2013 Comprehensive Formulary · 2019-06-20 · about this complete drug list This is a complete list of prescription drugs that are covered by the UnitedHealthcare Dual Complete™

00013507, 21 Y0066_3398318_000_Final_M11.8 CMS Approved

Inside• Drug tiers and drug payment stages • Complete list of drugs by category

• Requirements and limits • Index of covered drugs

Please read: This document contains information about the drugs covered by this plan.

Note to existing members: This complete formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

Formulary

2013

Comprehensive

(Complete list of covered drugs)

UnitedHealthcare Dual Complete™ (HMO SNP)

about this complete drug listThis is a complete list of prescription drugs that are covered by the UnitedHealthcare Dual Complete™ plan for the 2013 plan year. It is called the Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan.

For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered:

1. See if your drug is included in this complete drug list.2. Visit the plan website at www.UHCCommunityPlan.com. You can use online tools to look up your

drugs. The information is updated on a regular basis.3. Call Customer Service at 1-866-846-2762, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.

Customer Service can look up your drugs and let you know if they are covered.

For more informationPlease take the time to review your Evidence of Coverage and any other 2013 plan materials you have received. These materials give more detailed information about your drug coverage in the plan.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

Questions?If you have questions, we’re here to help. Call Customer Service at

1-866-846-2762, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week

Or visit www.UHCCommunityPlan.com

online toolsVisit www.UHCCommunityPlan.com to

• Look up your drugs and see what you could save with lower-cost drugs

• Find network pharmacies• Print plan forms and materials

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2013 Complete drug list

The UnitedHealthcare Dual Complete plan may help you manage your prescription drug costs. An important part of this is giving you choices so you and your doctor can choose the best course of treatment for you.

A formulary is a list of the drugs covered by a Medicare Advantage prescription drug plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

With your doctor’s help, you can use this drug list as a tool to choose the drugs that work best for you and to find lower-cost drugs, if needed.

using the drug listThere are two ways to find your prescription drugs in this complete drug list:

1. Alphabetical list (index): Turn to the “Index of covered drugs” section, which begins on page 57, to see the list of drug names in alphabetical order.

2. Medical condition: Turn to the “Covered drugs by category” section, which begins on page 8, to look for drug names based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Drugs” category and look under “Cholesterol Control Drugs.”

Is it a generic or brand name drug?The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin).

More information about your drugSome drugs have requirements or limits. Please see the “Requirements and limits” section on page 4 for more information on drugs you may use.

This document is a complete list of covered drugs. If your drug is not included in this drug list, you should contact Customer Service to ask if it’s covered, or go to www.UHCCommunityPlan.com to look it up online. If you learn that the plan does not cover your drug, you have two options:

1. You can ask Customer Service for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.

2. You can ask the plan to make an exception and cover your drug. See the “Coverage decisions” section on page 5 for information about how to request an exception.

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Drug tiers and drug payment stagesThe amount you pay for a covered drug will depend on:

• Your drug payment stage. The plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you’re in.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a different copay or coinsurance amount. The chart below shows the differences between the tiers.

For more information about drug payment stages and copay or coinsurance amounts for each tier, please refer to the plan’s Evidence of Coverage (EOC).

If you qualify for extra helpIf you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for extra help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are. You can also contact Customer Service.

Drug Tier Copay or Coinsurance Includes Helpful Tips

Tier 1: Preferred genericLowest copay

Lower-cost, commonly used generic drugs.

Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2: Non-preferred genericLow copay

Most generic drugs. Use Tier 2 drugs, instead of Tier 3 or 4, to help reduce your out-of-pocket costs.

Tier 3: Preferred brandMedium copay

Many common brand name drugs, called preferred brands, and some higher-cost generic drugs.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4: Non-preferred brandHighest copay

Non-preferred generic and non-preferred brand name drugs.

Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Tier 5: Specialty tierCoinsurance

Unique and/or very high-cost drugs.

You pay a percentage of the total drug cost, called coinsurance.

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Generic drugsThe plan covers both brand name and generic drugs. The Food and Drug Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs, whether preferred or non-preferred, may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one.

• To pay less out-of-pocket, talk with your doctor to see if any of the brand name drugs you take have generic versions. While most generics are in Tier 2 of the drug list, some generics can be found in Tier 1.

• While generic drugs usually cost less than brand name drugs, newly available generic drugs can be expensive so they may be in Tier 2, 3 or 4 of the drug list.

VaccinesThe plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines, like those for the flu and pneumonia, may be covered by Medicare Part B (doctor and outpatient health care).

For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state allows it. The administration fee likely will be lower at a network pharmacy than at your doctor’s office.

If you get your vaccines at your doctor’s office, you will pay the entire cost of the vaccine and administration fee to your doctor.

Please see your Evidence of Coverage for more information about vaccines and their costs.

To make sure a recommended vaccine is covered, call Customer Service at 1-866-846-2762, TTY 711.

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requirements and limitsSome of the plan’s drugs have requirements or limits to help ensure safe, effective and affordable use. If your drug has any requirements or limits, there will be a code(s) in the “Requirements & Limits” column of the drug list starting on page 8. The codes and what they mean are shown below. Visit www.UHCCommunityPlan.com for more information.

You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. See the “Coverage decisions” section on the next page or see your Evidence of Coverage to learn more.

If you do not get prior approval from the plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug.

B/D Medicare Part B or Part DDepending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

la Limited accessDrugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

Pa Prior authorizationThe plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.

ST Step therapyThere are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.

For more information about requirements and limits, call Customer Service at 1-866-846-2762, TTY 711.

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Coverage decisionsAt times you may need to ask for drug coverage that’s not normally provided by the plan. When you do, the plan will consider your request and respond with a coverage decision (coverage determination).

Examples of coverage decisions you may ask for include:

• Asking the plan to pay you back for the cost of a drug you bought at an out-of-network pharmacy.• Asking for an exception to the plan’s coverage rules.

How to request an exceptionYou can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

• You can ask the plan to cover your drug even if it is not on the formulary (formulary exception).

• You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception). For example, for certain drugs, the plan limits the amount of the drug that it will cover.

• You can ask the plan to provide a higher level of coverage for your drug (tier exception). If

your drug is in the non-preferred tier, you can ask the plan to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in the plan’s formulary, you may not ask us to provide a higher level of coverage for the drug. Tier exceptions are not available for drugs in the specialty tier.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Asking for a coverage decisionYou (or your authorized representative) and your doctor can ask for an initial coverage decision by calling Customer Service at 1-866-846-2762, TTY 711.

When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or physician should submit a statement supporting your request.

See your Evidence of Coverage for more information.

Receiving a coverage decisionGenerally, the plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If the plan agrees to a fast decision, you will receive a decision within 24 hours after the plan receives your prescriber’s or prescribing physician’s supporting statement.

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Drug list changesThe plan recognizes that drug list stability is very important to you. That is why the plan tries to make as few changes to the drug list as possible during the plan year. From time to time, drug list changes may be necessary for safety or other reasons.

The drug list may change throughout the year when the plan:

• Adds a new drug.• Removes a drug.• Changes the requirements or limits for a drug.• Moves a drug to a lower-cost tier.• Moves a drug to a higher-cost tier.

If the FDA declares a drug to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the drug list and inform affected members. If a drug moves to a higher-cost tier or undergoes some other change, the plan will inform affected members at least 60 days before the change or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.

Generally, if you are taking a drug on the 2013 drug list that was covered at the beginning of the year, the plan will not remove the drug from the drug list or move a drug to a higher tier during the 2013 coverage year except when a new, less expensive generic equivalent drug becomes available (for example, the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when new information about the safety or effectiveness of a drug is released.

Other types of changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan, except for cases in which you can save additional money or your safety is a concern.

If there are changes to the drug list such as regular or necessary updates, members may see information in the Explanation of Benefits statement, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The plan website also has updated information.

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Transition supply process New or continuing membersAs a new or continuing member in the plan, you may be taking drugs that are not on the formulary. Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception so that the plan will cover the drug you take. While you talk to your doctor to determine the right course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a member of the plan.

For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the plan will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, the plan will not pay for these drugs, even if you have been a member of the plan less than 90 days.

Long-term care facility residentsIf you’re a resident of a long-term care facility, the plan will allow you to refill your prescription until we have provided you with a 91- and up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90 days of your membership. If you need a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.

Other transitionsYou may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use the plan’s exception process. You may ask for a one-time emergency supply of up to 31 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.

For more informationFor more detailed information about UnitedHealthcare Dual Complete prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call Customer Service at

1-866-846-2762, TTY 7118 a.m. to 8 p.m. local time, 7 days a week


If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

Covered drugs by categoryThe comprehensive formulary (drug list) below provides coverage information about all of the drugs covered by the plan. It is current as of September 1, 2013.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the Requirements & Limits column tells you if the plan has any special requirements for coverage of your drug.

If you have trouble finding your drug in the list, turn to the “Index of covered drugs” section that begins on page 57. If your prescription is not in this complete formulary, please visit www.UHCCommunityPlan.com or call Customer Service at 1-866-846-2762, TTY 711, for additional help.

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Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy

Drug Name Drug Tier

Requirements & Limits

Ibuprofen (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

2

Ketoprofen 3Ketoprofen ER 3Ketorolac Tromethamine (15mg/ml Injection, 30mg/ml Injection)

3 PA

Meclofenamate Sodium 3Mefenamic Acid 3

Meloxicam (Tablet) 1

Meloxicam (Suspension) 2Nabumetone 3

Naproxen 2

Naproxen DR 2Naproxen Sodium (275mg Tablet, 550mg Tablet)

2

Oxaprozin 2Oxycodone/Ibuprofen 3

Drug Name Drug Tier


Analgesics — Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Nonsteroidal Anti-Inflammatory Drugs — Pain/Anti-Inflammatory DrugsArthrotec 4Celebrex 3

Diclofenac Potassium 2

Diclofenac Sodium DR 2

Diclofenac Sodium ER 2Diclofenac Sodium/Misoprostol

4

Diflunisal 2

Etodolac 2

Etodolac ER 2

Fenoprofen Calcium 2

Flurbiprofen 2

Covered drugs by categoryThe comprehensive formulary (drug list) below provides coverage information about all of the drugs covered by the plan. It is current as of September 1, 2013.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the Requirements & Limits column tells you if the plan has any special requirements for coverage of your drug.

If you have trouble finding your drug in the list, turn to the “Index of covered drugs” section that begins on page 57. If your prescription is not in this complete formulary, please visit www.myAARPMedicare.com or call UnitedHealthcare Customer Service at 1-800-643-4845, TTY 711, for additional help.

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Drug Name Drug Tier


Piroxicam 3

Sulindac 2Tolmetin Sodium 3Opioid Analgesics, Long-Acting — Opioid Pain RelieversAstramorph 3Avinza 3Conzip 4Duramorph 3Exalgo (12mg Tablet Extended Release 24 Hour, 16mg Tablet Extended Release 24 Hour, 8mg Tablet Extended Release 24 Hour)

3

Fentanyl (Patch) 3Kadian (200mg Capsule Extended Release 24 Hour)

5

Levorphanol Tartrate 3Methadone HCl (Concentrate, Oral Solution, 5mg Tablet, 10mg Tablet)

2

Methadone HCl (Injection) 2

Methadose (Tablet) 2Morphine Sulfate (Oral Solution, Tablet)

3

Morphine Sulfate ER 3Nucynta ER 3Opana ER (Crush Resistant) 3

Oxymorphone HCl ER 3Tramadol HCl ER (Tablet Extended Release 24 Hour)

4

Drug Name Drug Tier


Opioid Analgesics, Short-Acting — Opioid Pain RelieversAbstral (100mcg Tablet Sublingual) 4

Abstral (200mcg Tablet Sublingual, 300mcg Tablet Sublingual, 400mcg Tablet Sublingual, 600mcg Tablet Sublingual, 800mcg Tablet Sublingual)

5

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate

3

Acetaminophen/Codeine 2Actiq 5 PAButalbital/Aspirin/Caffeine/Codeine

3

Butorphanol Tartrate 3Co-Gesic 3

Codeine Sulfate (Tablet) 2Dilaudid (Injection) 4Endocet 3Endodan 3Fentanyl Citrate Oral Transmucosal

5 PA

Fentora 5 PA

10


Drug Name Drug Tier


Hydrocodone/Acetaminophen (Oral Solution, 300mg; 10mg Tablet, 300mg; 5mg Tablet, 300mg; 7.5mg Tablet, 325mg; 10mg Tablet, 325mg; 5mg Tablet, 325mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg; 2.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet)

3

Hydrocodone/Ibuprofen (7.5mg; 200mg Tablet)

3

Hydromorphone HCl (500mg/50ml Injection, Immediate-Release Tablet)

2

Lazanda 4 PANalbuphine HCl 3Onsolis 5 PAOxycodone HCl (Oral Solution, 10mg Tablet, 20mg Tablet)

2

Oxycodone HCl (Capsule, Concentrate, 15mg Tablet, 30mg Tablet, 5mg Tablet)

3

Oxycodone/Acetaminophen

3

Drug Name Drug Tier


Oxycodone/Aspirin 3Oxymorphone HCl 3Roxicet (500mg; 5mg Tablet)

3

Roxicet (Oral Solution) 4Stagesic 3Subsys (100mcg Liquid, 1200mcg Liquid, 200mcg Liquid, 400mcg Liquid, 800mcg Liquid)

5 PA

Synalgos-DC 4

Tramadol HCl 2Tramadol HCl/Acetaminophen

2

Vicodin 3Vicodin ES 3Vicodin HP 3

Anesthetics — Drugs for Numbing

Local AnestheticsLidocaine (Ointment) 3 B/DLidocaine 2% Viscous Solution

3

Lidocaine HCl (External Solution)

3

Lidocaine HCl (0.5% Injection, 1% Injection)

3 B/D

Lidocaine HCl (Gel) 3Lidocaine/Prilocaine (Cream)

3 B/D

Lidoderm 3

11

Drug Name Drug Tier


Antibacterials — Drugs to Treat Bacterial Infections

Aminoglycosides — AntibioticsAmikacin Sulfate (1gm/4ml Injection, 50mg/ml Injection)

3

Gentak (Ointment) 2Gentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution)

2

Gentamicin Sulfate/NaCl (1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection)

2

Gentamicin Sulfate/NaCl (0.9mg/ml; 0.9% Injection, 1.4mg/ml; 0.9% Injection)

3

Isotonic Gentamicin (0.8mg/ml; 0.9% Injection, 1.2mg/ml; 0.9% Injection)

2

Kanamycin Sulfate 3

Neomycin Sulfate (Tablet) 2Neomycin/Polymyxin B Sulfates

3

Paromomycin Sulfate 3Streptomycin Sulfate 4TOBI 5 B/DTOBI Podhaler 5Tobramycin Sulfate (Ophthalmic Solution)

2

Tobramycin Sulfate (10mg/ml Injection, 80mg/2ml Injection)

3

Tobramycin Sulfate/NaCl 3

Tobrex (Ointment) 3Tobrex (Ophthalmic Solution) 4

Drug Name Drug Tier


Antibacterials, Other — AntibioticsAltabax 4

BACiiM 2

Bacitracin 2

Bacitracin/Polymyxin B 2Bactroban (Cream) 4Chloramphenicol Sodium Succinate

3

Cleocin (75mg Capsule) 4Cleocin in D5W 4Cleocin Pediatric Granules 4

Cleocin Phosphate (900mg/6ml Injection) 4

Clindamycin HCl 2Clindamycin Phosphate (Cream)

2

Clindamycin Phosphate (150mg/ml Injection)

3

Clindamycin Phosphate in D5W

4

Colistimethate Sodium 4Coly-Mycin M 4 STCortisporin (Cream, Ointment) 4

Cubicin 5 B/DFlagyl ER 4Lincocin 4Mafenide Acetate 4Methenamine Hippurate 3MetroGel (1% Gel) 4Metronidazole (Capsule, Cream, 0.75% Gel, Lotion, Tablet)

3

Metronidazole in NaCl 0.79%

3

Metronidazole Vaginal 2

12


Drug Name Drug Tier


Mupirocin (Ointment) 2Mupirocin (Cream) 4Neomycin/Bacitracin/Polymyxin

2

Neomycin/Polymyxin/Gramicidin

2

Nitrofurantoin 3 PANitrofurantoin Macrocrystalline (50mg Capsule)

3 PA

Nitrofurantoin Monohydrate 3 PAPolymyxin B Sulfate 3Primsol 4

Silver Sulfadiazine 2

SSD 2Sulfamylon 4Synercid 5

Trimethoprim 2Trimethoprim Sulfate/Polymyxin B Sulfate

2

Tygacil 4Vancocin HCl 5 PAVancomycin HCl (1000mg Injection, 10gm Injection, 500mg Injection)

3 B/D

Vancomycin HCl (Capsule) 5 PA

Vandazole 2Vibativ (250mg Injection) 4Xifaxan (200mg Tablet) 4Xifaxan (550mg Tablet) 5Zyvox 5 PA

Drug Name Drug Tier


Beta-Lactam, Cephalosporins — AntibioticsCedax (Capsule) 4

Cefaclor (Capsule) 2

Cefaclor ER 2

Cefadroxil 2Cefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection)

3

Cefdinir 3Cefepime (1gm Injection, 2gm Injection)

3

Cefotaxime Sodium (10gm Injection, 1gm Injection, 2gm Injection)

3

Cefoxitin Sodium 3Cefoxitin Sodium/Dextrose 4

Cefpodoxime Proxetil 3Cefprozil 3Ceftazidime (1gm Injection, 2gm Injection, 6gm Injection)

3

Ceftazidime/Dextrose 3Ceftriaxone Sodium 3

Cefuroxime Axetil (Tablet) 2Cefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection)

2

13

Drug Name Drug Tier


Cephalexin (250mg Capsule, 500mg Capsule, Suspension Reconstituted, Tablet)

2

Claforan (1gm Injection, 2gm Injection) 4

Fortaz (1gm/50ml; 5% Injection, 2gm Injection, 2gm/50ml; 5% Injection, 6gm Injection)

4

Suprax (Capsule, 500mg/5ml Suspension Reconstituted, Tablet, Tablet Chewable)

3

Suprax (100mg/5ml Suspension Reconstituted, 200mg/5ml Suspension Reconstituted)

3

Zinacef 4Zinacef in Iso-Osmotic Dextrose 4

Zinacef in Iso-Osmotic Diluent 4

Beta-Lactam, Other — AntibioticsAzactam in Iso-Osmotic Dextrose 4

Aztreonam (1gm Injection) 3Cayston 5 PACefotetan 4Doribax (500mg Injection) 4

Imipenem/Cilastatin 3Invanz 4Meropenem (500mg Injection)

3

Primaxin 4

Drug Name Drug Tier


Beta-Lactam, Penicillins — Antibiotics

Amoxicillin 2Amoxicillin/Potassium Clavulanate

2

Amoxicillin/Potassium Clavulanate ER

2

Ampicillin 3Ampicillin Sodium (10gm Injection, 125mg Injection, 1gm Injection)

3

Ampicillin/Sulbactam (10gm; 5gm Injection, 2gm; 1gm Injection)

3

Bactocill in Dextrose (1gm/50ml Injection) 4

Bactocill in Dextrose (2gm/50ml Injection) 5

Bicillin C-R 4Bicillin L-A 4

Dicloxacillin Sodium 2Nafcillin Sodium (10gm Injection, 1gm Injection)

3

Nallpen/Dextrose 4Oxacillin Sodium (10gm Injection, 1gm Injection)

4

Penicillin G Potassium (5mu Injection)

4

Penicillin G Potassium in Iso-Osmotic Dextrose (Injection)

