PA NSO

letrozole oral tablet 2.5 mg (Femara) 1 $0

LEUKERAN ORAL TABLET 2

MG 2 $0



.



36

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

leuprolide subcutaneous kit 1

mg/0.2 ml 1 $0

LIBTAYO INTRAVENOUS

SOLUTION 350 MG/7 ML (50

MG/ML)

2 $0


days)

LONSURF ORAL TABLET 15-

6.14 MG 2 $0

PA NSO; QL (100 per

28 days)

LONSURF ORAL TABLET 20-

8.19 MG 2 $0

PA NSO; QL (80 per

28 days)

LORBRENA ORAL TABLET 100

MG 2 $0

PA NSO; QL (30 per

30 days)

LORBRENA ORAL TABLET 25

MG 2 $0

PA NSO; QL (90 per

30 days)

LUMOXITI INTRAVENOUS


PA NSO

LUPRON DEPOT (3 MONTH)


KIT 11.25 MG, 22.5 MG

2 $0



KIT 30 MG

2 $0



KIT 45 MG

2 $0

LUPRON DEPOT


KIT 3.75 MG, 7.5 MG

2 $0

LYNPARZA ORAL CAPSULE 50

MG 2 $0

PA NSO; QL (448 per

28 days)

LYNPARZA ORAL TABLET 100

MG, 150 MG 2 $0

PA NSO; QL (120 per

30 days)

LYSODREN ORAL TABLET 500

MG 2 $0





37

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

MATULANE ORAL CAPSULE 50

MG 2 $0

megestrol oral tablet 20 mg, 40 mg 1 $0 PA NSO-HRM; AGE

(Max 64 Years)

MEKINIST ORAL TABLET 0.5

MG 2 $0

PA NSO; QL (90 per

30 days)

MEKINIST ORAL TABLET 2 MG 2 $0 PA NSO; QL (30 per

30 days)

MEKTOVI ORAL TABLET 15

MG 2 $0

PA NSO; QL (180 per

30 days)

mercaptopurine oral tablet 50 mg 1 $0

methotrexate sodium (pf) injection

recon soln 1 gram 1 $0

PA BvD

methotrexate sodium (pf) injection

solution 25 mg/ml 1 $0

PA BvD

methotrexate sodium injection


PA BvD

methotrexate sodium oral tablet 2.5

mg 1 $0

PA BvD; ST

mitoxantrone intravenous

concentrate 2 mg/ml 1 $0

MYLOTARG INTRAVENOUS

RECON SOLN 4.5 MG (1 MG/ML

INITIAL CONC)

2 $0

PA NSO

NERLYNX ORAL TABLET 40

MG 2 $0

PA NSO; QL (180 per

30 days)

NEXAVAR ORAL TABLET 200

MG 2 $0

PA NSO; QL (120 per

30 days)

nilutamide oral tablet 150 mg (Nilandron) 1 $0

NINLARO ORAL CAPSULE 2.3

MG, 3 MG, 4 MG 2 $0


days)

ODOMZO ORAL CAPSULE 200

MG 2 $0

PA NSO; LA



.



38

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ONCASPAR INJECTION

SOLUTION 750 UNIT/ML 2 $0

PA NSO

ONIVYDE INTRAVENOUS

DISPERSION 4.3 MG/ML 2 $0

PA BvD

OPDIVO INTRAVENOUS

SOLUTION 100 MG/10 ML, 240

MG/24 ML, 40 MG/4 ML

2 $0

PA NSO

POMALYST ORAL CAPSULE 1

MG, 2 MG, 3 MG, 4 MG 2 $0

PA NSO; QL (21 per

28 days)

PORTRAZZA INTRAVENOUS


MG/ML)

2 $0

PA NSO; QL (100 per

21 days)

POTELIGEO INTRAVENOUS


PA NSO

PROLEUKIN INTRAVENOUS

RECON SOLN 22 MILLION UNIT 2 $0

PURIXAN ORAL SUSPENSION

20 MG/ML 2 $0

REVLIMID ORAL CAPSULE 10

MG, 15 MG, 2.5 MG, 20 MG, 25

MG, 5 MG

2 $0

PA NSO; LA; QL (28

per 28 days)

RITUXAN HYCELA

SUBCUTANEOUS SOLUTION

1400 MG/11.7 ML (120 MG/ML),

1600 MG/13.4 ML (120 MG/ML)

2 $0

PA NSO

RITUXAN INTRAVENOUS

CONCENTRATE 10 MG/ML 2 $0

PA NSO

RUBRACA ORAL TABLET 200

MG, 250 MG, 300 MG 2 $0

PA NSO; QL (120 per

30 days)

RYDAPT ORAL CAPSULE 25

MG 2 $0

PA NSO; QL (224 per

28 days)

SOLTAMOX ORAL SOLUTION

10 MG/5 ML 2 $0





39

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SPRYCEL ORAL TABLET 100

MG, 140 MG, 50 MG, 70 MG, 80

MG

2 $0

PA NSO; QL (30 per

30 days)

SPRYCEL ORAL TABLET 20 MG 2 $0 PA NSO; QL (60 per

30 days)

STIVARGA ORAL TABLET 40

MG 2 $0

PA NSO; QL (84 per

28 days)

SUTENT ORAL CAPSULE 12.5

MG, 25 MG, 37.5 MG, 50 MG 2 $0

PA NSO; QL (30 per

30 days)

SYLVANT INTRAVENOUS


PA NSO

SYNRIBO SUBCUTANEOUS


PA NSO; QL (28 per

28 days)

TABLOID ORAL TABLET 40 MG 2 $0

TAFINLAR ORAL CAPSULE 50

MG, 75 MG 2 $0

PA NSO; QL (120 per

30 days)

TAGRISSO ORAL TABLET 40

MG, 80 MG 2 $0

PA NSO; LA; QL (30

per 30 days)

TALZENNA ORAL CAPSULE

0.25 MG 2 $0

PA NSO; QL (90 per

30 days)

TALZENNA ORAL CAPSULE 1

MG 2 $0

PA NSO; QL (30 per

30 days)

tamoxifen oral tablet 10 mg, 20 mg 1 $0

TARCEVA ORAL TABLET 100

MG, 25 MG 2 $0

PA NSO; QL (60 per

30 days)

TARCEVA ORAL TABLET 150

MG 2 $0

PA NSO; QL (90 per

30 days)

TARGRETIN TOPICAL GEL 1 % 2 $0 PA NSO; QL (60 per

28 days)

TASIGNA ORAL CAPSULE 150

MG, 200 MG 2 $0

PA NSO; QL (112 per

28 days)

TASIGNA ORAL CAPSULE 50

MG 2 $0

PA NSO; QL (120 per

30 days)



.



40

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TECENTRIQ INTRAVENOUS

SOLUTION 1,200 MG/20 ML (60

MG/ML)

2 $0

PA NSO; QL (20 per

21 days)

TEMODAR INTRAVENOUS


PA NSO

thiotepa injection recon soln 15 mg (Tepadina) 1 $0

TIBSOVO ORAL TABLET 250

MG 2 $0

PA NSO; QL (60 per

30 days)

toposar intravenous solution 20

mg/ml 1 $0

TREANDA INTRAVENOUS


TRELSTAR INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 11.25 MG

2 $0

QL (1 per 84 days)


SUSPENSION FOR


2 $0

QL (1 per 168 days)


SUSPENSION FOR


2 $0

tretinoin (chemotherapy) oral

capsule 10 mg 1 $0

TYKERB ORAL TABLET 250 MG 2 $0

UNITUXIN INTRAVENOUS

SOLUTION 3.5 MG/ML 2 $0

PA NSO

VALSTAR INTRAVESICAL


VELCADE INJECTION RECON

SOLN 3.5 MG 2 $0

PA NSO

VENCLEXTA ORAL TABLET 10

MG 2 $0

PA NSO; LA; QL (60

per 30 days)





41

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

VENCLEXTA ORAL TABLET

100 MG 2 $0

PA NSO; LA; QL (180

per 30 days)

VENCLEXTA ORAL TABLET 50

MG 2 $0

PA NSO; LA; QL (30

per 30 days)

VENCLEXTA STARTING PACK

ORAL TABLETS,DOSE PACK 10

MG-50 MG- 100 MG

2 $0

PA NSO; LA; QL (42

per 28 days)

VERZENIO ORAL TABLET 100

MG, 150 MG, 200 MG, 50 MG 2 $0

PA NSO; QL (56 per

28 days)

vinorelbine intravenous solution 10

mg/ml, 50 mg/5 ml (Navelbine) 1 $0

VIZIMPRO ORAL TABLET 15

MG, 30 MG, 45 MG 2 $0

PA NSO; QL (30 per

30 days)

VOTRIENT ORAL TABLET 200

MG 2 $0

PA NSO; QL (120 per

30 days)

VYXEOS INTRAVENOUS

RECON SOLN 44-100 MG 2 $0

PA BvD

XALKORI ORAL CAPSULE 200

MG, 250 MG 2 $0

PA NSO; QL (60 per

30 days)

XATMEP ORAL SOLUTION 2.5

MG/ML 2 $0

PA BvD; ST

XOSPATA ORAL TABLET 40

MG 2 $0

PA NSO; QL (90 per

30 days)

XTANDI ORAL CAPSULE 40 MG 2 $0 PA NSO; QL (120 per

30 days)

YERVOY INTRAVENOUS


MG/ML), 50 MG/10 ML (5

MG/ML)

2 $0

PA NSO

YONDELIS INTRAVENOUS


PA NSO

YONSA ORAL TABLET 125 MG 2 $0 PA NSO; QL (120 per

30 days)



.



42

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ZEJULA ORAL CAPSULE 100

MG 2 $0

PA NSO; QL (90 per

30 days)

ZELBORAF ORAL TABLET 240

MG 2 $0

PA NSO; QL (240 per

30 days)

ZOLADEX SUBCUTANEOUS

IMPLANT 10.8 MG 2 $0

QL (1 per 84 days)

ZOLADEX SUBCUTANEOUS

IMPLANT 3.6 MG 2 $0

QL (1 per 28 days)

ZOLINZA ORAL CAPSULE 100

MG 2 $0

ZYDELIG ORAL TABLET 100

MG, 150 MG 2 $0

PA NSO; QL (60 per

30 days)

ZYKADIA ORAL CAPSULE 150

MG 2 $0

PA NSO; QL (90 per

30 days)

ZYTIGA ORAL TABLET 250 MG 1 $0 PA NSO; QL (120 per

30 days)

ZYTIGA ORAL TABLET 500 MG 2 $0 PA NSO; QL (120 per

30 days)

Anticholinergic Agents

Antimuscarinics/Antispasmodics

atropine injection syringe 0.05

mg/ml, 0.1 mg/ml 2 $0

propantheline oral tablet 15 mg 1 $0

Anticonvulsants

Anticonvulsants

APTIOM ORAL TABLET 200 MG,

400 MG, 600 MG, 800 MG 2 $0

ST

BANZEL ORAL SUSPENSION 40

MG/ML 2 $0

ST

BANZEL ORAL TABLET 200

MG, 400 MG 2 $0

ST





43

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

BRIVIACT INTRAVENOUS

SOLUTION 50 MG/5 ML 2 $0

QL (80 per 30 days)

BRIVIACT ORAL SOLUTION 10

MG/ML 2 $0


BRIVIACT ORAL TABLET 10

MG, 100 MG, 25 MG, 50 MG, 75

MG

2 $0

QL (60 per 30 days)

carbamazepine oral capsule, er

multiphase 12 hr 100 mg, 200 mg,

300 mg

(Carbatrol) 1 $0

carbamazepine oral suspension 100

mg/5 ml (Tegretol) 1 $0

carbamazepine oral tablet 200 mg (Epitol) 1 $0

carbamazepine oral tablet extended

release 12 hr 100 mg, 200 mg, 400

mg

(Tegretol XR) 1 $0

carbamazepine oral tablet,chewable

100 mg 1 $0

CELONTIN ORAL CAPSULE 300

MG 2 $0

DILANTIN ORAL CAPSULE 30

MG 1 $0

divalproex oral capsule, delayed rel

sprinkle 125 mg

(Depakote

Sprinkles) 1 $0

divalproex oral tablet extended

release 24 hr 250 mg, 500 mg (Depakote ER) 1 $0

divalproex oral tablet,delayed

release (dr/ec) 125 mg, 250 mg, 500

mg

(Depakote) 1 $0

EPIDIOLEX ORAL SOLUTION

100 MG/ML 2 $0

PA NSO

epitol oral tablet 200 mg 1 $0

ethosuximide oral capsule 250 mg (Zarontin) 1 $0



.



44

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ethosuximide oral solution 250 mg/5

ml (Zarontin) 1 $0

felbamate oral suspension 600 mg/5

ml (Felbatol) 1 $0

felbamate oral tablet 400 mg, 600

mg (Felbatol) 1 $0

fosphenytoin injection solution 100

mg pe/2 ml, 500 mg pe/10 ml (Cerebyx) 1 $0

FYCOMPA ORAL SUSPENSION

0.5 MG/ML 2 $0

ST

FYCOMPA ORAL TABLET 10

MG, 12 MG, 2 MG, 4 MG, 6 MG, 8

MG

2 $0

ST

gabapentin oral capsule 100 mg,

300 mg, 400 mg (Neurontin) 1 $0

gabapentin oral solution 250 mg/5

ml (Neurontin) 1 $0

gabapentin oral tablet 600 mg, 800

mg (Neurontin) 1 $0

lamotrigine oral tablet 100 mg, 150

mg, 200 mg, 25 mg (Lamictal) 1 $0

lamotrigine oral tablet, chewable

dispersible 25 mg, 5 mg (Lamictal) 1 $0

levetiracetam intravenous solution

500 mg/5 ml (Keppra) 1 $0

levetiracetam oral solution 100

mg/ml (Keppra) 1 $0

levetiracetam oral tablet 1,000 mg,

250 mg, 500 mg, 750 mg (Keppra) 1 $0

levetiracetam oral tablet extended

release 24 hr 500 mg, 750 mg (Keppra XR) 1 $0





45

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

LYRICA ORAL CAPSULE 100

MG, 150 MG, 200 MG, 225 MG, 25

MG, 300 MG, 50 MG, 75 MG

2 $0

QL (90 per 30 days)

LYRICA ORAL SOLUTION 20

MG/ML 2 $0


oxcarbazepine oral suspension 300

mg/5 ml (60 mg/ml) (Trileptal) 1 $0

oxcarbazepine oral tablet 150 mg,

300 mg, 600 mg (Trileptal) 1 $0

OXTELLAR XR ORAL TABLET


MG, 300 MG, 600 MG

2 $0

ST

PEGANONE ORAL TABLET 250

MG 2 $0

phenobarbital oral elixir 20 mg/5 ml

(4 mg/ml) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

phenobarbital oral tablet 100 mg,

15 mg, 16.2 mg, 30 mg, 32.4 mg, 60

mg, 64.8 mg, 97.2 mg

1 $0

PA NSO-HRM; AGE

(Max 64 Years)

phenytoin oral suspension 125 mg/5

ml (Dilantin-125) 1 $0

phenytoin oral tablet,chewable 50

mg (Dilantin Infatabs) 1 $0

phenytoin sodium extended oral

capsule 100 mg

(Dilantin

Extended) 1 $0

phenytoin sodium extended oral

capsule 200 mg, 300 mg (Phenytek) 1 $0

phenytoin sodium intravenous


phenytoin sodium intravenous

syringe 50 mg/ml 1 $0

primidone oral tablet 250 mg, 50 mg (Mysoline) 1 $0



.



46

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ROWEEPRA ORAL TABLET

1,000 MG, 500 MG, 750 MG 1 $0

SABRIL ORAL TABLET 500 MG 2 $0

SPRITAM ORAL TABLET FOR

SUSPENSION 1,000 MG 2 $0

ST; QL (60 per 30

days)

SPRITAM ORAL TABLET FOR

SUSPENSION 250 MG, 500 MG,

750 MG

2 $0

ST; QL (120 per 30

days)

subvenite oral tablet 100 mg, 150

mg, 200 mg, 25 mg 1 $0

tiagabine oral tablet 12 mg, 16 mg,

2 mg, 4 mg (Gabitril) 1 $0

topiramate oral capsule, sprinkle 15

mg, 25 mg (Topamax) 1 $0

topiramate oral capsule,sprinkle,er

24hr 100 mg, 150 mg, 200 mg, 25

mg, 50 mg

(Qudexy XR) 2 $0

topiramate oral tablet 100 mg, 200

mg, 25 mg, 50 mg (Topamax) 1 $0

TROKENDI XR ORAL

CAPSULE,EXTENDED RELEASE

24HR 200 MG

2 $0

ST; QL (60 per 30

days)

valproate sodium intravenous

solution 500 mg/5 ml (100 mg/ml) (Depacon) 1 $0

valproic acid (as sodium salt) oral

solution 250 mg/5 ml (Depakene) 1 $0

valproic acid oral capsule 250 mg (Depakene) 1 $0

vigabatrin oral powder in packet

500 mg (Sabril) 1 $0

vigadrone oral powder in packet

500 mg 1 $0

VIMPAT INTRAVENOUS


ST; QL (200 per 5

days)





47

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

VIMPAT ORAL SOLUTION 10

MG/ML 2 $0

ST; QL (1200 per 30

days)

VIMPAT ORAL TABLET 100 MG,

150 MG, 200 MG, 50 MG 2 $0

ST; QL (60 per 30

days)

zonisamide oral capsule 100 mg, 25

mg (Zonegran) 1 $0

zonisamide oral capsule 50 mg 1 $0

Antidementia Agents

Antidementia Agents

donepezil oral tablet 10 mg, 5 mg (Aricept) 1 $0 QL (30 per 30 days)

donepezil oral tablet,disintegrating

10 mg, 5 mg 1 $0

QL (30 per 30 days)

galantamine oral capsule,ext rel.

pellets 24 hr 16 mg, 24 mg, 8 mg (Razadyne ER) 1 $0

QL (30 per 30 days)

galantamine oral solution 4 mg/ml 1 $0 QL (200 per 30 days)

galantamine oral tablet 12 mg, 4

mg, 8 mg (Razadyne) 1 $0

QL (60 per 30 days)

memantine oral capsule,sprinkle,er

24hr 14 mg, 21 mg, 28 mg, 7 mg (Namenda XR) 1 $0

QL (30 per 30 days)

memantine oral solution 2 mg/ml 1 $0 QL (360 per 30 days)

memantine oral tablet 10 mg, 5 mg (Namenda) 1 $0 QL (60 per 30 days)

NAMZARIC ORAL

CAP,SPRINKLE,ER 24HR DOSE

PACK 7/14/21/28 MG-10 MG

2 $0


NAMZARIC ORAL


14-10 MG, 21-10 MG, 28-10 MG,

7-10 MG

2 $0

QL (30 per 30 days)

rivastigmine tartrate oral capsule

1.5 mg, 3 mg, 4.5 mg, 6 mg 1 $0

QL (60 per 30 days)

rivastigmine transdermal patch 24

hour 13.3 mg/24 hour, 4.6 mg/24 hr,

9.5 mg/24 hr

(Exelon) 1 $0

QL (30 per 30 days)



.



48

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Antidepressants

Antidepressants

amitriptyline oral tablet 10 mg, 100

mg, 150 mg, 25 mg, 50 mg, 75 mg 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

amoxapine oral tablet 100 mg, 150

mg, 25 mg, 50 mg 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

bupropion hcl oral tablet 100 mg,

75 mg 1 $0

bupropion hcl oral tablet extended

release 24 hr 150 mg, 300 mg (Wellbutrin XL) 1 $0

bupropion hcl oral tablet sustained-

release 12 hr 100 mg, 150 mg, 200

mg

(Wellbutrin SR) 1 $0

citalopram oral solution 10 mg/5 ml 1 $0 QL (600 per 30 days)

citalopram oral tablet 10 mg, 20

mg, 40 mg (Celexa) 1 $0

QL (30 per 30 days)

clomipramine oral capsule 25 mg,

50 mg, 75 mg (Anafranil) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

desipramine oral tablet 10 mg, 25

mg (Norpramin) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

desipramine oral tablet 100 mg, 150

mg, 50 mg, 75 mg 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

desvenlafaxine succinate oral tablet

extended release 24 hr 100 mg, 25

mg, 50 mg

(Pristiq) 1 $0

QL (30 per 30 days)

doxepin oral capsule 10 mg, 100

mg, 150 mg, 25 mg, 50 mg, 75 mg 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

doxepin oral concentrate 10 mg/ml 1 $0 PA NSO-HRM; AGE

(Max 64 Years)

duloxetine oral capsule,delayed

release(dr/ec) 20 mg, 60 mg (Cymbalta) 1 $0

QL (60 per 30 days)





49

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

duloxetine oral capsule,delayed

release(dr/ec) 30 mg (Cymbalta) 1 $0

QL (30 per 30 days)

EMSAM TRANSDERMAL

PATCH 24 HOUR 12 MG/24 HR, 6

MG/24 HR, 9 MG/24 HR

2 $0

QL (30 per 30 days)

escitalopram oxalate oral solution 5

mg/5 ml 1 $0

escitalopram oxalate oral tablet 10

mg, 20 mg, 5 mg (Lexapro) 1 $0

FETZIMA ORAL CAPSULE,EXT

REL 24HR DOSE PACK 20 MG

(2)- 40 MG (26)

2 $0


FETZIMA ORAL


24 HR 120 MG, 20 MG, 40 MG, 80

MG

2 $0

QL (30 per 30 days)

fluoxetine oral capsule 10 mg, 20

mg, 40 mg (Prozac) 1 $0

fluoxetine oral solution 20 mg/5 ml

(4 mg/ml) 1 $0

fluvoxamine oral tablet 100 mg, 25

mg, 50 mg 1 $0

imipramine hcl oral tablet 10 mg, 25

mg, 50 mg (Tofranil) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

maprotiline oral tablet 25 mg, 50

mg, 75 mg 1 $0

MARPLAN ORAL TABLET 10

MG 2 $0

mirtazapine oral tablet 15 mg, 30

mg (Remeron) 1 $0

mirtazapine oral tablet 45 mg, 7.5

mg 1 $0



.



50

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

mirtazapine oral

tablet,disintegrating 15 mg, 30 mg,

45 mg

(Remeron SolTab) 1 $0

nefazodone oral tablet 100 mg, 150

mg, 200 mg, 250 mg, 50 mg 1 $0

nortriptyline oral capsule 10 mg, 25

mg, 50 mg, 75 mg (Pamelor) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

nortriptyline oral solution 10 mg/5

ml 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

paroxetine hcl oral tablet 10 mg, 20

mg, 30 mg, 40 mg (Paxil) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

PAXIL ORAL SUSPENSION 10

MG/5 ML 2 $0

PA NSO-HRM; AGE

(Max 64 Years)

perphenazine-amitriptyline oral

tablet 2-10 mg, 2-25 mg, 4-10 mg,

4-25 mg, 4-50 mg

1 $0

PA NSO-HRM; AGE

(Max 64 Years)

phenelzine oral tablet 15 mg (Nardil) 1 $0

protriptyline oral tablet 10 mg, 5 mg 1 $0 PA NSO-HRM; AGE

(Max 64 Years)

sertraline oral concentrate 20

mg/ml (Zoloft) 1 $0

sertraline oral tablet 100 mg, 25

mg, 50 mg (Zoloft) 1 $0

tranylcypromine oral tablet 10 mg (Parnate) 1 $0

trazodone oral tablet 100 mg, 150

mg, 300 mg, 50 mg 1 $0

trimipramine oral capsule 100 mg,

25 mg, 50 mg (Surmontil) 1 $0

PA NSO-HRM; AGE

(Max 64 Years)

TRINTELLIX ORAL TABLET 10

MG, 20 MG, 5 MG 2 $0

ST; QL (30 per 30

days)

venlafaxine oral capsule,extended

release 24hr 150 mg (Effexor XR) 1 $0

QL (30 per 30 days)





51

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

venlafaxine oral capsule,extended

release 24hr 37.5 mg, 75 mg (Effexor XR) 1 $0

QL (90 per 30 days)

venlafaxine oral tablet 100 mg, 25

mg, 37.5 mg, 50 mg, 75 mg 1 $0

VIIBRYD ORAL TABLET 10 MG,

20 MG, 40 MG 2 $0

ST; QL (30 per 30

days)

VIIBRYD ORAL TABLETS,DOSE

PACK 10 MG (7)- 20 MG (23) 2 $0

ST; QL (30 per 180

days)

Antidiabetic Agents

Antidiabetic Agents, Miscellaneous

acarbose oral tablet 100 mg, 25 mg,

50 mg (Precose) 1 $0

QL (90 per 30 days)

GLUCAGEN HYPOKIT

INJECTION RECON SOLN 1 MG 2 $0

GLYXAMBI ORAL TABLET 10-5

MG, 25-5 MG 2 $0

ST; QL (30 per 30

days)

INVOKAMET ORAL TABLET

150-1,000 MG, 150-500 MG, 50-

1,000 MG

2 $0

ST; QL (60 per 30

days)

INVOKAMET ORAL TABLET 50-

500 MG 2 $0

ST; QL (120 per 30

days)

INVOKAMET XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 150-1,000 MG, 150-500 MG,

50-1,000 MG, 50-500 MG

2 $0

ST; QL (60 per 30

days)

INVOKANA ORAL TABLET 100

MG 2 $0

ST; QL (60 per 30

days)

INVOKANA ORAL TABLET 300

MG 2 $0

ST; QL (30 per 30

days)

JANUMET ORAL TABLET 50-

1,000 MG, 50-500 MG 2 $0

QL (60 per 30 days)



.



52

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR 100-

1,000 MG

2 $0

QL (30 per 30 days)

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR 50-1,000

MG, 50-500 MG

2 $0

QL (60 per 30 days)

JANUVIA ORAL TABLET 100

MG, 25 MG, 50 MG 2 $0

QL (30 per 30 days)

JARDIANCE ORAL TABLET 10

MG, 25 MG 2 $0

ST; QL (30 per 30

days)

JENTADUETO ORAL TABLET

2.5-1,000 MG, 2.5-500 MG, 2.5-850

MG

2 $0

QL (60 per 30 days)

JENTADUETO XR ORAL


24HR 2.5-1,000 MG

2 $0

QL (60 per 30 days)

JENTADUETO XR ORAL


24HR 5-1,000 MG

2 $0

QL (30 per 30 days)

KORLYM ORAL TABLET 300

MG 2 $0

PA; QL (112 per 28

days)

metformin oral tablet 1,000 mg (Glucophage) 1 $0 QL (75 per 30 days)

metformin oral tablet 500 mg (Glucophage) 1 $0 QL (150 per 30 days)

metformin oral tablet 850 mg (Glucophage) 1 $0 QL (90 per 30 days)

metformin oral tablet extended

release 24 hr 500 mg (Glucophage XR) 1 $0


metformin oral tablet extended

release 24 hr 750 mg (Glucophage XR) 1 $0

QL (60 per 30 days)

OZEMPIC SUBCUTANEOUS

PEN INJECTOR 0.25 MG OR 0.5

MG(2 MG/1.5 ML), 1 MG/0.75 ML

(2 MG/1.5 ML)

2 $0

QL (3 per 28 days)





53

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

pioglitazone oral tablet 15 mg, 30

mg, 45 mg (Actos) 1 $0

QL (30 per 30 days)

repaglinide oral tablet 0.5 mg 1 $0 QL (240 per 30 days)

repaglinide oral tablet 1 mg, 2 mg (Prandin) 1 $0 QL (240 per 30 days)

SYMLINPEN 120

SUBCUTANEOUS PEN

INJECTOR 2,700 MCG/2.7 ML

2 $0

PA; QL (10.8 per 28

days)

SYMLINPEN 60

SUBCUTANEOUS PEN

INJECTOR 1,500 MCG/1.5 ML

2 $0

PA; QL (10.8 per 28

days)

SYNJARDY ORAL TABLET 12.5-

1,000 MG, 12.5-500 MG, 5-1,000

MG, 5-500 MG

2 $0

ST; QL (60 per 30

days)

SYNJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR 10-1,000

MG, 25-1,000 MG

2 $0

ST; QL (30 per 30

days)

SYNJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR 12.5-

1,000 MG, 5-1,000 MG

2 $0

ST; QL (60 per 30

days)

TRADJENTA ORAL TABLET 5

MG 2 $0

QL (30 per 30 days)

TRULICITY SUBCUTANEOUS

PEN INJECTOR 0.75 MG/0.5 ML,

1.5 MG/0.5 ML

2 $0

QL (2 per 28 days)

VICTOZA SUBCUTANEOUS

PEN INJECTOR 0.6 MG/0.1 ML

(18 MG/3 ML)

2 $0

QL (9 per 30 days)

Insulins

FIASP FLEXTOUCH U-100

INSULIN SUBCUTANEOUS

INSULIN PEN 100 UNIT/ML (3

ML)

2 $0

QL (30 per 28 days)



.



54

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

FIASP U-100 INSULIN


100 UNIT/ML

2 $0

QL (40 per 28 days)

HUMULIN R U-500 (CONC)


SOLUTION 500 UNIT/ML

2 $0

QL (40 per 28 days)


KWIKPEN SUBCUTANEOUS


ML)

2 $0

QL (24 per 28 days)

LANTUS SOLOSTAR U-100



ML)

2 $0

QL (30 per 28 days)

LANTUS U-100 INSULIN


100 UNIT/ML

2 $0

QL (40 per 28 days)

NOVOLIN 70/30 U-100 INSULIN

SUBCUTANEOUS SUSPENSION

100 UNIT/ML (70-30)

2 $0

QL (40 per 28 days)

NOVOLIN 70-30 FLEXPEN U-100

SUBCUTANEOUS INSULIN PEN

100 UNIT/ML (70-30)

2 $0

QL (30 per 28 days)

NOVOLIN N NPH U-100


SUSPENSION 100 UNIT/ML

2 $0

QL (40 per 28 days)

NOVOLIN R REGULAR U-100

INSULN INJECTION SOLUTION

100 UNIT/ML

2 $0

QL (40 per 28 days)

NOVOLOG FLEXPEN U-100


INSULIN PEN 100 UNIT/ML

2 $0

QL (30 per 28 days)





55

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

NOVOLOG MIX 70-30 U-100

INSULN SUBCUTANEOUS

SOLUTION 100 UNIT/ML (70-30)

2 $0

QL (40 per 28 days)

NOVOLOG MIX 70-30FLEXPEN

U-100 SUBCUTANEOUS

INSULIN PEN 100 UNIT/ML (70-

30)

2 $0

QL (30 per 28 days)

NOVOLOG PENFILL U-100


CARTRIDGE 100 UNIT/ML

2 $0

QL (30 per 28 days)

NOVOLOG U-100 INSULIN

ASPART SUBCUTANEOUS

SOLUTION 100 UNIT/ML

2 $0

QL (40 per 28 days)

SOLIQUA 100/33


100 UNIT-33 MCG/ML

2 $0

ST; QL (30 per 30

days)

TOUJEO MAX U-300 SOLOSTAR


300 UNIT/ML (3 ML)

2 $0

QL (18 per 28 days)

TOUJEO SOLOSTAR U-300


INSULIN PEN 300 UNIT/ML (1.5

ML)

2 $0

QL (13.5 per 28 days)

XULTOPHY 100/3.6


100 UNIT-3.6 MG /ML (3 ML)

2 $0

ST; QL (15 per 28

days)

Sulfonylureas

glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 $0 QL (30 per 30 days)

glimepiride oral tablet 4 mg (Amaryl) 1 $0 QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 1 $0 QL (120 per 30 days)

glipizide oral tablet 5 mg (Glucotrol) 1 $0 QL (60 per 30 days)

glipizide oral tablet extended

release 24hr 10 mg (Glucotrol XL) 1 $0

QL (60 per 30 days)



.



56

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

glipizide oral tablet extended

release 24hr 2.5 mg, 5 mg (Glucotrol XL) 1 $0

QL (30 per 30 days)

glipizide-metformin oral tablet 2.5-

250 mg 1 $0


glipizide-metformin oral tablet 2.5-

500 mg, 5-500 mg 1 $0


glyburide micronized oral tablet 1.5

mg, 3 mg, 6 mg (Glynase) 1 $0

PA-HRM; AGE (Max

64 Years)

glyburide oral tablet 1.25 mg, 2.5

mg, 5 mg 1 $0

PA-HRM; AGE (Max

64 Years)

glyburide-metformin oral tablet

1.25-250 mg, 2.5-500 mg, 5-500 mg 1 $0

PA-HRM; AGE (Max

64 Years)

tolazamide oral tablet 250 mg 1 $0 QL (120 per 30 days)

tolazamide oral tablet 500 mg 1 $0 QL (60 per 30 days)

Antifungals

Antifungals

3-day vaginal cream 2 % * 4 $0

ABELCET INTRAVENOUS

SUSPENSION 5 MG/ML 2 $0

PA BvD

aloe vesta 2% antifungal oint 2 % * 4 $0

AMBISOME INTRAVENOUS

SUSPENSION FOR


2 $0

PA BvD

amphotericin b injection recon soln

50 mg 1 $0

PA BvD

anti-fungal 1% powder 1 % * 4 $0

antifungal 2% cream 2 % * 4 $0

baza antifungal 2% cream 12's 2 %

* 4 $0

blis-to-sol 1% liquid 1 % * 4 $0

caspofungin intravenous recon soln

50 mg, 70 mg (Cancidas) 1 $0





57

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ciclopirox topical cream 0.77 % (Ciclodan) 1 $0

ciclopirox topical solution 8 % (Ciclodan) 1 $0

clotrim 1% vaginal cream 1 % * (Clotrimazole-7) 4 $0

clotrimazole 1% cream (otc) 1 % * (Antifungal

(clotrimazole)) 4 $0

clotrimazole 1% solution (otc) 1 %

* 4 $0

clotrimazole mucous membrane

troche 10 mg 1 $0

clotrimazole topical cream 1 % (Antifungal

(clotrimazole)) 1 $0

clotrimazole-7 cream 1 % * 4 $0

clotrimazole-betamethasone topical

cream 1-0.05 % (Lotrisone) 1 $0

critic-aid clear af 2% oint 12's, w/

antifungal 2 % * 4 $0

cvs miconazole 3 combo pack 4 %

(200 mg)- 2 % (9 gram) * 4 $0

dermafungal 2% ointment 2 % * 4 $0

econazole topical cream 1 % 1 $0

fluconazole in nacl (iso-osm)


ml, 200 mg/100 ml, 400 mg/200 ml

1 $0

PA BvD

fluconazole oral suspension for

reconstitution 10 mg/ml, 40 mg/ml (Diflucan) 1 $0

fluconazole oral tablet 100 mg, 150

mg, 200 mg, 50 mg (Diflucan) 1 $0

flucytosine oral capsule 250 mg,

500 mg (Ancobon) 1 $0

formula 3 antifungal 1% soln 1 % * 4 $0

fungoid-d 1% cream 1 % * 4 $0

griseofulvin microsize oral

suspension 125 mg/5 ml 1 $0



.



58

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

griseofulvin microsize oral tablet

500 mg 1 $0

inzo antifungal 2% cream 2 % * 4 $0

itraconazole oral capsule 100 mg (Sporanox) 1 $0

ketoconazole oral tablet 200 mg 1 $0

ketoconazole topical cream 2 % 1 $0

ketoconazole topical shampoo 2 % (Nizoral) 1 $0

micatin 2% antifungal cream 2 % * 4 $0

miconazole 3 combo pack 3 sup,9gm

crm w/app 200 mg- 2 % (9 gram) * 4 $0

miconazole 7 100 mg vag supp 100

mg * 4 $0

miconazole nitrate 2% cream 2 % * (Miconazole 7) 4 $0

miconazole-3 vaginal suppository

200 mg 1 $0

monistat 7 cream 7 applicators 2 %

* 4 $0

NOXAFIL ORAL SUSPENSION

200 MG/5 ML (40 MG/ML) 2 $0

NOXAFIL ORAL

TABLET,DELAYED RELEASE

(DR/EC) 100 MG

2 $0

nyamyc topical powder 100,000

unit/gram 1 $0

nystatin oral suspension 100,000

unit/ml 1 $0

nystatin oral tablet 500,000 unit 1 $0

nystatin topical cream 100,000

unit/gram 1 $0

nystatin topical ointment 100,000

unit/gram 1 $0





59

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nystatin topical powder 100,000

unit/gram (Nyamyc) 1 $0

nystop topical powder 100,000

unit/gram 1 $0

qc 3 day vaginal 4% cream 200

mg/5 gram (4 %) * 4 $0

ra antifungal 1% cream 1 % * 4 $0

ra antifungal ringworm 1% crm 1 %

* 4 $0

remedy phytplx antifungal oint 2 %

* 4 $0

terbinafine 1% cream 1 % * (Antifungal

(terbinafine)) 4 $0

terbinafine hcl oral tablet 250 mg 1 $0

tolnaftate 1% cream 1 % * (Antifungal

(tolnaftate)) 4 $0

triple paste af 2% ointment 2 % * 4 $0

voriconazole intravenous solution

200 mg (Vfend IV) 1 $0

PA BvD

voriconazole oral suspension for

reconstitution 200 mg/5 ml (40

mg/ml)

(Vfend) 1 $0

voriconazole oral tablet 200 mg, 50

mg (Vfend) 1 $0

Antigout Agents

Antigout Agents, Other

allopurinol oral tablet 100 mg, 300

mg (Zyloprim) 1 $0

colchicine oral tablet 0.6 mg (Colcrys) 1 $0

probenecid oral tablet 500 mg 1 $0

probenecid-colchicine oral tablet

500-0.5 mg 1 $0



.



60

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ULORIC ORAL TABLET 40 MG,

80 MG 2 $0

QL (30 per 30 days)

Antihistamines

Antihistamines

alavert 10 mg odt 10 mg * 4 $0

alavert d-12 allergy-sinus tab 5-120

mg * 4 $0

aler-caps 25 mg capsule 25 mg * 4 $0

alka-seltzer plus allergy tab 25 mg * 4 $0

aller-chlor 4 mg tablet 4 mg * 4 $0

allerclear d-12hr tablet 5-120 mg * 4 $0

allerclear d-24hr er tablet non-

drowsy 10-240 mg * 4 $0

allergy 4 mg tablet 4 mg * 4 $0

aller-tec d 5-120 mg tablet 5-120

mg * 4 $0

aprodine tablet 2.5-60 mg * 4 $0

banophen 25 mg capsule 25 mg * 4 $0

banophen 25 mg tablet 25 mg * 4 $0

banophen 50 mg capsule 50 mg * 4 $0

banophen allergy 12.5 mg/5 ml a/f

12.5 mg/5 ml * 4 $0

BENADRYL ALLERGY 25 MG

ULTRATB ULTRATAB 25 MG * 4 $0

cetirizine hcl 1 mg/ml soln children,

s/f, grape (otc) 1 mg/ml *

(All Day Allergy

(cetirizine)) 4 $0

cetirizine hcl 10 mg chew tab

children's,outer,u-d 10 mg *

(Children's

Cetirizine) 4 $0

cetirizine hcl 10 mg tablet 10 mg * (24Hour Allergy) 4 $0

cetirizine hcl 5 mg chew tab

children's,outer,u-d 5 mg *

(Children's

Cetirizine) 4 $0





61

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cetirizine hcl 5 mg tablet indoor &

outdoor 5 mg * 4 $0

cetirizine-pse er 5-120 mg tab 5-120

mg *

(All Day Allergy-

D) 4 $0

child allegra allergy 30 mg/5 ml

suspension 30 mg/5 ml * 4 $0

child loratadine 5 mg/5 ml syr

grape, s/f 5 mg/5 ml *

(Allergy Relief

(loratadine)) 4 $0

child triaminic cold-allergy 1-2.5

mg/5 ml * 4 $0

child wal-itin 5 mg/5 ml soln 5 mg/5

ml * 4 $0

child wal-tap cold-allergy elx 1-2.5

mg/5 ml * 4 $0

child wal-zyr 1 mg/ml solution 1

mg/ml * 4 $0

children's wal-fex 30 mg/5 ml 30

mg/5 ml * 4 $0

child's aller-tec 1 mg/ml soln 1

mg/ml * 4 $0

child's wal-dryl 12.5 mg/5 ml

children,a/f,cherry 12.5 mg/5 ml * 4 $0

child's wal-zyr 10 mg chew tab 10

mg * 4 $0

chlorhist 4 mg tablet 4 mg * 4 $0

cold-allergy-sinus oral tablet 2.5-60

mg * 4 $0

compoz 25 mg gelcap 25 mg * 4 $0

cvs allergy 25 mg capsule 25 mg * 4 $0

cvs allergy 25 mg tablet 25 mg * 4 $0

cvs allergy relief-d12 tablet 5-120

mg * 4 $0



.



62

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs child allergy 10 mg chw tb 24

hr,indoor/outdoor 10 mg * 4 $0

cvs child allergy rlf 30 mg/5 30

mg/5 ml * 4 $0

cyproheptadine oral syrup 2 mg/5

ml 1 $0

PA-HRM; AGE (Max

64 Years)

dimaphen elixir a/f, grape, gluten-f

1-2.5 mg/5 ml * 4 $0

diphedryl 12.5 mg/5 ml elixir 12.5

mg/5 ml * 4 $0

diphen 25 mg caplet 25 mg * 4 $0

diphenhist 12.5 mg/5 ml soln 12.5

mg/5 ml * 4 $0

diphenhist 25 mg capsule 25 mg * 4 $0

diphenhist 25 mg captab captab 25

mg * 4 $0

diphenhydramine 25 mg capsule

(otc) 25 mg * (Aler-Cap) 4 $0

diphenhydramine hcl injection


diphenhydramine hcl injection


diphenhydramine hcl oral elixir 12.5

mg/5 ml

(Children's Allergy

(diphenhyd)) 1 $0

PA-HRM; AGE (Max

64 Years)

ed-a-hist 4 mg-10 mg tablet 4-10 mg

* 4 $0

fexofenadine hcl 180 mg tablet

24hr,original str (otc) 180 mg * (Allegra Allergy) 4 $0

fexofenadine hcl 60 mg tablet

indoor/outdoor (otc) 60 mg * (Allegra Allergy) 4 $0

geri-dryl 12.5 mg/5 ml liquid 12.5

mg/5 ml * 4 $0





63

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

geri-dryl 25 mg capsule 25 mg * 4 $0

hydroxyzine hcl intramuscular

solution 25 mg/ml, 50 mg/ml 1 $0

PA-HRM; AGE (Max

64 Years)

hydroxyzine hcl oral solution 10

mg/5 ml 1 $0

PA-HRM; AGE (Max

64 Years)

hydroxyzine hcl oral tablet 10 mg,

25 mg, 50 mg 1 $0

PA-HRM; AGE (Max

64 Years)

levocetirizine oral solution 2.5 mg/5

ml (Xyzal) 1 $0

levocetirizine oral tablet 5 mg (24HR Allergy

Relief) 1 $0

loratadine 10 mg softgel 10 mg * (Claritin Liqui-Gel) 4 $0

loratadine 10 mg tablet 10 mg * (Allerclear) 4 $0

loratadine-d 24hr tablet 10-240 mg

* 4 $0

nytol 25 mg quickcaps caplet caplet

25 mg * 4 $0

promethazine oral syrup 6.25 mg/5

ml 1 $0

PA-HRM; AGE (Max

64 Years)

promethazine-phenylephrine oral

syrup 6.25-5 mg/5 ml (Promethazine VC) 1 $0

PA-HRM; AGE (Max

64 Years)

ra allergy med 25 mg capsule 25 mg

* 4 $0

ra allergy med 25 mg tablet 25 mg * 4 $0

ra child allergy rlf 5 mg chew 5 mg

* 4 $0

ra sleep tablet 25 mg * 4 $0

siladryl 12.5 mg/5 ml liquid 12.5

mg/5 ml * 4 $0

simply sleep 25 mg caplet 25 mg * 4 $0

sudogest sinus and allergy tab 4-60

mg * 4 $0



.



64

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

UNISOM 25 MG SLEEPTABS 25

MG * 4 $0

wal-act d cold & allergy tab 2.5-60

mg * 4 $0

wal-dryl allergy 12.5 mg/5 ml 12.5

mg/5 ml * 4 $0

wal-dryl allergy 25 mg capsule 25

mg * 4 $0

wal-dryl allergy 25 mg minitab

minitab, coated 25 mg * 4 $0

wal-fex allergy 180 mg tablet 180

mg * 4 $0

wal-fex allergy 60 mg tablet 60 mg * 4 $0

wal-finate 4 mg tablet 4 mg * 4 $0

wal-finate-d tablet 4-60 mg * 4 $0

wal-itin 10 mg tablet non-drowsy,24

hr rlf 10 mg * 4 $0

wal-itin d 12 hour tablet 5-120 mg * 4 $0

wal-itin d 24 hour tablet 10-240 mg

* 4 $0

wal-phed pe sinus-allergy tab 4-10

mg * 4 $0

wal-phed sinus and allergy tab 4-60

mg * 4 $0

wal-tap elixir 1-2.5 mg/5 ml * 4 $0

wal-zyr 10 mg softgel 10 mg * 4 $0

wal-zyr 10 mg tablet 10 mg * 4 $0

wal-zyr d tablet 5-120 mg * 4 $0

Anti-Infectives (Skin And

Mucous Membrane)

Anti-Infectives (Skin And Mucous

Membrane)





65

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ABREVA 10% CREAM 10 % * 4 $0

clindamycin phosphate vaginal

cream 2 % (Cleocin) 1 $0

metronidazole vaginal gel 0.75 % (Metrogel Vaginal) 1 $0

terconazole vaginal cream 0.4 %,

0.8 % 1 $0

terconazole vaginal suppository 80

mg 1 $0

Antimigraine Agents

Antimigraine Agents

AIMOVIG (70 MG/ML) 140 MG

DOSE - 2 AUTOINJECTORS 70

MG/ML

2 $0


AIMOVIG 70 MG/ML

AUTOINJECTOR 70 MG/ML 2 $0


AIMOVIG AUTOINJECTOR (2

PACK) SUBCUTANEOUS AUTO-

INJECTOR 70 MG/ML

2 $0


AJOVY SUBCUTANEOUS

SYRINGE 225 MG/1.5 ML 2 $0

PA; QL (1.5 per 30

days)

dihydroergotamine injection

solution 1 mg/ml (D.H.E.45) 1 $0

QL (24 per 28 days)

dihydroergotamine nasal spray,non-

aerosol 0.5 mg/pump act. (4 mg/ml) (Migranal) 2 $0

QL (8 per 28 days)

ERGOMAR SUBLINGUAL

TABLET 2 MG 1 $0

QL (40 per 28 days)

rizatriptan oral tablet 10 mg (Maxalt) 1 $0 QL (18 per 28 days)

rizatriptan oral tablet 5 mg 1 $0 QL (18 per 28 days)

rizatriptan oral tablet,disintegrating

10 mg, 5 mg (Maxalt-MLT) 1 $0

QL (18 per 28 days)

sumatriptan nasal spray,non-

aerosol 20 mg/actuation, 5

mg/actuation

(Imitrex) 1 $0

QL (12 per 28 days)



.



