2019 Peoples Health Formulary...the front and back cover pages. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary,

Peoples Health Choices 65 #14 (HMO)

Peoples Health Choices Gold (HMO-POS)

Peoples Health Group Medicare (HMO-POS)

2019 Formulary

(List of Covered Drugs)

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

00019352, Version Number 6

This formulary was updated on 10/10/2018. For more recent information or other questions, please contact Peoples Health member services at 1-800-222-8600 or, for TTY users, 1-800-846-5277, seven days a week, from 8 a.m. to 8 p.m., or visit http://www.peopleshealth.com. If you contact us on a weekend or holiday, we will reach out to you within one business day.

Peoples Health is a Medicare Advantage organization with a Medicare contract to offer HMO plans. Enrollment depends on annual Medicare contract renewal.

H1961_19CF_FINAL_NOVEMBER OE Populated Template_C

http://www.peopleshealth.com/

Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs

Note to existing members: This formulary has changed since last year. Please review this document to make

sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Peoples Health. When it refers to

“plan” or “our plan,” it means Peoples Health Choices 65 #14 (HMO), Peoples Health Choices Gold (HMO-

POS) or Peoples Health Group Medicare (HMO-POS).

This document includes a list of the drugs (formulary) for our plan, which is current as of the date printed on

the front and back cover pages. For an updated formulary, please contact us. Our contact information, along

with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, copayments and coinsurance may change on January 1, 2020, and from time to time

during the year.

What is the Peoples Health formulary? A formulary is a list of covered drugs selected by Peoples Health in consultation with a team of health care

providers, which represents the prescription therapies believed to be a necessary part of a quality treatment

program. We will generally cover the drugs listed in our formulary as long as the drug is medically

necessary, the prescription is filled at a Peoples Health network pharmacy, and other plan rules are followed.

For more information on how to fill your prescriptions, please review the Evidence of Coverage.

Can the formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we

will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less

expensive generic drug becomes available, when new information about the safety or effectiveness of a drug

is released, or the drug is removed from the market. (See bullets below for more information on changes that

affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from

our formulary, will not affect members who are currently taking the drug. It will remain available at the same

cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the

drug list that will also affect members currently taking a drug:

Drugs removed from the market. If the Food and Drug Administration deems a drug on our

formulary to be unsafe, or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. For

instance, we may add a new generic drug to replace a brand name drug currently on the formulary or

add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may

make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior

authorization, quantity limits or step therapy restrictions on a drug, or move a drug to a higher cost-

sharing tier, we must notify affected members of the change at least 30 days before the change

1


becomes effective, or at the time the member requests a refill of the drug, at which time the member

will receive a 30-day supply of the drug.

The enclosed formulary is current as of the date printed on the front and back cover pages. To get updated

information about the drugs covered by our plans, please contact us. Our contact information appears on the

front and back cover pages. In the event of a mid-year, nonmaintenance formulary change, we will notify

you in writing of certain changes that may affect you.

How do I use the formulary? The formulary begins after this introduction. The drugs in this formulary are grouped into categories

depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a

heart condition have “Cardiovascular” listed in the Therapeutic Category column. Look in the Therapeutic Category column for the category name of what your drug is used for.

What are generic drugs? Peoples Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as

having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand

name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits

may include:

Prior Authorization: Peoples Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your

prescriptions. If you don’t get approval, we may not cover the drug.

Quantity Limits: For certain drugs, Peoples Health limits the amount of the drug that we will cover. For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in

addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Peoples Health 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 out if your drug has any additional requirements or limits by looking in the formulary that

begins after this introduction. You can also get more information about the restrictions applied to specific

covered drugs by visiting our website. We have posted online documents that explain our prior authorization

and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with

the date we last updated the formulary, appears on the front and back cover pages.

2


You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that

may treat your health condition. See the section “How do I request an exception to the Peoples Health formulary?” below for information about how to request an exception.

What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact member

services and ask if your drug is covered.

If you learn that Peoples Health does not cover your drug, you have two options:

You can ask member services for a list of similar drugs that are covered by our plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered

by our plans.

You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Peoples Health formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you

can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the

drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to

waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in

treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization

restriction exception. When you request a formulary, tiering or utilization restriction exception, you

should submit a statement from your prescriber or physician supporting your request. Generally, we

must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request

an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by

3


waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no

later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an

exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you

may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need

prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if

you should switch to an appropriate drug that we cover or request a formulary exception so that we will

cover the drug you take. While you talk to your doctor to determine the right course of action for you, we

may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will

cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these

drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your

ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will

cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Peoples Health provides a transition process for members who experience a level-of-care change and are

currently on a medication regimen that contains non-formulary drugs or formulary drugs with restrictions.

This transition process will occur when the coverage determination processing time frames could interrupt

the prescribed drug regimen. We will cover up to a 31-day temporary supply of these non-formulary drugs or

formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric

facilities; admissions to or discharges from long-term care facilities; giving up hospice status; or exceeding

the limit for days covered during a skilled nursing facility stay.

For more information For more detailed information about your plan’s prescription drug coverage, please review the Evidence of Coverage and other plan materials.

If you have questions about Peoples Health, please contact us. Our contact information, along with the date

we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-

MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,

visit http://www.medicare.gov.

4

http://www.medicare.gov/


Peoples Health formulary The formulary that begins after this introduction provides coverage information about the drugs covered by

Peoples Health.

During the initial coverage stage at network pharmacies, you pay the following, depending on your plan:

Peoples Health Choices 65 #14 (HMO) and Peoples Health Choices Gold (HMO-POS)

Drug Tier 30-Day Supply at a

Retail Pharmacy

90-Day Supply at a

Retail Pharmacy

Supply at a Mail-Order

Pharmacy

Tier 1 – Preferred Generic Tier $0 $0 $0 (90-day)

Tier 2 – Generic Tier $10 $30 $0 (90-day)

Tier 3 – Preferred Brand Tier $30 $90 $90 (90-day)

Tier 4 – Nonpreferred Drug Tier $80 $240 $240 (90-day)

Tier 5 – Specialty Tier 33% coinsurance Not covered

33% coinsurance

(30-day supply)

Peoples Health Group Medicare (HMO-POS)


Retail Pharmacy

90-Day Supply at a

Retail Pharmacy With

Preferred Cost-

Sharing or a Mail-

Order Pharmacy

90-Day Supply

at a Retail

Pharmacy With

Standard

Cost-Sharing

Tier 1 – Preferred Generic Tier $3 $0 $9

Tier 2 – Generic Tier $10 $0 $30

Tier 3 – Preferred Brand Tier $25 $50 $75

Tier 4 – Nonpreferred Drug Tier $50 $100 $150

Tier 5 – Specialty Tier 20% coinsurance

5


Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits


Retail Pharmacy

90-Day Supply at a

Retail Pharmacy With

Preferred Cost-

Sharing or a Mail-

Order Pharmacy

90-Day Supply

at a Retail

Pharmacy With

Standard

Cost-Sharing

Tier 1 – Preferred Generic Tier $0 $0 $0

Tier 2 – Generic Tier $0 $0 $0

Tier 3 – Preferred Brand Tier $20 $40 $60

Tier 4 – Nonpreferred Drug Tier $40 $80 $120

Tier 5 – Specialty Tier 20% coinsurance

6


KEY

This formulary provides information about the drugs covered by Peoples Health. The first column of the chart lists the drug name. Other columns in this chart provide more information

about the drug, including if there are any special requirements for coverage of the drug. Below is an explanation of what these columns mean.

