2019 PREFERREDONE PRIMARY

2019 Formulary Primary

Effective 01/01/19

LAST REVISED 12/27/2019

Introduction

This closed formulary is a list of generic and brand medications covered by your prescription drug

benefit. Please note that this formulary is not a complete list of medications and not all listed drugs

may be covered by your plan. It is designed to offer you and your doctor cost-effective choices for safe

and clinically effective prescription drugs.

Coverage for the drugs included on the 2019 PreferredOne Formulary is determined by your

benefit plan design. Please refer to the benefit documents provided by your employer or health

plan for information on your specific benefit coverage. You may also contact the PreferredOne

Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for more information.

How is the formulary developed?

This formulary was developed based on the recommendations of an independent Pharmacy and

Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several

times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing

review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to

determine whether a drug should be included in the formulary.

Does the formulary change throughout the year?

The 2019 PreferredOne Formulary may change throughout the year as new drugs or clinical information

becomes available. Drugs may be added as they are introduced to the marketplace and other drugs

may change tier status as generics become available.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit

PreferredOne.com for the most current formulary information.

What are formulary tiers?

This formulary is made up of different cost levels or tiers. Your health plan or employer determines your

out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit

structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative

lower tier options with your doctor to help save money on your out of pocket costs.

Are generic drugs different than brand drugs?

Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and

effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost

significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if a

generic medication is right for you.

http://preferredone.com/


How do I fill my specialty medication?

Specialty medications are typically used to treat rare or chronic conditions and often require special

handling.

To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications, your

plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty pharmacies

provide personalized care and offer convenient delivery to your home or other approved location.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit

PreferredOne.com for the most current formulary information.

Are there any restrictions on my coverage?

Some medications on the formulary may have additional requirements or limits on coverage. These

requirements or limits may include:

Prior Authorization — Your benefit plan may require that the medication you have been prescribed

receive prior authorization. This means that you will need to get approval from your plan before you fill

your prescription. If you don’t get approval, the medication may not be covered by your drug benefit.

Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your

benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by your

plan before coverage will apply.

Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your medical

condition before another drug for that condition will be covered. For example, if two drugs are used to

treat the same medical condition, you may be required to first try one drug before the second drug is

covered.

For more information about the 2019 PreferredOne Formulary:

Call the PreferredOne Customer Service Department at 1-800-997-1750

Or, visit PreferredOne.com


TIER DESCRIPTION

1 $0 Cost Share

2 Preferred Generics

3 Non-Preferred Generics

4 Brands

5Preferred

Specialty/Injectables

6Non-Preferred

Specialty/Injectables

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered

per prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get prior

authorization before you fill your prescription for this drug.

Without prior approval, we may not cover this drug.

ST Step Therapy

In some cases, you may be required to first try certain drugs

to treat your medical condition before we will cover another

drug for that condition.

Preferred Drug Preferred Drug.

QLC Quantity Limit (Custom)There is a limit on the amount of this drug that is covered

per prescription, or within a specific time frame.

PAGE 1 LAST UPDATED 12/2019

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICSNONSTEROIDAL ANTI-INFLAMMATORY DRUGS

adult aspirin (tablet dr) 1

adult aspirin regimen (tablet dr) 1

adult low dose aspirin ec (tablet dr) 1

aspir 81 (tablet dr) 1

aspir-low (tablet dr) 1

aspirin (81 mg tablet, cvs 81 mg tab, eq 81 mg tab,eql 81 mg tab, gnp 81 mg tab, gs 81 mg tab, hm 81mg tab, kro 81 mg tab, pub 81 mg tab, qc 81 mg tab,ra 81 mg tab, sm 81 mg tab)

1

aspirin ec (cvs ec 81 mg tablet, ec 81 mg tablet, eqec 81 mg tablet, eql ec 81 mg tablet, gnp ec 81 mgtablet, gs ec 81 mg tablet, hm ec 81 mg tablet, kroec 81 mg tablet, qc ec 81 mg tablet, ra ec 81 mgtablet, sb ec 81 mg tablet, sm ec 81 mg tablet)

1

celecoxib (capsule) 3 QL 2 / DAY

children's aspirin (tab chew) 1

choline mag trisalicylate (liquid) 2

diclofenac potassium (tablet) 2

diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75mg tab, ec 25 mg tab, ec 50 mg tab, ec 75 mg tab)

2

diclofenac sodium er (tab er 24h) 2

diflunisal (tablet) 2

ec-naproxen (tablet dr) 3

ecotrin ec 81 mg tablet 1

etodolac (200 mg capsule, 300 mg capsule, 400 mgtablet, 500 mg tablet)

2

etodolac er (tab er 24h) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fenoprofen 400 mg capsule 3

fenoprofen 600 mg tablet 2

flurbiprofen (tablet) 2

ibu (tablet) 2

ibuprofen (400 mg tablet, 600 mg tablet, 800 mgtablet)

2

ibuprofen 100 mg/5 ml susp 3

indomethacin (25 mg capsule, 50 mg capsule) 2

indomethacin er (capsule er) 2

ketoprofen (50 mg capsule, 75 mg capsule, er 200mg capsule)

2

ketorolac 10 mg tablet 2 QL 20 TABLETS / 30DAYS

ketorolac tromethamine (15 mg/ml carpuject, 15mg/ml isecure syr, 30 mg/ml carpuject, 60 mg/2 mlcarpuject)

3

lo-dose aspirin ec (tablet dr) 1

low dose aspirin ec (tablet dr) 1

meclofenamate sodium (capsule) 2

mefenamic acid (capsule) 3

meloxicam (7.5 mg tablet, 7.5 mg/5 ml susp, 15 mgtablet)

2

nabumetone (tablet) 2

naproxen (125 mg/5 ml suspen, 250 mg tablet, 375mg tablet, dr 375 mg tablet, 500 mg kit, 500 mgtablet, dr 500 mg tablet)

2

naproxen sodium (275 mg tab, 550 mg tab) 2

naproxen sodium cr (tbmp 24hr) 3

naproxen sodium ds (tablet) 2



naproxen sodium er (tbmp 24hr) 3

oxaprozin (tablet) 2

piroxicam (capsule) 2

salsalate (tablet) 2

st. joseph aspirin (tab chew) 1

st. joseph aspirin ec (tablet dr) 1

sulindac (tablet) 2

tolmetin sodium (200 mg tab, 400 mg cap, 600 mgtab)

2

OPIOID ANALGESICS, LONG-ACTING

EMBEDA (CAP ER PO) 4QL 2 / DAY

PA

hydromorphone er (tab er 24h) 2QL 2 / DAY

PA

methadone hcl (5 mg tablet, 10 mg tablet) 2 PA

methadone hcl (5 mg/5 ml solution, 10 mg/5 mlsolution, 10 mg/ml oral conc)

2

methadose 40 mg tablet dispr 2

morphine sulfate 30 mg cap er (generic for kadian) 2QL 2 / DAY

PA

morphine sulfate 30 mg cap er (not generic kadian) 2QL 1 / DAY

PA

morphine sulfate 60 mg cap er (generic for kadian) 2QL 2 / DAY

PA

morphine sulfate 60 mg cap er (not generic kadian) 2QL 1 / DAY

PA

morphine sulfate er (er 10 mg cap, er 20 mg cap, er30 mg cap, er 50 mg cap, er 60 mg cap, er 80 mgcap, er 100 mg cap, er 120 mg cap)

2QL 2 / DAY

PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmorphine sulfate er (er 15 mg tablet, er 30 mgtablet, er 60 mg tablet, er 100 mg tablet, er 200 mgtablet)

2QL 3 / DAY

PA

morphine sulfate er (er 45 mg cap, er 75 mg cap, er90 mg cap)

2QL 1 / DAY

PA

OXYCONTIN (TAB ER 12H) 4QL 4 / DAY

PA

oxymorphone hcl er (tab er 12h) 2QL 4 / DAY

PA

tramadol hcl er (er 100 mg tablet, er 200 mg tablet,er 300 mg tablet)

3 QL 1 / DAY

tramadol hcl er 150 mg capsule 3QL 1 / DAY

PA

OPIOID ANALGESICS, SHORT-ACTING

acetamin-caff-dihydrocod 320.5 3

PA

QLCQUANTITY LIMITSMAY APPLY BASEDON SHORT-ACTINGOPIOID PROGRAM.

acetaminophen-codeine (acetamin-codein 300-30mg/12.5, acetaminop-codeine 120-12 mg/5,acetaminophen-cod #2 tablet, acetaminophen-cod#3 tablet, acetaminophen-cod #4 tablet)

2

PA


asa-butalb-caffeine-codeine (capsule) 2

PA


ascomp with codeine (capsule) 2

PA


belladonna-opium (supp.rect) 3



butalb-acetaminoph-caff-codein (capsule) 3

PA


butalb-caff-acetaminoph-codein (capsule) 2

PA


butalbital compound-codeine (capsule) 2

PA


carisoprodol-aspirin-codeine (tablet) 2

PA


codeine sulfate (tablet) 2

PA


endocet (tablet) 2

PA


hydrocodone-acetaminophen (5-300 mg, 7.5-300,10-300 mg)

3

PA

QLCQUANTITY LIMITSMAY APPLY BASEDON SHORT-ACTINGOPIOID PROGRAM

hydrocodone-acetaminophen (5-325 mg, 7.5-325,10-325 mg)

2

PA




hydrocodone-acetaminophen (hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin 2.5-325,hydrocodone-acetamin 5-217/10, hydrocodone-acetamn 7.5-325/15)

3

PA


hydrocodone-ibuprofen (5-200 mg, 10-200) 3

PA


hydrocodone-ibuprofen 7.5-200 2

PA


hydromorphone 3 mg suppos 2

hydromorphone hcl (0.5 mg/0.5 ml, 1 mg/mlcarpujct, 1 mg/ml syringe, 2 mg/ml carpujct, 2mg/ml isecure, 4 mg/ml carpujct, hcl 4 mg/ml amp)

3

hydromorphone hcl (1 mg/ml solution, 5 mg/5 mlsoln)

3

PA


hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mgtablet)

2

PA


lorcet (tablet) 2

PA


lorcet hd (tablet) 2

PA




lorcet plus (tablet) 2

PA


lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325mg tablet)

2

PA


meperidine hcl (50 mg tablet, 50 mg/5 ml solution,100 mg tablet)

2

PA


morphine sulfate (10 mg/5 ml soln, 20 mg/5 ml soln,100 mg/5 ml conc)

2

PA


morphine sulfate (5 mg suppos, 10 mg suppos, 20mg suppos, 30 mg suppos)

2

morphine sulfate (5 mg/ml syringe, 10 mg/0.7 mlauto-inj)

3

morphine sulfate (ir 15 mg tab, ir 30 mg tab) 2

PA


oxycodone hcl (5 mg capsule, 5 mg tablet, 10 mgtablet, 15 mg tablet, 30 mg tablet)

2

PA


oxycodone hcl (5 mg/5 ml soln, 20 mg tablet, 100mg/5 ml conc)

3

PA




oxycodone hcl-aspirin (tablet) 2

PA


oxycodone hcl-ibuprofen (tablet) 2

PA


oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen7.5-325, oxycodone-acetaminophen 5-325,oxycodone-acetaminophen 10-325)

2

PA


oxymorphone hcl (tablet) 3

PA


pentazocine-naloxone hcl (tablet) 2

PA


tramadol hcl (tablet) 2

QL 8 TABLETS / DAY

PA


tramadol hcl-acetaminophen (tablet) 2

QL 8 TABLETS / DAY

PA


verdrocet (tablet) 3

PA




vicodin (tablet) 3

PA


vicodin es (tablet) 3

PA


vicodin hp (tablet) 3

PA


xylon 10 (tablet) 3

PA


ANESTHETICSLOCAL ANESTHETICS

bupivacaine 0.5% vial 3

butalb-aspirin-caffe 50-325-40 2

cocaine 4% solution 3

ethyl chloride (spray) 3

glydo (jel/pf app) 2

isoflurane (liquid) 3

ketamine hcl (100 mg/ml vial, 200 mg/20 ml vial,500 mg/10 ml vial, 500 mg/5 ml vial, 1,000 mg/10ml vial)

3

lidocaine 5% patch 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlidocaine hcl (0.5% vial, 1% 20 mg/2 ml, 1% 20 mg/2ml vl, 1% 300 mg/30 ml, 1% 50 mg/5 ml, 1% 50mg/5 ml vl, 1% ampul, 1% vial, 1.5% ampul, 2% 100mg/5 ml, 2% 40 mg/2 ml, 2% 40 mg/2 ml vl, 2%ampul, 2% vial, 4% ampul)

3

lidocaine hcl (2% jel urojet ac, 2% jelly, 2% jelly uro-jet, 4% solution)

2

lidocaine hcl 4% (mucous membrane) solution 2

lidocaine hcl 4% (topical) solution 3

lidocaine hcl viscous (solution) 2

lidocaine hcl-epinephrine (ampul, vial) 3

lidocaine-epinephrine (cartridge) 3

lidocaine-prilocaine (cream (g)) 2

lidocaine/prilocaine 2.5 %-2.5% (topical) cream 2

lidocaine/prilocaine 2.5 %-2.5% kit 3

mepivacaine hcl (cartridge) 3

polocaine-mpf (vial) 3

ropivacaine hcl (0.5% 100 mg/20 ml, 0.5% 1000mg/200ml, 0.5% 150 mg/30 ml, 0.5% 500 mg/100ml, 0.75% 150 mg/20 ml, 1% 100 mg/10 ml vl, 1%200 mg/20 ml vl)

3

sevoflurane (liquid) 3

terrell (liquid) 3

tetracaine hcl 1% ampul 3

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTSALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium (tablet dr) 3

disulfiram (tablet) 2

naltrexone hcl (tablet) 2



VIVITROL (SUS ER REC) 6

OPIOID DEPENDENCE TREATMENTS

buprenorphin-naloxon 8-2 mg sl 3 QL 3 / DAY

buprenorphine 2 mg tablet sl 3 QL 12 / DAY

buprenorphine 8 mg tablet sl 3 QL 3 / DAY

buprenorphn-naloxn 2-0.5 mg sl 3 QL 12 / DAY

OPIOID REVERSAL AGENTSnaloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2mg/2 ml syringe, 4 mg/10 ml vial)

3

SMOKING CESSATION AGENTS

buproban (tab er 12h) 1 QL 2 / DAY

bupropion hcl sr 150 mg tab 1 QL 2 / DAY

bupropion hcl sr 150 mg tablet (generic for zyban) 1 QL 2 / DAY

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX,1 MG TABLET)

1 QL 2 / DAY

CHANTIX STARTING MONTH BOX 1 QL 1 BOX (53 TABLETS) /28 DAYS

nicoderm cq (7 mg/24hr patch, 14 mg/24hr patch,21 mg/24hr patch)

1

nicorelief (gum) 1

nicotine gum (gum) 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine lozenge (2 mg, 2 mg mini, cvs 2 mg, cvs 2mg mini, 4 mg, 4 mg mini, cvs 4 mg, cvs 4 mg mini,eq 2 mg, eq 2 mg mini, eq 4 mg, eql 2 mg, eql 4 mg,gnp 2 mg, gnp 2 mg mini, gnp 4 mg, gnp 4 mg mini,gs 2 mg mini, gs 4 mg mini, hm 2 mg, hm 2 mg mini,hm 4 mg, kro 2 mg, kro 2 mg mini, kro 4 mg, kro 4mg mini, ra 2 mg, ra 2 mg mini, ra 4 mg, ra 4 mgmini, sm 2 mg, sm 4 mg, sw 2 mg, sw 4 mg)

1

nicotine patch (7 mg/24hr patch, cvs 7 mg/24hrpatch, 14 mg/24hr patch, cvs 14 mg/24hr patch, 21mg/24hr patch, cvs 21 mg/24hr patch, eq 7 mg/24hrpatch, eq 14 mg/24hr patch, eq 21 mg/24hr patch,gnp 7 mg/24hr patch, gnp 14 mg/24hr patch, gnp 21mg/24hr patch, hm 7 mg/24hr patch, hm 14mg/24hr patch, hm 21 mg/24hr patch, kro 7mg/24hr patch, kro 14 mg/24hr patch, kro 21mg/24hr patch, ra 7 mg/24hr patch, ra 14 mg/24hrpatch, ra 21 mg/24hr patch, sm 7 mg/24hr patch,sm 14 mg/24hr patch, sm 21 mg/24hr patch,transdermal system)

1

NICOTROL (CARTRIDGE) 1 QL 16 / DAY

NICOTROL NS (SPRAY) 1 QL 12 BOTTLES (120 ML)/ 30 DAYS

quit 2 (2 mg chewing gum, 2 mg lozenge) 1

quit 4 (4 mg chewing gum, 4 mg lozenge) 1

stop smoking aid (lozenge) 1

ANTIBACTERIALSAMINOGLYCOSIDES

gentak (oint. (g)) 2

gentamicin sulfate (0.1% cream, 0.1% ointment,0.3% eye drop, 0.3% eye ointment, 3 mg/ml eyedrop)

2

neomycin sulfate (tablet) 2

paromomycin sulfate (capsule) 2

tobramycin 0.3% eye drop 2



ANTIBACTERIALS, OTHER

bacitracin 500 unit/gm ophth 2

clindamycin hcl (capsule) 2

clindamycin palmitate hcl (soln recon) 3

clindamycin pediatric (soln recon) 3

clindamycin phosphate (ph 1% gel, ph 1% solution,phosp 1% lotion, 2% vaginal cream)

2

clindamycin phosphate 1% foam 3

colistimethate (vial) 3

hyophen (tablet) 3

linezolid 100 mg/5 ml susp 3 QL 6 BOTTLES (900 mL)/ 28 DAYS

linezolid 600 mg tablet 2 QL 28 / 30 DAYS

me-naphos-mb-hyo 1 (tablet) 3

methenamine hippurate (tablet) 3

methenamine md 500 mg tablet 2

metronidazole (vaginal 0.75% gl, 250 mg tablet, 500mg tablet)

2

metronidazole 375 mg capsule 3

mupirocin (cream, ointment) 2

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr50 mg cap, mcr 100 mg cap)

2

nitrofurantoin mono-macro (capsule) 2

phosphasal (tablet) 2

tinidazole (tablet) 3

trimethoprim (tablet) 2

ur n-c (tablet) 2



urin d.s. (tablet) 2

uro-458 (tablet) 3

uro-mp (capsule) 3

ustell (capsule) 3

utira-c (tablet) 2

vancomycin hcl (125 mg capsule, 250 mg capsule) 3

vilamit mb (capsule) 3

vilevev mb (tablet) 3

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5 ml susp, 375 mg/5 ml suspen) 4

cefaclor (250 mg capsule, 250 mg/5 ml susp, 500 mgcapsule)

2

cefaclor er (tab er 12h) 3

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp)

2

cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300mg capsule)

2

cefditoren pivoxil (tablet) 3

cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 3

cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 2

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)

3

cefprozil (125 mg/5 ml susp, 250 mg tablet, 250mg/5 ml susp, 500 mg tablet)

2

ceftibuten (180 mg/5 ml susp, 400 mg capsule) 3

cefuroxime (tablet) 2

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500mg tablet, 750 mg capsule)

2



BETA-LACTAM, PENICILLINSamoxicillin (125 mg tab chew, 125 mg/5 ml susp,200 mg/5 ml susp, 250 mg capsule, 250 mg tabchew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mgcapsule, 500 mg tablet, 875 mg tablet)

2

amoxicillin-clavulanate pot er (tab er 12h) 2

amoxicillin-clavulanate potass (200-28.5 mg tabchew, 200-28.5 mg/5 ml sus, 250-125 mg tablet,250-62.5 mg/5 ml sus, 400-57 mg tab chew, 400-57mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 mlsus, 875-125 mg tablet)

2

ampicillin trihydrate (125 mg/5 ml susp, 250 mgcapsule, 250 mg/5 ml susp, 500 mg capsule)

2

dicloxacillin sodium (capsule) 2

penicillin v potassium (125 mg/5 ml soln, 250 mgtablet, 250 mg/5 ml soln, 500 mg tablet)

2

MACROLIDESazithromycin (1 gm pwd packet, 100 mg/5 ml susp,200 mg/5 ml susp, 250 mg tablet, 500 mg tablet,600 mg tablet)

2

clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250mg/5 ml sus, 500 mg tablet)

2

clarithromycin er (tab er 24h) 2

DIFICID (TABLET) 4

ery (med. swab) 2

erythromycin (0.5% eye ointment, 2% gel, 2%pledgets, 2% solution, 250 mg filmtab, dr 250 mgcap, 500 mg filmtab)

2

erythromycin 200 mg/5 ml susp 3

erythromycin es 400 mg tab 2

QUINOLONES

ciprofloxacin (250 mg/5 ml susp, 500 mg/5 ml susp) 3

ciprofloxacin 0.2% otic soln 3 ST



ciprofloxacin er (tbmp 24hr) 2

ciprofloxacin hcl (0.3% eye drop, hcl 100 mg tab, hcl250 mg tab, hcl 500 mg tab, hcl 750 mg tab)

2

FACTIVE (TABLET) 4

gatifloxacin (drops) 3

levofloxacin (25 mg/ml solution, 250 mg tablet, 250mg/10 ml soln, 500 mg tablet, 500 mg/20 ml soln,750 mg tablet)

2

levofloxacin 0.5% eye drops 3

MOXEZA (DROPS VISC) 4

moxifloxacin (drop, drops) 2

moxifloxacin hcl (tablet) 2

ofloxacin (ear drops, eye drop, eye drops) 2

ofloxacin 400 mg tablet 3

SULFONAMIDES

silver sulfadiazine (cream (g)) 2

sulfacetamide sodium (drops, ointment) 2

sulfadiazine (tablet) 2

sulfamethoxazole-trimethoprim (ds tablet, ss tablet,susp)

2

TETRACYCLINES

avidoxy (tablet) 3

demeclocycline hcl (tablet) 2

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mgtab)

2

doxycycline monohydrate (25 mg/5 ml susp, mono50 mg tablet, mono 75 mg tablet, mono 100 mgtablet, mono 150 mg tablet)