3

Penicillin G Procaine 4Penicillin G Sodium 4

Penicillin V Potassium 2Pfizerpen-G (20mu Injection) 4

14


Drug Name Drug Tier


Piperacillin Sodium/Tazobactam Sodium (3gm; 0.375gm Injection, 4gm; 0.5gm Injection)

3

Timentin (0.1gm; 3gm Injection) 4

Unasyn (2gm; 1gm Injection) 4

Zosyn (3gm; 0.375gm Injection, 5%; 2gm/50ml; 0.25gm/50ml Injection, 5%; 3gm/50ml; 0.375gm/50ml Injection)

4

Macrolides — AntibioticsAkne-Mycin 4Azasite 3Azithromycin (500mg Injection, Suspension Reconstituted, Tablet)

2

Clarithromycin 3Clarithromycin ER 3Dificid 5 PA

E.E.S. 400 2E.E.S. Granules 3

Ery Pad 2% 2Ery-Tab 3EryPed 3Erythrocin Lactobionate (500mg Injection) 4

Erythrocin Stearate 4Erythromycin (External Solution, Gel, Ointment)

2

Drug Name Drug Tier


Erythromycin Base 2Erythromycin Ethylsuccinate

2

Ketek 4 PAPCE 4Zmax 4Quinolones — AntibioticsAvelox (Tablet) 3Avelox (Injection) 4Avelox ABC Pack 3Besivance 3Ciloxan (Ointment) 4Cipro (Suspension Reconstituted) 4

Cipro HC 4Cipro IV (200mg/100ml; 5% Injection) 4

Ciprodex 3Ciprofloxacin (400mg/40ml Injection)

2

Ciprofloxacin ER 3

Ciprofloxacin HCl 2Ciprofloxacin I.V. in D5W (200mg/100ml; 5% Injection)

2

Factive 4Levaquin (Tablet) 4Levofloxacin 3Levofloxacin in D5W (5%; 500mg/100ml Injection)

3

Moxeza 3

15

Drug Name Drug Tier


Noroxin 4Ofloxacin 3Vigamox 3Zymaxid 3Sulfonamides — AntibioticsSulfacetamide Sodium (Ointment, Ophthalmic Solution)

2

Sulfadiazine 3Sulfamethoxazole/Trimethoprim

2

Sulfamethoxazole/Trimethoprim DS

2

Tetracyclines — AntibioticsDemeclocycline HCl 3Doxycycline (75mg Capsule)

3

Doxycycline (Suspension Reconstituted)

4

Doxycycline Hyclate (Capsule, Injection, Tablet)

3

Doxycycline Hyclate DR (100mg Tablet Delayed Release, 75mg Tablet Delayed Release)

3

Doxycycline Hyclate DR (150mg Tablet Delayed Release)

4

Doxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet)

3

Minocycline HCl (Capsule) 2Minocycline HCl (Tablet) 4Minocycline HCl ER 4

Tetracycline HCl 2Vibramycin (Suspension Reconstituted, Syrup) 4

Drug Name Drug Tier


Anticonvulsants — Drugs to Treat Seizures

Anticonvulsants, Other — Seizure Control DrugsLevetiracetam (500mg/5ml Injection, Oral Solution, Tablet)

2

Levetiracetam ER 3Phenobarbital (Elixir, Tablet)

2

Potiga 4Calcium Channel Modifying Agents — Seizure Control DrugsCelontin 4Ethosuximide 3Lyrica 3

Zonisamide 2Gamma-Aminobutyric Acid (GABA) Augmenting Agents — Seizure Control Drugs

Clonazepam 2Clonazepam ODT 4

Clorazepate Dipotassium 2 PADiazepam (Gel) 4

Divalproex Sodium 2

Divalproex Sodium DR 2

Divalproex Sodium ER 2

Gabapentin 2Gabitril 4Onfi 4 PA

Primidone 2Sabril 5 PAStavzor 4

16


Drug Name Drug Tier


Tiagabine HCl 4Valproate Sodium (100mg/ml Injection)

3

Valproic Acid 2Glutamate Reducing Agents — Seizure Control DrugsFelbamate (Tablet) 4Felbamate (Suspension) 5Felbatol (Tablet) 4Felbatol (Suspension) 5Lamictal ODT (Tablet Dispersible) 4

Lamictal Starter Kit 4

Lamotrigine (Tablet) 2Lamotrigine (Tablet Chewable)

3

Topiramate 2Sodium Channel Agents — Seizure Control DrugsBanzel 4Carbamazepine 3Carbamazepine ER 3Dilantin 3Dilantin Infatabs 3Epitol 3Equetro 4Fosphenytoin Sodium (100mg pe/2ml Injection)

3

Oxcarbazepine (Tablet) 3Oxcarbazepine (Suspension)

4

Drug Name Drug Tier


Peganone 4

Phenytek 2

Phenytoin (Suspension) 2Phenytoin (Tablet Chewable)

3

Phenytoin Sodium (Injection)

2

Phenytoin Sodium Extended (Capsule)

2

Tegretol 3Tegretol-XR 3Trileptal (Suspension) 4Vimpat (Injection) 4 PAVimpat (Oral Solution, Tablet) 4

Antidementia Agents — Drugs to Treat Alzheimer’s Disease and Dementia

Cholinesterase Inhibitors — Alzheimer’s Disease and Dementia DrugsAricept (23mg Tablet) 3Donepezil HCl (10mg Tablet Dispersible, 5mg Tablet Dispersible, 10mg Tablet, 5mg Tablet)

2

Exelon (Oral Solution) 4Exelon (Patch 24 Hour) 4 STGalantamine Hydrobromide 3Rivastigmine Tartrate 3

17

Drug Name Drug Tier


N-methyl-D-aspartate (NMDA) Receptor Antagonists — Alzheimer’s Disease and Dementia DrugsNamenda (Solution, Tablet) 3

Namenda Titration Pak (Tablet) 3

Antidepressants — Drugs to Treat Depression

Antidepressants, Other — Antidepressants

Budeprion SR 2

Bupropion HCl 2

Bupropion HCl SR 2

Bupropion HCl XL 2Forfivo XL 3

Maprotiline HCl 2

Mirtazapine 2Mirtazapine ODT (30mg Tablet Dispersible, 45mg Tablet Dispersible)

2

Nefazodone HCl 2

Trazodone HCl 2Monoamine Oxidase Inhibitors — AntidepressantsEmsam 4 STMarplan 4Nardil 3

Phenelzine Sulfate 2Tranylcypromine Sulfate 3Zelapar 4Serotonin/Norepinephrine Reuptake Inhibitors — AntidepressantsCitalopram Hydrobromide (Tablet)

1

Citalopram Hydrobromide (Oral Solution)

3

Drug Name Drug Tier


Cymbalta 3

Escitalopram Oxalate 2Fluoxetine DR 4

Fluoxetine HCl 2Fluvoxamine Maleate (Tablet)

2

Paroxetine HCl 2Paroxetine HCl ER 4Paxil (Suspension) 4Pexeva 4Pristiq 4 PA

Sertraline HCl (Tablet) 1Sertraline HCl (Concentrate)

3

Venlafaxine HCl 3Venlafaxine HCl ER (Capsule Extended Release 24 Hour)

2

Venlafaxine HCl ER (Tablet Extended Release 24 Hour)

4

Viibryd 4Tricyclics — Antidepressants

Amitriptyline HCl 2 PAAmoxapine (100mg Tablet, 25mg Tablet, 50mg Tablet)

2

Amoxapine (150mg Tablet) 2

Clomipramine HCl 2 PADesipramine HCl 3

Doxepin HCl 2

Imipramine HCl 2 PAImipramine Pamoate 3 PANortriptyline HCl (Capsule)

2

18


Drug Name Drug Tier


Pamelor 5 STPerphenazine/Amitriptyline

2

Protriptyline HCl 3Trimipramine Maleate 3 PA

Antidotes, Deterrents and Toxicologic Agents — Drugs for Overdose or Deterrents

Alcohol Deterrents/Anti-Craving — Antidotes/Deterrents/ProtectantsAntabuse 3Campral 4Disulfiram 3Naltrexone HCl 3Vivitrol 5Opioid Antagonists — Antidotes/Deterrents/ProtectantsBuprenorphine HCl 3Buprenorphine HCl/Naloxone HCl

4

Naloxone HCl (1mg/ml Injection)

3

Suboxone 4Smoking Cessation Agents — Deterrents

Buproban 2Chantix 4Chantix Starting Month Pak 4

Nicotrol Inhaler 4Nicotrol NS 3

Drug Name Drug Tier


Antiemetics — Drugs to Treat Nausea and Vomiting

Antiemetics, Other — Nausea and Vomiting Drugs

Meclizine HCl (Tablet) 2Transderm-Scop 4Emetogenic Therapy Adjuncts — Nausea and Vomiting DrugsAloxi 4Anzemet (50mg Tablet) 4 B/DAnzemet (100mg Tablet) 5 B/DCesamet 5 B/D, PADronabinol (2.5mg Capsule, 5mg Capsule)

3 B/D, PA

Dronabinol (10mg Capsule) 5 B/D, PAEmend (Capsule) 3 B/D, PAGranisetron HCl (0.1mg/ml Injection, 1mg/ml Injection)

3

Granisetron HCl (Tablet) 3 B/DGranisol 3 B/D

Ondansetron HCl (Tablet) 2 B/DOndansetron HCl (4mg/2ml Injection)

3

Ondansetron HCl (Oral Solution)

3 B/D

Ondansetron ODT 2 B/DSancuso 5Zofran (Injection) 5 STZofran (Oral Solution, Tablet) 5 B/D

Zofran ODT 5 B/D

19

Drug Name Drug Tier


Antifungals — Drugs to Treat Fungal Infections

Antifungals — Fungal Infection DrugsAbelcet 5 B/DAmBisome 5 B/DAmphotec (50mg Injection) 4 B/D

Amphotericin B 3 B/DAncobon 5Cancidas 5Ciclopirox 3Ciclopirox Nail Lacquer 3Ciclopirox Olamine 3

Clotrimazole 2Clotrimazole/Betamethasone Dipropionate

2

Econazole Nitrate 2Eraxis (100mg Injection) 5Ertaczo 4Exelderm 4

Fluconazole 2Fluconazole in Dextrose (56mg/ml; 400mg/200ml Injection)

2

Flucytosine 5Grifulvin V 3Gris-PEG 4Griseofulvin Microsize 3Griseofulvin Ultramicrosize 4Gynazole-1 4Itraconazole 3 PAKetoconazole (Cream, Shampoo, Tablet)

2

Ketoconazole (Foam) 4Lamisil (Packet) 4

Drug Name Drug Tier


Mentax 4

Miconazole 3 2Mycamine 5Naftin (1% Cream, Gel) 4Natacyn 3Noxafil 5

Nyamyc 2Nystatin (Cream, Ointment, 100000unit/gm Powder, Suspension, Tablet)

2

Nystatin/Triamcinolone 2

Nystop 2ONMEL 5 PAOxistat 4

Pedi-Dri 2Sporanox (Oral Solution) 4 PASporanox (Capsule) 5 PA

Terbinafine HCl (Tablet) 2

Terconazole 2Vfend (Suspension Reconstituted) 5

Vfend (Tablet) 5 STVfend IV 4Voriconazole (Injection) 4Voriconazole (Tablet) 5

Zazole (Cream) 2

Antigout Agents — Drugs to Treat Gout

Antigout Agents — Gout Drugs

Allopurinol (Tablet) 2Allopurinol Sodium (Injection)

2

Colcrys 3

Probenecid 2

Probenecid/Colchicine 2Uloric 3 ST

20


Drug Name Drug Tier


Antimigraine Agents — Drugs to Treat Migraines

Ergot Alkaloids — Migraine DrugsDihydroergotamine Mesylate (Injection)

3

Migergot 3Serotonin (5-HT) 1b/1d Receptor Agonists — Migraine DrugsMaxalt 3Maxalt-MLT 3

Naratriptan HCl 2Rizatriptan Benzoate 3Sumatriptan Succinate (Tablet)

2

Sumatriptan Succinate (6mg/0.5ml Injection)

3

Sumavel DosePro 4

Antimyasthenic Agents — Drugs to Treat Myasthenia Gravis

Parasympathomimetics — Myasthenia Gravis DrugsGuanidine HCl 4Mestinon (Syrup) 4Mestinon Timespan 4Mytelase 4

Pyridostigmine Bromide 2

Regonol 2

Drug Name Drug Tier


Antimycobacterials — Drugs to Treat Infections

Antimycobacterials, Other — Miscellaneous Anti-InfectivesDapsone 3Mycobutin 4Antituberculars — Tuberculosis DrugsCapastat Sulfate 4Ethambutol HCl 3Isoniazid 3Paser 4Priftin 4Pyrazinamide 3Rifampin (Capsule) 3Rifampin (Injection) 4Rifater 4Seromycin 4Sirturo 5Trecator 4

Antineoplastics — Drugs to Treat Cancer

Alkylating Agents — Chemotherapy AgentsAlkeran (Injection) 4BiCNU 4Busulfex 5CeeNU 4Cyclophosphamide (Tablet) 3 B/DDacarbazine (200mg Injection)

3

21

Drug Name Drug Tier


Hexalen 5 PAIfosfamide (1gm Injection) 3Leukeran 3Matulane 5Melphalan HCl 4Mustargen 5Thiotepa 4Treanda (100mg Injection) 5 PA

Zanosar 5Antiangiogenic Agents — Chemotherapy AgentsCaprelsa 5 PARevlimid (10mg Capsule, 15mg Capsule, 25mg Capsule, 5mg Capsule)

5 PA, LA

Thalomid 5 PAAntiestrogens/Modifiers — Chemotherapy AgentsEmcyt 4 PAFareston 4Faslodex 5Soltamox 4

Tamoxifen Citrate 2Antimetabolites — Chemotherapy AgentsCladribine 5 B/DClolar 5Cytarabine (500mg Injection)

3 B/D

Cytarabine Aqueous (20mg/ml Injection)

2 B/D

Cytarabine Aqueous (100mg/ml Injection)

3 B/D

Droxia 4Elitek (1.5mg Injection) 5

Drug Name Drug Tier


Fluorouracil (2.5gm/50ml Injection)

3 B/D

Folotyn (40mg/2ml Injection) 5 PA

Gemcitabine HCl (1gm Injection)

5

Gemzar (1gm Injection) 5

Hydroxyurea 2Mercaptopurine 3Nipent 5 STPentostatin 5Tabloid 4 PAAntineoplastics, Other — Chemotherapy AgentsAbraxane 5 PAAdriamycin (2mg/ml Injection)

3 B/D

Alimta (500mg Injection) 5 PAAmifostine 5Arranon 5Bleomycin Sulfate (30unit Injection)

3 B/D

Camptosar (100mg/5ml Injection) 4 ST

Carboplatin (150mg/15ml Injection)

3

Cerubidine 4Cisplatin (100mg/100ml Injection)

3

Cometriq 5 PACosmegen 4Dacogen 5Daunorubicin HCl (5mg/ml Injection)

2

Dexrazoxane (500mg Injection)

5 PA

22


Drug Name Drug Tier


Docefrez 5Docetaxel (80mg/4ml Injection, 80mg/8ml Injection)

5

Doxil 5Doxorubicin HCl (2mg/ml Injection)

3 B/D

Ellence (200mg/100ml Injection) 5 ST

Eloxatin (100mg/20ml Injection) 5

Elspar 4Epirubicin HCl (50mg/25ml Injection)

3

Erivedge 5 PAFludarabine Phosphate (50mg Injection)

5

Fusilev 5Halaven 5 PAIclusig 5 PAIdamycin PFS (20mg/20ml Injection) 5 ST

Idarubicin HCl (10mg/10ml Injection)

5

Irinotecan (100mg/5ml Injection)

3

Istodax 5 PAIxempra Kit (45mg Injection) 5

Jakafi 5 PAJevtana 5 PA

Drug Name Drug Tier


Leucovorin Calcium (100mg Injection, 350mg Injection, Tablet)

3

Mekinist 5 PAMenest 3Mesna 3Mesnex (Tablet) 4Mitomycin (20mg Injection) 3Mitoxantrone HCl 3 PAOntak 5 PAOxaliplatin (100mg/20ml Injection)

5

Paclitaxel (300mg/50ml Injection)

3

Picato 4Pomalyst 5 PAProleukin 5 PASylatron 5 PASynribo 5 PATafinlar 5 PATaxotere (80mg/4ml Injection) 5

Trisenox 4 PAVelcade 5 PAVidaza 5 PAVinblastine Sulfate (10mg Injection)

3 B/D

Vincasar PFS 3 B/DVincristine Sulfate 3 B/DVinorelbine Tartrate (50mg/5ml Injection)

3

23

Drug Name Drug Tier


Zaltrap (100mg/4ml Injection) 5 PA

Zinecard (250mg Injection) 5 PA

Zolinza 5 PAZytiga 5 PAAromatase Inhibitors, 3rd Generation — Chemotherapy Agents

Anastrozole 2Aromasin 4Exemestane 3

Letrozole 2Enzyme Inhibitors — Chemotherapy AgentsEtopophos 5Etoposide (Injection) 3Hycamtin (Injection) 5Toposar 3Topotecan HCl (4mg Injection)

5

Molecular Target Inhibitors — Chemotherapy AgentsAfinitor 5 PABosulif 5 PAGleevec 5 PAInlyta 5 PANexavar 5 PASprycel 5 PAStivarga 5 PASutent 5 PATarceva 5 PATasigna 5 PATykerb 5 PAVotrient 5 PAXalkori 5 PAZelboraf 5 PA

Drug Name Drug Tier


Monoclonal Antibodies — Chemotherapy AgentsArzerra (100mg/5ml Injection) 5 PA

Avastin (100mg/4ml Injection) 5 PA

Campath 5 PAErbitux (100mg/50ml Injection) 5 PA

Herceptin 5 PAKadcyla (100mg Injection) 5 PA

Perjeta 5 PARituxan 5 PAVectibix (100mg/5ml Injection) 5 PA

Yervoy (50mg/10ml Injection) 5 PA

Retinoids — Chemotherapy AgentsPanretin 5 PATargretin 5 PATretinoin (Capsule) 5

Antiparasitics — Drugs to Treat Parasitic Infections

Anthelmintics — Worm Infection DrugsAlbenza 3Biltricide 3Stromectol 3Antiprotozoals — Protozoal Infection DrugsAlinia 4Atovaquone/Proguanil HCl (250mg; 100mg Tablet)

3

Chloroquine Phosphate 3Daraprim 3

24


Drug Name Drug Tier


Hydroxychloroquine Sulfate

2

Malarone 4

Mefloquine HCl 2Mepron 5Nebupent 4 B/DPentam 300 4Primaquine Phosphate 4Qualaquin 4 PAQuinine Sulfate 4 PATinidazole 3Pediculicides/Scabicides — Scabies and Lice DrugsEurax 4Lindane 3Malathion 3

Permethrin (Cream) 2Ulesfia 4

Antiparkinson Agents — Drugs to Treat Parkinson’s Disease

Anticholinergics — Parkinson’s Disease Drugs

Benztropine Mesylate 2 PACogentin 4

Trihexyphenidyl HCl 2 PA

Drug Name Drug Tier


Antiparkinson Agents — Parkinson’s Disease DrugsComtan 3Entacapone 3Tasmar 5Dopamine Agonists — Parkinson’s Disease DrugsApokyn 5Bromocriptine Mesylate 3Pramipexole Dihydrochloride (Immediate-Release Tablet)

3

Ropinirole HCl (Immediate-Release Tablet)

2

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors — Parkinson’s Disease Drugs

Carbidopa/Levodopa 2

Carbidopa/Levodopa ER 2Carbidopa/Levodopa ODT

2

Lodosyn 4Parcopa 4Stalevo 3Monoamine Oxidase B (MAO-B) Inhibitors — Parkinson’s Disease DrugsAzilect 3Selegiline HCl 3