Coverage Gap (CG): If this column is marked "yes," we provide additional coverage for the drug in the coverage gap. Peoples Health Group Medicare (HMO-POS) members have coverage

through the gap for all tiers. Please refer to the Evidence of Coverage for more information.

Mail Order: If this column is marked "yes," the drug is available through our mail-order pharmacy.

Prior Authorization (PA): If this column is marked "yes," we require you or your physician to get prior authorization for the drug. This means that you will need to get approval from us before

you fill a prescription for the drug. If you don’t get approval, we may not cover the drug.

Step Therapy (ST): In some cases, we require 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. If this column is marked "yes," we require you

to first try certain other drugs to treat your medical condition before we will cover the drug.

Limited Access (LA): If this column is marked "yes," the drug may be available only at certain pharmacies. For more information, see the Provider Directory or call member services at the

number on the front and back cover pages of this formulary.

Quantity Limits (QL): For some drugs, there is a limit on the amount of the drug you can have. For example, there may be limits to how many refills you can get, or how much of the drug you

can get each time you fill your prescription (if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill

per day). If this column is marked "yes," we limit the amount of the drug that we will cover. For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in

addition to a standard one-month or three-month supply.

Home Infusion (HI): If this column is marked "yes," the drug is covered under our medical benefit. For more information, call member services at the number on the front and back cover pages.

Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs

Drug Name Tier

Level CG

Mail

Order PA PA Criteria Name ST ST Criteria LA QL

QL

Amount QL Days HI

Brand/

Generic Therapeutic Category

ALLOPURINOL TAB 100MG 1 Yes Yes No No No No No Generic ANALGESICS

ALLOPURINOL TAB 300MG 1 Yes Yes No No No No No Generic ANALGESICS

APAP/CODEINE SOL 120-12/5 2 Yes No No No No Yes 2700 30 No Generic ANALGESICS

APAP/CODEINE TAB 300-15MG 2 Yes No No No No Yes 400 30 No Generic ANALGESICS



BUTORPHANOL INJ 1MG/ML 4 No No No No No No No Generic ANALGESICS

BUTORPHANOL INJ 2MG/ML 4 No No No No No No No Generic ANALGESICS

CELECOXIB CAP 100 MG 2 Yes Yes No No No Yes 120 30 No Generic ANALGESICS




COLCRYS TAB 0.6MG 3 No No No No No Yes 120 30 No Brand ANALGESICS

DICLOFENAC TAB 100MG XR 2 Yes Yes No No No No No Generic ANALGESICS

DICLOFENAC TAB 25MG EC 2 Yes Yes No No No No No Generic ANALGESICS

DICLOFENAC TAB 50MG EC 2 Yes Yes No No No No No Generic ANALGESICS

DICLOFENAC TAB 75MG DR 2 Yes Yes No No No No No Generic ANALGESICS

DICLOFENAC POT TAB 50MG 2 Yes Yes No No No Yes 120 30 No Generic ANALGESICS DICLOFENAC

SODIUM/MISOPROSTOL TAB 50-

0.2MG

2 Yes Yes No No No No No Generic ANALGESICS

DICLOFENAC

SODIUM/MISOPROSTOL TAB 75-

0.2 MG

2 Yes Yes No No No No No Generic ANALGESICS

DIFLUNISAL TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS

ENDOCET TAB 10-325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

ENDOCET TAB 5-325MG 2 Yes No No No No Yes 360 30 No Generic ANALGESICS

ENDOCET TAB 7.5-325M 2 Yes No No No No Yes 240 30 No Generic ANALGESICS

ENDOCET TAB 2.5-325 2 Yes No No No No Yes 360 30 No Generic ANALGESICS


Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


ETODOLAC CAP 200MG 2 Yes Yes No No No No No Generic ANALGESICS

ETODOLAC CAP 300MG 2 Yes Yes No No No No No Generic ANALGESICS

ETODOLAC TAB 400MG 2 Yes Yes No No No No No Generic ANALGESICS

ETODOLAC TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS

ETODOLAC ER TAB 400MG 2 Yes Yes No No No No No Generic ANALGESICS



FENTANYL DIS 100MCG/H 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS

FENTANYL DIS 12MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS



FENTANYL DIS 75MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS FENTANYL CITRATE 0.2 MG

TRANSMUCOSAL LOZENGES 5 No No Yes

ORAL-INTRANASAL

FENTANYL No No Yes 120 30 No Generic ANALGESICS

FENTANYL CITRATE 0.4 MG


ORAL-INTRANASAL




ORAL-INTRANASAL




ORAL-INTRANASAL




ORAL-INTRANASAL




ORAL-INTRANASAL


FENTORA 100 MCG BUCCAL

TABLET 5 No No Yes

ORAL-INTRANASAL

FENTANYL No No Yes 120 30 No Brand ANALGESICS


TABLET 5 No No Yes

ORAL-INTRANASAL



Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/



TABLET 5 No No Yes

ORAL-INTRANASAL



TABLET 5 No No Yes

ORAL-INTRANASAL



TABLET 5 No No Yes

ORAL-INTRANASAL


FLURBIPROFEN TAB 100MG 2 Yes Yes No No No No No Generic ANALGESICS

FLURBIPROFEN TAB 50MG 2 Yes Yes No No No No No Generic ANALGESICS HYDROCODONE/APAP SOL 7.5-

325 2 Yes No No No No Yes 2700 30 No Generic ANALGESICS

HYDROCODONE/APAP TAB 10-

325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

HYDROCODONE/APAP TAB 5-


HYDROCODONE/APAP TAB 7.5-

325 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

HYDROCODONE/IBUPROFEN TAB

7.5-200 2 Yes No No No No Yes 150 30 No Generic ANALGESICS

HYDROMORPHONE INJ (PF)

10MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS

HYDROMORPHONE INJ 50

MG/5ML (PF) INJ (10 MG/ML) 4 No No Yes B VS. D No No No No Generic ANALGESICS

HYDROMORPHONE INJ 500

MG/50ML (PF) INJ (10 MG/ML) 4 No No Yes B VS. D No No No No Generic ANALGESICS

HYDROMORPHONE LIQ 1MG/ML 2 Yes No No No No Yes 600 30 No Generic ANALGESICS

HYDROMORPHONE TAB 2MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS




Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


HYSINGLA ER TAB 100 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS







IBU TAB 600MG 1 Yes Yes No No No No No Generic ANALGESICS

IBU TAB 800MG 1 Yes Yes No No No No No Generic ANALGESICS

IBUPROFEN SUS 100/5ML 2 Yes Yes No No No No No Generic ANALGESICS

IBUPROFEN TAB 400MG 1 Yes Yes No No No No No Generic ANALGESICS



LORCET TAB 5-325MG 2 Yes No No No No Yes 240 30 No Generic ANALGESICS

LORCET HD TAB 10-325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

LORCET PLUS TAB 7.5-325 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

MELOXICAM TAB 15MG 1 Yes Yes No No No No No Generic ANALGESICS

MELOXICAM TAB 7.5MG 1 Yes Yes No No No No No Generic ANALGESICS

METHADONE CON 10MG/ML 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS

METHADONE SOL 10MG/5ML 2 Yes No Yes IR BEFORE ER No No Yes 450 30 No Generic ANALGESICS

METHADONE SOL 5MG/5ML 2 Yes No Yes IR BEFORE ER No No Yes 450 30 No Generic ANALGESICS

METHADONE TAB 10MG 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS

METHADONE TAB 5MG 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS

MITIGARE CAP 0.6MG 3 No No No No No Yes 60 30 No Brand ANALGESICS

MORPHINE 1 MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS

MORPHINE 8 MG/ML SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS MORPHINE SUL INJ 10MG/ML PF

SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS


Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


MORPHINE SUL INJ 10MG/ML PF

SYRINGE (10) 4 No No Yes B VS. D No No No No Generic ANALGESICS


VIAL 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 150/30ML

(5MG/ML) 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 2MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS MORPHINE SUL INJ 2MG/ML

SYRINGE 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 2MG/ML VIAL 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 4MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS MORPHINE SUL INJ 4MG/ML

(SYRINGE) 4 No No Yes B VS. D No No No No Generic ANALGESICS


(SYRINGE) 4 No No Yes B VS. D No No No No Generic ANALGESICS


(VIAL) 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 5MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS MORPHINE SUL INJ 8 MG/ML PF

SYRINGE 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL INJ 8 MG/ML PF

VIAL 4 No No Yes B VS. D No No No No Generic ANALGESICS

MORPHINE SUL INJ 8 MG/ML PF

VIAL (SSB) 4 No No Yes B VS. D No No No No Brand ANALGESICS

MORPHINE SUL SOL 10MG/5ML 2 Yes No No No No Yes 900 30 No Generic ANALGESICS

MORPHINE SUL SOL 20MG/5ML 2 Yes No No No No Yes 750 30 No Generic ANALGESICS

MORPHINE SUL SOL 20MG/ML 2 Yes No No No No Yes 180 30 No Generic ANALGESICS


Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


MORPHINE SUL TAB 100MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS

MORPHINE SUL TAB 15MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS



MORPHINE SUL TAB 30MG 2 Yes No No No No Yes 90 30 No Generic ANALGESICS


MORPHINE SUL TAB 60MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS MORPHINE SULFATE INJ 10

MG/ML SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS

MORPHINE SULFATE INJ PF 5

MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS

NABUMETONE TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS

NABUMETONE TAB 750MG 2 Yes Yes No No No No No Generic ANALGESICS

NALBUPHINE INJ 10MG/ML 4 No No No No No No No Generic ANALGESICS

NALBUPHINE INJ 20MG/ML 4 No No No No No No No Generic ANALGESICS

NAPROXEN TAB 250MG 1 Yes Yes No No No No No Generic ANALGESICS



NAPROXEN DR TAB 375MG EC 1 Yes Yes No No No No No Generic ANALGESICS

NAPROXEN DR TAB 500MG EC 1 Yes Yes No No No No No Generic ANALGESICS

NAPROXEN SOD TAB 275MG 2 Yes Yes No No No No No Generic ANALGESICS

NAPROXEN SOD TAB 550MG 2 Yes Yes No No No No No Generic ANALGESICS

NUCYNTA ER TAB 100MG 3 No No Yes IR BEFORE ER No No Yes 60 30 No Brand ANALGESICS






Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


OXAPROZIN TAB 600MG 2 Yes Yes No No No No No Generic ANALGESICS

OXYCODONE TAB 15MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS



OXYCODONE 5 MG CAPSULE 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

OXYCODONE HCL 10 MG TABLET 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

OXYCODONE HCL 20 MG TABLET 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

OXYCODONE HCL 20 MG/ML SOL 2 Yes No No No No Yes 180 30 No Generic ANALGESICS

OXYCODONE HCL 5 MG/5 ML SOL 2 Yes No No No No Yes 900 30 No Generic ANALGESICS

OXYCODONE/APAP TAB 10-


OXYCODONE/APAP TAB 2.5-325 2 Yes No No No No Yes 360 30 No Generic ANALGESICS

OXYCODONE/APAP TAB 5-


OXYCODONE/APAP TAB 7.5-325 2 Yes No No No No Yes 240 30 No Generic ANALGESICS

PIROXICAM CAP 10MG 2 Yes Yes No No No No No Generic ANALGESICS

PIROXICAM CAP 20MG 2 Yes Yes No No No No No Generic ANALGESICS

PROBEN/COLCH TAB 500-0.5 2 Yes Yes No No No No No Generic ANALGESICS

PROBENECID TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS

SULINDAC TAB 150MG 1 Yes Yes No No No No No Generic ANALGESICS

SULINDAC TAB 200MG 1 Yes Yes No No No No No Generic ANALGESICS

TRAMADOL HCL TAB 50MG 2 Yes No No No No Yes 240 30 No Generic ANALGESICS


Drug Name Tier

Level CG

Mail


QL

Amount QL Days HI

Brand/


TRAMADOL/APAP TAB 37.5-325 2 Yes No No No No Yes 240 30 No Generic ANALGESICS

ULORIC 40 MG TABLET 3 No Yes No Yes

You must try

ALLOPURINOL

before ULORIC is

covered

No No No Brand ANALGESICS

ULORIC 80 MG TABLET 3 No Yes No Yes

You must try

ALLOPURINOL

before ULORIC is

covered

No No No Brand ANALGESICS

LIDOCAINE INJ 0.5% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

LIDOCAINE INJ 0.5% (PF) 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

LIDOCAINE INJ 1% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

LIDOCAINE INJ 2% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

LIDOCAINE HCL 1% SYRINGE 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

LIDOCAINE HCL 1.5% AMPUL 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS

ABACAVIR TAB 300MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES ABACAVIR SULFATE SOLN 20

MG/ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ABACAVIR SULFATE-LAMIVUDINE

TAB 600-300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ABACAVIR SULFATE-LAMIVUDINE-