3

doxycycline monohydrate (50 mg cap, 75 mgcapsule, 100 mg cap, 150 mg cap)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSminocycline hcl (50 mg capsule, 75 mg capsule, 100mg capsule)

2

minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet)

3

minocycline hcl er (er 45 mg tablet, er 90 mg tablet,er 135 mg tablet)

3

mondoxyne nl (capsule) 2

morgidox (50 mg capsule, 100 mg capsule) 2

okebo (capsule) 2

tetracycline hcl (capsule) 2

ANTICONVULSANTSANTICONVULSANTS, OTHER

levetiracetam (100 mg/ml soln, 250 mg tablet, 500mg tablet, 750 mg tablet, 1,000 mg tablet)

2

levetiracetam er (tab er 24h) 2

POTIGA (TABLET) 4

roweepra (tablet) 2

roweepra xr (tab er 24h) 2

CALCIUM CHANNEL MODIFYING AGENTS

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 2

zonisamide (capsule) 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSdiazepam (2.5 mg rectal gel sys, 10 mg rectal gelsyst, 20 mg rectal gel syst)

2 QL 2 PACKAGES / RX

divalproex sodium (dr 125 mg cap sprnk, sod dr 125mg tab, sod dr 250 mg tab, sod dr 500 mg tab)

2

divalproex sodium er (tab er 24h) 2

gabapentin (100 mg capsule, 250 mg/5 ml soln, 300mg capsule, 400 mg capsule, 600 mg tablet, 800 mgtablet)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSphenobarbital (15 mg tablet, 16.2 mg tablet, 20mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mgtablet, 100 mg tablet)

2

phenobarbital sodium (vial) 3

primidone (tablet) 2

tiagabine hcl (tablet) 3

valproic acid (250 mg capsule, 250 mg/5 ml soln) 2

vigabatrin (500 mg powder packt, 500 mg tablet) 5 PA

vigadrone (powd pack) 5 PA

GLUTAMATE REDUCING AGENTSfelbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml susp)

3

lamotrigine (5 mg disper tablet, 25 mg disper tab, 25mg tablet, 100 mg tablet, 150 mg tablet, 200 mgtablet)

2

lamotrigine er (tab er 24) 2

lamotrigine odt (tab rapdis) 2

subvenite (tablet) 2

topiramate (15 mg sprinkle cap, 25 mg sprinkle cap,25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mgtablet)

2

topiramate er (cap spr 24) 3 ST

SODIUM CHANNEL AGENTS

APTIOM (TABLET) 4

carbamazepine (100 mg tab chew, 100 mg/5 mlsusp, 200 mg tablet)

2

carbamazepine er (er 100 mg cap, er 100 mg tablet,er 200 mg cap, er 300 mg cap)

3

carbamazepine er (er 200 mg tablet, er 400 mgtablet)

2



epitol (tablet) 2

fosphenytoin sodium (vial) 3

oxcarbazepine (150 mg tablet, 300 mg tablet, 300mg/5 ml susp, 600 mg tablet)

2

PEGANONE (TABLET) 4

phenytoin (50 mg infatab, 50 mg tablet chew, 125mg/5 ml susp)

2

phenytoin sodium extended (capsule) 2

VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

4

ANTIDEMENTIA AGENTSANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates (tablet) 2

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tablet, 10 mg tablet) 2

donepezil hcl odt (tab rapdis) 2

galantamine er (cap24h pel) 2

galantamine hbr (tablet) 2

galantamine hydrobromide (solution) 2

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 6 mg capsule)

2

rivastigmine (4.6 mg/24hr patch, 9.5 mg/24hr patch,13.3 mg/24hr ptch)

3

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (hcl 2 mg/ml solution, 5-10 mgtitration pk, hcl 5 mg tablet, hcl 10 mg tablet)

2

NAMENDA (5 MG TABLET, 10 MG TABLET) 4



ANTIDEPRESSANTSANTIDEPRESSANTS, OTHER

bupropion hcl (tablet) 2

bupropion hcl sr (100 mg tablet, 150 mg tablet, 200mg tablet)

2 QL 2 / DAY

bupropion hcl sr 150 mg tablet (generic forwellbutrin sr)

2 QL 2 / DAY

bupropion hcl xl 150 mg tablet 2 QL 3 / DAY

bupropion hcl xl 300 mg tablet 2 QL 1 / DAY

chlordiazepoxide-amitriptyline (tablet) 2

mirtazapine (7.5 mg tablet, 15 mg odt, 15 mg tablet,30 mg odt, 30 mg tablet, 45 mg odt, 45 mg tablet)

2

olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) 3 QL 3 / DAY

olanzapine-fluoxetine hcl (6-50 mg, 12-25 mg, 12-50mg)

3 QL 1 / DAY

perphenazine-amitriptyline (tablet) 2

MONOAMINE OXIDASE INHIBITORS

phenelzine sulfate (tablet) 2

tranylcypromine sulfate (tablet) 2

SSRI/SNRI (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITORS)

citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20mg tablet, 20 mg/10 ml sol, 40 mg tablet)

2

desvenlafaxine suc er 100 mg 2 QL 4 / DAY

desvenlafaxine succinate er (er 25 mg, er 50 mg) 2 QL 1 / DAY

escitalopram oxalate (5 mg tablet, 10 mg tablet, 20mg tablet)

2

escitalopram oxalate 5 mg/5 ml 3

fluoxetine dr (capsule dr) 3 QL 4 / 28 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfluoxetine hcl (hcl 10 mg capsule, hcl 10 mg tablet,20 mg/5 ml solution, hcl 20 mg capsule, hcl 40 mgcapsule)

2

fluvoxamine maleate (tablet) 2

fluvoxamine maleate er (cap er 24h) 3 QL 2 / DAY

maprotiline hcl (tablet) 2

nefazodone hcl (tablet) 3

paroxetine cr (tab er 24h) 2

paroxetine er (tab er 24h) 2

paroxetine hcl (tablet) 2

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet,hcl 50 mg tablet, hcl 100 mg tablet)

2

trazodone hcl (tablet) 2

venlafaxine hcl (tablet) 2

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er150 mg cap)

2

TRICYCLICS

amitriptyline hcl (tablet) 2

amoxapine (tablet) 2

ANAFRANIL (25 MG CAPSULE, 50 MG CAPSULE) 2

clomipramine hcl (capsule) 2

desipramine hcl (tablet) 2

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25mg capsule, 50 mg capsule, 75 mg capsule, 100 mgcapsule, 150 mg capsule)

2

imipramine hcl (tablet) 2

imipramine pamoate (capsule) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, 20mg/10 ml soln, hcl 25 mg cap, hcl 50 mg cap, hcl 75mg cap)

2

protriptyline hcl (tablet) 2

trimipramine maleate (capsule) 3

ANTIEMETICSANTIEMETICS, OTHER

compro (supp.rect) 2

dimenhydrinate 50 mg/ml vial 3

meclizine hcl (12.5 mg tablet, 25 mg tablet) 3

metoclopramide hcl (10 mg/2 ml syr, 10 mg/2 mlvial)

3

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10mg tablet, 10 mg/10 ml sol)

2

metoclopramide hcl odt (tab rapdis) 3

perphenazine (tablet) 2

phenadoz (supp.rect) 2

prochlorperazine (supp.rect) 2

prochlorperazine maleate (tablet) 2

promethazine hcl (12.5 mg tablet, 25 mg tablet, 50mg suppository, 50 mg tablet)

2

promethegan (supp.rect) 2

trimethobenzamide hcl (capsule) 2

EMETOGENIC THERAPY ADJUNCTS

dronabinol (capsule) 2QL 2 / DAY

PA

granisetron hcl 1 mg tablet 3 QL 4 / 30 DAYS

ondansetron 4 mg/5 ml solution 2 QL 120 ML / 30 DAYS



ondansetron hcl (4 mg tablet, 8 mg tablet) 2

ondansetron hcl (4 mg/2 ml amp, 4 mg/2 ml vial) 3 QL 60 VIALS (120 ML) /30 DAYS

ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 mlsyr)

3 QL 60 SYRINGES (120ML) / 30 DAYS

ondansetron hcl 24 mg tablet 2 QL 2 / 30 DAYS

ondansetron odt (tab rapdis) 2

ANTIFUNGALS

ciclodan 0.77% cream 2

ciclopirox (0.77% cream, 0.77% gel, 0.77% topicalsusp, 1% shampoo)

2

clotrimazole (solution, topical cream) 3

clotrimazole 10 mg troche 2

econazole nitrate (cream (g)) 2

exoderm (lotion) 2

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mgtablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

2

flucytosine (capsule) 3

griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 2

griseofulvin ultramicrosize (tablet) 2

itraconazole 100 mg capsule 2 PA

ketoconazole (2% foam, 200 mg tablet) 3

ketoconazole (cream, shampoo) 2

ketodan 2% foam 3

miconazole 3 200 mg vag supp 3

naftifine hcl (1% cream, 2% cream) 3

nyamyc (powder) 2



nyata (powder) 2

nystatin (100,000 unit/gm cream, 100,000 unit/gmoint, 100,000 unit/gm powd, 100,000 unit/ml susp,500,000 unit oral tab, 500,000 unit/5 ml sus)

2

nystatin-triamcinolone (cream, ointm) 2

nystop (powder) 2

oxiconazole nitrate (cream (g)) 3

terbinafine hcl (tablet) 2 QL 84 DAY SUPPLY / 180DAYS

terconazole (0.4% cream, 0.8% cream) 2

terconazole 80 mg suppository 3

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)

3

ANTIGOUT AGENTS

allopurinol (tablet) 2

colchicine 0.6 mg tablet 4 ST

COLCRYS (TABLET) 4

febuxostat (tablet) 3 ST

probenecid (tablet) 2

probenecid-colchicine (tablet) 2

ANTIMIGRAINE AGENTSERGOT ALKALOIDS

dihydroergotamine mesylate (1 mg/ml amp, 1mg/ml vl)

3

ergotamine-caffeine (tablet) 3

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate (tablet) 3 QL 12 / 30 DAYS

eletriptan hbr (tablet) 3 QL 12 / 30 DAYS



frovatriptan succinate (tablet) 3 QL 12 / 30 DAYS

naratriptan (tablet) 3 QL 9 / 30 DAYS

naratriptan hcl (tablet) 3 QL 9 / 30 DAYS

rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mgtablet)

2 QL 18 / 30 DAYS

sumatriptan (spray) 2 QL 2 PACKS (12 UNITS) /30 DAYS

sumatriptan 4 mg/0.5 ml inject 3 QL 10 PENS (5 ML) / 30DAYS

sumatriptan 6 mg/0.5 ml vial 3 QL 8 VIALS (4 ML) / 30DAYS

sumatriptan succinate (25 mg tablet, 50 mg tablet,100 mg tablet)

2 QL 9 / 30 DAYS

sumatriptan succinate (6 mg/0.5 ml inject, 6 mg/0.5ml syrng)

3 QL 10 SYRINGES (5 ML) /30 DAYS

zolmitriptan (tablet) 2 QL 12 / 30 DAYS

zolmitriptan 2.5 mg odt 2 QL 12 / 30 DAYS

zolmitriptan 5 mg odt 2 QL 9 / 30 DAYS

ANTIMYASTHENIC AGENTSPARASYMPATHOMIMETICS

guanidine hcl (tablet) 4

pyridostigmine br 60 mg tablet 2

pyridostigmine bromide er (tablet er) 2

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 2

rifabutin (capsule) 2

ANTITUBERCULARS

cycloserine (capsule) 3



ethambutol hcl (tablet) 2

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300mg tablet)

2

pyrazinamide (tablet) 2

rifampin (150 mg capsule, 300 mg capsule) 2

ANTINEOPLASTICSALKYLATING AGENTS

cyclophosphamide (25 mg capsule, 50 mg capsule) 4

HEXALEN (CAPSULE) 4

LEUKERAN (TABLET) 4

MATULANE (CAPSULE) 5

melphalan (tablet) 2

MYLERAN (TABLET) 4

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100MG CAPSULE, 140 MG CAPSULE, 180 MG CAPSULE,250 MG CAPSULE)

6 PA

temozolomide (capsule) 5 PA

VALCHLOR (GEL (GRAM)) 6 PA

ANTIANDROGENS

abiraterone acetate (tablet) 5 PA

bicalutamide (tablet) 2

flutamide (capsule) 2

NILANDRON (TABLET) 6

nilutamide (tablet) 5

XTANDI (CAPSULE) 6 PA

ZYTIGA (TABLET) 6 PA



ANTIANGIOGENIC AGENTS

POMALYST (CAPSULE) 6 PA

REVLIMID (CAPSULE) 5 PA

THALOMID (CAPSULE) 5 PA

ANTIESTROGENS/MODIFIERS

EMCYT (CAPSULE) 4

fulvestrant (syringe) 5

SOLTAMOX (SOLUTION) 1

tamoxifen citrate (tablet) 1

toremifene citrate (tablet) 2

ANTIMETABOLITES

azacitidine (vial) 6

capecitabine (tablet) 5 PA

floxuridine (vial) 6

hydroxyurea (capsule) 2

mercaptopurine (tablet) 5

TABLOID (TABLET) 5

XELODA (TABLET) 6 PA

ANTINEOPLASTICS, OTHER

bleo 15k (vial) 6

bleomycin sulfate (vial) 6

IMLYGIC (VIAL) 6

leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab,25 mg tab)

2

leucovorin calcium 350 mg vial 3

LONSURF (TABLET) 6 PA



LYSODREN (TABLET) 4

NINLARO (CAPSULE) 6 PA

thiotepa (vial) 6

ZOLINZA (CAPSULE) 5 PA

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole (tablet) 2

exemestane (tablet) 2

letrozole (tablet) 2

ENZYME INHIBITORS

etoposide 50 mg capsule 5

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 6

MOLECULAR TARGET INHIBITORS

AFINITOR (TABLET) 6QL 1 / DAY

PA

AFINITOR DISPERZ (TAB SUSP) 6 PA

BOSULIF (TABLET) 6 PA

CAPRELSA 100 MG TABLET 5QL 2 / DAY

PA

CAPRELSA 300 MG TABLET 5 PA

COMETRIQ (CAPSULE) 6 PA

COTELLIC (TABLET) 6 PA

erlotinib hcl (100 mg tablet, 150 mg tablet) 5 PA

erlotinib hcl 25 mg tablet 5QL 3 / DAY

PA

everolimus (tablet) 6QL 1 / DAY

PA



FARYDAK (CAPSULE) 6 PA

GLEEVEC (TABLET) 6 PA

IBRANCE (CAPSULE) 6 PA

imatinib mesylate (tablet) 5 PA

IRESSA (TABLET) 6 PA

JAKAFI (5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 25 MG TABLET)

5 PA

JAKAFI 10 MG TABLET 5QL 2 / DAY

PA

LYNPARZA 50 MG CAPSULE 6 PA

MEKINIST (TABLET) 5 PA

SPRYCEL (TABLET) 5 PA

STIVARGA (TABLET) 6 PA

SUTENT (CAPSULE) 5 PA

TASIGNA (CAPSULE) 6 PA

TYKERB (TABLET) 5 PA

ZYDELIG (TABLET) 6 PA

ZYKADIA 150 MG CAPSULE 6QL 5 / DAY

PA

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

BLINCYTO (KIT) 6 PA

UNITUXIN (VIAL) 6 PA

RETINOIDS

bexarotene (capsule) 5 PA

tretinoin 10 mg capsule 5



ANTIPARASITICSANTIHELMINTHICS

ivermectin 3 mg tablet 3

praziquantel (tablet) 2

ANTIPROTOZOALS

atovaquone (oral susp) 3

atovaquone-proguanil hcl (tablet) 3

chloroquine phosphate (tablet) 2

hydroxychloroquine sulfate (tablet) 2

mefloquine hcl (tablet) 2

primaquine (tablet) 2

quinine sulfate (capsule) 3 PA

PEDICULICIDES/SCABICIDES

lindane (lotion, shampoo) 2

malathion (lotion) 3

permethrin (cream (g)) 2

spinosad (suspension) 3

ANTIPARKINSON AGENTSANTICHOLINERGICS

benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)

2

benztropine mesylate (2 mg/2 ml ampule, 2 mg/2 mlvial)

3

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mgtablet)

2

ANTIPARKINSON AGENTS, OTHERamantadine (50 mg/5 ml solution, 100 mg capsule,100 mg/10 ml soln)

2

amantadine 100 mg tablet 3



carbidopa-levodopa-entacapone (tablet) 3

entacapone (tablet) 2

tolcapone (tablet) 3

DOPAMINE AGONISTS

APOKYN (CARTRIDGE) 6QL 20 CARTRIDGES (60

ML) / 30 DAYSPA

bromocriptine mesylate (2.5 mg tablet, 5 mgcapsule)

2

pramipexole dihydrochloride (tablet) 2

pramipexole er (tab er 24h) 3

ropinirole er (tab er 24h) 3

ropinirole hcl (tablet) 2

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa (tablet) 3

carbidopa-levodopa (10-100 mg odt, 25-100 mg odt,25-250 mg odt)

3

carbidopa-levodopa (10-100 tab, 25-100 tab, 25-250tab)

2

carbidopa-levodopa er (tablet er) 2

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

selegiline hcl 5 mg capsule 3

selegiline hcl 5 mg tablet 2

ANTIPSYCHOTICS1ST GENERATION/TYPICAL

chlorpromazine 25 mg/ml amp 3

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50mg tablet, 100 mg tablet, 200 mg tablet)

2

droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 3



fluphenazine 2.5 mg/ml vial 3

fluphenazine decanoate (vial) 3

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5mg/5 ml elix, 5 mg tablet, 5 mg/ml conc, 10 mgtablet)

2

haloperidol (tablet) 2

haloperidol decanoate (dec 50 mg/ml vial, dec 100mg/ml amp, dec 100 mg/ml vial, dec 500 mg/5 ml vl,decan 50 mg/ml amp)

3

haloperidol decanoate 100 (ampul) 3

haloperidol lac 2 mg/ml conc 2

haloperidol lactate (5 mg/ml ampul, 5 mg/ml vial, 50mg/10 ml vl)

3

loxapine (capsule) 2

molindone hcl (tablet) 3

pimozide (tablet) 3

thioridazine hcl (tablet) 2

thiothixene (capsule) 2

trifluoperazine hcl (tablet) 2

2ND GENERATION/ATYPICALaripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet,15 mg tablet, 20 mg tablet, 30 mg tablet)

2 QL 1 / DAY

aripiprazole 1 mg/ml solution 2 QL 5 BOTTLES (750 ML)/ 30 DAYS

aripiprazole odt (tab rapdis) 2 QL 2 / DAY

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MGTABLET, 120 MG TABLET)

4 QL 1 / DAY

LATUDA 80 MG TABLET 4 QL 2 / DAY

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mgtablet, 10 mg tablet, 15 mg tablet, 20 mg tablet)

2 QL 1 / DAY



olanzapine 10 mg vial 3

olanzapine odt (tab rapdis) 2 QL 1 / DAY

paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9mg tablet)

3 QL 1 / DAY

paliperidone er 6 mg tablet 3 QL 2 / DAY

quetiapine er 200 mg tablet 2 QL 3 / DAY

quetiapine fumarate (25 mg tab, 50 mg tab, 100 mgtab, 200 mg tab)

2 QL 3 / DAY

quetiapine fumarate (300 mg tab, 400 mg tab) 2 QL 2 / DAY

quetiapine fumarate er (er 50 mg tablet, er 150 mgtablet, er 300 mg tablet, er 400 mg tablet)

2 QL 2 / DAY

REXULTI (TABLET) 4 QL 1 / DAY

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mgtablet, 2 mg tablet, 3 mg tablet, 4 mg tablet)

2 QL 2 / DAY

risperidone 0.25 mg odt 3 QL 2 / DAY

risperidone 1 mg/ml solution 2 QL 8 BOTTLES (240 ML)/ 30 DAYS

risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3mg odt, 4 mg odt)

2 QL 2 / DAY

SAPHRIS (TAB SUBL) 4 QL 2 / DAY

ziprasidone hcl (capsule) 3 QL 2 / DAY

TREATMENT-RESISTANT

clozapine (25 mg tablet, 100 mg tablet) 2 QL 9 / DAY

clozapine 200 mg tablet 2 QL 4 / DAY

clozapine 50 mg tablet 2 QL 6 / DAY

clozapine odt (odt 25 mg tablet, odt 100 mg tablet) 3 QL 9 / DAY

clozapine odt 12.5 mg tablet 3 QL 3 / DAY

clozapine odt 150 mg tablet 3 QL 6 / DAY



clozapine odt 200 mg tablet 3 QL 4 / DAY

ANTISPASTICITY AGENTS

baclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

dantrolene sodium (25 mg cap, 50 mg cap, 100 mgcap)

2

tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mgcapsule)

3

tizanidine hcl (2 mg tablet, 4 mg tablet) 2

ANTIVIRALSANTI-CYTOMEGALOVIRUS (CMV) AGENTS

VALCYTE 50 MG/ML SOLUTION 4

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 2

ZIRGAN (GEL (GRAM)) 4

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil (tablet) 5

BARACLUDE 0.05 MG/ML SOLUTION 6 QL 3 BOTTLES (630 ML)/ 30 DAYS

entecavir (tablet) 5

EPIVIR HBV 25 MG/5 ML SOLN 5

HEPSERA (TABLET) 6

lamivudine 100 mg tablet 5

lamivudine hbv (tablet) 5

TYZEKA (TABLET) 6

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

EPCLUSA (TABLET) 5QL 1 / DAY

PA

HARVONI 45-200 MG TABLET 5QL 2 TABLETS / DAY

PA



HARVONI 90-400 MG TABLET 5QL 1 / DAY

PA

ledipasvir-sofosbuvir (tablet) 6QL 1 / DAY

PA

MAVYRET (TABLET) 5QL 3 / DAY

PA

OLYSIO (CAPSULE) 6QL 1 / DAY

PA

sofosbuvir-velpatasvir (tablet) 6QL 1 / DAY

PA

SOVALDI 200 MG TABLET 6QL 2 TABLETS / DAY

PA

SOVALDI 400 MG TABLET 6QL 1 / DAY

PA

ANTI-HEPATITIS C (HCV) AGENTS, OTHERINTRON A (10 MILLION UNITS VIL, 18 MILLIONUNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLIONUNIT/2.5ML, 50 MILLION UNITS VIL)