25

Drug Name Drug Tier


Antipsychotics — Drugs to Treat Mood Disorders

1st Generation/Typical — Mood Disorder DrugsChlorpromazine HCl (Injection, Tablet)

2

Compro 2Fluphenazine Decanoate 3Fluphenazine HCl (Concentrate, Elixir) 2

Fluphenazine HCl (Injection, Tablet)

2

Haloperidol 2Haloperidol Decanoate (Injection)

2

Haloperidol Lactate (Injection)

2

Loxapine Succinate 2Orap 3

Perphenazine 2

Prochlorperazine 2Prochlorperazine Edisylate (Injection)

3

Prochlorperazine Maleate 2Thioridazine HCl 3

Thiothixene 2

Trifluoperazine HCl 22nd Generation/Atypical — Mood Disorder DrugsAbilify 4Abilify Discmelt 4Abilify Maintena (300mg Injection) 5

Drug Name Drug Tier


Fanapt 4 STFanapt Titration Pack 4 STGeodon (Injection) 4Invega 4Invega Sustenna (39mg/0.25ml Injection, 78mg/0.5ml Injection)

4

Invega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, 234mg/1.5ml Injection)

5

Latuda 4Olanzapine 3Olanzapine ODT 3

Quetiapine Fumarate 2Risperdal Consta (12.5mg Injection, 25mg Injection)

4

Risperdal Consta (37.5mg Injection, 50mg Injection)

5

Risperidone (Tablet) 2Risperidone (Oral Solution) 3Risperidone ODT 3Saphris 3Seroquel XR 3Ziprasidone HCl (Capsule) 4Zyprexa (Injection) 4Treatment-Resistant — Mood Disorder DrugsClozapine 3Fazaclo 3

26


Drug Name Drug Tier


Antispasticity Agents — Drugs to Treat Spasms

Antispasticity Agents — Muscle Spasm Drugs

Baclofen 2Dantrolene Sodium (Capsule)

3

Gablofen (10000mcg/20ml Injection, 50mcg/ml Injection)

3 B/D, PA

Gablofen (40000mcg/20ml Injection)

5 B/D, PA

Lioresal Intrathecal (0.05mg/ml Injection, 10mg/20ml Injection)

3 B/D, PA

Lioresal Intrathecal (10mg/5ml Injection) 5 B/D, PA

Tizanidine HCl (Tablet) 2

Antivirals — Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents — Miscellaneous Antiviral DrugsCidofovir 5Cytovene 4 B/DFoscarnet Sodium 3 B/DGanciclovir 4 B/DValcyte 5Vistide 5Zirgan 4

Drug Name Drug Tier


Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors — HIV DrugsAtripla 5Complera 5Edurant 5Intelence (100mg Tablet, 200mg Tablet) 5

Nevirapine (Tablet) 3Rescriptor 4Stribild 5Sustiva 4Viramune (Tablet) 3Viramune (Suspension) 4Viramune XR 3Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors — HIV DrugsAbacavir 4Combivir 5Didanosine 3Emtriva 4Epivir (Oral Solution) 3Epivir (Tablet) 4Epivir HBV 3Epzicom 5Lamivudine 3Lamivudine/Zidovudine 5Retrovir IV Infusion 4Stavudine 3Trizivir 5Truvada 5

27

Drug Name Drug Tier


Videx Pediatric (2gm Oral Solution) 4

Viread 5Zerit (Oral Solution) 4Ziagen 4Zidovudine 3Anti-HIV Agents, Other — HIV DrugsFuzeon 5Isentress (25mg Tablet Chewable) 4

Isentress (Tablet, 100mg Tablet Chewable) 5

Selzentry 5Anti-HIV Agents, Protease Inhibitors — HIV DrugsAptivus 5Crixivan 3Invirase (Capsule) 4Invirase (Tablet) 5Kaletra (100mg; 25mg Tablet) 4

Kaletra (Oral Solution, 200mg; 50mg Tablet) 5

Lexiva (Suspension) 4Lexiva (Tablet) 5Norvir 4Prezista (150mg Tablet, 75mg Tablet) 4

Prezista (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

5

Reyataz (100mg Capsule) 3

Reyataz (150mg Capsule, 200mg Capsule, 300mg Capsule)

5

Viracept 5

Drug Name Drug Tier


Anti-Influenza Agents — Flu Drugs

Amantadine HCl 2Relenza Diskhaler 4

Rimantadine HCl 2Tamiflu 3Antihepatitis Agents — Hepatitis DrugsBaraclude (Oral Solution) 4

Baraclude (Tablet) 5Copegus 5 PAHepsera 5Incivek 5 PAInfergen (15mcg/0.5ml Injection) 5 PA

Intron-A (10mu/0.2ml Injection, 3mu/0.2ml Injection, 6000000unit/ml Injection)

4 PA

Intron-A (5mu/0.2ml Injection) 5 PA

Intron-A W/Diluent (10mu Injection) 5 PA

Peg-Intron (50mcg/0.5ml Injection) 5 PA

Peg-Intron Redipen 5 PAPegasys 5 PAPegasys ProClick (135mcg/0.5ml Injection) 5 PA

Rebetol (Oral Solution) 4 PARebetol (Capsule) 5 PARibapak (Tablet) 5 PARibasphere (Capsule, 200mg Tablet)

3 PA

Ribasphere (400mg Tablet, 600mg Tablet)

5 PA

Ribavirin 3 PA

28


Drug Name Drug Tier


Tyzeka 5Victrelis 5 PAVirazole 5Antiherpetic Agents — Herpes DrugsAcyclovir (Capsule, Suspension, Tablet)

2

Acyclovir (Ointment) 4Acyclovir Sodium (500mg Injection)

2 B/D

Denavir 4Famciclovir 3Trifluridine 3Valacyclovir HCl 3Zovirax (Cream, Ointment) 4

Anxiolytics — Drugs to Treat Anxiety

Anxiolytics, Other — Anxiety DrugsAlprazolam (Immediate-Release Tablet)

2

Buspirone HCl 2

Chlordiazepoxide HCl 2 PAChlordiazepoxide/Amitriptyline

2

Diazepam (Oral Solution, Tablet)

2 PA

Diazepam Intensol (Oral Solution) 2

Lorazepam (Tablet) 2Lorazepam Intensol (Oral Solution)

2

Drug Name Drug Tier


Bipolar Agents — Drugs to Treat Mood Disorders

Bipolar Agents — Mood Disorder DrugsOlanzapine/Fluoxetine 4Symbyax 4Mood Stabilizers — Mood Disorder Drugs

Lithium Carbonate 2

Lithium Carbonate ER 2

Lithium Citrate 2Lithobid 3

Blood Glucose Regulators — Drugs to Regulate Blood Sugar

Antidiabetic Agents — Diabetic Drugs

Acarbose 2Actoplus Met (15-500mg Tablet, 15-850mg Tablet) 3

Actos 3Avandamet 4 PAAvandaryl 4 PAAvandia 4 PAByetta 3Duetact 3

Glimepiride 2Glipizide (Immediate-Release Tablet)

1

Glipizide ER 2

Glipizide/Metformin HCl 2Glyset 4Janumet 3Janumet XR 3

29

Drug Name Drug Tier


Januvia 3Jentadueto 4Kombiglyze XR 3

Metformin HCl 1Metformin HCl ER 500mg, 750mg Tablet Extended Release 24 Hour (Generic Glucophage XR)

2

Nateglinide 3Onglyza 3Pioglitazone HCl 3Pioglitazone HCl/Glimepiride

3

Pioglitazone HCl/Metformin HCl

3

PrandiMet 4Prandin 4Riomet 4SymlinPen 120 4 PASymlinPen 60 4 PA

Tolazamide 2

Tolbutamide 2Tradjenta 4Victoza 3Glycemic Agents — Diabetic DrugsClinimix 4.25%/Dextrose 20% 4 B/D

Clinimix 5%/Dextrose 15% 4 B/D


Clinimix E 2.75%/Dextrose 10% 4 B/D



Drug Name Drug Tier



Clinimix E 5%/Dextrose 15% 4 B/D


Dextrose 10% Flex Container

3

Dextrose 10%/NaCl 0.2% 3Dextrose 10%/NaCl 0.45%

3

Dextrose 2.5%/NaCl 0.45%

3

Dextrose 5% 3Dextrose 5%/NaCl 0.2% 3Dextrose 5%/NaCl 0.225%

3

Dextrose 5%/NaCl 0.33% 3Dextrose 5%/NaCl 0.45% 3Dextrose 5%/NaCl 0.9% 3Glucagen HypoKit 4Glucagon Emergency Kit 3

Ionosol-B/Dextrose 5% 4Ionosol-MB/Dextrose 5% 4

KCl 0.075%/D5W/NaCl 0.45%

3

KCl 0.15%/D5W/LR 3KCl 0.15%/D5W/NaCl 0.2%

3

KCl 0.15%/D5W/NaCl 0.225%

3

KCl 0.15%/D5W/NaCl 0.9%

3

KCl 0.3%/D5W/NaCl 0.45%

3

30


Drug Name Drug Tier


KCl 0.3%/D5W/NaCl 0.9%

3

Normosol-R in D5W 3Potassium Chloride 0.15%/D5W/NaCl 0.33%

3

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex

3

Potassium Chloride 0.22%/D5W/NaCl 0.45%

3

Proglycem 4Insulins — Diabetic DrugsApidra 3Apidra SoloStar 3Humalog (Vial) 3Humalog KwikPen 3Humulin (Vial) 3Humulin Pen 3Lantus 3Lantus SoloStar 3Levemir 3Levemir FlexPen 3Novolin (Vial) 3Novolog (Vial) 3Novolog FlexPen 3

Drug Name Drug Tier


Blood Products/Modifiers/Volume Expanders — Drugs to Treat Blood Disorders

Anticoagulants — Blood ThinnersArgatroban (100mg/ml Injection) 5

Argatroban (125mg/125ml; 0.9% Injection)

5

Arixtra (2.5mg/0.5ml Injection) 4

Arixtra (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

5

Coumadin (Tablet) 3Coumadin (Injection) 4Eliquis 4 PAEnoxaparin Sodium (300mg/3ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection)

4

Enoxaparin Sodium (100mg/ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection)

5

Fondaparinux Sodium (2.5mg/0.5ml Injection)

4

Fondaparinux Sodium (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

5

31

Drug Name Drug Tier


Fragmin (25000unit/ml Injection, 2500unit/0.2ml Injection, 5000unit/0.2ml Injection)

4

Fragmin (10000unit/ml Injection, 12500unit/0.5ml Injection, 15000unit/0.6ml Injection, 18000unit/0.72ml Injection, 7500unit/0.3ml Injection)

5

Heparin Sodium (10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/ml Injection)

3

Heparin Sodium/D5W (5%; 40unit/ml Injection)

3

Heparin Sodium/NaCl (100unit/ml; 0.45% Injection, 50unit/ml; 0.45% Injection)

3

Heparin Sodium/NaCl 0.9% Premix

3

Jantoven 2Lovenox (300mg/3ml Injection) 4

Pradaxa 3 PA

Warfarin Sodium 2Xarelto 3 PA

Drug Name Drug Tier


Blood Formation Modifiers — Blood Formation DrugsAgrylin 4

Anagrelide HCl 2Aranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 25mcg/0.42ml Injection, 25mcg/ml Injection, 40mcg/0.4ml Injection, 40mcg/ml Injection, 60mcg/0.3ml Injection, 60mcg/ml Injection)

4 B/D, PA

Aranesp Albumin Free (150mcg/0.3ml Injection, 200mcg/0.4ml Injection, 200mcg/ml Injection, 300mcg/0.6ml Injection, 300mcg/ml Injection, 500mcg/ml Injection)

5 B/D, PA

Epogen 4 B/D, PALeukine 5 PAMozobil 5 PANeulasta 5 PANeumega 3 PANeupogen (300mcg/0.5ml Injection, 480mcg/0.8ml Injection, 480mcg/1.6ml Injection)

5 PA

Procrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml Injection, 4000unit/ml Injection)

4 B/D, PA

Procrit (20000unit/ml Injection, 40000unit/ml Injection)

5 B/D, PA

Promacta 5 PA

32


Drug Name Drug Tier


Blood Products/Modifiers/Volume ExpandersCinryze 5 PACoagulants — Blood Clotting DrugsCyklokapron 3Tranexamic Acid (Injection) 3Platelet Modifying Agents — Platelet Modifying DrugsAggrenox 3Brilinta 3

Cilostazol 2

Clopidogrel 2

Dipyridamole (Tablet) 2 PAEffient 3Ticlopidine HCl 3

Cardiovascular Agents — Drugs to Treat Heart and Circulation Conditions

Alpha-Adrenergic Agonists — Blood Pressure DrugsCatapres-TTS 4

Clonidine HCl (Tablet) 2Clonidine HCl (Patch Weekly)

3

Clorpres 4

Methyldopa 2Methyldopa/Hydrochlorothiazide

2

Methyldopate HCl 2Midodrine HCl 3

Drug Name Drug Tier


Alpha-Adrenergic Blocking Agents — Blood Pressure DrugsDibenzyline 4

Prazosin HCl 2

Reserpine 2Angiotensin II Receptor Antagonists — Blood Pressure DrugsBenicar 3Benicar HCT 3Diovan 3Diovan HCT 3Edarbi 4Edarbyclor 4

Irbesartan 2Irbesartan/Hydrochlorothiazide

2

Losartan Potassium 1Losartan Potassium/Hydrochlorothiazide

1

Micardis 4Micardis HCT 4Valsartan/Hydrochlorothiazide

3

Angiotensin-Converting Enzyme (ACE) Inhibitors — Blood Pressure Drugs

Benazepril HCl 1Benazepril HCl/Hydrochlorothiazide

1

Captopril 2Captopril/Hydrochlorothiazide

2

33

Drug Name Drug Tier


Enalapril Maleate 2Enalapril Maleate/Hydrochlorothiazide

2

Fosinopril Sodium 2Fosinopril Sodium/Hydrochlorothiazide

2

Lisinopril 1Lisinopril/Hydrochlorothiazide

1

Moexipril HCl 3Moexipril/Hydrochlorothiazide

3

Perindopril Erbumine 2

Quinapril HCl 2Quinapril/Hydrochlorothiazide

2

Ramipril 2

Trandolapril 2Antiarrhythmics — Heart Regulation DrugsAmiodarone HCl (50mg/ml Injection, Tablet)

2

Disopyramide Phosphate 2

Flecainide Acetate 2

Mexiletine HCl 2Multaq 3

Pacerone (200mg Tablet) 2Pacerone (100mg Tablet) 4

Procainamide HCl 3

Propafenone HCl 2Propafenone HCl ER 3Quinidine Gluconate 4

Quinidine Gluconate CR 2

Quinidine Sulfate 2

Quinidine Sulfate ER 2

Drug Name Drug Tier


Rythmol SR 4

Sorine 2Sotalol HCl (160mg Tablet, 240mg Tablet, 80mg Tablet)

2

Sotalol HCl (Injection) 3Sotalol HCl (AF) (120mg Tablet)

2

Tikosyn 4Beta-Adrenergic Blocking Agents — Blood Pressure Drugs

Acebutolol HCl 2

Atenolol 1

Atenolol/Chlorthalidone 1

Betaxolol HCl (Tablet) 2

Bisoprolol Fumarate 2Bisoprolol Fumarate/Hydrochlorothiazide

2

Bystolic 3

Carvedilol (Tablet) 1Innopran XL 4

Labetalol HCl 2Metoprolol Succinate ER 3Metoprolol Tartrate (Tablet)

1

Metoprolol Tartrate (Injection)

3

Metoprolol/Hydrochlorothiazide

3

Nadolol 3Nadolol/Bendroflumethiazide

3

Pindolol 2

Propranolol HCl 2

Propranolol HCl ER 2

34


Drug Name Drug Tier


Propranolol/Hydrochlorothiazide

2

Timolol Maleate (Tablet) 2Toprol XL 4Calcium Channel Blocking Agents — Blood Pressure Drugs

Afeditab CR 2

Amlodipine Besylate 1Amlodipine Besylate/Benazepril HCl

4

Azor 3

Cartia XT 2Dilt-CD (120mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

2

Dilt-XR (180mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour)

2

Diltiazem CD (120mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

2

Diltiazem HCl (100mg Injection, 50mg/10ml Injection, Tablet)

2

Drug Name Drug Tier


Diltiazem HCl ER (Capsule Extended Release 12 Hour, 180mg Capsule Extended Release 24 Hour, 360mg Capsule Extended Release 24 Hour, 420mg Capsule Extended Release 24 Hour)

2

Exforge 3Exforge HCT 3Felodipine ER 3Isradipine 3Matzim LA 4

Nicardipine HCl 2Nifediac CC (90mg Tablet Extended Release 24 Hour)

2

Nifedical XL 2

Nifedipine ER 2Nimodipine 4Nisoldipine 3Nisoldipine ER 3

Taztia XT 2Tribenzor 3Twynsta 4

Verapamil HCl (Tablet) 2Verapamil HCl (Injection) 3Verapamil HCl ER (Tablet Extended Release)

2

35

Drug Name Drug Tier


Verapamil HCl ER (Capsule Extended Release 24 Hour)

3

Verapamil HCl SR (360mg Capsule Extended Release 24 Hour)

3

Cardiovascular Agents, Other — Miscellaneous Cardiac DrugsDemser 5Digoxin (Injection, Oral Solution, 0.125mg Tablet)

2

Digoxin (0.25mg Tablet) 2 PALanoxin (0.125mg Tablet) 3Lanoxin (0.25mg Tablet) 3 PALanoxin Pediatric 4

Pentoxifylline ER 2Ranexa 3 STTekturna 3 STTekturna HCT 3 STVecamyl 5 PADiuretics, Carbonic Anhydrase Inhibitors — Cardiac DrugsAcetazolamide Sodium (Injection)

3

Diuretics, Loop — Cardiac Drugs

Bumetanide 2Edecrin 4

Furosemide 2Torsemide (20mg/2ml Injection, Tablet)

2

Diuretics, Potassium-Sparing — Cardiac Drugs

Amiloride HCl 2Amiloride/Hydrochlorothiazide

2

Dyrenium 4

Drug Name Drug Tier


Eplerenone 3

Spironolactone 2Spironolactone/Hydrochlorothiazide

2

Triamterene/Hydrochlorothiazide

2

Diuretics, Thiazide — Cardiac Drugs

Chlorothiazide 2Chlorothiazide Sodium (Injection)

2

Chlorthalidone (25mg Tablet, 50mg Tablet)

2

Diuril 4

Hydrochlorothiazide 2

Indapamide 2

Methyclothiazide 2

Metolazone 2Dyslipidemics, Fibric Acid Derivatives — Cholesterol Control DrugsAntara 3

Fenofibrate 2

Fenofibrate Micronized 2

Gemfibrozil 2Tricor 3Trilipix 3Dyslipidemics, HMG CoA Reductase Inhibitors — Cholesterol Control Drugs

Atorvastatin Calcium 2Crestor 3Lipitor 4

Lovastatin 2

Pravastatin Sodium 1

Simvastatin 1

36


Drug Name Drug Tier


Dyslipidemics, Other — Miscellaneous Cholesterol Control DrugsCholestyramine Light (Packet)

2

Colestipol HCl (Tablet) 2Colestipol HCl (Granules) 3Juxtapid 5 PAKynamro 5 PALovaza 4Niaspan 3

Prevalite (Powder) 2Vascepa 4Vytorin 4Welchol 3Zetia 3Vasodilators, Direct-Acting Arterial — Chest Pain DrugsBiDil 3