ZIDOVUDINE TAB 300-150-300

MG

5 No Yes No No No No No Generic ANTI-INFECTIVES

ABELCET INJ 5MG/ML 5 No No Yes B VS. D No No No Yes Brand ANTI-INFECTIVES

ACYCLOVIR CAP 200MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

ACYCLOVIR SUS 200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

ACYCLOVIR TAB 400MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

ACYCLOVIR TAB 800MG 1 Yes No No No No No No Generic ANTI-INFECTIVES


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Amount QL Days HI

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ACYCLOVIR NA INJ 50MG/ML 2 Yes No Yes B VS. D No No No Yes Generic ANTI-INFECTIVES

ADEFOVIR DIPIVOXIL TAB 10 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

ALBENZA TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES

ALINIA SUS 100MG/5M 5 No No No No No No No Brand ANTI-INFECTIVES

ALINIA TAB 500MG 5 No No No No No No No Brand ANTI-INFECTIVES

AMBISOME INJ 50MG 5 No No Yes B VS. D No No No Yes Brand ANTI-INFECTIVES

AMIKACIN INJ 1GM/4ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMIKACIN INJ 500/2ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN & K CLAVULANATE

TAB SR 12HR 1000-62.5 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN CAP 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN CHW 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN CHW 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN SUS 125/5ML 1 Yes No No No No No No Generic ANTI-INFECTIVES




AMOXICILLIN TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN TAB 875MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AMOXICILLIN/K CLAV CHW

200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMOXICILLIN/K CLAV CHW


AMOXICILLIN/K CLAV SUS

200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES


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AMOXICILLIN/K CLAV TAB






AMPHOTERICIN INJ 50MG 2 Yes No Yes B VS. D No No No Yes Generic ANTI-INFECTIVES AMPICILLIN & SULBACTAM

SODIUM FOR INJ 10-5 GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AMPICILLIN CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMPICILLIN INJ 10GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMPICILLIN INJ 125MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AMPICILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AMPICILLIN INJ 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMPICILLIN INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMPICILLIN INJ 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES AMPICILLIN INJ FOR IV SOLN

10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AMPICILLIN INJ FOR IV SOLN

1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

AMPICILLIN INJ FOR IV SOLN



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Amount QL Days HI

Brand/


AMPICILLIN-SULBACTAM 1.5 GM

VL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AMPICILLIN-SULBACTAM INJ


AMPICILLIN-SULBACTAM INJ

3GM (2-1 GM) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

APTIVUS CAP 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

APTIVUS SOL 5 No Yes No No No No No Brand ANTI-INFECTIVES ATAZANAVIR SULFATE CAP 150

MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

ATAZANAVIR SULFATE CAP 200


ATAZANAVIR SULFATE CAP 300


ATOVAQUONE SUS 750/5ML 5 No No No No No No No Generic ANTI-INFECTIVES ATOVAQUONE/ PROGUANIL 250-

100 MG TABLET 2 Yes No No No No No No Generic ANTI-INFECTIVES

ATOVAQUONE-PROGUANIL HCL

TAB 62.5-25 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

ATRIPLA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

AUGMENTIN SUS 125/5ML 4 No No No No No No No Brand ANTI-INFECTIVES

AZACTAM INJ 2GM 4 No No No No No No Yes Brand ANTI-INFECTIVES

AZACTAM 1 GM VIAL 4 No No No No No No Yes Brand ANTI-INFECTIVES

AZACTAM/DEX INJ 1GM 4 No No No No No No No Brand ANTI-INFECTIVES

AZACTAM/DEX INJ 2GM 4 No No No No No No No Brand ANTI-INFECTIVES AZITHROMYCIN 1 GM PWD

PACKET 2 Yes No No No No No No Generic ANTI-INFECTIVES

AZITHROMYCIN INJ 500MG VIAL

(2 MG/ML) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES


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Amount QL Days HI

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AZITHROMYCIN SUS 100/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

AZITHROMYCIN SUS 200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

AZITHROMYCIN TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AZITHROMYCIN TAB 250MG

PACK 1 Yes No No No No No No Generic ANTI-INFECTIVES

AZITHROMYCIN TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AZITHROMYCIN TAB 500MG

PACK 1 Yes No No No No No No Generic ANTI-INFECTIVES

AZITHROMYCIN TAB 600MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

AZTREONAM INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

AZTREONAM INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

BARACLUDE SOL .05MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES

BICILLIN L-A INJ 1200000 4 No No No No No No No Brand ANTI-INFECTIVES



BIKTARVY TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

BILTRICIDE TAB 600MG 3 No No No No No No No Brand ANTI-INFECTIVES CASPOFUNGIN ACETATE FOR IV

SOLN 50 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES

CASPOFUNGIN ACETATE FOR IV

SOLN 70 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES

CAYSTON INH 75MG 5 No No Yes CAYSTON No Yes No No Brand ANTI-INFECTIVES

CEFACLOR CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFACLOR CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFACLOR SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES



CEFACLOR ER TAB 500MG 4 No No No No No No No Generic ANTI-INFECTIVES

CEFADROXIL CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES


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CEFADROXIL SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFADROXIL SUS 500/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFADROXIL TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFAZOLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFAZOLIN INJ 1GM/50ML 3 No No No No No No No Generic ANTI-INFECTIVES

CEFAZOLIN INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFAZOLIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFAZOLIN INJ 20GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFAZOLIN INJ FOR IV SOLN 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFAZOLIN SODIUM-DEXTROSE

IV SOLUTION 2 GM/100ML-4% 3 No No No No No No No Brand ANTI-INFECTIVES

CEFDINIR CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFDINIR SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFDINIR SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFEPIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFEPIME INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFIXIME FOR SUSP 100 MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFIXIME FOR SUSP 200 MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFOTAXIME INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFOTAXIME INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFOTAXIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFOXITIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES



CEFPODOXIME TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFPODOXIME TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES


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CEFPODOXIME PROX SUS


CEFPODOXIME PROX SUS

50MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFPROZIL SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFPROZIL SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFPROZIL TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFPROZIL TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFTAZIDIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES



CEFTAZIDIME/ SOL D5W 1GM 4 No No No No No No No Brand ANTI-INFECTIVES

CEFTAZIDIME/ SOL D5W 2 GM 4 No No No No No No No Brand ANTI-INFECTIVES

CEFTRIAXONE INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFTRIAXONE INJ 250MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFTRIAXONE INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFTRIAXONE 1 GM VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFTRIAXONE 2 GM VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFTRIAXONE/DEX INJ 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFTRIAXONE/DEX INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFUROXIME INJ 1.5GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFUROXIME INJ 7.5GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFUROXIME INJ 750MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CEFUROXIME TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFUROXIME TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEFUROXIME INJ 1.5GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

CEPHALEXIN CAP 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

CEPHALEXIN CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

CEPHALEXIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES


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Amount QL Days HI

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CEPHALEXIN SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CHLOROQUINE TAB 250MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

CHLOROQUINE TAB 500MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

CIMDUO TAB 300MG-300MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

CIPROFLOXACIN 200 MG/100 ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CIPROFLOXACIN 400 MG/200 ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CIPROFLOXACIN FOR ORAL SUSP