6 PA

moderiba (200 mg tablet, 200-400 mg dosepack,400-400 mg dosepack, 600-400 mg dosepack, 600-600 mg dosepack)

6

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/MLVIAL)

6 PA

PEGASYS PROCLICK (PEN INJCTR) 6 PA

PEGINTRON (KIT) 6 PA

PEGINTRON REDIPEN (PEN IJ KIT) 6 PA

REBETOL 40 MG/ML SOLUTION 6

ribasphere (200 mg capsule, 400 mg tablet, 600 mgtablet)

6

ribasphere 200 mg tablet 5



ribavirin 200 mg capsule 6

ribavirin 200 mg tablet 5

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)ISENTRESS (25 MG TABLET CHEW, 100 MG POWDERPACKET, 100 MG TABLET CHEW, 400 MG TABLET)

5

ISENTRESS HD (TABLET) 6

STRIBILD (TABLET) 6

TIVICAY (TABLET) 5

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA (TABLET) 6 ST

COMPLERA (TABLET) 5

EDURANT (TABLET) 5

efavirenz (50 mg capsule, 200 mg capsule, 600 mgtablet)

5

INTELENCE (TABLET) 5

nevirapine (50 mg/5 ml susp, 200 mg tablet) 5

nevirapine er (tab er 24h) 5

RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 5

SUSTIVA 600 MG TABLET 6

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)

abacavir (20 mg/ml solution, 300 mg tablet) 5

abacavir-lamivudine (tablet) 5

abacavir-lamivudine-zidovudine (tablet) 5

didanosine (capsule dr) 5

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 5

EPZICOM (TABLET) 6


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlamivudine (10 mg/ml oral soln, 150 mg tablet, 300mg tablet)

5

lamivudine-zidovudine (tablet) 5

stavudine (1 mg/ml solution, 15 mg capsule, 20 mgcapsule, 30 mg capsule, 40 mg capsule)

5

tenofovir disoproxil fumarate (tablet) 5

TRUVADA (TABLET) 5

VIDEX (SOLN RECON) 5

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)

5

ZIAGEN 20 MG/ML SOLUTION 6

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300mg tablet)

5

ANTI-HIV AGENTS, OTHER

FUZEON (VIAL) 6 QL 2 VIALS / DAY

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET,75 MG TABLET, 150 MG TABLET, 300 MG TABLET)

5 PA

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 5

atazanavir sulfate (capsule) 5

CRIXIVAN (CAPSULE) 5

fosamprenavir calcium (tablet) 5

INVIRASE (200 MG CAPSULE, 500 MG TABLET) 5

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 5

KALETRA 80 MG-20 MG/ML SOLN 6

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 5

lopinavir-ritonavir (solution) 5

NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGELCAP)

5


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION,150 MG TABLET, 400 MG TABLET, 600 MG TABLET,800 MG TABLET)

5

REYATAZ 50 MG POWDER PACKET 5

ritonavir (tablet) 5

VIRACEPT (TABLET) 5

ANTI-INFLUENZA AGENTS

oseltamivir 6 mg/ml suspension 3 QL 6 BOTTLES (360 ML)/ 365 DAYS

oseltamivir phos 30 mg capsule 3 QL 40 / 365 DAYS

oseltamivir phosphate (45 mg capsule, 75 mgcapsule)

3 QL 20 / 365 DAYS

RELENZA (BLST W/DEV) 4 QL 2 INHALERS (40DISKS) / 365 DAYS

rimantadine hcl (tablet) 2

ANTIHERPETIC AGENTSacyclovir (5% ointment, 200 mg capsule, 200 mg/5ml susp, 400 mg tablet, 800 mg tablet)

2

famciclovir (tablet) 2

trifluridine (drops) 2

valacyclovir (tablet) 2 QL 4 / DAY

ANXIOLYTICSANXIOLYTICS, OTHER

buspirone hcl (tablet) 2

meprobamate (tablet) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmidazolam hcl (hcl 1 mg/ml vial, 2 mg/2 ml isecure,2 mg/2 ml syringe, hcl 2 mg/2 ml vial, hcl 2 mg/mlsyrup, 5 mg/ml isecure syr, 5 mg/ml syringe, hcl 5mg/5 ml vial, hcl 5 mg/ml vial, 10 mg/2 ml syringe,hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, hcl 25mg/5 ml vial, hcl 50 mg/10 ml vial)

3

BENZODIAZEPINESalprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mgtablet)

2 QL 4 / DAY

alprazolam 2 mg tablet 2 QL 5 / DAY

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 2 QL 1 / DAY

alprazolam er 2 mg tablet 2 QL 5 / DAY

alprazolam er 3 mg tablet 2 QL 3 / DAY

alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt1 mg tab)

3 QL 4 / DAY

alprazolam odt 2 mg tab 3 QL 5 / DAY

alprazolam xr (0.5 mg tablet, 1 mg tablet) 2 QL 1 / DAY

alprazolam xr 2 mg tablet 2 QL 5 / DAY

alprazolam xr 3 mg tablet 2 QL 3 / DAY

chlordiazepoxide 10 mg capsule 2 QL 30 / DAY



clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25mg odt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet,1 mg dis tablet, 1 mg odt, 1 mg tablet)

2 QL 3 / DAY

clonazepam (2 mg odt, 2 mg tablet) 2 QL 10 / DAY

clorazepate 15 mg tablet 2 QL 6 / DAY

clorazepate 3.75 mg tablet 2 QL 24 / DAY

clorazepate 7.5 mg tablet 2 QL 12 / DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSdiazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oralsoln, 5 mg/5 ml solution, 10 mg tablet)

2

diazepam (5 mg/ml oral conc, 10 mg/2 ml carpuject,10 mg/2 ml syringe)

3

lorazepam (0.5 mg tablet, 1 mg tablet) 2 QL 3 / DAY

lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20mg/10 ml vial, 40 mg/10 ml vial)

3

lorazepam 2 mg tablet 2 QL 5 / DAY

lorazepam 2 mg/ml oral concent 3 QL 5 BOTTLES (150 ML)/ 30 DAYS

lorazepam intensol (oral conc) 3 QL 5 BOTTLES (150 ML)/ 30 DAYS

oxazepam (capsule) 2 QL 4 / DAY

BIPOLAR AGENTSMOOD STABILIZERS

lithium (solution) 2

lithium carbonate (150 mg cap, 300 mg cap, 300 mgtab, 600 mg cap)

2

lithium carbonate er (tablet er) 2

BLOOD GLUCOSE REGULATORSANTIDIABETIC AGENTS

acarbose (tablet) 2

BYDUREON (VIAL) 4QL 4 VIALS / 28 DAYS

ST

BYDUREON BCISE (AUTO INJCT) 4QL 4 AUTO-INJECTOR

(3.4 ML) / 28 DAYSST

BYDUREON PEN (PEN INJCTR) 4QL 4 PENS / 28 DAYS

ST

BYETTA 10 MCG DOSE PEN INJ 4QL 1 PEN (2.4 ML) / 30

DAYSST



BYETTA 5 MCG DOSE PEN INJ 4QL 1 PEN (1.2 ML) / 30

DAYSST

chlorpropamide (tablet) 2

CYCLOSET (TABLET) 4 ST

glimepiride (tablet) 2

glipizide (tablet) 2

glipizide er (tab er 24) 2

glipizide xl (tab er 24) 2

glipizide-metformin (tablet) 2

glyburide (tablet) 2

glyburide micronized (tablet) 2

glyburide-metformin hcl (tablet) 2

INVOKAMET (TABLET) 4 ST

INVOKAMET XR (TAB BP 24H) 4 ST

INVOKANA (TABLET) 4 ST

JANUMET (TABLET) 4 ST

JANUMET XR (TBMP 24HR) 4 ST

JANUVIA (TABLET) 4 ST

JARDIANCE (TABLET) 4 ST

JENTADUETO (TABLET) 4 ST

metformin hcl (500 mg tablet, 850 mg tablet, 1,000mg tablet)

2

metformin hcl er 500 (generic for glucophage xr) 2

metformin hcl er 750 mg tablet 2

nateglinide (tablet) 2



pioglitazone hcl (tablet) 2

pioglitazone-glimepiride (tablet) 2

pioglitazone-metformin (tablet) 2

repaglinide (tablet) 2

repaglinide-metformin hcl (tablet) 3

SYMLINPEN 120 (PEN INJCTR) 4 PA

SYMLINPEN 60 (PEN INJCTR) 4 PA

SYNJARDY (TABLET) 4 ST

tolazamide (tablet) 2

tolbutamide (tablet) 2

TRADJENTA (TABLET) 4 ST

TRULICITY (PEN INJCTR) 4QL 4 PENS (2 ML) / 28

DAYSST

VICTOZA 2-PAK (PEN INJCTR) 4QL 3 PENS (9 ML) / 30

DAYSST

GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 4

GLUCAGON EMERGENCY KIT (VIAL) 4

glucagon hcl (vial) 3

INSULINSHUMALOG (100 UNIT/ML VIAL, 100 UNITS/MLCARTRIDGE)

4

HUMALOG JUNIOR KWIKPEN (INS PEN HF) 4

HUMALOG KWIKPEN U-100 (INSULN PEN) 4

HUMALOG KWIKPEN U-200 (INSULN PEN) 4



HUMALOG MIX 50-50 (VIAL) 4

HUMALOG MIX 50-50 KWIKPEN (INSULN PEN) 4

HUMALOG MIX 75-25 (VIAL) 4

HUMALOG MIX 75-25 KWIKPEN (INSULN PEN) 4

HUMULIN 70-30 (VIAL) 4

HUMULIN 70/30 KWIKPEN (INSULN PEN) 4

HUMULIN N (VIAL) 4

HUMULIN N KWIKPEN (INSULN PEN) 4

HUMULIN R (VIAL) 4

HUMULIN R U-500 (VIAL) 4

HUMULIN R U-500 KWIKPEN (INSULN PEN) 4

insulin aspart (vial) 4 ST

insulin aspart flexpen (insuln pen) 4 ST

insulin aspart penfill (cartridge) 4 ST

insulin aspart prot-insuln asp (insuln pen, vial) 4 ST

insulin lispro (vial) 4 ST

insulin lispro kwikpen u-100 (insuln pen) 4 ST

LANTUS (VIAL) 4

LANTUS SOLOSTAR (INSULN PEN) 4

NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/MLVIAL)

4

NOVOLOG FLEXPEN (INSULN PEN) 4

NOVOLOG MIX 70-30 (VIAL) 4

NOVOLOG MIX 70-30 FLEXPEN (INSULN PEN) 4



BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERSANTICOAGULANTS

ARIXTRA (SYRINGE) 6 QL 35 DAY SUPPLY / 180DAYS

citrate phosphate dextrose (solution) 3

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 mlsyr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/mlsyringe, 120 mg/0.8 ml syr, 150 mg/ml syringe, 300mg/3 ml vial)

6 QL 35 DAY SUPPLY / 180DAYS

fondaparinux sodium (syringe) 6 QL 35 DAY SUPPLY / 180DAYS

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/MLSYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 MLVL)


heparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2ml vial, 5,000 unit/ml carpujct, sod 5,000 unit/ 0.5ml, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod10,000 unit/ml vl, sod 20,000 unit/ml vl, 30,000unit/30 ml vial, 40,000 unit/4 ml vial, 50,000 unit/10ml vial, 50,000 unit/5 ml vial)

3

jantoven (tablet) 2

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 MLSYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 MLSYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL)


PRADAXA (CAPSULE) 4 QL 2 / DAY

sodium citrate 4% soln 3

warfarin sodium (tablet) 2

XARELTO (10 MG TABLET, 20 MG TABLET) 4 QL 1 / DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 4 QL 2 / DAY

XARELTO STARTER PACK 4 QL 1 PACK (51 TABLETS)/ 30 DAYS



BLOOD FORMATION MODIFIERS

anagrelide hcl (capsule) 2

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 MLSYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 MLSYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 MLSYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 MLSYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 MLSYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 MLSYRINGE, 300 MCG/ML VIAL, 500 MCG/1 MLSYRINGE)

5 PA

EPOGEN (VIAL) 6 PA

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5ML SYRINGE, 300 MCG/ML VIAL, 480 MCG/0.8 MLSAFE SYR, 480 MCG/0.8 ML SYRINGE, 480 MCG/1.6ML VIAL)

6 PA

LEUKINE (VIAL) 6 PA

MIRCERA (SYRINGE) 6 PA

NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6MG/0.6 ML KIT)

5 PA

NIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/MLVIAL, 480 MCG/0.8 ML SYRING, 480 MCG/1.6 MLVIAL)

5 PA

PROCRIT (VIAL) 5 PA

PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50MG TABLET, 75 MG TABLET)

6 PA

RETACRIT (VIAL) 5 PA

ZARXIO (SYRINGE) 5 PA

HEMOSTASIS AGENTS

ADYNOVATE (VIAL) 5

aminocaproic acid (500 mg tab, 1,000 mg tab) 2

ELOCTATE (VIAL) 5

NOVOEIGHT (VIAL) 5



NUWIQ (VIAL) 5

OBIZUR (VIAL) 6

tranexamic acid 650 mg tablet 3

TRETTEN (VIAL) 6

PLATELET MODIFYING AGENTS

BRILINTA (TABLET) 4

cilostazol (tablet) 2

clopidogrel (tablet) 2

dipyridamole (25 mg tablet, 50 mg tablet, 75 mgtablet)

2

prasugrel hcl (tablet) 2

ticlopidine hcl (tablet) 2

CARDIOVASCULAR AGENTSALPHA-ADRENERGIC AGONISTS

clonidine (patch tdwk) 3

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mgtablet)

2

guanfacine hcl (tablet) 2

methyldopa (tablet) 2

midodrine hcl (tablet) 2

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (tablet) 2

phenoxybenzamine hcl (capsule) 2

prazosin hcl (capsule) 2

terazosin hcl (capsule) 2



ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil (tablet) 2

eprosartan mesylate (tablet) 3

irbesartan (tablet) 2

losartan potassium (tablet) 2

olmesartan medoxomil (tablet) 2

telmisartan (tablet) 2

valsartan (tablet) 2

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (tablet) 2

captopril (tablet) 2

enalapril maleate (tablet) 2

fosinopril sodium (tablet) 2

lisinopril (tablet) 2

moexipril hcl (tablet) 2

perindopril erbumine (tablet) 2

quinapril hcl (tablet) 2

ramipril (capsule) 2

trandolapril (tablet) 2

ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400mg tablet)

2

disopyramide phosphate (capsule) 2

dofetilide (capsule) 3

flecainide acetate (tablet) 2



mexiletine hcl (capsule) 2

MULTAQ (TABLET) 4

pacerone 200 mg tablet 2

propafenone hcl (tablet) 2

propafenone hcl er (cap er 12h) 3

quinidine gluc 80 mg/ml vial 3

quinidine gluc er 324 mg tab 2

quinidine sulfate (sulf er 300 mg tab, sulfate 200 mgtab, sulfate 300 mg tab)

2

sorine (tablet) 3

sotalol (tablet) 2

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (capsule) 2

atenolol (tablet) 2

betaxolol hcl (10 mg tablet, 20 mg tablet) 2

bisoprolol fumarate (tablet) 2

carvedilol (tablet) 2

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)

2

metoprolol succinate (tab er 24h) 2

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mgtab)

2

metoprolol tartrate (37.5 mg tb, 75 mg tab) 3

nadolol (tablet) 2

pindolol (tablet) 2

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet,80 mg tablet)

2



propranolol hcl er (cap sa 24h) 2

timolol maleate (5 mg tablet, 10 mg tablet, 20 mgtablet)

2

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr (tablet er) 2

amlodipine besylate (tablet) 2

cartia xt (cap er 24h) 2

dilt-xr (cap er deg) 2

diltiazem 12hr er (cap er 12h) 2

diltiazem 24h er(cd) 360 mg cp 3

diltiazem 24hr er (cap sa 24h) 2

diltiazem 24hr er (cd) (120 mg, 180 mg, 240 mg, 300mg)

2

diltiazem 24hr er (la) (tab er 24h) 3

diltiazem 24hr er (xr) (cap er deg) 2

diltiazem 24hr er 360 mg cap (generic for cardizemcd)

3

diltiazem 24hr er 360 mg cap (generic for tiazac er) 2

diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mgtablet, 120 mg tablet)

2

felodipine er (tab er 24h) 2

isradipine (capsule) 2

matzim la (tab er 24h) 3

nicardipine hcl (20 mg capsule, 30 mg capsule) 2

nifedical xl (tab er 24) 2

nifedipine (capsule) 2

nifedipine er (tab er 24, tablet er) 2



nimodipine (capsule) 3

nisoldipine (tab er 24h) 3

taztia xt (cap sa 24h) 2

tiadylt er (cap sa 24h) 2

verapamil er (er 120 mg capsule, er 120 mg tablet,er 180 mg capsule, er 180 mg tablet, er 240 mgcapsule, er 240 mg tablet)

2

verapamil er pm (cap24h pct) 2

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mgtablet, 360 mg cap pellet)

2

verapamil sr (cap24h pel) 2

CARDIOVASCULAR AGENTS, OTHER

aliskiren (tablet) 2

amiloride-hydrochlorothiazide (tablet) 2

amlodipine besylate-benazepril (capsule) 2

atenolol-chlorthalidone (tablet) 2

benazepril-hydrochlorothiazide (tablet) 2

bisoprolol-hydrochlorothiazide (tablet) 2

BYVALSON (TABLET) 4

candesartan-hydrochlorothiazid (tablet) 3

captopril-hydrochlorothiazide (tablet) 2

digitek (tablet) 2

digox (tablet) 2

digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25mg tablet, 125 mcg tablet, 250 mcg tablet)

2

digoxin 0.25 mg/ml syringe 3

enalapril-hydrochlorothiazide (tablet) 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSephedrine sulfate (50 mg/ml ampul, sulfate 50mg/ml vl)

3

epinephrine (0.1 mg/ml syringe, 1 mg/ml ampul, 1mg/ml vial)

3

fosinopril-hydrochlorothiazide (tablet) 2

irbesartan-hydrochlorothiazide (tablet) 2

isoxsuprine hcl (tablet) 2

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET,187.5 MCG TABLET, 250 MCG TABLET)

4

lisinopril-hydrochlorothiazide (tablet) 2

losartan-hydrochlorothiazide (tablet) 2

methyldopa-hydrochlorothiazide (tablet) 2

metoprolol-hydrochlorothiazide (tablet) 2

moexipril-hydrochlorothiazide (tablet) 2

nadolol-bendroflumethiazide (tablet) 3

olmesartan-hydrochlorothiazide (tablet) 2

papaverine hcl (vial) 3

pentoxifylline (tablet er) 2

phenylephrine hcl (10 mg/ml vial, 50 mg/5 ml vial,100 mg/10 ml vl)

3

propranolol-hydrochlorothiazid (tablet) 2

quinapril-hydrochlorothiazide (tablet) 2

reserpine (tablet) 2

spironolactone-hctz (tablet) 2

TEKTURNA (TABLET) 4 ST

TEKTURNA HCT (TABLET) 4 ST

telmisartan-hydrochlorothiazid (tablet) 2



trandolapril-verapamil er (tab bp 24h) 2

triamterene-hydrochlorothiazid (37.5-25 mg cp,37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab)

2

valsartan-hydrochlorothiazide (tablet) 2

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (tablet) 2

acetazolamide er (capsule er) 3

KEVEYIS (TABLET) 6QL 4 / DAY

PA

DIURETICS, LOOPbumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5mg/10 ml vial)

3

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 2

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)

2

furosemide (20 mg/2 ml vial, 40 mg/4 ml syringe, 40mg/4 ml vial, 100 mg/10 ml syring, 100 mg/10 mlvial)

3

torsemide (tablet) 2

DIURETICS, POTASSIUM-SPARING

amiloride hcl (tablet) 2

eplerenone (tablet) 3

spironolactone (tablet) 2

DIURETICS, THIAZIDE

chlorothiazide (tablet) 2

chlorthalidone (tablet) 2

hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 25 mgtab, 50 mg tab)

2

indapamide (tablet) 2



methyclothiazide (tablet) 2

metolazone (tablet) 2

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (40 mg tablet, 120 mg tablet) 3

fenofibrate (43 mg capsule, 48 mg tablet, 50 mgcapsule, 54 mg tablet, 67 mg capsule, 130 mgcapsule, 134 mg capsule, 145 mg tablet, 150 mgcapsule, 160 mg tablet, 200 mg capsule)

2

fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mgtablet, dr 135 mg cap)

2

gemfibrozil (tablet) 2

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin 10 mg tablet 1

atorvastatin calcium (20 mg tablet, 40 mg tablet, 80mg tablet)

2

fluvastatin er (tab er 24h) 3

fluvastatin sodium (capsule) 3

lovastatin (10 mg tablet, 40 mg tablet) 2

lovastatin 20 mg tablet 1

pravastatin sodium (10 mg tab, 20 mg tab) 1

pravastatin sodium (40 mg tab, 80 mg tab) 2

rosuvastatin calcium (10 mg tab, 20 mg tab, 40 mgtab)

2

rosuvastatin calcium 5 mg tab 1

simvastatin (5 mg tablet, 20 mg tablet, 40 mg tablet,80 mg tablet)

2

simvastatin 10 mg tablet 1

DYSLIPIDEMICS, OTHER

cholestyramine light powder 2



colesevelam hcl (hcl 3.75 g packet, 625 mg tablet) 2

colestipol hcl (hcl 1 gm tablet, hcl granules, hclgranules packet, micronized 1 gm tab)

