2018 High Performance Formulary - healthplan.org · 01-04-2018 · oseltamivir oral suspension for reconstitution 1 PREZISTA ORAL SUSPENSION 2 PREZISTA ORAL TABLET 150 MG, 600 MG,

2018 High Performance Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 4/1/2018. For more recent information or other questions, please contact The Health Plan Pharmacy Services at 1.800.624.6961 extension 7914, or visit www.heathplan.org.

1

Table of Contents

ANTI - INFECTIVES ........................................................................................................................................ 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 10

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 12

CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 24

DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 32

DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 42

EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 43

ENDOCRINE/DIABETES .............................................................................................................................. 44

GASTROENTEROLOGY .............................................................................................................................. 52

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 59

MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 63

OBSTETRICS & GYNECOLOGY ................................................................................................................ 64

OPHTHALMOLOGY ..................................................................................................................................... 71

RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 75

UROLOGICALS .............................................................................................................................................. 79

VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 81

Index .................................................................................................................................................................. 88

2

List of Abbreviations

1: Generic Drug

2: Preferred Brand Drug

3: Non- Preferred Brand Drug

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

3

Drug Name Drug Tier

Requirements / Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

clotrimazole mucous membrane troche

1

CRESEMBA ORAL CAPSULE

2

fluconazole oral suspension for reconstitution

1 QL

fluconazole oral tablet

1 QL

flucytosine oral capsule

1

griseofulvin microsize oral suspension

1

griseofulvin microsize oral tablet

1

griseofulvin ultramicrosize oral tablet

1

itraconazole oral capsule

1 QL

ketoconazole oral tablet

1

NOXAFIL ORAL SUSPENSION

2

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

2

nystatin oral powder 150 million unit, 500 million unit

1

nystatin oral suspension

1

nystatin oral tablet 1

Drug Name Drug Tier


ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

2

SPORANOX ORAL SOLUTION

2 QL

terbinafine hcl oral tablet

1 QL

voriconazole oral suspension for reconstitution

1

voriconazole oral tablet

1

ANTIVIRALS

abacavir oral solution

1

abacavir oral tablet 1

abacavir-lamivudine oral tablet

1

abacavir-lamivudine-zidovudine oral tablet

1

acyclovir oral capsule

1 QL

acyclovir oral suspension 200 mg/5 ml

1

acyclovir oral tablet 1 QL

adefovir oral tablet 1

amantadine hcl oral capsule

1

amantadine hcl oral solution

1

amantadine hcl oral tablet

1

APTIVUS ORAL CAPSULE

2


4

Drug Name Drug Tier


APTIVUS ORAL SOLUTION

2

atazanavir oral capsule

1

ATRIPLA ORAL TABLET

2

BARACLUDE ORAL SOLUTION

2

COMPLERA ORAL TABLET

2

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2

DAKLINZA ORAL TABLET

3 PA; LA

DESCOVY ORAL TABLET

2

didanosine oral capsule,delayed release(dr/ec)

1

EDURANT ORAL TABLET

2

efavirenz oral capsule

1

efavirenz oral tablet 1

EMTRIVA ORAL CAPSULE

2

EMTRIVA ORAL SOLUTION

2

entecavir oral tablet 1

EPIVIR HBV ORAL SOLUTION

2

famciclovir oral tablet

1 QL

fosamprenavir oral tablet

1

Drug Name Drug Tier


FUZEON SUBCUTANEOUS RECON SOLN

2 PA

GENVOYA ORAL TABLET

2

INTELENCE ORAL TABLET

2

INVIRASE ORAL CAPSULE

2

INVIRASE ORAL TABLET

2

ISENTRESS HD ORAL TABLET

2

ISENTRESS ORAL POWDER IN PACKET

2

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET,CHEWABLE

2

KALETRA ORAL TABLET

2

lamivudine oral solution

1

lamivudine oral tablet

1

lamivudine-zidovudine oral tablet

1

LEXIVA ORAL SUSPENSION

2

lopinavir-ritonavir oral solution

1

nevirapine oral suspension

1


5

Drug Name Drug Tier


nevirapine oral tablet

1

nevirapine oral tablet extended release 24 hr

1

NORVIR ORAL CAPSULE

2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET

2

ODEFSEY ORAL TABLET

2

OLYSIO ORAL CAPSULE

3 PA; LA

oseltamivir oral capsule

1

oseltamivir oral suspension for reconstitution

1

PREZISTA ORAL SUSPENSION

2

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

2

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

2

RESCRIPTOR ORAL TABLET

2

RESCRIPTOR ORAL TABLET, DISPERSIBLE

2

Drug Name Drug Tier


REYATAZ ORAL POWDER IN PACKET

2

ribavirin inhalation recon soln

1 PA

rimantadine oral tablet

1

SELZENTRY ORAL SOLUTION

2

SELZENTRY ORAL TABLET

2

stavudine oral capsule

1

stavudine oral recon soln

1

STRIBILD ORAL TABLET

2

SUSTIVA ORAL TABLET

2

tenofovir disoproxil fumarate oral tablet

1

TIVICAY ORAL TABLET

2

TRIUMEQ ORAL TABLET

2

TRUVADA ORAL TABLET

2

TYBOST ORAL TABLET

3

valacyclovir oral tablet

1 QL

valganciclovir oral recon soln

1

valganciclovir oral tablet

1

VEMLIDY ORAL TABLET

2


6

Drug Name Drug Tier


VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

2

VIRACEPT ORAL TABLET

2

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

zidovudine oral capsule

1

zidovudine oral syrup

1

zidovudine oral tablet

1

CEPHALOSPORINS

cefaclor oral capsule 1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

1

cefaclor oral tablet extended release 12 hr

1

cefadroxil oral capsule

1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1

cefdinir oral capsule 1

Drug Name Drug Tier


cefdinir oral suspension for reconstitution

1

cefditoren pivoxil oral tablet

1

cefixime oral suspension for reconstitution

1

cefpodoxime oral suspension for reconstitution

1

cefpodoxime oral tablet

1

cefprozil oral suspension for reconstitution

1

cefprozil oral tablet 1

cefuroxime axetil oral tablet

1

cephalexin oral capsule

1

cephalexin oral suspension for reconstitution

1

cephalexin oral tablet

1

ERYTHROMYCINS & OTHER MACROLIDES

azithromycin oral packet

1

azithromycin oral suspension for reconstitution

1

azithromycin oral tablet

1


7

Drug Name Drug Tier


clarithromycin oral suspension for reconstitution

1

clarithromycin oral tablet

1

clarithromycin oral tablet extended release 24 hr

1

DIFICID ORAL TABLET

3

e.e.s. 400 oral tablet 1

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

erythrocin (as stearate) oral tablet 250 mg

1

erythromycin ethylsuccinate oral suspension for reconstitution

1

erythromycin ethylsuccinate oral tablet

1

erythromycin oral capsule,delayed release(dr/ec)

1

erythromycin oral tablet

1

MISCELLANEOUS ANTIINFECTIVES

ALBENZA ORAL TABLET

2 QL

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

2 QL

Drug Name Drug Tier


ALINIA ORAL TABLET

2 QL

atovaquone oral suspension

1

atovaquone-proguanil oral tablet

1 QL

BENZNIDAZOLE ORAL TABLET

2

BILTRICIDE ORAL TABLET

2

chloroquine phosphate oral tablet

1

clindamycin hcl oral capsule

1

clindamycin palmitate hcl oral recon soln

1

clindamycin pediatric oral recon soln

1

COARTEM ORAL TABLET

2 QL

CYCLOSERINE ORAL CAPSULE

3

dapsone oral tablet 1

EMVERM ORAL TABLET,CHEWABLE

2 QL

ethambutol oral tablet

1

hydroxychloroquine oral tablet

1

IMPAVIDO ORAL CAPSULE

2 QL


8

Drug Name Drug Tier


INVANZ INJECTION RECON SOLN

3

INVANZ INTRAVENOUS RECON SOLN

3

isoniazid oral solution

1

isoniazid oral tablet 1

ivermectin oral tablet

1 QL

linezolid oral suspension for reconstitution

1

linezolid oral tablet 1

mefloquine oral tablet

1 QL

metronidazole oral capsule

1

metronidazole oral tablet

1

NEBUPENT INHALATION RECON SOLN

2 QL

neomycin oral tablet 1

paromomycin oral capsule

1

PASER ORAL GRANULES DR FOR SUSP IN PACKET

3

PRIFTIN ORAL TABLET

2

PRIMAQUINE ORAL TABLET

3 QL

pyrazinamide oral tablet

1

Drug Name Drug Tier


quinine sulfate oral capsule

1 QL

rifabutin oral capsule

1

rifampin oral capsule

1

RIFATER ORAL TABLET

3

SIRTURO ORAL TABLET

2

SIVEXTRO ORAL TABLET

3

tinidazole oral tablet 1 QL

TRECATOR ORAL TABLET

3

XIFAXAN ORAL TABLET

2

PENICILLINS

amoxicillin oral capsule

1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

amoxicillin-pot clavulanate oral suspension for reconstitution

1

amoxicillin-pot clavulanate oral tablet

1


9

Drug Name Drug Tier


amoxicillin-pot clavulanate oral tablet extended release 12 hr

1

amoxicillin-pot clavulanate oral tablet,chewable

1

ampicillin oral capsule

1

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

2

dicloxacillin oral capsule

1

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet

1

QUINOLONES

AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK

2

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

1

ciprofloxacin hcl oral tablet

1

ciprofloxacin oral suspension,microcapsule recon

1

FACTIVE ORAL TABLET

3

Drug Name Drug Tier


levofloxacin oral solution

1

levofloxacin oral tablet

1

moxifloxacin oral tablet

1

MOXIFLOXACIN-SOD.ACE,SUL-WATER INTRAVENOUS PIGGYBACK

2

ofloxacin oral tablet 300 mg, 400 mg

1

SULFA'S & RELATED AGENTS

sulfadiazine oral tablet

1

sulfamethoxazole-trimethoprim oral suspension

1

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim oral suspension

1

TETRACYCLINES

avidoxy oral tablet 1

demeclocycline oral tablet

1

doxycycline hyclate oral capsule

1

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

1

doxycycline hyclate oral tablet,delayed release (dr/ec)

1


10

Drug Name Drug Tier


doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet

1

minocycline oral capsule

1

minocycline oral tablet

1

mondoxyne nl oral capsule

1

morgidox oral capsule 100 mg

1

okebo oral capsule 75 mg

1

tetracycline oral capsule

1

URINARY TRACT AGENTS

methenamine hippurate oral tablet

1

methenamine mandelate oral tablet

1

MONUROL ORAL PACKET

3

nitrofurantoin macrocrystal oral capsule

1

nitrofurantoin monohyd/m-cryst oral capsule

1

Drug Name Drug Tier


nitrofurantoin oral suspension

1

trimethoprim oral tablet

1

VANCOMYCIN

vancomycin oral capsule

1 PA

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium oral tablet

1

MESNEX ORAL TABLET

2

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

anastrozole oral tablet

1

azathioprine oral tablet

1

bicalutamide oral tablet

1

BOSULIF ORAL TABLET 400 MG

2

CABOMETYX ORAL TABLET

2 PA; LA

CYCLOPHOSPHAMIDE ORAL CAPSULE

2

cyclosporine modified oral capsule

1 PA

cyclosporine modified oral solution

1 PA


11

Drug Name Drug Tier


cyclosporine oral capsule

1 PA

DROXIA ORAL CAPSULE

2

EMCYT ORAL CAPSULE

2

etoposide oral capsule

1

exemestane oral tablet

1

FARESTON ORAL TABLET

2

flutamide oral capsule

1

gengraf oral capsule 1 PA

gengraf oral solution 1 PA

GLEOSTINE ORAL CAPSULE

2

HEXALEN ORAL CAPSULE

2

hydroxyurea oral capsule

1

letrozole oral tablet 1

LEUKERAN ORAL TABLET

2

LYSODREN ORAL TABLET

2

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

1

megestrol oral tablet 1

melphalan oral tablet

1

mercaptopurine oral tablet

1

Drug Name Drug Tier


methotrexate sodium (pf) injection recon soln

1

methotrexate sodium (pf) injection solution

1

methotrexate sodium injection solution

1

methotrexate sodium oral tablet

1

mycophenolate mofetil oral capsule

1 PA

mycophenolate mofetil oral suspension for reconstitution

1 PA

mycophenolate mofetil oral tablet

1 PA

mycophenolate sodium oral tablet,delayed release (dr/ec)

1 PA

MYLERAN ORAL TABLET

2

nilutamide oral tablet

1

RAPAMUNE ORAL SOLUTION

2

RYDAPT ORAL CAPSULE

2

SANDIMMUNE ORAL SOLUTION

2

sirolimus oral tablet 1 PA

SOLTAMOX ORAL SOLUTION

3

TABLOID ORAL TABLET

2


12

Drug Name Drug Tier


tacrolimus oral capsule

1 PA

tamoxifen oral tablet 1

tretinoin (chemotherapy) oral capsule

1

ZORTRESS ORAL TABLET

2

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET

3

BANZEL ORAL SUSPENSION

2

BANZEL ORAL TABLET

2

carbamazepine oral capsule, er multiphase 12 hr

1

carbamazepine oral suspension 100 mg/5 ml

1

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr

1

carbamazepine oral tablet,chewable

1

CELONTIN ORAL CAPSULE 300 MG

2

clonazepam oral tablet

1

clonazepam oral tablet,disintegrating

1

Drug Name Drug Tier


diazepam rectal kit 1

DILANTIN ORAL CAPSULE

2

divalproex oral capsule, delayed rel sprinkle

1

divalproex oral tablet extended release 24 hr

1

divalproex oral tablet,delayed release (dr/ec)

1

epitol oral tablet 1

ethosuximide oral capsule

1

ethosuximide oral solution

1

felbamate oral suspension

1

felbamate oral tablet 1

FYCOMPA ORAL SUSPENSION

3

FYCOMPA ORAL TABLET

3

gabapentin oral capsule

1

gabapentin oral solution 250 mg/5 ml

1

gabapentin oral tablet 600 mg, 800 mg

1

GABITRIL ORAL TABLET 12 MG, 16 MG

2

lamotrigine oral tablet

1


13

Drug Name Drug Tier


lamotrigine oral tablet disintegrating, dose pk

1

lamotrigine oral tablet extended release 24hr

1

lamotrigine oral tablet, chewable dispersible

1

lamotrigine oral tablet,disintegrating

1

lamotrigine oral tablets,dose pack

1

levetiracetam oral solution

1

levetiracetam oral tablet

1

levetiracetam oral tablet extended release 24 hr

1

LYRICA ORAL CAPSULE

2

LYRICA ORAL SOLUTION

2

ONFI ORAL SUSPENSION

2

ONFI ORAL TABLET 10 MG, 20 MG

2

oxcarbazepine oral suspension

1

oxcarbazepine oral tablet

1

PEGANONE ORAL TABLET

2

phenobarbital oral elixir

1

Drug Name Drug Tier


phenobarbital oral tablet

1

phenytoin oral suspension 125 mg/5 ml

1

phenytoin oral tablet,chewable

1

phenytoin sodium extended oral capsule

1

primidone oral tablet

1

roweepra oral tablet 1

tiagabine oral tablet 1

topiramate oral capsule, sprinkle

1

topiramate oral tablet

1

valproic acid (as sodium salt) oral solution 250 mg/5 ml

1

valproic acid oral capsule

1

VIMPAT ORAL SOLUTION

2

VIMPAT ORAL TABLET

2

zonisamide oral capsule

1

ANTIPARKINSONISM AGENTS

benztropine oral tablet

1

bromocriptine oral capsule

1

bromocriptine oral tablet

1


14

Drug Name Drug Tier


carbidopa oral tablet

1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet extended release

1

carbidopa-levodopa oral tablet,disintegrating

1

carbidopa-levodopa-entacapone oral tablet

1

entacapone oral tablet

1

pramipexole oral tablet

1

pramipexole oral tablet extended release 24 hr

1

rasagiline oral tablet 1

ropinirole oral tablet 1

ropinirole oral tablet extended release 24 hr

1

selegiline hcl oral capsule

1

selegiline hcl oral tablet

1

tolcapone oral tablet 1

trihexyphenidyl oral elixir

1

trihexyphenidyl oral tablet

1

MIGRAINE & CLUSTER HEADACHE THERAPY

Drug Name Drug Tier


almotriptan malate oral tablet

1

dihydroergotamine injection solution

1 PA; QL

dihydroergotamine nasal spray,non-aerosol

1

eletriptan hbr oral tablet

1

ERGOMAR SUBLINGUAL TABLET

3

ergotamine-caffeine oral tablet

1

frovatriptan oral tablet

1

isometh-dichloral-acetaminophn oral capsule

1

isomethepten-caf-acetaminophen oral tablet 65-20-325 mg

1

migergot rectal suppository

1

naratriptan oral tablet

1

RELPAX ORAL TABLET

3

rizatriptan oral tablet

1

rizatriptan oral tablet,disintegrating

1

sumatriptan nasal spray,non-aerosol

1

sumatriptan succinate oral tablet

1


15

Drug Name Drug Tier


sumatriptan succinate subcutaneous cartridge

1

sumatriptan succinate subcutaneous pen injector

1

sumatriptan succinate subcutaneous solution

1

sumatriptan-naproxen oral tablet

1

zolmitriptan oral tablet

1

zolmitriptan oral tablet,disintegrating

1

ZOMIG NASAL SPRAY,NON-AEROSOL

2

MISCELLANEOUS NEUROLOGICAL THERAPY

donepezil oral tablet 1

donepezil oral tablet,disintegrating

1

galantamine oral capsule,ext rel. pellets 24 hr

1

galantamine oral solution

1

galantamine oral tablet

1

memantine oral capsule,sprinkle,er 24hr

1

memantine oral solution

1

Drug Name Drug Tier


memantine oral tablet

1

NUEDEXTA ORAL CAPSULE

2

rivastigmine tartrate oral capsule

1

rivastigmine transdermal patch 24 hour

1

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

baclofen oral tablet 1

carisoprodol oral tablet 250 mg

3

carisoprodol oral tablet 350 mg

1

chlorzoxazone oral tablet

1

cyclobenzaprine oral tablet 10 mg, 5 mg

1

cyclobenzaprine oral tablet 7.5 mg

1 PA

dantrolene oral capsule

1

meprobamate oral tablet

1

MESTINON ORAL SYRUP

2

metaxall oral tablet 1

metaxalone oral tablet

1

methocarbamol oral tablet

1

orphenadrine citrate oral tablet extended release

1


16

Drug Name Drug Tier


pyridostigmine bromide oral tablet

1

pyridostigmine bromide oral tablet extended release

1

tizanidine oral capsule

1

tizanidine oral tablet 1

NARCOTIC ANALGESICS

acetaminophen-caff-dihydrocod oral capsule

1 ST; QL

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

1 ST; QL

acetaminophen-codeine oral tablet

1 ST; QL

ascomp with codeine oral capsule

1 QL

buprenorphine hcl sublingual tablet

1 PA

butalbital compound w/codeine oral capsule

1 QL

butalbital-acetaminop-caf-cod oral capsule

1 QL

butalbital-acetaminophen oral tablet

1 QL

butalbital-acetaminophen-caff oral capsule

1 QL

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

1 QL

Drug Name Drug Tier


butalbital-aspirin-caffeine oral capsule

1 QL

butalbital-aspirin-caffeine oral tablet

1 QL

capacet oral capsule 1 QL

codeine sulfate oral tablet

1 ST; QL

diskets oral tablet,soluble

1 PA

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

3 QL

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

1 ST; QL

fentanyl citrate buccal lozenge on a handle

1 PA; ST; QL

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

1

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

1 ST; QL

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

1 ST; QL


17

Drug Name Drug Tier


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

1 ST; QL

hydromorphone oral liquid

1 ST; QL

hydromorphone oral tablet

1 ST; QL

hydromorphone oral tablet extended release 24 hr

1 PA; QL

hydromorphone rectal suppository

1 ST; QL

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR

3 QL

ibuprofen-oxycodone oral tablet

1 ST; QL

levorphanol tartrate oral tablet

1 ST; QL

lorcet (hydrocodone) oral tablet

1 ST; QL

lorcet hd oral tablet 1 ST; QL

lorcet plus oral tablet 7.5-325 mg

1 ST; QL

marten-tab oral tablet

1 QL

meperidine oral solution

1 ST; QL

meperidine oral tablet

1 ST; QL

methadone injection solution

1 PA

methadone oral concentrate

1 PA

Drug Name Drug Tier


methadone oral solution

1 PA

methadone oral tablet

1 PA

methadone oral tablet,soluble

1 PA

methadose oral concentrate

1 PA

methadose oral tablet,soluble

1 PA

morphine concentrate oral solution

1 ST; QL

morphine oral capsule, er multiphase 24 hr

1 PA; QL

morphine oral capsule,extend.release pellets

1 PA; QL

morphine oral solution

1 ST; QL

morphine oral tablet 1 ST; QL

morphine oral tablet extended release

1 PA; QL

morphine rectal suppository

1 ST; QL

oxycodone oral capsule

1 ST; QL

oxycodone oral concentrate

1 ST; QL

oxycodone oral solution

1 ST; QL

oxycodone oral tablet

1 ST; QL

oxycodone-acetaminophen oral solution

1 ST; QL


18

Drug Name Drug Tier


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

1 ST; QL

oxycodone-aspirin oral tablet

1 ST; QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3 PA; QL

oxymorphone oral tablet

1 ST; QL

oxymorphone oral tablet extended release 12 hr

1 PA; QL

panlor(acetam-caff-dihydrocod) oral tablet

1 ST

tencon oral tablet 50-325 mg

1 QL

verdrocet oral tablet 1 ST; QL

vicodin es oral tablet 1 ST; QL

vicodin hp oral tablet

1 ST; QL

vicodin oral tablet 1 ST; QL

xylon 10 oral tablet 1 ST; QL

zebutal oral capsule 50-325-40 mg

1 QL

NON-NARCOTIC ANALGESICS

aspir-81 oral tablet,delayed release (dr/ec)

1 ACA; OTC

aspirin low dose oral tablet,delayed release (dr/ec)

1 ACA; OTC

Drug Name Drug Tier


aspirin oral tablet 1 ACA; OTC

aspirin oral tablet,chewable

1 ACA; OTC

aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg

1 ACA; OTC

aspir-low oral tablet,delayed release (dr/ec)