250 MG/5ML (5%) (5 GM/100ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES

CIPROFLOXACIN FOR ORAL SUSP

500 MG/5ML (10%) (10

GM/100ML)

2 Yes No No No No No No Generic ANTI-INFECTIVES

CIPROFLOXACIN TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES




CLARITHROMYCIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLARITHROMYCIN SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLARITHROMYCIN TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLARITHROMYCIN TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLARITHROMYCIN TAB 500MG ER 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLINDAMYCIN INJ 600MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES



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Amount QL Days HI

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CLINDAMYCIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLINDAMYCIN CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES CLINDAMYCIN INJ 150MG/ML IV

SOLUTION 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CLINDAMYCIN HCL CAP 75 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLINDAMYCIN INJ 150MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES CLINDAMYCIN PED SOL

75MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLINDAMYCIN PHOSPHATE IN

D5W IV SOLN 600 MG/50ML 2 Yes No No No No No No Generic ANTI-INFECTIVES


NACL 0.9% IV SOLN 300

MG/50ML

4 No No No No No No No Brand ANTI-INFECTIVES



MG/50ML




MG/50ML


CLINDAMYCIN PHOSPHATE INJ

300 MG/2ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

CLINDAMYCIN PHOSPHATE INJ 9

GM/60ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

CLINDAMYCIN PHOSPHATE INJ


CLINDAMYCIN PHOSPHATE IV INJ

900 MG/6ML 2 Yes No No No No No No Generic ANTI-INFECTIVES


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Brand/


COARTEM 20 MG/ 120 MG

TABLET 4 No No No No No No No Brand ANTI-INFECTIVES

COLISTIMETHATE INJ 150MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

COMPLERA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

CRIXIVAN CAP 200MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

CRIXIVAN CAP 400MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

CYCLOSERINE CAP 250 MG 5 No No No No No No No Generic ANTI-INFECTIVES

DAPSONE TAB 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

DAPSONE TAB 25MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES DAPTOMYCIN FOR IV SOLN 500

MG 5 No No No No No No Yes Generic ANTI-INFECTIVES

DESCOVY TAB 200/25 5 No Yes No No No No No Brand ANTI-INFECTIVES

DICLOXACILLIN CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DICLOXACILLIN CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DIDANOSINE CAP 200MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES



DIFICID TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES

DOXY 100 INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE TAB 20MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE HYC CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE HYC CAP 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE HYC INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES DOXYCYCLINE HYCLATE TAB


DOXYCYCLINE MONO 100 MG

CAP 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE MONO 50 MG CAP 2 Yes No No No No No No Generic ANTI-INFECTIVES


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DOXYCYCLINE MONO TAB 100

MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

DOXYCYCLINE MONO TAB 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES



E.E.S. 400 TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

EDURANT TAB 25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

EFAVIRENZ CAP 200 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

EFAVIRENZ CAP 50 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

EFAVIRENZ TAB 600 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

EMTRIVA CAP 200MG 3 No Yes No No No No No Brand ANTI-INFECTIVES

EMTRIVA SOL 10MG/ML 3 No Yes No No No No No Brand ANTI-INFECTIVES

EMVERM CHW 100MG 5 No No No No No No No Brand ANTI-INFECTIVES

ENTECAVIR TAB 0.5 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

ENTECAVIR TAB 1 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

EPCLUSA TAB 400-100 5 No No Yes EPCLUSA No No No No Brand ANTI-INFECTIVES

EPIVIR HBV SOL 5MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES

ERTAPENEM INJ 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

ERY-TAB TAB 250MG EC 2 Yes No No No No No No Generic ANTI-INFECTIVES



ERYTHROCIN INJ 500MG 4 No No No No No No Yes Brand ANTI-INFECTIVES

ERYTHROCIN TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

ERYTHROM ETH TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

ERYTHROMYCIN 250 MG CAP EC 2 Yes No No No No No No Generic ANTI-INFECTIVES


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ERYTHROMYCIN TAB 250MG BS 2 Yes No No No No No No Generic ANTI-INFECTIVES

ERYTHROMYCIN TAB 500MG BS 2 Yes No No No No No No Generic ANTI-INFECTIVES

ETHAMBUTOL TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

ETHAMBUTOL TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

EVOTAZ TAB 300-150 5 No Yes No No No No No Brand ANTI-INFECTIVES

FAMCICLOVIR TAB 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES



FLUCONAZOLE SUS 10MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

FLUCONAZOLE SUS 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

FLUCONAZOLE TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES




FLUCONAZOLE/ INJ DEX 400 2 Yes No No No No No No Generic ANTI-INFECTIVES FLUCONAZOLE-DEXT 200 MG/100

ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

FLUCONAZOLE-NS 200 MG/100

ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

FLUCONAZOLE-NS 400 MG/200

ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

FLUCYTOSINE CAP 250 MG 5 No No No No No No No Generic ANTI-INFECTIVES

FLUCYTOSINE CAP 500 MG 5 No No No No No No No Generic ANTI-INFECTIVES FOSAMPRENAVIR CALCIUM TAB

700 MG (BASE EQUIV) 5 No Yes No No No No No Generic ANTI-INFECTIVES

FUZEON INJ 90MG 5 No Yes No No No No No Brand ANTI-INFECTIVES GANCICLOVIR SODIUM FOR INJ

500 MG 2 Yes No Yes B VS. D No No No No Generic ANTI-INFECTIVES

GENTAM/NACL INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES


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GENTAMICIN INJ 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES GENTAMICIN PED 10 MG/ML

VIAL 2 Yes No No No No No No Generic ANTI-INFECTIVES

GENTAMICIN/NACL INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES GENTAMICIN/NACL INJ 60MG 50

ML (1.2 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES

GENTAMICIN/NACL INJ 80MG

100 ML (0.8 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES

GENTAMICIN/NACL INJ 80MG/

50 ML (1.6 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES

GENVOYA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES GRISEOFULVIN MICROSIZE TAB

500 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

GRISEOFULVIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

GRISEOFULVIN TAB ULTR 125 2 Yes No No No No No No Generic ANTI-INFECTIVES

GRISEOFULVIN TAB ULTR 250 2 Yes No No No No No No Generic ANTI-INFECTIVES

HARVONI TAB 90-400MG 5 No No Yes HARVONI No No No No Brand ANTI-INFECTIVES IMIPENEM/CILASTATIN INJ

250MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

IMIPENEM/CILASTATIN INJ


INTELENCE TAB 100MG 5 No Yes No No No No No Brand ANTI-INFECTIVES



INVANZ INJ 1GM 4 No No No No No No Yes Brand ANTI-INFECTIVES

INVANZ INJ 1GM FOR IV 4 No No No No No No No Brand ANTI-INFECTIVES

INVIRASE CAP 200MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

INVIRASE TAB 500MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

ISENTRESS SUSP 100MG 3 No Yes No No No No No Brand ANTI-INFECTIVES


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ISENTRESS TAB 400MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