2

ezetimibe (tablet) 3

JUXTAPID (CAPSULE) 6QL 1 / DAY

PA

KYNAMRO (SYRINGE) 6QL 4 SYRINGES (4 ML) /

28 DAYSPA

niacin 500 mg tablet 2

niacin er (tab er 24h) 2

niacor (tablet) 2

omega-3 acid ethyl esters (capsule) 2

PRALUENT PEN (PEN INJCTR) 5QL 2 PENS (2 ML) / 28

DAYSPA

PRALUENT SYRINGE (SYRINGE) 5QL 2 SYRINGES (2 ML) /

28 DAYSPA

prevalite powder 2

REPATHA PUSHTRONEX (WEAR INJCT) 5QL 1 CARTRIDGE (3.5

ML) / 28 DAYSPA

REPATHA SURECLICK (PEN INJCTR) 5QL 3 PENS (3 ML) / 28

DAYSPA

REPATHA SYRINGE (SYRINGE) 5QL 3 SYRINGES (3 ML) /

28 DAYSPA

triklo (capsule) 2



VASCEPA (CAPSULE) 4

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine 20 mg/ml vial 3

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mgtablet, 100 mg tablet)

2

minoxidil (2.5 mg tablet, 10 mg tablet) 2

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

amyl nitrite (ampul) 3

isochron (tablet er) 2

isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab,30 mg tab)

2

isosorbide dinitrate er (tablet er) 2

isosorbide mononitrate (tablet) 2

isosorbide mononitrate er (tab er 24h) 2

minitran (0.2 mg/hr patch, 0.4 mg/hr patch, 0.6mg/hr patch)

2

nitroglycerin (0.3 mg tablet sl, 0.4 mg tablet sl, 0.6mg tablet sl, er 2.5 mg cap, er 6.5 mg cap, er 9 mgcapsule)

2

nitroglycerin 400 mcg spray 3

nitroglycerin patch (patch td24) 2

CENTRAL NERVOUS SYSTEM AGENTSATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

dextroamp-amphetamin 30 mg tab 2QL 2 / DAY

PA

dextroamphetamine 10 mg tab 2QL 6 / DAY

PA

dextroamphetamine 5 mg tab 2QL 3 / DAY

PA



dextroamphetamine 5 mg/5 ml 2QL 1800 ML / 30 DAYS

PA

dextroamphetamine er 10 mg cap 2QL 6 / DAY

PA


PA


PA

dextroamphetamine-amphet er (cap er 24h) 2QL 1 / DAY

PA

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5mg tab, dextroamp-amphetamin 10 mg tab,dextroamp-amphetamin 15 mg tab, dextroamp-amphetamin 20 mg tab, dextroamp-amphetamine 5mg tab)

2QL 3 / DAY

PA

methamphetamine hcl (tablet) 2QL 5 / DAY

PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINESatomoxetine hcl (10 mg capsule, 18 mg capsule, 25mg capsule, 40 mg capsule)

2 QL 2 / DAY

atomoxetine hcl (60 mg capsule, 80 mg capsule, 100mg capsule)

2 QL 1 / DAY

clonidine hcl er (tab er 12h) 3

dexmethylphenidate er 20 mg cp 2QL 2 / DAY

PA

dexmethylphenidate hcl (tablet) 2QL 2 / DAY

PA

dexmethylphenidate hcl er (er 5 mg cap, er 10 mgcp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mgcp, er 40 mg cp)

2QL 1 / DAY

PA

guanfacine hcl er (tab er 24h) 2



metadate er (tablet er) 2QL 3 / DAY

PA

methylphenidate 10 mg chew tab 2QL 6 / DAY

PA

methylphenidate 10 mg/5 ml sol 2QL 900 ML / 30 DAYS

PA

methylphenidate 5 mg/5 ml soln 2QL 1800 ML / 30 DAYS

PA

methylphenidate er (er 10 mg tab, er 36 mg tab) 2QL 2 / DAY

PA

methylphenidate er (er 18 mg tab, er 27 mg tab, er54 mg tab)

2QL 1 / DAY

PA

methylphenidate er (la) (cpbp 50-50) 2QL 1 / DAY

PA

methylphenidate er 20 mg tab 2QL 3 / DAY

PA

methylphenidate hcl (2.5 mg chew tb, 5 mg chewtab, 5 mg tablet, 10 mg tablet, 20 mg tablet)

2QL 3 / DAY

PA

methylphenidate hcl cd (cpbp 30-70) 2QL 1 / DAY

PA

methylphenidate hcl er (cd) (cpbp 30-70) 2QL 1 / DAY

PA

methylphenidate la (10 mg cap, 20 mg cap, 30 mgcap, 40 mg cap)

2QL 1 / DAY

PA

methylphenidate la 60 mg cap 3QL 1 / DAY

PA

CENTRAL NERVOUS SYSTEM, OTHER

benzphetamine hcl (tablet) 3 PA



butalb-acetamin-caff 50-300-40 3

butalb-acetamin-caff 50-325-40 2

butalbital-acetaminophn 50-325 2

butalbital-asa-caffeine cap 2

caffeine and sodium benzoate (vial) 3

diethylpropion hcl (tablet) 3 PA

diethylpropion hcl er (tablet er) 3 PA

modafinil (tablet) 3QL 1 / DAY

PA

phendimetrazine tartrate (tablet) 3 PA

phendimetrazine tartrate er (capsule er) 3 PA

phentermine hcl (15 mg capsule, 30 mg capsule, 37.5mg capsule, 37.5 mg tablet)

3 PA

tencon (tablet) 2

tetrabenazine (tablet) 5 PA

vanatol lq (solution) 3

vanatol s (solution) 3

FIBROMYALGIA AGENTS

duloxetine hcl (dr 20 mg cap, dr 60 mg cap) 2 QL 2 / DAY

duloxetine hcl dr 30 mg cap 2 QL 3 / DAY

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200MG CAPSULE, 225 MG CAPSULE)

4 QL 3 / DAY

LYRICA 300 MG CAPSULE 4 QL 2 / DAY

pregabalin (25 mg capsule, 50 mg capsule, 75 mgcapsule, 100 mg capsule, 150 mg capsule, 200 mgcapsule, 225 mg capsule)

2 QL 3 / DAY

pregabalin 300 mg capsule 2 QL 2 / DAY



MULTIPLE SCLEROSIS AGENTS

AVONEX 30 MCG VIAL KIT 5QL 1 KIT (4 VIALS) / 28

DAYSPA

AVONEX PEN (PEN IJ KIT) 5QL 1 KIT / 28 DAYS

PA

AVONEX PREFILLED SYR 30 MCG KT 5QL 1 KIT / 28 DAYS

PA

BETASERON (KIT) 5QL 1 KIT (15 VIALS) / 30

DAYSPA

COPAXONE 20 MG/ML SYRINGE 5QL 1 KIT (30 SYRINGES) /

30 DAYSPA

COPAXONE 40 MG/ML SYRINGE 5QL 1 KIT (12 SYRINGES) /

28 DAYSPA

dalfampridine er (tab er 12h) 5QL 2 / DAY

PA

glatiramer 20 mg/ml syringe 5QL 1 KIT (30 SYRINGES) /

30 DAYSPA

glatiramer 40 mg/ml syringe 5QL 1 KIT (12 SYRINGES) /

28 DAYSPA

glatopa 20 mg/ml syringe 6QL 1 KIT (30 SYRINGES) /

30 DAYSPA

glatopa 40 mg/ml syringe 6QL 1 KIT (12 SYRINGES) /

28 DAYSPA

TECFIDERA (DR 120 MG CAPSULE, DR 240 MGCAPSULE)

5QL 2 / DAY

PA



TECFIDERA STARTER PACK 5QL

1 PACK (60CAPSULES) / 365DAYS

PA

DENTAL AND ORAL AGENTS

cevimeline hcl (capsule) 3

chlorhexidine 0.12% rinse 2

denta 5000 plus (cream (g)) 2

dentagel (gel (gram)) 2

doxycycline hyclate 20 mg tab 2

oralone (paste (g)) 2

paroex (mouthwash) 2

periogard (mouthwash) 2

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 2

sf (gel (gram)) 2

sf 5000 plus (cream (g)) 2

sodium fluoride (cream, gel) 2

sodium fluoride 5000 plus (cream (g)) 2

triamcinolone 0.1% paste 2

DERMATOLOGICAL AGENTS

acitretin (capsule) 2

adapalene (cream, gel) 2 PA

adapalene (gel, gel pump) 3 PA

ammonium lactate (cream, lotion) 3

amnesteem (capsule) 2 PA

avar cleanser 3



benzepro (6% foaming cloths, 7% creamy wash) 3

bp 10-1 (cleanser) 3

bp cleansing wash 3

bpo (4% gel, 6% foaming cloths, 8% gel) 3

calcipotriene (cream, ointment, solution) 3

calcitriol 3 mcg/g ointment 2

claravis (capsule) 2 PA

clind ph-benzoyl perox 1.2-5% 3

clindacin p (med. swab) 2

clindamycin phos 1% pledget 2

clindamycin-benzoyl perox 1-5% 2

clotrimazole-betamethasone (crm, lot) 2

COSENTYX (2 SYRINGES) (SYRINGE) 6 PA

COSENTYX PEN (2 PENS) (PEN INJCTR) 6 PA

COSENTYX PEN (PEN INJCTR) 6 PA

COSENTYX SYRINGE (SYRINGE) 6 PA

DUPIXENT 200 MG/1.14 ML SYRING 5QL 4 SYRINGES (4.6 ML)

/ 28 DAYSPA

DUPIXENT 300 MG/2 ML SYRINGE 5QL 4 SYRINGES (8 ML) /

28 DAYSPA

erythromycin-benzoyl peroxide (gel (gram)) 2

fluorouracil (2% soln, 5% soln) 3

fluorouracil 0.5% cream 4

fluorouracil 5% cream 2



hydrocort-pramoxine 1%-1% crm 2

imiquimod 5% cream packet 2

isotretinoin (capsule) 2 PA

lidocaine-hc 3-0.5% cream 3

methoxsalen (cap lq rap) 2

metopic (cream (g)) 3

metronidazole (cream, lotion, topical gl) 2

metronidazole (top gel pump, topical gel) 3

MIRVASO (GEL, GEL PUMP) 4

myorisan (capsule) 2 PA

neuac gel 3

podocon-25 (liquid) 2

podofilox (solution) 2

rosadan (cream, gel) 2

rosanil (cleanser) 3

salicylic acid (6% foam, 6% gel, 6% shampoo, 26%liquid, 27.5% liquid)

3

seb-prev (cleanser) 2

selenium sulfide 2.25% shampoo 3

selenium sulfide 2.5% lotion 2

silver nitrate (0.5% soln, 10% solution, 25% solution,50% solution)

2

silver nitrate 10% ointment 3

silver nitrate applicator (stick (ea)) 3

SKYRIZI (2 SYRINGES) KIT (SYRINGEKIT) 5 PA



sod sulfacetamide 10% shampoo 3

sod sulfacetamide-sulfur lotn 2

sodium sulfacetamide 10% wash 2

sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8% crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulface-sulfur 9-4.5% wash,sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacet-sulfur 10-5% clsr, sodium sulf-sulfur cleanser, sodium sulfacet-sulfur wash,sulfacetamide-sulfur 8-4% susp, sulfacetamide-sulfur10-2% crm)

3

sss 10-5 (10-5 cream, 10-5 foam) 3

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/MLSYRINGE)

5 PA

sulfacetamide sodium (sod top susp, sodium lotn) 3

tacrolimus (0.03% ointment, 0.1% ointment) 2

tretinoin (0.01% gel, 0.025% cream, 0.025% gel,0.05% cream, 0.05% gel, 0.1% cream)

2 PA

tretinoin microsphere (gel 0.04%, gel 0.1%) 2 PA

urea (35% foam, 39% cream, 40% cream, 41%cream, 45% cream, 45% nail gel, 47% cream, 50%nail stick)

3

urea 45% lotion 2

zenatane (capsule) 2 PA

ELECTROLYTES/MINERALS/METALS/VITAMINSELECTROLYTE/MINERAL REPLACEMENT

CARBAGLU (TAB DISPER) 5

cytra-k crystals packet 2

effer-k 25 meq tablet eff 2

fluoride (tab chew) 1

fluoritab 0.5 mg tablet chew 1



flura-drops (drops) 1

k effervescent (tablet eff) 2

klor-con 20 meq packet 2

klor-con m10 (tab er prt) 2

klor-con m20 (tab er prt) 2

klor-con sprinkle (capsule er) 2

klor-con-ef (tablet eff) 2

ludent fluoride (tab chew) 1

magnesium chl 200 mg/ml vial 3

magnesium sulfate (syringe, vial) 3

pot citrate-citric acid packet 2

potassium bicarbonate (tablet eff) 2

potassium chloride (er 8 meq capsule, er 8 meqtablet, 10% (20 meq/15ml), 10% (40 meq/30ml), er10 meq capsule, er 10 meq tablet, 20 meq packet,20% (40 meq/15ml), er 20 meq tablet, 25 meq tabeff)

2

potassium citrate er (er 5 tab, er 10 tb) 2

potassium citrate er 15 meq tb 3

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))

1

ELECTROLYTE/MINERAL/METAL MODIFIERS

clovique (capsule) 5 PA

deferasirox (125 mg susp, 250 mg susp, 500 mgsusp)

2 PA

deferasirox (90 mg tablet, 360 mg tablet) 5 PA

FERRIPROX (500 MG TABLET, 1,000 MG TABLET) 6 PA

JADENU (TABLET) 4 PA



JADENU SPRINKLE (GRAN PACK) 4 PA

kionex (15 gm/60 ml suspension, powder) 2

penicillamine (capsule) 5 PA

SAMSCA (TABLET) 5 QL 2 / DAY

sodium polystyrene sulfonate (sod polystyren sulf 15g/60 ml, sodium polystyrene sulf powder, sps 15gm/60 ml suspension, sps 30 gm/120 ml enema, sps50 gm/200 ml enema)

2

trientine hcl (capsule) 5 PA

PHOSPHATE BINDERScalcium acetate (667 mg capsule, 667 mg gelcap,667 mg tablet)

2

eliphos (tablet) 2

sevelamer carbonate 800 mg tab 2

VITAMINS

ascorbic acid 500 mg/ml vial 3

b-complex 100 injection 3

cyanocobalamin injection (vial) 3

fa-8 (capsule) 1

folic acid (0.4 mg tablet, 0.8 mg tablet, 400 mcgtablet, 800 mcg capsule, 800 mcg tablet, cvs 800mcg tablet, gnp 400 mcg tablet, hm 400 mcg tablet,ra 0.4 mg tablet, ra 800 mcg tablet, sm 0.4 mgtablet, sm 400 mcg tablet, sv 800 mcg tablet)

1

folic acid 1 mg tablet 2

folic acid 5 mg/ml vial 3

hydroxocobalamin (vial) 3

phytonadione (1 mg/0.5 ml syr, 10 mg/ml ampul) 3

pyridoxine 100 mg/ml vial 3



thiamine 200 mg/2 ml vial 3

vitamin k1 (ampul) 3

GASTROINTESTINAL AGENTSANTISPASMODICS, GASTROINTESTINAL

atropine sulfate (0.05 mg/ml syringe, 0.1 mg/mlsyringe, 0.4 mg/ml vial, 0.5 mg/5 ml abboject, 1mg/10 ml abboject, 1 mg/10 ml syringe, 1 mg/mlvial, 8 mg/20 ml vial)

3

belladonna-phenobarbital (tablet) 3

chlordiazepoxide-clidinium (capsule) 2

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20mg tablet)

2

ed-spaz (tab rapdis) 3

glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1 mgtablet, 1 mg/5 ml vial, 1.5 mg tablet, 2 mg tablet, 4mg/20 ml vial)

3

hyoscyamine 0.125 mg odt 3

hyoscyamine sulfate (0.125 mg tab sl, 0.125 mg/5 mlelix, 0.125 mg/ml drop, sulf 0.125 mg tab)

2

hyoscyamine sulfate er (tab er 12h) 2

hyoscyamine sulfate sr (tab er 12h) 2

methscopolamine bromide (tablet) 3

oscimin 0.125 mg odt 3

oscimin 0.125 mg tablet 2

oscimin sl (tab subl) 2

oscimin sr (tab er 12h) 2

phenohytro tablet 2

propantheline bromide (tablet) 2

symax (tab rapdis) 2



symax-sl (tab subl) 2

symax-sr (tab er 12h) 2

GASTROINTESTINAL AGENTS, OTHER

CHOLBAM (CAPSULE) 6 PA

cromolyn 100 mg/5 ml oral conc 2

diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025)

2

FULYZAQ (TABLET DR) 4 QL 2 / DAY

GATTEX 5 MG 30-VIAL KIT 6 PA

lansoprazol-amoxicil-clarithro (combo. pkg) 3

loperamide 2 mg capsule 3

MOTOFEN (TABLET) 4

MOVANTIK (TABLET) 4QL 1 / DAY

ST

MYALEPT (VIAL) 6 PA

MYTESI (TABLET DR) 4 QL 2 / DAY

opium tincture (tincture) 3

paregoric (liquid) 2

PYLERA (CAPSULE) 4

RELISTOR (12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL)

4QL 1 SYRINGE (0.6 ML) /

DAYPA

RELISTOR 8 MG/0.4 ML SYRINGE 4QL 1 SYRINGE (0.4 ML) /

DAYPA

ursodiol (250 mg tablet, 300 mg capsule, 500 mgtablet)

2



HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (300 mg tablet, 300 mg/5 ml soln, 400mg tablet, 800 mg tablet)

2

cimetidine 200 mg tablet 3

famotidine (20 mg tablet, 40 mg/5 ml susp) 3

famotidine 40 mg tablet 2

nizatidine (15 mg/ml solution, 150 mg capsule, 300mg capsule)

2

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150mg tablet, 150 mg/10 ml syrup, 300 mg capsule, 300mg tablet)

2

ranitidine hcl (hcl 150 mg/6 ml vl, 1,000 mg/40 mlvial)

3

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (tablet) 3 PA

AMITIZA (CAPSULE) 4QL 2 / DAY

ST

LINZESS (CAPSULE) 4QL 1 / DAY

ST

LAXATIVES

alophen pills (tablet dr) 1

bisa-lax (tablet dr) 1

bisacodyl (cvs ec 5 mg tablet, ec 5 mg tablet, fleet ec5 mg tab, ra ec 5 mg tablet, sb ec 5 mg tablet)

1

c-lax laxative (tablet dr) 1

citrate of magnesia (solution) 1

clearlax (eq powder, eql powder, gnp powder, gspowder, hm powder, powder, sm powder, swpowder)

1

constulose (solution) 2

cvs purelax powder 1



ducodyl (tablet dr) 1

enulose (solution) 2

gavilax (powder) 1

gavilyte-c (soln recon) 1

gavilyte-g (soln recon) 1

gavilyte-n (soln recon) 1

generlac (solution) 2

gentle laxative (5 mg tablet, cvs ec 5 mg tb, ec 5 mgtablet, eq dr 5 mg tab, eql ec 5 mg tb, gnp ec 5 mgtb, kro ec 5 mg tb, sm ec 5 mg tab)

1

gentlelax (powder) 1

glycolax (powder) 1

lactulose (10 gm/15 ml solution, 20 gm/30 mlsolution)

2

laxaclear (powder) 1

laxative (5 mg tablet, ec 5 mg tablet, gnp ec 5 mgtablet, hm ec 5 mg tablet, pub ec 5 mg tablet, ra ec 5mg tablet, sm tablet)

1

laxative feminine (tablet) 1

laxative peg 3350 (powder) 1

magnesium citrate (cvs magnesium soln, cvs ofmagnesia soln, eq magnesium solution, eqlmagnesium solution, gs magnesium solution, hmmagnesium solution, magnesium solution, qcmagnesium solution, sm magnesium solution)

1

natura-lax (powder) 1

peg 3350-electrolyte (soln recon) 1

peg-3350 and electrolytes (soln recon) 1

polyethylene glycol 3350 (otc) 1



polyethylene glycol 3350 (powd pack, powder) 3

powderlax powder 1

smoothlax powder 1

trilyte with flavor packets (soln recon) 1

woman's laxative (tablet) 1

women's gentle laxative (tablet dr) 1

women's laxative (eq women's 5 mg tab, eqwomen's ec 5 mg tb, qc women's ec 5 mg tb, rawomen's tablet, womans tablet, women's 5 mgtablet, women's ec 5 mb tab, women's ec 5 mg tab)

1

PROTECTANTS

misoprostol (tablet) 2

sucralfate (1 gm tablet, 1 gm/10 ml susp) 2

PROTON PUMP INHIBITORS

lansoprazole dr 15 mg capsule 3 QL 2 / DAY

lansoprazole dr 30 mg capsule 2 QL 2 / DAY

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr40 mg capsule)

2 QL 1 / DAY

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 2 QL 1 / DAY

rabeprazole sod dr 20 mg tab 2 QL 1 / DAY

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ADAGEN (VIAL) 6

BUPHENYL (500 MG TABLET, POWDER) 6

CERDELGA (CAPSULE) 6 PA

CREON (CAPSULE DR) 4

CYSTAGON (CAPSULE) 6

KUVAN (100 MG POWDER PACKET, 100 MG TABLET,500 MG POWDER PACKET)

5 PA



nitisinone (capsule) 5 PA

ORFADIN (4 MG/ML SUSPENSION, 20 MG CAPSULE) 6 PA

PROCYSBI (CAP DR SPR) 6 PA

RAVICTI (LIQUID) 6 PA

sodium phenylbutyrate (500mg tb, powder) 6

STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 MLVIAL, 40 MG/ML VIAL, 80 MG/0.8 ML VIAL)

5 PA

SUCRAID (SOLUTION) 6

GENITOURINARY AGENTSANTISPASMODICS, URINARY

flavoxate hcl (tablet) 3

MYRBETRIQ (TAB ER 24H) 4

oxybutynin chloride (5 mg tablet, 5 mg/5 ml syrup) 2

oxybutynin chloride er (tab er 24) 2

solifenacin succinate (tablet) 2

tolterodine tartrate (tablet) 3

tolterodine tartrate er (cap er 24h) 3

trospium chloride (tablet) 3

trospium chloride er (cap er 24h) 3

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er (tab er 24h) 2

dutasteride (capsule) 2

finasteride 5 mg tablet 2

tadalafil (2.5 mg tablet, 5 mg tablet) 2 QL 1 / DAY

tamsulosin hcl (capsule) 2



GENITOURINARY AGENTS, OTHER

bethanechol chloride (tablet) 2

CONCEPTROL (GEL/PF APP) 1

ELMIRON (CAPSULE) 4

gynol ii (jelly/appl) 1

phenazopyridine hcl (tablet) 2

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mgtablet)