1 ACA; OTC

aspir-trin oral tablet,delayed release (dr/ec)

1 ACA; OTC

bayer aspirin oral tablet

1 ACA; OTC

buprenorphine-naloxone sublingual tablet

1 PA

butorphanol tartrate injection solution

1 PA; ST

butorphanol tartrate nasal spray,non-aerosol

1 PA; ST; QL

celecoxib oral capsule

1

children's aspirin oral tablet,chewable

1 ACA; OTC

choline,magnesium salicylate oral liquid

1

diclofenac potassium oral tablet

1

diclofenac sodium oral tablet extended release 24 hr

1

diclofenac sodium oral tablet,delayed release (dr/ec)

1


19

Drug Name Drug Tier


diclofenac sodium topical drops

1 QL

diclofenac sodium topical gel 1 %

1 PA; QL

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

1

diflunisal oral tablet 1

e.c. prin oral tablet,delayed release (dr/ec)

1 ACA; OTC

ecotrin low strength oral tablet,delayed release (dr/ec)

1 ACA; OTC

ecotrin oral tablet,delayed release (dr/ec)

1 ACA; OTC

etodolac oral capsule

1

etodolac oral tablet 1

etodolac oral tablet extended release 24 hr

1

fenoprofen oral tablet

1

flurbiprofen oral tablet

1

ibuprofen oral suspension

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin oral capsule

1

indomethacin oral capsule, extended release

1

Drug Name Drug Tier


ketoprofen oral capsule

1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

1

ketorolac oral tablet 1

lite coat aspirin oral tablet

1 ACA; OTC

meclofenamate oral capsule

1

mefenamic acid oral capsule

1

meloxicam oral suspension

1

meloxicam oral tablet

1

nabumetone oral tablet

1

naloxone injection solution

1 PA

naloxone injection syringe

1 PA

naltrexone oral tablet

1

naproxen oral suspension

1

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet 275 mg, 550 mg

1

naproxen sodium oral tablet, er multiphase 24 hr

1


20

Drug Name Drug Tier


NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

2

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

3 QL

NUCYNTA ORAL TABLET

3 ST

oxaprozin oral tablet 1

piroxicam oral capsule

1

profeno oral tablet 1

salsalate oral tablet 1

SUBOXONE SUBLINGUAL FILM

2 PA

sulindac oral tablet 1

tolmetin oral capsule 1

tolmetin oral tablet 1

tramadol oral tablet 1 ST

tramadol oral tablet extended release 24 hr

1

tramadol oral tablet, er multiphase 24 hr

1

tramadol-acetaminophen oral tablet

1 ST

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

2 PA

Drug Name Drug Tier


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG

2

PSYCHOTHERAPEUTIC DRUGS

ADDYI ORAL TABLET

3

alprazolam intensol oral concentrate

1

alprazolam oral tablet

1

alprazolam oral tablet extended release 24 hr

1

alprazolam oral tablet,disintegrating

1

amitriptyline oral tablet

1

amitriptyline-chlordiazepoxide oral tablet

1

amoxapine oral tablet

1

aripiprazole oral solution

1

aripiprazole oral tablet

1

aripiprazole oral tablet,disintegrating

1

armodafinil oral tablet

1 PA

atomoxetine oral capsule

1

BELSOMRA ORAL TABLET

3

bupropion hcl oral tablet

1


21

Drug Name Drug Tier


bupropion hcl oral tablet extended release 12 hr

1

bupropion hcl oral tablet extended release 24 hr

1

buspirone oral tablet 1

chlordiazepoxide hcl oral capsule

1

chlorpromazine oral tablet

1

citalopram oral solution

1

citalopram oral tablet

1

clomipramine oral capsule

1

clonidine hcl oral tablet extended release 12 hr

1

clorazepate dipotassium oral tablet

1

clozapine oral tablet 1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

1

desipramine oral tablet

1

desvenlafaxine succinate oral tablet extended release 24 hr

1

dexmethylphenidate oral capsule,er biphasic 50-50

1

Drug Name Drug Tier


dexmethylphenidate oral tablet

1

dextroamphetamine oral capsule, extended release

1

dextroamphetamine oral solution

1

dextroamphetamine oral tablet

1

dextroamphetamine-amphetamine oral capsule,extended release 24hr

1

dextroamphetamine-amphetamine oral tablet

1

diazepam intensol oral concentrate

1

diazepam oral solution 5 mg/5 ml (1 mg/ml)

1

diazepam oral tablet 1

doxepin oral capsule 1

doxepin oral concentrate

1

duloxetine oral capsule,delayed release(dr/ec)

1

EMSAM TRANSDERMAL PATCH 24 HOUR

3

ergoloid oral tablet 1

escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet

1

estazolam oral tablet 1


22

Drug Name Drug Tier


eszopiclone oral tablet

1

FANAPT ORAL TABLET

3 QL

FANAPT ORAL TABLETS,DOSE PACK

3 QL

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

3

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

3

fluoxetine oral capsule

1

fluoxetine oral capsule,delayed release(dr/ec)

1

fluoxetine oral solution

1

fluoxetine oral tablet 1

fluphenazine hcl oral concentrate

1

fluphenazine hcl oral elixir

1

fluphenazine hcl oral tablet

1

flurazepam oral capsule

1

fluvoxamine oral capsule,extended release 24hr

1

fluvoxamine oral tablet

1

Drug Name Drug Tier


guanfacine oral tablet extended release 24 hr

1

guanidine oral tablet 1

haloperidol lactate oral concentrate

1

haloperidol oral tablet

1

imipramine hcl oral tablet

1

imipramine pamoate oral capsule

1

LATUDA ORAL TABLET

3 QL

lithium carbonate oral capsule

1

lithium carbonate oral tablet

1

lithium carbonate oral tablet extended release

1

lithium citrate oral solution 8 meq/5 ml

1

lorazepam intensol oral concentrate

1

lorazepam oral concentrate

1

lorazepam oral tablet

1

loxapine succinate oral capsule

1

maprotiline oral tablet

1

MARPLAN ORAL TABLET

3


23

Drug Name Drug Tier


metadate er oral tablet extended release

1

methamphetamine oral tablet

1

methylphenidate hcl oral capsule, er biphasic 30-70

1

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg, 60 mg

1

methylphenidate hcl oral solution

1

methylphenidate hcl oral tablet

1

methylphenidate hcl oral tablet extended release

1

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

1

methylphenidate hcl oral tablet,chewable

1

midazolam oral syrup 2 mg/ml

1

mirtazapine oral tablet

1

mirtazapine oral tablet,disintegrating

1

modafinil oral tablet 1 PA

nefazodone oral tablet

1

nortriptyline oral capsule

1

Drug Name Drug Tier


nortriptyline oral solution

1

olanzapine oral tablet

1

olanzapine oral tablet,disintegrating

1

olanzapine-fluoxetine oral capsule

1

oxazepam oral capsule

1

paliperidone oral tablet extended release 24hr

1

paroxetine hcl oral tablet

1

paroxetine hcl oral tablet extended release 24 hr

1

paroxetine mesylate(menop.sym) oral capsule

1

perphenazine oral tablet

1

perphenazine-amitriptyline oral tablet

1

phenelzine oral tablet

1

pimozide oral tablet 1

procentra oral solution

1

protriptyline oral tablet

1

quazepam oral tablet 1

quetiapine oral tablet

1


24

Drug Name Drug Tier


quetiapine oral tablet extended release 24 hr

1

REXULTI ORAL TABLET

3 QL

risperidone oral solution

1

risperidone oral tablet

1

risperidone oral tablet,disintegrating

1

ROZEREM ORAL TABLET

2

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

3 QL

seconal sodium oral capsule

1

sertraline oral concentrate

1

sertraline oral tablet 1

temazepam oral capsule

1

thioridazine oral tablet

1

thiothixene oral capsule

1

tranylcypromine oral tablet

1

trazodone oral tablet 1

triazolam oral tablet 1

trifluoperazine oral tablet

1

trimipramine oral capsule

1

Drug Name Drug Tier


TRINTELLIX ORAL TABLET

3 PA

venlafaxine oral capsule,extended release 24hr

1

venlafaxine oral tablet

1

venlafaxine oral tablet extended release 24hr

1

VIIBRYD ORAL TABLET

3 PA

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

3 PA

VYVANSE ORAL CAPSULE

2

VYVANSE ORAL TABLET,CHEWABLE

2

zaleplon oral capsule

1

zenzedi oral tablet 10 mg, 5 mg

1

ziprasidone hcl oral capsule

1

zolpidem oral tablet 1

zolpidem oral tablet,ext release multiphase

1

zolpidem sublingual tablet

1

CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS


25

Drug Name Drug Tier


amiodarone oral tablet

1

disopyramide phosphate oral capsule

1

dofetilide oral capsule

1

flecainide oral tablet 1

mexiletine oral capsule

1

MULTAQ ORAL TABLET

3

pacerone oral tablet 100 mg, 200 mg, 400 mg

1

propafenone oral capsule,extended release 12 hr

1

propafenone oral tablet

1

quinidine gluconate oral tablet extended release

1

quinidine sulfate oral tablet

1

sotalol af oral tablet 1

sotalol oral tablet 1

SOTYLIZE ORAL SOLUTION

2

ANTIHYPERTENSIVE THERAPY

acebutolol oral capsule

1

afeditab cr oral tablet extended release

1

amiloride oral tablet 1

Drug Name Drug Tier


amiloride-hydrochlorothiazide oral tablet

1

amlodipine oral tablet

1

amlodipine-benazepril oral capsule

1

amlodipine-olmesartan oral tablet

1

amlodipine-valsartan oral tablet

1

amlodipine-valsartan-hcthiazid oral tablet

1

atenolol oral tablet 1

atenolol-chlorthalidone oral tablet

1

benazepril oral tablet

1

benazepril-hydrochlorothiazide oral tablet

1

betaxolol oral tablet 1

bisoprolol fumarate oral tablet

1

bisoprolol-hydrochlorothiazide oral tablet

1

bumetanide oral tablet

1

BYSTOLIC ORAL TABLET

3

candesartan oral tablet

1


26

Drug Name Drug Tier


candesartan-hydrochlorothiazid oral tablet

1

captopril oral tablet 1

captopril-hydrochlorothiazide oral tablet

1

cartia xt oral capsule,extended release 24hr

1

carvedilol oral tablet 1

carvedilol phosphate oral capsule, er multiphase 24 hr

1

chlorothiazide oral tablet

1

chlorthalidone oral tablet 25 mg, 50 mg

1

clonidine hcl oral tablet

1

clonidine transdermal patch weekly

1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg

1

DEMSER ORAL CAPSULE

2

diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg

1

diltiazem hcl oral capsule,extended release 12 hr

1

diltiazem hcl oral capsule,extended release 24 hr 240 mg, 420 mg

1

Drug Name Drug Tier


diltiazem hcl oral capsule,extended release 24hr

1

diltiazem hcl oral tablet

1

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg

1

dilt-xr oral capsule,ext.rel 24h degradable

1

doxazosin oral tablet 1

DYRENIUM ORAL CAPSULE

3

EDARBI ORAL TABLET

3

EDARBYCLOR ORAL TABLET

3

enalapril maleate oral tablet

1

enalapril-hydrochlorothiazide oral tablet

1

eplerenone oral tablet

1

eprosartan oral tablet

1

ethacrynic acid oral tablet

1

felodipine oral tablet extended release 24 hr

1

fosinopril oral tablet 1

fosinopril-hydrochlorothiazide oral tablet

1


27

Drug Name Drug Tier


furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

furosemide oral tablet

1

guanfacine oral tablet

1

HEMANGEOL ORAL SOLUTION

3 PA; LA

hydralazine oral tablet

1

hydrochlorothiazide oral capsule

1

hydrochlorothiazide oral tablet

1

indapamide oral tablet

1

irbesartan oral tablet

1

irbesartan-hydrochlorothiazide oral tablet

1

isradipine oral capsule

1

labetalol oral tablet 1

LEVATOL ORAL TABLET

3

lisinopril oral tablet 1

lisinopril-hydrochlorothiazide oral tablet

1

losartan oral tablet 1

losartan-hydrochlorothiazide oral tablet

1

Drug Name Drug Tier


matzim la oral tablet extended release 24 hr

1

methyclothiazide oral tablet

1

methyldopa oral tablet

1

methyldopa-hydrochlorothiazide oral tablet

1

metolazone oral tablet

1

metoprolol succinate oral tablet extended release 24 hr

1

metoprolol ta-hydrochlorothiaz oral tablet

1

metoprolol tartrate oral tablet

1

minoxidil oral tablet 1

moexipril oral tablet 1

moexipril-hydrochlorothiazide oral tablet

1

nadolol oral tablet 1

nadolol-bendroflumethiazide oral tablet

1

nicardipine oral capsule

1

nifedipine oral tablet extended release

1

nifedipine oral tablet extended release 24hr

1


28

Drug Name Drug Tier


nimodipine oral capsule

1

nisoldipine oral tablet extended release 24 hr

1

olmesartan oral tablet

1

olmesartan-amlodipin-hcthiazid oral tablet

1

olmesartan-hydrochlorothiazide oral tablet

1

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

3 PA; LA

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

3 PA

perindopril erbumine oral tablet

1

phenoxybenzamine oral capsule

1

pindolol oral tablet 1

prazosin oral capsule

1

propranolol oral capsule,extended release 24 hr

1

propranolol oral solution

1

propranolol oral tablet

1

Drug Name Drug Tier


propranolol-hydrochlorothiazid oral tablet

1

quinapril oral tablet 1

quinapril-hydrochlorothiazide oral tablet

1

ramipril oral capsule

1

spironolactone oral tablet

1

spironolacton-hydrochlorothiaz oral tablet

1

taztia xt oral capsule,extended release 24 hr

1

TEKTURNA HCT ORAL TABLET

3

TEKTURNA ORAL TABLET

3

telmisartan oral tablet

1

telmisartan-amlodipine oral tablet

1

telmisartan-hydrochlorothiazid oral tablet

1

terazosin oral capsule

1

timolol maleate oral tablet

1

torsemide oral tablet 1

trandolapril oral tablet

1


29

Drug Name Drug Tier


trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

1

triamterene-hydrochlorothiazid oral capsule

1

triamterene-hydrochlorothiazid oral tablet

1

valsartan oral tablet 1

valsartan-hydrochlorothiazide oral tablet

1

verapamil oral capsule, 24 hr er pellet ct

1

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet 1

verapamil oral tablet extended release

1

CARDIAC GLYCOSIDES

digitek oral tablet 1

digox oral tablet 1

digoxin oral solution 50 mcg/ml

1

digoxin oral tablet 1

COAGULATION THERAPY

AMICAR ORAL SOLUTION

2

AMICAR ORAL TABLET

2

Drug Name Drug Tier


aspirin-dipyridamole oral capsule, er multiphase 12 hr

1

BRILINTA ORAL TABLET

2

cilostazol oral tablet 1

clopidogrel oral tablet

1

dipyridamole oral tablet

1

ELIQUIS ORAL TABLET

2

ELIQUIS ORAL TABLETS,DOSE PACK

2

FRAGMIN SUBCUTANEOUS SOLUTION

3 PA; LA

FRAGMIN SUBCUTANEOUS SYRINGE

3 PA; LA

hep flush-10 (pf) intravenous solution

1 PA

heparin (porcine) in 5 % dex intravenous parenteral solution

1 PA

heparin (porcine) in nacl (pf) intravenous parenteral solution

1 PA

heparin (porcine) injection cartridge

1 PA

heparin (porcine) injection solution

1 PA

heparin (porcine) injection syringe 5,000 unit/ml

1 PA


30

Drug Name Drug Tier


heparin flush(porcine)-0.9nacl intravenous kit

1 PA

heparin lock flush (porcine) intravenous solution 100 unit/ml

1 PA

heparin lock flush intravenous solution

1 PA

heparin lock flush intravenous syringe

1 PA

heparin lockflush(porcine)(pf) intravenous syringe

1 PA

heparin(porcine) in 0.45% nacl intravenous parenteral solution 100 unit/100 ml (1 unit/ml)