66

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sumatriptan succinate oral tablet

100 mg, 25 mg, 50 mg (Imitrex) 1 $0

QL (18 per 28 days)

sumatriptan succinate subcutaneous

cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose

Refill) 1 $0

QL (4 per 28 days)


pen injector 4 mg/0.5 ml, 6 mg/0.5

ml

(Imitrex STATdose

Pen) 1 $0

QL (4 per 28 days)


solution 6 mg/0.5 ml (Imitrex) 1 $0

QL (4 per 28 days)


syringe 6 mg/0.5 ml 1 $0

QL (4 per 28 days)

Antimycobacterials

Antimycobacterials

CAPASTAT INJECTION RECON

SOLN 1 GRAM 2 $0

dapsone oral tablet 100 mg, 25 mg 1 $0

ethambutol oral tablet 100 mg 1 $0

ethambutol oral tablet 400 mg (Myambutol) 1 $0

isoniazid oral solution 50 mg/5 ml 1 $0

isoniazid oral tablet 100 mg, 300

mg 1 $0

PASER ORAL GRANULES DR

FOR SUSP IN PACKET 4 GRAM 2 $0

PRIFTIN ORAL TABLET 150 MG 2 $0

pyrazinamide oral tablet 500 mg 1 $0

rifabutin oral capsule 150 mg (Mycobutin) 1 $0

rifampin intravenous recon soln 600

mg (Rifadin) 1 $0

rifampin oral capsule 150 mg, 300

mg (Rifadin) 1 $0

SIRTURO ORAL TABLET 100

MG 2 $0

PA; QL (188 per 168

days)





67

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TRECATOR ORAL TABLET 250

MG 2 $0

Antinausea Agents

Antinausea Agents

AKYNZEO (FOSNETUPITANT)

INTRAVENOUS RECON SOLN

235-0.25 MG

2 $0

AKYNZEO (NETUPITANT)

ORAL CAPSULE 300-0.5 MG 2 $0

PA BvD

aprepitant oral capsule 125 mg (Emend) 1 $0 PA BvD; QL (2 per 28

days)


days)


days)

aprepitant oral capsule,dose pack

125 mg (1)- 80 mg (2) (Emend) 1 $0

PA BvD; QL (6 per 28

days)

CINVANTI INTRAVENOUS

EMULSION 7.2 MG/ML 2 $0

QL (36 per 28 days)

compro rectal suppository 25 mg 1 $0

cvs motion sickness 50 mg tab 50

mg * 4 $0

cvs motion sickness relief tab

chewable tablet 25 mg * 4 $0

dimenhydrinate injection solution 50

mg/ml 1 $0

dramamine 50 mg tablet 50 mg * 4 $0

dramamine less drowsy 25 mg tb 25

mg * 4 $0

driminate 50 mg tablet 50 mg * 4 $0

dronabinol oral capsule 10 mg, 2.5

mg, 5 mg (Marinol) 1 $0

PA



.



68

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

EMEND (FOSAPREPITANT)


150 MG

2 $0

QL (2 per 28 days)

EMEND ORAL SUSPENSION

FOR RECONSTITUTION 125 MG

(25 MG/ ML FINAL CONC.)

2 $0

PA BvD; QL (6 per 28

days)

granisetron (pf) intravenous

solution 100 mcg/ml 1 $0

granisetron hcl intravenous solution

1 mg/ml, 1 mg/ml (1 ml) 1 $0

granisetron hcl oral tablet 1 mg 1 $0 PA BvD

meclizine 12.5 mg caplet caplet

(otc) 12.5 mg * 4 $0

meclizine 25 mg tablet (otc) 25 mg * (Dramamine Less

Drowsy) 4 $0

meclizine oral tablet 12.5 mg 1 $0 PA-HRM; AGE (Max

64 Years)

meclizine oral tablet 25 mg (Dramamine Less

Drowsy) 1 $0

PA-HRM; AGE (Max

64 Years)

ondansetron hcl (pf) injection

solution 4 mg/2 ml 1 $0

ondansetron hcl (pf) injection

syringe 4 mg/2 ml 1 $0

ondansetron hcl intravenous


ondansetron hcl oral tablet 24 mg 1 $0 PA BvD

ondansetron hcl oral tablet 4 mg, 8

mg (Zofran) 1 $0

PA BvD

ondansetron oral

tablet,disintegrating 4 mg, 8 mg 1 $0

PA BvD

phenadoz rectal suppository 12.5

mg, 25 mg 1 $0

PA-HRM; AGE (Max

64 Years)





69

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

prochlorperazine edisylate injection

solution 10 mg/2 ml (5 mg/ml), 5

mg/ml

1 $0

prochlorperazine maleate oral

tablet 10 mg, 5 mg (Compazine) 1 $0

prochlorperazine rectal suppository

25 mg (Compazine) 1 $0

promethazine injection solution 25

mg/ml, 50 mg/ml (Phenergan) 1 $0

PA-HRM; AGE (Max

64 Years)

promethazine oral tablet 12.5 mg,

25 mg, 50 mg 1 $0

PA-HRM; AGE (Max

64 Years)

promethazine rectal suppository

12.5 mg, 25 mg (Phenadoz) 1 $0

PA-HRM; AGE (Max

64 Years)

promethazine rectal suppository 50

mg (Phenergan) 1 $0

PA-HRM; AGE (Max

64 Years)

promethegan rectal suppository

12.5 mg, 25 mg, 50 mg 1 $0

PA-HRM; AGE (Max

64 Years)

ra motion sickness rlf tb chew

raspberry flavor 25 mg * 4 $0

ra travel sickness 50 mg tab 50 mg * 4 $0

scopolamine base transdermal patch

3 day 1 mg over 3 days (Transderm-Scop) 1 $0

PA-HRM; QL (10 per

30 days); AGE (Max

64 Years)

TRANSDERM-SCOP

TRANSDERMAL PATCH 3 DAY

1 MG OVER 3 DAYS

2 $0

PA-HRM; QL (10 per

30 days); AGE (Max

64 Years)

travel sickness 25 mg tab chew 25

mg * 4 $0

travel-ease 25 mg tablet 25 mg * 4 $0

wal-dram 50 mg tablet 50 mg * 4 $0

wal-dram-2 25 mg tablet 25 mg * 4 $0

Antiparasite Agents

Antiparasite Agents



.



70

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

albendazole oral tablet 200 mg (Albenza) 1 $0

ALBENZA ORAL TABLET 200

MG 2 $0

ALINIA ORAL SUSPENSION

FOR RECONSTITUTION 100

MG/5 ML

2 $0

ALINIA ORAL TABLET 500 MG 2 $0

atovaquone oral suspension 750

mg/5 ml (Mepron) 1 $0

atovaquone-proguanil oral tablet

250-100 mg (Malarone) 1 $0

atovaquone-proguanil oral tablet

62.5-25 mg

(Malarone

Pediatric) 1 $0

chloroquine phosphate oral tablet

250 mg, 500 mg 1 $0

COARTEM ORAL TABLET 20-

120 MG 2 $0

DARAPRIM ORAL TABLET 25

MG 2 $0

PA

hydroxychloroquine oral tablet 200

mg (Plaquenil) 1 $0

IMPAVIDO ORAL CAPSULE 50

MG 2 $0

PA; QL (84 per 28

days)

ivermectin oral tablet 3 mg (Stromectol) 1 $0

mefloquine oral tablet 250 mg 1 $0

NEBUPENT INHALATION


PA BvD

paromomycin oral capsule 250 mg 1 $0

PENTAM INJECTION RECON

SOLN 300 MG 2 $0

PRIMAQUINE ORAL TABLET

26.3 MG 1 $0





71

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Antiparkinsonian Agents

Antiparkinsonian Agents

amantadine hcl oral capsule 100 mg 1 $0

amantadine hcl oral solution 50

mg/5 ml 1 $0

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MG/ML 2 $0

QL (60 per 30 days)

benztropine injection solution 2

mg/2 ml (Cogentin) 1 $0

PA-HRM; AGE (Max

64 Years)

benztropine oral tablet 0.5 mg, 1

mg, 2 mg 1 $0

PA-HRM; AGE (Max

64 Years)

bromocriptine oral capsule 5 mg (Parlodel) 1 $0

bromocriptine oral tablet 2.5 mg (Parlodel) 1 $0

cabergoline oral tablet 0.5 mg 1 $0

carbidopa-levodopa oral tablet 10-

100 mg, 25-100 mg, 25-250 mg (Sinemet) 1 $0

carbidopa-levodopa oral tablet

extended release 25-100 mg, 50-200

mg

(Sinemet CR) 1 $0

carbidopa-levodopa-entacapone

oral tablet 12.5-50-200 mg (Stalevo 50) 2 $0




oral tablet 25-100-200 mg (Stalevo 100) 2 $0






oral tablet 50-200-200 mg (Stalevo 200) 2 $0

entacapone oral tablet 200 mg (Comtan) 1 $0



.



72

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

GOCOVRI ORAL


24HR 137 MG

2 $0

PA; QL (60 per 30

days)

GOCOVRI ORAL


24HR 68.5 MG

2 $0

PA; QL (30 per 30

days)

NEUPRO TRANSDERMAL

PATCH 24 HOUR 1 MG/24

HOUR, 2 MG/24 HOUR, 3 MG/24

HOUR, 4 MG/24 HOUR, 6 MG/24

HOUR, 8 MG/24 HOUR

2 $0

QL (30 per 30 days)

OSMOLEX ER ORAL TABLET,

IR - ER, BIPHASIC 24HR 129 MG,

193 MG, 258 MG

2 $0

ST; QL (30 per 30

days)

pramipexole oral tablet 0.125 mg,

0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5

mg

(Mirapex) 1 $0

rasagiline oral tablet 0.5 mg, 1 mg (Azilect) 1 $0

ropinirole oral tablet 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) 1 $0

selegiline hcl oral capsule 5 mg 1 $0

selegiline hcl oral tablet 5 mg 1 $0

trihexyphenidyl oral elixir 0.4 mg/ml 1 $0 PA-HRM; AGE (Max

64 Years)

trihexyphenidyl oral tablet 2 mg, 5

mg 1 $0

PA-HRM; AGE (Max

64 Years)

XADAGO ORAL TABLET 100

MG, 50 MG 2 $0

PA; QL (30 per 30

days)

Antipsychotic Agents

Antipsychotic Agents





73

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSION,EXTENDED REL

RECON 300 MG, 400 MG

2 $0

QL (1 per 28 days)

ABILIFY MAINTENA

INTRAMUSCULAR


SYRING 300 MG, 400 MG

2 $0

QL (1 per 28 days)

aripiprazole oral solution 1 mg/ml 1 $0 QL (900 per 30 days)

aripiprazole oral tablet 10 mg, 15

mg, 20 mg, 30 mg, 5 mg (Abilify) 1 $0

QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 1 $0 QL (60 per 30 days)

aripiprazole oral


ST; QL (90 per 30

days)

aripiprazole oral


ST; QL (60 per 30

days)

ARISTADA INITIO

INTRAMUSCULAR


SYRING 675 MG/2.4 ML

2 $0


ARISTADA INTRAMUSCULAR


SYRING 1,064 MG/3.9 ML

2 $0





2 $0





2 $0





2 $0


chlorpromazine injection solution

25 mg/ml 1 $0



.



74

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

chlorpromazine oral tablet 10 mg,

100 mg, 200 mg, 25 mg, 50 mg 1 $0

clozapine oral tablet 100 mg (Clozaril) 1 $0 QL (270 per 30 days)

clozapine oral tablet 200 mg 1 $0 QL (135 per 30 days)

clozapine oral tablet 25 mg (Clozaril) 1 $0 QL (90 per 30 days)

clozapine oral tablet 50 mg 1 $0 QL (90 per 30 days)

clozapine oral tablet,disintegrating

100 mg, 12.5 mg, 25 mg (FazaClo) 1 $0

ST; QL (90 per 30

days)


150 mg (FazaClo) 1 $0

ST; QL (180 per 30

days)


200 mg (FazaClo) 1 $0

ST; QL (120 per 30

days)

FANAPT ORAL TABLET 1 MG,

10 MG, 12 MG, 2 MG, 4 MG, 6

MG, 8 MG

2 $0

ST; QL (60 per 30

days)

FANAPT ORAL TABLETS,DOSE

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

2 $0

ST; QL (8 per 28 days)

fluphenazine decanoate injection


fluphenazine hcl injection solution

2.5 mg/ml 1 $0

fluphenazine hcl oral concentrate 5

mg/ml 1 $0

fluphenazine hcl oral elixir 2.5 mg/5

ml 1 $0

fluphenazine hcl oral tablet 1 mg, 10

mg, 2.5 mg, 5 mg 1 $0

GEODON INTRAMUSCULAR

RECON SOLN 20 MG/ML (FINAL

CONC.)

2 $0

QL (6 per 28 days)

haloperidol dec 50 mg/ml vial mdv

50 mg/ml (Haldol Decanoate) 1 $0





75

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

haloperidol decanoate

intramuscular solution 100 mg/ml (Haldol Decanoate) 1 $0


intramuscular solution 100 mg/ml (1

ml)

1 $0


intramuscular solution 50 mg/ml (Haldol Decanoate) 1 $0

haloperidol lactate injection

solution 5 mg/ml (Haldol) 1 $0

haloperidol lactate intramuscular


haloperidol lactate oral concentrate

2 mg/ml 1 $0

haloperidol oral tablet 0.5 mg, 1

mg, 10 mg, 2 mg, 20 mg, 5 mg 1 $0

INVEGA SUSTENNA


117 MG/0.75 ML

2 $0


INVEGA SUSTENNA


156 MG/ML

2 $0

QL (1 per 28 days)

INVEGA SUSTENNA


234 MG/1.5 ML

2 $0


INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 39

MG/0.25 ML

2 $0


INVEGA SUSTENNA


MG/0.5 ML

2 $0


INVEGA TRINZA


273 MG/0.875 ML

2 $0




.



76

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

INVEGA TRINZA


410 MG/1.315 ML

2 $0


INVEGA TRINZA


546 MG/1.75 ML

2 $0


INVEGA TRINZA


819 MG/2.625 ML

2 $0


LATUDA ORAL TABLET 120

MG, 20 MG, 40 MG, 60 MG, 80

MG

2 $0

QL (30 per 30 days)

loxapine succinate oral capsule 10

mg, 25 mg, 5 mg, 50 mg 1 $0

molindone oral tablet 10 mg 1 $0 QL (240 per 30 days)



NUPLAZID ORAL CAPSULE 34

MG 2 $0

PA NSO; QL (30 per

30 days)

NUPLAZID ORAL TABLET 10

MG 2 $0

PA NSO; QL (30 per

30 days)

NUPLAZID ORAL TABLET 17

MG 2 $0

PA NSO; QL (60 per

30 days)

olanzapine intramuscular recon soln

10 mg (Zyprexa) 1 $0

QL (30 per 30 days)

olanzapine oral tablet 10 mg, 15

mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg (Zyprexa) 1 $0

QL (30 per 30 days)

olanzapine oral tablet,disintegrating

10 mg, 15 mg, 20 mg, 5 mg (Zyprexa Zydis) 1 $0

QL (30 per 30 days)

paliperidone oral tablet extended

release 24hr 1.5 mg, 3 mg, 9 mg (Invega) 1 $0

QL (30 per 30 days)

paliperidone oral tablet extended

release 24hr 6 mg (Invega) 1 $0

QL (60 per 30 days)





77

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

perphenazine oral tablet 16 mg, 2

mg, 4 mg, 8 mg 1 $0

PERSERIS ABDOMINAL

SUBCUTANEOUS

SUSPENSION,EXTEND REL SYR

KIT 120 MG, 90 MG

2 $0

QL (1 per 30 days)

pimozide oral tablet 1 mg, 2 mg (Orap) 1 $0

quetiapine oral tablet 100 mg, 200

mg, 25 mg, 300 mg, 400 mg, 50 mg (Seroquel) 1 $0

QL (90 per 30 days)

REXULTI ORAL TABLET 0.25

MG 2 $0

ST; QL (120 per 30

days)

REXULTI ORAL TABLET 0.5 MG 2 $0 ST; QL (60 per 30

days)

REXULTI ORAL TABLET 1 MG,

2 MG, 3 MG, 4 MG 2 $0

ST; QL (30 per 30

days)

RISPERDAL CONSTA


12.5 MG/2 ML, 25 MG/2 ML, 37.5

MG/2 ML, 50 MG/2 ML

2 $0

QL (4 per 28 days)

risperidone oral solution 1 mg/ml (Risperdal) 1 $0 QL (480 per 30 days)

risperidone oral tablet 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg (Risperdal) 1 $0

QL (60 per 30 days)

risperidone oral

tablet,disintegrating 0.25 mg, 0.5

mg, 1 mg, 2 mg

1 $0

QL (60 per 30 days)

risperidone oral

tablet,disintegrating 3 mg, 4 mg 1 $0


SAPHRIS SUBLINGUAL

TABLET 10 MG, 2.5 MG, 5 MG 2 $0

ST; QL (60 per 30

days)

thioridazine oral tablet 10 mg, 100

mg, 25 mg, 50 mg 1 $0

thiothixene oral capsule 1 mg, 10

mg, 2 mg, 5 mg 1 $0



.



78

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

trifluoperazine oral tablet 1 mg, 10

mg, 2 mg, 5 mg 1 $0

VERSACLOZ ORAL


ST; QL (540 per 30

days)

VRAYLAR ORAL CAPSULE 1.5

MG, 3 MG, 4.5 MG, 6 MG 2 $0

ST; QL (30 per 30

days)

VRAYLAR ORAL

CAPSULE,DOSE PACK 1.5 MG

(1)- 3 MG (6)

2 $0

ST; QL (14 per 365

days)

ziprasidone hcl oral capsule 20 mg,

40 mg, 60 mg, 80 mg (Geodon) 1 $0

QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 210 MG, 300

MG

2 $0

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR


2 $0

QL (1 per 28 days)

Antivirals (Systemic)

Antiretrovirals

abacavir oral solution 20 mg/ml (Ziagen) 1 $0

abacavir oral tablet 300 mg (Ziagen) 1 $0

abacavir-lamivudine oral tablet

600-300 mg (Epzicom) 1 $0

abacavir-lamivudine-zidovudine

oral tablet 300-150-300 mg (Trizivir) 1 $0

APTIVUS ORAL CAPSULE 250

MG 2 $0

APTIVUS ORAL SOLUTION 100

MG/ML 2 $0





79

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

atazanavir oral capsule 150 mg, 200

mg, 300 mg (Reyataz) 1 $0

ATRIPLA ORAL TABLET 600-

200-300 MG 2 $0

BIKTARVY ORAL TABLET 50-

200-25 MG 2 $0

CIMDUO ORAL TABLET 300-300

MG 2 $0

COMPLERA ORAL TABLET 200-

25-300 MG 2 $0

CRIXIVAN ORAL CAPSULE 200

MG, 400 MG 2 $0

DELSTRIGO ORAL TABLET 100-

300-300 MG 2 $0

DESCOVY ORAL TABLET 200-

25 MG 2 $0

didanosine oral capsule,delayed

release(dr/ec) 125 mg, 200 mg, 250

mg, 400 mg

(Videx EC) 1 $0

EDURANT ORAL TABLET 25

MG 2 $0

efavirenz oral capsule 200 mg, 50

mg (Sustiva) 1 $0

efavirenz oral tablet 600 mg (Sustiva) 1 $0

EMTRIVA ORAL CAPSULE 200

MG 2 $0

EMTRIVA ORAL SOLUTION 10

MG/ML 2 $0

EPIVIR HBV ORAL SOLUTION

25 MG/5 ML (5 MG/ML) 2 $0

EVOTAZ ORAL TABLET 300-150

MG 2 $0

fosamprenavir oral tablet 700 mg (Lexiva) 1 $0



.



80

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

FUZEON SUBCUTANEOUS


GENVOYA ORAL TABLET 150-

150-200-10 MG 2 $0

INTELENCE ORAL TABLET 100

MG, 200 MG, 25 MG 2 $0

INVIRASE ORAL CAPSULE 200

MG 2 $0

INVIRASE ORAL TABLET 500

MG 2 $0

ISENTRESS HD ORAL TABLET

600 MG 2 $0

ISENTRESS ORAL POWDER IN

PACKET 100 MG 2 $0

ISENTRESS ORAL TABLET 400

MG 2 $0

ISENTRESS ORAL

TABLET,CHEWABLE 100 MG, 25

MG

2 $0

JULUCA ORAL TABLET 50-25

MG 2 $0

KALETRA ORAL TABLET 100-

25 MG, 200-50 MG 2 $0

lamivudine oral solution 10 mg/ml (Epivir) 1 $0

lamivudine oral tablet 100 mg (Epivir HBV) 1 $0

lamivudine oral tablet 150 mg, 300

mg (Epivir) 1 $0

lamivudine-zidovudine oral tablet

150-300 mg (Combivir) 1 $0

LEXIVA ORAL SUSPENSION 50

MG/ML 2 $0

lopinavir-ritonavir oral solution

400-100 mg/5 ml (Kaletra) 1 $0





81

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nevirapine oral suspension 50 mg/5

ml (Viramune) 2 $0

nevirapine oral tablet 200 mg (Viramune) 1 $0

nevirapine oral tablet extended

release 24 hr 100 mg, 400 mg (Viramune XR) 1 $0

NORVIR ORAL CAPSULE 100

MG 2 $0

NORVIR ORAL POWDER IN

PACKET 100 MG 2 $0

NORVIR ORAL SOLUTION 80

MG/ML 2 $0

ODEFSEY ORAL TABLET 200-

25-25 MG 2 $0

PIFELTRO ORAL TABLET 100

MG 2 $0

PREZCOBIX ORAL TABLET 800-

150 MG-MG 2 $0

PREZISTA ORAL SUSPENSION

100 MG/ML 2 $0

PREZISTA ORAL TABLET 150

MG, 600 MG, 75 MG, 800 MG 2 $0

RESCRIPTOR ORAL TABLET

200 MG 2 $0

RESCRIPTOR ORAL TABLET,

DISPERSIBLE 100 MG 2 $0

RETROVIR INTRAVENOUS


REYATAZ ORAL POWDER IN

PACKET 50 MG 2 $0

ritonavir oral tablet 100 mg (Norvir) 1 $0

SELZENTRY ORAL SOLUTION

20 MG/ML 2 $0



.



82

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SELZENTRY ORAL TABLET 150

MG, 25 MG, 300 MG, 75 MG 2 $0

stavudine oral capsule 15 mg, 20

mg, 30 mg, 40 mg 1 $0

stavudine oral recon soln 1 mg/ml 1 $0

STRIBILD ORAL TABLET 150-

150-200-300 MG 2 $0

SYMFI LO ORAL TABLET 400-

300-300 MG 2 $0

SYMFI ORAL TABLET 600-300-

300 MG 2 $0

SYMTUZA ORAL TABLET 800-

150-200-10 MG 2 $0

tenofovir disoproxil fumarate oral

tablet 300 mg (Viread) 1 $0

TIVICAY ORAL TABLET 10 MG,

25 MG, 50 MG 2 $0

TRIUMEQ ORAL TABLET 600-

50-300 MG 2 $0

TROGARZO INTRAVENOUS

SOLUTION 200 MG/1.33 ML (150

MG/ML)

2 $0

TRUVADA ORAL TABLET 100-

150 MG, 133-200 MG, 167-250

MG, 200-300 MG

2 $0

VEMLIDY ORAL TABLET 25

MG 2 $0

QL (30 per 30 days)

VIDEX 2 GM PEDIATRIC SOLN

10 MG/ML (FINAL) 2 $0

VIDEX 4 GRAM PEDIATRIC

ORAL RECON SOLN 10 MG/ML

(FINAL)

2 $0





83

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

VIDEX EC ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 125 MG

2 $0

VIRACEPT ORAL TABLET 250

MG, 625 MG 2 $0

VIRAMUNE ORAL SUSPENSION

50 MG/5 ML 2 $0

VIREAD ORAL POWDER 40

MG/SCOOP (40 MG/GRAM) 2 $0

VIREAD ORAL TABLET 150 MG,

200 MG, 250 MG 2 $0

ZERIT ORAL RECON SOLN 1

MG/ML 2 $0

zidovudine oral capsule 100 mg (Retrovir) 1 $0

zidovudine oral syrup 10 mg/ml (Retrovir) 1 $0

zidovudine oral tablet 300 mg 1 $0

Antivirals, Miscellaneous

foscarnet intravenous solution 24

mg/ml (Foscavir) 1 $0

PA BvD

oseltamivir oral capsule 30 mg (Tamiflu) 1 $0 QL (84 per 180 days)



oseltamivir oral suspension for

reconstitution 6 mg/ml (Tamiflu) 1 $0


PREVYMIS INTRAVENOUS


PA; QL (336 per 28

days)

PREVYMIS INTRAVENOUS


PA; QL (672 per 28

days)

PREVYMIS ORAL TABLET 240

MG, 480 MG 2 $0

PA; QL (28 per 28

days)

RELENZA DISKHALER

INHALATION BLISTER WITH

DEVICE 5 MG/ACTUATION

2 $0



.



84

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

rimantadine oral tablet 100 mg (Flumadine) 1 $0

SYNAGIS INTRAMUSCULAR

SOLUTION 100 MG/ML, 50

MG/0.5 ML

2 $0

PA

XOFLUZA ORAL TABLET 20

MG, 40 MG 2 $0

QL (4 per 180 days)

Hcv Antivirals

DAKLINZA ORAL TABLET 30

MG, 60 MG, 90 MG 2 $0

PA; QL (28 per 28

days)

EPCLUSA ORAL TABLET 400-

100 MG 2 $0

PA; QL (28 per 28

days)

HARVONI ORAL TABLET 90-400

MG 2 $0

PA; QL (30 per 30

days)

MAVYRET ORAL TABLET 100-

40 MG 2 $0

PA; QL (84 per 28

days)

SOVALDI ORAL TABLET 400

MG 2 $0

PA; QL (28 per 28

days)

TECHNIVIE ORAL TABLET 12.5-

75-50 MG 2 $0

PA; QL (56 per 28

days)

VIEKIRA PAK ORAL

TABLETS,DOSE PACK 12.5 MG-

75 MG -50 MG/250 MG

2 $0

PA; QL (112 per 28

days)

VIEKIRA XR ORAL TABLET, IR

- ER, BIPHASIC 24HR 8.33 MG-

50 MG- 33.33 MG-200 MG

2 $0

PA; QL (84 per 28

days)

VOSEVI ORAL TABLET 400-100-

100 MG 2 $0

PA; QL (28 per 28

days)

ZEPATIER ORAL TABLET 50-

100 MG 2 $0

PA; QL (30 per 30

days)

Interferons





85

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

INTRON A INJECTION RECON

SOLN 10 MILLION UNIT (1 ML),

18 MILLION UNIT (1 ML), 50

MILLION UNIT (1 ML)

2 $0

PA NSO

INTRON A INJECTION

SOLUTION 10 MILLION

UNIT/ML, 6 MILLION UNIT/ML

2 $0

PA NSO

PEGASYS PROCLICK

SUBCUTANEOUS PEN

INJECTOR 135 MCG/0.5 ML, 180

MCG/0.5 ML

2 $0

PEGASYS SUBCUTANEOUS

SOLUTION 180 MCG/ML 2 $0

PEGASYS SUBCUTANEOUS

SYRINGE 180 MCG/0.5 ML 2 $0

PEGINTRON SUBCUTANEOUS

KIT 50 MCG/0.5 ML 2 $0

SYLATRON SUBCUTANEOUS

KIT 200 MCG, 300 MCG, 600

MCG

2 $0


days)

Nucleosides And Nucleotides

acyclovir oral capsule 200 mg (Zovirax) 1 $0

acyclovir oral suspension 200 mg/5

ml (Zovirax) 1 $0

acyclovir oral tablet 400 mg, 800

mg (Zovirax) 1 $0

acyclovir sodium intravenous recon

soln 500 mg 1 $0

PA BvD

acyclovir sodium intravenous


PA BvD

adefovir oral tablet 10 mg (Hepsera) 1 $0

entecavir oral tablet 0.5 mg, 1 mg (Baraclude) 1 $0



.



86

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

famciclovir oral tablet 125 mg, 250

mg, 500 mg 1 $0

ganciclovir sodium intravenous

recon soln 500 mg (Cytovene) 1 $0

PA BvD

ganciclovir sodium intravenous


PA BvD

ribasphere oral capsule 200 mg 1 $0

ribasphere oral tablet 200 mg, 400

mg, 600 mg 1 $0

ribavirin inhalation recon soln 6

gram (Virazole) 1 $0

PA BvD

ribavirin oral capsule 200 mg (Ribasphere) 1 $0

ribavirin oral tablet 200 mg (Moderiba) 1 $0

valacyclovir oral tablet 1 gram, 500

mg (Valtrex) 1 $0

valganciclovir oral tablet 450 mg (Valcyte) 1 $0

Blood

Products/Modifiers/Volume

Expanders

Anticoagulants

BEVYXXA ORAL CAPSULE 40

MG, 80 MG 2 $0

QL (43 per 42 days)

CEPROTIN (BLUE BAR)


500 UNIT

2 $0

ELIQUIS ORAL TABLET 2.5 MG,

5 MG 2 $0

ELIQUIS ORAL TABLETS,DOSE

PACK 5 MG (74 TABS) 2 $0

enoxaparin subcutaneous solution

300 mg/3 ml (Lovenox) 1 $0





87

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

enoxaparin subcutaneous 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

(Lovenox) 1 $0

fondaparinux subcutaneous syringe

10 mg/0.8 ml, 2.5 mg/0.5 ml, 5

mg/0.4 ml, 7.5 mg/0.6 ml

(Arixtra) 1 $0

heparin (porcine) injection

cartridge 5,000 unit/ml (1 ml) 1 $0

heparin (porcine) injection solution

1,000 unit/ml, 10,000 unit/ml,

20,000 unit/ml, 5,000 unit/ml

1 $0

heparin (porcine) injection syringe

5,000 unit/ml 1 $0

heparin, porcine (pf) injection

solution 1,000 unit/ml 1 $0

heparin, porcine (pf) injection

syringe 5,000 unit/0.5 ml 1 $0

IPRIVASK SUBCUTANEOUS


PA; QL (24 per 28

days)

jantoven oral tablet 1 mg, 10 mg, 2

mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,

7.5 mg

1 $0

PRADAXA ORAL CAPSULE 110

MG, 150 MG, 75 MG 2 $0

ST; QL (60 per 30

days)

warfarin oral tablet 1 mg, 10 mg, 2

mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,

7.5 mg

(Coumadin) 1 $0

XARELTO ORAL TABLET 10

MG, 15 MG, 2.5 MG, 20 MG 2 $0

XARELTO ORAL


(42)- 20 MG (9)

2 $0

Blood Formation Modifiers



.



88

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

CINRYZE INTRAVENOUS

RECON SOLN 500 UNIT (5 ML) 2 $0

PA

DOPTELET ORAL TABLET 20

MG, 20 MG (15 PACK) 2 $0

PA

EPOGEN INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,

20,000 UNIT/2 ML, 20,000

UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML

2 $0

PA; QL (12 per 28

days)

FULPHILA SUBCUTANEOUS


GRANIX SUBCUTANEOUS

SOLUTION 300 MCG/ML, 480

MCG/1.6 ML

2 $0

PA

GRANIX SUBCUTANEOUS

SYRINGE 300 MCG/0.5 ML, 480

MCG/0.8 ML

2 $0

PA

HAEGARDA SUBCUTANEOUS

RECON SOLN 2,000 UNIT, 3,000

UNIT

2 $0

PA

LEUKINE INJECTION RECON

SOLN 250 MCG 2 $0

MOZOBIL SUBCUTANEOUS

SOLUTION 24 MG/1.2 ML (20

MG/ML)

2 $0

MULPLETA ORAL TABLET 3

MG 2 $0

PA

NEULASTA SUBCUTANEOUS

SYRINGE 6 MG/0.6ML 2 $0

NEUPOGEN INJECTION

SOLUTION 300 MCG/ML, 480

MCG/1.6 ML

2 $0

PA





89

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

NEUPOGEN INJECTION


MCG/0.8 ML

2 $0

PA

NIVESTYM SUBCUTANEOUS


MCG/0.8 ML

2 $0

PA

PROCRIT INJECTION

SOLUTION 10,000 UNIT/ML,

2,000 UNIT/ML, 20,000 UNIT/2

ML, 20,000 UNIT/ML, 3,000

UNIT/ML, 4,000 UNIT/ML

2 $0

PA; QL (12 per 28

days)

PROCRIT INJECTION

SOLUTION 40,000 UNIT/ML 2 $0


PROMACTA ORAL TABLET 12.5

MG 2 $0

PA; QL (30 per 30

days)

PROMACTA ORAL TABLET 25

MG 2 $0

PA; QL (120 per 30

days)


MG 2 $0

PA; QL (90 per 30

days)


MG 2 $0

PA; QL (60 per 30

days)

RETACRIT INJECTION

SOLUTION 10,000 UNIT/ML,

2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML

2 $0

PA; QL (12 per 28

days)

RETACRIT INJECTION

SOLUTION 40,000 UNIT/ML 2 $0


UDENYCA SUBCUTANEOUS


ZARXIO INJECTION SYRINGE

300 MCG/0.5 ML, 480 MCG/0.8

ML

2 $0

Hematologic Agents, Miscellaneous

anagrelide oral capsule 0.5 mg (Agrylin) 1 $0



.



90

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

anagrelide oral capsule 1 mg 1 $0

protamine intravenous solution 10

mg/ml 1 $0

TAVALISSE ORAL TABLET 100

MG, 150 MG 2 $0

PA; QL (60 per 30

days)

tranexamic acid intravenous

solution 1,000 mg/10 ml (100

mg/ml)

(Cyklokapron) 1 $0

tranexamic acid oral tablet 650 mg (Lysteda) 1 $0 QL (30 per 30 days)

Platelet-Aggregation Inhibitors

aspirin-dipyridamole oral capsule,

er multiphase 12 hr 25-200 mg (Aggrenox) 1 $0

BRILINTA ORAL TABLET 60

MG, 90 MG 2 $0

cilostazol oral tablet 100 mg, 50 mg 1 $0

clopidogrel oral tablet 75 mg (Plavix) 1 $0

dipyridamole oral tablet 25 mg, 50

mg, 75 mg 1 $0

PA-HRM; AGE (Max

64 Years)

pentoxifylline oral tablet extended

release 400 mg 1 $0

prasugrel oral tablet 10 mg, 5 mg (Effient) 1 $0 QL (30 per 30 days)

Caloric Agents

Caloric Agents

AMINOSYN 10 %

INTRAVENOUS PARENTERAL

SOLUTION 10 %

2 $0

PA BvD

AMINOSYN 7 % WITH

ELECTROLYTES


SOLUTION 7 %

2 $0

PA BvD





91

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

AMINOSYN 8.5 %


SOLUTION 8.5 %

2 $0

PA BvD

AMINOSYN 8.5 %-

ELECTROLYTES


SOLUTION 8.5 %

2 $0

PA BvD

AMINOSYN II 10 %


SOLUTION 10 %

2 $0

PA BvD

AMINOSYN II 15 %


SOLUTION 15 %

2 $0

PA BvD

AMINOSYN II 7 %


SOLUTION 7 %

2 $0

PA BvD

AMINOSYN II 8.5 %


SOLUTION 8.5 %

2 $0

PA BvD

AMINOSYN II 8.5 %-

ELECTROLYTES


SOLUTION 8.5 %

2 $0

PA BvD

AMINOSYN M 3.5 %


SOLUTION 3.5 %

2 $0

PA BvD

AMINOSYN-HBC 7%


SOLUTION 7 %

2 $0

PA BvD

AMINOSYN-PF 10 %


SOLUTION 10 %

2 $0

PA BvD



.



92

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

AMINOSYN-PF 7 % (SULFITE-

FREE) INTRAVENOUS

PARENTERAL SOLUTION 7 %

2 $0

PA BvD

AMINOSYN-RF 5.2 %


SOLUTION 5.2 %

2 $0

PA BvD

CLINIMIX 5%/D15W SULFITE

FREE INTRAVENOUS


2 $0

PA BvD

CLINIMIX 5%/D25W SULFITE-

FREE INTRAVENOUS


2 $0

PA BvD

CLINIMIX 2.75%/D5W SULFIT

FREE INTRAVENOUS

PARENTERAL SOLUTION 2.75

%

2 $0

PA BvD

CLINIMIX 4.25%/D10W SULF

FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX 4.25%/D5W SULFIT

FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX 4.25%-D20W SULF-

FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX 4.25%-D25W SULF-

FREE INTRAVENOUS


%

2 $0

PA BvD





93

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

CLINIMIX 5%-D20W(SULFITE-

FREE) INTRAVENOUS


2 $0

PA BvD

CLINIMIX E 2.75%/D10W SUL

FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX E 2.75%/D5W SULF

FREE INTRAVENOUS


%

2 $0

PA BvD


FREE INTRAVENOUS


%

2 $0

PA BvD


FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX E 4.25%/D5W SULF

FREE INTRAVENOUS


%

2 $0

PA BvD

CLINIMIX E 5%/D15W SULFIT

FREE INTRAVENOUS


2 $0

PA BvD


FREE INTRAVENOUS


2 $0

PA BvD


FREE INTRAVENOUS


2 $0

PA BvD

cvs glucose 4 gram tablet chew

assorted fruit 4 gram * (Dex4 Glucose) 4 $0



.



94

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dex4 glucose 4 gm tablet chew

orange,gluten-free 4 gram * 4 $0

dex4 glucose 40% gel 40 % * 4 $0

dextrose 10 % in water (d10w)

intravenous parenteral solution 10

%

2 $0

PA BvD



%

2 $0

PA BvD


intravenous syringe 2 $0

PA BvD


intravenous parenteral solution 2 $0

PA BvD



%

2 $0

PA BvD




intravenous piggyback 5 % 2 $0



PA BvD


intravenous syringe 2 $0

PA BvD



PA BvD

FREAMINE HBC 6.9 %


SOLUTION 6.9 %

2 $0

PA BvD

FREAMINE III 10 %


SOLUTION 10 %

2 $0

PA BvD

gluco burst 40% gel 40 % * 4 $0





95

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

glutose 15 gel 3's, outer, u-d 40 % * 4 $0

HEPATAMINE 8%


SOLUTION 8 %

2 $0

PA BvD

INSTA-GLUCOSE GEL 24

GRAM/31 GRAM * 4 $0

INTRALIPID INTRAVENOUS

EMULSION 20 %, 30 % 2 $0

PA BvD

KABIVEN INTRAVENOUS

EMULSION 3.31-9.8-3.9 % 2 $0

PA BvD

NEPHRAMINE 5.4 %


SOLUTION 5.4 %

2 $0

PA BvD

NUTRILIPID INTRAVENOUS

EMULSION 20 % 2 $0

PA BvD

PERIKABIVEN INTRAVENOUS

EMULSION 2.36-6.8-3.5 % 2 $0

PA BvD

PROCALAMINE 3%


SOLUTION 3 %

2 $0

PA BvD

PROSOL 20 % INTRAVENOUS

PARENTERAL SOLUTION 2 $0

PA BvD

relion glucose gel 15 gram fruit

punch 40 % * 4 $0

smoflipid intravenous emulsion 20

% 2 $0

PA BvD

TRAVASOL 10 %


SOLUTION 10 %

2 $0

PA BvD

TROPHAMINE 10 %


SOLUTION 10 %

2 $0

PA BvD



.



96

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TROPHAMINE 6%


SOLUTION 6 %

2 $0

PA BvD

trueplus glucose 4 gm tab chew 4

gram * 4 $0

Cardiovascular Agents

Alpha-Adrenergic Agents

clonidine hcl oral tablet 0.1 mg, 0.2

mg, 0.3 mg (Catapres) 1 $0

clonidine transdermal patch weekly

0.1 mg/24 hr (Catapres-TTS-1) 1 $0

QL (4 per 28 days)



QL (4 per 28 days)



QL (8 per 28 days)

cvs sinus pe decongestant tab 10 mg

* 4 $0

doxazosin oral tablet 1 mg, 2 mg, 4

mg, 8 mg (Cardura) 1 $0

guanfacine oral tablet 1 mg, 2 mg 1 $0 PA-HRM; AGE (Max

64 Years)

midodrine oral tablet 10 mg, 2.5 mg,

5 mg 1 $0

nasal decongestant pe 10 mg tb non-

drowsy 10 mg * 4 $0

NORTHERA ORAL CAPSULE

100 MG, 200 MG, 300 MG 2 $0

PA; QL (180 per 30

days)

phenylephrine hcl injection solution

10 mg/ml (Vazculep) 1 $0

prazosin oral capsule 1 mg, 2 mg, 5

mg (Minipress) 1 $0





97

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ra sinus pres-cng rlf pe 10 mg 10

mg * 4 $0

sudogest pe 10 mg tablet 10 mg * 4 $0

wal-phed pe 10 mg tablet non-

drowsy,pse free 10 mg * 4 $0

Angiotensin Ii Receptor

Antagonists

EDARBI ORAL TABLET 40 MG,

80 MG 2 $0

EDARBYCLOR ORAL TABLET

40-12.5 MG, 40-25 MG 2 $0

ENTRESTO ORAL TABLET 24-26

MG, 49-51 MG, 97-103 MG 2 $0

QL (60 per 30 days)

irbesartan oral tablet 150 mg, 300

mg, 75 mg (Avapro) 1 $0

irbesartan-hydrochlorothiazide oral

tablet 150-12.5 mg, 300-12.5 mg (Avalide) 1 $0

losartan oral tablet 100 mg, 25 mg,

50 mg (Cozaar) 1 $0

losartan-hydrochlorothiazide oral

tablet 100-12.5 mg, 100-25 mg, 50-

12.5 mg

(Hyzaar) 1 $0

olmesartan oral tablet 20 mg, 40

mg, 5 mg (Benicar) 1 $0

olmesartan-hydrochlorothiazide

oral tablet 20-12.5 mg, 40-12.5 mg,

40-25 mg

(Benicar HCT) 1 $0

telmisartan oral tablet 20 mg, 40

mg, 80 mg (Micardis) 1 $0

valsartan oral tablet 160 mg, 320

mg, 40 mg, 80 mg (Diovan) 1 $0



.



98

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

valsartan-hydrochlorothiazide oral

tablet 160-12.5 mg, 160-25 mg, 320-

12.5 mg, 320-25 mg, 80-12.5 mg

(Diovan HCT) 1 $0

Angiotensin-Converting Enzyme

Inhibitors

benazepril oral tablet 10 mg, 20 mg,

40 mg (Lotensin) 1 $0

benazepril oral tablet 5 mg 1 $0

captopril oral tablet 100 mg, 12.5

mg, 25 mg, 50 mg 1 $0

enalapril maleate oral tablet 10 mg,

2.5 mg, 20 mg, 5 mg (Vasotec) 1 $0

enalaprilat intravenous solution

1.25 mg/ml 1 $0

enalapril-hydrochlorothiazide oral

tablet 10-25 mg (Vaseretic) 1 $0

enalapril-hydrochlorothiazide oral

tablet 5-12.5 mg 1 $0

fosinopril oral tablet 10 mg, 20 mg,

40 mg 1 $0

lisinopril oral tablet 10 mg, 20 mg,

5 mg (Prinivil) 1 $0

lisinopril oral tablet 2.5 mg, 30 mg,

40 mg (Zestril) 1 $0

lisinopril-hydrochlorothiazide oral

tablet 10-12.5 mg, 20-12.5 mg, 20-

25 mg

(Zestoretic) 1 $0

perindopril erbumine oral tablet 2

mg, 4 mg, 8 mg 1 $0

quinapril oral tablet 10 mg, 20 mg,

40 mg, 5 mg (Accupril) 1 $0

ramipril oral capsule 1.25 mg, 10

mg, 2.5 mg, 5 mg (Altace) 1 $0





99

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

trandolapril oral tablet 1 mg, 2 mg,

4 mg 1 $0

Antiarrhythmic Agents

amiodarone oral tablet 200 mg, 400

mg (Pacerone) 1 $0

disopyramide phosphate oral

capsule 100 mg, 150 mg (Norpace) 1 $0

PA-HRM; AGE (Max

64 Years)

dofetilide oral capsule 125 mcg, 250

mcg, 500 mcg (Tikosyn) 1 $0

flecainide oral tablet 100 mg, 150

mg, 50 mg 1 $0

lidocaine (pf) intravenous syringe

100 mg/5 ml (2 %), 50 mg/5 ml (1

%)

1 $0

mexiletine oral capsule 150 mg, 200

mg, 250 mg 1 $0

MULTAQ ORAL TABLET 400

MG 2 $0

pacerone oral tablet 200 mg, 400

mg 1 $0

procainamide injection solution 100

mg/ml, 500 mg/ml 1 $0

procainamide intravenous syringe

100 mg/ml 1 $0

propafenone oral tablet 150 mg, 225

mg, 300 mg 1 $0

quinidine sulfate oral tablet 200 mg,

300 mg 1 $0

Beta-Adrenergic Blocking Agents

acebutolol oral capsule 200 mg, 400

mg 1 $0

atenolol oral tablet 100 mg, 25 mg,

50 mg (Tenormin) 1 $0



.