2 QL 6 / 30 DAYS

tadalafil 10 mg tablet 2 QL 6 / 30 DAYS

tadalafil 20 mg tablet (generic for cialis) 2 QL 6 / 30 DAYS

THIOLA (TABLET) 6

THIOLA EC (TABLET DR) 6

TODAY CONTRACEPTIVE SPONGE (CON.SPONGE) 1

vcf (film, foam, gel) 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

a-hydrocort (vial) 3

ala-cort 2.5% cream 2

alclometasone dipropionate (dipr oint, dipro crm) 2

amcinonide (cream, lotion, ointment) 3

betamethasone diprop augmented (crm, gel, lot, oin) 2

betamethasone dipropionate (crm, lot, oint) 2

betamethasone sod phos-acetate (vial) 3

betamethasone valer 0.12% foam 3

betamethasone valerate (va cream, va lotion, valerointm)

2

clobetasol propionate (cream, gel, ointment,solution)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSclobetasol propionate (prop foam, prop spray,shampoo, topical lotn)

3

clocortolone pivalate (cream ) 3

clodan 0.05% shampoo 3

cormax (solution) 2

cortisone acetate (tablet) 2

decadron 0.5 mg/5 ml elixir 2

desonide (cream, lotion, ointment) 2

desoximetasone (0.05% cream, 0.05% gel, 0.25%cream, 0.25% ointment)

2

desoximetasone 0.05% ointment 3

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mgtablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

2

dexamethasone 10 mg/ml syring 2

dexamethasone sodium phosphate (4 mg/mlsyringe, 4 mg/ml vial, 10 mg/ml vial, 20 mg/5 mlvial, 100 mg/10 ml vl, 120 mg/30 ml vl)

3

diflorasone 0.05% cream 2

diflorasone 0.05% ointment 3

fludrocortisone acetate (tablet) 2

fluocinolone acetonide (0.01% body oil, 0.01%cream, 0.01% solution, 0.025% cream, 0.025%ointment)

2

fluocinonide (cream, gel, ointment, solution) 2

fluocinonide 0.1% cream 3

flurandrenolide (cream, lotion) 3

fluticasone prop 0.05% lotion 3

fluticasone propionate (0.005% oint, 0.05% cream) 2



halobetasol propionate (cream, ointmnt) 3

hydrocort-pramoxine 2.5-1% crm 3

hydrocort-pramoxine 2.5-1% crm (analpram generic- perrigo)

2

hydrocortisone (1% cream, 2.5% cream, 2.5% lotion,2.5% ointment, 5 mg tablet, 10 mg tablet, 20 mgtablet)

2

hydrocortisone 1% ointment 3

hydrocortisone butyrate (buty cream, butyr oint,butyr soln)

2

hydrocortisone valerate (cream, ointmt) 2

KORLYM (TABLET) 6QL 4 / DAY

PA

methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mgtab, 16 mg tab, 32 mg tab)

2

methylprednisolone acetate (40 mg/ml vl, 80 mg/mlvl)

3

methylprednisolone sodium succ (40 mg vl, 125 mg) 3

mometasone furoate (cream, oint, soln) 2

prednicarbate (cream, ointment) 3

prednisolone (solution) 2

prednisolone sod ph 25 mg/5 ml 3

prednisolone sodium phos odt (tab rapdis) 3

prednisolone sodium phosphate (5 mg/5 ml soln, 15mg/5 ml soln)

2

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tabdose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mgtab dose pack, 10 mg tablet, 20 mg tablet, 50 mgtablet)

2

psorcon (cream (g)) 2

scalacort (lotion) 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONStriamcinolone acetonide (0.025% cream, 0.025%lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1%ointment, 0.5% cream, 0.5% ointment)

2

triamcinolone acetonide (0.147 mg/g spray, acet 40mg/ml vl, acet 40mg/ml vl, acet 50mg/5ml vl, acet200 mg/5 ml, acet 400 mg/10ml)

3

triderm (cream ) 2

u-cort (cream (g)) 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

chorionic gonad 10,000 unit vl 6 PA

desmopressin acetate (0.01% solution, 0.01% spray,0.1 mg/ml sol, acetate 0.1 mg tb, acetate 0.2 mg tb,10 mcg/0.1 ml spr)

2

desmopressin acetate (ac 4 mcg/ml ampul, ac 4mcg/ml vial, 40 mcg/10 ml vial)

3

FOLLISTIM AQ (CARTRIDGE) 6 PA

GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG,MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG,MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MGCARTRIDGE)

6 PA

GONAL-F (VIAL) 5 PA

GONAL-F RFF (VIAL) 5 PA

GONAL-F RFF REDI-JECT (PEN INJCTR) 5 PA

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MGCARTRIDGE, 24 MG CARTRIDGE)

6 PA

INCRELEX (VIAL) 6 PA

MENOPUR (VIAL) 6 PA

NORDITROPIN FLEXPRO (PEN INJCTR) 5 PA

NOVAREL 10,000 UNITS VIAL 6 PA

NOVAREL 5,000 UNIT VIAL 6QL 1 VIAL / 30 DAYS

PA



NUTROPIN AQ (CARTRIDGE) 5 PA

NUTROPIN AQ NUSPIN (PEN INJCTR) 5 PA

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10MG/1.5 ML CRTG)

5 PA

OVIDREL (SYRINGE) 5

PREGNYL (VIAL) 6 PA

SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8MG VIAL)

6 PA

SAIZEN-SAIZENPREP (CARTRIDGE) 6 PA

SEROSTIM (VIAL) 6 PA

ZOMACTON (VIAL) 6 PA

ZORBTIVE (VIAL) 6 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)

alprostadil (vial) 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)ANABOLIC STEROIDS

oxandrolone 10 mg tablet 3QL 2 / DAY

PA

oxandrolone 2.5 mg tablet 3QL 8 / DAY

PA

ANDROGENS

androxy (tablet) 2 PA

danazol (capsule) 2

methyltestosterone (capsule) 3 PA

testosterone (1.62% (2.5 g) pkt, 1.62% gel pump,1.62%(1.25 g) pkt, 25 mg/2.5 gm pkt, 50 mg/5 gramgel, 50 mg/5 gram pkt)

2 PA

testosterone 12.5 mg/1.25 gram 3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONStestosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100mg/ml, testosterone 200 mg/ml)

3 PA

testosterone enanthate (vial) 3 PA

ESTROGENS

afirmelle (tablet) 1

altavera (tablet) 1

alyacen (tablet) 1

amabelz (tablet) 3

amethia (tbdspk 3mo) 1

amethia lo (tbdspk 3mo) 1

amethyst (tablet) 1

apri (tablet) 1

aranelle (tablet) 1

ashlyna (tbdspk 3mo) 1

aubra (tablet) 1

aubra eq (tablet) 1

aurovela (tablet) 1

aurovela 24 fe (tablet) 1

aurovela fe (tablet) 1

aviane (tablet) 1

ayuna (tablet) 1

azurette (tablet) 1

balziva (tablet) 1

bekyree (tablet) 1



blisovi 24 fe (tablet) 1

blisovi fe (tablet) 1

briellyn (tablet) 1

camrese (tbdspk 3mo) 1

camrese lo (tbdspk 3mo) 1

caziant (tablet) 1

chateal (tablet) 1

chateal eq (tablet) 1

covaryx (tablet) 2

covaryx h.s. (tablet) 2

cryselle (tablet) 1

cyclafem (tablet) 1

cyred (tablet) 1

cyred eq (tablet) 1

dasetta (tablet) 1

daysee (tbdspk 3mo) 1

delyla (tablet) 1

desogestr-eth estrad eth estra (tablet) 1

desogestrel-ethinyl estradiol (tablet) 1

dotti (patch tdsw) 2

drospirenone-eth estra-levomef (tablet) 1

drospirenone-ethinyl estradiol (tablet) 1

eemt (tablet) 2

eemt h.s. (tablet) 2



elinest (tablet) 1

eluryng (vag ring) 1

emoquette (tablet) 1

enpresse (tablet) 1

enskyce (tablet) 1

estarylla (tablet) 1

estradiol (0.025 mg patch, tds 0.025 mg/day, 0.0375mg patch, 0.0375 mg/day patch, tds 0.0375 mg/day,0.05 mg patch, tds 0.05 mg/day, 0.06 mg/day patch,tds 0.06 mg/day, 0.075 mg patch, 0.075 mg/daypatch, tds 0.075 mg/day, 0.1 mg patch, tds 0.1mg/day, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

2

estradiol 0.01% cream 3

estradiol-norethindrone acetat (tablet) 3

estrogen-methyltestosterone (tablet) 2

estropipate (tablet) 2

ethynodiol-ethinyl estradiol (tablet) 1

etonogestrel-ethinyl estradiol (vag ring) 1

falmina (tablet) 1

fayosim (tbdspk 3mo) 1

femynor (tablet) 1

fyavolv (tablet) 3

gianvi (tablet) 1

gildagia (tablet) 1

gildess (tablet) 1

gildess 24 fe (tablet) 1



hailey (tablet) 1

hailey 24 fe (tablet) 1

introvale (tbdspk 3mo) 1

isibloom (tablet) 1

jasmiel (tablet) 1

jevantique lo (tablet) 3

jinteli (tablet) 3

jolessa (tbdspk 3mo) 1

juleber (tablet) 1

junel (tablet) 1

junel fe (tablet) 1

junel fe 24 (tablet) 1

kaitlib fe (tab chew) 1

kalliga (tablet) 1

kariva (tablet) 1

kelnor 1-35 (tablet) 1

kelnor 1-50 (tablet) 1

kimidess (tablet) 1

kurvelo (tablet) 1

larin (tablet) 1

larin 24 fe (tablet) 1

larin fe (tablet) 1

larissia (tablet) 1

leena (tablet) 1



lessina (tablet) 1

levonest (tablet) 1

levonorg-eth estrad eth estrad (tbdspk 3mo) 1

levonorgestrel-eth estradiol (tablet, tbdspk 3mo) 1

levora-28 (tablet) 1

lillow (tablet) 1

lo-zumandimine (tablet) 1

lomedia 24 fe (tablet) 1

lopreeza (tablet) 3

loryna (tablet) 1

low-ogestrel (tablet) 1

lutera (tablet) 1

marlissa (tablet) 1

melodetta 24 fe (tab chew) 1

mibelas 24 fe (tab chew) 1

microgestin (tablet) 1

microgestin fe (tablet) 1

mili (tablet) 1

mimvey (tablet) 3

mimvey lo (tablet) 3

mono-linyah (tablet) 1

mononessa (tablet) 1

myzilra (tablet) 1

necon (tablet) 1



nikki (tablet) 1

norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, noreth-estrad-fe 1-0.02(21)-75,noreth-estrad-fe 1-0.02(24)-75, norethin-estra-fe0.8-0.025 mg)

1

norethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)

1

norethindron-ethinyl estradiol (norethin-eth 1 mg-5mcg, norethind-eth 0.5-2.5)

3

norethindrone-eth estradiol-fe (tablet) 1

norgestimate-ethinyl estradiol (tablet) 1

nortrel (tablet) 1

NUVARING (VAG RING) 1

ocella (tablet) 1

ogestrel (tablet) 1

orsythia (tablet) 1

philith (tablet) 1

pimtrea (tablet) 1

pirmella (tablet) 1

portia (tablet) 1

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)

4

PREMPHASE (TABLET) 4

PREMPRO (TABLET) 4

previfem (tablet) 1

quasense (tbdspk 3mo) 1

rajani (tablet) 1

reclipsen (tablet) 1



rivelsa (tbdspk 3mo) 1

setlakin (tbdspk 3mo) 1

simliya (tablet) 1

simpesse (tbdspk 3mo) 1

sprintec (tablet) 1

sronyx (tablet) 1

syeda (tablet) 1

tarina 24 fe (tablet) 1

tarina fe (tablet) 1

tarina fe 1-20 eq (tablet) 1

tilia fe (tablet) 1

tri femynor (tablet) 1

tri-estarylla (tablet) 1

tri-legest fe (tablet) 1

tri-linyah (tablet) 1

tri-lo-estarylla (tablet) 1

tri-lo-marzia (tablet) 1

tri-lo-mili (tablet) 1

tri-lo-sprintec (tablet) 1

tri-mili (tablet) 1

tri-previfem (tablet) 1

tri-sprintec (tablet) 1

tri-vylibra (tablet) 1

tri-vylibra lo (tablet) 1



trinessa (tablet) 1

trinessa lo (tablet) 1

trivora-28 (tablet) 1

tydemy (tablet) 1

velivet (tablet) 1

vestura (tablet) 1

vienva (tablet) 1

viorele (tablet) 1

vyfemla (tablet) 1

vylibra (tablet) 1

wera (tablet) 1

wymzya fe (tab chew) 1

xulane (patch tdwk) 1

zarah (tablet) 1

zenchent (tablet) 1

zovia 1-35e (tablet) 1

zovia 1-50e (tablet) 1

zumandimine (tablet) 1

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA (TABLET) 1

PROGESTINS

aftera (tablet) 1

camila (tablet) 1

deblitane (tablet) 1



econtra ez (tablet) 1

econtra one-step (tablet) 1

errin (tablet) 1

fallback solo (tablet) 1

heather (tablet) 1

incassia (tablet) 1

jencycla (tablet) 1

jolivette (tablet) 1

levonorgestrel (tablet) 1

lyza (tablet) 1

medroxyprogesterone 150 mg/ml 1

medroxyprogesterone acetate (2.5 mg tab, 5 mgtab, 10 mg tab)

2

megestrol 625 mg/5 ml susp 3

megestrol acetate (20 mg tablet, 40 mg tablet, acet40 mg/ml susp)

2

my choice (tablet) 1

my way (tablet) 1

new day (tablet) 1

next choice one dose (tablet) 1

nora-be (tablet) 1

norethindrone (tablet) 1

norethindrone acetate (tablet) 2

norlyda (tablet) 1

norlyroc (tablet) 1



opcicon one-step (tablet) 1

option 2 (tablet) 1

progesterone (100 mg capsule, 200 mg capsule, 500mg/10 ml vial)

3

sharobel (tablet) 1

tulana (tablet) 1

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

clomiphene citrate (tablet) 2

raloxifene hcl (tablet) 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

EUTHYROX (TABLET) 2

LEVO-T (TABLET) 2

levothyroxine sodium (25 mcg tablet, 50 mcg tablet,75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcg tablet, 300 mcgtablet)

2

LEVOXYL (TABLET) 2

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcgtab)

2

np thyroid (tablet) 3

thyroid (tablet) 3

UNITHROID (TABLET) 2

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline (tablet) 3

CETROTIDE (KIT) 5 PA

EGRIFTA 1 MG VIAL 6QL 2 VIALS / DAY

PA

EGRIFTA 2 MG VIAL 6QL 1 VIAL / DAY

PA



ELIGARD 22.5 MG SYRINGE KIT 6QL 1 SYRINGE / 84 DAYS

PA

ELIGARD 30 MG SYRINGE KIT 6QL 1 SYRINGE / 112

DAYSPA

ELIGARD 45 MG SYRINGE KIT 6QL 1 SYRINGE / 168

DAYSPA

ELIGARD 7.5 MG SYRINGE KIT 6QL 1 SYRINGE / 28 DAYS

PA

GANIRELIX ACETATE (SYRINGE) 6 PA

leuprolide acetate (kit) 6 PA

LUPANETA PK 11.25-5 MG 3MO KIT 6QL 1 KIT / 90 DAYS

PA

LUPANETA PK 3.75-5 MG 1MO KIT 6QL 1 KIT / 30 DAYS

PA

LUPRON DEPOT (3.75 MG KIT, 11.25 MG 3MO KIT) 6 PA

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 22.5MG 3MO KIT, DEPOT 45 MG 6MO KIT)

5 PA

LUPRON DEPOT 7.5 MG KIT 5 PA

LUPRON DEPOT-PED (11.25 MG 3MO, 11.25 MG KIT) 6 PA

LUPRON DEPOT-PED (7.5 MG KIT, 15 MG KIT, 30 MG3MO KIT)

5 PA

octreotide acetate (0.05 mg/ml vl, 50 mcg/ml amp,50 mcg/ml syr, 50 mcg/ml vial, 100 mcg/ml amp,100 mcg/ml syr, 100 mcg/ml vl, 500 mcg/ml amp,500 mcg/ml syr, 500 mcg/ml vl)

6 PA

octreotide acetate (acet 200 mcg/ml vl, 1,000 mcg/5ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)

5 PA

SIGNIFOR (AMPUL) 6QL 2 AMPULES / DAY

PA



SOMATULINE DEPOT (SYRINGE) 6 PA

SOMAVERT (VIAL) 6 PA

SYNAREL (SPRAY) 4

ZOLADEX 10.8 MG IMPLANT SYRN 6 QL 1 IMPLANT / 84DAYS

ZOLADEX 3.6 MG IMPLANT SYRN 6 QL 1 IMPLANT / 28DAYS

HORMONAL AGENTS, SUPPRESSANT (THYROID)ANTITHYROID AGENTS

methimazole (tablet) 2

propylthiouracil (tablet) 2

IMMUNOLOGICAL AGENTSANGIOEDEMA AGENTS

icatibant (syringe) 5 PA

KALBITOR (VIAL) 6 PA

IMMUNE SUPPRESSANTS

azathioprine (tablet) 2

azathioprine sodium (vial) 3

CIMZIA (2X200 MG/ML SYRINGE KIT, 2X200MG/ML(X3)START KT, 200 MG VIAL KIT)

5 PA

cyclosporine (25 mg capsule, 100 mg capsule) 5

cyclosporine modified (25 mg, 50 mg, 100 mg,100mg/ml)

5

gengraf (25 mg capsule, 50 mg capsule, 100 mgcapsule, 100 mg/ml solution)

5

HUMIRA (SYRINGEKIT) 5 PA

HUMIRA PEDIATRIC CROHN'S (SYRINGEKIT) 5 PA

HUMIRA PEN (PEN IJ KIT) 5 PA

HUMIRA PEN CROHN'S-UC-HS (PEN IJ KIT) 5 PA



HUMIRA PEN PSOR-UVEITS-ADOL HS (PEN IJ KIT) 5 PA

HUMIRA(CF) (SYRINGEKIT) 5 PA

HUMIRA(CF) PEDIATRIC CROHN'S (SYRINGEKIT) 5 PA

HUMIRA(CF) PEN (PEN IJ KIT) 5 PA

HUMIRA(CF) PEN CROHN'S-UC-HS (PEN IJ KIT) 5 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS (PEN IJ KIT) 5 PA

methotrexate (50 mg/2 ml vial, 250 mg/10 ml vial) 3

methotrexate 2.5 mg tablet 2

methotrexate sodium (vial) 3

mycophenolate 200 mg/ml susp 6

mycophenolate mofetil (250 mg capsule, 500 mgtablet)

5

mycophenolic acid (tablet dr) 6

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE, 250 MG VIAL)

6 PA

ORENCIA CLICKJECT (AUTO INJCT) 6 PA

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/MLSYRINGE)

5 PA

SIMPONI ARIA (VIAL) 5 PA

sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 6

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mgcapsule)

5

XELJANZ (TABLET) 5 PA

XELJANZ XR (TAB ER 24H) 5 PA

IMMUNIZING AGENTS, PASSIVE

GAMASTAN (VIAL) 6 PA

GAMASTAN S-D (VIAL) 6 PA



GAMMAKED 1 GRAM/10 ML VIAL 6 PA

GAMUNEX-C 1 GRAM/10 ML VIAL 6 PA

HYQVIA (VIAL) 6 PA

IMMUNOMODULATORSACTEMRA (80 MG/4 ML VIAL, 162 MG/0.9 MLSYRINGE, 200 MG/10 ML VIAL, 400 MG/20 ML VIAL)

6 PA

ACTEMRA ACTPEN (PEN INJCTR) 6 PA

leflunomide (tablet) 2

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET,STARTER PACK)

5 PA

VACCINES

ACTHIB (VIAL) 1

ADACEL TDAP (SYRINGE, VIAL) 1

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL)

1

AFLURIA 2018-2019 (2018-2019 SYRINGE, 2018-2019 VIAL)

1

AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE,2017-2018 VIAL)

1

AFLURIA QUAD 2018-2019 (2018-2019 SYRINGE,2018-2019 VIAL)

1

AFLURIA QUAD 2019-20 (3YR UP) (SYRINGE) 1

AFLURIA QUAD 2019-20 (6-35MO) (SYRINGE) 1

AFLURIA QUAD 2019-2020 (VIAL) 1

BEXSERO (SYRINGE) 1

BOOSTRIX TDAP (SYRINGE, VIAL) 1

DAPTACEL DTAP (VIAL) 1

DIPHTHERIA-TETANUS TOXOIDS-PED (VIAL) 1

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/MLVIAL)

1



ENGERIX-B PEDIATRIC-ADOLESCENT (SYRINGE) 1

FLUAD 2017-2018 (SYRINGE) 1



FLUARIX QUAD 2017-2018 (SYRINGE) 1



FLUBLOK 2017-2018 (VIAL) 1

FLUBLOK QUAD 2017-2018 (SYRINGE) 1



FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL)

1


1


1

FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL)

1


1


1

FLUMIST QUAD 2018-2019 (NAS SP SYR) 1

FLUMIST QUAD 2019-2020 (NAS SP SYR) 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL)

1

FLUZONE HIGH-DOSE 2017-2018 (SYRINGE) 1





FLUZONE INTRADERM QUAD 2017-18 (SYRINGE) 1

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE,2017-2018 VIAL)