1

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

1 PA

heparin, porcine (pf) injection solution

1 PA

heparin, porcine (pf) injection syringe

1 PA

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

1 PA

heparin, porcine (pf) intravenous syringe

1 PA

jantoven oral tablet 1

MEPHYTON ORAL TABLET

2 PA

Drug Name Drug Tier


pentoxifylline oral tablet extended release

1

PRADAXA ORAL CAPSULE

3

prasugrel oral tablet 1

ticlopidine oral tablet

1

vitamin k injection solution

1 PA

vitamin k1 injection solution

1 PA

warfarin oral tablet 1

XARELTO ORAL TABLET

2

XARELTO ORAL TABLETS,DOSE PACK

2

ZONTIVITY ORAL TABLET

3

LIPID/CHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin oral tablet

1

atorvastatin oral tablet

1

cholestyramine (with sugar) oral powder

1

cholestyramine (with sugar) oral powder in packet

1

cholestyramine light oral powder

1

cholestyramine light oral powder in packet

1


31

Drug Name Drug Tier


colestipol oral granules

1

colestipol oral packet

1

colestipol oral tablet 1

ezetimibe oral tablet 1

ezetimibe-simvastatin oral tablet

1

fenofibrate micronized oral capsule

1

fenofibrate nanocrystallized oral tablet

1

fenofibrate oral tablet

1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

1

fenofibric acid oral tablet

1

fluvastatin oral capsule

1

fluvastatin oral tablet extended release 24 hr

1

gemfibrozil oral tablet

1

LIVALO ORAL TABLET

3

lovastatin oral tablet 1

niacin oral tablet extended release 24 hr

1

Drug Name Drug Tier


omega-3 acid ethyl esters oral capsule

1

pravastatin oral tablet

1

prevalite oral powder

1

prevalite oral powder in packet

1

rosuvastatin oral tablet

1

simvastatin oral tablet

1

triklo oral capsule 1

VASCEPA ORAL CAPSULE

2

WELCHOL ORAL POWDER IN PACKET

3

WELCHOL ORAL TABLET

3

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET

2

ENTRESTO ORAL TABLET

2

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

3

NITRATES

isosorbide dinitrate oral tablet

1

isosorbide dinitrate oral tablet extended release

1


32

Drug Name Drug Tier


isosorbide mononitrate oral tablet

1

isosorbide mononitrate oral tablet extended release 24 hr

1

nitro-bid transdermal ointment

1

nitroglycerin oral capsule, extended release

1

nitroglycerin sublingual tablet

1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual spray,non-aerosol

1

nitro-time oral capsule, extended release

1

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin oral capsule

1

calcipotriene scalp solution

1

calcipotriene topical cream

1

calcipotriene topical ointment

1

Drug Name Drug Tier


calcipotriene-betamethasone topical ointment

1

calcitrene topical ointment

1

calcitriol topical ointment

1

COAL TAR TOPICAL SOLUTION

2

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

3 PA; LA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

3 PA; LA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

3 PA; LA

COSENTYX SUBCUTANEOUS SYRINGE

3 PA; LA

drithocreme hp topical cream

1

hydrocortisone-pramoxine topical cream

1

seb-prev topical cleanser

1

selenium sulfide topical lotion

1

selenium sulfide topical shampoo 2.25 %

1


33

Drug Name Drug Tier


STELARA SUBCUTANEOUS SYRINGE

3 LA

sulfacetamide sodium topical cleanser

1

sulfacetamide sodium topical cleanser, gel

1

sulfacetamide sodium topical shampoo

1

BURN THERAPY

silver sulfadiazine topical cream

1

ssd topical cream 1

KERATOLYTICS

salicylic acid er-ceramides topical kit,cleanser and cream er

1

salicylic acid topical cream

1

salicylic acid topical cream,extended release

1

salicylic acid topical film forming liquid w/appl

1

salicylic acid topical film-forming soln er w/ appl

1

salicylic acid topical foam

1

salicylic acid topical gel

1

Drug Name Drug Tier


salicylic acid topical liquid 26 %

1

salicylic acid topical lotion

1

salicylic acid topical lotion,extended release

1

salicylic acid topical shampoo

1

salimez topical cream

1

salvax topical foam 1

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate topical cream

1

ammonium lactate topical lotion

1

avo cream topical emulsion

1

celacyn topical gel with pump

1

cem-urea topical gel 1

doxepin topical cream

1

eletone topical cream

1

ELIDEL TOPICAL CREAM

3

emulsion sb topical emulsion

1

fluorouracil topical cream 5 %

1

fluorouracil topical solution

1


34

Drug Name Drug Tier


hpr plus hydrogel topical kit,cream and gel

1

hpr plus topical cream

1

hpr plus topical foam

1

hpr topical foam 1

luxamend topical cream

1

mb hydrogel (cyclomethicone) topical kit,cream and gel

1

mb hydrogel topical kit,cream and gel

1

methoxsalen oral capsule,liqd-filled,rapid rel

1

nivatopic plus topical cream

1

PANRETIN TOPICAL GEL

3

PICATO TOPICAL GEL

3

podofilox topical solution

1

pruclair topical cream

1

prudoxin topical cream

1

prumyx topical cream

1

prutect topical emulsion

1

REGRANEX TOPICAL GEL

2

Drug Name Drug Tier


silver nitrate applicators topical stick

1

silver nitrate topical ointment

1

silver nitrate topical solution

1

sonafine topical emulsion

1

sp antipruritic topical gel

1

sp scar management topical gel with pump

1

tacrolimus topical ointment

1 PA

umecta topical foam 1

urea nail stick topical solution

1

urea topical cream 39 %, 40 %, 45 %, 47 %, 50 %

1

urea topical foam 1

urea topical gel 45 %

1

urea topical lotion 40 %, 45 %

1

ure-k topical cream 1

VEREGEN TOPICAL OINTMENT

3

THERAPY FOR ACNE

adapalene topical cream

1

adapalene topical gel

1


35

Drug Name Drug Tier


adapalene topical gel with pump

1

adapalene-benzoyl peroxide topical gel with pump

1

amnesteem oral capsule

1

avar topical cleanser 1

avita topical cream 1

AZELEX TOPICAL CREAM

3

benzepro topical towelette

1

benzoyl peroxide topical cleanser 7 %

1

benzoyl peroxide topical foam 9.8 %

1

bp 10-1 topical cleanser

1

bpo topical gel 1

bpo topical towelette 6 %

1

claravis oral capsule 1

cleansing wash topical cleanser

1

clindacin p topical swab

1

clindamycin phosphate topical foam

1

clindamycin phosphate topical gel

1

clindamycin phosphate topical lotion

1

Drug Name Drug Tier


clindamycin phosphate topical solution

1

clindamycin phosphate topical swab

1

clindamycin-benzoyl peroxide topical gel

1

clindamycin-benzoyl peroxide topical gel with pump

1

clindamycin-tretinoin topical gel

1

dapsone topical gel 1

EPIDUO FORTE TOPICAL GEL WITH PUMP

3

ery pads topical swab

1

erygel topical gel 1

erythromycin with ethanol topical gel

1

erythromycin with ethanol topical solution

1

erythromycin with ethanol topical swab

1

erythromycin-benzoyl peroxide topical gel

1

isotretinoin oral capsule

1

metronidazole topical cream

1

metronidazole topical gel

1


36

Drug Name Drug Tier


metronidazole topical gel with pump

1

metronidazole topical lotion

1

MIRVASO TOPICAL GEL

3

neuac topical gel 1

rosadan topical cream

1

rosadan topical gel 1

rosula cleansing cloths topical pads, medicated

1

SOOLANTRA TOPICAL CREAM

3

sss 10-5 topical cream

1

sss 10-5 topical foam

1

sulfacetamide sodium-sulfur topical cleanser

1

sulfacetamide sodium-sulfur topical cream

1

sulfacetamide sodium-sulfur topical lotion

1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

1

sulfacetamide sodium-sulfur topical suspension

1

Drug Name Drug Tier


sulfacetamide sod-sulfur-urea topical cleanser

1

sulfacetamide-sulfur-cleansr23 topical kit

1

sulfacleanse 8-4 topical suspension

1

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

1

tazarotene topical cream

1 PA

TAZORAC TOPICAL CREAM 0.05 %

2 PA

TAZORAC TOPICAL GEL

2 PA

tretinoin microspheres topical gel

1

tretinoin microspheres topical gel with pump

1

tretinoin topical cream

1

tretinoin topical gel 1

zenatane oral capsule

1

TOPICAL ANESTHETICS

cidaleaze topical cream

1

dermacinrx prizopak topical kit

1


37

Drug Name Drug Tier


ethyl chloride topical aerosol,spray

1

glydo mucous membrane jelly in applicator

1 QL

lidocaine hcl laryngotracheal solution

1

lidocaine hcl mucous membrane jelly

1 QL

lidocaine hcl mucous membrane jelly in applicator

1 QL

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

1

lidocaine hcl topical cream 3 %

1

lidocaine hcl topical lotion

1

lidocaine hcl-hydrocortison ac topical cream

1

lidocaine topical adhesive patch,medicated

1

lidocaine topical ointment

1 QL

lidocaine viscous mucous membrane solution

1

lidocaine-prilocaine topical cream

1 QL

lidocaine-prilocaine topical kit

1

lido-k topical lotion 1

lidopin topical cream 3 %

1

Drug Name Drug Tier


lidopril topical kit 1

relador pak plus topical kit

1

relador pak topical kit

1

TOPICAL ANTIBACTERIALS

ALTABAX TOPICAL OINTMENT

3

CORTISPORIN TOPICAL CREAM

3

CORTISPORIN TOPICAL OINTMENT

3

gentamicin topical cream

1

gentamicin topical ointment

1

hydrocortisone-iodoquinl-aloe2 topical gel

1

hydrocortisone-iodoquinol-aloe topical cream in packet

1

iodoquinol-hc topical cream

1

lugols topical solution

1

mafenide acetate topical packet

1

mupirocin calcium topical cream

1

mupirocin topical ointment

1

NEO-SYNALAR TOPICAL CREAM

3


38

Drug Name Drug Tier


sulfacetamide sodium (acne) topical suspension

1

SULFAMYLON TOPICAL CREAM

2

SULFAMYLON TOPICAL PACKET

2

TOPICAL ANTIFUNGALS

ciclodan topical cream

1

ciclodan topical solution

1

ciclopirox topical cream

1

ciclopirox topical gel

1

ciclopirox topical shampoo

1

ciclopirox topical solution

1

ciclopirox topical suspension

1

ciclopirox-ure-camph-menth-euc topical solution

1

clotrimazole topical cream

1

clotrimazole topical solution

1

clotrimazole-betamethasone topical cream

1

clotrimazole-betamethasone topical lotion

1

econazole topical cream

1

Drug Name Drug Tier


ERTACZO TOPICAL CREAM

3

EXELDERM TOPICAL CREAM

3

EXELDERM TOPICAL SOLUTION

3

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

3

ketoconazole topical cream

1

ketoconazole topical foam

1

ketoconazole topical shampoo

1

LUZU TOPICAL CREAM

3

MENTAX TOPICAL CREAM

3

naftifine topical cream

1

nyamyc topical powder

1

nystatin topical cream

1

nystatin topical ointment

1

nystatin topical powder

1

nystatin-triamcinolone topical cream

1

nystatin-triamcinolone topical ointment

1


39

Drug Name Drug Tier


nystop topical powder

1

oxiconazole topical cream

1

TRIACETIN LIQUID

2

TOPICAL ANTIVIRALS

acyclovir topical ointment

1

DENAVIR TOPICAL CREAM

3

ZOVIRAX TOPICAL CREAM

2

TOPICAL CORTICOSTEROIDS

ala-cort topical cream

1

alclometasone topical cream

1

alclometasone topical ointment

1

amcinonide topical cream

1

amcinonide topical lotion

1

amcinonide topical ointment

1

apexicon e topical cream

1

betamethasone dipropionate topical cream

1

betamethasone dipropionate topical lotion

1

Drug Name Drug Tier


betamethasone dipropionate topical ointment

1

betamethasone valerate topical cream

1

betamethasone valerate topical foam

1

betamethasone valerate topical lotion

1

betamethasone valerate topical ointment

1

betamethasone, augmented topical cream

1

betamethasone, augmented topical gel

1

betamethasone, augmented topical lotion

1

betamethasone, augmented topical ointment

1

clobetasol scalp solution

1

clobetasol topical cream

1

clobetasol topical foam

1

clobetasol topical gel

1

clobetasol topical lotion

1


40

Drug Name Drug Tier


clobetasol topical ointment

1

clobetasol topical shampoo

1

clobetasol topical spray,non-aerosol

1

clobetasol-emollient topical cream

1

clobetasol-emollient topical foam

1

clodan topical shampoo

1

CLODERM TOPICAL CREAM

2

cormax scalp solution

1

desonide topical cream

1

desonide topical lotion

1

desonide topical ointment

1

desoximetasone topical cream

1

desoximetasone topical gel

1

desoximetasone topical ointment

1

diflorasone topical cream

1

diflorasone topical ointment

1

fluocinolone and shower cap scalp oil

1

fluocinolone topical cream

1

Drug Name Drug Tier


fluocinolone topical oil

1

fluocinolone topical ointment

1

fluocinolone topical solution

1

fluocinonide topical cream

1

fluocinonide topical gel

1

fluocinonide topical ointment

1

fluocinonide topical solution

1

fluocinonide-emollient topical cream

1

flurandrenolide topical cream

1

flurandrenolide topical lotion

1

flurandrenolide topical ointment

1

fluticasone topical cream

1

fluticasone topical lotion

1

fluticasone topical ointment

1

halobetasol propionate topical cream

1

halobetasol propionate topical ointment

1

HALOG TOPICAL CREAM

3


41

Drug Name Drug Tier


HALOG TOPICAL OINTMENT

3

hydrocortisone butyrate topical cream

1

hydrocortisone butyrate topical lotion

1

hydrocortisone butyrate topical ointment

1

hydrocortisone butyrate topical solution

1

hydrocortisone butyr-emollient topical cream

1

hydrocortisone topical cream 1 %, 2.5 %

1

hydrocortisone topical lotion 2.5 %

1

hydrocortisone topical ointment 1 %, 2.5 %

1

hydrocortisone valerate topical cream

1

hydrocortisone valerate topical ointment

1

hydrocortisone-min oil-wht pet topical ointment

1

mometasone topical cream

1

mometasone topical ointment

1

Drug Name Drug Tier


mometasone topical solution

1

nolix topical cream 1

nolix topical lotion 1

prednicarbate topical cream

1

prednicarbate topical ointment

1

scalacort topical lotion

1

triamcinolone acetonide topical aerosol

1

triamcinolone acetonide topical cream

1

triamcinolone acetonide topical lotion

1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

1

trianex topical ointment

1

triderm topical cream

1

TOPICAL ENZYMES

SANTYL TOPICAL OINTMENT

2

TOPICAL SCABICIDES / PEDICULICIDES

EURAX TOPICAL CREAM

3

EURAX TOPICAL LOTION

3


42

Drug Name Drug Tier


lindane topical shampoo

1

malathion topical lotion

1

permethrin topical cream

1

spinosad topical suspension

1

ULESFIA TOPICAL LOTION

3

DIAGNOSTICS & MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers irrigation solution

1

neomycin-polymyxin b gu irrigation solution

1

ringer's irrigation solution

1

tis-u-sol pentalyte irrigation solution

1

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec)

1

acetic acid irrigation solution

1

alendronate oral tablet 40 mg

1

anagrelide oral capsule

1

caffeine citrate oral solution

1

cevimeline oral capsule

1

Drug Name Drug Tier


CHEMET ORAL CAPSULE

2

disulfiram oral tablet

1

etidronate disodium oral tablet

1

levocarnitine (with sugar) oral solution

1

levocarnitine oral tablet

1

midodrine oral tablet

1

pilocarpine hcl oral tablet 5 mg

1

riluzole oral tablet 1 PA

risedronate oral tablet 30 mg

1

sodium chloride 0.9 % injection solution

1 PA

sodium chloride 0.9 % injection syringe

1 PA

sodium chloride 0.9 % intravenous parenteral solution

1 PA

sodium chloride 0.9 % intravenous piggyback

1 PA

sodium chloride irrigation solution

1

sodium phenylbutyrate oral powder

1

sodium phenylbutyrate oral tablet

1

SYPRINE ORAL CAPSULE

3


43

Drug Name Drug Tier


trientine oral capsule

1

water for irrigation, sterile irrigation solution

1

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended release 12 hr

1 ACA

CHANTIX CONTINUING MONTH BOX ORAL TABLET

2 ACA

CHANTIX ORAL TABLET

2 ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

2 ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR

2 ACA; OTC

nicorelief buccal gum

1 ACA; OTC

NICORETTE BUCCAL GUM 2 MG

2 ACA; OTC

nicorette buccal gum 4 mg

1 ACA; OTC

NICORETTE BUCCAL LOZENGE

2 ACA; OTC

NICORETTE BUCCAL MINI LOZENGE

2 ACA; OTC

Drug Name Drug Tier


nicotine (polacrilex) buccal gum

1 ACA; OTC

nicotine (polacrilex) buccal lozenge

1 ACA; OTC

nicotine (polacrilex) buccal mini lozenge

1 OTC

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

1 ACA; OTC

nicotine transdermal patch, td daily, sequential

1 ACA; OTC

NICOTROL INHALATION CARTRIDGE

3 ACA

NICOTROL NS NASAL SPRAY,NON-AEROSOL

3 ACA

quit 2 buccal gum 1 ACA; OTC

QUIT 2 BUCCAL LOZENGE

2 ACA; OTC

quit 4 buccal gum 1 ACA; OTC

QUIT 4 BUCCAL LOZENGE

2 ACA; OTC

stop smoking aid buccal lozenge

1 ACA; OTC

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal aerosol,spray

1

azelastine nasal spray,non-aerosol

1


44

Drug Name Drug Tier


DEBACTEROL MUCOUS MEMBRANE SOLUTION

3

ipratropium bromide nasal spray,non-aerosol

1

olopatadine nasal spray,non-aerosol

1

oralone dental paste 1

pilocarpine hcl oral tablet 7.5 mg

1

triamcinolone acetonide dental paste

1

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution

1

ciprofloxacin hcl otic (ear) dropperette

1

floxin otic (ear) drops

1

fluocinolone acetonide oil otic (ear) drops

1

hydrocortisone-acetic acid otic (ear) drops

1

ofloxacin otic (ear) drops

1

OTIC STEROID / ANTIBIOTIC

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

3

Drug Name Drug Tier


CIPRODEX OTIC (EAR) DROPS,SUSPENSION

2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

3

neomycin-polymyxin-hc otic (ear) drops,suspension

1

neomycin-polymyxin-hc otic (ear) solution

1

ENDOCRINE/DIABETES

ADRENAL HORMONES

cortisone oral tablet 1

decadron oral tablet 1

deltasone oral tablet 20 mg

1

dexamethasone intensol oral drops

1

dexamethasone oral elixir

1

dexamethasone oral solution

1

dexamethasone oral tablet

1

fludrocortisone oral tablet

1

hydrocortisone oral tablet

1

methylprednisolone oral tablet

1


45

Drug Name Drug Tier


methylprednisolone oral tablets,dose pack

1

millipred dp oral tablets,dose pack

1

millipred oral tablet 1

prednisolone oral solution 15 mg/5 ml

1

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

prednisolone sodium phosphate oral tablet,disintegrating

1

prednisone intensol oral concentrate

1

prednisone oral solution

1

prednisone oral tablet

1

prednisone oral tablets,dose pack

1

veripred 20 oral solution

1

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg

1

propylthiouracil oral tablet

1

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES

Drug Name Drug Tier


ONETOUCH ULTRA TEST STRIP

3 OTC

ONETOUCH VERIO STRIP

3 OTC

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT

ACE AEROSOL CLOUD ENHANCER SPACER

2

AEROCHAMBER MINI SPACER

2

AEROCHAMBER PLUS FLOW-VU SPACER

2

AEROCHAMBER PLUS Z STAT SM MSK SPACER

2

AEROTRACH PLUS SPACER

2

AEROVENT PLUS SPACER

2

BREATHERITE MDI SPACER SPACER

2

CLEVER CHOICE CHAMBER-SM MASK SPACER

2

COMPACT SPACE CHAMBER-LRG MASK SPACER

2

EASIVENT HOLDING CHAMBER SPACER

2

E-Z SPACER SPACER

2


46

Drug Name Drug Tier


FLEXICHAMBER SPACER

2

INSPIRACHAMBER WITH MASK-LARGE SPACER

2

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.5 ML 29 GAUGE X 1/2"

2

LITEAIRE MDI CHAMBER SPACER

2

MICROCHAMBER SPACER

2

MICROSPACER SPACER

2

OPTICHAMBER DIAMOND LG MASK SPACER

2

POCKET CHAMBER SPACER

2

PRIMEAIRE SPACER

2

PROCHAMBER SPACER

2

RITEFLO AEROCHAMBER SPACER

2

VORTEX HOLDING CHAMBER CHILD SPACER

2

VORTEX VHC FROG MASK-CHILD SPACER

2

Drug Name Drug Tier


VORTEX VHC LADYBUG MASK-TODDLR SPACER

2

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT INJECTION RECON SOLN

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

2

PROGLYCEM ORAL SUSPENSION

2

INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU

AUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS INSULIN PEN

2 OTC

AUTOPEN 1 TO 21 UNITS SUBCUTANEOUS INSULIN PEN

2 OTC

AUTOSOFT 30 INFUSION SET

2

AUTOSOFT 90 INFUSION SET

2

CARTRIDGE STAMPED IR 1200 SUBCUTANEOUS CARTRIDGE

2 OTC

CLEO 90 INFUSION SET 24" INFUSION SET

2


47

Drug Name Drug Tier


COMFORT INFUSION SET 43" INFUSION SET

2

COMFORT SHORT INSULIN PUMP 23" INFUSION SET

2

CONTACT DETACH INFUS SET 23" INFUSION SET

2

HUMAPEN LUXURA HD SUBCUTANEOUS INSULIN PEN

2

INFUSION SET 43" 6MM INFUSION SET

2 OTC

INSET 30 INFUSION SET 23" INFUSION SET

2

INSET INFUSION SET 23" INFUSION SET

2

LANCETS 33 GAUGE

2 OTC

LANCING DEVICE 2 OTC

MINIMED INFUSION SET-MMT 390 INFUSION SET

2

MIO INFUSION SET INFUSION SET

2

ONETOUCH ULTRA CONTROL SOLUTION

3 OTC

ONETOUCH ULTRA2 KIT

3 OTC

Drug Name Drug Tier


ONETOUCH ULTRAMINI KIT

3 OTC

ONETOUCH VERIO FLEX

3 OTC

ONETOUCH VERIO IQ METER

3 OTC

ONETOUCH VERIO SYSTEM

3 OTC

PEN NEEDLE NEEDLE 31 GAUGE X 1/4"

2 OTC

QUICK-SET PARADIGM INFUSION SET

2

SAFE-CLIP BY MAIL DEVICE

2 OTC

SILHOUETTE INFUSION SET

2

SNAP INSULIN PUMP-INFUSION SET INFUSION SET

2

SOF-SET CANNULA 24" TUBING INFUSION SET

2

SOF-SET INFUSION SET

2

SOF-SET MICRO 24" POLYFIN TUB INFUSION SET

2

SURE-T PARADIGM INFUSION SET

2

T:30 INFUSION SET INFUSION SET

2


48

Drug Name Drug Tier


T:90 INFUSION SET 23" INFUSION SET

2

T:SLIM G4 SUBCUTANEOUS CARTRIDGE

2

T:SLIM SUBCUTANEOUS CARTRIDGE

2

TRUSTEEL INFUSION SET 32" INFUSION SET

2

VARISOFT INFUSION SET 43" INFUSION SET

2

VGO 20 DEVICE 2

VGO 30 DEVICE 2

VGO 40 DEVICE 2

INSULIN THERAPY

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

3 PA

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

3 PA

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT

2 PA

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

2 PA

Drug Name Drug Tier


HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

2 PA

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

2 PA

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

2 PA

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

2 PA

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

2 PA

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

2 PA

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

2 PA

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

2 PA

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

2 PA


49

Drug Name Drug Tier


HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

2 PA

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

2 PA

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

2 PA

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

2 PA

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

2 PA

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

2 PA

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

3 PA

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

3 PA

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

3

Drug Name Drug Tier


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

3

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

3

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

3

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

3

RELION NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

3

RELION NOVOLIN N SUBCUTANEOUS SUSPENSION

3

RELION NOVOLIN R INJECTION SOLUTION

3

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN

2

MISCELLANEOUS HORMONES

ANADROL-50 ORAL TABLET

3

cabergoline oral tablet

1


50

Drug Name Drug Tier


calcitonin (salmon) nasal spray,non-aerosol

1

calcitriol intravenous solution 1 mcg/ml

1 PA

danazol oral capsule 1

desmopressin nasal solution

1 PA

desmopressin nasal spray,non-aerosol

1 PA

desmopressin oral tablet

1 PA

doxercalciferol oral capsule

1

METHITEST ORAL TABLET

2 PA

methyltestosterone oral capsule

1 PA

oxandrolone oral tablet

1

paricalcitol intravenous solution

1 PA

paricalcitol oral capsule

1

SENSIPAR ORAL TABLET

2 PA

SYNAREL NASAL SPRAY,NON-AEROSOL

3 PA

testosterone cypionate intramuscular oil

1 PA

testosterone enanthate intramuscular oil

1 PA

Drug Name Drug Tier


testosterone transdermal gel

1 PA

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

1 PA

testosterone transdermal gel in packet

1 PA

testosterone transdermal solution in metered pump w/app

1 PA

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose oral tablet 1

AVANDIA ORAL TABLET 2 MG, 4 MG

2

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

2 PA

BYDUREON SUBCUTANEOUS PEN INJECTOR

2 PA

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

2 PA

BYETTA SUBCUTANEOUS PEN INJECTOR

2 PA

chlorpropamide oral tablet

1

CYCLOSET ORAL TABLET

3


51

Drug Name Drug Tier


FARXIGA ORAL TABLET

2 ST

glimepiride oral tablet

1

glipizide oral tablet 1

glipizide oral tablet extended release 24hr

1

glipizide-metformin oral tablet

1

glyburide micronized oral tablet

1

glyburide oral tablet 1

glyburide-metformin oral tablet

1

GLYXAMBI ORAL TABLET

2 ST

INVOKAMET ORAL TABLET

3 ST

INVOKANA ORAL TABLET

3 ST

JANUMET ORAL TABLET

2 ST

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

2 ST

JANUVIA ORAL TABLET

2 ST

JARDIANCE ORAL TABLET

2 ST

JENTADUETO ORAL TABLET

2 ST

Drug Name Drug Tier


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

2 ST

metformin oral tablet

1

metformin oral tablet extended release 24 hr

1

metformin oral tablet extended release 24hr

1

metformin oral tablet,er gast.retention 24 hr

1

miglitol oral tablet 1

nateglinide oral tablet

1

NESINA ORAL TABLET

3 ST

ONGLYZA ORAL TABLET

3 ST

pioglitazone oral tablet

1

pioglitazone-glimepiride oral tablet

1

pioglitazone-metformin oral tablet

1

repaglinide oral tablet

1

repaglinide-metformin oral tablet

1

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

2 PA


52

Drug Name Drug Tier


SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

2 PA

SYNJARDY ORAL TABLET

2 ST

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR

2 ST

TANZEUM SUBCUTANEOUS PEN INJECTOR

3 PA

tolazamide oral tablet

1

tolbutamide oral tablet

1

TRADJENTA ORAL TABLET

2 PA; ST

TRULICITY SUBCUTANEOUS PEN INJECTOR

2 PA

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

3 PA

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

3 PA

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

2 ST

THYROID HORMONES

ARMOUR THYROID ORAL TABLET

2

levothyroxine oral tablet

1

Drug Name Drug Tier


levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine oral tablet

1

nature-throid oral tablet

1

np thyroid oral tablet

1

thyroid (pork) oral tablet 120 mg, 15 mg

2

thyroid (pork) oral tablet 30 mg, 60 mg, 90 mg

1

THYROLAR-1 ORAL TABLET

3

THYROLAR-1/2 ORAL TABLET

3

THYROLAR-1/4 ORAL TABLET

3


3


3

unithroid oral tablet 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

1

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz oral tablet,disintegrating