ISENTRESS CHEW 100 MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

ISENTRESS CHEW 25 MG 3 No Yes No No No No No Brand ANTI-INFECTIVES

ISENTRESS HD TAB 600MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

ISONIAZID SYP 50MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ISONIAZID TAB 100MG 1 Yes Yes No No No No No Generic ANTI-INFECTIVES

ISONIAZID TAB 300MG 1 Yes Yes No No No No No Generic ANTI-INFECTIVES

ITRACONAZOLE CAP 100MG 2 Yes No Yes ITRACONAZOLE No No No No Generic ANTI-INFECTIVES

IVERMECTIN TAB 3 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

JULUCA TAB 50-25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

KALETRA TAB 100-25MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

KALETRA TAB 200-50MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

KETOCONAZOLE TAB 200MG 2 Yes No Yes KETOCONAZOLE No No No No Generic ANTI-INFECTIVES

LAMIVUDINE TAB 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES LAMIVUDINE ORAL SOLN 10

MG/ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

LAMIVUDINE TAB 150 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

LAMIVUDINE TAB 300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES LAMIVUDINE-ZIDOVUDINE TAB

150-300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

LEVOFLOXACIN 250 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES

LEVOFLOXACIN 500 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES

LEVOFLOXACIN 750 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES LEVOFLOXACIN IN D5W IV SOLN

250 MG/50ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

LEVOFLOXACIN IN D5W IV SOLN


LEVOFLOXACIN IN D5W IV SOLN



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Amount QL Days HI

Brand/


LEVOFLOXACIN INJ 25MG/ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES LEVOFLOXACIN ORAL SOLN 25

MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

LEXIVA SUS 50MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES

LINEZOLID TAB 600MG 5 No No No No No No No Generic ANTI-INFECTIVES LINEZOLID FOR SUSP 100

MG/5ML 5 No No No No No No No Generic ANTI-INFECTIVES

LINEZOLID IN SODIUM CHLORIDE

IV SOLN 600 MG/300ML-0.9% 4 No No No No No No No Generic ANTI-INFECTIVES

LINEZOLID IV SOLN 600

MG/300ML (2 MG/ML) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

LOPINAVIR-RITONAVIR SOLN 400-

100 MG/5ML (80-20 MG/ML) 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

MAVYRET TAB 100-40MG 5 No No Yes MAVYRET No No No No Brand ANTI-INFECTIVES

MEFLOQUINE TAB 250MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

MEROPENEM INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES MEROPENEM IV FOR SOLN 1000

MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

METHENAMINE HIP TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

METRONIDAZOLE TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

METRONIDAZOLE TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES METRONIDAZOLE/NACL INJ


MINOCYCLINE CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES



MODERIBA TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES


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MONDOXYNE NL CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

MONDOXYNE NL CAP 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

MORGIDOX CAP 1X50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

MORGIDOX CAP 2X100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES MOXIFLOXACIN HCL 400

MG/250ML INJ 4 No No No No No No No Brand ANTI-INFECTIVES

MOXIFLOXACIN HCL 400

MG/250ML IN SODIUM

CHLORIDE 0.8% INJ

2 Yes No No No No No No Generic ANTI-INFECTIVES

MOXIFLOXACIN TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

MYCAMINE INJ 100MG 5 No No No No No No Yes Brand ANTI-INFECTIVES

MYCAMINE INJ 50MG 5 No No No No No No Yes Brand ANTI-INFECTIVES

NAFCILLIN INJ 10GM 5 No No No No No No Yes Generic ANTI-INFECTIVES

NAFCILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

NAFCILLIN INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

NAFCILLIN INJ FOR IV SOLN 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

NAFCILLIN INJ FOR IV SOLN 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

NEBUPENT INH 300MG 4 No No Yes B VS. D No No No No Brand ANTI-INFECTIVES

NEOMYCIN TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

NEVIRAPINE TAB 400MG ER 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

NEVIRAPINE SUSP 50 MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

NEVIRAPINE TAB 200MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES NEVIRAPINE TAB SR 24HR 100

MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

NITROFURANTOIN MAC CAP

50MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES


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NITROFURANTOIN MONO-MAC

CAP 100MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES

NITROFURANTOIN-MACRO 100

MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES

NORVIR CAP 100MG 3 No Yes No No No No No Brand ANTI-INFECTIVES

NORVIR POW 100MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

NORVIR SOL 80MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES

NOXAFIL SUS 40MG/ML 5 No Yes No No No Yes 630 30 No Brand ANTI-INFECTIVES

NOXAFIL TAB 100MG 5 No Yes No No No Yes 93 30 No Brand ANTI-INFECTIVES

NYSTATIN TAB 500000 2 Yes No No No No No No Generic ANTI-INFECTIVES

ODEFSEY TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES OSELTAMIVIR PHOSPHATE CAP

30 MG 2 Yes No No No No Yes 168 365 No Generic ANTI-INFECTIVES

OSELTAMIVIR PHOSPHATE CAP


OSELTAMIVIR PHOSPHATE CAP


OSELTAMIVIR PHOSPHATE FOR

SUSP 6 MG/ML (BASE EQUIV) 2 Yes No No No No Yes 1080 365 No Generic ANTI-INFECTIVES

OXACILLIN INJ 10GM 5 No No No No No No Yes Generic ANTI-INFECTIVES

OXACILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

OXACILLIN INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

PAROMOMYCIN CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

PASER GRA 4GM 4 No No No No No No No Brand ANTI-INFECTIVES

PEGASYS 180 MCG/ML VIAL 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES PEGASYS INJ 180 MCG/0.5ML

SYRINGE 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES


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PEGASYS INJ PROCLICK 180

MCG/0.5ML 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES

PENICILLIN G PROC INJ 600000 4 No No No No No No No Generic ANTI-INFECTIVES

PENICILLIN G SOD INJ 5000000 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