1


1


1

FLUZONE QUAD PEDI 2017-2018 (SYRINGE) 1



GARDASIL 9 (9 SYRINGE, 9 VIAL) 1

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/MLVIAL)

1

HEPLISAV-B (20 MCG/0.5 ML SYRNG, 20 MCG/0.5ML VIAL)

1

HIBERIX (VIAL) 1

INFANRIX DTAP (SYRINGE, VIAL) 1

IPOL (VIAL) 1

KINRIX (TIP-LOK SYRINGE, VIAL) 1

M-M-R II VACCINE (VIAL) 1

MENACTRA (VIAL) 1

MENVEO A-C-Y-W-135-DIP (KIT) 1

PEDVAXHIB (VIAL) 1

PENTACEL (KIT) 1

PENTACEL ACTHIB COMPONENT (VIAL) 1

PENTACEL DTAP-IPV COMPONENT (VIAL) 1



PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 1

PREVNAR 13 (SYRINGE) 1

PROQUAD (VIAL) 1

QUADRACEL DTAP-IPV (VIAL) 1

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 MLVL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/MLVIAL)

1

ROTARIX (SUSP RECON) 1

ROTATEQ (SOLUTION) 1

SHINGRIX (KIT) 1

TDVAX (VIAL) 1

TENIVAC (SYRINGE, VIAL) 1

TRUMENBA (SYRINGE) 1

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)

1

VARIVAX VACCINE (VIAL) 1

ZOSTAVAX (VIAL) 1

INFLAMMATORY BOWEL DISEASE AGENTSAMINOSALICYLATES

APRISO (CAP ER 24H) 4

balsalazide disodium (capsule) 2

mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema,1,000 mg supp)

2

mesalamine er (cap er 24h) 2

GLUCOCORTICOIDS

anucort-hc (supp.rect) 2

budesonide ec (capdr - er) 2



colocort (enema) 2

hemmorex-hc 25 mg suppository 2

hemmorex-hc 30 mg suppository 3

hydrocortisone 100 mg/60 ml 2

hydrocortisone ac 25 mg supp 2

hydrocortisone ac 30 mg supp 3

procto-med hc (crm/pe app) 2

procto-pak (crm/pe app) 2

proctosol-hc (crm/pe app) 2

proctozone-hc (crm/pe app) 2

SULFONAMIDES

sulfasalazine (tablet) 2

METABOLIC BONE DISEASE AGENTS

alendronate sodium (35 mg tab, 70 mg tab) 2 QL 4 / 28 DAYS

alendronate sodium (sod 70 mg/75 ml, sodium 5 mgtablet, sodium 10 mg tab, sodium 40 mg tab)

2

calcitonin-salmon (spray/pump) 3 QL 1 BOTTLE (3.7 ML) /30 DAYS

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1mcg/ml solution)

2

d3-50 (capsule) 3

decara 50,000 unit softgel 3

doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcgcap)

3

etidronate disodium (tablet) 3

FORTEO (PEN INJCTR) 5 PA

ibandronate sodium 150 mg tab 2 QL 1 / 28 DAYS



NATPARA (CARTRIDGE) 6QL 2 CARTRIDGES / 28

DAYSPA

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcgcapsule)

2

PROLIA (SYRINGE) 6QL 2 SYRINGES (2 ML) /

365 DAYSPA

RECLAST (PGGYBK BTL) 6

risedronate sodium (5 mg tablet, 30 mg tab) 2

risedronate sodium 150 mg tab 2 QL 1 / 28 DAYS

risedronate sodium 35 mg tab 2 QL 4 / 28 DAYS

vitamin d2 1.25mg(50,000 unit) 2

vitamin d3 50,000 unit capsule 3

MISCELLANEOUS THERAPEUTIC AGENTS

accu-chek aviva plus meter 4

accu-chek aviva plus test strp 4 QL 10 / DAY

accu-chek compact plus kit 4

accu-chek compact plus strips (strip) 4 QL 10 / DAY

accu-chek guide me glucose mtr (each) 4

accu-chek guide monitor system (each) 4

accu-chek guide test strip (strip) 4 QL 10 / DAY

accu-chek nano smartview (each) 4

accu-chek smartview test strip 4 QL 10 / DAY

alcohol,dehydrated (ampule, vial) 3

calcium disodium versenate (ampul) 3

caya contoured (diaphragm) 1



deferoxamine 500 mg vial 3

diphen 12.5 mg/5 ml elixir 2

diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 2

DUROLANE (SYRINGE) 6 PA

EUFLEXXA (SYRINGE) 5 PA

fc2 female condom (each) 1

femcap (each) 1

formaldehyde (sol w/appl) 3

gel-one (syringe) 6 PA

genvisc 850 (syringe) 6 PA

HYALGAN 20 MG/2 ML VIAL 6 PA

HYMOVIS (SYRINGE) 6 PA

indocyanine green (vial) 3

isomethept-caff-acetaminophen (tablet) 3

isomethept-dichloralp-acetamin (capsule) 2

levocarnitine (1 g/10 ml soln, 330 mg tablet) 3

lugol's (solution) 3

md-gastroview (solution) 3

methylergonovine 0.2 mg tablet 2

methylergonovine maleate (0.2 mg/ml amp, 0.2mg/ml vl)

3

MONOVISC (SYRINGE) 6 PA

nodolor (capsule) 2

onetouch ultra blue test strp (strip) 4 QL 10 / DAY

onetouch ultra2 (each) 4



onetouch ultramini (kit) 4

onetouch verio flex (each) 4

onetouch verio iq (each) 4

onetouch verio meter system 4

onetouch verio test strip 4 QL 10 / DAY

ORTHOVISC (SYRINGE) 6 PA

oxytocin (vial) 3

physostigmine salicylate (ampul) 3

pralidoxime chloride (pen injctr) 3

sodium hyaluronate (syringe) 6 PA

supartz fx (syringe) 6 PA

SYNVISC (SYRINGE) 5 PA

SYNVISC-ONE (SYRINGE) 5 PA

tc99m sulfur colloid prep (vial) 3

trivisc (syringe) 6 PA

vaseline white petroleum (oint pack) 3

visco-3 (syringe) 6 PA

wide seal diaphragm (diaphragm) 1

XURIDEN (GRAN PACK) 6QL 4 / DAY

PA

OPHTHALMIC AGENTSOPHTHALMIC AGENTS, OTHER

ak-poly-bac (oint. (g)) 2

altacaine (drops) 2

ALTAFLUOR (DROPS) 3



atropine 1% eye drops 2

balanced salt (irrig soln) 3

cyclopentolate hcl (drops) 2

CYSTARAN (DROPS) 6QL 4 BOTTLES (60 ML) /

28 DAYSPA

fluorescein-proparacaine (drops) 3

flurox (drops) 3

green glo (strip) 3

homatropaire (drops) 2

homatropine hydrobromide (drops) 2

naphazoline hcl (drops) 2

neo-polycin (oint. (g)) 2

neo-polycin hc (oint. (g)) 2

neomycin-bacitracin-poly-hc (oint. (g)) 2

neomycin-bacitracin-polymyxin (oint. (g)) 2

neomycin-poly-hc eye drops 3

neomycin-polymyxin-dexameth (neomyc-polym-dexamet ointm, neomyc-polym-dexameth drop)

2

phenylephrine hcl (2.5% drop, 10% drops) 2

polycin (oint. (g)) 2

polymyxin b sul-trimethoprim (drops) 2

proparacaine hcl (drops) 2

sulfacetamide-prednisolone (drops) 2

tetcaine (drops) 2

tetracaine hcl (eye drop, steri-unit sol) 2



tobramycin-dexamethasone (drops susp) 2

tropicamide (drops) 2

OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine hcl 0.05% drops 2

cromolyn 4% eye drops 2

epinastine hcl (drops) 3

olopatadine hcl 0.1% eye drops 2

OPHTHALMIC ANTI-INFLAMMATORIES

bromfenac sodium (drops) 3 QL 4 BOTTLES (6.8 mL) /YEAR

diclofenac 0.1% eye drops 2

fluorometholone (drops susp) 2

flurbiprofen sodium (drops) 2

FML FORTE (DROPS SUSP) 4

FML S.O.P. (OINT. (G)) 4

ketorolac tromethamine (0.4% solution, 0.5%solution)

2

prednisolone ac 1% eye drop 2

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1% DROPS 4

apraclonidine hcl (drops) 3

AZOPT (DROPS SUSP) 4

betaxolol hcl 0.5% eye drop 2

BETOPTIC S (DROPS SUSP) 4

brimonidine tartrate (drops) 2

carteolol hcl (drops) 2



dorzolamide hcl (drops) 2

dorzolamide-timolol eye drops 2

levobunolol hcl (drops) 2

methazolamide (tablet) 2

metipranolol (drops) 2

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

timolol 0.5% eye drop 3

timolol maleate (0.25% gel-solution, 0.25% gfs gel-solution, maleate 0.25% eye drop, 0.5% gel-solution,0.5% gfs gel-solution, maleate 0.5% eye drops)

2

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 0.03% eye drops 2 QL 2.5 ML / 25 DAYS

latanoprost 0.005% eye drops 2

LUMIGAN (DROPS) 4 QL 2.5 ML / 30 DAYS

TRAVATAN Z (DROPS) 4 QL 2.5 ML / 25 DAYS

travoprost (drops) 2 QL 2.5 ML / 25 DAYS

OTIC AGENTS

acetic acid 2% ear solution 2

CIPRODEX (DROPS SUSP) 4

flac otic oil (drops) 3

fluocinolone acetonide oil (drops) 3

hydrocortisone-acetic acid (drops) 2

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort (solution) 2



RESPIRATORY TRACT/PULMONARY AGENTSANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1mg/2 ml inh susp)

3 QL 60 AMPULES (120ML) / 30 DAYS

budesonide 32 mcg nasal spray 3 QL 2 BOTTLES (17.2 G) /30 DAYS

FLOVENT 250 MCG DISKUS 4 QL 4 INHALERS (240BLISTERS) / 30 DAYS

FLOVENT DISKUS (50 MCG, 100 MCG) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

FLOVENT HFA (110 MCG, 220 MCG) 4 QL 2 INHALERS (24 G) /30 DAYS

FLOVENT HFA 44 MCG INHALER 4 QL 2 INHALERS (21.2 G)/ 30 DAYS

fluticasone prop 50 mcg spray 3

mometasone furoate 50 mcg spry 2 QL 2 BOTTLES (34 G) /30 DAYS

NASONEX (SPRAY/PUMP) 4 QL 2 BOTTLES (34 G) /30 DAYS

PULMICORT FLEXHALER (AER POW BA) 4 QL 2 INHALERS / 30DAYS

QVAR 40 MCG ORAL INHALER 4 QL 2 INHALERS (17.4 G)/ 30 DAYS

QVAR 80 MCG ORAL INHALER 4 QL 3 INHALERS (26.1 G)/ 30 DAYS

QVAR REDIHALER (HFA AEROBA) 4 QL 2 INHALERS (21.2 G)/ 30 DAYS

triamcinolone 55 mcg nasal spr 3

ANTIHISTAMINES

arbinoxa (tablet) 2

azelastine hcl (0.1% (137 mcg) spry, 0.15% nasalspray)

2 QL 2 BOTTLES (60 ML) /30 DAYS

carbinoxamine maleate (4 mg/5 ml liquid, maleate 4mg tab)

2



cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 3

clemastine fumarate (tablet) 2

cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 mlsyrup, 4 mg tablet, 4 mg/10 ml syrp)

2

desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 3

diphenhydramine hcl (50 mg/ml crpjt, 50 mg/mlsyrng)

3

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup,hcl 10 mg tablet, hcl 25 mg tablet, 50 mg/25 mlsyrup, hcl 50 mg tablet)

2

hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100mg/2 ml vial, 500 mg/10 ml vial)

3

hydroxyzine pamoate (capsule) 2

olopatadine 665 mcg nasal spry 3 QL 1 BOTTLE (30.5 G) /30 DAYS

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 mlsyrp)

2

ANTILEUKOTRIENESmontelukast sodium (4 mg granules, 4 mg tab chew,5 mg tab chew, 10 mg tablet)

2

zafirlukast (tablet) 2

BRONCHODILATORS, ANTICHOLINERGIC

INCRUSE ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (30BLISTERS) / 30 DAYS

ipratropium br 0.02% soln 2 QL 125 VIALS (312.5 ML)/ 30 DAYS

ipratropium bromide (0.03% spray, 0.06% spray) 2

SPIRIVA (CAP W/DEV) 4 QL 1 CAPSULE / DAY

SPIRIVA RESPIMAT (MIST INHAL) 4 QL 1 INHALER (4 G) / 30DAYS

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol 2.5 mg/0.5 ml sol 2 QL 150 VIALS / 30 DAYS



albuterol sul 2.5 mg/3 ml soln 2 QL 180 VIALS (540 ML) /30 DAYS

albuterol sul hfa 90 mcg inh (18 gram package size) 4QL 2 INHALERS (36 G) /

30 DAYSST

albuterol sul hfa 90 mcg inh (6.7 gram package size) 4QL 2 INHALERS (13.4 G)

/ 30 DAYSST

albuterol sul hfa 90 mcg inh (8.5 gram package size) 4QL 2 INHALERS (17 G) /

30 DAYSST

albuterol sulfate (0.63 mg/3 ml, 1.25 mg/3 ml) 2 QL 125 VIALS (375 ML) /30 DAYS

albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate 2 mgtab, sulfate 4 mg tab, sulfate er 4 mg tab, sulfate er8 mg tab)

2

epinephrine 0.15 mg auto-injct 2

epinephrine 0.15 mg auto-injct - impax generics 2

epinephrine 0.15 mg auto-injct - lineage impax g 2

epinephrine 0.15 mg auto-injct - mylan specialty 2

epinephrine 0.3 mg auto-inject - lineage impax g 2

epinephrine 0.3 mg auto-inject - impax generics 2

epinephrine 0.3 mg auto-inject - lineage impax g 2

epinephrine 0.3 mg auto-inject - mylan specialty 2

epinephrine 0.3 mg auto-inject - teva generic 2

EPIPEN 2-PAK 0.3 MG AUTO-INJCT - MYLANSPECIALTY

4 ST

levalbuterol 1.25 mg/3 ml sol 3 QL 90 VIALS (270 ML) /30 DAYS

levalbuterol concentrate (vial-neb) 3 QL 90 VIALS (45 ML) /30 DAYS



levalbuterol hcl (0.31 mg/3 ml, 0.63 mg/3 ml) 3 QL 180 VIALS (540 ML) /30 DAYS

metaproterenol sulfate (10 mg tablet, 10 mg/5 mlsyr, 20 mg tablet)

3

PROAIR HFA (HFA AER AD) 4 QL 2 INHALERS (17 G) /30 DAYS

SEREVENT DISKUS (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

terbutaline sulf 1 mg/ml vial 3

terbutaline sulfate (2.5 mg tab, 5 mg tab) 2

VENTOLIN HFA (HFA AER AD) 4 QL 6 INHALERS (48 G) /30 DAYS

VENTOLIN HFA 90 MCG INHALER (LARGE PACKAGESIZE)

4 QL 2 INHALERS (36 G) /30 DAYS

CYSTIC FIBROSIS AGENTS

BETHKIS (AMPUL-NEB) 5

CAYSTON (VIAL-NEB) 6 PA

KALYDECO (25 MG GRANULES PACKET, 50 MGGRANULES PACKET, 75 MG GRANULES PACKET, 150MG TABLET)

6 PA

KITABIS PAK (AMPUL-NEB) 6 ST

ORKAMBI (100 MG TABLET, 200 MG TABLET) 6QL 4 / DAY

PA

TOBI (AMPUL-NEB) 6 ST

TOBI PODHALER (CAP W/DEV, CAPSULE) 6 QL 1 KIT (224 CAPSULES)/ 56 DAYS

tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 6 ST

MAST CELL STABILIZERS

cromolyn 20 mg/2 ml neb soln 2



PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine cit 60 mg/3 ml oral 3

DALIRESP 500 MCG TABLET 4 PA

theochron (tab er 12h) 2

theophylline (80 mg/15 ml soln, er 400 mg tablet, er600 mg tablet)

2

theophylline anhydrous (tab er 12h) 2

PULMONARY ANTIHYPERTENSIVES

ADCIRCA (TABLET) 6QL 2 / DAY

PA

ADEMPAS (TABLET) 5QL 3 / DAY

PA

alyq (tablet) 5QL 2 / DAY

PA

ambrisentan (tablet) 5QL 1 / DAY

PA

bosentan (tablet) 5QL 2 / DAY

PA

OPSUMIT (TABLET) 5QL 1 / DAY

PA

ORENITRAM ER (TABLET ER) 6 PA

REMODULIN (VIAL) 6 PA

REVATIO 10 MG/ML ORAL SUSP 6QL 2 BOTTLES (224 ML)

/ 30 DAYSPA

REVATIO 20 MG TABLET 6QL 3 / DAY

PA

sildenafil 10 mg/ml oral susp 5QL 2 BOTTLES (224 ML)

/ 30 DAYSPA



sildenafil 20 mg tablet 5QL 3 / DAY

PA

tadalafil 20 mg tablet (generic for adcirca) 5QL 2 / DAY

PA

TRACLEER 32 MG TABLET FOR SUSP 5QL 4 TABLETS / DAY

PA

treprostinil (vial) 5 PA

TYVASO (AMPUL-NEB) 6QL 1 AMPULE (2.9 ML) /

DAYPA

TYVASO INSTITUTIONAL START KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA

TYVASO REFILL KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA

TYVASO STARTER KIT (AMPUL-NEB) 6QL 1 KIT / 28 DAYS

PA

UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET,1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCGTABLET)

6QL 2 / DAY

PA

UPTRAVI 200-800 TITRATION PACK 6QL 2 PACKS (400

TABLETS) / 365 DAYSPA

VENTAVIS (AMPUL-NEB) 6QL 9 AMPULES / DAY

PA

PULMONARY FIBROSIS AGENTSESBRIET (267 MG CAPSULE, 267 MG TABLET, 801MG TABLET)

6 PA

OFEV (CAPSULE) 6 PA



RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (10% vial, 20% vial) 2

ADVAIR DISKUS (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

ADVAIR HFA (HFA AER AD) 4 QL 1 INHALER (12 G) /30 DAYS

ANORO ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

benzonatate (100 mg capsule, 200 mg capsule) 2

benzonatate 150 mg capsule 3

BREO ELLIPTA (BLST W/DEV) 4 QL 1 INHALER (60BLISTERS) / 30 DAYS

bromfed dm (syrup) 3

brompheniramine-pseudoephed-dm (syrup) 3

COMBIVENT RESPIMAT (MIST INHAL) 4 QL 2 INHALERS (8 G) /30 DAYS

fluticasone-salmeterol (100-50, 250-50, 500-50) 2 QL 1 INHALER (60BLISTERS) / 30 DAYS

fluticasone-salmeterol (55-14, 113-14, 232-14) 2 QL 1 INHALER / 30 DAYS

hydrocod-cpm-pseudoephedrine (solution) 3

PA

QLCLimited to 240 mlper prescription.Limited to 2 fills per60 days.

hydrocodone-chlorpheniramne er (sus er 12h) 3

PA


hydrocodone-homatropine 5-1.5 2

PA

QLC

Limited to 6 tabs perday up to 7 dayssupply.Limited to 2 fills per60 days.



hydrocodone-homatropine mbr (soln, syrup) 2

PA


hydromet (syrup) 2

PA


ipratropium-albuterol (ampul-neb) 2 QL 180 VIALS (540 ML) /30 DAYS

nebusal 3% vial 3

NUCALA 100 MG VIAL 6QL 3 VIAL / 28 DAYS

PA

NUCALA 100 MG/ML AUTO-INJECTOR 6QL 3 AUTO-INJECTOR /

28 DAYSPA

NUCALA 100 MG/ML SYRINGE 6QL 3 SYRINGE / 28 DAYS

PA

promethazine vc (syrup) 2

promethazine vc-codeine (syrup) 2

PA


promethazine-codeine (syrup) 2

PA


promethazine-dm (syrup) 2

promethazine-phenyleph-codeine (syrup) 2

PA




pulmosal (vial-neb) 3

PULMOZYME (SOLUTION) 6 PA

sodium chloride (3% vial, 7% vial, 10% vial) 3

sodium chloride 0.9% inhal vl 2

STIOLTO RESPIMAT (MIST INHAL) 4 QL 1 INHALER (4 G) / 30DAYS

SYMBICORT (HFA AER AD) 4 QL 1 INHALER (10.2 G) /30 DAYS

tussigon (tablet) 2

PA

QLC

Limited to 6 tabs perday up to 7 dayssupply.Limited to 2 fills per60 days.

wixela inhub (blst w/dev) 2 QL 1 INHALER (60BLISTERS) / 30 DAYS

XOLAIR (75 MG/0.5 ML SYRINGE, 150 MG VIAL, 150MG/ML SYRINGE)

6 PA

SKELETAL MUSCLE RELAXANTS

carisoprodol 250 mg tablet 3

carisoprodol 350 mg tablet 2

carisoprodol compound (tablet) 2

carisoprodol-aspirin (tablet) 2

chlorzoxazone 250 mg tablet 3

chlorzoxazone 500 mg tablet 2

cyclobenzaprine 7.5 mg tablet 3

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2

metaxall (tablet) 3

metaxalone (tablet) 3



methocarbamol (500 mg tablet, 750 mg tablet) 2

methocarbamol 1,000 mg/10 ml 3

orphenadrine citrate (30 mg/ml vial, 60 mg/2 mlampule, 60 mg/2 ml vial)