1


53

Drug Name Drug Tier


belladonna alkaloids-opium rectal suppository

1 ST

belladonna-opium rectal suppository

1 ST

chlordiazepoxide-clidinium oral capsule

1

dicyclomine oral capsule

1

dicyclomine oral solution

1

dicyclomine oral tablet

1

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet

1

ed-spaz oral tablet,disintegrating

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

hyoscyamine sulfate oral drops

1

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet extended release 12 hr

1

hyoscyamine sulfate oral tablet,disintegrating

1

hyoscyamine sulfate sublingual tablet

1

hyosyne oral drops 1

Drug Name Drug Tier


hyosyne oral elixir 1

loperamide oral capsule

1

methscopolamine oral tablet

1

MOTOFEN ORAL TABLET

3

opium tincture oral tincture

1

oscimin oral tablet 1

oscimin oral tablet,disintegrating

1

oscimin sl sublingual tablet

1

oscimin sr oral tablet extended release 12 hr

1

paregoric oral liquid 1

phenobarb-hyoscy-atropine-scop oral tablet

1

phenohytro oral tablet

1

symax fastabs oral tablet,disintegrating

1

symax-sl sublingual tablet

1

symax-sr oral tablet extended release 12 hr

1

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO ORAL CAPSULE

2


54

Drug Name Drug Tier


alophen oral tablet,delayed release (dr/ec)

1 OTC

alosetron oral tablet 1

AMITIZA ORAL CAPSULE

2

anucort-hc rectal suppository

1

ANZEMET ORAL TABLET

3

aprepitant oral capsule

1

aprepitant oral capsule,dose pack

1

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

2

balsalazide oral capsule

1

bisacodyl oral tablet,delayed release (dr/ec)

1 OTC

bisa-lax oral tablet,delayed release (dr/ec)

1 OTC

budesonide oral capsule,delayed,extend.release

1

calcium acetate oral capsule

1

calcium acetate oral tablet 667 mg

1

CANASA RECTAL SUPPOSITORY

2

CESAMET ORAL CAPSULE

3

Drug Name Drug Tier


CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

3 PA; LA

CIMZIA SUBCUTANEOUS SYRINGE KIT

3 PA; LA

citrate of magnesia oral solution

1 OTC

citroma oral solution 1 OTC

clearlax oral powder 1 OTC

clearlax oral powder in packet

1 OTC

colocort rectal enema

1

compro rectal suppository

1

CORTIFOAM RECTAL FOAM

2

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

cromolyn oral concentrate

1

DIPENTUM ORAL CAPSULE

3

dronabinol oral capsule

1

ducodyl oral tablet,delayed release (dr/ec)

1 OTC

eliphos oral tablet 1

EMEND ORAL SUSPENSION FOR RECONSTITUTION

2


55

Drug Name Drug Tier


fleet laxative oral tablet,delayed release (dr/ec)

1 OTC

FOSRENOL ORAL POWDER IN PACKET

3

gavilax oral powder 1 OTC

gavilyte-c oral recon soln

1

gavilyte-g oral recon soln

1

gavilyte-n oral recon soln

1

gentle laxative oral tablet,delayed release (dr/ec)

1 OTC

gentlelax oral powder

1 OTC

glycolax oral powder

1 OTC

granisetron hcl oral tablet

1

healthylax oral powder in packet

1 OTC

hemmorex-hc rectal suppository

1

hydrocortisone acetate rectal suppository

1

hydrocortisone rectal enema

1

hydrocortisone topical cream with perineal applicator

1

hydrocortisone-pramoxine rectal cream

1

Drug Name Drug Tier


kionex (with sorbitol) oral suspension

1

kionex oral powder 1

lanthanum oral tablet,chewable

1

laxaclear oral powder

1 OTC

laxative (bisacodyl) oral tablet

1 OTC

laxative (bisacodyl) oral tablet,delayed release (dr/ec)

1 OTC

laxative feminine oral tablet

1 OTC

laxative peg 3350 oral powder

1 OTC

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

lidocaine hcl-hydrocortison ac rectal kit

1

lidocaine-hydrocortisone-aloe rectal gel

1

lidocaine-hydrocortisone-aloe rectal kit

1

LINZESS ORAL CAPSULE

2

magnesium citrate oral solution

1 OTC

meclizine oral tablet 12.5 mg, 25 mg

1


56

Drug Name Drug Tier


mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

1

mesalamine rectal enema

1

mesalamine with cleansing wipe rectal enema kit

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet,disintegrating

1

milk of magnesia concentrated oral suspension

1 OTC

milk of magnesia oral suspension

1 OTC

miralax oral powder in packet

1 OTC

MOVANTIK ORAL TABLET

2

MOVIPREP ORAL POWDER IN PACKET

3

natura-lax oral powder

1 OTC

ondansetron hcl oral solution

1

ondansetron hcl oral tablet

1

ondansetron oral tablet,disintegrating

1

oral saline laxative oral liquid

1 OTC

Drug Name Drug Tier


OSMOPREP ORAL TABLET

3 ACA

peg 3350-electrolytes oral recon soln

1

peg3350 oral powder

1 OTC

peg-electrolyte soln oral recon soln

1

peg-prep oral kit 1

PENTASA ORAL CAPSULE, EXTENDED RELEASE

2

PHOSLYRA ORAL SOLUTION

2

phosphate laxative oral liquid

1 OTC

polyethylene glycol 3350 oral powder

1

polyethylene glycol 3350 oral powder in packet

1

powderlax oral powder

1 OTC

pramcort rectal cream

1

PREPOPIK ORAL POWDER IN PACKET

3 ACA

prochlorperazine maleate oral tablet

1

prochlorperazine rectal suppository

1

procto-med hc topical cream with perineal applicator

1


57

Drug Name Drug Tier


procto-pak topical cream with perineal applicator

1

proctosol hc topical cream with perineal applicator

1

proctozone-hc topical cream with perineal applicator

1

purelax oral powder 1 OTC

purelax oral powder in packet

1 OTC

RECTIV RECTAL OINTMENT

2

RELISTOR SUBCUTANEOUS SOLUTION

2 PA

RELISTOR SUBCUTANEOUS SYRINGE

2 PA

scopolamine base transdermal patch 3 day

1

sevelamer carbonate oral powder in packet

1

sevelamer carbonate oral tablet

1

smoothlax oral powder

1 OTC

smoothlax oral powder in packet

1 OTC

sodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension

1

Drug Name Drug Tier


sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

sps (with sorbitol) oral suspension

1

sps (with sorbitol) rectal enema

1

sulfasalazine oral tablet

1

sulfasalazine oral tablet,delayed release (dr/ec)

1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

3

trilyte with flavor packets oral recon soln

1

trimethobenzamide oral capsule

1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

2

ursodiol oral capsule

1

ursodiol oral tablet 1

VARUBI ORAL TABLET

2

VELPHORO ORAL TABLET,CHEWABLE

2

VELTASSA ORAL POWDER IN PACKET

2 LA

VIBERZI ORAL TABLET

2


58

Drug Name Drug Tier


VIOKACE ORAL TABLET

2

woman's laxative oral tablet,delayed release (dr/ec)

1 OTC

women's gentle laxative(bisac) oral tablet,delayed release (dr/ec)

1 OTC

women's laxative (bisacodyl) oral tablet

1 OTC

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 5,000-17,000 -27,000 UNIT

3

ULCER THERAPY

amoxicil-clarithromy-lansopraz oral combo pack

1

CARAFATE ORAL SUSPENSION

2

cimetidine hcl oral solution

1

cimetidine oral tablet

1

Drug Name Drug Tier


DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

3 QL

esomeprazole magnesium oral capsule,delayed release(dr/ec)

1 QL

famotidine oral suspension

1

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule,delayed release(dr/ec)

1 QL

misoprostol oral tablet

1

NEXIUM 24HR ORAL TABLET,DELAYED RELEASE (DR/EC)

2 OTC; QL

nizatidine oral capsule

1

nizatidine oral solution

1

omeppi oral capsule 1 QL

omeprazole magnesium oral capsule,delayed release(dr/ec)

1 OTC

omeprazole oral capsule,delayed release(dr/ec)

1 QL

omeprazole oral tablet,delayed release (dr/ec)

1 OTC; QL


59

Drug Name Drug Tier


omeprazole-sodium bicarbonate oral capsule

1 QL

omeprazole-sodium bicarbonate oral packet

1 QL

pantoprazole oral tablet,delayed release (dr/ec)

1 QL

PREVACID 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2 OTC; QL

PRILOSEC OTC ORAL TABLET,DELAYED RELEASE (DR/EC)

2 OTC; QL

rabeprazole oral tablet,delayed release (dr/ec)

1 QL

ranitidine hcl oral capsule

1

ranitidine hcl oral syrup

1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral tablet 1

ZEGERID OTC ORAL CAPSULE

2 OTC; QL

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Drug Name Drug Tier


ARANESP (IN POLYSORBATE) INJECTION SOLUTION

3 PA; LA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

3 PA; LA

INTERFERONS

AUBAGIO ORAL TABLET

3 PA; LA

INTERLEUKINS

ALFERON N INJECTION SOLUTION

2 PA

imiquimod topical cream in packet

1

KINERET SUBCUTANEOUS SYRINGE

3 PA; LA

VACCINES & MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

3 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

2 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

2 ACA

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2


60

Drug Name Drug Tier


AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

2

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

2

BEXSERO INTRAMUSCULAR SYRINGE

2 ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION

2 ACA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

2 ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

2 ACA

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

2 ACA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

2 ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

2 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

2 ACA

Drug Name Drug Tier


FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

2

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

2

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

2

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

2

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2


61

Drug Name Drug Tier


FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

2

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

2

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

2

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

2

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

2

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

2

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

2

GAMMAGARD LIQUID INJECTION SOLUTION

2

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

2 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

2 ACA

Drug Name Drug Tier


GRASTEK SUBLINGUAL TABLET

2

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

2 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE

2 ACA

HIBERIX (PF) INTRAMUSCULAR RECON SOLN

2 ACA

HYQVIA SUBCUTANEOUS SOLUTION

3 PA; LA

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

2 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

2 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

2 ACA

IPOL INJECTION SUSPENSION

2 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE

2 ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE

3 ACA


62

Drug Name Drug Tier


MENACTRA (PF) INTRAMUSCULAR SOLUTION

2 ACA

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

2 ACA

ODACTRA SUBLINGUAL TABLET

2

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3 ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

2 ACA

PENTACEL (PF) INTRAMUSCULAR KIT

3 ACA

PNEUMOVAX 23 INJECTION SOLUTION

2 ACA

PNEUMOVAX 23 INJECTION SYRINGE

2 ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

2 ACA

PRIVIGEN INTRAVENOUS SOLUTION

2

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2 ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

2 ACA

Drug Name Drug Tier


RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

2 ACA

RAGWITEK SUBLINGUAL TABLET

2

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

2 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

2 ACA

ROTATEQ VACCINE ORAL SOLUTION

2 ACA

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

2

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

3 ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 ACA


63

Drug Name Drug Tier


TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

2 ACA

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

2 ACA

TRUMENBA INTRAMUSCULAR SYRINGE

2 ACA

TWINRIX (PF) INTRAMUSCULAR SYRINGE

2 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION

2 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE

2 ACA

VAQTA (PF) INTRAMUSCULAR SUSPENSION

3 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE

3 ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2 ACA

VARIZIG INTRAMUSCULAR RECON SOLN

2

VARIZIG INTRAMUSCULAR SOLUTION

2

Drug Name Drug Tier


VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION

2 ACA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2 ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2 ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2 ACA

MUSCULOSKELETAL & RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet

1

COLCRYS ORAL TABLET

2

MITIGARE ORAL CAPSULE

2

probenecid oral tablet

1

probenecid-colchicine oral tablet

1

ULORIC ORAL TABLET

2

OSTEOPOROSIS THERAPY

alendronate oral solution

1


64

Drug Name Drug Tier


alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1

FORTEO SUBCUTANEOUS PEN INJECTOR

3 PA; LA

FOSAMAX PLUS D ORAL TABLET

3

ibandronate oral tablet

1

raloxifene oral tablet 1 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg

1

risedronate oral tablet,delayed release (dr/ec)

1

TYMLOS SUBCUTANEOUS PEN INJECTOR

2 PA

OTHER RHEUMATOLOGICALS

DEPEN TITRATABS ORAL TABLET

2

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

2

leflunomide oral tablet

1

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

3 PA; LA

Drug Name Drug Tier


ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML

3 PA

RIDAURA ORAL CAPSULE

2

SAVELLA ORAL TABLET

2

SAVELLA ORAL TABLETS,DOSE PACK

2

SIMPONI ARIA INTRAVENOUS SOLUTION

3 PA; LA

SIMPONI SUBCUTANEOUS PEN INJECTOR

3 PA; LA

SIMPONI SUBCUTANEOUS SYRINGE

3 PA; LA

XELJANZ ORAL TABLET

3 PA; LA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

3 PA; LA

OBSTETRICS & GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED VAGINAL DIAPHRAGM

2

FEMCAP VAGINAL DEVICE 22 MM

2


65

Drug Name Drug Tier


MIRENA INTRAUTERINE INTRAUTERINE DEVICE

2 PA; LA

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE

2 PA; LA

WIDE-SEAL DIAPHRAGM

3

ESTROGENS & PROGESTINS

amabelz oral tablet 1

camila oral tablet 1 ACA

covaryx h.s. oral tablet

1

covaryx oral tablet 1

CRINONE VAGINAL GEL 4 %

2

deblitane oral tablet 1 ACA

DUAVEE ORAL TABLET

3

eemt hs oral tablet 1

eemt oral tablet 1

errin oral tablet 1 ACA

estradiol oral tablet 1

estradiol transdermal patch semiweekly

1

estradiol transdermal patch weekly

1

estradiol vaginal cream

1

Drug Name Drug Tier


estradiol vaginal tablet

1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

1 PA

estradiol-norethindrone acet oral tablet

1

estrogens-methyltestosterone oral tablet

1

estropipate oral tablet

1

fyavolv oral tablet 1

heather oral tablet 1 ACA

hydroxyprogesterone caproate intramuscular oil

1 PA

jencycla oral tablet 1 ACA

jevantique lo oral tablet

1

jinteli oral tablet 1

jolivette oral tablet 1 ACA

lopreeza oral tablet 1

lyza oral tablet 1 ACA

medroxyprogesterone intramuscular suspension

1 ACA

medroxyprogesterone intramuscular syringe

1 ACA

medroxyprogesterone oral tablet

1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

2


66

Drug Name Drug Tier


mimvey lo oral tablet

1

mimvey oral tablet 1

nora-be oral tablet 1 ACA

norethindrone (contraceptive) oral tablet

1 ACA

norethindrone acetate oral tablet

1

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

norlyda oral tablet 1

norlyroc oral tablet 1 ACA

PREMARIN ORAL TABLET

3

PREMARIN VAGINAL CREAM

3

progesterone micronized oral capsule

1

sharobel oral tablet 1 ACA

yuvafem vaginal tablet

1

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal cream

1

fem ph vaginal gel 1

GYNAZOLE-1 VAGINAL CREAM

3

isoxsuprine oral tablet

1

Drug Name Drug Tier


LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

3 PA; LA

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

3 PA; LA

metronidazole vaginal gel

1

miconazole-3 vaginal suppository

1

NEXPLANON SUBDERMAL IMPLANT

2 PA; LA

NUVARING VAGINAL RING

2

OSPHENA ORAL TABLET

3

terconazole vaginal cream

1

terconazole vaginal suppository

1

tranexamic acid oral tablet

1

vandazole vaginal gel

1

xulane transdermal patch weekly

1

ORAL CONTRACEPTIVES & RELATED AGENTS

altavera (28) oral tablet

1 ACA

alyacen 1/35 (28) oral tablet

1 ACA

alyacen 7/7/7 (28) oral tablet

1 ACA


67

Drug Name Drug Tier


amethia lo oral tablets,dose pack,3 month

1 ACA

amethia oral tablets,dose pack,3 month

1 ACA

amethyst oral tablet 1 ACA

apri oral tablet 1 ACA

aranelle (28) oral tablet

1 ACA

ashlyna oral tablets,dose pack,3 month

1 ACA

aubra oral tablet 1 ACA

aviane oral tablet 1 ACA

azurette (28) oral tablet

1 ACA

balziva (28) oral tablet

1 ACA

bekyree (28) oral tablet

1 ACA

blisovi 24 fe oral tablet

1 ACA

blisovi fe 1.5/30 (28) oral tablet

1 ACA

blisovi fe 1/20 (28) oral tablet

1 ACA

briellyn oral tablet 1 ACA

camrese lo oral tablets,dose pack,3 month

1 ACA

camrese oral tablets,dose pack,3 month

1 ACA

caziant (28) oral tablet

1 ACA

Drug Name Drug Tier


chateal oral tablet 1 ACA

cryselle (28) oral tablet

1 ACA

cyclafem 1/35 (28) oral tablet

1 ACA

cyclafem 7/7/7 (28) oral tablet

1 ACA

cyred oral tablet 1 ACA

dasetta 1/35 (28) oral tablet

1 ACA

dasetta 7/7/7 (28) oral tablet

1 ACA

daysee oral tablets,dose pack,3 month

1 ACA

delyla (28) oral tablet

1 ACA

desog-e.estradiol/e.estradiol oral tablet

1 ACA

desogestrel-ethinyl estradiol oral tablet

1

drospirenone-e.estradiol-lm.fa oral tablet

1 ACA

drospirenone-ethinyl estradiol oral tablet

1 ACA

econtra ez oral tablet

1 ACA; OTC

elinest oral tablet 1 ACA

ELLA ORAL TABLET

2 ACA

emoquette oral tablet

1 ACA

enpresse oral tablet 1 ACA

enskyce oral tablet 1 ACA


68

Drug Name Drug Tier


estarylla oral tablet 1 ACA

ethynodiol diac-eth estradiol oral tablet

1

falmina (28) oral tablet

1 ACA

fayosim oral tablets,dose pack,3 month

1

femynor oral tablet 1 ACA

gianvi (28) oral tablet

1 ACA

introvale oral tablets,dose pack,3 month

1 ACA

isibloom oral tablet 1

jolessa oral tablets,dose pack,3 month

1 ACA

juleber oral tablet 1 ACA

junel 1.5/30 (21) oral tablet

1 ACA

junel 1/20 (21) oral tablet

1 ACA

junel fe 1.5/30 (28) oral tablet

1 ACA

junel fe 1/20 (28) oral tablet

1 ACA

junel fe 24 oral tablet

1 ACA

kaitlib fe oral tablet,chewable

1 ACA

kariva (28) oral tablet

1 ACA

kelnor 1/35 (28) oral tablet

1 ACA

Drug Name Drug Tier


kimidess (28) oral tablet

1 ACA

kurvelo oral tablet 1 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

1 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

1

larin 1.5/30 (21) oral tablet

1 ACA

larin 1/20 (21) oral tablet

1 ACA

larin 24 fe oral tablet

1 ACA

larin fe 1.5/30 (28) oral tablet

1 ACA

larin fe 1/20 (28) oral tablet

1 ACA

larissia oral tablet 1 ACA

layolis fe oral tablet,chewable

1 ACA

leena 28 oral tablet 1 ACA

lessina oral tablet 1 ACA

levonest (28) oral tablet

1 ACA

levonorgestrel-ethinyl estrad oral tablet

1 ACA


69

Drug Name Drug Tier


levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1 ACA

levonorg-eth estrad triphasic oral tablet

1 ACA

levora-28 oral tablet 1 ACA

lillow oral tablet 1

loryna (28) oral tablet

1 ACA

low-ogestrel (28) oral tablet

1 ACA

lutera (28) oral tablet

1 ACA

marlissa oral tablet 1 ACA

melodetta 24 fe oral tablet,chewable

1

mibelas 24 fe oral tablet,chewable

1

microgestin 1.5/30 (21) oral tablet

1 ACA

microgestin 1/20 (21) oral tablet

1 ACA

microgestin fe 1.5/30 (28) oral tablet

1 ACA

microgestin fe 1/20 (28) oral tablet

1 ACA

mono-linyah oral tablet

1 ACA

mononessa (28) oral tablet

1 ACA

my choice oral tablet 1 OTC

my way oral tablet 1 ACA; OTC

myzilra oral tablet 1 ACA

necon 0.5/35 (28) oral tablet

1 ACA

Drug Name Drug Tier


necon 7/7/7 (28) oral tablet

1 ACA

next choice one dose oral tablet

1 ACA; OTC

nikki (28) oral tablet 1 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable

1 ACA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

1 ACA

norethindrone-e.estradiol-iron oral tablet

1 ACA

norethindrone-e.estradiol-iron oral tablet,chewable

1

norgestimate-ethinyl estradiol oral tablet

1 ACA

nortrel 0.5/35 (28) oral tablet

1 ACA

nortrel 1/35 (21) oral tablet

1 ACA

nortrel 1/35 (28) oral tablet

1 ACA

nortrel 7/7/7 (28) oral tablet

1 ACA

ocella oral tablet 1 ACA

ogestrel (28) oral tablet

1 ACA

opcicon one-step oral tablet

1 ACA; OTC

option-2 oral tablet 1 OTC

orsythia oral tablet 1 ACA

philith oral tablet 1 ACA


70

Drug Name Drug Tier


pimtrea (28) oral tablet

1 ACA

pirmella oral tablet 1 ACA

PLAN B ONE-STEP ORAL TABLET

2 ACA; OTC

portia oral tablet 1 ACA

previfem oral tablet 1 ACA

quasense oral tablets,dose pack,3 month

1 ACA

rajani oral tablet 1 ACA

reclipsen (28) oral tablet

1 ACA

rivelsa oral tablets,dose pack,3 month

1

setlakin oral tablets,dose pack,3 month

1 ACA

sprintec (28) oral tablet

1 ACA

sronyx oral tablet 1 ACA

syeda oral tablet 1 ACA

tarina fe 1/20 (28) oral tablet

1 ACA

tilia fe oral tablet 1 ACA

tri femynor oral tablet

1

tri-estarylla oral tablet

1 ACA

tri-legest fe oral tablet

1 ACA

tri-linyah oral tablet 1 ACA

tri-lo-estarylla oral tablet

1 ACA

Drug Name Drug Tier


tri-lo-marzia oral tablet

1 ACA

tri-lo-sprintec oral tablet

1 ACA

trinessa (28) oral tablet

1 ACA

trinessa lo oral tablet

1 ACA

tri-previfem (28) oral tablet

1 ACA

tri-sprintec (28) oral tablet

1 ACA

trivora (28) oral tablet

1 ACA

tri-vylibra oral tablet

1

velivet triphasic regimen (28) oral tablet

1 ACA

vestura (28) oral tablet

1 ACA

vienva oral tablet 1 ACA

viorele (28) oral tablet

1 ACA

vyfemla (28) oral tablet

1 ACA

vylibra oral tablet 1

wera (28) oral tablet 1 ACA

wymzya fe oral tablet,chewable

1 ACA

zarah oral tablet 1 ACA

zenchent (28) oral tablet

1 ACA

zovia 1/35e (28) oral tablet

1 ACA


71

Drug Name Drug Tier


zovia 1/50e (28) oral tablet

1 ACA

OXYTOCICS

methergine oral tablet

1

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE OPHTHALMIC (EYE) DROPS

3

bacitracin ophthalmic (eye) ointment

1

bacitracin-polymyxin b ophthalmic (eye) ointment

1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

3

ciprofloxacin hcl ophthalmic (eye) drops

1

erythromycin ophthalmic (eye) ointment

1

gatifloxacin ophthalmic (eye) drops

1

gentak ophthalmic (eye) ointment

1

gentamicin ophthalmic (eye) drops

1

Drug Name Drug Tier


gentamicin ophthalmic (eye) ointment

1

levofloxacin ophthalmic (eye) drops

1

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS

3

moxifloxacin ophthalmic (eye) drops

1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

2

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

1

neo-polycin ophthalmic (eye) ointment

1

ofloxacin ophthalmic (eye) drops

1

polycin ophthalmic (eye) ointment

1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

1


72

Drug Name Drug Tier


tobramycin ophthalmic (eye) drops

1

ANTIVIRALS

trifluridine ophthalmic (eye) drops

1

ZIRGAN OPHTHALMIC (EYE) GEL

3

BETA-BLOCKERS

betaxolol ophthalmic (eye) drops

1

carteolol ophthalmic (eye) drops

1

levobunolol ophthalmic (eye) drops 0.5 %

1

metipranolol ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) drops, once daily