100

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

atenolol-chlorthalidone oral tablet

100-25 mg (Tenoretic 100) 1 $0

atenolol-chlorthalidone oral tablet

50-25 mg (Tenoretic 50) 1 $0

betaxolol oral tablet 10 mg, 20 mg 1 $0

bisoprolol fumarate oral tablet 10

mg, 5 mg 1 $0

bisoprolol-hydrochlorothiazide oral

tablet 10-6.25 mg, 2.5-6.25 mg, 5-

6.25 mg

(Ziac) 1 $0

BYSTOLIC ORAL TABLET 10

MG, 2.5 MG, 20 MG, 5 MG 2 $0

BYVALSON ORAL TABLET 5-80

MG 2 $0

carvedilol oral tablet 12.5 mg, 25

mg, 3.125 mg, 6.25 mg (Coreg) 1 $0

esmolol intravenous solution 100

mg/10 ml (10 mg/ml) (Brevibloc) 1 $0

PA BvD

labetalol intravenous solution 5

mg/ml 1 $0

labetalol intravenous syringe 20

mg/4 ml (5 mg/ml) 1 $0

labetalol oral tablet 100 mg, 200

mg, 300 mg 1 $0

metoprolol succinate oral tablet


mg, 25 mg, 50 mg

(Toprol XL) 1 $0

metoprolol ta-hydrochlorothiaz oral

tablet 100-25 mg, 100-50 mg 1 $0

metoprolol ta-hydrochlorothiaz oral

tablet 50-25 mg (Lopressor HCT) 1 $0

metoprolol tartrate intravenous

solution 5 mg/5 ml (Lopressor) 1 $0





101

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

metoprolol tartrate intravenous

syringe 5 mg/5 ml 1 $0

metoprolol tartrate oral tablet 100

mg, 50 mg (Lopressor) 1 $0

metoprolol tartrate oral tablet 25

mg 1 $0

propranolol intravenous solution 1

mg/ml 1 $0

propranolol oral capsule,extended

release 24 hr 120 mg, 160 mg, 60

mg, 80 mg

(Inderal LA) 1 $0

propranolol oral solution 20 mg/5

ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) 1 $0

propranolol oral tablet 10 mg, 20

mg, 40 mg, 60 mg, 80 mg 1 $0

propranolol-hydrochlorothiazid

oral tablet 40-25 mg, 80-25 mg 1 $0

sorine oral tablet 120 mg, 160 mg,

240 mg, 80 mg 1 $0

sotalol af oral tablet 120 mg, 160

mg, 80 mg 1 $0

sotalol oral tablet 120 mg, 160 mg,

240 mg, 80 mg (Betapace) 1 $0

timolol maleate oral tablet 10 mg,

20 mg, 5 mg 1 $0

Calcium-Channel Blocking Agents

cartia xt oral capsule,extended

release 24hr 120 mg, 180 mg, 240

mg, 300 mg

1 $0

diltiazem hcl intravenous solution 5

mg/ml 1 $0

diltiazem hcl oral capsule,extended

release 12 hr 120 mg, 60 mg, 90 mg 1 $0



.



102

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


release 24 hr 420 mg (Tiazac) 1 $0


release 24hr 120 mg, 180 mg, 240

mg, 300 mg

(Cardizem CD) 1 $0

diltiazem hcl oral tablet 120 mg, 30

mg, 60 mg (Cardizem) 1 $0

diltiazem hcl oral tablet 90 mg 1 $0

dilt-xr oral capsule,ext.rel 24h

degradable 120 mg, 180 mg, 240 mg 1 $0

taztia xt oral capsule,extended

release 24 hr 120 mg, 180 mg, 240

mg, 300 mg, 360 mg

1 $0

verapamil intravenous syringe 2.5

mg/ml 1 $0

verapamil oral capsule, 24 hr er

pellet ct 100 mg, 200 mg, 300 mg (Verelan PM) 1 $0

verapamil oral capsule,ext rel.

pellets 24 hr 120 mg, 180 mg, 240

mg

(Verelan) 1 $0

verapamil oral capsule,ext rel.

pellets 24 hr 360 mg (Verelan) 2 $0

verapamil oral tablet 120 mg, 80 mg (Calan) 1 $0

verapamil oral tablet 40 mg 1 $0

verapamil oral tablet extended

release 120 mg, 180 mg, 240 mg (Calan SR) 1 $0

Cardiovascular Agents,

Miscellaneous

CORLANOR ORAL TABLET 5

MG, 7.5 MG 2 $0

PA; QL (60 per 30

days)

DEMSER ORAL CAPSULE 250

MG 2 $0





103

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

digitek oral tablet 125 mcg 1 $0

PA-HRM; High Risk

Med. PA Required for

ages 65 and older and

dose is greater than

125mcg per day; QL

(30 per 30 days); AGE

(Max 64 Years)

digitek oral tablet 250 mcg 1 $0 PA-HRM; AGE (Max

64 Years)

digox oral tablet 125 mcg 1 $0

PA-HRM; High Risk




125mcg per day; QL


(Max 64 Years)

digox oral tablet 250 mcg 1 $0 PA-HRM; AGE (Max

64 Years)

digoxin injection syringe 250

mcg/ml 1 $0

PA-HRM; AGE (Max

64 Years)

DIGOXIN ORAL SOLUTION 50

MCG/ML 2 $0

PA-HRM; AGE (Max

64 Years)

digoxin oral tablet 125 mcg (Digitek) 1 $0

PA-HRM; High Risk




125mcg per day; QL


(Max 64 Years)

digoxin oral tablet 250 mcg (Digitek) 1 $0 PA-HRM; AGE (Max

64 Years)

epinephrine injection auto-injector

0.15 mg/0.3 ml (EpiPen Jr) 2 $0

Mylan generic

preferred; QL (4 per 30

days)



.



104

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

epinephrine injection auto-injector

0.3 mg/0.3 ml (Auvi-Q) 2 $0

Mylan generic

preferred; QL (4 per 30

days)

FIRAZYR SUBCUTANEOUS


QL (18 per 30 days)

hydralazine injection solution 20

mg/ml 1 $0

hydralazine oral tablet 10 mg, 100

mg, 25 mg, 50 mg 1 $0

milrinone in 5 % dextrose


ml (200 mcg/ml), 40 mg/200 ml (200

mcg/ml)

1 $0

PA BvD

milrinone intravenous solution 1

mg/ml 1 $0

PA BvD

norepinephrine bitartrate

intravenous solution 1 mg/ml

(Levophed

(bitartrate)) 1 $0

PA BvD

RANEXA ORAL TABLET

EXTENDED RELEASE 12 HR

1,000 MG, 500 MG

2 $0

Dihydropyridines

afeditab cr oral tablet extended

release 30 mg, 60 mg 1 $0

amlodipine oral tablet 10 mg, 2.5

mg, 5 mg (Norvasc) 1 $0

amlodipine-benazepril oral capsule

10-20 mg, 10-40 mg, 5-10 mg, 5-20

mg, 5-40 mg

(Lotrel) 1 $0

amlodipine-benazepril oral capsule

2.5-10 mg 1 $0

amlodipine-valsartan oral tablet 10-

160 mg, 10-320 mg, 5-160 mg, 5-

320 mg

(Exforge) 1 $0





105

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nicardipine oral capsule 20 mg, 30

mg 1 $0

nifedipine oral tablet extended

release 24hr 30 mg, 60 mg, 90 mg (Procardia XL) 1 $0

nifedipine oral tablet extended

release 30 mg, 60 mg, 90 mg (Adalat CC) 1 $0

Diuretics

amiloride oral tablet 5 mg 1 $0

amiloride-hydrochlorothiazide oral

tablet 5-50 mg 1 $0

bumetanide injection solution 0.25

mg/ml 1 $0

bumetanide oral tablet 0.5 mg, 1

mg, 2 mg 1 $0

chlorothiazide oral tablet 250 mg,

500 mg 1 $0

chlorothiazide sodium intravenous

recon soln 500 mg (Diuril IV) 1 $0

chlorthalidone oral tablet 25 mg, 50

mg 1 $0

furosemide injection solution 10

mg/ml 1 $0

furosemide injection syringe 10

mg/ml 1 $0

furosemide oral solution 10 mg/ml,

40 mg/5 ml (8 mg/ml) 1 $0

furosemide oral tablet 20 mg, 40

mg, 80 mg (Lasix) 1 $0

hydrochlorothiazide oral capsule

12.5 mg (Microzide) 1 $0

hydrochlorothiazide oral tablet 12.5

mg, 25 mg, 50 mg 1 $0



.



106

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

indapamide oral tablet 1.25 mg, 2.5

mg 1 $0

JYNARQUE ORAL TABLETS,

SEQUENTIAL 45 MG (AM)/ 15

MG (PM), 60 MG (AM)/ 30 MG

(PM), 90 MG (AM)/ 30 MG (PM)

2 $0

PA; QL (56 per 28

days)

methyclothiazide oral tablet 5 mg 1 $0

spironolactone oral tablet 100 mg,

25 mg, 50 mg (Aldactone) 1 $0

torsemide oral tablet 10 mg, 20 mg (Demadex) 1 $0

torsemide oral tablet 100 mg, 5 mg 1 $0

triamterene-hydrochlorothiazid oral

capsule 37.5-25 mg (Dyazide) 1 $0


capsule 50-25 mg 1 $0


tablet 37.5-25 mg (Maxzide-25mg) 1 $0


tablet 75-50 mg (Maxzide) 1 $0

Dyslipidemics

atorvastatin oral tablet 10 mg, 20

mg, 40 mg, 80 mg (Lipitor) 1 $0

cholestyramine (with sugar) oral

powder in packet 4 gram (Questran) 1 $0

cholestyramine light oral powder 4

gram 1 $0

cholestyramine light packet 4 gram 1 $0

colestipol oral packet 5 gram (Colestid) 1 $0

colestipol oral tablet 1 gram (Colestid) 1 $0

endur-acin er 500 mg tablet 500 mg

* 4 $0





107

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

endur-acin er 750 mg tablet 750 mg

* 4 $0

ezetimibe oral tablet 10 mg (Zetia) 1 $0

fenofibrate micronized oral capsule

134 mg, 200 mg, 67 mg 1 $0

fenofibrate nanocrystallized oral

tablet 145 mg, 48 mg (Tricor) 1 $0

fenofibrate oral tablet 160 mg, 54

mg 1 $0

gemfibrozil oral tablet 600 mg (Lopid) 1 $0

JUXTAPID ORAL CAPSULE 10

MG, 30 MG, 40 MG, 60 MG 2 $0

PA; QL (30 per 30

days)


MG 2 $0

PA; QL (90 per 30

days)


MG 2 $0

PA; QL (45 per 30

days)

KYNAMRO SUBCUTANEOUS

SYRINGE 200 MG/ML 2 $0


LIVALO ORAL TABLET 1 MG, 2

MG, 4 MG 2 $0

QL (30 per 30 days)

lovastatin oral tablet 10 mg, 20 mg,

40 mg 1 $0

niacin 50 mg tablet 50 mg * 4 $0

niacin 500 mg capsule sa 500 mg * 4 $0

niacin 500 mg tablet 500 mg * (Niacor) 4 $0

niacin 750 mg tablet sa 750 mg * (Endur-Acin) 4 $0

niacin er 1,000 mg tablet 1,000 mg

* 4 $0

niacin er 500 mg caplet 500 mg * (Endur-Acin) 4 $0

niacin oral tablet extended release

24 hr 1,000 mg, 500 mg, 750 mg

(Niaspan

Extended-Release) 1 $0

niacin tr 500 mg caplet caplet 500

mg * (Endur-Acin) 4 $0



.



108

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

niacinamide 500 mg tablet 500 mg * (Niacin

(niacinamide)) 4 $0

niacor oral tablet 500 mg 1 $0

omega-3 acid ethyl esters oral

capsule 1 gram (Lovaza) 1 $0


plain niacin 500 mg tablet 500 mg * (Niacor) 4 $0

PRALUENT PEN

SUBCUTANEOUS PEN

INJECTOR 150 MG/ML, 75

MG/ML

2 $0


pravastatin oral tablet 10 mg 1 $0

pravastatin oral tablet 20 mg, 40

mg, 80 mg (Pravachol) 1 $0

prevalite oral powder in packet 4

gram 1 $0

REPATHA PUSHTRONEX

SUBCUTANEOUS WEARABLE

INJECTOR 420 MG/3.5 ML

2 $0

PA; QL (3.5 per 28

days)

REPATHA SURECLICK

SUBCUTANEOUS PEN

INJECTOR 140 MG/ML

2 $0


REPATHA SYRINGE


MG/ML

2 $0


rosuvastatin oral tablet 10 mg, 20

mg, 40 mg, 5 mg (Crestor) 1 $0

simvastatin oral tablet 10 mg, 20

mg, 40 mg (Zocor) 1 $0

simvastatin oral tablet 5 mg 1 $0

simvastatin oral tablet 80 mg (Zocor) 1 $0 QL (30 per 30 days)

VASCEPA ORAL CAPSULE 0.5

GRAM 2 $0






109

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

VASCEPA ORAL CAPSULE 1

GRAM 2 $0


WELCHOL ORAL POWDER IN

PACKET 3.75 GRAM 1 $0

WELCHOL ORAL TABLET 625

MG 1 $0

Renin-Angiotensin-Aldosterone

System Inhibitors

eplerenone oral tablet 25 mg, 50 mg (Inspra) 1 $0

TEKTURNA HCT ORAL TABLET

150-12.5 MG, 150-25 MG, 300-12.5

MG, 300-25 MG

2 $0

ST

TEKTURNA ORAL TABLET 150

MG, 300 MG 2 $0

ST

Vasodilators

BIDIL ORAL TABLET 20-37.5

MG 2 $0

isosorbide dinitrate oral tablet 10

mg, 20 mg, 30 mg 1 $0

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 1 $0

isosorbide dinitrate oral tablet

extended release 40 mg (ISOCHRON) 1 $0

isosorbide mononitrate oral tablet

10 mg, 20 mg 1 $0

isosorbide mononitrate oral tablet


mg, 60 mg

1 $0

minitran transdermal patch 24 hour

0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr 1 $0

QL (30 per 30 days)

minitran transdermal patch 24 hour

0.4 mg/hr 1 $0

QL (60 per 30 days)

minoxidil oral tablet 10 mg, 2.5 mg 1 $0



.



110

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

NITRO-BID TRANSDERMAL

OINTMENT 2 % 1 $0

nitroglycerin intravenous solution

50 mg/10 ml (5 mg/ml) 1 $0

nitroglycerin sublingual tablet 0.3

mg, 0.4 mg, 0.6 mg (Nitrostat) 1 $0

nitroglycerin transdermal patch 24

hour 0.1 mg/hr, 0.2 mg/hr, 0.6

mg/hr

(Minitran) 1 $0

QL (30 per 30 days)

nitroglycerin transdermal patch 24

hour 0.4 mg/hr (Minitran) 1 $0

QL (60 per 30 days)

Central Nervous System

Agents

Central Nervous System Agents

AMPYRA ORAL TABLET


MG

2 $0

PA; QL (60 per 30

days)

atomoxetine oral capsule 10 mg,

100 mg, 18 mg, 25 mg, 40 mg, 60

mg, 80 mg

(Strattera) 1 $0

AUBAGIO ORAL TABLET 14

MG, 7 MG 2 $0

PA; QL (28 per 28

days)

AUSTEDO ORAL TABLET 12

MG, 9 MG 2 $0

PA; QL (120 per 30

days)

AUSTEDO ORAL TABLET 6 MG 2 $0 PA; QL (60 per 30

days)

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT 30 MCG 2 $0

PA

AVONEX INTRAMUSCULAR

PEN INJECTOR KIT 30 MCG/0.5

ML

2 $0

PA





111

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

AVONEX INTRAMUSCULAR

SYRINGE KIT 30 MCG/0.5 ML 2 $0

PA

BETASERON SUBCUTANEOUS

KIT 0.3 MG 2 $0

PA

caffeine citrate intravenous solution

60 mg/3 ml (20 mg/ml) (Cafcit) 1 $0

PA BvD

caffeine citrate oral solution 60

mg/3 ml (20 mg/ml) 1 $0

COPAXONE SUBCUTANEOUS


PA; QL (30 per 30

days)

COPAXONE SUBCUTANEOUS


PA; QL (12 per 28

days)

dalfampridine oral tablet extended

release 12 hr 10 mg (Ampyra) 1 $0

PA; QL (60 per 30

days)

dexmethylphenidate oral tablet 10

mg, 2.5 mg, 5 mg (Focalin) 1 $0

QL (60 per 30 days)

dextroamphetamine oral tablet 10

mg, 5 mg (Zenzedi) 1 $0


dextroamphetamine-amphetamine

oral capsule,extended release 24hr

10 mg, 15 mg, 5 mg

(Adderall XR) 1 $0

QL (30 per 30 days)


oral capsule,extended release 24hr

20 mg, 25 mg, 30 mg

(Adderall XR) 1 $0

QL (60 per 30 days)


oral tablet 10 mg, 12.5 mg, 15 mg,

20 mg, 30 mg, 5 mg, 7.5 mg

(Adderall) 1 $0

QL (60 per 30 days)

EXTAVIA SUBCUTANEOUS KIT

0.3 MG 2 $0

PA

flumazenil intravenous solution 0.1

mg/ml 1 $0

GILENYA ORAL CAPSULE 0.25

MG, 0.5 MG 2 $0

PA; QL (30 per 30

days)



.



112

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

glatiramer subcutaneous syringe 20

mg/ml (Copaxone) 1 $0

PA; QL (30 per 30

days)

glatiramer subcutaneous syringe 40

mg/ml (Copaxone) 1 $0

PA; QL (12 per 28

days)

glatopa subcutaneous syringe 20

mg/ml 1 $0

PA; QL (30 per 30

days)

glatopa subcutaneous syringe 40

mg/ml 1 $0

PA; QL (12 per 28

days)

guanfacine oral tablet extended

release 24 hr 1 mg, 2 mg, 3 mg, 4

mg

(Intuniv ER) 1 $0

INGREZZA ORAL CAPSULE 40

MG, 80 MG 2 $0

PA; QL (30 per 30

days)

LEMTRADA INTRAVENOUS

SOLUTION 12 MG/1.2 ML 2 $0

PA

lithium carbonate oral capsule 150

mg, 300 mg, 600 mg 1 $0

lithium carbonate oral tablet 300

mg 1 $0

lithium carbonate oral tablet

extended release 300 mg (Lithobid) 1 $0

lithium carbonate oral tablet

extended release 450 mg 1 $0

lithium citrate oral solution 8 meq/5

ml 2 $0

methylphenidate hcl oral capsule, er

biphasic 30-70 10 mg, 20 mg, 40

mg, 50 mg, 60 mg

1 $0

QL (30 per 30 days)

methylphenidate hcl oral capsule, er

biphasic 30-70 30 mg 1 $0

QL (60 per 30 days)

methylphenidate hcl oral capsule,er

biphasic 50-50 10 mg, 20 mg, 40 mg (Ritalin LA) 1 $0

QL (30 per 30 days)





113

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


biphasic 50-50 30 mg (Ritalin LA) 1 $0

QL (60 per 30 days)


biphasic 50-50 60 mg 1 $0

QL (30 per 30 days)

methylphenidate hcl oral solution 10

mg/5 ml, 5 mg/5 ml (Methylin) 1 $0


methylphenidate hcl oral tablet 10

mg, 20 mg, 5 mg (Ritalin) 1 $0

QL (90 per 30 days)

NUEDEXTA ORAL CAPSULE 20-

10 MG 2 $0

PA; QL (60 per 30

days)

OCREVUS INTRAVENOUS


PA; QL (20 per 180

days)

PLEGRIDY SUBCUTANEOUS

PEN INJECTOR 125 MCG/0.5 ML,

63 MCG/0.5 ML- 94 MCG/0.5 ML

2 $0

PA

PLEGRIDY SUBCUTANEOUS


MCG/0.5 ML- 94 MCG/0.5 ML

2 $0

PA

RADICAVA INTRAVENOUS

PIGGYBACK 30 MG/100 ML 2 $0

PA; QL (2800 per 28

days)

REBIF (WITH ALBUMIN)


MCG/0.5 ML, 44 MCG/0.5 ML

2 $0

PA

REBIF REBIDOSE

SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44

MCG/0.5 ML, 8.8MCG/0.2ML-22

MCG/0.5ML (6)

2 $0

PA

REBIF TITRATION PACK

SUBCUTANEOUS SYRINGE

8.8MCG/0.2ML-22 MCG/0.5ML

(6)

2 $0

PA

riluzole oral tablet 50 mg (Rilutek) 1 $0



.



114

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SAVELLA ORAL TABLET 100

MG, 12.5 MG, 25 MG, 50 MG 2 $0

QL (60 per 30 days)

SAVELLA ORAL

TABLETS,DOSE PACK 12.5 MG

(5)-25 MG(8)-50 MG(42)

2 $0

QL (60 per 30 days)

TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG

2 $0

PA; QL (14 per 30

days)

TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG (14)-

240 MG (46), 240 MG

2 $0

PA; QL (60 per 30

days)

tetrabenazine oral tablet 12.5 mg,

25 mg (Xenazine) 1 $0

PA; QL (112 per 28

days)

Contraceptives

Contraceptives

aftera 1.5 mg tablet 1.5 mg * 4 $0 QL (6 per 365 days)

altavera (28) oral tablet 0.15-0.03

mg 1 $0

alyacen 1/35 (28) oral tablet 1-35

mg-mcg 1 $0

alyacen 7/7/7 (28) oral tablet

0.5/0.75/1 mg- 35 mcg 1 $0

amethia lo oral tablets,dose pack,3

month 0.10 mg-20 mcg (84)/10 mcg

(7)

1 $0

QL (91 per 84 days)

amethia oral tablets,dose pack,3


(7)

1 $0

QL (91 per 84 days)

apri oral tablet 0.15-0.03 mg 1 $0

aranelle (28) oral tablet 0.5/1/0.5-

35 mg-mcg 1 $0





115

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ashlyna oral tablets,dose pack,3


(7)

1 $0

aubra oral tablet 0.1-20 mg-mcg 1 $0

aviane oral tablet 0.1-20 mg-mcg 1 $0

azurette (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

balziva (28) oral tablet 0.4-35 mg-

mcg 1 $0

bekyree (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

blisovi 24 fe oral tablet 1 mg-20

mcg (24)/75 mg (4) 1 $0

blisovi fe 1.5/30 (28) oral tablet 1.5

mg-30 mcg (21)/75 mg (7) 1 $0

blisovi fe 1/20 (28) oral tablet 1 mg-

20 mcg (21)/75 mg (7) 1 $0

briellyn oral tablet 0.4-35 mg-mcg 1 $0

camila oral tablet 0.35 mg 1 $0

caziant (28) oral tablet 0.1/.125/.15-

25 mg-mcg 1 $0

cryselle (28) oral tablet 0.3-30 mg-

mcg 1 $0

cyclafem 1/35 (28) oral tablet 1-35

mg-mcg 1 $0

cyclafem 7/7/7 (28) oral tablet

0.5/0.75/1 mg- 35 mcg 1 $0

cyred 28 day tablet outer 0.15-0.03

mg 1 $0

cyred eq oral tablet 0.15-0.03 mg 1 $0

dasetta 1/35 (28) oral tablet 1-35

mg-mcg 1 $0



.



116

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dasetta 7/7/7 (28) oral tablet

0.5/0.75/1 mg- 35 mcg 1 $0

daysee oral tablets,dose pack,3


(7)

1 $0

QL (91 per 84 days)

deblitane oral tablet 0.35 mg 1 $0

delyla (28) oral tablet 0.1-20 mg-

mcg 1 $0

desog-e.estradiol/e.estradiol oral

tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Azurette (28)) 1 $0

desogestrel-ethinyl estradiol oral

tablet 0.15-0.03 mg (Apri) 1 $0

drospirenone-ethinyl estradiol oral

tablet 3-0.02 mg (Gianvi (28)) 1 $0

drospirenone-ethinyl estradiol oral

tablet 3-0.03 mg (Ocella) 1 $0

econtra ez 1.5 mg tablet outer 1.5

mg * 4 $0

QL (6 per 365 days)

elinest oral tablet 0.3-30 mg-mcg 1 $0

ELLA ORAL TABLET 30 MG 2 $0 QL (6 per 365 days)

emoquette oral tablet 0.15-0.03 mg 1 $0

enpresse oral tablet 50-30 (6)/75-40

(5)/125-30(10) 1 $0

enskyce oral tablet 0.15-0.03 mg 1 $0

errin oral tablet 0.35 mg 1 $0

estarylla oral tablet 0.25-35 mg-mcg 1 $0

ethynodiol diac-eth estradiol oral

tablet 1-35 mg-mcg (Kelnor 1/35 (28)) 1 $0

ethynodiol diac-eth estradiol oral

tablet 1-50 mg-mcg (Kelnor 1-50) 1 $0

falmina (28) oral tablet 0.1-20 mg-

mcg 1 $0





117

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

femynor oral tablet 0.25-35 mg-mcg 1 $0

gildagia oral tablet 0.4-35 mg-mcg 1 $0

hailey 24 fe oral tablet 1 mg-20 mcg

(24)/75 mg (4) 1 $0

heather oral tablet 0.35 mg 1 $0

incassia oral tablet 0.35 mg 1 $0

introvale oral tablets,dose pack,3

month 0.15 mg-30 mcg 1 $0

QL (91 per 84 days)

isibloom oral tablet 0.15-0.03 mg 1 $0

jencycla oral tablet 0.35 mg 1 $0

jolivette oral tablet 0.35 mg 2 $0

juleber oral tablet 0.15-0.03 mg 1 $0

junel 1.5/30 (21) oral tablet 1.5-30

mg-mcg 1 $0

junel 1/20 (21) oral tablet 1-20 mg-

mcg 1 $0

junel fe 1.5/30 (28) oral tablet 1.5

mg-30 mcg (21)/75 mg (7) 1 $0

junel fe 1/20 (28) oral tablet 1 mg-

20 mcg (21)/75 mg (7) 1 $0

junel fe 24 oral tablet 1 mg-20 mcg

(24)/75 mg (4) 1 $0

kariva (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

kelnor 1/35 (28) oral tablet 1-35

mg-mcg 1 $0

kelnor 1-50 oral tablet 1-50 mg-mcg 1 $0

kimidess (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

kurvelo oral tablet 0.15-0.03 mg 1 $0

l norgest/e.estradiol-e.estrad oral

tablets,dose pack,3 month 0.10 mg-

20 mcg (84)/10 mcg (7)

(Amethia Lo) 1 $0

QL (91 per 84 days)



.



118

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use



20 mcg/ 0.15 mg-25 mcg

(Fayosim) 1 $0

QL (91 per 84 days)



30 mcg (84)/10 mcg (7)

(Amethia) 1 $0

QL (91 per 84 days)

larin 1.5/30 (21) oral tablet 1.5-30

mg-mcg 1 $0

larin 1/20 (21) oral tablet 1-20 mg-

mcg 1 $0

larin 24 fe oral tablet 1 mg-20 mcg

(24)/75 mg (4) 1 $0

larin fe 1.5/30 (28) oral tablet 1.5

mg-30 mcg (21)/75 mg (7) 1 $0

larin fe 1/20 (28) oral tablet 1 mg-

20 mcg (21)/75 mg (7) 1 $0

larissia oral tablet 0.1-20 mg-mcg 1 $0

leena 28 oral tablet 0.5/1/0.5-35

mg-mcg 2 $0

lessina oral tablet 0.1-20 mg-mcg 1 $0

levonest (28) oral tablet 50-30

(6)/75-40 (5)/125-30(10) 1 $0

levonorgestrel 1.5 mg tablet (otc)

1.5 mg * (Aftera) 4 $0

QL (6 per 365 days)

levonorgestrel-ethinyl estrad oral

tablet 0.1-20 mg-mcg (Aubra) 1 $0


tablet 0.15-0.03 mg (Altavera (28)) 1 $0

QL (91 per 84 days)



30 mcg

(Introvale) 1 $0

QL (91 per 84 days)





119

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

levonorg-eth estrad triphasic oral

tablet 50-30 (6)/75-40 (5)/125-

30(10)

(Enpresse) 1 $0

levora-28 oral tablet 0.15-0.03 mg 1 $0

lillow oral tablet 0.15-0.03 mg 1 $0

loryna (28) oral tablet 3-0.02 mg 1 $0

low-ogestrel (28) oral tablet 0.3-30

mg-mcg 1 $0

lutera (28) oral tablet 0.1-20 mg-

mcg 1 $0

lyza oral tablet 0.35 mg 1 $0

marlissa oral tablet 0.15-0.03 mg 1 $0

microgestin 1.5/30 (21) oral tablet

1.5-30 mg-mcg 1 $0

microgestin 1/20 (21) oral tablet 1-

20 mg-mcg 1 $0

microgestin fe 1.5/30 (28) oral

tablet 1.5 mg-30 mcg (21)/75 mg (7) 1 $0

microgestin fe 1/20 (28) oral tablet

1 mg-20 mcg (21)/75 mg (7) 1 $0

mili oral tablet 0.25-35 mg-mcg 1 $0

mono-linyah oral tablet 0.25-35 mg-

mcg 1 $0

mononessa (28) oral tablet 0.25-35

mg-mcg 2 $0

my choice 1.5 mg tablet 1.5 mg * 4 $0 QL (6 per 365 days)

my way 1.5 mg tablet (otc) 1.5 mg * 4 $0 QL (6 per 365 days)

myzilra oral tablet 50-30 (6)/75-40

(5)/125-30(10) 1 $0

necon 0.5/35 (28) oral tablet 0.5-35

mg-mcg 1 $0

new day 1.5 mg tablet 1.5 mg * 4 $0 QL (6 per 365 days)



.



120

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

next choice one dose 1.5 mg tb (otc)

1.5 mg * 4 $0

QL (6 per 365 days)

nikki (28) oral tablet 3-0.02 mg 1 $0

nora-be oral tablet 0.35 mg 2 $0

norethindrone (contraceptive) oral

tablet 0.35 mg (Camila) 1 $0

norethindrone ac-eth estradiol oral

tablet 1-20 mg-mcg (Junel 1/20 (21)) 1 $0

norethindrone-e.estradiol-iron oral

tablet 1 mg-20 mcg (21)/75 mg (7)

(Blisovi Fe 1/20

(28)) 1 $0

norethindrone-e.estradiol-iron oral

tablet 1 mg-20 mcg (24)/75 mg (4) (Blisovi 24 Fe) 1 $0

norgestimate-ethinyl estradiol oral

tablet 0.18/0.215/0.25 mg-25 mcg

(Ortho Tri-Cyclen

LO (28)) 1 $0


tablet 0.18/0.215/0.25 mg-35 mcg

(28)

(Ortho Tri-Cyclen

(28)) 1 $0


tablet 0.25-35 mg-mcg (Estarylla) 1 $0

norlyda oral tablet 0.35 mg 1 $0

norlyroc oral tablet 0.35 mg 1 $0

nortrel 0.5/35 (28) oral tablet 0.5-35

mg-mcg 1 $0

nortrel 1/35 (21) oral tablet 1-35

mg-mcg 1 $0

nortrel 1/35 (28) oral tablet 1-35

mg-mcg 1 $0

nortrel 7/7/7 (28) oral tablet

0.5/0.75/1 mg- 35 mcg 1 $0

NUVARING VAGINAL RING

0.12-0.015 MG/24 HR 2 $0

QL (1 per 28 days)





121

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ogestrel (28) oral tablet 0.5-50 mg-

mcg 1 $0

opcicon one-step 1.5 mg tablet 1.5

mg * 4 $0

QL (6 per 365 days)

option 2 1.5 mg tablet 1.5 mg * 4 $0 QL (6 per 365 days)

orsythia oral tablet 0.1-20 mg-mcg 1 $0

philith oral tablet 0.4-35 mg-mcg 1 $0

pimtrea (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

pirmella oral tablet 0.5/0.75/1 mg-

35 mcg, 1-35 mg-mcg 1 $0

portia oral tablet 0.15-0.03 mg 1 $0

previfem oral tablet 0.25-35 mg-mcg 1 $0

quasense oral tablets,dose pack,3


QL (91 per 84 days)

reclipsen (28) oral tablet 0.15-0.03

mg 1 $0

setlakin oral tablets,dose pack,3


QL (91 per 84 days)

sharobel oral tablet 0.35 mg 1 $0

sprintec (28) oral tablet 0.25-35 mg-

mcg 1 $0

sronyx oral tablet 0.1-20 mg-mcg 1 $0

syeda oral tablet 3-0.03 mg 1 $0

tarina fe 1/20 (28) oral tablet 1 mg-

20 mcg (21)/75 mg (7) 1 $0

tilia fe oral tablet 1-20(5)/1-30(7)

/1mg-35mcg (9) 1 $0

tri femynor oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0

tri-estarylla oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0



.



122

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

tri-legest fe oral tablet 1-20(5)/1-

30(7) /1mg-35mcg (9) 1 $0

tri-linyah oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0

tri-lo-estarylla oral tablet

0.18/0.215/0.25 mg-25 mcg 1 $0

tri-lo-marzia oral tablet

0.18/0.215/0.25 mg-25 mcg 1 $0

tri-lo-sprintec oral tablet

0.18/0.215/0.25 mg-25 mcg 1 $0

tri-mili oral tablet 0.18/0.215/0.25

mg-35 mcg (28) 1 $0

trinessa (28) oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 2 $0

tri-previfem (28) oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0

tri-sprintec (28) oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0

trivora (28) oral tablet 50-30 (6)/75-

40 (5)/125-30(10) 1 $0

tri-vylibra oral tablet

0.18/0.215/0.25 mg-35 mcg (28) 1 $0

tulana oral tablet 0.35 mg 1 $0

velivet triphasic regimen (28) oral

tablet 0.1/.125/.15-25 mg-mcg 1 $0

vestura (28) oral tablet 3-0.02 mg 1 $0

vienva oral tablet 0.1-20 mg-mcg 1 $0

viorele (28) oral tablet 0.15-0.02

mgx21 /0.01 mg x 5 1 $0

vyfemla (28) oral tablet 0.4-35 mg-

mcg 1 $0

vylibra oral tablet 0.25-35 mg-mcg 1 $0





123

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

wera (28) oral tablet 0.5-35 mg-mcg 1 $0

xulane transdermal patch weekly

150-35 mcg/24 hr 1 $0

QL (3 per 28 days)

zarah oral tablet 3-0.03 mg 1 $0

zenchent (28) oral tablet 0.4-35 mg-

mcg 1 $0

zovia 1/35e (28) oral tablet 1-35

mg-mcg 1 $0

zovia 1/50e (28) oral tablet 1-50

mg-mcg 1 $0

Cough And Cold Products

Cough And Cold Products

adult robitussin peak cold dm non-

drowsy 10-100 mg/5 ml * 4 $0

adult wal-tussin dm syrup

a/f,cherry,adult 10-100 mg/5 ml * 4 $0

adult wal-tussin liquid 100 mg/5 ml

* 4 $0

benzonatate 100 mg capsule 100 mg

* (Tessalon Perles) 3 $0


* 3 $0


* 3 $0

brotapp dm liquid 1-15-5 mg/5 ml * 4 $0

children's mucinex cough liq 5-100

mg/5 ml * 4 $0

children's silfedrine liq 15 mg/5 ml

* 4 $0

CHILDS SUDAFED 15 MG/5 ML

LIQ NON-DROWSY,A/F,S/F 15

MG/5 ML *

4 $0



.



124

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

chl mucinex chest congest liq a/f

100 mg/5 ml * 4 $0

cough syrup 200 mg/10 ml 100 mg/5

ml * 4 $0

cough-cold tablet 4-30 mg * 4 $0

delsym cough+chest cngst dm lq 5-

100 mg/5 ml * 4 $0

diabetic tussin dm liquid 10-100

mg/5 ml * 4 $0

diabetic tussin ex liquid

a/f,d/f,na/f,s/f 100 mg/5 ml * 4 $0

dimaphen dm elixir grape,

a/f,gluten-f 1-2.5-5 mg/5 ml * 4 $0

expectorant 100 mg/5 ml syrup 100

mg/5 ml * 4 $0

expectorant 200 mg tablet 200 mg * 4 $0

extra action cough syrup 10-100

mg/5 ml * 4 $0

gnp chest congst-cough rlf tab 20-

400 mg * 4 $0

guaifenesin 200 mg tablet (otc) 200

mg * (Coughtab) 4 $0

guaifenesin er 1,200 mg tablet 1,200

mg * (Mucinex) 4 $0

kidkare cough & cold liquid 1-15-5

mg/5 ml * 4 $0

kro mucus dm er 600-30 mg tab 30-

600 mg * 4 $0

kro mucus dm max er 1200-60 mg

60-1,200 mg * 4 $0

kro mucus-er 600 mg tablet gluten-

free, 12 hour 600 mg * 4 $0





125

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

mucinex fast-max dm max liquid

maximum strength 5-100 mg/5 ml * 4 $0

mucus relief 400 mg tablet d/f 400

mg * 4 $0

mucus relief dm tablet 20-400 mg * 4 $0

mucus relief er 600 mg tablet

gluten-free, 12 hour 600 mg * 4 $0

mucus rlf dm er 600-30 mg tab 30-

600 mg * 4 $0

promethazine-dm solution 6.25-15

mg/5 ml * 3 $0

pseudoephed 30 mg/5 ml soln 30

mg/5 ml *

(Nasal

Decongestant

(pseudoeph))

4 $0

pseudoephedrine 30 mg tablet 30

mg *

(Nasal

Decongestant

(pseudoeph))

4 $0

pseudoephedrine 60 mg tablet ex-

str, non drowsy (otc) 60 mg * (Sudogest) 4 $0

ra anti-tussive dm syrup 10-100

mg/5 ml * 4 $0

ra expectorant cough syrup 100

mg/5 ml * 4 $0

ra tussin cough liquid s/f, d/f, a/f 10-

100 mg/5 ml * 4 $0

ra tussin dm syrup a/f 10-100 mg/5

ml * 4 $0

refenesen 400 mg tablet 400 mg * 4 $0

robafen 100 mg/5 ml syrup 100

mg/5 ml * 4 $0

robafen-dm syrup 10-100 mg/5 ml * 4 $0

robitussin cough-chest dm liq 5-100

mg/5 ml * 4 $0



.



126

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

safetussin dm liquid 10-100 mg/5 ml

* 4 $0

scot-tussin 100 mg/5 ml liq 100

mg/5 ml * 4 $0

siltussin sa 100 mg/5 ml syr 100

mg/5 ml * 4 $0

sm adult nasal decongestant lq 15

mg/5 ml * 4 $0

sm mucus relief cough liquid

childrens, a/f 5-100 mg/5 ml * 4 $0

sudogest 30 mg tablet boxed 30 mg

* 4 $0

sudogest 60 mg tablet 60 mg * 4 $0

suphedrin liquid 15 mg/5 ml * 4 $0

tusnel diabetic liquid (otc) 10-100

mg/5 ml * 4 $0

tussin cough-cold-flu oral liquid 1-

2.5-5-160 mg/5 ml * 4 $0

wal-phed 30 mg tablet non-drowsy

30 mg * 4 $0

wal-tussin syrup 100 mg/5 ml * 4 $0

zephrex-d 30 mg tablet 30 mg * 4 $0

Dental And Oral Agents

Dental And Oral Agents

chlorhexidine gluconate mucous

membrane mouthwash 0.12 %

(Paroex Oral

Rinse) 1 $0

oralone dental paste 0.1 % 1 $0

paroex oral rinse mucous membrane

mouthwash 0.12 % 1 $0

periogard mucous membrane

mouthwash 0.12 % 1 $0





127

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

pilocarpine hcl oral tablet 5 mg, 7.5

mg

(Salagen

(pilocarpine)) 1 $0

triamcinolone acetonide dental

paste 0.1 % (Oralone) 1 $0

Dermatological Agents

Dermatological Agents, Other

acitretin oral capsule 10 mg, 17.5

mg, 25 mg (Soriatane) 1 $0

acne medication 10% gel 10 % * 4 $0

acne medication 5% gel 5 % * 4 $0

acyclovir topical ointment 5 % (Zovirax) 1 $0 QL (30 per 30 days)

ALCOHOL PADS TOPICAL

PADS, MEDICATED 1 $0

amlactin 12% lotion 12 % * 4 $0

ammonium lactate 12% cream

fragrance free (otc) 12 % * (Geri-Hydrolac) 4 $0

ammonium lactate 12% lotion

fragrance free (otc) 12 % * (AmLactin) 4 $0

ammonium lactate topical cream 12

% (Geri-Hydrolac) 1 $0

ammonium lactate topical lotion 12

% (AmLactin) 1 $0

benzoyl peroxide 10% gel aqueous

(otc) 10 % * (Acne Medication) 4 $0

benzoyl peroxide 5% gel aqueous

(otc) 5 % * (Acne Medication) 4 $0

calcipotriene scalp solution 0.005 % 1 $0

calcipotriene topical cream 0.005 % (Dovonex) 1 $0

CASTELLANI PAINT 1.5%

COLORLESS 1.5 % * 4 $0

COSENTYX (2 SYRINGES)


MG/ML

2 $0

PA



.



128

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

COSENTYX PEN (2 PENS)

SUBCUTANEOUS PEN

INJECTOR 150 MG/ML

2 $0

PA

cutter backwoods 25% spray 25 % * 4 $0 QL (340 per 180 days)

cutter backwoods dry 25% spray 25

% * 4 $0

cutter skinsations 7% spray 7 % * 4 $0 QL (354 per 180 days)

cvs insect repellent 15% spray 15 %

* 4 $0

cvs skin treatment body lotion 12 %

* 4 $0

cvs total home insect 30% spr 30 %

* 4 $0

cvs zinc oxide ointment * 4 $0

DUPIXENT SUBCUTANEOUS


PA

fluorouracil topical cream 0.5 % (Carac) 2 $0

fluorouracil topical cream 5 % (Efudex) 1 $0

fluorouracil topical solution 2 %, 5

% 1 $0

geri-hydrolac 12% lotion 12 % * 4 $0

geri-hydrolac 5% lotion 5 % * 4 $0

imiquimod topical cream in packet 5

% (Aldara) 1 $0

PA NSO; QL (24 per

30 days)

INSECT REPELLENT 20%

SPRAY 20 % * 4 $0


methoxsalen oral capsule,liqd-

filled,rapid rel 10 mg (Oxsoralen Ultra) 1 $0

NATRAPEL 20% SPRAY 20 % * 4 $0 QL (354 per 180 days)

off active 15% spray 15 % * 4 $0 QL (340 per 180 days)

off deep woods 25% spray 25 % * 4 $0 QL (340 per 180 days)





129

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

off deep woods dry 25% spray 25 %

* 4 $0


off deep woods sportmn 25% spr 25

% * 4 $0

off deep woods sportmn 30% spr 30

% * 4 $0

off deep woods sportmn 98.25%

98.25 % * 4 $0

off familycare 15% rplnt i spr 15 %

* 4 $0


off familycare 7% rplnt spray 7 % * 4 $0

PANRETIN TOPICAL GEL 0.1 % 2 $0

persa-gel 10% 12's,max-strength 10

% * 4 $0

PICATO TOPICAL GEL 0.015 % 2 $0 QL (3 per 56 days)

PICATO TOPICAL GEL 0.05 % 2 $0 QL (2 per 56 days)

podofilox topical solution 0.5 % 1 $0

ra zinc oxide ointment * 4 $0

repel 100 98.11% spray 98.11 % * 4 $0

repel family 10% spray 10 % * 4 $0

repel family 15% spray 15 % * 4 $0

repel hunter's 25% spray 25 % * 4 $0

repel sportsmen 25% spray 25 % * 4 $0 QL (368 per 180 days)

repel sportsmen dry 25% spray 25

% * 4 $0

repel sportsmen max 40% spray 40

% * 4 $0


SANTYL TOPICAL OINTMENT

250 UNIT/GRAM 2 $0

SILIQ SUBCUTANEOUS


PA



.



130

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TALTZ AUTOINJECTOR

SUBCUTANEOUS AUTO-

INJECTOR 80 MG/ML

2 $0

PA

TALTZ SYRINGE


MG/ML

2 $0

PA

TOLAK TOPICAL CREAM 4 % 2 $0

topical light mineral oil * (Lobana Bath) 4 $0

TREMFYA SUBCUTANEOUS


PA

ultrathon 25% repellent spray 25 %

* 4 $0

VALCHLOR TOPICAL GEL 0.016

% 2 $0

zenatane oral capsule 10 mg, 20 mg,

30 mg, 40 mg 1 $0

zinc oxide 20% ointment 20 % * 4 $0

Dermatological Antibacterials

bacitracin 500 unit/gm ointmnt 500

unit/gram * (Bacitraycin Plus) 4 $0

bacitracin zn 500 unit/gm oint 500

unit/gram *

(Antibiotic

(bacitracin zinc)) 4 $0

bacitraycin plus 500 unit/gm 500

unit/gram * 4 $0

clindamycin phosphate topical

solution 1 % (Cleocin T) 1 $0

clindamycin phosphate topical swab

1 % (Cleocin T) 1 $0

cvs triple antibiotic ointment 3.5mg-

400 unit- 5,000 unit/gram * 4 $0

ery pads topical swab 2 % 1 $0

erythromycin with ethanol topical

gel 2 % (Erygel) 1 $0





131

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


solution 2 % 1 $0


swab 2 % (Ery Pads) 1 $0

gentamicin topical cream 0.1 % 1 $0

gentamicin topical ointment 0.1 % 1 $0

metronidazole topical cream 0.75 % (MetroCream) 1 $0

metronidazole topical gel 0.75 % (Rosadan) 1 $0

metronidazole topical gel 1 % (Metrogel) 1 $0

metronidazole topical lotion 0.75 % (MetroLotion) 1 $0

mupirocin topical ointment 2 % (Centany) 1 $0

neomycin-polymyxin b gu irrigation

solution 40 mg-200,000 unit/ml 1 $0

neosporin ointment 3.5mg-400 unit-

5,000 unit/gram * 4 $0

rosadan topical cream 0.75 % 1 $0

selenium sulfide topical lotion 2.5 % 1 $0

silver sulfadiazine topical cream 1

% (Silvadene) 2 $0

ssd topical cream 1 % 2 $0

sulfacetamide sodium (acne) topical

suspension 10 % (Klaron) 1 $0

triple antibiotic ointment 3.5mg-400

unit- 5,000 unit/gram * 4 $0

Dermatological Anti-Inflammatory

Agents

ala-cort topical cream 1 %, 2.5 % 1 $0

alclometasone topical cream 0.05 % 1 $0

alclometasone topical ointment 0.05

% 1 $0

aquanil hc 1% lotion 1 % * 4 $0

beta hc 1% lotion 1 % * 4 $0



.