3

orphenadrine citrate er (tablet er) 2

SLEEP DISORDER AGENTSGABA RECEPTOR MODULATORS

estazolam (tablet) 2 QL 1 / DAY

eszopiclone (tablet) 2 QL 1 / DAY

flurazepam hcl (capsule) 2QL 1 / DAY

PA

quazepam (tablet) 3 QL 1 / DAY

temazepam (capsule) 2 QL 1 / DAY

triazolam (tablet) 2 QL 2 / DAY

zaleplon 10 mg capsule 2 QL 2 / DAY

zaleplon 5 mg capsule 2 QL 1 / DAY

zolpidem tartrate (5 mg tablet, 10 mg tablet) 2 QL 1 / DAY

zolpidem tartrate er (tab mphase) 2 QL 1 / DAY

SLEEP DISORDERS, OTHER

HETLIOZ (CAPSULE) 6QL 1 / DAY

PA


Index of Covered Drugs

Aa-hydrocort 73abacavir 37abacavir-lamivudine 37abacavir-lamivudine-zidovudine 37abiraterone acetate 27acamprosate calcium 11acarbose 41accu-chek 96accu-chek aviva plus 96accu-chek compact plus strips 96accu-chek guide me glucose mtr 96accu-chek guide monitor system 96accu-chek guide test strip 96accu-chek nano smartview 96accu-chek smartview 96acebutolol hcl 49acetamin-caff-dihydrocodeine 5acetaminophen-codeine 5acetazolamide 53acetazolamide er 53acetic acid 101acetylcysteine 108acitretin 61ACTEMRA 91ACTEMRA ACTPEN 91ACTHIB 91acyclovir 39ADACEL TDAP 91ADAGEN 71adapalene 61ADCIRCA 106adefovir dipivoxil 35ADEMPAS 106adult aspirin 2adult aspirin regimen 2adult low dose aspirin ec 2ADVAIR DISKUS 108ADVAIR HFA 108ADYNOVATE 46

afeditab cr 50AFINITOR 29AFINITOR DISPERZ 29afirmelle 78AFLURIA 2017-2018 91AFLURIA 2018-2019 91AFLURIA QUAD 2017-2018 91AFLURIA QUAD 2018-2019 91AFLURIA QUAD 2019-20 (3YR UP) 91AFLURIA QUAD 2019-20 (6-35MO) 91AFLURIA QUAD 2019-2020 91aftera 85ak-poly-bac 98ala-cort 73albuterol sul hfa 90 mcg inh (18 gram packagesize) 104albuterol sul hfa 90 mcg inh (6.7 gram packagesize) 104albuterol sul hfa 90 mcg inh (8.5 gram packagesize) 104albuterol sulfate 103,104alclometasone dipropionate 73alcohol,dehydrated 96alendronate sodium 95alfuzosin hcl er 72aliskiren 51allopurinol 25almotriptan malate 25alophen pills 69alosetron hcl 69ALPHAGAN P 100alprazolam 40alprazolam er 40alprazolam odt 40alprazolam xr 40alprostadil 77altacaine 98ALTAFLUOR 98altavera 78alyacen 78alyq 106

amabelz 78amantadine 31ambrisentan 106amcinonide 73amethia 78amethia lo 78amethyst 78amiloride hcl 53amiloride-hydrochlorothiazide 51aminocaproic acid 46amiodarone hcl 48AMITIZA 69amitriptyline hcl 22amlodipine besylate 50amlodipine besylate-benazepril 51ammonium lactate 61amnesteem 61amoxapine 22amoxicillin 16amoxicillin-clavulanate pot er 16amoxicillin-clavulanate potass 16ampicillin trihydrate 16amyl nitrite 56ANAFRANIL 22anagrelide hcl 46anastrozole 29androxy 77ANORO ELLIPTA 108anucort-hc 94APOKYN 32apraclonidine hcl 100apri 78APRISO 94APTIOM 19APTIVUS 38aranelle 78ARANESP 46arbinoxa 102aripiprazole 33aripiprazole odt 33ARIXTRA 45

asa-butalb-caffeine-codeine 5ascomp with codeine 5ascorbic acid 66ashlyna 78aspir 81 2aspir-low 2aspirin 2aspirin ec 2atazanavir sulfate 38atenolol 49atenolol-chlorthalidone 51atomoxetine hcl 57atorvastatin calcium 54atovaquone 31atovaquone-proguanil hcl 31ATRIPLA 37atropine sulfate 67,99aubra 78aubra eq 78aurovela 78aurovela 24 fe 78aurovela fe 78avar 61aviane 78avidoxy 17AVONEX 60AVONEX PEN 60ayuna 78azacitidine 28azathioprine 89azathioprine sodium 89azelastine hcl 100,102azithromycin 16AZOPT 100azurette 78

Bb-complex 66bacitracin 14baclofen 35balanced salt 99

balsalazide disodium 94balziva 78BARACLUDE 35bekyree 78belladonna-opium 5belladonna-phenobarbital 67benazepril hcl 48benazepril-hydrochlorothiazide 51benzepro 62benzonatate 108benzphetamine hcl 58benztropine mesylate 31betamethasone diprop augmented 73betamethasone dipropionate 73betamethasone sod phos-acetate 73betamethasone valerate 73BETASERON 60betaxolol hcl 49,100bethanechol chloride 73BETHKIS 105BETOPTIC S 100bexarotene 30BEXSERO 91bicalutamide 27bimatoprost 101bisa-lax 69bisacodyl 69bisoprolol fumarate 49bisoprolol-hydrochlorothiazide 51bleo 15k 28bleomycin sulfate 28BLINCYTO 30blisovi 24 fe 79blisovi fe 79BOOSTRIX TDAP 91bosentan 106BOSULIF 29bp 10-1 62bpo 62BREO ELLIPTA 108briellyn 79

BRILINTA 47brimonidine tartrate 100bromfed dm 108bromfenac sodium 100bromocriptine mesylate 32brompheniramine-pseudoephed-dm 108budesonide 102budesonide ec 94bumetanide 53BUPHENYL 71bupivacaine hcl 10buprenorphine hcl 12buprenorphine-naloxone 12buproban 12bupropion hcl 21bupropion hcl sr 21bupropion hcl sr 150 mg tab 12bupropion hcl sr 150 mg tablet (generic forwellbutrin sr) 21bupropion hcl sr 150 mg tablet (generic for zyban)

12bupropion xl 21buspirone hcl 39butalb-acetaminoph-caff-codein 6butalb-caff-acetaminoph-codein 6butalbital compound-codeine 6butalbital-acetaminophen 59butalbital-acetaminophen-caffe 59butalbital-aspirin-caffeine 10,59BYDUREON 41BYDUREON BCISE 41BYDUREON PEN 41BYETTA 41,42BYVALSON 51

Cc-lax laxative 69cabergoline 87caffeine and sodium benzoate 59caffeine citrate 106calcipotriene 62

calcitonin-salmon 95calcitriol 62,95calcium acetate 66calcium disodium versenate 96camila 85camrese 79camrese lo 79candesartan cilexetil 48candesartan-hydrochlorothiazid 51capecitabine 28CAPRELSA 29captopril 48captopril-hydrochlorothiazide 51CARBAGLU 64carbamazepine 19carbamazepine er 19carbidopa 32carbidopa-levodopa 32carbidopa-levodopa er 32carbidopa-levodopa-entacapone 32carbinoxamine maleate 102carisoprodol 110carisoprodol compound 110carisoprodol-aspirin 110carisoprodol-aspirin-codeine 6carteolol hcl 100cartia xt 50carvedilol 49caya contoured 96CAYSTON 105caziant 79cefaclor 15cefaclor er 15cefadroxil 15cefdinir 15cefditoren pivoxil 15cefixime 15cefpodoxime proxetil 15cefprozil 15ceftibuten 15cefuroxime 15

celecoxib 2cephalexin 15CERDELGA 71cetirizine hcl 103CETROTIDE 87cevimeline hcl 61CHANTIX 12chateal 79chateal eq 79children's aspirin 2chlordiazepoxide hcl 40chlordiazepoxide-amitriptyline 21chlordiazepoxide-clidinium 67chlorhexidine gluconate 61chloroquine phosphate 31chlorothiazide 53chlorpromazine hcl 32chlorpropamide 42chlorthalidone 53chlorzoxazone 110CHOLBAM 68cholestyramine light 54choline mag trisalicylate 2chorionic gonadotropin 76ciclodan 24ciclopirox 24cilostazol 47cimetidine 69CIMZIA 89CIPRODEX 101ciprofloxacin 16ciprofloxacin er 17ciprofloxacin hcl 16,17citalopram hbr 21citrate of magnesia 69citrate phosphate dextrose 45claravis 62clarithromycin 16clarithromycin er 16cleansing wash 62clearlax 69

clemastine fumarate 103clindacin p 62clindamycin hcl 14clindamycin palmitate hcl 14clindamycin pediatric 14clindamycin phos-benzoyl perox 62clindamycin phosphate 14,62clindamycin-benzoyl peroxide 62clobetasol propionate 73,74clocortolone pivalate 74clodan 74clomiphene citrate 87clomipramine hcl 22clonazepam 40clonidine 47clonidine hcl 47clonidine hcl er 57clopidogrel 47clorazepate dipotassium 40clotrimazole 24clotrimazole-betamethasone 62clovique 65clozapine 34clozapine odt 34,35cocaine hcl 10codeine sulfate 6colchicine 25COLCRYS 25colesevelam hcl 55colestipol hcl 55colistimethate 14colocort 95COMBIVENT RESPIMAT 108COMETRIQ 29COMPLERA 37compro 23CONCEPTROL 73constulose 69COPAXONE 60cormax 74cortisone acetate 74

COSENTYX (2 SYRINGES) 62COSENTYX PEN 62COSENTYX PEN (2 PENS) 62COSENTYX SYRINGE 62COTELLIC 29covaryx 79covaryx h.s. 79CREON 71CRIXIVAN 38cromolyn sodium 68,100,105cryselle 79cyanocobalamin injection 66cyclafem 79cyclobenzaprine hcl 110cyclopentolate hcl 99cyclophosphamide 27cycloserine 26CYCLOSET 42cyclosporine 89cyclosporine modified 89cyproheptadine hcl 103cyred 79cyred eq 79CYSTAGON 71CYSTARAN 99cytra-k 64

Dd3-50 95dalfampridine er 60DALIRESP 106danazol 77dantrolene sodium 35dapsone 26DAPTACEL DTAP 91dasetta 79daysee 79deblitane 85decadron 74decara 95deferasirox 65

deferoxamine mesylate 97delyla 79demeclocycline hcl 17denta 5000 plus 61dentagel 61desipramine hcl 22desloratadine 103desmopressin acetate 76desogestr-eth estrad eth estra 79desogestrel-ethinyl estradiol 79desonide 74desoximetasone 74desvenlafaxine succinate er 21dexamethasone 74dexamethasone sodium phosphate 74dexmethylphenidate hcl 57dexmethylphenidate hcl er 57dextroamphetamine sulfate 56,57dextroamphetamine sulfate er 57dextroamphetamine-amphet er 57dextroamphetamine-amphetamine 56,57diazepam 18,41diclofenac potassium 2diclofenac sodium 2,100diclofenac sodium er 2dicloxacillin sodium 16dicyclomine hcl 67didanosine 37diethylpropion hcl 59diethylpropion hcl er 59DIFICID 16diflorasone diacetate 74diflunisal 2digitek 51digox 51digoxin 51dihydroergotamine mesylate 25dilt-xr 50diltiazem 12hr er 50diltiazem 24hr er 50diltiazem 24hr er (cd) 50

diltiazem 24hr er (la) 50diltiazem 24hr er (xr) 50diltiazem 24hr er 360 mg cap (generic forcardizem cd) 50diltiazem 24hr er 360 mg cap (generic for tiazacer) 50diltiazem hcl 50dimenhydrinate 23diphen 97diphenhydramine hcl 97,103diphenoxylate-atropine 68DIPHTHERIA-TETANUS TOXOIDS-PED 91dipyridamole 47disopyramide phosphate 48disulfiram 11divalproex sodium 18divalproex sodium er 18dofetilide 48donepezil hcl 20donepezil hcl odt 20dorzolamide hcl 101dorzolamide-timolol 101dotti 79doxazosin mesylate 47doxepin hcl 22doxercalciferol 95doxycycline hyclate 17,61doxycycline monohydrate 17dronabinol 23droperidol 32drospirenone-eth estra-levomef 79drospirenone-ethinyl estradiol 79ducodyl 70duloxetine hcl 59DUPIXENT 62DUROLANE 97dutasteride 72

Eec-naproxen 2econazole nitrate 24

econtra ez 86econtra one-step 86ecotrin 2ed-spaz 67EDURANT 37eemt 79eemt h.s. 79efavirenz 37effer-k 64EGRIFTA 87eletriptan hbr 25ELIGARD 88elinest 80eliphos 66ELLA 85ELMIRON 73ELOCTATE 46eluryng 80EMBEDA 4EMCYT 28emoquette 80EMTRIVA 37enalapril maleate 48enalapril-hydrochlorothiazide 51endocet 6ENGERIX-B ADULT 91ENGERIX-B PEDIATRIC-ADOLESCENT 92enoxaparin sodium 45enpresse 80enskyce 80entacapone 32entecavir 35enulose 70EPCLUSA 35ephedrine sulfate 52epinastine hcl 100epinephrine 52,104epinephrine 0.15 mg auto-injct - impaxgenerics 104epinephrine 0.15 mg auto-injct - lineage impaxg 104

epinephrine 0.15 mg auto-injct - mylanspecialty 104epinephrine 0.3 mg auto-inject - lineage impaxg 104epinephrine 0.3 mg auto-inject - impaxgenerics 104epinephrine 0.3 mg auto-inject - lineage impaxg 104epinephrine 0.3 mg auto-inject - mylanspecialty 104epinephrine 0.3 mg auto-inject - teva generic 104EPIPEN 2-PAK 0.3 MG AUTO-INJCT - MYLANSPECIALTY 104epitol 20EPIVIR HBV 35eplerenone 53EPOGEN 46eprosartan mesylate 48EPZICOM 37ergoloid mesylates 20ergotamine-caffeine 25erlotinib hcl 29errin 86ery 16erythromycin 16erythromycin ethylsuccinate 16erythromycin-benzoyl peroxide 62ESBRIET 107escitalopram oxalate 21estarylla 80estazolam 111estradiol 80estradiol-norethindrone acetat 80estrogen-methyltestosterone 80estropipate 80eszopiclone 111ethambutol hcl 27ethosuximide 18ethyl chloride 10ethynodiol-ethinyl estradiol 80etidronate disodium 95

etodolac 2etodolac er 2etonogestrel-ethinyl estradiol 80etoposide 29EUFLEXXA 97EUTHYROX 87everolimus 29exemestane 29exoderm 24ezetimibe 55

Ffa-8 66FACTIVE 17fallback solo 86falmina 80famciclovir 39famotidine 69FARYDAK 30fayosim 80fc2 female condom 97febuxostat 25felbamate 19felodipine er 50femcap 97femynor 80fenofibrate 54fenofibric acid 54fenoprofen calcium 3FERRIPROX 65finasteride 72flac otic oil 101flavoxate hcl 72flecainide acetate 48FLOVENT DISKUS 102FLOVENT HFA 102floxuridine 28FLUAD 2017-2018 92FLUAD 2018-2019 92FLUAD 2019-2020 92FLUARIX QUAD 2017-2018 92

FLUARIX QUAD 2018-2019 92FLUARIX QUAD 2019-2020 92FLUBLOK 2017-2018 92FLUBLOK QUAD 2017-2018 92FLUBLOK QUAD 2018-2019 92FLUBLOK QUAD 2019-2020 92FLUCELVAX QUAD 2017-2018 92FLUCELVAX QUAD 2018-2019 92FLUCELVAX QUAD 2019-2020 92fluconazole 24flucytosine 24fludrocortisone acetate 74FLULAVAL QUAD 2017-2018 92FLULAVAL QUAD 2018-2019 92FLULAVAL QUAD 2019-2020 92FLUMIST QUAD 2018-2019 92FLUMIST QUAD 2019-2020 92fluocinolone acetonide 74fluocinolone acetonide oil 101fluocinonide 74fluorescein-proparacaine 99fluoride 64fluoritab 64fluorometholone 100fluorouracil 62fluoxetine dr 21fluoxetine hcl 22fluphenazine decanoate 33fluphenazine hcl 33flura-drops 65flurandrenolide 74flurazepam hcl 111flurbiprofen 3flurbiprofen sodium 100flurox 99flutamide 27fluticasone propionate 74,102fluticasone-salmeterol 108fluvastatin er 54fluvastatin sodium 54FLUVIRIN 2017-2018 92

fluvoxamine maleate 22fluvoxamine maleate er 22FLUZONE HIGH-DOSE 2017-2018 92FLUZONE HIGH-DOSE 2018-2019 92FLUZONE HIGH-DOSE 2019-2020 93FLUZONE INTRADERM QUAD 2017-18 93FLUZONE QUAD 2017-2018 93FLUZONE QUAD 2018-2019 93FLUZONE QUAD 2019-2020 93FLUZONE QUAD PEDI 2017-2018 93FLUZONE QUAD PEDI 2018-2019 93FLUZONE QUAD PEDI 2019-2020 93FML FORTE 100FML S.O.P. 100folic acid 66FOLLISTIM AQ 76fondaparinux sodium 45formaldehyde 97FORTEO 95fosamprenavir calcium 38fosinopril sodium 48fosinopril-hydrochlorothiazide 52fosphenytoin sodium 20FRAGMIN 45frovatriptan succinate 26fulvestrant 28FULYZAQ 68furosemide 53FUZEON 38fyavolv 80

Ggabapentin 18galantamine er 20galantamine hbr 20galantamine hydrobromide 20GAMASTAN 90GAMASTAN S-D 90GAMMAKED 91GAMUNEX-C 91GANIRELIX ACETATE 88

GARDASIL 9 93gatifloxacin 17GATTEX 68gavilax 70gavilyte-c 70gavilyte-g 70gavilyte-n 70gel-one 97gemfibrozil 54generlac 70gengraf 89GENOTROPIN 76gentak 13gentamicin sulfate 13gentle laxative 70gentlelax 70genvisc 850 97gianvi 80gildagia 80gildess 80gildess 24 fe 80glatiramer acetate 60glatopa 60GLEEVEC 30glimepiride 42glipizide 42glipizide er 42glipizide xl 42glipizide-metformin 42GLUCAGEN 43GLUCAGON EMERGENCY KIT 43glucagon hcl 43glyburide 42glyburide micronized 42glyburide-metformin hcl 42glycolax 70glycopyrrolate 67glydo 10GONAL-F 76GONAL-F RFF 76GONAL-F RFF REDI-JECT 76

granisetron hcl 23GRANIX 46green glo 99griseofulvin 24griseofulvin ultramicrosize 24guanfacine hcl 47guanfacine hcl er 57guanidine hcl 26gynol ii 73

Hhailey 81hailey 24 fe 81halobetasol propionate 75haloperidol 33haloperidol decanoate 33haloperidol decanoate 100 33haloperidol lactate 33HARVONI 35,36HAVRIX 93heather 86hemmorex-hc 95heparin sodium 45HEPLISAV-B 93HEPSERA 35HETLIOZ 111HEXALEN 27HIBERIX 93homatropaire 99homatropine hydrobromide 99HUMALOG 43HUMALOG JUNIOR KWIKPEN 43HUMALOG KWIKPEN U-100 43HUMALOG KWIKPEN U-200 43HUMALOG MIX 50-50 44HUMALOG MIX 50-50 KWIKPEN 44HUMALOG MIX 75-25 44HUMALOG MIX 75-25 KWIKPEN 44HUMATROPE 76HUMIRA 89HUMIRA PEDIATRIC CROHN'S 89

HUMIRA PEN 89HUMIRA PEN CROHN'S-UC-HS 89HUMIRA PEN PSOR-UVEITS-ADOL HS 90HUMIRA(CF) 90HUMIRA(CF) PEDIATRIC CROHN'S 90HUMIRA(CF) PEN 90HUMIRA(CF) PEN CROHN'S-UC-HS 90HUMIRA(CF) PEN PSOR-UV-ADOL HS 90HUMULIN 70-30 44HUMULIN 70/30 KWIKPEN 44HUMULIN N 44HUMULIN N KWIKPEN 44HUMULIN R 44HUMULIN R U-500 44HUMULIN R U-500 KWIKPEN 44HYALGAN 97HYCAMTIN 29hydralazine hcl 56hydrochlorothiazide 53hydrocod-cpm-pseudoephedrine 108hydrocodone-acetaminophen 6,7hydrocodone-chlorpheniramne er 108hydrocodone-homatropine mbr 108,109hydrocodone-ibuprofen 7hydrocort-pramoxine 2.5-1% crm (analpramgeneric - perrigo) 75hydrocortisone 75,95hydrocortisone acetate 95hydrocortisone butyrate 75hydrocortisone valerate 75hydrocortisone-acetic acid 101hydrocortisone-pramoxine 63,75hydromet 109hydromorphone er 4hydromorphone hcl 7hydroxocobalamin 66hydroxychloroquine sulfate 31hydroxyurea 28hydroxyzine hcl 103hydroxyzine pamoate 103HYMOVIS 97

hyophen 14hyoscyamine sulfate 67hyoscyamine sulfate er 67hyoscyamine sulfate sr 67HYQVIA 91

Iibandronate sodium 95IBRANCE 30ibu 3ibuprofen 3icatibant 89imatinib mesylate 30imipramine hcl 22imipramine pamoate 22imiquimod 63IMLYGIC 28incassia 86INCRELEX 76INCRUSE ELLIPTA 103indapamide 53indocyanine green 97indomethacin 3indomethacin er 3INFANRIX DTAP 93insulin aspart 44insulin aspart flexpen 44insulin aspart penfill 44insulin aspart prot-insuln asp 44insulin lispro 44insulin lispro kwikpen u-100 44INTELENCE 37INTRON A 36introvale 81INVIRASE 38INVOKAMET 42INVOKAMET XR 42INVOKANA 42IPOL 93ipratropium bromide 103ipratropium-albuterol 109

irbesartan 48irbesartan-hydrochlorothiazide 52IRESSA 30ISENTRESS 37ISENTRESS HD 37isibloom 81isochron 56isoflurane 10isomethept-caff-acetaminophen 97isomethept-dichloralp-acetamin 97isoniazid 27isosorbide dinitrate 56isosorbide dinitrate er 56isosorbide mononitrate 56isosorbide mononitrate er 56isotretinoin 63isoxsuprine hcl 52isradipine 50itraconazole 24ivermectin 31