Hydralazine HCl 2

Minoxidil (Tablet) 2Vasodilators, Direct-Acting Arterial/Venous — Chest Pain DrugsDilatrate SR 4Isordil Titradose (40mg Tablet) 4

Isosorbide Dinitrate 2

Isosorbide Dinitrate ER 2

Isosorbide Mononitrate 2Isosorbide Mononitrate ER

2

Drug Name Drug Tier


Minitran 2Nitro-Bid 4Nitroglycerin (Injection, Patch)

2

Nitrolingual Pumpspray 4NitroMist 4Nitrostat 3

Central Nervous System Agents — Drugs to Treat Nerve Conditions

Attention Deficit Hyperactivity Disorder Agents, Amphetamines — ADHD DrugsAmphetamine/Dextroamphetamine (Capsule Extended Release 24 Hour)

2

Amphetamine/Dextroamphetamine (Tablet)

3

Dextroamphetamine Sulfate (Tablet)

3

Dextroamphetamine Sulfate ER

3

Methamphetamine HCl 3Vyvanse 4Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines — ADHD DrugsDexmethylphenidate HCl 3Intuniv 4 PA

Metadate ER 2

37

Drug Name Drug Tier


Methylphenidate HCl 2Methylphenidate HCl ER (20mg Tablet Extended Release)

2

Methylphenidate HCl ER (Capsule Extended Release 24 Hour)

3

Strattera 4 STCentral Nervous System, Other — Miscellaneous Central Nervous System DrugsButalbital/Acetaminophen/Caffeine/Codeine

3

Rilutek 3Riluzole 3Xenazine 5 PAFibromyalgia Agents — Fibromyalgia DrugsSavella 3Savella Titration Pack 3Multiple Sclerosis Agents — Multiple Sclerosis DrugsAmpyra 5 PAAubagio 5 PACopaxone 5 PAGilenya 5 PA

Dental and Oral Agents — Drugs to Treat Mouth and Throat Conditions

Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse

2

Kepivance 5

Periogard 2Pilocarpine HCl (Tablet) 3

Triamcinolone in Orabase 2

Drug Name Drug Tier


Dermatological Agents — Drugs to Treat Skin Conditions

Dermatological Agents — Skin Agents8-MOP 5Absorica 5Adapalene 3Aldara 4

Ammonium Lactate 2Amnesteem 3Avita 3 PACalcipotriene (External Solution, Ointment)

3

Calcipotriene (Cream) 4Carac 4Claravis 3Clindagel 4Clindamycin Phosphate (External Solution, Foam, Gel, Lotion, Swab)

3

Clindamycin/Benzoyl Peroxide (5%; 1% Gel)

3

Dovonex 4Elidel 4 STErythromycin/Benzoyl Peroxide

2

Finacea 3Fluorouracil (Cream, External Solution)

3

Imiquimod 4

LAClotion 2Myorisan 3Oxsoralen 4 PA

38


Drug Name Drug Tier


Oxsoralen Ultra 5 PAPodofilox 3Protopic 4 ST

Prudoxin 2Regranex 5 PARetin-A Micro 4 PASantyl 4

Selenium Sulfide (Lotion) 2Solaraze 4 PASoriatane 5Stelara 5 PASulfacetamide Sodium (Suspension)

3

Tazorac 4 PATretin-X (Kit) 4 PATretinoin (Cream, 0.01% Gel, 0.025% Gel)

3 PA

Uvadex 4Vectical 4Veltin 4 PAVoltaren (Gel) 3Ziana 4 PAZyclara 3

Drug Name Drug Tier


Enzyme Replacements/Modifiers — Drugs to Treat Enzyme Deficiency

Enzyme Replacements/Modifiers — Enzyme Replacement/Modifying DrugsAdagen 5Aldurazyme 5Buphenyl 5Carbaglu 5Cerezyme (200unit Injection) 5 PA

Creon 3Cystadane 5Cystagon 4Elaprase 5Elelyso 5 PAFabrazyme (35mg Injection) 5

Kuvan 5Lumizyme 5Myozyme 5Naglazyme 5Orfadin 5RAVICTI 5Sodium Phenylbutyrate 5Sucraid 5Viokace 5 STVPRIV 5 PAZavesca 5Zenpep 3

39

Drug Name Drug Tier


Gastrointestinal Agents — Drugs to Treat Bowel, Intestine and Stomach Conditions

Antispasmodics, Gastrointestinal — Bowel Treatment DrugsAtropine Sulfate (0.05mg/ml Injection, 0.1mg/ml Injection)

2 PA

Cuvposa 4Dicyclomine HCl (Capsule, Oral Solution, Tablet)

2 PA

Glycopyrrolate (4mg/20ml Injection, Tablet)

3

Methscopolamine Bromide 3

Propantheline Bromide 2Gastrointestinal Agents, Other — Miscellaneous Gastrointestinal DrugsChenodal 5Cromolyn Sodium (Concentrate)

3

Diphenoxylate/Atropine 2 PAGastrocrom 4Gattex 5 PAHalfLytely Bowel Prep/Flavor Packs 3

Loperamide HCl (Capsule)

2

Metoclopramide HCl 2OsmoPrep 4Relistor (12mg/0.6ml Injection) 4 PA

Ursodiol 3

Drug Name Drug Tier


Histamine2 (H2) Blocking Agents — Ulcer and Stomach Acid Drugs

Cimetidine 2

Cimetidine HCl 2Famotidine (Injection, Suspension Reconstituted, 20mg Tablet, 40mg Tablet)

2

Famotidine Premixed 3

Nizatidine 2Ranitidine HCl (Capsule, 150mg/6ml Injection, Syrup, 150mg Tablet, 300mg Tablet)

2

Zantac (50mg/50ml; 0.45% Injection) 4

Irritable Bowel Syndrome Agents — Bowel Treatment DrugsAmitiza 3Lotronex 5 PALaxatives — Bowel Treatment Drugs

Constulose 2

Enulose 2

GaviLyte-C 2

GaviLyte-G 2

GaviLyte-N/Flavor Pack 2

Generlac 2Kristalose 4

Lactulose 2MoviPrep 4NuLYTELY/Flavor Packs 3Polyethylene Glycol 3350 (Powder)

2

Suprep Bowel Prep 4

TriLyte 2

40


Drug Name Drug Tier


Protectants — Ulcer and Stomach Acid DrugsCarafate (Suspension) 4

Misoprostol 2

Sucralfate 2Proton Pump Inhibitors — Ulcer and Stomach Acid DrugsDexilant 4Lansoprazole 4Nexium 3Nexium I.V. 4Omeprazole (Capsule Delayed Release)

2

Pantoprazole Sodium (Tablet Delayed Release)

2

Pantoprazole Sodium (Injection)

4

Prevacid SoluTab 4Protonix (Injection) 4Vimovo 3

Genitourinary Agents — Drugs to Treat Bladder, Genital and Kidney Conditions

Antispasmodics, Urinary — Bladder Control DrugsFlavoxate HCl 3Gelnique 3Myrbetriq 3

Oxybutynin Chloride 2Oxybutynin Chloride ER 3Oxytrol 3Sanctura XR 4

Drug Name Drug Tier


Toviaz 3Trospium Chloride 3Trospium Chloride ER 4Vesicare 3Benign Prostatic Hypertrophy Agents — Prostate Enlargement Drugs

Alfuzosin HCl ER 2Avodart 3

Doxazosin Mesylate 2

Finasteride (5mg Tablet) 2Rapaflo 3

Tamsulosin HCl 2

Terazosin HCl 2Genitourinary Agents, Other — Miscellaneous Bladder, Genital and Kidney Conditions Drugs

Bethanechol Chloride 2Elmiron 4Phosphate Binders — Phosphate-Removing AgentsFosrenol 5Renagel 3 STRenvela 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) — Drugs to Regulate Hormones

Glucocorticoids/Mineralocorticoids — Anti-Inflammatory DrugsA-Hydrocort 3Ala-Cort 3Ala-Scalp 4

41

Drug Name Drug Tier


Alclometasone Dipropionate

2

Amcinonide 2Augmented Betamethasone Dipropionate

2

Betamethasone Dipropionate

2

Betamethasone Valerate (Cream, Lotion, Ointment)

2

Betamethasone Valerate (Foam)

4

Capex 4Clobetasol Propionate (External Solution, Gel, Lotion, Ointment, Shampoo)

2

Clobetasol Propionate (Foam)

3

Clobetasol Propionate E 2Clobex 4Cloderm Pump 4Cordran 4Cordran Tape 4Cortef 4Cortifoam 4

Cortisone Acetate 2Depo-Medrol (20mg/ml Injection) 4

Derma-Smoothe/FS 4Desonate 4

Desonide 2Desowen (Cream, Lotion) 4

Desoximetasone (Cream, Gel, 0.25% Ointment)

3

Drug Name Drug Tier


Dexamethasone (Elixir, Tablet)

2

Dexamethasone Intensol 2Dexamethasone Sodium Phosphate (4mg/ml Injection)

2

Diflorasone Diacetate 2

Fludrocortisone Acetate 2

Fluocinolone Acetonide 2Fluocinolone Acetonide Body Oil

2

Fluocinonide (External Solution, Gel, Ointment)

2

Fluocinonide-E 2Fluticasone Propionate (Cream, Lotion, Ointment)

2

Halobetasol Propionate 3Halog 4Hydrocortisone (1% Cream, 2.5% Cream, 2.5% Lotion, 1% Ointment, 2.5% Ointment, Tablet)

3

Hydrocortisone Butyrate 2Hydrocortisone Valerate 3Kenalog 4Locoid (External Solution, Lotion, Ointment)

4

Locoid Lipocream 4

LoKara 2Luxiq 4Methylprednisolone (Tablet)

2

Methylprednisolone Acetate (Injection)

3

Methylprednisolone Dose Pack

2

42


Drug Name Drug Tier


Methylprednisolone Sodium Succinate (125mg Injection, 1gm Injection, 40mg Injection)

3

Mometasone Furoate (Cream, External Solution, Ointment)

2

Olux-E 4Pandel 4

Prednicarbate 2Prednisolone Sodium Phosphate (Oral Solution)

2

Prednisone 2Prednisone Intensol (Oral Solution)

2

Procto-Pak 2

ProctoCream HC 2

Proctozone-HC 2Rayos 4 B/DSolu-Cortef (100mg Injection, 250mg Injection)

4

Solu-Medrol (125mg Injection, 2gm Injection, 40mg Injection, 500mg Injection)

4

Triamcinolone Acetonide (Cream, Lotion, Ointment)

2

Triderm 2

U-Cort 2Vanos 4

Drug Name Drug Tier


Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) — Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) — Hormone Replacement/Modifying DrugsActhar HP 5Chorionic Gonadotropin 3 PADDAVP (Injection) 5 STDesmopressin Acetate 3Egrifta (1mg Injection) 5 PAGenotropin (5mg Injection, 12mg Injection)

5 PA

Genotropin Miniquick (0.2mg Injection) 4 PA

Genotropin Miniquick (0.4mg Injection, 0.6mg Injection, 0.8mg Injection, 1.2mg Injection, 1.4mg Injection, 1.6mg Injection, 1.8mg Injection, 1mg Injection, 2mg Injection)

5 PA

Humatrope 5 PAIncrelex 5 PANorditropin FlexPro 5 PANorditropin NordiFlex Pen 5 PA

43

Drug Name Drug Tier


Novarel 3 PANutropin 5 PANutropin AQ 5 PAOmnitrope (10mg/1.5ml Injection, 5mg/1.5ml Injection)

4 PA

Omnitrope (5.8mg Injection) 5 PA

Pregnyl W/Diluent Benzyl Alcohol/NaCl

3 PA

Saizen 5 PASerostim 5 PAStimate 4Tev-Tropin 4 PAZorbtive 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) – Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) – Hormone Replacement/Modifying DrugsKorlym 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) — Drugs to Regulate Hormones

Anabolic Steroids — Hormone Replacement/Modifying DrugsOxandrolone (2.5mg Tablet)

3 PA

Oxandrolone (10mg Tablet) 5 PA

Drug Name Drug Tier


Androgens — Hormone Replacement/Modifying DrugsAndroderm 3Androgel (50mg/5gm Gel) 3

Androgel Pump (1.62% Gel) 3

Androxy 3Danazol 3Testosterone Cypionate 3Testosterone Enanthate 3Estrogens — Hormone Replacement/Modifying Drugs

Amethia 2

Amethyst 2

Apri 2

Aranelle 2

Aviane 2

Balziva 2

Briellyn 2Cenestin 4CombiPatch 4 PA

Cryselle 2

Cyclafem 1/35 2

Cyclafem 7/7/7 2Cyclessa 4Depo-Estradiol 4Desogen 4Drospirenone/Ethinyl Estradiol

2

Emoquette 2Enjuvia 3

Enpresse 2Estrace (Cream) 4

44


Drug Name Drug Tier


Estradiol (Tablet) 2 PAEstradiol Valerate 3Estradiol/Norethindrone Acetate (0.5mg; 0.1mg Tablet)

2

Estring 4Estrostep Fe 4Femhrt Low Dose 4Femring 4Femtrace 4Generess Fe 4

Gianvi 2

Gildagia 2

Introvale 2

Jinteli 2

Junel 2

Junel Fe 2

Kariva 2

Kelnor 2

Leena 2

Lessina 2

Levonest 2Levonorgestrel/Ethinyl Estradiol (0.03mg; 0.15mg Tablet)

2

Levora 2Lo/Ovral 4Loestrin Fe (20mcg; 75mg; 1mg Tablet) 4

Loryna 2

Drug Name Drug Tier


LoSeasonique 4

Low-Ogestrel 2

Lutera 2

Marlissa 2

Microgestin 2

Microgestin Fe 2Minastrin 24 Fe 4

MonoNessa 2

Necon 2

Necon 1/35 2

Nortrel 2

Nortrel 1/35 2NuvaRing 3

Ocella 2

Ogestrel 2

Orsythia 2Ortho Evra 4Ortho Tri-Cyclen Lo 4Ortho-Cept 4Ortho-Cyclen 4Ortho-Novum 7/7/7 4Ovcon-35 4Ovcon-50 28 4

Portia 2Prefest 4Premarin (Cream) 3

Previfem 2

Quasense 2

Reclipsen 2

45

Drug Name Drug Tier


Seasonale 4Seasonique 4

Sprintec 2

Sronyx 2

Tri-Legest Fe 2

Tri-Previfem 2

Tri-Sprintec 2

Trinessa 2

Trivora 2Vagifem 4

Velivet 2

Vestura 2Yasmin 4

Zenchent Fe 2

Zeosa 2

Zovia 2Progesterone — Hormone Replacement/Modifying DrugsElla 4Progestins — Hormone Replacement/Modifying Drugs

Camila 2Crinone 4Depo-Provera (400mg/ml Injection) 4

Errin 2

Jolivette 2Medroxyprogesterone Acetate

2

Megace ES 4 PA

Megestrol Acetate 2 PA

Nora-BE 2

Norethindrone Acetate 2Ortho Micronor 4

Progesterone (Capsule) 2

Drug Name Drug Tier


Selective Estrogen Receptor Modifying Agents — Hormone Replacement/Modifying DrugsEvista 3

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) — Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) — Thyroid Replacement DrugsLevothroid 3Levothyroxine Sodium (Tablet)

2

Levoxyl 2

Liothyronine Sodium 2Synthroid 3Thyrolar 3Unithroid (100mcg Tablet, 112mcg Tablet, 125mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet)

2

Hormonal Agents, Suppressant (Adrenal) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Adrenal) — Hormone SuppressantsLysodren 3

46


Drug Name Drug Tier


Hormonal Agents, Suppressant (Parathyroid) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Parathyroid) — Hormone SuppressantsSensipar (30mg Tablet) 3Sensipar (60mg Tablet, 90mg Tablet) 5

Hormonal Agents, Suppressant (Pituitary) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Pituitary) — Hormone SuppressantsCabergoline 3Eligard 4Firmagon (80mg Injection) 4 PA

Firmagon (120mg Injection) 5 PA

Leuprolide Acetate 3Lupron Depot (3.75mg Injection) 4

Lupron Depot (22.5mg Injection, 30mg Injection, 45mg Injection, 7.5mg Injection)

5

Lupron Depot-PED (11.25mg Injection – 3 Month)

4

Drug Name Drug Tier


Lupron Depot-PED (11.25mg Injection – 1 Month, 15mg Injection – 1 Month)

5

Octreotide Acetate (100mcg/ml Injection, 50mcg/ml Injection)

4 PA

Octreotide Acetate (1000mcg/ml Injection, 200mcg/ml Injection, 500mcg/ml Injection)

5 PA

Sandostatin 5 PASandostatin LAR Depot 5 PASignifor 5 PASomatuline Depot 5 PASomavert 5 PASynarel 5 PATrelstar Depot 5Trelstar LA 5Trelstar Mixject 5

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) — Drugs to Regulate Hormones

Antiandrogens — Hormone Suppressants

Bicalutamide 2Flutamide 3Nilandron 4Xtandi 5 PA

47

Drug Name Drug Tier


Hormonal Agents, Suppressant (Thyroid) — Drugs to Suppress Thyroid Hormones

Antithyroid Agents — Thyroid Suppressing Drugs

Methimazole 2

Propylthiouracil 2

Immunological Agents — Drugs that Stimulate or Suppress the Immune System

Immune Suppressants — Immune System DrugsAzasan 4

Azathioprine 2Azathioprine Sodium (Injection) 3

Benlysta (120mg Injection) 5 PA

Cellcept (Capsule) 4 B/D, PACellcept (Suspension Reconstituted, Tablet) 5 B/D, PA

Cellcept Intravenous 4 B/D, PACimzia 5 PACyclosporine 3 B/DCyclosporine Modified 3 B/DEnbrel 5 PAGengraf 3 B/DHumira 5 PAHumira Starter Kit 5 PAKineret 5 PA

Methotrexate (Tablet) 2Methotrexate Sodium (25mg/ml Injection)

2

Drug Name Drug Tier


Methotrexate Sodium (1gm Injection)

3

Mycophenolate Mofetil 3 B/D, PAMyfortic (180mg Tablet Delayed Release) 4 B/D

Myfortic (360mg Tablet Delayed Release) 5 B/D

Nulojix 5 B/D, PAOrencia 5 PAPrograf (Injection) 4 B/D, PARapamune (0.5mg Tablet) 4 B/D

Rapamune (Oral Solution, 1mg Tablet, 2mg Tablet)

5 B/D

Remicade 5 PASandimmune (Capsule, Oral Solution) 4 B/D

Simponi (50mg/0.5ml Injection) 5 PA

Tacrolimus (0.5mg Capsule, 1mg Capsule)

3 B/D, PA

Tacrolimus (5mg Capsule) 5 B/D, PATorisel 5Trexall 4Zortress (0.25mg Tablet) 4 B/D, PAZortress (0.5mg Tablet, 0.75mg Tablet) 5 B/D, PA

Immunizing Agents, Passive — Immune System DrugsAtgam 5 B/DCarimune Nanofiltered (3gm Injection) 5 B/D, PA

Gamastan S/D 3 PAGammagard Liquid 5 B/D, PA

48


Drug Name Drug Tier


Gammaplex (10gm/200ml Injection) 5 B/D, PA

Gamunex-C (1gm/10ml Injection) 5 B/D, PA

Privigen (20gm/200ml Injection) 5 B/D, PA

Thymoglobulin 5 B/DImmunomodulators — Immune System DrugsActemra (200mg/10ml Injection) 5 PA

Actimmune 5Arcalyst 5 PAAvonex 5 PABetaseron 5 PAExtavia 5 PAIlaris 5 PA

Leflunomide 2Rebif 5 PARebif Titration Pack 5 PARidaura 4Simulect (20mg Injection) 5 B/D

Synagis (50mg/0.5ml Injection) 5

Tecfidera 5 PATecfidera Starter Pack 5 PATysabri 5 PA, LAXeljanz 5 PA

Drug Name Drug Tier


VaccinesActHIB 3Adacel 3Boostrix 3Cervarix 4Comvax 3Daptacel 3Decavac 3Engerix-B 3 B/DGardasil 3Havrix 3Imovax Rabies (H.D.C.V.) 3 B/DInfanrix 3IPOL 3Ixiaro 3M-M-R II 3Menactra 3Menomune-A/C/Y/W-135 3

Menveo 3Pedvax HIB 3ProQuad 3Rabavert 3Recombivax HB (10mcg/ml Injection, 40mcg/ml Injection)

3 B/D

RotaTeq 3Tetanus Toxoid Adsorbed 3Tetanus/Diphtheria Toxoids-Adsorbed Adult

3

Twinrix 3

49

Drug Name Drug Tier


Typhim Vi 3VAQTA (25unit/0.5ml Injection) 3

Varivax 3YF-Vax 3Zostavax 4

Inflammatory Bowel Disease Agents — Drugs to Treat Inflammatory Bowel Disease

Aminosalicylates — Inflammatory Bowel Disease DrugsApriso 3Asacol (400mg Tablet Delayed Release) 3

Balsalazide Disodium 3Canasa 3Giazo 5Lialda 3Mesalamine (Kit) 3Pentasa 4sfRowasa 4Glucocorticoids — Inflammatory Bowel Disease DrugsBudesonide (Capsule Extended Release 24 Hour)

3

Colocort 3Hydrocortisone (Enema) 3Millipred (Tablet) 4Uceris 5 STSulfonamides — Inflammatory Bowel Disease Drugs

Sulfasalazine (Tablet) 2

Sulfazine EC 2

Drug Name Drug Tier


Metabolic Bone Disease Agents — Drugs to Treat Bone Conditions

Metabolic Bone Disease Agents — Osteoporosis (Bone Loss) DrugsActonel 3Alendronate Sodium (Tablet)

2

Alendronate Sodium (Oral Solution)

4

Atelvia 4Binosto 4Boniva (Injection) 4 B/DCalcitonin-Salmon 3Calcitriol (Capsule, Injection, Oral Solution)

2 B/D

Etidronate Disodium 3Forteo 4 B/D, PAFortical 3Hectorol 3 B/DIbandronate Sodium 3Miacalcin (Injection) 4 B/D, PAPamidronate Disodium (30mg/10ml Injection, 90mg/10ml Injection)

3 B/D

Pamidronate Disodium (6mg/ml Injection) 4 B/D

Prolia 4 PAReclast 4 PAXgeva 5 PAZemplar 3 B/DZoledronic Acid (5mg/100ml Injection)

4 PA

Zoledronic Acid (4mg/5ml Injection)

5

Zometa 5

50


Drug Name Drug Tier


Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

Alcohol Preps (Pad) 2Botox (100unit Injection) 4 PAFerriprox 5 PAFirazyr 5 PAFomepizole 5Gauze Pads 3Insulin Syringes, Needles 3

Intralipid (1.7%; 30% Injection) 4 B/D

Intralipid (2.25%; 20% Injection)

4 B/D

Lactated Ringers Irrigation 3Levocarnitine 3 B/DLiposyn III (1.2%; 2.5%; 10% Injection, 1.2%; 2.5%; 20% Injection)

4 B/D

Methergine 3Methylergonovine Maleate (Tablet)

2

Physiolyte 4Physiosol Irrigation 4Ringers Irrigation 3Sodium Chloride 0.9% (Irrigation Solution)

2

Sterile Water Irrigation 3Voraxaze 5

Drug Name Drug Tier


Ophthalmic Agents — Drugs to Treat Eye Conditions

Ophthalmic Agents, Other — Miscellaneous Eye DrugsAlcaine 4Cystaran 5Lacrisert 4

Naphazoline HCl 2

Proparacaine HCl 2Restasis 3Ophthalmic Anti-Allergy Agents — Allergy, Infection and Inflammation DrugsAlocril 4Alomide 4Azelastine HCl (Ophthalmic Solution)

3

Bepreve 4Cromolyn Sodium (Ophthalmic Solution)

2

Epinastine HCl 3Lastacaft 3Pataday 3Patanol 3Ophthalmic Anti-Inflammatories — Allergy, Infection and Inflammation DrugsAlrex 3Blephamide 3Blephamide S.O.P. 3Bromday 4

51

Drug Name Drug Tier


Bromfenac 3Dexamethasone Sodium Phosphate (Ophthalmic Solution)

2

Diclofenac Sodium (Ophthalmic Solution)

2

Durezol 3Flarex 3

Flurbiprofen Sodium 2FML 3FML Forte 3Ilevro 3Ketorolac Tromethamine (Ophthalmic Solution)

3

Lotemax 3Neomycin/Polymyxin/Bacitracin/Hydrocortisone

2

Neomycin/Polymyxin/Dexamethasone

2

Neomycin/Polymyxin/Hydrocortisone (Ophthalmic Suspension)

2

Nevanac 3Pred Mild 3Pred-G 3Pred-G S.O.P. 3

Prednisolone Acetate 2Prednisolone Sodium Phosphate (Ophthalmic Solution)

2

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

2

Tobradex (Ointment) 3Tobradex (Suspension) 4Tobradex ST 4

Drug Name Drug Tier


Tobramycin/Dexamethasone

3

Vexol 4Zylet 3Ophthalmic Antiglaucoma Agents — Glaucoma Drugs

Acetazolamide 2Acetazolamide ER 3Alphagan P (0.1% Ophthalmic Solution) 3

Apraclonidine 3Azopt 3Betaxolol HCl (Ophthalmic Solution)

2

Betimol 4Betoptic-S 4

Brimonidine Tartrate 2

Carteolol HCl 2Combigan 3

Dorzolamide HCl 2Dorzolamide HCl/Timolol Maleate

2

Iopidine (1% Ophthalmic Solution) 4

Isopto Carpine 4Istalol 4Levobunolol HCl (0.5% Ophthalmic Solution)

2

Methazolamide 2

Metipranolol 2Optipranolol 4Phospholine Iodide 3Pilopine HS 3Timolol Maleate (Gel Forming Solution, Ophthalmic Solution)

2

52


Drug Name Drug Tier


Ophthalmic Prostaglandin and Prostamide Analogs — Glaucoma Drugs

Latanoprost 2Lumigan 3Travatan Z 3Travoprost 3

Otic Agents — Drugs to Treat Ear Conditions

Otic Agents — Ear DrugsAcetasol HC 3

Acetic Acid (Otic Solution) 2Coly-Mycin S 4Cortisporin (Otic Solution, Suspension) 4

DermOtic 3Hydrocortisone/Acetic Acid

3

Neomycin/Polymyxin/Hydrocortisone (Solution, Suspension)

2

Respiratory Tract Agents — Drugs to Treat Allergies, Cough, Cold and Lung Conditions

Anti-Inflammatories, Inhaled Corticosteroids — Asthma/Lung DrugsAdvair Diskus 3Advair HFA 3Asmanex 4Budesonide (Inhalation Suspension)

3 B/D

Drug Name Drug Tier


Dulera 4Flovent Diskus 3Flovent HFA 3Flunisolide (0.025% Nasal Solution)

2

Fluticasone Propionate (Suspension)

2

Nasonex 3Omnaris 4Pulmicort 4 B/DPulmicort Flexhaler 3QVAR 3Symbicort 3Triamcinolone Acetonide (Inhaler)

3

Zetonna 4Antihistamines — Allergy DrugsAstepro 3Azelastine HCl (Nasal Solution)

3

Cetirizine HCl (Syrup) 2Dymista 3

Hydroxyzine HCl 2

Hydroxyzine Pamoate 2Levocetirizine Dihydrochloride (Tablet)

4

Patanase 3Phenadoz 3Promethazine HCl 3Promethazine VC 3

53

Drug Name Drug Tier


Promethegan (25mg Suppository, 50mg Suppository)

3

Antileukotrienes — Asthma/Lung Drugs

Montelukast Sodium 2Singulair 3

Zafirlukast 2Bronchodilators, Anticholinergic — Asthma/Lung DrugsAtrovent HFA 4Combivent 3Combivent Respimat 3Ipratropium Bromide (Inhalation Solution)

2 B/D

Ipratropium Bromide (Nasal Solution)

2

Ipratropium Bromide/Albuterol Sulfate

2 B/D

Spiriva Handihaler 3Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) — Asthma/Lung Drugs

Aminophylline 2Elixophyllin 3Theophylline ER (100mg Tablet Extended Release 12 Hour, 200mg Tablet Extended Release 12 Hour, 300mg Tablet Extended Release 12 Hour, 450mg Tablet Extended Release 12 Hour, 400mg Tablet Extended Release 24 Hour, 600mg Tablet Extended Release 24 Hour)

2

Drug Name Drug Tier


Bronchodilators, Sympathomimetic — Asthma/Lung DrugsAlbuterol Sulfate (Nebulization Solution)

2 B/D

Albuterol Sulfate (Syrup, Tablet)

2

Albuterol Sulfate ER 2Arcapta Neohaler 4 STAuvi-Q 4Brovana 4 B/DEpinephrine HCl (0.1mg/ml Injection)

3

EpiPen 3Foradil Aerolizer 3 STLevalbuterol HCl (0.31mg/3ml Nebulization Solution, 0.63mg/3ml Nebulization Solution, 1.25mg/0.5ml Nebulization Solution)

4 B/D, ST

Metaproterenol Sulfate 2Perforomist 4 B/DProair HFA 3Serevent Diskus 3 STTerbutaline Sulfate (Tablet)

2

Terbutaline Sulfate (Injection)

4

Twinject 4Mast Cell Stabilizers — Asthma/Lung DrugsCromolyn Sodium (Nebulization Solution)

3 B/D

Pulmonary Antihypertensives — Asthma/Lung DrugsAdcirca 5 PALetairis 5Remodulin 5 B/D, PA

54


Drug Name Drug Tier


Revatio 5 PASildenafil Citrate 5 PATracleer 5 LATyvaso 5 B/DVentavis 5 B/D, PARespiratory Tract Agents, Other — Asthma/Lung DrugsAcetylcysteine (Inhalation Solution)

2 B/D

Aralast NP (400mg Injection) 5 PA

Glassia 5 PAKalydeco 5 PAProlastin-C 5 PAPulmozyme 5 B/DTyzine 3Xolair 5 PAZemaira 5 PA

Sedatives/Hypnotics — Drugs for Sedation and Sleep

GABA Receptor Modulators — Sedation and Sleep DrugsLunesta 3 PATemazepam (15mg Capsule, 30mg Capsule)

2

Temazepam (22.5mg Capsule, 7.5mg Capsule)

4

Zaleplon 2 PAZolpidem Tartrate (5mg Tablet, 10mg Tablet)

2 PA

Drug Name Drug Tier


Sleep Disorders, Other — Miscellaneous Sedation and Sleep DrugsModafinil 4 PAProvigil 4 PARozerem 4Xyrem 3 PA, LA

Skeletal Muscle Relaxants — Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Skeletal Muscle Relaxants — Pain/Swelling Management DrugsCyclobenzaprine HCl (10mg Tablet, 5mg Tablet)

4 PA

Orphenadrine Compound DS

3

Orphenadrine/Aspirin/Caffeine

3

Therapeutic Nutrients/Minerals/Electrolytes — Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies

Electrolyte/Mineral Modifiers — Vitamin, Mineral and Body Fluid Deficiency DrugsAmmonium Chloride 4Chemet 4Exjade (125mg Tablet Soluble) 4

Exjade (250mg Tablet Soluble, 500mg Tablet Soluble)

5

Kionex (Powder) 2

55

Drug Name Drug Tier


Samsca 5 PA

Sodium Lactate (Injection) 2Sodium Polystyrene Sulfonate (15gm/60ml Suspension)

2

Syprine 4Electrolyte/Mineral Replacement — Vitamin, Mineral and Body Fluid Deficiency DrugsAminosyn 8.5%/Electrolytes

3 B/D

Aminosyn II (15% Injection) 3 B/D

Aminosyn II (7% Injection, 8.5% Injection, 10% Injection)

4 B/D

Aminosyn II 8.5%/Electrolytes

3 B/D

Aminosyn M 4 B/DAminosyn-HBC 4 B/DAminosyn-PF 4 B/DCalcium Acetate (Capsule) 3Clinimix 2.75%/Dextrose 5% 4 B/D

Clinimix 4.25%/Dextrose 10% 4 B/D





Clinisol SF 15% 3 B/DDextrose 5%/Lactated Ringers

2

Drug Name Drug Tier


Dextrose 5%/Potassium Chloride 0.15%

3

Eliphos 3FreAmine III (8.5% Injection)

4 B/D

FreAmine III 3% 4 B/DHepatAmine 3 B/DHepatasol 3 B/DIsolyte-H/Dextrose 5% 4Isolyte-M/Dextrose 5% 3Isolyte-P/Dextrose 5% 4Isolyte-S 4Isolyte-S/Dextrose 5% 4K-Tabs 3

Klor-Con 10 2

Klor-Con 8 2Klor-Con M15 3

Klor-Con M20 2Lactated Ringers Viaflex 3Magnesium Sulfate (50% Injection)

3

Nephramine 4 B/DNormosol-M in D5W 3Normosol-R 4PhosLo 3Phoslyra 4 STPlasma-Lyte 4Plasma-Lyte/D5W 4Potassium Chloride (0.4meq/ml Injection, 10meq/100ml Injection, 10meq/50ml Injection, 2meq/ml Injection, 30meq/100ml Injection)

3

56


Drug Name Drug Tier


Potassium Chloride 0.15%/NaCl 0.45% Viaflex

3

Potassium Chloride 0.15%/NaCl 0.9%

3

Potassium Chloride 0.224%/Dextrose 5% Viaflex

3

Potassium Chloride 0.3%/D5W

3

Potassium Chloride 0.3%/NaCl 0.9%

3

Potassium Chloride ER (Capsule Extended Release, 10meq Tablet Extended Release, 20meq Tablet Extended Release)

2

Potassium Citrate (Tablet Extended Release)

3

Premasol (10% Injection) 4 B/DPremasol (6% Injection) 4 B/DProcalamine 4 B/DProsol 4 B/DRingers Injection 3Sodium Chloride (0.9% Injection, 2.5meq/ml Injection, 3% Injection, 5% Injection)

2

Sodium Chloride 0.45% Viaflex (Injection)

2

Sodium Fluoride (Tablet) 2TPN Electrolytes 3Travasol 4 B/DTrophamine 4 B/D

Drug Name Drug Tier


Vitamins — Vitamin, Mineral and Body Fluid Deficiency Drugs

Niacor 2

Prenatal Vitamins 2

57

Index of covered drugs

8-MOP ................................... 37

AAbacavir ................................. 26

Abelcet ................................... 19

Abilify .................................... 25

Abilify Discmelt ..................... 25

Abilify Maintena .................... 25

Abraxane ................................ 21

Absorica .................................. 37

Abstral ...................................... 9

Acarbose ................................. 28

Acebutolol HCl ...................... 33

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate ..... 9

Acetaminophen/Codeine .......... 9

Acetasol HC ........................... 52

Acetazolamide ........................ 51

Acetazolamide ER .................. 51

Acetazolamide Sodium ........... 35

Acetic Acid ............................. 52

Acetylcysteine ......................... 54

Actemra .................................. 48

Acthar HP .............................. 42

ActHIB .................................. 48

Actimmune............................. 48

Actiq ......................................... 9

Actonel ................................... 49

Actoplus Met .......................... 28

Actos ...................................... 28

Acyclovir ................................ 28

Acyclovir Sodium ................... 28

Adacel ..................................... 48

Adagen ................................... 38

Adapalene ............................... 37

Adcirca ................................... 53

Adriamycin ............................. 21

Advair Diskus ......................... 52

Advair HFA ........................... 52

Afeditab CR ........................... 34

Afinitor ................................... 23

Aggrenox ................................ 32

Agrylin ................................... 31

A-Hydrocort ........................... 40

Akne-Mycin ........................... 14

Ala-Cort ................................. 40

Ala-Scalp ................................ 40

Albenza .................................. 23

Albuterol Sulfate .................... 53

Albuterol Sulfate ER .............. 53

Alcaine ................................... 50

Alclometasone Dipropionate ...41

Alcohol Preps ......................... 50

Aldara ..................................... 37

Aldurazyme ............................ 38

Alendronate Sodium .............. 49

Alfuzosin HCl ER ................. 40

Alimta .................................... 21

Alinia ..................................... 23

Alkeran ................................... 20

Allopurinol ............................. 19

Allopurinol Sodium ................ 19

Alocril .................................... 50

Alomide .................................. 50

Aloxi ....................................... 18

Alphagan P ............................. 51

Alprazolam ............................. 28

Alrex ....................................... 50

Altabax ................................... 11

Amantadine HCl .................... 27

AmBisome .............................. 19

Amcinonide ............................ 41

Amethia.................................. 43

Amethyst ................................ 43

Amifostine .............................. 21

Amikacin Sulfate .................... 11

Amiloride HCl ....................... 35

Amiloride/ Hydrochlorothiazide ............ 35

Aminophylline ........................ 53

Aminosyn 8.5%/Electrolytes ...55

Aminosyn-HBC ..................... 55

Aminosyn II ........................... 55

Aminosyn II 8.5%/ Electrolytes .......................... 55

Aminosyn M .......................... 55

Aminosyn-PF ......................... 55

Amiodarone HCl ................... 33

Amitiza................................... 39

Amitriptyline HCl ................. 17

Amlodipine Besylate .............. 34

Amlodipine Besylate/ Benazepril HCl ................... 34

Ammonium Chloride ............. 54

Ammonium Lactate ............... 37

Amnesteem ............................ 37

Amoxapine ............................. 17

Amoxicillin ............................. 13

58

Amoxicillin/ Potassium Clavulanate ......... 13

Amoxicillin/ Potassium Clavulanate ER ...13

Amphetamine/Dextroamphetamine ............ 36

Amphotec ............................... 19

Amphotericin B ...................... 19

Ampicillin .............................. 13

Ampicillin Sodium ................. 13

Ampicillin/Sulbactam ............ 13

Ampyra................................... 37

Anagrelide HCl ...................... 31

Anastrozole ............................ 23

Ancobon ................................. 19

Androderm ............................. 43

Androgel................................. 43

Androgel Pump ...................... 43

Androxy .................................. 43

Antabuse ................................. 18

Antara .................................... 35

Anzemet ................................. 18

Apidra .................................... 30

Apidra SoloStar ...................... 30

Apokyn ................................... 24

Apraclonidine ......................... 51

Apri ........................................ 43

Apriso ..................................... 49

Aptivus ................................... 27

Aralast NP ............................. 54

Aranelle .................................. 43

Aranesp Albumin Free ........... 31

Arcalyst .................................. 48

Arcapta Neohaler ................... 53

Argatroban ............................. 30

Aricept .................................... 16

Arixtra .................................... 30

Aromasin ................................ 23

Arranon .................................. 21

Arthrotec .................................. 8

Arzerra ................................... 23

Asacol ..................................... 49

Asmanex ................................. 52

Astepro ................................... 52

Astramorph .............................. 9

Atelvia .................................... 49

Atenolol .................................. 33

Atenolol/Chlorthalidone ........ 33

Atgam..................................... 47

Atorvastatin Calcium ............. 35

Atovaquone/Proguanil HCl ... 23

Atripla .................................... 26

Atropine Sulfate ..................... 39

Atrovent HFA ........................ 53

Aubagio .................................. 37

Augmented Betamethasone Dipropionate ........................ 41

Auvi-Q ................................... 53

Avandamet ............................. 28

Avandaryl ............................... 28

Avandia .................................. 28

Avastin ................................... 23

Avelox ..................................... 14

Avelox ABC Pack ................... 14

Aviane .................................... 43

Avinza ...................................... 9

Avita ....................................... 37

Avodart ................................... 40

Avonex .................................... 48

Azactam in Iso-Osmotic Dextrose .............................. 13

Azasan .................................... 47

Azasite .................................... 14

Azathioprine ........................... 47

Azathioprine Sodium ............. 47

Azelastine HCl ................. 50, 52

Azilect .................................... 24

Azithromycin ......................... 14

Azopt ...................................... 51

Azor ....................................... 34

Aztreonam .............................. 13

BBACiiM ................................. 11

Bacitracin................................ 11

Bacitracin/Polymyxin B ......... 11

Baclofen .................................. 26

Bactocill in Dextrose .............. 13

Bactroban ............................... 11

Balsalazide Disodium ............. 49

Balziva .................................... 43

Banzel ..................................... 16

Baraclude ................................ 27

Benazepril HCl ...................... 32

Benazepril HCl/Hydrochlorothiazide ............ 32

Benicar ................................... 32

Benicar HCT ......................... 32

Benlysta .................................. 47

Benztropine Mesylate ............. 24

Bepreve ................................... 50

Besivance ................................ 14

Betamethasone Dipropionate ...41

59

Betamethasone Valerate .......... 41

Betaseron ................................ 48

Betaxolol HCl ................... 33, 51

Bethanechol Chloride ............. 40

Betimol ................................... 51

Betoptic-S ............................... 51

Bicalutamide ........................... 46

Bicillin C-R ............................ 13

Bicillin L-A ............................ 13

BiCNU ................................... 20

BiDil ....................................... 36

Biltricide ................................. 23

Binosto ................................... 49

Bisoprolol Fumarate ............... 33

Bisoprolol Fumarate/Hydrochlorothiazide ............ 33

Bleomycin Sulfate ................... 21

Blephamide ............................. 50

Blephamide S.O.P................... 50

Boniva .................................... 49

Boostrix .................................. 48

Bosulif .................................... 23

Botox ...................................... 50

Briellyn ................................... 43

Brilinta ................................... 32

Brimonidine Tartrate .............. 51

Bromday ................................. 50

Bromfenac .............................. 51

Bromocriptine Mesylate ......... 24

Brovana................................... 53

Budeprion SR ......................... 17

Budesonide ....................... 49, 52

Bumetanide ............................ 35

Buphenyl ................................. 38

Buprenorphine HCl ................ 18

Buprenorphine HCl/ Naloxone HCl ..................... 18

Buproban ................................ 18

Bupropion HCl ....................... 17

Bupropion HCl SR ................. 17

Bupropion HCl XL ................ 17

Buspirone HCl ....................... 28

Busulfex .................................. 20

Butalbital/Acetaminophen/Caffeine/Codeine ................ 37

Butalbital/Aspirin/ Caffeine/Codeine .................. 9

Butorphanol Tartrate ................ 9

Byetta ..................................... 28

Bystolic ................................... 33

CCabergoline ............................ 46

Calcipotriene .......................... 37

Calcitonin-Salmon ................. 49

Calcitriol ................................. 49

Calcium Acetate ..................... 55

Camila .................................... 45

Campath ................................. 23

Campral .................................. 18

Camptosar .............................. 21

Canasa .................................... 49

Cancidas ................................. 19

Capastat Sulfate ...................... 20

Capex...................................... 41

Caprelsa .................................. 21

Captopril ................................ 32

Captopril/ Hydrochlorothiazide ............ 32

Carac ...................................... 37

Carafate .................................. 40

Carbaglu ................................. 38

Carbamazepine ....................... 16

Carbamazepine ER ................ 16

Carbidopa/Levodopa .............. 24

Carbidopa/Levodopa ER ....... 24

Carbidopa/Levodopa ODT .... 24

Carboplatin ............................. 21

Carimune Nanofiltered ........... 47

Carteolol HCl ......................... 51

Cartia XT ............................... 34

Carvedilol ............................... 33

Catapres-TTS ......................... 32

Cayston ................................... 13

Cedax ..................................... 12

CeeNU ................................... 20

Cefaclor .................................. 12

Cefaclor ER ............................ 12

Cefadroxil ............................... 12

Cefazolin Sodium ................... 12

Cefdinir .................................. 12

Cefepime ................................ 12

Cefotaxime Sodium ................ 12

Cefotetan ................................ 13

Cefoxitin Sodium ................... 12

Cefoxitin Sodium/Dextrose ... 12

Cefpodoxime Proxetil ............. 12

Cefprozil................................. 12

Ceftazidime ............................ 12

Ceftazidime/Dextrose ............ 12

Ceftriaxone Sodium ............... 12

Cefuroxime Axetil .................. 12

Cefuroxime Sodium ............... 12

Celebrex .................................... 8

60

Cellcept .................................. 47

Cellcept Intravenous ............... 47

Celontin .................................. 15

Cenestin ................................. 43

Cephalexin ............................. 13

Cerezyme ............................... 38

Cerubidine .............................. 21

Cervarix .................................. 48

Cesamet .................................. 18

Cetirizine HCl ....................... 52

Chantix ................................... 18

Chantix Starting Month Pak ...18

Chemet ................................... 54

Chenodal ................................ 39

Chloramphenicol Sodium Succinate.............................. 11

Chlordiazepoxide/ Amitriptyline ....................... 28

Chlordiazepoxide HCl ........... 28

Chlorhexidine Gluconate Oral Rinse ........................... 37

Chloroquine Phosphate .......... 23

Chlorothiazide ........................ 35

Chlorothiazide Sodium .......... 35

Chlorpromazine HCl ............. 25

Chlorthalidone ....................... 35

Cholestyramine Light ............ 36

Chorionic Gonadotropin ........ 42

Ciclopirox ............................... 19

Ciclopirox Nail Lacquer ......... 19

Ciclopirox Olamine ................ 19

Cidofovir ................................ 26

Cilostazol ................................ 32

Ciloxan ................................... 14

Cimetidine .............................. 39

Cimetidine HCl ..................... 39

Cimzia .................................... 47

Cinryze ................................... 32

Cipro ...................................... 14

Ciprodex ................................. 14

Ciprofloxacin .......................... 14

Ciprofloxacin ER .................... 14

Ciprofloxacin HCl .................. 14

Ciprofloxacin I.V. in D5W ..... 14

Cipro HC ............................... 14

Cipro IV ................................. 14

Cisplatin ................................. 21

Citalopram Hydrobromide ..... 17

Cladribine ............................... 21

Claforan .................................. 13

Claravis ................................... 37

Clarithromycin ....................... 14

Clarithromycin ER ................. 14

Cleocin ................................... 11

Cleocin in D5W ..................... 11

Cleocin Pediatric Granules ..... 11

Cleocin Phosphate .................. 11

Clindagel ................................ 37

Clindamycin/ Benzoyl Peroxide ................. 37

Clindamycin HCl ................... 11

Clindamycin Phosphate .... 11, 37

Clindamycin Phosphate in D5W ............................... 11

Clinimix 2.75%/ Dextrose 5% ........................ 55

Clinimix 4.25%/ Dextrose 5% ........................ 55

Clinimix 4.25%/ Dextrose 10% ...................... 55



Clinimix 5%/Dextrose 15% .... 29

Clinimix 5%/Dextrose 20% ... 29

Clinimix 5%/Dextrose 25%.... 55

Clinimix E 2.75%/ Dextrose 5% ........................ 29

Clinimix E 2.75%/ Dextrose 10% ...................... 29

Clinimix E 4.25%/ Dextrose 5% ........................ 29

Clinimix E 4.25%/ Dextrose 25% ...................... 29

Clinimix E 5%/ Dextrose 15% ...................... 29



Clinisol SF 15% ...................... 55

Clobetasol Propionate ............. 41

Clobetasol Propionate E ......... 41

Clobex .................................... 41

Cloderm Pump ....................... 41

Clolar ...................................... 21

Clomipramine HCl ................ 17

Clonazepam ............................ 15

Clonazepam ODT ................. 15

Clonidine HCl........................ 32

Clopidogrel ............................. 32

Clorazepate Dipotassium ........ 15

Clorpres .................................. 32

61

Clotrimazole ........................... 19

Clotrimazole/Betamethasone Dipropionate ........................ 19

Clozapine................................ 25

Codeine Sulfate ........................ 9

Cogentin ................................. 24

Co-Gesic .................................. 9

Colcrys ................................... 19

Colestipol HCl ....................... 36

Colistimethate Sodium ........... 11

Colocort .................................. 49

Coly-Mycin M ....................... 11

Coly-Mycin S ......................... 52

Combigan ............................... 51

CombiPatch ............................ 43

Combivent .............................. 53

Combivent Respimat .............. 53

Combivir ................................ 26

Cometriq ................................ 21

Complera ................................ 26

Compro .................................. 25

Comtan................................... 24

Comvax .................................. 48

Constulose .............................. 39

Conzip ...................................... 9

Copaxone................................ 37

Copegus .................................. 27

Cordran .................................. 41

Cordran Tape ......................... 41

Cortef ..................................... 41

Cortifoam ............................... 41

Cortisone Acetate ................... 41

Cortisporin ....................... 11, 52

Cosmegen ............................... 21

Coumadin............................... 30

Creon ...................................... 38

Crestor .................................... 35

Crinone................................... 45

Crixivan .................................. 27

Cromolyn Sodium ...... 39, 50, 53

Cryselle ................................... 43

Cubicin ................................... 11

Cuvposa .................................. 39

Cyclafem 1/35 ........................ 43

Cyclafem 7/7/7 ....................... 43

Cyclessa .................................. 43

Cyclobenzaprine HCl ............. 54

Cyclophosphamide ................. 20

Cyclosporine ........................... 47

Cyclosporine Modified ........... 47

Cyklokapron ........................... 32

Cymbalta ................................ 17

Cystadane ............................... 38

Cystagon ................................. 38

Cystaran ................................. 50

Cytarabine .............................. 21

Cytarabine Aqueous ............... 21

Cytovene ................................. 26

DDacarbazine ............................ 20

Dacogen ................................. 21

Danazol .................................. 43

Dantrolene Sodium ................ 26

Dapsone .................................. 20

Daptacel.................................. 48

Daraprim ................................ 23

Daunorubicin HCl ................. 21

DDAVP .................................. 42

Decavac .................................. 48

Demeclocycline HCl .............. 15

Demser ................................... 35

Denavir ................................... 28

Depo-Estradiol ....................... 43

Depo-Medrol ......................... 41

Depo-Provera ......................... 45

Derma-Smoothe/FS ............... 41

DermOtic ............................... 52

Desipramine HCl ................... 17

Desmopressin Acetate ............ 42

Desogen .................................. 43

Desonate ................................. 41

Desonide ................................ 41

Desowen ................................. 41

Desoximetasone ...................... 41

Dexamethasone ...................... 41

Dexamethasone Intensol ........ 41

Dexamethasone Sodium Phosphate ...................... 41, 51

Dexilant .................................. 40

Dexmethylphenidate HCl ...... 36

Dexrazoxane ........................... 21

Dextroamphetamine Sulfate ... 36

Dextroamphetamine Sulfate ER ........................... 36

Dextrose 2.5%/NaCl 0.45% ... 29

Dextrose 5% ........................... 29

Dextrose 5%/ Lactated Ringers ................. 55

Dextrose 5%/NaCl 0.2% ........ 29

Dextrose 5%/NaCl 0.9% ........ 29

Dextrose 5%/NaCl 0.33% ...... 29

62

Dextrose 5%/NaCl 0.45% ...... 29

Dextrose 5%/NaCl 0.225% .... 29

Dextrose 5%/ Potassium Chloride 0.15% ... 55

Dextrose 10% Flex Container ..................... 29

Dextrose 10%/NaCl 0.2% ...... 29

Dextrose 10%/NaCl 0.45% .... 29

Diazepam ......................... 15, 28

Diazepam Intensol ................. 28

Dibenzyline ............................ 32

Diclofenac Potassium................ 8

Diclofenac Sodium ................. 51

Diclofenac Sodium DR ............ 8

Diclofenac Sodium ER ............. 8

Diclofenac Sodium/ Misoprostol ............................ 8

Dicloxacillin Sodium .............. 13

Dicyclomine HCl ................... 39

Didanosine ............................. 26

Dificid .................................... 14

Diflorasone Diacetate ............. 41

Diflunisal .................................. 8

Digoxin .................................. 35

Dihydroergotamine Mesylate ...20

Dilantin .................................. 16

Dilantin Infatabs .................... 16

Dilatrate SR............................ 36

Dilaudid ................................... 9

Dilt-CD .................................. 34

Diltiazem CD......................... 34

Diltiazem HCl ....................... 34

Diltiazem HCl ER ................. 34

Dilt-XR .................................. 34

Diovan .................................... 32

Diovan HCT .......................... 32

Diphenoxylate/Atropine ......... 39

Dipyridamole .......................... 32

Disopyramide Phosphate ........ 33

Disulfiram .............................. 18

Diuril ...................................... 35

Divalproex Sodium ................. 15

Divalproex Sodium DR .......... 15

Divalproex Sodium ER .......... 15

Docefrez ................................. 22

Docetaxel ................................ 22

Donepezil HCl ....................... 16

Doribax .................................. 13

Dorzolamide HCl .................. 51

Dorzolamide HCl/ Timolol Maleate .................. 51

Dovonex ................................. 37

Doxazosin Mesylate ............... 40

Doxepin HCl .......................... 17

Doxil ...................................... 22

Doxorubicin HCl ................... 22

Doxycycline ............................ 15

Doxycycline Hyclate ............... 15

Doxycycline Hyclate DR ........ 15

Doxycycline Monohydrate...... 15

Dronabinol ............................. 18

Drospirenone/ Ethinyl Estradiol ................. 43

Droxia ..................................... 21

Duetact ................................... 28

Dulera ..................................... 52

Duramorph ............................... 9

Durezol .................................. 51

Dymista .................................. 52

Dyrenium ............................... 35

EEconazole Nitrate ................... 19

Edarbi ..................................... 32

Edarbyclor .............................. 32

Edecrin ................................... 35

Edurant .................................. 26

E.E.S. 400 .............................. 14

E.E.S. Granules ..................... 14

Effient .................................... 32

Egrifta .................................... 42

Elaprase .................................. 38

Elelyso .................................... 38

Elidel ...................................... 37

Eligard .................................... 46

Eliphos ................................... 55

Eliquis .................................... 30

Elitek ...................................... 21

Elixophyllin ............................ 53

Ella ......................................... 45

Ellence .................................... 22

Elmiron .................................. 40

Eloxatin .................................. 22

Elspar ..................................... 22

Emcyt ..................................... 21

Emend .................................... 18

Emoquette .............................. 43

Emsam ................................... 17

Emtriva ................................... 26

Enalapril Maleate ................... 33

Enalapril Maleate/Hydrochlorothiazide ............ 33

Enbrel ..................................... 47

Endocet .................................... 9

Endodan ................................... 9

63

Engerix-B ............................... 48

Enjuvia ................................... 43

Enoxaparin Sodium ................ 30

Enpresse ................................. 43

Entacapone ............................. 24

Enulose ................................... 39

Epinastine HCl ...................... 50

Epinephrine HCl .................... 53

EpiPen .................................... 53

Epirubicin HCl ...................... 22

Epitol ...................................... 16

Epivir ...................................... 26

Epivir HBV ............................ 26

Eplerenone .............................. 35

Epogen ................................... 31

Epzicom ................................. 26

Equetro ................................... 16

Eraxis ..................................... 19

Erbitux ................................... 23

Erivedge ................................. 22

Errin ....................................... 45

Ertaczo ................................... 19

Ery Pad 2% ............................. 14

EryPed .................................... 14

Ery-Tab................................... 14

Erythrocin Lactobionate ........ 14

Erythrocin Stearate ................ 14

Erythromycin ......................... 14

Erythromycin Base ................. 14

Erythromycin/ Benzoyl Peroxide ................. 37

Erythromycin Ethylsuccinate ...14

Escitalopram Oxalate ............. 17

Estrace .................................... 43

Estradiol .................................44

Estradiol/ Norethindrone Acetate ........44

Estradiol Valerate ...................44

Estring ....................................44

Estrostep Fe ............................44

Ethambutol HCl .................... 20

Ethosuximide ......................... 15

Etidronate Disodium .............. 49

Etodolac ................................... 8

Etodolac ER ............................. 8

Etopophos .............................. 23

Etoposide ................................ 23

Eurax ...................................... 24

Evista ...................................... 45