1

timolol maleate ophthalmic (eye) gel forming solution

1

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

2

CYCLOPLEGIC MYDRIATICS

Drug Name Drug Tier


atropine ophthalmic (eye) drops

1

atropine ophthalmic (eye) ointment

1

cyclopentolate ophthalmic (eye) drops

1

homatropaire ophthalmic (eye) drops

1

homatropine hbr ophthalmic (eye) drops

1

tropicamide ophthalmic (eye) drops

1

DIRECT ACTING MIOTICS

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

1

MISCELLANEOUS OPHTHALMOLOGICS

acuicyn topical spray,non-aerosol

1

ALOCRIL OPHTHALMIC (EYE) DROPS

3

ALOMIDE OPHTHALMIC (EYE) DROPS

3

altacaine ophthalmic (eye) drops

1

altafluor ophthalmic (eye) drops

1

azelastine ophthalmic (eye) drops

1


73

Drug Name Drug Tier


BEPREVE OPHTHALMIC (EYE) DROPS

3

cromolyn ophthalmic (eye) drops

1

EMADINE OPHTHALMIC (EYE) DROPS

3

epinastine ophthalmic (eye) drops

1

flucaine ophthalmic (eye) drops

1

fluorescein-proparacaine ophthalmic (eye) drops

1

flurox ophthalmic (eye) drops

1

LACRISERT OPHTHALMIC (EYE) INSERT

2

LASTACAFT OPHTHALMIC (EYE) DROPS

3

olopatadine ophthalmic (eye) drops

1

proparacaine ophthalmic (eye) drops

1

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS

2 PA; QL

Drug Name Drug Tier


RESTASIS OPHTHALMIC (EYE) DROPPERETTE

2 PA; QL

tetcaine ophthalmic (eye) drops

1

tetracaine hcl ophthalmic (eye) drops

1

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac ophthalmic (eye) drops

1

diclofenac sodium ophthalmic (eye) drops

1

flurbiprofen sodium ophthalmic (eye) drops

1

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION

3

ketorolac ophthalmic (eye) drops

1

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

3

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule, extended release

1

acetazolamide oral tablet

1


74

Drug Name Drug Tier


methazolamide oral tablet

1

OTHER GLAUCOMA DRUGS

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

3

bimatoprost ophthalmic (eye) drops

1

COMBIGAN OPHTHALMIC (EYE) DROPS

3

dorzolamide ophthalmic (eye) drops

1

dorzolamide-timolol ophthalmic (eye) drops

1

latanoprost ophthalmic (eye) drops

1

miostat intraocular solution

1

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

3

TRAVATAN Z OPHTHALMIC (EYE) DROPS

3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

3

STEROID-ANTIBIOTIC COMBINATIONS

Drug Name Drug Tier


neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

1

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

1

neo-polycin hc ophthalmic (eye) ointment

1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

1

STEROIDS

dexamethasone sodium phosphate ophthalmic (eye) drops

1

DUREZOL OPHTHALMIC (EYE) DROPS

3

fluorometholone ophthalmic (eye) drops,suspension

1

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

3


75

Drug Name Drug Tier


LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

3

LOTEMAX OPHTHALMIC (EYE) OINTMENT

3

prednisolone acetate ophthalmic (eye) drops,suspension

1

prednisolone sodium phosphate ophthalmic (eye) drops

1

STEROID-SULFONAMIDE COMBINATIONS

sulfacetamide-prednisolone ophthalmic (eye) drops

1

SULFONAMIDES

sulfacetamide sodium ophthalmic (eye) drops

1

sulfacetamide sodium ophthalmic (eye) ointment

1

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

2

apraclonidine ophthalmic (eye) drops

1

brimonidine ophthalmic (eye) drops

1

Drug Name Drug Tier


VASOCONSTRICTOR DECONGESTANTS

phenylephrine hcl ophthalmic (eye) drops

1

RESPIRATORY, ALLERGY, COUGH & COLD

ANTIHISTAMINE & ANTIALLERGENIC AGENTS

adrenalin injection solution

1

carbinoxamine maleate oral liquid

1

carbinoxamine maleate oral tablet

1

cetirizine oral solution 1 mg/ml

1

clemastine oral tablet 2.68 mg

1

cyproheptadine oral syrup

1

cyproheptadine oral tablet

1

desloratadine oral tablet

1

desloratadine oral tablet,disintegrating

1

diphenhydramine hcl oral capsule 50 mg

1

diphenhydramine hcl oral elixir

1

EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML, 0.3 MG/0.3 ML

2


76

Drug Name Drug Tier


epinephrine injection solution

1

epinephrine injection syringe 0.1 mg/ml

1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

2

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

2

hydroxyzine hcl oral solution 10 mg/5 ml

1

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral capsule

1

levocetirizine oral solution

1

levocetirizine oral tablet

1

phenadoz rectal suppository

1

phenergan rectal suppository

1

promethazine oral syrup

1

promethazine oral tablet

1

promethazine rectal suppository

1

promethegan rectal suppository

1

COUGH & COLD THERAPY

benzonatate oral capsule

1

Drug Name Drug Tier


brompheniramine-pseudoeph-dm oral syrup

1

centergy oral drops 1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

1

hydrocodone-cpm-pseudoephed oral solution

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

1

hydrocodone-homatropine oral tablet

1

hydromet oral syrup 1

promethazine vc-codeine oral syrup

1

promethazine-codeine oral syrup

1

promethazine-dm oral syrup

1

promethazine-phenylephrine oral syrup

1

tussigon oral tablet 1

PULMONARY AGENTS

acetylcysteine solution

1

ADCIRCA ORAL TABLET

3 PA; LA

albuterol sulfate inhalation solution for nebulization

1


77

Drug Name Drug Tier


albuterol sulfate oral syrup

1

albuterol sulfate oral tablet

1

albuterol sulfate oral tablet extended release 12 hr

1

ALVESCO INHALATION HFA AEROSOL INHALER

3

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3

ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

3

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

3

ATROVENT HFA INHALATION HFA AEROSOL INHALER

2

Drug Name Drug Tier


BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER

2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

3

BROVANA INHALATION SOLUTION FOR NEBULIZATION

3

budesonide inhalation suspension for nebulization

1

budesonide nasal spray,non-aerosol

1

COMBIVENT RESPIMAT INHALATION MIST

2

cromolyn inhalation solution for nebulization

1

DALIRESP ORAL TABLET

3 PA

DULERA INHALATION HFA AEROSOL INHALER

2

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

1

fluticasone nasal spray,suspension

1


78

Drug Name Drug Tier


FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED

2

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE

2

ipratropium bromide inhalation solution

1

ipratropium-albuterol inhalation solution for nebulization

1

LETAIRIS ORAL TABLET

3 PA; LA

levalbuterol hcl inhalation solution for nebulization

1

metaproterenol oral syrup

1

metaproterenol oral tablet

1

mometasone nasal spray,non-aerosol

1

montelukast oral granules in packet

1

montelukast oral tablet

1

montelukast oral tablet,chewable

1

nebusal inhalation solution for nebulization 3 %

1

Drug Name Drug Tier


PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

2

PROAIR HFA INHALATION HFA AEROSOL INHALER

2

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

2

pulmosal inhalation solution for nebulization

1

QVAR INHALATION AEROSOL

2

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED

2

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

3

sodium chloride inhalation solution for nebulization

1

STRIVERDI RESPIMAT INHALATION MIST

2


79

Drug Name Drug Tier


SYMBICORT INHALATION HFA AEROSOL INHALER

2

terbutaline oral tablet

1

theochron oral tablet extended release 12 hr

1

theophylline oral elixir

1

theophylline oral solution

1

theophylline oral tablet extended release 12 hr

1

theophylline oral tablet extended release 24 hr

1

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE

2

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

2

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

2

zafirlukast oral tablet

1

Drug Name Drug Tier


zileuton oral tablet, er multiphase 12 hr

1

ZYFLO ORAL TABLET

3

UROLOGICALS

ANTICHOLINERGICS & ANTISPASMODICS

darifenacin oral tablet extended release 24 hr

1

flavoxate oral tablet 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

oxybutynin chloride oral syrup

1

oxybutynin chloride oral tablet

1

oxybutynin chloride oral tablet extended release 24hr

1

tolterodine oral capsule,extended release 24hr

1

tolterodine oral tablet

1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

3

trospium oral capsule,extended release 24hr

1

trospium oral tablet 1

VESICARE ORAL TABLET

3


80

Drug Name Drug Tier


BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

alfuzosin oral tablet extended release 24 hr

1

CIALIS ORAL TABLET 2.5 MG, 5 MG

3

dutasteride oral capsule

1

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

1

finasteride oral tablet 5 mg

1

RAPAFLO ORAL CAPSULE

3

tamsulosin oral capsule,extended release 24hr

1

CHOLINERGIC STIMULANTS

bethanechol chloride oral tablet

1

MISCELLANEOUS UROLOGICALS

azuphen mb oral capsule

1

CAVERJECT IMPULSE INTRACAVERNOSAL KIT 20 MCG

2 PA

cytra k crystals oral packet

1

cytra-2 oral solution 1

cytra-3 oral solution 1

cytra-k oral solution 1

Drug Name Drug Tier


ELMIRON ORAL CAPSULE

2

hyolev mb oral tablet

1

hyophen oral tablet 1

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

2

methen-sod phos-meth blue-hyos oral tablet

1

phosphasal oral tablet

1

pot,sodium citrate-citric acid oral solution

1

potassium citrate oral tablet extended release

1

potassium citrate-citric acid oral solution

1

RENACIDIN IRRIGATION SOLUTION 6.602-3.268 GRAM/100 ML

2

sodium citrate-citric acid oral solution

1

tricitrates oral solution

1

uretron d-s oral tablet 81.6-10.8-40.8 mg

1

urimar-t oral tablet 1

urin ds oral tablet 1

uro-458 oral tablet 1


81

Drug Name Drug Tier


urogesic-blue oral tablet

1

uro-mp oral capsule 1

urophen mb oral tablet

1

uryl oral tablet 1

ustell oral capsule 1

utira-c oral tablet 1

vilamit mb oral capsule

1

vilevev mb oral tablet

1

virtrate-2 oral solution

1

virtrate-3 oral solution

1

virtrate-k oral solution

1

URINARY ANESTHETICS

phenazopyridine oral tablet 100 mg, 200 mg

1

VITAMINS, HEMATINICS & ELECTROLYTES

ELECTROLYTES

calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit

1 ACA; OTC

calcium 500 + d oral tablet,chewable

1 ACA; OTC

calcium 500 with d oral tablet

1 ACA; OTC

calcium 600 + d(3) oral capsule

1 ACA; OTC

Drug Name Drug Tier


calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

1 ACA; OTC

calcium 600 with vitamin d3 oral capsule

1 ACA; OTC

calcium 600 with vitamin d3 oral tablet,chewable

1 ACA; OTC

calcium carb and citrate-vitd3 oral tablet extended release

1 ACA; OTC

calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit

1 ACA; OTC

calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit

1 ACA; OTC

calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit

1 OTC


82

Drug Name Drug Tier


calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit

1 ACA; OTC

calcium citrate + d oral tablet

1 ACA; OTC

calcium citrate-vitamin d2 oral tablet

1 ACA; OTC

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit

1 OTC

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit, 250 mg calcium- 200 unit, 315-200 mg-unit, 315-250 mg-unit

1 ACA; OTC

citrus calcium oral tablet

1 ACA; OTC

effer-k oral tablet, effervescent 25 meq

1

hi-cal plus vit d oral tablet

1 ACA; OTC

k-effervescent oral tablet, effervescent

1

klor-con 10 oral tablet extended release

1

klor-con 8 oral tablet extended release

1

klor-con m10 oral tablet,er particles/crystals

1

Drug Name Drug Tier



1


1

klor-con oral packet 1

klor-con sprinkle oral capsule, extended release

1

klor-con/ef oral tablet, effervescent

1

k-phos-neutral oral tablet

1

k-tab oral tablet extended release 8 meq

1

lugols oral solution 1

oysco 500/d oral tablet

1 ACA; OTC

oyster shell + d3 oral tablet

1 ACA; OTC

oyster shell calcium-vit d3 oral tablet

1 ACA; OTC

oystercal-d oral tablet

1 ACA; OTC

phospha 250 neutral oral tablet

1

potassium bicarb and chloride oral tablet, effervescent

1

potassium bicarb-citric acid oral tablet, effervescent

1

potassium chloride oral capsule, extended release

1


83

Drug Name Drug Tier


potassium chloride oral liquid

1

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

strong iodine oral solution

1

virt-phos 250 neutral oral tablet

1

VITAMINS & HEMATINICS

b complex-vitamin b12 oral tablet

1 OTC

b complex-vitamin c-folic acid oral tablet

1 OTC

balanced b-100 complex oral tablet extended release 100 mg

1 OTC

balanced b-100 oral tablet 0.4 mg

1 OTC

balanced b-50 oral tablet

1 OTC

bal-care dha oral combo pack,tablet and cap,dr

1

b-complex with vitamin c oral tablet

1 OTC

calcium pnv oral capsule

1

calcium-folic acid-vitamin d oral wafer

1

Drug Name Drug Tier


cholecalciferol (vitamin d3) oral capsule 1,000 unit

1 ACA; OTC

cholecalciferol (vitamin d3) oral drops 400 unit/ml

1 ACA; OTC

cholecalciferol (vitamin d3) oral tablet 1,000 unit, 400 unit

1 ACA; OTC

cholecalciferol (vitamin d3) oral tablet,chewable 1,000 unit

1 ACA; OTC

classic prenatal oral tablet

1 OTC

c-nate dha oral capsule

1

complete natal dha oral combo pack

1

completenate oral tablet,chewable

1

complex b-100 oral tablet extended release

1 OTC

delta d3 oral tablet 1 ACA; OTC

dialyvite 800 oral tablet

1 OTC

dothelle dha oral capsule

1

d-vi-sol oral drops 1 ACA; OTC

elite-ob oral tablet 1

ergocalciferol (vitamin d2) oral tablet 400 unit

1 ACA; OTC


84

Drug Name Drug Tier


fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg

1 ACA

fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg

1

fluoride (sodium) oral drops

1 ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

1 ACA

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

1 ACA

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

folic acid oral tablet 400 mcg, 800 mcg

1 ACA; OTC

folivane-ob oral capsule

1

foltabs 800 oral tablet

1 OTC

full spectrum b-vitamin c oral tablet

1 OTC

hemenatal ob + dha oral combo pack

1

hemenatal ob oral tablet

1

Drug Name Drug Tier


hydroxocobalamin intramuscular solution

1 PA

kobee oral tablet 1 OTC

kpn oral tablet 1 OTC

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

1 ACA

multi-vitamin with fluoride oral drops

1

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

1

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

1

multivit-fluor (vit e acetate) oral drops

1

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

1

mynatal advance oral tablet

1

mynatal oral capsule 1

mynatal oral tablet 1

mynatal plus oral tablet

1

mynatal-z oral tablet 1

mynate 90 plus oral tablet extended release

1

natural b-100 complex oral tablet

1 OTC


85

Drug Name Drug Tier


newgen oral tablet 1

obstetrix dha oral combo pack,tablet and cap,dr

1

one daily prenatal oral combo pack 28-800-440 mg-mcg-mg

1 OTC

oyster shell calcium-vit d2 oral tablet 250 (625)-125 mg-unit

1 ACA; OTC

perry prenatal oral capsule

1 OTC

pnv 29-1 oral tablet 1

pnv ob+dha oral combo pack 27-1-50-250 mg

1

pnv-dha + docusate oral capsule

1

pnv-dha oral capsule 1

pnv-ferrous fumarate-docu-fa oral tablet

1

pnv-omega oral capsule

1

pnv-select oral tablet 1

pnv-vp-u oral capsule

1

pr natal 400 ec oral combo pack,tablet and cap,dr

1

pr natal 400 oral combo pack

1

pr natal 430 ec oral combo pack,tablet and cap,dr

1

pr natal 430 oral combo pack

1

Drug Name Drug Tier


prena1 chew oral tablet,chew,ir - dr,biphase

1

prena1 pearl oral capsule,ir - delay rel,biphase

1

prena1 true oral combo pack

1

prenaissance oral capsule

1

prenaissance plus oral capsule

1

prenatabs fa oral tablet

1

prenatabs rx oral tablet

1

prenatal complete oral tablet

1 OTC

prenatal formula oral tablet 28 mg iron- 800 mcg

1 OTC

prenatal multi-dha (algal oil) oral capsule

1 OTC

prenatal one daily oral tablet

1 OTC

prenatal oral tablet 28 mg iron- 800 mcg

1 OTC

prenatal plus (calcium carb) oral tablet

1

prenatal plus oral tablet

1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg

1 OTC


86

Drug Name Drug Tier


prenatal vitamin plus low iron oral tablet

1

prenatal vitamin with minerals oral tablet

1 OTC

prenatal vits96-iron fum-folic oral tablet

1 OTC

prenatal-u oral capsule

1

preplus oral tablet 1

pretab oral tablet 1

relnate dha oral capsule

1

rena-vite oral tablet 1 OTC

risacal-d oral tablet 1 ACA; OTC

se-natal 19 (with docusate) oral tablet

1

se-natal 19 oral tablet,chewable

1

stress formula oral tablet

1 OTC

stress formula with iron oral tablet

1 OTC

stress formula with iron(sulf) oral tablet

1 OTC

super b complex-vitamin c oral tablet

1 OTC

super b maxi complex oral tablet

1 OTC

super b-50 complex plus oral tablet

1 OTC

super quints b-50 oral tablet

1 OTC

super quints oral tablet

1 OTC

Drug Name Drug Tier


superplex-t oral tablet

1 OTC

taron-c dha oral capsule

1

taron-prex prenatal-dha oral capsule

1

thrivite-19 oral tablet

1

tl g-fol os oral tablet 1

total b/c oral tablet 1 OTC

trinatal rx 1 oral tablet

1

trinate oral tablet 1

tri-tabs dha oral combo pack

1

triveen-duo dha oral combo pack

1

tri-vitamin with fluoride oral drops

1

trust natal dha oral combo pack

1

ultimatecare one nf oral capsule

1

ultimatecare one oral capsule

1

ultra b-100 complex oral tablet

1 OTC

vemavite-prx-2 oral capsule

1

vinate care oral tablet,chewable

1

vinate ii oral tablet 1

vinate m oral tablet 1

vinate one oral tablet

1


87

Drug Name Drug Tier


virt-advance oral tablet

1

virt-c dha oral capsule

1

virt-nate dha oral capsule

1

virt-nate oral tablet 1

virt-pn dha oral capsule

1

virt-pn oral tablet 1

virt-pn plus oral capsule

1

virt-select oral capsule

1

virt-vite gt oral tablet

1

vit b complex-folic acid oral tablet

1 OTC

vitajoy daily d oral tablet,chewable

1 OTC

vitamin b complex oral tablet

1 OTC

vitamin d3 oral capsule 1,000 unit, 400 unit

1 ACA; OTC

Drug Name Drug Tier


vitamin d3 oral tablet 1,000 unit, 400 unit

1 ACA; OTC

vitamin d3 oral tablet,chewable

1 ACA; OTC

vitamins a,c,d and fluoride oral drops

1

vol-nate oral tablet 1

vol-plus oral tablet 1

vol-tab rx oral tablet 1

vp-ch plus oral capsule

1

vp-ch-pnv oral capsule

1

vp-ggr-b6 oral tablet 1

vp-heme ob oral tablet

1

vp-heme one oral capsule

1

zatean-ch oral capsule

1

zatean-pn dha oral capsule

1

zatean-pn plus oral capsule

1

zingiber oral tablet 1

88

Index A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-

zidovudine .......................... 3 acamprosate .......................... 42 acarbose ................................ 50 ACE AEROSOL CLOUD

ENHANCER .................... 45 acebutolol ............................. 25 acetaminophen-caff-

dihydrocod ........................ 16 acetaminophen-codeine ........ 16 acetazolamide ....................... 73 acetic acid ....................... 42, 44 acetylcysteine ....................... 76 acitretin ................................. 32 ACTHIB (PF) ....................... 59 acuicyn ................................. 72 acyclovir ........................... 3, 39 ADACEL(TDAP

ADOLESN/ADULT)(PF) 59 adapalene ........................ 34, 35 adapalene-benzoyl peroxide . 35 ADCIRCA ............................ 76 ADDYI ................................. 20 adefovir................................... 3 adrenalin ............................... 75 AEROCHAMBER MINI ..... 45 AEROCHAMBER PLUS

FLOW-VU ....................... 45 AEROCHAMBER PLUS Z

STAT SM MSK ............... 45 AEROTRACH PLUS ........... 45 AEROVENT PLUS.............. 45 afeditab cr ............................. 25 AFLURIA 2017-2018 .......... 60 AFLURIA 2017-2018 (PF) .. 59 AFLURIA QUAD 2017-2018

.......................................... 60 AFLURIA QUAD 2017-2018

(PF) ................................... 60 AKYNZEO........................... 53 ala-cort .................................. 39 ALBENZA ............................. 7 albuterol sulfate .............. 76, 77 alclometasone ....................... 39 alendronate ............... 42, 63, 64

ALFERON N ........................ 59 alfuzosin ............................... 80 ALINIA .................................. 7 allopurinol ............................ 63 almotriptan malate ................ 14 ALOCRIL ............................. 72 ALOMIDE............................ 72 alophen ................................. 54 alosetron ............................... 54 ALPHAGAN P ..................... 75 alprazolam ............................ 20 alprazolam intensol............... 20 ALTABAX ........................... 37 altacaine ................................ 72 altafluor ................................ 72 altavera (28) .......................... 66 ALVESCO............................ 77 alyacen 1/35 (28) .................. 66 alyacen 7/7/7 (28) ................. 66 amabelz ................................. 65 amantadine hcl ........................ 3 amcinonide ........................... 39 amethia ................................. 67 amethia lo ............................. 67 amethyst................................ 67 AMICAR .............................. 29 amiloride ............................... 25 amiloride-hydrochlorothiazide

.......................................... 25 amiodarone ........................... 25 AMITIZA ............................. 54 amitriptyline ......................... 20 amitriptyline-chlordiazepoxide

.......................................... 20 amlodipine ............................ 25 amlodipine-atorvastatin ........ 30 amlodipine-benazepril .......... 25 amlodipine-olmesartan ......... 25 amlodipine-valsartan ............ 25 amlodipine-valsartan-hcthiazid

.......................................... 25 ammonium lactate ................ 33 amnesteem ............................ 35 amoxapine ............................ 20 amoxicil-clarithromy-lansopraz

.......................................... 58 amoxicillin .............................. 8 amoxicillin-pot clavulanate 8, 9

ampicillin ................................ 9 ANADROL-50 ..................... 49 anagrelide ............................. 42 anaspaz ................................. 52 anastrozole ............................ 10 anucort-hc ............................. 54 ANZEMET ........................... 54 apexicon e ............................. 39 APIDRA SOLOSTAR U-100

INSULIN .......................... 48 APIDRA U-100 INSULIN ... 48 apraclonidine ........................ 75 aprepitant .............................. 54 apri ........................................ 67 APRISO ................................ 54 APTIOM ............................... 12 APTIVUS ........................... 3, 4 aranelle (28) .......................... 67 ARANESP (IN

POLYSORBATE) ............ 59 ARCAPTA NEOHALER ..... 77 aripiprazole ........................... 20 armodafinil ........................... 20 ARMONAIR RESPICLICK 77 ARMOUR THYROID .......... 52 ascomp with codeine ............ 16 ashlyna .................................. 67 ASMANEX HFA ................. 77 ASMANEX TWISTHALER 77 aspir-81 ................................. 18 aspirin ................................... 18 aspirin low dose .................... 18 aspirin-dipyridamole ............. 29 aspir-low ............................... 18 aspir-trin ............................... 18 atazanavir ................................ 4 atenolol ................................. 25 atenolol-chlorthalidone ......... 25 atomoxetine .......................... 20 atorvastatin ........................... 30 atovaquone .............................. 7 atovaquone-proguanil ............. 7 ATRIPLA ............................... 4 atropine ................................. 72 ATROVENT HFA ................ 77 AUBAGIO ............................ 59 aubra ..................................... 67 AUGMENTIN ........................ 9

89

AUTOJECT 2 INJECTION DEVICE ........................... 46

AUTOPEN 1 TO 21 UNITS 46 AUTOSOFT 30 .................... 46 AUTOSOFT 90 .................... 46 AVANDIA ........................... 50 avar ....................................... 35 AVELOX IN NACL (ISO-

OSMOTIC)......................... 9 aviane ................................... 67 avidoxy ................................... 9 avita ...................................... 35 avo cream ............................. 33 AZASITE ............................. 71 azathioprine .......................... 10 azelastine ........................ 43, 72 AZELEX .............................. 35 azithromycin ........................... 6 AZOPT ................................. 74 azuphen mb .......................... 80 azurette (28).......................... 67 B b complex-vitamin b12......... 83 b complex-vitamin c-folic acid

.......................................... 83 bacitracin .............................. 71 bacitracin-polymyxin b ........ 71 baclofen ................................ 15 balanced b-100 ..................... 83 balanced b-100 complex....... 83 balanced b-50 ....................... 83 bal-care dha .......................... 83 balsalazide ............................ 54 balziva (28) ........................... 67 BANZEL .............................. 12 BARACLUDE ....................... 4 bayer aspirin ......................... 18 b-complex with vitamin c ..... 83 bekyree (28).......................... 67 belladonna alkaloids-opium . 53 belladonna-opium ................. 53 BELSOMRA ........................ 20 benazepril ............................. 25 benazepril-hydrochlorothiazide

.......................................... 25 benzepro ............................... 35 BENZNIDAZOLE ................. 7 benzonatate ........................... 76 benzoyl peroxide .................. 35

benztropine ........................... 13 BEPREVE ............................ 73 BESIVANCE........................ 71 betamethasone dipropionate . 39 betamethasone valerate......... 39 betamethasone, augmented ... 39 betaxolol ......................... 25, 72 bethanechol chloride............. 80 BEVESPI AEROSPHERE ... 77 BEXSERO ............................ 60 bicalutamide ......................... 10 BILTRICIDE .......................... 7 bimatoprost ........................... 74 BIOTHRAX ......................... 60 bisacodyl ............................... 54 bisa-lax ................................. 54 bisoprolol fumarate............... 25 bisoprolol-hydrochlorothiazide

.......................................... 25 blisovi 24 fe .......................... 67 blisovi fe 1.5/30 (28) ............ 67 blisovi fe 1/20 (28) ............... 67 BOOSTRIX TDAP............... 60 BOSULIF ............................. 10 bp 10-1 .................................. 35 bpo ........................................ 35 BREATHERITE MDI

SPACER ........................... 45 BREO ELLIPTA .................. 77 briellyn.................................. 67 BRILINTA ........................... 29 brimonidine .......................... 75 bromfenac ............................. 73 bromocriptine ....................... 13 brompheniramine-pseudoeph-

dm ..................................... 76 BROVANA .......................... 77 budesonide ...................... 54, 77 bumetanide ........................... 25 buprenorphine hcl ................. 16 buprenorphine-naloxone ....... 18 bupropion hcl .................. 20, 21 bupropion hcl (smoking deter)

.......................................... 43 buspirone .............................. 21 butalbital compound w/codeine

.......................................... 16 butalbital-acetaminop-caf-cod

.......................................... 16

butalbital-acetaminophen ..... 16 butalbital-acetaminophen-caff

.......................................... 16 butalbital-aspirin-caffeine ..... 16 butorphanol tartrate .............. 18 BYDUREON ........................ 50 BYDUREON BCISE ............ 50 BYETTA .............................. 50 BYSTOLIC ........................... 25 C cabergoline ........................... 49 CABOMETYX ..................... 10 caffeine citrate ...................... 42 calcipotriene ......................... 32 calcipotriene-betamethasone 32 calcitonin (salmon) ............... 50 calcitrene ............................... 32 calcitriol .......................... 32, 50 calcium 500 + d .................... 81 calcium 500 with d ............... 81 calcium 600 + d(3)................ 81 calcium 600 with vitamin d3 81 calcium acetate ..................... 54 calcium carb and citrate-vitd3

.......................................... 81 calcium carbonate-vitamin d3

.................................... 81, 82 calcium citrate + d ................ 82 calcium citrate-vitamin d2 .... 82 calcium citrate-vitamin d3 .... 82 calcium pnv .......................... 83 calcium-folic acid-vitamin d . 83 camila ................................... 65 camrese ................................. 67 camrese lo ............................. 67 CANASA .............................. 54 candesartan ........................... 25 candesartan-hydrochlorothiazid

.......................................... 26 capacet .................................. 16 captopril ................................ 26 captopril-hydrochlorothiazide

.......................................... 26 CARAFATE ......................... 58 carbamazepine ...................... 12 carbidopa .............................. 14 carbidopa-levodopa .............. 14 carbidopa-levodopa-

entacapone ........................ 14

90

carbinoxamine maleate ......... 75 carisoprodol .......................... 15 carteolol ................................ 72 cartia xt ................................. 26 CARTRIDGE STAMPED IR

1200 .................................. 46 carvedilol .............................. 26 carvedilol phosphate ............. 26 CAVERJECT IMPULSE ..... 80 CAYA CONTOURED ......... 64 caziant (28) ........................... 67 cefaclor ................................... 6 cefadroxil ................................ 6 cefdinir ................................... 6 cefditoren pivoxil ................... 6 cefixime .................................. 6 cefpodoxime ........................... 6 cefprozil .................................. 6 cefuroxime axetil .................... 6 celacyn .................................. 33 celecoxib............................... 18 CELONTIN .......................... 12 cem-urea ............................... 33 centergy ................................ 76 cephalexin............................... 6 CESAMET ........................... 54 cetirizine ............................... 75 cevimeline ............................ 42 CHANTIX ............................ 43 CHANTIX CONTINUING

MONTH BOX .................. 43 CHANTIX STARTING

MONTH BOX .................. 43 chateal................................... 67 CHEMET ............................. 42 children's aspirin ................... 18 chlordiazepoxide hcl ............ 21 chlordiazepoxide-clidinium .. 53 chloroquine phosphate............ 7 chlorothiazide ....................... 26 chlorpromazine ..................... 21 chlorpropamide..................... 50 chlorthalidone ....................... 26 chlorzoxazone....................... 15 cholecalciferol (vitamin d3) . 83 cholestyramine (with sugar) . 30 cholestyramine light ............. 30 choline,magnesium salicylate

.......................................... 18

CIALIS ................................. 80 ciclodan ................................ 38 ciclopirox .............................. 38 ciclopirox-ure-camph-menth-

euc .................................... 38 cidaleaze ............................... 36 cilostazol ............................... 29 cimetidine ............................. 58 cimetidine hcl ....................... 58 CIMZIA ................................ 54 CIMZIA POWDER FOR

RECONST ........................ 54 CIPRO HC ............................ 44 CIPRODEX .......................... 44 ciprofloxacin ........................... 9 ciprofloxacin (mixture)........... 9 ciprofloxacin hcl ......... 9, 44, 71 citalopram ............................. 21 citrate of magnesia................ 54 citroma .................................. 54 citrus calcium ....................... 82 claravis.................................. 35 clarithromycin ........................ 7 classic prenatal ..................... 83 cleansing wash ...................... 35 clearlax ................................. 54 clemastine ............................. 75 CLEO 90 INFUSION SET 24

.......................................... 46 CLEVER CHOICE

CHAMBER-SM MASK... 45 clindacin p ............................ 35 clindamycin hcl ...................... 7 clindamycin palmitate hcl ...... 7 clindamycin pediatric ............. 7 clindamycin phosphate ... 35, 66 clindamycin-benzoyl peroxide

.......................................... 35 clindamycin-tretinoin ........... 35 clobetasol ........................ 39, 40 clobetasol-emollient ............. 40 clodan ................................... 40 CLODERM .......................... 40 clomipramine ........................ 21 clonazepam ........................... 12 clonidine ............................... 26 clonidine hcl ................... 21, 26 clopidogrel ............................ 29 clorazepate dipotassium ....... 21

clorpres ................................. 26 clotrimazole ...................... 3, 38 clotrimazole-betamethasone . 38 clozapine ............................... 21 c-nate dha .............................. 83 COAL TAR .......................... 32 COARTEM ............................. 7 codeine sulfate ...................... 16 COLCRYS ............................ 63 colestipol ............................... 31 colocort ................................. 54 COLY-MYCIN S ................. 44 COMBIGAN ........................ 74 COMBIVENT RESPIMAT .. 77 COMFORT INFUSION SET

43 ...................................... 47 COMFORT SHORT INSULIN

PUMP 23 .......................... 47 COMPACT SPACE

CHAMBER-LRG MASK 45 COMPLERA .......................... 4 complete natal dha ................ 83 completenate ......................... 83 complex b-100 ...................... 83 compro .................................. 54 CONTACT DETACH INFUS

SET 23 .............................. 47 CORLANOR ........................ 31 cormax .................................. 40 CORTIFOAM ....................... 54 cortisone ............................... 44 CORTISPORIN .................... 37 COSENTYX ......................... 32 COSENTYX (2 SYRINGES)

.......................................... 32 COSENTYX PEN ................ 32 COSENTYX PEN (2 PENS) 32 covaryx ................................. 65 covaryx h.s. ........................... 65 CREON ................................. 54 CRESEMBA ........................... 3 CRINONE ............................ 65 CRIXIVAN ............................. 4 cromolyn ................... 54, 73, 77 cryselle (28) .......................... 67 cyclafem 1/35 (28) ................ 67 cyclafem 7/7/7 (28) ............... 67 cyclobenzaprine .................... 15 cyclopentolate ....................... 72

91

CYCLOPHOSPHAMIDE .... 10 CYCLOSERINE .................... 7 CYCLOSET ......................... 50 cyclosporine ......................... 11 cyclosporine modified .......... 10 cyproheptadine ..................... 75 cyred ..................................... 67 cytra k crystals ...................... 80 cytra-2................................... 80 cytra-3................................... 80 cytra-k................................... 80 D DAKLINZA ........................... 4 DALIRESP ........................... 77 danazol ................................. 50 dantrolene ............................. 15 dapsone ............................. 7, 35 DAPTACEL (DTAP

PEDIATRIC) (PF)............ 60 darifenacin ............................ 79 dasetta 1/35 (28) ................... 67 dasetta 7/7/7 (28) .................. 67 daysee ................................... 67 DEBACTEROL ................... 44 deblitane ............................... 65 decadron ............................... 44 delta d3 ................................. 83 deltasone ............................... 44 delyla (28) ............................ 67 demeclocycline ....................... 9 DEMSER .............................. 26 DENAVIR ............................ 39 DEPEN TITRATABS .......... 64 dermacinrx prizopak ............. 36 DESCOVY ............................. 4 desipramine .......................... 21 desloratadine......................... 75 desmopressin ........................ 50 desog-e.estradiol/e.estradiol . 67 desogestrel-ethinyl estradiol . 67 desonide ................................ 40 desoximetasone .................... 40 desvenlafaxine succinate ...... 21 dexamethasone ..................... 44 dexamethasone intensol........ 44 dexamethasone sodium

phosphate .......................... 74 DEXILANT .......................... 58 dexmethylphenidate ............. 21

dextroamphetamine .............. 21 dextroamphetamine-

amphetamine .................... 21 dialyvite 800 ......................... 83 diazepam ......................... 12, 21 diazepam intensol ................. 21 diclofenac potassium ............ 18 diclofenac sodium..... 18, 19, 73 diclofenac-misoprostol ......... 19 dicloxacillin ............................ 9 dicyclomine .......................... 53 didanosine ............................... 4 DIFICID ................................. 7 diflorasone ............................ 40 diflunisal ............................... 19 digitek ................................... 29 digox ..................................... 29 digoxin .................................. 29 dihydroergotamine................ 14 DILANTIN ........................... 12 diltiazem ............................... 26 dilt-xr .................................... 26 DIPENTUM ......................... 54 diphenhydramine hcl ............ 75 diphenoxylate-atropine ......... 53 dipyridamole ......................... 29 diskets ................................... 16 disopyramide phosphate ....... 25 disulfiram.............................. 42 divalproex ............................. 12 dofetilide ............................... 25 donepezil .............................. 15 dorzolamide .......................... 74 dorzolamide-timolol ............. 74 dothelle dha .......................... 83 doxazosin .............................. 26 doxepin ........................... 21, 33 doxercalciferol ...................... 50 doxycycline hyclate ................ 9 doxycycline monohydrate .... 10 drithocreme hp ...................... 32 dronabinol ............................. 54 drospirenone-e.estradiol-lm.fa

.......................................... 67 drospirenone-ethinyl estradiol

.......................................... 67 DROXIA .............................. 11 DUAVEE.............................. 65 ducodyl ................................. 54

DULERA .............................. 77 duloxetine ............................. 21 DUREZOL ........................... 74 dutasteride ............................. 80 dutasteride-tamsulosin .......... 80 d-vi-sol .................................. 83 DYRENIUM ......................... 26 E e.c. prin ................................. 19 e.e.s. 400 ................................. 7 EASIVENT HOLDING

CHAMBER ...................... 45 econazole .............................. 38 econtra ez .............................. 67 ecotrin ................................... 19 ecotrin low strength .............. 19 EDARBI ............................... 26 EDARBYCLOR ................... 26 ed-spaz .................................. 53 EDURANT ............................. 4 eemt ...................................... 65 eemt hs .................................. 65 efavirenz ................................. 4 effer-k ................................... 82 eletone ................................... 33 eletriptan hbr ......................... 14 ELIDEL ................................ 33 elinest .................................... 67 eliphos ................................... 54 ELIQUIS ............................... 29 elite-ob .................................. 83 ELLA .................................... 67 ELMIRON ............................ 80 EMADINE ............................ 73 EMBEDA ............................. 16 EMCYT ................................ 11 EMEND ................................ 54 emoquette ............................. 67 EMSAM ............................... 21 EMTRIVA .............................. 4 emulsion sb ........................... 33 EMVERM ............................... 7 enalapril maleate ................... 26 enalapril-hydrochlorothiazide

.......................................... 26 endocet .................................. 16 ENGERIX-B (PF) ................ 60 ENGERIX-B PEDIATRIC

(PF) ................................... 60

92

enpresse ................................ 67 enskyce ................................. 67 entacapone ............................ 14 entecavir ................................. 4 ENTRESTO ......................... 31 EPIDUO FORTE.................. 35 epinastine .............................. 73 epinephrine ........................... 76 EPINEPHRINE .................... 75 EPIPEN 2-PAK .................... 76 EPIPEN JR 2-PAK ............... 76 epitol ..................................... 12 EPIVIR HBV.......................... 4 eplerenone ............................ 26 eprosartan ............................. 26 ergocalciferol (vitamin d2) ... 83 ergoloid................................. 21 ERGOMAR .......................... 14 ergotamine-caffeine .............. 14 errin ...................................... 65 ERTACZO ........................... 38 ery pads ................................ 35 erygel .................................... 35 ery-tab..................................... 7 erythrocin (as stearate) ........... 7 erythromycin .................... 7, 71 erythromycin ethylsuccinate .. 7 erythromycin with ethanol ... 35 erythromycin-benzoyl peroxide

.......................................... 35 escitalopram oxalate ............. 21 esomeprazole magnesium .... 58 estarylla ................................ 68 estazolam .............................. 21 estradiol ................................ 65 estradiol valerate .................. 65 estradiol-norethindrone acet . 65 estrogens-methyltestosterone 65 estropipate ............................ 65 eszopiclone ........................... 22 ethacrynic acid...................... 26 ethambutol .............................. 7 ethosuximide ........................ 12 ethyl chloride ........................ 37 ethynodiol diac-eth estradiol 68 etidronate disodium .............. 42 etodolac ................................ 19 etoposide............................... 11 EURAX ................................ 41

EXELDERM ........................ 38 exemestane ........................... 11 E-Z SPACER ........................ 45 ezetimibe .............................. 31 ezetimibe-simvastatin ........... 31 F FACTIVE ............................... 9 falmina (28) .......................... 68 famciclovir.............................. 4 famotidine ............................. 58 FANAPT .............................. 22 FARESTON ......................... 11 FARXIGA ............................ 51 fayosim ................................. 68 felbamate .............................. 12 felodipine .............................. 26 fem ph ................................... 66 FEMCAP .............................. 64 femynor ................................ 68 fenofibrate ............................ 31 fenofibrate micronized ......... 31 fenofibrate nanocrystallized . 31 fenofibric acid....................... 31 fenofibric acid (choline) ....... 31 fenoprofen ............................ 19 fentanyl ................................. 16 fentanyl citrate ...................... 16 FETZIMA ............................. 22 finasteride ............................. 80 flavoxate ............................... 79 flecainide .............................. 25 fleet laxative ......................... 55 FLEXICHAMBER ............... 46 floxin .................................... 44 FLUAD 2017-2018 (65 YR

UP)(PF) ............................ 60 FLUARIX QUAD 2017-2018

(PF) ................................... 60 FLUBLOK 2017-2018 (PF) . 60 FLUBLOK QUAD 2017-2018

(PF) ................................... 60 flucaine ................................. 73 FLUCELVAX QUAD 2017-

2018 .................................. 60 FLUCELVAX QUAD 2017-

2018 (PF) .......................... 60 fluconazole ............................. 3 flucytosine .............................. 3 fludrocortisone...................... 44

FLULAVAL QUAD 2017-2018 .................................. 60

FLULAVAL QUAD 2017-2018 (PF) .......................... 60

flunisolide ............................. 77 fluocinolone .......................... 40 fluocinolone acetonide oil .... 44 fluocinolone and shower cap 40 fluocinonide .......................... 40 fluocinonide-emollient ......... 40 fluor-a-day (with xylitol) ...... 84 fluorescein-proparacaine ...... 73 fluoride (sodium) .................. 84 fluoritab ................................ 84 fluorometholone ................... 74 fluorouracil ........................... 33 fluoxetine .............................. 22 fluphenazine hcl .................... 22 flurandrenolide ..................... 40 flurazepam ............................ 22 flurbiprofen ........................... 19 flurbiprofen sodium .............. 73 flurox .................................... 73 flutamide ............................... 11 fluticasone ....................... 40, 77 FLUTICASONE-

SALMETEROL ................ 78 fluvastatin ............................. 31 FLUVIRIN 2017-2018 ......... 61 FLUVIRIN 2017-2018 (PF) . 60 fluvoxamine .......................... 22 FLUZONE HIGH-DOSE