JJADENU 65JADENU SPRINKLE 66JAKAFI 30jantoven 45JANUMET 42JANUMET XR 42JANUVIA 42JARDIANCE 42jasmiel 81jencycla 86JENTADUETO 42jevantique lo 81jinteli 81jolessa 81jolivette 86juleber 81junel 81junel fe 81junel fe 24 81

JUXTAPID 55

Kk effervescent 65kaitlib fe 81KALBITOR 89KALETRA 38kalliga 81KALYDECO 105kariva 81kelnor 1-35 81kelnor 1-50 81ketamine hcl 10ketoconazole 24ketodan 24ketoprofen 3ketorolac tromethamine 3,100KEVEYIS 53kimidess 81KINRIX 93kionex 66KITABIS PAK 105klor-con 65klor-con m10 65klor-con m20 65klor-con sprinkle 65klor-con-ef 65KORLYM 75kurvelo 81KUVAN 71KYNAMRO 55

Llabetalol hcl 49lactulose 70lamivudine 35,38lamivudine hbv 35lamivudine-zidovudine 38lamotrigine 19lamotrigine er 19lamotrigine odt 19

LANOXIN 52lansoprazol-amoxicil-clarithro 68lansoprazole 71LANTUS 44LANTUS SOLOSTAR 44larin 81larin 24 fe 81larin fe 81larissia 81latanoprost 101LATUDA 33laxaclear 70laxative 70laxative feminine 70laxative peg 3350 70ledipasvir-sofosbuvir 36leena 81leflunomide 91lessina 82letrozole 29leucovorin calcium 28LEUKERAN 27LEUKINE 46leuprolide acetate 88levalbuterol concentrate 104levalbuterol hcl 104,105levetiracetam 18levetiracetam er 18LEVO-T 87levobunolol hcl 101levocarnitine 97levofloxacin 17levonest 82levonorg-eth estrad eth estrad 82levonorgestrel 86levonorgestrel-eth estradiol 82levora-28 82levothyroxine sodium 87LEVOXYL 87LEXIVA 38lidocaine 10

lidocaine hcl 11lidocaine hcl 4% (mucous membrane) solution 11lidocaine hcl 4% (topical) solution 11lidocaine hcl viscous 11lidocaine hcl-epinephrine 11lidocaine-epinephrine 11lidocaine-hydrocortisone 63lidocaine-prilocaine 11lidocaine/prilocaine 2.5 %-2.5% (topical) cream 11lidocaine/prilocaine 2.5 %-2.5% kit 11lillow 82lindane 31linezolid 14LINZESS 69liothyronine sodium 87lisinopril 48lisinopril-hydrochlorothiazide 52lithium 41lithium carbonate 41lithium carbonate er 41lo-dose aspirin ec 3lo-zumandimine 82lomedia 24 fe 82LONSURF 28loperamide 68lopinavir-ritonavir 38lopreeza 82lorazepam 41lorazepam intensol 41lorcet 7lorcet hd 7lorcet plus 8lortab 8loryna 82losartan potassium 48losartan-hydrochlorothiazide 52lovastatin 54LOVENOX 45low dose aspirin ec 3low-ogestrel 82loxapine 33

ludent fluoride 65lugol's 97LUMIGAN 101LUPANETA PACK 88LUPRON DEPOT 88LUPRON DEPOT-PED 88lutera 82LYNPARZA 30LYRICA 59LYSODREN 29lyza 86

MM-M-R II VACCINE 93magnesium chloride 65magnesium citrate 70magnesium sulfate 65malathion 31maprotiline hcl 22marlissa 82MATULANE 27matzim la 50MAVYRET 36md-gastroview 97me-naphos-mb-hyo 1 14meclizine hcl 23meclofenamate sodium 3medroxyprogesterone acetate 86mefenamic acid 3mefloquine hcl 31megestrol acetate 86MEKINIST 30melodetta 24 fe 82meloxicam 3melphalan 27memantine hcl 20MENACTRA 93MENOPUR 76MENVEO A-C-Y-W-135-DIP 93meperidine hcl 8mepivacaine hcl 11

meprobamate 39mercaptopurine 28mesalamine 94mesalamine er 94metadate er 58metaproterenol sulfate 105metaxall 110metaxalone 110metformin hcl 42metformin hcl er 42metformin hcl er 500 (generic for glucophage xr)

42methadone hcl 4methadose 4methamphetamine hcl 57methazolamide 101methenamine hippurate 14methenamine mandelate 14methimazole 89methocarbamol 111methotrexate 90methotrexate sodium 90methoxsalen 63methscopolamine bromide 67methyclothiazide 54methyldopa 47methyldopa-hydrochlorothiazide 52methylergonovine maleate 97methylphenidate er 58methylphenidate er (la) 58methylphenidate hcl 58methylphenidate hcl cd 58methylphenidate hcl er (cd) 58methylphenidate la 58methylprednisolone 75methylprednisolone acetate 75methylprednisolone sodium succ 75methyltestosterone 77metipranolol 101metoclopramide hcl 23metoclopramide hcl odt 23

metolazone 54metopic 63metoprolol succinate 49metoprolol tartrate 49metoprolol-hydrochlorothiazide 52metronidazole 14,63mexiletine hcl 49mibelas 24 fe 82miconazole 3 24microgestin 82microgestin fe 82midazolam hcl 40midodrine hcl 47mili 82mimvey 82mimvey lo 82minitran 56minocycline hcl 18minocycline hcl er 18minoxidil 56MIRCERA 46mirtazapine 21MIRVASO 63misoprostol 71modafinil 59moderiba 36moexipril hcl 48moexipril-hydrochlorothiazide 52molindone hcl 33mometasone furoate 75,102mondoxyne nl 18mono-linyah 82mononessa 82MONOVISC 97montelukast sodium 103morgidox 18morphine sulfate 8morphine sulfate 30 mg cap er (generic forkadian) 4morphine sulfate 30 mg cap er (not generickadian) 4

morphine sulfate 60 mg cap er (generic forkadian) 4morphine sulfate 60 mg cap er (not generickadian) 4morphine sulfate er 4,5MOTOFEN 68MOVANTIK 68MOXEZA 17moxifloxacin 17moxifloxacin hcl 17MULTAQ 49mupirocin 14my choice 86my way 86MYALEPT 68mycophenolate mofetil 90mycophenolic acid 90MYLERAN 27myorisan 63MYRBETRIQ 72MYTESI 68myzilra 82

Nnabumetone 3nadolol 49nadolol-bendroflumethiazide 52naftifine hcl 24naloxone hcl 12naltrexone hcl 11NAMENDA 20naphazoline hcl 99naproxen 3naproxen sodium 3naproxen sodium cr 3naproxen sodium ds 3naproxen sodium er 4naratriptan 26naratriptan hcl 26NASONEX 102nateglinide 42

NATPARA 96natura-lax 70nebusal 109necon 82nefazodone hcl 22neo-polycin 99neo-polycin hc 99neomycin sulfate 13neomycin-bacitracin-poly-hc 99neomycin-bacitracin-polymyxin 99neomycin-polymyxin-dexameth 99neomycin-polymyxin-hc 99,101neomycin-polymyxin-hydrocort 101neuac 63NEULASTA 46nevirapine 37nevirapine er 37new day 86next choice one dose 86niacin 55niacin er 55niacor 55nicardipine hcl 50nicoderm cq 12nicorelief 12nicotine gum 12nicotine lozenge 13nicotine patch 13NICOTROL 13NICOTROL NS 13nifedical xl 50nifedipine 50nifedipine er 50nikki 83NILANDRON 27nilutamide 27nimodipine 51NINLARO 29nisoldipine 51nitisinone 72nitrofurantoin 14

nitrofurantoin mono-macro 14nitroglycerin 56nitroglycerin patch 56NIVESTYM 46nizatidine 69nodolor 97nora-be 86NORDITROPIN FLEXPRO 76norethin-eth estra-ferrous fum 83norethindron-ethinyl estradiol 83norethindrone 86norethindrone acetate 86norethindrone-eth estradiol-fe 83norgestimate-ethinyl estradiol 83norlyda 86norlyroc 86nortrel 83nortriptyline hcl 23NORVIR 38NOVAREL 76NOVOEIGHT 46NOVOLOG 44NOVOLOG FLEXPEN 44NOVOLOG MIX 70-30 44NOVOLOG MIX 70-30 FLEXPEN 44np thyroid 87NUCALA 109NUTROPIN AQ 77NUTROPIN AQ NUSPIN 77NUVARING 83NUWIQ 47nyamyc 24nyata 25nystatin 25nystatin-triamcinolone 25nystop 25

OOBIZUR 47ocella 83octreotide acetate 88

OFEV 107ofloxacin 17ogestrel 83okebo 18olanzapine 33,34olanzapine odt 34olanzapine-fluoxetine hcl 21olmesartan medoxomil 48olmesartan-hydrochlorothiazide 52olopatadine hcl 100,103OLYSIO 36omega-3 acid ethyl esters 55omeprazole 71OMNITROPE 77ondansetron hcl 23,24ondansetron odt 24onetouch ultra blue test strp 97onetouch ultra2 97onetouch ultramini 98onetouch verio 98onetouch verio flex 98onetouch verio iq 98opcicon one-step 87opium tincture 68OPSUMIT 106option 2 87oralone 61ORENCIA 90ORENCIA CLICKJECT 90ORENITRAM ER 106ORFADIN 72ORKAMBI 105orphenadrine citrate 111orphenadrine citrate er 111orsythia 83ORTHOVISC 98oscimin 67oscimin sl 67oscimin sr 67oseltamivir phosphate 39OTEZLA 91

OVIDREL 77oxandrolone 77oxaprozin 4oxazepam 41oxcarbazepine 20oxiconazole nitrate 25oxybutynin chloride 72oxybutynin chloride er 72oxycodone hcl 8oxycodone hcl-aspirin 9oxycodone hcl-ibuprofen 9oxycodone-acetaminophen 9OXYCONTIN 5oxymorphone hcl 9oxymorphone hcl er 5oxytocin 98

Ppacerone 49paliperidone er 34pantoprazole sodium 71papaverine hcl 52paregoric 68paricalcitol 96paroex 61paromomycin sulfate 13paroxetine cr 22paroxetine er 22paroxetine hcl 22PEDVAXHIB 93peg 3350-electrolyte 70peg-3350 and electrolytes 70PEGANONE 20PEGASYS 36PEGASYS PROCLICK 36PEGINTRON 36PEGINTRON REDIPEN 36penicillamine 66penicillin v potassium 16PENTACEL 93PENTACEL ACTHIB COMPONENT 93

PENTACEL DTAP-IPV COMPONENT 93pentazocine-naloxone hcl 9pentoxifylline 52perindopril erbumine 48periogard 61permethrin 31perphenazine 23perphenazine-amitriptyline 21phenadoz 23phenazopyridine hcl 73phendimetrazine tartrate 59phendimetrazine tartrate er 59phenelzine sulfate 21phenobarbital 19phenobarbital sodium 19phenohytro 67phenoxybenzamine hcl 47phentermine hcl 59phenylephrine hcl 52,99phenytoin 20phenytoin sodium extended 20philith 83phosphasal 14physostigmine salicylate 98phytonadione 66pilocarpine hcl 61,101pimozide 33pimtrea 83pindolol 49pioglitazone hcl 43pioglitazone-glimepiride 43pioglitazone-metformin 43pirmella 83piroxicam 4PNEUMOVAX 23 94podocon-25 63podofilox 63polocaine-mpf 11polycin 99polyethylene glycol 3350 71polyethylene glycol 3350 (otc) 70

polymyxin b sul-trimethoprim 99POMALYST 28portia 83potassium bicarbonate 65potassium chloride 65potassium citrate er 65potassium citrate-citric acid 65POTIGA 18powderlax 71PRADAXA 45pralidoxime chloride 98PRALUENT PEN 55PRALUENT SYRINGE 55pramipexole dihydrochloride 32pramipexole er 32prasugrel hcl 47pravastatin sodium 54praziquantel 31prazosin hcl 47prednicarbate 75prednisolone 75prednisolone acetate 100prednisolone sodium phos odt 75prednisolone sodium phosphate 75prednisone 75pregabalin 59PREGNYL 77PREMARIN 83PREMPHASE 83PREMPRO 83prevalite 55previfem 83PREVNAR 13 94PREZISTA 39primaquine 31primidone 19PROAIR HFA 105probenecid 25probenecid-colchicine 25prochlorperazine 23prochlorperazine maleate 23

PROCRIT 46procto-med hc 95procto-pak 95proctosol-hc 95proctozone-hc 95PROCYSBI 72progesterone 87PROLIA 96PROMACTA 46promethazine hcl 23,103promethazine vc 109promethazine vc-codeine 109promethazine-codeine 109promethazine-dm 109promethazine-phenyleph-codeine 109promethegan 23propafenone hcl 49propafenone hcl er 49propantheline bromide 67proparacaine hcl 99propranolol hcl 49propranolol hcl er 50propranolol-hydrochlorothiazid 52propylthiouracil 89PROQUAD 94protriptyline hcl 23psorcon 75PULMICORT FLEXHALER 102pulmosal 110PULMOZYME 110purelax 69PYLERA 68pyrazinamide 27pyridostigmine bromide 26pyridostigmine bromide er 26pyridoxine hcl 66

QQUADRACEL DTAP-IPV 94quasense 83quazepam 111

quetiapine fumarate 34quetiapine fumarate er 34quinapril hcl 48quinapril-hydrochlorothiazide 52quinidine gluconate 49quinidine sulfate 49quinine sulfate 31quit 2 13quit 4 13QVAR 102QVAR REDIHALER 102

Rrabeprazole sodium 71rajani 83raloxifene hcl 87ramipril 48ranitidine hcl 69RAVICTI 72REBETOL 36RECLAST 96reclipsen 83RECOMBIVAX HB 94RELENZA 39RELISTOR 68REMODULIN 106repaglinide 43repaglinide-metformin hcl 43REPATHA PUSHTRONEX 55REPATHA SURECLICK 55REPATHA SYRINGE 55RESCRIPTOR 37reserpine 52RETACRIT 46REVATIO 106REVLIMID 28REXULTI 34REYATAZ 39ribasphere 36ribavirin 37rifabutin 26

rifampin 27rimantadine hcl 39risedronate sodium 96risperidone 34risperidone odt 34ritonavir 39rivastigmine 20rivelsa 84rizatriptan 26ropinirole er 32ropinirole hcl 32ropivacaine hcl 11rosadan 63rosanil 63rosuvastatin calcium 54ROTARIX 94ROTATEQ 94roweepra 18roweepra xr 18

SSAIZEN 77SAIZEN-SAIZENPREP 77salicylic acid 63salsalate 4SAMSCA 66SAPHRIS 34scalacort 75seb-prev 63selegiline hcl 32selenium sulfide 63SELZENTRY 38SEREVENT DISKUS 105SEROSTIM 77sertraline hcl 22setlakin 84sevelamer carbonate 66sevoflurane 11sf 61sf 5000 plus 61sharobel 87

SHINGRIX 94SIGNIFOR 88sildenafil citrate 73,106,107silver nitrate 63silver nitrate applicator 63silver sulfadiazine 17simliya 84simpesse 84SIMPONI 90SIMPONI ARIA 90simvastatin 54sirolimus 90SKYRIZI (2 SYRINGES) KIT 63smoothlax 71sodium chloride 110sodium citrate 45sodium fluoride 61,65sodium fluoride 5000 plus 61sodium hyaluronate 98sodium phenylbutyrate 72sodium polystyrene sulfonate 66sodium sulfacetamide 64sodium sulfacetamide-sulfur 64sofosbuvir-velpatasvir 36solifenacin succinate 72SOLTAMOX 28SOMATULINE DEPOT 89SOMAVERT 89sorine 49sotalol 49SOVALDI 36spinosad 31SPIRIVA 103SPIRIVA RESPIMAT 103spironolactone 53spironolactone-hctz 52sprintec 84SPRYCEL 30sronyx 84sss 10-5 64st. joseph aspirin 4

st. joseph aspirin ec 4stavudine 38STELARA 64STIOLTO RESPIMAT 110STIVARGA 30stop smoking aid 13STRENSIQ 72STRIBILD 37subvenite 19SUCRAID 72sucralfate 71sulfacetamide sodium 17,64sulfacetamide-prednisolone 99sulfadiazine 17sulfamethoxazole-trimethoprim 17sulfasalazine 95sulindac 4sumatriptan 26sumatriptan succinate 26supartz fx 98SUSTIVA 37SUTENT 30syeda 84symax 67symax-sl 68symax-sr 68SYMBICORT 110SYMLINPEN 120 43SYMLINPEN 60 43SYNAREL 89SYNJARDY 43SYNVISC 98SYNVISC-ONE 98

TTABLOID 28tacrolimus 64,90tadalafil 72,73tadalafil 20 mg tablet (generic for adcirca) 107tadalafil 20 mg tablet (generic for cialis) 73tamoxifen citrate 28

tamsulosin hcl 72tarina 24 fe 84tarina fe 84tarina fe 1-20 eq 84TASIGNA 30taztia xt 51tc99m sulfur colloid prep 98TDVAX 94TECFIDERA 60,61TEKTURNA 52TEKTURNA HCT 52telmisartan 48telmisartan-hydrochlorothiazid 52temazepam 111TEMODAR 27temozolomide 27tencon 59TENIVAC 94tenofovir disoproxil fumarate 38terazosin hcl 47terbinafine hcl 25terbutaline sulfate 105terconazole 25terrell 11testosterone 77testosterone cypionate 78testosterone enanthate 78tetcaine 99tetrabenazine 59tetracaine hcl 11,99tetracycline hcl 18THALOMID 28theochron 106theophylline 106theophylline anhydrous 106thiamine hcl 67THIOLA 73THIOLA EC 73thioridazine hcl 33thiotepa 29thiothixene 33

thyroid 87tiadylt er 51tiagabine hcl 19ticlopidine hcl 47tilia fe 84timolol maleate 50,101tinidazole 14TIVICAY 37tizanidine hcl 35TOBI 105TOBI PODHALER 105tobramycin 13,105tobramycin-dexamethasone 100TODAY CONTRACEPTIVE SPONGE 73tolazamide 43tolbutamide 43tolcapone 32tolmetin sodium 4tolterodine tartrate 72tolterodine tartrate er 72topiramate 19topiramate er 19toremifene citrate 28torsemide 53TRACLEER 107TRADJENTA 43tramadol hcl 9tramadol hcl er 5tramadol hcl-acetaminophen 9trandolapril 48trandolapril-verapamil er 53tranexamic acid 47tranylcypromine sulfate 21TRAVATAN Z 101travoprost 101trazodone hcl 22treprostinil 107tretinoin 30,64tretinoin microsphere 64TRETTEN 47tri femynor 84

tri-estarylla 84tri-legest fe 84tri-linyah 84tri-lo-estarylla 84tri-lo-marzia 84tri-lo-mili 84tri-lo-sprintec 84tri-mili 84tri-previfem 84tri-sprintec 84tri-vylibra 84tri-vylibra lo 84triamcinolone acetonide 61,76,102triamterene-hydrochlorothiazid 53triazolam 111triderm 76trientine hcl 66trifluoperazine hcl 33trifluridine 39trihexyphenidyl hcl 31triklo 55trilyte with flavor packets 71trimethobenzamide hcl 23trimethoprim 14trimipramine maleate 23trinessa 85trinessa lo 85trivisc 98trivora-28 85tropicamide 100trospium chloride 72trospium chloride er 72TRULICITY 43TRUMENBA 94TRUVADA 38tulana 87tussigon 110tydemy 85TYKERB 30TYVASO 107TYVASO INSTITUTIONAL START KIT 107

TYVASO REFILL KIT 107TYVASO STARTER KIT 107TYZEKA 35

Uu-cort 76UNITHROID 87UNITUXIN 30UPTRAVI 107ur n-c 14urea 64urin d.s. 15uro-458 15uro-mp 15ursodiol 68ustell 15utira-c 15

Vvalacyclovir 39VALCHLOR 27VALCYTE 35valganciclovir hcl 35valproic acid 19valsartan 48valsartan-hydrochlorothiazide 53vanatol lq 59vanatol s 59vancomycin hcl 15VAQTA 94VARIVAX VACCINE 94VASCEPA 56vaseline white petroleum 98vcf 73velivet 85venlafaxine hcl 22venlafaxine hcl er 22VENTAVIS 107VENTOLIN HFA 105VENTOLIN HFA 90 MCG INHALER (LARGEPACKAGE SIZE) 105

verapamil er 51verapamil er pm 51verapamil hcl 51verapamil sr 51verdrocet 9vestura 85vicodin 10vicodin es 10vicodin hp 10VICTOZA 2-PAK 43VIDEX 38vienva 85vigabatrin 19vigadrone 19vilamit mb 15vilevev mb 15VIMPAT 20viorele 85VIRACEPT 39VIREAD 38visco-3 98vitamin d2 96vitamin d3 96vitamin k1 67VIVITROL 12voriconazole 25vyfemla 85vylibra 85

Wwarfarin sodium 45wera 85wide seal diaphragm 98wixela inhub 110woman's laxative 71women's gentle laxative 71women's laxative 71wymzya fe 85

XXARELTO 45

XELJANZ 90XELJANZ XR 90XELODA 28XOLAIR 110XTANDI 27xulane 85XURIDEN 98xylon 10 10

Zzafirlukast 103zaleplon 111zarah 85ZARXIO 46zenatane 64zenchent 85ZIAGEN 38zidovudine 38ziprasidone hcl 34ZIRGAN 35ZOLADEX 89ZOLINZA 29zolmitriptan 26zolmitriptan odt 26zolpidem tartrate 111zolpidem tartrate er 111ZOMACTON 77zonisamide 18ZORBTIVE 77ZOSTAVAX 94zovia 1-35e 85zovia 1-50e 85zumandimine 85ZYDELIG 30ZYKADIA 30ZYTIGA 27

NDR PIC LV (1/18)

PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company (“PIC”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as:

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Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Grievance Specialist PreferredOne Insurance Company PO Box 59212 Minneapolis, MN 55459-0212 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]

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

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2019 PREFERREDONE PRIMARY