Exalgo ...................................... 9

Exelderm ................................ 19

Exelon .................................... 16

Exemestane............................. 23

Exforge ................................... 34

Exforge HCT ......................... 34

Exjade ..................................... 54

Extavia.................................... 48

FFabrazyme .............................. 38

Factive .................................... 14

Famciclovir ............................. 28

Famotidine ............................. 39

Famotidine Premixed ............. 39

Fanapt ..................................... 25

Fanapt Titration Pack ............. 25

Fareston .................................. 21

Faslodex .................................. 21

Fazaclo .................................... 25

Felbamate ............................... 16

Felbatol ................................... 16

Felodipine ER ........................ 34

Femhrt Low Dose ..................44

Femring ..................................44

Femtrace .................................44

Fenofibrate .............................. 35

Fenofibrate Micronized .......... 35

Fenoprofen Calcium ................. 8

Fentanyl .................................... 9

Fentanyl Citrate Oral Transmucosal ................ 9

Fentora ...................................... 9

Ferriprox ................................. 50

Finacea ................................... 37

Finasteride .............................. 40

Firazyr .................................... 50

Firmagon ................................ 46

Flagyl ER ............................... 11

Flarex...................................... 51

Flavoxate HCl ........................ 40

Flecainide Acetate .................. 33

Flovent Diskus ........................ 52

Flovent HFA .......................... 52

Fluconazole............................. 19

Fluconazole in Dextrose ......... 19

Flucytosine ............................. 19

Fludarabine Phosphate ........... 22

Fludrocortisone Acetate.......... 41

Flunisolide .............................. 52

Fluocinolone Acetonide .......... 41

Fluocinolone Acetonide Body Oil .............................. 41

Fluocinonide ........................... 41

64

Fluocinonide-E ....................... 41

Fluorouracil ...................... 21, 37

Fluoxetine DR ........................ 17

Fluoxetine HCl ....................... 17

Fluphenazine Decanoate ........ 25

Fluphenazine HCl .................. 25

Flurbiprofen .............................. 8

Flurbiprofen Sodium .............. 51

Flutamide ............................... 46

Fluticasone Propionate ..... 41, 52

Fluvoxamine Maleate ............. 17

FML ....................................... 51

FML Forte ............................. 51

Folotyn ................................... 21

Fomepizole ............................. 50

Fondaparinux Sodium ............ 30

Foradil Aerolizer .................... 53

Forfivo XL .............................. 17

Fortaz ..................................... 13

Forteo ..................................... 49

Fortical ................................... 49

Foscarnet Sodium ................... 26

Fosinopril Sodium .................. 33

Fosinopril Sodium/Hydrochlorothiazide ............ 33

Fosphenytoin Sodium ............. 16

Fosrenol .................................. 40

Fragmin .................................. 31

FreAmine III .......................... 55

FreAmine III 3% .................... 55

Furosemide ............................. 35

Fusilev .................................... 22

Fuzeon .................................... 27

GGabapentin ............................. 15

Gabitril ................................... 15

Gablofen ................................. 26

Galantamine Hydrobromide ...16

Gamastan S/D ....................... 47

Gammagard Liquid ................ 47

Gammaplex ............................ 48

Gamunex-C ............................ 48

Ganciclovir ............................. 26

Gardasil .................................. 48

Gastrocrom ............................. 39

Gattex ..................................... 39

Gauze Pads ............................. 50

GaviLyte-C ............................ 39

GaviLyte-G ............................ 39

GaviLyte-N/Flavor Pack ........ 39

Gelnique ................................. 40

Gemcitabine HCl ................... 21

Gemfibrozil ............................ 35

Gemzar ................................... 21

Generess Fe ............................44

Generlac ................................. 39

Gengraf .................................. 47

Genotropin ............................. 42

Genotropin Miniquick ........... 42

Gentak .................................... 11

Gentamicin Sulfate ................. 11

Gentamicin Sulfate/NaCl ...... 11

Geodon ................................... 25

Gianvi .....................................44

Giazo ...................................... 49

Gildagia ..................................44

Gilenya ................................... 37

Glassia .................................... 54

Gleevec ................................... 23

Glimepiride ............................ 28

Glipizide ................................. 28

Glipizide ER .......................... 28

Glipizide/Metformin HCl ..... 28

Glucagen HypoKit ................. 29

Glucagon Emergency Kit ....... 29

Glycopyrrolate ........................ 39

Glyset ..................................... 28

Granisetron HCl .................... 18

Granisol .................................. 18

Grifulvin V ............................. 19

Griseofulvin Microsize ........... 19

Griseofulvin Ultramicrosize ... 19

Gris-PEG ............................... 19

Guanidine HCl ...................... 20

Gynazole-1 ............................. 19

HHalaven .................................. 22

HalfLytely Bowel Prep/ Flavor Packs ........................ 39

Halobetasol Propionate ........... 41

Halog ...................................... 41

Haloperidol ............................ 25

Haloperidol Decanoate ........... 25

Haloperidol Lactate ................ 25

Havrix .................................... 48

Hectorol .................................. 49

Heparin Sodium ..................... 31

Heparin Sodium/D5W .......... 31

Heparin Sodium/NaCl........... 31

65

Heparin Sodium/ NaCl 0.9% Premix ............... 31

HepatAmine........................... 55

Hepatasol ................................ 55

Hepsera .................................. 27

Herceptin ................................ 23

Hexalen .................................. 21

Humalog ................................ 30

Humalog KwikPen ................. 30

Humatrope ............................. 42

Humira ................................... 47

Humira Starter Kit ................. 47

Humulin ................................. 30

Humulin Pen .......................... 30

Hycamtin ................................ 23

Hydralazine HCl .................... 36

Hydrochlorothiazide ............... 35

Hydrocodone/ Acetaminophen ................... 10

Hydrocodone/Ibuprofen ......... 10

Hydrocortisone ................. 41, 49

Hydrocortisone/Acetic Acid ... 52

Hydrocortisone Butyrate ........ 41

Hydrocortisone Valerate ......... 41

Hydromorphone HCl ............. 10

Hydroxychloroquine Sulfate ... 24

Hydroxyurea ........................... 21

Hydroxyzine HCl ................... 52

Hydroxyzine Pamoate ............ 52

IIbandronate Sodium ............... 49

Ibuprofen .................................. 8

Iclusig ..................................... 22

Idamycin PFS ......................... 22

Idarubicin HCl ....................... 22

Ifosfamide ............................... 21

Ilaris ....................................... 48

Ilevro ...................................... 51

Imipenem/Cilastatin .............. 13

Imipramine HCl ..................... 17

Imipramine Pamoate .............. 17

Imiquimod .............................. 37

Imovax Rabies ........................ 48

Incivek .................................... 27

Increlex ................................... 42

Indapamide ............................. 35

Infanrix................................... 48

Infergen .................................. 27

Inlyta ...................................... 23

Innopran XL .......................... 33

Insulin Syringes, Needles ....... 50

Intelence ................................. 26

Intralipid................................. 50

Intron-A ................................. 27

Intron-A W/Diluent ............... 27

Introvale .................................44

Intuniv .................................... 36

Invanz ..................................... 13

Invega ..................................... 25

Invega Sustenna ...................... 25

Invirase ................................... 27

Ionosol-B/Dextrose 5% .......... 29

Ionosol-MB/Dextrose 5% ...... 29

Iopidine .................................. 51

IPOL ...................................... 48

Ipratropium Bromide .............. 53

Ipratropium Bromide/ Albuterol Sulfate .................. 53

Irbesartan ............................... 32

Irbesartan/ Hydrochlorothiazide ............ 32

Irinotecan ............................... 22

Isentress .................................. 27

Isolyte-H/Dextrose 5% .......... 55

Isolyte-M/Dextrose 5% .......... 55

Isolyte-P/Dextrose 5% ............ 55

Isolyte-S ................................. 55

Isolyte-S/Dextrose 5% ............ 55

Isoniazid ................................. 20

Isopto Carpine ........................ 51

Isordil Titradose ..................... 36

Isosorbide Dinitrate ................ 36

Isosorbide Dinitrate ER.......... 36

Isosorbide Mononitrate ........... 36

Isosorbide Mononitrate ER .... 36

Isotonic Gentamicin ............... 11

Isradipine ................................ 34

Istalol ...................................... 51

Istodax .................................... 22

Itraconazole ............................ 19

Ixempra Kit ............................ 22

Ixiaro ...................................... 48

JJakafi ....................................... 22

Jantoven .................................. 31

Janumet .................................. 28

Janumet XR ............................ 28

Januvia .................................... 29

Jentadueto ............................... 29

Jevtana .................................... 22

Jinteli ......................................44

Jolivette ................................... 45

66

Junel ........................................44

Junel Fe ...................................44

Juxtapid .................................. 36

KKadcyla ................................... 23

Kadian ...................................... 9

Kaletra .................................... 27

Kalydeco ................................. 54

Kanamycin Sulfate ................. 11

Kariva .....................................44

KCl 0.3%/D5W/NaCl 0.9% ... 30

KCl 0.3%/D5W/NaCl 0.45% ...29

KCl 0.15%/D5W/LR ............. 29

KCl 0.15%/D5W/ NaCl 0.2% ........................... 29

KCl 0.15%/D5W/ NaCl 0.9% ........................... 29

KCl 0.15%/D5W/ NaCl 0.225% ....................... 29

KCl 0.075%/D5W/ NaCl 0.45% ......................... 29

Kelnor .....................................44

Kenalog .................................. 41

Kepivance ............................... 37

Ketek ...................................... 14

Ketoconazole .......................... 19

Ketoprofen ................................ 8

Ketoprofen ER ......................... 8

Ketorolac Tromethamine .... 8, 51

Kineret .................................... 47

Kionex .................................... 54

Klor-Con 8 ............................. 55

Klor-Con 10 ........................... 55

Klor-Con M15 ....................... 55

Klor-Con M20 ....................... 55

Kombiglyze XR ...................... 29

Korlym .................................... 43

Kristalose ................................ 39

K-Tabs .................................... 55

Kuvan ..................................... 38

Kynamro ................................. 36

LLabetalol HCl ........................ 33

LAClotion .............................. 37

Lacrisert ................................. 50

Lactated Ringers Irrigation .... 50

Lactated Ringers Viaflex ........ 55

Lactulose ................................ 39

Lamictal ODT ....................... 16

Lamictal Starter Kit ............... 16

Lamisil ................................... 19

Lamivudine ............................ 26

Lamivudine/Zidovudine ........ 26

Lamotrigine ............................ 16

Lanoxin .................................. 35

Lanoxin Pediatric ................... 35

Lansoprazole .......................... 40

Lantus .................................... 30

Lantus SoloStar ...................... 30

Lastacaft ................................. 50

Latanoprost ............................ 52

Latuda .................................... 25

Lazanda .................................. 10

Leena ......................................44

Leflunomide ........................... 48

Lessina ....................................44

Letairis ................................... 53

Letrozole ................................ 23

Leucovorin Calcium ............... 22

Leukeran ................................ 21

Leukine .................................. 31

Leuprolide Acetate ................. 46

Levalbuterol HCl.................... 53

Levaquin ................................. 14

Levemir .................................. 30

Levemir FlexPen .................... 30

Levetiracetam ......................... 15

Levetiracetam ER ................... 15

Levobunolol HCl .................... 51

Levocarnitine.......................... 50

Levocetirizine Dihydrochloride .................. 52

Levofloxacin ........................... 14

Levofloxacin in D5W ............. 14

Levonest .................................44

Levonorgestrel/ Ethinyl Estradiol .................44

Levora .....................................44

Levorphanol Tartrate ................ 9

Levothroid .............................. 45

Levothyroxine Sodium ........... 45

Levoxyl ................................... 45

Lexiva ..................................... 27

Lialda ..................................... 49

Lidocaine ................................ 10

Lidocaine 2% Viscous Solution .................. 10

Lidocaine HCl ........................ 10

Lidocaine/Prilocaine .............. 10

Lidoderm ................................ 10

Lincocin ................................. 11

Lindane .................................. 24

Lioresal Intrathecal ................. 26

Liothyronine Sodium ............. 45

67

Lipitor ..................................... 35

Liposyn III ............................. 50

Lisinopril ................................ 33

Lisinopril/ Hydrochlorothiazide ............ 33

Lithium Carbonate ................. 28

Lithium Carbonate ER .......... 28

Lithium Citrate ...................... 28

Lithobid .................................. 28

Locoid .................................... 41

Locoid Lipocream .................. 41

Lodosyn .................................. 24

Loestrin Fe .............................44

LoKara ................................... 41

Lo/Ovral ................................44

Loperamide HCl .................... 39

Lorazepam.............................. 28

Lorazepam Intensol ................ 28

Loryna ....................................44

Losartan Potassium ................ 32

Losartan Potassium/Hydrochlorothiazide ............ 32

LoSeasonique .........................44

Lotemax ................................. 51

Lotronex ................................. 39

Lovastatin ............................... 35

Lovaza .................................... 36

Lovenox .................................. 31

Low-Ogestrel .........................44

Loxapine Succinate ................. 25

Lumigan ................................. 52

Lumizyme .............................. 38

Lunesta ................................... 54

Lupron Depot ......................... 46

Lupron Depot-PED ............... 46

Lutera .....................................44

Luxiq ...................................... 41

Lyrica ..................................... 15

Lysodren ................................. 45

MMafenide Acetate ................... 11

Magnesium Sulfate ................. 55

Malarone ................................ 24

Malathion ............................... 24

Maprotiline HCl .................... 17

Marlissa ..................................44

Marplan .................................. 17

Matulane ................................ 21

Matzim LA ............................ 34

Maxalt .................................... 20

Maxalt-MLT .......................... 20

Meclizine HCl........................ 18

Meclofenamate Sodium ............ 8

Medroxyprogesterone Acetate ................................. 45

Mefenamic Acid ....................... 8

Mefloquine HCl ..................... 24

Megace ES ............................. 45

Megestrol Acetate ................... 45

Mekinist ................................. 22

Meloxicam ................................ 8

Melphalan HCl ...................... 21

Menactra ................................ 48

Menest .................................... 22

Menomune-A/C/Y/W-135 .... 48

Mentax ................................... 19

Menveo ................................... 48

Mepron ................................... 24

Mercaptopurine ...................... 21

Meropenem ............................ 13

Mesalamine ............................ 49

Mesna ..................................... 22

Mesnex ................................... 22

Mestinon ................................ 20

Mestinon Timespan ............... 20

Metadate ER .......................... 36

Metaproterenol Sulfate ........... 53

Metformin HCl ...................... 29

Metformin HCl ER ............... 29

Methadone HCl ....................... 9

Methadose ................................ 9

Methamphetamine HCl ......... 36

Methazolamide ....................... 51

Methenamine Hippurate ........ 11

Methergine ............................. 50

Methimazole .......................... 47

Methotrexate .......................... 47

Methotrexate Sodium ............. 47

Methscopolamine Bromide .... 39

Methyclothiazide .................... 35

Methyldopa ............................ 32

Methyldopa/Hydrochlorothiazide ............ 32

Methyldopate HCl ................. 32

Methylergonovine Maleate ..... 50

Methylphenidate HCl ............ 37

Methylphenidate HCl ER ...... 37

Methylprednisolone ................ 41

Methylprednisolone Acetate ... 41

Methylprednisolone Dose Pack ............................ 41

Methylprednisolone Sodium Succinate ................ 42

68

Metipranolol ........................... 51

Metoclopramide HCl ............. 39

Metolazone ............................. 35

Metoprolol/ Hydrochlorothiazide ............ 33

Metoprolol Succinate ER ....... 33

Metoprolol Tartrate ................ 33

MetroGel ................................ 11

Metronidazole ........................ 11

Metronidazole in NaCl 0.79% ..................... 11

Metronidazole Vaginal ........... 11

Mexiletine HCl ...................... 33

Miacalcin ................................ 49

Micardis ................................. 32

Micardis HCT ....................... 32

Miconazole 3 .......................... 19

Microgestin ............................44

Microgestin Fe .......................44

Midodrine HCl ...................... 32

Migergot ................................. 20

Millipred ................................ 49

Minastrin 24 Fe ......................44

Minitran ................................. 36

Minocycline HCl ................... 15

Minocycline HCl ER ............. 15

Minoxidil................................ 36

Mirtazapine ............................ 17

Mirtazapine ODT .................. 17

Misoprostol ............................. 40

Mitomycin .............................. 22

Mitoxantrone HCl .................. 22

M-M-R II .............................. 48

Modafinil ............................... 54

Moexipril HCl ........................ 33

Moexipril/ Hydrochlorothiazide ............ 33

Mometasone Furoate .............. 42

MonoNessa .............................44

Montelukast Sodium .............. 53

Morphine Sulfate ..................... 9

Morphine Sulfate ER ............... 9

MoviPrep ................................ 39

Moxeza ................................... 14

Mozobil .................................. 31

Multaq .................................... 33

Mupirocin ............................... 12

Mustargen .............................. 21

Mycamine ............................... 19

Mycobutin .............................. 20

Mycophenolate Mofetil .......... 47

Myfortic ................................. 47

Myorisan ................................ 37

Myozyme ................................ 38

Myrbetriq ............................... 40

Mytelase ................................. 20

NNabumetone ............................. 8

Nadolol ................................... 33

Nadolol/ Bendroflumethiazide ........... 33

Nafcillin Sodium .................... 13

Naftin ..................................... 19

Naglazyme .............................. 38

Nalbuphine HCl ..................... 10

Nallpen/Dextrose ................... 13

Naloxone HCl ........................ 18

Naltrexone HCl ...................... 18

Namenda ................................ 17

Namenda Titration Pak .......... 17

Naphazoline HCl ................... 50

Naproxen .................................. 8

Naproxen DR ........................... 8

Naproxen Sodium ..................... 8

Naratriptan HCl ..................... 20

Nardil ..................................... 17

Nasonex .................................. 52

Natacyn .................................. 19

Nateglinide ............................. 29

Nebupent ................................ 24

Necon .....................................44

Necon 1/35 .............................44

Nefazodone HCl .................... 17

Neomycin/Bacitracin/ Polymyxin ............................ 12

Neomycin/Polymyxin/Bacitracin/Hydrocortisone ... 51

Neomycin/ Polymyxin B Sulfates ........... 11

Neomycin/Polymyxin/Dexamethasone ................... 51

Neomycin/Polymyxin/Gramicidin .......................... 12

Neomycin/Polymyxin/Hydrocortisone .............. 51, 52

Neomycin Sulfate ................... 11

Nephramine ............................ 55

Neulasta .................................. 31

Neumega ................................ 31

Neupogen ............................... 31

Nevanac .................................. 51

Nevirapine .............................. 26

Nexavar .................................. 23

69

Nexium ................................... 40

Nexium I.V. ............................ 40

Niacor ..................................... 56

Niaspan .................................. 36

Nicardipine HCl ..................... 34

Nicotrol Inhaler ...................... 18

Nicotrol NS ............................ 18

Nifediac CC ........................... 34

Nifedical XL .......................... 34

Nifedipine ER ........................ 34

Nilandron ............................... 46

Nimodipine ............................ 34

Nipent..................................... 21

Nisoldipine ............................. 34

Nisoldipine ER ....................... 34

Nitro-Bid ................................ 36

Nitrofurantoin ........................ 12

Nitrofurantoin Macrocrystalline .................. 12

Nitrofurantoin Monohydrate ... 12

Nitroglycerin........................... 36

Nitrolingual Pumpspray ......... 36

NitroMist ............................... 36

Nitrostat ................................. 36

Nizatidine ............................... 39

Nora-BE ................................. 45

Norditropin FlexPro ............... 42

Norditropin NordiFlex Pen .... 42

Norethindrone Acetate ........... 45

Normosol-M in D5W ............ 55

Normosol-R ............................ 55

Normosol-R in D5W ............. 30

Noroxin .................................. 15

Nortrel ....................................44

Nortrel 1/35 ............................44

Nortriptyline HCl .................. 17

Norvir ..................................... 27

Novarel ................................... 43

Novolin ................................... 30

Novolog .................................. 30

Novolog FlexPen .................... 30

Noxafil .................................... 19

Nucynta ER .............................. 9

Nulojix .................................... 47

NuLYTELY/Flavor Packs ..... 39

Nutropin ................................. 43

Nutropin AQ .......................... 43

NuvaRing ...............................44

Nyamyc ................................... 19

Nystatin .................................. 19

Nystatin/Triamcinolone ......... 19

Nystop .................................... 19

OOcella .....................................44

Octreotide Acetate ................. 46

Ofloxacin ................................ 15

Ogestrel ..................................44

Olanzapine ............................. 25

Olanzapine/Fluoxetine ........... 28

Olanzapine ODT ................... 25

Olux-E .................................... 42

Omeprazole ............................ 40

Omnaris ................................. 52

Omnitrope .............................. 43

Ondansetron HCl................... 18

Ondansetron ODT ................. 18

Onfi ........................................ 15

Onglyza .................................. 29

ONMEL ................................ 19

Onsolis ................................... 10

Ontak ..................................... 22

Opana ER ................................ 9

Optipranolol ........................... 51

Orap ....................................... 25

Orencia ................................... 47

Orfadin ................................... 38

Orphenadrine/Aspirin/ Caffeine ............................... 54

Orphenadrine Compound DS .................... 54

Orsythia .................................44

Ortho-Cept ............................44

Ortho-Cyclen .........................44

Ortho Evra .............................44

Ortho Micronor ..................... 45

Ortho-Novum 7/7/7 ...............44

Ortho Tri-Cyclen Lo..............44

OsmoPrep ............................... 39

Ovcon-35 ................................44

Ovcon-50 28 ...........................44

Oxacillin Sodium ................... 13

Oxaliplatin.............................. 22

Oxandrolone ........................... 43

Oxaprozin ................................. 8

Oxcarbazepine ........................ 16

Oxistat .................................... 19

Oxsoralen ............................... 37

Oxsoralen Ultra ...................... 38