2017-18 (PF) ..................... 61 FLUZONE INTRADERM

QUAD 2017-18 ................ 61 FLUZONE QUAD 2017-2018

.......................................... 61 FLUZONE QUAD 2017-2018

(PF) ................................... 61 FLUZONE QUAD PEDI

2017-18 (PF) ..................... 61 folic acid ............................... 84 folivane-ob ............................ 84 foltabs 800 ............................ 84 FORTEO ............................... 64 FOSAMAX PLUS D ............ 64 fosamprenavir ......................... 4 fosinopril ............................... 26

93

fosinopril-hydrochlorothiazide .......................................... 26

FOSRENOL ......................... 55 FRAGMIN ........................... 29 frovatriptan ........................... 14 full spectrum b-vitamin c ..... 84 furosemide ............................ 27 FUZEON ................................ 4 fyavolv .................................. 65 FYCOMPA .......................... 12 G gabapentin ............................ 12 GABITRIL ........................... 12 galantamine .......................... 15 GAMMAGARD LIQUID .... 61 GARDASIL 9 (PF)............... 61 gatifloxacin ........................... 71 gavilax .................................. 55 gavilyte-c .............................. 55 gavilyte-g .............................. 55 gavilyte-n .............................. 55 gemfibrozil ........................... 31 gengraf .................................. 11 gentak ................................... 71 gentamicin ...................... 37, 71 gentle laxative ...................... 55 gentlelax ............................... 55 GENVOYA ............................ 4 gianvi (28) ............................ 68 GLEOSTINE ........................ 11 glimepiride ........................... 51 glipizide ................................ 51 glipizide-metformin .............. 51 GLUCAGEN HYPOKIT ..... 46 GLUCAGON EMERGENCY

KIT (HUMAN) ................ 46 glyburide............................... 51 glyburide micronized............ 51 glyburide-metformin ............ 51 glycolax ................................ 55 glycopyrrolate....................... 53 glydo ..................................... 37 GLYXAMBI ........................ 51 granisetron hcl ...................... 55 GRASTEK ........................... 61 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guanfacine ...................... 22, 27 guanidine .............................. 22

GYNAZOLE-1 ..................... 66 H halobetasol propionate .......... 40 HALOG .......................... 40, 41 haloperidol ............................ 22 haloperidol lactate ................ 22 HAVRIX (PF) ...................... 61 healthylax ............................. 55 heather .................................. 65 HEMANGEOL ..................... 27 hemenatal ob......................... 84 hemenatal ob + dha .............. 84 hemmorex-hc ........................ 55 hep flush-10 (pf) ................... 29 heparin (porcine) .................. 29 heparin (porcine) in 5 % dex 29 heparin (porcine) in nacl (pf) 29 heparin flush(porcine)-0.9nacl

.......................................... 30 heparin lock flush ................. 30 heparin lock flush (porcine) . 30 heparin lockflush(porcine)(pf)

.......................................... 30 heparin(porcine) in 0.45% nacl

.......................................... 30 heparin, porcine (pf) ............. 30 HEXALEN ........................... 11 HIBERIX (PF) ...................... 61 hi-cal plus vit d ..................... 82 homatropaire ......................... 72 homatropine hbr ................... 72 hpr ......................................... 34 hpr plus ................................. 34 hpr plus hydrogel .................. 34 HUMALOG JUNIOR

KWIKPEN U-100 ............ 48 HUMALOG KWIKPEN

INSULIN .......................... 48 HUMALOG MIX 50-50

INSULN U-100 ................ 48 HUMALOG MIX 50-50

KWIKPEN........................ 48 HUMALOG MIX 75-25

KWIKPEN........................ 48 HUMALOG MIX 75-25(U-

100)INSULN .................... 48 HUMALOG U-100 INSULIN

.......................................... 48 HUMAPEN LUXURA HD .. 47

HUMIRA PEN PSORIASIS-UVEITIS ........................... 64

HUMULIN 70/30 U-100 INSULIN .......................... 48

HUMULIN 70/30 U-100 KWIKPEN ........................ 48

HUMULIN N NPH INSULIN KWIKPEN ........................ 48

HUMULIN N NPH U-100 INSULIN .......................... 49

HUMULIN R REGULAR U-100 INSULN .................... 49

HUMULIN R U-500 (CONC) INSULIN .......................... 49

HUMULIN R U-500 (CONC) KWIKPEN ........................ 49

hydralazine ........................... 27 hydrochlorothiazide .............. 27 hydrocodone-acetaminophen 16 hydrocodone-chlorpheniramine

.......................................... 76 hydrocodone-cpm-

pseudoephed ..................... 76 hydrocodone-homatropine .... 76 hydrocodone-ibuprofen ........ 17 hydrocortisone .......... 41, 44, 55 hydrocortisone acetate .......... 55 hydrocortisone butyrate ........ 41 hydrocortisone butyr-emollient

.......................................... 41 hydrocortisone valerate ........ 41 hydrocortisone-acetic acid .... 44 hydrocortisone-iodoquinl-aloe2

.......................................... 37 hydrocortisone-iodoquinol-aloe

.......................................... 37 hydrocortisone-min oil-wht pet

.......................................... 41 hydrocortisone-pramoxine ... 32,

55 hydromet ............................... 76 hydromorphone ..................... 17 hydroxocobalamin ................ 84 hydroxychloroquine ................ 7 hydroxyprogesterone caproate

.......................................... 65 hydroxyurea .......................... 11 hydroxyzine hcl .................... 76 hydroxyzine pamoate ............ 76

94

hyolev mb ............................. 80 hyophen ................................ 80 hyoscyamine sulfate ............. 53 hyosyne................................. 53 HYQVIA .............................. 61 HYSINGLA ER ................... 17 I ibandronate ........................... 64 ibuprofen .............................. 19 ibuprofen-oxycodone ........... 17 ILEVRO ............................... 73 imipramine hcl...................... 22 imipramine pamoate ............. 22 imiquimod ............................ 59 IMOVAX RABIES VACCINE

(PF) ................................... 61 IMPAVIDO ............................ 7 INCRUSE ELLIPTA............ 78 indapamide ........................... 27 indomethacin ........................ 19 INFANRIX (DTAP) (PF)..... 61 INFUSION SET 43 .............. 47 INSET 30 INFUSION SET 23

.......................................... 47 INSET INFUSION SET 23 .. 47 INSPIRACHAMBER WITH

MASK-LARGE ................ 46 INSULIN SYRINGE-

NEEDLE U-100 ............... 46 INTELENCE .......................... 4 introvale ................................ 68 INVANZ................................. 8 INVIRASE ............................. 4 INVOKAMET ...................... 51 INVOKANA ........................ 51 iodoquinol-hc ....................... 37 IPOL ..................................... 61 ipratropium bromide ....... 44, 78 ipratropium-albuterol ........... 78 irbesartan .............................. 27 irbesartan-hydrochlorothiazide

.......................................... 27 ISENTRESS ........................... 4 ISENTRESS HD .................... 4 isibloom ................................ 68 isometh-dichloral-

acetaminophn ................... 14 isomethepten-caf-

acetaminophen .................. 14

isoniazid.................................. 8 isosorbide dinitrate ............... 31 isosorbide mononitrate ......... 32 isotretinoin ............................ 35 isoxsuprine............................ 66 isradipine .............................. 27 itraconazole ............................ 3 ivermectin ............................... 8 IXIARO (PF) ........................ 61 J jantoven ................................ 30 JANUMET ........................... 51 JANUMET XR ..................... 51 JANUVIA ............................. 51 JARDIANCE ........................ 51 jencycla ................................. 65 JENTADUETO .................... 51 JENTADUETO XR .............. 51 jevantique lo ......................... 65 jinteli ..................................... 65 jolessa ................................... 68 jolivette ................................. 65 JUBLIA ................................ 38 juleber ................................... 68 junel 1.5/30 (21) ................... 68 junel 1/20 (21) ...................... 68 junel fe 1.5/30 (28) ............... 68 junel fe 1/20 (28) .................. 68 junel fe 24 ............................. 68 K kaitlib fe ................................ 68 KALETRA ............................. 4 kariva (28) ............................ 68 k-effervescent ....................... 82 kelnor 1/35 (28) .................... 68 ketoconazole ..................... 3, 38 ketoprofen ............................. 19 ketorolac ......................... 19, 73 kimidess (28) ........................ 68 KINERET ............................. 59 KINRIX (PF) ........................ 61 kionex ................................... 55 kionex (with sorbitol) ........... 55 klor-con ................................ 82 klor-con 10 ........................... 82 klor-con 8 ............................. 82 klor-con m10 ........................ 82 klor-con m15 ........................ 82 klor-con m20 ........................ 82

klor-con sprinkle ................... 82 klor-con/ef ............................ 82 kobee ..................................... 84 K-PHOS ORIGINAL ........... 80 k-phos-neutral ....................... 82 kpn ........................................ 84 k-tab ...................................... 82 kurvelo .................................. 68 L l norgest/e.estradiol-e.estrad . 68 labetalol ................................ 27 LACRISERT ........................ 73 lactated ringers ...................... 42 lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine ...................... 12, 13 LANCETS ............................ 47 LANCING DEVICE ............ 47 lansoprazole .......................... 58 lanthanum ............................. 55 LANTUS SOLOSTAR U-100

INSULIN .......................... 49 LANTUS U-100 INSULIN .. 49 larin 1.5/30 (21) .................... 68 larin 1/20 (21) ....................... 68 larin 24 fe .............................. 68 larin fe 1.5/30 (28) ................ 68 larin fe 1/20 (28) ................... 68 larissia ................................... 68 LASTACAFT ....................... 73 latanoprost ............................ 74 LATUDA .............................. 22 laxaclear ................................ 55 laxative (bisacodyl) .............. 55 laxative feminine .................. 55 laxative peg 3350 .................. 55 layolis fe ............................... 68 leena 28 ................................. 68 leflunomide ........................... 64 lessina ................................... 68 LETAIRIS ............................ 78 letrozole ................................ 11 leucovorin calcium ............... 10 LEUKERAN ......................... 11 levalbuterol hcl ..................... 78 LEVATOL ............................ 27 LEVEMIR FLEXTOUCH U-

100 INSULN .................... 49 LEVEMIR U-100 INSULIN 49

95

levetiracetam ........................ 13 levobunolol ........................... 72 levocarnitine ......................... 42 levocarnitine (with sugar)..... 42 levocetirizine ........................ 76 levofloxacin ...................... 9, 71 levonest (28) ......................... 68 levonorgestrel-ethinyl estrad

.................................... 68, 69 levonorg-eth estrad triphasic 69 levora-28............................... 69 levorphanol tartrate .............. 17 levothyroxine ........................ 52 levoxyl .................................. 52 LEXIVA ................................. 4 lidocaine ............................... 37 lidocaine hcl ......................... 37 lidocaine hcl-hydrocortison ac

.................................... 37, 55 lidocaine viscous .................. 37 lidocaine-hydrocortisone-aloe

.......................................... 55 lidocaine-prilocaine .............. 37 lido-k .................................... 37 lidopin................................... 37 lidopril .................................. 37 lillow..................................... 69 lindane .................................. 42 linezolid .................................. 8 LINZESS .............................. 55 liothyronine .......................... 52 lisinopril ............................... 27 lisinopril-hydrochlorothiazide

.......................................... 27 lite coat aspirin ..................... 19 LITEAIRE MDI CHAMBER

.......................................... 46 lithium carbonate .................. 22 lithium citrate ....................... 22 LIVALO ............................... 31 loperamide ............................ 53 lopinavir-ritonavir .................. 4 lopreeza ................................ 65 lorazepam ............................. 22 lorazepam intensol................ 22 lorcet (hydrocodone) ............ 17 lorcet hd ................................ 17 lorcet plus ............................. 17 loryna (28) ............................ 69

losartan ................................. 27 losartan-hydrochlorothiazide 27 LOTEMAX .................... 74, 75 lovastatin .............................. 31 low-ogestrel (28) .................. 69 loxapine succinate ................ 22 ludent fluoride ...................... 84 lugols .............................. 37, 82 LUPANETA PACK (1

MONTH) .......................... 66 LUPANETA PACK (3

MONTH) .......................... 66 lutera (28) ............................. 69 luxamend .............................. 34 LUZU ................................... 38 LYRICA ............................... 13 LYSODREN ......................... 11 lyza ....................................... 65 M mafenide acetate ................... 37 magnesium citrate................. 55 malathion .............................. 42 maprotiline............................ 22 marlissa ................................. 69 MARPLAN .......................... 22 marten-tab ............................. 17 matzim la .............................. 27 mb hydrogel .......................... 34 mb hydrogel (cyclomethicone)

.......................................... 34 meclizine .............................. 55 meclofenamate...................... 19 medroxyprogesterone ........... 65 mefenamic acid..................... 19 mefloquine .............................. 8 megestrol .............................. 11 melodetta 24 fe ..................... 69 meloxicam ............................ 19 melphalan ............................. 11 memantine ............................ 15 MENACTRA (PF) ............... 62 MENEST .............................. 65 MENTAX ............................. 38 meperidine ............................ 17 MEPHYTON ........................ 30 meprobamate ........................ 15 mercaptopurine ..................... 11 mesalamine ........................... 56

mesalamine with cleansing wipe .................................. 56

MESNEX .............................. 10 MESTINON ......................... 15 metadate er ............................ 23 metaproterenol ...................... 78 metaxall ................................ 15 metaxalone ............................ 15 metformin ............................. 51 methadone ............................. 17 methadose ............................. 17 methamphetamine ................. 23 methazolamide ...................... 74 methenamine hippurate ........ 10 methenamine mandelate ....... 10 methen-sod phos-meth blue-

hyos ................................... 80 methergine ............................ 71 methimazole ......................... 45 METHITEST ........................ 50 methocarbamol ..................... 15 methotrexate sodium ............ 11 methotrexate sodium (pf) ..... 11 methoxsalen .......................... 34 methscopolamine .................. 53 methyclothiazide ................... 27 methyldopa ........................... 27 methyldopa-

hydrochlorothiazide .......... 27 methylphenidate hcl .............. 23 methylprednisolone ........ 44, 45 methyltestosterone ................ 50 metipranolol .......................... 72 metoclopramide hcl .............. 56 metolazone ............................ 27 metoprolol succinate ............. 27 metoprolol ta-hydrochlorothiaz

.......................................... 27 metoprolol tartrate ................ 27 metronidazole ....... 8, 35, 36, 66 mexiletine ............................. 25 mibelas 24 fe ......................... 69 miconazole-3 ........................ 66 MICROCHAMBER ............. 46 microgestin 1.5/30 (21) ........ 69 microgestin 1/20 (21) ........... 69 microgestin fe 1.5/30 (28) .... 69 microgestin fe 1/20 (28) ....... 69 MICROSPACER .................. 46

96

midazolam ............................ 23 midodrine ............................. 42 migergot ............................... 14 miglitol ................................. 51 milk of magnesia .................. 56 milk of magnesia concentrated

.......................................... 56 millipred ............................... 45 millipred dp .......................... 45 mimvey ................................. 66 mimvey lo ............................. 66 MINIMED INFUSION SET-

MMT 390 ......................... 47 minocycline .......................... 10 minoxidil .............................. 27 MIO INFUSION SET .......... 47 miostat .................................. 74 miralax .................................. 56 MIRENA .............................. 65 mirtazapine ........................... 23 MIRVASO ........................... 36 misoprostol ........................... 58 MITIGARE .......................... 63 M-M-R II (PF) ...................... 62 modafinil .............................. 23 moexipril .............................. 27 moexipril-hydrochlorothiazide

.......................................... 27 mometasone .................... 41, 78 mondoxyne nl ....................... 10 mono-linyah ......................... 69 mononessa (28) .................... 69 montelukast .......................... 78 MONUROL .......................... 10 morgidox .............................. 10 morphine............................... 17 morphine concentrate ........... 17 MOTOFEN........................... 53 MOVANTIK ........................ 56 MOVIPREP .......................... 56 MOXEZA ............................. 71 moxifloxacin..................... 9, 71 MOXIFLOXACIN-

SOD.ACE,SUL-WATER ... 9 MULTAQ ............................. 25 multi-vitamin with fluoride .. 84 multivitamins with fluoride .. 84 multivit-fluor (vit e acetate) . 84 mupirocin ............................. 37

mupirocin calcium ................ 37 mvc-fluoride ......................... 84 my choice ............................. 69 my way ................................. 69 mycophenolate mofetil ......... 11 mycophenolate sodium ......... 11 MYLERAN .......................... 11 mynatal ................................. 84 mynatal advance ................... 84 mynatal plus ......................... 84 mynatal-z .............................. 84 mynate 90 plus...................... 84 MYRBETRIQ ...................... 79 myzilra .................................. 69 N nabumetone .......................... 19 nadolol .................................. 27 nadolol-bendroflumethiazide 27 naftifine ................................ 38 naloxone ............................... 19 naltrexone ............................. 19 naproxen ............................... 19 naproxen sodium .................. 19 naratriptan ............................. 14 NARCAN ............................. 20 NATACYN .......................... 71 nateglinide ............................ 51 natural b-100 complex .......... 84 natura-lax .............................. 56 nature-throid ......................... 52 NEBUPENT ........................... 8 nebusal .................................. 78 necon 0.5/35 (28) .................. 69 necon 7/7/7 (28).................... 69 nefazodone............................ 23 neomycin ................................ 8 neomycin-bacitracin-poly-hc 74 neomycin-bacitracin-

polymyxin ......................... 71 neomycin-polymyxin b gu.... 42 neomycin-polymyxin b-

dexameth .......................... 74 neomycin-polymyxin-

gramicidin ......................... 71 neomycin-polymyxin-hc 44, 74 neo-polycin ........................... 71 neo-polycin hc ...................... 74 NEO-SYNALAR.................. 37 NESINA ............................... 51

neuac ..................................... 36 NEVANAC ........................... 73 nevirapine ........................... 4, 5 newgen .................................. 85 NEXIUM 24HR .................... 58 NEXPLANON ...................... 66 next choice one dose ............. 69 niacin .................................... 31 nicardipine ............................ 27 NICODERM CQ .................. 43 nicorelief ............................... 43 nicorette ................................ 43 NICORETTE ........................ 43 nicotine ................................. 43 nicotine (polacrilex) .............. 43 NICOTROL .......................... 43 NICOTROL NS .................... 43 nifedipine .............................. 27 nikki (28) .............................. 69 nilutamide ............................. 11 nimodipine ............................ 28 nisoldipine ............................ 28 nitro-bid ................................ 32 nitrofurantoin ........................ 10 nitrofurantoin macrocrystal .. 10 nitrofurantoin monohyd/m-

cryst .................................. 10 nitroglycerin ......................... 32 nitro-time .............................. 32 nivatopic plus ........................ 34 nizatidine .............................. 58 nolix ...................................... 41 nora-be .................................. 66 noreth-ethinyl estradiol-iron . 69 norethindrone (contraceptive)

.......................................... 66 norethindrone acetate ............ 66 norethindrone ac-eth estradiol

.................................... 66, 69 norethindrone-e.estradiol-iron

.......................................... 69 norgestimate-ethinyl estradiol

.......................................... 69 norlyda .................................. 66 norlyroc ................................. 66 nortrel 0.5/35 (28) ................. 69 nortrel 1/35 (21) .................... 69 nortrel 1/35 (28) .................... 69 nortrel 7/7/7 (28) ................... 69

97

nortriptyline .......................... 23 NORVIR................................. 5 NOVOLOG FLEXPEN U-100

INSULIN .......................... 49 NOVOLOG MIX 70-30 U-100

INSULN ........................... 49 NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 49 NOVOLOG PENFILL U-100

INSULIN .......................... 49 NOVOLOG U-100 INSULIN

ASPART........................... 49 NOXAFIL .............................. 3 np thyroid ............................. 52 NUCYNTA .......................... 20 NUCYNTA ER .................... 20 NUEDEXTA ........................ 15 NUVARING......................... 66 nyamyc ................................. 38 nystatin ............................. 3, 38 nystatin-triamcinolone .......... 38 nystop ................................... 39 O obstetrix dha ......................... 85 ocella .................................... 69 ODACTRA........................... 62 ODEFSEY .............................. 5 ofloxacin ..................... 9, 44, 71 ogestrel (28).......................... 69 okebo .................................... 10 olanzapine............................. 23 olanzapine-fluoxetine ........... 23 olmesartan ............................ 28 olmesartan-amlodipin-

hcthiazid ........................... 28 olmesartan-

hydrochlorothiazide .......... 28 olopatadine ..................... 44, 73 OLYSIO ................................. 5 omega-3 acid ethyl esters ..... 31 omeppi .................................. 58 omeprazole ........................... 58 omeprazole magnesium ........ 58 omeprazole-sodium

bicarbonate ....................... 59 ondansetron .......................... 56 ondansetron hcl .................... 56 one daily prenatal ................. 85

ONETOUCH ULTRA CONTROL ....................... 47

ONETOUCH ULTRA TEST .......................................... 45

ONETOUCH ULTRA2 ........ 47 ONETOUCH ULTRAMINI. 47 ONETOUCH VERIO ........... 45 ONETOUCH VERIO FLEX 47 ONETOUCH VERIO IQ

METER ............................ 47 ONETOUCH VERIO

SYSTEM .......................... 47 ONFI ..................................... 13 ONGLYZA ........................... 51 opcicon one-step ................... 69 opium tincture....................... 53 OPTICHAMBER DIAMOND

LG MASK ........................ 46 option-2 ................................ 69 oral saline laxative ................ 56 oralone .................................. 44 ORAVIG ................................ 3 ORENCIA ............................ 64 ORENITRAM ...................... 28 orphenadrine citrate .............. 15 orsythia ................................. 69 oscimin ................................. 53 oscimin sl .............................. 53 oscimin sr ............................. 53 oseltamivir .............................. 5 OSMOPREP ......................... 56 OSPHENA............................ 66 oxandrolone .......................... 50 oxaprozin .............................. 20 oxazepam .............................. 23 oxcarbazepine ....................... 13 oxiconazole ........................... 39 oxybutynin chloride .............. 79 oxycodone ............................ 17 oxycodone-acetaminophen .. 17,

18 oxycodone-aspirin ................ 18 OXYCONTIN ...................... 18 oxymorphone ........................ 18 oysco 500/d........................... 82 oyster shell + d3 ................... 82 oyster shell calcium-vit d2 ... 85 oyster shell calcium-vit d3 ... 82 oystercal-d ............................ 82

P pacerone ................................ 25 paliperidone .......................... 23 panlor(acetam-caff-

dihydrocod) ....................... 18 PANRETIN .......................... 34 pantoprazole ......................... 59 PARAGARD T 380A ........... 65 paregoric ............................... 53 paricalcitol ............................ 50 paromomycin .......................... 8 paroxetine hcl ....................... 23 paroxetine

mesylate(menop.sym) ....... 23 PASER .................................... 8 PEDIARIX (PF) ................... 62 PEDVAX HIB (PF) .............. 62 peg 3350-electrolytes ............ 56 peg3350 ................................ 56 PEGANONE ......................... 13 peg-electrolyte soln .............. 56 peg-prep ................................ 56 PEN NEEDLE ...................... 47 penicillin v potassium ............. 9 PENTACEL (PF) .................. 62 PENTASA ............................ 56 pentoxifylline ........................ 30 PERFOROMIST ................... 78 perindopril erbumine ............ 28 permethrin ............................. 42 perphenazine ......................... 23 perphenazine-amitriptyline ... 23 perry prenatal ........................ 85 phenadoz ............................... 76 phenazopyridine ................... 81 phenelzine ............................. 23 phenergan ............................. 76 phenobarb-hyoscy-atropine-

scop ................................... 53 phenobarbital ........................ 13 phenohytro ............................ 53 phenoxybenzamine ............... 28 phenylephrine hcl ................. 75 phenytoin .............................. 13 phenytoin sodium extended .. 13 philith .................................... 69 PHOSLYRA ......................... 56 phospha 250 neutral .............. 82 phosphasal ............................ 80

98

phosphate laxative ................ 56 PHOSPHOLINE IODIDE .... 72 PICATO ............................... 34 pilocarpine hcl .......... 42, 44, 72 pimozide ............................... 23 pimtrea (28) .......................... 70 pindolol................................. 28 pioglitazone .......................... 51 pioglitazone-glimepiride ...... 51 pioglitazone-metformin ........ 51 pirmella................................. 70 piroxicam .............................. 20 PLAN B ONE-STEP ............ 70 PNEUMOVAX 23 ............... 62 pnv 29-1................................ 85 pnv ob+dha ........................... 85 pnv-dha ................................. 85 pnv-dha + docusate .............. 85 pnv-ferrous fumarate-docu-fa

.......................................... 85 pnv-omega ............................ 85 pnv-select ............................. 85 pnv-vp-u ............................... 85 POCKET CHAMBER ......... 46 podofilox .............................. 34 polycin .................................. 71 polyethylene glycol 3350 ..... 56 polymyxin b sulf-trimethoprim

.......................................... 71 portia..................................... 70 pot,sodium citrate-citric acid 80 potassium bicarb and chloride

.......................................... 82 potassium bicarb-citric acid . 82 potassium chloride.......... 82, 83 potassium citrate ................... 80 potassium citrate-citric acid . 80 powderlax ............................. 56 pr natal 400 ........................... 85 pr natal 400 ec ...................... 85 pr natal 430 ........................... 85 pr natal 430 ec ...................... 85 PRADAXA........................... 30 pramcort ............................... 56 pramipexole .......................... 14 prasugrel ............................... 30 pravastatin ............................ 31 prazosin ................................ 28 prednicarbate ........................ 41

prednisolone ......................... 45 prednisolone acetate ............. 75 prednisolone sodium phosphate

.................................... 45, 75 prednisone ............................ 45 prednisone intensol ............... 45 PREMARIN ......................... 66 prena1 chew .......................... 85 prena1 pearl .......................... 85 prena1 true ............................ 85 prenaissance.......................... 85 prenaissance plus .................. 85 prenatabs fa........................... 85 prenatabs rx .......................... 85 prenatal ................................. 85 prenatal complete ................. 85 prenatal formula ................... 85 prenatal multi-dha (algal oil) 85 prenatal one daily ................. 85 prenatal plus ......................... 85 prenatal plus (calcium carb) . 85 prenatal vitamin .................... 85 prenatal vitamin plus low iron

.......................................... 86 prenatal vitamin with minerals

.......................................... 86 prenatal vits96-iron fum-folic

.......................................... 86 prenatal-u .............................. 86 preplus .................................. 86 PREPOPIK ........................... 56 pretab .................................... 86 PREVACID 24HR ............... 59 prevalite ................................ 31 previfem................................ 70 PREVNAR 13 (PF) .............. 62 PREZISTA ............................. 5 PRIFTIN ................................. 8 PRILOSEC OTC .................. 59 PRIMAQUINE ....................... 8 PRIMEAIRE ........................ 46 primidone.............................. 13 PRIVIGEN ........................... 62 PROAIR HFA ...................... 78 PROAIR RESPICLICK ....... 78 probenecid ............................ 63 probenecid-colchicine .......... 63 procentra ............................... 23 PROCHAMBER .................. 46

prochlorperazine ................... 56 prochlorperazine maleate ...... 56 procto-med hc ....................... 56 procto-pak ............................. 57 proctosol hc .......................... 57 proctozone-hc ....................... 57 profeno .................................. 20 progesterone micronized ...... 66 PROGLYCEM ..................... 46 promethazine ........................ 76 promethazine vc-codeine ...... 76 promethazine-codeine ........... 76 promethazine-dm .................. 76 promethazine-phenylephrine 76 promethegan ......................... 76 propafenone .......................... 25 proparacaine ......................... 73 propranolol ........................... 28 propranolol-hydrochlorothiazid

.......................................... 28 propylthiouracil .................... 45 PROQUAD (PF) ................... 62 protriptyline .......................... 23 pruclair .................................. 34 prudoxin ................................ 34 prumyx .................................. 34 prutect ................................... 34 pulmosal ............................... 78 purelax .................................. 57 pyrazinamide .......................... 8 pyridostigmine bromide ........ 16 Q QUADRACEL (PF) ............. 62 quasense ................................ 70 quazepam .............................. 23 quetiapine ....................... 23, 24 QUICK-SET PARADIGM ... 47 quinapril ................................ 28 quinapril-hydrochlorothiazide

.......................................... 28 quinidine gluconate .............. 25 quinidine sulfate ................... 25 quinine sulfate ........................ 8 quit 2 ..................................... 43 QUIT 2 .................................. 43 quit 4 ..................................... 43 QUIT 4 .................................. 43 QVAR ................................... 78 QVAR REDIHALER ........... 78

99

R RABAVERT (PF) ................ 62 rabeprazole ........................... 59 RAGWITEK......................... 62 rajani ..................................... 70 raloxifene .............................. 64 ramipril ................................. 28 RANEXA ............................. 31 ranitidine hcl ......................... 59 RAPAFLO ............................ 80 RAPAMUNE ....................... 11 rasagiline .............................. 14 reclipsen (28) ........................ 70 RECOMBIVAX HB (PF) .... 62 RECTIV ............................... 57 REGRANEX ........................ 34 relador pak ............................ 37 relador pak plus .................... 37 RELENZA DISKHALER ...... 5 RELION NOVOLIN 70/30 .. 49 RELION NOVOLIN N ........ 49 RELION NOVOLIN R ........ 49 RELISTOR ........................... 57 relnate dha ............................ 86 RELPAX .............................. 14 RENACIDIN ........................ 80 rena-vite ................................ 86 repaglinide ............................ 51 repaglinide-metformin .......... 51 RESCRIPTOR ........................ 5 RESTASIS ........................... 73 RESTASIS MULTIDOSE ... 73 REXULTI ............................. 24 REYATAZ ............................. 5 ribavirin .................................. 5 RIDAURA ............................ 64 rifabutin .................................. 8 rifampin .................................. 8 RIFATER ............................... 8 riluzole .................................. 42 rimantadine ............................. 5 ringer's .................................. 42 risacal-d ................................ 86 risedronate ...................... 42, 64 risperidone ............................ 24 RITEFLO AEROCHAMBER

.......................................... 46 rivastigmine .......................... 15 rivastigmine tartrate.............. 15

rivelsa ................................... 70 rizatriptan.............................. 14 ropinirole .............................. 14 rosadan.................................. 36 rosula cleansing cloths.......... 36 rosuvastatin ........................... 31 ROTATEQ VACCINE......... 62 roweepra ............................... 13 ROZEREM ........................... 24 RYDAPT .............................. 11 S SAFE-CLIP BY MAIL ........ 47 salicylic acid ......................... 33 salicylic acid er-ceramides ... 33 salimez .................................. 33 salsalate ................................ 20 salvax .................................... 33 SANDIMMUNE .................. 11 SANTYL .............................. 41 SAPHRIS (BLACK

CHERRY) ........................ 24 SAVELLA ............................ 64 scalacort ................................ 41 scopolamine base .................. 57 seb-prev ................................ 32 seconal sodium ..................... 24 selegiline hcl ......................... 14 selenium sulfide .................... 32 SELZENTRY ......................... 5 se-natal 19............................. 86 se-natal 19 (with docusate) ... 86 SENSIPAR ........................... 50 SEREVENT DISKUS .......... 78 sertraline ............................... 24 setlakin.................................. 70 sevelamer carbonate ............. 57 sharobel ................................ 66 SHINGRIX (PF) ................... 62 SILHOUETTE...................... 47 silver nitrate .......................... 34 silver nitrate applicators ....... 34 silver sulfadiazine ................. 33 SIMBRINZA ........................ 74 SIMPONI.............................. 64 SIMPONI ARIA ................... 64 simvastatin ............................ 31 sirolimus ............................... 11 SIRTURO ............................... 8 SIVEXTRO ............................ 8

smoothlax ............................. 57 SNAP INSULIN PUMP-

INFUSION SET ............... 47 sodium chloride .............. 42, 78 sodium chloride 0.9 % .......... 42 sodium citrate-citric acid ...... 80 sodium phenylbutyrate ......... 42 sodium polystyrene sulfonate

.......................................... 57 SOF-SET .............................. 47 SOF-SET CANNULA 24 ..... 47 SOF-SET MICRO 24 ........... 47 SOLTAMOX ........................ 11 sonafine ................................. 34 SOOLANTRA ...................... 36 sotalol ................................... 25 sotalol af ............................... 25 SOTYLIZE ........................... 25 sp antipruritic ........................ 34 sp scar management .............. 34 spinosad ................................ 42 spironolactone ....................... 28 spironolacton-hydrochlorothiaz

.......................................... 28 SPORANOX ........................... 3 sprintec (28) .......................... 70 sps (with sorbitol) ................. 57 sronyx ................................... 70 ssd ......................................... 33 sss 10-5 ................................. 36 STAMARIL (PF) .................. 62 stavudine ................................. 5 STELARA ............................ 33 stop smoking aid ................... 43 stress formula ........................ 86 stress formula with iron ........ 86 stress formula with iron(sulf)86 STRIBILD .............................. 5 STRIVERDI RESPIMAT .... 78 strong iodine ......................... 83 SUBOXONE ........................ 20 sucralfate ............................... 59 sulfacetamide sodium ..... 33, 75 sulfacetamide sodium (acne) 38 sulfacetamide sodium-sulfur 36 sulfacetamide sod-sulfur-urea

.......................................... 36 sulfacetamide-prednisolone .. 75

100

sulfacetamide-sulfur-cleansr23 .......................................... 36

sulfacleanse 8-4 .................... 36 sulfact na-sul-avobnz-otn-ocsa

.......................................... 36 sulfadiazine............................. 9 sulfamethoxazole-trimethoprim

............................................ 9 SULFAMYLON................... 38 sulfasalazine ......................... 57 sulfatrim ................................. 9 sulindac................................. 20 sumatriptan ........................... 14 sumatriptan succinate ..... 14, 15 sumatriptan-naproxen ........... 15 super b complex-vitamin c ... 86 super b maxi complex .......... 86 super b-50 complex plus ...... 86 super quints .......................... 86 super quints b-50 .................. 86 superplex-t ............................ 86 SUPREP BOWEL PREP KIT

.......................................... 57 SURE-T PARADIGM.......... 47 SUSTIVA ............................... 5 syeda ..................................... 70 symax fastabs ....................... 53 symax-sl ............................... 53 symax-sr ............................... 53 SYMBICORT....................... 79 SYMLINPEN 120 ................ 51 SYMLINPEN 60 .................. 52 SYNAREL ........................... 50 SYNJARDY ......................... 52 SYNJARDY XR .................. 52 SYPRINE ............................. 42 T T

30 INFUSION SET .......... 47 90 INFUSION SET 23 ..... 48 SLIM ................................ 48 SLIM G4 .......................... 48

TABLOID ............................ 11 tacrolimus ....................... 12, 34 tamoxifen .............................. 12 tamsulosin............................. 80 TANZEUM .......................... 52 tarina fe 1/20 (28) ................. 70 taron-c dha ............................ 86

taron-prex prenatal-dha ........ 86 tazarotene.............................. 36 TAZORAC ........................... 36 taztia xt ................................. 28 TEKTURNA ........................ 28 TEKTURNA HCT ............... 28 telmisartan ............................ 28 telmisartan-amlodipine ......... 28 telmisartan-hydrochlorothiazid

.......................................... 28 temazepam ............................ 24 tencon ................................... 18 TENIVAC (PF) .................... 62 tenofovir disoproxil fumarate . 5 terazosin................................ 28 terbinafine hcl ......................... 3 terbutaline ............................. 79 terconazole............................ 66 testosterone ........................... 50 testosterone cypionate .......... 50 testosterone enanthate........... 50 TETANUS,DIPHTHERIA

TOX PED(PF) .................. 63 TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 63 tetcaine.................................. 73 tetracaine hcl......................... 73 tetracycline ........................... 10 theochron .............................. 79 theophylline .......................... 79 thioridazine ........................... 24 thiothixene ............................ 24 thrivite-19 ............................. 86 thyroid (pork) ....................... 52 THYROLAR-1 ..................... 52 THYROLAR-1/2 .................. 52 THYROLAR-1/4 .................. 52 THYROLAR-2 ..................... 52 THYROLAR-3 ..................... 52 tiagabine ............................... 13 ticlopidine ............................. 30 tilia fe .................................... 70 timolol maleate ............... 28, 72 tinidazole ................................ 8 tis-u-sol pentalyte ................. 42 TIVICAY................................ 5 tizanidine .............................. 16 tl g-fol os .............................. 86 tobramycin ............................ 72

tobramycin-dexamethasone .. 74 tolazamide ............................. 52 tolbutamide ........................... 52 tolcapone ............................... 14 tolmetin ................................. 20 tolterodine ............................. 79 topiramate ............................. 13 torsemide .............................. 28 total b/c ................................. 86 TOUJEO SOLOSTAR U-300

INSULIN .......................... 49 TOVIAZ ............................... 79 TRADJENTA ....................... 52 tramadol ................................ 20 tramadol-acetaminophen ...... 20 trandolapril ........................... 28 trandolapril-verapamil .......... 29 tranexamic acid ..................... 66 tranylcypromine .................... 24 TRAVATAN Z ..................... 74 trazodone .............................. 24 TRECATOR ........................... 8 TRELEGY ELLIPTA ........... 79 tretinoin ................................. 36 tretinoin (chemotherapy) ...... 12 tretinoin microspheres .......... 36 tri femynor ............................ 70 TRIACETIN ......................... 39 triamcinolone acetonide .. 41, 44 triamterene-hydrochlorothiazid

.......................................... 29 trianex ................................... 41 triazolam ............................... 24 tricitrates ............................... 80 triderm .................................. 41 trientine ................................. 43 tri-estarylla ............................ 70 trifluoperazine ....................... 24 trifluridine ............................. 72 trihexyphenidyl ..................... 14 triklo ..................................... 31 tri-legest fe ............................ 70 tri-linyah ............................... 70 tri-lo-estarylla ....................... 70 tri-lo-marzia .......................... 70 tri-lo-sprintec ........................ 70 trilyte with flavor packets ..... 57 trimethobenzamide ............... 57 trimethoprim ......................... 10

101

trimipramine ......................... 24 trinatal rx 1 ........................... 86 trinate .................................... 86 trinessa (28) .......................... 70 trinessa lo.............................. 70 TRINTELLIX....................... 24 tri-previfem (28) ................... 70 tri-sprintec (28) ..................... 70 tri-tabs dha ............................ 86 TRIUMEQ .............................. 5 triveen-duo dha ..................... 86 tri-vitamin with fluoride ....... 86 trivora (28)............................ 70 tri-vylibra .............................. 70 tropicamide ........................... 72 trospium ................................ 79 TRULICITY ......................... 52 TRUMENBA ....................... 63 trust natal dha ....................... 86 TRUSTEEL INFUSION SET

32 ...................................... 48 TRUVADA ............................ 5 TUDORZA PRESSAIR ....... 79 tussigon................................. 76 TWINRIX (PF) .................... 63 TYBOST ................................ 5 TYMLOS ............................. 64 TYPHIM VI ......................... 63 U UCERIS ................................ 57 ULESFIA ............................. 42 ULORIC ............................... 63 ultimatecare one ................... 86 ultimatecare one nf ............... 86 ultra b-100 complex ............. 86 umecta .................................. 34 unithroid ............................... 52 urea ....................................... 34 urea nail stick ....................... 34 ure-k ..................................... 34 uretron d-s ............................ 80 urimar-t ................................. 80 urin ds ................................... 80 uro-458 ................................. 80 urogesic-blue ........................ 81 uro-mp .................................. 81 urophen mb ........................... 81 ursodiol ................................. 57 uryl ....................................... 81

ustell ..................................... 81 UTIBRON NEOHALER ...... 79 utira-c.................................... 81 V valacyclovir ............................ 5 valganciclovir ......................... 5 valproic acid ......................... 13 valproic acid (as sodium salt)

.......................................... 13 valsartan................................ 29 valsartan-hydrochlorothiazide

.......................................... 29 vancomycin .......................... 10 vandazole .............................. 66 VAQTA (PF) ........................ 63 VARISOFT INFUSION SET

43 ...................................... 48 VARIVAX (PF) ................... 63 VARIZIG.............................. 63 VARUBI ............................... 57 VASCEPA ............................ 31 VAXCHORA VACCINE..... 63 velivet triphasic regimen (28)

.......................................... 70 VELPHORO ......................... 57 VELTASSA.......................... 57 vemavite-prx-2 ..................... 86 VEMLIDY.............................. 5 venlafaxine ........................... 24 verapamil .............................. 29 verdrocet ............................... 18 VEREGEN ........................... 34 veripred 20 ............................ 45 VESICARE .......................... 79 vestura (28) ........................... 70 VGO 20 ................................ 48 VGO 30 ................................ 48 VGO 40 ................................ 48 VIBERZI .............................. 57 vicodin .................................. 18 vicodin es .............................. 18 vicodin hp ............................. 18 VICTOZA 2-PAK ................ 52 VICTOZA 3-PAK ................ 52 VIDEX 2 GRAM PEDIATRIC

............................................ 6 vienva ................................... 70 VIIBRYD ............................. 24 vilamit mb............................. 81

vilevev mb ............................ 81 VIMPAT ............................... 13 vinate care ............................. 86 vinate ii ................................. 86 vinate m ................................ 86 vinate one .............................. 86 VIOKACE ............................ 58 viorele (28) ........................... 70 VIRACEPT ............................. 6 VIREAD ................................. 6 virt-advance .......................... 87 virt-c dha ............................... 87 virt-nate ................................. 87 virt-nate dha .......................... 87 virt-phos 250 neutral ............. 83 virt-pn ................................... 87 virt-pn dha ............................ 87 virt-pn plus ............................ 87 virtrate-2 ............................... 81 virtrate-3 ............................... 81 virtrate-k ............................... 81 virt-select .............................. 87 virt-vite gt ............................. 87 vit b complex-folic acid ........ 87 vitajoy daily d ....................... 87 vitamin b complex ................ 87 vitamin d3 ............................. 87 vitamin k ............................... 30 vitamin k1 ............................. 30 vitamins a,c,d and fluoride ... 87 VIVOTIF .............................. 63 vol-nate ................................. 87 vol-plus ................................. 87 vol-tab rx .............................. 87 voriconazole ........................... 3 VORTEX HOLDING

CHAMBER CHILD ......... 46 VORTEX VHC FROG

MASK-CHILD ................. 46 VORTEX VHC LADYBUG

MASK-TODDLR ............. 46 vp-ch plus ............................. 87 vp-ch-pnv .............................. 87 vp-ggr-b6 .............................. 87 vp-heme ob ........................... 87 vp-heme one ......................... 87 vyfemla (28) ......................... 70 vylibra ................................... 70 VYVANSE ........................... 24

102

W warfarin ................................ 30 water for irrigation, sterile .... 43 WELCHOL .......................... 31 wera (28) .............................. 70 westhroid .............................. 52 WIDE-SEAL DIAPHRAGM

.......................................... 65 woman's laxative .................. 58 women's gentle laxative(bisac)

.......................................... 58 women's laxative (bisacodyl)58 wymzya fe ............................ 70 X XARELTO ........................... 30 XELJANZ ............................ 64 XELJANZ XR ...................... 64 XIFAXAN .............................. 8 XIGDUO XR........................ 52

xulane ................................... 66 xylon 10 ................................ 18 Y YF-VAX (PF) ....................... 63 yuvafem ................................ 66 Z zafirlukast ............................. 79 zaleplon ................................ 24 zarah ..................................... 70 zatean-ch ............................... 87 zatean-pn dha ........................ 87 zatean-pn plus ....................... 87 zebutal .................................. 18 ZEGERID OTC .................... 59 zenatane ................................ 36 zenchent (28) ........................ 70 ZENPEP ............................... 58 zenzedi .................................. 24 zidovudine .............................. 6

zileuton ................................. 79 zingiber ................................. 87 ZIOPTAN (PF) ..................... 74 ziprasidone hcl ...................... 24 ZIRGAN ............................... 72 zolmitriptan ........................... 15 zolpidem ............................... 24 ZOMIG ................................. 15 zonisamide ............................ 13 ZONTIVITY ......................... 30 ZORTRESS .......................... 12 ZOSTAVAX (PF) ................ 63 zovia 1/35e (28) .................... 70 zovia 1/50e (28) .................... 71 ZOVIRAX ............................ 39 ZUBSOLV ............................ 20 ZYFLO ................................. 79

This formulary was updated on 4/1/2018. For more recent information or other questions, please contact The Health Plan Pharmacy Services at 1.800.624.6961 extension 7914, or visit www.heathplan.org.

Documents

2018 High Performance Formulary - healthplan.org · 01-04-2018 · oseltamivir oral suspension for reconstitution 1 PREZISTA ORAL SUSPENSION 2 PREZISTA ORAL TABLET 150 MG, 600 MG,