132

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

betamethasone dipropionate topical

cream 0.05 % 1 $0


lotion 0.05 % 1 $0


ointment 0.05 % 1 $0

betamethasone valerate topical

cream 0.1 % 1 $0


lotion 0.1 % 1 $0


ointment 0.1 % 1 $0

betamethasone, augmented topical

cream 0.05 % 1 $0


gel 0.05 % 1 $0


lotion 0.05 % 1 $0


ointment 0.05 % (Diprolene) 1 $0

clobetasol scalp solution 0.05 % (Cormax) 1 $0

clobetasol topical cream 0.05 % (Temovate) 1 $0

clobetasol-emollient topical cream

0.05 % 1 $0

clocortolone pivalate topical cream

0.1 % (Cloderm) 2 $0

cormax scalp solution 0.05 % 1 $0

cortaid 1% cream 12 hr, anti-itch 1

% * 4 $0

cortizone-10 1% creme maximum

strength 1 % * 4 $0

cortizone-10 1% ointment 1 % * 4 $0





133

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dermarest eczema 1% lotion 1 % * 4 $0

desoximetasone topical cream 0.25

% (Topicort) 1 $0

ELIDEL TOPICAL CREAM 1 % 2 $0

EUCRISA TOPICAL OINTMENT

2 % 2 $0

fluocinolone topical cream 0.01 % 1 $0

fluocinolone topical cream 0.025 % (Synalar) 1 $0

fluocinolone topical ointment 0.025

% (Synalar) 1 $0

fluocinonide topical cream 0.05 % 1 $0

fluocinonide topical gel 0.05 % 1 $0

fluocinonide topical solution 0.05 % 1 $0

fluocinonide-e topical cream 0.05 % 1 $0

fluticasone topical cream 0.05 % (Cutivate) 1 $0

fluticasone topical ointment 0.005 % 1 $0

halobetasol propionate topical

cream 0.05 % (Ultravate) 1 $0

halobetasol propionate topical

ointment 0.05 % (Ultravate) 1 $0

hydro skin 1% lotion 1 % * 4 $0

hydrocortisone 0.5% cream (otc)

0.5 % * 4 $0

hydrocortisone 0.5% ointment 0.5 %

* 4 $0

hydrocortisone 1% cream maximum

strength (otc) 1 % * (Ala-Cort) 4 $0

hydrocortisone 1% lotion (otc) 1 %

* (Anti-Itch (HC)) 4 $0

hydrocortisone 1% ointment

maximum strength (otc) 1 % * (Anti-Itch (HC)) 4 $0

hydrocortisone topical cream 1 %,

2.5 % (Ala-Cort) 1 $0



.



134

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

hydrocortisone topical lotion 2.5 % 1 $0

hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 1 $0

hydrocortisone topical ointment 2.5

% 1 $0

mometasone topical cream 0.1 % (Elocon) 1 $0

mometasone topical ointment 0.1 % (Elocon) 1 $0

mometasone topical solution 0.1 % 1 $0

prednicarbate topical cream 0.1 % 2 $0

prednicarbate topical ointment 0.1

% (Dermatop) 1 $0

preparation h hc 1% cream 1 % * 4 $0

procto-med hc topical cream with

perineal applicator 2.5 % 1 $0

proctosol hc topical cream with


proctozone-hc topical cream with


triamcinolone acetonide topical

cream 0.025 % 1 $0


cream 0.1 %, 0.5 % (Triderm) 1 $0


lotion 0.025 %, 0.1 % 1 $0


ointment 0.025 %, 0.1 %, 0.5 % 1 $0

Dermatological Retinoids

adapalene topical cream 0.1 % (Differin) 1 $0

adapalene topical gel 0.1 % (Differin) 1 $0

ALTRENO TOPICAL LOTION

0.05 % 2 $0

PA

tazarotene topical cream 0.1 % (Avage) 1 $0





135

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TAZORAC TOPICAL CREAM

0.05 % 2 $0

tretinoin topical cream 0.025 % (Avita) 1 $0 PA

tretinoin topical cream 0.05 %, 0.1

% (Retin-A) 1 $0

PA

tretinoin topical gel 0.01 % (Retin-A) 1 $0 PA

tretinoin topical gel 0.025 % (Avita) 1 $0 PA

tretinoin topical gel 0.05 % (Atralin) 1 $0 PA

Scabicides And Pediculicides

cvs lice killing shampoo maximum

strength 0.33-4 % * 4 $0

lice treatment 1% creme rinse famly

pk,creme rinse 1 % * 4 $0

malathion topical lotion 0.5 % (Ovide) 1 $0

permethrin 1% lotion 1 % * (Lice Killing

(permethrin)) 4 $0

permethrin topical cream 5 % (Elimite) 1 $0

ra lice pyrinyl shampoo 0.33-4 % * 4 $0

ra lice treatment 1% crm rinse

2x59ml, 2 combs 1 % * 4 $0

sb lice killing shampoo maximum

strength 0.33-4 % * 4 $0

v-r lice cream rinse 1 % * 4 $0

Devices

Devices

1ST TIER UNILET

COMFORTOUCH 28 GAUGE, 30

GAUGE

4 $0

PA

ACCU-CHEK FASTCLIX

LANCET DRUM 4 $0

PA

ACCU-CHEK MULTICLIX

LANCET 4 $0

PA



.



136

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ACCU-CHEK SAFE-T-PRO 23

GAUGE 4 $0

PA

ACCU-CHEK SAFE-T-PRO PLUS

23 GAUGE 4 $0

PA

ACCU-CHEK SOFTCLIX

LANCETS 4 $0

PA

ACTI-LANCE LANCETS 17

GAUGE, 23 GAUGE, 28 GAUGE 4 $0

PA

ADVANCED TRAVEL LANCETS

28 GAUGE, 30 GAUGE 4 $0

PA

ADVOCATE LANCET 26

GAUGE, 30 GAUGE 4 $0

PA

ALTERNATE SITE LANCET 26

GAUGE 4 $0

PA

ASSURE HAEMOLANCE PLUS

18 GAUGE, 21 GAUGE, 25

GAUGE, 28 GAUGE

4 $0

PA

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X 1/2" 1 $0

ASSURE LANCE 25 GAUGE, 28

GAUGE 4 $0

PA

ASSURE LANCE PLUS 21


PA

BD MICROTAINER LANCET 21


PA

BD UF NANO PEN NEEDLE

4MMX32G 32 GAUGE X 5/32" 1 $0

BD ULTRA FINE LANCETS 33

GAUGE 4 $0

PA

BD ULTRA-FINE II LANCETS 30

GAUGE 4 $0

PA

BD VEO INS 0.3 ML 6MMX31G

(1/2) 0.3 ML 31 GAUGE X 15/64" 1 $0





137

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

BD VEO INS SYRING 1 ML

6MMX31G 1 ML 31 GAUGE X

15/64"

1 $0

BD VEO INS SYRN 0.5 ML

6MMX31G 1/2 ML 31 GAUGE X

15/64"

1 $0

BREEZE 2 TEST STRIPS STRIP 4 $0 PA

BULLSEYE MINI SAFETY

LANCETS 21 GAUGE, 25 GAUGE 4 $0

PA

CAREONE ULTRA THIN

LANCET 4 $0

PA

CARESENS LANCETS 30

GAUGE 4 $0

PA

CARETOUCH TWIST LANCET


PA

CLEVER CHEK LANCETS 30

GAUGE 4 $0

PA

COAGUCHEK LANCETS 4 $0 PA

COLOR LANCETS 21 GAUGE 4 $0 PA

COMFORT EZ LANCETS 21


PA

COMFORT LANCETS 4 $0 PA

CONTOUR NEXT TEST STRIPS

STRIP 4 $0

PA

CONTOUR TEST STRIPS STRIP 4 $0 PA

DROPLET LANCETS 30 GAUGE 4 $0 PA

EASY COMFORT LANCETS 30

GAUGE 4 $0

PA

EASY TOUCH LANCETS 28

GAUGE 4 $0

PA

EASY TOUCH SAFETY

LANCETS 21 GAUGE, 23

GAUGE, 26 GAUGE

4 $0

PA



.



138

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

EASY TOUCH TWIST LANCETS


GAUGE, 33 GAUGE

4 $0

PA

EASY TWIST AND CAP

LANCETS 28 GAUGE 4 $0

PA

EMBRACE LANCETS 30 GAUGE 4 $0 PA

E-Z JECT LANCETS , 26

GAUGE, 30 GAUGE, 32 GAUGE,

33 GAUGE

4 $0

PA

E-Z JECT THIN LANCETS 28

GAUGE 4 $0

PA

EZ SMART LANCETS 28 GAUGE 4 $0 PA

FIFTY50 SAFETY SEAL


PA

FINE 30 UNIVERSAL LANCETS

30 GAUGE 4 $0

PA

FINGERSTIX LANCETS 4 $0 PA

FORACARE LANCETS 30

GAUGE 4 $0

PA

FREESTYLE LANCETS 28

GAUGE 4 $0

PA

FREESTYLE UNISTIK 2 4 $0 PA

GAUZE PAD TOPICAL

BANDAGE 2 X 2 " 1 $0

GLUCOCOM LANCETS 28


PA

HEALTHY ACCENTS UNILET

LANCET 30 GAUGE 4 $0

PA

INCONTROL SUPER THIN


PA

INCONTROL ULTRA THIN


PA





139

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

INJECT EASE LANCETS 28


PA

INSULIN SYRINGE-NEEDLE U-

100 SYRINGE 0.3 ML 29 GAUGE

(Ultilet Insulin

Syringe) 1 $0


100 SYRINGE 1 ML 29 GAUGE X

1/2"

(Advocate

Syringes) 1 $0


100 SYRINGE 1/2 ML 28 GAUGE

(Lite Touch Insulin

Syringe) 1 $0

INVACARE LANCETS 30

GAUGE 4 $0

PA

LANCETS

(Accu-Chek

Fastclix Lancet

Drum)

4 $0

PA

LANCETS 21 GAUGE (Assure

Haemolance Plus) 4 $0

PA

LANCETS 26 GAUGE (Advocate Lancet) 4 $0 PA

LANCETS 28 GAUGE, 30 GAUGE (1st Tier Unilet

ComforTouch) 4 $0

PA

LANCETS 33 GAUGE (BD Ultra Fine

Lancets) 4 $0

PA

LANCETS, SUPER THIN 4 $0 PA

LANCETS,THIN , 23 GAUGE, 28

GAUGE 4 $0

PA

LANCETS,ULTRA THIN , 26

GAUGE 4 $0

PA

LITE TOUCH LANCETS 28


PA

MEDLANCE PLUS LANCETS 21


PA

MICROLET LANCET 4 $0 PA

MONOLET LANCETS 21 GAUGE 4 $0 PA



.



140

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

MONOLET THIN LANCETS 28

GAUGE 4 $0

PA

MYGLUCOHEALTH LANCETS

30 GAUGE 4 $0

PA

NOVA SAFETY LANCETS 23


PA

NOVA SUREFLEX LANCETS 4 $0 PA

ON CALL LANCET 30 GAUGE 4 $0 PA

ON CALL PLUS LANCET 30

GAUGE 4 $0

PA

ONETOUCH DELICA LANCETS


PA

ONETOUCH SURESOFT

LANCING DEV 18 GAUGE 4 $0

PA

ONETOUCH ULTRASOFT

LANCETS 4 $0

PA

ON-THE-GO LANCETS 30

GAUGE 4 $0

PA

PEN NEEDLE, DIABETIC

NEEDLE 29 GAUGE X 1/2"

(1st Tier Unifine

Pentips) 1 $0

PRESSURE ACTIVATED


PA

PRO COMFORT LANCET 30


PA

PRODIGY LANCETS 26 GAUGE,

28 GAUGE 4 $0

PA

PRODIGY TWIST TOP LANCET

28 GAUGE 4 $0

PA

PUSH BUTTON SAFETY


PA





141

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

READYLANCE SAFETY

LANCETS 21 GAUGE, 23


30 GAUGE

4 $0

PA

RELIAMED LANCET 23 GAUGE,


PA

RELIAMED SAFETY SEAL


PA

RELION THIN LANCETS 26

GAUGE 4 $0

PA

RELION ULTRA THIN PLUS

LANCETS 4 $0

PA

RIGHTEST GL300 LANCETS 30

GAUGE 4 $0

PA

SAFETY LANCETS 21 GAUGE,


PA

SAFETY SEAL LANCETS 28


PA

SAFETY-LET LANCETS 30

GAUGE 4 $0

PA

SINGLE-LET 4 $0 PA

SMART SENSE LANCETS 21


PA

SMARTEST LANCET 4 $0 PA

SOFT TOUCH LANCETS 4 $0 PA

SOLUS V2 LANCETS 28 GAUGE,

30 GAUGE 4 $0

PA

STERILANCE TL 30 GAUGE, 32

GAUGE 4 $0

PA

SUPER THIN LANCETS 28

GAUGE 4 $0

PA



.



142

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SURE COMFORT 0.5 ML

SYRINGE 0.5 ML 29 GAUGE X

1/2"

1 $0

SURE COMFORT LANCETS 18


28 GAUGE, 30 GAUGE

4 $0

PA

SURE-LANCE , 26 GAUGE, 28

GAUGE 4 $0

PA

SURE-LANCE ULTRA THIN 30

GAUGE 4 $0

PA

SURE-TOUCH LANCET 4 $0 PA

TECHLITE LANCETS 28


PA

TELCARE LANCETS 30 GAUGE 4 $0 PA

THIN LANCETS 26 GAUGE 4 $0 PA

TOPCARE UNIVERSAL1

LANCET , 33 GAUGE 4 $0

PA

TRUE COMFORT LANCET 30

GAUGE 4 $0

PA

TRUEPLUS LANCETS 26


33 GAUGE

4 $0

PA

TWIST LANCETS 30 GAUGE, 32

GAUGE 4 $0

PA

ULTILET BASIC LANCETS 30

GAUGE 4 $0

PA

ULTILET CLASSIC LANCETS ,


GAUGE

4 $0

PA

ULTILET LANCETS 28 GAUGE,


PA

ULTILET SAFETY LANCETS 23

GAUGE 4 $0

PA





143

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ULTRA FINE LANCETS 30

GAUGE 4 $0

PA

ULTRA THIN II LANCETS 30

GAUGE 4 $0

PA

ULTRA THIN LANCETS 28


33 GAUGE

4 $0

PA

ULTRA THIN PLUS LANCETS 33

GAUGE 4 $0

PA

ULTRA TLC LANCETS 4 $0 PA

ULTRA-CARE LANCETS 30

GAUGE 4 $0

PA

ULTRALANCE LANCETS 26


PA

ULTRA-THIN II LANCETS 26


PA

UNILET COMFORTOUCH

LANCET , 26 GAUGE 4 $0

PA

UNILET EXCELITE II LANCET 4 $0 PA

UNILET EXCELITE LANCET 4 $0 PA

UNILET GP LANCET 4 $0 PA

UNILET LANCET 28 GAUGE, 33

GAUGE 4 $0

PA

UNILET SUPER THIN LANCETS

30 GAUGE 4 $0

PA

UNISTIK 3 COMFORT LANCET 4 $0 PA

UNISTIK 3 EXTRA LANCET 21

GAUGE 4 $0

PA

UNISTIK 3 GENTLE 30 GAUGE 4 $0 PA

UNISTIK 3 LANCETS 21 GAUGE 4 $0 PA

UNISTIK 3 NORMAL LANCET

23 GAUGE 4 $0

PA



.



144

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

UNISTIK CZT LANCET 23


PA

UNISTIK PRO LANCET 21


PA

UNISTIK SAFETY 28 GAUGE, 30

GAUGE 4 $0

PA

UNISTIK TOUCH LANCETS 21


30 GAUGE

4 $0

PA

UNIVERSAL 1 LANCETS 21


33 GAUGE

4 $0

PA

Enzyme

Replacement/Modifiers

Enzyme Replacement/Modifiers

ADAGEN INTRAMUSCULAR


ALDURAZYME INTRAVENOUS

SOLUTION 2.9 MG/5 ML 2 $0

CERDELGA ORAL CAPSULE 84

MG 2 $0

PA

CEREZYME INTRAVENOUS

RECON SOLN 400 UNIT 2 $0

CREON ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 12,000-38,000 -

60,000 UNIT, 24,000-76,000 -

120,000 UNIT, 3,000-9,500- 15,000

UNIT, 36,000-114,000- 180,000

UNIT, 6,000-19,000 -30,000 UNIT

2 $0

ELAPRASE INTRAVENOUS






145

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ELITEK INTRAVENOUS RECON

SOLN 1.5 MG, 7.5 MG 2 $0

FABRAZYME INTRAVENOUS


GALAFOLD ORAL CAPSULE

123 MG 2 $0

PA; QL (14 per 28

days)

KANUMA INTRAVENOUS


PA

KRYSTEXXA INTRAVENOUS


PA BvD

KUVAN ORAL

TABLET,SOLUBLE 100 MG 2 $0

miglustat oral capsule 100 mg (Zavesca) 1 $0 QL (90 per 30 days)

NAGLAZYME INTRAVENOUS


NITYR ORAL TABLET 10 MG, 2

MG, 5 MG 2 $0

PA

ORFADIN ORAL CAPSULE 10

MG, 2 MG, 20 MG, 5 MG 2 $0

PA

ORFADIN ORAL SUSPENSION 4

MG/ML 2 $0

PA

PALYNZIQ SUBCUTANEOUS

SYRINGE 10 MG/0.5 ML, 2.5

MG/0.5 ML, 20 MG/ML

2 $0

PA

PROCYSBI ORAL CAPSULE,

DELAYED REL SPRINKLE 25

MG, 75 MG

2 $0

PULMOZYME INHALATION


PA BvD

REVCOVI INTRAMUSCULAR

SOLUTION 2.4 MG/1.5 ML (1.6

MG/ML)

2 $0

PA



.



146

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

STRENSIQ SUBCUTANEOUS


MG/ML

2 $0

PA; LA

VIMIZIM INTRAVENOUS


MG/ML)

2 $0

PA

VPRIV INTRAVENOUS RECON

SOLN 400 UNIT 2 $0

ZENPEP ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -

42,000 UNIT, 10,000-34,000 -

55,000 UNIT, 15,000-47,000 -

63,000 UNIT, 15,000-51,000 -

82,000 UNIT, 20,000-63,000-

84,000 UNIT, 25,000-79,000-

105,000 UNIT, 25,000-85,000-

136,000 UNIT, 3,000-10,000 -

14,000-UNIT, 3,000-10,000- 16,000

UNIT, 40,000-126,000- 168,000

UNIT, 5,000-17,000 -27,000 UNIT,

5,000-17,000- 24,000 UNIT

2 $0

Eye, Ear, Nose, Throat Agents

Eye, Ear, Nose, Throat Agents,

Miscellaneous

altamist 0.65% nose spray 0.65 % * 4 $0

apraclonidine ophthalmic (eye)

drops 0.5 % (Iopidine) 1 $0

artificial tears * 4 $0

artificial tears 1.4% drops 1.4 % * 4 $0

artificial tears drops p/f, sterile 0.1-

0.3 % * 4 $0

artificial tears drops strl 1-0.3 % * 4 $0





147

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

artificial tears eye drops strl 0.1-0.3

% * 4 $0

ARTIFICIAL TEARS EYE

OINTMENT 83-15 % * 4 $0

atropine ophthalmic (eye) drops 1 % (Isopto Atropine) 2 $0

ayr saline 0.65% nose spray 0.65 %

* 4 $0

azelastine nasal aerosol,spray 137

mcg (0.1 %) 1 $0

QL (30 per 25 days)

azelastine ophthalmic (eye) drops

0.05 % 1 $0

cromolyn ophthalmic (eye) drops 4

% 1 $0

cvs artificial tears drops sterile 1-

0.3 % * 4 $0

cvs lubricant 0.6% eye drop 0.6 % * 4 $0

cvs lubricant gel eye drops 0.25-0.3

% * 4 $0

cvs lubricating eye drops dry eye

soln 0.5-0.9 % * 4 $0

cvs nasal spray 0.05% 0.05 % * 4 $0

cvs nasal spray 0.05% no drip 0.05

% * 4 $0

cvs natural tears drops 0.1-0.3 % * 4 $0

cvs saline 0.65% nasal spray 0.65 %

* 4 $0

cvs saline 0.65% nose spray 0.65 %

* 4 $0

cyclopentolate ophthalmic (eye)

drops 0.5 %, 1 %, 2 % (Cyclogyl) 1 $0

CYSTARAN OPHTHALMIC

(EYE) DROPS 0.44 % 2 $0

deep sea 0.65% nose spray 0.65 % * 4 $0



.



148

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dristan long lasting mist 0.05 % * 4 $0

epinastine ophthalmic (eye) drops

0.05 % (Elestat) 1 $0

eq revive plus 0.5% eye drops 0.5 %

* 4 $0

GENTEAL TEARS 0.1%-0.2%-

0.3% 0.1-0.3-0.2 % * 4 $0

genteal tears 0.1%-0.3% drop 0.1-

0.3 % * 4 $0

GENTEAL TEARS SEVERE 0.3%

GEL INNER 0.3 % * 4 $0

ipratropium bromide nasal

spray,non-aerosol 0.03 % 1 $0

QL (30 per 28 days)

ipratropium bromide nasal

spray,non-aerosol 42 mcg (0.06 %) 1 $0

QL (15 per 10 days)

little remedies stuffy nose kt w/

nasal aspirator 0.65 % * 4 $0

lubricant 0.5-0.9% eye drops 0.5-

0.9 % * 4 $0

lubricant 0.5-0.9% eye drops 0.5-

0.9 % * 4 $0

lubricant pm eye ointment p/f 57.3-

42.5 % * 4 $0

lubricating plus 0.5% eye drps p/f,

30x0.4ml 0.5 % * 4 $0

lubrifresh pm eye ointment 83-15 %

* 4 $0

moist lubricant 0.25% eye drop 0.25

% * 4 $0

muro-128 2% eye drops 2 % * 4 $0

muro-128 5% eye drops 5 % * 4 $0

muro-128 5% eye ointment 5 % * 4 $0





149

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

nasal relief 0.05% spray sinus

formula 0.05 % * 4 $0

nasal spray 0.05% extra

moisturizing 0.05 % * 4 $0

natural balance tears eye drop 0.1-

0.3 % * 4 $0

neo-synephrine 12 hour spray 0.05

% * 4 $0

ocean 0.65% nasal spray 0.65 % * 4 $0

olopatadine ophthalmic (eye) drops

0.1 % (Patanol) 1 $0

olopatadine ophthalmic (eye) drops

0.2 % (Pataday) 1 $0

phenylephrine hcl ophthalmic (eye)

drops 10 %, 2.5 % 1 $0

proparacaine ophthalmic (eye)

drops 0.5 % 1 $0

ra 12hr nasal spray 0.05% for sinus

0.05 % * 4 $0

REFRESH CELLUVISC 1% EYE

DROPS 1 % * 4 $0

REFRESH CLASSIC EYE DROPS

U-D,P/F,30X.4ML 1.4-0.6 % * 4 $0

REFRESH LACRI-LUBE

OINTMENT 56.8-42.5 % * 4 $0

retaine hpmc 0.3% eye drops 0.3 %

* 4 $0

retaine nacl 5% eye drop 5 % * 4 $0

retaine nacl 5% eye ointment 5 % * 4 $0

saline mist 0.65% nose spry 0.65 %

* 4 $0

sinus relief nasal spray 0.05% 0.05

% * 4 $0



.



150

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sm lubricant eye drops strl 0.4-0.3

% * 4 $0

sm nasal spray sinus 0.05 % * 4 $0

sochlor 5% eye drops 5 % * 4 $0

sochlor 5% eye ointment 5 % * 4 $0

sodium chloride 5% eye drop 5 % * (Altachlore) 4 $0

sodium chloride 5% eye oint 5 % * (Altachlore) 4 $0

SYSTANE 0.3% EYE GEL 0.3 % * 4 $0

tears again 1.4% drops 1.4 % * 4 $0

vicks qlearquil 0.05% mist 0.05 % * 4 $0

vicks sinex 12 hour spray 0.05 % * 4 $0

Eye, Ear, Nose, Throat Anti-

Infectives Agents

acetic acid otic (ear) solution 2 % 1 $0

bacitracin ophthalmic (eye)

ointment 500 unit/gram 1 $0

bacitracin-polymyxin b ophthalmic

(eye) ointment 500-10,000

unit/gram

(AK-Poly-Bac) 1 $0

bleph-10 ophthalmic (eye) drops 10

% 1 $0

CIPRODEX OTIC (EAR)

DROPS,SUSPENSION 0.3-0.1 % 2 $0

ciprofloxacin hcl ophthalmic (eye)

drops 0.3 % (Ciloxan) 1 $0

ciprofloxacin hcl otic (ear)

dropperette 0.2 % (Cetraxal) 2 $0

erythromycin ophthalmic (eye)

ointment 5 mg/gram (0.5 %) 1 $0

gentak ophthalmic (eye) ointment

0.3 % (3 mg/gram) 1 $0





151

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

gentamicin ophthalmic (eye) drops

0.3 % 1 $0

levofloxacin ophthalmic (eye) drops

0.5 % 1 $0

MOXEZA OPHTHALMIC (EYE)

DROPS, VISCOUS 0.5 % 2 $0

moxifloxacin ophthalmic (eye) drops

0.5 % (Vigamox) 1 $0

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION 5 % 2 $0

neomycin-bacitracin-poly-hc

ophthalmic (eye) ointment 3.5-400-

10,000 mg-unit/g-1%

(Neo-Polycin HC) 1 $0

neomycin-bacitracin-polymyxin

ophthalmic (eye) ointment 3.5-400-

10,000 mg-unit-unit/g

(Neo-Polycin) 1 $0

neomycin-polymyxin b-dexameth

ophthalmic (eye) drops,suspension

3.5mg/ml-10,000 unit/ml-0.1 %

(Maxitrol) 1 $0

neomycin-polymyxin b-dexameth

ophthalmic (eye) ointment 3.5 mg/g-

10,000 unit/g-0.1 %

(Maxitrol) 1 $0

neomycin-polymyxin-gramicidin

ophthalmic (eye) drops 1.75 mg-

10,000 unit-0.025mg/ml

1 $0

neomycin-polymyxin-hc ophthalmic

(eye) drops,suspension 3.5-10,000-

10 mg-unit-mg/ml

1 $0

neomycin-polymyxin-hc otic (ear)

drops,suspension 3.5-10,000-1

mg/ml-unit/ml-%

1 $0

neomycin-polymyxin-hc otic (ear)

solution 3.5-10,000-1 mg/ml-

unit/ml-%

1 $0



.



152

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

neo-polycin hc ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit/g-

1%

1 $0

neo-polycin ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit-

unit/g

1 $0

ofloxacin ophthalmic (eye) drops 0.3

% (Ocuflox) 1 $0

ofloxacin otic (ear) drops 0.3 % 1 $0

polycin ophthalmic (eye) ointment

500-10,000 unit/gram 1 $0

polymyxin b sulf-trimethoprim

ophthalmic (eye) drops 10,000 unit-

1 mg/ml

(Polytrim) 1 $0

REFRESH OPTIVE ADVANCED

DROPS 0.5-1-0.5 % * 4 $0

sulfacetamide sodium ophthalmic

(eye) drops 10 % (Bleph-10) 1 $0

sulfacetamide sodium ophthalmic

(eye) ointment 10 % 1 $0

sulfacetamide-prednisolone

ophthalmic (eye) drops 10 %-0.23

% (0.25 %)

1 $0

tobramycin ophthalmic (eye) drops

0.3 % (Tobrex) 1 $0

tobramycin-dexamethasone

ophthalmic (eye) drops,suspension

0.3-0.1 %

(TobraDex) 1 $0

trifluridine ophthalmic (eye) drops 1

% (Viroptic) 1 $0

ZIRGAN OPHTHALMIC (EYE)

GEL 0.15 % 2 $0





153

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ZYLET OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.3-0.5 % 2 $0

Eye, Ear, Nose, Throat Anti-

Inflammatory Agents

ALREX OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.2 % 2 $0

ST

BROMSITE OPHTHALMIC (EYE)

DROPS 0.075 % 2 $0

dexamethasone sodium phosphate

ophthalmic (eye) drops 0.1 % 1 $0

diclofenac sodium ophthalmic (eye)

drops 0.1 % 1 $0

DUREZOL OPHTHALMIC (EYE)

DROPS 0.05 % 2 $0

flunisolide nasal spray,non-aerosol

25 mcg (0.025 %) 1 $0

QL (50 per 25 days)

fluorometholone ophthalmic (eye)

drops,suspension 0.1 % (FML Liquifilm) 2 $0

flurbiprofen sodium ophthalmic

(eye) drops 0.03 % 1 $0

fluticasone nasal spray,suspension

50 mcg/actuation

(24 Hour Allergy

Relief) 1 $0

ILEVRO OPHTHALMIC (EYE)


ketorolac ophthalmic (eye) drops

0.4 % (Acular LS) 1 $0

ketorolac ophthalmic (eye) drops

0.5 % (Acular) 1 $0

LOTEMAX OPHTHALMIC (EYE)

DROPS,GEL 0.5 % 2 $0





.



154

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


OINTMENT 0.5 % 2 $0

prednisolone acetate ophthalmic

(eye) drops,suspension 1 % (Omnipred) 2 $0

prednisolone sodium phosphate

ophthalmic (eye) drops 1 % 1 $0

PROLENSA OPHTHALMIC

(EYE) DROPS 0.07 % 2 $0

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 0.05 % 2 $0

QL (60 per 30 days)

Gastrointestinal Agents

Antiflatulents

cvs gas relief 125 mg chew tab extra


cvs gas relief 80 mg tab chew 80 mg

* 4 $0

gas free 125 mg softgel 125 mg * 4 $0

gas relief 125 mg chew tablet max

str,lactose-free 125 mg * 4 $0

gas relief 125 mg softgel softgel,ex-

str 125 mg * 4 $0

gas relief 80 tablet chew 80 mg * 4 $0

mi-acid gas 80 mg tab chew 80 mg * 4 $0

Antiulcer Agents And Acid

Suppressants

acid reducer 20 mg tablet maximum


acid reducer dr 20 mg cap 20 mg * 4 $0

cimetidine hcl oral solution 300

mg/5 ml 1 $0

cvs acid controller 10 mg tab 10 mg

* 4 $0





155

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs cimetidine 200 mg tablet (otc)

200 mg *

(Acid Reducer

(cimetidine)) 4 $0

cvs ranitidine 75 mg tablet 75 mg * (Acid Reducer

(ranitidine)) 4 $0

eq omeprazole dr 20 mg odt 20 mg * 4 $0

esomeprazole mag dr 20 mg cap

outer (otc) 20 mg *

(Heartburn

Treatment) 4 $0

esomeprazole sodium intravenous


esomeprazole sodium intravenous

recon soln 40 mg (Nexium IV) 1 $0

famotidine (pf) intravenous solution

20 mg/2 ml 1 $0

famotidine (pf)-nacl (iso-os)


famotidine 10 mg tablet 10 mg * (Acid Controller) 4 $0

famotidine intravenous solution 10

mg/ml 1 $0

famotidine oral tablet 20 mg (Acid Controller) 1 $0

famotidine oral tablet 40 mg (Pepcid) 1 $0

heartburn treatment 20 mg cap 20

mg * 4 $0

lansoprazole dr 15 mg capsule 2x14

day course (otc) 15 mg *

(Heartburn

Treatment 24

Hour)

4 $0

misoprostol oral tablet 100 mcg,

200 mcg (Cytotec) 1 $0

nizatidine oral capsule 150 mg, 300

mg 1 $0

omeprazole dr 20 mg tablet 20 mg * 4 $0

omeprazole mag dr 20.6 mg cap two

14-days course 20 mg *

(Acid Reducer

(omeprazole)) 4 $0



.



156

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

omeprazole oral capsule,delayed

release(dr/ec) 10 mg, 20 mg, 40 mg 1 $0

pantoprazole intravenous recon soln

40 mg (Protonix) 1 $0

pantoprazole oral tablet,delayed

release (dr/ec) 20 mg, 40 mg (Protonix) 1 $0

pub famotidine 20 mg tablet max

strength (otc) 20 mg * (Acid Controller) 4 $0

ranitidine 150 mg tablet maximum

strength (otc) 150 mg *

(Acid Control

(ranitidine)) 4 $0

ranitidine hcl injection solution 25

mg/ml, 50 mg/2 ml (25 mg/ml) (Zantac) 1 $0

ranitidine hcl oral syrup 15 mg/ml 1 $0

ranitidine hcl oral tablet 150 mg (Acid Control

(ranitidine)) 1 $0

ranitidine hcl oral tablet 300 mg (Zantac) 1 $0

sucralfate oral tablet 1 gram (Carafate) 1 $0

wal-zan 75 mg tablet 75 mg * 4 $0

zantac 75 mg tablet 75 mg * 4 $0

Gastrointestinal Agents, Other

acid gone antacid liquid 95-358

mg/15 ml * 4 $0

almacone liquid 200-200-20 mg/5

ml * 4 $0

almacone-2 liquid 400-400-40 mg/5

ml * 4 $0

aluminum hydroxide gel 600 mg/5

ml * 4 $0

aluminum hydroxide gel sugar-free

320 mg/5 ml * 4 $0

AMITIZA ORAL CAPSULE 24

MCG, 8 MCG 2 $0

QL (60 per 30 days)





157

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

antacid-antigas tab chew 1,000-60

mg * 4 $0

anti-diarrheal 2 mg caplet caplet 2

mg * 4 $0

bismatrol 525 mg/30 ml susp 262

mg/15 ml * 4 $0

bismatrol tablet chew 262 mg * 4 $0

calci-chew tablet 500 mg calcium

(1,250 mg) * 4 $0

calcium 500 mg chewable tablet tab

chew,p/f 500 mg calcium (1,250 mg)

*

(Calci-Chew) 4 $0

calcium antacid 1,000 mg tab ultra,

chew, max str 400 mg calcium

(1,000 mg) *

4 $0

calcium antacid 500 mg chw tab

assorted fruit 200 mg calcium (500

mg) *

4 $0

calcium antacid 750 mg tb chew

gluten-free 300 mg (750 mg) * 4 $0

cal-gest 500 mg tablet chew 200 mg

calcium (500 mg) * 4 $0

CARBAGLU ORAL TABLET,

DISPERSIBLE 200 MG 2 $0

comfort gel max str susp max-str

400-400-40 mg/5 ml * 4 $0

comfort gel suspension regular str,

cherry 200-200-20 mg/5 ml * 4 $0

constulose oral solution 10 gram/15

ml 1 $0

cvs antacid plus anti-gas liq

maximum strength 400-400-40 mg/5

ml *

4 $0



.



158

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs antacid ultra tab chew ultra

strength 400 mg calcium (1,000 mg)

*

4 $0

cvs antacid xtra str chew tab extra-

strength 300 mg (750 mg) * 4 $0

cvs anti-diarrheal 2 mg sftgel 2 mg

* 4 $0

cvs anti-diarrheal suspension 262

mg/15 ml * 4 $0

cvs bismuth 262 mg caplet 262 mg * 4 $0

cvs child antacid 400 mg/5 ml 400

mg/5 ml * 4 $0

cvs flavor chew antacid 750 mg 300

mg (750 mg) * 4 $0

cvs heartburn relief liquid 254-

237.5 mg/5 ml * 4 $0

cvs lax dietary 500 mg caplet 500

mg * 4 $0

cvs loperamide 1 mg/7.5 ml liq mint

1 mg/7.5 ml *

(Anti-Diarrheal

(loperamide)) 4 $0

diamode 2 mg tablet outer, f/c 2 mg

* 4 $0

dicyclomine oral capsule 10 mg 1 $0

dicyclomine oral solution 10 mg/5

ml 1 $0

dicyclomine oral tablet 20 mg 1 $0

diphenoxylate-atropine oral liquid

2.5-0.025 mg/5 ml 1 $0

PA-HRM; AGE (Max

64 Years)

diphenoxylate-atropine oral tablet

2.5-0.025 mg (Lomotil) 1 $0

PA-HRM; AGE (Max

64 Years)

enulose oral solution 10 gram/15 ml 1 $0





159

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

eq liquid antacid susp maximum

strength 400-400-40 mg/5 ml * 4 $0

foaming antacid liquid 95-358

mg/15 ml * 4 $0

GATTEX 30-VIAL

SUBCUTANEOUS KIT 5 MG 2 $0

PA

gelusil tablet chewable cool mint

200-200-25 mg * 4 $0

generlac oral solution 10 gram/15

ml 1 $0

geri-lanta liquid 200-200-20 mg/5

ml * 4 $0

glycopyrrolate injection solution 0.2

mg/ml 1 $0

glycopyrrolate oral tablet 1 mg, 2

mg 1 $0

hm magnesium 400 mg caplet

gluten-free, caplet 400 mg

magnesium *

4 $0

imodium a-d 2 mg softgel 2 mg * 4 $0

kaopectate 262 mg/15 ml susp

vanilla flavor 262 mg/15 ml * 4 $0

kionex (with sorbitol) oral

suspension 15-19.3 gram/60 ml 1 $0

lactulose oral solution 10 gram/15

ml (Constulose) 1 $0

LINZESS ORAL CAPSULE 145

MCG, 290 MCG, 72 MCG 2 $0

QL (30 per 30 days)

LOKELMA ORAL POWDER IN

PACKET 10 GRAM, 5 GRAM 2 $0

QL (90 per 30 days)

loperamide 1 mg/5 ml liquid 1 mg/5

ml *

(Anti-Diarrheal

(loperamide)) 4 $0



.



160

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

loperamide 1 mg/7.5 ml soln gluten-

free,mint 1 mg/7.5 ml *

(Anti-Diarrheal

(loperamide)) 4 $0

loperamide 1 mg/7.5 ml susp mint 1

mg/7.5 ml *

(Anti-Diarrheal

(loperamide)) 4 $0

loperamide oral capsule 2 mg (Anti-Diarrheal

(loperamide)) 1 $0

maalox advanced suspension

regular strength 200-200-20 mg/5

ml *

4 $0

magnesium oxide 400 mg tablet

s/f,p/f,gluten-free 400 mg (241.3 mg

magnesium) *

(MagOx) 4 $0

magnesium oxide 420 mg tablet 420

mg * 4 $0

magnesium oxide 500 mg capsule

500 mg * 4 $0

magnesium oxide 500 mg tablet

p/f,s/f,lactose-free 500 mg *

(Laxative Dietary

Supplement) 4 $0

medi-first pep-t-med tab chew 262

mg * 4 $0

methscopolamine oral tablet 2.5 mg,

5 mg 1 $0

metoclopramide hcl injection


metoclopramide hcl injection


metoclopramide hcl oral solution 5

mg/5 ml 1 $0

metoclopramide hcl oral tablet 10

mg, 5 mg (Reglan) 1 $0

mgo 400 mg tablet 400 mg (241.3

mg magnesium) * 4 $0





161

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

mi acid suspension 200-200-20

mg/5 ml, 400-400-40 mg/5 ml * 4 $0

mi-acid ds tablet 700-300 mg * 4 $0

mintox maximum strength susp max

str, lemon creme 400-400-40 mg/5

ml *

4 $0

mintox plus tablet chewable 200-

200-25 mg * 4 $0

mintox suspension mint creme 200-

200-20 mg/5 ml * 4 $0

MOVANTIK ORAL TABLET 12.5

MG, 25 MG 2 $0

QL (30 per 30 days)

OCALIVA ORAL TABLET 10

MG, 5 MG 2 $0

PA; QL (30 per 30

days)

phillips 500 mg caplet 500 mg * 4 $0

ra antacid-gas relief liquid 400-400-

40 mg/5 ml * 4 $0

ra magnesium 500 mg capsule 500

mg * 4 $0

RAVICTI ORAL LIQUID 1.1

GRAM/ML 2 $0

PA

RELISTOR ORAL TABLET 150

MG 2 $0

PA; QL (90 per 30

days)

RELISTOR SUBCUTANEOUS


PA; QL (28 per 28

days)

RELISTOR SUBCUTANEOUS


MG/0.4 ML

2 $0

PA; QL (28 per 28

days)

ri-gel ii suspension 400-400-40

mg/5 ml * 4 $0

ri-gel suspension 200-200-20 mg/5

ml * 4 $0



.



162

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

riginic suspension 131-31.7 mg/5 ml

* 4 $0

ri-mox suspension 200-200-20 mg/5

ml * 4 $0

sm foaming antacid tablet chew 80-

20 mg * 4 $0

sm stomach relief caplet 262 mg * 4 $0

sod polystyren sulf 15 g/60 ml

sorbitol free 15 gram/60 ml 1 $0

sodium bicarb 10 grain tablet 650

mg * 4 $0

sodium phenylbutyrate oral tablet

500 mg (Buphenyl) 1 $0

sodium polystyrene sulfonate oral

powder 1 $0

soothe 262 mg caplet caplet 262 mg

* 4 $0

soothe regular strength susp s/f 262

mg/15 ml * 4 $0

sps (with sorbitol) oral suspension

15-20 gram/60 ml 1 $0

ursodiol oral capsule 300 mg (Actigall) 1 $0

ursodiol oral tablet 250 mg (URSO 250) 1 $0

ursodiol oral tablet 500 mg (URSO Forte) 1 $0

VELTASSA ORAL POWDER IN

PACKET 16.8 GRAM, 25.2

GRAM, 8.4 GRAM

2 $0

QL (30 per 30 days)

VIBERZI ORAL TABLET 100

MG, 75 MG 2 $0

ST; QL (60 per 30

days)

XERMELO ORAL TABLET 250

MG 2 $0

PA; QL (90 per 30

days)

Laxatives





163

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

alophen pills 5 mg * 4 $0

bisac-evac 10 mg suppository 10 mg

* 4 $0

bisacodyl 10 mg suppository 10 mg

* (Bisac-Evac) 4 $0

bisacodyl ec 5 mg tablet usp 5 mg * (Alophen) 4 $0

biscolax 10 mg suppository 10 mg * 4 $0

clearlax powder packet 17 gram * 4 $0

cvs enema disposable 19-7

gram/118 ml * 4 $0

cvs fiber laxative 625 mg cplt caplet

625 mg * 4 $0

cvs fiber therapy 500 mg caplt

soluble, caplet 500 mg * 4 $0

cvs glycerin suppository child size

*

(Fleet Glycerin

(Child)) 4 $0

cvs milk of magnesia susp 400 mg/5

ml * 4 $0

cvs mineral oil * (Mineral Oil Extra

Heavy) 4 $0

cvs natural daily fiber powder 3.4

gram/7 gram * 4 $0

cvs purelax powder 17 gram/dose * 4 $0

cvs purelax powder packet s/f, 10

daily doses 17 gram * 4 $0

cvs senna plus tablet 8.6-50 mg * 4 $0

cvs stool softener-laxative tb 8.6-50

mg * 4 $0

docu liquid 50 mg/5 ml 50 mg/5 ml

* 4 $0

docuzen tablet 8.6-50 mg * 4 $0

dok 100 mg softgel softgel 100 mg * 4 $0

dok 100 mg tablet 100 mg * 4 $0



.



164

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dulcoease 100 mg softgel 100 mg * 4 $0

dulcolax ss 100 mg softgel 100 mg * 4 $0

enema ready to use 2x133ml, latex

free 19-7 gram/118 ml * 4 $0

enemeez plus mini enema outer 283-

20 mg/5 ml * 4 $0

eq fiber therapy powder * 4 $0

eq vegetable laxative tablet 8.6 mg * 4 $0

eql fiber therapy powder 3.4 gram/7

gram * 4 $0

eql laxative ec 5 mg tablet 5 mg * 4 $0

equalactin 500 mg tab chew 500 mg

* 4 $0

evac-u-gen 8.6 mg tablet 8.6 mg * 4 $0

fiber laxative 625 mg caplet caplet

625 mg * 4 $0

fiber tablet unboxed 625 mg * 4 $0

fiber therapy powder 2 gram/19

gram * 4 $0

fiber-lax captabs 500mg

polycarbophil 625 mg * 4 $0

FLEET BISACODYL 10 MG

ENEMA 10 MG/30 ML * 4 $0

fleet bisacodyl ec 5 mg tab 5 mg * 4 $0

fleet pedia-lax suppositories * 4 $0

gavilyte-c oral recon soln 240-

22.72-6.72 -5.84 gram 1 $0

gavilyte-g oral recon soln 236-

22.74-6.74 -5.86 gram 1 $0

gavilyte-n oral recon soln 420 gram 1 $0

glycerin pediatric suppository

infants & children *

(Fleet Glycerin

(Child)) 4 $0





165

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

glycolax powder 7 doses (otc) 17

gram/dose * 4 $0

healthylax powder packet 14x17gm,

outer 17 gram * 4 $0

HYDROCIL INSTANT PACKET * 4 $0

KONSYL 6 GM PACKET S/F,

GLUTEN-F, OUTER 6 GRAM * 4 $0

konsyl fiber 625 mg caplet caplet, s/f

625 mg * 4 $0

konsyl psyllium fiber packet orange,

gluten free 3.4 gram * 4 $0

kro gentlelax 17 gram powder 17

gram/dose * 4 $0

magic bullet 10 mg suppos 10 mg * 4 $0

milk of magnesia suspension 400

mg/5 ml * 4 $0

mineral oil * (Mineral Oil Extra

Heavy) 4 $0

mineral oil usp * (Mineral Oil Extra

Heavy) 4 $0

mineral oil, heavy * 4 $0

MOVIPREP ORAL POWDER IN

PACKET 100-7.5-2.691 GRAM 2 $0

natural fiber lax powder * 4 $0

peg 3350-electrolytes oral recon

soln 236-22.74-6.74 -5.86 gram (GaviLyte-G) 1 $0

peg 3350-electrolytes oral recon

soln 240-22.72-6.72 -5.84 gram

(Colyte with Flavor

Packs) 2 $0

phillips' lax liqui-gels 100 mg * 4 $0

polyethylene glycol 3350 oral

powder 17 gram/dose (ClearLax) 1 $0

polyethylene glycol 3350 powd 17

grams pkts,outer (otc) 17 gram * (ClearLax) 4 $0



.