PENICILLIN GK INJ 20MU 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

PENICILLIN GK INJ 5MU 2 Yes No No No No No No Generic ANTI-INFECTIVES

PENICILLIN GK/ INJ DEX 2MU 4 No No No No No No Yes Brand ANTI-INFECTIVES

PENICILLIN GK/ INJ DEX 3MU 4 No No No No No No Yes Brand ANTI-INFECTIVES

PENICILLIN VK SOL 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

PENICILLIN VK SOL 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

PENICILLIN VK TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

PENICILLIN VK TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

PENTAM 300 INJ 300MG 4 No No No No No No Yes Brand ANTI-INFECTIVES

PFIZERPEN-G INJ 20MU 2 Yes No No No No No No Generic ANTI-INFECTIVES

PFIZERPEN-G INJ 5MU 2 Yes No No No No No No Generic ANTI-INFECTIVES

PIPERACILLIN / TAZOBACTAM 12-

1.5 GRAM INJECTABLE SOLUTION 4 No No No No No No No Brand ANTI-INFECTIVES

PIPERACILLIN 200 MG/ML /

TAZOBACTAM 25 MG/ML

INJECTABLE SOLUTION

2 Yes No No No No No Yes Generic ANTI-INFECTIVES

PIPERACILLIN SODIUM-

TAZOBACTAM SODIUM FOR INJ

36-4.5 GM


PIPERACILLIN SODIUM-

TAZOBACTAM SODIUM FOR INJ 4-

0.5 GM



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PIPERACILLIN/TAZOBABACTAM

INJ 3-0.375G 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

PRAZIQUANTEL TAB 600 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

PREZCOBIX TAB 800-150 5 No Yes No No No No No Brand ANTI-INFECTIVES

PREZISTA TAB 150MG 5 No Yes No No No Yes 240 30 No Brand ANTI-INFECTIVES



PREZISTA TAB 800MG 5 No Yes No No No Yes 30 30 No Brand ANTI-INFECTIVES PREZISTA ORAL SUSPENSION

100MG/ML 5 No Yes No No No Yes 400 30 No Brand ANTI-INFECTIVES

PRIFTIN TAB 150MG 4 No No No No No No No Brand ANTI-INFECTIVES

PRIMAQUINE TAB 26.3MG 3 No No No No No No No Brand ANTI-INFECTIVES

PYRAZINAMIDE TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

QUININE SULFATE 324 MG CAP 2 Yes No Yes QUININE SULFATE No No No No Generic ANTI-INFECTIVES

REBETOL SOL 40MG/ML 5 No No No No No No No Brand ANTI-INFECTIVES

RELENZA MIS DISKHALE 3 No No No No No Yes 120 365 No Brand ANTI-INFECTIVES

RESCRIPTOR TAB 100 MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

RESCRIPTOR TAB 200MG 4 No Yes No No No No No Brand ANTI-INFECTIVES REYATAZ POWDER FOR

SUSPENSION 50 MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

RIBASPHERE CAP 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIBASPHERE TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIBASPHERE TAB 400MG 5 No No No No No No No Generic ANTI-INFECTIVES

RIBASPHERE TAB 600MG 5 No No No No No No No Generic ANTI-INFECTIVES

RIBAVIRIN CAP 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIBAVIRIN TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIFABUTIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIFAMPIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIFAMPIN CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES


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RIFAMPIN INJ 600 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RIFATER TAB 4 No No No No No No No Brand ANTI-INFECTIVES

RIMANTADINE TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

RITONAVIR TAB 100 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

SELZENTRY TAB 150MG 5 No Yes No No No No No Brand ANTI-INFECTIVES




SELZENTRY SOL 20MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES

SIRTURO TAB 100MG 5 No No Yes SIRTURO No Yes No No Brand ANTI-INFECTIVES

SIVEXTRO INJ 200MG 5 No No No No No No No Brand ANTI-INFECTIVES

SIVEXTRO TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES

SMZ/TMP DS TAB 800-160 1 Yes No No No No No No Generic ANTI-INFECTIVES

SMZ-TMP INJ 400-80/5 2 Yes No No No No No No Generic ANTI-INFECTIVES

SMZ-TMP TAB 400-80MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

SMZ-TMP SUS 200-40/5 2 Yes No No No No No No Generic ANTI-INFECTIVES

STAVUDINE CAP 15MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES




STREPTOMYCIN INJ 1GM 5 No No No No No No No Generic ANTI-INFECTIVES

STRIBILD TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

SULFADIAZINE TAB 500MG 4 No No No No No No No Generic ANTI-INFECTIVES

SULFATRIM PD SUS 200-40/5 2 Yes No No No No No No Generic ANTI-INFECTIVES

SUPRAX CAP 400MG 3 No No No No No No No Brand ANTI-INFECTIVES

SUPRAX CHW 100MG 4 No No No No No No No Brand ANTI-INFECTIVES

SUPRAX CHW 200MG 4 No No No No No No No Brand ANTI-INFECTIVES SUPRAX 500 MG/5 ML

SUSPENSION 3 No No No No No No No Brand ANTI-INFECTIVES


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SYMFI TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

SYMFI LO TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

SYMTUZA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

SYNERCID INJ 500MG 5 No No No No No No No Brand ANTI-INFECTIVES

TAZICEF INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES TAZICEF INJ 1GM VIAL FOR

RECONSTITUTION 2 Yes No No No No No No Generic ANTI-INFECTIVES

TAZICEF INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES TAZICEF INJ 2GM VIAL FOR

RECONSTITUTION 2 Yes No No No No No No Generic ANTI-INFECTIVES

TAZICEF INJ 6GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

TEFLARO INJ 400MG 5 No No No No No No No Brand ANTI-INFECTIVES

TEFLARO INJ 600MG 5 No No No No No No No Brand ANTI-INFECTIVES TENOFOVIR DISOPROXIL

FUMARATE TAB 300 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES

TERBINAFINE TAB 250MG 1 Yes No No No No Yes 90 365 No Generic ANTI-INFECTIVES

TETRACYCLINE CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

TETRACYCLINE CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

TIGECYCLINE FOR IV SOLN 50 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES

TIVICAY TAB 10MG 3 No Yes No No No No No Brand ANTI-INFECTIVES



TOBRAMYCIN INJ 1.2/30ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

TOBRAMYCIN INJ 1.2GM 5 No No No No No No No Generic ANTI-INFECTIVES

TOBRAMYCIN INJ 10MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

TOBRAMYCIN INJ 80MG/2ML 2 Yes No No No No No No Generic ANTI-INFECTIVES

TOBRAMYCIN INJ 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES


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TOBRAMYCIN NEBULIZATION

SOLN 300 MG/5ML 5 No No Yes TOBRAMYCIN No No No No Generic ANTI-INFECTIVES

TRECATOR TAB 250MG 4 No No No No No No No Brand ANTI-INFECTIVES

TRIMETHOPRIM TAB 100MG 1 Yes No No No No No No Generic ANTI-INFECTIVES

TRIUMEQ TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES

TROGARZO INJ 150MG/ML 5 No Yes No No Yes No No Brand ANTI-INFECTIVES

TRUVADA TAB 100-150 5 No Yes No No No Yes 60 30 No Brand ANTI-INFECTIVES




TYBOST TAB 150MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

VALACYCLOVIR TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES

VALACYCLOVIR TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES VALGANCICLOVIR HCL FOR SOLN

50 MG/ML (AG) 5 No Yes No No No No No Generic ANTI-INFECTIVES

VALGANCICLOVIR HCL TAB 450


VANCOMYCIN CAP 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

VANCOMYCIN CAP 250MG 5 No No No No No No No Generic ANTI-INFECTIVES

VANCOMYCIN INJ 1000MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

VANCOMYCIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

VANCOMYCIN INJ 750MG 2 Yes No No No No No No Generic ANTI-INFECTIVES

VANCOMYCIN 5 GM VIAL 2 Yes No No No No No No Generic ANTI-INFECTIVES

VANCOMYCIN 500 MG VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES VANCOMYCIN/NACL 0.9% INJ