Oxybutynin Chloride ............. 40

Oxybutynin Chloride ER ....... 40

70

Oxycodone/Acetaminophen ... 10

Oxycodone/Aspirin ................ 10

Oxycodone HCl ..................... 10

Oxycodone/Ibuprofen .............. 8

Oxymorphone HCl ................ 10

Oxymorphone HCl ER ............ 9

Oxytrol ................................... 40

PPacerone ................................. 33

Paclitaxel ................................ 22

Pamelor................................... 18

Pamidronate Disodium .......... 49

Pandel ..................................... 42

Panretin .................................. 23

Pantoprazole Sodium .............. 40

Parcopa ................................... 24

Paromomycin Sulfate .............. 11

Paroxetine HCl ....................... 17

Paroxetine HCl ER ................ 17

Paser ....................................... 20

Pataday ................................... 50

Patanase .................................. 52

Patanol .................................... 50

Paxil ....................................... 17

PCE ........................................ 14

Pedi-Dri ................................. 19

Pedvax HIB ............................ 48

Peganone ................................ 16

Pegasys ................................... 27

Pegasys ProClick .................... 27

Peg-Intron .............................. 27

Peg-Intron Redipen ................ 27

Penicillin G Potassium ........... 13

Penicillin G Potassium in Iso-Osmotic Dextrose ......... 13

Penicillin G Procaine ............. 13

Penicillin G Sodium ............... 13

Penicillin V Potassium ............ 13

Pentam 300 ............................ 24

Pentasa .................................... 49

Pentostatin .............................. 21

Pentoxifylline ER ................... 35

Perforomist ............................. 53

Perindopril Erbumine ............. 33

Periogard ................................ 37

Perjeta ..................................... 23

Permethrin ............................. 24

Perphenazine .......................... 25

Perphenazine/Amitriptyline ... 18

Pexeva ..................................... 17

Pfizerpen-G............................ 13

Phenadoz ................................ 52

Phenelzine Sulfate .................. 17

Phenobarbital ......................... 15

Phenytek ................................. 16

Phenytoin ............................... 16

Phenytoin Sodium .................. 16

Phenytoin Sodium Extended ...16

PhosLo ................................... 55

Phoslyra .................................. 55

Phospholine Iodide ................. 51

Physiolyte ............................... 50

Physiosol Irrigation ................ 50

Picato ...................................... 22

Pilocarpine HCl ..................... 37

Pilopine HS ............................ 51

Pindolol .................................. 33

Pioglitazone HCl .................... 29

Pioglitazone HCl/ Glimepiride ......................... 29

Pioglitazone HCl/ Metformin HCl ................... 29

Piperacillin Sodium/ Tazobactam Sodium ............ 14

Piroxicam.................................. 9

Plasma-Lyte ............................ 55

Plasma-Lyte/D5W ................. 55

Podofilox................................. 38

Polyethylene Glycol 3350 ........ 39

Polymyxin B Sulfate ............... 12

Pomalyst ................................. 22

Portia ......................................44

Potassium Chloride ................ 55

Potassium Chloride 0.3%/ D5W ................................... 56

Potassium Chloride 0.3%/ NaCl 0.9% ........................... 56

Potassium Chloride 0.15%/D5W/NaCl 0.33%............... 30

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex ... 30

Potassium Chloride 0.15%/ NaCl 0.9% ........................... 56

Potassium Chloride 0.15%/ NaCl 0.45% Viaflex ............. 56

Potassium Chloride 0.22%/D5W/NaCl 0.45% ............... 30

Potassium Chloride 0.224%/Dextrose 5% Viaflex ............ 56

Potassium Chloride ER .......... 56

Potassium Citrate ................... 56

Potiga ..................................... 15

Pradaxa ................................... 31

Pramipexole Dihydrochloride ...24

71

PrandiMet .............................. 29

Prandin ................................... 29

Pravastatin Sodium................. 35

Prazosin HCl .......................... 32

Pred-G ................................... 51

Pred-G S.O.P. ........................ 51

Pred Mild ............................... 51

Prednicarbate .......................... 42

Prednisolone Acetate .............. 51

Prednisolone Sodium Phosphate ...................... 42, 51

Prednisone .............................. 42

Prednisone Intensol ................ 42

Prefest .....................................44

Pregnyl W/Diluent Benzyl Alcohol/NaCl ...................... 43

Premarin .................................44

Premasol ................................. 56

Prenatal Vitamins ................... 56

Prevacid SoluTab .................... 40

Prevalite .................................. 36

Previfem .................................44

Prezista ................................... 27

Priftin ..................................... 20

Primaquine Phosphate ............ 24

Primaxin ................................. 13

Primidone ............................... 15

Primsol ................................... 12

Pristiq ..................................... 17

Privigen .................................. 48

Proair HFA ............................ 53

Probenecid .............................. 19

Probenecid/Colchicine ........... 19

Procainamide HCl.................. 33

Procalamine ............................ 56

Prochlorperazine .................... 25

Prochlorperazine Edisylate ..... 25

Prochlorperazine Maleate ....... 25

Procrit ..................................... 31

ProctoCream HC ................... 42

Procto-Pak .............................. 42

Proctozone-HC ...................... 42

Progesterone ........................... 45

Proglycem ............................... 30

Prograf .................................... 47

Prolastin-C ............................. 54

Proleukin ................................ 22

Prolia ...................................... 49

Promacta ................................. 31

Promethazine HCl ................. 52

Promethazine VC ................... 52

Promethegan .......................... 53

Propafenone HCl ................... 33

Propafenone HCl ER ............. 33

Propantheline Bromide ........... 39

Proparacaine HCl ................... 50

Propranolol HCl ..................... 33

Propranolol HCl ER .............. 33

Propranolol/Hydrochlorothiazide ............ 34

Propylthiouracil ...................... 47

ProQuad ................................. 48

Prosol ...................................... 56

Protonix .................................. 40

Protopic .................................. 38

Protriptyline HCl ................... 18

Provigil ................................... 54

Prudoxin ................................. 38

Pulmicort ................................ 52

Pulmicort Flexhaler ................ 52

Pulmozyme ............................ 54

Pyrazinamide .......................... 20

Pyridostigmine Bromide ........ 20

QQualaquin ............................... 24

Quasense ................................44

Quetiapine Fumarate .............. 25

Quinapril HCl ........................ 33

Quinapril/ Hydrochlorothiazide ............ 33

Quinidine Gluconate .............. 33

Quinidine Gluconate CR ....... 33

Quinidine Sulfate ................... 33

Quinidine Sulfate ER ............. 33

Quinine Sulfate ...................... 24

QVAR .................................... 52

RRabavert ................................. 48

Ramipril ................................. 33

Ranexa .................................... 35

Ranitidine HCl ...................... 39

Rapaflo ................................... 40

Rapamune .............................. 47

RAVICTI .............................. 38

Rayos ...................................... 42

Rebetol ................................... 27

Rebif ....................................... 48

Rebif Titration Pack ............... 48

Reclast .................................... 49

Reclipsen ................................44

Recombivax HB ..................... 48

72

Regonol .................................. 20

Regranex ................................. 38

Relenza Diskhaler .................. 27

Relistor ................................... 39

Remicade ................................ 47

Remodulin .............................. 53

Renagel ................................... 40

Renvela ................................... 40

Rescriptor ............................... 26

Reserpine ................................ 32

Restasis ................................... 50

Retin-A Micro ........................ 38

Retrovir IV Infusion ............... 26

Revatio ................................... 54

Revlimid ................................. 21

Reyataz ................................... 27

Ribapak .................................. 27

Ribasphere .............................. 27

Ribavirin ................................. 27

Ridaura ................................... 48

Rifampin ................................ 20

Rifater..................................... 20

Rilutek .................................... 37

Riluzole .................................. 37

Rimantadine HCl ................... 27

Ringers Injection .................... 56

Ringers Irrigation ................... 50

Riomet .................................... 29

Risperdal Consta .................... 25

Risperidone ............................ 25

Risperidone ODT .................. 25

Rituxan ................................... 23

Rivastigmine Tartrate ............. 16

Rizatriptan Benzoate .............. 20

Ropinirole HCl ....................... 24

RotaTeq .................................. 48

Roxicet .................................... 10

Rozerem ................................. 54

Rythmol SR ............................ 33

SSabril ...................................... 15

Saizen ..................................... 43

Samsca .................................... 55

Sanctura XR ........................... 40

Sancuso ................................... 18

Sandimmune .......................... 47

Sandostatin ............................. 46

Sandostatin LAR Depot ........ 46

Santyl ..................................... 38

Saphris .................................... 25

Savella..................................... 37

Savella Titration Pack ............. 37

Seasonale ................................ 45

Seasonique .............................. 45

Selegiline HCl ........................ 24

Selenium Sulfide ..................... 38

Selzentry ................................. 27

Sensipar .................................. 46

Serevent Diskus ...................... 53

Seromycin ............................... 20

Seroquel XR ........................... 25

Serostim ................................. 43

Sertraline HCl ........................ 17

sfRowasa ................................ 49

Signifor ................................... 46

Sildenafil Citrate..................... 54

Silver Sulfadiazine .................. 12

Simponi .................................. 47

Simulect .................................. 48

Simvastatin ............................. 35

Singulair ................................. 53

Sirturo .................................... 20

Sodium Chloride .................... 56

Sodium Chloride 0.9% ........... 50

Sodium Chloride 0.45% Viaflex ................................. 56

Sodium Fluoride ..................... 56

Sodium Lactate ...................... 55

Sodium Phenylbutyrate .......... 38

Sodium Polystyrene Sulfonate .............................. 55

Solaraze .................................. 38

Soltamox ................................. 21

Solu-Cortef ............................. 42

Solu-Medrol ........................... 42

Somatuline Depot .................. 46

Somavert ................................. 46

Soriatane ................................. 38

Sorine ..................................... 33

Sotalol HCl ............................ 33

Spiriva Handihaler ................. 53

Spironolactone ........................ 35

Spironolactone/Hydrochlorothiazide ............ 35

Sporanox ................................. 19

Sprintec .................................. 45

Sprycel .................................... 23

Sronyx..................................... 45

SSD ........................................ 12

Stagesic ................................... 10

Stalevo .................................... 24

Stavudine ................................ 26

Stavzor .................................... 15

73

Stelara ..................................... 38

Sterile Water Irrigation .......... 50

Stimate ................................... 43

Stivarga ................................... 23

Strattera .................................. 37

Streptomycin Sulfate .............. 11

Stribild .................................... 26

Stromectol .............................. 23

Suboxone ................................ 18

Subsys ..................................... 10

Sucraid .................................... 38

Sucralfate ................................ 40

Sulfacetamide Sodium ...... 15, 38

Sulfacetamide Sodium/Prednisolone Sodium Phosphate ............................ 51

Sulfadiazine ............................ 15

Sulfamethoxazole/ Trimethoprim ...................... 15

Sulfamethoxazole/ Trimethoprim DS ................ 15

Sulfamylon ............................. 12

Sulfasalazine ........................... 49

Sulfazine EC .......................... 49

Sulindac .................................... 9

Sumatriptan Succinate ............ 20

Sumavel DosePro ................... 20

Suprax ..................................... 13

Suprep Bowel Prep ................. 39

Sustiva .................................... 26

Sutent ..................................... 23

Sylatron .................................. 22

Symbicort ............................... 52

Symbyax ................................. 28

SymlinPen 60 ......................... 29

SymlinPen 120 ....................... 29

Synagis ................................... 48

Synalgos-DC .......................... 10

Synarel .................................... 46

Synercid .................................. 12

Synribo ................................... 22

Synthroid ................................ 45

Syprine ................................... 55

TTabloid .................................... 21

Tacrolimus .............................. 47

Tafinlar ................................... 22

Tamiflu ................................... 27

Tamoxifen Citrate .................. 21

Tamsulosin HCl ..................... 40

Tarceva ................................... 23

Targretin ................................. 23

Tasigna ................................... 23

Tasmar .................................... 24

Taxotere .................................. 22

Tazorac ................................... 38

Taztia XT ............................... 34

Tecfidera ................................. 48

Tecfidera Starter Pack ............. 48

Tegretol .................................. 16

Tegretol-XR ............................ 16

Tekturna ................................. 35

Tekturna HCT ....................... 35

Temazepam ............................ 54

Terazosin HCl ........................ 40

Terbinafine HCl ..................... 19

Terbutaline Sulfate ................. 53

Terconazole ............................. 19

Testosterone Cypionate ........... 43

Testosterone Enanthate .......... 43

Tetanus/Diphtheria Toxoids-Adsorbed Adult ..... 48

Tetanus Toxoid Adsorbed ....... 48

Tetracycline HCl .................... 15

Tev-Tropin .............................. 43

Thalomid ................................ 21

Theophylline ER .................... 53

Thioridazine HCl ................... 25

Thiotepa ................................. 21

Thiothixene ............................ 25

Thymoglobulin ....................... 48

Thyrolar ................................. 45

Tiagabine HCl ....................... 16

Ticlopidine HCl ..................... 32

Tikosyn .................................. 33

Timentin ................................ 14

Timolol Maleate ............... 34, 51

Tinidazole .............................. 24

Tizanidine HCl ...................... 26

TOBI ...................................... 11

TOBI Podhaler ...................... 11

Tobradex ................................. 51

Tobradex ST ........................... 51

Tobramycin/Dexamethasone ...51

Tobramycin Sulfate ................. 11

Tobramycin Sulfate/NaCl ...... 11

Tobrex ..................................... 11

Tolazamide ............................. 29

Tolbutamide............................ 29

Tolmetin Sodium...................... 9

Topiramate ............................. 16

Toposar ................................... 23

Topotecan HCl ....................... 23

Toprol XL ............................... 34

74

Torisel ..................................... 47

Torsemide ............................... 35

Toviaz ..................................... 40

TPN Electrolytes.................... 56

Tracleer ................................... 54

Tradjenta................................. 29

Tramadol HCl ........................ 10

Tramadol HCl/ Acetaminophen ................... 10

Tramadol HCl ER .................... 9

Trandolapril ............................ 33

Tranexamic Acid .................... 32

Transderm-Scop ..................... 18

Tranylcypromine Sulfate ........ 17

Travasol .................................. 56

Travatan Z .............................. 52

Travoprost ............................... 52

Trazodone HCl ...................... 17

Treanda................................... 21

Trecator .................................. 20

Trelstar Depot ........................ 46

Trelstar LA ............................. 46

Trelstar Mixject ...................... 46

Tretinoin ........................... 23, 38

Tretin-X .................................. 38

Trexall .................................... 47

Triamcinolone Acetonide ...42, 52

Triamcinolone in Orabase ...... 37

Triamterene/Hydrochlorothiazide ............ 35

Tribenzor ................................ 34

Tricor ...................................... 35

Triderm .................................. 42

Trifluoperazine HCl ............... 25

Trifluridine ............................. 28

Trihexyphenidyl HCl ............. 24

Tri-Legest Fe .......................... 45

Trileptal .................................. 16

Trilipix .................................... 35

TriLyte ................................... 39

Trimethoprim ......................... 12

Trimethoprim Sulfate/Polymyxin B Sulfate ............ 12

Trimipramine Maleate ........... 18

Trinessa .................................. 45

Tri-Previfem ........................... 45

Trisenox .................................. 22

Tri-Sprintec ............................ 45

Trivora .................................... 45

Trizivir .................................... 26

Trophamine ............................ 56

Trospium Chloride ................. 40

Trospium Chloride ER ........... 40

Truvada .................................. 26

Twinject .................................. 53

Twinrix ................................... 48

Twynsta .................................. 34

Tygacil .................................... 12

Tykerb ..................................... 23

Typhim Vi .............................. 49

Tysabri .................................... 48

Tyvaso .................................... 54

Tyzeka .................................... 28

Tyzine ..................................... 54

UUceris ...................................... 49

U-Cort.................................... 42

Ulesfia ..................................... 24

Uloric ...................................... 19

Unasyn .................................... 14

Unithroid ................................ 45

Ursodiol .................................. 39

Uvadex .................................... 38

VVagifem .................................. 45

Valacyclovir HCl .................... 28

Valcyte .................................... 26

Valproate Sodium ................... 16

Valproic Acid .......................... 16

Valsartan/ Hydrochlorothiazide ............ 32

Vancocin HCl ......................... 12

Vancomycin HCl .................... 12

Vandazole ............................... 12

Vanos ...................................... 42

VAQTA .................................. 49

Varivax .................................... 49

Vascepa ................................... 36

Vecamyl .................................. 35

Vectibix ................................... 23

Vectical ................................... 38

Velcade ................................... 22

Velivet ..................................... 45

Veltin ...................................... 38

Venlafaxine HCl ..................... 17

Venlafaxine HCl ER .............. 17

Ventavis .................................. 54

Verapamil HCl ....................... 34

Verapamil HCl ER ........... 34, 35

Verapamil HCl SR ................. 35

Vesicare ................................... 40

Vestura .................................... 45

Vexol ....................................... 51

75

Vfend ...................................... 19

Vfend IV ................................. 19

Vibativ .................................... 12

Vibramycin ............................. 15

Vicodin ................................... 10

Vicodin ES ............................. 10

Vicodin HP ............................ 10

Victoza ................................... 29

Victrelis .................................. 28

Vidaza .................................... 22

Videx Pediatric ....................... 27

Vigamox ................................. 15

Viibryd ................................... 17

Vimovo ................................... 40

Vimpat .................................... 16

Vinblastine Sulfate ................. 22

Vincasar PFS .......................... 22

Vincristine Sulfate .................. 22

Vinorelbine Tartrate ............... 22

Viokace ................................... 38

Viracept .................................. 27

Viramune ................................ 26

Viramune XR ......................... 26

Virazole .................................. 28

Viread ..................................... 27

Vistide .................................... 26

Vivitrol ................................... 18

Voltaren .................................. 38

Voraxaze ................................. 50

Voriconazole ........................... 19

Votrient ................................... 23

VPRIV ................................... 38

Vytorin ................................... 36

Vyvanse .................................. 36

WWarfarin Sodium ................... 31

Welchol .................................. 36

XXalkori.................................... 23

Xarelto .................................... 31

Xeljanz .................................... 48

Xenazine ................................. 37

Xgeva ...................................... 49

Xifaxan ................................... 12

Xolair ...................................... 54

Xtandi ..................................... 46

Xyrem ..................................... 54

YYasmin .................................... 45

Yervoy ..................................... 23

YF-Vax ................................... 49

ZZafirlukast .............................. 53

Zaleplon ................................. 54

Zaltrap .................................... 23

Zanosar ................................... 21

Zantac .................................... 39

Zavesca ................................... 38

Zazole ..................................... 19

Zelapar ................................... 17

Zelboraf .................................. 23

Zemaira .................................. 54

Zemplar .................................. 49

Zenchent Fe ........................... 45

Zenpep ................................... 38

Zeosa ...................................... 45

Zerit ....................................... 27

Zetia ....................................... 36

Zetonna .................................. 52

Ziagen .................................... 27

Ziana ...................................... 38

Zidovudine ............................. 27

Zinacef ................................... 13

Zinacef in Iso-Osmotic Dextrose .............................. 13

Zinacef in Iso-Osmotic Diluent ................................ 13

Zinecard ................................. 23

Ziprasidone HCl ..................... 25

Zirgan ..................................... 26

Zmax ...................................... 14

Zofran .................................... 18

Zofran ODT .......................... 18

Zoledronic Acid ..................... 49

Zolinza ................................... 23

Zolpidem Tartrate .................. 54

Zometa ................................... 49

Zonisamide ............................. 15

Zorbtive .................................. 43

Zortress .................................. 47

Zostavax ................................. 49

Zosyn ..................................... 14

Zovia ...................................... 45

Zovirax ................................... 28

Zyclara .................................... 38

Zylet ....................................... 51

Zymaxid ................................. 15

Zyprexa ................................... 25

Zytiga ..................................... 23

Zyvox ...................................... 12

76

Name of Medicineand Strength

DrugTier

I Take This Medicine For Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

“my medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

77

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This information is available for free in other languages. Please contact our Customer Service number at 1-866-846-2762, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con el nuestro Servicio al Cliente al número 1-866-846-2762, TTY 711, de 8 a.m. a 8 p.m. hora local, los 7 días de la semana.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

UHEX13HM3402674_008

This complete formulary (drug list) is effective September 1, 2013. It was updated September 2013. Changes may have been made to this list after it was printed.

Call Customer Service for complete, updated information.

1-866-846-2762, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week


Documents

2013 Comprehensive Formulary · 2019-06-20 · about this complete drug list This is a complete list of prescription drugs that are covered by the UnitedHealthcare Dual Complete™