166

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

polyethylene glycol 3350 powd 7

once-daily doses (otc) 17 gram/dose

*

(ClearLax) 4 $0

polyethylene glycol 3350 powd

outer (otc) 17 gram * (ClearLax) 4 $0

promolaxin 100 mg tablet 100 mg * 4 $0

pure & gentle saline enema 19-7

gram/118 ml * 4 $0

pv infant glycerin suppos * (Fleet Glycerin

(Child)) 4 $0

qc mineral oil heavy * (Mineral Oil Extra

Heavy) 4 $0

qc natura-lax 17 gm powder 17

gram/dose * 4 $0

ra enema twin pack 2 x 4.5oz, rtu

19-7 gram/118 ml * 4 $0

ra fast relief lax 10 mg supp 10 mg * 4 $0

ra laxative peg 3350 powder 30

once-daily doses 17 gram/dose * 4 $0

ra mineral oil extra-heavy extra-

heavy * 4 $0

ra p-col rite tablet 8.6-50 mg * 4 $0

reguloid powder orange * 4 $0

sani-supp pediatric suppos outer * 4 $0

senexon 8.6 mg tablet 8.6 mg * 4 $0

senexon-s tablet 8.6-50 mg * 4 $0

senna 8.6 mg tablet 8.6 mg * 4 $0

senna 8.8 mg/5 ml syrup grx 8.8

mg/5 ml * 4 $0

senna-time 8.6 mg tablet 8.6 mg * 4 $0

sennosides-docusate sodium tab 8.6-

50 mg * (Colace 2-In-1) 4 $0





167

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

senokot-s tablet 8.6-50 mg * 4 $0

silace 50 mg/5 ml liquid 50 mg/5 ml

* 4 $0

sm fiber laxative 500 mg cplt 500

mg * 4 $0

sm fiber smooth powder * 4 $0

sm laxative pediatric suppos * 4 $0

sm oral saline laxative liquid s/f * 4 $0

smoothlax powder packet s/f, 10

daily doses 17 gram * 4 $0

stool softener 100 mg softgel softgel

100 mg * 4 $0

stool softener 100 mg tablet 100 mg

* 4 $0

stool softener 240 mg softgel softgel

240 mg * 4 $0

SUPREP BOWEL PREP KIT

ORAL RECON SOLN 17.5-3.13-

1.6 GRAM

2 $0

trilyte with flavor packets oral recon

soln 420 gram 1 $0

v-r senna-s tablet 8.6-50 mg * 4 $0

Phosphate Binders

calcium acetate oral capsule 667 mg 1 $0

calcium acetate oral tablet 667 mg (Calphron) 1 $0

eliphos oral tablet 667 mg 1 $0

PHOSLYRA ORAL SOLUTION

667 MG (169 MG CALCIUM)/5

ML

2 $0

RENAGEL ORAL TABLET 400

MG, 800 MG 2 $0

sevelamer carbonate oral powder in

packet 0.8 gram, 2.4 gram (Renvela) 1 $0



.



168

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sevelamer carbonate oral tablet 800

mg (Renvela) 1 $0

VELPHORO ORAL

TABLET,CHEWABLE 500 MG 2 $0

Genitourinary Agents

Antispasmodics, Urinary

bethanechol chloride oral tablet 10

mg, 25 mg, 5 mg, 50 mg (Urecholine) 1 $0

MYRBETRIQ ORAL TABLET


MG, 50 MG

2 $0

oxybutynin chloride oral syrup 5

mg/5 ml 1 $0

oxybutynin chloride oral tablet 5 mg 1 $0

oxybutynin chloride oral tablet

extended release 24hr 10 mg, 5 mg (Ditropan XL) 1 $0

oxybutynin chloride oral tablet

extended release 24hr 15 mg 1 $0

tolterodine oral capsule,extended

release 24hr 2 mg, 4 mg (Detrol LA) 1 $0

tolterodine oral tablet 1 mg, 2 mg (Detrol) 1 $0

TOVIAZ ORAL TABLET


MG, 8 MG

2 $0

Genitourinary Agents,

Miscellaneous

alfuzosin oral tablet extended

release 24 hr 10 mg (Uroxatral) 1 $0

dutasteride oral capsule 0.5 mg (Avodart) 1 $0

finasteride oral tablet 5 mg (Proscar) 1 $0

tamsulosin oral capsule 0.4 mg (Flomax) 1 $0





169

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

terazosin oral capsule 1 mg, 10 mg,

2 mg, 5 mg 1 $0

Heavy Metal Antagonists

Heavy Metal Antagonists

CUPRIMINE ORAL CAPSULE

250 MG 2 $0

PA

deferoxamine injection recon soln 2

gram, 500 mg (Desferal) 1 $0

PA

DEPEN TITRATABS ORAL

TABLET 250 MG 2 $0

PA

EXJADE ORAL TABLET,

DISPERSIBLE 125 MG, 250 MG,

500 MG

2 $0

PA

FERRIPROX ORAL SOLUTION

100 MG/ML 2 $0

PA

FERRIPROX ORAL TABLET 500

MG 2 $0

PA

JADENU ORAL TABLET 180

MG, 360 MG, 90 MG 2 $0

PA

JADENU SPRINKLE ORAL

GRANULES IN PACKET 180 MG,

360 MG, 90 MG

2 $0

PA

trientine oral capsule 250 mg (Syprine) 1 $0 PA; QL (240 per 30

days)

Hormonal Agents,

Stimulant/Replacement/Modif

ying

Androgens

ANADROL-50 ORAL TABLET 50

MG 2 $0

PA

ANDROGEL TRANSDERMAL

GEL IN METERED-DOSE PUMP

20.25 MG/1.25 GRAM (1.62 %)

2 $0

PA; QL (150 per 30

days)



.



170

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ANDROGEL TRANSDERMAL

GEL IN PACKET 1.62 % (20.25

MG/1.25 GRAM), 1.62 % (40.5

MG/2.5 GRAM)

2 $0

PA; QL (150 per 30

days)

danazol oral capsule 100 mg, 200

mg, 50 mg 1 $0

testosterone cypionate

intramuscular oil 100 mg/ml

(Depo-

Testosterone) 1 $0

PA

testosterone cypionate

intramuscular oil 200 mg/ml

(Depo-

Testosterone) 1 $0

PA

testosterone enanthate

intramuscular oil 200 mg/ml 1 $0


testosterone transdermal gel in

metered-dose pump 20.25 mg/1.25

gram (1.62 %)

(AndroGel) 1 $0

PA; QL (150 per 30

days)


packet 1 % (25 mg/2.5gram), 1 %

(50 mg/5 gram)

(AndroGel) 1 $0

PA; QL (300 per 30

days)


packet 1.62 % (20.25 mg/1.25

gram), 1.62 % (40.5 mg/2.5 gram)

(AndroGel) 1 $0

PA; QL (150 per 30

days)

Estrogens And Antiestrogens

amabelz oral tablet 0.5-0.1 mg, 1-

0.5 mg 1 $0

PA-HRM; AGE (Max

64 Years)

DUAVEE ORAL TABLET 0.45-20

MG 2 $0

PA-HRM; AGE (Max

64 Years)

estradiol oral tablet 0.5 mg, 1 mg, 2

mg (Estrace) 1 $0

PA-HRM; AGE (Max

64 Years)

estradiol transdermal patch

semiweekly 0.025 mg/24 hr, 0.05

mg/24 hr, 0.075 mg/24 hr, 0.1

mg/24 hr

(Alora) 1 $0

PA-HRM; QL (8 per

28 days); AGE (Max

64 Years)





171

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

estradiol transdermal patch

semiweekly 0.0375 mg/24 hr (Minivelle) 1 $0

PA-HRM; QL (8 per

28 days); AGE (Max

64 Years)

estradiol transdermal patch weekly

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

(Climara) 1 $0

PA-HRM; QL (4 per

28 days); AGE (Max

64 Years)

estradiol vaginal cream 0.01 % (0.1

mg/gram) (Estrace) 1 $0

estradiol valerate intramuscular oil

20 mg/ml, 40 mg/ml (Delestrogen) 1 $0

estradiol-norethindrone acet oral

tablet 0.5-0.1 mg (Activella) 1 $0

PA-HRM; AGE (Max

64 Years)

estropipate oral tablet 0.75 mg, 1.5

mg, 3 mg 1 $0

PA-HRM; AGE (Max

64 Years)

FEMRING VAGINAL RING 0.05

MG/24 HR, 0.1 MG/24 HR 2 $0

QL (1 per 84 days)

fyavolv oral tablet 0.5-2.5 mg-mcg,

1-5 mg-mcg 1 $0

PA-HRM; AGE (Max

64 Years)

jinteli oral tablet 1-5 mg-mcg 1 $0 PA-HRM; AGE (Max

64 Years)

MENEST ORAL TABLET 0.3 MG,

0.625 MG, 1.25 MG, 2.5 MG 1 $0

PA-HRM; AGE (Max

64 Years)

mimvey lo oral tablet 0.5-0.1 mg 1 $0 PA-HRM; AGE (Max

64 Years)


tablet 0.5-2.5 mg-mcg

(Femhrt Low

Dose) 1 $0

PA-HRM; AGE (Max

64 Years)


tablet 1-5 mg-mcg (Fyavolv) 1 $0

PA-HRM; AGE (Max

64 Years)

PREMARIN INJECTION RECON

SOLN 25 MG 2 $0

PREMARIN ORAL TABLET 0.3

MG, 0.45 MG, 0.625 MG, 0.9 MG,

1.25 MG

2 $0

PA-HRM; AGE (Max

64 Years)



.



172

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

PREMARIN VAGINAL CREAM

0.625 MG/GRAM 2 $0

PREMPHASE ORAL TABLET

0.625 MG (14)/ 0.625MG-5MG(14) 2 $0

PA-HRM; AGE (Max

64 Years)

PREMPRO ORAL TABLET 0.3-

1.5 MG, 0.45-1.5 MG, 0.625-2.5

MG, 0.625-5 MG

2 $0

PA-HRM; AGE (Max

64 Years)

raloxifene oral tablet 60 mg (Evista) 1 $0

Glucocorticoids/Mineralocorticoids

a-hydrocort injection recon soln 100

mg 1 $0

betamethasone acet,sod phos

injection suspension 6 mg/ml

(Celestone

Soluspan) 1 $0

cortisone oral tablet 25 mg 1 $0

decadron oral elixir 0.5 mg/5 ml 1 $0 PA BvD

dexamethasone oral elixir 0.5 mg/5

ml (Decadron) 1 $0

PA BvD

dexamethasone oral tablet 0.5 mg,

0.75 mg, 4 mg, 6 mg (Decadron) 1 $0

PA BvD

dexamethasone oral tablet 1 mg, 1.5

mg, 2 mg 1 $0

PA BvD

dexamethasone sodium phos (pf)

injection solution 10 mg/ml 1 $0


injection solution 10 mg/ml, 4 mg/ml 1 $0


injection syringe 4 mg/ml 1 $0

EMFLAZA ORAL SUSPENSION

22.75 MG/ML 2 $0

PA; QL (104 per 30

days)

EMFLAZA ORAL TABLET 18

MG 2 $0

PA; QL (30 per 30

days)

EMFLAZA ORAL TABLET 30

MG, 36 MG, 6 MG 2 $0

PA; QL (60 per 30

days)





173

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

fludrocortisone oral tablet 0.1 mg 1 $0

hydrocortisone oral tablet 10 mg, 20

mg, 5 mg (Cortef) 1 $0

methylprednisolone acetate

injection suspension 40 mg/ml, 80

mg/ml

(Depo-Medrol) 1 $0

methylprednisolone oral tablet 16

mg, 32 mg, 4 mg, 8 mg (Medrol) 1 $0

methylprednisolone oral

tablets,dose pack 4 mg (Medrol (Pak)) 1 $0

methylprednisolone sodium succ

injection recon soln 125 mg, 40 mg 1 $0


intravenous recon soln 1,000 mg (Solu-Medrol) 1 $0

prednisolone 15 mg/5 ml soln a/f, d/f

15 mg/5 ml (3 mg/ml) 1 $0

PA BvD

prednisolone oral solution 15 mg/5

ml 1 $0

PA BvD

prednisolone sodium phosphate oral

solution 25 mg/5 ml (5 mg/ml), 5 mg

base/5 ml (6.7 mg/5 ml)

1 $0

PA BvD

prednisone oral solution 5 mg/5 ml 1 $0 PA BvD

prednisone oral tablet 1 mg, 2.5 mg,

5 mg, 50 mg 1 $0

PA BvD

prednisone oral tablet 10 mg 1 $0 PA BvD

prednisone oral tablet 20 mg (Deltasone) 1 $0 PA BvD

prednisone oral tablets,dose pack 10

mg, 10 mg (48 pack), 5 mg, 5 mg

(48 pack)

1 $0

SOLU-CORTEF (PF) INJECTION

RECON SOLN 100 MG/2 ML 2 $0

triamcinolone acetonide injection

suspension 40 mg/ml (Kenalog) 1 $0



.



174

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Pituitary

desmopressin 10 mcg/0.1 ml spr 10

mcg/spray (0.1 ml) (DDAVP) 1 $0

desmopressin injection solution 4

mcg/ml (DDAVP) 1 $0

desmopressin nasal solution 0.1

mg/ml (refrigerate) (DDAVP) 2 $0

desmopressin nasal spray,non-

aerosol 10 mcg/spray (0.1 ml) 1 $0

desmopressin oral tablet 0.1 mg, 0.2

mg (DDAVP) 1 $0

GENOTROPIN MINIQUICK

SUBCUTANEOUS 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

2 $0

PA

GENOTROPIN SUBCUTANEOUS

CARTRIDGE 12 MG/ML (36

UNIT/ML), 5 MG/ML (15

UNIT/ML)

2 $0

PA

HUMATROPE INJECTION

CARTRIDGE 12 MG (36 UNIT),

24 MG (72 UNIT), 6 MG (18

UNIT)

2 $0

PA

HUMATROPE INJECTION

RECON SOLN 5 (15 UNIT) MG 2 $0

PA

INCRELEX SUBCUTANEOUS


LUPRON DEPOT-PED (3

MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG

2 $0





175

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

LUPRON DEPOT-PED

INTRAMUSCULAR KIT 11.25

MG, 15 MG

2 $0

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

INJECTOR 10 MG/1.5 ML (6.7

MG/ML), 15 MG/1.5 ML (10

MG/ML), 30 MG/3 ML (10

MG/ML), 5 MG/1.5 ML (3.3

MG/ML)

2 $0

PA

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN

INJECTOR 10 MG/2 ML (5

MG/ML), 20 MG/2 ML (10

MG/ML), 5 MG/2 ML (2.5

MG/ML)

2 $0

PA

octreotide acetate injection solution

1,000 mcg/ml, 200 mcg/ml 1 $0

octreotide acetate injection solution

100 mcg/ml, 50 mcg/ml, 500 mcg/ml (Sandostatin) 1 $0

octreotide acetate injection syringe

100 mcg/ml (1 ml), 50 mcg/ml (1

ml), 500 mcg/ml (1 ml)

1 $0

OMNITROPE SUBCUTANEOUS

CARTRIDGE 10 MG/1.5 ML (6.7

MG/ML), 5 MG/1.5 ML (3.3

MG/ML)

2 $0

PA

OMNITROPE SUBCUTANEOUS


PA

ORILISSA ORAL TABLET 150

MG 2 $0

PA; QL (28 per 28

days)

ORILISSA ORAL TABLET 200

MG 2 $0

PA; QL (56 per 28

days)



.



176

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SAIZEN SAIZENPREP

SUBCUTANEOUS CARTRIDGE

8.8 MG/1.51 ML (FINAL CONC.)

2 $0

PA

SAIZEN SUBCUTANEOUS

RECON SOLN 5 MG, 8.8 MG 2 $0

PA

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR


RECON 10 MG, 20 MG, 30 MG

2 $0

SEROSTIM SUBCUTANEOUS

RECON SOLN 4 MG, 5 MG, 6 MG 2 $0

PA

SIGNIFOR SUBCUTANEOUS

SOLUTION 0.3 MG/ML (1 ML),

0.6 MG/ML (1 ML), 0.9 MG/ML (1

ML)

2 $0

QL (60 per 30 days)

SOMATULINE DEPOT


MG/0.5 ML, 60 MG/0.2 ML, 90

MG/0.3 ML

2 $0

QL (1 per 28 days)

SOMAVERT SUBCUTANEOUS

RECON SOLN 10 MG, 15 MG, 20

MG, 25 MG, 30 MG

2 $0

SUPPRELIN LA IMPLANT KIT

50 MG (65 MCG/DAY) 2 $0

QL (1 per 360 days)

SYNAREL NASAL SPRAY,NON-

AEROSOL 2 MG/ML 2 $0

TRIPTODUR INTRAMUSCULAR

SUSPENSION FOR


2 $0

QL (1 per 168 days)

ZOMACTON SUBCUTANEOUS


PA

ZORBTIVE SUBCUTANEOUS


PA





177

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Progestins

DEPO-PROVERA

INTRAMUSCULAR

SUSPENSION 400 MG/ML

2 $0

QL (10 per 28 days)

hydroxyprogesterone caproate

intramuscular oil 250 mg/ml 1 $0

PA NSO

medroxyprogesterone intramuscular

suspension 150 mg/ml (Depo-Provera) 1 $0

QL (1 per 84 days)

medroxyprogesterone intramuscular

syringe 150 mg/ml (Depo-Provera) 2 $0

QL (1 per 84 days)

medroxyprogesterone oral tablet 10

mg, 2.5 mg, 5 mg (Provera) 1 $0

megestrol oral suspension 400

mg/10 ml (40 mg/ml) 1 $0

PA-HRM; AGE (Max

64 Years)

norethindrone acetate oral tablet 5

mg (Aygestin) 1 $0

progesterone in oil intramuscular

oil 50 mg/ml 1 $0

progesterone micronized oral

capsule 100 mg, 200 mg (Prometrium) 1 $0

Thyroid And Antithyroid Agents

levothyroxine intravenous recon

soln 100 mcg, 200 mcg, 500 mcg 2 $0

levothyroxine oral tablet 100 mcg,

112 mcg, 125 mcg, 137 mcg, 150

mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

(Euthyrox) 1 $0

levothyroxine oral tablet 300 mcg (Levo-T) 1 $0

liothyronine oral tablet 25 mcg, 5

mcg, 50 mcg (Cytomel) 1 $0

methimazole oral tablet 10 mg, 5 mg (Tapazole) 1 $0

propylthiouracil oral tablet 50 mg 1 $0

Immunological Agents



.



178

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Immunological Agents

ACTEMRA INTRAVENOUS


MG/ML), 400 MG/20 ML (20

MG/ML), 80 MG/4 ML (20

MG/ML)

2 $0

PA

ACTEMRA SUBCUTANEOUS


PA

ARCALYST SUBCUTANEOUS


azathioprine oral tablet 50 mg (Imuran) 1 $0 PA BvD

azathioprine sodium injection recon

soln 100 mg 1 $0

PA BvD

CARIMUNE NF NANOFILTERED


12 GRAM, 6 GRAM

2 $0

PA BvD

CIMZIA POWDER FOR

RECONST SUBCUTANEOUS KIT

400 MG (200 MG X 2 VIALS)

2 $0

PA

CIMZIA SUBCUTANEOUS

SYRINGE KIT 400 MG/2 ML (200

MG/ML X 2)

2 $0

PA

cyclosporine intravenous solution

250 mg/5 ml (Sandimmune) 1 $0

PA BvD

cyclosporine modified oral capsule

100 mg, 25 mg (Gengraf) 1 $0

PA BvD

cyclosporine modified oral capsule

50 mg 1 $0

PA BvD

cyclosporine modified oral solution

100 mg/ml (Gengraf) 1 $0

PA BvD

cyclosporine oral capsule 100 mg,

25 mg (Sandimmune) 1 $0

PA BvD





179

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

DUPIXENT SUBCUTANEOUS


PA

ENBREL SUBCUTANEOUS

RECON SOLN 25 MG (1 ML) 2 $0

PA

ENBREL SUBCUTANEOUS

SYRINGE 25 MG/0.5ML (0.51), 50

MG/ML (0.98 ML)

2 $0

PA

ENBREL SURECLICK

SUBCUTANEOUS PEN

INJECTOR 50 MG/ML (0.98 ML)

2 $0

PA

FLEBOGAMMA DIF

INTRAVENOUS SOLUTION 10

%, 5 %

2 $0

PA BvD

GAMASTAN S/D

INTRAMUSCULAR SOLUTION

15-18 % RANGE

2 $0

PA BvD

GAMMAGARD LIQUID

INJECTION SOLUTION 10 % 2 $0

PA BvD

GAMMAGARD S-D (IGA < 1

MCG/ML) INTRAVENOUS

RECON SOLN 10 GRAM, 5

GRAM

2 $0

PA BvD

GAMMAPLEX (WITH

SORBITOL) INTRAVENOUS

SOLUTION 5 %

2 $0

PA BvD

GAMMAPLEX INTRAVENOUS

SOLUTION 10 %, 10 % (100 ML),

10 % (200 ML)

2 $0

PA BvD

gengraf oral capsule 100 mg, 25

mg, 50 mg 1 $0

PA BvD

gengraf oral solution 100 mg/ml 1 $0 PA BvD



.



180

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUS

SYRINGE KIT 40 MG/0.8 ML, 40

MG/0.8 ML (6 PACK)

2 $0

PA

HUMIRA PEN CROHNS-UC-HS

START SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.8 ML

2 $0

PA

HUMIRA PEN PSOR-UVEITS-

ADOL HS SUBCUTANEOUS PEN


2 $0

PA

HUMIRA PEN SUBCUTANEOUS

PEN INJECTOR KIT 40 MG/0.8

ML

2 $0

PA

HUMIRA SUBCUTANEOUS


MG/0.4 ML, 40 MG/0.8 ML

2 $0

PA

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS


MG/0.8 ML-40 MG/0.4 ML

2 $0

PA

HUMIRA(CF) PEN CROHNS-UC-

HS SUBCUTANEOUS PEN


2 $0

PA

HUMIRA(CF) PEN PSOR-UV-

ADOL HS SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML-40

MG/0.4 ML

2 $0

PA

HUMIRA(CF) PEN

SUBCUTANEOUS PEN


2 $0

PA

HUMIRA(CF) SUBCUTANEOUS


MG/0.2 ML, 40 MG/0.4 ML

2 $0

PA





181

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

HYPERRAB (PF)


300 UNIT/ML

2 $0

HYPERRAB S/D (PF)


150 UNIT/ML

2 $0

HYQVIA SUBCUTANEOUS

SOLUTION 10 GRAM /100 ML

(10 %), 2.5 GRAM /25 ML (10 %),

20 GRAM /200 ML (10 %), 30

GRAM /300 ML (10 %), 5 GRAM

/50 ML (10 %)

2 $0

PA BvD

ILARIS (PF) SUBCUTANEOUS

RECON SOLN 150 MG/ML 2 $0

PA

ILARIS (PF) SUBCUTANEOUS


PA

ILUMYA SUBCUTANEOUS


PA

IMOGAM RABIES-HT (PF)


150 UNIT/ML

2 $0

INFLECTRA INTRAVENOUS


PA

KEDRAB (PF)


150 UNIT/ML

2 $0

KEVZARA SUBCUTANEOUS

PEN INJECTOR 150 MG/1.14 ML,

200 MG/1.14 ML

2 $0

PA; QL (2.28 per 28

days)

KEVZARA SUBCUTANEOUS


MG/1.14 ML

2 $0

PA; QL (2.28 per 28

days)

KINERET SUBCUTANEOUS


PA; QL (18.76 per 28

days)



.



182

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

leflunomide oral tablet 10 mg, 20

mg (Arava) 1 $0

mycophenolate mofetil hcl

intravenous recon soln 500 mg

(CellCept

Intravenous) 1 $0

PA BvD

mycophenolate mofetil oral capsule

250 mg (CellCept) 1 $0

PA BvD

mycophenolate mofetil oral


mg/ml

(CellCept) 1 $0

PA BvD

mycophenolate mofetil oral tablet

500 mg (CellCept) 1 $0

PA BvD

NULOJIX INTRAVENOUS


PA BvD

OCTAGAM INTRAVENOUS

SOLUTION 10 %, 5 % 2 $0

PA BvD

OLUMIANT ORAL TABLET 2

MG 2 $0

PA; QL (30 per 30

days)

ORENCIA (WITH MALTOSE)


250 MG

2 $0

PA

ORENCIA CLICKJECT

SUBCUTANEOUS AUTO-

INJECTOR 125 MG/ML

2 $0

PA

ORENCIA SUBCUTANEOUS

SYRINGE 125 MG/ML, 50 MG/0.4

ML, 87.5 MG/0.7 ML

2 $0

PA

OTEZLA ORAL TABLET 30 MG 2 $0 PA; QL (60 per 30

days)

OTEZLA STARTER ORAL


(4)-20 MG (4)-30 MG (47), 10 MG

(4)-20 MG (4)-30 MG(19)

2 $0

PA; QL (60 per 30

days)





183

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

OTREXUP (PF)

SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.4 ML, 12.5

MG/0.4 ML, 15 MG/0.4 ML, 17.5

MG/0.4 ML, 20 MG/0.4 ML, 22.5

MG/0.4 ML, 25 MG/0.4 ML

2 $0

PRIVIGEN INTRAVENOUS

SOLUTION 10 % 2 $0

PA BvD

PROGRAF INTRAVENOUS


PA BvD

RAPAMUNE ORAL SOLUTION 1

MG/ML 2 $0

PA BvD

RASUVO (PF) SUBCUTANEOUS

AUTO-INJECTOR 10 MG/0.2 ML,

12.5 MG/0.25 ML, 15 MG/0.3 ML,

17.5 MG/0.35 ML, 20 MG/0.4 ML,

22.5 MG/0.45 ML, 25 MG/0.5 ML,

30 MG/0.6 ML, 7.5 MG/0.15 ML

2 $0

REMICADE INTRAVENOUS


PA

RIDAURA ORAL CAPSULE 3

MG 2 $0

SIMPONI ARIA INTRAVENOUS

SOLUTION 12.5 MG/ML 2 $0

PA

SIMPONI SUBCUTANEOUS PEN

INJECTOR 100 MG/ML, 50

MG/0.5 ML

2 $0

PA

SIMPONI SUBCUTANEOUS


ML

2 $0

PA

sirolimus oral tablet 0.5 mg, 1 mg, 2

mg (Rapamune) 1 $0

PA BvD

STELARA INTRAVENOUS


PA



.



184

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

STELARA SUBCUTANEOUS


PA

STELARA SUBCUTANEOUS


MG/ML

2 $0

PA

tacrolimus oral capsule 0.5 mg, 1

mg, 5 mg (Prograf) 1 $0

PA BvD

TYSABRI INTRAVENOUS


PA; LA; QL (15 per 28

days)

XELJANZ ORAL TABLET 10

MG, 5 MG 2 $0

PA; QL (60 per 30

days)

XELJANZ XR ORAL TABLET


MG

2 $0

PA; QL (30 per 30

days)

ZORTRESS ORAL TABLET 0.25

MG, 0.5 MG, 0.75 MG, 1 MG 2 $0

PA BvD

Vaccines

ACTHIB (PF) INTRAMUSCULAR

RECON SOLN 10 MCG/0.5 ML 2 $0

ADACEL(TDAP

ADOLESN/ADULT)(PF)

INTRAMUSCULAR

SUSPENSION 2 LF-(2.5-5-3-5

MCG)-5LF/0.5 ML

2 $0

ADACEL(TDAP

ADOLESN/ADULT)(PF)


LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

2 $0

BCG VACCINE, LIVE (PF)

PERCUTANEOUS SUSPENSION

FOR RECONSTITUTION 50 MG

2 $0

PA BvD





185

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

BEXSERO INTRAMUSCULAR

SYRINGE 50-50-50-25 MCG/0.5

ML

2 $0

BOOSTRIX TDAP

INTRAMUSCULAR

SUSPENSION 2.5-8-5 LF-MCG-

LF/0.5ML

2 $0

BOOSTRIX TDAP


2.5-8-5 LF-MCG-LF/0.5ML

2 $0

DAPTACEL (DTAP PEDIATRIC)

(PF) INTRAMUSCULAR

SUSPENSION 15-10-5 LF-MCG-

LF/0.5ML

2 $0

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION 20 MCG/ML

2 $0

PA BvD

ENGERIX-B (PF)


MCG/ML

2 $0

PA BvD

ENGERIX-B PEDIATRIC (PF)


MCG/0.5 ML

2 $0

PA BvD

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION 0.5 ML

2 $0


GARDASIL 9 (PF)

INTRAMUSCULAR SYRINGE 0.5

ML

2 $0


HAVRIX (PF)

INTRAMUSCULAR

SUSPENSION 1,440 ELISA

UNIT/ML, 720 ELISA UNIT/0.5

ML

2 $0



.



186

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

HAVRIX (PF)


1,440 ELISA UNIT/ML, 720

ELISA UNIT/0.5 ML

2 $0

HIBERIX (PF)

INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML

2 $0

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON

SOLN 2.5 UNIT

2 $0

PA BvD

INFANRIX (DTAP) (PF)

INTRAMUSCULAR

SUSPENSION 25-58-10 LF-MCG-

LF/0.5ML

2 $0

INFANRIX (DTAP) (PF)


25-58-10 LF-MCG-LF/0.5ML

2 $0

IPOL INJECTION SUSPENSION

40-8-32 UNIT/0.5 ML 2 $0

IPOL INJECTION SYRINGE 40-8-

32 UNIT/0.5 ML 2 $0

IXIARO (PF) INTRAMUSCULAR


KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10

LF/0.5 ML

2 $0

KINRIX (PF) INTRAMUSCULAR

SYRINGE 25 LF-58 MCG-10

LF/0.5 ML

2 $0

MENACTRA (PF)

INTRAMUSCULAR SOLUTION 4

MCG/0.5 ML

2 $0





187

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5

MCG/0.5 ML

2 $0

M-M-R II (PF) SUBCUTANEOUS

RECON SOLN 1,000-12,500

TCID50/0.5 ML

2 $0

PEDIARIX (PF)


MCG-25LF-25 MCG-10LF/0.5 ML

2 $0

PEDVAX HIB (PF)


7.5 MCG/0.5 ML

2 $0

PENTACEL (PF)

INTRAMUSCULAR KIT 15 LF

UNIT-20 MCG-5 LF/0.5 ML

2 $0

PENTACEL DTAP-IPV COMPNT

(PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5

LF UNIT/0.5ML

2 $0

PROQUAD (PF)


FOR RECONSTITUTION

10EXP3-4.3-3- 3.99 TCID50/0.5

2 $0

QUADRACEL (PF)

INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5

LF UNIT/0.5ML

2 $0

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 2.5 UNIT

2 $0

PA BvD



.



188

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

RECOMBIVAX HB (PF)

INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40

MCG/ML, 5 MCG/0.5 ML

2 $0

PA BvD

RECOMBIVAX HB (PF)


MCG/ML, 5 MCG/0.5 ML

2 $0

PA BvD

ROTARIX ORAL SUSPENSION

FOR RECONSTITUTION 10EXP6

CCID50/ML

2 $0

ROTATEQ VACCINE ORAL

SOLUTION 2 ML 2 $0

SHINGRIX (PF)

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 50 MCG/0.5

ML

2 $0

QL (2 per 365 days)

TENIVAC (PF)

INTRAMUSCULAR

SUSPENSION 5 LF UNIT- 2 LF

UNIT/0.5ML

2 $0

TENIVAC (PF)

INTRAMUSCULAR SYRINGE 5-

2 LF UNIT/0.5 ML

2 $0

TETANUS,DIPHTHERIA TOX

PED(PF) INTRAMUSCULAR

SUSPENSION 5-25 LF UNIT/0.5

ML

2 $0

TETANUS-DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

SUSPENSION 2-2 LF UNIT/0.5

ML

2 $0





189

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

TICE BCG INTRAVESICAL

SUSPENSION FOR


2 $0

TRUMENBA INTRAMUSCULAR


TWINRIX (PF)


720 ELISA UNIT- 20 MCG/ML

2 $0

TYPHIM VI INTRAMUSCULAR

SOLUTION 25 MCG/0.5 ML 2 $0

TYPHIM VI INTRAMUSCULAR


VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML, 50

UNIT/ML

2 $0

VAQTA (PF) INTRAMUSCULAR

SYRINGE 25 UNIT/0.5 ML, 50

UNIT/ML

2 $0

VARIVAX (PF)


FOR RECONSTITUTION 1,350

UNIT/0.5 ML

2 $0

QL (2 per 365 days)

YF-VAX (PF) SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION 10 EXP4.74

UNIT/0.5 ML

2 $0

ZOSTAVAX (PF)


FOR RECONSTITUTION 19,400

UNIT/0.65 ML

2 $0

QL (1 per 365 days)

Inflammatory Bowel Disease

Agents



.



190

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Inflammatory Bowel Disease

Agents

alosetron oral tablet 0.5 mg, 1 mg (Lotronex) 1 $0

APRISO ORAL


24HR 0.375 GRAM

2 $0

balsalazide oral capsule 750 mg (Colazal) 1 $0

budesonide oral

capsule,delayed,extend.release 3 mg (Entocort EC) 1 $0

CANASA RECTAL

SUPPOSITORY 1,000 MG 2 $0

colocort rectal enema 100 mg/60 ml 1 $0

DELZICOL ORAL CAPSULE

(WITH DEL REL TABLETS) 400

MG

2 $0

DIPENTUM ORAL CAPSULE 250

MG 2 $0

ST

hydrocortisone rectal enema 100

mg/60 ml (Colocort) 1 $0

LIALDA ORAL

TABLET,DELAYED RELEASE

(DR/EC) 1.2 GRAM

1 $0

mesalamine oral tablet,delayed

release (dr/ec) 800 mg (Asacol HD) 2 $0

sulfasalazine oral tablet 500 mg (Azulfidine) 1 $0

sulfasalazine oral tablet,delayed

release (dr/ec) 500 mg

(Azulfidine EN-

tabs) 1 $0

UCERIS RECTAL FOAM 2

MG/ACTUATION 2 $0

Irrigating Solutions

Irrigating Solutions





191

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

acetic acid irrigation solution 0.25

% 2 $0

LACTATED RINGERS

IRRIGATION SOLUTION 2 $0

sodium chloride irrigation solution

0.9 %

(Aqua Care

Sodium Chloride) 2 $0

water for irrigation, sterile

irrigation solution

(Aqua Care Sterile

Water) 2 $0

Metabolic Bone Disease

Agents

Metabolic Bone Disease Agents

alendronate oral tablet 10 mg, 5 mg 1 $0

alendronate oral tablet 35 mg 1 $0 QL (4 per 28 days)

alendronate oral tablet 70 mg (Fosamax) 1 $0 QL (4 per 28 days)

calcitonin (salmon) nasal

spray,non-aerosol 200

unit/actuation

1 $0


calcitriol intravenous solution 1

mcg/ml 1 $0

calcitriol oral capsule 0.25 mcg, 0.5

mcg (Rocaltrol) 1 $0

calcitriol oral solution 1 mcg/ml (Rocaltrol) 1 $0

doxercalciferol intravenous solution

4 mcg/2 ml (Hectorol) 1 $0

FORTEO SUBCUTANEOUS PEN

INJECTOR 20 MCG/DOSE - 600

MCG/2.4 ML

2 $0

PA; QL (2.4 per 28

days)

ibandronate intravenous solution 3

mg/3 ml 1 $0

QL (3 per 84 days)

ibandronate intravenous syringe 3

mg/3 ml (Boniva) 1 $0

QL (3 per 84 days)

ibandronate oral tablet 150 mg (Boniva) 1 $0 QL (1 per 28 days)



.



192

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

MIACALCIN INJECTION


NATPARA SUBCUTANEOUS

CARTRIDGE 100 MCG/DOSE, 25

MCG/DOSE, 50 MCG/DOSE, 75

MCG/DOSE

2 $0


paricalcitol hemodialysis port

injection solution 2 mcg/ml 1 $0

PARICALCITOL

HEMODIALYSIS PORT

INJECTION SOLUTION 5

MCG/ML

1 $0

paricalcitol oral capsule 1 mcg, 2

mcg (Zemplar) 1 $0

paricalcitol oral capsule 4 mcg 1 $0

PROLIA SUBCUTANEOUS


QL (1 per 180 days)

RAYALDEE ORAL


24 HR 30 MCG

2 $0

QL (60 per 30 days)

SENSIPAR ORAL TABLET 30

MG, 60 MG 2 $0

QL (60 per 30 days)

SENSIPAR ORAL TABLET 90

MG 2 $0


TYMLOS SUBCUTANEOUS PEN

INJECTOR 80 MCG (3,120

MCG/1.56 ML)

2 $0

PA; QL (1.56 per 30

days)

zoledronic acid intravenous recon

soln 4 mg 1 $0

zoledronic acid intravenous solution

4 mg/5 ml (Zometa) 1 $0

zoledronic acid-mannitol-water

intravenous piggyback 5 mg/100 ml (Reclast) 1 $0






193

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

zoledronic ac-mannitol-0.9nacl


ZOMETA INTRAVENOUS

PIGGYBACK 4 MG/100 ML 2 $0

Miscellaneous Therapeutic

Agents

Miscellaneous Therapeutic Agents

ACTIMMUNE SUBCUTANEOUS

SOLUTION 100 MCG/0.5 ML 2 $0

amifostine crystalline intravenous

recon soln 500 mg (Ethyol) 1 $0

BENLYSTA INTRAVENOUS


PA

BENLYSTA SUBCUTANEOUS

AUTO-INJECTOR 200 MG/ML 2 $0


BENLYSTA SUBCUTANEOUS



CETYLEV ORAL TABLET,

EFFERVESCENT 2.5 GRAM, 500

MG

2 $0

CYSTADANE ORAL POWDER 1

GRAM/1.7 ML 2 $0

droperidol injection solution 2.5

mg/ml 1 $0

ELMIRON ORAL CAPSULE 100

MG 2 $0

ENDARI ORAL POWDER IN

PACKET 5 GRAM 2 $0

PA; QL (180 per 30

days)

ergoloid oral tablet 1 mg 1 $0

EXONDYS 51 INTRAVENOUS


PA; LA

fomepizole intravenous solution 1

gram/ml 1 $0



.



194

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

guanidine oral tablet 125 mg 2 $0

hydroxyzine pamoate oral capsule

100 mg 1 $0

PA-HRM; AGE (Max

64 Years)

hydroxyzine pamoate oral capsule

25 mg, 50 mg (Vistaril) 1 $0

PA-HRM; AGE (Max

64 Years)

KEVEYIS ORAL TABLET 50 MG 2 $0 PA; QL (120 per 30

days)

leucovorin calcium injection recon

soln 100 mg, 200 mg, 350 mg, 50

mg, 500 mg

1 $0

leucovorin calcium injection


leucovorin calcium oral tablet 10

mg, 15 mg, 25 mg, 5 mg 1 $0

levocarnitine (with sugar) oral

solution 100 mg/ml (Carnitor) 1 $0

levocarnitine oral tablet 330 mg (Carnitor) 1 $0

LEVOLEUCOVORIN CALCIUM


175 MG

2 $0

levoleucovorin calcium intravenous

recon soln 50 mg (Fusilev) 1 $0

mesna intravenous solution 100

mg/ml (Mesnex) 1 $0

MESNEX ORAL TABLET 400

MG 2 $0

MESTINON ORAL SYRUP 60

MG/5 ML 2 $0

MINERAL OIL HEAVY * (Mineral Oil

Heavy) 4 $0

PROGLYCEM ORAL






195

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

pyridostigmine bromide oral tablet

60 mg (Mestinon) 1 $0

RENFLEXIS INTRAVENOUS


PA

TAKHZYRO SUBCUTANEOUS


MG/ML)

2 $0

PA

THALOMID ORAL CAPSULE 100

MG, 150 MG, 200 MG, 50 MG 2 $0

PA NSO; QL (60 per

30 days)

THIOLA ORAL TABLET 100 MG 2 $0

TOTECT INTRAVENOUS


TYBOST ORAL TABLET 150 MG 2 $0 QL (30 per 30 days)

VISTOGARD ORAL GRANULES

IN PACKET 10 GRAM 2 $0

QL (24 per 14 days)

XURIDEN ORAL GRANULES IN

PACKET 2 GRAM 2 $0

PA; QL (120 per 30

days)

Ophthalmic Agents

Antiglaucoma Agents

acetazolamide oral capsule,

extended release 500 mg 1 $0

acetazolamide oral tablet 125 mg,

250 mg 1 $0

acetazolamide sodium injection


ALPHAGAN P OPHTHALMIC

(EYE) DROPS 0.1 % 2 $0

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION 1 % 2 $0

brimonidine ophthalmic (eye) drops

0.2 % 1 $0

carteolol ophthalmic (eye) drops 1

% 1 $0



.



196

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

COMBIGAN OPHTHALMIC

(EYE) DROPS 0.2-0.5 % 2 $0

dorzolamide ophthalmic (eye) drops

2 % (Trusopt) 1 $0

dorzolamide-timolol ophthalmic

(eye) drops 22.3-6.8 mg/ml (Cosopt) 1 $0

latanoprost ophthalmic (eye) drops

0.005 % (Xalatan) 1 $0

levobunolol ophthalmic (eye) drops

0.5 % 1 $0

LUMIGAN OPHTHALMIC (EYE)

DROPS 0.01 % 2 $0


metipranolol ophthalmic (eye) drops

0.3 % 1 $0

pilocarpine hcl ophthalmic (eye)

drops 1 %, 2 %, 4 % (Isopto Carpine) 1 $0

RHOPRESSA OPHTHALMIC

(EYE) DROPS 0.02 % 2 $0


SIMBRINZA OPHTHALMIC

(EYE) DROPS,SUSPENSION 1-0.2

%

2 $0

timolol maleate ophthalmic (eye)

drops 0.25 %, 0.5 % (Timoptic) 1 $0

timolol maleate ophthalmic (eye) gel

forming solution 0.25 %, 0.5 % (Timoptic-XE) 1 $0

TRAVATAN Z OPHTHALMIC

(EYE) DROPS 0.004 % 2 $0


Replacement Preparations

Replacement Preparations

calcitrate 200 mg (950 mg) tab 200

mg (950 mg) * 4 $0





197

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

calcium 500+d tablet chew 500

mg(1,250mg) -400 unit * (Calcium 500 + D) 4 $0

calcium 600 + vit d 400 softgl 600

mg(1,500mg) -400 unit *

(Calcium 600 with

Vitamin D3) 4 $0

calcium 600 + vit d softgel 600

mg(1,500mg) -500 unit * 4 $0

calcium 600 mg tablet 600 mg

calcium (1,500 mg) * 4 $0

calcium 600+d softgel 600 mg

calcium- 200 unit * 4 $0

calcium 600-vit d3 500 softgel rapid

release, sftgl 600 mg(1,500mg) -500

unit *

(Calcium 600 with

Vitamin D3) 4 $0

calcium carb 1,250 mg/5 ml sus 500

mg/5 ml (1,250 mg/5 ml) * 4 $0

calcium carbonate 648 mg tab 260

mg calcium (648 mg) * 4 $0

calcium chloride intravenous

solution 100 mg/ml (10 %) 1 $0

calcium chloride intravenous

syringe 100 mg/ml (10 %) 1 $0

calcium cit 315-vit d3 250 tab 315-

250 mg-unit *

(Calcitrate-Vitamin

D) 4 $0

calcium citrate - vit d caplet caplet,

coated 315-200 mg-unit *

(Calcium Citrate +

D) 4 $0

calcium citrate + caplet

caplet,coated 315-200 mg-unit * 4 $0

calcium gluconate 500 mg tab 45

mg (500 mg) * 4 $0

citracal + d maximum caplet 315-

250 mg-unit * 4 $0

citrus calcium + d tablet 315-250

mg-unit * 4 $0



.



198

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs calcium citrate-vit d tab 315-250

mg-unit *

(Calcitrate-Vitamin

D) 4 $0

cvs magnesium 250 mg tablet 250

mg * 4 $0

cvs pediatric electrolyte soln * 4 $0

cvs pediatric electrolyte soln a/f, p/f

* 4 $0

cvs pediatric electrolyte soln

dye/free, strawberry * 4 $0

d10 %-0.45 % sodium chloride


d5 % and 0.9 % sodium chloride




electrolyte-48 in d5w intravenous

parenteral solution 2 $0

eq calcium citrate-d tablet

s/f,p/f,gluten-free 315-250 mg-unit *

(Calcitrate-Vitamin

D) 4 $0

IONOSOL-B IN D5W


SOLUTION 5 %

2 $0

IONOSOL-MB IN D5W


SOLUTION 5 %

2 $0

ISOLYTE-P IN 5 % DEXTROSE


SOLUTION 5 %

2 $0

ISOLYTE-S INTRAVENOUS

PARENTERAL SOLUTION 2 $0

klor-con m10 oral tablet,er

particles/crystals 10 meq 1 $0





199

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use





klor-con sprinkle oral capsule,

extended release 10 meq, 8 meq 1 $0

liquid calcium 600-vit d3 sfgl 600

mg(1,500mg) -400 unit * 4 $0

liquid calcium 600-vit d3 sfgl

softgel,p/f,gluten-f 600 mg(1,500mg)

-500 unit *

4 $0

liquid calcium with vitamin d

softgel, s/f, p/f 600 mg calcium- 200

unit *

4 $0

mag64 dr 64 mg tablet 64 mg * 4 $0

mag-g 500 mg tablet 27 mg

magnesium (500 mg) * 4 $0

magnesium 250 mg tablet 250 mg * 4 $0

magnesium 300 mg capsule 300 mg

* 4 $0

magnesium chloride ec 64 mg tb 64

mg * (Mag 64) 4 $0

magnesium sulfate in d5w

intravenous piggyback 1 gram/100

ml

1 $0

magnesium sulfate in water


gram/500 ml (4 %), 40 gram/1,000

ml (4 %)

1 $0

PA BvD

magnesium sulfate in water

intravenous piggyback 2 gram/50 ml

(4 %), 4 gram/100 ml (4 %), 4

gram/50 ml (8 %)

1 $0

PA BvD



.



200

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

magnesium sulfate injection solution

4 meq/ml (50 %) 1 $0

PA BvD

magnesium sulfate injection syringe

4 meq/ml 1 $0

PA BvD

natural calcium 500 mg tablet 500

mg calcium (1,250 mg) * 4 $0

NORMOSOL-M IN 5 %

DEXTROSE INTRAVENOUS

PARENTERAL SOLUTION

2 $0

NORMOSOL-R IV SOLUTION

L/F, SINGLE-USE 2 $0

NORMOSOL-R PH 7.4


SOLUTION

2 $0

oralyte freezer pops * 4 $0

oralyte solution * 4 $0

oysco-500 tablet 500 mg calcium

(1,250 mg) * 4 $0

oyster shell calcium 500 mg tb

500mg elemental ca 500 mg calcium

(1,250 mg) *

4 $0

PLASMA-LYTE 148


SOLUTION

2 $0

PLASMA-LYTE A


SOLUTION

2 $0

PLASMA-LYTE-56 IN 5 %

DEXTROSE INTRAVENOUS


2 $0

potassium chlorid-d5-0.45%nacl


meq/l, 30 meq/l, 40 meq/l

2 $0

PA BvD





201

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use



meq/l

2 $0

PA BvD

potassium chloride in 0.9%nacl


meq/l, 40 meq/l

2 $0

PA BvD

potassium chloride in 5 % dex


meq/l, 30 meq/l, 40 meq/l

2 $0

PA BvD

potassium chloride in lr-d5


meq/l, 40 meq/l

2 $0

potassium chloride in water

intravenous piggyback 10 meq/100

ml, 10 meq/50 ml, 20 meq/100 ml,

20 meq/50 ml, 30 meq/100 ml, 40

meq/100 ml

2 $0

PA BvD

potassium chloride intravenous

solution 2 meq/ml 1 $0

PA BvD

potassium chloride intravenous

solution 2 meq/ml (20 ml) 1 $0

PA BvD

potassium chloride oral capsule,

extended release 10 meq 1 $0

potassium chloride oral capsule,

extended release 8 meq

(Klor-Con

Sprinkle) 1 $0

potassium chloride oral liquid 20

meq/15 ml, 40 meq/15 ml 1 $0

potassium chloride oral tablet

extended release 10 meq, 20 meq, 8

meq

(K-Tab) 1 $0

potassium chloride oral tablet,er

particles/crystals 10 meq (Klor-Con M10) 1 $0

potassium chloride oral tablet,er

particles/crystals 20 meq (Klor-Con M20) 1 $0



.



202

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

potassium chloride-0.45 % nacl


meq/l

1 $0

potassium chloride-d5-0.2%nacl


meq/l, 20 meq/l, 30 meq/l, 40 meq/l

2 $0



meq/l

2 $0



meq/l, 40 meq/l

2 $0

potassium citrate oral tablet

extended release 10 meq (1,080 mg) (Urocit-K 10) 1 $0


extended release 15 meq (Urocit-K 15) 1 $0


extended release 5 meq (540 mg) (Urocit-K 5) 1 $0

ra calcium 600 mg tablet p/f 600 mg

calcium (1,500 mg) * 4 $0

ra pediatric electrolyte soln a/f * 4 $0

ra pediatric freezer pops * 4 $0

sm calcium citrate-vit d cplt caplet,

gluten-free 315-250 mg-unit *

(Calcitrate-Vitamin

D) 4 $0

sm magnesium 250 mg tablet 250

mg * 4 $0

sm pediatric electrolyte soln * 4 $0

sodium acetate intravenous solution

2 meq/ml 1 $0

sodium chloride 0.45 % intravenous

parenteral solution 0.45 % 1 $0

sodium chloride 0.9 % intravenous

parenteral solution 1 $0





203

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sodium chloride intravenous

parenteral solution 2.5 meq/ml 2 $0

sodium lactate intravenous solution

5 meq/ml 2 $0

sodium phosphate intravenous

solution 3 mmol/ml 1 $0

Respiratory Tract Agents

Anti-Inflammatories, Inhaled

Corticosteroids

ADVAIR DISKUS INHALATION

BLISTER WITH DEVICE 100-50

MCG/DOSE, 250-50 MCG/DOSE,

500-50 MCG/DOSE

2 $0

QL (60 per 30 days)

ADVAIR HFA INHALATION

HFA AEROSOL INHALER 115-21

MCG/ACTUATION, 230-21


MCG/ACTUATION

2 $0

QL (12 per 28 days)

ARNUITY ELLIPTA


DEVICE 100 MCG/ACTUATION,

200 MCG/ACTUATION, 50

MCG/ACTUATION

2 $0

QL (30 per 30 days)

BREO ELLIPTA INHALATION

BLISTER WITH DEVICE 100-25

MCG/DOSE, 200-25 MCG/DOSE

2 $0

QL (60 per 30 days)

budesonide inhalation suspension

for nebulization 0.25 mg/2 ml, 0.5

mg/2 ml, 1 mg/2 ml

(Pulmicort) 1 $0

PA BvD

DULERA INHALATION HFA

AEROSOL INHALER 100-5


MCG/ACTUATION

2 $0

QL (13 per 28 days)



.



204

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

FLOVENT 100 MCG DISKUS 100

MCG/ACTUATION 2 $0

QL (60 per 30 days)

FLOVENT 250 MCG DISKUS 250

MCG/ACTUATION 2 $0


FLOVENT DISKUS


DEVICE 100 MCG/ACTUATION,

50 MCG/ACTUATION

2 $0

QL (60 per 30 days)

FLOVENT DISKUS


DEVICE 250 MCG/ACTUATION

2 $0


FLOVENT HFA INHALATION

HFA AEROSOL INHALER 110

MCG/ACTUATION

2 $0

QL (12 per 28 days)



MCG/ACTUATION

2 $0

QL (24 per 28 days)



MCG/ACTUATION

2 $0


QVAR INHALATION AEROSOL

40 MCG/ACTUATION, 80

MCG/ACTUATION

2 $0


QVAR REDIHALER

INHALATION HFA AEROSOL

BREATH ACTIVATED 40

MCG/ACTUATION, 80

MCG/ACTUATION

2 $0


SYMBICORT 160-4.5 MCG

INHALER 60 INHALATIONS 160-

4.5 MCG/ACTUATION

2 $0

QL (12 per 30 days)





205

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

SYMBICORT INHALATION HFA

AEROSOL INHALER 160-4.5

MCG/ACTUATION

2 $0


SYMBICORT INHALATION HFA

AEROSOL INHALER 80-4.5

MCG/ACTUATION

2 $0

QL (11 per 25 days)

Antileukotrienes

montelukast oral tablet 10 mg (Singulair) 1 $0

montelukast oral tablet,chewable 4

mg, 5 mg (Singulair) 1 $0

zafirlukast oral tablet 10 mg, 20 mg (Accolate) 1 $0

Bronchodilators

albuterol sulfate inhalation solution

for nebulization 0.63 mg/3 ml, 1.25

mg/3 ml, 2.5 mg /3 ml (0.083 %), 5

mg/ml

1 $0

PA BvD

albuterol sulfate oral syrup 2 mg/5

ml 1 $0

albuterol sulfate oral tablet

extended release 12 hr 4 mg, 8 mg 1 $0

ANORO ELLIPTA INHALATION

BLISTER WITH DEVICE 62.5-25

MCG/ACTUATION

2 $0

QL (60 per 30 days)

ATROVENT HFA INHALATION


MCG/ACTUATION

2 $0


COMBIVENT RESPIMAT

INHALATION MIST 20-100

MCG/ACTUATION

2 $0

QL (8 per 30 days)

INCRUSE ELLIPTA


DEVICE 62.5 MCG/ACTUATION

2 $0

ipratropium bromide inhalation

solution 0.02 % 1 $0

PA BvD



.



206

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

levalbuterol tartrate inhalation hfa

aerosol inhaler 45 mcg/actuation (Xopenex HFA) 2 $0

QL (30 per 30 days)

LONHALA MAGNAIR STARTER

INHALATION SOLUTION FOR

NEBULIZATION 25 MCG/ML

2 $0

QL (60 per 30 days)

metaproterenol oral syrup 10 mg/5

ml 1 $0

metaproterenol oral tablet 10 mg,

20 mg 1 $0

PROAIR HFA INHALATION HFA

AEROSOL INHALER 90

MCG/ACTUATION

2 $0

PROAIR RESPICLICK

INHALATION AEROSOL

POWDR BREATH ACTIVATED

90 MCG/ACTUATION

2 $0

SEREVENT DISKUS


DEVICE 50 MCG/DOSE

2 $0

QL (60 per 30 days)

SPIRIVA RESPIMAT

INHALATION MIST 1.25

MCG/ACTUATION

2 $0

SPIRIVA RESPIMAT

INHALATION MIST 2.5

MCG/ACTUATION

2 $0

SPIRIVA WITH HANDIHALER

INHALATION CAPSULE,

W/INHALATION DEVICE 18

MCG

2 $0

STIOLTO RESPIMAT

INHALATION MIST 2.5-2.5

MCG/ACTUATION

2 $0

QL (4 per 28 days)





207

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

STRIVERDI RESPIMAT

INHALATION MIST 2.5

MCG/ACTUATION

2 $0

QL (4 per 28 days)

terbutaline oral tablet 2.5 mg, 5 mg 1 $0

terbutaline subcutaneous solution 1

mg/ml 1 $0

theophylline oral solution 80 mg/15

ml 1 $0

theophylline oral tablet extended

release 12 hr 100 mg, 200 mg, 300

mg

(Theochron) 1 $0


release 12 hr 450 mg 1 $0


release 24 hr 400 mg, 600 mg 1 $0

TRELEGY ELLIPTA


DEVICE 100-62.5-25 MCG

2 $0

Respiratory Tract Agents, Other

acetylcysteine intravenous solution

200 mg/ml (20 %) (Acetadote) 1 $0

PA BvD

acetylcysteine solution 100 mg/ml

(10 %), 200 mg/ml (20 %) 1 $0

PA BvD

CINQAIR INTRAVENOUS


PA

cromolyn inhalation solution for

nebulization 20 mg/2 ml 1 $0

PA BvD

cromolyn sodium nasal spray 5.2

mg/spray (4 %) *

(Nasal Allergy

Symptom Control) 4 $0

DALIRESP ORAL TABLET 250

MCG 2 $0

QL (28 per 28 days)

DALIRESP ORAL TABLET 500

MCG 2 $0

QL (30 per 30 days)



.



208

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ESBRIET ORAL CAPSULE 267

MG 2 $0

PA; QL (270 per 30

days)

ESBRIET ORAL TABLET 267 MG 2 $0 PA; QL (270 per 30

days)

ESBRIET ORAL TABLET 801 MG 2 $0 PA; QL (90 per 30

days)

FASENRA SUBCUTANEOUS



KALYDECO ORAL GRANULES

IN PACKET 50 MG, 75 MG 2 $0

PA; QL (56 per 28

days)

KALYDECO ORAL TABLET 150

MG 2 $0

PA; QL (56 per 28

days)

NUCALA SUBCUTANEOUS



days)

OFEV ORAL CAPSULE 100 MG,

150 MG 2 $0

PA; QL (60 per 30

days)

ORKAMBI ORAL GRANULES IN

PACKET 100-125 MG, 150-188

MG

2 $0

PA; QL (56 per 28

days)

ORKAMBI ORAL TABLET 100-

125 MG, 200-125 MG 2 $0

PA; QL (120 per 30

days)

PROLASTIN-C INTRAVENOUS

RECON SOLN 1,000 MG 2 $0

PA BvD

sodium chloride 0.9% inhal vl u-d,

suv, p/f (rx) 0.9 % * 3 $0

SYMDEKO ORAL TABLETS,

SEQUENTIAL 100-150 MG (D)/

150 MG (N)

2 $0

PA; QL (56 per 28

days)

XOLAIR SUBCUTANEOUS


PA

XOLAIR SUBCUTANEOUS


ML

2 $0

PA





209

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

baclofen oral tablet 10 mg, 20 mg 1 $0

carisoprodol oral tablet 350 mg (Soma) 1 $0

PA-HRM; QL (120 per

30 days); AGE (Max

64 Years)

chlorzoxazone oral tablet 500 mg 1 $0 PA-HRM; AGE (Max

64 Years)

cyclobenzaprine oral tablet 10 mg, 5

mg 1 $0

PA-HRM; AGE (Max

64 Years)

dantrolene oral capsule 100 mg 1 $0

dantrolene oral capsule 25 mg, 50

mg (Dantrium) 1 $0

methocarbamol oral tablet 500 mg (Robaxin) 1 $0 PA-HRM; AGE (Max

64 Years)

methocarbamol oral tablet 750 mg (Robaxin-750) 1 $0 PA-HRM; AGE (Max

64 Years)

revonto intravenous recon soln 20

mg 1 $0

tizanidine oral tablet 2 mg 1 $0

tizanidine oral tablet 4 mg (Zanaflex) 1 $0

Sleep Disorder Agents

Sleep Disorder Agents

armodafinil oral tablet 150 mg, 200

mg, 250 mg, 50 mg (Nuvigil) 1 $0

PA

BELSOMRA ORAL TABLET 10

MG, 15 MG, 20 MG, 5 MG 2 $0

QL (30 per 30 days)



.



210

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

eszopiclone oral tablet 1 mg, 2 mg,

3 mg (Lunesta) 1 $0

PA-HRM; (High Risk




with over 90 days

cumulative use with

any non-

benzodiazepine


per 30 days); AGE

(Max 64 Years)

HETLIOZ ORAL CAPSULE 20

MG 2 $0

PA; QL (30 per 30

days)

SILENOR ORAL TABLET 3 MG,

6 MG 2 $0

QL (30 per 30 days)

XYREM ORAL SOLUTION 500

MG/ML 2 $0

LA; QL (540 per 30

days)

zaleplon oral capsule 10 mg, 5 mg 1 $0

PA-HRM; (High Risk




with over 90 days

cumulative use with

any non-

benzodiazepine


per 30 days); AGE

(Max 64 Years)





211

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

zolpidem oral tablet 10 mg, 5 mg (Ambien) 1 $0

PA-HRM; (High Risk




with over 90 days

cumulative use with

any non-

benzodiazepine


per 30 days); AGE

(Max 64 Years)

Vasodilating Agents

Vasodilating Agents

ADCIRCA ORAL TABLET 20 MG 2 $0 PA; QL (60 per 30

days)

ADEMPAS ORAL TABLET 0.5

MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG 2 $0

PA; QL (90 per 30

days)

epoprostenol (glycine) intravenous

recon soln 0.5 mg, 1.5 mg (Flolan) 1 $0

PA

LETAIRIS ORAL TABLET 10

MG, 5 MG 2 $0

PA; QL (30 per 30

days)

OPSUMIT ORAL TABLET 10 MG 2 $0 PA; QL (30 per 30

days)

ORENITRAM ORAL TABLET

EXTENDED RELEASE 0.125 MG,

0.25 MG, 1 MG, 2.5 MG, 5 MG

2 $0

PA

REMODULIN INJECTION


MG/ML, 2.5 MG/ML, 5 MG/ML

2 $0

PA

sildenafil (antihypertensive)

intravenous solution 10 mg/12.5 ml (Revatio) 1 $0

PA; QL (37.5 per 1

day)

sildenafil (antihypertensive) oral

tablet 20 mg (Revatio) 1 $0

PA; QL (90 per 30

days)



.



212

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

tadalafil (antihypertensive) oral

tablet 20 mg (Adcirca) 1 $0

PA; QL (60 per 30

days)

TRACLEER ORAL TABLET 125

MG, 62.5 MG 2 $0


days)

TRACLEER ORAL TABLET FOR

SUSPENSION 32 MG 2 $0

PA; QL (112 per 28

days)

TYVASO INHALATION

SOLUTION FOR

NEBULIZATION 1.74 MG/2.9 ML

(0.6 MG/ML)

2 $0

PA

UPTRAVI ORAL TABLET 1,000

MCG, 1,200 MCG, 1,400 MCG,

1,600 MCG, 400 MCG, 600 MCG,

800 MCG

2 $0

PA; QL (60 per 30

days)

UPTRAVI ORAL TABLET 200

MCG 2 $0

PA; QL (240 per 30

days)

UPTRAVI ORAL

TABLETS,DOSE PACK 200 MCG

(140)- 800 MCG (60)

2 $0

PA; QL (400 per 365

days)

Vitamins And Minerals

Vitamins And Minerals

a thru z advanced formula tab

gluten-free 18-400 mg-mcg * 4 $0

a thru z advanced formula tab new

formula * 4 $0

a thru z advanced formula tab w/

lutein & lycopene 18-500-300-250

mg-mcg-mcg-mcg *

4 $0

a thru z select 50 plus tablet

advanced formula 0.4-300-250 mg-

mcg-mcg *

4 $0

a thru z select men 50+ tablet 300-

600-300 mcg * 4 $0





213

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

a thru z select multivit tab 500-300-

250 mcg * 4 $0

a thru z select multivit tab iron-free,

50+ form 0.4-300-250 mg-mcg-mcg

*

4 $0

a thru z select tablet new

formulation * 4 $0

a thru z select women's tablet * 4 $0

abc plus tablet 0.4-300-250 mg-

mcg-mcg * 4 $0

adult multi gummies 200 mcg * 4 $0

adult multivitamin extra d3 200 mcg

* 4 $0

adult multivitamin gummies

assorted flavors 200 mcg * 4 $0

adult one daily gummies 200 mcg * 4 $0

adults 50 plus daily formula 0.4-

300-250 mg-mcg-mcg * 4 $0

adults 50 plus multivitamin tb 0.4-

300-250 mg-mcg-mcg * 4 $0

animal chews tablet * 4 $0

apatate forte liquid * 4 $0

b complex capsule * (Super B-50

Complex) 4 $0

b complex formula #1 tablet * 4 $0

b complex tablet * 4 $0

b-12 500 mcg tablet 500 mcg * 4 $0

b-12 dots 500 mcg tablet 500 mcg * 4 $0

baby ddrops 400 unit/drop 400

unit/drop * 4 $0

baby vitamin d3 400 unit/drop 400

unit/drop * (Baby Ddrops) 4 $0



.



214

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

baby's super daily d3 400 unit 400

unit/drop * 4 $0

balance b-100 tablet * 4 $0

balance b-50 tablet * 4 $0

balanced b-100 tablet 100 mg * 4 $0

balanced b-50 tablet * 4 $0

b-complex plus vitamin c cplt * (Super B Complex-

Vitamin C) 4 $0

b-complex tablet 0.4 mg * (B Complex 100) 4 $0

b-complex with b12 tablet * 4 $0

b-complex with c tablet * (Super B Complex-

Vitamin C) 4 $0

bee-zee tablet * 4 $0

biosupp liquid * 4 $0

biotin 300 mcg tablet s/f,p/f,lactose-

free 300 mcg * 4 $0

biovol syrup * 4 $0

c-500 mg tablet 500 mg * 4 $0

calcidol drops 8,000 unit/ml * 4 $0

calcium 1,000 + d3 caplet 1,000

mg(2,500 mg)-800 unit * 4 $0

calcium 250-vit d3 125 tablet 250-

125 mg-unit *

(Oyster Shell +

D3) 4 $0

calcium 500-vit d3 600 tablet 500mg

(1,250mg) -600 unit * (Os-Cal 500 + D3) 4 $0

calcium 600 + vit d 400 caplet s/f,

p/f, caplet 600 mg(1,500mg) -400

unit *

4 $0

calcium 600 + vit d tablet 600-125

mg-unit * 4 $0

calcium 600-vit d3 200 tablet 600

mg(1,500mg) -200 unit * 4 $0





215

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

calcium 600-vit d3 400 tablet 600

mg(1,500mg) -400 unit *

(Calcium 600 +

D(3)) 4 $0

calcium 600-vit d3 800 tablet s/f,p/f

600 mg(1,500mg) -800 unit *

(Caltrate with

Vitamin D3) 4 $0

centamin liquid 9 mg iron/15 ml * 4 $0

centram-care multivit-min liq 9 mg

iron/15 ml * 4 $0

centravites 50 plus tablet * 4 $0

centravites 50 plus tablet outer 0.4-

300-250 mg-mcg-mcg * 4 $0

centrum adults tablet 18-400 mg-

mcg * 4 $0

centrum complete multivit tab 18-

400 mg-mcg * 4 $0

centrum multivit-mineral liq 9 mg

iron/15 ml * 4 $0

centrum silver tablet for adult 50+

0.4-300-250 mg-mcg-mcg * 4 $0

centrum vitamints chew tab 200 mcg

* 4 $0

centrum women tablet 18-400 mg-

mcg * 4 $0

century adults 50 plus tablet 0.4-

300-250 mg-mcg-mcg * 4 $0

century tablet adults under 50 18-

400 mg-mcg * 4 $0

century ultimate men's tablet 300-

600-300 mcg * 4 $0

century ultimate women's tab 18-

400 mg-mcg * 4 $0

cerovite advanced form tab 18-400

mg-mcg * 4 $0

cerovite senior tablet * 4 $0



.



216

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

certavite sr-antioxidant tab 0.4-300-

250 mg-mcg-mcg * 4 $0

certavite-antioxidant tablet 18-400

mg-mcg * 4 $0

chewable-vite tablet * 4 $0

chew-vites-iron tablet chew * 4 $0

child chew + iron tab chew * 4 $0

child chew vitamin tablet * 4 $0

child ferrous sulfate 15 mg/ml 15

mg iron (75 mg)/ml * (Children's Iron) 4 $0

child multivitamin plus iron 18 mg

iron * 4 $0

child vitamin-iron tab chew * 4 $0

childrens chew vitamin tab * 4 $0

children's chewable vitamin * 4 $0

childrens multivit tab chew * 4 $0

compete tablet * 4 $0

complete multi 50+ tablet 500-300-

250 mcg * 4 $0

complete multi tablet 18-500-300-

250 mg-mcg-mcg-mcg * 4 $0

complete senior tablet * 4 $0

cvs b-1 100 mg tablet p/f, s/f,gluten-

free 100 mg * 4 $0

cvs balanced b-50 caplet 400 mcg-

2.5 mg * 4 $0

cvs b-complex-vit c caplet caplet * (Super B Complex-

Vitamin C) 4 $0

cvs calcium 500 + vit d tablet oyster

shell 500 mg(1,250mg) -125 unit * 4 $0





217

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs calcium 600-vit d3 800 tab p/f,

s/f,gluten-free 600 mg(1,500mg) -

800 unit *

(Caltrate with

Vitamin D3) 4 $0

cvs child chew vitamn complete 18

mg iron * 4 $0

cvs child's vitamin-iron tb * 4 $0

cvs daily gummies p/f, gluten-free

200 mcg * 4 $0

cvs daily multiple tablet * 4 $0

cvs hair, skin and nails cplt * 4 $0

cvs iron 65 mg tablet

s/f,p/f,lactose/free 325 mg (65 mg

iron) *

4 $0

cvs men's daily gummies p/f, gluten-

free 200 mcg * 4 $0

cvs men's multi-vit tablet * 4 $0

cvs prenatal vitamin tablet * 4 $0

cvs spectravite adult 50+ tabs 0.4-

300-250 mg-mcg-mcg * 4 $0

cvs spectravite adult gummy 200

mcg * 4 $0

cvs spectravite advanced tab 18-400

mg-mcg * 4 $0

cvs spectravite senior tab * 4 $0

cvs spectravite senior tablet 500-

300-250 mcg * 4 $0

cvs spectravite ultra men's tb 300-

600-300 mcg * 4 $0

cvs spectravite ultra women tb 18-

400 mg-mcg * 4 $0

cvs super b complex-vit c cplt * 4 $0

cvs vitamin b-6 100 mg tablet 100

mg * (Vitamin B-6) 4 $0



.



218

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

cvs vitamin d3 400 unit/drop 400

unit/drop * (Baby Ddrops) 4 $0

cvs women's daily gummies p/f,

gluten-free 200 mcg * 4 $0

cyanocobalamin 1,000 mcg/ml

outer,latex-free 1,000 mcg/ml * 3 $0

d3 dots 2,000 unit tablet p/f 2,000

unit * 4 $0

daily multi vitamin-iron tab * 4 $0

daily multiple tablet 18-400 mg-mcg

* 4 $0

daily multiple vitamin tab sugar

coated * 4 $0

daily multiple vitamin tablet * 4 $0

daily multivitamin-iron tablet 18-

400 mg-mcg * 4 $0

daily value multivitamin tab s/f * 4 $0

daily vitamin + iron tablet * 4 $0

daily vitamin formula tablet * 4 $0

daily vitamin formula tablet * 4 $0

daily vitamin formula-iron tab 18-

400 mg-mcg * 4 $0

daily vite tablet s/f, p/f * 4 $0

daily vite tablet s/f,p/f * 4 $0

daily vite with iron tablet * 4 $0

daily-vite tablet * 4 $0

daily-vites with iron tablet * 4 $0

decara 10,000 unit softgel 10,000

unit * 4 $0

dino-life extra c tab chew * 4 $0

dino-life iron-zinc tab chew 4.5 mg

* 4 $0





219

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

dino-life tablet chewable * 4 $0

d-vi-sol 400 units/ml drop 400

unit/ml * 4 $0

eldertonic elixir 0.5-0.6-7-0.7 mg * 4 $0

endur-amide sr 500 mg tablet 500

mg * 4 $0

ENDUR-AMIDE SR 750 MG

TABLET 750 MG * 4 $0

eq child complete chew tablet 18 mg

iron * 4 $0

eq complete multivitamin tab 0.4-

300-250 mg-mcg-mcg * 4 $0

eq complete multivitamin tab gluten-

free 18-400 mg-mcg * 4 $0

eql century mature tablet 400-30

mcg * 4 $0

eql eye health plus lutein tab 1,000

unit-200 mg-60 unit-2 mg * 4 $0

eql one daily men's tablet * 4 $0

ergocalciferol 8,000 units/ml 8,000

unit/ml * (Calcidol) 4 $0

essentia tablet 18-400 mg-mcg * 4 $0

essential balance tablet * 4 $0

feosol 65 mg tablet 325 mg (65 mg

iron) * 4 $0

ferate 27 mg tablet 240 mg (27 mg

iron) * 4 $0

ferretts 325 mg tablet 325 mg (106

mg iron) * 4 $0

ferrex 150 capsule outer, u-d 150

mg iron * 4 $0

ferric x-150 capsule 150 mg iron * 4 $0



.



220

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ferrocite tablet 324 mg (106 mg

iron) * 4 $0

ferrous fumarate 324 mg tab 324 mg

(106 mg iron) * (Ferrocite) 4 $0

ferrous gluconate 240 mg tab

240mg=27mg elemental 240 mg (27

mg iron) *

(Ferate) 4 $0

ferrous gluconate 324 mg tab 324

mg (37.5 mg iron), 324 mg (38 mg

iron) *

4 $0

ferrous sulf 220 mg/5 ml elix 220 mg

(44 mg iron)/5 ml * (FeroSul) 4 $0

ferrous sulf 300 mg/5 ml liq 300 mg

(60 mg iron)/5 ml * 4 $0

ferrous sulf ec 324 mg tablet 324 mg

(65 mg iron) * 4 $0

ferrous sulf ec 325 mg tablet 325 mg

(65 mg iron) * 4 $0

ferrous sulfate 325 mg tablet f/c 325

mg (65 mg iron) * (Feosol) 4 $0

flintstones complete tablet * 4 $0

flintstones extra c tab chew * 4 $0

flintstones tablet chewable * 4 $0

flintstones with iron tab chew 18 mg

iron * 4 $0

folic acid 0.4 mg tablet 400 mcg * 4 $0

folic acid 1 mg tablet (rx) 1 mg * 3 $0

folic acid 1,000 mcg tablet p/f,s/f

(otc) 1 mg * 4 $0

fosfree tablet 175.5-14.5 mg * 4 $0

geriaton liquid * 4 $0





221

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

gnp century mature tablet gluten-

free 0.4-300-250 mg-mcg-mcg * 4 $0

gnp one daily essential tablet * 4 $0

gummi bear multivit tab chew

multivit & minerals * 4 $0

hair vitamins * 4 $0

hemocyte tablet 324 mg (106 mg

iron) * 4 $0

hm animal shapes complete chew

child's, w/ choline 18 mg iron * 4 $0

hm complete 50 plus tablet 0.4-300-

250 mg-mcg-mcg * 4 $0

hm complete multi-vit-mineral

gluten-free 18-400 mg-mcg * 4 $0

hm complete women tablet 18-400

mg-mcg * 4 $0

hm one daily with iron tablet gluten-

free 18-400 mg-mcg * 4 $0

honey bears chew tab * 4 $0

honey bears iron-zinc tab chew 4.5

mg * 4 $0

iferex 150 capsule 150 mg iron * 4 $0

iron 27 mg tablet 236 mg (27 mg

iron) * 4 $0


iron) * (Ferate) 4 $0


iron) * 4 $0


iron) * 4 $0

kenwood therapeutic liquid * 4 $0

kids multivitamin complete tab 18

mg iron * 4 $0



.



222

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

kobee tablet 0.4 mg * 4 $0

kpn tablet * 4 $0

kro prenatal vitamins tablet 28-800

mg-mcg * 4 $0

life-pack women's p/f,s/f 0.8 mg * 4 $0

little animals child tb chw * 4 $0

little animals-iron tab chew * 4 $0

lysiplex plus liquid * 4 $0

mega multivit-chelated min tab * 4 $0

men 50 plus multivitamin tab 300-

600-300 mcg * 4 $0

men's multivitamin gummies 200

mcg * 4 $0

MEPHYTON 5 MG TABLET 5

MG * 3 $0

milltrium senior multivit tab * 4 $0

multi complete-iron tablet 18-400

mg-mcg * 4 $0

multi for her tablet 18 mg iron-600

mcg-80 mcg * 4 $0

multi-day plus iron tablet 18-400

mg-mcg * 4 $0

multi-delyn with iron liquid 10 mg

iron/5 ml * 4 $0

multilex tablet * 4 $0

multilex-t-m-minerals tab * 4 $0

multiple vitamin with iron tab * (Daily Multiple

Vitamins/Iron) 4 $0

multiple vitamin w-minerals tb * 4 $0

multiple vitamins tablet one daily * 4 $0

multi-vitamin daily tablet * 4 $0





223

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

multivitamin with iron tablet 18-400

mg-mcg * 4 $0

multivitamin-mineral liquid 9 mg

iron/15 ml * 4 $0

multivitamins tablet * (Daily Multi-

Vitamin) 4 $0

multi-vite liquid 9 mg iron/15 ml * 4 $0

multivit-mineral hp cap * 4 $0

multivit-minerals tablet *

(Daily

Multivitamin-

Minerals)

4 $0

multivit-minerals tablet s/f,p/f *

(Daily

Multivitamin-

Minerals)

4 $0

my favorite multiple liquid * 4 $0

myvitalife soft-gel capsule * 4 $0

NASCOBAL 500 MCG NASAL

SPRAY OUTER 500 MCG/SPRAY

*

3 $0

nephplex rx tablet 1-60-300-12.5

mg-mg-mcg-mg * 3 $0

nephron fa tablet 66.6-75-1 mg * 3 $0

niacinamide er 500 mg tablet 500

mg * (Endur-amide) 4 $0

nu-iron 150 capsule 150 mg iron * 4 $0

ocutabs tablet s/f, w/lutein * 4 $0

onccor tablet 200-10-10 mcg * 4 $0

once daily tablet * 4 $0

once daily with iron tablet * 4 $0

oncovite tablet * 4 $0

one daily complete tablet * 4 $0

one daily complete tablet 18-0.4 mg

* 4 $0



.



224

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

one daily essential tablet * 4 $0

one daily for women tablet 18-0.4

mg * 4 $0

one daily maximum tablet 18-0.4 mg

* 4 $0

one daily multivitamin tablet 400

mcg * 4 $0

one daily multivitamin-iron tb 18-

400 mg-mcg * 4 $0

one daily multivit-mineral tab * 4 $0

one daily plus iron tablet 18-400

mg-mcg * 4 $0

one daily tablet * 4 $0

one daily tablet * 4 $0

one daily tablet men's formula * 4 $0

one daily with minerals tablet * 4 $0

one-a-day essential tablet * 4 $0

one-a-day max formula tab * 4 $0

one-a-day teen advantage tab 18-

400 mg-mcg * 4 $0

one-daily multi-vitamin tab * 4 $0

oysco 500-vit d3 200 tablet 500

mg(1,250mg) -200 unit * 4 $0

oyster shell 500-vit d3 200 tb 500

mg(1,250mg) -200 unit * 4 $0

oyster shell calcium-vit d tab 250

(625)-125 mg-unit * 4 $0

oyster shell calcium-vit d tab

p/f,s/f,gluten-free 500 mg(1,250mg)

-400 unit *

4 $0

oystercal-d 500 mg-400 unit tb 500

mg(1,250mg) -400 unit * 4 $0





225

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

pedia tri-vite drop 750 unit-35 mg -

400 unit/ml * 4 $0

perry prenatal capsule 13.5-0.4 mg

* 4 $0

phytonadione 1 mg/0.5 ml syr latex-

free, p/f,sdv 1 mg/0.5 ml * 3 $0

phytonadione 5 mg tablet 5 mg * (Mephyton) 3 $0

pnv prenatal plus multivit tab s/f,

gluten-free 27 mg iron- 1 mg 2 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

poly-iron 150 mg capsule 150 mg

iron * 4 $0

poly-vitamin tab chew * 4 $0

polyvitamin with iron tab chew 12

mg iron * 4 $0

prenatal formula tablet 28 mg iron-

800 mcg * 4 $0

prenatal multivitamin tablet 28 mg

iron- 800 mcg * 4 $0

prenatal multivitamin tablet 28 mg

iron- 800 mcg * 4 $0

prenatal tablet (otc) 27 mg iron- 0.8

mg * 4 $0

prenatal tablet (otc) 27 mg iron- 0.8

mg * 4 $0

prenatal tablet 27 mg iron- 800 mcg

* 4 $0


* 4 $0


* (Prenatal) 4 $0



.



226

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use


* (Prenatal Tablet) 4 $0

prenatal tablet outer (otc) 27 mg

iron- 0.8 mg * 4 $0

prenatal vitamin plus low iron oral

tablet 27 mg iron- 1 mg 2 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

prenatal vitamin tablet 27 mg iron-

800 mcg * 4 $0

prenatal vitamins tablet phosphorus

free 28 mg iron- 800 mcg * 4 $0

prosight tablet 5,000-60-30 unit-mg-

unit * 4 $0

pub multivitamin 50 plus tab * 4 $0

pyridoxine 100 mg/ml vial 25's, mdv

100 mg/ml * 3 $0

qc child complete vit chew tab 18

mg iron * 4 $0

qc children's chewable tablet * 4 $0

QUFLORA 0.125 MG GUMMIES

0.125 MG FLUORIDE * 4 $0

ra balanced b-100 tablet 0.4 mg * 4 $0

ra balanced b-50 tablet natural,p/f

* 4 $0

ra b-complex tablet p/f * 4 $0

ra b-complex tablet p/f * (B Complex 1) 4 $0

ra child complete chewable vit 18

mg iron * 4 $0

ra hi-cal plus vitamin d tab 500

mg(1,250mg) -200 unit * 4 $0

ra one daily energy tablet * 4 $0





227

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

ra one daily maximum tablet 18-0.4

mg * 4 $0

ra oyster shell 500-vit d3 200

natural,p/f 500 mg(1,250mg) -200

unit *

4 $0

ra prenatal tablet 28 mg iron- 800

mcg * 4 $0

ra vitamin d3 1,000 unit tab

s/f,gluten/f,yeast/f 1,000 unit * 4 $0

rena-vite rx tablet (otc) 1-60-300

mg-mg-mcg * 3 $0

right step prenatal vit tab 27 mg

iron- 0.8 mg * 4 $0

scooby-doo one a day tablet * 4 $0

senior tabs 0.4-300-250 mg-mcg-

mcg * 4 $0

sentry multivit & mineral cplt 18-

500-300-250 mg-mcg-mcg-mcg * 4 $0

sentry senior multivit caplet caplet

500-300-250 mcg * 4 $0

sentry senior tablet 0.4-300-250 mg-

mcg-mcg * 4 $0

sentry tablet 18-400 mg-mcg * 4 $0

sm animal shapes complete chew

gluten-free 18 mg iron * 4 $0

sm animal shapes tab chew toddlers

* 4 $0

sm animal shapes w-iron tab

chewable * 4 $0

sm b complex with vit c tablet

gluten-free *

(Super B Complex-

Vitamin C) 4 $0

sm complete senior formula tab * 4 $0



.



228

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sm complete senior formula tab 0.4-

300-250 mg-mcg-mcg * 4 $0

sm multivitamin w-iron tab * (Daily Multiple

Vitamins/Iron) 4 $0

sm multivitamins tablet * (Daily Multi-

Vitamin) 4 $0

sm natural balanced b-100 tab 100

mg * 4 $0

sm prenatal vitamins tablet 28 mg

iron- 800 mcg * 4 $0

sm super b complex-c caplet * 4 $0

sm therapeutic m tablet 27-0.4 mg * 4 $0

sm ultimate men's complete tab 300-

600-300 mcg * 4 $0

sm vitamin b complex tablet gluten-

free 0.4 mg * (B Complex 100) 4 $0

sm vitamin b-100 complex tab

gluten-free 0.4 mg * 4 $0

soothing pureway-c 500 mg tab 500

mg * 4 $0

stress b with zinc tablet * 4 $0

stress formula tablet * 4 $0

stress formula with iron tab * 4 $0

stress formula with iron tab 500 mg-

400 mcg- 18 mg iron * 4 $0

stress formula with iron tab 500 mg-

400 mcg- 27 mg iron * 4 $0

stress formula with zinc tab * 4 $0

stress-c tablet * 4 $0

stress-c with iron tablet 500 mg-400

mcg- 18 mg iron * 4 $0





229

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

sunvite tablet 18 mg iron-400 mcg-

25 mcg * 4 $0

super b maxi complex caplet 0.4 mg

* 4 $0

super b-50 complex capsule * 4 $0

super b-50 complex plus tab * 4 $0

super calcium 600-vit d3 400 s/f, p/f

600 mg(1,500mg) -400 unit *

(Calcium 600 +

D(3)) 4 $0

super multiple vit-mineral tab * 4 $0

super multivitamin tablet * 4 $0

super quints b-50 tablet 0.4 mg * 4 $0

super quints b-50 tablets * 4 $0

super thera vite m tablet * 4 $0

superior 35 vit-mineral tab sa * 4 $0

superplex-t tablet * 4 $0

support liquid * 4 $0

sv hair, skin and nails caplet 1 mg

iron-66.7 mcg-1,000 mcg * 4 $0

tab-a-vite tablet * 4 $0

tab-a-vite with iron tablet * 4 $0

tab-a-vite-minerals tablet * 4 $0

thera caplet * 4 $0

thera m plus tablet 9 mg iron-400

mcg * 4 $0

thera tablet 400 mcg * 4 $0

thera-d 2000 tablet 2,000 unit * 4 $0

theradex m tablet 27-0.4 mg * 4 $0

thera-m caplet * 4 $0

thera-m caplet caplet 27-0.4 mg * 4 $0

thera-m tablet w/beta carotene 9 mg

iron-400 mcg * 4 $0



.



230

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

therapeutic-m tablet 9 mg iron-400

mcg * 4 $0

thera-tabs m caplet caplet 27 mg

iron-400 mcg * 4 $0

thera-tabs tablet * 4 $0

theratrum complete 50 plus tab * 4 $0

theratrum complete 50 plus tab 0.4-

300-250 mg-mcg-mcg * 4 $0

theratrum complete tablet w/lutein,

p/f * 4 $0

therems tablet * 4 $0

therems-m tablet 27-0.4 mg * 4 $0

thiamine 200 mg/2 ml vial 25's, mdv

100 mg/ml * 3 $0

total b with vit c caplet * 4 $0

totalday multiple tablet sa * 4 $0

tri-vi-sol drops 750 unit-35 mg -400

unit/ml * 4 $0

ultra b-100 complex tablet * 4 $0

unicomplex-m tablet * 4 $0

v-c forte capsule 1 mg * 3 $0

vic-forte capsule 1 mg * 3 $0

vision plus lutein vitamin tab * 4 $0

vision vitamins * 4 $0

vitacel tablet 800-250-750 mcg * 4 $0

vitalets tablet chewable child,

orange,s/f * 4 $0

vitamin a 10,000 unit capsule

soluble 10,000 unit * 4 $0

vitamin and minerals tablet * 4 $0

vitamin b complex capsule * 4 $0





231

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

vitamin b complex tablet 500 mg-

400 mcg- 18 mg iron * 4 $0

vitamin b-1 50 mg tablet s/f, gluten

free 50 mg * 4 $0

vitamin b-12 1,000 mcg tablet 1,000

mcg * 4 $0

vitamin b-12 100 mcg tablet 100

mcg * 4 $0

vitamin b-12 250 mcg tablet 250

mcg * 4 $0

vitamin b12 500 mcg tablet 500 mcg

* 4 $0

vitamin b-50 complex tablet

s/f,p/f,dairy-free 0.4 mg * (B Complex 100) 4 $0

vitamin b-6 100 mg tablet 100 mg * 4 $0

vitamin b-6 50 mg tablet 50 mg * 4 $0

vitamin c 250 mg tablet 250 mg * 4 $0

vitamin c 500 mg tablet 500 mg * 4 $0

vitamin d 1,000 unit tablet 1,000

unit * 4 $0

vitamin d2 1.25 mg(50,000 unit)

capsule 50,000 unit * 3 $0

vitamin d3 1,000 unit tablet s/f,p/f

1,000 unit * 4 $0

vitamin d3 2,000 unit tablet 2,000

unit * (D3 DOTS) 4 $0

vitamin d3 400 unit/5 ml liq 400

unit/5 ml * 4 $0

vitamin d3 400 unit/ml drop

supplement drop 400 unit/ml * (D-Vi-Sol) 4 $0

vitamin k-1 1 mg/0.5 ml ampul

sdv,latex-free 1 mg/0.5 ml * 3 $0



.



232

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions,

Restrictions, or

Limits on Use

vitamin k-1 10 mg/ml ampul

sdv,latex-free 10 mg/ml * 3 $0

vitamins for hair tablet * 4 $0

vitatrum tablet 18-500-300-250 mg-

mcg-mcg-mcg * 4 $0

vitrum 50 plus senior tablet 500-

300-250 mcg * 4 $0

vitrum senior tablet f/f,p/f * 4 $0

vol-care rx tablet 1-60-300 mg-mg-

mcg * 3 $0

vp-vite rx tablet 1-60-300 mg-mg-

mcg * 3 $0

women's multivitamin gummies

gluten-f, lactose-f 200 mcg * 4 $0

yelets tablet 18-400 mg-mcg * 4 $0

zoo chews gummie tablet * 4 $0


I-1

1 12 hour nasal spray .............. 194

1ST TIER UNILET

COMFORTOUCH ........... 174

3 3 day vaginal .......................... 73

3-day vaginal .......................... 69

8 8 hour pain reliever .................. 3

A a thru z.................................. 277

a thru z advanced formula .... 277

a thru z high potency ............ 277

a thru z select ............... 277, 278

a thru z select 50plus formula

.................................. 277, 278

a thru z select women's ........ 278

abacavir .................................. 99

abacavir-lamivudine ............... 99

abacavir-lamivudine-zidovudine

............................................ 99

abc plus ................................ 278

ABELCET.............................. 69

ABILIFY MAINTENA ......... 91

ABRAXANE ......................... 35

ABREVA ............................... 81

acamprosate............................ 17

acarbose.................................. 62

ACCU-CHEK FASTCLIX

LANCET DRUM ............. 174

ACCU-CHEK MULTICLIX

LANCET .......................... 174

ACCU-CHEK SAFE-T-PRO

.......................................... 174

ACCU-CHEK SAFE-T-PRO

PLUS ................................ 174

ACCU-CHEK SOFTCLIX

LANCETS ........................ 174

acebutolol ............................. 126

acephen..................................... 3

acetaminophen ........... 3, 4, 7, 11

acetaminophen-codeine ............ 3

acetazolamide ....................... 255

acetazolamide sodium .......... 255

acetic acid ..................... 196, 249

acetylcysteine ....................... 271

acid controller ...................... 202

acid gone antacid .................. 204

acid reducer (famotidine) ..... 202

acid reducer (omeprazole) .... 202

acitretin................................. 161

acne medication .................... 162

ACTEMRA .......................... 233

ACTHIB (PF) ....................... 241

ACTI-LANCE LANCETS ... 175

ACTIMMUNE ..................... 252

acyclovir ....................... 107, 162

acyclovir sodium .................. 107

ADACEL(TDAP

ADOLESN/ADULT)(PF) 241

ADAGEN ............................. 188

adapalene .............................. 172

ADCIRCA ............................ 275

adefovir ................................ 108

ADEMPAS........................... 276

adriamycin .............................. 35

adrucil..................................... 35

adult multivitamin extra vitd3

.......................................... 278

adult multivitamin gummies 278

adult nasal decongestant....... 160

adult one daily gummies ...... 278

adult robitussin peak cold dm

.......................................... 157

adult wal-tussin .................... 157

adults 50 plus........................ 278

ADVAIR DISKUS ............... 266

ADVAIR HFA ..................... 266

ADVANCED TRAVEL

LANCETS ........................ 175

ADVOCATE LANCET ....... 175

afeditab cr ............................. 132

AFINITOR ....................... 35, 36

AFINITOR DISPERZ ............ 35

aftera ..................................... 145

a-hydrocort ........................... 225

AIMOVIG AUTOINJECTOR81

AIMOVIG AUTOINJECTOR

(2 PACK) ........................... 81

AJOVY ................................... 81

AKYNZEO

(FOSNETUPITANT) ......... 84

AKYNZEO (NETUPITANT) 84

ala-cort .................................. 168

alavert ..................................... 74

alavert d-12 allergy-sinus ....... 74

albendazole ............................. 87

ALBENZA ............................. 87

albuterol sulfate ............ 268, 269

alclometasone ....................... 168

ALCOHOL PADS ............... 162

ALDURAZYME .................. 188

ALECENSA ........................... 36

alendronate ................... 249, 250

aler-cap ................................... 74

alfuzosin ............................... 220

ALIMTA ................................ 36

ALINIA ............................ 87, 88

ALIQOPA .............................. 36

INDEX

I-2

alka-seltzer plus allergy ......... 74

aller-chlor ............................... 74

allerclear d-12hr ..................... 74

allerclear d-24hr ..................... 74

allergy (chlorpheniramine)..... 74

allergy (diphenhydramine) ..... 76

allergy medication .................. 79

allergy medicine ..................... 79

allergy relief d12 .................... 77

aller-tec d ............................... 74

allopurinol .............................. 73

almacone .............................. 204

almacone-2 ........................... 204

aloe vesta antifungal (micon) . 69

alophen ................................. 212

alosetron ............................... 248

ALPHAGAN P .................... 255

alprazolam .............................. 20

ALREX ................................ 199

altamist ................................. 191

altavera (28) ......................... 145

ALTERNATE SITE LANCET

.......................................... 175

ALTRENO ........................... 173

aluminum hydroxide gel ..... 204,

205

ALUNBRIG ........................... 36

alyacen 1/35 (28).................. 145

alyacen 7/7/7 (28) ................ 145

amabelz ................................ 223

amantadine hcl ....................... 89

AMBISOME .......................... 69

amethia ................................. 145

amethia lo ............................. 145

amifostine crystalline ........... 252

amiloride .............................. 132

amiloride-hydrochlorothiazide

.......................................... 133

AMINOSYN 10 % ............... 114

AMINOSYN 7 % WITH

ELECTROLYTES ........... 114

AMINOSYN 8.5 % .............. 114

AMINOSYN 8.5 %-


AMINOSYN II 10 % ........... 114

AMINOSYN II 15 % ........... 114

AMINOSYN II 7 % ............. 114

AMINOSYN II 8.5 % .......... 115

AMINOSYN II 8.5 %-


AMINOSYN M 3.5 % ......... 115

AMINOSYN-HBC 7% ........ 115

AMINOSYN-PF 10 % ......... 115

AMINOSYN-PF 7 %

(SULFITE-FREE) ............ 115

AMINOSYN-RF 5.2 %........ 115

amiodarone ........................... 125

AMITIZA ............................. 205

amitriptyline ........................... 58

amlactin ................................ 162

amlodipine ............................ 132

amlodipine-benazepril .......... 132

amlodipine-valsartan ............ 132

ammonium lactate ................ 162

amoxapine .............................. 58

amoxicillin ............................. 30

amoxicillin-pot clavulanate .... 30

amphotericin b........................ 69

ampicillin ............................... 31

ampicillin sodium ................... 31

ampicillin-sulbactam .............. 31

AMPYRA............................. 139

ANADROL-50 ..................... 222

anagrelide ..................... 112, 113

anastrozole ............................. 36

ANDROGEL ........................ 222

animal chews ........................ 278

animal shape vitamins .......... 298

animal shapes complete 289, 298

animal shapes plus iron ........ 298

ANORO ELLIPTA .............. 269

antacid anti-gas .................... 210

antacid anti-gas (ca carb-sim)

.......................................... 205

antacid extra-strength ........... 206

antacid plus anti-gas ............. 206

antacid ultra strength ............ 206

anti-diarrheal ........................ 206

anti-diarrheal (loperamide) .. 205,

206

antifungal (terbinafine) ........... 73

antifungal (tolnaftate) ............. 69

antifungal cream (miconazole)

............................................ 69

antifungal ringworm ............... 73

antitussive dm....................... 159

apatate forte .......................... 278

APOKYN ............................... 89

apraclonidine ........................ 191

aprepitant ................................ 84

apri ........................................ 145

APRISO................................ 248

aprodine .................................. 75

APTIOM ................................ 52

APTIVUS ............................... 99

aquanil hc ............................. 168

aranelle (28) ......................... 145

ARCALYST ......................... 233

aripiprazole ....................... 91, 92

ARISTADA............................ 92

ARISTADA INITIO .............. 92

armodafinil ........................... 274

ARNUITY ELLIPTA ........... 266

arsenic trioxide ....................... 36

ARTIFICIAL TEARS

(PETRO/MIN).................. 191

artificial tears (pf) ................. 191

artificial tears (polyvin alc) .. 191

artificial tears(dext70-hypro) 191

artificial tears(glycerin-peg) 191,

192

ashlyna .................................. 145

aspirin ......................... 12, 13, 16

aspirin low dose...................... 15

aspirin-dipyridamole ............ 113

aspir-low ................................. 13

I-3

aspir-trin ................................. 13

ASSURE HAEMOLANCE

PLUS ................................ 175

ASSURE ID INSULIN

SAFETY .......................... 175

ASSURE LANCE ................ 175

ASSURE LANCE PLUS ..... 175

atazanavir ............................... 99

atenolol ................................. 126

atenolol-chlorthalidone ........ 126

athenol .................................... 11

atomoxetine .......................... 139

atorvastatin ........................... 134

atovaquone ............................. 88

atovaquone-proguanil ............ 88

ATRIPLA ............................... 99

atropine .......................... 52, 191

ATROVENT HFA ............... 269

AUBAGIO ........................... 139

aubra ..................................... 145

AUSTEDO ........................... 140

AVASTIN .............................. 36

aviane ................................... 145

AVONEX ............................. 140

AVONEX (WITH ALBUMIN)

.......................................... 140

ayr saline .............................. 191

azacitidine .............................. 36

azathioprine .......................... 233

azathioprine sodium ............. 233

azelastine .............................. 191

azithromycin .................... 28, 29

AZOPT ................................. 255

aztreonam ............................... 29

azurette (28) ......................... 145

B b complex 1 .......................... 279

b complex 100 ...................... 299

b complex-vitamin b12 ........ 279

b-12 dots............................... 279

baby ddrops .......................... 279

baby's super daily d3 ............ 279

bacitracin ................ 23, 166, 196

bacitracin zinc ...................... 166

bacitracin-polymyxin b ........ 196

bacitraycin plus .................... 166

baclofen ................................ 273

balance b-100 ....................... 279

balance b-50 ......................... 279

balanced b-100 ............. 279, 297

balanced b-50 ............... 279, 297

balanced b-50 (with alfalfa) . 283

balsalazide ............................ 248

balziva (28) .......................... 145

banophen ................................ 75

banophen allergy .................... 75

BANZEL ................................ 52

BAVENCIO ........................... 36

BAXDELA............................. 32

baza antifungal ....................... 70

BCG VACCINE, LIVE (PF) 242

b-complex............................. 297

b-complex with vitamin c ... 279,

283, 298

BD MICROTAINER LANCET

.......................................... 175

BD ULTRA FINE LANCETS

.......................................... 176

BD ULTRA-FINE II LANCETS

.......................................... 176

BD ULTRA-FINE NANO PEN

NEEDLE .......................... 176

BD VEO INSULIN SYR HALF

UNIT ................................ 176

BD VEO INSULIN SYRINGE

UF..................................... 176

bee-zee ................................. 279

bekyree (28) ......................... 145

BELEODAQ .......................... 37

BELSOMRA ........................ 274

BENADRYL ALLERGY ...... 75

benazepril ............................. 124

BENDEKA............................. 37

BENLYSTA ......................... 252

benzonatate ........................... 157

benzoyl peroxide .................. 162

benztropine ............................. 89

BESPONSA ........................... 37

beta-hc .................................. 168

betamethasone acet,sod phos 225

betamethasone dipropionate . 168

betamethasone valerate ........ 169

betamethasone, augmented .. 169

BETASERON ...................... 140

betaxolol ............................... 126

bethanechol chloride ............ 220

BETHKIS ............................... 22

BEVYXXA .......................... 108

bexarotene .............................. 37

BEXSERO............................ 242

bicalutamide ........................... 37

BICILLIN L-A ....................... 31

BIDIL ................................... 138

BIKTARVY ........................... 99

biosupp ................................. 280

biotin .................................... 280

biovol.................................... 280

bisac-evac ............................. 212

bisacodyl .............................. 212

biscolax ................................ 212

bismatrol ............................... 205

bismuth ................................. 206

bisoprolol fumarate .............. 126

bisoprolol-hydrochlorothiazide

.......................................... 126

bleomycin ............................... 37

bleph-10 ................................ 196

BLINCYTO............................ 37

blisovi 24 fe .......................... 146

blisovi fe 1.5/30 (28) ............ 146

blisovi fe 1/20 (28) ............... 146

blis-to-sol (tolnaftate) ............. 70

BOOSTRIX TDAP .............. 242

BORTEZOMIB ...................... 37

BOSULIF ............................... 37

BRAFTOVI ............................ 37

I-4

BREEZE 2 TEST STRIPS ... 176

BREO ELLIPTA .................. 266

briellyn ................................. 146

BRILINTA ........................... 113

brimonidine .......................... 255

BRIVIACT ............................. 52

bromocriptine ......................... 89

BROMSITE ......................... 200

brotapp dm ........................... 157

budesonide ................... 248, 266

bufferin ................................... 13

BULLSEYE MINI SAFETY

LANCETS........................ 176

bumetanide ........................... 133

buprenorphine hcl .......... 3, 4, 17

buprenorphine-naloxone ........ 18

bupropion hcl ................... 58, 59

bupropion hcl (smoking deter)18

buspirone ................................ 20

butalbital-acetaminophen-caff . 4

butalbital-aspirin-caffeine ........ 4

BYSTOLIC .......................... 126

BYVALSON ........................ 126

C c-500 .................................... 280

cabergoline ............................. 89

CABOMETYX ...................... 37

caffeine citrate ...................... 140

calci-chew ............................ 205

calcidol ................................. 280

calcipotriene ......................... 162

calcitonin (salmon)............... 250

calcitrate ............................... 257

calcitriol ............................... 250

calcium 500 + d (d3) ............ 283

calcium 600 .................. 257, 265

calcium 600 + d(3) ....... 257, 280

calcium 600 with vitamin d3

.................................. 257, 260

calcium acetate ..................... 219

calcium antacid .................... 205

calcium carbonate ........ 205, 257

calcium carbonate-vitamin d3

.................. 257, 280, 283, 300

calcium chloride ................... 258

calcium citrate + ................... 258

calcium citrate-vitamin d3 .. 258,

259, 265

calcium gluconate ................ 258

CALDOLOR .......................... 13

cal-gest antacid ..................... 205

CALQUENCE ....................... 38

camila ................................... 146

CANASA ............................. 248

CAPASTAT ........................... 83

CAPRELSA ........................... 38

captopril ............................... 124

CARBAGLU ........................ 206

carbamazepine .................. 52, 53

carbidopa-levodopa ................ 89


...................................... 89, 90

CAREONE ULTRA THIN

LANCET .......................... 176

CARESENS LANCETS ...... 177

CARETOUCH TWIST

LANCET .......................... 177

CARIMUNE NF

NANOFILTERED ........... 233

carisoprodol .......................... 273

carteolol ................................ 255

cartia xt ................................. 128

carvedilol .............................. 127

caspofungin ............................ 70

CASTELLANI PAINT ........ 162

CAYSTON ............................. 29

caziant (28) ........................... 146

cefaclor ................................... 26

cefadroxil ............................... 26

cefazolin ................................. 26

cefazolin in dextrose (iso-os) . 26

cefdinir ................................... 27

cefditoren pivoxil ................... 27

cefepime ................................. 27

cefotaxime .............................. 27

cefoxitin .................................. 27

cefpodoxime ........................... 27

cefprozil .................................. 27

ceftazidime ............................. 27

ceftibuten .......................... 27, 28

ceftriaxone .............................. 28

cefuroxime axetil .................... 28

cefuroxime sodium ................. 28

celecoxib ................................ 13

CELONTIN ............................ 53

centamin ............................... 280

centram-care ......................... 281

centravites 50 plus ................ 281

centrum ................................. 281

centrum complete ................. 281

centrum silver ....................... 281

centrum vitamints ................. 281

centrum women .................... 281

century .................................. 281

century adults 50 plus ........... 281

century mature .............. 287, 289

century ultimate men's ......... 281

century ultimate women's ..... 281

cephalexin .............................. 28

CEPROTIN (BLUE BAR) ... 109

CERDELGA ........................ 188

CEREZYME ........................ 188

cerovite advanced formula ... 282

cerovite senior ...................... 282

certavite senior-antioxidant .. 282

certavite-antioxidant ............. 282

cetirizine ................................. 75

cetirizine-pseudoephedrine .... 75

CETYLEV............................ 252

CHANTIX .............................. 18

CHANTIX CONTINUING

MONTH BOX .................... 18

CHANTIX STARTING

MONTH BOX .................... 18

chest congestion-cough relief

.......................................... 158

I-5

chewable-vite ....................... 282

chewable-vite with iron........ 282

child allergy relf(cetirizine) ... 77

child chewable vitamn complete

.................................. 283, 297

child complete multivitamin 286

child mucinex chest congestion

.......................................... 157

child multivitamin plus iron . 282

child triaminic cold-allergy .... 76

child wal-tap cold-allergy ...... 76

children's allegra allergy ........ 75

children's allergy relief(fex) ... 77

children's allergy relief(lor) ... 79

children's aller-tec .................. 76

children's antacid .................. 206

children's chewable .............. 296

children's chewable vitamin . 282

children's complete vitamin . 296

children's fever reducing .......... 4

children's ibuprofen ................ 14

children's mapap ...................... 4

children's mucinex cough ..... 157

children's non-aspirin ............... 5

children's pain relief ................. 5

children's pain-fever relief ....... 4

children's silfedrine .............. 157

CHILDREN'S SUDAFED ... 157

children's tactinal ..................... 4

children's tylenol ...................... 4

children's wal-dryl allergy ..... 76

children's wal-fex ................... 76

children's wal-zyr ................... 76

childs chew vite.................... 282

child's chewable vitamins/iron

.......................................... 282

child's vitamin with iron ...... 283

childs/iron ............................ 282

chloramphenicol sod succinate

............................................ 23

chlordiazepoxide hcl .............. 20

chlorhexidine gluconate ....... 161

chlorhist .................................. 76

chloroquine phosphate ........... 88

chlorothiazide ....................... 133

chlorothiazide sodium .......... 133

chlorpromazine................. 92, 93

chlorthalidone....................... 133

chlorzoxazone ...................... 273

cholecalciferol (vitamin d3) 279,

285, 304

cholestyramine (with sugar) . 134

cholestyramine light ............. 135

ciclopirox ............................... 70

cilostazol .............................. 113

CIMDUO ............................... 99

cimetidine ............................. 202

cimetidine hcl ....................... 202

CIMZIA ............................... 233

CIMZIA POWDER FOR

RECONST ....................... 233

CINQAIR ............................. 272

CINRYZE ............................ 110

CINVANTI ............................ 84

CIPRODEX .......................... 196

ciprofloxacin .......................... 33

ciprofloxacin hcl ............ 32, 196

ciprofloxacin in 5 % dextrose 32,

33

ciprofloxacin lactate ............... 33

citalopram............................... 59

citracal + d maximum .......... 258

citrus calcium ....................... 258

clarithromycin ........................ 29

clearlax ................................. 212

CLEVER CHEK LANCETS 177

clindamycin hcl ...................... 24

clindamycin in 5 % dextrose .. 24

clindamycin phosphate .... 24, 81,

166

CLINIMIX 5%/D15W

SULFITE FREE ............... 116

CLINIMIX 5%/D25W

SULFITE-FREE............... 116

CLINIMIX 2.75%/D5W

SULFIT FREE ................. 116

CLINIMIX 4.25%/D10W SULF

FREE ................................ 116

CLINIMIX 4.25%/D5W

SULFIT FREE ................. 116

CLINIMIX 4.25%-D20W

SULF-FREE ..................... 116

CLINIMIX 4.25%-D25W

SULF-FREE ..................... 117

CLINIMIX 5%-

D20W(SULFITE-FREE) . 117

CLINIMIX E 2.75%/D10W

SUL FREE ....................... 117


SULF FREE ..................... 117


SUL FREE ....................... 117


SUL FREE ....................... 117


SULF FREE ..................... 118

CLINIMIX E 5%/D15W

SULFIT FREE ................. 118

CLINIMIX E 5%/D20W

SULFIT FREE ................. 118

CLINIMIX E 5%/D25W

SULFIT FREE ................. 118

clobazam ................................ 20

clobetasol .............................. 169

clobetasol-emollient ............. 169

clocortolone pivalate ............ 169

clofarabine .............................. 38

clomipramine .......................... 59

clonazepam ....................... 20, 21

clonidine ....................... 121, 122

clonidine hcl ......................... 121

clopidogrel ............................ 113

clorazepate dipotassium ......... 21

clotrimazole ............................ 70

clotrimazole-7 ........................ 70

clotrimazole-betamethasone ... 70

I-6

clozapine ................................ 93

COAGUCHEK LANCETS . 177

COARTEM ............................ 88

codeine sulfate ......................... 4

colchicine ............................... 74

cold-allergy-sinus ................... 76

colestipol .............................. 135

colistin (colistimethate na) ..... 24

colocort ................................ 248

COLOR LANCETS ............. 177

COMBIGAN ........................ 256

COMBIVENT RESPIMAT . 269

COMETRIQ ........................... 38

COMFORT EZ LANCETS . 177

comfort gel ........................... 206

comfort gel extra strength .... 206

COMFORT LANCETS ....... 177

compete ................................ 283

COMPLERA .......................... 99

complete 50+ ........................ 289

complete multi ..................... 283

complete multi 50+ .............. 283

complete multivitamin ......... 286

complete multivitamin-mineral

.................................. 287, 289

complete senior ............ 283, 298

complete women .................. 289

compoz ................................... 76

compro ................................... 84

constulose ............................. 206

CONTOUR NEXT TEST

STRIPS ............................ 177

CONTOUR TEST STRIPS.. 177

COPAXONE ........................ 140

COPIKTRA............................ 38

CORLANOR........................ 130

cormax.................................. 169

cortaid .................................. 169

cortisone ............................... 225

cortizone-10 ......................... 170

COSENTYX (2 SYRINGES)

.......................................... 163

COSENTYX PEN (2 PENS) 163

COTELLIC ............................ 38

cough and cold (chlorphen-dm)

.......................................... 158

cough syrup .......................... 158

cough syrup dm .................... 158

CREON ................................ 188

critic-aid clear af .................... 70

CRIXIVAN ............................ 99

cromolyn ...................... 191, 272

cryselle (28).......................... 146

CUPRIMINE ........................ 221

cutter backwoods.................. 163

cutter backwoods dry ........... 163

cutter skinsations .................. 163

cyanocobalamin (vitamin b-12)

.......................... 279, 285, 303

cyclafem 1/35 (28) ............... 146

cyclafem 7/7/7 (28) .............. 146

cyclobenzaprine ................... 273

cyclopentolate ...................... 192

cyclophosphamide .................. 38

CYCLOPHOSPHAMIDE ...... 38

cyclosporine ................. 233, 234

cyclosporine modified .. 233, 234

cyproheptadine ....................... 77

CYRAMZA ............................ 38

cyred ..................................... 146

cyred eq ................................ 146

CYSTADANE ..................... 252

CYSTARAN ........................ 192

D d10 %-0.45 % sodium chloride

.......................................... 259

d3 dots .................................. 285

d5 % and 0.9 % sodium chloride

.......................................... 259


.......................................... 259

daily fiber (psyllium-sucrose)

.......................................... 213

daily gummies ...................... 283

daily multiple ............... 283, 285

daily multi-vitamin ............... 291

daily multivitamin with iron 285,

291

daily multi-vitamins/iron ...... 285

daily value ............................ 285

daily vitamin formula ........... 285

daily vitamin formula-iron ... 285

daily vitamin formula-minerals

.......................................... 285

daily vitamin with iron ......... 285

daily vites/iron ...................... 286

daily-vite .............................. 286

DAKLINZA ......................... 106

dalfampridine ....................... 140

DALIRESP ........................... 272

danazol ................................. 222

dantrolene ............................. 274

dapsone ................................... 83

DAPTACEL (DTAP

PEDIATRIC) (PF) ........... 242

daptomycin ............................. 24

DARAPRIM ........................... 88

DARZALEX .......................... 38

dasetta 1/35 (28) ................... 146

dasetta 7/7/7 (28) .................. 146

DAURISMO .......................... 38

daysee ................................... 147

deblitane ............................... 147

decadron ............................... 225

decara ................................... 286

decitabine ............................... 39

deep sea nasal ....................... 192

deferoxamine ........................ 221

DELSTRIGO........................ 100

delsym cough-chest congest dm

.......................................... 158

delyla (28) ............................ 147

DELZICOL .......................... 248

DEMSER.............................. 130

DEPEN TITRATABS .......... 221

DEPO-PROVERA ............... 231

I-7

dermafungal ........................... 70

dermarest eczema (hydrocort)

.......................................... 170

DESCOVY ........................... 100

desipramine ............................ 59

desmopressin ................ 227, 228

desog-e.estradiol/e.estradiol . 147

desogestrel-ethinyl estradiol 147

desoximetasone .................... 170

desvenlafaxine succinate ........ 59

dex4 glucose......................... 118

dexamethasone ..................... 225

dexamethasone sodium phos

(pf).................................... 225

dexamethasone sodium

phosphate ................. 200, 225

dexmethylphenidate ............. 141

dextroamphetamine .............. 141

dextroamphetamine-

amphetamine .................... 141


.......................................... 118


.......................................... 119


.......................................... 119


.......................................... 119


.......................................... 119

dextrose 5 % in water (d5w) 119


.......................................... 119


.......................................... 119

diabetic tussin dm ................ 158

diabetic tussin ex .................. 158

diamode ................................ 207

DIASTAT .............................. 21

DIASTAT ACUDIAL ........... 21

diazepam ................................ 21

diazepam intensol................... 21

diclofenac potassium .............. 13

diclofenac sodium .......... 13, 200

dicloxacillin ............................ 31

dicyclomine .......................... 207

didanosine ............................ 100

DIFICID ................................. 29

digitek................................... 130

digox..................................... 130

digoxin ......................... 130, 131

DIGOXIN............................. 130

dihydroergotamine ........... 81, 82

DILANTIN............................. 53

diltiazem hcl ................. 128, 129

dilt-xr .................................... 129

dimaphen (pe) ........................ 77

dimaphen dm ........................ 158

dimenhydrinate....................... 84

dino-life ................................ 286

dino-life with extra c ............ 286

dino-life with iron-zinc ........ 286

DIPENTUM ......................... 248

diphedryl ................................ 77

diphen ..................................... 77

diphenhist ............................... 77

diphenhydramine hcl ........ 77, 78

diphenoxylate-atropine......... 207

dipyridamole ........................ 113

disopyramide phosphate ....... 125

disulfiram ............................... 18

divalproex............................... 53

docu ...................................... 213

docuzen ................................ 213

dofetilide .............................. 125

dok ................................ 213, 214

donepezil ................................ 57

DOPTELET ......................... 110

dorzolamide .......................... 256

dorzolamide-timolol ............. 256

doxazosin ............................. 122

doxepin ................................... 59

doxercalciferol ..................... 250

doxorubicin ............................ 39

doxorubicin, peg-liposomal .... 39

doxy-100 ................................ 34

doxycycline hyclate ................ 34

doxycycline monohydrate 34, 35

dramamine .............................. 84

dramamine less drowsy .......... 84

driminate ................................ 85

dristan long lasting ............... 192

dronabinol .............................. 85

droperidol ............................. 252

DROPLET LANCETS ......... 177

drospirenone-ethinyl estradiol

.......................................... 147

DROXIA ................................ 39

DUAVEE ............................. 223

dulcoease .............................. 214

dulcolax stool softener (dss) . 214

DULERA.............................. 267

duloxetine ............................... 59

DUPIXENT .................. 163, 234

DUREZOL ........................... 200

dutasteride ............................ 220

d-vi-sol ................................. 286

E e.c. prin ................................... 14

EASY COMFORT LANCETS

.......................................... 177

EASY TOUCH LANCETS.. 178

EASY TOUCH SAFETY

LANCETS ........................ 178

EASY TOUCH TWIST

LANCETS ........................ 178

EASY TWIST AND CAP

LANCETS ........................ 178

econazole ................................ 71

econtra ez ............................. 147

ecotrin ..................................... 13

ed a-hist .................................. 78

EDARBI ............................... 123

EDARBYCLOR ................... 123

EDURANT ........................... 100

efavirenz ............................... 100

I-8

ELAPRASE ......................... 188

eldertonic.............................. 286

electrolyte-48 in d5w ........... 259

ELIDEL................................ 170

ELIGARD .............................. 39

ELIGARD (3 MONTH) ......... 39



elinest ................................... 147

eliphos .................................. 219

ELIQUIS .............................. 109

ELITEK................................ 189

ELLA ................................... 147

ELMIRON ........................... 252

EMBRACE LANCETS ....... 178

EMCYT.................................. 39

EMEND ................................. 85

EMEND (FOSAPREPITANT)

............................................ 85

EMFLAZA ................... 225, 226

emoquette ............................. 147

EMPLICITI ............................ 39

EMSAM ................................. 60

EMTRIVA ........................... 100

enalapril maleate .................. 124

enalaprilat ............................. 124

enalapril-hydrochlorothiazide

.......................................... 124

ENBREL .............................. 234

ENBREL SURECLICK ....... 234

ENDARI .............................. 253

endocet ..................................... 5

endur-acin ............................ 135

endur-amide ......................... 286

ENDUR-AMIDE ................. 286

enema ................................... 217

enema disposable ................. 213

enemeez plus ........................ 214

ENGERIX-B (PF) ................ 242

ENGERIX-B PEDIATRIC (PF)

.......................................... 242

enoxaparin ............................ 109

enpresse ................................ 147

enskyce ................................. 147

entacapone .............................. 90

entecavir ............................... 108

ENTRESTO ......................... 123

enulose ................................. 207

EPCLUSA ............................ 106

EPIDIOLEX ........................... 53

epinastine ............................. 193

epinephrine ........................... 131

epitol....................................... 53

EPIVIR HBV ....................... 100

eplerenone ............................ 138

EPOGEN .............................. 110

epoprostenol (glycine).......... 276

equalactin ............................. 214

ergocalciferol (vitamin d2) .. 287,

304

ergoloid ................................ 253

ERGOMAR ............................ 82

ERIVEDGE ............................ 39

ERLEADA ............................. 39

errin ...................................... 147

ertapenem ............................... 29

ery pads ................................ 167

erythromycin .................. 29, 197

erythromycin ethylsuccinate .. 29

erythromycin with ethanol ... 167

ESBRIET ............................. 272

escitalopram oxalate ............... 60

esmolol ................................. 127

esomeprazole magnesium .... 202

esomeprazole sodium ........... 202

essentia ................................. 287

essential balance with lutein 287

estarylla ................................ 148

estradiol ................................ 223

estradiol valerate .................. 223

estradiol-norethindrone acet . 223

estropipate ............................ 223

eszopiclone ........................... 274

ethambutol .............................. 83

ethosuximide .......................... 53

ethynodiol diac-eth estradiol 148

etodolac .................................. 14

ETOPOPHOS ......................... 40

etoposide ................................ 40

EUCRISA ............................. 170

evac-u-gen (sennosides) ....... 214

EVOTAZ .............................. 100

exemestane ............................. 40

EXJADE ............................... 221

EXONDYS 51 ...................... 253

expectorant ........................... 158

expectorant cough syrup ...... 159

EXTAVIA ............................ 141

eye health plus lutein ............ 287

E-Z JECT LANCETS .......... 178

E-Z JECT THIN LANCETS 178

EZ SMART LANCETS ....... 178

ezetimibe .............................. 135

F FABRAZYME ..................... 189

falmina (28) .......................... 148

famciclovir ........................... 108

famotidine .................... 203, 204

famotidine (pf) ..................... 202

famotidine (pf)-nacl (iso-os) 203

FANAPT ................................ 93

FARESTON ........................... 40

FARYDAK ............................ 40

FASENRA............................ 272

FASLODEX ........................... 40

felbamate ................................ 53

FEMRING ............................ 224

femynor ................................ 148

fenofibrate ............................ 135

fenofibrate micronized ......... 135

fenofibrate nanocrystallized . 135

fentanyl ..................................... 6

fentanyl citrate .......................... 5

feosol .................................... 287

ferate ..................................... 287

ferretts .................................. 287

I-9

ferrex 150 ............................. 287

ferric x-150........................... 287

FERRIPROX........................ 221

ferrocite ................................ 287

ferrous fumarate ................... 287

ferrous gluconate .......... 288, 290

ferrous sulfate............... 282, 288

FETZIMA .............................. 60

feverall ..................................... 6

fexofenadine ........................... 78

FIASP FLEXTOUCH U-100

INSULIN............................ 65

FIASP U-100 INSULIN ........ 65

fiber (calcium polycarbophil)

.......................................... 214

fiber (psyllium husk/sugar) .. 214

fiber laxative (ca polycarbo) 213,

214

fiber laxative (methylcellulo)218

fiber smooth ......................... 218

fiber therapy (m-cell/sugar) . 214

fiber therapy (m-cellulose) ... 213

fiber therapy(psyl seed-sugar)

.......................................... 214

fiber-lax ................................ 215

FIFTY50 SAFETY SEAL

LANCETS........................ 178

finasteride ............................. 221

FINE 30 UNIVERSAL

LANCETS........................ 179

FINGERSTIX LANCETS ... 179

FIRAZYR ............................ 131

FIRVANQ .............................. 24

flavor chews antacid ............ 206

FLEBOGAMMA DIF .......... 234

flecainide .............................. 125

FLECTOR .............................. 14

FLEET BISACODYL .......... 215

fleet glycerin (child) ............. 215

fleet laxative ......................... 215

flintstones complete (iron) ... 288

flintstones multivitamin ....... 288

flintstones with iron ............. 288

flintstones/extra c ................. 288

FLOVENT DISKUS ............ 267

FLOVENT HFA .................. 267

floxuridine .............................. 40

fluconazole ............................. 71

fluconazole in nacl (iso-osm) . 71

flucytosine .............................. 71

fludrocortisone ..................... 226

flumazenil............................. 141

flunisolide............................. 200

fluocinolone ......................... 170

fluocinonide ......................... 170

fluocinonide-e ...................... 170

fluorometholone ................... 200

fluorouracil ..................... 40, 163

fluoxetine ............................... 60

fluphenazine decanoate .......... 93

fluphenazine hcl ............... 93, 94

flurbiprofen ............................ 14

flurbiprofen sodium.............. 200

flutamide ................................ 40

fluticasone .................... 170, 200

fluvoxamine ........................... 60

foaming antacid ............ 207, 211

folic acid ............................... 288

fomepizole ............................ 253

fondaparinux ........................ 109

FORACARE LANCETS ..... 179

formula 3 ................................ 71

FORTEO .............................. 250

fosamprenavir....................... 100

foscarnet ............................... 105

fosfree................................... 289

fosinopril .............................. 124

fosphenytoin ........................... 53

FREAMINE HBC 6.9 % ...... 120

FREAMINE III 10 % ........... 120

FREESTYLE LANCETS .... 179

FREESTYLE UNISTIK 2 ... 179

FULPHILA .......................... 111

fungoid-d ................................ 71

furosemide ............................ 133

FUZEON .............................. 100

fyavolv .................................. 224

FYCOMPA ............................ 54

G gabapentin .............................. 54

GALAFOLD ........................ 189

galantamine ...................... 57, 58

GAMASTAN S/D ................ 234

GAMMAGARD LIQUID .... 234

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 235

GAMMAPLEX .................... 235

GAMMAPLEX (WITH

SORBITOL) ..................... 235

ganciclovir sodium ............... 108

GARDASIL 9 (PF) .............. 243

gas free extra strength .......... 201

gas relief ............................... 201

gas relief 80 .......................... 202

gas relief extra strength ........ 201

GATTEX 30-VIAL .............. 207

GAUZE PAD ....................... 179

gavilyte-c .............................. 215

gavilyte-g .............................. 215

gavilyte-n .............................. 215

GAZYVA ............................... 40

gelusil antacid and anti-gas .. 208

gemfibrozil ........................... 135

generlac ................................ 208

gengraf .................................. 235

GENOTROPIN .................... 228

GENOTROPIN MINIQUICK

.......................................... 228

gentak ................................... 197

gentamicin .............. 23, 167, 197

gentamicin in nacl (iso-osm) .. 22

gentamicin sulfate (ped) (pf) .. 23

gentamicin sulfate (pf) ........... 23

genteal tears mild ................. 193

GENTEAL TEARS

MODERATE.................... 193

I-10

GENTEAL TEARS SEVERE

GEL .................................. 193

gentlelax ............................... 216

GENVOYA .......................... 100

GEODON ............................... 94

geriaton ................................ 289

geri-dryl.................................. 78

geri-hydrolac ................ 163, 164

geri-lanta .............................. 208

gildagia ................................. 148

GILENYA ............................ 141

GILOTRIF ............................. 40

glatiramer ............................. 141

glatopa .......................... 141, 142

GLEOSTINE.......................... 40

glimepiride ............................. 68

glipizide.................................. 68

glipizide-metformin ............... 68

GLUCAGEN HYPOKIT ....... 62

gluco burst ............................ 120

GLUCOCOM LANCETS .... 179

glucose ................................. 118

glucose gel ........................... 121

glutose 15 ............................. 120

glyburide ................................ 69

glyburide micronized ............. 69

glyburide-metformin .............. 69

glycerin (child) ..... 213, 215, 217

glycolax ................................ 215

glycopyrrolate ...................... 208

glydo ...................................... 16

GLYXAMBI .......................... 62

GOCOVRI ............................. 90

granisetron (pf)....................... 85

granisetron hcl ........................ 85

GRANIX .............................. 111

griseofulvin microsize ............ 71

guaifenesin ........................... 158

guanfacine .................... 122, 142

guanidine .............................. 253

gummi bear multivitamin ..... 289

H HAEGARDA ....................... 111

hailey 24 fe ........................... 148

hair vitamins ......................... 289

hair,skin and nails ........ 283, 301

halobetasol propionate ......... 171

haloperidol ............................. 94

haloperidol decanoate ............ 94

haloperidol lactate .................. 94

HARVONI ........................... 106

HAVRIX (PF) ...................... 243

HEALTHY ACCENTS

UNILET LANCET .......... 179

healthylax ............................. 215

heartburn relief ..................... 207

heartburn treatment .............. 203

heather .................................. 148

hemocyte .............................. 289

heparin (porcine) .................. 109

heparin, porcine (pf) ..... 109, 110

HEPATAMINE 8% ............. 120

HERCEPTIN .......................... 41

HETLIOZ ............................. 275

HEXALEN ............................. 41

HIBERIX (PF) ..................... 243

hi-cal plus vit d ..................... 297

honey bears .......................... 289

honey bears with iron-zinc ... 289

HUMATROPE ..................... 228

HUMIRA ............................. 236

HUMIRA PEDIATRIC

CROHNS START ............ 235

HUMIRA PEN ..................... 236

HUMIRA PEN CROHNS-UC-

HS START ....................... 235

HUMIRA PEN PSOR-UVEITS-

ADOL HS ........................ 235

HUMIRA(CF) ...................... 236

HUMIRA(CF) PEDI CROHNS

STARTER ........................ 236

HUMIRA(CF) PEN ............. 236

HUMIRA(CF) PEN CROHNS-

UC-HS .............................. 236

HUMIRA(CF) PEN PSOR-UV-

ADOL HS......................... 236


INSULIN ............................ 66


KWIKPEN ......................... 66

hydralazine ........................... 131

hydrochlorothiazide .............. 133

HYDROCIL INSTANT ....... 215

hydrocodone-acetaminophen ... 6

hydrocodone-ibuprofen ............ 6

hydrocortisone ...... 171, 226, 248

hydromorphone ........................ 7

hydromorphone (pf) ................. 7

hydroskin .............................. 171

hydroxychloroquine ............... 88

hydroxyprogesterone caproate

.......................................... 231

hydroxyurea ............................ 41

hydroxyzine hcl ...................... 78

hydroxyzine pamoate ........... 253

HYPERRAB (PF) ................ 237

HYPERRAB S/D (PF) ......... 237

HYQVIA .............................. 237

HYSINGLA ER ....................... 7

I ibandronate ........................... 250

IBRANCE .............................. 41

ibu ........................................... 14

ibuprofen .......................... 14, 16

ibuprofen jr strength ............... 14

ICLUSIG ................................ 41

IDHIFA .................................. 41

iferex 150 ............................. 290

ifosfamide ............................... 41

ifosfamide-mesna ................... 41

ILARIS (PF) ......................... 237

ILEVRO ............................... 200

ILUMYA .............................. 237

imatinib .................................. 41

I-11

IMBRUVICA ......................... 41

IMFINZI ................................ 42

imipenem-cilastatin .......... 29, 30

imipramine hcl ....................... 60

imiquimod ............................ 164

IMLYGIC .............................. 42

imodium a-d ......................... 208

IMOGAM RABIES-HT (PF)

.......................................... 237

IMOVAX RABIES VACCINE

(PF) .................................. 243

IMPAVIDO............................ 88

incassia ................................. 148

INCONTROL SUPER THIN

LANCETS........................ 179

INCONTROL ULTRA THIN

LANCETS........................ 179

INCRELEX .......................... 228

INCRUSE ELLIPTA ........... 269

indapamide ........................... 133

indomethacin .......................... 14

indomethacin sodium ............. 15

INFANRIX (DTAP) (PF) .... 243

infant's advil ........................... 15

infant's ibuprofen ................... 15

infant's pain relief ..................... 7

INFLECTRA........................ 237

INGREZZA.......................... 142

INJECT EASE LANCETS .. 180

INLYTA ................................. 42

insect repellent (deet) ........... 163

INSECT REPELLENT

(PICARIDIN) ................... 164

INSTA-GLUCOSE (WITH

DEXTRIN) ....................... 120

INSULIN SYRINGE-NEEDLE

U-100 ............................... 180

INTELENCE........................ 100

INTRALIPID ....................... 120

INTRON A................... 106, 107

introvale ............................... 148

INVACARE LANCETS ...... 180

INVANZ ................................ 30

INVEGA SUSTENNA .... 94, 95

INVEGA TRINZA ................. 95

INVIRASE ........................... 101

INVOKAMET ................. 62, 63

INVOKAMET XR ................. 63

INVOKANA .......................... 63

inzo antifungal........................ 71

IONOSOL-B IN D5W ......... 259

IONOSOL-MB IN D5W ...... 259

IPOL ..................................... 244

ipratropium bromide .... 193, 269

IPRIVASK ........................... 110

irbesartan .............................. 123

irbesartan-hydrochlorothiazide

.......................................... 123

IRESSA .................................. 42

iron ....................................... 290

iron (ferrous sulfate)............. 284

ISENTRESS ......................... 101

ISENTRESS HD .................. 101

isibloom ................................ 148

ISOLYTE-P IN 5 %

DEXTROSE ..................... 259

ISOLYTE-S ......................... 260

isoniazid ................................. 83

isosorbide dinitrate ............... 138

isosorbide mononitrate ......... 138

itraconazole ............................ 71

ivermectin............................... 88

IXEMPRA .............................. 42

IXIARO (PF)........................ 244

J JADENU .............................. 221

JADENU SPRINKLE .......... 221

JAKAFI .................................. 42

jantoven ................................ 110

JANUMET ............................. 63

JANUMET XR ...................... 63

JANUVIA .............................. 63

JARDIANCE ......................... 63

jencycla ................................ 148

JENTADUETO ...................... 63

JENTADUETO XR ......... 63, 64

jinteli .................................... 224

jolivette ................................. 148

jr. acetaminophen ..................... 5

juleber ................................... 148

JULUCA .............................. 101

junel 1.5/30 (21) ................... 148

junel 1/20 (21) ...................... 149

junel fe 1.5/30 (28) ............... 149

junel fe 1/20 (28) .................. 149

junel fe 24 ............................. 149

JUXTAPID ........................... 135

JYNARQUE ......................... 134

K KABIVEN ............................ 120

KALETRA ........................... 101

KALYDECO ........................ 272

KANUMA ............................ 189

kaopectate (bismuth subsalicy)

.......................................... 208

kariva (28) ............................ 149

KEDRAB (PF) ..................... 237

kelnor 1/35 (28) .................... 149

kelnor 1-50 ........................... 149

ketoconazole ..................... 71, 72

ketorolac ......................... 15, 200

KEVEYIS ............................. 253

KEVZARA ........................... 238

KEYTRUDA .......................... 42

kidkare cough/cold ............... 158

kids multivitamin complete .. 290

kimidess (28) ........................ 149

KINERET ............................. 238

KINRIX (PF) ........................ 244

kionex (with sorbitol) ........... 208

KISQALI ................................ 43


...................................... 42, 43

klor-con m10 ........................ 260

klor-con m15 ........................ 260

klor-con m20 ........................ 260

I-12

klor-con sprinkle .................. 260

kobee .................................... 290

konsyl (sugar)....................... 216

konsyl fiber .......................... 215

KONSYL SUGAR-FREE .... 215

KORLYM .............................. 64

kpn........................................ 290

KRYSTEXXA ..................... 189

kurvelo ................................. 149

KUVAN ............................... 189

KYNAMRO ......................... 135

KYPROLIS ............................ 43

L l norgest/e.estradiol-e.estrad 149

labetalol ................................ 127

LACTATED RINGERS ...... 249

lactulose ............................... 208

lamivudine............................ 101

lamivudine-zidovudine ........ 101

lamotrigine ............................. 54

LANCETS............................ 180

LANCETS, SUPER THIN... 180

LANCETS,THIN ................. 180

LANCETS,ULTRA THIN ... 181

lansoprazole ......................... 203

LANTUS SOLOSTAR U-100

INSULIN............................ 66

LANTUS U-100 INSULIN.... 66

larin 1.5/30 (21) ................... 150

larin 1/20 (21) ...................... 150

larin 24 fe ............................. 150

larin fe 1.5/30 (28) ............... 150

larin fe 1/20 (28) .................. 150

larissia .................................. 150

LARTRUVO .......................... 43

latanoprost ............................ 256

LATUDA ............................... 96

laxative (bisacodyl) ...... 214, 217

laxative (glycerin-pediatric) . 218

laxative dietary supplement . 207

laxative peg 3350 ................. 217

LAZANDA .............................. 7

leena 28 ................................ 150

leflunomide .......................... 238

LEMTRADA ....................... 142

LENVIMA ............................. 43

lessina ................................... 150

LETAIRIS ............................ 276

letrozole .................................. 43

leucovorin calcium ............... 253

LEUKERAN .......................... 44

LEUKINE ............................ 111

leuprolide ............................... 44

levalbuterol tartrate .............. 269

levetiracetam .......................... 54

levobunolol........................... 256

levocarnitine ......................... 254

levocarnitine (with sugar) .... 253

levocetirizine .......................... 78

levofloxacin .................... 33, 197

levofloxacin in d5w ................ 33

levoleucovorin calcium ........ 254

LEVOLEUCOVORIN

CALCIUM ....................... 254

levonest (28) ......................... 150

levonorgestrel ....................... 150

levonorgestrel-ethinyl estrad 150

levonorg-eth estrad triphasic 151

levora-28 .............................. 151

levothyroxine ....................... 232

LEXIVA ............................... 101

LIALDA ............................... 249

LIBTAYO .............................. 44

lice cream rinse .................... 174

lice killing .................... 173, 174

lice pyrinyl shampoo ............ 173

lice treatment ................ 173, 174

lidocaine ................................. 17

lidocaine (pf) ............ 16, 17, 125

lidocaine hcl ........................... 17

lidocaine viscous .................... 17

lidocaine-prilocaine ................ 17

life-pack women's ................ 290

lillow .................................... 151

linezolid .................................. 25

linezolid in dextrose 5% ......... 24

linezolid-0.9% sodium chloride

............................................ 24

LINZESS .............................. 208

liothyronine .......................... 232

liquid antacid ........................ 207

liquid calcium with vitamin d

.......................................... 260

lisinopril ............................... 124

lisinopril-hydrochlorothiazide

.......................................... 125

LITE TOUCH LANCETS ... 181

lithium carbonate .................. 142

lithium citrate ....................... 142

little animals ......................... 290

little animals-iron ................. 290

little remedies ....................... 193

little remedies fever and pain ... 7

LIVALO ............................... 136

lo-dose aspirin ........................ 15

LOKELMA .......................... 208

LONHALA MAGNAIR

STARTER ........................ 269

LONSURF.............................. 44

loperamide ............ 207, 208, 209

lopinavir-ritonavir ................ 101

loratadine .......................... 76, 78

loratadine-d ............................ 78

lorazepam ......................... 21, 22

LORBRENA .......................... 44

lorcet (hydrocodone) ................ 7

lorcet hd .................................... 7

lorcet plus ................................. 7

loryna (28) ............................ 151

losartan ................................. 123

losartan-hydrochlorothiazide 123

LOTEMAX .................. 200, 201

lovastatin .............................. 136

low-ogestrel (28) .................. 151

loxapine succinate .................. 96

lubricant eye ......................... 193

I-13

lubricant eye (cmc-glycer)(pf)

.......................................... 193

lubricant eye (cmc-glycerin) 193

lubricant eye (pg-peg 400) ... 195

lubricant eye (propyl glycol) 192

lubricant gel ......................... 192

lubricating drops .................. 192

lubricating plus..................... 193

lubrifresh pm ........................ 194

LUCEMYRA ......................... 18

LUMIGAN ........................... 256

LUMOXITI ............................ 44

LUPRON DEPOT .................. 45


............................................ 44


............................................ 44


............................................ 44

LUPRON DEPOT-PED ....... 228

LUPRON DEPOT-PED (3

MONTH).......................... 228

lutera (28) ............................. 151

LYNPARZA .......................... 45

LYRICA ................................. 54

lysiplex plus ......................... 290

LYSODREN .......................... 45

lyza ....................................... 151

M maalox advanced .................. 209

mag 64 .................................. 260

mag-g ................................... 260

magnesium ........... 258, 260, 265

magnesium (oxide/aa chelate)

.......................................... 261

magnesium chloride ............. 261

magnesium oxide . 208, 209, 210

magnesium sulfate ............... 261

magnesium sulfate in d5w ... 261

magnesium sulfate in water . 261

malathion.............................. 173

mapap (acetaminophen) ....... 7, 8

mapap arthritis pain .................. 8

mapap extra strength ................ 8

maprotiline ............................. 60

marlissa ................................ 151

MARPLAN ............................ 60

masophen ................................. 8

MATULANE ......................... 45

MAVYRET .......................... 106

meclizine ................................ 85

MEDLANCE PLUS LANCETS

.......................................... 181

medroxyprogesterone ........... 231

mefenamic acid ...................... 15

mefloquine ............................. 88

mega multiple/chelated mineral

.......................................... 290

megestrol ........................ 45, 232

MEKINIST............................. 45

MEKTOVI ............................. 45

meloxicam .............................. 15

memantine .............................. 58

men 50 plus multivitamin .... 290

MENACTRA (PF) ............... 244

MENEST .............................. 224

men's daily gummies ............ 284

men's multi-vitamin ............. 284

men's multivitamin gummies 291

men's one daily ..................... 287

MENVEO A-C-Y-W-135-DIP

(PF)................................... 244

MEPHYTON ....................... 291

mercaptopurine....................... 45

meropenem ............................. 30

mesalamine........................... 249

mesna ................................... 254

MESNEX ............................. 254

MESTINON ......................... 254

metaproterenol ..................... 270

metformin ............................... 64

methadone ................................ 8

methadose................................. 8

methenamine hippurate .......... 25

methimazole ......................... 232

methocarbamol ..................... 274

methotrexate sodium .............. 45

methotrexate sodium (pf) ....... 45

methoxsalen .......................... 164

methscopolamine .................. 209

methyclothiazide .................. 134

methylphenidate hcl ..... 142, 143

methylprednisolone .............. 226

methylprednisolone acetate .. 226


.......................................... 226

metipranolol ......................... 256

metoclopramide hcl ...... 209, 210

metoprolol succinate ............ 127

metoprolol ta-hydrochlorothiaz

.......................................... 127

metoprolol tartrate ................ 127

metronidazole ........... 25, 81, 167

metronidazole in nacl (iso-os) 25

mexiletine ............................. 125

mgo ....................................... 210

MIACALCIN ....................... 250

mi-acid .................................. 210

mi-acid gas relief .................. 202

micatin .................................... 72

miconazole 7 .......................... 72

miconazole nitrate .................. 72

miconazole-3 .................... 70, 72

microgestin 1.5/30 (21) ........ 151

microgestin 1/20 (21) ........... 151

microgestin fe 1.5/30 (28) .... 151

microgestin fe 1/20 (28) ....... 151

MICROLET LANCET......... 181

midodrine ............................. 122

miglustat ............................... 189

mili ....................................... 151

milk of magnesia .......... 213, 216

milltrium senior .................... 291

milrinone .............................. 131

milrinone in 5 % dextrose .... 131

mimvey lo............................. 224

I-14

mineral oil .... 166, 213, 216, 217

MINERAL OIL .................... 254

mineral oil extra heavy......... 217

mineral oil heavy.................. 216

minitran ................................ 139

minocycline ............................ 35

minoxidil .............................. 139

mintox .................................. 210

mintox maximum strength ... 210

mintox plus........................... 210

mirtazapine ....................... 60, 61

misoprostol ........................... 203

mitoxantrone .......................... 46

M-M-R II (PF) ..................... 244

moisturizing lubricant .......... 194

molindone .............................. 96

mometasone ......................... 171

mondoxyne nl......................... 35

monistat 7 ............................... 72

MONOLET LANCETS ....... 181

MONOLET THIN LANCETS

.......................................... 181

mono-linyah ......................... 151

mononessa (28) .................... 152

montelukast .......................... 268

morphine .................................. 9

MORPHINE ............................. 9

morphine concentrate ............... 9

motion sickness ...................... 84

motion sickness relief(mecliz)

...................................... 84, 87

MOVANTIK ........................ 210

MOVIPREP ......................... 216

MOXEZA ............................ 197

moxifloxacin .................. 33, 197

MOZOBIL ........................... 111

mucinex fast-max dm max ... 159

mucus dm ..................... 158, 159

mucus dm max er ................. 159

mucus relief .......................... 159

mucus relief cough ............... 160

mucus relief dm.................... 159

mucus relief er ...................... 159

MULPLETA ........................ 111

MULTAQ............................. 125

multi complete with iron ...... 291

multi for her ......................... 291

multi-day with iron............... 291

multi-delyn with iron ........... 291

multilex ................................ 291

multilex-t and m ................... 291

multiple vitamin-minerals .... 291

multiple vitamins.................. 291

multivitamin ................. 292, 298

multivitamin 50 plus ............ 296

multi-vitamin hp/minerals .... 292

multivitamin with iron . 291, 298

multivitamin with minerals .. 292

multi-vite .............................. 292

mupirocin ............................. 167

muro 128 .............................. 194

my choice ............................. 152

my favorite multiple ............. 292

my way ................................. 152

mycophenolate mofetil ......... 238

mycophenolate mofetil hcl ... 238

MYGLUCOHEALTH

LANCETS ........................ 181

MYLOTARG ......................... 46

MYRBETRIQ ...................... 220

my-vitalife ............................ 292

myzilra ................................. 152

N nabumetone ............................ 15

nafcillin .................................. 31

nafcillin in dextrose iso-osm .. 31

NAGLAZYME .................... 189

naloxone ................................. 18

naltrexone ............................... 18

NAMZARIC .......................... 58

naproxen ................................. 15

NARCAN ............................... 19

nasal decongestant (pe) ........ 122

nasal relief ............................ 194

nasal spray (oxymetazoline) . 192

nasal spray extra moisturizing

.......................................... 194

nasal spray sinus ................... 195

NASCOBAL ........................ 292

NATACYN .......................... 197

NATPARA ........................... 250

NATRAPEL ......................... 164

natural b-100 complex .......... 299

natural balance tears ............. 194

natural calcium ..................... 261

natural fiber laxative therapy 216

natural tears (pf) ................... 192

natura-lax .............................. 217

NEBUPENT ........................... 88

necon 0.5/35 (28) ................. 152

nefazodone ............................. 61

neomycin ................................ 23

neomycin-bacitracin-poly-hc 197

neomycin-bacitracin-polymyxin

.......................................... 197

neomycin-polymyxin b gu ... 167

neomycin-polymyxin b-

dexameth .......................... 197

neomycin-polymyxin-

gramicidin ........................ 198

neomycin-polymyxin-hc ...... 198

neo-polycin ........................... 198

neo-polycin hc ...................... 198

neosporin (neo-bac-polym) .. 167

neo-synephrine 12 h spr (oxym)

.......................................... 194

nephplex rx ........................... 292

NEPHRAMINE 5.4 % ......... 120

nephron fa ............................. 292

NERLYNX ............................. 46

NEULASTA ......................... 111

NEUPOGEN ........................ 111

NEUPRO ................................ 90

nevirapine ............................. 102

new day ................................ 152

NEXAVAR ............................ 46

I-15

next choice one dose ............ 152

niacin .................................... 136

niacinamide .................. 136, 292

niacor.................................... 136

nicardipine............................ 132

nicorelief ................................ 19

nicotine ................................... 19

nicotine (polacrilex) ......... 18, 19

NICOTROL ........................... 19

nifedipine ............................. 132

nikki (28) .............................. 152

nilutamide .............................. 46

NINLARO.............................. 46

NITRO-BID ......................... 139

nitrofurantoin macrocrystal .... 25

nitrofurantoin monohyd/m-cryst

............................................ 25

nitroglycerin ......................... 139

NITYR ................................. 189

NIVESTYM ......................... 111

nizatidine .............................. 203

non-aspirin ..................... 5, 9, 11

non-aspirin childrens ................ 9

non-aspirin extra strength ........ 5

non-aspirin jr strength .............. 5

non-aspirin pain relief ............ 11

nora-be ................................. 152

NORDITROPIN FLEXPRO 229

norepinephrine bitartrate ...... 131

norethindrone (contraceptive)

.......................................... 152

norethindrone acetate ........... 232

norethindrone ac-eth estradiol

.................................. 152, 224

norethindrone-e.estradiol-iron

.......................................... 152

norgestimate-ethinyl estradiol

.......................................... 153

norlyda ................................. 153

norlyroc ................................ 153

NORMOSOL-M IN 5 %

DEXTROSE ..................... 261

NORMOSOL-R ................... 261

NORMOSOL-R PH 7.4 ....... 262

nortemp .................................... 9

NORTHERA ........................ 122

nortrel 0.5/35 (28) ................ 153

nortrel 1/35 (21) ................... 153

nortrel 1/35 (28) ................... 153

nortrel 7/7/7 (28) .................. 153

nortriptyline ............................ 61

NORVIR .............................. 102

NOVA SAFETY LANCETS 181

NOVA SUREFLEX LANCETS

.......................................... 181

NOVOLIN 70/30 U-100

INSULIN ............................ 66

NOVOLIN 70-30 FLEXPEN U-

100 ...................................... 66

NOVOLIN N NPH U-100

INSULIN ............................ 66

NOVOLIN R REGULAR U-

100 INSULN ...................... 67

NOVOLOG FLEXPEN U-100

INSULIN ............................ 67

NOVOLOG MIX 70-30 U-100

INSULN ............................. 67

NOVOLOG MIX 70-

30FLEXPEN U-100 ........... 67

NOVOLOG PENFILL U-100

INSULIN ............................ 67

NOVOLOG U-100 INSULIN

ASPART ............................ 67

NOXAFIL .............................. 72

NUCALA ............................. 272

NUCYNTA ............................ 10

NUCYNTA ER ...................... 10

NUEDEXTA ........................ 143

nu-iron .................................. 292

NULOJIX ............................. 238

NUPLAZID ............................ 96

NUTRILIPID ....................... 120

NUTROPIN AQ NUSPIN ... 229

NUVARING ........................ 153

nyamyc ................................... 72

nystatin ............................. 72, 73

nystop ..................................... 73

nytol........................................ 79

O OCALIVA ............................ 210

ocean nasal ........................... 194

OCREVUS ........................... 143

OCTAGAM.......................... 238

octreotide acetate .................. 229

ocutabs .................................. 292

ODEFSEY ............................ 102

ODOMZO .............................. 46

OFEV ................................... 272

off active ............................... 164

off deep woods ..................... 164

off deep woods dry ............... 164

off deep woods sportsmen .... 164

off familycare (with deet) ..... 164

ofloxacin ......................... 33, 198

ogestrel (28) ......................... 153

okebo ...................................... 35

olanzapine .............................. 96

olmesartan ............................ 123

olmesartan-hydrochlorothiazide

.......................................... 123

olopatadine ........................... 194

OLUMIANT ........................ 238

omega-3 acid ethyl esters ..... 136

omeprazole ................... 202, 203

omeprazole magnesium ........ 203

OMNITROPE ...................... 229

ON CALL LANCET ............ 181

ON CALL PLUS LANCET . 181

ONCASPAR .......................... 46

onccor ................................... 293

once daily ............................. 293

oncovite ................................ 293

ondansetron ............................ 86

ondansetron hcl ...................... 86

ondansetron hcl (pf) ............... 85

one daily ............................... 293

I-16

one daily complete ............... 293

one daily energy ................... 297

one daily essential ........ 289, 293

one daily for women ............ 293

one daily maximum...... 293, 297

one daily multi-vit w-mineral

.......................................... 293

one daily multivitamin . 293, 294

one daily multivit-iron(folic) 293

one daily plus iron ........ 289, 293

one daily plus minerals ........ 294

one daily with iron ............... 293

one-a-day essential ............... 294

one-a-day maximum formula294

one-a-day teen advantage ..... 294

ONETOUCH DELICA

LANCETS........................ 182

ONETOUCH SURESOFT

LANCING DEV .............. 182

ONETOUCH ULTRASOFT

LANCETS........................ 182

ONFI ...................................... 22

ONIVYDE ............................. 46

ON-THE-GO LANCETS..... 182

opcicon one-step .................. 153

OPDIVO ................................ 46

OPSUMIT ............................ 276

option-2 ................................ 153

oral saline laxative ............... 218

oralone.................................. 161

oralyte .................................. 262

ORENCIA ............................ 239

ORENCIA (WITH MALTOSE)

.......................................... 239

ORENCIA CLICKJECT ...... 239

ORENITRAM ...................... 276

ORFADIN ............................ 189

ORILISSA.................... 229, 230

ORKAMBI ........................... 273

orsythia ................................. 154

oseltamivir............................ 105

OSMOLEX ER ...................... 90

OTEZLA .............................. 239

OTEZLA STARTER ........... 239

OTREXUP (PF) ................... 239

oxacillin .................................. 31

oxcarbazepine ......................... 55

OXTELLAR XR .................... 55

oxybutynin chloride ............. 220

oxycodone .............................. 10

oxycodone-acetaminophen ..... 10

oxycodone-aspirin .................. 11

OXYCONTIN ........................ 11

oysco 500/d .......................... 294

oysco-500 ............................. 262

oyster shell calcium 500 ....... 262

oyster shell calcium-vit d2 ... 294

oyster shell calcium-vit d3 .. 294,

297

oystercal-d ............................ 294

OZEMPIC .............................. 64

P pacerone ............................... 125

pain and fever ......................... 11

pain relief ................................. 5

pain relief adult ........................ 5

pain reliever extra strength ....... 6

pain reliever jr strength .......... 11

paliperidone ............................ 96

PALYNZIQ .......................... 189

PANRETIN .......................... 164

pantoprazole ......................... 203

paricalcitol .................... 250, 251

PARICALCITOL ................. 251

paroex oral rinse ................... 161

paromomycin ......................... 88

paroxetine hcl ......................... 61

PASER ................................... 83

PAXIL .................................... 61

p-col rite ............................... 217

pedia tri-vite ......................... 294

pediacare fever reducer .......... 11

PEDIARIX (PF) ................... 244

pediatric electrolyte ..... 258, 259,

265

pediatric freezer pops ........... 265

PEDVAX HIB (PF).............. 244

peg 3350-electrolytes ........... 216

PEGANONE .......................... 55

PEGASYS ............................ 107

PEGASYS PROCLICK ....... 107

PEGINTRON ....................... 107

PEN NEEDLE, DIABETIC . 182

penicillin g potassium ............ 32

penicillin g procaine ............... 32

penicillin v potassium ............ 32

PENNSAID ............................ 15

PENTACEL (PF) ................. 245

PENTACEL DTAP-IPV

COMPNT (PF) ................. 245

PENTAM ............................... 88

pentoxifylline ....................... 113

pep-t-med ............................. 209

PERIKABIVEN ................... 121

perindopril erbumine ............ 125

periogard .............................. 161

permethrin ............................ 173

perphenazine .......................... 97

perphenazine-amitriptyline .... 61

perry prenatal ....................... 294

persa-gel ............................... 165

PERSERIS.............................. 97

pfizerpen-g ............................. 32

pharbetol ................................. 11

phenadoz ................................ 86

phenelzine .............................. 61

phenobarbital .......................... 55

phenylephrine hcl ......... 122, 194

phenytoin ................................ 55

phenytoin sodium ................... 55

phenytoin sodium extended .... 55

philith ................................... 154

phillips .................................. 210

phillips' liqui-gels ................. 216

PHOSLYRA ......................... 219

I-17

phytonadione (vitamin k1) ... 295

PICATO ............................... 165

PIFELTRO ........................... 102

pilocarpine hcl .............. 161, 256

pimozide ................................. 97

pimtrea (28) .......................... 154

pioglitazone ............................ 64

piperacillin-tazobactam .......... 32

pirmella ................................ 154

PLASMA-LYTE 148 ........... 262

PLASMA-LYTE A .............. 262

PLASMA-LYTE-56 IN 5 %

DEXTROSE ..................... 262

PLEGRIDY .......................... 143

pnv cmb#95-ferrous fumarate-fa

.......................................... 296

podofilox .............................. 165

polycin.................................. 198

polyethylene glycol 3350 .... 216,

217

poly-iron ............................... 295

polymyxin b sulfate................ 25

polymyxin b sulf-trimethoprim

.......................................... 198

polyvitamin with iron ........... 295

poly-vitamins ....................... 295

POMALYST .......................... 46

portia .................................... 154

PORTRAZZA ........................ 47


.................................. 262, 263

potassium chloride ....... 263, 264

potassium chloride in 0.9%nacl

.......................................... 263

potassium chloride in 5 % dex

.......................................... 263

potassium chloride in lr-d5 .. 263

potassium chloride in water . 263

potassium chloride-0.45 % nacl

.......................................... 264


.......................................... 264


.......................................... 264


.......................................... 264

potassium citrate .......... 264, 265

POTELIGEO .......................... 47

PRADAXA .......................... 110

PRALUENT PEN ................ 137

pramipexole ............................ 90

prasugrel ............................... 113

pravastatin ............................ 137

prazosin ................................ 122

prednicarbate ........................ 172

prednisolone ......................... 226

prednisolone acetate ............. 201

prednisolone sodium phosphate

.......................... 201, 226, 227

prednisone ............................ 227

PREMARIN ......................... 224

PREMPHASE ...................... 224

PREMPRO ........................... 224

prenatal ......... 290, 295, 296, 299

prenatal formula ................... 295

prenatal multivitamins.......... 295

prenatal plus (calcium carb) . 295

prenatal tablet ....................... 297

prenatal vitamin.... 284, 295, 296

prenatal vitamin plus low iron

.......................................... 296

prenatal vit-iron fum-folic ac 296

prenatal vits96-iron fum-folic

.......................................... 295

preparation h hydrocortisone 172

PRESSURE ACTIVATED

LANCETS ........................ 182

prevalite ................................ 137

previfem ............................... 154

PREVYMIS ......................... 105

PREZCOBIX ....................... 102

PREZISTA ........................... 102

PRIFTIN................................. 83

PRIMAQUINE....................... 89

primidone ............................... 56

PRIVIGEN ........................... 239

PRO COMFORT LANCET . 182

PROAIR HFA ...................... 270

PROAIR RESPICLICK ....... 270

probenecid .............................. 74

probenecid-colchicine ............ 74

procainamide ........................ 126

PROCALAMINE 3%........... 121

prochlorperazine ..................... 86

prochlorperazine edisylate ..... 86

prochlorperazine maleate ....... 86

PROCRIT ............................. 112

procto-med hc ....................... 172

proctosol hc .......................... 172

proctozone-hc ....................... 172

PROCYSBI .......................... 190

PRODIGY LANCETS ......... 182

PRODIGY TWIST TOP

LANCET .......................... 182

progesterone in oil ................ 232

progesterone micronized ...... 232

PROGLYCEM ..................... 254

PROGRAF ........................... 239

PROLASTIN-C .................... 273

PROLENSA ......................... 201

PROLEUKIN ......................... 47

PROLIA ............................... 251

PROMACTA........................ 112

promethazine .................... 79, 86

promethazine-dm .................. 159

promethazine-phenylephrine .. 79

promethegan ........................... 87

promolaxin ........................... 217

propafenone .......................... 126

propantheline .......................... 52

proparacaine ......................... 194

propranolol ........................... 128

propranolol-hydrochlorothiazid

.......................................... 128

propylthiouracil .................... 232

PROQUAD (PF) .................. 245

I-18

prosight ................................ 296

PROSOL 20 % ..................... 121

protamine ............................. 113

protriptyline............................ 61

pseudoephedrine hcl............. 159

PULMOZYME .................... 190

pure and gentle disposable ... 217

purelax.................................. 213

PURIXAN .............................. 47

PUSH BUTTON SAFETY

LANCETS........................ 183

pyrazinamide .......................... 83

pyridostigmine bromide ....... 254

pyridoxine (vitamin b6) 284, 296

Q QUADRACEL (PF) ............. 245

quasense ............................... 154

quetiapine ............................... 97

QUFLORA ........................... 296

quinapril ............................... 125

quinidine sulfate ................... 126

QVAR .................................. 268

QVAR REDIHALER........... 268

R RABAVERT (PF) ................ 245

RADICAVA ........................ 143

raloxifene ............................. 225

ramipril ................................. 125

RANEXA ............................. 132

ranitidine hcl ................ 202, 204

RAPAMUNE ....................... 239

rasagiline ................................ 91

RASUVO (PF) ..................... 240

RAVICTI ............................. 210

RAYALDEE ........................ 251

READYLANCE SAFETY

LANCETS........................ 183

ready-to-use enema .............. 214

REBIF (WITH ALBUMIN) 143

REBIF REBIDOSE .............. 144

REBIF TITRATION PACK 144

reclipsen (28) ....................... 154

RECOMBIVAX HB (PF) .... 245

refenesen .............................. 160

REFRESH CELLUVISC ..... 195

REFRESH CLASSIC (PF)... 195

REFRESH LACRI-LUBE ... 195

REFRESH OPTIVE

ADVANCED (PF) ........... 199

reguloid ................................ 217

RELENZA DISKHALER .... 105

RELIAMED LANCET ........ 183

RELIAMED SAFETY SEAL

LANCETS ........................ 183

RELION THIN LANCETS . 183

RELION ULTRA THIN PLUS

LANCETS ........................ 183

RELISTOR................... 210, 211

remedy phytoplex antifungal . 73

REMICADE ......................... 240

REMODULIN ...................... 276

RENAGEL ........................... 219

rena-vite rx ........................... 297

RENFLEXIS ........................ 254

repaglinide .............................. 64

REPATHA PUSHTRONEX 137

REPATHA SURECLICK .... 137

REPATHA SYRINGE ......... 137

repel 100 ............................... 165

repel family .......................... 165

repel hunter's ........................ 165

repel sportsmen .................... 165

repel sportsmen dry .............. 165

repel sportsmen max ............ 165

RESCRIPTOR ..................... 102

RESTASIS ........................... 201

RETACRIT .......................... 112

retaine hpmc (pf) .................. 195

retaine nacl ........................... 195

RETROVIR .......................... 102

REVCOVI ............................ 190

revive plus ............................ 193

REVLIMID ............................ 47

revonto ................................. 274

REXULTI ............................... 97

REYATAZ ........................... 103

RHOPRESSA ....................... 256

ribasphere ............................. 108

ribavirin ................................ 108

RIDAURA............................ 240

rifabutin .................................. 83

rifampin .................................. 83

ri-gel ..................................... 211

ri-gel ii .................................. 211

right step prenatal vitamins .. 297

RIGHTEST GL300 LANCETS

.......................................... 183

riginic ................................... 211

riluzole .................................. 144

rimantadine ........................... 105

ri-mox ................................... 211

RISPERDAL CONSTA ......... 97

risperidone ........................ 97, 98

ritonavir ................................ 103

RITUXAN .............................. 47

RITUXAN HYCELA............. 47

rivastigmine ............................ 58

rivastigmine tartrate ............... 58

rizatriptan ............................... 82

robafen .................................. 160

robafen dm ........................... 160

robitussin cough-chest cong dm

.......................................... 160

ropinirole ................................ 91

rosadan ................................. 167

rosuvastatin .......................... 137

ROTARIX ............................ 246

ROTATEQ VACCINE ........ 246

ROWEEPRA .......................... 56

RUBRACA ............................ 47

RYDAPT ................................ 47

S SABRIL.................................. 56

safe tussin dm ....................... 160

SAFETY LANCETS ............ 183

SAFETY SEAL LANCETS . 183

I-19

SAFETY-LET LANCETS ... 183

SAIZEN ............................... 230

SAIZEN SAIZENPREP....... 230

saline mist ............................ 195

saline nasal ........................... 192

saline nose ............................ 192

SANDOSTATIN LAR DEPOT

.......................................... 230

sani-supp (infant) ................. 218

SANTYL .............................. 165

SAPHRIS ............................... 98

SAVELLA ........................... 144

scooby-doo one a day........... 297

scopolamine base ................... 87

scot-tussin expectorant ......... 160

selegiline hcl .......................... 91

selenium sulfide ................... 168

SELZENTRY ....................... 103

senexon ................................ 218

senexon-s.............................. 218

senior tabs ............................ 298

senna .................................... 218

senna plus ............................. 213

senna-s.................................. 219

sennosides-docusate sodium 218

senokot-s .............................. 218

SENSIPAR ........................... 251

sentry .................................... 298

sentry (with lutein) ............... 298

sentry senior ......................... 298

SEREVENT DISKUS .......... 270

SEROSTIM .......................... 230

sertraline ................................. 61

setlakin ................................. 154

sevelamer carbonate ............. 219

sharobel ................................ 154

SHINGRIX (PF) .................. 246

SIGNIFOR ........................... 230

silace .................................... 218

siladryl sa ............................... 79

sildenafil (antihypertensive). 276

SILENOR ............................. 275

SILIQ ................................... 165

siltussin sa ............................ 160

silver sulfadiazine ................ 168

SIMBRINZA ........................ 256

simply sleep............................ 79

SIMPONI ............................. 240

SIMPONI ARIA .................. 240

simvastatin ........................... 137

SINGLE-LET ....................... 184

sinus pe decongestant ........... 122

sinus pressure-cong relief pe 122

sinus relief (oxymetazoline) . 195

sirolimus ............................... 240

SIRTURO............................... 83

skin treatment ....................... 163

sleep tablet (diphenhydramine)

............................................ 79

SMART SENSE LANCETS 184

SMARTEST LANCET ........ 184

smoflipid .............................. 121

smoothlax ............................. 218

sochlor .................................. 195

sodium acetate ...................... 265

sodium bicarbonate .............. 211

sodium chloride ... 195, 249, 265,

273

sodium chloride 0.45 % ....... 265

sodium chloride 0.9 % ......... 265

sodium lactate ...................... 265

sodium phenylbutyrate ......... 211

sodium phosphate ................. 266

sodium polystyrene (sorb free)

.......................................... 211

sodium polystyrene sulfonate

.......................................... 211

SOFT TOUCH LANCETS .. 184

SOLIQUA 100/33 .................. 67

SOLTAMOX ......................... 47

SOLU-CORTEF (PF) .......... 227

SOLUS V2 LANCETS ........ 184

SOMATULINE DEPOT ...... 230

SOMAVERT ........................ 230

soothe (bismuth subsalicylate)

.......................................... 211

soothe regular strength ......... 212

soothing pureway-c .............. 299

sorine .................................... 128

sotalol ................................... 128

sotalol af ............................... 128

SOVALDI ............................ 106

spectravite adult ................... 284

spectravite adult 50 plus ....... 284

spectravite advanced formula

.......................................... 284

spectravite senior .................. 284

spectravite ultra men's sr ...... 284

spectravite ultra women ....... 284

SPIRIVA RESPIMAT ......... 270

SPIRIVA WITH

HANDIHALER................ 270

spironolactone ...................... 134

sprintec (28) ......................... 154

SPRITAM .............................. 56

SPRYCEL ........................ 47, 48

sps (with sorbitol) ................. 212

sronyx ................................... 154

ssd ......................................... 168

st joseph aspirin ...................... 16

st. joseph aspirin ..................... 16

stavudine .............................. 103

STELARA ............................ 240

STERILANCE TL ............... 184

STIOLTO RESPIMAT ........ 271

STIVARGA............................ 48

stomach relief ....................... 211

stool softener ................ 218, 219

stool softener (docusate cal) . 219

stool softener-laxative .......... 213

stop smoking aid .................... 19

STRENSIQ ........................... 190

streptomycin ........................... 23

stress b with zinc .................. 299

stress formula ....................... 299

stress formula 600 c ............. 300

I-20

stress formula plus iron ........ 299

stress formula with iron 299, 300

stress formula with iron(sulf)299

stress formula with zinc ....... 299

STRIBILD............................ 103

STRIVERDI RESPIMAT .... 271

SUBLOCADE........................ 11

SUBOXONE .......................... 20

subvenite ................................ 56

sucralfate .............................. 204

sudogest................................ 160

sudogest pe ........................... 122

sudogest sinus and allergy ..... 79

sulfacetamide sodium........... 199

sulfacetamide sodium (acne) 168

sulfacetamide-prednisolone . 199

sulfadiazine ............................ 33

sulfamethoxazole-trimethoprim

...................................... 33, 34

sulfasalazine ......................... 249

sulfatrim ................................. 34

sulindac .................................. 16

sumatriptan ............................. 82

sumatriptan succinate ............. 82

sunvite .................................. 300

super b complex-vitamin c .. 284,

299

super b maxi complex .......... 300

super b-50 complex .............. 300

super b-50 complex plus ...... 300

super multiple....................... 300

super multivitamin ............... 300

super quints .......................... 300

super quints b-50 .................. 300

super thera vite m ................. 300

SUPER THIN LANCETS ... 184

superior 35 ........................... 300

superplex-t............................ 300

suphedrin .............................. 160

support.................................. 300

SUPPRELIN LA .................. 231

SUPRAX ................................ 28

SUPREP BOWEL PREP KIT

.......................................... 219

SURE COMFORT INS. SYR.

U-100 ............................... 184

SURE COMFORT LANCETS

.......................................... 184

SURE-LANCE ..................... 184

SURE-LANCE ULTRA THIN

.......................................... 184

SURE-TOUCH LANCET.... 184

SUTENT ................................ 48

syeda..................................... 154

SYLATRON ........................ 107

SYLVANT ............................. 48

SYMBICORT ...................... 268

SYMDEKO .......................... 273

SYMFI ................................. 103

SYMFI LO ........................... 103

SYMLINPEN 120 .................. 64

SYMLINPEN 60 .................... 65

SYMTUZA .......................... 103

SYNAGIS ............................ 105

SYNAREL ........................... 231

SYNERCID ............................ 26

SYNJARDY ........................... 65

SYNJARDY XR .................... 65

SYNRIBO .............................. 48

SYSTANE GEL ................... 196

T tab-a-vite .............................. 301

tab-a-vite/iron ....................... 301

tab-a-vite-minerals ............... 301

TABLOID .............................. 48

tacrolimus ............................. 241

tactinal .................................... 12

tactinal extra strength ............. 12

tadalafil (antihypertensive) .. 276

TAFINLAR ............................ 48

TAGRISSO ............................ 48

TAKHZYRO ........................ 254

TALTZ AUTOINJECTOR .. 165

TALTZ SYRINGE ............... 166

TALZENNA .......................... 48

tamoxifen ................................ 48

tamsulosin ............................ 221

TARCEVA ............................. 48

TARGRETIN ......................... 48

tarina fe 1/20 (28) ................. 154

TASIGNA ........................ 48, 49

TAVALISSE ........................ 113

tazarotene ............................. 173

tazicef ..................................... 28

TAZORAC ........................... 173

taztia xt ................................. 129

tears again (pva) ................... 196

TECENTRIQ.......................... 49

TECFIDERA ........................ 144

TECHLITE LANCETS ........ 185

TECHNIVIE ........................ 106

TEFLARO .............................. 28

TEKTURNA ........................ 138

TEKTURNA HCT ............... 138

TELCARE LANCETS ......... 185

telmisartan ............................ 123

temazepam .............................. 22

TEMODAR ............................ 49

TENIVAC (PF) .................... 246

tenofovir disoproxil fumarate

.......................................... 103

terazosin ............................... 221

terbinafine hcl ......................... 73

terbutaline ............................. 271

terconazole ............................. 81

testosterone ................... 222, 223

testosterone cypionate .......... 222

testosterone enanthate .......... 222

TETANUS,DIPHTHERIA TOX

PED(PF) ........................... 246

TETANUS-DIPHTHERIA

TOXOIDS-TD.................. 246

tetrabenazine ........................ 144

tetracycline ............................. 35

THALOMID ........................ 254

the magic bullet .................... 216

I-21

theophylline.......................... 271

thera...................................... 301

thera m plus (ferrous fumarat)

.......................................... 301

thera-d .................................. 301

theradex m ............................ 301

thera-m ................................. 301

therapeutic liquid ................. 290

therapeutic-m ....................... 301

therapeutic-m vitamin/minerals

.......................................... 299

thera-tabs .............................. 301

thera-tabs m .......................... 301

theratrum complete 50 plus/lut

.......................................... 301

theratrum complete 50 plus-lyc

.......................................... 302

theratrum complete with lutein

.......................................... 302

therems ................................. 302

therems-m ............................ 302

thiamine hcl (vitamin b1) ..... 302

THIN LANCETS ................. 185

THIOLA ............................... 255

thioridazine ............................ 98

thiotepa ................................... 49

thiothixene.............................. 98

tiagabine ................................. 56

TIBSOVO .............................. 49

TICE BCG ........................... 247

tigecycline .............................. 35

tilia fe ................................... 155

timolol maleate............. 128, 256

TIVICAY ............................. 103

tizanidine .............................. 274

TOBI PODHALER ................ 23

tobramycin ........................... 199

tobramycin in 0.225 % nacl ... 23

tobramycin in 0.9 % nacl ....... 23

tobramycin sulfate .................. 23

tobramycin-dexamethasone . 199

TOLAK ................................ 166

tolazamide .............................. 69

tolnaftate................................. 73

tolterodine ............................ 220

TOPCARE UNIVERSAL1

LANCET .......................... 185

topiramate............................... 56

toposar .................................... 49

torsemide .............................. 134

total b/c ................................. 302

total home insect repellent ... 163

totalday multiple .................. 302

TOTECT .............................. 255

TOUJEO MAX U-300

SOLOSTAR ....................... 68

TOUJEO SOLOSTAR U-300

INSULIN ............................ 68

TOVIAZ ............................... 220

TRACLEER ......................... 276

TRADJENTA......................... 65

tramadol ................................. 12

tramadol-acetaminophen ........ 12

trandolapril ........................... 125

tranexamic acid .................... 113

TRANSDERM-SCOP ............ 87

tranylcypromine ..................... 61

TRAVASOL 10 % ............... 121

TRAVATAN Z .................... 257

travel sickness ........................ 87

travel sickness (meclizine) ..... 87

travel-ease (meclizine) ........... 87

trazodone ................................ 61

TREANDA............................. 49

TRECATOR........................... 83

TRELEGY ELLIPTA .......... 271

TRELSTAR ........................... 49

TREMFYA........................... 166

tretinoin ................................ 173

tretinoin (chemotherapy) ........ 49

tri femynor............................ 155

triamcinolone acetonide ...... 161,

172, 227

triamterene-hydrochlorothiazid

.......................................... 134

tri-buffered aspirin ................. 16

trientine ................................ 221

tri-estarylla ........................... 155

trifluoperazine ........................ 98

trifluridine ............................ 199

trihexyphenidyl ...................... 91

tri-legest fe ........................... 155

tri-linyah ............................... 155

tri-lo-estarylla ....................... 155

tri-lo-marzia .......................... 155

tri-lo-sprintec ........................ 155

trilyte with flavor packets ..... 219

trimethoprim ........................... 26

tri-mili .................................. 155

trimipramine ........................... 62

trinessa (28) .......................... 155

TRINTELLIX ........................ 62

triple antibiotic ............. 166, 168

triple paste af .......................... 73

tri-previfem (28) ................... 155

TRIPTODUR ....................... 231

tri-sprintec (28) ..................... 155

TRIUMEQ............................ 103

tri-vi-sol ................................ 302

trivora (28) ........................... 156

tri-vylibra .............................. 156

TROGARZO ........................ 103

TROKENDI XR ..................... 56

TROPHAMINE 10 % .......... 121

TROPHAMINE 6% ............. 121

TRUE COMFORT LANCET

.......................................... 185

trueplus glucose .................... 121

TRUEPLUS LANCETS....... 185

TRULICITY ........................... 65

TRUMENBA ....................... 247

TRUVADA .......................... 104

tulana .................................... 156

tusnel diabetic ....................... 161

I-22

tussin cough-chest congestion

.......................................... 160

tussin cough-cold-flu ........... 161

tussin dm .............................. 160

TWINRIX (PF) .................... 247

TWIST LANCETS .............. 185

TYBOST .............................. 255

TYKERB................................ 49

tylophen.................................. 12

TYMLOS ............................. 251

TYPHIM VI ......................... 247

TYSABRI ............................ 241

TYVASO ............................. 277

U UCERIS ............................... 249

UDENYCA .......................... 112

ULORIC ................................. 74

ULTILET BASIC LANCETS

.......................................... 185

ULTILET CLASSIC

LANCETS........................ 185

ULTILET LANCETS .......... 185

ULTILET SAFETY LANCETS

.......................................... 185

ultimate men's complete 50+ 299

ultra b-100 complex ............. 302

ULTRA FINE LANCETS ... 186

ULTRA THIN II LANCETS 186

ULTRA THIN LANCETS ... 186

ULTRA THIN PLUS

LANCETS........................ 186

ULTRA TLC LANCETS ..... 186

ULTRA-CARE LANCETS . 186

ULTRALANCE LANCETS 186

ULTRA-THIN II LANCETS186

ultrathon ............................... 166

unicomplex-m ...................... 302

UNILET COMFORTOUCH

LANCET .......................... 186

UNILET EXCELITE II

LANCET .......................... 186

UNILET EXCELITE LANCET

.......................................... 186

UNILET GP LANCET ........ 187

UNILET LANCET .............. 187

UNILET SUPER THIN

LANCETS ........................ 187

UNISOM (DOXYLAMINE) . 79

UNISTIK 3 COMFORT

LANCET .......................... 187

UNISTIK 3 EXTRA LANCET

.......................................... 187

UNISTIK 3 GENTLE .......... 187

UNISTIK 3 LANCETS ........ 187

UNISTIK 3 NORMAL

LANCET .......................... 187

UNISTIK CZT LANCET .... 187

UNISTIK PRO LANCET .... 187

UNISTIK SAFETY.............. 187

UNISTIK TOUCH LANCETS

.......................................... 188

UNITUXIN ............................ 50

UNIVERSAL 1 LANCETS . 188

UPTRAVI ............................ 277

ursodiol................................. 212

V valacyclovir .......................... 108

VALCHLOR ........................ 166

valganciclovir ....................... 108

valproate sodium .................... 56

valproic acid ........................... 57

valproic acid (as sodium salt) . 57

valsartan ............................... 123

valsartan-hydrochlorothiazide

.......................................... 124

VALSTAR ............................. 50

vancomycin ............................ 26

VAQTA (PF)........................ 247

VARIVAX (PF) ................... 247

VASCEPA ........................... 137

v-c forte ................................ 302

vegetable laxative ................. 214

VELCADE ............................. 50

velivet triphasic regimen (28)

.......................................... 156

VELPHORO ........................ 219

VELTASSA ......................... 212

VEMLIDY ........................... 104

VENCLEXTA ........................ 50

VENCLEXTA STARTING

PACK ................................. 50

venlafaxine ............................. 62

verapamil .............................. 129

VERSACLOZ ........................ 98

VERZENIO ............................ 50

vestura (28) ........................... 156

VIBERZI .............................. 212

vic-forte ................................ 302

vicks qlearquil(oxymetazoline)

.......................................... 196

vicks sinex 12-hour .............. 196

VICTOZA .............................. 65


.......................................... 104


.......................................... 104

VIDEX EC ........................... 104

VIEKIRA PAK .................... 106

VIEKIRA XR ....................... 106

vienva ................................... 156

vigabatrin ................................ 57

vigadrone ................................ 57

VIIBRYD ............................... 62

VIMIZIM ............................. 190

VIMPAT ................................ 57

vinorelbine .............................. 50

viorele (28) ........................... 156

VIRACEPT .......................... 104

VIRAMUNE ........................ 104

VIREAD ............................... 104

vision .................................... 302

vision plus lutein .................. 302

VISTOGARD ....................... 255

vitacel (with lutein) .............. 302

vitalets .................................. 302

I-23

vitamin a............................... 303

vitamin b complex........ 278, 297

vitamin b complex-folic acid

.......................... 279, 299, 303

vitamin b-1 ................... 283, 303

vitamin b-6 ........................... 303

vitamin c....................... 303, 304

vitamin d3 .................... 297, 304

vitamin k .............................. 304

vitamin k1 ............................ 304

vitamins and minerals .......... 303

vitamins b complex ...... 279, 303

vitamins for hair ................... 304

vitatrum ................................ 304

vitrum senior ........................ 304

VIZIMPRO ............................ 50

vol-care rx ................................ 2

VOLTAREN .......................... 16

voriconazole ........................... 73

VOSEVI ............................... 106

VOTRIENT............................ 50

VPRIV.................................. 190

vp-vite rx .................................. 2

VRAYLAR ............................ 98

vyfemla (28) ......................... 156

vylibra .................................. 156

VYXEOS ............................... 50

W wal-act d cold and allergy ...... 79

wal-dram ................................ 87

wal-dram 2 ............................. 87

wal-dryl allergy ................ 79, 80

wal-fex allergy ....................... 80

wal-finate ............................... 80

wal-finate-d ............................ 80

wal-itin ............................. 76, 80

wal-itin d ................................ 80

wal-itin d 12 hour ................... 80

wal-phed ......................... 80, 161

wal-phed pe .......................... 122

wal-phed pe sinus and allergy 80

wal-profen .............................. 16

wal-tap .................................... 80

wal-tussin ............................. 161

wal-tussin dm ....................... 157

wal-zan 75 ............................ 204

wal-zyr (cetirizine) ................. 80

wal-zyr d ................................ 80

warfarin ................................ 110

water for irrigation, sterile ... 249

WELCHOL .......................... 138

wera (28) .............................. 156

womens daily gummies ........ 285

women's multivitamin gummies

.............................................. 2

X XADAGO .............................. 91

XALKORI .............................. 51

XARELTO ........................... 110

XATMEP ............................... 51

XELJANZ ............................ 241

XELJANZ XR...................... 241

XERMELO .......................... 212

XIFAXAN .............................. 26

XOFLUZA ........................... 105

XOLAIR............................... 273

XOSPATA ............................. 51

XTAMPZA ER ...................... 12

XTANDI ................................ 51

xulane ................................... 156

XULTOPHY 100/3.6 ............. 68

XURIDEN ............................ 255

XYREM ............................... 275

Y yelets ........................................ 2

YERVOY ............................... 51

YF-VAX (PF) ...................... 247

YONDELIS ............................ 51

YONSA .................................. 51

Z zafirlukast ............................. 268

zaleplon ................................ 275

zantac 75 ............................... 204

zarah ..................................... 156

ZARXIO ............................... 112

ZEJULA ................................. 51

ZELBORAF ........................... 51

zenatane ................................ 166

zenchent (28) ........................ 156

ZENPEP ............................... 190

ZEPATIER ........................... 106

zephrex-d .............................. 161

ZERIT .................................. 104

zidovudine .................... 104, 105

zinc oxide ............. 163, 165, 166

ziprasidone hcl ....................... 98

ZIRGAN ............................... 199

ZOLADEX ............................. 51

zoledronic acid ..................... 251

zoledronic acid-mannitol-water

.......................................... 251

zoledronic ac-mannitol-0.9nacl

.......................................... 251

ZOLINZA .............................. 51

zolpidem ............................... 275

ZOMACTON ....................... 231

ZOMETA ............................. 252

zonisamide .............................. 57

zoo chews ................................. 2

ZORBTIVE .......................... 231

ZORTRESS .......................... 241

ZOSTAVAX (PF) ................ 248

zovia 1/35e (28) .................... 156

zovia 1/50e (28) .................... 157

ZUBSOLV ............................. 20

ZYDELIG .............................. 51

ZYKADIA.............................. 51

ZYLET ................................. 199

ZYPREXA RELPREVV .. 98, 99

ZYTIGA ................................. 52

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VNSNY CHOICE FIDA Complete (Plan Medicare-Medicaid )

H8490_CY2019_LOCD_16702_sb2_Approved_10122018

Para inscribirse en VNSNY CHOICE FIDA Complete y conocer mássobre otras opciones para su atención médica, llame al Agente de

Inscripciones (New York Medicaid Choice) al número gratuito:1-855-600-FIDA TTY: 1-888-329-1541de 8:30 am a 8 pm, de lunes a viernes

de 10 am a 6 pm, los sábadoso visite www.nymedicaidchoice.com

Llame gratis a CHOICE al 1-866-783-1444

TTY: 711de 8 am a 8 pm, los 7 días de la semana

220 East 42nd Street, 3rd Floor, New York, NY 10017 www.vnsnychoice.org

2019 List a de Medicam

entos Cubiertos (Formulario) V

NSN

Y CHO

ICE FIDA

Complete

ID del formulario: 19099, Version: 09

©2019 VNSNY CHOICE Actualizado: 01/23/2019

Vigencia: 01 de febrero de 2019

ID del Formulario : 19099, Version: 00 Vigencia: 01 de enero de 2019

Actualizado: 12/2018

Documents

2019 LISTA DE MEDICAMENTOS CUBIERTOS (FORMULARIO) … · 2019-01-31 · de 8:30 am a 8 pm, de lunes a viernes de 10 am a 6 pm, los sábados o visite Llame gratis a CHOICE al 1-866-783-1444