1000 MG/200ML 4 No No No No No No No Brand ANTI-INFECTIVES

VANCOMYCIN/NACL 0.9% INJ 500

MG/100ML 4 No No No No No No No Brand ANTI-INFECTIVES


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VANCOMYCIN/NACL 0.9% INJ 750

MG/150ML 4 No No No No No No No Brand ANTI-INFECTIVES

VEMLIDY TAB 25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIDEX SOL 2GM 4 No Yes No No No No No Brand ANTI-INFECTIVES

VIDEX 4 GM PEDIATRIC SOLN 4 No Yes No No No No No Brand ANTI-INFECTIVES

VIDEX EC CAP 125MG 4 No Yes No No No No No Brand ANTI-INFECTIVES

VIRACEPT TAB 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIRACEPT TAB 625MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIRAMUNE SUS 50MG/5ML 4 No Yes No No No No No Brand ANTI-INFECTIVES

VIREAD POW 40MG/GM 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIREAD TAB 150MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIREAD TAB 200MG 5 No Yes No No No No No Brand ANTI-INFECTIVES

VIREAD TAB 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES VORICONAZOLE FOR SUSP 40

MG/ML 5 No No No No No No No Generic ANTI-INFECTIVES

VORICONAZOLE INJ 200MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES

VORICONAZOLE TAB 200 MG 5 No No No No No No No Generic ANTI-INFECTIVES

VORICONAZOLE TAB 50 MG 5 No No No No No No No Generic ANTI-INFECTIVES

VOSEVI TAB 5 No No Yes VOSEVI No No No No Brand ANTI-INFECTIVES

ZEPATIER TAB 50-100MG 5 No No Yes ZEPATIER No No No No Brand ANTI-INFECTIVES

ZERIT SOL 1MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES

ZIDOVUDINE CAP 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ZIDOVUDINE SYP 50MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ZIDOVUDINE TAB 300MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES

ABRAXANE INJ 100MG 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS ADRIAMYCIN INJ 2MG/ML (20

MG/ 10 ML) 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

ADRUCIL INJ 500/10ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

ADRUCIL INJ 2.5G/50M 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS


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ADRUCIL INJ 5GM/100M 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

AFINITOR TAB 10MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS

AFINITOR TAB 2.5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS

AFINITOR TAB 5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS

AFINITOR TAB 7.5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS

AFINITOR DISPERZ TAB 2MG 5 No No Yes AFINITOR No No Yes 150 30 No Brand ANTINEOPLASTIC AGENTS



ALECENSA CAP 150MG 5 No No Yes ALECENSA No Yes No No Brand ANTINEOPLASTIC AGENTS

ALIMTA INJ 500MG 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

ALIMTA 100MG VIAL 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

ALUNBRIG TAB 180MG 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS



ALUNBRIG PAK 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS

ANASTROZOLE TAB 1 MG 2 Yes Yes No No No No No Generic ANTINEOPLASTIC AGENTS

AVASTIN INJ 5 No No Yes AVASTIN No Yes No No Brand ANTINEOPLASTIC AGENTS

AVASTIN 400 MG/16 ML VIAL 5 No No Yes AVASTIN No Yes No No Brand ANTINEOPLASTIC AGENTS

AZACITIDINE INJ 100MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

BENDEKA INJ 100/4ML 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

BEXAROTENE CAP 75 MG 5 No Yes Yes BEXAROTENE No No No No Generic ANTINEOPLASTIC AGENTS

BICALUTAMIDE TAB 50MG 2 Yes Yes No No No No No Generic ANTINEOPLASTIC AGENTS

BLEOMYCIN INJ 15UNIT 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

BLEOMYCIN INJ 30UNIT 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

BORTEZOMIB INJ 3.5MG 5 No No Yes VELCADE No No No No Brand ANTINEOPLASTIC AGENTS

BOSULIF TAB 100MG 5 No No Yes BOSULIF No No No No Brand ANTINEOPLASTIC AGENTS



BRAFTOVI CAP 50MG 5 No No Yes BRAFTOVI No Yes No No Brand ANTINEOPLASTIC AGENTS


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BRAFTOVI CAP 75MG 5 No No Yes BRAFTOVI No Yes No No Brand ANTINEOPLASTIC AGENTS

CABOMETYX TAB 20MG 5 No No Yes CABOMETYX No Yes Yes 30 30 No Brand ANTINEOPLASTIC AGENTS



CALQUENCE CAP 100MG 5 No No Yes CALQUENCE No Yes No No Brand ANTINEOPLASTIC AGENTS

CAPRELSA TAB 100MG 5 No No Yes CAPRELSA No Yes No No Brand ANTINEOPLASTIC AGENTS

CAPRELSA TAB 300MG 5 No No Yes CAPRELSA No Yes No No Brand ANTINEOPLASTIC AGENTS

CARBOPLATIN INJ 150/15ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS CARBOPLATIN 450 MG/45 ML

VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CARBOPLATIN 50 MG/5 ML VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CARBOPLATIN 600 MG/60 ML

VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CISPLATIN INJ 100MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CISPLATIN INJ 200MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CISPLATIN INJ 50/50ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

COMETRIQ KIT 100MG 5 No No Yes COMETRIQ No Yes No No Brand ANTINEOPLASTIC AGENTS



COTELLIC TAB 20MG 5 No No Yes COTELLIC No Yes No No Brand ANTINEOPLASTIC AGENTS

CYCLOPHOSPHAMIDE CAP 25MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CYCLOPHOSPHAMIDE CAP 50MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CYCLOPHOSPHAMIDE INJ 1GM 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CYCLOPHOSPHAMIDE INJ 500MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS


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CYCLOPHOSPHAMIDE 2 GM VIAL 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

CYTARABINE INJ 20MG/ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DACARBAZINE 100 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DEPO-PROVERA INJ 400/ML 4 No Yes Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

DEXRAZOXANE INJ 500MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 160/8ML 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 20MG/2ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 20MG/2ML

(MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

DOCETAXEL INJ (20MG/ML) 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 160/16ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 160/16ML (MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 200/10 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 80 MG/4ML

(20MG/ML) 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 80MG/4ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOCETAXEL INJ 80MG/8ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 80MG/8ML

(MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS

DOXORUBICIN INJ 2MG/ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOXORUBICIN 10 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOXORUBICIN 50 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

DOXORUBICIN HCL LIPOSOMAL

INJ (FOR IV INFUSION) 2 MG/ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

EMCYT CAP 140MG 4 No No No No No No No Brand ANTINEOPLASTIC AGENTS

EPIRUBICIN INJ 50/25ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS


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EPIRUBICIN 200 MG/100 ML VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS

ERIVEDGE CAP 150MG 5 No No Yes ERIVEDGE No Yes N

Documents

2019 Peoples Health Formulary...the front and back cover pages. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary,